8- Revision Head & Neck MSQs Only Flashcards
(160 cards)
1
Q
1- The motor nucleus of cranial nerve V supplies all except which of the following muscles?
A
Masseter
Posterior belly of digastric( Right)
Temporalis
Tensor tympani
Tensor veli palatini
……………………………………………..
The posterior belly of digastric is supplied by the branchial motor component of the facial nerve.
All of the other muscles are supplied by axons from the motor nucleus of cranial nerve V.
2
Q
2- Which of the following is a recognised tributary of the retromandibular vein?
A
Maxillary vein
The retromandibular vein is formed from the union of the maxillary and superficial temporal veins.
3
Q
3- When performing minor surgery in the scalp, which of the following regions is considered a danger area as regards spread of infection into the CNS?
A
Loose areolar tissue
This area is most dangerous as infections can spread easily. The emissary veins that drain this area may allow sepsis to spread to the cranial cavity.
4
Q
4- The space between the vocal cords is referred to as which of the following?
A
Rima glottidis
The rima glottidis is the narrowest part of the laryngeal cavity.
5
Q
5- Which of the following muscles is penetrated by the parotid duct?
A
Buccinator
The duct crosses the masseter muscle and buccal fat pad and then penetrates the buccinator muscle to enter the oral cavity opposite the second upper molar tooth.
6
Q
6- A 32 year old lady is admitted with weakness, visual disturbance and peri orbital pain. On examination, she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response is preserved when light is shone into the unaffected eye. Which of the cranial nerves listed below is responsible for the diminished direct response?
A
Optic
This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response).
The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).
7
Q
7- A 34 year old lady suffers from hyperparathyroidism. The right inferior parathyroid is identified as having an adenoma and is scheduled for resection. From which of the following embryological structures is it derived?
A
Third pharyngeal pouch
The inferior parathyroid is a derivative of the third pharyngeal pouch. The superior parathyroid originates from the fourth pharyngeal pouch.
8
Q
8- A 56 year old man is undergoing a superficial parotidectomy for a pleomorphic adenoma. During the dissection of the parotid, which of the following structures will be encountered lying most superficially?
A
Facial nerve
Most superficial structure on the parotid gland = facial nerve
The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular vein, with the arterial layer lying most deeply.
9
Q
9- Which of the following statements relating to sternocleidomastoid is untrue?
A
The external jugular vein lies posteromedially.( Right)
It is supplied by the accessory nerve.
It has two heads of origin
It inserts into the lateral aspect of the mastoid process.
It marks the anterior border of the posterior triangle.
………………………
The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.
10
Q
10- Which of the following muscles is not innervated by the ansa cervicalis?
A
Sternohyoid
Mylohyoid( Right)
Omohyoid
Sternothyroid
None of the above
……………………………………..
Ansa cervicalis muscles:
GHost THought SOmeone Stupid Shot Irene
GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid
Mylohyoid is innervated by the mylohyoid branch of the inferior alveolar nerve.
11
Q
11- Which of the following most commonly arises from the brachiocephalic artery?
A
Thyroidea ima artery
Other occasional branches include the thymic and bronchial branch.
12
Q
14- Into which of these veins does the middle thyroid vein drain?
A
Internal jugular
It drains to the internal jugular vein. Which is one of the reasons why it bleeds so copiously if a ligature slips.
12
Q
12- In relation to the middle cranial fossa, which of the following statements relating to the foramina is incorrect?
A
The foramen rotundum transmits the maxillary nerve
The foramen lacerum is closely related to the internal carotid artery
The foramen spinosum lies posterolateral to the foramen ovale
The foramen ovale transmits the middle meningeal artery( Right)
The foramen rotundum lies anteromedial to the foramen ovale
…………………………………….
The foramen spinosum transmits the middle meningeal artery. The foramen ovale transmits the mandibular nerve. As the foramina weaken the bone, a fracture at this site is not uncommon.
13
Q
13- Which muscle is not innervated by the trigeminal nerve?
A
Medial pterygoid
Mylohyoid
Stylohyoid( Right)
Masseter
Temporalis
……………………………………..
Stylohyoid is innervated by the facial nerve.
14
Q
15- The recurrent laryngeal is connected to which of the following nerves?
A
Vagus
15
Q
16- Which of these statements relating to the external carotid is false?
A
It ends by bifurcating into the superficial temporal and ascending pharyngeal artery( Right)
Its first branch is the superior thyroid artery
The superior thyroid, lingual and facial arteries all arise from its anterior surface
The ascending pharyngeal artery is a medial branch
Initially it lies anteromedial to the internal carotid
…………………………………..
It terminates by dividing into the superficial temporal and maxillary branches. The external carotid has eight branches, 3 from its anterior surface ; thyroid, lingual and facial. The pharyngeal artery is a medial branch. The posterior auricular and occipital are posterior branches.
16
Q
17- Which of the following is not a content of the anterior triangle of the neck?
A
Ansa cervicalis
Vagus nerve
Anterior jugular vein
Transverse cervical nerve ( Right)
Hypoglossal nerve
…………………………………………
The transverse cervical nerve lies within the posterior triangle. The anterior jugular vein is formed in the submental region and descends in the superficial fascia near the median plane. It passes inferior to enter the suprasternal space, it is linked to the contralateral anterior jugular vein by the jugular venous arch.
17
Q
18- Which of the following is not a direct branch of the facial nerve?
A
Greater petrosal nerve
Nerve to stapedius
Auriculotemporal ( Right)
Chorda tympani
Buccal branch of facial nerve
…………………………
The auriculotemporal nerve is a direct branch of the mandibular nerve.
Other branches of the mandibular nerve include:
Lingual
Inferior alveolar
Nerve to the mylohyoid
Mental
18
Q
19- You are working as an anatomy demonstrator and the medical students decide to test your knowledge on the Circle of Willis. Which of the following comments is false?
A
The anterior communicating artery links the right and left sides
Asymmetry of the circle of willis is a risk factor for the development of intracranial
aneurysms
Majority of blood passing through the vessels mix together ( Right)
Includes the anterior communicating artery
The circle surrounds the stalk of the pituitary gland
19
Q
20- A 34 year old man with a submandibular gland stone is undergoing excision of the submandibular gland. The incision is sited transversely approximately 4cm below the mandible. After incising the skin, platysma and deep fascia which of the following structures is most likely to be encountered.
A
Facial vein
When approaching the submandibular gland the facial vein and submandibular lymph nodes are the most superficially encountered structures. Each sub mandibular gland has a superficial and deep part, separated by the mylohyoid muscle. The facial artery passes in a groove on the superficial aspect of the gland. It then emerges onto the surface of the face by passing between the gland and the mandible. The facial vein is encountered first in this surgical approach because the incision is made 4cm below the mandible (to avoid injury to the marginal mandibular nerve).
20
Q
21- A 35 year old man is admitted to hospital with vomiting, nausea and severe headaches. An MRI scan reveals a tumour of the cerebellopontine angle. Which one of the following pairs of cranial nerves is most likely to be compressed by this tumour?
A
Facial and vestibulocochlear
The cerebellopontine angle is located between the superior and inferior limbs of the angular cerebellopontine fissure formed by the petrosal cerebellar surface folding around the pons and middle cerebellar peduncle. The cerebellopontine fissure opens medially and has superior and inferior limbs that meet at a lateral apex. The fourth through the eleventh cranial nerves are located near or within the angular space between the two limbs commonly referred to as the cerebellopontine angle. The commonest lesion to affect this site is an acoustic neuroma.
Therefore the vestibulocochlear nerve is commonly compromised. Larger lesions may also affect the facial nerve which lies closest to this site.
21
Q
23- Which of the following is not a content of the posterior triangle of the neck?
A
Spinal accessory nerve
Phrenic nerve
External jugular vein
Occipital lymph nodes
Internal jugular vein( Right)
……………………………………….
The IJV does not lie in the posterior triangle. However, the terminal branches of the external jugular vein do.
22
Q
22- Which of these openings transmits the facial nerve into the temporal bone?
A
Internal acoustic meatus
It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid foramen.
23
Q
24- A builder falls off a ladder whilst laying roof tiles. He sustains a burst fracture of L2. The MRI scan shows complete nerve transection at this level, as a result of the injury. Which clinical sign will not be present initially?
A
Flaccid paralysis of the legs
Extensor plantar response(Right)
Sensory loss in the legs
Incontinence
Areflexia
…………………………………………….
In lower motor neuron lesions everything is reduced
The main purpose of this question is to differentiate the features of an UMN lesion and a LMN lesion. The features of a LMN lesion include:
· Flaccid paralysis of muscles supplied
. Atrophy of muscles supplied.
· Loss of reflexes of muscles supplied.
· Muscles fasciculation
For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss of the patella reflex but there will be no extensor plantar reflex.
24
25- Which nerve is at risk during submandibular gland excision?
Marginal mandibular nerve
The marginal mandibular nerve lies deep to platysma. It supplies the depressor anguli oris and the depressor labii inferioris. If injured it may lead to facial asymmetry and dribbling.
25
26- A 73 year old man presents with a tumour at the tip of his tongue. To which of the following regions will the tumour initially metastasise?
Sub mental nodes
26
27- Which statement is false about the foramina of the skull?
The hypoglossal canal transmits the hypoglossal nerve
The foramen spinosum is at the base of the medial pterygoid plate. ( Right)
The jugular foramen transmits the accessory nerve
The foramen lacerum is located in the sphenoid bone
The stylomastoid foramen transmits the facial nerve
27
28- A 16 year old boy is hit by a car and sustains a blow to the right side of his head. He is initially conscious but on arrival in the emergency department is comatose. On examination his right pupil is fixed and dilated. The neurosurgeons plan immediate surgery. What type of initial approach should be made?
Right parieto-temporal craniotomy
A unilateral dilated pupil is a classic sign of transtentorial herniation. The medial aspect of the temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. In addition the brainstem is compressed. As the ipsilateral oculomotor nerve is being compressed, craniotomy (rather than Burr Holes) should be made on the ipsilateral side.
28
29- A 22 year old man sustains a blow to the side of his head with a baseball bat during a fight. He is initially conscious. However, he subsequently loses consciousness and then dies. Post mortem examination shows an extradural haematoma. The most likely culprit vessel is a branch of which of the following?
Maxillary artery
The middle meningeal artery is the most likely source of the extradural haematoma in this setting. It is a branch of the maxillary artery. The middle cerebral artery does not give rise to the middle meningeal artery. Note that the question is asking for the vessel which gives rise to the middle meningeal artery ("the likely culprit vessel is a branch of which of the following")
29
30- Which of the following structures attaches periosteum to bone?
Sharpeys fibres
Periosteum is attached to bone by strong collagenous fibers called Sharpey's fibres, which extend to the outer circumferential and interstitial lamellae. It also provides an attachment for muscles and tendons.
30
31- The following muscles are supplied by the recurrent laryngeal nerve except:
Transverse arytenoid
Posterior crico-arytenoid
Cricothyroid ( Right)
Oblique arytenoid
Thyroarytenoid
........................................
Innervates: all intrinsic larynx muscles (excluding cricothyroid)
The external branch of the superior laryngeal nerve innervates the cricothyroid muscle.
31
32- Which of the following relationship descriptions regarding the scalene muscles is incorrect?
The brachial plexus passes anterior to the middle scalene muscle
The phrenic nerve lies anterior to the anterior scalene muscle
The subclavian artery passes posterior to the middle scalene( Right)
The subclavian vein lies anterior to the anterior scalene muscle at the level of the first rib
the anterior scalene insert in firist rib
.................................................
The subclavian artery passes anterior to the middle scalene.
32
33- A man is undergoing excision of a sub mandibular gland. As the gland is mobilised, a vessel is injured lying between the gland and the mandible. Which of the following is this vessel most likely to be?
Facial artery
............................
The high salivary viscosity of submandibular gland secretions favors stone formation.
Most stones are radio-opaque.
The marginal mandibular nerve is the most superficial structure.
The facial artery lies between the gland and mandible and is often ligated during excision of the gland. The lingual artery may be encountered but this is usually later in the operative process as Whartons duct is mobilised.
33
34- What is the level of the hyoid bone?
C3
34
35- An 18 year old male presents to casualty with a depressed skull fracture. This is managed surgically. Over the next few days he complains of double vision on walking down stairs and reading. On testing ocular convergence, the left eye faces downwards and medially, but the right side does not do so. Which of the nerves listed below is most likely to be responsible?
Trochlear
The trochlear nerve has a relatively long intracranial course and this makes it vulnerable to injury in head trauma. Head trauma is the commonest cause of an acute fourth nerve palsy.
A 4th nerve palsy is the commonest cause of a vertical diplopia. The diplopia is at its worst when the eye looks medially which it usually does as part of the accommodation reflex when walking down stairs.
35
36- A 53 year old man presents with unilateral hyperacousia. Which of the following nerves is least likely to be functioning normally?
Facial
Damage to the nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no longer dampened.
36
37- An injury to the spinal accessory nerve will have the greatest effect on which of the following movements?
Upward rotation of the scapula
The spinal accessory nerve innervates trapezius. The entire muscle will retract the scapula. However, its upper and lower fibres act together to upwardly rotate it.
37
38- Which of the following statements relating to the tympanic membrane is false?
The umbo marks the point of attachment of the handle of the malleus to the tympanic membrane
The lateral aspect of the tympanic membrane is lined by stratified squamous epithelium
The chorda tympani nerve runs medial to the pars tensa(Right)
The medial aspect of the tympanic membrane is lined by mucous membrane
The tympanic membrane is approximately 1cm in diameter
...........................................................
The chorda tympani runs medially to the pars flaccida. The relationship is shown from the medial aspect
in the dissection below.
38
39- Which cranial nerve provides general sensation to the anterior two thirds of the tongue?
Trigeminal
Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies general sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve).
39
40- A 43 year old lady develops a cerebello-pontine angle lesion. Which of the nerves listed below is likely to be affected first?
CN V
The most likely lesion to occur in the cerebello-pontine angle is an acoustic neuroma.
The trigeminal nerve has a broad base and involvement of at least part of this nerve is the most likely initial finding. The defect may be subtle such as loss of the ipsilateral corneal reflex. Ipsilateral hearing loss will also occur. Untreated, progressive lesions, may ultimately affect cranial nerve roots in this region.
40
41- Which of the following nerves is responsible for the innervation of the posterior belly of the digastric muscle?
Facial nerve
The posterior belly of digastric is innervated by the facial nerve and the anterior belly by the mylohoid nerve.
41
45- Which cranial nerve supplies the motor fibres of styloglossus?
Hypoglossal
The hypoglossal nerve supplies motor innervation to all extrinsic and intrinsic muscles of the tongue.
The only possible exception to this is palatoglossus, which is innervated by the vagus.
42
42- Where does Stensens duct primarily open?
Opposite the second molar tooth
Stensens duct conveys secretions from the parotid gland and these enter the oral cavity at the level of the second molar tooth.
43
43- A 40 year old woman had the anterior lobe of the pituitary removed because of a tumour. Without postoperative supplements, which of the following could occur?
Failure to produce adequate amounts of thyroxine
Its an anterior pituitary lesion and that is the reason thyroxine secretion is affected. ADH is released by the posterior pituitary.
43
44- Which of the following statements relating to the posterior cerebral artery is false?
It supplies the visual cortex
It is closely related to the 3rd cranial nerve
It is a branch of the basilar artery
It is connected to the circle of Willis via the superior cerebellar artery( Right)
When occluded may result in contralateral loss of field of vision
.................................
The posterior cerebral arteries are formed by the bifurcation of the basilar artery and is connected to the circle of Willis via the posterior communicating artery.
The posterior cerebral arteries supply the occipital lobe and part of the temporal lobe.
44
46- A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region.
Post operatively the patient has difficulty shrugging his left shoulder. What is the most likely reason?
Accessory nerve lesion
The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the shoulder, he may also have difficulty lifting his arm above his head.
45
47- A 45 year old man is undergoing a lymph node biopsy from the posterior triangle of his neck. Which structure forms the posterior border of this region?
Trapezius muscle
46
48- Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?
Accessory nerve
The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.
47
50- A 56 year old man is undergoing a carotid endarterectomy. The internal carotid artery is mobilised. How many branches does this vessel give off in the neck?
0
The internal carotid does not have any branches in the neck.
47
49- Which option is false in relation to the trigeminal nerve?
The nerve originates at the pons
The posterior scalp is supplied by the trigeminal nerve(Right)
The maxillary nerve exits via the foramen rotundum
The maxillary nerve is purely sensory
The motor root is not in the trigeminal ganglion
................................................
The posterior scalp is supplied by C2-C3.
48
51- From which of these foraminae does the opthalmic branch of the trigeminal nerve exit the skull?
Superior orbital fissure
Mnemonic:
Standing Room Only -Exit of branches of trigeminal nerve from the skull
V1 -Superior orbital fissure
V2 -foramen Rotundum
V3 -foramen Ovale
The opthalmic branch of the trigeminal nerve exits the skull through the superior orbital fissure.
49
52- An ENT surgeon is performing a radical neck dissection. She wishes to fully expose the external carotid artery. To do so she inserts a self retaining retractor close to its origin. Which of the following structures lies posterolaterally to the external carotid at this point?
Internal carotid artery
The internal carotid artery lies posterolaterally to the external carotid artery at it's origin from the common carotid. The superior thyroid, lingual and facial arteries all arise from its anterior surface.
50
53- A 28 year old man has a pleomorphic adenoma and the decision is made to resect this surgically. Which of the following structures is least likely to be encountered during surgical resection of the parotid gland?
Mandibular nerve
...........................................
Structures passing through the parotid gland
. Facial nerve and branches
. External carotid artery (and its branches; the maxillary and superficial temporal)
· Retromandibular vein
· Auriculotemporal nerve
The mandibular nerve is well separated from the parotid gland.
The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs through the parotid gland.
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating (Freys Syndrome).
The facial nerve branch is the marginal mandibular branch and this is related to the gland.
51
54- Which of the following nerve roots contribute nerve fibres to the ansa cervicalis?
C1, C2 and C3
The ansa cervicalis is composed of a superior and inferior root, derived from C1, C2 and C3. The superior root arises where the nerve crosses the internal carotid artery. It descends anterior to the carotid sheath in the anterior triangle. It is joined in the region of the mid neck by the inferior root. The inferior root may pass either superficially or deep to the internal jugular vein.
52
55- At which of the following vertebral body levels does the common carotid artery typically bifurcate into the external and internal carotid arteries?
C4
It terminates at the upper border of the thyroid cartilage, Which is usually located at C4.
53
56- A 21 year old man is hit with a hammer and sustains a depressed skull fracture at the vertex. Which of the following sinuses is at risk in this injury?
Superior sagittal sinus
The superior sagittal sinus is at greatest risk in this pattern of injury. This sinus begins at the front of the crista galli and courses backwards along the falx cerebri. It becomes continuous with the right transverse sinus near the internal occipital protuberance.
54
57- A 22 year old man undergoes a superficial parotidectomy for a pleomorphic adenoma. The operation does not proceed well and a diathermy malfunction results in division of the buccal branch of the facial nerve. Which of the following muscles will not demonstrate impaired function as a result?
Mentalis
Buccal branch supplies:
Zygomaticus minor: Elevates upper lip
Risorius: Aids smile
Buccinator: Pulls corner of mouth backward and compresses cheek
Levator anguli oris: Pulls angles of mouth upward and toward midline
Orbicularis: Closes and tightens lips together
Nasalis: Flares nostrils and compresses nostrils
55
58- An 18 year old man is stabbed in the neck and has to undergo repair of a laceration to the internal carotid artery. Post operatively he is noted to have a Horners syndrome. Which of the following will not be present?
Loss of sweating on the entire ipsilateral side of the face
The anhidrosis will be mild as this is a distal lesion and at worst only a very limited area of the ipsilateral face will be anhidrotic.
56
59- During a carotid endarterectomy the internal carotid artery is cross clamped. Assuming that no shunt is inserted, which of the following vessels will not have diminished or absent flow as a result?
Anterior cerebral artery
Ophthalmic artery
Middle cerebral artery
Maxillary artery(Right)
None of the above
..................................
Mnemonic for branches of the cerebral portion of the internal carotid artery 'Only Press Carotid Arteries Momentarily'
Only = Opthalmic
Press = Posterior communicating
Carotid = Choroidal
Arteries = Anterior cerebral
Momentarily = Middle cerebral
The maxillary artery is a branch of the external carotid artery.
57
60- Which of the following structures separates the intervertebral disks from the spinal cord?
Posterior longitudinal ligament
The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of the intervertebral disks.
58
61- Which of the following muscles is supplied by the external laryngeal nerve?
Transverse arytenoid
Cricothyroid(Right)
Thyro-arytenoid
Posterior crico-arytenoid
Oblique arytenoid
.............................................
The others are all supplied by the recurrent laryngeal nerve.
59
62- A man is stabbed in the chest to the right of the manubriosternal angle. Which structure is least likely to be injured in this case?
Right pleura
The trachea
Right phrenic nerve
Right recurrent laryngeal nerve( Right)
Brachiocephalic vein
.........................................
The right recurrent laryngeal nerve branches off the right vagus more proximally and arches posteriorly round the subclavian artery. So of the structures given it is the least likely to be injured.
60
63- A 24 year old man is involved in a fight and his face is cut with a knife. The wound lies immediately anterior to the tragus of the ear and extends anteriorly. The wound is surgically explored and the laceration is found to be mainly superficial. It extends slightly more deeply immediately inferior to the main trunk of the facial nerve. Bleeding is observed, from which of the following is it most likely to originate?
Retromandibular vein
The retromandibular vein lies slightly more deeply than the facial nerve in the parotid gland. It is formed from the maxillary and superficial temporal vein.
61
62
65- A 23 year old lady with sialolithiasis of the submandibular gland is undergoing excision of the gland.
Which of the following nerves is at risk as the duct is mobilised?
Lingual nerve
The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.
63
66- Which nerve lies medially on the thyroid gland, in the groove between the oesophagus and trachea?
Recurrent laryngeal nerve
The recurrent laryngeal nerve may be injured at this site during ligation of the inferior thyroid artery.
64
67- Which of the following statements relating to the Cavernous Sinus is false?
The pituitary gland lies medially
The internal carotid artery passes through it
The temporal lobe of the brain is a lateral relation
The mandibular branch of the trigeminal and optic nerve lie on the lateral wall(Right)
The ophthalmic veins drain into the anterior aspect of the sinus
..................................................
The veins that drain into the sinus are important as sepsis can cause cavernous sinus thrombosis. The maxillary branch of the trigeminal and not the mandibular branches pass through the sinus
65
68- Which of these muscles is innervated by the cervical branch of the facial nerve?
Platysma
The cervical branch of the facial nerve innervates platysma.
66
69- Which of the following is not a branch of the subclavian artery?
Superior thyroid artery( Right)
Vertebral artery
Thyrocervical trunk
Internal thoracic artery
Dorsal scapular artery
.................................
Mnemonic for the branches of the subclavian artery: VIT C & D
V ertebral artery
I nternal thoracic
T hyrocervical trunk
C ostalcervical trunk
D orsal scapular
Superior thyroid artery is a branch of the external carotid artery.
67
70- During a thyroidectomy the surgeons ligate the inferior thyroid artery. From which vessel does this structure usually originate?
Thyrocervical trunk
The inferior thyroid artery originates from the thyrocervical trunk. This is a branch of the subclavian artery.
68
71- Which of the following statements relating to the vertebral column is false?
There are 7 cervical vertebrae
The cervical and lumbar lordosis are secondary curves developing after birth due to change in
shape of the intervertebral discs
The lumbar vertebrae do not have a transverse process foramina
The lumbar vertebrae receive blood directly from the aorta
The spinous process is formed by the junction of the pedicles posteriorly( Right)
................................................................
The spinous process is formed by 2 laminae posteriorly.
69
73- A man develops an infection in his external ear. The infection is extremely painful. Which of the following nerves conveys sensation from this region?
Auriculotemporal nerve
Tensor tympania and stapedius are the only two muscles of the middle ear. Contraction of tensor tympani will tend to dampen the vibrations produced by loud sounds, it is innervated by a branch of the trigeminal nerve. The stapedius dampens movements of the ossicles in response to loud sounds and is innervated by a branch of the facial nerve.
The auriculotemporal nerve, which is derived from the mandibular branch of the trigeminal nerve supplies this area.
69
72- The following structures are closely related to the brachiocephalic artery except:
Trachea posteriorly
Right brachiocephalic vein
Inferior thyroid vein
Right recurrent laryngeal nerve( Right)
None of the above
.....................................
There is no brachiocephalic artery on the left, however the left brachiocephalic vein lies anteriorly to the roots of all the 3 great arteries (including the brachiocephalic artery). The right recurrent laryngeal nerve has no relation to the brachiocephalic artery.
70
74- Which of the following does not pass through the superior orbital fissure?
Oculomotor nerve
Abducens nerve
Ophthalmic artery( Right)
Ophthalmic division of the trigeminal nerve
Ophthalmic veins
.....................................................
The ophthalmic artery, a branch of the internal carotid enters the orbit with the optic nerve in the canal.
71
75- Which of the following pairings of foramina and their contents is not correct?
Superior orbital fissure and the oculomotor nerve
Foramina rotundum and the maxillary nerve
Jugular foramen and the hypoglossal nerve( Right)
Foramina spinosum and the middle meningeal artery
Carotid canal and the internal carotid artery
.................................................
The hypoglossal nerve passes through the hypoglossal canal.
72
77- A 55 year old man with carcinoma of the larynx is undergoing a difficult laryngectomy. The surgeons divide the thyrocervical trunk, from which of the following vessels does this structure most commonly originate?
Subclavian artery
The thyrocervical trunk is a branch of the subclavian artery. It arises from the first part between the subclavian artery and the inner border of scalenus anterior. It branches off the subclavian distal to the vertebral artery.
73
76- A 25 year old man sustains a severe middle cranial fossa basal skull fracture. Once he has recovered it is noticed that he has impaired tear secretion. This is most likely to be the result of damage to which of the following?
Greater petrosal nerve
The greater petrosal nerve may be injured and carries fibres for lacrimation (see below).
74
78- Which structure is least likely to be found at the level of the sternal angle?
Left brachiocephalic vein
The left brachiocephalic vein lies posterior to the manubrium, at the level of its upper border. The sternal angle refers to the transition between manubrium and sternum and therefore will not include the left brachiocephalic vein.
75
79- What is the most useful test to clinically distinguish between an upper and lower motor neurone lesion of the facial nerve?
Raise eyebrow
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.
76
80- Which of the following nerves conveys sensory information from the laryngeal mucosa?
Glossopharyngeal
Laryngeal branches of the vagus( Right)
Ansa cervicalis
Laryngeal branches of the trigeminal
None of the above
...................................................
The laryngeal branches of the vagus supply sensory information from the larynx.
76
81- A 22 year old man is involved in a fight and sustains a skull fracture with an injury to the middle meningeal artery. A craniotomy is performed, and with considerable difficulty the haemorrhage from the middle meningeal artery is controlled by ligating it close to its origin. What is the most likely sensory impairment that the patient may notice post operatively?
Parasthesia of the ipsilateral external ear
The auriculotemporal nerve is closely related to the middle meningeal artery and may be damaged in this scenario. The nerve supplied sensation to the external ear and outermost part of the tympanic membrane. The angle of the jaw is innervated by C2,3 roots and would not be affected. The posterior third of the tongue is supplied by the glossopharyngeal nerve.
77
82- Where is the vomiting centre located?
Medulla oblongata
ABC's of Non- GI causes of vomiting
Acute renal failure
Brain (Increased ICP)
Cardiac (Inferior MI)
DKA
Ears (labyrinthitis)
Foreign substances (Tylenol, theo, etc)
Glaucoma
Hyperemesis Gravidarum
Infections (pyelonephritis, meningitis)
78
Which of the following statements relating to the basilar artery and its branches is false?
The superior cerebellar artery may be decompressed to treat trigeminal neuralgia
Occlusion of the posterior cerebral artery causes contralateral loss of the visual field
The oculomotor nerve lies between the superior cerebellar and posterior cerebral arteries
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery ( Right)
The labyrinthine branch is accompanied by the facial nerve
..................................................
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery. The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies the facial and vestibulocochlear nerves into the internal auditory meatus. The posterior cerebral artery is often larger than the superior cerebellar artery and it is separated from the vessel, near it's origin, by the oculomotor nerve. Arterial decompression is a well established therapy for trigeminal neuralgia.
78
84- Which of the following structures is not closely related to the carotid sheath?
Sternothyroid muscle
Sternohyoid muscle
Hypoglossal nerve
Superior belly of omohyoid muscle
Anterior belly of digastric muscle( Right)
.....................................
At its lower end the carotid sheath is related to sternohyoid and sternothyroid. Opposite the cricoid cartilage the sheath is crossed by the superior belly of omohyoid. Above this level the sheath is covered by the sternocleidomastoid muscle. Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid. Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.
78
85- Which of the following is not a branch of the external carotid artery?
Facial artery
Lingual artery
Superior thyroid artery
Mandibular artery( Right)
Maxillary artery
.......................................
External carotid artery branches mnemonic:
'Some Angry Lady Figured Out PMS'
Superior thyroid (superior laryngeal artery branch)
Ascending pharyngeal
Lingual
Facial (tonsillar and labial artery)
Occipital
Posterior auricular
Maxillary (inferior alveolar artery, middle meningeal artery)
Superficial temporal
79
87- A 21 year old develops tonsillitis. He is in considerable pain. Which of the following nerves is responsible for the sensory innervation of the tonsillar fossa?
Glossopharyngeal nerve
The glossopharyngeal nerve is the main sensory nerve for the tonsillar fossa. A lesser contribution is made by the lesser palatine nerve. Because of this otalgia may occur following tonsillectomy.
79
86- Which of the following pairings are incorrect?
Aortic bifurcation and L4
Transpyloric plane and L1
Termination of dural sac and L4 ( Right)
Oesophageal passage through diaphragm and T10
Transition between pharynx and oesophagus at C6
..............................................
Vena cava T8 (eight letters)
Oesophagus T10 (ten letters)
Aortic hiatus T12 (twelve letters)
It terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.
80
88- A young child undergoes a difficult craniotomy for fulminant mastoiditis and associated abscess. During the procedure the trigeminal nerve is severely damaged within Meckels cave. Which deficit is least likely to be present?
Anaesthesia over the ipsilateral anterior aspect of the scalp
Loss of the corneal reflex
Weakness of the ipsilateral masseter muscle
Anaesthesia of the anterior aspect of the lip
Anaesthesia over the entire ipsilateral side of the face(Right)
.....................................................
The angle of the jaw is not innervated by sensory fibres of the trigeminal nerve and is spared in this type of injury.
Remember the trigeminal nerve provides motor innervation to the muscles of mastication. The close proximity of the site of injury to the motor fibres is likely to result in at least some compromise of motor muscle function.
81
90- A 63 year old man is admitted with severe headache, nausea and recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to have diplopia. Which of the cranial nerves listed accounts for the latter?
Abducens
The long intracranial course of this nerve makes it susceptible to damage early in the course of raised ICP.
82
89- Which of the following is not a content of the anterior triangle of the neck?
Vagus nerve
Submandibular gland
Phrenic nerve( Right)
Internal jugular vein
Hypoglossal nerve
..........................................
The phrenic nerve is a content of the posterior triangle. The anterior triangle contains the carotid sheath and its contents.
83
91- Which of the following cranial foramina pairings are incorrect?
Carotid canal and internal carotid artery.
Foramen ovale and mandibular nerve.
Optic canal and ophthalmic artery.
Optic canal and ophthalmic nerve.( Right)
Foramen rotundum and maxillary nerve.
............................................................
The optic canal transmits the optic nerve. The ophthalmic nerve traverses the superior orbital fissure.
84
92- A 22 year old man is undergoing an endotracheal intubation. Which of the following vertebral levels is consistent with the origin of the trachea?
C6
The trachea commences at C6. It terminates at the level of T5 (or T6 in tall subjects in deep inspiration).
85
93- A 44 year old lady is recovering following a transphenoidal hypophysectomy. Unfortunately there is a post operative haemorrhage. Which of the following features is most likely to occur initially?
Bi-temporal hemianopia
The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm in the same manner as an expanding pituitary tumour.
86
94- Which of the following is not considered a major branch of the descending thoracic aorta?
Bronchial artery
Mediastinal artery
Inferior thyroid artery( Right)
Posterior intercostal artery
Oesophageal artery
...................................................
The inferior thyroid artery is usually derived from the thyrocervical trunk, a branch of the subclavian artery.
87
95- A 45 year old man sustains a significant head injury and a craniotomy is performed. The sigmoid sinus is bleeding profusely, into which of the following structures does it drain?
Internal jugular vein
The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.
88
96- In which of the following cranial bones does the foramen spinosum lie?
Sphenoid bone
The foramen spinosum (which transmits the middle meningeal artery and vein) lies in the sphenoid bone.
88
97- A 34 year old lady undergoes a thyroidectomy for Graves disease. Post operatively she develops a tense haematoma in the neck. In which of the following fascial planes will it be contained?
Pretracheal fascia
The pretracheal fascia encloses the thyroid and is unyielding. Therefore tense haematomas can develop.
89
98- A 45 year old man presents with a lipoma located posterior to the posterior border of the sternocleidomastoid muscle, approximately 4cm superior to the middle third of the clavicle. During surgical excision of the lesion troublesome bleeding is encountered. Which of the following is the most likely source?
External jugular vein
The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian vein. During surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may result. The internal jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of the subclavian artery is also a content of the posterior triangle
90
100- Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?
Cervical sympathetic chain
The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.
91
99- A 64 year old man has a suspected lymphoma and lymph node biopsy from the posterolateral aspect of the right neck is planned. Which of the nerves listed is at greatest risk?
Accessory
The accessory nerve has a superficial course and is easily injured. It lies under platysma and may be divided during the early part of the procedure.
92
101- A 43 year old lady underwent an attempted placement of a central line into the internal jugular vein. Unfortunately, the doctor damaged the carotid artery and this necessitated surgical exploration. As the surgeons incise the carotid sheath a nerve is identified lying between the internal jugular vein and the carotid artery. Which of the following is this nerve most likely to be?
Vagus
The vagus lies in the carotid sheath. The hypoglossal nerve crosses the sheath, but does not lie within it.
93
102- A motorcyclist is injured in a road traffic accident and is not wearing a helmet. He suffers a severe closed head injury and develops raised intracranial pressure. The first cranial nerve to be affected by this process is likely to be:
Abducens
The abducens nerve (CN VI) has a long intra cranial course and is thus susceptible to raised intra cranial pressure. It also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.
94
103- Which of the following is the first vessel to branch from the external carotid artery?
Superior thyroid artery
Mnemonic
(Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like (Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)
The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk. The other branches are illustrated below.
95
104- A 53 year old man is to undergo a thyroidectomy. Which nerve is at greatest risk?
Recurrent laryngeal
Recurrent laryngeal nerve injury may complicate thyroid surgery in up to 1-2% of cases.
96
105- A patient presents to the clinic following a surgical procedure. She complains that she is unable to shrug her shoulder. What is the most likely underlying nerve injury?
Accessory nerve
The accessory nerve may be injured in operations in the posterior triangle. Injury will affect trapezius.
97
106- Which of the following structures is not transmitted by the jugular foramen?
Hypoglossal nerve( Right)
Accessory nerve
Internal jugular vein
Inferior petrosal sinus
Vagus nerve
.............................................
Contents of the jugular foramen:
Anterior: inferior petrosal sinus
Intermediate: glossopharyngeal, vagus, and accessory nerves
Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries
The jugular foramen may be divided into three compartments:
· Anterior compartment transmits the inferior petrosal sinus
. Middle compartment transmits cranial nerves IX, X and XI
. Posterior compartment transmits the sigmoid sinus
98
107- Which of the following statements relating to the root of the neck is false?
The lung projects into the neck beyond the first rib and is constrained by Sibson's fascia
The subclavian artery arches over the first rib anterior to scalenus anterior( Right)
The trunks of the brachial plexus lie posterior to the subclavian artery on the first rib
The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles
The thyrocervical trunk is a branch of the subclavian artery
....................................................
The subclavian artery lies posterior to scalenus anterior, the vein lies in front. Sibson's fascia is another name for the suprapleural membrane.
99
108- Following a carotid endarterectomy a man notices that he has a weakness of his tongue. Damage to which of the following nerves is the most likely explanation for this process?
Hypoglossal
The hypoglossal nerve innervates the tongue and is one of the structures more commonly at risk in carotid surgery.
100
109- A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:
Common carotid artery
The common carotid artery is a lateral relation of the inferior parathyroid.
101
110- A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?
Optic tract
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion
Unfortunately we thought as surgeons we could forget about visual field defects! However the college seem to like them. Remember a homonymous hemianopia is indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or pituitary tumours.
102
111- The vertebral artery traverses all of the following except?
Transverse process of C6
Transverse process of the axis
Vertebral canal
Foramen magnum
Intervertebral foramen( Right)
....................................
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen
103
112- Where is a gomphoses type of fibrous joint typically found?
Teeth
104
113- Which of the following structures separates the subclavian artery from the subclavian vein?
Scalenus anterior
The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle of the first rib.
105
114- What is the sensory nerve supply to the skin overlying the angle of the jaw?
Greater auricular nerve (C2-C3)
The trigeminal nerve is the major sensory nerve to the face except over the angle of the jaw. The angle of the jaw is innervated by the greater auricular nerve.
106
115- Which of the following statements relating to the right phrenic nerve is false?
It lies deep to the prevertebral layer of deep cervical fascia
Crosses posterior to the 2nd part of the subclavian artery(right)
It runs on the anterior surface of the anterior scalene muscle
On the right side it leaves the mediastinum via the vena cava hiatus at a level of T8
The right phrenic nerve passes over the right atrium
106
116- A 20 year old man is hit with a hammer on the right side of the head. He dies on arrival in the emergency department. Which of these features is most likely to be found at post mortem?
Laceration of the middle meningeal artery
This will account for the scenario given where there is a brief delay prior to death. The other options are less acute and a supratentorial herniation would not occur in this setting.
107
117- During a radical neck dissection, division of which of the following fascial layers will expose the ansa cervicalis?
Pretracheal fascia
The ansa cervicalis lies anterior to the carotid sheath. It may be exposed by division of the pretracheal fascia at the posterolateral aspect of the thyroid gland. The pre vertebral fascia lies more posteriorly and division of the investing layer of fascia will not expose this nerve.
108
118- What is the arterial blood supply to the lacrimal apparatus?
Ophthalmic artery
The ophthalmic artery supplies the gland
109
119- Which of the nerves listed below is responsible for providing innervation to the lower molar teeth?
Inferior alveolar nerve
The branches of the lower molar and premolar teeth are supplied by branches of the inferior alveolar nerve. Those of the canine and incisors by the incisive branch of the same nerve. The gingiva and supporting structures are innervated by the lingual nerve.
109
120- An 18 year old man undergoes a tonsillectomy for attacks of recurrent acute tonsillitis. Whilst in recovery he develops a post operative haemorrhage. Which of the following vessels is the most likely culprit?
External palatine vein
The external palatine vein lies immediately lateral to the tonsil and if damaged may be a cause of reactionary haemorrhage following tonsillectomy.
110
121- Which of the following does not pass through the superior orbital fissure?
Lacrimal nerve
Abducens nerve
Opthalmic artery(right)
Trochlear nerve
Superior opthalmic vein
..............................................................
Mnemonic for the nerves passing through the supraorbital fissure:
Live Frankly To See Absolutely No Insult
Lacrimal
Frontal
Trochlear
Superior Division of Oculomotor
Abducens
Nasociliary
Inferior Division of Oculomotor nerve
The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the supratrochlear and dorsal nasal arteries.
111
122- A 45 year old lady develops severe back pain and on examination is found to have clinical evidence of an L5/ S1 radiculopathy. Her symptoms deteriorate and eventually a laminectomy is performed. During a posterior surgical approach the surgeons encounter a tough ligamentous structure lying anterior to the spinous processes. This structure is most likely to be the
Ligamentum flavum
112
123- Which cranial nerve supplies general sensation to the posterior third of the tongue?
Glossopharyngeal
The glossopharyngeal nerve supplies general sensation to the posterior third of the tongue and contributes to the gag reflex.
113
124- A 44 year old man is undergoing a parotidectomy and the surgeon is carefully preserving the facial nerve. Unfortunately his trainee then proceeds to divide it. Which of the following will not be affected as a result?
Taste sensation from anterior two thirds of the tongue(Right)
Closing the ipsilateral eyelid
Raising the ipsilateral side of the lip
Ipsilateral corneal reflex
None of the above
...............................................
The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event! The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or conjunctiva; the facial nerve initiates the motor response of the reflex.
114
125- Which of the following structures suspends the spinal cord in the dural sheath?
Denticulate ligaments
The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the dura mater.
115
126- Parasympathetic fibres innervating the parotid gland originate from which of the following?
Otic ganglion
Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.
116
127- An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:
Medial inferior surface of the frontal lobe
Corpus callosum
Medial surface of the frontal lobe
Olfactory bulb
Brocas area(right)
....................................................
Brocas area is usually supplied by branches from the middle cerebral artery.
117
128- At which of the following levels does the inferior thyroid artery enter the thyroid gland?
C6
118
129- Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
II
.....................................
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
The parasympathetic functions served by the cranial nerves include:
III (oculomotor): Pupillary constriction and accommodation
VII (facial): Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal): Parotid
X (vagus): Heart and abdominal viscera
The optic nerve carries no parasympathetic fibres.
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)
119
130- An elderly man develops a squamous cell carcinoma affecting the lobule of his ear. To which lymph node is the lesion most likely to metastasize?
Superficial cervical nodes
The lobule drains to the superficial cervical nodes.
120
131- Which of the following structures does not pass through the foramen ovale?
Lesser petrosal nerve
Accessory meningeal artery
Maxillary nerve (Right)
Emissary veins
Otic ganglion
.........................................
Mnemonic: OVALE
O tic ganglion
V3 (Mandibular nerve:3rd branch of trigeminal)
A ccessory meningeal artery
L esser petrosal nerve
E missary veins
121
132- A 10 year old child has a grommet inserted for a glue ear. What type of epithelium is present on the external aspect of the tympanic membrane?
Stratified squamous
The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in the development of middle ear infections when this type of epithelium may migrate inside the middle ear.
122
133- Where does the spinal cord terminate in neonates?
L3
At the 3rd month the foetus's spinal cord occupies the entire length of the vertebral canal. The vertebral column then grows longer exceeding the growth rate of the spinal cord. This results with the cord being at L3 at birth and L1-2 by adulthood.
123
134- A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
Aqueduct of Sylvius
The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.
124
135- A 43 year old man is due to undergo an excision of the sub mandibular gland. Which of the following incisions is the most appropriate for this procedure?
A transversely orientated incision 3cm below the mandible
To access the sub mandibular gland a transverse incision 3cm below the mandible should be made. Incisions located higher than this may damage the marginal mandibular branch of the facial nerve.
125
136- Which of the following is not a content of the cavernous sinus?
Oculomotor nerve
Internal carotid artery
Opthalmic nerve
Abducens nerve
Optic nerve(Right)
.............................................
Mnemonic for contents of cavernous sinus:
O TOM CAT
Occulomotor nerve (III)
Trochlear nerve (IV)
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Carotid artery
Abducent nerve (VI)
T
OTOM=lateral wall components
CA= components within sinus
The optic nerve lies above and outside the cavernous sinus.
126
137- In which space is a lumbar puncture performed?
Subarachnoid space
Samples of CSF are normally obtained by inserting a needle between the third and fourth lumbar vertebrae. The tip of the needle lies in the sub arachnoid space, the spinal cord terminates at L1 and is not at risk of injury. Clinical evidence of raised intracranial pressure is a contraindication to lumbar puncture.
127
138- A 22 year old man is undergoing a wedge excision of his great toenail. As the surgeon passes a needle into the area to administer local anaesthetic, the patient notices a sharp pain. By which pathway will this sensation be conveyed to the central nervous system?
Spinothalamic tract
Spinothalamic tract- Pain and temperature
Vestibulospinal tract- Motor neuronal signals relating to posture
Cuneate fasciculus- Fine touch, pressure and proprioception
Posterior spinocerebellar tract- Proprioceptive signals to cerebellum
Anterior corticospinal tract- Conveys motor signals from precentral gyrus to motor cells within the cord
Pain impulses are transmitted via the spinothalamic tract
128
139- Which of the structures listed below is not a content of the carotid sheath?
Internal jugular vein
Internal carotid artery
Vagus nerve
Recurrent laryngeal nerve( Right)
Common carotid artery
....................................................
Contents of carotid sheath:
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve
129
140- A cervical rib is due to which of the following?
Elongation of the transverse processes of the 7th cervical vertebra
Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.
130
141- Which of the following structures separates the subclavian artery and vein?
Anterior scalene muscle
The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the subclavian artery (posterior).
131
142- Which of the nerves listed below provides sensory innervation to the skin overlying the lateral aspect of the nose?
Lateral nasal branches of the ethmoidal nerve
The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal nerve. The ethmoidal nerve is a branch of the nasociliary nerve which is one of the divisions of the trigeminal.
131
143- A 35 year old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?
Subclavian vein
The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).
132
144- During a neck dissection, a nerve is noted to pass posterior to the medial aspect of the first rib. Which of the nerves listed below is this most likely to be?
Phrenic nerve
The key point is that the phrenic nerve runs posterior to the medial aspect of the first rib. Superiorly, it lies on the surface of scalenus anterior.
132
145- A 12 year old boy undergoes surgery for recurrent mastoid infections. Post operatively he complains of an altered taste sensation. Which of the following nerves has been injured?
Chorda tympani
The chorda tympani branch of the facial nerve passes forwards through itrs canaliculus into the middle ear, and crosses the medial aspect of the tympanic membrane. It then passes antero-inferiorly in the infratemporal fossa. It distributes taste fibres to the anterior two thirds of the tongue.
133
146- An 21 year old man undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia. Which nerve is responsible?
Glossopharyngeal
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
134
147- Which of the following nerves is most commonly damaged during a superficial parotidectomy?
Greater auricular
The greater auricular nerve and in particular its lobular branch is commonly injured in parotid surgery and consent usually makes particular reference to this. In a superficial parotidectomy, the facial nerve should not be injured and this is less common than a greater auricular nerve injury.
134
148- A 67 year old man undergoes a carotid endarterectomy and seems to recover well following surgery. When he is reviewed on the ward post operatively he complains that his voice is hoarse. What is the most likely cause?
Damage to the vagus
Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for a hoarse voice.
135
149- A 22 year old woman has recently undergone a surgical excision of the submandibular gland. She presents to the follow up clinic with a complaint of tongue weakness on the ipsilateral side to her surgery. Which nerve has been damaged?
Hypoglossal nerve
Three cranial nerves may be injured during submandibular gland excision.
· Marginal mandibular branch of the facial nerve
· Lingual nerve
· Hypoglossal nerve
Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor.
136
150- A 43 year old lady is undergoing a total thyroidectomy for an extremely large goitre. The surgeons decide that access may be improved by division of the infra hyoid strap muscles. At which of the following sites should they be divided?
In their upper half
Should the strap muscles require division during surgery they should be divided in their upper half. This is because their nerve supply from the ansa cervicalis enters in their lower half.
137
151- An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?
Pterygopalatine ganglion
The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.
138
152- Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?
Glottic(right)
Supraglottic
Subglottic
Transglottic
Aryepiglottic fold
........................................
The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed.
The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.
138
153- Which of the following cranial venous sinuses is unpaired?
Superior sagittal sinus
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The superior sagittal sinus is unpaired
The superior sagittal sinus is unpaired. It begins at the crista galli, where it may communicate with the veins of the frontal sinus and sometimes with those of the nasal cavity. It arches backwards in the falx cerebri to terminate at the internal occipital protuberance (usually into the right transverse sinus). The parietal emissary veins link the superior sagittal sinus with the veins on the exterior of the cranium.
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155- A 78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection?
Hypoglossal nerve
Nerves at risk during a carotid endarterectomy:
· Hypoglossal nerve
· Greater auricular nerve
· Superior laryngeal nerve
During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein and then the internal jugular is dissected exposing the common and the internal carotid arteries. The nerves at risk during the operation include:
· Hypoglossal nerve
. Greater auricular nerve
· Superior laryngeal nerve
The sympathetic chain lies posteriorly and is less prone to injury in this procedure.
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154- As regards the internal jugular vein, which of the following statements is untrue?
It lies within the carotid sheath
It is the continuation of the sigmoid sinus
The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein (right)
The hypoglossal nerve is closely related to it as it passes near the atlas
The vagus nerve is closely related to it within the carotid sheath
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156- A surgical resection specimen is analysed histologically. The pathologist comments that at the periphery of the resected specimen, oxyphil cells are identified. In which of the structures listed below are these cells typically found?
Parathyroid gland
Oxyphil cells are typically found in parathyroid glands
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157- A 21 year old man undergoes surgical removal of an impacted 3rd molar. Post operatively, he is noted to have anaesthesia on the anterolateral aspect of the tongue. What is the most likely explanation?
Injury to the lingual nerve
The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect of the tongue. The inferior alveolar nerve innervates the teeth themselves.
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158- A 73 year old man presents with a tumour at the central aspect of the posterior third of the tongue. To which of the following lymph node groups is it most likely to metastasise?
Bilateral deep cervical nodes
Posterior third tumours of the tongue commonly metastasise to the bilateral deep cervical lymph nodes
Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels may cross the median plane at this location.
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159- What is the correct embryological origin of the stapes?
Second pharyngeal arch
Embryological origin stapes = 2nd pharyngeal arch
The ectoderm covering the outer aspect of the second arch originates from a strip of ectoderm lateral to the metencephalic neural fold. The cartilaginous element to this, eponymously known as Reicherts cartilage extends from the otic capsule to the midline on each side. Its dorsal end separates and becomes enclosed in the tympanic cavity as the stapes.
The dorsal ends of the cartilages of the first and second pharyngeal arches articulate superior to the tubotympanic recess. These cartilages form the malleus, incus and stapes. At least part of the malleus is formed from the first arch and the stapes from the second arch. The incus is most likely to arise from the first arch.
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160-A 19 year old female is admitted with suspected meningitis. The House Officer is due to perform a lumbar puncture. What is the most likely structure first encountered when the needle is inserted?
Supraspinous ligament
