VIVA – Anatomy – Neck Flashcards

Question

**What are the components of the lower esophageal sphincter? (5 components)**

Answer 1

Mucosa Muscularis mucosa Circular muscular layer Longitudinal muscular layer Crural component from diaphragm

Answer 2

Angle of mandible to between heads SCM

Answer 3

In a line drawn from the angle of the mandible to the middle of the clavicle at the posterior border of the SCM

Answer 4

* Inferior petrosal sinus * Pharyngeal plexus * Common Facial vein * Lingual vein * Superior thyroid veins * Many potential variations

Answer 5

It divides into two branches: * an *anterior*, which passes forward and unites with the [anterior facial vein](http://en.wikipedia.org/wiki/Anterior_facial_vein) to form the [common facial vein](http://en.wikipedia.org/wiki/Common_facial_vein) * a *posterior*, which is joined by the [posterior auricular vein](http://en.wikipedia.org/wiki/Posterior_auricular_vein) and becomes the [external jugular vein](http://en.wikipedia.org/wiki/External_jugular_vein).

Answer 6

Formed by the junction of the posterior division of the [retromandibular vein](http://en.wikipedia.org/wiki/Retromandibular_vein) with the [posterior auricular vein](http://en.wikipedia.org/wiki/Posterior_auricular_vein).

Answer 7

Posterior external jugular Transverse cervical Suprascapular Anterior jugular vein

Answer 8

Deep to platysma Superficial to deep investing fascia, but pierces inferiorly to join subclavian

Answer 9

Commence under chin and run to suprasternal region Begins near the hyoid bone by the confluence of several superficial veins from the submaxillary region Its tributaries are some laryngeal veins, and occasionally a small thyroid vein Pierce deep fascia at suprasternal region entering suprasternal space and anastomose – may drain some of inferior thyroid vein here Run lateral under SCM to join EJV near termination

Answer 10

Deep to prevertebral musculature Emerge between middle and anterior scalenes

Answer 11

Compression at the [superior thoracic outlet](http://en.wikipedia.org/wiki/Superior_thoracic_outlet) wherein excess pressure placed on a neurovascular bundle passing between the [anterior scalene](http://en.wikipedia.org/wiki/Anterior_scalene) and [middle scalene](http://en.wikipedia.org/wiki/Middle_scalene) muscles. It can affect one or more of the nerves that innervate the [upper limb](http://en.wikipedia.org/wiki/Upper_limb) and/or [blood vessels](http://en.wikipedia.org/wiki/Blood_vessel) as they pass between the chest and upper extremity; specifically in the [brachial plexus](http://en.wikipedia.org/wiki/Brachial_plexus), the [subclavian artery](http://en.wikipedia.org/wiki/Subclavian_artery), and - rarely - the [subclavian vein](http://en.wikipedia.org/wiki/Subclavian_vein), which does not normally pass through the scalene hiatus. Causes = congenital (e.g. cervical 1^st rib), trauma, tumour

Answer 12

Originates anterior to the body of second lumbar vertebra, the cisterna chyli, and ascends, along the right side of vertebral column, through the aortic hiatus of the diagram into the posterior mediastinum, traveling between the aorta (to its L) and azygous vein (to its right) towards the fifth thoracic vertebra, where it crosses to the left and continues to ascend up into the neck. In the neck located to R of and behind L common carotid/vagus (ant to subclavian)à from here arches upwards, forwards and laterally 3-4cm above root of neck, passing between IJV and in front of ant scalene muscle and phrenic nerve Opens into IJV, subclavian or junction Ant to thyrocervical trunk and transverse cervical artery, superior to deep cervical fascia and phrenic Cross anterior to the vertebral, thyrocervical and subclavian arteries

Answer 13

Through aortic hiatus (T12)

Answer 14

Junction of IJV and subclavian (medial border anterior scalene)

Answer 15

Chemical composition of chyle is similar to that of tissue lymph, with higher concentration of cholesterol, phospholipids, and fat particles, particularly triglyceride rich chylomicrons and long-chain (\>10 carbon atoms) esterified fats.

Answer 16

* recognize injury to duct and search for it * head down/Valsalva if necessary (30mmHg pressure), cream down NGT, abdominal pressure * loupes * oversew surrounding tissues with silk (inflammatory reaction), ligar clip * local flap – pec/SCM * surgicel

Answer 17

* recognize it and confirm Dx with lab testing for chylomicrons * triglyceride in drain fluid – cholesterol:triglyceride ratio \<1 compated to plasma levels * CXR to rule out chylothorax * accurate measurement * nil by mouth or elemental diet with MTC (absorbed directly into portal system – less accessible and practical than fat free) * pressure dressing on neck * monitor fluid and nutritional state * consider TPN – increased risk of infection and venous thrombosis with TPN but likely more effective than low fat diet * octreotide – somatostatin analogue à nil prospective RCTs b/c low incidence – based on isolated cases and cohorts * if \>600ml/day for 5 days, \>1000ml/day from outset or Cx of ongoing leak – return to theatre * neck exploration and measures as above * thoracoscopic R side approach thoracic duct ligation – occlusion by mass ligation of tissue above supra-diaphragmatic hiatus between azygous vein and aorta

Answer 18

Pharyngeal tubercle anterior to foramen magnum in midline – pharyngeal raphe – receives fibres from the constrictors Passes laterally convex forward over longus capitis and back part of foramen lacerum to petrous temporal bone anterior to carotid canal Attachment to cartilaginous part of auditory tube Below eustacian tube orifice à sharp posterior border medial pterygoid plate Continues down to the hamulus of the plate

Answer 19

?Diminishes in thickness as it passes below superior constrictor to be absent by the level of the hard palate

Answer 20

Upper fibres of palatopharyngeus run horizontally from one side to the anterolateral edge of the aponeurosis on the other side via the posterior wall Forms a sphincter which when contracted causes posterior wall in pharynx to bulge (Passavant’s ridge) Some lower fibres from sup constrictor contribute Soft palate elevation closes nasopharynx

Answer 21

TVP Origin * Scaphoid fossa upper medial pterygoid plate * Lateral cartilaginous Eustacian tube * Spine of sphenoid LVP Origin * Quadrate area inferior surface apex petrous temporal bone, anterior to carotid canal Adjacent medial cartilaginous eustactian tube

Answer 22

* ? Levator Veli Palati (Medial to fascia) * ?TVP (Lateral to fascia) * ?Eustachian tube * ?ascending palatine artery

Answer 23

* Plugged by back of tongue * Stylopharyngeus passes into pharynx * Styloglossus,Glossopharyngeal and Lingual nerve pass to tongue

Answer 24

* Gap between middle and inferior constrictor anteriorly * Closed by thyrohyoid membrane – walls in piriform recess * Internal laryngeal nerve and superior laryngeal vessels pierce membrane

Answer 25

* RLN and inferior laryngeal vessels

Answer 26

* Stylopharyngeus * Deepest and highest * Passes nearly vertically down to larynx * Passes between ECA and ICA * Styloglossus * Arises from anterior inferior process * Stylohyoid * Arises high on posterior aspect * Passes superficial to both ECA and ICA

Answer 27

* Stylohyoid ligament emanates from it’s tip * Passes to lesser horn of hyoid * Stylomandibular Ligament * Thickening of deep lamina of parotid fascia * From vaginal process of tympanic temporal bone to angle of mandible

Answer 28

Hamulus à Mandible above post end mylohyoid line Ends at level of post border of last molar tooth

Answer 29

Triangular area in the wall of the [pharynx](http://en.wikipedia.org/wiki/Human_pharynx) between the thyropharyngeus part of the [inferior constrictor](http://en.wikipedia.org/wiki/Inferior_constrictor) of the pharynx and the [cricopharyngeus muscle](http://en.wikipedia.org/wiki/Cricopharyngeus_muscle), also of the inferior constrictor muscle of the pharnyx

Answer 30

Upper oesphagus below cricopharyngeus Post wall composed of circular fibres only as longitudinal fibres swinging laterally

Answer 31

Arises from lower part of cartilaginous eustacian tube Runs down to blend with palatopharyngeus and inserts of post border thyroid lamina

Answer 32

Arises from deep aspect styloid process high up Inserts on posterior border thyroid lamina

Answer 33

Common incidental benign midline nasopharyngeal mucosal cyst Forms as a result of retraction of the notochord where it contacts with the endoderm of the primitive pharynx. Initially is forms a small diverticula. Eventually inflammation results in obliteration of the mouth, resulting in a cyst. The cyst is lined by respiratory epithelium and accumulates with fluid with variable proteinaceous content.

Answer 34

* Transoral * Mandibulotomy (median, paramedian or lateral) * Mandibulectomy * Median translingual pharyngotomy * small midline BOT lesions * Suprahyoid pharyngotomy * small midline BOT lesions * Lateral pharyngotomy * tongue drop “Columbian neck tie

Answer 35

**Com**bined **m**andibular **and** **o**ral cavity resection + neck dissection

Answer 36

* Mainly via lower pole * Tonsillar Br of dorsal lingual a anteriorly (from lingual a) * Tonsillar Br of ascending palatine a posteriorly (from facial a) * Tonsillar br of facial a (Largest) – arches over upper border of styloglossus and pierces sup constrictor * Upper pole arterial supply * Ascending pharyngeal artery posteriorly * Lesser palatine artery anteriorly (via descending palatine from maxillary a)

Answer 37

* Reticular crypt epithelium * Perifollicular zone (rich in T-cells) * Mantle zone of follicle * Germinal centre of follicle * Efferent lymphatics only

Answer 38

Paratonsillar vein

Answer 39

Posterior pharyngeal wall Piriform fossae Post-cricoid region Lateral pharyngeal wall

Answer 40

* Inverted pyramid * From pharyngoepiglottic fold to inferior border of cricoid cartilage (commencement of cervical esophagus) * Aryepiglottic fold medially + arytenoid and cricoid cartilages * Thyroid cartilage anterolaterally * Medial pyriform mucosa forms post wall of paraglottic space à separated from endolarynx by AE folds and lat cricoarytenoid muscles * Thyrohyoid membrane superolaterally

Answer 41

Tensor veil palatini Levator palate Palatoglossus Palatopharyngeus Muscularis uvulae

Answer 42

* Origin * Scaphoid fossa upper medial pterygoid plate * Lateral cartilaginous Eustacian tube * Spine of sphenoid * Trianglular muscle passes down between pterygoid plates * Tendon turns medially around pterygoid hamulus above the origin of buccinators * Either attached to or flattens as the palatine aponeurosis

Answer 43

* Origin * Quadrate area inferior surface apex petrous temporal bone, anterior to carotid canal * Adjacent medial cartilaginous eustactian tube * Rounded belly inserts on nasal surface aponeurosis between 2 heads palatopharyngeus * Forms a “V” shaped sling

Answer 44

* Arises from undersurface palatine aponeurosis * Passes down to interdigitate with styloglossus

Answer 45

* Arises from 2 heads * Anterior from posterior border hard palate and anterior aponeurosis * Posterior head from posterior aspect palatine aponeurosis * Heads arch down and join running in palatopharyngeal fold with the lower part blending with the stylopharyngeus and salpingopharyngeus * Inserts mainly on posterior border thyroid lamina and horns

Answer 46

* 2 strips of muscle on upper surface aponeurosis * From posterior nasal spine of palatine bone to mucosa of uvula

Answer 47

* All supplied by pharyngeal plexus * Nucleus Ambiguus via cranial accessory nerve and pharyngeal branch of vagus * Exceptions * Tensor Palati = Br from nerve to medial pterygoid (V3) * Secretomotor via pterygopalatine ganglion running in lesser palatine nerves (Superior salivary nucleus / nervus intermedius / Greater petrosal) * Also carry taste * Sensation via lesser palatine (V2) * Slight overlap with CNIX * Gag reflex * CNIX afferent * CN X efferent

Answer 48

Palatopharyngeus

Answer 49

Anterior: Eustachean tube and levator veli palati muscle. Antero-laterally - TVP Posterior: Pharyngeal wall mucosa overlying the pharyngobasilar fascia and retro pharyngeal space, containing the retropharyngeal lymph nodes of Rouviere. Superior: Foramen lacerum, petrous apex, carotid canal posteriorly, and the foramina ovale and spinosum anterolaterally. ``` Postero lateral (apex): Carotid canal opening and petrous apex posteriorly, foramen ovale and spinosum laterally. Lateral: Tensor palati muscle, mandibular nerve and parapharyngeal space. ```

Answer 50

Sternomastoid Sterno-occipitalis Cleido-occipitalis Cleidomastoid

Answer 51

Between cleidomastoid (deep) and remaining parts

Answer 52

Epipericardial ridge - contains the mesodermal rudiments of the sternocleidomastoid, trapezius, and the infrahyoid and lingual musculature. The nerves of the epipericardial ridge are the hypoglossal and spinal accessory. The proliferation of mesoderm in this area eventually causes overgrowth and narrowing of the third, fourth, and sixth arches into an ectodermal pit, known as the cervical sinus of His

Answer 53

* Origin attachment lateral to sternohyoid at lateral inferior hyoid bone * Passes deep to SCM lying over carotid sheath and IJV where it forms a tendon held down by investing fascia * Runs back horizontally to attach to upper border scapula and transverse scapula lig à investing fascia secures

Answer 54

* Posterior Border SCM * Anterior border Trapezius * Clavicle * Roof = Investing layer deep cervical fascia * Floor = Prevertebral fascia

Answer 55

Splenius Levator scapulae Scalene post Scalene medius +/- Scalene ant / Serratus Ant / Semispinalis capitis

Answer 56

* Origin * Anterior tubercles C3-6 * Muscle passes forward and laterally under prevertebral fascia * Insertion is scalene tubercle and adjacent ridge of the inner upper surface 1^st rib.

Answer 57

* 15-20 horse-shoe shaped rings of hyaline cartilage, deficient posteriorly

Answer 58

* Total length 11cm * 5cm within neck * Stretches to ~15cm with inspiration

Answer 59

* Maximum length of segment to be rescted is 5-6cm (less in the elderly b/c less elasticity, short people)

Answer 60

* Older pts lose elasticity of annular ligaments à need releasing procedures when more than 1-2cm resected * Can release annular ligaments in young people à extra 2.5cm à place incision on one side of lat trachea above anastomosis and on opposite side below to preserve blood supply to both tracheal segments * Mobilisation procedures to allow tension free closure * Suprahyoid release – 5cm * Release of mylohoid, geniohyoid, genioglossus and stylohyoid ligament * Body of hyoid transected in the midline- to insertion of digastric tendon * Allows up to 5cm of release of larynx/trachea * Mediastinal mobilization of trachea – 6cm

Answer 61

* Shorter, wider and more vertical than (L)

Answer 62

Air trapping - early Atelectasis or consolidation - late Pneumothorax Pneumonia (several days after event) Comparison of inspiratory and expiratory CXRs may show inspiratory hypoinflation (atelectasis) and expiratory hyperinflation due to ball-valve effect à initially then proceeds to consolidation on lung Expiratory hyperinflation w/. mediastinal shift toward the normal side on expiration (ball-valve effect)

Answer 63

* Anterior Rami C1-4 * Lies in series with brachial plexus on scalene medius and behind the prevertebral fascia * NOT IN POSTERIOR TRIANGLE but lies under upper SCM * Receives * Grey rami communicans from superior cervical ganglion * Sensory Branches * Supply posterior fossa meninges, front and sides of neck, while also contributing to scalp, face and chest * C1-3 Meningeal branches * C1 ascend with hypoglossal * C1/2 ascend with vagus * C2/3 pass thru foramen magnum * Lesser Occipital Nerve (C2) * Hooks around accessory * Runs up on posterior border SCM * Supplies posterior upper neck and post-auricular region +/- Auricle * Greater Auricular Nerve (C2/3) * Passes vertically up lateral surface SCM * Supplies angle of mandible, preauricular region, parotid fascia, Cranial surface auricle and Lateral lower ½ auricle below EAC, mastoid skin * Transverse Cervical nerve (C2/3) * Curves around posterior border SCM * Pierces investing fascia * Supplies front of neck from chin to sternum via ascending and descending branches * Ascending branch may communicate with cervical branch facial nerve * Supraclavicular nerve (C3/4) * Exits posterior border SCM and branches (Medial, intermediate and lateral) * Supplies skin down to sternal angle, across R2 to ½ way down deletion and back along spine of scapula * Motor Branches * Segmental to prevertebral muscles * Longus capitis / Longus Coli / Scalenes * Thyrohyoid and Geniohyoid * Via C1 branch running with hypoglossal * C2/3 to SCM and C3/4 to trapezius * Mainly proprioceptive but some motor * Inferior root Ansa Cervicalis * Formed by C2/3 * Runs lateral to IJV * Descends to join superior root at Ansa * Superior root from C1 * Phrenic Nerve * C4 with C3/5 contributions * Runs vertically over scalene anterior under prevertebral fascia * Passes lateral to ascending cervical branch of Inferior thyroid atery * Behind Subclavian vein to enter mediastinum * Sometimes joined by accessory phrenic arising from nerve to subclavius below subclavian vein * Sole motor supply to Diaphragm * Sensory distribution to Diaphragm, pericardium, pleura and peritoneum

Answer 64

Loop of nerves that are part of the cervical plexus. It lies superficial to the internal jugular vein in the carotid triangle. Branches from the ansa cervicalis innervate three of the four infrahyoid muscles: the sternohyoid muscle, the sternothyroid muscle, and the omohyoid muscle. It does not innervate the thyrohyoid muscle, which receives its innervation from the ventral root of C1. Has 2 roots – superior root from C1 via hypoglossal, inferior root from C2-3

Answer 65

*Superior:* Temporal bone medial to foramen ovale (lateral to this is considered the infratemporal fossa) Sphenoid bone including the carotid canal, jugular foramen and hypoglossal foramen 3 bony landmarks * scaphoid fossa * spine of sphenoid * styloid process 3 fascia * pharyngobasilar fascia * tensor veli palatine fascia * medial pteryoid fascia *Inferior:* Posterior belly digastric and greater horn hyoid *Posterior:* Prevertebral fascia *Anterior:* Pterygomandibular raphe Medial pterygoid fascia *Medial:* Superior constrictor – fascia over Tensor and levator veli palatini muscles *Lateral:* Fascia over medial pteryoid Mandibular ramus Deep lobe of parotid Posterior digastric

Answer 66

Divisions: Separated by styloid process or fascia that extends from styloid process to tensor veli palatine *1. Pre-styloid compartment: Anterolateral* Contents: * Fat * Muscle: styloglossus and stylopharyngeus * Lymph nodes? * Deep lobe of parotid gland * Minor and ectopic salivary glands * Arteries: Internal maxillary, ascending pharyngeal * Veines: Pharyngeal venous plexus? * Nerves: Branches of the mandibular division of the trigeminal nerve namely inferior alveolar, lingual and auriculotemporal *2. Post-styloid compartment: Posteromedial* Contents: * ICA * IJV * CNs IX-XII * SNS chain * Lymph nodes * Glomus tissue

Answer 67

Salivary neoplasms – 90% pleomorphic Paragangliomas Neurogenic – mainly schwannoma

Answer 68

Transcervical-transparotid Transcervical Transoral Transcervical-transmandibular Infratemporal fossa

Answer 69

Mandibulotomy Division of stylomandibular ligament Removal/mobilization of SMG Excision of superficial parotid Ia, IIb dissection Removal of styloid Division of post belly of digastric

Answer 70

Trachea/oesphagus RLN Vagus Thoracic duct Sympathetic chain Vertebral artery Thyrocervical trunk Phrenic nerve Anterior scalene Brachial plexus Middle scalene

Answer 71

1^st part subclavian artery before is passes behind scalene anterior. Gives off 3 branches 1. Vertebral artery * Arises from upper convexity subclavian * Passes up to foramen of C6 1. Thyrocervical trunk * Arises lateral to vertebral artery * Divides into * Transverse cervical * Suprascapular * Inferior thyroid artery 1. Internal thoracic artery * Arises from lower surface * Passes down over apex of lung * Crosses phrenic 2^nd part lies behind scalene anterior * Costocervical trunk arises here * Divides into superior intercostal artery and deep cervical artery * Deep cervical artery passes up behind transverse process C7 and ascends to anastomose with occipital artery 3^rd part - Dorsal scapular artery arises here * Runs infront of scalene medius * Thru bnrachial plexus * Then passes deep to levator scap

Answer 72

Course divided into 4 parts *1^st part* * arise from 1^st part of subclavian artery * runs upward and backward between the [Longus colli](http://en.wikipedia.org/wiki/Longus_colli) and the [Scalenus anterior](http://en.wikipedia.org/wiki/Scalenus_anterior). * in front of it are the [internal jugular](http://en.wikipedia.org/wiki/Internal_jugular) and [vertebral veins](http://en.wikipedia.org/wiki/Vertebral_vein), and it is crossed by the [inferior thyroid artery](http://en.wikipedia.org/wiki/Inferior_thyroid_artery); the left vertebral is crossed by the [thoracic duct](http://en.wikipedia.org/wiki/Thoracic_duct) also. * Middle cervical ganglion is medial and anterior to artery * Stellate ganglion lies medial but posterior à connected by ansa subclavia *2^nd part* * second part runs upward through the [foramina](http://en.wikipedia.org/wiki/Vertebral_foramen) in the [transverse processes](http://en.wikipedia.org/wiki/Transverse_processes) of the C6 to C2 vertebræ * surrounded by branches from the inferior cervical sympathetic ganglion and by a plexus of veins which unite to form the vertebral vein at the lower part of the neck. *3^rd part* * at the C1 level, the vertebral arteries travel across the posterior arch of the [atlas](http://en.wikipedia.org/wiki/Atlas_(anatomy)) through the [suboccipital triangle](http://en.wikipedia.org/wiki/Suboccipital_triangle) before entering the [foramen magnum](http://en.wikipedia.org/wiki/Foramen_magnum) * The third part issues from the C2 foramen transversarium on the medial side of the [Rectus capitis lateralis](http://en.wikipedia.org/wiki/Rectus_capitis_lateralis). * further subdvided into the vertical part V3v passing vertically upwards, crossing the C2 root and entering the foramen transversarium of C1, and the horizontal part V3h, curving medially and posteriorly behind the [superior articular process of the atlas](http://en.wikipedia.org/w/index.php?title=Superior_articular_process_of_the_atlas&action=edit&redlink=1), the anterior ramus of the first cervical nerve being on its medial side; it then lies in the groove on the upper surface of the posterior arch of the atlas, and enters the vertebral canal by passing beneath the [posterior atlantoöccipital membrane](http://en.wikipedia.org/wiki/Posterior_atlanto%C3%B6ccipital_membrane). * This part of the artery is covered by the [Semispinalis capitis](http://en.wikipedia.org/wiki/Semispinalis_capitis) and is contained in the [suboccipital triangle](http://en.wikipedia.org/wiki/Suboccipital_triangle) *4^th part* * pierces the [dura mater](http://en.wikipedia.org/wiki/Dura_mater) and inclines medialward to the front of the [medulla oblongata](http://en.wikipedia.org/wiki/Medulla_oblongata) * placed between the [hypoglossal nerve](http://en.wikipedia.org/wiki/Hypoglossal_nerve) and the anterior root of the first cervical nerve and beneath the first digitation of the [ligamentum denticulatum](http://en.wikipedia.org/wiki/Ligamentum_denticulatum). * at the lower border of the [pons](http://en.wikipedia.org/wiki/Pons) it unites with the vessel of the opposite side to form the [basilar artery](http://en.wikipedia.org/wiki/Basilar_artery). * piercing the lateral angle of the posterior atlanto-occipital membrane. It deeply grooves the posterior arch of the atlas before entering the skull through the foramen magnum.

Answer 73

2 layers of investing fascia are the deficient in midline above their sternal attachments for 2-3cm – forming the Suprasternal Space of Burns. * Anterior jugular veins may lie in this space and anastomose heavily * Occasionally contains a LN

Answer 74

Subclavius, clavicle, subclavian vein, subclavian artery

Answer 75

* Superior cervical ganglion * 3cm long * Pregnaglionic fibres arise from upper 3 thoracic nerves via white rami communicantes * Lies at level of 2^nd/3^rd cervical vertebrae over longus capitus * Posteromedial to 1^st part of ICA * Inferior (nodose) ganglion of vagus lies anterior * Gives off grey rami communicantes to C1-4 nerves * Multiple branches to each nerve * Pierce longus capitus * Join muscular branches of cervical nerves 1-4 * Communications * Vagus * Hypoglossal * Branches * Internal Carotid Branch * Leaves upper end of nerve * Forms ICA plexus * Postganglionic fibres * Many fibres leave at cavernous sinus to reach the orbit * Distribute to Intracranial branches * Branches that form External Carotid Plexus * Superior Cervical cardiac nerve * Middle and Vertebral cervical ganglia * Small, inconsistent * Usually between inferior and superior ganglia but not always present * Middle Cervical Ganglia * Lies medial to carotid tubercle (C6) * Usually associated with inferior thyroid artery * Usually gives rise to supply to C5/6 nerves * Can be fused to the lower end of the superior ganglion * Gives off Middle cardiac nerve * Vertebral Ganglion * Aka Intermediate ganglion * Lower than middle ganglion anterior to the vertebral artery, close the the subclavian * Often connected to upper end of the inferior ganglion * Inferior lies behind or medial to the vertebral artery * Fibres pass either side of the artery * Ansa subclavia joins middle and inferior ganglia * Small trunk * Passes anterior to subclavian artery * May send a ramus to C8 * Inferior cervical ganglion * Aka Stellate / Cervicothoracic ganglion * Small mass when separate but often fused with first thoracic ganglion to form stellate ganglion * Anatomy * 1 x 0.5cm dimensions * Lies anterior to 1^st rib neck * Posterior or posteromedial to the vertebral artery * Behind subclavian artery * Branches * Inferior cervical cardiac nerve * Branches to vertebral ganglion * Ansa subclavia (preganglionic) fibres looping under then anterior to the subclavian * Usually joins vertebral or middle ganglion * Grey rami communicantes to C6-8 and T1 * May run up as vertebral nerve of vertebral artery

Answer 76

* Somatic (Grey) * Pass to all 8 cervical nerves * Superior ganglion to 1^st 4 * Middle to 5/6 * Inferior to 7/8 * Visceral Branches * One branch from each plexus to cardiac plexus * All branches pass behind common carotid and usually behind subclavian * Vascular branches * Superior ganglion to ICA and ECA * ICA branches via internal carotid nerve * Distributed to pterygopalatine ganglion and eyeball * Motor supply dilator pupillae * ECA branches accompany all vessels * Also supplies pharyngeal plexus, submandibular and otic ganglia * Middle ganglion gives branches to; * Subclavian artery * Inferior thyroid artery (Visceral only) * Inferior ganglion * Branch to vertebral artery (Somatic)

Answer 77

Interruption of cervical trunk at any level below superior ganglion leads to Horner’s syndrome * Temporary flushing * Absence of sweating (anyhdrosis) * Miosis * Ptosis of upper lid 1^st thoracic nerve gives majority of eye fibres à Sectioning below this level spares the eye

Answer 78

* bounded by rectus capitis posterior major and the superior and inferior oblique muscles * floor contains the posterior arch of the atlas and the posterior atlanto-occipital membrane. * across the floor runs the vertebral artery, and through the floor emerges the suboccipital (CI) nerve. * across the roof run the greater occipital (C2) nerve and the occipital artery. * Rectus capitis posterior major arises from the outer surface of the bifid spinous process of C2 vertebra and extends obliquely upwards and outwards to be attached to the lateral part of the area below the inferior nuchal line. Its action is to extend the head and rotate it (with the atlas) back towards its own side. * The inferior oblique (obliquus capitis inferior) is attached between the outer surface of the bifid spine of the axis (below rectus capitis posterior major) and the back of the lateral mass of the atlas. Its action is to rotate the atlas (and the skull with it) back towards its own side. * The superior oblique (obliquus capitis superior) extends from the back of the lateral mass of the atlas to the lateral part of the occipital bone between superior and inferior nuchal lines. Attached to atlas and skull it can only move one on the other—the movement is of lateral flexion of the skull combined with slight extension.

Answer 79

Completely envelopes Head & Neck from skull to chest Deep to platysma Creates submental, masticator and parotid spaces * Attachments * Ligamentum Nuchae /Vertebral spinous processes * Superior and Anterior * Hyoid bone * Lower border mandible – attaches on inner and outer surfaces * Mastoid process * External occipital protuberance and superior nuchal line * Zygoma. * Inferiorly * Scapula (spine and acromion) * Clavicle * Manubrium of sternum. * Laterally * Extends from greater cornu of hyoid and splits to enclose submandibular gland * Further posteriorly splits to enclose medial pterygoid and masseter and intervening angle/ramus of mandible à one portion along external surface of masseter to zygomatic arch and the other following inner surface of medial pterygoid to pterygoid plate * Splits to encircle trapezius (deep layer thicker) and sternomastoid while also forming the ligamentous sling for omohyoid inferiorly attaching it to the clavicle

Answer 80

Stylomandibular ligament

Answer 81

* This space lies between the alar fascia and the bucco-pharyngeal fascia (antero-superiorly covering constrictors) and antero-inferiorly – fascia covering the posterior aspect of the oesophagus * Continuous laterally with Parapharyngeal space * The alar layer of deep cervical fascia extends from BOS to second thoracic vertebra where it fuses with sheath of oesophagus (C6-T4) -?bifurcation of trachea

Answer 82

* Between the alar fascia and the prevertebral fascia is the danger space (Grodinsky) or prevertebral space. * BOS to diaphragm * Potential for rapid inferior spread of infection to the posterior mediastinum

Answer 83

* Behind prevertebral facia * Prevertebral space from BOS to coccyx – limited lat by attachment of prevertebral fascia to transverse processes

Answer 84

Buccopharyngeal fascia Ala fascia Prevertebral fascia

Answer 85

Investing layer in deep cervical fascia splits to surround mandible and mastication muscles thus forming this space. * Limited by * Anteriorly – attachment of fascia in front of muscles to mandible/maxilla * Superiorly – by origin of temporalis from skull * Superficially – by temporalis origin from temporalis fascia Freely communicates superomedially with temporal space medial to zygomatic arch

Answer 86

* mucosa overlying ascending ramus of mandible towards coronoid process * continuous with buccal mucosa lat and ant tonsillar pillar medially * superior extent = maxillary tuberosity * ant margin is post aspect of 2^nd molar

Answer 87

* Space at C2 more than half size of adjacent vertebral body on inspiration with neck extended * Widening of these soft tissues is pathologic until proven otherwise. Measuring at the level of C2, the distance from the anterior surface of the vertebrae to the posterior border of the airway should be 7 mm or less, regardless of the patient's age. At C6, this distance should be 14 mm or less in children younger than 15 years. A distance of 22 mm is considered normal in an adult. A simpler (but less precise) rule is that the soft tissue plain should be less than one half the width of the corresponding vertebral body * May reveal gas * Loss of normal C=spine lordosis * False positive if expiratory film or flexed neck

Answer 88

Children under 5. Retro pharyngeal space is the space most commonly affected by retropharyngeal abscesses – LNs tend to atrophy after age of 5 – nodes of Rouvier – nodes from BOS-C3

Answer 89

Origin is Mandible and maxilla adjacent molar teeth, pterygomandibular raphe and pterygomaxillary ligament Pterygomaxillary ligament extends from tip of hamulus to the nearest point of the tuberosity of the maxilla Extends to mandible just above posterior end of mylohyoid line Mandibular attachment is separated from the posterior attachment of the mylohyoid by lingual nerve Muscle converges on modiolus à Raphe fibres decussate

Answer 90

Ligamentous band of the buccopharyngeal fascia, attached superiorly to the hamulus of the medial pterygoid plate, and inferiorly to the posterior end of the mylohyoid line, of the mandible * Its *medial surface* is covered by the mucous membrane of the mouth * Its *lateral surface* is separated from the ramus of the mandible by a quantity of adipose tissue * Its *posterior border* gives attachment to the superior pharyngeal constrictor muscle * Its *anterior border* attaches to the posterior edge of the buccinator

Answer 91

Fibrous band extending from tip of hamulus to the nearest point of the tuberosity of the maxilla

Answer 92

Via trigeminal nerve * Zones of innervation meet at the margins of he eyelids and lips and curve upwards * Greater Auricular contributes to the area over the angle of mandible * Also provide proprioception to the muscles of the face

Answer 93

* Co-phenylcaine to nose * 1ml half way between the medial canthus and the glabella on each side down to the periosteum * anaethetizes the nasocillary nerve branches (external nasal and infratrochlear) and acts as a haematoma block.

Answer 94

External nasal nerve +/- infra-orbital

Answer 95

Supratrochlear

Answer 96

Supraorbital

Answer 97

Facial Vein =\> Cavernous Sinus * Via ophthalmic veins at medial canthus * When facial vein blocked, blood will flow via the orbit into cavernous sinus Deep Facial Vein =\> Pterygoid Plexus =\> Cavernous SInus

Answer 98

* Skin * Sebaceous glands ++ * Provides insertion for scalp muscles * Firm attachment via connective tissue to muscle and aponeurosis * Vessels / Nerves within the skin layer unite with those in aponeurosis layer * Connective Tissue * Aponeurosis * Occipitofrontalis muscle at front and back * Inserts into external occipital protruberance * Blends with temporoparietal fascia (superficial) to reach zygomatic arch * Loose Areolar tissue * Plane for “Scalping” * Allows scalp rotation flaps on vascular pedicle * Extends beneath orbicularis oculi into eyelids * Limited posteriorly by insertion of occipitalis * Pericranium Skull periosteum loosely attached except at sutures

Answer 99

* Roof = Temporalis fascia * Floor = Skull including pterion (frontal/Parietal/Squamous temporal bones articulate with greater wing sphenoid) * Lies over course of Middle Meningeal artery anterior branch * Anterior Wall = zygomatic process frontal bone, zygomatic bone, maxilla * Inferiorly becomes infratemporal fossa

Answer 100

From superior and inferior salivary nuclei Otic ganglion * Small body lying between tensor palati and mandibular nerve * Just below foramen ovale * 2-3mm diameter * Flat and closely applied to medial aspect of mandibular nerve * Function * Relay for parasympathetic secretomotor for the parotid ganglion * Input * Preganglionic fibres arise from * Lesser Petrosal branch of CNIX – from inferior salivar * May contain a few fibres from X via Arnolds nerve * Output * 3 motor branches of V3 closely associated with and sometimes pass thru the ganglion * Nerve to Medial Pterygoid * Nerve to tensor tympani * Nerve to tensor veli palatine * Consist of motor and proprioceptive fibres * Postgangionic fibres via Auriculotemporal nerve * Communicating twig from the sympathetic plexus of the middle meningeal artery

Answer 101

* Chief autonomic innervation of the nose * Largest parasympathetic ganglion * Triangular shape * Supplies * Lacrimal gland * Paranasal sinuses * Glands and mucosa of the nasal cavity / pharynx / gingiva / hard palate * Communicates anteriorly with the nasopalatine nerve * Functions are mainly vasodilation and secretion * Location * Immediately anterior to the opening of the pterygoid canal * Hence lies suspended from the Maxillary nerve (V2) * Large single trunk connects with V2 * Immediately adjacent sphenopalatine foramen * Just posterior to and slightly superior to the posterior end of the Middle turbinate * Roots * From superior salivary nucleus * Sensory Root * Typically multiple * Derived from sphenopalatine branches of V2 * Sensory fibres of Vidian nerve * Majority of fibres pass directly to palatine nerves but some pass thru the ganglion without synapse * Parasympathetic Root * Preganglionic fibres via Nervus Intermedius (CNVII) * Greater Superficial Petrosal nerve (Pre-synaptic) * Joins deep petrosal nerve in foramen laceum * Lies lateral to the ICA * Enters Vidian canal leaving as Vidian nerve * Synapse within ganglion * Sympathetic Innervation * Efferent post-ganglionic SNS fibres from the superior cervical ganglion * Travel thru Internal carotid plexus * Then via *deep petrosal nerve* * Joins GSPN to form nerve of pterygoid canal (Vidian) * Pass thru ganglion without synapse * Primarily vasoconstricting fibres * Post-Ganglionic Branches * Distributed via branches of the trigeminal nerve * Sphenoid and posterior ethmoid sinuses * Nose * Palate * Upper pharynx * 5 branches distributed to the nose and palate * Each carries a mix of sensory, secretomotor and sympathetic * Secretomotor to the lacrimal gland join V2, pass to zygomatic branch in the orbit then join lacrimal branch of ophthalmic nerve * Remaining fibres are sensory and pass directly thru the ganglion * Branches include * Orbital Branches * 2-3 twigs entering orbit via IOF * Run up to posterior ethmoidal foramen * Pass to sphenoid and ethmoid sinuses * Nasopalatine nerve * Greater and Lesser Palatine nerves (x2) * Leave via Greater and Lesser palatine foramen * GP gives off posterior nasal nerves to supply lower posterior nasal cavity * LP supplies soft palate and twigs to tonsil * Pharyngeal Branch * Passes back and medially * Distributed to upper pharynx, sphenoid and posterior choanae

Answer 102

* Minute body ~2mm diameter * Lies on lateral side of optic nerve, medial to the lateral rectus * Anterior to ophthalmic artery * 8mm from apex of orbit * Associated with the Nasociliary and Oculomotor nerves and closely associated with the ophthalmic artery or its branches which are also lateral to the nerve * Receives 3 incoming branches * Ramus Communicans from Nasociliary nerve (V1) * Passes thru without synapse to supply cornea, iris, sclera and ciliary body * SENSORY * Can include SNS fibres in some cases * Division abolishes corneal reflex * Sympathetic Ramus * Branch from carotid plexus within the cavernous sinus with cell bodies in superior cervical ganglion * Enters orbit via tendinous ring below nasociliary nerve * Can in some cases join CN III directly * Passes thru without synapse * Vasoconstrictor to orbital vessels * Oculomotor Root * Preganglionic fibres arise at the Edinger Westpal nucleus * Leave brainstem with CN III * Fibres concerned with pupil constriction and accommodation lie in the superior part of the nerve * Vulnerable to compression from above * Pass to the inferior division of the nerve then separate from the branch to inferior oblique * 35% have more than 3 branches with doubling of the oculomotor root the most common. * Ciliary Ganglion Branches (Short Ciliary Nerves) * Contain fibres from all 3 roots * 4-12 branches * Long ciliary nerves contain sensory and SNS fibres, Short ciliary nerves contain PNS, Sensory and SNS * Scattered ganglia and ganglion cells may be found along the short ciliary nerves * Pierce sclera around attachment of optic nerve * Majority go to ciliary body (Muscle) for accommodation * 3% go to sphincter pupillae * Only short ciliary nerves alter lens shape and pupil constriction

Answer 103

* Located suspended below lingual nerve * Preganglionic fibres travel within chorda tympani to join lingual nerve * Leave lingual nerve at level of submandibular gland * Post-Ganglionic fibres are distributed to the sublingual and submandibular glands * Actions * PNS – Watery secretions * SNS – Viscous secretions * ? distribution to serous v mucous cells * Note that the glands can function in a denervated state with only a reduction of function, not abolition * ? function related to variation in blood flow rather than innervation

Answer 104

Gustatory sweating * Skins sweat glands normally supplied by sympathetic fibers, which are divided during flap raising for parotidectomy * parasympathetic fibers to the gland via the AT nerve, also get disrupted * parasympathetic fibers regrow into severed axonal sheaths of the sympathetic nerves to provide an aberrant innervation of the sweat glands and blood vessels * stimulus for salivary flow caused sweating over the anterior skin flap

Answer 105

Faulty regeneration of parasympathetic fibres to lacrimal instead of salivary gland after Bells palsy Lacrimation after salivary stimulus

Answer 106

Palpebral part confined to the lids * Fibres arise from medial palpebral ligament * Arch across lids anterior to tarsal plates * Insert on lateral palpebral raphe * May also attach to posterior lacrimal crest and lacrimal sac * Contraction closes eyes gently “blinking” Orbital part extends beyond the bony orbit * Arises from anterior lacrimal crest and frontal process maxilla * Fibres circumscribe the orbital margin in concentric loops * Flat over forehead and cheek * Lowers eyebrow and forces lids together * Normally lateral lid come down before medial, helping spread lacrimal secretions medially

Answer 107

* Orbital septum forms the framework * Thickened at lid margins as tarsal plate * Dense fibrous tissue * Crescent shaped that curve with the eyeball * Eyelashes attach to tarsal plates * Contain Meibomian Glands * Modified sebaceous glands * Secrete oily substance minimising tear evaporation * Palpebral conjunctiva densely adherent to tarsal plates * Orbicularis oculi is anterior to the tarsal plate * Attaches to anterior lacrimal crest and margins of orbit * Septum thickens here as the medial palpebral ligament * Anchors tarsal plates to anterior lacrimal crest * Lateral palpebral ligament is thinner and fuses with raphe of orbicularis oculi * Attaches to marginal tubercle of Zygomatic bone * Palpebral fissure sits between the lids * Orbicularis Oculi * Palpebral part lies anterior to tarsal plates * Thin skin and loose fibrous tissue sit between the muscle and skin surface

Answer 108

Levator labii superioris, levator angular oris

Answer 109

* Atypical synovial Joint between head of mandible and mandibular fossa of squamous temporal bone * Fibrocartilaginous disc separates it into upper and lower cavities Joint surfaces covered with fibrocartilage

Answer 110

Because no hyaline cartilage in joint

Answer 111

* Attached to neck of mandible at articular margin * Superior attachment is to transverse prominence of articular tubercle and squamotympanic suture line * Between those two points it is strong but lax

Answer 112

* Lateral Temporomandibular Ligament * Passes down and back from zygomatic arch to posterior border of neck and ramus of mandible * Deep fibres blend with capsule * Becomes taut with movement away from resting position * Sphenomandibular Ligament * From spine of sphenoid to lingual of mandible * Lower attachment is at the axis of rotation of TMJ, hence constant length and tension in all TMJ movement

Answer 113

* in depression of the mandible (opening the jaw), there is not only a hinge movement of the head below the disc but also gliding movement of the disc on the articular tubercle * heads are pulled forwards by the lateral pterygoids and the chin is pulled down and back by the digastric muscles

Answer 114

Masseters, medial pterygoids and temporalis

Answer 115

In anterior dislocation, spasm of the masseter holds the head of the mandible tight against the articular tubercle; for reduction the operator's thumbs must first press downwards on the molar teeth to overcome this before guiding the head back into its fossa.

Answer 116

* Communicates with the Infratemporal fossa via the Pterygomaxillary fissure * Posterior aspect of maxilla is anterior margin * Pyramindal process of palatine bone is inferior margin * Lateral pterygoid plate is posterior margin * Zygomatic arch is superior margin * Medially the Perpendicular plate of the Palatine bone on the lateral nasal wall separates the maxilla and medial pterygoid plate * POSTERIOR = Sphenoid bone (root of pterygoid process) * Contents include * Pterygoid canal * Foramen Rotundum – greater wing * MEDIAL = Palatine bone * SPA foramen superiorly * ANTERIOR = Posterior wall of maxilla * ROOF = Body of sphenoid and orbital process of palatine bone

Answer 117

* Pterygomaxillary Fissure * Maxillary artery * Maxillary veins * Posterior superior alveolar nerve * Inferior Orbital fissure * Zygomatic nerve * Infraorbital nerve * Sphenopalatine foramen * SPA * SPV * Nasopalatine nerve * Lateral posterior superior nasal nerves * Foramen Rotundum * Maxillary nerve (V2) * Pterygoid canal / Foramen lacerum (below and medial to foramen rotundum) * Nerve of Pterygoid canal (Vidian nerve) * Greater Palatine foramen * Lesser palatine foramen * Palatovaginal Canal * Pharyngeal branch of pterygopalatine ganglion

Answer 118

Vascular structures superficial (and inferior)

Answer 119

* Meningeal * Anterior MCF sensation * Zygomatic * Arises in Pterygopalatine fossa * Runs above maxillary nerve to enter inferior orbital fissure * Runs along lower lateral aspect orbital wall and enters zygomatico-orbital foramen where it divides into 2 branches * Prior to division gives off a communicating branch to lacrimal nerve providing ecretomotor fibres to the lacrimal gland * Zygomaticofacial Nerve * Emerges from foramen on outer surface zygomatic bone * Supplies overlying skin * Zygomaticotemporal nerve * Emerges in temporal fossa via fossa on surface zygoma * Supplies skin over anterior temple at level of upper lid * Posterior Superior Alveolar Nerve * Runs thru pterygomaxillary fissure on posterior wall maxilla * Infraorbital * Enters orbit via Inferior Orbital fissure * Runs with infraorbital artery * Enters Infraorbital canal * Emerges thru infraorbital foramen beteen levator labii superioris and levator anguli oris * Immediately breaks into a tuft of branches * Palpebral branches to lower lid and cheek * Nasal branches to side of nose and ala * Labial branches to upper lip and gum * Many anastomoses with facial nerve branches * Nasopalatine nerve * Thru Sphenopalatine foramen * Crosses roof of nose * Distributed to septum and incisive gum of hard palate * Lateral posterior superior nasal nerve * Pass thru Sphenopalatine foramen * Supply posterosuperior quadrant of lateral nasal wall * Greater Palatine Nerve * Passes down thru greater palatine canal * Runs forward from greater palatine foramen to supply hard palate mucosa * Nasal branches supply post/inf lateral nasal wall and medial wall maxillary sinus * Lesser Palatine Nerves (2) * Pass down behind greater palatine nerve * Exit via lesser palatine foramen * Innervate soft palate and mucosa of palatine tonsil * Pharyngeal Nerve * Passes back thru palatovaginal canal * Emerges at roof of nose * Supplies mucosa of upper nasopharynx, sphenoid and ethmoid sinuses Orbital branches supply orbit periosteum

Answer 120

* Nasopalatine – through SPF, crosses roof of nose, distributed to septum and incisive gum of hard palate * Lateral posterior superior nasal – through SPF and turn forward to supply post-superior quadrant of lat wall of nose * Greater palatine – through greater palatine canal and at GPF turns forward to supply mucus membrane of hard palate – nasal branches supply post-inf quadrant of lat wall of nose + maxillary sinus * Lesser palatine x 2 – behind greater palatine, emerge in kisser palatine foramina behind crest of palatine à soft palate and tonsil * Pharyngeal nerve – palatatovaginal canal – upper nasopharynx – o * ?orbital branches to sphenoid and ethmoid

Answer 121

Endoscopic * large middle meatal antrostomy * SPA ligated * Bone removed anterior to SPA foramen Transmaxillary-transantral

Answer 122

From maxillary nerve * Upper molars = Posterior superior alveolar nerve * Upper Pre-molars = Middle superior alveolar nerve * Upper Canine and Incisors = Anterior superior alveolar nerve 

Answer 123

PSAN * rise from the trunk of the maxillary nerve just before it enters the infraorbital groove * generally two in number, but sometimes arise by a single trunk * runs thru pterygomaxillary fissure on posterior wall maxilla * descend on the tuberosity of the maxilla and give off several twigs to the gums and neighboring parts of the mucous membrane of the cheek * They then enter the alveolar canals on the infratemporal surface of the maxilla MSAN - drops from the infraorbital portion of the maxillary nerve ASAN * given off from the maxillary nerve just before its exit from the infraorbital foramen * descends in a canal in the anterior wall of the maxillary sinus, and divides into branches which supply the incisor and canine teeth

Answer 124

- Laterally, the septum is attached to the orbital margin, 1.5 mm in front of the lateral orbital tubercle attachment of the lateral palpebral ligament à Eisler fat pocket separates the lateral palpebral ligament from the orbital septum - from there, the septum continues along the superior orbital rim at the arcus marginalis - superomedially, the septum bridges the supraorbital groove, passes inferomedially anterior to the trochlea, and then follows the posterior lacrimal crest. As it runs down the posterior lacrimal crest, it lies anterior to the medial check ligament and posterior to the Horner muscle (and hence, behind the lacrimal sac). - line of attachment crosses the lacrimal sac fascia to reach the anterior lacrimal crest at the level of the lacrimal tubercle - from there, it passes inferiorly down the anterior lacrimal crest and laterally along the inferior orbital rim - a few millimeters lateral to the zygomaticomaxillary suture, the attachment leaves the rim and lies several millimeters from it on the facial aspect of the zygomatic bone, thus forming the fat-filled premarginal recess of Eisler. The line of attachment then continues to again reach the lateral orbital rim, just below the level of the Whitnall ligament. - blends with some fibres of levator palpebrae superioris superiorly

Answer 125

* Thickened at lid margins as tarsal plate * Dense fibrous tissue * Crescent shaped that curve with the eyeball * Eyelashes attach to tarsal plates * Contain Meibomian Glands * Modified sebaceous glands * Secrete oily substance minimising tear evaporation * Palpebral conjunctiva densely adherent to tarsal plates * Orbicularis oculi is anterior to the tarsal plate * Attaches to anterior lacrimal crest and margins of orbit * Septum thickens here as the medial palpebral ligament * Anchors tarsal plates to anterior lacrimal crest * Lateral palpebral ligament is thinner and fuses with raphe of orbicularis oculi * Attaches to marginal tubercle of Zygomatic bone * Palpebral fissure sits between the lids

Answer 126

* Superior division carries sympathetic fibres from the cavernous plexus to the visceral-muscle part of the levator * Inferior division gives off nerve to inferior oblique which gives off parasympathetic root to ciliary ganglion à cells bodies in Edinger Westphal nuclei

Answer 127

The initial clinical examination of the extraoccular eye muscles is done by examining the movement of the globe of the eye through the *six cardinal eye movements*. When the eye is turned in (nasally) and horizontally, the function of the medial rectus muscle is being tested. When it is turned out (temporally) and horizontally, the function of the lateral rectus muscle is tested. When turning the eye down and out, the inferior rectus is contracting. Turning the eye up and out relies on the superior rectus. Paradoxically, turning the eye up and in uses the inferior oblique muscle, and turning it down and in uses the superior oblique. All of these six movements can be tested by drawing a large "H" in the air with a finger or other object in front of a patient's face and having them follow the tip of the finger or object with their eyes without moving their head. Having them focus on the object as it is moved in toward their face in the midline will test *convergence*, or the eyes' ability to turn inward simultaneously to focus on a near object

Answer 128

Down and out

Answer 129

* MEDIAL * From Anterior to Posterior * Lateral surface of lateral pterygoid plate * Tensor and levator palate muscles * Superior constrictor * Pterygomaxillary fissure * Anterior to Pterygoid plate and posterior to maxilla * Communication with pterygopalatine fissure * LATERAL * Ramus of Mandible and Coronoid process * ANTERIOR WALL * Posterior surface of maxilla * Contains foramina for posterior superior alveolar nerves and vessels * Infraorbital fissure * Greater wing of Sphenoid * POSTERIOR * Upper part Carotid sheath * ROOF * Infratemporal surface of greater wing sphenoid (Medially) and adjacent Squamous temporal bone (?Petrous) in front of articular tubercle * Lateral roof is deficient (beyond infratemporal crest) and continuous with the temporal fossa

Answer 130

* Arises from 2 heads * Infratemporal surface skull * Lower lateral surface lateral pterygoid plate * Heads lie edge to edge and converge fusing into a common tendon * Insertion into pterygoid fovea below the medial mandibular head * Upper fibres pass to articular disc of TMJ and anterior joint capsule * Innervation is Anterior division Mandibular nerve (V3)

Answer 131

* Arises from 2 heads * Deep head (larger) – medial surface lateral pterygoid plate and fossa between it aand medial pterygoid plate * Diverges down from lateral pterygoid * Superficial head from tuberosity of maxilla and pyramidal process of palatine bone * Passes over lower margin lateral pterygoid * Fuses with main muscle * Runs down and back at 45deg to reach angle of mandible where it inserts on the border * Mylohyoid nerve runs deep to muscle adjacent mandible * Innervation via mandibular nerve

Answer 132

Terminal branch of ECA Course * Passes deep to neck of mandible and superficial to sphenomandibular ligament to enter infratemporal fossa à auriculotemporal nerve above and veins below * Deep to lower head lateral pterygoid then passes between both heads à highly variable * Passes through pterygomaxillary fissure to enter pterygopalatine fossa * Lies below maxillary nerve * Within pterygopalatine fossa it gives off 5 branches that pass with the branches of the pterygopalatine ganglion Divided into 3 parts by the lateral pterygoid muscle * 5 branches from each part * 1^st part (5 Branches) * Before the lateral pterygoid muscle * Inferior alveolar Artery (Mandibular foramen) * Runs down to inferior alveolar nerve * Supplies pulp of mandibular teeth * Mental branch from mental foramen * Middle meningeal artery (Spinosum) * Arises in Infratemporal fossa * Embraced by roots auriculotemporal nerve * Passes thru foramen spinosum to enter MCF * Passes laterally on MCF floor * Turns up over greater wing of sphenoid * Then divides into anterior and posterior branches * Accompanied by veins * Frontal branch towards pterion then vertx * No supply to brain, only bones of the skull vault * Accessory meningeal artery (Ovale) * Dura of middle fossa and meckels cave * Trigeminal ganglion * Deep auricular artery * Supplies EAC * Passes between cartilage and bone * Anterior tympanic artery (Petrotympanic fissure) * ME and TM * 2^nd Part (5 Branches) * Lateral pterygoid * Medial pterygoid * Deep temporal branches (2) * Masseteric * Lingual branch * Buccal branch * 3^rd part * Beyond lateral pterygoid within pterygopalatine fossa * Leaves fossa as Sphenopalatine artery * Posterior Superior Alveolar artery * Divides into dental branches which pierce posterior wall of maxilla separately – distributed to molar teeth and mucous membrane of maxillary sinus * Gingivival branch runs along alveolar margin up to 1^st molar * Greater palatine artery * Pharyngeal artery – palatovaginal * Artery of pterygoid canal * Infraorbital artery Passes thru infraorbital fissure with infraorbital nerve

Answer 133

V3 leaves foramen ovale * Deep to infratemporal head lateral pterygoid * Sits on Tensor Palati muscle * Otic ganglion applied to deep surface of nerve – 4cm deep to articular tubercle through mandibular notch * Divides into small Anterior (motor) and large Posterior (Sensory) branches

Answer 134

* 2 rootlets from the posterior division * Embrace the middle meningeal artery

Answer 135

Passes below lateral pterygoid on side wall of pharynx Passes between medial pterygoid and mandible Passes between pterygomandibular raphe and mylohyoid insertions Enters mouth on surface of mylohyoid by passing below the inferior border of superior constrictor at its’ mandibular attachment Lies against mandibular periosteum at 3^rd molar then runs on upper surface mylohyoid *à* Gives of gingival branch Runs deep between sublingual gland and mandible Passes under submandibular gland duct and runs forward on surface hyoglossus

Answer 136

Endoscopic Open – pre, post-auricular, facial POST AURICULAR TECHNIQUE * described by Fisch * 3 basic types * extratemporal facial nerve identification and superficial parotidectomy for Type A * follow upper branch only for Type B and C PREAURICULAR ITF APPROACH * can expose the upper cervical and intrapetrous ICA without facial nerve transposition * access same areas as Type B and C * frontotemporal craniotomy can be included if necessary for tumour clearance * no obliteration of EAC so middle ear function is preserved * Eustachian tube often sacrificed though resulting in chronic OM * more likely to need to resect mandibular condyle to access ICA * risk of traction injury to facial nerve so need monitoring * reflection of temporalis and zygoma allow access to ITF Advantage * shorter procedure as no drilling * lower risk of facial nerve injury Disadvantage * limited exposure to lesions that extend into the temporal bone or posterior fossa FACIAL TRANSLOCATION AND MAXILLOTOMY APPROACHES Gives unrivaled exposure of the middle cranial base, ITF, nasopharynx, PPF Disadvantage is facial incisions

Answer 137

* Recieves blood from the orbit, cranial vault and brain * Superior Ophthalmic Vein * Inferior Ophthalmic vein * Both also drain significant amouns of blood to the pterygoid plexus before reaching the anterior wall of the cavernous sinus * Sphenoparietal Sinus * Drains blood from skull vault in temporal region * Enters roof of sinus

Answer 138

Superior petrosal Sinus * Leaves superior posterior wall * Runs along upper border petrous temporal bone at attachment of tentorium cerebelli * Enters commencement of sigmoid sinus * Receives inner ear blood Inferior petrosal sinus * Larger and empties majority of cavernous sinus blood * Leaves posterior wall below Petroclinoid ligament * B/W apex of temporal bone and posterior clinoid process * Abducens either within or beside the sinus under the ligament * Runs down the side of the clivus * Enters anterior compartment of jugular foramen medial to CN IX * Joins IJV just below BOS Pterygoid plexus * Via an emissary vein usually passing thru foramen ovale (or venous foramen of Vesalius if present)

Answer 139

Because of its connections with the facial vein via the superior ophthalmic vein, it is possible to get infections in the cavernous sinus from an external facial injury within the Danger area of the face. In patients with thrombophlebitis of the facial vein, pieces of the clot may break off and enter the cavernous sinus, forming a cavernous sinus thrombosis. From there the infection may spread to the dural venous sinuses.Infections may also be introduced by facial lacerations and by bursting pimples in the areas drained by the facial vein Also from pterygoid plexus via vein in foramen ovale

Answer 140

* Hypoglossal nucleus adjacent midline in medulla on floor 4^th ventricle * Under hypoglossal trigone

Answer 141

* Leaves medulla via a series of rootlets between the pyramid and the olive * Rootlets unite to form 2 roots * Enter hypoglossal canal separately, divided by a septum of dura which occasionally ossifies but unite within

Answer 142

* Emerges from skull at Hypoglossal canal * Medial to ICA / IJV * Receives a branch from C1 anterior ramus * Spirals posterior to inferior ganglion of the vagus nerve * Exchanges branches with vagus / SNS

Answer 143

* Passes between ICA (Deep) and IJV (Superficial), deep to the posterior belly of the digastric and in doing so passes thru the carotid sheath * Passes deep to IJV in \<10% * It then descends on the carotid sheath, deep to styloid muscles and posterior belly digastric * It hooks around (under) the origin of the occipital artery (off ECA) and curves forward lateral to the ICA, ECA and Lingual arteries * Just below the posterior belly of digastric – 3-7mm * Just above the tip of the greater cornu of the hyoid. * Deep to digastric tendon and SMG * Runs forward on lower border hyoglossus deep to Mylohyoid, accompanied by veins draining the tip of tongue. * Note the lingual artery moves deep to hyoglossus. * Enters the mouth * Supplies all tongue muscles except Palatoglossus * At the anterior border of hyoglossus the trunk breaks into multiple radiating branches

Answer 144

Hooks around occipital artery

Answer 145

Thyrohyoid Geniohyoid All tongue muscles except palatoglossus

Answer 146

* All non-lingual branches are derived from C1 * Meningeal branch to posterior cranial fossa enters via hypoglassal canal * Superior root Ansa Cervicalis (C1) as it crosses ICA, curling around occipital artery * Joins inferior root * Run on IJV within the anterior layer of the carotid sheath * Nerve to Thyrohyoid (Also C1 @ Lingual a) * Nerve to Geniohyoid (@ mouth above mylohyoid) * Tongue branches * Tongue is derived from suboccipital myotome*s* * These pass between the carotid vessels deep to the IJV * Drag nerve with them

Answer 147

Tongue will deviate towards affected side on testing

Answer 148

Bulbar (cranial) motor fibres originate in lower nucleus ambiguous Spinal motor fibres from spinal nucleus of accessory nerve * Spinal fibres arise from C2/3/4 anterior horn * Enter posterior fossa via foramen magnum * Arise from rootlets posterior to the denticulate ligament which unite into a single trunk

Answer 149

Bulbar portion travels anterolaterally to exit lateral medulla in post-olivary sulcus inferior to CN IX and X à through basal cistern Bulbar and spinal portions join within lateral basal cistern

Answer 150

Pars vascularis of jugular foramen (middle section)

Answer 151

1cm above Erbs point Enters trapezius muscle 3-5cm above clavicle (lower 1/3) Under posterior belly of digastric Crosses the anterior /lateral surface of the IJV * 70% anterior * 26.8% posterior * 3.2% through Upper branch of occipital artery is a guide to the accessory nerve in front of the upper border of the SCM

Answer 152

Cervical plexus come from deep to fascia

Answer 153

Levator scapulae

Answer 154

Between cleidomastoid (deep) and remaining parts

Answer 155

Branches from C2 +/- 3 join in posterior triangle Branches from C3/4 join under trapezius

Answer 156

Contraction of one muscle produces the 'wry neck' position with the ear approaching the tip of the shoulder and the chin rotating to the opposite side

Answer 157

Has 3 nuclei within medulla * nucleus ambiguous – motor nerve * dorsal nucleus – innervate involuntary muscles * nucleus of tract solitaries – sensory nerve Sensory from regional meninges and ear project to spinal nucleus CN5

Answer 158

Pars vascularis (middle component)

Answer 159

* Meningeal Branch * C1/2 fibres which join the vagus as it exits the skull * Passes up from the superior ganglion * Supply to the posterior fossa dura below the tentorium * Auricular Branch (Arnold’s nerve) * Runs laterally thru a canaliculus in the lateral wall of the jugular foramen between the tympanic and mastoid temporal bones * Supplies * Posteroinferior quadrant of outer surface TM * Adjacent EAC skin * Corresponding skin behind auricle * Carotid Body Branch * Forms a plexus with the carotid sinus branch of the glossopharyngeal nerve * Pharyngeal Branch * Passes between ECA and ICA providing motor and sensory fibres to the pharyngeal plexus on middle constrictor muscle * Runs parallel and below CNIX * Fibres derived from cranial accessory nerve (nucleus ambiguous) * Supplies muscles of pharynx except stylopharyngeus and muscles of palate except tensor palati * Superior Laryngeal Nerve * Arises at inferior ganglion vagus near jugular foramen * Passes posterior and deep to ICA – travels medial to ICA and ECA * Divides into Internal and External laryngeal Nerves at approximately the level of the greater cornu of hyoid – may be before * Cervical Cardiac Branches Recurrent Laryngeal Nerve

Answer 160

Medial to both ECA and ICA

Answer 161

Passes between ECA and ICA

Answer 162

L lower cervical cardiac branch

Answer 163

Cell bodies for the meningeal (dura of post fossa) and auricular branch – parasympathetic and sensory

Answer 164

Has cell bodies for other sensory branches * Receives cranial root of Accessory nerve just above the inferior ganglion * Provides innervation for all striated muscle of the pharynx, soft palate, larynx and oesophagus

Answer 165

Tympanic branch (Jacobson’s nerve) * Leaves nerve at inferior ganglion * Passes thru tympanic canaliculus between jugular fossa and carotid canal * Supplies ME, mastoid air cells and bony eustacian tube with sensation as well as parasympathetic branches from the inferior salivary nucleus Carotid Nerve * Arises just below the ganglia * Runs down closely adherent to the ICA within the carotid sheath * Main supply to carotid sinus and body * Connections via nucleus of tractus solitarius with vasomotor/autonomic centres Nerve the Stylopharyngeus (Only muscular branch) * Cell bodies in nucleus ambiguous Pharyngeal Branches * Form pharyngeal plexus with the Vagus (Afferent) on middle constrictor * Pierce muscle and supply mucous membrane of oropharynx with sensation, taste and parasympathetic innervation from inferior salivary nucleus (relay in small ganglia in mucous membrane of pharynx) Tonsillar branch - Supplies mucosa over palatine tonsil with lesser palatine nerve Lingual branch * Sensation post 1/3 of tongue and taste * Sensation over same distribution * Secretomotor to posterior 1/3 glands - relay in small ganglia of mucous membrane

Answer 166

* Leaves anterior compartment jugular foramen * Creates a deep notch in the inferior petrous temporal bone via inferior ganglion just below IAM * Smaller superior * Contain cell bodies of most sensory fibres within the nerve * Posterior cranial fossa * Posterior 1/3 tongue, oropharynx, tonsil * **Tympanic branch (Jacobson’s nerve)** * Leaves nerve at inferior ganglion * Passes thru tympanic canaliculus between jugular fossa and carotid canal * **Carotid Nerve** * Arises just below the ganglia * Runs down closely adherent to the ICA within the carotid sheath * Passes down on ICA * Passes laterally between IJV and ICA then between ICA and ECA * Curves forward around lateral side of stylopharyngeus then passes parallel to inferior border of sytloglossus, below lower border of superior constrictor * Gives off **Nerve the Stylopharyngeus** (Only muscular branch) * Cell bodies in nucleus ambiguus * Passes behind posterior border hyoglossus to reach the tongue * Terminates as pharyngeal, tonsillar and lingual branches

Answer 167

* Curves forward around lateral side of stylopharyngeus then passes parallel to inferior border of sytloglossus, below lower border of superior constrictor

Answer 168

Pre-ganglionic = Inferior salivary nucleus in medulla * Via the glossopharyngeal nerve (travels through anterior part of jugular foramen) and petrosal ganglion * Tympanic branch given off outside skull (jacobsen’s nerve) * Enters middle ear through inferior tympanic canaliculus * Gives off hypotympanic branch in 50% (explaining why tympanic neurectomy may not work unless this branch is also sectioned) * Travels across the promontory (submucosal or bony groove or canal) * Rejoined by hypotympanic branch, then exits through superior tympanic canaliculus * Enters middle cranial fossa (outside dura) as lesser superficial petrosal nerve * Leaves skull through foramen ovale * Accompanies auriculotemporal nerve before passing to otic ganglion * Thin serous secretions Post – Ganglionic = Arise in Otic ganglion, run along auriculotemporal nerve * Synapses in otic ganglion * Then rejoins auriculotemporal nerve from where it is distributed to the parotid glandular tissue

Answer 169

* Abducens nucleus situated beneath the facial colliculus in the floor of the 4^th Ventricle. * Axons pass thru the pons in a ventrocaudal direction and emerge at the junction of the pons and the pyramids. * Some Inter-nuclei neurons are present to oculomotor nucleus to inhibit medial rectus. * Nerve leaves near ventral midline pontomedullary junction * Runs upwards thru pontine cistern between the Pons and AICA * Pierces the dura over the clivus inferolateral to the dorsum sellae. * Runs forward over the petrous temporal bone, passing over it’s apex à Dorello’s Canal * Passes into the posterior aspect of the cavernous sinus. * At this point it is lateral to the internal carotid artery and medial to the inferior petrosal sinus * Then moves below ICA * Leaves anterior wall of sinus via SOF

Answer 170

Pierces the dura over the clivus (basisphenoid) inferolateral to the dorsum sellae à to enter Dornello’s canal Within Dornello’s canal is surrounded by arachnoid

Answer 171

= Otorrhoea, CN 6 palsy, Retroorbital pain Likely due to inflammation in Dornello’s canal Can also get fever, facial palsy, hearing loss, vertigo, meningism Involvment of V, VII, VI

Answer 172

Osseo-fibrous canal between the petrous apex and the petrosphenoidal ligament Abducens runs within the canal within a meningeal tube à key restriction to movement

Answer 173

CN VI Inferior petrosal sinus

Answer 174

* Meningeal * Anterior MCF sensation * Zygomatic * Arises in Pterygopalatine fossa * Runs above maxillary nerve to enter inferior orbital fissure * Runs along lower lateral aspect orbital wall and enters zygomatico-orbital foramen where it divides into 2 branches * Prior to division gives off a communicating branch to lacrimal nerve providing ecretomotor fibres to the lacrimal gland * Zygomaticofacial Nerve * Emerges from foramen on outer surface zygomatic bone * Supplies overlying skin * Zygomaticotemporal nerve * Emerges in temporal fossa via fossa on surface zygoma * Supplies skin over anterior temple at level of upper lid * Posterior Superior Alveolar Nerve * Runs thru pterygomaxillary fissure on posterior wall maxilla

Answer 175

* Nasopalatine nerve * Thru Sphenopalatine foramen * Crosses roof of nose * Distributed to septum and incisive gum of hard palate * Lateral posterior superior nasal nerve * Pass thru Sphenopalatine foramen * Supply posterosuperior quadrant of lateral nasal wall * Greater Palatine Nerve * Passes down thru greater palatine canal * Runs forward from greater palatine foramen to supply hard palate mucosa * Nasal branches supply post/inf lateral nasal wall and medial wall maxillary sinus * Lesser Palatine Nerves (2) * Pass down behind greater palatine nerve * Exit via lesser palatine foramen * Innervate soft palate and mucosa of palatine tonsil * Pharyngeal Nerve * Passes back thru palatovaginal canal * Emerges at roof of nose * Supplies mucosa of upper nasopharynx, sphenoid and ethmoid sinuses Orbital branches supply orbit periosteum

Answer 176

Nasopalatine Lateral posterior superior nasal  

Answer 177

* Only nerve to emerge from the dorsum of the brainstem.

Answer 178

*Intracranial* * Trochlear nucleus is inferior to the oculomotor nucleus at the inferior colliculus level. * Fibres decussate within the midbrain and curve around the PAG and emerge below the inferior colliculus. * It is the only nerve to emerge from the dorsum of the brainstem. * Behind the inferior colliculus * The nerve passes lateral to the superior cerebral peduncle then moves around the midbrain into the middle cranial fossa. * It runs below the tentorium cerebella between the superior cerebellar arteries and posterior cerebral arteries. (within posterior fossa) * Lateral to Oculomotor nerve in interpeduncular cistern * The trochlear nerve then enters the roof of the cavernous sinus * Enters behind the oculomotor nerve * Crosses forwards in lateral wall * Enters SOF above and lateral to oculomotor nerve *Extracranial* * Enters the orbit via the superior orbital fissure superolateral to the tendinous ring. * Medial to the frontal nerve * Runs medially above Levator Palpebrae superioris * Terminates within the superior oblique muscle * Rotates and depresses the eyeball (Down and In)

Answer 179

Nerve to inferior oblique from inferior division

Answer 180

* Nuclei * Oculomotor Nucleus is situated in the Periaqueductal grey matter of the midbrain * Ventral to the aqueduct at the level of the Superior Colliculus. * Edinger-Westphal Nucleus is dorsal to the main oculomotor nucleus. * Superior rectus fibres appear to be crossed while inferior rectus, medial rectus and Inferior Oblique receive uncrossed fibres. * Inter-nuclear neurons pass in the medial longitudinal fasciculus to the trochlear and Abducens nuclei to inhibit antagonists * Myelinated axons curve ventrally thru the tegmentum, many passing thru the Red nucleus and emerge as rootlets along the side of the Interpeduncular fossa medial to the cerebral peduncle on the ventral brainstem. * It passes forward between the PCA and superior cerebellar arteries * just below and lateral to the posterior communicating artery * Below the free edge of the tentorium cerebelli, * Adjacent to the inferior temporal lobe. * Pierces the dura lateral to the posterior clinoid process to enter the roof of the cavernous sinus (initially on lateral wall). * As it descends medially it passes over the trochlear nerve and nasociliary branch of the ophthalmic division CN V. * Passes medial to these nerves * Gains SNS fibres from ICA Nerve for levator palpebrae superioris * Divides into superior and inferior divisions at the anterior end of the cavernous sinus. * Enters the orbit via the medial aspect of the SOF

Answer 181

* *located* at the junction of the body and greater wing of sphenoid, petrous apex and occipital bone * in the fresh state the *lower part* of this aperture is filled up by a layer of fibrocartilage à no major structure passes from cranial cavity to exterior * *transmits* ICA, deep petrosal nerve and greater petrosal nerve ® Vidian nerve, meningeal branch from the ascending pharyngeal artery and an emissary vein from the cavernous sinus to the pterygoid plexus

Answer 182

* *located* in the occipital bone * dura mater attached to margins * *transmits* the apical ligament of the odontoid process of axis, tectorial membrane, medulla and meninges, spinal part of CN XI, meningeal branches of upper cervical nerves, vertebral arteries, anterior spinal artery and posterior spinal arteries * lower medulla with spinal arteries and veins, vertebral arteries and spinal roots of CN XI transverse foramen in subarachnoid space * meningeal branches of vertebral artery and communicating veins from occipital sinuses to internal vertebral plexus lie outside dura * adherent to DM is tectorial membrane, then in front cruciform and then alar ligaments

Answer 183

Inf alveolar artery Periosteal (predominant around age 40, changeover occurs around 30)

Answer 184

Usually in line with **2^nd premolar** Mental nerve + vessels usually halfway bt sup and inf borders Infant (more inf as mandible full of teeth) Elderly (more sup as mandible regresses)

Answer 185

Last 2 molars

Answer 186

1) Closed vs compound 2) **Kazanjian + Converse** (according to teeth) Class I Teeth both sides of # line Class II Teeth one side of # Class III Edentulous 3) **Type** Favourable Muscle forces naturally bring fragments in good alignment Unfavourable Muscle forces naturally pull fragments apart

Answer 187

Condyle 35% Body 20% Angle 20% Symphysis 15% Other 10% Alveolus, Ramus, Coronoid Note: **50% are bilateral**

Answer 188

Sphenomandibular ligament

Answer 189

Odontogenic * Ameloblastoma * From enamel organ * Epi * 20-40yrs, except teenagers (unicystic) * esp. post mandible * male = female * Malignant variant exists * Local aggressive * Rx WLE (large margins) * Adenomatoid * From enamel epithelium of the dental follicle * Calcifying epithelial (Pindborg) * Assoc with unerupted teeth * Gorlin cyst * Neoplasm with cystic tendencies * Myxoma * Odontoma * Complex * Compound * Cementoblastoma Non odontogenic * Osteosarcoma * Chondrosarcoma * Fibrosarcoma * Myeloma * Mets Renal, breast, prostate Non neoplastic * Osteomyelitis, BIO, ORN * Cysts * Odontogenic * Dentigerous * 2˚ unerupted tooth * esp. 3^rd molars * Periapical * most common cyst * 2˚ infected tooth causing pulp necrosis * Primordial * Develops instead of a tooth * Residual * From tooth that have been removed * Gingival newborn * From dental lamina remnants * Keratocyst * aggressive, destructive * esp. Gorlin syndrome * Non * Stafne * aberrant salivary gland tissue * Traumatic * ? 2˚ intramedullary haemorrhage * Focal osteoporotic * Aneurysmal Other Fibrous dysplasia Brown tumour

Answer 190

**M**yxoma **A**meloblastoma **C**herubism **H**aemangioma **O**dontogenic keratocyst

Answer 191

Articulates pyramidal process palatine bone (+/- lat pterygoid plate), medial pterygoid muscle

Answer 192

Re-circulation

Answer 193

Lateral to lateral incisior

Answer 194

Descending palatine artery (upwards) and the nasopalatine nerve (downwards)

Answer 195

Nasopalatine nerves (left passing through anterior, right through the posterior)

Answer 196

Sharp petrosal margin, overhangs pterygoid canal

Answer 197

* *located* in the greater wing of sphenoid, perforate base of spine of sphenoid * *transmits* the middle meningeal vessels and meningeal branch of V1

Answer 198

Mandibular nerve (V3), lesser petrosal nerve (or petrosal foramen), accessory meningeal artery and an emissary vein from the cavernous sinus to the pterygoid plexus (or foramen of Vesalius)

Answer 199

(occasional) medial to foramen ovale Contents Vein from Cavernous sinus to pterygoid plexus

Answer 200

Sphenomandibular ligament

Answer 201

Medial Pharyngeal br of SPA

Answer 202

Lateral Pharyngeal nerve + pharyngeal br of IMAX

Answer 203

Petrosal foramen or foramen ovale

Answer 204

60% sellar (pneumatisation extends behind pit fossa) 30% Mixed 10% Presellar (reaches ant wall of pit fossa) 2% conchal (rudimentary sinus)

VIVA – Anatomy – Neck Flashcards

(266 cards)