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Saad Alqahtani, Twitter @saaddes

lymphatic system
Which of the following structures carry lymph into the node's subcapsular
sinus, through the cortical sinus and into the superficial cortex and para-
cortex?
efferent lymphatic vessels
afferent lymphatic vessels
both afferent and efferent lymphatic vessels
neither afferent or efferent lymphatic vessels
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afferent lymphatic vessels
Lymph nodes are small oval bodies enclosed in fibrous capsules. Lymph nodes con-
tain phagocytic cort ical t issue (reticular t issue) adapted to fi lter lymph. Specialized
bands of connective t issue, call ed trabeculae, divide t he lymph node.
Afferent lymphatic vessels carry lymph into the node's subcapsular sinus, through
the cortical sinus and into t he superficial cortex and paracortex. Conversely, t he lymph
may travel directly f rom the cortical sinus into the medull ary sinus. It is pri marily in
these cort ices and t he medullary sinus that t he lymph is cleansed by macrophages,
and antigens are presented and processed by lymphocytes, and plasma cells. The f il -
tered lymph leaves t he node through the efferent lymphatic vessels, whi ch merge
through t he concave hilum and t ransport the lymph into efferent collecting vessels,
which converge into larger vessels cal led lymph trunks (there are five major lymph
trunks in t he body). The thoracic duct receives lymph from three out of t he four quad-
rants of t he body; both lower quadrants and the upper left quadrant. The right lym-
phatic duct receives lymph only from t he upper right quadrant.
Note: The thoracic duct receives lymph from three out of t he four quadrants of the
body; both lower quadrants and the upper left quadrant. The right lymphatic duct re-
ceives lymph only f rom the upper ri ght quadrant.
Important:
1. The afferent lymphatic vessels enter on t he convex surface of the node.
2. There are fewer efferent vessels t han afferent vessels associated with a node.
3. The spleen, thymus, palatine, and pharyngeal tonsils do not have numerous af-
ferent vessels entering them as do lymph nodes.
4.The paracortex is dominated byT-cell s.
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Trabeculum
Postcapillary
(high ondotholial)
lary
cortex
Lymph node structure. The bean-shaped lymph node has a hilum into which blood ves-
sels enter, and from which efferent lymphatics emerge. It has an investing capsule. Af-
ferent lymphatic vessels penetrate the convex surface of the gland and drain into the
subcapsular and medullary sinus system. The lymphoid parenchyma is subdivided into
cortex, paracortex and medulla. The most prominent structures in the cortex are the lym-
phoid follicles.
11
(Reproduced wilh permission from Slcvcns. A. and Lowe J. H11mall Histology. cd 3. Elsev1er, Philndelpbia. 2005.)
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Area draining to right
lymphatic duct
Right and left
venous angles
OeCp cervical
Right nodes
lymphatic
duct --------LM

vei n
Central and --
posterior
axillary
nodes
Deep
lymphatic
vessels
Cubital
nodes
Area draining to
horacic duct
Lymphoid system. Pattern of lymphatic drainage. Except for right superior quadrant
of the body (pink), lymph ultimately drains into the left venous angle via the thoracic
duel. The right superior quadrant drains into the right venous angle, usually via a right
lymphatic duel. Lymph ty pically passes through several sets of lymph nodes, in a gen-
erally predictable order, before it enters the venous system.
1Al
Reproduced wilh penmssion (rom Moore KL. Daile)' AF. andAgur AMR. Cliiiicaii)'OrienteJ Anatomy. cd 6. Wollcrs Kluwcr, Ballmtorc. 2010.
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lymphatic system
Which of the following vessels are characterized by the presence of valves?
arterioles only
capil laries only
sinusoids only
veins only
lymphatics only
lymphatics and capil laries
lymphatics and veins
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lymphatics and veins
Primary lymphatic organs are responsible for the generation and selection of lymphocytes.
These are the thymus and bone marrow. Secondary lymphatic organs include the tonsils, spleen,
lymph nodes, appendix, which are responsible for the fil tering component. There are also areas
of diffuse lymphoid tissue throughout the body including MALT, GALT, and SALT (mucosa-, gut-
' and bronchus-associated lymphoid tissue, respectively). GALT includes the tonsils and Peyer's
patches. The common component to all lymphatic tissues is the presence of lymphocytes.
Functions of the lymphatic system:
Returns tissue fluid to the bloodstream: when this fluid enters lymph capillaries, it is
called lymph. Lymph is returned to the venous system via two large lymph ducts, the
thoracic duct and the right lymphatic duct
Transports absorbed fats: within the villi in the small intestine, lymph capillaries,
called lacteals, transport the products of fat absorption away from the Gl tract and
eventually into the circulatory system through the thoracic duct
Provides immunological defenses against di sease-causing agents: lymph filters
through lymph nodes, which filter out microorganisms (such as bacteria) and foreign
substances. Lymph nodes have also been shown to trap cancerous cells in the body.
1. Lymph contains a liquid portion that resembles blood plasma, as well as white
blood cells (mostly lymphocytes) and a few red blood cells.
2. Lymph is absorbed from the tissue spaces by the lymphatic capillaries (which is a
system of closed tubes) and eventually returned to the venous circulation by the
lymphatic vessels, after lymph flows through the filtering system (lymph nodes).
3. In the upper limb, a hallmark of lymphatic vessels is that they follow the veins.
4.The lymphatic system does not have a central pump to move lymph throughout
the body. "Instead, the lymphatic system depends on the contractions of skeletal
muscles, the presence of valves in lymphatic vessels (similar to those in veins),
breathing, and simple gravity to move fluid throughout the o d y ~
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The Lymphatic System
Cervical lymph nodes
Thymus
Right lymphatic
duct
CiSterna chyli
Axillary lymph
nodes
Spleen
Thoracic duct
21
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lymphatic system
T cells are produced in the ___ .and mature in the __ .
liver, thymus
bone marrow, liver
bone marrow, thymus
lymph nodes, thymus
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bone marrow, thymus
The thymus i s a bilobed lymphoid organ posit ioned i n the superior mediasti num i n adult s, with t he
i nf erior part contai ned in the anteri or mediasti num of chi ldren; it does not contain lymph nodules or
vessel s.The mai n function of t he t hymus is t o pot ent i at e i mmunocompetent T cells from t hei r
i mmunoincompetent precursors. Addit ionally, self-recognizi ng T cells are destroyed i n t he t hymus. The
t hymus i s relatively large in newborns, conti nues to grow until puberty, at which poi nt i t undergoes
i nvol ution, bei ng replaced by adipose t i ssue. Note: In the adult thymus, t he blood supply is i solated
f rom the parenchyma (which i s t he funct ioni ng portion of the gland as disti ngui shed from t he connect ive
t i ssue or stroma). Thi s i s someti mes referred to as the blood thymus barrier. In t he child thymus, t he
bl ood supply is not isol ated f rom the parenchyma.
Hassall's corpuscles: are st ructures found in t he medulla of t he human thymus, formed from
eosinophilic type VI epithelial reticul ar cells arranged concentrically. The f unct ion of Hassall's
corpuscles is current ly unclear.
Digeorge syndrome: i s a congeni tal disease that is charact erized by absent or underdevel-
oped t hymus and parathyroid glands. It's typically caused by a deletion on t he chromosome
numbered 22. Patients suffering f rom Digeorge have profound i mmunodefici ency due to a
lack ofT cells. No other i mmune cell populations are affected.
The spleen i s formed by ret icular and lymphat i c t i ssue and is the l argest lymph organ. The spleen lies
bet ween the fundus of t he stomach and t he diaphragm. The spl een i s purpli sh i n color and varies in size
i n different i ndividual s. The spleen i s slightly oval in shape wit h the hil um on t he lower medial border. The
spleen is entirely covered by peritoneum, except at t he hilum. It i s encl osed i n a fibroelastic capsule t hat
dips i nto the organ, forming trabeculae, but t rabeculae DO NOT divide the spl een i nto lobes/lobul es. The
spleen al so has no di stinct cortex or medulla. The cellular material, consi sti ng of lymphocyt es and macro-
phages, i s called splenic pulp, and i t lies between t he t rabeculae. Supplied by the splenic artery, a branch
of t he cel iac artery.
The spleen is the largest single mass of lymphoid t i ssue i n t he body. The spleen can be considered as two
organs i n one; it filters the bl ood and removes abnormal cell s (such as old and def ective red bl ood cells),
and i t makes di sease-f ight i ng component s of t he i mmune system (i ncludi ng antibodi es and
lymphocytes). The body of t he spleen appears red and pulpy, surrounded by a tough capsule. The red
pulp consi st s of blood vessels (splenic si nusoi ds) i nterwoven with connect ive t issue (splenic cords). The
red pulp filt ers t he blood and removes old and defective blood cells. It, along wi th t he l iver, are site of
erythropoiesis (blood formation) i n the fetus and i nfant. The white pulp is inside the red pul p, and
consi st s of little l umps of lymphoid t i ssue. Anti bodies are made i nside the white pulp.
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Pericardium

'-----Thyroid gland
I leart
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3AI
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lymphatic system
Posterior 1/3 of the tongue drains into:
facial nodes
occipital nodes
submandibular nodes
deep cervical nodes
submental nodes
jugulodigastric nodes
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deep cervical nodes
The deep cervical lymph nodes are located along the length of the internal jugular vein on each
side of the neck, deep to the sternocleidomastoid muscle. The deep cervical nodes extend from
the base of the skull to the root of the neck, adjacent to the pharynx, esophagus, and trachea.
The deep cervical nodes are further classified as to their relationship to the sternocleidomastoid
muscle as being superior or inferior.
The deep cervical lymph nodes are responsible for the drainage of most of the circular
chain of nodes, and receive direct efferents from the salivary and thyroid glands, the
posterior 1/3 of the tongue, the tonsils, the nose, the pharynx, and the larynx. All these
vessels join together to form the jugular lymph trunk. This vessel drains into either the
thoracic duct on the left, the right lymphatic duct on the right, or independently drains
into either the internal jugular, subclavian, or brachiocephalic veins.
Some regional groups of lymph nodes:
Parotid lymph nodes - receive lymph from a strip of scalp above the parotid salivary
gland, from the anterior wall of the external auditory meatus, and from the lateral parts of
the eyelids and middle ear. The efferent lymph vessels drain into the deep cervical nodes.
Submandibular lymph nodes - located between the submandibular gland and the mand-
ible; receive lymph from the front of the scalp, the nose, and adjacent cheek; the upper lip and
lower lip (except the center part}; the paranasal sinuses; the maxillary and mandibular teeth
(except the mandibular incisors); the anterior two-thirds of the tongue (except the tip); the
floor of the mouth and vestibule; and the gingiva. The efferent lymph vessels drain into the
deep cervical nodes.
Submental lymph nodes -located behind the chin and on the mylohyoid muscle; receive
lymph from the tip ofthe tongue, the floor of the mouth beneath the tip of the tongue, the
mandibular incisor teeth and associated gingiva, the center part of the lower lip, and the
skin over the chin. The efferent lymph vessels drain into the submandibular and deep
cervical nodes.
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vein
Lymphatic drainage of face and scalp. A. Superficial drainage. A pericervical collar o f superficial lymph
nodes is formed at the j unction of the head and neck by the submental, submandibular, parotid, mastoid, and
occipital nodes. These nodes initially receive most of the lymph drainage from the face and scalp. B. Deep
drainage. All lymphatic vessels from the head and neck ultimately drain into the deep cervical lymph nodes,
either directly from the tissues or indirectly after pass ing through an outlying group o f nodes.
41
(Reproduced with pcnniS$ion from Moore KL, Daile)' Af. and Agur AMR. C/inicol/y Oriented AnaJOmy. ed 6. Wolters Kluwer. Ballimore.
20t0.)
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Lymphatic drainage of the tongue and oral fl oor. A Left lateral view. B Anterior view.
The lymphatic drainage of the tongue and oral floor is mediated by submental and submandibular groups
of lymph nodes that ultimately drain into the lymph nodes along the internal jugular vein. (A, j ugular
lymph nodes). Because the lymph nodes receive drainage from both the ipsilateral and contralateral sides
(B), tumor cells may become widely disseminated in this region (e.g., metastatic squamous cell carci-
noma, especially on the lateral border of the tongue, frequently metastasizes to the opposite side).
4 AI
Reproduced with pe-rmission from Baker E.W. /lead tmd Neck Auatomr.ft,r Den/til Thieme. New York. 20 I 0.
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lymphatic system
When antigen recognition occurs by a lymphocyte, B cells are activated and
migrate to which area oft he lymph node?
inner medull ary region
medul lary cords
medul lary sinuses
germinal centers
I refer to card 1-1 for illustration!
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germinal centers
lymph nodes are small, round specialized dilations of lymphatic tissue that are permeated by
lymphatic channels. Their function is primarily to act as filters. They help to remove and dest roy
antigens that ci rculate in the blood and lymph. For this purpose, lymph nodes contain a lot of
macrophages. Lymphoid tissue in the nodes also produces antibodies and stores lymphocytes.
Note: The nodes generally occur in clusters along the connecti ng lymphatic vessels particularly in
t he armpits, the groin, the lower abdomen, and the sides of the neck.
Each lymph node is enclosed in a fibrous capsule with internal trabeculae (connective tissue)
supporting lymphoid tissue and lymph sinuses.
The node consists of:
Outer (superficial) cortical region: contai ns separate masses of lymphoid tissue called
lymphoid follicles. Primary foll icles are not responding to antigen. They stain uniformly.
Secondary follicles contain predominately B cells (lightly staining germinal centers) they are
active follicles responding to antigen and are a source of lymphocytes.
Paracortical region: is dominated by T cells. B cells enter the node from the blood in this region
and quickly migrate to the superficial cortex.
Inner medullary region: lymphoid tissue here is arranged in medullary cords,which are a
source of plasma cells (they secrete anti bodies). Also contains medullary sinuses.
lymph nodes can be classified as primary or secondary. Lymph from a part icular region drains into
a pri mary node or regional node. Primary nodes, in turn, drain into a secondary node or central node.
Definitions:
Germinal centers: are sites within lymph nodes (also within lymph nodules in peripheral lymph
t issues) where mature B lymphocytes rapidly proliferate, differentiate, mutate their antibodies
(through somatic hypermutation), and class switch their antibodies during a normal immune re-
sponse to an infection.
Medullary cord is a portion of the medulla of the lymph node which contains lymphatic tissue
and project into the medullary sinus. B cells and plasma cells are the main cel l types found in the
medullary cords.
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lymphatic system
The lymph from the lower extremities drains into the:
left i nternal jugular vein
left subcl avian vein
junction of the left internal jugular and subclavian veins
superior vena cava
junction of the right internal jugular and subclavian veins
I refer to card 1 A-I, 2-1 for illustration!
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junction of the left inte rnal jug ular and subclavian veins
The thoracic duct is the main duct of the lymphatic system and is located in the
posterior mediastinum. It begins below in the abdomen as a dil ated sac, the cisterna
chyli (at the level of the Tl 2 vertebra) and ascends through the thoracic cavity in front of
the spinal column (between the descending thoracic aorta [to its left) and the azygos vein
[to its right)). It is the common trunk of all the lymphatic vessels of the body, and drains
the lymph from the majority of the body (legs, abdomen, left side of head, left arm, and
left thorax). Note: The right lymphatic duct drains much less of the body lymph (only the
lymph from the right arm, right thorax, and right side of the head).
Important: The thoracic duct is approximately 40 em long and t ransports lymph from
the entire lower half of the body and left upper quadrant. It empti es into the left venous
angle bet ween the left internal jugular vein and the left subclavian vein (which is actually
the beginning of t he left brachiocephal ic vein). The right lymphatic duct is
approximately 1 em long and collects lymph from the right upper quadrant of the body
and empties into the right venous angle at the j unction of the right internal jugular vein
with the right subclavian vein (which is actuall y the beginning of the right
brachiocephalic vein).
1. The thoracic duct ascends through the aortic opening in the diaphragm, on
the right side of the descending aorta.
2. The thoracic duct contains valves and ascends between the aorta and the
azygos vein in the thorax.
3. The intercostal lymphatic vessels transport lymph from the left and right
intercostal spaces to t he thoracic duct.
4. Mammary glands drain lymph into axillary lymph nodes.
5. Ki dneys drain lymph into lumbar lymph nodes.
6. Lungs and trachea drain lymph into hilar lymph nodes (which are located in
the hilum of the lung).
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lymphatic system
Which of the following is NOT a function of the spleen?
removal of old or defective blood cel ls from blood
forming crypts that trap bacteria
storage of blood platelets
storage of iron
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forming crypts that trap bacteria
The spleen lies in the left hypochondriac region of the abdominal cavity between the fundus of
stomach and the diaphragm. The spleen is an ovoid organ roughly the size of a fist. The spleen
contains white and red pulp. The white pulp contains compact masses of lymphocytes
surrounding branches of the splenic artery. The red pulp consists of a network of blood-filled
sinusoids, along with lymphocytes, macrophages, plasma cells, and monocytes (phagocytic white
blood cells).
There are three major functions of t he spleen, and these are handled by three different tissues
within the spleen:
Reticuloendothelial tissue: concerned with phagocytosis of erythrocytes and cell debris from
the bloodstream. This same tissue may produce foci of hemopoiesis when RBCs are needed.
Venous sinusoids: along with the power of the spleen to contract, provides a method for
expelling the contained blood to meet increased circulatory demands
White pulp: provides lymphocytes and a source of plasma cells and hence antibodies for the
cellular and humoral specific immune defenses composed of nodules containing malpighian
corpuscles
Blood enters the spleen at the hilum through the splenic artery and is drained by the splenic
vein, which joins t he superior mesenteric vein to form the hepatic portal vein to the liver. The
nerves to the spleen accompany the splenic artery and are derived from the celiac plexus. Note:
Like the thymus, the spleen possesses only efferent lymphatic vessels.
Remember: Although the spleen does not develop from the primitive gut, as do the lungs, liver,
pancreas, gallbladder, stomach, esophagus, and intestines, it shares the blood supply of the foregut
which is supplied by the celiac trunk. The spleen develops from mesenchymal cells of the
mesentery attached to the pri mitive stomach.
1. Infectious mononucleosis: is a common, acute, usually self-limited infectious disease
caused by the EBV, characterized by fever, membranous pharyngitis, lymph node and
splenic enlargement.
2. Asplenia: refers to the absence of normal spleen function and is associated with some
serious infection risks, especially encapsulated bacteria such as streptococcus pneumo-
niae, haemophilus influenzae and neisseria meningitidis.
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Spleen-Visceral
view
Splenic vein
Impression of the
colon (left colic flexure)
border
otch In superior
border
stomach
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lymphatic system
Which of the following tonsil(s) is/are covered by nonkeratinized stratified
squamous epithelium?
Select all that apply.
lingual tonsil s only
pharyngeal tonsil only
palatine tonsils only
pharyngeal and palatine tonsil s
lingual and palatine tonsi ls
all of the above
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lingual and palatine tonsils
The t onsils are lymphatic organs that l ie under t he surface l ini ng of the mouth and throat. They are con-
sidered part of the secondary immune system. They si t i n the respiratory and al iment ary t racts i n
position to be exposed to i nspi red or i ngested ant i gens f rom air or food. When sufficient antigen i s pres-
ent, t hi s sti mulates t he 8 cells i n the germi nal zone of the lymphoid foll icle to differentiate and produce
antibodies. The tonsi ls are i nvolved in the production of mostl y secret ory lgA, whi ch i s t ransport ed to t he
surface, provi ding local immune protection. There are t hree sets of tonsil s, named according to t hei r
position.
The adenoids (pharyngeal tonsil) are l ocat ed on t he posterior wall of the nasopharynx. They are at
t hei r peak of development duri ng childhood. They are surrounded partly by connective ti ssue and
part ly by ciliated pseudostratified columnar epithelium (respi ratory epit hel ium). They contai n no
crypts.
The palatine tonsils are located on t he posterolateral walls of the throat , one on each si de. They
reach t heir maxi mum size duri ng early childhood, but after puberty dimi nish considerably i n size.
These are the t onsils t hat are noticeably enlarged when a person suffers from a sore throat." They
cont ain many crypts, lymphoi d follicles. but no sinuses. The palat i ne tonsi ls are surrounded partly by
connecti ve t issue and part ly by nonkeratinized stratified squamous epithelium.
Important point:The best way to disti ngui sh t he palati ne t onsil from the pharyngeal tonsi l on t he
hi stologic level i s t he t ype of epithelium associat ed with it .
The lingual tonsils are smaller and more numerous. They are a collection of lymphoid foll icl es on t he
posteri or portion of t he dorsum of t he tongue. Each has a si ngle crypt. They are surrounded by non-
keratinized stratified squamous epithelium. Note: The t hree groups of tonsil s are often referred to
as Waldeyer's Ring or the Tonsillar Ring.
Remember: Peyer's patches are similar in structure and functi on to the t onsils (Peyer's pat ches form
"intestinal tonsils"). Located in t he small i ntesti ne (specifically, the ileum}, t hey serve to destroy t he
abundant bacteria, which would otherwise t hrive in the moi st envi ronment of the i nt estine. Note: Peyer's
patches and tonsi ls are considered subepithelial and non-encapsulat ed lymphoid t i ssues.
Tonsillectomy: is a surgical procedure i n which the tonsils are removed from eit her side of t he t onsillar
fossa. The procedure is performed in response to cases of repeat ed occurrence of acute tonsi llit i s or ade-
noidit i s, obstructi ve sleep apnea, nasal airway obstruction, diptheria carri er stat e, snori ng, or peri tonsillar
abscess. For children. the adenoids are removed at the same ti me, a procedure called adenoi dectomy.
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Inferior
surface
of
tongue
Apex
The anterior free part constituting the maj ority of the mass of the tongue is the body. 111e posterior at-
tached portion is the root. The anterior (two thirds) and posterior (third) parts of the dorsum of the tongue
are separated by the terminal sulcus (groove) and foramen cecum. Brackets, indicate parts of the dorsum
of the tongue and do not embrace specitic parts.
8 1
Reproduced Ytith llcrmission from Moore KL Oalley Af:. andAgur AMR. (1inico/ly OrimMI A11t11omy. c:d 6. Wolters Kluwer. Baltimore, 2010.
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blood
In which of the following locations would one most likely find yellow bone
marrow in an adult?
diaphysis offemur
epiphysis of humerus
ribs
cranial bones
vertebrae
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diaphysis offemur
***Yellow marrow is found in the hollow center of the diaphysis (the long shaft of the
bone) known as the medullary cavity.
The bones are not solid structures. Cavities in the cranial bones, vertebrae, ribs, ster-
num, and the ends of long bones contain red bone marrow. This blood-forming tissue
produces erythrocytes, leukocytes, and thrombocytes within bones by a process call ed
hemopoiesis.
1. Before birth, the formed elements are also produced in a number of other
locations, including the yolk sac, liver, spleen, and lymph nodes.
2. Erythropoiesis refers specifically to the production of erythrocytes.
The red bone marrow contains precursor cel ls called hemocytoblasts (multipotent
stem cells) that give rise to all of the formed elements of the blood. The hemocyto-
blasts give rise to vari ous committed progenitor cells, which give rise to the different
types of formed elements. For example, the erythrocytes develop from proerythrob-
lasts; the platelets develop f rom large cells cal led megakaryocytes.
When a chil d is 7 years of age, yell ow marrow begins to appear in the distal bones of
the limbs. This replacement of marrow gradually moves proximall y, so that by the time
the person becomes an adult, the red marrow is restricted to the bones of the skull,
the vertebral column, the thoracic cage, the girdle bones, and the head ofthe humerus
and femur.
***At birth, all bone marrow is red.
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Which of the following cells are agranulocytes?
Select all that apply.
basophils
eosinophil s
lymphocytes
monocytes
neutrophils
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blood
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lymphocytes
monocytes
Formed Avg. No./mm
3
Element Description Function
Erythrocytes 5 million Biconcave, anuclcated cell Transport oxygen
Platelets 150,000300,000 Small cellular fragments Hcmoslasis
LeukOC)'tes 10,000
Granulocytes:
Lobed nucleus, fine granules Part of the immune system
.
Ncutrophils 5,400
(phagocytosis)
.
Eosinophils 275
Lobed nucleus, red or yellow May phagocytize AbAg
granules complexes (active against parasites)
.
Basophils 35
Obscure nucleus, light purple Release histamine, heparin, and
granules serotonin
Agranulocytes:
.
Monocytes
540 Kidneyshaped nucleus Phagocytosis, differentiate into tissue
macrophages
.
Macrophagcs
Ruffied membrane, cytoplasm Phagocytosis, secretion of cytokines
with vacuoles and vesicles
.
Lymphocytes
2,750 Round nucleus, liulc cytoplasm Produce Abs, destroy specific target
cells
***Absolute neutrophil count measures cell s per microli ter. A risk of infection increases
dramatically with a reading of <500/ mm3, potential ly following dental treatment and
should not receive dental care.
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blood
Which of the following statements is NOT true regarding erythrocytes?
They:
are biconcave in shape
have an average lifespan of 30 days
rely completely on anaerobic metabol ism
have no nucleus
have no mitochondria
are disposed of by the spleen
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have an average lifespan of 30 days
The process of erythrocyte production i s called erythropoiesis. The hormone that stimulates
erythropoiesis is called erythropoietin, which is produced primarily by t he kidneys. The average l ife span
of a red blood cell is 120 days.
Differentiation stages of erythroblast: Hemocytoblast -common myel oid progenitor- uni potent
stem cell - proerythroblast- basophilic erythroblast- polychromatophi lic erythroblast -normoblast
- reticulocyte- erythrocyte
Erythrocytes, or red blood cells, make up t he largest population of blood cell s, numbering from 4.5 million
to 6 million per cubic millimeter of blood. Their principal function is to transport oxygen and carbon
dioxide. The hemoglobin molecules in erythrocytes combine with oxygen in the lungs to form
oxyhemoglobin. The oxygen is t ransported in t his state to the tissues of the body. In the tissues, t he
oxygen is released to diffuse into the interstitial fluid. Within the t issues, carbon dioxide is combined wit h
the hemoglobi n molecules to form carbaminohemoglobin, which is transported to t he lungs.
Note: About 70% of carbon dioxide, however, is transported by the blood plasma as bicarbonate ions
(HCOj) one of t he most important extracel l ular buffers.
Remember: (1) The proportion of erythrocytes i n a sample of blood is called the hematocrit (usually
around 46% for males and 40% for females). (2) The precursor cell found in the red bone marrow that
gives rise to all of the formed el ements of the blood is the hematocytoblast (these are pluri potent stem
cell s), which gives rise to various committed multipotent progenitor cells (aka Colony-forming cell s or
CFC), which then give rise to the different types of formed el ements.
Note: Granulocyte Colony-stimulating factor (G-CSF) is the hormone that sti mulates precursor cells in t he
bone marrow to differentiate i nto white blood cells (leukocytes).
8
1. Sickle cell anemia is an autosomal recessive genet ic blood disorder in which the body pro-
duces abnormally shaped red blood cell s. The cells are shaped l ike a crescent or sickl e. They don't
last as long as normal, round red blood cells, which l eads to anemia. The sickle cell s also get stuck
i n blood vessels, blocking blood fl ow. This can cause pai n and organ damage. Mutation is a hy-
drophil ic gl utami c acid (polar) substituti on wit h a hydrophobic amino acid valine.
2. Genetic defi ciency of glucose-6-phosphate-dehydrogenase (G6PD) causes severe hemolytic
crisis in affected individual s secondary to decreased NADPH and t he inabil it y of RBC's to main-
tain membrane i ntegrity. It's i nduced by sulfa drugs, oxidants and fava beans.
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blood
The formed elements of blood include all of the following EXCEPT one. Which
one is the EXCEPTION?
plasma
red blood cell s
platelets
white blood cell s
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plasma
BLOOD LEUKOCYTES
FORMED
8%of
ELEMENTS
body VOLUME
(number per cubic mm)
Neutrophils
weight 60-70%
Plasma
Leukocyt es
--+ Lymphocytes
4 to 6 liters
--+
55%
5-l 0 thousand
20-30%
Monocytes
Temp = For med
Platelets
2-6%
38"C Elements
-
Eosinophils 150-300 thousand
45% 1-4%
pH of 7.35
Erythrocytes
Basophils
To 7.45
4.3-5.8 million
0- 1%
Important: The mnemonic " Never Let Monkeys Eat Bananas" identifies the order of
abundance of leukocytes.
Note: The term leukocyte refers to all types of white blood cells as listed above, while
the term granulocyte refers only to those containing visible cytoplasmic granules. The
granulocytes are the neutrophils, eosinophil s and basophils.
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blood
Regarding the difference between plasma and serum, which of the following
statements is true?
serum is yellow; plasma has no color
serum contains antibodies; plasma does not
plasma contains clotting proteins; serum does not
plasma contains hemoglobin; serum does not
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plasma contains clotting proteins; serum does not
Plasma is approximately 91% water; the other portion is made up of various
materials (see chart below). The porti on of the blood that is not plasma consists of
formed elements, which includes erythrocytes (red blood cells), leukocytes (white
blood cel ls), and cell fragments called platelets.
Note: Serum= blood plasma without fibrinogen (after coagulation)
BLOOD
{
Albumins
PLASMA
55%
8%of (WEIGHT)
Globulins
body
VOLUME
/
38%
weight Proteins
Fibrinogen
Plasma 7%
7%
4 to 6 liters
-
55%
Water
Temp = Formed 9 1%
{
Metabolic end products
3sc Elements
Food materials
45% Other Solutes
Respiratory gases
pH of7.35 2.0%
Hormones, etc.
To 7.45
Ions
Human serum albumin is the most abundant protein in human blood plasma. It is pro-
duced i n the li ver. Albumin constitutes about half of the blood serum protein. It trans-
ports hormones, fatty acids, and other compounds, buffers pH, and maintains osmotic
pressure.
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Platelets are best described as:
megakaryocytes
cytoplasmic fragments
agranulocytes
immature leukocytes
lymphoid cells
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blood
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cytoplasmic fragments
*** Although platelets are often classified as blood cells, platelets are actually
fragments of large bone marrow cells call ed megakaryocytes.
Platelets are minute, irregularly shaped, disc-li ke cytoplasmic bodies found in blood
plasma that promote blood clotting and have no definite nucleus, no DNA, and no
hemoglobin.
Normal blood contains 150,000 to 300,000 platelets per cubic mm. Their li fe span is
7-10 days; they are removed in the spleen and the liver. Note: Thrombopoietin (a
glycoprotein hormone) is produced by the kidney and liver. Thrombopoietin
stimulates precursor cells in the bone marrow to differentiate into megakaryocytes.
Megakaryocytes give rise to platelets.
Remember: Platelets stop blood loss by forming a platelet plug. This plug begins to
form when platelets are exposed to a rough surface. They contain many secretory
vesicles (granules), which contain chemicals that promote clotting. When platelets
adhere to collagen, they release ADP and other chemicals from thei r secretory
vesicles. Many of these chemicals, including ADP, induce changes in the platelet
surface that cause the surface to become 'sticky: As a result, additional platelets
adhere to the original platelets and form a "plug:'
Important: (1) Thromboxane A
2
(TXA
2
), produced by activated platelets, has
prothrombotic properties, stimulating activation of new platelets as wel l as
increasing platelet aggregation. (2) Prostacycl in (PGI
2
) decreases platelet aggregation
and causes vasodil atation.
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joints
Which of the following is CORRECT regarding the articular cartilages?
Select all that apply.
they are covered by disks
most of them are covered by hyaline cartilage
they are covered by perichondrium
they are covered by periosteum
they are vascular
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most of them are covered by hyaline cartilage
Synovial joint s are freely movable (diarthrodial), with movement limited only by j oint surfaces, lig-
aments, muscles, or tendons.
They are characterized by four features:
1. Articular cartilage - a thin layer of hyaline cartilage that covers the smooth articular bone sur-
faces. This layer contains no blood vessels or nerves. Note: The temporomandibular joint con-
tains fibrocartilage, not hyaline cart ilage.
2. Joint cavity- small fluid-filled space separating the ends of adjoining bones.
3. Articular (joint) capsule- double-layered; outer layer of fibrous connective tissue that encloses
the joint.
4. Synovial membrane- produces synovial fluid. Found on both bursa and articular cartilage.
Note: Most joi nts of the body are synovial joints. They are classified functionally as diarthroses
(means freely movable). In addition to the features above, some synovial joints have articular discs
(TMJ and sternoclavicular joint). These discs consist of fibrocartilage. They divide the cavity into two
separate cavities.
Synovial fluid is a clear, thick fluid secreted by the synovial membrane, which fills the joint capsule
and lubricates the articular cartilage at the ends of the articulating bones.
Supporting ligaments (capsular, extracapsular, and intracapsular ligaments) maintain the normal
position of the bones.
Ten percent of synovial joints have a washer-like structure between bone ends called the meniscus.
Its purpose is to absorb shock, to stabilize the joint, and to spread synovial fluid. The meniscus is
made out of fibrocartilage, but the meniscus also has no blood supply, no nerves, and no lym-
phatic channels. Biologically, the meniscus can't heal itself. The knee meniscus is the most famous
and most injured meniscus in the body.
Note: A bursa is a fluid-sac that is lined with a synovial membrane. The function of a bursa is tore-
duce friction. For example, a bursa may be located bet ween a tendon and a bone to reduce the fric-
t ion of the tendon passing over the bone when the tendon's muscle contracts. Inflammation of the
lining of a bursa is referred to as bursitis.
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Joint cavity
Str ucture of Synovial Joints
15 1
wilh permission from Patton KT, Thibodeau GA; Mosby's Hnndbook of Anatomy & Physiology. St. loUJs. 2000. Mosby.
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Which of the following joints is/are a synarthrosis?
Select all that apply.
temporomandibular joint
skull sutures
synovial joints
condyloid joints
ANATOMIC SCIENCES
joints
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skull sutures
Articulations (joints) are the structures where bones connect. There are three main
classes of articulations based on the amount of motion they allow:
1. Synarthrosis - immovable joint (fibrous joint). Sutures found between the flat
bones of t he skull are of this type.
Note: Gomphosis is an example of a synarthrosis. It is t he joint that binds t he
teeth to the bony sockets (dental alveol i) in the mandible and maxilla.
2. Amphiarthrosis - sli ghtly movable joint (cartil aginous joint). One example is the
symphysis pubis, where t he two os coxa bones join anteri orly.
3. Diarthrosis - freely movable joint (synovial joint).
Joints can also be classified based on the type of associated connective tissue:
Fibrous (joined by fibrous connective t issue) - two types: sutures (of skull) and
syndesmoses (between radius and ulna)
Cartilaginous (joined by fibrocartilage or hyal ine carti lage) - two types: syn-
chondroses, which are joined by hyali ne cartil age (epiphyseal plates withi n long
bones), and symphyses, whi ch are joined by a plate of fi brocartilage (pubic sym-
physis)
Synovial (joint capsule containing a synovial membrane that secretes a synovial
fluid)- most joints, such as the temporomandibular joints, are synovial
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joints
The spheno-occipital joint and epiphyseal cartilage plates are classified as
which of the following joints?
sutures
symphyses
synchondrosis
syndesmoses
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synchondrosis
Joints are places of union between two or more bones. Joints are classified on the basis of their structural fea-
tures into fibrous, cartilaginous, and synovial types.
Fibrous joints (synarthroses): are barely movable or non-movable and are found in t hese forms:
Sutures are connected by fibrous connective t issue and are found between the flat bones of the skull.
Coronal suture: between frontal and parietal bones
Sagittal suture: between two parietal bones
lambdoid: between parietal and occipital bones
Bregma: intersection of coronal and sagittal sut ures, it's the site of anterior fontanelle In an infant
lambda: intersection of saginal and lambdoid sutures, It's the site of posterior fontanelle in an infant
Syndesmoses are connected by fibrous connective tissue and occur as the Inferior tibiofibular and tympa-
nostapedial syndesmoses.
Cartilagi nous joints (amphiarthroses):
Synchondrosis (primary cartilaginous j oints) are united by hyaline cartilage and permit no movement but
growth in the length of the bone. These include epiphyseal cartilage plates and the first rib and sternum.
Symphyses (secondary cartilaginous j oints) are joined by a plate of fi brocartilage and are slightly movable
joints. These include the pubic symphysis and the intervertebral discs.
Synovial joints (diarthrodial j oints):
Permit a great degree of free movement. They are characterized by four features: joi nt (synovial) cavity, ar-
ticular cartilage, synovial membrane, and articular capsule. These joints are classified according to axes of
movement Into:
Gliding (plane): include those joints found in the carpal bones of t he wrist and the tarsal bones of the
ankle
Hinge: the elbow and knee joints are examples
Pivot found between atl as (Cl )and axis (C2)ofthe vertebral column
Ellipsoidal (condyloid): found between the distal surfaces of t he forearm bones (radius and ulna) and
the adj acent carpal bones
Saddle: found where the metacarpal of the thumb meets the trapezium of the carpus (wrist)
Ball-and-socket (universal): allows almost all types of movements. Examples include t he shoulder j oint
and the hip j oint.
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Ball-and socket
joint
Head of femur (ball)
Scaphoid bone
Ellipsoidal
(condyloid) joint

Y'Y"'
Carpal bones
Ulna
Art iculations- Ball-and-socket joint, Ellipsoidal joint, Gliding joint
17-1
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Saddle joint
Humrus Hinge Joint
Trochlea
(of humerus) process
17AI
Articulations- Hinge joint, Pivot joint, Saddle joint
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joints
The paramedics arrive at the scene of a minor motor vehicle collision. One
driver claims to have experienced whiplash and is having trouble shaking her
head in a "NO" motion. She is fine with nodding her head in a "YES" manner.
Which of the following joints allows maximum rotational movement of the
head about its vertical axis (saying "NO")?
intervertebral joint
atlantoaxial joint
atlanta-occipital joint
costovertebral joint
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atlantoaxial joint
This joint is the synovial articulation between the inferior art iculating facets of the
atlas (first cervical vertebra) and the superior art iculating facets of the axi s (second
cervical vertebra). The atlas and axis, or Cl and C2, do not have an intervertebral disc
nor an intervertebral foramen between them. Cl has two lateral masses (no vertebral
body) where it makes contact with the occiput and C2. The inferior art icular facets of
the Cl and the superior art icular facets of C2 form 2 joints, one on each side. There is
also a third joint formed by the dens, or odontoid process, of C2 and the interi or of the
anterior arch of Cl. This is the joint you use to shake your head as in saying "NO':
Note: The atlanto-occipital joint permits rocking or nodding movements of the
head as in saying "YES:' This joint is the synovial articulation between the superior
articulating facets of the atlas (first cervical vertebra) and the occipital condyles of the
skul l.
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joints
When someone is rotating the forearm with the palm turning outward, this
motion is termed as:
abduction
adduction
flexion
extension
pronation
supination
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supination
Movement Desc.ription Examples
Flexion Decreasing the inner angle of the Bending the elbow
joint Dropping the chin to the chest
Folding forward (flexion of spine)
Extension Increasing the inner angle of the joint Back bend
Kicking leg back ( hip extension)
Abduction Moving away from the midline of Lifting leg to the side
the body Lifting anns up from sides into T position
Adduction Moving towards the midline of the Crossing one leg in front of the other
body Crossing arm in front of torso or behind back
Lateral Flexion Side bending (neck/torso) Dropping ear towards shoulder
Crescent Stretch (dropping one hand down
same s ide of body)
Rotation Rotating or pivoting around a long Twisting along s pinal column (seated twist)
axis Turning palms up and down
Pronation Rotating the foreann with the palm Lifting ann then turning arm (like emptying a
turning inward can of soda)
Supination Rotating the fore.ann with the palm Lifting ann then turning arm back (tuming
turning outward palms towards ceiling)
Evers ion Turning the foot laterally resulting in Standing with the weight on the inner edge of
the sole moving outward the foot
Protraction Draw forward (shoulder) Round shoulders forward "spreading" back
Retraction Draw back (shoulders) Squeezing shoulder blades together
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urinary system
The ureter connects which of the following parts of the kidney to the urinary
bladder?
renal papi ll a
renal columns
renal calyx
renal pelvis
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renal pelvis
The kidneys are located at the back of the abdomen, one on each side of the spine, at the
level of the lower ribs. They are a pair of reddish, bean-shaped organs that are highly
vascul arized and perform the following functi ons of the urinary system: (1) forming urine
(2) maintaining homeostasis and (3) hormone secretion (i.e., erythropoietin and renin).
The kidneys are located on either side of the lumbar spine. They lie retroperitoneally
(external to t he peritoneal li ning of the abdominal cavity) in front of the muscles attached
to the vertebral column.
Internal features of kidney:
Cortex - outer light-brown layer (glomeruli and proximal and distal convoluted tub-
ul es are located here). Site of blood filtration.
Medulla - inner dark-brown layer, contains cone-like structures call ed renal pyramids
that are separated by renal columns.
Renal columns - extensions of renal cortex.
Renal pelvis - a hollow inner structure that joins with t he ureters (t he tubes that con-
duct urine to the bladder). Receives urine through the calyces.
Renal papilla - apex of pyramids, here the collecting ducts pour into minor calyces
Renal calyx - extension of the renal pelvis. Minor calyces unite to form major caly-
ces, which urine is empt ied into.
1. The right kidney lies slightly lower than the left kidney due to the large
size of the right lobe of the liver.
2. Each kidney is surrounded by a fibrous renal capsule and is supported
by the adipose capsul e.
3. Each kidney has an indentation, the hilum, on the medial border, through
which the ureters, renal vessels, and nerves enter or leave.
4. Each kidney receives its blood supply from a renal artery, a branch of
the abdominal aorta.
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Renal pyramid (medul
Renal column
2().1
Kidney- Coronal view of right kidney
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urinary system
Name the following structures of the nephron in the order they are encoun-
tered from blood to urine.
(1) distal convoluted tubule (2) bowman's capsule (3) collecting duct (4) glomerulus
(5) loop of Henle (6) proximal convoluted tubule
2,4,6, 1 ,5,3
4,2,6,5, 1,3
6,2,4,5, 1,3
2,6,4,5, 1,3
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4, 2,6, 5, 1,3
The subunit of a kidney t hat purifi es bl ood and maintains a saf e balance of solutes and water i s the
nephron; it i s t he f unctional unit of the human excretory syst em. About one million nephrons are i n t he
cort ex of each kidney, and each one i s a l ong tubul e wi th a closed end, called the Bowman's capsule.
Component s of the nephron incl ude:
Renal corpuscle: whi ch consists of a glomerulus (network of parallel capi llari es) and a double-walled
cup, t he Bowman's capsule whi ch surrounds t he glomerulus and collects filtrat e. The renal corpuscle
i s t he site of filtration; this normally produces protein-free and cell -free fi lt rate that passes i nto the prox-
i mal convoluted t ubules.
The tubular portion: has four mai n regions. Fi lt rate from the Bowman's capsule f irst passes i nt o the
proximal convoluted tubule in the cortex. Here, glucose, amino acids, met abolites, and electrolyt es are
reabsorbed f rom filtrat e and ret urned to circulation. Next, t he filtrate enters t he loop of Henle, first
through its descending l imb and t hen through its ascendi ng l imb. Here, the fi ltrate is concent rated
through electrolyte exchange and reabsorption t o produce a hyperosmolar fl uid. Thi s loop ext ends deep
i nto the medulla. From there. fl uid enters t he distal convoluted tubule, also in the cortex. Here, sodium
i s reabsorbed under the i nfl uence of aldosterone. From the di stal convol uted t ubule. fi lt rate enters t he
collecting duct, which is t he distal end of the nephron. Thi s i s the site of final concent ration of fi ltrat e,
which then empti es i nto papillary ducts deep within t he medulla.
Aft er fi lt ration, fl uid i n thet ubulesofthe nephrons undergoes t wo more processes, both i nvolving the per-
i tubular capillari es: tubular reabsorption and tubular secretion. Some bl ood i s not fi l tered and passes i nto
the eff erent vessel s and perit ubular capi llaries. Many subst ances that are fi ltered are returned t o the per-
i tubular capillaries from t he tubules by reabsorption, oft en at high rat es (e.g., wat er, gl ucose, sodium). Waste
products are ret ained and empti ed i nto a collecti ng tubule, which i s discharged t o t he ureters.
Macula densa i s an area of closely packed specialized cells l ini ng t he wall of the distal tubule. The cells of
the macula densa are sensit ive t o the concent rat ion of sodi um chl ori de in the distal convol uted t ubul e. A
decrease i n sodium chloride concent ration i ni tiat es a signal from the macula densa t hat has t wo effect s: (1)
i t decreases resi st ance to blood flow in the afferent arterioles, which increases glomerular hydrost at ic pres-
sure and helps ret urn glomerul us filtration rate (GFR) toward normal, and (2) it i ncreases reni n release from
the j uxtaglomerular cells of the afferent and efferent art erioles, which are the maj or storage sit es for reni n.
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Tubular and collecting syst em of the nephron. 'f he
first pan of [he tubular system is the proximal lUbule,
which is a continuation of Bowman's capsule and ini
tiall y pursues a convoluted course (rhe pmximal convo-
lured tubules). remaining close to the glome1ulus from
which it arise$.
The proximal mbule the-n straightens and descends co-
ward the medulla (pmximal !Uraig/H luhu/es. or the I hick
descending limb t?fthe loop of Henle). merging with a
thin-walled part of the tubular system (lhiu limb of rite
loop of Henle). nlis I'Uns down the co11ex, and rhen in
the medulla, toward the papillary tip (descending thin
limb). It dten loops back on itself (ascending rhin loop)
and re-enters the corcex. 1' he wall then become-S thicker,
formi ng the straight segment of rhe distal rubule {the
thick ascending limb of the Mop of Henle or I he diswl
!Uraighltubule).
In the cortex, close to the glomeruli. the distal mbule be.
comes convolmed (dislfll comoluted 1ubule). and emp.
t ies into a collecting n1bule. which in turn empties imo a
co11ecting duc( lying within the medullary ray.
The collecting ducts descend imo the medulla whe.e a
number converge to produce large.diamere.r ducts in the
papillae (papillary ducts r>r ducts t?{Bellini). 11lese ducts
open into the calyces at the ti ps of the papillae, the con.
centration of the openings producing a sieve .. ! ike surface
appearance to the papillary tip (the area cribi'Osa).
Reproduced wilh from Stevens, A. and Lowe J. f1111t1a11 Histol
tJfP' ed 3. Ellievier. Philadclplua, 200S.
21-1
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urinary system
Which of the following persists as the definitive (permanent) kidney?
pronephos
metanephros
mesonephros
none of the above
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metanephros
The urinary system consists of the kidneys, the ureters, the urinary bladder, and the urethra. This
system filters the blood and maintains the volume and chemical composition of the blood.
The kidneys are paired organs, which contain extensive vascularity and millions of nephrons within
the renal cortex and renal medulla. The kidneys fi lter blood and regulate the volume and
composition of body fluids duri ng the formation of uri ne.
Note: The development of the kidney proceeds through a series of successive phases, each marked
by the development of a more advanced kidney: the pronephros, mesonephros, and metanephros.
The pronephros is the most immature form of kidney, while the metanephros is most developed.
The metanephros persists as the definitive adult kidney.
The ureters are long, slender, fibromuscular tubes that transport urine from the pelvis of the kidney
to the base of the urinary bladder. Because the left kidney is higher t han the right, the left ureter is
usual ly slightly longer than the right. The ureters are narrowest where they originate, at the renal
pelvis (ureteropelvic j unction). Note: Filling of the bladder constricts the ureters at the
ureterovesical j unction, where they enter the bladder. Peristaltic waves, occurring about one to five
t imes each minute, move urine through the ureters.
Remember: In the female, the ureter descends posterior to the ovary and into the base broad lig-
ament passing under the uterine artery"water under the bridge.
The urinary bladder is a distensible sac that is situated in the pelvic cavity posterior to the
symphysis pubis. The urinary bladder is slightly lower in the female than in the male.lt concentrates
and serves as a reservoi r for urine, which the bladder receives from the kidneys through the ureters
and discharges through the urethra.
Remember: Transitional epithelium is found lining the urinary bladder, and the cells of this tissue
are specialized to change shape in response to pressure. When the bladder is empty, these cells are
more or less cuboidal in shape, but as the bladder fills the cells become compressed and flattened.
The urethra is a fibromuscular tube that carries urine from the urinary bladder to the outside of the
body. In males, the urethra carries semen as well as urine. Note: The portion of the male urethra
t hat passes through the urogenital diaphragm is called the membranous urethra.
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Urinary System (male)
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foramina
A 26-year-old female has been previously diagnosed with McCune-Albright
syndrome. There is bony fibrous dysplasia of the anterior cranial base leading
to the encasement and narrowing of the optic canal. Although her vision is
normal, there is concern that there will be compression of the optic nerve
and which of the following other structure(s)?
ophthalmic nerve (CN Vl)
crani al nerves Il l, IV, and VI
ophthalmic ar tery
ophthalmic vei ns
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ophthalmic artery
The optic canal is located posteriorly in the lesser wing of the sphenoid. It commun-
icates with the middle cranial fossa. It transmits t he optic nerve and the ophthalmic
artery.
Bony Opening Location (Bone) Contents
Cribrifonn plate with foramina Ethmoid Olfactory nerves (CN I)
Hypoglossal canal Occipital Hypoglossal ner\e (CN XII)
Carotid canal Temporal Internal carotid artery
Lacrimal canal Maxilla and lacrimal Nasolacrimal (tem) duct
Inferior orbital fissure Sphenoid and maxilla Infraorbital and zygomatic branches of max-
illary nerve (V2), infraorbital artery, and part
of inferior ophthalmic vein
Superior orbital fissure Sphenoid Oculomotor (CN I II), trochlear (CN IV), and
abducens (VI) nerves; lacrimal, frontal and
nasoci liary branches of ophthalmic nerve
(VI); superior and inferior divisions of
ophthalmic vein; sympathetic fibers from
cavernous plexus
Optic canal and foramen Sphenoid bone Optic nerve (CN II) and ophthalmic artery
Stylomastoid foramen Temporal Facial nerve (CN VII)
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Frontal incisure
Posterior
ethmoidal
foramen
Anterior
ethmoidal
foramen
r---+- 7 --Optic canal
Infraorbital
foramen
Right Orbit-Anterior View
Reproduced wilh permi.i>Sion from Shut nke M. Schulte E.. Schumacht'T U; /lead ami
Neck Dental Medid11e: New Yort., 2010. Thieme Medica] Publishers.
Nasal bone
Lacrimal bone
23 1
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foramina
A 62-year-old female visits the family physician with complaints of right-sided
hearing loss, ringing in the right ear (tinnitus), numbness over the right half
of her face, and dizziness. The physician diagnoses her with an acoustic
schwannoma that is occluding her right internal acoustic meatus. The internal
acoustic meatus pierces the posterior surface of the petrous part of the tem-
poral bone. The internal acoustic meatus transmits which two structures?
trigeminal nerve (CN V) and facial nerve (CN VII)
facial nerve (CN VII) and vestibulocochlear nerve (CN VIII)
vestibulocochlear nerve (CN VI II) and vagus nerve (CN X)
trigeminal nerve (CN V) and vagus nerve (CN X)
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facial nerve (CN VII) and vestibulocochlear nerve (CN VIII)
The vestibulocochlear nerve enters the internal acoustic meatus and remains withi n t he
temporal bone, to the cochlear duct (hearing}, semicircular ducts, and maculae (balance).
The fadal nerve enters the internal acoustic meatus, the facial canal in the temporal bone, and emerges
from the stylomastoid foramen. The stylomastoid foramen lies between the styloid and mastoid
processes of the temporal bone. Note: The facial nerve, upon entering the internal acoustic meatus also
gives rise to the chorda tympani branch (which is responsible for the parasympathetic innervation to the
submandibular and sublingual gland). It also provides sensory taste fibers for the anterior 2/3 of the tongue.
After the main trunk of the facial nerve exits from t he stylomastoid foramen, it enters into
t he substance of the parotid gland. It is here that it gives off five main branches that will supply
motor innervation to the muscles offacial expression.
Facial nerve branches mnemonic: "The Zebra Bi t My Cow"- From superior to inferior:
Temporal branch
Zygomatic branch
Buccal branch
Mandibular branch
Cervical branch
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foramina
Which of the following foramina appears as a small round radiolucent area
on the mandibular premolar and can be confused with a periapical abscess if
not recognized correctly?
mandibular foramen
incisive foramen
mental foramen
foramen ovale
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mental foramen
The mandibular foramen is located on the medial surface of the ramus of the
mandible just below the lingula, midway between the anterior and posterior borders
of the ramus. The foramen leads into the mandibular canal, which opens on the
lateral surface of the body of the mandible at the mental foramen.
Important: In relationship to the occlusal plane of the mandibular molars, the
mandibular foramen is located at or slightly above the occl usal plane and posterior to
the molars.
Note: The lingula is a tongue-shaped projection of bone that serves as the
attachment for the sphenomandibular ligament.
Remember: The inferior alveolar nerve (branch of V3), artery, and vein travel
through the mandibular foramen. At the mental foramen, the i nferior alveolar nerve
ends by dividing into (1) the mental nerve, which exits the mental foramen and
supplies the skin of the mental region, mucous membrane and attached gingiva of
the ipsil ateral mandibular anterior and premolar teeth and (2) the inci sive branch
which continues coursing through the mandible and supplies the pulp chambers of
the anterior teeth and adjacent mucous membrane.
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Reproduced with
from Shue.nke M, E.
U; Nt!tul and
Net:k An11tmny fi'r Dental
Mt!dicint!; York. 20 I 0.
Medic.al
Mental
Mandibular
notch
Head of
condyle
11-"o::::J---Pterygoid
fovea
Mental Body of Oblique
foramen mandible line
Ramus of
mandible
Oblique left lateral view of the mandible. This view displays the coronoid process, the condylar
process, and the mandibular notch between them. The coronoid process is a site for muscular attach-
ments, and the condylar process bears the head of the mandible, which a1ticulates with the a1ticular disc
in the mandibular fossa of the temporal bone. 2s- 1
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foramina
Through which ofthe following foramina does the largest ofthe three (paired)
arteries that supplies the meninges pass?
foramen magnum
jugular foramen
foramen rotundum
foramen ovale
foramen spinosum
foramen lace rum
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foramen spinosum- the artery i s the middle meningeal artery which i s the largest
of the three (paired) arteries which supply the meninges, the others being the
anterior meningeal artery and t he posterior meningeal artery
The jugular foramen lies between the lower border of the petrous part of the temporal bone
and the condylar part of the occipital bone. The jugular foramen transmits the following
structures: inferior petrosal sinus, sigmoid sinus (becoming the internal jugular vein), the
posterior meningeal arterty (at this point, still called the ascending pharyngeal artery) and the
glossopharyngeal, vagus, and accessory nerves.
Bony Opening
Foramen rotundum
Foramen ovalc
Foramen magnum
Foramen spinosum
Mental foramen
Location
(Bone)
Sphenoid
Sphenoid
Occipital
Sphenoid
Mandible
Greater palatine for.smcn Palatine
Lesser palatine foramen Palatine
Incisive fOramen Maxilla
Jugular fOramen Occipital and
temporal
Cont ents
Maxillary nerve (V-2)
Mandibular nerve (V-3)
Spinal cord, vertebral arteries, and "spinal rootsH of the
nerve
Middle meningeal artery
Mental nerve, artery and vein
Greater palatine nerve, artery, and vein
Lesser palatine nerve, artery, and vein
Nasopalatine nerve and branches of the sphenopalatine
artery
Inferior petrosal sinus, sigmoid sinus (becoming the
internal jugular vein), posterior meningeal artery, and
glossopharyngeal, vagus and acccs.;;ory nerves
Remember: The accessory nerve (CN XI) enters the cranial cavity through the foramen mag-
num, where it immediately j oins with the vagus nerve (CN X) and subsequently exits the cranial
cavity through the jugular foramen.
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Palatine bone
Greater palatine
foramen
Lesser palatine
foramen
Infratemporal crest -
Scaphoid fossa
Sphenoidal foramen
Foramen ovale
Foramen splnosum-
Foramen laeerum --
Petrotympanic fissure
Carotid canal
Jugular foramen
Stylomastoid foramen
Hypoglossal canal
Foramen magnum
Inferior nuchal i n ~
Superior nuchal line
Supreme nuchal line
The basal aspect of the skull
Incisive
foramen
Choana
Zygomatic bone,
temporal surface
Inferior orbital
fissure
Zygomatic
arch
Hamulus
Pharyngeal canal
Vomerovaglnal canal
Pharyngeal tubercle
Mandibular fossa
Occi pital condyle
Mastoid process
Mast oid Incisure
Condylar canal
Mastoid foramen
._.1"'---EO><toornal occipital
protuberance
26-1
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Chiasmatic groove
Optic canal
Anterior clinoid process
Foramen ovate
Foramen spinosum
Arterial groove
Clivus
PetrCKH:e:ipital
fissure
Hypoglossal canal
Groove for sigmoid
sinus
Ethmoid bone,
cribrifonn plate
l nlerior of I be base of I be skull
Frontal Frontal
crest sinus
Ethmoid bono.
crista galll
Frontal bone
Sphenoid bone.
lesser wing
Sphenoid bone,
greater wing
Sphenoid bone,
hypophyseal fossa
Posterior clinoid
process
Temporal bone,
petrous part
Internal acoustic
meatus
Jugular foramen
Foramen magnum
Cerebellar fossa
lntomal occipital crest
Internal occipital
protuberance
Cerebral fosaa
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foramina
The cranial nerves that supply motor innervations to the muscles that move
the eyeball all enter the orbit through a foramen that is between the:
lesser wing of sphenoid and frontal bone
lesser wing of sphenoid and ethmoid bone
greater and lesser wings of sphenoid bone
lesser wing of sphenoid, frontal and ethmoid bones
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greater and lesser wings of sphenoid bone
The superior orbital fissure is located posteriorly between t he greater and lesser wings of the
sphenoid bone. The superior orbital fissure communicates with the middle cranial fossa.
It transmits the: superior and inferior divisions of t he oculomotor nerve (CN Ill)
trochlear nerve (CN IV)
lacrimal, frontal, and nasociliary branches of t he ophthalmic nerve (CN Vl)
abducent nerve (CN VI)
superior and inferior divisions of t he ophthalmic vein
sympathetic fibers from the cavernous plexus
Bony Opening Location (Bone) Contents
Mandibular foramen Mandible Inferior alveolar nerve, artery, and vein
Petrotympanic Temporal Chorda tympani nerve
fissure
Foramen lacerum Sphenoid, occipital, Nerve of pterygoid canal (greater and deep
and temporal petrosal nerves), and artery of pterygoid canal
Supraorbital foramen Frontal Supraorbital nerve. artery. and vein
and canal
Infraorbital foramen Sphenoid and maxilla
Jnfr.sorbital nerve, artery, and vein
and canal
Pterygoid canal Sphenoid Area nerves and vessels
lntemal acoustic Temporal Facial and vestibulocochlear nerves
meatus
Extemal acoustic Temporal Opening to tympanic cavity
meatus
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Plerlon Coronal suture
Frontal bone Squamous suture
Sphenoparietal suture
Sphenofrontal suture
Sphenosquamous
suture
Supraorbital
foramen
Sphenoid bone,
greater wing
Ethmoid bone
Nasal bone
Anterior nasal
spine
Maxilla
Mandible
protuberance
Mental foramen
Lateral 'iew of tbe skuU
glenoid
tubercle
Zygomatic
Zygomatic arch
bone
External
acoustic
meatus
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respiratory system
Which of the following terms means air in the chest?
hemothorax
pyothorax
pneumothorax
pulmothorax
pulmonary inflation
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pneumothorax
A penetration wound of the chest wall can lead to a pneumothorax (air in the pleural cavity) or a
hemothorax (blood in the pleural cavity).ln both of these situations, the surface tension that binds
t he lungs to the chest wall is eliminated, and the lung will instantly shrink to the size of a tennis ball.
The lungs fill the pleural divisions of the thoracic cavity; they extend from the root of the neck to
the diaphragm. The lungs are the main component of the respiratory system; they distribute air and
exchange gases. The right and left lungs are separated by the mediastinum, which contains t he
heart, blood vessels, and other midline structures; fissures divide each lung into Jobes. Each
primary bronchus enters its respective lung at the hilus, an indentation on the mediastinal surface.
The bronchi and pulmonary blood vessels are bound together by connective tissue to form the root
of the lung. The base, the inferior surface of the lung, rests on the diaphragm. The apex, the most
superior portion of the lung, projects above the clavicle.
Right lung:
Has three Jobes (superior, middle, and inferior) and three secondary (lobar) bronchi
Contains ten bronchial segments (corresponding to the t ertiary bronchi)
Usually receives one bronchial artery
Has a slightly larger capacity than the left lung
The azygos vein leaves an impression on the right lung as the vein arches over the root
Left lung:
Has two Jobes (superior and inferior) and two secondary (lobar) bronchi
Contains eight bronchial segments (corresponding to the tertiary bronchi)
Contains a cardiac notch (on its superior lobe), which is an indentation providing room for
the heart
Usually receives two bronchial arteries
Contains a lingula, which is a tongue-shaped portion of its superior lobe that corresponds to
the middle lobe of the right lung
Each lung is enclosed in a double-layered pleural sac. One layer is called the visceral pleura; t he
other is called the parietal pleura. Between t he two layers is the pleural cavity, which is filled with
serous fluid.
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fissure
..._ __
notch lobe
Inferior
lobe
Right lung
(B) views
Inferior
lobe
Cardiac
notch
281
Costal surfaces of lungs. The lungs arc shown in isolation in antcrior(A) and lateral views (B), demon-
strating lobes and fissures. C. The heart and lungs are shown in situ.
Reproduced with permission from 1\>loorc KL. Dalley AF. and Agur AMR. Clinit<llfy Oriftu('({ An(llonty. 00 6. Wolters Kluwer. Baltimore. 2010.
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respiratory system
The ridge that marks the bifurcation of the trachea into the right and left pri-
mary bronchi is the:
carina
lingula
mediastinum
bronchial t ree
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carina
The trachea connects the upper respi ratory t ract to t he lower respi ratory tract. It i s about 9-15 em i n length.
It i s located i n front of t he esophagus and behi nd t he t hyroid gland i n the neck. It i s consi dered t o be i n the
superior and middle mediasti num. It i s made up of 16-20 incomplete hyaline carti laginous ri ngs that are
open posteri orly. The trachea bif urcates into t he ri ght and l eft mai n stem bronchi at a location called t he
carina, which i s located at t he level ofthe sternal angle (T4-T5). A series of ( -shaped ri ngs of hyaline car-
tilage strengthen the t rachea and prevent i t f rom collapsing during i nspirati on. The t rachea is lined wit h
ciliated pseudostr atified columnar epithelium and mucous-secreting goblet cells, which t rap i nhaled
debri s. Ciliary act ion moves debri s toward the oropharynx for removal by coughi ng.
The trachea branches off into t wo mai n bronchi, the l eft and right pri mary bronchi, which lead t o the left
and ri ght l ung respectively. The right l ung i s larger and heavi er t han t he left, but it is shorter and wi der
because the ri ght dome of t he diaphragm i s higher and the heart and pericardi um bulge more to the left .
The right and left mainstem bronchi branch from the trachea at different angles, t he right more vertical
and more di rectly i n l ine with the t rachea, t hus the right bronchus i s more likely to receive aspi rat ed
material. At thi s point i n breat hi ng, the ai r has been moistened, puri fi ed and warmed. Each bronchi ent ers
i ts l ung and begi ns on a series of branches, called the bronchial or respiratory tree. The first of these
branches is the lobar (secondary) branch. On the left , t here are t wo lobar branches, while on the right,
t here are three. Each lobar branches into one lobe. The next branch is called t he segment al (tertiary)
branch. Each branch conti nues to branch i nt o smaller and smaller bronchioles. The f inal branch is called
the terminal bronchioles. These bronchioles are smaller t han 0.5 mm i n diameter. Each of these t erminal
bronchioles gives rise t o several respiratory bronchiol es. Note: The first few l evels of bronchi are
supported by ri ngs of cartilage. Branches after t hat are supported by i rregularl y shaped discs of cart ilage,
while t he latest l evel s of the tree have no support whatsoever.
Note: The right main bronchus divides i nt o three lobar bronchi, and t he left main bronchus divides
i nt o two lobar bronchi. Each secondary or lobar bronchus serves one of the five lobes of the t wo l ungs.
Each respiratory bronchiole subdivides into several alveolar ducts, which end in cl usters of small, t hin-
walled air spaces called alveoli. These cl usters of alveol i are called alveolar sacs and form the funct ional
unit of t he lung.
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primary bronchus
Bronchi in situ -Anterior view
29 1
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respiratory system
Which of the following components of the respiratory system does NOT have
cilia?
tertiary bronchioles
primary bronchioles
alveolar ducts
respiratory bronchioles
terminal bronchioles
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alveolar ducts
Conducting bronchioles are smaller extensions of bronchi (little bronchi). Those devoid
of alveoli in their walls are nearer the hilum of the lung. These conducting passageways
deliver air to passageways that have alveoli. The last generations of conducting
bronchioles are called terminal bronchioles.
Respiratory bronchioles, continui ng from terminal bronchioles, branch nearer to the
alveolar ducts and sacs and have occasional alveoli in their wall s. These bronchioles
capable of respiring are the first generation of passageways of the respiratory portion
of the bronchial tree.
Remember:
The conducting zone of the respiratory system is made up of the nose, pharynx, lar-
ynx, t rachea, bronchi, bronchioles, and terminal bronchioles; their functi on is to fil ter,
warm, and moisten air and conduct it into the lungs. It's also called the dead zone be-
cause there is no 0
2
exchange happens here.
The respiratory zone is the site of oxygen and carbon dioxide gas exchange, and is
composed of t he respiratory bronchioles, alveolar ducts, and alveoli.
Bronchioles are characterized by:
A diameter of one millimeter or less
An epithelium that progresses from ciliated pseudostratified columnar to simple
cuboidal (respiratory bronchioles)
Small bronchioles have non-ciliated bronchiolar epithelial cells (Clara cells) that
secrete a surface-active lipoprotein
Walls devoid of glands in the underlying connective t issue
Woven bundles of smooth muscle to regulate t he bronchiolar diameter
Walls devoid of cartilage (small diameter prevents them f rom collapsing at end of
expiration)
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(A) (B)
The Trachea, Bronchi, Bronchioles, and Alveoli
(A) The trachea and bronchi
(B) The termination of bronchioles into alveoli
30-1
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respiratory system
Which of the following vessel s supply blood to the bronchi?
pulmonary arteries
pulmonary veins
subclavian arteries
none of the above
I refer to card 29-1, 30-1 for illustration!
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none of the above- the bronchial arteries supply blood to the bronchi
Each lung is shaped l ike a cone. It has a blunt apex, a concave base (that sits on the diaphragm), a
convex costal surface, and a concave mediastinal surface. At the mi ddle of the mediastinal surface, the
hilum is located, which is a depression in which the bronchi, vessels, and nerves that form the root enter
and l eave the lung.
The root of the lung contains the following structures:
Primary bronchus: the right and left bronchi arise from the trachea and carry ai r to the hil um of the
l ung during inspiration and carry ai r from the l ung duri ng expi ration
A pulmonary artery: enters the hilum of each lung carrying oxygen-poor blood
Pulmonary vein(s): a superior and inferior pair for each l ung leave the hilum carryi ng oxygen-rich
blood
1. The small bronchial arteries (whi ch are branches of the thoracic portion of the descending
aorta) also enter the hil um of each lung and del iver oxygen-rich blood to the t i ssues. The
bronchi al arteries tend to follow the bronchial tree to the respi ratory bronchioles where the
bronchial arteri es anastomose with the pulmonary vessel s.
2. Branches of the vagus nerve pass behind the root of each l ung to form the posterior pul-
monary plexus.
Innervation of the lung: The lung is i nnervated by parasympathetic nerves via the vagus and sympathetic
nerves derived from the second to fourth thoracic sympatheti c ganglia. These nerves form plexuses around
the hilus of the l ung and give rise to intrapulmonary nerves accompanying the bronchial tree and bl ood
vessels. Both sympathetic and parasympatheti c nerves to the lung contain efferent and afferent fibers.
Important: When foreign objects are aspirated into the trachea, they usually pass into the right primary
bronchus because it is larger, straighter, and shorter than the left. It is also i n a more di rect li ne wi th the tra-
chea (important in a dental chair because if a patient swallows an object it tends to lodge i n the right
bronchus).
Tubercul osis seems to be more common i n the right l ung than the l eft due to the shorter right bronchus.
The reason that the di sease is usually restricted to the apex of the lungs i s due to the fact that venti la-
tion/ perfusion rati o is high as the blood flow is reduced leading to higher alveolar P0
2
this provides a bet-
ter envi ronment for the obl igate aerobes to grow.
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respiratory system
Which of the following is NOT a part of the lower respiratory tract?
laryngopharynx
trachea
primary bronchus
alveolar duct
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laryngopharynx
The mediastinum lies between the right and left pleura in and near the median sagittal plane of the
chest. It extends from the sternum in front to the vertebral column behind, and contains all the tho-
racic viscera except the lungs. It may be divided for purposes of description into two parts:
An upper portion, above the upper level of the pericardium, which is named the superior me-
diastinum
A lower portion (inferior mediastinum) which is subdivided into three parts:
- that in front of the pericardium, the anterior mediastinum
-that containing the pericardium and its contents, the middle mediastinum
-and that behind the pericardium, the posterior mediastinum
The respiratory system consists of the upper and lower respiratory tracts, the lungs, and the thoracic
cage. The respiratory system is designed to exchange the carbon dioxide accumulated in the blood
for oxygen in the airways, which enters the lungs as air from the surrounding atmosphere.
Blood travels continuously through t wo different circulations: the pulmonary and the systemic cir-
culations. The heart pumps deoxygenated blood from the veins of the systemic circulation into the
arteries of the pulmonary circulation. This blood is oxygenated by the lungs, and then flows back to
the heart to be pumped into the arteries of the systemic circulation.
The structures of the upper respiratory tract include the nose, mouth, nasopharynx, oropharynx,
laryngopharynx, and larynx. Besides warming and humidifying inhaled air, these structures provide
for taste, smell, and the chewing and swallowing of food.
The lower respiratory tract structures are the trachea, bronchi, and lungs. Bronchi branch into bron-
chioles, which in turn branch into lobules. The lobule includes the terminal bronchioles and alveoli.
A mucous membrane containing hair-like cilia lines the lower tract. Functionally, the lower tract is
subdivided into conducting airways (the trachea and the primary, lobar, and segmental bronchi)
and alveoli, the sites of gas exchange.
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primary bronchus
Diaphragm
Respiratory System
32 1
Reproduced with perm1ssion from BaJTons Ant11omy fo1:bh Card.;;:. Australia. 2009. Global Book l'ublshing.
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respiratory system
All of the paranasal sinuses drain into one of the three meatuses (superior,
middle, and inferior) EXCEPT one. Which one is the EXCEPTION?
maxillary sinus
frontal sinus
ethmoidal sinus
sphenoidal sinus
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sphenoidal sinus- which drains into sphenoethmoidal recess
Air enters through the nostrils (external nares) that lead to the vestibules of the nose.
The bony roof of the nasal cavity is formed by the cribriform plate ofthe ethmoid bone.
The lateral walls have bony projections cal led conchae (superior, middle, and inferior),
which are also referred to as the nasal turbinates. These conchae form shelves that have
spaces (or grooves) beneath them cal led meatuses (superior, middle, and inferior). All
of the paired paranasal sinuses drain into the nasal cavity by way of these meatuses
except for the sphenoidal sinus which drains into the sphenoethmoidal recess. The na-
solacrimal duct, which drains tears f rom the surface of the eyes, also empties into the
nasal cavity by way of the inferior meatus. The f loor is formed by the hard palate. The
nasal cavity opens posteri orly into the nasopharynx via funnel-li ke openings called the
choanae (posterior nares). The maxillary sinus drains into the middle meatus through
the semil unar hiatus.
1. The vestibules are li ned with nonkeratinized stratified squamous ep-
ithelium.
2. The conchae of the nasal fossae are lined with pseudostratified ciliated
columnar epithel ium.
3. The olfactory epithelium is very prominent in the upper medial portion of
the nasal cavity. Both olfactory and respiratory epithelium are characterized
as pseudostratified columnar epithel ium; olfactory epithelium is unique in
that it contains olfactory sensory cell s.
4. The nasal cavity receives sensory innervation from the olfactory nerve for
smell and f rom the trigeminal nerve for other sensations. The nasal cavity's
blood supply is from branches of the ophthalmic and maxillary arteries.
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Inferior
nasal
meatus
Lateral Wall of Nose
Reproduced with pcnmssion from Atlll.1 ojH11man AlllJtiJmy: Springhouse:. 2001. Springhouse.
Nasal
vestibule
33 1
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respiratory system
While ascending to 30,000 feet, the passengers on a commercial flight expe-
rience the sensation of their ears "popping:' The swallowing or yawning that
triggers this equalizes the pressure of the middle ear with the surrounding
atmosphere via the eustachian (auditory) tube. The pharyngeal opening for
this tube, along with the salpingopharyngeal fold, pharyngeal recess, and
pharyngeal tonsils (adenoids) are all located in the:
laryngopharynx
oropharynx
nasopharynx
none of the above
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nasopharynx
The pharynx (the throat) is a t ube that serves as a passageway for the respiratory and di-
gestive tracts. It extends from the mouth and nasal cavities to the larynx and esophagus.
The pharynx is divided into three regions:
1. Nasopharynx- is the most superior division of the pharynx. It is inferior to the sphe-
noid bone and li es at the level of the soft palate. The pharynx is li ned with ciliated pseu-
dostratified epithelium (respiratory epitheli um). The nasopharynx has four openings:
two auditory (eustachian) tubes: each opening out of a lateral wall and connecting
with the mi ddle ear (tympanic cavity)
two openings of the posterior nares (choanae)
Note: nasopharynx -location of the pharyngeal tonsils
The soft palate and uvula form the anterior wall of the nasopharynx. Note: The tensor veli
palatini and the levator veli palatini muscles prevent food from entering the nasophar-
ynx.
2. Oropharynx - the middle division of the pharynx; is continuous with the posterior
oral cavity and is lined with stratifi ed squamous epithelium. The oropharynx extends in-
feriorly from the soft palate to the hyoid bone. The opening into the oropharynx from the
mouth is call ed the fauces. The lingual tonsils protrude into the oropharynx from the
oral cavity at the base of the tongue. The anterolateral walls of the oropharynx support
the palatine tonsils. It is a food and air passageway.
3. Laryngopharynx- is the most inferior division of the pharynx; the laryngopharynx ex-
tends from the hyoid bone to the opening of the esophagus. The laryngopharynx is li ned
with stratified squamous epithelium. extends from the oropharynx above to the larynx
and esophagus. The laryngopharynx also serves as a passageway for food and air. Air
entering the laryngopharynx goes to the larynx whil e food goes to the esophagus.
Note: Food entering the larynx would be expelled by violent coughing.
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Middle turbinate
Inferior turbinate
Vestibule
Pharynx
Pharyngeal tonsil (adenoids)
34-1
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respiratory system
A women in Ethiopia who has a human papillomavirus infection, starts to
grow warts on her larynx and respiratory tract. In order to allow her to breathe
an emergency airway maybe established by opening into the trachea:
through the thyrohyoid membrane
between the thyroid and cricoid cartilage
between thyroid cartilages
above the level of thyroid cartilage
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between the thyroid and cricoid cartilage
An emergency tracheotomy (tracheostomy) is most easil y made by an incision
through the median cricothyroid ligament. This li gament runs from the cricoid cartilage
to t he thyroid cart il age and is inferior to t he space between the vocal cords (rima glot-
tidis) where aspirated objects usuall y get lodged. The tracheotomy all ows for air to
pass between the lungs and the outside air. Important: The space entered is cal led
the cricothyroid space.
Important: A cricothyrotomy is preferabl e to tracheostomy for non-surgeons in
emergency respiratory obstructions. In t his procedure, an incision is made through
the skin and cricothyroid membrane for t he reli ef of acute respiratory obstruction.
Note: A t racheotomy (tracheostomy) is rarely performed and is li mited to patients with
extensive laryngeal damage and infants wit h severe airway obstruction. Because of
the presence of major vascular structures (carotid arteries and internal jugular vein), t he
thyroid gland, nerves (recurrent laryngeal branch of the vagus nerve), the pleural cav-
ities, and t he esophagus, meticulous attention to anatomical detail has to be observed.
Laryngeal prominence (Adam's apple) is a protuberance t hat is formed by the angle
ofthe thyroid cartilage surrounding t he larynx. This protuberance is more pronounced
in men.
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respiratory system
Which of the following describes the function of the surfactant?
increases the surface area of the alveoli
reduces the attractive forces of 0
2
molecules and increases surface tension
reduces the cohesive force of H
2
0 molecules and lowers surface tension
increases the cohesive force of ai r molecules and raises surface tension
none of the above
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reduces the cohesive force of H
2
0 molecules and lowers surface tension
Surfactant is a complex substance containing phospholipids and a number of apopro-
teins. This essential fluid is produced by the Type II alveolar cells, and lines the alveoli
and smallest bronchi oles. Surfactant reduces surface tension throughout the lung,
thereby contributing to its general compli ance. It is also important because it stabi-
lizes the alveoli.
Neonatal respiratory distress syndrome (or respiratory distress syndrome of new-
born) is a syndrome in premature infants caused by developmental insufficiency of
surfactant production and structural immaturi ty in the lungs. It begins short ly after
birt h and is manifest by tachypnea, tachycardia, chest wall retractions (recession), ex-
piratory grunting, nasal fl aring and cyanosis during breathing efforts.
Cells of respiratory mucosa:
Clara cells are dome-shaped cell s with short microvilli found in the small airways
(bronchi oles) of the lungs. Clara cells are found in the ci li ated simple epithelium.
These cell s may secrete glycosaminoglycans to protect t he bronchiole l ining.
Type I pneumocytes (simpl e squamous alveolar cells) are responsible for gas ex-
change in t he alveoli and cover a majority of t he alveolar surface area (>95%).
Type II pneumocytes are granular and roughly cuboidal in shape. They cover a
much small er surface area t han type I cell s (<5%). Their function is t he production
and secretion of surfactant (the majority of which are dipalmitoylphosphatidyl-
choli ne), a group of phospholipids t hat reduce t he alveolar surface tension.
Alveolar macrophages (or dust cell s) are type of macrophages found in t he pul-
monary alveolus, near t he pneumocytes, but separated f rom the wall. Dust cells are
another name for monocyte derivatives in t he lungs t hat reside on respiratory sur-
faces and cl ean off particles such as dust or microorganisms.
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arteries
The external carotid artery terminates within the parotid gland, just behind
the neck of the mandible, where the external carotid artery gives off two final
branches. Which of the following is one of those terminal branches?
superior thyroid artery
superficial temporal artery
posterior auricular artery
occipital artery
facial artery
middle meningeal artery
anterior ethmoidal artery
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superficial temporal artery
The external carotid artery suppli es st ructures within the neck, face, and scalp, and also
supplies the maxilla and tongue. As with t he internal caroti d artery, the external carotid
artery begins at the upper border of the thyroid cartilage (i.e., at the termi nation of the
common carotid artery and t he carotid sheath). The external carotid artery termi nates
within the parotid gland, j ust behind the neck of the mandible, where the artery gives off
two final branches, the superficial temporal and the maxillary arteries. Note: At its
origin, where pulsations can be felt, the external carotid artery lies within the carotid
triangle.
Branches of the external carotid artery (from inferior to superior):
Superior thyroid artery - supplies thyroid gland, gives off a branch to t he sterno-
cleidomastoid muscle and superior laryngeal artery
Lingual artery- suppli es the tongue
Facial artery- supplies the face, including lips and the submandibular gland
Ascending pharyngeal artery - supplies the pharyngeal wall
Occipital artery- supplies the pharynx and suboccipital triangle
Posterior auricular artery - suppli es back of the scalp
Maxillary artery - terminal branch of external carotid, it gives off branches to the
mandibl e, and the middle meningeal artery before passing through the
pterygomaxillary fi ssure to enter the pterygopalatine fossa to supply t he maxilla
Superficial temporal artery- terminal branch of external caroti d, supplies skin over
frontal and temporal regions of scalp
Mnemonic of the external carotid artery branches (Egyptian one):
"Some American Lady Found Our Pyramids So Magnificent"
Important: The external carotid artery and its branches supply t he muscles of the neck
and face, thyroid gland, salivary glands, scalp, tongue, jaws, and teeth.
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Reproduced With pt'nn1ssion from Fehren-
bach MJ, Ht'1Ting SW: Jllu.flratetf Anatomy
and Neck. ed 1: St. Louis, 2007,
Saunders.
Parietal branch
1-- - ----+-l'':\--ofsuperficial
temporal artery
Pathway of the Superficial Temporal Artery
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Pathway of the Facial Artery
37 A l
Rqwoduccd With pemliSlHOO (rom Fehrenbach MJ. Herring SW; 11/u:urated A11atmny o[tl1e Head and Neck, tNI J; St Louis. 2007. Saunders.
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arteries
The Circle of Willis is formed by all of the following arteries EXCEPT one. Which
one is the EXCEPTION?
anterior communicating artery
posterior communicating artery
anterior cerebral artery
superior cerebell ar artery
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superior cerebellar artery
Blood is supplied to the brain, face, and scalp via two major sets of vessels: the right and left
common carotid arteries and the right and left vertebral arteries. The right common carotid
arises from the brachiocephalic trunk, while the left common carotid arises from the aortic
arch directly. The common carotid lies within the carotid sheath and runs upwards in the neck to
the superior border of the thyroid cartilage. Here it divides into t wo pairs of blood vessels, the
external and internal carotid arteries. The external carotid arteries supply the face and scalp with
blood. The internal carotid arteries divide furt her in the middle cranial fossa into the anterior and
middle cerebral arteries, which supply blood to the anterior three-fifths of cerebrum, except for
parts of the temporal and occipital lobes. The vertebrobasilar arteries supply the posterior two-
fifths of the cerebrum, part of the cerebellum, and the brain stem.
Remember:
Four major arteries, t he two vertebral and the two carotid, supply the brain with oxygenated
blood. The two vertebral arteries (which are branches of t he subclavians) converge to become
the basilar artery, which supplies the posterior brain.
The circle of Willis (also called the cerebral arterial circle) is formed by:
Terminal part of internal carotid artery (left and right)
Anterior cerebral artery (left and right)
Middle cerebral artery (left and right)
Posterior cerebral artery (branch of basilar artery) (left and right)
Anterior communicating artery
Posterior communicating artery
**"* This ci rcle of Will is forms an important means of collateral circulation in the event of
obstruction.
The internal carotid artery has no branches outside the skull and enters the skull through the
carotid canal. Inside the skull, the internal carotid artery gives off the ophthalmic artery, which
supplies the optic nerve, eye, orbit, and scalp. The artery t erminates by passing through t he
cavernous sinus to join the c.ircle of Willis and supply the brain.
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Anterior communicating
Arterial Blood Supply of Cerebral Hemispheres
38 1
Reproduced With pem1issum (rom Moore KL. Dalley AF. Agur AMR: Clinical Oriented Anatomy. eJ 6; Baltimore, 2010. Lippincott Will iams
&Walkins.
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right common
carotid artery
brachiocephalic
artery
right subclavian
artery
aorta
sternocleidomastoid

left subclavian
artery
clavicle
first rib
Origins from the heart of the arterial blood supply for the head and neck highlight-
ing the pathways ofthe common carotid and subclavian arteries. Note the pathways
are different on the right and left sides of the body.

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arteries
In carotid sinus syncope, the carotid sinus is overly sensitive to manual stim-
ulation and can lead to loss of consciousness. Given this, which of the follow-
ing statements is true?
it is stimulated by changes in blood pressure
it functions as a chemoreceptor
it is innervated by the facial nerve
it is located at the terminal end of the external carotid artery
it communicates freely with the cavernous sinus
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it is stimulated by changes in blood pressure
The carotid sinus is a localized dilation of the internal carotid artery at i ts origin, the common
carotid artery. The carotid sinus contains numerous baroreceptors, which function as a "sam-
pling area" for many homeostatic mechanisms for maintaining blood pressure. The carotid sinus
baroreceptors are innervated by the sinus nerve of Hering, which is a branch of cranial nerve
IX (glossopharyngeal nerve).
The carotid body is a small cluster of chemoreceptors and supporting cells located near the bi-
furcation of the common carotid artery. The carotid body detects changes in the composition
of arterial blood flowing through it, mainly the partial pressure of oxygen, but also of carbon
dioxide. Furthermore, i t is also sensitive to changes in pH and temperature.
The aortic body is one of several small clusters of chemoreceptors, baroreceptors, and sup-
porting cells located along t he aortic arch. l t measures changes in blood pressure and the com-
position of arterial blood flowing past it, including the partial pressures of oxygen and carbon
dioxide and pH. The aortic body is innervated by cranial nerve X (vagus nerve).
The baroreflex or baroreceptor reflex is one of the body's homeostatic mechanisms for main-
taining blood pressure. It provides a negative feedback loop in which an elevated blood pres-
sure reflexively causes heart rate to decrease therefore causing blood pressure to decrease;
likewise, decreased blood pressure activates t he baroreflex, causing heart rate to increase t hus
causing an increase in blood pressure. The system relies on specialized neurons, known as
baroreceptors, in the aortic arch, carotid sinuses, and elsewhere to monitor changes in blood
pressure and relay them to the brainstem. Subsequent changes in blood pressure are mediated
by the autonomic nervous system.
Carotid sinus syndrome is a temporary loss of consciousness that sometimes accompanies
convulsive seizures because of the intensity of the carotid sinus reflex when pressure builds in
one or both carotid sinuses.
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External carotid artery
Internal carotid
Pathway of the internal carotid artery after
branching off the common carotid artery
39 1
Rqwoduccd With pemliSlHOO (rom Fehrenbach MJ. Herring SW; 11/u:urated A11atmny o[tl1e Head and Neck, eil J; St Louis. 2007. Saunders.
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arteries
Which of the following branches of the internal carotid artery is most fre-
quently implicated in a stroke?
ophthalmic artery
anteri or choroidal artery
middle cerebral artery
anteri or cerebral artery
I refer to card 38-1 for illustration)
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middle cerebral art ery
The middle cerebral artery is the largest branch of the internal carotid. The artery
supplies a portion of the frontal lobe and the lateral surface of the temporal and parietal
lobes, including the primary motor and sensory areas of the face, throat, hand, and arm
and in the dominant hemisphere, the areas for speech. The middle cerebral artery is the
artery most often occl uded in stroke.
Note: Small, deep penetrating arteries known as the lenticulost riate arteries branch
from the middle cerebral artery. These arteries are often called the "arteries of stroke"
because they are often involved in a stroke (also called a cerebrovascul ar accident).
The anterior cerebral artery is the small er branch of the internal carotid artery that
supplies oxygenated blood to most medial portions of the f rontal lobes and superior
medial parietal lobes. The left and right anterior cerebral arteries are connected by the
anterior communicating artery (part of Circle of Willis).
Stroke warning signs:
Sudden weakness, paralysis, or numbness of the face, arm, and leg on one or both
sides of the body
Loss of speech or diffi culty speaking or understanding speech
Dimness or loss of vision, particularly in only one eye
Unexplained dizziness (especially when associated with other neurologic symptoms),
unsteadiness, and sudden falls
Sudden severe headache and loss of consciousness
An int racranial berry aneurysm, also known as a saccular aneurysm, is a sac-l ike out-
pouching in a cerebral blood vessel, which can seem berry-shaped, hence the name. Once
a berry aneurysm has formed it is likely to rupture, causing a stroke. Thus they are serious
medical emergencies, and should be treated as soon as possible. Note: Berry aneurysms are
usually found in the region of the Circle of Willi s.
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arteries
The sinusoids are most likely found in all of the following organs EXCEPT one.
Which one is the EXCEPTION?
spleen
bone marrow
cartilage
parathyroid glands
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cartilage
A sinusoid is a small blood vessel simil ar to a capillary but wit h a discontinuous en-
dothelium. Sinusoids are found in the liver, lymphoid t issue, endocrine organs, and
hematopoietic organs such as the bone marrow and the spleen.
Sinusoids are highly permeable, having larger inter-cellular clefts, fewer t ight junctions,
and discont inuous endothelial cells (meaning t hat t he individual endothel ial cells do
not overlap as in capillaries and are spread out). The level of permeabil ity is such as to
all ow small - and medium-sized prot eins such as albumin t o enter and leave the blood-
stream. Some spaces are large enough for blood cel ls to pass. Oxygen, carbon dioxide,
nut ri ents, protei ns, and wastes are exchanged t hrough the t hin walls of t he sinusoids.
Sinusoids:
Have a large lumen (30 to 40 microns in diamet er) - capillaries have a small
lumen (average 8 microns in diameter)
Are wider and more irregular than capil laries
Have walls that consist partly of phagocytic cells
Form a part of t he reticuloendothelial system, which is concerned chiefly with
phagocytosis and antibody formation
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arteries
The most prominent functional component in the tunica media of large
arteries is the:
skeletal muscle cells
elastic f ibers
smooth muscle cells
coll agen f ibers
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elastic fibers
*** Key: If the question referred to small arteries, the answer would have been
smooth muscle cells.
The wall s of blood vessels are composed of the foll owing tunics (layers):
1. Tunica intima - innermost layer, consists of a layer of simple squamous epithel i-
um (call ed endothelium) and a thin connective-tissue basement membrane. The
endotheli um of this layer is the only layer present in vessels of all sizes.
Note: Atherosclerosis is the emergence of plaque between the basement mem-
brane and the endotheli al cells of the tunica intima.
2. Tunica media - middle layer, is usually very thick in arteries, and consists of
smooth muscle f ibers mixed with elastic fibers. Increases or decreases lumen diam-
eter; affects blood pressure.
3. Tunica adventitia - an outer layer of connective t issue, containing elastic and
coll agenous f ibers. The tunica adventit ia of the larger vessels is infiltrated with a
system of tiny blood vessels call ed vasa vasorum ("vessels of the vessels") that
nourish the more external tissues of the blood vessel wall.
Blood is carried away from the heart in large vessels call ed arteries. These divide into
smal ler arteries, and the small er arteries divide into arterioles. Arteri oles divide into
microscopic capillaries (the exchange area of the system). The capil laries converge to
form vessels called venules, which join to form still larger vessels called veins. Veins
return the blood to the heart.
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I Tunica Intima
.,.lli".--oruernal olastJc
Muscular artery
Tunica adventltJa
enous and elastic tissue
and vasa vasorum))
large vein
vasa vasorum)
Muscular artery and large vein. Arteries have a more muscular wall, thus a much thicker tunica media
than the veins, and they have a greater amount of elastic tissue. Conversely, the tunica adventitia of veins
are much thicker than those of the arteries. The outermost layer is the tunica adventitia, composed of
fibroelastic connective tissue, whose vessels, the vasa vasorum, penetrate the outer regions of the tu-
nica media, supplying its cells with Remember: Veins, unlike arteries, may possess valves that
prevent the retlux of blood.
42 1
Rqwoduccd with pemtissuln (rom Gartner LP. Htntt JL; Color Atlcu ed 5, Bnhimore. 200C), Lappincolt \Valhnms & Wtlkins.
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arteries
The tunica media and adventitia are absent in which blood vessel type?
arteries
arterioles
capil laries
venules
veins
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capillaries
Through capi ll ary walls, which consist of a single layer of endothelial cell s, blood and
tissue cells exchange gases and metabolites.
Capillaries are tiny blood vessels with extremely thin wall s that consist of endotheli -
um only; no tunica media or adventitia is present. They join arteri oles and venules.
These blood vessels accommodate erythrocytes one at a time.
In certain structures (liver, spleen, bone marrow, and certain glands), the arterioles,
rather than connecting with capill aries, empty into blood vessels call ed sinusoids.
They have very, very thin walls that conform to the space in which they are located
(form i rregular tortuous tubes).
8
1. The velocity of blood flow is slowest in capill aries.
2. A decrease in vessel diameter causes an increase in resistance to blood
flow.
Poiseuille's Law: F=
81']1
In which F is the rate of blood flow, t.P is the pressure
difference between the ends of the vessel, r is the radius
of the vessel, 1 is the length of the vessel, and 11 is vis-
cosity of the blood.
Note particularly in t his equation t hat t he rate of blood flow is directly proportional to
the fourth power of the radius of the vessel, whi ch demonstrates once again t hat
the diameter of a blood vessel (which is equal to twice the radius) plays by far the
greatest role of all factors in determining the rate of blood flow t hrough a vessel.
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Continuous Capillary
Sinusoidal (Discontinuous) Capillary
Fenestrated Capil lary
Capillaries consist of a simple squamous epithelium rolled into
a narrow cylinder 8-10 p m in diameter. Continuous (somaHc)
capillaries have no fenestrae; material traverses the endothe-
lia l cell in either direction via pinocytotic vesicles. Fenes-
trated (visceral) capillaries are characterized by the presence
of perforations, fenestrae, 60-80 p m in diameter, which may
or may not be bridged by a diaphragm. Sinusoidal capillar-
ies have a large lumen (30-40 pm in diameter), possess nu-
merous fenestrae, have discontinuous basal lamina, and lack
pinocytotic vesicles. Frequently, adjacent endothelial cells of
s inusoida l capillaries overlap one another in an incomplete
fashion.
43- t
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The hepatic veins that drain the liver empty into the:
hepatic sinusoids
azygous vein
inferi or vena cava
inferi or vena cava and azygous veins
portal vein
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inferior vena cava
The hepatic artery brings oxygenated blood to the li ver, while the hepatic portal
vein bri ngs food-laden blood from the abdominal viscera.
Remember: All the blood supplied to the l iver from the hepatic arteri es and the por-
tal vein eventually drains via the hepatic veins to the inferior vena cava.
Important: The most unusual aspect of hepatic circulation is that all the blood
supplied to the li ver from the hepatic arteri es and the portal vein empties into the
same sinusoids (minute endotheli al-li ned passageways in the liver lobules), which
therefore contain a mixture of arterial and venous blood. The sinusoids of each lobule
empty into a common central vein. The common central vein of each lobule then
empties into one of three hepatic veins. These veins all empty into the inferior vena
cava, which transports the blood to the heart.
Remember: The portal triad is a distinctive arrangement in the liver. It is a compo-
nent of the hepatic lobule and consists of the following structures:
Hepatic artery
Portal vein
Bil e duct
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Hepatic ar chitecture - lobule and acinus. (A} Diagram showing the architecture of the liver and
the relationship between the vessels and ducts in the portal trdct, the sinusoids and the central veins.
44-1
Reproduced wilh pcnn ission from Stevens A. l.owt' J: Huma11 iN/ J. Phaladdphaa. 200S. !!bevier.
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Aorta Hepatic portal vein
Hepatic artery
Central veins
The Pathway of Blood Through the Liver
44 A I
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arteries
The greatest drop in blood pressure is seen at the transition from:
arterioles to capi ll aries
arteries to arterioles
capil laries to venules
venules to veins
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arteries to arterioles
Important: The highest pressure of circulating blood is found in arteries, and gradu-
ally drops as the blood flows through the arterioles, capil laries, venules, and veins
(where it is the lowest). The greatest drop in blood pressure occurs at the transition
from arteries to arterioles.
Arterioles are one of the blood vessels of the smallest branch of the arterial circula-
tion. Blood flowing from the heart is pumped by the left ventricle to the aorta (largest
artery), which in turn branches into smaller arteries and final ly into arterioles. The
blood continues to flow through these arterioles into capi ll aries, venules, and finally
veins, which return the blood to the heart.
Arterioles have a very small diameter (<0.5 mm), a small lumen, and a relatively
thick tunica media that is composed almost enti rel y of smooth muscle, with li ttle
elastic t issue. This smooth muscle constricts and di lates in response to neurochemical
stimuli, which in turn changes the diameter of the arterioles. This causes profound
and rapid changes in peripheral resistance. This change in diameter of the arteri-
oles regulates the flow of blood into the capillaries. Note: By affecting peripheral
resistance, arterioles directly affect arterial blood pressure.
Primary function of each type of blood vessel:
- Arteries - transport blood away from the heart, generally have blood that is ri ch
in oxygen
-Arterioles- control blood pressure
-Capi ll aries- diffusion of nutrients/oxygen
-Veins- carry blood back to the heart, generally have blood that is low in oxygen
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arteries
All of the following vessels supply blood to the tonsils EXCEPT one. Which
one is the EXCEPTION?
ascending pharyngeal artery
tonsil lar branch of facial artery
superior labial artery
dorsal lingual artery
I refer to card 37 A-1 for illustration I
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superior labial artery
The facial artery supplies blood to t he face, tonsils, palate, labial glands, and muscles of t he
lips. The facial artery also supplies the submandibular gland, the ala and dorsum of the nose,
and t he muscles of facial expression.
The facial artery originates in t he external carotid artery and gives off branches t hat supply
the neck and face. Branches of the facial art ery (cervical and facial portion) include:
Cervical portion:
Tonsillar - to the tonsils
Ascending palatine - ascends alongside the pharynx, to reach the base of the skull
Submental -to the area below the chin, the submandibular salivary glands and a
portion of the sublingual salivary glands
Facial portion:
Inferior labial -to t he lower lip
Superior labial - to the upper li p and vestibule of nose
Lateral nasal - to the lateral wall of the nose (outer side)
Angular - to the medial side of the eye. It is t he terminal branch of the facial artery
and can anastomose with t he dorsal nasal branch of the ophthalmic artery
Blood supply of palatine tonsils: Blood supply is provided by tonsillar branches of five arter-
ies: the dorsal lingual artery (of t he lingual artery), ascending palatine artery (of the facial
artery), tonsillar branch (of the facial artery), ascending pharyngeal artery (of t he external
carotid artery), and t he lesser palatine artery (of the descending palatine artery). The tonsils
venous drainage is by t he peritonsillar plexus, which drain into t he lingual and pharyngeal
veins, which in turn drain into the internal j ugular vein.
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Pathway of the Facial Artery
37 A l
Rqwoduccd With pemliSlHOO (rom Fehrenbach MJ. Herring SW; 11/u:urated A11atmny o[tl1e Head and Neck, tNI J; St Louis. 2007. Saunders.
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arteries
Which of the following arteries is found between the hyoglossus and
genioglossus muscles?
inferi or alveolar artery
posterior superior alveolar artery
l ingual artery
infraorbital artery
facial artery
[refer to card 37 A-1 for illustration]
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lingual artery
The lingual artery arises from the anterior surface of the external carotid artery,
opposite the tip of the greater cornu of the hyoid bone. The li ngual artery loops
upward and then passes deep to the posterior border of the hyoglossus muscle to
enter the submandibular region. The loop is crossed superficially by the hypoglossal
nerve. The loop supplies blood to the tongue, suprahyoid region, sublingual gland,
palatine tonsil s, and floor of the mouth.
Important: In the oral region, the lingual artery usual ly is found between the hyo-
glossus and genioglossus muscles.
Branches of the lingual artery include the suprahyoid, dorsal lingual, subli ngual, and
deep lingual branches.
Note: The inferior alveolar vein, artery, and nerve along with the lingual nerve are
found in the space between the medial pterygoid muscle and the ramus of the mandible
(pterygomandibular space).
Important: The injection site for the inferior alveolar nerve block is probed with a
cotton t ip applicator at the depth of the pterygomandibular space on the medial
surface of the ramus. The needle is inserted into the tissues of the pterygomandibu-
lar space until the mandible is contacted. The needle is withdrawn 1 mm from the tis-
sues to protect the peri osteum, and then the injection is administered.
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arteries
If the palatal mucosa opposite to the maxillary first molar was lacerated and
bleeding occurred, which of the following arteries is most likely to be
involved?
greater palatine artery
descending palatine artery
nasopalatine artery
lesser palatine artery
middle superior alveolar artery
posterior superi or alveolar artery
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greater palatine artery
In t he pterygopalatine fossa, the maxillary artery gives rise to the descending
palatine artery, whi ch travels to the palate through the pterygopalatine canal, which
then terminates in both the greater palatine artery and lesser palatine artery by
way of the greater and lesser palatine foramina to supply the hard and soft palates,
respectively.
The maxill ary artery ends by becoming t he sphenopalatine artery, which suppl ies
the nasal cavity. The sphenopalatine artery gives rise to t he posterior lateral nasal
branches and septal branches, including a nasopalatine branch that accompanies
the nasopalatine nerve through the incisive foramen on the maxilla.
1. The greater palatine artery suppli es the mucosa of the hard palate poste-
rior to the maxil lary canine.
2. Mucosa of the hard palate anterior to the maxillary canine is supplied by
the nasopalatine artery.
3. The soft palate and tonsils are suppli ed by the lesser palatine artery.
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Greater palatine
artery
Pterygopalatine
(opened)
Pathways of the greater palatine artery, lesser palatine artery,
and sphenopalatine artery
43-1
Rqwoduccd With pemliSlHOO (rom Fehrenbach MJ. Herring SW; 11/u:urated A11atmny o[tl1e Head and Neck, tNI J; St Louis. 2007. Saunders.
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lateral posterior
nasal arteries
Posterior septal
branches
lesser palatine
artery
Greater palatine artery
Sphenopalatine artery. Medial view of right nasal wall and right sphenopalatine artery. The
sphenopalatine artery enters the nasal cavity through the sphenopalatine foramen. The anterior por-
tion of the nasal septum contains a highly vascularized region (Kiesselbach's area), which is sup-
plied by both the posterior septal branches of the sphenopalatine artery (external carotid artery)
and the anterior septa l branches of the anterior ethmoidal artery (internal carotid arte1y via oph-
thalmic artery). When severe nasopharyngeal bleeding occurs, it may be necessary to ligate the
maxi llary artery in the pterygopalatine fossa.
48AI
Reproduced wilh from Shucnkc M. Schultc E, Schumacher U; Head and Neck Ana/Omyfor Vema/ MN/ici11e; New York, 1010,
Tlucmc Medical Publishers.
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arteries
Examination of a patient with an ulcerative carcinoma of the posterior third
of the tongue revealed bleeding from the lesion and difficulty swallowing
(dysphagia). The bleeding was seen to be arterial; which of the following
arteries was involved?
deep lingual artery
dorsal li ngual artery
tonsillar artery
sublingual artery
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dorsal lingual artery
***The dorsal lingual artery runs on the superficial surface of the tongue - it is a branch of the
lingual artery that delivers blood to the posterior superficial tongue. So, this artery must be the
source of the hemorrhage.
The tongue is supplied by the lingual artery, the tonsillar branch of the facial artery, and the
ascending pharyngeal artery. The veins drain into the internal jugular vein.
The lingual artery arises from the external carotid artery at the level of the tip of the greater
horn of the hyoid bone in the carotid triangle. Branches include:
Dorsal lingual: supplies the base and body of the tongue (posterior superficial tongue}
Suprahyoid: supplies the suprahyoid muscles
Sublingual: supplies the mylohyoid muscle, sublingual salivary gland, and mucous membr-
anes of the floor of the mouth
Deep lingual (terminal branch}: supplies the apex of the tongue
Remember (information about the tongue}:
1. Motor innervation is from the hypoglossal nerve (CN XII} except for palatoglossus
muscle which i s innervated by vagus nerve (CN X}.
2. Sensory innervation - lingual (branch of trigeminal CN V-3} supplies the anterior two-
thirds, glossopharyngeal (CN IX} supplies the posterior one-third (including vallate papill-
ae}, vagus (CN X} through the internal laryngeal nerve supplies the area near the epigl ot-
tis.
3. Taste- facial (CN VII} via chorda tympani supplies the anterior two-thirds; glossophar-
yngeal (CN IX} supplies the posterior one-third.
1. The tonsillar artery is a branch of the facial artery that also supplies blood to the
palatine tonsil.
2. The ascending pharyngeal artery is the smallest branch of the external carotid
artery. Branches include the pharyngeal and meningeal arteries.
3. The lingual artery and facial artery often arise from a common trunk of the external
carotid artery.
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Maxillary artery
Facial artery
lingual
Pathway of the external carotid artery after branching off the common carotid artery
49-1
Rq'lroduccd With pc:m1issum (rom c h ~ n b a c h MJ. Herring SW: 11/u.fll'ated A11atomy oftlle Head and Neck. ed J; St Louis. 2007. Saunders.
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GG Genioglossus
JiG Hyoglossus
l\1 Mandible
MC Middle pharyngeal constrictor
SG Styloglossus
SLSublingual gland
Blood supply of the tongue. The main artery to the tongue is the lingual, a branch of the external
carotid artery. The dorsal lingual arteries provide blood supply to the root of the tongue and a branch
to the palatine tonsi l. The deep lingual a11eries supply the body of the tongue. The sublingual ar
teries provide blood supply to the floor of the mouth, including the sublingual glands.
49AI
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&Walkins.
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arteries
During a boxing match a boxer got a blow on the lateral side of the skull,
immediately he fell unconscious for several seconds. He was asymptomatic
for the first 24 hours then he developed symptoms of elevated intracranial
pressure (headache, nausea and vomiting). Which of the following arteries is
most likely involved?
inferior alveolar artery
middle meningeal artery
infraorbital artery
deep temporal artery
middle cerebral artery
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middle meningeal artery
The middle meningeal artery is typically the thi rd branch of the first part (retro-
mandibular part) of the maxillary artery, one of the two terminal branches of the
external carotid artery. After branching off the maxil lary artery in the infratemporal
fossa, it runs through the foramen spinosum to supply the dura mater (the outermost
meninges) and the calvari a. The middle meningeal artery is the largest of the three
(paired) arteri es which supply the meninges, the others being the anteri or meningeal
artery and the posterior meningeal artery.
In approximately half of subjects it branches into an accessory meningeal artery.
The anterior branch ofthe middle meningeal artery runs beneath the pteri on. It is vul-
nerable to injury at this point, where the skull is thin. Rupture of the artery may give
rise to an epidural hematoma. In the dry cranium, the middle meningeal, which runs
within the dura mater surrounding the brain, makes a deep indentation in the calvar-
ium.
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arteries
Which arteries supply the greater curvature of the stomach?
right gastric, left gastri c and short gastri c arteri es
right and left gastroepiploic arteries
right gastric, left gastroepiploic and short gastri c arteries
right gastroepiploic, left gastroepiploic and short gastric arteries
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right gastroepiploic, left gastroepiploic and short gastric arteries
All of the arteri es that supply t he stomach are derived directly or indirectly f rom the cel iac trunk (celiac
artery). The celiac artery takes its origin f rom t he abdominal aorta j ust below t he diaphragm at about
the level of t he twelfth thoracic vertebra. It is the artery that supplies t he foregut. The cel iac artery is
surrounded by the cel iac plexus and l ies behind t he lesser sac of peritoneum. The cel iac artery has three
terminal branches: the splenic, left gastric, and the common hepatic arteries.
Splenic artery - the large splenic artery runs to the left in a wavy course along the upper border of the
pancreas and behind the stomach. On reaching the left ki dney the artery enters the lienorenal ligament and
runs to the hilum of the spleen. It has the following branches:
I. Pancreatic branches
2. The left gastroepi ploic artery
3. The short gastric arteri es
Left gastric artery - the small left gastric artery runs to the cardiac end of the stomach, gives off a few
esophageal branches, then turns to the right along the lesser curvature of the stomach. It anastomoses with
the right gastric artery.
Common hepatic artery - the medium-sized hepatic artery runs forward and to the right and then ascends
between the layers of the lesser omentum. At the porta hepatis it divides into right and left branches to
supply the corresponding lobes of the liver.
*** The common hepatic artery gives ri se to t he gastroduodenal artery, right gastric artery, and
hepatic artery proper (a.k.a. proper hepatic artery). The hepatic artery proper then gives off a right
and left hepatic artery, with the cystic artery comi ng off of the right hepat ic artery.
Note: For purposes of descri ption, the hepatic artery is sometimes divided i nto the common hepatic
artery, which extends from its origin to t he gastroduodenal branch, and the hepatic artery proper,
which is t he remai nder of the artery.
Arterial supply of the stomach:
The lesser curvature of the stomach is supplied by t he right gastric artery i nferiorly, and the l eft gas-
tric artery superiorly, which al so supplies the cardiac region.
The greater curvature is supplied by the right gastroepi ploic artery i nferiorly and t he left gastroepiploic
artery superi orly. The f undus of t he stomach, and also the upper portion of the greater curvature, is sup-
plied by the short gastri c artery which arises f rom splenic artery.
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esophageal branches esophageal hiatus of diaphragm
gastroduodenal artery
superior pancreaticoduodenal artery
right gastroepiploic artery
51 1
Arteries that supply the stomach. Note that all of the arteries are derived from branches
of the celiac artery.
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arteries
The internal thoracic artery ends in the sixth intercostal space by dividing
into the:
anterior and posterior intercostal arteries
subclavian and inferior epigastric arteries
superi or epigastri c and musculophrenic arteri es
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superior epigastric and musculophrenic arteries
The internal thoracic artery suppli es the anterior wall of the body from the clavi-
cle to the umbili cus. It is a branch of the first part oft he subclavian artery in the neck.
This artery descends vert ically on the pleura behind the costal cartilages, just lateral
to the sternum, and ends in the sixth intercostal space by dividing into the superior
epigastric and musculophrenic arteries.
Branches of the internal thoracic artery include:
Anterior intercostal arteries that supply the upper six intercostal spaces.
Note: The anterior intercostal arteri es of the remaini ng lower spaces are branches
of the musculophrenic artery that itself is a branch of internal thoracic artery.
Perforating arteries, which accompany the terminal branches of the correspon-
ding intercostal nerves
The pericardiacophrenic artery, which accompanies the phrenic nerve and sup-
pli es the pericardium
Mediastinal arteries to the contents of the anterior mediastinum, for example,
the thymus gland
The superior epigastric artery, which enters the rectus sheath and supplies the
rectus muscle as far as the umbilicus
The musculophrenic artery, which runs around the costal margin of the
diaphragm and suppli es the lower intercostal spaces and the diaphragm
Note: The inferior epigastric artery, a branch of the external iliac artery,
anastomoses with the superior epigastric artery in the rectus sheath in the area of t he
umbili cus.
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Right common carotid artery
Internal thoracic artery
Bronchial artery
Descendi ng thoracic aorta
Anterior i ntercoStal 3rtery
Superior epigastric artery
Subcostal artery
Left common carotid artery
Ar teries of the t horacic wall. The arterial supply to the thoracic wall derives from the thomcic
am1a through the posterior intercostal and subcostal arteries, from the axi llary artery, and from the
subclavian artery through the intemal thoracic and superior intercostal arteries.
52

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Reproduced With pem1is!HOO (rom Moore KL. Dalley AF. Agur AMR: C/inictd Oritmted Anatom)'. eJ 6: Baltimore. 2010.lippinoou Williams
&Walki ns.
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arteries
At what level does the abdominal aorta bifurcate into the common iliac
arteries and also gives rise to the middle sacral artery?
TlO
T12
T2
l4
l 5
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l4
The aorta i s the main trunk of a series of vessel s that convey the oxygenat ed blood t o the ti ssues of the
body for their nutrition. The aorta commences at the upper part of the left ventricle, and after ascendi ng
for a short di stance, arches backward and to the l eft side, over the root of the left lung; the aorta then
descends within the thorax on the l eft side of the vertebral col umn, passes into t he abdominal cavi ty
through the aorti c opening of the diaphragm i n front of the twelfth thoracic vertebra(T12). The aorta
descends behi nd the peritoneum on the anterior surface of the bodies of the lumbar vertebrae. At the
l evel of the fourth lumbar vertebra (l4), the aorta divi des i nto the two common iliac arteries. Just
proxi mal t o thi s termi nal bifurcation i s the median sacral artery, an unpaired pari et al branch. Note: The
characteristic feature of the aorta i s that it contains a lot of elastic fibers in its tunica media (middle
layer of blood vessel wall).
Anatomically, the aorta i s tradi tionally divided i nto the ascendi ng aorta, the aortic arch, and the
descending aorta. The descending aorta is, in turn, subdivided into the t horacic aorta (that descends
within the chest) and the abdomi nal aorta (that descends withi n the abdomen).
Ascending aorta: a short vessel that starts at the aortic openi ng of the left ventri cl e. The only
branches of the ascendi ng aorta are the right and left coronary arteries, whi ch supply the heart
muscle.
Aortic arch: gives ri se to three arterial branches: the brachiocephalic, the left common carotid,
and the left subclavian. These arteries furni sh all of the blood to the head, neck, and upper l imbs.
Descending aorta:
Thoracic portion (above the diaphragm): extends from T4 to T12 (lies in the posterior
mediasti num). All of the arterial branches (posterior i ntercostal, subcostal arteri es) from thi s part
are smal l. They supply the thorax and the diaphragm. Note: The bronchi receive blood from
branches of the thoracic aorta, t ermed bronchial arteri es that are often found t o show considerable
variations. Normally, there i s one bronchial artery on the right side of the body and two bronch-
ial arteries on the left. The right bronchial artery usually branches from the third posterior inter-
costal artery, while the left bronchial arteries (superior & inferi or) spl it di rectly from the thoracic
aorta.
Abdominal portion(below the diaphragm): begi ns at the aorti c hiatus in the diaphragm and
extends from T12 -l 4. Arteri es from thi s area supply the abdomen and pel vic region as well as the
lower l imbs. Arteri es from this area supply the abdomen and pelvic regi on as well as the lower
l imbs.
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Inferior epigastric
Arteries of Posterior Abdominal \Vall - Branches of the Aorta
Branches of abdominal aorta
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&Walkins.
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arteries
The blood supply of the mucosa of the nasal septum is derived mainly from
the:
facial artery
maxill ary artery
inferi or alveolar artery
internal carotid artery
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maxillary artery
The sphenopalatine artery, a branch ofthe maxillary artery, supplies most ofthe blood of
the nasal mucosa.
It enters by t he sphenopalatine foramen and sends branches to the posterior regions of t he
lateral wall and to the nasal septum.
After the greater palatine artery emerges from t he greater palatine foramen it courses
anteriorly and passes through the incisive foramen where it anastamoses with t he posterior
septal branch of the sphenopalatine artery to supply the anterior nasal septum.
The anterior and posterior ethmoidal arteries, branches of the ophthalmic artery, supply
t he anterosuperior part of the mucosa of the lateral wall of the nasal cavity and nasal septum.
Three branches of t he facial artery (superior labial, ascending palatine, and lateral nasal) also
supply t he anterior parts of t he nasal mucosa.
Remember:
1. The ophthalmic artery is a branch of the internal carotid artery.
2. The maxillary artery and the superficial temporal artery are the terminal branches
of the external carotid artery.
3. The pterygopalatine fossa is a cone-shaped paired depression deep to the infra-
temporal fossa. The pterygopalatine fossa is located between the pterygoid process
and the maxillary tuberosity, close to the apex of t he orbit. This fossa contains t he maxillary
artery and nerve and their branches arising here, including the infraorbital and sphenopal-
atine arteries, the maxillary division of t he trigeminal nerve and branches, and the pterygo-
palatine ganglion. The pterygopalatine fossa communicates laterally with the infratemporal
fossa through the pterygomaxillary fissure, medially wit h the nasal cavity through the
sphenopalatine foramen, superiorly wi th the skull through the foramen rotundum, and
anteriorly with the orbit through the inferior orbital fissure.
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Anterior
ethmoidal

sphenopalatine
artery
Lateral wall of nasal cavity
Greater palatine artery
Nasal septum
superior
labial artery
Arterial supply of nasal cavity. An open-book view of the lateral and medial walls of the 1ight side
of the nasal cavity is shown. The left '"page" shows the lateral wall of the nasal cavity. The
sphenopalatine artery (a branch of the maxillary) and the anterior ethmoidal artery (a branch of the
ophthalmic) are the most important m1eries to the nasal cavity. The right "page" shows the nasal
septum. An anastomosis of four to five named arteries supplying the septum occurs in the an-
teroinferior portion of the nasal septum (Kiesselbacharea , shaded on picture), an area commonly
involved in chronic epistaxis (nosebleeds).
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arteries
The distal portion of the duodenum receives arterial supply from the inferi-
or pancreaticoduodenal artery which branches from the:
celiac trunk
gastroduodenal artery
superior mesenteric artery
inferi or mesenteric artery
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superior mesenteric artery
The duodenum proximal to the entry of the bile duct receives its arterial supply from the superi-
or pancreaticoduodenal artery, a branch of the gastroduodenal artery which in turn branches from
the common hepatic artery which comes off the celiac trunk. The distal portion of the duodenum
receives its arterial supply from the inferior pancreaticoduodenal artery, which branches from the
superior mesenteric artery.
The arterial supply of the jejunum and ileum is from branches of the superior mesenteric artery.
The intestinal branches arise from the left side of the artery and run in the mesentery to reach the
gut. They anastomose with one another to form a series of arcades. The lowest part of the ileum is
also supplied by the ileocolic artery.
The large intestine extends f rom the ileum to the anus. The large intestine is divided into the
cecum, the appendix, the ascending colon, the transverse colon, the descending colon, and the sig-
moid colon. The blood supply to these areas is as follows:
Cecum: the arterial blood supply is from the ant erior and posterior cecal arteries, which are
branches of the ileocolic artery, a branch of the superior mesenteric artery
Appendix: the arterial supply is by means of the appendicular artery, a branch of the posterior
cecal artery
Ascending colon: the arterial blood supply is from the ileocolic and right colic branches of the
superior mesenteric artery
Transverse colon: the arterial blood supply of the proximal two-thirds is from the middle colic
artery, a branch of the superior mesenteric artery. The distal third is supplied by the left colic
artery, a branch of the inferior mesenteric artery
Descending colon: the arterial blood supply is f rom the left colic and sigmoid branches of the
inferior mesenteric artery
Sigmoid colon: the arterial blood supply is from the sigmoid branches of the inferior mesen-
teric artery
Note: The arterial blood supply to the rectum is from the superior, middle, and inferior rectal arter-
ies. The superior rectal artery is a direct conti nuation of the inferior mesenteric artery. The middle
rectal artery is a small branch of the internal iliac artery. The inferior rectal artery is a branch of the
internal pudendal artery in the perineum. The arterial blood supply to the anus (anal canal) is from
the superior and inferior rectal arteries.
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Inferior vena
Superior
pancreatico-
duodenal
artery
Duodenum
idi""-li------Joferior pancreaticoduodenal artery
l"i''F-------Siuc,eri,or mesenteric artery
artery
Duodenum, pancreas, and spleen. The duodenum, pancreas, and spleen and their blood
supply are revealed by removal of the stomach, transverse colon, and peritoneum.
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arteries
All of the following are direct branches of the subclavian artery EXCEPT one.
Which one is the EXCEPTION?
internal t horacic artery
thyrocervical artery
inferi or thyroid artery
dorsal scapular artery
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inferior thyroid artery- which is a branch of the thyrocervical artery
The arch of the aorta is a continuat ion of the ascending aorta. The aortic arch lies behind the
manubrium sterni and arches upward, backward, and to the left in front of the trachea (its main
direction is backward). It then passes downward to the left of t he t rachea, and at the level of t he
sternal angle (T 4) it becomes the descending or thoracic aorta.
Branches include:
The brachiocephalic artery is an extremely short artery and is the first branch from the aortic
arch. This artery passes upward and to the right of the trachea and divides into t he right
common carotid and right subclavian arteries behind the right sternoclavicular joint.
Remember: There are two (right and left) brachiocephalic veins but only one brachiocephalic
artery.
The left common carotid artery arises from the convex surface of the aortic arch on the left
side of the brachiocephalic artery. The left common carotid artery runs upward and to the left of
the trachea and enters the neck behind the left sternoclavicular joint.
The left subclavian artery arises from the aortic arch behind the left common carotid artery.
The left subclavian artery runs upward along the left side of the trachea and the esophagus to
enter the root of the neck. This artery arches over the apex of the left lung.
Subclavian artery branches are:
Vertebral artery
Internal thoracic artery: terminating in the superior epigastric artery and the musculophrenic
artery
Thyrocervical trunk: Very short. Divides into inferior thyroid artery, suprascapular artery and
transverse cervical artery
Costocervical trunk
Dorsal scapular artery
Mnemonic: These may be remembered by the mnemonic "VITamin C and o
Important:
1. The upper limbs are supplied by the subclavian arteries (both right and left).
2. The head and neck are supplied by the right and left common carotid arteries.
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anterior cardiac vein
atrioventricular groove
anterior interventricular
artery
apex
interventricular groove
Anterior surface ofthe heart and great blood vessels
Note the course of coronary arteries and cardiac veins.
56-I
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arteries
All of the following statements concerning the common carotid arteries are
true EXCEPT one. Which one is the EXCEPTION?
the common carotid arteri es are the same in length
the common carotid arteri es differ in their mode of origin
the ri ght common carotid artery is a branch of the brachiocephali c trunk
the left common carotid artery is a branch of the aortic arch
[refer to card 38 A-1, 49-1 for illustration)
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the common carotid arteries are the same in length
The major arteries that supply the head and neck are the common carotid and subclavian arteries.
The origins from the heart of the common carotid and subclavian arteries that supply the head and
neck are different for the right and left sides of the body. For the right side of the body, the common
carotid and subclavian arteries are both branches from the brachiocephalic artery. The
brachiocephalic artery is a direct branch of the aorta.
The common carotid artery is branchless and travels up the neck, lateral to the trachea and larynx,
to the upper border of the thyroid cartilage. The common carotid artery travels in a sheath deep to
the sternocleidomastoid muscle. This sheath also contains the internal jugular vein and the vagus
nerve. The common carotid artery ends by dividing into the internal and external carotid arter-
ies at about the level of the larynx.
The internal carotid has no branches in the neck. The branches of the internal carotid artery
supply the structures inside the cranial cavity. The internal carotid gives rise to t he ophthalmic
artery, the major blood supply of the orbit and eye, that enters the orbit through the optic
foramen (canal) with the optic nerve. The internal carotid ends by dividing into the anterior and
middle cerebral arteries that contribute to the great cerebral circle (of Willis).
The external carotid has eight branches that mainly supply head st ructures outside the
cranial cavity. The branches are as follows:
Anterior branches: Posterior branches:
1. Superior thyroid artery 1. Ascending pharyngeal artery
2. Lingual artery 2. Occipital artery
3. Facial artery 3. Posterior auricular artery
4. Maxillary artery 4. Superficial temporal artery
The subclavian artery arises lateral to the common carotid artery. The subclavian artery gives off
branches to supply both intracranial and extracranial structures, but its major destinat ion is the
upper extremity (arm).
Remember: On the left side of the body, the left common carotid and left subclavian arteries arise
from the arch of the aorta in the superior mediastinum.
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right common
carotid artery
brachiocephalic
artery
right subclavian
artery
aorta
sternocleidomastoid

left subclavian
artery
clavicle
first rib
Origins from the heart of the arterial blood supply for the head and neck highlight-
ing the pathways ofthe common carotid and subclavian arteries. Note the pathways
are different on the right and left sides of the body.

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Maxillary artery
Facial artery
lingual
Pathway of the external carotid artery after branching off the common carotid artery
49-1
Rq'lroduccd With pc:m1issum (rom c h ~ n b a c h MJ. Herring SW: 11/u.fll'ated A11atomy oftlle Head and Neck. ed J; St Louis. 2007. Saunders.
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arteries
What is the major arterial origin supplying the mandibular anterior teeth?
mandibular artery
facial artery
vertebral artery
maxill ary artery
[refer to card 49-1 for illustration]
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Artery
Maxillary
maxillary artery
\rtt.ri.tl Supph ol tht. .tnd \t.mdihul.tr I t.t.th
Source CourSe
Exu rnal carotid artery Gives rise 10 3 branches that form a plexus 10 supply the maxil-
lary arch:
Anterior superior alwolar
Middle superior alveolar
Poste.rior superior alve.olar
Giws rise 10 I branch that supplies the mandibular arth
Inferior alveolar
Maxillary Tedh
Anteri or superior alveolar l nfrnorbilal anery Arises afle-r the infraorbital artery through the inferior
(of t he maxillary artt.ry) orbital li s..o:ure and into t he infraolbital canal
Middle superior alve.olar l nfraoJbiM.I art<: I)'
superi or alveolar Third part of Lhe
ll t.axillary artery
Inferior alveolar FirSt part of the
maxillary artery
Descends via the alveolar canals to supply pan oflht m.a:<il-
lary arch
Supplits the maxillary sinus and the anterior lt.eth
May or may not be pre.o:t nl
l fprts tn4 arises from the infraOfbital artel)' of the maxillary
artery a Her il passes Lhrough the inferi or orbilal lis..o:ure and inlo
t he infraolbiwl <:anal
Descends via the alvt.olar canals to supply t he maxillary sinus
and the plexus at t he canine
Ar ises before t he nt.axillary artery enterS the ptcrygopalaline
fossa
Enlcrs t he infratemporul sudi'tce of the maxilla 10 supply the
maxilla')' sinus.. premolar s. and molarS
Mandibular T ctth
Orstends inferiorly following t he inferior alveolar neTVe 10
enter the mandibular forumen
Ttrminatts into the mental and incisive a11eries at the region
of the second premolar
Supplies all of the mandibular teelh
Menoal Inferi or alveolar artel)' Supplies the labial gingiva of the anteri or Ieeth
Incisive Inferi or alveolar artel)' Supplies the anterior teeth
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-
Firat (man<libulat)

arteries
Parts and Branches of the Maxillary artery
c:o-
Branches
Deep auricular artOty
Anterior tympanic
110<f
Ml<ldto monlngool
Proodmot (po<IO!Io<) 10 talorol
artOty
pterygoid muscle; runo horizon:aly,
- (medial) to nod< ct condylar
process: o1 mandible and lateral to
stylome.ndibu!ar ligament

artery
Inferior alveotar artery
M<wielericiU'tery
Ooeplelllj)Of1lt
Adjacent (ouperficl81 or CIHp) to
arteri es
18IORII pCctygold muscle: OISCOnds
obliQuely anterosuporiorfy. mediel

Pterygoid brrdl"
Buccal artery
-
&ppPes extemal aeousiJc mealus, ext&roal
merri)mne, and lemporomandl:lular joint
Sutli)NM in1&rrd of tympanic membrane
En!EK'S cranial cavity via foramen spinoGum to iUPP'Y
bent, tOd bOI'Ie mal'rOW, duta mauw ol
lat4ral wal anct catvarla of neurocranium, trtgeminif
ganglion. facial nerve and geniculale gaf9ion,
1ympa:nic cavity. and tensor tympani musde
En1ers crenk\1 cevMy vie foremen ovale; its
cistribution is mainly tetrac:rania11o muscles of
l"'fra..,mporallossa, sphenOid bOne. mandibUlar
neiVO, and otic ganglion
Desoends to enter mandibular canal of m.andibte via
mandibUlar loramGn; supples mancl!blO, manclltx.Har
teeth, dlln, mylohyoid muid
Traverses mandilnlar notch, suppty;ng tempofO-
mandbular ,k*tt and mas&etet muscte
Anterior and poetoriot arteries asoend b01woen
tempotalis mueeto and bone of tempoml fossa,
supplying mainly muse..,
tnegoAorln- "'M pterygo1c1 muscle

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Parts and Branches of the Maxillary artery !continued from front!
Pos&erior5l4>Eirior Descends oo ma:xlla's Infratemporal surface with
alveol81'at1ef)' ol\'OOINcanalsiO oupply -lleoy
molar and promolar teeth, gingiva., and
muc::ous membrane ol Plus
lnfloa-otblalaf10oy Travertet lnteriof orbltalli$Sure, Wra-ortlital groove.
canal, and supplies ini&tb' obliqll8 8f'd
rec::tus muades. facrirnal sac, maxillary canines and
Incisors Ieeth, mucous membrane of maxllaty slnu&.
and akin ot intra-orbital roQM)n ot taco
Distal {anlerorne<lal) to lateral
Attetyolp18f}l101d PasS85 pos:teriofty through p1e.rygold canal; supplies
pteryoo'd muecle; passes between
""""'
M\.IIC()$3 of upper ph8irynx. tube,
Thiod (plerygdd
headS OIIOIO!al piOoygaklancl
end tympanic ea,;ly
palatl.-.)
thrOUgh porygomaxMta:ry fissure
IntO piOf\'l!OpolallnO ro.sa
Pharyngoal """""'
- po!Otovaglnal""""' -
mucosa ol nasaJ roof, nasopharynx, sphOnOICfal aJr

Oeoeending polatine Doaeencls thfoo.l9h polot'no canol. dvidlno into
11118')' ond loSSM paltltino tiJ'IOriOSIO mucosa :lind
ol hard and eott palate
Sphenopoleflno Tet'lftnel btanQ\ ot me:xhl8.ry Mef'Y, traverses
arteoy &phenOpaaatin klram&l'l to sl4)ply walls and septum
ol nasal aMty; frorrl:al, ethmoidal, sphenoid, and
ma>Oiruy $:nUGO$; and antcriOf"''nnOS't peJato
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deep temporal branches
pharyngeal artery
artery of pterygoid canal
anterior tympanic
lateral pterygoid
muscle
superficial temporal artery
maxillary - 1st part
middle meningeal
external carotid
accessory meningeal
inferior alveolar
masseteric branch
pterygoid branch
sphenopalatine
infra-orbital
maxillary- 3rd part
posterior superior
alveolar
middle superior
alveolar
descending palatine
......., __ _.;_;:.-.- , buccal branch
Pnrts a nd Branches of Maxill ary Artery
59-1
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arteries
Which of the following statements is TRUE regarding the left and right renal
arteries?
they both arise from the abdominal aorta below the superior mesenteric artery
the left renal artery is longer that the right renal artery
the right renal artery is somewhat higher than the left renal artery
the right renal artery arises below the superior mesenteric artery, whil e the left one
arises below the inferior mesenteric artery
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they both arise from the abdominal aorta below the superior mesenteric artery
The renal arteries normally arise off the side of the abdominal aorta, immediately below
the superior mesenteric artery, and supply the kidneys with blood. Each is directed across
the crus of the diaphragm, so as to form nearly a right angle with the aorta.
The renal arteries carry a large portion of total blood flow to t he kidneys. Up to a third of
total cardiac output can pass t hrough the renal arteries to be fil tered by the kidneys.
The arterial supply of the kidneys is variable and t here may be one or more renal arteries
supplying each kidney. It is located above the renal vein. Supernumerary renal arteries (two
or more arteries to a single kidney) are the most common renovascular anomaly, occur-
rence ranging from 25% to 40% of ki dneys.
Asymmetries between left and right renal artery:
Due to the position of the aorta, the inferior vena cava and the kidneys in the body, the
right renal artery is normally longer than the left renal artery.
The right passes behi nd the inferior vena cava, the right renal vein, t he head of the pan-
creas, and t he descendi ng part of the duodenum.
The left is somewhat hi gher than t he right; it li es behind the left renal vein, t he body of
the pancreas and the splenic vein, and is crossed by t he inferior mesenteric vein.
1. As renal arteries pass into the kidneys, they branch into successively small er
arteries: interlobar arteries- arcuate arteries- interlobular arteries- afferent
arterioles leadi ng to the nephrons.
2. Venous blood is returned through a series of vessels that generally correspond
to t he arterial pathways.
3. Urinary bladder is suppli ed by the vesicular branches of t he internal iliac
arteries.
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arteries
The subscapular artery which supplies the subscapularis muscle branches off
the:
subclavian artery
1st part of axi ll ary artery
2nd part of axil lary artery
3rd part of axillary artery
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3rd part of axillary artery
The axillary artery is the continuation of the subclavian artery into the axilla. The artery is
cl osely related to the cords of the brachial plexus and in fact the cords of the brachial plexus
are named according to their relation with the second part of the axillary artery; the pos-
terior cord of the brachial plexus lies posterior to the second part of the axill ary artery, the
medial cord lies medial and the lateral cord li es lateral to it.
Origin and termination of axillary artery:
The axill ary artery begins at the lateral border of the fi rst rib as a continuation of the sub-
clavian artery into the axilla. It termi nates at the lower border of the teres major muscle
and then continues downward in the arm as the brachial artery. The axillary artery is often
referred to as having three parts, with these divisions based on its location relative to the
Pectoralis minor muscle, which is superficial to the artery.
Parts of the axillary artery:
First part - the part of the artery medial to pectoralis minor. It has one branch only;
superior thoracic artery (supreme thoracic artery)
Second part- the part of the artery that lies behind pectorali s minor. It has 2 branches;
thoracoacromial artery and lateral thoracic artery
Third part - the part of the artery lateral to pectoralis minor. It has 3 branches; sub-
scapular artery, anterior humeral circumflex and posterior humeral circumflex artery
Note: The brachial artery is cl osely related to the median nerve; in proximal regions, the me-
dian nerve is immediately lateral to the brachial artery. Distally, the median nerve crosses
the medial side of the brachial artery and lies anterior to the elbow j oint.
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arteries
Which of the following statements is CORRECT regarding vertebral arteries?
inside the skull, the two vertebral arteri es join up to form the basilar artery
they arise from thyrocervical trunk
they enter the skul l through carotid canal
they pass through the t ransverse foramina of all 7 cervical vertebrae
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inside the skull, the two vertebral arteries join up to form the basilar artery
The vertebral arteries are major arteries of the neck. They branch from the subclavian
arteri es and merge to form the single midline basilar artery in a complex called the
vertebrobasilar system, which suppli es blood to the posterior part of the circle ofWill is
and thus significant portions of the brain.
The vertebral arteries arise from the subclavian arteries, one on each side of the body,
and then enter deep to the transverse process of the level of the 6th cervical vertebrae
(C6). They then proceed superiorly, in the transverse foramen of each cervical vertebra
until C1. This path is largely parall el to, but distinct f rom, the route of the carotid artery
ascending through the neck. At the C1 level the vertebral arteri es travel across the pos-
terior arch of the atlas through the suboccipi tal triangle before entering the foramen
magnum.
Inside the skull, the two vertebral arteri es join up to form the basil ar artery at the base
of the medulla oblongata.
The basilar artery is the main blood supply to the brainstem and connects to the Cir-
cle of Willi s to potentially supply the rest of the brain if there is compromise to one of
the carotids. At each cervical level, the vertebral artery sends branches to the sur-
rounding musculature via anterior spinal arteries.
Note: Branches of the vertebral and basi lar artery are responsible for circulation to
cerebellum.
Vertebra Is give rise to: PICA (posterior inferi or cerebellar artery)
Basilar gives rise to: AICA (anterior inferi or cerebellar artery) and SCA (superior cere-
bel lar artery)
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bone
Which ofthe following structures provides attachment to falx cerebri?
cribriform plate
crista galli
lesser wing of sphenoid
greater wing of sphenoid
corpus call osum
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crista galli
The viscerocranium (facial skeleton) consists of 15 irregul ar bones: 3 single bones
centered on or lying in the midli ne (mandible, et hmoid, and vomer) and 6 bones
occurring as bilateral pairs (maxill ae; inferior nasal conchae; and zygomatic, palati ne,
nasal, and lacrimal bones). Several bones of the cranium (frontal, temporal, sphenoid, and
ethmoid bones) are pneumatized bones, which contain air spaces, presumably to
decrease their weight .
The ethmoid bone is exceedingly li ght and spongy, and cubical in shape; this bone is sit-
uated at the anterior part of the base of the cranium, between the two orbits, at the roof
of the nose, and contributes to each of t hese cavities. The ethmoid bone consists of four
parts: a horizontal or cribriform plate, forming part of the base of t he cranium; a per-
pendicular plate, constituting part of t he nasal septum; and two lateral masses or
labyrinths.
Cribriform plate: Contains many olfactory foramina. The olfactory nerves pass
through t hese forami na. Note: Damage to t his area t ypically results in the loss of sense
of smell.
Perpendicular plate: The crista galli is a midline proj ection from the perpendicular
plate that serves as an attachment for the falx cerebri.
Lateral masses (right and left) proj ect downward f rom t he cribriform plate. They
contain t he ethmoid sinuses and the orbital plate of the ethmoid bone (lamina
papyracea). The lamina papyracea forms t he paper-thin medial wall of the orbit. The
superior and middle nasal conchae are scroll-like projections that extend medially from
the lateral masses into the nasal cavity.
Note: Each ethmoidal sinus is divided into anterior, middle, and posterior ethmoidal air
cells.
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perpendicular
plate
cribriform plate
-/ orbital
plate
r ~ ~ ethmoidal
sinuses
Oblique lateral view of the ethmoid bone with its
perpendicular, cribriform, and orbital plates
middle nasal
concha
63 1
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nasal bone
superior nasal
concha
middle nasal
concha
crista galli
sphenoidal
sinus
sphenoid
.. bone
inferior nasal
maxilla .... ,- concha
palatine bone
Lateral wall of the right nasal cavity with the ethmoid bone highlighted
63AI
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bone
The hypophyseal fossa is located in a depression in the body of the sphenoid
bone; it houses which of the following structures?
hypothalamus
pituitary
cerebellum
hippocampus
corpus cal losum
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pituitary
The sphenoid bone is situated at the base of the skull in front of the temporal and basilar
part of the occipital bone. It somewhat resembles a bat with its wings extended, and is
divi ded into a median portion or body, two great and t wo small wings extending
outward from the sides of the body, and two pterygoid processes that project from the
bone below.
Hollow body: contains the sella turcica, which houses the pituitary gland and the
sphenoidal sinuses. Note: The sella turcica and the hypophyseal fossa should be
considered different entities, the latter being part of the former.
Greater wings: help to form the lateral wall of the orbit and the roof of the infratemp-
oral fossa. Contain foramen rotundum: transmits maxillary nerve (V-2), foramen
ovale: transmits mandibular nerve (V-3), and foramen spinosum: transmits the mid-
dle meningeal vessels and nerves to the tissues covering the brain.
Lesser (small) wings: help to form the roof of the orbit and the superior orbital fiss-
ure; contain the optic canal (optic foramen) that transmits the optic nerve (CN II) and
ophthalmic artery.
Pterygoid processes: one on either side, descend perpendicularly from the regions
where the body and great wings unite. Each process consists of a medial and a lateral
plate, the upper parts of which are fused anteriorly; a vertical sulcus, the pterygopala-
tine groove, descends on the front of the line of fusion.
Remember: The lateral pterygoid plate provides the origin for both the lateral and the
medial pterygoid muscles. Medial surface of the lateral plate provides origin for the
medial pterygoid muscle, while the lateral surface of the lateral pterygoid plate provides
origin for the lateral pterygoid muscle.
*** Important: The hamulus is a process of the medial pterygoid plate of sphenoid
bone. It provides origin for the tensor veli palatini muscle.
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bone
Flat bones of the skull, maxilla, major parts of the mandible and clavicles are
formed by:
endochondral ossification
subchondral ossification
intramembranous ossification
primary ossification
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intramembranous ossification
The first evidence of bone ossification (bone formation) occurs around the eighth week of prenatal
development. Bones develop either through endochondral ossification (going through a cartilagi-
nous stage) or through intramembranous ossification (forming directly as bone). The dist inction
between endochondral and intramembranous formation rests on whether a carti lage model serves
as the precursor of the bone (endochondral ossification) or whether the bone is formed by a simpler
method, without the intervention of a cartilage precursor (intramembranous ossification).
Most bones are endochondral, meaning that they began as a hyaline cartilage model before they
ossify. This takes place within hyaline cartilage. This type of ossification is principally responsible for
the formation of the bones of the base of the skull, condyles of the mandible, short and long bones.
Bone replaces carti lage (osteocytes replace chondrocytes). The bones of the ext remities and those
parts of the axial skeleton that bear weight (e.g., vertebrae) develop by endochondral ossification.
Flat bones of the skull, the maxilla, and major parts of the mandible and clavicles are formed by
intramembranous ossification. Intramembranous ossification occurs within a membranous, con-
densed plate of mesenchymal cells. At the initial site of ossification (ossification center) mesenchy-
mal cells (osteoprogenitor cells) differentiate into osteoblasts. The osteoblasts begin to deposit the
organic bone matrix, the osteoid. The matrix separates osteoblasts, which, from now on, are locat-
ed in lacunae within the matrix. The collagen fibers of the osteoid form a woven network without a
preferred orientation, and lamellae are not present at this stage. Because of the lack of a preferred
orientation of the collagen fibers in the matrix, this type of bone is also called woven bone. The
osteoid calcifies leading to the formation of primitive trabecular bone. Further deposition and calci-
fication of osteoid at sites where compact bone is needed leads to the formation of primitive com-
pact bone. Important points: (1 J Intramembranous ossification does not require the existence of
a cartilage bone model (2) In endochondral ossification, the cartilage does not transform into bone;
bone replace cartilage.
Remember: Once intramembranous bone is formed, it grows by appositional growth only
(growth by addition of new layers on those previously formed). Endochondral bone grows by both
appositional and interstitial growth.
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bone
During distalization of molars in bodily orthodontic movement, the alveolar
bone distal to the tooth must resorb, and the alveolar bone mesial to the
tooth must appositionally grow. In orthodontic movement, the alveolar
bone is being remodeled. This remodeling is a function of:
osteocl asts and osteoblasts
chondroblasts and osteoblasts
osteoblasts and osteocytes
chondrocytes and osteocytes
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osteoclasts and osteoblasts
Osteoclasts are cells t hat break down and remove exhausted bone tissue. Osteoblasts build
new bone tissue to repl ace this loss.
Osteoblasts are the principal bone-building cells; t hey synthesize collagenous fibers and
bone matrix, and promote mineralization during ossification. Once t his has been accom-
plished, the osteoblasts, which are trapped in their own matrix, develop into osteocytes t hat
maintain the bone t issue.
. ~ . l .Osteoblasts are derived from mesenchyme (fibroblasts) and have a high RNA con-
~ ~ tent and stain intensely wi th basic dyes.
2. Osteodasts (which are derived from stem cells in the bone marrow - the same
ones that produce monocytes and macrophages) are large multinucleated cells
that contain lysosomes and phagocytic vacuoles. They are stimulated by PTH which
causes an increase in serum calcium.
Note: A Howship's lacuna is a small hollow created on the bone surface by osteo-
clastic activity.
3. Osteoid is newly formed organic bone matrix that has not undergone calcifica-
tion. It is a specialized form of type I collagen surrounded by glycosaminoglycan gel.
This gel contains proteins possessing a high affinity for calcium binding.
*** Important: Osteoid differs from bone in that osteoid does not have a mineralized matri x.
It also has more water content than the mature bone.
Remember: Bone is hard and resists compression because of the mineralization of its
extracellular matrix. When bone matrix mineralizes, inorganic hydroxyapatite crystals
(primarily calcium phosphate) are deposi ted around the existing collagen fibrils, and the water
content of the matrix decreases. Bone derives its fl exibility and tensile strength from its
abundant collagen fibers.
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bone
All are functions of the skeletal system EXCEPT one. Which one is the EXCEP-
TION?
lymph filtration
mineral storage
support
protection
body movement
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lymph filtration
Functions of the skeletal system:
Support: skeleton forms a rigid framework to which are attached the softer tissues and
organs of t he body.
Protection: the skull and vertebral column enclose t he CNS; the rib cage protects t he
heart, lungs, great vessels, liver, and spleen; and t he pelvic cavi ty supports the pelvic viscera.
Body movement: bones serve as anchoring attachments for most skeletal muscles. In this
capacity, the bones act as levers wi th t he joints functioning as pi vots when muscles contract
to cause body movement.
Hemopoiesis: the red bone marrow of an adult produces red blood cells, white blood
cells, and platelets.
Mineral storage: the inorganic matrix of bone is composed primarily of the minerals
calcium and phosphorus. These minerals give bone its rigidity and account for approxi-
mately two-thirds of t he weight of bone. About 95% of the calcium and 90% of t he phos-
phorus within t he body are deposi ted in t he bones and teeth.
Bone exists in two forms: Compact (appears as a solid mass) and spongy or cancellous bone,
which consists of a branching network of trabeculae.
Important: The ini tiation of bone mineralization involves the following (1) Holes or pores in
collagen fibers. (2) The release of matrix vesicles by osteoblasts. (3) Alkaline phosphatase
activity in osteoblasts and matrix vesicles. (4) The degradation of matrix pyrophosphate to
release an inorganic phosphate group.
Fracture repair involves the following events: (1 ) Blood clot formation, (2) Bridging callus
formation, (3) Periosteal call us formation, and (4) New endochondral bone formation.
Pseudarthrosis (or "nonunions"): is a fracture t hat has not united in the stipulated time in
which such fractures usually unite and has no chance of union wi thout intervention. There is
movement of a bone at the location of a fracture resul ting from inadequate healing of the frac-
t ure.
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bone
At the temporomandibular joint (TMJ), hinge movements occur between
the:
condyle and articular eminence
art icular disc and articular eminence
condyle and articular disc
art icular disc and articular cavity
condyle and articular cavity
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condyl e and articular disc
The TMJ is a synovial joint with two articular cavities. Each cavity is responsible for a differ-
ent movement at the joint. An articular disc sits between the condylar process of the
mandible on its inferior side and the mandibular fossa and articular eminence of the tem-
poral bone on the superior side. This disc divides the joint into the two articular cavities,
with one cavity acting as a hinge component and the other cavity serving as a gliding
component. The lower part of the joint, between the condyle and the articular disc, is the
hinge component of the j oint. When the joint moves, this hinge component of the j oint
moves first, to initiate mandibular opening. The upper part of the joint, between the
articular disc and the mandibular fossa and articul ar eminence of the temporal bone, cre-
ates the gliding component. During joint movement, this gli ding cavity moves after the
hinge component to terminate mandibular opening.
1. The condyle of the mandible rests in the mandibular fossa (also called gle-
noid fossa) of the temporal bone. The fossa articulates with the condyle of the
mandible to form the TMJ.
2. The articular eminence forms the anterior boundary of the fossa and helps
maintain the mandible in position. This area is the functional and articular por-
t ion of the TMJ.
3. Separating the mandibul ar fossa from the tympanic plate posteriorly is the
squamotympanic fissure, through the medial end of which (petrotympanic fi s-
sure) the chorda tympani exits f rom the tympanic cavity.
4. The concave area between the mandibular condyle and coronoid process is
the mandibular notch (also known as the coronoid notch). The mandibul ar
notch transmits arteries and nerves to the masseter muscle.
5. *** Important: The post erior slope of this eminence is lined by fibrous con-
nective tissue.
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bone
A patient comes into the orthodontist's office as referred to by his general
dentist. The orthodontist notes the patient's tongue thrusts and notes that
early treatment could prevent skeletal problems. Soft tissue development is
thought to encourage mandibular growth:
upward and forward
upward and backward
downward and forward
downward and backward
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downward and forward
The space between the jaws into which the teeth erupt is generall y considered to be
provided by growth at the mandibular condyles (especiall y the molars). The
condyle is a major site of growth. Many arguments have been made about condyle
function in mandibular growth. Most authori ties agree that soft-tissue development
carries the mandible forward and downward, whil e condylar growth fills in the
resultant space to maintain contact with the base of the skul l.
The bone of the alveolar process exists only to support the teeth. If a tooth fails to
erupt, alveolar bone never forms in that area; and if a tooth is extracted, the alveolus
resorbs after the extraction until finall y the alveolar ridge completely atrophies. The
position of the tooth, not the functional load placed on it, determines the shape of
the alveolar ridge.
Note: The long axes of the mandibular condyles intersect at the foramen magnum,
which indicates that these axes are directed posteromedially.
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bone
Which of the following structures does NOT form a portion of the lateral wall
of the nasal cavity?
maxill a
palatine bone
conchae
vomer
ethmoid bone
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vomer
The lateral walls are formed primarily by the frontal process of the maxi ll a,
perpendicular plate of the palatine bone, ethmoid bone, the superior, middle and
inferior conchae. The medial wall or nasal septum is formed by the perpendicular
plate of the ethmoid bone, the vomer bone, and the septal cartilage. The rest of
the framework of the nose consists of several plates of cartilage, specifically, the
lateral nasal cartilage and the greater and lesser alar cartilage. The cartilage is held
together by fibrous connective tissue.
The nasal cavity opens on the face through the nostril s or nares and communicates
with the nasopharynx through two posterior openings call ed the choanae. The area
below each concha (superior, middle, and inferior) is referred to as a meatus.
The nasal cavity receives innervation from the olfactory nerve (CN I) and branches
of the trigeminal nerve (CN V). The nasal cavity blood supply is mainly from the
sphenopalatine branch of the maxillary artery.
Note: The nasopalatine nerve is a parasympathetic and sensory nerve that arises in
the pterygopalatine ganglion, passes through the sphenopalatine foramen,
across the roof of the nasal cavity to the nasal septum, and obli quely downward to
and through the inci sive canal, and innervates the glands and mucosa of the nasal
septum and the anterior part of the hard palate.
Important: The communication between the pterygopalatine fossa and the nasal
cavity is the sphenopalatine foramen. The sphenopalatine artery and the nasopala-
tine nerve extend through the sphenopalatine foramen.
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ethmoW
bone
sphenoid bone __ ..,._ ......,.
zygomatic bone --
frontal bone
nasal bones
====t=-- lacrimal bones
.---'--- sphenoid bone
zygomatic bone
Yomer
Cranium, facial (frontal) aspect
7().1
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fronta I bone ...._....,.. __ ..,....
superior concha
superior meatus ~ l ~ t ~ ~ ; _ _ ; ~ ~ ~
middle concha -"
frontal process__. _ _ ...,..,
l aaimal bone
middle meatus
Inferior concha
Inferior meatus
Medial view right lateral
wall of nasal cavity
palatine
process
of maxilla
aista galfi
crest of
sphenoid
bone
vomer
nasal crest of
palatine bone
nasal crest
of maxilla
septal
cartilage
Lateral and mcdoal (septal) walls of right
side of nasal cavity. The medial view
shows the right lateral wall of the nasal
cavity, and the lateral view shows the nasal
seplllm. The nasal septum has a hard
(bony) part located deeply ( posteriorly)
where it is protected and a son or mobile
pan located superficially (anteriorly)
mostly in the more vulnerable external
nose.
70A_.
Lateral view nasal septum
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A tubercle is:
a small, rounded process
a prominent elevated ridge or border of a bone
a large, rounded, roughened process
a sharp, slender, projecting process
ANATOMIC SCIENCES
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a small, rounded process
Surface Features of Bone (enlargements and processes):
Process: the most generic term for bone projection that serves as a point for attach-
ment of other structures. Example: Acromion process of the scapula, transverse proc-
ess of vertebrae and hamul ar process of the sphenoid bone.
Epicondyle: a projection or swelling on a condyle (or above, in some cases).
Example: Medial and lateral epicondyles of femur.
Spine: a sharp, slender projecting process. Example: Spinous process of vertebrae,
spine of the scapul a.
Tubercle: a small, rounded process. Example: Greater and lesser tubercles of humer-
us.
Tuberosity: a large, rounded, roughened process. Example: Ischial tuberosity of the
ischium.
Trochanter: a large blunt projection for muscle attachments on the femur.
Example: Greater and lesser trochanters of the femur.
Crest: a promi nent elevated ridge or border of a bone. Example: Ili ac crest of the
ilium.
Linea (line): a small crest, usually somewhat straighter than a crest. Example: Li nea
aspera of femur.
Ramus: a major branch or division of the main body of a bone. This may have its own
articulations or processes. Example: The coronoid and condylar processes of the man-
dible are subdivisions of the ramus.
Neck: a slight narrowing of the body of the bone that supports the head.
Example: Necks of the humerus and femur.
Lamina: a very thin layer of bone. Example: The lami nae of the vertebrae.
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bone
The shaft of a long bone is capped on the end by spongy bone that is sur-
rounded by compact bone. This is called the:
peri osteum
diaphysis
endosteum
epiphysis
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epiphysis
Long bones have a tubular shaft, the diaphysis, and usually an epiphysis at each end. During the
growing phase, the diaphysis is separated from the epiphysis, by an epiphyseal cartilage. The part
of the diaphysis that lies adjacent to the epiphyseal carti lage iscalled the metaphysis. The shaft has
a central marrow cavity containing bone marrow. The outer part of the shaft is composed of
compact bone that is covered by a connective ti ssue sheath, the periosteum.
A typical long bone includes the following structures:
Structure
Diaphysis
Epiphysis
Location and Function
Bone shatl; consists of a cylindl'ical tube of du1able c.ompac[ bone.
Caps diaphysis; consisu of spongy bone surrounded by compac[ bone;
contain...; red bone marrow for the producrion of red blood cells, white
blood cells. and plateleu.
Epiphyseal plate Between the epiphysis and the diaphysis; region of mitotic acth' ity
responsible for elongation of bone.
lvtedullary c.avity Centrally positioned spac.e within diaphysis; contain..o; fatty yellow bone-
Nutrient foramen Opening into diaphysis; provide..; site fo1 nurrient vessels to enter and
exit the medullary cavity.
Articular ca11ilage Caps e.ach epiphysis; c.omposed of hyaline ca11ilage; facilitates joint
moveme-nt.
Endosteum
Periosteum
Compact bone
Cancellmu
(spottgy)
l ines medullary c-avity; consists of suppo11ive dense regular c.onnective
tissue-.
Covers the surface of bone; con..o; ists of dense regular c.onnective issue-;
site for ligament- and tendon-muscle auachment and respon..o;ible for
diametric. bone growth.
Hard, outer layer of bone-tissue; covered by periosteum, serve-s for at-
tachment of muscles, provides JU'Otection, and gives durable-strength to
the bone.
Porous, highly vascular, inne-r layer of bone dssue; m.akes the bone
lighter and provides spaces for red bone marrow where. blood cells are
produced.
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epiphysis
red marrow cavities
medullary cavity
endosteum
diaphysis
- - yellow marrow
1
r-periosteum
epiphysis
Longitudinal Section of the Tibia
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bone
The hypophyseal fossa which houses the pituitary gland is located within
which of the following cranial fossae?
anteri or cranial fossa
middle cranial fossa
posterior cranial fossa
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middle cranial fossa
The internal surface of the base of the skull consists of three cranial fossae, the anterior, middle,
and posterior. They increase in size and depth from anterior to posterior. The anterior and
middle fossae are separated by t he lesser wing of t he sphenoid bone, and the middle and
posterior fossae are separated by the petrous part of the temporal bone.
The anterior cranial fossa is adapted for reception of the frontal lobes of the brain, and is
formed by portions of the frontal, ethmoid, and sphenoid bones. The crista galli, a midline
process of the ethmoid bone, gives attachment to the anterior end of the falx cerebri. On each
side of the crista galli are the grooved cribriform plates of the ethmoid bone, providing
numerous orifices for the delicate olfactory nerves from the nasal mucosa to synapse in the
olfactory bulbs.
The middle cranial fossa is composed of the body and great wings of t he sphenoid bone, the
squamous and petrous parts of the temporal bones and the frontal angles of the parietal
bones. This fossa is the"busiest of the cranial fossae. This fossa contains laterally the temporal
lobes of the brain. This fossa contains the optic chiasma, optic canal, sella t urcica, and the
hypophyseal fossa that houses the pituitary gland. Within this fossa, the superior orbital fissure,
foramen rotundum, foramen ovale, foramen lacerum, and foramen spi nosum are found. In the
temporal bone, t he hiatus for both the lesser and greater petrosal nerves are found. On t he
anterior surface of the petrous portion of the temporal bone is the trigeminal impression,
which lodges the trigeminal ganglion (semilunar or gasserian) of the fifth nerve.
The posterior cranial fossa, the deepest of the fossae, houses the cerebellum, medulla, and
pons. Anteriorly, the posterior cranial fossa extends to t he apex of the petrous temporal.
Posteriorly, it is enclosed by the occipital bone. laterally, portions of the squamous temporal
and mastoid part of the temporal bone form its walls. It contains four important foramina, the
internal acoustic meatus (in the petrous part of the temporal bone), the j ugular foramen
(between the temporal and occipital bones), t he hypoglossal canal (in the occipi tal bone), and
the foramen magnum (a large median opening in the floor of the fossa, where the medulla
oblongata is continuous with the spinal cord).
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bone
Treacher Collins syndrome is a rare genetic disorder that presents with many
craniofacial deformities. One of the characteristic traits is downward slanti-
ng eyes, which is caused by underdevelopment of the bone that forms the
substance of the cheek. Which bone is this that anchors many of the muscles
of mastication and facial expression?
ethmoid bone
zygomatic bone
occipital bone
sphenoid bone
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zygomatic bone - al so called the cheek bone or malar bone
The zygomatic bone is situated at the upper and lateral part of the face: this bone
forms the prominence of the cheek, part of the lateral wall and floor of the orbit, and
parts of the temporal and infratemporal fossae. The zygomatic bone presents a malar
and a temporal surface; four processes, the frontosphenoidal, orbital, maxillary, and
temporal; and four borders.
The zygomatic bone articulates with four bones: the frontal, sphenoidal, temporal
(to form the zygomatic arch), and maxilla. Above the zygomatic arch is the temporal
fossa, which is filled with the temporali s muscle. Attached to the lower margin of the
zygomatic arch is the masseter muscle. Note: The temporalis muscle passes medial
to the zygomatic arch before the muscle inserts into the coronoid process of the
mandible.
The temporal fossa is a shallow depression on the side of the cranium bounded by
the temporal lines and terminating below the level of the zygomatic arch. The
infratemporal crest of the greater wing of the sphenoid bone separates the
temporal fossa from the infratemporal fossa below it.
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temporal bone
Crnnium, lateral aspect
74-1
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bone
Which of the following can be defined as a tube-like passage running
through a bone?
fovea
meatus
fossa
fissure
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meatus
Surface Features of Bone
Depressions:
Fissure (a sharp, deep groove): a sharp, narrow, cleft-like opening between the
parts of a bone t hat allows for t he passage of bl ood vessels and nerves
Example: superior orbital f issure of the sphenoid.
Sulcus (a groove, but shallower and a less abrupt cleft t han a f issure): a shall ow,
wide groove on the surface of a bone that allows for t he passage of blood vessels,
nerves, and tendons
Example: intertubercular sulcus of t he humerus, alternately known as the bicipit-
al groove.
Incisure (notch): a deep indentation on the border of a bone
Example: greater sciatic incisure or notch of the os coxa.
Fovea: a small, very shallow depression
Example: fovea capitis on the head of the femur accepts a li gament from t he hip
socket or acetabulum.
Fossa: a shall ow depression. This may or may not be an articulating surface
Example (of art iculating surface): glenoid fossa of the scapula or mandi bular
fossa of the temporal bone. Example (non-articulating surface) : subscapular
fossa.
Openings:
Foramen: an opening t hrough which blood vessels, nerves, or ligaments pass
Example: foramen magnum of t he occipital bone, mental foramen of t he mand-
ible.
Meatus (canal): a tube-li ke passage running through a bone
Example: t he acoustic meatus of the temporal bone.
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bone
The ganglion that supplies the mucous membrane of the mouth and nose
with parasympathetic fibers is located in which of the following fossae?
pterygopalatine fossa
infratemporal fossa
temporal fossa
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of Fossae
Superior
Anterior
Medial
Lateral
Inferior
Post erior
Muscles
pterygopalatine fossa- the ganglion is pterygopalatine ganglion
Boundaries of Fossa<' ol the Skull
Tempor al Fos.sa Infratemporal Fossa Pterygopalatine Fossa
Inferior cemporal line Greater wing of sphenoid bone Inferior stwfac.e of sphenoid bone body
Frontal process of Maxillary tubero.(jiry Maxillary tuberosity
zygomatic bone
Surface of temporal Lateral pterygoid plate
bone
Zygomatic arch Mandibular ramus and 11e1ygomaxillary fissure
zygomatic. arch
Infratemporal crest of No bony border J>te.rygopalatine c.anal
sphe.noid bone
Inferior cemporal line No bony bo1der l>tt .1ygoid process of sphenoid bone
\Iuscl<s. Blood\ <sscls. and :\er\l's ol r ossac of the Skull
Temporal Fossa Infratemporal Fossa
Temporal is muscle Prerygoid muscles and lowe1 pan of
rempora1is muscle
Pter ygopalatine Fossa
Blood vessels Area blood vessels Pcerygoid venous plexus and
maxillary a11ery (second J>OI'Iion)
and branches including middle
meningeal arre.ry, inferio1 alveolar
arte1y, and posterior superior
alveolar anery
Maxillary artery (third portion)
and branches including
infraorbiral and .sphenopalatine
aneries
Nenes Area nerves Mandibular nerve including inferior Prerygopalatine ganglion and
alveolar, buccal and lingual nerves maxillary nerve
as well a.s cho1da ()'lllpani and otic
ganglion
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zygomatic arch
orbit----=:::
inferior
orbital fissure
pterygomaxillary
fissure
palatine
bone
~ lateral pterygoid
plate of the
sphenoid bone
maxillary tuberosity
Oblique lateral view ofthe base ofthe skull and the roof
ofthe pterygopalatine fossa and its boundaries
76-1
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bone
The pterygopalatine fossa communicate laterally with infratemporal fossa
though which of the following?
sphenopalatine foramen
foramen rotundum
foramen lacerum
pterygomaxill ary fissure
inferi or orbital fissure
I refer to card 76-1 for illustration]
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pterygomaxillary fissure
The pterygopalatine fossa is a small triangular space behind and below the orbital cavity.
The pterygopalatine ganglion lies in the pterygopalatine fossa just below the maxillary nerve (V-
2). The pterygopalat ine ganglion receives pregangl ionic parasympathetic fibers from the facial
nerve by way of the greater petrosal nerve. The pterygopalatine ganglion sends postganglionic
parasympathetic fibers to the lacrimal gland and glands in the palate and the nose.
Note: The maxillary nerve (V2) and the pterygopalatine portion of the maxillary artery pass
t hrough the pterygopalati ne fossa.
The following passages connect the pterygopalatine fossa with other parts of the skull:
Connection- direction Connection- direction
Nasal cavity- medially Orbit- anteriorly
Middle cranial fossa, foramen lacerum- posteriorly Oral cavity- inferiorly
Infratemporal fossa- laterally)
Middle cranial fossa- posteriorly
Bony Opening Location (Bone)
Sphenopalatine foramen Sphenoid and palatine
Pterygoid canal Sphenoid
(vidian canal)
Ptcrygomaxillary Sphenoid and maxilla
fissure
Foramen rotundum Sphenoid
Inferior orbital fissure Sphenoid and maxilla
Pterygopalatine canal Maxilla and palatine
(greater palatine canal)
Pharyngeal canal Sphenoid and palatine
Nasal cavity/nasopharynx- posteriorly
Contents
Sphenopalatine artery and vein, nasopalatine nerve
Deep and greater petrosal nerves which fonn nerve
of pterygoid canal, area vessels
Posterior superior alveolar vein, artery and nerve,
maxillary artery
IVhLxillary nerve (V2)
Infraorbital and zygomatic nerves, Infraorbital
artery. and ophthalmic vein
Greater and lcs..o;cr palatine veins, arteries and
nerves
Pharyngeal branch of V-2
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bone
Which ofthe following receives the opening ofthe nasolacrimal duct?
superi or meatus
middle meatus: ethmoidal bul la
middle meatus: Hiatus of semilunaris
sphenoethmoidal recess
inferi or meatus
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inferior meatus
The nasal conchae are three pai rs of scroll-like, deli cate shelves or projections, which
hang into the nasal cavity from the lateral walls. These projections assist in increasing
the surface area within the nasal cavity for fil tering, heating, and moistening the air.
The superior and middle conchae are part of the ethmoid bone; whil e the inferior
concha is a separate bone (also called the inferior turbinate). The space below each
concha is referred to as a meatus.
Superior meatus: lies below and lateral to the superior concha. The superior
meatus receives the openings of the posterior ethmoidal sinuses.
Middle meatus: lies below and lateral to the middle concha. The middle meatus
receives the openings of the frontal, maxil lary, anterior, and middle ethmoidal sin-
uses. The middle ethmoidal sinuses drain onto the ethmoidal bulla (rounded
prominence on the lateral wall of the middle meatus). The anterior ethmoidal
sinuses drain into the infundibulum (funnel-li ke structure that empties into a
groove called the hiatus semi lunaris on the lateral wall of the middle meatus). The
frontal sinuses drain into the infundibulum or directly into the middle meatus. The
maxillary sinus drains di rectly into the hiatus semilunaris; its opening (ostium) is
located near the top of the sinus.
Inferior meatus: li es below and lateral to the inferi or conchae. It receives the
opening of the nasolacrimal duct. The nasolacri mal duct drains lacri mal fluid from
the surface of the eye into the meatus for evaporation during respiration.
Note: Maxillary sinus cysts or neoplasms usuall y compress the nasolacri mal duct
leading to obstruction of this duct.
Sphenoethmoidal recess: is a small space posterior and superi or to the superior
concha into which the sphenoidal sinus opens.
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limen
nas.al vestibllle
nasal hairs
(vibrissae)
superior nasal concha
middle nasal concha
I
sphenoidal sinus
pons
fourth ventricle
medulla oblongata
atlas (Cl "'rtebra)
poslerior
oerebeUomedullary
cisttm
Cl
a>is (C2 "'rteb<a)
--"""---spinal cord
pharyngeal opening of
tube
Lateral wall of nasal c.avity of right half of head. The inferior and middle conchae, curving me-
dially and inferiorly from the lateral wall, divide the wall into three nearly equal parts and cover
the inferior and middle meatus, respectively. The superior concha is small and anterior to the sphe-
noidal sinus and the middle concha has an angled inferior border and ends inferior to the sphe-
noidal sinus. The inferior concha has a sl ightly curved inferior border and ends inferi or to the
middle concha.
78-1
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nasion
bridge of
nose
Cranium, facial (frontal) aspect
nasal bones
middle nasal
conchae
78AI
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bone
A prosthodontist designs his maxillary removable complete and partial
dentures to engage the hamular notch behind the maxillary tuberosities.
The hamulus is a small slender hook, which accommodates the action of the
tensor veli palatini. The hamulus is a component of which bone?
lateral pterygoid plate of sphenoid bone
medial pterygoid plate of sphenoid bone
maxil la
hori zontal plate of palatine bone
perpendicular plate of palatine bone
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medial pterygoid plate of sphenoid bone
The left and right pterygoid processes project downward from near the junction of each of t he greater
wings within t he body of the sphenoid bone. These processes run along t he posterior portion of the nasal
passage toward the palate. Each process consists of a medial and a lateral pterygoid plate.
The lateral pterygoid plate provides the ori gin for both lateral and medial pterygoid muscles. The plate
also forms t he medial wall of the infratemporal fossa. The medial pterygoid plate forms t he posterior
l imit of t he lateral wall of the nasal cavi ty. The medial plat e ends inferiorly as a hamulus, a small, slender
hook t hat acts as a pulley for the tensor veli palatini (i nnervat ion: medial pterygoid nerve, CN V3) t endon
to change it s direction of pull from vertical t o horizont al, thereby tensi ng the soft palate.
Pl'oce.s..-.es of Skull Skull Bones Associated Structures
Alveolar Mandible Cl)ntains roots of mandibular teeth
Alveolar proces.o; f\<la..;<illa Contains roots of maxillary teeth
Coronoid f>.<landible P011ion of ramus
Frontal process: Maxilla Forms medial infraotbital ri i'H
Frontal Fonns anterior lat.:-ral orbital wall
wing Sphe--noid Anterior proce-s:s to sphenoid hone body
Greater Sphe-noid Poste-rolateral process: to sphenoid bone-. c.avity
Mastoid prol.'e-s:s Temporal Composed of mastoid air ce-lls
Maxillary proee-s:s Zygomatic Fonns infraorbital rim and potion of anterior lateral orbital \\'all
Palatine proces..o; r-.<ta:<illa Fonns anterior hard palate
Postglenoid process: Temporal Poste-rior to TMJ
Pterygoid proc.es..o; Sphe-noid Cl)nsiSL!; of medial and lateral pt.:-rygoid
Styloid proces..o; Temporal Serves as auac-hme--nt fOr 1t1ustles and ligame-nu
T t -1\lpl)ral proces..o; Zygomatic P011ion of zygomatic arch
Zygomatic process Fron1a.l Lateral h) orbit
Zygomatic process Ma:<illa Fonns late-ral portion of infraorbital rim
Zygomatic process Temporal P011ion of zygomatic arch
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greater wing of
sphenoid bone
infratemporal
crest
spine of sphenoid bone
hamulus of medial pterygoid plate
lateral pterygoid plate
Cutaway view of the lateral aspect of the upper portion
of the skull with the sphenoid bone highlighted
79 1
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bone
A young patient arrives in the physician's office with unexplained, persistent
symptoms. The patient has had bloody nasal discharge and painful oral
lesions. A chest x-ray reveals "coin and labs reveal kidney failure.
Ultimately, the isolation of the AN CAs - lgG antibodies - yield a diagnosis of
Wegener's granulomatosis. The dentist who referred this patient to the
physician made a note of the necrotizing oral lesion that had perforated the
hard palate into the nasal cavity. The roof of the oral cavity is formed by the:
ethmoid and palatine bones
maxill a and nasal bones
maxill a and palatine bones
nasal and vomer bones
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maxilla and palatine bones
***Specifically, the palatine processes of the maxilla and the horizontal plates of the
palatine bones.
The structure formed by this union is the hard palate. The anterior two-thirds of the
hard palate is formed by the palatine processes of the maxilla, and t he posterior one-
third is formed by the horizontal plates of the palatine bones. The hard palate forms not
only the roof of the oral cavity proper but also the floor of the nasal cavity. It is covered
with a mucous membrane and beneath the mucosa are palatal salivary glands. The
greater (anterior) palatine vein, artery, and nerve travel along the maxillary alveolar
processes anteriorly where they join the nasopalatine nerves and sphenopalatine artery
and vein, exiting the nasal cavity from the incisive foramen.
The soft palate is continuous with the hard palate posteriorly and is "soft" because it does
not have a bony substrate but contains a tough fibrous connective tissue sheet, the
palatal aponeurosis, and is covered with a mucosa. Salivary glands are found in the under-
lying connective tissue. Posteriorly, the soft palate suspended in the oropharynx ends in
the midline uvula.
Remember: Most of the palatal muscles receive motor innervation from the pharyngeal
plexus of nerves. The tensor muscles of the palate (tensor veli palatini) receive motor
branches from the mandibular division of the trigeminal nerve (CN V3). Sensory inner-
vation is provided by the maxillary division of the t rigeminal nerve (CN V2). Arterial sup-
ply is from the descending palatine artery (a branch of the maxillary artery), which in turn
branches into the greater and lesser palatine arteries.
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maxilla,
palatine process
groove for greater
palatine vessels
interpalatine
suture
palatine { horizontal plate
bone pyramidal process
vomer
Palate
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bone
Most precisely, osteocytes are located in which of the following spaces?
canaliculi
lacunae
lamell ae
trabeculae
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lacunae
There are two types of bone t issue: compact and spongy. The names imply that t he
two types of bone t issue differ in density, or how tightly t he tissue is packed togeth-
er. There are t hree types of cells t hat contribute to bone homeostasis. Osteoblasts are
bone-forming cell s, osteoclasts resorb or break down bone, and osteocytes are
mature bone cell s. An equilibrium between osteoblasts and osteocl asts maintains
bone tissue.
Compact bone consists of closely packed osteons or haversian systems. The haver-
sian system consists of a central canal call ed the haversian canal, which is surround-
ed by concentri c rings (lamell ae) of matrix. Between the rings of matrix, t he bone cells
(osteocytes) are located in spaces called lacunae. Small channels (canaliculi) radiate
f rom the lacunae to the haversian canal to provide passageways through the hard
matrix, they provide oxygen and nutrients to the osteocytes. In compact bone, the
haversian systems are packed t ightly together to form what appears to be a sol id
mass. The haversian canals contain blood vessels that are parallel to the long axis of
the bone. These blood vessels interconnect, by way of perforating canals, with vessels
on the surface of the bone.
Spongy (cancell ous) bone is lighter and less dense than compact bone. Spongy bone
consists of plates (trabeculae) and bars of bone adjacent to small, irregular cavities
that contain red bone marrow. The canaliculi connect to the adjacent cavities, instead
of a central haversian canal, to receive their blood supply. It may appear that the t ra-
beculae are arranged in a haphazard manner, but they are organized to provide max-
imum strength similar to braces that are used to support a building. The trabeculae of
spongy bone follow the li nes of stress and can reali gn if the direction of stress
changes.
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cancellous
(spongy) bone

medullary
marrow cavity
trabeculae
t-::::1---'1.,..- haversian (central)
canals
volkmann's (transverse)
canals
The longitudinal section oflong bone shows cancellous and compact bone
81-1
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circumferential
lamellae
osteon
( Haversion system)
blood vessels
The magnified section of compact bone
lacunae
containing
osteocytes
8 A ~
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bone
Which of the following is the largest bone of the pelvis?
ilium
ischium
pubis
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ilium
The os coxa or hipbone is formed by the fusion of the ilium, ischium, and pubis on
each side of the pelvis. The os coxa articulates with t he sacrum at t he sacroiliac joint
to form the pelvic girdle. The two hip bones articulate with one another anteri orly at
the symphysis pubis.
The ilium is the uppermost and largest bone in the pelvis; the ilium possesses the
iliac crest, whi ch ends in front at t he anterior superior iliac spine and behind at the
posterior superior iliac spine. The i li um possesses a large notch called the greater
sciatic notch.
The ischium is l-shaped with an upper thicker part (body) and a lower thi nner
part(ramus). This part bears t he weight of the body when a person is in an upright,
seated position. Features incl ude ischial spine and ischial tuberosity. The obtur-
ator foramen is formed by the ramus of the ischium together with the pubis.
The pubis is divided into a body, a superior ramus, and an inferior ramus. The
bodies of the two pubic bones articulate with each other in the midline anteri orly
at the symphysis pubis. l ateral to the symphysis is the pubic tubercle. The ing-
uinal ligament connects the pubic tubercle to the anteri or superior ili ac spine.
Remember: The acetabulum is a cup-shaped cavity on the lateral side of the hip
bone that receives the head of the femur. It is formed superiorly by the ilium,
posteroinferiorly by the ischium, and anteromedially by the pubis.
Note: The sciatic nerve is t he largest single nerve in t he human body going from the
top of the leg to the foot on posteri or aspect.
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inter-
trochanteric
line
/
Ilium
pubofemoral
y llgament
Hip J oint - Anterior view
82-1
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acetabular labrum
articular capsule -
greater
trochanter
Hip Joint- Frontal section
articular cavity
ligamentum teres
82AI
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bone
The trachea divides into left and right main bronchi at the level of?
the upper part of sternum
the mid part of the body of the sternum
just above the xiphoid process
junction of manubrium and body of sternum
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junction of manubrium and body of sternum- (sternal angle)
The sternum is made of three individual parts. The most superior part is the manubrium. The clavicle (col-
l ar bone) connects to the manubrium and the shoulder. lnferiortothe manubrium is the body of the ster-
num. The most i nferior portion of the sternum is the xiphoid process.
Sternal angle: i s formed by the junction of the manubrium and the body of the sternum. It marks t he fol-
l owing:
approximate l evel of the 2nd pair of costal cartilages
approximately the beginning and end of the aorti c arch
bifurcation of the trachea i nto the left and right main bronchi
boundary between the superi or and inferior portion of the mediastinum
There are 24 ribs (12 pai rs). All ri bs are attached posteriorly to the 12 thoracic vertebrae. The anterior por-
tion of rib pai r number one attach to the manubrium. Rib pairs number 2 through 7 have an anterior at-
tachment to the body of the sternum. Rib pairs number 8 through 10 have an anterior attachment to the
carti lage of the rib above them. Ri b pai rs number 11 and 12 do not have an anteri or attachment at all . The
ribs are divided i nto the following categori es. Rib pairs number 1 through 7 are called true ribs, rib pairs
number 8 through 12 are false ribs and rib pai rs number 11 and 12 are floating ribs.
Costal groove: is a groove between the ridge of the internal surface of the rib and the i nferior border. It con-
tains the intercostal vessels and intercostal nerve, the order of which (from superior to inferior) can be re-
membered with the mnemonic "VAN" which stands for Vein, Artery, Nerve, which means that the
i ntercostal nerve is most likely to be damaged in case of injury to that area because the nerve is least pro-
tected by the costal groove.
The vertebral column consists of 24 individual vertebrae, one sacrum (5 fused vertebrae), and one coc-
cyx (3-5 f used vertebrae). The first seven vertebrae are called cervical vertebrae. These make up t he bones
of our neck. The vertebrae i n the thoracic region are called the thoracic vertebrae. There are twelve of
those. Each one has a pai r of ribs attached to it . The last five vertebrae are the lumbar vertebrae.
Mnemonic: For the vertebrae, just remember the t i mes people typically eat meal s; 7am - breakfast - 7 cer-
vical vertebrae, 12 pm - lunch - 12 thoracic vertebrae, 5pm- dinner - 5 1umbarvertebrae.
Note: The body of each vertebra develops from the caudal part of one sclerotome and cranial portion of
the next sclerotome, whil e the nucleus pulposus (central porti on of the vertebral disk) devel ops from the
notochord.
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bone
Which of the following bones articulates with the capitulum of the humerus?
radius
acromion
ulna
scapula
cl avicle
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radius
Clavicle: the clavicle connects to the manubrium of the sternum and t he acromi on of the scapula.
Scapula: is also called the shoulder blade. The glenoid cavity i s the lateral edge of the scapula and is t he
socket portion of t he ball-and-socket j oi nt of the shoulder. The acromion of the scapula connect s to the clav-
i cl e.
Humerus: the head of the humerus fi ts i nto t he glenoid cavity of the scapula. Lateral t o t he head is the
greater tubercle. At the inf erior (distal) end of the humerus are two condyles. These have special names, the
lat eral condyl e i s the capitulum (whi ch art iculat es with the radius) and the medial condyle i s t he trochlea
(which art iculates with the ul na). Lateral to t he capitul um i s a rather l arge bump called t he lateral epi-
condyle. Medial t o the trochlea i s t he medial epicondyle. There is a groove between t he medial epicondyle
and t he t rochlea. when people hit t his area. They say they've hit t hei r ' f unny o n e ~ There is a nerve that
passes t hrough t hat area, which i s t he ul nar nerve. On t he ant erior si de of t he humerus, at t he distal end.
t here is a depression called the coronoid fossa. On the opposi te side is a large depression called t he ole-
cr anon fossa.
Radius: there are two bones compri si ng t he l ower arm. The radius i s the lateral bone and the ulna i s t he
medial bone. When the hand is in the supinate posit ion, t he radius and ul na are parallel t o each other. When
the hand is pronated, the radi us crosses over the ul na. The head of the radi us pivot s on the capit ul um.
Ulna: t he ulna has large bulge on t he posterior side called the olecranon process. This is the el bow. An-
terior to the olecranon process i s a huge notch called the trochlear notch. The t rochl ear notch pivots on
t he t rochl ea on the ulna.
Mnemonics:
Elbow joint: radius vs. ul na ends CRAzy TULips
- Capitul um= RAdi us
- Trochl ea= Ulna
Wrist: radial side vs. ulnar side
- Make a fi st with your thumb in the ai r and say:RAQ!", your thumb is now poi nt i ng t o your RADi us
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bone
Which of the following bones forms the major part of the lateral wall of the
orbit?
frontal bone
zygomatic bone
maxillary bone
sphenoid bone
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zygomatic bone
The Walls of t he Orbit:
Each orbit has four walls: superior (roof), medial, inferior (Ooor) and lateral
The medial walls of the orbit are almost parallel with each other and with t he superior part of the nasal cav-
i ties separating them
The lateral walls are approximately at right angles to each other
The Superior Roof of the Orbit:
The superior wall or roof of the orbit Is formed almost completely by the orbital plate of the frontal bone
Posteriorly, the superior wall is formed by the lesser wing of the sphenoid bone
The roof of the orbit is thin, translucent, and gently arched. This plate of bone separates t he orbital cavity
and the anterior cranial fossa.
The optic canal is located in t he posterior part of the roof
The Medial Wall of the Orbit:
This wall is paper-thin and is formed by the orbital lamina or lamina papyracea of the ethmoid bone, along
with contributions from the frontal, lacrimal, and sphenoid bones (papyraceus, "made of papyrus" or parch-
ment paper).
There is a vertical lacrimal groove in t he medial wall, which is formed anteriorly by t he maxilla and posteri-
orly by the lacrimal bone
It forms a fossa for the lacrimal sac and the adjacent part of the nasolacrimal duct
Along the sut ure between the ethmoid and frontal bones are two small foramina; t he anterior and posterior
ethmoidal foramina
These transmit nerves and vessels of the same name
The Inferior Wall ofthe Orbit
The thin inferior wall of t he orbit or the floor is formed mainly by the orbital surface of the maxilla and partly
by the zygomatic bone, and orbital process of the palatine bone
The fl oor of the orbit forms the roof of the maxillary sinus
The fl oor is partly separated from the lateral wall of the orbit by t he inferior orbital fissure
The Lateral Wall of the Orbit:
- This wail Is t hick, particularly its posterior part, which separates the orbit from t he middle cranial fossa
-The lateral wall is formed by the frontal process of the zygomatic bone and the greater wing of the sphenoid
bone
-Anteriorly, t he lateral wall lies between t he orbit and the temporal fossa
- The lateral wall is partially separated from t he roof by the superior orbital fissure
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cell
Kartagener syndrome is a hereditary syndrome; it's characterized by recur-
rent upper and lower respiratory tract infections. Dysfunction of which
organelle is responsible for this syndrome?
centriole
flagell um
vacuole
cilium
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cilium
Flagella are present in the human body only in the spermatozoa. Flagell a are similar
in structure to cilia but are much longer. The action of the f lagellum produces move-
ment
The cilium is a short, hair-like projection f rom the cell membrane. The coordinated
beating of many cili a produce organized movement.
The basic structure of f lagell a and cili a is the same. They resemble centrioles in hav-
ing nine sets of microtubules arranged in a cyli nder. But unlike centrioles, each set is
a doublet rather than a triplet of microtubules, and two singlets are present in the
center of the cylinder (9 + 2 arrangement). At the base of the cylinders of cil ia and f la-
gella, within the main portion of the cell, is a basal body. The basal body is essential
to the functioning of the cilia and flagella. From the basal body, f ibers project into the
cytoplasm, possibly to anchor the basal body to the cell.
Note: Prokaryotic flagella are much thinner than eukaryotic flagella, and they Jack the
typical "9 + 2" arrangement of microtubules.
Both cilia and f lagella usually function either by moving the cell or by moving li quids
or small particles across the surface of the cell. Flagell a move with an undulating
snake-like motion. Cil ia beat in coordinated waves. Both move by the contraction of
the tubular proteins contained within them.
Kartagener syndrome (immotile cilia syndrome): is a hereditary syndrome; it's
characterized by recurrent upper and lower respiratory tract infections; it's caused by
a defect in the action of the cilia.
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cell
The inactive X chromosome in a female cell is called the ____ which is
an example of ___ _
pineal body, euchromatin
lateral body, heterochromatin
golgi body, euchromatin
barr body, heterochromatin
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barr body, heterochromatin
In the female, the genetic activity of both X chromosomes is essential only during the
first few weeks after conception. Later development requires just one functional X
chromosome. The other X chromosome is inactivated and appears as a dense
chromatin mass call ed the Barr body. This Barr body is attached to the nuclear
membrane in the cell s of a normal female. In the cell s of a normal male, who has only
one functional X chromosome, the Barr body is absent.
Important: The Barr body's presence is the basis of sex determination tests (for
example, amniocentesis) .
1. The sex of an embryo can be determined at about the eighth week.
2. Females have 45 active chromosomes and one inactive Barr body.
iJl 3. Barr body is also found in the cells of males with Kleinfelter syndrome
(XXY).
4. Barr body is an excell ent example of Heterochromatin.
Heterochromatin: is highly condensed and t ranscriptionally inactive form of DNA.
Euchromatin: is extended and t ranscriptionally active form of DNA.
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cell
In which cellular component are glycoproteins assembled for extracellular
use?
the Golgi apparatus
the endoplasmic reticulum
the nucl eus
the nucl eolus
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the Golgi apparatus
The function of the Golgi apparatus is two-fold: First, t he modification of l ipids and
proteins; Second, the storage and packaging of materials t hat will be exported f rom
the cell. The Golgi apparatus is often called t he "shipping department" of t he cell.
The vesicles t hat pinch off f rom the Golgi apparatus move to t he cel l membrane, and
the material in the vesicl e is released to t he outside of t he cell. Some of these
pinched-off vesicl es also become lysosomes. Important: The Golgi apparatus is
where glycoproteins are assembled for extracellular use. N-li nked glycosylations
are the most common and occur in the ER. 0 -linked glycosylations occur in the
golgi apparatus.
The Golgi apparatus (sometimes call ed the Golgi body) is similar to endoplasmic retic-
ulum (ER). It is composed of flat, membranous sacs, or cisternae, arranged in stacks
of paral lel rows, one above the other, l ike pancakes. These stacks have two poles- t he
convex cis face, which receives materials for processing, and t he concave trans face,
oriented toward t he cell membrane for t ransport. Between these two faces are sever-
al intermediate cisternae known as the medial face.
1. These cisternae are located between t he nucleus and t he secretory sur-
face of a cell.
2. They package, store, and modify products that are secreted f rom the cell.
3. Procollagen filaments aggregate in t he cisternae of Golgi apparatus.
Procollagen is formed in t he lumen of endoplasmic reticulum by binding of
sugars with the amino acids that were previously polymerized on the ribo-
somes. Then it will move to t he cis face of Golgi apparatus.
Lysosomes are cytoplasmic membrane-bound vesicl es that contain a wide variety of
glycoprotein hydrolytic enzymes that serve to digest and destroy exogenous mate-
rial, such as bacteria.
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utncelular spoce
0
.............._ Golci
'-.,. lraRSIIOrl
tesicle
- Golgl
ER
G-- transiiOrl
tesicle
Endoplasmic reticulum. Diagram above shows the relationship between ER <md Golgi . The lumen
of the rough ER is continuous with the pelinuclear space and with the lumen of smooth ER, whereas
the Golgi f01ms a separate membrane system. Communication between ER and Golgi is mediated
by small vesicles ofER which break off, move through the cytosol and fuse with Golgi membrane.
The vesicles derived from RER are coated with a specifi c protein, COJ>TT, which targets them for
fusion with the Golgi. 88 1
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cell
Which of the following is the distinctive array of microtubules in the core of
cilia and flagella composed of a central pair surrounded by a sheath of nine
doublet microtubules (characteristic "9 + 2" pattern)?
centri ole
axoneme
tubul in
malleolus
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axoneme
An axoneme is the core scaffold of the eukaryotic cilia and flagella, which are projections from the cell made up
of mlcrotubules. Thus, the axoneme serves as the "skeleton" of these organelles, both giving support to the
structure and, in most cases, causing it to bend. Though distinctions of function and/or length may be made
between cilia and flagella, the internal structure of the axoneme is common to both.
The characteri stic feature of the axoneme is its "9 + 2" arrangement of microtubules and associated proteins, as
shown in t he image below. Nine pairs of "doublet" mlcrotubules, a component of the cellular cytoskeleton,
form a ring around a "central pair" of single microtubules. Ciliary dynei n arms, the motor complexes that allow
the axoneme to bend, are anchored to these microtubules. The interactions between the ciliary dynei n proteins
and outer doublet microtubules generate force by sliding the doublets parallel to each other, which bends the
cilium and enables it to beat.
The radial spoke, a protein complex important in regulating the motion of the axoneme, Is also housed in the
axoneme; it projects from each set of outer doublets toward the central mlcrotubules. The radial spoke is a multi-
unit protein structure found in the axonemes of eukaryotic cilia and flagella. Nexln is a protelnous Inter-doublet
linkage that prevents microtubules in the outer layer of axonemes from movement with respect to each other.
dyndn arms
(evtry 24 nm) radial s p o ~
ntxin lil'\kjng (Mry 29 nm)
protein
(tvery8G nm)
central pair
of mkrotubules
Diagram of a cross-section of a cilium.The nine outer doublet
tubules are made of tubulin, whereas arms composed of the protein
dynein occur every 24 nm down the length of the cilium and inter-
act with adjacent doublets as a "molecular motor to produce bend-
Ing. links composed of another protein, nexin, are more widely
spaced (every 86 nm) and hold the mlcrotubules in position. Radial
spokes extend from each of the nine outer doublets toward a cen-
tral pair of tubules at 29 nm Intervals, and the central sheath projec-
tions are present every 14 nm.
Note: Centrioles are cell organelles that constit ute the centrosome and thus aid in formation of the mitotic
spindle.
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cell
Which ofthe following organelles have double membranes?
Select all that apply.
mitochondria
golgi apparatus
peroxisomes
centriole
nucleus
nucleolus
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mitochondria
nucleus
Cdl Structure Functions
Membranous:
Plastna membrane Serves as a boundary of the c.cll, maintaining its integrity; protein mo lecules e mbedded
in pJasma membrane perform various functions
EndopJasmic reticulum Ribosomes attached to roughER synthesize proteins that Jeave ceiJs via the Golgi
complex; smooth ER synthesize lipids incorporated in c.cll membranes, steroid
and certain carbohydrates used to fom1 glycoprotcins
Golgi apparatus Composed of membranous s.acs; carbohydrates, combines it with protein,
and packages the product as globules of g lycoprotein
Lysosomcs A cell 's "digc$tivc system"
Pcroxisomes Contain enzymes that detoxify hannful substances. Cata]ase breaks down toxic
hydroge n peroxide into water and oxygen.
Mitochondria Double membranous structure; catabolism; ATP synthe$is; a ceJI's ' 'power plant".
Mitochondria have their own cyclic. DNA which makes some protein.'i that are used by
the mitochondria; this DNA is transmitted from the mother to the fetus.
Nucleus Double membranous structure; houses the genetic code, which in tum dicta tes
protein thereby playing an essential role in other cell activities, munely,
cell transport, metabolism, and growth
Nonmembranous:
Ribosomes
Cytoskeleton
Nucleolus
Site of protein synthesis; a cell 's " protein factories"
Acts as a framework to support the cell and its organelles; func tions in cell movement;
fom1s cell extension (microvilli, cilia, flagella)
Plays an essential role in the fom1a tion of ribosomes
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cell
All of the following are considered as specialized types of macrophages
EXCEPT one, which one is the EXCEPTION?
kupffer cell s
microglial cell s
osteoclasts
langerhans cel ls
plasma cells
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plasma cells
of Different Cells and Theil Function
Cell Primary Function
Plasma Antibody synthesis (Immunoglobulins)
Mast Mediators of intlammation on contact with antigen
Schwann Form myelin sheath around axons of the PNS
Sertoli Produces testicular tluid
Leydig Produces testosterone
Fibroblast Produces collagen and reticular tibers
Osteoblast Forms bone matrix, gives rise to osteocytes
Odontoblast Forms dentin
Ameloblast Forms enamel
T (Lymphocytes) Cell-mediated immunity
B (Lymphocytes) Humoral immunity; Diflerentiate into plasma cells
Alpha (Pancreatic) Produce glucagon
Beta (Pancreatic) Produces insulin
Langerhans Antigen presenting cells (APCs) located in the skin
Microglial Special ized macrophages located in the nervous system
Kupffer Special ized macrophages located in the liver
Osteoclasis Special ized macrophages located in the bone; bone resorption
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cell
Which cell lines the lumen of the seminiferous tubules and secretes horm-
ones, androgen binding proteins (ABPs) and other proteins that facilitate
spermatogenesis?
interstitial cells of Leydig
principal cells
sertoli cells
clara cel ls
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sertoli cells
Sertoli cell.s, together with a stratifi ed layer of developing gametes comprise the cellular majority of t he
seminiferous t ubules. These cell s are responsible for secret ing testicular fluid, androgen bindi ng proteins
(ABPs) and hormones such as inhibi n; which regulates FSH secretion (sertol i cells are sensi tive t o FSH) ..
Interstitial cells of Leydig are located in t he loose vascular connective t issue surrounding the seminifer-
ous tubules and are responsibl e for secreti ng testosterone.
ol Dilfcrcnt Cells and 'I heir Locations
Cell Primary Location
Sustentacular Internal ear (organ of Corti). taste buds, olfactory epithelium
Pyramidal Cerebral cortex (cerebrum)
Endothelial Lining blood and lymph vessels, endocardium (inner layer)
Ependymal Lining the brain ventricles and spina) cord
Sertoli Seminiferous tubules of the testis
Ganglionic In a ganglion peripheral to the CNS
Globular Transitional epitheJium (kidney. water. bladder)
Prickle Stratum spinosum of epideml is
Fibroblast Most common cell of connecti ve tissue
Chromaffin Adrenal medulla and paravertebral ganglia of sympathetic nervous system
Purkinj e Cerebellar cortex (cerebellum)
Goblet Mucous membranes of respiratory and intestinal tracts
Interstitial Connecti ve tissue of ovary and testis
Islet Pancreas
JuxtaglomeruJar Renal corpuscle of kidney
Mesenchymal Found between ectodeml and endodenn of embtyos
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cell
Protein synthesis occurs in all of the following phases EXCEPT one. Which
one is the EXCEPTION?
G
1
phase
S phase
G
2
phase
M phase
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M phase
The cell cycle consists of interphase (incl uding growth and synthesis) and mitosis.
Growth is the increase in cellular mass as the result of metabolism.
Synthesis is the replication of DNA in preparation for mitosis.
Mitosis is the splitting of the nucleus and cytoplasm that results in t wo diploid cells being formed.
The cell cycle can be further divided into:
Interphase: the interval between successive cell divisions duri ng which the cel l is metabolizing
and the chromosomes are directing RNA synthesis.
It includes: 1. G
1
phase - the first growth phase
2. S phase - DNA synthesis
3. G
2
phase - the second growth phase
M phase- mitosis (also called karyokinesis), in this phase both cell growth and protein
production stop. All of the cell's energy is focused on the complex and orderly division into two
similar daughter cells.
Note: G
0
phase - is a resting phase where the cell has left the cycle and has stopped dividing
@
Nuclear
Ohi1Sion Cell di'li sion
"
Morogrowth ((a hto.io
preporot 1on far
G1 DNA replicat ion

DNA reolicot ion ond
chromatid dupli cetl on
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cell
The plasma membrane (cell membrane):
surrounds the cell wall and serves to protect t he cell from changes in osmotic pres-
sure
is a polysacchari de-containing structure that functions in attachment to sol id sur-
faces, preventing desiccation, and protection
is a non-permeable membrane enclosing t he cell wall
is a dynamic, selectively permeabl e membrane enclosing t he cytoplasm
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is a dynamic, selectively permeable membrane enclosing the cytoplasm
The plasma membrane (cell membrane) is a thin elastic structure 7.5 to 10 nanometers thick. It is
located between the cell wall and the cytoplasm. Normal cell membrane function is essential for
passive nutrient diffusion in and out of the cell, as well as for active (i.e., requiring energy) transport
across the membrane. The plasma membrane consists of a phosphol ipid bilayer containing integral
and peripheral proteins. This type of membrane is called a fluid mosaic and is found in both
prokaryotic and eukaryotic cells.
The cell wall surrounds the plasma membrane and serves to protect the cell f rom changes in
osmotic pressure, anchor flagella, maintain cell shape, and control the transport of molecules into
and out of the cell. Structures interior to the cell wall include the plasma membrane, the cytoplasm,
and cytoplasmic constituents such as DNA, ribosomes, and inclusions.
Remember: The mitochondria and nucleus are double membrane organelles. Mitochondria are
the principal energy source of the cell (major site of ATP production) and are involved in all oxida-
tive processes. They contain cyclic DNA.
Plasma membrane
Integral
proteins
Note: Fatty acids content of the lipids
form the interior hydrophobic tails of
plasma membrane. Remember "phobia
= fear" so hydrophobic means "water
fearing" that's why they arrange to the
inside away from water.
Peripheral proteins can be removed
with detergents and change in pH envi-
ronment, however integral proteins can-
not be purified w/o disruption of the cell
membrane structure.
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cell
What type of cell in the dental papilla adjacent to the inner enamel epitheli-
um differentiates into odontoblasts?
stell ate reticular cel l
mesenchymal cel l
ameloblast
follicular cell
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mesenchymal cell - also called mesoblastic cells
These cells have the potential to proliferate and differentiate into diverse types of
cells (fibroblasts, chondroblasts, odontoblasts, and osteoblasts). Mesenchymal cells
form a loosely woven tissue called mesenchyme or embryonic connective tissue.
Important: The mesenchymal cells in the dental papilla adjacent to the inner enam-
el epithel ium differentiate into odontoblasts, which produce predentin that calcifies
to become dentin.
Mesectoderm (also call ed ectomesenchyme) is that part of the mesenchyme deri ved
f rom ectoderm, especially from the neural crest in the very young embryo. Neural
crest cells give rise to spinal ganglia (dorsal root ganglia) and the ganglia of the
autonomic nervous system. These cell s also give rise to neurolemma cells
(Schwann cells), cell s of the meninges that cover the brain and spinal cord, pigment
cells (melanocytes), chromaffin cells of the adrenal medull a, and several skeletal and
muscular components of the head.
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Ectomes-
enchyme
from neural
crest
Summary of Tooth Formation
Dental papilla
Dental follicle
95- 1
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cell
On the playground at recess, a young girl is stung by a bee and immediately
breaks out in hives and starts gasping for air. The teacher grabs an epineph-
rine autoinjector from the first aid kit and is able to save the girl. What cells,
when bound by lgE, are responsible for this anaphylactic reaction?
mast cel ls
macrophages
platelets
kupffer cells
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mast cells
Mast cells are large cell s with coarse metachromatic granules containing heparin
(anticoagulant), histamine (vasodil ator), and other substances (i.e., chemotactic
factors, such as eosinophi l chemotactic factor of anaphylaxis and neutrophil
chemotactic factor). They occur in most loose connective t issue, especially along the
path of blood vessels. These cell s act as mediators of inflammation on contact with
antigen. Note: Normall y, mast cell s are not found in circulation.
Both mast cell s and basophils l iberate heparin into the blood. Heparin can prevent
bl ood coagulation as well as speed the removal of fat particl es from the blood after a
fatty meal. They both also release histamine as well as smaller quantities of
bradykinin and serotonin. Note: It is mainly the mast cell s in inflamed t issues that
release t hese substances during inflammation.
The mast cells and basophils play an exceedingly important role in some types of
allergic reactions because t he type of antibody that causes allergic reactions (the lgE
type) has a special propensity to become attached to mast cells and basophils. The
reaction between antigen and anti body causes t he mast cell or basophil to rupture
and release exceedingly large quantities of histamine, bradykinin, serotonin,
heparin, SRS-A (slow-reacting substance of anaphylaxis), and a number of
lysosomal enzymes. This, in turn, causes local vascular and tissue reactions t hat
cause many, if not most, of t he all ergic manifestations.
Note: Mast cells and basophil s are deri ved from different precursors in bone marrow,
that's why they are considered separate cell types.
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cell
A chromosome is maximally condensed chromatin wrapped around a protein
base of primarily:
hydroxyapatite
hyaluronan
histones
haploid
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histones
Chromosomes are maximally condensed forms of chromatin. Chromatin consists of
strands of DNA wound around a protein base of primarily histones and looks like a
beaded string under an electron microscope. Four histone proteins make up a
nucleosome core. This is the basic unit for which DNA is wrapped around.
Chromatin occurs in two forms: euchromatin (extended) and heterochromatin
(condensed). When a cell prepares to divide, the chromatin coils into compact
chromosomes.
Except in the gametes (germ cells), chromosomes appear in pairs. One chromosome
from each pair comes from the male germ cell (sperm), the other from the female
germ cell (ovum).
Normal human cel ls contain 23 pairs of chromosomes, which makes the diploid
number 46. The diploid number is the number of chromosomes of a normal cell. The
haploid number is the number of chromosomes in a gamete. Usually, the diploid
number is twice the haploid number. In these cell s, 22 pairs are called homologous
chromosomes or autosomes. These sets contain genetic information that controls the
same characteristics or functions. The 23rd pair are sex (X andY) chromosomes. The
composition of these chromosomes determi nes the person's sex - XX produces a
genetic female; XV, a genetic male.
Histones are positively charged basic proteins; they carry a highly positively charged
N-terminus with many lysine and arginine residues, their charge is positive because
they need to interact with DNA, which is negatively charged. Note: The basic amino
acids are arginine, lysine and histidine.
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cell
Plasma cells are immediate derivations of which cell type?
CDS+ T cell
CD4+ T cell
B lymphocyte
neutrophil
eosinophil
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B lymphocyte
Plasma cell s are further differentiated B cell s that are very important in the produc-
t ion of antibody. They are rarely found in the peripheral blood. They comprise f rom
0.2% to 2.8% of the bone marrow white cell count. Mature plasma cell s are often oval
or fan shaped, measuring 8 to 15 1Jm. Their appearance (on light microscopy) is quite
characteristic: they have basophil cytoplasm and an eccentri c nucleus, in addition to
a pale zone in the cytoplasm that (on electron microscopy) contains an extensive
Golgi apparatus. They are found mainly in bone marrow and connective t issue. They
have a short l ifetime of 5 to 10 days.
T cells (T lymphocytes or thymus-derived lymphocytes): produce cell -mediated
immunity. They account for 70% to 80% of circulating lymphocytes and become asso-
ciated with the lymph nodes, spleen, and other lymphoid t issues. Upon interacting
with a specific antigen, T lymphocytes become sensit ized and differentiate into sev-
eral types of daughter cells. These include memory T cells, which remain inactive
until future exposure to the same antigen; killer T cell s, which combine with antigen
on the surface of the foreign cell s, causing lysis of the foreign cells and the release of
cytokines; and different subsets of he I perT cells, which help activate other T lympho-
cytes. Note: HIV virus selectively infects T-helper cel ls or CD4+ T cells.
B cell s (B lymphocytes, complete maturation in the bone marrow): produce antibody-
mediated immunity. They account for 20% to 30% of circulating lymphocytes and like
T lymphocytes become associated with lymphoid organs (lymph nodes, spleen, etc.).
As B lymphocytes become sensit ized to an antigen, mature B cel ls develop into plas-
ma cells or become memory B cells. Memory B cell s are formed specific to the anti-
gen(s) encountered duri ng the primary immune response; able to live for a long time,
these cells can respond quickly upon second exposure to the antigen for which they
are specific.
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cell
Which ofthe following is a specialized macrophage located in the liver?
fibroblasts
hepatocyte
kupffer cell
erythrocyte
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kupffer cell
The liver's functional unit, the lobule, consists of plates of hepatic cells, or
hepatocytes, that encircle a central vein and radiate outward. Separating the
hepatocyte plates from each other are sinusoids, the liver's capillary system.
Hepatocytes make up 60% to 80% of the cytoplasmic mass of the li ver. These cells are
involved in protein synthesis, protein storage and transformation of carbohydrates,
synt hesis of cholesterol, bi le salts and phospholipids, and detoxification,
modification, and excretion of exogenous and endogenous substances. The
hepatocyte also initiates the formation and secretion of bile.
Hepatocytes have abundant organell es that perform their numerous functions.
Smooth endoplasmic reticulum produces bile salts and detoxifies poisons.
Peroxisomes also detoxify poisons. Rough endoplasmic reticulum manufactures
membranes and secretory proteins. In certain leukocytes, the rough ER produces
anti bodies. In pancreatic cell s, the rough ER produces insulin. The Golgi apparatus
packages bil e and other secretory products of t he cell. Glycosomes store sugar.
Finally, numerous mitochondria fuel cell activity.
Kupffer cells are reticuloendotheli al macrophages, which line the sinusoids. They
function to remove bacteri a and toxins that have entered t he blood through the
intestinal capi ll aries. These cells have definite cytologic characteristics such as clear
vacuoles, lysosomes, and granular endoplasmic reticulum.
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cell
Which of the following is the site of synthesis of rRNA and is NOT bound by a
membrane?
endoplasmic reticulum
ribosomes
golgi apparatus
nucleolus
plasma membrane
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nucleolus
The nucleolus is an oval body found inside the nucleus. The nucleolus consists of RNA and pro-
tein and is not bounded by a limiting membrane. The nucleolus is the site of rRNA synthe-
sis. Ribosomes are small particles consisting of rRNA and protein. They are commonly called
the "protein factories" of the cell. They are responsible for the process of translation, or tak-
ing the information from the DNA, encoding on RNA, and using it to create the proteins need-
ed by the cell.
The endoplasmic reticulum is a membranous network through the cytoplasm. The endoplas-
mic reticulum is continuous with the cell and nuclear membranes.
There are two types of endoplasmic reticulum:
1. Smooth (ribosomes are absent)- steroid synthesis; intercellular transport; detoxification.
The SER in smooth and striated muscle cells is known as sarcoplasmic reticulum which is
responsible for storage and release of Ca2+.
2. Rough (ribosomes are attached) - synthesis of proteins for use outside a cell (extracellu-
lar use).
1. The nucleus of a cell is surrounded by two membranes and contains DNA.
2. Active cells which synthesize large amounts of proteins (fibroblasts, osteoblasts,
plasma cell s, etc.) are characterized by an abundance of rough endoplasmic
reticulum.*** NBDE favorite question: The cytoplasm of osteoblasts appears to be
basophilic via normal H&E stain due to the presence of large amounts of rough
endoplasmic reticulum.
3. RNA and DNA can be distinguished from one another by the Feulgen reaction.
4. Any substance that is stained by the basic dye (appears blue or purple) is
considered to be basophilic, such as nucleus and rough endoplasmic reticulum,
because of their high content of DNA and RNA respectively.
5. Any substance that is stained by the acidic dye (appears pink or red) is considered
to be acidophilic, such as mi tochondria and lysosomes.
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cell
In which phase of mitosis do the chromosomes condense and become visi -
ble, the nuclear membrane breaks down, and the mitotic spindle apparatus
forms at opposite poles of the cell?
interphase
prophase
metaphase
anaphase
telophase
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prophase
Mitosis is the process of normal cell division. Mitosis occurs whenever body cells need to
produce more cell s for growth or for replacement and repair. The result of mitosis is two
identical daughter cells with the same chromosomal content as the parent cell. Mitosis
is part of the entire life span of the cell, also called the cell cycle. This entire cycle consists
of the following stages:
Interphase: the interval between successive cell divisions during which the cell is
metabolizing and the chromosomes are directing DNA synthesis. It includes:
1. G
1
phase: the fi rst growth phase
2. S phase: DNA synthesis
3. G
2
phase: the second growth phase
Mitosis can be divided into four principal stages:
Prophase: the chromosomes condense and become visible, the nuclear membrane
breaks down, and the mitotic spindle apparatus forms at opposite poles of the cell.
Metaphase: the chromosomes align at the equatorial plate and are held in place by
microtubules attached to the mitotic spindle and to part of the centromere.
Anaphase: the cent rome res divide. Sister chromatids separate and move toward the
corresponding poles.
Telophase: daughter chromosomes arrive at the poles, and the mi crotubul es disap-
pear. The condensed chromatin expands, and the nuclear envelope reappears. The
cytoplasm divides (cytokinesis), and the cell membrane pinches inward, ultimately pro-
ducing two daughter cell s.
Note: The mitotic spindle is made up of microtubules.
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cell
All of the following statements regarding differences between meiosis and
mitosis are FALSE EXCEPT one. Which one is the EXCEPTION?
both require one division to complete the process
crossing over occurs in mitosis, it does not occur in meiosis
meiosis occurs in germ cel ls only
in mitosis the daughter cell s have half the number of chromosomes as the parent
cell (2n ton), whil e in meiosis the daughter cells have the same number of chromo-
somes as the parent cells (2n to 2n)
in meiosis the daughter cell s have the same genetic information as the parent cell,
while in mitosis the daughter cell s are genetically different from the parent cell
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meiosis occurs in germ cells only
Mitosis Meiosis
Requires one division only to complete the Requires two di vi.i> ions 10 (.'.(Unplete. the process
<k'<CurS in all somatic cdls OceurS in germ only
The. daughter have the same number of The daughter cdlo: have half Lhe number of
chromosomes as 1he parent cells (2n to 2n) as 1he paren1 ails (2n ton)
4 The. daughter cdlo; have the. same gent .lic 4 The daughter cells art gentlicall > difftrtnt from
information as the parenl cell the parent <:.ell
Cro.o;sing over belween chromosomes dots not occur Cro.o:sing over belween chromosomes dots oceur
Phases of meiosis: There are t wo divisions in meiosis; the fi rst division is meiosis 1 and the second is
meiosis 2. The phases have the same names as those of mitosis. A number i ndicates the division number
( 1st or 2nd): Meiosis 1: prophase 1, metaphase 1, anaphase 1, and telophase 1
Meiosis 2: prophase 2, metaphase 2, anaphase 2, and telophase 2
In the first meiot ic division, t he number of cells is doubled but the number of chromosomes is not. This
results in 1/ 2 as many chromosomes per cel l. The second meiot ic division is l ike mitosis; the number of
chromosomes does not get reduced.
The events t hat occur duri ng prophase of mitosis also occur during prophase I of meiosis. The chromo-
somes coil up, the nuclear membrane begi ns to disintegrate, and the centrosomes begin movi ng apart.
Synapsis {joi ning) of homologous chromosomes produces tetrads (al so called bivalents)
The two chromosomes may exchange fragments by a process called crossing over. When the chromo-
somes partially separate in late prophase, the areas where crossing over occurred remain attached and
are referred to as chiasmata. They hold the chromosomes together until t hey separate during anaphase.
Metaphase 1:
Bivalents (tetrads) become aligned i n t he center of t he cell and are attached to spindle f ibers
Anaphase 1: begins when homologous chromosomes separate
Telophase 1: the nuclear envelope reforms and nucleoli reappear
Note: Interkinesis is similar to interphase except DNA synthesis does not occur. The events t hat occur
duri ng mei osis II are similar to mitosis.
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cell
Almost all human body cells have mitochondria EXCEPT one, which one is the
EXCEPTION?
fibroblasts
RBCs
osteobl asts
osteoclasts
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RBCs
Mitochondria (energy plants): the function of mitochondria is to yield ATP, it has two
membranes; outer and inner, the inner one contains many enzymes important for the
oxidative phosphorylation which is an important process for yielding ATP. The inner
membrane also has a lot of infoldings call ed cristae, they are responsible for increas-
ing the inner surface area of mitochondria. The number of mitochondria and cristae is
proportional to the activity of the cell (e.g., kidney and cardiac cells require a lot of en-
ergy so those cells possess high content of mitochondria).
Important: Mitochondria also have their own DNA which is maternally transmitted
hence; a female with a mitochondrial disorder will transmit it to all her offspring.
1. Mature red blood cell s have no mitochondri a, so all of their energy needs
are suppl ied by anaerobic glycolysis.
2. Striated duct cells of salivary glands have a lot of mitochondria arranged
in rows giving them a stri ated appearance. They need energy for actively
transporting ("pumping") ions.
3. Myoepithelial cells: these are non-secretory cells that are known to have
contractile properties in sweat glands and mammary glands. They are located
between the secretory cells and their basement membrane. They are de-
rived from ectoderm.
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gastrointestinal system
The main distinguishing feature of the jejunum is the presence of promi -
nent:
brunner's glands
rugae
peyer's patches
teniae coli
plicae circulares
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plicae circulares - aka valves of Kerckring
The small intestine i s the main site of absorption of digested food. The small intestine is specialized for
the compl etion of the digestion processes and the subsequent absorption of the digested products. The
small intestine consists of three main segments: the duodenum, jej unum, and ileum.
Characteristic features of the small intestine include:
Intestinal villi. These are finger-like proj ections i nto the l umen (consisting of surface epi thel ium and
underlying lami na propria).
The epithelium lining the lumen consists of a si mpl e col umnar epitheli um with goblet cells. The
apical surface of the absorptive epithel ial cells has a "brush border" (resul ti ng from an orderly
arrangement of closely packed mi crovilli, whi ch may number several hundred per absorptive cell). The
main f unction of the microvilli is to increase the surface area availabl e for absorption.
The lamina propria of the small intestine is formed from loose connective tissue. This contai ns
blood vessels, nerves, and large lymphati c vessel s (si te of absorption of lipids).
Intestinal glands. These are si mpl e tubul ar gl ands that open to the intesti nal lumen between t he
base of the vi lli . The i ntestinal glands are sometimes called the crypts of Lieberkuhn. The crypts
secrete various enzymes, including sucrase and maltase, along with enteropeptidase. Al so, new epithe-
l ium is formed here. Secretory cells (Paneth cells) with large acidophilic granules are found at the base
of the i ntesti nal glands. The f unction of these secretory cells is still not fully understood, but it is known
that they secrete lysozyme, whi ch has anti-bacterial properties.
Important:
1. The main disti ngui shing f eat ure of the duodenum is the presence of glands in the submucosa. These
duodenal or Brunner's glands produce al kal ine secretions to counteract the effects of gastri c acids that
reach the duodenum. These glands also provide the necessary alkal ine envi ronment for the functioni ng
of the exocrine pancreati c secretions.
2. The ileum i s al most devoid of pl icae ci rculares, however large accumulations of lymphatic ti ssue, both
nodular and dense, are found in the lamina propria. These can often be seen macroscopically as large
whi te patches and are commonly known as Peyer's patches occupi ed by M-cell s. The i leum is the pre-
ferred site for vitamin 812 absorption. Vitamin 812 is also known as cobalamin.
Remember: Pernicious anemia is an autoimmune disorder which attacks gastric pari etal cells. These cells
secrete intri nsic factor whi ch i s i ntegral for vi tamin B12 absorption.
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DIGESTIVE SYSTEM
Ascending
colon -
Cecum_
. ----
AppendiX
- -Stomach
------Jejunum
_ Flexura of
transverse colon
--Decending
colon
---Rectum
._Anus
104-1
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jej unum
plicae clc:utares
thick wall
ilieum
thin wall
arterial arcades
smooth mucous
membrane
superior mesenteric
artery fat
Some external and internal differences between the jejunum and ileum
104AI
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gastrointestinal system
A patient comes to the emergency room presenting with jaundice and
intense pain in the upper abdominal and between the shoulder blades. The
physician suspects choledocholithiasis that is caused by cholesterol stones
formed in which organ that stores and concentrates the bile.
appendix
gall bladder
liver
pancreas
spleen
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gallbladder
The gallbladder is a sac-shaped organ roughly 3 to 4 inches long. It is firmly attached to
the lower surface of the liver and li es on the right side of the abdomen j ust below the ribs
at the front. The gallbladder is joined by the cystic duct to the common hepatic duct to
form the common bile duct which passes down through the head of pancreas to drain
into the ampulla of Vater. Just before the duct enters the duodenum, the common bile
duct is j oined by the pancreatic duct.
Note: The gall bladder's lining is folded into rugae (simil ar to those in the stomach). The
middle layer consist s of smooth muscle fibers that contract to eject bile.
Bile is continuously produced by t he liver and drains through the hepatic ducts and bile
duct to the duodenum. When the small intestine is empty of food, the sphincter (Oddi's
sphincter) of the hepatopancreatic ampulla (ampulla of Vater) constricts, and bile is
forced up the cystic duct to the gallbladder for storage.
Important: Secreti on of the hormone cholecystokinin after a fatty meal st imul ates gall-
bladder cont raction and relaxation of Oddi's sphinct er, and the bile mixes with the chyme.
1. The sphincter (Oddi's sphincter) of the hepatopancreatic ampullaris is a circu-
lar muscle that surrounds the hepatopancreati c ampulla (ampull a of Vater).
2. The gallbladder does not contain a submucosa as do the stomach and intes-
tines (both large and small).
3. Bile emul sifies neutral fats and absorbs fatty acids, cholesterol, and certain
vitamins.
4. The gallbladder receives blood f rom the cystic artery, a branch of the right
hepatic artery. The gallbladder is innervated by vagal fibers from the celiac
plexus. The lymph drains into a cysti c lymph node, then into the hepatic nodes,
and eventually into the celiac nodes.
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Common HepJtic Duct
Common Bile Duct
Duodenal Papilla
Duodenum
Pancreas, Duodenum and Gallbladder
105 1
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gastrointestinal system
The smooth muscle coat of the large intestine consists of three bands called
taeniae coli.
The walls of the large intestine have more villi than the small intestine.
both statements are t rue
both statements are false
the f irst statement is t rue, the second is false
the f irst statement is false, the second is t rue
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the first statement is true, the second is false
The large intestine consists of the colon and rectum. The colon Is composed of various parts: t he cecum, ascend-
i ng colon, transverse colon, descending colon, and sigmoid colon. The appendix is attached to the cecum. The
rectum is the second to last part of the digestive tract and leads into t he last part, t he anus.
The large Intesti ne Is composed of three parts:
1. Cecum: the beginning of the large intestine, bag-like structure that receives the ileum of the small intest-
ine. The vermiform appendix is a narrow, blind tube that extends downward from t he cecum. It contains a
large amount of lymphoid tissue. Note: Because the appendix is a blind tract. it is frequently a site of inflam-
mation (appendicitis).
2. Colon: parts of t he colon Include the ascending colon - the shortest part of the large intestine that
extends upward from the cecum on the right posterior abdominal wall. The t ransverse colon extends
across the upper abdomen where the colon bends downward along t he left posterior abdominal wall as the
descending colon. Low in the abdomen, the colon curves into the pelvis toward t he midline as the 5-shaped
sigmoid col on.
3. Rectum: extends from the sigmoid colon to the anus. It is straight and does not possess the taeniae coli
t hat are present in the rest of the large intestine. The rectum ends as the anal canal (3 - 4 em), which opens
to the exterior through t he anus. The anal canal is surrounded by t he internal and external sphincter muscles
t hat control the expulsion of contents (bowel movements).
Important: Unlike those of the rest of the Gl tract, longitudinal muscles do not form a continuous layer
around the large intestine. Instead t hree bands of longitudinal muscle, called taeniae coli, run the length of
t he colon. Contractions gather the colon into bands (haustra), giving t he colon its puckered' appearance.
1. The large intestine lacks folds or villi. It is characterized by many tubular Intestinal glands with
r large numbers of goblet cells. This is sometimes described as a glandular epithelium.
,. 2. The large intestine is the site of water absorption (via columnar absorptive cells) and is also the site
of formation of t he feces. The secretions of the goblet cell s provide lubri cation for the luminal sur-
faces.
3. Abundant lymphatic t issue is common in the lamina propria (owing to the large bacterial popula-
t ion i n the lumen of the large intestine).
4. Whereas t he circular smooth muscle layer is continuous, the longitudinal smooth muscle of the
muscularis is in the form of t hree thick bands, known as taeniae coli.
5. The anal region, unlike the rest of the large intestine, has a series of longitudinal folds, and the
epithelium becomes a stratified squamous epithelium.
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S m a l l ~ .
intestine
1-- E:I\Cirnal anal sphincter
(skeletal muscle)
Anus anal sphincter
(smooth muscle)
Large intesti ne 106-1
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gastrointestinal system
Name the glands found in the submucosa of the duodenum that secrete an
alkaline mucus to protect the walls of the mucosa.
peyer's patches
glands of Kerckring
hertwig's glands
brunner's glands
crypts of Lieberkuhn
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brunner's glands
Brunner's glands (also called duodenal glands or submucosal glands) are small, branched, coiled,
tubular glands situated deeply in the submucosa of the duodenum. These glands make alkaline
material that act along with bile and pancreatic juice to neutralize the very acidic chyme entering
the duodenum through pylorus. They also help to achieve optimal PH for the activity of pancreatic
enzymes. Note: Histologically, it is possible to distinguish the duodenum from the stomach by the
presence of these submucosal glands.
Remember:
1. The duodenum is the first part of the small intesti ne and measures around 12 inches in length.
The duodenum has a "C" shape, with the curvature of the"C encircling the head of the pancreas.
It is the shortest but widest part of the small intestine.
2. The interior of the duodenum has a folded surface, which increases the available surface area
for absorption of minerals (especially iron) and amino acids.
3. It is mostly retroperitoneal (lies behind the peritoneum). The exception is the first 2cm of the
first part (ampulla, duodenal cap).
4. It receives the common bile duct and pancreatic duct at the duodenal papilla (which is a
small, rounded elevation in the wall of the duodenum).
5. The duodenum receives blood from the superior pancreaticoduodenal artery, a branch of
the gastroduodenal artery, and the inferior pancreaticoduodenal artery, a branch of the
superior mesenteric artery.
Important: The sympathetic and parasympathetic divisions of the autonomic nervous system
control contraction of smooth muscles in the intestinal wall. (1) Sympathetic: The splanchnic
nerve passes through the celiac plexus. Postganglionic fibers innervate the small intestine.
Sympathetic stimulation slows motility of the small intestine. (2) Parasympathetic: The vagus
nerve supplies a vast distribution of parasympathetic fibers. Postganglionic fibers from t he celiac
plexus associated with the vagus nerve innervate the small intestine. Parasympathetic stimulation
of the small intestine causes increased motility. Note: The preganglionic parasympathetic neurons
to the duodenum are located in the dorsal motor nucleus of the vagus nerve.
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gastrointestinal system
At which level does the esophagus pierce the diaphragm?
C6
TS
TlO
T12
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T1 0- it begins at C6
The esophagus starts at t he lower border of t he 6th cervical vertebrae. It is a 1 0-inch
collapsible muscular tube t hat lies dorsal to the trachea and ventral to the vertebral column.
The esophagus extends from t he oropharynx anterior to the vertebral column, enters t he
mediastinum, leaves the thorax via t he esophageal hiatus (at T1 0) and joins the stomach. The
point where the esophagus ends and t he stomach begins is the esophagogastric junction.
The opening through which the abdominal part of t he esophagus enters the cardiac portion
of t he stomach is called the cardiac orifice. Important: There is an abrupt change in the type
of surface epithelium at the junction of t he esophagus and stomach - from stratified
squamous to simple columnar.
The esophageal wall contains four layers, as follows from the lumen outward:
Mucosa - epithelium, lamina propria, and glands
Submucosa -connective tissue, blood vessels, and glands
Muscularis (middle layer) - Proximal third of esophagus: striated muscle; Middle thi rd of
esophagus: smooth and striated muscles; Distal third of esophagus: smooth muscle
Adventitia - connective tissue that merges with connective t issue of surrounding struc-
t ures
The esophagus receives blood from the inferior thyroid artery, from branches of the
descending thoracic aorta, and from branches of t he left gastric artery.
"GERD" stands for gastroesophageal reflux disease, and "Barrett's esophagus" is the
metaplasia, or abnormal change, in the epithelium of the lower end of t he esophagus (gastric
or intestinal columnar epithelium replaces the normal stratified squamous epithelium of t he
esophagus) thought to be caused by chronic acid damage. Note: Strong association with
esophageal adenocarcinoma.
Remember: The esophagus receives parasympathetic fibers from the esophageal branches
of the vagus nerve. The esophagus receives motor fibers from the recurrent laryngeal
branches of the vagus nerve and sympathetic innervation from the esophageal plexus of
nerves.
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gastrointestinal system
The lateral surface of the stomach is called the:
lesser curvature
greater curvature
lesser omentum
greater omentum
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greater curvature
The stomach is a collapsible, pouch-like structure about 10 inches long and capable of holding 2 to
4 quarts. Attached to the lower end of the esophagus, the stomach lies immediately inferior to the
diaphragm and extends to the duodenal portion of the small intestine. The stomach lies in the left
upper quadrant of the abdominal cavity.
The lat eral surface of the stomach is called the greater curvature; the medial surface, the lesser
curvature. The lesser omentum layer of the peri toneum extends around the stomach, and the
greater omentum is found along the greater curvature of the stomach. The interior of the stomach
is lined with rows of folds or wrinkles, called rugae.
The stomach has four main regions:
1. Cardia: immediately distal to the gastroesophageal junction of the stomach and esophagus.
2. Fundus: enlarged portion distal to the cardia, lying above and to the left of the gastroesophag-
eal opening.
3. Body: the middle or main port ion of the stomach, distal to the fundus and tapering in size.
4. Pylorus: the lower portion, between the body and the gastroduodenal j unction.
The stomach has three layers of smooth muscle - the outer longitudinal, the middle circular, and t he
inner oblique muscles.
1. The maximum capacity of the stomach is about 3 to 4 liters.
2. The stomach receives blood from all three branches of t he celiac artery (celiac trunk) . The
left gastric artery supplies the lesser curvature of the fundus and the body of the stomach.
The right gastric artery is a loop that supplies the lesser curvature and then forms an
anastomosis wit h t he left gast ric artery. The left and right gastro-omental arteries supply
the greater curvat ure.
The mucosa of the stomach contains many gastric glands in the lamina propria:
Parietal (oxyntic) cells: located in fundus and body; secrete HCL and intrinsic factor
Zymogenic (chief) cells: located in fundus and body; secrete pepsinogen
G cells: present throughout the stomach; produce gastrin
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pyloric
sphincter
mucosa and
submucosa
Stomach - Internal view
"
greater
curvature
circular
muscle
layer
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gastrointestinal system
Which ofthe following vessels does NOT supply blood to the liver?
hepatic veins
hepatic portal vein
common hepatic artery
celiac trunk
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hepatic veins
The liver receives blood from t wo sources: the hepatic artery proper, which is a branch of the
common hepatic artery, which in turn branches from the celiac trunk and the hepatic portal vein.
The hepatic artery proper supplies oxygenat ed blood from the aorta, while the hepatic portal vein
carries the products of digestion to the liver for processing. This blood eventually drains via the
hepatic veins into the inferior vena cava, which transports the blood to the heart. Note: The portal
triad consists of the: hepatic artery, portal vein and bile duct.
The liver is t he heaviest and most active internal organ in the body. Many of the liver's functions are
vital for life. Normally reddish brown in color, the liver lies under the cover and protection of the
lower ribs on the right side of the abdomen. The liver has an upper (diaphragmat ic) surface and a
lower (visceral) surface; the two surfaces are separated at the front by a sharp inferior border. The
liver is attached to the diaphragm by the falciform, triangular, and coronary ligaments. The liver
is also j oined to the stomach and duodenum by the lesser omentum (gastrohepatic omentum) and
hepatoduodenal ligaments respectively. The visceral surface of the liver is in contact with t he
gallbladder, the right kidney, part of the duodenum, the esophagus, the stomach, and the hepatic
flexure of the colon. The porta hepatis - the point where vessels and ducts enter and exit the liver
- lies on the ventral surface. The liver is divided into right, left, caudate, and quadrate lobes.
Anatomically, the right lobe includes the caudate and quadrate lobes. The caudate lobe and t he
majorit y of the quadrate lobe are, however, funct ionally part of the left lobe, as they receive their
blood supply from the left hepatic artery and deliver their bile into the left hepatic duct.
Bile is produced and excreted by hepatocytes (liver cells), which are the most versatile cells in t he
body. Bile is secreted by the liver into the common hepatic duct. A short cystic duct from t he
gallbladder j oins the common hepatic duct to form the common bile duct, which transports the bile
inferiorl y to the duodenum to help emulsify fat for digest ion. Note: Kupffer cells line the sinusoids
of the liver and function to filter bacteria and small foreign particles out of the blood.
Remember: The liver has digestive, metabolic, and regulatory functions; it s chief digestive function
is producing bile, which acts as a fat emulsifier in the small intestine.
Note: The lesser omentum (gastrohepatic omentum) is the double layer of peritoneum that
extends from the liver to the lesser curvature of the stomach and the start of the duodenum.
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right lobe
of liver
coronary ligament
inferior border
Liver- Anterior view
110.1
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cystic artery
gastro
duodenal
artery
left gastric artery
splenic artery
Typical patterns of branching of celiac trunk and hepatic arteries
110AI
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gastrointestinal system
One significant difference between the jejunum and the ileum is that the ileum
characteristically contains more of which feature below?
pli cae circulares
brunner's glands
taeniae coli
peyer's patches
vil li
[refer to card 104 A-1 for illustration)
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peyer's patches
The ileum is characterized by extensive lymphoid tissue. Lymphoid cells aggregate to form Peyer's
patches.
Note: The jej unum has more plicae circulares (valves of Kerckring) and more villi.
The lower part of the ileum has no plicae circulares.
Comparison of the jejunum and ileum:
Jejunum (middle portion of the small intestine)- ext ends from the duodenum to t he ileum:
1. Thicker muscular wall for more active peristalsis.
2. Has a mucosal inner lining of greater diameter for absorption.
3. Has more (and larger) plicae circulares (valves of Kerckring) and more villi for greater
absorption.
4. Absorption of carbohydrates and proteins.
Ileum (distal portion of the small intestine)- extends from the jejunum to the cecum:
1. More mesenteric fat.
2. More lymphoid tissue (Peyer's patches).
3. Blood supply is more complex.
4. More goblet cells, which secrete mucus.
5. Absorption of vitamin B 12 and bile salts.
Remember:
1. Valves of Kerckring. The lining of the small intestine has permanent folds known as valves of
Kerckring or plicae circulares. These are most prominent in the jejunum. These folds, seen
macroscopically in transverse sections, consist of mucosa and submucosa.
2. 1ntestinal villi. These are finger-like projections into the lumen (consist ing of surface epitheli-
um and underl ying lamina propria).
*""*The epithelium lining the lumen consists of a simple columnar epithelium with goblet cells.
The apical surface of the absorptive epithelial cells has a "brush border" (resulting from an
orderly arrangement of closely-packed microvilli, which may number several hundred per
absorptive cell). The main function of the microvilli is to increase the surface area avai lable for
absorption.
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gastrointestinal system
Peristalsis for what organ is controlled by taeniae coli?
esophagus
stomach
large intestine
small intestine
I refer to card 106-1 for illustration!
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large intestine
Unli ke those of the rest of the Gl tract, longitudinal muscles do not form a conti nuous
layer around the large intestine. Instead, three bands of longitudi nal muscle, call ed
taeniae coli, run the length of the colon. Contractions gather the colon into bands
(haustra), giving the colon its "puckered" appearance.
The major function of the large intestine (also called the colon) is the removal of
water from the material (chyme) entering it. Water is removed by absorption.
Unli ke the small intestine, the large intestine does not secrete enzymes into its
lumen.
Histologic characteristics:
Epithelium: simple columnar with microvillus border to increase surface area for
absorption of water from the lumen. Mucus secreted by goblet cells lubri cates
dehydrating fecal mass. Intestinal glands (crypts of Lieberkuhn) invade lamina
propria. The epitheli um lacks villi.
Muscularis externa: inner circle consisting of a smooth muscle layer. Contains
the three bands of longitudinal muscle, called taeniae coli, for peri stalsis.
Important: The vagus nerve supplies parasympathetic fibers to the ascending and
transverse colons, while the descending and sigmoid colon along wit h the rectum and
anus are supplied by the pelvic splanchnic nerves.
Hirschsprung's disease: is a congenital disease caused by the absence of the myen-
teric plexus (Auerbach and Meissner plexi). Thi s leads to decreased parasympathetic
activity which results in decreased motili ty and obstruction of the intestine.
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gastrointestinal system
Which cells, located in the crypts of Lieberkiihn, secrete an antibacterial
enzyme that maintains the gastrointestinal barrier?
paneth cells
enteroendocrine cells
sertoli cells
absorptive cell s
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paneth cells
Characteristic features of the small intestine include:
Intestinal villi. These are fi nger-like proj ections into the lumen (consisting of surface
epithelium and underlying lamina propria).
***The epithelium lining the lumen consists of a simple columnar epithelium with
goblet cells. The apical surface of the absorptive epitheli al cell s has a "brush border"
(resulting f rom an orderly arrangement of closely-packed microvilli, which may number
several hundred per absorptive cell). The main function of the microvilli is to increase
the surface area available for absorption.
*** The lamina propria of the small intestine is formed from loose connective t issue.
This contains blood vessels, nerves, and large lymphatic vessels (site of absorption of
lipids).
Intestinal glands. These are simple tubular glands that open to the intestinal lumen
between the base of the villi. The intestinal glands are sometimes call ed the crypts of
Lieber kuhn. Paneth cells are specialized secretory epithelial cell s located at the bases
of intestinal crypts (crypts of Lieberki.ihn). They are most commonly found in the ileum.
Their function is still not fully understood, but it is known that they secrete lysozyme,
which has anti-bacterial properties and helps maintain the gastrointestinal barrier.
Valves of Kerckring. The lining of the small intestine has permanent folds known as
valves of Kerckring or plicae circulares. These are most prominent in the jejunum.
These folds, seen macroscopically in transverse sections, consist of mucosa and submu-
cosa.
Three types of epithelial cells line the microvilli of the "brush border":
1. Goblet cells: secrete mucus, abundant in ileum.
2 Absorptive cells: participate in absorption, simple columnar cells.
3. Enteroendocrine cells: secrete enterogastrones (secretin and cholecystokinin) into
the blood- stream. Abundant in the duodenum.
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gastrointestinal system
Which ofthe following cells are responsible for secreting glucagon?
alpha cell s
beta cells
delta cells
gamma cell s
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alpha cells
The pancreas is an elongated gland lying behind the stomach and in front of the aorta and
inferior vena cava. The large head of the pancreas is framed by the C -shaped loop of the duo-
denum. Extending to the left from the head region are the neck, body, and tail of the pancreas,
respectively. The tail meets the spleen on the left of the abdomen.
Note: Patients with cancer of the head of pancreas usually present with j aundice. The jaundice
develops because of t he blockage of the bile duct.
Pancreatic secretions are collected by t he main pancreatic duct (and accessory pancreatic
duct), which, together with the bile duct, enters the duodenum at the hepatopancreatic
ampulla (ampulla of Vater).
The exocrine port ion is formed by secretory cells arranged in small sacs called acini, which
secrete digestive enzymes called pancreatic juices into the intestine. The endocrine portion
consists of clusters of cells called pancreatic i slets (islets of Langerhans), which are scattered
among the acini. These cells produce insulin and glucagon, hormones that promote the cel-
lular uptake of glucose and the breakdown of glycogen, respectively.
1. Endocrine portion (secretes into bloodstream): takes the form of many small clusters of
cells called Islets of Langerhans:
Alpha cells: secrete glucagon, which counters the action of insulin
Beta cells: secrete insulin, which promotes uptake and storage of glucose
Delta cells: secrete somatostatin
Gamma cells: secrete polypeptides
2. Exocrine portion (secret es through duct into duodenum): secretes t he following
enzymes: pancreatic li pase, amylase, carboxypeptidase, elastase, and chymotrypsinogen.
Acinar cells: produce enzymes that digest proteins, carbohydrates, and fats.
Trypsinogen is then converted to trypsin in t he small intestine.
Note: Cholecystokinin is produced by the duodenum and regulates pancreatic j uice secre-
tion.
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Pancreas, Duodenum, and Gallbladder
114-1
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gastrointestinal system
Which of the following provides parasympathetic stimulation to the sigmoid
colon?
vagus nerve
phrenic nerve
Tl-l2
52-54
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S2-S4
Divisions of gut tube:
Foregut: includes esophagus, stomach, liver, gallbladder, pancreas and proximal
part of duodenum (to the point of entry of common bile duct) as well as the spleen
(Note: that it is located in the foregut region, but is not a gut organ).
-Arterial supply: celiac trunk
-Venous drainage: hepatic portal system (via left gastric and splenic veins)
-Lymphatic drainage: celiac nodes
-Sympathetic innervation: t horacic splanchnic nerve synapsing in celiac plexus
-Parasympathetic innervation: vagus
Midgut: incl udes distal part of duodenum, jejunum, il eum, cecum, appendix, as-
cending colon and two t hirds of the transverse colon.
-Arterial supply: superi or mesenteri c artery
-Venous drainage: hepatic portal system (via superior mesenteric vein)
-Lymphatic drainage: superi or mesenteric nodes
- Sympathetic innervation: t horacic splanchnic nerve synapsing in superi or
mesenteric plexus
-Parasympathetic innervation: vagus
Hindgut: includes distal one third of the t ransverse colon, descending colon, sig-
moid colon and rectum.
-Arterial supply: inferior mesenteric artery
-Venous drainage: hepatic portal system (via inferior mesenteric vein)
-Lymphatic drainage: superi or and inferior mesenteric nodes
-Sympathetic innervation: inferior mesenteric plexus
-Parasympathetic innervation: 52-54
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muscle
Which of the following triangles is bounded by the sternocleidomastoid, the
posterior belly of digastric and the superior belly of omohyoid muscle?
submental triangle
digastric tri angle
carotid triangle
muscular triangle
occipital tri angle
subclavian triangle
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carotid triangle
The neck is divided i nto triangles, the two most prominent being formed as the sternocleidomastoid crosses the
neck to form t he anterior and posterior triangles.
The anterior triangle is further subdivided by the anterior and posterior bellies of t he digastrics and t he superi-
or belly of the omohyoid.
(1 ) Submental triangle:
(a) Boundaries: Anterior belly of digastric muscle, hyoid bone and the midline of t he neck
(b) Floor: Mylohyoid
(c) Contents (main): Submental lymph nodes, floor of the mouth
(2) Digastric (or submandibular) triangle:
(a) Boundaries: Anterior and posterior bellies of digastric muscle and inferior border of the body of the
mandible
(b) Floor: Mylohyoid and hyoglossus
(c) Contents (main): Submandibular gland
(3) Carotid triangle:
(a) Boundaries: Sternocleidomastoid, posterior belly of digastric and superior belly of omohyoid muscle
(b) Floor: Thyrohyoid, hyoglossus, and pharyngeal constrictors
(c) Contents (main): bifurcation of common carotid artery, i nternal j ugular vein, vagus and hypoglossal nerve
(4) Muscular triangle:
(a) Boundaries: Superior belly of omohyoid, sternoclei domastoid and midline of the neck
(b) Floor: Sternohyoid and sternothyroid
(c) Contents (main): lnfrahyoid muscles, thyroid and parathyroid glands
The posterior triangle is subdivided by the Inferior belly of the omohyoid.
(1 ) Occipital Triangle:
(a) Boundaries: Sternocleidomastoid, trapezius, and inferior belly of omohyoid muscle
(b) Floor: Splenius capitis, levator scapulae, and t he middle and posterior scalenes
(c) Contents (main): Accessory nerve
(2) Subclavian {or supraclavicular) t riangle:
(a) Boundaries: Sternocleidomastoid, inferior belly of omohyoid muscle and clavicle
(b) Floor: 1st rib and serratus anteri or
(c) Contents (main): Subclavian artery and vein, brachial plexus and supraclavicular nerves
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posteri or
cervical
reglon
lateral cervical regiOn 3
anterior
cervical
region 1
submandibular
triangle
lesse< supraclavicular
fossa
Cervical regions. 1. Anterior cervical region 2. Sternocleidomastoid region 3. Lateral cervical re-
gion 4. Posterior cervica I region u s-1
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sternocleido-
mastoid muscle ----
lateral cervical
region (lateral ----
cervical triangle)
trapezius
clavicle
lesser supra-
clavicular fossa
Muscle Dissection of the Neck - Right lateral view
submandibular
triangle
digastric muscle
ante11or
6 A ~
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muscle
Which of the following muscles assists in opening the pharyngeal orifice of
the auditory tube during swallowing?
stylopharyngeus
palatopharyngeus
salpingopharyngeus
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salpingopharyngeus
Longitudinal \lnsclrs of the h a r ~ II\
Muscle Origin Insertion Action
Stylopharyngeus Styloid process of temporal Latera] and posterior Elevates the larynx and pharynx
bone pharyngeal walls during swallowing
Palatopharyngeus Posterior border of the hard Laryngopharynx and Pulls the wall of the pharynx up
palate and from the palatine thyroid cartilage ward. Acting together, they pull
aponeurosis the palatopharyngeal arches
toward the midline
Salpingopharyngeus Lower part of the cartilage Fibers pass downward Assists in elevating the pharyn.x,
of the auditory tube and blend with the it aJso assists in opening the
palatopharyngeus pharyngeal orifice of the
muscJc auditory tube during swallowing
The musculature of the pharynx is comprised entirely of voluntary muscles. The
muscular arrangement is unique in t hat it is the only area in the alimentary tract
where a layer of longitudinal muscles is contained within a layer of circular muscles.
The external ci rcular layer includes t he superior, middle and inferior pharyngeal con
strictors. The internal longitudinal layer includes the palatopharyngeus, sty
lopharyrngeus and the salpingopharyngeus.
Remember: All of the longitudinal muscles of the pharynx are innervated by the
vagus nerve via the pharyngeal plexus except the stylopharyngeus muscle which is
innervated by the glossopharyngeal nerve (CN IX).
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muscle
Which ofthe following contains thick myosin filaments ONLY?
H zone
I band
A band
all of the above
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H zone
Each skeletal muscle fiber is surrounded by a membrane, the sarcolemma. In the
muscle fiber's cytoplasm (sarcoplasm) are tiny myofibrils, arranged lengthwise. Each
myofibril consists of two types of finer fibers cal led filaments (thick myosin filaments
and thin actin fi laments). The filaments are stacked in compartments cal led
sarcomeres, the functional units of skeletal muscle. During muscle contraction, the
sarcomere shortens when thick and thin fil aments slide over each other.
The striated pattern that is so characteristic of skeletal muscle directly results from the
structure of the contractile units of the muscle. Each fiber of the muscle is striated and
made up of many myofibril s, which are also stri ated in the same pattern of alternating
dark and light bands called the A bands and I bands, respectively. In the center of
each A band is a lighter zone called the H zone; in the center of each I band is a dark,
thin line called the Z line. The portion of a myofibril between two Z li nes constitutes
a single contractil e unit termed a sarcomere. Each sarcomere is composed of two
sets of protein filaments. The thick myosin fil aments are located in the A band. The
thin actin filaments are located primari ly in the I bands but extend into the A
bands. The overlap of the actin and myosin filaments causes the dark coloration of
the A bands; actin's absence from the center of the A bands results in the lighter H
zone of each A band. Note: The H zone contains thick filaments but no thin fi laments.
Note: The tension produced by a sarcomere depends on the number of actin-myosin
cross-bridges it forms. The number of cross bridges depends on the length of the sar-
comere, because this determines how much overlap between myosin and actin fila-
ments occurs. A bands do not change in length upon contraction. Only the H zone
and I bands change.
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Relaxed
thick filament Z line
E ~ ~
H zone
I band A band
Contracted
~ ~ ~
1
thin filament sarcomere
Filament movement and muscle fiber shortening
A muscle fi ber shortens when the thin fi laments move past the thick filaments toward the
center of the sarcomeres, and the Z lines are drawn close together.
11111
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muscle
The is the most superficially located and strongest muscle of mas-
tication?
temporalis
medial pterygoid
lateral pterygoid
masseter
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masseter
The masseter muscle originates from the lower border and medial surface of the zygomatic arch.
The muscles fibers run downward and backward to be attached to the lateral aspect of the ramus of
the mandible. It is the st rongest muscle of mastication, it will be enlarged in pat ient s with severe
clenching.
The medial pterygoid muscle consists of two heads; the bulk of the muscle arises as a deep head
from j ust above the medial surface of the lateral pterygoid plate, the smaller, superficial head
originates from the maxillary tuberosity and the pyramidal process of the palatine bone. This muscle
inserts on the medial surface of the angle and ramus of the mandible. The insertion joins the
masseter muscle to form a common tendinous sling (masseteric sling) which allows t he medial
pterygoid and masseter to be powerful elevators of the jaw. The angle of the mandible rests in this
sling. Note: The lingual nerve is located directly on the lateral surface of the medial pterygoid
muscle.
Important: The temporal is (mainly the anterior portion) helps the medial pterygoid and masseter
muscles elevate the mandible duri ng jaw closing (biting and chewing).
~ . 1. The superior origin of the lateral pterygoid muscle is from the infratemporal crest of
~ ~ ~ t he greater wing oft he sphenoid bone, and the inferior origin is from the lateral surface
" i ~ J : i f of the lateral pterygoid plate of sphenoid bone. Both heads insert at the articular disc of
TMJ and neck of mandibular condyle.
2. Remember:
The mandible is protruded by t he action of both lat eral pterygoid muscles
One muscle causes lateral deviation of the mandible (shifts mandible to opposite
side)
3. All of the muscles of mastication are innervated by the mandibular division of the
trigeminal nerve.
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Lateral
views
A. Lateral and medial pterygoid
B. Temporalls
-

___ ,... ..
.. _
C. Masseter and Temporalis
--
--
-
Muscles acting on the mandibleffl\1J
11.9-1
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Posterior view of
viscerocranium
Anterolateral view
with head rotated
slightly to the left
Temporo
mandibular
joint
Laternl ptel}tOid
Temporal
Masseter
Medial pterygoid
Muscles acting on the mandible I TMJ
119A I
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muscle
The anterior and posterior pillars of the fauces enclose which area of lym-
phoid tissue?
li ngual tonsil s
pharyngeal tonsils
palatine tonsil s
peyer's patches
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palatine tonsils
The palate is the roof ofthe oral cavity, consisting anteriorly of the bony hard palate and posterior-
ly of the soft palate. Transverse ridges, called palatal rugae, are located along the mucous mem-
branes of the hard palate, where they serve as friction bands against which the tongue is placed dur-
ing swallowing. The uvula is suspended from the soft palate. During swallowing, the soft palate and
uvula are drawn upward, closing the nasopharynx and preventing food and fluid from entering the
nasal cavity. The neurovascular bundle of the soft palate is the lesser palatine vein, artery, and nerve.
The pharyngeal plexus of nerves supplies the uvular area.
The fauces is a narrow passage from the mouth to the pharynx, situated between the soft palate
and the base of the tongue; this is also called the isthmus of the fauces. On either side of the pas-
sage, two membranous folds, called the pillars of the fauces, enclose the palatine tonsils (consist
of predominantly lymphoid tissue).
The two arches formed by the anterior and posterior folds of mucous membrane are:
The palatoglossal arch (glossopalatine arch, anterior pillar of fauces or anterior faucial pillar) on
either side runs downward, lateralward, and forward to the side of the base of the tongue, and is
formed by the projection of the palatoglossus muscle with its covering mucous membrane.
The palatopharyngeal arch (pharyngopalatine arch, posterior pillar of fauces or posterior fau-
cial pillar) is larger and projects farther toward the middle line than the anterior; it runs down-
ward, lateral, and backward to the side of the pharynx, and is formed by the projection of the
palatopharyngeus muscle, covered by mucous membrane.
1. The palatal salivary glands are found beneath t he mucous membrane of the hard and
soft palate. They are mostly of the mucous type and contribute to the oral fluid.
2. Bifid uvula results from failure of complete fusion of the palatine shelves. A unilateral-
ly damaged pharyngeal plexus of nerves causes the uvula to deviate to the opposite side.
This is because t he uvular muscle shortens the uvula when it contracts and the muscle on
the intact side pulls the uvula toward that side.
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Superior lip
Superior
labial frenulum
Central incisor
Lateral incisor
Canine
Palatine
Premolars
raphe
Hard palate
Soft palate
Molars
Palatoglossal
arch
Uvula
Palatopharyngeal
Oropharynx
arch
Palatine tonsil
Tongue
Molars
Frenulum linguae
Duct of
submandibular gland
Sublingual
papilla
Premolars (biscuspids)
Gingivae (gums) Canine (cuspid)
Lateral incisor
Inferi or labial
frenulum
Central incisor
Inferior lip
120.1
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muscle
Which of the following muscles are innervated by the axillary nerve?
Select all that apply.
pectorali s major
pectorali s minor
teres major
teres minor
deltoid
latissimus dorsi
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deltoid
teres minor
Muscle Nerve s upply Action
Pectoralis major Medial and lateral pectoral Adducts the arm and rotates it medially
nerves from medial and lateral cords of
brachial plexus
Pectoralis minor Medial pectoral nerve from medial Pulls the s houlder downward and forward
cord of brachial plexus
Latissimus dorsi Thoracodorsal nerve from posterior Extends, adducts, and medially
cord of brachial plexus rotates the arm
Deltoid Axillary nerve (C5 and C6) With the help of the supraspinatus muscle, it
abducts the upper limb at the shoulder joint
Teres major Lower subscapular nerve from Medially rotates and adducts the arm
posterior cord of brachial plexus
Teres minor Branch of axillary nerve Laterally rotates the arm and stabilizes the
shoulder joint
Note: The axillary nerve is mixed. The motor branches innervate the deltoid and the
teres minor muscles.
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teres minor
Rotator Cuff Muscles- Posterior view
121-1
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trapezius
deltoid--
pectoralis
minor
Superficial and Deep Muscles of
the Shoulder- Anterior view
pectoralis
major
121A I
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muscle
All the following muscles are innervated by the same nerve that innervates
the muscles of mastication EXCEPT one, which one is the exception?
mylohyoid
tensor tympani
tensor vel i palatini
anteri or belly of digastric
posterior bel ly of digastric
[refer to card 119 A-1 for illustration)
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posterior bell y of digastric - which is innervated by the facial nerve
Important: All of the muscles of mastication are innervated by the mandibular division
of the trigeminal nerve (V3) - (see note below). They receive blood from the pterygoid
portion of the maxillary artery.
masseteric branch supplies the masseter
deep temporal branch supplies the temporal is
pterygoid branch suppli es both the medial and lateral pterygoids
Mastication is defined as the physical process of chewing food in preparation for swallow-
ing and ultimately digestion. Four pairs of muscles in the mandible make chewing possi-
ble. These muscles can be grouped into t wo different functions. The first group incl udes
three pairs of muscles (masseter, temporali s, and medial pterygoids) that elevate the
mandible to close the mouth. The second group includes one pair of muscles (lateral
pterygoids) that work to depress the mandible (drop the j aw), translate the jaw from side
to side, and protrude the mandible forward.
Note: There is one motor nucleus, a special visceral efferent (SVE) nucleus, associated
with the trigeminal nerve. It innervates the muscl es of the fi rst branchial arch, which con-
sists mostly of the muscles of mastication. They also include the tensor tympani and sev-
eral other small muscles. The nucleus is located in the mid pons at the level of attachment
of the trigemi nal nerve to the brain stem. Fibers of the trigemi nal motor nucleus emerge
as a separate motor root.
Remember: The muscles of mastication, mylohyoid, tensor tympani, tensor veli palatini
and anterior belly of digastric muscle are all derived f rom the first pharyngeal arch. This
will help you to remember the innervation of those muscles which is the mandibular
branch (V3) of the t rigemi nal nerve (CN V).
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muscle
All the muscles of the tongue are innervated by the hypoglossal nerve
EXCEPT one. Which one is the exception?
hyoglossus
styloglossus
palatoglossus
genioglossus
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palatoglossus
The extrinsic muscles (genioglossus, hyoglossus, styloglossus, and palatoglossus) anchor
the tongue to the skeleton (mandible, hyoid, and temporal bones). These muscles control
the protrusion (genioglossus), retract ion (styloglossus), depression (hyoglossus and
genioglossus), and lateral movement (palatoglossus) of the tongue. Remember: All
extrinsic muscles end in - glossus (tongue) and begin with their site of origin.
The intrinsic muscles lie entirely within the tongue itself. The fi bers of these muscles are
named according to the three spatial planes in which they run: longitudinal, transverse,
and vertical. When these fibers or muscles contract , they squeeze, fold, and curl the
tongue.
All of the muscles of the tongue, both intrinsic and extrinsic, except the palatoglossus
muscle, are innervated by t he hypoglossal nerve. The palatoglossus muscle is innervat-
ed by the pharyngeal plexus via the vagus nerve.
Note: The palatoglossus is a small ext rinsic muscle of the tongue that arises from the soft
palate and inserts in t he tongue. The palatoglossus acts to elevate the tongue.
The tongue receives its maj or blood supply from the lingual artery (which is a branch of
the external carotid artery). Note: The terminal part of the li ngual artery, the deep li ngual
artery, supplies the t ip of the tongue.
The veins drain into the internal jugular vein.
Remember: The trigeminal nerve provides the sensory input to the anterior two-thirds
of the tongue; whil e the glossopharyngeal nerve suppli es the posterior one-third.
Note: The muscl es of the tongue are derived from myoblasts that mi grate from t he
myotomes of occipital somites. Connective t issue, lymphatics and blood vessels of the
tongue (and possibly some muscle fibers) are derived from t he pharyngeal arch mes-
enchyme.
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muscle
Most of the muscles that act on the shoulder girdle and upper limb joints are
supplied by branches of the brachial plexus. Which of the following is NOT?
levator scapulae
rhomboid major
rhomboid minor
trapezius
serratus anterior
pectorali s minor
subclavius
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trapezius- is innervated by the accessory nerve (CN XI)
\lusdcs ol th< l'cctoral Girdle
Muscle Action I nnervation
Serratl lS anterior Pulls scapula forward and downward Long thoracic nerve, which
arises from roots C5, 6, and 7
of the brachial plexus
Pectoralis minor Pulls the shoulder downward and forward Medial pectoral nerve from
medial cord of brachial plexus
Subclavius Depresses the clavicle and steadies this bone Nerve to the subclavius from
during movements o f the shoulder girdle the upper trunk of the brachia l
plexus
Trapezius Suspends the shoulder girdle from the skull and the Motor fi bers from the spinal
vertebral column. T11e upper fi bers elevate the part of the accessory nerve and
scapula. The middle fibers pull the scapula sensory fi bers from the third
medially. The lower fibers pull the medial border and fourth cervical nerves
of the scapula downward so that the glenoid cavity
faces upward and forward
Levator scapulae Raises the medial border of the scapula Third and fourth cervical
nerves and from the dorsal
scapular ner\e (C5)
Rhomboid major With the rhomboid minor and levator scapulae, it Dorsal scapular nerve (C5)
elevates the medial border of the scapula and pulls
it medially
Rhomboid minor With the rhomboid major and levator scapulae, it Dorsal scapular nerve (C5)
elevates the medial border of the scapula and pulls
it medially
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latissimus dorsi
Superficial and Deep Muscles of the
Shoulder- Posterior view
momboid minor
infraspinatus
124-1
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muscle
A 16-year-old girl who is just about to have her junior prom comes crying
into the physician's office, but is lacrimating only from her right eye. The left
half of her face is also paralyzed. An oral exam reveals trauma to her buccal
mucosa where her teeth have bitten her cheek. Which muscle is responsible
for keeping mucous membranes out of the plane of occlusion and food out
ofthe buccal vestibule?
medial pterygoid
lateral pterygoid
buccinator
masseter
temporalis
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buccinator
The bucci nat or i s one of t he muscles of t he cheeks and l ips. On each side, t he bucci nator has a compl ex
origi n f rom:
The maxilla along t he alveol ar process superi or to alveolar margi n horizontally between t he anterior
border of the fi rst and t hi rd molars
The mandible along the oblique l ine of the mandible between t he fi rst and thi rd molars
The pterygomandibular raphe: a thin, fibrous connecti on between the superior pharyngeal con-
strictor and the bucci nator. The buccinator i s the first muscle pierced when giving a mandibular IAN
nerve block.- It inserts at orbiculari s ori s and ski n at t he angle of the mouth. It i s traversed by t he
parotid duct.
It is not a primary muscle of mastication - it does not move the jaw - and t hi s i s refl ected i n t he buccina-
tor's motor innervation from the facial nerve. However, propriocept ive fi bers are deri ved from the buccal
branch of t he mandibular branch of t he t rigeminal nerve.
The facial muscles i nclude: occipitofrontal is, t emporopari etali s muscle, procerus, nasal is muscl e, depres-
sor sept i nasi, orbi cularis oculi, corrugator supercil ii, depressor superci lii, auricular muscles (anterior, supe-
rior, posterior), orbiculari s ori s, depressor anguli ori s, ri sori us, zygomaticus major, zygomat icus mi nor, lev-
ator labii superi ori s, l evator labii superi ori s alaeque nasi, depressor labi i inferi ori s, l evator anguli ori s, buc-
cinator and mental is.
The platysma i s innervated by the facial nerve. Although i t i s mostl y in t he neck, due to its common
i nnervation it can sometimes al so be considered a muscle of facial expression. The stylohyoid muscle,
stapedius and posterior belly of t he digastric muscle are al so innervated by the facial nerve, but are not
considered muscles of facial expression.
1. The facial and maxillary arteries supply blood to bucci nator muscle.
2. Food accumulati ng i n the vestibule might suggest t hat the bucci nator is not worki ng prop-
erly.
3. If the poi nt of a needle ent ers the parotid gland during an i nferior alveolar i nj ection and
solution i s deposited i n the gland, the most l ikely result i s paralysis of the buccinator mus-
cle.
4. Damage to the facial nerve or i ts branches may cause weakness or paralysi s of facial mus-
cles called Bell's palsy.
5. Parotid duct travel s over t he masseter muscle and penetrates the buccinat or muscle to enter
t he oral cavity. It opens into t he mouth opposite the upper 2nd molar.
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Supr.wtrocnlear
.....
/
Mental nen-e
Menta Is
Temporal is
_ .::....,_ .... ---~ ~ ~ ~ r f l e b r e
Lateral polebral
ligament
125 1
Cutaneous branches of trigeminal nerve, muscles of facial expression, and eyelid
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Fronta belly of
occipitofrontal
Temporalis
Obicularis { orbital
oculi palpebral
Zygomaticus
major
Depressor
anguli oris
Depressor labU Mentalis
inferioris
Muscles of facial expression
Procerus
Levator ongull
oris
Buccinator
Masse1er
125AI
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Frontal belly of
occipitofrontal
levator labii ---""7."---=
superloris
ObiaJiarls
Mentalis
Depressor
ancu11 oris
Platysma
Muscles of facial expression
Epic:....,ial
apooeu10$1s
Temporolls
2 5 8 ~
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muscle
All of the following muscles are responsible for elevating the mandible
EXCEPT one. Which one is the exception?
masseter
medial pterygoid
mylohyoid
temporalis
)refer to card 119 A-1 for illustration)
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mylohyoid
The temporal is muscle is a broad, fan-shaped muscle of mastication on each side of the head
that fills the temporal fossa, superior to the zygomatic arch. This muscle originates from the
entire temporal fossa. The temporalis then passes medially (downward and deep) to the zygo-
matic arch as a thick tendon before inserting on the coronoid process of the mandible .
. 1. The primary function of the anterior portion (fibers) of the temporal is muscle is
to elevate the mandible.
2. The posterior fibers retract the jaw and maintain the resting posit ion of closure of
the mout h.
Accessory depressors of the mandible: The depressor muscles of the mandible all have t he
hyoid bone in common as an attachment si te. When the hyoid bone is immobi lized by a con-
traction of the muscles below it, the contraction of the depressor muscles located between the
hyoid bone and the mandible pulls the mandible downward (opens the mouth). The suprahy-
oid depressors of the mandible are the mylohyoid, geniohyoid, and digastric muscles.
Mylohyoid: The paired mylohyoid muscles are attached to the mylohyoid lines on the
internal surfaces of t he mandible, the right and left mylohyoid muscles join in the midline
to form the floor of the mouth, and the posterior end of this midline junction attaches to the
hyoid bone
Geniohyoid: The two geniohyoid muscles are found next to each other, on each side of
t he midline, directly on top of the mylohyoid muscles. The sites of attachment are the genial
t ubercle and the hyoid bone
Digastric Muscles: The digastric muscl e bundle is divided into an anterior belly and a pos-
terior belly by a short tendon. This intermediate tendon passes through a loop of fibrous tis-
sue secured to the body of the hyoid bone. The end of the anterior belly attaches to the
digastric fovea and the posterior belly fastens onto the mastoid process of the temporal
bone.
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muscle
The action of which of the following muscles would be affected if the hamu-
lus was fractured?
uvular
palatopharyngeus
tensor vel i palatini
palatoglossus
levator veli palatini
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tensor veli palatini
Five paired skeletal muscles ofthe soft palate:
1. Palatoglossus muscle: pull s the root of the tongue upward and backward. Both
muscles contracting together cause the palatoglossal arches to approach the mid-
li ne, and thus the opening (oropharyngeal isthmus) between the oral pharynx and
the mouth is narrowed.
2. Palatopharyngeus muscl e: pull s the wal ls of the pharynx upward. Acting
together, the muscles pull the palatopharyngeal arches toward the midline.
3. Levator veli palatini muscle: raises the soft palate.
4. Tensor veli palatini muscle: the two muscles tighten the soft palate so that it
may be moved upward or downward as a tense sheet. This muscle curves around
the pterygoid hamulus. Therefore, if the hamulus was fractured, the actions of
this muscle would be affected. Both tensor and levator veli palatini muscles pre-
vent food from enteri ng the nasal cavity by elevating the soft palate.
5. Uvular muscle: raises and shortens the uvula to help seal the oropharynx from
the nasopharynx.
Important: All the paired skeletal muscles of the soft palate are innervated by the
pharyngeal plexus except the tensor veli palatini, which is innervated by a branch
of the nerve to the medial pterygoid, which is a branch of the mandibular division
of the trigeminal nerve (V3).
1. The anteri or zone of the palatal submucosa contains fat, while the post-
'otcs erior zone contains mucous glands.
2. The salivary glands of the hard palate are located in the posterolateral
zone. They arise from ectoderm and are separated by connective tissue
septa.
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muscle
Which of the following travels with the esophagus through the esophageal
opening in the diaphragm?
aorta
thoracic duct
azygos vein
vagus nerve
right phrenic nerve
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vagus nerve
*""" You can remember this because the vAGUS travels with the esophAGUS.
The diaphragm is a flat muscle in a dome-like shape that separates the chest cavity from the abdom-
inal cavity. The diaphragm is pierced by several structures that pass between t he two cavities. The
three largest of these structures are the esophagus, the aorta, and the inferior vena cava. The
central part of the diaphragm is the central tendon, which is fibrous rather than muscular. The
undersurface of the diaphragm forms the roof of the abdominal cavity, and lies over the stomach on
t he left and the liver on the right. Note: The diaphragm is higher on t he right side than the left,
allowing the liver to be tucked up under the bottom edge of the right rib cage.
When the diaphragm contracts, it pulls down into the abdomen, thus creating a vacuum in t he chest
cavity that draws air into the lungs. Exhaling is done by contracting the muscles of the abdomen to
force the diaphragm upward when it is relaxed. During inspiration the diaphragm moves down,
increasing the volume in the thoracic cavity. During expiration the diaphragm moves up, decreas-
ing t he volume in the thoracic cavity. The upper surface is in contact with the heart and lungs; the
lower surface contacts the liver, stomach, and spleen.
Important: The esophagus passes through the diaphragm, while the aorta, azygos vein, and tho-
racic duct pass posterior to it.
The diaphragm has three openings:
1. Aortic opening: transmits the aorta, the thoracic duct, and the azygos vein.
2. Esophageal opening: transmits the esophagus and right and left vagus nerves.
3. Caval opening: transmits the inferior vena cava and the right phrenic nerve.
Other respiratory muscles include the external, internal and innermost intercostals, subcostal, and
transversus thoracis. These muscles are all innervated by the intercostal nerve while the
diaphragm is innervated by t he phrenic nerve.
Note: The phrenic nerve travels through the thorax between the pericardium and the pleura (in the
middle mediastinum).
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vtrttbrllatudlmt iJt
of clnphracm
INfldlbrr .. tn
........
......
tbdomirvJ


tre.._
abdomlnsl
Muscl es of respiration
128-1
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cardiac notch
apex of
the heart
6th db
lOth rib
Topography of the lungs and mediastinum
128 AI
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muscle
Which costal muscle can typically cross more than one intercostal space?
external intercostal
internal intercostal
innermost intercostals
subcostal
transverse thoracic
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subcostal
The thorax contains vital structures that enable such functions as breathing to occur. Its
major muscles are the thoracic wall and upper limb muscles as well as the diaphragm.
Anterior thoracic wall muscles include:
External intercostal muscles: eleven on each side between the ribs. Pass f rom rib to
rib and run anteriorly and inferiorly (hands-in-pocket direction) at right angles to the
fibers of the internal and innermost muscles. Continue toward sternum as the external
intercostal membrane. They raise the ribs during inspiration.
Internal intercostal muscles: eleven on each side between the ribs. Their fibers run
posteriorly and inferiorly. They continue toward the vertebral column as the internal
intercostal membrane. They depress the ribs during expiration.
Innermost intercostals: run in the same direction as internal intercostals but are sep-
arated from them by nerves and vessels. Action unknown but probably the same as
internal intercostals.
Subcostal muscles: originate on the inner surface of each rib near the costal angle
and insert on the inner surface of the first, second, or third rib below. They raise the
ribs during inspiration.
Transverse thoracic muscles: attach the posterior surface of the lower sternum to
the internal surface of costal cartilages 2 through 6. These muscles pull the ribs down-
ward during expiration.
Remember: The diaphragm is the main muscle of inspiration. It is innervated by the
phrenic nerve. The intercostal muscles are mainly active during forced respiration.
During quiet breathing these muscles increase tonus, all owing for the thoracic wall to
remain rigid without producing movement. These muscles are innervated by their corre-
sponding intercostal nerves.
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Lateral View
Muscles of the thoracic wall 2 ~
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muscle
Name the molecule that lies along the surface ofF-actin and physically cov-
ers myosin binding sites during the resting state.
G-actin
tropomyosin
troponin
li ght meromyosin
heavy meromyosin
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tropomyosin
The main contractile system of all muscular tissue is based on the interactions of two proteins,
actin and myosin. The system of these proteins is sometimes called the actin-myosin con-
tractile system.
Actin filaments (thin myofilaments, 5-8 nm in diameter) are composed of:
Actin: globular actin (G-actin} molecules are arranged into double helical chains
called fibrous actin (F-acti n}
Tropomyosin: long, thread-like molecules, lie along the surface of F-actin strands and
physically cover myosin binding sites during the resting state. Upon release of calcium from
the sarcoplasmic reticulum, calcium binds to troponin C (calcium bi nding troponin). This
"unlocks" tropomyosin from actin, allowing it to move away from the binding groove.
Myosin heads can now access the binding sites on actin. Once one myosin head binds, this
fully displaces tropomyosin and allows additional myosin heads to bind, initiating muscle
shorteni ng and contraction. Once calcium is pumped out of the cytoplasm and calcium
levels return to normal, tropomyosin again binds to actin, preventing myosin from binding.
Troponin: a small, oval-shaped molecule attached to each tropomyosin
Myosin filaments (thick myofilaments, 12-18 nm in diameter) are composed of:
Myosin, which has two components:
1. light meromyosin (LMM) makes up the rod-like backbone of myosin filaments.
2. Heavy meromyosin (HMM) forms the shorter globular lat eral cross-bridges, which link
to the binding sites on the actin molecules during contraction.
Skeletal muscle contracts when a stimulus from the nervous system excites the individual
muscle fibers. This starts a series of events that lead to interactions between the myosin (thick
filaments) and actin (thin filaments) of the sarcomeres of the fibers.
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muscle
The right and left rectus abdominis muscles are entirely independent, being
separated by a connective structure called the:
pyramidali s
gubernaculum
li nea alba
il iopectineal arch
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Muscle
External oblique
Internal oblique

abdominus
linea alba
\lusdl'\ ul thl' \nit' I wr \hdunun.tl \\.til
Action
Supports abdominal c.oments; compresses abdominal
c.ontents; assists in tle.xing and rotation of trunk.
Assists in forced expiration, micturition, defecation,
parturition, and vomiting
Same a.s abo\'e
abdominal contents
Inner vation
Lower six thoracic nen'es and
iliohypogastric and ilioinguinal
nerves (ll)
Same as above
Same as above
abdominis abdominal contents and flexes venebral Lower six thoracic nen
1
es
c.olumn; accessory muscle of expiration
Pyramidalis Tenses the. linea alba Twelfth thoracic nerve.
(if present)
1. As the spermatic cord (or round l igament of the uterus) passes under the
lower border of the internal oblique, the spermatic cord carries with it some
of the muscle fibers that are call ed the cremaster muscle.
2. The posterior abdominal muscles include psoas major and minor
(innervated by the lumbar plexus), quadratus lumborum (innervated by the
lumbar plexus), and the iliacus (innervated by the femoral nerve).
3. The linea alba is a tendinous raphe that runs down the midli ne of the
abdomen in humans and ot her vertebrates. In human, linea alba runs from
xiphoid process to pubic symphysis. It is formed by the f usion of t he
aponeuroses of the abdominal muscles, and it separates the left and right rectus
abdomi nis muscles.
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Superficial Muscles of the Thorax and
Abdomen -Anterior view
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Internal
intercostals
Transversus
abdominus
Internal
oblique
Deep Muscles of the Thorax and Abdomen - Anterior view
131AI
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muscle
All of the following structures are located between the superior and middle
pharyngeal constrictors EXCEPT one. Which one is the EXCEPTION?
stylopharyngeus muscle
glossopharyngeal nerve
stylohyoid l igament
recurrent laryngeal nerve
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recurrent laryngeal nerve - is located inferior to inferior pharyngeal constrictor
The constrictor muscles of the pharynx are involved in the digestive process, being responsible for
moving food down to the esophagus. The stylopharyngeus, along with the deeper muscles of the
palatopharyngeus and the salpingopharyngeus, are invol ved in elevat ing the larynx.
Circular \lusclcs of the l h a r ~ nx
Muscle Origin Inser tion Action
Superior Medial pterygoid plate of the sphenoid bone Median pharyngeal raphe Cons trias
constrictor and the pterygomandibular raphe upper pharynx
Middle Greater and lesser horns of hyoid; Median pharyngeal raphe Constricts
constrictor stylohyoid ligament lower pharynx
Inferior Arch of cricoid and oblique line of thyroid Median pharyngeal raphe ConstriCls
constrictor cartilages lower pharynx
1. All of the circular muscles (constrictors) are innervated by the pharyngeal plexus
which consists of a pharyngeal branch from the vagus and glossopharyngeal nerves as
well as a sympathetic branch from t he superior cervical ganglion.
2. The stylopharyngeus, palatopharyngeus, and salpingopharyngeus are all longitudinal
muscles of the pharynx.
Along the lateral sides of the pharynx, you will find four gaps associated with the superior, middle
and inferior constrictors. Specific structures pass through each of these gaps.
Above the superior pharyngeal constrictor: Between the middle and inferior constrictors:
-auditory tube - internal branch of the superior laryngeal nerve
- levator palatini muscle - superior laryngeal artery
-ascending palatine artery Below the inferior constrictor:
Between the superior and middle constrictors: -recurrent laryngeal nerve
-stylopharyngeus muscle -inferior laryngeal artery
- glossopharyngeal nerve
-styl ohyoid ligament
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Longitudinal
muscle o f ~ ~
esophagus
Superior
constrictor
Circular muscle
of esophagus
Muscles of the Pharynx- Posterior view
132-1
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muscle
The connective tissue layer surrounding each individual muscle fiber is
called the:
perimysium
epimysium
endomysium
sarcolemma
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endomysium
As an organ, skeletal muscle consists of several tissue types. Skeletal muscle fibers are long, thread-
like cells that compose skeletal (striated) tissue. These cells have the abil ity to shorten their length
or contract.
Dense fibrous connective tissue (fascia) weaves through a skeletal muscle at several different levels.
The epimysium is the connective tissue layer that envelopes the entire skeletal muscle
The perimysium is a conti nuation of this outer fascia, dividing the interior of the muscle into
bundles of muscle cells. The bundle of cells surrounded by each perimysium is called a fascicu-
lus.
Each of the three levels of fascia is interconnected, allowing vessels and nerves to reach individual
fibers and cells.
(surrounds
faseiC\IIi)
(surrounds
fibers)
(surrounds
entire muscle)
Cross section of skeletal muscle
Remember: The axon of a motor neuron is highly branched, and one motor neuron innervates
numerous muscle fibers. When a motor neuron transmit s an impulse, all of the fibers it inner-
vates contract simultaneously.
Note: When muscles attach to tendons, the connective tissue surrounding the muscle continues
uninterrupted around the tendon. In the tendon, the collagen fibers unite at one end to the bone
or ot her struct ure that the tendon attaches to and at t he other end to the sarcolemma of t he mus-
cle fiber.
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muscle
At a picnic, the kids all decide to hang upside down on the monkey bars. One
daring kid decides that he will try to eat a grape while hanging upside down
and finds that he has no trouble doing this. Peristalsis and other similar
movements are produced by which type of muscle tissue?
smooth muscle tissue
striated muscle tissue
skeletal muscle t i ssue
cardiac muscle tissue
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smooth muscle tissue
Smooth muscle tissue is located throughout the body, particularly within the tunica
(wall s) of hollow internal organs. The smooth muscle fibers are elongated and
spindle-shaped with a single nucleus. The myofibril s lack transverse striations.
They are responsible for involuntary movements of internal organs (e.g., peristalsis) .
Types of smooth muscle:
Single-unit: have numerous gap junctions (electri cal synapses) between adjac-
ent fibers. These fibers contract spontaneously without nerve signals.
Examples include: the muscular tunica of the Gl tract, uterus, ureters, and arter-
ioles.
Multi-unit: lack gap junctions and the individual fibers are autonomically inner-
vated. Examples include: the ciliary muscle and the smooth muscle of the iris,
ductus deferens, and arteri es.
Skeletal muscle tissue attaches to the skeleton and is responsible for voluntary
body movement. It consists of many elongated, cylindrical cells, which are
multinucleated and have distinct transverse striations consisting primarily of actin
and myosin proteins.
Remember: Each skeletal muscle fiber is innervated by an axon of a motor neuron
at a motor end plate (which is a large and complex terminal formation by which an
axon of a motor neuron establi shes synaptic contact with a skeletal muscle).
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muscle
A surgeon performing a thyroidectomy accidentally transects a nerve. The
patient then presents with hoarseness and difficulty breathing. There is a
loss of sensation below the vocal folds and loss of motor innervation to all of
the intrinsic muscles of the larynx except the cricothyroid muscle. Which
nerve was transected during the surgery?
recurrent laryngeal nerve
internal branch of superior laryngeal nerve
external branch of superior laryngeal nerve
accessory nerve
glossopharyngeal nerve
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recurrent laryngeal nerve
Note: Damage to this nerve (as a result of surgery or disease) can result in hoarseness
and difficulty breathing.
Intrinsic \lusclcs of the nx
Muscle Action
Cricothyroid Stretches the vocal cords
Posterior cricoarytenoid Maintains wide airways (for breathing)
TI1yroarytcnoid Clos<" the vc,,tibule
Aryepiglottic Clos<" the vc,,tibule
Transverse arytenoid Contracts to close the airway posteriorly for speech
Lateral cricoarytenoid Adducts the vocal cords
Thyr<>cpiglottic Helps close
Vocalis Shortens vocal cords, is the antagonist of the cricothyroid muscle
The vagus nerve provides sensory and motor innervation to the larynx:
1. The recurrent laryngeal nerve supplies all the intrinsic muscles except the
cricothyroid.
2.The cricothyroid muscle is supplied by the external branch of the superior laryn-
geal nerve.
3. Sensation above the vocal folds is suppli ed by the internal branch of the supe-
rior laryngeal nerve.
4. Sensation below the vocal folds is suppli ed by the recurrent laryngeal nerve.
5. The internal laryngeal nerve plays an important role in the cough reflex, which
keeps the interi or of the larynx free of the foreign material.
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muscle
The axilla, or armpit, is a localized region of the body between the upper
humerus and thorax. It provides a passageway for the large, important
arteries, nerves, veins, and lymphatics that ensure that the upper limb
functions properly. The muscle that forms the bulk of the anterior axillary
fold is the:
lati ssimus dorsi
pectoralis major
subscapulari s
teres minor
teres major
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pectoralis major
The axill a can be visualized as having a floor, an apex, and four walls (medial, lateral, ant-
erior, and posterior).
The apex is pointi ng toward the root of the neck. It is formed by the convergence of
the clavicle (anterior), the scapula (posterior), and the first rib (medially). All t he nerves
and vessels of the upper limb pass through this area.
The anterior axillary fold is made up of the pectoralis maj or and mi nor muscles
The posterior axillary fold is made up of the lati ssimus dorsi and teres maj or muscles
The base faces inferiorly and is formed by t he skin and fascia of t he concave axilla
(armpit)
The medial wall is formed by the upper four or fi ve ribs and their intercostal muscles
and the serratus anterior muscle
The lateral wall is formed by the humerus (specifically, the coracobrachialis and
biceps muscles in the bicipital groove of the humerus)
The posterior wall is formed by the subscapularis, teres major, and latissimus dorsi
muscles
The anterior wall is formed by the pectoralis maj or, mi nor, and subclavius muscles
Contents of the axilla:
Axillary artery and its branches
Axillary vein and its tributari es
Infraclavicular part of the brachial plexus
Axillary lymph nodes and the associated lymphatics
The long thoracic and intercostobrachial nerve
Axillary fat and areolar tissue in which the other contents are embedded
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muscle
All the infrahyoid muscles are innervated by the ansa cervicalis (Cl -3)
EXCEPT one. Which one is the EXCEPTION?
sternohyoid
sternothyroid
thyrohyoid
omohyoid
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thyrohyoid - which is supplied by Cl via the hypoglossal nerve
Musd e
Stcrnocleidomastold
Digastnc
OriJ:in
Manubrium stcmi and medial
third of davidc
lnJtrtion
Ma:oid proct."SS of
emporal bone and occipiwl
bone
Ac-tion
Two muscles acting
together ext end head
und flex neck: one
muscle rotates head to
opposite side
lnner,'ation
Spinal pan of accessory
nerve Cl nnd3
(post..-rior and Ma:oid pn:K'css of temporal Digastric tOssa of the Elevates the Facial nerve (posterior
antcnor bellies con- bone mandible hyoid hdps de bell y)
ncl"' cd by a tendon press and rcuact the
a11achcd to the hyoid mandible Ncn.c to myloh)oid. a
r.n bone) branch of the interior
i.,
______________ _, ____________
0
Mylohyoid Mylohyoid line of body of Bod) of hyoid bone and Elevates lloor of Tri gemi nal (V-3) nerve
a: mandi bk librous raphe mouth and hyoid bone
- or mandible
____
temporal bon-e

Geniohyoid lntCrior memul spine of man- Body of hyoid bone
diblc
Stctnoh)'Oid Manubrium sterni and cluvide Body of the h)'Oid bone
Elevates hyoid bone or First cervical nerve viu the
depresses mandible hypogtossal nerve
lkpn:sses the b)oid
bone
Ansa ocrviealis (C 1.2. und
l)
= ______
thyroid ctutduge larynx 3}


3 lamina of thyroid canilage hyoKI bone hypogtossal nerve

iniC- Supcrior border of thc seupula Body of the h)<oid bone the b)oid ocrviealis (CI.l and
rior bellies
by a tendon)
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.,... ----..!...---,
Tltii)Oid
'lll)!ol<l
certolaet
stomooyold ____ __:
....;...,...---- Sternoc:leldome""ld
ckWIUar tletd
Omotl!tWillfetlo<
liOiy
Tbe suprahyoid and infra byoid muscles of the neck
UH
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muscle
Which of the following is NOT a characteristic of cardiac muscle?
multinuclear
intercalated discs
gap junctions
desmosomes
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multinuclear
The heart is a functional syncytium (not to be confused with a true "syncytium"
in which all the cells are fused together, shari ng the same plasma membrane as
in skeletal muscle). In a functional syncytium, electri cal impulses propagate
freely between communicating cells via gap junctions, so that the myocardium
functions as a single contractil e unit. This property allows rapid, synchronous
depolarization of the myocardium.
Li ke skeletal muscle fibers, cardiac muscle fibers contain myofilaments (contractile
units) and are striated with actin and myosin.
Cardiac muscle fibers contain large, oval centrally placed nuclei as well as strong, but
thin, unions between fibers call ed intercalated di scs. These intercalated discs
provide low resistance for current flow. In addition, cardiac muscle has relatively large
T-tubules and a less developed sarcoplasmic reticulum when compared to skeletal
muscle.
Important: Withi n the intercalated discs, desmosomes attach one cell to another
while gap junctions allow electrical impulses to spread from cell to cell.
Cardiac muscle fibers contract spontaneously without any nerve stimulus. They
respond to increased demand by increasing the size of the fiber; this is known as
compensatory hypertrophy.
Note: Skeletal and cardiac muscle fibers cannot mitotically divide, but certain
smooth muscle fibers can under hormonal influences (e.g., during pregnancy, the
smooth muscle fibers of the myometrium of the uterus increase in length, and new
cells are formed).
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muscle
A nervous dental student is performing the inferior alveolar nerve block for
the first time. His injection passes the ramus, but he thinks deposition of the
anesthetic will work. His patient complains that he can't "move his face" on
the side ofthe injection. Which gland did the dental student penetrate?
subl ingual gland
submandibular gland
parotid gland
von Ebner's glands
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parotid gland
If the needle mistakenly passes posteriorly at the level of the mandibular foramen, the needle will
penetrate the parotid gland, and the pat ient may devel op paralysis of the muscles of facial
expression. If the tip of the needle is resting well below the mandibular foramen, you will be
penetrating the medial pterygoid muscle.
Correct needle penetration into the pterygomandibular space during an inferior alveolar block. If
the needle is inserted too far posteriorly, it may enter the parotid salivary gland containing the facial
nerve, causing a complication such as transient facial paralysis.
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muscle
Biceps brachii is the major ____ of elbow joint, and ____ ofthe fore-
arm.
f lexor, pronator
f lexor, supinator
extensor, pronator
extensor, supinator
pronator, supinator
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Lateral head
Medial head
Brachial is
Coracobrachialis
Biceps brachii
Long head
Sho1t head
Infraglenoid tubercle
of scapula
Upper half of posterio
surface of shaft of
hume1us
Lower half of poste-
l'ior surface of shaft of
hume1us
f ront of lowe.r half of
hume1us
process of
Supraglenoid tubercle
ofsc.apu1a
Coracoid process of
scapula
Olecranon process of
u1na
Coronoid process of
ulna
Medial as pee' of shaft
of humerus
of radius
Radial nerve
Musculocmaneous
nene
lvlusculocutaneous
nerve
l\tusculocutaneous
nerve
flexor, supinator
the foreamt (extensor
ofrhe elbow joinT)
f lexo1 of elbow joint
Flexe.s the amt
Supinator of fore.ann and
nexor of elbow joint
Note: The radial nerve is most commonly i nj ured in a mid-humeral shaft fracture,
because this nerve runs in the radial (spi ral) groove of the humerus. The biceps
brachii partici pates in flexion at both the glenohumeral and humeroulnar joints.
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pectoralis major
biceps brachli
brachioradialis
tendon of flex
carpi radialis
flexor digitorum ----1-lfl.'-
superficialis
Superficial Muscles of the Upper Limb- Anterior view
14().1
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muscle
Which of the following muscles originates from the medial surface of the
lateral pterygoid plate?
superficial head of the medial pterygoid
deep head of the medial pterygoid
lower head of the lateral pterygoid
upper head of the lateral pterygoid
I refer to card 119 A-1 for illustration I
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Muscle.
Temporal is
deep head of the medial pterygoid
of \l:.htication
Origin
Bony t1oor ofu!mporal fossa
Insertion Mandibular movements
Coronoid of mandible The. anterior and supe1ior tibet's
elevate the mandible
The-posterior fibers retract the
mandibl e
lower border and medial surface Late-ral aspect of the ramus of Raise-s (elevates) the mandible to
of the zygomatic arch the mandible occlude the. teeth in mastication
Me.dial pterygoid The superficial head arise-s from Medial surface of the angle of Assists in raising (elevating) the
Lateral pterygoid
(two heads)
the-tube-rosity of the maxilla and the mandible mandible
the pyramidal process of the-
palatine bone.
The deep he-ad arises from the
medial surfac.e of the lateral
pre.rygoid plate
The-upper head arises from the
infratemporal surfac.e of the
wing of the sphenoid
bone.
The-lower head arises fron'l the
lateral surface of the lateral
pterygoid plate
Tile upper htad in.,.;e.rts into
the articular disc and fibrous
capsule of the TMJ
Tile lower head inse-11S into
the neck of condyle of the
mandible
Lowtr heads: slight
of the- mandible (during jaw
opening)
One muscle: late-ral deviation of
the mandible (shift mandible lO
opposite side-)
Both muscles: J,rotrusion of the
mandible
Important: The muscles of mastication are innervated by the trigeminal nerve
(specifically, the mandibular division-V3).
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muscle
A patient comes to the emergency room after boxing practice. He was hit
with an uppercut and heard a crack in his jaw joint. ACT scan shows a condy-
lar fracture with damage to the articular disc. When the patient attempts
protrusion, the mandible markedly deviates to the left. Which muscle is
unable to contract?
left lateral pterygoid
right lateral pterygoid
left medial pterygoid
right medial pterygoid
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left lateral pterygoid
The right and left pterygoids acting together are the prime protractors of the
mandible. When one muscle is not functioning properl y, the contralateral muscle's
action is unopposed. The lack of the left lateral pterygoid trying to push the mandible
to the right al lows the right muscle to move the mandible to the left. With this injury,
the mandible deviates toward the affected side. Similarly, because the muscle's inser-
tion is disrupted (disconnected from the body of the mandible) in the case of a
condylar fracture, the mandible will also deviate toward the affected side. The mus-
cle is intact and can move the condyle when it contracts but not the body of the
mandible because of the fracture. The unopposed ri ght lateral pterygoid then
remains capable of displacing the mandible to the left.
Important: In addition to opening and protruding, the lateral pterygoids move the
mandible from side to side. For right lateral excursive movements, the left lateral
pterygoid muscle is the prime mover and vice versa.
Note: With a condylar neck fracture, muscle contractions might result in
displacement of the injured condyle into the infratemporal fossa.
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muscle
A 46-year-old woman comes into the dentist's office for a cleaning. He
notices that her tongue is slightly swollen, fiery red, and smooth. Her diet
history indicates that she has had a loss of appetite for quite some time and
that she has been feeling fatigued. A call to her physician indicates a histo-
ry of iron deficiency anemia and associated glossitis. In glossitis, the smooth
nature is caused by a lack of which papillae that are the most numerous and
cover the anterior two-thirds of the tongue?
foliate
circumvall ate
fungiform
fili form
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filiform
The dorsum of the tongue is studded with papillae, of which there are four types:
Filiform: most numerous, small cones arranged in"V"-shaped rows paralleling the sulcus termi-
nalis on the anterior two-thirds of the tongue. They are characterized by the absence of taste
buds and increased keratinization. They serve to grip food.
Fungiform: knob-like or mushroom-shaped projections, they are found on the tip and sides of
the tongue. These papillae are innervated by the facial nerve (VII).
Circumvallate (vallate): largest but fewest in number (7-12), they are arranged in an inverted
"V"-shaped row on t he back of t he tongue. Associated with the ducts of Von Ebner's glands.
These papilla are innervated by the glossopharyngeal nerve (IX).
Foliate: found on lateral margins as 3 to 4 vertical folds. These taste buds are innervated by both
the facial nerve (VII - anterior papillae) and the glossopharyngeal nerve (IX- posterior papillae).
The receptors for the sense of taste (gustation) are located in taste buds on the surface of the
tongue. The taste buds are associated with peg-like projections on the tongue mucosa called lingual
papillae. A taste bud contains a cluster of 40 to 60 gustatory cells, as well as many more supporting
cells. Each gustatory cell is innervat ed by a sensory neuron.
The tongue and the roof of the mouth contain most of the receptors for the taste nerve fibers in
branches of the facial, glossopharyngeal, and vagus nerves. Located on taste cells in the taste buds,
these receptors are stimulated by chemicals. They respond to four taste sensations perceived by
specific areas on the tongue: sweet: on the tip bitter: on the back
sour: along the sides salty: on the tip and sides
The underside of the tongue is soft and kept very moist by salivary gland secretions. Beneath t he
tongue lie the openings of the ducts from the sublingual and submandibular glands. The frenulum
forms the midline ridge on the lower surface of the tongue. The paired deep arteries and veins of
the tongue lie on each side of this ridge.
Plummer-Vinson syndrome: presents as a triad of dysphagia (due to esophageal webs), glossitis,
and iron deficiency anemia. It most usually occurs in postmenopausal women.
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ian glossoepiglottic fold
14)1
Tongue- Superior view
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muscle
Which ofthe following muscles cells does NOT contain troponin?
skeletal muscl e cell
cardiac muscl e cell
smooth muscle cell
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smooth muscle cell
Smooth muscle fibers are composed of uninucleate, spindle-shaped cells (f usiform
cells). They are much small er than skeletal muscle fibers. The nuclei are situated in the
widest part of each fiber. They do not possess T tubules, and their sarcoplasmi c reticulum
is poorly developed. These muscle fibers do not possess regul arly ordered myofibrils and
are therefore not striated. Their contraction process is slow and not subject to voluntary
control. Smooth muscle does not contain the protein troponin; instead calmodulin
(which takes on the regulatory role in smooth muscle), caldesmon and calponin are
significant proteins expressed within smooth muscle.
Skeletal muscle fibe rs are composed of bundles of very long, cyli ndrical,
multinucleated cells that possess regularly ordered myofibril s that are responsible for the
striated appearance of the cell. The nuclei are either slender ovoid or elongated and are
situated peripherally. They do contain transverse tubules (T tubules), and the
sarcoplasmic reticulum is very well-developed. Their contraction is qui ck, forceful, and
usually under voluntary control. The myofibrils (actin and myosin) are the contractile
element.
Remember: Cardiac muscle fi bers contain centrally placed nuclei as well as
intercalated discs (contain desmosomes and gap junctions), which represent j unctions
between cardiac muscle cells.
1. The satellite cell is responsible for skeletal muscle regeneration.
!. 2. Two T t ubules lie within a single skeletal muscle sarcomere.
>;-., 3. 1n skeletal muscle, a triad refers to aT t ubule sandwiched between two dilated
cisternae of the sarcoplasmi c reticulum.
4. Motor units consist of a motor neuron and all the muscle fibers it supplies.
5. The major regulatory proteins in muscle t issue are troponin and tropomyosin.
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muscle
Skeletal muscle possesses a well developed sarcoplasmic reticulum. This
along with T tubules and terminal cisternae function in the release and
reuptake of:
sodium
phosphate
calcium
glucose
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calcium
The sarcoplasmic reticulum is a network of tubules and sacs in skeletal muscles.
This network is analogous, but not identical, to the smooth endoplasmic reticulum
of other cell s.
Remember: The endoplasmic reticulum is an extensive network of membrane-
enclosed tubules in the cytoplasm of cell s. This organelle is classifi ed as granular or rough
surfaced when ribosomes are attached to the surface of the membrane and as agranular
or smooth surfaced when ribosomes are absent. The structure functions in t he synthesis
of proteins and lipids and in the transport of these metabolites within the cell.
The cytoplasm of muscle cells is called sarcoplasm. The sarcoplasm of each skeletal
muscle fiber contains many parall el, thread-like struct ures called myofibrils. Each
myofibril is composed of small er st rands called myofilaments that contain the contractile
proteins, actin and myosin. The regul ar spatial organization of the contractile proteins
within the myofibrils forms the cross banding. A network of membranous channels,
called the sarcoplasmic reticul um, extends t hroughout the sarcoplasm.
Note: It is mainly a great increase in t he numbers of additional myofibrils (which is caused
by progressively greater numbers of both acti n and myosin filaments in the myofibrils)
that causes muscle fi bers to hypertrophy.
Important: The number of muscle fi bers does not increase; the size of each fiber
increases.
Note: Troponin C binds to ca2+ in cardiac and skeletal muscles, whil e in smooth muscles
ca2+ binds to calmoduli n.
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muscle
Which ofthe following muscles elevates and abducts the eyeball?
medial rectus
lateral rectus
superior rectus
inferi or rectus
superior obli que
inferi or obli que
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inferior oblique
Extraocular 1\lusclcs
Muscle Action Innervation
Medial rectus Adducts CN III
Lateral rectus Abducts CNVI
Superior rectus Elevates, adducts, and medially rotates CN III
Inferior rectus Depresses, adducts, and laterally rotates CN III
Superior oblique Depresses abducts, and medially rotates CNIV
Inferior oblique Elevates, abducts, and laterally rotates CN III
Abducts the eyeball = moves the eyeball laterally = away from the nose
Adducts the eyeball = moves the eyeball medially = toward the nose
Innervation of eyeball muscles mnemonic:
A good mnemonic to remember which muscles are innervated by what nerve is to para-
phrase it as a molecular equation (LR
6
S0
4
)]
Lateral Rectus - Cranial Nerve VI
Superior Oblique- Cranial Nerve IV
The rest of the muscles- Cranial Nerve Ill
Note: All extraocular muscles are supplied by the lateral and medial muscular branches of
the ophthalmic artery.
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muscle
Rul<s of :\cnc u p p l ~ lor \luscl< Groups
All muscles of: Supplied by: Exc.ept:
Pharynx Pharyngeal plexus ( IX and X) Stylopharyngeus
Larynx Recurrent laryngeal Cricothyroid
Tongue Hypoglossal (XII) Palatoglossus
Soft palate Pharyngeal plexus (IX and X) Tensor veli palatini
lnfrahyoid Ansa cervicalis Thyrohyoid
Eyeball Oculomotor (Ill) Lateral rectus
Superior oblique
ANATOMIC SCIENCES
Which is supplied by:
Glossopharyngeal ( IX)
External branch of superior
laryngeal nerve
Vagus (X)
Nerve to medial pterygoid, a
branch of mandibular nerve
(V3)
C I via hypoglossal nerve
(XII)
Abducent (VI)
Trochlear (IV)
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Comparison ul \lusdcs
Characteristics Skeletal muscle Cardiac muscle Smooth muscle
Skeletal attachment Yes No No
Striation Yes Yes No
Sarcoplasmic reticulum Extensive lntennediate Limited
Muscle fiber s hape. Cylindrical Branched Fusifonn
Functional syncytium No Yes Yes
Nucleus/fiber Multiple Single Single
Sarcomere. Regular Regular Absent
Actin attached with Z-line Z-line Dense bodies
Ca' binding protein Troponin Troponin Calmodulin
Response to stimulus Graded by recruitment All-or-none Changes in tone or rhythm
Electrical coupling Absent Intercalated disk Gap junctions
between fibers and gap junctions
Sensitivity to extracellular No Yes Yes
Cal+
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embryology
During the 4'h week of embryonic development the tongue appears in the
form oftwo lateral lingual swellings and one medial swelling, the so-called:
foramen cecum
sulcus terminalis
tuberculum impar
epiglottic swell ing
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tuberculum impar
During the 4" week of embryonic development t he tongue appears In the form of two lateral lingual swellings
and one medial swelling, the so-called tuberculum impar_ These three swellings originate from the first
branchial arch. A second median swelling (the copula) is formed by mesoderm of the second, third, and
fourth arches. The lateral lingual tongue swellings overgrow the t uberculum i mpar and merge with each other,
forming the anterior two-thi rds of the tongue.
The posterior third of the tongue originates from the second, t hird and fourth pharyngeal arches. The extreme
posterior part of the tongue Is derived from the fourth pharyngeal arch. The anterior two-thirds of the tongue
are separated from t he posterior third by a V-shaped groove called the terminal sulcus. The foramen cecum,
the remnant of t he proximal end of the t hyroglossal duct is located at the apex of the terminal sulcus.
Remember: The branchial arches are stacked bilateral swellings of tissue that appear inferior to the
stomodeum (primitive mouth) during t he fourth week of embryonic development. These branchial arches are
six pairs of U-shaped bars with a core mesenchyme which is formed by mesoderm and neural crest cells that
migrate to the neck region. The branchial arches are covered externally by ectodermal lined branchial clefts.
They are internally lined by endodermal lined branchial pouches. These arches support the lateral walls of the
primitive pharynx.
8
1. Bifid tongue is the result of lack of f usion of the distal tongue buds (or lateral swellings). This
seems to be common in South American infants.
2. Most tongue muscles develop from myoblasts originating in the occipital somites. Therefore, the
tongue musculature is innervated by t he hypoglossal nerve.
3. The f ifth branchial arch is so rudimentary that they are absent in humans or are included with the
fourth branchial arches.
Between the sixth and eighth weeks of prenatal development, the three major salivary glands begin as
epithelial proliferations, or buds, from the ectodermal lini ng of the primitive mouth (stomodeum). The rounded
terminal ends of these epithelial buds grow i nto the underlying mesenchyme, producing t he secretory cells, or
glandular acini, and the ductal system. The parotid glands appear early in the sixth week and are the first to
form. The submandibular glands appear late in the sixth week, and the sublingual glands appear in the eighth
week.
Parotid gland is derived from ectoderm.
Sublingual and submandibular salivary glands are derived from endoderm.
In some books the branchial (arches, pouches and clefts) are referred to as pharyngeal (arches,
pouches and clefts), "branchial=pharyngeal"
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1st branchial arch
0 2nd branchial arch
3rd branchial arch
0 4th-6th branchial arch
A: Copula and its ivolvement in
the fonnation of the base of the
tongue.
B
Tuberclum
impar
Development of the Tongue
A: Tuberculum impar and
lateral lingual swellings and
their involvement in the
formation of the body of the
tongue .
Lateral lingual swellings
148-1
Reproduced with p..-nnission (rom Ba1h4 Balogh M. Fehrenbach MJ; IU!Nratcd Dental Entbi)"Oiogy. Histology. and Anatomy. cd 2. St. LOUIS, 2006,
Saunders.
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embryology
The cartilages of first and second branchial arches are derived from meso-
derm.
The cartilages of the fourth through sixth branchial arches are derived from
neural crest cells.
both statements are t rue
both statements are fal se
the fi rst statement is true, the second is false
the first statement is false, the second is true
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both statements are false
***The cartilages of first and second branchial arches are derived from neural crest cells. While
the cartilages of t he fourth-sixth branchial arches are derived from mesoderm.
Each paired branchial arch has its own developing cartilage, nerve, vascular, and muscular
components withi n each mesodermal core. These elements are of neural crest origin except
for the cartilages of the fourth through sixth branchial arches which are derived from
mesoderm.
Derivatives of the branchial arch cartilages:
First arch cartilage (Meckel's cartilage): is closely related to t he developi ng middle ear;
becomes ossified to form the malleus and incus of the middle ear, sphenomandibular
ligament, and portions of the sphenoid bone.
Note: Most of this cartilage di sappears as t he bony mandible forms by intramembranous
ossification lateral to and in close association with it, yet only some of Meckel's cartilage
makes a contribution to it. Its fate is said to be dissolution with minor contributions to
ossification.
Mandibulofacial Dysostosis: this developmental defect affects t he derivatives of the first
branchial arch. The patient usually exhibits micrognathia (small lower jaw), malar (zygomatic)
hypoplasia, deformity of the lower rim of the orbit and malformed external ear. These defor-
mit ies clearly indicate problems with neural crest cells migration of t he first branchial arch.
Second arch cartilage (Reichert's carti lage): is also closely related to t he developi ng
middle ear; becomes ossified to form the stapes of the middle ear, the styloid process of
the temporal bone, the stylohyoid ligament, the lesser cornu of the hyoid bone, and the
upper half of the body of hyoid bone.
Third arch cartilage: ossifies to form the greater cornu of the hyoid bone and the
lower half of the body of the hyoid bone.
Fourth through sixth arch cartilage (laryngeal cartilages): forms the cartilages of t he
larynx (thyroid, cricoid, arytenoid, corniculate and cuneiform).
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embryology
Failure offusion of which ofthefollowing will lead to cleft lip?
frontonasal process; lateral nasal process
maxillary process; medial nasal process
lateral nasal process; medial nasal process
maxillary process; lateral nasal process
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maxillary process; medial nasal process
Thus, the maxillary processes contribute to the si des of t he upper l ip, and t he two medial nasal processes
cont ribute to the middle of t he upper lip. Fusi on of t hese processes to form t he upper l ip i s completed dur-
i ng the sixth week of prenatal development, when t he grooves between the processes are obliterat ed. The
maxillary processes on each side of t he developi ng face part ially fuse with t he mandibular arch t o form
t he labial commissures, or corners, of the mouth.
After format ion of the stomodeum (t he pri mitive mouth) but still wi thi n t he fourth week, t wo bulges of tis-
sue appear i nferior t o t he pri mi tive mouth. t he two large mandibular processes of t he fi rst branchial arch.
The mandible forms as a result of the fusion of the right and left mandibular processes. The mandible i s t he
f irst portion of t he face to form after t he creat ion of t he stomodeum.
The maxilla is formed primari ly by mergi ng of t he two smaller maxillary processes of t he fi rst branchial
arch. These maxillary processes al so form t he upper cheek regions and most of t he upper l ip.
Duri ng t he fourth week. the frontonasal process (promi nence) al so forms. It is a bulge of t issue i n t he
upper facial area, at t he most cephal ic end of t he embryo. and i s t he cranial boundary of t he stomodeum.
In the future, t he f ront onasal process gives ri se to the upper face. which includes t he forehead. bridge of
nose, primary palate, nasal septum, and all structures related to t he medial nasal processes.
The nasal placodes form i n t he anterior port ion of the frontonasal process, just superior to the stomodeum,
during the fourth week. These two buttonl ike structures form as bilateral ectodermal thi ckenings that later
develop i nto olfactory cell s for the sensat ion of smell. The middle portion of the ti ssue growi ng around the
nasal placodes appears as two crescent-shaped swell ings and are called t he medial nasal processes, which
fuse to form t he middle portion of t he nose f rom t he root to the apex and the center porti on of the upper
l ip and al so t he philtrum region. On the outer port ion of t he nasal placodes, t here are al so t wo other cres-
cent -shaped swellings. t he lateral nasal processes, whi ch will form the alae. or sides of t he nose. Fusion
of t he lateral nasal, maxi llary, and medial nasal processes forms t he nares (nostril s).
Note: Partial unilateral and bilat eral cleft i ng of t he l ip results from the failure of t he maxillary and medial
nasal processes to fuse. Cl efts involvi ng t he hard and soft palat e are the result of a lack of fusion among
t he lateral palatal processes. t he pri mary palate, and the nasal septum, depending on the degree; i n other
words. failure of fusion of palatine shelves will lead to cleft palat e.
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Frontal view Lateral view
The adult face and its embryonic derivatives of five facial processes: the single
frontonasal process and the paired maxillary and mandibular processes.
150.1
Reproduced with p..-nnission (rom Bath-Balogh M. Fehrenbach MJ; Demo/ EmhtJ'illogy. Histology. om/ ed 2. St Ll"'Uis. 2006.
Saunders.
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Oropharyngeal
membrane
processes
Frontonasal
Stomodeum
Mandibular symphysis
Maxillary
process
Mandibular
arch
Third through fourth weeks of embryonic development - Frontal aspect
Disintegration of the oropharyngeal membrane enlarges the stomodeum of the embryo
and allows access between the primitive mouth and the primitive pharynx. The mandibu-
lar processes also fuse, forming the mandibular arch inferior to the enlarged stomodeum.
lSOA I
Reproduced wilh pem1ission (rom B.mh-Balogh M. Fehrenbach MJ; 11/u.ftraled Demal Emb'J'illogo,: Histology. am/ ed 2, SL Louis. 2006.
Saunders..
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Medial nasal
process
Nasal pit
Lateral nasal
process
Medial nasal
processes
fusing with

other
Medial nasal
process
fusing with
maxillary
process
Nasolacrimal
groove
Phi ltrum
Upper lip
Lateral nasal
process
Phi ltrum
The development of the nose from the medial and lateral nasal processes
150 8-1
Reproduced wilh pem1ission (rom B.mh-Balogh M. Fehrenbach MJ; 11/u.ftraled Demal Emb'J'illogo,: Histology. am/ ed 2, SL Louis. 2006.
Saunders..
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Developing brain
Nasal placodes
Site of otic placode
Developing heart
K
The embryo at the fourth week of prenatal development.
The developing brain, face, and heart are noted.
150 C.l
Reproduced with p..-nnission (rom Bath-Balogh M. Fehrenbach MJ; Demo/ EmhtJ'illogy. Histology. om/ ed 2. St Ll"'Uis. 2006.
Saunders.
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embryology
During the fourth week of embryonic development, the first branchial arch
divides to form:
the two medial nasal processes
the mandibular and maxi llary processes
the two lateral nasal processes
the lateral and medial nasal processes
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the mandibular and maxillary processes- also called maxillary
and mandibular prominences
The branchial arches are stacked bilateral swellings of tissue that appear inferior to
the stomodeum (primiti ve mouth) during the fourth week of embryonic
development. These branchial arches are six pairs of U-shaped bars with a core
mesenchyme which is formed by mesoderm and neural crest cel ls that migrate to the
neck region. The branchial arches are covered externally by ectodermal li ned
branchial clefts. The arches are bordered medially by the pharynx, which is li ned by
endoderm. Medial ly each of the branchial arches is separated by a pharyngeal
pouch. These pouches approach the corresponding branchial cleft. The
approximation of the ectoderm of the pharyngeal cleft with the endoderm of the
pharyngeal pouch forms the pharyngeal membrane. The grooves and pouches are
named (numbered) the same as the preceding arch.
After formation of the stomodeum (the primi tive mouth) but still within the fourth
week, two bulges of t issue appear inferior to the pri mitive mouth, the two large
mandibular processes of the fi rst branchial arch.
Important: The mandible forms as a result of the fusion of the these two large
mandibular processes.
Note: The mandibular symphysis is a faint ridge in the midline on the surface of the
bony mandible where the mandible is formed by the fusion of the mandibular
processes.
The two smaller maxillary processes of the first branchial arch form the maxi ll a, the
upper cheek regions, and most of the upper l ip.
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The second branchial pouch gives rise to the:
eustachi an tube
palatine tonsi l
middle ear cavity
superi or parathyroid gland
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embryology
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palatine tonsil
Four well-defined pairs of pharyngeal pouches devel op as endodermal evaginations from the lat-
eral walls lining the pharynx. The pouches devel op as balloon-like structures in a craniocaudal se-
quence between the branchial arches.
Pharyngeal Pouch Structures Derived From
First Contributes to the formation of the tympanic membrane (with first branchial groove).
auditory tube, tympanic ca,ity, mastoid antrum
Second Palatine tonsils
Third I nferior parathyroid glands (from the dorsal part) and th)mus gland (from the
ventral part)
Fourth Super ior par athyr oid glands (from the dorsal part)
Fifth Ultimobr anchial bodies which gives rise to C cells of the thyroid
--: . 1. Some books menti on that there is fifth branchial pouch that forms the ultimo-
s ~ branchial bodies which gives ri se to C cells of the thyroid glands. Others consider the
fifth branchial pouch as a rudimentary pouch or a part of fourth branchial pouch which
gives rise to the ul timobranchi al bodies and C cells.
2. C cell s of the thyroid are responsible for secreting calcitonin hormone.
3. The first brachial cleft forms the external auditory meatus.
Digeorge syndrome: congenital malformation caused by underdevelopment of t hi rd and
fourth branchial pouches leading to absence or hypopl asia of the parathyroid glands. The pa-
t ients usually have congenital heart defects and compromi sed immunity.
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embryology
The thyroid gland is first identifiable during the fourth week of gestation,
beginning as an endodermal invagination of the tongue at the site of:
tuberculum impar
copula
terminal sulcus
foramen cecum
stomodeum
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foramen cecum
The oral cavity (primitive mouth or stomodeum) appears as a shallow depression in the
embryonic surface ectoderm.
This stomodeum (aka, stomatodeum) is limi ted in size by the first branchial arch, and in depth
by the oropharyngeal membrane (buccopharyngeal membrane). This temporary membrane,
consisting of external ectoderm overlying endoderm, was formed during the third week of
prenatal development. The membrane also separates the stomodeum from the primitive
pharynx. The primitive pharynx is the cranial portion of the foregut, the beginning of the future
digestive tract.
The first event in t he development of the face, during the fourth week of prenatal development,
is di sintegration of the oropharyngeal membrane. With this disintegration of the membrane,
t he stomodeum is increased in depth, enlarging it.
In t he future, the stomodeum will give rise to t he oral cavity, which is lined by oral epithelium,
derived from ectoderm as a resul t of embryonic folding. The oral epithelium and underlying tis-
sues will give rise to the teeth and associated structures.
Note: A plane passing through the right and left anterior pillars marks t he separation between
the oral cavity and oropharynx in the adult.
Thyroid gland: the initial site of thyroid gland lies between the copula and the tuberculum
impar which is called (foramen cecum), then it descends through thyroglossal duct to its per-
manent location below the thyroid cartilage in the neck.
Thyroglossal tract (duct): this duct extends from foramen cecum on of tongue to the perma-
nent location of thyroid gland below thyroid cartilage. This duct is supposed to close and dis-
appear after the descendent of thyroid into the neck, if i t fails to close and disintegrate; portions
of this tract and remnants of thyroid tissue associated with it may persist at any point between
t he tongue and t he t hyroid. Thyroglossal duct remnants are referred to as thyroglossal duct
cyst.
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embryology
The primary palate or median palatal process is formed by the merging of the
frontonasal process with which other processes?
lateral nasal processes
medial nasal processes
maxill ary processes
mandibular processes
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medial nasal processes
The palate is formed from two separate embryonic structures: the primary palate and
the secondary palate. The palate is then completed during the 12th week of prenatal de-
velopment.
The palate is developed in three consecutive stages:
The formation of the primary palate
The formation of the secondary palate
The completion of the palate
Primary palate formation: around the fifth week, the intermaxillary segment arises as
a result of fusion of the two medial nasal processes and the frontonasal process within the
embryo. The intermaxillary segment gives rise to the primary palate. The primary palate
will form the premaxillary portion of the maxilla (the anterior one-third of the final palate).
This small portion is anterior to the incisive foramen and will contain the maxillary incisors.
Secondary palate formation: around the sixth week, the bil ateral maxillary processes
give rise to two palatal shelves, or lateral palatine processes. These two palatal shelves
elongate and move medially toward each other, fusing to form the secondary palate. The
secondary palate will give rise to the posterior two-thirds of the hard palate, which will con-
tain the maxillary canines and posterior teeth, posterior to the incisive foramen. The sec-
ondary palate also gives rise to the soft palate and its uvula.
Completion of the palate: To complete the palate, the secondary palate meets the pos-
terior portion of the primary palate, and fuses together. These three processes are com-
pletely fused, forming the fi nal palate, both hard and soft portions, during the 12th week
of prenatal development.
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A
Maxillary process Maxillary process
.._-::::::::....1,---- --'ti Stomodeum
Palatal shelt-H----;;iDll/ Palatal shelf
B
Maxillary process
1+----.---.illt r--, l.'li:.---.----11f-- P alatal shelf
Stomodeum
mandible
The developing palate (highlighted). A: Palatal shelves form from the maxillary
process deep on the inside of the stomodeum. B: Palatal shelves grow in a horizon-
tal direction toward each other, after "flipping" in a superior direction, to form the
secondary palate.
154-1
R<'produccd \ltith penni$.iion (rom Ebtb-Balogh M. Fchrcnbacoh MJ; Demal Emb'J'ology. Histology. om/ ed 2. St Louis. 2006.
Saunders.
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Secondary palate fonned from
fused palatal shelves with
canines and
Primary palate with
four incisor teeth
Soft palate
The adult palate and its developmental portions
Reproduced \1,-ilh from Ba1h-Balogh M, Fehrenbac-h MJ; 11/u.ftraled Demal EmhtJ'illogy. Histology. am/ ed 2. St. Louis. 2006.
Saunders.
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embryology
All of the following muscles are derived from first branchial arch EXCEPT
one. Which one is the EXCEPTION?
tensor tympani
anterior belly of digastric
temporalis
masseter
levator veli palatini
tensor veli palatini
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Arch
Fistarch
(mtmdibult1r)
Second arch
(hyoid)
Third arch
Fourth arch
Sixth arch
levator veli palatini
\1 ch .md Dt.J i' .1ti\ l' Structuns
Future and .Muscles
I rigemjnal nerve (V1 and Y3l.
muscles of masrication. mylohyoid
and anterior belly of digasttic,
[tnsor cympani. rt-ll$01' veli palatini
muscles
Eacialne.M. smpedius muscle-.
muscles of facial expression.
posre.rior belly of the digastric
muscle. stylohyoid muscle
neo:e
scylopharyngeal muscle
Superior Ja1yngeal branch of vagus
pha1yngeal cons1rictors,
levator veli 1,alatini and c-ric.othyroid
musc-le
Future Skeletal Structures and Ligaments.
lvlalleu..o; and i ncus of middle ea1'. including anterior l igame.m
of the malleus, sphe-nomandibular ligament. and p011ion..o; of
the sphenoid bone
Stapes and po11ion..o; of malleus and incus of middle ear.
stylohyoid ligament, styloid process of the U!'ll\poral bone.
cornu of hyoid bone, upper portion of body of hyoid
bone
Grea[er comu of hyoid bone,lowe.r pot[ ion of body of hyoid
bone
Laryngeal car1ilages
Recurre-nt laryngeal branch of Laryngeal car1ilages
muscles of the
larynx except lhe cricothyroid
Ph:uyngeal Arch Structures Derived From
First Mandible and maxilla, Meckel's cartilage, incus, malleus, sphenomalleolar ligament,
sphenomandibular ligament
Second Reicherts carti lage. styloid process. stylohyoid ligament, lesser comu and upper
part of hyoid bone and stap<',<
Third Greater cornu and lower part of hyoid bone
Fourth through sixth Laryngeal cartilages
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embryology
The nasal cavities are formed from which embryonic structure?
stomodeum
f rontonasal process
intermaxill ary segment
nasal pits
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Embr yonic Structure
Stomodeum
Mandibular arch
(first branchial arch)
Maxillary process(cs)
Frontonasal process
Nasal pits
Medial nasal process( cs)
Jntennaxillary segment
Lateral nasal proccss(cs)
NasoJacritnal cord
nasal pits
DeHlopment of the Face
Origin
Ectodennal depression enlarged
by disintegration of oropharyngeal
membrane
Fused mandibular proce.'ises
neural crest c.ells
Superior and anterior swclling(s)
from mandibular arch and neural
crest cells
Ectodcnnal tissue and neural crest
cells
Nasal placodes
Frontonasal process medial to
nasal pits
Fused medial nasal processes
Future Tissues
Oral cavity proper
Lower lip, lower face, mandible with
associated tissues
M idfacc. Upper lip sides, cheeks,
secondary palate, posterior portion of
ma..xilla with associated tissues, zygomatic
bones, portion of temporal bones
Medial and lateral nasal processes
Nasal cavities
Middle of nose, philtrum region,
intennaxillary segment
Anterior portion of maxilla with associated
tissues, primary palate
Frontonasal process lateral to nasal Nasa] aJac
pits
Nasolacrimal groove Lacritnal sac, Nasolacrimal duct
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embryology
All of the following are neural crest cells derivatives EXCEPT one. Which one
is the EXCEPTION?
melanocytes
dorsal root gangl ia
adrenal medull a
autonomic gangli a
adrenal cortex
schwann cells
sensory gangli a of cranial nerves
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adrenal cortex- it is derived from mesoderm
Neural Crest Cell Neuroectoderm Surface Ectoderm
Derivatives Derivatives Derivatives

Autonomic ganglia

Neurohypophysis

Adenohypophysis

Dorsal root ganglia
(posterior pituitary) (anterior pituitary

Leptomeninges (the pia
Central Nervous

Epidermis
and arachnoid)
System

Hair

Schwann cells
0 ligodendrocytes

Nails

Adrenal medulla
Astrocytes

Inner ear

Melanocytes
Pineal gland

External ear

Sensory cells of cranial
Retina and optic

Lens of eye
nerves
nerve

Parotid gland
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embryology
Which two ofthe following are NOT derived from endoderm?
lung
liver
gut tube derivatives
pancreas
spleen
thymus
dura mater
parathyroid gland
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Mesodermal

Heart
Blood
Dennis
Muscles
Vc$scls
Adrenal cortex
Bone
Spleen
Kidney and ureter
Endodermal
Derivatives
Gl tmct: foregut, midgut and hindgut
Lung
Liver
Pancreas
Thymus
Thyroid
Parathyroid
Submandibular and sublingual glands
Middle car and auditory tube
spleen
dura mater
Note: The dura mater is derived from neural crest cells of the ectoderm.
Fetal Circulation Derivathes
Fetus Adult
Umbilical vein Ligamentum teres
Umbilical arteries Medial umbilical ligaments
Ductus arteriosus Ligamentum artcriosum
Ductus venosus Ligamentum vcnosum
For.uncn ovate Fo.o;sa ovalis
Allantios Urachus (medial umbilical ligament)
Notochord Nucleus pulposus
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heart
Which ofthe following arteries accompanies the great cardiac vein?
ci rcumflex artery
anterior interventricular artery
posterior interventricular artery
right marginal artery
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anterior interventricular artery
When viewed from the back (posterior view), t he most obvious structure lying in the coronary
sulcus is the coronary sinus. Thi s sinus receives most of the venous blood from the heart and
empties into the right atrium. Its tributaries are the small cardiac vein, middle cardiac vein,
and the great cardiac vein. There is a small vein that arises along the left side of the left atrium
j ust beneath the lower left pulmonary artery (called the oblique vein). This vein is a remnant of
the embryonic left superior vena cava.
The great cardiac vein: opens into the left extremity of the coronary sinus. This vein re-
ceives tributaries from the left atrium and both ventricles: one, the left marginal vein, is of
considerable size, and ascends along the left margin of the heart.
The small cardiac vein: opens into the right extremity of the coronary sinus. This vein re-
ceives blood from the back of the right atrium and ventricle; the right marginal vein ascends
along the right margin of t he heart and joins the small cardiac vein in the coronary sinus, or
opens directly into the right atrium.
The middle cardiac vein: ends in t he coronary sinus near its right extremity.
The oblique vein: ends in the coronary sinus near its left extremity; thi s vein is continuous
above with t he ligament of the left vena cava.
The following cardiac veins do not end in t he coronary sinus:
The anterior cardiac veins: comprising three or four small vessels which collect blood from
the front of the right ventricle and open into the right atrium; the right marginal vein fre-
quently opens into the right atrium, and is therefore sometimes regarded as belonging to t his
group.
The smallest cardiac veins (thebes ian veins): consisting of a number of minute veins which
arise in the muscular wall of the heart,; the maj ori ty open into the atria, but a few end in t he
ventricles.
Note: The anterior interventricular artery (left anterior descending artery), a branch of the
left coronary artery, accompanies the great cardiac vein. The posterior (or descending) inter-
ventricular artery, a branch of the right coronary artery, accompanies t he middle cardiac vein.
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Coronary sinus
Great
cardiac vein
Cardiac Veins- Posterior view
Right atrium
Inferior
vena cava
Small
cardiac
vein
Middle
cardiac
vei n
Right
ventricle
159-1
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Right coronary
artery
Posterior
interventricular
artery
Marginal
artery
Arterial supply of the heart
Left coronary
artery
Circumfl ex
artery
159 A I
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heart
Sympathetic stimulation will have which direct effect on the heart?
decreased automaticity
AV block
increased vagal response
bradycardia
increased stroke volume
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increased stroke volume
The strength and frequency of the heart beat are controlled by the autonomi c nervous system. Both
parasympathetic and sympathetic parts of the autonomi c nervous system are involved in the control of
the heart.
The heart al so has an i nternal nervous system made up of the SA (si noatrial node) and the AV (atrioven-
tricular) node. The AV bundle (His) l eaves the AV node near the lower part of t he i nteratrial septum and
splits overt he upper part oft he interventricular septum i nto a left bundle branch and a right bundle branch.
The cardiac muscle is then suppl ied by branches of the two bundles.
Specialized cardiac muscle cells i n the wall of the heart rapidly initiate or conduct an electri cal i mpul se
throughout the myocardium. The signal is initiated by t he sinoatrial (SA) node (pacemaker) and spreads
to the rest of the right atrial myocardium directly, to the left atrial myocardium by way of a bundle of in-
teratrial conducting fibers, and to the atrioventricular (AV) node byway of three internodal bundles. The AV
node then i nit iates a signal that is conducted through the ventricular myocardium by way of t he atri oven-
tricular bundle (bundle of His) and Purkinj e fi bers.
Important: (1) The sinuatrial node is located at the j unction of the superior vena cava and the right
auricle; it's the most rapidly depolarizing cardiac muscle t issue of t he heart. This is why the SA node is
referred to as t he "pacemaker" of the heart. (2) The AV node is an area of special ized tissue between the
atria and the ventri cles of the heart, specifically in the posteroinf erior region of the interatrial septum near
the openi ng of the coronary sinus, which conducts the normal electrical impulse from the atria to the
ventricles.
Remember: The conducti ng system of the heart is all modified cardiac muscle fibers and not nerves.
The sympathetic fibers ari se from segments T2-T4 of the spinal cord and are distributed through the mid-
dle cervical and cervi co-thoraci c (or stellate) ganglia and the fi rst four ganglia of the t horacic sympathetic
chai n. The sympathet ic fibers pass i nto the cardiac plexus and from there to the SA node and the cardiac
muscle. The effect of the sympathetic nerves at the SA node is an increase in heart rate. The effect on the
muscle is an increase in rise of pressure within the ventricle, thus increasi ng stroke vol ume.
The vagus nerve provides parasympathetic control to the heart. The effect of the vagus nerve at the SA
node is the opposite of the sympatheti c nerves; it decreases the heart rate. The vagus nerve also decreases
the excitabil ity of the junctional tissue around the AV node, and this resul ts in slower transmission.
Note: Strong vagal stimulation here may produce an AV block.
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Right
Atrioventrfcular node
The Cardiac Conduction System
160-1
Reproduced wtth pcm1is!HOO (rom BM. Stanton BA; Berne & LeV)' ed tS: Philaddphia, 2008.. Elsc:vtcr.
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heart
Which of the following is the correct conduction pathway through the heart?
SA node- ventricular muscle- AV node- His bundle- bundle branches- Purkinje fibers
-atri al muscle
SA node- atrial muscle- AV node- bundle branches- His bundle- Purkinje fibers-
ventricular muscle
SA node- atrial muscle- AV node- His bundle- bundle branches- Purkinje fibers-
ventricular muscle
SA node- Purkinje fibers- AV node- His bundle- bundle branches- atrial muscl e-
ventricular muscle
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SA node - atrial muscle- AV node- His bundle -bundle branches- Purkinje
fibers - ventricular muscle
The heart contains masses of nodal tissue, excitable tissue that conducts impulses and st imulates the
heartbeat intrinsically. This conduction system signals the heart to beat independently. It does not
require any external influences. The impulse to stimulate the heartbeat passes through the conduc-
tion system structures in this order: SA node - atrial muscle - AV node - His bundle - bundle
branches - Purkinje fibers - ventricular muscle
The SA node is in the wall of the right atrium, near the entrance of the superior vena cava. The SA
node typically depolarizes spontaneously at the rate of 60 to 100 times per mi nute, causing the atria
to contract. Impulses from the SA node pass to the atrioventricular node (AV node), atrioventricular
bundle (AV bundle, or bundle of His), and finally to the conduction myofibers (Purkinj e fibers) within
the ventricular walls. Stimulation of the conduction myofibers causes the ventricles to contract si-
multaneously.
~ ~ 1. The rate of the discharge of the SA node set s the rhythm of the entire heart.
.fJ!ftes1 2. The rhythm originates frorn the SA node because the SA node depolarizes more fre-
ti quently (60-100 beats per minute) than the AV node (4Q-60 beats per minute) and ven-
tricular conducting system (3Q-40 beats per minute) so t he AV node and ventricular
conducting system are captured by the sinus impulse and driven at 60-100 beats per
minute.
3.1n sinus rhythm, every P-wave is followed by a QRS complex, the R-R interval is regu-
lar, and the P-R interval is less than 0.2 seconds. A fast sinus rhythm, faster t han 100 beats
a minute, is known as sinus tachycardia while a slow rhythm, slower than 60 beats a
minute, is known as sinus bradycardia.
ECG Component vent
I' wa\'c Atrial depolarization
QRS Ventricular depolarization
l)k Impulse between SA and A V node (AV conduction)
T W1\'C Ventricular t('polarizution
Qi Ejcctton of blood
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The apex of the heart is located at the level of the:
third left intercostal space
fourth left intercostal space
fifth left intercostal space
sixth left intercostal space
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fifth left intercostal space
The apex of the heart is formed by t he t ip of the left ventricle and is located at the level of the fifth
left intercostal space.
The ventricles are larger and thicker walled than the atria. The right ventricle pumps blood to the
lungs. The left ventricle is larger and thicker walled than the right; it pumps blood through all other
vessels of the body.
Note: The ventricles receive blood from the atria.
Important: The left ventricle enlarges briefly in response to coarctation (constriction) of the aorta.
Remember: The heart functions as a double pump. The right side (right atri um) receives
deoxygenated blood from the systemic circuit via the superior and inferior venae cavae as well as
the coronary sinus. The bl ood then goes from the right atrium to the right ventricle via the right AV
valve. The right ventricle then pumps bl ood into the pulmonary circuit (via the pulmonary
semilunar valve, which allows blood to flow into the pulmonary arteries).
Note: Resistance to pul monary blood flow in the lungs causes a strain on the right ventricle and
results in ventricular hypertrophy.
The left side [left atrium) receives oxygenated blood from the lungs by way of the pulmonary
veins. This blood then flows through the left AV valve into the left ventricle. From the left ventricle,
blood passes through the aort ic valve and enters the arch of the aorta, which will deliver the blood
to the body's systemic circuits.
Remember: Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are
the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart.
Note: Heart failure may affect the right side, the left side, or bot h sides of the heart. The left side of
the heart receives blood rich in oxygen from the lungs and pumps it to the remainder of the body.
As the ability to pump blood forward from the left side of the heart is decreased, the remainder of the
body does not receive enough oxygen especially when exercising. This results in fatigue. In addi-
tion, the pressure in the veins of the lung increases, which may cause fl uid accumulation in the lung.
This result s in shortness of breath and pulmonary edema.
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RJeM
pulmonary
artery
Right superior
pulmonary vein
Right inierlor
pulmonary vein
Brachlo<:ept>allc
artery
lelt Sllperior
....
Lett Inferior
vein
Anterior descending
branch of left coronary
artery
lett ventrtde
Heart -Anterior view
162-1
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heart
Which of the following describes the function of the ductus arteriosus in the
fetus?
it shunts blood from the aorta to the pulmonary artery
it shunts blood from the pulmonary artery to the aorta
it shunts blood from the ri ght atrium to t he left atrium
it shunts blood from the umbilical vein to the inferi or vena cava
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it shunts blood from the pulmonary artery to the aorta
The ligamentum arteriosum is a remnant of the ductus arteriosus in the fetus. The
ductus arteriosus is a normal fetal structure, allowing blood to bypass circulation to
the lungs (blood is shunted from the pulmonary artery to the aortic arch). Since the
fetus does not use his or her lungs (oxygen is provided through the mother's
placenta), flow from the right ventricle needs an outlet. The ductus provides this,
shunting flow from the left pulmonary artery to the aorta just beyond the origin of
the artery to the left subclavian artery. The high levels of oxygen that the ductus is
exposed to after birth causes the ductus to close in most cases withi n 24 hours. When
it does not close, it is termed a patent ductus arteriosus. After birth, the ductus
arteriosus becomes the li gamentum arteriosum, which connects the arch of the aorta
to the left pulmonary artery.
Remember: The fossa ovalis is a depression in the ri ght atrium of the heart, the
remnant of a thin fibrous sheet that covered the foramen ovale during fetal
development. During fetal development, the foramen ovale all ows blood to pass
from the ri ght atrium to the left atrium, bypassing the nonfunctional fetal lungs whi le
the fetus obtains its oxygen from the placenta. Upon bi rth, the foramen ovale is
initiall y closed by the septum primum (valve of foramen ovale) as pressure in the left
atrium exceeds that in the right atrium. Eventually, the foramen ovale becomes
permanently closed with fibrous connective tissue and becomes the fossa oval is in
the adult.
Note: The atrial portion of the heart has relatively thin walls and is divided by the
atrial septum into the right and left atria. The ventricular portion of the heart has
thick wall s and is divided by the ventricular septum into right and left ventricles.
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Before Birth
Right Atrium
Higher pressure
Septum t ~
secundum
Oval
foramen
Left Atrium
Lower pressure
.-septum
primum
(valve of
oval
foramen)
After Birth
Right Atrium
Lower pressure
Septum-
secundum
Oval ------
fossa
Left Atrium
Higher pressure
-
- septum
primum
Development of Features of Right Atrium
163-1
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heart
A worker in the meat-processing industry comes down with an illness,
presenting with symptoms of fever, headache, and sore throat. A few days
later, he feels chest pain and has pink, frothy sputum. His physician states
that the worker has a viral infection caused by coxsackie B. This patient has in-
flammation of which layer of the heart?
epicardium
myocardium
endocardium
pericardium
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myocardium
Myocarditi s: is the inflammation of the muscular layer of the heart (myocardium)
Layers of the heart:
1. Internal or endocardium - Homologous with the tunica intima of blood vessels.
Li nes the surface of the heart chambers with a simple squamous endothelium and
underlying loose connective t issue containing small blood vessels.
2. Myocardium - Homologous with the tunica media of blood vessels. Forms the
bulk of the heart mass and consists predominantly of cardiac muscle cells arranged
in a spiral configuration. This spiral arrangement allows the heart to"wring"the blood
from the ventricles toward the aortic and pulmonary semilunar valves.
3. Pericardium - is the set of membranes around the heart (it is actually composed
of three layers of membranes). The innermost is the visceral pericardium, the mid-
dle is the parietal pericardium, and the outer one is the extra one, called the fibrous
pericardium. The inner two (visceral and parietal) are rather thin and delicate. The
outer one, the f ibrous peri cardium, is tough. Important: The major sensory nerve to
the parietal pericardium is f rom branches of the phrenic nerve (C3-CS).
Important: The middle mediastinum is of the highest cl inical importance as it con-
tains the pericardium and the heart and the immediately adjacent parts of the great ar-
teries, phrenic nerves, main bronchi, and other structures in the root of the lungs.
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heart
The left atrium and left ventricle receive their major arterial supply from
which artery?
anterior interventricular branch of the left coronary artery
circumflex branch of the left coronary artery
marginal branch of the ri ght coronary artery
posterior i nterventri cular branch of the right coronary artery
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circumfl ex branch of the left coronary artery
The arterial blood supply of the heart is provided by the ri ght and left coronary arter-
ies, which ari se from the ascending aorta immediately above the aort ic valve. The coro-
nary arteries and their major branches are distributed over the surface of the heart,
lying within subepicardial connective t issue.
The ri ght coronary artery arises from the anterior aortic sinus of the ascending aorta
and runs forward between the pulmonary trunk and the right auri cle. This artery gives
rise to an important branch immediately after leaving the ascending aorta. This is the
anterior right atrial branch, which gives ri se to the important sinoatrial nodal ar-
tery. This artery supplies the SA node or pacemaker of the heart. The right coronary ar-
tery continues in the coronary sulcus, giving off a marginal branch, which suppl ies
the right ventricle. Finally, the ri ght coronary artery gives rise to the posterior inter-
ventricular branch (posterior descendi ng artery), which suppli es both ventricles, and
then anastomoses with the circumflex artery from the left coronary artery.
The left coronary artery, which is usually larger than the ri ght coronary artery, ari ses
f rom the left posterior aortic sinus oft he ascending aorta and passes forward between
the pulmonary t runk and the left auricle. It suppl ies the major part of the heart, in-
cluding the greater part of the left atrium, left ventricle, and ventricular septum. lt then
enters the atri oventri cular groove and divides into an anterior interventricular
branch (descending branch) and a circumflex branch.
Important: (1) Coronary arteri es receive the majori ty of their blood f low during ven-
tricular relaxation, or diastole, when the left ventricle is filling with blood (2) The an-
terior interventricular artery is the one most often involved in coronary occlusions
and is often the one that is bypassed in bypass cardiac surgery.
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Ascending tract
Site of SA Node
Right coronary
artery (RCA) Within
coronary sulcus
Atrioventricular
(AV) nodal branch
of RCA
Right marginal
branch of RCA
(A) Anterior view
Left pulmonary artery
Left coronary
artery (LCA)
Anterior
interventricular
branch of LCA
(B) Posterolnferior view
Arch of aorta
A ...-"'!k---,,_)111 terior Interventricular
branch of LCA
Posterior interventricular
branch within posterior
interventricular groove
ch of aorta
Coronary arteries. A.B. In the
most common pattern of distri-
bution, the RCA anastomoses
with the circumflex br.lnch of
Superior vena the LCA (anastomoses are not
cava (SVC) shown) after the RCA has
Sinuatrial (SA) . . . .
nodal branch g1ven nse to the postenor m-
o_f _RCA tcrventricular (IV) artery.
.,,--,--Fiight pumonary
veins
Rcprodutcd wuh &om
Moon- KL A Aaw- AMR;
Clmica/ Ot'ttmed Anotonn, 6; Sal
tunorc, 1010. Lipptnoon William!' &
WiUans.
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Circumflex branch of LCA
Ant eri or
Anteri or
Septal branches
Left coronary artery
AV nodal artery
......_Apex of heart
Arteries of the interventri cular septum (IVS) are shown. The RCA branch to the AV node
is the first of many septal branches of the posterior IV artery. The septal branches of the ante-
rior interventricular branch of the LCA supply the anterior two thirds of the IVS. Because the
AV bundle and bundle branches are centrally placed in and on the IVS, the LCA typically pro-
vides the most blood to this conducti ng tissue.
16SA I
Reproduced wath pcmtission !rom Moore Kl. Oall cy AF, Ag.ur AMR: Clinical Oriented ed 6: Baltmtorc. 2010.lippincou Wi ll inms
& Walki ns.
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heart
Which ofthe following does NOT empty directly into the right atrium?
azygous vein
inferior vena cava
superior vena cava
coronary sinus
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azygous vein
The coronary sinus lies in the posterior part of the coronary sulcus (atrioventricular
groove) and opens in the right atrium between the opening of the inferi or vena cava
and the right atrioventricular orifice, its opening being guarded by a semil unar valve
(Thebesian valve).
The superior vena cava opens into the upper part of the right atrium. The superior
vena cava returns the blood from the upper half of the body.
The inferior vena cava (larger than the superior vena cava) opens into the lower part
of the right atrium. The inferior vena cava returns the blood from the lower half of the
body.
Flow of the blood through the heart:
1. Entering the right atrium are the coronary sinus and the superi or and inferior
venae cavae carrying deoxygenated blood from the systemic circuit.
2. Upon contraction of the right atrium, blood passes through the ri ght AV valve
to the right ventricle.
3. Upon contraction of the right ventricle, blood leaves to pass to the right and
left lungs via the pulmonary arteries.
4. Blood gases are exchanged in the lung, and oxygenated blood returns via
pulmonary veins to the left atrium.
5. Upon contraction of the left atrium, blood passes through the left AV valve to
the left ventricle.
6. Upon contraction of the left ventricle, oxygenated blood passes through the
aortic valve to the systemic circuit via the aorta and its branches.
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heart
A patient with a "heart-valve problem" comes into the dental clinic for
periodontal therapy. She says that her old periodontist always gave her
antibiotics before treatment, and insisting that the dentist hear the problem,
she places the stethoscope in the left fifth intercostal space medial to the nip-
ple line. Which heart valve is best heard over the apex of the heart?
t ri cuspid valve
mitral valve
pulmonary valve
aortic valve
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mitral val ve (bicuspid val ve)
The four val ves of the heart are designed to allow one-way flow only of blood. Their function
is to prevent backflow into the releasing chamber.
The four heart val ves work in pairs in tandem:
During ventricular systole, the ventricles of the heart contract, and the pulmonary and
aortic val ves open to allow blood to be pumped into t he pulmonary and general circula-
tory systems, respectively, while the mitral and tricuspid valves remain closed.
During ventricular diastole, the aortic and pulmonary valves close, while the atrioventric-
ular valves (the mi tral and tricuspid valves) open to allow blood to pass from the atria to the
ventricl es.
1. The atrioventricular val ves - the mi tral and t ricuspid valves- separate the atrium
and ventricle on t he left and right sides of the heart respectively.
2. The aortic and pulmonary valves are said to be semilunar valves, because each
consists of three hal f-moon-shaped valve cusps that are attached to t he inside wall of
the aortic and pulmonary arteries.
3. The apex of the heart lies in the left fi fth intercostal space medial to the nipple line,
about 9 em from the midline. This location is useful for determining t he left border of
the heart and for auscultation of the mitral (bicuspid) valve.
4. The tricuspid val ve is best heard over the right half of the lower end of the body
of the sternum.
5. The pulmonary val ve is best heard over the second left intercostal space.
6. The aortic val ve is best heard over the second right intercostal space.
Htarl sound Produttd by:
Fir..l (SI) l o s u r ~ of AV valves (mitral and tri cuspid)
Second (S2) Closure of semilunar valves (aortic and pulmonary)
Third (S3) Rapid ventri cular filling
fourth (S4} Atri al contradion
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pulmonary valve
chordae tendineae
167-1
Heart Valves - Ventricular diastole
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pulmonary valve
mitral valve
167 A l
Heart Valves - Ventricular systole
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heart
A 1 0-year-old girl comes into the physician suffering from rheumatic fever.
She is presenting with aortic valve stenosis, which is causing her dizziness
and syncopal episodes. In the healthy heart, after ventricular systole, the aor-
tic valve:
prevents reflux of blood into the right ventricle
prevents reflux of blood into the right atrium
prevents reflux of blood into the left atrium
prevents reflux of blood into the left ventricle
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prevents reflux of blood into the left ventricle
There are four valves that keep blood flowing in one direction through the heart:
The right and left atrioventricular valves -separate the atrium and ventricle on t he left
and right sides of the heart, respectively.
- Tricuspid valve or right AV valve- guards t he right atrioventricular orifice; consists of
three cusps. This valve controls the flow of blood through the right AV opening.
Note: Thin but strong fibrous cords of the chordae tendineae attach the cusps of t his
valve to t he papillary muscles of t he right ventricl e.
-The mitral valve or left AV valve -guards the left atrioventricular orifice; consists of two
cusps. Chordae tendineae attach t hese cusps to papillary muscles of the left ventricle.
Important: Overdistension of the valves of the atrioventricular orifices of the heart is prevent-
ed by t he papillary muscles and the trabeculae carneae (muscle ridges and bulges lining the
right ventricle of the heart).
The semilunar valves:
- Pulmonary valve - guards the pulmonary orifice (between the right ventricle and the
pulmonary artery); consists of three semilunar cusps.
- Aortic valve - guards the aortic orifice; consists of three semilunar cusps. Note: When
this valve is closed it prevents backflow of blood into the left ventricle.
*** Important: There are no chordae tendineae or papillary muscles associated with these
valve cusps. Papillary muscles are found only in the ventricles of the heart.
Major Jones Criteria for Diagnosing Rheumatic Fever:
Migratory polyarthritis: a temporary migrating inflammation of the large j oints
Carditis: inflammation of heart muscle (myocardi tis) and may affect endocardium and peri-
cardium too
Subcutaneous nodules: containing Aschoff bodies
Sydenham chorea: involuntary rapid movements ofthe extremities
Erythema marginatum: a long standing reddi sh rash distributes in a"bathing suit" pattern
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heart
Which of the following structures prevent the AV valves from everting (or
being blown out) back into the atria during ventricular contraction?
crista terminal is and papillary muscles
chordae tendineae and papil lary muscles
pectinate muscles and papillary muscles
chordae tendineae and pectinate muscles
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chordae tendineae and papillary muscles
Remember: Papillary muscles are cone-shaped muscles that terminate in the
tendinous cords (chordae tendineae) that attach to the cusps of the atri oventri cular
valves (tricuspid and mitral valve). Papil lary muscles are found only in the ventricles
of the heart. The papillary muscles do not help the valves to close. Instead, these
muscles prevent the cusps from being everted (or being blown out) back into the
atri um during ventricular contraction. Mitral valve prolapse is a prevalent heart
condition and dysfunction of these papillary muscles. It can predispose a patient to
infective endocarditis.
The pectinate muscles are prominent ridges of atrial myocardium located on the
inner surfaces of much of the right atrium and of both auricles (which are small
conical pouches projecting from the upper anterior portion of each atrium).
The crista terminal is is a vertical muscular ridge that runs along the right atrial wall
from the opening of the superior vena cava to the inferi or vena cava. The crista
terminal is provides the origin for the pectinate muscles.
Note: The crista terminalis represents the junction between the sinus venosus and
the heart in the developing embryo. It is represented on the external surface of the
heart by a vertical groove cal led the sulcus terminalis.
Important: The SA node is located in the right atrium at the junction of the crista
terminalis near the opening of the superior vena cava.
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The diaphragmatic surface ofthe heart is formed by:
right atrium and right ventri cle
right atrium and both ventri cles
left ventricle only
right ventricle only
both ventricles
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both ventricles
The adult heart is a hollow, four-chambered muscular organ that is about the size of a
closed fist. About two-thirds of the heart's mass is to the left of the body midline. The heart
and its pericardium make up t he content s of the middle mediasti num. The pericardium is
a tough double-walled fi brous membranous sac t hat surrounds the heart. The outer wall
of the sac is called the parietal pericardium; the inner wall of the sac is called the vi sceral
pericardium (epicardium). The parietal and visceral pericardia are continuous. This conti-
nuity takes place at the points where t he maj or blood vessels enter and leave the heart. In
between t hese wall s is the pericardia! cavity, which contains serous fluid t hat minimizes
friction as the heart beats.
The anterior surface of the heart is also known as the sternocostal surface. The anterior
surface shows part s of each of the four chambers of the heart:
Right atrium (RA) } are small and located toward t he superior region of the heart
Left atrium (LA) and are separated by the thin, muscular interatrial sept um.
Right ventricl e (RV) } are larger and are located at the apex of the heart and are
Left ventricle (LV) separated by the thick, muscular interventricular septum.
Three borders of the heart:
Right border: made up of the right atrium
Inferior border: made up of right atrium, right ventricle, and left ventricle
Left border: made up of the left vent ricle
The left and right ventricles make up the diaphragmatic surface of the heart. This part
rests on the fibrous part of the diaphragm.
The left atrium makes up the so-called base of the heart. When the body is in the supine
position (lying on its back), the heart rests on its base, and the apex of the heart (the t ip of
the left ventricle) projects up and to the left and fits into a depression on the diaphragm.
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endocrine system
The pituitary gland is composed of two distinct tissue types. These tissue
types have their embryonic origin in what layer(s)?
ectoderm
mesoderm
endoderm
ectoderm and mesoderm
ectoderm and endoderm
all of the above
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ectoderm
The pituitary gland (also called the hypophysis) is no larger than a pea (weighs only
0.5 gram), and rests in the sella turcica, a depression in the sphenoidal bone at the
base of the brain. The pituitary connects with the hypothalamus via the
infundibulum, through which this gland receives chemical and neural stimuli.
The pituitary gland is often referred to as the "master endocrine gland" because it
controls so many other glands. It does this through the action of tropic hormones -
hormones that affect the activity of another endocrine gland. For this reason, the
pituitary gland is essential for life.
The pituitary develops from two different sources: an upgrowth from the ectoderm
of the stomodeum and a downgrowth from the neuroectoderm of the
diencephalon, in other words, an upgrowth from the roof of the mouth and a
down growth from the floor of the brain.
This double origin explains why the pituitary gland is composed of two completely
different types oftissue. The adenohypophysis (glandular portion) arises from the oral
ectoderm, and the neurohypophysis (nervous portion) origi nates from the
neuroectoderm.
During the developmental stage (about the third week), a diverticulum call ed
Rathke's pouch ari ses from the roof of the stomodeum (primitive mouth) and grows
toward the brain. As this pouch approaches the developing neurohypophysis
(posterior lobe), its attachment with the mouth is lost. The pouch then goes on to
form the portion of the pituitary gland known as the adenohypophysis {ant erior
lobe).
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The Pituitary Gland
7 ~
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HUMAN BRAIN -SIDE VIEW
Corpus
Callosum
171 A l
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endocrine system
Diabetes insipidus is characterized by the secretion of large amounts of
dilute urine because of a deficiency in antidiuretic hormone. Antidiuretic
hormone is secreted from the:
anterior pituitary
posterior pituitary
adrenal medull a
adrenal cortex
thyroid
kidney
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posterior pituitary
The pituitary has two main regions. The larger region, the anterior pituitary (adenohy-
pophysis), produces at least six hormones:
Mnemonic- GPA 8-FLAT - yH, f,rolactin f rom Acidophil s. ESH, J.H, ACTH, I SH.
1. Growth hormone (GH)- promotes growth in general, particularly the skeletal system.
2. Corticotropin (ACTH)- controls the secretion of adrenocortical hormones, which in
turn affect the metabolism of glucose, proteins, and fat.
3. Thyroid-stimulating hormone (TSH) - controls the secretion of thyroxine by the thy-
roid gland.
4. Prolactin- promotes mammary gland development and milk production.
5. Follicle-stimulating hormones (FSH) - stimulates growth of Graafian follicles in the
ovary and promotes spermatogenesis in the male.
6. Luteinizing hormone (LH)- stimulates secretion of sex hormones by the ovary and
testis.
The posterior pituitary, which makes up about 25% of the gland, serves as a storage area
for:
1. ADH (antidiuretic hormone or vasopressin)- controls the rate of water reabsorpt ion in
the kidneys.
2. Oxytocin - has a number of functions, many of which are associated with labor and de-
livery and nursing mothers. During labor, oxytocin facilitates rapid and efficient deliv-
ery, and after birth, the hormone promotes milk production in nursing mothers.
Note: ADH and oxytocin are produced in the hypothalamus and transported in axons to
the posterior lobe of the hypophysis for storage and secretion.
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Hypothalamus:
ADH
Kidney
OT
Mammary
glands
17N
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endocrine system
A SO-year-old female was diagnosed with anaplastic thyroid cancer and
underwent aggressive surgery to remove most of the thyroid. Unfortunately,
the surgeon also excised the parathyroid glands. Which oft he following could
result from the excision of the parathyroid glands?
strengthening of muscles
weakening of bones
muscle convulsions
decalcification of bones
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muscle convulsions
***A deficiency of PTH can lead to tetany, muscle weakness due to a lack of available calcium
in t he blood.
The body's smallest known endocrine glands, the parathyroid glands are small, pea-like organs
embedded beneath the posterior surface of the thyroid gland. Most people have four of them.
Working together as a single gland, the parathyroid glands produce parathyroid hormone.
Parathyroid hormone is the most important regulator of calcium and phosphorus concentration
in extracellular fluid. It finds its maj or target cells in bone and kidney. These glands are essen-
tial for life.
Each parathyroid gland has a fibrous tissue capsule and two types of cells:
Chief cells - produce parathyroid hormone, which acts to raise the concentration of cal-
cium in t he blood and reduce the concentration of phosphate ions
Oxyphil cells - function is undetermined
They receive innervation from t he postganglionic sympathetic fibers of the superior cervical
ganglion. The superior pair receives its blood supply from the superior thyroid artery (from ex-
t ernal carotid) and the inferior pair from the inferior thyroid artery (from thyrocervical trunk).
Note: The thyrocervical trunk is short and thick and arises from the first portion of the sub-
clavian artery close to the medial border of the scalenus anterior. This trunk divides almost im-
mediately into the following three branches: inferior thyroid, suprascapular, and transverse
cervical (or superficial cervical) arteries.
5 - ~ i ' l 1. These glands develop from the third and fourth pharyngeal pouches.
' 2. The tiny pineal gland lies at the back of the third ventricle of t he brain. This
gland produces the hormone melatonin. This hormone is thought to play a number
of roles in humans, including the regulation of t he sleep-wake cycle, body
temperature regulation, and appeti te.
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Pharyngeal
muscles
Esopllagus
Parathyroid Glands
Thyroid
17].1
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endocrine system
The innervation to the parotid gland and its sheath comes from all of the fol-
lowing nerves EXCEPT one. Which one is the EXCEPTION?
auriculotemporal nerve
great auricular nerve
facial nerve
glossopharyngeal nerve
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facial nerve
The parotid gland is the largest of the salivary glands and is a purely serous gland. It is
situated below the external auditory meatus and lies in a deep hollow behind the
ramus of the mandible and in front of the sternocleidomastoid. This gland is divided into
deep and superficial lobes (which enclose the facial nerve). Therefore, a porti on of the
parotid lies superficial to the mandibular ramus, and another portion lies deep.
The parotid gland is drained by Stensen's duct, which crosses the masseter muscle and
pierces the buccinator muscle to open into the vestibule of the mouth opposite the
maxillary second molar.
The parotid sheath and overlying skin are innervated by the auriculotemporal nerve
(branch of V3) and the great auricular nerve (C2, C3 f rom cervical plexus).
Parasympathetic secretomotor fibers from the inferior salivatory nucleus of the
glossopharyngeal nerve supply the parotid gland. The nerve fibers pass to the otic
ganglion via t he tympanic branch of the glossopharyngeal nerve and the lesser petrosal
nerve. Postganglionic parasympathetic f ibers reach the parotid gland via the
auricul otemporal nerve (branch V-3), which lies in contact with t he deep surface of the
gland. Sympathetic innervati on originates from the external carotid nerve plexus.
Note: Although the termi nal branches of the facial nerve (CN VII) pass through t he gland,
they do not participate in its innervation.
The external carotid artery and its terminal branches within the gland, namely the
superficial temporal and the maxillary arteries, supply the parotid gland. The lymphatic
vessels drain into the parotid lymph nodes and the deep cervical lymph nodes.
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Submandibular gland
Accessory
Parotid parotid Masseter
Facial
vein
g
Salivary Glands- Lateral view
Internal jugular vein
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endocrine system
The part of a developing salivary gland destined to become responsible for
its functioning is called the:
nephron
folli cle
adenomere
lobule
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adenomere - it is the functional unit in salivary glands
Exocrine glands are struct urally and functionally subdivided by septa, plate-like invagina-
tions of their connective tissue capsules. This arrangement appli es mainly to the pancreas
and salivary glands.
1. Lobes are the largest of the subunits and are separated by connective t issue septa.
2. Lobules are subunits of the lobes and are separated by thin extensions of the septa.
3. Adenomeres are secretory subunits of lobul es. Adenomeres consist of all the secre-
tory cells that release their products into a single intralobular duct.
4. Acini (or alveoli) are smaller secretory subunits. Each acinus is a spheric coll ection of
secretory cells surrounding the bli nd-ended termination of a single intercalated duct.
An adenomere is composed of:
Intercalated ducts - are lined by low cuboidal cell s found in intercalated duct s
Striated ducts- contain a lot of mitochondria responsible for electrolyte and water
transport during secretion. Simple, low columnar epithelium line these ducts.
Glandular cells- synt hesize glycoproteins
The salivary glands are divided into 2 groups:
Major
1. Parotid gland - purely serous gland
2. Submandibular (submaxillary) gland - mixed serous and mucous gland with
serous predominating
3. Sublingual gland- mixed serous and mucous gland with mucous predominating
Minor are located on the:
1. Lips
2. Cheek
3. Tongue- von Ebner's glands are associated with circumvallate papill a. They are
purely serous.
4. Hard palate
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The Salivary Glands
Parotid duct
---- Sublingual gland - - ...,.
\_
Submandibular u c t ~
Submandibular gland _/
I Parotid gland
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endocrine system
A death-row inmate who was notorious for aggressive and hyperactive
behavior is complaining of abdominal pain. Hospital tests reveal bilateral
tumors that are secreting excessive catecholamines. Which of the following
glands is involved?
anterior pituitary
pancreatic islets (Langerhans)
adrenal medull a
parathyroids
adrenal cortex
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adrenal medulla
Stimulation of the adrenal medulla causes the release of large quantities of epinephrine and
norepinephrine. The same effects are also caused by direct sympathetic stimulation, except
the effects last longer when the medulla secretes the hormones. With or without one or t he
other (medulla or sympathetic nerves), the organs would still be stimulated. In other words, the
medulla functions in a manner similar to postganglionic sympathetic cells.
The two adrenal glands (also called suprarenal glands) are flattened, somewhat triangular-
shaped endocrine glands resting upon t he superior poles of each kidney at t he back of the ab-
domen. Each gland has an outer part, t he cortex, and a core, the medulla.
The adrenal cortex produces t hree main types of hormones:
Glucocorticoids: whi ch are produced and released under t he control of adrenocorti-
cotrophic hormone (ACTH) from the pitui tary, influences t he metabolism of fat, protein, and
carbohydrates, promoting the breakdown of protein and the release of fat and sugars into the
bloodstream
Mineralocorticoids: enhance sodium reabsorption in the collecting duct of the kidneys
Sex steroids
The adrenal medulla contains many modified nerve cells, which produce and release about
80% epinephrine (adrenaline) and 20% norepinephrine (noradrenaline). These hormones are
released in bursts during emergency situations or accompanying intense emotion. They act to
increase the strength and rate of heart contractions, raise the blood sugar level, elevate t he
blood pressure, and increase breathing.
Important: The adrenal medulla develops from neuroectoderm, while the adrenal cortex de-
velops from mesoderm.
Note: Neuroectoderm is a specialized group of cell s that differentiate from the ectoderm.
Neural crest cell s are a specialized group of cells developed from neuroectoderm that
migrate from the crests of the neural folds and disperse to specific sites within the mesenchyme.
They also influence a special type of mesenchyme, t he ectomesenchyme, to form dental tissues.
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Adrenal
gland
Kidney (left)
Adrenal Gland - Coronal view of left adrenal gland
176-1
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The Adrenal Gland
Adrenal cortex:
Zona glomerulosa
Zona fasciculata
Zona reticularis
176A-1
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endocrine system
The portion of the pituitary gland that does NOT arise from the hypothala-
mus is the:
neurohypophysis
pars nervosa
adenohypophysis
infundibulum
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adenohypophysis
Remember: The posterior lobe (i.e., neurohypophysis, pars nervosa), the
infundibulum and the pituitary stalk all arise from the hypothalamus. The
neurohypophysis contains axons from the neurosecretory cel ls of the hypothalamus.
The anterior lobe (adenohypophysis) is formed from an i nvagi nation of the
pharyngeal epithelium (Rathke's pouch)- thus, the epithelial nature of its cells.
Important:
1. The anterior pituitary or adenohypophysis is a classical gland composed pre-
dominantly of cells that secrete protein hormones.
2. The posterior pituitary or neurohypophysis is not really an endocri ne gland;
rather, it is largely a collection of axonal projections from the hypothalamus t hat ter-
minate behind the anterior pituitary gland. It also forms the so-call ed pituitary stalk,
which appears to suspend the anterior gland from the hypothalamus.
The tropic hormones (FSH, LH, ACTH, and TSH) are hormones that affect the activity
of another endocrine gland. Releasing or inhi biting hormones produced by the
hypothalamus control t hese hormones of the anteri or pituitary. Prolactin and
growth hormone (GH) are also made in the anterior pituitary. These two hormones
are not considered to be tropic hormones.
Secretory cell s of the anterior pituitary are categorized into two groups, according to
their staining properties.
Acidophils (acidic stain): secrete GH, and prolactin
Basophils (basic stain): secrete TSH, FSH, LH, and ACTH
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endocrine system
Exocrine glands include all of the following EXCEPT one. Which one is the
EXCEPTION?
sweat glands
the prostate gland
bile-producing glands of the l iver
the pituitary gland
lacri mal glands
gastric glands
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the pituitary gland
Exocrine glands are glands whose secretions pass into a system of ducts that lead ulti mately
to the exterior of the body. So the inner surface of the glands and the ducts that drain them
are topologically continuous with the exterior of the body (the skin}. Endocrine glands, in
contrast, secrete their products, hormones, directly into the blood rather than through a duct.
Classification of exocrine glands:
Type of secretion
1. Mucous (secrete mucus= water + mucin}- buccal glands, glands of the esophagus,
cardiac and pyloric glands of the stomach
2. Serous (enzymes}- parotid gland, von Ebner glands, pancreas and uterine glands
3. Mixed (mucous and serous}- submandibular and sublingual salivary glands, glands
of the nasal cavity, para nasal sinuses, nasopharynx, larynx, trachea, and bronchi
Mode of secretion
1. Merocrine - only cell secretory product released from membrane bound secretory
granules- pancreatic acinar cells
2. Apocrine- secretion of product plus small portion of cytoplasm- fat droplet secretion
by mammary glands
3. Holocrine- entire cell with secretory product- sebaceous glands of skin and nose
Structure of duct system
1. Unbranched -"simple" glands- sweat glands
2. Branched - "compound" glands- pancreas
Shape of secretory unit
1. Tubular - cylindrical lumen surrounded by secretory cells- sweat glands
2. Acinar (alveolar}- dilated sac-like secretory unit- sebaceous and mammary glands
3.Tubuloacinar (tubuloalveolar} - intermediate in shape or having both tubular and
alveolar secretory units- major salivary glands
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Cllmti((A/
sard.illtd
Skinswfou
Exocrine gland

sttrd<dintubl.,J
Endocrine gland
178-1
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endocrine system
A young girl presents to the physician with a large, round face, a "buffalo
hump:' and central obesity. She also has a history of hypertension and
insulin resistance as a result of increased cortisol. Which anterior pituitary
hormone controls the production and secretion of cortisol?
follicle-stimulating hormone (FSH)
luteinizing hormone (LH)
adrenocorticotropic hormone (ACTH)
thyroid-stimulating hormone (TSH)
corticotropin-releasing hormone (CRH)
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adrenocorticotropic hormone (ACTH) - also called corticotropin
Adrenocorticotropic hormone, as its name implies, stimulates the adrenal cortex.
More specifically, this hormone stimulates secretion of glucocorticoids such as
cortisol, and has li ttle control over secretion of aldosterone, the other major steroid
hormone from the adrenal cortex.
ACTH is secreted from the anteri or pi tuitary in response to corticotropin-releasing
hormone (CRH) from the hypothalamus. Corticotropin-releasing hormone is secreted
in response to many types of stress, whi ch makes sense in view of the "stress manage-
ment" functions of glucocorticoids. Corticotropin-releasing hormone itself is inhibited
by glucocorticoids making it part of a classical negative feedback loop.
Follicle-stimulating hormone (FSH):
In females, FSH initiates ovari an follicl e development and secretion of estrogens
in t he ovaries
In males, FSH stimulates sperm production in the testes (spermatogenesis)
Luteinizing hormone (LH):
In females, LH stimulates secretion of estrogen by ovarian cells to result in ovula-
tion and stimulates formation of t he corpus luteum and secretion of progesterone
In males, LH stimulates the interstitial cells of Ieydig in the testes to secrete
testosterone
Thyroid-stimulating hormone (TSH) regulates t hyroid gland activities, uptake of
iodine, and synthesis and release of thyroid hormones.
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Hypothalamus
Gonad
. J ..
. . .
. . .
...
..
179 1
The hypothalamic pituitary axes
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endocrine system
A pancreatic cancer patient has a tumor that presses on the ampulla of Vater.
This has been causing him Gl problems because the tumor obstructs the
common bile duct and the main excretory duct of the pancreas which is
known as:
wharton's duct
the duct of Wirsung
bartholin's duct
wolffian duct
Stenson's duct
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the duct of Wirsung
The pancreas is a retroperitoneal organ located post erior t o t he stomach on t he posterior abdomi nal
wall. The pancreas's large head is framed by t he ( -shaped loop of the duodenum, while the t ail touches
the spl een. The pancreas plays a role in bot h t he digestive and endocri ne systems. The pancreas i s covered
i n a t issue capsule that partit ions t he gland into lobules.
Endocri ne portion (islets of Langerhans - endocrine cell s of pancreas):
Alpha cells- secrete glucagon, which counters the act i on of i nsulin
Beta cells - secrete insulin, which hel ps carbohydrate metabol ism
Delta cells- secrete somatostatin, which acts locally wi thi n t he i sl ets of langerhans themsel ves to
depress the secret ion of bot h insulin and gl ucagon
Important: The degeneration of the i sl et s of Langerhans l eads to diabetes mellitus.
Exocrine portion:
Acinar cells (pancreatic exocri ne cells) - t hese cells are fi lled with secretory granules containing the
digestive enzymes (mai nly trypsi n, chymotrypsin, pancreatic l ipase, and amylase) t hat are secreted
i nto the l umen of t he acinus.
Remember: Pancreat ic secret ions contai n bicarbonate ions and are alkaline i n order to neutralize the acidic
chyme t hat the stomach churns out. Bicarbonat e secretions are sti mul at ed by secret ion produced i n t he
duodenum.
The endocrine function of the pancreas i s concerned with both foodstuff rel ease duri ng f asti ng and food-
stuff storage aft er meal s. The two pancreatic hormones responsible for t hese funct ions are glucagon and
insulin, respectively. These t wo hormones are produced i n special cell t ypes within many t i ny spherical
clumps of pancreatic t i ssue, which are known as the pancreatic i slets or t he islets of Langerhans. Wi thi n
t he i slets of Langerhans, the alpha cells secrete glucagon, which elevat es blood sugar; beta cells secrete
insulin, whi ch affects t he metabol ism of f ats, protei ns, and carbohydrates; and delta cells secrete so-
matostatin, whi ch can i nhibit t he release of both glucagon and i nsul in.
Two ducts t hat may be associated wi th the pancreas:
1. The main pancreatic duct (duct of Wi rsung) - begi ns at t he tai l and j oins the common bil e duct t o
form the hepatopancreati c ampulla (ampulla of Vater) before opening into the duodenum. This ampulla
discharges bil e and pancreatic enzymes i nto t he descending porti on (second part) of t he duodenum.
2. The accessory pancreatic duct (Santori ni's duct) - when present opens separately into the duodenum.
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endocrine system
On a patient's panoramic radiograph, the dentist notices a small, well-defined
radiolucency that sits inferior to the mandibular canal. The dentist performs a
sialogram that rules out a true cyst and makes the working diagnosis a static bone
cavity (Stafne bone cyst). Which of the following salivary glands creates the
depression in bone that radiographically gives the above appearance?
sublingual gland
von Ebner's glands
submaxillary gland
parotid gland
[refer to card 174-1, 175-1 for illustration]
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submaxillary gland
The submandibular gland weighs half the weight of the parotid. This gland is often referred to as the
submaxillary gland. This gland lies in the submandibular triangle formed by the anterior and
posterior bellies of the digastric muscle and the inferior margin of the mandible. The gland is
positioned medial and inferior to the mandibular ramus partly superior and partly inferior to the
base of the posterior half of the mandible. The gland forms a u shape around the posterior border
of the mylohyoid muscle, which divides the submandibular gland into a superf icial and deep lobe.
The deep lobe comprises the majority of the gland. The glandular elements are a mixt ure of serous
(mostly) and mucous acini with some serous demilunes. As is the case with the parotid gland, the
submandibular gland is invested in its own capsule, which is also continuous with the superficial
layer of deep cervical fascia. Important: The marginal mandibular branch of the facial nerve
courses superficial to the submandibular gland and deep to the platysma.
The submandibular duct (Wharton's duct) arises from the deep portion of the gland and crosses
the lingual nerve in the region of the sublingual gland to terminate on the sublingual caruncle
(papilla) adjacent to the base of the sublingual frenulum. When the sublingual duct (Bart holin's
duct) is present, it usually terminates on or near the sublingual caruncle also. Important: The
lingual nerve wraps around Wharton's duct, starting lateral and ending medial to the duct, while
CN XII (the hypoglossal nerve) parallels the submandibular duct, running j ust inferior to it.
Blood supply: The blood supply is from the facial and lingual arteries. The facial artery forms a
groove in the deep part of the gland, and then curves up around the inferior margin of the mandible
to supply the face. The veins drain into the facial and lingual veins. The lymph vessels drain into the
submandibular and deep cervical lymph nodes.
Innervation: Parasympathetic secretomotor fibers from the superior salivatory nucleus of the
facial nerve. The nerve fibers pass to the submandibular ganglion via the chorda tympani nerve
and the lingual nerve. Postganglionic parasympathetic fibers pass to the gland via the lingual
nerve. Postganglionic sympathetic fibers reach the gland as a plexus of nerves around the facial
and lingual arteries.
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endocrine system
The thymus is a prominent feature of the middle mediastinum during infancy
and childhood.
The thymus is the central control organ for the immune system.
both statements are t rue
both statements are false
the first statement is t rue, the second is false
the f irst statement is false, the second is t rue
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the f irst statement is fal se, the second is true
The thymus is a prominent feature of the superior mediastinum during infancy and
childhood. The thymus plays an important role in the development and maintenance of
the immune system. As puberty is reached, the thymus begins to diminish in relative size.
By adulthood, it is usually replaced by adipose tissue and is often scarcely recognizable;
however, it continues to produce T lymphocytes.
Whil e the thymus is part of the endocrine system, the thymus's primary functi on is that of
a lymph organ. The thymus is the central control organ for the immune system.
Lymphocytes originate from hemocytoblasts (stem cell s) in red bone marrow. Those that
enter the thymus mature and develop into activated T lymphocytes (i.e., able to respond
to antigens encountered elsewhere in the body). They then divide into two groups:
Those that re-enter the blood; these are t ransported to developing secondary
lymphoid ti ssues, such as lymph nodes and spleen
Those that remain in t he thymus gland and are the source of f uture generations of T
lymphocytes
Many nutrients function as important cofactors in the manufacture, secretion, and
function of thymi c hormones. Zinc, vitamin B& and vitami n Care perhaps the most critical.
Zinc is perhaps the most critical mineral involved in thymus gland function and t hymus
hormone action. Zinc is involved in virtually every aspect of immunity.
1. The thymus has no afferent lymphati cs or lymphatic nodules.
2. Other lymphoid organs originate exclusively from mesenchyme, whereas
the thymus has a double embryologic origin. The lymphocytes are derived
f rom hematopoietic stem cel ls (mesenchyme), while Hassall's corpuscles
(epithelium) are derived from endoderm of t he t hird pharyngeal pouch.
3. The arteries supplying the thymus are derived f rom the internal mammary,
superior thyroid, and inferior t hyroid arteries. It is innervated by t he vagus
nerve.
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endocrine system
Mature lymphocytes constantly travel through the blood to the lymphoid or-
gans and then back to the blood. This constant recirculation insures that the
body is continuously monitored for invading substances. The major areas of
antigen contact and lymphocyte activation are the secondary lymphoid or-
gans. These include all of the following EXCEPT one. Which one is the EXCEP-
TION?
spleen
lymph nodes
thymus gland
tonsils
mucosal associated lymphoid tissue (MALT)
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thymus gland
The thymus gland is a primary lymphoid organ (along with the bone marrow) that
consist s of two lobes surrounded by a thin layer of connective t issue. The thymus gland is
located deep to the sternum in the superior mediastinum. This gland consists of an
outer cortex that is primarily lymphocytes. The inner medulla also contains lymphocytes
and Hassall's corpuscles. These corpuscles are thought to be vestiges of epithelium; their
function is unknown.
Important: This organ appears to be t he master organ in immunogenesis in the young
and is believed by some (but not all) to monitor the total lymphoid system throughout
life.
Remember: The primary function of the thymus is the processing and maturation of spe-
ciallymphocytes (white blood cells) called T lymphocytes orT cell s, which play a central
role in cell-mediated immunity. T lymphocytes migrate from the bone marrow to the thy-
mus, where they mature and differentiate until activated. While in the thymus, the lym-
phocytes do not respond to pathogens and foreign agents. After the lymphocytes have
matured, they enter the blood and go to other lymphatic organs, where the lymphocytes
help provide defense against disease. The thymus also produces a hormone, thymosin,
which stimulates t he maturation of lymphocytes in ot her lymphatic organs.
1. The thymus gland also produces thymic lymphopoietic factor (TLF), which
confers immunological competence on t hymus-dependent cell s and induces
lymphopoiesis.
2. Defects in chromosome 22 (cause of most cases of DiGeorge syndrome) may
cause a baby's thymus gland to be smaller than normal (hypoplastic). In some
cases, children wit h DiGeorge syndrome don't have a thymus gland at all.
3. MALT ranges from loose clusters of lymphoid cell s in the intestinal lamina propria,
to more complex organizations as in the Peyer's Patches, tonsils, and appendix.
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Right common
carotid artery
Right
subclavian
artery
Internal
Internal thoracic
thoracic artery
Inferior vein
thyroid
vein
Left common
carotid artery
Left
brachiocephalic
vein
183-1
Superior mediastinum - Superficial dissection
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The Endocrine System
Pineal gland Hypothalamus
Pituitary gland
U f------ Thyroid gland
Thymus
Testes
(male)
Ovaries
(female) '----- --
183
A I
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endocrine system
All of the following contain mucus-secreting cells EXCEPT one. Which one is
the EXCEPTION?
submandibular glands
subli ngual glands
parotid glands
glands of the esophagus
mucosa of the t rachea
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parotid glands- these glands are completely serous
Both the major and minor salivary glands are composed of both epithelium and connective tissue.
Epithelial cells both line the duct system and produce the saliva. Connect ive tissue surrounds the ep-
ithelium, protecting and supporting the gland. The connective tissue of the gland is divided into the
capsule, which surrounds the outer portion of the entire gland, and septa. Each septum helps divide
the inner portion of the gland into larger lobes and smaller lobules.
Epithelial cells that produce saliva are called secretory cells. The two types of secretory cells are clas-
sified as either mucous or serous cells. Secretory cells are found in a group, or acinus (plural, acini),
which resembles a cluster of grapes. Each acinus consists of a single layer of cuboidal cells, epi thelial
cells surrounding a lumen, a central opening where the saliva is deposited after being produced by
the secretory cells.
The three forms of acini are classified in terms of the type of epithelial cell present and the secretory
product being produced.
Serous Acini:
Composed of serous cells producing a serous secretory product; are generally spherical with
a narrow lumen
Serous cells contain large amounts of RER, free ri bosomes, a prominent Golgi complex, and
numerous protein-rich, membrane-bound vesicles called secretory granules. In cells that pro-
duce digestive enzymes, these vesicles are called zymogen granules
Mucous Acini:
Composed of mucous cells producing a mucous secretory product; are usually more tubu-
lar wi th a wider lumen
Most mucous cells contain large numbers of mucinogenic granules in their apical cytoplasm
Mixed Acini:
Have both mucous cells surrounding the lumen and a serous demilune or cap of serous
cells superficial to the group of mucous secretory cells
These caps, or serous demilunes, secrete into the highly convoluted intercellular space, be-
tween the mucous cells.*** They are associated with the mixed acini of the sublingual and
submandibular glands as well as the glands of the esophagus and trachea.
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Calcitonin is secreted by the:
thyroid gland
parathyroid gland
adrenal glands
thymus gland
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thyroid gland
The largest of the endocrine glands, the thyroid gland consists of two lobes, the right
and left, which are joined across by a thin band cal led the isthmus. The thyroid gland
is an "H"-shaped structure located anterior to the upper part of the trachea near its
junction with the larynx.
Thyroid epitheli al cells, the cel ls responsible for synthesis of thyroid hormone, are
arranged in spheres call ed thyroid follicles. These follicles are fill ed with colloid. Col-
loid is composed of thyroglobul in and iodine and is the storage form of the thyroid
hormones T3 and T 4.
Note: Thyroid hormone is composed of two different substances: thyroxine (also
call ed T4, or tetraiodothyronine) and triiodothyronine (T3). Thyroid hormone has
several functions, the main one being to determine the metabolic rate of body tis-
sues.
Important: The production of thyroid hormone is under the control of thyroid-stim-
ulating hormone (TSH), which is released from the pituitary gland. Overproduction
ofTSH can lead to Graves' disease.
In addition to thyroid epitheli al cell s, the thyroid gland houses one other important
endocrine cel l. Nestled in spaces between thyroid follicles are parafollicular or C cells,
which secrete the hormone calcitonin. Calcitonin acts to reduce blood calcium, op-
posing the effects of parathyroid hormone (PTH).
Note: The thyroglossal duct is a narrow canal that connects the thyroid gland to the
tongue during development. This duct disappears soon after development of the
gland. In the adult, the proximal end ofthe duct persists as the foramen cecum of the
tongue.
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Thyroid gland
Thyroid cartilage Anterior Posterior
Anterior Posterior
185 1
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endocrine system
Hospital tests on a patient identify a tumor in the hypophysis that is exces-
sively secreting growth hormone. Given that the patient is a 4-year-old male,
what is the expected outcome if no treatment is performed?
pituitary gigantism
acromegaly
pituitary dwarfism
achondroplasia
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pituitary giganti sm
The amount of growth hormone secreted by the anterior pituitary gland can have a
dramatic effect on bone development:
Pituitary gigantism - tumor prior to adolescence, excessive GH delays ossification of
epiphyseal cartilage (non-fusion of epiphyses)
Acromegaly- tumor after adolescence, excess GH secreted after epiphyseal cartilages
have been replaced by bone (fusion of epiphyses)
Pituitary dwarfism- GH deficiency resulting in early replacement of epiphyseal cart-
ilages by bone
Important point: The deciding factor in whether gigantism or acromegaly will occur when
there is over secretion of growth hormone by the pituitary gland is whet her the epiphyses
of the long bones have fused with the shaft or not.
Two lobes of the pituitary gland (hypophysis cerebri):
1. Posterior lobe - unmyelinated nerve fibers, secretes ADH and oxytocin.
2. Anterior lobe - pars distalis is the anterior part of the adenohypophysis that is the
major secretory part of the gland.
Alpha cell s (acidophil s; stain strongly with acid dyes)
1. Somatotrophs - secrete GH
2. Lactotrophs - secrete prolactin
Beta cells (basophils; stain strongly with basic dyes)
1. Corticotrophs - secrete ACTH
2. Gonadotrophs - secrete FSH and LH
3. Thyrotrophs - secrete TSH
*** The pars intermedia and tuberalis have no proven f unction in mammals.
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endocrine system
The arterial blood supply of the adrenal glands comes from 3 sources, with
branches arising from the inferior phrenic artery, the renal artery, and the
aorta.
Venous drainage flows directly into the inferior vena cava on the right side
and into the left renal vein on the left side.
both statements are t rue
both statements are false
the first statement is true, the second is false
the first statement is fa lse, the second is t rue
I refer to card 176 A-1 for illustration)
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both statements are true
The adrenal glands are small, yellowish organs that rest on the upper poles of t he kidneys in
t he back of the abdomen. The right adrenal gland is pyramidal, whereas t he left one is more
crescentic, extending toward the hilum of the kidney.
Each adrenal gland is composed of 2 distinct parts: the adrenal cortex and the adrenal medulla.
The cortex is divided into 3 zones. From exterior to interior, these are t he zona glomerulosa, t he
zona fasciculata, and the zona reticularis.
Zona Glomerulosa: is t he outer layer of the adrenal cortex. This layer is responsible for mak-
ing mineralocorticoids. Mineralocorticoids help the body regulate salt and fluid levels, and
maintain normal blood circulation. Aldosterone is the most important mineralocorticoid
made by the adrenal glands.
Zona Fasciculata: this middle layer of t he adrenal cortex produces glucocorticoids. Glu-
cocorticoids regulate sugar levels, maintain normal blood pressure, and help you respond to
stress and ill ness. Cortisol is t he most important glucocorticoid made by t he adrenal glands.
Zona Reticularis: is the innermost layer of the adrenal cortex. This layer is responsible for
producing androgens (male hormones). Androgens play an important role in the develop-
ment of the genitals and the development of sexual characteristics such as armpit hair, gen-
ital hair, and adul t-type body odor. They also help to speed up growth. Both males and
females normally produce androgens. The androgens produced in greatest quantity by the
adrenal cortex are "dehydroepiandrosterone (DEHA) and androstenedione. A portion of
these hormones is then made into "testosterone'; which is the most potent androgen.
Remember: The medulla of the adrenal gland really is modified nervous ti ssue and func-
tions in a manner simil ar to postganglionic sympathetic cells - stimulati on of the adrenal
medulla causes t he release of large quantities of epinephrine and norepinephrine. The
same effects are also caused by direct sympatheti c stimulat ion, except the effects last
longer when the medulla secretes t he hormones. With or without one or the other (medulla
or sympathetic nerves), the organs would still be stimulated.
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endocrine system
Meibomian glands (or tarsal glands) are sebaceous glands located at the rim
of the eyelid that function to protect the eyes from drying out. Meibomian
glands, release the entire secretory cell. This type of gland is referred to as:
merocrine
apocrine
holocrine
endocrine
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holocrine
Exocrine glands have a duct through which t heir product (sweat, saliva, digestive enzymes, etc.) is
released. Exocrine glands within the integumentary system include sebaceous glands (which are
associated with hair follicles and are deri ved from ectoderm), sweat glands, and mammary glands.
Within the digestive system, exocrine glands include the salivary glands, gastric glands within the
stomach, and the exocri ne portion of the pancreas.
Mammary glands, certain sweat
glands
Holocrine Accumulate their secretions in each cell's cytoplasm Sebaceous l a n d ~ of skin
and release the v.1lole cell into the duct. This destroys
the cell, which is cell.
Endocrine glands secrete their products (hormones) into the interstitial fluid surrounding the
secretory cells from which they diffuse into capillaries to be carried away by the blood. Endocrine
glands constitute the endocrine system and include the hypothalamus, pituitary, thyroid,
parathyroid, thymus, adrenal, and pineal glands as well as the gonads and the islets of Langerhans
(endocrine cells of the pancreas).
The major salivary glands (parotid, submandibular, and sublingual) are classified as compound
tubuloalveolar glands. They deliver their salivary secretions into the mouth by way of large
excretory ducts (Stensen's, Wharton's, and the numerous small Rivinus's ducts) respectively.
Remember: The parotid gland and von Ebner's glands are the only adult salivary glands that are
purely serous.
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endocrine system
Which salivary gland(s) can have either numerous small ducts that open onto
the floor of the mouth or a single main excretory duct (Bartholin's duct)?
submandibular gland
parotid gland
sublingual gland
von Ebner glands
[refer to card 174-1, 175-1 for illustration]
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sublingual gland
The subli ngual gland is the small est of the three main salivary glands. It contains both
serous and mucous (with serous demilunes) acini, the latter predominating. It is located
beneath the oral mucosa in the fl oor of the mout h between the mandible on one side and
the genioglossus and hyoglossus muscles on the other side. The subli ngual gland sits on
the mylohyoid muscle. Unlike the submandibular gland, which drains via one large duct,
the sublingual gland drains via approximately 12-20 small ducts (Rivinus's ducts) along
the subli ngual fold along the fl oor of the mout h.
The sublingual gland is innervated by parasympathetic secretomotor fibers from
superior sal ivatory nucleus of the facial nerve. The nerve f ibers pass to the
submandibular ganglion via the chorda tympani nerve and the lingual nerve.
Postganglionic parasympathetic fibers pass to the gland via the lingual nerve.
Postganglionic sympat hetic fibers reach the gland as a plexus of nerves around the facial
and lingual arteries.
The blood supply is from the sublingual branch of the lingual artery and from the
submental branch of t he facial artery.
Important:
The veins drain into the facial and lingual veins. The lymph vessels drain into the
submandibul ar and deep cervical lymph nodes.
Sometimes the numerous sublingual ducts (1 2 to 20 in number) join to form a single
main excretory duct (Bartholin's duct ) that usually empti es into the submandibul ar
duct.
Note: von Ebner's glands are located around the circumvallate papilla of the tongue.
Their main function is to rinse t he food away f rom the papilla after the food has been
tasted by the taste buds. These glands are purely serous.
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endocrine system
Which portal venous system is critical for proper endocrine function?
hypophyseal
renal
hepatic
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hypophyseal
A portal venous system occurs when a capillary bed drains into another capil lary bed
through veins. Both capil lary beds and the blood vessels that connect the beds are
considered part ofthe portal venous system. They are relatively uncommon as the ma-
jority of capil lary beds drain into the heart, not into another capill ary bed. Portal venous
systems are considered venous because the blood vessels that join the two capillary
beds are either veins or venules. Examples of such systems include the hepatic portal
system, the hypophyseal portal system, and the renal portal system.
Blood supply to the pituitary gland is f rom the right and left superior hypophyseal ar-
teri es and from the ri ght and left inferior hypophyseal arteries, which are branches of
the internal carotid artery. These form the rich vascular hypophyseal portal system.
This system of blood vessels links the hypothalamus and the anteri or pituitary. This
system all ows endocrine communication between the two structures. The veins drain
into the intercavernous sinuses.
Important: The neurohypophysis contains abundant axons whose cell bodies are lo-
cated mainly in the supraoptic and paraventricular nucl ei of the hypothalamus.
of Origin and of Pituitary Gland
Oral ectoderm Adenohypophysis Pars distal is
} Anterior lobe
(from roof of stomodeum) (glandular portion) Pars tuberalis
Pars intem1edia
Neuroectoderm Neurohypophysis Pars nervosa
} Posterior lobe
(from .floor of diencephalon) (nerve portion) Infundibulum
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endocrine system
A pathologist receives a salivary tissue biopsy of what the dentist believes is
pleomorphic adenoma. However, the dentist forgot to mention the site of the
biopsy. The pathologist identifies certain histological structures that would
indicate that this sample is not from the parotid gland. What structures can
be seen in histologic examination of the submandibular and sublingual
glands but NOT in the adult parotid gland?
myoepitheli al cells
serous cell s
intercalated ducts
serous demilunes
striated ducts
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se rous demilunes
Important: Secretory cell s are found in a group, or acinus (plural, acini), which resembles
a cluster of grapes. There are three forms of acini: serous, mucous, and mixed.
Mixed acini: these glands have both serous and mucous cell s.
-The mucous cells form tubul es, but their ends are capped by serous cell s that secrete
between the mucous cells' intercellul ar space. These serous caps on mucous cells are
called serous demilunes.
Approximately 10% of submandibular glands contain serous demilunes, but these
glands are predomi nantly serous acini, which constitute 90% of the gland.
The sublingual gland contains serous demilunes amid its predominant mucous cell
population. Serous cells are present exclusively on demilunes of mucous tubules.
Note: The key point is that the parotid gland and the von Ebner's glands are purely
serous and do not contain any mucous or mixed acini.
These demilune cell s secrete mucus that contains the enzyme lysozyme that degrades
the cell walls of bacteria. In this way, lysozyme confers antimicrobial activity to mucus.
Remember: All of the major salivary glands (parotid, submandibular, and sublingual) are
classified as compound tubuloalveolar glands. This means that their ducts branch
repeatedly (compound) and their secretory portions are tubular and composed of small
sacs call ed alveoli or acini.
Myoepithelial cells (or basket cells): are contractil e cells that li e between the basement
membrane and the plasma membrane of the secretory cell s. They are also found in the
proximal part of the duct system. Myoepithelial cell s possess many actin-containing mi-
crofilaments, which squeeze on the secretory cells and move their products toward the ex-
cretory ducts.
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endocrine system
Thyroid epithelial cells (follicular cells) which are responsible for the synthe-
sis ofthyroid hormone are arranged in spheres called thyroid follicles.
These follicles are filled with colloid.
both statements are t rue
both statements are false
the f irst statement is t rue, the second is false
the f irst statement is false, the second is t rue
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Colloid is composed of thyroglobulin and iodine and is the storage form of the thy-
roid hormones T3 (iodothyronine) and T4 (thyroxine or tetraiodothyronine).
When the pituitary gland secretes thyrotropin, the colloid becomes active, and
thyroglobul in molecules are released and taken back into the foll icular cells by
endocytosis, where the molecules are broken down into thyroid hormones,
thyroxine (T4) and triiodothyronine (T3).
Note: The T3 and T4 are collectively referred to as the thyroid hormones.
These hormones then pass out of the foll icular cells and enter the bloodstream. Within
the bloodstream, almost all of the thyroid hormones are bound to plasma proteins
such as thyroid-binding globuli n (TBG).
The thyroid normally produces about 10% T3 and 90% T4.1n the t issues, however, much
of the T4 is converted to T3, which is the major active form of the thyroid hormones at
the cellular level.
Follicular cells remain inactive at times of low thyroid hormone need and can be
activated when it is necessary for the mobili zation of coll oid found within the thyroid
follicle. Note: Metabolically inactive follicular colloid will stain acidophilic (stains
strongly with acid stains) while metabolically active foll icular coll oid will stain
basophilic (stains strongly with basic stains).
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endocrine system
After being seen by a neurologist, a patient is diagnosed with a pituitary
adenoma. As the neoplasm increases in size, it will most likely affect which
cranial nerve?
CNI
CN II
CN Ill
CN IV
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CN II
Pituitary adenomas are tumors that can affect vision, sometimes causing vision loss. As
they grow in size, pituitary adenomas can put pressure on important structures in the body,
such as the optic nerve. Putting pressure on the optic nerve may cause blindness.
The sella turcica (literally Turkish saddle) is a saddle-shaped depression in the sphenoid bone
at the base of the skull. The seat of the saddle is known as the hypophyseal fossa which holds
the pituitary gland (hypophysis cerebri).located anteriorly to the hypophyseal fossa is the tu-
berculum sellae. Completing the formation of the saddle posteriorly is the dorsum sellae. The
dorsum sellae is terminated laterally by the posterior clinoid processes.
1 .The crista galli is a sharp upward projection of the ethmoid bone in the mi dline,
for the attachment of the falx cerebri.
2. The cribriform plate consists of perforated areas on either side of the crista
galli. It transmits olfactory nerve bundles.
3. The infratemporal fossa lies inferior to the temporal fossa and the infratem-
poral crest on the greater wing of the sphenoid bone.
4. The floor of the sella turcica is also the roof of the sphenoid sinus.
Important points to remember concerning the pituitary gland:
1. Blood supply is from the right and left superior hypophyseal arteries and from the
right and left inferior hypophyseal arteries, which are branches of the internal carotid
artery. These form the rich vascular hypophyseal portal system.
2. The anterior pituitary or adenohypophysis is a classical gland composed predomi-
nantly of cell s that secrete protein hormones.
3. The posterior pituitary or neurohypophysis is not really an organ but an extension of
t he hypothalamus. The posterior pituitary is composed largely of the axons of hypo-
thalamic neurons that extend downward as a large bundle behind the anterior pituitary.
The posterior pituitary also forms the so-called pituitary stalk (infundibulum) which ap-
pears to suspend the anterior gland from the hypothalamus.
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endocrine system
Oxytocin and vasopressin are synthesized in the hypothalamus and are trans-
ported to the pituitary gland for storage by way of:
myeli nated nerve fibers
both myelinated and unmyelinated nerve fibers
unmyelinated nerve fibers
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unmyelinated nerve fibers
As opposed to the anterior lobe (adenohypophysis), which presents epitheli al
characteristics, the posteri or lobe (neurohypophysis) consists of about 100,000
unmyelinated axons of secretory nerve cells, the cell bodies of which are housed in
the supraoptic and paraventri cular nuclei of the hypothalamus. The secretory
products (oxytocin and vasopressin [ADH]) are t ransported down the axons and
stored in the axon terminals, known as Herring bodies, in the neurohypophysis.
Herring bodies are in cl ose contact with capillari es, all owing the hormones to be
released into the bloodstream when needed. Thus, oxytocin and vasopressin are
synthesized in the hypothalamus and stored in and released by the
neurohypophysis (specificall y, the pars nervosa).
Important: The hypothalamo-hypophyseal portal tract refers to the way in which
secretions by the anterior pituitary are controlled by hormones cal led
hypothalamic releasing and inhibiting factors. These factors are secreted within
the hypothalamus itself and then conducted to the anteri or pituitary through the rich
vascular hypophyseal portal system. This system of blood vessels links the
hypothalamus and the anterior pituitary. This system allows endocrine
communication between the two structures.
Note: Prolactin is unique among the pituitary hormones in that it is under tonic in-
hibitory control by the hypothalamus. Transection oft he pituitary stalk therefore results
in an increase in the production of prolactin, but a decrease in all other pituitary hor-
mones. Prolactin inhibitory factor is none other than the neurotransmitter dopamine,
which is secreted by the hypothalamic tuberoinfundibular neurons.
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nervous system
Which of the following tracts is responsible for coordinating eye and head
movements?
tectospinal t ract
rubrospinal tract
vestibulospinal tract
reticulospinal tract
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tectospinal tract
Tracts descending to the spinal cord are concerned with voluntary motor function, mus-
cle tone, reflexes and equilibrium, visceral innervation, and modulation of ascending sen-
sory signals. Universally regarded as the single most important tract concerned with skilled
voluntary activity, the corticospinal t ract originates from pyrami d-shaped cell s in the pre-
motor, primary motor, and primary sensory cortex.
\l.1jol DcsccndinJ! 1 r.1ds of the Spin.1l ( 01 d
Name Function Location Origin Termination
L<ueral conicospinal Voluntary movement, lateral white columns t>.<fotor areas or ce-rebral lateral or anterior
(or crossed pyramidal) c.omracrion of individual cone-:< opposite side- from gray c.olumtt.(!
or small gtoups of muscle$ tract location in cord
Anterior corticospinal Same as lateral conicospi- Anterior whi[e columns ?>.lotor cortex bul on same lateral or anterior
(or direc[ pyramidal} nat except mainly muscl es side as location in cord gray c.olumns
of same side
Larenl reticulospinal Mainly facilitato1y inOu- lateral white columns Reticular fbnn.arion, mid- lateral or ante-ior
ence on motOI' neuron..o; to brain, pon..o;, and medulla g.rayc.olum.n..o;
skeletal muscles
rvtedial reticulospinal to.'lainly inhibiory intlu- Anterior whie columns Relicular fbnn.alion, lateral or anterior
e.nce on motOI' neuron..o; to mainly the medulla g.rayc.olum.n..o;
skeletal muscles
Rubi'OSJ,inal Coordination of body lateral white columns Red nucleus (of midbrain) lateral or anterior
movement and posnll'e g.rayc.olum.n..o;
Vestibulo..o;pinal Mediates the-influenc.es of lateral white columns Lateral vestibular nucleus lateral or ante-ior
the ve..o;tibular end organ g.rayc.olum.n..o;
and he cerebellum upon
e-xten..o;or muscle [One
Tectospinal ract Coordination of head. Anterior whie columns Midbrain tec.rum Rexed laminae of
(c.olliculospinal tract) neck and eye movements g.rayc.olumn
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p
Fasciculus gracilis........_ ',
Fasciculus
Posterior spinocerebellar._
Anterior
spinocerebellar
Anterior
spinothalamic
'
'
'
'
'
'
'
'
'
'
'A
The major ascending (sensory) tracts, shown only on the left here, are highlighted. The major
descending (motor) tracts, shown only on the right, are highlighted. The broken line indicates
the anterior/posterior orientation angle.
195 1
Reproduced w1th permission from l'auon KT. GA: Miuby.f Handbook of AnaiMI)' & St. Louis, 2000. Mm;by.
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nervous system
A 56-year-old male patient with type II diabetes comes into the emergency
room with a painful blistering skin rash localized over the left side of his fore-
head. The localized area of skin with sensory innervation from a single nerve root
ofthe spinal cord is called what?
fa sci cui us
dermatome
spindle
bundle
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dermatome
Dermatomes are t he areas of skin supplied by a single spinal nerve; however, there is usually
some overlap between adjacent dermatomes. Each of the 31 segments of the spinal cord gives
rise to a pair of spinal nerves, which carry messages into and out of the CNS. These spinal nerves
branch into and service part icular areas of the body. Ultimately, each nerve ends up innervati ng a
different region of the skin, called a dermatome, with the exception of spinal nerve Cl , which
does not play a role in dermatomes.
Peripheral nerve innervation of the skin (cutaneous innervat ion) usually forms a different pattern
from spinal nerve skin innervation (dermatome) because the ventral primary divisions of spinal
nerves form plexuses. This allows multiple spinal nerves to constitute a peripheral nerve. For exam
pie, the musculocutaneous nerve is composed of ventral primary divisions of spinal nerves CS, C6,
and C7. When the cutaneous port ion of the nerve reaches the skin of the lateral foramen, the
branches from each of the spinal nerves supply their respective dermatomes. Key point to remem
ber: The pattern of distribution of the peripheral nerve (musculocutaneous) is different from the
dermatome pattern.
Important: Cranial nerve dermatomes do not have any overlap (are not innervated by more t han
one nerve) whereas spinal nerve dermatomes overlap each other by SO% as insurance against
anesthesia of a dermatome. The loss of t he overlap requires the loss of innervation to three
adjacent dermatomes to produce anesthesia in the middle dermatome. For example, all three of
the dorsal roots or intercostal nerves of T4, TS, and T6 woul d have to be severed or damaged to
create anesthesia in dermatome TS. Severing a peripheral nerve produces a different pattern of
anesthesia on the skin. Note: This is diagnosed by the neurologist to determine if the lesion is in a
spinal nerve or a peri pheral nerve.
Remember: Referred pain is caused when the sensory fibers from an internal organ enter t he spinal
cord in the same root as fibers from a dermatome. The brain is poor at interpreting visceral pain and
instead interprets it as pain from the somatic area of the dermatome. So pain in the heart is often
interpreted as pain in the left arm or shoulder, pain in the diaphragm is interpreted as along the left
clavicle and neck, and the "stitch in your side" you sometimes feel when running is pain in the liver
as it s vessels vasoconstrict.
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196-1
Dermatome distribution of spinal nerves. A, The front of the body's surface. B, The back
of the body' s surface.
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nervous system
Wernicke's area is located within which cerebral lobe?
parietal lobe
occipital lobe
temporal lobe
frontal lobe
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temporal lobe
The cerebrum or cortex (the extensive outer layer of gray matter of the cerebral hemi-
spheres) is the largest part of the human brain, associated with higher brain function
such as thought and action. The cerebral cortex is divided into four sections, called
" lobes": the frontal lobe, pari etal lobe, occipital lobe, and temporal lobe.
Note: (1) The l imbic system, often referred to as the "emotional brain; is found buried
within the cerebrum. (2) Basal nuclei are gray matter structures deep within each cere-
bral hemisphere that hel p to control skeletal muscle activity.
2. Motor area
Control s thin muscl es of the body {fi ngers.
mouth, feet, eye ...
Cootdinates movements
Control s speech (articul ation of words}
Frontal lobe (1,2)
3. Prefrontal area
-Elaborates the thinking
process
Planning of complex move-
ments
3. Somesthetic area
Receives sensations, tempetature and pain
sensations from the body
Parietal lobe (3)
Occipital lobe (4)
4. Visual area
Detects visual signals
Temporal lobe (5,6,7)
S. Auditory area
- Detects audi tory si gnal s
6. Wernicke's area
-Interprets the significance of sentences as they
are heard and wrinen
7. Short-term memory area
- Stores shotHefm memory (that
lasts for a few seconds)
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Occipital
Lobe
Parietal Lobe
Spinal Cord
Frontal Lobe
Temporal
Lobe
Medulla Oblongata
Lobes of the Brain - Lateral view
197-1
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Median section of the brain
Corpus
callosum
Lateral
ventricle
Thalamus
Hypothalamus
Midbrain //
/ Pons
Central
sulcus
Temporal lobe
Medulla oblongata
Spinal cord
Occipital
lobe
Cerebellum
197 A l
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The Basal Nuclei
Lateral ventricle
Third ventricle
~ ~ J Putamen
-+l,__,_o.,.L.----Jo+- Globus pallidus
Thalamus
197 B l
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behaviour
Intelligence
memory
movement
TEMPORAL LOBE
beh I!LJr
h anng
poeeh
VISiOn
mt ry
PARIETAL LOBE
intelligE>.,ce
language
reading
sensation
CEREBELLUM
balance
coor dination
BRAIN STEH
bloCid pre ou-- P
brcathmg
consciOusness
heartbeat
swallowing
197 C-1
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nervous system
Which structural component of a neuron sends impulses away from the cell
body?
neurogl ial cell
perikaryon
dendrite
axon
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axon
Nervous t issue is composed of two types of cell s:
1. Neurons - transmit nerve impulses.
2. Neuroglial cells (gl ial cells) - are non-conducting "support cells" of nervous
tissue. Examples include astrocytes, attached to t he outside of a capil lary blood
vessel in the brain, phagocytic microglial cells, and ciliated ependymal cells t hat
form a sheath that usually li nes fluid cavities in t he ventricular system of the brain.
Structure of a neuron:
Cell body (perikaryon)- contains the nucleus and most of the cytoplasm. Located
mostly in the central nervous system as clusters called nuclei, some found in the
peripheral nervous system as groups cal led ganglia.
Dendrites - neuronal processes that send t he impulse toward the cell body. There
may be one or many dendrites per cell. Some neurons Jack dendrites.
Axon (nerve fiber) - neuronal process that sends t he impulse away f rom the cell
body.
***If the axon is covered with a fatty substance called myelin, t he axon is referred to
as a myelinated fiber. If there is no myeli nated cover, then the axon is referred to as
an unmyelinated fiber.
Neurons are classified according to structure (based on t he number of processes t hat
extend from t he cell body): bipolar, unipolar, or mult ipolar (most common). They are
also classified according to function: motor (efferent), sensory (afferent), or
interneurons (which l ie between sensory and motor neurons in the CNS).
Note: Whether or not someone feels different stimuli (pain, temperature, pressure, etc.)
is determined by t he specific nerve f iber stimulated.
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A multipolar neuron (Ex. spinal motor neuron)
Initial
segment
signal transmission
y-NodeofRanvier
D11ect1on of \
""'"'"'""-::--- v ~
~
198-1
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Types of Neurons
Multlpopar neurons
Pur1<inje cell
Dendrites
Axon
Bipolar neurons
Retinal neuron
Anaxonic neuron
~
~ . -
Dendrites
198A I
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nervous system
A 14-year-old female patient presents to the physician with hyperpigmented
lesions (cafe-au-fait spots), hamartomas of the iris (Lisch nodules), and
axillary freckling (Crowe's sign). The patient had previously been diagnosed
with neurofibromatosis, but is now complaining of generalized pain and
tingling. The physician discovers multiple neurilemmomas, classifying the
disease as a form of neurofibromatosis. Neurilemmomas are a neoplasm of
myelin producing cells in the peripheral nervous system known as?
astrocyte
oligodendrocyte
schwann cell
microgli al cell
satellite cell
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schwann cell - also called neurolemmocyte or neurolemma cell
Schwann cell s in the peripheral nervous system serve as supportive, nutritive, and
service facil ities for neurons. The gaps in the myelin sheath that occur between
adjacent Schwann cells are called nodes of Ranvier, and serve as points along the
neuron for generating a signal. Signals jumping from node to node t ravel hundreds
of times faster than signals traveli ng along the surface ofthe axon (known as saltatory
conduction). This al lows your brain to communicate with your toes in a few
thousandths of a second.
Note: There are no Schwann cells in the CNS (central nervous system); the myelin
sheath (in the CNS) is formed by the processes of the oligodendrocytes.
Remember: The neural crest is a band of neuroectodermal cells that lie dorsolateral
to the developing spinal cord, where they separate into clusters of cells (neural crest
cells) that develop into dorsal root ganglion cells, autonomic ganglion cell s,
chromaffin cells of the adrenal medulla, neurolemma cel ls (Schwann cell s),
integumentary pigment cells (melanocytes), and the leptomeninges (pia mater
and arachnoid mater), whil e the dura mater is derived from mesoderm.
Important: Microglial cells are the resident immune cell s of the central nervous
system. Their function resembles that of tissue macrophages.
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nervous system
Which of the following ascending tracts of the spinal cord function to
carry pain and temperature sensory information to the thalamus?
lateral spinothalamic t ract
anteri or spinothalamic tract
fasciculus gracili s
fasciculus cuneatus
spinocerebellar t ract
I refer to card 195-1 for illustration]
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lateral spinothalamic tract
The white matter of the spinal cord contains tracts that travel up and down the cord. Many of these
tracts travel to and from the brain to provide sensory input to t he brain, or bri ng motor stimuli from
the brain to control effectors. Ascending tracts, those t hat travel toward the brain are sensory,
descending tracts that travel away from the brain are motor.
\ l ~ t o r \srl'ndinj;! I rach of lhl' Spin.tl Curd
Name Function Location Origin Termination
Lateral spinothalamic Pain, temperamre, and crude Lateral white columns Posterior gmy column l'halamus
wuch of opposite side of opposite side
Anterior spinothalamic Crude rouch and pressure Anterio1 white colum.ns Posterior gmy column l'halamus
of opposite side
Fasciculus gracilis and Discriminating touch and ("'ostel'ior white columns Spinal ganglia of same Medulla
cuneatus pressure sensations side
Anterior and posterior Unconscious kinesthe$ia Lateral white columns Antel'io1 or JX>Steriol' Cerebellum
spinocerebe.llar gray column
Note: Axons of cells within nucleus gracilis and nucleus cuneatus cross as internal arcuate fibers and
form the medial lemniscus. The medial lemniscus is thus a large ascending bundle of heavily myeli-
nated axons (fast conducting) whose cell bodies lie in the contralateral nucleus gracilis and nucl eus
cuneatus. The medial lemniscus passes rostrallythrough the medulla, pons and midbrain to terminate
in the vent ral posterolateral (VPL) nucleus of the thalamus. Cells in the VPL then send their axons to
t he postcentral gyrus (somatosensory cortex) of the cerebral cortex.
Note: For most tracts, the name will indicate if it is a motor or sensory tract. Most sensory tracts names
begin with spino, indicating origin in the spinal cord, and their names end with the part of the brain
where the tract leads. For example, the spinothalamic tract travels from the spinal cord to the thal-
amus. Tracts whose names begin wit h a part of the brain are motor. For example, t he corticospinal
tract begins with fibers leaving the cerebral cortex and travels down toward motor neurons in the
cord.
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p
Fasciculus gracilis........_ ',
Fasciculus
Posterior spinocerebellar._
Anterior
spinocerebellar
Anterior
spinothalamic
'
'
'
'
'
'
'
'
'
'
'A
The major ascending (sensory) tracts, shown only on the left here, are highlighted. The major
descending (motor) tracts, shown only on the right, are highlighted. The broken line indicates
the anterior/posterior orientation angle.
195 1
Reproduced w1th permission from l'auon KT. GA: Miuby.f Handbook of AnaiMI)' & St. Louis, 2000. Mm;by.
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nervous system
Which of the following spinal nerve structures is exclusively composed of
sensory fibers?
ventral root
dorsal root
ventral rami
dorsal rami
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dorsal root
The spinal cord is the connection center for the reflexes as well as the afferent (sensory) and efferent (motor)
pathways for most of the body below the head and neck. The spinal cord begins at the brainstem and ends
at about the second lumbar vertebra. The sensory, motor, and interneurons are found in specific parts of
the spi nal cord and nearby structures. Sensory neurons have their cell bodies i n the spinal (dorsal root)
ganglion. Their axons travel through the dorsal root i nto the gray matter of the cord. Within the gray mat-
ter are interneurons wi th which the sensory neurons may connect. Al so located in the gray matter are the
motor neurons whose axons travel out of the cord through the ventral root. The whit e matter surrounds
the gray matter. It contai ns the spi nal tracts that ascend and descend the spi nal cord.
At 31 places along the spinal cord, the dorsal and ventral roots come together to form spinal nerves. Spi nal
nerves contain both sensory and motor fibers, as do most nerves. Spi nal nerves are given numbers that in-
dicate the portion of the vert ebral col umn i n which the nerves ari se. There are 8 cervical (C1-C8), 12 tho-
racics (T1-T1 2), 5 lumbar (L 1-L5), 5 sacral (S 1-S5), and 1 coccygeal nerve. Nerve ( 1 arises between t he
cranium and atlas (1st cervical vertebra), and (8 ari ses between the 7th cervical and 1st thoracic vertebra.
All the others arise below the respective vertebra orformer vertebra in the case of the sacrum.
Spi nal nerves divide into branches called rami. Ventral pri mary rami exit anteriorly, and dorsal pri mary rami,
posteri orly.
A nerve pl exus i s a network of adj acent spi nal nerves that join t ogether. The name of each plexus descri bes
the area its nerves supply. The maj or nerve plexuses and areas they supply are:
cervical: head, neck, shoulders, diaphragm
brachial: upper l imbs, and some neck and shoulder muscles
lumbar: part of the abdominal wall, lower l imbs, and external mal e genital ia
sacral: peri neum, buttocks, and most of the lower l imbs
pudendal: external f emal e genitalia
Sensory impulses travel along the sensory (afferent, or ascending) neural pathways to the sensory cor-
tex i n the parietal lobe of the brain where they are i nterpreted. Motor impulses travel f rom the brain to the
muscles along t he motor (efferent, or descending) pathways. These i mpul ses originate i n the motor cor-
tex of the frontal lobe and travel along upper motor neurons to t he peripheral nervous system. Upper
motor neurons origi nate in t he brain and form two major systems, the pyramidal and extrapyramidal
systems.
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Ventral root
Spinal nerve
""'- ventral ramus
2011
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Anatomy of a Nerve
Spinal nerve

Blood vessels

Unmyelinated
nerve fiber
Myelinated
nerve fiber
Endoneurium Cross section
201 A-1
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nervous system
A student dozing off in class is unexpectedly called on by the professor to
answer a question. Not knowing the answer, the hair on the back of the
student's neck stands up, his pupils dilate, and his heart starts to race. This
fight-or-flight response is controlled by the:
somatic nervous system
autonomic nervous system
central nervous system
sensory nervous system
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autonomic ner vous system
The central nervous syst em includes the brain and spinal cord. The peripheral nervous
syst em consists of all body nerves. Motor neuron pathways are of two types: somatic
(skeletal) and autonomic (smooth muscl e, cardiac muscle, and glands). The autonomic sys-
tem is subdivided into the sympathetic and parasympat hetic systems.
The PNS consists of all nervous structures located outside the CNS. The PNS includes the
cranial nerves, arising from the inferior aspect of the brain, and the spinal nerves, arising
from the spinal cord. The PNS is divided functionally into afferent (sensory) and efferent
(motor) divisions.
The afferent division of the PNS includes somatic sensory neurons which carry im-
pulses to the CNS f rom the skin, fascia, and j oints, along with visceral sensory neurons,
which carry impulses from the viscera of the body (hunger pangs, blood pressure) to the
CNS
The efferent division of the PNS is divided into the somatic (voluntary) and auto-
nomic (involuntary) nervous system
Comparison of the Somatic and Autonomic Nen ous ~ stems
Feature Somatic Autonomic
Effectors Skeletal muscle Glands, smooth muscle, cardiac muscle
Control Usually volumary Usually involuntary
Efferent pathways One nerve fiber from CNS Two nerve fibers from CNS to effector;
to effector; no ganglia synapse at a ganglion
Neurotransmitters Acetylcholine (Ach) Ach and norepinephrine (N)
Effect on target cells Always excitable Excitatory or inhibitory
Effect of denervation Flaccid paralysis Denervation hypersensitivity
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Divisions of the Nervous System
2021
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nervous system
Which ofthe following separates the occipital lobe and the cerebellum?
falx cerebri
falx cerebelli
tentorium cerebell i
corpus call osum
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tentorium cerebelli
The meninges are t hree concentric protective membranes surrounding the brai n and spi nal cord (the CNS).
1. Dura mater- the outermost t ough fi brous layer that li nes t he skull and forms folds, or reflections,
t hat descend i nto the brai n fissures and provide stabi lity.
The dural folds are t he following:
Falx cerebri -lies in the longit udinal fi ssure and separates t he cerebral hemispheres
Tentorium cere belli - separat es the occipi tal l obe of t he cerebrum and t he cerebellum
Falx cere belli - separates t he two lobes of the cerebell um
2. Arachnoid mater - i s a fragile network of collagen and elastin fibers with a cobweb-like appearance.
The arachnoid membrane has moderate vascularit y and lies bet ween t he dura mat er and t he pia mat er.
3. Pia mater- i nnermost membrane, i t i s an extremely t hi n membrane made up of collagen and elas-
t ic fi bers cont ai ni ng many bl ood vessel s. The pi a mater adheres closely to the brai n and spinal cord.
** *These are the struct ures involved in meni ngiti s, an i nfl ammation of t he meninges, which, if severe, may
become encephaliti s (an inflammation of the brain).
The subarachnoid space, fi lled with cerebrospinal fluid, separat es t he arachnoid membrane and t he pia
mater. In addit ion, t he meni ngeal area has two pot ential spaces:
Epidural space- over t he dura mat er; becomes a real space i n the presence of pathology, such as ac-
cumul ation of blood from a torn meningeal artery (an epidural hemat oma)
Subdural space - a closed space with no egress bet ween t he dura mater and the arachnoid mem-
brane; often the site of hemorrhage aft er head trauma
Note: In t he ventricles of t he brai n, the pia mater and ependymal cells contribute to t he formation of t he
choroid plexuses. It i s these pl exuses t hat regulate t he i ntravent ri cular pressure by secretion of cere-
brospi nal fl uid.
Typt of Meningealllemorrhage Associated Vessel
l!ptdural Middle meningeal artery
Subdural Bridging vein
Subamchno1d C1rd c o( Wdhs (berry aneurysm)
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Choroid
plexus (CSF
production)
Monro
Skull
Fourth
ventricle
Pia mater
space
space
Meninges and Ventricles of the Brain
203-1
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Superior sagittal sinus
The meninges of the brain
Skull
I
Dura
mater
Arachnoid mater
Subarachnoid
space
Pia mater
Brain
Z03A I
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nervous system
Which of the following cranial nerves arise in the pons?
Select all that apply.
trochlear nerve (CN IV)
trigeminal nerve (CN V)
abducens nerve (CN VI)
facial nerve (CN VI I)
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trigeminal nerve (CN V)
abducens nerve (CN VI)
facial nerve (CN VII)
*..,.The olfactory, optic, oculomotor and trochlear cranial nerves are located in the anterior portion
of the brain. The trigeminal, abducens, and facial nerves arise in the pons. The vestibulocochlear nerve
arises in the inner ear and goes to the pons. The glossopharyngeal, vagus, accessory and hypoglos-
sal nerves are attached to the medulla oblongata.
The brain stem, which is continuous with the spinal cord below, consists of the midbrain, pons, and
medulla. Passing through the brain stem are ascending pathways carrying sensory information from
the spinal cord to the brain, and descending pathways, carrying motor commands down to the spinal
cord. Centers in the brain stem regulate many vital functions, including heartbeat, respirat ion, and
blood pressure.
The midbrain connects dorsally with the cerebellum. The midbrain relays motor signals from
the cerebral cortex to the pons, and sensory transmission in the opposite direction, from the spinal
cord to the thalamus. The substantia nigra in the midbrain helps to control movement. Lesions
of the substantia cause Parkinson's disease.
The pons lies below the midbrain and connects the cerebell um with the cerebrum. The pons
also links the midbrain to the medulla oblongata.lt is involved with motor activity of the body
and organs. In addition to housing one of the brain respiratory centers, the pons acts as a pathway
for conduction tracts between brain centers and the spinal cord, and serves as the exit point for
cranial nerve V.
The medulla oblongata is the most inferior portion of the brain stem and is a small, cone-shaped
structure that j oins the spinal cord at the level of the foramen magnum. The medulla oblongata
functions primari ly as a relay station for the crossing of motor tracts between the spinal cord and
the brain. The medulla oblongata also contai ns mechanisms for controlling reflex activities such
as coughing, gagging, swallowing, and vomiting. The medulla oblongata also contains a central
core of gray matter called the reticular formation. This area is involved in regulat ing sleep and
arousal (via reticular activating center) and in pain perception, and includes vital centers that reg-
ulate breathing and heart activity.
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HUMAN BRAIN
callosum
ellum
204 1
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nervous system
Which of the following meningeal structures is a ring-shaped fold that allows
the passage of the infundibulum of the pituitary gland?
tentori um cerebelli
falx cerebri
falx cerebelli
diaphragma sellae
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diaphragma sellae
The dura mater is the outermost tough fibrous layer that lines the skull and forms
folds, or reflections, that descend into the brain's fissures and provide stabili ty. The dura
mater is composed of two layers. The periosteal layer adheres tightly to the inner sur-
face of the cranium, and the meningeal layer forms partitions (folds or reflections)
that descend into the brain's fissures and provide stabili ty.
The dural folds are the following:
Two vertical folds:
Falx cerebri - lies in the longitudinal fissure and separates the cerebral
hemispheres. Contains inferior and superior sagittal sinuses.
Falx cerebelli - separates the two lobes of the cerebellum. Contains occipital
sinus.
A horizontal fold:
Tentorium cerebelli - separates the cerebrum and the cerebellum. Contains
the straight, transverse, and superior petrosal sinuses.
The dural venous sinuses are spaces between the periosteal and meningeal
layers of the dura. The sinuses contain venous blood that originates for the most part
f rom the brain or cranial cavity. The sinuses contain an endotheli al li ning that is
continuous into the veins t hat are connected to the sinuses. There are no valves in
the sinuses or in the veins that are connected to the sinuses. The vast majori ty of the
venous blood in the sinuses drains f rom the cranium via the internal jugular vein.
Note: The diaphragma sellae is a ring-shaped fold of dura mater covering the sell a tur-
cica, and containing an aperture for passage of the infundibulum ofthe pituitary gland.
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Stra'ight
sinus
Dural reflections (large shaded areas toward inside) and dural sinuses (small shaded
areas on peripheral) after removal of the brain. The sigmoid sinus of the right side
is seen through the tentorial incisura.
205

1
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nervous system
The diencephalon lies beneath the cerebral hemispheres and contains which
of the following?
Select all that apply.
thalamus
pons
medulla
hypothalamus
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thalamus
hypothalamus
The brain lies within the cranial cavity of the skull and is made up of billions of nerve cells (neurons)
and supporting cells (glia). Neuronal cell bodies group together as gray matter, and their processes
group together as white matter.
The brain can be divided into four main parts: the cerebrum, diencephalon, brain stem, and cerebel-
lum.
The cerebrum is the largest part of t he brain and consists of t he four paired lobes with the two
cerebral hemispheres, connected by a mass of white matter called the corpus callosum. The
cerebrum accounts for about 80% of the brain's mass and is concerned with higher functions, in-
cluding perception of sensory impulses, instigation of voluntary movement, memory, thought,
and reasoning. There are two layers of the cerebrum:
-The cerebral cortex is the thin, wrinkled gray matter covering each hemisphere
-The cerebral medulla is a thicker core of white matter
The diencephalon lies beneath the cerebral hemispheres and has two main structures- the thal-
amus and the hypothalamus. The walnut-sized thalamus is a large mass of gray matter that lies
on either side of the third ventricle. The thalamus is a great relay station on the afferent sensory
pathway to the cerebral cortex. The tiny hypothalamus forms the lower part of the lateral wall
and floor of the third ventricle. The hypothalamus exerts an influence on a wide range of body
functions.
The cerebellum is attached to the brain and feat ures a highly folded surface.lt is important in
the control of movement and balance.
The brainstem is the lower extension of the brain where it connects to the spinal cord. It consists
of the midbrain, pons, and medulla.
Remember - Each portion of the brain consists basically of three areas:
1. Gray matter - composed primarily of unmyelinated nerve cell bodies
2. White matter - composed basically of myelinated nerve fibers
3. Ventricles - spaces filled with cerebrospinal fluid
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Corpus callosum
Hypothalamus
Brain stem
Brain - Sagittal view
206 1
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nervous system
Which type of neuroglial cells form myelin in the CNS?
astrocytes
oligodendrocytes
microgli a
ependymal cel ls
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oli godendrocytes
Neuroglial cells, t he other maj or cell type in neural tissue, provide struct ural integrity to the nervous
system and functional support that enables neurons to perform. Neuroglia do not typically have
synapses at their surface. Classically neuroglial cells are described as existing only in the central
nervous system (brain and spinal cord). Cells in the PNS that support neurons include Schwann
cells and satellite cells. Note: With the exception of microglia, which deri ve from mesoderm, all
neuroglia derive from ectoderm.
Cell St ructure Function
CNS
.
Astrocytes Many processes attached to their Provide s tmctural
cell body
.
Oligodendrocytes Smaller cell bodies than Form myelin sheaths around axons in
a'itrocytes and relatively fewer the CNS
proc.esses leaving the cell body
.
Microglia Smallest cell bodies a mong the. Main phagocytic cell and antigen-
neuroglia l>resenting cells in the CNS
.
Ependymal cells Columnar cells with ciliated free . Line most of the ventricular system of
surfaces the CNS
.
Choroidal cells Modified ependymal cells Form the inner layer of the choroid
l.,lexu.s. Secrete cerebrospinal fluid
into the ventricles
PNS
. Satellite. cells Small, fl attened cells Support cell in ganglia within
the PNS
. Schwann cells Flattened cells arranged in series Form myelin within the PNS
around axon.s
1. Schwann cells in the PNS myelinate a single axon
2. Oligodendrocytes in the CNS myelinate many (50+) axons
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nervous system
Cell bodies of preganglionic sympathetic fibers to the head are located in the:
superior and middle cervical gangli a
lateral gray horns of segments Tl to T4 of the spinal cord
anterior gray horns of segments Tl to T4 of the spinal cord
lateral gray horns of segments 52 to 54 of the spinal cord
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lateral gray horns of segments T1 to T4 of the spinal cord
The autonomic nervous system runs bodily functions without our awareness or control. It is the mot or sys-
tem to vi sceral organs. It is divided i nto t wo systems:
Sympathetic (t horacol umbar) division:
- "Fight, fright, or flight"
- Derived from t horacic and l umbar spi nal nerves (T1 -L2)
Preganglionic neurons (myeli nated): rel atively short
- Cell bodies are located in t he i nt ermediolateral gray col umn of thoracic and lumbar vertebrae
- The axons of preganglionic neurons exit ventral root i nto t he white ramus communication t hen
they synapse with postgangl ionic axons i n peri pheral gangl ion at t he same level or another l evel
- Neurotransmi tter is acetylcholi ne
Postganglionic axons (unmyeli nated): relatively long
- Cell bodies i n peri pheral ganglia extend t o visceral organs
- Di stri bution i s wi despread
-Neurotransmi tter is norepi nephri ne except for adrenal medulla and sweat glands
Parasympathetic (cranial-sacral) divisi on:
-"rest and digest
- Derived from cranial and sacral nerves - CN Ill, VII, IX, and X; 52-54
Preganglionic neurons (myel inated): relat ively long
-Synapse with postgangl ionic axons i n ganglia close t o organs
-Neurotransmi tter is acetylcholi ne
Postganglionic axons (unmyelinated): relatively short
-Neurotransmi tter is acetylcholi ne
- Di stri bution i s more specific and less diffuse t han sympathet i c
Sympathetic vs. Parasympathetic
Most organs have dual innervation
In general, the act ions of one system oppose t hose of t he other
Bot h divi si ons are cooperative i n sal ivary glands
Predominant tone i s parasympatheti c i n most organs
Sympathetic tone exists solely i n adrenal medulla, sweat glands, piloerector muscles of skin, and many
blood vessels
Sympathetic distribut ion t ends to be more diffuse whereas parasympathetic i s more specific
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nervous system
The lateral ventricles communicate with each other by:
the two foramina of Luschka
the interventricular foramen
the cerebral aqueduct
septum pellucidum
the foramen of Magendie
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septum pellucidum
There are four ventricles in the brain. They connect with each other, the central canal of the
spinal cord, and the subarachnoid space surrounding the brain and spinal cord. The ven-
tricles contain cerebrospinal flui d, which acts as a shock absorber, cushioning t he brain
from mechanical forces.
The right and left lateral ventricles are in the right and left cerebral hemispheres, respec-
tively. They communicate with each other by the septum pellucid urn. They also commu-
nicate with the narrow third ventricle in the diencephalon through a small opening, the
interventricular foramen (foramen of Monro). The third ventricle is continuous with the
fourth ventricle via the cerebral aqueduct (also call ed the aqueduct of Sylvius) that trav-
erses the midbrain. The fourth ventricle is located dorsal to the pons and medulla, and ven-
tral to the cerebellum. A single median aperture (foramen of Magendie) and a pair of
lateral apertures (foramina of Luschka) provide communication between the fourth ven-
tricle and the subarachnoid space.
Cerebrospinal fluid is produced mainly by a structure call ed the choroid plexus in the
lateral, third and fourth ventricles. CSF flows from the lateral ventricle to the third ventricle
through the interventricular foramen (also called the foramen of Monro). The third ven-
tricle and the fourth ventricl e are connected to each other by the cerebral aqueduct (also
called the aqueduct of Sylvius). CSF then flows into the subarachnoid space through the
foramina of Luschka (there are two of these) and the foramen of Magendie (only one of
these).
Note: Absorption of the CSF into the bloodstream takes place in the superior sagittal sinus
through structures called arachnoid granulations (arachnoid villi). When the CSF pressure
is greater than the venous pressure, CSF will flow into the bloodstream. However, the arach-
noid villi act as "one way valves"- if the CSF pressure is less than the venous pressure, the
arachnoid villi will NOT let blood pass into the ventricul ar system.
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Lateral
... space
Posterior horn
Third
Cerebral aqueduct
Fourth ventricle
Brain Ventricles - Sagittal view
2091
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The spinal cord terminates at the:
conus medullari s
subarachnoid space
f il um terminale
arachnoid space
cauda equina
central canal
ANATOMIC SCIENCES
nervous system
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conus medullaris
The spinal cord ends in the adult as a constriction call ed the conus medullaris around ll
(ll to l 2). The dura and arachnoid, however, continue down to level 52, where the
arachnoid fuses with the filum terminale. Thus, a needle inserted between the spines at
L3, l4, or lS will enter the subarachnoid space, which is filled with cerebrospi nal fluid,
without injuring the spinal cord.
Cauda equina is a bundle of nerves occupying the spinal column below the spinal cord in
most vertebrates that consists of nerve roots and rootl et s attached to the spinal cord. It
serves the legs.
Cerebrospinal fluid (CSF) is a colorless, thin fluid found in the ventricles of the brain, the
subarachnoid space, and the central canal of the spinal cord. CSF is produced mainly by a
st ructure called the choroid plexus in the lateral, third and fourt h ventricles. CSF escapes
the ventricular system of the brain through the t hree foramina of the fourth ventricle and
so enters the subarachnoid space. CSF now circulates both upward over the surfaces of
the cerebral hemispheres and downward around the spinal cord. The subarachnoid space
extends down as far as the second sacral vertebra. Event ually, the fluid enters the
bloodstream by passing into t he arachnoid villi and diffusing t hrough their walls.
1. The choroid plexuses regulate the intraventricul ar pressure by secretion of
cerebrospinal flui d.
2. The cerebrospinal fluid, along with the bony and li gamentous walls of the
vertebral canal, protects the spinal cord f rom injury.
3. Ependymal cell s are cells t hat make up the lining membrane of the ventricles
of the brain and of the central canal of the spinal cord. They are also present in
the choroid plexus of the central nervous system and participate in the
production of cerebrospinal fluid.
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Supraspinous ligament
Interspinous ligament
Extradural (epidural) CSF in lumbar cistern
space
lumbar spi nal puncture -.....1-'111'..- ..,..J llt----1
Spi nous process of l4
for spi nal anesthesi a
/
lumbar injection for
epidural anesthesia Extradural space In sacral canal
Lumbar Spinal Puncture
Rcproc:b:cd vrmh pnmlSSIOil from MOOR KL lniiC') Af. Apr AMR; Chn1tal Onmtcd Amtomy. cd 6: lblluno".2010. Larruacou Wtllums
&.W1Ikau.
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nervous system
The dorsal root ganglion is a collection of cell bodies for afferent nerve fibers
(mostly sensory) that exists just outside of the spinal cord.
There is no ventral root ganglion because the motor efferent fibers have their
cell bodies in the ventral horns (anterior portion of the grey matter) of the
spinal cord.
both statements are true
both statements are fa lse
the first statement is true, the second is fa lse
the first statement is fa lse, the second is t rue
ANATOMIC SCIENCES
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both statements are true
The spinal cord extends from the base of the skull to a point above two-thi rds of the way down the back.
running through the vertebral canal.
Wi thin the spinal cord, the H-shaped mass of gray matter is divided into horns, which consi st mai nly of
neuronal cell bodies and an i ntermediate zone.
Posterior (dorsal) horns: are special ized to process sensory information such as touch, pai n. and
j oi nt sensation, and to relay this i nformation to the brai n
Anterior (ventral) horns: contain motor neurons. which transmit messages out to the muscles
via spinal nerves
Note: In the devel oping nervous system, the basal plate is the region of the neuraltube ventral to the sul-
cus l imitans. It extends from the rostral mesencephalon to the end of the spinal cord and contai ns prima-
ri ly motor neurons, whereas neurons found i n the alar plate are pri marily associated wi th sensory f unctions.
Dorsal root ganglia (or spinal ganglion): is a nodul e on a dorsal root that contains cell bodies of neurons
i n afferent spinal nerves. The axons of dorsal root ganglion neurons are known as afferents.ln the periph-
eral nervous system, afferents refer to the axons that relay sensory information into the central nervous
system (i.e. the brai n and the spinal cord). These neurons are of the pseudo-unipolar type, meaning they
have an axon with two branches that act as a si ngle axon, often referred to as a distal process and a proxi-
mal process.
Upper motor neurons (UMNs): are motor neurons that originate in the motor region of the cerebral cor-
tex or the brain stem and carry motor information down to the final common pathway. that is, any motor
neurons that are not directly responsi ble for stimulating the target muscle. The main effector neurons for
vol untary movement lie within layer V of the primary motor cortex and are called Betz cells. The cell bod-
ies ofthese neurons are some of the largest in the brain, approachi ng nearly 100 ~ m n diameter.
Lower motor neurons (LMNs): are the motor neurons connecti ng the brainstem and spinal cord to mus-
cle fibers. bri nging the nerve impul ses from the upper motor neurons out to the muscles. A l ower motor
neuron's axon terminates on an effect or (muscle). l ower motor neurons are classi fi ed based on the type of
muscle fiber they innervate:
Alpha motor neurons innervate extrafusal muscle fibers. the most numerous type of muscle fiber and
the one involved i n muscle contraction.
Gamma motor neurons innervate intrafusal muscle fi bers, which together wit h sensory afferents com-
pose muscle spindles. These are part of the system for sensing body position (propriocepti on).
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Spinothalamic
Posterior ramus of
spinal nerve
Dura mater
Spinal Cord - Cross-Section view
Schwann
cell
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211-1
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nervous system
In the peripheral nervous system, which fibers carry impulses to smooth and
cardiac muscle as well as to glands?
somatic afferent f ibers
visceral afferent fibers
somatic efferent fibers
visceral efferent fibers
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visceral efferent fibers
Functionally. the fibers of peri pheral nerves may either be somatic or visceral and al so either sensory
(afferent) or motor (efferent).
There are four types of fibers:
1. Somatic sensory (afferent) fibers carry i mpul ses from cutaneous and proprioceptive receptors.
2. Visceral sensory (afferent) f i bers carry i mpul ses from t he vi scera.
3. Somatic motor (efferent) fibers carry i mpul ses to skelet al muscle.
4. Vi sceral motor (efferent) fibers carry i mpul ses to smoot h and cardiac muscle and t o glands.
Somatic motor vs. Visceral motor:
Somati c motor neurons are di rected from cort ical level s to skelet al muscles and are vol untary
Visceral motor neurons are directed from the hypothalamus and mi dbrai n and are i nvoluntary, but
have input f rom t he cortex and t halamus
Somatic lower motor neurons are i n t he ventral horn of gray matter and the neurotransmitter at
skelet al muscle i s acetylchol ine
Visceral motor neurons come from cranial nerves or the i ntermediolat eral gray horn, involve t wo neu-
rons, and t he neurotransmitter is either acetylchol ine or norepi nephrine at either cardiac muscl e, smooth
muscle, or glands
( of '' mpalhllll ant.l Paras\ mpalhllll On l'!oiUR'!o
Ftatur\ Symparhttit Parasympalhetic
Origin in CNS Thoracolumbnr (T IL2) (CN Ill, VII. IX. and X; S2-S4)
Location of ganglia ganglia adjacent to Tcmlinal ganglia near or wrthin targcc
spinal column and prcvertebrol organs
ganglia an1crior to rt
Fiber lengths Shon prcganghonic Long preganglionic
Long postganglionic Shon postganglionic
Neuronal divergcne< Extensive (about 1:17) Mmunal {about I :2)
EO.ttcs on system Ol)cn and general More local and spiftc
Prcganghonic Acykhohne Acylcbolanc
neurotransmitter
Postgangl ionic Noradrenaline for sweat
ncurotransmincr glands and adrenal medulla)
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Parasympathetic System
Constricts pupils
Stimulates flow
of saliva
Constricts bronchi
Slows

and secretion
Stimulates bile
release
Contracts bladder
2121
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Sympathetic System
Dilates pupils
Inhibits salivation
Relaxes bronchi
Accelerates heartbeat
Inhibits peristalsis
and secretion
Stimulates glucose
production and release
Inhibits bladder contraction
Stimulates orgasm
212AI
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nervous system
The ciliary, pterygopalatine, submandibular, and otic ganglia are all:
sympathetic ganglia
parasympathetic ganglia
both sympathetic and parasympathetic ganglia
neither sympathetic nor parasympathetic ganglia
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parasympathetic ganglia
Parasympathet ic ganglia are the autonomic gangl ia ofthe parasympathetic nervous system. Most are small
t ermi nal ganglia or intramural ganglia, so named because they lie near or within the organs they i nnervat e.
Parasympathetic ganglia:
CN Ill = Ciliary ganglion- eye - cil iary muscl e (accommodati on of l ens), sphi ncter pupillae muscle
(mi osi s of pupil)
CN VII= Pterygopalatine ganglion- lacrimal gland, oral and nasal mucosa; submandibular gang-
lion- subli ngual and submandibular sal ivary glands
CN IX= Otic ganglion- parotid sal ivary gland
CN X= Terminal ganglia that i nnervate organs i n thorax and abdomen
S2-S4 = termi nal gangl ia that innervat e large i nt esti ne, rectum, genital ia, uret ers, and urinary bladder
*** Neurotransmitter is acetylcholine at pre- and postganglionic synapses.
Sympathetic ganglia: organized i nt o t wo chains that run parallel to and on either side of the spinal cord.
Paravertebral ganglia: lie on each side of the vertebrae and are connected to form the sympathetic
chai n or t runk. There are usually 21 or 23 pai rs of t hese gangl ia: 3 i n the cervical region, 12 i n t he t ho-
raci c region, 4 in t he lumbar region, 4 i n the sacral regi on, and a single, unpai red ganglion lying in f ront
of the coccyx called the ganglion impar.
Cervical ganglia- superior, middle or inferior cervical ganglion
Thoracic, lumbar and sacral ganglia
Prevertebral (or preaort ic) ganglia: provide axons t hat are di stri buted with t he three maj or gastroi n-
testi nal arteries ari si ng from the aorta
Celiac ganglion
Superior and inferior mesenteric ganglion
Inferior hypogastric ganglion
* "* Neurotransmitter is norepinephrine (NE), except on adrenal medulla where it is acetylcholine.
White ramus and gray ramus communicans:
White ramus communicans: all sympathetic preganglionic neurons enter t he paravertebral gan-
gl ion chain via the white ramus communicans. They are whit e because the nerves are myelinated.
Gray ramus communicans: carry unmyel inated postganglionic sympathetic nerves to peripheral
organs. They are gray because they are unmyelinated.
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nervous system
Neurulation is the stage of organogenesis in vertebrate embryos, during
which the neural tube is transformed into the primitive structures that will
later develop into the central nervous system. When does the neurulation
begin?
1" week
3'd week
S'h week
7'hweek
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3'dweek
Duri ng the latter part of the third week of prenatal development the central nervous system begins
to develop in the embryo. Many steps occur during this week to form the beginning of the spinal
cord and brain.
First, a specialized group of cells differentiates from the ectoderm. These cells are the neuroecto-
derm, and they are localized to the neural plate of the embryo. The neural plate is a band of cells that
extends the length of the embryo, from the cephalic end to the caudal end. This plate undergoes fur-
ther growth and thickening, which cause the plate to deepen and invaginate centrally, forming the
neural groove. Near the end of the third week, the neural groove deepens further and is surrounded
by the neural folds. As further growth of the neuroectoderm occurs, the neural folds meet superior
to the neural groove, and a neural tube is formed during the fourth week. The neural tube undergoes
fusion at its most superior portion and forms the future spinal cord as well as other neural tissues.
Important: During the third week, another specialized group of cells, the neural crest cells,
develop from the neuroectoderm. These cells migrate from the crests of the neural folds and
disperse within the mesenchyme. These migrated cel ls are involved in the development of many
face and neck structures, such as the branchial arches.
Note: These neural crest cells are essential in the development of the face, neck, and oral tissues.
Remember: The growth of neural tissue during the fourt h week of prenatal development causes
folding of the embryonic disc into an embryo, establishing for the first time the human axis and plac-
ing tissues in their proper positions for furt her embryonic development.
Neurulation: is the stage of organogenesis in vertebrate embryos, during which the neural tube is
transformed into the primitive structures that will later develop into the central nervous system.
Neurulation begins in the third week with the folding of the ectoderm lying above the notochord,
forming an indentation along the back of the embryo. This indentation is called the neural groove.
Neural tube defects: Closure of the neural tube occurs in the middle, and then moves anteriorly and
posteriorly. Fail ure to close the neural tube anteriorly results in anencephaly, a condition character-
ized by forebrain and skull degeneration, which is always fatal. Failure to close the posterior tube is
known as spina bifida, which in its most severe form is characterized by failure to form the neural
plate.
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nervous system
An endodontist is performing root canal therapy on his anxious dental
patient. His anesthesia has been successful throughout the access prepara-
tion, cleaning, and shaping. Just before he starts to obturate, he sticks a paper
point in the first canal to dry it out. The patient jumps up in pain from the stim-
ulus. Which type of primary afferent fiber carries information related to sharp
pain and temperature?
A-alpha f ibers
A-beta f ibers
A-delta fibers
C -nerve fibers
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A-delta fibers
Primary afferent axons are the nerve fibers connected to the different types of
receptors in the skin, muscle, and internal organs. These pri mary afferent axons come
in different diameters and can be divided into different groups based on their size.
Here, in order of decreasing size, are the different nerve fiber groups: A-alpha, A-
beta, A-delta, and C-nerve fibers. A-alpha, A-beta, and A-delta nerve fibers are
insulated with myelin. C-nerve fibers are unmyelinated. The thickness of the nerve
fiber is correlated to the speed with which information travels in it - the thicker the
nerve fiber, the faster information travels in it.
Important:
A-alpha nerve fibers carry information related to proprioception (muscle sense)
A-beta nerve fibers carry information related to touch
A-delta nerve fibers carry information related to pain and temperature
C-nerve fibers carry information related to pain, temperature, and itch
Autonomic neurotransmitters:
All autonomic preganglionic synapses have Ach as the neurotransmitter (nico-
tinic receptors)
All postganglionic parasympathetic synapses have Ach as the neurotransmitter
(muscari nic receptors)
Most postganglionic sympathetic synapses have NE as the neurotransmitter
(adrenergic receptors)
Sympathetic preganglionic neurotransmitter at adrenal medulla is Ach (nico-
tinic receptor) - release of epinephri ne and norepinephrine (80/20)
Sympathetic postganglionic neurotransmitter at sweat glands is Ach (musca-
rinic receptors)
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nervous system
Which ofthe following cells is the only excitatory cell in the cerebellum?
basket cells
stel late cell s
granule cells
purkinje cells
golgi cell s
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granule cells
The term cerebellum literally means "little brain. It is located dorsal to the brainstem and is con-
nected to the brainstem by 3 pairs of cerebellar peduncles.
Functions:
1. Coordination oft he movement: the cerebellum controls the timing and pattern of muscle ac-
tivat ion during movement
2. Maintenance of equilibrium (in conjugation with the vestibular system)
3. Regulation of muscle tone: modulates spinal and brain stem mechanisms involved in postural
control.
Dysfunction:
1. Ataxia: a disturbance t hat alters the di rection and extent of voluntary movements; abnormal
gait and uncoordinated movements
2. Dysmetria: altered range of motion (misj udge distance)
3. 1ntention tremor: oscillating motion, especially of head during movement
4. Vestibular signs: nystagmus, head ti lt
The cerebellar cortex has three layers:
1. Molecular layer: most superficial, consisting of axons of granule cells (parallel fibers) and bas-
ket and stellate cells
2. Purkinje layer: middle layer consisting of a single layer of large neuronal cell bodies (Purkinje
cells)
3. Granular layer: deepest layer (next to white matter) consisting of small neurons called granule
cells
Cell types of the cerebellar cortex:
1. Purkinje cells: the only output neuron from the cortex utilizes GABA to inhibit neurons in deep
cerebellar nuclei
2. Granule Cells: intrinsic cells of cerebellar cortex; use glutamate as an excitatory transmitter; ex-
cites Purkinje cells via axonal branches called "parallel fibers
3. Basket Cells: inhibitory interneuron; utilizes GABA to inhibit Purkinje cells
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nerve
Preganglionic parasympathetic fibers reach the otic ganglia through
which of the following nerves?
greater petrosal nerve
lesser petrosal nerve
mandibular branch of t ri geminal nerve
vagus nerve
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lesser petrosal nerve
The glossopharyngeal nerve is a mixed nerve (motor and sensory), which originates from
the anterior surface of the medulla oblongata along with the vagus nerve (CN X) and
spinal accessory nerve (CN XI). The glossopharyngeal nerve passes laterally in the
posterior cranial fossa and leaves the skull through t he jugular foramen to supply
sensation to t he pharynx and posterior third of the tongue. The cell bodies of t hese
sensory neurons are located in the superior and inferior ganglia of this nerve. The
glossopharyngeal nerve then descends through the upper part of the neck along with the
internal jugular vein and internal carotid artery to reach the posterior border of the
stylopharyngeus muscle of the pharynx to which the nerve supplies somatic motor
fibers.
The otic ganglion is a small parasympat hetic ganglion that is functionally associated with
the glossopharyngeal nerve. The otic gangli on is located immediately below the
foramen ovale in the inf ratemporal fossa. The ot ic gangl ion is one of four
parasympathetic ganglia of t he head and neck. (the others are t he submandibular
ganglion, pterygopalatine gangli on, and ciliary gangli on). The tympanic and lesser
petrosal branches of the glossopharyngeal nerve supply preganglionic
parasympathetic secretomotor fibers to the otic ganglion. Here the fibers synapse,
and the postganglionic fibers leave t he ganglion and join the auricul otemporal nerve.
As t he auricul otemporal nerve passes the paroti d gland, postgangli onics leave the nerve
to enter the substance of the gland.
Important: Terminal ganglia receive preganglionic fibers f rom the parasympathetic
division. The following cranial nerves also contain preganglionic parasympathetic
fi bers: oculomotor (cil iary ganglion), facial (pterygopalatine and submandibular
ganglia), and vagus (small terminal ganglia).
Note: The vagus nerve (CN X) provides the efferent (motor) limb of the gag reflex,
whereas the glossopharyngeal nerve (CN IX) provides the afferent limb.
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salivary
gland
ganglion
Rootlets of glossopharyngeal nerve
uperior and inferior sensory ganglia
Internal carotid artery
Common carotid artery
Pharyngeal branch
Distribution of the Glossopharyngeal Nen 'e
217-1
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nerve
Your most recent patient presents to your office complaining of severe pain
in his jaws around the temporomandibular (TMJ) joint. He chews three
packs of gum a day, and his wife tells him he grinds his teeth at night. What
nerve provides major sensory innervation to the TMJ?
masseteric nerve
auriculotemporal nerve
facial nerve (CN VI I)
trochlear nerve (CN IV)
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auriculotemporal nerve
The auriculotemporal nerve ari ses f rom the posteri or division of the mandibular
nerve (V3). The auriculotemporal nerve suppl ies the posterior portion of the TMJ.
The nerve to the masseter (masseteric nerve), also a branch of V3, carries a few
sensory fibers to the anterior portion of the TMJ. The deep temporal nerves (anterior,
middle, and posterior branches) innervate the temporal is muscle and carry a few fibers
to the anterior port ion of the TMJ as well.
' ~ 1. Pain impulses from a patient's fractured condylar neck are carried by the
auriculotemporal nerve.
2. Pain (TMJ patient) is transmitted in the capsule and periphery of the disc
by the auriculotemporal nerve.
3. The auriculotemporal nerve carries some secretory f ibers f rom the otic gan-
glion to the parotid sali vary gland.
4. The TMJ, as is the case with all joints, receives no motor innervation. The
muscles that move the joint receive the motor innervation.
S. lts arterial blood supply is provided by the superficial temporal and max-
illary branches of the external carotid artery.
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Medial pterygoid
Zygomatic branch
of facial nerve
Nen'es of the Temporomandibular Region
Rcprodud with pennission from Alfo.t of H11man Anatomy: Springhouse, 2001, Springhouse.
218 1
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nerve
When walking to his car late at night, a professor hears footsteps behind
him. His sympathetic response results in dilated pupils, a dry mouth, and
constriction of blood vessels in his face resulting in an ashen look. The
sympathetic response for the head and neck is mediated by cell bodies
located in the:
superior cervical ganglion
middle cervical ganglion
inferi or cervical gangli on
ganglion impar
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superior cervical ganglion
Paravertebral sympathetic ganglia lie on each side of the vertebrae and are connected to form the
sympathetic chain or trunk. There are usually 21 or 23 pairs of these ganglia: 3 in the cervical region,
12 in the thoracic region, 4 in the lumbar region, 4 in the sacral region, and a single, unpaired gan-
glion lying in front of the coccyx called the ganglion impar.
Sympathetic gangl ia:
1. Cervical ganglia
Superior cervical ganglion: the uppermost and largest, stretching from the level of C1 to
t he level of C2 or C3. This ganglion lies between the internal carotid artery and the internal
jugular vein. The superior cervical ganglion innervates viscera of the head.
Middle cervical ganglion: small, located at the level of the cricoid cartilage. This ganglion
is related to the loop of the inferior thyroid artery. Innervates viscera of the neck, thorax (i.e., t he
bronchi and heart), and upper li mb.
Inferior cervical ganglion: occurs at the C7 vertebral level. Most commonly is fused to the
first thoracic sympathetic ganglion to form a stellate ganglion. Innervates viscera of the neck,
thorax (i.e., the bronchi and heart), and upper limb.
2. Thoracic chain ganglia: send postganglionic fibers to the entire gastrointestinal tract up to the
upper colon
3. Lumbar and sacral ganglia: send postganglionic sympathetic fibers to the digestive tract below
the upper colon, including the rectum, and to the smooth muscle and glands of t he bladder, and
external genitalia.
Horner's syndrome: is the combination of drooping of the eyelid (ptosis) and constriction of the
pupil (miosis), sometimes accompanied by decreased sweating of the face on the same side; redness
of the conj unctiva of the eye is often also present.
Important:
The gray rami connect the sympathet ic trunk to every spinal nerve. The white rami are limit-
ed to the spinal cord segments between T1 and L2.
The cell bodies of the visceral efferent fibers in visceral branches of the sympathetic trunk are
located in the intermediolateral cell column (or lateral horn) of the spinal cord; the cell bodies
of visceral afferent fibers are located in the dorsal root ganglia.
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Sympathetic
nervous system
Proj ections of
sympathetic
nervous system
Blood vessels [ - .
Sweat glands
Smooth muscle -
T12
L1
':.5
51
Eye
..
/
Lacrimal and
:J salivary
--superior
chain
cervical ganglion
\,. ng
:;<,lddle
lrf.-Reproductive
or gans
Parasympathetic
nervous syst em
Thoracic
lumbar
Sacral
Schematic showing t he sympathetic and parasympathetic pathways. Sympathetic pathways are
shown on left and par asympathetic pathways on right. Preganglionics are shown in darker shades
and postganglionics in lighter shades.
219

1
with penniss1on (rom Koeppen BM, Stanton BA: Berne & levy Physiology. cd 6: l'hiladelpbin. 2008. Elscvacr.
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nerve
Which of the following trigeminal nuclei is involved with the proprioception
oftheface?
spinal nucleus
masticatory nucleus
mesencephal ic nucleus
chief nucleus
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mesencephalic nucleus
The axons of the neurons enter the pons t hrough t he sensory root and terminate in one of t he
three nuclei of the trigeminal sensory nuclear complex.
Mesencephalic nucleus is involved with proprioception of the face, t hat is, the feeling of
position of the muscles. Unlike many nuclei within the CNS, the mesencephalic nucleus
contains no chemical synapses but is electrically coupled. Instead, neurons of this nucleus
are pseudounipolar cells receiving proprioceptive information from the mandible, and
sending projections to the motor trigeminal nucleus to mediate monosynaptic jaw j erk
reflexes. It is also the only structure in the CNS to contain the cell bodies of primary afferent
neurons, which are usually contained within ganglia (like the trigeminal ganglion).
Main sensory nucleus (or"chief nucleus" or "pontine nucleus") is a group of second order
neurons whi ch have cell bodies in the dorsal Pons. It receives information about
discriminative sensation and light touch of t he face as well as conscious proprioception of
t he jaw via first order neurons of CN V. Most of the sensory information crosses the midline
and travels to the contralateral ventral posteromedial (VPM) of the thalamus via the Ventral
trigeminothalamic tract. However, information of the oral cavity travels to the ipsilateral
Ventral Posteromedial (VPM) of the t halamus via the dorsal trigeminothalamic tract.
Spinal nucleus (mediates pain and temperature from t he head and neck) can be divided
into three regions along its length; the region closest to the mout h is called subnucleus
orali s, the middle region is called subnucleus interpolaris, and t he region closest to the
tail is called subnucleus caudal is. The pain fibers actually synapse in subnucleus caudal is.
The trigeminal motor nucleus contains motor neurons t hat innervate muscles of t he first
branchial arch. This nucleus is located in the mid-pons.
Nucleus Funcliora
1- Mt'St'aocphahc Propri ocepttoa of thc titoc
2- Moin sensory 0 JscrimintJti\'C' touch oflhc foce
3- Spinal Painftemtlcraturc of the face
Supplies muscles o ~ 1st branchial arch
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nerve
Preganglionic parasympathetic axons are associated with all oft he following
cranial nerves EXCEPT one. Which one is the EXCEPTION?
oculomotor
facial
t ri geminal
glossopharyngeal
vagus
I refer to card 219-1 for illustration]
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trigeminal
There are four pai red gangl ia which supply all parasympathetic i nnervation to the head and neck. They are
t he ci liary ganglion, pterygopalat i ne ganglion, submandibular ganglion, and t he otic ganglion.
Each has t hree root s ent ering t he gangl ion and a variabl e number of exi ti ng branches:
The motor root carri es presynaptic parasympathetic nerve fibers t hat t ermi nat e in t he ganglion by
synapsi ng wit h the postsynapt ic fibers t hat travel to target organs
The sympathetic root carri es postsynaptic sympathetic fibers that t raverse t he ganglion without
synapsi ng
The sensory root carri es general sensory fibers t hat al so do not synapse i n the ganglion
Some gangl ia al so carry special sensory fibers for tast e.
Ganglion Location
Ciliary Posterior part of the orbit
on Lhe late.rnl side of the
optic nerve
Pte-rygopalatine Ouply plac.e-d in the.
pterygopalatine fos.<>a
Submandibular Situatcxl on Lhe late.rnl
surface of the hyoglossus
muscle
Otic Situated j ust below the
foramen ovale and is
medial to the mandibular
P .tr.ts\ mpalhlltc Ganglia
Fibers
Prtgang.lionk panuympMhC'tic fibers from the oculomotor nen e
P(t!ltganglionic parasympalhdic ObC'nl lcavc ganglion in the short
ciliary nen es
Sympathetic libt. n from the internal caroti d plc:xu.'>
Prt'ganglionk !lterttll mutor fibers arise in the lacri mal nudeu.'> of the
facial nerve
Pn!ltgangllonic pan sympalht.'t.ic fi bC" n reach Lhe maxillary nerve by
one o f its ganglionic branches-these reach the- lacri mal gland: others
run in the palati ne and nasal nerves to the palati ne and rw.sal glands
Sympathetic libt. n reach the ganglion via the internal carotid plexus
Prtgang_lionk panuympathr tic ftbtrs reach the ganglion from the
superior salivatory nut leu.'> ufthe facial nen'e via the chorda tympani and
lingual ner\'es
Pn!ltg_anglionic parasympatht.'tic libr n pass to the submandibular
gland. to which they are secretomotor. Other secretomotor fi bers pass to
the sublingual gland
Sympalht.'tic libcn are v.a.'>omotor to the blood ves.'>ds o f the gland.'>
panuympathr tic ftbtrs originate in the
inferior salivatory nucleus ufthe glossopharyngeal nerve
Pt't!llg_anglionic parasympalht.'tic Obr n lca.:e the ganglion and join the
auriculotemporal nerve .. fibers arc secretomotor to the parutjd gland
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nerve
Which of the following cranial nerves is the only nerve that emerges from the
dorsal aspect ofthe brainstem?
t rochl ear nerve (CN IV)
abducens nerve (CN VI)
oculomotor nerve (CN Ill)
optic nerve (CN II)
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trochlear nerve (CN IV)
The oculomotor nerve (CN Ill), trochlear nerve (CN IV), and abducens nerve (CN VI) all exit the
cranium through the superior orbital fissure. They innervate the extrinsic ocular muscles,
resulting in movements of the eyeball.
The trochlear nerve (CN IV) supplies the superior oblique muscle (the muscle that turns the
eyeball inferiorly and laterally), and the abducens nerve (CN VI) supplies the lateral rectus of the
eye. Note: The trochlear nerve is the smallest cranial nerve and the only cranial nerve that
emerges from the dorsal (back) aspect of the brain stem and innervates contralateral structures.
The oculomotor nerve supplies the following extraocular muscles: medial, superior, and inferior
recti; inferior oblique; and levator palpebrae superioris. The oculomotor nerve sends
preganglionic parasympathetic fibers to the ciliary ganglion. The postganglionic fibers leave the
ganglion in the short ciliary nerves to supply the sphincter pupillae and the cil iary muscle.
Note: In most cases, ptosis is caused by either a weakness of the levator muscle (muscle that raises
the lid), or a problem with the oculomotor nerve.
Edinger-Westphal nucleus: it contains the parasympathetic ganglionic cells, whose efferent axons
in the oculomotor nerve travel to the ciliary ganglion in the orbits where they are relayed to post-
ganglionic neurons, whose fibers innervate the pupillary sphincter in the anterior eye. The nucleus is
located posterior to the oculomotor nucleus and is also known as t he accessory oculomotor nucleus.
The pupillary light reflex: is a reflex that controls the diameter of the pupil, in response to the in-
tensity (luminance) of light that falls on the retina of the eye, thereby assisting in adaptat ion to vari-
ous levels of darkness and light, in addition to retinal sensitivity. Greater intensity light causes t he
pupil to become smaller (all owing less light in), whereas lower intensity light causes the pupil to be-
come larger (allowing more light in). Thus, the pupillary light reflex regulates the intensity of light
enteri ng the eye. The optic nerve, or more precisely, the photosensitive ganglion cells through the
reti nohypothalamic tract, is responsible for the afferent limb of the pupillary reflex - it senses the in-
coming light. The oculomotor nerve is responsible for the efferent limb of the pupillary reflex- it
drives the muscles that constrict the pupil.
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nerve
The splanchnic nerves (greater, lesser, and least) arise from the:
cervical sympathetic ganglion (chain)
thoracic sympathetic ganglion (chain)
lumbar sympathetic ganglion (chain)
sacral sympathetic ganglion (chain)
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thoracic sympathetic ganglion (chain)
Remember: Paravertebral sympathetic ganglia li e on each side of the vertebrae
and are connected to form the sympathetic chain or trunk. These nerves ari se from
thoracic ganglia (TS- T12). Note: They all pass through the diaphragm.
The preganglionic sympathetic fibers may pass through the paravertebral gangli a
on the thoracic part of the sympathetic trunk without synapsing to terminate in the
prevertebral ganglia. These myeli nated fibers form the splanchnic nerves, of which
there are three:
1. Greater- formed from sympathetic fibers from TS- T9. The nerve passes through
the crura of the diaphragm to end in the celi ac ganglion.
2. Lesser - formed from sympathetic fibers from TlO- Tll. The nerve passes through
the diaphragm with the greater to end in the aorticorenal ganglion.
3. Least- ari ses from the last thoracic gangli on, and, piercing the diaphragm, ends
in the renal plexus.
Important: Thoracic splanchnic nerves (specifically the greater splanchnic nerve) to
the celiac plexus consist primaril y of preganglionic vi sceral efferent fibers. The
postganglionic fibers arise from the excitor cell s in the celi ac plexus and are
distributed to the smooth muscle and glands of the viscera.
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nerve
Which ofthe following nerves penetrates the cricothyroid membrane?
Select all that apply.
recurrent laryngeal nerve
facial nerve
accessory nerve
internal laryngeal nerve
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recurrent laryngeal nerve
Both recurrent laryngeal nerves pass deep to the lower margin of the inferior constrictor
muscle to innervate the intrinsic muscles of the larynx responsible for controlling the
movements of the vocal folds.
The right recurrent laryngeal nerve innervates:
All of the muscles of the larynx, except the cricothyroid, which is supplied by the extern-
al laryngeal branch of the superior laryngeal nerve
The mucous membrane of the larynx below the vocal folds
The mucous membrane of the upper part of the trachea
Note: This nerve comes in contact with the thyroid gland and comes into close relationship
with the inferior thyroid artery
The left recurrent laryngeal nerve innervates:
The same muscles and mucous membranes as the right recurrent laryngeal, except on the
left side
*** The right recurrent laryngeal nerve splits from the right vagus before entering the
superior mediastinum at the level of the right subclavian artery. The nerve hooks posteriorly
around the right subclavian artery and also ascends in the groove between the esophagus and
trachea.
***The left vagus gives rise to the left recurrent laryngeal nerve.
~ 1. Recurrent laryngeal. nerves are vulnerable during thyroid surgery. If one is damaged
.. ")1iiS'1 the quality of voiCe w1ll be affected resulting 1n hoarseness (rough vo1ce).
~ . 4 1 t / 2. The recurrent laryngeal nerve penetrates the cricothyroid membrane from behind
of the cricothyroid joint.
3. The left laryngeal nerve, which is longer, branches from the vagus nerve to loop
under the arch of the aorta, posterior to the ligamentum arteriosum before ascending.
On the other hand, the right branch loops around the right subclavian artery.
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Right recurrent laryngeal nerve---1- ""Tl
Inferior cardiac
Pulmonary
Esophageal plexus
Cellae ganglion and plexus
Superior mesenteric
Pyloric
Renal
Hepatic flexure
Vagus Nerve Di stribution
recurrent laryngeal nerve
to small and largo Intestine
224-1
-.h. pennw.on &om A tillS of HffMIIfl A .. aro.r.; Spnngl:lottsc. 1001. $prulgbouK
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nerve
The hypoglossal nerve travels from the carotid triangle into the
submandibular triangl e of the neck.
This nerve is a motor nerve supplying all of the intrinsic and extrinsic
muscles of the tongue, except the palatoglossus, which is supplied by the
facial nerve.
both statements are t rue
both statements are false
the first statement is t rue, the second is false
the first statement is fa lse, the second is true
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the first statement is true, the second is false
The hypoglossal nerve leaves the skull through the hypoglossal canal medial to the
carotid canal and jugular foramen. Note: The jugular foramen all ows for the exit of
the spinal accessory nerve from the cranial cavity. Soon after the hypoglossal nerve
leaves the skull through the hypoglossal canal, it is joined by Cl and C2 fibers from
the cervical plexus. Important: The hypoglossal nerve travels from the carotid
triangle into the submandibular t riangle of the neck. This nerve is a motor nerve
supplying all of the intrinsic and extrinsic muscles of the tongue, except the
palatoglossus, which is supplied by the vagus nerve.
Lesions of the hypoglossal nerve:
Unilateral lesions of the hypoglossal nerve result in the deviation of the protrud-
ed tongue toward the affected side. This is due to the lack of function of the genio-
glossus muscle on the diseased side.
Injury of the hypoglossal nerve eventually produces paralysis and atrophy of
the tongue on the affected side with the tongue deviated to the affected side.
Dysarthria (inabil ity to articulate) may also be found.
Important: If the genioglossus muscle is paralyzed, the tongue has a tendency to
fall back and obstruct the oropharyngeal airway with ri sk of suffocation.
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Hypoglossal Nerve- Cranial Nerve XII
Supplies the muscles of the tongue
2251
Reproduced wilh pcnnission from Spenc-e AP, Mason EB: Huma11 Anammyaml ed 4; St Paul. 19'1)2. Wesl Publislung Company.
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nerve
After depositing enough lidocaine 2% to anesthetize the nerve entering
the mandibular foramen, a dental student removes the needle to approxi -
mately half the depth of the initial target, whereupon another bolus of anes-
thetic is deposited. What nerve is most likely anesthetized by the second
bolus?
hypoglossal nerve
long buccal nerve
inferi or alveolar nerve
li ngual nerve
glossopharyngeal nerve
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lingual nerve
The lingual nerve is a branch of the mandibular division (V3) of the tri geminal
nerve. It suppli es general sensation for the anterior two-thirds of the tongue, the
floor of the mouth, and mandibular lingual gingiva. Note: The submandibular duct
has an intimate relation with t he lingual nerve, which crosses it twice.
The lingual nerve descends deep to t he lateral pterygoid muscl e, where the nerve is
joined by the chorda tympani (branch of the facial nerve), which conveys the
preganglionic parasympathetic fibers to the submandibular ganglion and taste
fibers from the anterior two-thirds of t he tongue.
Important: If you cut t he li ngual nerve after its junction with t he chorda tympani, t he
tongue would have a loss of taste and tactile sense to the anterior two-thirds.
1. The chorda tympani emerges from a small canal in the posterior wall of
the tympanic cavity (petrotympanic fissure) after crossing t he medial
surface of the tympanic membrane. It joins the l ingual nerve in t he
infratemporal fossa.
2. The chorda tympani nerve conveys general visceral efferent fibers
(motor fibers) of the parasympathetic division of the autonomic nervous
system to the submandibular gangli on. It also carries special visceral
afferent fibers for taste.
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The pathway of the posterior trunk ofthe mandibular
nerve ofthe trigeminal nerve is highlighted
226 1
with pcnn is..-.ion from Fchrcnbach MJ, Hcning SW; llluslril tcd Anatomy of the Head and Ncl' k. cd 3; St. Louis. 2007. Saunders.
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Lateral pterygid nerve
Lateral pterygoid--::..-..-...::---;
muscle
Buccal nerve -l'-----l'lllllif-:
on of
horda tympani nerve
In petrotympanic
fissure
Masseteric nerve
The pathway of the anterior tr unk of the mandibular
nerve of the trigeminal nerve is highlighted
226AI
with pcnn is..-.ion from Fchrcnbach MJ, Hcning SW; llluslriltcd Anatomy of the Head and Ncl'k. cd 3; St. Louis. 2007. Saunders.
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nerve
The lesser petrosal nerve carries preganglionic parasympathetic fibers to
which of the following ganglia?
otic ganglia
geniculate ganglia
submandibular gangli a
subli ngual ganglia
I refer to card 217-1 for illustration]
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otic ganglia
The glossopharyngeal nerve innervates the stylopharyngeus muscle (via the
muscular branch). It is the only muscle that is suppl ied by this nerve. This muscle is a
landmark for locating the glossopharyngeal nerve because as the nerve enters the
pharyngeal wall, it curves posteriorly around the lateral margin of this muscle.
In addit ion to the somatic motor innervation of the stylopharyngeus, the
glossopharyngeal nerve suppl ies pregangli onic parasympathetic motor fibers to the
otic ganglion. These fibers synapse with the postganglionic fibers in the gangli on to
supply the parotid gland.
The preganglionic nerves leave the glossopharyngeal nerve as the tympanic nerve,
which enters the middle ear cavity and participates in the formation of the tympanic
plexus. The tympanic nerve reforms as the lesser petrosal nerve, leaves the cranial
cavity through the foramen ovale, and enters the otic gangl ion. Postganglionics are
carried by the auri culotemporal nerve (V3) to the parotid gland.
Visceral sensory branches of the glossopharyngeal nerve:
Lingual branches - are two in number; one suppli es the vallate papillae and the
mucous membrane covering the base of the tongue; the other suppli es the
mucous membrane and foll icular glands of the posterior one-third of the
tongue, and communicates with the lingual nerve.
Pharyngeal - distributed to the mucous membrane of the pharynx. Is the
sensory limb of the gag reflex.
Carotid sinus nerve - to carotid sinus (baroreceptor) and carotid body
(chemoreceptor)
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salivary
gland
ganglion
Rootlets of glossopharyngeal nerve
uperior and inferior sensory ganglia
Internal carotid artery
Common carotid artery
Pharyngeal branch
Distribution of the Glossopharyngeal Nen 'e
217-1
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nerve
The cervical plexus consists of anterior rami from Cl - C4; some ofthese fibers
reach the hyoid muscles by running concurrently with which cranial nerve?
phrenic nerve
vagus nerve
glossopharyngeal nerve
spinal accessory nerve
hypoglossal nerve
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hypoglossal nerve
Adjacent ventral rami will form complex interwoven networks of nerve fibers (axons} known as
a nerve plexus. Four plexuses - cervical, brachial, lumbar, & sacral emerging from each plexus
will be specifically named peripheral nerves, which will contain fibers from multiple spi nal cord
levels.
1. Cervical plexus (C1-C4} - provides cutaneous innervation to the skin of the neck, should-
er, and upper anterior chest wall as well as motor innervation to the infra hyoid (strap} mus-
cles and geniohyoid muscle. The major nerve branches are:
Ansa cervical is (C1-C3}: supplies infra hyoid muscles except for thyrohyoid which is sup-
plied by C1 only
Phrenic nerve (C3-CS}: supplies t he diaphragm
Great auricular nerve (C2 and C3}: It provides sensory innervation for the ski n over
parotid gland and mastoid process, and both surfaces of the outer ear
2. Brachial plexus (CS-CS and T1} - formed in the posterior triangle of the neck, the brachial
plexus extends into the axilla, supplying nerves to the upper limb.
It has three cords:
posterior - axillary and radial nerves are main branches
lateral - musculocutaneous nerve is main branch
medial - ulnar nerve is main branch
Note: The median nerve forms its two heads (medial and lateral} from the medial and
lateral cords.
3. Lumbar plexus (L 1-L4}- formed in the psoas major muscl e, the lumbar plexus supplies
the lower abdomen and parts of the lower limb. Main branches are the femoral and obt-
urator nerves.
4. Sacral plexus (L4-LS and Sl -54} - lies in t he posterior pelvic wall in front of
the piriformis muscle. The sacral plexus supplies the lower back, pelvis, and parts of
t he thigh, leg, and foot. The main branch is the sciatic (largest nerve in t he body).
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The Cervical Plexus
Hypoglossal nerve (XII) ------
--------- Cl
--- Lesser occi pital nerve
---.,;:..,r#-- Great auricular nerve
22111
Phrenic nerve
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cs
(6
C7
(8
Tl
The Brachial Pl exus
Musculocutaneous
nerve
\ - !:...._---+ Radial nerve
228 A l
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Anterior divisions
- Posteri ordivisions
Iliohypogastric nerve
Ilioingui nal nerve
Genitofemoral nerve
lateral femoral
cutaneous nerve
Obturator nerve
Femoral nerve
The Lumbar Plexus
T12
L1
228 ~
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nerve
The branch of the trigeminal nerve that innervates the midface, palate and
paranasal sinuses exits the cranial cavity through which structure?
superior orbital fissure
optic canal
foramen rotundum
pterygomaxillary fissure
foramen ovale
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foramen rotundum -the nerve is the maxillary nerve
The ophthalmic division (V1) enters the orbit through the superior orbital fissure and provides
sensory innervation to the eyeball, t ip of the nose, skin over the upper eyelid, and skin of the face
above the eye. Branches include the lacri mal, frontal, nasociliary, supraorbital, supratrochlear,
infratrochlear, and ext ernal nasal nerves. Note: The skin of the lower eyelid is supplied by branches
of the infrat rochlear at the medial angle, the rest is supplied by branches of the infraorbital nerve of
t he maxillary division (V2).
l .During a sinus attack, painful sensation from the ethmoid cells is carried in the
nasociliary nerve.
2. The ophthalmic nerve is purely sensory.
3. The ophthalmic nerve i s often infected with the herpes zoster virus, whereas
invol vement of the lower two divi sions is rare.
The maxillary division (V2) passes through the foramen rotundum and provides sensory
innervation to the midface (below the eye and above the upper lip), palate, paranasal sinuses, and
t he maxillary teeth.
1. The tickling sensation felt in the nasal cavity j ust prior to a sneeze is carried by the
maxillary division of trigeminal. Branches include the infraorbital, zygomaticofacial,
and zygomaticotemporal nerves.
2. The maxillary nerve is purely sensory.
3. 1t's most frequent ly affected by tic doulourex (trigeminal neural gia).
Sensory innervation of mandibular division (V3) is to the skin of the cheek, the skin of the
mandibl e, and the lower lip and side of the head. Sensory innervation also includes the TMJ,
mandibular teeth, the mucous membranes of the cheek, the fl oor of the mouth, and the anterior
part of the tongue. Branches include the mental, buccal, and auriculotemporal nerves.
Important: The t rigeminal nerve contains no parasympathetic component at its origin. The
nerves branches are used by the ocul omotor, facial, and gl ossopharyngeal nerves to distribute their
preganglionic parasympathetics fibers to the parasympathetic head ganglia.
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Maxillary nerve
(V2)
\
The general pathway of the trigeminal or fifth cranial ner ve
and its motor and sensory roots and three divisions
Trigeminal
nerve
2291
Reproduced wilh pcnnission from fehrenbach MJ, Hcni ng SW; AIWI<ml)' of the Head and Neck. ed J: St. Louis.. 2007. Saund<'rs.
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\
The pathway of the maxillary nerve ofthe trigeminal nerve is highlighted
229 A l
Rqlroduccd wuh pem1issuln from MJ. Herring SW; 11/u:urated Anatomy of tl1e Nead and Neck, f'(l J; St Louis. 2007. Saunders.
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nerve
The mylohyoid nerve is derived from the inferior alveolar nerve just before
it enters the mandibular foramen. The mylohyoid nerve descends in a
groove on the deep surface of the ramus of the mandible, to supply the
mylohyoid and what other muscle?
anteri or digastric
geniohyoid
stylohyoid
genioglossus
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anterior digastric
Function of mylohyoid: elevates hyoid bone, base of tongue, and floor of mouth. The
mylohyoid line, which gives origin to the mylohyoid, is found on the body of the
mandible. The sublingual gland is located superior to the mylohyoid muscle. When film is
placed for a periapical view of the mandibular molars, it is the mylohyoid muscle that get s
in the way if it is not relaxed. Important: Swelling at the angle of the mandible and the
lateral neck is often the result of deflection of exudates by t he mylohyoid muscle.
Suprahyoid muscles:
- Digastric muscles
- Anterior belly: innervated by nerve to the mylohyoid, which is a branch of the
mandibul ar division of the trigeminal nerve
-Posterior belly: innervated by the facial nerve
- Mylohyoid muscle: innervated by nerve to the mylohyoid, which is a branch of the
mandibular division of the trigeminal nerve
- Geniohyoid muscle: innervated by the first cervical nerve through the hypoglossal
nerve
- Stylohyoid: innervated by the facial nerve
lnfrahyoid muscles:
- Omohyoid muscle: innervated by ansa cervical is- Cl, 2, and 3
- Sternohyoid muscle: innervated by ansa cervicalis- Cl , 2, and 3
- Sternothyroid muscle: innervated by ansa cervical is - Cl, 2, and 3
- Thyrohyoid muscle: innervated by the first cervical nerve, which accompanies the
hypoglossal nerve to the suprahyoid region, and then branches from it to reach the
thyrohyoid muscle
Remember: The mylohyoid nerve arises from the inferior alveolar nerve, a branch of the
mandibular division (V3) of the trigeminal nerve (V).
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nerve
Which of the following nerves innervates the medial rectus muscle of the
eyeball?
optic
olfactory
oculomotor
trochl ear
abducens
ophthalmic (Vl)
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oculomotor
Nerve Site of Exit from Skull Component Function
OlfactOC')'(CNI) Clibntbrm plmc of ethmoid bon-e Spial 5tnsory
(special afferent)
Sense of smell
Optic(CN IJ) Oplic foramen
(kulomotor(CN Ill) SUt)Crior orbJtal ti.ssurc
Troc-hlcar(CN IV) Supcriororbltal ti.ssurc
Abducens {CN VI) Superior orbnal ti.ssurc
Spial 5ensory
(special nffcrent)
Conveys visual
infom1auon from the re-tina
Somatic motor Supplies four of the six
(general somatic cfiercnt) extraocular muscles of1bc
eye and the levator palpebrae
supcrioris musdc of the
uppcrcychd
Vi.sral motor Par.-.sympathctlC inncrvalion
(gencrnl vise<ral of the constrictor pupillae
nnd dha1y muscles
Somatic motor lnmr\'atcsth<: supcnor
(general somatic cfrcn-nt) obhqu(' musc-le
Somatic motor lnncrvatc:stbc I:Jtcrul rc<:tus
(gcnc-ml somatic efferent) musdc
Remember: The abducens (CN VI) nerve innervates the lateral rectus muscle of the eye. The lateral
rectus muscle is responsible for lateral gaze (its contraction causes the eye to be abducted). A lesion
of this nerve results in medial strabismus (cross-eyed) and diplopia (double vision).
Note: Every cranial nerve that innervates the eye (CN Ill, IV, Vl, VI) passes through the superior or-
bital fissure except for the opt ic nerve which goes through the optic foramen.
The corneal reflex, also known as the blink reflex, is an involuntary blinking ofthe eyelids elicited by
stimulation of the cornea (such as by touching or by a foreign body), or bright light, though could re-
sult from any peripheral stimulus. Stimulation should elicit both a direct and consensual response
(response of the opposite eye). The reflex consumes a rapid rate of 0.1 second. The evolutionary pur-
pose of this reflex is to protect the eyes from foreign bodies and bright lights (the latter known as the
optical reflex). The reflex is mediated by:
The nasociliary branch of the ophthalmic branch (Vl) of the 5th cranial nerve (trigeminal nerve)
sensing t he stimulus on the cornea, lid, or conjunctiva (i.e., it is the afferent).
The 7th cranial nerve (facial nerve) initiating the motor response (i.e., it is the efferent).
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Oculomotor Nerve
SuperiL rectus
Inferior oblique
Medial rect us
Oculomotor
nerve (Ill)
2311
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Olfactory Nerve- Cranial Nerve I
231AI
Rcproduc.:>ed with pennission from Spence AP. Ma.mn I!B: liuman Am'IIOmy tmd PIJy.fiolfJg)'. ed 4: St. Paul. 1992. Wcsl Publ11ihing Company.
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Optic Nerve- Cranial Nerve II
231 B l
Reproduoc-d with from Sp.:ncc AP. i\1la.wn I::B: Human A11atomy tmd ed 4: St. Paul. 1992. Wcs1 Publ1shing Company.
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.
oblique
muscle
''"'---jf
.

Abducens
nerve
Trochlear Nerve - Cranial Nerve IV
orbital
fissure
231 C l
Reproduoc-d with pennission from Spence AP. Mason EB: AJJatomy tmd PIJ.}'.fiology. ed 4: St. Ptml. 1992. Wcs1 Publ1shing Company.
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nerve
The principal types of nerves found in the dental pulp are:
parasympathetic and efferent fibers
sympathetic and afferent fibers
sympathetic and efferent f ibers
parasympathetic and afferent fibers
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sympathetic and afferent fibers
The sensory nerve fibers in the dental pulp originate in the trigeminal ganglion and
are categorized, f rom smal lest to largest diameter, into (-fibers, A-delta, and some A-
beta fibers. On the other hand, postgangli onic sympathetic nerve fibers originate in
the superior cervical ganglion. A-delta fibers are myelinated low-threshold mechano-
receptors and are responsible for the so-called "first pain si gnal:' (-fibers are un-
myelinated, high-threshold fibers. They are termed poly-nodal because they respond
to several types of stimuli such as mechanical, chemical, or thermal stimulation of the
pulp. (-fibers most likely mediate the sensation of "second pain:' Note: The pulp con-
tains both myelinated and unmyelinated nerve fibers.
Tooth pulp consists of a loose type of connective t issue. Its main components are thin
col lagen fibers arranged asymmetricall y plus a ground substance containing gly-
cosaminoglycans. Tooth pulp is a highly innervated and vascularized t issue. Numer-
ous fibroblasts are present. Surrounding the pulp and separating it from the dentin are
the odontoblasts.
Important: Pain originates in the pulp due to free nerve endings (afferent f ibers),
which are the only type of nerve endings found in the pulp and are specific receptors
for pain. Regardless of the source of stimulation (heat, cold, and pressure), the only re-
sponse will be pain. Note: Vasomotor sympathetic fibers are thought to end on blood
vessels.
Functions ofthe pulp:
1. Nutritive - very rich blood supply that surrounds the odontoblasts.
2. Formative - peri pheral layer of pulp cells gives rise to the odontoblasts that form
dentin.
3. Sensory - free nerve endings that make contact with the odontoblasts.
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nerve
Which ofthe following cranial nerves has visceral sensory innervation?
t ri geminal nerve
facial nerve
vagus nerve
hypoglossal nerve
I refer to card 224-1 for illustration]
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vagus nerve
The vagus nerve is a mixed nerve that leaves the brain from the medulla and passes out of the
cranial cavity through the jugular foramen. The vagus nerve descends in the neck in the
carotid sheath behind the internal and common carotid arteries and the internal jugular vein.
Both right and left vagal trunks pass through the posterior mediastinum on the esophagus
and enter the abdominal cavity with the esophagus. The vagus nerves supply the viscera of the
neck, thorax, and abdomen to the left colic (splenic) flexure of the large intestine. The vagus
nerve consists of the following components:
Component
Somatic (Branchial) Motor
\ Cr.mi.ll '\crH \.
Function
To dte soft palate; pharynx; intrinsic laryngeal muscles (phonation); and a
nominal exrrinsic tongue muscle. the palawg1ossus, which is actually a
palatine muscle based on its derivation and innervation
l,ropriocepthe To rhe muscle..; lis ted above
(l,arasympathetic) Motor To dtoracic and abdominal viscera
Somatic (General) Sensory From the infe-rior pharynx, and lal')' llX
Vbceral Sensory r-rom the thomcic and abdominal organs
Taste and Somatic (General) Sensation r-rom the I'OOt of the tongue and taste buds on the epiglonis. Branches of the
internal laryngeal ne-l've (a bmnch of CN X} supply a small area. mostly
somatic (ge.neml) sensory but also some special sensation (taste)
1. The abdominal viscera below the left colic flexure and the pelvic and genitalia
are supplied with preganglionic parasympathetic fibers from the pelvic splanchnic
nerves.
2. The pharyngeal plexus of nerves contains both motor and sensory components.
The motor nerves are believed to come from the vagus nerve.
3. The vagus nerve forms the efferent limb of the gag reflex.
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Right recurrent laryngeal nerve---1- ""Tl
Inferior cardiac
Pulmonary
Esophageal plexus
Cellae ganglion and plexus
Superior mesenteric
Pyloric
Renal
Hepatic flexure
Vagus Nerve Di stribution
recurrent laryngeal nerve
to small and largo Intestine
224-1
-.h. pennw.on &om A tillS of HffMIIfl A .. aro.r.; Spnngl:lottsc. 1001. $prulgbouK
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nerve
Which ofthe following is a component ofthe optic disc or papilla?
central artery
cones
sensory efferent fibers
myel inated nerve fibers
oculomotor nerve
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central artery
The optic disc (also called the optic papi ll a) is the small blind spot on the surface of
the retina, located about 3 mm to the nasal side of the macula. The optic disc is the
only part of the retina that contains no photoreceptors (rods or cones). The disc
consists of unmyelinated axons of gangli on cell s exiting the retina to form the optic
nerve. These fibers become myelinated posterior to the optic disc and are
accompanied by the central artery and vein of the retina.
The optic nerve has only a special sensory component. Special sensory conveys
vi sual information from the retina (special afferent). Visual information enters the
eye in the form of photons of li ght that are converted to electrical signals in the retina.
These signals are carried via the optic nerves, chiasma, and tract to the lateral
geniculate nucleus of each thalamus and then to the visual centers of the brain for
interpretation.
Remember: After exiting the eye at the optic disc, the two optic nerves (one from
each eye) meet at the optic chiasma. It is here that the axons from the medial (nasal)
half of each retina cross to the opposite side, while those from the lateral half of
each retina remain on the same side. From the optic chiasma, axons that perceive the
left visual field form the right optic tract. These optic t ract fibers synapse in the lateral
geniculate nuclei with geniculocalcarine fibers (optic radiations) that terminate on
the banks of the calcarine sulcus in the primary visual cortex (Brodmann's area 17) of
the occipital lobe. Thus, the right visual field is interpreted in the left hemisphere of
the brai n and vice versa.
Note: The central artery of the retina, a branch of the ophthalmic artery, pierces the
optic nerve and gains access to the retina by emerging from the center of the optic
disc.
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Opdcchlil5m

nudeus
Superior
colliculus
Left
The Vi sual Proj ection Pathway
U.C:.ral

nucleus ofthe
thalamus
2l41
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nerve
Which of the following ganglia receives fibers from the motor, sensory, and
parasympathetic components of the facial nerve and sends fibers that will
innervate the lacrimal, submandibular, and sublingual glands?
the semilunar ganglion
the geniculate ganglion
the otic gangli on
the cili ary ganglion
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the geniculate ganglion
The geniculate ganglion is an L-shaped collection of fibers and sensory neurons of the facial nerve
located in the facial canal of the head. The geniculate ganglion receives fibers from the motor, sen-
sory, and parasympathetic components of the facial nerve and sends fibers that will innervate the
lacrimal glands, submandibular glands, sublingual glands, tongue (anterior two-thirds), palate, phar-
ynx, external auditory meatus, stapedius, posterior belly of the digastric muscle, stylohyoid muscle,
and muscles of facial expression.
Sensory and parasympathetic inputs are carried into the geniculate ganglion via the nervus inter-
medius. Motor fibers are carried via the facial nerve proper. The greater petrosal nerve, which car-
ries sensory fibers as well as preganglionic parasympathetic fibers, emerges from the anterior
aspect of the ganglion.
Important branches of the intrapetrous part of the facial nerve:
The greater petrosal nerve arises from the facial nerve at the geniculate ganglion. The nerve
contains preganglionic parasympathetic fibers that pass to the pterygopalati ne ganglion and are
there relayed through the zygomatic and lacrimal nerves to the lacrimal gland; other postgan-
glionic fibers pass through the nasal and palatine nerves to the glands of the mucous membrane
of the nose and palate. The nerve also contains many taste fibers from the mucous membrane of
the palate. The nerve emerges on the superior surface of the petrous part of the temporal bone
and runs forward to enter the foramen lacerum. It is here joined by the deep petrosal nerve
from the sympathetic plexus on the internal carotid artery and forms the nerve to the pterygoid
canal (vidian nerve). This passes forward and enters the pterygopalatine fossa, where it ends in the
pterygopalatine ganglion. Note: The loss of lacrimation (dry eye) can be due to an injury to the
greater petrosal nerve.
The nerve to the stapedius arises from the facial nerve to supply the stapedius muscle.
The chorda tympani arises from the facial nerve just above the stylomastoid foramen. The nerve
leaves the tympanic cavity through the petrotympanic fissure and enters the infratemporal fossa,
where the nerve joins the lingual nerve. The chorda t ympani contains many taste fibers from
the mucous membrane covering the anterior two-thirds of the tongue, and the floor of the mouth.
The nerve also contains preganglionic parasympathetic secretomotor fibers that reach the sub-
mandibular ganglion and are there relayed to t he submandibular and sublingual salivary glands.
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nerve
The left optic tract contains:
fibers from the left eye only
fibers from the right eye only
fibers from the nasal half of the left eye and temporal half of the right eye
fibers from the temporal half of the left eye and nasal half of the right eye
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fibers from the temporal half of the left eye and nasal half of the right eye
The optic nerve (CN II) ari ses from axons of ganglion cells of the retina, which
converge at the optic disc. The optic nerve leaves the orbital cavity by passing
through the optic foramen (also called optic canal) of the sphenoid bone with the
ophthalmic artery and then enters the cranial cavity. The nerves on both sides join
one another to form the optic chiasma. Here, the nerve fibers that ari se from the
medial (nasal) half of each retina cross the midline and enter the optic tract of the
opposite side; the fibers from the lateral (temporal) half of each retina pass posteriorly
in the optic tract of the same side.
The optic tract emerges from the posterolateral angle of the optic chiasma and passes
backward around the lateral side of the midbrain to reach the lateral geniculate body.
Remember: The optic nerves carry impulses associated with vision. Like the
olfactory nerves, the optic nerves are entirely sensory. The optic nerves are actually
brain tracts rather than true nerves, since the optic nerves are formed from
outgrowths of the embryonic diencephalon.
Note: The optic nerve fibers originating from the nasal halves of the retina cross in the
optic chiasm. The fibers from the temporal halves do not cross but continue on the ip-
sil ateral side. Hence, the ri ght tract contains the fibers from the temporal half of the
right eye and from the nasal half of the left eye. The left tract contains fibers from the
temporal half of the left eye and from the nasal half of the ri ght eye.
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nerve
Which statement concerning the left vagus nerve is FALSE?
it can be cut on the lower part of the esophagus to reduce gastric secretion (termed
a vagotomy)
it forms the anterior vagal trunk at the lower part of the esophagus
it passes in front of the left subclavian artery as it enters the thorax
it contains parasympathetic postganglionic f ibers
it contributes to the anterior esophageal plexus
I refer to card 224-1 for illustration]
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it contains parasympathetic postganglionic fibers
*** This is false; the vagus nerve carries parasympathetic preganglionic fibers to the
t horacic and abdominal viscera.
The left vagus nerve enters the thorax in front of t he left subclavian artery and behind the
left brachiocephalic vein. The nerve then crosses t he left side of t he aortic arch and is i tself
crossed by t he left phrenic nerve. The left vagus nerve passes behind the root of the left lung,
forms the pulmonary plexus, and continues to form the esophageal plexus. The left vagus
nerve enters the abdomen in front of the esophagus through the esophageal hiatus of the
diaphragm as the anterior vagal trunk (reaches t he anterior surface of the stomach).
Note: The vagus nerves lose their identity in the esophageal plexus. At the lower end of the
esophagus, branches of the plexus reunite to form an anterior vagal trunk (anterior gastric
nerve), which can be cut (vagotomy) to reduce gastric secretion.
The right vagus nerve crosses the anterior surface of the right subclavian artery and enters
t he thorax posterior to the right brachiocephalic vein, lateral to the trachea, and just
posterior to the arch of the azygos vein. The nerve passes posterior to the root of the right lung,
contributing to the pulmonary plexus. The nerve also contributes to t he esophageal plexus.
The nerve enters the abdomen behind the esophagus through the esophageal hiatus of the
diaphragm as the posterior vagal trunk (reaches the posterior surface of the stomach).
The Vagus Nerve (CN X)- General Functions:
Motor to and sensory from the larynx
Motor to palatoglossus muscle
Motor to all of the muscles of the pharynx except the stylopharyngeus (from CN IX) and all
muscles of t he soft palate except the tensor veli palatini (from mandibular division of CN V)
Conveys taste from area around epiglottis
Sensory from external auditory meatus
Afferent from viscera above left (splenic) colic flexure
Parasympathetic to the lungs, heart, stomach, and myenteric plexus
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nerve
Which of the following nerves penetrates the thyrohyoid membrane?
facia I nerve
internal laryngeal nerve
accessory nerve
recurrent laryngeal nerve
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internal laryngeal nerve
The vagus nerve possesses two sensory ganglia:
1. Superior ganglion - lies on nerve within the jugular foramen
2. Inferior ganglion - lies on nerve just below the j ugular foramen
Branches that arise from the superior ganglion:
Meningeal - supplies dura mater
Auricular - supplies auricle, external auditory meatus
Branches that arise from the inferior ganglion:
Pharyngeal - forms pharyngeal plexus, supplies all of the muscles of the pharynx, except the
stylopharyngeus muscle (innervated by glossopharyngeal nerve) and all of the muscles of t he
soft palate, except the tensor veli palatini (innervated by mandibular nerve, V3).
*"'*It joins branches from the glossopharyngeal nerve and the sympathetic trunk, to form the
pharyngeal plexus.
Superior laryngeal - divides into:
- Internal laryngeal - ravels with superior laryngeal artery and pierces the thyrohyoid
membrane. Supplies mucous membranes of the larynx above the vocal folds.
- External laryngeal - travels with superior thyroid artery and supplies the cricothyroid
muscle.
*"'* Remember: The recurrent laryngeal nerve penetrates t he cricothyroid membrane from behind
of the cricothyroid j oint
Nucleus ambiguus: is located in t he ventrolateral medulla in it s upper half. It is a column of motor
neurons that sends its axons to the cranial nerves IX (glossopharyngeal), X (vagus) and XI (accessory)
through its caudal port ion. The X is important and the IX is insignificant (since it only supplies motor
innervation to stylopharyngeus).
The somatic motor part of vagus nerve axons comes from nucleus ambiguus and it innervates the
soft palat e (including uvula), pharynx, larynx and upper esophagus.
A unilateral lesion in nucleus ambiguus will produce ipsilateral paralysis of soft palate, deviation of
t he uvula away from t he lesioned side, nasal regurgitation (soft palate), hoarseness (larynx) and dys-
phagia (pharynx and upper esophagus).
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nerve
Which cranial nerve supplies the derivatives ofthe hyoid arch?
glossopharyngeal
t ri geminal
vagus
facial
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Arch
First ar('h (mumbbulor)
Second arch (hymd)
Third arch
Fourth through sixth
arch
facial
Branchial \rch and Ocrh ath l '
Future Nerves and Muscles
Trige-minal nerve-. of
mastica1ion, mylohyoid and anterior
belly of digastric, tt-n..o;or tympani.
tensor veli palatine
Facial nerve-. stapediu.o; nllt..o;c le,
.nu..o;de$ of facial cxpre$Sion,
posterior bdly of the diga..o;tric
mu..o;cle. stylohyl)id muscle
Glossopharyngeal nerve,
s1ylopharynge.al 1nuscle
Supe-ril)r laryngeal branch and re-
currenl laryngeal branc.h of vagus
nerve, levator veli palatini muscle$,
pharyngeal conslrklors. intin..o; ic
mlLo;cles of the larynx
Future Skeletal Structures and Ligaments
Malleus and incus of middle ca1. including antetior ligament
of the malleus, sphenomandibular ligament, and portions of
the sphenoid bone
Stapes and portions of malleu..o; and incus of middle ear,
stylohyoid ligament. styloid proces..o; of the bone,
Je.sser ('ornu of hyoid bone. upper portion ofbodyofhyoid
bone
Grea1er c.ornu of hyoid bone, lower por'lion of body of hyoid
bone
Laryngeal cartilages
Note: The cranial nerves that innervate the derivatives ofthe branchial arches (CNV, VII,
IX and X) are the only mixed CNs, the rest are either sensory or motor nerves.
Note: The trigeminal, facial, glossopharyngeal, and vagus nerves are said to be
branchiomeric (non-somitic) in origin because they originate from the branchial
arches.
Important: The ophthalmic nerve (CN Vl) i s not considered branchiomeric. It does
not innervate branchial arch derivatives. Instead, it innervates structures derived from
the paraxial mesoderm found in the frontonasal process of the developing embryo.
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nerve
A lesion of the facial nerve just after it exits from the stylomastoid foramen
would result in:
an ipsil ateral loss oftaste to the anterior tongue
a decrease in saliva production in the f loor of the mouth
a sensory loss to the tongue
an ipsil ateral paralysis offacial muscles
a contralateral paralysis of facial muscles
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an ipsilateral paralysis of facial muscles
The facial nerve i s the nerve of facial expression. The facial nerve is a mixed nerve contai ning both
sensory and motor components. It emerges from the brai nstem between the pons and the medulla, and
control s the muscles of facial expression, and taste to the anterior two-thi rds of the tongue.
The facial nerve' s main function is motor control of most of the facial muscles and muscles of the i nner ear.
Thi s nerve al so suppli es parasympathetic fibers t o the submandibular gland and sublingual glands via
the chorda tympani nerve and the submandibular ganglion, and t o the lacrimal gland via the
pterygopalatine ganglion. In addition, the nerve recei ves taste sensati ons from the anterior two-thirds
of the tongue. The faci al nerve has four components with distinct functions:
f. .td.tl - Cr.uu.tl :\lJH \II
Component Function
Somatic (Branchial) Motor As the nerve of the 2nd pharyngeal arch, it supplies striated muscles derived
from its mesodenn, mainly the muscles of facial and auricular
muscle$. It also supplies the. posterior be.llies of the digastric, stylohyoid,
and muscles.
Visceral (Parasympathetic) Provides parasympathetic fi bers to the pterygopalatine ganglion
for innervation ofr he lacrimal and to the submandibular ganglion for
innervation of the sublingual and submandibular salivary The ptery
gopalatine ganglion is associa1ed with the maxillary ne.rve (CN V2). which
distribute$ its fi bers. where.as the submandibular ganglion is
associate.d with the mandibular nerve (CN V3).
Somatic (General) Sen,sory Some fi bers from the geniculate ganglion supply a small area of rhe. skin of
the concha of the auricle, close 10 external acous1ic me.atus
Special Sensory (fa.ste) Fibers carrie.d by the chorda tympani join the lingual nerve 10 convey taste
sensa1ion from the anterior two 1hirds of the longue and soft palate
Key point: Branchial motor fibers constitute the largest portion of the facial nerve. The remai ni ng three
components are bound in a disti nct fascial sheath from the branchial motor fibers. Collectively, these
three components are referred to as the nervus intermedius.
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Postganglionic
parasympathetic
neurons
A
gland
Facial Nerve- Cranial Nerve VII
(A) Sensory and parasympathetic Neurons
(B) Somatic Motor Branches
B
240 I
Reproduced wilh pcnnission from Spenc-e AP, Mason EB: Huma11 Anammyaml ed 4; St Paul. 19'1)2. Wesl Publislung Company.
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nerve
The spinal part of accessory nerve enters the skull through and
then it joins the cranial root. Together they leave the skull through the
carotid canal, jugular foramen
carotid canal, foramen magnum
jugular foramen, foramen magnum
foramen magnum, jugular foramen
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foramen magnum, jugular foramen
The accessory nerve is a nerve that controls specific muscles of the neck. As a part of
it is t raditionall y believed to originate in the brain, it is considered a cranial nerve. Based
on its location relative to other such nerves, it's designated the eleventh of twelve cra-
nial nerves, and is thus abbreviated CN XI.
It is purely motor and has two roots, cranial and spinal. The spinal root arises f rom an-
terior horn cel ls of the upper 5 cervical segments, and it enters the skul l through fora-
men magnum, these fibers are joi ned by the cranial root which arises f rom the caudal
part of the nucleus ambiguus and together they leave the skull through the jugular
foramen with the vagus.
In the jugular foramen the cranial root fibers join the vagus to be distributed along
with fibers of the vagus to the pharynx and larynx. This part of nerve cannot be tested
separately. The spinal part suppli es the sternocleidomastoid and trapezius muscle.
Note: A patient exhibiting accessory nerve paralysis would have difficulty turning their
head to the left or ri ght, and shrugging their shoulders.
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Accessory Nerve- Cranial Ner ve XI
\Vith cranial and spinal portions separated
241 1
with pcrmis..-.ion from Spcacx AI', Mason EB: Httma11 AntiiMIJ' Ond ed 4; St Paul. 1992. Wesl Publit>lung Company.
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nerve
Which ofthe following nerves innervates the lower lip?
mental nerve
incisive branch of IAN
facial nerve
lingual nerve
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mental ner ve
t n ~ o n llmtn.ltwn of tht Or al< ,l\lt\
Ntn't Origin Supplies the Following Areas
Lingual Mandibular nerYe (V3) General sensation of anterior 2/3 of the tongue, lingual gingiva of lower
ili'Ch
Chorda ()rmpani Facial neiVe (VII) Taste sensation ofanterior2/3 of the tongue (except for the vallate
papillae)
Glossopha1yngeal General and caste sensation ofthe posterior 1/3 of the tongue (including
the vallate papillae)
Vagus Taste sensation ofthe base of the tongue and e-piglottis
Inferior alveola Mandibular nerve (V3) Lower premolar and molar tee[h and buccal surfaces; in the molar region
nerve
Incisi ve Inferior alveolar ne-rve. Lower ame-rio1 teeth
Me-mal Inferior alveolar ne-rve. Amerio aspect.; of the chin and lower lip as well as the buccal gingivae
of the mand1bula1 anterior tee.th and premolars
Bucc.al Mandibular nerve (V3) Buccal surfaces in the molar region
Posterior superior Maxillary nerve (V2) Upper molar teeth (except for the mesiobucc-al root of the lirst molar)
alveolar and buccal surfaces in the molar region
Middle superior Maxillary nerve (V2) Upper premolar teeth, mesiobuccal root of upper first molar and bucc.al
alveolar surt3ces in upper p1emola1 region
Anterior superio1 Maxillary nerve (V2) Upper aJlterior teeth and bucc.al surfaces in upper anterior teeth
alveolar
Greater palarine Pterygopalatine ganglion l'alatal side of upper [eeth (except in incis.al area)
Nasopalatine Pterygopalatine ganglion l'alatal side of upper amerior teedl (incisal area)
Jnfrao1bital Maxillary nerve (V2) Upper lip
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nerve
Which of the following nerves is derived from both the medial and lateral
cords ofthe brachial plexus?
Select all that apply.
musculocutaneous
axill ary
ulnar
median
radial
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median
The brachial plexus is a somatic nerve plexus formed by intercommunications among the ventral rami of the
lower four cervical nerves (CS-C8) and the first thoracic nerve (Tl ). The plexus is responsible for the motor Inner-
vation to all of the muscles of the upper limb with the exception of the trapezius and levator scapula. it supplies
all of t he cutaneous innervation of the upper limb with t he exception of an area near the axilla (armpit) which is
supplied by the i ntercostobrachial nerve.
Formation of the Brachial Plexus:
A. Roots: The ventral rami of spinal nerves CS to T1 are referred to as the roots of plexus
B. Trunks Shortly after emerging from the intervertebral foramina, these 5 roots unite to form t hree trunks:
-The ventral rami of CS and C6 unite to form t he upper trunk
-The ventral ramus of C7 continues as the middle trunk
-The ventral rami ofC8 andTl unite to form the lower trunk
C. Divisions Each trunk splits i nto an anterior division and a posterior division
The anterior divisions usually supply Oexor muscles
The posterior divisions usually supply extensor muscles
D. Cords The anterior divisions of upper and middle trunks unite to form the lateral cord
The anterior division of t he lower trunk forms the medial cord
All3 posterior divisions from each of the 3 trunks all uni te to form the posterior cord
The cords are named according to t heir position relative to the axillary artery
E. Terminal branches
Musculocutaneous nerve: is derived from t he lateral cord; this nerve innervates the muscles in the Oexor
compartment of t he arm; it carries sensation from the lateral (radial) side of the forearm
Ulnar nerve: is derived from the medial cord; it supplies motor innervation mainly to intrinsic muscles of
the hand; it carries sensory innervation from the medial (ulnar) 1 & v, digits (the 5th of the 4th digits)
Median nerve: is derived from both the lateral and medial cords; it supplies motor innervation to most of
flexor muscles in t he forearm and intrinsic muscles of the t humb; it carries sensory innervation from the lat-
eral (radial) 3 & v, digits (the thumb and first 2 and
Axillary nerve: is derived from the posterior cord; it supplies motor innervat ion to deltoid and teres minor
muscles only; it carries sensory innervation from the skin just below the point of the shoulder
Radial nerve: is also deri ved from posterior cord; called great extensor nerve because it innervates the
extensor muscles of the elbow, wrist and fi ngers; it carries sensory innervation from the skin on t he dorsum
of t he hand on the radial side
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nerve
Which sensory receptor is most sensitive to linear acceleration?
cri sta
utricle
saccule
macula
organ of cort i
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macula
Vestibulocochlear nerve (CN VIII )
Functions: Special sensory (special somatic afferent) that is, special sensations of
hearing and equili bri um.
Nuclei: Four vestibular nuclei are located at the junction of the pons and medull a
in the lateral part of the floor of the 4th ventri cle; two cochlear nuclei are in the
medul la.
The vestibulocochlear nerve (CN VIII) emerges from the junction of the pons and
medul la and enters the internal acoustic meatus. Here it separates into the vestibular
and cochlear nerves.
The vestibular nerve is concerned with equi li brium. It is composed of the central
processes of bipolar neurons in the vestibular gangli on; the peripheral processes of
the neurons extend to the maculae ofthe utricle and saccule (sensitive to the li ne of li n-
ear acceleration relative to the position of the head) and to the ampullae of the semi-
ci rcular ducts (sensit ive to rotational acceleration).
The cochlear nerve is concerned with hearing. It is composed of the central processes
of bipolar neurons in the spinal gangli on; the peripheral processes of the neurons ex-
tend to the spiral organ.
Organ of Corti (spiral organ): The t rue organ of hearing, a spiral structure within the
cochlea containing hair cells that are stimulated by sound vibrations. The hair cell s con-
vert the vibrations into nerve impulses that are transmitted by the cochlear portion of
the eighth cranial nerve to the brain.
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Ampulla
Semicircular
ducts
auditory
meatus
Vestibular
ganglion
Internal
auditory
meatus
Vestibular
nerve
Vestibulocochlear Ner ve- Cr anial Ner ve VIII
Showing the vestibular nerve that supplies the vestibule and
ampullae and the cochlear nerve that supplies the cochlea.
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body cavities and regions
Which of the following organs is retroperitoneal?
Select all that apply.
stomach
kidneys
l iver
gall bladder
inferi or vena cava
spleen
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kidneys
inferior vena cava
Abdominal cavity: the maj or part of t he abdomi nopelvic cavity, bounded by the t horacic diaphragm and
t he pelvic i nl et . The abdomi nal cavity i ncludes both t he peritoneal cavity and the retroperitoneal space.
Peritoneal cavity: t hat part of the abdomen surrounded by peritoneum. This i s a pot ential space be-
tween t he parietal and visceral layers of perit oneum
Retroperitoneal space: t he area behi nd (post erior to) the peritoneum. Retroperitoneal organs are l o-
cat ed i n t hi s space
Abdominal contents:
Peri toneum: a thi n, serous membrane l ining the wall s of the abdomi nal and pelvic cavities and cloth-
ing t he abdomi nal and pelvic viscera. The peritoneum can be regarded as a "balloon i nto which organs
are pressed i nto from t he outside. The peritoneum has visceral and parietal layers, just like the pleu-
ral cavity.
Parietal peritoneum: l ines the walls of the abdomi nal and pelvic cavit i es
Visceral peritoneum: covers t he organs
** *The potential space between t he t wo layers, which i s i n effect the i nside space of the balloon, i s
called the peritoneal cavity.
The peritoneal cavity can be divided into two parts:
Greater sac: i s t he mai n component of the peritoneal cavity and extends from t he diaphragm down
t o the pelvi s
Lesser sac: i s smaller and lies behi nd the stomach
* ** The t wo sacs are in free communi cation wi th one another through an oval wi ndow call ed t he
opening of the lesser sac, or the epiploic foramen.
The terms intraperitoneal and retroperitoneal are used to describe the relationshi p of vari ous organs to
the peritoneal coveri ng. An organ is said to be intraperitoneal when i t i s al most tot ally covered with vi s-
ceral perit oneum. The followi ng organs are considered t o be intraperitoneal: t he stomach, jej unum, i leum,
spleen, t ransverse colon, liver, and gallbladder. Retroperitoneal organs are those that lie behi nd the peri-
t oneum and are only part ially covered wi th vi sceral peritoneum. The following organs or st ructures are
considered t o be retroperitoneal: t he aort a, i nf eri or vena cava, kidneys, adrenal glands, pancreas, uret ers,
most of the duodenum, and the ascendi ng and descending parts of the colon.
Note: Mesenteries are two-layered folds of peri toneum connect i ng parts of the i nt esti nes to t he posterior
abdominal wal l. These folds permit bl ood, lymph vessels, and nerves t o reach t he vi scera.
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body cavities and regions
A 1 5-year-old patient comes into the emergency room with diffuse abdomi-
nal pain, loss of appetite, and a fever. On palpation of the lower right ab-
domen he feels pain, and even greater rebound pain when the pressure is
released. The diagnosis is appendicitis. The appendix is located in which ab-
dominal region?
umbilical
epigastri c
hypogastric
lumbar
hypochondriac
iliac
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Right Hypochondriac
liW I'
Gallbladder
Small intesrine
Ascending colon
Transverse colon
Righ[ kidney
Right Lumbar
Liveo (ti p)
Gallbladder
Small inte;aine
Ascending c.olon
Righ[ kidney
Right Iliac
Small intestine
Appendix
Cecum and
ascending colon
Right ovary (female-s)
Righ[ fallopian n1be
I ht:" :\uu.
Epigastric
Esophagus
Stomach
liver
Pancreas
SJ)Ieen
Small imesaine
Tran..werse colon
Right and lef[ adre11als
Right and Jef[ kidneys
Right and Jef[ ure[ers
Umbilical
Stomach
Pancreas
Small imesaine
Tran..werse colon
Right and lef[ kidneys
Right and Jef[ ure[t-rs
Cisre-rna chylii
Hypogastric
Small inte$tine
Sigmoid c.olon
Rectum
Right and Je_f[ ure[e-rs
Urina1y bladde-r
Female
Uten1.s
Right and Jef[ ovaries
Right and Je-f[ fallopian mbes
)1ale
Vas deferen..o;
Seminal vesicles
Prostate
Left Hypochondriac
S[omach
Liver (tip)
Pancreas (tail)
Splee1l
Small intestine
T1ansve1'Se colon
Desc.ending c.olon
Ld l kidney
Left Lumbar
Small intesrine
Desc-ending colon
Ldl kidney (tip)
Left Iliac
Small intesrine
Desc-ending c.olon
Sigmoid colon
Ld! oval) (female)
Left fallopian tube (female)
Iliac
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Abdominal Regions- Anterior view
246 I
Reproduced with pcnmssion from Atlas of Human Springhouse. 2001. Springhouse.
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body cavities and regions
In an elderly adult, the thymus is mostly atrophied, and the remains lie in the
superior mediastinum. In a pubescent boy, the thymus is at its largest, with an
average mass of 35 grams. When it is this size, the thymus will be present in
which other division ofthe mediastinum?
anterior mediastinum
middle mediastinum
posterior mediastinum
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anterior mediastinum
The thoracic cavity is surrounded by the ri bs and chest muscles. It's subdivided into
the pleural cavities, each of which contains a lung, and the mediastinum, which con-
tains the heart, large vessels of the heart, trachea, esophagus, thymus, lymph nodes,
and other blood vessels and nerves. The mediastinum is further divided into four areas.
Li sted below are some of the major structures contained within the different regions.
(It is not within the scope of these cards to list all of the contents of the mediastina).
Note: Some structures overlap into different areas.
Superior mediastinum: arch of the aorta, left and ri ght subclavian arteries and
veins, ri ght and left common carotid arteri es, right and left internal jugular veins,
right and left brachiocephalic veins, brachiocephali c artery, upper half of the supe-
ri or vena cava, right and left primary bronchus, t rachea, esophagus, thoracic duct,
thymus, the phrenic nerves, vagus nerves, cardiac plexus of nerves, and left recurrent
laryngeal nerve.
Inferior mediastinum: region directly below the superi or mediastinum. This is
subdivided into three regions: anterior, middle, and posteri or.
1. Anterior mediastinum: lymph nodes, branches of internal thoracic artery; in
children, contains the inferior part of the thymus gland.
2. Middle mediastinum: peri cardium, heart and adjacent great vessels, the
phrenic nerves, and the main bronchi.
3. Posterior mediastinum: thoracic aorta, thoracic duct, esophagus, trachea, right
and left main bronchus, brachiocephali c artery, left common carotid artery, left
subclavian artery, arch of aorta, esophageal plexus (branches of vagus and
splanchnic nerves), sympathetic chain gangli a, azygos and hemiazygos veins, and
many lymph nodes.
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Superior-L
mediastinum
Mediasti num - Subdivisions
Middle
mediastinum
Posterior
mediastinum
2471
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The diaphragm is located in the:
pelvic cavity
t horacic cavity
abdominal cavity
vertebral cavity
body cavities and regions
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ANATOMIC SCIENCES
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thoracic cavity
Body cavities are spaces within the body that contain the internal organs. The dorsal (posterior)
and ventral (anterior) cavities are the two major closed cavities.
Dorsal cavity is subdivided into two cavities:
1. Cranial cavity (skull}: encases the brain
2. Vertebral cavity (also called the spinal or vertebral canal}: is formed by portions of the
bones (vertebrae) that form the spine. It encloses the spinal cord.
*** These two cavities communicate through the foramen magnum. These cavities are
lined by meninges. The fluid in t hese cavities is called cerebrospinal fluid.
Ventral cavity: is subdivided into two cavities:
1. The thoracic cavity, is surrounded by the ribs and chest muscles. The thoracic cavity is
subdivided into:
Pleural cavities (right and left): each of which contains a lung and the mediastinum,
which contains the heart, large vessels of the heart, trachea, esophagus, thymus, lymph
nodes, and other blood vessels and nerves
Remember: The mediastinum is further divided into four areas: the middle, the anter-
ior, posterior, and superior areas.
Pericardia! cavity: between the visceral and parietal layers ofthe serous pericardium,
contains a thi n film of fluid
2. Abdominopelvic cavity, which has two regions:
Abdominal cavity: contains the stomach, intestines, spleen, liver, and other internal
organs
Pelvic cavity: inferior to the abdominal cavity, contains bladder, some reproductive
structures (""" See below), and the rectum
*** In the male: the paired ductus deferens and seminal vesicle and the unpaired
prostate. ln the female : the paired ovaries and the unpaired uterus.
***The two cavities (thoracic and abdominopelvic) communicate through an opening in the
diaphragm called the hiatus.
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Ventral
cavity
cavity
Abdominopelvic
Dorsal
cavity
cavity ------+-'
Body CaYitics 248-1
The dorsal cavity, in t he posterior region of the body, is divided into the cranial caYity and the
Yer tebr al canal (Yer tebr al c.avity). The Yentral cavity, in the anterior region, is divided into the
thoracic and abdominopeiYic cavities.
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miscellaneous
Extracellular fluid comprises ___ of the amount of total body water.
25%
33%
50%
66%
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33%
The body's water is effectively compartmentalized into several major divisions.
Intracellular fluid (ICF) comprises two-thirds of the body's water
-If your body is 60% water by weight, ICF is two-thirds of that, or 40% of your total weight.
-The ICF is primarily a solution of potassium and organic anions, proteins, etc. (Cellular Soup!).
-The cell membranes and cellular metabolism control the constituents of this ICF.
- ICF is not homogeneous in the body. ICF represents a conglomeration of fluids from all the dif-
ferent cells.
Extracellular fluid (ECF) is the remaining one-third of the body's water
- ECF is about 20% of your weight.
-The ECF is pri marily a NaCI and NaHC0
3
solution.
- The ECF is further subdivided into three subcompartments:
Interstitial Fluid (ISF) surrounds t he cells, but does not circulate. It comprises about three-
quarters of the ECF.
Plasma circulates as the extracellular component of blood. It makes up about one-quarter
ofthe ECF.
Transcellular fluid is a set of fluids that are outside of the normal compartments. These 1-
21iters of fluid make up the CSF, digestive j uices, mucus, etc.
Note: The epidermis of t he skin obtains nourishment by diffusion of tissue fluid from capillary beds
located in the dermis. This tissue fluid (also called interstitial fluid) contains a small percentage of
plasma proteins of low molecular weight that pass through the capillary walls as a consequence of
the hydrostatic pressure of the blood. This fluid bathes the cells.
Inner ear fluids:
Perilymph is an extracellular fluid located within the cochlea (part of the ear) in two of its three
compartments: the scala tympani and scala vestibule. The ionic composition of peri lymph is com-
parable to that of plasma and cerebrospinal fluid. The major cation in peri lymph is sodium.
Endolymph is the fluid contained in the membranous labyrinth of the inner ear. The main cation
of this unique extracellular fluid is potassium, which is secreted from the stria vascularis. The high
potassium content of the endolymph means that potassium, not sodium, is carried as the depo-
larizing electrical current in the hair cel l.
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miscellaneous
All of the following are anatomic structures of the auricle EXCEPT one. Which
one is the EXCEPTION?
tragus
helix
antrum
concha
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antrum
External ear: consists of the auricle (pi nna) and the external auditory canal. This part receives
sound waves. The auricle consists of cartilaginous ant ihelix, crux of the helix, lobule, t ragus,
and concha. The external auditory canal is a narrow chamber measuring about 1 inch long.
This canal connects the auricle with t he tympanic membrane in the middle ear.
Middle ear (tympanic cavity): an air-filled cavity within the petrous part of the temporal
bone. The middle ear contains three small bones or ossicles, the malleus (hammer), stapes
(stirrup), and incus (anvil) that transmi t sound. Lined with mucosa, the middle ear is bounded
laterally by the tympanic membrane and medially by t he oval and round windows. Also cont-
ains two muscles - the stapedius muscle, which is the smallest of the skeletal muscles in t he
body, and the tensor tympani muscle. The tympanic membrane, consisting of layers of skin,
fibrous tissue, and mucous membrane, transmits sound vibrations to the internal ear.
Inner ear: consists of cl osed, fluid-filled spaces within t he temporal bone. The inner ear is a
bony labyrinth, which includes three connected structures - the vestibule, the semicircu-
lar canals, and the cochlea. These structures are lined wi th a serous membrane that forms t he
membranous labyrinth. A fluid called perilymph fills the space between t he bony labyri nth
and the membranous labyrinth. Note: Within the cochlea lies the cochlear duct, a triangular,
membranous structure housing the organ of Corti. The receptor organ for hearing, the organ
of Corti t ransmits sound to the cochlear branch of the acoustic (CN VIII) nerve.
Clinical considerations: Middle ear infections (otitis media) are quite prevalent and may
become extensive due to connections between the tympanic cavity and both the mastoid air
cells and the nasopharynx. Note: Streptococcus pneumoniae is the most frequent microbe
causing otitis media.
The auditory tube equalizes air pressure on either side of the tympanic membrane. The
middle ear communicates posteriorly with the mastoid air cells and the mastoid antrum
through the aditus ad antrum.
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I Auricle
(pinna)
\
External ear
I
(Not to scale)
Middle ear
I
Auditory
ossicl es
Inner ear
I
External, Middle, and Inner Ears
(Note: anatomic stmctures not draw11 to scale)
25().1
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miscellaneous
Which of the following helps the lens change its shape to better focus light to
the retina?
neural retina
pupil
iris
cil iary body
conjunctiva
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ciliary body
Parts oft he eye: Eye Anatomy consists of many intricate parts of the eye.lt involves parts that allow
light refraction, maintaining the shape of the eye, light conversion and much more.
Cornea: The cornea is the dome shape outer covering of the eye. The cornea is where most of the
focusing of light occurs. It consists of many layers including the epitheli um which is the tough
outer layer that regenerates fairly quickly. The epitheli um is usually removed or cut duri ng many
refractive procedures where the cornea is reshaped to focus light better.
Sclera: The sclera is the outer white part of the eye that you can see. It provides protection and
st ructure for the inner parts of the eye.
Conjunctiva and lacrimal glands: The conjunctiva is a mucus layer that keeps the eye moist In-
fections to this area are known as the popular "Pink Eye." Lacrimal glands are found on the outer
part of each eye and are producers of tears.
Vitreous humor and aqueous Humor: The vitreous humor is a gel-like substance in the back
part of the eyeball which provides the shape of the eyeball. The aqueous humor is the watery re-
gion in the front of the eye ball. It is separated into two regions, the anterior chamber in front of
the iris and the posterior chamber behind it. The canal of Schlemm drains water in thi s region and
is sometimes blocked off leading to the disease known as glaucoma or other complications.
Iris and pupil: The pupil is the dark, black circle of the eye. It contracts with brightness and ex-
pands during darkness allowing light to be better transmitted. The iris is the colored part of the
eye. This coloring is due to pigment cells in tissue in the iris. The iris contains the sphincter pupil-
lae, a muscle used to narrow the pupil, and the dilator pupillae, a muscle used to widen the pupil.
Lens: The lens is a clear layer behind the pupil that does j ust what a regular lens does. The lens
main purpose is to focus light by changing its shape. The ciliary body are muscles attached to the
lens that help the lens change its shape to better focus light to the reti na.
Retina: The retina is the inner most layer of sensitive tissue. When light is transmitted here im-
ages can clearly be transmitted to the brain. The retina consists of many layers including layers of
rods and cones. Many cells in the reti na transform light into chemical and electrical energy that is
transferred to optic nerves. The back center of the retina contains the macula. The Macula is a
highly sensitive part of the retina. It is responsible for our detailed vision. The center of the mac-
ula is called the fovea which has a major role in detailed perception. When there is damage to the
macula, we are unable to see fi ner details.
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reproductive system
The ovaries are homologous with the testes in the male.
Each ovary lies in a shallow depression, named the ovarian fossa, on the
lateral wall of the pelvis; this fossa is bounded above by the external iliac
vessels, in front by the obliterated umbilical artery, and behind by the ureter.
both statements are t rue
both statements are false
the first statement is t rue, the second is false
the first statement is fa lse, t he second is true
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both statement are true
The ovaries are elliptical organs, situated close to the side wall s of the pelvi s, and are supported by the
broad ligament of the uterus. All the ovary's blood and lymphatic vessels, and nerves enter at the hilum.
Beneath its surface epi thel ium i s a cortex that encloses the medulla at i ts core. The bulk of the ovary i s
the supporti ng structure called the stroma. Note: The main functi on of the ovari es is to produce mature
ova.
The cortex contains ova at different stages of development The ova begin as primordial oocytes, sur-
rounded by a layer of fl at cells called granulosa cells. At puberty, the granulosa cells begin to mul ti ply and
form the multilayered theca interna that secretes androgens (in response to LH) that are the precursors of
estrogens. Note: Granulosa cell s have aromatase that converts the androgens produced by the theca in-
terna into the necessary estrogens. The surrounding stromal cells form the theca externa.
A split appears in the theca interna and expands to form a fluid-tilled cavity that pushes the oocyte to one
side; the foll icle is now a Graafian follicle.
Ovulation takes place in t he middle of each menstrual cycle- a Graafian follicle ruptures to rel ease its
ovum, which enters the uterine tube. The empty follicle tills with blood and regresses into a corpus luteum.
If the ovum is fertilized, t he corpus luteum will persist and cont inue secreting progesterone to mai ntain
pregnancy. If not, the corpus l uteum shri nks i nto a small mass of collagenous ti ssue- the corpus albicans.
p _ ; : ~ 1. Meiosis, the process by which gametes are formed, can al so be called gametogenesis, l iterally
G "creation of gametes. The specific type of meiosis that forms sperm is called spermatogenesis,
while the formation of egg cells, or ova, is called oogenesi s. The most important thing you need
to remember about both processes is that they occur through meiosis.
2. Just l ike spermatogenesis, oogenesis i nvolves the formation of haploid cells f rom an original
diploid cell, called a primary oocyte, through meiosis. The female ovari es contain the primary
oocytes. There are two maj or differences between the male and female production of gametes.
Fi rst of all, oogenesis only leads to the production of one final ovum, or egg cell, from each
primary oocyte (in cont rast to the four sperm that are generated from every spermatogonium).
Of the four daughter cell s that are produced when the primary oocyte divides meioti cally, three
come out much smaller than the fourth. These smaller cells, called polar bodies, eventually
disintegrate, l eavi ng only the larger ovum as the fi nal product of oogenesis. The producti on of
one egg cell via oogenesis normally occurs only once a month, from puberty to menopause.
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Female Reproductive System
Uterus
2521
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Corpu$
luteum
Normal Ovary 252A I
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reproductive system
Consider the following structures:
1. Spongy urethra 2. Ductus deferens 3. Prostatic urethra 4. Epididymis
Name the path that sperm travels upon ejaculation.
1, 2, 3, 4
2, 4, 1, 3
4, 2, 1, 3
4, 2, 3, 1
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4,2, 3, 1 (epididymis, ductus deferens, prostatic urethra, spongy urethra)
Sperm is formed in the testes and then passes along the ductus deferens, which j oins the duct
of the seminal vesicle to form t he ejaculatory duct. During ejaculation, the sperm combines
with secretions from t he prostate gland and seminal vesicles to form t he seminal fluid.
The testes are two oval organs contained in the scrotum; t he right one is usually higher than
the left by nearly a half inch. The testis is capped by the epididymis. The epididymis is a
tortuous, (-shaped, cord-like tube about 20 feet long located in the scrotum. The t ube
emerges from the tail as the ductus (vas) deferens. The ductus deferens and its surrounding
vessels and nerves form the spermatic cord, which runs upward to t he level of the pubic
tubercle of the pubic bone, passes through the inguinal canal, and t hen turns sharply to enter
t he pelvic cavity. The ductus deferens then heads toward t he back of the prostate gland, where
t he ductus deferens expands into an ampulla and joins the duct of the seminal vesicle to form
t he ejaculatory duct. The ej aculatory duct penetrates t he prostate gland to open into t he
prostatic urethra. After leaving t he prostate gland, the urethra runs t hrough the muscles of
t he urogenital diaphragm, and enters the penis.
. 1. The ejaculatory duct is one of the two passageways that carry semen from t he
: ' prostate gland to the urethra. The oviduct (fallopian tube) is one of a pair of ducts
opening at one end into t he uterus and at the other end into the peritoneal cavity,
over t he ovary. Each t ube serves as a passage through which an ovum is carried to
the uterus and through which spermatozoa move out toward the ovary.
2. Stereocilia are long, nonmotile microvilli that cover the free surfaces of some of
the pseudostratified columnar epithelium that lines the inside of t he epididymis.
Stereocilia serve to facilitate the passage of nutrients from the epithelium to t he
sperm by increasing the epithelium's surface area.
Note: Stereocilia are also present in the ductus (vas) deferens, which is also lined
with pseudostratified columnar epithelium.
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MALE REPRODUCTIVE TRACT
5 3 ~
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Male Urinary
Bladder and
Urethra
Trigone----
Ureter
Urinary
bladder
Prostatic-----+-.. "+----Prostate
urethra gland

urethra
Penile
urethra
External-----....
urethral orifice
Bulbourethral
gland
Vas deferens
Epididymis
Testis
Scrotum
253 A l
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reproductive system
Cooper's ligaments are fibrous bands attached to musculature and function to
support:
each testis
each ovary
each body of the epididymis
each breast
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each breast
The mammary glands (breasts) are located on either side of the anterior chest wall over the
greater pectoral and the anterior serratus muscles. These glands are specialized accessory
glands that secrete milk. They are formed from many small tubules grouped into a lobule.
Several lobules constitute a lobe, each of which has an interlobular duct. Many of these ducts
combine to form a lactiferous duct, which terminates at the nipple. The nipple is present on
each breast as a centrally located pigmented area of erectile tissue ringed by an areola that's
darker than the adjacent tissue.
The arterial supply of the breast is from perforating branches of the internal thoracic artery
and the intercostal arteries. The axillary artery also supplies the gland via its lateral thoracic
and thoracoacromial branches.
Several chains of lymph nodes drain different areas of the breast and axilla. The node chains and
the areas they drain are as follows:
pectoral- most of the breast and anterior chest
brachial- most of the arm
subscapular- posterior chest wall and part of the arm
midaxillary- pectoral, brachial, and subscapular nodes
internal mammary nodes- mammary lobes
m - ~ .. 1. Breast cancer causes dimpl ing ("peau d'orange") of the overlying skin and nipple
_ ;,.Y ' retraction.
' 2.The suspensory ligaments (Cooper's ligaments) are strong, fibrous processes that
run from the dermis of the skin to the deep layer of superficial fascia through the
breast.
3. 1mportant: Mammary, sweat, lacrimal, and salivary glands contain a special type of
smooth muscle cell called myoepithelial cells (star-shaped). These cells have
processes that spiral around some of the secretory cells of these glands. The
contraction of these processes forces the secretion of the glands toward the ducts.
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reproductive system
The inguinal canal is an oblique passage through the lower part of the
anterior abdominal wall and is present in both males and females. In
females its primary content is the round ligament of the uterus. In males,
which of the following structures does NOT pass through the inguinal canal?
spermatic cord
ductus deferens
testicular veins
ejaculatory duct
lymph vessels
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ejaculatory duct
The inguinal canal all ows structures of the spermatic cord to pass to and from the testi s
to the abdomen in the male. In the female, the small er canal permits the passage of the
round ligament of the uterus from t he uterus to the labium majus. Note: In both sexes,
the canal also transmits the ilioinguinal nerve.
The spermatic cord is a collection of struct ures t hat traverse t he ingui nal canal and pass
to and from the testi s. The spermatic cord is covered with three concentric layers of fascia
derived f rom t he layers of the anterior abdomi nal wall, and begins at the deep inguinal
ring lateral to t he inferior epigast ric artery and ends at the testi s.
Structures of the spermatic cord:
Ductus (vas) deferens - it is a cord-li ke structure; it conveys sperm from the
epididymis to the ejaculatory duct, which is a passageway formed by the union of
the deferent duct (vas deferens) and the excretory duct of the seminal vesicle. The
ej aculatory duct opens into the prostatic urethra.
Testicular artery - branch of the abdominal aorta; supplies mainly the testis and
the epididymi s.
Testicular veins - an extensive venous plexus, the pampiniform plexus, leaves the
posterior border of t he testis. As the plexus ascends, it becomes reduced in size into a
single testicular vein. This runs up on the posterior abdomi nal wall and drains into the
left renal vein on the left side, and into the inferior vena cava on the right side.
Testicular lymph vessels - ascend through the inguinal canal and pass up over the
posterior abdomi nal wall to reach the lumbar lymph nodes on the side of the aorta at
the level of the fi rst lumbar vertebra.
Autonomic nerves- sympathetic fibers run with the testicular artery from the renal
or aorti c sympathetic plexuses. Afferent sensory nerves accompany the efferent
sympathet ic fibers.
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reproductive system
Cystitis is a term that refers to urinary bladder inflammation. It is most com-
monly caused by a urinary tract infection. It affects females more than males.
This is mainly due to the difference in length of the:
ureter
urethra
theca intern a
fall opian tube
renal pelvis
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urethra
The urethra is a tube that conveys urine from the uri nary bladder to the outside of the body. The
wall of the urethra is li ned with mucous membranes and contains a relatively thick layer of smooth
muscle tissue.lt also contains numerous mucous glands, called "urethral glands," that secrete mucus
into the urethral canal.
The urethra being shorter in the female (about 4 em long) than it is in the male (about 20 em long)
subj ects the female to more frequent bladder infections. Because the male urethra travels in the
penis, the male urethra is longer than the female urethra. This requires an invading organism to travel
a greater distance to gain access to the urinary bladder. Eliminating urine by the male tends to flush
the urethra before an invading organism can reach the urinary bladder.
if':': , 1. The female urethra opens into the vestibule bet ween the clitoris and the vagina.
2. In the male, the urethra also conveys semen from the reproductive organs during ej acu-
lat ion. The male urethra is divided into three parts:
-prostatic: it is the widest and most dilatable portion of the urethra
- membranous: it is the shortest and least dilatable portion of the urethra
-penile: it is the longest and narrowest portion; bulbourethral glands open into it
3. The ureter is a paired passageway that transports the urine from the kidney to the uri nary
bladder for concentrat ion and storage until the urine is voided.
Important: The accessory glands, which produce most of the semen, include the:
The seminal vesicles are paired sacs at the base of the bladder.
The bulbourethral glands (Cowper's glands), also paired, are located inferior to the prostate
gland.
The prostate gland is shaped like an inverted pyramid and lies under the bladder, with the apex
pointing downward. Emerging from the neck of the bladder, the urethra runs vertically through
the prostate gland, and exits just in front of the apex. The prostate gland has two maj or groups of
glands: -periurethral glands: are in the central zone surrounding the urethra
- main glands: are in the peri pheral zone
*'** All the glands open into the prostatic urethra and secrete the enzyme acid phosphatase, fib-
rinolysin, and some proteins. Prostatic secretion makes up about 25% of semen.
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.. -----Spongy (penile) urethra
.-----Erectile t issue of penis
u,;..;....--External urethral orifice
Comparison of Male & Female Urethra
256-1
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reproductive system
Where does the fertilization of an oocyte occur?
vagina
ovary
peritoneum
ampulla
uterus
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Organ
Ovaries
Uterine mbes
(fallopian lube.<)
Utems
Vagina
Labia majora
Labia minora
Clitoris
Vestibular glands
l\hnunary glands
Bartholin s gland-:
ampulla
"' unction
Produces ova (female germ cells) and female sex honnones (e.o; trogen.s and progesrerone)
Receive the ovum from the ovary and provide a site where feni lization of rhe ovum can take
place. Tlle tube$ sene as a conduit along which the spermatozoa travel to reach the ovum.
Serves as a site for the reception, rele.ntion, and nutrition oft he fertil ized ovum
Not only is the fe-male ge-nital canal but also serves as lhe excntory duct fOI' the menstmal flow
and fomts pan of the birth canal
Form margins of pudendal cleft; enclose and protect the other external re-productive organs
Form margins of vestibule; protect openings of vagina and urethra
Provides feeling of pleasure during stimulation
Secrere lubricating fl uid into the vestibule and vaginal opening during coitus
J)roduce and secrere milk fo1 nourishment of an infant
1'hey secrete mucus to lubricare the vagina and are homologous to bulbourethral glands in males
Fallopian tubes are the two long, t hin t ubes that connect to a woman's uterus (one on each side).
The other ends of the tubes flare open wi th several long fringes, called fimbriae, on the end. After
ovulation, these fimbriae beat back and forth to help guide the egg into the fallopian tube. Once in-
side t he tube, tiny hairs called cilia push the egg along and toward the uterus. Fertilization typically
occurs in the fallopian tube if the egg encounters a sperm. There are four parts of the fallopian tube
from the ovary to the uterus:
The fimbriae
Infundibulum
Ampulla- where the ovum is fertil ized
Isthmus
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Mons pubice
Clitoris
Labia minc1ra-------..
Labia
Vagina
Anus
External genitalia- Female
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reproductive system
The two tubes on the top side of the penis are called the:
the erectile tissue
spongy tubes
corpus cavernosum
corpus spongiosum
urethra
[refer to card 253-1, 253 A-1 for illustration)
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corpus cavernosum
Or:,:a nsul tlu.: \LIIc Hxpruducll\c '\slun
Organ Function
Tesoes(2) Produce spcnn and testosterone (male sex hormone)
Scr01um
Epididymis (2) Portion ofthe St"minal du<: t in which Sperm m.aturc and an: stort.d
Ductus (vas) deferens (2) Transport spenn during ej aculation upward inside the spenn.ati<: cord 10 the urelhrn
gland Produces st.men, the Huid thai carrie-s spt.nn; this fluid helps protect spcnn from the vagina's
acidity during cj aculalion
Semi nal (2 pair) Secrete the majori1)' of the Ruid (alkali ne and ri ch in fru<: IO!ic) in semen
Bulbourethral glands Seatle fluid that lubricate.<: urdhra and end of penis
(Cowpers gland)
EjaculatOI)' docts ( 2) Receive spenn and additives to pn)duce seminal lluid: run through the prostale and open into the
urtthrn
Penis Male sexual organ that both urine and spcnn
The penis is the male sex organ, reaching its full size during puberty. In addition to its sexual func-
tion, the penis acts as a conduit for urine to leave the body. The penis is made of several parts:
Glans (head) of the penis: In unci rcumcised men, the glans is covered with pink, moist tissue
called mucosa. Covering the glans is the foreskin (prepuce). In circumcised men, the foreskin is
surgically removed and the mucosa on the glans transforms into dry skin.
Corpus cavernosum: Two columns of tissue running along the sides of the penis. Blood fill s this
tissue to cause an erection.
Corpus spongiosum: A column of sponge-like tissue running along the front of the penis and
ending at the glans penis; it fills with blood during an erection, keeping the urethra -which runs
through it - open.
The urethra runs through the corpus spongiosum, conducti ng urine out of the body.
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reproductive system
When sperm cells are formed, they migrate in an immature state to the long,
narrow structure attached to the back of each testicle called the:
vas deferens
prostate
rete testis
seminal vesicles
epididymis
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epididymis
The t estes (singul ar: testis) are paired structures that are suspended within the scrotum in
the male. They produce spermatozoa and sex hormones (androgens). Sperm are
produced in the seminiferous tubules and stored outside the testis in the epididymis
until ej aculated. Androgens, the most important one being testosterone, are synthesized
and secreted into the bloodstream by interstitial cells (of Leydig) found in the interstitium
of the testis between the seminiferous tubules. Testosterone is responsible for growth and
maintenance of male sexual characteristics and for sperm production.
The ovaries are ellipt ical organs, situated close to the side wall s of the pelvis, and are
supported by the broad ligament of the uterus. All of the ovary's blood and lymphatic
vessels, and nerves enter at the hilum. Beneath its surface epithelium is a cortex that
encloses the medulla at its core. The bulk of the ovary is the supporting structure call ed
the stroma. Note: The main function of the ovaries is to produce mature ova. The ovaries
also produce steroid hormones estrogen and progesterone.
Estrogen - promotes the development and maintenance of female sexual character-
istics and the proper sequence of events in the female reproductive cycle (menstrual
cycle)
Progesterone - maintains (along with estrogen) the lining of the uterus necessary
for successful pregnancy
Remember: Ovulation takes place in the middle of each menstrual cycle - a Graafian
follicle ruptures to release its ovum, which enters the uterine tube. The empty follicle fill s
with blood and regresses into a corpus luteum. If the ovum is fertilized, the corpus
luteum will persist and continue secreting progesterone to maintain pregnancy. If not,
the corpus luteum shrinks into a small mass of collagenous t issue- the corpus albicans.
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Tail
Spermatozoon
I
Midpiece
I
Endpfece
Corona radiata
I
Egg cytoplasm
Ovum
259-1
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f emale Ovary. Showing ovulntioo step
Hormonal control of ovulation

-
I
+
5 9 A ~
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periodontium
Surrounding the gingival portion ofthe root of each tooth is a specialized ep-
ithelium known as the:
connective t issue attachment
periodontal ligament attachment
junctional epithelium
external basal lamina
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junctional epithelium
The dentogingival epithelium is the j unction between the tooth surface and t he gingival
tissues. Together, t he sulcular epithelium and junctional epithelium form the
dentogingival junctional tissues. They are composed of nonkeratinized stratified
squamous epithelium.
Sulcular epithelium (also called crevicular epithelium) - stands away from the tooth,
creating a gingival sulcus, or space that is filled with gingival fluid or crevicular fluid.
Junctional epithelium - a deeper extension of the sulcular epithelium, the junctional
epithelium begins at the base of the sulcus. This epi thelium is a collar like band of stratified
squamous epithelium that is firmly attached to the tooth surface by way of an epithelial
attachment. At the epithelium's beginning, it is approximately 15 to 30 cell layers t hick,
and at its apical end, the epithelium is only a few cell layers thick. The j unctional epitheli um
consists of two layers: a basal layer and suprabasallayer.
Important: The superficial, or supra basal, epithelial cells of the j unctional epit helium provide
t he hemidesmosomes and an internal basal lamina t hat create the epithelial attachment.
The epithelial attachment is very strong in a healthy state, acting as a type of seal between the
soft gingival t issues and the hard t issue surface.
***In ideal gingival health, the j unctional epithelium is located entirely on enamel above t he
cementoenamel junction.
Note: Histologically, the best way to distingui sh the free gingiva from the epithelial
attachment (junctional epithelium) is the fact that the epithelium of the epithelial attachment
does not contain rete pegs or connective tissue papillae and the free gingiva does. Rete
pegs are epithelial proj ections that extend into the gingival connective t issue. Connective
tissue papillae are connective tissue proj ections that extend into t he overlying epithelium.
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periodontium
Which of the following gingival fibers extend between the cementum of
approximating teeth?
circular fibers
dentogingival fibers
transseptal fibers
alveologingival fibers
dentoperiosteal fibers
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transseptal fibers
Although not strictly part of the POL, other groups of collagen fibers are associated with
maintaining the functional integrity of the periodontium. These groups are found in the lam-
ina propria of the gingiva and collectively form the gingival ligament. Five groups of fiber
bundles compose the ligament:
Circular group - this fiber subgroup of the gingival fiber group is located in the lamina
propria of the marginal gingiva. The circular ligament encircles the tooth and helps maintain
gingival integrity.
Dentogingival group - this fiber subgroup ofthe gingival fiber group inserts in the cem-
entum on the root, apical to the epithelial attachment, and extends into the lamina propria
of the marginal gingiva. Thus, this ligament has only one mineralized attachment to the
cementum. The dentogingival ligament works with the circular ligament to maintain ging-
ival integrity.
Alveologingival group - this fiber subgroup of the gingival fiber group extends from the
alveolar crest of the alveolar bone proper and radiates coronally into the overlying lamina
propria of the marginal gingiva. These fibers may possibly help to attach the gingiva to the
alveolar bone because of their one mineralized attachment to bone.
Dentoperiosteal group- this fiber subgroup of the gingival fiber group courses from the
cementum, near the cementoenamel junction, across the alveolar crest. These fibers possi-
bly anchor the tooth to the bone and protect the deeper periodontal ligament.
Transseptal group - this fiber subgroup of the gingival fiber group are located interprox-
imally and form horizontal bundles that extend between the cementum of approximating
teeth into which they are embedded. They lie in the area between the epithelium at the
base of the gingival sulcus and the crest of the interdental bone and are sometimes class-
ified with the principal fibers of the periodontal ligament.
Note: Some histologists consider the gingival ligament to be part of the principal fibers (also
called the al veolodentalligament) of the POL.
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A B
c
group
Alveolar bone 261-1
The arrangement of the principal tiber groups within the periodontium. A, Principal tiber groups. B,
Fiber groups of the gingival ligament. C, Gingival ligament fibers as seen interproximally related to the
gingival col.
ReprodllC.'cd with permission from Nand A: Te11 CmeS Orallii.mJ!og)' IXIell1pment. Structure. a11d Fmu:tion: St. LOUIS, 200!), Elsevier.
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The mucosa found on the hard palate is known as:
lining mucosa
masticatory mucosa
specialized mucosa
none of the above
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masticatory mucosa
The oral mucosa is composed of two layers:
1. Stratified squamous epithelium, which may be nonkerati nized, parakeratinized, or orthoker-
atinized dependi ng upon its location.
2. Lamina propria (connective tissue), which supports the epithelium. Subdivided into t wo layers
(papillary and dense). It may be attached to the periosteum of t he alveolar bone or i nterposed over
the submucosa (the submucosa contains glands, blood vessels, and nerves).
Type Region
lining mucosa Buccal mucosa. labial
mucosa, alveolar
mu<:()Jt.il, floor of the
mouth, ve.ntraltonguc
surfac.e, and soil pklle
Ma.sticaiOry
mucosa
Free gingiva. attached
gingiva. interdental
gingiva. hard palate-,
and dorsal surface of
tongue
I' pn ol Oral l u n t ~ a
Central Clinical
Apptarance
Softe.r texture. m<>ist
l>Urface. and ability to
l>lretch and be compressed,
acti ng a.s a cushion
Rubbery ii urfac.: texture
and re-siliency, serving a..::
finn base
Specialized
mucosa
Oo.-salt<>ngue-surfac:.e Associated with lingual
papillae
Remember:
Gtnl'nd Microscopic
ApJ)l'aranct'
Thin nonktratinlzed l>lratifitd
squamous epithe-lium, few rete
pegs. thin lamina propria
Ktratini:ttd epithelium, many
rete pe-gs, thick lamina propria
tv1o.stl y kerati nized. Note: The
fi liform and circumvallate
papillae arc ke-ratinized, but Lhc
fung,ifonn and foliate papillae
art nonke.r.uinizcd
1. The crevicular (sulcular) epithelium and gingival col are nonkeratinized gingival ti ssues. The gingi-
val col is t he interdental depression in the gingiva, between the buccal and l ingual papillae.
2. The lining of a healthy sulcus is composed of nonkerati ni zed epithelial t issues with no rete pegs. The
presence of rete pegs is indicative of the presence of i nflammation.
3. The junction of the li ning mucosa with t he masti catory mucosa is the mucogingival junction.
Note: A basement membrane is located bet ween the oral epithelium and the connective tissue. The
basement membrane is composed of two layers - basal and reticular lamina.
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periodontium
Scaling and root planning are periodontal treatments that can remove calcu-
lus and also stimulate the gingiva. Usually, a periodontist waits four to six
weeks after a scaling and root planning procedure for reevaluation of ther-
apy. This allows healing of the connective tissue by what main cellular com-
ponent of the gingival connective tissue?
osteoblast
odontoblast
fibroblast
ameloblast
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fibroblast
All forms of epithelium, whether associated with li ning, masticatory, or specialized mu-
cosa, have a lamina propria deep to the basement membrane. The lamina propria,
li ke all forms of connective tissue proper, has two layers: papillary and dense.
The lamina propria is densely collagenous with a system of collagen fiber bundles
called the gingival fibers (gingival ligament). These fibers brace the marginal gingiva
against the tooth, provide the rigidity necessary to withstand the mechanical insults
of mastication, and unite the free marginal gingiva with the cementum of the root
and adjacent attached gingiva. These fibers are continuous with the periodontal
li gament. The POL is also considered to be connective tissue. It surrounds the root
and connects it with the alveolar bone by its principal fibers (alveolodental
li gament), which are also collagenous fibers.
The most common cell in the lamina propri a, like all types of connective tissue proper,
is the fibroblast . The fibroblast is responsible for the synthesis and secretion of
collagen as well as other proteins. Therefore, fibroblasts are responsible for healing of
the gingiva following surgery or disease processes. Other cells present in the lamina
propria in small er numbers are the white blood cells such as PMNs, mast cell s,
macro phages, and lymphocytes.
Note: The gingival apparatus is a term used to describe the gingival ligament
(or groups) and the epithelial attachment.
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periodontium
Which structure below is NOT a derivative of the dental follicle?
pulp
cementum
periodontal ligament
alveolar bone
[refer to card 95-1, for illustration I
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pulp
The dental follicle (aka, dental sac), is responsible for the development of the sup-
porting structures of the tooth. This i ncludes the cementum, periodontal li gament
(PDL), and the alveolar bone. The pulp is a derivation of the dental papilla.
The peri odontal li gament is that part of the periodontium that provides for the at-
tachment of the teeth to the surrounding alveolar bone by way of the cementum. The
PDL appears as the periodontal space on radiographs (0.2 mm average width), a
radiolucent area between the radiopaque lamina dura of the alveolar bone proper and
the radiopaque cementum.
The PDL is an organized fibrous connective tissue that also maintains the gingiva in
proper relationship to the teeth. In addition, the PDL transmits occl usal forces f rom the
teeth to the bone, all owing for a small amount of movement and acting as a shock ab-
sorber for the soft t issue structures around the teeth, such as the nerves and blood
vessels.
1. The PDL becomes very thin and loses the regular arrangement of its
f iber when a tooth loses its function (hypofunction). This also occurs in
areas of tension as opposed to areas of compression. Teeth in hyperfunct-
ion have an increased POL width.
2. Unlike other connective tissues of the periodontium, the PDL does not
show the changes related to aging, although the PDL can undergo drastic
changes as a result of periodontal disease.
3. Remnants of Hertwig's epithel ial root sheath found in the PDL of a funct-
ional tooth are called epithelial rests of Malassez. These groups of epithel-
ial cel ls may become mineralized in the mature periodontal ligament form-
ing cementicles. Note: Peri apical and radicular cysts derive their cyst li nings
from the rests of Malassez.
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periodontium
Which periodontal ligament fiber group mainly resists movements of a tooth
in an occlusal direction?
alveolar crest group
horizontal group
apical group
interradicular group
oblique group
I refer to card 261 -1 for illustration]
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apical group
The principal fibers of the POL are primarily composed of bundles of type I collagen fibrils. These fibers
connect the cementum t o the alveolar bone. The main pri nci pal fiber group i s the alveolodental
ligament, which consi sts of fi ve fiber groups:
Alveolodentalligament:
The alveolar crest group of the alveolodentalligament: origi nates i n the alveolar crest of the alveolar
bone proper and fans out to i nsert i nto the cervical cementum at various angles. The f unction of t hi s
group i s to resist t i lting, i ntrusive, extrusive, and rotational forces.
The apical (periapical) group of t he alveolodental ligament: radiates from t he apical regi on of the
cementum to insert into the surrounding alveolar bone proper. The function of this group i s to resi st
extrusive forces, which try to pull the tooth outward (in an occlusal direction), and rotational forces.
The oblique group of the alveolodentalligament: the most numerous of the fiber groups and covers
the apical two-thi rds of the root. Thi s group originat es in the alveolar bone proper and extends apically
to i nsert more apically i nto the cementum in an oblique manner. The function of this group i s to resi st
i ntrusive forces, which try to push the t ooth i nward, as well as rotational forces.
The horizontal group of the alveolodental l igament: origi nates in the alveolar bone proper apical t o
i ts alveolar crest and i nserts into the cementum horizontally. The f unction of this group i s to resist t ilti ng
forces, which work to force the ti p either mesially, distally, lingually, or facially, and to resist rotational
forces.
The interradicular group of the alveolodentalligament: found only between the roots of mul ti rooted
teeth (furcation area). Run from the cementum i nto bone, forming t he crest of the i nterradicular
septum. The f unction of this group i s to work together with the alveolar crest and apical groups to resi st
i ntrusive, extrusive, tilting, and rotational forces.
Note: Another principal fiber other than the alveolodentalligament is the interdental ligament, or
transseptalligament. Thi s fiber group (called transseptal fibers) inserts mesi ally or interdentally into the
cervical cementum of neighboring teeth over the alveolar crest of the alveolar bone proper. Thus, the fibers
travel from cementum to cementum without any bony attachment. The function of this group is to resist
rotational forces and t hus hold the teeth in interproximal contact.
Important: The ends of the pri ncipal fibers, which are embedded into the cementum and alveolar bone,
are called Sharpey's fibers.
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periodontium
Which ofthe following is the most common cell found in the POL?
cementoblasts
undifferentiated mesenchymal cells
osteoblasts
f ibroblasts
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fibroblasts
Contents of the POL
Fibroblasts: like all connective tissues, they are t he most common cell
Cementoblasts and cementoclasts
Osteoblasts and osteoclasts
Macrophages, mast cells, and eosinophils
Undifferentiated mesenchymal cells
Ground substance: proteoglycans, glycosaminoglycans, glycoproteins, and water
Functions of the POL:
Support: provides attachment of the tooth to the alveolar bone
Formative: contains cells responsible for formation of the periodontium
Nutritive: contains a vascular network providing nutrients to its cells
Sensory: contains afferent nerve fibers responsible for pain, pressure, and proprioception
Remodeling: contains cells responsible for remodeling of the periodontium
Important: Orthodontic treatment is possible because the POL continuously responds and
changes as the result of the functional requirements imposed upon the POL by externally
applied forces.
The POL has a vascular supply (arises from the maxillary artery), lymphatics (drain to the sub-
mandibular lymph nodes except for the mandibular incisors which drain to t he submental
lymph nodes), and a nerve supply, which enter the apical foramen of the tooth to supply the
pulp.
Two types of nerves are found within the POL
1. One type is afferent, or sensory, which is myelinated and transmits sensation.
2. The other type is autonomic sympathetic, which regulates the blood vessels.
Two types of nerve endings are found in the POL:
1. Free nerve endings; convey pain.
2. Encapsulated nerve endings; convey pressure.
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tissue
Which of the following epithelia lines the endothelium of the aorta and the
mesothelium ofthe peritoneal cavity?
simple squamous epitheli um
stratified columnar epitheli um
stratified cuboidal
transitional epithelium
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simple squamous epithelium
Simple squamous epithelium- single layer of t hi n, flat cells; functions i n gas exchange; li nes blood ves-
sel s and various membranes:
Endotheli um l ining the cardiovascular system( e.g., the aorta)
Epit helium lini ng the alveoli i n l ungs
Mesot helium li ni ng body cavi ti es and coats organs of these cavit ies
Simple cuboidal epithelium- single layer of cube-shaped cell s; carries on secret ion and absorption:
Epit hel ium li ni ng collecting ducts, proxi mal, and distal tubul es of t he kidney
Epithelium li ni ng t hyroid follicles
Simple columnar epithelium - elongated cells; functions in prot ect ion. secretion and absorption:
Lini ng of t he small and large intesti ne, the gallbladder, and the stomach
Uterine epi thel ium
Sal ivary gland striated ducts
Internal l ini ng of t he maj ority of the t ubular gastroi ntesti nal t ract
Stratified squamous epithelium- composed of many layers of cell s; prot ects underlyi ng cell s from
envi ronment al fluct uations:
Epidermi s of t he ski n (kerati nized)
Lini ng of t he esophagus (usually not keratinized)
Stratified cuboidal epithelium- composed of many layers of cube-shaped cell s:
Ducts of t he sweat glands
Stratified columnar epithelium- composed of many layers of el ongated cells:
Large duct s of salivary glands
Male urethra
Specialized epithelium:
- Pseudostratified columnar epithelium- elongated cells atop one another with nucl ei located at
two or more l evels wit hi n cells; may have ci lia that funct i on t o move fl uids past the cells:
Lini ng of the upper respi ratory t ract
-Transitional epithelium - special ized to undergo distension; helps prevent urinary fl uids from dif -
fusing outwards:
Bladder
Ureter
Lini ng of parts of the male reproductive system
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Simple squamous
Slratified squamous

Simple cuboidal
.L


-


.......____ __ ___,
Transilional
Epithelia
Simple columnar with microvilli
Pseudostratified columnar with
cilia and microvilli
26J.I
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tissue
Which of the following cell layers of the epidermis contains keratohyalin
granules?
stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum basale
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stratum granulosum
The skin is composed of three primary layers, the epidermi s, dermis and hypodermi s. The
epidermis is the outer, thinner portion of the skin. The epidermis is avascular. It develops
from embryonic ectoderm. The epidermis consists of five layers; they receive their nutri-
ents f rom blood vessels in the dermis. From innermost to outermost, they are:
l.Stratum basale (germinativum) - deepest layer; cuboidal to columnar cells; site of con-
tinuous cellul ar reproduction. Melanocytes, which produce melanin, are located here.
The cells of this layer are the least differentiated of all epidermis cell layers.
2. Stratum spinosum - next deepest layer; contains cell s call ed Langerhans cell s; con-
tains nerve cells.
3. Stratum granulosum- three to five rows of fl at cells; these cell s have basophilic ker-
atohyalin granules.
4.Stratum lucidum- only in the thick skin of the palms and soles; consists of clear, flat,
dead cells.
5. Stratum corneum- outermost layer of epidermi s; 25 to 30 rows of flat, dead cells filled
with keratin; continuously shed and replaced.
Note: The bottom layer, the stratum basale, has cell s that are shaped like columns. In this
layer, the cells divide and push already formed cells into higher layers. As the cells move into
the higher layers, the cells flatten and eventually die. The top layer of the epidermis, the
stratum corneum, is made of dead, fl at skin cell s that shed about every two weeks.
Important: There are three types of specialized cell s in the epidermis. Melanocytes pro-
duce pigment (melanin), Langerhans cells are the frontli ne defense of the immune system
in the skin, and keratinocytes produce keratin (a protective protein). They are the most
common cell types in the epidermi s of the skin. Note: Tonofi bril s (fibrill ar structural pro-
teins) and desmosomes are especially well developed in keratinocytes.
Mnemonic: B.ad yet J.eg C.ramps. This is an acronym for the layers of the skin
from the innermost to the outermost layer.
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Structure of the Epidermis
'-- ---- Dead keratinocytes,
those on the surface ftake off
OLO
Melanocyte
YOUNG
Dividing keratinocyte (stem cell)
Tactile cell
--- -- Sensory nerve ending
268-1
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Epidermis:
Stratum corneum
Stratum lucidum
Stratum basale
Dermis
Reticular
Subcutaneous
fatty tissue
Pain receptor
(free nerve
endings)
Sweat duct
Touch
receptor
Nerve
Capillary
Sweat
gland
Vein
Pressure
receptor
Artery
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tissue
What is the main difference between parakeratinized and orthokeratinized
epithelium?
para keratinized epitheli um has keratohyali n granules
parakeratinized epithelium has nuclei
parakeratinized epithelium has more prominent RER
para keratinized epitheli um are rich in mitochondria
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para keratinized epithelium has nuclei
This stratified squamous epithelium acts as a mechanical barrier and protects the underlying
tissues. There are three types found within the oral cavity:
1. Non keratinized (most common) - selective barrier, acts as a cushion. Cells do not contain
keratin. Is associated with lining mucosa (i.e., buccal and labial mucosa, mucosa lining the floor
of the mouth, ventral surface of the tongue, and the soft palate)
2. Orthokeratinized (least common) -associated with mast icatory mucosa (i.e., hard palate and
the attached gingiva, also the lingual papillae on the dorsal surface of the tongue)
3. Parakeratinized - associated with masticatory mucosa (i.e., attached gingiva, in higher levels
than orthokeratinization, and the tongue's dorsal surface)
Note: The main difference bet ween para keratinized epithelium and orthokeratinized epithelium
is in the cells of the keratin layer. In parakeratinized epitheli um, the superficial layer is stil l being shed
or lost, but these cells of the keratin layer contain not only kerati n but also nuclei, unlike those of or-
thokeratinized epithelium.
Other cell types (ot her than keratinocytes) found in the oral epithelium:
Epithelial cells - form a cohesive sheet that resists physical forces and serves as a barrier
to infection
Melanocytes - synthesize melanin
Langerhans cells - antigen presenting cells, part of immune system
Granstein cells- antigen presenting cells, part of immune system
Merkel cells- associated with sensory nerve endings
White blood cells - PMNs are the most commonly occurring
All forms of epithelium (whether associated with lining, masticatory, or specialized mucosa) have a
lamina propria (connective tissue proper) deep to the basement membrane. It supports the
epithelium and is subdivided into two layers (papillary and dense). It may be attached to the
periosteum of the alveolar bone or interposed over the submucosa (the submucosa contains
glands, blood vessels, and nerves).
Note: A basement membrane is located between the oral epithelium and the connective tissue.
The basement membrane is composed of two layers - basal and reticular lamina.
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tissue
Which type of collagen is found mainly in dentin and bone?
type I
type II
type Il l
type IV
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type I
*** 90% of the collagen in the body is in types I, II, Ill, and IV. Type I is associated wi th (bONE),
and i s the principle fiber of the POL. Type II i s associated with cartilage (carTWOilage). Type Il l is
associated with reticular fibers (reTHREEicular). Type IV is associated with the floor (FOUR) or
t he basement membrane.
The basement membrane is a thin, acellular structure always located between any form of ep-
ithelium and its underlying connective t i ssue. The basement membrane consi sts of two layers:
The basal lamina (produced by the epithelial cells): superfici al portion of t he basement
membrane. Consists of two layers microscopi cally:
-The lamina Iucida: clear layer, closer to the epithelium
-The lamina densa: dense layer, closer to the connective tissue
The reticular lamina: this layer is a thin layer composed of type Ill collagen fibers as well
as reticular fibers produced and secreted by the underlying connective tissue.
Attachment mechanisms are al so part of t he basement membrane. These involve hemidesmo-
somes wi th their attachment plaques, tonofilaments from the epithelium, and the anchoring
collagen fibers from the connective t i ssue.
Important: Keloid is a result of an overgrowth of granulation ti ssue (collagen type Ill) at the site
of a healed skin injury which is t hen sl owly replaced by collagen type I.
1. Every t hird amino acid in collagen i s glycine; other amino acids t hat are important
in collagen structure are proline, hydroxyproline and hydroxylysine.
2. Vitamin C i s required for hydroxylation reactions of proline and lysine to hydrox-
yproline and hydroxylysine respectively. Deficiency of vitamin C will cause incomplete
hydroxylation of these amino acids; this causes scurvy which is characterized by poor
wound healing and gum bleeding.
3. Lysyl oxidase i s an extracellular enzyme which plays an important role in procol-
lagen crosslinking.
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tissue
Which of the following epithelial tissues is most often specialized for diffu-
sion and filtration?
simple columnar epitheli um
stratified cuboidal epitheli um
simple squamous epitheli um
pseudostratified epithelium
I refer to card 267-1 for illustration]
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simple squamous epithelium
Simple epithelium has only a single layer of cells, all contacting the basal lamina.
Stratified epithelium has two or more layers, with only the deeper layer contacting
the basal lamina.
Pseudo stratified epithelium appears multilayered, but is actually only a single layer
with all of the cells touching the basal lamina. The positioning of the nuclei within the
individual columnar cel ls causes this il lusion.
S u m m u ~ of Different 1 p c ~ of Epithelium
Epitheli um Cells Function (s)
Simple Squamous Diffusion and filtrat ion
Cuboidal Secretion or absorption
Columnar Absorption and secretion
Stratified Squamous Protection; prevents water loss
Cuboidal Protection and secretion
Columnar Protection
Specialized:
.
Transitional Varies between cuboidal and squamous Specialized to undergo distens ion
.
Pseudostratified Columnar cells atop one another with May have cilia that function to move
nuclei located at two more levels within fluids past the cells
cells
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Simple squamous
Slratified squamous

Simple cuboidal
.L


-


.......____ __ ___,
Transilional
Epithelia
Simple columnar with microvilli
Pseudostratified columnar with
cilia and microvilli
26J.I
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tissue
Which of the following cells is the most abundant cell type found in
connective tissues?
osteoblast
chondroblast
mast cell
fibroblast
macrophage
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fibroblast
Pnrtl.'lp.tl Kinds ol llsSUl'S
Type Description and Function Types/Examples
Epithelial May be one (simple) or several (stratified) layers Two types:
tissues thick; lower surface bound to a supportive . Surface epithelium covers the
basement mitotically active tissue; outside of the body and lines
avascular; covers the surface of the body and line internal organs
the various body cavities, ducts and vessels .
Glandular epithelium
Connective Highly vascular (except for cartilage); contains Tendons and ligaments; cartilage and
tissues considerable intercellular matrix; mitotically bone, adipose tissue, blood
active tissue; used for support (bones and
cartilage), for anachment of other tissues Types of connective tissue proper:
(tendons, ligaments, and fascia), or for other .
Areolar
specialized functions (such as blood)
.
Dense (regular)
.
Elastic
.
Reticular
.
Adipose
Muscular Limited mitotic activity; composed of Three types:
tissues specialized cells that are capable of contracting
.
Smooth
and thereby decreasing in length; these tissues .
Cardiac
move the skeleton, propel the blood throughout .
Skeletal
the body, and aid in digestion by moving food
through the digestive tract
Nervous Limited mitotic transmit messages Form brain, spinal cord, and nerves;
tissues throughout the body consist largely of cells (neurons)
with long protoplasmic extensions
Note: Fibroblasts are the most abundant cell s of the connective t issue.
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Intervertebral discs are made up of:
elastic cartil age
periosteum
fibrocartilage
hyal ine carti lage
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fibrocartilage
Cartilage is a type of dense, fibrous connective tissue, which supports and shapes various struct ures.
It also cushions and absorbs shocks. Cartilage is composed of cells called chondrocytes that are dis-
persed in a firm, gel-like ground substance, called the matrix. These cells reside in depressions in the
matrix, called lacunae. Cartilage contains no blood vessels, and nutrients are diffused through the
matrix. Cartilage is found in the joints, the rib cage, the ear, the nose, and the throat and between in-
tervertebral discs. Note: The only blood supply to cartilage is provided by blood vessels that enter the
cartilage through the perichondrium.
Important: The exception to the rule that cartilage is always covered by a perichondrium is the ar-
ticular cartilage at a synovial joint.
There are three subtypes based on the composition of the matrix:
1. Hyaline cart ilage- has a high proportion of matrix and fine collagenous fibers. Throughout
childhood and adolescence, hyaline cartilage plays an important part in the growth in length of
long bones (epiphyseal plates are composed of hyaline cart ilage). Covers the articular surfaces
of nearly all synovial joints. It is incapable of repair when fractured.
Note: Type II collagen makes up 40% of this cartilage's dry weight.
2. Fibrocartilage - has a large number of collagen fibers embedded in a small amount of matrix.
Fibrocartilage is found in the discs within j oints (e.g., the TMJ, intervertebral discs, sternoclav-
icular joint, and knee joint) and on the articular surfaces of the clavicle and mandible. Fibro-
cartilage is formed mainly by collagen type I.
3. Elastic carti lage- similar to hyali ne cartilage, except elastic cartilage possesses large numbers
of elastic fibers embedded in the matrix. Elastic cartilage is very flexible and is found in the auri-
cle of the ear, the external auditory meatus, the auditory tube, and the epiglottis. Elastic car-
tilage is composed of elastic fibers and collagen type II.
1. Carti lage is a precursor to endochondral bone.
2.The matrix is mainly composed of proteoglycans, which consist of glycosaminoglycans
and core protein. The most common types are chondroitin sulfate and keratan sulfate.
3. The perichondrium is very important in the growth of cartilage.
4. No calcium salts are present and, therefore, cartilage does not appear on x-rays.
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tissue
All of the following bones are formed completely by intramembranous ossi -
fication EXCEPT one. Which one is the EXCEPTION?
clavicles
mandible
maxill a
frontal bone
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mandibl e- the condyles are formed by endochondral ossification
Endochondral ossifi cation begins with points in the cartilage called "primary
ossification centers:' They mostly appear during fetal development, though a few short
bones begin their primary ossification after birth. They are responsible for the formation
of the diaphyses of long bones, short bones, and certain parts of irregular bones.
"Secondary ossification" occurs after birth, and forms the epiphyses of long bones and
the extremities of irregul ar and flat bones. The diaphyses and the epiphyses of long bones
remain separated by a growing zone of cartil age (the metaphysis) until the child reaches
adulthood (18 to 25 years of age), whereupon the cartilage ossifies, fusing the two
together. Note: Heterotopic ossification is the formation of bone outside the skeleton
and is seen in diseases such as myositis ossifi cans.
Long bones increase in length during growth and development. The epiphyseal plat e
(disc) is a wedge of hyali ne cartil age accounting for this increase. This plate is found be-
tween the epiphysis (bulbous end) and diaphysis (tubular shaft) at each end of the bone.
The cartilage cells of the epiphyseal plate form layers of compact bone t issue, adding to the
length of the bone (interstit ial growth). This disc becomes inactive in most individuals by
the late teens or early twenties.
Note: Hyaline cartilage does not calcify and become bone; rather, it calcifies and is re-
placed by bone.
Remember: Bone formation or development occurs by two methods:
1. Intramembranous ossifi cation mainly occurs during formation of the flat bones of
the skull; the bone is formed f rom mesenchyme t issue.
2. Endochondral ossification occurs in long bones, such as limbs; the bone is formed
f rom cartilage.
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Reproduced with permission from Stevens A. Lowe Hmn(m ed J. Philadelphia. 2005. Elsevier.
Chondroblasts
Early perichondrium
Periosteum
B c D
Primitive Developing Developi ng Primary (diaphyseal)
mesenchyme cartilage model bone collar ossification center
Prenatal long bone development (endochondral ossification)
A. Chondroblasts develop in primitive mesenchyme and form an early perichondrium and cartilage model.
B. The developing cartilage model assumes the shape of the bone 10 be formed, and a surrounding peri-
c hondrium becomes identifiable.
C. At the mids haft of the diaphysis the perichondrium becomes a periosteum through the development of
osteoprogenitor cells and osteoblasts, the osteoblasts producing a collar of bone by intramembranous ossi-
fication.
D. Blood vessels grow through the periosteum and bone collar, carrying osteoprogenitor cells within them.
These establish a primary (or diaphyseal) ossification center in the center of the diaphysis.
E. Bony trabeculae spread out from the primary ossification center to occupy the entire diaphysis, linking
up with the previously formed bone collar. which now forms the cortical bone of the diaphysis. At this stage
the terminal club-shaped epiphyses are still composed of cartilage.
F. At about tem1 (the precise time varies between long bones). secondary or epiphyseal ossification centers
are established in the center of each epiphysis by the ingrowth along with blood vessels of mesenchymal cells
which become osteoprogenitor cells and osteoblasts. z
74

1
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tissue
A patient in the dental clinic states in his medical history that he has heart
disease and occasionally takes nitroglycerin for his pain. During treatment,
the patient clutches his chest and frantically points to his jacket pocket. The
dentist obtains the nitroglycerin bottle from his jacket, removes one tablet,
and places it:
on the soft palate
on the gingiva
on the oral vestibule
on the floor of the mouth
on the buccal tissue
any of the above
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on the floor of the mouth
Note: The reason of the ease of diffusion is because the epidermis and lamina propria
is thin in the floor of the mouth.
In general, the permeabili ty of the oral mucosa is as follows, from most permeable to
least: sublingual > buccal mucosa > palatal mucosa. This ranked order is based on
the relative thickness and degree of keratinization of those tissues. The subl ingual
mucosa is thin and nonkeratinized. The buccal mucosa is thicker than the
sublingual mucosa and is also nonkeratinized. The hard palatal mucosa is thicker
still, with a thick keratinized layer.
Important point: The oral cavity is highly acceptable for systemic drug delivery. The
mucosa is relatively permeable with a rich blood supply, and the virtual lack of
Langerhans cells makes the mucosa tolerant of potential all ergens. This route also
bypasses the fi rst pass effect and avoids pre-systemic el imination in the Gl tract.
Example: Nitroglycerin tabl ets are given subl ingually for rapid absorption.
Remember: The oral mucosa is composed of an outermost layer of stratified
squamous epithelium. Below this lies a basement membrane, a lamina propria
(connective t issue proper) fol lowed in most cases by the submucosa as the
innermost layer. The composition of the epithel ium varies depending on the site
in the oral cavity. The mucosa of areas subjected to mechanical stress (the gingiva and
hard palate) is keratinized (specificall y, orthokeratinized). The mucosa of the soft
palate, the sublingual, and the buccal regions, however, is not keratinized.
Note: Alveolar mucosa is very simi lar to subl ingual mucosa in that it, too,
appears red due to the numerous blood vessels and the thin epithel ial covering.
Fordyce spots (ectopic sebaceous glands) are yell owish small papules that are some-
times found on the buccal mucosa or on the vermili on border of the l ips.
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tissue
Which of the following is the principle component of ground substance of
the cartilage?
fibroblasts
coll agen fibers
reticular fibers
chondroitin sulfate
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chondroitin sulfate
Cartilage and bone are specialized forms of connective tissue. They contain cells which produce
fibers and ground substance. Together, the fibers and ground substance compri se the organic
matrix. The principal constituents of ground substance are proteoglycans, which consist of pro-
t ein combined with complex carbohydrates such as chondroitin sulfate and keratan sulfate.
These carbohydrates are called glycosaminoglycans, usually abbreviated GAGs.
The GAGs radiate from the protein core li ke the brist les of a bottle brush. The principal GAGs of
cartilage are chondroitin sulfate and keratan sulfate. Another matrix component is
hyaluronic acid, a gelatinous mucopolysaccharide. The hyaluronic acid acts as a sort of
cement to bi nd the proteoglycans together into large aggregates.
Note: All GAGs are sul fated and have a protein core except hyaluronic acid.
Important: Because of the chemical nature and organization of t he glycosaminoglycans, t he
ground substance can readily bind and hol d water, which allows the t issue to assume a
gelatinous nature that can resist compression and permit some degree of diffusion through
the matrix.
Note: Chondrocytes produce all t he components of cartilage: the matri x material and t he fibers
as well.
Hyaline cartilage forms nearly all of the fetal skeleton. In the adult, the remnants are:
Articular cartilage - smooth and slippery, it lines movabl e joints
Costal cartilages - at the sternal ends of t he ribs
Respiratory cartilages - movable external nose and septum, larynx, trachea, and bronch-
ial walls
Stl'ucture Function
Collagen fibers Provide tensile. strength
Elastic fibers Provide elasticity
Ground substance Provide strenglh
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tissue
At the gymnastics center, a 22-year-old male doing flips on the trampoline
lands incorrectly on his ankle and dislocates it. In the emergency room, the
physician provides traction to correctly relocate the ankle. The patient is told
that although there are no fractures the bands of fibrous connective tissue
that connect bone to bone are almost definitely torn. These bands are called:
tendons
bursae
ligaments
menisci
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ligaments
Ligaments are dense, strong, f lexible bands of fibrous connective tissue that t ie bones
to other bones. Ligaments that connect the joint ends of bones either l imit or facili-
tate movement. Ligaments also provide stabil ity.
Tendons are strong, f lexible bands of f ibrous connective t issue that attach muscles to
the fibrous membrane that covers bones (periosteum). Tendons move bones when
skeletal muscles contract.
Important: When a t endon or ligament is attached to the bone, the attaching f ibers
are called Sharpey's fibers. They are periosteal col lagen fibers that penetrate the bone
matrix, binding the periosteum to the bone.
Remember: The periodont al li gament contains collagen f ibers that are inserted on
one side in the cementum and on the other side in alveolar bone. The ends of these col-
lagen fibers are Sharpey's fibers.
Bursae are small , synovial, fluid-fil led sacs located around joints at friction points
between tendons, ligaments, and bones. Bursae act as cushions.
. 1. A fasciculus is a bound group of individual muscle fibers. The fasciculi are
..JJ the bundles of muscle fibers composing a muscle. In turn, each muscle is sur-
lid rounded by a connective t issue called fascia.
2. The fascia secures the muscle to a tendon. lt attaches the muscles to nearby
bones by blending with the periosteum of these bones.
3. An aponeurosis is a sheetlike tendon.
4. Menisci are crescent-shaped interradicular fibrocarti lages in certain joints,
including the knee.
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tissue
Which type of connective tissue is most commonly observed in ligaments
and tendons?
loose connective tissue
dense irregular connective t issue
dense regular connective tissue
elastic connective t issue
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dense regular connective tissue
Connective t i ssue derives from mesenchyme (mesoderm). Compared with epithel ium, connective t issue
i s usually composed of f ewer cells spaced further apart and containing larger amounts of matrix between
the cells (except in adipose connective t issue). The most common cell i s the fibroblast. Other cells found
i n connective tissue include migrated white blood cells such as macrophages (histiocytes), basophi ls
(mast cells), lymphocytes (including plasma cells), and neutrophils (PMNs).
Essential components of connective tissue are:
Ground substance (proteoglycans to which GAGs are attached and glycoprotei ns)
Fibers (collagen, elasti c, and reticular fibers)
Cells
Connective ti ssue can be classified into:
1. Connective ti ssue proper:
Loose (areolar): consists predominantly of cells or matrix in an irregular or loose arrangement and
few fibers. Serves as padding for t he deeper portions of the body
Dense: which provides structural support, has greater fiber (protein) concentration, few cells
and less ground substance and is t ightly packed. Dense is further subdivided i nto:
Dense regular connective t issue: has a regular arrangement of t ightly packed, strong, parallel
collagen fibers with few fi broblast cells. This t issue i ncludes tendons, ligaments, aponeuroses
and cornea.
Dense irregular connective t issue: has t ightly packed, strong collagen fibers arranged in an
inconsistent or irregular pattern. This t issue is found in the dermi s, submucosa of Gl tract, org-
an capsules, deep fascia, periosteum and peri chondrium.
2. Special connective tissue:
Elastic connective ti ssue: consist predominantly of elastic fi bers. It's found in large arteries (aorta),
vocal cords and between t he arches of the vertebrae (l igamenta fl ava).
Adipose connective tissue: i t consists mainly of adipocytes. This t issue has diminished access by
antibiotics and leukocytes because of the poor blood supply.
Reticular connective tissue: it consists mai nly of reticular fi bers (collagen type Ill). Reti cular con-
nective tissue is found around t he l iver, the kidney, the endocrine glands, t he spleen, and lymph
nodes, as well as in bone marrow.
3. Supportive connective tissue: Bone and cartilage
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tissue
The greatest resistance to the movement of the molecules between cells is
mainly achieved by which of the following intercellular junctions?
desmosomes
hemidesmosomes
adherens junctions
gap junctions
zonula occludens
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zonula occludens
Bricks in a building must be stuck together and also tied somehow to the foundation. Similarly, cells
within tissues and organs must be anchored to one another and attached to components of the ex-
tracellular matrix. Cells have developed several types of intercellular junctions to serve these func-
t ions, and in each case, anchoring proteins extend through the plasma membrane to link cytoskeletal
proteins in one cell to cytoskeletal proteins in neighboring cells as well as to proteins in the extra-
cell ular matrix.
An intercellular junction bet ween cells is a desmosome. The desmosome appears to be disc-shaped
and can be likened to a spot weld."
Another type of intercellular j unction is a hemidesmosome, which involves an attachment of a cell
to an adjacent noncellular surface. Important: This type of attachment is present with the gingival
epithelium that attaches to the tooth surface (called the junctional epithelium of the epithelial
attachment) as well as in that which occurs between nails and nail beds.
Note: The clinical condition known as bullous pemphigoid involves the disruption of
hemidesmosomes and consequent separation of the epithelium from the basal lamina.
Another type of intercellular j unction is what is called an adherens junction (also called zonula ad-
herens). These j unctions share the characteristic of anchoring cells through their cytoplasmic actin
fi laments. There is considerable morphologic diversity among adherens junctions. Those that tie cells
to one another are seen as isolated st reaks or spots, or as bands that completely encircle the cell. The
band-type of adherens j unctions is associated with bundles of actin filaments that also encircle the
cell just below the plasma membrane. Spot-like adherens j unctions help cells adhere to the extra-
cellular matrix. Adherens j unctions are thought to part icipate in folding and bending of epithelial
cell sheets.
Tight junctions (zonula occludens): are formed by fusion of the outer leaflets of apposed cell mem-
branes on the lateral cell surfaces, j ust beneat h apical poles. They form barrier to permeability, or a
seal around the cell.
Gap junctions: are small channels that form direct intercellular connections through which small
molecules and ions can flow. Each gap j unction is formed by two hemichannels or (connexons).
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tissue
In contrast to tight and adherens junctions, gap junctions do NOT seal
membranes together, nor do they restrict the passage of material between
membranes.
Gap junctions allow electrical and metabolic coupling among cells so that
signals initiated in one cell can readily propagate to neighboring cells.
both statements are t rue
both statements are false
the f irst statement is t rue, the second is false
the f irst statement is false, the second is t rue
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both statements are true
In contrast to t ight and adherens junctions, gap junctions do not seal membranes to-
gether, nor do they restrict the passage of material between membranes. Rather, gap junc-
tions are composed of arrays of small channels t hat permit small molecules to shuttle from
one cell to another and thus directly link the interior of adjacent cells. Most Importantly,
gap junctions allow electrical and metabolic coupli ng among cells so that signals initiated
in one cell can readily propagate to neighboring cells.
Gap junctions are proteinaceous tubes some 1.5-2 nm in diameter. These tubes allow
material to pass from one cell to the next without having to pass through the plasma
membranes of the cells. Dissolved substances such as ions or glucose can pass through
the gap junctions. They are formed by t ransmembrane proteins called connexins.
Functionally, there are three groups of cell junctions:
1. Occluding junctions - which join the plasma membranes of adjacent cells t ightly
together.
2. Anchoring junctions- which physically connect adjacent cells and their cytoskele-
tons, but leave a space separating the plasma membranes.
3. Communicating junctions - which permit the passage of chemi cal and electrical
signals between the joined cells. Gap junctions belong to this group.
Such specialized cell junctions are found in many tissues throughout the body, but are es-
pecially abundant in epithelial tissues, where some cell junctions are organized into
groups called junctional complexes.
Three distinct components of a junctional complex:
A tight junction
An intermediate junction
A desmosome
***All of which are associated with the plasma membranes of adjacent cells.
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tissue
Where would you expect to find the fewest matrix-embedded elastic fibers?
nasal cartilage
epiglottis
auricle
eustachian tube
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nasal cartilage
Remember: Elastic cartil age is simil ar to hyaline cartilage, except elastic cartil age pos-
sesses large numbers of elastic fibers embedded in matrix. Elastic cartilage is very flex-
ible and is found in the auricle oft he ear, the external auditory meatus, the auditory
tube, and the epiglottis. Nasal cartil age consists of hyali ne cartilage.
Cartilage can develop or grow in size in two different ways:
1 .Interstitial growth - is growth from deep withi n the t issue by t he mitosis of each
chondrocyte, producing a large number of daughter cells within a single lacuna,
each of which secretes more matrix, thus expanding the tissue.
2. Appositional growth - is layered growth on t he outside of the tissue from an
outer layer of chondrobl asts within perichondrium.
Growth of bone:
Appositional growth - or layered formation of bone along its peri phery, is ac-
compli shed by the osteoblasts, which later become entrapped as osteocytes. Be-
cause of its rigid structure and t he infrequent abil ity of osteocytes to divide,
interstitial growth in bones is not possible.
*** Do not confuse bone growth with bone formation or development. Bone forms
by either endochondral ossification or intramembranous ossification.
Remember:
Endochondral ossification: increases bone length by continued interstitial
growth of cartilage which is then replaced by bone
Appositional growth: increases bone girth by apposition of new bone subpe-
riosteall y
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tissue
Which layer of skin is mainly composed of areolar connective tissue and adi -
pose tissue?
epidermis
hypodermis
dermis
I refer to card 268-1 for illustration]
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hypodermis - aka, the subdermis
The integumentary system consi sts of the skin and its many derivatives (hair, glands, nails, and
sensory receptors). The skin is composed of many t issues structurally j oined for specific func-
t ions.
Structure of skin:
The outer epidermi s: which consists of stratified squamous epi thelium. It develops from
embryonic ectoderm. The outer epidermis is avascular. The principal cell of t he epidermis is
called a keratinocyte.
The inner dermis: thicker portion of t he skin; composed of connective tissue with collage-
nous and elastic fi bers for toughness. The inner dermis develops from embryonic mesoderm
and contains blood vessels, nerves, glands, and hair follicles. It is a strong, stretchable layer
t hat essentially holds t he body together. The inner dermis has two main regions:
papillary layer: upper dermal region
reticular layer: lower dermal layer
***The subdermis (hypodermis) is the layer of tissue directly underneath the dermis. The sub-
dermis is mainly composed of areolar (loose) connective tissue and adipose tissue. Physiolog-
ical functions of the subdermis include insulation, storage of energy, and aid in the anchoring
of the skin. The subdermis al so cushions t he underlying body for extra protection against
trauma.
The skin al so contains several other relevant structures, incl uding the following:
Basement membrane: collagenous membrane between the epidermis and dermis t hat
holds them together
Meissner's corpuscle: oval body in t he dermis, thought to participate in tactile sensation
Ruffini's corpuscle: oval capsule containing the ends of sensory fibers in t he dermal papil-
lae. It's sensi tive to skin stretch, and contributes to the kinesthetic sense of and control of fin-
ger position and movement. It is believed to be useful for monitoring slippage of obj ects
along the surface of the skin, allowing modulation of grip on an obj ect.
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Structure of the Epidermis
'-- ---- Dead keratinocytes,
those on the surface ftake off
OLO
Melanocyte
YOUNG
Dividing keratinocyte (stem cell)
Tactile cell
--- -- Sensory nerve ending
268-1
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tissue
When we look at our fingers, we can see fingerprints. Which of the following
layers of skin are we looking at in order to see the fingerprints?
papill ary layer of the dermis
stratum corneum of the epidermis
reticular layer of the dermis
stratum lucidum of the epidermis
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papillary layer of the dermis
The dermis is t he t hicker portion oft he ski n. The dermi s i s composed of connecti ve ti ssue with collagenous
and elastic fibers for toughness. The dermi s develops from embryonic mesoderm and cont ai ns blood ves-
sel s, nerves. glands, and hai r foll icles. The dermi s is a strong, stret chabl e layer t hat essentially holds t he
body together. The dermis has two mai n regions:
1. Papillary layer: thin and less fibrous; has pri mary and secondary dermal ridges (aka, ret e pegs).
t hat extend up t oward t he epidermal layer. Epidermal ridges are t he interdi gi tations of t he epidermi s
with t hese dermal ri dges. Thi s layer contains t he blood vessel s that supply the overl ying epidermi s.
The layer contai ns f ibroblasts, mast cells, and macrophages.
2. Reticular layer: thick and fibrous, and i s conti nuous wit h the hypodermi s. Blood vessel s from t he
hypodermi s pass t hrough this layer. It contai ns more reticular f ibers and fewer cells than the papillary
layer. Thi s layer consists of an i nterwoven meshwork of dense i rregular connect ive t issue.
Characteristics of t he subdermis (hypodermis) t hat connects the dermis with the underlyi ng fascia of
muscles: Composed primarily of loose (areolar) connect ive t i ssue
Major site of fat deposition (50% of body fat)
Has good blood supply
Functions ofthe skin:
Vitami n D producti on Prot ecti on agai nst physi cal and chemical stresses
Excretion via sweat glands Hemostatic regulat i on of body t emperat ure
Sensation of touch. pai n and pressure
Note: Arteriovenous shunt s are found i n t he ski n and are innervated by sympathetic vasoconstrictor fibers.
Skin appendages:
Cutaneous glands
-Sebaceous glands: t hey produce oil which is a l ubri cant for ski n which keeps ski n soft and moi st
- Sweat glands:
Eccrine: they are the most numerous
Apocrine: found mostly in armpits and geni tal areas
Hair: produced by hai r foll icle which are made of hard kerat i nized epithel ial cells
Arr ector pili: smooth muscles t hat pull hairs straight
Nail: modified strat um corneum and heavi ly keratinized
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tooth components
A 17-year-old man falls down and chips the incisal edge of his maxillary cen-
tral incisor, reducing the length of the crown. The dentist informs him that the
tooth may erupt a little to compensate for the loss. Which of the following
structures will be deposited in the apex of the tooth when the tooth contin-
ues to erupt?
cementum
bundle bone
dentin
pulp
enamel
peri odontal l igament
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cementum
Cementum is t he bone-like mineralized tissue covering the anatomical roots of teeth. The
primary function of cementum is to attach Sharpey's fibers. It has the following
characteristics:
Slightly softer and lighter in color (yellow) than dent in
Formed by cementoblasts from the POL, as opposed to dentin, which is formed from
odontoblasts of the pulp. It develops from the dental follicle (a.k.a., dental sac)
Most closely resembles bone (more so than dentin). except there are no haversian syst-
ems or blood vessels; i t is avascular
Mature cementum is by composi tion 45-50% mineralized inorganic material (mainly
calcium hydroxyapatite). and 50% organic material, namely collagen and noncollagenous
matrix protein
The organic portion is primarily composed of collagen and protein
Has no nerve innervation
Thickest at the tooth's apex and thinnest at the CEJ at the cervix of the tooth
Important in orthodontics. Cementum is more resistant to resorption than al veolar
bone, permi tting orthodont ic movement of teeth without root resorption.
Two types of cementum (functionally t here is no difference):
1. Acellular (sometimes called primary cement um): consists of the first layers of cementum
deposi ted at the DCJ; acellular cement um is formed at a slow rate and contains no embed-
ded cementocytes, usually predominate on the coronal two-thirds of the root. Thinnest
at the CEJ.
2. Cellular (sometimes called secondary cementum): consists of t he last layers of cementum
deposi ted over t he acellular cementum; cellular cement um is formed at a faster rate than
acellular cement um and contains embedded cementoblasts. Cellular cement um occurs
more frequently on the apical third of t he root. Cellular cement um is usually the thickest to
compensate for occlusal/incisal wear and passive eruption of t he tooth.
Note: The composition of bone is roughly 50% inorganic, 25% collagen, and 25% water.
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tooth components
Intertubular dentin is formed in peripheral parts oft he mineralized dentin in-
side the walls of dentin tubules.
Peritubular dentin is highly mineralized and it also contains little collagen.
both statements are t rue
both statements are false
the first statement is t rue, the second is false
the f irst statement is false, the second is t rue
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the first statement is false, the second is t rue
~ pt's ul Dl'nhn
Type Location/Chronology Description
f'eritubular fomted in peripheral parto; of the Highly mineralized and ir also contains litde collagen
(intratubular) mineralized dentin inside the walls of
dentin. mbules
lntertubuhw Fomted by odomoblasrs through Dense collagen matrix
predentin mineralization berv.een che
tubule..o;
Mantle Outemtosr layer of primary de min f irst dentin fomted. slightly l e ~ ~ mineralized than
other laye1s of the primary dentin (i.e. circumpu1pal}
Circumpulpal laye around outer pulpal wall De.ntin fomted after mantle dentin
Primary Fomted nlpidly during cooth More mineralized than secondat'y
fomtation. It outlines the pulp chamber
and constitutes the main pan of the
dentin mass
Secondary fomted after completion of the apical Less mineralized than primary
foramen; fonns slower than. primary
Teniary Fomted as a re$uh of injury IITegula pattern of tubule$
(eparmive or
reactionary dentin)
Remember: Each dentinal tubule contains the cytoplasmic cell process (Tomes' fiber) of an
odontoblast.
Important: Odontoblasts secrete the organic components of the dentin matrix. The fibrous matrix
is mostly type I collagen.
Note: Dead tracts consist of groups of empty tubules due to the death of the odontoblasts whose
processes formerly fill ed the tubules. These tracts have been attributed to the aging process of the
dentinal ti ssue. They may also be caused by caries, erosion, cavity preparation, or odontoblastic
crowding.
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tooth components
Which of the following areas of the pulp is also known as the "zone of Wei I?"
f ibroblastic layer
odontoblastic layer
cell-rich zone
cell-free zone
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cell -free zone
The pulp is the innermost tissue of the tooth. The pulp is formed from the central cells of the
dental papilla.
Anatomy of the pulp:
Coronal pulp: located in t he pulp chamber and forms pulp horns
Radicular pulp: located in the pulp canals (root portion of tooth)
Apical foramen: communicates with the POL
*** Accessory canals may also be associated with the pulp. Remember: These form when
Hertwig's epithelial root sheath encounters a blood vessel during root formation. Root
structure then forms around the vessel, forming the accessory canal.
Architecture of the pulp:
The peripheral aspect of dental pulp, referred to as the odontogenic zone, differentiates
into a layer of dentin-forming odontoblasts. lmmediately subjacent to the odontoblast layer
is the cell-fre.e zone (of Wei I). This region contains numerous bundles of reticular (Korff's)
fibers. These fibers pass from the central pulp region, across the cell-free zone and between
t he odontoblasts, their distal ends incorporated into t he matrix of t he dentin layer. Numer-
ous capillaries and nerves are also found in this zone.
Just under the cell-free zone is the cell-rich zone containing numerous fibroblasts, t he
predominant cell type of pulp. Since odontoblasts themselves are incapable of cell division,
any dental procedure that relies on the formation of new dentin after destruction of odont-
oblasts, depends on the differentiation of new odontoblasts from these mul tipotential cells
of the pulp. Lymphocytes, plasma cells and eosinophils are other cell types also common in
dental pulp.
Medial to the cell-rich zone is the deep pulp cavi ty that contains subodontoblastic plexus
of Raschkow.
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Cellrich
zone
Odontoblastic layer
Schematic representation of the cells bordering the pulp. rER, Rough endoplasmic reticulum
286-1
ReprodllC.'cd with permission from Nand A: Te11 CmeS Orallii.mJ!og)' IXIell1pment. Structure. a11d Fmu:tion: St. LOUIS, 200!), Elsevier.
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tooth components
All of the following are stages of amelogenesis EXCEPT one. Which one is the
EXCEPTION?
presecretory
secretory
transitional
morphogenic
maturation
post-maturational
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morphogenic
Amelogenesis is the process of enamel matrix formation t hat occurs during the apposi tional
stage of tooth development. Enamel matrix is produced by ameloblast cells. These cells are
columnar cells that differentiate during t he bell stage in the crown area. The enamel matrix is
secreted from each ameloblast from its Tomes' process. Tomes' process is t he secretory surface
of t he ameloblast that faces the dentinoenamel junction (DEJ). Enamel matrix is first formed
in the incisal/occlusal portion of the future crown near the forming DEJ.
Important: The DEJ is the interface between the dentin and enamel. The DEJ is the remnant
of the onset of enamel formation. During amelogenesis, ameloblasts enter t heir first
formative state after t he first layer of dentin is formed. They secrete enamel matrix as they
retreat away from the DEJ. This matrix then mineralizes.
Remember: Enamel is produced in a rhythmic fashion.
Important: The odontoblasts begin dentin formation (dentinogenesis) immediately before
enamel formation by the ameloblasts. Dentinogenesis begins with the odontoblasts laying
down a dentin matrix or predentin, moving from the DEJ inward toward the pulp. The most
recently formed layer of dentin is always adjacent to t he pulpal surface. Note: Predentin or
dentin matrix is a mesenchymal product consisting of non mineralized collagen fibers.
These odontoblasts are induced by the newly formed ameloblasts to produce predentin in lay-
ers, moving away from the DEJ.
~ . . 1. The DEJ is also t he area at which calcification of a tooth begins.
~ ~ J 2. The morphology of the DEJ is determined at the bell stage.
~ l i ~ 3. The oldest enamel in a fully erupted molar is located at the DEJ underlying a
cusp.
4. Research has shown that in order for ameloblasts to form enamel, cells from the
stratum intermedium must be present.
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tooth components
Pulpal involvement of a carious lesion in a young child is much more likely
because:
caries progress faster in primary teeth
caries can enter primary teeth from the enlarged apical foramen
the pulp chamber is larger in primary teeth compared to permanent teeth
reparative dentin is not as functional in primary teeth as it is in permanent teeth
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the pulp chamber is larger in primary t eeth compared to permanent teeth
The dental pulp is a connective tissue, and thus has all of the components of such a t issue: intercellular sub-
stance, tissue Ould. cells, lymphatics, vascular system, nerves, and fibers (mainly collagen and some reticular fi bers).
Cells found in the pulp:
Fibroblasts: most numerous
Odontobl asts: only cell bodies are located in the pulp
Undifferentiat ed mesenchymal cells
Lymphocytes, plasma cells and eosinophils
Several large nerves enter the apical foramen of each molar and premolar with single ones entering the anterior
teeth. A young premolar may have as many as 700 myelinated and 2,000 unmyelinated axons entering t he apex.
These nerves have two primary modalit ies:
1. Aut onomic Nerve Fibers. Only sympathetic autonomic fibers are found in the pulp. These fibers extend
from the neurons whose cell bodies are found in the superior cervical ganglion at the base of the skull. They
are unmyelinated fibers and travel with the blood vessels. They innervate the smooth muscle cells of the ar-
terioles and therefore function i n regulation of blood Oow in the capillary network.
2. Afferent (Sensory) Fibers. These arise from the maxillary and mandibular branches of t he fifth cranial nerve
(trigeminal). They are predominantl y myelinated fibers and may terminate in the central pulp. From t his re-
gion some will send out small individual fibers that form the subodontoblastic plexus (of Raschkow) just under
the odontoblast layer.
In addition to being the formative organ of the dentin, the pulp also has the following functions:
Nut ritive: the pulp keeps the organic components of the surrounding mineralized tissue supplied with
moisture and nutrients
Sen.sory: extremes in temperature, pressure, or trauma to the dentin or pulp are perceived as pain
Protective: the formation of reparative or tertiary dentin (by the odontoblasts)
Important clinical information:
Pulp capping is more successful in young teeth because:
The apical foramen of a young pulp is large
The young pulp contains more cells (odontoblastic)
The young pulp is very vascul ar
The young pulp has fewer fibrous elements
The young pulp has more tissue flui d
"*" The young pulp l acks a collateral circulation
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The main function of cementum is to:
maintain the width of the PDL
supply nutrition to the pulp
stimulate formation of dentin
attach sharpey's fibers
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attach sharpey's fibers
Cementum is composed of a mineralized fibrous matrix and cell s (cementocytes).
The fibrous matrix consists of both Sharpey's fibers and intri nsic nonperiosteal
fibers. Sharpey's fibers are the terminal portions of t he principal fibers of the POL
(alveolodental ligament) that are each partially inserted into t he outer part of the
cementum at 90 degrees, or a right angle, to the cementa! surface, as well as the
alveolar bone on their other end.
Remember: Cementum is the bone-like mineralized tissue coveri ng t he anatomical
roots of teeth. The two basic types are acellular and cellular.
Other functions of cementum incl ude the foll owing:
Compensates for t he loss of tooth surface due to occl usal wear by apical deposit-
ion of cementum throughout l ife
Protects the root surface from resorption duri ng vertical eruption and tooth
movement
f;?y 1. Histologically, cementum differs from enamel in the fol lowing ways:
Cementum has collagen fi bers
Cementum has cellular components in the mature tissue
2. Cementoid is t he peripheral layer of developing cementum t hat is laid
down by cementoblasts undergoing cementogenesis. Cementoid is uncalci-
fied or immature.
3. When t he cementoid reaches t he full thickness needed, the cementoid sur-
rounding the cementocytes becomes calci fied or matured and is then consid-
ered cementum.
4. Cementocytes are cementoblasts entrapped by t he cementum they prod-
uce.
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tooth components
An irritating or painful response to cold, hot or pressure stimuli is usually
caused by sensitivity of which oral tissue?
dentin
cementum
pulp
enamel
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dentin
Cump.trisun ol lhl 0l'IIlalllard
Enamel Dentin Cementum Alveolar Bone
Embryological Enamel organ Dental papilla Dental sac Mesodenn
background
Type of tissue Epithelial Connective tissue Connective tissue Connective tissue
Inorganic levels 96% 70% 65% 60"1.
Organic levels; water 1%;3% 20"1.; 10% 23%; 12% 25%; 15%
levels
Incremental lines Lines of Retzius Imbrication lines Arrest and reversal Arrest and reversal
of von Ebner lines lines
Fonnative cells Ameloblasts Odontoblasts Cementoblasts Osteoblasrs
Resorptive cells Odontoclasts Odontoclasts Cementoclasts Osteoclasts
Tissue fonnation after None Possible Possible Possible

Vascularity None None None Present
Innervation None Present None Present
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tooth components
Generally, as the dental pulp ages, the number of cells ___ , and the num-
ber of collagen fibers ___ .
decreases, decreases
decreases, increases
increases, decreases
increases, increases
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Important: As the dental pulp ages, the following changes take place:
Decreased: - i ntercellul ar substance, water. and cells
decreases, increases
"**Major decrease in the number of undifferentiated mesenchymal cells
- size of the pulp cavity due to t he addition of secondary or tertiary dent in
Increased: - number of collagen fibers
- calcifications within the pulp (called dent icles or pulp stones)
Important point: As the pulp ages, it becomes more fibrotic, leading to a reduction in the regenerative ca-
pacity of the pulp.
Remember:
1. The only type of nerve ending found i n the pulp i s the free nerve ending, which is a specific
receptor for pain. These pain receptors are located i n the plexus of Raschkow. Regardless of the
source of sti mulation (heat, cold, pressure), the only response will be pain.
2. The pulp contains both myelinated (mostly) and unmyel inated nerve fi bers. They are afferent and
sympathetic.
3. The myelinated fibers are the axons of sensory or afferent neurons that are located i n the dentinal
tubules i n denti n.
4. The unmyelinated fibers are sympathetic and associated with the blood vessels.
Note: Propri oceptors (which respond to stimul i regarding movement) are not found in the pulp.
Pulp stones: are nodular calcified bodies having an organic matrix and they occur frequently i n relation to
the coronal pulp. There are two types of pulp stones, true and fal se, and both variants of pulp stones can
be either"free"within the pulpal mass or they may be"attached" to the dentinal wall.
True pulp stones: are composed predomi nantly of denti n and have dentinal tubules. They may have
an outer layer of predenti n and are often l ocated adjacent to odontoblast cells
False pulp stones: are composed of concentric layers of calci fied material with no tubular structures
According to their location in the dental pulp, stones can be classified as:
Free pulp stones: are surrounded on all sides by pulpal tissue and are not attached to the dentinal wall
Attached pulp stones: are those, which are attached to t he dent inal wall of the pulp chamber
Embedded pulp stones: pulp stones that are surrounded by reactionary or secondary dent in
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tooth components
Which ofthe following has the least amount of collagen?
bone
dentin
enamel
cementum
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enamel
Enamel is the hardest calcified tissue in the human body and the richest in calcium.
Enamel is highly mi neralized and is totally acellular. It consists of approximately 96%
inorganic material (primarily calcium and phosphorus as hydroxyapatit e), 1% organic
material, and 3% water. Enamel is of ectodermal origin. The organic matrix consists
mainly of protein, which is rich in proline.
The fundamental morphologic unit of enamel is the enamel rod or prism which is bound
together by an interprismatic substance (interred substance). Each is formed in
increments by a single enamel-forming cell, the ameloblast . Most enamel rods extend
the width of the enamel f rom the DEJ to the outer enamel surface. Consequently, each
enamel rod is oriented somewhat perpendicular to the DEJ and the outer enamel surface.
The specific shape of the enamel rod is dictated by the Tomes' process of the ameloblast.
In most cases, each enamel rod is cylindrical in the longitudinal section. In most areas of
enamel, the enamel rod is about 4 micrometers in diameter. Note: The oldest enamel in a
fully erupted tooth is located at the DEJ underlying a cusp or cingulum.
Other important facts about enamel:
It has no power of regeneration -the ameloblasts lose their functional ability when
the crown of the tooth has been completed
It has no power of metaboli sm
It has no means of combating bacterial invasion - the susceptibility of the mineral
component to dissolution in an acid environment is the basis for dental decay
It has no nerve supply
It is a good thermal insulator
The acid solubility of the surface enamel is reduced by fl uoride (this is the basis for
the topical appli cation of fluorides in dental caries prevention)
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tooth components
All of the following age changes in enamel are true EXCEPT one. Which one is
the EXCEPTION?
attrition
discoloration
flattening of grooves and fissures
modifications in the surface layer
increased permeabil ity
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increased permeability
Enamel is a nonvital tissue that is incapable of regeneration. With age, enamel becomes
progressively worn in regions of masticatory attrition. Wear facets increasingly are
pronounced in older persons, and in some cases substantial portions of the crown
(enamel and dentin) become eroded. Other characteristics of aging enamel include
discoloration, reduced permeability, and modifications in the surface layer.
Note: Linked to these changes is an apparent reduction in the incidence of caries.
Teeth darken with age. Whether this darkening is caused by a change in the structure of
enamel is debatable. Although darkening could be caused by the addition of organic ma-
terial to enamel from the environment, darkening also may be caused by a deepening of
dentin color (the layer becomes thicker with age) seen through the progressively thinning
layer of translucent enamel.
No doubt exists that enamel becomes less permeable with age. Young enamel behaves as
a semipermeable membrane, permitting t he slow passage of water and substances of small
molecular size through pores between the crystals. With age the pores diminish as the crys-
tals acquire more ions and as the surface increases in size.
The surface layer of enamel reflects most prominently the changes within thi s tissue. Dur-
ing aging, the composition of the surface layer changes as ionic exchange with the oral en-
vironment occurs. In particular, a progressive increase in the fluoride content affects the
surface layer (and that, incidentally, can be achieved by topical application).
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tooth components
Enamel tufts and lamellae may be likened to geologic faults and have no
known clinical significance.
The striae of Retzius often extend from the DEJ to the outer surface of enamel,
where they end in shallow furrows known as perikymata.
both statements are t rue
both statements are false
the fi rst statement is true, the second is false
the fi rst statement is false, the second is true
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both statements are true
Enamel tufts are fan-shaped, hypocalcifi ed st ructures of enamel rods that
proj ect from the dentinoenamel junction into the enamel proper. They are found
in t he inner one-third of enamel and represent areas of less mineralization.
Enamel tufts are an anomaly of crystallization and seem to have no cli nical
importance.
Enamel spindles represent short dentinal t ubul es near the DEJ. They result
f rom odontoblasts that crossed the basement membrane before it mi neralized
into the DEJ. These dentinal tubul es become trapped during the apposition of
enamel matrix, and enamel becomes mineralized around t hem. They may serve
as pain receptors.
Enamel lamellae are part ially calcified vertical defects in the enamel
resembli ng cracks or fractures that traverse the entire length of the crown from
the surface to the DEJ. They are narrower and longer than enamel t ufts. Enamel
lamellae are an anomaly of crystallization and seem to have no cl inical
importance.
Over the cusps of teeth the enamel rods appear twisted around each other in a
seemingly complex arrangement known as gnarled enamel.
As a toot h erupts, it is covered by a pellicle consisting of debris from the enamel
organ that is lost rapidly.
Salivary pellicle, a nearly ubiquitous organic deposit on the surface of the
teeth, always reappears shortly af ter teet h have been polished. Dental plaque
forms readily on the pellicle, especially in more protected areas of the dentition.
Hunter-Schreger bands are an opt ical phenomenon produced by changes in direction
between adjacent groups of enamel rods. The bands are seen most clearly in longitudinal
ground sections viewed by reflected light and are found in t he inner two thirds of the
enamel.
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tooth components
You would expect to see all oft he following in dentin EXCEPT one. Which one
is the EXCEPTION?
incremental l ines of von Ebner
contour lines of Owen
striae of Retzius
granular layer ofTomes
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striae of Retzius
The incremental (or imbrication) lines of von Ebner in dentin can be li kened to the
growth rings or incremental lines of Retzius in enamel. The incremental li nes of von
Ebner show the incremental nature of dentin apposition and run at right angle to the
dentinal tubules.
The contour lines of Owen are a number of adjoining parall el imbrication li nes that are
present in stained dentin. These contour li nes demonstrate a disturbance in body me-
taboli sm that affects the odontoblasts by altering their formation efforts. These contour
li nes appear together as a series of dark bands.
Tomes' granular layer is most often found in the peri pheral portion of the dentin be-
neath the root's cementum adjacent to the DCJ (dentinocemental junction). This area
only looks granular because of its spotty microscopic appearance. The cause of the
change in this region of dentin is unknown.
1. Enamel formation begins at the future cusp and spreads down the cusp
,., slope. As the ameloblasts retreat in incremental steps, the ameloblasts create
an artifact in the enamel called the lines of Retzius (a.k.a. striae of Retzius).
2. One of the lines of Retzius is accentuated and is more obvious than the oth-
ers. It is the neonatal line that marks the division between enamel formed
before birth and that which is produced after birth- this neonatal line is found
in all deciduous teeth and in the larger cusps of the permanent first molars.
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tooth components
The organic phase of dentin is about 90% collagen, mainly type __ with
small amounts of types __ .
I, II and IV
I, Ill and V
Ill, I and IV
IV, I and Ill
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I, Ill and V
Dentin is the specialized connective tissue that makes up the bulk of the tooth,
extending for almost its entire length. Dentin is hard, elastic, 70% inorganic, 20%
organic, and 10% water. The inorganic component consists of mainly calcium
hydroxyapatite with the chemical formula of Ca
10
(P0
4
)
6
(0H)
2
. This calcium
hydroxyapatite is simi lar to that found in higher percentages in enamel and in lower
percentages in bone and cementum. Smaller amounts of other minerals, such as
carbonate and fluori de, are also present.
The organic phase of dentin is about 90% collagen (mainly type I with small amounts
of types Ill and V) with fractional inclusions of vari ous non coll agenous matrix proteins
and lipids.
1. Unlike enamel, which is acellular, dentin has a cellular component that
is retained after its formation by odontoblasts.
2. Dentin and pulp tissue are both formed by the dental papilla. Pulp tissue
is a loose, very vascular, and non-calcified connective tissue while dentin is
avascular and a calcified tissue.
3. The main cell type in dentin is the odontoblast, which is derived from
ectomesenchyme.
4. Dentin is softer than enamel but slightly harder than bone. Dentin is more
flexible (lower modulus of elasticity) than enamel. Dentin's compressive
strength is much higher than its tensil e strength.
5. Dentin is more mineral ized than cementum or bone but less mineralized
than enamel. Morphologically and chemically, dentin has many characterist-
ics in common with bone.
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tooth components
In orthodontic tooth movement, bone remodeling is forced. The bands,
wires, or appliances put pressure on one side of the tooth and adjacent
alveolar bone, creating a zone of __ in the POL This leads to bone __ .
On the opposite side of the tooth and bone, a __ zone develops in the POL
and causes the of bone.
tension, deposit ion, compression, resorption
compression, resorption, tension, deposit ion
compression, deposit ion, tension, resorption
tension, resorption, compression, deposition
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compression, resorption, tension, deposition
Orthodontic movement of teeth always causes remodeling of the alveolar bone
proper to accommodate movement of the teeth. Important: The new alveolar bone
deposited duri ng orthodontic t reatment is best described as intramembranous.
Remember:
Osteoblasts (derived from mesenchyme, i.e., fibroblasts) are bone-forming cells
that secrete the coll agen and minerals needed to lay down new bone in their
vicinity.
Osteoblasts that have been t rapped in the osteoid produced by other surrounding
osteoblasts are called osteocytes Osteocytes maintain bones, play a role in
controlli ng the extracell ular concentration of calcium and phosphate, and are
di rectly stimulated by calcitonin and inhibited by PTH (parathyroid hormone).
Osteoclasts (which are deri ved from stem cell s in the bone marrow - the same
ones that produce monocytes and macrophages) are bone-resorbing cel ls. They
are essential partners for bone modeling and remodeli ng. Their resorptive activity
allows the permanent renewing of bone and regulates calcium homeostasis.
1. A similar situation is the alternate loosening and tightening of a deciduous
S' j tooth before it is lost. This is caused by the alternate resorption (cementa-
, ' clasts, osteoclasts) and apposition (cementoblasts, osteoblasts) of cement-
um and bone.
2. During active tooth eruption, there is apposition of bone on all surfaces
of the alveolar crest and on all walls of the bony socket.
Remember: Permanent teeth move occlusally and facially when erupting.
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tooth components
Apical abscesses of which teeth have a marked tendency to produce cervical
spread of infection most rapidly?
mandibular central and lateral incisors
mandibular canine and first premolar
maxill ary first and second molars
mandibular second and third molars
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mandibular second and third molars
Certain anatomic features determine to a large extent the actual direction that infection may
take. The attachment of muscles may determine the route that an infection will take,
channeling the infection into certain tissue spaces.
lctth m ( hmc.1l Present.1t10n ol \bsccsscs and l-1stul.lc
Clinical Presentation of lesion Teeth Most Commonly Involved
Maxillary vestibule Maxillary central and lateral incisor
Maxillary canine (i f root is short and inferior to levator anguJi oris)
Maxillary premolars
Maxillary molars (if buccal roots are short and inferior to buccinator)
Penetration of nasal floor Maxillary central incisor
Nasolabial skin region Maxillary canine (i f root is long and superior to levator anguli oris)
Palate Maxillary lateral incisor
Maxillary premolars (lingual root)
Maxillary molars (palatal root)
Perforation into maxillary sinus Maxillary molars (if buc.cal roots are long)
Buccal skin surface Maxillary molars (if buccal roots are superior to buccinator)
Mandibular vestibule Mandibular incisors (if roots are short and superior to mentalis)
Mandibular canines and premolars (if root.-. are short and superior to depressors)
Mandibular fi rst and second molars (if roots are short and superior to buccinator)
Submental skin region Mandibular incisors (if roots are long and inferior to mentalis)
Sublingual region Mandibular fi rst molar (if lingual root is short and superior to mylohyoid)
Mandibular second molar (if lingual root is short and superior to mylohyoid)
Submandibular skin region Mandibular second molar (if lingual root is long and inferior to mylohyoid)
Mandibular third molars (i f roots are inferior to mylohyoid)
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tooth components
The bone directly lining the socket (inner aspect of the alveolar bone) specifi-
cally is referred to as:
bundle bone
cancellous bone
osteoid
trabecular bone
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bundle bone
The al veolar process is that bone of the jaws containing the sockets (alveoli) for the
teeth. The alveolar process consists of an outer (buccal and li ngual) cortical plate, a
central spongiosa, and bone li ning the alveolus (alveolar bone). The cortical plate
and alveolar bone meet at the alveolar crest (usually 1.5 to 2 mm below the level of
the cementoenamel junction on the tooth it surrounds). Alveolar bone comprises inner
and out components; it is perforated by many foramina, which t ransmit nerve and ves-
sels; thus sometimes is referred to as the cribriform plate. Radiographically, alveolar
bone also is referred to as the lamina dura because of an increased radiopacity.
The bone directly li ning the socket (inner aspect of alveolar bone) specifical ly is re-
ferred to as bundle bone. Embedded within this bone are the extrinsic collagen f iber
bundles of the POL, which, as in cellular cementum, are mineralized only at their pe-
riphery. Bundle bone thus provides attachment for the POL fiber bundles that insert
into it.
The cortical plate consists of surface layers of lamellar bone supported by compact
haversian system bone of vari able thickness. The cortical plate is generally thinner in
the maxill a and thickest on the buccal aspect of mandibular premolars and molars. The
trabecular (or spongy) bone occupying the central part of the alveolar process also
consists of bone disposed in lamell ae with haversian systems occurri ng in the large
trabeculae.
Trabecular bone is absent in the region of the anterior teeth, and in this case, the cor-
tical plate and alveolar bone are fused together. The important part of this complex in
terms of tooth support is the bundle bone.
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tooth components
A newly erupted tooth has a membranous covering. It is derived from which
structure?
peri kymata
dental papill a
dental follicle
oral epitheli um
gubernaculum
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oral epithelium
Also known as Nasmyth's membrane, the secondary enamel cuticle is the thin mem-
brane covering newly erupted teeth. It is a remnant of the reduced enamel epithe-
li um, and is ectodermally derived. It is produced by the ameloblast cell after it produces
the enamel rods. The secondary enamel cuticle consists of two extremely thin layers
(the inner one clear and structureless, the outer one cell ular), covering the entire crown
of newly erupted teeth and subsequently abraded by mastication; the cuticle is evi-
dent microscopically as an amorphous material between the attachment epithelium
and the tooth. This cuticle is worn away by mastication and cleaning. Nasmyth's mem-
brane is replaced by an organic deposit called the pellicle, which is formed by salivary
proteins. It is this pel li cle that is invaded by bacteria to form bacterial plaque that, if
not removed, will cause dental caries and periodontal disease.
Note: The primary enamel cuticle is the organic matrix responsible for binding the ep-
ithelium to the tooth during development.
Gaburnaculal canal: is a small canal located between the permanent tooth germ and
the apex ofthe deciduous tooth, containing remnants of dental lamina and connective
tissue.
Remember: Enamel is incapable of repai ring itself once it is destroyed (unlike
dentin). After the ameloblasts are f inished with both enamel apposition and matura-
tion, they become part of the reduced enamel epithelium, along with the other por-
tions of the compressed enamel organ. The reduced enamel epithelium fuses with the
oral mucosa, creating a canal to al low the enamel cusp t ip to erupt through the oral
mucosa into the oral cavity. Unfortunately, the ameloblasts are lost forever as the
fused t issues disintegrate during tooth eruption, preventing any further enamel ap-
position.
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tooth components
Dentin is considered a living tissue because of odontoblastic cell processes
known as:
triacetate f iber
Tomes' fiber
tag f iber
Korff's f iber
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Tomes' fiber
These odontoblastic processes (Tomes' fibers) occupy the dentinal tubules. There is
one per odontoblast.
It is because of these odontoblastic cell processes that dentin is considered a living
tissue, with the capability to react to different stimul i and produce secondary,
sclerotic, and/or reparative dentin.
Dentin sensitivity is not well understood. One theory is that Tomes' fibers are
receptors and t ransmit an impulse to pulpal nerves. The preferred theory is that fluid
movement within the tubules, in response to a stimulus, t ri ggers the pulpal nerves.
Remember: The odontoblasts begin dentin formation (dent inogenesis)
immediately before enamel formation by the ameloblasts. Dentinogenesis begins
with the odontoblasts laying down a dentin matrix or predentin, moving from the
DEJ inward toward the pulp. The most recently formed layer of dentin is al ways
adjacent to the pulpal surface. Note: Predentin or dentin matrix is a mesenchymal
product consisting of nonmineralized collagen fibers.
Remember: Amelogenesis is the process of enamel matrix formation that occurs
during the appositional stage of tooth development. Enamel matrix is produced by
ameloblast cells. These cells are columnar cells that differentiate duri ng the
apposition stage in the crown area. The enamel matrix is secreted from each
ameloblast by its Tomes' process. Tomes' process is the secretory surface of the
ameloblast that faces the dentinoenamel junction (DEJ).
~ i : l 1. The cell body of the odontoblast lies in the pulp cavity.
. ' 2. The dentinal tubules are S-shaped (curvature) in the crown due to
overcrowding of odontoblasts. This curvature of the tubules decreases in
root dentin.
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tooth components
Secondary dentin is produced in reaction to various stimuli, such as
attrition, caries, or a restorative dental procedure.
Tertiary dentin is produced only by those cells directly affected by the
stimulus.
both statements are t rue
both statements are false
the first statement is true, the second is false
the first statement is false, the second is true
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the first statement is fal se, the second is true
Tertiary dentin (also referred to as reactive or reparative dentin) is produced in
reaction to various stimuli, such as attri tion, caries, or a restorative dental procedure.
Unli ke pri mary or secondary dentin that forms along the entire pulp-dentin border,
tertiary dentin is produced only by those cells directly affected by the stimulus.
Tertiary dentin is subclassified as reactionary or reparative dentin, the former
deposited by preexisting odontoblasts and the latter by newly differentiated
odontoblast-like cells.
Primary dentin is the dentin formed in a tooth before the completion of the apical
foramen of the root. Primary dentin is characterized by a regular pattern of tubules.
Secondary dentin is the dentin that is formed after completion of the apical
foramen. Secondary dentin is formed at a slower rate than pri mary dentin and is less
minerali zed. Secondary dentin is a regular and somewhat uniform layer of dentin
around the pulp cavity. Secondary dentin is made by the odontoblastic layer that
li nes the dentin-pulp interface.
Note: The junction between pri mary and secondary dentin is characterized by a
sharp change in the direction of dentinal tubules.
When dentin is damaged, usually by the chronic injury of cari es, odontoblastic
processes die or retract, leaving empty dentinal tubules. Areas with empty dentinal
tubules are called dead tracts and appear as dark areas in ground sections of tooth.
With t ime, these dead t racts can become completely filled calcified material
(sclerotic dentin). This region is called blind tracts and appears white in sections of
ground tooth. The adaptive advantage of blind tracts is the seali ng off of the dentinal
tubules to prevent bacteri a from entering the pulp cavity. Clinically, this sclerotic
dentin appears dark, smooth, and shiny.
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tooth development
The dental lamina, a thickening of the oral epithelium that produces the
swellings of the enamel organs, is first seen histologically around the:
second week in utero
sixth week in utero
tenth week in utero
fourth month in utero
I refer to AS card 303-1, 308 B-1, 308 C-1 for illustration I
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sixth week in utero
By the third week after conception, the primitive mouth (stomodeum) has formed.
Over the next few weeks, the tongue, jaws, and palate develop. During the sixth to
seventh weeks, formation of the teeth commences, and by eight weeks, all of the
primary (deciduous) incisors, canines, and molars are discernible.
Tooth development appears to be initiated by the mesenchyme's inductive influence
on the overlying ectoderm. Early in the sixth week, there appears to be a thickening of
the oral epithel ium (which is a derivative of the surface ectoderm). These thickenings
or U-shaped bands are call ed the dental lamina and foll ow the curve of the pri mitive
jaws.
At certain points on the dental lamina, the ectodermal cell s proliferate and produce
swellings that become the enamel organ. Inside the depression of the enamel organ,
an area of condensed mesenchyme becomes t he dental papilla. Surrounding both
the enamel organ and dental papi ll a is a capsule-like structure of mesenchyme called
the dental sac.
Note: The enamel organ separates from the dental lamina after the first layer of dentin
is deposited.
Remember: Each tooth is t he product of two t issues that interact duri ng tooth
development, the oral epithelium and the underlying ectomesenchyme. The oral
epitheli um grows down into the underlying ectomesenchyme and forms small areas
of condensed mesenchyme, which become tooth germs.
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The bud stage of tooth development seen in
coronal section (A) and sagittal section (B)
303 1
Reproduced with p..-rmission from Nand A: Tell CtJte's Oral Hi.11tdOJ;JIXrelnpntent, Stmcmre. tmd Function: St. Lou1s. 2 0 0 ~ Elsevier.
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Primordium of the Successional
dental lamina
The cap stage of tooth development, which involves prol iferation and differentiation,
forming the tooth germ, the primordium of a primary tooth. Note the components of the
tooth germ: the enamel organ, dental papilla, and dental sac. Also note that the develop-
ing primordium of the permanent succedaneous tooth lingual to the primary tooth gem1
is in the bud stage.
303AI
Reproduced with pcrmission from Bath
4
Balogh M. MJ: 1/llt$/Yated Dental Hi:aology. and ed 1. St Louis.
2006. Saunders.
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Early Bud Stage of Tooth Development
The enamel organ seems to be divided by the enamel cord
303 Bl
Reproduced with permission from Nand A: 1l!tJ CmeS Oral Hi.mdogJ Dervdi1J>ment, Strocture. tmd Function: St. LOUIS, 0 0 ~ Elsevier.
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tooth development
When enamel maturation is completed, the ameloblast layer and the adja-
cent papillary layer regress and together constitute the:
cervical loop
epitheli al root sheath
reduced enamel epithelium
junctional epithelium
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reduced enamel epithelium
When enamel is ful ly mature, the ameloblast layer and the adjacent papill ary layer
regress and together constitute the reduced enamel epithelium that covers the
tooth through eruption. The ameloblasts stop modulating, reduce their size, and
assume a cuboidal appearance. This epithel ium, although no longer involved in the
secretion and maturation of enamel, continues to cover it and has a protective
function.
Important: The reduced enamel epitheli um remains until the tooth erupts. As the
tooth passes through the oral epithelium, the part of the reduced enamel
epithel ium situated incisally is destroyed, whereas that found more cervical ly
interacts with the oral epitheli um to form the junctional epithelium.
Remember: The junctional epithelium (or epithel ial attachment) attaches the
gingival t issues to the tooth using hemidesmosomes. The apical extent of the
junctional epithelium is usuall y the cementoenamel junction.
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II
Outer enamel epithelium ]-Compressed to
Stellate reticulum fonn reduced
Stratum intermedium enamel
Ameloblasts epithelium
The reduced enamel epithelium is produced after the completion of enamel apposi-
tion when the enamel organ under goes compression of its many layers on the enamel
surface.
304-1
Reproduced \1,-ilh from Ba1h-Balogh M, Fehrenbac-h MJ; 11/u.ftraled Demal EmhtJ'illogy. Histology. am/ ed 2. St. Louis. 2006.
Saunders.
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Connective
tissue
Stages in the process of tooth eruption. A: Oral cavity before the eruption process begins. Reduced
enamel epithelium covers the newly fonned enamel. B: f usion of the reduced enamel epithel ium with
the oral epithelium. C: Disintegration of the central fused tissue, leaving a tunnel for tooth movement.
0: Coronal fused tissues peel back from the crown during eruption, leaving the initial j unctional ep-
ithelium near the cementoenamel j unction. 304A-I
R<'produccd \ltith p<'nni$.iion (rom Ebtb-Balogh M. Fchrcnbacoh MJ; Demal Emb'J'ology. Histology. om/ ed 2. St Louis. 2006.
Saunders.
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tooth development
Epithelial cells of the inner and outer epithelium proliferate from the cervical
loop of the enamel organ to form a double layer of cells known as:
dental lamina
dental papi ll a
reduced enamel epithel ium
Hertwig's epitheli al root sheath
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Hertwig's epithelial root sheath
The structure responsible for root development is the cervical loop. The cervical loop is the
most cervical portion of the enamel organ, a bilayer rim that consists of only inner and outer
enamel epithelium of the enamel organ. The cervical loop begins to grow deeper into t he sur-
rounding mesenchyme of the dental sac, elongating and moving away from the newly com-
pleted crown area to enclose more of the dental papilla t issue and form Hertwig's epithelial
root sheath (HERS).
Hertwig's sheath is an epithelial diaphragm that is derived from the inner and outer enamel
epithelium of the enamel organ. After crown formation, the root sheath grows down and
shapes the root of the tooth and induces formation of root dentin. Uniform growth of this
sheath will resul t in the formation of a single-rooted tooth, while medial outgrowths or
evaginations of t his sheath will produce multi-rooted teeth.
After the first root dentin is deposited, t he cervical portion of Hertwig's epithelial root sheath
breaks down, and this new dentin comes in contact with the dental sac. This communication
stimulates cells to differentiate into cementoblasts that produce cementum. This process is
called cementogenesis.
Accessory canals, defined as a communication between the pulp t issue and t he
periodontal ligament other than t hrough the root apex, are the result of a localized failure
in the formati on of Hertwig's sheath during embryonic stages of tooth formati on. This
leads to a failure in odontoblastic differentiati on and denti n formati on and event ually to
the formation of the accessory canal.
An enamel pearl is a non-neoplastic excrescence of enamel where enamel is not supposed
to be, such as on a root surface. They are found usually in the area between roots, which is
called a furcation, of molars. Enamel pearls are not common in teet h with a single root. The
most common location of an enamel pearl is the furcation areas of the maxillary and
mandibular third molar roots. The enamel pearls are formed essentially from the Hertwig' s
epit helial root sheath.
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A
Enamel
Stellato
reticulum
Outer enamel
oplthollum
Ameloblasts
lntermedlum
Dental sac
Inner enamel
epithelium
Stratum
lntermedlum
' ftl

Dentin
Pulp
Inner
enamel
epithelium
Hartwig's
epithelial
root
L----1---------J sheath
B
enamel
epithelium
Stagr.s in root development. A: Cervical loop of a primary tooth, which is composed of the most
cervical portion of the enamel organ and is responsible for root development. B: Hertwig's ep-
ithelial root sheath is formed fiom elongation of the cervical loop, which is responsible for the
shape o