Anatomy Exam 1 Blue Boxes

CRANIUM (822-842)
Head Injuries Complications: hemorrhage, infection, injury to brain and cranial nerves Most common symptom: disturbance in level of consciousness Account for 10% of US deaths; 50% of traumatic deaths involve brain injury Occur mostly ages 15-24; vehicle and motorcycle accidents are prominent causes Headaches and Facial Pain Usually benign and associated with tension, fatigue, or mild fever May indicate more serious intracranial problem: brain tumor, subarachnoid hemorrhage, meningitis Neuralgia characterized by severe throbbing or stabbing pain in the course of a nerve o caused by a demyelinating lesion o common cause of facial pain o facial neuralgia diffuse painful sensations, as opposed to localized aches which have specific names: odontalgia toothache; otalgia earache Injury to Superciliary Arches Blow to these relatively sharp bony ridges (e.g., boxing) may lacerate skin and cause bleeding Black eye - bruising of skin surrounding orbit causes tissue fluid and blood to accumulate in the surrounding connective tissue Malar Flush Redness of skin covering the zygomatic prominence (malar eminence) Associated with fever and diseases such as tuberculosis and systemic lupus erythematosus disease Fractures of the Maxillae and Associated Bones

Le Fort I fracture horizontal fracture of maxillae, passing superior to maxillary alveolar process, crossing bony nasal septum and possibly pterygoid plates of sphenoid (i.e., horizontal line under nose and above maxillary tooth roots) Le Fort II fracture from posterolateral parts of maxillary sinuses through the infra-orbital foramina, lacrimals, or ethmoids to the bridge of the nose (i.e., central part of face, including maxillary alveolar processes, is separated from rest of cranium) Le Fort III fracture horizontal fracture through superior orbital fissures, ethmoid, and nasal bones and extends laterally through the greater wings of the sphenoid and the frontozygomatic sutures (i.e., maxillae and zygomatic bones separate from rest of cranium) Fractures of the Mandible Usually involves two fractures on opposite sides of the mandible Fractures of coronoid process uncommon and usually single Fractures of neck of mandible usually transverse and associated with dislocation of TMJ on same side Fractures of angle of mandible usually oblique and may involve the socket of the 3rd molar Fractures of body of mandible frequently pass through the socket of the canine Resorption of Alveolar Bone Following extraction, the sockets begin to fill in with bone and the alveolar process begins to resorb Mental foramina may disappear in the process, exposing the mental nerves to injury or causing pain when pressure is placed on the exposed nerve by a denture during eating Edentulism results in decreased vertical facial dimension and mandibular prognathism (overclosure)

Anatomy Exam 1 Blue Boxes Fractures of Calvaria Depressed fractures bone fragment is depressed inward, compressing the brain, as a result of a hard blow to the thin area of the calvaria Linear calvarial fractures most frequent type, occur at point of impact but fracture lines radiate away from it in two or more directions Comminuted fractures bone is broken into several pieces Contrecoup (counterblow) fracture no fracture occurs at point of impact (thicker calvaria) but fracture occurs on the opposite side of cranium (force transmitted to thinner calvaria) Surgical Access to Cranial Cavity: Bone Flaps Craniotomy section of neurocranium (bone flap) is elevated or removed Adult pericranium has poor osteogenic properties so little regeneration occurs after bone loss Reintegration of surgically produced bone flaps are most successful when bone is reflected with overlying muscle and skin so it retains its own blood supply during the procedure and after repositioning Craniectomy bone flap not replaced by bone but instead by plastic or metal plate Development of Cranium Intramembranous ossification bones of calvaria and some parts of cranial base Endochondral ossification most parts of cranial base Newborns: facial skeleton forms 1/8 of cranium; Adults: facial skeleton forms 1/3 of cranium Sutures in newborn cranium: o Frontal suture separates halves of frontal bone Metopic suture persistence of remnant of frontal suture (beyond 8 years of age) o Coronal suture separates frontal and parietal bones o Intermaxillary suture separates maxillae o Mandibular symphysis separates mandibles No mastoid processes at birth: facial nerves are close to the surface when they emerge from the stylomastoid foramina and can be easily injured by forceps during difficult delivery Fontanelles membranous intervals separating the bones of the calvaria of a newborn o Anterior fontanelle largest, diamond shaped, bounded by halves of frontal bone anteriorly and parietal bones posteriorly (junction of sagittal, coronal, and frontal sutures the future site of bregma) o Posterior fontanelle triangular, bounded by parietal bones anteriorly and occipital bone posteriorly (junction of lambdoid and sagittal sutures future site of lambda) o Sphenoidal and Mastoid fontanelles overlain by temporal muscle, fuse during infancy Halves of mandible fuse early in 2nd year; two maxillae and nasal bones usually do not fuse Softness of cranial bones and their loose connections at sutures and fontanelles enable the shape of the calvaria to change during passage through birth canal: halves of frontal bone flatten, occipital bone drawn out, one parietal bone slightly overrides the other Increase in size of calvaria is greatest during first two years (most rapid brain development) Age Changes in Face Mandible is most dynamic of facial bones: o Newborn mandible consists of two halves united by cartilaginous join (mandibular symphysis) o Fibrocartilage union begins during 1st year, halves are fused by end of 2nd year o Body of mandible is a shell, lacking alveolar processes, enclosing deciduous teeth o Body of mandible elongates to accommodate tooth development Rapid growth of face during youth coincides with eruption of deciduous teeth, vertical growth of upper face results mainly from dentoalveolar development Enlargement of frontal and facial regions associated with increase in size of paranasal sinuses Obliteration of Cranial Sutures Obliteration of sutures between calvarial bones usually begins between age 30-40 on the internal surface and approximately 10 years later on the external surface Obliteration begins at bregma and continues sequentially in sagittal, coronal, and lambdoid sutures

Anatomy Exam 1 Blue Boxes Age Changes in Cranium With age, cranial bones become progressively thinner and lighter Diplo gradually become filled with gray gelatinous material as bone marrow loses blood cells and fat Craniosynostosis and Cranial Malformations Primary craniosynostosis premature closure of cranial sutures that results in cranial malformations Occurs 1 in 2000 births, more common in males, cause is unknown but genetic factors important Prevailing hypothesis: abnormal development of the cranial base creates exaggerated forces on the dura mater that disrupt normal cranial sutural development Scaphoncephaly premature closure of sagittal suture, anterior fontanelle small or absent, results in long, narrow, wedge-shaped cranium Plagiocephaly premature closure of coronal or lambdoid suture on one side only, results in twisted and asymmetrical cranium Oxycephaly premature closure of coronal suture, results in a high, tower-like cranium (more common in females)

VERTEBRAE (456-460 only those related to cervical vertebrae)

Vertebral Body Osteoporosis Common metabolic bone disease detected during routine radiographs Results from net demineralization of bones caused by disruption of normal balance of calcium deposition and resorption Most affected areas: bodies of vertebrae (mostly thoracic), neck of femur, metacarpals, radius Especially affects the horizontal trabecule of spongy bone of vertebral body. Vertical striping results, reflecting the loss of the horizontal supporting trabeculae and thickening of vertical struts Later stages may reveal vertebral collapse and increased thoracic kyphosis Laminectomy Surgical excision of one or more spinous processes and the adjacent supporting vertebral laminae Also denotes removal of most of the vertebral arch by transecting the pedicles Used to gain access to the vertebral canal, providing posterior exposure of spinal cord and/or roots of specific spinal nerves Often performed to relieve pressure on spinal cord or nerve roots as caused by a tumor, herniated disc, or bony hypertrophy Dislocation of Cervical Vertebrae Cervical vertebrae less tightly interlocked than other vertebrae due to more horizontally oriented articular facets and thus can be dislocated in neck injuries with less force than required for fracture Because of large vertebral canal in cervical region, slight dislocation can occur without damage to the spinal cord (severe dislocations or fracture-dislocations will injure the spinal cord) The dislocated cervical vertebra may self-reduce (slip back in place) if dislocation doesnt result in facet jumping with locking of the displaced articular processes Fracture and Dislocation of Atlas Because the taller side of the lateral mass of C1 is directed laterally, vertical forces (e.g., striking bottom of pool when diving) compressing the lateral masses between the occipital condyles and the axis drive them apart, fracturing one or both of the anterior or posterior arches Jefferson fracture - if force is sufficient, rupture of transverse ligament will also occur, not necessarily causing spinal cord injury because the dimension of the bony ring actually increases Fracture and Dislocation of Axis Fractures of vertebral arch of axis are one of the most common injuries of the cervical vertebrae Traumatic spondylolysis of C2 - fracture occurs in the pars interarticularis (bony column formed by superior and inferior articular processes of the axis), as a result of hyperextension of head on the neck (as opposed to combined hyperextension of head and neck which results in whiplash) Such hyperextension of head on neck was used to execute by hanging and thus is also called a hangmans fracture

Anatomy Exam 1 Blue Boxes More serious injuries may cause body of C2 to be displaced anteriorly with respect to the body of C3, with injury of the spinal cord and/or brainstem likely, sometimes resulting in quadriplegia or death Fractures of the dens are also common axis injuries which may result from a horizontal blow to the head or as a complication of osteopenia (pathological loss of bone loss) Cervical Ribs Developmental costal element of C7 which normally becomes a small part of transverse process that lies anterior to the transverse foramen becomes abnormally enlarged in 1-2% of people May be small protruberance or may be a complete rib Thoracic outlet syndrome - supernumerary rib or a fibrous connection extending from its tip to the first thoracic rib may put pressure on structures that emerge from superior thoracic aperture subclavian artery or inferior trunk of brachial plexus

VERTEBRAL COLUMN (474-482 focus on cervical region)

Aging of Intervertebral Discs Nuclei pulposi dehydrate, lose elastin and proteoglycans, and gain collagen, resulting in loss of turgor, increased stiffness, and increased resistance to deformation As the nucleus dehydrates, the two parts of the disc appear to merge as the distinction between nucleus pulposus and annulus fibrosis becomes increasingly diminished. Nucleus becomes dry and granular, and may disappear altogether, thus placing increased load on the annulus fibrosis Intervertebral discs actually increase in size with age, reason for slight loss of height with aging is due to superior and inferior surfaces of vertebral bodies becoming shallow concavities (?) Disc narrowing (especially if more narrow than a superior disc) suggests pathology, not normal aging Herniation of Nucleus Pulposus Herniation of nucleus pulposus through the annulus fibrosis is well-recognized cause of lower back pain and lower limb pain Discs are strong in young people (vertebrae often fracture before discs rupture) and have great turgor due to high water content Flexion of vertebral column squeezes the nucleus pulposus further posteriorly toward the thinnest part of the annulus fibrosus, and may herniate into the vertebral canal and compress the spinal cord or the nerve roots of the cauda equine Herniations usually extend posterolaterally where the annulus fibrosus is not supported by anterior or posterior longitudinal ligaments Acute pain results from pressure on longitudinal ligaments and local inflammation Chronic pain results from compression of spinal nerve roots and is usually referred to dermatome Hyperflexion of the cervical region such as in head-on collision, may rupture the disc posteriorly without fracturing the vertebral body, compressing the nerve exiting at that level (rather than the level below as in the lumbar region) however, cervical spinal nerves exit superior to the vertebra of the same number so the relationship is the same. Most commonly ruptured cervical discs: C5-C6 and C6-C7, compressing spinal nerve roots C6 and C7 Fracture of Dens Transverse ligament of the atlas is stronger than the dens of the axis Most common dens fracture occurs at its base, which are often unstable because the transverse ligament of the atlas becomes interposed between fragments and because the dens no longer has a blood supply resulting in avascular necrosis Also common are fractures of the vertebral body inferior to base of dens, which heals more readily because of retained blood supply Rupture of Transverse Ligament of Atlas Atlanto-axial subluxation when transverse ligament of atlas ruptures, the dens is set free, resulting in incomplete dislocation of the median antlanto-axial joint Pathological softening of the transverse and adjacent ligaments (usually disorders of connective tissue) may also cause atlanto-axial subluxation (20% of Down syndrome show laxity/agenesis of ligament)

Anatomy Exam 1 Blue Boxes Dislocation due to transverse ligament rupture is more likely to cause spinal cord compression than that resulting from fracture of dens (in this case the dens is held to the atlas by the transverse ligament) Compression of the spinal cord between the posterior arch of the atlas and the dens can cause quadriplegia or death Steeles Rule of Thirds approximately 1/3 of atlas ring is occupied by dens, 1/3 occupied by spinal cord, and 1/3 occupied by fluid-filled space and tissues surrounded the cord Rupture of Alar Ligaments Alar ligaments are weaker than transverse ligament of the atlas and combined flexion/rotation of the head may tear one or both alar ligaments Rupture of alar ligament results in 30% increase in range of movement to the contralateral side Fractures and Dislocations of Vertebrae Crush or Compression fracture fracture of body of one or more vertebrae caused by sudden forceful flexion (e.g., car wreck, blow to back of head) Hyperextension injury of the neck injury caused by sudden forceful extension of neck (e.g., headbutting, football illegal block) Severe hyperextension of the neck (i.e., whiplash) anterior longitudinal ligament stretched or may be torn (e.g., rear-end collision), may also rupture annulus fibrosus of C2-C3, thus separating the cranium, C1, and dens and body of C2 from the rest of the axial skeleton, usually severing the spinal cord Hyperflexion injury may occur as the head rebounds from severe hyperextension Most common causes of cervical region vertebral fractures: football, diving, falls from horses, vehicle collisions Injury and Disease of Zygapophyseal Joints Zygapophyseal joints are close to the intervertebral foramina through which the spinal nerves emerge from the vertebral canal When these joints are injured or develop osteophytes (osteoarthritis), the spinal nerves are often affected, causing pain along dermatomal distribution pattern and myotomal muscle spasms Abnormal Curvatures of Vertebral Column Excessive kyphosis abnormal increase in thoracic curvature (humpback) Excessive lordosis anterior tilting of pelvis (hollow back) Scoliosis abnormal lateral curvature

BONES OF NECK (985)

Cervical Pain Several causes: inflamed lymph nodes, muscle strain, protruding intervertebral discs Enlarged cervical lymph nodes may be indicative of malignant tumors of head or thorax/abdomen (e.g., lung cancer may metastasize through the neck to the cranium) Most chronic cervical pain is caused by bony abnormalities (e.g., cervical osteoarthritis) or by trauma Injuries of Cervical Vertebral Column Fractures and dislocations may injure the spinal cord and/or the vertebral arteries and sympathetic plexuses passing through the foramina transversaria Fracture of Hyoid Bone Occurs in people who are manually strangled by compression of the throat, resulting in depression of the body of the hyoid onto the thyroid cartilage Inability to elevate the hyoid and move it anteriorly beneath the tongue makes swallowing and maintenance of the separation of the alimentary and respiratory tracts difficult and may result in aspiration pneumonia

Anatomy Exam 1 Blue Boxes

CRANIAL CAVITY AND MENINGES (874-877)

Fracture of Pterion Can be life threatening because pterion overlies the anterior branches of the middle meningeal vessels, which lie in grooves on the internal aspect of the lateral wall of the calvaria Hard blow to the side of the head may fracture the thin bones forming the pterion, and the resulting hematoma exerts pressure on the underlying cerebral cortex Untreated middle meningeal artery hemorrhage may cause death within a few hours Thrombophlebitis of Facial Vein An infection of the face may spread to the cavernous sinus and pterygoid venous plexus, possible due to the following connections of the facial vein: o To the cavernous sinus through the superior ophthalmic vein o To the pterygoid venous plexus through the inferior ophthalmic and deep facial veins Because the facial vein has no valves, blood may pass through it in the opposite direction Thrombophlebitis of the facial vein inflammation of the facial vein with secondary thrombus (clot) formation, which may lead to pieces of the infected clot extending into the intracranial venous system, producing thrombophlebitis of the cavernous sinus Infection of the facial veins spreading to the dural venous sinuses may result from lacerations of the nose or can be initated by squeezing pimples (seriously.) on the side of the nose and upper lip This triangular area from the upper lip to the bridge of the nose is considered the danger triangle of the face, due to the risk of facial vein infection Blunt Trauma to Head Blow to the head can detach the periosteal layer of dura mater from the calvaria without fracturing the cranial bones Fracture of the cranial base usually tears the dura, resulting in leakage of CSF, because here the two dural layers are firmly attached and difficult to separate from the bones Dural border cell layer innermost part of the dura, composed of flattened fibroblasts that are separated by large extracellular spaces, is a plane of weakness at the dura-arachnoid junction Tentorial Herniation Tentorial notch - opening in the tentorium cerebella for the brainstem Space-occupying lesions, such as tumors in the supratentorial compartment, can result in increased intracranial pressure and may cause part of the adjacent temporal lobe of the brain to herniated through the tentorial notch During such tentorial herniation, the temporal lobe may be lacerated by the tough tentorium cerebella, and the oculomotor nerve may be stretched and/or compressed Oculomotor lesions may result in paralysis of extrinsic eye muscles supplied by CN III Bulging of Diaphragma Sellae Pituitary tumors may extend superiorly through the aperture in the diaphragma sellae or cause it to bulge, often expanding the diaphragma sellae which disturbs endocrine function Superior extension of a tumor may cause visual symptoms owing to pressure on the optic chiasm, where the optic nerve fibers cross Occlusion of Cerebral Veins and Dural Venous Sinuses May result from thrombi, thrombophlebitis, or tumors Most frequently thrombosed dural venous sinuses: transverse, cavernous, and superior sagittal Cavernous sinus thrombosis usually results from infections in the orbit, nasal sinuses, and superior part of the face (i.e., the danger triangle) Thrombophlebitis of the cavernous sinus (remember this is often caused by thrombophlebitis of the facial vein) usually involves only one sinus but may spread to the opposite side through the intercavernous sinuses Thrombophlebitis of the cavernous sinus may affect the abducent nerve as it traverses the sinus and may also affect the nerves embedded within the lateral wall of the sinus

Anatomy Exam 1 Blue Boxes Acute meningitis often develops as a result of septic thrombosis of the cavernous sinus Metastasis of Tumor Cells to Dural Venous Sinuses The basilar and occipital sinuses communicate through the foramen magnum with the internal vertebral venous plexuses Because these are valveless, compression of the thorax, abdomen, or pelvis (e.g., coughing or heavy strain) may force venous blood from these regions into the internal vertebral venous system, and from it into the dural venous sinuses Thus, this provides a pathway for tumor cells in these regions to spread to the brain Fractures of Cranial Base Fractures of the cranial base risk tearing of the internal carotid artery, producing an arteriovenous fistula within the sinus, in which case arterial blood rushes into the cavernous sinus, enlarging it and forcing retrograde blood flow into its venous tributaries, especially the ophthalmic veins Results in exophthalmos (the eyeballs can pulsate along with the radial pulse, pulsating exophthalmos) and chemosis (engorged conjunctiva) CN III, IV, V, and VI lie in or close to the lateral wall of the cavernous sinus and thus may be affected when the sinus is injured Dural Origin of Headaches Pulling on arteries at the cranial base or veins near the vertex where they pierce the dura can cause pain (dura is pain sensitive) Distension of the scalp or meningeal vessels may be a cause of headaches (many headaches appear to be dural in origin, such as the headache after spinal puncture for CSF removal) Leptomeningitis Inflammation of the leptomeninges (arachnoid and pia) resulting from pathogenic microorganisms Infection and inflammation usually confined to subarachnoid space and the arachnoid-pia Bacteria may enter subarachnoid space through the blood (septicemia) or spread from an infection of the heart, lungs, or other viscera; or from a compound cranial fracture or a fracture of nasal sinuses Acute purulent meningitis can result from infection with almost any pathogenic bacteria Head Injuries and Intracranial Hemorrhage Extradural or epidural hematoma following a blow to the head, blood from torn branches of a middle meningeal artery may collect between the external periosteal layer of the dura and the calvaria Typically a brief concussion occurs, followed by short lucid interval, drowsiness, and eventual coma Dural border hematoma aka subdural hematoma usually caused by extravasated blood that splits open the dural border cell layer, creating a blood-filled space at the dura-arachnoid junction Dural border hemorrhage usually follows a blow to the head that jerks the brain inside the cranium and injures it, commonly resulting from tearing a superior cerebral vein Subarachnoid hemorrhage extravasation of blood, usually arterial, into the subarachnoid space, most likely a result of rupture of a saccular aneurysm (sac-like dilation on side of artery such as the internal carotid)

CRANIAL NERVES (1078-1082)

Cranial Nerve Injuries Injury to the cranial nerves is a frequent complication of a fracture in the base of the cranium Excessive movement of the brain within the cranium may tear or bruise cranial nerve fibers, esp CN I Because of fixed positions and often close relationships to bony or vascular formations, intracranial portions of cranial nerves are subject to compression from tumor or aneurysm, in which case the symptom onset occurs gradually and the effects depend on the extend of the exerted pressure Because of their close relationship to the cavernous sinus, CN III, CN IV, CN V1, and especially CN VI are susceptible to compression or injury related to pathologies affecting the sinus See Table 9.6 Summary of Cranial Nerve Lesions (though he will probably ask from the specific examples given next)

Anatomy Exam 1 Blue Boxes OLFACTORY NERVE Anosmia Loss of Smell Elderly often have reduced sensation of smell, resulting from progressive reduction in the number of olfactory receptor neurons in the olfactory epithelium Most people with anosmia state their chief complaint is loss or alteration of taste Allergic rhinitis inflammation of the nasal mucous membrane, can cause transitory olfactory impairment In severe head injuries, the olfactory bulbs may be torn away from the olfactory nerves, or some olfactory nerve fibers may be torn as they pass through a fractured cribriform plate If all nerve bundles on one side are torn, a complete loss of smell will occur on that side so anosmia can signal fracture of the cranial base and CSF rhinorrhea (leakage through the nose) Tumor and/or abscess in the frontal lobe of the brain or a tumor of the meninges (meningioma) in the anterior cranial fossa may also cause anosmia by compressing the olfactory bulb and/or tract Olfactory Hallucinations False perceptions of smell that may accompany lesions in temporal lobe of the cerebral hemisphere Lesion that irritates the lateral olfactory area deep to the uncus may cause temporal lobe epilepsy or uncinate fits characterized by imaginary disagreeable odors and involuntary lip/tongue movement OPTIC NERVE Demyelinating Diseases and Optic Nerves Because the optic nerves are actually CNS tracts, the myelin sheath that surrounds the sensory fibers from the point at which the fibers penetrate the sclera is formed by oligodendrocytes rather than Schwann cells Consequently, the optic nerves are susceptible to the effects of CNS demyelinating diseases (e.g., MS) which usually do not affect other nerves of the PNS Optic Neuritis Lesions of the optic nerve that cause diminution of visual acuity Optic neuritis may be caused by inflammatory, degenerative, demyelinating, or toxic disorders Toxic substances that may injure optic nerve: methyl/ethyl alcohol, tobacco, lead, mercury Visual Field Defects Result from lesions that affect different parts of the visual pathway, where the type of defect depends upon where the pathway is interrupted (Fig B9.1 p 1080): o Section of an optic nerve results in blindness in the temporal and nasal visual fields of the ipsilateral eye o Section of the optic chiasm reduced peripheral vision and results in bitemporal hemianopsia, the loss of vision in half of the visual field of each eye o Section of the right optic tract eliminates vision from the left temporal and right nasal visual fields (contralateral homonymous hemianopsia visual loss is in similar fields) This is the most common form of visual field loss and is often observed in patients with strokes. Defects of vision caused by compression of the optic pathway (e.g., tumors of pituitary or aneurysms of the internal carotid) may produced only part of the visual losses described above OCULOMOTOR NERVE Injury to the Oculomotor Nerve Lesion of CN III results in ipsilateral oculomotor palsy which affects most of the ocular muscles, the levator palpebrae superioris, and the sphincter papillae: o superior eyelid droops and cannot be raised voluntarily because of the unopposed activity of the orbicularis oculi o pupil is fully dilated and non-reactive because of the unopposed dilator papillae o pupil is fully abducted and depressed because of the unopposed activity of the lateral rectus and superior oblique

Anatomy Exam 1 Blue Boxes Compression of Oculomotor Nerve Rapidly increasing intracranial pressure (e.g., extradural hematoma) often compresses CN III against the crest of the petrous part of the temporal bone Superficial autonomic fibers in CN III are affected first, as a result the pupil dilates progressively on the injured side First sign of CN III compression: ipsilateral slowness of the papillary response to light Aneurysm of Posterior Cerebral or Superior Cerebellar Artery May also exert pressure on CN III as it passes between these vessels Effects of the pressure depend on its severity TROCHLEAR NERVE CN IV is rarely paralyzed alone, lesions of this nerve or its nucleus cause paralysis of the superior oblique and impair the ability to turn the affected eyeball inferomedially CN IV may be torn when there are severe head injuries because of its long intracranial course Trochlear nerve injury classically presents as diplopia (double vision) when looking down TRIGEMINAL NERVE Injury to Trigeminal Nerve CN V may be injured by trauma, tumors, aneurysms, or meningeal infection. Isolated lesion of the spinal trigeminal tract may also occur with MS. CN V injury results in: o Paralysis of muscles of mastication with deviation of mandible toward the side of the lesion o Loss of the ability to appreciate soft tactile, thermal, or painful sensations in the face o Loss of corneal reflex and the sneezing reflex Common causes of facial numbness: dental trauma, herpes zoster ophthalmicus (infection caused by herpes virus), cranial trauma, head and neck tumors, intracranial tumors, idiopathic trigeminal neuropathy Trigeminal neuralgia the principal disease affecting the sensory root of CN V Dental Anesthesia CN V is the sensory nerve of the head, serving the teeth and mucosa of the oral cavity Because the superior alveolar nerves (CN V2 branches) are not accessible, the maxillary teeth are locally anesthetized by injecting the agent into the tissues surrounding the tooth roots and allowing the solution to infiltrate the tissue to reach the terminal nerve branches that enter the roots The inferior alveolar nerve (CN V3) is readily accessible and is most frequently anesthetized ABDUCENT NERVE CN VI is often stretched when intracranial pressure rises, partly because of the sharp bend it makes over the crest of the petrous part of the temporal bone after entering the dura Space occupying lesions (e.g., brain tumor) may compress CN VI, causing paralysis of the lateral rectus Complete paralysis of CN VI causes medial deviation of the affected eye, diplopia is also present Paralysis of CN VI may also result from: o Aneurysm of cerebral arterial circle at base of the brain o Pressure from an atherosclerotic internal carotid artery in the cavernous sinus o Septic thrombosis of the sinus due to infection in the nasal cavities and/or paranasal sinuses FACIAL NERVE CN VII is the most frequently paralyzed of all the cranial motor nerves Injury to CN VII may cause paralysis of facial muscles without loss of taste on the anterior two thirds of the tongue or altered secretion of the lacrimal and salivary glands Lesion of CN VII near its origin loss of motor, gustatory, autonomic function, motor paralysis of superior and inferior facial muscles on the ipsilateral side Central lesion of CN VII paralysis of muscles in the inferior face on the contralateral side

Anatomy Exam 1 Blue Boxes CN VII is vulnerable to compression when a viral infection produces inflammation (viral neuritis) and swelling of the nerve just before it emerges from the stylomastoid foramen Because the branches of CN VII are superficial, they are subject to injury from knife and gunshot wounds, cuts, and birth injuries CN VII damage is common with fracture of the temporal bone and by tumors of the brain and cranium, aneurysms, meningeal infections, and herpes viruses Bell Palsy unilateral facial paralysis of sudden onset resulting from a lesion of CN VII

VESTIBULOCOCHLEAR NERVE Injuries to the Vestibulocochlear Nerve Although the vestibular and cochlear nerves are essentially independent, peripheral lesions often produce concurrent clinical effects because of their close relationship Lesions of CN VIII may cause tinnitus, vertigo, and impairment or loss of hearing Deafness Two kinds of hearing loss: o Conductive deafness involving the external or middle ear o Sensorineural deafness disease of the cochlea or in pathway from the cochlea to the brain Acoustic Neuroma Slow-growing benign tumor of the neurolemma (Schwann cells) Tumor begins in the vestibular nerve while it is in the internal acoustic meatus Early symptom of acoustic neuroma is usually loss of hearing Trauma and Vertigo Dizziness, vertigo, and headache in association with head trauma are usually related to a peripheral vestibular nerve lesion GLOSSOPHARYNGEAL NERVE Lesions of Glossopharyngeal Nerve Isolated lesions of CN IX or its nuclei are uncommon and are not associated with perceptible disability Taste is absent on the posterior third of tongue and the gag reflex is absent on the side of the lesion Injuries of CN IX resulting from infection or tumors are usually accompanied by signs of involvement of adjacent nerves: because CN IX, X, and XI pass through the jugular foramen, tumors in this region produce multiple cranial nerve palsies (jugular foramen syndrome) Pain in distribution course of CN IX may be associated with involvement of the nerve in a neck tumor Glossopharyngeal Neuralgia Sudden intensification of pain is of a burning or stabbing nature, often initiated by swallowing, protruding the tongue, talking, or touching the palatine tonsil Uncommon and cause is unknown VAGUS NERVE Isolated lesions of CN X are uncommon Injury to pharyngeal branches of CN X results in dysphagia (difficulty swallowing) Lesions of the superior laryngeal nerve produce anesthesia of the superior part of the larynx and paralysis of the cricothyroid muscle Injury of recurrent laryngeal nerve may be caused by aortic arch aneurysm and causes hoarseness and dysphonia (difficulty speaking) due to paralysis of vocal cords Paralysis of both recurrent laryngeal nerves causes aphonia (loss of voice) and inspiratory stridor (harsh, high pitched respiratory sound) Because of its longer course, lesions of the left recurrent laryngeal nerve are more common than those of the right

Anatomy Exam 1 Blue Boxes SPINAL ACCESSORY NERVE Because of its nearly subcutaneous passage through the posterior cervical region, CN XI is susceptible to injury during surgical procedures such as lymph node biopsy, cannulation of the internal jugular vein, and carotid endarterectomy HYPOGLOSSAL NERVE Injury to CN XII paralyzes the ipsilateral half of the tongue and after some time, the tongue atrophies, making it appear shrunken and wrinkled When the tongue is protruded, the apex deviates towards the paralyzed side because of the unopposed action of the genioglossus muscle on the normal side of the tongue

CERVICAL FASCIA (988-989)

Paralysis of Platysma Results from injury to the cervical branch of the facial nerve and causes the skin to fall away from the neck in slack folds During surgical dissections of the neck, extra care is necessary to preserve the cervical branch of the facial nerve and, when suturing wounds of the neck, surgeons carefully suture the skin and edges of the platysma, otherwise the skin wound will be distracted by the contracting platysma muscle fibers Spread of Infections in Neck Investing layer of deep cervical fascia helps prevent the spread of abscesses caused by tissue destruction (if the infection occurs between investing layer and muscular part of pretracheal fascia surrounding the infrahyoid muscles) If the infection occurs between the investing fascia and the visceral part of the pretracheal fascia, it can spread into the thoracic cavity anterior to the pericardium Infection from abscess posterior to the prevertebral layer of deep cervical fascia may extend laterally in the neck and form a swelling posterior to the SCM Retropharyngeal abscess pus perforates prevertebral layer of deep cervical fascia, producing a bulge in the pharynx, causing dysphagia and dysarthria (difficulty speaking) Infections in the head may also spread inferiorly posterior to the esophagus and enter the posterior mediastinum or may spread anterior to the trachea and enter the anterior mediastinum Air from a ruptured trachea, bronchus, or esophagus (pneumomediastinum) can pass superiorly in the neck

SUPERFICIAL STRUCTURES OF NECK: CERVICAL REGIONS (1007-1011)

Congenital Torticollis Contraction or shortening of the cervical muscles that produces twisting of neck and slanting of head Most common type (wry neck) results from a fibrous tissue tumor that develops in the SCM before or shortly after birth, often the abnormal position of the infants head usually requires a breech delivery Muscular torticollis occurs when the SCM fibers are torn when an infants head is pulled too much during a difficult birth A hematoma occurs that may develop into a fibrotic mass that entraps a branch of the spinal accessory nerve and thus denervates part of the SCM Stiffness and twisting of the neck results from fibrosis and shortening of the SCM Spasmatic Torticollis aka Cervical dystonia abnormal tonicity of the cervical muscles that usually begins in adulthood May involve any bilateral combination of lateral neck muscles, especially SCM and trapezius Characterized by sustained turning, tilting, flexing, or extending of the neck, involuntarily shifting the head laterally or anteriorly, and shoulder elevated and displaced anteriorly to side which chin turns

Anatomy Exam 1 Blue Boxes Subclavian Vein Puncture Point of entry for central line placement, such as Swan-Ganz catheter Central lines are inserted to administer parenteral (venous nutritional) fluids and medications and to measure central venous pressure If the needle is not inserted carefully, it may puncture the pleura and lung, resulting in pneumothorax If needle is inserted too far posteriorly, it may enter the subclavian artery Right Cardiac Catheterization Puncture of the internal jugular to insert a catheter through the right brachiocephalic vein and into the superior vena cava to take measurements of pressures in the right chambers of the heart Preferred route is through IJV or subclavian, but it may be necessary to use the external jugular which is not ideal due to its angle of junction with the subclavian vein Prominence of External Jugular Vein EJV may serve as an internal barometer: when venous pressure is normal, the EJV is visible above the clavicle for only a short distance but when pressure rises (e.g., heart failure), the vein is prominent throughout its course along the side of the neck Examination of EJV may be diagnostic for: heart failure, SVC obstruction, enlarged supraclavicular lymph nodes, or increased intrathoracic pressure Severance of External Jugular Vein If EJV is severed along posterior border of SCM where it pierces the roof of the lateral cervical region, its lumen will be held open by the tough investing layer of deep cervical fascia and the negative intrathoracic pressure will suck air into the vein This produces a churning noise in the thorax and cyanosis (bluish discoloration of skin due to reduced hemoglobin in blood) This venous air embolism will fill the right side of the heart with froth, which nearly stops blood flow through it, resulting in dyspnea Lesions of Spinal Accessory Nerve (CN XI) Lesions of CN XI are uncommon but may be caused by: o Penetrating trauma (e.g., stab or bullet wound) o Surgical procedures in the lateral cervical region o Tumors at cranial base or cancerous cervical lymph nodes o Fractures of the jugular foramen where CN XI leaves the cranium People with CN XI damage usually have weakness in turning the head to the opposite side against resistance due to weakness and atrophy of the trapezius Unilateral paralysis of the trapezius is evident by the patients inability to elevate and retract the shoulder and by difficulty in elevating the upper limb above horizontal Drooping of the shoulder is an obvious sign of CN XI injury Important to have awareness of its location during lateral cervical region surgical procedures (e.g., removing cancerous lymph nodes) because CN XI is the most commonly iatrogenic nerve injury Severance of Phrenic Nerve, Phrenic Nerve Block, and Phrenic Nerve Crush Severance of a phrenic nerve results in paralysis of the corresponding half of the diaphragm Phrenic nerve block produces temporary paralysis of hemidiaphragm (e.g., during lung operation) Surgical phrenic nerve crush (e.g., compressing nerve with forceps) produces a longer period of paralysis. If an accessory phrenic nerve is present, it must also be crushed to produce complete paralysis of the hemidiaphragm. Nerve Blocks in Lateral Cervical Region For regional anesthesia before neck surgery, a cervical plexus block inhibits nerve impulse conduction Anesthetic is injected mainly at junction of SCM superior and middle thirds: the nerve point of the neck For anesthesia of upper limb, the anesthetic in a supraclavicular brachial plexus block is injected around the supraclavicular part of the brachial plexus Injury to Suprascapular Nerve Suprascapular nerve is vulnerable to injury in fractures of the middle third of the clavicle Injury results in loss of lateral rotation of the humerus at the glenohumeral joint

Anatomy Exam 1 Blue Boxes The relaxed limb rotates medially into the waiters tip position Ligation of External Carotid Artery Sometimes this is necessary to control bleeding from on its less accessible branches Blood will then flow in a retrograde direction into the artery from the external carotid on the other side through communications between its branches (face and scalp) and across the midline When ligated, the descending branch of the occipital artery provides the main collateral circulation, anastomosing with the vertebral and deep cervical arteries Surgical Dissection of Carotid Triangle Carotid triangle provides access to carotid system of arteries as well as IJV, vagus and hypoglossal nerves, and the cervical sympathetic trunk Damage or compression of vagus and/or recurrent laryngeal nerves during surgical dissection of the carotid triangle may produce an alteration in the voice because these nerves supply laryngeal muscles Carotid Occlusion and Endarterectomy Atherosclerotic thickening of the intima of internal carotid may obstruct blood flow, causing stenosis A partial occlusion may cause a TIA, transient ischemic attack, a sudden focal loss of neurological function that disappears within 24 hrs May also cause a minor stroke, a loss of neurological function such as weakness or sensory loss on one side of the body that exceeds 24 hrs but disappears within 3 weeks Doppler color studies are used to observe the obstruction of blood flow in arteries Carotid endarterectomy is a procedure in which the artery is opened at its origin and the artherosclerotic plaque is stripped off Because of the relation to the ICA, risk of cranial nerve injury during the procedure may involve CN IX, X, XI, or XII Carotid Pulse Easily felt by palpating the common carotid in the side of the neck, where it lies in a groove between the trachea and the infrahyoid muscles It is routinely checked during CPR, absence of carotid pulse indicates cardiac arrest Carotid Sinus Hypersensitivity Exceptional responsiveness of the carotid sinus in various types of vascular disease External pressure on the carotid may cause slowing of the heart rate, decreased blood pressure, and cardiac ischemia resulting in fainting (syncope) In all forms of syncope, symptoms result from a sudden and critical decrease in cerebral perfusion Role of Carotid Bodies Location is ideal to monitor the oxygen content of the blood before it reaches the brain Decrease in PO2 activates the aortic and carotid chemoreceptors, increasing alveolar ventilation Carotid bodies also respond to increased CO2 tension or free hydrogen ions in the blood Glossopharyngeal nerve conducts the information, resulting in increased depth and rate of breathing, and increased pulse rate and blood pressure, thus taking in more O2 and reducing [CO2] Internal Jugular Pulse Pulsations of IJV can provide info about heart activity IJV pulsations are transmitted through the surrounding tissue and may be observed beneath the SCM superior to the medial end of the clavicle Pulsations are especially visible when a persons head is lower than legs (Trendelenburg position) IJV pulse increases in conditions such as mitral valve disease, which increases pressure in the pulmonary circulation and the right side of the heart Right IJV is examined because it runs a more direct course to the right atrium Internal Jugular Vein Puncture Right IJV is preferable because it usually larger and straighter Clinician will palpate common carotid and insert needle into IJV just later to it, aiming at the apex of the triangle between the sterna and clavicular heads of the SCM, the lesser supraclavicular fossa

Anatomy Exam 1 Blue Boxes

DEEP STRUCTURES OF NECK (1017)

Cervicothoracic Ganglion Block Anesthetic injected around the large cervicothoracic ganglion blocks transmission of stimuli through the cervical and superior thoracic ganglia This block may relieve vascular spasms involving the brain and upper limb, or when deciding if surgical resection of the ganglion would be beneficial Lesion of Cervical Sympathetic Trunk Results in sympathetic disturbance called Horner Syndrome, characterized by: miosis (paralysis of dilator pupillae), ptosis (paralysis of levator palpebrae superioris), enopthalmos (paralysis of orbital muscle in floor of orbit), and anhydrosis (lack of sympathetic nerve supply to blood vessels and sweat glands)

FACE AND SCALP (860-864)

Facial Lacerations and Incisions Facial lacerations tend to gape (skin must be carefully sutured to prevent scarring) due to absence of any distinct deep fascia and looseness of subcutaneous tissue between the cutaneous attachments of the facial muscles Looseness of subcutaneous tissue also enables fluid and blood to accumulate (bruising) With age, skin loses resiliency, ridges and wrinkles occur in the skin perpendicular to the direction of facial muscle fibers. Skin incisions along these wrinkle lines (Langer lines) heal with minimal scarring Scalp Injuries Partially detached scalp may be replaced as long as one of the vessels supplying scalp remains intact During an attached craniotomy, the superficial temporal artery is included in the tissue flap for this purpose The scalp proper (first three layers of scalp) is clinically regarded as single layer because they remain together when a scalp flap is made or scalp is torn off Arteries of scalp supply little blood to calvaria, which is supplied by middle meningeal arteries, therefore loss of scalp does not produce necrosis of calvarial bones Scalp Wounds Because of the strength of the epicranial aponeurosis, superficial scalp wounds do not gape However, deep scalp wounds gape widely when the aponeurosis is lacerated in the coronal plane because of the pull of the frontal and occipital bellies of the occipitofrontalis in opposite directions Scalp Infections Loose connective tissue layer (fourth layer of scalp) is the danger area of the scalp because pus or blood can spread easily in it Infection of this layer can also pass into the cranial cavity through emissary veins, which pass through parietal foramina in the calvaria and reach intracranial structures such as the meninges Pus or blood can enter the eyelids and root of nose because the frontalis inserts into the skin and subcutaneous tissue does not attach to the bone. Consequently periorbital ecchymosis (black eyes) can result from an injury to the scalp and/or forehead. Sebaceous Cysts Ducts of sebaceous glands associated with hair follicles may become obstructed, resulting in retention of secretions and formations of sebaceous cysts These cysts move with the scalp because they are in the skin Cephalhematoma After a difficult birth, bleeding may occur between the babys pericranium and calvaria, usually over one parietal bone Blood becomes trapped in the area, causing cephalhematoma Flaring of Nostrils True nasal breathers can flare their nostrils distinctly, whereas habitual mouth breathers have diminished ability to flare the nostrils

Anatomy Exam 1 Blue Boxes Children who are chronic mouth breathers often develop dental malocclusion because the alignment of the teeth is maintained to a large degree by normal periods of occlusion and labial closure Anti-snoring devices have been developed that attach to the nose to flare the nostrils and maintain a more patent air passageway (Breathe-Right strips) Paralysis of Facial Muscles Injury to facial nerve or its branches produces paralysis of some or all facial muscles on the affected side (Bell palsy) The affected area sags, and facial expression is distorted, making it appear passive or sad Loss of tonus of orbicularis oculi causes the inferior eyelid to evert and lacrimal fluids are not adequately spread across the cornea, making the cornea vulnerable to ulceration If the injury weakens or paralyzes the buccinators, food will accumulate in the buccal vestibule When the sphincters or dilators of the mouth are affected, displacement of the mouth (drooping of the corner) is produced by contraction of unopposed contralateral facial muscles and gravity (food and saliva dribble out of side of mouth) Weakened lip muscles affect speech and ability to whistle and blow Infra-Orbital Nerve Block Local anesthesia of the inferior part of the face is achieved by infiltration of the infra-orbital nerve for treating wounds of upper lip and cheek or for repair of maxillary incisors Injection is made in the region of the infra-orbital foramen, by elevating the upper lip and passing the needle through the junction of the oral mucosa and gingival at the superior aspect of the oral vestibule To determine where the infra-orbital nerve emerges, pressure is exerted on the maxilla in the region of the infra-orbital foramen (too much pressure causes considerable pain) Because companion vessels leave the infra-orbital foramen along with the nerve, aspiration of the syringe during injection prevents inadvertent injection of anesthetic into a blood vessel Careless injection could result in passage of anesthetic into the orbit, causing temporary paralysis of the extraocular muscles Mental and Incisive Nerve Blocks Injection of anesthetic into mental foramen will block the mental nerve that supplies the skin and mucous membrane of the lower lip from the mental foramen to the midline Buccal Nerve Block Anesthetic injection can be made into the mucosa covering the retromolar fossa, located posterior to the 3rd mandibular molar between the anterior border of the ramus and the temporal crest This is used to anesthetize the skin and mucous membrane of the cheek Trigeminal Neuralgia Sensory disorder of the sensory root of CN V that occurs most often in middle-aged and elderly Paroxysm (sudden sharp pain) can last for 15 minutes or more CN V2 is most frequently involved, CN V1 is least frequently involved In most cases, demyelination of axons in the sensory root occurs, caused by pressure of a small aberrant artery Simplest surgical procedure is avulsion or cutting of branches of the nerve at the infra-orbital foramen Other treatments have used radiofrequency selective ablation of parts of the trigeminal ganglion by a needle electrode passing through the cheek and the foramen ovale Rhizotomy (sensory root cut between ganglion and brainstem) or tractotomy (sectioning the spinal tract of CN V resulting in loss of sensation of the skin) are other treatment possibilities Lesions of Trigeminal Nerve Lesions of the entire CN V cause widespread anesthesia involving the: o Corresponding anterior half of the scalp o Face, except for an area around the angle of the mandible, the cornea, and the conjunctiva o Mucous membranes of the nose, mouth, and anterior part of the tongue o Paralysis of muscles of mastication

Anatomy Exam 1 Blue Boxes Herpes Zoster Infection of Trigeminal Ganglion Infection is characterized by an eruption of groups of vesicles following the course of the affected nerve (any division of CN V may be involved, but ophthalmic is most common) Usually the cornea is involved, resulting in painful corneal ulceration and subsequent scarring of the cornea Injuries to Facial Nerve Injury to branches of the facial nerve cause paralysis of facial muscles (Bell Palsy), with or without loss of taste on the anterior two thirds of the tongue or altered secretion of the lacrimal and salivary glands Most common nontraumatic cause of facial nerve palsy is inflammation of the facial nerve near the stylomastoid foramen, often as a result of viral infection Injury of facial nerve also occurs from fracture of temporal bone, surgical complication, dental manipulation, vaccination, pregnancy, HIV, Lyme disease, and infections of middle ear o Lesion of zygomatic branch paralysis, including loss of tonus of the orbicularis oculi in the inferior eyelid o Paralysis of buccal branch paraylysis of buccinators and superior portion of orbicularis oris and upper lip muscles o Paralysis of marginal mandibular branch paralysis of inferior portion of orbicularis oris and lower lip muscles (occurs when an incision is made along inferior border of mandible) Compression of Facial Artery Facial artery can be occluded by pressure against the mandible where the vessel crosses it Compression of the artery on one side does not stop all bleeding from a lacerated facial artery or its branches due to the numerous anastomoses Pulses of Arteries of Face and Scalp Pulses of superficial temporal and facial arteries may be used for taking pulse Stenosis of Internal Carotid Artery At the medial angle of the eye, an anastomosis occurs between the facial artery, a branch of the external carotid, and the cutaneous branches of the internal carotid With age, the internal carotid may become stenotic but intracranial structures still receive blood due to the anasomoses Scalp Lacerations Most common type of head injury requiring surgical care Bleed profusely because the arteries entering the periphery of the scalp bleed from both ends (due to abundant anastomoses) Also, these arteries do not retract in response to laceration because they are held open by the dense connective tissue of the scalp (second layer of scalp) Squamous Cell Carcinoma of Lip Usually involves lower lip, with overexposure to sun or chronic irritation from pipe smoking common factors Cancer cells from central part of lower lip, floor of mouth, and apex of tongue can spread to the submental lymph nodes Cancer cells from lateral parts of the lower lip will spread to the submandibular lymph nodes