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

2. Major Points
Cranial nerves are tested directly or indirectly on the majority of questions
Know the course of each nerve, especially the foramen each passes through
Know cutaneous distribution for sensory nerves and muscles innervated for motor nerves
Memorize presentation of deficits associated with loss of each nerve

3. Major topics Cranial Nerves: Sensory Cranial Nerves: Motor
Cranial Nerves: Autonomic
Vasculature
Neck
Lymphatics
Embryology
Connections

4. CRANIAL NERVES: SENSORY
CN I – Olfactory – Olfaction
CN II – Optic – Vision
CN V – Trigeminal – Facial Sensation
CN VII – Facial – Taste
CN VIII – Vestibulocochlear – Balance, Hearing
CN IX – Glossopharyngeal – Pharyngeal Sensation
CN X – Vagus – Laryngeal Sensation

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

6. Nasal Ethmoid Vomer Sphenoid Lacrimal
1. which bone, when fractured, may be associated with inability to smell (Anosmia) as well as leakage of CSF?
Nasal
Ethmoid
Vomer
Sphenoid
Lacrimal 10

7. Ethmoidal fracture
May result in damage to CN I fibers as they pass through the cribriform plate of the ethmoid
Ethmoid is particularly vulnerable to trauma
Also associated with CSF leakage (CSF rhinorrhea)

8. Don’t Do this!
Nasogastric
Tube

9. 2. Where might tumor invasion lead to anesthesia over the upper lip, infraorbital region, and temporal region? 1 2 3 4 5 10

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

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

12. Cutaneous Innervation of Ear
Auriculotemporal nerve (CN V3)
Root, superior helix, crus, tragus, ext auditory canal, tympanic membrane
Auricular branch (CN VII)
Concha, ext auditory canal
Jacobsen’s nerve (CN IX)
Arnold’s nerve (CN X)
Concha, ext auditory canal, antihelix
Lesser occipital nerve (C2)
Superoposterior ear
Great auricular (C2,3)
Lateral helix, lobule, posteroinferior ear

13. Chorda tympani Lingual Hypoglossal Glossopharyngeal Vagus
4. What nerve has been compromised if a patient experiences numbness of the anterior tongue?
Chorda tympani
Lingual
Hypoglossal
Glossopharyngeal
Vagus 10

14. Tongue Innervation Lingual nerve = sensation to anterior 2/3 of tongue
Chorda tympani = taste to anterior 2/3 of tongue
Hypoglossal = motor to intrinsic and extrinsic tongue muscles (except palatoglossus)
Glossopharyngeal = taste AND sensation to posterior 1/3 of tongue
Vagus = taste for small patch near epiglottis

15. 5. Which of the following nerves carries the afferent limb of the corneal reflex?
Ophthalmic
Maxillary
Facial
Occulomotor
Mandibular

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

17. 6. Which nerve supplies the skin overlying the vertex of the skull?
Lacrimal
Supratrochlear
Infratrochlear
Infraorbital
Supraorbital

18. Vertex

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

20. Angle of jaw Lower lip Upper lip Buccal region Zygomatic region 10
7. Which area of the face would be expected to experience anesthesia following a fracture of the body of the mandible?
Angle of jaw
Lower lip
Upper lip
Buccal region
Zygomatic region 10

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

22. CRANIAL NERVES: MOTOR CN III – Oculomotor
CN IV – Trochlear extraocular muscles
CN VI – Abducens
CN V3 – Mandibular – muscles of mastication
CN VII – Facial – muscles of expression
CN IX – Glossopharyngeal – stylopharyngeus
CN X – Vagus – muscles of pharynx and larynx
CN XI – Spinal Accessory – trapezius, SCM
CN XII – Hypoglossal – tongue muscles

23. swallowing phonation chewing shrugging taste 10
8. A posterior fossa tumor impinges on the jugular foramen. Which of the following will be entirely preserved?
swallowing
phonation
chewing
shrugging
taste 10

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

25. Masseter Infrahyoid muscles Lateral pterygoid Medial pterygoid
9. Which of the following most directly opposes the action of the temporalis?
Masseter
Infrahyoid muscles
Lateral pterygoid
Medial pterygoid 10

26. Muscles of Mastication (V3)
temporalis = elevate and retract the mandible
lateral pterygoid = depress and protrude mandible
Elevation: Temporalis, Masseter, Medial Pterygoid
Depression: Lateral Pterygoid, Suprahyoid/Infrahyoid Muscles
Protrusion: Lateral Pterygoid, Masseter, Medial Pterygoid
Retrusion: Temporalis, Masseter
Lateral Movements: Temporalis of same side, Pterygoids of Opposite Side, Masseter
Remember: Unilateral V3 lesion causes deviation to same side as lesion due to unopposed action of the contralateral medial and lateral pterygoid
Temporalis
Lateral Pterygoid

27. Levator veli palatini Palatopharyngeus Stylohyoid Stylopharyngeus
10. Patients with paralysis of the trigeminal nerve Lose function in which of the following muscles?
Levator veli palatini
Palatopharyngeus
Stylohyoid
Stylopharyngeus
Tensor veli palatini 10

28. CN V3 - Mandibular nerve (motor)
Temporalis
Masseter
Lateral pterygoid
Medial pterygoid
Mylohyoid
Anterior belly of digastric
Tensor tympani
Tensor veli palatini

29. 11. Which of the following dominates the efferent Limb of the gag reflex?
CN V
CN IX
CN X
CN XII 10

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

31. CN V CN VII CN IX CN X CN XII
12. Which nerve is damaged if a person must constantly press their cheek in while eating?
CN V
CN VII
CN IX
CN X
CN XII 10

32. Buccinator innervated by the Facial Nerve
keeps food out of the oral vestibule
meets the superior pharyngeal constrictor (CN X) posteriorly at the pterygomandibular raphe

33. Superior rectus Lateral rectus Superior Oblique Sphincter pupillae
13. Which of the following would remain functional following compression of the common tendinous ring?
Superior rectus
Lateral rectus
Superior Oblique
Sphincter pupillae
Dilator pupillae 10

34. Common tendinous ring Through the common tendinous ring Outside:
OPTIC NERVE
Ophthalmic artery
Motor (Occulomotor n. , Abducens n.), except the Trochlear nerve
Nasociliary nerve
Outside:
Opthalmic vein
Sensory (Lacrimal n., Frontal n.), except the nasociliary nerve (which supplies the eyeball)
Trochlear nerve

35. Left glossopharyngeal Right glossopharyngeal Left hypoglossal
14. When a patient sticks out her tongue, it deviates to the right side. Which nerve has been damaged?
Left glossopharyngeal
Right glossopharyngeal
Left hypoglossal
Right hypoglossal 10

36. Hypoglossal nerve
Unilateral lesion causes the tongue to deviate to the SAME side when protruded
The intact genioglossus pulls the back of the tongue forward, deviating the tongue to the other side

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

38. Ophthalmic Oculomotor Long Ciliary Facial Maxillary 10
15. A patient complains of dry eyes following trauma. Which of the following nerves may have been damaged at its origin?
Ophthalmic
Oculomotor
Long Ciliary
Facial
Maxillary 10

39. PTERYGOPALATINE GANGLION

40. Trigeminal (semilunar)
16. Which ganglion is located just below the foramen ovale and, when damaged, leads to Dry mouth (xerostomia)?
Ciliary
Pterygopalatine
Otic
Submandibular
Geniculate
Trigeminal (semilunar) 10

42. OTIC GANGLION

43. Greater palatine Lesser petrosal Greater petrosal Chorda tympani
17. Which of the following nerves carries presynaptic parasympathetic fibers to the submandibular gland?
Greater palatine
Lesser petrosal
Greater petrosal
Chorda tympani
Inferior alveolar 10

44. SUBMANDIBULAR
GANGLION

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

46. Vasculature External Carotid and its branches
Anterior: superior thyroid, lingual, facial
Posterior: Occipital, Posterior Auricular
Medial: Ascending Pharyngeal
Terminal: Superfical Temporal, Maxillary
Internal Carotid and Circle of Willis
Dural Venous Sinuses
Basic Venous Drainage
Be familiar with major branches of maxillary, facial arteries

47. Sphenopalatine foramen
18. When significant trauma is inflicted at the pterion, an epidural hematoma often results. By what route does the involved artery enter the cranium?
Foramen ovale
Foramen rotundum
Foramen spinosum
Foramen lacerum
Sphenopalatine foramen 10

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

49. Anterior cerebral artery Middle cerebral artery
19. Which Of the following does Not typically branch from the internal carotid artery?
Anterior cerebral artery
Middle cerebral artery
Posterior cerebral artery
Posterior communicating artery
Ophthalmic artery 10

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

51. Superior sagittal sinus Occipital sinus Straight sinus Sigmoid sinus
20. Which of the following drains blood away from the confluence of the sinuses?
Transverse sinus
Superior sagittal sinus
Occipital sinus
Straight sinus
Sigmoid sinus 10

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

53. Neck Fascial planes Major vessels
Strap muscles – innervated by ansa cervicalis (C1 to C5) * know segments contributed to each muscle
Larynx – structure, muscles, innervation

54. Superficial (investing) fascia Prevertebral fascia Pretracheal fascia
21. Upon swallowing, what helps to elevate the thyroid along with the trachea and larynx?
Superficial (investing) fascia
Prevertebral fascia
Pretracheal fascia
Suspensory ligaments
Pyramid lobe of the thyroid 10

55. Fascial Layers of Neck Superficial investing fascia Pretracheal fascia
Suprahyoid muscles
SCM
Trapezius
Pretracheal fascia
Thyroid
Trachea
Move as a unit
Prevertebral fascia
Scalenes
Paravertebral muscles

56. 22. Between which structures would a pharyngeal infection be most likely to spread to the mediastinum?
Between the trachea and the carotid sheath
Between the trachea and the strap muscles
Between the trachea and the esophagus
Between the esophagus and the prevertebral muscles
Between the trapezius and the prevertebral muscles 10

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

58. posterior cricoarytenoid lateral cricoarytenoid vocalis
23. Which of the following muscles would be most active in forced respiration, as in when taking a deep breath?
cricothyroid
thyroarytenoid
posterior cricoarytenoid
lateral cricoarytenoid
vocalis 10

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

60. Lymphatics Expect 2 or 3 lymph questions
Lymph drainage of the face and tongue are key
Remember to keep an eye out for small details when studying

61. submental submandibular Inferior jugular buccal parotid
24. To which lymph nodes would you expect this squamous cell carcinoma to metastasize first?
submental
submandibular
Inferior jugular
buccal
parotid 10

62. Major Drainage patterns
submental: central lower lip, chin, apex of tongue
submandibular: upper lip, lateral lower lip, lateral part of anterior 2/3 of tongue
Inferior deep cervical: medial part of anterior 2/3
Superior deep cervical: posterior 1/3 of tongue
Parotid: lateral face and scalp, eyelids

63. Embryology Branchial Arches Eye Development Ear Development
Know the precursors

64. 25. from which of the branchial arches is the affected nerve derived?
First
Second
Third
Fourth
Fifth

65. Second branchial pouch
26. The external auditory meatus develops from which of the following embryologic structures?
First branchial arch
Second branchial arch
Third branchial arch
First branchial cleft
Second branchial pouch 10

66. Branchial arch derivatives
Nerve
Skeletal Structures
Muscles 1
CN V
Mandible, malleus, incus, greater wing of sphenoid
Muscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani, tensor veli palatini 2
CN VII
Stylohyoid process, stapes, upper body & lesser horn of hyoid
Muscles of facial expression, stylohyoid, stapedius, postberior belly digastric 3
CN IX
Lower body & greater horn of hyoid
Stylopharyngeus 4
CN X
Superior laryngeal
Thyroid cartilage
Cricothyroid, levator veli palatini, palatopharyngeus, palatoglossus, pharyngeal constrictors
5-6
Recurrent laryngeal
Cricoid cartilage
Intrinsic muscles of larynx (except cricothyroid & stylopharyngeus)

67. Branchial Clefts & Pouches

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

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

70. Connections the cranium is a maze learn the major passageways
especially true for the face

71. 28. Where do tears Enter the nasal cavity?
Inferior meatus
Middle meatus
Superior meatus
Sphenopalatine foramen
Pterygomaxillary fissure 10

72. Sinus Drainage Inferior meatus Middle meatus Superior meatus
Nasolacrimal duct
Middle meatus
Frontal sinus
Anterior ethmoidal air cells
Maxillary sinus
Superior meatus
Posterior ethmoidal air cells
Sphenoethmoidal recess
Sphenoidal sinus (associated with pituitary gland)

73. Superior orbital fissure Inferior orbital fissure Optic canal
29. A tumor from the infratemporal fossa gains entrance to the orbit. What is the most likely route?
Superior orbital fissure
Inferior orbital fissure
Optic canal
Sphenopalatine foramen
Pterygoid canal 10

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

75. Practical
Be sure to spend some time with the models; there are a lot more on this exam
Be able to identify structures with the head in various positions
No mock practical this time, but use the structured lab review as a guide

76. How soon before the exam would you like the review?
Earlier
A week is good
Later 10

77. Good luck!