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Tom Eck –  Cranial nerves are tested directly or indirectly on the majority of questions  Know the course of each nerve, especially.

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Presentation on theme: "Tom Eck –  Cranial nerves are tested directly or indirectly on the majority of questions  Know the course of each nerve, especially."— Presentation transcript:

1 Tom Eck –

2  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  Cranial Nerves: Sensory  Cranial Nerves: Motor  Cranial Nerves: Autonomic  Vasculature  Neck  Lymphatics  Embryology  Connections

4  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 , Ophthalmic artery Middle meningeal artery Labyrinthine artery, Posterior meningeal artery,

6 1. Nasal 2. Ethmoid 3. Vomer 4. Sphenoid 5. Lacrimal

7  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 Nasogastric Tube

9

10  Numbness in the upper lip, infraorbital region, and temporal region suggests the tumor has invaded the maxillary nerve (V 2 ), 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 1. Maxillary nerve (V 2 ) 2. Mandibular nerve (V 3 ) 3. Facial nerve (CN VII) 4. Glossopharyngeal nerve (CN IX) 5. Vagus nerve (CN X)

12  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)  Concha, ext auditory canal  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 1. Chorda tympani 2. Lingual 3. Hypoglossal 4. Glossopharyngeal 5. Vagus

14  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 1. Ophthalmic 2. Maxillary 3. Facial 4. Occulomotor 5. Mandibular

16  Afferent Limb: Ophthalmic Nerve, V 1 (Nasociliary Branch)  Efferent Limb: Zygomatic Branch of Facial Nerve (CN VII) to palpebral portion of orbicularis oculi  Remember: V 1 includes the eyes and the tip of the nose

17 1. Lacrimal 2. Supratrochlear 3. Infratrochlear 4. Infraorbital 5. Supraorbital

18 Vertex

19  Supplies much of the forehead and scalp  a branch of the ophthalmic nerve (V 1  frontal nerve  supraorbital)  Exits the skull via the supraorbital foramen

20 1. Angle of jaw 2. Lower lip 3. Upper lip 4. Buccal region 5. Zygomatic region

21  branches off the inferior alveolar nerve (V 3 ), which courses through the mandible, supplying the skin of the chin (mental region) and lower lip  exits the mandible via the mental foramen

22  CN III – Oculomotor  CN IV – Trochlear extraocular muscles  CN VI – Abducens  CN V 3 – 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 1. swallowing 2. phonation 3. chewing 4. shrugging 5. taste

24  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 (V 3 )

25 1. Masseter 2. Infrahyoid muscles 3. Lateral pterygoid 4. Medial pterygoid

26  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 1. Levator veli palatini 2. Palatopharyngeus 3. Stylohyoid 4. Stylopharyngeus 5. Tensor veli palatini

28  Temporalis  Masseter  Lateral pterygoid  Medial pterygoid  Mylohyoid  Anterior belly of digastric  Tensor tympani  Tensor veli palatini

29 1. CN V 2. CN IX 3. CN X 4. CN XII

30  Th e 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 V 2 (along with nasal mucosa); lower laryngopharynx supplied by internal laryngeal (CN X)  Motor Exceptions: stylopharyngeus (CN IX), tensor veli palatini (CN V 3 ) *These are also involved in the reflex

31 1. CN V 2. CN VII 3. CN IX 4. CN X 5. CN XII

32  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 1. Superior rectus 2. Lateral rectus 3. Superior Oblique 4. Sphincter pupillae 5. Dilator pupillae

34  Through the common tendinous ring  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 1. Left glossopharyngeal 2. Right glossopharyngeal 3. Left hypoglossal 4. Right hypoglossal

36  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  COPS 3977 (Parasympathetic Ganglia)  C iliary = CN 3 (pupillary constriction and accomodation)  O tic = CN 9 (salivation)  P terygopalatine = CN 7 (lacrimation)  S ubmandibular = CN 7 (salivation)  Sympathetic fibers carried by arteries from superior cervical ganglion

38 1. Ophthalmic 2. Oculomotor 3. Long Ciliary 4. Facial 5. Maxillary

39 PTERYGOPALATINE GANGLION

40 1. Ciliary 2. Pterygopalatine 3. Otic 4. Submandibular 5. Geniculate 6. Trigeminal (semilunar)

41

42 OTIC GANGLION

43 1. Greater palatine 2. Lesser petrosal 3. Greater petrosal 4. Chorda tympani 5. Inferior alveolar

44 SUBMANDIBULAR GANGLION

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

46  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 1. Foramen ovale 2. Foramen rotundum 3. Foramen spinosum 4. Foramen lacerum 5. Sphenopalatine foramen

48  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 1. Anterior cerebral artery 2. Middle cerebral artery 3. Posterior cerebral artery 4. Posterior communicating artery 5. Ophthalmic artery

50  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 1. Transverse sinus 2. Superior sagittal sinus 3. Occipital sinus 4. Straight sinus 5. Sigmoid sinus

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

54 1. Superficial (investing) fascia 2. Prevertebral fascia 3. Pretracheal fascia 4. Suspensory ligaments 5. Pyramid lobe of the thyroid

55  Superficial investing fascia  Suprahyoid muscles  SCM  Trapezius  Pretracheal fascia  Thyroid  Trachea  Move as a unit  Prevertebral fascia  Scalenes  Paravertebral muscles

56 1. Between the trachea and the carotid sheath 2. Between the trachea and the strap muscles 3. Between the trachea and the esophagus 4. Between the esophagus and the prevertebral muscles 5. Between the trapezius and the prevertebral muscles

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

58 1. cricothyroid 2. thyroarytenoid 3. posterior cricoarytenoid 4. lateral cricoarytenoid 5. vocalis

59  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  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 1. submental 2. submandibular 3. Inferior jugular 4. buccal 5. parotid

62  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  Branchial Arches  Eye Development  Ear Development  Know the precursors

64 1. First 2. Second 3. Third 4. Fourth 5. Fifth

65 1. First branchial arch 2. Second branchial arch 3. Third branchial arch 4. First branchial cleft 5. Second branchial pouch

66 ArchNerve Skeletal Structures Muscles 1CN V Mandible, malleus, incus, greater wing of sphenoid Muscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani, tensor veli palatini 2CN VII Stylohyoid process, stapes, upper body & lesser horn of hyoid Muscles of facial expression, stylohyoid, stapedius, postberior belly digastric 3CN 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 CN X Recurrent laryngeal Cricoid cartilage Intrinsic muscles of larynx (except cricothyroid & stylopharyngeus)

67

68 1. Utricular part; surface ectoderm 2. Utricular part; neural ectoderm 3. Saccular part; surface ectoderm 4. Saccular part; neural ectoderm

69  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  the cranium is a maze  learn the major passageways  especially true for the face

71 1. Inferior meatus 2. Middle meatus 3. Superior meatus 4. Sphenopalatine foramen 5. Pterygomaxillary fissure

72  Inferior 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 1. Superior orbital fissure 2. Inferior orbital fissure 3. Optic canal 4. Sphenopalatine foramen 5. Pterygoid canal

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

75  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 1. Earlier 2. A week is good 3. Later

77 Good luck!


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