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Main Menu User Menu= Strabismus
SBAQ: Anatomy Question: SBAQ1028
Strabismus: ^ Tag
Report A 16-year-old girl presents with double vision. She is holding her head tilted to the right-hand side. On this examination of her eye movements you note that both eyes can look normally to the left but on looking to the question right, her right eye cannot turn outwards past the midline. The left eye is unaffected when looking to the right.
What is the SINGLE most likely nerve to be involved in this case?
Answer Option Question Statistics
Left oculomotor nerve I m ]
Left trochlear nerve | m ]
Right trochlear nerve |J itm )
Left abducens nerve 1 m 1 Right abducens nerve L— — fBEfck ]
Explanation:
This patient has an right-sided abducens nerve palsy (6th cranial nerve palsy), which has resulted in paralysis of the lateral rectus muscle. The lateral rectus muscle is responsible for abduction of the eye.
Inability to abduct the eye will result in the affected eye being unable to turn outwards. In this case it can be seen that the patients right eye is unable to turn outwards. This will result in a convergent strabismus and diplopia. Patients often hold their head turned towards the side of the paralysed muscle in an attempt to neutralise the diplopia.
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SBAQ: Anatomy Question 5BA: #1213C
Anatomical consideration5 in airway management: S*ore 1 1 Tag ^ A patient in the resus area of yotir Emergency Department is being prepared for a rapid sequence intubation; You make a careful airway assessment as part of the preparation. tQ Report this question which SINGLE statement regarding the anatomy of airways is true?
Answer Option Question Statistics
When attemptfng intubation witb a curved aryngoscope it is essentialto avoid the valleculas ^
Foreign bodies can lodge in the piriform fossa and lead to airway |£gjjj ] obstruction
The recurrent laryngeal nerves Supplies roughly half or the intrinsic S# ! muscles of the arynx that are responsib e for movement of the vocal ' cords
Emergency crieothyroidotomy is performed through the cricotracheal membrane
A bilateral recurrent ^aryngea: nerve palsy renders the glottis unable to [iM J close
Explanation:
The valieculae are shallow depressions just beh - ntl the root of the tongue. They are an important iandmark in laryngoscopy. When attempting intubation. the laiyngoscopc should be irserted as far as possible into the val eculae to optimise the view of the glottis.
The piriform fossa {or recess) is the space between the aryep gintrie membrane and the s des of the thyroid cartilage. It is a common site for :oreign bodies to become stuck.
Trie recurrent laryngeal nerves supply all the intrinsic muscles of the la-ynx that a -e responsible for movement of the vocal cords. In complete palsy the vocal cards take up a neutral position,, midway between closed and open. In a unilateral complete palsy die other cord din compensate so symptoms can bo minimal. In bilateral complete palsy both cords taka up a neutral position
anti the glottis Is partially obstructed, n an incomplete palsy the vocal cord abductors are affected more than the vocal cord adductors (Semcm' s Law) so the cord lies fully adducted. In bilateral incomplete palsy there will be adduction of both vocal cords and complete obstruction of the glottis.
A cricothyroidotomy is performed through the cricothyroid membrane which extends from the thyroid cartilage to tho crico'd carr iage and is palpab e as a depression inferior to the laryngeal prominence. The tricotcached membrane is lower In the neck, extending from the cricoid carriage to the first tracheal rirg.
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Question 8 of 50
SBAQ: Anatomy Question SBA: #29021
Cervical radiculopathy: Score 1 of 1 Tag ^ A 71-year-old-man presents with an 8-week history of worsening pain over the ulnar aspect of his left forearm. On examination the grip strength of his left hand is weakened and he has reduced sensation over Report the ulnar aspect of his left forearm. His upper limb reflexes are all intact. You suspect a diagnosis of cervical this radiculopathy. question
Which interspace is most likely to have been affected in this case? Select ONE answer only.
Answer Option Question Statistics
C4-C5
T1-T2
C6-C7 m
C7-T1 57%
C5-C6 E
Explanation:
The following table outlines the classic patterns of cervical radiculopathy:
Nerve Pain Interspace Abnormalities root distribution
Motor - None
Lower neck Sensory - Cape distribution (i.e. lower neck and upper C4 C3-C4 Trapezius shoulder girdle)
Reflex - None
Motor - Deltoid, elbow flexion Neck C5 C4-C5 Shoulder Sensory - Lateral arm Lateral arm Reflex - Biceps
Motor Biceps, wrist extension Neck - Dorsal lateral C6 C5-C6 Sensory Lateral forearm, thumb arm - Thumb Reflex - Brachioradialis
Motor - Triceps, wrist flexion Neck Dorsal lateral C7 C6 C7 Sensory Dorsal forearm, middle finger - forearm - Middle finger Reflex - Triceps
Motor - Finger flexors Neck C8 C7-T1 Medial forearm Sensory - Medial forearm, ulnar digits Ulnar digits Reflex - None
Motor - Finger instrinsics T1 T1-T2 Ulnar forearm Sensory - Ulnar forearm
Reflex - None
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Main Menu User Menu= Cervical spine anatomy
SBAQ: Anatomy Question: SBAQ1113
Cervical spine anatomy: ^ Tag Report You examine the cervical spine of a 25-year-old man that has been involved in a road traffic accident. this question
At which vertebral level does the most clearly palpable spinous process lie at? Select ONE answer only.
Answer Option Question Statistics C6 a m
C2 i] m
C7
C5 | ST
C3 IJ m
Explanation:
The most clearly palpable spinous process lies at C7, for this reason it has been given the name vertebra prominens. It has a long and prominent spinous process that is easily palpable from the skin surface.
Body
Transverse . process • - 'V Ant.root ( - * / .• : -- Bust. root
Superior f, articular surface i
Spinous process
The vertebra prominens (from Gray's Anatomy)
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Main Menu User Menu= Cervical spine injuries
SBAQ: Anatomy Question: SBAQ1036
Cervical spine injuries: ^ Tag Report A 44-year-old woman has been involved in a road traffic accident 1 hour ago. She has been brought in by this ambulance to the resus area of your ED. She is complaining of neck pain and is unable to move her hands and question legs. She is able to extend her wrists and shrug her shoulders. A CT scan of her C-spine is performed and is shown below:
At what vertebral level has her injury occurred? Select ONE answer only.
Answer Option Question Statistics
C7-C8 1 ]
C4-C5 1 m ]
C3-C4 | mC
C5-C6 m i
C6-C7
Explanation:
This CT scan shows a fracture-dislocation at the level of C6-C7 (three column injury). On performing her neurological examination her sensory level should be over her thumb as the C6 nerve emerges between C5 and C6 and should be unaffected.
This patient should have immediate C-spine immobilisation if not already instituted. She will require an urgent neurosurgical referral and the use of IV methylprednisolone (30mg/ kg over 15 minutes) should be considered.
Image sourced from Wikipedia d? Courtesy of Frank Gaiiiard CC BY-SA 3.0 C
Hide Correct Answer The cranial nerves exit the skull at the following anatomical locations:
Anatomical location Nerve
Cribiform plate Olfactory nerve (CN 1)
Optic foramen Optic nerve (CN II)
Oculomotor nerve (CN III) Trochlear nerve (CN IV) Superior orbital fissure Trigeminal nerve (CN V1 - Ophthalmic nerve) Abducens nerve (CN VI)
Trigeminal nerve (CN V2 - Foramen rotundum Maxillary nerve)
Trigeminal nerve (CN V3 - Foramen ovale Mandibular nerve)
Facial nerve (CN VII) Internal auditory canal Vestibulocochlear nerve (CN VIII)
Glossopharyngeal nerve (CN IX) Jugular foramen Vagus nerve (CN X) Accessory nerve (CN XI)
Hypoglossal canal Hypoglossal nerve (CN XII) FRCEMExamPrep.co.uk Your Passport to Success in the FRCEM Exam
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Question 29 of 50
SBAQ: Anatomy Question SBA: #29031
Cranial nerves: Score 1 of 1 Tag ^ You are asked to perform a cranial nerve examination on a patient that has presented with neurological symptoms. Report this question Which of the following cranial nerves originates in the cerebrum? Select ONE answer only.
Answer Option Question Statistics
Trigeminal nerve
Olfactory nerve 93%
Vagus nerve
Abducens nerve
Oculomotor nerve \
Explanation:
There are twelve paired cranial nerves in total and they all arise directly from the brain.
The cranial nerves are accordingly numbered by the location within the brainstem, (superior to inferior then medial to lateral), and the order of their exit from the cranium (anterior to posterior).
The first two cranial nerves, the olfactory nerve and the optic nerve, arise from the cerebrum, whereas the remaining ten cranial nerves arise from the brainstem. They either arise from a specific part of the brainstem (midbrain, pons, or medulla), or from a junction between the two parts.
Cranial nerves lll-XII arise from the following locations within the brainstem:
Location arisen from Cranial nerve
Midbrain Trochlear nerve (CN IV)
Midbrain-pontine junction Oculomotor nerve (CN III)
Pons Trigeminal nerve (CN V)
Abducens nerve (CN VI) Pontine-medulla junction Facial nerve (VII) Vestibulocochlear nerve (CN VIII)
Glossopharyngeal nerve (CN IX) Medulla oblongata Vagus nerve (CN X) (posterior to the olive) Accessory nerve (CN XI)
Medulla oblongata Hypoglossal nerve (CN XII) (anterior to the olive)
Olfactory ) l V I Optic
Oculomotor ^ V // l \ , \| Trigeminal Trochlear VJSTI / Y UK Abducens & i \ki^ Facial v Vestibulocochlear I l ^ Glossopharyngeal Hypoglossal pv/ I p Vagus / /
Accessory
Image sourced from Wikipediai ' Courtesy of Patrick J. Lynch CC BY-SA 2.51
Next question Explanation:
The superior part of the nose receives the anterior and posterior ethmoidal arteries, which are branches of the internal carotid artery.
The rest of the nose and sinuses is supplied by the greater palatine, sphenopalatine and superior labial arteries, which are the maxillary branches of the external carotid arteries.
In the anterior septum there is a plexus of vessels where the branches of the internal and external carotid artery anastamose. This is Kiesselbach's plexus (Little's area), which is the most common site for anterior bleeding. FRCEMExamPrep.co.uk
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iGAtJ: Anatomy Question 5BA: #1141£
Head injury: Store 0 of 1 %Tag A 42-year-old gentleman has fallen down a flight of stairs ? n a nightclub whilst intoxicated with alcohol. He is drowsy hut responsive and has bruising over nis forehead. His observarions are HR 97, RP 123/73, 3aG T3 Report ^ 94% on ail and GCS 14/15. HisCT head is shown below ; this question
Ar
Which of the following anatomical structures have been damaged in this tase7 Select ONE answer only,
Answer Option Question Statistics
nternaI carotid aitciy pWJF
Middle meningeal arteiy 74%
Basilar artery 5S
nternal jugular vein
X Bridging veins I -TMI v '
Explanation:
Tiie patient's Cl scan shows a right-sided extradural haematoma. An extradural haematema is a collection of blood that forms between the Inner surface of the skull and the|< titer layer of the dura (periosteum). They are commonly associated with head trauma and skull fracture.
Extradural hacmatomas can be distinguished from subdural hacmatomas on CT scan because of their biconvex lens shape- In contrast subdural haematftmas are usually crescent shaped (concave).
The majority of exLradural haernatumas originate from ir ury Lo the miedle meningeal arteries, particularly in the temporal region.
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Main Menu User Menu= The facial artery
SBAQ: Anatomy Question: SBAQ1402
The facial artery: ^ Untag
Report A 23-year-old man is slashed across the face with a knife during an altercation. The facial artery is damaged as a this consequence of his injury. question
Which SINGLE statement regarding the facial artery is FALSE?
Answer Option Question Statistics
It has a remarkably tortuous course I
It is a continuation of the internal carotid artery in'
It is easily palpable at the lower border of the mandible
It ends at the medial canthus of the eye
It arises in the carotid triangle
Explanation:
The facial artery arises in the carotid triangle from the external carotid artery just above the lingual artery. It then runs above the hyoid bone, deep to the digastric and stylohyoid muscles. It then arches to enter a groove on the posterior surface of the submandibular gland.
It then follows a tortuous course looping initially interiorly and then upwards around the lower border of the mandible. At this point it is easily palpable as crosses the bone anterior to the insertion of the masseter muscle.
It then runs in the superficial tissues of the face, ascending along the side of the nose, and then ending at the medial canthus of the eye.
The remarkably tortuous course of the facial artery serves to accommodate itself to the wide range of movements of the face and neck that can occur.
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The arterial supply of the face (from Gray's Anatomy)
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SBAQ: Anatomy Question 5BA: #20136
The extracranial course of the facial nerve: Store Cusfl Tag % A patient presents to the Emergency Department with a recent onset facial nerve palsy.
Report this question Which SINGLE statement regarding the extracranialeourse of the facial nerve is FALSE?
Answer Option Question Statistics
X It passes between the posterior belly of the digastric muscle and the mi i stylohyoid muse e
It divides into five terminal branches within the parotid gland
It gives off the posterior auricular nerve after exilingthe cranium ft' J
It exits the cranium Lhrough the stylomastoid formamen 1 fi -' - ' _]
It gives off a temporal branch just anterior to die outer ear m 1
Explanation:
The fadaI nerve exits the cran ium through the stylomastoid formamen, .us t poster -!o to che styloid process of tho temporal 00no.
As the nerve exits the stylomastoid foramen ii gives of the posterior auricular nerve, which controls movements of some of the scalp muscles around the ear.
After exiting the cranium, it runs anter oi ly to tne cute-' ear before passing between the posterior belly of the digastric muscle and the stylohyoid muscle, giving off branches to ea£h or these muscles in the process.
It then enters the parotid gland., which it docs not innervate. Lying between the deep and superficial lobes of che gland the nerve d.v des nto ts five terminal motor branches, which innervate the muscles of facial expression; * Temporal branch Zygomatic branch * Buccal branch * Marginal mandibular branch * Cervical branch
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mjmormtal i- TP Df jtT trfe ' ^ T- \ Afferent fiber -Buccal * To Styte-hfoid ' Ifandihiitetr ' Cervical -- L F*
Efferent texcti&'Qtanflutart fiber* to xubnuixiUary ami ay^Zfat^ual ffarrf/lfft cued ^hinrl.T
A pien of the course of the faciei nerve, its trenches end communications (adapted from Grey's Anatomy)
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Question 22 of 50
SBAQ: Anatomy Question SBA: #20201
The terminal branches of the facial nerve: Score 1 of 1 Tag ^ A 25-year-old man is involved in a fight outside a nightclub. He is cut across the face with the egde of a broken glass and the temporal branch of the facial nerve is severed. Report this question Which of the following muscles is NOT innervated by the temporal branch of the facial nerve? Select ONE answer only.
Answer Option Question Statistics
Frontalis fiSSKl
Corrugator supercilli
Orbicularis oculi
Auriculares anterior
V Procerus
Explanation:
The facial nerve divides into its five terminal motor branches, which innervate the muscles of facial expression, within the parotid gland: • Temporal branch • Zygomatic branch • Buccal branch • Marginal mandibular branch • Cervical branch
The muscles of facial expression are sometimes innervated by more than one of these branches. The muscles innervated by each of the branches is shown in the table below:
Branch of the facial nerve Muscles innervated Frontalis Orbicularis oculi Corrugator supercilli Temporal branch Auriculares anterior Auriculares superior (also acts as efferent limb of the corneal reflex) Orbicularis oculi Zygomatic branch Zygomaticus Orbicularis oris Procerus Buccinator Zygomaticus Buccal branch Risorius Levator labii superioris Levator labii superioris alaeque nasi Nasalis Depressor septi nasi Mentalis Marginal mandibular branch Depressor labii inferioris Depressor anguli oris Cervical branch Platysma
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Main Menu User Menu= Hoarse voice
Question: SBAQ1040
Hoarse voice: ^ Tag
Report A patient with known lung cancer presents to the Emergency Department with a hoarse voice. On examination this he has several enlarged deep cervical lymph nodes. question
Which nerve is MOST likely to be the cause of his symptoms? Select ONE answer only.
Answer Option Question Statistics Internal laryngeal nerve r m Glossopharyngeal nerve r
External laryngeal nerve r •VS Superior laryngeal nerve r
Recurrent laryngeal nerve I
Explanation:
The recurrent laryngeal nerves are branches of the vagus nerve that arise at the level of the arch of the aorta. The right recurrent laryngeal nerve hooks underneath the right subclavian artery and then ascends towards the larynx. The left recurrent laryngeal nerve hooks underneath the arch of the aorta then ascends towards the larynx. These nerves are one of only a few to follow a recurrent course i.e. moving in the opposite direction to the nerve they arise from.
The recurrent laryngeal nerves supply sensation to the larynx and supply all of the intrinsic muscles of the larynx apart from the cricothyroid muscles.
The course of the left recurrent laryngeal nerve is shown in the diagram below:
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superior 11 laryngeal nerve
larynx vagus nerve
to esophagus
to trachea
left recurrent laryngeal nerve
aortic arch
Image sourced from Wikipedia c? Courtesy ofjkwchui CC BY-SA 3.0 c?
The recurrent laryngeal nerves can be damaged by surgery (most notably of the thyroid or parathyroids, by trauma or by tumour spread. As the intrinsic muscles of the larynx are innervated by these nerves the most common presenting symptoms are hoarseness or aphonia. Approximately 5-15% of lung cancer patients develop hoarseness as a consequence of recurrent laryngeal nerve compression and the left side is most commonly affected.
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SBAQ: Anatomy Question 5BA: #2S41G
The infrahyoid muscles: S«>relnfl Tag ^ A SS-year-oJet woman with cervical spine trauma suffers damage to the ansa cervicalis. This has resulted in paresis of the infrahyoid muscles. T3 Report this question which of the following is an action of the infrahyoid mustles7 select ONE answer only.
Answer Option Question Statistics
Depression of the larynx
Widening of the oesophagus during swallowing
Lateral rotation of the neck iil J
Extension of rhe neck (#: 1
Elevation of the hyoid hone Ijfj'i-
Explanation:
The infrahyoid muscles are four muscles in the anterior neck that are located below the hyoid bone, They are: The sternohyoid muscle * The sternothyroid muscle * The thyrohyoid muscle * The omohyoid muscle
These four muscles nave different individual actions but m general assist with depressien of the hyoid bone and the larynx during speech sod swallowing.
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T.Pe infrahyoid rnuscies V/ ? p/rr/; facfapfecf /ro.m Gray's A/ ? a;omy by Mikael Hbggsirow }
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r,
EftSLOTTlS PIRIFORM RECESS
VOCAL CORD MTEPKiUOTnC FOLD
CURNKVIILATE CUNEIFORM TRACHEA TU6ERCLE TUBtRCLl I FRCEMExamPrep.co.uk
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iSAQ: Anatomy Question 5BA: #1145 G
Complications of dental surgery: Score 1 of 1 %Tag A patient presents to A& fc following a procedure to remove a wisdom tooth by her dentist yesterday , ^he is still comp aining of loss of sensation over the anterior two-thirds of the efr side of her tongue. 13 Report this question Which nerve is MOST likely to have been injured by this procedure? Select ONE answer only,
Answer Option Question Statistics
Anterior super ior alveolar nerve »
Zygomatic nerve fas-
Mylohyoid nerve
Inferior aiveoiar nerve
Lingual nerve 74%
Explanation:
The lingual nerve is a branch of:ho mandioular division of the trigemina nerve, it supplies sensory innervation to the anterior two-thirds of the tongue and the floor of the mouthy It a so carries fibres of the chorda tympani,a branch of the foc al nerve which returns caste information from the anterior two thirds of the torgue. The relations of the lingual nerve in the mouth cavity con be seen in the diagram below:
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Relations of the Ungual nerve in the mouth cavity (from Gray 's Anatomy )
The most common cause of lingual nerve injuries s chird molar (wisdom tooth surge:y}. The risk o : temporary injury f ram wisdom LooLh extraction is approximately 2% and the damage is permanent in of cases.The nerve can also be damaged by loca anaesthedc clenta Injections,
The anterior superior alveolar nerve is a branch of the maxillary division of the cr geminal nerve. It supplies sensac on to the incisor and canine teeth
The inierior alveolar nerve is a branch of the mandibular division ot trigemina - nerve It supplies sensation to the lower teeth.
The zygomatic nerve is a branch of the maxillary d:vision of the trigemma nerve. It supplies sensation to the skin over the zygomatic arid temporal bones.
The myohyolcl nerve is a motor nerve that supplies the mylohyoid and the anterior belly of the digastric.
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Question 3of 50
Question SBA: #17246
The mandibular nerve: Score o of 1 Tag ^ A patient suffers a facial injury that causes damage to the mandibular nerve. Report this question Which SINGLE statement regarding the mandibular nerve is FALSE?
Answer Option Question Statistics
•y The sensory and motor roots exit the cranium through different foramina
It provides sensory innervation to the cheek
The sensory root emerges from the lateral part of the trigeminal ganglion
It gives off a branch that innervates the dura mater m
x It Is the only branch of the trigeminal nerve that has both sensory and motor fibres
Explanation:
The mandibular nerve is the largest of the three branches of the trigeminal nerve (CN V ). It is the only branch that has both sensory and motor fibres.
The large sensory root emerges from the lateral part of the trigeminal ganglion and exits the cranium through the foramen ovale. The small motor root passes under the ganglion and also passes through the foramen ovale before uniting with the sensory root just outside the skull. It has a short course of 3-4 mm before dividing into the anterior and posterior divisions, which provide terminal branches.
The mandibular nerve gives off the following terminal branches:
1.From the main trunk of the nerve (before the division): • The meningeal branch innervates the dura mater • Muscular branches innervate the medial pterygoid, tensor tympani, and tensor veli palatini
2.From the anterior division: • The buccal nerve provides sensory innervation to the cheek • The masseteric nerve innervates the masseter muscle and the temporomandibular joint • The deep temporal nerves innervate the temporalis muscle • The lateral pterygoid nerve innervates the lateral pterygoid muscle
3.From the posterior division: • The auriculotemporal nerve provides sensory innervation to the skin in the temporal region, the auricle, the external acoustic meatus and the outer side of the tympanic membrane. • The lingual nerve provides sensory innervation to the anterior two-thirds of the tongue. • The inferior alveolar nerve provides sensory innervation to the lower teeth and motor innervation to the mylohyoid and the anterior belly of the digastric muscle.
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The mandibular division of the trigeminal nerve(from Gray's Anatomy)
Next question -. E A SLMRIMAl H Pi - V / Vj-> ‘ r A, f z i.r - v- - SUPRATROCHLEAR N « 't * \ ) / nr SUPftAORGITAL .HL : e r . ' » * f LLJ LO TEMPCRALBR EM * . = X Of f ELSPVHO MALAL=S i - ai iPtfflAT«OCHLc^ riw T- :4 ! *-" - J - ¥l v A - Li NASAL rtEflVE :: W;i \ .. MALAR BR. OF iNFRAOKRItA TCMPORO MALAR v. IT - ftERVE - a ' - CL AUfilCULO-TLMpyMAL I* WEftWE t N A BUCCAL NERVE ,V -:- v . > F r > ' : CO - 3 :VS / V -V M V* r ' o MENTAL SFRVf o tn $ % V =- 4 UJ . i ? * v . 0 O .N1 ' E H- ** FRCEMExamPrep.co.uk
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Question^ ofi>v S&AQ: Anatomy Question 5BA: £2558G
The maxillary artery: Score t nf 1 Tag ^ A 22-year-old man is slashed across the face with a broken bottle in a fight outside a local nightclub. I his wound causes an irjury to the maxillai'y artery. 13 Report this question The maxillary artery arises from the external carotid artery at which of the following points? Select ONE answer only.
Answer Option Question Statistics
In the jugular foramen
In the submandibular gland p
y Behind the reck of the mandible
In the pterygopalatine fossa
Between the ramus of the mandible and sphenornandibular ligament
Explanation:
The maxillary artery supplies the deep structures of the face. It is derived from the external carotid artery and arises behinc the neck of the mandible.
It is njtiajly embeeded in ihe substance of trie parotid gland and then passes, forward between the ramus of the mandible and sphenomandibular ligament into the pterygopalatine fossa. It can be ti v ded into mandibular,. pterygoid, and pterygopalatine portions
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The maxiHary artery and its branches (from Greys' Anatomy)
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Question 47 of 50
SBAQ: Anatomy Question SBA: #17221
The maxillary nerve: Score 1 of 1
A 25-year-old woman falls down a flight of stairs and suffers a skull fracture. The fracture causes damage to the maxillary nerve. Report this question Which SINGLE statement regarding the maxillary nerve is true?
Answer Option Question Statistics
It passes across the floor of the posterior cranial fossa |§S
It gives off branches in the pterygopalatine fossa
It is a mixed motor and sensory nerve 21%
It gives of the middle meningeal nerve in the infraorbital canal
It exits the cranium through the foramen ovale
Explanation:
The maxillary nerve is one of the three branches of the trigeminal nerve (CN V). It is a sensory nerve that has no motor fibres.
The maxillary nerve leaves the trigeminal ganglion and runs forward low down in the lateral wall of the cavernous sinus before passing onto the floor of the middle cranial fossa.
It exits the cranium through the foramen rotundum in the greater wing of the sphenoid fossa. It then runs into the pteryogopalatine fossa, where it gives off branches, before passing into the orbit via the inferior orbital fissure to become the infraorbital nerve.
The terminal branches of the maxillary nerve can be divided into four groups, depending upon where they branch off:
1. In the cranium: • The middle meningeal nerve is given off directly after its origin from the trigeminal ganglion, before CN V exits the foramen rotundum. It supplies the dura mater.
2. In the pteryogopalatine fossa: • The zygomatic nerve innervates the skin over the zygomatic and temporal bones. • The nasopalatine nerve innervates the palatal structures around the anterior maxillary teeth. • The posterior superior alveolar nerve innervates the 1st, 2nd and 3rd maxillary molars. • The greater palatine nerve innervates the gums, mucous membrane and glands of the hard palate. • The lesser palatine nerve innervates the soft palate, tonsil and uvula • The pharyngeal nerve innervates the mucous membrane of the nasal part of the pharynx.
3. In the infraorbital canal: • The infraorbital nerve innervates the lower eyelid, upper lip and part of the nasal cavity. • The middle superior alveolar nerve innervates the sinus mucosa, the maxillary premolars and the first maxillary molar. • The anterior superior alveolar nerve innervates the anterior teeth.
4. On the face: • The inferior palpebral nerve innervates the skin and conjunctiva of the lower eyelid. • The superior labial nerve innervates the skin of the upper lip, the mucous membrane of the mouth, and the labial glands.
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The distribution of the maxillary and mandibular nerves (from Gray's Anatomy)
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SBAQ: Anatomy Question: SBAQ1042
Neck trauma: ^ Untag
Report A 27-year-old man is brought in by ambulance to the Emergency Department. He has been stabbed in the right this side of his neck at the C4 vertebral level. question
Which structure is MOST likely to have been injured in this case? Select ONE answer only.
Answer Option Question Statistics
Middle cervical ganglion
Cricoid cartilage » J
Bifurcation of the common carotid artery 5%
Stellate ganglion | j
Spinal root of the accessory nerve Ij %E>
Explanation:
The only structure listed in this question that lies at the C4 vertebral level is the bifurcation of the common carotid artery, this is therefore the most likely structure to have been injured in this case.
The spinal root of the accessory nerve lies at the C1 vertebral level.
The cricoid cartilage and middle cervical ganglion both lie at the C6 vertebral level.
The stellate ganglion lies at the C7 vertebral level.
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Head and Neck - SBAQ - 50
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SBAQ: Anatomy Question 5BA: #24041
Ptosis: S Y which SINGLE statement regarding the diagnosis in this case fs true? Answer Option Question Statistics V The congenital form can result ir heterochromia iareaI It cannot be clinically d fferentiated from a third nerve palsy Id It causes contralateral miosis E L It causes true enophthalrros OS'- K It can bo caused by an aneurysm of the external carotid artery Explanation: This patient nas a diagnosis of Horner' s Syndrome, which results when the sympathetic supply to the head Is damaged. The typical features reflect this loss of sympathetic supply and are: * Ips1 ateral ptosis [superior tarsal musce palsy) ' * Ipsi ateral miosis or pupil constriction [loss of innervation to dilator nupi ae ) * Apparent erropErdiamos or sunken eye {though this is an Illusion created by tf'.e narrowed palpebral fissure). There may also be anhydrosis [loss of sweating) arid flushing ( loss of sympathetic mediated vasoconstriction) Interruption to the sympathetic neurones at any part of their course can cause Horner' s Syndrome. The sym oathetic trunk arises In the chest and ascends through the neck, Afte -' synapsing in ihe superior cervical gangHon, tho oost ganglionic fibres run as a olexus on the wa of the internal carotict artery, following it through the neck and into the cavernous sinus. Thus d issection or aneurysm of the internal carotid artery can disrupt the nerves and cause Horner' s Syndrome. The ptosis caused by Horner's syndrome s due to loss of the superior tarsal muscle. This is in : carit - asL to the ptosis caused by an occulomotor nerve palsy,, which is due to loss of the evator palpebrae supericris ( LPS) muscle. The L?S is the :arger muscle of the two and responsible fer a greater degree of elevation of the eyelid, Thus the ptosis of Horner ' s syndrome is subtler [and often unnoticcaolo) compared TO that of a CY II palsy. Other differentiating signs are that Horner's Syndrome is associated with miosis (pupil constriction) and CK Hi palsy with mydriasis {pupi dilation due to loss of parasympathetic supply that runs with CN I il). Congenital Horner's syndrome can result in heterochromia. The heterochromia results from decreased melatonn production due to reduced sympathetic st mularion in tlie affected eye. ifftijlgesourced from Wsktpodi : Courtesy of A tteutfyai etolCt BY-SA 2.5 if? Next question 4 FRCEMExamPrep.co.uk *r r Your Passport to Success In the FRCEM Exam Main Menu Head and Neck - SBAQ - 50 View Take Results Statistics Question 4 of 50 SBAQ: Anatomy Question 5BA: #12141 Scalenus anterior: Score 1 of 1 ^ Tag T3 Report which SINGLE statement regarding scalenus anterior is true? this question Answer Option Question Statistics V If acts synerg scically co elevate the first rib I Mfe. I It arises from the transverse processes of the Cl -3 vertebrae f&i It inserts onto the clavicle The subclavian artery and the brach ;al plexus run on the surface jjjf, of it " It lies anterior to sternocleidomastoid jssT Explanation; The scalene muscles are a group of three pairs of muscles situated in the lateral neck: * Scalenus anterior * Scalenus medius * Scalenus posterior Scaienus anterior and medius art synergistic ally to elevate the first rib and lateral y flex the neck to the same side. Scalenus posterior elevates the second rlb anc tilts the neck Le same side. Scalenus anterior arises from, the transverse processes of the C3-6 vertebrae and inserts onto the 1st rib. It lies deep at the side of the neck, behind the sternocleidomastoid muscle, It is innervated by the ventral ramus of C5 and G6 and is supplied blood by the ascending cervical artery. The subclavian artory runs behind scalenus anterior and is divided into 3 parts by it; before, beneath and after. The brachial plexus lies in close relation to the subc avian artery,, also emerging between scalenus anterior and scalenus media. The phrenic nerve roots unite at the lateral border of sea enus anterior at the evel of the cricoid cart age. The nerve then runs anteriorly ana mferiorly across the surface of the muscle. r L h 1 K KC it * r u ' fc n P ILL! * r A % - - I a L\ L F J * .' > - r 0, *\ I - t .s i s L * 5 Anterior - Medius i - T -- u u 'l m - Posterior - H V : i f z i a J ?M ? . : . h - ' 3 ,y ' r. l . 4 N.. - ;> 2 r V - * ' 431 A y > /7 * % u - sK *KT 3 The ncci /'ene nvjso'es (aoaptad from Urey's Anatomy by Mikae! HzggsfromJ Next question FRCEM ExamPrep.co.uk Your Passport to Success in the FRCEM exam Main Menu User Menu= Sialolithiasis SBAQ: Anatomy Question: SBAQ1015 Sialolithiasis: ^ Tag Report A 25-year-old man presents with a facial swelling that is worse on eating. You suspect a diagnosis of sialolithiasis. this question Which salivary gland is most likely to be affected? Select ONE answer only. Answer Option Question Statistics Von Ebner gland I m } Minor salivary gland I m } Parotid gland } Sublingual gland i m I Submandibular gland Explanation: Sialolithiasis is a condition where a calcified stone (sialolith) forms within a salivary gland. Approximately 90% occur in the submandibular gland (Wharton's duct), with the majority of the remainder occurring within the parotid gland. Occasionally they can also occur in the sublingual gland or minor salivary glands. Hide Correct Answer FRCEMExamPrep.co.uk Your Passport to Success in the FRCEM Exam Main Menu User Menu= Anatomy - FRCEM SBAQ - 50 View Take Results Statistics Question 10 of 50 SBAQ: Anatomy Question SBA: #25331 Sternocleidomastoid: Score 1 of 1 You have been asked to test the power of the sternocleidomastoid muscle in a patient as part of a neurological assessment. Report this question Which SINGLE statement regarding the sternocleidomastoid muscle is true? Answer Option Question Statistics Acting alone it rotates the head to the same side It receives its blood supply from the inferior thyroid artery It is a deep muscle lying in the side of the neck The clavicular head inserts into the lateral third of the clavicle E J Acting together with the other sternocleidomastoid muscle it flexes the neck Explanation: Sternocleidomastoid is a large, superficial muscle that is situated on the side of the neck. Sternocleidomastoid originates from the lateral surface of the mastoid process of the temporal bone and the lateral half of the superior nuchal line. It has two heads, the sternal head and the clavicular head: • The sternal head inserts into the anterior surface of the manubrium of the sternum • The clavicular head inserts into the medial third of the clavicle It receives its blood supply from the occipital and superior thyroid arteries. Sternocleidomastoid receives its motor innervation from the spinal root of the accessory nerve . Sensation, including proprioception, is supplied by the ventral rami of C2 and C3. Its actions can be divided depending upon whether it is acting alone or with the other sternocleidomastoid muscle: • Unilaterally - it acts to rotates the head to the opposite side and to tilt the head laterally to the same side • Bilaterally - it acts to flex the neck and extend the head V m s. m I N .. mmA..'. 7//M V , " j toidP * . S * a „v; r-f l : _ > l vfato •V - * /A m W i > A k . f 8 ' 5 « * 85 / * S3 SillBody Ajigle % a s°, i 3 r * c n t: o A B I C oifvi r c i -i r . vi 6 DO; 4" * I M u * c A iK *r O U1 * 58 / 7 VS *> &o r O '. r. * z TS o . - fa o , U 2 t r. • A ? a • / / HS i . e *7 i u "N V m£ : i ft * Si & x fVlavicnUrr^ m ^ 1 / 9 .V JSMMteZS VA Tfte sternocleidomastoid muscle highlighted in red (adapted from Gray's Anatomy by U Next question 4 FRCEMExamPrep.co.uk *r r Your Passport to Success In the FRCEM Exam Main Menu rail Head and Neck - SBAQ - 50 View Take Results Statistics Question 4b of 50 iQAQ: Anatomy Question 5BA: #11421 Head injury: Score 0 of 1 Tag ^ A fj? year-ole ady has fohen from her bed in her nursing home and hit her head on the floor . She lost consciousness initially end is now drowsy. She has been brought in by ambulance with high flow oxygen in T3 Report place, Her CT head scan is shown below, with an arrow pointing to the most obvious abnormality: this question « » h > < / / Which of the following anatomical structures have been damaged in this case7 Select ONE answer only, Answer Option Question Statistics ntarnaI carotid artery K bridging veins 57% Basilar artery X Middle meningea artery 33% nternal jugular vein Explanation: The patient's. CT scan shows s left-sided subdural haematoma. A -subdural haemacama Is a collection of blood chat forms between the dure meter end the brein. Subdural haematornas can be distinguished from extradural haernalomas on CT scan because of their erescor.t (concove) shops In contrast extradural hacmatemas usually have a biconvex lens shape. The majority of subdural haematomas; or girate from tears to the budging veins which cross the subdural space. ifridge sourced from Wikipedia Courtesy of James rlstiman CC BY -SA B . 0 :. Next question FRCEMExamPrep.co.uk J- i Your Passport to Success In the FRCEM Exam Main Menu User Menu Head and Neck - SBAQ - 50 View Take Results Statistics Questional of 50 SBAQ: Anatomy Quest!on 5BA: #13736 The superficial temporal artery: Score 1 of 1 A patient with suspected giant-cell arteritis undergoes a superficial tempera artery biopsy. Report this 11\. o-i WhichSlMGLEstatement regarding the superficia E ternporaJ an ery is true? Answer Option Question Statistics It passes in front of the neck of the mandible early in its course " E§ ' J It terminates by dividing into maxillary and a parietal branch E': j It car 0e palpated at tne posterior end of tne zygomatio process L It is a continuation of the internal caret d artery 1 ft passes through the SLfbmandhbular gland shortly after formation ¥ Explanation: The external carotid artery terminates by bifurcating into two branches, the superficial temporal artery and the maxillary artery. The superficial temporal artery is the im; er of these two terminal branches. It runs superiorly between the deep and superficial lobes of the parotid gland, behind the neck of the manmnle* . IT then posses ove- the posterior end of the zygomatic process, where it is easily palpable . !t terminates about 5 cm above the zygomatic process by dividing into Lwo terminal branches, the frontal and parietal branches. The superficial temporal artery Is affected in tempo-al artcr 'tis and can be biopsicd to confirm the diagnosis. 1. s 2 - *v- > = 7 L : / - ' .-i \ / J 1 s ; I f / V V IlfJ . r* 1 K U i \ i > i ' 4 J * i f ft , j / 'i » i r •J u t fA 1 a 5 T t X i I E t 1 r I ' V. - mu iff, < s / m r- r wV - 1.1 5 m n a j "i . - > i \ Girt 4 i- ' mK TU i * : i 1 n ? HrT t t MS I' : r rf- I ' t ~ Jl _ X L ' i i J ‘ - r V in r K i'l r'-r ; I .1 V r X - ol ' V- £4 1 XoA> - i If 1 *! . *- itl V - > - % r; > X * r- r r i > - I / . > 111 t I- \ t ... % 1 . v •H L .. ** > . J * ' Y // : y - V iM V V >. . V . L- lb t i J K J V n h . V .!y * * - ... , 1 l i i / a ii / . S&6B v- a r < j- A *A V r h v / labial - !: : Superior r m as i ... > sr . i i. rf / ' i- Y ,EI7, : f 7 n , . ri :? fabMl ' TKJC ' 1 r /, 1. > HU. H r T f Ayr ' T J 1 i V - . L I . . 1 r ; I'- l' t * J .. / * - - ¥ / The arteri-3! supply of the face (from Gray's Anatomy) Next question 4 FRCEMExamPrep.co.uk *r r Your Passport to Success in the FRCEM Exam Main Menu iFsffl Head and Neck - SBAQ - 50 View Take Results Statistics OLI'L'TIVT'I'I of 50 SBAQ: Anatomy Question 5BA: #25391 The suprahyoid muscles: Score t of 1 13 Report which of the following is NOT one oF the suprahyoid muscles? select ONE a nswer only. this question Answer Option Question Statistics V Sternohyoid 71% Mylohyoid Stylohyoid S0 Geniohyoid Digastric Explanation: Sternohyoid is one of the four infrahyoid muscles. The suprahyoid muscles are four muscles that are located above the hyoid bone in the neck. They are: The digastric muscle * The stylohyoid muscle * The geniohyoid muscle * The mylohyoid muscle These four muscles have different individual actions but in general assist with elevation of the hyoid bone and widening of the oesophagus during swallowing. is ' 1*1 - * $ * I J ir*!'r rr r r 1 - L- ' C -> : j/ 5 -= T ! a EL - £ - I " « _ V » i _ 0 “ n I v P IT r> a a i - i -r f 1f. ^ I -4 r? : - I i : i : i { P Q-* . t f 1M r. *j i [ i 5 \ - OP i V tY\ V 03 r xV I !- ' t U > f I r > Vca& 7 trfft / i v St&rnuito 77?e sijprartgpfrf musetes from S s/s Anafl$T>y jfry /tfirfrae/ Hdggstrom) ^ Next question Explanation: The thyroid gland secretes hormones directly into the bloodstream and is therefore a highly vascular gland. The arterial supply to the thyroid gland is from the following arteries: • Superior thyroid artery (branch of the external carotid artery) - supplies the superior and anterior portions of the gland • Inferior thyroid artery (branch of the thyrocervical trunk) - supplies the inferior and posterior portions of the gland • Thyroid ima artery (branch of the brachiocephalic trunk in most people) - supplies the anterior isthmus in approximately 10% of the population Venous drainage is via the superior, middle, and inferior thyroid veins, which together form a venous plexus. The superior and middle thyroid veins drain into the internal jugular veins whilst the inferior thyroid vein drains into the brachiocephalic vein. 4 FRCEMExamPrep.co.uk *r r Your Passport to Success In the FRCEM Exam Main Menu rail Head and Neck - SBAQ - 50 View Take Results Statistics Question ofi?i > SBAQ: Anatomy Question 5BA: #2S47G Relations of the thyroid gland: o$1 ^ Tag 13 Report which of the following is a posterior relation of the thyroid gland? select ONE answer only. this question Answer Option Question Statistics ~ Carotid sheath i : Pnrafhyroin glands [ gfE? | Sternothyroid ^ 1 X Pretracheal fascia i ^ .i i Mylohyoid ] Explanation: The mein relations of the thyroid gland ore summarised in the toblc below: Pretracheal fascia Sternohyoid Anterior relations SternoLiiyroid Sternocleidomastoid Prevertebral Fascia Parathyroid glands Posterior relations Trachea Larynx Oesophagus Recurrent laryngeal nerve Trachea Medial relations Larynx Oesophagus Lateral relations Carotid sheath Hyoid bone i i Thyrcxl cartilage " * Supsuor thyroid artery liltHTlUl ot the Ihyrtwj Cofnmofi esrotuj r ’a artemw Trachea i) Anchor view < m Hyoid butte K !i t J i Thyrod cartiUigd Ci'iccmJ carttoga \ i Right pflrathynjrd L(P1 parJIhyrOtiJ V . glands gfciflde .V f r . L oh iriVirlnr lhyrr.d Bight irton r ThyrOid artery 'i artery ^ r1 rT r From left iutd-au i images sourced from ' p& Courtesy ai Carl Fredrik CC dV-SA 3 Next question Explanation: Lymphatic drainage of the thyroid gland is into the deep lateral cervical lymph nodes, the pretracheal lymph nodes and the paratracheal lymph nodes. FRCEMExamPrep.co.uk SO T v Your Passport to Success fn the FRCEM Exam Main Menu Head and Neck - SBAQ - 50 View Take Results Statistics Quezon 50AQ: Anatomy Question 5BA: #25426 The thyroid: Store 1 of 1 Tag % A 69-year-old female fell in the bathroom on a slipoery floor and struck her anterior neck. About three hours after die event, she is admitted hy ambulance to the emergency department fmj ofyour hospital. A Report CT scan reveals the presence of a thyroid gland haematoma. this question The thyroid gland spans between which vertebral levels? Select ONE answer only. Answer Option Question Statistics I C3 - C7 30% C4'C5 i .jaSEfr I (17- 3 K CO- 2 m C5-T1 Expiration: The thyroid is a large gland situated u the anterior neck. Its primary function Is the product on of the iod' -ic containing Hormones, triiodotnyror nc (T3) and thyroxine (T41. and the pope cle hormone, caicitonir. Ir is butterfly soaped and 'S composed of two lobes that are connected by an isthmus. The isthmus connects the ower Lhires of the left and right looes and is attached to the tracheal rings posteriorly. The thyroid gland spans approximately between the C5 and T1 vertebrae and ies in the visceral compartment of the neck It lies behind the s'e nohyoid and sternothyroid fhusdes with die top of the g and lying immediately below the thyroid card ago. The gland is easily palpab c from beb- nd by feeing for the cricoid cartilage and the 15L tracheal ring directly below it, The isthmus d rl overlies the 2 to 4 trachea; rings. The thyroid gland weighs approximately £5-30 gra ms in adu is and the size increases during pregnancy and menstruation. Each lobe is approximately cm longr 3 cm wide and 2 cm thick. Hytpid- bone r . ft ^ L flu ( r Thynord cartilage Sciptnor thyroid artery s ~L Isthmus d iha thyrad f Common carotid Till! arienea Trachea a) Anlonor vhc* Hyoidbone 4 IB T hyrotd CdrhLnfcd v CnccwJ curtilage 11 ¥ *11 Right parathyroid ten parathyroid gianet glLinJi fenlirSl- J ( Pan in'or lor Ittyrad Right interior thyroid artery r artery J I TT I From leh subclavian frem n it subclavian artery artery ^ tj) Posterior vtew ' tmage.i f tteced from Wik if >&.ifa Courtesy^of Cart Predriki. . 3 V SA 3.Q Next question * FRCEMExamPrep.co.uk -I T V Your Passport to Success In the FRCEM Exam Main Menu Head and Neck - SBAQ - 50 View Take Results Statistics Question 37 of 50 SBAQ: Anatomy Question 5BA: #24051 The tongue: SwreOoM Tag ^ A patient presents to the minors area of your Emergency Department having bitten their own tongue. On examination there is a large flap wound on the anterior tongue. Report this question which SINGLE statement regarding the tongue is true? Answer Option Question Statistics The tip of the tongue drains into the deep cervical nodes -;| X Sensation to the posterior third of che tongue is via the hypoglossal te 1 nerve ~ Motor innervation far almost all the tongue is via tine vagus nerve fig ] ~ Blood supply to the tongue is mainly via tine tonsilar branch of the i facial artery ^ T he terminal sulcus divides it into anterior and posterior parts 1 Explanation: The tongue is muscuar organ situated within the mouto. Its main function is to manipulate food for mastication and to assist with swallowing. The miriline sulcus runs rfowr the centre of the enter or tongue to drv de it into right and left halves. Tne terminal sulcus is the shallow inverted -V shaped depression,, which divices the tongue into an anterior (ora ) 2/5 and posterior [pharyngeal; 1 /3. The innervation of the tongue consists of motor fibres, special sensory fibres ror taste, and general sensory fibres fer sensation. Motor innervation for almost all the muscles of the tongue is via the hypoglossal nerve. Falatog ossusisthe exception and is innervated by the vagus nerve. The innervation of taste and sensation is different far the anterior and posterior ports of the tongue because they are derived from different embryo -ogical structures: * The anterior 2/3 of the tongue - taste is via the chorda tympanl breach of the fec al nerve anc sensation is via trie lingual branch of the mandibular nerve * The posterior 1/3 of the tongue - taste and sensation are both via the g ossoohaiyngeal nerve * The base of the tongue taste and sensation are both via the internal laryngeal ncivc, which is ^ I]ranch of the vagus nerve Blood supply to tine tongue comes primarily from the lingual artery ( a branch of tine external carotid) with addition concnbuttons from the torisilar branch of the facial artery and the ascend ng phaiyngeal^alter/ [also branches of tine external carotid). Lymphatic drainage of the tongue is as follows; * The tip of the tongue - drains to the submental nodes * The lateral anterior tongue - drains to the submandibular nodes * The central anterior tongue - drains to ctie inferior cervical nodes The posterior tongue - dr ains to the deep cervical nodes Next question FRCEMExamPrep.co.uk Your Passport to Success in the FRCEM Exam Main Menu User Menu= Anatomy - FRCEM SBAQ - 50 View Take Results Statistics Question 35 of 50 SBAQ: Anatomy Question SBA: #20466 The trachea: Score 1 of 1 A trauma patient with severe facial injuries develops airway obstruction. The anaesthetist is unable to intubate the patient and prepares to perform a tracheotomy. Report this question Which SINGLE statement regarding the trachea is FALSE? Answer Option Question Statistics ~ It is lined by ciliated pseudostratified columnar epithelium |T 1 It arises at the lower border of the cricoid cartilage M 1 The carina lies at the T5 vertebral level tea] 1 The trachea inclines slightly to the left during its descent It contains 15 to 20 incomplete C-shaped tracheal rings Explanation: The trachea marks the start of the tracheobronchial tree, arising at the lower border of the cricoid cartilage, as a continuation of the larynx. This is at the C6 vertebral level. It travels inferiorly into the superior mediastinum, bifurcating at the level of the sternal angle to form the right and left bronchi. Inside the trachea, at the T5 vertebral level, there is a cartilaginous ridge called the carina of trachea that marks the point of bifurcation. During its descent the trachea is located anterior to the oesophagus and inclines slightly to the right. Below the cricoid cartilage there are 15 to 20 incomplete C-shaped tracheal rings (tracheal cartilages), which are composed of hyaline cartilage, and serve to reinforce the front and sides of the trachea to protect and maintain the airway. The free ends of these rings are supported by the trachealis muscle. The trachea and bronchi are lined by ciliated pseudostratified columnar epithelium, interspersed by goblet cells, which produce mucous. The combination of sweeping movements by the cilia and mucous from the goblet cells forms the functional mucociliary escalator, that traps particles and pathogens and moves them up and out of the airways to be swallowed and destroyed. Superior C&mu. ' Inferior Cornu. -AA&J & /• r 1 % y a s 7 X- 7 - § 9 A Anatomy of the trachea and bronchi (from Gray's anatomy) Next question