REVIEW OF HEAD AND NECK: CRANIAL NERVES, ETC. OUTLINE: USE SKULL AND CRANIAL NERVES AS BASIS FOR...

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REVIEW OF HEAD AND NECK: CRANIAL NERVES, ETC. OUTLINE: USE SKULL AND CRANIAL NERVES AS BASIS FOR REVIEW 1. INTRODUCTION: SKULL, DURA, VENOUS SINUSES 2. CRANIAL NERVES AND AREAS SUPPLIED

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Transcript of REVIEW OF HEAD AND NECK: CRANIAL NERVES, ETC. OUTLINE: USE SKULL AND CRANIAL NERVES AS BASIS FOR...

Page 1: REVIEW OF HEAD AND NECK: CRANIAL NERVES, ETC. OUTLINE: USE SKULL AND CRANIAL NERVES AS BASIS FOR REVIEW 1. INTRODUCTION: SKULL, DURA, VENOUS SINUSES 2.

REVIEW OF HEAD AND NECK: CRANIAL NERVES, ETC.

OUTLINE: USE SKULL AND CRANIAL NERVES AS BASIS FOR REVIEW

1. INTRODUCTION: SKULL, DURA, VENOUS SINUSES

2. CRANIAL NERVES AND AREAS SUPPLIED

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BONES OF SKULL: OVERVIEWADULT - BONES RIGIDLY LINKED BY SUTURES BIRTH - BONES LINKED BY

FLEXIBLE CT, FONTANELLES

1. ANTERIOR FONTANELLE AT BREGMA

3. LATERAL FONTANELLE AT PTERION

2. POSTERIOR FONTANELLE - AT LAMBDA

VENOUS SINUSES CAN BE ACCESSEDIN NEONATES THROUGH FONTANELLES; SUPERIOR SAGITTAL VENOUS SINUS VIA ANTERIOR FONTANELLE

CALVARIUM

SAGITTAL SUTURE

CORONAL SUTURE

LAMBDOIDAL SUTURE

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DURA MATER - tough connective tissue layer, composed of two layers -

1) INNER MEMBRANE LAYER (true dura)

2) OUTER ENDOSTEAL LAYER - periosteum on inner side of calvarium

Two layers - fused in most places - separate to form DURAL REFLECTIONS

3 layers, like spinal cord: Dura Mater – tough mother; Arachnoid = spiderlike; Pia Mater = tender mother; - arrangement different: NO EPIDURAL SPACE

MENINGES OF BRAIN: OVERVIEW

FALX CEREBRI

SUPERIOR SAGITTAL VENOUS SINUS

CSF INSUBARACHNOIDSPACE

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VENOUS SINUSES OF BRAIN: OVERVIEW

SUPERIOR SAGITTAL SINUS

INFERIORSAGITTALSINUS

STRAIGHTSINUS

TRANSVERSESINUS

CAVERNOUSSINUS

SIGMOID SINUS

INTERNAL JUGULARVEIN

falx cerebri

tentorium cerebelli

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ANTERIORCRANIALFOSSA

POSTERIORCRANIALFOSSA

CRANIAL NERVESNOSE

INTERIOR OF SKULL - Calvarium removed

 I. Olfactory II. OpticIII. OculomotorIV. TrochlearV. TrigeminalVI. AbducensVII. FacialVIII. Vestibulo‑cochlear IX. GlossopharyngealX. VagusXI. Accessory XII. Hypoglossal

MIDDLECRANIALFOSSA

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 I. Olfactory Nerve/ Nasal Cavity -1) Fracture of Cribriform plateof ethmoid bone

ANTERIOR CRANIAL FOSSA -

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OLFACTORYFORAMINA IN CRIBIFORM PLATE OF ETHMOID BONE –CN IOLFACTORYNERVE

CRISTAGALLIOFETHMOID

ANTERIORCRANIALFOSSA

OLFACTORYNERVECN I

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I - OLFACTORY NERVE

OLFACTORY BULB

OLFACTORYNERVE BRANCHES (fila olfactoria)

DAMAGE - loss of sense of smell

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CT CORONAL PLANE OF HEAD

ANTERIORCRANIAL FOSSA

ORBIT

MAXILLARYSINUS

NASAL CAVITY

INFERIORCONCHA (TURBINATE)

NASAL SEPTUM

CRISTAGALLI OF ETHMOID

ETHMOIDSINUS

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Nasal Septum1)Septal Cartilage2)Ethmoid (PerpendicularPlate)3)Vomer

ANT. CRANIAL FOSSA

FRACTURE OF NOSE - can break cribriform plate of ethmoid bone, floor of Ant. Cranial fossa - leak CSF from nose; spread of infection

CLINICAL QUESTION: BLOW TO NOSE PRODUCES LEAKAGE OF FLUID FROM NOSE; FRACTURE CRIBRIFORM PLATE OF ETHMOID

NOSE

Crista galli of ethmoid bone

Nasal Bones

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Nerves1.Olfactory N. - smell; Olfactory Area

2.General Sensation -touch, pain, etc. - V1 Anterior Ethmoidal N. - V2 Nasal Branches- V2 Nasopalatine N.

3. Mucous Glands of nose - Parasympathetics - VII - Facial N. by Pterygopalatine Ganglion (hitchhike with branches of V)

OVERVIEW: NERVES of NASAL CAVITY

OLFACTORY N. PTERYGO-PALATINE GANGLION

ANT. ETHMOIDALN.

NASOPALATINEN.

NASALBR.

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OPTICFORAMEN CN IIOPTICNERVE,OPHTHALMICARTERY

MIDDLECRANIALFOSSA

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Optic Nerve

II - OPTIC NERVE OPHTHALMIC ARTERY ENTERS ORBIT WITH OPTIC NERVE

OPHTHALMIC ARTERY - from Int. Carotid

Optic Nerve

CENTRALARTERY OFRETINA

FORE-HEAD

NASALCAVITY

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CLINICAL QUESTION: SUDDEN ONSET OF BLINDNESS IN ONE EYE

CENTRAL ARTERY OF RETINA - BRANCH OF OPTHALMIC ART.NO ANASTOMOSES; OCCLUSIONRESULTS IN BLINDNESS

RETINA

OPHTHALMOSCOPE VIEW

BRANCHES OFCENTRAL ARTERYAND VEINS

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DURA & SUBARACHNOID SPACE (CSF) EXTEND AROUND OPTIC NERVE;

OPTIC NERVE FUNCTION COMPROMISED BY INCREASED CSF PRESSURE

CSF INSUBARACHSPACE

PAPILLEDEMA - engorgementof retinal veins (correspond to branches of central artery)

COMMUNICATING HYDROCEPHALUS - INCREASE IN CSF PRESSURE CAN PRODUCE VISUAL DEFICITS; slow onset; headaches

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SUPERIORORBITALFISSURE –CN III, IVV1, VI,OPHTHALMICVEINS

MIDDLECRANIALFOSSA

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EYE MOVEMENTS DIAGRAM

ADD

DEP

ELEV

ABD

RESTING POSITION OF EYE: DETEMINED BYBALANCE OF ACTION OF OPPOSING MUSCLES

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ABDUCENS (VI): AT REST MEDIAL STRABISMUS (CROSS-EYED) DUE TO DAMAGE/PARALYZE LATERAL RECTUS

PATIENT WITH ABDUCENS (VI) NERVE DAMAGE

ABDUCENS NERVE DAMAGE

SYMPTOM: DIPLOPIA

X

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PATIENT CANNOT LOOK DOWN AND OUT

TROCHLEAR (IV) NERVE PALSY: INABILITY TO TURN EYE DOWN AND OUT; ALSO HEAD TILT TO OPPOSITE SIDE

Symptoms - Difficultywalking down stairs;HEAD TILTED

NORMAL

EYE

HEAD

Rotation - occurs when tilt head; rotateeye medially when tilt head laterally

AFTER IV DAMAGE - eye rotated laterally;PATIENT TILTS HEAD TO OPPOSITE SIDE so both eyes similarly rotated

EYE

HEAD

X

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DAMAGE: AT REST

- LATERAL STRABISMUS (WALL-EYED) DUE TO PARALYZE MEDIAL RECTUS

ALSO - PTOSIS - DROOPING EYELID- PARALYZE LEV. PALPEBRAE SUPERIORIS - DILATED PUPIL - PARALYZE PUPILLARY CONSTRICTOR

OCULOMOTOR (III) NERVE DAMAGE

Oculomotor Nerve supplies -- Superior, Inferior, Medial Rectus- Inferior Oblique- Levator palpebra - lift eyelid- Parasymp: pupil constrictor, ciliarymuscle

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LEVATOR PALPEBRAE

TARSAL PLATE

LEVATOR PALPEBRAE SUPERIORIS MUSCLE - ORIGIN FROM TENDINOUS RING - COMPOSED OF SKELETAL (CN III) & SMOOTH (SYMPATHETICS) MUSCLE PARTS

ANATOMY: LEVATOR PALPEBRAE SUPERIORIS

DAMAGE INNERVATION PTOSIS = DROOPING EYELID

skeletal muscle III

smooth muscle sympathetics

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OCULOMOTOR NERVE PALSYother symptoms:- Pupil is dilated - denervate pupillary constrictor- Also affect Eye movements- Accomodation

SYMPATHETICS - HORNER'S SYNDROME - 1) Ptosis- Miosis - constricted pupil- Anhydrosis - lack of sweating

Sympathetic pathway: out spinal cord T1 and T2; ascend sympathetic chain; synapse Sup. Cervical ganglion; distribute with arteries(Ophthalmic A.)

SKELETAL MUSCLE PART

PTOSIS = DROOPING EYELID; CAN BE SIGN OF DAMAGE TOOCULOMOTOR NERVE (III) OR SYMPATHETICS

SMOOTH MUSCLE PART

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IRIS - PIGMENTED, CONTRACTILE LAYER SURROUNDING PUPIL

PUPIL

DILATOR PUPIL- RADIALSMOOTH MUSCLE; SYMPATHETICS

CONSTRICTOR PUPIL- CIRCULARSMOOTH MUSCLE; PARASYMPATHETICS III

EYE- STRUCTURE OF EYEBALL- VASCULAR LAYER

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CILIARY MUSCLES-

SMOOTH MUSCLES CONTRACT PRODUCE

- RELAXATION OF LIGAMENTS

- THICKENING LENS

ACCOMODATION- THICKEN LENS FOR NEAR VISION; PARASYMPATHETIC CONTROL- III (CILIARY GANGLION)

CILIARY MUSCLES

PARASYMPATHETIC MECHANISM OF ACCOMODATION

SUSPENSORY LIGAMENTS OF LENS

CILIARY BODY- ATTACHES SUSPENSORY LIGAMENTS OF LENS

CONTAINS CILIARY MUSCLES

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CAVERNOUSSINUS –III, IV, V1, V2,VI pass through

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CAVERNOUS SINUS

Cavernous sinuses - in middle cranial fossa; on side of the body of the sphenoid bone; receive blood from Sup. and Inf. Ophthalmic veins, Cerebral veins; drain to Sup. and Inf. Petrosal sinuses

Sup. and Inf. Petrosal sinuses - on petrous part of temporal boneSup. drains to Transverse sinusInf. drains to Internal Jugular V.

Pituitarystalk

OPHTHALMIC VEINS

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Anastomoses of Facial and Ophthalmic Vv.- Ophthalmic veins drain to cavernous sinus (venous sinus inside skull)

OPHTHALMICVEIN

Question: Prolonged infection on face (lateral to nose) produces 'Blurredvision' (Diplopia) - Why? Prolonged infections spread via veins (pressure low, no valves) through orbit via Ophthalmic Veins to Cavernous Sinus- Infections lateral to nose particularly dangerous; also infections from teeth can spread through pterygoid venous plexus

NOSE

PTERYGOID VENOUS PLEXUS

FACIALVEIN

SPREAD OF INFECTION FROM FACE TO BRAIN

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PITUITARY

CAV.SINUS

INTERNALCAROTID

IIIIV

V1,V2

VI

STRUCTURES PASSING THROUGH WALL OF CAVERNOUSSINUS - Int. Carotid A., Cranial N.'s III, IV, V1, V2, VI;SYMPTOM of Infection in Sinus – ‘BLURRED’ VISION; not affect CN II

no directeffect onII

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INTERNAL CAROTID ARTERY PASSES IN WALL OF CAVERNOUS SINUS

INTERNALCAROTIDARTERY

CAROTID-CAVERNOUSFISTULA - artery ruptures intovenous sinus

CAROTID SIPHON

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FORAMENSPINOSUM –MIDDLEMENINGEALARTERY,NERVOUSSPINOSUS

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INTRACRANIAL HEMATOMAS

EPIDURAL HEMATOMA – Middle meningeal artery - branch of Maxillary artery from External Carotid Artery

- provides blood supply to calvarium- outside Dura

MaxillaryArtery

External CarotidArtery

Middle Meningeal Artery

SuperficialTemporalArtery

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CORONAL SUTURE CALVARIUM THIN ON LATERAL SIDE OF SKULL

PTERION

- JUNCTION OF TEMPORAL SPHENOID PARIETAL & FRONTAL BONES

NOSE

BLOWS TO HEAD LATERAL SIDE

PIC THANKS TO DR. ALBERICO

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Clinical question - Car accident; patient lucid at first; coma/death within hours.Why? Bleeding is arterial, profuse and rapid; tentorial herniationcauses death.

Fracture Near Pterion

EPIDURAL HEMATOMA

CT -BONEWHITE;NOTEASYMMETRYLATERALVENTRICLES

NORMALCT

EPIDURAL HEMATOMA - LENS-SHAPEDON CT, MRItentorial herniation

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SUBDURAL HEMATOMA

- Bleed into potential space betweenDura & Arachnoid- from tear 'Bridging' vein or sinus- bleeding often slow- chronic subdural hematomas can remainundetected

Clinical questions - causes can be diverse- trauma; car accident; headachesdays later- non-traumatic - in elderly Crescent-shaped hematoma

on CT/MRI

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VENOUS DRAINAGE INTO SUPERIOR SAGITTAL SINUS

Receive blood from brain, orbit, emissary veins

Superior Sagittal Sinus – in upper border of falx cerebri; blood from Superior Cerebral veins through 'bridging veins'; also blood from emissary veins (pass from diploe in calvarium or through bones of skull)

'BRIDGING' VEINS

EMISSARYVEINS

SUBDURAL HEMATOMA

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DURAREFLECTED

Superior Sagittal Sinus – in upper border of falx cerebri; receives blood from Superior Cerebral veins through 'bridging veins'

Superior Cerebral veins

'bridging veins'

Superior Sagittal Sinus

BLOOD FROM CEREBRAL CORTEX DRAINS TO SUPERIOR SAGITTAL SINUS

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Arachnoid villi -sites of CSF reabsorption

SuperiorSagittalSinus

CSF REABSORBED INTO VENOUS SINUSES

LacunaeLaterales

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Sup. Sagittal Sinus

Arachnoid Villi

CSF reabsorbs into venous sinuses at Arachnoid Villi;

Reduced Re-Absorption - Clinical: Communicating Hydrocephalus - In elderly arachnoid villi can become calcified- Arachnoid Granulations

CSF REABSORBED INTO VENOUS SINUSES

Sub-arachnoidspace

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REVIEW OF HEAD AND NECK: CRANIAL NERVES, ETC.

OUTLINE: USE SKULL AND CRANIAL NERVES AS BASIS FOR REVIEW

1. INTRODUCTION: SKULL, DURA, VENOUS SINUSES

2. CRANIAL NERVES AND AREAS SUPPLIED

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FORAMENROTUNDUM –CN V2

FORAMENOVALE –CN V3

SUPERIORORBITALFISSURE –CN V1

MIDDLECRANIALFOSSA

TRIGEMINALNERVE V

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Boundary-Lateral edgeof eye

Boundary Lateral edgeof mouth

V. TRIGEMINAL NERVE – SENSORY INNERVATION TO SKIN OF HEAD – 3 DIVISIONS

V1 – OPHTHALMICDIVISION

V2 – MAXILLARYDIVISON

V3 – MANDIBULARDIVISION

V1 - alsoCORNEALREFLEX -touch cornea V1close eye VII

V3 -JAW JERKREFLEX (STRETCHREFLEX) - ALL Vstretch muscles mastication (tap down on mandible)contract muscles of mastication (mouth closes)

Numbness in Region of Face - can be correlated with damage to specific division of Trigeminal nerve

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TRIGEMINAL SENSORY DISTRIBUTIONsensory to skin, ORAL cavity, NASAL cavity, joints

ALMOST ALLTRIGEMINAL VEXCEPTION:SKIN OF OUTER EARALSO1) VII- FACIAL2) IX - GLOSSO-PHARYNGEAL3) X - VAGUS

PAIN IN EXTERNAL AUDITORY MEATUS : BELL'S PALSY (VII) - PARALYSIS OF FACIAL MUSCLES; IN RECOVERY, PATIENTS COMPLAIN OF EARACHES

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STRUCTURES DERIVED FROM BRANCHIAL ARCHES

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V MOTOR - DIVERSE

MUSCLES OF MASTICATION

ACTIONS - MOST CLOSE MOUTH - MASSETER, TEMPORALIS, MED. PTERYGOIDOPEN MOUTH - LAT. PTERYGOID

TENSOR TYMPANI - dampen sound

MYLOHYOID -raise floor of mouth in swallowing

TENSOR PALATI -tenses palate in swallowing

ANT. BELLY OFDIGASTRIC -opens mouth

MASSETER

TEMPORALIS

LAT. AND MED. PTERYGOID

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CLINICAL: WEAKNESS MUSCLE OF MASTICATION -

MOTOR SIGN:OPENING MOUTH -JAW DEVIATESTOWARDPARALYZED SIDE -

CAUSE: EX. TUMORAT FORAMENOVALE

V - DAMAGE: PARALYZE MUSCLE MASTICATION, DIFFICULTY CHEWING

V DAMAGE - MOSTLY SENSORY, MOTOR SYMPTOM

VIEW FROM BEHINDMANDIBLELATERAL

PTERYGOID

MEDIALPTERYGOID

X

INTACTDAMAGE

PUSHED BY INTACT LATERAL PTERGYOID ONOPPOSITE SIDE

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Petrous part of temporal bone

Int. aud.meatus

VII - FACIAL AND VIII - VESTIBULO-COCHLEAR

VIII - ends inCochlea andSemicircularCanals (VestibularApparatus)

cochlea

VII

POST. CRANIALFOSSA

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VII MOTOR

MUSCLES OF FACIAL EXPRESSION

FACIALPARALYSIS

STYLOHYOID,POST. BELLY DIGASTRIC

STAPEDIUS - DAMAGE HYPERCOUSIA - sounds seem too loud

sagging faceloss of naso-labial fold,inability close eye

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FACIAL NERVE (CRANIAL NERVE VII) - MANY BRANCHES INSIDE TEMPORAL BONE

VII - EXITS SKULL VIA STYLOMASTOID FORAMEN

VII - leaves post cranialfossa via Internal Auditory Meatus

Branches arise in petrous temporal bone:

1) Parasympathetics - to Pterygopalatineganglion - Lacrimal gland, Mucous glandsnose palate2) Taste fibers to ant. 2/3tongue Chorda tympani - also contains parasymp. Submand., Sub.ling saliv. glands

branches only to Muscles Facial Expression,Neck muscles

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SYMPTOMS OF DAMAGE TO FACIAL NERVE DEPEND UPON LOCATION

VIII - auditory/vestibular deficits

VII - Bell's Palsy - all FACIAL NERVE SYMPTOMS - facial paralysis, lossof taste, hyperacousia, decrease insecretion of lacrimal and salivary glands

ACOUSTIC NEUROMA (NEURINOMA)-tumor at INTERNAL AUDITORYMEATUS - BLOCK VII AND VIII

Int. aud.meatus

Stylo-mastoidforamenor in ParotidGland

VII - FACIAL AND VIII - VESTIBULO-COCHLEAR VII - ONLY

VII - ONLY facial paralysis;NO loss of taste, NO hyperacousia, NO decrease in secretion of lacrimal and salivary glands

NO auditory/vestibular deficitsVIII NOT AFFECTED

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JUGULARFORAMEN –CN IX, X, XI,INTERNALJUGULARVEIN

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Tonsillar

Lingual

Pharyngeal br

Carotid

Tympanic

IX - GLOSSOPHARYNGEAL - TONGUE AND PHARYNX

PHARYNX -- GAG REFLEX (IX IN, X OUT) - IX is SENSORY touch to pharynx- motor to stylopharyngeus

TONGUE -- Taste and Touch toposterior 1/3 of tongue

ALSO- CAROTID BRANCHES -sensory to carotid sinus (blood pressure) and carotid body (chemoreception)- sensory to MIDDLE EAR- PARASYMPATHETICS -to Parotid Salivary gland

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STRUCTURES DERIVED FROM BRANCHIAL ARCHES

X- GAG REFLEX - is motor to all muscles of Pharynx (except Stylopharyngeus)

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MUSCLES OF LARYNX

Cricothyroid muscle -raises pitch TENSES

VOCALLIGAMENTS

Thyroarytenoid muscle -lowers pitch RELAXES

CHANGE PITCH OF SOUNDOPEN/CLOSELARYNX (RIMA GLOTTIDIS)

Arytenoid and LateralCricoarytenoid - CloseRima Glottidis

Posterior Cricoarytenoid -Opens Rima Glottidis

ALL MUSCLES INNERVATED BY VAGUS NERVE (X)

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VAGUS (X) - ALL NERVES OF LARYNX

A. Superior Laryngeal N.divides to -1. Internal Laryngeal N.Sensory to LarynxAbove True Vocal Folds2. External Laryngeal N.Motor to Cricothyroid

B. Recurrent Laryngeal N. -(Inferior Laryngeal Branch)- Sensory to Larynx Below True Vocal Folds- motor to all other Muscles of Larynx

SUP. LARYNG. N.

RECURRENTLARYNG. N.

Int. Laryng. N.

Ext. Laryng. N.

CLINICAL QUESTION - Damage to recurrent laryngeal nerveduring thyroid surgery; also repair cervical intervertebral discs; patient has hoarse voice; damage all muscles except Cricothyroid

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Superior Const.

Middle Const.

Inferior Const.

X- ALL MUSCLES OF PHARYNX EXCEPT STYLOPHARYNGEUS

ALSO - PALATO-PHARYNGEUS- SALPINGO- PHARYNGEUS

X- ALL MUSCLES OF PALATE EXCEPT TENSOR PALATI

MUSCULUSUVULI -elevates uvula

LEVATOR PALATI -lifts palate

also PALATO- GLOSSUS - lowers palate

CLINICAL - MOTOR PART OF GAG REFLEX - pharyngeal constrictors - TEST MUSCLES OF PALATE – RAISE UVULA WHEN SAY AAAH!

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STERNOCLEIDO-MASTOID

TRAPEZIUS

XI - ACCESSORY NERVE

Motor to twomuscles

CLINICAL: TORTICOLLIS –Contracture of Sternocleidomastoid;Face turned to opposite side

Shrugshoulders

Turn head

CLINICAL TESTTRAPEZIUS -shrug shoulders

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PROTRUDED TONGUE DEVIATES TOWARD SIDE OF LESION - due to unopposed action of the Genioglossus muscle which protrudes tongue(Lower Motor Neuron Lesion).

HYPOGLOSSAL NERVE (XII) - ALL MUSCLES OF TONGUE - GSE MOTOR

DAMAGEHYPOGLOSSALNERVE ON ONESIDE

GENIO-GLOSSUSINTACT

GENIO-GLOSSUSPARALYZED

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SENSORY INNERVATION OF TONGUE

PHARYNGEAL PART- POST 1/3 and ANT. TO EPIGLOTTIS

ORAL PART - ANT 2/3

MOTOR - ALL MUSCLES INNERVATED BY XII HYPOGLOSSAL (GSE) – PALATOGLOSSUS IS MUSCLE OF PALATE INNERVATED BY X (VAGUS)

ANT. TO EPIGLOTTIS -1) X- VAGUSTOUCH AND TASTE

POST. 1/3 OF TONGUE1) IX - GLOSSO-PHARYNGEAL TOUCHAND TASTE

ANT. 2/3 OF TONGUE1) V3 - LINGUAL N.TOUCH2) VII - CHORDA TYMPANI -TASTE

NOTE:

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GOOD LUCK!


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