Download Review session for anatomy 34 yo WDO WF Chief complaint

Review session for anatomy
 34 yo WDO WF
o Chief complaint: persistent headache, congestion, eye pain
 Probably sinus infection: maxillary is the one that causes the most problems
with congestion
 Sinuses hollow skull – makes it lighter, resonance of voice, immune system
(chonchae warm, filter, hydrate, and humidifies the air) – protective function
 Two most common sinuses with problems: frontal and maxillary sinuses
 Treatments: antihistamines, steroids (but not long term),
 Eye pain due to lamina paprysia of the orbital walls
 Ophthalmic nerve (V1) provides sensory innervation to orbit
 Maxillary sinus problems can also mask itself as teeth pain
 Teeth are innervation by anterior/posterior superior and inferior alveolar nerve
(branch off maxillary nerve (V2))
 19 yo AAM WD WN
o Chief complaint: fell on pen in mouth. Pen penetrated posterior soft palate and
posterior wall of oropharynx
 Cranial nerve branches from 9 and 10 (9 sensory, 10 motor), 7 also innervates
soft palate (the taste buds) – functions of gag reflex (swallowing) is probably
disrupted
 First check for spinal cord disruption
 Could get all the way to the foramen magnum/spinal column
 52 yo WD WN WM, college professor
o Former tobacco user, both smoked (2p/d x 12ys) and snuff (4 cans/wk x 3 yr)
 Examine tongue first – on examination, notice soft nodular lesions around
phrenulum of tongue
 Canines and incisors are displaced and loose in their sockets
 Lingual carcinoma – in advanced stages, can erode mandible
 CNs damaged – lingual nerve (sensory nerve of tongue and floor of the mouth) –
branch ofV3; 12 – follow along genioglossal muscles
 Artery: dorsal/deep lingual branch and lingual branch; probably will have more
blood supply due to tumor
 Treatment: probably surgery – probably won’t regain full function (especially of
genioglossus, maybe others (most intrinsic muscles are underneath the
submucosa layer) – going to have difficulties swallowing, preventing the tongue
from falling backwards, problems with talking (geniohyoid- ventral ramus of C1
innervation – thyrohyoid muscles (forms ansa cervicalis) and all infrahyoid
muscles but stylohyoid muscle)
 56 yo WF, housewife, borderline obese
o Upon examination, pulse on left side is hard to detect, right side is very distinct and
prominent; carotid arteries have the same findings
o BP is 20-30 higher on the right
o Want a chest x-ray immediately – will find dissecting aneurysm to the descending arch
of the aorta
o Right side of the face is normal, but left side becomes pale and control isn’t as normal
(due to restriction of blood flow by plaque in the facial artery branch or the 3 anterior
branches of the external carotid artery) – if occipital portion is pale, probably have
external carotid blockage
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Patient comes in with total dysphagia for several days. Upon questions, been having progressive
gagging and chocking problems for months that has been getting worse, now liquids are
difficult.
o Have them shrug their shoulders, and have little motion detected as well as turning
head left and right
o Lack of CN 10 and 11 for sure, and 9 is the sensory to the pharynx and muscular
innervation to stylopharyngeus – look outside jugular foramen (superior jugular bulb
forming the internal jugular vein also passes there)
 CN10 has 2 ganglia just inferior to this, may get tumors
 Could have an abscess, thrombosis/clot, tumor in the posterior fossa, skull
fracture (occipital bone  skull fracture – pushed superior); or massive lesion of
brainstem at origins of 9,10, 11
Patient comes to you and tells you that they have a ring in their ear on the right side that won’t
go away (tinnitus) and food doesn’t taste as good as it used to
o Stimulation of CN8  causes tinnitus
o CN7 – does taste buds of anterior 2/3rds of tongue (smiling checks motor innervation)
o Internal auditory meatus or within the petrous bone
o Treatment= referral
3 yo with a history of persistent sore throat, tonsillitis
o Treatment with antibiotics, froze out palatine arch and tonsils
o Now has URIs due to lack of protection by tonsils
 Don’t have chronic GI problems
Patient has difficulty seeing – vision problems – in the corner, see diplopia
o Right face is numb (parasthesia/tingling) and immobile right eye
 Relatively retina avascular retina, but vision is just fine
 CN 3,4,6 = extraoccular muscles check
 Can still see since optic nerve runs superior to it
 Also have CNV problems – trigeminal ganglia sits inferior and posterior to
supraorbital fissure (also explains blood occlusion due to ophthalmic artery –
goes through carotid canal)
 May have temporal lobe tumor – may have also seizures on the opposite side of
the body
Patient with difficulty closing eye (obicularis oculi), chewing (buccinator and orbiculars oris) and
numbness right behind the ear (problem with facial nerve) – plexus problem in the parotid gland
(zygomatic branch and buccinators branch are gone)
o Need to check taste to determine if sensory is involved as well and parasympathetics to
nasal cavity (ask if dry nose) – if included, is probably in the temporal lobe
Patient complains of tongue falling out uncontrollably and every time I try to swallow I get pain
in the neck deep and right behind and below ear and it’s harder to swallow – pain is bilateral
o Styloglossus muscles (innervated by CN12) pulls tongue straight in
 Besides constrictors, stylopharyngeus (motor innervation = pharyngeal arch 3 –
CN9) and stylohyoid muscles (innervation = CN7) control tongue and swallowing
o Pain and difficulty with swallowing is due to fractured styloid process (usually forced
cervical flexion) – recent accident, punched in the neck
Patient went to seafood restaurant and ordered a boned fish. Developed a sharp pain in
alimentary canal. Have pain and difficulty swallowing – get an xray – one of the fish bones
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penetrated the wall of the pharynx and now have an abscess right where the middle and inferior
constrictors overlap on the lateral side
o Need to worry about superior laryngeal artery – supplies half of the blood supply to the
larynx and superior laryngeal nerve which is a branch of CN10 (only cricothyroid muscles
– changes pitch of voice – is innervated by this branch)
o Immediately at risk = muscles; in the pretracheal space – need to worry about thyroid
gland; carotid sheath is immediately lateral – internal jugular vein, common carotid,
internal carotid, and vagus nerve
Between the alar and prevertebral = dangerous space 4
Stylopharyngeus muscle is innervated by CN9
Posterior digastric
Only inferior not innervated by ansa cervicalis
4 yo patient with chronic ear infections – lots of antibiotic treatments
o Child’s face isn’t very mobile on either side and have difficulty holding head stable and
not very responsive when ask questions and have to raise your voice
o CN 7 motor branch and CN8 problems; head held up by SCM (mastoid process must
form)
o Infection can spread from middle ear to mastoid process and cause damage to CN7 and
CN8; labyrinthine artery is supplying this; right behind petrous ridge = sigmoid sinus 
becomes internal jugular vein; at base of petrous ridge posteriorly = jugular foramen
(CN9,10,11)
Patient complains of general ill feverish, flushedpale, rapidslow pulse, etc
o Exudate superior and posterior to superior choncha – probably sphenoid sinus infection
– really close to cavernous sinus – hypophyseal fossa – affects pituitary gland and
explains symptoms