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Ministry of Health of Ukraine
BUKOVINIAN STATE MEDICAL UNIVERSITY
“APPROVED”
on methodical meeting of the Department of
Anatomy, Topographical anatomy and Operative
Surgery
“………”…………………….2008 р. (Protocol №……….)
The chief of department
professor ……………………….……Yu.T.Achtemiichuk
“………”…………………….2008 р.
METHODICAL GUIDELINES
for the 3d-year foreign students of English-spoken groups of the Medical Faculty
(speciality “General medicine”)
for independent work during the preparation to practical studies
THE THEME OF STUDIES
“The contents of the cranial cavity”
Module 1
Topographical Anatomy and Operative Surgery
of the Head, Neck, Thorax and Abdomen
Semantic module
“Topographical Anatomy and Operative Surgery of the Head and Neck”
Chernivtsi – 2008
1. Actuality of theme:
The topographical anatomy and operative surgery of the head are very
importance, because without the knowledge about peculiarities and variants of
structure, form, location and mutual location of their anatomical structures, their agespecific it is impossible to diagnose in a proper time and correctly and to prescribe a
necessary treatment to the patient. Surgeons usually pay much attention to the
topographo-anatomic basis of surgical operations on the head.
2. Duration of studies: 2 working hours.
3. Objectives (concrete purposes):
To know the definition of regions of the head.
To know classification of surgical operations on the cerebral part of the head.
To know the topographical anatomy and operative surgery of the brain.
4. Basic knowledges, abilities, skills, that necessary for the study themes
(interdisciplinary integration):
The names of previous disciplines
1. Normal anatomy
2. Physiology
3. Biophysics
The got skills
To describe the structure and function of the
different organs of the human body, to determine
projectors and landmarks of the anatomical
structures. To understand the basic physical
principles of using medical equipment and
instruments.
5. Advices to the student.
5.1. Table of contents of the theme:
Craniotopographical Circuit by Kreinlein-Bryusova
The neurosurgeons makes the craniotopographical circuit by Kreinlein-Brusova (Fig. 2-17) taking
into consideration peculiarities of a patient. It is very important for surgical approaches to intracranial
structures and for reading radiograms and angiograms while diagnosticating different diseases. For its
construction is carrying out a lower horizontal line, or Frankfort line, (through the infraorbital margin
and along the zygomatic arch), upper horizontal line (through the supraorbital margin and parallel
to lower horizontal line), sagittal line (along the sagittal suture) and three vertical lines (forward
vertical – through the middle of zygomatic arch, middle vertical – through the head of mandible, posterior vertical – through the back point of the basement of mastoid process).
With the help of the mentioned scheme are projected:
1)basic trunk of middle meningeal artery – at a place of crossing of the forward vertical with
the zygo-matic arch;
2)central sulcus of brain – on the line led from a point of crossing of the forward vertical line
with the upper horizontal line up to the point of crossing of the back vertical line with sagittal line
(Fig. 2-18);
3)lateral sulcus of brain – on the bisectrix of the corner between a projection of the central
sulcus and the upper horizontal line;
4)anterior cerebral artery – S.S.Brusova has lead the third horizontal line going from a point of
crossing of the projection of the lateral sulcus with the back vertical in parallel of the upper horizontal
line.
Blood supply of the Brain
The brain receives it arterial supply from two pairs of vessels, the vertebral and internal carotid
arteries, the cranial cavity through the foramen magnum each vertebral artery gives off a small
meningeal branch.
Continuing forward, the vertebral artery gives rise to three additional branches before joining
with its companion vessel to form the basilar artery:
- one branch joins with its companion from the other side to form the single anterior spinal
artery, which then descends in the anterior median fissure of the spinal cord;
which are interconnected in the cranial cavity to produce an arterial circle (of Willis).
The two vertebral arteries enter the cranial cavity through the foramen magnum and just
inferior to the pons fuse to form the basilar artery.
The two internal carotid arteries enter the cranial cavity through the carotid canals on either
side.
Vertebral Arteries
Each vertebral artery arises from the first part of each subclavian artery in the lower part of the
neck, and passes superiorly through the transverse foramina of the upper six cervical vertebrae. On
entering a second branch is the posterior spinal artery, which passes posteriorly around the medulla
then descends on the posterior surface of the spinal cord in the area of the attachment of the posterior
roots-there are two posterior spinal arteries, one on each side;
- just before the two vertebral arteries join, each gives off a posterior inferior cerebellar artery.
The basilar artery travels in a rostral direction along the anterior aspect of the pons. Its branches in a
caudal to rostral direction include the anterior inferior cerebellar arteries, several small pontine arteries,
and the superior cerebellar arteries. The basilar artery ends as a bifurcation, giving rise to two posterior
cerebral arteries.
Internal Carotid Arteries
The two internal carotid arteries arise as one of the two terminal branches of the common
carotid arteries. They proceed superiorly to the base of the skull where they enter the carotid canal.
Entering the cranial cavity each internal carotid artery gives off the ophthalmic artery, the
posterior communicating artery, the middle cerebral artery, and the anterior cerebral artery.
Arterial Circle of Willis
The cerebral arterial circle (of Willis) is formed at the base of the brain by the interconnecting
vertebrobasilar and internal carotid systems of vessels. This anastomotic interconnection is accomplished
by:
- an anterior communicating artery connecting the left and right anterior cerebral arteries to each
other;
- two posterior communicating arteries, one on each side, connecting the internal carotid artery with
the posterior cerebral artery.
Venous drainage
Venous drainage of the brain begins internally as networks of small venous channels lead to
larger cerebral veins, cerebellar veins, and veins draining the brainstem, which eventually empty into
dural venous sinuses. The dural venous sinuses are endothelial-lined spaces between the outer
periosteal and the inner meningeal layers of the dura mater, and eventually lead to the internal jugular
veins.
Also emptying into the dural venous sinuses are diploic veins, which run between the internal
and external tables of compact bone in the roof of the cranial cavity, and emissary veins, which pass
from outside the cranial cavity to the dural venous sinuses.
The emissary veins are important clinically because they can be a conduit through which
infections can enter the cranial cavity because they have no valves.
Dural Venous Sinuses
The dural venous sinuses include the superior sagittal, inferior sagittal, straight, transverse,
sigmoid, and occipital sinuses, the confluence of sinuses, and the cavernous, sphenoparietal, superior
petrosal, inferior petrosal and basilar sinuses.
Dural Partitions
The dural partitions project into the cranial cavity and partially subdivide the cranial cavity. They
include the falx cerebri, tentorium cerebelli, falx cerebelli, and the diaphragma sellae.
5.2. Theoretical questions to studies:
1.
2.
3.
4.
5.
The structure of the brain.
The layer-by-layer structure of the scalp.
The blood supply of the brain.
The nerve supply of the brain.
The meninges of the brain.
5.3. Materials for self-control:
DIRECTIONS: Each question below contains four or five suggested responses. Select the one best
response to each question.
1. The carotid sheath and its contents may be safely retracted as a unit during surgical procedures on
the neck. The contents of the carotid sheath include all the following structures EXCEPT the
A common carotid artery
B external carotid artery
C internal jugular vein
D sympathetic chain
E vagus nerve
2. All the following statements correctly pertain to the sternomastoid muscle EXCEPT
A It divides the neck into anterior and posterior triangles
B It receives innervation from a nerve that passes through the foramen magnum
C The head is extended when both left and right sternomastoid muscles contract simultaneously
D Torticollis (wry neck) results from unilateral spasm of the sternomastoid muscle
E Unilateral contraction brings the chin toward the contralateral shoulder
Questions 3-6
A 28-year-old man is treated in an emergency room for a superficial gash on his forehead. The
wound is bleeding profusely, but examination reveals no fracture. While the wound is being
sutured, he relates that while he was using an electric razor, he remembers becoming dizzy and then
“waking up on the floor with blood everywhere.” The physician suspects a hypersensitive cardiac
reflex.
3. The afferent component of the cardiac reflex that slows the heart is carried by
A cardiac nerves arising from the cervical sympathetic chain
B a branch of the glossopharyngeal nerve
C the inferior root of the ansa cervicalis
D the superior root of the ansa cervicalis
E the vagus nerve
4. The efferent component of the cardiac reflex that slows the heart is carried by
A cardiac sympathetic nerves
B a branch of the glossopharyngeal nerve
C the inferior root of the ansa cervicalis
D the superior root of the ansa cervicalis
E the vagus nerve
5. The forehead and scalp bleed profusely. All the following statements correctly pertain to the
blood supply to the scalp EXCEPT
A bleeding deep to the epicranial aponeurosis may spread widely over the cranium
B bleeding superficial to the epicranial aponeurosis may exacerbate a depressed cranial fracture
C contralateral anastomotic connections are abundant
D portions of the scalp are supplied by branches of the external carotid artery
E portions of the scalp are supplied by branches of the internal carotid artery
6. The patient’s epicranial aponeurosis (galea aponeurotica) is penetrated, which results in severe
gaping of the wound. The structure underlying the epicranial aponeurosis is
A a layer containing blood vessels
B bone
C the dura mater
D the periosteum (pericranium)
E the tendon of the epicranial muscles (occipitofrontalis)
Questions 7-12
A 53-year-old woman has a paralysis of the right side of her face that produces an expressionless
and drooping appearance. She is unable to close her right eye, has difficulty chewing and drinking,
perceives sounds as annoyingly intense in her right ear, and experiences some pain in her right
external auditory meatus. Physical examination reveals loss of the blink reflex in the right eye upon
stimulation of either cornea and loss of taste from the anterior two-thirds of the tongue on the right
side. Lacrimation appears normal in the right eye, the jaw-jerk reflex is normal, and there appears to
be no problem with balance.
7. The inability to close the right eye is the result of involvement of
A the buccal branch of the facial nerve
B the buccal branch of the trigeminal nerve
C the levator palpebrae superioris muscle
D the superior tarsal muscle (of Muller)
E none of the above
8. The difficulty with mastication is the result of paralysis of
A the right buccinator muscle
B the right lateral pterygoid muscle
C the right masseter muscle
D the right zygomaticus major muscle
E none of the above
9. The pain in the external auditory meatus is due to involvement of sensory neurons that have their
cell bodies in the
A facial nucleus
B geniculate ganglion
C pterygopalatine ganglion
D spinal nucleus of cranial nerve V
E trigeminal ganglion
10. The hyperacusia associated with the right ear results from involvement of
A the auditory nerve
B the chorda tympani nerve
C the stapedius muscle
D the tensor tympani muscle
E the tympanic nerve of Jacobson
11. The branch of the facial nerve that conveys secretomotor neurons involved in lacrimation is the
A chorda tympani
B deep petrosal nerve
C greater superficial petrosal nerve
D lacrimal nerve
E lesser superficial petrosal nerve
12. To produce the described signs and symptoms, a lesion involving the facial (CN VII) nerve
would be: located
A in the internal auditory meatus
B at the geniculate ganglion
C in the facial canal just distal to the geniculate ganglion
D at the stylomastoid foramen
E within the parenchyma of the parotid gland
13. Which of the following statements concerning the lacrimal apparatus is correct?
A The lacrimal gland lies in the medial portion of the orbit
B Lacrimal fluid is secreted at the puncta in the medial edges of both upper and lower lids
C The nasolacrimal duct has a blind-ending lacrimal sac as its upper portion
D the nasolacrimal duct ends in the middle meatus of the nose
E None of the above
14. A small tumor of the orbit that involves the orbital foramen will produce which of the following
signs and symptoms?
A Blindness in one eye
B Dilated pupil with loss of the pupillary reflex and accommodation
C Paralysis of the superior rectus, inferior rectus, medial rectus, inferior oblique, and levator
palpebrae superioris muscles
D Venous engorgement of the retina
E None of the above
15. A 24-year-old boxer, after stumbling repeatedly, sees an ophthalmologist. He is found to have
20/20 vision. Upon testing the extraocular muscles, the examiner finds that elevation is balanced,
but in depression the right eyeball deviates slightly toward the midline and the patient reports
seeing double. The examiner has determined that the problem lies in the right
A abducens nerve
B inferior division of the oculomotor nerve
C optic nerve
D superior division of the oculomotor nerve
E trochlear nerve
16. All the following statements about the ciliary ganglion are correct EXCEPT
A it contains the cell bodies of postganglionic parasympathetic neurons
B preganglionic parasympathetic axons reach it via the oculomotor nerve
C postganglionic neurons from this ganglion innervate the ciliary muscle
D postganglionic neurons from this ganglion innervate the dilator pupillae muscle
E sensory fibers passing through this ganglion participate in the blink reflex
17. Sympathetic fibers to the eye
A are preganglionic from C1-C2
B have preganglionic cell bodies in the superior cervical ganglion
C have preganglionic cell bodies in the T1-T2 cord levels
D have postganglionic cell bodies in the ciliary ganglion
E reach the eye via gray rami communicantes
18. Infection in the region drained by the angular vein may result in venous thrombosis of the
cavernous sinus via the
A anterior superior alveolar vein
B infraorbital vein
C internal maxillary vein
D sphenopalatine vein
E superior ophthalmic vein
19. All the following signs could result from infection within the right cavernous sinus EXCEPT
A constricted pupil in response to light
B engorgement of the retinal veins upon ophthalmoscopic examination
C loss of corneal blink reflex upon touching right conjunctiva
D ptosis (drooping) of the right eyelid
E right ophthalmoplegia (loss of all voluntary movement of an eye)
20. Concerning the arterial supply to the brain, all the following statements correctly pertain to the
cerebral arterial circle (of Willis) EXCEPT
A it usually consists of the anterior communicating artery, anterior cerebral arteries, middle cerebral
arteries, and posterior cerebral arteries
B it should provide collateral circulation when a cerebral artery or internal carotid artery becomes
occluded
C it is complete in less than 50 percent of the population
D it is particularly prone to aneurysms
E it will adequately supply the lateral aspect of the left cerebral hemisphere in the event of
occlusion of the left middle cerebral artery in the lateral fissure
21. The vertebral arteries are correctly described by which of the foj. lowing statements?
A They arise from the common carotid artery on the left and the brachiocephalic artery on the right
B They enter the cranium via the anterior condylar canals
C They enter the cranium via the posterior condylar canals
D They pass through the transverse processes of several cervical vertebra
E They give rise to the posterior cerebral arteries
22. Reflexes that protect the inner ear from excessive noise involve the contraction of the tensor
tympani and stapedius muscles. Correct statements about the tensor tympani muscle include all
the following EXCEPT
A it inserts onto the malleus
B it is derived from the first branchial arch
C it is innervated by the chorda tympani nerve
D it lies parallel to the auditory tube
23. In addition to hearing loss and balance disturbances, a tumor in the internal acoustic meatus may
be responsible for all the following signs and symptoms EXCEPT
A dry eye from loss of secretion of the lacrimal gland
B loss of secretion of the parotid gland on one side
C loss of secretion of the submandibular and sublingual glands on one side
D dry nasal mucosa from loss of secretion of the nasal glands on one side
E facial paralysis
24. Tic douloureux (trigeminal neuralgia) is characterized by sharp pain over the distribution of the
trigeminal nerve. This syndrome involves neurons that have their cell bodies in
A the geniculate ganglion
B the otic ganglion
C the pterygopalatine ganglion
D the submandibular ganglion
E none of the above
25. A cranial fracture through the foramen rotundum that compresses the enclosed nerve results in
A inability to clench the jaw firmly
B paralysis of the inferior oblique muscle of the orbit
C regurgitation of fluids into the nasopharynx during swallowing
D uncontrolled drooling from the mouth
E none of the above
26. Which of the following statements concerning opening the jaw is correct?
A The axis of rotation passes through the mandibular foramen
B The gliding movement is the result of contraction of the medial pterygoid muscle
C The jaw openers are innervated by the maxillary division of the trigeminal nerve
D There is gliding movement in the inframeniscal compartment of the temporomandibular joint
E There is rotation in the suprameniscal compartment of the temporomandibular joint
27. In dislocation of the jaw, displacement of the articular disk beyond the articular tubercle of the
temporomandibular joint results from spasm or excessive contraction of which of the following
muscles?
A Buccinator
B Lateral pterygoid
C Medial pterygoid
D Masseter
E Temporalis
28. Infection may spread from the nasal cavity to the meninges along the olfactory nerves.
Olfactory fibers pass from the mucosa of the nasal cavity to the olfactory bulb via
A the anterior and posterior ethmoidal foramina
B the hiatus semilunaris
C the sphenopalatine foramen
D the nasociliary nerves
E none of the above
29. The blood supply to the vestibular region of the nasal cavity is from branches of all the
following vessels EXCEPT the
A anterior ethmoidal branch of the ophthalmic artery
B incisive branch of the descending palatine artery
C posterior ethmoidal branch of the ophthalmic artery
D sphenopalatine artery
E superior labial branch of the facial artery
30. Although the ciliary action of the mucosa facilitates drainage of the paranasal sinuses, body
position is paramount. Paranasal sinuses that drain by gravity with the body in the erect position
include all the following EXCEPT the
A frontal
B inferior ethmoidal
C middle ethmoidal
D maxillary
E superior ethmoidal
Literature
1. Snell R.S. Clinical Anatomy for medical students. – Lippincott Williams &
Wilkins, 2000. – 898 p.
2. Skandalakis J.E., Skandalakis P.N., Skandalakis L.J. Surgical Anatomy and
Technique. – Springer, 1995. – 674 p.
3. Netter F.H. Atlas of human anatomy. – Ciba-Geigy Co., 1994. – 514 p.
4. Ellis H. Clinical Anatomy Arevision and applied anatomy for clinical
students. – Blackwell publishing, 2006. – 439 p.