Anatomy Infratemporal Fossa & Prevertebral Region
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Mr. Chotas, a budding medical student, underwent surgery for his impacted mandibular third molar. As a good doctor, the surgeon warns Mr. Chotas about the possible lasting numbness in the tip of his tongue. This loss of general sensation is due to the damage of what nerve?
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Auriculotemporal nerve
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Chorda tympani
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Lingual nerve
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Mental nerve
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Nerve to mylohyoid
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Explore the complex anatomy of the infratemporal fossa and prevertebral region through targeted questions. Assess your understanding of nerve damage and its consequences, essential for medical students and professionals alike.
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- 2.
A 55-year-old man undergoes surgery on his parotid gland. When presenting for a follow-up visit one month later, he reports feeling his skin damp over his surgical site when he eats. The surgeon replies that this is likely a consequence of his surgery. He explains that this is likely because of incorrect regeneration of which of the following nerves?
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Lesser petrosal nerve
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Greater petrosal nerve
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Auriculotemporal nerve
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Inferior alveolar nerve
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Superficial temporal nerve
Correct Answer
A. Auriculotemporal nerveExplanation
This is a description of Frey’s Syndrome, where fibers of the auriculotemporal branch of the trigeminal nerve regenerate incorrectly; there is crossover between the sympathetic fibers supplying sweat glands of the scalp and parasympathetic fibers supplying parotid gland salivation, causing sweating over the parotid while eating. Lesions of the remainder of these nerves would not create this clinical picture.Rate this question:
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- 3.
Which of the following structures is formed by branching while in the infratemporal fossa?
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Chorda tympani branching from the lingual nerve
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Chorda tympani branching from the facial nerve
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Nerve to mylohyoid branching from the lingual nerve
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Nerve to mylohyoid branching from the facial nerve
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Middle meningeal artery branching from the superficial temporal artery
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Middle meningeal artery branching from the maxillary artery
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Lingual artery branching from the external carotid artery
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Lingual artery branching from the maxillary artery
Correct Answer
A. Middle meningeal artery branching from the maxillary arteryExplanation
Several of the answers have incorrect pairs, while others are correct pairings but do not branch in the infratemporal region. Answer A is incorrect because chorda tympani does not branch from the lingual nerve. Rather, it joins a branch of V3 to form the lingual nerve. Chorda tympani is actually a branch of the facial nerve, but the process branching occurs will in the middle ear, not infratemporal fossa. Therefore, answer B is incorrect. The nerve to the mylohyoid does branch in the infratemporal fossa, but not from the lingual or facial nerves. It is a branch of V3 (trigeminal). Therefore, answers C and D are incorrect. The middle meningeal artery is a branch of the maxillary artery and this occurs in the infratemporal fossa. Therefore answer F is correct and E is incorrect. Lastly, the lingual artery is a branch of the external carotid artery, but this occurs more caudally (in the neck), making both G and H incorrect.Rate this question:
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- 4.
A 65-yo, female presents to your primary care clinic after undergoing extensive facial plastic surgery in Beverly Hills. The surgery was uneventful, and the patient is very satisfied with the results. However, lately she has been complaining of difficulty swallowing her food. She says that she feels like she always has to take a drink of water when chewing and swallowing meals. Furthermore, the patient describes polydipsia and consequently polyuria but no trouble expressing facial emotions. As a knowledgeable physician, you begin exploring possible differentials given the patient's presentation and history and you suspect that the surgeon may have cut a nerve contributing to your patient's symptoms. Which nerve and respective modality was MOST LIKELY injured in this patient?
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Facial n.; GSE
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Facial n.; GVE
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Glossopharyngeal n.; GSE
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Facial n.; GSA
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Glossopharyngeal n.; GVE
Correct Answer
A. Glossopharyngeal n.; GVEExplanation
Cranial nerve IX, glossopharyngeal innervates the parotid gland not V3 mandibular branch of the trigeminal nerve. Yes CN IX does "hand" over the signal/fibers to V3 to reach the parotid gland, but CN IX still gets creditRate this question:
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- 5.
A physician takes a small feather and touches the anterior portion of his patients tongue. The patient asks what does that test? Thinking back to your anatomy you reply?
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Taste of Anterior 2/3 of tongue via CN VII
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Taste of Anterior 2/3 of tongue via CN IX
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General sensation of Anterior 2/3 of tongue via CN VII
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General sensation of Anterior 2/3 of tongue via CN V division 3
Correct Answer
A. General sensation of Anterior 2/3 of tongue via CN V division 3Explanation
Remember general sensation and taste follow two different cranial nerves on the anterior 2/3 of the tongue. Taste is mediated via CN 7 while sensation follows the V3 of Trigeminal nerve. The posterior 1/3rd of the tongue is innervated through CN 9 for sensation and taste.Rate this question:
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- 6.
A 25 year old man comes into the ER after getting into a street brawl late Friday night, the right side of his face is extremely swollen, he also complains of dry mouth and an x-ray is taken. Results show a fracture of the neck of the mandible, what is the origin of the parasympathetic nerve you suspect to be damaged?
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Glossopharyngeal
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Facial
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Trigeminal
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Lingual
Correct Answer
A. GlossopharyngealExplanation
The Auriculotemporal nerve is commonly damaged in fractures of the neck of the mandible, which carries parasympathetic fibers to supply the partoid gland from the Lesser petrosal branch of cranial nerve IX.Rate this question:
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- 7.
A patient undergoes removal of a parotid adenoma, resulting in removal of her left parotid gland. Which of the following can be a likely complication resulting from parotid gland surgery?
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Loss of pain and temperature on the left side of her face
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Loss of light touch and proprioception on the left side of her face
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Drooping of her left face
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Hoarseness
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Drooping of her left shoulder
Correct Answer
A. Drooping of her left faceExplanation
Drooping of the left side of her face. The facial nerve (VII) runs through the parotid gland and is easily injured in parotid gland surgery. The facial nerve is responsible for innervating the muscles of facial expression, and damage to this nerve results in drooping of the face, Bell’s palsy (left side in the case). (a) and (b) would result from damage to the trigeminal nerve. The trigeminal nerve branches before exiting the skull and neither branch runs through the parotid gland, and is not easily injured in surgery of the parotid gland. (d) would result from damage to the vagus nerve, which does is not run through the parotid gland. IT exits the skull via the jugular foramen and runs through the carotid sheath. (e) this presentation is consistent with damage to the spinal accessory nerve, which is not located near the parotid gland and highly unlikely to be damaged in parotid gland surgery.Rate this question:
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- 8.
The parotid gland is innervated by CN , via the ganglion. Once the gland is stimulated it secretes fluid through the duct.
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VII, PPG, serous, Wharton
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IX, Otic, mucinous, Wharton
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VII, PPG, mucinous, Stensens
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IX, Otic, serous, Stensens
Correct Answer
A. IX, Otic, serous, StensensExplanation
The parotid gland is innervated by CN IX, via the Otic ganglion and the auriculotemporal nerve (V3). Once the gland is stimulated it secretes serous fluid through the Stensens duct. The submandibular and sublingual glands are innervated by CN VII and secrete mucinous fluid through the Whartons and sublingual ducts, respectively.Rate this question:
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- 9.
The parasympathetic innervation of the parotid gland involves the glossopharyngeal nerve to hitch hike onto other nerves. What is the correct sequence from the tympanic plexus to the parotid gland?
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Tympanic nerve → Otic ganglion → Auriculotemporal nerve of V3 → to parotid gland
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Greater petrosal nerve → Otic ganglion → Auriculotemporal nerve of V3 → to parotid gland
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Lesser petrosal nerve → Otic ganglion → Auriculotemporal nerve of V3 → to parotid gland
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Lesser petrosal nerve → Tympanic ganglion → Auriculotemporal nerve of V2 → to parotid gland
Correct Answer
A. Lesser petrosal nerve → Otic ganglion → Auriculotemporal nerve of V3 → to parotid glandExplanation
from the medulla, fibers from CN IX hitch hike onto the tympanic nerve to the tympanic plexus, then becomes lesser petrosal nerve to the Otic ganglion. After the otic ganglion, post-ganglionic fibers hitch hike onto auriculotemporal to the parotid gland.Rate this question:
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- 10.
What is the function of the temporalis muscle?
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Elevates and protrudes the mandible
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Elevates and retracts the mandible
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Depresses and protrudes mandible
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Depresses and retracts mandible
Correct Answer
A. Elevates and retracts the mandibleExplanation
The temporalis muscle is responsible for elevating and retracting the mandible. It is one of the main muscles involved in chewing and closing the mouth. When the temporalis muscle contracts, it pulls the mandible upwards (elevation) and backwards (retraction), allowing for the closing of the mouth and the grinding of food.Rate this question:
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- 11.
A 28-year old lady is involved in a motor accident. After the accident, she presents to your clinic because she has difficulty in opening her mouth, but has no difficulty in closing it. Which of the following muscles was MOST LIKELY damaged?
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Medial pterygoid
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Masseter
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Lateral pterygoid
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Temporalis
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Orbicularis oris
Correct Answer
A. Lateral pterygoidExplanation
the lateral pterygoids are the only muscles of mastication that open the mouth.Rate this question:
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- 12.
A 56-year-old woman undergoes a partial thyroidectomy for a malignant tumor. During the operation the internal laryngeal nerve was damaged. Which of the following structures will lose sensation?
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Over the epiglottis only
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The larynx below the vocal cord
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The ventricle of the larynx
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The larynx above the vocal cord
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The saccule of the larynx only
Correct Answer
A. The larynx above the vocal cordExplanation
the internal laryngeal nerve (branch of the superior laryngeal) provides sensory innervation above the vocal cords while the inferior laryngeal nerve (branch of the recurrent laryngeal) provides sensory innervation below the vocal cords.Rate this question:
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- 13.
A 65-year-old man has difficulty swallowing and frequently aspirates fluids while drinking. MRI scan reveals that he has a tumor near the jugular foramen. Involvement of which structure is responsible for the presenting symptoms?
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Ansa cervicalis
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Vagus Nerve
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Cervical sympathetic trunk
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Accessory nerve
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Hypoglossal nerve
Correct Answer
A. Vagus NerveExplanation
The vagus nerve (CN X), which exits the skull through the jugular foramen, is the motor nerve to the pharynx and allows for swallowing.Rate this question:
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- 14.
A 56 year old male comes into the clinic and is diagnosed with Horner's Syndrome. Which one of the following will he not suffer from?
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Miosis
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Mydriasis
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Ptosis
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Anhidrosis
Correct Answer
A. MydriasisExplanation
A patient with Horner's syndrome will have a problem with his sympathetic nervous system. This will result in miosis (pupillary constriction), ptosis (drooping eyelid), and anhidrosis (decreased sweatng on face). Mydriasis is pupillary dilation, which will not be seen in Horner's syndrome.Rate this question:
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- 15.
A 37 year old female went to see her primary care physician complaining of sharp, burning and aching pain in the 4th and 5th digits in her left hand. The physician orders an MRI and the results reveal massive inflammation of her left anterior scalene muscle. Which of the following nerves innervates the anterior scalene muscle?
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Dorsal ramus of C3 and C4
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Ventral ramus of C3 and C4
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Spinal accessory nerve
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Dorsal ramus of C4 to C6
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Ventral ramus of C4 to C6
Correct Answer
A. Ventral ramus of C4 to C6Explanation
The woman is complaining of pain due to thoracic outline syndrome involving her anterior scalene muscle.Rate this question:
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- 16.
A 54 year old female undergoes thyroidectomy. While ligating the superior thyroid artery, the surgeon accidentally severs a nearby nerve. Which of the following muscles is denervated as a result of this injury?
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Thyroarytenoid
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Lateral cricoarytenoid
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Posterior cricoarytenoid
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Cricothyroid
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Aryepiglotticus
Correct Answer
A. CricothyroidExplanation
the superior thyroid artery, superior thyroid vein, and external branch of the superior laryngeal nerve run together in a neurovascular triad that originates superior to the thyroid gland and lateral to the thyroid cartilage. Because the external branch of the superior laryngeal nerve courses just deep to the superior thyroid artery, it is at risk of injury during thyroidectomy. The cricothyroid muscle is the only muscle innervated by this nerve. The remaining laryngeal muscles are innervated by the recurrent laryngeal nerves, and also provide sensory innervation to the larynx below the vocal folds. a), b), c), and e) are all innervated by the recurrent laryngeal nerve.Rate this question:
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- 17.
The lesser petrosal nerve carries preganglionic parasympathetic fibers to the:
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Geniculate ganglion
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Otic ganglion
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Submandibular ganglion
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Ciliary ganglion
Correct Answer
A. Otic ganglionExplanation
The lesser petrosal nerve is a branch of the glossopharyngeal nerve (CN IX). The lesser petrosal nerve carries presynaptic parasympathetic fibers to the otic ganglion. These fibers synapse in the otic ganglion, and the postsynaptic fibers travel on the auriculotemporal nerve to innervate the parotid gland. The geniculate ganglion is the sensory ganglion of the facial nerve--it holds the cell bodies of the neurons that carry taste sensations from the anterior 2/3 of the tongue.Rate this question:
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- 18.
The internal laryngeal nerve branches directly off which nerve?
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Vagus nerve
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Recurrent laryngeal nerve
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External laryngeal nerve
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Superior laryngeal nerve
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Inferior laryngeal nerve
Correct Answer
A. Superior laryngeal nerveExplanation
The internal laryngeal nerve branches directly off the superior laryngeal nerve to supply sensory sensation to the larynx above the vocal cords. The second branch of the superior laryngeal nerve is the external laryngeal nerve, which provides motor innervation to the cricothyroid muscle. Below the vocal cords, sensation is provided by the recurrent laryngeal nerve. Rate this question:
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- 19.
The external and internal laryngeal nerves are branches of the superior laryngeal nerve (which is a branch of the vagus nerve). Which of the following is correct?
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External laryngeal provides sensory innervation to the larynx above the vocal cords
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The internal laryngeal provides motor innervation to the larynx
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The internal laryngeal provides sensory innervation to the larynx above the vocal cords.
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The internal laryngeal provides sensory innervation to the vocal cords.
Correct Answer
A. The internal laryngeal provides sensory innervation to the larynx above the vocal cords.Explanation
The internal laryngeal nerve provides sensory innervation to the larynx above the vocal cords. This nerve punctures the thyrohyoid membrane and travels with the superior laryngeal artery(branch of external carotid artery). The internal laryngeal nerve travels through the piriform recess. The external laryngeal nerve supplies motor innervation to the cricothyroid muscle and some innervation to the inferior constrictors.Rate this question:
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- 20.
A 60-year-old man with a history significant for arteriosclerosis and hypertension presents with recent onset of periodic syncopal episodes. Upon performing an angiogram, the physician notes significant stenosis of the internal carotid artery; however, the patient's collateral arterial circulation is able to sustain blood flow to his brain. Which of the following vessels provide an anastamosis for the internal carotid artery as it enters the skull?
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Superficial temporal artery
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Angular artery
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Superior thyroid artery
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Suprascapular artery
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Ascending cervical artery
Correct Answer
A. Angular arteryExplanation
The angular and ophthalmic arteries provide the primary anastamosis for the ICA on the anterior head; posteriorly, this anastamosis may be provided by the occipital and meningeal arteries. None of the remainder of the answer choices provide any anastamosis with the as regarding blood supply to the brain.Rate this question:
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- 21.
During thyroidectomy, the surgeon ligates the most inferior vessel supplying blood to the gland. Trace the vessel back to its origin.
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Inferior thyroid A. → Costocervical trunk → Subclavian A. → Aorta
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Inferior thyroid A. → Costocervical trunk → Brachiocephalic trunk → Aorta
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Inferior thyroid A. → Thyrocervical trunk → Subclavian A. → Aorta
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Inferior thyroid A. → Thyrocervical trunk → Common Carotid A. → Aorta
Correct Answer
A. Inferior thyroid A. → Thyrocervical trunk → Subclavian A. → AortaExplanation
The inferior thyroid artery supplies the posteroinferior portion of the thyroid gland and originates off of the thyrocervical trunk. The thyrocervical trunk is a branch of the subclavian artery which originates off of the aorta on the left side and off of the brachiocephalic trunk on the right side.Rate this question:
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- 22.
During the winter, a patient comes to your office with chief complaints of unexpectedly sweaty skin on the left side of her face. On physical exam, her left pupil diameter is notably larger than the left. Which of the following best describes information involved with this case?
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The patient has trigeminal neuralgia
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The patient is showing signs of Horner's syndrome
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The patient will need to be treated by stimulating one of the cervical chain ganglia
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The patient will need to be treated by paralyzing the stellate ganglion
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The patient has an early stage of a Pancoast tumor
Correct Answer
A. The patient will need to be treated by paralyzing the stellate ganglionExplanation
The patient is showing signs and symptoms of Reynaud's disease, which is described by overstimulation of sympathetic nerve fibers leading to a widened pupil and increase activation of sweat glands. Treatment of this disease often involves surgically induced paralysis of the stellate ganglion in order to reduce the unpleasant symptoms. Trigeminal neuralgia (A) is mostly a sensory deficit involving increase sensitivity to touch stimuli. Horner's syndrome (B) is characterized by a lack of sweating and a miotic (constricted) pupil. Answer C is incorrect because you do not want to further stimulate the sympthathetic chain for Reynaud's. Early stage Pancoast tumors (E) effects the lung in its early stages.Rate this question:
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- 23.
Mr. Jones presents to your office 3 days after completing a partial thyroidectomy due to a follicular thyroid carcinoma involving the right and left lateral thyroid lobes. The patient is complaining of hoarseness in his voice and just not feeling "right" lately. Furthermore, EKG and lab results indicate that Mr. Jones has a slight cardiac arrhythmia that which you suspect may be related to his abnormally low serum calcium levels. You begin to worry that the surgeon may have mistakenly removed the parathyroid glands and injured a nerve in close proximity to the thyroid gland. Which artery runs in close proximity with the nerve that was MOST likely damaged in this patient?
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Subclavian a.
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Superior thyroid a
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Internal Carotid a.
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Inferior thyroid a.
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External Carotid a.
Correct Answer
A. Inferior thyroid a.Explanation
The inferior thyroid artery and vein run in close proximity with the recurrent laryngeal nerve. The patient is presenting with hoarseness of voice. This should be a clear indication that the nerve which the surgeon most likely cut was a branch of the vagus nerve; more specifically the recurrent laryngeal nerve. Remember, be able to trace back your nerve roots to the original source. It's not enough to memorize the endings. This is a fair option some professors may choose when providing answer choices for mini questions (i.e., vagus n. ----> superior laryngeal n.-----> external and internal laryngeal n. etc.) The parathyroid gland is responsible for maintaining normal calcium levels in the body. These glands are small and may sometimes be mistaken for parts of the thyroid. In other words, it was a red herring in the question and you should learn to filter this type of information in question stems.Rate this question:
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