Pharynx, Larynx, Nasal & Oral Cavity - Pt 2

1. A patient presents to your office complaining of her tongue feeling funny. On further examination you determine the patient has lost general sensation and taste to the posterior 1/3 of her tongue. Knowing your anatomy of the tongue, which nerve is most likely damaged?

Hypoglossal nerve

Chorda tympani nerve

Lingual nerve

Buccal nerve

Glossopharyngeal nerve

damage to the glossopharyngeal nerve would result in loss of general sensation and loss of taste to the posterior 1/3 of the tongue.

Explanation

damage to the glossopharyngeal nerve would result in loss of general sensation and loss of taste to the posterior 1/3 of the tongue.

2. A 32 year old patient presents to the emergency room after a car accident. He undergoes a full Cranial Nerve exam and is asked to stick his tongue out. The tongue deviates to the left. Which nerve is likely to be damaged?

Right Vagus

Left Hypoglossal

Left Glossopharygneal

Right Facial

Remember the movements of the tongue are controlled by CN XII or the hypoglossal nerve. Deficits to the hypoglossal nerve will cause ipsilateral deviation of the tongue.

Explanation

Remember the movements of the tongue are controlled by CN XII or the hypoglossal nerve. Deficits to the hypoglossal nerve will cause ipsilateral deviation of the tongue.

3. The patient comes into the ER with a hard blow to the neck. The patient states they only thing he can do with his tongue is raise the back part. Since you are a well trained ER doctor and remember your 2nd semester anatomy you realize he's damaged his hypoglossal nerve. All muscle of the tongue were damaged except for this one:

Hyoglossus muscle

Genioglossus muscle

Palatoglossus muscle

Styloglossus muscle

All of the tongue muscles are innervated by the hypoglossal nerve. So, hyoglossus, genioglossus, and styloglossus are all innervated by the hypoglossal nerve. palatoglossus is the exception and is innervated by the vagus.

Explanation

All of the tongue muscles are innervated by the hypoglossal nerve. So, hyoglossus, genioglossus, and styloglossus are all innervated by the hypoglossal nerve. palatoglossus is the exception and is innervated by the vagus.

4. A 38 year old female patient has had heart palpitations, heat intolerance, and is losing weight despite the fact that she also has a big increase in appetite. The Dr. notices a swelling in her throat and after imaging results agree with the patient she has hyperthyroidism and agrees to have the lower lobes of her thyroid removed. Which neurovasculature should the surgeon be careful with while in surgery?

Inferior thyroid artery and Inferior laryngeal

Common carotid artery and Phrenic Nerve

Inferior Thyroid artery and Recurrent laryngeal

Superior laryngeal artery and Internal branch of superior laryngeal

The recurrent laryngeal nerve runs with the inferior thyroid artery toward the lower lobes of the thyroid. This means that the recurrent laryngeal nerve would be at risk in any surgery involving the inferior thyroid artery or the inferior poles of the thyroid.

Explanation

The recurrent laryngeal nerve runs with the inferior thyroid artery toward the lower lobes of the thyroid. This means that the recurrent laryngeal nerve would be at risk in any surgery involving the inferior thyroid artery or the inferior poles of the thyroid.

5. Which of the following is the only intrinsic laryngeal muscle that abducts the vocal cords?

Thyroarytenoid

Lateral cricoarytenoid

Posterior cricoarytenoid

Cricothyroid

Transverse and oblique arytenoids

The posterior cricoarytenoid is the only laryngeal muscle which opens or abducts the vocal cords. The thyroarytenoid, transverse and oblique arytenoids and lateral cricoarytenoid close or adduct the vocal cords. The cricothyroid muscle tenses the vocal cords

Explanation

The posterior cricoarytenoid is the only laryngeal muscle which opens or abducts the vocal cords. The thyroarytenoid, transverse and oblique arytenoids and lateral cricoarytenoid close or adduct the vocal cords. The cricothyroid muscle tenses the vocal cords

6. A coffee-lover purchases a venti mocha from Starbucks and tells the barista to make it 'extra hot.' During the first sip, he burns the very tip of his tongue. Which nerve carries the sensation that he felt?

Trigeminal nerve

Facial nerve

Glossopharyngeal nerve

Vagus nerve

Hypoglossal nerve

The anterior 2/3rds of the tongue has pain, temperature and touch carried by the trigeminal nerve (V3). While the facial nerve also innervates this region, it only provides taste (SVA), therefore answer B is incorrect. CN IX innervates the posterior 1/3rds of the tongue and CN X does the epiglottis region, therefore both C and D are incorrect. Had the 'lingual nerve' also been listed, that would be been a correct answer. The lingual nerve is what carries CN V3 and CN VII fibers from the tongue (therefore it carries all sensory modalities for the tongue). The hypoglossal nerve (E) is motor only, and therefore is incorrect.

Explanation

The anterior 2/3rds of the tongue has pain, temperature and touch carried by the trigeminal nerve (V3). While the facial nerve also innervates this region, it only provides taste (SVA), therefore answer B is incorrect. CN IX innervates the posterior 1/3rds of the tongue and CN X does the epiglottis region, therefore both C and D are incorrect. Had the 'lingual nerve' also been listed, that would be been a correct answer. The lingual nerve is what carries CN V3 and CN VII fibers from the tongue (therefore it carries all sensory modalities for the tongue). The hypoglossal nerve (E) is motor only, and therefore is incorrect.

7. A 26 year old man recently sustained head trauma after getting into an automobile accident. He was rushed to the Emergency Department where radiographic studies revealed a fractured jugular foramen. Which of the following clinical signs would the patient likely display?

Loss of taste from the posterior 1/3 of the tongue

Loss of taste from the anterior 2/3 of the tongue

Loss of general sensation from the anterior 2/3 of the tongue

Loss of motor function to the tongue

The Glossopharyngeal nerve carries special taste sensation to the poster 1/3 of the tongue, and exits the skull via the jugular foramen. CN IX, X & XI exit the Jugular Foramen.

Explanation

The Glossopharyngeal nerve carries special taste sensation to the poster 1/3 of the tongue, and exits the skull via the jugular foramen. CN IX, X & XI exit the Jugular Foramen.

8. A drunken sailor is dining on bonefish and the next day is surprised to discover that he has no problems rapidly downing his scalding coffee, singing a pirate song and setting sail. Supposing a rogue fish bone is to blame, which of the following locations is most likely?

Palatoglossal folds

Piriform recess

Vellecula

Phyaryngoglossal folds

Esophageotracheal groove

the sailor just slammed a hot cup of coffee, this indicates a sensory deficit. Since he can sing and swallow it must be damage to the internal Laryngeal n. which gives sensory above the true vocal cords. This nerve pierces the thyrohyoid membrane and travels thru the piriform recess. A, C and D are too high, and would produce difficulty breathing, singing or swallowing. E is not accessible from the phayrnx as it lies outside the GI tract

Explanation

the sailor just slammed a hot cup of coffee, this indicates a sensory deficit. Since he can sing and swallow it must be damage to the internal Laryngeal n. which gives sensory above the true vocal cords. This nerve pierces the thyrohyoid membrane and travels thru the piriform recess. A, C and D are too high, and would produce difficulty breathing, singing or swallowing. E is not accessible from the phayrnx as it lies outside the GI tract

9. A tumor obstructing the petrotympanic fissure may produce what deficits?

Loss of taste to the anterior 2/3 of tongue

Loss of sensation to the greater palate

Loss of taste and sensation to the posterior 1/3 and root of tongue

Loss of sensation to the anterior 2/3 of the tongue.

Cranial nerve VII passes through the internal auditory meatus and the petrotympanic fissure as the chorda tympani. The chorda tympani provides taste sensation to the anterior 2/3 of the tongue.

Explanation

Cranial nerve VII passes through the internal auditory meatus and the petrotympanic fissure as the chorda tympani. The chorda tympani provides taste sensation to the anterior 2/3 of the tongue.

10. A 23 year old male came into the ED with an infected piercing on the right lateral lower lip. Where is the lymph going to drain first?

Submental nodes

Submandibular nodes

Sublingual nodes

Tonsilar nodes

Towards the lateral portions of the lips and tongue, the lymph drainage will be directed to submandibular lymph nodes

Explanation

Towards the lateral portions of the lips and tongue, the lymph drainage will be directed to submandibular lymph nodes

11. A young man complains of a numbness of the anterior tongue, while retaining the ability to taste food. Which of the following nerves is characterized correctly from the choices below?

The nerve synapses at the submandibular ganglion

The nerve is distal to the carotid nerve branch‬‬‬‬‬

The nerve is one of the modalities carried in the lingual nerve

The nerve is a branch of the maxillary nerve

The nerve is one of the modalities carried in the chorda tympani nerve

This is the GSA component of the lingual nerve, a branch of the mandibular nerve. A is incorrect because only the GVE (PNS) and SVA components of the lingual nerve synapse at the SMG. B describes the terminal branch of the glossopharyngeal nerve (lingual branch, which is not the lingual nerve), which innervates the posterior 2/3 of the tongue. D is wrong because the lingual nerve is not a branch of the maxillary nerve, but rather the mandibular. E only carries GVE (PNS) and SVA components to the lingual nerve. ‬

Explanation

This is the GSA component of the lingual nerve, a branch of the mandibular nerve. A is incorrect because only the GVE (PNS) and SVA components of the lingual nerve synapse at the SMG. B describes the terminal branch of the glossopharyngeal nerve (lingual branch, which is not the lingual nerve), which innervates the posterior 2/3 of the tongue. D is wrong because the lingual nerve is not a branch of the maxillary nerve, but rather the mandibular. E only carries GVE (PNS) and SVA components to the lingual nerve. ‬

12. During a thyroidectomy a surgeon attempts to ligate the superior thyroid artery, which structure is most vulnerable?

Recurrent laryngeal nerve

External laryngeal nerve

Internal laryngeal nerve

Phrenic nerve

Glossopharyngeal nerve

The superior thyroid artery and the external laryngeal nerve have a close relationship anatomically. The external laryngeal nerve can easily be damaged when ligating the superior thyroid artery.

Explanation

The superior thyroid artery and the external laryngeal nerve have a close relationship anatomically. The external laryngeal nerve can easily be damaged when ligating the superior thyroid artery.

13. Where should an opening be made in performing a tracheostomy?

Inferior to the thyroid gland.‬

Between the 1st and 2nd tracheal rings

Between the 4th and 5th tracheal rings.‬‬‬‬‬

Superior to the thyroid cartilage.‬‬‬‬‬

Through the thyrohyoid membrane.‬‬‬‬‬

This is the correct location for a tracheostomy; the remainder of choices are not appropriate locations and may have severe consequences, including arterial hemorrhage.‬

Explanation

This is the correct location for a tracheostomy; the remainder of choices are not appropriate locations and may have severe consequences, including arterial hemorrhage.‬

14. A patient is undergoing a radiographic examination of an enlarged swelling in his neck. The radiologist has administered radioactive iodine to circumscribe the lobes and isthumus of the thyroid. The patient is concerned and asks, "where is all this radioactive stuff going to go afterwards?" The doctors states that any excess will enter the veins and then eventually be excreted in the urine. Which structure does the inferior thyroid vein immediately drain its contents into in order to eventually makes its way to the heart and then kidneys?

Left internal jugular vein

Right internal jugular vein

Superior vena cava

Right brachiocephalic vein

Left brachiocephalic vein

Right atrium of the heart

This is mostly a test of memorization and some basic anatomy. While the superior and middle thyroid veins are bilateral and drain into the IJV, the inferior thyroid vein is only found in the midline (unpaired) and drains straight downwards, causing it to join the left brachiocephalic vein. See slide 5 of Barremkala's thyroid and larynx lecture for an excellent image of venous structures around the thyroid region. Note that the majority of venous drainage first enters the thyroid venous plexus before entering the superior, middle or inferior thyroid veins.

Explanation

This is mostly a test of memorization and some basic anatomy. While the superior and middle thyroid veins are bilateral and drain into the IJV, the inferior thyroid vein is only found in the midline (unpaired) and drains straight downwards, causing it to join the left brachiocephalic vein. See slide 5 of Barremkala's thyroid and larynx lecture for an excellent image of venous structures around the thyroid region. Note that the majority of venous drainage first enters the thyroid venous plexus before entering the superior, middle or inferior thyroid veins.

15. A patient complains to their doctor about a fatigued and hoarse voice. The patient particularly has trouble making a high pitch sound. Which nerve is mostly likely responsible for this patient's symptoms?

Internal laryngeal n.

Recurrent laryngeal n.

External laryngeal n.

Superior laryngeal n.

The patient has hoarseness, but specifically trouble with high pitch sounds. This is an indication of a lesion to cricothyroid muscle that tenses the vocal cords to change pitch. The nerve is a branch from superior laryngeal n., but External laryngeal is the specific branch innervating the cricothyroid m. and inferior pharyngeal constrictors.

Explanation

The patient has hoarseness, but specifically trouble with high pitch sounds. This is an indication of a lesion to cricothyroid muscle that tenses the vocal cords to change pitch. The nerve is a branch from superior laryngeal n., but External laryngeal is the specific branch innervating the cricothyroid m. and inferior pharyngeal constrictors.

16. A 19 year old female came into the clinic after a tongue piercing resulted in an infection. Her piercing was in the middle part of her tongue. Where are you most likely to see swollen lymph nodes?

Submandibular lymph nodes

Submental lymph nodes

Inferior deep cervical lymph nodes

Superior deep cervical lymph nodes

The lymphatic drainage from the medial part of the body of the tongue goes to the inferior deep cervical lymph nodes. Lymph drainage from the lateral parts of the body of the tongue go to the submandibular lymph nodes. Lymph drainage from the root of the tongue drains to the superior deep cervical lymph nodes. Lymph drainage from the tip of the tongue goes to submental lymph nodes.

Explanation

The lymphatic drainage from the medial part of the body of the tongue goes to the inferior deep cervical lymph nodes. Lymph drainage from the lateral parts of the body of the tongue go to the submandibular lymph nodes. Lymph drainage from the root of the tongue drains to the superior deep cervical lymph nodes. Lymph drainage from the tip of the tongue goes to submental lymph nodes.

17. From superior to inferior the correct order of structures/spaces in the larynx are?

Ventricle, rima vestibule (vestibular fold), vestibule, rima glotidis (true vocal cord).

Vestibule, rima glotidis (true vocal cord), ventricle, rima vestibule (vestibular fold).

Ventricle, rima glotidis (true vocal cord), vestibule, rima vestibule (vestibular fold).

Vestibule, rima vestibule (vestibular fold), ventricle, rima glotidis (true vocal cord).

The most likely place the cancer would spread is the cervical lymph nodes due it's proximity to the larynx

Explanation

The most likely place the cancer would spread is the cervical lymph nodes due it's proximity to the larynx