MSP Problem Set #6—More fun with the head and neck
1. Infections from nasopharynx to middle ear cause otitis media (middle ear infections)
which are extremely common among pediatric patients.
a. How is this spread of infection possible? (Through what route or opening?)
b. What's the muscle that opens the cartilaginous part of the tube in (a) to equalize
air pressure in middle ear and pharynx and what innervates it?
c. What's the sensory nerve to mucosa of nasopharynx before (anterior to) the tube
in (a)? Posterior to it?
2. Say "AAAH"
Palatine tonsils lay within a fossa between palatine arches
a. Name the arches and the muscles that form them and their innervation.
b. Since you've had so much trouble getting your pediatric patients to open their
mouths, you've invented the "Cherry Tongue depressor," and you test it on your
neighbor's kid. How is he going to taste the cherry and cooperate with you in
keeping his mouth open? (i.e., what are the general and special sensory to the
tongue?)
3. The External muscles of pharynx are
For the following structures, choose:
a. passing above superior constrictor
b. passing between superior and middle constrictor
c. passing between middle and inferior constrictor
d. passing inferior to the inferior constrictor.
Ascending palatine artery
Recurrent laryngeal nerve
Stylopharyngeus muscle
Inferior laryngeal artery
superior laryngeal artery
glossopharyngeal nerve
levator palatini muscle
internal laryngeal nerve
4. During some dental procedures an injection needle is passed through the mandibular notch
into the infratemporal fossa (extraoral approach), where the local anesthetic is injected.
a) What nerves would most likely be anesthetized?
b) The boundaries of the infratemporal fossa are as follows: lateral wall is formed by
ramus of mandible, medial wall by lateral pterygoid plate, anterior wall by
infratemporal surface of the maxilla and posterior wall formed by anterior surface of the
condylar process of the mandible, but more importantly what structures (ie. nerves,
muscles, arteries) are within this fossa?
.
c) After the procedure the patient complained of a dry mouth and lack of taste in the anterior
2/3 of the tongue, what would be one possible explanation involving the nerves in the
infratemporal fossa?
d) The maxillary artery is the major blood supply to the deep face. Although it is divided
into three parts by the lateral pterygoid muscle, only two of its three parts are considered
to be in the infratemporal fossa. Yes, what are these branches and destination?
5. You are in Anatomy lecture after a long night of studying the deep face and you can help it,
but to yawn. After yawning you realize there is something wrong, because you can’t close
your mouth. Embarrassed you decide to leave the classroom and receive some medical
assistance.
a) Using your anatomy, what is best explanation of the incident?
b) As this incident demonstrates, the muscles of mastication are very important. Name
these muscles and their respective actions?
.
6. The pterygopalatine fossa is a small, elongated, pyramidal space and is located just inferior to
the apex of the orbit. Laterally, the pterygopalatine fossa opens into the infratemporal fossa.
Also, the fossa is located between the pterygoid process of the sphenoid bone posteriorly and
the palatine bone medially. This inconspicuous region has several important structures and
communications into other regions.
a) Name the communications with this fossa.
b) Remember that the maxillary artery was divided into three parts by the lateral pterygoid.
The third part passes through the pterygomaxillary fissure and enters the pterygopalatine
fossa, where it lies anteriorly to the pterygopalatine ganglion. Name the remaining
branches off the maxillary artery.
c) Is the pterygopalatine ganglion parasympathetic or sympathetic and where does these
fiber come from?
7. One of your many patients comes into your office late Wednesday afternoon before
Thanksgiving to talk about the surgery he will be having next week to remove his thyroid.
You struggle to keep thoughts of moist turkey, fluffy mashed potatoes, and sweet pumpkin
pie out of your head in order to get through this pre-surgery interview. Halfway through the
interview (a little slow this day due to circumstances) you notice that your patient sounds a
bit hoarse. You find out that his voice has been getting progressively worse over the last
month and that he is also experiencing trouble speaking for long periods of time. You think
that his larynx and recurrent laryngeal nerve are being effected, despite not having had a
thyroidectomy or cricothyrotomy in the past. You suddenly remember one other common
cause of this problem, occurring only on the left side. What is it?
What muscle is most responsible for the hoarseness in this patient?
Which other muscles are effected and what are their functions?
Despite impressing even yourself with your abilities as a surgeon, you are concerned
about the possibility of damaging the left recurrent laryngeal nerve during the upcoming
surgery, which would result in acute breathlessness (dyspnea) because both vocal cords
would move toward the midline and close off the air passage. Which intrinsic muscle of
the larynx would be spared if this were to occur and by which nerve is it innervated?
8. Proceeding effortlessly through another one of your physical exams (like riding a bike with
one handle bar and one pedal up a hill) at your preceptors office, you notice the patients five
year old son, who is having a great time making faces at you, and his giant tongue which
seems to be always sticking out to the right side. After further exam of the boy, which has
caused him to begin crying, you feel confident that there is a problem with cranial nerve
_ on the right/left side. What muscles are not functioning?
Elevation of the back of the tongue is intact, why?
You resume your original exam on the mother, which coincidentally was stopped at testing
the cranial nerves, and find that when asked to stick out her tongue, she can barely get it past
her lips. What structure (that you wish the boy had inherited) produces this finding along
with severe speech impediment if pronounced? What structures are most involved with
speech?