Part 1 book “Clinical anatomy - A problem solving approach” has contents: Anatomy—Past, present and future, basic tissues of the body, cartilage, bones and joints, vascular tissue and lymphatic tissue, general embryology and genetics, clinicoanatomical problems and solutions, bones of upper extremity,… and other contents.
Clinical Anatomy (A Problem Solving Approach) Clinical Anatomy (A Problem Solving Approach) Second Edition Neeta V Kulkarni md Professor of Anatomy Dr Somervell Memorial CSI Medical College Karakonam, Thiruvananthapuram Kerala, India Formerly Professor and Head, Department of Anatomy Government Medical College Thiruvananthapuram, Kerala, India Foreword BR Kate JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London Jaypee Brothers Medical Publishers (P) Ltd Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd., 83 Victoria Street London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights medical publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: 507-317-0160 Fax: +50-73-010499 Email: cservice@jphmedical.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2012, Jaypee Brothers Medical Publishers All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the author(s) contained herein are original, and is intended for educational purposes only While every effort is made to ensure a accuracy of information, the publisher and the author(s) specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the authors(s) Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Publisher: Jitendar P Vij Publishing Director: Tarun Duneja Editor: Richa Saxena Cover Design: Seema Dogra, Sumit Kumar Clinical Anatomy (A Problem Solving Approach) First Edition: 2006 (Reprint 2007) Second Edition: 2012 ISBN 978-93-5025-497-4 Printed at: Ajanta Offset & Packagings Ltd., New Delhi Dedicated to The memory of my husband Dr VP Kulkarni who was a pillar of strength during the making of first edition Foreword I am extremely happy to write a foreword for the second edition of the book entitled Clinical Anatomy (A Problem Solving Approach) by Dr Neeta V Kulkarni Generally, we observe that most books of anatomy and embryology are mainly based on description of structures Like a born teacher, she has not only described structure but has shown her talent and maturity of thought by stressing the main purpose of knowing gross anatomy and embryology In the book, the author has given considerable justice to the living anatomy by inclusion of images of plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), digital subtraction angiography (DSA) and three dimensional reconstruction images using multidetector CT Added to this, there are intraoperative photographic views of various internal organs in the body She has shown how technology can be harnessed to convert this so-called static subject into a dynamic entity She has been an anatomy teacher throughout her career and has assimilated the subject well Knowledge when it becomes ripe gives wisdom and she has used her experienced wisdom to innovate the presentation according to the need of the day This edition covers general embryology, genetics, special embryology, gross anatomy and basic knowledge of the tissues of the body with emphasis on application The reduction in the time of teaching anatomy at preclinical level is a very unfortunate step This exhaustive subject deserves ample time to learn and understand Clinical anatomy for students with its problem-solving approach will minimize the hardships of learning to understand anatomy I often used to wonder, if we should have separate anatomy texts catering to the needs of undergraduate curriculum, clinical postgraduate curriculum (as per the specialty chosen) and separate books for anatomists But now I feel that books like Clinical Anatomy can build the bridges and provide a refreshing anatomical elixir to all involved in providing health care Let me wish a wholesome response to the new edition BR Kate ms, fams, fsams Ex-Director of Medical Education and Research Mumbai, Maharashtra, India Preface to the Second Edition Anatomy is the basis of medical profession as human body is the focus of examination, investigation and intervention for diagnosis and treatment of diseases There is a re-awakening of the importance of anatomy with the realization that sound knowledge of anatomy is the backbone of safe medical practice A doctor with sound anatomical knowledge is well-equipped to perform safe procedure or surgery, than the one who makes mistakes by cutting normal anatomical relations of the structure or organ, operated upon (for which the doctor is sued in the court of law for negligence) One must appreciate that application of anatomical knowledge is the ongoing process throughout the medical career Therefore, clinical anatomy occupies the center stage right from the outset of medical training There are intentional efforts by health educationists over the world to bridge the gray zone between preclinical anatomy and clinical anatomy Learning anatomy (which includes gross anatomy, microscopic anatomy, embryology and genetics) in a short span of time is a Herculean task Therefore, though it is not conceptually difficult, its sheer bulk makes anatomy overwhelming In this context, a shift towards teaching/learning basic anatomy alongside clinical anatomy is a progressive step The key to successful and enjoyable learning lies in consciously integrating the basic and the clinical anatomy right from the entry point by initiating the trainees to identify normal anatomical structures in plain radiographs, CT scans, ultrasound scans, MRI, etc Added to this, they may be exposed to patients presenting with typical deformities due to nerve injury, patients with hemiplegia, paraplegia, etc., patients with obvious congenital defects, patients with thyroid swelling, parotid swelling, etc This is bound to arouse their interest in learning Another very interesting approach is to train the trainee in clinical problem solving by using anatomical knowledge This approach not only convinces the trainees that preclinical anatomy is an integral part of bedside medicine but also expands their thinking capacity (brain power) This approach is indispensable for concept clarity and retention (rather than rote learning) Giving due regard to the constructive suggestions and comments from readers (both students and teachers) and bowing down to the request of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India the work on second edition of Clinical Anatomy (A Problem Solving Approach) was undertaken The basic theme of the first edition developing skills in anatomical thinking for solving clinical problems has been retained New chapters have been added on general anatomy (for giving conceptual background about basic tissues), general embryology and genetics besides osteology All chapters on regional anatomy have been extensively revised and enriched with plenty of new figures including photographs of clinical material (collected from various clinicians) and radiological images (collected from radiologists) to emphasize relevance of anatomy in the practice of medicine The solved examples on clinicoanatomical problems and multiple choice questions (MCQs) (given at the end of each section) not only aid in revising but also lend credence to the theme of the book Clinical insight, embryologic insight and know more are displayed in boxes I am sure that this edition too will spread positive vibes towards this tough subject and will reiterate the fact that the subject is interesting only, if looked through the mirror of its clinical relevance Moreover, this text can be a good resource material in problem-based learning (PBL) curriculum in graduate medical education Neeta V Kulkarni Section 04 456 Head and Neck front of semicircular canals Its contents are the utricle and saccule of membranous labyrinth The anterior wall of the vestibule shows an opening leading in to the scala vestibuli of cochlear canal The lateral wall presents fenestra vestibuli on the medial wall of middle ear It is closed by footplate of stapes and annular ligament The posterior wall bears five openings of three semicircular canals The inner surface of medial wall shows two recesses The spherical recess lodges the saccule and the fibers of vestibular nerve reach the saccule through the floor of the recess The elliptical recess lodges the utricle and the fibers of the vestibular nerve reach the utricle through the floor of this recess The opening of the bony canal called aqueduct of vestibule (for passage of endolymphatic duct) is located below the elliptical recess The aqueduct of vestibule reaches the epidural space on the posterior surface of petrous temporal bone Semicircular Canals The three semicircular canals are situated posterosuperior to the vestibule The canals are named, anterior (superior), lateral (horizontal) and posterior They contain semicircular ducts and lie in planes that are at right angles to each other Each canal has an ampullated or dilated end and a nonampullated end The nonampullated ends of posterior and anterior canals unite to form crus commune In this way, the semicircular canals open in the vestibule by five openings The anterior (superior) semicircular canal produces arcuate eminence in the anterior surface of petrous temporal bone in the middle cranial fossa The lateral semicircular canal is in relation to the medial wall of middle ear, medial wall of mastoid antrum and its aditus The right and left lateral semicircular canals are in the same plane but the anterior canal of one side is parallel to the posterior canal of the opposite side Perilymph The source, circulation and absorption of perilymph are as yet not fully known The perilymph contains high sodium, low potassium and high protein The cochlear canaliculus (perilymphatic duct or aqueduct of cochlea) carries the perilymph in to the subarachnoid space at the roof of the jugular foramen So probably the perilymph is partly derived from CSF and partly from the blood vessels surrounding perilymphatic spaces of the bony labyrinth The movements of the perilymph follow a definite sequence The medial movement of the footplate of stapes in fenestra vestibuli produces pressure waves in the perilymph of the vestibule and of the scala vestibuli The waves are passed on to the perilymph of scala tympani at helicotrema After producing movements of basilar membrane the waves cause a compensatory bulge of the secondary tympanic membrane in the middle ear Thus, the wave is generated at fenestra vestibuli and terminated at fenestra cochleae Membranous Labyrinth (Fig 51.10) The membranous labyrinth consists of cochlear duct, utricle and saccule, three semicircular ducts and endolymphatic duct and sac, which together form endolymph filled closed system of channels The membranous labyrinth contains the receptors or end organs for hearing and balance Cochlear Duct The cochlear duct or membranous cochlea or scala media is coiled like the bony cochlea It is blind at the apex (lagena) but is connected to the saccule by ductus reunions at the base It is located near the outer part of bony cochlear canal between the scala tympani below and scala vestibuli above Its boundaries are, basilar membrane inferiorly (which separates it from the scala tympani), the vestibular or Reissner’s membrane superomedially (which separates it from the scala vestibuli) and stria vascularis laterally The width of the basilar membrane increases from the basal to the apical region of the cochlear duct because the width of the osseous spiral lamina decreases from below upwards The end organ of hearing, spiral organ of Corti is located inside the cochlear duct Spiral Organ of Corti The spiral organ is composed of a special type of sensory epithelium and the tectorial membrane The epithelium consists of sensory hair cells and different types of supporting cells, which are arranged on the basilar membrane The pillar cells rest on the basilar membrane by broad bases The outer and inner pillar cells enclose a central triangular space (tunnel of Corti) This tunnel contains cortilymph, which nourishes the sensory epithelium Internal to the Fig 51.10: Spiral organ of Corti in a section through cochlear duct Ear (External and Middle), Eustachian Tube, Mastoid Antrum and Internal Ear 457 Clinical insight i Inflammation of labyrinth is called labyrinthitis ii Noise trauma can lead to hearing loss Degenerative changes in organ of Corti may occur in people exposed to continuous loud sounds over a period of time The boilermakers, coppersmiths, ironsmiths and artillerymen are susceptible to this condition Sudden loud sound (loud explosion, gunfire or a powerful cracker) may damage hair cells in organ of Corti or rupture the vestibular membrane iii Presbycusis is the physiological hearing loss associated with aging process iv Cochlear implants are the electronic devices that are used in place of a totally nonfunctioning cochlea Utricle and Saccule i The utricle is an irregular sac that occupies the elliptical recess of bony vestibule It receives five openings of the semicircular ducts ii The saccule is a globular sac lying in the spherical recess of the bony vestibule It is connected to the cochlear duct by the ductus reunions iii The utriculosaccular duct is Y-shaped It connects the saccule and utricle to each other The vertical limb of the Y continues as the endolymphatic duct iv The macula is the sensory epithelium of the utricle and saccule It consists of large number of hair cells The cilia of the hair cells project in the gelatinous cap called statoconial or otolithic membrane containing crystals of calcium carbonate (otoliths) The hair cells respond to orientation of head with respect to gravity hence the maculae of utricle and saccule are known as static labyrinth The peripheral processes of the neurons of vestibular ganglion supply sensory fibers to hair cells of maculae Excessive stimulation of utricle and saccule is responsible for motion sickness, in which the person experiences vertigo, nausea and vomiting Semicircular Ducts The semicircular ducts are much smaller in diameter than the semicircular canals of bony labyrinth The anterior, lateral and posterior ducts open by five openings into the utricle The ampullary end of each duct bears a raised crest (crista ampullaris), which projects into the lumen Each ampullary crest carries specialized hair cells The stereocilia and one kinocilium from the hair cell are inserted in a vertical plate of gelatinous material called cupula The angular acceleration and deceleration movements of head bring about movements of endolymph in semicircular ducts, which results in deflecting of cupula and stimulation of the hair cells of crest The peripheral processes of the bipolar neurons of vestibular ganglion provide sensory supply to these hair cells The ampullary cristae are also known as kinetic labyrinth on account of their function Endolymphatic Duct and Sac The endolymphatic duct continues from the junction of Y-shaped utriculosaccular duct It is carried in a bony canal (vestibular aqueduct) to the posterior aspect of petrous temporal bone Its dilated terminal part is called endolymphatic sac, which projects between the periosteum and the dura mater on the posterior surface of petrous temporal bone in the posterior cranial fossa near the sigmoid sinus The endolymph, which is rich in potassium and poor in sodium, is secreted by stria vascularis within the cochlear duct It enters the ductus endolymphaticus for removal from its sac in the extradural vascular plexus Clinical insight Meinere’s Disease The blockage of the endolymphatic duct or damage to the sac leads to accumulation of endolymph in the membranous labyrinth This condition is called endolymphatic hydrops or Meniere’s disease It is characterized by vertigo, hearing loss and tinnitus Blood Supply of Labyrinth i The labyrinthine artery, more frequently a branch from anterior inferior cerebellar artery (instead of the basilar artery) enters the inner ear via internal acoustic meatus At the bottom of the meatus it divides in to cochlear and vestibular branches, of which the cochlear branch enters the modiolus ii The stylomastoid branch of either the occipital or the posterior auricular artery may also give additional supply to the labyrinth iii The veins of the labyrinth end in labyrinthine vein, which drains in to the superior petrosal sinus Chapter inner pillar cells there is a single row of inner hair cells External to the outer pillar cells there are three or four rows of outer hair cells The tectorial membrane is a stiff gelatinous plate containing glycoproteins (tectorins) It is attached to the vestibular lip of the spiral lamina It overlies the apical aspect of the sensory epithelium The hair or stereocilia of outer hair cells are embedded in it The vibrations of basilar membrane cause the shearing forces between the tectorial membrane and hair cells It is these forces that stimulate the outer hair cells as well as the inner hair cells, which transduce sound energy in to electrical impulse The nerve fibers supplying the hair cells (peripheral processes of the bipolar neurons of spiral ganglion) carry the nerve impulse to the cochlear nerve The hair cells also receive efferent olivocochlear fibers from the superior olivary nucleus via the Oort’s anastomosis These fibers are believed to modulate the function of inner hair cells through inhibitory influence of outer hair cells 51 Section 04 458 Head and Neck Embryologic insight Membranous Labyrinth The ectodermal thickening in the region of hindbrain (in the vicinity of future first branchial cleft) forms the auditory or otic placode in the fourth week of intrauterine life The placode sinks beneath the surface to form otocyst or auditory vesicle, from which different parts of membranous labyrinth develop The inner ear achieves adult size by the sixteenth week of intrauterine life Congenital Anomalies i Michel aplasia is complete absence of inner ear ii Maternal infection with rubella (German measles) during the sixth to ninth weeks of gestation may lead to congenital deaf-mutism due to destruction of organ of Corti Drugs like streptomycin, thalidomide and chloroquine given to the pregnant woman during early pregnancy may cross the placental barrier and damage the cochlea 52 CLINICOANATOMICAL PROBLEMS AND SOLUTIONS nerve point of the neck The nerves related are, spinal accessory, medial, intermediate and lateral supraclavicular nerves and great auricular, lesser occipital and transverse cutaneous nerve of neck CASE A one-year-old girl was brought to the hospital for check up Examination revealed that the head of the girl was tilted towards right shoulder and her face was turned towards left and upwards History revealed that the baby was delivered using forceps during which she suffered soft tissue injury in the neck Describe cervical sinus and name its anomalies found along the anterior margin of this muscle Questions and Solutions Name the muscle of the neck (with its side) involved in birth injury in this case Right sternomastoid muscle What is the clinical condition called? Torticollis or wry neck Give the attachments and nerve supply of the involved muscle The sternal head arises from anterior surface of manubrium sterni and clavicular head from superior surface of the medial third of the clavicle The muscle is inserted into lateral surface of the mastoid process and lateral half of superior nuchal line It is supplied by spinal accessory nerve Which blood vessel is present between the two heads of origin of this muscle? Internal jugular vein is present in the interval between its two heads of origin This space is called lesser supraclavicular triangle Name the nerves related to the posterior margin of this muscle About midpoint of the posterior margin of the sternomastoid seven nerves, bunch together Hence, it is called During the branchial phase of the embryo (4th–5th weeks) pharyngeal clefts (surface depressions) give uneven appearance to the neck Subsequently, the ectoderm covering the second arch grows down faster overlapping the succeeding clefts This overhanging ectoderm fuses distally with epicardial ridge The ectoderm-lined closed space is called the cervical sinus Normally, the sinus soon obliterates The branchial cyst forms if the sinus obliterates partially The failure of the sinus to close distally forms a fistula The branchial fistulae and cysts appear along the anterior margin of sternomastoid muscle The cyst is usually located at the angle of mandible and the fistula is located at the lower end of sternomastoid CASE A 12-year-old boy fell from a tree and suffered injury on the forehead near the hairline on the right side Since there was severe bleeding the boy was rushed to the casualty, where the wound was sutured to control bleeding After third day, the boy was brought back to the hospital because his both eyes were black Questions and Solutions Explain with the help of a diagram the communication between the upper eyelids and the scalp Refer to Figure number 37.2, which shows the continuity of subaponeurotic space with the upper eyelids This space is closed posteriorly at the bony attachment of Section 04 460 Head and Neck the occipitalis Laterally, it is closed by the attachment of galea aponeurotica at the superior temporal lines Anteriorly, the space extends into the upper eyelids because of absence of bony attachments of the frontalis muscles The blood from the upper eyelids may enter the lower ones also and after clotting, it imparts black color to the eyes Which layer of scalp contains nerves and blood vessels? Superficial fascia or dense connective tissue layer contains nerves and blood vessels Why scalp wound bleed profusely? There are two reasons for this There are rich anastomoses between arteries of two sides hence they bleed from two ends when cut The cut ends of the arteries not contract because their walls are pulled by the dense connective tissue to which they are adherent Name the sensory and motor nerves of the anterior quadrant of scalp There are four sensory nerves (supratrochlear, supraorbital, zygomatico-temporal and auriculotemporal) The only one motor nerve is temporal branch of facial nerve Give anatomical reason for the movement of swelling with swallowing Draw a diagram to show the parts and relations of the gland Emissary veins pass through this space These veins are peculiar in that they connect the extracranial veins with intracranial venous sinuses and they are valveless These veins may be torn in traction injuries of the scalp and give rise to bleeding in the subaponeurotic space The emissary veins may act as conduits for spread of infection from the scalp to the meninges or brain The thyroid gland has two capsules, true and false The veins pierce the capsules and form venous plexus underneath the true capsule During thyroidectomy (surgical removal of gland) the veins are ligated and the gland is removed along the intercapsular plane to avoid injury to venous plexus Give the surgical importance of the arterial supply of the gland The superior thyroid artery is in close relation to external laryngeal nerve except at the upper pole of the gland Hence, the surgeon ligates this artery as close to the upper pole of gland as possible The inferior thyroid artery is closely related to recurrent laryngeal nerve near the lower pole of the gland Hence, the surgeon ligates this artery as much away from the lower pole as possible Write briefly on the development of the gland CASE A 34-year-old woman came to the hospital with a nodular swelling in the midline of the neck The swelling moved with swallowing On examination, it was found that she had slight tremors on outstretched hands, her pulse rate was 100 per minute and there was slight bulging of the eyes Blood levels of T3 and T4 were high and TSH level was low Questions and Solutions Refer to Figure 43.1 What is the clinical importance of the capsules of the gland? Which vessels pass through the subaponeurotic layer of scalp and what is their clinical importance? The pretracheal fascia forms the false capsule A thickening of the false capsule (ligament of Berry) connects the lobe of thyroid to the cricoid cartilage Because of this firm anchorage to the laryngeal cartilage the thyroid moves with swallowing i The follicular cells of the thyroid gland develop from the endodermal thyroid diverticulum, which begins in the pharyngeal floor at the site of foramen cecum The diverticulum becomes the thyroglossal duct, which passes downward through the developing tongue The duct has peculiar relation to the hyoid bone At first, it passes in front of the bone then winds round it to come down to pass in front of the thyroid cartilage and cricoid arch Having reached below they cricoid cartilage by around weeks, the lower end of the duct divides to form lateral lobes and the connection is retained as isthmus ii The parafollicular cells (C cells) develop from cells of caudal pharyngeal complex (ultimobranchial body) Name the gland that is responsible for midline swelling in the neck and the clinical condition CASE Two days following total thyroidectomy the patient experienced paraesthesia (altered sensation) around the mouth Thyroid gland is enlarged The clinical condition is toxic goiter or thyrotoxicosis Clinicoanatomical Problems and Solutions 461 finger inside the oral cavity and the thumb outside in front of the angle of the mandible Questions and Solutions Questions and Solutions Which salivary gland is palpated in this case? Name the clinical condition giving its physiological basis Tetany is the clinical condition due to deficiency of parathormone Which structures were inadvertently removed by the surgeon during thyroidectomy? The parathyroid glands were inadvertently removed along with thyroid gland as parathyroid glands are intimately related to thyroid gland on posterior aspect of their lateral lobes How does the surgeon identify these structures during thyroid surgery? Glandular branches of inferior thyroid artery are the surgeon’s guide to parathyroid glands At times, the surgeon resorts to identification by frozen section biopsy (during operation) Give the number and position of these structures There are two pairs of parathyroid glands (superior and inferior) They are located posterior to the thyroid gland in side the false capsule The superior pair is located at the level of junction of upper and middle one-third of the thyroid lobe The inferior pair is located near the lower end of the thyroid gland Mention their development The superior parathyroid glands develop from the endoderm of fourth pouch and the inferior parathyroid from the endoderm of third pouch The submandibular salivary gland is palpated by bidigital examination Name the parts of this gland and the muscle that separates these parts The submandibular gland has larger superficial part and smaller deep part The two parts are continuous with each other around the posterior free margin of mylohyoid muscle What is the length of its duct and where does it open? The submandibular duct (Wharton’s duct) is cm long It opens into the floor of the mouth at the summit of the sublingual papilla by the side of the frenulum linguae Which is the narrowest part of the duct? The submandibular duct is narrowest at the oral orifice Name the radiological investigation done to visualize the duct system of salivary glands Sialography Draw a diagram of secretomotor innervation of this gland Refer to Figure 41.10 CASE 6 Name the cells in parathyroid glands and which one is the source of parathormone (PTH)? The cells in parathyroid are called chief cells and oxyphil cells The chief cells of parathyroid glands secrete parathormone A middle-aged woman complained of pain, tingling and numbness along the medial side of the right forearm and hand She had difficulty in gripping the objects firmly in the right hand On examination, the radial pulse was weaker on the right side compared to the left Adson’s test was positive on right side Plain X-ray of chest showed cervical rib on the same side To relieve the symptoms the cervical rib was removed along with its periosteum CASE Questions and Solutions A patient had swelling below the lower jaw on the right side The swelling increased in size during eating The surgeon inspected the sublingual papilla in the floor of the mouth and did a bidigital examination by putting index What is the morphology of the cervical rib? A cervical rib is the enlarged costal element of the 7th cervical vertebra (costotransverse bar, anterior Chapter followed by tingling and numbness in fingers and toes and painful cramps in hands and feet Blood calcium level was found to be very low 52 Section 04 462 Head and Neck tubercle and anterior root of the transverse process form the costal element) Which structures are likely to be compressed by the cervical rib? The neurovascular structures, which are related to the superior surface of the first rib, namely, third part of subclavian artery and lower trunk of brachial plexus on right side Which of these structures is affected? How the branches of affected structure leave from the gland? Explain the patient’s inability to hold the objects in the hand Because of compression of lower trunk of branchial plexus the motor supply of intrinsic muscles of hand (C8 and T1 segment of spinal cord) via ulnar and median nerves is affected Give the extent of the compressed artery on the side of the lesion The right subclavian artery is one of the terminal branches of the brachiocephalic trunk It extends from the sternoclavicular joint to the outer margin of the first rib CASE Questions and Solutions Name the gland that is swollen Parotid gland Name the major structures inside this gland The major structures inside the parotid gland are facial nerve, retromandibular vein and external carotid artery (their order being superficial to deep) Inability to close the eye is due to paralysis or weakness of orbicularis oculi Inability to blow the cheek is due to weakness or paralysis of buccinator muscle Write briefly on the duct of this gland If the periosteum is left behind during surgical removal of the rib its inner cellular layer will regenerate the rib A 58-year-old man presented with a complaint of rapidly growing painful swelling on the face below the ear lobule on the left side On examination, the left ear lobule was found to be lifted by the swelling There was inability to close the left eye and to blow the cheek The angle of mouth was deviated to the right side The facial nerve divides into five branches inside the parotid gland The temporal branch leaves from its base at upper end The zygomatic, buccal and mandibular branches leave from the anterior margin The cervical branch leaves from its apex at the lower end What is the reason for the inability to close the right eye and inability to blow the cheek? Explain why the cervical rib is surgically removed along with its periosteum? Facial nerve The parotid duct (Stensen’s duct) collects serous secretions of the gland It is about cm long It leaves the gland from its anterior margin and travels forward on the masseter muscle Its superior relations are, upper buccal branch of facial nerve, transverse facial artery and accessory parotid gland At the anterior margin of the masseter, the duct turns inwards to pierce in succession the buccal pad of fat, buccopharyngeal fascia, buccinator and buccal mucosa It opens in the vestibule of the oral cavity opposite the crown of upper second molar tooth What is the clinical importance of fascial capsule of this gland? The fascial capsule of the parotid gland is derived from the deep fascia of neck It is called parotido-masseteric fascia It is very tough and unyielding Therefore, if there is parotid swelling it is intensely painful (the tough fascia does not allow the swelling to expand) The parotid abscess unlike abscess in other locations does not show induration and fluctuation CASE A 24-year-old woman survived the knife attack by robbers but was injured in the neck She was rushed to the hospital because of profuse bleeding from the neck injury On examination, it was found that there was no deep cut in the neck She was breathless, cyanotic and had low blood Clinicoanatomical Problems and Solutions 463 CASE What is the anatomical reason for the inability of the vein to contract after injury? A 76-year-old woman noticed a hard painless lump in the right side of her neck On examination, the lump was found to be an enlarged lymph node in the posterior triangle An open excision biopsy was performed Two days following the procedure, the patient complained of difficulty in combing her hair with right hand The surgeon confirmed the loss of hyperabduction on right side However, the surgeon noted that she was able to turn her face to the left side Questions and Solutions Name the vein that is injured and exposed to atmospheric air The external jugular vein is injured The external jugular vein is injured at the point, where it pierces the investing layer of deep cervical fascia The wall of the vein is adherent to the fascia hence its lumen remains patent The negative intrathoracic pressure sucks the atmospheric air into the vein What is the cause of churning and splashing sound in the heart? The atmospheric air that enters the external jugular vein forms venous air embolus, which travels via the subclavian vein, brachiocephalic vein and superior vena cava to the right atrium and then to right ventricle The mixing of blood and air in right side of heart produces churning and splashing sounds Which nerve in the roof of posterior triangle is injured during the biopsy procedure? Spinal accessory nerve on right side Name the muscle that is paralyzed Trapezius of right side Name the muscle that is supplied by the same nerve but spared in this patient Sternomastoid right side What is the fatal complication of this condition? What is the anatomical basis of asking the patient to turn the face to the left side? The air embolus enters the pulmonary trunk and reaches the lungs causing fatal pulmonary embolism Which immediate first aid measure can prevent entry of air into this vein? Application of firm pressure (compression) on the bleeding point until the suturing is done Describe the formation, course and termination of this vein The external jugular vein is formed by the union of posterior division of retromandibular vein and posterior auricular vein just below the parotid gland The vein courses downwards on the anterior surface of sternomastoid muscle being covered with skin, superficial fascia and platysma It pierces the investing layer of deep cervical fascia in the posterior triangle at the posterior border of sternomastoid to cm above clavicle Having entered the subclavian triangle, it crosses the brachial plexus and third part of subclavian artery to join the subclavian vein behind the middle of the clavicle This is to test the function of right sternomastoid muscle Name the boundaries and subdivisions of posterior triangle of neck i Anterior boundary is formed by posterior margin of sternomastoid muscle ii Posterior boundary is formed by anterior margin of trapezius muscle iii The base is formed by the middle-third of the clavicle iv The apex is located superior nuchal line of the occipital bone between the attachments of the trapezius and sternomastoid v Fascial roof is the investing layer of deep fascia of neck covered by superficial fascia and skin vi The muscular floor is covered by fascial carpet of prevertebral fascia The muscles in the floor from below upwards are scalenus medius, levator scapulae, semispinalis capitis and splenius capitis Subdivisions The inferior belly of omohyoid muscle divides the posterior triangle into: Chapter pressure On auscultation, it was observed that churning and splashing sounds masked the normal heart sounds The physician suspected venous air embolism 52 Section 04 464 Head and Neck i An upper occipital triangle ii A lower subclavian or supraclavicular triangle (omoclavicular triangle) Give the importance of lower subdivision of posterior triangle in clinical examination of the patient The subclavian triangle is important in the clinical examination of a patient This region is inspected from the front but palpated from behind i The trunks of the brachial plexus can be felt on deep palpation behind and just above the middle third of the clavicle ii For brachial plexus block the anesthetic agent is injected around the trunks just above the midpoint of clavicle iii Injuries to the trunks of the brachial plexus are commonly due to trauma at birth or due to motorcycle accidents or stab wounds Injury to the upper trunk causes Erb’s palsy and injury to the lower trunk results in Klumpke’s palsy iv The supraclavicular lymph nodes are palpated at this site The left supraclavicular nodes are enlarged in cancer of the stomach, colon or testis These nodes are called Virchow’s nodes If the left supraclavicular lymph nodes are enlarged in cancer of stomach it is called Troisier’s sign v The subclavian vein at this site is often used for central venous access Through the central venous catheter it is safe to give powerful drugs and it can also be used for long-term feeding in a serious patient (in cases where all the peripheral veins are thrombosed or collapsed) vi The pulsations of the subclavian artery can be felt on deep pressure behind the middle-third of the clavicle The bleeding due to severe lacerations of the brachial or axillary artery can be controlled by compressing the third part of the subclavian artery downward and backward against upper surface of the first rib CASE 10 A 45-year-old man living in high altitude in Himalayas developed a pulsatile swelling in the left side of the neck He sought medical assistance due to frequent episodes of fainting Examination revealed that the swelling was located in the carotid triangle and it moved transversely but not vertically A provisional diagnosis of potato tumor of neck was made Questions and Answers Give the boundaries and contents of carotid triangle The carotid triangle presents three boundaries (anterosuperior, anteroinferior and posterior), floor and roof The anterosuperior boundary is formed by posterior belly of digastric and the stylohyoid muscles The anteroinferior boundary is formed by superior belly of omohyoid muscle The posterior boundary is formed by anterior margin of the sternomastoid muscle The floor consists of parts of four muscles, hyoglossus and thyrohyoid anteriorly and middle and inferior constrictors of the pharynx posteriorly The roof consists of skin, superficial fascia with platysma and the investing layer of deep fascia of neck Contents i The bifurcation of common carotid artery into internal and external carotid arteries takes place at the level of upper margin of thyroid cartilage The internal carotid, external carotid and common carotid arteries are inside the carotid sheath along with internal jugular vein and vagus nerve The external carotid artery gives five of its branches in the triangle The carotid sinus is a localized dilatation at the bifurcation of common carotid artery The carotid body is small reddish structure containing glomus cells and ganglion cells behind the bifurcation ii The vagus nerve passes vertically downward in posterior position inside the carotid sheath It gives superior laryngeal nerve, which divides into internal and external laryngeal nerves here iii The spinal accessory nerve crosses the superolateral angle of the carotid triangle to enter the sternomastoid muscle iv The hypoglossal nerve enters the carotid triangle deep to the posterior belly of digastric between the internal jugular vein and internal carotid artery It crosses superficial to internal carotid artery, external carotid artery and the loop of the lingual artery from lateral to medial side Here, the nerve gives off superior root of ansa cervicalis and a branch to thyrohyoid muscle The ansa cervicalis is formed in the anterior wall of the carotid sheath v The cervical sympathetic chain extends vertically posterior to the carotid sheath in front of the prevertebral fascia vi The jugulo-digastric and jugulo-omohyoid lymph nodes are located in the vicinity of the internal jugular vein Clinicoanatomical Problems and Solutions 465 Describe the opening of this air sinus into nasal cavity Carotid body What is the location of this structure? The carotid body is located posterior to bifurcation of common carotid artery What is the dilatation of common carotid artery at its bifurcation called? Carotid Sinus What are the effects of compression of this dilated part by the potato tumor? It precipitates an attack of carotid sinus syndrome The cardinal signs of this syndrome are fainting, hypotension and bradycardia Give the main innervation of this dilated part The maxillary sinus opens hiatus semilunaris of the middle meatus of the nasal cavity by an opening that is located high up on its medial wall The high location of the opening does not favor natural drainage Moreover, the position of the opening in hiatus semilunaris compared to opening of the frontal sinus favors drainage from the frontal to the maxillary sinus This is the reason maxillary sinus is described as reservoir of frontal sinus Which route is used for antral puncture for drainage of pus from this sinus? Accumulation of pus in the maxillary sinus is drained by a method called antral puncture, which is done through the inferior meatus of nasal cavity Name the nerves closely related to this sinus The carotid sinus is innervated by sinus branch of glossopharyngeal nerve The infraorbital nerve travels in the roof The anterior superior alveolar nerve runs in a canal in the anterior wall The posterior superior alveolar nerve is related to posterior wall The pain due to sinusitis may be referred to the upper teeth and face CASE 11 A 52-year-old man with history of chronic smoking came to the ENT consultant with complaints of recurrent sinusitis, weight loss and severe pain in upper teeth and right cheek On examination, it was noted that his right cheek was swollen and there was proptosis of right eye CT scan confirmed presence of growth in the paranasal air sinus Questions and Solutions Name the sinus involved Questions and Solutions Which neurons are affected in herpes zoster of ophthalmic nerve? Maxillary air sinus Name the structures involved if the growth in this sinus spreads anteriorly, medially, posteriorly and upwards CASE 12 A man presented in the hospital with painful vesicles in the area of distribution of ophthalmic division of the trigeminal nerve due to herpes zoster (shingles) If the growth spreads anteriorly it invades the soft tissues of the cheek (causing swelling of cheek) If it spreads medially it invades the nasal cavity Posterior spread leads to infiltration into infratemporal and sphenopalatine fossae Upward spread leads to infiltration into the orbit Pseudounipolar neurons in the trigeminal ganglion are involved in herpes zoster Where does the ophthalmic nerve begin? The ophthalmic nerve begins in the trigeminal ganglion in the middle cranial fossa Where does the ophthalmic nerve divide? Name its terminal branches The ophthalmic nerve courses in the lateral wall of the cavernous sinus, where it divides into nasociliary, frontal and lacrimal nerves Chapter Name the structure in carotid triangle that causes potato tumor of neck in people exposed to hypoxic atmosphere (high altitudes) 52 Section 04 466 Head and Neck How the terminal branches leave the cranium? Which is the tonsillar lymph node? The lacrimal, frontal and nasociliary leave the cranium to enter the orbit via superior orbital fissure Which of the terminal branches crosses the optic nerve in the orbit? The jugulo-digastric lymph nodes are called tonsillar nodes Name the components of Waldeyer’s ring The nasociliary nerve crosses the optic nerve from lateral to medial inside the orbit Lingual tonsils, palatine tonsils, tubal tonsils and pharyngeal tonsil are the components of Waldeyer’s ring Describe the course and distribution of this terminal branch Name the epithelium lining the medial surface of the tonsil Give reason for its pitting appearance Refer to chapter 46 CASE 13 A 10-year-old boy came to the hospital with a history of recurrent attacks of sore throat On inspection of the oropharynx, the palatine tonsils almost touched each other in the midline Questions and Solutions The medial or pharyngeal surface of tonsil is lined by stratified squamous nonkeratinized epithelium The epithelium dips into the substance of the tonsil as tonsillar crypts The openings of about 15 to 20 crypts on the medial surface give it a pitted appearance Write briefly on peritonsillar space What is crypta magna? A deep tonsillar crypt located near the upper pole is known as crypta magna or intratonsillar cleft Give its developmental significance? It is the remnant of second pharyngeal pouch Name the main structures forming tonsillar bed The pharyngobasilar fascia, superior constrictor muscle and the buccopharyngeal fascia form the bed of the tonsil Describe the arterial supply of tonsil The tonsil is richly supplied with following arteries: i Dorsal lingual branch of lingual artery ii Ascending palatine branch of facial artery iii Descending palatine branch of ascending pharyngeal artery iv Tonsillar branch of facial artery (main tonsillar artery) v Greater palatine branch of maxillary artery Which nerve is in danger during tonsillectomy? The glossopharyngeal nerve is in danger The submucosa in relation to the lateral surface of tonsil is known as peritonsillar space It separates the tonsillar hemicapsule from the tonsillar bed The peritonsillar space is filled with areolar tissue and the paratonsillar vein passes through it Since the plane of dissection passes through this space during tonsillectomy (surgical removal of tonsil) the paratonsillar vein is likely to injure causing postoperative bleeding Pus accumulates in this space in chronic tonsillitis resulting in abscess formation, which is known as peritonsillar abscess or quinsy CASE 14 A student yawned widely during afternoon anatomy lecture class To his dismay he could not close his mouth His jaw was stuck Questions and Solutions Name the joint that is dislocated Temporomandibular joint Give the type of this joint and name the bones taking part in it It is a bicondylar type of synovial joint Bones taking part in it are the condyle of the mandible and the mandibular fossa of squamous temporal bone Clinicoanatomical Problems and Solutions 467 Name the parts of rima glottis The mandible is mobile Name the parts of the articular disc and the muscle attached to the disc From anterior to posterior the parts are, anterior extension, anterior thick band, intermediate zone, posterior thick band and bilaminar zone The lateral pterygoid muscle is inserted into it Name the movements of the joint and the muscles responsible for them Elevation and depression (opening the mouth), protraction and retraction and chewing or side-toside movements take place in the joint For muscles of mastication refer to chapter 45 Which part of the ear is a close relation of this joint? Bony part of external acoustic meatus is closely related to the joint How is the anterior dislocation of the TMJ reduced? The mandible is depressed posteriorly by exerting pressure on lower molar teeth with the help of both thumbs This will overcome the spasm of pterygoid muscles Simultaneously, the assistant elevates the chin so that head of mandible is pushed in the fossa CASE 15 A 4-year-old child swallowed a shirt button Since the child began to suffocate she was rushed to the hospital, where on X-ray examination impaction of foreign body in the larynx was confirmed Questions and Solutions Which is the narrowest part of laryngeal cavity? The vocal folds extend from the vocal process of arytenoid to inner surface of the middle of thyroid angle Each fold contains vocal ligament and vocalis muscle What is the color of the vocal folds? Which muscle is called the safety muscle of larynx and why? Posterior cricoarytenoid muscle is the safety muscle of the larynx It is so called because being the only abductor of the vocal folds it keeps the rima glottis open to allow air to enter the lungs Enumerate the cartilages of the larynx and describe the leaf-shaped cartilage The skeleton of the larynx consists of three unpaired and three paired cartilages The unpaired cartilages are the epiglottis, the thyroid and the cricoid The paired cartilages are the arytenoid, cuneiform and the corniculate The epiglottis is the leaf shaped cartilage Histologically, it is elastic type of cartilage It forms the anterior wall of the laryngeal inlet Its upper end projects upwards and backwards behind the hyoid bone and the base of tongue Its upper end is free and broad and lower end is narrow and pointed It has anterior and posterior surfaces and two lateral margins The upper part of anterior surface is covered with stratified squamous epithelium and is connected to the tongue by three mucosal folds, the median and lateral glossoepiglottic folds The lower part of anterior surface, which is devoid of mucosa, is connected to hyoid bone by hyoepiglottic ligament Below this attachment, the anterior surface is separated from the thyrohyoid membrane by a space called pre-epiglottic space, which is filled with fat Each lateral margin provides attachment to the aryepiglottic fold in its lower part The lower end is attached to inner surface of thyroid angle by thyroepiglottic ligament The mucosa on the posterior surface of epiglottis is of respiratory type in the lower part and stratified squamous type in the upper part and is pitted by small mucous glands The branches of internal laryngeal nerve pierce the mucosa on this surface Rima glottis is the narrowest part of laryngeal cavity Give the attachments and contents of the vocal folds? The parts of rima glottis are, anterior three-fifth intermembranous and posterior two-fifth intercartilaginous The color of the vocal folds is pearly white Name the emergency operation for restoring the airway in case of blocked glottis Tracheostomy Which anatomical layers in the midline of neck are encountered during surgical approach to trachea? The skin, superficial fascia with platysma, investing layer of deep cervical fascia, infrahyoid group of strap muscles and pretracheal fascia are encountered in succession from superficial to deep Chapter Which bone is mobile in this articulation? 52 Section 04 468 Head and Neck Single Best Response Type MCQs Which of the following lymph nodes are called Virchow nodes? a Right supraclavicular b Left supraclavicular c Right infraclavicular d Left infraclavicular The cutaneous branch of posterior primary ramus of C2 is called a Lesser occipital b Greater occipital c Posterior auricular d Great auricular Which of the following veins pierces the fascial roof of posterior triangle? a External jugular b Subclavian c Transverse cervical d Suprascapular Which structure is located behind the prevertebral layer of cervical fascia? a Sympathetic chain b Carotid sheath c Subclavian artery d Subclavian vein Following are the derivatives of third arch mesoderm except: a Stylopharyngeus b Palatopharyngeus c Lower half of the body of hyoid bone d Greater horn of hyoid bone 10 The branches of subclavian artery supply the following structures except a Thyroid gland b Second intercostal space c Submandibular gland d Supraspinatus Superior parathyroid glands develop from a Mesoderm of third arch b Mesoderm of fourth arch c Endoderm of third arch d Endoderm of fourth arch 11 The arcuate eminence is produced by a Anterior semicircular canal b Posterior semicircular canal c Lateral semicircular canal d Vestibule The ligament of Berry fixes the thyroid gland to a Thyroid cartilage b Cricoid cartilage c First tracheal ring d Hyoid bone 12 The following nerve hooks round the spinal accessory nerve a Great auricular b Greater occipital c Lesser occipital d Supraclavicular Hypoglossal nerve crosses the following arteries (in the neck) anteriorly except a Occipital b Lingual c Internal carotid d External carotid The absence of tears is due to lesion in a Trigeminal ganglion b Ciliary ganglion c Sphenopalatine ganglion d Superior cervical sympathetic ganglion 13 The philtrum of the upper lip develops from a Lateral nasal process b Globular process c Maxillary process d Fusion of maxillary and globular processes 14 The suprasternal space contains all except a Interclavicular ligament b Jugular arch c Clavicular head of sternomastoid d Lymph node Clinicoanatomical Problems and Solutions 469 23 The tympanic membrane develops from a Ectoderm and endoderm of first cleft membrane only b Ectoderm and mesoderm of first cleft membrane c All the germ layers of second cleft membrane d All the germ layers of first cleft membrane 16 Which of the following pairs correctly describes the sources of parathormone and calcitonin? a Oxyphil and chief b Parafollicular and follicular c Parafollicular and follicular d Chief and parafollicular 24 The paralysis of left genioglossus muscle causes a Deviation of the tongue to the right on protrusion b Total inability to protrude the tongue c Deviation of the tongue to the left on protrusion d Loss of taste sensations on the left half of tongue 17 The external carotid artery divides at the level of a Superior margin of thyroid cartilage b Angle of mandible c Neck of mandible d Condyle of mandible 18 The safety muscle of the tongue is a Intrinsic b Hyoglossus c Genioglossus d Styloglossus 19 Which of the following laryngeal cartilages is a complete ring? a Epiglottis b Thyroid c Arytenoid d Cricoid 20 The cornea is supplied by following nerves a Supraorbital b Long ciliary c Short ciliary d Infraorbital 21 Which cranial nerve gives sensory supply to middle ear? a Trigeminal b Facial c Glossopharyngeal d Vagus 22 Which of the following form the inner nuclear layer of retina? a Bipolar b Rods and cones c Ganglion d Amacrine 25 Piriform fossa is located in a Laryngeal inlet b Laryngopharynx c Oropharynx d Nasopharynx 26 The medial wall of orbit is formed by the following bones except a Lamina papyracea b Lacrimal bone c Lesser wing of sphenoid d Frontal process of maxilla 27 What is true about nasopharynx? a Is always patent b Is located below the soft palate c Choanae open into its posterior wall d Is connected to the inner ear 28 Which latero-medial sequence of the following regions is correct? a Pterygopalatine fossa-sphenopalatine foramen nasal cavity infratemporal fossa b Sphenopalatine foramen-nasal cavity- infratemporal fossa-pterygopalatine fossa c Infratemporal fossa-pterygopalatine fossa-sphenopalatine foramen-nasal cavity d Sphenopalatine foramen-infratemporal fossa-nasal cavity-pterygopalatine fossa 29 The circumvallate papillae develop from a Hypobranchial eminence b Lingual swellings c Tuberculum impar d Second arch endoderm 30 The scala media and scala vestibuli are separated by a Basilar membrane b Tectorial membrane Chapter 15 Which one is not the tributary of internal jugular vein? a Inferior petrosal sinus b Superior thyroid vein c Middle thyroid vein d Inferior thyroid vein 52 Section 04 470 Head and Neck c Vestibular membrane d Stria vascularis c Elevation in medially rotated eyeball d Depression in medially rotated eyeball 31 Constriction of pupil results due to lesion of all the following except a Ciliary ganglion b Internal carotid nerve c Middle cervical sympathetic ganglion d First white ramus communicans 37 The triangle in which superior limb of ansa cervicalis originates from hypoglossal nerve is a Carotid b Muscular c Occipital d Digastric 32 Which of the following nerves is outside the common tendinous ring? a Oculomotor b Trochlear c Abducent d Nasociliary 38 A 30-year-old woman came to the doctor with the complaint of severe pain in nose, upper lip and upper teeth, which was triggered by face washing Which of the following nerves is responsible for the symptoms? a Facial b Maxillary c Mandibular d Great auricular 33 Killian’s dehiscence is seen in posterior wall of a Oropharynx b Larynx c Nasopharynx d Laryngopharynx 34 Medial wall of the middle ear shows a Pyramid b Promontory c Canal for tensor tympani d Canal for chorda tympani 35 A knife wound just behind the sternomastoid and above the clavicle caused numbness of skin over the clavicle and acromion Which of the following cutaneous nerves is injured? a Lesser occipital b Transverse cervical c Great auricular d Supraclavicular 36 Which movement is tested for inferior oblique muscle of eyeball? a Depression in laterally rotated eyeball b Elevation in laterally eyeball 39 What is the vertebral extent of thyroid gland? a C3 to C6 b C4 to C7 c C6 to T2 d C5 to T1 40 The internal carotid artery pulsations can be felt through a Carotid triangle b Below mastoid process c Tonsillar fossa d Behind last molar tooth KEY TO MCQs 1-b, 2-a, 3-b, 4-d, 5-b, 6-a, 7-c, 8-b, 9-c, 11-d, 12-c, 13-b, 14-c, 15-d, 16-d, 17-c 19-d, 20-b, 21-c, 22-a, 23-d, 24-c, 25-b, 27-a, 28-c, 29-a, 30-c, 31-a, 32-b, 33-d, 35-d, 36-c, 37-a, 38-b, 39-d, 40-c 10-c, 18-c, 26-c, 34-b, ... side) 11 0 • Boundaries of Upper Triangular Space 11 0 • Boundaries of Lower Triangular Space 11 0 • Axillary Nerve 11 1 • Suprascapular Nerve 11 1 Pectoral Girdle 11 3 • Special Features .. .Clinical Anatomy (A Problem Solving Approach) Clinical Anatomy (A Problem Solving Approach) Second Edition Neeta V Kulkarni md Professor of Anatomy Dr Somervell Memorial CSI Medical College... Thiruvananthapuram for providing the image of peau d’ orange I am thankful to Dr Chandrakumari and Dr Vilasini Anatomy Department, Gokulam Medical College, Thiruvananthapuram, Kerala, India, for