Gross Anatomy Forum Head

HEAD FORUM 2007

1. What is the significance of the arachnoid granulations? Where are they located?
A: Aggregations of arachnoid villi are called arachnoid granulations and drain cerebral spinal
fluid (CSF) into the venous system. They are most abundant in the superior sagittal sinus.

2. Which major vessel supplies the major arterial supply to the dura?
A: The middle meningeal artery is the most clinically significant as it can be damaged with head
injuries such as those to the pterion of the skull. Other arteries that supply the dura are the
anterior meningeal, posterior meningeal, accessory meningeal, internal carotid artery, maxillary
artery, ascending pharyngeal artery, and occipital artery.

3. Identify the major sensory nerves that supply the dura.

A: Trigeminal nerve and vagus nerve, along with C1-C3 and sympathetic branches. Since the
trigeminal nerve is involved, stretching of the dura could refer pain to the facial region
(headache). Tentorium of the dura is V1 (ophthalmic).

4. In which layer of the scalp do the vessels travel? Muscles located? Danger layer?
A: The vessels are within the (dense) connective tissue layer, layer 2. The muscles are found
within the aponeurotic layer, layer 3. These muscles are innervated by CN VII. The “danger
layer” is the loose areolar layer (loose connective tissue), layer 4.
Vessels in the 2nd layer are held apart in scalp lacerations and bleed profusely due to
anastamoses (arteries bleed from both ends). Infections in the danger layer can spread rapidly
and even into the intracranial venous sinuses via the valveless emissary veins.

5. Identify by landmarks the distribution of CN V to the face.

A: See Image #1. V1 covers the top of the head and forehead including to the tip of the nose. V2
covers the maxillary region of the upper lip. V3 covers from the top of the ear to the jaw, not
including the corner of the jaw. The corner of the jaw is supplied by the great auricular nerve.
Lower eyelid is V2, upper eyelid and eye is V1.

6. Identify the 4 major arteries that contribute to the circulation of the face.
A: Facial artery, maxillary artery, ophthalmic artery, and transverse facial artery (superficial
temporal artery). See Image #2.

7. Identify the course and branches of CN VII after it exits the stylomastoid foramen.
A: See Image #3. After leaving the stylomastoid foramen, the facial nerve passes anteriorly
through the parotid gland and distributes into its branches:
The five terminal branches are temporal, zygomatic, buccal, mandibular, and cervical. These can
be visualized by putting your hand on the side of your face and naming your fingers in order.
Also a posterior auricular branch that does ear muscles.
Great petrosal nerve arises from the nerve at the geniculate ganglion.
Nerve to stapedius supplies the stapedius muscle in the middle ear.
Chorda tympani arises in the facial canal in the posterior wall of the middle ear.
Posterior auricular nerve is muscular branche coming off right after the stylomastoid foramen.

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8. Paralysis of CN VII leads to ________________________.

A: Bell’s palsy

9. Where does the parotid duct open?

A: The vestibule of the mouth upon a small papilla opposite the upper second molar tooth.

10. Identify the important structures that course through the parotid gland.
A: The facial nerve, auriculotemporal nerve, external carotid artery, and retromandibular vein.

11. Identify the muscles which: close the eye, close the mouth, keep food between the teeth.
What is their innervation and embryological origin (pharyngeal arche)?
A: Close eyes: obicularis oculli; facial nerve (zygomatic branch); pharyngeal arch 2
Close mouth; obicularis aurus (and temporalis, masseter, and medial pterygoid); trigeminal
(mandibular branch); pharyngeal arch 1
Food between teeth; buccinator; facial nerve (buccal branch); pharyngeal arch 2

12. Identify muscles that elevate the larynx and pharynx during swallowing.
A: Larynx muscles are the stylopharngeus salpingopharyngeus, and palatopharyngeus.
Also digastric and stylohyoid as they suspend hyoid.
Pharynx muscles are the superior, middle, and inferior constrictors.

13. Identify the muscle which, when it contracts, opens the auditory-pharyngeal tube.
A: Tensor veli palatine (and levator veli palatini)

14. Paralysis of the right levator palatini muscle results in deviation of the uvula to which side?
A: The uvula will deviate toward the unaffected (contralesional) side; so the left.

15. Identify two antagonistic muscles working at the cricothyroid joint.

A: Cricothyroid and thyroarytenoid.

16. Identify the muscle that acts to abduct the true vocal folds.
A: Abduction is done by the posterior cricoarytenoid muscle. Adduction is done by the lateral
cricoarytenoid muscle. Tensing by cricothyroid, relaxing by thyroarytenoid, and approximation
by the transverse arytenoids muscle.

17. Innervation of the larynx is accomplished by which cranial nerve?

A: Intrinsic muscle by the recurrent laryngeal (vagus) nerve, except for cricothyroid muscle
which is innervated by the external branch of the superior laryngeal nerve.

18. Identify the nerve responsible for innervating the majority of the intrinsic muscles of the
larynx. The cricothyroid? The mucosa of the true vocal fold?
A: Recurrent laryngeal nerve. External branch of superior laryngeal nerve. Internal branch of
superior laryngeal nerve.

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19. Identify the muscles of mastication that close the mandible.

A: Temporalis, masseter, and medial pterygoid.

20. Identify the innervation of the muscles of mastication.

A: Trigeminal (mandibular branch); Pharyngeal arch 1 (embryonic)

21. Identify the muscles that are responsible for side-to-side movements of the mandible.
A: Medial and lateral pterygoids.

22. Identify two specific branches of GVE - P cranial nerves whose postganglionic fibers travel
with V3.
A: Chorda tympani nerve via lingual (to submandibular ganglion) and auriculotemporal nerve
(otic ganglion to parotid gland).

23. The lingual and inferior alveolar nerves pass between which two muscles?
A: Medial and lateral pterygoids.

24. Identify the nerve that innervates both the inside and the outside of the cheek.
A: Buccal nerve branch of mandibular nerve (trigeminal nerve).

25. The superior and middle nasal conchae are part of which bone?
A: Ethmoid bone.

26. Identify the 3 components of the nasal septum.

A: Septal cartilage, the vertical plate of the ethmoid (PPE), and the vomer bone. See Image #4.

27. Identify the paranasal sinuses that open into the middle meatus.
A: The maxillary sinus (via hiatus semilunaris), frontal sinuses (via infundibulum), anterior
ethmoidal sinuses (via infundibulum), and middle ethmoidal sinuses (on or above the bulla
ethmoidalis). The posterior ethmoidal sinus goes to the superior meatus.

28. Identify the arteries that form Kiesselbach's plexus (the arterial plexus on the nasal septum).
A: Anterior ethmoid artery, great palatine artery, sphenopalatine artery, and superior labial artery.
About 80% of nose bleeds (epistaxis) arise from Kiesselbach’s area.

29. Identify three major areas to which venous blood of the nasal cavity drains.
A: Cavernous sinus/plexus, facial vein, and pterygoid plexus.

30. Identify the major nerves that supply branches to the nasal mucosa.
A: Olfactory nerves, opthalmic branch of trigeminal nerve via nasociliary, maxillary branch of
trigeminal nerve, nasopalatine, and maybe infraorbital.

31. Identify the cranial nerve and its specific GVE - P branch which provides preganglionic
parasympathetic innervation to nasal mucosal glands.
A: Greater petrosal nerve of CN VII (hitchhiking on CN V2 into PPG and then maxillary branches).
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32. The pterygopalatine ganglion provides postganglionic parasympathetic innervation to which

general areas/structures of the head?
A: Lacrimal gland, nasopharynx, mucosa membrane of oral/nasal cavity.

33. Identify the three major osseous and cartilaginous attachments of tongue musculature.
A: Superior genial spine of mandible (genioglossus), body and greater cornu of hyoid bone
(hyoglossus), styloid process of temporal bone (styloglossus), palatine aponeurosis (palatoglossus).

34. A patient protrudes his tongue and it deviates to the right. Identify the nerve and the general site
of the lesion.
A: Hypoglossal nerve and the ipsilesional side; right side.

35. Identify the nerves that supply SVA fibers to the tongue. GSA fibers. GVA fibers.
A: Muscle movement by hypoglossal nerve. GSA is CN V. GVA is CN IX/X. SVA is CN VII.
Anterior 2/3 of the tongue sensation is lingual branch of mandibular division of trigeminal nerve and
taste is chorda tympani branch of facial nerve.
Posterior 1/3 of tongue sensation and taste is glossopharngeal nerve.
Root of tongue sensation, taste, and movement (palatoglossus) by the vagus nerve.

36. Identify the route by which sublingual nitroglycerin reaches the heart.
A: Sublingual medication enters the sublingual veins to the vena comitantes nervi hypoglossi to the
facial vein to jugular vein. The drugs quickly enter the caval venous circulation and bypass the liver,
which reduces initial breakdown and is useful for drugs with a high first-pass metabolism (e.g.
nitroglycerine). Sublingual administration is also useful for drugs with a displeasing taste (e.g.
nitroglycerine).

37. Where do you locate the deep portion of the submandibular gland?
A: Beneath the mucous membrane of the mouth on the side of the tongue.

38. What structure crosses the submandibular duct twice?

A: Lingual nerve.

39. Describe the route of sympathetic and parasympathetic innervation to the submandibular and
sublingual salivary glands.
A: Parasympathetic innervation is by the facial nerve via the chorda tympani. The postganglionic
fibers come form the submandibular ganglion and go directly to the gland, following lingual nerve.
Sympathetic innervation is indirect via the sympathetic nervous system which regulates secretions
through vasoconstriction of the arteries that supply the glands.

40. Identify the cranial nerve used to adduct the eye.

A: Looking medially (adduction) is medial rectus, CN III

41. Identify the cranial nerve used abduct the eye.

A: Looking laterally (abduction) is lateral rectus, CN VI

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42. Accommodation involves what three actions? By what cranial nerve are they mediated?
A: Accomodation of lens (parasympathetics), convergence of eyes (CN III for medial rectus), and
constriction of pupil (parasympathetics).

43. Identify the innervation of the tympanic membrane.

A: External by auriocotemporal nerve (3/4th) and the auricular branch of the vagus (1/4th). Internal
bympanic branch of glossypharangeal nerve (CN IX).

44. Identify the mucosal innervation of the middle ear cavity.

A: Tympanic plexus of glossypharangeal nerve (CN IX) and sympathetic fibers.

45. What mechanism is provided to keep the middle ear ossicles from over vibrating?
A: The tensor tympani and stapedius muscles dampen the vibrations of the tympanic membrane and
stapes, respectively. Paralysis of these muscles would result in sensitive, or amplified, hearing.

46. Define the terms otosclerosis and hyperacusis.

A: Otosclerosis: A progressively degenerative condition of the temporal bone which can result in
hearing loss. Or, degerenation of the synovial joints between ear ossicles.
Hyperacusis: Over-sensitivity to certain frequency ranges of sound. Someone with this condition
would have difficulty tolerating everyday sounds. It is associated with inner ear damage, CN VII.

47. List and describe the origin, course and importance of the following nerves associated
with the middle ear:
a. Chorda tympani
A: In the middle ear, it traverses the posterior canaliculus; runs in the mucosa over the handle of
the malleus and leaves via the anterior canaliculus.

b. Tympanic branch of IX
A: Supplies the mucosa, tube, and mastoid air cells. Continues as the lesser petrosal nerve.

48. Identify the cranial nerves, including their specific modalities, which are involved in the
following reflexes:
a. Light reflex: In by 2, out by 3
A: CN II; pupils reduce in size in response to light. Direct papillary reflex occurs when light is
shown in an eye and that eye constricts. Consensual papillary reflex occurs when light is shown
in an eye and the other eye constricts.
The pathway includes the retinal ganglion cells and bypasses the lateral geniculate nucleus
(primary visual cortex) and axons go to the Edinger-Westphal nucleus whose axons run along
both the left and right oculomotor nerves. These axons synapse on ciliary ganglion neurons
whose axons innervate the constrictor muscle of the iris.

b. Corneal reflex: In by 5, out by 7

A: Sensory is from the nasociliary branch of the ophthalmic division (V1) of the trigeminal
nerve, sensing a stimulus on the cortex. Motor response is from the facial nerve. A direct and
consensual response can be seen. This reflex helps prevent objects from entering the eye.

c. Gag reflex: In by 9SVA, out by 10SVE

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A: Sensory (afferent limb) is from the glossopharyngeal nerve (CN IX) and motor (efferent limb)
is from the vagus nerve (CN X). This reflex helps prevent choking when an object touches the
back of the throat (oropharynx).

d. Cough reflex: In by 10GVA, out by 10

A: Sensory and motor are from the vagus nerve. Sensory is just superior to the glottis and helps
prevent objects from entering the respiratory tract.

49. List the major branches of the following cranial nerves:

a. CN V1
A: Nasociliary nerve, lacrimal nerve, and frontal nerve.
b. CN V2
A: Middle meningeal nerve, zygomatic nerve, pterygopalatine ganglion branches, posterior
superior alveolar nerve, anterior superior alveolar nerve, middle superior alveolar nerve, inferior
palpebral nerve, and superior labial nerve.
c. CN V3
A: Medial pterygoid nerve, nerve to tensor tympani, nerve to tensor veli palatini, masseteric
nerve, deep temporal nerves, buccal nerve, lateral pterygoid nerve, auriculotemporal nerve,
lingual nerve, inferior alverolar nerve, and mylohyoid nerve.
d. CN VII
A: Greater petrosal nerve, nerve to stapedius, chorda tympani, posterior auricular nerve, and
facial branches (temporal, zygomatic, buccal, marginal mandibular, cervical).
e. CN IX
A: Tympanic, stylopharyngeal, tonsillar, nerve to carotid sinus, and branches to posterior 1/3 of
tongue.
James Lamberg
50. Name the sensory ganglia which house the cell bodies of origin of the sensory components of
the following cranial nerves:
a. CN V
A: Trigeminal (semilunar) ganglion.
Testing the nerve anywhere on the face, neurons are sitting in this ganglion.
b. CN VII
A: Geniculate ganglion.
c. CN IX
(1)
A: Superior glossopharyngeal ganglion. GSA.
(2)
A: Inferior glossopharyngeal ganglion. GVA.
d. CN X
(1)
A: Superior vagal ganglion. GSA.
(2)
A: Inferior vagal ganglion. GVA.

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Muscles of the Head

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Image #1 – Trigeminal Sensory Map

Image #2 – Arteries of the Head and Neck

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Image #3 – Facial Nerve Distribution and Branches

Image #4 – Nasal Septum

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