am wnw.emres.comiquestion/question.php?4=0 MRCS VY Question tof 520 [Aa year old man presents win a tumour atthe posterior third ofthe tongue, To \shich of he following Iymph node groups I most Ike to metastasse? © A. Submontal (© B Submandiouar © © stateral deep conical nodes © D. Contralateral deep cervical nade V. © E Bilateral deop corvial nodes ‘Tumours of the posterior hird ofthe tongue wil typicaly metastasiso arly and bilateral nodalinyalement i welrecogrised, Lymphatic draina of the tongue. + The mphatic drainage ofthe anterior wo thirds ofthe tongue shows only rinimal communication of lymphatics across the midline, so metastasis to the ipstateral nodes is usual + The phat drainage ofthe posterior thd of the tongue have communicating networks, 98a result early bilateral nodal metastases are ‘more common in this area, + Lymphatis from th tp of he tongue usually pass tothe sub mental nodes and from thereto the deep cervical nodes. + Lymphatis from the mid porton of the tongue usualy drain tothe submandibular nodes and then tothe deep cervicalnedes. Mid tongue tumours that are lateral located vl usualy drain to the psatral deep carvcal nodes, those trom more central regions may have bilateral deep cervical nodal ovalvament, Rate question Neat uestion www. omres. com/question/question pho 2% sr 378% ofusar aneweredie Score 100% tv 4"am wnw.emres.comiquestion/question.php?4=0 MRCS VY Question 3 of 520 Seo 10% |A6 year old man is undergoing a superficial parotdectomy for a pleomorphic sow ‘adenoma. Dung the dissection ofthe parotid, whieh ofthe following structures tn wil be encountered Wing most supericial ying most supericialy? ton VY © A Facil neve staat savor © 8. Eden ert atoy senses © ©. Ocepital artery © D. Maxtary artery (© E Retromanalblar voin “The facial nerve is te most superficial structure inthe parte gland. Slghtly ‘deeper to this les the doopy, Parotid gland ‘Anatomy ofthe parotid gland Location ‘Ovting ne mandibular ramus ari and infrir ewar Satvaryduct Crosses the masseter pleces he buasratr and dis agcante ‘he 2nd upper mol oth (Senses dt, twos Facial none (ramonc: The Zebra Buggered My Cat Tempore passingtrough Zygor, Bucs! Nana, Caniea) the lan + Geomalenrta anny 1 Revomandbste se 2 Ainalcomport nen Relations + fetarioe matsear mesa pengold, supra tampa ane ‘matllyaron, facial none shlomaneult aren! Stemocldomasalg, schol bral caoed ater masts process, sod areca ‘Atariatsuppy Branches ofextemel carta aney Venous draage Revomanbaar in Lmahate ——Osep cena nodes asinage Nerve tmervaton | ParssynpabatoSeaetomtar 1 SympaineteSuserior cara gangton 1 Sensory Grete eurcularnene Parasympathetic stimulation produces a water reh, serous salva. Sympathetle ‘stimulation loads to the producton of alow volume, orzyme-ich saliva ato question: eat question www. omres. com/question/question phoam wnw.emres.comiquestion/question.php?4=0 MRCS HX Question 5 of 520 se 887% {878 yar oldman sue to undergo an endarerecomy ofthe neal carai aa fer. Wie of he allowing nervous sutures are mos a isk cing te anal dissection? “ wm ty © A. Recurentlanngeal neve 22% ctusen anor ie KX © B. Sympathetic cna ‘uaston conse V © ©. Hrpoglossl neve © D. Pret nerve © & Ungialnere ‘Theme from May 2011 exam During a carotié endarterectomy the strnocteidomastoid muscle is dissectod, ‘th gation of he comman facial vein and then the internal jugular fe cissacted ‘exposing the common and the intemal caro artes. The nerves at risk during ‘he operation inclu: + Hypoalossal nerve + Greater auricular nerve + Superior laryngeal nerve ‘The sympathetic chain les posteriorly andis less prone to injury inthis procedure, Internal carotid artery ‘The intemal carci artery i formed from the common carotid cppasite the upper border ofthe thyroid catlage.l extends superioty to ener the skull via the ‘caret canal. From the carotid canalit thon passes through the cavernous sus, ‘above vent aivdes int the anteror and midcle cerebral ate Relations in the neck Posterior + Longue caps + Smsatete chen StberorTanngesinatv Medally | + Exxmal care nears) alto onan 1 secendng anneal any Lateraly + Inemal jugular roves postr onirice tl) 1 Vapuenene (nestporeraatoraty 1 riposorea nore Relations in the carotid cans + Intomal carotid plonis + Cochiea an mice ear cavity + Trigeminal ganglon (superar) + Leaves eanalies above the foramen lcerum www. omres. com/question!question phoame _wna-emres.comiquestion/question php sath and relations in the eranial cavity ‘The artery bends sharply forwards inthe cavernous sinus, the aducens nerve Hes ose tots nferolatoral aspect The oculomotor, trochlear,opthalmic and, usually ‘the maxillary nerves ein he atralvallf he sins. Neat the superior otal Fesure it turns posterior and passos postore-modaly to plarco the roof of the ‘cavernous sinus inferior fo the optic nerve. then passes between the optic and ‘oculomotor nerves to terminate below the anterior perforated substance by living into to anterior and mide corebralartris. Branches + Anterior and midale cerebral artery + Ophthaimic artery + Posterior communicating artery + Anterior choroid artery + Moningeal arteries ‘+ Hypophysea arteries Image demonstrating the intemal cart artery ands relationship tothe external ‘carob artery Rate question Neat uestioni912 wnw.emres.comiquestion/question.php?4=0 MRCS VY Questions of 517 Sor: 78% Which ofthe following laryngeal tumours wil nat ypicaly metastasise tothe — 2 cervical lymph nodes? 22% 2X 10% av V © A Gite amt © B Supragbtic 29.9% tena aanors ti z © ©. Sutote Gpeston comet tv ©. Transglotic ay ©. Ayepiaote fo Tho vocal cords have no lmphate drainage and throfor this region sorves a3 lymphatic watershed. The supragotc part drain to tho upper deop cervical nodes through vessels piercing the thyrohyold membrane. The sub glo part ‘rains tothe pre laryngeal pre Yachoal and inferior deep corvial nodes. Tho aryepigotic and vestibular folds have a rion ymphatc drainage and vil rmotasasis early Larynx “Ths larynx in tho anavor part of tho neck athe eves of C3 o CS vertobral bodies. The laryngeal skelaton consists ofa numberof eartlagenaus segments, Thv0o ofthese are pao aryormoid,eotlculate and cuneiform, Three are Single; thyroid, cricid and epglotc. The cco cartilage forms a complete ring {the onl one todo 50). “The laryngeal cavity extonds from the laryngeal nl oth level of the ineror border ofthe cricid cartilage, Divisions ofthe laryngeal av Lanmgealvenle is batasenvstbulr aide ana sparrows oor Traqltccavty _|Eeends tom vocal corde neo borer of he ecldearlge ‘The vocal folds (rue vocal cords) control sound production. The apexf each fold projects medal into the laryngeal caviy. Each vocal fold includes: + Vocal garment + Vocals muscle (most medial pat of hyroarytenoié muscle) “The glottis is composed of he vocal ols, processes and ra glottis. Th lotta isthe narrowest potential ste within the larynx as the vocal cords may be ‘combletely opposed, forming a complete barr Muscles of the larynx muscle | Orn Inwerbon eneraton| Acton Chomrgared [otioningct | anfoeld Lannea Lrat | chofecald | scalar procoss of | Racuront | uc vocal a oapanoie tents "ange ‘Tyoanfenod Poster aspect | Musclarprooass of | Recarent | Rela wea ol tyodcatage | even apnoea Tranmere Mofenodcariige Contaltral ——Recarant Closure of tedcbiave tenis Tapges!_inecarlogonour ytenlse paterine ers Vooale Depression | ecaligamntand Recurent_|Rels posteror beacean lamina welpoeass of lannges!| oes game tno cantons | ayonai cartons lenses erator www. omres.com/question!question pho?Ties _www.emres.comvquestioniquestion php?4=0 pat [roomed Arison pen nfesormaranand ern Trees esl oreo ometinyed layngea Blood supply ‘Arterial supply is via he laryngeal arteries, branches ofthe superior and inferior ‘tyroid arteries. The superior laryngeal artery is closely related to the internal laryngeal nerve. Th inferior laryngeal artery i elated tothe inferior laryngeal nerve. Venous érainage i via superior and infer laryngeal veins, the former raining ito the superior hye vein athe latter raining into the milo {thyroid vein, or thyroid venous plenss. Lymphatic drainage “The vocal cords have no Iymohatic drainage and this watershed. Supra pat | Upper deep ceves nade Subglte pat Prelanngeal ane proactea nodes aninaor deep cena odes ‘The aryopgltc fol and vestbulrflds have a dense plans of mohatcs associated wth them and malignancies at tse sites havea greater propensity {or nodal metastasis, “Topography ofthe larynx Rate question: we. ones, comiquestion’question pha?a=0i912 www. omres. com/question/question pho wnw.emres.comiquestion/question.php?4=0 MRCS VV Question 9 of 513 [An 18 yer ld man is cuting some plants when a small piece of vegetable matter ‘enters his eye. Hs eye becomes watery. Which of te flowing is responsibie for relaying parasympathetic neuronal signals to the lacrimal apparatus? Prerygopslatine ganglion tie ganglion ‘Submandibular ganglion Clary gangton © E None af ho above “The parasymoathetic bres othe lacrimal apparatus trans via the prerygopalatne ganglion. ‘This question thome has oocurre frequently in the exam. Lacrimal system Lacrimal gland Consists ofan oral part and palpebralpart. They are continuous posterolatraly around the concave laeral edge of the lator palpebra ‘superiors musde Tho ducts ofthe ternal gland open ito the superior formic Those from the ortital part penetrate tho aponeuross of lvatorpalpebras superiors to jon ‘those trom the palpebral part. Therefore excsion of the palpebral partis funetonally similar to excision ofthe ent gland Blood supply Lacimal branch of the opthatic artery. Vanous drainage sto the superior ‘opthalic vein Innervation “The gland is imervatd by he sscretometor paraympathatic flres from the pterygopatatine ganglion whicn in turn may reach the gland va the zygomatic or lacrimal branches ofthe maxilary nerve or pass relly tothe gland. The preganglionic fbres travel to the ganglion inthe greater petrosal nerve (a branch ‘ofthe fala nerve atthe goniulate ganglon). Nasolacrimal duct Descends rom the laerial sac to open anterinyin the inferior meatus ofthe Lacrimation reflex Occurs in sponse to conunctvaliration (or emotional events). The ‘conjunctiva wil send signals va the opthalnc nerve. These then pass to the ‘superior salivary centre, The efferent signals pass va the greater petrosal nerve (parasympathetic preganglionic Fores) and the deep petrosal nerve which carios ‘the post ganglion sympathetic res. The parasympathetic flores wil layin the pterygepalatne ganglion, tre sympatheté fos do nt synapse, They in tun wil relay tothe lacrimal apparatus, Rate question: Neat question sare 203% ofusar anaweredie Score: 100% 4"i912 wnw.emres.comiquestion/question.php?4=0 MRCS SH Question 11 of 511 ueston stats seo 0% | vax : 'A22 year old women has recent undergone a surgieal excision of the (CI warm submandibular gland. Se presents to the follow up cin weh a compart of cn om 2 tongue weakness onthe ipsilateral side to her surgor. Which nerve has been = a ‘ damages? F 5 el osx 5 1 © A Myohoid nerve {2 tora aenore ne YX © 8 Lnoiarane ©. wer sheoar noe © B. Fac none © E Lesser petrosal nerve * “Theme from Apri 2012 Exam (Damage tothe mylohoid branch of the Inferior akeolar nerve wil result in tongue weakness Submandibular gland Relations of the submandibular gland Supertica| Plays, cee esc and mancible Sutmandbtar i ph od Facal win facial ae rear man) Haran mandir nene Cees rane he aoa none Deep | Fac rey (infor othe mana) mono musee yedussus Musee Suomandibutargenaton Hrpoalossalrene Submandibul duct (Wharton's duct) '+ Opens lateral to the lingual rerulum on the anterior foor of mouth + Semlengty + Lingual nerve wraps around Wharton's duc. As the duct passes forwards it crosses mada othe nerve to le above it and then crosses back, lateral fo I, to reach a postion below the nerve Innervation www. omres. com/question!question phoTies wnw.emres.comiquestion/question.php?4=0 + Sympathetic inervation- Superior Cerviel ganglion via the Lingual nerve + Parasympatneicinnervaton- Submandibubr ganglon artery. The facial artery passes through the gland to groove its doop surface. then emarges onto te face by passing between the gland and ‘tye mance, Venous drainage [Anterior Facial vein (ies deep tothe Marginal Mancbular 8) Lymphatic drainage Deep cervical and jugular chains of nodes Rate question: www. omres. com/question/question phoi912 MRCS VY Question 13 of 511 seare:s0% ‘A12 year old boy undergoes surgery for recurrent mastoid infections. Past are 2 ‘operatively he complains ofan altered taste sensation. Which of he folbwng ox : nerves has been injured? 4 om 5 sea 5 Glossopharyngeal Z 5.2% ofusar aeweredie ‘roa pool © ©. Ofcory © bs Tegerna V © E. Chonda ympeni kk * < “Theme from April 2012 Exam “The chorda tympani branch of the facial nerve passes foraards through tre ‘canals into the mie war, and erosees the medial aspect of he tympanic ‘membrane. then passes anteroifery inthe inratemporal fossa Kcstributes {ase ores to the anterior two thirds ofthe tongue Facial “The facial nerve i the main nerve supplying the structures ofthe second ‘embryonic branchial arch. predominantly an efferent nerve to the muscles of facial expression, digastric muscle and also to many glandular structures. contains afew afferent fibres which originate inthe cell of ks gencular ganglion ‘and are eoncorned ith ast, + Ear newe to stapedus + Taste: supplies antarior wosthirds of tongue + Tear: parasympathetic ores to lacrimal glands, also salivary glands Path Subarachnoid path + Origin: motor: pons, ensory-nervus intermedius + Pass though the petrous temporal bone ino the internal auditory meatus we. ons. comiquestion’question php?a=0Ties www. omres. com/question/question pho wnw.emres.comiquestion/question.php?4=0 wth the vestinulocach nerve, Here they combine to become the facial Facial canal path ‘+The canal passes superior tothe vestibule ofthe inner ear + Atthe modal aspect ofthe mile ear, it bacomes wider and contains the gencuate gangion = 8 branches: 1. greater petrosal nerve 2 nerve to stapedus 8 chorda tympani Stylomastoid foramen + Passes through the sylomastoid foramen (iympanic cay antaror and mastoid anttum postery) + Posterior auricular nerve ané branch to Postrir belly of Digastc and Stylohyeid muscle Face Enters parotid gland and dives into 8 branches: + Temporal branch + Zygomatic branch + Buccal branch ‘+ Marginal mandibular branch + Ceorval branch Rate question: at uestioni912 wnw.emres.comiquestion/question.php?4=0 MRCS VY Question of 514 unto sae seow:667% ‘8.34 year old lay suffers from hyperparathyroidism, The ight inferior parathyroid sd we 2 ‘sorted as having an adenoma ans scwcued fr eseclon.Fromuch of = : the flonng emryeogicalsrucure i derived? emines oll 16 i oll ose a © A. Second pharyngeat pouch z ‘7 2%ctusen arene LV © 8. Thi pharyngeal pouch ehoteomay © ©. Fourth pharyngeal pouch a © D. Frstpharyngea! pouch “ye © . None ofthe above = eseten : ra “The inferior parathyroid is a derivative of he third pharyngeal pouch, The ‘superior parathyroid is branch of the fourth pharyngeal pouch, x thyroid tomy + Four parathyroid glands + Located posterior tothe thyroid gland + Thay lis wthia the pretracheal fascia Embryology “The parathyoids develop rom the exremites ofthe third and fourth pharyngeal pouches, The paratnyoiss derived fram the fourth pharyngeal pouch are lated more superiorly and are associated with the thyroid gland. Those derived from ‘the the! pharyngeal pouen le mor inferior and may become associated wih te thymus. Blood supply “The blood supply tothe parathyroid glands is derived from the inferior and suporior thyroid arteros), There i a rich anastomosis botwoen the two vossas. \Vorous drainage is into the thyroid veins. Relations Lateraly | Common crass Medally | Reciren’ lnngealnene, rato ‘ater [Typo Posterior Prevachealiacca References, “LNoborl, M., et a, Blood supply of the parathyroid gland from the superior tyros artery. Surgery, 1994, 115(4:p. 417-23. Rate question Nest uestion www. omres. com/question/question phoi912 www. omres. com/question!question pho MRCS VY Question 33 of 511 [hic ofthe sractures ste below nota content ofthe carotid sheath? © A. ermal jugular vein (© B tornalcarotié artery © © Vagus nerve . Recurrent laryngeal nerve . Common carota arry CAROTD SHEATH: Contents: cca ron Internal jugular vein Vagus nerve Common carotid artery “The right common caro artery arses al the biurcalion ofthe brachiacophallc trunk, the lf commen carta arses from te arch ofthe aorta, Bath terminate at ‘tho lool ofthe uppor border ofthe thyroid eating (tho wor border of tho th conical vertobra) by dividing into the internal and external carotid a Left common carotid artery “This vessol arses inmociataly tothe left and sighly behind the origin of the brachiocephale trunks thoracic portions 2.5 3.5 cmin length and runs superotaterally tothe sternoclavicular joint Inte tora “The vesselis in contact, rom below upwards, wih the vachea, left recurrent laryngeal nerve, left margin ofthe oesophagus. Aneriy the left brachiocephalic veln runs across the artery, an the cardiac branches from he le vagus. doscond in rot oft. Those structures togothor wih the thymus and tho anterior mmargas of he lft ing and pleura separate the artery rom the manubrium, Inthe neck “The artery runs superiorly deep to sterocledomastold and then enters the anterior tiangle. AL this pont ites wihin the carotid sheath with the vagus nerve ‘and tho intoral jugular vein. Posteroly the sympathetic trunk as between the ‘vessel andthe prevertebral fas, A the lavel of C7 the vertabral artery ang thoracic duct te behind it.The anterior tuboree of CB transverse process is prominent and the ater can be compressed agains! his structure (t corresponds tothe level ofthe erica, Anteriory at C6 the omahyold muscle passes superficial othe artery. [nin the carotid sheath tho jugular vain fos lateral the artery. Right common carotid artory “The rignt common carci arises fromthe brachiocephalic artery. The right common cart artery coresponds wth the cervical portion ofthe let common caro, except that there ie no thoracic duct on the right, The aosophagus i ess Closely related tothe right carotid than the left. Summary points about the carotid anatomy Path Passos behind the sternoclavicular jit (12% patients above this lve tothe 29% a m6 oa sox 152% ofusar aneweredie sons 7 : i ‘ i : t aX ay ERERRERERERBREREE a2Ties wnw.emres.comiquestion/question.php?4=0 upper border ofthe thyroid carlage, to dvide int the external (ECA) and internal carob arteries (1A. Relations + Level of Bh coral vertabra erosed by amohyold ‘+ Ton passos deop tothe tnyrohyid,stornohyeid,stornomastoid muscles, + Passes behind the carotid tubercle (vansverse process 6th cervical vorlobra)-NB compression here stops haemorthage. +The inferior thyroid artery passes posterior tothe common carck artery. + Then: Left common earti artery crossed by thoracic duct, Right common carotid ator crossod by recurrent laryngeal nerve La conn geome ea oer Soe sranicc fate row — ¥ ato question: www. omres. com/question/question phoi912 wnw.emres.comiquestion/question.php?4=0 MRCS SX Question 40 of 507 Which ofthe follwing is nota content ofthe cavernous sinus? XK © A ceuonotor neve 3. nornal carta artery Opthalnie nerve 3. Abducens nerve Optic nerve Mnemonic for contents of cavernous sins OTOMCAT Cceulamoter nerve (i) ‘Trochlear nerve (N) (Ophthalmic nerve (V1) Maxllary nerve (V2) cari artery Aeducont nerve (0) T (0TONtateral wall components (CAs components win sinus “The optic nerve liss above and ouside the cavernous sinus. Cavernous sinus ge collection of thin-walled veins creating a cavity + Bordered by the temporal bone of the skull ang the phenols bone + Modal: ptutary fossa, sphonoid sinus + Lateral: temporal be Contents 1. Lateral wall components, rom top o bottom: culomotar nerve ‘rechlear nerve Ophthaimic nerve Maxillary nerve 2, Components win the sinus, tom medi to aera Internal carota artery (and sypathatic plonss) Abucons nerve Blood supply Ophthalmic vein, superficial conical vein, baila plexus of vine posterioy Drains inte the internal jugular ven vi: the superior and inferior potosal sinuses ll sae off eas nm « a" sexta 0% 1 2 a 4 5 5 1 BER BEREKEERERREEREREE 8 * a2Ties _wnw.emres.comiquestion/question php Inder cari artery Rate question Nea uestioni912 wnw.emres.comiquestion/question.php?4=0 MRCS XK Question 41 of 507 ‘Score 0% 48% ‘ ‘A443 year old man is due to undergo an excision ofthe sub mandibular glan. oe z ‘Which ofthe folowing inslons is the most appropiate for this procedure? oo : o/ © A Arann ested ekion Arn baw te mendes i : 6 & Armen trates ten et rare : owe cum ot XK © ©. Avera! incon 3 emartror tothe ange of the mandble and 8 sci a © D. Atransversely orientated incision 2em above the mandible a © & Aramnytrsesin onto oni 2 thee an 208 am “To accoss the sub mandibular gland a transverse incision 4cm bolow tho ‘mandible should be made. ncislons located higher than this may damage the rnarginal mandibular branch of the facial nerve ‘Anterior tla Air borer he Snmateldomaog (aarbonerstmanas sown icine Sub triangles (divided by Digastric above and Omohyoid) ‘+ Muscular bianglo: Neck strap musclos + Carota tangle: Carotid sheath + Submanalblar Tangle (sigastie) Contents of the anterior triangle gets tiangle | Submancbubr para BERBER ERE BRERBPRERER “x Hypoalssatnene muscular angle | Seap muscles 4“ somal ugsrain CGarotdtiange | Ceotd shee (Common exo, agus andintea Ugur in Poaacarieae Nerve supply to digastric muscle + Anterior: Myonyeid nerve + Posterior: Facil nerveTies _wna.emres.comiquestion/question php Rate question: Nea uestioni912 MRCS VY Auestion 46 of 507 [AO year old child nas a grommet inserted fora glue ear. What ype of epthelum Is present onthe extemal aspect ofthe tympanic membrane? V © A States sunrous © B. Clisted columnar © © Non ciated columnar © D. Non stratified squamous © E, None of the above: The external aspect ofthe tympanic mambrane i ined by strated squamous ‘pitnolum. Ths is sgnfeantciricaly inthe developmant of middle ear infactons when tis ype af eptrelummay migrate inside the middle ea. natormny “The oar is composed of thee anatomical stint regions. External ear ‘Auris composed of elastic cartilage covered by skin. The lobule has ro calage anc contains fat and fbrous issue Exteral audtory meatus is approximatoly 25m long Lateral tid of the xcemal austory meatus is carlaginous andthe medial wo thirds bony. “The ragon is innervated by tne greater auricular nerve, The aurieulotemporal branch ofthe tigerinal nerve supplies most the of external autory meatus and the lateral surface of he aul Middle Space between the tympanic membrane and cochlea. The adtus leads to the rastoid ai cols isthe rout trough which mid oar infections may cause rastodtis. Anterorly the eustaian tube connects the middle ear tothe nso pharyne “The tympanic menbrane consists of + utr layer of strated squamous epithelium. + Maile layer of Rorous su. + Inner layer of nucous membrane continuous wh the mile ar. The tympanie membrane fs approximately 1em in dlamster. “The chorda tympani norve passes onthe medial sido of th pars flaccida The midle ear I Inervated by the glossopharyngeat nerve and pain may radiate to the mide 02 folowing tonsilectomy. Ossicies Nallous attaches tothe tympanic membrane (the Unb). Nallaus articulates win the incus (ynovil on) Ineus attaches to stapes (another synovial joint), Cochlea, semicircular canale and vestibule (Organ of cris the sense organ of hearing and is located onthe inside of the cochlear duct on the bastar membrane, www. omres.comiquestion/question phip?4=0 180% sar% 474% ofusar aewered ie Sear 383% BERBER ERE BRERBPRERER EB “x EERE DR I q a2Ties wnw.emres.comiquestion/question.php?4=0 ‘Vestibule accommodates he uircule ang the saccule. These sretures contain ‘ondolynph and are surrounded by periph within the vestibule, Tho somicccula canals tie at various angles tothe porous tamporat bone. Al share a common opering int the vestoub Rate question: eat question www. omres. com/question/question phoi912 MRCS VY uestion 56 of 507 Sco saan : 2 ‘Ads yoar ol man is undergcng a paroisectamy andthe surgeon is careful foae preserving the facial newve. UortunataWy his trainee then proceads to die toe : ‘Which of the oloving wil not be affect asa result? ‘ 26% 5 58 5 VV © A Taste sensaton from anterior tw ths of he tongue z 22.3% furore aanore ie © B. Closing the ipsiatra aya weston corecky : . Raising the islatra sda of the ip : © B. pesiateal eorneat reex a ©. None ofthe above 2 ‘The Chorda typmpani branches inside the fail canal ad wil therefore be unaffected by this most unfortunate event! ‘The facial nerve is the main nerve supplying the structures of the second “embryonic branchial arch. is pracominantly an efferent nave to the muscles of facial expression, dgasvc muscle ana also to many glandular structures. contains afew affront fos which orignal in the calls of ts ganicuar ganglion ‘and ara concerned vt taste, Supply - Taco, car, taste, oar 1+ Face: muscos of facia expression + Ear: nerve to stapedus + Taste: supplies anterior wo-theds of tongue + Tear: parasympathetic fore fo lacrimal glands, alo salivary glands Path Subarachnoid path + Origin motor: pons, sensory: nervus intermedi + Pass trough the petrous tomporal bons into tho intornal auditory meatus wih the vestoulocachlear nerve, Here they combine to become te facial BERBER ERE BRERBPRERER is “x Facial canal path ‘+The canal passes superior tothe vestibule ofthe ner ear + Atthe modal aspect ofthe mile ear, it bacomes wider and contains the geneulate ganglion q +8 branches: 1. greater petrosal nerve 2 nerve to stapedus 5. ehorda tympani Stylomastoid foramen + Passes through the eylomastold foramen (Sympanie cay anterior and ‘mastoid antrum posterely) + Posterior auricular nerve ans branch to Postrir belly of Digastrc and Stylohysid muscle SER EREB BER E BRED I NS Face Enters parotid gland and dvides into 5 branches: www. omres.comiquestion/question phip?4=0Ties wnw.emres.comiquestion/question.php?4=0 + Temporal branch + Zygomatic branch + Buccal branch + Marginal mandibular branch + Coevcal brane Rate question: www. omres. com/question/question phoi912 wnw.emres.comiquestion/question.php?4=0 MRCS SX Question 67 of 507 uerton state Seo 40% am] mam : Which ofthe folowing doesnot passthrough he superior ort fissure? a ton : e ose : XO A terior optnani vein off oAK : © B. Abducens nerve ‘ll 104% 5 z V. © © Opthanic anery 1.8 foros anor ie z © B. Trochlear nowe wonton conecty : © E Superior opthalnie vein 0 Memon forthe what nerves passthrough the supraorbial fissure: Live fankly To See Absolutely No nsut Lactmal Frontal ‘Trochleat ‘Superior Dision of Oculomotor Absucons Nasoctary Inferior Dvision of Oeulomotar nerve Foramina of the base of Foramen | Lasation | Contents Foramen Sphenoid Oteganaon foal | bone YS (Msndbular are 38 branch ot ‘egennal posesson/meningel aay BERBER ERE BRERBPRERER Foramen—Sphenoid| Mase meningealarary stinotum bone Meningeal ranch afte Mela mene Formen SphenoidMasllnyrene (2) feunun Sone “x Foramen | Sphenci | Base afhe medal pega plat Jugutar | Temporal |Atoror rie potest snus foramen | bone aedal:gtssopnarygea. vous, and aocesson/nenes. Poresor nia sn acorn he ema open 8nd some menngesl banehes for he oeepinraaseera29 shane ares. Foramen | Oedpal | Ate and posterorepinalatares magnum bone | Verebeenere Medute oblonga Shlomastd| Temporal | Siamasii ary Suporor | Sphenoi | Osulbmtornene BEE EREBRBREBRERE eS ois bone soenenrnene ‘osire Inesmal ronal an nazosinny branches of ophaimienene wy Sbdecent nen (4) a Base of skull anatomical overview www. omres. com/question!question phoTies _www.emres.comvquestioniquestion php?4=0 Rate question we. ones, comiquestion’question pha?a=0i912 www. omnes. com/questioniquestion pho? MRCS SX uestion 58 of 07 [An 18 year old man undergoes a tonalectomy fr attacks of recurrent acute {onsittis. Whilst in recovery he develops a post operate haemorrhage. Which of ‘he folowing vessels is the mest thay culprit? © A Facial vein vo ‘Exoral palatine vein . Exermal corti artery © D. bermat jugular ven X © E None of the above ‘The extornal palatine vein fos immediately lateral to the tonsil and # damaged may be cause of reactionary haemorrhage following tonllecrony, Tonsil ‘Anatomy + Each palatine tons has two surfaces, a medial surface uhich projects into the pharynx and a lateral surface that fs embedded in the wal the praryms. + They are usually 25mm ‘aby 15mm wide, although tis varies accorsing to ‘age and may be almost completly atrophies inthe eldety ‘+ Thoir arterial suppl is rom tho tonsillarartory, a branch ofthe facial artery. 1s veins piece the constctor muscle to oi the extemal palatine oF facial \voing The external palatine veins immediatly lateral tothe toni, which ‘may resultin nasmeshage during tonsilectony. + Lymphatic drainage isthe juguledgastic node and the deap corvicl nodes. Tonsilitis + Usually bacteria (50%)- group A Streptococcus. Remainder val + May be compieatod by developmant of abscess (quiny). This maycistort the wl, - Indications for tonsilactomy include recurrent acute tonsils, suspected ralgnancy, enlargement causing step apnoea - Dissection tonslactomy isthe proferod technique with haemorrhage boing the commenest compilation. Delayed talila may occur owing to irtaton ofthe ‘lossopharyngeal neve, Rate question: a erm 5 ofan answer Sear 383% BERBER ERE BRERBPRERER is “x q BEE EREBRBREBRERE 8 we a2i912 wn.emres.comiquestion!question.php?4=0i912 wnw.emres.comiquestion/question.php?4=0 MRCS HK auestion 62 of 507 ‘Score: 28.6% 238% 2 During @ radical neck dissection division of which of the folowing fascial layers wil vue z ‘expose the ansa comleals? tome S 1 2% 5 V © A Provacheal tesa san : aot sheath z © B. Carote se 203% ofusar aeweredie i © ©. Provera fascia anton corse 2 XK © D. bvesng ayer cf asia f © &. Staons fascia a ‘Tho ansa corals es anterior othe carotid heath may be exposed by 8 division ofthe pretracheal fascia atthe posterolateral agpect ofthe thyrod gland 2 “The prevertebral fascia les more posteriorly and ehision ofthe investing layer of fascia wil not expose this nerve, ‘Ansa corvicalis Interior | Ostia for 62 ané G3 roo, pastes posterolateral jugular root ses rays warden orspertee 8), Stenetyo Onohels “The ansa cervcals tes anteror tothe carota sheath. The nerve supply tothe ioc strap muscles enters a tho’ inforior aspect. Therefore ween dividing these muscles to expose a large gotre, the muscles shoul be civdedin thir upper hal BERBER ERE BRERBPRERER “x i BEE EREBRBREBRERE 8 weS - BEE www. omres. com/question!question phoTies _wna-emres.comiquestion/question php Rate question Neat uestionrane MRCS VY uestion tof 3 [AB year old man is due to undergo an endarterectomy ofthe internal cart artery. Whi ofthe fellowing nervous structues are most at sk curing the diseection? Recurrent laryngeal nerve ‘Sympatetc chain Hyposlossal nerve Phonic nerve (© E Lingual nerve ‘Theme from May 2011 exam During a carotié endarterectomy the strnocteidomastoid muscle is dissectod, ‘th gation of he comman facial vein and then the internal jugular fe cissacted ‘exposing the commen and the int ‘he operation inclu: + Hypoalossal nerve + Greater auricular nerve + Superior laryngeal nerve ‘The sympathetic chain les posteriorly andis less prone to injury inthis procedure, Internal carotid artery ‘The intemal carci artery i formed from the common carotid oppask border ofthe thyroid catlage.l extends superioty to ener the skull via the ‘caret canal. From the carotid canalit thon passes through the cavernous sus, Relations in the neck Posterior + Longue caps + Smsatete chen Stbetrtanngeatnene Medally | + Exxmal care nears) alto onan 1 secendng anneal any Lateraly + Inemal jugular roves postr onirice tl) 1 Vapuenene (nestporeraatoraty 1 riposorea nore inthe carotid cans + Intomal carotid plonis + Cochiea an mice ear cavity + Trigeminal ganglon (superar) + Leaves eanalies above the foramen lcerum we. ons. comiquestion’question php?a=0 a carotid arteries. The nerves a sk ding the upper Sore 100% ean tv 25% 108% 322% ofusar anenered.ie a2rane _wna-emres.comiquestion/question php sath and relations in the eranial cavity ‘The artery bends sharply forwards inthe cavernous sinus, the aducens nerve Hes ose tots nferolatoral aspect The oculomotor, trochlear,opthalmic and, usually ‘the maxillary nerves ein he atralvallf he sins. Neat the superior otal Fesure it turns posterior and passos postore-modaly to plarco the roof of the ‘cavernous sinus inferior fo the optic nerve. then passes between the optic and ‘oculomotor nerves to terminate below the anterior perforated substance by living into to anterior and mide corebralartris. Branches + Anterior and midale cerebral artery + Ophthaimic artery + Posterior communicating artery + Anterior choroid artery + Moningeal arteries ‘+ Hypophysea arteries Image demonstrating the intemal cart artery ands relationship tothe external ‘carob artery Rate question Neat uestionTren Reference ranges Reference ranges vary according to individual labs. All values are for adults unless otherwise stated Full blood count www.omres.commelpirefange html Haemoglobin | Men: 13.5-18 gidl Women: 11.5-16 gid Mean cell volume | 82-100 Platelets 150-400" 10% White blood cells | 4-14 * 10% Urea and electrolytes Sodium 135-145 mmol Potassium 35-50 mmol Urea 2.0-7 mmoll Creatinine 55-120 umolt Bicarbonate 22-28 mmol Liver function tests Bilirubin ‘Aanine transferase (ALT) Asparlate transaminase (AST) ‘Alkaline phosphatase (ALP) Gamma glutamy! transferase (yST) ‘Abbumin Total protein Other haematology Erythrocyte sedimentation rate (ESR) Prothrombin time (PT) ‘Aetivated partial thromboplastin time Ferritin Vitamin B12 Fotate Reticulocytes wo. omres.comfhelpirefrange html 3-17 umoll 3-40 iu 3.30 jut 30-100 umold 8-60 un 36-50 of 60-80 gf Men: < (age /2) mmihr Women: < ((age + 10)/2) mm/hr 10-14 secs (APTT) 25-35 secs 20-230 ngimi 200-900 ng 3.0 nmol 05-15% 1rene Other biochemistry Calcium Phosphate oRP Thyroid stimulating hormone (TSH) Free thyroxine (T4) Total thyroxine (T4) ‘Amyjase Uric acid Arterial blood gases pH 7.38-7.45 pCO2 45-6.0kPa poz 10-14 kPa Lipids Desirable lipid values depend on other risk factors for cardiovascular disease, below is just a guide Total cholesterol <5 mmolil Triglycerides <2 mmol! HDL cholesterol > 1 mmoli! LDL cholesterol <3 mmol! wow. omres.comfhelpirefrange html www.omres.commelpirefange html 2.4-2.6 mmol 0.81.4 mmoll <10 mall 05-55 mul 9-48 pmol 70-140 nmoin 70-300 ul 0,18-0.48 mmol 22