Exam 4: The Final Segment of

Live with your TAs at 5

• Corneal (blink) reflex:
Reflexes
– Afferent: Nasociliary (GSA) of V1
– Efferent: Facial N (SVE)
• Sneeze reflex:
– Afferent: V2 (GSA)
– Efferent: Vagus (SVE)
• Jaw Jerk reflex:
– Afferent: V3 (GSA)
– Efferent: V3 (SVE)
• Pupillary Light reflex
– Afferent: Optic N
– Efferent: Parasympathetics within CN3
• Gag reflex and Cough reflex:
– Afferent: CN9 (GVA)
– Efferent: CN10 (SVE)
 Muscles of Mastication
All innervated by V3 (SVE)
• “Might Lose My Temper”
– Masseter
• Elevates
• Retracts
– Lateral Pterygoid
• Depresses (ONLY muscle that depresses mandible)
• Protracts “P” in
– Medial Pterygoid 🡪 same fiber direction as Pterygoid for
masseter (helps close jaw) Protracts
• Elevates
• Protracts
– Temporalis
• Elevates
• Retracts
– ***The jaw is OPENED by Lateral pterygoid***
– ***The jaw is CLOSED by the other 3***
 4 Laws of Cranial Nerves
“The PGA”
• 1) Any muscle with “Tensor” in its name is innervated by
Trigeminal Nerve (V3)
– Tensor veli palatini (medial pterygoid N)
– Tensor tympani (medial pterygoid N)
• 2) Any muscle with “Palat” in its name is innervated by Vagus
N (EXCEPT Tensor Veli Palatini bc law 1 takes precedence)
– Palatoglossus (Pharyngeal branch) **Narrows Fauces**
– Levator veli palatini (Pharyngeal branch)
– Palatopharyngeus (Pharyngeal branch)
• 3) Any muscle with “glossus” in its name is innervated by
Hypoglossal N (EXCEPT Palatoglossus bc law 2 takes
precedence)
– Hyo-, stylo-, genio-glossus
• 4) Any muscle with “Arytenoid” in its name is innervated by
Vagus N (Inferior branch of the recurrent branch)
 Trigeminal (V1) Branches
• V1 3 Major Branches:
– Nasociliary: NEL SCENIT
– Frontal: FML SiSTa
– Lacrimal
• NEL SCENIT
– Nasociliary
– Ethmoidal (Ant/Post)
– Long/Short Ciliary
– External Nasal (most medial branch)
– InfraTrochlear
• FML SiSTa
– Frontal
– Medial/Lateral Supraorbital
– SupraTrochlear
 Trigeminal (V2) Branches
• 2 ZP SANIO
– V2
– Zygomatic
– Palatine (Greater/Lesser)
– Superior Alveolar
– Nasopalatine
– InfraOrbital
 Trigeminal (V3) Branches
• Sensory: “More BAIL Money”
– Meningeal
– Buccal
– Auriculotemporal
– Inferior alveolar
– Lingual
– Mental (After inferior alveolar nerve transverses mental foramen)
• Motor: “3 Moronic MDs Love Making Patients Mad”
– V3
– Motor
– Mylohyoid
– Deep temporal (Anterior/Posterior)
– Lateral/Medial Pterygoid
– Massenteric
 Trigeminal Nerve
• “Standing Room Only”
– Superior orbital fissure: Opthalamic Division (V1)
• ONLY sensory (GSA)
– Foramen Rotundum: Maxillary Division (V2)
• Only sensory (GSA)
– Foramen Ovale: Mandibular Division (V3)
• Sensory AND motor
– GSA
– SVE – Motor fibers to the muscles from the 1st brachial arch which
include the tensor veli palatini, tensor tympani, anterior belly of
digastric, and mylohyoid muscle as well as muscles of mastication
 Google MAPS

G Geniohyoid C1

M Mylohyoid
V3
A Anterior belly of digastric (N to Mylohyoid)

P Posterior belly of digastric Facial N

S Stylohyoid
 CSF Flow
• “Lady Monro has 3 Aqueducts that go to 4 Magical and
Luscious Subarachnoid Spaces At Grand Superior
Store”
– Lateral ventricles
– Foramen of Monro (Interventricular foramen)
– 3rd Ventricle
– Cerebral Aqueducts
– 4th Ventricle
– Median/Lateral apertures
– Subarachnoid spaces
– Arachnoid Granulations
– Superior sagittal Sinus
 Laryngeal muscles/Vocal Folds
• Thyrohyoid
– Action: Elevates larynx
– Innervation: C1
• Cricothyroid
– Action: Contraction results in thyroid cartilage tipping anteriorly inferiorly which increases
distance between thyroid and arytenoid cartilage which tenses/elongates vocal ligaments
(Higher voice pitch)
– Innervation: External laryngeal N (Branch of Superior laryngeal N)
• Interarytenoid
– Action: Pulls arytenoid cartilage towards one another = ADDucts vocal folds
– Innervation: Inferior laryngeal N (Branch of recurrent branch of vagus)
• Posterior cricoarytenoid:
– Action: ONLY muscle that opens rima glottis (ABDuction of vocal folds)
– Innervation: Inferior laryngeal N
• Thyroarytenoid
– Action: Relaxes vocal ligaments; tilts thyroid cartilage posteriorly (Lower pitch voice)
– Innervation Inferior laryngeal N
• Lateral Cricoarytenoid
– Action: ADDucts vocal ligaments
– Innervation: Inferior laryngeal N
 Laryngotomy
🡪 umbrella term for procedures that open up larynx to
allow airflow
• Cricothyrotomy
– Incision through cricothyroid
membrane to gain access to
trachea

• Tracheotomy
– Incision of 3rd & 4th rings of
trachea from jugular notch to
thyroid notch
 Problems with thyroidectomy
• Thyroid ima artery, inf. thyroid vein are vulnerable
• Hemorrhage via ant. Jugular vein
• Inadvertent parathyroidectomy
– Decreased levels of PTH🡪 low Ca2+ and high PO4- levels 🡪muscle
spasms (tetany)
• Esophageal injury due to immediate posterior location to
trachea
– See Alfred and Chris for details…
• Pneumothorax
– Damage cervical portion of pleura that extends above rib 1
• Nerve paralysis via recurrent laryngeal nerve
– Chronic hoarseness
 Infrahyoid Muscles
• GHost THought SOmeone STupid SHot Irene
– GenioHyoid (C1)
– ThyroHyoid (Nerve to thyrohyoid)
– Superior Omyhyoid (Superior root of AC)
– SternoThyroid (Inferior root of AC)
– SternoHyoid (Superior/Inferior root of AC)
– Inferior omyhyoid (Inferior root of AC)
• Injury to C4 would affect which of the
following?
 Ansa Cervacalis (C1-C3)

Is the ansa cervicalis responsible for referred pain to the

shoulder?
 Parasympathetic Ganglion
• COPS
– Ciliary (CN 3)
• Preganglionic: Inferior division of CN 3
• Postganglionic: Short ciliary N
– Otic (CN 9)
• Preganglionic: From CN 9 (Parasympathetics in Lesser petrosal Nerve, tympanic
nerve)
• Postganglionic: Auriculotemporal Nerve (V3)
– Pterygopalatine (CN 7)
• Preganglionic:
– Parasympathetics via N to pterygoid canal (Greater petrosal + Deep petrosal Nerve)
– Postganglionic sympathetics by way of the deep petrosal nerve and the nerve of the
pterygoid canal which are distributed with the postganglionic parasympathetic fibers
• Postganglionic: Various branches of V2 and Lacrimal N (V1)
– Submandibular (CN 7)
• Preganglionic: Chorda tympani
• Postganglionic: Lingual N (V3)
– **Fibers that synapse on COPS are ALL GVE**
 Hyperacusis
• Lesion of Facial Nerve proximal to the facial canal
will damage the N to the stapedius
– Stapedius is attached to the stapes which is in contact
with the oval window
• Its job is to dampen the vibrations of the stapes so that it will
not over react (or be too extra) in response to a loud noise
• Contraction of the stapedius muscle causes the stapes to
vibrate less (or not be so extra)
• Patient will perceive A LOT of auditory noise due to
overstimulation
Glossopharyngeal (CN9)

Maroon 🡪 GVA
Green 🡪 SVA
Yellow 🡪 SVE
Light Blue 🡪 GSA
Purple 🡪 GVE
 CN 9
• Parotid gland pain is not conveyed by CN 9. It
is conveyed by Auriculotemporal (V3) via GSA
fibers
• Question:
– Baby born without making crying noise, which
muscle is most likely damaged?
 Proximal: Lesion of chorda
tympani before it joins lingual

Facial Nerve Lesions nerve = Loss of taste ONLY

• What fibers are contained

within lingual nerve
proximal to chorda tympani?
• ONLY GSA (V3)

Lesion at Stylomastoid foramen

will NOT affect taste

Distal: Lesion after chorda

tympani has joined lingual =
Loss of sensory and taste

• What fibers are contained

within lingual nerve
DISTAL to chorda tympani?
• GVE, SVA (From
chorda tympani)
• GSA
 Tongue Lymph
• Root 🡪 Bilaterally to the Superior Deep
Cervical LN
• R/L Lateral portions 🡪 Submandibular LN
• Medial portion 🡪 Bilaterally to Inferior Deep
Cervical LN
• Apex/Frenulum 🡪 Bilaterally to Submental LN
There’s levels to this, you and I know…..Head/Neck
Lymph Nodes with associated levels
 CN 3 • Edinger-Westphal N:
Origin of
preganglionic
parasympathetic
fibers
• The INFERIOR root of
CN 3 synapse in the
ciliary ganglion
• The ciliary ganglion is
the origin of SHORT
ciliary nerves which
cause contraction of
sphincter pupillae and
Petite (Short) – Parasympathetic (GVE)
cilary musculature
Constrict (Constriction)
Slong – Sympathetic (GVE) “PCSD”
Parasympathetic = Constriction
Dilate
Sympathetic = Dilation
Eye Movements: Clinical Test
 Eye Muscle Movements

(LR6SO4)3

• ObLique actions are Opposite of their name and

responsible for Lateral rotation (Abduction)
• Rectus actions are Rightly fitting of their name
 Flow of Aqueous Humor in Eye
• “a Couple Pre-Professional Anglers Stayed in Canal of
Schlem And Almost Came Out Victorious”
– Ciliary processes
– Posterior chamber
– Pupil
– Anterior chamber
– Spaces of fontana
– Canal of Schlem
– Aqueous vein
– Anterior Ciliary vein
– Venous system
Common Tendinous ring for muscles of the
eye
 Ear
Sound pathway
• “TMI, SO Skanky Victoria Had Super Terrible Rep”
– Tympanic membrane
– Malleous
– Incus
– Stapes
– Oval window
– Scala Vestibuli
– Helicotrema
– Scala Tympani
– Round window
 Ear
• The scala tympani is separated from the
cochlear duct (scala media) by the basilar
membrane and it extends from the round
window to the helicotrema where it continues
as the vestibular duct (Scala vestibule) to the
oval window
 Basilar Membrane
• Base of Basilar Membrane (Narrower/Stiffer)
– Higher Frequency

• Apex of Basilar Membrane (Wider/More

flexible)
– Lower Frequency
 Innervation of Tympanic Membrane
• Internal (medial) Surface:
– Innervated by the tympanic branch of the
glossopharyngeal nerve (GSA fibers from the
superior ganglion of CN 9)
• External (lateral) Surface:
– Innervated by the auricular branch of the Vagus
nerve (GSA fibers from the superior ganglion of CN
10)
 Utricle and
Saccule

S U

Saccule 🡪 Vertical motion

Utricule 🡪 horizontal motion

Lingual Stuff
What that
hypoglossal
nerve do??
• Know the orientation of the structures in
relation to other structures
• The lingual Nerve first passes lateral, then
inferior, then medial to the submandibular
duct
• It spider webs out towards the anterior
2/3s tongue
• Sublingual ganglion can not be identified on
body. Find on a model
• The lingual artery passes MEDIAL to the
hyoglossus muscle
• Once the sublingual branch is given off
the lingual artery’s name changes to DEEP
LINGUAL ARTERY
 Pharynx Sensory
• Nasopharynx above Auditory Tube and the
torus tubarius is Innervated by the Mandibular
division of trigeminal nerve
• Oropharynx: Innervated by Glossopharyngeal
nerve
• What happens to tongue protrusion if you lose
sensation to the oropharynx?