Essay - Handwritten Prose. 10 Points.

• Essay Question #1: An apical abscess of the lower molars may erupt into the floor of the mouth and then enter the submandibular space by way of the posterior free edge of the mylohyoid muscle. This infection may then erode into deeper cervical regions.Discuss the spaces defined by the cervical fasciae. Include boundaries, contents, relationships, lymphatic drainage, and clinical significance.

True/False. 1 Point Each.

• Statement.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 56 y.o. female patient presents with miosis, mild ptosis, anhidrosis, flushed skin and conjunctival injection on the left side of the face, in addition to left upper limb weakness, hiccups, and hoarseness. She is diagnosed with a Pancost tumor of the left lung. Describe the boundaries and contents (including nerves, vasculature, fascia, and lymphatic structures) of the left vertebral triangle. Explain the presentation of her symptoms.
• Essay Question #2: You are performing a neck dissection to remove a tumor in the carotid triangle. Discuss the anatomical structures which may be affected by the tumor. Include in your answer boundaries, contents, fascial layers, vasculature, and nerves of the carotid triangle.

True/False. 1 Point Each.

• The great auricular nerve provides SVE innervation to the auricularis and GSA innervation to the opening of the external acoustic meatus.
• The lesser occipital nerve crosses lateral to sternocleidomastoid, parallel to the external jugular vein.
• The nerve to mylohyoid is a branch off the hypoglossal nerve within the submandibular triangle, and supplies SVE innervation to both mylohyoid and the anterior belly of digastric.
• Anterior to the anterior border of the masseter muscle, the facial artery is very superficial and can be palpated at the inferior border of the mandible.
• A supernumerary cervical rib can extend into the interscalene triangle, resulting in weakness and sensory deficits of the upper limbs.
• The superior thyroid artery pierces the thyrohyoid membrane with the internal branch of the superior laryngeal nerve.
• The ansa cervicalis can be distinguished from the right recurrent laryngeal nerve because it travels anterior to the subclavian artery.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 50-year-old female presents to the ED with ptosis and drooping on the left side of her face. Upon examination, she cannot fully close her eye and has the inability to smile. Describe the anatomy of the facial nerve and muscles of facial expression. Be specific. What muscle does each branch innervate? What are the functions of these muscles and how do they convey expression?
• Essay Question #2: A 30-year-old male with multiple head lacerations is rushed into the ED after a motorcycle accident. One wound is superficial and bleeding profusely, the other is a large scalp avulsion with minimal bleeding. Describe the anatomy of the scalp including fascial layers, vasculature, and lymphatics. Include how those layers relate to the fascial layers of the face. Why does one bleed more than the other?

True/False. 1 Point Each.

• The muscles that elevate the upper lip are innervated by the zygomatic and buccal branches of the facial nerve
• All muscles in the circumorbital/palpebral group are innervated by the temporal and zygomatic branches of the facial nerve
• Superficial temporal fascia is in the same plane but not continuous with the superficial musculo-aponeurotic system (SMAS) tissue layer of the face

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 26-year-old male reports to your clinic with drooping of his left face and hyperacusis of his left ear. He also has developed a “scratchy” painful sensation in his left eye and decreased taste on the left side of his tongue (anterior 2/3). Describe the anatomy of the facial nerve, accounting for the symptoms described above. What is your diagnosis for this patient? Describe a potential site of lesion.
• Essay Question #2: A 34-year-old female was referred to your otolaryngology clinic for progressive hoarseness, dysphagia, and weakness of the left sternocleidomastoid and tongue. In the neurologic exam, you detect uvular deviation to the right, tongue deviation to the left upon protrusion, and left vocal cord paralysis. MRI confirms a glomus tumor near the jugular foramen. Describe the anatomy of the posterior cranial fossa, with emphasis on cranial nerve anatomy. Account for all of the patient’s symptoms described above. If the tumor is left unchecked, discuss other possible deficits this patient might experience.

True/False. 1 Point Each.

• The olfactory nerves (CN I) contain bipolar neurons that convey SSA information from the olfactory mucosa of the nasal cavity to the olfactory bulb through the cribriform foramina of the ethmoid bone.
• The optic nerve (CN II) passes through the optic canal along with the ophthalmic vein.
• The superior division of the oculomotor nerve (CN III) conveys GVE fibers to the ciliary ganglion.
• The trochlear nerve (CN IV) innervates the superior oblique muscle from the muscle’s superior surface.
• The ophthalmic division of the trigeminal nerve (V1) serves as the afferent limb of the corneal blink reflex.
• The abducens nerve (CN VI) innervates the lateral rectus muscle from the muscle’s lateral surface.
• The facial nerve (CN VII) provides parasympathetic fibers to the lacrimal gland, oral and nasal mucosa, as well as the submandibular, sublingual, and parotid salivary glands.
• The facial nerve (CN VII) provides SVE fibers to the muscles of facial expression.
• The vestibulocochlear nerve (CN VIII) conveys SSA information from the vestibular apparatus and cochlea through the internal acoustic meatus to the brainstem.
• The glossopharyngeal nerve (CN IX) provides GSA and GVA innervation to the posterior 1/3 of the tongue.
• An iatrogenic injury to the recurrent laryngeal nerve (branch of vagus nerve, CN X) may result in in vocal fold paralysis on the ipsilateral side of injury.
• The spinal accessory nerve (CN XI) ascends innervates the sternocleidomastoid and trapezius muscles.
• Lesion of the hypoglossal nerve (CN XII) will result in tongue deviation upon protrusion to the side contralateral the injury.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 16-year-old patient presents with trismus (painful muscle spasms) of the medial pterygoid muscle and a dental abscess on their 3rd mandibular molar. You determine the patient has an infection in the infratemporal fossa. Discuss the anatomy of the infratemporal fossa including muscles, vasculature, and nerves (including ganglia). Be sure to account for spread of infection from the infratemporal fossa.
• Essay Question #2: A 35-year-old patient presents with an inability to sense temperature, pain, or touch on the anterior 2/3 of the their tongue, however they have no issues with taste on anywhere on their tongue. You determine the lingual branch of the trigeminal nerve is affected, while the chorda tympani nerve is unaffected. Discuss the branches of the mandibular division of the trigeminal nerve and their functions. Be sure to describe the function of chorda tympani and lingual nerve. Please explain where you think the lesion would be located.

True/False. 1 Point Each.

• The medial pterygoid muscle and lateral pterygoid muscle are contents of the infratemporal fossa.
• The temporalis muscle and masseter muscle are contents of the temporal fossa.
• The inferior alveolar nerve travels through the mandibular foramen and canal.
• The mandibular nerve goes through the foramen spinosum to enter the infratemporal fossa.
• The middle meningeal artery is encircled by the two roots of the auriculotemporal nerve.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A patient presents with pain, swelling and stiffness in the jaw and face. Upon examination, you note there is difficulty in jaw closure as well as a misalignment of the upper and lower jaw. Discuss the anatomy of the temporomandibular joint, including bones, ligaments, muscles, movements, cavities and contents. Provide a potential diagnosis for the patient.
• Essay Question #2: A patient is found to have a large tumor in their left parotid gland and is scheduled to undergo a total parotidectomy. Following surgery, the patient presents with moderate left-sided facial paralysis. Discuss the anatomy of the parotid region, including boundaries, contents, relationships, innervation and function. Provide an account for what may have caused the facial paralysis.

True/False. 1 Point Each.

• The articular disc of the TMJ attaches to the internal aspect of the fibrous capsule establishing a superior and inferior synovial cavity.
• Translational movements (protraction and retraction) are movements of the superior synovial cavity.
• The posterior fibers of the temporalis muscle retract the mandible.
• The posterior auricular nerve emerges prior to the facial nerve entering the parotid gland.
• Stenson’s duct courses along the superficial surface of the masseter muscle before it pierces the buccinator muscle.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A weekend warrior, not wearing a batter’s helmet, is hit on the side of the head by a wildpitch. Initially, she is “knocked out.” She regains consciousness. Then, thirty minutes later she, once again, loses consciousness. Discuss the anatomy of the pterion and epidural hematoma.
• Essay Question #2:

True/False. 1 Point Each.

• Statement.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 38 year-old male presents to the Emergency Department with a swollen left eye. He denies trauma to the eye. He initially reports having a headache “on the top of my head.” He now has a generalized headache, fever, pain behind his eye, and double vision. On exam, there is ptosis, proptosis, conjunctival injection, and inability to track with his left eye. He has hyperesthesia of his left face, from the lateral forehead to the upper lip. His fundoscopic exam displays papilledema. Discuss the anatomy of the cavernous sinus. Include boundaries, contents, and relationships. Account for symptoms caused by damage to structures within the cavernous sinus?

True/False. 1 Point Each.

• Statement.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 19-year-old baseball player is hit in the side of the head by a wild pitch while at bat. You are told that he lost consciousness immediately after he was hit in the head, but he is now lucid and reports of a headache. Upon radiographic examination you determine the patient has an epidural hematoma. What artery was most likely ruptured to cause this epidural hematoma? Describe the layers and spaces of the meninges that surround the brain. Compare and contrast epidural and subdural hematomas.
• Essay Question #2: A 65-year-old male reports to the clinic with sudden onset of a severe headache and a stiff neck. Upon radiographic examination you determine the patient has a ruptured aneurysm at the proximal aspect of the middle cerebral artery. Where would blood collect with a rupture in the middle cerebral artery? Discuss the blood supply to the brain, including the arteries that make up the circle of Willis.

True/False. 1 Point Each.

• The neural tube forms the spinal cord and brain.
• Oligodendrocytes create the myelin sheath around axons in the peripheral nervous system.
• The inferior petrosal sinus and sigmoid sinus join to form the internal jugular vein.
• The posterior inferior cerebellar artery participates in the circle of Willis.
• The trigeminal nerve arises from the pons.
• The cerebral aqueduct connects the 3rd and 4th ventricles.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1:
• Essay Question #2:

True/False. 1 Point Each.

• Statement.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A patient is found to have a tumor on the cranial floor at the entrance to the internal acoustic meatus. Another patient has a tumor within the parotid gland. Both patients have facial muscle paralysis. Discuss the anatomy, functional components, and distribution of the facial nerve. Compare the deficits resulting from a lesion of the facial nerve at the internal auditory meatus to the deficits resulting from a lesion of the facial nerve at the parotid gland.
• Essay Question #2: Damage to the lingual nerve disrupts GSA (touch, temperature, pain, and pressure) sensation to the tongue. SVA (taste) sensation and GVE (salivation) may be intact or not depending on where the lingual nerve is damaged. The patient may appreciate the sweetness, but not the temperature, of a sip of coffee. Provide an anatomical account for the dissociation of the GSA, GVE, and SVA functional components supplying the tongue based on damage to the lingual nerve.

True/False. 1 Point Each.

• Statement.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 60-year-old woman visits her ophthalmologist and is diagnosed with glaucoma, a condition of increased intra-ocular pressure due to an increased volume of aqueous humor in the anterior and posterior chambers of the globe. Discuss the anatomy of the globe. Be sure to describe the refracting media of the globe, including the aqueous humor.
• Essay Question #2: Blinking of the eyelids spreads tears across the surface of the eyeball. Discuss the anatomy of the eyelid and the lacrimal apparatus. Consider describing the path of a tear.

True/False. 1 Point Each.

• The sphincter pupillae muscle fibers are circularly arranged within the lens, while the dilator pupillae muscle fibers are radially arranged within the lens.
• In the case of a detached retina, the nonvisual part of the retina separates from the optic part of the retina.
• The depression in the center of the optic disc is called the fovea centralis.
• Zonular fibers suspend the lens and are, therefore, referred to collectively as the suspensory ligament of the lens.
• Aqueous humor is absorbed into the scleral venous sinus (the canal of Schlemm).
• Opacity of the cornea is known as a cataract.
• The optic nerve (CN II) carries afferent information from the sclera to the brain.
• The superior and inferior tarsus are extensions of periosteum.
• The conjunctiva is a thin membrane with two parts, the palpebral and bulbar conjunctiva.
• The nasolacrimal duct extends inferiorly from the lacrimal sac and opens into the superior meatus of the nasal cavity.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: Discuss the anatomy of the annulus tendineus. Include relationships to superior orbital fissure and nerves, arteries, and veins.
• Essay Question #2: Discuss the autonomic innervation to the orbit and globe. Include preganglionic and postganglionic pathways leading to the orbit.

True/False. 1 Point Each.

• The lateral rectus muscle adducts the globe and is the sole innervation of the abducens nerve.
• The superior oblique muscle moves the globe in abduction, depression, and medial rotation.
• The inferior oblique muscle elevates, abducts, and laterally rotates the globe.
• The annulus tendineus provides a site of origin for the rectus muscle of the orbit but not for the superior oblique.
• The nasociliary nerve, but not the frontal or trochlear nerves, pass through the annulus tendineus.
• The frontal nerve, lacrimal nerve, and trochlear nerve all enter the orbit without passing through the annulus tendineus.

Essay - Handwritten Prose. 10 Points.

• Essay Question: A 53 year old female opera singer presents with a conspicuous mass on the right side of her neck. She notes it has been enlarging over time, and adds that she suspects it is related to her recent decline in vocal ability, especially with high notes. After some tests, it is confirmed the mass is a goiter. A thyroidectomy is scheduled due to the goiter compressing nearby structures. During surgical resection, the surgeon fails to identify the right recurrent laryngeal nerve and accidentally fully transects it. The left RLN remains fully intact. List the specific functions of the recurrent laryngeal nerve with respect to the larynx (including sensory and motor innervation). Describe the potential deficits the patient may experience. Would the patient still be able to speak? Is her operatic career over?

***note, this story is loosely based on Amelita Galli-Curci, but she was said to have suffered from a SLN injury. I changed it to an RLN injury because it is the more common injury seen today of the two. Please do not mix them up!

True/False. 1 Point Each.

• The inferior laryngeal nerve innervates 4 of the 5 intrinsic laryngeal muscles.
• Contractionn of the cricothyroid muscle rocks the thyroid cartilage anterior with respect to the cricoid cartilage, which relaxes (decreases tension) the vocal folds.
• The posterior cricoarytenoid muscle is the only muscle which can widen the glottis (abduct the vocal folds).
• During whispering the vocal folds are adducted and air escapes between the arytenoid cartilages. This results in no vibration of the vocal folds (no voicing) for any speech sounds, even those that do have vibration (voicing) in normal speech.
• The internal branch of the superior laryngeal nerve pierces the cricothyroid membrane to enter the larynx.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A sugar-crazed 27-year-old female had an apical root infection of the lower molars that erupted into the floor of the mouth. Infection could then spread into cervical spaces. Subsequent swelling may cause stridor and death. Discuss the retropharyngeal space and danger space, as well as the facial layers creating leading up to and creating these spaces. Consider in your discussion why an infection in the danger space is life threatening.
• Essay Question #2: A 55-year-old male was drinking a soda, when his colleague made a hilarious joke. As he began laughing, the soda shot out his nose and he began coughing. As the pharynx participates in swallowing and respiration, it is essential that swallowed contents do not enter the larynx or nasal cavities. Review the anatomy of pharyngeal regions and movements during swallowing that separate the pathway of swallowed contents from the pathway of respiration. If helpful to your response, the cough reflex could also be explained.

True/False. 1 Point Each.

• The levator veli palatini, tensor veli palatini, and salpingopharyngeus muscles contribute to the movements of swallowing and to the equalization of air pressure in the middle ear.
• The palatine tonsils are located within the pharyngeal arch defined by the palatopharyngeus and salpingopharyngeus muscles.
• The gag reflex is mediated by the GVA component of the glossopharyngeal nerve.
• The cough reflex is mediated by the GVA component of the glossopharyngeal nerve.
• The median and lateral glossoepiglottic folds define the vallecula.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A seventy two year-old male comes to your office with complaints of hoarseness and postnasal drip. You note the distinct smell of tobacco. He has ptosis of the left eye and the left pupil is smaller than the right. There is fullness over the left supraclavicular region. A Pancoast tumor is highly suspected. Discuss the anatomy of the left vertebral triangle. Include boundaries, contents, relationships, fascial specializations, vasculature, innervation, lymphatic drainage, and the clinical significance of damage to structures in the area.

True/False. 1 Point Each.

• Statement.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 45-year-old patient reports to the clinic with ear pain. Nasal, oral, pharyngeal, or laryngeal cancers may present with the chief concern of ear pain as an initial symptom. Discuss the sensory innervation to the external and middle ear that may mediate referred pain from the nasal cavity, oral cavity, pharynx, and larynx.
• Essay Question #2: A mother brings her 4-year-old boy to the clinic. She tells you her son had a cold and now complains of an ear ache. Upon otoscopic examination, you detect increased air-fluid levels in the tympanic cavity and an inflamed tympanic membrane. You diagnose the boy with otitis media (a middle ear infection). Discuss the anatomy of the tympanic cavity including bones, muscles, vasculature, and innervation.

True/False. 1 Point Each.

• The carotid canal transmits the external carotid artery.
• The tympanic canaliculus transmits the recurrent tympanic nerve.
• The external ear consists of the auricle and external acoustic meatus and functions to funnel and direct sound waves.
• The stapedius muscle is innervated by the stapedial branch of the facial nerve.
• The mucosa of the tympanic cavity is innervated by the recurrent tympanic nerve and tympanic plexus.
• The vestibular apparatus of the inner ear functions to detect sound levels.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A treatment for trigeminal neuralgia is to inject nerve blocking agents into the pterygopalatine fossa. This procedures blocks neural transmission for all nerves within the pterygopalatine fossa. Thereafter, the patient may suffer from a disruption of functional components (GVA,SVA,GVE,GSA) within the nervious distributions of the pterygopalatine fossa. Review the distribution of nervious pathways of the pterygopalatine fossa.

True/False. 1 Point Each.

• Statement.

• Subheading