Assistant Professor, University of California, Riverside School of Medicine
The alveolar arch has 16 sockets or alveoli for teeth arrhythmia questions buy hyzaar 50 mg overnight delivery, varying in size and depth; some are single blood pressure 210120 hyzaar 50mg on line, and some are divided by septa in adaptation to tooth roots high blood pressure medication and xanax order 50 mg hyzaar otc. The nasal fossae 2014 2014 buy cheap hyzaar 50 mg online, separated in the midline by the nasal septum, lie above the hard palate. The two posterior nasal apertures (choanae) are located where the nasal fossae end. The upper border of the vomer is applied to the inferior aspect of the body of the sphenoid, where it expands into an ala on each side. The two may touch, or the vaginal process may overlap the ala of the vomer inferiorly. The inferior surface of the vaginal process bears an anteroposterior groove, which is converted into a canal anteriorly by the superior aspect of the sphenoidal process of the palatine bone. This palatovaginal canal opens anteriorly into the pterygopalatine fossa and transmits a pharyngeal branch of the pterygopalatine ganglion and a pharyngeal branch from the third part of the maxillary artery. An inconstant vomerovaginal canal may lie between the ala of the vomer and the vaginal process of the sphenoid bone, medial to the palatovaginal canal, and lead into the anterior end of the palatovaginal canal. Middle Part of the Cranial Base the middle part of the cranial base is made up of the occipital, sphenoid and temporal bones. The body of the sphenoid bone lies anteriorly, and the basilar part of the occipital bone lies posteriorly, just in front of the foramen magnum. Where these two bones meet in the growing skull, the junction between them is a primary cartilaginous joint, the spheno-occipital synchondrosis. This joint is important for growth of the skull in an anteroposterior direction and ossifies at approximately 14 to 16 years of age. The basilar part of the occipital bone bears a small midline pharyngeal tubercle, which provides an attachment to the pharyngeal raphe and the highest attachment of the superior pharyngeal constrictor. The middle part of the cranial base is completed by the petrous processes of the two temporal bones, which pass from the lateral sides of the base of the skull toward the site of union of the sphenoid and occipital bones. Each petrous process meets the basilar part of the occipital bone at a petrooccipital suture, which is deficient posteriorly at the jugular foramen. The petrosphenoidal suture and the groove for the pharyngotympanic tube lie between the petrous process and the infratemporal surface of the greater wing of the sphenoid. The apex of the petrous process does not meet the spheno-occipital suture, and the deficit produced is called the foramen lacerum. Each pterygoid process of the sphenoid bone bears medial and lateral pterygoid plates separated by a pterygoid fossa. Anteriorly, the plates are fused, except below, where they are separated by the pyramidal process of the palatine bone. Laterally, the pterygoid plates are separated from the posterior maxillary surface by the pterygomaxillary fissure, which leads into the pterygopalatine fossa. The posterior border of the medial pterygoid plate is sharp and bears a small projection near the midpoint, above which it is curved and attached to the pharyngeal end of the pharyngotympanic tube. Above, the medial pterygoid plate divides to enclose the scaphoid fossa; below, it projects as a slender pterygoid hamulus, which curves laterally and is grooved anteriorly by the tendon of tensor veli palatini. The lateral pterygoid plate projects posterolaterally, and its lateral surface forms the medial wall of the infratemporal fossa. Superiorly and laterally, the pterygoid process is continuous with the infratemporal surface of the greater wing of the sphenoid bone, which forms part of the roof of the infratemporal fossa. This surface forms the posterolateral border of the inferior orbital fissure and bears an infratemporal crest associated with the origin of the upper part of the lateral pterygoid. The infraorbital and zygomatic branches of the maxillary nerve and accompanying vessels pass through the inferior orbital fissure. Laterally, the greater wing of the sphenoid bone articulates with the squamous part of the temporal bone. Features associated with the pterygoid plate region can be assessed radiographically. A thin-walled depression in the temporal bone, the mandibular fossa, can be inspected when the mandible is removed; in front of this, the zygomatic arch extends laterally. A distinct ridge, the articular eminence, is anterior to the fossa, and three fissures can be distinguished behind it. The squamotympanic fissure extends from the spine of the sphenoid, between the mandibular fossa and the tympanic plate of the temporal bone, and curves up the anterior margin of the external acoustic meatus. A thin wedge of bone forming the inferior margin of the tegmen tympani lies within the fissure and divides the squamotympanic fissure into petrotympanic and petrosquamous fissures. The petrotympanic fissure transmits the chorda tympani branch of the facial nerve from the skull into the infratemporal fossa. The foramen lacerum is bounded in front by the body and adjoining roots of the pterygoid process and greater wing of the sphenoid bone, posterolaterally by the apex of the petrous part of the temporal bone and medially by the basilar part of the occipital bone. A large, almost circular foramen, the carotid canal, lies behind and posterolateral to the foramen lacerum in the petrous part of the temporal bone. The internal carotid artery enters the skull through this foramen, ascends in the carotid canal and turns anteromedially to reach the posterior wall of the foramen lacerum. It ascends through the upper end of the foramen lacerum with its venous and sympathetic nerve plexuses. Meningeal branches of the ascending pharyngeal artery and emissary veins from the cavernous sinus also traverse the foramen lacerum. In life, the lower part of the foramen lacerum is partially occluded by cartilaginous remnants of the developmental chondrocranium. The pterygoid canal can be seen on the base of the skull at the anterior margin of the foramen lacerum, above and between the pterygoid plates of the sphenoid bone. It leads into the pterygopalatine fossa and contains the nerve of the pterygoid canal and accompanying blood vessels.
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The medial longitudinal fasciculus adjoins the somatic efferent column hypertension diet plan order hyzaar 50 mg amex, dorsal to the decussating superior cerebellar peduncles hypertension nih hyzaar 50mg low price. The medial blood pressure elevated buy cheapest hyzaar and hyzaar, trigeminal arrhythmia of the stomach buy 50 mg hyzaar visa, lateral and spinal lemnisci form a curved band dorsolateral to the substantia nigra. Fibres in the medial, spinal and trigeminal lemnisci continue a rostral course to synapse with neurones in the lateral and medial ventral posterior nuclei of the thalamus, respectively (see Figs 8. Some fibres of the lateral lemniscus end in the nucleus of the inferior colliculus, encapsulating it and synapsing with its neurones. Some fibres to the inferior colliculus are collaterals of direct lemniscal fibres. Superiorly, level with the superior colliculus, the tegmentum contains the red nucleus, which extends into the subthalamic region. The ventromedial central grey matter around the aqueduct contains the oculomotor nucleus, which is elongated and is related ventrolaterally to the medial longitudinal fasciculus and caudally reaches the trochlear nucleus. The oculomotor nucleus is divisible into neuronal groups that are partially correlated with the motor distribution of the oculomotor nerve. Substantia Nigra the substantia nigra is a lamina of many multipolar neurones that extends through the whole midbrain, from the medial to the lateral crural sulcus and from the pons to the subthalamic region. The substantia nigra is semilunar in transverse section, concave dorsally and thicker medially, where it is traversed by oculomotor axons as they stream ventrally to their point of exit in the interpeduncular fossa. Extensions from its convex ventral surface pass between fibres of the crus cerebri. The substantia nigra is subdivided into a dorsal pars compacta and a ventral pars reticulata (reticularis), and the cells of these two parts have different connections. The pars compacta consists of many darkly pigmented neurones that contain neuromelanin granules. Their arrangement is irregular, and they partially penetrate the subjacent pars reticulata. The pars reticulata extends rostrally as far as the subthalamic region and is considered to be homologous with the medial segment of the globus pallidus, which it resembles structurally. There are reciprocal connections between the substantia nigra and the basal ganglia. Efferent fibres from the basal ganglia end largely, but by no means exclusively, in the pars reticulata. Topographically organized striatonigral fibres originate from the caudate nucleus and putamen and project to the pars reticulata. The head of the caudate nucleus projects to the rostral third of the substantia nigra, while the putamen projects to all parts. The subthalamic nucleus sends an important glutamatergic projection to the pars reticulata and to the globus pallidus. It projects to the ipsilateral superior colliculus, which may control saccadic eye movements. A few terminate on neurones in the pars reticulata, but many more are fibres of passage to the red nucleus and reticular formation. The red nucleus is an ovoid mass approximately 5 mm in diameter, with a pink tinge, dorsomedial to the substantia nigra. The tint appears only in fresh material and is caused by a ferric iron pigment in its multipolar neurones. Their proportions and arrangements vary among species; for example, in primates, the magnocellular element is decreased, and there is a reciprocal increase in the size of the parvocellular component. In humans, the larger neurones are restricted to the caudal part of the nucleus and have been estimated to be as few as 200 in number. The magnocellular element is considered phylogenetically old, which accords with the parvocellular predominance in primates. Rostrally, the red nucleus is poorly demarcated, and it blends into the reticular formation and caudal pole of the interstitial nucleus. It is traversed and surrounded by fascicles of nerve fibres, including many from the oculomotor nucleus. Principal afferent connections of the red nucleus travel via corticorubral and cerebellorubral fibres. Uncrossed corticorubral fibres originate from primary somatomotor and somatosensory areas. In animals, the red nucleus receives fibres from the contralateral nucleus interpositus (which corresponds to the human globose and emboliform nuclei) and dentate nucleus, via the superior cerebellar peduncle. In humans, the rubrospinal tract is small and originates from the caudal magnocellular part of the red nucleus. The fibres decussate and then run obliquely laterally in the ventral tegmental decussation, ventral to the tectospinal decussation and dorsal to the medial lemniscus. On reaching the grey matter ventral to the inferior cerebellar peduncle, the tract turns caudally to enter the lateral part of the lateral lemniscus. It continues descending ventral to the tract and nucleus of the trigeminal nerve throughout the medulla and enters the upper part of the cervical cord, intermingled with fibres of the lateral corticospinal tract (Ch. Some efferent axons form a rubrobulbar tract to motor nuclei of the trigeminal, facial, oculomotor, trochlear and abducens nerves. The largest group of efferents from the red nucleus in humans is found in the massive uncrossed central tegmental tract (fasciculus), which lies in the ventral part of the midbrain. Initially it lies lateral to the medial longitudinal fasciculus and dorsolateral to both the red nucleus and the decussation of the superior cerebellar peduncles (see Figs 10.
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The lower branch descends in the medial wall of the piriform recess and supplies the aryepiglottic fold arteria ethmoidalis posterior order hyzaar online from canada, the mucosa on the back of the arytenoid cartilage and one or two branches to the transverse arytenoid (which unite with twigs from the recurrent laryngeal nerve to supply the same muscle) blood pressure medication bystolic side effects purchase online hyzaar. The internal laryngeal nerve ends by piercing the inferior pharyngeal constrictor to unite with an ascending branch from the recurrent laryngeal nerve arteria 60 purchase generic hyzaar. As it ascends in the neck blood pressure blurry vision order hyzaar 50mg on line, it supplies branches, more numerous on the left, to the mucosa and tunica muscularis of the oesophagus and trachea and to the inferior constrictor. Pharyngeal Branch the pharyngeal branch of the vagus is the main motor nerve of the pharynx. It emerges from the upper part of the inferior vagal ganglion and consists chiefly of filaments from the cranial accessory nerve. It passes between the external and internal carotid arteries to the upper border of the middle pharyngeal constrictor and divides into numerous filaments that join rami of the sympathetic trunk and glossopharyngeal nerve to form a pharyngeal plexus. A minute filament, the ramus lingualis vagi, joins the hypoglossal nerve as it curves round the occipital artery. They may arise from the inferior ganglion or travel in the pharyngeal branch and sometimes in the superior laryngeal nerve. They form a plexus with the glossopharyngeal rami and branches of the cervical sympathetic trunk. Branches to the Carotid Body 204 Chapter 11 / Cranial Nerves Facial nerve Posterior auricular artery Accessory nerve Sternocleidomastoid Occipital artery Internal jugular vein External carotid artery Third cervical ventral primary ramus Splenius capitis Internal carotid artery Levator scapulae Carotid sinus Fourth cervical ventral primary ramus Scalenus medius Ascending cervical artery Phrenic nerve Inferior thyroid artery Scalenus anterior Superficial cervical artery Facial artery Hypoglossal nerve Lingual artery Nerve to thyrohyoid Internal laryngeal nerve Superior thyroid artery External laryngeal nerve Vagus nerve Common carotid artery Subclavian artery, third part Suprascapular artery Thyrocervical trunk Transmedian cricothyroid arterial anastomosis. The parotid and submandibular glands have been removed, together with the lower part of the internal jugular vein, most of the sternocleidomastoid and the upper parts of the stylohyoid and posterior belly of the digastric. The external laryngeal nerve, smaller than the internal, descends behind the sternohyoid with the superior thyroid artery, but on a deeper plane. It lies first on the inferior pharyngeal constrictor, then pierces it to curve around the inferior thyroid tubercle and reach the cricothyroid, which it supplies. Behind the common carotid artery, the external laryngeal nerve communicates with the superior cardiac nerve and superior cervical sympathetic ganglion. His neurological examination is normal, but laryngoscopy demonstrates paralysis of the left vocal cord. A diagnosis of recurrent laryngeal nerve palsy secondary to operative trauma is made. Discussion: Although the relationship between surgery and vocal cord palsy appears clear in this case, recurrent laryngeal nerve palsy can be caused by a variety of mechanisms, including nerve compression by enlarged mediastinal lymph nodes, local invasion by metastatic carcinoma and compression by a large aortic aneurysm. The nerve can also be affected by systemic polyneuropathy or damaged during placement of an endotracheal tube. The left recurrent laryngeal nerve is more commonly involved than the right, presumably by virtue of its longer anatomical course. Recurrent Laryngeal Nerve the recurrent laryngeal nerve differs, in origin and course, on the two sides. On the right, it arises from the vagus anterior to the first part of the subclavian artery and curves backward, below and then behind it, to ascend obliquely to the side of the trachea behind the common carotid artery. Near the lower pole of the lateral lobe of the thyroid gland, it is closely related to the inferior thyroid artery and crosses in front of, behind or between its branches. On the left, the nerve arises from the vagus on the left of the aortic arch, curves below it immediately behind the attachment of the ligamentum arteriosum to the concavity of the aortic arch and ascends to the side of the trachea. As the recurrent laryngeal nerve curves around the subclavian artery or the aortic arch, it gives cardiac filaments to the deep cardiac plexus. On both sides, the recurrent laryngeal nerve ascends in or near a groove between the trachea and oesophagus. It is closely related to the medial surface of the thyroid gland before it passes under the lower border of the inferior constrictor, and it enters the larynx behind the articulation of the inferior thyroid cornu with the cricoid cartilage. The recurrent laryngeal nerve supplies all laryngeal muscles, except the cricothyroid, and it communicates with the internal laryngeal nerve, supplying sensory filaments to the laryngeal mucosa below the vocal folds. It exits the skull through the jugular foramen and unites for a short distance with the spinal root. After traversing the foramen, the cranial root separates from the spinal part and immediately joins the vagus nerve superior to the inferior vagal ganglion. Those of its fibres that are distributed in the pharyngeal branches of the vagus are derived from the nucleus ambiguus and probably innervate the pharyngeal and palatal muscles, except tensor veli palatini. Other fibres enter the recurrent laryngeal nerve to supply the adductor muscles of the vocal cords, thyroarytenoid and lateral cricoarytenoid. The spinal root arises from an elongated nucleus of motor cells situated in the lateral aspect of the ventral horn that extends from the junction of the spinal cord and medulla to the sixth cervical segment. Their line of exit is irregular rather than linear, and the spinal root usually passes through the first cervical dorsal root ganglion. The rootlets form a trunk that ascends between the ligamentum denticulatum and the dorsal roots of the spinal nerves and enters the skull via the foramen magnum, behind the vertebral artery. It then turns upward and passes laterally to reach the jugular foramen, which it traverses in a common dural sheath with the vagus, but separated from that nerve by a fold of arachnoid mater. As the spinal root exits the jugular foramen, it runs posterolaterally and passes either medial or lateral to the internal jugular vein. The nerve then crosses the transverse process of the atlas and is itself crossed by the occipital artery. It descends obliquely, medial to the styloid process, stylohyoid and posterior belly of the digastric. Running with the superior sternocleidomastoid branch of the occipital artery, it reaches the upper part of the sternocleidomastoid and enters its deep surface, to form an anastomosis with fibres from C2 alone, C3 alone, or C2 and C3, the ansa of Maubrac. More commonly, it emerges a little above the midpoint of the posterior border of the sternocleidomastoid, Cranial Root Spinal Root generally above the emergence of the great auricular nerve (usually within 2 cm of it) and between 4 and 6 cm from the tip of the mastoid process. There the nerve is relatively superficial and related to the superficial cervical lymph nodes. About 3 to 5 cm above the clavicle, it passes behind the anterior border of the trapezius, often dividing to form a plexus on its deep surface that receives contributions from C3 and C4 or from C4 alone.
