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UPPER LIMB RAJ

04/19/2012

coraco-clavicular ligament - situated at medial third - important for


transferring force from UL to trunk hence clavicle usually breaks here.
C2 is the most prominent cervical vertebrae
roots of brachial plexus are ventral rami of selected spinal nerves.
Roots of nerves is different. It is where they emerge from spinal
cord.
roots > nerve > ventral (motor)/dorsal(sensory) rami (branches of
spinal nerves)
elevation depression protraction retraction rotation - scapula
all UL supplied by brachial plexus except trapezius - accessory nerve
nerve that supplies serratus anterior is superficial to it. not deep.
hence easily damaged.
SA & trapezius together causes rotation of scapula.
how to tell if orientation of humerus - BICIPITAL GROOVE in front.
glenohumeral point - principles for stability (similar to that of arches
of the foot)
-bony
capsule not very important because it is very lax to promote range
of movement.
rotator cuff is the most important. - weak below. (dislocation
common)
may dislocate anteriorly as well subscapular bursa there.
-ligamental
-muscular

greater tuberosity prominence when abduct, gets impinged on


coracoacromial arch - clinical: painful arch / tendonitis
-supraspinatus
-infraspinatus
-teres minor
*must laterally rotate head of humerus before it can be fully
abducted. This is to allow the prominence at greater tuberosity to pass
under the coraco-acromial ligament/arch.
axillary nerve humeral neck fracture
radial nerve mid-shaft fracture
median nerve supracondylar fracture
ulnar nerve medial condylar fracture / compression
CLINICAL: medial rotation how is it demonstrated at
glenohumeral joint
1. flex elbow
2. turn forearm medially/laterally
if do with elbow extended, can cheat by pronation/supination
joints hyaline cartilage @ articular surface (except TMJ)
joint cavity inside is synovial membrane.
Long head of biceps covered synovial membrane
Tendon of biceps INTRA-CAPSULAR EXTRASYNOVIAL
Glenoid covered by labrum - Fibrocartilage. Does not repair well.
Similar to menisci in the knee joint.

Orientation: Medial epicondyle is very prominent! ulnar nerve


injury. Claw hand. Ulnar paradox.
Trochlear hinge joint. Only flexion and extension at trochlear.
(ulnar ONLY flexion and extension)
Capitulum-radius allows rotation! radius allows pronation and
supination.
Ulnar tuberosity brachialis. ONLY FLEXION
Coronoid process
Radial tuberosity biceps attached to it. Causes supination when
elbow is flexed. When extended, supinator is the main muscle that causes
it.
Capsule of elbow joint is lax in front and behind. Ligaments at the
side to prevent inappropriate abduction and adduction. (Medial and lateral
collateral ligaments)
Carpal bones found in the hand! (not wrist) *no direct articulation
between carpal bones and ULNAR hence radio-carpal joint
What separates carpal bones from ulnar? fibrocartilaginous disc
Principle: things that separate bones of a joint usually
fibrocartilaginous
E.g. knee joint/vertebrae/wrist joint
Transmission of fall on outstretched hand.
1. Palm
2. RADIUS
Scaphoid and lunate usual victims of injury
Scaphoid usually breaks at its waist.
*unusual PROXIMAL part will undergo avascular necrosis because blood
supply is from distal to proximal same as head of femur

Lunate more prone to dislocation FORWARDS. Flexor retinaculum


is in front of carpal bones ; if lunate dislocate forwards, its going to
increase pressure within carpal tunnel impinge on median nerve
(median nerve compression!)
1st carpal-metacarpal joint. (thumb)
Saddle joint! behaves like a ball and socket joint.
pisiform sticking out. Medially pisiform & distal to that hook of
hamate laterally tuberosity of scaphoid and distally the trapezium:
BOUNDARIES OF FLEXOR RETINACULUM
median nerve compression
sensory lateral 3.5
motor thenar eminence and first two lumbricals (does not include
adductor pollicis *outside thenar eminence supplied by ulnar nerve)
hold a piece of paper by using the proximal end of the thumb to test
for adductor pollicis.
Metacarpal phalangeal joint: bi-axial joint.
Dorsal interossei abduct PAD DAB
Middle finger either way its abduction ; 2 interrosei acts on it
*thumb
abduction forwards away from palm
adduction backwards towards palm
flexion across palm
extension sideways away from palm

latissimus dorsi
- adduction
- extension
- weak medial rotator
innervated by posterior cord of brachial plexus thoracodorsal
nerve
gluteus medius and minimus superior gluteal nerve
gluteus maximus inferior gluteal nerve
cephalic vein enters the deltopectoral triangle to empty into the
axillary vein
pectoralis major causes medial rotation, adduction and flexion.
Anterior division of brachial plexus lateral and medial cords
Lateral and medial pectoral nerve
Axillary folds anteriorly pectoralis major; posteriorly latissimus
dorsi
Posterior fold is lower from the front can see both folds
Neurovascular bundle is deep to biceps brachii and coracobrachialis.
Deltoid is CONTINUOUS with brachialis. ; can trace it down to
identify brachialis when biceps is removed.
Medial epicondyle flexor group
Lateral epicondyle extensor group [1st muscle to be seen; most
superficial BRACHIORADIALIS

Arrangement of forearm muscles digits in the middle, wrists on


either sides
Most superficial from lateral side brachioradialis first!!!! Flexor
carpi radialis, palmaris longus, flexor carpi ulnaris
Lateral to radialis : where you feel the radial pulse
[lateral to radialis radial artery; lateral to ulnaris ulnar artery]
flexor digitorum profundus medially (where the digits are)
flexor pollicis longus laterally (where the thumb is)
palm of the hand superficial and lateral to the flexor tendons:
LUMBRICALS ; cannot be interossei because interossei is deep.
Action of lumbricals important because it is the basis of claw hand!
Flexion to metacarpal phalangeal joint; extension to interphalangeal joint
Distal transverse border of the metacarpal phalangeal joint =
proximal border of flexor sheath.
SURFACE MARKING FOR MEDIAN NERVE
Flex wrist to show prominence of FCR and Palmaris longus.
IN BETWEEN the two is the surface marking of median nerve.
Extensor carpi radialis
- longus lateral

- brevis medial
first dorsal interosseus ABDUCTS the index finger!
Anatomical snuffbox!
Going from flexor side of arm AROUND WRIST to extensor side
of arm
Abductor pollicis brevis, [abductor pollicis longus, extensor pollicis
brevis,] extensor pollicis longus
- crossed by important structures
1. radial artery
2. radial nerve
3. cephalic vein
extensor pollicis longus turns around a tubercle on the radius
scaphoid deep into anatomical snuffbox!
Lower border of Pectoralis minor is where the axillary vessels becomes the
brachial vessels
Biggest nerve in the axilla median nerve
Musculocutaneous nerve pierces the coracobrachialis.
M supplies the anterior portion of arm.
Tips of the M musculocutaneous, median, ulnar
Musculocutaneous nerve supplies both biceps and brachialis. Hence it lies
between them and eventually becomes CUTANEOUS at the cubital fossa.
Median nerve is medial to brachial artery

C4 until sternal angle to lower deltoids (cervical plexus) as if standing


in water
Hence to test C5 test below to that line.
Profunda brachii accompanies radial nerve on its way towards radial
groove.
Radial nerve divides into deep and superficial branches.
Superficial sensory (branch that passes the anatomical snuffbox)
Deep motor
o If injury to deep branch motor loss partial/complete wrist
drop!
o No significant sensory loss
o Does not extend to the anatomical snuffbox (wrist)
(crutch palsy)
stretch reflex feedback mechanism to control muscle length by
causing muscle contraction
tendon reflex feedback mechanism to control muscle tension by
causing muscle relaxation before muscle force becomes so great that
tendons might be torn.
Trigger finger: inflammation of tendons in the palm that acts as
pulleys for the hand movements (grasping). Tendons that are supposed to
glide smoothly through gets stuck and it becomes hard to straighten the
fingers.
Injury to Brachial plexus*:
Upper trunk of brachial plexus C5,6 Erb Duchenne Palsy
Damage causes:
Arms hang by the side

Elbows cannot flex


Arm medially rotated
Forearm pronated (weakness of supination)
Waiters tip
Loss of sensation over deltoid (C5) & lateral upper limb (C6)
Nerves involved:
Suprascapular (infraspinatus)
Nerve to subclavius
Lateral pectoral
Musculocutaneous (biceps brachii, brachialis, coracobrachialis)
Median
Axillary (Teres minor, deltoids)
Lower trunk of brachial plexus C8, T1 Klumpkes paralysis
Damage causes:
Paralysis of intrinsic muscles of the hand
Paralysis of flexors of the wrist and fingers
Axillary lymph nodes first affected by infection of the hand are the
LATERAL ones.
Axillary lymph nodes first affected by BREAST CANCER are the
ANTERIOR/PECTORAL ones.
Ulnar nerve innervates deep head of flexor pollicis brevis in the
thenar eminence

Median cubital vein is commonly used for venipuncture. This vein is


separated from underlying neurovascular structures by the bicipital
aponeurosis. This protects internal structures from accidental punctures.
The brachial artery is directly below the median cubital vein.
Superficial palmar arch ulnar
Deep palmar arch radial mnemonic: DoctoR.
Dual innervation flexor digitorum profundus & flexor pollicis brevis
Filum terminale is the continuation of pia mater.
Conus medullaris is the terminal end of spinal cord.
Nuchal ligament is the fibrous membrane, which, in the neck,
represents the supraspinal ligaments of the upper vertebrae (req. for
running)
Ligamenta flava ligaments which connect the laminae of adjacent
vertebrae
Posterior longitudinal ligament within vertebral canal, in front of
spinal cord.
Anterior longitudinal ligament outside vertebral canal, in front of
vertebra.
Sternoclavicular joint is the joint that serves as the only bony
attachment of the superior limb to the axial skeleton.
1st rib proximal fracture compresses thoracic duct or sympathetic
chain. results in horners syndrome.
External rotation at shoulder:
Infraspinatus
Deltoids
Teres minor

Temporomandibular joint is the only synovial joint that has articular


surfaces covered by fibrocartilage including the articular disc.
Third part of axillary artery forms collateral circulation with the first
part of subclavian artery, providing collateral circulation.
Upper motor neuron lesion (usually UMN exerts inhibitory effect):
Exaggerated reflex action
Lower motor neuron lesion:
Absent reflex action

Components of the arch of foot


Orientation of femur lesser trochanter points a little posteriorly
Major muscle for lateral rotation gluteus maximus
Iliofemoral ligament attached to anterior inferior iliac spine.
Prevents over-extension!! As gravity is pointed behind the iliofemoral
joint.
Clues for orientation: lateral side of the femur @ the condyles is a
tubercle for attachment of the popliteus tendon!
Adductor tubercle is found at the supracondylar ridge at the medial
side.
The lateral anterior side of condyle is more prominent to
prevent the femur from dislocating laterally!
PATELLA falls on the lateral side when you put it down. *lol like a
rigged dice
Common peroneal nerve crosses the lateral ridge at the fibula.
Easier injured as it is superficial.
PED TIP

Injury results in foot drop and inability to dorsiflex. usually from


habitual crossing of the leg
Medial collateral ligament (attached to medial meniscus) prevents
adduction and abduction.
Anterior cruciate ligament drawer test.
Medial malleolus from tibia. Lateral malleolus from fibula. Lateral
malleolus is longer. Weaker at the lateral side medial side has strong
deltoid ligament.
Joint stronger in dorsiflexion as it increases the contact of talus with
malleolus.
Anterior talofibular ligament prevents forward displacement of the
foot on the leg
Extensor digitorum brevis to dorsiflex the toes even when the
ankle joint is at right angles. The hand doesnt have this.
Sciatic nerve exits just below piriformis.
Stability of hip joint acetabulum
deep acetabulum socket made deep by acetabular labrum
ball & socket joint
ligaments
muscles
what stabilizes the lateral meniscus?
Anterolateral stabilization iliotibial tract, capsule
Posterolateral stabilization:
Collateral ligament

Popliteus muscle and tendon


Arcuate ligaments
Lateral gastrocnemius muscle

Triceps surae causes flexion at the knee and plantar flexion at the
ankle.
Gastrocnemius originates from condyles of femur
When sitting down from the standing position, the muscle that is
least active is the biceps femoris (hamstring muscles)
Medial longitudinal arch
Bony:
o Calcaneus
o Talus
o Navicular
o 3 cuneiforms
o first 3 metatarsals
Ligamental:
o Plantar calcaneonavicular ligament (spring ligament)
o Plantar aponeurosis
o Tibialis anterior and posterior
o Peroneus longus
o Flexor hallucis longus
o Flexor digitorum longus

Lateral longitudinal arch:


Bony:
o Calcaneus
o Cuboid
o 4th & 5th metatarsal
Ligamentum:
o Long plantar ligament
o Plantar calcaneocuboid ligament
Internal rotators of the knee:
Popliteus
Semimembranosus
Semitendinosus
The FEMUR is laterally rotated ON THE TIBIA when unlocking of the
knee occurs. *be careful of the phrasing.trick qn
Internal rotation of femur at hip:
Tensor facia lata
Gluteus medius
Gluteus minimus
External rotation of femur at hip:
Gluteus maximus
Lateral rotator group pretty girls often get off quickly

Sartorius
Obturator externus

External rotation of the leg at the knee:


Biceps femoris
Femoral nerve supplies sensation to the medial side of the leg and
the BIG TOE (foot) via the saphenous nerve.
Anterior cruciate prevents forward displacement.
Posterior cruciate prevents backward displacement.
Lateral meniscus of the knee joint is attached to the popliteus
muscle.
Stability of the ankle joint is best assisted by dorsiflexion which
increases the surface area of contact
Safest place for injection at the gluteal area is at the upper lateral
quadrant.
Sciatic nerve is most at risk in an injection over the lower medial
quadrant
Surface mark sciatic nerve: midpoint between ischial tuberosity and
greater trochanter
Flexor hallucis longus tendon runs in a groove beneath the
sustentaculum tali.
Abductors & flexor digitorum brevis in the foot lie in the first layer.
Longus toe muscles lie in the 2nd layer
Adductors and brevis toe muscles lie in the 3rd layer.

Deep peroneal nerve innervates the area of skin between the big
toe and the 2nd toe.
Femoral triangle:
Superior: inguinal ligament
Medial: ADDUCTOR LONGUS (not gracilis!)
Lateral: Sartorius
Floor: pectineus & adductor longus & iliopsoas
Roof: Fascia lata
Superficial peroneal nerve innervates the anterolateral compartment
of leg muscles. Injury to this nerve results in inability to EVERT and loss
of sensation over the dorsum of the foot (except for the area bet. Big toe
and 2nd toe)
Deep peroneal nerve foot drop & inversion affected.
Supplies anterior compartment:
o Tibialis anterior
Chief flexor of the thigh: iliopsoas
Popliteus tibial nerve
Short head of biceps femoris is NOT part of hamstrings.
Gastrocnemius is unable to plantarflex the ankle when knee is
FLEXED.
Surface marking of femoral artery:

Point midway between ASIS & symphysis pubis adductor tubercle


Femoral nerve saphenous nerve (narrow medial side of leg and
medial border of foot as far as ball of big toe)
Injury to sciatic nerve sensory loss below the knee except for
the aforementioned region
Common peroneal nerve pierces peroneus longus. Deep peroneal
nerve supplies area of skin bet. Big toe and 2nd toe.
Small saphenous nerve behind lateral malleolus
Great saphenous nerve in front of medial malleolus
Deep venous drainage of leg 85%
Superficial venous drainage of leg 15%
Medial malleolus is used for cathetering when median cubital vein is
not visible.
Histology of lymph nodes
Bean-shaped surrounded by collagenous capsule
B lymphocytes arranged in lymphatic follicles with germinal
centres at the superficial cortex
T lymphocytes mainly at the paracortex between cortical nodules
and medulla
Medulla contains mainly plasma cells and macrophages
Vastus intermedius prevents hyperextension. Vastus medialis
prevents lateral dislocation of patella.
Blood supply to femoral head
Lateral and medial femoral circumflex arteries retinacular
branches

Small acetabular branch of the obturator artery

4 quadrants
superior quadrants lymph vessels drain into axillary nodes
inferior quadrants lymph vessels drain into superficial inguinal
lymph nodes
sternal angle T4
cervical up to sternal angle sensory C4. Upper limb C5
like standing in shallow water
C6 is the last intercostal nerve to reach sternum/xiphoid process
The rest continues as thoracoabdominal nerves
Tumor at inlet of lungs impede on certain nerves
Sympathetic cervical chain (Horners Syndrome). T1 affected.
Brachial plexus affected.
Tubercle of ribs articulates with the same number vertebrae
transverse process.
Head articulates with same number and preceding number
vertebrae.
Pleural and lung reflections! 2-4-6-8-10-12
Thymus gland migration from neck to anterior mediastinum.
Drains backwards into the left brachiocephalic vein.

In cases of obstruction of aorta


Anterior intercostals anastomose with posterior intercostals
Superior epigastric anastomose with inferior epigastric ->external
iliac and femoral artery epigastric anastomosis lies within the rectus
sheath
Phrenic nerve from cervical plexus as diaphragm developed in
region of neck and migrated down. C3,4,5 referred pain to shoulder!
Splanchnic nerves go towards plexuses celiac, superior
mesenteric, etc
Artery normally anterior superior, veins posterior inferior sagittal
cut at mediastinum. Bronchus thicker with cartilage.
Auscultation of lungs lower lobe from behind. Upper lobe from in
front. Middle lobe from axilla below T4 as horizontal fissure corresponds
with T4.
Injury to phrenic nerve: tone of muscles unable to keep diaphragm
down. Abdominal pressure pushes it up on the injured side. [see-saw
movement]
Apex beat of the heart
In front of root of lungs phrenic
Behind root of lungs & hook around arch of aorta (right side:
subclavian) vagus nerve / recurrent laryngeal nerve
Pericardium covered by parietal pleura. Fibrous pericardium
between parietal pleura and parietal pericardium.
Right atrium giving off pulmonary trunk. In between SVC and
pulmonary trunk arch of aorta
Left anterior interventricular branch of left coronary artery :
commonly obstructed RV, LV & IV septum affected.

Conducting system mostly supplied by right coronary artery


In the heart pulmonary artery ABOVE pulmonary veins explains
arrangement in the root of the lungs.
Left atrium below with the pulmonary veins! Mitral valve!
Arch of azygos joins SVC at the sternal angle! T4!!!
A pump that matters!
Hemiazygos (with descending aorta) at the left side. Azygos at the
right side.
Ligamentum arteriosum allows blood to bypass the fetal lungs as
ductus arteriosum. [right to left shunt]
Patent ductus arteriosum caused congestive heart failure.
Fossa ovalis at the bottom of fossa ovalis represents primordial of
interatria septum: septum primum. On top is septum secundum.
Below and in front of fossa ovalis opening to coronary sinus.
Behind left atrium esophagus! one of the potential causes of
dysphagia when hypertrophy of atrium occurs.
Between azygos and aorta/esophagus THORACIC DUCT opens
at the confluence of left subclavian and internal jugular vein [left side]
Capillaries have:
No gap junctions
No muscular fibres

A basal membrane surrounding it


Pericytes (a type of cell found in CNS) in some instances
Continuous with TIGHT junctions/ fenestrated (in glomerulus)

Azygos Veins:
Formed by the union of ascending lumbar veins and the right
subcostal veins at T12
Communicates with the common iliac vein and (the lumbar veins
via the ascending lumbar)
Annulus ovalis is the prominent ridge of the fossa ovalis. It is
formed by the septum secundum
Hilum of lungs
Bronchiolar arteries (from arch of aorta)
Pulmonary veins (posterior inferior)
Pulmonary arteries (anterior superior)
Lymphatic vessels
Sympathetic nerve vessels
NO BRONCHIOLES
Bronchus
Closure of the mitral valve and tricuspid valve causes the first heart
sound.
Capillaries have NO gap junctions.
Atrial septa defect involves:

Septum primum
Foramen ovale
Ostium secundum
*endocardial cushions of atrioventricular canal.

The bronchopulmonary segments are partially covered by visceral


pleura.
Anterior interventricular artery accompanies great cardiac vein.
Posterior interventricular artery accompanies middle cardiac vein.
Azygos vein makes the most pronounced impression on the RIGHT
lung.
LEFT lung arch of aorta
Sternal

angle:
Thymus
Arch of aorta
Arch of azygos
Bifurcation of trachea

C4
Bifurcation of the common carotid artery
Vertebrae T11 & T12 do NOT have costal facets for the articulation
of ribs.
Scalene tubercle for attachment of scalenus anterior:

Anterior groove: subclavian vein


Posterior groove: subclavian artery

Posterior border of lungs: spinous process of 7th cervical vertebra to


level of 10th thoracic vertebra.
Two types of pleural recesses:
Costo-diaphragmatic recess
Costo-mediastinal recess
Needle aspiration:
Skin
Superficial fascia & subcutaneous tissue(containing fats)
Serratus anterior and pectoral muscles
Ribs
Thin but strong intercostal muscle
o External
o Internal
o (intercostal nerves and arteries)
o Innermost
Endothoracic fascia
Parietal pleura
Trachea starts at C6 and ends at T4.

When tumor cells invade lymph nodes, enlargement of lymph nodes


may compress the left recurrent laryngeal nerve producing paralysis of
the left vocal cord, causing hoarseness of the voice.
Heart is prone to infarction as heart tissues are very efficient at
obtaining oxygen from blood so the only way to increase O2 supply to
heart is to increase blood flow which would be impinged by
artherosclerosis.
Anastomosis between terminal branches of RCA and LCA are
usually not large enough to provide adequate blood supply to
cardiac muscles should any one of them become occluded.
Must use terms like operating at the top of the cardiac output curve
hence not much CARDIAC reserve left.
Coronary arteries are muscular.

Anterior superior iliac spine L4,5


Inguinal ligament (to pubic tubercle)
Lateral cutaneous femoral nerve
Sartorius
Anterior inferior iliac spine
Rectus femoris
Lumbar vertebrae DOES NOT allow for rotation.
Costal margin 7th costal cartilage to 10th costal cartilage
Umbilicus T10

Appendix McBurneys Point (lateral 1/3 along the line from ASIS to
umbilicus)
Rectus sheath anterior more extensive than posterior
Posterior stops below umbilicus @ arcuate line
Contents of spermatic cord
Skin
Dartos
External spermatic fascia
Cremasteric fascia
Internal spermatic fascia
Parietal Tunica Vaginalis
Visceral Tunica Vaginalis
Testicles
Transversus Abdominis has no contribution to the spermatic cord!
Below umbilicus; perineum, anus, thigh, abdominal wall
superficial inguinal lymph node
Cutting of nerves in surgery causes weakening of abdominal
muscles predisposing to hernia!
E.g. ilioinguinal nerve L1 (area of referred pain for kidney and
ureter)
Anastomosis between inferior and superior epigastric is within
rectus sheath

Parietal peritoneum somatic ; sensitive to pain


Deep inguinal ring lateral to inferior epigastric artery
Reinforced in front by external oblique and internal oblique.
Differentiate bet direct/indirect/femoral hernia
All the way from mouth till liver/stomach/greater omentum (dorsal
mesogastrium)/lesser omentum (ventral mesogastrium) foregut
Falciform ligament at the free border ligamentum teres
Ligament of treitz attached duodenum to liver
Between liver and gallbladder quadrate lobe! Behind quadrate lobe
porta hepatis
Hepato-renal pouch part of greater omentum past right paracolic
gutter iliac fossa - pelvis rectovesical pouch in men
Normal direction twisting of intestines superior mesenteric in front
of duodenum behind transverse colon. Wrong direction reverse.
Retroperitoneal structures SAD PUCKER
Appendices epiplocae
Liver from the top. Notch on the left side for gastroesophageal
junction.
Ligamentum venosum fresh blood that bypasses liver
If finger inside epipolic foramen anterior is portal vein (with portal
triad)/posterior is IVC

Fundus & pylorus mostly protective mucous glands (isthmus


mucous neck cells). Only at the body H+ secreting glands
parietal/oxynitic cells
Chief cells pepsinogen
Inferior mesenteric vein drains into splenic vein SMV joins splenic
vein to form portal vein.
Ureter in X-rays: L2 - transverse processes ischial spine
bladder
Supracrestal plane bet two iliac crest L4/5 location for lumbar
puncture
Orientation of systems GIT in front of Gonadal in front of Renal +
suprarenal glands
Transpyloric plane above this plane : no renal
L1:
Left renal pelvis (hilum)
superior mesenteric artery arises at L1
1st part of duodenum
pylorus of stomach
right and left colic flexure
neck of pancreas
fundus of gallbladder
loin to groin pain
T12:

Foramen of winslow
Median arcuate ligament where aorta and thoracic duct pierces
the diaphragm
Splanchnic nerves pierce diaphragm at this level

Relations of spleen*
Liver in front of stomach in front of spleen
Pancreas is key landmark for celiac and superior mesenteric vessels.
Colic vessels in front of gonadal vessels in front of ureter.
Main source of blood supply to rectum is superior rectal artery
Renal fascia separate peri- and pararenal fat. Clinically important
because abscess collects there.
Peri-renal fat separates suprarenal glands from kidneys.
Volvulus twisting of intestines.
Right & left hepatic duct joins to form the common hepatic duct.
The common bile duct terminates at the 2nd part of the duodenum
Segmental arteries to the kidneys have poor anastomoses!
Segmental > interlobar > arcuate > interlobular > afferent

Transpyloric plane:
End of spinal cord
Spleen
Left kidney
Duodenum (junction of 2nd & 3rd part)
Ureteropelvic junction
Transverse colon
Pancreas with uncinate process
Renal veins & artery
Duodenojejunum junction
L4
Bifurcation of aorta into common iliac vessels
Lymphatic drainage:
Scrotum superficial inguinal lymph nodes
Testes para-aortic lymph nodes
Main branches of celiac:
Remember with relation. Stomach on the left. Liver on the right.
Spleen on the left. Hence:
Left gastric
Common hepatic
Splenic

Porta Hepatis:
Hepatic arteries
Hepatic ducts
Autonomic nerves from celiac plexus
Portal vein [**do not confuse with hepatic vein exits liver
superiorly to join the IVC]
Common bile duct, hepatic artery and portal vein are fond grouped
together in the hepatoduodenal ligament.
Boundaries of the lesser sac:
Lateral: (left) Gastrosplenic ligament, Splenorenal ligament
Superior: Left triangular ligament of liver
Anterior: Lesser omentum (hepatoduodenal ligament[with portal
triad inside] & hepatogastric ligament)
Posterior: Pancreas , IVC
Floor: Pancreas
**lesser sac develop mainly from ventral mesogastrium
gastric anastomoses occur in the serosa
inguinal hernias pass SUPERIOR to inguinal ligament
femoral hernias pass INFERIOR to inguinal ligament
Counterclockwise rotation of gut:
SMA anterior to duodenum & posterior to transverse colon

Transverse colon posterior to duodenum & SMA


Clockwise rotation of gut
Needle in vagina can be used to determine fluid-dependent spaces
within the peritoneal cavity Rectouterine pouch of douglas!
Palpation through the vagina from the position of the cervix
At the fornix can palpate uteric stones in the ureter close to the
bladder
Each suprarenal gland is drained by a single vein.
Right suprarenal drains into IVC
Left suprarenal drains into left renal or left inferior phrenic
Usually 3 arteries supply suprarenal glands
Superior suprarenal inferior phrenic artery
Middle suprarenal abdominal aorta
Inferior suprarenal renal artery
Suprarenal glands innervated by preganglionic sympathetic fibres
derived from the splanchnic nerves; most of the nerves end in the
medulla of the gland.
Right suprarenal (under liver) - pyramidal
Left suprarenal crescent
Epithelium of PCT: simple cuboidal with MICROVILLI
Epithelial of bladder ureter renal pelvis: transitional epithelium

*random note:
blood transfusion only RBC
massive blood transfusion all blood components [severe
hemorrhage]
No intervertebral discs are found between first two cervical
vertebrae as well as sacrum and coccyx.
Transversus abdominis does not contribute to the inguinal ligament.
Any nerve that innervates a striated muscle must also carry afferent
sensory for fine tuning of contractions!
Indirect inguinal hernia
Leaves abdominal cavity lateral to inferior epigastric vessels
Hernia sac formed by patent processus vaginalis and all 3 fascia
of spermatic cord
Medial to pubic tubercle (processus vaginalis guides the hernia
sac into scrotum)
Traverses entire inguinal canal
Direct inguinal hernia
Leave abdominal cavity medial to inferior epigastric vessels
o Protrudes through relatively weak part of posterior wall of
inguinal canal
Emerges through or around conjoint tendon to reach superficial
inguinal ring
Hernia sac formed by transversalis fascia
o Runs parallel to spermatic cord and outside inner 1 or 2
fascia coverings of the cord.
Caused by weakness/defect in transversalis fascia area of
hesselbach triangle (inguinal triangle).

Traverses only part of inguinal canal

Femoral hernia
Below and lateral to pubic tubercle (above and medial to pubic
tubercle in inguinal hernia)
Only splenic artery is related to the stomach! Not the splenic vein
which joins the superior mesenteric vein to form the portal vein.
Portal vein = short, wide vein formed by SMV and splenic veins
posterior to neck of pancreas, ascending anterior to IVC, and divides at
right end of porta hepatis into right and left branches that ramify within
the liver.
In the liver, lymph and bile drains in the opposite direction as blood
flow (central to peripheral)
Morphology: form of the organ and the relationships with its
structure
Ventral mesentery (derived from septum transversum) gives rise to
Lesser omentum
Falciform ligament
Kupffer cells are intrasinusoidal.
Lymph nodes acts as filter for lymph. Spleen is the immunologic
filter for blood.
Superior mesenteric vessels are sandwiched between the pancreatic
head and uncinate head.
Pancreas developed from dorsal and ventral buds of endodermal
cells from foregut

Superior mesenteric vein is situated to the right of superior


mesenteric artery, because it joins the splenic vein to form the portal vein
and drains eventually to the liver, which is situated on the right!
In large intestines:
No villi for absorption epithelial cells have microvilli, giving a
brush border appearance
Lymphoid tissues exist as mucosa-associated lymphoid tissue
(MALT) in the mucosa layer. Lymphoid vessels are absent.
o Therefore, colonic cancer develops slowly as metastasis
can only occur until cells breach the submucosa where the
lymphatic vessels lie.
Myenteric nerve plexus present between outer longitudinal and
inner circular muscular layer
Appendicular artery goes from base to tip of appendix and passes
on to mesoappendix. It may sometimes pass through posterior to
terminal ileum compression of artery
Anatomical end artery hence blood supply to appendix affected.
Necrosis perforation and eventually peritonitis of greater sac.
Identification of kidneys in SPOTs:
Lower pole: ureter runs parallel
Upper pole: broader for suprarenal gland attachment
Left renal vein longer than right renal vein
Anterior surface: convex
Posterior surface: flatter for attachment to posterior abdominal
wall
Anteroposteriorly at hilum of kidneys:
VAUA
Ureter:

On psos crossed anteriorly by gonadal vessels, posteriorly by


genitofemoral nerve
Before termination, crossed anteriorly by vas deferens.

GIT in front of Gonadal in front of Renal/Suprarenal


Pain from urethra: conducted through pelvic splanchnic nerves
(parasympathetic)
Pain from ureter: sympathetic accompanied by other sympathetic
effects.
Kidney nephrons:
PCT simple columnar-to-cuboidal with brush border microvilli
DCT simple cuboidal no brush border
Collecting tubule simple cuboidal-to-columnar
Collecting ducts - simple columnar
@ calyxes and renal pelvis: transitional epithelium
Spleen:
1 by 3 by 5
weighs approx. 7 oz
lies between 9-11th rib at the mid axillary line
red pulp mechanical filtration
o sinus filled with blood
o splenic cords (cords of billroth) filled with reticular fibres,
macrophages and monocytes
o marginal zones bordering on white pulp

white pulp active immune response through humoral and cellmediated pathways
o composed of nodules malpighian corpuscles
lymphoid follicles rich in B lymphocytes
Periarteriolar Lymphoid Sheaths (PALS) rich in T
lymphocytes

At least 10 cm diameter for delivery pelvic inlet


Shape of pelvis male VS female
Arcuate line in the pelvis attachment of pelvic diaphragm
Pudendal nerve mixed nerve
Renal pelvis transitional epithelium
Parasympathetic supply from pelvic splanchnic nerves to erectile
tissue runs along prostate with venous plexus of prostate and finally
into penis
FEMALE
Fallopian tube:
Posterior ovaries
Anterior round ligament of ovaries going towards the deep
inguinal ring
Fimbriae
Infundibulum
Ampulla
Isthmus

Broad ligament of ovaries* MEQ


What system stimulates the emptying of seminal vesicles?
Ejaculation sympathetic
Gonadal vessels in front of ureter water under the bridge
Rectum drains into internal iliac lymph nodes.
Rest of inguinal and anal canal drains into the inguinal lymph nodes.
Femoral pulse is best felt at the mid-inguinal point
Pelvic Diaphrahm VS Urogenital Diaphragm
Pelvic Diaphragm levator ani
Urogenital diaphragm triangular ligament that separates deep
perineal sac from upper pelvis.
Lumbar puncture/spinal anesthesia
skin
subcutaneous tissue
supraspinous ligament
interspinous ligament
ligamentum avum
epidural space [containing the internal vertebral venous plexus]

dura
arachnoid
and nally the subarachnoid space

valveless pelvic venous plexus.


Network of valveless veins that connects deep pelvic veins and
thoracic veins(draining the urinary bladder, breast, prostate) to the
internal vertebral venous plexus.
Due to location and lack of valves, it is a route for cancer
metastases.
E.g. from rectum/prostate/viscera to sacrum to vertebrae to
skull.
SVC valveless too!
Sacrum 5 rudimentary vertebrae fused together to from a wedge
shaped bone.
Coccyx 4 vertebrae fused together to form a single, small
triangular bone.
Foramen Transversarium transmits vertebral artery and veins
except C7!
Atlanto-occipital joint:
3 synovial joints:
2 lateral atlanto-axial joints: gliding joint (right and left)
1 median atlantoaxial joint: pivot joint

Dorsal rami of sacrum supply erector spinae & skin near midline

Sacral hiatus caudal anesthesia


External genitalia
Crura corpus cavernous
Bulb > corpus spongiosus > contains urethra
Change of epithelium in anal canal.
Pudendal nerve, ilioinguinal nerve contributes to sensory innervation
to external genitalia.
Vas deferens begins at the bottom then goes up to epididymis!
Lymphatic drainage follows blood supply.
External iliac vessels from inguinal nodes, vagina, cervix
Internal iliac pelvic viscera, perineum, buttock, thigh
Para-aortic testes & ovaries
External genitalia, lower part of anal canal Superficial inguinal
lymph nodes
Lower part of rectum (together with upper part of anal canal)
internal iliac nodes
Upper part of rectum inferior mesenteric nodes
Bladder external iliac
Prostate internal iliac
Body of uterus external iliac and lumbar nodes
Cervix external & internal iliac

Broad ligament of uterus encloses:


Ovarian ligament
Uterine tube (fallopian tube)
Round ligament
Uterine artery
*NOT THE URETER
obturator internus leaves the pelvis by passing through the lesser sciatic
foramen.
Uterine artery does not cross the pelvic brim as it is from the internal
iliac!
Rectouterine pouch (of douglas) is most likely to accumulate fluid.
Upper canal and lower canal differ in embryological origin separated by
cloacal membrane.
Anal continence
internal & external sphincters
puborectalis
for anesthesia
spinal subarachnoid
epidural epidural space
caudal epidural space

transverse ligaments ensure the stability of the uterus position.


Transverse cervical
Pubocervical
Sacrocervical

Sacral nerves/plexus supplies the obturator internus, iliococcygeus,


coccygeus.
Levator ani supplied by perineal branch of 4th sacral nerve &
perineal branch of pudendal.
Fallopian tube simple ciliated columnar epithelium
Micturition reflex is centered in the sacral cord.
An oocyte surrounded by ONE layer of squamous follicle-like cells
primordial follicle
An ANTRUM is characteristic of SECONDARY & GRAAFIAN
FOLLICLES
Primary oocytes are diploid. 1st haploid is at secondary
oocyte/spermatid.
Sertoli cells produce androgen-binding proteins to concentrate
testosterone within seminiferous tubules for spermatogenesis.
Testes originate in RETROPERITONEAL SPACE! NOT ABDOMINAL
CAVITY.
Descend 2 months prior to birth

Prostate secrete alkaline mucus


Seminal vesicle fructose, prostaglandins, mucus, vitamin C,
enzymes
Result of oogenesis = ONE secondary oocyte [haploid]
Thyroid hormone is an amine hormone with steroid hormone
mechanism.
Most important support to the uterus is the tone of levator ani
muscles.
Urethra
Prostatic
o Widest/transitional
Membranous
o Narrowest/deep perineal pouch/external urethral sphincter/
pseudostratified columnar
Penile
o Pseudostratified columnar stratified squamous
Ureter cannot be palpated in an rectal examination!

Neck Triangles

Clavicle 2 key muscles attached to top 2 key muscles attached to


bottom.
Top:
o Trapezius
o SCM
Bottom
o Pectoralis Major
o Deltoids
Coracoid process
Pectoralis minor
Short head of biceps
Coracobrachialis
C2 first and most prominent
Atlas holding up the world
Atlanto-axial rotation
Atlanto-occipital flexion/extension/sideways flexion
Can/yes joint nodding & boleh
C1 no skin innervation
Scalenus anterior originate from anterior tubercle
Scalenus posterior originate from posterior tubercle

If damage mandibular branch of facial nerve cant close mouth


properly so food will spill out
Hyoid c3
Bifurcation of carotid; top of thyroid; adams apple c4
Cricoid cartilage c6
Best point for injection of anesthetic for cervical plexus - midpoint
of SCM
Will numb skin from neck to sternal angle and superior deltoids
Part of the ear to the back of the scalp
****Superior laryngeal nerve damage leads to weakening of the
voice

Safe place to cut/ligate this nerve is close to thyroid gland


Accompanying superior thyroid artery and said nerve getting
further apart near the gland.
****for the inferior thyroid artery safer to cut far from the gland
near the gland, the nerve and artery are getting closer together
(converging)
Dont confuse ansa cervicalis (anterior) with vagus (posterior)
*hypoglosseal nerve emerge at angle of mandible and cross before the
ICA and ECA finally disappearing inside the mylohyoid.
Tracheal esophageal junction: important thing is the recurrent laryngeal
nerve
Under carotid sheath demonstrates the inferior thyroid arteries.

SVC phrenic closely related.


CRANIAL CAVITY
Muscles that opposes orbicularis oculi
levator palpebrae superioris
innervated by occulomotor nerve
sphincters are more important.
Danger area
Through orbit
o Superior & inferior ophthalmic vein
Infra-temporal fossa
o Inferior ophthalmic vein through inferior orbital fissure
Homunculus is upside down!
ECA ICA anastomoses
Inter-tragic notch to philtrum parotid duct opens at 2nd upper
molar
External carotid directly above digastric
Important branches of facial nerve:
Zygomatic

Marginal mandibular branch


Buccal

Parotid duct lined by simple columnar.


Pterion 2 fingers breadth above zygomatic arch, 1 thumbs
breadth behind vertical part of zygomatic bone
Anterior clinoid process most anterior and superior is the optic canal.
The other is the groove for ICA
Nasopharyngeal cancer invades sphenoid air sinus.
From sphenoid can invade into cavernous sinus
Implication of 3,4,6
Abduction 6 abducens
Depression 4 superior oblique
Accommodation, convergence of eye, pupillary constriction 3
Middle meningeal anterior branch crosses pterion. Hemorrhage here
affects upper body! homunculus upside down
Granular pits ; arachnoid granulations reabsorption of CSF
Dura includes endosteum.
Damage to superior cerebral veins results in subdural hemorrhage
between dura and arachnoid - at the top impede on cortex that affects
lower body.

Falx & tentorium stabilize the brain and limit its mobility as it floats
in CSF
Nerves appear different from foramina because nerves travel
between dura and endosteum
Vertebral artery supplies occipital region visual
Carotid supplies motor and sensory regions
9 10 11 beside jugular tubercle
7 8 inside internal acoustic meatus
4 seldom seen smallest of cranial nerves
ALL EXCEPT ONE:
ALL sensory information that eventually reach cortex must pass
through thalamus EXCEPT olfaction
pyramidal cells occupy ALL horizontal cortical layers of cerebral
cortex EXCEPT layer IV (stellate cells)
prefrontal cortex has 2-way connections with ALL parts of cortex
EXCEPT primary motor & somatosensory cortex.
ALL strap muscles are supplied by ansa cervicalis EXCEPT
thyrohyoid (C1).
Recurrent laryngeal nerve supplies ALL of laryngeal muscles
(intrinsic) EXCEPT cricothyroid (extrinsic) (external laryngeal branch of
superior laryngeal nerve of vagus)

facial nerve supplies ALL the glands in the Head EXCEPT Parotid
Gland (9)
facial nerve supplies all muscles of facial expression EXCEPT
levitator palpebral superioris (3).
all pharyngeal muscles AND larynx muscles supplied by pharyngeal
plexus from vagus except stylopharyngeus (CN IX)
ALL mixed nerves have parasympathetic and taste EXCEPT
trigeminal nerve.
Vagus nerve supplies ALL intrinsic muscles of soft palate EXCEPT
tensor veli palatine (V3).
Hypoglossal nerve supplies ALL muscles of the tongue EXCEPT
palatoglossal (palatoglossus X)

ALL muscles of the mouth closes the mouth EXCEPT lateral


pterygoid.
ALL muscles of the UL are supplied by brachial plexus EXCEPT
trapezius (by spinal accessory nerve)
lateral geniculate nucleus - primary visual cortex (no connection
between left and right visual cortex)
medial geniculate nucleus - primary auditory cortex (bilateral
pathway - receives input from both ears)
vertebral artery merges with the other vertebral artery at the
pontomedullary junction to form basilar artery

hemiplegia = total paralysis of arm leg trunk on same side of body


hemineglect = deficit in attention to or awareness of one side of
body
agraphia = inability to write
hemiparesis = weakness in one side of body
.
lesion of mandibular branch of facial nerve will cause drooping of the
mouth at the contralateral side due to the unopposed muscular tone of
the contralateral side.
Superior surface of atlas articulating with occipital bone is the only
vertebral bone surface covered by hyaline.
Parotid gland is separated from the submandibular gland by the
stylomandibular ligament.
Medial pterygoid has 2 heads (maxillary tuberosity/medial side of lateral
pterygoid plate)
Superior orbital fissure is bounded by greater and lesser wings of
sphenoid.
Most muscles of mastication are innervated by cranial nerve V. Only
buccinators are supplied by facial nerve(motor) and long buccal nerve of
V (sensory).
Central sulcus in the cerebrum, separates the frontal/parietal lobe.
Oligodendrocytes : schwann cells
CNS:PNS
Cranial dural sinus = venous blood sinuses like cavernous sinus

Right and left gray matter areas of spinal cord are connected by the gray
commissure.
The membrane that supplies most of the blood to the brain is the pia
mater.
Majority of the nerve fibers decussate at the level of the medulla!
Brocas motor speech area is usually in the left area of the frontal lobe.
Junction of the parietal, temporal & occipital association areas is called
the general interpretative area a.k.a Wernickes area which develops at
the contralateral side(from your master hand) of the brain.
Dopamine is the most significant neurotransmitter in the basal ganglia
(related to motor function; cohesive functional unit).
500ml of CSF are produced daily.
Medullary vital center:
cardiac
vasomotor (baroreceptors)
respiratory
reflex centers for vomiting, coughing, sneezing and swallowing
*NOT BLOOD PRESSURE
fasciculus gracilis carries sensory impulses from skin and joints to
the brain.
Partial or complete inability to coordinate voluntary movement =
ataxia

Visual and auditory reflexes are centered in the midbrain.


Cerebellum coordinates skeletal muscle movements.
Commissural fibres:
Corpus callosum connects homologous regions of the two
hemispheres.
There are no known connections between right and left primary
visual cortices

The basal ganglia are a group of interconnected structures in the


forebrain. The primary function of the basal ganglia appears to be action
selection: they send inhibitory signals to all parts of the brain that can
generate motor behaviors, and in the right circumstances can release the
inhibition, so that the action-generating systems are able to execute their
actions. Reward and punishment exert their most important neural effects
by altering connections within the basal ganglia
TMJ is a condyloid joint. The lateral ligament is pulled taut when the jaw
is elevated. This is to prevent backward deviation so as to protect the
important acoustic meatus.
Where to feel for carotid pulse:
Anterior border of SCM @ the level of the superior border of
thyroid cartilage (C4)
Cervical rib:
Compression neuropathies

Scapular anastomosis 1st part of subclavian with 3rd part of


axillary
If beginning of subclavian blocked occipital artery (ECA) & deep
cervical artery (costocervical trunk of 1st part of subclavian)

Canadian Ladies Give Superb Blowjobs


-Layers of skin from superficial to deep: stratum Corneum
Lucidum (only present in thick skin)
Granulosum
Spinosum
Basale
Course of Facial artery:
Arises from external carotid branches to upper and lower lip
and nose
Arch upwards and over submandibular salivary gland,
curves around inferior margin of body of mandible at the anterior
border of the masseter
Traverses face tortuous course towards angle of the mouth,
covered by platysma and risorius
Ascends deep to zygomaticus (runs along side of nose to medial
angle of the eye, where it anastomoses with the supraorbital and
supratrochlear arteries (ophthalmic artery ICA)
Venous drainage of danger area:
(anterior & posterior ethmoidal vein) ophthalmic vein
(sphenopalatine & greater palatine veins) pterygoid veins
(angular vein, lateral nasal & superior labial veins) facial vein
all of the above finally drain into cavernous sinus in cranial cavity
Parotid gland:
Ramus of mandible (anterior)
Anterior border of SCM (posterior)
Posterior masseter muscle (deep)
External auditory meatus & mastoid process (superficial)

Parotid duct:
o Runs over masseter (one finger breadth below zygomatic
arch)
o Pierces buccinators to open into mouth opposite 2nd upper
molar
o Surface marking: line between intertragic notch to philtrum

Cerebral arteries entering the substance of the brain carry a sheath


of pia with them.
Vertebral artery perforate dura & arachnoid and pass through
foramen magnum.
Intracranial parts unite at caudal border of PONS (basilar artery)
SUPPLY OF DIFFERENT ARTERIES TO THE BRAIN:
Anterior cerebral: medial and superolateral surfaces of the cerebral
hemisphere
Middle cerebral: entire lateral surface of cerebral hemisphere;
except narrow strip along superolateral margin (by anterior cerebral),
occipital pole and inferolateral surface (by posterior cerebral)
Posterior cerebral: Inferolateral surfaces of temporal lobe and visual
cortex on the lateral and medial surfaces of the occipital lobe
Basilar: Pons, Cerebellum
Vertebral: Medulla Oblongata, Pons
Significance of Circle of Willis:
Creates redundancies in cerebral circulation
If one part of circle becomes occluded, cerebral perfusion can
still be preserved well enough to avoid symptoms of ischemia

VENOUS DRAINAGE OF BRAIN:


Thin walled, valves-less veins pierce arachnoid and meningeal
layers of Dura to end in the nearest Dura venous sinuses IJV
Superior cerebral veins superior sagittal sinus
Inferior and superficial middle cerebral veins straight,
transverse and superior petrosal sinus
Great cerebral veins inferior sagittal sinus straight sinus
Cerebellum drained by superior and inferior cerebellar veins into
transverse and sigmoid sinuses.
Pia is thickened on either side between the nerve roots to form
ligamentum denticulatum, which passes laterally to be attached to the
dura.
This allows the spinal cord to be suspended in the middle of the
dural sheath.
Pia mater extends along each nerve root and becomes
continuous with the connective tissues surrounding each spinal
nerve
Spinal cord terminates at L1/L2; whereas the subarachnoid space
extends down as far as S2.
Hence, lower lumbar part of vertebral canal is occupied by
subarachnoid space, which contains cauda equine and filum
terminale.
Prolapsed disc:
Herniation/protrusion of gelatinuous nucleus pulposus into or
through annulus fibrosus
Violent hyperflexion of spine rupture IV disc
o Flexion produces compression anteriorly, squeezing nucleus
pulposus posteriorly toward thinnest part of annulus
fibrosus.
o If annulus fibrosus degenerate, nucleus pulposus may
herniate into vertebral canal and compress spinal
cord/nerve roots of caudal equine.
Commonly: herniates posterolaterally (where annulus fibrosus is
relatively thin and does not receive support from either posterior
or anterior longitudinal ligaments)
Localized back pain due to pressure on longitudinal ligaments
and local inflammation caused by chemical irritation by
substances from the ruptured nucleus pulposus.
Chronic pain due to compression of spinal nerve roots
LUMBAGO: acute lower back pain (L5 S1, affects nociceptive
endings in the region)

Sciatica: pain in lower back and hip radiating down back of thigh
into the leg (L5/S1 compression)

Levator palpebrae superioris is an antagonist of orbicularis oculi.


Retina has two separate layers with different embryological origins
(mesoderm & neural crest)
TMJ articular disc! The only other joint with an articular disc is the
sternoclavicular joint.
Upper joint compartment gliding; protrusion/retraction
Lower joint compartment hinge; elevation/depression, rotation
Ligaments : (Lateral) TMJ, stylomandibular, sphenomandibular.
Lingual cancer in posterior part of tongue spreads to deep cervical
lymph nodes on both sides.
Tumor in the anterior part usually does not metastasize to the
inferior deep cervical lymph nodes until late in the disease as these nodes
are closely related to the IJV.
Hence metastases from the tongue may be widely distributed
through the submental and submandibular region along IJV in the neck.
Damage to facial nerve: (injury of facial nerve at internal acoustic
meatus)
Damage proximal to the point where greater petrosal nerve and
chorda tympani are given off as branches of CN VII
Ipsilateral salivation and lacrimation are diminished.
Taste lost over anterior 2/3
Hyperacusis nerve to stapedius also interrupted
Nasopharyngeal tonsils adenoids