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Anatomy teaching Session 3 CVR anatomy and RadiologyDisclaimer • The following presentation has been made for students by students and we are not held accountable for any inaccuracies. This is a learning tool that has not been reviewed by the University of Sheffield and therefore the use of this session is to facilitate your learning only.Aims and objectives • To describe the course of the ascending aorta, azygos vein, oesophagus and thoracic duct. • Describe the anatomy of the sympathetic trunk and the splanchnic nerves. • To discuss the anatomy of the posterior intercostal space and thoracic innervations. • To describe the bones and cartilages of the neck. • Describe and understand the neck triangles and structures inside. • To describe the major blood supplies and thyroid supply in the neck. • Describe the function of the Carotid sinus and the common nerves in the neck. • To understand the role of imaging of the neck. • To describe the anatomy of the pharynx and its muscles including innervations. • To understand the laryngeal skeleton and the anatomy of the vocal folds. • To understand the anatomy of the Rima Glottides and the larynx innervations. • To understand the bones and boundaries of the nasal cavity including innervations and blood supply. • To describe the anatomy of paranasal sinuses and the eustachian tube. • Describe the anatomy of hard and soft palate. • To describe the boundaries of the oral cavity and it’s innervations. • To describe the anatomy of the extrinsic and intrinsic muscles of the tongue. • Describe the anatomy and functions of the tonsils. • To understand the clinical relevance of this anatomy and how imaging is used. Azygos vein It receives blood from the posterior intercostal veins, oesophageal veins, and bronchial veins. The azygos veins are located on the bodies of the thoracic vertebrae Anatomy handbook Thoracic duct • What sac does the thoracic duct start from? • Cisterna chyli Lymph from the lower limbs, pelvis and abdomen https://thetraumapro.com/2019/ flows towards the cisterna chyli in the abdomen, the-thoracic-duct/blunt-injury-to- And left limbs but right upper limb is drained separately https://en.wikipedia.org/wiki/Thoracic_duct Exam question!! Sympathetic chain Only: T1-L2/3 • What is a ganglia? • Collection of cell bodies • The sympathetic trunks are located on the posterior thoracic wall, either side of the vertebral column and posterior to the parietal pleura. They are thin, fibres regularly interspersed with ganglia Anatomy handbook Neurones • If a sympathetic nerve must reach an area that is covered by the T1-L3 spinal nerves, it can simply enter the sympathetic trunk, synapse, and then leave • If a sympathetic nerve must reach an area that is not covered by the T1-L3 spinal nerves,it will enter the sympathetic trunk, then travel up or down to the point at which it needs to leave, synapse, and then leave the sympathetic trunk Anatomy handbook Splanchnic nerves • Sometimes, sympathetic fibres from several levels must combine when they reach the sympathetic trunk, and travel together to fibres are called splanchnic nerves.thetic • Greater splanchnic nerve (sympathetic fibres originate from T5-T9 segments of the spinal cord) • Lesser splanchnic nerve (from T10-11) • Least splanchnic nerve (from T12). • sympathetic to heartnchnic nerveà Anatomy handbookThoracic viscera Common exam question • The cardiopulmonary splanchnic nerves convey sympathetic fibres to the thoracic viscera and the vagus nerves convey parasympathetic fibres to the thoracic viscera. efferent fibres), they also carry information back to the spinal cord and brain (via visceral afferent fibres).Referred pain • of feeling pain in a part of the body that is distant or separate from the area when the painful stimulus is occurring. • Phrenic nerve C3-5. C 3-5 receive info from both diaphragm and nec and right shoulder. • Same with heart and chest arm neck. https://medizzy.com/feed/11568336Case • A hiatus hernia occurs when the abdominal segment of the oesophagus and part of the stomach moves proximally through the oesophageal opening in the diaphragm and into the chest. Patients may experience symptoms such as heartburn and acid reflux. https://www.radiologymasterclass.co.uk/ gallery/chest/mediastinum_hilum/hiatus _hernia Neck Many muscles Anatomy Handbook https://posturegeek.com/blog/understanding-sternocleidomastoid-muscle-functions-care/Larynx • The hyoid bone is a slender bone situated anteriorly in the upper neck, inferior to the mandible. • Larynx is the voice box https://teachmeanatomy.info/neck/bones/hyoid-bone/T riangles of the neck • Anterior triangle: • the trachea and larynx • the thyroid gland, parathyroid glands, and the submandibular salivary gland • the suprahyoid muscles which connect the hyoid to the skull. • the common carotid artery and its terminal branches the external carotid artery to the head and neck • the internal jugular vein • branches of the facial nerve (CN VII), the glossopharyngeal nerve (CN IX), the XII). nerve (CN X), the accessory nerve (CN XI) and the hypoglossal nerve (CN • Posterior triangle: • muscles that move the head. • part of the subclavian artery and the subclavian vein • the external jugular vein which drains the scalp and face • the accessory nerve (CN XI) • the roots of the brachial plexus Anatomy handbook • the phrenic nerve. Infra and suprahyoid muscles Don’t need the names of individuals muscles: low yield! • The Suprahyoid Muscles • Located superior to the hyoid bone and they form the floor of the mouth. When they contract, they raise the hyoid bone and larynx during speech and swallowing. • The Infrahyoid Muscles • Located inferior to the hyoid bone just lateral to the anterior midline of the neck. They pull the hyoid bone and larynx down during speech and swallowing. https://quizlet.com/527629153/suprahyoid-and-infrahyoid-muscles-flash-cards/ Thyroid • Know where the superior and inferior thyroid arteries arise from. • Some people have an ima artery. • There are usually four parathyroid glands • Right and left superior and inferior glands • located posterior to the thyroid gland. They produce parathyroid hormone which plays a role in calcium regulation. • You will cover this in MSK lectures. 8034000&source=images&cd=vfe&opi=89978449&ved=0CBYQjhxqFwoTCJCu5aXY9IkDFQAAAAAder%2F AAAAABAECarotid arteries • The common carotid arteries ascend in the right and left sides of the neck. • Tbranches in the neck and supplies the brain.e to any • The external carotid artery gives rise to several branches that supply parts of the head and neck. • At the point of bifurcation of the common carotid artery there is a small swelling - the carotid sinus. • Baroreceptors here constantly monitor arterial blood pressure. https://www.medicalnewstoday.com/articles/carotid-arteryVeins in the neck • The internal jugular vein blood from the brain and part of the face. • It unites with the subclavian vein, which returns blood from the upper limb, to form the brachiocephalic vein. • The right and left brachiocephalic veins unite to form the superior vena cava. • The external jugular vein drains blood from the scalp and face.Nerves in the neck • This will be covered in more depth in neuro • Phrenic Nerve • This nerve originates from the C3-C5 nerve roots, and travels anterior to the hila of the lungs and along the surface of the pericardium to reach the diaphragm. • Vagus Nerve • Whilst in the neck, it gives off branches to supply the muscles of the pharynx and larynx. When it reaches the thorax, it passes behind the hila of the lungs, along the surface of the oesophagus and into the abdomen. • Glossopharyngeal Nerve • This is another cranial nerve (CN IX). It carries somatic sensory fibres from the pharynx, and carries visceral sensory fibres from the carotid sinus. • Hypoglossal Nerve • This cranial nerve (CN XII) and provides motor innervation to the tongue.Nerves These are less high yield than last page. • Sympathetic Fibres • The sympathetic trunk extends as far up as the base of the skull so is located very deep in the neck, next to the cervical spine. Many sympathetic fibres to the head and face leave the sympathetic trunk and travel alongside the carotid arteries. • Accessory Nerve • It descends in the neck immediately posterior to sternocleidomastoid (which it supplies) and it continues down to supply trapezius. Pharynx • Can come up in the exam as a SBA! • The nasopharynx is posterior to the nasal cavity. • The oropharynx is posterior to the oral cavity. • The laryngopharynx is posterior to the larynx (sometimes called the hypopharynx). https://jamiekoufman.com/what-is-lpr-what-is-the-pharynx/ Pharyngeal muscles • No need to be able to identify them but just know that they exist. • The walls of the pharynx are composed of an outer layer of circular muscle and an inner layer of longitudinal muscle. • The external circular muscle layer is composed of three constrictor muscles - the superior, middle, and inferior constrictors • palate.e function of the epiglottis and the soft Anatomy handbook T onsils • The tonsils are collections of lymphoid tissue in the upper parts of the pharynx. • The pharyngeal and tubal tonsils are found in the nasopharynx. The pharyngeal tonsils (also known as adenoids) are located in the roof of the nasopharynx. • The tubal tonsil surrounds the opening of the auditory tube • The palatine tonsils are located next to the pharyngeal wall in the oropharynx. • The lingual tonsils are a collection of lymphoid tissue on the posterior aspect of the tongue. https://teachmeanatomy.info/neck/misc/tonsils-and-adenoids/ Laryngeal skeleton Know about cricothyroid and thyrohyoid membranes! • The three unpaired cartilages are the epiglottis, thyroid cartilage, and the cricoid cartilage. • The three paired cartilages are much smaller than the unpaired cartilages. • They are the arytenoids, the cuneiforms and the corniculate cartilages. The latter two pairs are very small. • The unpaired ones are more important landmarks! https://www.slideshare.net/slideshow/larynx-dr-mehul-tandel/57766428 Internal larynx The vestibular folds are folds of mucous membrane located superior to the vocal folds. The vocal folds are folds of mucous membrane that cover and protect the vocal ligaments. The vocal ligaments are attached anteriorly to the internal aspect of the laryngeal prominence and posteriorly to the arytenoid cartilages. The space between the true vocal cords is called the rima glottidis. Adduction of the true vocal cords closes the rima glottidis, Handbook whilst abduction of the cords opens it. Phonation requires adduction of the cords and closure of the rima glottidis. Know the phonation that is important.Nerves • Very common exam question! • The superior laryngeal nerve innervates the cricothyroid muscle and carries sensory fibres from the larynx above the vocal folds. • The recurrent laryngeal nerve innervates all the intrinsic muscles except for the cricothyroid and carries sensory fibres from the larynx below the vocal folds. • If you remember one thing from larynx remember this! handbookCase • A 45-year-old male presents with progressive hoarseness and difficulty swallowing over the past month. Physical exam reveals no palpable neck masses, but the patient reports recent unintentional weight loss. • Imaging Request: A contrast-enhanced CT scan of the neck is performed to evaluate the pharynx, larynx, and nearby structures. • CT Findings: The scan reveals a soft tissue mass in the piriform recess (a part of the hypopharynx), compressing the recurrent laryngeal nerve on the left side. • Question: • Based on the nerve affected (recurrent laryngeal nerve), which muscle groups involved in speech might be compromised? • Which cervical vertebral level is most likely to correspond with the hypopharynx for this lesion? • Why wasn’t a neck X-ray ordered? CT of neck https://www.researchgate.net/figure/Contrast-enhanced-CT-scan-of-the-neck-in-another_fig2_240619257Answer • Muscle groups compromised: The recurrent laryngeal nerve innervates all intrinsic muscles of the larynx (except the cricothyroid). This includes muscles like the posterior cricoarytenoid (vocal cord abduction) and lateral cricoarytenoid(vocal cord adduction), affecting speech and breathing. • Cervical vertebral level: The hypopharynx corresponds to the levels of C3–C6. • Nlike CT or MRI. They are used in very specific scenarios where they provide quick, inexpensive, andes sometimes crucial information. • Remember that larynx is at C3-C6 Nasal cavity • nasopharynx posteriorly. • Also communicates with the paranasal sinuses,. • The midline nasal septum is formed of cartilage anteriorly and two thin plates of bone posteriorly. • The perpendicular plate of the ethmoid bone forms the superior part of the posterior septum, and the vomer forms the inferior part of the posterior septum. (Not high yield !) • The lateral wall of the nasal cavity has three bony shelves that project into the nasal cavity which are called the superior, middle, and inferior conchae or turbinates. • The spaces inferior to them are the meatuses. • As inspired air travels through the meatuses it is warmed, humidified, and filtered. (This can be an easy SAQ question! Functions are generally good easy questions.) https://revisedental.com/lesson/the-nasal-cavity/ Palate • The Hard Palate • It prevents food or fluid entering the nasal cavity. • Wduring the first phase of swallowing. hard palate • Tthe hard palate. A midline projection known as the uvula ‘hangs’. • The key point to appreciate is that the muscles of the soft palate contract during swallowing which elevates the soft palate and this closes off the nasopharynx from the oral cavity. • The muscles of the soft palate are innervated by the vagus nerve. • Most important!! https://en.wikipedia.org/wiki/Hard_palate Don’t need to know most of these labels Don’t need to know names of bones of the hard palate !!Sinuses • The frontal sinus drains into the middle meatus. • The sphenoid sinus drains into the spheno- ethmoidal recess (above the superior concha). • The ethmoid air cells drain into the superior and middle meatuses. • The maxillary sinus drains into the middle meatus. • The nasal cavity also has another opening: the nasolacrimal duct. This tube drains the fluid meatus.’). The duct opens into the inferior Anatomy hanbook T eeth • Adults have 32 teeth – 16 embedded in the maxilla (upper jaw) and 16 embedded in the mandible (lower jaw). • canines, four premolars and six molars (including wisdom teeth). Anatomy handbook https://www.vcdental.com.au/tooth-anatomy-education/ T ongue • It has papillae on its superior surface, some of which detect taste (‘taste buds’). • Taspect of the epiglottis is called the vallecula.erior • Taste in the anterior two thirds of the tongueà the facial nerve (CN VII). • General sensation (touch, pain, temperature) in the anterior two thirds à trigeminal nerve (CN V). • Taste and general sensation in the posterior third à glossopharyngeal nerve (CN IX). • These nerves are high yield!! https://www.statpearls.com/point-of-care/21235Salivary glands • Parotid is innervated by glossopharyngeal innervates the other glands.ugh parotid and • Glands are activated by parasympathetic innervation. Handbook Case • A 16-year-old female presents with nosebleeds and swelling after falling off her bike and hitting her face. She complains of pain on the bridge of her nose and difficulty breathing through her nostrils. • Imaging Request: A plain X-ray of the nasal bones is performed to evaluate the injury. • X-Ray Findings: The X-ray shows an abnorality of the nasal bone with mild displacement. • Questions: • Can you spot any abnormalities? • What is the most likely structure causing difficulty breathing through the nostrils? • What imaging technique would give more detailed information about the surrounding soft tissues? https://radiopaedia.org/articles/nasal-bone-fractureAnswer • Structure: The nasal septum is fractured, which may be deviated or swollen, causing obstruction. • Imaging Technique: A CT scan would provide detailed images of the soft tissues and any septal involvement.Which one of the followings directly drains to the superior Vena Cava? • A) Posterior intercostal veins • B) Thoracic Duct • C) Azygos vein • D) Hemiazygos veinWhich one of the followings directly drains to the superior Vena Cava? • A) Posterior intercostal veins • B) Thoracic Duct Drains to the junction of the left subclavian and internal jugular veins • C) Azygos vein • D) Hemiazygos veinA patient was admitted to hospital. When he was asked to extrude his tongue it deviates to the right side and he can’t control the movement. Which nerve innervates the internal muscles of the tongue? • A) Hypoglossal nerve • B) Glossopharyngeal nerve • C) Vagus nerve • D) Accessory nerveA patient was admitted to hospital. When he was asked to extrude his tongue it deviates to the right side and he can’t control the movement. Which nerve innervates the internal muscles of the tongue? • A) Hypoglossal nerve • B) Glossopharyngeal nerve • C) Vagus nerve • D) Accessory nerve • Nerves are very high yield. Learn them and this will be revisited in the neuro block.A patient has sinusitis which is infection in the sinuses. The pus in that sinus can not be empties until they are lying down on one side. Which sinus is infected? • A) Ethmoidal • B) Frontal • C) Sphenoid • D) MaxillaryA patient has sinusitis which is infection in the sinuses. The pus in that sinus can not be empties until they are lying down on one side. Which sinus is infected? • A) Ethmoidal • B) Frontal • C) Sphenoid • D) Maxillary • This sinus opens antero medially meaning in upright position it cannot be cleared. • This is a but more clinical and a hard question but can be answered based on anatomy so well done if you got it right!Which of the following veins do the posterior intercostal veins drain into? • A) Azygos vein • B) Thoracic duct • C) Hemiazygos vein • D) Internal jugular veinWhich of the following veins drains the posterior intercostal veins? • A) Azygos vein • B) Thoracic duct • C) Hemiazygos vein • D) Internal jugular vein • Hemiazygos is technically not wrong but always select the best answer.A patient comes in with a rubber stuck in their throat at the larynx level. The doctors need to create an emergency airway path. Which of the following will be punctured for inserting the tube? • A) Thyrohyoid membrane • B) Cricothyroid membrane • C) Cricothyroid ligament • D) Cricothyroid muscleA patient comes in with a rubber stuck in their throat at the larynx level. The doctors need to create an emergency airway path. Which of the following will be punctured for inserting the tube? • A) Thyrohyoid membrane • B) Cricothyroid membrane • C) Cricothyroid ligament • D) Cricothyroid muscleThanks for listening Session 2 psanikhani1@Sheffield.ac.ukReferences • Anatomy handbook. University of Sheffield. School of medicine and population health. Cardiovascular and respiratory anatomy. • https://en.wikipedia.org/wiki/Thoracic_duct • https://thetraumapro.com/2019/05/17/zebra-alert-blunt-injury-to-the-thoracic-duct/ • https://medizzy.com/feed/11568336 • https://www.radiologymasterclass.co.uk/gallery/chest/mediastinum_hilum/hiatus_hernia • https://posturegeek.com/blog/understanding-sternocleidomastoid-muscle-functions-care/ • https://teachmeanatomy.info/neck/bones/hyoid-bone/ • https://quizlet.com/527629153/suprahyoid-and-infrahyoid-muscles-flash-cards/ • https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.jaypeedigital.com%2FeReader%2Fchapter%2F9788180617348%2Fch73&psig=AOvVaw2lSwUe3JJ7mG2_ooCmh0D 9&ust=1732528108034000&source=images&cd=vfe&opi=89978449&ved=0CBYQjhxqFwoTCJCu5aXY9IkDFQAAAAAdAAAAABAE • https://www.medicalnewstoday.com/articles/carotid-artery • https://jamiekoufman.com/what-is-lpr-what-is-the-pharynx/ • https://teachmeanatomy.info/neck/misc/tonsils-and-adenoids/ • https://www.slideshare.net/slideshow/larynx-dr-mehul-tandel/57766428 • https://revisedental.com/lesson/the-nasal-cavity/ • https://en.wikipedia.org/wiki/Hard_palate • https://www.vcdental.com.au/tooth-anatomy-education/References • https://www.statpearls.com/point-of-care/21235 • https://www.researchgate.net/figure/Contrast-enhanced-CT-scan-of-the-neck-in-another_fig2_240619257 • https://radiopaedia.org/articles/nasal-bone-fracture