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OK. Uh We're gonna start now. So thanks. Uh Thanks for joining everyone. So today we're gonna cover CVR with some radiology uh related to it as well. So, uh again, this is made by us for you guys. So just take it with a pinch of salt. If you think something is inaccurate, let us know and we'll clarify it. So, the aims of this session are quite a lot, but I would say these sessions probably is not as high yield in the exam as previous session that we had. Uh But again, it's some stuff that do come up, so it's good to know them. So, what we're gonna talk about is we're gonna talk about er like the root, the cause of er az vein aorta, er esophagus and thoracic duct. We are gonna talk about what is meant with like sympathetic trunk and spla nerves. We are also gonna talk about postal space, uh nerves, drainage and um things associated with that. We're also gonna uh try to cover uh like the bones and cartilages of the neck as well. So the hyoid is specifically um and your larynx. So, uh we are gonna talk about uh the blood supply of the thyroid as well, which is a common exam question. And we'll also talk about uh car carotid sinus. So, carotid arteries and specifically, and we'll also try to understand why would we use uh like uh imaging to do with neck as well. Uh We're also gonna talk about uh like pharynx, larynx, their muscles. Uh We're gonna talk about laryngo, skeleton, vocal cords, vocal falls and essentially renal glottis. How does that relate to you guys? Why do we need to know all of that? Uh And we're gonna talk about that in more detail as well. We're gonna talk about uh the essentially uh essentially nasal cavity and oral cavity as well and er other things associated with it. And for example, in oral cavity, we're gonna talk about tongue, the muscles, innervation. Um And at the end, we'll also cover some specific cases to help you guys uh try to visualize everything that we've been talking about. So firstly, we'll talk about a vein. So it seems like it's a vein. So it's gonna drain a lot of stuff and it's gonna receive blood uh from poster to costal space. It also receives blood from er, esophagus, er, essentially, and bronchial veins as well that supplies your bronchus. So, um Azac vein is located at the back, as you can imagine, uh next to your thoracic vertebra, do you guys think Azac vein is gonna be to the right side or to the left side of your thoracic body? So, if you have the thoracic body at the back, do you think it's gonna be towards its right or is it gonna be towards its left? Any ideas feel free to put it in the chat? Give us a shout. Either way works. Uh Right. Yeah, I agree. Uh Thanks. Uh Loy. So that's really good. So good stuff. So, what we have another vein as well that is gonna be towards the left side, which is gonna be hemiazygos, right. So, essentially it does drain into the hazardous vein and it does drain similar stuff to the hazardous vein, but I don't really need to understand its roots, for example. And there is some more stuff that if you go to, for example, teaching anatomy is gonna tell you about, uh, some more veins are gonna drain into it specifically. You don't need to know anything about them. These are the most important ones that we talked about. Er, good job. So, um, ok, then we're going to talk about a thoracic duct. So thoracic duct is to do with lymphs. So it's quite similar concept to a vein, but thoracic ducts is gonna be lymphatic drainage. So there's a sac that will collect the lymph and then that's gonna cross through the diaphragm and come up. So, do you guys know what do we call that sac? The name of that sack? Any ideas of what that could be anyone has any ideas. It starts with c, it's got a strange name. No. Ok. It's Charlie. Some people got Kylie say Charlie. Er, but again, that's essentially, you need to remember that it's not the most high yield thing in the exam. But again, it's good to know CC is essentially the swelling, er, that's gonna collect the limb from your abdomen and then it's gonna form the thoracic duct essentially, um, as it comes up. So the thoracic duct is gonna er pass alongside your thoracic er vertebra. So it's gonna be on the body, essentially anterior to the thoracic body, er vertebral bodies and it's gonna come up. So another thing that you need to understand if you go back to the fourth, the slide to the AZ vein, the drainage, where do they drain to is a common exam question as well. So, Azac vein drains to the superior Vena cava, but thoracic duct does not drain to their, um, essentially their superior vena cava directly. Does anyone know where does it drain to? So it's gonna drain to a big vein. Does anyone know the name of the vein where it drains to? Any ideas? Good. Uh Thanks. So on. So, yeah. So Clavin is good. So it's gonna be at the point of the junction between subclavian and um essentially internal er, jugular vein that's gonna come up from your brain essentially. So it is gonna be drained to subclavian because internal jugular vein drains to subclan essentially as well, they join together. So at the, at the exact point of the junction, that's where they're gonna drain to, but good stuff. So, um, we need to understand what is s like sympathetic chain is. So firstly, we need to understand the idea of a ganglia. So does anyone know what is meant by ganglia? So when we say ganglia, so I do remember like that a lot of us see ganglia very commonly, but some people don't really understand what it means. So it's good to actually understand these concepts first before we talk about them. So, any ideas for what a ganglia is? Ok. Good. So, collection of nerves outside the spine that is very close? Thanks. Uh again, Lomi, so that's very good. So it is, you are nearly right. But again, in medicine, sometimes you've gotta be specific er to essentially get the mark. So it's a collection of nerve bodies. That's where their like body is gonna lie. So it's not gonna be just like their axon and loss of axons. That, that would be a nerve bundle, for example, but you are on the right lines. Good stuff. So essentially that's where the nuclei is gonna essentially be um for the nerve. So um have you had the sympathetic trunk? So essentially gonna be next to er your thoracic vertebra. So it's gonna be both er left side and the right side. So, er it's gonna enter and the nerves are gonna get out of it. So at ganglia, imagine that we have a loads of different, er, for example, nuclei and cell bodies. So what's gonna happen is that they're probably gonna synapse. So that's the whole point of it. Um Yeah, so we are gonna have different pathways that these uh nerves can actually take. So they could essentially enter the uh essentially sympathetic trunk, which treated as just a trunk like a nerve uh like fiber thing like that goes up and down. So what it's gonna do is those are gonna enter while a white ramus communicans. So remember that, and they're gonna get out of the sympathetic trunk and go back to the essentially nerves via D Dr Ramus communicans. So what is gonna happen? There's different pathways they could take, they could either come in, sign up and get out, they could come in, go up or down, sign ups, get out, they could come in, not sign up and get out. So these are the three pathways they could take a very common exam question is the thing that I've mentioned here many times and it was on the last slide as well. TV, to essentially um L2 slash L3. So that's where your sympathetic chain is gonna end and it start from. So you're not gonna have a sympathetic uh nerve fiber coming out of cervical vertebra. So you might ask, OK, so how am I gonna essentially um supply sympathetic join to our face if don't get any from a cervical vertebra. So how that happens is why this is specific path pathway that we're talking about, they could essentially move up or down from that thoracic vertebra in the, in the sympathetic trunk and get out of the cervical uh like vertebra, for example. So um the main important one that you need to really know about is a very common exam question is when they enter and they don't sign up and they just exit back. They go to target a factor. So it doesn't mean that they're not gonna sign up, they are gonna sign ups, they're s they're gonna sign up closer to the viscera. So viscera are the organs. Um But the s like the essentially why is this important is because of the fact that cardioplegic um like pulmonary nerves, lesser splanchnic nerve, least and greater splanchnic nerve that you might, you guys might have heard of do essentially do that. So, uh you also need to remember that greater splanchnic nerve is gonna be between T five to T nine less. Say it's T 10 to 11, at least it's T 12 cardiopulmonary spla nerve. You do not need to know what its roots are. So, roots are essentially what vertebral level do they come out of? So how I used to remember this is think about greater is gonna be higher. So T five to T nine, the next one is lesser to lower and then the least is just there one closer to the bottom. So it's the inferior one. So it's like, again, they could ask you er questions about this, but you will learn this in more detail when you do gi so we've got to revise gi in a few weeks time as well. So um essentially, I remember these ones and try to make like connections. So I personally used to remember that T 10 is gonna be very um like umbilical cord is so essentially think of it as OK. So greater spinal nerve is probably gonna supply um the same place as well. Er like because usually these nerves don't just have one function of supplying the viscera, they could supply the skin as well. So you will learn more about that when you do gi. So in terms of thoracic viscera, this is a very common exam question. What are, what do, what, what nerves innervate the thoracic viscera. So cardiopulmonary spinal nerve, essentially, you don't really hear about it much. It actually does supply sympathetic to the viscera like heart. Uh but you do hear vagus nerve quite often, it does come up very often in exam questions. So it does parasympathetic uh fibers to the viscera. And also remember lots of people think of these as one nerve supplying someplace it's actually not they're a bundle and there might be some nerves going in the opposite direction as well. So usually these nerve fibers do also have some uh like sensory information that go back to your central nervous system as well. So remember that, that whenever you're supplying a nervous system, something you're probably getting some sensory information back from it. But these ones are usually gonna be um the sensory input that you can't really control uh and it's gonna be unconscious anyways. So we have a concept called referred pain. So we have phrenic nerve. So you might actually essentially ask what is meant by referred pain, referred pain is where you have pain, somebody in your body, but where you actually feel it is some different. So a common example is phrenic nerve. So phrenic nerve remember that it comes up in like nearly most years in the exam, it could be a common er license short answer question for like three marks, two marks. So it's an easy question, make sure, remember it. So C three to C five, what it does, you can imagine it goes from your neck down to your f uh like diaphragm. So it supplies the diaphragm. And what you can see is it does probably supply some dermatomes which are the areas of the skin that are supplied by one nerve as well. So they're gonna supply somewhere on your chest. Um So you might think, OK, so when you do get information from both, uh essentially your shoulder, relatively uh coming a little bit to your chest, um, from that area your input is gonna like to your brain is gonna seem like exactly the same as your diaphragm. It can differentiate where the pain is coming from, so it just gives you a signal. Oh, that your right shoulder is hurting. Well, actually it's coming from diaphragm, but c clinicians actually are trained to be able to pick these stuff up quite quickly. So, have you guys heard anywhere else in the body that you might get referred pain? Any common one that you guys might have heard of? Some people is a very common cardiovascular condition that people get other places like their back shoulders that they get pain on any ideas. No ideas, jaws. Uh So good question. You could actually get some pain in your jaws. But what I was mainly referring to was uh essentially like a condition that m makes you to get that. But it's a good thought. So essentially when you get tight chest pain, sometimes because of a heart attack, sometimes you might hear that it radiates to your shoulder or to your back. So it doesn't mean that you've got uh essentially a shoulder pain, you've got a tendon injury, it could go to your jaw a little bit as well. So it goes to your neck, but it usually stops before it goes to your jaw. Uh But again, it's essentially the same idea that the nerve fibers coming from your heart also. Uh have essentially, are there sensor information from er, some dermatomes of the skin which your brain is not gonna be able to differentiate where exactly the pain is coming from. But good thinking guys. So we've got a question here. So we've got a case of a hiatus hernia. So you guys might have heard of it. So, hiatus hernia, essentially when your, uh, like essentially esophagus or your stomach essentially perforates and goes a little bit higher than where it should be and it can cause some acid reflux and acid problems. So, in this X ray, if you guys can look at it, abdomen always has air in it, like not always, but it's usually not fully filled. Um Essentially the fungus at the top is usually filled with air. So you guys can actually see that there is a level of gas. So you can actually see it's half full, for example, in here. Well, you can actually see that it's quite high. You won't expect to go get your um like uh stomach that high. Do you guys have any ideas? What other structure you might expect to see there on a normal x-ray that you are now actually seeing the stomach there. If you remember when we did chest x rays. W why is the structure that is commonly there is? Yeah, absolutely. Absolutely. So the heart is actually the place where the essentially the stomach is right now. So good thing. You're very well, done. So the problem here is it's probably not gonna be, oh just where the heart is, it's gonna push everything up and uh your stomach is probably gonna be anterior to your heart as well. So it's not gonna cause uh disruptions to your heart necessarily. But what it will do, it will cause loads of chest pain for you and loads of acid reflux and some cardiovascular problems. So it is, this is specific example, it is very severe and just need in treatment. Well, very well done guys. So if we now move up a little bit to our neck, there's a lot going on with the neck. It's very complex, but you do need to understand it because in clinical practice, you can see common injuries with the neck, which are quite important. So there's a lot of muscles, you don't need to know every single one. The main important ones are steroid, a mastoid platysma. So platysma is essentially just the covering part is very thin. It the most superficial on your neck. And Acela a mastoid is the one that attaches to er your mastoid process um and essentially to your sternum. So you might ask, what does it do to me, it was quite hard to visualize, why is this action? So it's action is turning your head. So when it pulls, it turns it, so that's essentially what it does. Ok. So the next thing to think about in the neck is the larynx is very good to understand and know the common bones and landmarks. Uh and also try to remember uh the most common um essentially things muscles associated with it, which we, we are gonna cover. So higher bone is not the most common exam question, but clinically relevant because you can feel it here. So it's quite uh it's quite superficial. I would say it's quite close to your jaw. Um So you, you will be able to actually feel it. You don't need to know much about the fact that it has some inferior horns and anterior horns at the back, which is gonna be essentially um where other things connect to it, but it's not too important. The most important part is actually understanding that larynx is your voice box. So I apo is that this is quite small. I just try to name everything that there is in anterior triangle and posterior triangle. So guys, can you tell me what is the main muscle that divides the anterior triangle and the posterior triangle? We've got it up on the screen. Absolutely. Er Thanks also, Aoc no mastoid is exactly right. So essentially that's what you need to remember. So be behind a sla mastoid is gonna be er the post triangle, er anterior to it is gonna be anterior triangle. So always try to link your stuff and don't worry if you think, oh I don't understand this is between muscles. Why? Because you might have just not covered them yet. For example, the trapezius that you see at the back, don't worry about it too much at this stage because you'll cover it more in detail in the neuro. But again, it's always good to visualize the stuff. So there's a lot going on. You do need to know the key important stuff in anterior and posterior triangles. You do not need to know all very specific stuff like personal experience. They're not gonna ask you the net thing in the exam. They're gonna check to see, oh, you know, the most important stuff. So um tracheal and larynx are gonna be anterior triangle. Y just think of it as you can touch them. So they're quite superficial and anterior. So thyroid and parathyroid gland as well, you can feel them. Um So they're essentially anterior triangle as well. So the muscles are associated with larynx as well because the larynx is anterior. So it's muscles are gonna be like anterior as well, internal jugular vein, which you might actually think that might go towards the back, but it's actually the exception. So it does drain your brain, er, but it doesn't go towards post triangle. So in terms of nerves, I would say it's not too important, it is actually important, but er you don't need to remember exactly all of the nerves, which one is posterior, which was anterior. I used to remember the ones that are posterior are the phrenic nerve that go through through the posterior triangle and also parts of the accessory nerve because you can see accessory nerves in both of them. So these are the two and the rest are gonna pass through your anterior triangle. So I try to think about it. You're most likely gonna get a question like this in the single best answer if, even if you do. So if you remember the exceptions to the rule that might make it slightly easier for you to remember. So, and also external drug low is gonna go towards your posterior triangle as well, which is quite important. So you might think what is the relevant. So you can actually feel your pulse there. So if you identify your sternal muscle, you could easily feel your pulse there. And um you could uh essentially put some medications there into the patients. So if you know where the jugular internal jugular, um essentially RNA uh you could do something called intravenous central line insertion that you might have seen in the MTU. So those are the clinical relevance, but you don't need to know pretty much anything clinical from phase one. So we have different muscles that we call infrahyoid muscles and suprahyoid muscles. So, supra, high muscles are gonna be superior to the hyoid. So, supra is superior. Infra is inferior. So what are they gonna do? They're gonna raise the hyoid bone. So specifically when you're speak, uh speaking, and you can imagine infra higher muscles are gonna pull it down because imagine just push down uh as their job is. So I checked, you got your, your anatomy handbook. You do not need to know the specific names of Junior hyoid Myelo high, the gastric stylo high, these are the four super high muscles. There's four infra high as well. It's a very low yield anyways. So, um you don't need to really understand what it means, but you do need to understand the overall function. So if you now go on to thyroid, it's again, you, you will be covered in m uh M SK lectures in more detail, but the arterial supply could be an easy exam question. So make sure you know it. So the the thyroid is gonna be supplied by superior and inferior uh arteries and think of it as the inferior is probably gonna come from something inferior. In this specific example, it's gonna be subclavian artery and the superior is gonna come from a superior artery, which is the external carotid artery to remember. So in some people, you might get uh another third artery, it's called the eur artery. Uh but again, not everyone has it. But again, it's good to know it. So we have four essentially a small glands that are called parathyroid glands as well. That essentially right behind where thyroid glands are. Does anyone know by any chance which of these two groups? So you have a 5050 chance of getting it. Is it the superior arteries or is it the inferior thyroid arteries that supply the, er, parathyroid hormones as well? Anyone has any ideas? You have a 5050 chance. You can just say, you can guess there's nothing wrong with guessing it. We've got one rotor inferior thyroid arteries. Does anybody else have any opinions? I'm not saying it's wrong. Yeah, you guys are quite shy. It's absolutely right. So, uh well done. It is actually inferior thyroid arteries. So I don't think there is a specific way to try to remember that. Er, but again, sometimes anatomy is about memorizing stuff as well. Uh So good, you don't need to really understand what parathyroid hormones like do at this stage. You just need to know if it's something to do with calcium regulation in the body. You will cover it in more depth uh when you do M SK. So don't worry about knowing absolutely everything and everything's physiological pathways in the first term. So, carotid arteries are very common exam questions. They just come up very often. So about the nerves specifically. So you can actually see that I'll put it here. So when we do get those carotid arteries going up, they're gonna bifurcate. So bate means splitting in two and they're gonna give us external carotid artery and internal carotid artery. So external carotid artery is actually anterior, internal carotid arteries, posterior. So external carotid artery is gonna give branches in the neck in the face, but internal crossed artery is gonna go straight to your brain, which you might have heard of ser Clovis and um anastomosis there that it does. So you need to understand the bifurcation. So the bifurcation is uh very important why? Because we have something called baro receptors which are essentially the uh pressure receptors. Uh You don't need to understand really the fact like physiology behind it. But you just need to know that it senses pressure, a very common exam question that I've seen many times is what nerve uh essentially innervates the carotid sinus. Does anyone have any ideas? So there is one very common one that innovates a lot of stuff. I was gonna say vagus, which is on the right lines, but it's actually not true. Vagus actually does supply the carotid sinus, not the carotid sinus, sorry, er the bar receptors at um your aortic arch. So you do have some bar receptors there and it's gonna supply those ones. But it's a good guess. So, if then if you ever get stuck between any nerves, I will put down chronic nerve or vagus nerve, mainly vagus nerve is more likely to be right because it supplies most of the stuff. Yeah. And I know the person that said, so ra you said recurrent laryngeal nerve, which is a good shout, to be honest because it's in the neck, but it's actually not why because recurrent laryngeal nerve supplies your larynx, uh the muscles and essentially sensory innervation from there is not gonna really uh be outside of the larynx where these carotid arteries are. So, actually this one is a glossopharyngeal artery. So glo like sorry nerve. So glossopharyngeal nerve, it's gonna be the one that supplies this one. So you will, don't worry about knowing these ones in more detail. Glossopharyngeal nerve and vagus nerve will keep repeating themselves over and over again. Er So you'll get used to their er functions but good stuff guys. So veins in the neck are important as well. So internal jugular vein, er that is gonna come up from your face, brain and the skull, er and it's gonna unite with subclavian vein. It's gonna make brachiocephalic vein. So imagine you've got a left one and a right one as well and they're gonna join together and make the superior vena cava the external jugular vein. A lots of people think. Ok. So doesn't it er join both the internal jugular and sub cla as well? It does, but essentially er external jugular when it is quite small. So we don't need to actually take it into account in too much depth. We can't really put like a insertion er like IV line or anything in there because it's quite small. Er but again, it does drain to the brachycephalic rings. So then we have the nerves in the neck. So I've put some details for you guys to have a look at, but I'll highlight the most important one. So for phrenic nerve, no, C three to C five, know that what it's gonna do. It's again, I've seen this in past meds quite often that they ask uh what is the most anterior thing in the hilar of the lung? Which the answer is just gonna be phrenic nerve and vagus nerve is gonna be the most posterior. So that's just gonna be at the back of your chest. And phrenic is gonna come through the front essentially. Uh But again, that comes back to last, remember, doctor R RL, right, anterior, left, superior, that's the position of uh the artery with the bronchus. But again, you could remember this as well. So vagus nerve, it just gives uh parasympathetic nerves to the thoracic abdomen, viscera. But what it does is also gonna give branches to the pharynx and lax. So we have two branches. We talked about recurrent laryngeal nerve. Does anyone know the second one? There is a branch of vagus as well that supplies the larynx. It's a bit superior to require a laryngeal nerve. So, what would you call it? It's not recurrent, it's just superior. What do we call it? Do you guys think any ideas? Yeah, absolutely. Thanks. So, superior, laryngeal nerve is essentially the, the, its name. Um So that's how, how you can remember stuff just always make it easier for yourself to think about. Where does it supply? We're gonna talk about it in more depth as well in a second. So, glossopharyngeal nerve is cranial nerve nine, learn about them in more detail. It's got acronyms, right? It's not that hard to remember and it does give a sensory fibers to kerat sinus and to the pharynx as well. So, hypoglossal nerve is a cranial nerve. The only thing you need to know at this stage is that it innervates the tongue, so sympathetic fiber, it does still uh go next to the cervical spine and it's gonna be uh traveling alongside the carotid arteries because they're close anyways and accessory nerve as well. Uh It's the one that some people forget. Once again, it is a common exam question. They need to know that it supplies the acetic, the mastoid and Trapezius. So, Trapezius is main function is shrugging. So how we test for accessory nerve damage is just we tell the patient to shrug simple as that. Uh or you could tell them to tilt their head as well. So these are the clinical relevance as well. We should learn in more depth. So we have the pharynx that are essentially above the larynx. And you guys need to know just these three divisions are the most important ones. They could actually give you a picture and ask you what is this one? So you need to be able to say this is nasopharynx, oropharynx or larynx, laryngopharynx. Some people call laryngopharynx, hypopharynx as well. So not both of them, uh, but the terms that they use in the anatomy book is what they're gonna ask in the exam as well. So, if you don't see a term in the anatomy book, it's less likely to come up in the exam. So, er, the nasopharynx is just back of the nose, the, or er, oropharynx is just back of the oral cavity and laryngopharynx is just back of the larynx as simple as that, we're gonna talk about larynx and all of those in more details, but don't worry about it too much. So, pharyngeal muscles, you just need to know they exist. It's quite hard to, I like, identify them. But again, know that there's two different types of muscles, there's a circular muscle that's outside and there's longitudinal muscles are inside and those circular muscles are called constrictors. So we have superior, middle and inferior constrictors down from up to the bottom. You don't need to differentiate between them, but just know that they exist. So we have tonsils as well. So tonsils are a common thing to know, maybe even if it doesn't go up in your exam, they're very relevant. You just do see infections quite often. So it's good to know them. So know that we have four different tonsils, pharyngeal, tubal, palatine and lingual tonsils. So, lingual uh essentially like the easiest one to remember because it just relates to the tongue and to think about it as what, what would the rest be as well. So, pharyngeal is probably gonna be um somewhere in the pharynx, which it is. So it's gonna be er in this specific example, pharyngeal tonsils are gonna be in the nasopharynx and tubal tonsils are next to the tube, which is a Eustachian tube or um some people call it uh the like essentially the tube that connects your ear to um your, essentially um to your pharynx. So another thing to mention is pharyngeal tonsils are all like sometimes referred to as a adenoids. You don't need to know it because it's not mentioned in the booklet, but it's good to know. Ok, palate and tonsils are also gonna be next to your, um, lingula. So like soft palate. So they're gonna be in the or back of the oropharynx. So I've got the pictures there. You can have a look at it as well. So, laryngeal skeleton is quite important. So we have impaired cartilages, impaired cartilages. So, the three unpaired cartridges which are alone are the most important ones. Epiglottis, thyroid and cricoid. So, er, epiglottis is just gonna be, er, what, what it's gonna cover the larynx when you're swallowing, so it's gonna close it. But thyroid and cricoid could easily be, feel filled specifically with men, er, because we have a better laryngeal, er, prominence. So you could actually feel it here and then you have the cricoid beneath it. So we have some paired cartilages as well, which are called arytenoid, cuneiform, corniculate, don't bother with any of them except arytenoids. So, arytenoids are important one because their main function is to do something to do with their RMO glottis. But the rest is just too small and just don't come up. So don't bother learning them really, but they're important landmarks anyways. So, internal larynx as well, what we do have is something called vestibular falls, uh which are essentially your false vocal falls. So they're essentially just a fold which are essentially a, a little bit anterior and superior to your proper uh vocal folds. So, vocal falls are gonna are gonna be a fold that have the vocal cords inside them. And what, what is the point? So the point is your voice box, you're gonna be able to talk. So uh we have RMO glottis as well. So remember that that's just the space between the two fours, we just called RGs. So phonation, which means essentially speaking requires adoption, which is the closure of remo this. So one thing that people find hard is what is meant by abduction, adoption. How do we remember it? I always think of it as abduction is going away from center abdo A adoption means coming towards the center. So in terms of r if I ad adopt them, I'm bringing them now down to the center. Same with uh your vocal course. What are you gonna do if you adopt them? You're gonna bring them down to said you're gonna close them. So we have nerves which are quite important. So I get a very common exam question. It can come up. Uh, we have superior laryngo nerves and recurrent laryngo nerves. So we talked about them. Superior laryngo nerve supplies one nerve trichoid nerve, which you don't need to know what it does. It just tenses your larynx, your vocal forward, essentially, that's what it does. And your recurrent laryngo nerve is gonna supply all of the other er muscles. And also it's gonna supply the sensory below the vocal force. So all the sensory er like er a stimulation are gonna go down through a recurrent laryngeal nerve below er the vocal force above it, they're gonna go through superior laryngeal nerve. So if you're remembering one thing from today, remember this because this does come up quite often. So we've got some muscles, I'm just gonna ask you guys, do you guys know what is the muscle that is gonna close your vocal cord? So, what is gonna be the muscle? So we've got, we talked about, it's not your um trichoid, posterior cricothyroid. It could be your interarytenoid muscles or it could be uh your posterior cricoarytenoid muscles. Absolutely. Thanks. So, spot on interarytenoid, spot on. So I do remember from my booklet, they call them transverse arytenoids, but for you guys, they've used the other name which is inter er anoides. We essentially think of it as they're transverse. So what they do is when they contract, they, they, they become shorter. So, what they would do is they would bring the vocal fors together. So, the other one, what it does is is when they contract, they bring the, uh, vocal fors essentially a, from each other. So we've got a case here as well. We're gonna talk about. So, imagine we've got a 45 year old male that actually comes with the hoarseness and difficulty, hoarseness of the voice, which essentially er when, when you've got some problems there, they, it's a, it's essentially an expression that they use to say, oh, your voice is maybe a little bit high pitched. Um and you can read about it in more detail as well if you want. And uh there's no palpable mass in the neck. So it's probably not something to do with their thyroid. And the patient actually reports some weight loss. So we are gonna like do some imaging on them. So we do a contrast enhanced CT scan. So it's a CT scan that shows different stuff via contrast medium. And they evaluate the larynx pharynx and structures and they find out that one of the nerves that was the recurrent laryngeal nerve is essentially compromised. So I've got a few questions for you guys. So firstly, which muscle group do you think is compromised? Based on the fact that recurrent laryngeal nerve is a nerve that has been compressed, any muscles that you guys can name. So there are gonna be muscles of the larynx and we talk about it specifically, except for one of them, the rest are gonna be supplied with uh with Ricura laryngo. So if you mention any of the other ones, you will be right, essentially any ideas. Ok. Good Cricothyroid. So, Cricothyroid is the only one that is actually gonna be uh like essentially not supplied with um your recurrent laryngeal. It's gonna be supplied with your superior laryngo. But again, the rest are gonna be. So, thanks. So, interarytenoid are gonna be and pro uh posterior cricoarytenoid are gonna be as well and which are the ones that are open there won't go to this but good. Uh well done guys. So, OK, which vertebral level do you guys think uh is associated with the hypopharynx and this, this region essentially? So this is again a thing you need to know sometimes, uh they, they could ask you these goofy questions of what vertebral level is, something located at. So you need to know actually larynx, what vertebral level it would correspond to any ideas, what it would be C four, C five, C five to C seven. They're all on the right side. So well done guys. So C three to C six and slash C seven is gonna be where it precisely is. So you are all right. But again, you're all between it. So make sure you just remember this one and AC three to C six, C seven is roughly gonna be where the entire larynx er, is gonna be. But if you write it down to C five to C seven, I'll allow it honestly, but C four C five is gonna be a important landmark of bifurcation and things like that, but it's not gonna be very, exactly, your, er, larynx is gonna be cos that's essentially too narrow. Larynx is slightly bigger than that. So, before we talk about that as well, why do you guys think we didn't order an X ray? What is the significance of that? Why didn't I just go and do a CT scan that gives them a lot more radiation? So CT scans give you 300 times more than an x-ray in terms of radiation. Why do you think? I just didn't say, oh, I need, I'd go with uh x-ray. So I've showed you part of the onset if, if anyone can remember it as well, feel free to saint any ideas. Ok. Don't worry, guys, I'll tell you. So why? Because they're, I was gonna say they're useless, but not really x-rays are very valuable at every stage. Why? Because they're quite easy to do uh and they're quite cheap as well. But the main problem here, the in the neck, there's a lot of the structures which are essentially muscle. So you're not gonna get that much accuracy and detail with an X ray. So it's better to do a CT or Mr MRI, um which might be more expensive, but it still gives you um more detailed image that you could look at. So if we move on to the nasal cavity, er essentially, we need to understand the back of it is nasopharynx that we talked about. There is some important things you need to know. So there is something called turbinates or concave, which are essentially gonna be those bridges that you get uh from the side of your nose and not the side. Actually, they're, they're, they're like essentially, it is gonna be the roof side aspect of it and what they are, they're quite important why? Because air can pass under them and under them is gonna be uh very different, er, like essentially cavities open to and bring fluids from different places that we are gonna talk about as well. So there's different things that you need to know as well. They tell you, you need to know. So about the, specifically the septum of the nose which divides you to the right and left side, they tell you you need to know the bones making it. So you have a bone that's called Pericar plate of the Ethmoid bone. So Ethmoid bone is very close to here. Pericar plate of ethmoid bone is frontal and then you have a little bit uh inferior to it, the vomer, but it just doesn't really come up in the exam. So if you can remember it too, but don't lose the sleep over it essentially. So, um another thing to mention as well is a space below their turbinate is called meatus. So we have superior, inferior, middle, uh meatus and turbinate which corresponds to where they're located. So the pallets, we have the hard palate and soft pallet. So hard palate has different again, bones like er like horizontal processes like horizontal plates of the palatine bone and palatine process process of the maxilla. You don't need to know that they've removed it from your booklet as well. The only thing you need to know is that there is a difference between soft pallet and hard palate. So soft balls at the back is mus muscle. Um but hard pet is just um the roof of your mouth and thing is just this clinical significance. When you swallow stuff, when you try to eat food, your heart failure is gonna help you to chew it essentially. But the soft palate, you need to know its innervation. The most important thing you wanna remember from this is that vagus nerve is gonna supply um your soft palate. You don't need to know any of the uh like labels here. You just need to know soft palate, hard palate. So if you move on to sinuses again, you do need to understand them because they're clinically very irrelevant as well for your future practice. So we have four different sinuses that you need to know frontal sinus which is above your eyebrows. You have maxillary sinus, which is where your maxillary bone is your face. And you're gonna have ethmoidal sinus and a SAS a sphenoid sign. So, sphenos is just there towards center and ethmoidal is just a little bit back uh from maxillary sinus. So you can see them very well in the MTU but just understand that their function because it could be an easy question to do with nose as well or these sinuses, what is their function? You could ask them the short answer questions, just say they're humidified, they're make uh warmer and uh things like that essentially. And you do need to understand nasal like criminal dot as well. So nasal, criminal dot What it's gonna do is gonna drain tears and go to your inferior meatus. So remember that as well. If you can, it might be good to remember where they drain to as well. So there are different stuff, drain two different meatuses as well. Uh Just try to remember them if you can, maybe Doctor Fishwick is focused on them but uh don't lose sleep over them. So, teeth again, we're not dentist, but we do need to understand the basic anatomy of the teeth. So you have 32 teeth, 16, um uh the maxilla 16, uh uh the Mandibles, I just know the fact that there is four incisors that are essentially the first four. Then you have um two canines which are gonna be the sharp ones which look different and then you're gonna have four premolars and six molars and they do include your wisdom tooth as well, er, which are gonna go towards your back. So if, if you were, if, if they ever asked, you just look and count, so count to start from the middle count and that's gonna give you a good idea of uh what type it would be. You don't need to really remember how it looks like. Do know that you do need to know that enamel, dentin and pulp are the three layers of the tooth and the pulp is where the nerves are gonna be. Uh And then you will learn about the joint as well in M SK module, which is called the gum ofs joints with your gums. But don't worry about it too much at this point. So the tongue, we've got intrinsic and extrinsic muscles of the tongue. So don't worry about them too much. You do need to know their innervation very well. So, extrinsic muscle of the tongue are gonna be the muscles that are coming from the outside. So what they do is they usually control the overall movement of the tongue. Intrinsic muscles are gonna be the muscles inside your actual tongue so that can change the shape of your tongue. So, intrinsic muscles of the tongue are innervated by hypoglossal nerve, but you do need to understand this. This is a very common exam question. So, taste in an anterior two thirds of the tongue is facial nerve, general sensation, anterior two thirds is trigeminal nerve, taste and general sensation in a posterior third is gonna be glossopharyngeal nerve. It is a very high yield. So as you guys have probably picked up by now, the most common thing to come up in your exam is nerves and ask about nerve supply er rather than anything else. So if we talk about uh these specific salivary glands as well, you can see that we have parotid, we have submandibular and sublingual glands. So, parotid is gonna be the main big one that gives you saliva but uh saliva er and also you have submandibular which is below your mandibles and sublingual, which is er just underneath your tongue. But you do need to again remedy innervation. So, facial nerve actually comes down and goes past your uh pa pa like uh glands, but it actually doesn't innervate it. It just branches right through it as it passes through and it does innervate the submandibular and sublingual. But the nerve that does er innervate the parotid uh gland is gonna be your glossopharyngeal, which is essentially if you've realized when. Now, gosh really does like uh your pharynx as the name suggests as well. So, er as your pa is close to your pharynx, it supplies that as well. I always remember parasympathetic innervation actually activates glands. So, ok, we've got a short case and then we'll have some exam questions and then uh we'll finish off. So we've put the certificate there as well. If you guys want, feel free. If you are, if you need to leave urgently, feel free to um do the full feedback now. And uh you'll get an email with the certificate as well, but let's go through the case. So we have a 16 year old female that has COVID a nose bleed and swelling after falling off her bike and she complains of pain on like at the bridge of her nose and difficulty breathing through her nostrils. So there's a problem with her nose. So she's probably hit the ground in her nose or something like that. So what we do again, we are a radiologist. We're gonna do an X ray on them because there are a lot of pain CT takes long time and then we find out there's some nasal uh bone abnormality. So my question for you guys is look at the noses specifically, can you spot any abnormalities with the nose? Yeah, very well done. Absolutely. So there is a fracture there. So there's a slight fracture, so very well done for getting it. So it would be actually like hard to identify it. But always when you're trying to look for any abnormalities, look for where continuity of bone is lost. So as you guys did, so you can see at the top there is that fracture that you can see. So essentially this fracture is gonna cause um uh some problems. So it might cause infla inflammation, swelling that might cause problems with the breathing. But what imaging technique do you guys think they could have used to actually get a better detailed uh image about the surrounding tissue perhaps more than the bones? Is there any other techniques that you guys have encountered that is that gives you better quality image than an X ray? Any ideas? OK. MRI, thanks. Yeah, absolutely. MRI is a good one. So the only problem with the MRI S are in an acute problem, if you are gonna do an M MRI, it takes 30 minutes and the patient has to be still like on the ground. And it just if, if they are in a lot of pain, they usually not go with an MRI. But yes, CT is a slightly better option, but both of them are valid. Um If, if they had the time when they were not in too much pain, CT would still take longer than an X ray, that's why we've done an X ray here. But again, um CT would be a good option as well, but the advantage of MRI would be the fact that it doesn't give any ionizing radiations to the patient. So very well done guys, you're spot on. So we've got some exam questions we're gonna go through. So firstly, which one of the following directly drives to the superior Vena Cava. So always remember for these questions, you're always choosing the best answer you're asking about directly to the superior, you know. Well, it's spot on. We've got three words for C Absolutely. So Azac Rain is the one that we talked about. Thoracic duct. Some people think like, confuse them with Azac vein. Actually, it doesn't think of it as a thoracic duct, get all of the limb from the left side of your body as a picture. I showed you guys and it's gonna drain probably to the left side, but as you explain, it's towards your right and your, er, superior Vena cava is towards your right as well. So it's more likely to drain there anyways. Good stuff guys spot on. So now usually I, er, I'm gonna show you a question that usually in your exam you're gonna get something similar. So they might have some questions that have a clinical stem which is not really relevant. Er, they're just giving you an idea. Um, but again, I don't think that uh you might get your exam, don't expect to get all questions that have, er, clinical irrelevance. So, like Krebs cycle, they're probably just gonna ask you a question about it. They're not gonna give you a clinical irre at the start. So here we have a patient who I was admitted to the hospital and when he was asked to put, like, extrude his tongue, he actually said he can't control the movement. So, which nerve do you guys think in a way to muscles of the tongue? So, we've got two words for hypoglossal nerve. Anyone else is, agrees. Agrees too much. Absolutely. You're spot on. So, hypoglossal nerve is, right. Uh, so again, it's the one that supplies, uh, in a way, it's actually your, um, tongue, which you can just remember. It's one of the easy cranial nerves because it just doesn't do as much as like loss ofher or vagus nerve. What, what on? So they will revisit this uh in the neural block. So don't worry about doing too much depth at the moment. So we have a patient that has sinusitis, sinusitis and which is essentially the infection of sinuses. And they've got pus in their, again, guys, very well done. You don't even need me to read you the question. So spot on Maxillary spot on, right. So again, this specific question would be slightly hard to s to ask you guys. But if they do ask you, they're essentially just ask for anatomy, you don't need to know anything about like uh the infection of sinuses, if it's bacterial, viral or anything. The only thing you need to understand is that it the maxillary um like essentially gonna the maxillary sinus is gonna drain anteromedially. So in normal upfront position, it, it's very hard for it to drain. So you're gonna lie down. So that's the clinical significance of it, but very well done. Guys, it's spot on. So we've got another question. So which of the following like following vein did the posterior intercostal veins drain into? So is it the hazardous vein, thoracic duct, hemi hazardous vein, internal jugular vein? So we've got one person who's at hazardous, right? Any other thoughts? Ideas. Co always remember that it just doesn't matter if you get it wrong. It's absolutely fine. I mean, you guys are really smart anyway, so you get it right. Yes, it's always right. Spot on guys. So as it gets red is right. So essentially that's why I always choose the best answer. I always read the question carefully because the lymph does go to thoracic duct, but they ask about veins. So if you see a vein, they might give you a question that you might think. Oh, this is the right answer as well. Not really always read the question properly. So Azac vein is the one that is right and he aus vein as well. It can drain to uh like essentially er like Postera, sorry. Poster Inter can actually drain into Hemz as well, but it's not the best answer cos it's not their main job. So always choose the best answer as you guys did. So spot on. So last question. So we've got a patient who got a rubber stuck in their throat, so we wanna get an emergency airway uh pass essentially. So remember top of the larynx is blo blocked. So which one do you want to er puncture cricothyroid membrane, spot on the eyes. You'll want to step ahead, you want to step ahead very well done. So, you're absolutely right. So, cricothyroid membrane is a membrane between your cricoid and the thyroid. So you could actually puncture it and put a tube in as long as the blockage is not below it. And it's easy, but you can actually leave it there for too long. You've gotta uh like think about doing something for the patient because they can't survive for along with that. But also remember that cricothyroid muscle is a muscle or ligament is a ligament. They are usually not gonna want to puncture a ligament or a muscle. Does anyone know? Why would we really not like to puncture a ligament specifically or even a muscle? Why would am I want to just uh puncture someone's muscle or ligament? Any ideas? Do ligaments have good blood supply or are both of them? Do they heal very easily? So that's the answer essentially guys. So they don't heal very easily. So you can actually expect them to say, oh, I puncture it, it's gonna be fine. The uh the membrane does heal slightly better and ligaments have poor blood supply. Muscles do have good blood supplies, but ligaments are specifically hard to treat because of the lack of like blood supply essentially, but very well done guys. So spot on. Thanks for participating in the questions as Well, so that was everything for today. So we've covered all the important stuff for the last three.