Neck Practice Questions

Q: Killian dehiscence is associated with which muscle?

Inferior constrictor. ***Inferior constrictor*** - Killian dehiscence (Killian's triangle) is a **triangular area of weakness** in the posterior pharyngeal wall located **between** the **thyropharyngeus** (oblique fibers) and **cricopharyngeus** (horizontal fibers) portions of the **inferior constrictor muscle**. - This is the **weakest point** in the pharyngeal wall and is the site where **Zenker's diverticulum** (pharyngoesophageal pouch) develops. - Clinically, Killian dehiscence is associated with the **inferior constrictor muscle** as it represents a natural gap within this muscle's fiber arrangement. *Superior constrictor* - Located in the **upper pharynx**, extending from the skull base to the level of the hyoid bone. - Not related to Killian dehiscence, which occurs at the **pharyngoesophageal junction** (C5-C6 level). *Middle constrictor* - Situated **between the superior and inferior constrictors**, originating from the **hyoid bone**. - Contributes to the **middle pharyngeal wall** and is not involved in Killian dehiscence formation. *Cricopharyngeus* - While cricopharyngeus is one of the **two parts** of the inferior constrictor that bounds Killian dehiscence, the dehiscence is not within cricopharyngeus itself but rather in the **gap above it**. - Acts as the **upper esophageal sphincter** and forms the inferior boundary of the dehiscence.

Q: What is the lower limit of the retropharyngeal space?

Bifurcation of trachea. Bifurcation of trachea - The retropharyngeal space extends inferiorly to approximately the level of T4-T5 vertebrae, corresponding to the bifurcation of the trachea and the superior mediastinum. - This space lies between the buccopharyngeal fascia (posterior to pharynx) and the alar layer of prevertebral fascia. - Clinically, infections or abscesses in this space can descend into the posterior mediastinum, making knowledge of this inferior extent crucial for surgical management. - Note: Some anatomical texts describe the space ending at T1-T2, but for clinical and surgical purposes, the functional inferior limit extends to the bifurcation of the trachea. C7 - While some texts describe the retropharyngeal space as terminating around C7 (level of the lower border of cricoid cartilage), this represents the narrower definition. - The clinical and surgical definition extends the space further inferiorly to allow for tracking of infections into the chest. - C7 alone does not represent the accepted lower limit for examination purposes. 4th esophageal constriction - The fourth esophageal constriction is not a standard anatomical landmark (esophagus has 3-4 constrictions depending on classification). - Esophageal constrictions are luminal narrowings within the esophagus itself and do not define the boundaries of the retropharyngeal space, which is a fascial space posterior to both pharynx and esophagus. None of the options - This is incorrect because bifurcation of the trachea is the recognized lower limit of the retropharyngeal space for clinical and examination purposes. - Understanding this anatomical boundary is essential for predicting the spread of deep neck space infections.

Q: Which of the following laryngeal cartilage is hyaline?

Cricoid. Cricoid - The **cricoid cartilage** is a ring-shaped cartilage that forms the inferior part of the larynx and is composed of **hyaline cartilage**. - Hyaline cartilage provides **structural support** and is flexible, but it can also ossify with age. - Other laryngeal cartilages composed of hyaline cartilage include the **thyroid cartilage** and the **arytenoid cartilages**. *Epiglottis* - The **epiglottis** is composed of **elastic cartilage**, which allows it to be very flexible and bend easily to cover the laryngeal inlet during swallowing. - Elastic cartilage contains numerous elastic fibers in its matrix, giving it greater flexibility compared to hyaline cartilage. *Corniculate* - The **corniculate cartilages** are small, cone-shaped cartilages located at the apex of the arytenoid cartilages and are composed of **elastic cartilage**. - They contribute to the structure of the aryepiglottic folds and vocal fold movement. *Cuneiform* - The **cuneiform cartilages** are also small, rod-shaped cartilages embedded within the aryepiglottic folds and are composed of **elastic cartilage**. - They provide support to the aryepiglottic folds and help maintain the patency of the laryngeal aditus.

Q: The thyrocervical trunk is a branch of which part of subclavian artery?

1st part. ***1st part*** - The **thyrocervical trunk** is one of the three primary branches arising from the **first part** of the subclavian artery. - The first part lies medial to the **anterior scalene muscle**. *2nd part* - The **second part** of the subclavian artery gives rise to the **costocervical trunk**. - This part lies posterior to the **anterior scalene muscle**. *3rd part* - The **third part** of the subclavian artery typically has no branches or may give off the **dorsal scapular artery**. - This part lies lateral to the **anterior scalene muscle**. *4th part* - This option is incorrect as the **subclavian artery has only three parts**, divided by their relationship to the anterior scalene muscle. - There is no anatomical fourth part of the subclavian artery.

Q: The joint that permits nodding of the head while saying "yes" is:

Atlanto-occipital joint. The joint that permits nodding of the head while saying "yes" is: ***Atlanto-occipital joint*** - This joint is formed by the **articulation** of the **superior articular facets** of the atlas (C1 vertebra) with the **occipital condyles** of the skull. - It is a **condyloid joint** that primarily permits flexion and extension, which are the main movements involved in nodding the head to say "yes." *Atlanto-axial joint* - This joint is located between the **atlas (C1)** and the **axis (C2)** vertebrae and is primarily responsible for the rotation of the head, as in shaking the head "no." [1] - It consists of three separate articulations: two **lateral atlanto-axial joints** and one **median atlanto-axial joint**, which is a pivot joint. *C2-C3 joint* - This refers to a typical **intervertebral joint** between the second and third cervical vertebrae. - These joints are **symphyses** formed by an **intervertebral disc** and allow for limited movements such as flexion, extension, lateral flexion, and rotation within the cervical spine segment, but not the primary "yes" motion. *C3-C4 joint* - Similar to the C2-C3 joint, this is an **intervertebral joint** between the third and fourth cervical vertebrae. - Its structure and function are consistent with other typical cervical intervertebral joints, allowing for general cervical spine movements rather than specific head nodding.

Q: The fascia around the nerve bundle of the brachial plexus is derived from?

Prevertebral fascia. ***Prevertebral fascia*** - The **brachial plexus** and the subclavian artery emerge between the **anterior and middle scalene muscles**. - As they exit the neck, they become surrounded by a tubular sheath derived from the **prevertebral fascia**, forming the **axillary sheath**. *Pretracheal fascia* - This fascia surrounds the **trachea**, esophagus, thyroid gland, and infrahyoid muscles. - It lies anterior to the vertebral column and has no direct involvement in forming the sheath around the brachial plexus. *Investing layer* - The investing layer of deep cervical fascia encircles the entire neck, enclosing the **sternocleidomastoid** and **trapezius muscles**. - While it's a superficial layer of deep cervical fascia, it does not specifically form the immediate sheath around the brachial plexus. *Superficial cervical fascia* - This layer is synonymous with the **subcutaneous tissue** of the neck and contains the platysma muscle. - It is superficial to the deep cervical fascia layers and does not contribute to the fibrous sheath of the brachial plexus.

Q: Which of the following statements about the upper airways of a neonate is true?

The epiglottis is large and omega-shaped.. ***The epiglottis is large and omega-shaped.*** - In neonates, the **epiglottis** is relatively **large**, U-shaped or **omega-shaped**, and floppy - This anatomical feature can contribute to airway obstruction due to its proximity to the soft palate - This anatomical difference from adults has important implications for **intubation and airway management**, as it makes visualizing the vocal cords more challenging - **This is the correct statement** about neonatal upper airway anatomy *The larynx extends from C1 to C3.* - The **larynx of a neonate** is located more **superiorly** and anteriorly compared to an adult, generally extending from **C3 to C4** (NOT C1 to C3) - Its higher position contributes to the neonate's obligate **nasal breathing** and makes the airway more susceptible to obstruction - The stated vertebral level (C1-C3) is **incorrect** *The cricoid cartilage is the narrowest part of the airway in neonates.* - **Historically**, the **cricoid cartilage** was considered the narrowest part of the pediatric airway, and this remains in many older textbooks - **Recent evidence** suggests that the **rima glottidis** (at the level of the vocal cords) is actually the narrowest point in most neonates and children - This evolving understanding has implications for **tube sizing** and airway management in pediatric patients - Based on current anatomical evidence, this statement is considered **incorrect** *More than one of the above statements is true.* - As only **one statement** is anatomically correct regarding the neonate's upper airway (the omega-shaped epiglottis), this option is **incorrect** - The detailed anatomical differences, such as the position of the larynx and the shape of the epiglottis, are crucial for understanding neonatal airway physiology

Q: Laryngeal membranes are classified into extrinsic and intrinsic. Extrinsic membranes of the larynx are all, except:

Quadrangular membrane. ***Quadrangular membrane*** - The quadrangular membrane is an **intrinsic laryngeal membrane**, forming the lateral wall of the upper larynx and extending between the epiglottis and the arytenoid cartilages. - It forms the **vestibular folds** (false vocal cords) at its inferior free margin. *Cricothyroid membrane* - The cricothyroid membrane is an **extrinsic laryngeal membrane** that connects the cricoid cartilage inferiorly to the thyroid cartilage superiorly. - It plays a crucial role in maintaining the integrity of the **laryngeal framework** and is the site for an emergency cricothyroidotomy. *Thyrohyoid membrane* - The thyrohyoid membrane is an **extrinsic laryngeal membrane** connecting the superior border of the thyroid cartilage to the posterior surface of the hyoid bone. - It is pierced by the superior laryngeal artery and nerve, carrying sensory fibers to the **laryngeal mucosa**. *Cricotracheal membrane* - The cricotracheal membrane is an **extrinsic laryngeal membrane** that connects the inferior border of the cricoid cartilage to the first tracheal ring. - It helps to anchor the larynx to the trachea and provides stability to the lower part of the **laryngeal complex**.

Q: Bezold's abscess is located in?

Deep to sternocleidomastoid muscle. ***Deep to sternocleidomastoid muscle*** - **Bezold's abscess** is a complication of acute **mastoiditis**, where infection erodes through the mastoid tip and spreads into the **sternocleidomastoid muscle** or surrounding cervical fascia. - This creates an abscess deep to the muscle, typically presenting as a swelling in the **upper neck**, inferior to the mastoid tip. *Submandibular region* - Abscesses in the **submandibular region** are usually associated with **odontogenic infections** or **sialadenitis** (inflammation of salivary glands). - This location is distinct from the mastoid and does not arise from complications of **mastoiditis**. *Diagastric triangle* - The **digastric triangle** is a part of the **anterior cervical triangle** and typically contains lymph nodes, submandibular gland, and parts of the facial artery. - While it is a neck region, Bezold's abscess specifically burrows **deep to the sternocleidomastoid**, which is not the primary anatomical definition of the digastric triangle. *Infratemporal region* - The **infratemporal region** is located below the temporal bone and contains structures like the pterygoid muscles, mandibular nerve, and maxillary artery. - Abscesses here are typically related to **deep facial infections** or spread from the parapharyngeal space, not directly from **mastoiditis**.

Q: Following a penetrating injury in the submandibular triangle, the tongue of a 45-year-old patient deviates to the left on protrusion. Which of the following nerves is likely injured?

Left hypoglossal nerve. ***Left hypoglossal nerve*** - Injury to the **hypoglossal nerve (CN XII)** on one side causes weakness and **atrophy** of the ipsilateral intrinsic and extrinsic muscles of the tongue. - **Key clinical rule**: The tongue deviates **toward the side of the lesion** on protrusion. - This occurs because the **genioglossus muscle** (innervated by CN XII) normally protrudes the tongue to the **opposite side**. When the left CN XII is injured, the **unopposed right genioglossus** pushes the tongue to the left (toward the weak side). - Location: The hypoglossal nerve courses through the **submandibular triangle**, making it vulnerable to penetrating injuries in this region. *Right glossopharyngeal nerve* - The glossopharyngeal nerve (CN IX) primarily mediates **taste from the posterior one-third of the tongue**, **general sensation from the pharynx**, and motor innervation to the **stylopharyngeus muscle**. - Its injury would result in difficulty swallowing, loss of gag reflex, and altered taste, **not tongue deviation on protrusion**. *Left glossopharyngeal nerve* - Similar to a right glossopharyngeal nerve injury, a left-sided injury would manifest as dysphagia, absent gag reflex, and sensory deficits in the pharynx and posterior tongue. - It does **not control the motor function** of the tongue muscles responsible for protrusion. *Right accessory nerve* - The accessory nerve (CN XI) innervates the **sternocleidomastoid** and **trapezius muscles**, controlling head and shoulder movements. - Injury would lead to weakness in shrugging the shoulder and turning the head, with **no impact on tongue movement** or deviation.

Question 1

Killian dehiscence is associated with which muscle?

Accepted Answer

Inferior constrictor

Answer

Superior constrictor

Answer

Middle constrictor

Answer

Cricopharyngeus

Question 2

What is the lower limit of the retropharyngeal space?

Accepted Answer

Bifurcation of trachea

Answer

4th esophageal constriction

Answer

C7

Answer

None of the options

Question 3

Which of the following laryngeal cartilage is hyaline?

Accepted Answer

Cricoid

Answer

Epiglottis

Answer

Cuneiform

Answer

Corniculate

Question 4

The thyrocervical trunk is a branch of which part of subclavian artery?

Accepted Answer

1st part

Answer

2nd part

Answer

3rd part

Answer

4th part

Question 5

The joint that permits nodding of the head while saying "yes" is:

Accepted Answer

Atlanto-occipital joint

Answer

Atlanto-axial joint

Answer

C2-C3 joint

Answer

C3-C4 joint

Question 6

The fascia around the nerve bundle of the brachial plexus is derived from?

Accepted Answer

Prevertebral fascia

Answer

Superficial cervical fascia

Answer

Pretracheal fascia

Answer

Investing layer

Question 7

Which of the following statements about the upper airways of a neonate is true?

Accepted Answer

The epiglottis is large and omega-shaped.

Answer

The larynx extends from C1 to C3.

Answer

More than one of the above statements is true.

Answer

The cricoid cartilage is the narrowest part of the airway in neonates.

Question 8

Laryngeal membranes are classified into extrinsic and intrinsic. Extrinsic membranes of the larynx are all, except:

Accepted Answer

Quadrangular membrane

Answer

Thyrohyoid membrane

Answer

Cricotracheal membrane

Answer

Cricothyroid membrane

Question 9

Bezold's abscess is located in?

Accepted Answer

Deep to sternocleidomastoid muscle

Answer

Submandibular region

Answer

Digastric triangle

Answer

Infratemporal region

Question 10

Following a penetrating injury in the submandibular triangle, the tongue of a 45-year-old patient deviates to the left on protrusion. Which of the following nerves is likely injured?

Accepted Answer

Left hypoglossal nerve

Answer

Right glossopharyngeal nerve

Answer

Left glossopharyngeal nerve

Answer

Right accessory nerve

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