Deck 6: The Blood Vessels of the Head and Neck

Question 1

A 40-year-old man mentioned to his physician during a medical checkup that on four occasions during the past 5 months he had fainted at work. On each occasion the fainting attack occurred while he was sitting at his desk. He said that the attack took place when he turned his face to the left and bent down to open a bottom drawer. He also complained that he first felt dizzy before he fainted. The physician noted that the patient was rather formally dressed with a stiff collar and a regimental tie. When the physician commented on his collar, the patient stated that he always wore this type of collar to work. On careful examination of the patient no abnormal physical signs were found. In fact, the man looked very fit.

-Using your knowledge of anatomy and physiology, make the most likely diagnosis.

A) Atrial fibrillation
B) Cardiac ischemia
C) Carotid sinus syndrome
D) Anemia
E) Petit mal (a form of epilepsy)

Answer 1

Carotid sinus syndrome

Question 2

Two sisters were playing in their bedroom having a pillow fight, when one of them tripped and fell head first against a window. The glass was shattered and a knifelike piece became impaled in her neck. Within seconds the wound spurted bright red blood and she ran screaming to her parents. In the emergency department of the local hospital it was immediately apparent that a large artery in the front of the neck had been pierced by the glass.

-The examining physician made the following observations and comments, all of which were correct except which?

A) The entry wound was situated along the anterior border of the sternocleidomastoid muscle at about the level of the upper border of the thyroid cartilage.
B) The artery involved could be either the terminal part of the common carotid artery or the beginning of the external or internal carotid arteries.
C) The arteries were situated beneath the investing layer of deep cervical fascia within the carotid fascial sheath.
D) The internal jugular vein, which is also located within the carotid sheath, is not involved because the blood was bright red in color and spurted from the wound on removing the pressure gauze pad.
E) Branches of the trigeminal nerve lie in the sheath at this level and are likely to have been damaged.

Answer 2

Branches of the trigeminal nerve lie in the sheath at this level and are likely to have been damaged.

Question 3

A 7-year-old boy was playing in his grandparents' garden when he suddenly disappeared from view. His grandfather rushed over to see what had happened to his grandson when he heard muffled crying coming from a hole in the ground. On peering into the hole, the child's head was just visible about five feet from the surface. The local rescue team determined that the child had fallen down a disused well. Fortunately, the opening of the hole was large enough to allow the emergency physician to be lowered to the child. Having reassured the child, it was necessary to check his vital signs. The only arteries that could be palpated were restricted to the head and neck.

-Name sites in the head and neck where the arterial pulse can be felt.

A) On the upper surface of the head in the midline
B) Just in front of the auricle of the ear, the lower margin of the mandible, or the anterior border of the sternocleidomastoid muscle at the level of the upper margin of the thyroid cartilage
C) Behind the ear over the mastoid process or at the root of the nose
D) In the midline of the front of the neck in the suprasternal notch or just below the mandible
E) At the apex of the posterior triangle of the neck or halfway down the posterior border of the sternocleidomastoid muscle

Answer 3

Just in front of the auricle of the ear, the lower margin of the mandible, or the anterior border of the sternocleidomastoid muscle at the level of the upper margin of the thyroid cartilage

Question 4

A 53-year-old man was admitted to the emergency room unconscious. Apparently he had attempted to cross the road on crutches when he was hit on the side of the head by a car. On examination he was found to have a large swelling over the left side of the head in the temporal region. The neurologic findings included a rightsided hemiplegia. A lateral radiograph of the skull showed a fracture line across the region of the lower anterior end of the right parietal bone.

-Name the artery that was most likely to have been damaged in the accident.

A) The left middle cerebral artery
B) The right posterior cerebral artery
C) The anterior division of the left middle meningeal artery
D) The posterior division of the left middle meningeal artery
E) The left superficial temporal artery

Question 5

A 42-year-old workman was cutting down a tree. During the cleanup of the site, he was feeding the cut branches into a large wood chipping machine and the sleeve of his shirt on his right arm became caught in the machinery. Within seconds his arm was dragged into the cutters. The man attempted to turn off the machine but could not reach the switch. His right upper limb was cut to pieces and he fell to the ground in agony and quickly lost consciousness. When the emergency personnel arrived on the scene they found the man to be still alive but unconscious and lying in a pool of blood. They had to stop the bleeding immediately.

-Using your knowledge of anatomy, where would you apply pressure at the root of the limb to stop the bleeding?

A) Just above the manubrium sterni in the midline to compress the right brachiocephalic artery
B) Above the right sternoclavicular joint to compress the right subclavian artery
C) Behind the medial part of the right clavicle, applying pressure downward and backward on the right subclavian artery as it lies on the upper surface of the first rib
D) High up in the right armpit to compress the axillary artery
E) Behind the lateral part of the right clavicle, applying pressure backward to compress the right subclavian artery as it becomes the axillary artery

Question 6

A 45-year-old man was rushed to hospital complaining of cardiac pain referred to the root of his neck. After a thorough workup, including a coronary arteriogram, which showed extensive blockage of the coronary arteries, it was decided to do an immediate triple bypass operation. At operation, because of the poor condition of his superficial leg veins, an artery rather than a vein was selected to perform the bypass.

-From the list of arteries given below, choose an artery in the chest cavity that could be used to perform a coronary bypass.

A) Right superior intercostal artery
B) Right and left anterior thoracic arteries
C) Phrenic arteries
D) Musculophrenic artery
E) Superior epigastric artery

Question 7

A patient with a malignant melanoma in the left temporal region was told that because of the seriousness of the condition and the likelihood of metastases, an extensive operation was required including the removal of the deep cervical lymph nodes in the neck.

-Using your knowledge of anatomy, explain why it is necessary to remove the internal jugular vein in the neck as well as the deep cervical lymph nodes.

A) The deep cervical lymph nodes lie deep to the internal jugular vein, and it is necessary to remove the vein to get at the lymph nodes.
B) Damage to the internal jugular vein would result in serious air embolism.
C) The numerous tributaries of the internal jugular vein would complicate the procedure
D) The deep cervical lymph nodes are embedded in the carotid sheath and the tunica adventitia of the internal jugular vein.
E) Metastases of the melanoma commonly invade the internal jugular vein.

Question 8

A 57-year-old woman was examined by her physician and found to have right-sided heart failure. As the patient lay propped up on pillows in bed, her physician noticed that the blood in a superficial vein on the side of the neck (in the posterior triangle) could be easily seen.

-From the list of veins in the neck given below, select the most likely one that the physician could see.

A) Anterior jugular vein
B) Suprascapular vein
C) Superficial cervical vein
D) Internal jugular vein
E) External jugular vein

Question 9

The jugular veins are commonly used to establish a central venous line. Why is it sometimes difficult to pass a catheter from the external jugular vein into the right atrium?

A) The catheter tip may catch in the valves.
B) The vein turns at a right angle before it drains into the subclavian vein.
C) The catheter tip may enter the mouth of the anterior division of the retromandibular vein.
D) The vein may be very small in professional singers.
E) The vein is normally constricted as it passes behind the clavicle

Question 10

In deep penetrating injuries of the neck involving the common carotid artery, the status of the collateral circulation determines the feasibility of ligation versus a reconstructive procedure. Describe the collateral circulation of the common carotid artery. How may injury to the artery produce loss of sight on the same side and contralateral hemiplegia? How may a carotid artery injury produce airway obstruction?

Question 11

Why is air embolism a complication of a lacerated wall of the internal jugular vein?

Question 12

In subclavian vein catheterization using the infraclavicular approach, the following problems may occur, even when great care is exercised: (a) The needle may hit the clavicle; (b) the needle may hit the first rib; (c) the needle may hit the subclavian artery. How would you deal with these problems?
the body for taking the pulse, the following arteries are easily palpable: The pulsating facial artery can be felt as it winds around the lower margin of the mandible in line with the anterior border of the masseter muscle (see text Fig. 6-10). The superficial temporal artery may be palpated in front of the auricle of the ear as it ascends over the zygomatic arch (see text Fig. 6-1). The classical site for feeling the pulse in the neck is along the anterior border of the sternocleidomastoid muscle at the level of the upper border of the thyroid cartilage (see text Fig. 6-3). Here, the common carotid artery divides into the external carotid and internal carotid arteries, and all three are quite superficial at this location.