Unit 4: Lecture 3

Injury resulting in permanent damage to olfactory cells can cause which condition? A. Anosmia B. Hemianopia C. Anisocoria D. Tic douloureux

A. Anosmia Answer found on lecture slide 8

Which of the following is the correct correlation of a branch of the trigeminal nerve and the point at which it exits the cranium? A. Ophthalmic branch-Superior orbital fissure B. Maxillary branch- Foramen ovale C. Mandibular branch- Foramen rotundum D. Ophthalmic branch- Foramen rotundum

A. Ophthalmic branch-Superior orbital fissure

A 78-year-old male presents to clinic reporting that for a while now he has had a decreased sense of smell and has not been able to enjoy his food because it "all tastes different". After thorough workup, the patient is found to have a lesion near the cribriform plate and this is noted to be the cause of his anosmia. Which cranial nerve is affected? A. CN III B. CN I C. CN IV D. CN II

B. CN I slide 6-8

Which of the following is not innervated by CN V3? A. Lower lip B. Eyelid C. Floor of mouth D. Ear canal

B. Eyelid Slides 28 and 29

You are the working in the ER and notice that a well educated possible diagnosis was entered in the patient note section for your next patient. The note states "possible right trochlear nerve palsy". As you enter the patient's room, what position do you expect to find your patient as a way to compensate for the extorsion and hypertropia? A. Head and chin tilted up and away from affected eye and looking downward slightly B. Head and chin tucked and toward affected eye looking upward slightly C. Head and chin in neutral position with eyes pointed upward slightly D. Head and chin tucked and away from affected eye and looking upward slightly

D. Head and chin tucked and away from affected eye and looking upward slightly Slide 24

Which of the following is true regarding cranial nerve IV? A. It is the second largest cranial nerve. B. It's primary function is sensory. C. It is responsible for double vision due to trigeminal dysfunction. D. It innervates the superior oblique muscle.

D. It innervates the superior oblique muscle. slides 22-24

A four year old boy was excitedly eating the pizza when he bit the anterior tip of his tongue. His mom was concerned that the bleeding hadn't stopped right away and brought him to urgent care with a bloody wad of paper towel hanging from his mouth. You know that the pain stimulation from the bitten tongue is coming from which cranial nerve? A) CN V B) CN VI C) CN I D) CN IV

A) CN V

Which of the following nerves and their exit is not correctly matched? A) Ophthalmic- Inferior Orbital Fissure B) Maxillary- Foramen Rotundum C) Mandibular- Foramen Ovale D) Optic- Optic Canal E) Trochlear-Superior Orbital Fissure

A) Ophthalmic- Inferior Orbital Fissu p13/slide 26 of powerpoint (ophthalmic-SUPERIOR orbital fissure is correct)

Which nerve is responsible for the general sensory fibers of the anterior 2/3's do the tongue, floor of the mouth, lower lip, and mandibular teeth? A) V3 B) V2 C) V1 D) III E) II F) I

A) V3

A 52 year old female patient presents to your office with complaints of painful spasms that occur in the face. She explains that the pain is severe and occurs intermittently radiating from the jaw and she desires immediate treatment so that she can return to work since it has become disruptive. Compression of what cranial nerve branches are most likely responsible for the patient's symptoms? A. CN V2 and CN V3 B. CN V1 and CNV 3 C. CN VII and CN V5 D. CN V1 and CNV4

A. CN V2 and CN V3 Found in slide on Tic Doulouroux; Typically affects the maxillary and mandibular branches more than ophthalmic division.

The student refrigerator hosted a pool of spilled milk in the cheese drawer for over a month at HSC. For several weeks, most students opted to place their lunch boxes in the alternate refrigerator, though some brave souls (or those suffering from anosmia) continued to chill their sandwiches in with the molding milk. Unfortunately, for those of us with functional olfactory systems, the "odiferous gasses aerosolized" in the student lounge, thus stimulating more olfactory receptor neurons than we would have liked. From what part of the cranium does CN1 exit? A. Cribiform plate B. Superior orbital fissure C. Foramen rotundum D. Foramen ovale E. Jugular foramen

A. Cribiform plate (pg 1054, 1058, slide 6)

Mary is a 56-year-old patient that you have been seeing in clinic for many years. She has always been the picture of health. Today she presents to urgent care with the complaint that she cannot see anything in her peripheral/lateral fields of vision. She states that before she went to bed last night, her vision was perfectly clear, but upon waking this morning her lateral vision was decreased and nearly absent. She denies any trauma, no "curtain-drawn" loss of vision, or use of new medications. In testing her visual field, you note that she is unable to see your fingers almost until there are directly in front of her. You suspect that she may be experiencing bitemporal hemianopia. If you are correct, on imaging you would expect to see a lesion at what point of the optic nerve path? A. Optic chiasm B. Meyer's loop C. Optic tract D. Left optic nerve

A. Optic chiasm Answer found on lecture slide 15

What ocular muscle does the trochlear nerve innervate? A. Superior Oblique B. Inferior Oblique C. Medial Lateral Rectus D. Lateral Rectus E. Superior Rectus

A. Superior Oblique Found in slides. CNIV

As you are playing catch with your nephew, he is having issues catching the baseball. You tell him to keep his eye on the ball and he'll catch it. So with the next toss, he keeps his on the ball a little too long and gets hit just between the left eye and the supraorbital ridge. When you examine his eye you note that he is unable to open his left eyelid and when instructed to look up, his right eye goes up but his left eye does not move. When instructed to look down and in, both eyes are able to do so. What nerve was likely damaged? A. Superior division of CN III (Oculomotor) B. Inferior division of CN III (Oculomotor) C. Superior division of CN IV (Trochlear) D. Inferior division of CN IV (Trochlear)

A. Superior division of CN III (Oculomotor) Slides 18 and 24

Cranial nerve 3, the oculomotor nerve, leaves the the cranial cavity and enters the orbit via what structure? A: Superior Orbital Cavity B: Hypophysial Fossa C: Optic Canal D: Inferior Orbital Cavity

A: Superior Orbital Cavity -Slide 17 from Lecture

A 26-year-old female presents to your office with galactorrhea, headache, and vision changes. As you start to think about her constellation of symptoms you begin to work your way through what might be causing each. You first rule out the patient breastfeeding. You then begin to think about prolactin and its role in the development of galactorrhea. Thinking about excess prolactin in combination with her symptoms of headache and vision changes you start to work her up for a possible pituitary adenoma. Upon physical exam, which of the following vision changes would you expect to see based on the location of the possible tumor? A) Bilateral superior quadrantanopia B) Bitemporal hemianopsia C) Bilateral inferior quadrantanopia D) Binasal hemianopsa

B) Bitemporal hemianopsia

A young woman is brought into the ER after taking a fall while trying to study while walking. Witnesses say she tripped and hit her head on a railing. You see the the paramedics have controlled the bleeding of a small gash on the side of her head. You check her pupils and notice anisocoria, or unequal dilation, of her eyes. The upper eyelid of the dilated eye is also drooping slightly and when you ask, she says her vision is blurred. Based on these symptoms, you are concerned she has a subdural hematoma that is putting pressure on what nerve? A) Optic/CNII B) Oculomotor/CNIII C) Trochlear/CNIV D) Abducens/CNVI

B) Oculomotor/CNIII p10-11/slides19-21 of power point

You are caring for a 54 year old female patient with a history of metastatic breast cancer. She has declined further cancer treatments. Today she presents to your clinic with a complaint of new headaches and double vision. On exam, you immediately note that her left eyelid is droopy, and that the left eye appears to be gazing inferiorly and laterally compared to the right eye. You are concerned for a new metastasis affecting which of the following nerves? A. CN II - Optic B. CN III - Oculomotor C. CN IV - Trochlear D. CN VI - Abducens

B. CN III - Oculomotor (Lecture slides 16-20)

A patient presents to your clinic after taking a punch straight to the left eye about 2 weeks ago and never got it checked out immediately afterward. Upon examination, there is no lingering edema or lacerations, but you notice that his left eyelid is hanging slightly lower when compared to the right side. On further inspection, you also note anisocoria in the left pupil. He denies vision loss. You obtain imaging, which shows a small, freshly healed fracture in the area of the superior orbital fissure. You're concerned that the patient has injured which nerve that is located in this fissure and explains the droopy eyelid? A. CN II - optic Nerve B. CN III - oculomotor Nerve C. CNV(1) - ophthalmic branch of the trigeminal nerve D. CN VI - abducens nerve

B. CN III - oculomotor Nerve

A 36 year old male patient presents to the clinic concerned about about recent numbness and tingling of the front of his tongue, floor of his mouth, and his lower teeth and lips. He is worried something is wrong and questions you about what could be causing this. Which of the following nerves could impinged and causing these symptoms? A. CN IV B. CN V C. CN VI D. CN VII

B. CN V

What nerve is responsible for motor supply of the eyelid? A. Optic nerve B. Oculomotor nerve, superior division C. Oculomotor nerve, inferior division D. Oculomotor nerve, central division

B. Oculomotor nerve, superior division Slide 18

Which of the following Cranial Nerves is not commonly tested during neurologic portions of physical exams? A. Trochlear Nerve B. Olfactory Nerve C. Ophthalmic Branch of the Trigeminal Nerve D. Abducens Nerve

B. Olfactory Nerve Slide 8

While evaluating cranial nerves on a patient, you realize that the lunch special in the cafeteria today is tacos. Since your stomach owns your life, you want to hurry along and get your lunch. Which exam piece will allow you to test three cranial nerves in one test, letting you get to your lunch that much faster? A. Have the patient identify familiar scent with eyes closed B. Test extraocular muscles with an "H" formation C. Shine a light on one of the patient's pupils checking for constriction in both D. Ask the patient to hold their jaw open while you try to close it E. Have the patient read from a card, one eye at a time

B. Test extraocular muscles with an "H" formation Slide 8 - I think the oculomotor does as well - slide 18

A 55 year old female patient presents with diploma and a medically rotated eye which cannot be abducted past the midline. She attempts to compensate by rotation her head to allow the eye to look sideways. Which nerve do you suspect is injured? A) Trochlear Nerve B) Trigeminal Nerve C) Abducens Nerve D) Facial Nerve E) Oculomotor Nerve F) Accessory Nerve

C) Abducens Nerve

A 67 year old male with uncontrolled Type II Diabetes, hypertension, and hyperlipidemia presents to the ED. He was having a beer with his golfing buddies when suddenly experienced a change in vision. This has never happened to him before. He described it as having blinders on and only being able to see his nose. You determine that he has lost vision in one half of the visual fields of both eyes. What kind of visual field defect is he experiencing? A. Right Monocular Blindness B. Left Homonymous Hemianopsia C. Bitemporal Hemianopsia D. Right Nasal Hemianopia E. Bitemporal Monocular Blindness

C. Bitemporal Hemianopsia Slide 15 of Cranial Nerve I-VI and pg 1080 of Moore

What cranial nerve is often not tested during a neurological examination? A. CN IV B. CN VIII C. CN I D. CN X

C. CN I Slide 8

Which nerve divides within the superior orbital fissure into a superior division which has a motor supply and an inferior division which has a motor and parasympathetic supply? A. CN I B. CN II C. CN III D. CN IV E. CN V

C. CN III Slide 18

While working in the Emergency Department on a busy Friday evening, you go to see a 17-year old male who suffered an excessive hit to the head during his high school football game. Upon reviewing his chart you find out that he failed the "eye movement and pupil" neurological screening on his SCAT evaluation but otherwise is A&Ox3 and denies having a headache, double vision, or dizziness. Upon walking in the room you immediately notice he has severe anisocoria. Which cranial nerve has been affected in the injury? A. CN I B. CN II C. CN III D. CN IV E. CN V

C. CN III Slide 20

Which Cranial Nerve allows for motor function of the lateral rectus muscles? A. CN IV B. CN V C. CN VI D. CN VII

C. CN VI

Which eye muscle does CN VI provide motor innervation for? A. Superior oblique muscle B. Inferior rectus muscle C. Lateral rectus muscle D. Inferior oblique muscle

C. Lateral rectus muscle slide 33

Which type of lesion would produce right homonymous hemianopia? A. Left optic nerve lesion B. Optic chiasm lesion C. Left optic tract lesion D. Outer optic tract lesion E. Left temporal lesion

C. Left optic tract lesion slide 15

A 65 yo female patient presents to the clinic complaining of difficulty in seeing at night. She explains these symptoms have gradually progressed over the last few months. She notes no changes in her day vision, but does note complications with visualizing movement. Assuming she is experiencing an optic nerve dysfunction, which photoreceptor do you expect is deteriorating? A. Cones: Peripheral B. Cones: Central C. Rods: Peripheral D. Rods: Central

C. Rods: Peripheral slide 19

Cranial nerve III exits through what location in the skull? A. Foramen rotundum B. Foramen ovale C. Superior orbital fissure D. Cribriform plate

C. Superior orbital fissure Cranial nerve I-IV slide 17

What is cranial nerve V and its general functional type? A. Olfactory, Special sensory B. Trochlear, Motor C. Trigeminal, Mixed (motor and sensory) D. Glossopharyngeal, Mixed E Abducens, Motor

C. Trigeminal, Mixed (motor and sensory) (pg 1057, slide 25)

A 33 year old male comes into the clinic complaining of issue with his R eye and having double vision when he looks down and inwards. While examining the patient, he reports that when he tilts his head away from his R eye and tucks his chin downwards, he no longer sees double. The history and physical exam exhibits possible damage (palsy) of what cranial nerve? A: Olfactory Nerve (I) B: Trigeminal Nerve (V) C: Trochlear Nerve (IV) D: Abducens Nerve (VI)

C: Trochlear Nerve (IV) -Slide 24 from Lecture

Which is not true regarding the trochlear nerve? A) Supplies motor control to the Superior oblique muscle B) Trochlear nerve palsy results in diplopia when looking down C) It is the smallest cranial nerve D) It is cranial nerve V

D) It is cranial nerve V

Which of the following cranial nerves exits the skull through the superior orbital fissure? A) Trigeminal Nerve (CN V) B) Spinal Accessory (CN XI) C) Optic Nerve (CN II) D) Trochlear Nerve (CN IV)

D) Trochlear Nerve (CN IV) (Slide 23, Cranial Nerve Lecture 1)

A patient comes in to see you with complaints of vision problems. As part of the physical exam you perform several cranial nerve tests. You note that when the patient is asked to follow your finger to the patients right, she is unable to abduct the right eye. You decide that further work up is required following your initial diagnosis of what? A. CN II palsy B. CN X palsy C. CN I palsy D. CN VI palsy

D. CN VI palsy

The olfactory bulb gives rise to olfactory nerves, which extend into the nasal cavity through which of the following bony structures? A. Sphenoid B. Inferior nasal conchae C. Maxillae D. Cribriform plate

D. Cribriform plate (lecture notes slide 6)

A patient presents at your clinic complaining of dropping of their eyelid. Upon examination you also notice a difference in pupil size. These two presentations are common with dysfunction of what cranial never? A. IV B. V C. I D. III

D. III Cranial nerves I-VI slide 20

You are seeing a middle-aged man whose chief complaint is that he no longer has sensation in the anterior 2/3 of his tongue. Upon further questioning you discover that over the past four months he has bit his tongue without realization and has slowly lost his ability to detect the temperature of his food. You know that loss of somatic sensation over the anterior two-thirds of the tongue indicates damage to the A. Maxillary branch of the trigeminal B. Chorda tympani of trigeminal C. Ophthalmic branch of the trigeminal D. Mandibular branch of the trigeminal

D. Mandibular branch of the trigeminal Slide 29

After growing tired of studying and the ongoing Duluth "spring," a student decides that the circus is calling her name once again. She ends up in your emergency department with an eye injury involving a stunt with a sharp object. Somehow, only the superior orbital fissure of her right eye was involved in the injury. Which nerve is NOT affected A. Abducens B. Trochlear C. Oculomotor D. Optic E. All of the above are affected

D. Optic Slides 11, 18, 23, 34

Which afferent cranial nerve fiber is correctly matched with its function? A. General Somatic: taste, smell B. General visceral: touch, heat, pressure from skin C. Special visceral: lungs, heart, GI tract D. Special somatic: vision, hearing, balance

D. Special somatic: vision, hearing, balance

Where does CN3 enter the orbit? A. Cribriform Plate B. Foramen Rotundum C. Superior Orbital Sinus D. Superior Orbital Fissure E. Optic Canal

D. Superior Orbital Fissure Slide 17 of Cranial Nerve I-VI

Odette, a 53-year-old, presents with complaints of intense, stabbing, left-sided jaw pain. She explains to you that it begins at the angle of her jaw and radiates toward her mouth. When taking a history, you learn that the pain has been occurring twice every day for the past three weeks, each episode lasting several seconds at a time. Upon physical examination, you find that Odette is currently experiencing facial pain, but you do not find any abnormalities that may be causing the pain. You suspect that your patient has Trigeminal Neoplasia, which can result from compression, degeneration, or inflammation the trigeminal nerve. What division of the Trigeminal Nerve is often involved in Trigeminal Neoplasia? A. Ophthalmic B. Maxillary C. Mandibular D. A and C E. B and C

E. B and C Slide 31 and Moore pg. 1081

You are working as a PA at the Twin Ports Pain Clinic. Your next new patient's paperwork indicates she is a 56 year old female who complains of jaw pain. You meet her and find that she is experiencing intense stabbing pain which recurs frequently. Pain occurs randomly but also accompanies eating, chewing, and brushing her teeth. The pain pattern follows the angle of the jaw and will extend into the upper teeth and chin. The patient explains that her prior neurologist thought it was an issue with a nerve in her face becoming inflamed or compressed. Her referral requests pain medication management for which condition? A. Cranial Nerve VI Dysfunction B. Tic Douloureux C. Tourettes D. Trigeminal Neuralgia E. Both B & D

E. Both B & D slide 31

You are a primary care PA completing a pre-op physical for one of your long time patients. She has been a challenging patient as she has been suffering from "Tic Douloureux" for the past 2 years after a car accident where the side of her face struck an air bag. She is now finally undergoing a procedure to relieve her of her symptoms. Recalling the most common manifestations of her condition, also known as Trigeminal Nerve Palsy, which of these symptoms would she be least likely to experience? a) itching and burning in her eyes b) excoriating pain medial to her ear c) severe tooth pain without pathology d) stabbing pain from her jaw radiating to her chin

a) itching and burning in her eyes Slide 31: the opthalmic division of CN V is usually not affected by this condition

What Cranial nerve functions in the movement of the Superior Oblique muscle of the eye? a. Trochlear (CN IV) b. Oculomotor (CN III) c. Abducens (CN VI) d. Optic (CN II)

a. Trochlear (CN IV) (Slide 22)

After suffering a stroke, Ron is experiencing visual field loss that is affecting the vision in both of his eyes. He can only see things in his visual field on the right side. It was determined that he has Homonymous Hemianopia. This results in visual field loss on the same side of the vertical midline in both eyes. If Ron can only see things in his visual field on the right side, where would you expect to see the defect? a. Right optic tract b. Left optic tract c. Left optic nerve d. Right optic nerve e. Optic chiasm

b. Left optic tract (slide 15, Dr. Robinson talked about how people who have suffered strokes can have optic tract lesions that restrict vision to one side of the visual field in both eyes.) Number D in the picture.

Which branch of the Trigeminal nerve is responsible for motor and sensory function? a. Ophthalmic b. Mandibular c. Maxillary d. Zygomatic

b. Mandibular Lecture slide 25

A 60 year old female patient comes into the clinic complaining of facial pain. She says," my husband keeps telling me that I am crazy, but it feels like someone is stabbing my cheek!" When you ask her to point to the area of pain, she points to the inferior border of her zygomatic arch. You begin to suspect trigeminal nerve neuralgia. Which branch of the trigeminal nerve do you suspect is causing this patient's pain? a. Ophthalmic b. Maxillary c. Mandibular d. Zygomatic

b. Maxillary From Lecture slide titled "Cranial Nerve V: Dysfunction Trigeminal Neuralgia: Tic Douloureux "

CNII enters the cranium through a. Foramen Ovale, Sphenoid Bone b. Optic Canal, Sphenoid Bone c. Internal Acoustic Meatus, Temporal Bone d. Hypoglossal Canal, Temproal Bone e. Olfactory Foramina, Ethmoid bone

b. Optic Canal, Sphenoid Bone

Where does CN IV, the Trochelar nerve, exit the cranium? a) optic canal b) cribiform plate c) superior orbital fissure d) foramen ovale

c) superior orbital fissure slide 23

During a routine day in a family medicine clinic with your preceptor, you are testing the extraocular movements of a patient and notice that upon exam, the patient is unable to abduct her left eye and the eye seems to turn in medially. Her right eye is unaffected. Which of the following nerves is most likely affected in this nerve palsy? a. CN IV b. CN III c. CN VI d. CN II

c. CN VI Lecture slide 35

After the last snow of April, we finally began getting flowers in Duluth. You go to the Duluth rose garden and smell all of the flowers. What is the correct passage way of the olfactory stimulus? a. Stimulus->olfactory bulb->cribriform plate->olfactory cilia->olfactory tract−&γτ;brain b. Stimulus−&γτ;olfactory bulb−&γτ;cribriform plate−&γτ;olfactory tract->olfactory cilia->brain c. Stimulus->olfactory cilia->cribriform plate->olfactory tract->olfactory bulb->brain d. Stimulus->olfactory cilia->cribriform plate->olfactory bulb->olfactory tract->brain

d. Stimulus->olfactory cilia->cribriform plate->olfactory bulb->olfactory tract->brain From lecture and olfactory cilia discussed on page 1062 in Moore.

The difference between pupil sizes in physiologic anisocoria is typically ≤ 1 mm. Concerning exam results in anisocoria are; ptosis, anhidrosis, pupils that respond more to accommodation than light, and impaired extraocular movements. If the difference in size is greater in the dark, the smaller pupil is abnormal. If the difference is greater in light, the larger pupil is abnormal. (Merck Manual) Aside from loss of parasympathetic control of the affected pupil, Cranial Nerve III dysfunction also causes a. Depressed and Abducted resting eye. Loss of Muscle control except CN IV and VI b. Blurred vision of Affected Eye: Parasympathetic loss and no accommodation of lens c. Ptosis: Superior Division to Upper Lid d. Constriction of Affected Eye: Sympathetic loss (dilation) e. a, b and c

e. a, b and c