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Course and Relations the vestibular nerve arises from the lateral aspect of the pontomedullary junction prehypertension at 19 best 25mg coreg, passes through the pontocerebellar angle and enters the internal acoustic meatus along with the facial nerve and labyrinthine vessels. In the lateral part of the internal acoustic meatus, the nerve divides into three distinct branches: superior and inferior divisions and singular nerve. These branches pass through the foramina in the fundus of the meatus and innervate the sensory receptors for equilibrium (cristae ampullaris and maculae) in the membranous labyrinth of the internal ear. The cochlear nerve also arises from the lateral aspect of the pontomedullary junction and takes a similar course to enter the internal acoustic meatus. At the medial end of the internal acoustic meatus, it enters into bony labyrinth of the middle ear through tractus spiralis foraminosus in the fundus of the meatus and reaches the modiolus of the internal ear. In the modiolus, the cochlear nerve possesses a sensory ganglion called the spiral ganglion made of bipolar neurons. The peripheral process of these neurons innervates the sensory receptor of hearing - the organ of Corti. The vestibular nerve is concerned with the maintenance of equilibrium, while the cochlear nerve is concerned with hearing. The vestibular nerve is commonly involved by acoustic neuroma, which arises from the sheath cells of its constituent fibres in the region of cerebellopontine angle. The acoustic neuroma is one of the common intracranial tumors, and if large, it may involve the adjacent trigeminal, facial, and glossopharyngeal nerves and may compress cerebellum and medulla. The hypoglossal nerve is medial to others, curves round behind the vagus nerve, and then passes forward, superficial to the vagus nerve, internal carotid, and external carotid arteries. The close relationship of the last four cranial nerves can be well appreciated by studying the features of the base of the skull around the jugular foramen. The jugular foramen is located in front of the jugular process of the occipital bone. The jugular fossa is a bony depression between the jugular foramen and base of the skull. At first, they lie between the internal jugular vein and the internal carotid artery, where the cranial root of the accessory nerve joins the vagus nerve and is distributed through it. Thereafter, the glossopharyngeal nerve passes forward across the internal carotid artery and then deep to the external carotid artery. It derives its name from the fact that it provides sensory innervation to the tongue and pharynx. General visceral efferent fibres: They supply the secretomotor fibres to the parotid gland. Tonsil Middle constrictor Tongue preganglionic parasympathetic fibres and arise from the inferior salivatory nucleus. Special visceral afferent fibres: They carry taste sensations from the posterior one-third of tongue including vallate papillae and terminate in the nucleus tractus solitarius. General visceral afferent fibres: They carry general sensations of pain, touch, and temperature from the mucous membrane of the pharynx, tonsil, soft palate, and the posterior one-third of tongue and terminate in the dorsal nucleus of the vagus. General somatic afferent fibres: They carry proprioceptive sensations from the stylopharyngeus and skin of the auricle and terminate in the nucleus of the spinal tract of 5th nerve. The rootlets unite to form a single trunk which runs forward and laterally to leave the cranial cavity by passing through the intermediate compartment of the jugular foramen enclosed in a separate sheath of dura mater. The superior and inferior sensory ganglia are located on the nerve as it passes through the jugular foramen. The smaller superior ganglion lies within the jugular foramen and is considered the detached part of the inferior ganglion. The larger inferior ganglion lies just below the jugular foramen and contains the cell bodies of most of the sensory fibres of the nerve. After emerging from the jugular foramen at the base of the skull, the nerve passes downward and forward between the internal carotid artery and the internal jugular vein. It then descends anterior to the internal carotid artery to the styloid process and muscles attached to it (in this position, it lies lateral to the tonsillar bed formed by the superior constrictor) to reach the lower border of the stylopharyngeus. From here it passes along with the stylopharyngeus through the gap between the superior and middle constrictors of the pharynx. It then curves forward along the lateral aspect of the stylopharyngeus muscle which it supplies, and then passes deep to the stylohyoid ligament and posterior edge of the hyoglossus muscle. Here it breaks up into terminal branches, which supply the mucous membrane of the posterior onethird of the tongue, pharynx, and tonsil. Branches and Distribution the glossopharyngeal nerve gives the following important branches: 1. The tympanic plexus gives off: (a) the lesser petrosal nerve and (b) twigs to tympanic cavity, auditory tube, and mastoid air cells. The lesser petrosal nerve carries the preganglionic parasympathetic fibres which relay in the otic ganglion. Carotid nerve (nerve of Herring): It is a branch to carotid sinus and carotid body. It serves as an afferent limb for pressoreceptor and chemoreceptor reflexes from the carotid sinus and carotid body to regulate the heart rate and respiration, respectively. Pharyngeal branch: It joins the pharyngeal branches of the vagus and the cervical sympathetic chain to form the pharyngeal plexus on the middle constrictor of the pharynx. Branch to stylopharyngeus: It arises as the nerve, winds round the stylopharyngeus muscle. Tonsillar branches: They supply the mucous membrane of tonsil, fauces, and palate. Lingual branches: They supply the posterior one-third of the tongue and vallate papillae and convey taste and general sensations. Its field of distribution extends beyond the head and neck - to the thorax and abdomen. It conveys most of the efferent fibres of the cranial part of the parasympathetic outflow and distributes the fibres of an cranial part of the accessory nerve. Clinical correlation · Lesions of glossopharyngeal nerve: the lesion of the glossopharyngeal nerve is rare in isolation since there is often associated involvement of the vagus nerve. However, the complete lesion of the glossopharyngeal nerve results in: (a) the loss of taste and general sensations over the posterior one-third of the tongue, (b) difficulty in swallowing, (c) the loss of the salivation from the parotid gland, and (d) the unilateral loss of the gag reflex (see Chapter 14). It is characterized by paroxysmal attacks of intractable pain in the area of the sensory distribution of the glossopharyngeal nerve. Special visceral efferent fibres: supply the muscles of palate, pharynx, and larynx. Special visceral afferent fibres: carry taste sensations from the posteriormost part of the tongue and epiglottis and terminate in the nucleus tractus solitarius. General visceral afferent fibres: carry general sensations from the mucous membrane of pharynx, larynx, trachea, esophagus, and thoracic and abdominal viscera and terminate in the nucleus tractus solitarius and some in the dorsal nucleus of the vagus. General somatic afferent fibres: carry general sensations from skin of the auricle and terminate in the nucleus of the spinal tract of the trigeminal nerve. These nerve rootlets unite to form the nerve trunk which runs laterally, crosses the jugular tubercle, and leaves the cranial cavity by passing through the middle part of the jugular foramen enclosed in the common dural sheath with the 11th nerve. The right vagus nerve enters the thorax by crossing in front of the right subclavian artery, whereas the left vagus nerve enters the thorax by passing between the left common carotid and left subclavian arteries. For course of vagus nerves in the thorax, see Textbook of Anatomy: Upper Limb and Thorax, Vol. The superior and inferior sensory ganglia are located on the nerve as it passes through the jugular foramen: 1. Both the ganglia contain the cell bodies of the sensory fibres of the vagus nerve. The cranial root of the accessory (11th) nerve unites with the vagus nerve just below its inferior ganglion and thus transfers all its fibres to the vagus nerve for distribution. After coming out of the cranial cavity through the jugular foramen, the nerve runs vertically downward within the carotid sheath in the neck first between the internal jugular vein laterally and the internal carotid artery medially and then between the internal jugular vein (laterally) and the common carotid artery (medially). Meningeal branch: It arises from the superior ganglion, takes a recurrent course, and enters the cranial cavity through the jugular foramen to supply the dura mater of the posterior cranial fossa. Then it enters the meatus between its bony and cartilaginous parts to supply the floor of the meatus and the tympanic membrane. Stimulation of this nerve, as in syringing of the ear, may cause reflex coughing (ear cough), vomiting, and even cardiac arrest.

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It dilates the lacrimal sac by exerting traction on the lacrimal fascia blood pressure home remedies cheap coreg 6.25mg on line, thus helping in the drainage of lacrimal fluid. Corrugator supercilii: It arises from the medial end of the superciliary arch, passes laterally and upwards to be inserted into the skin of the eyebrow above the middle of the supraorbital margin. It drags the eyebrow medially and downwards producing vertical wrinkles on the forehead as in frowning, an expression of annoyance. The frontalis elevates the eyebrows and produces transverse wrinkles on the forehead as an expression of surprise, horror or fright. Levator palpebra superioris: It is not a muscle of the face but one of the orbital muscles, hence described in detail under orbit (Chapter 19). Levator palpebrae superioris is an antagonist to the sphincteric action of palpebral part of orbicularis oculi. Muscles Around the Nasal Cavity the muscles associated with nasal cavity are as follows: 1. Procerus: It arises from nasal bone, passes upwards to be inserted into the skin of the lower part of the forehead. It produces transverse wrinkles across the bridge (root) of the nose as in frowning. Nasalis: It consists of two parts: transverse part called compressor naris and alar part called dilator naris. Compressor naris arises form maxilla close to the nasal notch, passes upwards and medially to form an aponeurosis across the bridge of nose where it becomes continuous with its counterpart on the opposite side. Dilator naris arises from maxilla from the margin of the nasal notch and inserted into the lateral part of the ala of the nose. Depressor septi: It arises from the incisive fossa of the maxilla and is inserted into the lower mobile part of the nasal septum. It fixes the nasal septum to allow dilatation of anterior nasal aperture by dilator naris. Actions Because of its complex nature, orbicularis oris is capable of producing wide variety of movements of lips such as closing, pouting, pursing, twisting, etc. Muscles Around the Mouth the muscles around the mouth are responsible for the movement of lips and cheek. The major extrinsic (or superficial) portion is composed of interlacing fibres of the muscles which converge around the mouth for their insertion into the lips, viz. The uppermost and lowermost fibres pass straight into their respective lips, whereas the middle fibres decussate, so that the upper fibres pass into the lower lip, and lower into the upper lip. The intrinsic portion consists of fibres running obliquely between the skin and mucus membrane of the lips, and incisive slips, which pass laterally into the lips from the jaws adjacent to the incisor teeth and interlace with the fibres of Clinical correlation Paralysis of orbicularis oris: the paralysis of one-half of orbicularis oris prevents the proper closure of lips on that side. Consequently the speech is slurred and the saliva escapes between the lips at the angle of the mouth (dribbling of saliva from the angle of the mouth). Scalp, Temple, and Face 55 the muscle of chin called mentalis is usually discussed with muscles around the mouth. Levator labii superioris alaeque nasi arises from the frontal process of the maxilla and is inserted into the ala of nose by one slip and to the upper lip by another slip. Levator labii superioris arises from maxilla just above the infraorbital foramen and is inserted into the upper lip. Levator anguli oris arises from maxilla below the infraorbital foramen and is inserted into the angle of the mouth. Zygomaticus major arises from zygomatic bone and is inserted into the angle of the mouth. Depressor labii inferioris arises from the anterior oblique line of the mandible and is inserted into the lower lip. Depressor anguli oris arises from the posterior part of the oblique line of the mandible and is inserted into the angle of the mouth. Risorius arises from parotid fascia as a continuation of posterior fibres of platysma and is inserted into the angle of the mouth. Mentalis, a small conical muscle arises from the incisive fossa of the mandible and is inserted into the skin of the lower lip. Fibrous band that extends from pterygoid hamulus to maxillary tuberosity (pterygomaxillary raphe). Pterygomandibular raphe, which extends from pterygoid hamulus to the mandible behind the third molar tooth. After origin, the fibres run towards the mouth and fill the gap between the upper and lower jaws. Insertion: the buccinator is inserted in a complicated manner into the upper and lower lips. On reaching near the angle of the mouth: (a) upper fibres pass into upper lip, (b) lower fibres pass into the lower lip, and (c) intermediate fibres decussate and as a result upper fibres of this group pass into lower lip and lower fibres pass into the upper lip. It flattens the cheek against the gum and teeth, and thus prevents the accumulation of food in the vestibule of mouth during mastication. The outer surface of buccinator muscle is covered by buccopharyngeal fascia and its inner surface is lined by a mucus membrane. The pterygomandibular raphe separates it from superior constrictor of the pharynx. A gap between maxillary fibres and those from pterygomaxillary raphe provides passage to the tendon of tensor palati. It is formed due to interlacing of fibres of five muscles which converge towards the angle of the mouth. It can be easily palpated by using opposed thumb and index finger to compress the skin and mucosa simultaneously. The inadvertent damage of modiolus during plastic surgery leads to unacceptable facial asymmetry. Buccinator, by asking the patient to puff his mouth and then blow out the air forcefully. After coming out of cranial cavity through stylomastoid foramen, the facial nerve wind around the lateral aspect of styloid process and then enters the parotid gland. These five sets of terminal branches form the goose-foot pattern (pes anserinus) on the face (also see p. Facial Muscles and Emotional Expressions the facial muscles responsible for important emotional expressions are presented in Table 3. Clinical Testing of the Muscles of Facial Expression the muscles of facial expression are involved in facial nerve lesion. They are tested clinically in the following ways: Frontalis, by asking the patient to look upwards without moving his head and then look for horizontal wrinkles on the forehead. Corrugator supercilii, by asking the patient to frown and then look for vertical wrinkles between the two eyebrows. Facial asymmetry (affected side is drawn to the healthy side) - due to unopposed action of muscles of normal side. Loss of horizontal wrinkles on forehead - due to paralysis of occipitofrontalis muscle. Widening of palpebral fissure and inability to close the eye - due to paralysis of orbicularis oculi. Tears flow down from the eye (epiphora) - due to paralysis of the lower part of the orbicularis oculi. Sagging of the angle of the mouth towards the affected side and inability of the angle of the mouth to move upwards and laterally during laughing - due to paralysis of zygomaticus major. Loss of nasolabial furrow - due to paralysis of levator labii superioris alaeque nasi. Accumulation of food into the vestibule of the mouth - due to paralysis of buccinator muscle. Dribbling of saliva from the angle of the mouth - due to paralysis of orbicularis oris. Loss of resistance when one presses cheek with inflated vestibule and air leaks out from between the lips - due to paralysis of buccinator muscle. In upper motor neuron type paralysis of facial muscles due to involvement of the pyramidal tract, the upper part of the face is not affected. This part of face remains normal because lower motor neurons supplying this part of face receive corticonuclear fibres (upper motor neurons) from cerebral cortex of the both sides (bilateral cortical innervation; for detail see Chapter 22). Thus the original beard area has been drawn up to the temple and necessarily the neck skin is drawn up to overlap the angle of the mandible. Note trigeminal and spinal fields (V1 = ophthalmic division of trigeminal nerve, V2 = maxillary division of trigeminal nerve, V3 = mandibular division of trigeminal nerve). The upper one-third face (developing from frontonasal process) is supplied by ophthalmic division, middle third of face (developing from maxillary processes) is supplied by maxillary division and lower third of face (developing from mandibular processes) is supplied by mandibular division of the trigeminal nerve.

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Paralysis of this muscle following external laryngeal nerve lesion alters the voice quite significantly and is especially noticeable in singers blood pressure medication that starts with m buy cheap coreg 25mg. Clinical correlation Safety muscles of larynx: the posterior cricoarytenoid muscles are the only intrinsic muscles of the larynx, which abduct the vocal cords to allow entry of air through rima glottidis in the respiratory tract below it. When posterior cricoarytenoids contract, muscular processes of both the arytenoid cartilages rotate medially. As a result, the vocal processes rotate laterally (abducting vocal cords) providing wide diamond-shaped opening of the glottis. If posterior cricoarytenoids are paralyzed, the adductor muscles (of vocal cords) take the upper hand and the person might die due to lack of air. Hence the posterior circoarytenoid muscles are called safety muscles of the larynx. It is the detached medial part of the thyroarytenoid and lies within the vocal fold just lateral and cranial to the vocal ligament. On its contraction the anterior part of vocal ligament tenses whereas its posterior part is relaxed. The segmental tension of vocal ligament helps in the modulation of voice like the fingers of a violinist. It is a triangular muscle, which arises from the posterior surface of the cricoid lamina lateral to its median ridge. After origin, the fibres pass upwards and laterally to be inserted into the back of the muscular process of the arytenoid. Nerve Supply All the intrinsic muscles of the larynx are supplied by recurrent laryngeal nerve except cricothyroid, which is supplied by the external laryngeal nerve. Clinical correlation · Damage of external laryngeal nerve: If it is damaged, there is some weakness of phonation due to loss of tightening effect of cricothyroid muscle on the vocal cords. But, usually the other cord is able to compensate and the phonation is not much affected. The sound (normal) produced by vocal cords move freely and even cross the midline to meet the paralyzed vocal cord; (b) If damaged bilaterally, both the vocal cords lie in the paramedian position with consequent loss of phonation and difficulty in breathing. Thyroepiglotticus Aryepiglotticus Quadrangular membrane Vestibular ligament Vocal ligament Cricovocal membrane N. Exceptions: · the cricothyroid is the only muscle lying on the outer aspect of the larynx. Clinical correlation Laryngeal obstruction: the mucous membrane of the superior part of larynx is very sensitive. If this reflex is slowed or absent as in neurological lesion or after consuming alcohol, a foreign body. If foreign body is not dislodged and expelled out immediately by Heimlich maneuver, person will die within minutes, almost certainly before there is time to take him to the hospital. By doing this, the residual air in the lungs is squeezed up in trachea and larynx with force, dislodging foreign body and thus relieving laryngeal obstruction (choking). Within the laryngeal cavity, two pairs of folds of the mucous membrane extend (on each side) posteroanteriorly from arytenoid cartilage to the thyroid cartilage: 1. The upper folds are produced by vestibular ligament and called vestibular folds or false vocal cords. When the vestibular folds come together, they prevent food and liquids from entering the larynx and air from leaving the lungs, as when a person holds his breath. The lower folds are produced by the vocal ligaments and vocalis muscle, and called vocal folds or true vocal cords. They extend from the middle of the thyroid angle to the vocal processes of arytenoids. Vestibule (supraglottic compartment): It extends from laryngeal inlet to the vestibular folds. Its anterior wall is formed by the mucous membrane covering the posterior surface of epiglottis, posterior wall by the mucous membrane covering the apices of arytenoids cartilages, and corniculate cartilages, and sides by aryepiglottic folds. Ventricle or sinus of the larynx (glottic compartment): It is the deep elliptical space between vestibular and vocal folds. On each side, a narrow blind diverticulum of the mucous membrane extends posterosuperiorly between the vestibular fold and lamina of the thyroid cartilage, called saccule of the larynx. It is provided with the mucous glands, whose secretions lubricate the vocal cords. Clinical correlation the mucosa (lined by stratified squamous epithelium) lining the vocal cords is firmly adhered to the vocal ligaments and there is no intervening submucosa. The edema of larynx does not involve the true vocal cords since there is no submucous tissue. The laryngocele may be internal, when it is located within the larynx or external, when distended saccule herniates through the thyrohyoid membrane and comes outside the larynx. Sensory nerve supply: the mucous membrane of larynx above the vocal folds is supplied by the internal laryngeal nerve, while below the vocal folds by the recurrent laryngeal nerve. Infraglottic compartment: It extends from vocal folds to the lower border of the cricoid cartilage. Clinical correlation If internal laryngeal nerve is damaged, there is anesthesia of the mucous membrane in the supraglottic portion and loss of protective cough reflex. The whole of the laryngeal cavity is lined by ciliated columnar epithelium except the anterior surface and upper half of the posterior surface of the epiglottis, upper parts of aryepiglottic folds and vocal folds, which are lined by stratified squamous epithelium. Above the vocal fold by superior laryngeal artery, a branch of superior thyroid artery. Below the vocal fold by inferior laryngeal artery, a branch of inferior thyroid artery. Intercartilaginous part in the posterior one-fifth, between the vocal processes of arytenoid cartilage. The anteroposterior diameter of glottis is 24 mm in adult males and 16 mm in adult females. On each side: Vocal fold in anterior three-fifth and vocal process of arytenoid cartilage in the posterior two-fifth. In full inspiration, the glottis widens and becomes diamond shaped due to abduction of vocal cords. During high-pitched voice, the rima glottidis is reduced to a linear chink, due to adduction of both intermembranous and intercartilaginous parts. During whispering, the intermembranous part is highly adducted and intercartilaginous part is separated by triangular gap, thus rendering an inverted funnel shape to the rima glottidis. Subdivisions of Rima Glottidis the rima glottidis is divided into the following two parts: 1. Clinical correlation Laryngoscopy: the interior of the larynx can be inspected directly by laryngoscope (direct laryngoscopy), or indirectly through a laryngeal mirror (indirect laryngoscopy). Infraglottic air pressure is generated by the exhaled air from lungs by the contraction of abdominal, intercostal, and other expiratory muscles. As the moving air passes through the vocal cords it makes them to vibrate producing sound. Sound is converted into speech by the modulatory actions of lips, tongue, palate, pharynx, and teeth. Since the vocal cords are usually longer in males than females, they vibrate with greater amplitude but with lower frequency. Hence in individuals, who overuse their voice, such as teachers, pop singers, the inflammatory nodules develop at these sites called vocal nodules. The wife who was sitting by his side suspected that probably he has consumed too much alcohol. So he immediately opened his mouth and observed that a piece of meat was caught in the posterior part of the pharynx. On being unsuccessful he rolled his daddy into a prone position and with his hands interlocked against the epigastrium exerted pressure on abdomen 2 or 3 times. Because of the following two reasons: (a) People who are drunk are less able to chew their food properly and to detect a large bite. It is a first-aid procedure by which foreign bodies lodged in the respiratory tract are dislodged and expelled out (for details see page 226).

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The inferior vermis is more clearly demarcated from the hemispheres in the floor of vallecula cerebelli blood pressure zoladex buy coreg online pills. The inferior surface presents a deep median notch called vallecula which separates the two cerebellar hemispheres. Notches the anterior aspect of cerebellum is marked by a wide shallow anterior cerebellar notch which accommodates pons and medulla. The horizontal fissure is most conspicuous and runs along the lateral and posterior margins of the cerebellum. It marks the junction between the superior and inferior surfaces of the cerebellum. The posterolateral fissure lies on the inferior surface of the cerebellum and separates the flocculonodular lobe from the rest of the cerebellum (corpus cerebelli). The V-shaped fissura prima on the superior surface cuts the superior vermis at the junction of its anterior two-third and posterior one-third. There are several other fissures which subdivide the vermis and cerebellar hemispheres into lobules and given fanciful names. Most of them are ignored to lessen the complexity of the cerebellum and only those which have a functional or descriptive value are given. Posterior/middle lobe: It lies between the fissura prima on the superior surface and posterolateral fissure on the inferior surface. Flocculonodular lobe: It is the smallest of all and lies on the inferior surface in front of the posterolateral fissure. Archicerebellum (Vestibular cerebellum): Phylogenetically, it is the oldest part of the cerebellum. The archicerebellum is chiefly vestibular in connections and concerned with the maintenance of equilibrium, tone, and posture of trunk muscles. Paleocerebellum (Spinal cerebellum): Phylogenetically, it is the next part of the cerebellum to appear. It consists of anterior lobe (except lingula) and pyramid, and the uvula of inferior vermis. The paleocerebellum is chiefly spinocerebellar in connections and is concerned with the tone, posture, and crude movements of the limbs. Neocerebellum (Cerebral cerebellum): Phylogenetically, it is the most recent part of the cerebellum to develop. It is made up of middle lobe, the largest part of the cerebellum (except the pyramid and the uvula of inferior vermis). The neocerebellum is chiefly corticopontocerebellar in connections and is concerned with the smooth performance of skilled voluntary movements. Embedded within the central core of white matter are masses of grey matter called intracerebellar nuclei. The cerebellar cortex is folded in such a way that the surface of cerebellum presents a series of parallel transverse fissures and intervening narrow leaf-like bands called folia. Each folium consists of a slender branched lamina of central core of white matter covered by a thin layer of grey matter. The central core of white matter being arranged in the form of branching pattern of a tree is called arbor vitae cerebelli (arbor vitae = tree of life). Molecular (plexiform) layer: It mainly consists of numerous dendritic arborizations of Purkinje cells and relatively few nerve cells which are widely spaced. The nerve cells are of two types: (a) the basket cells and (b) the stellate cells. Purkinje cell layer: It consists of a single row of large flaskshaped cells, the Purkinje cells. The outgoing Purkinje axons constitute the sole output from the cerebellar cortex and exert an inhibitory influence on the intracerebellar nuclei. Granular layer: the inner granular layer consists of numerous closely packed small granule cells. The dentate nucleus is the most prominent of the intracerebellar nuclei and largest in primates, especially in humans. It is the nucleus of neocerebellum, and therefore receives afferent fibres from it. The emboliform nucleus is oval in shape and situated medial to the dentate nucleus, partially covering its hilum. The globose nucleus is rounded in shape and lies between the emboliform and fastigial nuclei. The globose and emboliform nuclei together are sometimes referred to as nucleus interpositus. The fastigial nucleus lies near the midline in the vermis and close to the roof of the 4th ventricle is the nucleus of archicerebellum, hence receives afferent fibres from the flocculonodular lobe (archicerebellum). Neocerebellum Paleocerebellum Archicerebellum Dentate nucleus Red nucleus and thalamus Red nucleus Intrinsic Neurons of the Cerebellar Cortex There are five types of intrinsic neurons in the cerebellar cortex, viz. All the intrinsic neurons of cerebellar cortex are inhibitory except granule cells. Such a collection of inhibitory neurons is not found anywhere else in the central nervous system except in the cerebellum. The superior cerebellar peduncles connect the cerebellum to the midbrain, the middle cerebellar peduncles to the pons, and the inferior cerebellar peduncles to the medulla oblongata. The inferior cerebellar peduncle is formed on the posterolateral aspect of the upper half of the medulla oblongata. The inferior cerebellar peduncle consists mainly of afferent fibres to the cerebellum from the spinal cord, the olivary nuclei, the reticular formation of the medulla, and the vestibular nuclei and nerve. It also transmits a few efferent fibres from the cerebellum to the medulla, principally to the vestibular nuclei and reticular formation. The middle cerebellar peduncle consists of only afferent fibres which arise from the pontine nuclei of the opposite side. The superior cerebellar peduncle emerges from the anterior cerebellar notch and forms the lateral boundary of the upper half of the 4th ventricle. It mainly consists of efferent fibres passing from the dentate nucleus to the red nucleus, thalamus and cerebral cortex of the opposite side. It is the principal efferent pathway from the cerebellum and its fibres arise mainly in the dentate nucleus. It is situated in the posterior cranial fossa in front of the cerebellum and behind the pons and the upper part of medulla oblongata. The cavity of the ventricle presents a triangular outline in the sagittal section and appears rhomboidal (lozenge shaped) in the horizontal section. Superior cerebellar artery: a branch of basilar artery supplies the superior surface of the cerebellum. Anterior inferior cerebellar artery: a branch of basilar artery supplies the anterior part of the inferior surface of the cerebellum. Posterior inferior cerebellar artery: a branch of vertebral artery supplies the posterior part of the inferior surface of the cerebellum. Superior cerebellar peduncle Median sulcus Locus ceruleus Facial colliculus Superior fovea Sulcus limitans Vestibular area Clinical correlation Lesions of cerebellum: the cerebellar lesions due to trauma, vascular occlusion, tumors, etc. The characteristic signs and symptoms of the cerebellar syndrome are as follows: (a) Generalized muscular hypotonia, leading to staggering gait. Floor (Rhomboid Fossa) the floor of the 4th ventricle is formed by the posterior surface of the pons and the upper part of the medulla. The upper triangular part is bounded on each side by the superior cerebellar peduncle, while the lower triangular part is bounded on each side by gracile and cuneate tubercles and the inferior cerebellar peduncle. Features of the floor of the fourth ventricle (Rhomboid fossa) the floor of the 4th ventricle exhibits the following features: 1. The entire floor is divided into right and left symmetrical halves by a median sulcus, which extends from the aperture of the aqueduct of the midbrain above to the commencement of the central canal below. At its widest part, the floor is crossed transversely by glistening white fibres, the stria medullaris. These fibres are derived from arcuate nuclei, which emerge from the median sulcus and run transversely across the floor to enter into the inferior cerebellar peduncle.

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The superior and posterior free margins of the auricle forming a kind of rim are called helix blood pressure 8050 buy cheap coreg 6.25mg, which ends inferiorly at the fleshy protuberance of the ear called ear lobule. The upper end of the helix is typically at the level of the eyebrows and the glabella. Clinical correlation the external auditory meatus and tragus are important landmarks to use when taking extraoral radiographs and administering local anesthesia on a patient. The pulsations of superficial temporal artery can be felt by putting the fingertip just in front and above the tragus on the root of zygoma. Glabella Superciliary arch Frontozygomatic suture Frontal prominence Eyebrow Supraorbital notch Nasion Bridge of nose Infraorbital foramen Nostril (or nare) Angle of mouth Mental foramen Clinical correlation the parotid gland is often enlarged following infection by mumps virus. The parotid gland is also the site of slow growing painless tumor called mixed parotid tumor. Eyebrow is a ridge of hair along the superciliary arch above the orbit, which protects the eyes against sunlight and mechanical blow. The two movable eyelids reflexly close to protect eyes from foreign particles and bright sunlight (for details on eyelids see Chapter 3). Behind the lateral part of the upper eyelid and within the orbit is the lacrimal gland, which produces lacrimal fluid or tears. The tears wash away chemical and foreign particles and lubricate the front of the eye to prevent the surface of the eyeball, particularly the all-important cornea from drying. The conjunctiva is a delicate thin mucous membrane which lines the inner surface of the eyelids and the front of the eyeball. Eyebrow Upper eyelid the outer corner where the upper and lower eyelids meet is called lateral (outer) canthus. A fleshy pinkish elevation in the medial angle of the eye is called lacrimal caruncle. Frontozygomatic suture, which is marked by a slight irregular depression on the lateral orbital margin. Clinical correlation the condition of the eyes profoundly affects the facial appearance. A few easily recognizable and surgically relevant conditions are as follows: · Arcus senilis, a white rim around the outer edge of the iris, is commonly seen in elderly people. It occurs due to sclerosis and deposition of cholesterol in the edge of the cornea. If multiple and growing, they indicate underlying abnormality of cholesterol metabolism, diabetes, or arterial disease. The commonest cause of both bilateral and unilateral exophthalmos is thyrotoxicosis (hyperthyroidism). Living Anatomy of the Head and Neck 5 narrow bony portion below the nasion is the bridge of the nose. The nose below this level has pliable cartilaginous framework that maintains the openings of the nose. The distinctive external nose with exuberant growth of cartilages forming prominent dorsum, tip, and alae is a characteristic feature of human beings. The zygomatic arch extends from just inferior to lateral margin of the eye towards the upper portion of the auricle. Inferior to the zygomatic arch and just anterior to the tragus of the ear is the temporomandibular joint. The zygomatic arch is bony bridge that spans the interval between the ear and the eye. The zygomatic bone forms the bony prominence of the cheek below and lateral to the orbit. The movements of the temporomandibular joint can be felt by opening and closing the mouth or moving the lower jaw from side to side. One way to feel the movements of head of mandible is to gently place a finger into the outer portion of the external auditory meatus. The hypertrophy and adenomatous changes of these glands gives rise to a lobulated tumor called rhinophyma. The lips are chiefly composed of muscles covered externally by skin and internally by mucous membrane. The lips are outlined from the surrounding skin by a transition zone called vermillion border. The apex of philtrum is towards the nasal septum and the base downwards where it terminates in a thicker area called tubercle of the upper lip. The corners of mouth where upper and lower lips meet are called labial commissure. The groove running upward between the labial commissure and the alae of nose is called nasolabial sulcus. The lips are a common site for carcinoma, mostly affecting individuals above 60 years of age. Carcinoma of the lip usually occurs in lower lip (93%) as compared to the upper lip (5%). Uvula Palatopharyngeal arch Palatoglossal arch Palatine tonsil the bone underlying the upper lip is the alveolar process of the maxilla, whereas the bone underlying the lower lip is the alveolar process of the mandible. The alveolar processes contain teeth and are called maxillary and mandibular teeth. The labial mucosa is continuous with the equally pink and thick buccal mucosa that lines the inner cheek. On the inner aspect of buccal mucosa opposite the upper second molar tooth is a small elevation called parotid papilla on which opens the parotid duct. The gingiva is a part of oral mucosa that covers the alveolar processes of the jaws. The roof of oral cavity which presents two portions: (a) a firm anterior portion is called hard palate and a flexible posterior portion is called soft palate. A cone-shaped projection hanging down from the middle of the posterior free margin is called uvula of the palate, which is continuous with palatopharyngeal arch on each side. A curved, leaf-like flap of cartilage is located behind the base of tongue and in front of oropharynx. The tonsil lies in triangular fossa called tonsillar fossa located between the palatoglossal and palatopharyngeal arches. Note that the tonsils lie opposite the angle of mandible between the back of tongue and soft palate. Topographically, the structures of the neck are organized into anterior and posterior compartments. In the midline there are two tubes: the respiratory tract (larynx and trachea) in front and digestive tract (pharynx and esophagus) behind. The thyroid gland clasps the front and sides of the larynx and trachea and overlaps the carotid tree on either side. These structures are bounded anteriorly by pretracheal fascia, which extends on either side to merge with the investing layer of deep cervical fascia deep to sternocleidomastoid. On either side of the midline tubes are several ascending and descending neurovascular structures, such as carotid tree consisting of common carotid, internal carotid and external carotid arteries, internal jugular vein and last four cranial nerves. At the upper end these structures enter or leave the skull through various foramina in the base of the skull, viz. This musculoskeletal block is bounded by prevertebral fascia, which merges behind on either side with the deep fascia enclosing the trapezius muscle. The vertebral canal within the cervical vertebral column provides passage to the spinal cord. The roots of cervical spinal nerves come out through intervertebral foramina in this region. The ventral rami of the first four cervical nerves form the cervical plexus and ventral rami of the lower four cervical nerves along with ventral ramus of T1 form the brachial plexus. The spinal cord, digestive and respiratory tracts, and major blood vessels traverse this highly flexible area. The neural structures present in the region include: last four cranial nerves and cervical and brachial plexuses. A newborn baby has no visible neck because his or her lower jaw and chin touches the shoulders and thorax.

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They often have trouble with giveand-take in normal conversations blood pressure kits at walgreens buy coreg 12.5mg with amex, difficulties making eye contact, a lack of facial expressions, and difficulties adjusting behavior to fit different social situations. They also engage in obsessive and repetitive patterns of behavior, interests, or activities. Others have more severe forms of the disorder with noticeable disability and a lifelong dependence on others to meet their needs. Accessed November 6, 2013 At 12 Months · A child with typical development will turn his head when he hears his name. At 18 Months · A child with delayed speech skills will point, gesture, or use facial expressions to make up for her lack of talking. In most cases, sudden and severe diarrhea often goes away on its own as the underlying condition clears up. Until then, however, make sure your child has enough fluids to prevent dehydration. If she has mild diarrhea and is vomiting, offer her an electrolyte solution in place of her normal diet. You should teach your child to wash his hands with soap and water every time he uses his potty-chair or the toilet. Coping With Diarrhea Water and salt lost in diarrhea must be replenished to prevent dehydration. Give your child small amounts of the drink (no more than an ounce at a time) frequently, every 15 minutes or so, to have the best effect. The Big Book of Symptoms 70 Diarrhea in inFantS anD ChilDren YoUr ConCernS Your child suddenly develops diarrhea with abdominal cramps, is vomiting, and has a mild fever. Talk with your pediatrician, who will examine your toddler to rule out any serious health problems. He or she may suggest dietary changes, such as having your child consume smaller amounts of juices and sweet drinks, if any. Call your pediatrician, who will examine your toddler or young child, order diagnostic tests as required, and recommend treatment. He has several loose bowel movements every day but is otherwise healthy and gaining weight. Infectious bacterial diarrhea (eg, salmonella or shigella) Nonspecific diarrhea (common in toddlers) Too much juice Bacterial food poisoning Parasitic infection, such as giardiasis, especially if your toddler or young child attends group care Medication side effect Your child has diarrhea during or just after antibiotic treatment. Your otherwise healthy school-aged child has alternating bouts of diarrhea and constipation that occur at times of stress. If your child needs an antibiotic, your pediatrician will prescribe an alternative and advise on diet. Talk with your pediatrician, who will examine your child to rule out any serious disorders. If your pediatrician confirms irritable bowel syndrome, treatment of it may involve an increase in dietary fiber or medication that relieves cramps. Talk with your pediatrician without delay, who will order diagnostic tests and recommend treatment, if required. Talk with your pediatrician without delay; diagnostic tests and appropriate treatment are necessary. Children with vertigo, on the other hand, sense that the room is spinning around or their body is veering out of control. If your child has vertigo and ringing or buzzing in her ears, she should be seen by your pediatrician. Keeping a Sense of Balance Our ability to remain upright depends on a delicate interplay between the nerves and muscles involved in hearing, sight, and touch. Our limbs and muscles are equipped with sense organs that help us gauge our position relative to our surroundings. A disturbance in any part of this balance mechanism may cause dizziness, vertigo, and nausea. Vertigo, on the other hand, is often an ongoing sensation caused by a problem with the inner ear. People with vertigo sometimes have tinnitus as well; this ringing or buzzing sound is caused by a related disturbance in the nerve we use to perceive sound. YoUr ConCernS Your child is unwell and feverish with a temperature higher than 100°F (37. If your child looks quite ill and lethargic (lacking energy), he may need an emergency evaluation for illnesses such as meningitis. Your child gets dizzy and nauseated while riding in a car, an elevator, or a boat. Ask your pediatrician what measures you should take to prevent motion sickness in your child. If your child has lost consciousness or appears confused and disoriented, an emergency evaluation may be required. Post-viral cerebellar ataxia (weakness and loss of muscle coordination) Motion sickness Head injury Your child complains of dizziness and disorientation. Absence seizure (an abrupt, transient loss or impairment of consciousness, not subsequently remembered, sometimes with light twitching or fluttering eyelids) Unusual health problem, such as a tumor, that requires diagnosis and treatment Your child has headaches that become worse when he lays down. Although rare in children, these conditions can occur and require prompt treatment (see "Headache," page 96). In rare cases, ataxia (neuromuscular problem) Talk with your pediatrician, who will examine your child and determine whether she should be seen by another specialist. The increased flow of saliva that often signals the appearance of a new tooth seems to soothe tender gums; however, if your baby appears to be drooling excessively and looks ill, she may be having trouble swallowing, which requires medical attention. His saliva softens and moistens food once solids are part of his diet, keeps his mouth moist and makes it easier for him to swallow, washes away food residues, and protects his teeth. The submandibular gland lies under the jaw, the sublingual gland is under the tongue, and the parotid is close to the ear. The Big Book of Symptoms 74 DroolinG YoUr ConCernS Your infant is between 3 and 6 months of age. He is a little fussy, and he seems to want to chew and bite on firm objects, including your fingers. Viral infection of the throat or mouth Streptococcal throat infection Tonsillitis (inflammation of the tonsils) Viral infection of the tongue or gums such as handfoot-and-mouth disease Herpes Epiglottitis (inflammation of the flap of tissue that prevents food and liquids from entering the trachea [windpipe]) Call your pediatrician, who will examine your child and recommend treatment. If your pediatrician agrees, give your child acetaminophen or ibuprofen to reduce her fever. Call 911 or your local emergency number, or take your child to the nearest hospital emergency department. Once a grave threat, it has become less common since the introduction of the Hib vaccine for children. Have someone else call 911 or your local emergency number while you start the Heimlich maneuver or chest compressions on your baby. During the seizure, make sure your child is safe from objects that could injure her (see page 222). Ear problems are common in children 2 years or younger because they are exposed to a host of germs before their immune systems are mature enough to resist infections. Luckily children tend to outgrow these illnesses as their susceptibility to them decreases and their eustachian tubes mature. These signs include nighttime crying and daytime irritability, fever (a temperature of 100. An infant with an ear infection will often cry in distress when feeding as his ear pressure changes with the sucking motion. Symptoms of ear pain, called otalgia, and a short-lived loss of hearing may appear rapidly in older children and teens. A middle ear infection may result in a sudden rupture of the eardrum with drainage of fluid from the ear canal. Call your pediatrician if your child has earache along with ·· Discharge from his ear ·· Swelling around his ear ·· Headache ·· Fever of 102. Formula or other liquid can sometimes travel up the eustachian tube and create ideal conditions for bacterial growth in her middle ear. Children who are exposed to secondhand tobacco smoke have an increased risk of developing upper respiratory infections; bronchiolitis, which is a lung infection; ear infections; and other health problems.

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In the supranuclear lesion blood pressure guidelines safe coreg 25mg, only lower half of the face on the opposite side is paralyzed. Site B Above the origin of chorda tympani: All the signs and symptoms of lesion A. Site C Above the origin of nerve to stapedius: All the signs and symptoms of lesion B plus hyperacusis. Site D At the geniculate ganglion: All the signs and symptoms of lesion C plus loss of lacrimation. It results in the facial nerve lesion proximal to the geniculate ganglion because regenerating preganglionic fibres meant to provide secretomotor supply to the submandibular and sublingular salivary glands during regeneration are misdirected and grow in the endoneural sheaths of preganglionic secretomotor fibres which supply the lacrimal gland. Clinically, it presents with the following signs and symptoms: ­ Herpetic vesicles on the auricle. It consists of preganglionic parasympathetic fibres which relay in the pterygopalatine ganglion and supply the secretomotor fibres to the lacrimal gland and the mucous glands of nasal cavity and palate. Nerve to stapedius - arises from the vertical part of the facial nerve opposite the pyramidal eminence, runs forward through a short canal within it to reach the stapedius muscle to supply it. Chorda tympani nerve - arises from the vertical part of the facial nerve about 6 mm above the stylomastoid foramen, and enters the middle ear through the posterior canaliculus (on the posterior wall of the middle ear), runs across its lateral wall of the middle ear (pars flaccida of the tympanic membrane); passing between the long process of incus and the handle of malleus, and leaves the middle ear by entering the anterior canaliculus (on the anterior wall of the middle ear). It then traverses through the bony canaliculus and enters the inferotemporal fossa through the medial end of petrotympanic fissure. After emerging from the petrotympanic fissure, it runs medially forward and downward, crossing the medial aspect of the spine of sphenoid, to join the posterior aspect of the lingual nerve. The fibres carrying the sensory information for equilibrium terminate in the vestibular nuclei within the brainstem. The fibres carrying the sensory information for hearing terminate in the dorsal and ventral cochlear nuclei, located respectively on the dorsal and ventral aspects of the inferior cerebellar peduncle. Pharyngeal branch: It arises from the inferior ganglion, passes forward between the internal and external carotid arteries, and takes part in the formation of pharyngeal plexus. It supplies: (a) all the muscles of pharynx except the stylopharyngeus, which is supplied by the glossopharyngeal nerve, and (b) all the muscles of soft palate except the tensor palati which is supplied by the mandibular nerve (through the nerve to medial pterygoid). Superior laryngeal nerve (nerve of 4th arch): It arises from the inferior ganglion, passes downward and forward deep to the internal carotid artery to reach the middle constrictor where it divides into external and internal laryngeal nerves: (a) the external laryngeal nerve (motor) runs downward in company with superior thyroid vessels and supplies cricothyroid muscle. It supplies the: 348 Textbook of Anatomy: Head, Neck, and Brain (i) mucous membrane of larynx above the vocal cords, and (ii) mucous membrane of the pharynx, epiglottis, vallecula, and the posteriormost part of the tongue. Superior and inferior cervical cardiac branches: the superior cardiac branch arises in the upper part of the neck and the inferior cardiac branch in the lower part of the neck. They carry preganglionic parasympathetic fibres to the heart and are cardio-inhibitory. The inferior cervical cardiac branch of the left vagus nerve joins the superficial cardiac plexus. The remaining cervical cardiac branches of both the vagus nerves join the deep cardiac plexus. Recurrent laryngeal nerve (nerve of 6th arch): (a) On the right side, it arises in the root of the neck from the vagus nerve as it crosses in front of the subclavian artery, winds around the first part of the subclavian artery, and then ascends up (in a recurrent direction) in the tracheoesophageal groove. It hooks below the arch of the aorta on the left side of ligamentum arteriosum behind the arch of aorta on its way to the tracheoesophageal groove. The recurrent laryngeal nerve provides motor innervation to all the intrinsic muscles of the larynx (except the cricothyroid which is supplied by the external laryngeal nerve) and sensory innervation to the mucous membrane of laryngeal cavity up to the vocal cord. Each recurrent laryngeal nerve passes deep to the inferior constrictor muscle to enter the laryngeal cavity deep to the cricothyroid joint. In the unilateral lesion, there is flattening (drooping) of palate arch on the side of paralysis and uvula pulled to the normal side. The cranial root is accessory to the vagus and its fibres are distributed through the vagus nerve. The spinal root has an independent course and is generally regarded as spinal accessory nerve, or simply as accessory nerve. Special visceral efferent fibres: provide motor supply to the muscles of soft palate, pharynx, and larynx. General somatic efferent fibres: provide motor supply to the sternocleidomastoid and trapezius muscles. They arise from the spinal nucleus of accessory nerve, in the ventral horns of the upper five spinal segments and form the spinal root. The Alderman in ancient Roman days used to stimulate their appetite by dropping cold water behind the ear supplied by the auricular branch of the vagus nerve. Apparently, this occurs by a reflex increase in gastric motility supplied by the vagus nerve (to the stomach). Cranial Nerves 349 Vagus nerve Cranial root of accessory nerve Spinal root of accessory nerve Foramen magnum Accessory nerve Muscles of palate Muscles of pharynx Muscles of larynx internal jugular vein toward the carotid triangle. It crosses in front of the transverse process of the atlas under the posterior belly of the digastric muscle and occipital artery. The nerve pierces the sternocleidomastoid muscle at the junction of its upper one-fourth with the lower three-fourth and supplies it. The nerve passes through the muscle and emerges through its posterior border a little above its middle to enter the posterior triangle where it runs downward and backward underneath the fascial roof of the posterior triangle, parallel to the fibres of levator scapulae. It leaves the posterior triangle by passing deep to the anterior border of the trapezius about 5 cm above the clavicle. The C2 and C3 spinal nerves carry proprioceptive fibres from the sternocleidomastoid while C3 and C4 carry proprioceptive fibres from the trapezius muscle. The spinal root arises by a number of rootlets from the lateral aspect of the spinal cord (upper five cervical spinal segments) along a vertical line between the ventral and dorsal roots of the spinal nerves. These rootlets unite to form a single trunk which ascends in the vertebral canal to enter the cranial cavity through the foramen magnum behind the vertebral artery. The spinal root leaves the skull through the jugular foramen where it fuses with the cranial root. The combined trunk comes out of the cranial cavity through the middle compartment of the jugular foramen enclosed in the dural sheath along with the vagus nerve. The cranial root joins the vagus nerve just below its inferior ganglion and is distributed through the branches of the vagus to the muscles of the palate, pharynx, and larynx. The spinal root of the accessory nerve descends vertically downward between the internal jugular vein and the internal carotid artery. All the muscles of the palate except the tensor palati and tensor tympani which are supplied by the mandibular nerve (nerve to medial pterygoid): (a) All the muscles of the pharynx except the stylopharyngeus which is supplied by the glossopharyngeal nerve. Clinical correlation · Lesions of spinal accessory nerve: It may be damaged by the fracture base of the skull through the jugular foramen or stab wounds in the neck or during the surgical removal of cervical lymph nodes. Unilateral/lesion of the spinal accessory nerve proximal to sternocleidomastoid causes: ­ ipsilateral paralysis of the sternocleidomastoid, with the result that the patient is unable to tilt his head toward the ipsilateral shoulder and unable to turn his face toward the opposite side, ­ paralysis of trapezius, with the result that the patient is unable to shrug his shoulder against the resistance. In a normal condition, a person can do it and sternocleidomastoid stands out prominently. The trapezius muscle can be tested by asking the patient to shrug his shoulder against the resistance. Course and Relations the hypoglossal nerve arises on the ventral aspect of the medulla from the anterolateral sulcus between the pyramid and the olive by 10­15 rootlets. The rootlets of the hypoglossal nerve are attached in line with the rootlets of the ventral root of the 1st cervical spinal nerve. The rootlets of the hypoglossal nerve run laterally and pass behind the vertebral artery to form two roots. The two roots pierce the dura mater separately near the anterior condylar (hypoglossal canal) in which they enter. In the canal, the two roots unite to form a single trunk and come out of the cranial cavity. It then passes downward and laterally behind the internal carotid artery and the 9th and 10th cranial nerves to reach the interval between the internal jugular vein and the internal carotid artery. Now it descends vertically in this interval in front of the 10th nerve up to the level of the angle of the mandible. Here the nerve curves forward crossing in front of the internal and external carotid arteries, and the loop of the 1st part of the lingual artery to reach the posterior margin of the hypoglossal muscle by passing deep to the tendon of the posterior belly of the digastric.

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About 75% fibres of pyramidal tract run backward and laterally across the midline to reach the lateral white column of the opposite side of the spinal cord where they run downward as the lateral corticospinal tract arrhythmia of heart cheap coreg 6.25 mg line. Each detached anterior horn divides to form the spinal nucleus of the accessory nerve and the supraspinal nucleus of the 1st cervical nerve. Diffuse zone appears containing a network of fibres and scattered nerve cells within it, in the lateral white column adjacent to the nucleus of the spinal tract of the trigeminal nerve is called reticular formation. The nucleus gracilis and nucleus cuneatus become more pronounced and are separated from the central grey matter. The fibres of fasciculus gracilis and fasciculus cuneatus terminate in these nuclei. The internal arcuate fibres arising from gracile and cuneate nuclei course forward and medially around the 9. The internal arcuate fibres cut off the spinal nucleus and tract of the trigeminal nerve from the central grey matter. Immediately dorsolateral to the cuneate nucleus lies the accessory cuneate nucleus which receives the more lateral fibres (derived from the cervical segments of the cord) of the fasciculus cuneatus and gives rise to posterior external arcuate fibres conveying proprioceptive impulses to the cerebellum of the same side through inferior cerebellar peduncle. The separated spinal nucleus and tract of trigeminal nerve lies ventrolateral to the cuneate nucleus. The central grey matter contains the: (a) hypoglossal nucleus, (b) dorsal nucleus of vagus, and (c) nucleus of tractus solitarius. The medial longitudinal bundle/fasciculus fasciculus lies posterior to the medial lemniscus. It is a small compact tract of nerve fibres which interconnect the 3rd, 4th, 6th, 8th, and spinal nucleus of the 11th cranial nerve nuclei. Spinocerebellar and lateral spinothalamic tracts lie in the anterolateral area of lateral white column. Lateral and anterior spinothalamic tracts are very close to each other and collectively form spinal lemniscus. The central grey matter is spread over the floor of the 4th ventricle and contains the nuclei of several cranial nerves. From medial to lateral, these are: hypoglossal nucleus, nucleus intercalatus, dorsal nucleus of vagus, and vestibular nuclei (inferior and medial). The nucleus ambiguus lies deep within the reticular formation and gives origin to the motor fibres of 9th, 10th, and 11th cranial nerves. The arcuate nuclei, thought to be inferiorly displaced pontine nuclei, are situated on the anteromedial aspect of the pyramids. Laterally, from dorsal to ventral lie two prominent structures: (a) inferior cerebellar peduncle and (b) inferior olivary nucleus. Transverse section of medulla just inferior to the pons presents the same features as those seen in the transverse section of medulla at the level of the olives, except that: ­ the lateral vestibular nucleus replaces the inferior vestibular nucleus. The dorsal and ventral cochlear nuclei lie on the dorsolateral and ventrolateral aspects of the inferior cerebellar peduncle, respectively. Clinical correlation · Lateral medullary (posterior inferior cerebellar artery) syndrome of Wallenberg: It occurs due to thrombosis the of posterior inferior cerebellar artery, thus affecting a wedge-shaped area on the dorsolateral aspect of the medulla and the inferior surface of the cerebellum, and produces the following main signs and symptoms: ­ Contralateral loss of pain and temperature sensation in the trunk and limbs, due to involvement of spinothalamic tract. It produces the following signs and symptoms: ­ Contralateral hemiplegia/paralysis of arm and leg, due to damage of pyramid. On either side, the pons is continuous as the middle cerebellar peduncle, thus forming a bridge between the two cerebellar hemispheres, hence its name pons (L. The dorsal or tegmental part is a direct upward continuation of the medulla excluding the pyramids. The structure of basilar part is the same at all levels of pons, but the structure of tegmental part varies considerably in the upper and lower parts of the pons. Basilar part Basilar part is composed of the longitudinal bundles of fibres, the transverse fibres, and the pontine nuclei: 1. Longitudinal bundles of fibres include corticopontine, corticonuclear, and corticospinal fibres. Transverse fibres arise in the pontine nuclei and cross to the opposite side to form the middle cerebellar peduncle. Tegmental part Tegmental part is traversed by a number of ascending and descending tracts and contains a decussation of transversely running fibres, the trapezoid body. It also contains the nuclei of trigeminal (5th), abducent (6th), facial (7th), and vestibulocochlear (8th) nerves. Since the structure of tegmentum differs in the lower (caudal) and upper (cranial) parts of the pons, it is studied by examining transverse sections at these two levels. Features on the Ventral Aspect the ventral surface of pons is convex in both the directions, i. In the median plane, it presents a vertical groove, the basilar groove which lodges the basilar artery. The trigeminal nerve is attached to this surface by two roots: a small motor and a large sensory root (the motor root lies medial to the sensory root). Rostrally, the junction between the midbrain and pons is marked by cerebral peduncles and the intervening interpeduncular fossa; caudally the pontomedullary junction is marked by a shallow groove. In this groove, from medial to lateral, the abducent (6th), facial (7th), and vestibulocochlear (8th) nerves emerge. The superior cerebellar arteries curve along the superior border, intervening between the oculomotor and trochlear nerves. Features on the Dorsal Aspect the dorsal surface of the pons is covered by the cerebellum, and separated from it by the cavity of the 4th ventricle. The dorsal surface of the pons is triangular and forms the upper part of the floor of the 4th ventricle. For details of features on the dorsal surface of pons, see the floor of the 4th ventricle described in detail in Chapter 25. The abducent nerve nucleus lying beneath the facial colliculus in the floor of the 4th ventricle. The motor nucleus of the facial nerve lying ventrolateral to the abducent nucleus. The fibres of the facial nerve first wind round the abducent nucleus, producing the facial colliculus, then pass anteriorly between the facial nucleus and the nucleus of the spinal tract of the trigeminal nerve. The superior salivatory, inferior salivatory, and lacrimatory nuclei lying medial to the motor nucleus of the facial nerve. The ventral or basilar part is continuous inferiorly with the pyramids of the medulla and on each side with the middle cerebellar peduncle. The tegmentum at this level presents the following features: Grey Matter the grey matter at this level comprises: 1. The motor nucleus of trigeminal nerve situated in the dorsolateral part, beneath the lateral part of the 4th ventricle. The emerging motor fibres travel anteriorly through the substance of the pons and exit on its anterior surface. The principal (main) sensory nucleus of the trigeminal nerve situated lateral to the motor nucleus. White Matter the white matter at this level consists of the same ascending tracts as in the lower part. The trigeminal lemniscus consisting of trigeminothalamic fibres is also seen between medial lemniscus and spinal lemniscus. The ventral part of tegmentum, immediately posterior to the basilar part, presents four lemnisci. From the medial to lateral side, these are: medial lemniscus, trigeminal lemniscus, spinal lemniscus, and lateral lemniscus. The nucleus of tractus solitarius lying lateral to the superior salivatory nucleus. The vestibular nuclei lying beneath the vestibular area in the floor of the 4th ventricle. The dorsal and ventral cochlear nuclei situated dorsal and ventral to the inferior cerebellar peduncle, respectively. The spinal nucleus of the trigeminal nerve and its tract located on the anteromedial aspect of the inferior cerebellar peduncle. The trapezoid body that is a trapezium-shaped mass of white fibres lying in the anterior part of the tegmentum, just posterior to the basilar part of the pons. It is formed by the decussation of transversely running fibres arising from the cochlear nuclei of both the sides. The medial lemniscus situated in the most anterior part of the tegmentum with its long axis running transversely. The spinal lemniscus lying lateral to the medial lemniscus and occupying the same peripheral position as in the medulla.

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A still-developing sense of size and strength Your child is especially fearful and withdrawn around people outside your family or in unfamiliar situations heart attack while running generic 25 mg coreg free shipping. Fear of the dark Separation anxiety Fatigue Overstimulation Night terrors (Also see "Seizures," page 134. He complains of severe but vague symptoms (eg, headache, nausea, dizziness) to avoid school. Less commonly, fever may signal the presence of an internal threat, such as an autoimmune disorder. The use of aspirin has been linked to an increased risk of Reye syndrome - a rare but serious disease affecting the brain and liver - following viral infections. Fever: A Symptom, Not an Illness Many parents get very nervous when their child has a fever. Our body temperature is controlled by a part of the brain called the hypothalamus, which balances signals from heat- and cold-sensitive receptors throughout the nervous system. Among the factors that influence temperature are infections; medications; injury; inflammatory, autoimmune, and glandular disorders; and tumors. If your child is playful and drinking and sleeping well, you can hold off on giving him a the Big Book of Symptoms 86 Fever in BaBieS anD ChilDren fever-reducing medicine. But you should keep a close watch and be prepared to call your pediatrician in case new symptoms emerge or if the fever is above 101°F (38. YoUr ConCernS Your child also has a cough, a runny nose, difficulty breathing, a sore throat, or muscle aches. Finding the cause of the fever is more important than getting rid of the fever itself. She also has conjunctivitis (inflammation of the membrane that lines the eyelids), and her hands and feet are swollen. Your pediatrician will examine your child and, if necessary, prescribe antibiotic treatment. The cause of this unusual disease is unknown, but your pediatrician will treat it to prevent any health complications caused by it. Infectious gastroenteritis (viral or bacterial inflammation of the stomach and intestinal lining) Health condition that requires diagnosis and treatment Kawasaki disease with fever and inflammation affecting the blood vessels Lyme disease or another autoimmune disorder Roseola infantum (a contagious viral illness) Your pediatrician will examine your child and may order blood tests. They can be very serious, with the bone broken in several places or pushing through the skin (an open fracture). Less serious fractures, seen more often in children, involve a slight crack in the bone or a buckle (bulge) on the edge of the bone. In a greenstick fracture, the bone bends like green wood but with a break only on one side. These fractures may damage the growth plates at the ends of the bones and cause the bones to grow improperly or not at all. That is why your child, depending on her age and severity of the fracture, should have regular follow-up visits for at least 1 year after, especially for growth plate fractures. Most childhood fractures need only to be kept free of movement long enough for the bone to grow back together. A molded cast of plaster or fiberglass is the usual treatment; surgical repair is seldom necessary. A little knot of bone, called a callus, forms over the fracture as a normal part of the healing process. Preventing Childhood Fractures Many broken bones in children can be prevented if parents follow these simple safety measures. You should also be aware of the risks involved using trampolines, all-terrain vehicles, lawn mowers, and motorcycles. In a displaced or compound fracture, the broken ends of the bone must be realigned; a segment of bone may penetrate through the soft tissue and skin. Normal Displaced or compound Greenstick Simple YoUr ConCernS Your child had a severe blow to her head or face. Call 911 or your local emergency number, or take your child to the nearest emergency department. Call your pediatrician without delay for an examination, x-rays, and treatment, if necessary. Call your pediatrician, who will examine your child and prescribe appropriate treatment. Broken rib Fracture Sprain Shin splints Stress injury Slipped capital femoral epiphysis (displacement of the head of the thigh bone) Fracture Your child has swelling and pain at the site following injury to a bony part of her body, including fingers or toes. Call your pediatrician, who will examine your child, order x-rays if advisable, and recommend any treatment. Skull fracture Call 911 or your local emergency number at once, or take your child to the nearest emergency department. Young babies who are eager to feed often gulp down air, which builds up as gas in their intestines. Many pediatricians believe that discomfort due to gas is one of the factors that can aggravate colic (see page 2). A certain amount of gas is normally produced as food is digested; however, children as well as adults often have excess gas because their diet is too high in certain types of insoluble fiber, which ferments in the intestine. Many infants and toddlers also swallow air when crying or breathing through the mouth because of a stuffy nose. A few children who are older than 4 years have gas because they slowly over time lose the ability to digest the sugar in milk, called lactose. Option 2: Support the baby on your lap in a sitting position with one hand and pat her back with your other hand. Use your knee to support her head a little higher than her chest, and gently rub her back. Whatever position she prefers, protect your clothing with a towel or cloth diaper in case she spits up. The Big Book of Symptoms 90 GaS YoUr ConCernS Your newborn or young infant passes a lot of gas during periods of colicky crying. Your preschooler or older child has gas along with frequent colds, sniffles, and a stuffed-up nose. Your school-aged child has a long history of gassiness with diarrhea that starts and stops, bloating, and discomfort. Talk with your pediatrician, who will examine your child and recommend treatment, if necessary. If your child thinks a certain food causes the discomfort, omit it from his diet for 1 or 2 weeks and bring it back to see if symptoms recur. Talk with your pediatrician, who will examine your child and recommend treatment, depending on the cause of the diarrhea (see page 5). Call your pediatrician, who may substitute another medication or recommend measures to keep side effects to a minimum, such as taking medication at meal times. Reduce the amount of bran and other insoluble dietary fiber, and add more soluble fiber from fruits and vegetables. Swallowing air during mouth breathing Intolerance to lactose or another food substance Celiac disease (gluten sensitivity) Another malabsorption problem Food allergy (rare) Irritable bowel syndrome Infectious diarrhea Parasitic infection such as giardiasis Medication side effect Your child suddenly develops bloating, cramping, and diarrhea with excess gas. Your child has had gassiness and an upset stomach since taking an antibiotic or another medication. All of the measurements for weight, length (height), and head size should be plotted on growth curves, and your pediatrician should share this information with you. During the first 3 years of life, babies and toddlers often shift from one curve to another until they settle on their genetic curve, which pediatric specialists refer to as shifting growth curves of infancy. Because some babies are born long but have "short genes," or some babies are born short but have "long genes," shifting may be quite normal. Nutrition is important to growth, and if a child takes in too few calories, growth may be slowed. Addressing Growth Concerns Some children who are small in stature have inadequate levels of the growth hormone. If a growth hormone deficiency is diagnosed, hormone treatment during the growing years can help a child reach an acceptable adult height.

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The cerebellar lesion is characterized by all of the following signs/symptoms except: 6 pulse pressure 75 generic 25mg coreg free shipping. The cerebral peduncle consists of all of the following parts except: Crus cerebri Substantia nigra Tegmentum Tectum Ataxia Muscular hypotonia Nystagmus Tremors at rest Answers 1. Select the incorrect statement about the longitudinal cerebral fissure: (a) It completely separates the two cerebral hemispheres (b) It lodges the falx cerebri (c) It incompletely separates the two cerebral Thalamus Mamillary bodies Metathalamus Subthalamus 2. Which of the following structures represents the submerged portion of the cerebral cortex? The Y-shaped sheet of white matter that divides thalamus into its three main parts (anterior, medial, and lateral) is called: Lamina terminalis Stria medullaris thalami Internal medullary lamina Lamina cribrosa Fronto-parietal operculum Insula Hippocampus Temporal operculum Medial surface of the cerebral hemisphere Superolateral surface of the cerebral hemisphere Tentorial surface of the cerebral hemisphere Orbital surface of the cerebral hemisphere 3. The area between parieto-occipital and calcarine sulci on the medial surfaces of the cerebral hemisphere is known as: 5. All of the following statements about hypothalamus are correct except: (a) It forms the floor of the 3rd ventricle (b) It weighs about 4 g (c) It is regarded as the head ganglion of the autonomic 6. All of the following are the examples of bundles of commissural fibres except: nervous system (d) It is bounded anteriorly by lamina cribrosa 7. Which of the following structures consists of both projection and commissural fibres? Basal nuclei include all of the following structures except: medial surface of the cerebral hemisphere (d) Its fibres arise mainly from mammillary body Answers 1. All of the following arteries partake part in the formation of circle of Willis except: 2. Corpus striatum includes all of the following except: Anterior communicating Anterior cerebral Middle cerebral Posterior cerebral 3. All of the following arteries are branches of cerebral part of internal carotid artery except: Anterior cerebral Middle cerebral Ophthalmic Anterior inferior cerebellar 4. Anterior choroid artery is a branch of: Crus cerebri Substantia nigra Red nucleus Subthalamus 6. Most of the superolateral surface of the cerebral hemisphere is supplied by: Hippocampus Dentate gyrus Fornix Medial and lateral longitudinal striae Stria medullaris thalami Stria terminalis Mammillothalamic tract Fornix Anterior cerebral artery Middle cerebral artery Posterior cerebral artery None of the above Superficial middle cerebral veins Internal cerebral veins Anterior cerebral veins Middle cerebral veins 6. Normal, fussy crying should not be confused with colic - bouts of intense crying that last for hours at a time and may repeat daily. They begin when a newborn is 2 to 4 weeks old and usually last up to 3 or 4 months, although some infants are still colicky at 6 months of age. About 1 in 5 babies develops colic; interestingly, firstborn babies and boys are affected more often than later-born babies and girls. To soothe your baby you might also consider using a white noise machine, an electric fan (pointed elsewhere in the room) for white noise, or even a morning radio station turned to static. Colic caused by sensitivity to any of these foods should disappear within a few days. Getting a handle on your anger and frustration is important to prevent abusive head trauma, a serious form of child abuse that occurs mostly in infants in the first year of life. Call on your pediatrician and your support network when you need to talk about your worries. Coping With Colic Many babies with colic cry at about the same time every day, for just about the same length of time. A colicky newborn or young infant often cries for 3 to 5 hours a day, beginning in the late afternoon or evening. This difficult phase will pass eventually; colic rarely lasts beyond 4 or 5 months of age. He cries regularly throughout the day and especially hard for 1 to 3 hours in the late afternoon or evening. Your baby cries a lot at the end of a day that involved several new experiences, such as meeting new people. She enjoys your company and will soon find ways to ask for it other than fussy crying. Make sure your baby is properly fed and burped, is Colicky crying, comfortably clothed, and has a clean diaper. Cuddle which normally your baby, and train yourself to put up with his crying, occurs between knowing it will stop on its own within a few weeks 2 weeks and 4 or (see "Coping With Colic," page 2). If his crying seems 5 months of age unusually desperate, call your pediatrician, who may wish to examine your baby to rule out any medical causes. Some newborns and young infants are extremely sensitive to new experiences and simply need time to get used to them. A baby with an ear infection may appear fine during the day but experience severe pain when you lay her down or at night. Talk with your pediatrician and, if he or she agrees, eliminate all dairy products from your diet for 2 weeks. Her abdomen is tense and distended (larger and rounder because of pressure from inside). Abusive head trauma can cause serious brain damage, blindness, damage to the spinal cord, and delay in normal development. Signs and symptoms include irritability, lethargy (trouble staying awake), tremors (shakiness), vomiting, seizures, trouble breathing, and coma. If your baby has been shaken by a caregiver, take him to the emergency department or your pediatrician right away. Keeping Your Baby Happy With a Pacifier Pacifiers should never be used to replace or delay feedings. Babies who are formula-fed pass stools that are yellow to tan and about as firm as peanut butter. For diarrhea in older infants and young children, see "Diarrhea in Infants and Children," page 70. As long as your baby is feeding and growing normally, you should not be concerned unless her stools are whitish and clay-like, watery and filled with mucus, or hard and dry. If your baby is younger than 3 months and has a fever (see "Fever in Babies Younger Than 3 Months," page 8) as well as diarrhea, call your pediatrician at once. Coping With Diarrhea in Babies A viral infection that causes vomiting and diarrhea may make your baby irritable for 1 or 2 days. Your pediatrician will advise giving fluids to your baby to make up for the fluids and electrolytes (eg, sodium, potassium) lost with the diarrhea. If your baby is formula-fed, your pediatrician may instruct you to give your baby a special drink that contains electrolytes and sugar. Pharmacies carry premixed drinks with the right balance of electrolytes for newborns and young infants; homemade solutions may not have the correct electrolyte balance and therefore should not be used. Call your pediatrician, who may wish to examine your child and recommend treatment. Early on your baby should be fed about every 2 to 3 hours on demand, with your attempts to feed him occurring 8 to 12 times a day. If your baby sleeps longer than 4 to 5 hours and starts missing feedings, wake him up and offer a bottle or breast. In fact, if your baby is younger than 2 to 3 months and sleeping through the night without feeding, he may not be getting enough to eat. On the other hand, some babies may "cluster feed" every 1 to 2 hours, which helps increase your milk supply. These occur around 3 weeks, 6 weeks, 3 months, and 6 months of age, although they may vary from baby to baby. For feeding problems in older children and teenagers, see "Eating Disorders," page 184. After the first few days of life, your formula-fed newborn will take 2 to 3 ounces (60­90 mL) of formula per feeding. By the end of their first month, they will be up to at least 4 ounces (120 mL) per feeding, with a fairly predictable schedule of feedings about every 4 hours. By 6 months of age, your infant will consume 6 to 8 ounces (180­240 mL) at each of his 4 or 5 feedings in a 24-hour period. Most babies are satisfied with 3 to 4 ounces (90­120 mL) at each feeding during the first month of life. They will increase that amount by 1 ounce (30 mL) per month until they reach a maximum of about 7 to 8 ounces (210­240 mL) when they are 7 to 8 months of age. If your baby consistently seems to want more or less than this amount of food, talk with your pediatrician. Your baby spits up after most feedings but is gaining weight normally (see "Spitting Up," page 16). Your baby may need only simple measures, but your pediatrician should examine her to rule out any serious health problems.