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Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
LCRS – Anatomy of the Head, Neck and Spine The Vertebral Column and the Spinal Cord 1. Recognise and name the following parts of a typical vertebra in osteological specimens or in suitable imaging: body, pedicle, lamina, transverse process, spinous process, articular surfaces Spinous Process
Superior Articular Facet Transverse Processes
Spinal Canal
Vertebral Body
2. Recognise the distinctive features of cervical, thoracic and lumbar vertebrae Cervical Vertebrae (7)
Thoracic Vertebrae (12)
Lumbar Vertebrae (5)
Sacral Vertebrae (5 fused)
A triangular vertebral foramen Vertebral body is short in height and square shaped A foramen in each transverse process for arteries and veins A bifid (two-pronged) spinous process, except C1 and C7 The atlas and axis (C1 and C2) are specialised for movement
Larger and stronger Facets for rib articulation (inferior and superior costal facets, and transverse costal facet) A spinous process orientated in a marked inferior fashion Vertebral foramen circular Vertebral body is somewhat heart-shaped from above
Identifiable by their large size, particular of the body Have rounded upper and lower facets to prevent rotation Thin, long transverse processes (except LV) Vertebral body is cylindrical Vertebral foramen is triangular in shape
Sacral vertebrae are fused to form the sacrum Triangular in shape Concave anterior surface L shaped facets – articulation with pelvic bones
Coccyx (3-4 fused) Absence of vertebral arches and canal
3. Explain the roles of intervertebral discs, ligaments and muscles in load bearing in the vertebral column Joints The two major types of joints between vertebrae are: o Symphyses between vertebral bodies o Synovial joints between articular processes Each vertebra has a total of 6 joints with adjacent vertebrae (4 synovial (2 above, 2 below) and 2 symphyses (one above, one below) In between each vertebrae (C2 to S1) are intervertebral discs which consist of: o An annulus fibrosus – tough hyaline cartilaginous rim- limits rotation o A nucleus pulposus – fibrocartilagenous core – softer, probably derived from remnants of the notochord – absorbs compression forces between vertebrae Rupture of the annulus fibrosus may allow the softer nucleus pulposus to herniate which can compress the spinal cord or segmental nerve roots – slipped disc There is no disc between the base of the skull and C1, or between C1 and C2 due to specialised movements which occur here The synovial joints between articular processes on adjacent vertebrae are the zygapophysial joints In cervical regions, the zygapophysial joints slope inferiorly from anterior to posterior. This orientation facilitates flexion and
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine extension In thoracic regions, the joints are oriented vertically and limit flexion and extension, but facilitate rotation. In lumbar regions, the joint surfaces are curved and adjacent processes interlock, thereby limiting range of movement, though flexion and extension are still major movements in the lumbar region Although the movement between any two vertebrae is limited, the summation of movement among all vertebrae results in a large range of movement by the vertebral column Movements by the vertebral column include flexion, extension, lateral flexion, rotation, and circumduction Ligaments of the vertebral column: Ligamentum nuchae – triangular, sheet like structure – Skull to CVII Supraspinous ligaments – between the tips of the spinous processes – CVII to the sacrum Interspinous ligaments – between adjacent spinous processes Ligamentum flava – between vertebral arches connecting adjacent laminae – this ligament is pierced during a lumbar puncture. Form part of posterior surface of vertebral canal. o Predominantly elastic tissue o Resist separation of laminae in flexion o Assist in extension back to anatomical position Anterior longitudinal ligament – covers and connects the anterior surfaces of the vertebral bodies and intervertebral discs – base of skull to anterior surface of the sacrum o The anterior longitudinal ligament is mostly commonly damaged in whiplash Posterior longitudinal ligament – runs within the vertebral canal on the posterior surface of the vertebral bodies - anterior surface of vertebral canal Articular ligaments – all synovial articulations (facet joints) are surrounded by ligaments
Muscles of the vertebral column: Contraction of the muscles of the abdominal wall causes flexion and lateral flexion
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine There are two main groups of muscle in the back: o Superficial extrinsic muscles including trapezius, latissimus dorsi, rhomboid minor/major, levator scapulae o Deep intrinsic muscles, particularly the erector spinae muscles, which are important in controlling the movement of the vertebral column. The large muscle bulk is posterior and lateral to the vertebral column
4. Describe the relative extents of antero-posterior flexion, lateral flexion and axial rotation in the major regions of the vertebral column and explain this in terms of skeletal anatomy C1-C7 T1-T6 T7-T12 L1-sacrum
Flexion/extension ++ 0 + ++
Lateral flexion ++ + ++ +
Cervical – is the most flexible part of the spine. The articular surfaces between the vertebrae are almost horizontal and so allow rotation. The neck is slender with less surrounding bulk tissue and so there is less resistance to flexion and extension. Although the intervertebral discs are thin, they are relatively thick compared to the vertebrae. Thoracic – the attachment to ribs limits flexion and extension. Movement is also intervertebral discs. Joints are oriented vertically and limit flexion and extension, but Lumbar – there are large intervertebral discs. The intervertebral articular surfaces are midline of the body) orientated and so whilst these are compatible with flexion/extension and lateral flexion, they are not compatible with rotation.
Rotation ++ + ++ 0 cervical
limited by thin facilitate rotation. sagitally (vertically down the
5. Identify the atlas and axis and explain their functions in head movement Axis = C2 A typical cervical vertebra with the body extended upwards to form the dens (tooth) The dens is the pivot around which C1 rotates Large articular facets on upper and lateral sides for gliding movements with C1 Atlas = C1 Has no body Lies behind the mouth Posterior surface of anterior arch has a facet for articulation with the dens Has inferior articular facets for reciprocal facets on C2 The C1-C2 atlanto-axial joint Midline A synovial joint between the dens and the back of the anterior arch of the atlas, bursa between the dens and the transverse ligament behind Laterally the articular surfaces are flat to allow gliding The transverse ligament separates the dens from the spinal meninges The skull and C1 rotate on C2 as a unit. Excessive rotation at these joints is prevented by ligaments Atlanto-occiptal joints – between C1 and the occipital bone of the skull form synovial by apical ligaments to allow nodding of the head
and a synovial
the alar joints linked
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
6. Demonstrate on each other the location of C7, T3, T7, L2 and L4 vertebrae C7 – only cervical vertebrae with a prominent spinous process T3 – level with the medial end of the scapular spine T7 – level with the inferior angle of the scapula L2 – level of lowest rib L4 – Level of the iliac crest
7. State the number of vertebrae in each region of the spine, and how the pairs of spinal nerves are related to them Cervical Thoracic Lumbar Sacral Coccyx Total
Number of vertebrae 7 12 5 5 (fused) 1-4 (fused) 30-33
Number of spinal nerves 8 12 5 5 1 31
Relationship of nerve to vertebra All above corresponding vertebra except for C8 All below corresponding vertebra All below corresponding vertebra All below corresponding vertebra Below (or between if unfused)
8. Explain the arrangement of the meninges around the spinal cord and roots, and indicate any differences from the cranial meninges The spinal cord is surrounded by the meninges which are continuous with the meninges of the brain Pia mater – on the surface of, and inseparable from the spinal cord. On each side of the spinal cord, a longitudinally orientated sheet of pia (denticulate ligament) extends laterally from the cord toward the arachnoid and dura mater. Arachnoid mater – the arachnoid mater is against, but not adherent to the dura mater. Terminates at SII. Between it and the pia matar is the sub-arachnoid space containing CSF. Delicate strands of tissue (arachnoid trabeculae) are continuous with the arachnoid mater on one side and the pia mater on the other, span the subarachnoid space and interconnect the two adjacent membranes. Large blood vessels are suspended in the subarachnoid space by similar strands of material. Dura mater – tough and fibrous. At the point where a spinal nerve passes through the intravertebral foraemen the dura is continued along the nerve as the epineurium. Nerve roots in the subarachnoid space do not have this protection. Between the dura matar and the sub-arachnoid is the subdural space. Outside the dura matar between it and the walls of the bony canal is the extra or epidural space. It contains connective tissue, fat and the internal vertebral venous plexus Difference between spinal and cranial meninge There is no extradural (epidural) space in the cranium as the cranial dura matar is firmly adherent to the skull except at certain sites where they part to form the venous sinuses (principal collecting ducts for blood from the brain) Filum Terminale
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine At the lower margin of the spinal cord at about LII, the pia mater is prolonged (pial part). After the termination on the subarachnoid space (SII) the dura mater is prolonged and attaches to the coccyx (dural part). See Grays page 63 It is formed at the spinal cord withdraws upwards during development Together with the nerve roots forms the cauda equine below LII
9. Identify two major reasons for carrying out lumbar puncture, and explain the basis for the puncture site The vertebral level below L1/L2 is only occupied by CSF (up to S2), and the cauda equine This forms the lumber cistern of CSF – so needles may be inserted without damage to nerves A needle passes through the skin, slightly off centre → through the ligamentum flavum (a give is felt) between the adjacent vertebral laminae → the tip of the needle is in the epidural space → pierces the dura and arachnoid together (another pop/give) into the subarachnoid space→ CSF should pass out In an adult best done at L3/L4 – the highest point of the iliac crest. In a child it is performed one or two vertebral spaces lower Carried out to obtain a sample of CSF for examination (e.g. suspected meningitis) and for spinal anaesthesia (agent injected into subarachnoid space) Epidural anaesthesia – a liquid agent can be injected into the epidural space to anaesthetise the spinal nerve roots The sacral hiatus allows administration of caudal epidural anaesthesia
10. Explain the danger of carrying out lumbar puncture without excluding the presence of raised intracranial pressure In cases of intracranial pressure, the sudden release of CSF pressure, associated with the procedure of a lumbar puncture, could cause the brainstem to herniate through the foramen magnum and into the vertebral canal. This would be fatal.
11. Outline the steps taken to avoid neurological complication in casualties with a possibility of cervical spine injury At the scene signs of cervical spine injury Low BP with bradycardia – loss of sympathetic tone, vasodilation Large erection – Custer's last stand Flaccid paralysis Large bladder with inability to micturate At the scene management Assume all patients have an intact spinal cord with an unstable fracture All patients who can't tell you they have no neck pain must be assumed to have neck pain Use cervical collar and blocks to immobilise neck – only remove when C spine is clear In hospital Primary injury is done, damage cannot be reversed – aim is to reduce further damage Take lateral and AP C Spine – if fracture image with CT/MRI Give steroids – probably prevent the death of around 1cm of spinal cord – could be the difference between being independent or not in the cervical region. Treat any other symptoms e.g. low BP
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 12. Explain in anatomical terms the most common causes of back pain The lower spine is subject to increased stresses of weight-bearing and so the lumbar region is most commonly affected We tend to abuse our backs, particularly when lifting heavy objects. Extending the spine from the fully flexed position under a heavy load can inflame intervertebral joints or place unequal pressure on the intervertebral disks, leading to local joint pain and referred neurological pain, if there is also pressure on the spinal nerve. Additional attempts to rotate the spine at the same time creates extra stress on the lumbar joints.
13. Describe the most common abnormalities of spinal curvature Scoliosis – lateral deviation of the vertebral column Kyphosis – excess thoracic curvature, "hump back" Lordosis – excess lumbar curvature, e.g. due to obesity
The Cranium and Brain 1. Demonstrate on a skull and in radiographs the following bones: frontal, parietal, temporal (squamous, petrous and mastoid process), ethmoid, sphenoid (body and wings) and occipital
Frontal Bone
Parietal Bone
Sphenoid Bone (wing)
Occipital Bone
Nasal Bone
Temporal Bone Mastoid Process
Styloid Process
Anterior Cranial Fossa Ethmoid bone (cribriform plate) Lesser wing of sphenoid Greater wing of sphenoid Middle Cranial Fossa Petrous of Temporal Bone Foramen Magnum Posterior Cranial Fossa
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 2. Identify both on the brain and in x-ray, CT and MRI images the following: ventricles, cerebral hemispheres, thalamus, hypothalamus, internal capsule, basal ganglia, brainstem, optic chiasm and pituitary gland MRI 1
Lateral ventricle [may be cut through twice in horizontal or coronal plane]
Third ventricle [may look like a hole or a slit in coronal and horizontal plane, depending on angle of section]
Fourth ventricle
Corpus callosum [may be cut through twice in horizontal plane] – connects right and left hemisphere
Frontal lobe
Occipital lobe
Parietal lobe
Temporal lobe
Basal ganglia [may be more than one part] – group of nuclei – motor, cognition, emotions, and learning
Internal capsule [both anterior and posterior limbs seen in horizontal plane]
Optic chiasma
very similar – see notes
3. Identify the different tissue components of the scalp Skin –contains many sweat and sebaceous glands and hair follicles. It is covered in hair with lots of vasculature Connective tissue – richly vascularised that is well supplied by cutaneous nerves Aponeurosis – also known as epicranial aponeurosis. A membranous sheet and tendon of the epicranius muscles Loose connective tissue – many spaces which allows the 'scalp' to move over the pericranium Pericranium – a dense layer of connective tissue, which is continuous with endocranium in the cranial sutures. It is important to avoid infection of lacerations to the scalp as it can spread infection into the cranial cavity via emissary vessels which go through the skull – thus bypassing the blood-brain barrier See picture below
4. Demonstrate the relationship between the brain and the different cranial fossae Anterior cranial fossa – frontal lobes of brain Middle cranial fossa – temporal lobes of brain Posterior cranial fossa – cerebellum and brainstem
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 5. Describe the structure and function of the meninges
Inner layer inseparable from the brain = pia mater Middle layer = arachnoid Outer layer = dura mater Between the arachnoid and pia = sub arachnoid space – continuous and containing CSF The contours of the dura reflect the folds of the brain o Falx Cerebri – separates the two cerebral hemispheres – attached to ethmoid at front and vault above and below o Tentorium cerebelli – separates the cerebellum from the cerebrum - a more or less horizontally arranged sheet extending back from the ridge of the petrous temporal bone to the internal occipital protuberance. It forms a complete diaphragm over the posterior cranial fossa except for the tentorial notch through which the brain stem and surrounding nerves and vessels pass
6. Draw a simple diagram to explain the flow of cerebrospinal fluid in and around the brain CSF is produced by the choroid plexus – a vascular plexus formed where the vessels of the pia mater come into contact with the ependymal lining of the central canal Lateral ventricles → third ventricle → through cerebral aqueduct → fourth ventricle → some enters the central canal of the spinal cord, most enters the subarachnoid space through foramina in the roof of the fourth ventricle → flows around the brain and is absorbed back into the venous circulation through arachnoid villi/granulations in the venous sinuses Hydrocephalous is over production of CSF or reduced absorption
7. Explain the term herniation with respect to the brain and give examples of its neurological consequences Space occupying lesion (eg. blood, tumour, oedema, cyst) in any compartment may raise intracranial pressure and lead to herniation of part of brain.
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 1) Subfalcine herniation – not usually clinically significant 2) Uncal herniation– affects midbrain – unconsciousness 3) Tonsilar herniation– affects medulla – cardiorespiratory failure
8. Identify on a skull the main exit/entry routes for the cranial nerves and the major blood vessels
Cribiform Plate
Optic Canal
Olfactory (I) Nerve Fibres
Optic Nerve (II) including (central artery of retina) Opthlamic Artery Oculomotor Nerve (III) Trochlear Nerve (IV)
Superior Orbital Opthalmic division of Trigeminal (V) Fissure Abducens Nerve (VI)
Superior Opthalmic Vein
Foramen Rotundum Foramen Ovale
Maxillary Division of Trigeminal Nerve (V)
Mandibular Division of Trigeminal Nerve (V)
Foramen Spinosum Foramen Lacerum
Middle Meningeal Artery and Vein
Carotid Canal
Internal Carotid Artery
Facial Nerve (VII) (including intermediate nerve
Internal Acoustic Vestibulocochlear Nerve (VIII) Meatus Labyrinthine Artery
Glossopharyngeal Nerve (IX)
Hypoglossal Canal Hypoglossal Nerve (XII)
Jugular Foramen
Vagus Nerve (X) Accessory Nerve (XI) Sigmoid Sinus → Internal Jugular Vein
Foramen Magnum
Vertebral Arteries, Medulla of Brain Spinal roots of Accessory (XI) Nerve
9. Draw a simple diagram of the Circle of Willis
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
10. Demonstrate the main venous sinuses
The Superior Saggital Sinus
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine In the midline at the attachment to the falx cerebri to the skull vault Blood in it drains posteriorly and at the internal occipital protuberance turns right, forming the right transverse sinus Transverse sinus turns into the sigmoid sinus as it passes the petrous temporal bone Sigmoid sinus passes through the jugular foramen and becomes the right internal jugular vein The Inferior Saggital Sinus In the midline in the inferior free margin of the flax cerebri Blood in it drains posteriorly and is joined at the tentorium/falx junction by blood from the great cerebral vein emerging at the back of the brain stem They unit to form the straight sinus which passes back in the attachment of the falx and turns left at the internal occipital protuberance becoming the left transverse sinus The pattern mirror this on the right forming the left internal jugular vein o Sometimes the pattern is reversed with the superior saggital sinus turning left and the straight saggital sinus turning right o At the internal occipital protuberance the venous channels may communicate – the confluence of sinuses o Right sided drainage normally bigger than left, indeed the left jugular vein can be absent all together The Cavernous Sinus Formed in the embryo from the coalescence of several venous channels Forms a system of interconnecting caverns around the internal carotid The right and left cavernous sinuses lie either side of the pituitary fossa and communicate with the transverse sinuses and internal jugulars via petrosal sinuses Arachnoid Granulations The dural walls of the sinuses, particular in the superior saggital sinus posses small defects These defects allow underlying arachnoid to billow out into the sinus Only the arachnoid, and endothelium of the sinus separate CSF from venous blood The site of CSF reabsorption
11. Outline how venous anatomy presents opportunities for intracranial infection The facial vein makes clinically important connections with the: o Cavernous sinus – (a venous sinus of the dura mater covering the brain) through the superior ophthalmic vein. o Pterygoid venous plexus – (a network of small veins within the infratemporal fossa) though the inferior ophthalmic and deep facial veins. The facial vein has no valves - blood may pass through it in the opposite direction Venous blood from the face may enter the cavernous sinus Patients with thrombophlebitis of the facial vein (inflammation of the facial vein with secondary thrombus formation) - pieces of an infected clot may extend into the intracranial venous system; producing thrombophlebitis of the cavernous sinus Compression of the thorax can also force venous blood from these areas into the dural sinus system – bypassing the BBB and possibly leading to infection or metasteses
12. Identify the pterion and explain the clinical importance of its relationship to the middle meningeal artery An area on the lateral side of the skull where the frontal, parietal, temporal and sphenoid bones meet Its surface marking is about 4cm above a point 1/3 of the way from ear to eye The middle meningeal artery is a branch of the maxillary artery and enters the middle cranial fossa through thr foramen spinosum The anterior division runs deep to the pterion – the thinnest and weakest part of the cranium Injury at this site can easily tear the artery causing an extradural haemorrhage The MCA also runs deeper to this point and if damaged can cause a subarachnoid haemorrhage
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
Root of the Neck 1. Sketch the thoracic inlet to show the relations of the following structures at the neck-chest interface: 1st thoracic vertebra, 1st ribs and cartilages, manubrium, pleura and lungs, oesophagus, trachea, brachiocephalic veins, vagus nerves, brachiocephalic artery, left common carotid and subclavian arteries, sympathetic trunks, left recurrent laryngeal nerve, phrenic nerves
of C1 C2 C3
Vertebral Levels the neck – open mouth – superior ganglion – body of hyoid C4 – upper border of
thyroid cartilage, bifurcation of the common carotid artery C6 – cricoid cartilage, middle cervical ganglion C7 – inferior cervical ganglion 3 main compartments in the column of the neck: o Visceral compartment (trachea, oesophagus, thyroid) o Carotid sheath/vascular (vagus nerve, carotid artery, jugular vein, associated with sympathetic chain behind) o Vertebral compartment (vertebral column, nuchal muscles, scalene muscles) 1st Rib The strap muscles are functionally connected to the visceral compartment and move the larynx during swallowing The deep cervical fascia/investing layer is Manubrium made of connective tissue and holds the contents in The sternocleidomastoid provides protection to the carotid sheath when the head is turned
2. Locate the carotid pulse and explain the main uses of this central pulse Main uses of the carotid pulse: o Assessment of pulse rhythm, rate character (easy to find) o Timing of murmurs o To locate the jugular vein The carotid pulse (the pulse that can be felt in the neck) is easily felt by palpating the common carotid artery on either side of the neck, where it lies in a groove between the trachea and the infrahyoid (strap) muscles o Posteriorly lateral to the upper border of the thyroid cartilage
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 3. Demonstrate the technique for palpation of the cervical lymph nodes and define their field of drainage All nodes eventually drain into the deep cervical nodes of the jugular vein There are 2 basic patterns of lymph nodes: o A ring at the junction of head and neck o Vertical line in the neck There are some deep nodes associated with the larynx which are not on the diagram Lymph drainage Parotid, Masotid & Occipital – drains side of face, ear and scalp Superficial cervical (along the jugular vein) – drains the posterior triangle Submandibular and Submental – drains the inside of the mouth and lips Jugulodigastic – drains the back of the throat Supraclavicular drains all of the head and neck up from the thorax The lymph nodes can become inflamed o Infection – reactive, local, generalised, in the gland itself o Neoplastic – of the node (lymphoma), metastatic
4. Define the boundaries of the anterior and posterior triangles of the neck Boundaries of the posterior triangle Posterior border of sternocleidomastoid Anterior border of trapezius Middle 1/3 of the clavicle Contents of posterior triangle Mainly nerves and blood vessels o External jugular vein o Spinal accessory nerve o Trunks of the brachial plexus, emerging posterior to scalenus anterior o Subclavian artery posterior to scalenus anterior o Subclavian vein anterior to scalenus anterior o Phrenic nerve lying in the anterior surface of scalenus
Boundaries of the anterior triangle Anterior border of sternocleidomastoid The midline The lower border of the mandible Contents of the anterior triangle Mainly muscles o Platysma o Digastric muscle o Strap muscles (infrahyoid) o Mylohyoid Common carotid arteries Internal jugular vein Larynx and trachea
5. Identify the infrahyoid (strap) muscles, mylohyoid and the digastric muscle Key muscles Platysma – supplied by facial nerve Mylohyoid – supplied by mandibular branch of the trigeminal nerve Anterior belly of digastric – supplied by mandibular branch of trigeminal nerve Posterior belly of digastric – supplied by facial nerve The infrahyoid (strap) muscles – omohyoid, sternothyroid, sternohyoid (supplied by ansa cervicalis) and thyrohyoid (supplied by C1 fibres via the hypoglossal nerve)
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
6. Demonstrate on the subject and on prosections the of the roots of the plexus
Medial – C7 Inferior – C8, T1
living suitable position and trunks brachial
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 7. Demonstrate in prosections the position and key relations of the subclavian artery and vein, and brachial plexus
8. Demonstrate the courses of the internal thoracic and vertebral branches of the subclavian artery Branches of the first part of the artery Vertebral artery – supplies the spinal cord, brainstem and brain through foramen in the transverse processes of the cervical vertebrae Internal thoracic artery – supplies the breast, anterior chest wall, anterior abdominal wall , pericardium and diaphragm Thyrocervical trunk – supplies the thyroid (via the inferior thyroid artery), upper scapular and anterior neck *Anatomy workbook – blood supply to the thyroid* Superior thyroid artery, branch of the external carotid Inferior thyroid artery, branch of thyrocervical trunk o In 10% of people also have the thyroid ima artery arising from the brachiocephalic trunk Superior thyroid vein drains in to the internal jugular vein Middle thyroid vein drains in to the internal jugular vein Inferior thyroid vein drains into brachiocephalic vein
9. Explain the uses of central venous lines and indicate the landmarks for insertion of a central line into the internal jugular vein Uses of central lines Monitoring central venous pressure (CVP) in the right atrium, central venous saturations Central venous access for delivery of certain drugs, large amounts of intravenous medication, and central feeding Internal jugular vein (IJV) The right internal jugular is preferred as is it is normally larger and straighter The puncture site is found by palpating the common carotid artery and inserting the needle into the IJV just lateral to it at a 30° angle, aiming at the apex of the triangle between the sternal and clavicular heads of the SCM The needle is then directed inferolaterally towards the ipsilateral nipple.
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 10. List the possible complications of insertion of central venous lines Arterial puncture leading to haematoma and potential airway obstruction Pneumothorax Nerve damage Air embolism Thrombosis Misplacement Perforation of the great vessels and heart Infection
11. Describe the origin, course and function of the phrenic and spinal accessory nerves The spinal accessory nerve originates from neuronal cell bodies located in the cervical cord and caudal medulla Most are located in the spinal cord and ascend through the foramen magnum and exit the cranium through the jugular foramen They are branchiomotor in function and innervate the sternocleidomastoid and trapezius muscles in the neck and back
Phrenic nerve – origin is C3-C5 Its course is over the anterior scalene muscle and enters the thorax between the subclavian artery and vein, and then down the mediastinum and over the lung hilus between the pleura and pericardium The right phrenic nerve passes close to the inferior vena cavae and the central tendon, whilst the left phrenic passes through the diaphragmatic muscle Its function is motor to the diaphragm and sensory to the diaphragmatic pleura and peritoneum
Biting, Chewing and Swallowing 1. Outline the main neuromuscular systems involved in biting, chewing, salivation and swallowing The muscles of mastication Masseter: o Supplied by mandibular branch of trigeminal (V) o Zygomatic arch to lateral surface of ramus and angle of mandible o Elevates mandible for forced closure of mouth Temporalis: o Mandibular branch of trigeminal (V) o Temporal fossa to coronoid process of mandible o Elevates and retracts mandible (posterior fibres) Medial Pterygoid: o Mandibular branch of trigeminal (V) o Lateral pterygoid plate/maxilla/palate of angle of mandible o Elevates, protracts and lateral movement of mandible for fast chewing Lateral Pterygoid: o Mandibular branch of trigeminal (V) o Sphenoid /lateral pterygoid process to neck of mandible o Depresses and protracts mandible to open mouth (mainly gravity) Buccinator o Supplied by the facial nerve (VII) o Cheek muscle and aids mastication by pressing the cheeks against the molar teeth when chewing – keeps food in occlusal plane The suprahyoid and infrahyoid muscles o Primarily used to raise and depress the hyoid bone and larynx, respectively, during swallowing o Indirectly, they can also help to depress the mandible, especially when opening the mouth suddenly or against resistance. The facial nerve (VII) keeps the lips closed
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine Biting Biting and
and Chewing involves the opening closing the jaw Chewing requires
the protrusion and retrusion of the and lateral movements The lateral movements are produced pterygoid muscle of the opposite Mastication is
chin, by the temporal muscle of the same side as the jaw movement and the side to the jaw movement aided by the buccinator muscles which push the cheeks against the molar teeth when chewing
o Innervated by the Bolus into oropharynx o Palatoglossus o Cranial root of the accessory nerve (XI) or vagus (X) – sources differ Close off nasopharynx by raising soft palate Raise the larynx, closed off by epiglottis Peristaltic wave of constrictor muscles Relax cricopharyngeus, open oesophagus
Swallowing Elevation and retraction of the tongue o Styloglossus and intrinsic muscles of the tongue hypoglossal nerve (XII)
*Anatomy workbook – the tongue* Muscles (inervated by the hypoglossal XII): o Styloglossus – retracts and elevates during swallowing o Hyoglossus – depresses tongue o Genioglossus – protracts tongue o Intrinsic muscles Salivation The parotid gland is supplied by the glossopharyngeal (IX) and opens into the parotid duct which opens at the upper second molar The submandibular salivary gland is located beneath and medial to the angle of the mandible The submandibular duct passes forwards to open out either side of the frenulum of the tongue The sublingual salivary glands are scattered along the submandibular duct into which some of them open. Some open directly into the oral cavity Secretomotor impulses to both glands are supplied by presynaptic parasympathetic, secretomotor fibres conveyed from the facial nerve to the lingual nerve by the chorda tympani nerve, which synapse with postsynaptic neurons in the submandibular ganglion
2. Identify the major branches of the external carotid artery (superior thyroid, ascending pharyngeal, lingual, facial, posterior auricular, occipital, superficial temporal, maxillary) The internal carotid artery has no branches until it enters the skull The external carotid artery has many branches In order of ascending branch, they are: superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior auricular, superficial temporal, and the maxillary artery
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
3. Assess those functions of the trigeminal, facial, glossopharyngeal, vagus and hypoglossal nerves which relate to biting chewing and swallowing Cranial nerve Trigeminal (V)
Facial (VI)
Glossopharyngeal (IX)
Vagus (X)
Function Ophthalmic division (V1) supplies skin of the forehead, upper eyelids, nose midline, and the anterior surface of the eye, nasal mucosa and frontal sinus Maxillary division (V2) supplies the skin of the temple and face as inferior as the corners of the mouth, and also upper teeth, lip, gums, and palate Mandibular division (V3) supplies a strip of skin from the temple to the chin, the lower teeth, gums, lips, floor of the mouth, and the anterior two thirds of the tongue. Also, see muscles of mastication. Proprioception (coordinate movements) of the muscles of the face and taste of the anterior two thirds of the tongue. Also somatic motor to muscles of the face, scalp and neck, and parasympathetic to the lacrimal, sublingual, submandibular, nasal, and palatine glands. Somatic and taste sensation from posterior third of tongue and oropharynx, and proprioception of the swallowing muscles. Also motor to the stylopharyngeus muscle and parasympathetic to the parotid gland. Somatic sensation from larynx and also taste from small number of receptors in epiglottis and pharynx.
Test Test sensations of the face and mouth in response to touch, pain, temperature and muscle sense. See if they can chew.
Test their taste and ask them to smile, salivate or cry.
Test taste and sensation at back of tongue. Encourage the gag reflex and check ability to salivate. Test swallowing, coughing and voice production. Check taste
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
Hypoglossal (XII)
Also motor to muscles of throat and neck and parasympathetic to smooth muscle of the trachea and oesophagus Main function is as the only motor nerve of the tongue causing movement through speech and swallowing
Test chewing, speaking and swallowing. If the nerve is injured on one side only then the tongue will deviate towards the side of the lesion. Long term – muscle wasting
4. Demonstrate how the temporo-mandibular joint and muscles of mastication produce chewing movements The temporo-mandibular joint is divided into two separate synovial cavities by a fibrocartilaginous disc o The lower part of the joint allows mainly the hinge-like depression and elevation of the mandible o The upper part of the joint allows the head of the mandible to translocate forward (protrusion) onto the articular tubercle and backward (retraction) into the mandibular fossa. Opening the mouth involves both depression and protrusion The forward or protrusive movement allows greater depression of the mandible by preventing backward movement of the angle of the mandible into structures in the neck Side to side movements - sliding occurs unilaterally, the head of the contralateral mandible rotates on the inferior surface of the articular disc. Movements about the temporo-mandibular joint are all produced by the muscles of mastication
5. Demonstrate the routes by which the maxillary, mandibular, facial, glossopharyngeal, vagus and hypoglossal nerves leave the skull, and indicate the courses of the lingual and inferior alveolar nerves The mandibular nerve (V3) is the largest and most inferior branch of the trigeminal nerve and it exits through the foramen ovale o The lingual nerve arises from the mandibular nerve (including chorda tympani VII component). The lingual nerve lies anterior to the inferior alveolar nerve. It is sensory to the anterior two-thirds of the tongue, the floor of the mouth, and the lingual gingivae o The inferior alveolar nerve enters the mandibular foramen and passes through the mandibular canal forming the inferior dental plexus, which sends dental branches to all mandibular teeth on its side The maxillary nerve (V2) leaves through the foramen rotundum The facial nerve (VII) leaves through the internal acoustic meatus The glossopharyngeal nerve (IX) leaves through the jugular foramen The vagus (X) leaves through the jugular foramen
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine The hypoglossal (XII) leaves through the hypoglossal canal
6. Describe the relationship between the facial nerve and the parotid gland The parotid gland lies at the side of the face superficially (parotid swellings, i.e. mumps) The parotid duct emerges from the anterior border and passes forwards on the masseter, then turns medially and penetrates the buccinator and opens into the mouth opposite the second upper molar tooth Parasympathetic secretomotor impulses come from the glossopharyngeal (IX) – the lesser petrosal nerve The facial nerve emerges from the skull through the stylomastoid foramen in the temporal bone It enters the parotid gland (does not innervate it), continues superficially, and forms a complex and variable plexus Branches of VII emerge from the anterior margin in five groups: o Temporal – to frontal belly of occipitofrontalis o Zygomatic – to orbicularis oculi and upper face o Buccal – to buccinatorm orbicularis oris and mid face o Marginal mandibular – to orbicularis oris and the corner of the mouth o Cervical – to platysma As the nerve is superficial, it is easy to damage leading to facial palsy. The mandibular branch is particulary in danger as it passes just below the lower margin of the mandible Bell's palsy = a lower motor lesion of the facial nerve – lesion of cell bodies or the nerve itself causing the muscles of the face to sag on the affected side
7. Identify the positions of the parotid and submandibular glands and the lymph nodes draining the oral and oropharyngeal structures Parotid The parotid gland is the largest of the three main salivary glands in the head and numerous structures pass through it It is anterior to and below the lower half of the ear, superficial, posterior, and deep to the ramus of the mandible It extends down to the lower border of the mandible and up to the zygomatic arch Posteriorly it covers the anterior part of the sternocleidomastoid muscle and continues anteriorly to halfway across the masseter muscle Submandibular Each submandibular gland lies along the body of the mandible, partly superior and partly inferior to the posterior half of the mandible, Partly superficial and partly deep to the mylohyoid muscle Lymph Drainage To the deep cervical nodes either directly or via the submandibular, retropharyngeal, submental or parotid nodes
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
Parotid Gland
Sub-lingual Gland
Sub-mandibular Gland
8. Identify the teeth in the living mouth and record them accurately; recognise characteristic dental patterns for children and adults Left Upper Right Upper Left Lower Right Lower • • • • •
Incisors 2 2 2 2
Canines 1 1 1 1
Premolars 2 2 2 2
Molars 3 3 3 3
In a full adult set there are 32 teeth, including wisdom teeth, or 28 without There are 20 teeth in a complete deciduous set (no premolars (8) or wisdom teeth (4)) The first deciduous teeth first come at 6-8 months and are complete by 20-24 months Permanent adult teeth start at 6 years and are complete by the early 20's These ages can be used as milestones to assess general development
9. Be able to identify the following structures in the living mouth: hard and soft palate, uvula, faucial pillars, palatine tonsils, lingual papillae, parotid and submandibular papillae, sublingual glands, frenulum, genioglossal ridge Faucil pillars - a pair of curved ridges running down the soft palate Parotid papillae – small raised patch neer the 2nd upper molar – opening of parotid duct Submandibular papillae – felshy tag with a forked tip found as you run doen the low gums and mandibular symphysis – where the submandicular salivary ducts open Sublingual glands – bumpy bit on the lower lateral buccal floor (the lingual papillae) Frenulum - small fold of tissue that secures or restricts the motion of a mobile organ in the body o Oral tissue: Frenula of the mouth include the frenulum linguae under the tongue, the frenulum labii superioris inside the upper lip, the frenulum labii inferioris inside the lower lip, and the buccal frena which connect the cheeks to the gum Genioglossal ridge – a smooth, firm rounded ridge running along the midline of the floor of the mouth to the tongue formed by the genioglossus muscle
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
Palatopharangeal fold
Breathing, Palatine tonsil
Palatoglossal fold
Posterior wall of oropharynx
and Hearing 1. List the mechanisms which protect the lungs and bronchi against aspiration of food and drink There are two main mechanisms which function when swallowing o Levator veli palatine - muscle elevates the soft palate during swallowing, pushing the soft palate against the wall of the pharynx, thereby preventing the passage of the food into the nasal cavity o When swallowing, a peristaltic wave of activity of the constrictor muscles of the pharynx raises the larynx which becomes closed off by the epiglottis Gag reflex Sneezing – see below Coughing – see below
2. Explain (in terms of sensory and motor pathways and muscle groups) the sneeze and cough reflexes SNEEZING COUGHING Inspiration Intrathoracic pressure raised (glottis closed, abdominal muscles contracted)
Soft palate depressed against tongue (palatopharyngeus/palatoglossus)
Soft palate raised and tensed against posterior wall of pharynx. (Levator veli palatini, tensor veli palatini, sup. constrictor)
Sudden abduction of vocal folds to release intrathoracic pressure through nose or mouth
Cough o o
Afferent - irritation of receptors in larynx and trachea (laryngeal branches of X – internal laryngeal) Efferent Deep inspiration, phrenic nerves (C3-5) to diaphragm and intercostal nerves (T1-12) Build up of pressure against closed glottis - recurrent laryngeal – posterior cricoarytenoid muscle Forced exhalation with oropharyngeal isthmus open - soft palate is raised and tensed against the posterior wall of the pharynx using the levator veli palatini (innervated by the cranial part of the accessory nerve (CN XI)), tensor veli palatini (innervated by the medial pterygoid nerve which is a branch of the mandibular nerve (CN V)), and the superior constrictor muscles of the pharynx (innervated by the cranial part of the accessory nerve (CN XI)) Sudden abduction of vocal cords - air escapes through mouth
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine o o
Afferent - irritation of receptors in larynx and trachea (laryngeal branches of X – internal laryngeal) Efferent Deep inspiration, phrenic nerves (C3-5) to diaphragm and intercostal nerves (T1-12) Build up of pressure against closed glottis - recurrent laryngeal – posterior cricoarytenoid muscle Forced exhalation with oropharyngeal isthmus closed - soft palate becomes depressed against the tongue using the palatopharyngeus and palatoglossus muscles, innervated by the cranial part of the accessory nerve (CN XI) Sudden abduction of vocal cords - air escapes through nose
3. Demonstrate in dissected specimens the landmarks of the nasal cavities, nasopharynx and soft palate
Frontal and cribiform plates/bones Mucus glands and capillary plexus for warming and humidification
Vocal Fold with Vestibular Fold above
Hard palate – front of mouth and is formed by processes of the maxillae and palatine bones and is covered by mucous membrane Soft palate – is further back. It is a moveable fold of mucous membrane that tapers at the back of the mouth to form a fleshy hanging flap of tissue called the uvula The lowest part of the airway – the larynx is modified for the production of voice
4. Demonstrate in living subjects the body of the hyoid, the thyroid and cricoid cartilages, the cervical part of the trachea, and the thyroid isthmus These structures constitute the larynx The hyoid bone is located at the base line of the mandible and serves as a point of an attachment to some neck muscles Inferiorly is the thyroid cartilage (made from two lamina which meet to form the adam's apple, and leave an open back) Then inferior to this is the cricoid cartilage (which is a complete ring that is thicker posteriorly). Below this are the cartilaginous tracheal rings Between each of the structures is a membrane - the thyrohyoid membrane and cricothyroid membrane The isthmus of the thyroid is located just inferior to the cricothyroid cartilage
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
Phonation is the vocal sounds created when air is forced between vocal cords The quadrangular membrane merges with the cricothyroid membrane and bulges to form the vestibular fold and the vocal fold (which flattens/bulges when talking to help shape sound) The pitch depends on relative position and tension in vocal folds by movement of arytenoid cartilages and cricothyroid joint The inferior horn of the thyroid cartilage is articulated by the cricothyroid muscle (external laryngeal nerve) which causes changes in tension of the vocal cords and so changes in pitch The arytenoid cartilage inserts into the vocal cord and can move them further up, together or twist them causing movement of the vocal folds/chord – further alterations to pitch (recurrent laryngeal nerve) The intensity of a sound depends on force with which air is pushed through the glottis The quality of sound depends on resonation in the pharynx, mouth, and paranasal sinuses Words depend on shaping of sound with the mouth, particularly the tongue and lips
5. Demonstrate in living subjects and imaging the positions of the paranasal sinuses; define their sensory nerve supply; explain the clinical significance of their drainage routes The paranasal sinuses reduce the weight of the facial skeleton Act as resonators for the voice Are lined with respiratory epithelium and may become infected Are connected to the pharynx by small holes and therefore are a route of infection – build up of mucus in sinuses causes pain which doesn't always clear easily.
Frontal sinuses – located in the frontal bone above the nose and terminate laterally in
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine the mid-orbital plane o The frontal sinuses drain into the frontonasal duct into the infundibulum, which opens into the semilunar hiatus of the middle meatus o Innervated by branches of the supraorbital nerves (arise from the trigeminal nerve). Ethmoidal sinus – comprised of several cavities known as ethmoidal air cells. These are located in the ethmoid bone behind the nose o The anterior and middle ethmoidal cells drain directly into the middle meatus through the infundibulum o The posterior ethmoidal cells open directly into the superior meatus. o Innervated by the nasocilliary nerves (CN V1), which is a branch of the trigeminal nerve. Maxillary sinus – these are in the maxilla, behind the cheeks, just lateral to the nose extending between the inferior border of the orbit and the upper lip o This sinus does not drain particularly well as the exit to the nasal cavity is 2/3 of the way up its medial border, and so has to fill before it actually drains anything o There is also a thin layer of bone between the sinus and the teeth and so a tooth infection can infect the sinus as well o Each maxillary sinus drains by an opening, called the maxillary ostium, into the middle meatus of the nasal cavity o Innervation of the maxillary sinus is via the anterior, middle, and posterior superior alveolar nerves. They are all branches of the maxillary nerve (arises from 2nd branch of the trigeminal nerve (CN V2)). Sphenoidal sinus – this is located just posterior to the ethmoidal air cells in the sphenoid bone o This is located in close proximity to the pituitary gland, and so can be utilised when operating on the pituitary (transphenoidal surgery) o The sphenoidal sinus is also in close proximity to the optic nerves, the optic chiasm, the internal carotid arteries, and the cavernous sinuses o These sinuses are innervated by the posterior ethmoidal nerve (a branch of the trigeminal nerve (CN V))
6. Explain the importance of the relationship of the maxillary sinus to the roots of the upper teeth, and of the sphenoid sinus to the pituitary fossa The maxillary sinus has the roots of teeth directly underneath and so abscesses/infection of the teeth can spread to the maxillary sinus o Because the superior alveolar nerves supply both the maxillary teeth and the mucous membrane of the maxillary sinus, inflammation of the mucosa of the sinus is frequently accompanied by a sensation of toothache in the molar teeth, especially when the maxilla is very thin in the floor of this sinus The sphenoid sinus provides a route of surgical entry through the nose for pituitary surgery
7. Explain pressure equalisation between the pharynx and the middle ear The pharyngotympanic tube (or auditory tube) connects the tympanic cavity to the nasopharynx, where it opens posterior to the inferior meatus of the nasal cavity The tube is tonically closed by a sphincter at its medial end, but during swallowing and yawning, it opens so that air can leave or enter the middle ear and equalise pressure with the nasopharynx and thus the atmosphere It is also a possible route of infection from the pharynx to the middle ear/mastoid air cells
8. Explain the clinical importance of the relationship of the mastoid antrum and air cells to the middle ear cavity in the skull
the mastoid
Mastoid air cells are located in the mastoid protcess They are connected via mastoid antrum to the tympanic cavity of the middle ear which in turn is connected to the pharynx via the auditory tube The pharyngotympanic tube can act as a route for infection from the pharynx to either the middle ear or the mastoid air cells (where there are tiny air filled compartments). Infections of the mastoid antrum and mastoid cells (mastoiditis) result from a middle ear infection that causes inflammation of the mastoid process Untreated, this can lead to temporal bone erosion The air cells are also close to the base of the brain where the bone can sometimes be incomplete giving a route for meningitis spread Infection can also spread to the sigmoid sinus via the internal jugular giving risk of thromboses
9. Identify the features of the external auditory meatus and eardrum that can be seen through an auroscope
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
If the cone of light is present then this indicates the ear is normal If infection is present in the middle ear then the cone of light reflection if lost
10. Outline the contributions of the structures and spaces of the airway and oral cavity to voice production See above
11. List the actions that may be taken to restore patency of the airway in an emergency Chin lift or jaw thrust (this straightens the airway, and opens up the airways making it easier for the patient to breathe of their own accord) Oropharyngeal or nasopharyngeal airway Endotracheal intubation – this is where an intubation tube is forced down the trachea, through the vocal cords, into the main bronchus of the lungs. Once this is done, the patient can be bagged, and therefore his breathing controlled Cricothyroidotomy (see the next learning objective) Tracheostomy (see the next learning objective)
12. Describe the anatomical basis of tracheotomy and cricothyroidotomy Cricothyroidotomy – would be done through the cricothyroid membrane in the midline, between the thyroid cartilage above and the cricoid cartilage below o Needle cricothyroidotomy – a large-bore intravenous cannula is inserted directly through the membrane. o Surgical cricothyroidotomy – a surgical hole is made in the cricothyroid membrane, and a cuffed tube, similar to a short endotracheal tube is inserted directly. This method affords much better airway protection Tracheostomy – a more permanent procedure. The infrahyoid muscles are retracted laterally, the isthmus of the thyroid gland is divided (much lower than a cricothyroidotomy) and an opening is made in the trachea between the 1 st and 2nd tracheal rings, or through the 2nd through 4th rings. A tracheostomy tube is then inserted and secured with neck straps
13. Explain likely consequences of disease or injury of a recurrent laryngeal nerve and of the superior part of the cervical sympathetic chain Any one of the following effects can occur during surgery – perhaps the worst effect being if the recurrent laryngeal nerve is damaged, as this will cause complete loss of voice
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine
With superior thyroid artery
With inferior thyroid artery LEFT: bronchial or oesophageal tumour/swollen mediastinal lymph nodes
*Further Information covered in lecture* Facial Nerve Has 3 functional components: o Motor – muscles of facial expression o Sensory – branches to the cauda tympani where it joins the linguinal nerve (a branch of the mandibular branch of the trigeminal) just after the acoustic meatus. Sensory to anterior 2/3 of tongue o Parasympathetic secretor motor – salivary (not parotid) and lacrimal glands via the submandibular, and pterygopalantine ganglia Leaves the brain stem at the junction of the pons and medulla via the internal acoustic meatus The stylomastoid foramen is a hole between the mastoid and styloid processes of the temporal bone The nucleus solitarius receives input from the taste buds and synapses with rely neurones to send information to the brainstem Bells Palsy – inflammation of the boney canal causes pressure on nerve which causes facial paralysis on one side. In 80% of cases nerve regenerates after treatment Depending on how high up the inflammation is will depend on which branches it affects and how much is affected
The Eye and Sight 1. Describe briefly the margin and walls of the bony orbit and name its important contents The orbit is a pyramidal, bony cavity in the facial skeleton with its base anterior and its apex posterior The bony orbit contains the visual apparatus together with nerves, vessels and lacrimal apparatus that maintain it, the muscles that move it and the orbital fat pad that cushions it
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine The bones forming the orbit are lined with periorbita (periosteum of the forms the facial sheath of the eyeball
orbit), which
Roof (superior wall) Orbital plate of frontal bone o Small contribution from the lesser wing of the sphenoid posteriorly Medial Wall Frontal process of maxilla Lacrimal Orbital plate of ethmoid o Small contribution from the lesser wing of the sphenoid Floor (inferior wall) Orbital surface of the maxilla o Small contribution from zygomatic and palatine bones Lateral Wall Zygomatic (anteriorly) Greater wing of sphenoid (posteriorly)
2. Identify on a skull the superior orbital fissure and the optic and name the nerves and vessels passing through them
Optic canal o Optic nerve (II) o Ophthalmic artery Superior orbital fissure o Oculomotor (III), Trochlear (IV), Ophthalmic nerve (V1), Abducens (VI) o Ophthalmic vessels o Sympathetic fibres Inferior orbital fissure o Maxillary nerve (V2) o Infraorbital vessels
3. Identify the rectus and oblique muscles, levator palpebrae superioris and orbicularis oculi in suitable specimens
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine Note the axis of explain
the eyeball the action of muscles.
compared to the axis of orbit. This helps to the attached
Extrinsic muscles of eyeball o Four rectus muscles – superior,
o o
inferior, medial Two oblique Levator
and lateral muscles – superior and inferior plapebrae superioris - above the superior
rectus and below
the frontal bone. It acts to elevate the upper eyelid and acts with the superior rectus (i.e. when you look up) Orbicularis oculi – consists of two parts o orbital part - surrounds the orbit – tightly closes o palpebral part - which is in the eyelids – gently closes
4. Test the function of the following cranial nerves: oculomotor, trochlear, abducens, ophthalmic division of trigeminal, facial (to orbicularis oculi) Superior Rectus (III - occulomotor) Inferior Rectus (III) Lateral Rectus (VI - abucens) Medial Rectus (III) Inferior Oblique (III) Superior Oblique (IV – trochlear)
The series of movements aim to isolate the function of and test the specific supplying it
Levator Palpebrae Superioris (III) and sympathetic innervation o Sympathetic loss – partial ptosis (Horner's Syndrome) o Occulomotor loss – complete ptosis Orbicularis Oculi (VII – facial) o Tested by closing the patient's eye(s) tightly and asking the patient to resist your attempt to open them The ophthalmic nerve (a sensory nerve) - first branch of the trigeminal nerve (CN V1) o Can be tested by light touch, pin prick, and temperature over the forehead region o A partial loss can be diagnosed by comparing the response to the same stimulus on the other side
5. Explain the clinical significance of the close relationship between the superior orbital fissure and the cavernous sinus The superior ophthalmic veins drain into the cavernous sinus through the superior orbital fissure, providing a potential route for the spread of infection from around the orbit, nasal sinuses and superior part of the face This can lead to a cavernous sinus thrombosis and subsequent impairment of all the structures passing through it (lacrimal and frontal nerve (branches of ophthalmic division of trigeminal), trochlear nerve, occulomotor nerve and abducens
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine 6. Describe briefly the arterial supply and venous drainage of the eye, including the retina The orbit is supplied almost exclusively by the ophthalmic artery (a branch of the internal off immediately after it leaves the cavernous sinus). It has many braches: o Lacrimal artery → anterior ciliary branch o Central retinal artery o Posterior ciliary arteries o Muscular arteries (intrinsic of eyeball) o Supra-orbital arteries(forehead and scalp) o Ethmoidal arteries (ethmoidal air cells) o Palpebral arteries (medial eyelids) o Dorsal nasal arties (upper nose surface) o Supratrochlear (forehead) Superior and inferior ophthalmic vein o Superior → superior orbital fissue → cavernous sinus o Inferior is smaller → leaves by Joining superior ophthalmic vein; Draining through superior orbital fissure on its own; or Passing through inferior orbital fissure to join with pterygoid
carotid – given
7. Understand how to test corneal and consensual light reflexes and explain the afferent and efferent components of these This diagram shows the corneal or pupillary light reflex Retinal photoreceptors detect the light, and the optic nerve (CN II (sensory)) transmits a signal to the pretectal nucleus At this stage, a motor signal is transmitted along the oculomotor nerves (CN III (motor)) to the ciliary ganglia This causes parasympathetic innervation of the pupillary sphincter which causes constriction of the pupil This response is a consensual reflex – that is both pupils constrict, even if only exposed to the light The patient is asked to look at a distant object The light is slowly shone into the left eye for a few seconds. In this time, you must observe the pupillary response of both eyes In normal people, the pupil will constrict in both eyes (perhaps more in the eye that the light is shone in to (so in this case the left eye)), but there will be a notable change in the size of the other pupil (of the right eye) This procedure will therefore be testing the optic nerve of the left eye, and the oculomotor nerves of both eyes. You then need to test the optic nerve of the other eye (in this case the right eye). this time is shone into the right eye, and again the responses of both pupils is Again, in a normal person, both pupils should constrict.
one eye is
So the light observed.
There is also something called afferent pupil defect test, or the swinging light test. Here the light is initially shone into one eye for a few seconds, and is then switched to the other eye, and then this cycle is repeated several times If any of the two optic nerves or two oculomotor nerves are slightly damaged, there will be a lagging of one or both eyes
8. Identify the optical and neural parts of the eye The parts of the eye can be divided into three main categories The muscles of the eye (already described) The optical structures of the eye The nervous supply of the eye Optical structures of the eye The cornea The iris and pupil The lens and ciliary muscles associated with it (for accommodation) The optic retina
Jack Roberts – 2nd Year Revision Notes 2008-09 – LCRS – Anatomy of the Head, Neck and Spine The yellow spot (fovea), which is technically known as the macula lutea Nervous supply to the eye In addition to the optic nerve, the nerves of the orbit include those that enter the through the superior orbital fissure and supply the ocular muscles o CN III supplies the levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, and inferior oblique. o CN IV supplies the superior oblique. o CN VI supplies the lateral rectus. Several branches of the ophthalmic nerve (CN V1) pass through the superior orbital fissure and supply structures in the orbit o The lacrimal nerve arises in the lateral wall of the cavernous sinus and passes to the lacrimal gland, giving branches to the conjunctiva and skin of the superior eyelid and providing secretomotor fibres conveyed to it from the zygomatic nerve (CN V2) o The frontal nerve divides into the supraorbital nerve and supratrochlear nerve, which supply the upper eyelid, forehead, and scalp. o The nasociliary nerve, the sensory nerve to the eye, supplies several branches to the orbit. The infratrochlear nerve, a terminal branch of the nasociliary nerve, supplies the eyelids, conjunctiva, skin of the nose, and lacrimal sac The ethmoidal nerves, also branches of the nasociliary nerve, supply the mucous membrane of the sphenoidal and ethmoidal sinuses and the nasal cavities, and the dura of the anterior cranial fossa The short ciliary nerves, branches of the ciliary ganglion, carry parasympathetic and sympathetic fibres to the ciliary body and the iris (III). The long ciliary nerves, branches of the nasociliary nerves (CN V1), transmit postsynaptic sympathetic fibres to the dilator pupillae and afferent fibres from the iris and cornea. *See Grays Anatomy diagrams – too many/complex to include*
9. Outline the mechanisms of tear secretion, tear-film maintenance and tear drainage The lacrimal gland is a small exocrine gland in the upper part of the orbit Arranged around the anterior portion of levator palpebrae superioris – divided into two parts Secretomotor fibers from the parasympathetic part of the autonomic division of the PNS stimulate fluid secretion from the lacrimal gland. These preganglionic parasympathetic neurons leave the CNS in the facial nerve [VII], enter the greater petrosal nerve (a branch of the facial nerve [VII]), and continue with this nerve until it becomes the nerve of the pterygoid canal The nerve of the pterygoid canal eventually enters the pterygopalatine ganglion where the preganglionic parasympathetic neurons synapse on postganglionic parasympathetic neurons. The postganglionic neurons join the maxillary nerve [V2] and continue with it until the zygomatic nerve branches from it, and travel with the zygomatic nerve until it gives off the zygomaticotemporal nerve, which eventually distributes postganglionic parasympathetic fibers in a small branch that joins the lacrimal nerve (branch of V 1) . The lacrimal nerve passes to the lacrimal gland Numerous ducts open into the conjunctival sac, tears lubricating and protecting the eyeball, creating a tear film Tears then pass medially over the surface of the eyeball to the lacrimal lake, then into the lacrimal canaliculi via the puncta They drain into the lacrimal sac, then through the nasolacrinal duct into the inferior meatus of the nasal cavity Infection of the lacrimal canaliculi or ducts may block tears leading to dripping down cheeks. Excessive production has the same effect
Published on Nov 17, 2011
Head, Neck & Spine - Jack Roberts


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With four scholarships available for the 2010 class, it appears that Virginia would like to use one of those spots on a talented combo guard.
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Vista PEAK Exploratory
Soccer Team
Congratulations to our girls' soccer team! 2nd place in the district!
Vista Peak Track and Field
Congratulations to all of our track and field athletes for a wonderful season and a wonderful showing at the City Championships. Special congratulations to Mikenzie Jones for breaking the 7th grade shot put record for Aurora Public Schools!


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Free BreatheHeavy promo.
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First Listen! Ralf GUM feat. Omar – Love Core (Sir LSG Vocal Mix) (GOGO Music)
Sometimes you happen to listen to things which, altogether, sound like natural… Like an evidence! This is nothing but the proper of music cleverly thought and masterfully put together. And this is pretty much what to expect on this smooth joint.
'Love Core' marks the reunion between GOGO music label head Ralf GUM and Brit-Soul icon Omar Lye Fook MBE.
The latter once again, makin' proof of his ability to express himself in many different territories. South African producer Sir LSG subtly spicin' up the whole with an Afro/Jazz feel along with Kafele Bandele on trumpet…
A definitive masterpiece, 'Love Core' is one of the numeroous highlights from Ralf GUM's 'In My City' album. This along with 'Free (Is All I Wanna Be)' featuring Portia Monique. But also 'The Pap' featuring Monique Bingham. Not to mention 'With Her Hand' and 'In The City' along with Hugh Masekela.
Download from Traxsource.
Lesego Sefako (Sir LSG) began his career as a DJ in 2006 whilst studying to become an electrical engineer at the University of The Witwaterstrand. It seems the love for music soon took precedence as the young Sir LSG started collecting records. Soon after co-founding Hood Natives in 2007 with 3 other DJ's based in Soweto, he enrolled at the Soul Candi Institute of Music. There he learnt more about electronic music production. He then went to the Academy of Sound Engineering to do a two year diploma majoring in Music Production & Audio Post Production.
It was the 2008 Southern African Music Conference that became a defining juncture in Sir LSG's music path. There, he caught the ear of DJ Christos, who since became his mentor. With thanks to the relationship with the latter, German producer Ralf GUM came across LSG's 'Sax In The City' in 2011. The track finally found its way to light when released on GOGO Music. With remixes from Raw Artistic Soul, and fellow South African DJ/producer Nastee Nev, it reached the second spot on Traxsource's top singles chart.
On a solo path since breaking away from Hood Natives, Sir LSG has since done remixes for Ralf GUM, Andy Compton and Nathan Adams among others. He has also collaborated with Brian Temba, a South African R&B singer/songwriter and trumpeter Kafele on a song titled 'All I Am'. A track which enjoyed great airplay on South African radio stations and became a local dance floor anthem.
In 2014, Sir LSG was voted by Traxsource at Number 20 on the Top 100 Afro House producers of the year.
You might also like…
10 essential Afro House gems…


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Keep your running goals going through the summer, make some friends, have a great time!
As part of the lead up to the Raccoon Mountain Marathon, Half Marathon and Relay, Run Chattanooga hosted a free half marathon in January 2015 called FREEze Your Half Off. Over 100 runners participated in the inaugural event, braving the 17 degree weather! Almost 25% were first time half marathoners.
We had so much fun, we decided to do another one six months later. Enter BURN Your Half Off, a FREE half marathon, where the weather will be different, but the fun will be the same. In 2016, Burn was so popular, we split it into two days. We're doing the same for 2017! Run Saturday or Sunday, or run both days!
The course is a double-out-and-back where you'll pass the "aid station" more than once. You bring your own cup or water bottle (we'll have water, Gatorade, and plenty of ice available), and energy gels or anything else you think you'll need. We'll count your laps and time it. And we'll even provide the medals. (Although keep in mind, this is a low-key race…medals will be kitschy, not fancy!)
GPS Coordinates for the Fry Center on the Riverwalk are:
35.097580, -85.252631
Post-race food is potluck – bring something to share!
You are welcome to go the whole distance – there is no time limit, so walkers are welcome – or just run your prescribed training plan distance, bring some food for the potluck, ring a cowbell, give out high fives, and enjoy the camaraderie!
This is a no prizes, no pressure, no whining, no time limit event. If you want to run fast and treat this like a race – go for it! If you want to walk the whole thing – you can do that too!
Due to new costs imposed on us for this event, the fee for each race is $5. If you purchase a race shirt or other race-specific merchandise, the fee for the race is waived. If you volunteer for at least 4 hours at Run Amok in November or Raccoon Mountain in March, you run Burn Your Half Off for free.
Invite anyone you want! The more the merrier!
ONLY REGISTERED PARTICIPANTS will receive a finisher's "medal"!


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Your rail is an AM/MM rail so if you search "automag forgrip," anything that's not for an RT or RTP will fit. However that will require removing
Thanks for the replies everyone. Some great ideas all around.
looking for a warp left ule body, possible even a warp left rail
black preferable, but not required


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Vans Drops Van Doren-Approved Holiday Collection
Vans closes out its 50th anniversary year with a curated Holiday 2016 collection by brand legend, Steve Van Doren.
Vans revisits its past by reissuing the skull and bones print from the archives, but offers an update for the holiday season with festive candy cane and Santa hats, which adorn the Sk8-Hi 38 and Old Skool 36 Reissue silhouettes. The Sidestripe footwear models are finished with a canvas and suede material blend and jolly "Ho Ho Ho 50" decorative laces.
The Van Doren Approved collection also includes festive apparel, including the Holidaze longsleeve t-shirt, pullover hoodie and sweater, each adorned with the skull and bones Santa print. Rounding out the holiday arrangement are the Holiday crew socks, Pom beanie and trucker hat, fit for any ugly sweater or festive party occasions.
The Van Doren Approved holiday collection is available now at Vans retail stores and online.


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The end of another week, and the beginning of another Instagram weekly roundup! This week we flipped through our +400 Common Core aligned goals to find materials that focused on communication - recognizing emotions in others, using different types of sentences in conversation, effectively making requests of others, and counting. Finally, we took a look at an important social arena for many people with autism - the internet - and specifically focused on how to help students stay safe on the web.
We hope everyone is enjoying their summer and finding use for materials and checklists whether for planning for next year or helping kids have fun on their breaks! Remember: lots of sunscreen, and follow us on Instagram, Twitter, and Facebook for updates throughout the summer.


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My favourites Your English speaking Romanian Real Estate experts since 2006
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1 Bedroom Apartment for rent in Unirii
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White Mountain Property is pleased to present you for rent a spacious apartment with one bedroom situated in Unirii area (5 minutes from metro station), on Unirii Boulevard. Near the block are Unirii Square, Unirea Shopping Center (3 minutes), supermarkets & the impressive Peoples House. Also the distance to the Historic Center of Bucharest is only 5 minutes walk.
This fully furnished apartment is located at 2nd floor from 10 floors of the building, and it's composed as following: a cozy living room, a bedroom with double bed and wardrobes, a fully equipped open space kitchen, a bathroom with bath tub and a balcony. The total usable area is 65 sqm and the orientation provides you a great view over the Unirii Boulevard and also brings great light into the apartment.
The apartment is offered for rent completely furnished at the good standards, that will make the ideal home for families or business people who would like to live in a peaceful and safe environment in center of the city.
For further details and viewings, do not hesitate to contact us at the phone number: (+40) 745 872 540 or e-mail: firstname.lastname@example.com. We will help you with pleasure.
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Bucuresti/ Bucharest
72 m2
Rent: 490 €


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The Bottom Line: Lexington - February 10, 2017 Podcast
The Kentucky Reboot travels to Alabama on Saturday. Can the Tide extend UK's February slump? Why the most important 3-pointer in the Calipari Era, is one that an opposing team missed. Why isn't Hamidou Diallo playing? Why the big NCAA Bracket Reveal is like telling us 1 of the 4 college football playoff teams. Charles Oakley vs. The Knicks. Russ vs. KD. More reasons why NBA drama is more interesting than the games themselves. Joe Montana finally showed some bitterness towards Tom Brady, which makes us like him. Kyle Shanahan has no accountability for choking the Falcons Super Bowl chances. Ken Starr lives a charmed life. How does Homer Bailey look himself in the mirror with all the money he is stolen. A new Red could be a darkhorse for playing time this year. A Ken Griffey Jr. anniversary. MLB win totals have a shocking number for the Reds. And we look to continue our incredibly hot college basketball picks, 8-2 in February.
Twitter: @bottomlinelex Email: firstname.lastname@example.com


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Heirloom Jewelry Chest
Previous price was $385.00.
This exquisite jewelry chest with Bubinga and Elm burl inlays is fit for a queen. High gloss with black enamel accents, lift the lid to see 2 swing-out necklace bars with a shirred pocket, multiple ring rolls and two open compartments. Open the side doors to find a necklace hook and shirred pocket on each. Once the doors are opened, you may open each of the 3 pull out drawers. The first features 9 compartments, the second has 4 compartments and the bottom has a single spacious open area for holding bracelets, watches, earrings, etc. Chamois faux suede interior with tarnish resistant lining. Gold plated brass hardware, lock and key with mode beige tassel. Measures 9-1/8" x 15" x 9-1/4".


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Belle Époque Films
"The Bigger Picture" starring #RobertSheehan & #RosieDay coming September 2016! #London #robertsheehan #rosieday More pics coming soon Blue Shadows Films Belle Époque Films
About to leave #Versailles to celebrate... Belle Époque Films wishes you a Merry Christmas and Happy New Year 2017! So what is your best story from 2016? #storyhistory
Giving it a go at the #Gibson showroom for our coming feature shooting in #SouthOfFrance! #storyhistory 🇫🇷🇺🇸🎤🎬
This coming Saturday, Alan Swyer will be the guest host on one of the very best U.S. radio show, Bill Gardner's "Rhapsody In Black." Rumor has it that some songs featured in our coming feature shooting in France in September may be heard... USA: from 2 PM to 4, California time, on KPFK 90.7. Int'l: stream it at KPFK.org.
We're glad to announce that 'Belle Époque, an introduction' has been selected at the #Cannes Media & TV Awards! Congrats to the whole team and see you in Cannes in October! ;) #DreamTeam
Already 5 Belle Époque Films Franco-American #films scheduled to be shot in #France in the coming 2 years! Here just next to the office: parterre de Latorre #chateau #versailles #shootinginfrance ☀
In this love-hate relationship, violence means both violence on others and on themselves... We're sending "Au Rythme Où Bat Mon Coeur" over to Festivals. Thanks to all for your incredible support! #IndieFilm #ChristineAubry
We're finishing #post... Wait for #film greatness! "The Rain" episode by Jenny Stang coming soon! #WebSeries #VFX #DreamSeries #Raindance
Belle Époque Films is happy to attend Cannes Film Festival & Market the whole time again this year! To set up a meeting, please call our Paris office +33 (0)950 75 66 69 or send an email firstname.lastname@example.com - see you there! #Cannes2016
Me & my bestie.... Thank you for inviting us on #Wondercon, John Semper Jr.! Wonderful people and wonderful characters - had a great time!


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The Grange, Shanklin
- Free breakfast, free WiFi in lobby, and free parking
Main amenities
- 16 guestrooms
- Near the beach
- Bar/lounge
- Sauna
- Spa services
- Childcare
- Coffee/tea in a common area
- Daily housekeeping
- Garden
- Library
- Lobby fireplace
- Meeting rooms
- Free breakfast, free WiFi in lobby, and free parking
For families
- Free cribs/infant beds
- Babysitting or childcare
- Connecting/adjoining rooms available
- Private bathroom
- Television
- Free toiletries
What's around
- Shanklin Chine (0.2 mi / 0.3 km)
- Shanklin Theatre (0.2 mi / 0.3 km)
- Rylstone Gardens (0.5 mi / 0.8 km)
- Pirates Cove Adventure Golf (0.9 mi / 1.4 km)
- Small Hope Beach (0.9 mi / 1.5 km)
The Grange, Shanklin
Hotel Info: 866-539-8117from $93
- Standard Twin Room
- Standard Double Room
- Standard Double Room Single Use, Twin Beds
- Standard Double Room Single Use
More great choices
At a glance
Key facts
Hotel size
- This hotel has 16 rooms
- This hotel is arranged over 3 floors
- Check-in time 4:00 PM-10:00 PM
- Check-out time is noon
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Babysitting/childcare
- Pets not allowed
- Free WiFi in public areas
- Free self parking (limited)
Nearby Four Star Shanklin hotels
In the hotel
- Free breakfast daily
- Bar/lounge
- Coffee/tea in a common area
- Spa services on site
- Spa treatment room(s)
- Sauna
- Meeting rooms
- Multilingual staff
- Number of buildings/towers - 1
- Year Built 1820
- Designated smoking areas
- Garden
- Library
- Fireplace in lobby
- Accessible bathroom
- Roll-in shower
In the room
- Coffee/tea maker
- Iron/ironing board (on request)
- Hypo-allergenic bedding available
- Down comforter
- Blackout drapes/curtains
- Premium bedding
- Sleep Number by Select Comfort mattress
- Individually decorated
- Patio
- Private bathroom
- Bathtub or shower
- Free toiletries
- Hair dryer
- Daily housekeeping
- Connecting/adjoining rooms available
- Access via exterior corridors
Top Shanklin hotels
Recently reviewed hotels in Shanklin
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"Good hotel, close to old town Portsmouth, yet close to the Historic Dockyards. About a 11 minute walk from Gunwharf Quays Holiday Inn Express. Great breakfast, clean, orderly,…"Aug 17, 2017
- Holiday Inn Express Portsmouth - NorthFrom
"The shower was a little too small, and the cleaning need to be more detail (dust in the fan in the bathroom and corners). Breakfast was ok and the beds were comfortable. "Aug 16, 2017
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"I stayed at the Gothic View and it was great. I arrived late to find the hosts worried, as I was in the country for my first time with no phone. The building itself is beautiful…"Aug 16, 2017
- Jurys Inn SouthamptonFrom
"The location is excellent - close to the coach station and across the street from a park. Room was clean, but the sink gurgled loudly. Otherwise, very nice."Aug 14, 2017
Also popular with travelers from the USA
Special features
On Site
- Sauna
- Yoga classes/instruction on site
- Bicycle rentals nearby
- Golf lessons available nearby
- Golfing nearby
- Hiking/biking trails nearby
- Kayaking nearby
- Mountain biking nearby
- Parasailing nearby
- Sailing nearby
- Scooter/moped rentals nearby
- Surfing/boogie boarding nearby
- Water skiing nearby
- Windsurfing nearby
The Grange, Shanklin's small print
Also known as
- Grange Hotel Shanklin
- Grange Shanklin
The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.
Reservations are required for massage services and spa treatments and can be made by contacting the property before arrival at the number on the booking confirmation.
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Is the description of this hotel not correct? Tell us


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On the back of my copy of Unto This Last there is a quote by Gandhi in which he states that the book "captured me and transformed my life."
I have read about forty pages so far, which I think is probably enough to know that I should put aside any hopes of being captured or transformed.
Is it very unreasonable of me that I'd prefer to see some other kind of quotes on book covers? A snippet insisting on a book's profound effect on a critic's personal life or its importance/superiority in relation to any and every other book on the face of the planet doesn't make me eager to read it so much as it makes me feel slightly cranky and let down when I don't end up being able to experience the same thing. I think the silliest quote of all time that has ever been used to promote a book was one that on my old copy of Trainspotting, in which a reviewer declared that "it's better than the Bible!"
Because, you know, the defining text of Christianity and a pop book about a group of Scottish heroin addicts are totally comparable.
And while I'm sort of on the subject, I'm also not a terribly big fan of anyone who tells you that a certain age/situation/experience will be the best time of your life. There is too much pressure, too many expectations in that sort of statement. For awhile, lately, I've been thinking an awful lot about this, about how so many people seem to feel that their "best time" was childhood or college or even (oh dear) high school. I had been feeling a bit anxious and behind schedule until I realized that knowing that the best time of your life still hasn't been lived just yet is probably the best place to be.
Monday, January 29, 2007
No Subject
Posted by norma alexander at 10:43 PM
Friday, January 26, 2007
I Don't Know Where These Things Come From
I remember once hearing somewhere that during her prime Hedy Lamarr would spend hours roaming from room to room in her Beverly Hills mansion weeping inconsolably, a beautiful girl haunted by the vague but inevitable fear of getting old and losing her looks.
I think about this a lot. Sometimes I think I can understand it perfectly, simply because I too have a knack for worrying about things a whole lifetime before they will ever happen.
I think about this a lot. Sometimes I think I can understand it perfectly, simply because I too have a knack for worrying about things a whole lifetime before they will ever happen.
Posted by norma alexander at 8:14 PM
Subscribe to: Posts (Atom)


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Perfect for my work as a writer last Christmas and New Year, as walls and private pool by the little villa offered magnificent peace and working inspiration. It's clean and well serviced and the Swedish-Thai-ownership with its background in luxury hotel businesses, makes the establishment very trustworthy. Their Xmas and New Year celebrations is very joyful, a lovely place for these holidays.
The Nai Yang beach just south of Phuket airport is of high quality and surprisingly empty, and faces marvellous sunsets to the west. A village 300 m further south offers many small, inexpensive restaurants along the beach, with very good value. It is considered a 4 star, but to me this is a true 5 star (boutique) resort, which is highly recommendable.
- Official Description (provided by the hotel):
- Integrating both resort and residential living, Dewa Phuket with its 34 pool villas and 62 one and two bedroom residences,offers the perfect retreat for the discerning traveler seeking a tranquil, tropical beach holiday amidst true Thai hospitality. Complimentary hi-speed internet & wifi, 24 hours room service, kids room, fitness room, Spa, jacuzzi, laundry service, bakery, library, close proximity to Blue Canyon Golf Course, airport and marinas. ... more less
- Reservation Options:
- TripAdvisor is proud to partner with Expedia, Agoda, Booking.com, TravelUp, ACCOR, Ctrip TA, Hotels.com, Ebookers, TripOnline SA, HotelQuickly, Cancelon and Evoline ltd so you can book your Dewa Phuket Resort Nai Yang Beach reservations with confidence. We help millions of travellers each month to find the perfect hotel for both holiday and business trips, always with the best discounts and special offers.
- Also Known As:
- Dewa Phuket Nai Yang
- Dewa Phuket Hotel Nai Yang
- Dewa Phuket Resort Nai Yang Beach


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