1.

A muscular patient who regularly lifts weights presents with pain

and weakness in his right upper limb that has been slowly
developing over time. His limb is cool and there is an obvious
vascular insufficiency in his upper extremity. Subsequent tests
show that a large vessel passing between the anterior and middle
scalene muscles is being occluded by hypertrophy (enlargement)
of the muscles due to the excercise. The artery involved is the:
axillary
brachial
brachiocephalic
subclavian
suprascapular
2. In repairing a damaged right subclavian artery, the surgeon notices
and protects a large nerve passing around to the posterior surface
of the artery. This nerve, which does not encircle the subclavian on
the left side, is the:
Phrenic
Vagus
Recurrent laryngeal
Sympathetic trunk
Ansa cervicalis
3. A stab wound just above the left clavicle, lateral to the
sternocleidomastoid muscle, may be life-threatening because of
the possibility of injury to the:
Brachial plexus
Internal jugular vein
Axillary artery
Subclavian artery
Thoracic duct

4. A 27-year-old man who is a professional weight lifter comes to his
physician complaining of recent weakness in his left arm and
frequent tingling in his hand and fingers during exercise sessions
which subsides with rest. He is diagnosed as having vasuclar
insufficiency due to scalenus anticus syndrome and as a remedy it
is decided to transect the anterior scalene muscle where it inserts
on the first rib. During surgery, which structure in contact with the
anterior surface of the muscle must the surgeon be careful of
sparing?
Inferior trunk of the brachial plexus
Long thoracic nerve
Phrenic nerve
Sympathetic trunk
Vagus nerve
5. A 60-year-old man with a previous history of right carotid
endarterectomy, comes to his physician complaining of light-
headedness and dizziness whenever he uses his right hand
vigorously. He is diagnosed as having subclavian steal syndrome
due to an atherosclerotic plaque at the point where his subclavian
artery branches from the brachiocephalic trunk. The cerebral
insufficiency is the result of blood being stolen from which artery?
External carotid
Internal carotid
Middle cerebral
Thyrocervical trunk
Vertebral
6. A first year resident attempts to insert a central venous catheter
into the heart by a subclavicular approach to the subclavian vein.
Following the attempt, it is noted that the patient has difficulty
breathing. What nervous structure lying immediately deep to the
subclavian vein, as it crosses the anterior scalene muscle, may
have been injured?
External branch of the superior laryngeal nerve

Phrenic nerve
Recurrent laryngeal nerve
Sympathetic trunk
Vagus nerve
7. Which statement is true of the internal jugular vein?
It drains all of the thyroid gland on that side of the body
It drains into the external jugular vein
It is accompanied by the deep cervical chain of lymph nodes
It lies deep to the prevertebral fascia
It passes superficial to the sternocleidomastoid muscle
8. Which structure lies immediately anterior to the right anterior
scalene muscle at its costal attachment?
Subclavian artery
Subclavian vein
Thoracic duct
Thyrocervical trunk
Vagus nerve
9. A person develops a primary tumor of the thyroid gland and,
among other symptoms, drooping of the eyelid and constriction of
the pupil on the right side of the eye are noted. What nerve fibers
have been interrupted by the tumor?

postganglionic parasympathetic
postganglionic sympathetic
preganglionic parasympathetic
the carotid nerve
the cervical sympathetic trunk

10. An abscess was surgically removed from the middle of the
posterior triangle on the right side. During recovery the patient
noticed that her shoulder drooped and she could no longer raise
her right hand above her head to brush her hair. Which nerve has
been cut?
Accessory (XI)
Ansa cervicalis
Facial (VII)
Hypoglossal (XII)
Suprascapular
11. A surgeon doing a deep cervical lymph node dissection may
encounter these structures upon the anterior surface of the
anterior scalene muscle EXCEPT:
Phrenic nerve
Subclavian vein
Middle trunk of the brachial plexus
Transverse cervical artery
Cervical part of the thoracic duct
12. The middle cervical sympathetic ganglion, recurrent
laryngeal nerve, and parathyroid glands are all closely related with
which blood vessel?
Inferior thyroid artery
Inferior thyroid vein
Superior thyroid artery
Superior thyroid vein
13. During surgical procedures of the neck, structures within the
carotid sheath can be retracted (pulled aside) as a unit. Which of
the following structures would remain in place when the carotid
sheath is retracted?
common carotid artery

cervical sympathetic trunk
internal jugular vein
internal carotid artery
vagus nerve
14. Which of the following nerves is derived from the dorsal
primary rami of spinal nerves?
great auricular
greater occipital
lesser occipital
phrenic
supraclavicular
15. Which of the following hyoid muscles is an important
landmark in both the anterior and posterior triangles of the neck?
geniohyoid
mylohyoid
omohyoid
sternohyoid
stylohyoid


1. The correct answer is: Subclavian
The subclavian artery runs between the anterior and middle scalene
muscles. Since this is the major artery supplying blood to the upper limb,
occluding this artery might cause the symptoms of pain and weakness.
This patient has a thoracic outlet syndrome, which means that one of the
arteries or nerves that is passing from the thoracic outlet into the upper
limb or or lower neck is being compressed. Thoracic outlet syndrome

may be caused by several things, including a cervical rib (when ribs start
forming on C7, not T1) , hypertrophy of scalene muscles, or
hyperabduction of the upper limb. Specifically, this patient has scalenus
anticus syndrome, which means that there is a compression of
structures between the scalene muscles.
The axillary artery is the continuation of the subclavian artery lateral to
the 1st rib, and the brachial artery is the continuation of the axillary
artery distal to teres major. These arteries and their branches are not
receiving blood because the subclavian artery is compressed. The
brachiocephalic trunk is the structure off the aortic arch which gives rise
to the right subclavian and common carotid arteries, and the
suprascapular artery is a branch off the thyrocervical trunk that
contributes to the scapular anastomosis.

2. The correct answer is: Recurrent laryngeal
The recurrent laryngeal nerves have different relationships to structures
on the right and left sides of the body. On the right side, the recurrent
laryngeal nerve loops around the right subclavian artery at
approximately the T1/T2 vertebral level. On the left side, the recurrent
laryngeal nerve loops around the arch of the aorta, behind the
ligamentum arteriosum, at approximately the T4/T5 level. After this, both
the right and left recurrent laryngeals ascend in the tracheoesophageal
groove to innervate all the intrinsic muscles of the larynx, except the
cricothyroid. So, you should see that the right recurrent laryngeal has a
special relationship to the right subclavian that would put it in danger
during a surgical procedure.
The phrenic nerves lie on the anterior scalene muscles on both the right
and left side. This means that the phrenic nerves are anterior to the
subclavian arteries. The vagus nerves also pass anterior to the
subclavian arteries. On both the left and right side, the sympathetic trunk
lies in front of the prevertebral muscles in the prevertebral fascia. Finally,
the ansa cervicalis hangs in a loop anterior to the internal jugular vein on
the right and left sides. None of these other structures have special
relationships with the right subclavian artery.


3. The correct answer is: subclavian artery.
The subclavian artery crosses between the anterior and middle scalene
muscles, which means that it is also posterior to the sternocleidomastoid
muscle. Lateral to the sternocleidomastoid muscle, the subclavian artery
runs just above the clavicle. Eventually, this artery descends toward the
upper limb. So, it is in the right position to be injured in the stabbing. The
question also mentions that the wound was life-threatening, so you
should really be looking for an answer about an artery.
The brachial plexus is also in the area of the stab wound, but a brachial
plexus injury would not be life-threatening. The internal jugular vein is
located medial and posterior to the sternocleidomastoid muscle--it is not
likely that this vein would be cut. The axillary artery is a continuation of
the subclavian artery beneath the level of the first rib, which is inferior to
the area of interest. The thoracic duct, which dumps into the
brachiocephalic vein on the left side, might be injured in the stabbing,
but this would not be a life-threatening problem.

4. The correct answer is: Phrenic nerve
The phrenic nerve is formed from contributions from the C3, 4, and 5
ventral primary rami. It lies on the anterior scalene muscle, which means
that the surgeon would need to watch for this nerve while transecting the
anterior scalene. None of the other structures lie upon the anterior
scalene. The roots of the brachial plexus come out between the anterior
and middle scalenes, and the trunks lie lateral to the anterior scalene.
The long thoracic nerve comes off the C5, 6 and 7 roots of the brachial
plexus and can be seen piercing the middle scalene muscle. This nerve
lies on the surface of serratus anterior in the thorax, innervating that
muscle. The sympathetic trunk is found deep to the scalene muscles; it
runs in the prevertebral fascia along the front of the vertebral column.
The vagus nerve runs within the carotid sheath, superficial to the
anterior scalene muscle. It passes between the subclavian artery and
vein.


5. The correct answer is: Vertebral
Subclavian steal syndrome occurs when there are abnormal blockages
in vessels coming off of the aortic arch. Due to these blockages, there
may be low blood flow to one arm through the subclavian artery. During
high activity in the underperfused arm, the body needs to find a way to
send blood to the arm to meet metabolic demands. It does this by
shunting blood from the vertebral arteries.
Usually, blood flows from the left and right vertebral arteries to the
basilar arteries to the brain. However, with subclavian steal syndrome,
blood can flow from the left vertebral artery toward the right vertebral
artery. Then, there will be retrograde flow from the right vertebral artery
toward the subclavian artery, which should help supply blood to the arm.
This means that blood that should be getting to the brain is going to the
arm, so these patients might present with symptoms of dizziness and
lightheadedness - they aren't getting enough blood to their brains. The
other arteries listed cannot participate in similar shunts from the brain to
the upper limb.
You should remember the specific association with subclavian steal
syndrome and the vertebral arteries!

6. The correct answer is: Phrenic nerve
The phrenic nerve is formed from contributions from the C3, 4, and 5
ventral primary rami. It lies on the anterior scalene muscle, immediately
deep to the subclavian vein. Since the phrenic nerve innervates the
diaphragm, the patient's symptom (difficulty breathing) fits with an injury
to the phrenic nerve.
The external branch of the superior laryngeal nerve travels with the
superior thyroid artery to innervate the cricothyroid muscle. It is found
medial to the scalene muscles. The recurrent laryngeal nerves are
branches of the vagus that branch in the thorax. The right recurrent

laryngeal loops around the subclavian artery and the left recurrent
laryngeal loops around the aortic arch. Then, the two nerves ascend to
the larynx, running medial to the scalenes. The sympathetic trunk lies in
the prevertebral fascia behind the carotid sheath and in front of the
prevertebral muscles. Finally, the vagus nerve runs in the carotid sheath,
superficial to the scalene muscles.

7. The correct answer is: It is accompanied by the deep cervical chain
of lymph nodes
The deep cervical chain of lymph nodes runs closely with the internal
jugular vein. The internal jugular vein does not drain all of the thyroid
gland--the superior and middle thyroid veins drain into the internal
jugular vein, but the inferior thyroid veins drain directly into the
brachiocephalic veins. The internal jugular vein does not drain into the
external jugular vein. The external jugular vein is a smaller vein on the
lateral neck which drains into the subclavian vein. The internal jugular
vein meets the subclavian vein, and the two vessels join to form the
brachiocephalic vein. The prevertebral fascia is found deep in the neck,
over the vertebrae and the prevertebral muscles. So, the internal jugular
vein is very superficial to this fascia. Finally, the sternocleidomastoid
muscle crosses over the internal jugular vein.

8. The correct answer is: Subclavian vein
The subclavian vein lies anterior to the right and left anterior scalene
muscles. It can be found coursing over the anterior scalene muscles on
both the right and left sides. The subclavian arteries lie posterior to the
anterior scalene muscles--they travel between the anterior and middle
scalenes on both sides of the neck. The thoracic duct is found on the left
side only--it would not be on the right side of the neck. On the left side,
the thoracic duct enters the left brachiocephalic vein where it is formed
by the union of the subclavian and internal jugular veins. So, the thoracic
duct does contact the anterior scalene muscle, but only on the left side

of the neck. The thyrocervical trunk is a branch of the first part of the
subclavian artery, medial to the anterior scalene. It is not in contact with
the anterior scalene. Finally, the vagus nerve travels with the carotid
vessels in the carotid sheath. It is anterior to the anterior scalene, but not
in immediate contact with the muscle. This means that subclavian vein is
the best answer.

9. The correct answer is: Cervical sympathetic trunk
A tumor of the thyroid gland could disrupt the preganglionic fibers
traveling in the cervical sympathetic trunk. The cervical sympathetic
trunk lies in front of the preverterbral muscles in the preverterbral fascia--
it is in the right location to be compressed by a thyroid tumor. Disrupting
the cervical sympathetic trunk leads to Horner's syndrome, a disorder
with a variety of characteristic symptoms. Sympathetic nerves innervate
the dilator pupillae muscle, which allows the eye to dilate. If these
sympathetic nerves are lost in a patient with Horner's syndrome, the
pupil will contract due to unopposed parasympathetic action on sphincter
pupillae. Ptosis (a droopy eyelid) is seen because the superior tarsal
muscle, which raises the eyelid involuntarily, is innervated
sympathetically. If this muscle is paralyzed, the eyelid droops. You might
also observe enophthalmos (a sunken eye), possibly due to the
paralysis of a smooth muscle in the floor of the orbit. Without the
sympathetic nerve supply, the vasculature of the face cannot constrict.
So, the arterioles in the patient's face are vasodilated, making the face
red. Sympathetic nerves also innervate sweat glands; if these nerves are
interrupted, the patient will not sweat and the face will appear very dry.
These are all characteristic symptoms of Horner's syndrome, and you
should be familiar with all of these!
Parasympathetic fibers innervate the glands of the face, cause the pupil
to constrict, and allow for accommodation of the eye for close vision;
they are not involved with Horner's syndrome. The internal carotid nerve
carries postsynaptic sympathetic fibers from the superior cervical
ganglion to the nasal cavity. The thyroid gland is near the level of the
middle cervical ganglion, not the superior cervical ganglion.


10. The correct answer is: Accessory nerve
Remember: if the tip of the shoulder is drooping, trapezius is
denervated, and the accessory nerve has been damaged! The
accessory nerve (CN XI) runs through the posterior triangle, so it is likely
to be injured in posterior neck triangle operations. If the accessory nerve
is damaged there, the trapezius will be denervated, but the
sternocleidomastoid will be OK. Ansa cervicalis is a structure of the
cervical plexus that innervates the strap muscles; if this structure was
injured, you would note weakness in the strap muscles, not the
trapezius. The facial nerve innervates the muscles of facial expression; it
is not found in the posterior triangle. The hypoglossal nerve provides
motor innervation to the tongue--it is also not in the posterior triangle.
Finally, the suprascapular nerve innervates supraspinatus and
infraspinatus. It is located in the posterior triangle, and it might get
injured in posterior neck operations, but the symptoms here are
consistent with an injury to the accessory nerve.

11. The correct answer is: middle trunk of the brachial plexus
The roots of the brachial plexus are between the anterior and middle
scalene muscles; the trunks of the brachial plexus which come from
these roots travel in the posterior triangle. So, the trunks of the brachial
plexus are not related to the anterior surface of the anterior scalene
muscle. The phrenic nerve is comprised of contributions from the ventral
primary rami of C3, C4, and C5. This nerve courses along the anterior
surface of the anterior scalene. The brachiocephalic vein also crosses
the anterior surface of the anterior scalene as it reaches its connection
with the internal jugular vein. The transverse cervical artery is a branch
of the thyrocervical trunk which crosses the anterior scalene. Finally, the
cervical part of the thoracic duct dumps into the brachiocephalic vein on
the left side of the neck. So, on the left side of the neck, the thoracic duct
lies on the anterior part of the anterior scalene.


12. The correct answer is: Inferior thyroid artery
The inferior thyroid artery branches from the thyrocervical trunk to
provide blood to the lower poles of the thyroid gland. This artery
approaches the posterior side of the thyroid gland, crossing the recurrent
laryngeal nerve and coming near the middle cervical sympathetic
ganglion. This artery also supplies blood to the parathyroid glands,
which are on the posterior surface of the thyroid. The inferior thyroid
veins are associated with the lower parts of the gland--however, these
veins are on the anterior side of the thyroid and are not as closely
associated with these structures found deep to the gland. The superior
thyroid artery and vein are associated with the superior pole of the
thyroid. Remember--the important relationship here is that the superior
thyroid artery travels with the external branch of the superior laryngeal
nerve.

13. The correct answer is: Cervical sympathetic trunk
The cervical sympathetic trunk lies in front of the prevertebral muscles in
the prevertebral fascia. It is not part of the carotid sheath. All of the other
structures listed are in the carotid sheath. The carotid sheath contains 3
vessels: internal carotid, common carotid, and internal jugular vein. It
also contains 2 nerves: vagus and the superior ramus of ansa cervicalis.

14. The correct answer is: greater occipital
The greater occipital nerve is a branch of the dorsal primary ramus of
spinal nerve C2--it provides cutaneous innervation to the posterior scalp.
None of the other listed nerves are dorsal primary rami. The great
auricular nerve comes from the C2 and C3 branches in the cervical
plexus; it provides sensory innervation to the ear and the skin below the
ear. The lesser occipital nerve also comes from C2 in the cervical
plexus--it innervates the skin behind the ear. The phrenic nerve is
comprised of contributions from the ventral primary rami of C3, C4, and

C5--it innervates the diaphragm. The supraclavicular nerves come from
C3 and C4 in the cervical plexus. These cutaneous nerves provide
sensory innervation to the skin of the root of the neck, upper chest, and
upper shoulder.

15. The correct answer is: omohyoid
The omohyoid muscle is an important landmark in both the anterior and
posterior triangles of the neck. In the anterior triangle, the superior belly
of the omohyoid muscle serves as the superolateral border of the
muscular triangle and the anterior border of the carotid triangle. In the
posterior triangle, the inferior belly of the omohyoid muscle divides the
omoclavicular triangle from the occipital triangle. So, in both the anterior
and posterior triangles, the omohyoid is an important muscle that
subdivides the triangles.
All of the other listed muscles are associated with the anterior triangle
only. Geniohyoid runs from the hyoid bone to the genu of the mandible--
it is a deep muscle on the floor of the mouth. It is found deep to the
submental triangle. Mylohyoid is another muscle associated with the
floor of the mouth--it is in the submandibular triangle and the submental
triangle. Sternohyoid is a strap muscle -- it is in the muscular triangle.
Finally, stylohyoid is a small muscle innervated by the facial nerve which
retracts and elevates the hyoid. It is found in the submandibular triangle.