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The inferior thyroid • The costocervical trunk: a small artery that passes backwards to veins pass downwards in front of the trachea to open into the left bra- supply muscles of the back order advair diskus 500 mcg with amex. The facial vein communicates around the orbit with tributaries of the • The thyrocervical trunk: gives off the superficial cervical and ophthalmic veins so that infections of the face may spread to the cav- suprascapular arteries and then passes medially as the inferior thyroid ernous sinus if not properly treated cheap 100mcg advair diskus visa. It has a variable relation to the recurrent laryngeal of the retromandibular vein with other small veins cheap advair diskus 250 mcg overnight delivery. It passes obliquely nerve buy 100 mcg advair diskus amex, lying in front or behind them buy cheap advair diskus 500mcg line, but may branch early with the across sternomastoid to open into the subclavian vein. It descends along the medial border of the scapula but may • The anterior jugular vein: begins below the chin and runs down the arise in common with the superficial cervical artery. The veins • The subclavian vein: lies in a groove on the 1st rib but is separated The veins of the brain drain into dural venous sinuses (Fig. It receives the most important of these are: external jugular vein, veins corresponding to the branches of the sub- • The superior sagittal sinus: passes backwards in the midline in the clavian artery and, at its junction with the internal jugular vein, the thor- attached border of the falx cerebri from just above the cribriform plate acic duct on the left and the right lymph duct on the right. It then transversarium from the vertebral plexus of veins that accompany the winds down on the back of the petrous temporal as the sigmoid sinus vertebral artery. Trachea The arrows indicate the posterior triangle Pretracheal fascia Sternomastoid External jugular Thyroid Carotid sheath Vagus Thoracic duct Sympathetic trunk Longus colli Scalenus anterior Spinal nerve Long thoracic nerve Plane of accessory nerve Prevertebral Scalenus medius fascia Levator scapulae Splenius Trapezius Semispinalis Vertebral artery Fig. There are still some structures omitted from the diagram for the sake of simplicity, for example the strap muscles Greater auricular Anterior belly of digastric Lesser occipital Parotid Digastric triangle Semispinalis Posterior belly of digastric External jugular Splenius capitis vein Trapezius Transverse Levator scapulae cutaneous Accessory nerve Supraclavicular nerves Scalenus medius Hyoid bone Anterior jugular Submental Brachial plexus vein triangle Carotid (upper trunk) Omohyoid Omohyoid triangle Scalenus anterior Muscular triangle Fig. These are as follows: ous, without interruption, from one triangle to another so that it is more 1 The cervical vertebrae surrounded by a number of muscles and convenient to describe them individually in other chapters. Below the level of C6 these give way to the oesophagus The posterior triangle is bounded by: and trachea. Stretching between the two muscles is the investing layer of deep 5 An outer enclosing sheath consisting of the sternomastoid and fascia which splits to enclose them and continues to the anterior tri- trapezius and the investing layer of deep fascia of the neck. Embedded in the deep fascia is the spinal part of the accessory nerve which leaves the sternomastoid about halfway down its posterior The anterior triangle border and passes into trapezius two fingerbreadths above the clavicle. Four cutaneous nerves (transverse cervical, • The lower border of the mandible and its backward continuation. The external jugular vein begins near the upper end of The anterior triangle is subdivided into: sternomastoid and runs down obliquely across this muscle to enter the (a) The digastric triangle, bounded by: subclavian vein. Anterior and posterior triangles 137 62 The pharynx and larynx Superior constrictor Nerves Vocal process Buccinator Glossopharyngeal Epiglottis Pterygomandibular ligament Thyroid Stylopharyngeus cartilage Stylohyoid ligament Arytenoid Vocal Superior laryngeal Muscular ligament Internal laryngeal process Cricovocal Attachment of External laryngeal Crico- membrane thyrohyoid arytenoid joint Cricoid Attachment of sternohyoid Facet for First ring Inferior constrictor inferior horn of trachea Cricothyroid of thyroid Cricoid cartilage Recurrent laryngeal Fig. It is important be- nasal cavity, the mouth and the larynx, thus being made up of the cause a carcinoma in this region can remain ‘silent’ until it has spread nasopharynx, the oropharynx and the laryngopharynx. The space between the vocal and vestibular folds is the • The inferior constrictor: arises from the thyroid and cricoid sinus of the larynx. The larynx • Nerve supply: Palpable components • Motorarecurrent laryngeal nerve, except for the cricothyroid • Hyoid bone, level of C3. Below the vocal cords, the recurrent laryngeal nerve (which is therefore a Other components mixed nerve) which enters the larynx just behind the cricothyroid • Arytenoid cartilages: attached to upper border of the cricoid by syn- joint. If one of the recurrent laryngeal upper border of the cricoid and passes inside the thyroid to be attached nerves is divided, the cord lies in a position midway between adduction to the back of the thyroid and to the vocal processes of the arytenoids and abduction but this does not produce very severe voice changes (Fig. The upper border is thickened to form the vocal ligament because the uninjured cord can cross the midline to reach the para- which, with the mucous membrane that covers it, forms the vocal lysed cord. If both nerves are damaged but not • Cricothyroid joint: a small synovial joint between the inferior horn completely divided the cords are adducted since the abductors are of the thyroid cartilage and the cricoid, permitting a hinge-like move- more affected than the adductors (Semon’s law). The pharynx and larynx 139 63 The root of the neck Middle cervical ganglion Scalenus medius Vertebral artery Scalenus anterior Sympathetic trunk Phrenic nerve Inferior thyroid artery Upper trunk of brachial plexus Superficial cervical artery Vagus Suprascapular artery, nerve Subclavian artery Dorsal scapular artery Subclavian vein Carotid sheath Internal thoracic artery Inferior cervical ganglion Thoracic duct Fig. The curved arrow on the right side of the diagram indicates the course of the thoracic duct Scalenus posterior Sympathetic trunk Superior intercostal artery Attachment of scalenus medius 1st thoracic nerve Serratus anterior 8th cervical nerve (first digitation) Lower trunk of brachial plexus Scalene tubercle, Subclavian artery for attachment of Subclavian vein scalenus anterior Subclavius Costoclavicular ligament Fig. The subclavian artery and the Through this relatively confined space pass the trachea and oesopha- trunks of the brachial plexus are between the two muscles and the sub- gus, the carotid and subclavian arteries and the corresponding large clavian vein is in front of scalenus anterior. At the outer border of the 1st rib it becomes the axillary scalenus anterior before crossing the subclavian artery and entering the artery. The The veins middle cervical ganglion is close to the entry of the artery into the fora- • The subclavian vein: begins at the outer border of the 1st rib and lies men transversarium of C6 and the inferior cervical ganglion is near the in a shallow groove on the upper surface of the rib in front of scalenus neck of the 1st rib behind the origin of the vertebral artery. At the medial border of this muscle it is joined by the internal fused with the 1st thoracic ganglion to form the stellate ganglion. The internal jugular vein is enclosed in the carotid sheath, along with the common carotid artery The thoracic duct (Fig. The duct ascends out of the thorax between the ies but the inferior thyroid veins are solitary and run down from the trachea and oesophagus and arches laterally between the carotid sheath lower border of the thyroid gland, in front of the trachea, to reach the in front and the vertebral artery behind. The nerves • The upper, middle and lower trunks of the brachial plexus: emerge from between the scalenus anterior and medius and pass down The root of the neck 141 64 The oesophagus and trachea and the thyroid gland Thyrohyoid Superior thyroid artery Sternothyroid Cricothyroid Common carotid artery Inferior thyroid artery Inferior thyroid artery Right recurrent laryngeal nerve Inferior thyroid veins Left brachiocephalic vein Fig.

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During pregnancy buy advair diskus 500mcg cheap, the mother must supply all the food and oxygen for the developing baby and eliminate its waste materials buy advair diskus 250mcg lowest price. In particular proven advair diskus 500 mcg, the heart has to pump harder advair diskus 100 mcg free shipping, and the lungs have more work to do supplying the needs of the enlarged uterus and the placenta order 100mcg advair diskus overnight delivery. A balanced and varied diet containing plenty of fresh fruit and vegetables, as well as dairy products (calcium is required for the bones of both mother and baby), meat and cereals, is appropriate. Women are taught exercises to strengthen the back and abdominal muscles, breathing exercises to help with the various stages of labour, and strategies to cope with them. Aches and pains will develop in unusual areas as muscles that are not normally used are called into play to support the extra weight, normally between 7 and 12 kg (baby + fluid + placenta + enlarged uterus + enlarged breasts), that the mother is carrying around. Visiting the hospital or birthing centre that you have booked into for the confinement can be helpful, so that the facilities and the labour ward will not appear cold and impersonal when they are used. After the baby is born, visits to a physiotherapist to get the tone back into your abdominal muscles and to strengthen the stretched muscles around the uterus and pelvis will help the woman regain her former figure. The pregnancy may continue for many weeks but in due course the placenta is unable to supply the growing foetus with adequate nutrition as it is not implanted into the normal site in the uterus but attaches to whatever structures and organs it comes into contact with in the abdomen. The woman may be aware that she is pregnant, and her belly swells in a similar way to pregnancy, but the swelling is higher and more irregular than the smooth feeling of a pregnancy in the uterus. When the placenta starts to fail, usually at about 20 weeks of pregnancy, it separates from the structures in the abdomen to which it has been attached, bleeding into the abdomen occurs, and the woman experiences severe pain. At this stage the diagnosis is usually made, and as a result it is very rare for a foetus to survive an abdominal pregnancy. An operation is necessary to remove the usually dead foetus from the mother’s belly, but a lot of the placenta is often left behind to shrink naturally as attempts to remove it from the structures in which it is embedded can cause serious bleeding. The normal values are: - Weeks of pregnancy Lower limit Upper limit 14 14 55 15 15 61 16 17 69 17 20 81 18 23 94 19 26 106 20 30 122 21 36 143 Term >50 A slow decrease in values indicates a normal pregnancy. On the other hand, a steady rise indicates foetal distress, defect of spinal development (neural tube defect), kidney disease (eg. Alpha-fetoprotein levels can also be measured in blood for the same reasons as above, plus assessment of liver diseases and cancer of the ovary and testes. Very high blood levels may indicate Down syndrome (trisomy 21) or a neural tube (spinal cord) defect in the foetus. A high level can occur with liver cancer (hepatic carcinoma), bowel cancer (colon carcinoma), stomach cancer, hepatitis, liver cirrhosis, other liver diseases, ovary cancer (teratoma) or testicular cancer. A steady rise occurs throughout a normal pregnancy, but a drop in levels late pregnancy indicates foetal distress. A sample may be obtained in a process called amniocentesis by putting a needle through the skin of the lower abdomen and into the uterus and drawing off a small amount of amniotic fluid. The amniotic fluid is created by the urine and faeces of the foetus, and by secretions from the placenta. The foetus is constantly swallowing and processing the fluid from about 15 weeks onwards, and it aids the growth and nutrition of the foetus. The dark colouration may only be noticed at the beginning of labour when the waters break with the rupture of the amniotic sac in which the fluid and foetus are contained. The volume of amniotic fluid steadily increases throughout pregnancy until about 36 weeks, after which it slowly decreases. Hormones and waste produced by the foetus are also present as these are excreted in the urine of the foetus. It is attached to the edges of the placenta and otherwise is pushed against, but not attached to, the inside of the uterus. The procedure is usually performed through the vagina and cervix with a pair of toothed forceps that are used to grasp and tear the membrane. Antenatal care involves regular visits to a doctor or nurse from the third month of pregnancy onwards. During these visits appropriate blood and ultrasound tests will be ordered when necessary, and the mother’s urine will be tested. Other checks on the mother and baby’s health will also be performed depending on the stage of pregnancy, and may include weight, blood pressure, checking for swollen ankles and feet, checking the size of the uterus, listening for the baby’s heart beat, checking the baby’s position and feeling the baby’s movements. The score is derived by giving a value of 0, 1 or 2 to each of five variables - heart rate, breathing, muscle tone, reflexes and colour.

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Below the level of the zygomatic arch and deep to the vertical portion of the mandible is another space called the infratemporal fossa order advair diskus 250mcg without prescription. Both the temporal fossa and infratemporal fossa contain muscles that act on the mandible during chewing discount 100 mcg advair diskus mastercard. The zygomatic arch is formed jointly by the zygomatic process of the temporal bone and the temporal process of the zygomatic bone cheap advair diskus 500mcg line. The space inferior to the zygomatic arch and deep to the posterior mandible is the infratemporal fossa order advair diskus 100mcg fast delivery. This cavity is bounded superiorly by the rounded top of the skull buy advair diskus 500 mcg, which is called the calvaria (skullcap), and the lateral and posterior sides of the skull. The bones that form the top and sides of the brain case are usually referred to as the “flat” bones of the skull. This is a complex area that varies in depth and has numerous This OpenStax book is available for free at http://cnx. Inside the skull, the base is subdivided into three large spaces, called the anterior cranial fossa, middle cranial fossa, and posterior cranial fossa (fossa = “trench or ditch”) (Figure 7. The shape and depth of each fossa corresponds to the shape and size of the brain region that each houses. The boundaries and openings of the cranial fossae (singular = fossa) will be described in a later section. The base of the brain case, which forms the floor of cranial cavity, is subdivided into the shallow anterior cranial fossa, the middle cranial fossa, and the deep posterior cranial fossa. These include the paired parietal and temporal bones, plus the unpaired frontal, occipital, sphenoid, and ethmoid bones. These are paired bones, with the right and left parietal bones joining together at the top of the skull. Each parietal bone is also bounded anteriorly by the frontal bone, inferiorly by the temporal bone, and posteriorly by the occipital bone. Common wisdom has it that the temporal bone (temporal = “time”) is so named because this area of the head (the temple) is where hair typically first turns gray, indicating the passage of time. Below this area and projecting anteriorly is the zygomatic process of the temporal bone, which forms the posterior portion of the zygomatic arch. Projecting inferiorly from this region is a large prominence, the mastoid process, which serves as a muscle attachment site. On the interior of the skull, the petrous portion of each temporal bone forms the prominent, diagonally oriented petrous ridge in the floor of the cranial cavity. Located inside each 262 Chapter 7 | Axial Skeleton petrous ridge are small cavities that house the structures of the middle and inner ears. The mandible (lower jaw) joins with the skull at this site as part of the temporomandibular joint, which allows for movements of the mandible during opening and closing of the mouth. Both the articular tubercle and mandibular fossa contribute to the temporomandibular joint, the joint that provides for movements between the temporal bone of the skull and the mandible. This structure serves as an attachment site for several small muscles and for a ligament that supports the hyoid bone of the neck. The canal then runs anteromedially within the bony base of the skull, and then turns upward to its exit in the floor of the middle cranial cavity, above the foramen lacerum. The petrous ridge (petrous portion of temporal bone) separates the middle and posterior cranial fossae. At its anterior midline, between the eyebrows, there is a slight 264 Chapter 7 | Axial Skeleton depression called the glabella (see Figure 7. Near the middle of this margin, is the supraorbital foramen, the opening that provides passage for a sensory nerve to the forehead. These are located just behind your eyebrows and vary in size among individuals, although they are generally larger in males. This flattened region forms both the roof of the orbit below and the floor of the anterior cranial cavity above (see Figure 7. Occipital Bone The occipital bone is the single bone that forms the posterior skull and posterior base of the cranial cavity (Figure 7. On its outside surface, at the posterior midline, is a small protrusion called the external occipital protuberance, which serves as an attachment site for a ligament of the posterior neck. The nuchal lines represent the most superior point at which muscles of the neck attach to the skull, with only the scalp covering the skull above these lines. On the base of the skull, the occipital bone contains the large opening of the foramen magnum, which allows for passage of the spinal cord as it exits the skull. These condyles form joints with the first cervical vertebra and thus support the skull on top of the vertebral column.

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Positive nitrogen balance occurs in growing children who are increasing their body weight and incorporating more amino acids in to protein than they breakdown generic 250 mcg advair diskus visa. Cysteine and Arginine are 144 not essential in adults but essential in children because they are synthesized from Methionine and ornithine purchase advair diskus 250 mcg visa. Negative Nitrogen balance occurs in injury when there is net destruction of tissue and in major trauma or illness cheap advair diskus 100 mcg free shipping. Nitrogen Excretion and the Urea Cycle: Excess amino Nitrogen from amino acids is removed as ammonia generic 250 mcg advair diskus overnight delivery, which is toxic to the human body 100 mcg advair diskus for sale. Some ammonia is excreted in urine, but nearly 90% of it is utilized by the liver to form urea, which is highly soluble and is passed in to circulation for being excreted by the kidneys. The urea-cycle starts in the mitochondrial matrix of hepatocytes and few of the steps occur in the cytosol: the cycle spans two cellular compartments. Some ammonia also arrives at the liver via the portal vein from the intestine, when it is produced by bacterial oxidation of amino acids. Carbamoyl phosphate reacts with ornithine transferring the carbamoyl moiety to produce citrulline: by the enzyme i. Ornithine is thus re-generated and can be transported in to the mitochondrion to initiate another round of the urea - cycle. Energetics of the urea cycle If the urea cycle is considered in isolation, the synthesis of one molecule of urea require four high energy phosphate groups 1. All the five enzymes are synthesized at higher rates in starving animals and in animals on a very high protein diet than well fed animals eating primarily carbohydrates and fats. Ammonia intoxication can be caused by inherited or acquired defects in ammonia trapping or in urea cycle most of the inhabited defects occur at a rate of 1 in every 30,000 births all. Ammonia intoxication caused by inherited defects in the urea cycle enzyme after arginosuccenate synthase can be treated by a diet low in protein and amino acid and supplemented by Arginine and citrulline. Treatment with sodium benzoate can produce additional disposal of non-urea nitrogen by combining with glycine the product hippuric acid, is excreted in the urine. Sodium phenyl lactate is even more effective, since it condenses with glutamine, the major carrier of excess Nitrogen. Acquired defects in urea–cycle Any disease or condition that adversely affects liver mitochondria can also produce an increased level of ammonia in the blood such condition include liver cirrhosis, alcoholism, hepatitis, and Reye’s syndromes. The Glucose-Alanine Cycle Alanine also serves to transport ammonia to the liver via the Glucose-Alanine Cycle: In a reversal of Alanine aminotrasferase, Alanine transfers its amino group to α-Ketoglutarate, forming Glutamate in the cytosol of hepatocytes. Some of the glutamate is transported in to the mitochondria and acted by glutamate dehydrogenase, releasing ammonia. The use of Alanine to transport Ammonia from a hard working skeletal muscles to the liver is an example of the intrinsic economy of living organisms, mainly because vigorously contracting skeletal muscle operate anaerobically producing not only Ammonia but also large amounts of pyruvate from Glycolysis. In the initial reaction, phenylalanine is hydroxylated by phenylalanine hydroxylase, a monooxygenase that utilizes oxygen and tetrahydrobiopterin a pteridine co-factor. When untreated, this metabolic defect leads to excessive urinary excretion of phenyl pyruvate and phenyl lactate, followed by severe mental retardation, seizure, psychosis and eczema. Alkaptonuria (Black urine disease) A second inherited defect in the phenyl a larine – tyrosine pathway involves a deficiency in the enzyme that catalyses the oxidation of homogentisic acid (an intermediate in the metabolic breakdown of tyrosine and phenyalanin). This condition occurs 1 in 1,000,000 live birth homogentisic acid accumulates and gets excreted in urine where the urine turns black on standing. There is a form of arthritis in late cases and generalized pigmentation of connective tissues; this is believed to be due to the oxidation of homogentisic acid by polyphenol oxidase forming benzoquinone acetate that polymerises and binds to connects tissues molecules. High doses of ascorbic acid have been used in some patients, to help reduces the deposition of pigment on collagen, but progress of the disease has not been significantly affected by this strategy. When untreated this condition may lead to both physical and metal retardation of the newborn and a distinct maple syrup odor of the urine. Creatine and creatine phosphate: Synthesis of creatine and creatine phosphate creatine is produced by the liver, kidney and pancreas and is transported to its site of usage principally muscle and brain. Creatine is derived from glycine and Arginine by the enzyme Amidinotransferase where ornithine and Guandioacetate are generated. Further Guanidoacetate gets transmethylated by S- adenosine Methionine removing Adenosine and generating Homocystine and creatine. It plays multiple roles in the nervous system, including neurotransmission and a precursor of melatonin, which is involved in regulation of sleepiness and wakefulness, vegetative behaviors like feeding, mood, sexual arousal etc. Tyrosine gives rise to a family of catecholamines that include Dopamine, Norepinephrine and epinephrine. Dopamine The importance of Dopamine in neural transmission is emphasized by the number of major neurological disease that is associated with improper Dopamine regulation. It is a progressive disease caused by the death of dopamine-producing cells in the substantia nigra and locus ceruleus.

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