POSTERIOR NECK 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 exercise. The artery involved is the A. B. C. D. E. axillary brachial brachiocephalic subclavian suprascapular

2. In repairing a defective right subclavian artery, the surgeon notices and protects a large nerve passing around to the posterior surface of the artery. This nerve, which would not be expected on the left side, is the: A. B. C. D. E. Phrenic Vagus Recurrent laryngeal Sympathetic trunk Ansa cervicalis

3. A stab wound just above the left clavicle, lateral to the sternocleidomastoid muscle, may be lifethreatening because of the possibility of injury to the: A. B. C. D. E. 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 vascular 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? A. B. C. D. E. Inferior (lower) 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

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his subclavian artery branches from the brachiocephalic trunk. The cerebral insufficiency is the result of blood being stolen from which artery? A. External carotid B. Internal carotid C. Middle cerebral D. Thyrocervical trunk E. Vertebral 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? A. External branch of the superior laryngeal nerve B. Phrenic nerve C. Recurrent laryngeal nerve D. Sympathetic trunk E. Vagus nerve Which statement is true of the internal jugular vein? A. It drains all of the thyroid gland on that side of the body B. It drains into the external jugular vein C. It is accompanied by the deep cervical chain of lymph nodes D. It lies deep to the prevertebral fascia E. It passes superficial to the sternocleidomastoid muscle Which structure lies immediately anterior to the right anterior scalene muscle at its costal attachment? A. Subclavian artery B. Subclavian vein C. Thoracic duct D. Thyrocervical trunk E. Vagus nerve 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? A. postganglionic parasympathetic B. postganglionic sympathetic C. preganglionic parasympathetic D. the carotid nerve E. the cervical sympathetic trunk

ANTERIOR NECK 10. A person receives a shallow knife wound just behind the sternocleidomastoid muscle and about 1 1/2 inches above the clavicle. There is an immediate numbness of the skin below the wound and over the acromion and clavicle. The nerve most likely severed was the: A. great auricular B. lesser occipital C. supraclavicular D. suprascapular E. transverse cervical 11. Which muscle is innervated by a branch of the ansa cervicalis? A. Sternocleidomastoid 2

B. Platysma C. Sternohyoid D. Trapezius 12. The layer of encircling cervical fascia that splits to enclose sternocleidomastoid and trapezius muscles is the: A. Superficial fascia B. Investing layer of deep cervical fascia C. Infrahyoid fascia D. Prevertebral fascia E. Visceral fascia 13. Which of the following is a dorsal ramus of a spinal nerve? A. Supraclavicular n. B. Transverse cervical n. C. Great auricular n. D. Greater occipital n. E. Lesser occipital n. 14. 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? A. Accessory (XI: Spinal portion) B. Ansa cervicalis C. Facial (VII) D. Hypoglossal (XII) E. Suprascapular 15. A 20 year old man was brought into the emergency room with a stab wound in the upper part of the neck. Although there was no major damage done, he lost sensation from the skin over the angle of the jaw. Which nerve has been cut? A. Supraclavicular n. B. Transverse cervical n. C. Great auricular n. D. Greater occipital n. E. Lesser occipital n. 16. The triangle in which the superior branch of the ansa cervicalis separates from the hypoglossal nerve is the: A. Carotid B. Muscular C. Subclavian D. Submental E. Occipital 17. A surgeon doing a deep cervical lymph node dissection may encounter these structures upon the anterior surface of the anterior scalene muscle EXCEPT: A. Phrenic nerve B. Subclavian vein C. Middle trunk of the brachial plexus D. Transverse cervical artery E. Cervical part of the thoracic duct 18. A 35 year old woman was diagnosed with an adenoma of the thyroid gland. This required excision of the lower pole (left lobe) of the gland and ligation of the artery supplying that region. Which of the following nerves accompanying the artery is most likely to be damaged if the surgeon is not careful? 3

A. External branch of the superior laryngeal B. Internal branch of the superior laryngeal C. Recurrent laryngeal D. Vagus E. Sympathetic trunk 19. One of the motor components of the cervical plexus, the ansa cervicalis, innervates all of the following muscles except the: A. Omohyoid B. Sternohyoid C. Sternothyroid D. Stylohyoid E. Thyrohyoid 20. A man has metastatic carcinoma and enlarged deep cervical lymph nodes. One of his symptoms is a hoarse voice, barely heard above a whisper. Subsequently he succumbs to the disease and at autopsy it is found that one of the enlarged nodes has put pressure on a nerve in the tracheoesophageal groove. Presumably this was the reason for the hoarse voice. What nerve was involved? A. External branch of the superior laryngeal nerve B. Internal branch of the superior laryngeal nerve C. Nerve to the cricothyroid muscle D. Pharyngeal branch of the glossopharyngeal nerve E. Recurrent laryngeal branch of vagus 21. You are called on to do a venous catheterization to measure central venous pressure in the heart. Which muscle of the neck would provide the best area of approach to the internal jugular vein? A. Anterior scalene B. Digastric C. Omohyoid D. Sternocleidomastoid E. Sternohyoid 22. A patient is brought into the Emergency Room in respiratory distress. It is quickly decided to create an emergency airway to restore respiration. At what level could you rapidly create an airway below the vocal cords with a minimum danger of hemorrhage? A. Just above the jugular notch B. Just above the thyroid cartilage C. Just below the cricoid cartilage D. Just below the thyroid cartilage E. Through the 3rd tracheal ring 23. A 47-year-old woman is diagnosed as having a thyroid tumor. Surgery to remove the cancerous growth is undertaken. In which triangle of the neck will the surgeon make an incision to gain access to the gland? A. Carotid B. Muscular C. Subclavian D. Submandibular E. Submental 24. A 50-year-old woman is brought to the operating room for a biopsy of a suspicious looking nevus (mole) which is found along the anterior border of her sternocleidomastoid muscle at about its midlength. What nerve must be locally anesthetized for the operation to proceed without pain? A. Ansa cervicalis B. External branch of the superior laryngeal C. Great auricular 4

D. Suprascapular E. Transverse cervical 25. Following surgery on the upper pole of the right lobe of the thyroid gland, a patient complains of hoarseness and weakness of voice. What nerve may have been injured? A. Ansa cervicalis B. External branch of the superior laryngeal C. Inferior laryngeal D. Internal branch of the superior laryngeal E. Recurrent laryngeal 26. These structures are all located in the superficial fascia of the neck EXCEPT: A. External jugular vein B. Platysma muscle C. Cervical branch of the facial nerve D. Omohyoid muscle E. Transverse cervical nerve 27. The superior belly of the omohyoid forms the anterior border of which cervical triangle? A. Carotid B. Muscula C. Omoclavicular D. Posterior E. Submandibular 28. The cervical plexus innervates all of the structures EXCEPT: A. Diaphragm B. Omohyoid muscle C. Platysma D. Skin over thyroid cartilage E. Skin over clavicle 29. An emergency room patient presented with considerable bleeding from a shallow stab wound in the omoclavicular triangle. Which vessel was most likely cut? A. Axillary vein B. Common carotid artery C. External jugular vein D. Inferior thyroid vein E. Superior thyroid artery 30. Which structure or area receives NO nerve fibers from the cervical plexus? A. Diaphragm B. Skin over the angle of the mandible C. Skin over the external occipital protuberance D. Thyrohyoid muscle 31. The middle cervical sympathetic ganglion, recurrent laryngeal nerve, and parathyroid glands are all closely related with which blood vessel? \ A. Inferior thyroid artery B. Inferior thyroid vein C. Superior thyroid artery D. Superior thyroid vein 32. Any irritation of the diaphragm (e.g. infection, tumor) may create referred pain that seems (to the patient) to originate in the area atop the shoulder. This is due to the fact that the phrenic nerve shares spinal segments with what cutaneous nerve in the shoulder region? A. Dorsal scapular B. Lesser occipital nerve 5

C. Long thoracic nerve D. Supraclavicular nerve E. Suprascapular nerve 33. Which of the following statements about the cervical plexus is true? A. It comprises spinal segments C1-C3 B. It consists solely of cutaneous nerves C. It consists solely of ventral rami of spinal nerves D. It supplies motor innervation to platysma 34. Which of the following is true of the inferior thyroid arteries? A. They arise from the external carotid arteries B. They cross over the superior cervical sympathetic ganglion C. They supply most of the anterior surface of the thyroid gland D. They often supply all four parathyroid glands 35. Exploration of the tracheoesophageal groove at the level of the thyroid gland would reveal what important structure bilaterally? A. Cervical sympathetic trunk B. Phrenic nerve C. Pyramidal lobe D. Recurrent laryngeal nerve E. Superior thyroid artery 36. A six-year-old child, whose medical history includes a rather difficult birth, has a permanently tilted head posture, with the right ear near the right shoulder and the face turned upward and to the left. Which of the following muscles was very likely damaged during birth? A. Anterior scalene B. Omohyoid C. Sternocleidomastoid D. Trapezius E. Platysma 37. 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 exercise. The artery involved is the: A. axillary B. brachial C. brachiocephalic D. subclavian E. suprascapular SCALP 38. During an intramural baseball game a player is hit in the side of the head, between the eye and the ear. He immediately loses consciousness, wakes up momentarily and then becomes comatose. He is rushed to the ER and is immediately given a CT scan. The scan shows a skull fracture and an accumulation of blood between the dura and the cranial bone on the side of his head, compressing his cerebrum. He is rushed to surgery where a hole is bored into his skull to relieve the pressure. After a few tense hours, he regains consciousness and has an uneventful recovery. The hemorrhage from the fracture would be described as: A. Epidural B. Intracerebral 6

C. Subaponeurotic D. Subarachnoid E. Subdural 39. An infant was diagnosed as having hydrocephalus. It was determined that there was a blockage in the ventricular system of the baby's brain between the third and fourth ventricles. The blockage therefore must have involved the: A. Central canal B. Cerebral aqueduct C. Foramen of Luschka (lateral foramen) D. Foramen of Magendie (medial foramen) E. Interventricular foramen 40. An 84-year old woman suffers a stroke, with paralysis on the right side of her body. Neurological tests show that the intracerebral hemorrhage has interrupted the blood supply to the posterior part of the frontal, the parietal and medial portions of the temporal lobes of the left cerebral hemisphere. Which vessel was involved? A. Anterior cerebral artery B. Great cerebral vein C. Middle cerebral artery D. Middle meningeal artery E. Posterior cerebral artery 41. A sixty-four-year old man was diagnosed with an acoustic neuroma (tumor of the VIIIth cranial nerve) where it entered the temporal bone. What other cranial nerve might also be affected since this nerve uses the same foramen as the VIIIth in its course? A. Abducens B. Facial C. Glossopharyngeal D. Trigeminal E. Vagus 42. Infections may spread from the nasal cavity to the meninges along the olfactory nerves, as its fibers pass from the mucosa of the nasal cavity to the olfactory bulb via the: A. Cribriform plate of the ethmoid B. Crista galli C. Foramen caecum D. Superior orbital fissure 43. The "danger zone" of the scalp is recognized as which of the following layers? A. Galea aponeurotica B. Loose connective tissue C. Pericranium D. Skin E. Subcutaneous connective tissue 44. The presence of blood in a spinal tap taken from an individual with a closed head injury signals arterial bleeding into the: A. Cavernous sinus B. Epidural space C. Subarachnoid space D. Subdural space 45. An infection in which scalp layer is likely to spread most readily? A. Skin B. Connective tissue layer C. Aponeurotic layer 7

D. Loose areolar tissue E. Pericranium 46. A patient who has sustained a fracture to the middle cranial fossa following a fall from a height, might have any of these nerves injured EXCEPT: A. Trigeminal B. Oculomotor C. Abducens D. Trochlear E. Hypoglossal 47. The most likely source of blood in a patient with an epidural hemorrhage is: A. Vertebral artery B. Middle meningeal artery C. Superior cerebral veins D. Anterior cerebral artery E. Circle of Willis 48. In a fall from a horse, a rider sustains a severe neck injury at the C6 level. In addition to crushing the spinal cord, the left transverse process of the C6 vertebra is fractured. What artery is endangered? A. Common carotid B. Costocervical C. Inferior thyroid D. Internal carotid E. Vertebral 49. A 35-year-old man was admitted to the hospital complaining of double vision (diplopia), inability to see close objects, and blurred vision in the right eye. A verterbrobasilar angiogram revealed an aneurysm of the superior cerebellar artery close to its origin on the right side. The doctor attributed the symptoms to the compression of an adjacent cranial nerve by the aneurysm. The compressed nerve is the: A. Abducens (CN VI) B. Oculomotor (CN III) C. Optic (CN II) D. Trigeminal (CN V) E. Trochlear (CN IV) 50. An elderly patient developed fever and worsening headache a few days after sustaining a scalp laceration and subsequent infection due to a car accident. At the hospital the case was diagnosed as meningitis and superior sagittal sinus thrombosis. The attending physician suggested that infection to the sinus initially spread through one of the scalp layers. The scalp layer involved is: A. Areolar tissue B. Connective tissue C. Epicranial aponeurosis D. Periosteum E. Skin 51. While riding her bicycle on campus without a helmet a student is hit by a car and falls, hitting her head on the pavement. She is brought to the Emergency Room in an unconscious state with signs of a closed head injury. Tests reveal blood in her cerebrospinal fluid taken from a spinal tap. Diagnosis is of torn cerebral veins as they pass from the brain to the superior sagittal sinus. From which of the following was the bloody fluid taken? A. Cavernous sinus B. Epidural space C. Subarachnoid space D. Subdural space 8

E. Verterbal venous plexus 52. You have been asked to assess the neurological deficit that might exist in a patient diagnosed with cavernous sinus thrombosis. You will focus your examination on cranial nerves related to the sinus that includes all the following EXCEPT : A. Abducens (CN VI) B. Facial (CN VII) C. Oculomotor (CN III) D. Ophthalmic division of the trigeminal nerve (CN V1) E. Trochlear (CN IV) 53. The glossopharyngeal nerve exits the skull via what opening? A. Foramen ovale B. Carotid canal C. Jugular foramen D. Hypoglossal canal E. Stylomastoid foramen 54. An infant was found to have hydrocephalus. Studies revealed that the hydrocephalus was caused because CSF could not get out of the third ventricle. The passage blocked was the: A. Central canal B. Cerebral aqueduct C. Interventricular foramen D. Lateral foramen (of Luschka) E. Medial foramen (of Magendie) 55. A person develops a cavernous sinus thrombosis. Because of its relationship to the sinus, which cranial nerve might be affected? A. Abducens B. Facial C. Mandibular V3 D. Olfactory E. Optic 56. Blockage of the flow of cerebrospinal fluid (CSF) within the cerebral aqueduct (of Sylvius) normally would result in the enlargement of all of the following ventricular spaces Except the: A. Fourth ventricle B. Interventricular foramen (of Monro) C. Lateral ventricle D. Third ventricle 57. All of the following nerves exit the cranial cavity by way of bony openings located in the middle cranial fossa EXCEPT : A. Abducens B. Facial C. Oculomotor D. Trigeminal E. Facial 58. During childbirth, an excessive anteroposterior compression of the head may tear the anterior attachment of the falx cerebri from the tentorium cerebelli. The bleeding that follows is likely to be from which of the following venous sinuses? A. Occipital sinus B. Sigmoid sinus C. Straight sinus D. Superior sagittal sinus E. Transverse sinus 9

59. The inferior sagittal sinus is found in the free edge of what structure? A. Diaphragma sellae B. Falx cerebelli C. Falx cerebri D. Filum terminale E. Tentorium cerebelli CAROTID SHEATH 60. Twenty-four hours following a partial thyroidectomy where the inferior thyroid artery was also ligated (tied off); the patient now spoke with a hoarse voice (whisper), and had difficulty in breathing. Which nerve was injured? A. Internal branch of superior laryngeal B. Ansa cervicalis C. Ansa subclavia D. Recurrent laryngeal E. External branch of superior laryngeal 61. Which of the following nerves is derived from the dorsal primary rami of spinal nerves? A. great auricular B. greater occipital C. lesser occipital D. phrenic E. supraclavicular 62. Which of the following hyoid muscles is an important landmark in both the anterior and posterior triangles of the neck? A. geniohyoid B. mylohyoid C. omohyoid D. sternohyoid E. stylohyoid 63. 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? A. common carotid artery B. cervical sympathetic trunk C. internal jugular vein D. internal carotid artery E. vagus nerve 64. In performing a thyroidectomy, caution should be exercised when ligating (tying) the inferior thyroid artery, as it lies in a very close relationship to which nerve? A. ansa cervicalis B. hypoglossal C. phrenic D. recurrent laryngeal E. vagus 65. A 60-year-old man has occasional blackouts and light-headedness. Studies reveal atherosclerotic plaques within the common carotid arteries and the bifurcation of the vessels. A carotid endartectomy is undertaken. Which nerve bundle running vertically within the carotid sheath must the surgeon be careful not to injure? A. Accessory (Spinal portion) 10

B. Cervical sympathetic trunk C. Glossopharyngeal D. Hypoglossal E. Vagus 66. A 55-year-old woman has difficulty swallowing and frequently aspirates fluids while drinking. She is diagnosed as having a skull base tumor occupying the space behind the jugular foramen. Involvement of which structure is responsible for the findings? A. Ansa cervicalis B. Cervical sympathetic trunk C. Accessory nerve (Spinal portion) D. Hypoglossal nerve E. Vagus 67. While doing a postoperative physical on a patient who has undergone carotid endarterectomy on the right side, it was noted that the tongue deviated toward the right when the patient was asked to point the tongue outward. What nerve crossing the carotid artery must have been injured? A. Glossopharyngeal B. Hypoglossal C. Inferior alveolar D. Lingual E. Vagus 68. Following thyroid surgery, it was noted that a patient frequently aspirated fluid into her lungs. Upon examination it was determined that the area of the piriform recess above the vocal fold of the larynx was numb. What nerve may have been injured? A. External branch of the superior pharyngeal B. Hypoglossal C. Internal branch of the superior laryngeal D. Lingual E. Recurrent laryngeal 69. The laryngeal muscle most responsible for stretching (elongating) the vocal ligament is the : A. Posterior cricoarytenoid B. Lateral cricoarytenoid C. Thyroarytenoid D. Arytenoid E. Cricothyroid 70. Any manipulation of the superior thyroid artery must be undertaken with care not to damage its small companion nerve, the: A. Cervical sympathetic trunk B. External branch of the superior laryngeal C. Inferior root of the ansa cervicalis D. Internal branch of the superior laryngeal E. Recurrent laryngeal 71. The muscle most responsible for the abduction of the vocal folds is the : A. Arytenoid B. Cricothyroid C. Lateral cricoarytenoid D. Posterior cricoarytenoid E. Thyroarytenoid 72. The major motor nerve to the entire larynx is the: A. Glossopharyngeal nerve, pharyngeal branch B. Recurrent laryngeal nerve 11

C. Superior laryngeal nerve, external branch D. Superior laryngeal nerve, internal branch E. Thyrohyoid nerve 73. The carotid body is innervated by a branch of the: A. Glossopharyngeal nerve B. Hypoglossal nerve C. Spinal portion of the Accessory nerve D. Sympathetic trunk E. Vagus nerve 74. The constrictor muscles of the pharynx receive their motor nerve supply from the: A. Glossopharyngeal nerve B. Hypoglossal nerve C. Cranial portion of the Accessory nerve D. Sympathetic trunk E. Facial nerve 75. The vocalis muscle is probably the one most responsible for the fine control of phonation because of its attachment into the: A. Arytenoid cartilage B. Cricoid cartilage C. Thyroid cartilage D. Vestibular ligament E. Vocal ligament FACE 76. Loss of sensation from the temporal region and loss of secretory function of the parotid gland would be caused by interruption of which nerve? A. Auriculotemporal B. Chorda tympani C. Deep temporal, posterior D. Facial E. Great auricular 77. An elderly man presented with severe pain beneath the left eye, radiating into the lower eyelid, lateral side of the nose and upper lip. What nerve was involved? A. Buccal B. Infraorbital C. Mental D. Supratrochlear E. Zygomatic 78. During a facelift operation on a 48-year-old woman, the plastic surgeon inadvertently cut the marginal mandibular branch of the facial nerve. Which of the following muscles would be paralyzed because of the injury? A. Buccinator B. Depressor anguli oris C. Levator anguli oris D. Levator labii superioris E. Stylohyoid 79. As a result of a face lift operation, a 46-year-old woman noticed an asymmetry of the inferior lip and could not fully depress the angle of her mouth on the right side. Which of the following nerves was most likely damaged during the surgery? 12

A. zygomatic (VII) B. buccal (VII) C. mental (V3) D. marginal mandibular (VII) E. infraorbital (V2) 80. An elderly woman complained of a severe pain, felt above the right eye radiating to the upper eyelid, side of the nose and forehead. Branches of which of the following nerves convey pain sensations from areas of the skin described? A. maxillary (V2) B. great auricular nerve C. ophthalmic (V1) D. mandibular (V3) E. facial (VII) 81. Due to multiple salivary calculi (stones) in the submandibular duct, the submandibular gland of a 45year-old individual was surgically removed. What major artery directly related to the gland was of special concern to the surgeon? A. lingual B. superior thyroid C. facial D. ascending pharyngeal E. maxillary 82. To study the compensatory response of selective suprahyoid muscles in elevating the hyoid bone, an experiment was designed in which the posterior belly of the digastric and stylohyoid muscles were paralyzed by drugs. The muscular branches of which of the following nerves must be chemically interrupted to produce paralysis in both muscles? A. inferior alveolar B. facial C. hypoglossal D. glossopharyngeal E. lingual 83. Which nerve provides motor innervation to the buccinator muscle? A. Auriculotemporal nerve B. Buccal branches of VII C. Buccal nerve D. Mandibular division of V E. Marginal mandibular nerve 84. Which nerve provides cutaneous innervation to the skin of the angle of the mandible? A. Auriculotemporal nerve B. Lesser petrosal nerve C. Buccal branches of VII D. Marginal mandibular nerve E. Great auricular nerve 85. Which nerve carries postganglionic parasympathetic fibers to the parotid gland? A. A. Auriculotemporal nerve B. Lesser petrosal nerve C. Glossopharyngeal nerve D. Great auricular nerve E. Marginal mandibular nerve 86. A patient is unable to wink; what muscle is affected? A. frontalis 13

B. levator palpebrae superioris C. orbicularis oculi D. superior tarsal E. zygomaticus major 87. Which nerve conveys postganglionic parasympathetic fibers to the parotid gland? A. Facial B. Glossopharyngeal C. Vagus D. Auriculotemporal E. Posterior auricular 88. A deep laceration of the face in the middle of the parotid gland could affect the: A. External jugular vein B. Facial nerve C. Glossopharyngeal nerve D. Hypoglossal nerve E. Lingual artery 89. Pain elicited from an infected facial wound is primarily conveyed by what nerve? A. Facial B. Great auricular C. Hypoglossal D. Transverse cervical E. Trigeminal 90. Inability to close the lips relates to the action of which muscle? A. Anterior belly of the digastric B. Mylohyoid C. Orbicularis oris D. Platysma E. Zygomaticus major 91. Which muscle will not be affected when the mandibular division of the trigeminal nerve (V3) is anesthetized? A. Anterior belly of digastric B. Buccinator C. Medial pterygoid D. Mylohyoid E. Temporalis 92. A 38-year-old female patient complained of parotid pain that increased while eating. Intraoral examination detected some pus oozing from the parotid duct opening. What was the most likely anatomical reference that the physician considered to locate the parotid duct opening? A. Mucosa of the sublingual caruncle behind the central incisor teeth B. Mucosa of the cheek across the 2nd upper (maxillary) molar tooth C. Mucosa of the floor of the mouth along the sublingual fold D. Mucosa of the cheek across the 2nd lower (mandibular) molar tooth 93. While recovering from a right facial paralysis, a 36-year-old female patient complained that food accumulated between the teeth and the cheek mucosa when chewing. The deficiency of which muscle was most likely the cause of the chewing problem? A. Zygomaticus major B. Orbicularis oris C. Buccinator D. Levator labii superioris 94. The parotid space contains all EXCEPT: 14

A. External carotid artery B. Facial nerve C. Parotid lymph nodes D. Medial pterygoid muscle E. Retromandibular vein 95. As a result of meningitis, a patient develops Bell's palsy. One of the symptoms was hyperacusis. What nerve was involved? A. Facial B. Glossopharyngeal C. Oculomotor D. Trigeminal E. Vagus 96. Frey Syndrome is marked by profuse sweating over one cheek, temple, and surrounding areas of the face, precipitated by eating. The condition may be idiopathic, but often follows parotid surgery. The condition is attributable to aberrant reinnervation, the redirection of autonomic fibers normally going to salivary glands being redirected to sweat glands. What is the source of the nerve fibers involved? A. Facial B. Glossopharyngeal C. Oculomotor D. Trigeminal E. Vagus 97. While recovering from multiple dental extractions, an elderly man experienced a radiating pain affecting the lower eyelid, lateral side of the nose, upper lip and over the zygomatic and temporal areas on the left side. Which nerve is involved in the patient's perception of pain? A. Facial B. Opthalmic division of trigeminal C. Glossopharyngeal D. Mandibular division of trigeminal E. Maxillary division of trigeminal 98. The facial muscle most responsible for moving the lips both upward and laterally to produce a smile is: A. Buccinator B. Levator anguli oris C. Levator labii superioris D. Platysma E. Zygomaticus major 99. What structure lies deepest in the parotid gland? A. External carotid artery B. External jugular vein C. Facial artery D. Facial nerve E. Retromandibular vein INFRATEMPORAL FOSSA 100. To drain an abscess (a closed collection of pus) affecting the cheek area, an emergency room physician used local anesthesia for the surgery. Which of the following nerves must be anesthetized because it carries pain sensation from the cheek area? A. buccal (V3) B. buccal (VII) 15

C. inferior alveolar D. lingual E. mental 101. A patient who experienced bilateral anterior dislocation of the jaw (temporomandibular joints) could not swallow or talk since the mouth was held open. What is the position of the condyles of the mandible as a result of the dislocation? A. against the external acoustic meatus B. against the anterior slope of the articular eminence C. against the posterior slope of the articular eminence D. in the mandibular fossa E. in the pterygoid fossa 102. In reducing an ankylosis of the TMJ, a surgeon provoked an intense hemorrhage by lacerating the artery coursing transversely just medial to the neck of the condyle. Which artery was involved in the accident? A. Buccal B. External carotid C. Maxillary D. Middle meningeal E. Superficial temporal 103. After an uneventful recovery from a face lift operation, a patient noticed that she could not draw the corner of the mouth up and back. The action of which muscle was most likely impaired as a result of the surgery? A. Levator labii superioris B. Platysma C. Orbicularis oris D. Zygomaticus major E. Buccinator 104. The predominant muscle most associated with retraction of the mandible is the: A. lateral pterygoid B. masseter C. medial pterygoid D. temporalis E. mylohyoid 105. At the temporomandibular joint (TMJ), hinge movements occur between the: A. condyle and articular eminence B. articular disk and articular eminence C. condyle and articular disk D. articular disk and articular cavity E. condyle and articular cavity 106. A 38-year-old patient complained of acute dental pain. The attending dentist found penetrating dental caries (dental decay) affecting one of the mandibular molar teeth. Which nerve would the dentist need to anesthetize to work on that tooth? A. Lingual B. Inferior alveolar C. Buccal D. Mental E. Mylohyoid 107. Incapacity to protrude the mandible indicates a dysfunction of which muscle? A. Anterior belly of digastric B. Buccinator 16

C. Lateral pterygoid D. Mylohyoid E. Temporalis 108. Damage to the facial nerve near the stylomastoid foramen would likely cause each of the following motor deficits EXCEPT: A. Paralysis of the buccinator muscle B. Inability to whistle C. Paralysis of the muscles that elevate the mandible D. Inability to close the lips 109. The lesser petrosal nerve carries preganglionic parasympathetic fibers to the: A. Geniculate ganglion B. Otic ganglion C. Submandibular ganglion D. Ciliary ganglion 110. What bony feature of the mandible can be used to find and palpate the facial artery? A. Oblique line B. Mental trigone C. Angle D. Premasseteric notch 111. Which of the following suprahyoid muscles would be paralyzed if the inferior alveolar nerve were severed at its origin? A. Geniohyoid m. B. Hyoglossus m. C. Mylohyoid m. D. Stylohyoid m. 112. Which nerve is endangered during surgical removal of an impacted third mandibular molar tooth? A. Hypoglossal n. B. Glossopharyngeal n. C. Inferior alveolar n. D. Lingual n. 113. After the mandibular condyle is moved forward onto the articular eminence (e.g., by opening the mouth widely), what muscle can then retract the mandible? A. Superficial head of masseter m. B. Deep head of masseter m. C. Posterior part of temporalis m. D. Anterior part of temporalis m. 114. Two nerves usually emerge from between the two heads of the lateral pterygoid muscle: the anterior deep temporal nerve and the: A. Masseteric n. B. Buccal n. C. Lingual n. D. Inferior alveolar n. 115. The chorda tympani enters the infratemporal fossa after it exits the: A. Stylomastoid foramen B. Foramen spinosum C. Foramen lacerum D. Petrotympanic fissure 116. Paralysis of which of the following muscles would impede retraction of the mandible? A. Buccinator 17

B. Lateral pterygoid, lower portion C. Lateral pterygoid, upper (sphenomeniscus) portion D. Medial pterygoid E. Temporalis 117. A cranial fracture through the foramen ovale that compresses the enclosed nerve, will have effect on all muscles EXCEPT : A. Tensor tympani B. Masseter C. Buccinator D. Mylohyoid E. Temporalis 118. Which muscle is also known as the sphenomeniscus? A. Inferior head of the lateral pterygoid B. Masseter C. Medial pterygoid D. Superior head of the lateral pterygoid E. Temporalis 119. Forward movement of the condyle of the mandible during wide opening of the jaws is accomplished mainly by the: A. anterior part of temporalis muscle B. lateral pterygoid muscle C. masseter muscle D. medial pterygoid muscle E. posterior part of the temporalis muscle 120. To drill a mandibular tooth without causing undo pain, a dentist has injected an anesthetic into the space located between the medial pterygoid muscle and the mandible near the lingula. Given the nerves passing through the immediate vicinity of the injection site, where would one expect anesthesia in addition to the mandibular teeth? A. back of tongue B. external ear C. maxillary incisor teeth D. skin of chin E. upper lip 121. The middle meningeal artery: A. enters the skull through the foramen ovale B. passes through a split in the trunk of the mandibular nerve (V3) C. is typically a branch of the second part of the maxillary artery D. supplies blood to the temporal lobe of the brain E. usually arises deep to the neck of the mandible 122. The surgical removal of a metastatic tumor in the infratemporal fossa caused an intense hemorrhage. The surgeon clamped the main source of arterial supply to the area, which is the: A. Internal carotid B. Lingual C. Maxillary D. Posterior auricular E. Superficial temporal 123. In acute inflammation (arthritis) of the TMJ, the muscle most likely to be affected by the inflammatory process is the: A. Temporal B. Medial pterygoid 18

C. Masseter D. Lateral pterygoid 124. In explaining the pain caused by the drilling of a mandibular molar tooth crown to a freshman medical student, a dentist identified the nerve conducting the pain sensations as the: A. Lingual B. Mylohyoid C. Inferior alveolar D. Buccal 125. The temporomandibular joint is characterized by all EXCEPT: A. capsule strengthened by ligaments on its lateral side only B. completely flat surface for its gliding action C. An articular disc D. Extracapsular ligaments E. Two joint cavities of different shapes 126. In dislocation of the jaw, displacement of the articular disk beyond the articular tubercle of the temporomandibular joint results from excessive contraction of which muscle? A. Buccinator B. Lateral pterygoid C. Medial pterygoid D. Masseter E. Temporalis SUBMANDIBULAR 127. Sympathetic fibers reach the tongue by way of the: A. lingual nerve B. maxillary artery. C. hypoglossal nerve D. lingual artery E. glossopharyngeal nerve 128. After a radiograph revealed a sialolith (stone) in a patient's right submandibular duct, the surgeon exposed the duct via an intraoral approach. In this approach, what tissues or structures must be cut through? A. Mucous membrane only B. Mucous membrane and genioglossus muscle C. Mucous membrane and mylohyoid muscle D. Mucous membrane and hyoglossus muscle 129. Damage of the lingual nerve before it is joined by the chorda tympani in the infratemporal fossa would cause loss of: A. general sensation to the anterior two thirds of the tongue B. general sensation to the posterior one third of the tongue C. secretion of the submandibular gland D. taste sensation from the anterior two thirds of the tongue E. taste sensation from the posterior one third of the tongue 130. The soft palate is active in all of the following Except: A. Breathing B. Chewing C. Coughing D. Swallowing E. Yawning 19

131.

132.

Most paranasal sinuses and/or air cells drain, directly or indirectly, into the: A. Inferior meatus B. Middle meatus C. Superior meatus D. Nasal vestibule E. Sphenoethmoidal recess The teeth and gums separate the oral cavity proper from the: A. Nasal cavity B. Oral vestibule C. Oropharynx D. Paralingual space E. Submandibular space Description for the following questions: Examination of a patient with an ulcerative carcinoma of the posterior third of the tongue revealed bleeding from the lesion and difficulty swallowing (dysphagia).

133.

134.

135. the:

The bleeding was seen to be arterial; which of the following arteries was involved? A. Deep lingual B. Dorsal lingual C. Facial D. Sublingual E. Tonsillar The difficulty in swallowing was due to involvement of which muscle that elevates the tongue? A. Genioglossus B. Hyoglossus C. Styloglossus D. Stylohyoid E. Stylopharyngeus Cutting of the hypoglossal nerve in the hypoglossal canal would not interrupt the nerve supply to

A. Hyoglossus muscle B. Genioglossus muscle C. Palatoglossus muscle D. Styloglossus muscle 136. The contents of the paralingual space do NOT include the: A. Hypoglossal nerve B. Lingual artery C. Lingual nerve D. Submandibular gland E. Sublingual gland 137. A patient is unable to taste a piece of sugar placed on the anterior part of the tongue. Which cranial nerve is most likely to have a lesion? A. Facial nerve B. Glossopharyngeal nerve C. Hypoglossal nerve D. Trigeminal nerve E. Vagus nerve 138. The chorda tympani contain which component before it joins the lingual nerve? A. Preganglionic sympathetics 20

B. Postganglionic sympathetics C. Preganglionic parasympathetics D. Postganglionic parasympathetics E. Taste fibers to the posterior third of the tongue 139. Irrigation of the maxillary sinus through its opening is a supportive measure to accelerate the resolution of a maxillary sinus infection. Which of the following nasal spaces is the most likely approach to the sinus opening? A. choana B. inferior meatus C. middle meatus D. sphenoethmoidal recess E. superior meatus 140. In assessing a deep laceration of the right side of the nose, the attending physician determines that the cartilage on the lateral side of the nostril has been cut. What cartilage was injured? A. Accessory B. Alar C. Lateral D. Septal E. None of the above 141. The nasolacrimal duct empties into which part of the nasal cavity? A. Hiatus semilunaris B. Inferior meatus C. Middle meatus D. Sphenoethmoidal recess E. Vestibule 142. The middle nasal concha is a part of which bone? A. Ethmoid B. Maxillary C. Palatine D. Sphenoid 143. The cell bodies of the taste fibers from the anterior two-thirds of the tongue are located in the: A. Geniculate ganglion B. Otic ganglion C. Pterygopalatine ganglion D. Submandibular ganglion E. Trigeminal ganglion 144. The pharyngeal tonsils, or adenoids, may become inflamed and in serious cases need to be removed. Where would the physician search for them? A. In the tonsillar fossa B. In the pharyngeal recess C. In the piriform recess D. In the roof of the nasopharynx E. Upon the dorsal surface of the tongue 145. Which of the following structures is located in the vestibule of the oral cavity? A. Tongue B. Opening of the parotid duct C. Opening of the submandibular duct D. Sublingual fold E. Uvula 146. The middle nasal concha is part of what bone? 21

A. Ethmoid bone B. Maxilla C. Palatine bone D. Sphenoid bone E. Vomer 147. When one presses the tongue tip against the anterior (incisor) teeth, which of the following muscles must contract? A. Styloglossus B. Hyoglossus C. Genioglossus D. Superior longitudinal E. Verticalis 148. The muscle responsible for raising the floor of the mouth in the early stages of swallowing is the: A. genioglossus B. geniohyoid C. hyoglossus D. mylohyoid E. palatoglossus 149. The cell bodies of the postganglionic parasympathetic neurons innervating the sublingual gland are found in which of the following ganglia? A. ciliary B. otic C. submandibular D. superior cervical E. trigeminal 150. A 23-year-old man comes to you complaining that he can't stop crying, i.e. tears regularly run down the right side of his face. You suspect that one of the lacrimal ducts on the right side of the face is blocked. You look into an endoscope to see if the nasolacrimal duct is blocked. Into which part of the nasal cavity would you look to see the opening of the duct? A. Hiatus semilunaris B. Inferior meatus C. Middle meatus D. Sphenoethmoidal recess E. Superior meatus 151. A 46-year-old female patient comes to the emergency department complaining of pain in the area just below her mandible on the right side of her face. She says that the pain is particularly severe when she eats. The area of the submandibular gland is tender and swollen, as is the area in the floor of her mouth lateral to the tongue. You suspect a stone in the submandibular duct, and a plain film radiograph shows a density in that region consistent with a stone. In order to remove the stone, the duct must be incised in the floor of the mouth. What nerve that loops around the duct is in danger in such an incision? A. Chorda Tympani B. Glossopharyngeal C. Hypoglossal D. Internal branch of the superior laryngeal E. Lingual 152. In accessing the submandibular gland in the submandibular triangle, what vessel coursing through the gland and triangle would need to be protected? A. External jugular vein B. Facial artery 22

153.

154.

155.

156.

C. Maxillary artery D. Retromandibular vein E. Superior thyroid artery Which structure forms a border of the tonsillar fossa? A. Torus tubarius B. Palatopharyngeal fold C. Salpingopharyngeal fold D. Lateral glossoepiglottic fold E. Medial pterygoid plate The communication between the pharynx and the nasal cavity is known as the: A. Aditus B. Auditory tube C. Choanae D. Fauces E. Piriform recess All of the following may be found in the paralingual space EXCEPT: A. Hypoglossal nerve B. Lingual nerve C. Sublingual gland D. Submandibular gland duct E. Superficial lobe of the submandibular gland The muscle which separates the submandibular triangle from the paralingual space is the: A. Digastric, posterior belly B. Hyoglossus C. Mylohyoid D. Stylohyoid E. Styloglossus

EAR 157. The entry of bacteria through which space could lead to an infection in the mastoid air cells: A. Auditory (nasopharyngeal) tube B. Cochlea C. External acoustic meatus D. Internal acoustic meatus E. Sacculus 158. Which structure is attached to the center of the tympanic membrane? A. Foot plate of the stapes B. Handle (manubrium) of the malleus C. Long process of the incus D. Tragus E. Utricle 159. A 45-year old woman with recurrent left middle ear infection (otitis media) complained of partial dryness of her mouth to her ENT surgeon. Taste sensation and hearing were normal. After a thorough clinical examination at the hospital, the doctor concluded that the infection must have spread to a component of the glossopharyngeal nerve (CN IX) that supplies the parotid gland. On which of the following walls of the middle ear is this nerve component located? A. Anterior B. Lateral C. Medial 23

D. Posterior E. Roof 160. A 3-year-old girl ruptured her eardrum when she inserted a pencil into her ear. Her mother took her to the emergency department after noticing that the child was crying and complaining of pain in her ear with a few drops of blood in the external auditory meatus. The attending doctor examined the child for possible injury to a nerve that runs across the eardrum. The most likely nerve to be injured is the A. Auricular branch of the vagus B. Chorda tympani C. Glossopharyngeal (CN IX) D. Lesser petrosal E. Trigeminal (CN V) 161. . An elderly patient with chronic otitis media (middle ear infection) might have all the following complications EXCEPT: A. Inability to chew food due to injury to the mandibular division of the trigeminal nerve (CN V) B. Loss of taste in the anterior part of the tongue due to injury to the chorda tympani nerve. C. Mastoiditis. D. Paralysis of facial muscles due an injury to the facial nerve (CN VII). E. Some degree of deafness due to damage to the ossicles. 162. A patient with a facial nerve paralysis suffers from inability to dampen loud noises (hyperacusis) due to denervation of which muscle? A. Posterior belly of digastric B. Stapedius C. Tensor tympani D. Stylohyoid muscle 163. All of the following are true about the middle ear EXCEPT: A. The joints between ossicles are synovial B. The chorda tympani nerve is related to the lateral wall C. The facial nerve passes in a canal situated in the medial and anterior walls D. The auditory tube connects the nasopharynx with the anterior wall E. Its mucous membrane is supplied by the glossopharyngeal nerve (CN IX) 164. A patient has sustained a fracture to the base of the skull. Thorough examination concluded that the right greater petrosal nerve, among other structures, has been injured. This conclusion was based on which of the patient's signs: A. Partial dryness of the mouth due to lack of salivary secretions from the submandibular and sublingual glands. B. Partial dryness of the mouth due to lack of salivary secretions from the parotid gland. C. Dryness of the right cornea due to lack of lacrimal secretion. D. Loss of taste sensation from the right anterior 2/3rd of the tongue. E. Loss of general sensation from the right anterior 2/3rd of the tongue. 165. The location of the otic ganglion is in the: A. Pterygopalatine fossa B. Internal ear C. Infratemporal fossa D. Middle cranial fossa E. None of the above 166. A patient complains of loss of hearing in the right ear. Examination reveals anklyosis (otosclerosis) of the footplate of the stapes to the surrounding bone. Which part of the bony labyrinth is involved? 24

A. Aditus ad antrum B. Cochlear (round) window C. Cochlear duct D. Internal acoustic meatus E. Vestibular (oval) window 167. The geniculate ganglion is the sensory ganglion of which nerve: A. Facial B. Glossopharyngeal C. Trigeminal D. Vagus E. Vestibulocochlear 168. Repeated middle ear infections have destroyed the tympanic plexus in the middle ear cavity. The loss of preganglionic parasympathetic fibers that pass through the plexus diminish production of: A. Mucus in the nasal cavity B. Mucus on the soft palate C. Saliva by the parotid gland D. Saliva by the submandibular and sublingual glands E. Tears by the lacrimal gland EYE 169. You are testing the extraocular muscles and their innervation in a patient who periodically experiences double vision. When you ask him to turn his right eye inward toward his nose and look downward he is able to look inward, but not down. Which nerve is most likely involved? A. Abducens B. Nasociliary C. Oculomotor, inferior division D. Oculomotor, superior division E. Trochlear 170. The outermost layer of the optic nerve sheath is a continuation of the: A. Arachnoid membrane B. Meningeal dura C. Periosteal dura D. Pia mater E. Retina 171. The inner lining of the eyelid is called the: A. Orbital septum B. Palpebral conjunctiva C. Periorbita D. Sclera E. Tarsal plate 172. What would the examining physician notice in the eye of a person who has taken a sympathetic blocking agent? A. Exophthalmos and dilated iris B. Enophthalmos and dry eye C. Dry eye and inability to accommodate for reading D. Wide open eyelids and loss of depth perception E. Ptosis and miosis (pin-point iris)

25

173. You are examining a patient who has a pituitary tumor involving the cavernous sinus. While doing a preliminary eye exam, you suspect the right abducens nerve of the patient has been damaged by the tumor. In which direction would you have the patient turn his right eye to confirm the defect? A. Inward B. Outward C. Downward D. Down and out E. Down and in F. Upward G. Up and out H. Up and in 174. You have a patient with a drooping right eyelid. You suspect Horner's syndrome. Which of the following signs on the right side would confirm a diagnosis? A. Constricted pupil B. Dry eye (Lack of tears) C. Exopthalmos D. Pale, blanched face E. Sweaty face 175. Following endarterectomy on the right common carotid, a patient is found to be blind in the right eye. It is appears that a small thrombus embolized during surgery and lodged in the artery supplying the optic nerve. What artery would be blocked? A. Central artery of the retina B. Infraorbital C. Lacrimal D. Nasociliary E. Supraorbital 176. You are asked to check the integrity of the trochlear nerve in the right eye of a patient. Starting with the eyes directed straight ahead, you would have the patient look: A. Inward, toward the nose and downward B. Inward, toward the nose and upward C. Toward the nose in a horizontal plane D. Laterally in a horizontal plane E. Outward, away from the nose and downward F. Outward, away from the nose and upward 177. The ducts of the lacrimal gland open into the: A. Superior fornix of the conjunctiva B. Inferior fornix of the conjunctiva C. Lacrimal puncta D. Lacrimal canaliculi E. Lacrimal lake 178. Starting from a position gazing straight ahead, to direct the gaze downward, the inferior rectus muscle must be active along with the: A. Superior oblique B. Inferior oblique C. Medial rectus D. Lateral rectus E. Superior rectus 179. During a physical examination it is noted that a patient has ptosis. What muscle must be paralyzed? A. Orbicularis oculi, lacrimal part 26

B. Orbicularis oculi, palpebral part C. Stapedius D. Superior oblique E. Superior tarsal 180. The extraocular muscle that does not originate at or near the apex of the orbit is the : A. Inferior oblique B. Inferior rectus C. Levator palpebrae superioris D. Superior oblique E. Superior rectus 181. An adolescent boy suffers from severe acne. As is often the case he frequently squeezed the pimples on his face. He subsequently develops a fever and deteriorates into a confused mental state and drowsiness. He is taken to his physician and after several tests a diagnosis of cavernous sinus infection and thrombosis is made. The route of entry to the cavernous sinus from the face was most likely the: : A. Carotid artery B. Mastoid emmisary vein C. Middle meningeal artery D. Superior ophthalmic vein E. Parietal emmisary vein 182. If a person looking inward towards their nose is unable to look down, which nerve may be injured? A. Abducens (CN VI) B. Inferior division of oculomotor (III) C. Optic (II) D. Superior division of oculomotor (III) E. Trochlear (IV) 183. If a person is taking a sympathetic blocking agent, what would you notice in her or his eyes? A. Dry eyes and inability to accommodate for reading B. Enophthalmos and teary eyes (III) C. Exophthalmos and dilated pupil D. Ptosis and constricted pupil E. Wide open eyes and loss of depth perception (IV)

27

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49

D C D C E B C B E C C B D A C A C C D E D D B E B D A C C C A D C D D C D A B C B A B C D E B E B

51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

C B C B A A E C C D B C B D E E B C E B D B A E E A B B D C C B B E A C D B E C B B C D A D E E A

101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149

B C D D C B C C B D C C C B D E C D B D E C D C B B D A A A B B B C C B A C C B B A A D B A C D C

151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183

E B B C E C A B C B A B C C C E A C E B B E B A A A A A E A D E D

199

28

50

100

150

200

29