Arthritis Australia

By N. Cronos. Curry College. 2018.

Rizatriptan versus usual care in long-term treatment of migraine 500mg biaxin sale. Efficacy biaxin 250 mg discount, safety and tolerability of Wrong Publication oral eletriptan (40mg and 80mg) in the acute treatment of migraine: results of a Type-ABSTRACT phase III study. ONLY Triptans Page 75 of 80 Final Report Update 4 Drug Effectiveness Review Project Reason for Study exclusion Tfelt-Hansen P and Steiner TJ. Sumatriptin vs dihydroergotamine: Patient Wrong Design preference. Patients preference between 25, 50 and 100mg oral Wrong Publication doses of sumatriptan. Effect of rizatriptan versus sumatriptan on migraine- Wrong Publication associated symptoms. Disintegration Profiles of Encapsulated And Wrong Outcome- Non-Encapusulated Sumatriptan: Gamma Scientography in Healthy Volunteers. Background Triptans Page 76 of 80 Final Report Update 4 Drug Effectiveness Review Project Appendix E. Pooled relative risks (95% confidence interval) for pain- free outcomes in placebo-controlled trials of early treatment with triptans Relative risk Cochrane Q (degrees Triptan (95% CI) of freedom), Triptan dose n/N (%) Placebo n/N (%) NNT P value 2-hour pain-free Frovatriptan 1. Adverse events in head-to-head trials of triptans % Patients Reporting Any Adverse Event Author P A12. Triptans Page 80 of 80 Drug Class Review Triptans Final Report Update 4 Evidence Tables June 2009 Update 3: November 2005 Update 2: September 2004 Update 1: December 2003 Original Report: March 2003 The literature on this topic is scanned periodically. The purpose of this report is to make available information regarding the comparative effectiveness and safety profiles of different drugs within pharmaceutical classes. Reports are not usage guidelines, nor should they be read as an endorsement of, or recommendation for, any particular drug, use, or approach. Oregon Health & Science University does not recommend or endorse any guideline or recommendation developed by users of these reports. Mark Helfand, MD, MPH Kim Peterson, MS Drug Effectiveness Review Project Marian McDonagh, PharmD, Principal Investigator Oregon Evidence-based Practice Center Mark Helfand, MD, MPH, Director Oregon Health & Science University Copyright © 2009 by Oregon Health & Science University Portland, Oregon 97239. Final Report Update 4 Drug Effectiveness Review Project TABLE OF CONTENTS Evidence Table 1. Results of triptan head-to-head trials……………………………………………………… 36 Evidence Table 3. Triptan compared with placebo: Characteristics and outcomes………………………... Triptan compared with placebo: Understudied drugs………………………………..... Triptans compared with placebo controls: Assessment of internal validity………..... Triptan compared with placebo: Sumatriptan SC pain outcomes…………………...... Triptan compared with placebo: Summary of quality-of-life results………………….. Triptan compared with placebo: Summary of disintegrating drug results……………. Triptan compared with placebo: Summary of early treatment results………………. Prior versions of this report can be accessed at the DERP website. Triptans Page 2 of 184 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 1. Characteristics of head-to-head trials Age Author Number Gender Year Design Setting randomized Ethnicity Patients Inclusion criteria Bomhof Multicenter single-dose RCT Not stated 618 39 years I H S criteria 6-month history of migraine; 1-8 1999 conducted in Europe of 84% female 18-65 men and reports per month; no evidence naratriptan vs. Characteristics of head-to-head trials Number screened/ Author Funding sources eligible/ Year Exclusion criteria and role of funder Other medications enrolled Bomhof H. O cva, cardiovascular disease, Merck, co-investigator Permitted NR 1999 significant ecg abnormality, history or (maker of rizatriptan) drug or alcohol use, past use of study drugs Carpay 1997 Known narcotic/alcohol abuse Glaxo NR 142/124/124 ergotamine abuse pregnancy, breast-feeding history of ECG evidence of ischaemic heart disease significant concomitant disease significant psychiatric illness known hypersensitivity to/intolerance of sumatriptan current use of fluarizine Triptans Page 4 of 184 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 1. Characteristics of head-to-head trials Number Author withdrawn/ Year lost to follow-up Bomhof 96 (did not take study 1999 medication) Carpay 1997 NR/NR Triptans Page 5 of 184 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 1. Characteristics of head-to-head trials Age Author Number Gender Year Design Setting randomized Ethnicity Patients Inclusion criteria Charlesworth Multicentre, DB, Double- 42 centers in 1547 Mean age=19. Characteristics of head-to-head trials Number screened/ Author Funding sources eligible/ Year Exclusion criteria and role of funder Other medications enrolled Charlesworth History of basilar, ophthalmoplegic AstraZeneca NR 1547/1383/1372 2003 migraine reported non-migraine > 10 days/month 6 months before study pregnancy, lactation, inadequate conception in women ischaemic heart disease, arrhythmias/cardiac accessory uncontrolled hypertension, use of monoamine oxidase-A inhibitors, methylergometrine within 2 weeks of study clinically significant abnormal laboratory result recent history of drug/alcohol abuse known hypersensitivity/adverse reaction to study treatments/triptans existing serious medical condition participation in another clinical study at same time of this study risk of transmitting Hep B/HIV Colman, 2001 Subjects could not have uncontrolled Pharmacia Rescue medications NR/NR/1255 Spierings, hypertension, defined as a diastolic allowed at 2 hours 2001 blood pressure higher than 95 mm Hg or a systolic blood pressure higher than 160 mm Hg, or clinically significant disease affecting any system but especially the cardiovascular or gastrointestinal tract Triptans Page 7 of 184 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 1. Characteristics of head-to-head trials Number Author withdrawn/ Year lost to follow-up Charlesworth 66/8 2003 Colman, 2001 NR/NR Spierings, 2001 Triptans Page 8 of 184 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 1. Characteristics of head-to-head trials Age Author Number Gender Year Design Setting randomized Ethnicity Patients Inclusion criteria Diez Multicenter, randomized, open, NR 436 Mean age: 36.

R adiation:C ontrolled-clinicaltrials A uth or buy 500mg biaxin fast delivery, Y ear Design Inclusioncriteria Type ofradiation Directcom parison trials Spitz er R CT generic 250 mg biaxin with amex,D B Ptswith adiagnosisof eitherm alignantdiseaseoraplastic 11fractionseach of 120cG yof radiationover4daysfora 2000 Parallel anem iaandwhowerehospitaliz edtoreceive11fractionsof totalradiationex posureof 1320cG ypriortoBM T and M ulticenter 120cG yover4dayspriortoBM T andinitiationof any chem o. F em alesof childbearing potentialwere radiationtoprotectthelungs. Theblockwasrem ovedfor requiredtohaveanegativeserum orurinehCG pregnancy fractionsgivenondays2and3toallow forradiationof the testandhadtocontinueusing adequatecontraception ribsandsofttissueunderlying thelungs. R T = radioth erapy;O DT = orallydisintegratingtablets;B M T = bonemarrow transplantation;TB I= totalbodyirradiation Antiemetics Page 279 of 492 Final Report Update 1 Drug Effectiveness Review Project Evidence Table 7. R adiation:C ontrolled-clinicaltrials A uth or, Y ear Exclusioncriteria Intervention Directcom parison trials Spitz er E x cludedwereptswith aK arnofskyPerform anceStatusscore<60,thosewhohadreceived G :G ranisetron2m g 2000 aninvestigationalnew drug within30daysor5half livesof them edication,received O :O ndansetron24m g M ulticenter conditioning orintrathecalchem owithin24h of firstdoseof TBI,receivedem etogenic system ic orintrathecalchem oduring thestudy,orwhohadanunstablem edicaldisorderor prim aryorsecondarybrainneoplasm with increasedintracranialpressure. O therreasonsfor ex clusionincludedknownhypersensitivitytoany5HT3receptorantagonist,unwillingnessor inabilitytocom plywith thestudyprotocol,oranym edicationwith antiem etic activitytaken within24h of receiving studym edicationonD ay0. Thosewhoex periencednauseawithin1 hroranyem esis(vom iting orretching)within24h of receiving studym ediationsonD ay0 wereex cludedfrom theprotocoldefinedpopulationbutwereincludedintheintenttotreat population. R T = radioth erapy;O DT = orallydisintegratingtablets;B M T = bonemarrow transplantation;TB I= totalbodyirradiation Antiemetics Page 280 of 492 Final Report Update 1 Drug Effectiveness Review Project Evidence Table 7. R adiation:C ontrolled-clinicaltrials A ge A uth or, G ender Y ear A llowed oth erm edication R un-in/W ash out Eth nicity O th erpopulationch aracteristics Directcom parison trials Spitz er N o N o/N R 41. R adiation:C ontrolled-clinicaltrials Screened/ W ith drawn/ A uth or, Eligible/ L ostto fu/ Y ear Enrolled A nalyz ed R esults Directcom parison trials Spitz er 36/34/34 2/0/34 Data givenas G ranpo 2 vs O nd po 8 2000 Com pleteem etic control:noem etic episodesandnorescueantiem etic m edication M ulticenter use overall:27. R adiation:C ontrolled-clinicaltrials A uth or, Y ear A dverse events C om m ents Directcom parison trials Spitz er Data givenas G ranpo 2 vs O nd po 8 2000 Alladverseevents M ulticenter R ash:0% vs12. R adiation:C ontrolled-clinicaltrials A uth or, Y ear Design Inclusioncriteria Type ofradiation Placebo- controlled trials B ey R CT,D B Cancerpts≥ 18yof eithergenderundergoing radiotherapy Singlefractionradiotherapyof ≥6G yoverfieldsof either80- 1996 m ulticenter totheupperabdom inalfield,incl. L anciano R CT,D B Cancerpts≥ 18yof eithergenderundergoing radiotherapy;Abdom inalradiotherapytofieldsencom passing T11-L 3with 2001 m ulticenter m alesweresurgicallysteriliz edoragreedtopractice afieldsiz e≥ 100cm 2;ptshadtoreceivebetween10and30 parallel adequatecontraceptionduring thestudy. F em aleswereof fractionsof radiotherapywith a radiationdoseof ≥ 1. R T = radioth erapy;O DT = orallydisintegratingtablets;B M T = bonemarrow transplantation;TB I= totalbodyirradiation Antiemetics Page 284 of 492 Final Report Update 1 Drug Effectiveness Review Project Evidence Table 7. R adiation:C ontrolled-clinicaltrials A uth or, Y ear Exclusioncriteria Intervention Placebo- controlled trials B ey If ptshadchem owithin2weeksof thestudy;alsoex cludedwereptswhohadradiotherapy<7 D 1:D olasetron(D ol)0. Alsoex cludedwereptswho 30m inbeforeradiationstart werepregnantorfem aleof childbearing potentialnotusing contraceptionm easures,had beenadm inisteredanydrug with antiem etic efficacywithin24h of studyinitiation,had receivedprevioustherapywith D ol,hadvom itedasaresultof anyorganic etiologyorhad vom itedinthe24h preceding radiotherapy,hadex periencedSW O G grade2-4nauseainthe 24h preceding radiotherapy,orhadusedanyinvestigationaldrug within21daysof thestudy. L anciano Ptswerenoteligibleif theyhadparticipatedinanydrug trialusing aninvestigationaldrug G :G ran2m g (n= 134)poqd 2001 within30dor5-half lives(whicheverwaslonger)priortoscreening,hadanunstablem edical Pl:Placebo disorder,oraK arnofskyperform ancestatusscoreof <60. Theycouldnotreceivechronic (≥1 m onth)orconcurrent(day0andthrough endof assessm enttreatm entwith agentsknownto havesignificanteffectonem esis,including ondansetron,sedating antihistam ines, antipsychotics,cannabinoids,corticosteroids,m etoclopram ide,narcotic analgesicsand benz odiaz epines. Ptscouldnothaveprim aryorsecondarybraintum orswith signsor sym ptom sof increasedintracranialpressure. Ptswereex cludedif theyhadknown hypersensitivityto5-HT3receptorantagonistorwereunwilling/unabletocom plywith study protocolorex periencednauseawithin1h and/orem esiswithin24h beforeadm inistrationof studym edicationonD ay0. E m etogenic chem ocouldnotbeadm inisteredwithin72h of study m edicationorduring studyassessm entperiod. Previousabdom inalradiotherapy(T11-L 3), wedge-fieldradiationtherapytothespine,andprophylactic radiotherapy totheCN S werealsoreasonsforex clusion. N oradiationtherapycouldbeadm inistered24h pr R T = radioth erapy;O DT = orallydisintegratingtablets;B M T = bonemarrow transplantation;TB I= totalbodyirradiation Antiemetics Page 285 of 492 Final Report Update 1 Drug Effectiveness Review Project Evidence Table 7. R adiation:C ontrolled-clinicaltrials A ge A uth or, G ender Y ear A llowed oth erm edication R un-in/W ash out Eth nicity O th erpopulationch aracteristics Placebo- controlled trials B ey N o W ashout:2wksforchem o,7d M edianage:63y M ediandoseof radiotherapy:6. R adiation:C ontrolled-clinicaltrials Screened/ W ith drawn/ A uth or, Eligible/ L ostto fu/ Y ear Enrolled A nalyz ed R esults Placebo- controlled trials B ey N R /50/50 N R /N R 50 A lldata are givenas D1;D2;D3;Pl(ifnotnoted;p=N S and pgivenonly foreach D 1996 groupvs. R adiation:C ontrolled-clinicaltrials A uth or, Y ear A dverse events C om m ents Placebo- controlled trials B ey 1seriousAE inD 2group (aptwhopresentedwith asuspectedcoloncancerandwas 1996 hospitaliz edform ildm elena48h afterstudym edicationadm inistration)wasnot consideredtoberelatedtostudym edication;9eventsacrossthefourgroups(8events in6D olptsand1eventin1Plpt)wereconsideredtreatm ent-related. M ostcom m onlyreportedAE s:(data givenas D1;D2;D3;Pl) O verallrate:27. R adiation:C ontrolled-clinicaltrials A uth or, Y ear Design Inclusioncriteria Type ofradiation L eB ourgeois R CT,D B M aleandfem alepts ≥ 18ywith adiagnosisof cancerwho ≥ 5dailyfractionsof radiotherapytositesbetweenthethorax 1999 m ulticenter weretoreceiveacourseof ≥5dailyfractionsof andpelvis parallel radiotherapytositesbetweenthethorax andpelvis. R adiation:C ontrolled-clinicaltrials A uth or, Y ear Exclusioncriteria Intervention L eB ourgeois Ptswith severeconcurrentillness(otherthanneoplasia)orwith otherpotentialcausesof O 1:O nd8m g O D T 1999 em esisandnausea(. O therex clusioncriteriawere: concurrentorpastm edicalconditionsthatm ightinterferewith thestudy,im pairedhepatic Ptswereinstructedtotakestudydrug function,pregnancy,orlactation. R adiation:C ontrolled-clinicaltrials A ge A uth or, G ender Y ear A llowed oth erm edication R un-in/W ash out Eth nicity O th erpopulationch aracteristics L eB ourgeois N o W ashout:5dforchem o,30d M eanage:48y M eanweight:70. R adiation:C ontrolled-clinicaltrials Screened/ W ith drawn/ A uth or, Eligible/ L ostto fu/ Y ear Enrolled A nalyz ed R esults L eB ourgeois N R /1492/1489 unclear Data givenas O 1 vs O 2 vs Pl 1999 /unclear/461 treatm entsuccess(ts):0-1em etic episodesin0-2h afterstudym edication;0em etic episodesafter2h untiltheendof assessm entpd;noworsethanm ildnauseaduring assessm entperiod;norescue;nowithdrawal Com pletecontrol(noem esis,nausea,rescue,orprem aturewithdrawal): 53% vs58% vs405(p = N S forO 1vsO 2) % of ptswith treatm entsuccess(ts)in12h afteradm inistrationof studym eds: 53% vs56% vs41% (p= N S forO 1vsO 2) % of ptswith tsin2h periodim m ediatelyafteradm inistrationof studym eds: 69% vs70% vs52% (p = N S forO 1vsO 2) Tiley and Powles N R /20/20 Data givenas O vs Pl 1992 U K Vom iting during TBI:10% vs50%,p= 0. R adiation:C ontrolled-clinicaltrials A uth or, Y ear A dverse events C om m ents L eB ourgeois SeriousAE inO 1group:2ptsex periencednauseaandvom iting and1ptavarietyof 1492was#of pts 1999 eventsrelatedtobreathing disordersandbone/skeletalpain entering study;butstudy onlyevaluatedthose data givenas O 1 [n=150]vs O 2 [n=139]vs Pl[n=127] whohadnauseaor M ostcom m onAE sduring treatm ent: em esisafterradiation AnyAE :8% vs4% vs3% (total= 5%) treatm ent,sothenum ber N auseaandvom iting:3% vs0. Headache:2% vs0% vs3% (total:2%) D iarrhea:0% vs2% vs0% (total:0. R adiation:C ontrolled-clinicaltrials A uth or, Y ear Design Inclusioncriteria Type ofradiation A ctive-controlled trials Sykes R CT >18ptswhoweretoreceivepallativesinglefraction 60ptsreceivedasinglefractiontothelowerhalf-bodyof 8 1997 Singlecenter radiotherapy G y;6ptsreceivedasinglefractionof 12.

Maintenance therapy with bortezomib or lenalidomide (or both in very-high-risk patients) is a reasonable option for long-term disease control and improvement in overall survival order biaxin 500mg overnight delivery. Incorporation of new agents into the continuum of multiple myeloma care should result in improved outcomes and long-term disease control purchase biaxin 250mg visa. Introduction GEP and other molecular techniques, including next-generation Multiple myeloma (MM) is a malignant plasma cell proliferation sequencing and single nucleotide polymorphism arrays, are future that occurs within a spectrum of diseases that includes monoclonal strategies that could facilitate the systematic incorporation of new gammopathy of undetermined significance, primary amyloidosis, therapies into the continuum of MM treatment. The development of nonsecretory myeloma, and solitary plasmacytoma. CRAB (which stands for “hyperCalcemia, Renal proved outcomes for all MM patients. Other indications include symptom- Induction regimens for MM patients requiring therapy have im- atic hyperviscosity, recurrent bacterial infections, and amyloidosis proved over the last decade. A recent report updated the continued with organ involvement. We review here the continuum of treat- improvement in survival for transplantation-eligible and transplanta- ment of the transplantation-eligible MM patient, including induc- 10 tion-ineligible MM patients over the past 10 years. Induction tion therapy, hematopoietic stem cell transplantation (HSCT), and regimens for transplantation-eligible MM patients have improved posttransplantation consolidation and maintenance. Induction regimens for transplantation-eligible patients are de- Immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs) signed to decrease the malignant plasma cell burden and improve 2 were first used as salvage agents, then later as part of combination the depth of response. Depth of response after autologous transplan- induction therapy. The combination of an IMiD with a PI along with tation appears to correlate with the duration of disease control dexamethasone has resulted in marked improvements in disease before disease progression occurs with the need for salvage response. Improved depth of response has resulted in improved therapy. These risk factors included an IMiD or PI and increasing frequency; both drugs are will change over time as new agents are developed, which will used in combination with dexamethasone. Attempts to increase to 4 change risk stratification. As an example, the del(13) cytogenetic or more agents have not yet resulted in improved responses due to abnormality by metaphase karyotyping was considered high risk increased toxicity. High-risk factors at diagnosis transplantation could be offered to the MM patient who relapses Cytogenetics: del(13), t(4;14), t(14;16), del(17p), del(1p), and 1q after at least 12-24 months after the first autologous transplantation; Renal failure, elevated LDH, plasma cell leukemia, GEP 70, EMC-92 collecting PBSCs early in the course of treatment will diminish Comorbidities limiting therapy exposure to potentially mutagenic therapies. Double or tandem International Scoring System stage II or III autologous HSCT has been shown to be superior to single autolo- gous HSCT in patients who do not attain at least a VGPR. RecommendthatFISH be performed after CD138 selection of BM cells to increase plasma cell yield. GEP certain whether tandem autologous HSCT up-front is superior to a 70 is validated; EMC-92 has early validation and is ongoing. New molecular genetic single transplantation followed by second autologous HSCT after testsawaitvalidationinmultipledatasets. With the use of novel agents and consolidation LDH indicates lactate dehydrogenase; EMC, Erasmus Medical Center; and GEP, after transplantation, new studies will help to determine the role of geneexpressionprofile. There has been one phase 3 study examining induction followed by up-front autologous HSCT com- There have been no phase 3 studies comparing these approaches, pared with rescue autologous HSCT at disease progression/relapse, but there will be opportunities for examining different strategies for which found no difference in the 2 approaches. At present, attaining a CR and maintaining this was reported more than 10 years ago, ongoing studies incorporating response continues to be a reasonable approach to maintain disease newer agents will help to identify patients benefiting most from control and improve OS based on different strategies. Two early reports of phase 3 trials work has also demonstrated that attaining VGPR predicts for examining chemotherapy versus up-front tandem autologous HSCT long-term disease control, yet attaining and sustaining CR has been have shown an improved PFS without a difference in OS. Based on the published MPR (melphalan, prednisone, lenalidomide) or tandem autologous literature, treatment until best response may be the optimal ap- 2 HSCT with melphalan at 200 mg/m (Mel200) with each transplan- proach. In the absence of response after 1-2 cycles of induction, tation. All patients were then randomized to lenalidomide mainte- changing to another regimen to attain VGPR is a standard 33 nance until progression. At a median follow-up of 45 months from approach because treatment with an autologous HSCT without diagnosis, the median PFS for the tandem Mel200 arm was disease control usually results in short-term responses. The second study examined 389 newly diagnosed MM patients who HSCT received Rd induction followed by randomization to CRD (cyclo- Autologous HSCT phosphamide, lenalidomide, dexamethasone) or tandem autologous The transplantation-eligible patient may be defined by age and/or HSCT with Mel200. A second randomization occurred to lenalido- comorbidities. In some countries, most patients over the age of 65 mide/prednisone versus lenalidomide maintenance until progres- years do not undergo autologous HSCT. These 2 studies did not use bortezomib other factors, especially comorbidities and performance status, during induction or maintenance and longer follow-up will be influence the decision for a patient to undergo an autologous HSCT. Autologous HSCT has become the standard approach to improve or Other phase 3 studies are ongoing that will help define the role of deepen response and can be considered a form of consolidation.

The branches of the maxillary the deep temporal nerves which supply temporalis discount biaxin 250mg on line. The mandibular nerve are the greater and lesser palatine nerves to the hard and soft division thus contains both motor and sensory branches generic 500 mg biaxin. The trigeminal nerve (V) 129 58 Cranial nerves VI–XII Greater petrosal Internal auditory meatus Facial nerve Temporal Middle ear Stylomastoid foramen Zygomatic Chorda tympani Buccal Marginal mandibular Cervical Fig. The nerve passes through the middle ear and the parotid gland Vagus Spinal accessory Cranial accessory Foramen magnum Internal carotid Cardiac branch External carotid To sternomastoid Pharyngeal and trapezius Superior laryngeal Internal jugular vein Internal laryngeal External laryngeal Cricothyroid Cardiac branch Subclavian artery Recurrent laryngeal (left) Fig. The spinal root of the accessory is shown in yellow 130 Head and neck • VI. In terior border of the pons and has a long intracranial course (so is often the neck the vagus (and cranial root of the accessory) gives the follow- the first nerve to be affected in raised intracranial pressure) to the cav- ing branches: ernous sinus, where it is closely applied to the internal carotid artery, • The pharyngeal branch which runs below and parallel to the glos- and thence to the orbit via the superior orbital fissure. It supplies the lat- sopharyngeal nerve and supplies the striated muscle of the palate eral rectus. It reaches thorax to take part in the cardiac plexuses. The former enters the larynx by piercing the the parotid gland, in which it divides into five branches (temporal, thyrohyoid membrane and is sensory to the larynx above the level of zygomatic, buccal, marginal mandibular and cervical) which are the vocal cords, and the latter is motor to the cricothyroid muscle. On the right side it loops under the posterior belly of the digastric. In the middle ear it gives off the greater subclavian artery before ascending to the larynx behind the com- petrosal branch which carries parasympathetic fibres to the mon carotid artery. On the left side it arises from the vagus just sphenopalatine ganglion and thence to the lacrimal gland. In the middle below the arch of the aorta and ascends to the larynx in the groove ear it also gives off the chorda tympani which joins the lingual nerve between the trachea and oesophagus. Sensory fibres in the chorda tympani have nerves supply all the muscles of the larynx except for cricopharyn- their cell bodies in the geniculate ganglion which lies on the facial geus and are sensory to the larynx below the vocal cords. The vestibulocochlear (auditory) nerve: this leaves the brain side of the medulla with the vagus and is distributed with it. The spinal next to the facial nerve and enters the internal auditory meatus. It root arises from the side of the upper five segments of the spinal cord, divides into vestibular and cochlear nerves. It leaves the vagus below the jugular foramen and passes back- the side of the medulla and passes through the jugular foramen. It then wards to enter sternomastoid, which it supplies. It then crosses the pos- curves forwards between the internal and external carotid arteries to terior triangle to supply trapezius (see Fig. It also gives a branch to the carotid body and passes through the hypoglossal canal. It supplies the intrinsic and extrinsic muscles of the tongue. It nerve but the spinal root of the accessory leaves it again almost imme- gives off the descendens hypoglossi but this is actually composed of diately. The cranial root is distributed with the vagus (hence the fibres from C1. This joins the descendens cervicalis, derived from C2 nameait is accessory to the vagus). The vagus carries two ganglia for and 3, to form the ansa cervicalis. From this, branches arise to supply the cell bodies of its sensory fibres. It descends between the internal the ‘strap muscles’, i. Cranial nerves VI–XII 131 59 The arteries I Superficial temporal Foramen spinosum Middle meningeal Maxillary Occipital Facial Tonsillar branch Dorsal Hypoglossal nerve lingual Internal carotid Lingual External carotid Carotid sinus Laryngeal branch Superior thyroid Recurrent laryngeal nerve Thyroid Inferior thyroid Thyrocervical trunk Subclavian Fig. The intracranial parts of the two vertebral arteries are also shown diagrammatically although they are in a different plane 132 Head and neck The common carotid artery • The middle meningeal arteryaruns upwards to pass through the Arises from the brachiocephalic artery on the right and from the arch of foramen spinosum. Inside the skull it passes laterally and then the aorta on the left (Chapter 4). Each common carotid passes up the ascends on the squamous temporal bone in a deep groove, which it neck in the carotid sheath (Fig. The anterior branch passes vein and the vagus nerve. At the level of the upper border of the thyroid upwards and backwards towards the vertex and the posterior branch cartilage it divides into internal and external carotid arteries. It supplies the dura mater and the bones of the no branches. After head injuries it may bleed to produce a subdural haemorrhage, the symptoms of which may be delayed for some time The external carotid artery (Fig. Ascends in the neck a little in front of the internal carotid to divide into • Branches which accompany the branches of the maxillary nerve in its two terminal branches, the maxillary and superficial temporal arter- the pterygopalatine fossa and have the same names.