Region Organ/ Structure Condition/ Description

Significance
Neck Platysma Surgical repair Wrinkles skin
If injured in wound of neck, should be sutured so that would
will not be distracted by contracting severed muscle
Langer’s lines Collagen bands of Incision across will result in ugly scar after surgery
neck
Investing layer of Structures covered Submandibular and parotid, SCM and trapezius
deep cervical
fascia
Pretracheal layer Structures covered Thyroid, attaches to laryngeal cartilages in midline, inferiorly
Tumors of thyroid descends in front of trachea and fuses with fibrous
pericardium
Attaches to larynx also => move gland with swallowing
Tumors of thyroid move with swallowing
Prevertebral Structures covered Attaches from investing to cervical vertebrae
Scalene and brachial plexus
Carotid sheath Structures contained Common and internal carotids, IJV and vagus nerve
Superficial nerves Origin Ant divisions of CN II, III and IV, emerging at post border of
of neck SCM
Lesser occipital Innervation Innervates post aspect of ear and scalp
Greater auricular Both surfaces of lower part of ear
Transverse cervical Passes ant across SCM
Supraclavicular 3 of them, medial middle and lateral thirds of clavicle
Supraclavicular Origin and C3/4, supplies skin over ICS 1 and shoulder
nerves innervation
Phrenic Origin and C3/4 ant rami and supplies motor and sensory to diaphragm
innervation Pain impulses appear to be coming from skin than diaphragm
Referred pain from because skin is supplied by sensory cortex more than any
diaphragm other structures => shoulder pain due to diaphragmatic
irritation
Post facial vein Location and Lower border of parotid gland, divide into ant and post
drainage Ant -> ant facial vein -> common facial vein
Post -> post auricular -> EJV
EJV Subclavian Pierces investing fascia above clavicle and then joins
catheterization subclavian. Visualized by lowering head and raising
intrathroacic pressure by aspiring against closed glottis.
Air embolism
- Used to thread catheter thorugh subclavian to SVC and
heart. Not ideal route because angle of union makes passage
difficult, preferred route is through IJV
- If vein severed where pierces fascia, held open by fascia and
air sucked into lumen by negative intrathoracic pressure =>
air embolism
AJV Suicidal cutthroat Usually severed due to position down the neck from the chin
until it joins the EJV
Severed during laryngotomy
Mylohyoid Position and From myloid line to hyoid bone, forms floor of submental
relevance triangle (sides formed by hyoid bone and ant bellies of the
digastric muscles)
Diaphragm of mouth, post border free => lingual nerve,
submandibular and hypoglossal nerve enter through here to
enter mouth.
Hyoid bone Position and Only bone to not articular with another, serves as attachment
relevance point for many muscles
Sternohyoids Tracheostomy Almost meet at midline and so easier than separating muscles
is to separate the fibers of one or the other
Sternothyroid Swelling of thyroid Restricted because attaches over the upper lobe of the gland
gland and prevents enlargement upward.
Omohyoid Location and Attached by tendinous sling to the clavicle is because
development originally inserted there and during development strayed to
the suprascapular notch of the scapula
Good landmark for surgery
Strap muscles Function Steady hyoid bone, allowing for opening of the mandible and
help control pitch of voice
SCM Structures covered Carotid/subclavian arteries, IJV and subclavian veins, brachial
Accessory nerve plexus, strap muscles
 Function Accessory nerve passes obliquely through muscle entering
and upper and second quarter junction and leaving at junction
of upper and second thirds and makes for trapezius
Flex and extend head when acting together
Acting along, rotates face to opposite side and bend head to
same side
Accessory muscle of inspiration
Thyroid gland Development From a duct beginning at junction of ant 2/3 and post 1/3
(foramen cecum) and passing down between muscles of
tongue to ant surface of hyoid and then follows down behind
its post surface deviating either to right or left due to
laryngeal prominence
At trachea, gives rise to isthmus covering tracheal rings 2,3
and 4, and lateral lobes covering 6th ring to thyroid cartilage
Pyramidal lobe Small prominence on sup border of isthmus usually left side
Fibrous remains of May persist and little muscle called levator glandulae
thyroid duct thyroideae may be present on it
Relations to Recurrent and external laryngeal nerves and esophagus and
structuresh trachea, these may be affected by glandular enlargements
Post surface has parathyroid glands
Arterial supply Sup thyroid artery (EC) reach apex of lateral lobe
Inf thyroid artery (subclavian via thyrocervical trunk) – related
closely to recurrent laryngeal nerve
Also blood supply from vessels supplying esophagus and
trachea => tying off thyroid vessels not very serious
Venous supply Sup thyroid veins, middle thyroid -> IJV needs to be divided to
Tracheostomy mobilize gland
Downward Inf thyroid veins -> brachiocephalic, in danger if tracheostomy
enlargement of done below isthmus of thyroid instead of through it
thyroid Downward enlargement diagnosed by compression of inf
thyroid and brachiocephalic => enlargement showing
mediastinal compression
Parathyroid glands Function Calcium metabolism
Development Upper pair = from fourth pharyngeal pouch
Vascular supply Lower pair = from third pouch along with thymus =>
sometimes migrate along with migrating thymus into sup
mediastinum => tumors can be anywhere from thyroid gland
to mediastinum
Sup/inf thyroid vessels supply
Common carotid Bifurcation At level of upper border of thyroid cartilage bifurcates into EC
Location and and IC
structural relations After escaping covering by SCM nad strap muscles, makes for
hemorrhaging carotid tubercle of C6 vertebra => can be compressed
against it to stop hemorrhage
Lies next to trachea and esophagus
Abnormal bifurcation Much higher than usual => dangerous if cut before
bifurcation
Carotid sinus At bifurcation, is a baroreceptor for controlling intracranial
Tachycardia blood pressure, reflexively slows heart (via afferent CN9 (sinus
nerve) and efferent CN 10)
Cause tachycardia in cases of low blood pressure, alleviated
by massaging carotid sinus to slow heart rate
If compressed at carotid sinus for too long, faintness due to
lowering of heart rate
Carotid body Behind the sinus, detect changes in chemical constitution =>
chemoreceptor
IC and EC Development IC from dorsal aorta and EC from ventral, and then goes
intracranially and extracranially respectively
At birfurcation, IC lies external and deeper than EC
EC Branches and supply Ascending pharyngeal – pharyngeal structures
Sup thyroid – moves upon swallowing, supplies larynx through
internal laryngeal branch piercing thyrohyoid membrane
Lingual – ligated in operations of tongue, hypoglossal crosses
loop of lingual, preserved when vessel is dilated (artery deep,
nerve superficial)
Facial – deep to digastric, enter post border of submandibular
and embedded there, at inf border of mandible easily
 palpable because escapes gland (tonsillar artery – runs on
outer surface and perforates wall of pharynx to supply tonsil
Labial – contributes to nasal septal anastomosis – Kiesselbach
anastomosis)
Post auricular & occipital – muscles and skin of back of neck
(come off post surface of EC)
Maillary & sup temporal – terminal branches after entering
parotid gland
Maxillary artery Supply and branches External and middle ear
Muscles of mastication
Orbit (along with ophthalmic artery)
Upper teeth and nose

Inf dental branch – mandible nad teeth

Meningeal branches – middle and large – enter skull through
foramen spinosum, extradurally located, supply meninges and
skull bones
Acessory meningeal – pass through foramen ovale and
supplies trigeminal ganglion (one of causes of trigeminal
neuralgia)
Superficial Supply and location Runs with auriculotemporal nerve in front of tragus of ear and
temporal Temporal arteritis divides into ant and post branches to supply temporal region
of scalp
Sometimes diseased causing temporal arteritis
IC Location and Deep to post digastric and styloid process, entering through
problems carotid foramen into skull
No collateral anastomoses => intracranial collateral
circulation used to bypass deficiency = risky
Carries sympathetic nerves into cranial cavity from sup
cervical ganglion (control caliber of intracranial vessels)
Ophthalmic artery is a branch
IJV Location and relation Grouped around are CN IX, X and XI which enter jugular
to IC foramen and XII exits just medially
Carotid sheath Deep to post digastric and stylohyoid muscles
Pneumothorax Carotid sheath is not thick, is distensible
Meets medial quarter of clavicle in notch between heads of
SCM
Pneumothorax because needle punctured at junction with
clavicle may puncture cervical pleura
Branches Pharynx, tongue, face, thyroid
Common facial vein – ant facial and ant retromandibular
Used to pass cannula into IJV for feeding in pediatric patients
Junctions and With inf petrosal sinus which carries intracranial blood when
features larger intracranial veins are blocked
Two bulbs – one superiorly at floor of tympanic antrum
Other above bicuspid valve above clavicle
Deep cervical chain of lymph nodes surround IJV
Deep Cervical nerves Transverse processes Have grooves for the large ant rami of nerves on C3-7
neck of cervical vertebrae vertebrae
Large ant rami of lower cervicals lie between scalenus ant and
medius
Deep neck muscles Prevertebral fascia Covers scalenes, levator scapulae, longus capitis, longus
cervicis
Sibson’s fascia Suprapleural Prevent inflated lung with pleura from rising high into neck,
membrane covering runs from inf border of first rib to transverse process of C7
apex of lung vertebra
Subclavians run (between scalenes medius and ant and
crosses first rib becoming axillary artery) across sibson’s on
way to upper limb
Subclavian vein, in front of scalene ant and becomes axillary
vein after crossing first rib
Subclavian artery Branches of 1st part Vertebral artery – enters suboccipital triangle after making
wide curve, which is needed so that fainting does not occur
Subclavian Steal with every rotation of neck
syndrome If narrowed at origin subclavian steal syndrome => opposite
Coarctation of Aorta vertebral artery fills by diverting blood away from basilar to fill
affected subclavian from above => reduction of blood
Location of inf reaching medullary region of brain with ischemia of upper
 cervical/ stellate limb/ giddiness resulting
ganglion Stellate ganglion right below origin of vertebral artery

Int thoracic – divides into musculophrenic (diaphragm, adj

muscles) and sup epigastric, and pericardiophrenic supplying
phrenic nerve
Branches to each intercostals, thymus, pleura and
pericardium
If aorta congenitally narrowed beyond origin of subclavian
(coarctation) blood reaches aorta via anastomosis between IC
branches of int thoracic and aorta => dilation of IC branches
Used in coronary artery occlusive disease – implanted into
vessel beyond narrowed segment
Branches of 2nd part Thyrocervical trunk –
- inf thyroid along inner border of scalenus ant, enters thyroid
gland to supply bulk of gland, related closely to recurrent
laryngeal nerve
supplies parathyroid glands, => if ligated then hypofunction
of these glands
- transverse cervical & suprascapular – muscles of scapular
region, scapular anastomoses which play role in coarctation of
aorta
- costocervical trunk – sup IC to supply first two IC spaces and
anastomose with aorta, and deep cervical to supply deep
neck muscles
Subclavian vein Drainage Most of analogous branches of artery
If not into subclavian, then drain into EJV or brachiocephalic
vein
Cervical nerves Brachial plexus C5/6 form upper trunk, C7 is middle trunk, C8-T1 is lower
Thoracic outlet trunk
syndrome Sandwiched between scalenes after further subdivisions into
Cervical branches ant and post behind clavicle, regroup to from cords in axilla

Thoracic outlet syndrome (scalenus ant syndrome,

costoclavicular syndrome) – due to subclavian vein, artery
and plexus passing between clavicle and first rib, subclavius
muscle cushions this compression
Radial pulse can be obliterated by bracing down, channel
enlarged by either removing scalenus ant, first rib or extra
cervical ribs
Cervical branches – supply subclavius, suprascapular nerve
and serratus anterior (all start with S)
Long thoracic nerve which supplies serratus ant is from C5 but
has fibers from C6 and C7 too (rhomboids receive supply from
own branch of C5 not from brachial plexus)
Cervical plexus C4 in both brachial and cervical
Mostly behind scalenus medius
Phrenic – C345, curve around lateral edge of scalenus ant,
mixed sensory and motor
Thoracic duct Drainage From everywhere except right chest arm head and neck and
Malignancy lower half of right lung
Malignant cells pass from rest of body to venous system, pass
from cervical part to neighboring supraclavicular nodes
Head Diploe Function and location Spongy bone between inner and outer tables of skull bones,
responsible for making blood cells and also deposition site of
secondary tumors
Skull bones Sutures Initially membranous and ossify with passing years
Molding Fetus able to compress its head to smallest possible size
Sutures overlap during delivery – molding, if excessive
molding due to tight fit, then damage to intracranial
structures
Frontal bones Metopic suture Suture between frontal bones that disappears in 90 % of
Features skulls
Supraorbital nerve passes through supraorbital foramen and
anesthetic at this notch will anesthetize substantial area of
scalp
Lacrimal gland slightly above junction of the zygomatic
process to form zygomatic arch
 Trochlea, spine by the articulation of frontal with nasal bone,
attaches pully for sup oblique muscle of eye
Superciliary ridges become larger in elderly
Frontal tuberosity more pronounced in child
Frontal air sinus Frontal air sinuses separated by a not so median septum
Filled with pus etc. and if fractures of frontal bone pass into
frontal air sinus then can get infected and enter cranial cavity
Parietal bones Features Asterion at the junction of occipital parietal and temporal
bones
To each side of the sagital-lambdoidal junction are grooves for
the emissary veins between scalp and sagittal sinus
Occipital bone Features Made up of four bones that are separate at birth and soon
fuse
Foramen magnum transmits – spinal cord with meninges,
spinal roots of accessory nerves, vertebral vessels and
sympathetic plexuses and spinal vessels and apical ligament
Temporal bone Features Ext auditory meatus mostly tympanic plate of temporal bone
McEwan’s triangle Medially fuses with petrous part of temporal
Mastoiditis Triangle is formed by line down from ext acoustic meatus,
supramastoid crest, suprameatal spine to the zygomatic
process is the McEwan’s triangle
Beneath triangle is mastoid antrum, prolongation of middle
ear and commonly involved in middle ear infections
Mastoid process is post and inf to the antrum, and develops
starting when baby begins lifting head
Cavity prolonged into process by intercommunicating air cells,
which allows spread of middle ear infections to cause
Mastoiditis
Styloid process – formed from second pharyngeal arch
cartilage
Mastoid – from petrous
Sphenoid bone Features Separated by deviated septum like frontal bones
Tuberculum sellae site where ant lobe of pituitary passes form
origin in oral cavity to interior of skull
Tumors migrate from pharynx to cranium –
craniopharyngeomas, dorsum sellae over sella turcica
Optic chiasma ant to tuberculum sellae
Post surface united to occipital with a cartilaginous joint
Sup orbital fissure between greater and lesser wings of
sphenoid
Pterygoid processes attach muscles of palate and upper
pharynx, medial pterygoid ends in hamulus which hooks
tensor palatine muscle
Foramena Rotundum – maxillary nerve
Ovale – mandibular nerve
Spinosum – middle meningeal vessels
Sup orbital fissure - ophthlamic
Ethmoid Features Crista galli on perpendicular process, attaches falx cerebri
Ethmoiditis Cribriform plate – passage of olfactory nerve rootlets
Two lateral masses of ethmoid honeycombed by air cells – ant
and middle post sinuses
Infection of air sinuses – ethmoiditis
Zygomatic Features Forms prominence of cheek and inf boundary of orbit
Nasal, lacrimal, Features Maxillary process in orbit articulates with lacrimal bone and
maxillary contains the lacrimal sac – absorbs tears that are produced by
lacrimal gland after flowing across eye
Maxillary air sinus, infraorbital foramen where terminal part of
maxillary nerve exits to face are features of maxillary bone
Palatine Features Has a vertical portion wedged between pterygoid process of
sphenoid and maxilla
Vomer Features Articulates with bones forming roof and floor of nose
Mandible Features Coronoid process and condyle
Attachment for temporalis muscle and articulation with
mandibular fossa for the TMJ respectively
Notch between where the muscular branch (masseteric) of
mandibular nerve passes over mandible
Mental foramen for passage of mental nerve
 Supraorbital and mental foramina lie in same vertical line next
to space between two premolar teeth
Lingula in the mandibular fossa landmark for anesthetizing
the dental nerve which supplies the teeth of the lower jaw
Base of skull Features Premaxilla contains the four incisor teeth, and is joined to
Cleft palate/ hare lip maxilla by a suture which then fuses
Torus palatinus When maxillary bones do not fuse – cleft lip
When premaxillary bones also do not fuse – hare lip because
lip also involved
Torus palatinus – when a large lump found at junction of
palatine plates of maxilla and palatine bones
Foramen lacerum – on undersurface of petrous temporal,
posterolateral to it lies the carotid foramen admitting int
carotid artery, closed by cartilage in life
(Int carotid so convoluted so as to reduce impact of a pulsatile
inflow into a rigid cavity)
Jugular fossa – accommodates the jugular bulb a dilatation of
the IJV
Digastric fossa for attachment of digastric
Medial to this is groove for occipital artery
Stylomastoid foramen – admits CN VII
Condylar canal in front of condyle through which hypoglossal
nerve emerges
Fossae Clinical aspects Ant – fracture of cribriform plate of ethmoid or orbital plate of
frontal bone will cause bleeding into nose and/or orbit
When fracture of roof of nose involves meninges, CSF leaks
into nose – cerebrospinal rhinorrhea, may spread as
meningitis from nose to meninges, olfactory nerve usually
damaged because runs through cribriform plate => anosmia
Subconjunctival hemorrhage in fracture eof orbital plate,
cause bulging of eyeball or paralysis of eye muscle when
blood flows from orbit and beneath conjunctiva

Middle – tegmen tympani fracture (roof of middle ear) causes

bleeding into middle ear => bluish bulge of tympanic
membrane
May involve meninges and causes leakage of CSF into ear –
otorrhea

Post – if basilar part of occipital bone fractured where it forms

roof of pharynx, bleeding will occur into pharynx and usually
regurgitates into mouth
Skull Development Vault and sides – membranous
Base – cartilaginous
Mandible fuse in year 2, frontals later
Ossification of parietal and frontal bones begins at prominent
tuberosities and spreads throughout bones later

Fontanelles – ant useful for sampling ventricles or blood from

sup sagittal sinus (closes by end of second year)
Bulging indicates increased intracranial pressure and
depression means dehydration

Mastoid process does not develop completely until SCM fully

active => stylomastoid foramen is near the surface in infant
skull and nerve may be damaged
External acoustic meatus very short in child because
tympanic bone grows later from an incomplete ring at birth.

Face is small in child because of:

- rudimentary air sinuses (grows at age 7/8 and puberty)
- lack of development of teeth and therefore of mandible

Failure of fusion of skull usually at ant and post extremities

and protrusion of meninges with or without brain tissue might
occur
Easy to diagnose at occipital because bulging at coughing or
crying => increased intracranial pressure
 At nasal region will bulge into nose but may be removed in
place of a polyp.
Scalp Features Due to blockage of sebaceous glands at hair follicles
Sebaceous cysts Inflammatory lesions extremely painful because connective
Gaping wounds tissue layer which contains nerves and blood vessels is dense,
Black eyes also infiltration of anesthetic is difficult as a result. Dense
Cephalhematoma fibrous tissue holds blood vessels open causing profuse
bleeding
Aponeurotic layer stretches between occipitalis and frontalis
and laterally to zygomatic arch and so wounds here gape
because pulled open by two muscles
Black eye affecting upper lid and lower lid due to blood
accumulation in areolar layer of injury to scalp gravitates
inferiorly to eyelids
Cephalhematoma – collection of blood under pericranium of
bone following excessive molding, usually affecting parietal
bone (most mobile)
Lymphatic drainage No lymph nodes on scalp so drains to nodes at base of scull
Main supply for skull bones is from meningeal vessels
internally and vessels supply muscles attached to eh skull
externally NOT from scalp vessels
Arterial supply EC and IC
Ophthalmic -> supratrochlear and supraorbital
EC branches – facial and superficial temporal and posterior
auricular and occipital supply skin of the head
-Facial - IC cutaneous and EC facial anastomose at inner angle
of eye. Increased pulse amplitude within facial artery
indicates blockage of IC (Facial crosses body of mandible in
front of masseter muscle and then up to inner angle of eye)
-Sup temporal - palpable in front of tragus of ear – biopsies
taken here might include auriculotemporal nerve
-Occipital – anastomosed to facial in cases of intracranial
ischemia
Venous drainage - Facial more superficlaly and straighter than artery
Facial -> deep facial -> pterygoid plexus over buccinator
muscle -> cavernous sinus
So two venous connections between face and cavernous sinus
and allow infected facial lesion to spread
=> area around side of nose and upper lip = dangerous area
of face
- Mastoid emissary: intracranial sigmoid sinus -> post
auricular also allow for extracranial lesions to spread
intracranially
Innervation - Facial nerve – opththalmic – side of nose, upper eyelid, scalp
upto vertex
Maxillary – area of cheek
Mandibular – area of lower jaw
Three areas meet at angle of mouth
- Cervical: post scalp – greater and lesser occipital – post and
ant rami of C2
Skin over angle of mandible – greater auricular – ant ramus of
C2
Face Features No deep fascia so muscles insert into bone or skin
Infection and injury accompanied by swelling
Muscles – innervated by terminal branches of facial nerve
So facial nerve paralysis => cannot close eyes or mouth
TMJ Features Articular eminence and postglenoid fossa – mandibular fossa
Clicking of jaw – loose articular disc
Mumps – glenoid lobule of parotid passes between tympanic
plate and condyle of mandible => opening and closing jaw is
painful
Dislocation – due to sudden contractions sending condyle
forward over eminence into the infratemporal fossa.
Neighboring muscles go into spasm to prevent painful
movement so condyle pulled upward by masseter and medial
pterygoid
Reduction – by pulling mandible downward to overcome
spasm and then backward push
 Capsule and disc attachment get looser with each succeeding
dislocation
Muscles Temporalis and masseter – elevate
Digastric, mylohyoid, geniohyoid – depression
Lateral pterygoid – protrusion
Medial pterygoid – retraction
Muscles of mastication – motor root of mandibular nerve
Buccinator – passing food from vestibule into mouth for
proper mastication – CN VII, drooling if inactive
Salivary glands Parotid Lies in contact with masseter, medial pterygoid, SCM and
disgastirc because of their relationships to the mandible and
mastoid foramen respectively
Duct palpable crossing the contracted masseter, pierces
buccinator opposite third molar to enter mouth – oblique
passage prevents refliux into duct form mouth
From most superficial to deepest:
- Facial nerve s- splits into two terminal divisions to supply
facial muscles => swelling with paralysis of nerve
- retromandibular vein – leaves at lower border and ant ->
facial, post -> EJV
- EC enters gland and bifurcates into internal maxillary and
sup temporal

Important lymph nodes – parotid mass could be primary

tumor in pharynx spreading to parotid lymph node
Auriculotemporal nerve – close to parotid, joins sup temporal
artery on side of face
Serous secretion => no calculi
Submandibular For removal:
- Incision made well below lower border of mandible to avoid
severing mandibular branch of facial as it turns up over
mandible
- Grasped and freed from mylohyoid (has a free post border
around which the gland hooks) and quadrilateral hyoglossus
on a slightly deeper plane
- Facial artery buries itself in post portion of gland before
turning up between gland and lower border of mandible which
it crosses
- hyoglossus has (1) large lingual nerve with PSNS secretory
branches, (2) submandibular duct behind post border of
mylohyoid which could get entangled with lingual nerve, (3)
hypoglossal nerve with accompanying vein
Usually removed to remove diseased submandibular lymph
nodes, or if stone blocks duct of Wharton whose orifice can be
seen lateral to frenulum
Sublingual Mostly mucous secretion, problems rare
Teeth Development From a shelf of epithelium from which ingrowths pass deeply
to form primitive tooth buds
Mandibular appear before maxillary
1st molar at 6th year – first permanent tooth, second
permanent molar at 12, from 18 wisdom tooth (sometimes
may stay impacted in mandible => trouble)
Roots Upper premolar and molars project into floor of maxillary air
sinus
Sometimes only mucous membrane separates – hard to
distinguish between sinusitis and tooth abcesses
Second and third molars of lower jaw lie below mylohyoid line
=> root abscesses from these teeth present in neck, those of
others present in mouth
Nerve supply Maxillary – terminal branches of maxillary nerve
Mandibular – terminal branches of mandibular nerve, ear also
innervated => toothache may present as earache
Same for sixth year molar eruption which may cuase ear
ache.
Tongue Development and From first and third arches and muscle from occipital
features myotomes
Second arch – buried in substance of tongue
Ant 2/3 covered by thick mucous membrane with projecting
 filiform and fungiform papillae
Filiform – roughness
Fungiform – small pink spots
Vallate – in front of sulcus terminalis
Foramen cecum – origin of thyroglossal duct at apex of sulcus
terminalis
Ant 2/3 is flat, Post 1/3 has lingual tonsil
Muscles Intrinsic – shape, extrinsic – position (genio, hyo and
styloglossus)
Genio – protrudes, hyo – downward and sideways, stylo –
retracts
Mylohyoid - elevates
Vascular Lingual artery which loops allowing for protrusion
Lymphatics Ant 2/3 drains to submandibular
Post 1/3 draines to deep cervical
Post 1/3 and area near midline – drain bilaterally
Innervation Ant 2/3 – general - lingual branch of mandibular
Taste – chorda tympani of CN VII
Post 1/3 incl. vallate papillae – glossopharyngeal
Motor – CN XII – every muscle except palatoglossus
CN X and IX – palatoglossus
CN V – lingual branch has sensation to ear, and also earaches
arise from lesions on tongue
Facial nerve lesion – lose taste from ant 2/3
Hypoglossal lesion – that half would be paralyzed
Pituitary gland Function and Controls secretion of all other endocrine organs
structure Ant lobe passes from buccal cavity through base of skull to
reach intracranial cavity
Post lobe is a downgroth of base of brain, and between two
lobes is pars intermedia
Infundibulum connects it to base of brain through the dorsum
sellae
Disease Either excessive or insufficient secretion, or enlargement of
gland which compresses surrounding structures
Laterally: cavernous sinuses where III IV V2/3 VI and IC lie, and
often involved in pituitary tumor
Ant lies optic chiasma and if involved in tumor, visual defect
occurs
Sup compress base of brain and inf excavates sella trucica
and encroaches on sphenoidal sinus => seen radiographically
Reach fosa to remove tumor via nasal cavity and sphenoid
sinus and avoid nasal contents by staying in a plane deep to
mucous membrane
Nasal Nose Functions and Warm humidify filter inspired air, using columnar ciliated cells
passage structure interspersed with goblet cells. Vascular plexus heats air.
s, Sneeze reflex removes objectionable material
pharynx Deviated septums are common due to trauma
and Chonae are bones that create meatuses – upper two are
larynx processes of ethmoid and inf is an independent bone
Innervation V1 V2
Arterial supply Maxillary artery post and facial artery ant, anastomosis at
region of vestibule
Venous drainage Submucosal plexus of veins
Paranasal air Bones involved and Sphenoidal – drains into sphenoethmoidal recess above
sinuses location superior concha
Ethmoidal – lateral mass of ethomoid and consists of ant
middle and post air cells, drain into middle meatus
Ethmoidal sinusitis due to inflammation
Frontal – deep under superciliary ridges, frontonasal duct
drains into middle meatus.
Frontal sinusitis presents with frontal headache with
tenderness over sinus and pus in middle meatus.
Maxillary – opening into middle meatus is near upper part of
sinus near its roof, also roots of some upper teeth esp
bicuspids and molars project into floor of maxillary sinus
Pharynx Structure Squamous mucous membrane except for nasal area where it
is ciliated with submucous glands
 Inf constricter acts as sphincter, area between transverse and
oblique fibers of this muscle called the dehiscence of Killian is
weakened by strong propulsive effects and may cause a
diverticulum but may be so symptomatic as to require
removal
Innervation Pharyngeal nerve plexus mainly CN XI fibers carried in
pharyngeal branch of X with some of sup cervical ganglion
and ext and recurrent laryngeal nerves
Diseases of X or XI lead to paresis of constrictor muscles –
difficulty swallowing also called bulbar palsy.
Nsaopharynx Relations Phyrngeal opening of pharyngotympanic tube lies 1cm behind
and just below post end of inf nasal concha
Posterosup. is tubal elevation (torus) caused by shape of
underlying tubal cartilage and collection of lymphoid tissue
Diseases Lymphoid tissue may swell in addition to torus and cause
blockage of tube => deafness during cold
Nasopharyngeal tonsil atrophies at puberty and reappears in
elderly causing an increase in retropharyngeal space =>
diagnosis of enlarged nasopharyngeal tonsil
Oropharynx Structure nad Behind mouth between soft palate and tip of epiglottis,
location palatoglossal and palatopharyngeal arches separate the
arches form the cavity.
Palatine tonsils Tonsillar pits
Sup constricter muscle lies outside and is pierced by several
tonsillar arteries esp tonsillar branch of facial artery
Veins pass to pharyngeal venous plexus
 post-tonsillectomy hemorrhage
Drains to upper deep cervical nodes esp tonsillar
(jugulodigastric) node at junction of common facial vein and
IJV, commonly results after sore throat
Innervation V and IX really diffuse – local infiltration via local infiltration
instead of regional block
Waldeyer’s ring – lingual, palatines, adenoid, tubal
Laryngopharynx Features Piriform fossa on either side hiding place for tumors
Palatopharygeus form hard palate, salpingopharyngeus from
Eustachian tube, stylopharyngeus from styloid process
outside constrictors and passing between upper two to join
the other muscles
Elevators of pharynx
Palate Hard palate Maxillae and palatine bones
Mucous membrane strongly adherent and imp in cleft palate
operation
Small salivary glands so salivary gland tumors may present
here
Soft palate and Tensor palatine muscle closely related to Eustachian tube so
muscles contraction opens the tube allowing air to pass between nose
and middle ear
Levator palatini main function is to elevate the soft palate but
also opens up Eustachian tube
Both together abolish aircraft deafness
Palatopharyngeus and palatoglossus help close off oral cavity
from oropharynx
Musculus uvulae nerve supply interruption – displacement of
uvula to opposite side
Innervation Naso: V esp V2 and V3, pharyngeal branch of maxillary
Oro: IX
Laryngo: X
Motor: tenosr palatini by V via otic ganglion
All others by pharyngeal plexus from XI which enters X and
distributed by pharyngeal branch

Phonation and deglutition: nasopharynx sealed off by

elevating soft palate against sup constrictor
Larynx Function and Phonation
cartilages Criocoid – only completely circular one, bears arytenoids
Arytenoids – ant projection for vocal cord and laterl for
muscles and sup for corniculate cartilage
 Thyroid – laryngeal prominence in male
Corniculate and epiglottis– yellow elastic along with epiglottis,
does not calcify with age
Whole larynx in adult: C3-6, in child: C3-4
ligaments Cricovocal – free border is vocal cord
Quadrangular – upper free border is areepiglottic fold
Lower is vestibular fold or false vocal cord
Thyrohyoid – small bursa between membrane and hyoid bone
= subhyoid bursa facilitates laryngeal movement, pierced by
sup laryngeal artery and int laryngeal nerve
Muscles Intrinsic:
Cricothyroid – tilds thyroid forward or cricoid backward, to
separate them so vocal cord lengthened
Thyroarytenoid – shortens vocal cord
Post cricoarytenoid – more oblique with descent and so upper
horizontal and lower vertical, former rotate, latter separate
arytenoids (dilator of larynx)
Lateral cricoarytenoid – adductor of cords
Interarytenoid – connect the two arytenoids, pulls epiglottis
and arytenoids together & closes laryngeal inlet

Extrinsic:
Elevators: mylo, stylo, geniohyoid, stylo, salpingo,
palatopharyngeus
Depressors: strap muscles ant to laryngeal skeleton
Mucosa Mainly columnar ciliated with scattered goblet cells
Squamous – vocal folds and laryngeal inlet
Vocal fold – no submucosa, minimal blood vessels => whitish
Laryngeal edema – submucous tissues swell markedly,
swelling may continue downwards and result in complete
laryngeal obstruction and asphyxiation
Other structures During mouth to mouth head should be fully extended to
bring oral cavity in line with larynx
Vallecula – between lateral glossoepiglottic folds of mucous
membrane where neoplasms may hide and foreign bodies
impact
Saccule – projects from ventricle between false cord and
lamina of thyroid cartilage and secretes mucus
Functional Aryepiglottis and interarytenoids contract and close sphincter
movements Expiration of air through vocal cords vary intensity and pitch
of sound
Arterial supply Above folds – sup laryngeal branch of sup thyroid
Below – inf laryngeal branch of inf thyroid
Innervation Above – int laryngeal branch of vagus – sensory and
secretomotor
Below - recurrent laryngeal nerve
All muscles except cricothyroid (ext laryngeal branch of sup
laryngeal) – recurrent laryngeal
First cricothyroid innervated pulling cords on stretch
stimulating other muscles to act => tuning fork of larynx
Lymphatics Deep cervical nodes as they lie along jugular vein, upper half
to upper and lower half to lower
Involved in laryngeal disease
Some also to prelaryngeal and pretracheal nodes
Lymph Chains Circular Occipital - most post, between mastoid process and inion
nodes of post auricular – on mastoid process behind pinna drain scalp
head back of pinna and ext auditory meatus
and preauricular – immediately in front of tragus of ear and
neck superficial to parotid, drains outer side of pinna
parotid – more superficial for eyes front of scalp and ext
auditory meatus, deeper ones for nasopharynx and back of
nose
facial – on buccinator below orbit and over facial vessels as
they cross mandible, drain conjunctiva eyelids nose and
cheek
submandibular – same fascial capsule as submandibular
glands
submental – drain central part of lower lip, floor of mouth tip
 of tongue and incisor area of mandible
Vertical Superficial – ant cervical in midline draining larynx and
trachea
Deep – along recurrent laryngeal called paratracheal
Lymph node of tonsil in angle between IJV and common facial
Lymph node of tongue between at bifurfaction of common
carotid involved in tongue lesions
Supraomohyoid above point where ant belly of omohyoid
crosses carotid sheath
Final drainage – into jugular lymph trunk leaving inf deep
cervical and enter junction of subclavian and IJV on R and
thoracic duct on L
Clinical approach - No lymph nodes on cranium
- Nodes in lower third enlarge due to diseases below clavicle
eg. virchow-troisier enlargement from stomach cancer
- middle third enlarged node emanates from thyroid gland
disease
- upper third due to disease of head and upper neck
- ant submental drain central wedge of tissue in floor of
mouth including tip of tongue floor of mouth gums lower lip
opposite four lower incisor teeth
- post submandibular drain lateral part of lower lip all upper
lip and ext nose and ant 2/3 of tongue , also from paranasal
sinuses and ant half of walls of nasal cavity
- Most post drain structures not drained by aforementioned
- more post higher to which they drain i.e. highest jugular for
pharyngeal tonsils
Ear External ear Features Cellulites unlikely due to lack of subcutaneous fat
Ant to tragus is preauricular lymph node and pulse of
superficial temporal artery
Innervation Sensory – greater auricular to lower part
Auriculotemporal and lesser occipital to facial and cranial
surfaces
External auditory Features Short meatus of child
meatus Thick hairs and sebaceous and wax glands on cartilaginous
part and smooth of bony
Inflammatory lesions common in meatus
Proximal to tympanic membrane is depression where foreign
bodies can hide
Skin is closely adherent to underlying cartilage or bone
Innervation Auricular branch of vagus for post half
Auriculotemporal for ant half
=> elderly patients may faint as result of cardiac syncope if
syringing out ear due to vagal innervation, same with
coughing and gagging
Intraoral structure pain referred to ear eg. Pain from erupting
tooth
Middle ear Features Tympanic membrane so oblique in child almost horizontal
Fibrous tissue lined by skin ext and mucous membrane int
Cartilaginous part 2x as long as bony part of Eustachian tube
Aditus into upper part of tympanic antrum leads to mastoid
air cells so infections spread from aditus into tympanic antrum
and mastoid air cells
Auditory ossicles only bones which are full sized at birth
Problems Conductive defect - diagnosed if easier to hear tuning fork
placed on mastoid process than near ext ear
Occlusion of auditory tube – absorption of iar, potential
vacuum prevented by outpouring of sticky fluid => glue ear
Destructive lesions of middlear can damage facial nerve as it
passes through
Middle and ext ear Development Pinna – series of tubercles around margins of first branchial
groove
Ext meatus – remains of first ext branchial groove or cleft
Middle ear – first pharyngeal pouch from lateral recess of
pharynx
Auditory tube and tympanic cavity – ectoderm of ext
diverticulum
Tympanic antrum well developed but not mastoid process at
 birth => infections of tympanic antrum common in first two
years due to wide short Eustachian and frequent upper
respiratory tract infections
Inner ear Features VIII reaches walls of semicircular canals and cochlea and
consists of cochlear division for cochlea for hearing and
vestibular division to utricle saccule and semicircular canals
for equilibrium
Orbit Orbit Features Protect globe by root of nose and supraorbital margin
Medial - Small depression with trochlea on medial wall for
attachment of tendon of sup oblique, also related to
ethmoidal sinus via ethmoid bone
Floor – infraorbital terminal branch of maxillary nerve
Lateral – zygomatic withstand molar masticatory force if
fractured will result in depression of orbital floor and dropping
of eyeball with consequent diplopia (double vision)
Optic canal transmits optic nerve with meningeal coverings
=> eye is an extension of the brain => better to enucleate
eye from capsule than sever optic nerve to avoid meningitis
Outer layer of dura becomes periostium of orbit
Contents Globe Outer fibrous, middle vascular, inner nervous continued as
optic nerve
Post 5/6 – sclera, ant 1/6 – cornea
Corneal scarring – impaired vision
Corneal transplantion – successful due to lack of vasculature
Muscles Rectus muscles from common tendinous ring
Sup rectus – elevation/adduction, inf – depression/abduction
lateral rectus – abduction, medial – adduction
Sup oblique – muscle of tramp – down and out
Levator palpebrae sup – probably was once same as sup
rectus because lie over each other and share nerve supply
Smooth muscle – muller’s muscle of eyelid – SNS
Horner’s syndrome – drooping of upper lid due to loss of nerve
supply to these muscles
Fascial sheath Blend with sclera and composed of areolar tissue to allow for
(Tenon) movement of eyeball
Check ligaments – fascial extensions of lateral and medial
recti allowing for movement of eyeball via the suspensory
ligament of the eye, facia bulbi forms a socket for a glass eye
when eye is removed
Arterial supply Infraorbital branch of maxillary (and opththalmic artery),
passes through optic canal below opththalmic nerve
Central artery of retina pierces optic nerve to reach retina
before dividing into branches
Venous drainage Sup vein accompanies ophthalmic artery and communicates
with ant facial vein
Inf vein communicates with pterygoid plexus through inf
orbital fissure
Both drain into cavernous sinus allowing for infections of head
and neck to spread to cavernous sinus
Eyelids Features No subcutaneous fat and easily fills up with fluid
Orbicularis oculi – two parts palpebral part from medial
palpebral ligament and lacrimal sac and orbital portion
running over forehead and check in concentric loops
Tarsal plates Have tarsal glands visible through conjunctiva
Medial palpebral ligament joins palpebral fascia to each bony
crest, helps in locating the lacrimal sac
Eyelashes Sweat and sebaceous glands related to and opening ducts
near hairs
When infected => stye forms and when tarsal glands get
blocked – meimobian cyst develops
Lacrimal apparatus Features Orbital and palpebral parts of lacrimal gland
Mucous membrane thrown into folds preventing substances
from entering eye via the lacimal apparatus
Corneal reflex: involuntary blinking upon irritation via
orbicularis oris (VII) and sensation via cornea (V)