2021MSC Oral Biology Semester 1 2013

Laboratory Manual Anatomy of the Head and Neck Region Laboratory 5

Cranial Nerves, Local Anaesthesia Oral Cavity Pharynx and larynx

Laboratory 6: Cranial Nerves, foramina and innervation

Learning Objectives

Review the foramina on the skull through which the cranial nerves pass. Study the cranial nerves in relation to their course in head and neck and the structures they innervate. Be able to identify the cranial nerves from the brainstem. Identify the nerves closely related to the pharyngeal muscles.

Describe the primary innervation of structures in the oral cavity.

Describe the innervation of the tongue muscles. Identify and study the relationship of important nerves in the floor of the mouth. Study the anatomical relations of the parotid gland. Identify the facial nerve and note the relationship of the facial nerve with this gland. Be able to identify the mandibular and maxillary nerves and their main branches; and describe the structures supplied by these nerves.

Describe the nerve supply of th e larynx and the major anatomical features of the larynx.
Be able to identify the nerves of the neck. Examine the oral cavity and identify the major structural features Understand the role of the constrictor muscles in swallowing Explore the muscles of the tongue

Station 1
Cranial nerves: Osteological foramina

On the open skull, identify the foramina through which the cranial nerves pass: o Cribriform plate of the ethmoid bone Which cranial nerve/nerves? _________________________________________________________________

o Optic canal - Which cranial nerve/nerves?

_________________________________________________________________

o Superior orbital fissure - Which cranial nerve/nerves?

_________________________________________________________________

o Foramen rotundum - Which cranial nerve/nerves?

_________________________________________________________________

o Foramen ovale - Which cranial nerve/nerves?

_________________________________________________________________

o Internal acoustic (auditory) meatus - Which cranial nerve/nerves?

_______________________________________________________________

o Jugular foramen - Which cranial nerve/nerves?

_________________________________________________________________

o Hypoglossal canal - Which cranial nerve/nerves?

_________________________________________________________________

Identify and label the foramina through which each of the cranial nerves exits (later, you can also label the other structures to help your review). Indicate where the nerve will then progress to (ie what does it innervate)

 Using models and specimen, examine the base of the brain to identify the sites of emergence of cranial nerves. Name the cranial nerves.

Note how the cranial nerves are numbered sequentially, from anterior to posterior

Note that olfactory and optic nerves appears like extensions of the brain. Identify the following:

o CN 1 Olfactory bulb & olfactory tract o CN 2 Optic nerve. Note the optic chiasma

o CN 3 Oculomotor. Emerge at the junction between pons and midbrain between the two cerebral peduncles (interpeduncular fossa) o CN 4 Trochlear. It is the only cranial nerve that emerges from the posterior aspect of the brain. o CN 5 Trigeminal. It emerges from the anterior aspect of the pons as two roots (motor and sensory). The 3 branches of the trigeminal nerve: v Ophthalmic (CN 5 I or V1 ) sensory v Maxillary (CN 5II or V2 ) sensory v Mandibular (CN 5III or V3 ) sensory & motor o CN 6 Abducens, CN 7 Facial & CN 8 Vestibulocochlear. They emerge at the angle formed by the medulla, pons and cerebellum. This is a relatively common site for tumours. o CN 9 Glossopharyngeal, CN 10 Vagus and CN 11 Accessory. They emerge between the olive and the inferior cerebellar peduncle. o CN 12 Hypoglossal. It emerges between the olive and pyramid of the medulla.

Now match the cranial nerves to the foramina through which they pass Foramen o Cribriform plate of the ethmoid bone o Optic canal
Cranial Nerves

o Superior orbital fissure o Foramen rotundum o Foramen ovale o Internal acoustic (auditory) meatus o Jugular foramen o Hypoglossal canal
By examining the point of emergence from the brain and the point of exit from the skull you can develop and understanding of the intracranial course of the cranial nerves. The diagram on the next page illustrates each of the nerves as they pass into the skull (left side) and pass out of the skull (right side).

Station 2
Infratemporal fossa:
contains the two pterygoid muscles, branches of the maxillary artery/veins, pterygoid venous plexus, branches of the mandibular nerve and the chorda tympani.
Boundaries: Medial: Lateral pterygoid plate Lateral: Medial surface of the ramus of the mandible Anterior: Tuberosity of the maxilla Posterior: Deep part of the parotid region Superior: greater wing of sphenoid bone Inferior: Medial pterygoid muscle

Pterygopalatine fossa and pterygomaxillary fissure Identify the pterygomaxillary fissure and fossa on the TMJ diagram below

Locate the pterygopalatine fossa.

o Which branch of the trigeminal nerve can be seen within this fossa?

Identify the nerves on the above diagram. Identify the trigeminal nerve branches within this fossa and the areas that they innervate.

Does the diagram above represent sensory or motor innervation?

Now locate the foramen ovale.

o Which branch of the trigeminal nerve can be seen emerging from this foramen? o Identify the major branches of this branch of trigeminal nerve emerging from this foramen and name the areas they innervate: v Sensory

v Motor

CLINICAL NOTE: The inferior alveolar nerve is anaesthetized during dental procedures. Local anesthetic is injected near the mandibular foramen (through which ligament?) to block the inferior alveolar nerve. This will usually result in anesthesia of the lower jaw teeth (inferior alveolar nerve) and lower lip (mental nerve).

Parotid gland

Note the superficial part of the parotid gland lying superficial to the masseter muscle. The gland fills the gap between the mandible and the mastoid process. View the lateral side of the face and recognise the relat ionship/locations of the branches of the facial nerve, external jugular vein, external carotid artery, parotid duct, superficial temporal vessels, transverse facial vessels and auriculotemporal nerve to the parotid gland. The diagram on the next page has had the parotid gland removed to better illustrate the relationships between the neurovascular and glandular structures in the region.

Now locate the stylomastoid foramen.

o Which nerve emerges from this foramen? o This nerve provides special visceral efferent or motor nerve function to all of the muscles from pharyngeal arch number______? These muscles include those of facial expression, buccinators, platysma, scalp, external ear, stapedius, stylohyoid and the ______________belly of digestive. o It provides special sensory for taste to which part of the tongue?
___________________________________________________________________ What is the name of the nerve which provides this special sensory taste sensation (and parasympathetic innervation to the submandibular gland?) ___________________________________________________________________ This nerve has five major branches to the face (plus the nerves to stylohyoid, digastric and tongue. To represent this, put you right hand palmar surface onto the lateral side of your face. Your little finger should be on the anterior neck (cervical branches), your ring finger, marginal mandibular, your middle finger buccal branches, index finger zygomatic branches and your thumb, temporal branches. There is also a posterior auricular branch posterior to ear.

Where is the petrotympanic fissure? o Name the nerve that emerges from this fissure?
____________________________________________________________________ What structure does it innervate? ____________________________________________________________________

Parasympathetic nerve supply:

Which cranial nerve carries the preganglionic parasympathetic fibres to the parotid gland? _________________________________________________________________________

Name the ganglion in which these fibres synapse.

_________________________________________________________________________ How do the postganglionic secretomotor fibres reach the parotid gland? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

If the facial nerve was damaged near its origin or near the geniculate ganglion, identify whether the following clinical signs would be observed:
Motor paralysis of upper and lower parts of the face on the ipsilateral side Motor paralysis of only the upper parts of the face on the ipsilateral side Loss of taste on posterior third of tongue Loss of taste on anterior two thirds of tongue Altered secretion of lacrimal and salivary glands Altered secretion of lacrimal, salivary and parotid glands

If the facial nerve was damaged more centrally, between the geniculate ganglion and the origin of chorda tympani, identify how the clinical symptoms may vary:

If the facial nerve was damaged as it appears from the stylomastoid foramen, identify how the clinical symptoms may vary:

Given that facial nerve damage affects the muscles of facial expression, what specific clinical signs of impaired facial muscle function would you readily observe?

What specific tests would you use to detect these functional changes?

What is Bells Palsy? What clinical signs would you observe or would your patient report?

Station 3
Pharynx
Identify the actions of the pharyngeal muscles Name
Levator veli palatini Tensor veli palatini Musculus uvulae

innervation
Pharyngeal p lexus

Action (simple action)

Elevates palate (name predicts action)

V2
Pharyngeal p lexus Pharyngeal p lexus Pharyngeal p lexus IX Pharyngeal p lexus

Tenses palate (name predicts action)

Moves uvula (name predicts action) (name predicts action) (name predicts action)

Palatoglossus
Palatopharyngeus Stylopharyngeus Salp ingopharyngeus auditory tube

Superior pharyngeal constrictor origin: medial pterygoid plate,& pterygomandibular raphe Middle pharyngeal constrictor hyoid bone &stylohyoid lig

Pharyngeal plexus

Pharyngeal plexus

Inferior pharyngeal constrictor cricoid and thyroid cartilages

Pharyngeal plexus & recurrent laryngeal of X

Identify the 3 circular muscles that form the majority of the pharynx on the specimens and models:

Superior constrictor pterygomandibular raphe + hamulus + mandible

Middle constrictor
hyoid bone - stylohyoid ligament (lesser horn) + greater horn Inferior constrictor thyroid + cricoid cartilages

Posteriorly all 3 are attached to pharyngeal raphe

o Pharyngeal fascia

Identify the following in the models/specimens provided.

o Superior constrictor o Middle constrictor o Inferior constrictor o Pterygomandibular raphe o Buccinator o 3 longitudinal muscles attached to the styloid process, cartilage of the auditory tube and to the soft palate. Describe the nerve supply to the muscles of the pharynx.

There are gaps that separate the superior and middle constrictors and the middle and inferior constrictors. These spaces or gaps are the most common path for nerves and blood vessels to pass through to the oral cavity and the floor of the mouth. o CN 9 or _______________________passes between the superior and middle constrictor o Internal laryngeal branch of the vagus nerve (CN 10) (piercing above thyroid cartilage)

o Recurrent laryngeal branch of vagus nerve (CN 10) passing under the inferior constrictor.

o What structures do CN9 and CN 10 innervate?

Larynx
Identify the following cartilages which form the skeleton of the larynx.

o Thyroid o Cricoid o Arytenoids o Epiglottis

Identify the following structures inside the larynx:

o Glottis o False vocal cord o True vocal cord

Which cranial nerves are involved in speech?

Describe how the vagus nerve innervates the larynx.

Briefly note the actions on the vocal folds and give their nerve supply.

Note that the larynx is attached to the hyoid bone. Therefore the muscles that elevate the hyoid bone, elevate the larynx during swallowing. What are the muscles that elevate the hyoid bone?

Station 4
Innervation of the teeth and palate
Revise the structures of the oral cavity

Observe the following structures in the oral cavity.

o Teeth o Hard palate o Soft palate o Palatoglossal arch o Palatopharyngeal arch o Tonsil o Uvula (note the symmetrical movement of uvula) o Dorsum of the tongue (note the circumvallate papillae) o Gingiva o Underside of the tongue:
Note the frenulum Region of the sublingual gland The opening of the submandibular duct at the sublingual papilla. Note that the openings of the sublingual gland are often numerous, and may open into the submandibular duct as well as along the sublingual fold. Roll your finger on the parotid duct on the face (determine where it lies in relation to the zygomatic arch) with your teeth clenched, then feel the saliva emptying into the cheek near the upper second molar teeth as you compress on the duct.

Soft Palate: This muscular structure is suspended between the nasal pharynx and the oral pharynx and its flexibility and soft construction permits muscle action to elevate it to isolate the oral cavity from the nasal pharynx. The sides are connected to the lateral pharyngeal walls and the anterior to the hard palate. The posterior structure, the uvula is very flexible. Name the muscles that form the soft palate and give the sensory and motor nerve supply to this (note there is more than one motor nerve supply to these muscles)

Examine in your colleague the following:

o Palatoglossal arch (formed by palatoglossus muscle) o Palataopharyngeal arch (formed by palatopharyngeus muscle) o Palatine tonsils (lie between the 2 arches)

Which nerves typically innervate the upper teeth (note the possible variations):

If you have a challenge anaesthetizing the upper teeth, which additional nerve/s do you need to anaesthetize.

If you need to anaesthetize the lower teeth, which nerve/s typically innervate the lower teeth?

Label the features of the hard palate on the figure below

Which nerves typically innervate the hard palate.

Station 5
Floor of the mouth and tongue
List the intrinsic and extrinsic muscles of the tongue.

Understand the nerve supply to the tongue (appreciate the anterior 2/3 and posterior 1/3 supply is different, due to its embryological development): o Sensory -

o Taste

o Motor -

How do the taste fibres from CN 7 reach the anterior 2/3 of the tongue?

Annotate the diagram below to describe the boundaries of general sensory and taste
innervation of the tongue, including the specific nerves that innervate the regions

Hyoglossus: o Study the diagrams or specimens which show the relationships of this muscle to the submandibular gland/duct, lingual and hypoglossal nerves and lingual artery.

State the path taken by the parasympathetic (secretomotor) fibres to reach the submandibular/sublingual and parotid glands (clearly identify which cranial nerve these fibres hitch on to.

Station 6
Neck
Revisit the boundaries of the anterior and posterior triangles of the neck.
Note the contents of the posterior triangle. Identify the landmark features.

o external jugular vein o spinal accessory nerve (CN 11)

o What do es CN11 innervate?