Skull Bones Sutures Landmarks

OSTEOLOGY OF THE HEAD AND NECK
THE SKULL
NORMA VERTICALIS:
- The skull is oval in shape broadened posteriorly by the parietal eminences.
- In children the prominent frontal eminences together with the parietal give the
skull a square shape.
Visible bones:
1-The frontal bone anteriorly
2-The occipital bone posteriorly
3-The two parietals in between
-The upper part of squamous temporal laterally
!-The "ygomatic arch #"ygomatic process of the temporal $ temporal process of the
"ygomatic bones%.
Visible sutures:
1-The coronal suture&
- 'cross the skull
- (etween the frontal $ parietal bones
2-The sagittal suture&
- (etween the two parietals in the midline plane
- It meets the coronal suture anteriorly $ the lambdoid posteriorly
3-The lambdoid suture&
- )ery coarse* tortuous* inverted-) like suture whose ape+ meets the posterior end of
the sagittal suture
- Its diverging two limbs descend in the direction of the mastoid process to meet
the occipito-temporal suture
- ,eparates the occipital from the parietal bones
- -requently contains sutural bones.
-.etopic suture&
- Is a vertical suture that separates the frontal bone into two bones
- /sually obliterated but may persist in 01 of adults
Stigmata:
1-The superciliary ridges&
- form the anterior limit of this view.
2-The lambda 2posterior fontanelle3&
- The meeting point between the sagittal $ lambdoid sutures
- It is a triangular opening in neonates $ closes in the very early few months of
life
3-The bregma 2anterior fontanelle3&
- Is the meeting point between the sagittal $ coronal sutures
- It is a star-shape opening in neonates whose closure is delayed to 1.! years of
life
-The parietal foramina&
- Two small foramina* one in each parietal bone near the sagittal suture
Head & Neck Dr. Nawfal K. Al-Hadithi 1
- They transmit parietal emissary veins
- They are nearer to the posterior pole
NORMA FRONTALIS:
Visible bones:
1-The frontal bone.
2-The bones of the nose&
- 4asal bones
- )omer
- 5thmoid
- Inferior turbinates
3-The bones of the orbit&
- 6acrimal
- ,phenoid
- 5thmoid
- 7ther facial bones
-The ma+illae.
!-The "ygomatic bones.
8-The mandible.
Visible sutures:
1- The fronto-nasal suture* between the nasal bones $ the nasal process of the frontal
bone.
2- The internasal suture* between the two nasal bones.
3- The fronto-"ygomatic suture& between the "ygomatic process of the frontal bone $
the frontal process of the "ygomatic bone lateral to the orbit.
- The "ygomatico-ma+illary suture& oblique suture between the "ygomatic bone
laterally $ ma+illa medially.
!- Inconstant sutures& sometimes seen as the metopic $ the interma+illary sutures.
Stigmata:
1-,uperciliary arches& are two blunt elevations in the frontal bone overlying the
medial ends of both orbits
2-The glabella9 is the depression between the two superciliary arches
3-The supra-orbital foramina& are located at the :unction of the medial $ middle
thirds of each superior orbital margin $ transmit the vessels $ nerves of its own
name.
-The nasion& is the cross point between the fronto-nasal $ internasal sutures
!-The orbit& will be discussed later
8-The anterior nasal aperture& an oval opening narrower above than below from
which the cavity of the bony nose is seen
;-The anterior nasal spine& is a sharp spine in the inferior border of the anterior nasal
aperture in the midline
0-The canine eminence& is an elevation surrounding the root of the canine tooth
<-The incisive fossa& a light depression in the ma+illa medial to the canine eminence
1=-The canine fossa& a more deep depression lateral to the eminence
11-The infra-orbital foramina& well defined rounded foramina in the ma+illae :ust
below the inferior orbital margin* they transmit the nerves $ vessels carrying its own
name
12-The symphysis menti& is a midline ridge in the body of the mandible
13-The mental protuberance& enlarged triangular lower end of the symphysis
1-.ental foramina& small foramina in the mandible* one below each second lower
premolar tooth $ transmit the mental vessels $ nerves
NORMA OCCIPITALIS:
Visible bones:
1-The occipital bone
2-The parietal bones
3-The temporal bones
Visible sutures:
1-,agittal suture
2-6ambdoidal suture
3-7ccipito-temporal #occipito-mastoid% suture
->arieto-mastoid suture.
Stigmata:
1-The lambda.
2-The mastoid foramen& ad:acent to the occipito-mastoid suture* transmits the
mastoid emissary vein
3-The e+ternal occipital protuberance #57>%& a marked rounded process in the
occipital bone in the midline easily felt through the skin
-The e+ternal occipital crest& a well-defined midline ridge e+tending between the
57> $ the foramen magnum
!-The highest nuchal line& faint line starts from the 57> $ e+tends laterally in an
upward curve in the direction of the mastoid process
8-The superior nuchal line& :ust below the highest one $ more marked than it
;-The inferior nuchal line& between the superior one $ foramen magnum* it is also a
well defined line.
NORMA LATERALIS:
Visible bones:
1-The frontal bone.
2-The parietal bone.
3-The occipital bone.
-The temporal bone.
!-The sphenoid.
8-The "ygomatic bone.
;-The nasal bone.
0-The ma+illa.
<-The lacrimal bone.
1=-The mandible.
Visible sutures:
1- The coronal suture.
2-Temporo-parietal #squamosal% suture.
3- The occipito-mastoid suture.
- Temporo-"ygomatic suture.
!- ?ygomatico-ma+illary suture.
8- The fronto-nasal suture.
;- The spheno-frontal suture.
0- The spheno-parietal suture.
<- ,pheno-squamosal suture.
Stigmata:
1-The temporal lines&
- Two lines #superior $ inferior%
- ,tart at the root of the "ygomatic process of the frontal bone $ diverge as they
go posteriorly curving upward* then inferiorly $ then anteriorly completing the
circle by :oining the posterior root of the "ygomatic arch.
2-The infratemporal crest&
- The rough lower free edge of the greater wing of the sphenoid bone
- /sually hidden by the "ygomatic arch
- It separates the temporal fossa above from the infratemporal fossa below
3-The pterygo-ma+illary fissure&
- ' vertical slit e+ists between the posterior border of the ma+illa $ the anterior
border of the pterygoid plate
- This fissure connects the infratemporal with the sphenopalatine fossae $
transmits the posterior superior alveolar vessels $ nerves
-The temporal fossa& is the area bounded by the superior temporal line $
infratemporal crest.
!-The "ygomatic arch& formed by the "ygomatic process of the temporal bone
#posterior @% $ the temporal process of the "ygomatic bine #anterior A%
8-The pterion&
- Is the point where the coronal suture meets the spheno-parietal suture in the
floor of the temporal fossa
- It represents the lateral fontanelle
- ;-The asterion& is the meeting point between the temporo-parietal $ lambdoid
sutures
0-The temporo-mandibular :oint&
- ,een at the inferior aspect of the posterior root of the "ygomatic arch
- 5minentia articularis lies in front of it.
<-The e+ternal acoustic meatus.
1=-The suprameatal triangle&
- 6ies postero-superior to the meatus
- Is an important surgical landmark in ear surgery
11-The mastoid process& is the downward pro:ecting mamillary process of the
temporal bone lies behind the e+ternal acoustic meatus
12-The styloid process&
- ,ometimes seen pro:ecting down deep to the e+ternal acoustic meatus
Head & Neck Dr. Nawfal K. Al-Hadithi
- Is a part of the temporal bone
NORMA BASALIS:
Visible bones:
1-The ma+illa.
2-The hori"ontal plate of the palatine bone.
3-The pterygoid processes $ greater wing of sphenoid.
-The vomer.
!-The temporal bone.
8-The "ygomatic bones.
;-The occipital bones.
0- >arietal bone #sometimes%.
Visible sutures:
1-The interma+illary suture.
2-The palato-ma+illary sutures.
3-The "ygomatico-ma+illary suture
-The temporo-"ygomatic suture
!-The spheno-squamosal suture.
8-The squamo-tympanic suture.
;-The petro-squamous suture.
0-The petro-tympanic suture.
<-The occipito-mastoid suture.
Stigmata:
1-The alveolar process of the ma+illa&
- The curved* teeth-carrying bone which bounds the skull anteriorly in this view
2-The hard palate&
- 6ies in the concavity of the alveolar process
- -ormed by the palatal processes of both ma+illae #anterior 2B3% and the
hori"ontal plates of the palatine bones #posterior 1B3%
- Cepresents the roof of the mouth $ floor of the nasal cavity
3-The incisive fossa&
- 'nterior depression in the midline of the hard palate in which lies the incisive
foramen which connects the oral to the nasal cavities
- Transmits the long spheno-palatine vessels $ nerves
-The ma+illary tuberosity&
- The non tooth-bearing part of the alveolar process behind the last molar tooth
- Dives attachment to the pterygoma+illary ligament
!-The posterior nasal spine&
- The midline spine pro:ecting from the back of the hard palate
- Dives attachment to musculus uvulae
8->osterior nasal apearture&
- The posterior opening of the nasal cavity
- The vomer divides it into two openings #the choanae%
;-The pharyngeal canal&
- 6ies :ust above the :unction between the vomer $ pterygoid plates
Head & Neck Dr. Nawfal K. Al-Hadithi !
- Transmits the pharyngeal branch of the spheno-palatine ganglion
0-The pharyngeal tubercle&
- ' midline tubercle on the undersurface of the occipital bone anterior to
foramen magnum
- -rom this tubercle shallow ridges pass laterally for the attachment of the
pharyngo-basilar fascia
<-The pterygoid plates&
- Two downward pro:ecting processes related to the sphenoid
- They bound the posterior nasal apearture on each side
- 5ach one diverge posteriorly into two plates&
a%The medial pterygoid plate9
- 6ong $ narrow with a hook in its lower end called 2pterygoid hamulus3
- Eigh up* the base of this plate is hollowed laterally forming the 2scaphoid
fossa3
- The posterior border of this plate is sharp $ shows a spur above which lies the
cartilaginous part of auditory tube as it enters the nasopharyn+
b%The lateral pterygoid plate9
- (roader than the medial
- This plate gives attachment to the pterygoid muscles on each side
F>terygoid fossa9 is the deep fossa between the two pterygoid plates $ is almost
filled by medial pterygoid muscle
1=-The pterygoid canal&
,ituated high up in the root of the pterygoid plate
It leads from the base of the skull to the pterygo-palatine fossa $ transmits the nerve
of pterygoid canal
11-The spine of sphenoid&
The greater wing of sphenoid e+tends laterally where it shows a sharp spine
pro:ecting inferiorly from its posterolateral aspect
Dives attachment to the sphenomandibular ligament
12-The foramen ovale&
- 'n oval foramen perforates the greater wing of sphenoid near the root of the
lateral pterygoid plate
- It connects the infratemporal fossa with the middle cranial fossa
- Transmits9 mandibular nerve* accessory meningeal artery* emissary vein
between the cavernous sinus $ pterygoid ple+us and the lesser petrosal nerve
13--oramen spinosum&
- ' small* rounded foramen which perforates the spine of sphenoid
- Transmits the middle meningeal artery $ the meningeal branch of mandibular
nerve
1-The mandibular fossa&
- ' depression in the squamous temporal in which the head of mandible rests to
form the T. :oint
- It is bounded posteriorly by the tympanic plate $ anteriorly by the articular
eminence which provides anterior stability for the :oint
1!--oramen lacerum&
- The petrous part of temporal bone is wedged in !7 antero-medially between
the temporal $ sphenoid anteriorly and the occipital posteriorly
- The ape+ of the petrous bone ends short of the way to the occipital bone
leaving a gap between its ape+* the occipital bone $ the root of pterygoid plate
- This irregular gap is called foramen lacerum which is closed from below
during life but its upper part remains patent to transmit the IG' as it emerges
from the medial end of the carotid canal
18-The carotid canal&
- ' circular opening in the undersurface of the petrous bone through which the
IG' enters the bone
- The carotid sheath is applied at its margins
1;-The tympanic plate&
- )-shape plate which is applied to the undersurface of the temporal bone
forming the e+ternal auditory canal
- Its lower free edge is sharp $ gives attachment to the deep layer of parotid
fascia
- The plate is pushed slightly ateriorly by the position of the styloid process
- 't this curved part the parotid fascia is thickened from the styloid process
down to the mandible forming the stylomandibular ligament
10-The styloid process&
- ' hook-like process pro:ects downward $ anteriorly from behind the tympanic
plate
- Its ossification is variable $ consequently its length is variable too
- It gives attachment to three muscles $ a ligament* the muscles are9
stylopharyngeus* styloglossus $ stylohyoid* the ligament is the stylohyoid
ligament
1<-The stylomastoid foramen&
- 6ies behind the styloid process between it $ the mastoid process
- It transmits the facial nerve $ stylomastoid branch of the posterior auricular
artery
2=-The :ugular foramen&
- (etween a notch in the petrous bone $ a notch of the occipital bone
- Transmits9 IH)* inferior petrosal sinus* II* I* $ II nerves.
21-The mastoid process& discussed.
22-The digastric notch& Jeep to the mastoid process lies a deep elongated notch for
the origin of the posterior belly of digastric muscle
23-The occipital condyles&
- ' pair of oval articulating surfaces conve+ downward to fit the superior
articular facets of G1
- They are applied in an anteromedial obliquity to the anterior K of foramen
magnum.
2-'nterior condylar canal& perforates the root of the occipital condyle $ transmits
the hypoglossal nerve
2!->osterior condylar canal& smaller than #2% $ transmits emissary veins
28--oramen magnum&
Head & Neck Dr. Nawfal K. Al-Hadithi ;
- The largest foramen in the skull* lies in the occipital bone
- Transmits9 medulla $ its meninges* the anterior $ posterior spinal arteries*
spinal accessory nerve* vertebral arteries* articular structures.
2;-The mandible& bounds the anterior K of the skull $ shows the following
landmarks&
a%The head&
- ' rounded condaloid process
- 'rticulates with the temporal bone at the mandibular fossa
b%The neck& is the thin part of the bone which lies below the head
c%The coronoid process& is the upward pro:ection which lies anterior to the head
d%The mandibular notch&
- (etween the head $ neck behind and the coronoid process in front
- ,tructures pass through this notch in their way to $ from the infratemporal
fossa
e%The ramus& is the part of the bone which lies vertical between the body below $ the
processes above
f%The mandibular foramen&
- 6ies on the medial side of the ramus
- (ony spine protects its inlet called the lingula for the attachment of the
sphenomandibular ligament
- Transmits the inferior alveolar vessels $ nerves
g%The body& is the anteriorly curved hori"ontal part of the bone which carries the
alveolar process $ teeth.
h%The myelohyoid line&
- 6ong line on the inner aspect of the body reaches back near the mandibular
foramen
- Dives attachment to myelohyoid.
i%The superior $ inferior genial tubercles&
- 6ie anteriorly on each side of the symphysis menti
- -or the attachment of genioglossus $ geniohyoid respectively
:%The digastric fossa&
- ' light depression in the lower border of the mandible near the chin
- Dives attachment of the anterior bellies of digastric
THE CRANIUM:
he cal!aria:
Is the inside of the vault of the skull* it shows some landmarks&
1-The groove for superior sagittal sinus&
This long depression grooves the sagittal suture from its inside $ broadens as it goes
backward ending on the internal occipital protuberance.
2-The lateral blood lakes&
7n each side of the above sinus near the verte+ lie a variable-si"e depression which
marks the lateral blood lakes.
he anterior cranial fossa:
The floor:
- -ormed by the orbital plate of the frontal bone #anterior 2B3% completed
posteriorly by the lesser wing of sphenoid
- ' gap in the midline between the two orbital plates is closed by the cribriform
plate of the ethmoid bone $ crista galli
- The floor of this fossa forms the roof of the orbit #laterally%* the ethmoidal air
cells #intermediate% $ the nasal cavity #in the midline%
Boundaries:
- 'nteriorly $ laterally& the frontal bone
- >osteriorly& (ody $ the free edge of the lesser wing of sphenoid
Stigmata:
1-The frontal crest&
- ' midline sharp ridge between the cribriform plate $ the anterior wall of the
fossa
- It gives attachment to the fal+ cerebri
2-The crista galli&
- The midline ridge which is centered on the cribriform plate
- It represents the upper part of the vertical plate of the ethmoid
- Dives attachment for the fal+ cerebri
3-The cribriform plate&
- Is the hori"ontal plate of the ethmoid which roofs the nasal cavity
- It is perforated by many foramina for the passage of the olfactory rootlets
- The ethmoidal foramina also lie in this plate laterally
-The anterior clinoid process&
- 's the posterior free border of this fossa curves medially* it will end in a sharp
pro:ection faces posteriorly called the 'G>
- -or the attachment of the tentorium cerebelli
he middle cranial fossa:
The floor:
- -ormed anteriorly by the greater wing of sphenoid completed laterally by the
squamous temporal $ posteriorly by the petrous temporal
- The narrow midline part of the floor which connects the two fossae is formed
by the body of sphenoid
- The floor of the fossa roofs the infratemporal fossa laterally $ the sphenoidal
air cells in the midline
Boundaries:
- 'nteriorly& sphenoidal wings separated from each other by the superior orbital
fissure
- 6aterally& the greater wing of sphenoid $ squamous temporal bones curves
from the floor upward to form the lateral wall of the fossa
- >osteriorly the petrous bone closes it.
Stigmata:
1-The hypophyseal fossa&
Head & Neck Dr. Nawfal K. Al-Hadithi <
- The midline deep notch in the sphenoid body to lodge the pituitary gland
- The fossa with its anterior wall #tuberculum sellae% $ posterior wall #dorsum
sellae% look like the Turkish saddle $ therefore this comple+ is called the sella
turcica
2-The middle clinoid processes& Two shallow pro:ections anterior to the pituitary
fossa $ posterior to the optic sulcus
3-The dorsum sellae& is the back of the pituitary fossa.
-The posterior clinoid processes& are the two pro:ections that pro:ect from each side
of the dorsum sellae.
!-The optic canal&
- ' rounded foramen medial to the anterior clinoid process leads from the .G-
to the orbit
- Transmits the optic nerve $ the ophthalmic artery
8-The optic sulcus #groove%& The shallow sulcus which connects the the two optic
canals.
;-The foramen rotundum&
- ' rounded foramen in the anterior wall of the fossa
- Transmits the ma+illary nerve from the .G- to the spheno-palatine fossa
0-The superior orbital fissure&
- The elongated gap between the two wings of the sphenoid in the anterior wall
of the fossa
- It leads to the orbit $ transmits the III* I)* )I nerves $ the ophthalmic division
of ) nerve with the superior orbital veins.
<--oramina ovale* spinosum $ lacerum& discussed.
1=-The groove for the middle meningeal artery&
- ' clear groove starts in the floor of the fossa from foramen spinosum
- Jivides into anterior $ posterior grooves according to the branches of the
middle meningeal artery
11-The arcuate eminence&
- ' laterally placed shallow eminence in the anterior wall of the petrous bone
- It is produced by the underlying superior semicircular canal of the internal ear
he "osterior cranial fossa:
The floor:
- -ormed mainly by the occipital bone completed laterally by the temporal bone.
(oundaries&
- 'nteriorly& the occipital bone as it forms the dorsum sellae in the midline and
petrous temporal bone lateral to it
- 6aterally& the mastoid part of the temporal
- >osteriorly& the occipital bone
Stigmata:
1--oramina magnum* :ugular $ hypoglossal& discussed.
2-The internal acoustic meatus&
- 'n oval foramen located in the anterior wall of the fossa
Head & Neck Dr. Nawfal K. Al-Hadithi 1=
- Transmits the facial* vestibulo-cochlear nerves $ nervus intermedius together
with the labyrinthine artery
3-The vestibular aqueduct&
- )ery small slit lies postero-lateral to the internal acoustic meatus
- Transmits the endolymphatic duct of the membranous labyrinth
-Internal occipital protuberance& lies opposite to the e+ternal one on the inner aspect
of the occipital bone.
!-Drooves for the transverse sinuses& -rom the internal occipital protuberance two
grooves pass one to each side of the protuberance representing the transverse sinuses
8-Drooves for the sigmoid sinuses&
- ,tart at the root of the petrous bone laterally
- Droove the deep surface of the mastoid bone
- Jescend down in an ,-shape deep groove to end in the :ugular foramen
;-The internal occipital crest&
- ' blunt crest from the internal occipital protuberance to the foramen magnum
in the midline
- -or the attachment of the fal+ cerebelli
0-The cerebellar fossae&
- 6ie on each side of the internal occipital crest
- They lodge cerebellar hemispheres
ANATOMY OF THE VERTEBRA
he !ertebra is com"osed of the following "arts:
1- The body&
- Eas the shape of a short cylinder with rough upper $ lower surfaces e+cept for
the smooth rounded circumference
- (odies are separated $ bound to each other by the intervertebral discs at the
upper $ lower surfaces
- They are also connected to each other by the anterior $ posterior longitudinal
ligaments at the anterior $ posterior surfaces respectively
2- The pedicles&
- The short processes that pro:ect from the posterolateral aspect of the body
- )ertebral notches indent the upper $ lower parts of the pedicle so when
vertebrae articulate with each other these notches will produce the
intervertebral foramina for passage of the spinal nerves
3- The laminae&
- The broad flat bony blades that converge posteomedially from the pedicles to
meet at the root of the spinous process
- They are connected to each other along their upper $ lower surfaces by
ligamenta flava
- The spine&
- ,lopes posteroinferiorly from the :unction of the two laminae in the midline
- They are connected with each other along their upper $ lower borders by the
interspinous ligaments $ at their tips by the supraspinous ligaments which are
deficient in the cervical region #ligamentum nuchae replaces them%.
!- The transverse processes&
- Two processes pro:ect laterally from the :unction of the pedicle $ lamina
between the articular processes
- They are connected with each other along their upper $ lower borders by the
weak intertransverse ligaments
8- The articular processes&
- Two superior $ two inferior pro:ections from the roots of the transverse
processes
- Their shape and direction govern thetype of movement in the region
THE CERVICAL REGION
Atypical cervical vertebrae are the 1st (atlas), 2nd (ais) ! "th (vertebra
prominence), all the remaining are typical#
he anatom# of the $%&'A( cer!ical !ertebra:
' typical cervical vertebra has the following characteristics&
1$ Bodies:
- ,mall* rectangular $ have superior surfaces which are concave transversely
with pro:ecting lips on either side
- These lips articulate with a corresponding conve+ity in the inferior border of
the vertebra above forming the :oints of 6ushka
- There is no vertebral region in the column which has direct articulation
between vertebral bodies but the cervical region.
2$ %edicles:
- >ro:ect from the vertebral bodies midway between the superior $ inferior
surfaces so that the superior $ inferior notches are equal in si"e
- In the other regions the pedicle is nearer to the superior than inferior surface
- This modification is to fit the e+tra spinal nerve in the region
&$ 'ertebral foramina are large $ triangular in shape.
($ Spines are short $ bifid.
)$ Transverse processes:
- ,hort with prominent tubercles
- Garry foramina transversaria which transmit vertebral vessels $ vertebral
nerve ple+us e+cept that of G; which transmit vertebral veins only.
*$ Articular surfaces:
- -lat $ oval permitting free movement at these :oints
At#"ical cer!ical !ertebrae:
The atlas (+1):
1- (ecause it has lost part of its body which fused with the a+is as the odontoid
process $ has no spine it looks like an oval bony ring.
2- The atlas has a short anterior $ a longer posterior arches with two lateral masses
carrying superior $ inferior articular processes.
3- The anterior arch carries an anterior tubercle in the midline at its anterior surface
for the attachment of the anterior longitudinal ligament $ a facet on its posterior
surface for articulation with the anterior surface of the odontoid process of G2.
- The posterior arch carries a groove on its superior surface immediately behind the
lateral mass for passage of vertebra artery $ G1.
!- ,uperior articular facet is large* kidney-shape $ concave facing upward* medially
$ posteriorly.
8- Inferior articular facet is nearly flat $ oval fitting the superior articular facet of G2.
The ais (+2):
1- FThe part of the body of G1 which fused with the a+is is represented by the
odontoid process #dens% which rests on the anterior part of the atlantic body.
FThis constitutes the pivot around which the skull $ atlas rotate on the a+is.
F-or this reason* the anterior surface of the dens carries an oval facet which
articulates with a corresponding facet on the back of the anterior arch of the body of
atlas.
F,tructures which hold the dens in position are the cruciate together with the apical $
alar ligaments.
2- >edicles $ laminae are heavy $ broad.
3- ,pine is very broad* heavy $ bifurcated.
- ,uperior articular facet is large* flat $ faces superolaterally* while the inferior
resembles the inferior facets of other cervical vertebrae.
'ertebra prominence (+"):
1- ,pine is long* prominent $ not bifid.
2- Transverse processes are larger than other vertebrae.
3- Transverse foramina are smaller than other vertebrae $ transmit vertebral veins
only. 7ccasionally they are absent.
he atlanto-occi"ital )oint:
- The two occipital condyles represent the two lateral parts of a single ellipsoid
surface the transverse diameter of which is longer than the antero-posterior
one.
- These articulate with the superior facets of atlas so the general shape of the
:oint looks like an egg lies on its side in an egg-saucer* so the only permitted
movement for this egg is to rotate around the longer a+is of the ellipse
therefore the only permitted movement in this :oint is head nodding #fle+ion L
e+tension of the skull%
- The articulation between the superior articular facets of G1 $ occipital condyles are
synovial :oints with strong la+ capsules
- The anterior $ posterior atlanto-occipital membranes close the gaps between the
corresponding atlantic arches $ the base of skull around foramen magnum
he atlanto-a*ial )oint:
$ This ,oint is formed of:
1- The lateral atlanto-a+ial :oints& TM7 :oints between the superior articular facets of
a+is with the inferior of atlas. These are synovial :oints with la+ capsule to permit
rotation of the atlas carrying the skull on them.
2- The median atlanto-a+ial :oint&
- TM7 :oints* the 1st between the anterior surface of the dens $ the facet on the
back of the anterior arch of atlas
- The 2nd between the back of the dens $ the fibro-cartilagenous face of the
transverse limb of the cruciate ligament
- These are synovial :oints with thin capsules.
- The cruciate ligament&
1- The transverse limb&
- Is thick $ strong band passes behind the dens
- It is attached between two tubercles located on the medial aspect of the lateral
masses of atlas
- The part in relation to the dens is a fibro-cartilagenous face forming a :oint
with the back of the process
2- The longitudinal limb&
- -rom the back of the body of a+is* a smaller band passes upward to be inserted in
the anterior edge of foramen magnum
The apical ligament& is a single slender ligament passes from the ape+ of the dens to
the anterior margin of foramen magnum.
- 'lar ligaments& are two small but strong ligaments diverge superolaterally from
each side of the apical ligament to be attached to the medial surface of the
corresponding occipital condyles.
- .embrana tectoria&
- Is the upward e+tension of the posterior longitudinal ligament which broadens
as it passes upward from the back of the body of a+is to be attached within the
anterior edge of foramen magnum* where it will be continuous with dura mater.
- It is the most posterior structure in this :oint $ its ligaments
THE NECK
Head & Neck Dr. Nawfal K. Al-Hadithi 1!
SURFACE ANATOMY
+on# & cartilagenous landmarks:
1- Eyoid bone&
- 6ies in the angle between the chin $ the front of the neck
- -ormed of body $ two horns #greater $ lesser%
2- Thyroid cartilage& -orms the midline prominence of the laryn+ 1-2 cm below the
hyoid bone
3- Gricoid cartilage&Hust below the thyroid cartilage separated from it by a sulcus
- Tracheal rings& -requently felt below the cricoid.
,uscular landmarks:
1- ,ternocliedomastoid& (isect the side of the neck into anterior $ posterior triangles
2- Jigastric& (y its two bellies divide the suprahyoid compartment into
submandibular $ submental triangles
3- 7mohyoid& (ehind ,G. divides the anterior $ posterior triangles into further
smaller ones.
SUPERFICIAL DISSECTION OF THE NECK:
he skin:
-anger lines .lines of cleavage/:
- These lines represent the direction of arrangement of the collagen bands in the
skin
- 'n incision along 6anger lines heals with a minimum scar while an incision
across them leaves
- an unfavorable scar tissue after healing 6anger lines in the neck are arranged
transversely along the circumference of the neck so incisions should be done in
this direction unless contra-indicated
Subcutaneous conn. tissue:
N -ormed of loose areolar $ fatty tissues
N Ceplaced anteriorly by platysma
N Gontains the cutaneous vessels $ nerves which lie deep to platysma
%lat#sma:
7rigin9 -ascia covering pectoralis ma:or $ deltoid
Insertion9 6ower border of the mandible $ skin of lower part of the face $ corners of
the mouth
4erve supply9 Gervical branch of )II
'ction9 Jepresses the corner of the mouth $ lower border of the mandible
Su"erficial !eins:
The 0ternal 1ugular 'ein:
N -ormed behind the angle of the mandible by union of the posterior auricular v.
$ posterior division of retromandibular v.
N Jescends vertically between platysma $ ,G. towards the middle of the
clavicle
N 2 cm above the clavicle it pierces the neck fascia $ drains into the subclavian
vein
N >rovided with 2 pairs of valves9 one at its end in the subclavian v. $ the other
cm above
N Tributaries&
- >osterior 5H) from the back of neck
- 'nterior H) from the anterior part of the neck
- ,uprascapular $ transverse cervical vv.
Glinical importance of the 5H)&
1- .edical& as it is used sometimes as a sign of heart failure $ to measure the central
venous pressure ..
2- ,urgical& sometimes used in cannulation $ i.v therapy O
Anterior 1ugular 'ein:
N -ormed near the hyoid bone by confluence of small submental vv.
N Jescends vertically on each side of the midline #sometimes as a single vein in
the midline%
N 3 cm above the manubrium* it perforates the superficial layer of deep cervical
fascia $ enters the suprasternal space
N In this space it communicates with its fellow be the :ugular venous arch
N Then it turns laterally to empty in the 5H) at its termination
'utaneous ner!es:
2 )3erves of the bac4:
- These are the Jorsal >rimary Cami of Gervical 4erves
1- Dreater 7ccipital 4erve& G2
>ierces semispinalis capitis $ trape"ius at their skull attachments and supplies the
back of the scalp as high as the verte+.
2- Third 7ccipital 4erve& G3
Gommunicates with the great occipital n. $ supplies the upper part of the back of the
neck.
3- G&
,upplies the reminder of the back of the neck.
22 )3erves of the front:
- These are the cutaneous branches of cervical ple+us
- 4erves approach the surface near the midpoint of the posterior border of ,G.
where they diverge.
1- 6esser occipital 4erve& G2 $ 3
- 'scends along the posterior border of ,G.
- ,upplies skin $ subcutaneous tissue at the insertion of the muscle $ behind $
above the auricle.
2- Dreat auricular 4erve& G2 $ 3
- Eooks below the posterior border of ,G.
- 'scends in the direction of the auricle $ angle of the mandible where it
supplies&
,kin over the antero-inferior part of mastoid (P mastoid branches
'uricle* e+cept the upper K of lateral surface (P auricular br.
,kin over parotid $ angle of mandible (P facial br.
3- 'nterior cutaneous nerve& G2 $ 3
Head & Neck Dr. Nawfal K. Al-Hadithi 1;
- Grosses ,G. hori"ontally deep to platysma to reach the anterior triangle
- It divides into superior $ inferior branches penetrating platysma $ supplies
skin $ subcutaneous tissues of the cylinder of the neck
- Its block in local anaesthesia results in sensory loss in a wide area of the neck.
- ,upraclavicular nerves& G3 $
Jescend toward the clavicle where they divide into 3 main groups&
- .edial9 skin over manubrium sterni
- Intermediate9 skin over the pectoral region down to the 3rd rib
- 6ateral9 skin over deltoid as far as the distal 1B3 of muscle
DEEP DISSECTION OF THE NECK:
Dee" fascia:
-7/C entities of well defined deep fasciae are diagnosed in the neck&
1- The investing cervical fascia
2- The pretracheal fascia
3- The prevertebral fascia
- The carotid sheath #one on each side%
The 2nvesting 5ascia:
N Jouble layered membrane encloses the whole structures of the neck like a
collar
N It splits at certain areas to enclose 2 muscles $ 2 glands on each side
N /pper attachment #to the skull base%&
5+ternal occipital protuberance - superior nuchal line #splits for trape"ius $ ,G.% -
mastoid process - splits in <= degrees&
- ,uperficial layer #covers the parotid gland%9 6ower border of "ygomatic arch - lower
border of mandible
- Jeep layer #deep to the parotid gland%9 6ower border of tympanic plate - fuse with
carotid sheath
6ower attachment&
To the pectoral girdle around the attachment of ,G. $ trape"ius
-i+ation points&
To the hyoid bone forming the angle between the chin $ the neck
,pecial derivatives&
- >arotid fascia
- ,ubmandibular fascia
- ,tylomandibular ligament& thickening in the deep layer of parotid fascia
between the styloid process $ the angle of mandible
5nclosed structures&
- >arotid $ submandibular glands
- ,G. $ trape"ius
- ,uprasternal space containing the H)'
The %revertebral 5ascia:
N -orms a smaller cylinder inside the large investing one enclosing the vertebral
column $ the surrounding muscles
N ,uperior attachment is to the base of the skull anterior to the attachments of the
prevertebral muscles
N 6aterally it is attached to the tips of transverse processes of the cervical spines
N Then e+tends laterally to cover the pre- $ para-vertebral muscles reaching
ligamentum nuchae $ the vertebral spines
N Jownward it reaches the lowest limit of longus colli #T%
N 5+tends along the a+illary artery as the a+illary sheath
The %retracheal 5ascia:
N 'ttached superiorly to the hyoid bone $ the oblique line of thyroid cartilage
N 5ncloses the thyroid gland forming its sheath
N It is responsible for the upward movement of the thyroid gland $ any related
swelling during deglutition
N 6aterally it reaches the carotid sheath
N Inferiorly it blends with fascial coverings of the aortic arch
N It is pierced by the thyroid vessels
The +arotid Sheath:
N ' dense cylindrical condensation of connective tissue surrounding the GG'*
IG'* IH) $ vagus nerve
N 'ttached superiorly at the margins of carotid canal
N Ceaches downward to the aortic arch
N Its deficient around the IH) #for venous e+pansion%
N -used laterally with the deep layer of investing fascia $ antero-medially with
the pretracheal fascia
N It is loosely attached to the anterior aspect of the prevertebral fascia along the
tips of transverse processes of the cervical spines
issue s"aces of the neck:
Behind the prevertebral fascia:
The space descend down to reach the lowest attachment of the fascia at T* though an
abscess there usually points in the posterior triangle by pathological walling off
2n front of the prevertebral fascia (retropharyngeal space):
The space e+tends from the base of the skull down to the posterior mediastinum
Anterior to the pretracheal fascia:
The space reaches down through the superior to the anterior mediastinum
Bet6een the pretracheal ! prevertebral fasciae:
The space leads down through the superior to the posterior mediastinum
%osterior cer!ical triangle:
Is the triangular space which lies in a spiral fashion on the postero-lateral aspect of
the neck.
Boundaries:
- 'nterior9 posterior border of ,G.
- >osterior9 anterior border of trape"ius
- Inferior9 middle 1B3 of clavicle
7oof:
Head & Neck Dr. Nawfal K. Al-Hadithi 1<
,kin* subcutaneous tissue* platysma* investing fascia
5loor:
,calene muscles* levator scapulae $ splenius capitis covered by prevertebral fascia
Sternocliedomastoid:
7rigin&
- Tendinous sternal head from the anterior surface of manubrium sterni
- -leshy clavicular head from the upper surface of the medial 1B3 of clavicle
Insertion& 6ateral side of mastoid process $ lateral K of superior nuchal line
4erve supply& 'ccessory nerve
'ction&
- /nilateral contraction draws the mastoid process toward the shoulder #pushes
the face to the opposite side%
- (ilateral contraction fle+es the head over the neck
- Mith stabili"ation of the head* it is an accessory muscle of inspiration
Scalenus anterior:
7rigin& 'nterior tubercles of transverse processes of G3-G8
Insertion& ,calene tubercle on the upper surface of the 1st rib
4erve supply& G!-G; anterior primary rami
Scalenus medius:
7rigin& >osterior tubercles of transverse processes of G2-G;
Insertion& /pper surface of the 1st rib behind subclavian artery groove
4erve supply& G3-G0 anterior primary rami
Scalenus posterior:
7rigin& >osterior tubercles of transverse processes of G!-G;
Insertion& 6ateral surface of the 2nd rib rib
4erve supply& G; $ G0 anterior primary rami
'ontents of the "osterior triangle:
2) 2n the roof (superficial to the investing fascia):
1->latysma.
2-5H).
3-5H lymph nodes& 1-2 nodes along the 5H) receive from the ear $ parotid $ send to
the superior group of deep cervical nodes.
-Gutaneous branches of cervical ple+us* especially the lesser occipital $
supraclavicular nerves.
22) 2n the triangle (bet6een the investing ! prevertebral fasciae):
3erves8
1$ The spinal root of accessory nerve:
N Grosses the triangle on the undersurface of investing fascia
N Is directed vertically toward the tip of the shoulder between the posterior
border of ,G. $ anterior border of trape"ius
N It supplies trape"ius $ ,G.
'ccessory nerve in:ury&
/nilateral in:ury of the accessory nerve results in paralysis of the ,G. muscle on
that side with the resultant unopposed action of the contralateral muscle so the face
turns to the in:ured side $ the mastoid process on the healthy side approaches the
shoulder in a 2wry neck3 deformity.
2$ The cervical pleus:
N -ormed by the ventral primary rami of the upper four cervical nerves inside the
substance of the prevertebral muscles.
N It gives sensory $ motor branches.
N The sensory branches were discussed.
N The motor branches&
'% Jirect muscular branches to prevertebral muscles&
G1*29 longus capitis $ the anterior $ lateral recti
G2*3*9 longus capitis $ longus colli
G3*9 levator scapulae $ the scalene
(% >hrenic nerve& G3 $ G
N Jescends vertically across the oblique course of scalenus anterior from its
lateral to medial border
N 6ies deep to the prevertebral fascia $ crossed by the transverse cervical $
suprascapular arteries
N 5nters the thoracic inlet in a variable relation to the subclavian vein #usually
behind it% $ descends in the thora+ to the diaphragm.
G% G1 fibers to hypoglossal nerve&
N III nerve receives fibers from the G1 nerve at the anterior condylar canal
N These fibers leave III as branches&
1- .eningeal branch to the dura around foramen magnum
2- ,uperior ramus of ansa cervicalis #descendens hypoglossi%
3- 4erve to thyrohyoid
- 4erve to geniohyoid
J% Inferior ramus of ansa cervicalis #descendens cervicalis%& G2 $ G3
N Jescends behind the carotid sheath to :oin the superior ramus usually lateral to
the IH)
N 'nsa cervicalis* so formed around the IH) in a P-shape or loop pattern* has a
variable vertical position
N It supplies the infrahyoid muscles e+cept thyrohyoid.
N Their supply is segmental #upper part of the muscle receives G1* middle part
G2 $ the lower part G3%
5% >roprioceptive fibers to ,G. $ trape"ius #G2 $ 3%.
A7T0720S8
1$ The transverse cervical ! suprascapular arteries:
N 're branches of the thyrocervical trunk
N Grosses laterally in the base of the triangle above $ parallel to the clavicle to
hide underneath the anterior border of trape"ius #TG% $ behind the inferior
belly of omohyoid #,,%.
N The transverse cervical lies superior to the suprascapular.
2$ The occipital artery:
Cuns part of its course in the ape+ of the triangle in its way to the scalp
'023S8
,imilar to arteries.
-9:%; 3<=0S8
1$ The supraclavicular lymph nodes:
N 're e+tension from the postero-inferior group of the deep cervical nodes along
the transverse cervical vessels.
N Ceceive lymph #in addition to the normal drainage of the postero-inferior
nodes% from the apical a+illary nodes* breast $ sometimes from the upper limb
$ anterior chest wall.
2$ The occipital lymph nodes:
N ,ituated along the occipital vessels in the ape+ of the triangle.
N Jrains the back of the scalp upward to the verte+.
<T;07S8
The inferior belly of omohyoid:
N 5merges from behind the lower part of the posterior border of ,G. $ enters
deep to trape"ius.
N Jivides the triangle into occipital $ supraclavicular ones.
222) 2n the floor of the triangle (deep to the prevertebral fascia):
307'0S8
Brachial pleus:
(ranches from the roots $ trunks& these are branches have part of their course in the
neck* though they are distributed to muscles in the upper limb&
a) =orsal scapular nerve: passes over scalenus medius ! posterior ! hides deep
to levator scapulae
b) -ong thoracic nerve: leaves scalenus medius by t6o roots 6hich unite do6n to
form the nerve
c) Suprascapular nerve:passes above the pleus ! hides under trape>ius
'0SS0-S8
The subclavian artery:
- -rom the aortic arch #on the left% $ brachioceohalic trunk #on the right%* the
artery leaves the back of the corresponding sternoclavicular :oint $ goes
laterally in the root of the neck
- Grosses over the 1st rib behind scalenus anterior which divides it into 3 part
#1st medial* 2nd behind $ 3rd lateral to it%
- 'round the 1st part of the right artery the right recurrent laryngeal nerve hooks
- It leaves the outer border of the 1st rib to the a+illa as the a+illary artery.
(ranches&
I& -rom the 1st part&
1- )ertebral artery&
- 'rises from the dorsosuperior aspect of the subclavian
- 5nters the foramen transversarium of G8
- 'scends in the upper 8 cervical vertebrae in front of the emerging spinal nerves
- 'rching behind the atlanto-occipital :oint* it enters foramen magnum $ unites
with its fellow at the clivus forming the basilar artery
(ranches9
F muscular #in the neck%& to deep neck muscles
F spinal #in spinal canal%& radicular arteries
2- Thyrocervical trunk&
- ,hort thick artery arises from the subclavian a. opposite to the internal thoracic
a.
- ,oon after its origin it divides into&
F Transverse cervical a.
F ,uprascapular a.
F 'scending cervical a.& passes medial to the phrenic nerve anterior to scalenus
anterior
F Inferior thyroid a.&
- 'rches up as high as the cricoid cartilage where it pierces the prevertebral
fascia $ enters behind the thyroid gland
- The recurrent laryngeal nerve lies in between its !-8 branches which pierce the
pretracheal fascia separately $ enters the thyroid gland
- It gives the inferior laryngeal a. to the lower part of the laryn+.
3- Internal thoracic artery&
- 'rises from the inferior aspect of the subclavian a.
- Jescends behind the subclavian v. $ phrenic nerve to enter the thora+
- It passes on each side of the sternum #1 cm away%
- Dives the anterior intercostal arteries
- 5nds by dividing into superior epigastric $ musculophrenic arteries.
II& -rom the 2nd part&
The costocervical trunk&
- 'scends on the back of cervical pleura $ ape+ of the lung
- >asses between the trunks of brachial ple+us
- 7n the neck of 1st rib it divides into highest intercostal $ deep cervical artery
III& -rom the 3rd part&
- In ;=1 * the dorsal scapular a. leaves the 3rd part of the artery $ follows the
corresponding nerve after disappearing underneath the anterior border of
trape"ius
- In 3=1* this artery arises from the transverse cervical artery
The subclavian vein:
- 6ies in the root of the neck anterior to scalenus anterior crossing over the 1st
rib $ then grooves the ape+ of the corresponding lung $ cervical pleura
- Hoined by the IH) at the medial border of the muscle forming the
brachiocephalic v.
- Ceceives only the 5H)
he anterior cer!ical triangle:
N Is the area of the neck which lies between the anterior borders of the two ,G.
muscles $ the lower border of the mandible.
N The anterior midline divides this area into two anterior cervical triangles.
N Jigastric $ the superior belly of omohyoid further divide each of the two
triangles into carotid* muscular $ submandibular triangles.
N The remaining area between the anterior bellies of both digastrics in the single
submental triangle.
The carotid triangle:
Coof #lateral wall%&
,kin* subcutaneous tissue* platysma and investing fascia
-loor #medial wall%&
- 'nteriorly& hyoglossus $ thyrohyoid
- >osteriorly& middle and inferior constrictor muscles
Gontents&
1- Garotid sheath $ its contents.
2- 4erves9 ansa cervicalis* hypoglossal nerve.
3- Jeep cervical lymph nodes.
Gontents of the carotid sheath&
The +ommon +arotid Artery (++A):
- -rom behind the corresponding ,GH* the GG's diverge as they ascend on each
side of the neck separated by the laryn+ $ thyroid gland
- Their course is in the carotid line #a vertical line midway between the angle of
the mandible $ the mastoid process%
- 't the upper border of thyroid cartilage #G3-% it divides into 5G' $ IG'
- The artery is crossed from below upward by the IH)* ,G.* superior belly of
omohyoid* superior laryngeal a. $ thyroid veins
The carotid sinus:
- It is a dilatation at the bifurcation of the GG' especially around the origin of
the IG'
- Its walls are especially elastic $ contain baroreceptors responsible for
regulation of blood pressure
The carotid body:
- ' mass of cells in the posterior wall of the sinus
- Gontains chemoreceptors for regulation of blood osmolarity
N (7TE carotid sinus $ body are supplied by the sinu-carotid branch of II
nerve
N Garotid body tumor 2>otato tumor3&
' tumor affecting the carotid body resulting in a pulsetile swelling in the lateral
aspect of the neck
The 2nternal +arotid Artery (2+A):
N 't the bifurcation* the IG' is postero-lateral to the 5G'* then it takes a medial
relation alongside the pharyn+.
N It passes upward with the IH) to reach the base of the skull where it enters the
temporal bone through the carotid canal.
N It gives no branch in the neck.
N It supplies the brain $ structures inside the orbit.
The 0ternal +arotid Artery (0+A):
N 'bout equal in caliber to the IG'* the 5G' e+tends between the upper border
of thyroid cartilage $ the neck of the mandible where it ends by dividing into
its two terminal branches
N In the carotid triangle* the 5G' lies superficial being covered directly by the
investing fascia of the roof* it is crossed by the facial* lingual $ sometimes the
superior thyroid veins
N 6eaving this triangle* the artery passes deep to the posterior belly of digastric
$ stylohyoid muscles separating them from stylopharyngeus
N Eere* the 5G' lies in the deep lobe of the parotid gland together with the
retromandibular vein $ facial nerve.
(ranches of the 5G'&
'% 'nterior branches&
1- ,uperior thyroid a.
2- 6ingual a.
3- -acial a.
(% >osterior branches&
- 7ccipital a.
!- >osterior auricular a.
G% .edial branch&
8- 'scending pharyngeal a.
J% Terminal branches&
;- .a+illary a.
0- ,uperficial temporal a.
,uperior thyroid artery&
- Diven at the beginning of the 5G' :ust below the tip of greater horn of the hyoid
bone
- Jescends downward towards the ape+ of the lateral lobe of the thyroid gland
accompanied by the e+ternal laryngeal nerve
- >ierces the pretracheal fascia at the ape+ of the thyroid lobe $ divides into anterior
$ posterior branches which descend on the corresponding surfaces of the gland $
anastomose with the inferior thyroid branches
- (ranches&
a% ,uperior laryngeal a.9 pierces the thyrohyoid membrane together with the internal
laryngeal n. $ supplies the laryn+ above the level of vocal folds
b% ,ternomastoid a.9 to ,G.
c%.uscular branches to the inferior constrictor muscle
6ingual artery&
- 'rises opposite to the tip of the greater horn of hyoid bone.
- 'fter an upward loop* the artery passes forward to disappear deep to hyoglossus.
- It is crossed laterally by the hypoglossal nerve* posterior belly of digastric $
stylohyoid.
- (ranches&
a% Jorsal lingual a.9 given at the back of the tongue $ supplies the tonsils* soft palate
$ epiglottis.
b% ,ublingual a.9 to the sublingual gland
-acial artery&
- Diven :ust above the tip of greater horn of hyoid bone.
- 'scends up deep to the posterior belly of digastric in the submandibular triangle
where it lies between the submandibular gland $ myelohyoid.
- 'fter an ,-shape course in the triangle* the artery curves over the lower border of
the mandible at the anterior edge of masseter to ascend in the face.
- (ranches&
a% 'scending palatine a.9 ascends between styloglossus $ stylopharyngeus to lie on
the superior constrictor muscle. It supplies the upper pharyngeal wall* soft palate*
palatine tonsils $ auditory tube
b% Tonsillar a.9 to the palatine tonsils
c% Dlandular branches to the submandibular gland
d% ,ubmental a.9 given before the facial a. curves on the mandible* it passes back
between the anterior belly of digastric $ myelohyoid with the nerve to myelohyoid in
the submental triangle.
7ccipital artery&
- Diven from the back of the 5G' at the level of the facial a.
- 'scends parallel to the lower border of the posterior belly of digastric to hide deep
to ,G..
- It grooves the skull in the region of the occipito-mastoid suture to appear in the ape+
of the posterior triangle
- >ierces the fascia of the neck $ ascends in the back of the scalp supplying it up to
the verte+.
- (ranches&
a% .uscular branches to digastric* stylohyoid $ posterior cervical muscles.
b% ,ternomastoid a.9 to ,G.
c% .eningeal* auricular $ mastoid branches
>osterior auricular artery&
- 'scends parallel to the upper border of the posterior belly of digastric.
- >asses in the region of the parotid gland supplying it
- Grosses superficial to the mastoid process behind the auricle.
- (ranches&
a% ,tylomastoid a.9 enters the corresponding foramen $ gives stapedial arery to
stapedius.
b% 'uricular a.
c% 7ccipital arteries to the scalp
'scending pharyngeal artery&
- -rom the medial aspect of the 5G'* this long $ slender branch ascends on the
sidewall of the pharyn+ deep to the IG'.
- (ranches&
a% >haryngeal branches to the superior $ middle constrictor muscles
b% >alatine a.9 to the soft palate $ palatine tonsils.
c% Inferior tympanic a.9 to the middle ear
d% .eningeal branches to the dura mater after entering the hypoglossal canal or the
:ugular foramen.
,uperficial temporal artery&
- The smaller of the 2 terminal branches of the 5G'
- Diven deep to the neck of the mandible
- 'scends in the temporal fossa
.a+illary artery&
- The larger of the 2 terminal branches of the 5G'
- Diven deep to the neck of the mandible
- >asses forward into the infratemporal fossa
The 2nternal 1ugular 'ein (21'):
N It is the continuation of the dural sigmoid sinus in the posterior compartment of
the :ugular foramen.
N In the carotid sheath* the IH) is posterolateral to the artery in the upper part of
the neck* then becomes lateral $ in the root of the neck it is almost anterior
N 'nsa cervicalis is usually formed around it
N Jeep cervical 6. 4. lie around it
N 't its beginning it has a dilatation called superior bulb* a similar #inferior% bulb
lies at its termination
N Tributaries&
- Inferior petrosal sinus& :ust below the base of the skull.
- Thyro-glosso-facial confluence of v.& superior thyroid* lingual $ facial vv.
usually open in common or separately in the IH) at the level of the origin of
lingual a. from the 5G'.
- >haryngeal veins& from the pharyngeal ple+us* terminate in the IH) at the level
of the angle of mandible.
- .iddle thyroid v.
The 'agus 3erve:
N 6eaves the skull with the IH)* II $ II nerves through the :ugular foramen.
N Jescends in the neck inside the carotid sheath throughout which the nerve lies
between the IH) $ the carotids.
N In the neck it gives the following branches&
- .eningeal n.& to the dura of posterior cranial fossa
- 'uricular n.& to the e+ternal acoustic meatus $ tympanic membrane
- >haryngeal n.& usually 2 in number to the pharyngeal ple+us
- ,uperior laryngeal n.& divides into internal $ e+ternal laryngeal nerves
- Gervical cardiac n.& usually 2 in number to the cardiac ple+us
- Cecurrent laryngeal n.
;ypoglossal 3erve:
N Jescends in a downward curve on the lateral aspect of the 5G' crossing it at
the point of origin of the lingual artery.
N 5nters the floor of the mouth lateral to hyoglossus.
N In the neck it gives the branches of G1 which hitch-hacked along it.
=eep +ervical -ymph 3odes
The muscular triangle:
Is the space between midline* superior belly of omohyoid $ the anterior border of the
lower part of ,G.
Coof &
,kin* subcutaneous connective tissue* platysma and investing fascia.
Gontents&
1- Infrahyoid #strap% muscles.
2- Thyroid gland.
3- ,tructures of the midline #pharyn+* laryn+* trachea $ oesophagus%.
2nfrahyoid muscles:
1- ,ternohyoid&
- This thin narrow muscle is the most medial of the infrahyoid muscles
- ,eparated from its fellow on the opposite side by the midline $ 'damQs apple
only
7rigin9 >osterior end of the sternal end of clavicle $ back of manubrium sterni.
Insertion9 The lower border of the body of hyoid bone.
4. supply9 G1*2*3 by ansa cervicalis.
2- 7mohyoid&
-ormed of 2 bellies $ lies lateral to sternoh.
7rigin9 Inferior belly arises from the scapular ligament $ upper border of scapula
Insertion9 6ying in the base of the posterior triangle* the inferior belly ends in an
intermediate tendon behind ,G. being held to this muscle by the deep layer of
investing fascia. -rom this tendon the superior belly arises $ ascends lateral to
sternohyoid to the lower border of the body of the hyoid bone.
4. supply9 'nsa cervicalis* G1 to the superior belly $ G2*3 to the inferior one.
3- ,ternothyroid&
,horter* broader $ deeper than sternohyoid.
7rigin9 (ack of manubrium sterni reaching lower than sternohyoid* $ 1st
costalcartilage.
Insertion9 oblique line of thyroid cartilage.
4. supply9 (y ansa cervicalis*G2 $ 3.
- Thyrohyoid&
7rigin9 7blique line of thyroid cartilage as a continuation of sternothyroid.
Insertion9 6ower aspect of greater horn of hyoid bone.
4. supply9 4erve to thyrohyoid* G1 fibers given as a branch from the III nerve.
'ction of infrahyoid muscles&
N Together with the suprahyoid muscles* these muscles move $ regulate the
movements of the hyoid bone* tongue $ laryn+
N They depress the hyoid bone either directly or by depressing the thyroid
cartilage.
N Thyrohyoid could elevate the laryn+ to produce high notes if the hyoid bone is
fi+ed from above
N ,ternothyroid could depress the laryn+ to produce low notes if the hyoid bone
is fi+ed from above
The Thyroid ?land:
,hape $ position&
This E-shape gland has two lateral lobes connected in the midline by an isthmus&
The lateral lobe&
- Is a pyramidal shape lobe with an upward ape+ lying deep to thyrohyoid $ a
wide base reaches down to the level of the 8th tracheal ring
- The anterior border is thin $ inclines inferomedially from the ape+ to reach the
midline
- The rounded posterior border are separated from each other by the airway $
foodway $ touching the carotid sheaths posterolaterallly
The isthmus& Gonnects the two lateral lobes in the midline opposite to the 2nd* 3rd $
th tracheal rings.
The pyramidal lobe&
- ,ometimes arises from the isthmus $ directed to one lobe #usually the left%
- ,ometimes it is connected to the hyoid by levator glandulae thyroidae muscle
-ascia&
- The pretracheal fascia invests the gland within which lies free inside it e+cept
at the region of the isthmus
- The fascia is attached superiorly to the thyroid cartilage therefore the gland and
any related swelling will move upward during deglutition
Gapsule&
The gland has a histological fibrous capsule which sends septa into the gland dividing
it into lobules
Celations&
F 'ntero-laterally& Infrahyoid muscles #e+cept thyrohyoid%.
F >osteriorly& Garotid sheath.
F .edially& Thyroid $ cricoid cartilages $ the upper 8 tracheal rings 2anteriorly3 and
thyropharyngeus* cricopharyngeus $ upper oesophagus 2 posteriorly3.
'rteries&
1- ,uperior thyroid artery&
- (ranch of 5G'
- >ierces the fascia $ distributed to the gland by an anterior $ posterior
branches.
2- Inferior thyroid artery&
- (ranch of the thyrocervical trunk from the 1st part of subclavian a.
- 'rches up then down behind the carotid sheath to reach behind the lower
border of the gland where it divides into #!-8% branches which penetrate the
fascia separately $ distributed to the gland
- The recurrent laryngeal n. lies in between them.
- It gives tracheal* oesophageal* inferior laryngeal $ pharyngeal branches
3- Thyroidea ima artery&
- ,mall branch arises from the brachiocephalic trunk or aortic arch $ enters the
lower pole
- They are seen n 1=1 of individuals.
)eins&
1- ,uperior thyroid vein&
- -ormed on the anterolateral aspect of the lateral lobe of the gland
- Grosses in front of the GG' $ receives tributaries corresponding to the
branches of the superior thyroid a.
- It empties in the IH) separately or with the facio-lingual v.
2- .iddle thyroid vein&
- -ormed at the lateral surface of the gland
- This short wide v. courses laterally to empty in the lower part of the IH)
3- Inferior thyroid veins&
- 'rise from the venous ple+us which lies near the lower pole of the gland $
communicates with the upper 2 veins
- They descend down receiving tributaries which correspond to the branches of
the inferior thyroid a.
- >ass behind the manubrium to end in the corresponding brachiocephalic vein.
- ,ometimes the 2 veins unite forming a single vein which empties in the left
brachiocephalic v.
4erves&
1- ,ensory& Cecurrent laryngeal n.
2- ,ympathetic #vasomotor%& .iddle cervical sympathetic ganglion along the
branches of the inferior thyroid a.
6ymph&
'long arteries&
N ,uperior thyroid& 'nterosuperior group of deep cervical nodes
N Inferior thyroid& >osteroinferior group of deep cervical nodes
'pplied anatomy&
N ' midline neck swelling that moves with swallowing is related to the thyroid
gland until proved otherwise.
N Incisions for thyroidectomy are made hori"ontally at the lower part of the neck.
N The recurrent laryngeal nerve is commonly in:ured during ligation of the
inferior thyroid arteries in thyroid surgery
%haryn ! -aryn 6ill be discussed later
Trachea:
N (egins at the cricoid cartilage #G8% $ ends at the carinaT level* a 12 cm long
tube K of which lies in the neck
N The GG' lie on each side of the trachea being separated from it above by the
lateral lobes of the thyroid.
N The oesophagus lies behind it $ the intervening groove is occupied by the
recurrent laryngeal nerves
N Thyroid isthmus lies anterior to the rings 2-
N Trachea is formed of G-shape cartilages opened behind $ the opening is closed
by trachealis muscle.
N Gervical trachea is supplied by the inferior thyroid a.* drained by inferior
thyroid v. * its nerve supply is similar to the thyroid gland $ its lymph goes to
the postero-inferior group of deep cervical nodes.
Applied anatomy:
N Tracheostomy is a life-saving operation to open the airway in acute $ chronic
airway obstruction.
N The incision is done below the cricoid cartilage $ the trachea is e+posed after
dividing the successive layers in front of it
N ' tube is inserted to keep the airway patent
<esophagus:
N 2! cm tube begins at the level of G8 vertebra #cricopharyngeus% $ ends at the
cardiac opening of the stomach
N The carotid sheaths lie on each side being separated from it by the posterior
part of the lateral lobe of the thyroid.
N The trachea lies anterior to it $ the intervening groove is occupied by the
recurrent laryngeal nerves
N The prevertebral muscles lie behind it with the sympathetic trunk on each side.
N Gervical oesophagus is supplied by the inferior thyroid a.* drained by inferior
thyroid v. * its nerve supply is similar to the thyroid gland $ its lymph goes to
the postero-inferior group of deep cervical nodes.
The submandibular triangle:
Is the space between the two bellies of digastric $ the lower border of the mandible.
Coof &
,kin* subcutaneous connective tissue*
platysma and investing fascia.
-loor&
.yelohyoid 2anteriorly3
Eyoglossus $ part of the middle
constrictor 2posteriorly3
Gontents&
1- ,uprahyoid muscles.
2- ,ubmandibular gland.
3- -acial artery.
- Gommon facial vein.
!- ,ubmandibular lymph nodes.
8- Gervical branch of facial nerve.
Suprahyoid :uscles:
Jigastric&
7rigin&
- 'nterior belly& -rom the digastric fossa at the lower border of the mandible on
each side of symphysis menti
- >osterior belly& -rom the digastric notch on the medial aspect of the mastoid
process.
Insertion&
The 2 bellies are directed to the body of the hyoid bone where they are united by an
intermediate tendon which is held to the hyoid bone by a fibrous sling.
4erve supply&
- 'nterior belly& 4erve to myelohyoid #branch from the mandibular n. )c%
- >osterior belly& -acial nerve
'ction&
- 5levate the hyoid bone* laryn+ $ pharyn+ during swallowing
- 7pens the mouth widely
,tylohyoid&
7rigin&
- -rom the posterior aspect of the styloid process near its root.
Insertion&
The muscle descends superomedial $ parallel to the posterior belly of digastric to
reach the intermediate tendon of digastric* here it divides into 2 slips which pass on
each side of the intermediate tendon of digactric $ inserted on the hyoid bone near
the greater horn.
4erve supply&
-acial nerve
'ction&
- >ulls the hyoid backward $ upward.
.yelohyoid&
7rigin&
-rom the whole length of myelohyoid line on the inner surface of the mandible
Insertion&
- -ibers descend medially $ backward
- >osterior part of it will reach the body of hyoid bone to which they are inserted
- 'nterior fibers meet each other in a midline raphe which e+tends between the
hyoid bone $ the mandible
4erve supply&
4erve to myelohyoid #from
the mandibular nerve )c%
'ction&
- -orms the floor of the mouth
on which the tongue rests $ move
- >lays a ma:or role in swallowing.
Deniohyoid&
7rigin&
Inferior genial tubercle.
Insertion&
The two ribbon like muscles descend side by side between myelohyoid $
genioglossus to be inserted into the upper border of the body of hyoid bone.
4erve supply&
G1 fibers from the III nerve.
'ction&
>ulls the hyoid anterosuperiorly.
Eyoglossus&
This is a tongue muscle $ is an important key around which the structures of the
floor of the mouth are distributed
7rigin&
The upper border of the greater cornu of the hyoid.
Insertion&
The rectangular muscle ascends up to be inserted into the side of the tongue
posteriorly
4erve supply&
III nerve.
'ction&
- >ulls the hyoid up
- Jepresses the side of the tongue
- (oth retract the tongue
Submandibular gland:
Mill be discussed later.
5acial artery:
Jiscussed.
+ommon facial vein:
N -ormed at the lower border of the mandible by union of the anterior facial v. $
anterior division of retromandibular v.
N >asses superficial to the submandibular gland in the direction of the carotid
triangle of the neck
N Terminates in the IH) either separately or together with the superior thyroid $
lingual veins
N It drains the structures in the submandibular triangle
Submandibular lymph nodes:
+ervical branch of '22 &
Jescends vertically from behind the mastoid process to platysma.
The submental triangle:
Is the space between the anterior bellies of the 2 digastrics $ the hyoid bone.
Coof &
,kin* subcutaneous connective tissue* platysma and investing fascia.
-loor&
.yelohyoid
Gontents&
1- ,ubmental branch of facial artery.
2- 4erve to myelohyoid.
3- beginning of 'H).
- ,ubmental lymph nodes.
Submental branch of facial artery:
Jiscussed.
A1':
Jiscussed.
Submental lymph nodes:
:yelohyoid nerve:
N Diven from the inferior alveolar nerve at the mandibular foramen.
N >ierces the sphenomandibular ligament $ passes forward in the floor of the
submental triangle inferior to myelohyoid between it $ the anterior belly of
digastric supplying both.
N It is accompanied by the submental artery.
he "re!ertebral region:
Is the area which lies in front of the vertebral column $ constitutes the prevertebral $
paravertebral muscles covered by the prevertebral fascia.
%revertebral :uscles:
Cectus capitis anterior&
7rigin9 lateral mass of atlas
Insertion9 basi-occiput
4erve supply9 G1
'ction9 fle+es the head
Cectus capitis lateralis&
7rigin9 transverse process of atlas
Insertion9 :ugular process of occipital bone
4erve supply9 G1
'ction9 laterally fle+es the head
6ongus capitis&
7rigin9 anterior tubercles of T.> of the typical cervical vertebrae end-to-end with
the tendons of scalenus anterior
Insertion9 basi-occiput anterior to foramen magnum
4erve supply9 G1-G
'ction9 fle+es the head $ neck
6ongus colli&
This muscle e+tends on the anterior surface of the vertebral column from G1 to G
7rigin9
)ertical part& bodies of thoracic vertebrae
,uperior oblique part& T.> of upper cervical vertebrae
Inferior oblique part& bodies of upper thoracic vertebrae
Insertion9
- )ertical part& bodies of cervical vertebrae
- ,uperior oblique part& anterior tubercle of G1
- Inferior oblique part& T.> of lower cervical vertebrae
4erve supply9 G1-T
'ction9 fle+es $ rotates the neck
The +ervical Sympathetic Trun4:
N 'n upward e+tension of the thoracic ,.T which is located behind the carotid
sheath on the prevertebral fascia
N In a cord-like form or multiple strands* the ,.T develops three ganglia in the
neck9 superior* middle $ inferior
N 5ach one of the three has three sets of branches9 somatic* vascular $ visceral.
N The body of the cervical ,.T is formed mainly of preganglionic fibers which
traverse the white rami communicantes of the upper ! thoracic segments
N Gervical ,.T possesses no white rami communicantes attaching it to the spinal
nerves since there is no lateral gray column in the cervical segments

)ascular br. )isceral br. ,omatic br. >osition Danglion
-Garotid
sympathetic
ple+us
-,uperior
cervical cardiac
nerves
-The left to the
superficial
cardiac ple+us
-The right to the
deep G.>
-Dray rami
communicants
to G1-G spinal
nerves
-6argest #2.!-
3.!% cm long
-G2 level
,uperior
G.D
-Inferior
thyroid sym.
>le+us
-.iddle cervical
cardiac nerves to
the deep G.>
-Dray rami
communicants
to G! $ G8
spinal nerves
-,mallest #1.3
cm% long
-G8 level
.iddle G.D
-)ertebral
sym. ple+us
-Inferior cervical
cardiac nerves to
the deep G.>
-Dray rami
communicants
to G; $ G0
spinal nerves
-In 021 fused
with the T1
ganglion to
form the the
stellate gan.
on the neck of
the 1st rib
Inferior
G.D
-oot of the neck:
- The root of the neck is based on the supra-pleural membrane which inclines
downward $ forward with the inclination of the first rib
- (ehind $ inferior to the membrane lies the lung apices with their cervical
pleura
- In front $ superior to the membrane lies structures of the root.
- The neck root is studied according to structure relation to scalenus anterior
The triangular space .of +hassaignac/:
- It is the space bounded laterally by the medial border of scalenus anterior*
medially by the sloping lateral border of longus colli $ inferiorly by the neck
of the 1st rib
- Its ape+ is the carotid tubercle #G8 T.>% against which the GG' can be
compressed
- It contains the 1st part of subclavian artery $ the 8th cervical sym. ganglion
'nterior relations&
1- >hrenic nerve& passes vertically across the obliquity of the muscle leaving its
medial border inferiorly to pass to the thora+.
2- )agus nerve& descends anterior $ medial to the muscle to reach the front of the
subclavian artery $ gives the recurrent laryngeal n. around this vessel on the right
side.
3- 'scending cervical artery& ascends from the inferior thyroid a. on the muscle
medial to the phrenic nerve.
- Transverse cervical $ suprascapular arteries& cross anterior to the lower part of the
muscle in their way to the posterior triangle.
!- IH)& lies anterior to the lower part of the muscle.
8- ,ubclavian vein& crosses the lower part of the muscle to meet the IH) medial to it
in the pyramidal space.
;- Jeep cervical 6.4& around the IH)* inferior nodes lie especially in front of the
muscle.
0- ,G.& covers all the above structures.
.edial relations&
1- )agus nerve.
2- .iddle $ inferior cervical sympathetic ganglia& lie in the pyramidal space on the
medial side of scalenus anterior connected in front of the subclavian artery by the
ansa subclavia.
3- -irst part of subclavian artery& with its three branches
- )ertebral vein#s%& leave the T.> of G; $ course forward to enter the confluence of
the subclavian v. $ IH).
!- Thoracic duct #on the left% $ right lymph duct #on the right%& arch in the pyramidal
space to enter the confluence of the subclavian v. $ IH).
>osterior relations&
1- Coots of brachial ple+us& as they emerge from the intervertebral foramina to the
posterior triangle* they lie superior to the subclavian artery.
2- ,econd part of subclavian artery& behind the muscle on the 1st rib* here it gives the
costocervical a+is.
6ateral relations&
1- Trunks of brachial ple+us& in the posterior triangle.
2- Third part of subclavian artery& behind the prevertebral fascia in the floor of the
posterior triangle.
- The muscles of the back of the neck are enclosed by the thoracolumbar fascia
in the posterior compartment of which the postvertebral muscles lie
- 5+ternally the investing fascia wraps the whole neck
+ack of the neck:
-igamentum nuchae:
' strong* triangular sheet of fibrous tissue dividing the back of the neck into two
halves $ provides an important origin for many muscles* it is attached by its three
borders to&
1- The e+ternal occipital crest* superiorly.
2- Tips of cervical spines $ supraspinous ligaments* anteriorly.
3- >osterior free border to which the investing fascia comes from either side of the
neck to be attached.
Thoracolumbar fascia:
- ' strong fascia attached to the spines $ transverse processes of the vertebral
column enclosing within its two compartments the muscles
- This arrangement persists in the the lumbar region* in the thoracic $ cervical
regions the anterior lamella of the fascia disappears leaving the middle $
posterior lamellae only enclosing in between the postvertebral muscles
:uscles of the bac4 of the nec4:
,plenius&
- Its name in latin means 2bandage3 revealing its shape $ function
- The muscle lies deep to trape"ius $ covers the deep muscles of the neck like a
strap.
7rigin& from ligamentum nuchae $ spines of G8 $ ; with the supraspinous
ligaments.
Insertion& The muscle is directed upward $ laterally $ divided into two parts&
- ,plenius capitis9 inserted into the deep part of mastoid $ the lateral 1B3 of the
superior nuchal line.
- ,plenius cervicis9 inserted into the posterior tubercles of T.> of the upper 3 cervical
vertebrae.
4erve supply& posterior rami of G2-G8.
'ction& pulls the head back $ laterally in the direction of the active muscle. (oth
e+tend the neck.
5rector spinae&
- This group of muscles e+tend from the sacrum to the skull in the form of three
longitudinal parallel columns $ occupy the posterior compartment of lumbar
fascia
- ,ome of them are inserted into various regions #lumbar $ thoracic% $ some
muscles belong to the head $ neck.
- Their nerve supply is segmental
6ongissimus&
Is the intermediate column of 5.,
Eas three parts #thoracis* cervicis $ capitis%.
'rise from T.> of lower vertebrae.
Inserted into T.>. of higher vertebrae.
Gapitis muscle is inserted into the back of the mastoid process deep to splenius
$ ,G..
,emispinalis&
7ccupy the medial column of the 5.,
Its limited to the thoracic #thoracis%* cervical #cervicis% $ head #capitis%regions
,. cervicis $ thoracis arise from the T.> of all thoracic vertebrae
They are inserted into the spines of -8 vertebrae above. The highest fibers of cervicis
muscle are inserted into the undersurface of the spine of a+is
They e+tend the upper vertebral column $ rotate it to the opposite side
,. capitis arises from T.> of G;-T8
It is the largest muscle in the back of the neck*being inserted into the occipital bone
between the 2 nuchal lines medially
It is the most powerful skull e+tensor
The suboccipital muscles :
Cectus capitis posterior ma:or&
7rigin& spine of G2
Insertion& the area between inferior nuchal line $ foramen magnum* laterally
Cectus capitis posterior minor&
7rigin& posterior tubercle of G1
Insertion& the area between inferior nuchal line $ foramen magnum* medially
,uperior oblique&
7rigin& T.> of G1
Insertion& the area between the two nuchal lines* lateral to semispinalis capitis
Inferior oblique&
7rigin& spine of G2
Insertion& T. > of G1
The suboccipital triangle :
Is the triangle embraced by the supoccipital muscles e+cept rectus capitis posterior
minor which lies medial to it.
-loor& the posterio atlanto-occipital membrane $ posterior arch of atlas
Gontents&
1- )ertebral artery9 in the floor.
2- ,uboccipital nerve* G1.
3- Dreater occipital nerve* G2& hooks below the inferior oblique $ ascends in the
roof of the triangle.
- 7ccipital artery& ascends medially in the roof of the triangle in its way to the scalp
together with the greater occipital nerve.
THE HEAD
he scal":
Is a five-layered structure covering the vault of skull $ bears the hair of the head* its
name is derived from its ! layers which are&
o ,kin
o Gonnective tissue #subcutaneous connective tissue%
o 'poneurosis # galea aponeurotica of occipito-frontalis muscle%
o 6oose areolar tissue #subaponeu. space
o >eriosteum #pericraneum%
S4in:
N Thin* hairy with generous amount of sweat $ sebaceous glands
N -irmly adherent to the ne+t layer
Subcutaneous connective tissue:
N Thick layer made of connective tissue septa in all directions to form a dense
network enclosing fatty loculi
N Eair follicles pierce this layer
N 'rteries* veins $ nerves of the scalp lie in this layer and are held in position by
the firm fibrous network
N 'dheres to the layer deep $ superficial to it* so the three layers could not be
separated from each other $ move together when moving the scalp
0picranial aponeurosis:
N ' musculo-aponeurotic layer formed by the bellies of occipito-frontalis
muscle connected by their galea aponeurotica
N 7ccipito-frontalis&
- The muscle arises by two bellies from the highest nuchal lines posteriorly
- The 2 bellies are inserted into the back of the aponeurosis which is formed of
sagittally running fibers. -rom the anterior end of the aponeurosis the two
frontal bellies arise and go forward to be inserted into the skin of eyebrows $
root of the nose
- The muscle is innervated by facial nerve #posterior auricular branch to
occipitalis $ temporal branch to frontalis%
- It acts to pull the scalp backward $ elevate the eyebrows as in surprise
e+pression.
Subaponeurotic space:
N 5+tensive space lies beneath the galea $ contains loose areolar tissue
N .ovements of the superficial three layers take place in this plane
N It is only limited by the attachment of the galea
N anteriorly it is continuous with the eyelids $ eyebrows
N -luid accumulation in this space tend to go to the dependent areas* i.e9 over the
occipital bone posteriorly $ in the eyelids anteriorly #if blood causes black
eye%
%ericraneum:
N Is the periosteum of skull bones
N Is firmly adherent to the sutures
N (leeding deep to this layer takes the shape of underlying bone
Arteries of the scalp:
- (ranches from the 5G' $ IG' supply the scalp and anastomose freely with
each other $ with those of the opposite side
- 'rteries are held by the fibrous septa of the 2nd layer which pull them $
prevent their contraction when severed.
Branches of 0+A:
1- 7ccipital a.9
- -rom the back of 5G' goes deep to the posterior belly of digastric then in the
ape+ of the posterior triangle grooving the occipito-mastoid suture on the skull
then in the roof of the suboccipital triangle where it accompanies the greater
occipital nerve to reach the scalp
- It divides into medial $ lateral terminal branches which supply the scalp up to
the verte+.
2- >osterior auricular a.9
- -rom the back of the 5G' :ust above the posterior belly of digastric
- It passes superficial to the styloid process to lie in the groove between the
mastoid process $ the e+ternal auditory meatus
- Its branches are&
- ,tylomastoid& enters the stylomastoid foramen $ supplies the tympanic cavity*
antrum $ mastoid cavities.
- 'uricular& supplies the auricle* posterior part of temporal area.
- 7ccipital& supplies the skin over the mastoid process $ occipitalis.
3- ,uperficial temporal a.9
- The smallest of the 2 terminal branches of 5G'
- -rom behind the neck of mandible the artery grooves the root of the "ygomatic
arch with the auriculotemporal nerve
- 'scends in the temporal fossa to end ! cm above the "ygomatic arch by
dividing into frontal $ parietal branches. Its branches are&
- Transverse facial& from its anterior aspect this artery passes over masseter between
the parotid duct $ "ygomatic arch supplying all structures in the region.
- .iddle temporal& arises above the root of the "ygomatic arch $ perforates the
temporal fascia $ muscle to lie directly on the squamous temporal bone grooving it
with its accompanying vein.
- ?ygomatico-orbital* anterior auricular $ terminal branches supply muscles $ skin
in their regions.
Branches of 2+A:
1- ,upra-orbital a.9
- from the ophthalmic artery this branch leaves the supra-orbital notch to supply
the scalp up to the verte+
- It anastomose with the termination of facial artery #angular a.% $ the frontal
branch of superficial temporal artery.
2- ,upra-trochlear a.9
Head & Neck Dr. Nawfal K. Al-Hadithi =
- -rom the ophthalmic artery this branch leaves the supra-orbital notch with the nerve
of its name to supply the middle of the forehead.
'eins of the scalp:
- 'ccompany the corresponding arteries
- 'nastomose freely with their ad:acent veins of the same side $ of the opposite
side.
1- ,upratrochlear v.9 unite at the medial canthus with the supra-orbital v. of its same
side to form the angular v. which descends in the face as the facial vein.
2- ,upra-orbital v.9 is connected #before forming the angular v.% to the superior
ophthalmic vein in the orbit which drains to the cavernous sinus.
3- ,uperficial temporal v.9
- 'ccompanies the artery $ receives branches similar to those of the artery.
- (ehind the neck of the mandible it receives the two ma+illary veins to form the
retromandibular v. which enters the parotid gland.
- >osterior auricular v.9 larger than the corresponding artery* it descends to meet the
posterior division of retromandibular v. forming the 5H).
!- 7ccipital v.9 accompanies the artery an ends in the deep cervical $ vertebral
venous ple+us. 7ccasionally it ends in the IH).
3erves of the scalp:
Trigeminal nerve supplies the anterior part of the scalp up to the verte+ by branches
derived from its three divisions&
1- 7phthalmic division &
- ,upratrochlear n.9 supplies the middle of the forehead up to the hairline.
- ,upra-orbital n.9 supplies the lateral part of the forehead $ meets its opposite
fellow above the distribution of the supratrochlear n. to supply the scalp up to
the verte+.
2- .a+illary division&
?ygomatico-temporal n.9 supplies the non hairy part of the temple.
3- .andibular division&
'uriculotemporal n.9 from the infratemporal fossa this nerve accompanies the
superficial temporal a. $ crosses the root of the "ygomatic arch to ascend in the
temple. It supplies the upper half of the auricle e+ternally* parotid gland $ the hairy
temple.
>osterior primary rami of G2 #greater occipital n.% and 2to lesser amount3 G3 supply
the back of the scalp up to the verte+.
-ymph of the scalp:
- 'nterior $ lateral parts to the submandibular 6.4
- >osterior part to the occipital 6.4
Applied anatomy:
N Mounds of the scalp opens the 3 superficial layers therefore they have two
main characteristics&
1- 7pen widely* due to the stretch effect of the aponeurosis.
2- (leeds profusely* because the scalp is rich in blood vessels which lie in the second
layer $ this layer is stretches by the aponeurosis so the vessels tear more $
hemostasis will be difficult.
N (ecause the scalp moves freely on the bone* the superficial in:uries may not
coincide with deep ones.
N ,ubaponeurotic hematoma will descend in the dependent areas leading to black
eyes $ posterior hematomas
N ,ubperiosteal hematomas take the shape of the underlying bone.
N 'nastomosis between the 5G' $ IG' in the scalp is at a sagittal line which
lies above the lateral end of the eyebrow* bleeding here is very profuse.
he face:
:uscles of 5acial 0pression:
- The face lacks deep fascia $ its superficial fascia is modified into muscles
whose one end is attached to bone 2usually3 $ the other to the facial skin
which they move producing various movements.
- The superficial muscles of the face are arranged around facial orifices
#palpebral fissure* nostrils $ oral fissure% as two groups around each orifice*
dilator $ constrictor.
- .an has trained himself to e+press $ understand some facial movements
produced by some of these muscles
- .any facial muscles produce no e+pression like buccinator* indeed a very
meaningful e+pressions are produced by muscles not belonging to the face like
genioglossusRR
2) :uscles of the palpebral fissure:
,>EI4GT5C,&
7rbicularis oculi&
- This muscle is formed of concentric fibers which are arranged
circumferentially around the opening of the eyelid
- It is formed of three parts&
1- The orbital part&
- 'rises from the medial orbital margin $ the medial palpebral ligament
- ,preads onto the forehead $ cheeks
- It is the most peripheral part of the muscle.
2- The palpebral part&
- 'rises from the lateral end of the medial palpebral ligament
- Gourse in the subcutaneous connective tissue of the eyelids
- Interdigitate laterally forming the lateral palpebral raphe.
3- The lacrimal part&
- -rom the posterior part of the medial palperal lig. $ psterior lacrimal crest
- These fine fibers are inserted into the lacrimal sac $ tarsal plates
F The medial palpebral ligament&
- Is a strong band * ! mm long
- 'rises from the frontal process of the ma+illa $ e+tends laterally to divide into
2 slips each one is continuous with its corresponding tarsal plate
4erve supply&
- -acial nerve supplies the muscle by its temporal $ "ygomatic branches
'ction&
- 7rbital part9 depresses the eyebrows $ protects from light as in looking from
distance
- >alpebral part9 closes the eyelids gently as in blinking
- 6acrimal part9 squee"es the lacrimal sac
- '66 the parts9 close the eyes forcibly as in protection from accidents
JI6'T7C,&
5rontalis:
Jiscussed. It is the opponent of the orbital part of 7. oculi.
-evator palpebrae superioris:
This muscle is the opponent of the palpebral part of 7. oculi.
7rigin9 -rom the back of the orbit in front of the optic canal
Insertion9
- The muscle broadens as it traverses the uppermost part of the orbit forward to
enter the upper eyelid
- It is inserted into the upper part of the orbital septum $ 7. oculi.
This muscle is formed of skeletal #voluntary component% $ smooth muscle fibers
#involuntary component%* the latter is responsible for its unconscious prolonged $
sustained contraction in opening the eyes for long time without fatigue.
4erve supply&
- ,keletal part& superior division of oculomotor nerve
- ,mooth muscle part& superior thoracic sympathetic ganglion #T1% whose in:ury
in 2EornerQs syndrome3 is responsible for ptosis in this condition.
22) :uscles of the nose:
JI6'T7C,&
Gorrugator&
7rigin9 the superciliary arch
Insertion9 medial half of the eyebrow skin
'ction9 pulls the eyebrows medially producing vertical wrinkles
>rocerus&
7rigin9 lower part of nasal bone $ alar cartilage
Insertion9 skin between the eyebrows
'ction9 pulls the skin overlying the root of the nose downward
'lar part of nasalis&
7rigin9 canine eminence
Insertion9 fibers ascend superomedially to meet its fellow on the nose
'ction9 depresses $ dilate nostrils
,>EI4GT5C,&
,eptal part of nasalis #depressor septi%&
7rigin9 ma+illa* near the anterior nasal spine
Insertion9 lower part of the septum
'ction9 pulls the septum down $ diminishes the openings of the nostrils
4erve supply of nasal muscles&
/pper fibers& temporal branch of facial n.
6ower fibers& "ygomatic $ buccal branches of facial n.
222) :uscles of the oral fissure:
JI6'T7C,&
5levators of the upper lip&
6evator labii superioris alaeque nasi&
7rigin9 frontal process of ma+illa
Insertion9 partly in alar cartilage $ partly in the lateral half of the upper lip
'ction9 elevates the angle of the mouth $ dilates the nostril
6evator labii superioris&
7rigin9 inferior orbital margin above the infra-orbital foramen
Insertion9 lateral half of the upper lip
'ction9 elevates the upper lip
?ygomaticus ma:or&
7rigin9 "ygomatic bone anterior to the "ygomatico-temporal suture
Insertion9 skin on the lateral side of the mouth $ 7. oris
'ction9 draws the mouth superolaterally
?ygomaticus minor&
7rigin9 lower part of "ygomatic bone
Insertion9 upper lip* medial to the mouth angle
'ction9 elevates the upper lip
6evator anguli oris&
7rigin9 from the canine fossa
Insertion9 the muscle lies deep to 66, ends in the mouth angle
'ction9 elevates the angle of the mouth
Cisorius&
7rigin9 parotid fascia
Insertion9 skin of the angle of the mouth
The muscle is a contribution of many muscles$ it is an important landmark for
dentists.
Jepressors of the lower lip&
Jepressor labii inferioris&
7rigin9 mandible* medial to the mental foramen
Insertion9 lateral side of the lower lip
'ction9 draws the lower lip downward $ laterally
Jepressor anguli oris&
7rigin9 oblique line of the mandible
Insertion9 angle of the mouth
'ction&depresses the mouth angle
.entalis&
7rigin9 mandible* below the incisor teeth
Insertion9 skin of the chin
'ction9 modifies the oral aperture indirectly by dimpling the skin of the chin.
,>EI4GT5C,&
7rbicularis oris&
Intrinsic part of 7. oris #superficial part%&
N /pper #ma+illary% fibers from the alveolar process of the ma+illa above the
incisor teeth* these fibers go laterally $ wind around the angle of the mouth to
dip in the lower lip
N 6ower #mandibular% fibers from the alveolar process of the mandible below the
incisor teeth* these fibers go laterally to wind around the mouth angle $ ascend
in the upper lip
5+trinsic part of 7. oris #deep part%&
-ormed by contributions from the dilators $ buccinator
'ction&
- ,phincter of the mouth
- -lattens the lip
- >rotrudes the lip
4erve supply of oral muscles&
- 'bove the mouth angle& "ygomatic $ buccal br. of )II
- (elow the mouth angle& mandibular br. of )II
(uccinator&
This quadrilateral muscle lies in a deeper stratum than other muscles of the face $
forms the main bulk of the cheeks.
7rigin9 from 3 lines forming $ G-shape origin&
N 'lveolar process of ma+illa in a line which overlies the upper molar teeth
#upper fibers%
N 'lveolar process of the mandible in a line which lies parallel to the lower
molar teeth #lower fibers%
N >terygomandibular raphe which e+tends from the pterygoid hamulus to the
deep surface of the mandibular angle #middle fibers% sharing this origin with
the superior pharyngeal constrictor muscle
Insertion9 the most peripheral fibers of buccinator #upper $ lower% pass directly into
the corresponding lip* while the middle fibers interlace at the angle of the mouth* the
upper go to the lower lip $ the lower to the upper lip.
4erve supply9 buccal branch of facial nerve
'ction9 compresses the cheek $ increases the intra-oral pressure* its paralysis tend to
accumulate food in the vestibule of the mouth.
N It is pierced by the parotid duct to which it gives a sphincter-like action
N The buccal branch of mandibular nerve is sensory to the muscle $ ends in the
skin overlying it
All facial muscles are supplied by proprioception from the sensory nerves supplying
the overlying s4in
Arteries of the face:
'rteries of the face lie in the subcutaneous tissue . The main artery of the face is the
facial artery* other arteries which share in the supply of the face are&
1- Transverse facial artery.
2- Infraorbital artery.
3- .ental artery.
- (uccal artery.
1$ 5acial artery:
'n anterior branch of the 5G' leaving it deep to the posterior belly of digastric
muscle $ passes in the submandibular triangle to reach the lower border of the
mandible where it curves up to the face.
In the face the artery is superficial at its beginning being covered only by skin
$ platysma.
The artery ascends in a very tortuous course towards the medial angle of the
eye* its relation to the face muscles is variable but usually it is superficial to
buccinator $ levator anguli oris $ deep to the "ygomatic muscles.
The facial vein lies lateral to the artery $ its course is less tortuous.
(ranches of the facial artery&
I % In the neck #do not reach the face%&
a- 'scending palatine a.
b- Tonsillar a.
c- .uscular branches
d- Dlandular branches to the submandibular gland
e- ,ubmental a.
II % In the face&
a- Inferior labial a.
b- ,uperior labial a.
c- 6ateral nasal a.
d- 'ngular a.
- The labial branches&
N 'rise opposite to the angle of the mouth $ enter the corresponding lips
between 7. oris $ the mucous membrane
N ,upply muscles* glands $ mucous membranes of the lips
N 'nastomose with labial branches of the opposite side
- 6ateral nasal branch&
'rises alongside the nose
,upplies the ala $ dorsum of the nose
'nastomose with the opposite artery* infraorbital a.
- 'ngular artery&
The terminal part of facial artery lies at the medial canthus
,upplies 7. oculi $ the lacrimal sac
'nastomoses with the infraorbital a.
2$ Transverse facial artery# .discussed/
&$ 2nfraorbital artery:
N 7ne of the terminal branches of ma+illary artery
N 6eaves the infraorbital foramen $ lies deep to lavator labii superioris
N Dives palpebral* nasal $ labial branches
($ :ental artery:
N Is the terminal branch of the inferior alveolar artey
N 'ppears in the face from the mental foramen deep to depressor anguli oris
N ,upplies the chin
)$ Buccal artery:
N ' branch of ma+illary artery
N 'ccompanies its vein $ the buccal branch of mandibular nerve to reach the
area of buccinator
N ,upplies buccinator $ skin $ m.m. of the cheek
'eins of the face:
1$ Anterior facial vein:
N (egins at the medial canthus as the angular vein by confluence of supraorbital
$ supratrochlear veins
N Gonnected to the superior ophthalmic vein which :oins it to the cavernous sinus
N Jescends on the lateral side of the artery receiving corresponding tributaries
N Gontains no valves so blood can go up to the cavernous sinus or down to the
IH)
N 't the angle of the mouth near buccinator* the anterior facial v. is connected to
the pterygoid ple+us #which is connected to the cavernous sinus% by the deep
facial v.
N Jangerous "one& between the angular $ the deep facial veins where facial
venous blood can easily drains to the cavernous sinus transmitting infections
resulting in sinus thrombosis
N In the submandibular triangle the vein lies superficial to the gland :ust deep to
the roof of the triangle $ receives veins from the gland
N It meets the anterior division of retromandibular v. forming the common facial
v. which drains to the IH)
2$ Transverse facial vein#
&$ 2nfraorbital vein#
($ :ental vein#
)$ Buccal vein#
3erves of the face:
.7T7C&
5acial nerve:
- 'fter leaving the stylomastoid foramen it gives muscular branches to
occipitalis $ to the posterior belly of digastric $stylohyoid
- In its way to the face this nerve enters the posterior surface of the parotid gland
medially then passes very superficial in the gland dividing into&
- Temporofacial branch9 the upper division which gives the temporal $
"ygomatic branches.
- Gervicofacial branch9 the lower one which gives the buccal* mandibular $
cervical branches
- Temporal br supplies muscles above the palpebral fissure
- ?ygomatic br supplies muscles between the palpebral $ oral fissures
- (uccal br is for buccinator
- .arginal mandibular br. supplies muscles of the lower lip
- Gervical br. is for platysma
,54,7CP&
1 ) Trigeminal nerve:
Terminal branches of the three divisions of trigeminal nerve supply the face as
follows&
I& 7phthalmic division&
,upraorbital n.& forehead up to the verte+
,upratrochlear n.& middle part of forehead up to hairline
Infratrochlear n.& medial K of the upper lid $ bridge of the nose
6acrimal n.& lateral K of the upper lid
5+ternal nasal n.& middle of e+ternal nose down to the tip
II& .a+illary division&
?ygomaticofacial n.& prominence of the cheek
Infraorbital n.&
>alpebral br.& lower lid
4asal br.& lateral side of the e+ternal nose
6abial br.& upper lip
III& .andibular division&
(uccal n.& skin over buccinator
.ental n.& chin $ lower lip
2 % Dreat auricular nerve&
,upplies skin over the angle of the mandible.
Applied anatomy of the face:
1- Gavernous sinus thrombosis could follow face infections especially with force
manipulations* with the resultant ophthalmoplegia $ high mortality rate.
2- Three branches of facial nerve could be easily in:ured in the face* the temporal $
"ygomatic as they pass over the ". arch could be in:ured in fractures of the arch
producing dry eye $ partial ptosis* the 3rd is the marginal nerve at the lower border
of the mandible could be in:ured in abscess drainage producing drop lip.
3- Gomplete facial palsy is of two types&
a% /pper motor neuron9 especially evident in the upper muscles
b% 6ower motor neuron9 clear paralysis seen affecting all ipsilateral facial muscles
with its characteristic appearance.
he tem"oral fossa:
- 6ies at the side of the head* being bounded by the temporal lines above*
anteriorly $ posteriorly and by the infratemporal crest of the sphenoid below.
- The floor of the fossa is formed by frontal* parietal* squamous temporal bones
$ greater wing of sphenoid.
Temporal fascia:
' strong membrane that arises from the area between the superior $ inferior temporal
lines and descends down covering temporalis muscle to be attaches to the upper
border of the "ygomatic arch $ posterior border of the "ygomatic bone.
Temporalis:
7rigin9 floor of the temporal fossa $ temporal fascia.
Insertion9 -ibers of this fan-shape muscle converge from this wide origin into a
tringular tendon which slides in the gutter between the posterior root of the ". arch $
the squamous temporal bone to be inserted in the coronoid process of the mandible
4erve supply9 anterior $ posterior deep temporal branches from the anterior division
of )c.
'ction9
- 'nterior fibers #vertical%& close the mouth
- >osterior fibers #hori"ontal%& retract the mandible
'essels of the fossa:
,uperficial temporal vessels* discussed.
Sensory nerves of the fossa:
1- ?ygomaticotemporal n. #branch of )b%& non-hairy part
2- 'uriculotemporal n. #branch of )c%& hairy part
The fossa communicates inferiorly through the infratemporal crest with the
infratemporal fossa.
he "reauricular region:
.asseter&
- ' thick quadrangular muscle that lies on the lateral side of the angle of the
mandible partly covered by the anterior portion of the parotid gland $ crossed
by its duct
- It is one of the muscles of mastication
7rigin&
- The superficial part& anterior 2B3 of the "ygomatic arch
- The deep part& posterior 1B3 $ medial surface of the arch
Insertion& 7n the lateral aspect of the angle of the mandible
4erve supply& .asseteric nerve* a branch of anterior division of )c enters the deep
surface of the muscle after passing through the mandibular notch from the IT-
'ction& Gloses the mouth.
he sali!ar# glands:
-This is a group of glands that function as an initial digestion apparatus.
-They lubricate the mouth $ partially digest some sorts of food.
-The main glands are three* parotid* submandibular $ sublingual* though the mucous
membranes of the oral cavity contains a lot of minute glands.
-Their secretion is a mi+ture of mucous $ serous fluid called the saliva.
The parotid gland:
Is the largest of the salivary glands* almost totally serous in secretion.
Shape:
The gland is a pyramid with an irregular triangular base directed laterally
%osition:
FThe pyramid is wedged in the slit between the e+ternal auditory meatus posteriorly
$ the mandible anteriorly.
FThe base of the pyramid lies laterally in the preauricular region* $ the three borders
are&
- ,uperior& along the "ygomatic arch
- >osterior& anterior to the 57. $ mastoid process
- 'nterior& actually it is antero-inferior overlies the posterior part of masseter.
FThe ape+ of the pyramid lies deep in the slit reaching the carotid sheath.
7elations:
F ,uperiorly& The "ygomatic arch $ the skull base above
F >osteriorly&
- .astoid process sandwiched by the sternomastoid muscle $ the posterior belly
of digastric
- The 57.* styloid process $ stylohyoid are also posterior relations.
F 'ntero-inferiorly& The angle of the mandible sandwiched between masseter $
medial pterygoid muscles
F 6aterally& The fatty tissue of the side of the face
F .edially& The carotid sheath $ lateral pharyngeal space
The parotid duct:
- The duct leaves the anterior border of the gland 1 cm below the "ygomatic
arch.
- It courses over masseter in a hori"ontal line that could be marked on the
surface as the middle 1B3 of a line passing from the intertragic notch to the
point midway between the red margin of the lip $ the lower border of the nose.
- 't the anterior border of masseter* the duct dips medially piercing the buccal
pad of fat $ buccinator opposite to the last molar tooth.
- 'fter a short course in buccinator #which acts as a valve%* the duct opens in the
vestibule of the mouth opposite to the upper second molar tooth.
The parotid isthmus:
- Is the thinnest portion of the gland that lies between the mandible $ the
mastoid process
- The part of the gland superficial to the isthmus is called #wronglyR% the
superficial lobe $ the part deep to it called the deep lobe.
- 'ctually* )II is the structure which separates the gland into its two lobes
The accessory parotid gland:
-rom the duct over masseter sometimes a piece of parotid tissue lies $ may e+tend
high up to the temporal fossa. This is the accessory parotid g. or sometimes named
#glenoid lobe%.
The parotid fascia:
Is derived from the investing cervical fascia which splits to enclose the gland.
The superficial layer of the fascia will be attached above to the "ygomatic arch $
after it crosses the gland it fuses with masseteric fascia.
The deep layer is attached above to the lower border of the tympanic plate $ reaches
medially the carotid sheath with which it fuses.
' thickening in the deep layer stretches between the styloid process $ the angle of
the mandible called the stylomandibular ligament which separates the gland from the
submandibular gland.
The fascia is supplied by the great auricular nerve.
+ontents of the gland:
.any important structures lie within or very near to the parotid gland* structures
which lie within the substance of the gland are9 from superficial to deep&
Head & Neck Dr. Nawfal K. Al-Hadithi !=
1-The facial nerve&
- 'fter leaving the stylomastoid foramen in its way to the face this nerve enters
the posterior surface of the gland medially then passes very superficial in its
substance where it gives its terminal branches from the anterior border of the
gland to the face.
- The facial branches are almost hori"ontal at their beginning and could be
in:ured in parotid incisions.
2-The retromandibular vein&
- The two ma+illary veins leave the IT- $ go forward medial to the neck of the
mandible to enter the parotid deep to the facial nerve
- 'fter receiving the superficial temporal vein* the retromandibular vein is
formed within the gland.
- It drains the parotid $ divides into&
a% 'nterior division& receives the anterior facial vein to form the common facial
vein in the submandibular triangle.
b% >osterior division& receives the posterior auricular vein to form the 5H) behind
the angle of the mandible.
3-The e+ternal carotid artery&
- 5nters the gland from below $ ascends in it deep to the above two structures
- Mhen reaches the neck of the mandible the 5G' divides into its two terminal
divisions which leave the gland from its anterior $ superior borders.
- The preauricular #parotid% lymph nodes&
a% ,uperficial nodes& between the gland $ its fascia.
b% Jeep nodes& embedded within the gland.
!- The auriculo-temporal nerve&
In its way from the IT- to the temporal fossa* it passes through the upper part of the
gland to accompany the superficial temporal artery $ go to the scalp.
Blood supply:
- ,uperficial temporal a.
- >osterior auricular a.
'enous drainage:
Cetromandibular vein.
-ymphatic drainage:
The parotid lymph nodes.
3erve supply:
1- ,ensory $ secretomotor& 6esser petrosal fibers from the otic ganglion via the
auriculotemporal nerve.
2- >arotid fascia is supplied by the great auricular nerve.
Applied anatomy:
N .alignant tumors of the parotid sometimes involve the facial nerve forming
lower motor facial palsy.
N Incisions in the substance of the gland should be hori"ontal along the facial
nerve branches because they are superficial to the vessels of the gland $
paralysis could occur by cutting the facial nerve before a serious bleeding is
encountered.
Head & Neck Dr. Nawfal K. Al-Hadithi !1
N Inflammation of the parotid as in mumps usually obliterate the angle between
the lobule of the auricle $ the angle of the mandible.
The submandibular gland:
Shape ! position:
- This mi+ed gland occupies most of the submandibular triangle
- It rests on the investing fascia while the latter is stretched between the mandible $
the hyoid bone
- It leaves a smooth impression on the inside of the mandible below the mylohyoid
line
- The gland goes posteriorly to reach the angle of the mandible near the parotid gland*
here it turns up around the free posterior border of mylohyoid #which overlies it% $
the remaining part of it will lie above this muscle in the floor of the mouth
- The part of the in the neck is called 2superficial lobe3 while the part in the floor of
the mouth is called 2deep lobe3
7elations:
- 'nterolateral& mandible
- (elow& investing fascia
- 'bove& mylohyoid
- (ehind& parotid* digastric 2post. belly3 $ stylohyoid
- .edial& digastric 2ant. belly3 $ hyoid bone
Structures in close relation to the gland:
1- -acial artery& lies between the gland $ mylohyoid then between it $ the mandible
where it enters the face.
2- Gommon facial vein& is formed in the triangle superficial to the gland.
3- ,ubmandibular lymph nodes& in and around the gland.
The submandibular fascia:
- 6ike the parotid* this gland derives its fascia from the investing layer of deep
cervical fascia on which the gland rests.
- The investing fascia encloses the gland by a superficial layer superficial to it $
a deep layer between it $ myelohyoid.
- Infection of the submandibular space causes 6udwigQs angina with increased
pressure in the space pushing the tongue out of the mouth
The submandibular duct:
- ' ! cm duct leaves the anterior portion of the tongue-like deep lobe to pass in
the floor of the mouth between mylohyoid $ hyoglossus.
- 7n the lateral surface of hyoglossus the duct lies together with the lingual $
hypoglossal nerves being crossed by the former twice.
- The duct then lies more anteriorly on the lateral surface of genioglossus $
e+tends forward to open in the sublingual papilla on each side of the frenulum
linguae.
Blood supply:
-acial artery.
'enous drainage:
Gommon facial vein.
-ymphatic drainage:
The submandibular lymph nodes.
3erve supply:
1- ,ensory $ secretomotor #parasympathetic%& chorda tympani fibers from the
submandibular ganglion via the lingual nerve.
2- ,ubmandibular fascia is supplied by the anterior cutaneous nerve of the neck.
The sublingual gland:
N The smallest of the three main salivary glands* almost totally mucous in
secretion.
N 'n almond si"ed gland lies in the floor of the mouth being covered only with
the mucous membrane of the floor of the mouth.
N It is bounded medially by the two genial muscles $ laterally by the mandible
on which it leaves a smaller impression than the submandibular one above the
mylohyoid line.
N The gland opens by numerous duct onto the sublingual papilla $ in the floor of
the mouth.
N The gland has no fascia.
N It is supplied by the sublingual branch of the lingual artery $ the submental
branch of the facial artery.
N )eins are similar to arteries.
N 4erve supply is identical to the submandibular gland.
he infratem"oral fossa:
N This is the space which lies between the pharyn+ medially $ the angle of the
mandible laterally.
N (oundaries&
-'nteriorly& the back of ma+illa $ pterygoid process
->osteriorly& the styloid apparatus laterally $ the carotid sheath medially
-6aterally& the ramus $ angle of the mandible
-.edially& the wall of the pharyn+ $ medial pterygoid plate
-,uperiorly& the floor of the middle cranial fossa formed by the greater wing of
sphenoid $ squamous temporal* the roof ends laterally in the infratemporal crest
which leads to the temporal fossa
-Inferiorly& the IT- is continuous with the neck at the retropharyngeal space which
leads down through the superior into the posterior mediastinum.
+ontents:
N .uscles&
1- 6ateral pterygoid
2-.edial pterygoid
N 'rteries&
.a+illary artery.
N )eins&
>terygoid venous ple+us.
N 4erves&
1- .andibular nerve.
2- 7tic ganglion.
The lateral pterygoid muscle&
- This muscle occupies the upper part of the IT-
- Its fibers are directed almost hori"ontally from the front backwards
7rigin&
/pper head 2small3& infratemporal surface of the greater wing of sphenoid
6ower head 2large3& lateral surface of the lateral pterygoid plate
Insertion&
/pper head& Jisc $ capsule of T.H
6ower head& >terygoid pit
4erve supply&
4erve to lateral pterygoid* a branch of the anterior division of mandibular n.
'ction&
- It is a masticatory muscle* it starts opening the mouth
- 6ateral pterygoid is a protractor of the mandible too.
The upper head pulls the articular disc $ anterior part of the capsule anteriorly
preventing its nipping by the bone.
The medial pterygoid muscle&
- This muscle is seen at a lower level in the fossa
- -ibers are arranged in a posterior* inferior $ lateral direction.
7rigin&
,uperficial head 2small3& ma+illary tuberosity
Jeep head 2large3& medial surface of lateral pterygoid plate
Insertion&
The two heads are inserted on the deep surface of the angle of the mandible almost
almost alike the insertion of masseter on the lateral surface
4erve supply&
4erve to medial pterygoid* a direct branch from the main trunk of the mandibular
nerve. This nerve has two main characteristics&
1-It enters the otic ganglion without relay of its fibers in it.
2-It supplies tensor palati $ tensor tympani muscles too.
'ction&
- Gloses the mouth together with masseter.
- It is a grinding muscle* by the lateral orientation of its fibers the muscle pulls the
mandible towards the opposite side
The maillary artery:
- The larger of the two terminal branches of the 5G'
- 5nters the IT- by passing deep to the mandibular neck* between it $ the
sphenomandibular ligament* together with the ma+illary veins $ the
auriculotemporal nerve
- It possesses a tortuous course passing usually #in 2B3 of individuals% lateral to
lat. pterygoid according to which the artery is divided into three parts&
1- -irst 2mandibular3 part& before reaching the lateral pterygoid* it gives ! branches
each enters a bone.
2- ,econd 2pterygoid3 part& lies along #medial or lateral% to the lateral pterygoid* it
gives ! branches to soft tissue* of them to the masticatory muscles $ the !th is the
buccal.
3-Third 2pterygopalatine3 part& which enters the pterygopalatine fossa through the
pterygoma+illary fissure $ gives ! branches that accompany those of the
pterygopalatine ganglion $ each branch of ma+illary nerve.
(ranches of the first part&
1- Jeep auricular artery&
- >enetrates the e+ternal auditory meatus
- Dives a branch to the T. :oint
- ,upplies the skin of the meatus $ outer surface of the tympanic membrane.
2- 'nterior tympanic artery&
- 'scends parallel to the deep auricular artery
- 5nters the tympanic cavity through petrotympanic fissure together with chorda
tympani
- ,upplies the tympanic cavity $ the inner surface of the tympanic membrane
3- .iddle meningeal artery&
- Is the prime artery of the cranial dura
- 'scends upward enclosed by the two roots of the auriculotemporal nerve* to enter
the .G- through foramen spinosum
- 't the floor of the .G- it lies between the greater wing of sphenoid $ dura mater
- 'fter a short course it divides into anterior $ posterior divisions&
1-anterior9 continues grooving the sphenoid then it reaches the parietal bone which it
grooves near its anterior border as the artery ascends to the verte+.
2-posterior9 goes back to groove the squamous temporal $ ascends to the parietal
bone near its posterior border* then along the superior sagittal sinus to reach the
occipital bone.
- 'ccessory meningeal artery&
- -requently a branch of the middle meningeal
- ,upplies some e+tracranial structures
- 5nters foramen ovale to supply the trigeminal ganglion $ ad:acent dura mater
!- Inferior alveolar #dental% artery&
- Jescends to the mandibular foramen behind the accompanying nerve
- (efore it enters the foramen* the artery gives two branches&
1-lingual9 with the lingual nerve
2-mylohoid9 with mylohyoid nerve* piercing the sphenomandibular ligament $
supplies the muscle
- In the bone* the artery supplies the teeth in a manner similar to nerve supply
- Terminates near the mental foramen by dividing into incisive $ mental arteries
(ranches from the second part&
1- .asseteric artery&
- 5nters the mandibular notch
- ,upplies masseter $ anastomoses with the transverse facial artery
Head & Neck Dr. Nawfal K. Al-Hadithi !!
2- 'nterior $ posterior deep temporal arteries&
- 'ccompany the corresponding nerves to temporalis
- The accompanying veins impress the bone in the temporal fossa
3 $ - >terygoid branches&
- ,upply the two pterygoids
!- (uccal artery&
- 'ccompanies the long buccal nerve
- Does to the region of buccinator
- ,upplies skin of the cheek $ mucous membranes of the mouth
(ranches from the third part&
'% (ranches which accompany those of the pterygopaltine ganglion&
1->osterior superior lateral nasal arteries.
2- Dreater palatine artery.
3- 6esser palatine arteries.
- 4asopalatine #anterior palatine% artery.
!- >haryngeal artery.
(% (ranches accompanying the ma+illary nerve branches&
1- >osterior superior alveolar artery.
2- Infraorbital artery.
3- 'nterior superior alveolar artery.
%terygoid venous pleus:
- ' ple+us of veins which lie in $ around the lateral pterygoid muscle
- It receives tributaries corresponding to those of the ma+illary artery branches
- It is drained by two ma+illary veins which leave the fossa deep to the neck of
the mandible to the parotid in order to :oin the superficial temporal vein
forming the retromandibular vein.
'pplied anatomy&
F,tagnation of venous blood in the ple+us initiates refle+ contraction of lateral
pterygoid muscle producing yawning.
FThe ple+us is connected to&
1-'nterior facial vein by two ways&
)ia the infraorbital v. L supraorbital - angular
)ia the deep facial v. which lies between masseter $ buccinator.
2- Gavernous sinus by two ways&
'% )ia the infraorbital L supraorbital - cavernous
(% )ia an emissary vein which enters foramen ovale
These two connections of the anterior facial vein to the cavernous sinus facilitates
transmission of infection from the face to the sinus therefore the area between these
two connections #mask area% is regarded as dangerous area.
The :andibular nerve:
FThe largest of the 3 divisions of the trigeminal nerve
FIt takes all the motor component of ) nerve
F5nters the IT- from its roof through foramen ovale
FIt lies very deep in the fossa near the medial wall #pharyngeal wall% on the lateral
surface of tensor veli palatini
FIt is closely related in this position to the otic ganglion
FIt is divided into anterior $ posterior divisions* the anterior is the smaller $ is
almost totally motor $ the posterior is the larger $ is almost completely sensory
F(ranches&
'%-rom the trunk& - .eningeal n.
- 4erve to medial pterygoid
(%-rom the anterior division& - .asseteric n.
- Jeep temporal nn. 2.7T7C3
- >terygoid n.
- 6ong buccal n. 2,54,7CP3
G%-rom the posterior division& - 'uriculotemporal n.
- 6ingual n. 2,54,7CP3
- Inferior alveolar n. 2.II5J3
-rom the trunk&
1-.eningeal nerve&
- This branch is given :ust below the skull base
- Ce-enters the cranium through foramen spinosum to supply dura mater in the
floor of the .G-
2-4erve to medial pterygoid&
- -rom the trunk of )c* this nerve is given to medial pterygoid muscle
- It passes through the otic ganglion without functional relation to it
- It supplies also tensor veli palatini by a branch which enters it near its origin
and tensor tympani by a branch which enters the cartilage of the auditory tube.
-rom the anterior division&
1-.asseteric nerve&
- This branch is given from the anterior division of )c.
- >asses through the mandibular notch to enter the deep surface of masseter
2-Jeep temporal nerves&
- 2-3 nerves arise from the anterior division of )c
- 'fter passing in the roof of IT- they enter the temporal fossa by passing over
the infratemporal crest
- 7n the deep surface of temporalis* these nerves pass $ supply the muscle
3-6ateral pterygoid nerve&
- This branch is given from the anterior division of )c.
- ,upplies lateral pterygoid muscle by entering its deep surface
-6ong buccal nerve&
- Is the only sensory branch in the anterior division
- -ollowing temporalis tendon* the nerve passes in the direction of buccinator
muscle accompanied by a branch from the ma+illary artery
- 7ver buccinator it divides to supply the overlying skin of the cheek $
undelying mucous membranes
Head & Neck Dr. Nawfal K. Al-Hadithi !;
- ,hould be differentiated from the buccal branch of facial nerve which comes
from a more superficial plane but forms a ple+us with this nerve over
buccinator
-rom the posterior division&
1- 'uriculotemporal nerve&
- 'rises by two roots embracing the origin of the middle meningeal a.
->asses deep to 6>t. muscle in a posterior direction to leave the IT- between the neck
of the mandible $ sphenomandibular lig. with the ma+illary vessels
-It passes in the upper part of the parotid gland
-It is accompanied by postganglionic fibers from the otic ganglion to supply the
parotid gland with secretomotor supply* the preganglionic fibers are brought to the
ganglion via the lesser petrosal branch of the II nerve from the inferior salivatory
nucleus.
-(ranches&
1-Dlandular9 sensory fibers to the parotid
2-'uricular9 to the e+ternal acoustic meatus $ upper lateral K of the auricle
3-'rticular9 to the T. :oint
-Temporal9 to the hairy part of the temple.
2- 6ingual nerve&
->asses on the lateral side of .>t. muscle anterior to the inferior alveolar nerve.
-Drooves the medial aspect of the mandible at the mandibular attachment of the
pterygomanibular raphe :ust behind mylohyoid
->asses forward on the lateral surface of hyoglossus in a curve which descends $
then ascends across the submandibular duct
-In this region it hangs the submandibular ganglion from which it takes
postganglionic secretomotor fibers to the submandibular $ sublingual glands. The
preganglionic of these came together with taste fibers by chorda tympani nerve which
has :oined the lingual nerve high in the IT- near the skull base.
-It supplies&
1-7rdinary sensation to the anterior 2B3 of the tongue* floor of the mouth $ lingual
aspect of the lower gingiva.
2-,ecretomotor to submandibular $ sublingual glands $ minute glands of the floor
of the mouth 2chorda tympani3.
3-Taste sensation to the anterior 2B3 of the tongue 2chorda tympani3.
3-Inferior alveolar nerve&
->asses on the lateral side of .>t. muscle between it $ the mandible behind the
lingual nerve.
-It takes the whole remaining part of the motor component of the ) nerve.
-5nters the mandibular foramen $ passes in the inferior alveolar canal accompanied
by the inferior alveolar vessels.
-(ranches&
1-4erve to mylohyoid9 carries all the motor component of the posterior division*
given :ust before the nerve enters the mandibular foramen* pierces the
sphenomandibular ligament $ passes forward between the anterior belly of digastric
$ mylohyoid supplying both.
2-Inferior dental branches9 to the pulps of the lower canine* premolars $ molars.
3-Terminal branches9 at the mental foramen the nerve divides into&
a%Incisive branch9 for the lower incisors.
b%.ental branch9 e+its from the mental foramen $ supplies skin $ m.m of the lower
lip.
Structures related to the 2T5:
1->terygomandibular raphe&
-Intermuscular raphe e+tending from the pterygoid hamulus to the mandible.
-It is the site where buccinator $ superior constrictor muscles interdigitate*
buccinator goes forward $ superior constrictor backward.
2->terygoma+illary ligament&
-' short ligament e+tending between the pterygoid hamulus $ the ma+illary
tuberosity
-It will form an osseo-ligamentous canal for the passage of the tendon of tensor palati
muscle
3-,phenomandibular ligament&
-' wide ligament lies superficial to medial pterygoid between it $ the mandible* it
e+tends between the spine of sphenoid $ the lower border of the mandible near the
angle
-It embraces the ma+illary vessels $ auriculotemporal nerve between it $ the neck of
the mandible
-It is pierced by nerve to mylohyoid $ mylohoid artery
he orbit:
The bony orbi:
N The orbit is a four-sided pyramidal shape space whose base lies anterior $ its
ape+ posterior
N The base is almost 3.! I cm $ the depth is about ! cm
N .edial walls are parallel to each other with a 2 cm distance separating them
N 6ateral walls diverge laterally at !7 from medial walls thus the lateral walls
are <=7 at each other
N 7rbital a+is lies along the center of the orbit $ both will also be perpendicular
on each other
Orbi!" #!r$in%:
The margins of the orbit are strong bones* they are even stronger than its four walls
N ,uperior& supraorbital arch of the frontal bone
N 6ateral& frontal process of "ygomatic bone $ "ygomatic process of frontal
bone
N Inferior& "ygomatic bone $ ma+illa
N .edial& frontal process of ma+illa $ ma+illary process of frontal bone
7oof:
--ormed by orbital process of the frontal bone completed posteriorly by the lesser
wing of sphenoid
Head & Neck Dr. Nawfal K. Al-Hadithi !<
-It is concave especially laterally where the lacrimal fossa which accomodates the
lacrimal gland lies
5loor:
--ormed by the the orbital surface of the ma+illa supplemented laterally by the
"ygomatic
-It slopes upward in the direction of the medial wall
-It contains the infraorbital groove which connects the inferior orbital fissure to the
infraorbital canal
-ateral 6all:
--ormed by the "ygomatic bone in front $ greater wing of sphenoid behind
:edial 6all:
--ormed from in front backwards by& frontal process of ma+illa* lacrimal bone*
orbital lamina of ethmoid $ near the ape+ by the body of sphenoid
-It is very thin $ lies almost vertical
-It separates the orbit from the ethmoidal $ spheboidal air cells
-It shows the site of the lacrimal sac which is bounded by anterior $ posterior
lacrimal crests
-It contains anterior $ posterior ethmoidal foramina at its :unction with the roof
Re"!ion%:
The orbit is bounded &
N 'bove& anterior cranial fossa $ frequently the frontal air sinus
N .edially& sphenoidal $ ethmoidal air cells
N Inferiorly& ma+illay air sinus
N 6aterally& temporal fossa
An!o#y o& he eye"i'%:
The eyelid is composed of five layers&
1-,kin&
-very thin $ moist
2-,ubcutaneous tissue&
-la+* scanty $ rarely contains any fat
-contains the roots of the eyelashes with the accompanying sebaceous glands 2of
?eis3 $ modified sweat glands 2of .oll3.
-contains vessels $ nerves of the lid
3-.uscular layer &
-consists of the palpebral $ lacrimal parts of 7. oculi
-palpebral part 2discussed3
-lacrimal part connects the lacrimal sac $ posterior lacrimal crest to the tarsus
-its posteromedial direction of contraction provides better contact between the eyeball
$ eyelid $ consequently better distribution of tear film* also it dilates the lacrimal
sac
-Tarso-fascial layer&
-is the skeleton of the eyelid
-formed of two layers* the tarsal plate 2tarsus3 $ orbital septum&
FTarsal plate&
-tough fibrous layer e+tends between the medial $ lateral palpebral ligaments
-2.! I 1 cm in dimensions
-semilunar in shape with the straight edge at the lid margin
F7rbital septum&
-thin membrane which is continuous with the periosteum of the superior $ inferior
orbital margins
-the superior one is perforated by the levator palpebrae superioris
-away from this muscle* the tarso-fascial layer forms a complete septum between the
superficial compartment of the eyelid which is continuous with the face $ deep
compartment which is continuous with the orbit
Tarsal glands&
're modified sebaceous glands on the deep surface of the tarsus secrete an oily layer
to prevent tear overflow at the lid margins
!- Gon:unctiva&
-the transparent membrane which lines the lids #palpebral c.% $ onto the eyeball
#bulbar c.%
-the site of reflection is called the forni+* so we have superior $ inferior fornices
-palpebral c. differs from the bulbar in being thicker* opaque $ more vascular
-modifications in the con:unctiva&
1-lacrimal lake& a shallow bay on the medial angle of the eye bounded laterally by the
semilunar fold* it acts as reservoir for lacrimal fluid.
2-semilunar fold& a rudimentary fold in the con:unctiva
3-lacrimal caruncle& a rounded elevation in the lacrimal lake formed of moist skin
with fine hairs* sebaceous $ sweat glands.
Conen% o& he orbi:
1$0yeball#
2$:uscles: $ -%S
- four recti
- two oblique
&$3erves: - motor #III* I) $ )I%
- sensory #)a%
($'essels: - ophthalmic artery
- ophthalmic veins
)$5ascial modifications: - periorbita
- muscular fasciae
- check $ suspensory ligaments
- retrobulbar fat
*$-acrimal apparatus: - lacrimal gland
- lacrimal sac
- nasolacrimal canal
:uscles o the orbit:
The recti are in number&
- ,uperior rectus
- .edial rectus
- Inferior rectus
- 6ateral rectus
7rigin&
'll the recti arise from a tendinous ring surrounding the medial end of the ,7-
Insertion&
The muscles* narrow at their origin broaden as they come forward to be inserted into
the sclera anterior to the coronal equator forming a muscular cone around the eyeball
3- 7blique muscles&
a% ,uperior oblique&
7rigin& from the bone :ust above the optic canal
Insertion&
- the muscle passes forward in the :unction between the roof $ medial wall of
the orbit to reach the anterior part of the orbit as a thin tendon which hooks
around the trochlea 2pulley3 which is attached in the roof of the orbit above the
lacrimal crest.
- -rom this pulley the tendon returns postero-laterally to be inserted into the
sclera deep to ,C tendon behind the equator of the globe
b% Inferior oblique&
7rigin& from the orbital surface of the ma+illa lateral to the lacrimal groove
Insertion& the muscle is located below the eyeball* passes postero-laterally below IC
to be inserted in the sclera beneath 6C
F The recti will move the globe&
- ,C superiorly S nasally #elevation S adduction%
- IC inferiorly S nasally #depression S adduction%
- .C nasally #adduction%
- 6C temporally #abduction%
F The oblique muscles move the globe&
- ,7 inferiorly S temporally #depression S abduction%
- I7 superiorly S temporally #elevation S abduction%
3erve supply of ocular muscles:
6C 8 ,7 7thers 3
Moor ner(e% o& he orbi:
1- 7culomotor n.&
-enters the orbit through the ,7- as superior $ inferior branches
-the superior branch crosses over the optic n. under ,C supplying it $ passes medial
to it to terminate in the undersurface of 6>,
-the inferior branch crosses below the optic n. to supply
D,5 to .C* IC* $ I7
D)5 to sphincter pupillae $ ciliary muscle 2parasympathetic3 with a relay in the
ciliary ganglion* this component reaches the globe via branch to I7
2- Trochlear n.&
-the smallest of all cranial nerves* enters the orbit through the ,7- being the highest
of all nerves entering the orbit
-lies in the roof of the orbit medial to the frontal n.
-supplies ,7 at its posterior 1B3
3- 'bducent n.&
-enters the orbit through the ,7- inferior to all nerves
-enters the ocular surface of 6C supplying it
4.(&
The above three motor nerves have a communication with )a in the cavernous sinus
which make them able to carry the proprioceptive sensation from the muscles they
supply.
Sen%ory ner(e% o& he orbi:
-the ophthalmic division of trigeminal nerve 2)a3 is the smallest of the three
divisions of ) nerve* it is entirely sensory
-from the semilunar ganglion* )a leaves forward in the lateral wall of the cavernous
sinus together with motor nerves of the orbit with which it forms some
communication
-it divides into its three terminal division short of the way to the ,7- after it gives the
tentorial branch to the tentorial dura
-the three divisions of )a* namely the lacrimal* frontal $ nasociliary nerves enter the
orbit through the ,7- to supply its contents
-in addition to the orbit $ its contents* )a supplies&
Fsome skin of the face $ scalp
Fsome mucous membranes of the nasal cavity $ paranasal sinuses
-'66 ,TC/GT/C5, MEIGE 54T5C TEC7/DE TE5 ,.7.- J7 MITEI4 TE5
G745 7- ./,G65, 2TEC7/DE TE5 T54JI47/, CI4D3 5IG5>T
T6'GCI.'6 4.* -C74T'6 4.* TC7GE65'C 4. $ TE5 7>ETE'6.IG
)5I4,U
1-6acrimal nerve&
-the smallest of )a branches* passes over the 6C muscle
-half its way in the orbit it receives contribution from the "ygomaticotemporal branch
of )b supplying it with parasympathetic component from the pterygopalatine
ganglion to the lacrimal gland
-it supplies the gland with sensory $ parasympathetic supply* together with the lateral
K of the upper lid $ its con:unctiva
2--rontal nerve&
-the largest of )a branches* passes between 6>, $ the roof of the orbit
-in the middle of the orbit it divides into its terminal branches&
Fthe supraorbital n.9 leaves the supraorbital notch #or foramen%* supplies the lateral
part of the skin of the forehead $ the anterior K of the scalp up to the verte+
Fthe supratrochlear n.9 lies medial to the former* it leaves the orbit above the trochlea
of ,7 to supply skin of the middle of the forehead below the hairline
3-4asociliary nerve&
-enters through the muscle cone $ crosses the optic nerve from lateral to medial
-passes under the ,C $ 6>,* the nerve is directed to the medial wall of the orbit
where it divides into its principal branches9 the posterior ethmoidal* anterior
ethmoidal $ infratrochlear nerves
(ranches&
1-sensory root of ciliary ganglion9 runs on the lateral aspect of the optic nerve to enter
the ganglion
2-long ciliary nerves9 pierce the sclaera to supply the eyeball with sensation
3-posterior ethmoidal nerve9 enters the corresponding foramen to supply sensation to
the posterior ethmoidal $ sphenoidal air cells.
-infratrochlear nerve9 leaves the orbit below the trochlea of ,7 to supply the medial
K of the upper lid $ its con:unctiva together with the skin of the bridge of the nose
!-anterior ethmoidal nerve9
-leaves the orbit through the anterior ethmoidal foramen
-supplies the anterior $ middle ethmoidal air sinuses
-enters the floor of 'G- $ courses over the cribriform plate
-enters the nasal cavity through the nasal slit on each side of crista galli
-supplies mucous membranes of the anterosuperior A of the lateral wall of nasal
cavity $ upper part of nasal septum
-leaves the nasal cavity between the nasal bone $ cartilage as the e+ternal nasal nerve
which supplies the middle of the skin of e+ternal nose below the bridge
The optic nerve&
-is the 2nd cranial nerve
-wholly sensory
-enters the back of the eyeball :ust medial to its posterior pole
-its medial fibers transmit image from nasal side of the retina #temporal field%
-its lateral fibers transmit image from temporal side of the retina #nasal field%
-decussation of nasal fibers occur in optic chiasma so each eye will see the opposite
K of visual field
-the nerve is crossed inside the orbit by many structures like the ophthalmic artery*
nasociliary nerve* some motor nerves O
-ciliary ganglion lies on its lateral side
Areri!" %)**"y o& he orbi:
-the ophthalmic artery* branch of IG' :ust after it leaves the cavernous sinus* enters
the orbit through the optic canal
-it is directed in the orbit from lateral to medial across the optic nerve
(ranches&
1-(ranches to the eyeball&
- central artery of the retina
- long $ short posterior ciliary branches
- anterior ciliary branches
2-(ranch with each of the sensory nerves of the orbit9 taking its course $ destination
3-.uscular branches9 with the motor nerves of the orbit supplying ocular muscles $
give the anterior ciliary arteries
FThe central artery of retina&
-pierces the optic n. near the middle of its intraorbital course
-supplies the distal 1B3 of the optic nerve $ the whole retina
-its damage leads to total blindness of that eye with optic atrophy
FThe short posterior ciliary arteries&
-pierce the back of sclera near the optic nerve
-supply the choroid
FThe long posterior ciliary arteries&
-pierce the back of sclera near the optic nerve
-pass between the sclera $ choroid to the iris
F'nterior ciliary arteries&
-branches of muscular arteries
-pierce the sclera near the cornea
-end in the greater arterial circle of the iris
Veno)% 'r!in!$e o& he orbi:
1-,uperior ophthalmic vein&
-formed at the supraorbital foramen by union of the supraorbital $ supratrochlear
veins
-has the same course $ branches of the ophthalmic artey
-:oined by the inferior ophthalmic vein at the medial end of ,7-
-enters the cavernous sinus after leaving the orbit
2-Inferior ophthalmic vein&
-formed in the floor of the orbit by union of muscular veins
-communicates with pterygoid venous ple+us through the inferior orbital fissure
-empties in the ,7) at the medial end of ,7-
-sometimes empties directly in the cavernous sinus
F!%+i!e o& he orbi:
1->eriorbita&
-the double-layered dura mater of the cranial cavity enters the orbit with the optic
nerve
-the fibrous coat remains with the nerve $ the endosteal layer leave the fibrous layer
to form the periosteal layer of the orbit #periorbita%
-unlike in the cranial cavity* periorbita could be easily stripped from bones of the
orbit
-the site where the two dural layers diverge in the orbit represents the site of complete
separation of the orbital from cranial cavities
2-.uscular fasciae&
-fascia covering ocular muscles
-muscular fascia of .C thickened at certain site to be attached to the posterior
lacrimal crest forming the 2medial check ligament3
-the same thing occur in 6C fascia $ attaches it to the "ygomatic bone forming the
2lateral check ligament3
-these two thickenings fuse with fasciae of I7 $ IC to form the hammock-like sling
on which the eyeball rests 2suspensory ligament of the eyeball3
3- Cetrobulbar #orbital% fat&
' fi+ed-si"ed cushion of fatty tissue on which the globe rests with a fi+ed position of
its center.
The lacrimal apparatus&
1- 6acrimal gland&
-an oval gland occupies the superolateral part of the orbit 2lacrimal fossa3
-it is pierced by 6>, muscle which incompletely divides it into orbital part which
remains in the roof of the orbit partially invested by fascia of ,C $ 6C muscles* $
palpebral part which pro:ects inside the upper eyelid with its deep surface in relation
to the con:unctiva
-ducts of the gland are 8-1= in number* all empty in the superior forni+ of con:unctiva
-supplied by lacrimal branch of ophthalmic artery
-drained by lacrimal v. which empties in the superior ophthalmic v.
-supplied by lacrimal nerve which carries autonomic component derived from the
"ygomaticotemporal branch of )b
2- 6acrimal canaliculi&
-open in the eyelids as the lacrimal puncta whose openings are directed toward the
lacrimal lake
-course over the corresponding eyelids* the puncta open in the lacrimal sac
-they collect tears from the lake to the sac
3- 6acrimal sac&
-it is the upper dilated end of nasolacimal duct
-measures =.! I 1 cm
-receives the lacrimal canaliculi separately
-lies in front of the lacrimal part of orbicularis oculi $ behind the medial palpebral
ligament
-contraction of the lacrimal part of 7. oculi dilates the sac making negative pressure
which sucks tears from the lake by the canaliculi
- 4asolacrimal duct&
-e+tends from the lacrimal sac downward* backward $ laterally towards the inferior
nasal meatus
-transmits tears from the sac to the nasal cavity
-is about 2 cm long
he "ter#go-"alatine fossa:
N 'pyramidal space located in the interval between the root of the pterygoid
process posteriorly $ the back of ma+illa anteriorly.
N (oundaries&
-'nterior& back of ma+illa
->osterior& root of pterygoid process $ body of sphenoid
-6ateral& IT-
-.edial& nasal cavity
-,uperior& ape+ of the orbit
-Inferior& ma+illary sinus
connections&
TEC7/DE T7
-oramen Cotundum .G-
>terygoma+illary fissure IT-
Inferior orbital fissure 7rbit
,phenopalatine foramen 4asal cavity
>terygoid canal -oramen lacerum
>alatine foramina 7ral cavity
>haryngeal canal (ase of skull
Conen%:
1- >terygopalatine ganglion&
- Is one of the four cranial autonomic ganglia
- Is the ganglion of hay fever
- ,upplies mucous membrane from the lower lid to the upper lip
- Dives five branches&
N Dreater palatine n.
N 6esser palatine n.
N >osterior superior lateral nasal n.
N 4asopalatine n.
N >haryngeal n.
2- .a+illary nerve&
-Is the 2nd branch of trigeminal nerve
-5nters the fossa through foramen rotundum
-6eaves the fossa through the inferior orbital fissure to pass in the floor of the orbit
- Dives the following branches
N ,ensory root of pterygopalatine ganglion
N >osterior superior alveolar n. 9 pierces the back of ma+illa $ supplies the molar
teeth with ad:acent gingiva $ m.m.
N .iddle superior alveolar n. 9 given in the infraorbital canal to supply the
bicuspid teeth of ma+illa $ ad:acent gingiva $ m.m.
N 'nterior superior alveolar n. 9 to the canine $ incisors
N Terminal branches 9 "ygomatico-facial* "ygomatico-temporal $ infra-orbital
nerves
3- Third part of ma+illary artery&
- 5nters the fossa through the pterygoma+illary fissure
-Dives a branch with each of ma+illary nerve branches $ >>D branches* these
branches posses the same names of the corresponding nerves e+cept the nasopalatine
called long sphenopalatine artery $ >,64 called short sphenopalatine arteries
,tructures passing in $ out&
TEC7/DE ,TC/GT/C5
-oramen Cotundum in )b
>terygoma+illary fissure
In .a+illary artery
out >ost. ,up. 'lv. ).$4.
Inferior orbital fissure In-out
Gonnection between I7)
$ pt. ple+us
,phenopalatine foramen out
>,64 ).$4.
4asopalatine ).$4.
>terygoid canal in )idian nerve
>alatine foramina out >alatine ).$4.
>haryngeal canal out >haryngeal ).$4.
A**"ie' !n!o#y:
The >>D is the ganglion of seasonal allergy.
'llergic rhinitis $ con:unctivitis involve mainly m.m. supplied by this ganglion
whose sensory root is derived from )b.
he nose:
The E,ern!" No%e:
S4eleton:
1-The bony part&
It is formed by the two nasal bones* it forms the upper part of the e+ternal nose.
2-The cartilagenous part&
- -ormed by two lateral nasal $ two alar cartilages
- -orms the lower part of the nose.
- 6ateral nasal cartilage9 is a triangle whose borders articulate with the nasal
bone above* septal cartilage medially $ alar catilage inferior ly.
- 'lar cartilage9 thin fle+ible cartilage* hooks around the nostrils from lateral
rounded part to the medial hook-shaped part * the medial ends of the two
cartilages are connected by loose tissue in the midline below the septum
Arterial supply:
1-6ateral nasal branch of facial artery.
2-4asal branches of infraorbital artery.
3-Jorsal nasal branch of inferior ophthalmic artery.
)eins&
'ccompany arteries.
3erves:
1-(ridge9 infratrochlear #)a%
2-.idline shin below the bridge9 e+ternal nasal #)a%
3-6ateral side9 infraorbital #)b%
The N!%!" C!(iy:
S4eleton:
1- 6ateral wall&
F/pper part& from before backward the bones are&
4asal bone* frontal process of ma+illa* lacrimal bone* ethmoid* body of sphenoid
F6ower part& from before backward the bones are&
.a+illa* inferior concha* palatine bone* pterygoid plate
2-Coof& cribriform plate of ethmoid.
3--loor& hard palate #palatal process of ma+illa $ hori"ontal plate of palatine%.
-.edial wall #septum%&
>osterosuperior9 perpendicular plate of ethmoid
>osteroinferior9 vomer
'nterior9 septal cartilage
P!r% o& he no%e:
N )estibule9 is the skinny part of the nasal cavity at the nostrils* it carries coarse
hairs with other skin derivatives
N Ghoanae9 are the posterior nasal apertures which open to the nasopharyn+* they
are 2 I 1.! cm in dimensions $ separated from each other by the posterior part
of the septum
N Gonchae&
- 're the three scroll-like pro:ections in the lateral wall of the nose
- Their si"e increase as we descend downward
- The upper two are parts of the ethmoid while the lower is a separate bone
- Their medial ends almost reach the septum
- Their action is to increase surface area of m.m. to humidify $ warm air
- They also act as shelves for the underlying meatuses
- Their covering m.m. is highly vascular $ contain erectile tissue so their si"e
may increase or decrease according to the situation
N .eatuses&
- 're the groove-like passages underneath the corresponding conchae
- The superior meatus receives the opening of the posterior ethmoidal air sinus
- The middle meatus show a bulging #bulla ethmoidalis% formed by the middle
ethmoidal sinus on which opens the sinus itself.
- (elow the bulla $ parallel to it lies the uncinate process of the ethmoid
converting the area between it $ the bulla into a smilunar hiatus #hiatus
semilunaris% into its anterior end opens the frontonasal duct #frontal sinus%* :ust
behind it opens the anterior ethmoidal sinus $ in the posterior part of the hiatus
opens the ma+illary sinus.
- The inferior meatus receives the opening of the nasolacrimal duct.
N ,pheno-ethmoidal recess&
Is the part of the lateral nasal wall between the superior concha $ the body of
sphenoid* it receives the sphenoidal ostia
:ucous membranes:
- The nasal cavity is lined with m.m. e+cept for the vestibule
- m.m. of the nose is firmly bounded to the periosteum $ perichondrium of the
underlying structures #mucoperiosteum $ mucoperichondrium%
- ..m. is continuous with other m.m. of the chambers with which the nasal
cavity is continuous like the nasopharyn+* paranasal sinuses* con:unctiva* ..
3erve supply:
1- 6ateral wall&
'ccording to nerve supply the lateral wall of the nose could be divided into four
quadrants&
N 'nterosuperior& anterior ethmoidal n.
N >osterosuperior& posterior superior lateral nasal n.
N 'nteroinferior& anterior superior alveolar n.
N >osteroinferior& greater $ lesser palatine n.
2- The septum&
- The nasopalatine branch of the >>D #)b% descends on each side of the nasal
septum in an antero-inferiorly in the direction of the incisive foramen of the
palate.
- The part below the course of this nerve is supplied by the same nerve
- The part above it is supplied by the medial nasal branches of the anterior
ethmoidal n. #)a%
3- The roof&
The roof is lined by olfactore neroepithelium $ is supplied by the olfactory nerve.
Arterial supply:
-ollows the same way of nerve supply for both lateral wall $ the septum.
)enous drainage&
- ,tarts in the cavernous ple+us on the middle $ inferior conchae $ lower part
of the septum
- -rom the lateral wall&
F'nterior K9 anterior facial vein
F>osterior K9 pterygoid venous ple+us
- -rom the septum like lateral wall.
- connections&
Fveins of the roof9 superior sagittal sinus
Fanterior ethmoidal9 superior ophthalmic v.
Applied anatomy:
N Jeviation of nasal septum is a common problem involving usually the septal
cartilage commonly associated with part of the perpendicular plate of ethmoid
$ B or vomer.
N 5pista+is* bleeding from the nose most often takes place in 6ittleQs area on the
lower part of the septum where the cavernous venous ple+us $ capillaries
often in:ured by the fingers $ foreign bodies.
he "aranasal sinuses:
N >4, are pneumatic areas in the frontal* ethmoidal* sphenoidal $ ma+illary
bones.
N They are lined with m.m. which is continuous with that of the nasal cavity
through the sinus apertures in the lateral wall of the nose.
N The ma+illary sinus is well developed at birth* the frontal $ sphenoidal e+hibit
a definite cavity at the ;th year of life while the ethmoidal develop late at
puberty.
N The definite function of the >4, is not well known* theories about lightening
the skull $ resonating the voice e+ist but still there is more to be studied.
The &ron!" %in)%e%:
N These two sinuses are located on each side of the midline in the frontal bone
behind the superciliary ridges.
N They are rarely symmetrical.
Head & Neck Dr. Nawfal K. Al-Hadithi ;=
N They are roughly triangular in sagittal section with a ma+imum vertical length
of 2.! cm $ ma+imum '> depth of 2 cm in the orbital plate of the frontal bone.
N It drains through the frontonasal duct to the lateral wall of the nose where its
ostium opens in the most anterior part of the hiatus semilunaris.
N ,upraorbita* supratrochlear $ anterior ethmoidal nerves $ vessels supply the
sinus.
The eh#oi'!" %in)%e%:
N These three groups of sinuses are located in the lateral mass of the ethmoid in
its labyrinth. They are named9 anterior* middle $ posterior sinuses #air cells%.
N The walls of these spaces are very thin $ completed by other bones like the
lacrimal* sphenoid* palatine* frontal $ ma+illae.
N .edial to them lies the nasal cavity* laterally lies the orbit* superiorly the 'G-
$ inferiorly the nasal cavity $ ma+illary antrum.
N The anterior opens in the anterior part of the hiatus* the middle in the summit
of the bulla $ the posterior in the superior meatus.
N The anterior $ middle sinuses are supplied by anterior ethmoidal vessels $
nerves while the posterior is supplied by the posterior ethmoidal vessels $
nerves.
The %*henoi'!" %in)%e%:
N These two sinuses are located on each side of the midline in the body of
sphenoid separated from each other by thin plate of bone.
N They lie behind the posterior ethmoidal cells* in front of the dorsum sellae*
inferior to the hypophyseal fossa superior to the nasopharyn+ $ bounded on
each side by the .G-.
N Their ostia open in the spheno-ethmoidal recess.
N They are supplied by the posterior ethmoidal vessels $ nerves $ by the
pharyngeal branch of the >>D.
The #!,i""!ry %in)%e%:
N These two sinuses occupy most of the ma+illary body e+tending from the
lateral nasal wall medially to the "ygomatic process of the ma+illa laterally $
from the floor of the orbit superiorly to the alveolar process of ma+illa
inferiorly.
N They are pyramidal cavities with their bases open in the lateral nasal wall $
apices in the direction of the "ygomatic process.
N The big opening in the lateral nasal wall produced by the ma+illary sinus is
blocked for most of its si"e by the overlapping inferior concha.
N The sinus opens in the posterior part of hiatus semilunaris.
N It is supplied by vessels $ nerves of the region* i.e9 superior alveolar*
infraorbital* "ygomaticofacial O
A**"ie' !n!o#y:
N Infection of nasal mucosa as in flu leads to blockage of the draining system of
one or more of the >4, with the consequent accumulation of secretion in the
sinus $ superadded infection resulting in sinusitis. ,o this condition could not
be treated unless the draining system is restored $ normal physiology of its
cilia is resumed either medically or surgically.
Head & Neck Dr. Nawfal K. Al-Hadithi ;1
N >ain from sinusitis is usually referred to areas supplied by the same nerves $
ad:acent areas like the orbit* upper teeth* forehead $ nose.
N The root of the upper second premolar tooth sometimes perforates the floor of
the ma+illary sinus $ its e+traction may lead to oro-antral fistula.
he oral ca!it#:
The "i*%:
- 're two muscular folds covered by skin* lined by m.m $ formed mainly by
muscles including the constrictors $ dilators of the oral fissure
- The upper e+tends laterally to the nasolabial fold $ the lower e+tend inferiorly
to the mentolabial fold
- The philtrum are two skin ridges end below at the labial tubercle $ above at
the nasal septum
- The red margin #vemilion border% is covered by dry transparent m.m which
give the underling red color of the highly vascular organ
- The upper lip is supplied by the infraorbital n. $ the lower by the mental n.*
both are supplied by facial artery
- 6abial glands are mucous gland in the submucosa $ open by small individual
ducts to the surface of m.m
The +hee-%.
- Cesemble the lips in structure but their main muscle is buccinator
- The fatty subcutaneous tissue #buccal pad of fat% is very loose $ transmits the
parotid duct
- The buccal glands simulate labial glands
The $in$i(!e.
- Gonsist of dense fibrous connective tissue firmly attached to the underlying
alveolar process
- Govered by smooth highly vascular m.m
- The gingivae also surround the necks of teeth
- The main blood supply to the upper gum are the palatine arteries $ to the
lower is the lingual artery
The or!" +!(iy:
N The mouth consists of two parts&
1- The vestibule9 is the narrow cavity in the interval between the gums $ teeth on one
side and the lips $ cheeks on the other side.
2- The mouth proper9 is the part of the cavity within the alveolar arches roofed by the
palate* floored by the mylohyoid muscle $ contains the tongue.
The roof of the mouth&
1- The hard palate9
- -orms the anterior 2B3 of the roof* it is formed in its anterior 2B3 by the palatal
process of ma+illa $ in its posterior 1B3 by the hori"ontal plate of the palatine
bone.
- The m.m is firmly bounded to the periosteum #mucoperiosteum% especially in
the anterior part therefore any in:ection in this area is severely painful.
- It is supplied by the greater palatine $ terminal parts of nasopalatine vessels $
nerves.
2- The soft palate9 will be discussed later.
The tongue:
- The tongue is a highly mobile muscular organ important for mastication*
swallowing* taste $ speech.
- 't its root it is fi+ed by its connection to the palate #palatoglossus%* pharyn+
#superior constrictor% $ epiglottis #glosso-epiglottic folds%* while its anterior part is
free for movement
- It is partially separated into two symmetrical halves by a median septum of areolar
tissue
- Tongue is composed embryologically of two different parts which possess different
structure* appearance $ in nerve supply $ lymphatic drainage* they are the oral part
#anterior 2B3% $ pharyngeal part #posterior 1B3%.
- The anterior 2B3 is separated from the posterior 1B3 by a v-shape sulcus terminalis
whose ape+ is directed posteriorly at foramen caecum of the tongue
- The m.m of the anterior2B3 is fur-like $ adheres to the underlying muscles* it is also
characteri"ed by the presence of the filiform* fungiform $ vallate papillae* while m.m
of the posterior 1B3 is smooth $ movable over the muscle $ shows multiple round
elevations produced by the underlying lymphoid follicles #lingual tonsil%.
- -renulum linguae is a m.m fold in the midline connects the undersurface of the
tongue to the floor of the mouth
:uscles of the tongue:
I% Intrinsic muscles9
- These are muscle fibers arranged within the tongue in three directions* antero-
posterior #superior $ inferior longitudinal%* hori"ontal $ vertical
- They are attached by their ends to the m.m. $ to the midline lingual septum
- Their contraction changes the shape of the tongue* the si"e of the tongue mass
is static* any change in one dimension affects other dimensions* e.g9 flattening
of the tongue #contraction of vertical group% is always associated with increase
side to side length of it an d so on.
II% 5+trinsic muscles9
There are three muscles which are related to the tongue* they connect the tongue to
three different bones $ their contraction alters the position $ direction of the tongue.
>alatoglossus* thogh it is a palatal muscle it will be discussed here for its important
action.
Eyoglossus&
7rigin9 upper border of greater horn $ body of hyoid
Insertion9 fibers ascend anteosuperiorly to be inserted in the posterior part of the
lateral border of the tongue intermingling with other muscles.
'ction9 retracts the tongue $ depresses its sides. It also elevates the hyoid bone.
Denioglossus&
7rigin9 inferior genial tubercle
Insertion9 fibers go back to enter the substance of the tongue contributing to its mass*
the superior fibers are inserted into the tip of the tongue* middle fibers into the
dorsum $ the lowest fibers are inserted inferiorly.
'ction9 -protracts the tongue
-the superior fibers brings the tip of the tongue in contact with the floor of the
mouth
-the dorsal fibers cause cupping of the tongue
,tyloglossus9
7rigin9 lower part of styloid process anteriorly
Insertion9 fibers descend anteroinferiorly $ medialward to be inserted into the
posterior part of hyoglossus* the fibers entr the tongue $ pass forward along its side
'ction9 retracts the tongue $ deviates it laterally
>alatoglossus&
7rigin9-oral surface of the palatine aponeurosis
Insertion9 fibers arch down under the m.m of the mouth raising the anterior pillar of
the fauces #palatoglossal arch% to be inserted into the side of the tongue.
'ction9 It is the opponent of 6)>&
-sphincter of the fauces
-depresses the soft palate
-raises the tongue
3erve supply of lingual muscles:
'll muscles of the tongue are supplied by the hypoglossal nerve e+cept palatoglossus
which is supplied #as a palatal muscle% by the pharyngeal ple+us.
Sensory nerve supply of the tongue:
N 'nterior 2B39
-lingual n.9 common sensation
-chorda tympani9 taste sensation
Ghorda tympani is an autonomic nerve derived from nervus intermedius #)IIV%* it
:oins the )c :ust below the base of the skull in the IT- $ runs in its lingual branch to
supply parasympathetic power to the submandibular ganglion $ give taste fibers to
the anterior 2B3 of the tongue
N >osterior 1B39
glossopharyngeal nerve supplies it with both types of senses
'rterial supply of the tongue&
-ingual artery:
This branch of 5G' provides the tongue with all its blood* at its origin #level with the
tip of grater horn of hyoid% it is crossed e+ternally by the III nerve $ posterior belly
of digastric $ stylohyoid muscles. It passes forward to lie deep to hyoglossus
between it $ the septum of the tongue ! mm deep to the inferior surface of the
tongue* it gives&
a% Jorsal lingual branches to the tongue mass.
b% ,ublingual branches to the sublingual gland $ floor of the mouth
'eins of the tongue:
1- Jeep lingual veins9 two in number* accompany the lingual artery $ receive similar
tributaries* they empty in the IH)
2- )eni comitans nervi hypoglossi9 accompany the III* bring blood from the tip* they
are larger than the deep veins $ empty in the facial vein.
The floor of the mouth:
- The floor of the mouth is mylohyoid
7rigin9 mylohyoid line of the mandible
Insertion9
- The fibers descend downward $ backward* those of anterior 2B3 interdigitate
with the opposite one in a midline raphe which e+tends from the symphysis
menti to the hyoid bone
- The posterior fibers reach the hyoid bone leaving a posterior free border for the
muscle which connects the oral mouth to the submandibular triangle
4erve supply9 mylohyoid nerve* branch of the inferior alveolar nerve
'ction9
'% 'n essential swallowing muscle* by wavy elevation of the tongue from anterior
to posterior direction against the palate it compresses the bolus backward
(% .oves the tongue changing its position $ direction
G% 5levates the hyoid $ eventually the laryn+
Structures in the floor of the mouth:
- ' coronal section through the mid-mouth reveals a slit like cavity in the floor
of the mouth between mylohyoid laterally $ the side of the tongue
#hyoglossus% medially.
- This cavity is covered with m.m of the floor of the mouth $ contain important
structures in relation to the lateral surface of hyoglossus* these are&
F6ingual nerve above #hooks around the submandibular duct%
F,ubmandibular duct in the middle
FIII nerve is the lowest
- ,tructures deep to hyoglossus are&
FJeep lingual artery
F,tylohyoid ligament
FII nerve
he soft "alate:
- Is a triangular fold of m.m containing aponeurosis of tensor palati* muscle
fiber* mucous glands* vessels $ nerves
- It hangs from the posterior border of the hard palate where its anterior surface
will face forward to the oral cavity $ its posterior surface faces backward
- The tip of the triangle contains a rounded mass of muscle fibers #musculus
uvulae% with mucous glands it is called the uvula
- The main function of the soft palate is to act as policeman between the airway
$ foodway regulating swallowing in relation to berathing.
- .uscles of the soft palate are9 tensor veli palatini* levator veli palatini*
palatoglossus* palatopharyngeus $ musculus uvulae
Ten%or (e"i *!"!ini:
- 7ne should think of this muscle as two triangles* a muscular one lies in the IT-
$ an aponeurotic one in the oral cavity
Head & Neck Dr. Nawfal K. Al-Hadithi ;!
- These two triangles are united to each other by a tendon which get access to
the mouth through the fibro-osseous canal produced by attachment of the
pterygoma+illary ligament between the pterygoid hamulus $ ma+illary
tuberosity
7rigin&
The muscular triangle in the IT- arises by two of its limbs9
- from the roof of IT- #from the spine of sphenoid to the scaphoid fossa%
-from the posterior border of medial pterygoid plate passing over the cartilagenous
part of the auditory tube
The third border of the muscle is free
The muscle will lie in the fossa between the medial pterygoid plate $ muscle to taper
as it approaches the ma+illary tuberosity into a slender tendon
Insertion&
The slender tendon after entering the fibro-osseous canal e+pands into aponeurotic
triangle with three borders&
- 7ne is attached to the posterior border of the hard palate
- The other will fuse with the opposite fellow
- The third will hang freely inside the oropharyn+ suspending the uvula
'ction&
Gontraction of T)> causes tension of the soft palate #aponeurosis of the muscle%
which becomes straight $ lower down to be elevated by the levator muscle to fit the
>assavant ridge in the :unction between the oro- $ nasopharyn+ separating the two.
Le(!or (e"i *!"!ini:
7rigin& -rom the petrous ape+ $ cartilagenous part of the auditory tube
Insertion& the pencil-like muscle descends deep to the m.m of the nasopharyn+
elevating a ridge near the tube orifice to be inserted into the dorsal surface of the
palatine aponeurosis
'ction& elevate the tense palatine aponeurosis closing the naso from oropharyn+
(oth T)> $ 6)> contraction opens the auditory tube since part of their origin is
taken from it $ since their contraction occurs mainly during swallowing this process
will open the auditory tube equali"ing pressure on both sides of the eardrum
P!"!o$"o%%)%:/'i%+)%%e'/
P!"!o*h!ryn$e)%:
7rigin&
- 4asal side of palatine aponeurosis
- >osterior part of the hard palate
Insertion& fibers arch down behind palatoglossal fibers to raise the posterior pillar of
the fauces #palatopharyngeal fold% $ inserted in the posterior border of the thyroid
cartilage
'ction& - depresses the soft palate
- elevates the laryn+ in the early stage of deglutition
4erve supply of palatal muscles&
'll palatal muscles are supplied by the pharyngeal branch of I nerve in the
pharyngeal ple+us e+cept T)> which is supplied by nerve to medial pterygoid from
the main trunk of )c.
Arerie% o& he *!"!e:
1- Dreater palatine9 hard palate
2- 6ong sphenopalatine9 hard palate
3- 6esser palatine9 soft palate
- 'scending palatine br. of facial a.9 soft palate
!- >alatine br. of ascending pharyngeal9 soft palate
Vein% o& he *!"!e:
,imilar to arteries9 pterygoid venous ple+us
Ner(e% o& he *!"!e:
1- Dreater palatine n.
2- 4asopalatine n.
3- 6esser palatine n.
- >haryngeal branch of >>D
!- II nerve.
he "har#n*:
N Is a muscular tube common for airway $ foodway e+tends from the base of the
skull down to the level of cricoid cartilage #G8 vertebra% where both ways
diverge from each other
N It is located behind $ opens anteriorly into three openings* the nasal cavity* the
oral cavity $ the laryn+ from above downward* so its cavity is divided into the
nasopharyn+* oropharyn+ $ laryngeal pharyn+
N It is about 12 cm long* its widest diameter is ! cm at the base of the skull* its
narrowest diameter is 1.! cm at the upper oesophagus* so it possesses a funnel
shape
The 0!"" o& he *h!ryn,:
N The structure of the pharyngeal wall looks like four cups one inside the other
N The highest $ innermost is the pharyngobasilar fascia which is attached to the
skull base.
N The ne+t three are the pharyngeal constrictors
N 5ach constrictor muscle has an anterior small origin from which its fibers fan
out posteriorly to meet its fellow in the posterior midline forming the
pharyngeal ligament #the posterior pharyngeal raphe% which e+tends from the
base of the skull to the lower border of thyroid cartilage
N >haryngeal constrictors are the intrinsic muscles of the pharyn+
The pharyngo$basilar fascia:
N This strong fascia lines the muscular layer of the nasopharyn+ $ e+tends from
the base of the skull to the hard palate #G1 vertebra%
N It is responsible for keeping the nasopharyn+ always open for respiration
N 7rigin9
- -rom the pharyngeal tubercle in the base of the skull the line of origin goes
laterally in a forwrad conve+ity to reach the petrous ape+ which is involved by
the origin of fascia
- Then it passes forward to reach the base of the medial pterygoid plate where
the cartilagenous part of the auditory tube is lodged.
Head & Neck Dr. Nawfal K. Al-Hadithi ;;
- It passes over the tube then takes origin from the posterior border of the medial
pterygoid plate medial to the superior pharyngeal constrictor where its origin
ends at the level of the pterygoid hamulus
The superior pharyngeal constrictor:
7rigin& from the posterior border of the medial pterygoid plate below the
cartilagenous part of the auditory tube - pterygoid hamulus - pterygomandibular
raphe - posterior border of mylohyoid line
Insertion& fibers fan so that upper fibers ascend to reach the base of the skull in the
midline* middle fibers go hori"ontally $ lower fibers go down inside the middle
constrictor to the level of the lower border of thyroid cartilage* all are inserted
posteriorly in the pharyngeal raphe
The middle pharyngeal constrictor:
7rigin& from the angle between the lesser $ greater horns of the hyoid bone $ lower
part of stylohyoid ligament
Insertion& fibers fan so that upper fibers ascend to reach the base of the skull in the
midline outside the superior constrictor* middle fibers go hori"ontally $ lower fibers
go down inside the inferior constrictor to the level of the lower border of thyroid
cartilage* all are inserted posteriorly in the pharyngeal raphe
The inferior pharyngeal constrictor:
Thyropharyngeus9
- This is the largest portion of the IG. $ the largest of all constrictors
- It arises from the oblique line of the thyroid cartilage $ area above
- -ibers ascend up $ go medially but not inferiorly to be inserted into the
midline pharyngeal raphe
Gricopharyngeus9
- This circular muscle arises from the cricoid cartilage $ is continuous with the
upper part of the oesophagus
- It is continuous with its opposite fellow
- There is a gap between it $ the thyropharyngeus part
The e,rin%i+ #)%+"e% o& he *h!ryn,:
Stylopharyngeus8
- 7rigin9 from the back of the root of styloid process
- Insertion9 the slender muscle passes with II $ pharyngeal branch of I
between the IG' $ 5G' to be inserted into the posterior border of thyroid
cartilage in front of palatopharyngeus
%alatopharyngeus8 .discussed/
Salpingopharyngeus8
- 7rigin9 from the lower border of the auditory tube
- Insertion9 fibers converge on palatopharyngeus with which it is inserted into
the back of the thyroid cartilage
Re"!ion% o& he *h!ryn,:
F /pper part&
N 6aterally9 carotid sheath containing IG'* GG'* IH)$ the last cranial nerves
N >osteriorly9 retropharyngeal space containing sympathetic trunk
posterolaterally
N 'nteriorly9 nasal cavity
F 6ower part&
N 6aterally9 carotid sheath containing GG'* IH) $ I nerve
N >osteriorly9 same relations
N 'nteriorly9 laryn+
Ner(e %)**"y o& he *h!ryn$e!" #)%+"e%:
'll pharyngeal muscles are supplied by the pharyngeal branch of I through the
pharyngeal ple+us* e+cept&
-,tylopharyngeus9 glossopharyngeal n.
-Gricopharyngeus9 e+ternal laryngeal n.
The pharyngeal pleus of nerves:
This ple+us is formed on the lateral surface of the .G.* it is formed by&
1- >haryngeal branch of I9 motor
2- >haryngeal branch of II9 sensory
3- >haryngeal branch of superior cervical sympathetic ganglion vasomotor
G!*% in he *h!ryn$e!" 0!"":
1- (etween the pharyngo-basilar fascia $ base of the skull&
filled anteriorly by the cartilagenous part of 5ustachian tube.
2- (etween the ,G. $ .G.& enters stylopharyngeus $ II.
3- (etween the .G. $ IG.&
internal laryngeal nerve $ superior laryngeal artery.
Arerie% o& he *h!ryn,:
1- 'scending pharyngeal #5G'%.
2- 'scending palatine #facial a.%.
3- Jescending palatine $ pharyngeal aa. #3rd part of ma+illary a.%.
- .uscular branches of superior thyroid artery
Vein% o& he *h!ryn,:
N 'ccompany arteries
N -orm two venous ple+uses* one e+ternal $ the other between the constrictors
$ pharyngobasilar fascia
N The upper part of the pharyn+ drains to the pterygoid ple+us
N The lower part drains to the IH)
The inerior o& he *h!ryn,:
The pharyngeal cavity is divided according to the part it lies behind into &
1- The nasopharyn+9 which lies behind the nasal cavity $ e+tends from the base of
the skull to the level of the hard palate #61%.
2- The oropharyn+9 which lies behind the oral cavity $ e+tends from the level of the
hard palate to the glosso-epiglottic folds.
3- The laryngeal pharyn+9 which lies behind the laryngeal orifice.
5ach one of these parts possesses special stigmata* structure* arterial $ nerve supply.
The nasopharyn:
N Is completely respiratory $ opens anteriorly to the posterior nasal choana
N Its cross section simulates the origin of the pharyngobasilar fascia which
strengthens its wall keeping it always patent
N ,tructures in this part are&
Head & Neck Dr. Nawfal K. Al-Hadithi ;<
1- The nasopharyngeal tonsils 2adenoids3&
a collection of lymphatic tissue in the posterior wall of the nasopharyn+ near its roof.
2- The tubal tonsils& lymphatic tissue collections around the orifices of the auditory
tubes.
3- The openings of 5ustachian tubes&
on each side* near the roof connecting it to the tympanic cavity.
- The salpingopharyngeal fold&
a mucosal fold produced by the underlying salpingopharyngeaus e+tending from the
back of tubal orifice downward.
!- The pharyngeal recess #fossa of Cosenmuller%&
lies posterolateral in the wall* it contains the levator palati muscle deep to its m.m. $
immediately lateral to it lies the IG'.
The oropharyn:
N Is common respiratory $ digestive path. 7pens anteriorly to the oral cavity
constituting the back of the tongue $ superiorly to the nasopharyn+.
N ,tructures in this part are&
1- The palatoglossal fold& a mucosal fold raised by the the underlying palatoglossus
separating the oral cavity from the oropharyn+.
2- The palatopharyngeal fold& a mucosal fild raised by the underlying
palatopharyngeus muscle.
3- The palatine tonsils&
- Two big collections of lymphoid tissue lying between the palatoglossal $
palatopharyngeal folds measuring 2cm in greatest dimension
- They donQt fill the area between the two arches but leave the supratonsillar
recess above them
- Their free surface is characteri"ed by the tonsillar crypts
- Their deep surface is covered by thin but firm capsule which is continuous
above with the pharyngobasilar fascia $ lies deep to the superior constrictor
- 6ingual tonsils& in the posterior 1B3 of the tongue.
The MaldeyerQs tonsillar ring&
The laryngopharyn:
N 6ies opposite to the laryngeal inlet.
Pharyngeal
T 1
Tubal T 1 Tubal T 1
Palatine T 1 Palatine T 1
Lingual T 1
0=
N Its anterior wall is characteri"ed by&
1- The median glosso-epiglottic fold9 a midline mucosal fold between the epiglottis $
the posterior 1B3 of the tongue.
2- The lateral glosso-epiglottic fold9 one on either side* connecting the lateral borders
of the posterior 1B3 of the tongue to the epiglottis.
3- The valleculae9 on each side of the medial D5- bounded by the median D5- $
lateral D5- $ the posterior 1B3 of the tongue.
- The piriform recess9 is part of the laryn+ between the quadrate membrane medially
$ thyrohyoid membrane laterally.
Ner(e %)**"y o& he #)+o%! o& he *h!ryn$e!" +!(iy:
F4asopharyn+9 pharyngeal branch of >>D #)b%
F7ropharyn+9 pharyngeal branch of II nerve
F6aryngeal pharyn+9 superior laryngeal branch of I nerve
A**"ie' !n!o#y:
F5nlarged adenoid - nasal blockage - block auditory tube - recurrent ear infections $
reduced hearing.
F>haryngeal diverticulum& herniation of food-containing mucosal pouch through the
gap between the two parts of inferior constrictor seen as a swelling at the side of the
neck.
he (ar#n*:
The laryn+ lies in the anterior part of the neck in the midline opposite to G-G8
vertebrae forming the laryngeal prominence #'damQs apple%
't this level the 6. is triangular in cross section while lower down at the level of the
cricoid cartilage it is circular in cross section
Re"!ion%:
- 'nterolaterally9 Thyroid gland $ strap muscles
- 6aterally9 Garotid sheath
- >osteriorly9 >haryn+
S-e"eon:
The thyroid cartilage:
N This hyaline cartilage is composed of two quadrilateral laminae meet in the
midline
N The meeting angle is <=7 in male $ 12=7 in female #therefore the 6 is more
prominent in male%
N The superior thyroid notch is a )-shape notch :ust above the prominence
N The posterior border of the cartilage is thick $ rounded $ e+tends above $
below the laminae as the superior $ inferior horns
N The superior $ inferior borders are characteri"ed by superior $ inferior
tubercles between them the oblique line of the cartilage e+tends which gives
attachment to thyrohyoid* sternothyroid $ thyropharyngeus
N The upper border is attached to the thyrohyoid membrane which is thickened in
the midline as the median thyrohyoid ligament $ thickened laterally between
the superior horn $ tip of greater horn of the hyoid as the lateral thyrohyoid
ligament
N The inferior thyroid notch lies opposite to the superior one* from its deep
surface the root of the epiglottis arises
The cricoid cartilage:
N This signet ring-like cartilage is characteri"ed by an anterior arch $ posterior
broad lamina
N It lies at the level of G8 vertebra $ forms the foundation on which the rest of
the laryn+ is built
N The posterior lamina is marked in the midline by a ridge on either side of
which lies a shallow depression for the posterior crico-arytenoid muscle
N The arch which is ! mm in vertical height gives attachment anterolaterally to
crico-thyroid muscle $ posteriorly to the cricopharyngeus :ust above which the
lateral crico-arytenoid arises
N The upper border of the arch gives attachment to the conus elasticus
N The sloping shoulders of the lamina provides a synovial :oint for the arytenoid
cartilages
N 't the :unction of the arch $ lamina is a synovial :oint for articulation of the
inferior horns of the thyroid cartilages
The arytenoid cartilage:
N This is a three sided pyramidal hyaline cartilage whose ape+ pro:ects
posteromedially $ carries the corniculate cartilages
N The base of the pyramid carries three processes
N The anterior sharp process is the vocal process $ to which the upper free end
of the conus elasticus is attached as the vocal fold
N The lateral process is the muscular process to which the lateral $ posterior
crico-arytenoids are attached
N The medial surface of the pyramid is flat $ faces the opposite one
N The anterolateral surface is curved $ gives attachment for the thyro-arytenoid
muscle
N The posterior surface is smooth $ gives attachment for the transverse
arytenoid muscle
N The arytenoid cartilage sits on the elongated facet on the sloping shoulder of
the cricoid lamina forming the crico-arytenoid synovial :oint
The corniculate cartilage:
N This small nodular elastic cartilage lies on the ape+ of the arytenoid to prolong
it backward $ medialward
N They are enclosed by the ary-epiglottic folds
The cuneiform cartilage:
N 're rod like elastic cartilages lies on the previous ones in the ary-epiglottic
folds
The epiglottis:
N This elastic* leaf-like cartilage is attached by its lower 1B2 to the back of the
thyroid cartilage by the thyro-epiglottic ligaments in the midline* its upper 1B2
stands erect behind the posterior 1B3 of the tongue $ the hyoid bone
N The anterior surface of the epiglottis is attached to the hyoid bone by the hyo-
epiglottic ligament
N The m.m of the 5. is reflected on the posterior 1B3 of the tongue as three folds*
the median $ two lateral glosso-epiglottic folds which mark the division
between the oro- $ laryngo-pharyn+* on each side of the median one lies a
vallecula
N The cartilage is well pitted to receive the multiple mucous glands which cover
it
N To the margins of the free upper K is attached the quadrate membrane
L!ryn$e!" #e#br!ne%:
1-Thyro-hyoid membrane&
- ,uspends the thyroid cartilage to the hyoid bone
- It passes from the upper border of the thyroid cartilage to the upper border of
the hyoid bone passing behind the bone separated from it by a bursa
- It shows one median $ two lateral ligaments of the same name
- It is pierced by the superior laryngeal artery $ internal laryngeal nerve.
- It forms the lateral boundary of the piriform recess
2- Gonus elasticus&
- Is a half-circle ligament whose lower attachment is to the whole length of the
upper border of the cricoid arch
- Its free upper border is attached on either side to the vocal process of the
arytenoid cartilage forming the vocal fold #true vocal cord% which contains in
its free border muscle fibers #vocalis%
- 'nteriorly the membrane is attached to the back of the thyroid cartilage in the
angle between the two laminae in the midline midway between the superior $
inferior notches converting the curved membrane to )-shape membrane
- Its thickening in the midline anteriorly produces the median crico-thyroid
ligament
3- Wuadrate membrane&
- Is a weak membrane whose posterior border is attached to the anterior surface
of the arytenoid cartilage $ its anterior border is attached to the sides of the
lower half of the epiglottis
- Its upper free border will e+tend between the epiglottis $ the arytenoid
cartilage forming the ary-epiglottic fold which involves in its substance the
corniculate $ cuneiform cartilages
- Its lower free border will be parallel to the upper free border of the conus #true
vocal cords% forming the vestibular fold #false cords%
- It forms the medial boundary of the piriform recess
The inerior o& "!ryn,:
The laryngeal inlet:
- 7pens in the anterior wall of the pharyn+ in a vertical plane
- Is an inverted triangle whose base is formed by the epiglottis antero-superiorly
$ its ape+ is the narrow interval between the two arytenoids postero-inferiorly
- The sides of the triangle is the ary-epiglottic olds
The laryngeal vestibule:
- Is the triangular cavity beyond the laryngeal inlet until the rima glottidis
- It is bounded on each side by the quadrate membrane
- It shows three features&
1- The vestibular folds9 are the lower free border of the quadrate membranes
2- The laryngeal ventricle9 is a sac like mucosal herniation between the true $ false
vocal folds whose upper border e+tends up $ may reach the
upper border of the thyroid cartilage* it is filled with mucosal glands for lubrication
3- The rima vestibuli9 is the opening between the vestibular folds* it is wider than the
rima glottidis.
The vocal folds:
- 're formed by the free upper border of the conus stretched between the thyroid
cartilage anteriorly $ the arytenoids posteriorly
- The anterior 3B! are true components of the conus while the posterior 2B! are
formed by the vocal process of the arytenoids
- They contain in their free edge the vocalis muscle which increases the apposed
surface area of the cords during phonation
- The opening between them is called the rima glottidis
- Dlottis* is a term applied to the two vocal cords $ the rima glottidis as they are
the main structure involved in phonation
The rima glottidis:
- Is the interval between the two vocal cords
- Is 23 mm long in male $ 1; mm in female
- It could be opened either in )-shape or diamond shape manner according to the
type of movement of the arytenoid
- Jownward movement of the arytenoid on the sloping shoulders of the cricoid
lamina pulls the two ends of the conus downward separating them $ opens the
rima in a )-shape manner* here the vocal processes of the arytenoids are
parallel to each other* this occurs in quite respiration
- Cotation of the arytenoids around their vertical a+es pulls the free ends of the
conus away $ opens the rima in a diamond shape manner* the back of the
diamond is formed by the vocal processes of the arytenoids which become
perpendicular on each other* this occurs in forced respiration
- Juring phonation the folds come in contact with each other $ the rima
becomes slit like
Inrin%i+ #)%+"e%:
The ary$epiglottic muscle:
- 5+tends in the ary-epiglottic fold from the arytenoids to the lateral border of
the epiglottis
- The oblique inter-arytenoids are regarded as the continuation of the muscle to
the vocal process of the opposite arytenoid
- Gontraction of both brings the arytenoids near each other $ oppose the ary-
epiglottic folds $ pull the epiglottis as a shelf over the constricted laryngeal
inlet producing an effective sphincteric action for the inlet
The posterior crico$arytenoid:
7rigin9 from the back of cricoid lamina from the fossa on each side of the midline
ridge
Insertion9 upper fibers go hori"ontally to the vocal process of the arytenoid while the
lower fibers go vertically to the to the same process
'ction9 upper fibers rotate the arytenoids so they open the rima glottidis in a diamond
shape while the lower fibers pull the arytenoids away from each other so they open
the rima in a )-shape
The transverse arytenoid:
- This is a muscle formed of fine $ short fibers stretched between the two
arytenoids deep to the oblique one
- Its contraction opposes the vertical fibers of the posterior c-a muscle
The lateral crico$arytenoid:
- 'rises from the posterior part of the cricoid arch
- Inserted into the vocal process of the arytenoid
- Its contraction opposes the hori"ontal fibers of the posterior c-a muscle
The crico$thyroid:
- This muscle arises from the anterolateral surface of the cricoid arch
- Its fibers radiate upward $ backward to be inserted into the lower border $
medial aspect of the thyroid cartilage
- Its contraction appro+imates the thyroid $ cricoid cartilages diminishing the
area between them* this will bring the thyroid cartilage away from the
arytenoid increasing the length $ hence tension of the vocal cords affecting
consequently the type of the voice
The thyro$arytenoid:
- This muscle arises from the inner surface of the thyroid lamina
- Its fibers pass backward to be inserted into the muscular process of the
arytenoid
- Its contraction appro+imates the thyroid $ arytenoid cartilages diminishing the
area between them* this will decrease the length $ hence tension of the vocal
cords affecting consequently the type of the voice* this movement also acts as a
laryngeal sphincter
Arerie% o& he "!ryn,:
1- ,uperior laryngeal artery9
- ' branch of the superior thyroid a.
- pierces the thyrohyoid membrane together with the internal laryngeal nerve to
lie underneath the m.m of the floor of the piriform recess
- supplies the laryn+ to supply mucosa down to the level of the vocal cords.
2- Inferior laryngeal artery9
- ' branch of the inferior thyroid artery
- enters the lower part of the laryn+ deep to the inferior pharyngeal constrictor
- supplies it up to the vocal cords #vocal cords are supplied by the inferior one%.
Ner(e% o& he "!ryn,:
:otor:
'll muscles of the laryn+ are supplied by the recurrent laryngeal n. e+cept
cricothyroid which is supplied by the e+ternal laryngeal branch of the superior
laryngeal nerve #I nerve%.
Sensory:
N 'bove the vocal folds & internal laryngeal branch of superior laryngeal nerve
#I nerve% accompanies the sup. laryngeal artery.
N (elow the vocal folds& recurrent laryngeal nerve accompanies the inferior
laryngeal artery
The e!r:
The e,ern!" e!r +on%i)e%:
1% The auricle #pinna%.
2% The e+ternal auditory #acoustic% meatus.
3% The tympanic membrane #eardrum%.
The auricle:
N Is an oval cartilage attached to the side of the skull by anterior $ posterior
auricular ligaments.
N The skin is thin $ well attached to the underlying perichondrium $ prolonged
inward into the e+ternal auditory meatus as far as the tympanic membrane.
N The cartilage is prolonged inward to be continuous with the e+ternal 1B3 of the
5'..
N Three auricular muscles are present to move the auricle but their function is
negligible in human.
N )essels9 posterior auricular $ superficial temporal vessels.
N 4erves9 great auricular* vagus and auriculotemporal nerves share the supply of
the auricle as mentioned.
The eam:
N Is 2 mm in length
N Its lateral 1B3 is cartilagenous $ directed upward $ backward as it goes
medially
N Its medial 2B3 is bony $ directed downward $ forward as it goes medially
N The bony canal is narrower than the cartilagenous
N The skin is adherent to the underlying bone $ cartilage
N The narrowest part of the canal is the isthmus which is the :unction between its
two parts
N The skin of the cartilagenous part contains hair with sebaceous $ ceruminous
glands
N The 5'. is bounded anteriorly by the T. :oint $ parotid gland $ posteriorly
by the mastoid process
N The inferior wall of the canal is ! mm longer than the superior one due to the
obliquity of the eardrum
N )essels9 as the auricle $ deep auricular vessels.
N 4erves9 auriculotemporal $ auricular branch of the vagus nerves.
The eardrum:
N ' nearly oval membrane 0I1= mm* set in a cone like shape whose concavity
faces outward $ its most concave point is its center 2umbo3
N It is semitransparent* pearly grey in color
N It is applied in an oblique manner in the 5'. so that its lateral surface faces
downward* forward $ laterally making !!7 angle with the floor
N Its circumference is a fibrocartilagenous ring set in the tympanic sulcus
N It is composed of three layers&
a% 7uter layer of modified skin continuous with that of the 5'.
b% Inner layer of m.m continuous with that of the middle ear
c% Intermediate fibrous layer formed of circular $ radial fibers which is
responsible for the strength of the membrane
N The upper 1B8 of the membrane lacks the intermediate layer so it is la+ $
called pars flaccida* the rest of the membrane is called pars tensa
N The handle of the malleus is fused with the upper part of the membrane
Applied anatomy:
N In order to straighten the 5'. in e+amination of the ear it should be pulled
upward* backward $ laterally in adults and downward* backward $ laterally in
children
N Ma+ of the e+ternal ear mostly affects the lateral 1B3 of the 5'.
N In ear syringing* the no""le should be directed forward at first then backward*
upward $ medially to avoid in:ury to the tympanic membrane
N 4ormal tympanic membrane is semitransparent $ pearly grey with a cone of
light in its antero-inferior part* a diseased membrane looses its shiny
appearance $ the cone of lightX
The #i''"e e!r:
Is a small* si+-walled cavity in the temporal bone where the sound waves are
converted into mechanical waves
N The cavity is 1! mm in height* 1! mm in '> dimension but narrow from side
to side where it is narrowest in the center #2 mm%but wider above $ below
#like a biconcave lens%
N The cavity communicates anteriorly with the nasopharyn+ via the 5ustachian
tube $ posteriorly with the mastoid air cells through the aditus* their mucosal
lining is continuous with each other $ is respiratory in type
%arts:
a% 5pitympanum 2epitympanic recess 7C attic39 the part of the cavity which
e+tends above the level of the tympanic membrane
b% .esotympanum9 the part of the cavity opposite to the eardrum
c% Eypotympanum9 the part below the level of the eardrum
N Gontents&
a% 745 nerve9 chorda tympani
b% TM7 muscles9 tensor tympani $ stapedius
c% TEC55 bones9 incus* malleus $ stapes
@alls of the middle ear:
The roof:
The roof of the tympanic cavity is formed by the thin plate of tegmen tympani which
separates the ear from the cranial cavity
The floor:
N The floor of the middle ear separates the ear from the :ugular fossa
N It is perforated by the tympanic branch of glossopharyngeal nerve
The lateral 6all:(discussed)
The medial 6all:
F The most prominent feature of the medial wall is the promontory of the internal ear
which is the basal turn of the cochlea
F The promontory is grooved by branches of the tympanic ple+us
F The oval window 2fenestra vestibuli3& is an oval opening above the promontory
whose long a+is is hori"ontal $ ma+imum conve+ity is superior* it is closed in life by
the footplate of the stapes
F The round window 2fenestra cochleae39 lies below $ behind the promontory $
closed in life by the secondary tympanic membrane
F The facial canal seen in the medial wall as a prominence of bone above the oval
window which then curves inferiorly $ nearly vertically behind the promontory* the
bone may be so thin in this area
F The prominence of the lateral semicircular canal sometimes seen as a prominent
ridge above the facial canal
The anterior 6all:
N This wall separates the middle ear from the carotid canal
N It is perforated by the coraticotympanic nerves which leaves the carotid ple+us
around the IG' to enter the tympanic ple+us over the promontory
N In the upper end of the anterior wall lies the opening of the 5ustachian tube
N 'bove the auditory tube opening lies the semicanal for tensor tympani muscle
N Tensor tympani* a 2cm long muscle which arises from the septum between the
auditory tube $ its canal $ from the cartilagenouos part of the tube gives rise
to a slender tendon which hooks around the processus $ then directed laterally
to insert into the handle of the malleus* its contraction tenses the tympanic
membrane by pulling the handle of the malleus medially resulting in
dampening of its vibrations
The auditory (0ustachian) tube:
N This 3.! cm long tube connects the cavities of the middle ear $ nasopharyn+
N Its tympanic 1B3 is osseous $ pharyngeal 2B3 is cartilagenous
N The direction of the tube from the ear to the nasopharyn+ is downward*
forward $ medially making !7 angle with the sagittal plane $ 3!7 angle
with the hori"ontal plane
N The mucosa of the middle ear therefore is continuous with that of the
nasopharyn+ through the tube
N .ucous glands are present in the cartilagenous part whose pharyngeal end is
surrounded by the tubal tonsils
N The tube is shorter* wider $ more hori"ontal in children
The posterior 6all:
N The upper part of the posterior wall is open to the mastoid antrum through the
aditus ad antrum which is a large irregular opening leading from the middle ear
to the mastoid antrum
N -ossa incudis lies below the opening of the mastoid antrum* it lodges the short
process of the incus
N The vertical facial canal lies medially in the posterior wall
N The pyramidal eminence pro:ects from the posterior wall in front of the facial
canal* it is hollow structure whose walls give rise to stapedius muscle
N ,tapedius arises from the pyramidal eminence* its tendon is inserted into the
posterior part of the neck of the stapes* its contraction tilts the footplate of the
stapes resulting in dampening of its effect on the internal ears #protective
function%
The mastoid air cells:
N These are small bony cavities communicating with each other located within
the mastoid process
N The first cell is the largest $ called mastoid antrum which lies immediately
behind the attic with which it communicates through the aditus ad antrum
N The si"e $ number of mastoid air cells vary considerably* sometimes only few
small cells are present within the mastoid $ called sclerotic mastoid
N The mastoid process develop into a definite elevation only at the age of 2 years
N The lining mucosa is continuous with that of the tympanic cavity
The auditory ossicles:
N Three bones* the incus* malleus $ stapes united by true synovial :oints form a
lever system which convert the vibrations of the tympanic membrane into
mechanical energy represented by the pressure of the footplate of stapes on the
oval window
N The fi+ation of these bones in the tympanic cavity is provided by&
1% The attachment of the malleus handle to the eardrum
2% The attachment of the stapedial footplate to the oval window
3% The anterior $ posterior ligaments of the bones
The malleus&
- The boneQs name is derived from its resemblance to a hammer
- The rounded head of the bone lies in the epitympanic recess
- The long handle is fused with the upper half of the tympanic membrane
- The head shows a posterior oval concavity which receives the incus in the
incudo-mallear :oint which is of the saddle variety
- The short anterior process is connected to the petro-tympanic fissure of the
anterior wall by a ligament
The incus&
- The anterior part of the body of the incus has a concavo-conve+ facet for
articulation with the mallear head
- The short process #posterior crus% e+tends posteriorly to lie in the fossa incudis
- The long process #inferior crus% descends vertically parallel to the handle of the
malleus to end in a rounded structure* the lenticular process which is received
by the head of stapes in the incudo-stapedial :oint which is of ball $ socket
variety
The stapes&
- The head of stapes is hollowed for reception of the lenticular process of the incus
- The narrow neck receives posteriorly the insertion of stapedius
- Two crura diverge from the neck to attach the footplate
- The footplate closes the oval window to which it is attached by a ring like ligament
Blood supply of the middle ear:
The arterial supply&
- The main artery of the eardrum is the anterior tympanic branch of ma+illary
artery
- The main artery of the tympanic cavity* mastoid antrum $ mastoid air cells is
the stylomastoid branch of posterior auricular branch of the 5G' together with
the anterior tympanic branch of the ma+illary artery
- ,maller branches from the ascending pharyngeal artery* middle meningeal
artery* artery of pterygoid canal share in the supply of the middle ear
The veins&
- 're parallel to arteries $ drain to&
1% ,uperior petrosal sinus
2% >terygoid ple+us
3erve supply of the middle ear:
The tympanic cavity* the deep surface of the tympanic membrane $ mastoid air cells
are supplied by the tympanic ple+us.
Tympanic ple+us&
'n autonomic ple+us formed at the promontory of the internal ear by contribution of&
1% The tympanic branch of glossopharyngeal nerve
2% Goraticotympanic branches of the carotid sympathetic ple+us
3erves in the middle ear:
1% -acial nerve has part of its course in the medial $ posterior walls of the
tympanic cavity but this part does not contribute to ear supply
2% Ghorda tympani traverses the tympanic cavity between its bones but also give
no branch to the ear.
Applied anatomy:
N Gommunication between the nasopharyn+ $ middle ear results in transmission
of infections from the nose $ pharyn+ to the ear so otitis media is one of the
complications of upper respiratory tract infection which complicates children
infections more than adults due to the shape of their tubes $ the possibility of
associated adenoids
N Gommunication between the middle ear $ the mastoid air cells results in
transmission of infection from the middle ear to the mastoid resulting in acute
or chronic mastoiditis
N -acial nerve involvement may be associated with diseases of the middle ear
#6.4J%* (ellQs palsy
The inner e!r:
N The inner ear is the essential organ of hearing $ equilibrium
Head & Neck Dr. Nawfal K. Al-Hadithi <=
N It consists of the membranous labyrinth which is filled with endolymph $
located inside a similar bony structure* the bony labyrinth which is filled with
perilymph
N The membranous labyrinth consists of the&
1% Gochlear duct9 is the snail like part of the inner ear responsible for hearing
2% Interconnecting channels responsible for maintaining equilibrium&
a% The utricle $ saccule9 stimulated by linear acceleration
b% The semicircular ducts9 stimulated by angular acceleration
c% The part of the bony labyrinth lodging the cochlear duct is named the cochlea
d% The part lodging the semicircular ducts is called the semicircular canals
e% The part lodging the utricle $ saccule is called the vestibule
The bony labyrinth:
The +ochlea
- Cesembles a snail shell formed of 2.! turns $ lies on its side
- It is the most anterior part of the bony labyrinth situated in front of the
vestibule $ internal acoustic meatus
- It is =.! cm in height $ its basal turn measures 1 cm in diameter
- The central a+is of it is called the modiolus from which the spiral lamina arises
$ pro:ects inside the cochlear turns $ partially divides the cavity of the
cochlea into scala vestibuli above the lamina $ scala tympani below it
- The oval window opens to scala vestibuli $ the fluid surge made by the
pressure of the footplate of stapes ascends to reach the summit of the cochlea
#helicotrema% where it is transmitted to scala tympani which ends below in the
secondary tympanic membrane occluding the round window
- 'nother opening in the basal turn of the cochlea opens to the inferior surface of
the petrous bone called the cochlear aqueduct
The 'estibule:
- It is the middle part of the inner ear bounding the middle ear medially
- In its lateral wall the oval window opens to the tympanic cavity from which the
stapedial footplate closes this window
- )ibration of the footplate of the stapes results in fluid surge in the perilymph of
the vestibule
The Semicircular +anals:
- 're three* anterior #superior%* posterior $ lateral
- They lie above $ behind the vestibule $ behind the internal acoustic meatus
- 5ach canal describes a greater part of a circle whose diameter is 1 mm $ has a
dilatation in one end called the ampulla
- The canals are perpendicular to each other* the superior is vertical $ lies
transverse to the long a+is of the petrous bone* the posterior* also vertical* lies
in the long a+is of the bone while the lateral lies hori"ontally so its conve+ity
lies laterally making a bony bulge in the medial wall of the middle ear
- 7nly five opening of the ,GG opens into the vestibule since the posterior end
of the anterior canal opens in the posterior ,GG in the crus commune
The membranous labyrinth:
Head & Neck Dr. Nawfal K. Al-Hadithi <1
- These channels contain the sensory organs of hearing $ equilibrium swimming in
the endolymph&
- The sensory organ of the cochlear duct is the spiral organ of Gorti
- The sensory organ of the ,GG is the crista
- The sensory organ of the utricle $ saccule is the macula
- The speciali"ed cells in each sensory organ are the hair cells
Arteries of the labyrinth:
N The main artery is the labyrinthine branch of the basilar artery
N The stylomastoid branch of the posterior auricular artery supplies some of the
blood
'eins of the labyrinth:
,imilar to arteries $ drain to the inferior petrosal sinus
he cranial ca!it#:
The Cr!ni!" Menin$e%:
The brain $ spinal cord are enveloped by three layers of meninges variable in
consistency $ arrangement* they are from within outward&
1% >ia mater.
2% 'rachnoid mater.
3% Jura mater* which is divided into&
'9 Inner fibrous layer* the dura proper or fibrous dura.
(9 7uter membranous layer* the endosteal #periosteal% dura.
%ia mater:
N This is a delicate* intimate areolar investment which faithfully follows the
contour of the brain $ cannot be dissected from it.
N It is invaginated into the nervous tissue with blood vessels surrounded by a
tubular prolongation of G,--filled subarachnoid space named the perivascular
space.
N It is evaginated with cranial #$ spinal% nerves which leave the nervous tissue.
N It is meshed with blood vessels so it e+hibits the name #vascular membrane%.
Arachnoid mater:
N This is a delicate* transparent membrane made mainly of collagenous $ elastic
fibers $ lined by squamous mesenchymal epithelium.
N It is separated from the pia by the G,--filled subarachnoid space.
N It is loosely applied to the brain $ donQt strictly follows its contour* so it
approaches #$ may come in touch with% the pia over brain gyri but diverge
from it over the sulci.
N The only invagination of the arachnoid on the brain is into the longitudinal
fissure of the brain.
The subarachnoid space&
N This G,--filled space is crossed by trabeculae derived from the two bounding
meninges.
N In regions where brain contour change markedly* the arachnoid mater bridges
over wide intervals of pia-covered brain tissue resulting in large G,- lakes
called subaracnoid cisterns.
N These cisterns are mainly located under the brain $ they are traversed by
cranial nerves $ blood vessels in the region of the cistern. The main cisterns
are four&
a% Gisterna cerebellomedullaris9 between the undersurface of the cerebellum
above $ the roof of the fourth ventricle below.
b% Gisterna interpeduncularis9 lies in front of the midbrain between the two
cerebral peduncles.
c% Gisterna pontis9 lies in front of the basilar part of the pons between it $ the
basilar part of the occipital bone.
d% Gisterna chiasmatica9 lies :ust below the optic chiasma
N 'rachnoid villi9 finger-like pro:ections of arachnoid through the fibrous dura
into the superior sagittal sinus where G,- diffuses into the venous blood
N 'rachnoid granulations9 are the folded round ends of the villi which have
special histological structure to permit G,- diffusion
=ura mater:
5ndosteal layer&
- This is the periosteum of the undersurface of the cranial bones lies e+ternal to
the fibrous layer.
- (ecause of its more intimate relation $ fusion with the fibrous dura than
cranial bones from which it can easily be pealed off* this layer is regarded as an
e+ternal layer of cranial dura mater
- )enous sinuses are located in separations of the two layers of dura or between
folds of the fibrous layer of dura mater
-ibrous layer 2dura proper3&
- This is a tough* dense* fibrous membrane which encloses $ protects brain
tissue
- -olds of this layer between various parts of brain tissue are responsible for
preventing the effects of movements of the head on the floating brain
- Jural folds are four in number&
1% -al+ cerebri
2% Tentorium cerebelli
3% -al+ cerebelli
% Jiaphragma sellae
-al+ cerebri&
- This is a sickle-shape dural fold which occupies the median longitudinal
fissure of the brain
- It is attached anteriorly to crista galli $ broadens as it goes backward to end by
becoming continuous with the dorsal surface of the tentorium cerebelli
- Its upper conve+ border is attached to the midline of cranial bones $ sagittal
suture enclosing the superior sagittal sinus* it ends posteriorly at the internal
occipital protuberance
- The inferior concave margin arches over corpus callosum of the brain to end
posteriorly in the straight sinus
Tentorium cerebelli&
- This fold separates the cerebellum from the undersurface of occipital lobes of
the cerebrum
- It is elevated in the midline like a tent where it meets the posterior end of fal+
cerebri
- Its attached posterior margin encloses the lateral #transverse% sinuses which
diverge from the internal occipital protuberance on the occipital bone
- Its attached anterior margin encloses the superior petrosal sinuses along the top
of the petrous bone
- The anterior concave free margin arches around the brainstem $ is attached
anteriorly to the anterior clinoid processes
- The straight sinus lies in the line of :unction of the tentorium with the fal+
cerebri
-al+ cerebelli&
- This shallow fold separates the two cerebellar hemispheres
- It is attached to the internal occipital crest
- It contains the occipital venous sinuses
Jiaphragma sellae&
- This is a hori"ontal fold of dura pro:ecting from the margins of sella turcica
- It roofs the sella leaving a midline opening for the pituitary stalk
D)r!" (eno)% %in)%e%:
N These are endothelial-lined spaces between the two dural layers or between
folds of fibrous dura
N They are the collecting channels of cerebral* meningeal $ diploic veins
N They communicate with e+ternal veins by emissary veins
N They end in the IH) either directly or indirectly
N They are classified by many classifications* one of them is&
1- .idline unpaired sinuses
2- >aired sinuses
Anpaired sinuses:
1- ,uperior sagittal sinus&
- (egins at foramen caecum where it receives a vein from the roof of the nose
- >asses back in the root of the fal+ cerebri to the internal occipital protuberance
being triangular in coronal section
- 's it goes backward it becomes larger as it receives more blood
- The lateral blood lakes #lacunae% lie on each side of it at parietal level* into
these lakes the arachnoid granulations bulge for diffusion of G,-
- It receives cerebral* diploic $ emissary veins
- 't the internal occipital protuberance it ends in the sinus confluence or
bifurcates into right $ left lateral sinuses or continues to one side 2usually the
right3 as the lateral sinus
2- Inferior sagittal sinus&
- (egins one third the distance behind the attachment of the fal+ cerebri
- It occupies the inferior margin of the fal+
- 5nds posteriorly in the straight sinus
- It receives tributaries from the medial surface of the hemispheres $ from the
fal+
3- ,traight sinus 2sinus rectus3&
- It is the continuation of the inferior sagittal sinus in the tentorium cerebelli
- It lies in the line of :unction of the fal+ cerebri $ the tentorium
- It receives the great cerebral $ superior cerebellar veins
- 5nds as the superior sagittal sinus at the internal occipital protuberance buts it
has the tendency to continue as the left transverse sinus
%aired sinuses :
1- Gavernous sinus&
- They lie in the .G- on either side of sella turcica e+tending from the superior
orbital fissure anteriorly to the ape+ of petrous bone posteriorly
- They are trabeculated as to be given the name 2cavernous3
- They begin anteriorly by union of the superiorophthalmic vein $
sphenoparietal sinus
- They end posteriorly by division into the superior $ inferior petrosal sinuses
- They communicate with the angular vein $ pterygoid ple+us
a% Gontents of the lateral wall&
- 7culomotor nerve
- Trochlear nerve
- 7phthalmic $ ma+illary divisions of trigeminal nerve
b% Gontents of the lumen&
- 'bducent nerve
- IG' enters the sinus from below posteriorly at foramen lacerum $ passes in its
floor grooving the bone to pierce its roof anteriorly medial to the anterior
clinoid process to the circle of Millis
2- Intercavernous sinuses&
- Gonnect the two cavernous sinuses
- >ass anterior $ posterior to the stalk of the hypophysis
3- ,phenoparietal sinuses&
- 6ie in the dural fold at the lesser wing of sphenoid
- Ceceive radicles from the midle meningeal veins
- 5nd in the cavernous sinus
- ,uperior petrosal sinus&
- 6ie in the attached anterior margin of the tentorium at the top of the petrous
bone
- They connect the cavernous with sigmoid sinuses
- They receive the cerebellar* inferior cerebral $ tympanic veins
!- Inferior petrosal sinus&
- 'rise from the postero-inferior part of cavernous sinus
- Droove the petro-occipital fissue
- >ass through the anterior compartment of :ugular foramen
- 5nd in the IH)
- Ceceive pontine* labyrinthine* medullary $ cerebellar veins
Head & Neck Dr. Nawfal K. Al-Hadithi <!
8- (asilar ple+us&
- 6ie on the basilar part of the occipital bone
- Gonnect the two inferior petrosal sinuses
- Gonnected to the anterior vertebral venous ple+us
;- 7ccipital sinuses&
- 'rise from union of small veins near foramen magnum
- >ass through the root of fal+ cerebelli
- 5nds at the internal occipital protuberance at the confluence of sinuses
0- ,phenoparietal sinuses&
- 'rises by receiving a radical from the middle meningeal vein deep to the
pterion
- 6ies in dura on the undersurface of the lesser wing of sphenoid
- 5nds in the anterior part of the cavernous sinus
<- Transverse #lateral% sinuses&
- (egin at the internal occipital protuberance
- They lie in the posterior attached margin of the tentorium cerebelli
- They e+tend laterally to reach the base of the petrous temporal where they
receive the superior petrosal sinus $ descend in the posterior cranial fossa the
sigmoid sinuses
- They receive the inferior cerebral $ superior cerebellar veins
1=- ,igmoid sinuses&
- 're large ,-shape sinuses formed at the root of the petrous bone by confluence
of the lateral $ superior petrosal sinuses
- They groove the deep surface of the mastoid process of temporal bones
- They continue on the occipital bone to reach the :ugular foramen
- 't the :ugular foramen they continue as the IH)
- They receive the mastoid emissary veins $ inferior cerebellar veins
B"oo' %)**"y o& +r!ni!" ')r!:
Arteries:
The endosyeal layer of dura is very richly supplied by blood* unlike the fibrous layer
which needs little supply.
1- ,upratentorial part is supplied by the middle meningeal artery* a branch of
ma+illary artery which enters the cranium through foramen spinosum $ divides into
anterior $ posterior divisions.
The anterior division courses up passing over the precentral gyrus* haematoma in this
region causes contralateral paralysis.
The posterior one passes back courses over the superior temporal gyrus* haematoma
from this artery causes contralateral deafness.
2- Granial fossae&
'% 'nterior G-& ophthalmic $ anterior ethmoidal arteries.
(% .iddle G-& middle $ accessory meningeal arteries.
G% >osterior G-& vertebral arteries.
'eins:
(lood is collected into two main sources&
1- .iddle meningeal veins* accompany the arteries $ leave the cranium through
foramen spinosum to enter the pterygoid ple+us.
2- Jiploic veins* which drain either to the e+terior or to dural venous sinuses
especially the superior sagittal.
3erves:
1- ,upratentorial dura & tentorial branches of )a.
2- Granial fossae&
'% 'G-& 'nterior $ posterior ethmoidal n.
(% .G-& )b $ )c.
G% >G-& meningeal branches of II $ I cranial nerves
J% The area around foramen magnum& the upper three cervical spinal nerves.
(#m"hatic drainage of the head & neck:
- 6ymph from E $ 4 is collected into two ma:or circles of lymph node chains*
superficial $ deep circles
- -rom both circles* lymph is eventually collected to the deep cervical lymph
nodes which lie along the IH) between the two circles
- Jeep G64* as they lie along the IH) is roughly divided into superior $ inferior
groups* each of which is further divided into anterior $ posterior
- 7f the anterosuperior group* the :ugulodigastric node is of special importance
since it collects lymph from the tongue $ palatine tonsils
- 7f the posteroinferior group* the :uguloomohyoid node is of special
importance since all lymph from the tongue pass directly to it bilaterally before
it is collected in the :ugular lymph trunk
- -rom the deep G64* lymph is collected into the :ugular lymph trunk* then to
the thoracic duct #left side% $ right lymph duct
S)*er&i+i!" +ir+"e:
1- ,ubmental 64
2- ,ubmandibular 64
3- >reauricular #parotid% 64
- >ost #Cetro% auricular #mastoid% 64
!- 7ccipital 64
8- .andibular 64
;- (uccal 64
0- 'nterior :ugular 64
<- 5+ternal :ugular 64
Dee* +ir+"e:
1- >retracheal 64
2- >aratracheal 64
3- Cetropharyngeal 64
#1=%& J55> G5C)IG'6 64
Submental -3:
>osition& ,ubmental triangle between the two anterior bellies of digastric
'fferent& Medge shape piece between the two lower canines including the lower
incisors* their gum* lower lips* floor of the mouth $ tip of the tongue
Head & Neck Dr. Nawfal K. Al-Hadithi <;
5fferent& ,ubmandibular $ anterosuperior group of JG64
Submandibular -3:
>osition& ,ubmandibular triangle in $ around the gland
'fferent& 'rea of the face anterior to the facial artery* anterior nose* gums* tongue*
hard palate* submandibular gland $ ad:acent nodes #submental* buccal $
mandibular%
5fferent& 'nterosuperior group of JG64
%reauricular -3:
>osition& In $ around the parotid gland
'fferent& 'nterolateral part of the scalp* temporal fossa* part of the face lateral to
facial arteries* e+ternal ear* lateral part of eyelids $ parotid gland
5fferent& 'nterosuperior group of JG64
7etroauricular -3:
>osition& 7n the mastoid process
'fferent& >osterolateral part of the scalp $ e+ternal ear
5fferent& JG64
<ccipital -3:
>osition& In the ape+ of posterior triangle along the occipital artery
'fferent& (ack of the neck $ posterior part of the scalp
5fferent& JG64
:andibular -3:
>osition& 't the lower border of the mandible as the facial artery enters the face
'fferent& 'd:acent area of face $ neck
5fferent& ,ubmandibular 64
Buccal -3:
>osition& 7n buccinator
'fferent& 'd:acent area of the face* nose $ lips
5fferent& ,ubmandibular 64
Anterior ,ugular -3:
>osition& 'round the 'H)
'fferent& 'd:acent area of neck
5fferent& JG64
0ternal ,ugular -3:
>osition& 'round the 5H)
'fferent& 'd:acent area of the cervical skin* parotid region $ lower lateral part of the
e+ternal ear
5fferent& JG64
%retracheal ! prelaryngeal -3:
>osition& 'nterior to trachea $ laryn+
'fferent& Trachea* laryn+* ad:acent parts of the thyroid gland
5fferent& JG64
%aratracheal -3:
>osition& (etween the trachea $ oesophagus near the recurrent laryngeal nerve
'fferent& Trachea* oesophagus $ lateral part of the thyroid gland
5fferent& JG64
7etropharyngeal -3:
>osition& 'nterior to the prevertebral fascia* behind the pharyn+ $ oesophagus* its
enlargement causes dysphagia
'fferent& >haryn+* oesophagus* posterior part of nasal cavity* paranasal sinuses*
nasopharyn+* oropharyn+ $ back of the tongue
5fferent& JG64
%aras#m"athetic ganglia in the head & neck:
- The parasympathetic system of the E $ 4 is represented by -7/C cranial
parasympathetic ganglia which share in the supply of structures recommending
this type of autonomic supply
- These are& GI6I'CP* >T5CPD7>'6'TI45* ,/(.'4JI(/6'C $ 7TIG
ganglia
- 5ach of the four possesses three roots&
1- ,ensory& from the trigeminal nerve for common sensation
2- ,ympathetic& >ostganglionic branches from the superior cervical sympathetic
ganglion reaching via a branch from the carotid system
3- >arasympathetic #motor%& from parasympathetic nuclei in the brainstem
- >ostganglionic branches of these ganglia contain fibers from all the three modalities
are furnished to the specific areas
Ci"i!ry G1:
,ensory root& 4asociliary n. #)a%
,ympathetic root& 'long 7phthalmic branch of IG'
>arasympathetic root& 5-M nucleus in the midbrain L III - 4. to inferior oblique
>ostganglionic branches #short ciliary n%&
- Giliary $ sphincter pupillae muscles
Pery$o*!"!ine G1:
,ensory root& .a+illay n. #)b%
,ympathetic root& #Jeep petrosal n% 'long IG'
>arasympathetic root& ,uperior salivary nucleus - nervus intermedius - greater
petrosal nerve
Dreater S deep petrosal nerves Y vidian nerve #n. of pterygoid canal%
>ostganglionic branches&
- 6acrimal* nasal* nasopharyngeal $ palatal glands
S)b#!n'ib)"!r G1:
,ensory root& 6ingual n. #)c%
,ympathetic root& 'long facial branch of 5G'
>arasympathetic root& ,uperior salivary nucleus - nervus intermedius - chorda
tympani
- ,ubmandibular $ sublingual salivary glands
Oi+ G1:
,ensory root& 'uriculotemporal n. #)c%
Head & Neck Dr. Nawfal K. Al-Hadithi <<
,ympathetic root& 'long middle meningeal branch of ma+illary artery #5G'%
>arasympathetic root& Inferior salivary nucleus L II - lesser petrosal nerve
- >arotid gland
he tem"oromandibular )oint:
- This is an articulation between the mandibular head $ the mandibular fossa on
the undersurface of the squamous temporal bone.
- ,ince both heads of the mandible belong to one bone* movement of one T.H
will inevitably move the other one* therefore the T.H is regarded as a bilateral
components of one cranio-mandibular articulation.
The +!*%)"e:
The strong fibrous capsule is attached at the skull to&
- 5minentia articularis OO 'nteriorly
- ,quamotympanic fissure OO >osteriorly
- .argins of the articular surface OO on each side
The attachment on the mandible is around the articular surface e+cept posteriorly
where the capsular attachment is much lower than anterior level
The 'i%+:
- The :oint cavity is divided* by a fibrocartilagenous disc* into upper $ lower
compartments.
- The disc is attached at the periphery to the underside of the annular fibrous
capsule.
- The disc concavoconve+ anteroposterioly in the sagittal plane
S!bi"iy:
In addition to the bony contour $ muscular attachment* stability of the T.H is
enhanced by three main ligaments&
1- 6ateral lig.& -rom the undersurface of the "ygomatic arch passes lateral to the neck
of the mandible to be attached to the posterior part of the neck* it prevents forward
dislocation.
2- ,tylomandibular lig.& -rom the styloid process down to the back of the angle of the
mandible.
3- ,phenomandibular lig.& -rom the spine of sphenoid to the lingula of mandibular
foramen.
The latter two ligaments pass medial to the :oint.
'nterior dislocation of the mandible&
FThe T.H is more stable in occlusion than open position since the teeth stabili"e the
mandible on the ma+illa
F'rticular eminence $ tension of masticatory muscles #e+cept lateral pterygoid%
prevent open mouth from anterior dislocation
F6a+ muscles $ ligament with forced opening of the mouth will lead to anterior
mandibular dislocation which will not return due to spasm of the three stabili"ing
muscles themselves
FIn order to reduce this dislocation* downward push on the molar teeth for a moment
before reducing the dislocation is mandatory to overcome muscular spasm
Head & Neck Dr. Nawfal K. Al-Hadithi 1==
Mo(e#en% o& he TM2:
F5levation-depression* #open-close% mov.&
- '+is&rotation occurs around a hori"ontal a+is passing through both mandibular
heads
- Hoint compartment& lower #below the disc%
- .ain muscles&
7pen& digastric $ lateral pterygoid
Glose& other three masticatory muscles
FDliding #side-to-side% movement&
- '+is& Cotation of the mandible around a+is which lies :ust behind the head on
the other side
- Gompartment& /pper #above the disc%
- .ain muscles& >terygoids on one side push the mandible to the other
F>rotractio-retraction movement&
- Gompartment& /pper
- .ain muscles& 'll masticatory muscles protract $ passive recoil retract
B"oo' 3 ner(e %)**"y:
- The :oint is supplied by arteries $ veins in the vicinity.
- ,uperficial temporal $ ma+illary arteries are the main distributors
- 'uriculotemporal nerve is the main sensory nerve for the :oint
2oin y*e:
T.H is a typical synovial :oint of ball $ socket variety
Head & Neck Dr. Nawfal K. Al-Hadithi 1=1

Skull Bones Sutures Landmarks

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Skull Bones Sutures Landmarks

Enviado por

Direitos autorais:

Formatos disponíveis

OSTEOLOGY OF THE HEAD AND NECK

Você também pode gostar