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Head and neck

The skull
The Neurocranium
bones
• Frontal bone
• Parietal bones ( paired)
• Temporal bones ( paired)
• Occipital bone
• Sphenoid bone
• Ethmoid bone
> Largely flat, curved and united by
fibrous interlocking sutures.
Facial skeleton
( viscerocranium or splanchnocranium )
• Lacrimal bones ( 2 )
• Nasal bones ( 2 )
• Maxillae ( 2 )
• Zygomatic bones ( 2 )
• Palatine bones ( 2 )
• Inferior nasal conchae ( 2 )
• Mandible ( 1 )
• Vomer ( 1 )
Anterior Skull
• Glabella – the smooth slightly depressed
area between the superciliary arches.
• Nasion – the intersection of the frontal and the
nasal bone ( bridge 0f the nose)
• Supraorbital arch – the angular boundary between
the squamous and orbital bones.
• Supraorbital notch or foramen – passage for vessels and nerves.
• Superciliary arch – a ridge superior and lateral to
the glabella.
• Orbital fissures – superior and inferior
• Optic canal – for passage of optic nerve
Anterior Skull
• Zygomatic bones ( zygoma, cheekbone, malar bone)
• Zygomatico facial foramen
• Piriform apertures – pear shaped anterior nasal apertures
• Nasal septum – bony divide of the nasal cavity
• Nasal conchae – curved bony plates on the lateral wall
• Maxillae – the upper jaw (alveolar processes for the maxillary
teeth ).
• Infraorbital foramen – passage for the infraorbial nerves
• Mandible – U shaped bone with alveolar process for the
mandibular teeth
• Mental foramina – for the mental nerve and vessels.
• Mental protuberance – prominence of the chin.
Clinical applications
• Injury to Superciliary arches – laceration with
profuse bleeding,
• Blackeye – bruising and bleeding of tissues around
the orbit with hematoma formation.
• Malar flush – redness of the skin covering the
zygomatic prominence.e.g. fever in PTB
• Le Fort Fracture - Fractures of the maxillae, alveolar
process, bony nasal septum, lacrimal, pterygoid
plates of the sphenoid, bridge of the nose.
• Resorption of alveolar bones – due to loss of teeth.
• Mandibular prognathism – decrease in vertical facial
dimensions with overclosure due to total loss of
teeth.
Clinical…

• Fractures of the Calvaria –

a. Depressed fracture
b. Linear fracture
c. Comminuted fracture
d. Contrecoup fracture
(counterblow)
Lateral aspect of the
skull
• Pterion – the union of frontal, parietal, sphenoid and
temporal bones.
Importance - It overlies the anterior branch of the
middle meningeal artery.
• Temporal fossa – boundaries; superior/posterior by temporal lines, inferiorly
by the zygomatic arch.
• Zygomatic arch – formed by the union of the temporal process of
zygomatic and zygomatic process of temporal bone
• External acoustic meatus –
• Mastoid process –
• Infratemporal fossa – space inferior and deep to the
zygo arch, mandible and posterior maxilla.
Posterior aspect of the
skull
• Occiput – from occipital,parietal,mastoid part of
temporal
• Inion - Occipital protuberance
• Foramen magnum – large opening at
the base
• Superior nuchal line
• Lambda – the junction of the sagittal
and lambdoid sutures
Superior aspect of skull
• Parietal eminence –
• Frontal eminence
• Coronal sutures – separates frontal and parietal
bone
• Sagittal sutures – separates parietal bones
• Lambdoid sutures – separates the parietal and
temporal bone from occipital bone
• Bregma – intersection of sagittal and coronal
sutures.
• Vertex – most superior point of the skull
• Parietal foramen – found posteriorly near the
sagittal sutures, transmits emissary veins.
Landmark Shape and location

Pterion G. Wing
sphenoid
Lambda Pt. of coronal/sagittal
sutures

Bregma(forepart of Pt. of coronal/sagittal

sutures
head)

Vertex Superior part of skull

Asterion Starshaped,
parietomastoid,
occipitomastoid and
lambdoid sutures

Glabella At the root of the nose

Inion ( back of Prominent at external

occipital protuberance
head)
SCALP

• S – Skin
• C – Subcutaneous tissue
• A - Aponeurosis
• L – Loose connective
tissue
• P - Periostium
Muscles of facial
expression
• Buccinator - this is the muscle of the cheek. It is used in
whistling and sucking and is also involved in mastication.
• Zygomaticus minor - it elevates the upper lip in order to show
contempt and deepens the nasolabial sulcus to express
sadness.
• Levator anguli oris - this raises the corner of the mouth.
• Depressor labii inferioris - it depresses the lip and is used in
the expression of impatience.
• Levator labii superioris - this elevates and everts the upper lip
and aids the zygomaticus minor muscle in the expression of
sadness.
• Risorius - this is involved in grinning.
• Procerus - this small muscle runs from the bridge of the nose
to the forehead and is useful in frowning and in reducing the
glare of bright lights.
• Platysma - this is a sheet-like muscle which covers the neck
and lower face. It has an embryological role related to the
facial nerve.
Facial muscles Facial
expression
1. Orbicularis Oral sphincter, pucker,
whistle
oris
2. Dilator Open mouth wide

muscles
3. Levator labii Elevate upper lip and
wing of nose
superioris alaque
nasi
4. Mentalis Expression of doubt

5. Buccinator Aids in mastication,

blowing
6. Depressor anguli Frowning,depress angle
oris mouth
7. Procerus Draws eyebrow inferior,
frown

8. Levator anguli Elevates corner of mouth

oris
Smile, laughing
Muscles of the Nose
• Procerus small slip from frontalis, draws
eyebrow inferiorly as in frowning or from
glare.
• Depressor septi, from maxilla into mobile part
of nasal septum. Helps in deep inspiration
• Nasalis – main muscle, composed of the a.
compressor naris – transverse, compress the
piriform aperture ( nostril)
b. dilator naris – alar (wing) part, from maxilla
to alar cartilage
* All innervated by buccal branch of facial
nerve
Branches of Facial
nerve
• Temporal - cross the parotid, to auriclaris,
occipito frontalis & orbicularis oculi.
• Zygomatic – inferior orbicularis occuli, inferior of
eye.
• Buccal – buccinators, orbicularis oris, lev. labii
sup.
• Mandibular – risorius & muscles of lower lip/chin.
• Cervical – platysma and superficial neck muscles.
Facial nerve injury
Injury results to paralysis of the affected muscles.
1. Inflammation at the stylomastoid foramen produces
edema and swelling and compression of the nerve.
2. Loss of tonus of orbicularis oculi > eversion of
lower lid
3. Cornea cannot be lubricated, becomes dry,
ulcerations or keratitis
4. Patient cannot blow, whistle or chew effectively.
Weakens the buccinator, orbicularis oris, cheek
and lip muscle. Results to displacement and
drooping of mouth corners due to contraction of
unopposed contralateral facial muscles cause
saliva and food dribbling at the sides of the mouth.
Nerves of the face

• Trigeminal nerve (C.n.V)– sensory

nerve of the face, and motor nerve for
mastication
• Branches of the Trigeminal ganglion:
a. Ophthalmic nerve*****
1. nasociliary nerve
2. Frontal nerve
3. Lacrimal nerve
b. Maxillary nerve
c. Mandibular nerve , sensory part
Ophthalmic nerve
Cutaneous branches:
a. external nasal nerve
b. infratrochlear nerve
c. supratrochlear nerve
d. supraorbital nerve
e. lacrimal nerve
Maxillary nerve

• Cutaneous branches
1. Infraorbital nerve – to the upper cheek,
mucosa of maxillary sinus, incisors,
canine, premolar, upper gingiva,
inferior eyelids, nose, skin and mucosa
of upper lip.
2. Zygomaticotemporal nerve – to the
temple
3. Zygomaticofacial nerve – to the face at
the zygoma
Mandibular nerve
Cutaneous Branches
• Auriculotemporal nerve – to the
auricle, external acoustic meatus,
tympanic membrane.
• Buccal nerve – to the buccinator,
mucosa of cheek and gingiva
• Mental nerve – to the chin mucous
membrane of lower lip and inferior
labial fold.
Facial Vasculature
• Mostly from the External carotid artery
1. Facial artery – cervical branches; ascending
palatine, tonsillar, glandularSMG,submental, muscular.
facial br.;inferior/sup. Labial, Lateral nasal,muscular &
angular
2. Superficial temporal artery – transverse facial,
medial temporal, anterior auricular, frontal & parietal.
3. Maxillary artery , composed of 3 parts
1st part(bet. Mandibular/sphinopalatine) = ant. Tympanic,
deep auricular, middle meningeal(cranial via for.ovale),
accessory meningeal, inferior alveolar to mandible,
gingiva, teeth.
Maxillary artery,
continue…
• 1st part – branches thru foramen and canals, ant. Tympanic,
deep auricular, middle meningeal (cranial via for.ovale),
accessory meningeal, inferior alveolar to mandible, gingiva,
teeth.
* 2nd part - supplies muscles, 2 deep temporals, pterygoids,
masseteric, buccal arteries
• 3rd part - accompanied by maxillary nerve thru bony canal, lie
at [pterygopalatine fossa lateral to the ganglion.
branches; posterior superior alveolar, infraorbital, descending
palatine, artery of pterygoid canal, pharyngeal,
sphenopalatine.
* Features: there are 5 branches from each part, first 5 reach
destination by entering foramina, middle 5 supply soft tissue
& use no foramina, last 5 use foramina. The infraorbital the 6th
branch is really the termination of the maxillary artery.
Other clinical facts of the facial
vasculatures
• Compression of facial artery on one side cannot stop any
bleeding due to anastomoses of its branches and other
facial vessels. Facial wounds bleed freely and heal
quickly.
• Pulses of the Facial arteries;
a. temporal pulse, just anterior to auricle
b. facial pulse, at inferior border of mandible
• Transverse facial artery from the superfacial temporal
artery supply the parotid gland and duct, masseter and
skin of face anastomose with facial artery.
• There are anastomoses in the head between the
branches of the internal and external carotid artery.
• Branches of the Post. Sup. Alveolar supply the gum,
molar, premolars and maxillary sinus.
Other clinical features…

• Branches of the infraorbital artery supply the

orbital structures, maxillary sinus, via the
anterior superior alveolar branch of canine and
incisor teeth.
• Descending palatine artery divides into greater
and lesser palatine arteries.
• The pharyngeal branch via the pharyngeal canal
supplies the pharynx posterior to the auditory
tube.
• The sphenopalatine artery passes thru the
sphenopalatine foramen and supplies the lateral
wall and septum of nasal cavity.
Facial venous drainage

• Supratrochlear vein
• Supraorbital vein
• Facial vein
• Superfacial temporal vein
• Retromandibular vein
Infratemporal fossa and its
contents
• An irregular shaped space lying behind the maxilla,
deep to the ramus of the mandible and inferior to
the temporal bone.
• Boundaries:
Lateral = ramus of mandible
Medial = lateral pterygoid plate
Anterior = infratemporal surface of maxilla
Posterior = anterior surface of condylar process of
mandible, styloid process of temporal bone.
Roof = inferior surface of greater sphenoid wing.
Inferior = insertion of medial pterygoid to the
mandible near the angle
Infratemporal fossa ,
continue…
Contents:
• Lower part of temporalis muscle
• Medial and lateral pterygoid muscles
• Maxillary artery and branches
• Pterygoid plexus of veins
• Mandibular division of Trigeminal
nerve **
• Chorda tympanni (cn.Vll)
• Otic ganglion
Mandibular division of Trigeminal
nerve and its branches

1. Inferior alveolar nerve

2. Nerve to mylohyoid muscles
3. Lingual nerve
4. Buccal nerve
5. Auriculotemporal nerve
6. Nerves to muscles of mastication
Mandibular nerve block = local anesthesia thru 2 routes:
extraoral = via the mandibular notch, anesthesia to the auriculo
temporal, inferior alveolar, lingual, buccal nerve, skin.
Intraoral = thru the buccal mucosa & buccinator muscle medial to
mandibular ramus, near foramen. Affects the inferior alveolar
and lingual nerve to mandibular body, ramus, mandibular
teeth and gingiva, mucosa of anterior 2/3 of tongue.
Triangles of the Neck

Cervical Triangles
Anterior
Anterior triangle:
Ventrally by midline, SCM lateral,
cephalic by body of mandible
Subdivisions:
1. Digastric (submandibular) = sup. by mandible,
anterior and below by digastric ant. belly, post
below by digastric and stylohyoid muscles
2. Carotid = sup. by post belly digastric & stylohyoid,
inf. by sup.belly omohyoid, post. by SCM
3. Submental (suprahyoid) = lat. by ant. belly digastric,
inferiorly by hyoid, medially by midline of neck.
4. Muscular = post. & inferior by SCM, post. & superior
by
sup.belly omohyoid, medially by midline from hyoid
to sternum.
Posterior triangle:
anterior by SCM, posterior by
trapezius,
inferior by clavicle
Subdivisions:
1. Occipital triangle = posterior by
trapezius, anterior by SCM, caudally
by inferior belly omohyoid.
2. Subclavian ( omoclavicular) =
anterior by SCM, Superior by inferior
belly omohyoid, inferiorly by
clavicle
Cervical fascia

• Superficial = covers the ant. and post. Triangle, splits to

enclose SCM and trapezius. Attaches to ext. occipital
protuberance. Lig. Nuchae, C7 spine, sup. Nuchal line, mastoid
process, mandible, clavicle, manubrium, acromion, scapular
spine.
• Fascia of Infrahyoid muscle = Superficial enclose
the sternohyoid and omohyoid, DEEP invests the sternohyoid
and thyrohyoid muscles.
• Visceral fascia = encloses the pharynx, larynx, trachea,
esophagus, thyroid. Parts pretracheal encloses larynx and
trachea, Buccopharyngeal covers the buccinator and posterior
esophagus.
• Prevertebral fascia = encloses the vertebral column
and its muscles. Covers the prevertebral muscles and forms the
floor of posrterior triangle.
• Sibsons fascia ( suprapleural membrane deep to the scalene
muscle) covers the cervical pleura.
Carotid sheath

• An investment (cover) of the:

1. internal carotid
2. common carotid arteries
3. Internal jugular veins
4. Vagus nerve.
• It is adherent to the thyroid sheath
and fascia under the SCM.
• Attachment, cepahlically bone at
jugular foramen and carotid canal,
caudally continues to the thorax.
Veins of the neck

• Internal jugular vein, start in jugular fossa as

continuation of Sigmoid sinus.
Tributaries : 1. inferior petrosal sinus & meningeal veins 2.
pharyngeal plexus veins 3. common facial veins 4. lingual veins, 5.
superior thyroid veins thyroid veins 6. middle thyroid veins 7. right
lymphatic ducts or the left thoracic duct.
• External jugular vein = formed by the posterior
retromandibular and posterior auricular veins. Tributaries: 1.
posterior auricular, occipital, retromandibular and anterior jugular
vein
2. posterior external jugular from cephalic part of back of neck.
3. Transverse scapular from scapular region 4. Transverse cervical
• Subclavian vein = from axillary veins. Tributaries: 1.
external jugular 2. transverse cervical 3. thoracoacromial from
shoulder and upper pectoral region.
Arteries of the Head and Neck

1. Common carotids
2. Vertebral arteries
3. Basilar arteries
4. Posterior cerebral arteries
5. Subclavian artery branches
6. External carotid artery and its
branches
Common carotid artery

• Left arise from the arch independently

• In the carotid sheath with internal jugualr vein and vagus
nerve.
• Division:
1. Internal carotid, S shaped curved artery, divides into
middle and anterior cerebral artery with branches to the:
A. middle ear ( caroticotympanic)
B. cavernous sinus nerves, trigeminal ganglion,
hypophysis and choroid plexus
C. Ophthalmic artery to the orbit
2. Middle cerebral artery to the frontal and temporal lobe to
the cerebrum
3. Anterior cerebral artery to the corpus callosum. Both
cerebrals are terminal and have no collateral circulations
and occludes easily.
Vertebral artery

• A branch of the subclavian. Runs superiorly

to the verterbral column and enters the
transverse process C6
• Vertebral supplies: muscles, vertebral
column, spinal column meninges, medulla,
pons, cerebellum and cerebrum.
• Spinal branches enters intervertebral
foramina to supply the cord.
• Last branch of the vertebral is the
Posterior Inferior Cerebellar artery.
Basilar artery,

• terminates in the interpeduncular cistern and

divides into right and left cerbral.
1. Pontine = to pons, ventrolateral cerebellar cortex,
inferior midbrain
2. Internal auditory = to dura of canal, cochlea,
labyrinth, facial nerves
3. Anterior inferior cerebellar = to brain stem,
superior and middle cerebellar peduncle, anterior
cerebellar hemisphere
4. Superior cerebellar = to the inferior colliculi,
superior cerebellar peduncle and dentate nerve
5. Posterior Cerebral artery
Posterior cerebellar artery

Branches:
a. posteromedial ganglion to
hypothalamus, thalamus, choroid plexus
and 3rd ventricle.
b. posterior choroidal branch, thalamus,
subthalamus, internal capsule, choroid
plexus, 3rd ventricle, lateral ventricle
c. cortical branch = to inferior surface of
temporal and occipital lobes
External carotid artery, branches:

1. Superior thyroid = infrahyoid region, larynx, thyroid gland

2. Ascending pharyngeal = pharynx, prevertebral muscles,
meninges, soft palate
3. Lingual = tongue, suprahyoid, sublingual gland, palatine
tonsils.
4. Facial = submandibular gland, lips, nose, facial muscles,
angle of eye
5. Occipital = to SCM, meningeal branches, scalp
6. Posterior auricular = tympanic membrane, external ear,
posterior scalp.
7. Superficial temporal = parotids, ear, face, zygomatic and
temporal regions.
8. Maxillary artery = to masticatory muscles
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