FOURTH EDITION

ME4RG BdoTecfc
ACC No J.

BD Chaurasia's

Regional and Applied
Dissection and Clinical
VOLUME 3

Head, ec! and Brain

Late Dr BD Chaurasia
"#3$%"#&'

FOURTH EDITION
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BD ChaurasiaV)

Regional and Applied
Dissection and Clinical

VOLUME 3 Head, ec! and Brain
CB-

CBS PUBLISHERS & DISTRIBUTORS
E. DELH/ + BA 0ALORE

Medical !no1ledge is constantl2 changing3 As ne1 in4or5ation 6eco5es a7aila6le, changes in treat5ent, procedures, e8uip5ent and the use o4 drugs 6eco5e necessar23 9he author and the pu6lisher ha7e, as 4ar as it is possi6le, ta!en care to ensure that the in4or5ation gi7en in this te:t is accurate and up to date3 Ho1e7er, readers are strongl2 ad7ised to con4ir5 that the in4or5ation, especiall2 1ith regard to drug usage, co5plies 1ith the latest legislation and standards o4 practice3

BD Chaurasia's

HUMAN ANATOM Re!io"a# a"$ A%%#ie$ Disse&tio" a"$ C#i"i&a#
Volume 3 4/e

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Editor:

9he 4ourth edition has 6een re7ised 62 Dr Brishna 0arg, E:%<ro4essor and Head, Depart5ent o4 Anato52, Lad2 Hardinge Medical College, e1 Delhi3

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Y ^l/ima

FOURTH EDITION

BD Chaurasia's

Regional and Applied
Dissection and Clinical
VOLUME "

Upper Li56 and 9hora: Lo1er Li56, A6do5en <el7is
VOLUME 3 VOLUME =

ec!

Brain

4lBOU9 9HA KD/9OR
Dr3 Brishna 0arg Foined Depart5ent o4 4lnato5u, lad2 Hardinge Medical College, euF Delhi, in "#A? and learnt and taught anato52 tiil "##A e:cept 4or a 6rie4 stint at Maulana 4lLad Medical College3 -he has 6een decorated as Jelloui o4 /ndian Medical Rssociatio4t%4!ade52 o4 Medical -pecialists, Me56er o4 4lcade52 o4 Medical -ciences and 4ello1 o4 /nternational Medical -cience 4lcade523 -he recie7ed 4lppreciation 4luiard in "### 4ro5 Delhi Medical 4lss0dation and E:cellence 4luiard in Rnato52 on Doctors Da2 in =>>?3 Brishna 0arg is the co%author o4 9e:t6oo! o4 Histolog2 and euroanate5u, Ha7ing re7ised BD Chaurasia's Hand Booh o4 0eneral 4lneito52 in "##A,she has nouF re7ised and 6rought out the ?th edition o4 the three 7olu5es o4 BD Chaurasia's Hu5an 4lnato5u3

9his hu5an anato52 is not s2ste5ic 6ut regional Oh 2es, it is theoretical os uuell as practical Besides the gross 4eatures, it is chie4l2 dinical /nducted in anato52, it is also histologicoF 4lnato52 is not onl2 o4 adult 6ut also e56r2ological /t is concise, co5prehensi7e and dinieal -ur4ace 5ar!ing is pro7ided in the 6eginning 9o light the instinct o4 surgeon%in% the%4na!ing

Lots o4 ta6les 4or the 5uscles are pro7ided K7en 5ethods 4or testing are incorporated u5erous coloured illustrations are added -o that right hal4 o4 6rain gets sti5ulated Hope these 7olu5es turn highl2 use4ul 9he editor's patience and perse7erance pro7e 4ruit4ul

Preface to the Fourth Edition
In July 1996, I had gone to the office of CBS Publishers and Distributors to hand over the anuscri!t of the third edition of our Textbook of Histology, "hen #r S$ Jain, #anaging Director of CBS, re%uested e to shoulder the res!onsibility of editing the three volu es of their e&tre ely !o!ular boo' BD Chaurasia's Human Anatomy, the third edition of "hich "as earlier edited by res!ected Prof( Inderbir Singh( )his "as a *+od given gift* "hich I acce!ted "ith great gratitude( )his had also been the "ishful thin'ing of y son, no" a ne!hrologist in the ,S( )he three volu es of the fourth edition of this boo' are e&tre ely student-friendly( .ll out efforts have been ade to bring the closer to their hearts through serious and subtle efforts( /arious "ays "ere thought of, "hich I discussed "ith y colleagues and students, and have been incor!orated in these volu es( 0ne significant ethod suggested "as to add *!ractical s'ills* so that these volu es enco !ass theoretical, !ractical and clinical as!ects of various !arts of hu an body in a functional anner( )he !aragra!hs describing hu an dissection, !rinted "ith blue bac'ground, !rovide necessary instructions for dissection( )hese entail identifying structures dee!er to s'in "hich need to be cut and se!arated to visualise the anato ic details of various structures( Dissection eans !atiently clearing off the fat and fasciae around nerves, blood vessels, uscles, viscera, etc( so that their course, branches and relations are a!!reciated( )his !rovides the !hotogenic e ory for the *doctor-in- a'ing*( 1irst year of #BBS course is the only ti e in life "hen one can dissect at ease, although it is too early a !eriod to a!!reciate its value( +ood surgeons al"ays refresh their anato ical 'no"ledge before they go to the o!eration theatre( 2ssential !art of the te&t and so e diagra s fro the first edition have been incor!orated glorifying the real author and artist in BD Chaurasia( . nu ber of diagra s on ossification, surface ar'ing, uscle testing, in addition to radiogra!hs, have been added( )he beauty of ost of the four-colour figures lies in easy re!roducibility in nu erous tests and e&a inations "hich the reader can aster after a fe" !ractice sessions only( )his a'es the userfriendly volu es( 1igures are a!!reciated by the underutilised right half of the cerebral corte&, leaving the do inant left half for other 3obs in about 945 of right-handed individuals( .t the beginning of each cha!ter, a fe" introductory sentences have been added to highlight the i !ortance of the to!ic covered( . brief account of the related histology and develo! ent is !ut forth so that the given to!ic is covered in all res!ects( )he entire clinical anato y has been !ut "ith the res!ective to!ic, highlighting its i !ortance( )he volu es thus are concise, co !rehensive and clinically-oriented ( /arious co !onents of u!!er and lo"er li bs have been described in a tabular for to revise and a!!reciate their 6diversity in si ilarity6( .t the end of each section, an a!!endi& has been added "herein the segregated course of the nerves has been aggregated, !roviding an overvie" of their entire course( )hese a!!endices also contain so e clinicoanato ical !roble s and ulti!le choice %uestions to test the 'no"ledge and s'ills ac%uired( Prayers, !atience and !erseverance for al ost 4 years have brought out this ne" edition ai ed at !roviding a holistic vie" of the a a7ing structures "hich constitute the hu an anato y( )here are bound to be so e errors in these volu es( Suggestions and co ents for correction and i !rove ent shall be ost "elco e8 )hese ay !lease be sent to e through e- ail at cbs!ubs9del:(vsnl(net(in( $;IS<=. +.;+

E cerpts from

Preface to the First Edition
)he boo' has been intentionally s!lit in three !arts for convenience of handling( )his also a'es a !rovision for those "ho cannot afford to have the "hole boo' at a ti e( It is %uite !ossible that there are errors of o ission and co ission in this ostly single handed atte !t( I "ould be grateful to the readers for their suggestions to i !rove the boo' fro all angles( I a very grateful to y teachers and the authors of nu erous !ublications, "hose 'no"ledge has been freely utilised in the !re!aration of this boo'( I a e%ually grateful to y !rofessor and colleagues for their encourage ent and valuable hel!( #y s!ecial than's are due to y students "ho ade e feel their difficulties, "hich "as a great incentive for "riting this boo'( I have derived a&i u ins!iration fro Prof( Inderbir Singh B;ohta'C, and learned the decency of "or' fro Shri SC +u!ta BJi"a3i ,niversity, +"aliorC( I a dee!ly indebted to Shri $# Singhal B=ational Boo' <ouse, +"aliorC and #r S$Jain BCBS Publishers and Distributors, DelhiC, "ho have ta'en unusual !ains to get the boo' !rinted in its !resent for ( 1or giving it the desired get-u!, #r /$ Jain and ;a3 $a al 2lectric Press are gratefully ac'no"ledged( )he cover !age "as designed by #r/asant Paran3!e, the artist and !hotogra!her of our collegeD y sincere than's are due to hi ( I ac'no"ledge "ith affection the do estic assistance of #unne #iyan and the untiring co !any of y ;ani, !articularly during the odd hours of this "or'(

r

l>he necessity of having a si !le, syste ati7ed ?@ and co !lete boo' on anato y has long been felt( )he urgency for such a boo' has beco e all the ore acute due to the shorter ti e no" available for teaching anato y, and also to the falling standards of 2nglish language in the a3ority of our students in India( )he national sy !osiu on 6.nato y in #edical 2ducation6 held at Delhi in 19A4 "as a call to change the e&isting syste of teaching the unnecessary inute details to the undergraduate students( )his atte !t has been ade "ith an ob3ect to eet the re%uire ents of a co on edical student( )he te&t has been arranged in s all classified !arts to a'e it easier for the students to re e ber and recall it at "ill( It is ade%uately illustrated "ith si !le line diagra s "hich can be re!roduced "ithout any difficulty, and "hich also hel! in understanding and e ori7ing the anato ical facts that a!!ear to defy e ory of a co on student( )he onotony of describing the individual uscles se!arately, one after the other, has been ini ised by "riting the out in tabular for , "hich a'es the sub3ect interesting for a lasting e ory( )he relevant radiological and surface anato y have been treated in se!arate cha!ters( . sincere atte !t has been ade to deal, "herever re%uired, the clinical a!!lications of the sub3ect( )he entire a!!roach is such as to attract and ins!ire the students for a dee!er dive in the sub3ect of anato y(

+"alior 1ebruary, 1941

BD C<.,;.SI.

Acknowledgements
I a grateful to .l ighty for giving e the o!!ortunity to edit these three volu es, and further for sustaining the interest "hich any a ti es did oscillate( Ehen I et #r Y= .r3una, Publishing Director in CBS, in #ay FGG:, light "as seen at the end of the tunnel and it "as felt that the "or' on the volu es could begin "ith definite schedule( <e too' great interest in going through the anuscri!t, correcting, odifying and i !roving "herever necessary( <e inducted e to "rite an introductory !aragra!h, brief outlines of e bryology and histology to a'e it a concise and co !lete te&tboo'( <aving retired fro @ady <ardinge #edical College "ithin a fortnight of getting this assign ent and having 3oined Santosh #edical College, +ha7iabad, y colleagues there really hel!ed e( I a obliged to Prof( /arsha $atira, Prof(/ishra Singh, Dr Poona $harb, Dr )ri!ta Bhagat B#S SurgeryC, Dr =isha $aul and #s Jaya( )hey even did dissection "ith the ste!s "ritten for the ne" edition and odified the te&t "herever necessary( 1ro FGGG-G:, "hile "or'ing at Subharti #edical College, #eerut, the editing of the te&t continued( DrSatya $hare, .ssociate Professor, suggested e to "rite the full course of nerves, ganglia, ulti!le choice %uestions, etc( "ith a vie" to revise the i !ortant to!ics %uic'ly( So, a!!endices have co e u! at the end of each section( I a grateful to Prof( .$.sthana, Dr .$+arg and Dr .rchana Shar a for hel!ing e "hen re%uired( )he good "ishes of Prof( #ohini $aul and Prof( Indira Bahl "ho retired fro #aulana .7ad #edical CollegeD Director-Prof( ;e"a Choudhry, Prof( S ita $a'ar, Prof( .nita )uli, Prof( Shashi ;ahe3a of @ady <ardinge #edical CollegeD Director-Prof( /i3ay $a!oor, Director-Prof( J# $aul, Director-Prof( Shi!ra Paul, Prof( ;$ Suri and Prof( =eela /asudeva of #aulana .7ad #edical CollegeD Prof( +ayatri ;ath of /ardh an #ahavir #edical CollegeD Prof( ;a Pra'ash, Prof( /eena Bhariho'e, Prof( $a lesh $hatri, Prof( Jogesh $hanna, Prof( #ahindra =agar, Prof( Santosh Sanghari of ,niversity College of #edical SciencesD Prof( $iran $ucheria, Prof( ;ani $u ar, Prof( Shashi Eadh"a, Prof( ,sha Sabher"al, and Prof( ;a3 #ehra of .ll India Institute of #edical Sciences and all y colleagues "ho have hel!ed e sail through the dile a( I a obliged to Prof( D; Singh, 2&-<ead, De!art ent of .nato y, $+#C, @uc'no", for his Delhi .!ril FGGH constructive guidance and Dr #S Bhatia, <ead, De!art ent of Psychiatry, ,C#S, Delhi, "ho suggested the addition of related histology( It is y !leasure to ac'no"ledge Prof( #ahdi <asan, 2&-Prof( I <ead, De!art ent of .nato y, and Princi!al, J= #edical College, .ligarhD Prof( /eena Sood and Dr Poona Singh of D#C, @udhianaD Prof( S @a'sh anan, ;a3ah #uthiah #edical College, )a il =aduD Prof( ,sha Dhall and Dr Sudha Chhabra, Pt( BD Shar a P+I#S, ;ohta'D Prof( .sho' Sahai, $+ #edical College, @uc'no"D Prof( Balbir Singh, +ovt( #edical College, ChandigarhD Prof( .sha Singh, 2&-Prof( I <ead, #.#C, =e" DelhiD Prof( /asundhara $ulshrestha, S= #edical College, .graD and Dr Bri3endra Singh, <ead, De!art ent of .nato y, I)S Centre for Dental Science and ;esearch, #uradnagar, ,P, for ins!iring e to edit these volu es( I a obliged to y other-in-la" and y other "hose blessings have gone a long "ay in the co !letion of this arduous tas'( #y sincere than's are due to y husband Dr DP +arg, our children #ano3 and ;e'ha, #eena'shi and San3ay, #anish and Shil!a, and the grandchildren, "ho challenged e at ti es but su!!orted e all the "hile( )he coo!eration e&tended by ;e'ha is uch a!!reciated( I a dee!ly indebted to #r S$ Jain #anaging Director of CBS, #r /$ Jain, Production Director, #r B# Singh and their tea for their 'een interest and all out efforts in getting the volu es !ublished( I a than'ful to #r .sho' $u ar "ho has s'illfully !ainted blac' and "hite volu es into coloured volu es to enhance clarity( #s Dee!ti Jain, #s .nu!a Jain and #s Parul Jain have carried out the corrections very diligently( @astly, the 3ob of !agination ca e on the shoulders of #r $ar7an @ai Prashar "ho has left no stone unturned in doing his 3ob !erfectly( @ast, but not the least, the s!elling ista'es have been corrected by y students, es!ecially #s ;uchi'a +irdhar and #s <ina +arg of 1st year Bachelor of Physiothera!y course at Banarsidas Chandi"ala Institute of Physiothera!y, =e" Delhi, and #r .shutosh +u!ta of 1 st Year BDS at I)S Centre for Dental Science and ;esearch, #uradnagar( #ay .l ighty ins!ire all those "ho study these volu es to learn and a!!reciate C@I=IC.@ .=.)0#Y and DISS2C)I0= and be ha!!y and successful in their lives( $;IS<=. GARG

!ontents
Preface to the Fourth Edition Preface to the First Edition "e cerpts# vi i i

-ection " HEAD AND NEC' " Osteolog2 o4 the Head and ec!
#esoder al derivatives of !haryngeal arches #! Derivatives of endoder al !ouches #! Derivatives of ectoder al clefts 3' )he andible 3" 1ora ina and relations to nerves and vessels :: 0ssification :: Clinical anato y :H )he a&illa :H 1eatures :J #a&illary sinus :A 0ssification :4 )he hyoid bone 3 Clinical anato y 3! Cervical vertebrae (' )y!ical HG 1irst (" Second HF Seventh H: 0ssification H: 0ssification of cranial bones H:

Bones of the s'ull 3 S'ull 3oints 3 .nato ical !ositiion : 2&terior of the s'ull H =or a verticalis H =or a occi!italis J =or a frontalis 6 .ttach ents Structures !assing through fora ina =or a lateralis ! Structures !assing through fora ina 1" 2 issary veins "# =or a basalis "# .nterior !art "# #iddle !art 1: Posterior !art "$ Structures !assing through fora ina "%&"! Interior of s'ull "! Di!loic veins "! Cranial vault "! Base of s'ull #' .nterior cranial fossa #' #iddle cranial fossa ## Connections of !arasy !athetic ganglia #3 Posterior cranial fossa #3 .ttach ents on interior of s'ull #$ Structures !assing through fora ina FJ )he orbit #6 1ora ina in relation to orbit #% 1oetal s'ull #

( S&a#%) Te*%#e a"$ Fa&e 45 So e features on the living face HJ Scal! and su!erficial te !oral region H6 Dissection (6 Clinical anato y ( )he face (! Dissection $' 1acial uscles $' #otor nerve su!!ly of the face J: Clinical anato y JH Sensory nerve su!!ly of the face JH Clinical anato y JH Dissection JJ

1acial artery $6 2yelids or !al!ebrae $! Dissection 6' Clinical anato y 6# @acri al a!!aratus 6# Dissection 6# + Si$e o. The Ba&. the 1erte2ra# Ca"a# Contents $ Dissection $ S!inal dura ater $ . the Ne&Introduction AA Dissection AA #uscles of the bac' A4 Subocci!ital triangle %! Subocci!ital uscles # Clinical anato y 3 0 Co"te"ts o. the Ne&5 @and ar's on the side of the nec' 6$ Dee! cervical fascia 66 Investing layer 66 Pretracheal layer 6% Prevertebral layer 6% Carotid sheath 6 Bucco!haryngeal fascia 6 Pharyngobasilar fascia 6 Clinical anato y 6 Posterior triangle 6! Dissection 6! Contents %# Sternocleido astoid uscle %3 Clinical anato y AH .o.bducent nerve ""$ Clinical anato y ""% % A"terior Tria"!#e o.rachnoid ater 6 Pia ater 6 /ertebral syste of veins % Clinical anato y 4 The Cra"ia# Ca5it6 Cranial cavity ! Dissection ! Cerebral dura ater !' Clinical anato y !3 Cavernous sinuses !3 Clinical anato y !$ <y!o!hysis cerebri ! Dissection ! Clinical anato y "'' )rige inal ganglion "'' Dissection AGG 30 // #iddle eningeal artery "'" Clinical anato y "'# Cranial nerves 1GF Dissection "'# Petrosal nerves "'3 # Co"te"ts o. the Ne&##" Surface land ar's ""! Structures in the anterior edian region "#' Dissection "#' Clinical anato y "## Infrahyoid uscles "## . the Or2it #$5 Introduction "'$ Dissection "'$ Contents of the orbit "'$ 2&traocular uscles 1GA Dissection 1GA Clinical anato y ""' 0!hthal ic artery ""' 0!tic nerve ""# Clinical anato y ""# 0culo otor nerve ""# Clinical anato y ""3 Ciliary ganglion ""( )rochlear nerve ""$ Clinical anato y ""$ .nterior triangle of nec' "#3 Dissection "#( Sub ental triangle AFH Digastric triangle AFH Carotid triangle AF6 Dissection AF6 Co on carotid artery AF6 2&ternal carotid artery AFA #uscular triangle A:G Dissection A:A 7 The Paroti$ Re!io" /++ Parotid gland A:: Dissection A:: Surface ar'ing A:H 2&ternal features A:J Clinical anato y A:4 1acial nerve A:4 1unctional co !onents A:4 !" .

Course and relations A:9 Branches and distribution A:9 Clinical anato y AHA .

Co"te"ts 8iii 9: Te*%ora# a"$ I".+ .rticular surfaces "$' Dissection "$' #ove ents "$" Clinical anato y 1JF #andibular nerve "$# Dissection "$# Surface ar'ing 1JF Branches "$3 Clinical anato y JJJ 0tic ganglion 1J6 99 The Su2*a"$i2u#ar Re!io" /0/ Su!rahyoid uscles "$% Dissection "$% Sub andibular salivary gland "$ Dissection "$ Clinical anato y "6# Sublingual salivary gland "6# Sub andibular ganglion "6# 9( Dee% Stru&tures i" the Ne&/40 )hyroid gland "6$ Dissection "66 .rate*%ora# Fossa @and ar's on the lateral side of head "(3 #uscles of astication "(( Dissection "(( #a&illary artery "(% Dissection "(% Branches "( )e !oro andibular 3oint 1JG .elations "66 Develo! ent "%' Clinical anato y "%" Parathyroid glands "%" Clinical anato y "%# )hy us "%# Clinical anato y "%# Subclavian artery "%# Dissection "%3 Surface ar'ing "%3 Branches "%( Clinical anato y "%6 Co on carotid artery "%6 Dissection "%6 Internal carotid artery "%% Clinical anato y "%% Internal 3ugular vein "%! Clinical anato y " ' /.

The Mouth a"$ Phar6"8 )he oral cavity #'% )eeth FG4 Develo! ent of teeth FG9 Clinical anato y F1G =>3 207 .ccessory nerve 14J 1unctional co !onents 146 Course and distribution of the cranial root 146 Course and distribution of the s!inal root 146 Clinical anato y " % <y!oglossal nerve " % 1unctional co !onent " % Course and relations 144 Branches and distribution 149 Clinical anato y 149 Cervical !art of sy !athetic trun' 149 Branches of cervical sy !athetic ganglia 191 Clinical anato y 19F Cervical !le&us 19F Phrenic nerve 19: Clinical anato y 19H )rachea 19H Dissection 19H Clinical anato y 19J 0eso!hagus 19J @y !h nodes of head and nec' 19J Scalene uscles "!% Cervical !leura 199 Styloid a!!aratus FGG 207 9+ The Pre5erte2ra# Re!io" Prevertebral uscles FG1 /ertebral artery FGF Dissection FGF Branches of vertebral artery Joints of the nec' FGH Clinical anato y FG6 9.B r a c h i o c e ! h a l i c v e i n " ' + l o s s o ! h a r y n g e a l n e r v e " " D i s s e c t i o n " " 1unctional co !onents " " Course and relations " # Branches " 3 Clinical anato y " 3 /agus nerve 14: 1unctional co !onents 14H Course and relations in head and nec' 14H Branches in head and nec' 14H Clinical anato y 14J .

7 (00 (47 94 The Lar6"8 &'" Introduction F:9 Dissection F:9 Cartilages of laryn& FHG @aryngeal liga ents and e branes FH1 Cavity of laryn& FHF Intrinsic uscles of the laryn& FH: #uscles acting on the laryn& FH: #ove ents of vocal folds FHJ #echanis of s!eech FH6 Clinical anato y FHA .<ard !alate #"' Dissection #"' Soft !alate #"' Passavant*s ridge #"# #uscles of the soft !alate #"3 Develo! ent of !alate F1: Clinical anato y #"( Pharyn& #"( Dissection #"( =aso!haryn& F1J 0ro!haryn& F16 Ealdeyer*s ly !hatic ring F16 Palatine tonsil F1A Clinical anato y #" @aryngo!haryn& F19 #uscles of the !haryn& FF1 +a!s bet"een !haryngeal uscles FF1 $illian*s dehiscence FF: Deglutition FFH Clinical anato y FFJ .%ueous hu our FAJ )he lens FA6 Dissection FA6 /itreous body FA6 Develo! ent FA6 Clinical anato y FAA (.uditory tube FFJ Clinical anato y FF6 90 The Nose a"$ Para"asa# Si"uses Introduction FFA 2&ternal nose FFA =asal cavity FFA Dissection FFA =asal se!tu FF4 Clinical anato y F:G @ateral "all of nose F:G Dissection F:G Conchae and eatuses F:G Dissection F:F Clinical anato y F:: Paranasal sinuses F:: Dissection F:: Clinical anato y F:J Pterygo!alatine fossa F:J #a&illary nerve F:6 Pterygo!alatine ganglion F:6 Branches F:A ((/ 9( The To"!ue Introduction FH9 Dissection FH9 2&ternal features FJG #uscles of the tongue FJ1 Develo! ent of tongue FJ: Clinical anato y FJ: 93 The Ear a"$ 1esti2u#o&o&h#ear Ner5e 2&ternal ear FJJ .uricle FJJ 2&ternal acoustic eatus FJ6 Dissection FJ6 Clinical anato y FJ6 )y !anic e brane FJ6 Clinical anato y FJ4 #iddle ear FJ4 Dissection FJ4 Boundaries FJ9 Clinical anato y F6F 2ar ossicles F6F Clinical anato y F6: )y !anic antru F6: Dissection F6: #astoid air cells F6: Clinical anato y F6H Internal ear Bony labyrinth F6H #e branous labyrinth F6J Develo! ent F66 /estibulocochlear nerve F6A Clinical anato y F6A 97 The E6e2a## )he outer coat F69 )he sclera F69 Dissection FAG Cornea FA1 Dissection FA1 )he iddle coat FAF Choroid FAF Ciliary body FAF Iris FAF )he inner coatKretina FAH .

eticular for ation ::H Clinical anato y ::6 (4 The Cer6ellu5 Introduction ::A Dissection ::A 2&ternal features ::4 Connections ::9 Clinical anato y :HG ++/ .rteries # " /einsKvenous sinuses # " =erves F4F +lands F4: Palatine tonsil F4H Paranasal sinuses F4H 1rontal sinus F4H #a&illary sinus F4H .ltrasound scans F46 Appendi: " Cranial nerves F4A <orner*s syndro e #!" Phrenic nerve F9F Cervical !le&us F9F Parasy !athetic ganglia F9F C#i"i&oa"ato*i&a# Pro2#e*s (7+ Mu#ti%#e Choi&e .adiological anato y F4H . (3/ -ection = BRAIN =" /nroduction to the Brain Introduction F99 Cellular architecture F99 Classification of neurons :GG Clinical anato y :GG . Radiological and /5aging Anato52 =$# Surface land ar's FA9 Surface ar'ing F41 .=> -ur4ace Mar!ing.scending tracts :1J Clinical anato y :FG +:7 (0 Nu&#ei o.uestio"s (7. the Brai" a"$ Cere6rospinal F#ui$ Introduction :G: Dura ater :G: . The Brainste5 )he edulla oblongata :F1 Internal structure :F: Clinical anato y :FJ )he !ons :FJ Internal structure :FJ )he idbrain :FA Internal structure :F4 Develo! ent :F9 Clinical anato y ::G 3=M +:+ (+ The S%i"a# Cord Introduction :G9 Internal structure :G9 =uclei of s!inal cord :G9 @a inar organisation 3"" Dissection :1F Sensory rece!tors 3"# )racts of the s!inal cord :"3 Descending tracts :1H .efle& arc :GG Parts of the =ervous Syste :GG Parts of Brain :G1 (77 (( Meningies o. Cra"ia# Ner5es a"$ The Reticular For*atio" ++/ =uclei of cranial nerves ::1 2 bryology ::1 +eneral so atic efferent nuclei ::F S!ecial visceral efferent nuclei ::: +eneral visceral efferent nuclei ::: +eneral visceral afferent and s!ecial visceral afferent nuclei ::H +eneral so atic afferent nuclei ::H S!ecial so atic afferent nuclei ::H .rachnoid ater :G: Pia ater :G: Subarachnoid s!ace :GH Cisterns :GH Dissection :GJ Cerebros!inal fluid :GJ Clinical anato y :G6 (.

a&e A"ato*6) Ra$io#o!i&a# A"ato*6 a"$ E5o#utio" o.oof 3(" Dissection :HF 1loor :HF Clinical anato y :H: (3 The Cere2ru* Introduction :HJ Dissection :HJ 2&ternal features :H6 Cerebral sulci and gyri :HA #ain functional areas :J".adiological anato y :9H 2volution of head :9H A%%e"$i8 ( /entricles of brain :9A =uclear co !onents of cranial nerves :94 2fferent !ath"ays of cranial !art of !arasy !athetic nervous syste :99 C#i"i&oa"ato*i&a# Pro2#e*s Mu#ti%#e Choi&e .uestio"s +/0 345 +3+ '"# +7/ +77 .:/ Inde) 4$' .ssociation fibres :6F Co issural fibres :6F Cor!us callosu :6: Internal ca!sule :6: 1ibres in internal ca!sule :6J Blood su!!ly :6H Clinical anato y :6J (7 The Thir$ a"$ Latera# 1e"tri&#es) a"$ Li*2i& S6ste* )he third ventricle :6A )he lateral ventricle :69 @i bic syste :AG '4# +: So*e Neura# Path<a6s Pyra idal tract :AJ Path"ay of !ain and te !erature :A6 Path"ay of touch :A6 Path"ay of !ro!rioce!tive i !ulses :A6 /isual !ath"ay :AA . Hea$ Investigations in a neurological case :91 Surface anato y :9F . 3$# )he dience!halon :J" )he thala us :J: Connections and functions :JH. :JJ Clinical anato y :JH #etathala us :JH 2!ithala us :J6 <y!othala us :J6 Clinical anato y :J4 Subthala us 3$ Basal nuclei :J9 Cor!us striatu :J9 Dissection :J9 Connections :6G Clinical anato y 36" Ehite atter of cerebru :61 . the S%i"a# Cor$ a"$ Brai" S!inal cord :4: Cerebru :4: I !ortant arteries of the brain :4J /eins of the cerebru :4A Cerebellu . brainste :44 +( I"5esti!atio"s i" a Neuro#o!i&a# Case) Sur.uditory !ath"ay :A4 /estibular !ath"ay :4G 0lfactory !ath"ay :4G )aste !ath"ay :4" +9 B#oo$ Su%%#6 o.85i Hu*a" A"ato*6 (/ The Fourth 1e"tri&#e Co unications 3(" @ateral boundaries :H1 .

o o o .

retina. BbC the facial s'eleton constitutes the rest of the s'ull and includes the andible( Eith the e&ce!tion of the te !oro andibular 3oint "hich !er its free ove ents. a fe" !ri ary cartilaginous and only a !air of synovial 3oint the te !oro andibular 3oint( )his obile 3oint !er its us to s!ea'. for our o"n good and for the good of the society as "ell( THE S'ULL = INTRODUCTION Bo"es o. the t"o ter s s'ull and craniu . develo! by intra e branous ossification. olfactory ucous e brane.aria or brain box is the u!!er !art of the craniu "hich encloses the brain. the bones are interloc'ed and the sutures cannot o!en u!( In old age.C )he calvaria or brain case is co !osed of 4 bones( /aire+ -n. i(e( s'ull "ith andible.aire+ 1(Parietal 1(1rontal F()e !oral F(0cci!ital :(S!henoid H(2th oid BBC The fa*ial skeleton is co !osed of /aire+ 1H bones( 1(#andible F(/o er -n. s%ua ous te !oral and a !art of occi!ital bones. ost of the 3oints of the s'ull are i ovable and fibrous in ty!eD these are 'no"n as sutures( . and taste buds( )he "eight of the brain is not felt as it is floating in the cerebros!inal fluid( 0ur !ersonality. !o"er of s!eech. are often used synony ously( )he s'ull can be divided into t"o ain !arts8 BaC )he **+. fe" are !ri ary cartilaginous 3oints( During childhood the sutures can o!en u! if intracranial tension increases( In adults. seven cervical vertebrae and the hyoid. S-u## )he s'ull can be !laced in !ro!er orientation by considering any one of the t"o !lanes( . the sutures are gradually obliterated by fusion of the ad3oining bonesD fusion begins on the inner surface of the s'ull bet"een the ages of :G and HG yearsD and on the outer surface bet"een HG and JG years( A"ato*i&a# Positio" o. but also s!ecial senses li'e cochlear and vestibular a!!aratus. eat. !arietal. 3udge ent. the S-u## )he s'ull consists of the FF bones "hich are na ed as follo"s( B. concentration. develo!ed fro the second and third branchial arches( )he s'ull ca! for ed by frontal. and intellect are because of the brain that "e !ossess and its !ro!er use. drin' and laugh( S'ull lodges not only the brain.Osteolog2 o4 the Head and ec! Bones of head and nec' include so atic bones. being a %uic'er one-stage !rocess( )he base of the s'ull in contrast ossifies by intracartilaginous ossification "hich is a t"o-stage !rocess B e brane-cartilage-boneC( )he 3oints in the s'ull are ostly sutures. attention.aire+ 1(#a&illa F(Lygo atic :(=asal H(@acri al J(Palatine 6(Inferior nasal concha( S-u## Joi"ts Ter*s )he s'eleton of the head is called the skull) It consists of several bones that are 3oined together to for the craniu ( )he ter s'ull also includes the andible or lo"er 3a" "hich is a se!arate bone( <o"ever. the s'ull.

and it runs do"n"ards and for"ards across the cranial vault( F(1eto.ault of the s'ull is the arched roof for the do e of the s'ull( F()he bregma is the eeting !oint bet"een the coronal and sagittal sutures( In the foetal s'ull. -agittal suture 9e5poral lines %<arietal 6one %<arietal 4ora5en % La56doid suture ' Occipital 6one 1( )he s'ull can be studied as a "hole( )his is of greater !ractical i !ortance and utility than 'no"ing the details of individual bones( . iddle and !osterior cranial fossae( C( )he s'ull can also be studied as individual bones( E>TERIOR OF THE S'ULL NORMA 1ERTICALIS 0amb+oi+ suture) It lies !osteriorly bet"een the occi!ital and the t"o !arietal bones.!!er ost !art of the occi!ital bone !osteriorly( :(. called the anterior fontanelle. %: Norma verticalis. the S-u## Coronal suture Jrontal 6one Breg5a La56da Fig.eid*s base line is a hori7ontal line obtained by 3oining the infraorbital argin to the centre of the e&ternal acoustic eatus.ertex is the highest !oint on the sagittal suture( 1()he .( )he "hole s'ull can be studied fro the outside or e&ternally in different vie"s8 1(Su!erior vie" or norrna verticalis( F(Posterior vie" or nor a occi!italis( :(. "hich closes at eighteen onths of age B1ig( 1(FC( :()he la bda is the eeting !oint bet"een the sagittal and la bdoid sutures( In the foetal s'ull. this is the site of a e branous ga!. i(e( auricular !oint( F()he 1ran'furt hori7ontal !lane of orientation is obtained by 3oining the infraorbital argin to the u!!er argin of the e&ternal acoustic eatus( Metho$s o. Stu$6 o. this is the site of the !osterior fontanelle "hich closes at t"o to three onths of age( 1(.i* suture) )his is occasionally !resent in about : to 45 individuals( It lies in the edian !lane and se!arates the t"o halves of the frontal bone( -o5e other Named Features $hape Ehen vie"ed fro above the s'ull is usually oval in sha!e( It is "ider !osteriorly than anteriorly( )he sha!e ay be ore nearly circular( &ones $een in Norma 'erticalis I ) )he . %.!!er !art of the frontal bone anteriorly( F(.nterior vie" or nor a frontalis( H(@ateral vie" or nor a later alls( J(Inferior vie" or nor a basalis( B( )he "hole s'ull can be studied fro the inside or internally after re oving the roof of the calvaria or s'ull ca!8 1(Internal surface of the cranial vault( F(Internal surface of the cranial base "hich sho"s a natural subdivision into anterior.1(. !arietal bone on each side( $utures 1(Coronal AnterolateraN 4ontanelle suture) )his is !laced bet"een the frontal bone and the t"o !arietal bones( )he suture crosses the cranial vault fro side to side and runs do"n"ards and for"ards B1ig( 1(1C( F(Sagittal suture( It is !laced in the edian !lane bet"een the t"o !arietal bones( .

Anterior 4ontanelle <osterior . . 4ontanelle <osterolateral 4ontanelle Fi*+ #+&: Fontanelles of skull.

1()he .!!er !art of the s%ua ous !art of the occi!ital bone belo" B1ig( 1(:C( :(#astoid !art of the te !oral bone. it o!ens at the sig oid sulcus( )he astoid fora en trans its an e issary vein.arietal foramina and obelion have =or a occi!italis is conve& u!"ards and on each side. they fuse to for a single line( )raced !osteriorly. F(J to H c in front of the la bda( )he !arietalfora en trans its an e issary vein fro the veins of scal! into the su!erior sagittal sinus( :()he obelion is the !oint on the sagittal suture bet"een the t"o !arietal fora ina( H()he tem. arch bac'"ards and u!"ards. the su!erior line fades out over the !osterior !art of the !arietal bone.itomastoi+ suture lies bet"een the occi!ital bone and the astoid !art of the te !oral bone( F()he .ora*e" La*2$a La*2$oi$ suture Hi!hest "u&ha# #i"e Su%erior "u&ha# #i"e Parieta# 2o"e .oral lines begin at the 7ygo atic !rocess of the frontal bone.arietalforamen.erior nu*hal lines are curved bony ridges !assing laterally fro the !rotuberance( )hese also ar' the 3unction of the head and the nec'( )he area belo" the su!erior nuchal lines "ill be studied "ith the nor a basalis( H()he highest nu*hal lines are not al"ays !resent( )hey are curved bony ridges situated about 1 c above the su!erior nuchal lines( )hey begin fro the u!!er !art of the e&ternal occi!ital !rotuberance and are ore arched than the su!erior nuchal lines( J()he o**i.ital . but the inferior te !oral line continues do"n"ards and for"ards( NORMA OCCIPITALIS 1()he o**i.arietal tuber 2eminen*e3 is the area of a&i u conve&ity of the !arietal bone( )his is a co on site of fracture of the s'ull( F()he . and the eningeal branch of the occi!ital artery( Parieta# . su!erior and inferior( )raced anteriorly. the coronal suture and the !arietal bone( 0ver the !arietal bone there are t"o lines.oint is a edian !oint a little above the inion( It is the !oint farthest fro the glabella( 6()he mastoi+ foramen is located on the astoid !art of the te !oral bone at or near the occi!ito astoid suture( Internally. one on each side. and cross the frontal bone.ital . and is flattened belo"( &ones $een 1(Posterior !arts of the !arietal bones. .rotuberan*e is a edian !ro inence in the lo"er !art of this nor a( It ar's the 3unction of the head and the nec'( )he ost !ro inent !oint on this !rotuberance is called the inion) :()he su. on each side( $utures 1( )he lamb+oi+ suture lies bet"een the occi!ital bone and the t"o !arietal bones( Sutural bones are co on along this suture( Sa!itta# suture been e&a ined in the nor a verticalis( F()he external o**i.arietomastoi+ suture lies bet"een the !arietal bone and the astoid !art of the te !oral bone( :()he !osterior !art of the sagittal suture is also seen( (ther Features 1(0amb+a. above( F(. !ierces the !arietal bone near its u!!er border.

): Norma occipitalis.@ Parieto*astoi$ suture A.S?ua*ous %art o. . Mastoi$ %ro&ess B O&&i%ito*astoi$ suture CDE' Mastoi$ . o&&i%ita# 2o"e .ora*e" ' E8ter"a# o&&i%ita# &rest @ . %.erior "u&ha# #i"e E8ter"a# o&&i%ita# %rotu2era"&e Fig. I".

curved elevation situated 3ust above the edial !art of each orbit( It overlies the frontal sinus and is better ar'ed in ales than in fe ales( F()he glabe-a is a edian elevation connecting the t"o su!erciliary arches( Belo" the glabella the s'ull recedes to the frontonasal suture at the root of the nose( :()he noston is a edian !oint at the root of the nose "here the internasal suture eets "ith the frontonasal suture( H()he frontal tuber or eminen*e is a lo" rounded elevation above the su!erciliary arch. and the lo"er !art gives attach ent to the u!!er end of the ligamentum nu*hae Bsee 1ig( 1(1JC( F()he edial one-third of the su!erior nuchal line gives origin to the tra!e7ius.lenius *a. one on each side( Orbital Openin*s frontal bone for s the forehead( Its u!!er !art is s ooth and conve&.e4ius.arietal bone is occasionally !resent( It is a large triangular bone located at the a!e& of the s%ua ous occi!ital( )his is not a sutural or accessory bone but re!resents the e branous !art of the occi!ital bone "hich has failed to fuse "ith the rest of the bone( Attachments 1()he the bony !ro inence of the su!erolateral !art of the chee's( F()he man+ible for s the lo"er 3a"( )he =or a 1rontalis "ill be studied under the follo"ing heads8 BaC 1rontal regionD BbC orbital o!eningD BcC anterior !irifor .4 Hea$ a"$ Ne&- A( )he inter.sha!ed bony a!erture of the noseD and BdC lo"er !art of the face( Fro"ta# Re!io" 1()he 4ygomati* bones for u!!er !art of the e&ternal occi!ital !rotuberance gives origin to the tra.oneurosis edially.italis or occi!ital belly of occi!itofrontalis uscle laterally B1ig( 1(HC( NORMA FRONTALIS )he nor a frontalis is roughly oval in outline. but the lo"er !art is irregular and is interru!ted by the orbits and by the anterior bony a!erture of the nose B1ig( 1(JC( F()he right and left maxillae for the u!!er 3a"( :()he right and left nasal bones for the bridge of the nose( 1()he 2ach orbital o!ening is %uadrangular in sha!e and is bounded by the follo"ing four argins( 1( )he su.itis belo"( :()he highest nuchal lines !rovide attach ent to the e.er*iliary ar*h is a rounded. and give origin to the o**i. it !resents the su!raorbital notch or fora en( Fro"ta# 2e##6 .i*ranial a.t the 3unction of its lateral t"o-thirds and its edial one-third. and the lateral !art !rovides insertion to the stemo*lei+omastoi+ above and to the s. being "ider above than belo"( &ones )he frontal region !resents the follo"ing features8 1()he su.raorbital margin is for ed by the frontal bone( .

O&&i%ita# 2e##6 .E%i&ra"ia# a%o"eurosis Fi*+ #+4: Attachments of the occipitofrontalis muscle.

"ith the o!!osite bone at the internasal suture.osteriorly. asal 6one %?H asal aperture O Anterior nasal spine O)/ %Q2go5atic 6one %/n4raor6ital 4ora5en Ma:illa Mandi6le Mental 4ora5en -25ph2sis 5enti %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% *%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Me"ta# protru6erance Fig.+: Norma frontalis.bove8 by the lo"er border of the nasal bones( Belo"8 by the nasal notch of the body of the a&illa on each side( Features =ote the follo"ing( 1( 6rti*ulations of the nasal bone7 BaC 6nteriorly.eriorly. being "ide belo" and narro" above( &oundaries . BcC su.. and BdC inferiorly.. BbC . %. and the a&illa edially( F()he me+ial orbital margin is ill-defined( It is for ed by the frontal bone above. and by the lacri al crest of the frontal !rocess of the a&illa belo"( :()he lateral orbital margin is for ed ostly by the frontal !rocess of 7ygo atic bone but is co !leted above by the 7ygo atic !rocess of frontal bone( 5ronto4ygomati* suture lies at their union( Anterior Bon2 Aperture o4 the ose )he nasal bone is one of the most *ommonly fra*ture+ bones of the fa*e) )he anterior bony a!erture is !ear-sha!ed. the u!!er nasal cartilage is attached to it( .Jrontal 6one % asion P -upraor6ital notch 3O 9e5poral line L P "O JrontoL2go5atic suture . "ith the frontal bone at the frontonasal suture. "ith the frontal !rocess of the a&illa. 1()he infraorbital margin is for ed by the 7ygo atic bone laterally.

F( )he anterior nasal s.ine is a shar! !ro3ection in the edian !lane in the lo"er boundary of the !irifor a!erture B1ig( 1(HC(
Lo1er <art o4 the Jace
/a illa

#a&illa contributes a large share in the for ation of the facial s'eleton( )he anterior surface of the body of the a&illa !resents BaC the nasal not*h ediallyD BbC the anterior nasal s.ine8 BcC the infraorbitalforamen, 1 c belo" the infraorbital arginD BdC the in*isi,e fossa above the incisor teethD and BeC the *aninefossa lateral to the canine e inence Bsee 1ig( 1(F9C( In addition, three out of four !rocesses of the a&illa are also seen in this nor a( BaC )he frontal .ro*ess of the maxilla is directed u!"ards( It articulates anteriorly "ith the nasal bone, !osteriorly "ith the lacri al bone, and su!eriorly "ith the frontal bone, BbC )he 4ygomati* .ro*ess of the maxilla is short but stout and articulates "ith the 7ygo atic bone, BcC )he al,eolar .ro*ess of the maxilla bears soc'ets for the u!!er teeth(
0ygomatic &one

Lygo atic bone for s the !ro inence of the chee'( )he 4ygomati*ofa*ial foramen is seen on its surface(
/andible

#andible for s the lo"er 3a"( )he u..er bor+er or al,eolar ar*h lodges the lo"er teeth( )he lo9er bor+er

and

or base is rounded( )he iddle !oint of the base is called the mental .oint or gnathion) )he anterior surfa*e of the body of the andible !resents8 BaC )he sy !hysis menti, the mental .rotuberan*e and the mental tuber*les anteriorlyD BbC the mental foramen belo" the interval bet"een the t"o !re olar teeth, trans itting the mental ner,e an+ ,essels8 and BcC the obli:ue line "hich runs u!"ards and bac'"ards fro the ental tubercle to the anterior border of the ra us of the andible( $utures of the Norma Frontalis 1(Internasal F(1rontonasal :(=aso a&illary H(@acri o a&illary J(1ronto a&illary 6(Inter a&illary A(Lygo atico a&illary 4(Lygo aticofrontal Attachments
1()he

edial !art of the su!erciliary arch gives origin to the *orrugator su.er*ilii uscle B1ig( F(6C( F()he .ro*erus uscle arises fro the nasal bone near the edian !lane B1ig( 1(6C( :()he orbital !art of the orbi*ularis o*uli arises fro the frontal !rocess of the a&illa and fro the nasal !art of the frontal bone B1ig( F(6C(

frontal !rocess of the a&illa bet"een the frontal and a&illary origins of the orbicularis oculi( F()he le,ator labii su.erior alae:ue nasi arises fro the frontal !rocess of the a&illa in front of the orbicularis oculi B1ig( F(4C( :()he le,ator labii su.erioris arises fro the a&illa bet"een the infraorbital argin and the infraorbital fora en B1ig( F(6C( H()he le,ator anguli oris arises fro the canine fossa( J()he nasalis and the +e.ressor se.ti arise fro the surface of the a&illa bordering the nasal notch( 6()he in*isi,e uscle arises fro an area 3ust belo" the de!ressor se!ti B1ig( 1(AC( It for s !art of orbicularis oris( 1G( )he 4ygomati*us ma;or an+ minor arise fro the surface of the 7ygo atic bone B1ig( F(AC( )he 4ygomati*us minor uscle arises belo" the 7ygo aticofacial fora en( )he 4ygomati*us ma;or arises lateral to the inor uscle( 11( Buccinator arises fro a&illa and andible o!!osite olar teeth and fro .terygoman+ibular ra.he B1ig( 1(AC( It also for s !art of orbicularis oris(
Fi*+ #+(: Fibres of orbicularis oris.

1()he me+ial.al.ebral ligament is attached to the

<rocerus

/ncisi7e slips

Buccinator

$tructures Passing through Foramina
1()he su.raorbital not*h or foramen trans its the

su.raorbital ner,es an+ ,essels B1ig( F(JC( F()he external nasal ner,e e erges bet"een the nasal bone and the u!!er nasal cartilage( :()he infraorbital foramen trans its the infraorbital ner,e an+ ,essels B1ig( F(19C( H()he 4ygomati*ofa*ial foramen trans its the nerve of the sa e na e, a branch of maxillary ner,e) J()he mentalforamen on the andible trans its the ental nerve and vessels(
Fi*+ #+ : Procerus.

Osteolog2 NORMA LATERALIS

#

&ones

1( 1rontalD F( !arietalD :( occi!italD H( te !oralD J( s!henoidD 6( 7ygo aticD A( andibleD 4( a&illaD 9( nasal B1ig( 1(4C(
Features

te !oral lines have been studied in the nor a verticalis( )he inferior te !oral line, in its !osterior !art, turns do"n"ards and for"ards and beco es continuous "ith the su.ramastoi+ *rest on the s%ua ous te !oral bone near its 3unction "ith the astoid te !oral( )his crest is continuous anteriorly "ith the !osterior root of the 7ygo a( F()he 4ygomati* ar*h is a hori7ontal bar on the side of the head, in front of the ear, a little above the tragus( It is for ed by the te !oral !rocess of the 7ygo atic bone in anterior one-third and the 7ygo atic !rocess of the te !oral bone in !osterior t"o-thirds( )he 4ygomati*o&tetn.oral suture crosses the arch obli%uely do"n"ards and bac'"ards( )he arch is se!arated fro the side of the s'ull by a ga! "hich is dee!er in front than behind( Its lateral surfa*e is subcutaneous( )he anterior end of the u!!er border is called the ;ugal .oint) )he !osterior end of the 7ygo a is attached to the s%ua ous te !oral bone by anterior and .osterior roots) )he arti*ular tuber*le of the root of the 7ygo a lies on its lo"er border, at the 3unction of the anterior and

1()he

!osterior roots( )he anterior root !asses edially in front of the arti*ular fossa) )he !osterior root !asses bac'"ards along the lateral argin of the andibular fossa, then above the e&ternal acoustic eatus to beco e continuous "ith the su!ra astoid crest( )"o !ro3ections are visible in relation to these roots( 0ne is articular tubercle or tubercle of the root of 7ygo a at its lo"er border( )he other is visible 3ust behind the andibular or articular fossa and is 'no"n as !ostglenoid tubercle( :( )he external a*ousti* meatus o!ens 3ust belo" the !osterior !art of the !osterior root of the 7ygo a( Its anterior and inferior argins and the lo"er !art of the !osterior argin are for ed by the ty !anic !lateD and the !osterosu!erior argin is for ed by the s%ua ous te !oral bone( )he argins are roughened for the attach ent of the auricular cartilage( )he su.rameatal triangle is a s all de!ression !osterosu!erior to the eatus( It is boun+e+ above by the su!ra astoid crestD in front by the !osterosu!erior argin of the e&ternal eatusD and behind by a vertical tangent to the !osterior argin of the eatus( )he su.rameatal s.ine ay be !resent on the anteroinferior argin of the triangle( )he triangle for s the lateral "all of the ty !anic or astoid antru ( H( )he mastoi+ .art of the tem.oral bone lies 3ust behind the e&ternal acoustic eatus( It is continuous anterosu!eriorly "ith the s%ua ous te !oral bone( . !artially obliterated s:uamomastoi+ suture ay be

Coronal suture Jrontal 6one <terion%%%%%%%%%%% Q2go5atic 6one P Ma:illa ,

-8ua5ous te5poral P PP % <arietal 6one PP P3 , 9e5poral lines % Q2go5atic arch )'

OC%%%%%%%%%%La56doid suture asal 6one %3
:

E:ternal occipital protu6erance
:

-uperior nuchal line

-upra5astoid crest E:ternal acoustic 5eatus Mastoid process -t2loid process Ra5us and + 6od2 o4 5andi6le

Fig. %.1: Norma lateralis.

visible 3ust in front of and !arallel to the roughened area for uscular insertions( )he astoid te !oral bone articulates !osterosu!eriorly "ith the !osteroinferior !art of the !arietal bone at the hori7ontal !arieto ostoid sutureD and !osteriorly "ith the s%ua ous occi!ital bone at the o**i.itomastoi+ suture) )hese t"o sutures eet at the lateral end of the la bdoid suture( )he asterion is the !oint "here the !arieto astoid, occi!ito astoid and la bdoid sutures eet( In infants the asterion is the site of the .osterolateral or mastoi+ fontanelle, "hich closes at the end of the first year B1igs 1(F, 1(:C( )he mastoi+ .ro*ess is a ni!!le-li'e large !ro3ection fro the lo"er !art of the astoid te !oral bone, !osteroinferior to the e&ternal acoustic rneatus( It a!!ears during the second year of life( )he tynn.anomastoi+ fissure is !laced on the anterior as!ect of the base of the astoid !rocess B1ig( 1(:C( )he astoid foramen lies at or near the occi!itoastoid suture( J( )he styloi+ .ro*ess is a needle li'e thin, long !ro3ection fro the nor a basalis situated antero edial to the astoid !rocess( It is directed do"n"ards, for"ards and slightly edially( Its base is !artly ensheathed by the ty !anic !late( )he a!e& or ti! is usually hidden fro vie" by the !osterior border of the ra us of the andible B1ig( 1(1HC( B+( )he tem.oral fossa) Boun+aries7 BaC 6bo,e, by thete !oral line of the frontal bone, BbC Belo9, by the u!!er border of the 7ygo atic arch laterallyD and by the infrate !oral crest of the greater "ing of the
Posterior branch

s!henoid bone edially( )hrough the ga! dee! to the 7ygo atic arch, the te !oral fossa co unicates "ith the infrate !oral fossa, BcC )he anterior 9all is for ed, by the 7ygo atic bone and by !arts of the frontal and s!henoid bones( )his "all se!arates the fossa fro the orbit B1igs 1G(1, 1G(FC( 5loor7 )he anterior !art of the floor is crossed by an <-sha!ed suture "here four bonesD frontal, !arietal, s!henoid and te !oral ad3oin each otherD )his area is ter ed the .terion) It lies H c above the id!oint of the 7ygo atic arch or H c above the 7ygo a and F(J c behind the fronto7ygo atic suture( Dee! to the !terion there lie the mi++le meningeal ,ein, the anterior +i,ision of the mi++le meningeal artery, and the stem of the lateral sul*us of the brainCB1ig( 1(9C( 0n the te !oral surface of the 7ygo atic bone for ing the anterior "all of the fossa there is the 4ygomati*o&tem.oral foramen) %) Infratem.oral fossa) Boun+aries7 BaC )he roof is for ed edially by the infrate !oral surface of the greater "ing of the s!henoid and by a s all !art of the s%ua ous te !oral bone( @aterally, the roof is inco !lete "here the infrate !oral fossa co unicates "ith the te !oral fossa through the ga! dee! to the 7ygo atic arch( )he roof for ed by greater "ing is !ierced by the foramen o,ale and by the foramen s.inosum) BbC )he Jloor is o!en, BcC )he me+ial 9all is for ed by the lateral !terygoid !late and the !yra idal !rocess of the !alatine bone, BdC )he lateral 9all is for ed by the ra us of the

Anterior 6ranch

<terion

Jacial arter2

Middle 5eningeal arter2 Fi*+ #+": $urface marking of facial artery and middle meningeal artery with its anterior and posterior branches.

andible, BeC )he anterior 9att is for ed by the infrate !oral or !osterior surface of the a&illa and by the edial surface of the 7ygo atic bone( )he anterior and edial "alls are se!arated in their u!!er !arts by the !terygo a&illary fissure through "hich the infrate !oral fossa co unicates "ith the !terygo!alatine fossa( )he u!!er end of the !terygo a&illary fissure is continuous "ith the anterior !art of the inferior orbital fissure through "hich the infrate !oral fossa co unicates "ith the orbit, BfC )he !osterior 9att is o!en B1ig( 1J(11C( )he contents of the fossa are described in Cha!ter 1G( 4( /terygo.alatine fossa7 It is described in Cha!ter 1J(
Attachments
1()he tem.oral

1()he

edial surface and lo"er border of the 7ygo atic arch give origin to the masseter B1ig( 1(1GC( F()he lateral ligament of the tem.oroman+ibular ;oint is attached to the tubercle of the root of the 7ygo a B1ig( 1G(9C( :()he sterno*lei+omastoi+, s.lentus *a.itis an+ longissimus *a.itis are inserted in that order fro before bac'"ards on the !osterior !art of the lateral surface of the astoid !rocess B1ig( 1(1JC( H()he ga. bet"een the 7ygo atic arch and the side of the s'ull trans its8 BaC )he tendon of the te !oralis uscleD BbC the dee! te !oral vesselsD and BcC the dee! te !oral nerves(
$tructures Passing 2hrough Foramina
1()he

fas*ia is attached to the su!erior te !oral line and to the area bet"een the t"o te !oral lines( Inferiorly, it is attached to the outer and inner li!s of the u!!er border of the 7ygo atic arch( F()he tem.oratts mus*le arises fro the "hole of the te !oral fossa, e&ce!t the !art for ed by the 7ygo atic bone( Beneath the uscle there lie the +ee. tem.oral ,essels and ner,es) )he mi++le tem.oral ,essels !roduce vascular ar'ings on the te !oral bone 3ust above the e&ternal acoustic eatus B1ig( 1(1GC(

tym.anomastoi+ fissure on the anterior as!ect of the base of the astoid !rocess trans its the auricular bran*h of the ,agus ner,e) F()he astoid fora en trans its8 BaC .n e issary ,ein connecting the sigmoi+ sinus "ith the .osterior auri*ular ,ein8 and BbC a eningeal branch of the occi!ital artery B)able 1(1C( :()he 4ygomati*otem.oral foramen trans its the nerve of the sa e na e and a inute artery(
NORMA BASALIS

1or convenience of study, the nor a basalis is divided arbitrarily into anterior, iddle and !osterior

Te*%ora#is

Fig. %.%3: 2emporalis and masseter muscles.

9(

Ne&Ta2#e 9.9= The e*issar6 5ei"s o, the s-u##

Name "3<arietal e5issar2 7ein =3Mastoid e5issar2 7ein 33E5issar2 7ein ?3Cond2lar e5issar2 7ein '3=%3 e5issar2 7eins A3E5issar2 7ein $3E5issar2 7ein

Foramen of skull <arietal 4ora5en Mastoid 4ora5en H2poglossal canal <osterior cond2lar 4ora5en Jora5en laceru5 Jora5en o7ale Jora5en caecu5

'eins outside skull Veins o4 scalp Veins o4 scalp /nternal Fugular 7ein -u6occipital 7enous ple:us <har2ngeal 7enous ple:us <ter2goid 7enous ple:us Veins o4 roo4 o4 nose

'enous sinus -uperior sagittal 9rans7erse sinus -ig5oid sinus -ig5oid sinus Ca7ernous sinus Ca7ernous sinus -uperior sagittal sinus

!arts( )he anterior .art is for ed by the hard !alate and the alveolar arches( )he mi++le an+ .osterior .arts are se!arated by an i aginary transverse line !assing through the anterior argin of the fora en agnu B1ig( 1(11C(
A"terior Part o, Nor*a Basa#is

4ard Palate
1(5ormation7

Alveolar Arch

.lveolar arch bears soc'ets for the roots of the u!!er teeth(

BaC .nterior t"o-thirds, by the !alatine !rocesses of the a&illae and BbC !osterior one-third by the hori7ontal !lates of the !alatine bones( F(<utures7 )he !alate is crossed by a crucifor suture ade u! of inter a&illary, inter!alatine and !alato a&illary sutures( :(Dome7 BaC It is arched in all directions, and BbC sho"s !its for the !alatine glands(

Bo"6 %a#ate

Fora*e" *a!"u*

E8ter"a# o&&i%ita# %rotu2era"&e

O&&i%ita# &o"$6#e /n4erior nuchal line

Basio&&i%ut

Fig. %.%%: Norma basalis.

Su%erior "u&ha# #i"e

surface of the s!henoidal !rocess of the !alatine bone( )he canal o!ens anteriorly into the !osterior "all of the !terygo!alatine fossa B1ig( 1J(11C( 1()he ,omero,aginal *anal )he lateral border of each ala of the vo er co es into relationshi! "ith the vaginal !rocess of the edial !terygoid !late, and ay overla! it fro above to enclose the vo erovaginal canal( F()he broad bar of bone is ar'ed in the edian !lane by the .haryngeal tuber*le a little in front of the fora en agnu (
5ateral Area

boneM!terygoid !rocess and greater "ing( .lso seen are three !arts of the te !oral boneD !etrous te !oral, ty !anic !late and s%ua ous te !oral( F()he .terygoi+ .ro*ess !ro3ects do"n"ards fro the 3unction of the greater "ing and the body of the s!henoid behind the third olar tooth( Inferiorly it divides into the me+ial an+ lateral .terygoi+ .lates "hich are fused together anteriorly, but are se!arated !osteriorly by the /sha!ed .terygoi+fossa) )he fused anterior borders of the t"o !lates articulate edially "ith the !er!endicular !late of the !alatine bone, and are se!arated laterally fro the !osterior surface of the body of the a&illa by the !terygoa&illary fissure( )he me+ial .terygoi+ .late is directed bac'"ards( It has edial and lateral surfaces and a free !osterior border( )he u!!er end of this border divides to
Jora5en spinosu5 /n4rate5poral crest Jora5en o7ale -pine o4 sphenoid P Articular tu6ercle %% Mandi6ular 4ossa O 925panic plate % -t2loid process

1()he lateral area sho"s t"o !arts of the s!henoid

enclose a triangular de!ression called the s*a.hoi+ fossa) #edial to this fossa there is a s all .terygoi+ tuber*le "hich !ro3ects into the foramen la*erum) It hides fro vie" the !osterior o!ening of the !terygoid canal( )he lo"er end of the !osterior border is !rolonged do"n"ards and laterally to for the .terygoi+ hamulus B1ig( 1(1:C( )he lateral .terygoi+ .late is directed bac'"ards and laterally( It has edial and lateral surfaces and a free !osterior border( )he lateral surface for s the edial "all of the infrate !oral fossa( )he lateral and edial surfaces give origin to uscles( )he !osterior border so eti es has a !ro3ection called the .terygos.inous .ro*ess "hich !ro3ects to"ards the s!ine of the s!henoid B1ig( 1(1:C( :( )he infratem.oral surfa*e of the greater 9ing of the s.henoi+ is !entagonal8 BaC Its anterior margin for s the !osterior border of the inferior orbital fissureD BbC its anterolateral margin for s the infrate !oral crestD BcC its .osterolateral margin articulates "ith the s%ua ous te !oralD BdC its .osterome+ial margin articulates "ith !etrous te !oralD and BeC anterome+ially it is continuous "ith the !terygoid !rocess and "ith the body of the s!henoid bone( )he !osterior ost !oint bet"een the !osterolateral and !ostero edial argins !ro3ects do"n"ards to for the s.ine of the s!henoid B1ig( 1(1HC( .long the !ostero edial argin, the surface is !ierced by the follo"ing fora ina8 BaC )he foramen o,ale is large and oval in sha!e( It is situated !osterolateral to the u!!er end of the !osterior

PPPPPPPP-caphoid 4ossa PPPPPP Jora5en laceru5

Carotid canal <har2ngeal tu6ercle %%%%%%%<etrous te5poral % % H2poglossal canal ', 0lossophar2ngeal notch %%%%% Occipital cond2le Jora5en 5agnu5

-t2lo5astoid 4ora5en PP Mastoid process O Mastoid notch % Mastoid canaliculus ))' Cugular 4ossa R

,,%Cond2lar canal S R Cugular 4ora5en 925panic canaliculus Cugular process o4 occipital 6one Fig. %.%6: /iddle part of norma basalis.

Osteo#o!6 90

border of the lateral !terygoid !late, BbC The foramen s.inosumis s all and circular in sha!e( It is situated !osterolateral to the fora en ovale, and is li ited !osterolaterally by the s!ine of the s!henoid B1ig( 1(1HC( BcC So eti es there is the emissary s.henoi+al foramen or foramen of=esalius) It is situated bet"een the fora en ovale and the sca!hoid fossa( Internally, it o!ens bet"een the fora en ovale and the fora en rotundu ( BdC .t ti es there is a *anali*ulus innominatus situated bet"een the fora en ovale and the fora en s!inosu ( )he s.ine of the s!henoid ay be shar!ly !ointed or blunt( )he sul*us tubae is the groove bet"een the !ostero edial argin of the greater "ing of the s!henoid and the !etrous te !oral bone( It lodges the *artilaginous .art of the au+itory tube) Posteriorly, the groove leads to the bony !art of the auditory tube "hich lies "ithin the !etrous te !oral bone B1igs 1H(14, 1H(19, 14(1GC( H( )he inferior surface of the !etrous !art of the te !oral bone is triangular in sha!e "ith its a!e& directed for"ards and edially( It lies bet"een the greater "ing of the s!henoid and the basiocci!ut( Its a.ex is !erforated by the u!!er end of the carotid canal, and is se!arated fro the s!henoid by the fora en laceru ( )he inferior surfa*e is !erforated by the lo"er end of the *aroti+ *anal !osteriorly( )he *aroti+ *anal runs for"ards and edially "ithin the !etrous te !oral bone( )he foramen la*erum is a short, "ide canal, 1 c long( Its lo"er end is bounded !osterolaterally by the a!e& of the !etrous te !oral, edially by the basiocci!ut and the body of the s!henoid, and anteriorly by the root of the !terygoid !rocess and the greater "ing of the s!henoid bone( . !art of the !etrous te !oral bone, called the tegmen tym.ani is !resent in the iddle cranial fossa( It has a do"nturned edge "hich is seen in the s:uamotym.ani* fissure and divides it into the .etrotym.ani* and .etros:uamous fissures( $) The tym.ani* .art of the tem.oral bone also *alle+ as the tym.ani* .late is a triangular curved !late "hich lies in the angle bet"een the !etrous and s%ua ous !arts( Its a!e& is directed edially and lies close to the s!ine of the s!henoid( )he base or bor+er is curved, free and roughened( Its anterior surfa*e for s the !osterior "all of the andibular fossa( )he .osterior surfa*e is concave and for s the anterior "all, floor, and lo"er !art of the !osterior "all of the bony e&ternal acoustic eatus( Its u..er bor+er bounds the !etroty !anic fissure( )he lo9er bor+er is shar! and free( 1e+ially it !asses along the anterolateral argin of the lo"er end of the carotid canalD and laterally it for s the anterolateral

!art of the sheath of the styloi+ .ro*ess) Internally, the ty !anic !late is fused to the !etrous te !oral bone N1ig( 1(1HC( 6( The s:uamous .art of the tem.oral bone for s8 BaC )he anterior !art of the andibular articular fossa "hich articulates "ith the head of the andible to for the te !oro andibular 3ointD BbC the articular tubercle "hich is continuous "ith the anterior root of the 7ygo aD and BcC a s all !osterolateral !art of the roof of the infrate !oral fossa B1ig( 1G(4C(
Posterior Part o, Nor*a Basa#is

/edian Area edian area sho"s fro before bac'"ards8 BaC )he fora en agnu , BbC the e&ternal occi!ital crestD and BcC the e&ternal occi!ital !rotuberance( F(The foramen magnum is the largest fora en of the s'ull( It o!ens u!"ards into the !osterior cranial fossa, and do"n"ards into the vertebral canal( It is oval in sha!e, being "ider behind than in front "here it is overla!!ed on each side by the occi!ital condyles B1ig( 1(1HC( :()he external o**i.ital crestbegins at the !osterior argin of the fora en agnu and ends !osteriorly and above at the e&ternal occi!ital !rotuberance( H()he external o**i.ital .rotuberan*e is a !ro3ection located at the !osterior end of the crest( It is easily felt in the living, in the idline, at the !oint "here the bac' of the nec' beco es continuous "ith the scal!( )he su!erior nuchal lines begin at the e&ternal occi!ital !rotuberance and the inferior nuchal lines at the iddle of the crest( Both of the curve laterally and bac'"ards and then laterally and for"ards( 5ateral Area
1()he lateral area sho"s8 BaC )he condylar !art of 1()he

the occi!ital boneD BbC the s%ua ous !art of the occi!ital boneD BcC the 3ugular fora en bet"een the occi!ital and !etrous te !oral bonesD BdC the styloid !rocess of the te !oral boneD and BeC the astoid !art of the te !oral bone( F()he *on+ylar or lateral .art of the o**i.ital bone !resents the follo"ing, BaC )he o**i.ital *on+yles are oval in sha!e and are situated on each side of the anterior !art of the fora en agnu ( )heir long a&is is directed for"ards and edially( )hey articulate "ith the su!erior articular facets of the atlas vertebra to for the atlanto-occi!ital 3oints, BbC )he hy.oglossalor anterior *on+y lar *anal !ierces the bone anterosu!erior to the occi!ital condyle, and is

directed laterally and slightly for"ards( BcC )he *on+ylar

at the anterior end of the astoid notch( 6( )he mastoi+ .haryngobasilar fas*ia is attached to the "hole length of its !osterior border B1ig( 1H(1AC( 1()he !osterior border of the hard !alate !rovides Musculus u7ulae Medial pter2goid Masseter 9ensor 7eli palatini Longus capitis Rectus capitis lateralis Rectus capitis posterior 5aFor Rectus capitis posterior 5inor Lateral pter2goid .ital bone) )his is ar'ed by the su!erior and inferior nuchal lines entioned above( F()he .ro*ess is a large conical !ro3ection located !osterolateral to the stylo astoid fora en( It is directed do"n"ards and for"ards( It for s the lateral "all of the mastoi+ not*h B1ig( 1(:C( Attachments on E terior of $kull attach ent to the !alatine a!oneurosis( )he !osterior nasal s!ine gives origin to the usculus uvulae B1ig( 1(1JC( F()he !alatine crest !rovides attach ent to a !art of the tendon of the tensor veli !alatini uscle( :()he attach ents on the inferior surface of the basiocci!ital are as follo"s8 )he .at of o**i.ro*ess of the o**i.t the !osterior end of the fora en.ani* canaliculus o!ens on or near the thin edge of bone bet"een the 3ugular fossa and the lo"er end of the carotid canal( J( )he sty lai+ .haryngeal tonsil) )he longus *a.ugular fossa "hich lodges the su!erior bulb of the internal 3ugular vein( )he fossa is larger on the right side than on the left( )he lateral "all of the 3ugular fossa is !ierced by a inute canal.erior *onstri*tor uscle of the !haryn& B1ig( 1H(1AC( )he area in front of the tubercle for s the roof of the naso.t the a!e& of the notch there is an o!ening that leads into the *o*hlear *anali*ulus B1ig( 1(1HC( )he tym.itis is inserted lateral to the !haryngeal tubercle( )he re*tus *a.ro*ess "ill be described in Cha!ter 1F( )he stylomastoi+ foramen is situated !osterior to the root of the styloid !rocess.osterior *on+ylar *anal is occasionally !resent in the floor of a condylar fossa !resent behind the occi!ital condyle( Su!eriorly it o!ens into the sig oid sulcus( BdC )he .ugular . its anterior "all B!etrous te !oralC is hollo"ed out to for the .or .haryngeal tuber*le gives attach ent to the ra!he "hich !rovides insertion to the u!!er fibres of the su. "ith its long a&is directed for"ards and edially( It is !laced at the !osterior end of the !etroocci!ital suture B1ig( 1(1HC( . the mastoi+ *anali*ulus) =ear the edial end of the 3ugular fora en there is the 3ugular not*h) .harynx and su!!orts the .ital bone lies lateral to the occi!ital condyle and for s the !osterior boundary of the 3 ugular fora en B1ig( 1(1HC( 1(<:uamous .ugular foramen is large and elongated.itis anterior is inserted a little !osterior and edial to the hy!oglossal canal B1ig( 1(1JC( H( )he attach ents on the edial !terygoid !late are as follo"s8 BaC )he .

$'@ /uscles attached to the base of skull. %.Le7ator 7eli palatini T Rectus capitis anterior 3R Digastric Gposterior 6ell2H -plenius capitis %Longissi5us capitis -ternocleido5astoid O6li8uus capitis 9rapeLius Occipitalis superior -e5ispinalis capitis Fig. .

and is crossed by the dee! te !oral and asseteric nerves( F()he s.alatine uessels.he is attached to the ti! of the !terygoid ha ulus( J( )he attach ents on the lateral !terygoid !late are as follo"s8 BaC Its lateral surface gives origin to the lo9er hea+ of the lateral . and laterally to the rectus ca!itis .@2C( . both of "hich run for"ards in the groove that !asses for"ards fro the fora en B1ig( 1J(1FC( :()he lesser .terygo. the lesser .osterior minor. su!erficial head of this uscles arises fro the a&illary tuberosity and the ad3oining !art of the !yra idal !rocess of GcH the !alatine bone( )he !terygos!inous !rocess gives attach ent to the liga ent of the sa e na e( 1()he infrate !oral surface of the greater "ing of the s!henoid gives origin to the u.haryngeal bran*h fro the .oral ner.e and au+itory tube) Its ti! !rovides attach ent to the s!heno andibular ligament) Its anterior as. 1:(HC( 1()he liga entu nuchae is attached to the e&ternal occi!ital !rotuberance and crest( F()he rectus ca!itis lateralis is inserted into the inferior surface of the 3ugular !rocess of the occi!ital bone B1ig( 1(1JC( :()he follo"ing are attached to the s%ua ous !art of the occi!ital bone( )he area bet"een the su!erior and inferior nuchal lines !rovides insertion edially to the se is!inalis ca!itis.er hea+ of the lateral .%7: /asseter and lateral pterygoid muscles.or B1ig( H(JC( H()he astoid notch gives origin to the .ale trans its the andibular ner.e.ine of the s!henoid is relate+ laterally to the auri*ulotem.etrosal ner.terygoi+ mus*le B1ig( BbC 1(16C( Its edial surface gives origin to the +ee.e.es) H()he !alatinouaginal canal trans its8 BaC .e*t gives origin to the ost !osterior fibres of the tensor . an e issary uein connecting the cavernous sinus "ith the !terygoid !le&us of veins.e. ..ani ner. the a**essory meningeal artery.itis . 1J(4C( F()he greater .osterior ma.osterior belly of the +igastri* mus*le B1ig( 11(1C( $tructures Passing 2hrough Foramina 1(2ach incisiue foramen trans its8 Latera# %ter6!oi$ F Masseter *us&#e Fig.e fro !terygo !alatine ganglion and vessels( 6()he foramen o.alatini mus*le) 1()he inferior surface of the !etrous te !oral bone gives origin to the leuatar .eli .osterior .alatineforamina trans it the iddle and .terygoi+) )he s all.alatine ganglion8 and BbC a s all !haryngeal branch of the a&illary artery( J()he .aginal *anal Bif !atentC trans its branches of the !haryngeal ner. and BbC the anterior !alatine ner.e fro the nose to the !alate B1igs 1J(J.terygoi+ mus*le. give origin to the su!erior constrictor of the !haryn&( )he u!!er !art of GcH the !osterior border is notched by the au+itory tube. and the !terygoid ha ulus. BdC )he .alatine ner. and occasionally the anterior trun' of the iddle eningeal vein B#.e. and edially to the *hor+a tym.omero. %.alatine foramen trans its8 BaC )he greater . BaC )he ter inal !arts of the greater !alatine uessels fro the !alate to the noseD and BbC the ter inal !art of the noso!alatine ner.alatini) F()he argins of the fora en agnu !rovide attach ent to8 BaC )he anterior atlantoocci!ital membrane anteriorlyD BbC the !osterior atlanto-occi!ital e brane !osteriorlyD and BcC the alar liga ents on the roughened edial surface of each occi!ital condyle B1igs 1:(:.BbC )he lo"er !art of the !osterior border.terygoman+ibular ra. and laterally to the su!erior obli%ue uscle( )he area belo" the inferior nuchal line !rovides insertion edially to the re*tus *a. hea+ of the me+ial .eli .

a*e a( S!inal accessory nerves( b( /ertebral arteries( c( Sy !athetic !le&us around the vertebral arteries( d( Posterior s!inal arteries( e( .nterior s!inal artery( Through the narro9 anterior . the eningeal branch of the andibular nerve or nervus s!inosus.etrosal ner.enous and sym. .etrotym.terygoi+ *anal "hich leaves the fora en by entering the !terygoid canal in the anterior "all of the fora en laceru B1ig( 1(1AC( 1()he edial end of the .e unites "ith the +ee.art a( .art a( @o"est !art of edulla oblongata b( )hree eninges( Through the subara*hnoi+ s.e of the .henoi+al foramen trans its an emissary .lexuses around the artery B1ig( 1(1AC( F()he structures !assing through the foramen la*erum are as follo"s( During life the lo"er !art of the fora en is filled "ith cartilage.inosum trans its the mi++le eningeal artery.3%%%%% <etrous te5poral POSTERIOR E5issar2 7ein%%%%%%%%%%%% <ter2goid ple:us o4 7eins%%%%%%%% PPPPPPP Meningeal 6ranch o4 ascending phar2ngeal arter2 Fig. and the !osterior trun' of the iddle eningeal vein( 4()he emissary s. %. .ani* fissure trans its the chorda ty !ani nerve and the anterior ty !anic artery( F(The foramen magnum trans its the follo"ing B1ig( 1(14C( Through 9i+er .etrosal ner.ein connecting the cavernous sinus "ith the !terygoid !le&us of veins( 9(Ehen !resent the *analis innominatus trans its the lesser !etrosal nerve( 1()he carotid canal trans its the internal *aroti+ artery. the u!!er !art of the fora en is traversed by the internal carotid artery "ith venous and sy !athetic !le&uses around it( In the anterior !art of the fora en.!ical liga ent of dens( b( /ertical brand of cruciate liga ent( c( #e brana tectoria B1ig( 1:(:C( /nternal carotid arter2 1ith s25pathetic ple:us around it % %%%%% Ca7ernous sinus PPPP Deep petrosal ner7e P P 0reater petrosaN ner7e <ter2goid process%%%%%%%%% er7e o4 pter2goid canalPPPPPP ANTERIOR U +@ + 33 +'.osterior .%8: 9iagram showing some relationships of the foramen lacerum.A()he foramen s. e&ce!t for the eningeal branch of the ascending !haryngeal artery and an e issary vein fro the cavernous sinus( <o"ever.atheti* . and the . and no significant structure !asses through the "hole length of the canal. the greater .e to for the ner.

. %.Apical liga5ent Me56rana tectoria Verte6ral arter2 G?th partH 1ith s25pathetic ple:us -pinal root o4 accessor2 ner7e Upper 7ertical 6and o4 cruciate liga5ent Anterior spinal arter2 Jirst tooth o4 liga5entu5 denticulatu5 Lo1est part o4 5edulla o6longata <osterior spinal arter2 Fig.%1: $tructures passing through foramen magnum.

hy.ein connecting the sig oid sinus "ith the internal 3ugular vein( F()he .n outer table of co !act bone "hich is thic'. the meningealbran*h of the hy!oglossal nerve. crosses the facial canal.ugular foramen trans its the follo"ing structures( Through the anterior .loe "hich consists of s!ongy bone filled "ith red arro". the bones !resent. arachnoid granulations.nternal $urface of !ranial 'ault IOth. the meningeal bran*h of the ascending !haryngeal artery.art a( Internal 3ugular vein( b( #eningeal branch of the occi!ital artery( )he glosso!haryngeal notch near the edial end of the 3ugular fora en lodges the inferior ganglion of the glosso!haryngeal nerve( 1()he astoid canaliculus in the lateral "all of the 3ugular fossa trans its the auricular branch of the vagus( )he nerve !asses laterally through the bone.oglossalner. and in children than in adults( :(#ost of the cranial bones consist of8 BaC . !terygoid !lates do not have any di!loe( .ani* *anali*ulus on the thin edge of the !artition bet"een the 3ugular fossa and the carotid canal trans its the ty !anic branch of the glosso!haryngeal nerve to the iddle ear cavity( :()he stylomastoi+ foramen trans its the facial nerve and the stylo astoid branch of the !osterior auricular artery( )he sha!e.e. the bones are thinner in fe ales than in ales.(= Di%#oi& 5ei"s "3Jrontal diploic 7ein =3Anterior te5poral or parietal diploic 7ein 33<osterior te5poral or parietal diploic 7ein ?3Occipital diploic 7ein GlargestH '3-5all unna5ed diploic 7eins -upraor6ital 4ora5en /n the greater 1ing o4 sphenoid Mastoid 4ora5en Jora5en in occipital 6one <ierce inner ta6le o4 s!ull close to the 5argins o4 superior sagittal sinus Drain into supraor6ital 7ein -phenoparietal sinus or in anterior deep te5poral 7ein 9rans7erse sinus Occipital 7ein or con4luence o4 sinuses Venous lacunae .osterior .osterior *on+ylar *anal trans its an e issary vein connecting the sig oid sinus "ith the subocci!ital venous !le&us B)able 1(1C( :(The . and e erges at the ty !ano astoid fissure( )he nerve is e&tracranial at birth. the follo"ing general !oints ay be noted( 1()he craniu is lined internally by en+o*ramum "hich is continuous "ith the !ericraniu through the fora ina and sutures( F()he thi*kness of the cranial vault is variable( )he bones covered "ith uscles. i(e( te !oral and !osterior cranial fossae are thinner than those covered "ith scal!( 1urther. and the sutures uniting the have been described "ith the nor a verticalis( )he follo"ing features ay be noted( 1( )he inner table is thin and brittle( It !resents markings !roduced by eningeal vessels. and an emissary . resilient and toughD BbC an inner table of co !act bone "hich is thin and brittleD and BcC the +i.art 1()he INTERIOR OF THE S'ULL Before beginning a syste atic study of the interior. but beco es surrounded by bone as the ty !anic !late and astoid !rocess develo!( F()he tym. Oth and Olth cranial nerves( Through the .oglossal or anterior *on+ylar canal trans its the hy.art a( Inferior !etrosal sinus b( #eningeal branch of the ascending !haryngeal artery( Through the mi++le . e(g( the te !oral fossa and the subocci!ital region( )he blood fro the di!loe is drained by four di!loic veins on each side draining into venous sinuses B)able 1(FC( #any bones li'e vo er. in bet"een the t"o tables( )he s'ull bones derive their blood su!!ly ostly fro the eningeal arteries fro inside and very little fro the arteries of the scal!( Blood su!!ly fro the outside is rich in those areas "here uscles are attached. and to so e e&tent by cerebral gyri( It also !resents raised ridges for ed by the attach ents of the dural folds( Ta2#e 9. venous sinuses.

ranial Fossa &oundaries 6nteriorly an+ on the si+es.a&e o. Lesser 1ing o4 sphenoid % Cugu5 sphenoidale ))) R: Anterior clinoid process Jig3 $3=>U -o5e features to be seen in the anterior cranial fossa.1()he frontal *rest lies anteriorly in the edian !lane( It !ro3ects bac'"ards( F()he sagittal sul*us runs fro before bac'"ards in the edian !lane( It beco es !rogressively "ider !osteriorly( It lodges the su!erior sagittal sinus( :()he granular fo. irregular. Jrontal crest Jora5en caecu5 Cri6ri4or5 plate O Jora5en leading into nose Anterior eth5oidal canal <osterior eth5oidal canal Or6ital plate o4 4rontal 6onePPPPP . iddle and !osterior cranial fossae( )he dura ater is fir ly adherent to the floor of the fossae and is continuous "ith the !ericraniu through the fora ina and fissures B1ig( 1(19C( -nterior . the S-u## )he interior of the base of the s'ull !resents natural subdivisions into the anterior. large. !its situated on each side of the sagittal sulcus( )hey are for ed by arachnoid granulations( )hey are larger and ore nu erous in aged !ersons( H()he .ressions for *erebral gyri are less distinct( )hese beco e very !ro inent in cases of raised intracranial tension( I"ter"a# Sur. $#@ 2he cranial fossae.eolae are dee!. :. the Base o. by the frontal bone B1ig( 1(FGC( Anterior cranial 4ossa Jrontal 6one % -phenoid 6one %Middle cranial 4ossa 9e5poral 6one O <arietal 6one % P <osterior cranial 4ossa O Occipital 6one + Crista galli % Cri6ri4or5 plate % <osterior 5argin o4 lesser 1ing o4 sphenoid %% Anterior clinoid process % -uperior edge o4 petrous te5poral 6one G HC Posterior &#i"oi$ %ro&ess % Jora5en 5agnu5 Fig.arietal foramina o!en near the sagittal sulcus F(J to :(AJ c in front of the la bdoid suture( A( )he im. and the acco !anying vein runs u!"ards 1 c behind the coronal suture( S aller grooves for the branches fro the anterior and !osterior branches of the iddle eningeal vessels run u!"ards and bac'"ards over the !arietal bone B1ig( 1(9C( J()he . 2he boundaries of the bones present in the floor of the fossae are shown in interrupted lines.as*ular markings) )he groove for the anterior branch of the iddle eningeal artery.

henoi+ is broad 1ig( ?? ) )he *ribriform.or #esser %etrosa# "er5e Ar&uate e*i"e"&e Su%erior e$!e o.e an+ .ossa Posterior &#i"oi$ %ro&ess Fora*e" rotu"$u* Fora*e" o5a#e Fora*e" s%i"osu* S%he"oi$a# a"!#e o.osterior roots.late of the ethmoi+ bone.issure O%ti& &a"a# Su#&us &hias*ati&us %A"terior &#i"oi$ %ro&ess %Tu2er&u#u* se##ae H H6%o%h6sea# .late of the ethmoi+ bone se!arates the anterior cranial fossa fro the nasal cavity( It is %uadrilateral in sha!eC BaC )he anterior argin articulates "ith the frontal bone at thefrontoethmoi+al suture "hich is ar'ed in the edian !lane by the foramen *ae*um) )his fora en is usually blind. it is for ed anteriorly by the *ribriform .osterior bor+er fits into the ste of the lateral sul*us of the brain) It ends edially as a !ro inent !ro3ection.ugum s. but is occasionally !atent.essels !ass to the nasal cavity( )he !late is also !erforated by numerous foramina for the !assage of olfactory nerve rootlets( 1()he .ugum s. %arieta# 2o"e B Fig.henoi+ale) >n ea*h si+e. $3=$@ -o5e features to be seen in the middle cranial fossa. BbC )he .or !reater %etrosa# "er5e Hiatus . "hich enclose the o!tic *anal B1ig 1(F1C( CLINICAL ANATOM 1racture of the anterior cranial fossa ay cause bleeding and discharge of cerebros!inal fluid through the nose( It ay also cause a condition called bla*k eye "hich is !roduced by see!age of blood into the eyelid( Su%erior or2ita# . the !osterior border for s the u!!er boundary of the su.late of the frontal bone se!arates the anterior cranial fossa fro the orbit( It su!!orts the orbital surface of the frontal lobe of the brain. it is se!arated fro the iddle cranial fossa by the free .erior orbital fissure) #edially. the lesser "ing is connected to the body of the s!henoid by anterior an+ .late of the frontal bone. %etrous te*%ora# B Mastoi$ a"!#e o. the floor is for ed ostly by the orbital .osterior margin articulates "ith the lesser "ing of the s!henoid( :()he lesser 9ing of the s.or *i$$#e *e"i"!ea# arter6 S?ua*ous te*%ora# B Out#i"e o.osterior bor+er of the lesser 9ing of the s.henoi+ale se!arates the anterior ural 8rio r it to the ires cranial fossa fro In the me+ian . and !resents reci!rocal i !ressions( )he frontal air sinus ay e&tend into its antero edial !art( )he me+ial margin of the !late covers the labyrinth of the eth oidD and the . and !osteriorly by the su!erior surface of the anterior !art of the body of the s!henoid or .henoi+.osterior margin articulates "ith the 3ugu s!henoidale( . and the anterior margin of the sul*us *hiasmati*us) Floor anterior ethmoi+al ner.osterior ethmoi+al *anals.ro*ess) Inferiorly. #e!*e" t6*%a"i C . %arieta# 2o"e Iroo5e .t the !osterolateral corners "e see the . C Dorsu* se##ae Caroti$ !roo5e Fora*e" #a&eru* Tri!e*i"a# i*%ressio" JD Hiatus . 2*3 Its lateral margins articulate "ith the orbital !late of the frontal bone8 the suture bet"een the !resents the anterior ethmoi+al *anal !laced behind the crista galli B1ig( 1(FGC( .less 8s of Posteriorly.nteriorly. the anterior *linoi+ .lane.ro*ess. the anterior *linoi+ . the cribrifor !late has a idline !ro3ection called the *rista galli) 0n each side of the crista galli there are fora ina through "hich the r edially "here it is continuous "ith the 3ugu s!henoidale and ta!ers laterally( )he free . and is co !leted !osteriorly by the lesser "ing of the s!henoid( (ther Features the s!henoidal sinuses( F()he orbital .

. and edially by the body of the s!henoid(C BcC )he sella tur*i*a) )he u!!er surface of the body of the s!henoid is hollo"ed out in the for of a )ur'ish saddle.erior orbital fissure o!ens anteriorly into the orbit( It is boun+e+ above by the lesser "ing.hyseal fossa lodges the hy!o!hysis cerebri( Beneath the floor of the fossa lie the s!henoidal air sinuses( )he dorsu sellae is a transverse !late of bone !roP ecting u!"ardsD it for s the bac' of the saddle( )he su!erolateral angles of the dorsu sellae are e&!anded to for the !osterior clinoid !rocesses( 0ateral 6rea 1()he lateral area is dee! and lodges the te !oral lobe of the brain( F(It is related anteriorly to the orbit. and is 'no"n as the sella turcica( It consists of the tuberculu sellae in front.o. being narro" and shallo" in the iddleD and "ide and dee! on each side( &oundaries 6nterior7 BaC Posterior border of the lesser "ing of the s!henoidD BbC anterior clinoid !rocessD and BcC anterior argin of the sulcus chias aticus B1ig( 1(F1C( /osterior7 BaC Su!erior border of the !etrous te !oral boneD and BbC the dorsurn sellae of the s!henoid( @ateral8 BaC +reater "ing of the s!henoidD BbC anteroinferior angle of the !arietal boneD and BcC the s%ua ous te !oral bone in the iddle( 5loor7 1loor is for ed by body of s!henoid in the edian region and by greater "ing of s!henoid.o. s%ua ous te !oral and anterior surface of !etrous te !oral on each side( >ther 5eatures Median Area )he body of the s!henoid !resents the follo"ing features( BaC )he sulcus chias aticus or o!tic groo.hyseal fossa) Its lateral ends for the mi++le *linoi+ . in front and behind by the t"o roots of the lesser "ing. L It is dee!er than the anterior cranial fossa.e leads. laterally to the te !oral fossa. to the o!tic canal( )he o!tic chias a does not occu!y the sulcusD it lies at a higher level "ell behind the sulcus( ubC )he o!tic canal leads to the orbit( It is bounded laterally by the lesser "ing of the s!henoid.ro*ess "hich ay 3oin the anterior clinoid !rocess( )he hy. the hy!o!hyseal fossa in the iddle and the dorsu sellae behind( )he tuberculu sellae se!arates the o!tic groove fro the hy. and is sha!ed li'e a butterfly. and inferiorly to the infrate !oral fossa( :()he su. on each side./iddle !ranial JossaH V.

for the ty !anic cavity and for the canal for the tensor ty !ani( )he lateral argin of the teg en ty !ani is turned do"n"ardsD it for s the lateral "all of the bony auditory tube( Its lo"er edge is seen in the s%ua oty !anic fissure and divides it into the !etroty !anic and !etros%uarnous fissures( A( )he *erebral surfa*e of the s:uamous tem. behind the fora en laceru ( It lodges the trige inal ganglion "ithin its dural cave B1igs 6(11.henoi+alforamen or fora en of /esalius( )hese fora ina have been seen on the base of the s'ull.inosum lies !osterolateral to the fora en ovale( It also leads. and edially by the body of the s!henoid( )he edial end is "ider than the lateral( )he long a&is of the fissure is directed laterally. BeC )he tegmen tym.oral bone !resents the follo"ing features8 BaC )he trigeminal im.etrosal ner. BeC )he grooue for the mi++le meningeal vessels leads for"ards fro the fora en s!inosu B1ig( 1(F1C( F(The foramen la*erum lies at the !osterior end of the carotid groove and !ostero edial to the fora en ovale( Its u!!er end is bounded !osterolaterally by the a!e& of the !etrous te !oral bone.etrosal ner. inferiorly.ale lies !osterolateral to the fora en rotundu and lateral to the lingula( It leads inferiorly to the infrate !oral fossa. u!"ards and for"ards( )he lo"er border is ar'ed by a s all !ro3ection. but traces of the .belo" by the greater "ing.e for the lesser .ression lies near the a!e&. "hich !rovides attach ent to the co on tendinous ring of@inn) )he ring divides the fissure into three !arts( 1()he greater 9ing of the s. and antero edially by the body of the s!henoid and by the !ostero edial argin of the greater "ing( :()he anterior surfa*e of the .oral bone is concave( It sho"s i !ressions for the te !oral lobe and grooves for branches of the iddle eningeal vessels( Its lo"er border is united to the anterior surface of the !etrous te !oral.henoi+ !resents the follo"ing features8 BaC )he foramen rotun+um lies !osteroinferior to the edial end of the su!erior orbital fissure( It leads anteriorly to the !terygo!alatine fossa containing !terygo!alatine ganglia B)able 1(:C( BbC The foramen o.etrous tem.e for the greater . lie lateral to the hiatus for the greater !etrosal nerve( )hey lead to the fora en ovale or to the canaliculus inno inatus( BdC Still ore laterally there is the arcuate eminen*e "hich is !roduced by the su!erior se icircular canal.6(1FC( BbC )he hiatus and groo. to the infrate !oral fossa( BdC)he emissary s.e. BcC )he foramen s.e are !resent lateral to the trige inal i !ression( )hey lead to the fora en laceru ( BcC )he hiatus and groo.ani is a thin !late of bone anterolateral to the arcuate e inence( It for s a continuous slo!ing roof for the ty !anic antru .

)0#Y 1racture of the iddle cranial fossa !roduces8 BaC Bleeding and discharge of CS1 through the earD BbC bleeding through the nose or outh ay occur due to involve ent of the s!henoid boneD and BcC the seventh and eighth cranial nerves ay be da aged if the fracture also !asses through the internal acoustic eatus( If a se icircular canal is da aged. the s%ua ous te !oral. vertigo ay occur( )he iddle cranial fossa is ost co only fractured( )he fracture l ine usually follo"s a defini te cours e( It begi ns at the !arietal tuber " hic h is us ua ll y t he s i t e of in3 ury a nd !as s es through the !arietal bone. iiH -o5e 4i6res pass through L2go5atic ner7e % L2te5p3 ner7e %co55unicating 6r3 to lacri5al ner7e % lacri5al gland3 <ter2gopalatine = 6ranches 4ro5 5a:illar2 ner7e3 Deep petrosal 4ro5 ple:us around internal carotid arter23 -u65andi6ular = 6ranches 4ro5 lingual ner7e3 Branch 4ro5 ple:us around 4acial art3 iH -u65andi6ular. paranasal sinuses.+= Co""e&tio"s o.ranial Fossa/+ 012 3i40 5 r C@I=IC.@ ..estphal nucleus %* oculo5otor ner7e %* ner7e to in4erior o6li8ue3 9istribution iH Ciliaris 5uscles and iiH -phincter pupillae <le:us along ophthal5ic arter23 Otic Branch 4ro5 auriculote5poral ner7e3 <le:us along 5iddle 5eningeal arter23 /n4erior sali7atoc2 nucleus %W glossophar2ngeal ner7e %W t25panic 6ranch OW t25panic ple:us OW lesser petrosal ner7e3 -uperior sali7ator2 nucleus. iiH 9ensor 7eil palatini and tensor t25pani 7ia ner7e to 5ed3 pter2goid Gunrela2edH3 iH Mucous glands o4 nose. and lacri5ator2 nucleus %* ner7us inter5edius %W 4acial ner7e %W geniculate ganglion O* greater petrosal ner7e3 X deep petrosal ner7e Y ner7e o4 pter2goid canal3 -uperior sali7ator2 nucleus %W 4acial ner7e %W chorda t25pani%Foins the lingual ner7e3 Branch 4ro5 ner7e to 5edial pter2goid3 iH -ecreto5otor to parotid gland 7ia auriculote5poral ner7e. iiH -u6lingual and iiiH Anterior lingual glands3 !et ros %ua os a l s ut ure ar e oft e n se en e ven i n t he adult( K Posterior . nasophar2n:. and fre%uently involving the internal acoustic eatus and the fora en ovale( )his is the largest and dee!est of the three cranial fossae( )he !osterior cranial fossa contains the hin+brain "hich consists of the :erebettum behin+ an+ the .ans an+ me+ulla in front) &oundaries 4lp 4r2( 6nterior7 BaC Su!erior border of the !etrous te !oral boneD and NbC the dorsu sellae of the s!henoid bone B1ig( 1(FFC( /osterior7 S%ua ous !art of the occi!ital bone( >n ea*h si+e7 BaC #astoid !art of the te !oral bone and BbC the astoid angle of the !arietal bone( Floor 1e+ian area7 BaC Slo!ing area behind the dorsu sellae or clivus in frontD BbC the fora en agnu in the iddleD and BcC the s%ua ous occi!ital behind( 0ateral area7 BaC Condylar or lateral !art of occi!ital boneD BbC !osterior surface of the !etrous te !oral .=. palate.anglia Ciliar2 -ensor2 root Jro5 nasociliar2 ner7e3 $ympathetic root Ta2#e 9. and the !etrous te !oral bones usually involving the teg en ty !ani. %aras6*%atheti& !a"!#ia /otor root $ecretomotor root Edinger% .

Jora5en laceru5 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -uperior edge o4 petrous te5poral%%%%%%%%%%%%%%%%% -u6arcuate 4ossa%%%%%%%%%%%%%%%%%% Cugular 4ora5en -------Clivus =>? /nternal acoustic 5eatus R <etro%occipital suture Attach5ents o4@ %%%%%%%%Me56rana tectoria RF Upper 7ertical 6and o4 cruciate liga5ent f@ > A5. BcC )he trans.art of the tem.etrous .estibule is a narro" slit lying behind the internal acoustic eatus( BcC )he subar*uate fossa .lexus of .etro&o**i.erse sul*us is %uite "ide and runs laterally fro the internal occi!ital !rotuberance to the astoid angle of the !arietal bone "here it beco es continuous "ith the sig oid sulcus( )he transverse sulcus lodges the trans.erse sinus) )he right transverse sulcus is usually "ider than the left and is continuous edially "ith the su!erior sagittal sulcus( BdC 0n each side of the internal occi!ital crest there are +ee.art of the o**i. BaC )he internal o**i.oglossal *anal !ierces the bone !osteroanterior to the 3ugular tubercle and runs obli%uely for"ards and laterally along the line of fusion bet"een the basilar and the condylar !arts of the occi!ital bone.e+by the edial surfaces of the occi!ital condyles( F()he s:uamous .ital bone sho"s the follo"ing features. BbC )he internal o**i.art of the o**i.BC>*D Apical liga5ent o4 dens + =fEE>El D* H2poglossal canal . fossae "hich lodge the cerebellar he is!heres( KK( 0ateral 6rea 1()he *on+ylar . and su!!orts the !ons and edulla B1ig( 1(FFC( 0n each side.. !osteriorly by the s%ua ous !art of the occi!ital bone. the clivus is se!arated fro the !etrous te !oral bone by the .<<: $ome features to be seen in the posterior cranial fossa. +%%%%%%%/nternal Jora5en 5agnu5 occipital protu6erance Ver5ian 4ossa %%%%%% /nternal occipital crest Mastoid angle o4 parietal 6one ) Cere6ellar 4ossa %' Fig.osterior surfa*e of the .ital *rest runs in the edian !lane fro the internal occi!ital !rotuberance to the fora en agnu "here it for s a shallo" de!ression. BcC )he *on+ylar *anal o!ens in the lo"er !art of the sig oid sulcus "hich indents the 3ugular !rocess of the occi!ital bone B1ig( 1(FFC( F()he .3 Cugular tu6ercle . the .ermian fossa. boneD BcC astoid te !oral boneD and BdC angle of the !arietal bone( (ther Features astoid I) 1e+ian 6rea ") )he *li.eins. and on each side by the condylar !art of the occi!ital bone( )he anterior !art of the fora en is narro" because it is o.oral bone for s the anterolateral "all of the !osterior cranial fossa( )he follo"ing features ay be noted8 BaC )he internal a*ousti* meatus o!ens above the anterior !art of the 3ugular fora en( It is about one c long and runs transversely in a lateral direction( It is closed laterally by a !erforated !late of bone 'no"n as lamina *ribrosa "hich se!arates it fro the internal ear( BbC )he orifice of the a:ue+u*t of the .ital bone is ar'ed by the follo"ing8 BaC )he 3ugular tuber*le lies over the occi!ital condyle( BbC )he hy.us is the slo!ing surface in front of the fora en agnu ( It is for ed by fusion of the !osterior !art of the body of the s!henoid including the dorsu sellae "ith the basilar !art of the occi!ital bone or basiocci!ut( It is related to the basilar . and is continuous behind "ith the 3ugular fora en( 1()he foramen magnum lies in the floor of the fossa( It is boun+e+ anteriorly by the basiocci!ut.rotuberan*e lies o!!osite the e&ternal occi!ital !rotuberance( It is related to the confluence of sinuses.. %.erla.ital . and is grooved on each side by the beginning of the transverse sinuses.ital fissure "hich is grooved by the inferior !etrosal sinus.

ani* antrum) )he mastoi+ foramen o!ens into the u!!er !art of the sulcus( CLINICAL ANATOM !osterior clinoid !rocess to the anterior end of the attached argin of the tentoriu cerebelli. fora en agnu . but occasionally it trans its a vein fro the u!!er !art of the nose to the su!erior sagittal sinus( F()he . and the !ons and edulla in front( F()he lo"er !art of the clivus !rovides attach ent to the a.ernous sinus lies on each side of the body of the s!henoid( )he internal carotid artery !asses through the cavernous sinus B1ig( 6(6C( F()he su!erior border of the !etrous te !oral bone is grooved by the su. hy!oglossal canal.e) Posterior !ranial Fossa 1()he 1racture of the !osterior cranial fossa causes bruising over the astoid region e&tending do"n over the sternocleido astoid uscle( -ttach6ents and 7elations of the Interior of the S8ull Attachment on 'ault 1()he !osterior cranial fossa contains the hindbrain "hich consists of the cerebellu behind.ugular foramen lies at the !osterior end of the !etro-occi!ital fissure bet"een the dee! 3ugular notch of the !etrous te !oral bone above and the shallo" 3ugular notch of the occi!ital bone belo"( )he u!!er argin is shar! and irregular.here) F()he tuberculu sellae !rovides attach ent to the +ia. tenth an+ ele.oral lobe of the *erebral hemis.enth *ranial ner.hragma sellae B1ig( 6(JC( :()he hy!o!hyseal fossa lodges the hy. and to the !etros!henoidal liga ent B1ig( 6(:C( 1(0ne *a.ti* *anal trans its the o!tic nerve and the o!hthal ic artery( J()he three !arts of the su.haryngeal not*h) )he lo"er argin is s ooth and regular( F()he mastoi+ .erior orbital fissure B1ig( A(HC trans it the follo"ing structures8 0ateral .etrosal sinus and !rovides attach ent to the atta*he+ margin of the tentorium *erebelli) It is grooved in its edial !art by the trigeminal ner.o.erior . 3ugularfora en.art of the tem. it is ar'ed by the sigmoi+ sul*us "hich begins as a do"n"ard continuation of the transverse sulcus at the astoid angle of the !arietal bone. u!!er vertical band of cruciate liga ent and to the membrana te*toria 3ust above the a!ical liga ent B1ig( 1(FFC( :()he internal occi!ital crest gives attach ent to the falx *erebelli) H()he 3ugular tubercle is grooved by the ninth.i*al ligament of the +ens near the fora en agnu . lateral to the internal acoustic eatus( 1(The .oral bone for s the lateral "all of the !osterior cranial fossa 3ust behind the !etrous !art of the bone( . and !resents the glosso.lies belo" the arcuate e inence.dditional fora ina seen in the cranial fossae are as follo"s( 1()he foramen *ae*um in the anterior cranial fossa is usually blind. and ends at the 3ugular fora en( )he sig oid sulcus lodges the sigmoi+ sinus "hich beco e the internal 3ugular vein at the 3ugular fora en( )he sulcus is related anteriorly to the tym. e issary s!henoidal fora en. fora en laceru .art7 BaC @acri al nerveD BbC frontal nerveD BcC trochlear nerveD BdC su!erior o!hthal ic veinD . and !osterior condylar canal( .nteriorly. fora en s!inosu .es as they !ass to the 3ugular fora en( J()he subarcuate fossa on the !osterior surface of the !etrous te !oral bone lodges the flo**ulus of the *erebellum) $tructures Passing 2hrough Foramina frontal crest gives attach ent to the fal& cerebri B1ig( 1(FGC( F()he li!s of the sagittal sulcus give attach ent to the fal& cerebri B1ig( 6(FC( Anterior !ranial Fossa 1()he crista galli gives attach ent to the fal& cerebri( F()he orbital surface of the frontal bone su!!orts the frontal lobe of the brain( :()he anterior clinoid !rocesses give attach ent to the free argin of the tentoriu cerebelli B1ig( 6(:C( /iddle !ranial Fossa 1()he iddle cranial fossa lodges the tem.hysis cerebri( H()he u!!er argin of the dorsu sellae !rovides attach ent to the dia!hrag a sellaeD and the )he follo"ing fora ina seen in the cranial fossae have been dealt "ith under the nor al basalis8 fora en ovale.osterior ethmoi+al *anals trans it the vessels of the sa e na e( =ote that the nerves do not !ass through the canals as they ter inate earlier( :()he anterior ethmoi+al *anals trans it the corres!onding nerves and vessels( H()he o.

art7 BaC Inferior o!hthal ic vein and BbC sy !athetic nerves fro the !le&us around the internal carotid artery( 1()he foramen rotun+um trans its the a&illary nerve B1ig( 1J(1:C( F()he internal a*ousti* meatus trans its the se.art7 BaC . the S-u## end of the orbit at the edial end of su!erior orbital fissureD BbC a base the orbital o!ening on the faceD and BcC four 9alls7 roof. each ade u! of a single boneD and BdC the uscles covering the thin areas( F(Since the s'ull is an elastic s!here filled "ith the se ifluid brain.essels B1ig( 9(AC( Pri"&i%#es Io5er"i"! Fra&tures o. !laced anterolaterally.enth an+ eighth *ranial ner. 7oof of the s'ull are !revented by8 BaC Its elasticityD BbC rounded sha!eD BcC construction fro a nu ber of secondary elastic arches.erior obli:ue mus*le) 9ateral :all )his is the thic'est and strongest of all the "alls of the orbit( It is for ed8 BaC By the anterior surface of the greater "ing of the s!henoid bone !osteriorlyD and BbC the orbital surface of the frontal !rocess of the 7ygo atic bone anteriorly( Felations )he orbits are !yra idal bony cavities. BbC )he frontal air sinus ay e&tend into its antero edial !art( Named Features BaC )he la*rimal fossa.arietal area of the vaultD and BbC the mi++le *ranialfossa of the base( )his fossa is "ea'ened by nu erous fora ina and canals( )he facial bones co only fractured are8 BaC )he nasal bone and BbC the man+ible) THE ORBIT 1(1ractures It is concave fro side to side( It is for ed BaC ainly by the orbital !late of the frontal boneD and BbC is co !leted !osteriorly by the lesser "ing of the s!henoid B1ig( 1(FHC( Felations 0!tic nerve BaC It se!arates the orbit fro the anterior cranial fossa. inferolateral to the foregoing nerves( 1e+ial .litting effe*t co encing at the site of the blo" and tending to !ass along the lines of least resistance( :()he base of the skull is more fragile than the vault. BcC the tro*hlear fossa. situated one on each side of the root of the nose( )hey !rovide soc'ets for rotatory ove ents of the eyeballs( )hey also !rotect the eyeballs( Shape and Disposition BaC )he greater "ing of the s!henoid se!arates the orbit fro the iddle cranial fossa. lateral and edial "alls B1ig( 1(JC( )he long a&is of the orbit !asses bac'"ards and edially( )he edial "alls of the t"o orbits are !arallel and the lateral "alls are set at right angles to each other B1ig( 1(F:C( Visual a:is O Or6ital a:is%%%%%%%% GH< Fi*+ #+&': 9iagram %%%%%%%% Medial 1all o4 or6it comparing the a is and Lateral 1all o4 or6it orientation of the orbital the visual a is. lies antero edially( It !rovides attach ent to the fibrous !ulley or trochlea for the tendon of the su. a violent blo" on the s'ull !roduces a s. causing considerable da age to the brain( 0ccasionally only the inner table is fractured and the outer table re ains intact( J()he *ommon sites of fracture in the s'ull are8 BaC )he . !articularly along the fora ina( H()he inner table is more brittle than the outer table( )herefore. at the 3unction of the roof and edial "all. BbC the o.ti* *anal lies !osteriorly.n a!e& situated at the !osterior .BaC eningeal branch of the lacri al arteryD and BbCanasto otic branch of the iddle eningeal artery "hich anasto oses "ith the recurrent branch of the lacri al artery( 1i++le . fractures are ore e&tensive on the inner table. and is ore co only involved in such fractures. floor.!!er and lo"er divisions of the oculo otor nerveD BbC nasociliary nerve in bet"een the t"o divisions of the oculo otorD and BcC the abducent nerve. lodges the lacri al gland.es and the labyrinthine . BbC )he 7ygo atic bone se!arates it fro the te !oral fossa( 2ach orbit rese bles a four-sided !yra id on one side( )hus it has8 BaC .

erior orbitalfiss9e occu!ies the !osterior /edial Jall !art of the 3unction bet"een the roof and lateral "all( BbCThe foramen for the 4ygomati* ner. BbC )he orbital !late of the eth oid se!arates the orbit fro the eth oidal air sinuses. All the features Named Features BaCThe su.OO and anterior lacri5al crest on 4rontal process o4 5a:illa ) . seen from the front. BcC Ahitnall's or 4ygomati* tuber*le is a !al!able elevation on the 7ygo atic bone 3ust "ithin the orbital argin( It !rovides attach ent to the lateral chec' liga ent of the eyeball( Floor It is very thin( 1ro before bac'"ards it is for ed by8 BaC )he frontal !rocess of the a&illaD BbC the lacri al boneD BcC the orbital !late of the eth oidD and BdC the body of the s!henoid bone(C Felations It slo!es u!"ards and edially to 3oin the edial "all( It is for ed8 BaC #ainly by the orbital surface of the a&illaD BbC by the lo"er !art of the orbital surface of the 7ygo atic bone. through nasolacri al canal.e runs for"ards in relation to the floor. are se!arated fro the orbit only by a thin layer of bone( . BcC . %% crest o4 lacri5al 6one . anterolaterallyD and BcC the orbital !rocess of the !alatine bone.osterior ethrnoi+alforamina !art of the 3unction bet"een the lateral "all and liet the frontoeth oidal suture. BcC )he s!henoidal sinuses. for ed by the a&illa and the lacri al bone. to the inferior eatus of the BaC )he inferior orbital fissure occu!ies the !osterior the nosey BbC )he anterior an+. BbC )he infraorbital Foramina in Felation to the (rbit groo. at the 3unction of floor( )hrough this fissure the orbit co unicates the roof and edial "all( "ith the infrate !oral fossa anteriorly and "ith the !terygo!alatine fossa !osteriorly.Or6ital plate o4 4rontal 6one -uperior or6ital 4lssure %PFE 0reater 1ing o4 sphenoid Q2go5atic 6one and 4ora5ina on it % Lacri5al 4ossa DI /n4erior or6ital 4issure /n4raor6ital groo7e and 4ora5en s S Lesser 1ing o4 sphenoid -upraor6ital notch . se!arates the orbit fro the nasal cavity. at the !osterior Named Features angle( 2 > > f BaC )he lacri al groove lies anteriorly on the edial "all( It is bounded anteriorly by the lacri al crest of the frontal !rocess of the a&illa.I Optic canal E%%%%%%%%%%%%%%% Anterior and posterior eth5oidal 4ora5ina E V % 9rochlear 4ossa %%%%% asal 6one 3PPL%+%%%%%%%% Lacri5al groo7e D5iPPP F 6et1een G'. s all de!ression on the antero edial !art of the 1( )he structures !assing through the o!tic canal floor gives origin to the inferior obli:ue mus*le) and through the su!erior orbital fissure have been described in cranial fossae B1ig( %)(3) BaC )he la*rimal groo.e.E. "3=?@ 2he orbit shown cannot be seen from any particular direction. and !osteriorly by Felation the crest of the lacri al bone( )he floor of the groove is for ed by the a&illa in front and by the lacri al It se!arates the orbit fro the a&illary sinus( bone behind( )he groove lodges the lacri al sac "hich lies dee! to the lacri al fascia bridging the Named Features lacri al groove( )he groove leads inferiorly..%$%9C. Opening o4 nasolacri5al duct + % Or6ital plate o4 eth5oid )% Or6ital process o4 palatine 6one Fig..e is seen in the 7ygo atic bone.

the orbital bran*hes of the .alatine ganglion. the infraorbital ner. and the co unication bet"een the inferior o!hthal ic vein and the !terygoid !le&us of veins B1ig( 1J(1FC( 1()he infraorbital groo. non-eru!tion of teeth.terygo. though internal ear is al ost of adult si7e the !etrous te !oral has not reached the adult length( halves of frontal bone are se!arated by eto!ic suture( F()he andible is also !resent in t"o halves( It is a derivative of the first branchial arch B)able 1(HC( :(0cci!ital bone is in four !arts Bs%ua ous one. and basilar oneC( H()he four bony ele ents of te !oral bone are se!arate. e&ce!t for the co encing union of the ty !anic !art "ith the s%ua ous and !etrous !arts( )he second centre for styloid !rocess has not a!!eared( J( .e an+ *anal trans it the corres!onding nerve and vessels( F()he 4ygomati* foramen trans its the 7ygo atic nerve( :()he anterior ethmoi+al foramina trans it the corres!onding nerves and vessels( Posterior eth oidal fora ina only trans it vessels( / FOETAL S'ULL $tructure of &ones )he bones of the cranial vault are s ooth and unila ellarD there is no di!loe( )he tables and di!loe a!!ear by fourth year of age B1ig( 1(FJC and )able 1(F( &ony Prominences 1(1rontal and !arietal tubera are !ro inent( F(+labella. it is half of calvaria( )he foetal s'eleton is s all due to rudi entary andible and a&illae.e.K F( )he inferior orbital fissure trans its the ^4ygomati* ner. and s all si7e of a&illary sinus and nasal cavity( )he large si7e of calvaria is due to !recocious gro"th of brain( F(Base of the skull is short and narro". condylar t"o.essels.e an+ .nossified e branous ga!s a total of 6 fontanelles at the angles of the !arietal bones are !resent B1ig( 1(FC( Paranasal Air $inuses 1()"o )hese are rudi entary or absent( <osterior te5poral Anterior te5poral Occipital . the facial s'eleton is 1 K4th of calvariaD in adults. su!erciliary arches and astoid !rocesses are not develo!ed( (ssification of &ones 9imensions " ) S'ull is large in !ro!ortion to the other !arts of s'eleton( 1(5oetal skeleton is s all as co !ared to calvaria( In foetal s'ull.

Jrontal Fig. $3='@ 9iploic veins. .

Ta2#e 9..= Mesoder5al $eri5ati5es o, %har6"!ea#K2ra"&hia# ar&hes 9he 6ones, cartilages, liga5ents o4 arches are 4or5ed 4ro5 neural crest deri7ed 5esench25e3 Mesoder5 gi7ing origin to the 5uscles is deri7ed 4ro5 unseg5ented para%a:ial 5esench25e o4 head, the so5ato5eres Arch / Arch GaH Ma:illar2 s1elling palatopter2go%8uadrate cartilage G6H Mandi6ular s1elling GMec!el's cartilageH $keletal elements /ncus Malleus, anterior liga5ent o4 5alleus and spheno5andi6ular /uscles Muscles o4 5astication, i3e3 te5poralis, 5asseter, lateral and 5edial pter2goid, tensor 7eli palatini, le7ator7eli palatini, 52loh2oid and anterior 6ell2 o4 digastric Nerve Mandi6ular di7ision o4 V ner7e

liga5ent3 Most o4 the 5andi6le Gintra5e56ranous ossi4icationH ote@ B2 intra5e56ranous ossi4ication o4 5esench25e o4 / arch, 5a:illa, L2go5atic, s8ua5ous part o4 te5poral are de7eloped II Ar&h Reichert's cartilage -tapes, st2loid process, st2lo% h2oid liga5ent, lesser cornua and upper hal4 o4 6od2 o4 h2oid Muscles o4 4acial e:pression and occipito4rontalis, auricular 5uscles, plat2s5a, st2loh2oid and posterior 6ell2 o4 digastric -t2lophar2ngeus Jacial ner7e GV//H

I Ar&h

0reater cornua o4 h2oid and lo1er hal4 o4 h2oid 6one 9h2roid, cricoid, ar2tenoid, cunei4or5 and corniculate cartilages

0lossophar2ngeal ner7e G/T ner7eH E:ternal lar2ngeal and recurrent lar2ngeal 6ranches o4 7ago%accessor2 co5ple:

I1 a"$ 1I Ar&h

Cricoth2roid, constrictors o4 phar2n: and other 5uscles o4 lar2n:

2emporal &one 1()he

1()y

internal ear, ty !anic cavity, ty !anic antru , and ear ossicles are of adult si7e B)able 1(JC( F()he ty !anic !art is re!resented by an inco !lete ty !anic ring( :(#astoid !rocess is absent, it a!!ears during the later !art of second year( H(2&ternal acoustic eatus is short and straight( Its bony !art is unossified and re!resented by a flbrocartilaginous !late(

!anic e brane faces ore do"n"ards than laterally due to the absence of astoid !rocess B)able 1(6C( F(Stylo astoid fora en is e&!osed on the lateral surface of the s'ull because astoid !ortion is flat( :(Styloid !rocess lies i ediately behind the ty !anic ring and has not fused "ith the re ainder of the te !oral bone( H(#andibular fossa is flat and !laced ore laterally, and the articular tubercle has not develo!ed(

Ta2#e 9.0= Deri5ati5es o, e"$o$er*a# %ou&hes Pharyngeal pouch Dorsal ends o4 / and // pouches 4or5 + 9u6ot25panic recess 9erivative s ///<har2ngeal pouch Gulti5o6ranchial 6od2H

Ventral part o4 // phar2ngeal pouch

/<har2ngeal pouch

//<har2ngeal pouch

<ro:i5al part o4 tu6ot25panic recess gi7es rise to auditor2 tu6e Distal part gi7es rise to t25panic ca7it2 and 5astoid antru53 Mastoid cells de7elop at a6out t1o 2ears o4 age Epitheliu5 co7ering the palatine tonsil and tonsillar cr2pts, l25phoid tissue is 5esoder5al in origin 9h25us and in4erior parath2roid gland or parath2roid ///3 9h25ic epithelial reticular cells and Hassall's corpuscles are endoder5al3 L25phoc2tes are deri7ed 4ro5 hae5opoietic ste5 cells during "=th 1ee! -up erio r par ath2 roid or par ath2 roid /V <ar a4oll icul ar or 'C' cell s o4 the th2r oid glan d

Dorsal part o4 / ectoder5al cle4t O Auricle

Ta2#e 9.4= Deri5ati5es o, e&to$er*a# &#e,ts Epitheliu5 o4 e:ternal auditor2 5eatus -i: auricular hilloc!sU three 4ro5 / arch and three 4ro5 // arch

Rest o4 ectoder5al cle4ts o6literated 62 the o7ergro1th o4 // phar2ngeal arch3 9he closing 5e56rane o4 the 4irst cle4t is the t25panic 5e56rane

9( )he subarcuate fossa is very dee! and !ro inent( 1G( 1acial canal is short(
(rbits

!losure of Fontanelles

.nterior fontanelle by 14 onths8 !osterior fontanelle by F-: onthsD s!henoidal fontanelle by F-: onthsD and astoid fontanelle by 1F onths B1ig( 1(FC(
+

)hese are large( )he ger s of develo!ing teeth lies close to the orbital floor(
POSTNATAL IROLTH OF S'ULL

2hickening of &ones
1()"o

)he gro"th of calvaria and facial s'eleton !roceeds at different rates and over different !eriods( +ro"th of calvaria is related to gro"th of brain, "hereas that of the facial s'eleton is related to the develo! ent of dentition, uscles of astication, and of the tongue( )he rates of gro"th of the base and vault are also different(
;rowth of the 'ault
1(Bate7

tables and di!loe a!!ear by fourth year( Differentiation reaches a&i u by about thirty-five years, "hen the di!loic veins !roduce characteristic ar'ing in the radiogra!hs B1ig( 1(FJC( F(#astoid !rocess a!!ears during second year, and the astoid air cells during 6th year(
(bliteration of $utures of the 'ault
1(0bliteration

;a!id during first year, and then slo" u! to the seventh year "hen it is al ost of adult si7e( F(Cro9th in brea+th7 )his gro"th occurs at the sagittal suture, sutures bordering greater "ings, occi!ito astoid suture, and the !etroocci!ital suture at the base( :(Cro9th in height7 )his gro"th occurs at the fronto7ygo atic suture, !terion, s%ua osal suture, and asterion( H(Cro9th in antero.osterior +iameter7 )his gro"th occurs at the coronal and la bdoid sutures(
;rowth of the &ase

begins on the inner surface bet"een thirty and forty years, and on the outer surface bet"een forty and fifty years( F()he ti ings are variable, but it usually ta'es !lace first in the lo"er !art of the coronal suture, ne&t in the !osterior !art of the sagittal suture, and then in the la bdoid suture(
in (ld Age

)he base gro"s in antero!osterior dia eter at the three cartilaginous !lates situated bet"een the occi!ital and s!henoid bones, bet"een the !re- and !osts!henoids, and bet"een the s!henoid and eth oid(
;rowth of the Face
1(+ro"th

)he s'ull generally beco es thinner and lighter but in s all !ro!ortion of cases it increases in thic'ness and "eight( )he ost stri'ing feature is reduction in the si7e of andible and a&illae due to loss of teeth and absor!tion of alveolar !rocesses( )his causes decrease in the vertical height of the face and a change in the angles of the andible "hich beco e ore obtuse(
SE> DIFFERENCES IN THE S'ULL

)here are no se& differences until !uberty( )he !ost!ubertal differences are listed in )able 1(A(
Jormian or $utural &ones

of orbits and eth oid is co !lete by seventh year( F(In the face, the gro"th occurs ostly during first year, although it continues till !uberty and even later(

)hese are s all irregular bones found in the region of the fontanelles, and are for ed by additional ossification centres(

Ta2#e 9./= Se8 $i,,ere"&es i" the s-u##
Features Females /ales

"3.eight =3-iLe 33Capacit2 ?3.alls

Hea7ier Larger 0reater in 5ales 9hic!er More

Lighter -5aller ">V less than 5ales 9hinner Less 5ar!ed

'3Muscular ridges,

5ar!ed gla6ella, superciliar2 arches, te5poral lines, 5astoid processes, superior nuchal lines, and e:ternal occipital protu6erance A3925panic plate Larger, and 5argins roughened More rounded -loping GrecedingH Less pro5inent Rounded Longer due to greater depth o4 the Fa1s G5ore o4 the lo1er Fa1H3 Chin is 6igger and proFects 5ore 4or1ards3 /n general, the s!ull is 5ore rugged due to 5uscular 5ar!ings and processesU and L2go5atic 6ones are 5ore 5assi7e

)he length or longest dia eter is easured fro the glabella to the occi!ital !ointD the breadth or "idest dia eter is easured usually a little belo" the !arietal tubera( <u an races ay be8 BaC Dolichoce!halic or long-headed "hen the inde& is AJ or lessD BbC mesati*e.ha-* "hen the inde& is bet"een AJ and 4GD and BcC brochyce!halic or short-headed or roundheaded "hen the inde& is above 4G( Dolichoce!haly is a feature of !ri itive races li'e 2s'i oes, =egroes, etc( Brachyce!haly through esatice!haly has been a continuous change in the advanced races, li'e the 2uro!eans(
<. Facial Angle

$3-upraor6ital
5argin &3Jorehead

-5aller and 5argins are less roughened -harp Vertical More pro5inent -o5e1hat 4lat% tened RoundedU 4acial 6ones are s5ootherU and 5andi6le and 5a:illae are s5aller

#3Jrontal and
parietal tu6era ">3Vault ""3Contour o4 4ace

)his is the angle bet"een t"o lines dra"n fro the nasion to the basion or anterior argin of fora en agnu and the !rosthion or central !oint on u!!er incisor alveolus( 1acial angle is a rough inde& of the degree of develo! ent of the brain because it is the angle bet"een facial s'eleton, i(e( s!lanchnocraniu , and the calvaria, i(e( neurocraniu , "hich are inversely !ro!ortional to each other( )he angle is s allest in the ost evolved races of anD it is larger in lo"er races, and still larger in anthro!oids(
). Abnormal !rania

>xy*e.haly or acroce!haly, to"er-s'ull, or stee!les'ull is a abnor ally tall s'ull( It is due to !re ature closure of the suture bet"een !res!henoid and !osts!henoid, and the coronal suture, so that the s'ull is very short antero!osteriorly( Co !ensation is done by the u!"ard gro"th of s'ull for the enlarging brain( <*a.ho*e.haly or boat-sha!ed s'ull is due to !re ature synostosis in the sagittal suture, as a result the s'ull is very narro" fro side to side but greatly elongated(
AAAAAAAAAAAAAATHE MANDIBLEAAAAAAAAAAAAAAA

)hey are ost co on at the la bda and at the asterionD co on at the !terion Be!i!teric boneCD and rare at the breg a Bos $erc'ringC( Eor ian bones are co on in hydroce!halic s'ulls(
CRANIOMETR

/3 !ephalic .nde

It e&!resses the sha!e of the head, and is the !ro!ortion of breadth to length of the s'ull( )hus8 breadth & 1GG Ce!halic inde& Q ------------------length

)he andible, or lo"er 3a", is the largest and strongest bone of the face( It develo!s fro the first .haryngea0 ar*h) It has a horseshoe-sha!ed body "hich lodges the teeth, and a !air %Kra i "hich !ro3ect u!"ards fro the !osterior ends of the body and !rovide attach ent to uscles( The Bo$6 2ach half of the body has outer and inner surfaces, and u!!er and lo"er borders(

)he outer surfa*e !resents the follo"ing features( B1C)he sym.hysis menti is the line at "hich the right and left halves of the bone eet each other( It is ar'ed by a faint ridge( BFC)he mental .rotuberan*e 2mentum D chinC is a edian triangular !ro3ecting area in the lo"er !art of the idline( )he inferolateral angles of the !rotuberance for the ental tubercles( B:C)he mental foramen lies belo" the interval bet"een the !re olar teeth B1ig( 1(F6C( BHC)he obli:ue line is the continuation of the shar! anterior border of the ra us of the andible( It runs do"n"ards and for"ards to"ards the ental tubercle( BJC)he in*isi,e fossa is a de!ression that lies 3ust belo" the incisor teeth( )he inner surfa*e !resents the follo"ing features( B1C)he mylohyoi+ line is a !ro inent ridge that runs obli%uely do"n"ards and for"ards fro belo" the third olar tooth to the edian area belo" the genial tubercles Bsee belo"C( BFCBelo" the ylohyoid line the surface is slightly hollo"ed out to for the subman+ibular fossa, "hich lodges the sub andibular gland( B:C.bove the ylohyoid line there is the sublingual fossa in "hich the sublingual gland lies( BHC)he !osterior surface of the sy !hysis enti is ar'ed by four s all elevations called the su!erior and inferior genial tubercles( BJC)he ylohyoid groove B!resent on the ra usC e&tends on to the body belo" the !osterior end of the ylohyoid line( )he u..er or al,eolar bor+er bears soc'ets for the teeth( )he lo9er bor+er of the andible is also called the base) =ear the idline the base sho"s an oval de!ression called the +igastri* fossa)

argin of the andibular fora en is ar'ed by a shar! tongue-sha!ed !ro3ection called the lingula) )he lingula is directed to"ards the head of the andible( F()he mylohyoi+ groo,e begins 3ust belo" the andibular fora en, and runs do"n"ards and for"ards to be gradually lost over the sub andibular fossa( )he u..er bor+er of the ra us is thin and is curved do"n"ards for ing the man+ibular not*h, )he lo9er bor+er is the bac'"ard continuation of the base of the andible( Posteriorly, it ends by beco ing continuous "ith the !osterior border at the angle of the andible(

1()he anterior

)he anterior bor+er is thin, "hile the .osterior bor+er is thic'( )he *oronoi+ .ro*ess is a flattened triangular u!"ard !ro3ection fro the anterosu!erior !art of the ra us( Its anterior border is continuous "ith the anterior border of the ra us( )he !osterior border bounds the andibular notch( )he *on+yloi+.ro*ess is a strong u!"ard !ro3ection fro the !osterosu!erior !art of the ra us( Its u!!er end is e&!anded fro side to side to for the hea+) )he head is covered "ith fibrocartilage and articulates "ith the te !oral bone to for the te !oro andibular 3oint( )he constriction belo" the head is the ne*k) Its anterior surface !resents a de!ression called the .terygoi+ fo,ea)
Attach5ents and Relations o4 the Mandi6le

1( )he obli%ue line on the lateral side of the body gives origin to the bu**inator as far for"ards as the anterior border of the first olar tooth( In front of this origin, the +e.ressor labii inferioris and the +e.ressor anguli oris arise fro the obli%ue line belo" the ental fora en B1ig( 1(F6C(

9he Ra5us

Te*%ora#is

)he ra us is %uadrilateral in sha!e and has t"o surfaces, lateral and edialD four borders, u!!er, lo"er, anterior and !osteriorD and the coronoid and condyloid !rocesses( )he lateral surfa*e is flat and bears a nu ber of obli%ue ridges( )he me+ial surfa*e !resents the follo"ing( 1( )he man+ibular foramen lies a little above the centre of the ra us at the level of the occlusal surfaces of the teeth( It leads into the man+ibular *anal "hich descends into the body of the andible and o!ens at the mental foramen)

Masseter
Bu&&i"ator Me"ta# ,ora*e"

Me"ta#is De%ressor #a2ii i",erioris De%ressor a"!u#i oris C'ENiCHAAJ@CEEE'''E'

P#at6s*a

Fi*+ #+& : (uter surface of the left half of the mandible.

1()he incisive fossa gives origin to the mentalis

and the mental sli.s of the orbi*ularis oris B1ig( 1(AC( F(Parts of both the inner and outer surfaces 3ust belo" the alveolar argin are covered by the ucous e brane of the outh( :()he ylohyoid line gives origin to the mylohyoi+ mus*le B1ig( 1(FAC( H()he su.erior *onstri*tor mus*le of the !haryn& arises fro an area above the !osterior end of the ylohyoid line( J()he .terygoman+ibular ra.he is attached i ediately behind the third olar tooth in continuation "ith the origin of the su!erior constrictor( 6()he u..er genial tuber*le gives origin to the genioglossus, and the lo9er tuber*le to the geniohyoi+ B1ig( 1(FAC( A()he anterior belly of the +igastri* uscle arises fro the digastric fossa( 4()he +ee. *er,i*al fas*ia Binvesting layerC is attached to the "hole length of the lo"er border B1ig( :(FC( 1()he .latysma is inserted into the lo"er border( F()he "hole of the lateral surface of the ra us e&ce!t the !osterosu!erior !art !rovides insertion to the masseter mus*le B1ig( 1(1GC( :()he !osterosu!erior !art of the lateral surface is covered by the .aroti+ glan+ B1ig( 9(1C( H()he s.henoman+ibular ligament is attached to the lingula( J()he me+ial .terygoi+ mus*le is inserted on the edial surface of the ra us, on the roughened area belo" and behind the ylohyoid groove( It is in contact "ith the edial surface in front of the groove B1ig( 1(FAC(

1()he tem.oralis is inserted into the a!e& and

edial surface of the coronoid !rocess( )he insertion e&tend do"n"ards on the anterior border of the ra us B1ig( 1(1GC( F()he lateral .terygoi+ mus*le is inserted into the !terygoid fovea on the anterior as!ect of the nec'( )he uscle is related to the edial surface of the ra us, above the andibular fora en B1ig( 1(16C( :()he lateral surface of the nec' !rovides attach ent to the lateral ligament of the tem.oro&man+ibular ;oint B1ig( 1G(9C(
Jora5ina and Relations to er7es and Vessels
1()he

ental fora en trans its the mental ner,e an+ ,essels B1ig( F(19C( F()he inferior al,eolar ner,e an+ ,essels enter the, man+ibular *anal through the man+ibular foramen, and run for"ards "ithin the canal B1ig( 1(FAC( :()he mylohyoi+ ner,e an+ ,essels lie in the mylohyoi+ groo,e) H()he lingual ner,e is related to the edial surface of the ra us in front of the ylohyoid groove B1ig( 1(FAC( J()he area above and behind the andibular fora en is related to the inferior al,eolar ner,e an+ ,essels and to the maxillary artery) 6()he masseteri* ner,e an+ ,essels !ass through the andibular notch( A()he auri*ulotem.oral ner,e is related to the edial side of the nec' of the andible( Ossification: )he andible is the se*on+ bone, next to the *la,i*le, to ossify in the body( Its greater !art ossifies in membrane) )he !arts ossifying in *artilage include the in*isi,e .art belo" the incisor

Lateral pter2goid

,' 0enioh2oid

Digastric anterior 6ell2

Fig. %.<8: .nner surface of the left half of the mandible. Auriculote5poral ner7e%%%%%% -uper4icial te5poral arter2 O E:ternal carotid arter2 O Ma:illar2 arter2 O % 9e5poralis

- E?
1l,% /n4erior al7eolar ner7e in 5andi6ular 4ora5en Lingual ner7e M2loh2oid groo7e % %Medial pter2goid % % -u65andi6ular 4ossa M2loh2oid -uperior constrictor PPP % E/% -u6lingual 4ossa E'/ =IfID*II 0enioglossus

teeth, the *oronoi+ an+ *on+yloi+ .ro*esses, and the u..er half of the ra us above the level of the andibular fora en( 2ach half of the andible ossifies fro only one *entre "hich a!!ears at about the 6th 9eek of intrauterine life in the esenchy al sheath of 1e*kel's *artilage near the future ental fora en( #ec'el*s cartilage is the s'eletal ele ent of first .haryngeal ar*h) .t birth the andible consists of t"o halves connected at the sym.hysis menti by fibrous tissue( Bony union ta'es !lace during the first year of life(
A!e Cha"!es i" the Ma"$i2#e .n .nfants and !hildren
1()he t"o halves of the

B

ADULT

andible fuse during the first year of life B1ig( 1(F4.C( F(.t birth the mental foramen, o.ens belo" the soc'ets for the t"o deciduous olar teeth near the lo9er bor+er) )his is so because the bone is ade u!

OLD AIE

Fi*+ #+&!: Age changes in the mandible. "A# !hild, "&# adult, "!# old age.

CH/LD

only of the alveolar !art "ith teeth soc'ets( )he man+ibular *anal runs near the lo9er bor+er) )he fora en and canal gradually shift u!"ards( :( )he angle is obtuse) It is 1HG degrees or ore because the head is in line "ith the body( )he coronoid !rocess is large and !ro3ects u!"ards above the level of the condyle(
.n Adults
1()he mental foramen o.ens mi+9ay bet9een the

1(.lveolar border

u..er an+ lo9er bor+ers because the alveolar and subalveolar !arts of the bone are e%ually develo!ed( )he andibular canal runs !arallel "ith the ylo-hyoid line( F()he angle re+u*es to about ""' or "#' +egrees because the ra us beco es al ost vertical B1ig( 1(F4BC(
.n (ld Age
1()eeth fall out and the alveolar border is absorbed,

"ith soc'ets for u!!er teeth faces do"n"ards "ith its conve&ity directed out"ards( 1rontal !rocess is the longest !rocess "hich is directed u!"ards( F(#edial surface is ar'ed by a large irregular o!ening, the maxillary hiatus) Features 2ach a&illa has a body and four !rocesses, the frontal, 7ygo atic, alveolar and !alatine( Bo$6 of ;a)illa )he body of a&illa is !yra idal in sha!e, "ith its base directed edially at the nasal surface, and the a!e& directed laterally at the 7ygo atic !rocess( It has four surfaces and encloses a large cavityD the a&illary sinus( )he surfaces are 8 B1C .nterior or facialD BFC !osterior or infrate !oralD B:C su!erior or orbitalD and BHC edial or nasal(
Anterior or Facial $urface

:(@ateral to canine

e inence there is a larger and dee!er de!ression, the *anine fossa, "hich gives origin to le,ator anguli oris B1ig( 1(F9C(

so that the height of the body is ar'edly reduced B1ig( 1(F4CC( F()he mental foramen an+ the man+ibular *anal are *lose to the al,eolar bor+er) :()he angle again be*omes obtuse about "(' degrees because the ra us is obli%ue(
CLINICAL ANATOM

)he andible is co only fractured at the canine soc'et "here it is "ea'( Involve ent of the inferior alveolar nerve in the callus ay cause neuralgic !ain, "hich ay be referred to the areas of distribution of the buccal and auriculote !oral nerves( If the nerve is !aralysed, the area su!!lied by the ental nerve beco es insensitive( )he ne&t co on fracture of the andible occurs at the angle(

AAAAAAAAAAAAAAA THE MA>ILLAAAAAAAAAAAAAAAA

1(.nterior surface is

#a&illa is the second largest bone of the face, the first being the andible( )he t"o a&illae for the "hole of the u!!er 3a", and each a&illa enters into the for ation of face, nose, outh, orbit, the infrate !oral and !terygo!alatine fossae(
Si$e Deter*i"atio"

1( .nterior surface ends edially into a dee!ly concave border, called the nasal notch( Posterior surface is conve&(

directed for"ards and laterally( F(.bove the incisor teeth there is a slight de!ression, the in*isi,e fossa, "hich gives origin to +e.ressor se.ti) In*isi,us arises fro the alveolar argin belo" the fossa, and the nosafis su!erolateral to the fossa along the nasal notch(

H( .bove the canine fossa there is inKraorbital foramen, "hich trans its infraorbital ner,e an+ ,essels) 1(0e,ator labii su.erioris arises bet"een the infraorbital argin and infraorbital fora en( F(#edially, the anterior surface ends in a dee!ly concave border, the nasal notch, "hich ter inates belo" into !rocess "hich "ith the corres!onding !rocess of o!!osite a&illa for s the anterior nasal s!ine( .nterior surface bordering the nasal notch gives origin to nosalis and +e.ressor se.ti) Posterior or .nfratemporal $urface
1(Posterior surface

is conve& and directed bac'"ards

and laterally( F(It for s the anterior "all of infrate !oral fossa, and is se!arated fro anterior surface by the 7ygo atic !rocess and a rounded ridge "hich descends fro the !rocess to the first olar tooth( :(=ear the centre of the surface o!en t"o or three alueolar canals for !osterior su.erior al,eolar ner,e an+ ,essels) H(Posteroinferiorly, there is a rounded e inence, the a&illary tuberosity, "hich articulates su!ero edially "ith !yra idal !rocess of !alatine bone, and gives origin laterally to the su.erfi*ial hea+ of me+ial .terygoi+ mus*le) J(.bove the a&illary tuberosity the s ooth surface for s anterior "all of .terygo.alatine fossa, and is grooved by a&illary ner,e)

Jrontal process Or6icularis oculi Le7ator la6ii superioris alae8uae nasi asal notch Anterior nasal spine /n4raor6ital 4ora5en asalis Depressor septi Jor eth5oid Or6ital sur4ace

%/n4raor6ital groo7e %Q2go5atic process Le7ator la6ii superioris Ma:illar2 tu6erosit2 Le7ator anguli oris Fig. %.<K: 5ateral aspect of ma illa with muscular attachments. Buccinator

Canine e5inence

and e

$uperior or (rbital $urface
1(Su!erior

1()he

surface is s ooth, triangular and slightly concave, and for s the greater !art of the floor of orbit) F(6nterior bor+er for s a !art of infraorbital argin( #edially it is continuous "ith the lacri al crest of the frontal !rocess( :(/osterior bor+er is s ooth and roundedD it for s ost of the anterior argin of inferior orbital fissure( In the iddle it is notched by the infraorbital groove( H(1e+ial bor+er !resents anteriorly the lacri al notch "hich is converted into nasola*rimal canal by the descending !rocess of lacri al bone( Behind the notch, the border articulates fro before bac'"ards "ith the la*rimal, labyrinth of ethmoi+, an+ the orbital .ro*ess of .alatine bone)

surface !resents infraorbital groo,e leading for"ards to infraorbital *anal "hich o!ens on the anterior surface as infraorbital foramen) )he groove, canal and fora en trans it the infraorbital ner,e an+ ,essels) =ear the id!oint the canal gives off laterally a branch, the canafe sinuosus, for the !assage of anterior su.erior al,eolar ner,e an+ ,essels) F(Inferior obli:ue mus*le of eyeball arises fro a de!ression 3ust lateral to lacri al notch at the antero edial angle of the surface(
/edial or Nasal $urface
1(#edial

surface for s a !art of the lateral 9all of nose) F(/osterosu.eriorly it dis!lays a large irregular o!ening of the a&illary sinus, the maxillary hiatus B1igs 1(:G, 1(:1C(

<alato5a:illar2 suture Fig. %.)3: -pheno%eth5oidal recess -phenoidal air sinus -uperior 5eatus Jrontal air sinus Middle concha Eth5oidal 6ulla Descending part o4 lacri5al 6one -phenopalatine 4ora5en Opening o4 5a:illar2 air sinus in 5iddle 5eatus /n4erior nasal concha S <erpendicular plate o4 palatine 6one ' /n4erior 5eatus Uncinate process

/edial aspect of intact ma illa.

Ma:illar2 hiatus asolacri5al groo7e

Eth5oidal crest Anterior nasal spine Middle 5eatus I Conchal crest /n4erior 5eatus

<alatine process

Jor perpendicular plate o4 palatine 6one

Fig.

0reater palatine canal %.)%: /edial aspect of disarticulated left ma illa.

#eo#o!6

1(.bove the hiatus, there are !arts of air sinuses

"hich are co !leted by the eth oid and lacri al bones( F(Belo" the hiatus, the s ooth concave surface for s a !art of inferior meatus of nose) :(Behind the hiatus, the surface articulates "ith !er!endicular !late of !alatine bone, enclosing the greater .alatine *anal "hich runs do"n"ards and for"ards, and trans its greater .alatine ,essels an+ the anterior, mi++le an+ .osterior .alatine ner,es B1ig( 1(:1C( H(In front of the hiatus, there is nasola*rtmal groo,e, "hich is converted into the nasolacri al canal by articulation "ith the +es*en+ing .ro*ess of la*rimal bone and the la*rimal .ro*ess of inferior nasal *on*ha) )he canal trans its nasola*rimal +u*t to the inferior meatus of nose B1ig 1(:1C( J(#ore anteriorly, an obli%ue ridge for s the *on*hal *rest for articulation "ith the inferior nasal concha( 6(.bove the conchal crest, the shallo" de!ression for s a !art of the atrium of mi++le meatus of nose B1ig( 1J(6C(
Ma8i##ar6 Si"us
1()he

si7e after

a&illary sinus is a large cavity in the body of a&illa( It is .yrami+al in sha!e, "ith its base directed edially to"ards the lateral "all of nose, and the a!e& directed laterally into the 7ygo atic !rocess of a&illa( F()he sinus o!ens into the iddle eatus of nose usually by t"o o!enings one of "hich is closed by ucous e brane( )he large bony hiatus of the sinus is re+u*e+ in the articulated s'ull by follo"ing bones8 BaC 1ro above, by uncinate !rocess of eth oid and descending !art of lacri al bone BbC fro belo", by inferior nasal conchaD and BcC fro behind, by !er!endicular !late of !alatine bone B1ig( 1(:GC( :(Si7e is variable( .verage easure ents are8 height :(A c D "idth, F(J c D and antero!osterior de!th, :(A c ( H(Its roof is for ed by the floor of orbit, and is traversed by the infraorbital canal( )he floor is for ed by the alveolar !rocess of a&illa and lies about 1(F c belo" the level of floor of nose( )he floor is ar'ed by several conical elevations !roduced by the roots of u!!er olar and !re olar teethD they ay even !enetrate the bony floor to lie beneath the ucous lining( Canine tooth ay !ro3ect into the anterolateral "all( J(1axillary sinus is first to +e,elo.) It a!!ears as a shallo" groove on the edial surface of a&illa during fourth onth of intrauterine life, gro"s ra!idly during si& to seven years, and reaches full

and bears soc'ets for the roots of u!!er teeth( .art of orbi*ularis o*uli and le. and su!erior surfaces or a&illa converge( In front and behind. in front "ith nasal bone.ebral ligament.erior&is alae:ue nasi) )he !osterior grooved area for s the anterior half of the floor of la*rimal groo. BbC Fthmoi+al *rest is a hori7ontal ridge about the iddle of the !rocess( Posterior !art of the crest articulates "ith iddle nasal concha. for"ards on the chee'.ator labii su. !osterior. but su!eriorly it is rough for articulation "ith the 7ygo atic bone( Frontal Process 1()he frontal !rocess !ro3ects u!"ards and bac'"ards to arti*ulate above "ith the nasal argin of frontal bone. and the anterior !art lies beneath the agger nasi( BcC )he area belo" the eth oidal crest is hollo"ed out to for the atriu of the iddle eatus( BdC Belo" the atriu is the *on*hal crest "hich articulates "ith inferior nasal concha. or bac'"ards into the infrate !oral fossa( 2&traction of olar teeth ay da age the floor of the sinus( Four Pro&esses o. the anterior la*rimal *rest.ol.!!er ost area is rough for articulation "ith eth oid to close the anterior eth oidal sinuses. Ma8i##a 0ygomatic Process )he 7ygo atic !rocess is a !yra idal lateral !ro3ection on "hich the anterior. lengthC rather than at the fourth onth( 6( Carcino a of a&illary sinus arises fro ucosal lining( )hin "all of the sinus ay allo" e&tension of the gro"th u!"ards into the orbit !ushing the eyeball edially into the nasal cavity. BeC Belo" the conchal crest there lies the inferior eatus of the nose "ith nasolacri al groove ending 3ust behind the crest B1ig( 1(:1C( Alveolar Process 1( It alveolar !rocess for s half of the alveolar arch.the eru!tion of all !er anent teeth( $oranne and #onteiro B1969C noted in 1F hu an foetuses that the sinus a!!ears in the ninth "ee' of intrauterine life B:A C.e B1ig( 1(F9C( :(1e+ial surfa*e for s a !art of the lateral "all of nose( 1ro above do"n"ards the surface !resents follo"ing features8 BaC . and is continuous belo" "ith the infraorbital argin( )he anterior s ooth area gives origin to the orbital . into a s ooth anterior !art and a grooved !osterior !art( )he lacri al crest gives attach ent to la*rimalfas*iaan+the me+ial. and behind "ith lacri al bone( F(0ateral surfa*e is divided by a vertical ridge. it is continuous "ith the corres!onding surfaces of the body.

the nasal.erior surfa*e is concave fro side to side.In adults there are eight so*kets7 *anine so*ket is +ee. and the t"o !alatine !rocesses for anterior three-fourths of the bony !alate( It !resents nu erous vascular fora ina and !its for !alatine glands( Posterolaterally. the ain centre a!!ears above the incisive fossa during seventh .remolar so*kets are single8 and the first . vo er. it is ar'ed by t"o antero!osterior grooves for the greater !alatine vessels and anterior !alatine nerves( :()he su. frontal and lacri al( F(#edially.est8 molar so*kets are 9i+est and divided into three inor soc'ets by se!taD the incisor and second . !alatine and o!!osite a&illa( :(@aterally. the maxillary torus. inferior nasal concha. it articulates "ith three bones.remaxilla) )he centre for a&illa !ro!er a!!ears above the canine fossa during si&th "ee' of intrauterine life( 0f the t"o !re a&illary centres. the 7ygo atic( Ossification: #a&illa ossifies in e brane fro three centres. and for s greater !art of the floor of nasal cavity( H(1e+ial bor+er is uch thic'er in front than behind( It is raised su!eriorly into the nasal crest( +roove bet"een the nasal crests of t"o a&illae receives lo"er border of vo erD anterior !art of the ridge is high and is 'no"n as in*isor *rest "hich ter inates anteriorly into the anterior nasal s!ine( Incisive canal traverses near the anterior !art of the edial border( J(Posterior border articulates "ith hori7ontal !late of !alatine bone( 6(0ateral bor+er is continuous "ith the alveolar !rocess( Arti&u#atio"s o. the eth oid. Ma8i##a 1(Su!eriorly.remolar so*ket is so eti es +i. is so eti es !resent on the inner surface o!!osite the olar soc'ets( Palatine Process 1()he !alatine !rocess is a thic' hori7ontal !late !ro3ecting edially fro the lo"est !art of the nasal surface( It for s a large !art of the roof of outh and the floor of nasal cavity B1ig( 1(:1C( F()he inferior surfa*e is concave. and t"o for os incisivu or . it articulates "ith five bones. it articulates "ith one bone. rough ridge.i+e+ into t9o) 1(Buccinator arises fro the !osterior !art of its outer surface u! to the first olar tooth B1ig( 1(F9C( F(. one for the a&illa !ro!er.

"ee' of intrauterine life( )he second centre B!arase!tal or !revo erineC a!!ears at the ventral argin of nasal se!tu during tenth "ee' and soon fuses "ith the !alatal !rocess of a&illa( )hough !re a&illa begins to fuse "ith alveolar !rocess al ost i ediately after the ossification begins.osterior surfa*e is concave and is directed bac'"ards and do"n"ards( 2ach lateral end of the body is continuous !osteriorly "ith the greater horn or cornua( <o"ever. the tooth soc'ets reaching to the floor of orbitD BdC a&illary sinus is a ere furro" on the lateral "all of the nose( 1(In the adult /ertical dia eter is greatest due to develo! ent of the alveolar !rocess and increase in the si7e of the sinus( F(In the old )he bone reverts to infantile condition( Its height is reduced as a result of absor!tion of the alveolar !rocess( AAAAAAAAAAAAAA THE H OtD BONEAAAAAAAAAAAAA )he hyoid bone is .han*es 1( . the evidence of !re a&illa as a se!arate bone ay !ersist until the iddle decades( -*e . called the body.t birth BaC )he transverse and antero!osterior dia eters are each ore than the vertical dia eterD BbC frontal !rocess is "ell ar'edD BcC body consists of a little ore than the alveolar !rocess. and to the e!iglottis and !haryn& behind B1ig( 1H(FC( )he bone consists of the central !art. till iddle life the connection bet"een the body and greater cornua is fibrous( . and u!!er and lo"er borders( )he anterior surfa*e is conve& and is directed for"ards and u!"ards( It is often divided by a edian ridge into t"o lateral halves( )he . to the laryn& belo".-sha!ed( It develo!s fro second and third branchial arches( It is situated in the anterior idline of the nec' bet"een the chin and the thyroid cartilage( .t rest it lies at the level of the third cervical vertebra behind and the base of the andible in front( It is 'e!t sus!ended in !osition by uscles and liga ents( )he hyoid bone !rovides attach ent to the floor of the outh and to the tongue above. greater and lesser( The Body It has anterior and !osterior surfaces. and of t"o !airs of cornua.

as&ia Di!astri& %u##e6 St6#oh6oi$ Th6roh6oi$ M6#oh6oi$ HHC O*oh6oi$ Msu%erior 2e##6 Pretra&hea# .as&ia CSter"oh6oi$ CTh6roi$ &arti#a!e Pretra&hea# .retra*heal fas*ia) In front of the fascia.ornua )hese are s all conical !ieces of bone "hich !ro3ect u!"ards fro the 3unction of the body and greater cornua( )he lesser cornua are connected to the body by fibrous tissue( 0ccasionally they are connected to the greater cornua by synovial 3oints "hich usually !ersist throughout life.er bor+er of the body !rovides insertion to the lo"er fibres of the genioglossi and attach ent to the thyrohyoi+ membrane) )he lo9er bor+er of the body !rovides attach ent to the . e&tending bac' to the lo"er border of the greater cornua B1ig( 1(::C( )he me+ial bor+er of the greater cornua !rovides attach ent to the thyrohyoi+ membrane. but ends in a tubercle( It has t"o surfacesMu!!er and lo"erD t"o bordersM edial and lateral and a tubercle( The 9esser .ornua )hese are flattened fro above do"n"ards( 2ach cornua ta!ers !osteriorly. <tylohyoi+ mus*le and +igastri* . but ay get an'ylosed( -ttach6ents on the =yoid Bone F( )he u. Ie"ioh6oi$ . "hile lo"er !art of body and greater cornua develo!s fro the third arch( CLINICAL ANATOM Fi*+ #+'&: Anterosuperior view of the left half of hyoid bone showI ing its attachments. Ie"io!#ossus NF @ Ie"ioh6oi$ 9 ) H6oi$ 2o"e O LKO LC E %i! #ot ti s i 0 4 H6oe%i!#otti& #i!a*e"t M6#oh6oi$ I"5esti"! .as&ia .. fracture of the hyoid bone strongly indicates throttling or strangulation( > HJr 34> H#HE Th6roh6oi$ *e*2ra"e O H Su2h6oi$ 2ursa . ) Ar6te"oi$ &arti#a!e La*i"a o.esting fas*ia is attached throughout its length( )he lesser cornua !rovides attach ent to the <tylohyoi+ ligament at its ti!( )he mi++le *onstri*tor uscle arises fro its !osterolateral as!ect e&tending on to the greater cornua B1ig( 1(:FC( 9evelopment I) )he anterior surface of the body !rovides insertion to the geniohyoi+ and mylohyoi+ uscles and gives origin to a !art of the hyoglossus "hich e&tends to the greater cornua B1ig( 1(:FC( Mi$$#e &o"stri&tor St6#oh6oi$ #i!a*e"t Lesser &or"ua H6o!#ossus F Ie"io!#ossus F 8 I"5esti"! . F Di!astri& a"terior 2e##6 C' I"5esti"! .as&ia CAr&h o.!!er !art of body and lesser cornua develo!s fro second branchial arch. the sternohyoi+ is inserted edially and the omohyoi+ laterally( Belo" the o ohyoid there is the linear attach ent of the thyrohyoi+. &ri&oi$ &arti#a!e C.as&ia DE In a sus!ected case of urder. .Osteo#o!6 +7 The <reater .ulley) )he lateral bor+er of the greater cornua !rovides insertion to the thyrohyoid uscle anteriorly( )he in. &ri&oi$ &arti#a!e Fi*: #+'': $agittal section through the floor of the mouth and laryn showing the attachments to the body of the hyoid bone.

being conve& fro side to side and concave fro before bac'"ards( )he lateral borders are bevelled and for synoviaR 3oints "ith the !ro3ecting li!s of the ne&t lo"er vertebra( )he anterior border !ro3ects do"n"ards and ay hide the intervertebral disc( BHC the anterior an+ .= !ervical vertebrae.erior surfa*e is concave transversely "ith u!"ard !ro3ecting li!s on each side( )he anterior border of this surface ay be bevelled( B:C )he inferior surf a*e is saddle-sha!ed. out of "hich the third to si&th are ty!ical.dentification )he cervical vertebrae are identified by the !resence of fora ina transversaria( )here are seven cervical vertebrae.+.a&et La*i"a EJ S%i"e Fi*+ #+' : 2ypical cervical vertebrae seen from above. Bo$6 Fora*e" tra"s5ersariu* A"terior tu2er&#e 4 Costotra"s5erse 2ar 1erte2ra# Fora*e" /ertebral fora en is larger than the body( It is triangular in sha!e because the !edicles are directed bac'"ards and laterally( 1erte2ra# Ar&h 1()he . second and seventh are aty!ical( T PICAL CER1ICAL 1ERTEBRA The Bo$6 B1C )he body is s all and brooder fro side to side than fro before bac'"ards( BFC Its su.ro*esses for articular !illars "hich !ro3ect laterally at the 3unction of !edicle and the la ina( )he su!erior articular facets are flat( )hey are directed bac'"ards and u!"ards( )he inferior articular facets are also flat but are directed for"ards and do"n"ards( F()he trans.erior an+ inferior arti*ular .ine is short and bifid( )he notch is filled u! by the liga entu nuchae B1ig( 1(:6C( Fi*+ /. 1()he su.osterior surfa*es rese ble those of other vertebrae B1ig( 1(:HC( Fi*+ #+'5: !ervical vertebrae. being thinner above than belo"( Atta&h*e"ts a"$ Re#atio"s . lateral view. "hile the first.ro*esses are !ierced by3 fora ina transversaria( 2ach !rocess has anterior and .osterior tuber*le) )he anterior tubercle of the si&th cervical vertebra is large and is called the *aroti+ tuber*le because the co on carotid artery can be co !ressed against it( :()he s.THE CER1ICAL 1ERTEBRAE . laterally( )he su!erior and inferior vertebral notches are of e%ual si7e B1ig( 1(:JC( F()he laminae are relatively long and narro".e+i*les are directed bac'"ards and Posterior tu2er&#e 1erte2ra# &a"a# ? @ Su%erior arti&u#ar .erse bar) )he *ostal element isl re.resente+ by the anterior root. anterior view.osterior roots "hich end in tubercles 3oined by the *ostotrans. the *ostotrans.erse .erse bar an+ the .

ertebral .1( )he anterior an+ .erti*al .osterior longitu+inal ligaments are attached to the u!!er and lo"er borders of the body in front and behind.eins) . res!ectively( 0n each side of the anterior longitudinal liga ent. the .art of the longus *otii is attached to the anterior surface( )he !osterior surface has t"o or ore fora ina for !assage of basi.

t9o for the ti!s of the transverse !rocesses.erse .inalis *er. edially and bac'"ards( It articulates "ith the corres!onding facet on the a&is vertebra to for an atlantoa&ial 3oint( )he edial surface of the lateral ass is ar'ed by a s all roughened tubercle( )he trans. and t9o for the bifid s!ine a!!ear during !uberty.er obli:ue .. semis. a long !osterior arch.Osteo#o!6 1()he u!!er borders and lo"er !arts of the anterior surfaces of the la inae !rovide attach ent to the -gamentaflaua) F()he foramen trans.ulae.a&et %Fora*e" tra"s5ersariu* %C Tra"s5erse %ro&ess J Iroo5e . and transverse !rocesses( )he anterior ar*h is ar'ed by a edian anterior tuber*le on its anterior as!ect( Its !osterior surface bears an o. s.ertebral artery. and the ilio*ostalis *er.erior arti*ular fa*et) )his facet is elongated Bfor"ards and ediallyC.lenius *er. an+ multifi+us B1ig( H(HC( Ossification: . and !rovides insertion on each side to the u.inalis thora*is an+ *er.or 5erte2ra# arter6 .osterior.ertebral .inales. the le.i*is.rimary *entre for each half of the neural arch during nine to ten "ee's of foetal life and one for the *entrum in three to four onths of foetal life( )he t"o halves of the neural arch fuse !osteriorly "ith each other during the first year( Synostosis at the neurocentral synchondrosis occurs during the third year( )he se*on+ary *entres.ator s*a.erse bars are grooved by the anterior . ty!ical cervical vertebra ossifies fro three !ri ary and si& secondary centres( )here is one .osterior tuber*les give origin to the s*alenus me+ius. t9o for the annular e!i!hyseal discs for the !eri!heral !arts of the u!!er and lo"er surfaces of the body.i*is.erior o2#i?ue C Su%erior o2#i?ue A" te"or tu2er&#e A"terior ar&h Tra"s5erse #i!a*e"t C Su%erior arti&u#ar . and is directed do"n"ards. s*alenus . and is directed u!"ards and edially( It articulates "ith the corres!onding condyle to for an atlanto-occi!ital 3oint( )he lo"er surface is ar'ed by the inferior arti*ular fa*et) )his facet is nearly circular. the longus *a. the .rimary rami of the corres!onding cervical nerves( H()he .i*is B1ig( H(:C( J()he s!ine gives origin to the dee! uscles of the bac' of the nec' inters.eins and a bran*h. the longissimus *er. right and left lateral asses. the s. and fuse "ith the rest of the vertebra by t"enty-five years( FIRST CER1ICAL 1ERTEBRA It is ring-sha!ed( It has no body( It also has no s!ine( )he atlas has a short anterior arch.itis.i*is.art of the longus *olli) Re&tus &a%itis a"terior Re&tus &a%itis #atera#is Le5ator s&a%u#ae 5 I".i*al ganglion) )he anterior tuber*les give origin to the s*alenus anterior. ore or less flat.osterior ar*h for s about t"o-fifths of the ring and is uch longer than the anterior arch( Its !osterior surface is ar'ed by a edian !osterior tubercle( )he u!!er surface of the arch is ar'ed behind the lateral ass by a groo.al fa*et "hich articulates "ith the +ens B1ig( 1(:AC( )he . concave.ro*ess !ro3ects laterally fro the lateral ass( It is unusually long and can be felt on the surface of the nec' bet"een the angle of the andible and the astoid !rocess( Its long length allo"s it to act as an effective lever for rotatory ove ents of the head( )he transverse !rocess is !ierced by the fora en transversariu ( Atta&h*e"ts a"$ Re#atio"s It is called the atlas) It can be identified by the follo"ing features( 1( )he anterior tubercle !rovides attach ent Bin the edian !laneC to the anterior longitu+inal ligament.i*is.art of the longus *olli B1ig( 1:(1C( :()he *ostotrans.ersarium trans its the .rom the inferior *er. and the obli:ue .e) 2ach lateral mass sho"s the follo"ing i !ortant features( Its u!!er surface bears the su.

+/P -tlas Aertebra seen fro6 .Re&tus &a%itis %osterior *i"or aboAe+ 5 Posterior ar&h Posterior tu2er&#e Fi*+ /.

!laced in front of the inferior articular !rocess( )he su!erior vertebral notch is very shallo" and is !laced on the u!!er border of the la ina. one for each lateral ass "ith half of the !osterior arch.ertebral not*h. the s. 1erte2ra# Ar&h 1()he . the inferior obli:ue fro its lo"er surface of the ti!.erse ligament of the atlas B1ig( 1:(HC( A()he anterior surface of the lateral ass gives origin to the re*tus *a.ital membrane B1ig( H(6C( J()he lo"er border of the !osterior arch gives attach ent to the highest !air of ligamenta.erior obli:ue fro its u!!er surface !osteriorly.es origin to the re*tus *a.itis anterior) 4()he transverse !rocess gi.a) 6()he tubercle on the edial side of the lateral ass gives attach ent to the trans. circular facet "hich is directed u!"ards and laterally( It articulates "ith the inferior facet of the atlas vertebra to for the atlantoa&ial 3oint( 2ach inferior arti*ular fa*et lies !osterior to the transverse !rocess and is directed do"n"ards and for"ards to articulate "ith the third cervical vertebra( . and the s*alenus me+ius fro the !osterior tubercle of transverse !rocess( Ossification: .tlas ossifies fro three centres.)1: A is vertebra. the su.ita-4ation of atlas and this ay at ti es co !ress the s!inal cord "hich re%uires surgical deco !ression( F()he !haryngeal and retro!haryngeal infla ations ay cause decalcification of atlas vertebra( )his ay lead to loosening of the attach ents of transverse liga ent "hich ay eventually yield.erior arti&u#ar %ro&ess D S%i"e Fig. one for the anterior arch( )he centres for the lateral asses a!!ear during seventh "ee' of intrauterine life and unite !osteriorly at about three years( )he centre for anterior arch a!!ears at about first year and unites "ith the lateral ass at about seven years( SECOND CER1ICAL 1ERTEBRA CLINICAL ANATOM 1(. flat.erior surfa*e of the body is fused "ith the dens.ital membrane B1ig( 1:(:C( F()he lo"er border of the anterior arch gives attach ent to the lateral fibres of the anterior longitu+inal ligament) :()he !osterior tubercle !rovides attach ent to the ligament9n nu*hae in the edian !lane and gives origin to the re*tus *a. it overhangs the fora en.itis . behind the su!erior articular !rocess( F()he laminae are thic' and strong( :(.rticular facets8 2ach su.itis lateralis fro its u!!er surface anteriorly.e+i*les are concealed su!eriorly by the )his is called the a&is( It is identified by the !resence of the dens or odontoid !rocess "hich is a strong.osterior atlanto&o**i. and !osteriorly "ith the transverse liga ent of the atlas( su!erior articular !rocesses( )he inferior surface !resents a dee! and "ide inferior . and is encroached u!on on each side by the su!erior articular facets( )he dens articulates anteriorly "ith the anterior arch of the atlas.ulae fro its lateral argin and lo"er border.i*al ner.tlas ay fuse "ith the occi!ital bone( )his is called o**i.ator s*a. causing sudden +eath fro dislocation of +ens) :()he inferior surfa*e has a !ro inent anterior argin "hich !ro3ects do"n"ards( edian ridge on each side of "hich there are hollo"ed out i !ressions B1ig( 1(:4C( H()he anterior surfa*e !resents a Bo$6 PPPPPP %% Jacet 4or atlas Dens OE% AAACCCCCC Fora*e" tra"s5ersariu* C C Tra"s5erse %ro&ess EH C C 1erte2ra# .1()he u!!er border of the anterior arch gives attach ent to the anterior atlanto&o**i.erior arti*ular fa*et occu!ies the u!!er surfaces of the body and of the assive !edicle( @aterally.osterior minor on each side B1ig( 1(:AC( H()he groove on the u!!er surface of the !osterior arch is occu!ied by the .ertebral artery and by the first *er. %.e) Behind the groove the u!!er border of the !osterior arch gives attach ent to the .la.lenius *er.i*is. tooth-li'e !rocess !ro3ecting u!"ards fro the body( )he dens is usually believed to re!resent the centru or body of the atlas "hich has fused "ith the centru of the a&is( Bo$6 a"$ De"s 1( )he su. posterosuperEor view. the le. transversariu ( It is a large.ora*e" H H C H I".

inalis ceruicis.inalis ceruicis. the ti! of "hich can be felt through the s'in at the lo"er end of the nuchal furro"( Its s!ine is thic'. the rhomboi+eus minor.ias .ine !rovides attach ent to the Attach5ents 1()he dens !rovides attach ent at its a!e& to the a. -uperior articular process -pine Fig.i*al ligament. %.or. belo" the a!e& to the alar ligaments B1ig( 1:(HC( F()he anterior surface of the body receives the insertion of the longus *ollt )he anterior longitu+inal ligament is also attached to the anterior surface B1ig( 1:(1C( :()he !osterior surface of the body !rovides attach ent. fro belo" u!"ards. the inters. to the . the s*lenus me+ius anteriorly and the s. the inferior obli:ue8 the s. long and nearly hori7ontal( It is not bifid. but ends in a tubercle B1ig( 1(HGC( Frontal: It ossifies in e brane( )"o !ri ary centres a!!ear during eighth "ee' near frontal e inences( .t birth the bone is in t"o halves.erti*al limb of the *ru*iate ligament B1ig( 1:(:C( H()he la inae !rovide attach ent to the ligamenta Gla. articular process Bod2 9rans7erse process )he transverse !rocesses are co !aratively large in si7eD the !osterior root is larger than the anterior( )he anterior tubercle is absent( )he fora en transversariu is relatively s all. or ay be entirely absent( Attach5ents ligamentum nuchae. and the multifi+us B1ig( H(:C( F(Trans.ro*ess) Theforamen trans.leural membrane) )he lo"er bor+er !rovides attach ent to the Leuatorcostaru B1ig( H(HC( )he anterior root of the transverse !rocess ay so eti es be se!arate( It then for s a *er.osterior tuber*le !rovides attach ent to the su.erse .ias.1()he trans. the tra.lenius *erui*is !osteriorly( )he intenrans. the semis.ery s all and Jora5en trans7ersariu5 <osterior tu6ercle Verte6ral 4ora5en re!resent the true !osterior tubercles only( )he fora en transversariu is directed u!"ards and laterally B1ig( 1(:9C( F()he s. ter inating in t"o rough tubercles( -pine O Dens 0roo7e 4or trans7erse liga5ent Jacet 4or atlas Jora5en trans7ersariu5 /n4erior A * . the s.ine is large.erior. %.ulae.rominens because of its long s!inous !rocess. se!arate centre for each costal !rocess a!!ears during si&th onth of intrauterine life and fuses "ith the body and transverse !rocess during fifth to si&th years of life( OSSIFICATION OF CRANIAL BONES Fig. lateral view.63: $eventh cervical vertebra seen from above.inalis an+ the multifi+us BCha!ter HC( SE1ENTH CER1ICAL 1ERTEBRA It is also 'no"n as the .inalis th. the inters.ra. so eti es double.osterior ma.ertebra . 1()he ti! of the s.inales.)K: A is vertebra.e4ius.a) J()he transverse !rocess gives origin by its ti! to the le.osterior su. the re*tus *a. se!arated by a suture.lenius *a. the serratus .ersarium usually trans its only an accessory ver tebral vein( )he .ro*esses are . "hich soon start to fuse( But re ains of eto!ic suture ay be seen in about 95 of adult s'ulls( Parietal: It also ossifies in e brane( )"o centres a!!ear during seventh "ee' near the !arietal e inence and soon fuse "ith each other( Occipital: It ossifies !artly in e brane and !artly in cartilage( )he !art of the bone above highest . the s.erse . the membrana te*toria and the .ator s*a.inalis ceruicis. thic' and very strong( It is dee!ly grooved inferiorly( Its ti! is bifid.erse mus*les are attached to the u!!er and lo"er surfaces of the !rocess( 6()he s!ine gives attach ent to the ligamentum nu*hae8 the semis. and on each side.ra*is.osterior longitu+inal ligament.i*al rib of variable si7e( Ossification: Its ossification is si ilar to that of a ty!ical cervical vertebra( In addition.

art consisting of !osterior !art of body.henoi+al .art is ossified by several centres "hich a!!ear in cartilaginous ear ca!sule during fifth onth( <tyloi+ .art "hich lies in front of tuberculu sellae and lesser "ings ossifies fro si& centers in cartilage8 )"o for body of s!henoid during ninth "ee'( )"o for the t"o lesser "ings during ninth "ee'( )"o for the t"o s!henoidal conchae during fifth onth( B( /osts.henoi+al .( /res.art fro one center "hich a!!ears during third onth( 1ollo"ing t"o !arts ossify in cartilage8 /remastoi+ .ani* . greater "ings and !terygoid !rocesses ossifies fro eight centres8 )"o for t"o greater "ings during eighth "ee' for ing the root only( )"o for !osts!henoidal !art of body during fourth onth( )"o centres a!!ear for the t"o !terygoid ha ulus during third onth of foetal life( )hese si& centres a!!ear in cartilage( )"o .art by one center "hich a!!ears during seventh "ee'( Tym. Hea$ a"$ Ne&- nuchal line ossifies in e brane by t"o centres "hich a!!ear during second onth of foetal lifeD it ay re ain se!arate as inter!arietal bone( )he follo"ing centres a!!ear in cartilage8 )"o centres for s%ua ous !art belo" highest nuchal line a!!ear during seventh "ee'( 0ne $erc'ring center a!!ears for !osterior argin of fora en agnu during si&teenth "ee'( )"o centres one for each lateral !arts a!!ear during eighth "ee'( 0ne centre a!!ears for the basilar !art during si&th "ee'( Temporal: 1ollo"ing t"o !arts ossify in e brane8 S%ua ous ..ro*ess develo!s fro cranial end of second branchial arch cartilage( )"o centres a!!ear in it8 )y !anohyal before birth and stylohyal after birth( S !eno"d: It ossifies in t"o !arts8 ..

centres for edial !terygoid !lates a!!ear during ninth "ee' in e brane( )he re aining !ortion of the greater "ings and lateral !lates ossify in e brane fro the centres for the root of greater "ing only( Et!mo"d: It ossifies in cartilage( )hree centres a!!ear in cartilaginous nasal ca!sule( 0ne centre a!!ears in !er!endicular !late during first year of life( )"o centres one for each labyrinth a!!ear bet"een fourth and fifth onths of intrauterine life( Mand"#le: 2ach half of the body is ossified in e brane by one centre "hich a!!ears during si&th "ee' near the ental fora en( )he u!!er half of ra us ossifies in cartilage( 0ssification s!reads in condylar and coronoid !rocesses above the level of the andibular fora en( Inferior nasal concha: It ossifies in cartilage( 0ne centre a!!ears during fifth onth in the lo"er border of the cartilaginous nasal ca!sule( $alat"ne: 0ne centre a!!ears during eighth "ee' in !er!endicular !late( It ossifies in e brane( 0a*rimal7 It ossifies in e brane( 0ne centre a!!ears during t"elfth "ee'( =asal8 It also ossifies in e brane fro one centre "hich a!!ears during third onth of intrauterine life( Vomer: It ossifies in e brane( )"o centres a!!ear during eighth "ee' on either side of idline( )hese fuse by t"elfth "ee'( Zygomatic: It ossifies in e brane by one centre "hich a!!ears during eighth "ee'( Ma%"lla& It also ossifies in e brane by three centres( 0ne for ain body "hich a!!ears during si&th "ee' above canine fossa( )"o centres a!!ear for !re a&illa during seventh "ee' and fuse soon( .

<.se of cos etics should be li ited because of their ill-effects and the tendency to cause allergic reactions( Cos etics try to enhance the e&ternal beauty only te !orarily( )he real beauty of good and hel!ing nature co es fro "ithin "hich no cos etic can atch( SOME FEATURES THAT CAN BE IDENTIFIED ON THE LI1INI FACE :( )he . 9e5ple and Jace n>ace is the ost !ro inent !art of the body( 1acial 1 uscles.a. etc( )he face.al.-calp.ebral fissure is an elli!tical o!ening bet"een the t"o eyelids( )he lids are 3oined to each other at the edial and lateral angles or *anthi of the eye( )he free argin of each eyelid has eyelashes or cilia arranged along its outer edge B1ig( F(1C( P#i&a se*i#u"aris H@^ * E6e2ro< @E6e#ashes Lacus lacri5alis % O%%Lateral angle i.un*ti.%: $ome features to be seen on the face around the leftI eye. "ith a nonhairy thin s'in intervening bet"een the t"o argins( )he li!s ?' . anger. e&!ress a variety of e otions li'e ha!!iness.al.tum "hich se!arates the t"o nasal cavities( 2ach nostril is bounded laterally by the ala) )hrough the !al!ebral fissure are seen8 BaC the o!a%ue sclera or "hite of the eye. grinning.ebral *on. therefore. fro"ning.un*ti. and the !art lining the !osterior surface of the lids is the .t the lo"er end of the nose "e see the right and left nostrils or anterior nares) )he t"o nostrils are se!arated by a soft edian !artition called the *olumella) )his is continuous "ith the nasal se.un*ti.il can be seen( )he eyeballs are lodged in bony soc'ets. being the uscles of facial e&!ression.a) )he line along "hich the bulbar con3unctiva beco es the !al!ebral con3unctiva is 'no"n as the *on.al sac Bsee 1ig( F(F4C( H( )he oral fissure or outh is the o!ening bet"een the u!!er and lo"er li.ais a oist. 1()he forehea+ is the u!!er !art of the face bet"een the hairline of the scal! and the eyebro"s( )he su!erolateral !ro inence of the forehead is 'no"n as the frontal eminen*e) F(Identify the follo"ing in relation to the nose( )he !ro inent ridge se!arating the right and left halves of the nose is called the +orsum) )he u!!er narro" end of the nose 3ust belo" the forehead. is an in+ex of min+) 0ne*s innerself is e&!ressed by the face itself as it is controlled by the higher centres( 1acial vein co unicates "ith the cranial venous sinuses( Infection fro the face thus can reach the brain( )hough the dangerous area of the face is bet"een the nasal o!enings and the u!!er li!. o4 e2e Lacri5al caruncle ris and : pupil seen through cornea Lacri5al %a%i##a <ith %u"&tu* Fig.alfornix) )he s!ace bet"een the t"o is the *on. 3oy. called the orbits B1ig( 19(1C( )he *on. is the root of the nose( )he lo"er end of the dorsu is in the for of a so e"hat rounded ti!( . trans!arent e brane( )he !art "hich covers the anterior surface of the eyeball is the bulbar *on. the "hole of the face is considered dangerous fro the infection !oint of vie"( .un*ti. BbC the trans!arent circular *ornea through "hich the coloured iris and the dar' circular . sadness.u.s) It lies o!!osite the cutting edges of the u!!er incisor teeth( )he angle of the outh usually lies 3ust in front of the first !re olar tooth( 2ach li! has a re+ margin at ucocutaneous 3unction and a bla*k margin.un*ti.

as in the !al s and soles( Fi*+ &+&: 5ines of dissection. and the ental fora en id"ay bet"een the u!!er and lo"er borders of the andible( )he su. called the external a*ousti* meatus) )he auricle hel!s in catching the sound "aves. !assing id"ay bet"een the lo"er t"o !re olar teeth.sually the s'in is so adherent to the sub3 acent connective tissue and a!oneurotic layers that these all co e off together( Dissect the layers. BHC loose areolar tissues. ly !hatics and identify these structures in the cadaver( )he soft tissues covering the cranial vault for scal!( E tent of $calp the .eflect the s'in in four fla!s( . B:C dee! fascia in the for of the e!icranial a!oneurosis or galea a!oneurotica "ith the occi!itofrontalis uscle. and the follo"ing descri!tion. crosses the infraorbital fora en five illi etre belo" the infraorbital argin. vessels.er*iliary arch is a curved bony ridge situated i ediately above the edial !art of each su!raorbital argin( )he glabella is the edian elevation connecting the t"o su!erciliary arches.inna8 and a dee! canal. and !rovides the !ro!er ediu for !assage of vessels and nerves to the s'in( )he o**i. including the nerves. and BJC !ericraniu B1ig( F(:C( )he s'in is thic' and hairy( It is adherent to the e!icranial a!oneurosis through the dense su!erficial fascia. the su!erficial te !oral region is studied "ith the scal!.erfi*ialfas*ia is ore fibrous and dense in the centre than at the !eri!hery of the head( It binds the s'in to the sub3acent a!oneurosis. called the auri*le or . su!raorbital arginsD !osteriorly. and corres!onds to the elevation bet"een the t"o eyebro"s( THE SCALP AND SUPERFICIAL TEMPORAL AAAAAAAAAAAAAAAAAA REIIONAAAAAAAAAAAAAAAAAA Place F-: "ooden bloc's under the head to raise it about 1G-1F c fro the table( +ive a edian incision in the s'in of scal! e&tending fro root of the nose to the !ro inent e&ternal occi!ital !rotuberance B1ig( F(F line "ith dashesC( +ive a coronal incision across the !revious incision fro root of one auricle to the other( 2&tend the incision fro the auricles to the astoid !rocess !osteriorly and to root of 7ygo a anteriorly( .nor ally close the outh along their red argins( )he . therefore.hiltrum is the edian vertical groove on the u!!er li!( J( )he external ear is ade u! of t"o !arts8 a su!erficial !ro3ecting !art. "ill cover both the regions( )he scal! is ade u! of five layers8 B1C S'in. and is a characteristic feature of a als( Details of the structure of the auricle "ill be considered later( La"$*ar-s o" the Fa&e DISSECTION )he su. vertical line dra"n fro the su!raorbital notch to the base of the andible.raorbital margin lies beneath the u!!er argin of the eyebro"( )he su!raorbital notch is !al!able at the 3unction of the edial one-third "ith the lateral t"o-thirds of the su!raorbital argin( .ital bellies are s all and se!arate( 2ach . the su!erior te !oral lines( $tructure Conventionally.itofrontalis mus*le has t"o bellies. e&ternal occi!ital !rotuberance and su!erior nuchal linesD and on each side. occi!ital or occi!italis and frontal or frontalis. both of "hich are inserted into the e!icranial a!oneurosis( )he o**i. BFC su!erficial fascia. )he su.nteriorly.

arises fro the lateral t"o-thirds of the su!erior nuchal line.eri*ranium.i&ia# .i*ranial a. J( te !oralis uscle. ingling "ith the orbicularis oculi and the corrugator su!ercilli( It is su!!lied by the tem. is ade u! of loose areolar tissue) It e&tends anteriorly into the eyelids B1ig F(HC because the frontalis uscle has no bony attach entD !osteriorly to the highest and su!erior nuchal linesD and on each side to the su!erior te !oral lines( )he fifth layer of the scal!. it receives the insertion of the frontalis. . and into the subconGunctival area. it receives the insertion of the occi!italis and is attached to the e&ternal occi!ital !rotuberance.oneurosis.osterior auri*ular branch of the fa*ial ner. or galea a!oneurotica is freely ovable on the !ericraniu along "ith the overlying and adherent s'in and fascia( .e) )he frontal bellies are longer.oral bran*h of the facial nerve( )he uscle raises the eyebro"s and causes hori7ontal "rin'les in the s'in of the forehead B1igs F(:.S-i" <ith hair Su%er. called the . and is su!!lied by the . and to the highest nuchal lines in bet"een the occi!ital bellies( 0n each side the a!oneurosis is attached to the su!erior te !oral line. is loosely attached to the surface of the bones. but sends do"n a thin e&!ansion "hich !asses over the te !oral fascia and is attached to the 7ygo atic arch B1ig( 1(HC( )he fourth layer of the scal!. "ider and !artly united in the edian !lane( 2ach arises fro the s'in of the forehead.as&ia <ith 2#oo$ 5esse#s Epicranial aponeurosis O Loose connecti7e tissue O E5issar2 7ein O O +)))) CCCCCCCCC Peri&ra"iu* C Di%#oe i" 2et<ee" outer a"$ i""er ta2#es o. 6( loose areolar tissue and A( !ericraniu ( AAAC Or2ita# se%tu* Fi*+ &+4: $chematic Or2i&u#aris o&u#i section through the scalp and upper eyelid to show how fluids can pass from the suboponeurotic space of the scalp into the eyelid. :( thin e&tension of e!icranial a!oneurosis "hich gives origin to e&trinsic uscles of the auricle. F( su!erficial fascia.nteriorly. F(HC( Co"Nu"&ti5a E%i&ra"ia# a%o"eurosis Fro"ta#is C Fro"ta# 2o"e )he e. s-u## JEE'D Dura *ater -uperior sagittal sinus Fi*+ &+': 5ayers of the scalp. H( te !oral fascia. Note that this is possible because the frontalis muscle has no bony attachment. !osteriorly. but is fir ly adherent to their sutures "here the sutural liga ents bind the !ericraniu to the endocraniu ( Superficial temporal region: It is the area bet"een the su!erior te !oral line and the 7ygo atic arch( )his area contains the follo"ing seven layers8 1( S'in.

er extensi.ital arteries.erfi*ial tem.ly derived fro both the internal and the e&ternal carotid arteries. the scal! is su!!lied fro before bac'"ards by the BHC . S&a#% a"$ Su%er.. the scal! has a rich bloo+ su.ulse+ . blee+ .. sub*utaneous haemorrhages are ne. and BJC o**i. both of "hich are branches of the e&ternal carotid artery( )hus. "hich o!en here ay trans it infection fro the scal! to the cranial venous sinuses( 6(Collection of blood in the layer of loose connective tissue causes generalised s"elling of the scal!( )he blood ay e&tend anteriorly into the root of the nose and into the eyeli+s.e. and the inflammations in this layer *ause little s9elling but mu*h .rofusely because the vessels are !revented fro retracting by the fibrous fascia( Bleeding can be arrested by a!!lying !ressure against the bone( H(Because of the density of fascia. collections of fluid dee! to the !ericraniu 'no"n as *e. . the t"o syste s anasto osing over the te !le( -upratrochlear arter2 -upratrochlear ner7e -upraor6ital ner7e 0reater Lesser occipital ner7e Q2go5atico%te5poral ner7e % VCPC3 HI?LO% %%%%%%%-upraor6ital arter2 -uper4icial te5poral arter2 <inna <osterior auricular arter2 Occipital arter2 occipital ner7e % 9hird Auriculote5poral ner7e % <.osterior auri*ular. the scal! is a co on site for seba*eous *ysts) F(Since the blood su!!ly of scal! and su!erficial te !oral region is very richD a.ain) J()he layer of loose areolar tissue is 'no"n as the +angerous area of the scal! because the e issary veins.oral arteries B1ig( F(JC( )he first t"o are branches of the o!hthal ic artery "hich in turn is a branch of the internal carotid artery( )he su!erficial te !oral is a branch of the e&ternal carotid artery( Behind the auricle.+: nerve scalp occipital ner7e' Fig. the scal! is su!!lied fro before bac'"ards by the B1C <u.ortions nee+ not be *ut a9ay) )hey can be re!laced in !osition and stitched8 they usually ta'e u! and heal "ell( :(Eounds of the s*al.i&ia# Te*%ora# Re!io" In front of the auricle.halhaematoma ta'e the sha!e of the bone concerned( Arteria# Su%%#6 o.raorbital8 and B:C su.ratro*hlear8 BFC su. Arterial and supply of and superficial temporal region.3 Hea$ a"$ Ne&CLINICAL ANATOM 1(Because of the abundance of sebaceous glands. causing bla*k eye) B1ig( F(HC 1(Eounds of the scal! do not ga!e unless the e!icranial a!oneurosis is divided transversely( F(Because the !ericraniu is adherent to sutures.

ein ends in anterior dee! te !oral vein or s!heno!arietal sinus( /osterior tem.ratro*hlear and su. therefore.ugular . but also cause acne in young adults( S"eat glands hel! in regulation of the body te !erature( 1(0axity of the greater !art of the s'in facilitates ra!id s!read of oede a( . enters the !arotid gland.loi* . the s&a#% a"$ su%er.ein) )he occi!ital veins ter inate in the subocci!ital venous !le&us Bsee 1ig( F(FFC( 2 issary veins connect the e&tracranial veins "ith the intracranial venous sinuses to e%ualise the !ressure( )he .ein !asses through the !arietal fora en to the su!erior sagittal sinus( )he mastoi+emissary uein!asses through the astoid fora en to the sig oid sinus( .nterior te !oral +i. co on to both the face and the scal!( -!in 1()he facial s'in is . therefore. tend to ga!e( .erfi*ial tem. or into the transverse sinus near the edian !lane B)able 1(FC( "3 -upratrochlear.oral +i.enal oede a a!!ears first in the eyelids and face before s!reading to other !arts of the body( F(Boils in the nose and ear are acutely !ainful due to the .oral .ein to for the external . situated on the surface of the !arotid gland( )he !osterior !art of the scal! drains into the !osterior auricular or astoid and occi!ital ly !h nodes Bsee 1ig( F(FJC( er7e -uppl2 )he scal! and te !le are su!!lied by ten nerves on each side( 0ut of these five nerves Bfour sensory and one otorC enter the scal! in front of the auricle( )he re aining five nerves Bagain four sensory and one otorC enter the scal! behind the auricle B1ig( F(J and )able F(1C( a'es the face blush and blanch( Eounds of the face bleed !rofusely but heal ra!idly( )he results of !lastic surgery on the face are e&cellent for the sa e reason( F()he facial s'in is rich in seba*eous an+ s9eat glan+s) Sebaceous glands 'ee! the face oily.ein "hich ulti ately drains into the subclauian .osterior auri*ular . 6ranch o4 "3 <osterior di7ision o4 great the 4rontal Gophthal5ic auricular ner7e GC=. 4ro5 cer7ical ple:us =3Q2go5aticote5poral. and on each side to the auricle( )he forehead is.n front of auricle $ensory nerves -ensor2 ner7es )he veins of the scal! acco !any the arteries and have si ilar na es( )he su.ich vascularity L25phatic Drainage )he anterior !art of the scal! drains into the !reauricular or !arotid ly !h nodes. C3H di7ision o4 trige5inal ner7eH 4ro5 cer7ical ple:us "3-upraor6itai.7 Venous Drainage Ta2#e (. inferiorly to the chin and the base of the andible. dorsal ra5usH ner7e /otor nerve " 3 9e5poral 6ranch o4 4acial ner7e /otor nerve "3 <osterior auricular 6ranch o4 4acial ner7e 9HE JACE )he face. and 3oins the a&illary vein to for the retro andibular vein( )he anterior division of the retro andibular vein unites "ith the facial vein to for the co on facial vein "hich drains into the internal 3ugular vein( )he !osterior division of the retro andibular vein unites "ith the .loi* .ein o!ens either into the occi!ital vein.as*ular) .i&ia# te*%ora# &ehind the auricle re!io"s . or countenance.loi* .S&a#%) Te*%#e a"$ Fa&e .9= Ner5es o.e aining e issary veins are !ut in )able 1(1( 2&tracranial infections ay s!read through these veins to intracranial venous sinuses( )he Jrontal +i.raorbitai veins unite at the edial angle of the eye for ing the angular vein "hich continues do"n as the fa*ial vein( )he su.ein ends in the transverse sinus( )he occi!ital di!loic . 6ranch o4 4rontal =3 Lesser occipital ner7e Gophthal5ic di7ision o4 trige5inal ner7eH GC=H.ein descends in front of the tragus. dorsal ra5usH 33Auriculote5poral 6ranch o4 5andi6ular di7ision o4 trige5inal ?3 9hird occipital ner7e GC3.ery . e&tends su!eriorly fro the adolescent !osition of hairline.ein e erges at the su!raorbitai notch o!ens into the su!raorbitai vein( .. 6ranch o4 33 0reater occipital ner7e L2go5atic ner7e G5a:illar2 di7ision o4 trige5inal ner7eH GC=.arietal emissary .*tty of the s'in to the underlying cartilages( :(1acial s'in is very elasti* an+ thi*k because the facial uscles are inserted into it( )he "ounds of the face.

but is "ell develo!ed in the chee's.hologi*ally. and over the buccinator "here it for s the bu**o. and a variable nu ber of dilators( S!hincters are naturally circular and the dilators radial in their arrange ent( )hese uscles are better develo!ed around the eyes and outh than around the nose B)able F(FC( )he occi!itofrontalis uscle has been described "ith scal!( Details of the other uscles are given in )able F(:( . for ing the buccal !ads that are very !ro inent in infants in "ho they hel! in suc'ing( )he +ee. centre of !hiltru of u!!er li!. F(11C :(Crief7 De!ressor anguli oris( H(6nger7 Dilator naris and de!ressor se!ti( J(5ro9ning7 Corrugator su!ercilii and !rocerus( B1igs F(1F.anni*ulus *amosus. na ely the !al!ebral fissures. to centre of lo"er li! to the chin( +ive a hori7ontal incision fro the angle of the outh to !osterior border of the andible B1ig( F(FC line "ith dotsC( . ost of these uscles ay be regarded !ri arily as regulators of the three o!enings situated on the face. su!!lied by the third cranial nerveC 1us*les of the Iose 1(Procerus F(Co !ressor naris B1ig( F(6C( :(Dilator naris H(De!ressor se!ti 1us*les 6roun+ the 1outh 1(0rbicularis oris B1ig( F(6C F(@evator labii su!erioris alae%uae nasi :(Lygo aticus a3or B1ig( F(AC H(@evator labii su!erioris B1ig( F(4C J(@evator anguli oris B1ig( F(AC 6(Lygo aticus inor A(De!ressor anguli oris 4(De!ressor labii inferioris 9(#entalis 1G(. fas*ia is absent fro the face. or the uscles of facial e&!ression. su!!lied by the facial nerve( 1or. e&ce!t over the !arotid gland "here it for s the !arotid fascia. fe" of the *ommon fa*ial ex. they develo! fro the esoder of the second branchial arch.ressions and the uscles !roducing the are given belo"( 1(<miling an+ laughing7 Lygo aticus a3or B1ig( F(9C F(<a+ness7 @evator labii su!erioris and levator anguli oris( B1igs F(1G./ and i% I DISSECTION +ive a edian incision fro the root of nose. and are. the uscles are grou!ed under the follo"ing si& heads( 1us*le of the <*al. they re!resent the best re nants of the . BFC the vessels and nerves. are subcutaneous uscles( )hey bring about different facial e&!ressions( Fmbryologi*a-y.hi*ally.uricularis su!erior :(. and B:C a variable a ount of fat( 1at is absent fro the eyelids.ll of the are inserted into the s'in( To.ogra. 9(JCC( 1(.uricularis !osterior 1us*les of the Fyeli+s 1(0rbicularis oculi B1ig( F(6C F(Corrugator su!ercilii B1ig( F(6C :(@evator !al!ebrae su!erioris Ban e&traocular uscle. ongst these otor branches on the face are the sensory branches of the three divisions of the trige inal nerve( )ry to identify all these "ith the hel! of their course given in the te&t B1igs F(19.isorius 11(Buccinator #uscles of the Ie*k 1( Platys a B1ig( F(AC 5un*tionally. the nostrils and the oral fissure( 2ach o!ening has a single s!hincter.haryngeal fas*ia) Fa&ia# Mus&#es )he facial uscles. all of "hich are inserted into the s'in. across the dorsu of nose. 1( 0cci!itofrontalis 1us*les of the 6uri*le Situated around the ear .eflect the lo"er fla! to"ards and u! to the lo"er border of andible( Direct and reflect the u!!er fla! till the auricle( Sub3acent to the s'in the facial uscles are directly encountered as these are inserted in the s'in( Identify the various functional grou!s of facial uscles( )race the various otor branches of facial nerve e erging fro the anterior border of !arotid gland to su!!ly these uscles( . F(1:C Su%er. therefore. on their "ay to the uscles and to the s'in.i&ia# Fas&ia It contains8 B1C )he facial uscles.uricularis anterior F(. a continuous subcutaneous uscle sheet seen in so e ani als( .

Q2go5aticus 5inor Q2go5aticus 5aFor Buccinator Le7ator anguli oris Risorius Modiolus Depressor anguli oris Or6icularis oris <lat2s5a . <.7: 2he facial muscles. 9e5ple and Jace 0alea aponeurotica '" Depressor supercilii Corrugator supercilii <rocerus %Co5pressor nans %Le7ator la6ii superioris %Q2go5aticus 5inor Jrontalis Or6icularis oculi Le7ator la6ii superioris alae8uae nasi % % Le7ator la6ii superioris O Q2go5aticus 5inor%%%%%% Q2go5aticus 5aFor % ) ' Risorius %%) Depressor anguli oris O Depressor la6ii in4eriors Q2go5aticus 5aFor 888(K( I@ GJ ^/KyK D %%%%%%%%% Le7ator anguli oris Depressor septi O Or6icularis oris %%%%%%%%%%%%%%%%% <lat2s5a :S Mentalis fig.-calp.

.8: $ome of the facial muscles.Fig. <.

e:cept the Or6icularis oris the sphincter.isorius 1(Contem.t7 Lygo aticus inor( F(Closing the mouth7 0rbicularis oris B1ig( F(16C .a&ia# *us&#es $phincter Or6icularis oculi 9ilators (pening A3 <alpe6ral 4issure "3Le7ator palpe6rae superioris =3Occipito4rontalis% B3 Oral 4issure Or6icularis oris 4rontalispart All the 5uscles around the 5outh. and the C3 ostrils 5entalis 1hich does not 5ingle 1ith or6i% cularis oris Gsee a6o7eH Co5pressor naris "3Dilator naris =3Depressor septi 33Medial slip o4 le7ator la6ii superioris alae% 8uae nasi Fi*+ &+": 0ygomaticus maGorOsmile. terror an+ fright7 Platys a B1ig( F(1HC F(Sur!rise8 1rontalis B1ig( F(1JC :(Doubt7 #entalis H(Crinning7 .(= Fu"&tio"a# !rou%s o. 1(Horror.1: $ome . <. . Ta2#e (.of Le7ator la6ii superioris alae8uae nasi Le7ator la6ii superioris Or6icularis oris the facial Depressor la6ii /n4erioris muscles.Mentalis Fig.

F(1AC( Clini*ally.1F( Ahistling7 Buccinator. and 0rbicularis oris B1igs F(16.er*ilii7 1ro"ning and a'ing vertical "rin'les of the forehead B1ig( F(1FC( . and loo' for the nor al hori7ontal "rin'les of the forehead B1ig( F(1JC( BFCCorrugator su.s' the !atient to loo' u!"ards "ithout oving his head. the facial nerve is e&a ined by testing the follo"ing facial uscles( B1C5rontalis7 .

=3"?H Releases pressure o4 s!in on the su6Facent 7einsU depresses 5andi6leU pulls the angle o4 the 5outh do1n1ards as in horror or surprise B1C>rbi*ularis o*uli7 )ight closure of the eyes B1ig( F(6C( BFC>rbi*ularis oris7 Ehistling and !ursing the outh( B1ig( F(16C B:CDilators of mouth7 Sho"ing the teeth( BHCBu**inator7 Puffing the outh and then blo"ing forcibly as in "histling B1ig( F(1AC( BJC/latysma7 1orcible !ulling of the angles of the outh do"n"ards and bac'"ards for ing !ro inent vertical folds of s'in on the side of the nec'( )he !latys a contracts along "ith the risorius B1ig( F(1HC( Motor Ner5e Su%%#6 o. 4ro5 pter2go5andi6ular raphe Upper parts o4 pectoral and deltoid 4asciae Ji6res run up1ards and 5ediall2 "3 Upper 4i6res. 7er2 thin sheet 63 E:trinsic part. 4ro5 5a:illa opposite 5olar teeth Lips and the angle o4 the 5outh ?3 Buccinator. deepest stratu5. 4ro5 5andi6le. to the 6ase o4 the 5andi6leU posterior 4i6res to the s!in o4 the lo1er 4ace and lip. deri7ed 4ro5 ele7ators and depressors o4 lips and their angles "3 Upper 4i6res. opposite 5olar teeth =3Middle 4i6res. orbicularis oculi B1ig( F(6C( Lygo aticM0rbicularis oculi B1ig( 9(J CC( BuccalM uscles of the chee' and u!!er li! B1igs F(A. "3$H "3Lo1er 4i6res.nsertion -!in o4 5id%e2e6ro1 Action Vertical lines in 4orehead@ 4ro1ning Closes lids tightl2U 1rin!lingU <rotects e2e 4ro5 6right light Closes lids gentl2U 6lin!ing Dilates lacri5al sacU directs lacri5al puncta into lacus lacri5alisU supports the lo1er lid Closes and purses the 5outhU nu5erous e:trinsic 5uscles 5a!e it 5ost 7ersatile 4or 7arious t2pes o4 gri5aces "3Corrugatorsupercilii GJig3 =3"=H =3Or6icularis oculi GJig3 =3AH a3 Or6ital part.9a6le =33@ 9he 4acial 5uscles /uscle (rigin Medial end o4 superciliar2 arch Medial part o4 5edial palpe6ral liga5ent and adFoining 6one Lateral part o4 5edial palpe6ral liga5ent Lacri5al 4ascia and lacri5al 6one . and 5a2 6e continuous 1ith the risorius '3 <lat2s5a GJig3 =3A.e is the otor nerve of the face( Its five ter inal branches. 7ygo atic. t1o strata. arginal andibular and cervical e erge fro the !arotid gland and diverge to su!!ly the various facial uscles as follo"s( )e !oralMfrontalis. lateral and deep to the lacri5al sac Concentric rings return to the point o4 origin Lateral palpe6ral raphe Upper and lo1er e2elids 33 Or6icularis oris a3 /ntrinsic part. 4ro5 5a:illaU /n4erior incisi7us. te !oral. auricular uscles. buccal. F(4C( . straight to the upper lip "3Lo1er 4i6res. 4ro5 5andi6le Angle o4 5outh 9hic!est 5iddle stratu5. the 5uscle o4 F the chee! GJig3 =3"$. on and around the or6ital 5argin 63 <alpe6ral part. deri7ed 4ro5 6uccinatorU thic! super4icial stratu5. straight to the lo1er lip )$ W% Jlattens chee! against n gu5s and teethU pre7entsE accu5ulation o4 4ood in the 7esti6ule3 9his is a 1histling 5uscle C +Cp =3Middle 4i6res decussate 6e4ore passing to the lips Anterior 4i6res. the Fa&e The fa*ial ner. in the lids c3 Lacri5al part. 4or5ed 62 con7erging 5uscles GJig3 =3"AH -uperior incisi7us.

%3: 5evaItor ta6E$ superioris O $adness. <. . Hea$ a"$ Fig.0.

the Fa&e )he trigeminal ner. refractive errors of the eyes.ny atte !t to s ile dra"s the outh to the nor al side( During astication. the ain sensory root. including that lining the anterior and iddle cranial fossae B1ig( F(FGD )able F(HC( In infranu*lear lesions B1ig( F(14C of the facial nerve. the !aranasal air sinuses BsinusitisC. the eyeball.e*ting 9G5 alcohol into the affected division of the trige inal ganglion. glauco a and infection of the eninges as in eningitis( F(Trigeminal neuralgia ay involve one or ore of the three divisions of the trige inal nerve( It causes attac's of very severe burning and scalding !ain along the distribution of the affected nerve( Pain is relieved either BaC by in.rann*lear lesions of the facial nerveD usually a !art of he i!legia. chee's.rticulation of labials is i !aired( In su. the "hole of the face of the sa e side gets !aralysed( )he face beco es asy etrical and is dra"n u! to the nor al side( )he affected side is otionless( Erin'les disa!!ear fro the forehead( )he eye cannot be closed( . infections and infla ations of teeth and gu s. food accu ulates bet"een the teeth and the chee'( . 'no"n as Bell*s !alsy. or BbC by se*tioning the affected nerve. the outh cavity.e through its three branches is the chief sensory nerve of the face B1ig( F(19D )able sensory distribution of the trige inal nerve e&!lains "hy hea+a*he is a unifor ly co on sy !to in involve ents of the nose Bco on cold. the sensory distribution of the trige inal nerve is also to the nasal cavity. the inde& finger on the 7ygo atic bone. or the s!inal tract of the trige inal nerve "hich is situated su!erficially in the edulla( )he !rocedure is called edullary tractoto y( . !alate. the !aranasal air sinuses. gu s. boilsC. C:C( In addition to ost of the s'in of the face. only the lo"er !art of the o!!osite side of face is !aralysed( )he u!!er !art "ith the frontalis and orbicularis oculi esca!es due to its bilateral re!resentation in the cerebral corte&( CLINICAL ANATOM 1()he Se"sor6 Ner5e Su%%#6 o. #arginal andibularM uscles of lo"er li!( CervicalM!latys a( )his can be understood by !utting your right "rist on the right ear and s!reading five digitsD the thu b over the te !oral region. teeth and anterior t"o-thirds of tongue and the su!ratentorial !art of the dura ater. the ring finger on the lo"er li! and the little finger over the nec'( CLINICAL ANATOM F(HC( )he s'in over the angle of the 3a" and over the !arotid gland is su!!lied by the great auricular nerve BCF.Fi*+ &+##: ieva=or anguli orisO$adness. iddle finger on the u!!er li!.

.S&a#%) Te*%#e a"$ Fa&e Fig. <.%<: !orrugator supercilii O Frowning.

SSS Fig. <. buccinator uscle. Fig.%6: PlatysmaOFright. <.%): ProcerusOFrowning. the Fa&e )he face is richly vascular( It is su!!lied by8 B1C )he facial artery. ucous e brane of the outh to o!en into its vestibule o!!osite second u!!er olar tooth Bsee 1ig( F(F6C( . running across the chee' t"o centi etre belo" the 7ygo atic arch( )he duct !ierces bucco!haryngeal fascia. BFC the transverse facial artery. Arteries o. <.Fig.%+: Frontalis? $urpriMe. reflecting off so e of the facial uscles if necessary( Straight facial vein runs on a !osterior !lane than the artery( Identify bucco!haryngeal fascia on the e&ternal surface of buccinator uscle( Clean the dee!ly !laced buccinator uscle situated lateral to the angle of outh( Identify !arotid duct. and B:C arteries that acco !any the cutaneous nerves( DISSiCTION )ortuous facial artery enters the face at the lo"er border of andible( Dissect its course fro the anteroinferior angle of asseter uscle running to the angle of outh till the edial angle of eye.

%7: (rbicularis orisOPursing the mouth. .04 Hea$ a"$ Ne&- Fig. <.

Fig. second !oint 1(F c lateral to the angle of the outh( . and finally enters the face( anterior border of the asseter uscle( BaC . !oint on the base of the andible at the BbC .%8: &uccinator?Jhistling. Fig. <. it !asses through the sub andibular region.%1: &ell.s palsy on right side. <. Facial -rtery BFacial Part? $urface /arking )he facial artery is the chief artery of the face B1ig( It is ar'ed on the face by 3oining the follo"ing F(F1C( It is a branch of the e&ternal carotid artery three !oints B1ig( 1(9C( the ti! of the greater cornua of the hyoid bone( In its given off in the carotid triangle 3ust above the level of cervical course.

!oint at the edial angle of the eye( )he artery is tortuous in its course and is ore so bet"een the first t"o !oints( Course )he anterior branches on the face are large and na ed( )hey are8 B1C Inferior labial. 0ygomaticofacial$.reat auricular. so that cut arteries s!urt fro both ends( F(S all !osterior branches anasto ose "ith the transverse facial and infraorbital arteries( Ta2#e (. $upraclavicular. the . "here it ter inates by su!!lying the lacri al sacD and by anasto osing "ith the dorsal nasal branch of the o!hthal ic artery( F()he facial artery is very tortuous( )he tortuosity of the artery !revents its "alls fro being unduly stretched during ove ents of the andible. anasto oses are large. BFC su!erior labial. the li!s and the chee's( :(It lies bet"een the su!erficial and dee! uscles of the face( )he course of the artery in the nec' is described in sub andibular region( Branches 1(1irst BcC .nfrafrochlear+.nfraorbital. Auriculotemporal. /ental.B(. C3H =3Upper di7ision o4 trans7erse GanteriorH cutaneous ner7e o4 .K.0ygomaticotemporal. and B:C lateral nasal. .= Cuta"eous "er5es o. it runs u!"ards and for"ards to a !oint 1(FJ c lateral to the angle of the outh( )hen it ascends by the side of the nose u! to the edial angle of the eye. and by !iercing the dee! cervical fascia.6. to the ala and dorsu of the nose( )he !osterior branches are s all and unna ed( Anastomosis 1()he 1( It enters the face by "inding around the base of the andible. . to the u!!er li! and the anteroinferior !art of the nasal se!tu . E ternal nasal.a&e $ource !utaneous nerve "3-upratrochlear ner7e =3-upraor6ital ner7e 33Lacri5al ner7e ?3/n4ratrochlearner7e '3E:ternal nasal ner7e "3/n4raor6ital ner7e =3Q2go5atico4acial ner7e 33Q2go5aticote5poral ner7e "3Auriculote5poral ner7e =3Buccal ner7e 33Mental ner7e Area of distribution A3 Ophthal5ic di7ision o4 trige5inal ner7e nec! GC =.%K: 2he sensory nerves of the 4ace3 E3 $upratrochlear=3 -upraor6EtaEU 3 . 5esser occipital. Palpebral branch of lacrimal.. <.7.%<. &uccal%%. at the anteroinferior angle of the asseter uscle( It can be !al!ated here and is called *anaesthetist*s artery*( large anterior branches anasto ose "ith si ilar branches of the o!!osite side and "ith the ental artery( In the li!s.S&a#%) Te*%#e a"$ Fa&e 0/ fig. C3H B3 Ma:illar2 di7ision o4 trige5inal ner7e C3 Mandi6ular di7ision o4 trige5inal ner7e D3 Cer7ical ple:us "3Anterior di7ision o4 great auricular ner7e GC=.%6. .%+.%). 2ransverse cutaneous nerve of neck. to the lo"er li!.8.

4oreheadU upper e2elidU conFuncti7a. dorsu5 and tip o4 nose Upper lipU side and ala o4 noseU 5ost o4 the lo1er e2elidU upper part o4 chee!U and anterior part o4 te5ple Lo1er lipU chinU lo1er part o4 chee!U lo1er Fa1 e:cept o7er the angleU upper =E3 o4 lateral sur4ace o4 auricleU and side o4 head -!in o7er the angle o4 the Fa1 and o7er the parotid gland3 Lo1er 5argin o4 the lo1er Fa1 .-calp up to 7erte:. s5all part o4 lo1er e2elidU and root.

<3: 9istribution of the cutaneous nerves in the head and neck. -uperior la6ial arter2 /n4erior la6ial arter2 Mental arter2 -upraor6ital arter2 -upratrochlear arter2 Dorsal nasal arter2 Lateral nasal arter2 . <.'& Head and ec! Ma:illar2 ner7e Ophthal5ic ner7e <osterior pri5ar2 ra5i o4 cer7ical ner7es Auricular 6ranch o4 7agus Mandi6ular ner7e Anterior pri5ar2 ra5i o4 cer7ical ner7es Fig.

<%: Arteries of the face. it runs for"ards over the asseter bet"een the !arotid duct and the 7ygo atic arch. -uper4icial te5poral arter2 :( .fter e erging fro the !arotid gland./n4raor6ital arter2 9rans7erse 4acial arter2 Buccal arter2 Jacial arter2 Fig.t the edial angle of the eye. a site for anasto osis bet"een the branches of the e&ternal and internal carotid arteries( 2ransverse Facial Artery )his s all artery is a branch of the su!erficial te !oral artery( . ter inal branches of the facial artery anasto ose "ith branches of the o!hthal ic artery( )his is. therefore. acco !anied . <.

drains into the subman+ibular no+es. BcC )he lo9er territory. F(F:C( :(The fa*ial . called the +angerous area of the fa*e B1ig( F(FHC( L6*%hati& Drai"a!e o. the lateral !art of the chee' and the !arotid area. lie on the bucco!haryngeal fascia around the !arotid duct( . asseter and the overlying s'in. including the central !art of the lo"er li! and the chin. including a stri! over the edian !art of the forehead. running do"n"ards and bac'"ards behind the facial artery. the con3unctiva. *onne*tions of the facial vein include8 BaC .er territory.ll these glands o!en into the vestibule of the outh B1ig( F(F6C( AAAAAAAAAA E ELIDS OR PALPEBRAEAAAAAAAAAA )he u!!er and lo"er eyelids are ovable curtains "hich !rotect the eyes fro foreign bodies and bright Su%raor2ita# 5ei" Su%ratro&h#ear 5ei" F A"!u#ar 5ei" Ca5er"ous si"us K H 5 F C Su%er.reauri*ular . including the greater !art of the forehead. and BbC another "ith the !terygoid !le&us through the +ee. and ends by anasto osing "ith neighbouring arteries B1ig( F(F1C( 1ei"s o.e+' arrangement 2ach corner of the *E is !rolonged u!"ards into the scal! and do"n"ards into the nec' B1igs F(FF. drains into the .aroti+ no+es. co unication bet"een the su!raorbital and su!erior o!hthal ic veins. but "ith a straighter course( It crosses the anteroinferior angle of the asseter. drains into the submental no+es B1ig( F(FJC( La2ia#) Bu&&a# a"$ Mo#ar Mu&ous I#a"$s )he labial and buccal ucous glands are nu erous( )hey lie in the sub ucosa of the li!s and chee's( )he olar ucous glands. the e&ternal nose.S&a#%) Te*%#e a by the u!!er buccal branch of the facial nerve( It su!!lies the !arotid gland and its duct. the edial halves of the eyelids. crosses the sub andibular gland.i&ia# . the u!!er li!. fa*ial vein "hich !asses bac'"ards over the buccinator( )he facial vein co unicates "ith the cavernous sinus through these connections( Infections fro the face can 1()he )he face has three ly !hatic territories8 BaC )he u. the edial !art of the chee'. the lateral halves of the eyelids.ein is the largest vein of the face "ith no valves( It begins as the angular vein at the edial angle of the eye( It is for ed by the union of the su!ratrochlear and su!raorbital veins( )he angular vein continues as the facial vein. the Fa&e s!read in a retrograde direction and cause thrombosis of the cavernous sinus( )his is s!ecially li'ely to occur in the !resence of infection in the u!!er li! and in the lo"er !art of the nose( )his area is. and 3oins the anterior division of the retro andibular vein belo" the angle of the andible to for the co on facial vein( )he latter drains into the internal 3ugular vein( It is re!resented by a line dra"n 3ust behind the facial artery( )he other veins are described "ith the scal!( H( Dee. the lateral !art of the lo"er li!.. the Fa&e veins of the face acco !any the arteries and drain into the co on facial and retro. BbC )he mi++le territory. and the greater !art of the lo"er 3a". therefore. !ierces the dee! fascia. four or five.andibular veins( )hey co unicate "ith the cavernous sinus( F()he veins on each side for a 'A&sha.

a&ia# 5ei"CCCCCCCCC DE Q JE F . I"ter"a# Nu!u#ar 5ei" E' Fi*+ &+&&: 2he veins of the face and their deep connections with the . retro*a"$i2u#ar 5ei" Fa&ia# 5ei" BAPrr-AAA Dee% . cavernous sinus and the pterygoid ple us of veins.a&ia# 5ei"CCCCCCCCC 6 C Pter6!oi$ %#e8us B Co**o" .te*%ora# 5ei" Retro*a"$i2u#ar 5ei" a"$ its a"terior $i5isio" CCCCC E8ter"a# Nu!u#ar 5ei" Ma8i##ar6 5ei"CCCCCCCCCR A )C Su2&#a5ia" 5ei" Posterior auri&u#ar 5ei" CCCCCC 2@4B Posterior $i5isio" o.

drains into the . the e&ternal nose. called the +angerous area of the fa*e B1ig( F(FHC( L6*%hati& Drai"a!e o. running do"n"ards and bac'"ards behind the facial artery. !ierces the dee! fascia. the Fa&e veins of the face acco !any the arteries and drain into the co on facial and retro. but "ith a straighter course( It crosses the anteroinferior angle of the asseter.er territory..a&ia# 5ei" Pter6!oi$ %#e8usCCCCCCC @ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC Retro*a"$i2u#ar 5ei" a"$ its a"terior $i5isio" Posterior auri&u#ar 5ei" Posterior $i5isio" o.ein is the largest vein of the face "ith no valves( It begins as the angular vein at the edial angle of the eye( It is for ed by the union of the su!ratrochlear and su!raorbital veins( )he angular vein continues as the facial vein. including a stri! over the edian !art of the forehead. BbC )he mi++le territory. the lateral !art of the lo"er6 li!. the lateral !art of the chee' and the !arotid area. retro*a"$i2u#ar 5ei" . the lateral halves of the eyelids. including the central !art of the lo"er li! and the chin.a&ia# 5ei"CCCCCCCCC@C C Co**o" . the edial halves of the eyelids.e+' arrangement) 2ach corner of the E is !rolonged u!"ards into the scal! and do"n"ards into the nec' B1igs F(FF. the edial !art of the chee'. lie on the bucco!haryngeal fascia around the !arotid duct( . and 3oins the anterior division of the retro andibular vein belo" the angle of the andible to for the co on facial vein( )he latter drains into the internal 3ugular vein( It is re!resented by a line dra"n 3ust behind the facial artery( )he other veins are described "ith the scal!( H( Dee. and ends by anasto osing "ith neighbouring arteries B1ig( F(F1C( Veins o4 the Jace s!read in a retrograde direction and cause thrombosis of the cavernous sinus( )his is s!ecially li'ely to occur in the !resence of infection in the u!!er li! and in the lo"er !art of the nose( )his area is. drains into the submental no+es B1ig( F(FJC( La2ia#) Bu&&a# a"$ Mo#ar Mu&ous I#a"$s )he labial and buccal ucous glands are nu erous( )hey lie in the sub ucosa of the li!s and chee's( )he olar ucous glands. crosses the sub andibular gland.reauri*ular . the u!!er li!.ll these glands o!en into the vestibule of the outh B1ig( F(F6C( AAAAAAAAAA E ELIDS OR PALPEBRAEAAAAAAAAAA )he u!!er and lo"er eyelids are ovable curtains "hich !rotect the eyes fro foreign bodies and bright -upraor6ital 5ei" C Su%er. and the greater !art of the lo"er 3a". fa*ial vein "hich !asses bac'"ards over the buccinator( )he facial vein co unicates "ith the cavernous sinus through these connections( Infections fro the face can 1()he )he face has three ly !hatic territories8 BaC )he u. four or five. F(F:C( :()heKociol . *onne*tions of the facial vein include8 BaC .i&ia# te*%ora# 5ei" Su%ratro&h#ear 5ei" Ma8i##ar6 5ei"CCCCCCC A A"!u#ar 5ei" Fa&ia# 5ei" BAL Dee% . the con3unctiva. BcC )he lo9er territory. and BbC another "ith the !terygoid !le&us through the +ee.S&a#%) Te*%#e a"$ Fa&e 07 by the u!!er buccal branch of the facial nerve( It su!!lies the !arotid gland and its duct. asseter and the overlying s'in. co unication bet"een the su!raorbital and su!erior o!hthal ic veins. including the greater !art of the forehead. therefore.andlbular veins( )hey co unicate "ith the cavernous sinus( F()he veins on each side for a 'A&sha. drains into the subman+ibular no+es.aroti+ no+es.

.)C Su2&#a5ia" 5ei" Fi*+ &+&&: 2he veins of the face and their deep connections with the cavernous sinus and the pterygoid ple us of veins.

area "b# drains into the submandibular nodes. loose and easily distensible by oede a fluid or blood( Latera# %a#%e2ra# ra%he KE HC Or2ita# se%tu* I". Area "a# drains into the preauricular nodes.at Fi*+ &+& : $cheme of coronal section showing structures in the cheek. there is a la*rimal . the bulbar con3unctiva is !inched u! to for a vertical fold called the . ade u! of odified s'in and s'in glands( @ateral to the caruncle.as&ia Mo#ar *u&ous !#a"$ Paroti$ $u&t CheeBu&&a# #6*%h "o$e Bu&&a# %a$ o. 2he parotid duct pierces buccai pad of fat.li*a semilunaris B1ig( F(1C( 2ach eyelid is attached to the argins of the orbital o!ening( Its free edge is broad and has a rounded outer li! and a shar! inner li!( )he outer li! !resents t"o or ore ro"s of eyelashes or cilia. buccopharyngeal fascia.t the !oint "here eyelashes cease.a. Bu&&a ! a"$s O O Se&o"$ *o#ar tooth Bu&&i"ator Bu&&o%har6"!ea# . buccinator muscle and the mucous membrane to open into the vestibule of mouth opposite the crown of the upper second molar tooth.erior tarsus Su%erior tarsus A La&ri*a# sa& A Me$ia# %a#%e2ra# #i!a*e"t BIAAA S . e&ce!t in the boundary of the lacus lacri alis( . .illa on the su it of "hich there is the la*rimal .and area "c# drains into the submental nodes. the locus la*rimalis) Eithin it there is an elevated la*rimal *arun*le.un*tum) =ear the inner li! of the free edge there is a ro" of o!enings of the tarsal glands( B1ig( F(1C $tructure 2ach lid is ade u! of the follo"ing layers fro "ithout in"ards8 1( )he skin is thin.S&a#%) Te*%#e a"$ Fa&e 49 1esti2u#e Fi*+ &+&5: 2he lymphatic territories of the face.

"&# $agittal section of the upper eyelid. .B Or2i&u#aris o&u#i Mor2ita# %artT BE KJ 'E Co"Nu"&ti5a E Ci#iar6 !#a"$s B ))Le5ator %a#%e2rae su%erioris C Su%erior &o"Nu"&ti5aV .or"i8 Or2ita# se%tu* AA Or2i&u#aris o&u#i M%a#%e2ra# %artT Su%erior tarsusCCCCCCCK AU Tarsa# !#a"$ Cor"ea Fi*+ &+&(: "A# (rbital septum.

and BcC sebaceous or tarsal glan+s.erioris uscle( It has BaC an orbital .lates or torsi in the lids and the . and BFC the lateral !al!ebral branch of the lacri al artery( )hey for an arcade in each lid( )he veins drain into the o!hthal ic and facial veins( Nerve $upply 1(@acri al !uncta and lacri al canaliculi( F(@acri al sac( :(=asolacri al duct( DISSECTION )he u!!er eyelid is su!!lied by the lacri al.a lines the !osterior surface of the tarsus( . the larger glands found in the lids are8 BaC @arge sebaceous glands also called as @eis's glan+s at the lid argin associated "ith ciliaD BbC odified s"eat glands or 1oll's glan+s at the lid argin closely associated "ith Leis*s glands and cilia. causing a locali7ed s"elling !ointing in"ards( A(Ble!haritis is infla ation of the eyelids.al.ebrae su. hard and !ainful.un*ti.!art fro the usual glands of the s'in. and ucous glands in the con3unctiva.4( Hea$ a"$ Ne&- su.ebral .al. and BbC a . and the lateral halves into the !reauricular nodes B1ig( F(FJC( LACRIMAL APPARATUS La&ri*a# I#a"$ )he structures concerned "ith secretion and drainage of the lacri al or tear fluid constitute the lacri al a!!aratus( It is ade u! of the follo"ing !arts8 1(@acri al gland and its ducts B1ig( F(F4C( F(Con3unctival sac( It is a serous glan+ situated chiefly in the lacri al fossa on the anterolateral !art of the roof of the bony orbit and !artly on the u!!er eyelid( S all a**essory la*rimal glan+s are found in the con3unctival fornices( )he gland is *J* sha!ed. and the "hole of the lid is oede atous( )he !us !oints near the base of one of the cilia( 6(Chala7ion is infla ation of a tarsal gland.erioris) Tarsal glan+s or #eibo ian glands are e bedded in the !osterior surface of the tarsiD their ducts o!en in a ro" behind the cilia( H( )he *on. su!ratrochlear and infratrochlear nerves fro lateral to edial side( )he lo"er eyelid is su!!lied by the infraorbital and infratrochlear nerves B1ig( F(19C( 5ymphatic 9rainage 0n the lateral side of the u!!er lid cut the !al!ebral fascia( )his "ill sho" the !resence of the lacri al gland dee! in this area( Its !al!ebral !art is to be traced in the u!!er eyelid( 0n the edial ends of both the eyelids loo' for lacri al !a!illa( )hese are ideally seen in your friend*s eyes( Pal!ate and dissect the edial !al!ebral liga ent binding the edial ends of the eyelids( )ry to locate the s all lacri al sac behind this liga ent( )he edial halves of the lids drain into the sub andibular nodes.ator . lying "ithin the eyelid B1ig( F(F4C( .al.ebrae su.tum) Its thic'enings for tarsal .art "hich is larger and dee!er.al.ebral fas*ia of the t"o lids for s the orbital se.al. being indented by the tendon of the le.ator . su!raorbital. these are also 'no"n as 1eibomian glan+s) &lood $upply 1()he CLINICAL ANATOM 1()he !al!ebral con3unctiva is e&a ined for anae ia and for con3unctivitisD the bulbar con3unctiva for 3aundice( F(1oreign bodies are often lodged in a groove situated F fro the edge of each eyelid( :(Con3unctivitis is one of the co onest diseases of the eye( It ay be caused by infection or by allergy( H()racho a is a contagious granular con3unctivitis caused by the tracho a virus( It is regarded as the co onest cause of blindness( J(Stye or hordeolu is a su!!urative infla ation of one of the glands of Leis( )he gland is s"ollen. s!ecially of the lid argin( )he eyelids are su!!lied by8 B1C )he su!erior and inferior !al!ebral branches of the o!hthal ic artery.erfi*ial fas*ia is "ithout any fat( It contains the !al!ebral !art of the orbicularis oculi B1ig( F(FABC( F()he .art s aller and su!erficial.ebral ligaments at the angles( )arsi are thin !lates of condensed fibrous tissue located near the lid argins( )hey give stiffness to the lids( )he u!!er tarsus receives t"o tendinous sli!s fro the le.

un*ti. highly vascular. . and adherent to the tarsal !late( )he .al sa*) )he lines along "hich the !al!ebral con3unctiva of the u!!er and lo"er eyelids is reflected onto the eyeball are called the su!erior and inferior *on.bout a do7en of its +u*ts !ierce the con3unctiva of the u!!er lid and o!en into the con3unctival sac near the su!erior forni&( #ost of the ducts of the orbital !art !ass through the !al!ebral !art( .un*ti. <.ebral *on. o!a%ue.al forni*es) )he .un*ti. it overflo"s as tears( ConFuncti7aN -ac )he con3unctiva lining the dee! surfaces of the eyelids is called !al!ebral con3unctiva and that lining the front of the eyeball is bulbar con3unctiva( )he !otential s!ace bet"een the !al!ebral and bulbar !arts is the *on.al.fter re oval.e oval of the latter is functionally e%uivalent to re oval of the entire gland( . the con3unctiva and cornea are oistened by accessory lacri al glands( )he gland is su!!lied by the lacri al branch of the o!hthal ic artery and by the lacri al ner.e) )he nerve has both sensory and secreto otor fibres( )he secreto otor fibres run as follo"s8 @acriatory nucleusMnervus inter ediusM geniculate ganglionMgreater !etrosal nerveMnerve of !terygoid canalM!terygo!alatine ganglionMrelayMFygo atic nerveM7ygo aticote !oralMlacri al nerveM lacri al gland B)able 1(:C( )he lacri al fluid secreted by the lacri al gland flo"s into the con3unctival sac "here it lubricates the front of the eye and the dee! surface of the lids( Periodic blin'ing hel!s to s!read the fluid over the eye( #ost of the fluid eva!orates( )he rest is drained by the lacri al canaliculi( Ehen e&cessive.-calp. 9e5ple and Ducts Le7ator palpe6rae superioris Lacri5al punctu5 Lacri5al caruncle Lacri5al sac asolacri5al duct ConFuncti7aN sac Lacri5al gland <alpe6ral part O Fig.a is thic'.<1: 5acrimal apparatus.

and loosely attached to the eyeball( 0ver the cornea it is re!resented by the anterior e!itheliu of the cornea( Lacri5al <uncta and Canaliculi 2ach lacri al canaliculus begins at the la*rimal . bac'"ards and laterally. and is 1G long( It has a vertical !art "hich is F long and a hori7ontal !art "hich is.bulbar *on. 4 long( )here is a dilated a !ulla at the bend( Both canaliculi o!en close to each other in the lateral "all of the lacri al sac behind the edial !al!ebral liga ent( La&ri*a# Sa& It is e branous sac 1F long and J "ide. situated in the lacri al groove behind the edial !al!ebral liga ent( Its u!!er end is blind( )he lo"er end is continuous "ith the nasolacri al duct( )he sac is related anteriorly to the edial !al!ebral liga ent and to the orbicularis oculi( #edially. it is related to the lacri al fascia and the lacri al !art of the orbicularis oculi( Infla ation of the lacri al sac is called dacrocystitis( Naso#a&ri*a# Du&t It is a e branous !assage 14 long( It begins at the lo"er end of the lacri al sac. the lacri al groove se!arates it fro the nose( @aterally. trans!arent.un*tum.al. and o!ens into the inferior eatus of the nose( .un*ti. fold of ucous e brane called the . runs do"n"ards.a covers the sclera( It is thin.e of Hasner forms an i !erfect valve at the lo"er end of the duct( .

!hiltru of u!!er li! and !re a&illa bearing u!!er four incisor teeth( #a&illary !rocess for s "hole of u!!er li! e&ce!t the !hiltru and ost of the hard and soft !alate e&ce!t the !art for ed by the !re a&illa( #andibular !rocess for s the "hole lo"er li!( Cord of ectoder gets buried at the 3unction of frontonasal and a&illary !rocesses( Canalisation of ectoder al cord of cells gives rise to nasolacri al duct( . t"o a&illary and. one frontonasal. the nasal se!tu .Hea$ a"$ Ne&DE1ELOPMENT OF FACE 1ive !rocesses of face. t"o andibular !rocesses for the face( 1rontonasal !rocess for s the forehead.

by the clavicle( )his %uadrilateral s!ace is divided obli%uely by the sternocleido astoid uscle into the anterior an+ . therefore. i ediately anteroinferior to the ti! of the astoid !rocess( )he fourth *er. seven.i*al trans.ugular . by the anterior edian lineD !osteriorly.ro*ess of the atlas .erse .-ide o4 the ec! *)>he beauty of the nec' lies in its dee! or cervical J( fascia( )he sternocleido astoid is an i !ortant land ar' bet"een the anterior and !osterior triangles( )he !osterior triangle contains the s!inal root of accessory nerve dee! to its fascial roof and the roots and trun's of brachial !le&us dee! to its fascial floor( It also contains a !art of the subclavian artery.e4ius mus*le beco es !ro inent on elevation of the shoulder against resistance( )he side of the nec' is roughly %uadrilateral in outline( It is boun+e+ anteriorly.i*ular fossa lies above and behind the iddle one-third of the clavicle( It overlies the cervical !art of the brachial !le&us and the third !art of the subclavian artery( H()he lesser su.erse . leads to air e bolis .i*ular fossa is a s all de!ression bet"een the sternal and clavicular !arts of the sternocleido astoid( It overlies the internal 3ugular vein( J()he mastoi+ .ra*la.ro*ess is a large bony !ro3ection behind the auricle( 6()he trans. do not su!!ly the nec'( )he territory of fourth cervical nerve e&tends . dee! to the anterior border of the sternocleido astoid uscle( A( )he anterior bor+er of the tra. great auricular. unless the dee! fascia !ierced by the vein is also cut to colla!se the vein( LANDMAR'S ON THE SIDE OF THE NEC' 1()he sterno*lei+omastoi+ uscle is seen !ro inently "hen the chin is turned to the o!!osite side( )he ridge raised by the uscle e&tends fro the clavicle and sternu to the astoid !rocess( F()he external . broad band of s'in over the !osterior !art is su!!lied by dorsal !osterior !ri ary ra i B1ig( F(FGC( 1irst cervical s!inal nerve has no cutaneous distribution( Cervical five. by the base of the andible.ro*ess is 3ust !al!able at the level of the u!!er border of the thyroid cartilageD and the sixth *er.ein crosses the sternocleido astoid obli%uely.i*al . running do"n"ards and bac'"ards fro near the auricle to the clavicle( It is better seen in old age( :()he greater su. a line 3oining the angle of the andible to the astoid !rocess.erse . "hich continues as the a&illary artery for the u!!er li b( .ertebra can be felt on dee! !ressure id"ay bet"een the angle of the andible and the astoid !rocess.rteries li'e the rivers are na ed according to the regions they !ass through( Congestive cardiac failure can be seen at a glance by the raised 3ugular venous !ressure( )his vein lies in the su!erficial fascia and if cut. eight and thoracic one nerves su!!ly the u!!er li b through the brachial !le&usD and. si&.osterior triangles B1ig( :(1T S-i" )he s'in of the nec' is su!!lied by the second.ra*la. and the su!erior nuchal lineD and inferiorly.i*al trans. by the anterior border of the tra!e7iusD su!eriorly.erse .ro*ess of the sixth *er. lesser occi!ital and su!raclavicular nerves( . third and fourth cervical nerves( )he anterolateral !art is su!!lied by anterior !ri ary ra i through the anterior cutaneous.ertebra is the largest of all such !rocesses and is called the *aroti+ tuber*le of Chassaignac( )he co on carotid artery can be best !ressed against this tubercle.ro*ess at the level of the cricoid cartilage( )he anterior tubercle of the trans.

6J .

eriorly7 BaC 2&ternal occi!ital !rotuberance. into the !ectoral region through the su!raclavicular nerves and eets second thoracic der ato e at the level of the second costal cartilage( DEEP CER1ICAL FASCIA MFASCIA COLLIT )he dee! fascia of the nec' is condensed to for the follo"ing layers8 B1C Investing layer. and is attached to the 7ygo atic arch( )he dee! la ina is thin and is attached to the styloid !rocess. both of "hich are described belo" B1ig( :(FC( /osteriorly7 BaC @iga entu nuchaeD and BbC s!ine of seventh cervical vertebra( 6nteriorly7 BaC Sy !hysis entiD BbC hyoid bone( Both above and belo" the hyoid bone it is continuous "ith the fascia of the o!!osite side( 9rachea V TR)'@%S' Fi*+ '+&: 'ertical e tent of the first three layers of the deep cervical fascia. and B6C !haryngobasilar fascia( Manu6riu5 %%%%%% Arch o4 aorta%%%%%%%% AL. BbC acro ion !rocess.L. 5ateral view. and BdC anubriu ( )he fascia s!lits to enclose the su!rasternal and su!raclavicular s!aces.aroti+ fas*ia is thic' and dense. and is !ierced by the e&ternal carotid artery( Inferiorly7 BaC S!ine of sca!ula.O /n7esting 4ascia -25ph2sis 5enti O in7esting 4ascia [ <retracheal 4ascia % % Liga5entu5 nuchae % <re7erte6ral 4ascia . BeC bet"een the angle of the * andible and the astoid !rocess. !ontinuity between the tissue space of the neck and the mediastinum can be seen. B:C !revertebral layer. . ). BdC base of the andible. and surrounds the nec' li'e a collar( It for s the roof of the !osterior triangle of the nec'( -ttach6ents %A"terior tria"!#e iiZZ B Tra%eWius F B Posterior tria"!#e C A&ro*io" C#a5i&#e EJD Ma"u2riu* Fig. BJC bucco!haryngeal fascia. BFC !retracheal layer. the fascia s!lits to enclose the !arotid gland( )he su!erficial la ina na ed as . BcC astoid !rocess and the. C t <u.%: 2he triangles of the neck. BcC clavicle. *a"$i2#e B Su%erior "u&ha# #i"e 312B Mastoi$ %ro&ess %Ster"o&#ei$o*astoi$ I"5esti"! La6er It lies dee! to the !latys a.. BHC carotid sheath. . the andible and the ty !anic !late( Bet"een the styloid !rocess and the angle of the andible the dee! la ina is thic' and for s the styloman+ibular ligament 9hi*h se!arates the !arotid gland fro the sub andibular gland. BbC su!erior nuchal line.Base a"$ a"!#e o.

>. E:ternal Fugular 7ein %/nternal Fugular 7ein Co55on carotid arter2 D=D=I. BcC a ly !h node. /n7esting 4ascia . !asses behind the brachioce!halic veins.h% Jused pre7este6ral + and 6uccophar2ngeal 4asciae '%%%%%% 4O <re7erte6ral 4ascia O3% I6PP 7entral and D. and ay e&tend to the thyroid cartilage( )hey su!!ort the thyroid gland. including ly !hatics( <retracheal Jascia B1C) h e i n v e s t i n g l a y e r o f d e e ! c e r v i c a l f a s c i a >n either si+e7 It fuses "ith the front of the carotid sheath dee! to the sternocleido astoid B1ig( 1F(HC( (ther Features B1C)he !osterior layer of the thyroid ca!sule is thic'( 0n either side it for s a sus.a*e contains8 BaC )he sternal heads of the right and left sternocleido astoid uscles.II. and BcC cutaneous vessels. Vagus ner7e >D=G@.rasternal s..eriorly7 It is attached to the base of the s'ull B1ig( :(FC( Inferiorly7 It e&tends into the su!erior ediastinu "here it is attached to the anterior longitudinal liga ent and to the body of the fourth thoracic vertebra( )he i !ortance of this fascia is that it encloses and sus!ends the thyroid gland and for s its false ca!sule B1ig( :(:C( Attachments <u.a *es M s u !r as ter nal an d su!raclavicular( BFCIt also for s .S .II Oesophagus %%(@D3P L25ph node in retrophar2ngeal space .O 9rachea . and BcC cricoid cartilage.ulleys to bind the tendons of the digastric and o ohyoid uscles( )he su. and BdC the interclavicular liga ent( )he su. and for s the floor of the !osterior triangle of the nec' B1ig( :(:C( Attachments and Felations <u.B>Gf.eriorly7 BaC <yoid bone in the edian !lane BbC obli%ue line of thyroid cartilage.GP B>D>=+3O -pinal accessor2 ner7e ' -calenus anterior and scalenus 5edius -calenus posterior'' Le7ator scapulae / Muscles o4 6ac! 9h2roid gland .= Carotid sheath . ore laterally( Inferiorly7 Belo" the thyroid gland it encloses the inferior thyroid veins..* -25pathetic trun!O+\M( <hrenic ner7e . and B cC s .(ther Features s.ra*la.ary glan+s M !arotid and s ub an di bul ar. BbC the 3ugular venous arch.. <retracheal 4ascia .a*e is traversed by8 BaC )he e&ternal 3ugular vein. <lat2s5a .i*ular s.NfODD Dorsal ra5i o4 cer7ical ner7e R Longus cer7icis Muscles o4 6ac! % -plenius capitis Anterior Fugular 7ein ' -ternoth2roid R 9rapeLius E .ensory ligament for the thyroid gland 'no"n as ligament of Berry B1ig( 1F(HC( )he liga ents are attached chiefly to the cricoid cartilage. and finally blends "ith the arch of the aorta( -ternoh2oid O5oh2oi d -ternocleido5astoid . BbC the su!raclavicular nerves.lits to enclose8 BaC 1us*les Mtra!e7ius and sterno-cleido astoidD BbC sali. and do not let it sin' into the ediastinu ( )he ca!sule of the thyroid is very "ea' along the !osterior borders of the lateral lobes( BFC)he fascia !rovides a sli!!ery surface for free ove ents of the trachea during s"allo"ing( <re7erte6ral Jascia It lies in front of the !revertebral uscles.

): 2ransverse section through the neck at the level of the seventh cervical vertebra. .Fig. ).

<<>><B<<II#II>>B><IIIII>I<<##I>>I><###I>>>><<#i>>>>><il< It is a condensation of the fibroareolar tissue around the ain vessels of the nec'( )here are the co on and internal carotid arteries and internal 3ugular vein and the vagus nerve( It is thin over the vein B1ig( :(H. !lastered to the !revertebral fascia( :()he sheath is overla!!ed by the anterior border of the sternocleido astoid. whereas the sympathetic chain lies posteI rior to the sheath. "A# $urface view.re. the oeso!hagus and the carotid sheaths during ove ents of the nec' and during s"allo"ing( Carotid -heath ansa cervicalis lies e bedded in the anterior "all of the carotid sheath( F()he cervical sy !athetic chain lies behind the sheath..<ead and =ec' 6nteriorly7 It is se!arated fro the !haryn& and bucco!haryngeal fascia by the retro!haryngeal s!ace containing loose areolar tissue( 0aterally7 It is lost dee! to the tra!e7ius( (ther Features 1()he Felations 1()he cervical and brachial !le&uses lie behind the !revertebral fascia( )he fascia is !ierced by the four cutaneous branches of the cervical !le&us B1ig( 1F(F4C( F(. they carry "ith the a covering of the !revertebral fascia 'no"n as the axillary sheath "hich e&tends into the a&illa( )he subclavian and a&illary veins lie outside the sheath and as a result they can dilate during increased venous return fro the li b( :(1ascia !rovides a fi&ed base for the ove ents of the !haryn&. i(e( for ation of !us in the retro!haryngeal ly !h nodes( )he !us for s an a*ute retro.B. and the subclavian artery. Cervical 1ascia 1(Parotid s"ellings are very !ainful due to the unyielding nature of the !arotid fascia( F(Ehile e&cising the sub andibular salivary gland. the e&ternal carotid artery should be secured before dividing it.haryngeal abs*ess .ertebral fas*ia arise usually fro tuberculosis of the cervical vertebrae or the cervical caries( Pus !roduced as a result ay e&tend in various directions( It ay !ass for"ards for ing a *hroni* retro. 2he ansa cervicalis is embedded in the anterior wall of the sheath. or in the lateral "all of the a&illa( It ay e&tend do"n"ards into the su!erior ediastinu .s the trun's of the brachial !le&us. BC( I"ter"a# &aroti$ arter6 AAAAA Co**o" &aroti$ arter6 AAAA Nu!u#ar 5ei" A A I"ter"a# E8ter"a# &aroti$ arter6 A"sa &er5i&a#is %%O C1a!us "er5e S6*%atheti& tru"B R9OO 33' fi*+ '+4: Fight carotid sheath with its contents. !ass laterally through the interval bet"een the scalenus anterior and the scalenus edius. and is fused to the first three layers of the dee! cervical fascia( Buccophar2ngeal Jascia )his fascia covers the su!erior constrictor uscle e&ternally and e&tends on to the su!erficial as!ect of the buccinator uscle B1ig( 1H(1GC( <har2ngo6asilar Jascia )his fascia is es!ecially thic'ened bet"een the u!!er border of su!erior constrictor uscle and the base of the s'ull( It lies dee! to the !haryngeal uscles B1igs 1H(1G. in the edian !lane( )he !us ay e&tend laterally through the a&illary sheath and !oint in the !osterior triangle. "&# $ectional view. 1H(1JC( CLINICAL ANATOM iiil9<<#>>>>.haryngeal abs*ess "hich ay for a bulging in the !osterior "all of the !haryn&. other"ise it ay retract through the stylo andibular liga ent and cause serious bleeding( :()he thyroid gland and all thyroid s"ellings ove "ith deglutition because the thyroid is attached to the laryn& by the sus!ensory liga ents of Berry B1ig( 1F(HC( H(Ie*k infe*tions behin+ the . "here its descent is li ited by fusion of the !revertebral fascia to the fourth thoracic vertebra( J(=ec' infections in front of the !revertebral fascia in the retro!haryngeal s!ace usually arise fro su!!uration.

"hich bulges .

arame+ian . nerve to subclavius( #edial to the brachial !le&us locate the third !art of subclavian artery( 1ollo" the ter inal !art of e&ternal 3ugular vein through the dee! fascia into the dee!ly !laced subclavian vein( Identify su!rasca!ular artery running 3ust above the clavicle B1ig( :(AC( Define the attach ents and relations of sternocleido astoid uscle( )o e&!ose scalenus anterior uscle cut across the clavicular head of sternocleido astoid uscle and !ush it edially( Scalenus anterior uscle covered by "ell defined !revertebral fascia can be identified( @ocate the subclavian artery and u!!er !art of brachial !le&us dee! to the scalenus anterior uscle( .for"ards in the .eflect the su!erficial la ina to e&!ose the su!rasternal s!ace and identify its contents( Define the attach ents of investing layer.ro*ess) Befle*t only the skin to9ar+s the anterior border of tra!e7ius uscle( Platys a. %osterior tria"!#e fig.osition +ue to fusion of the bucco!haryngeal fascia to the !revertebral fascia in the edian !lane( )he infection ay e&tend do"n through the su!erior ediastinu into the !osterior ediastinu B1ig( :(:C( 1(Ie*k infe*tions in front of the . o*oh6oi$ HC C#a5i&#e Su%ra&#a5i&u#ar %art o. ). D'SiCTION 1(+ive a edian incision fro the chin do"n"ards to"ards the su!rasternal notch situated above the anubriu of sternu ( F(#a'e another incision in the s'in of base and along the !osterior border of the andible till the mastoi+ . a !art of the subcutaneous uscle is visible( . roof.+: &oundaries of the posterior triangle.erior 2e##6 o. !retracheal layer.eflect the !latys a to"ards the andible( Identify the anterior or transverse cutaneous nerve of the nec' in the u!!er !art of su!erficial fascia( .ex7 @ies on the su!erior nuchal line "here the tra!e7ius and sternocleido astoid eet( -uperior 6ell2 o4 o5oh2oid C Tra%eWius CCCCCCC Ster"o&#ei$o*astoi$ C Posterior tria"!#e Mo&&i%ita# %artT I". attached fir ly to the vein( AAAAAAAAA POSTERIOR TRIANILEAAAAAAAAAAA )he !osterior triangle is a s!ace on the side of the nec' situated behind the sternocleido astoid uscle( Boundaries 6nterior7 Posterior border of sternocleido astoid B1ig( :(JC( /osterior7 . floor. dorsal sca!ular nerve.retra*heal fa*ia ay bulge in the su!rasternal area or e&tend do"n into the anterior ediastinu ( F(Division of the e&ternal 3ugular vein in the su!raclavicular s!ace ay cause air embolism an+ *onse:uent +eath because the cut ends of the vein are !revented fro retraction and closure by the fascia.nterior 3ugular vein running vertically close to the edian !lane is also encountered( . long thoracic nerve.e ove the su!erficial fascia till the dee! fascia of nec' is seen B1ig( :(6C( :( . divisions and contents of the !osterior triangle( Identify and clean the inferior belly of o ohyoid( 1ind the transverse cervical artery along the u!!er border of this uscle( )race it both "ays( Dee! to this uscle is the u!!er or su!raclavicular !art of brachial !le&us( Identify the roots. !revertebral layer and carotid sheath( )ry to dissect and clean the cutaneous nerves "hich !ierce the investing layer of fascia at the iddle of !osterior border of sternocleido astoid uscle( De arcate the course of e&ternal 3ugular vein( Cut carefully the dee! fascia of !osterior border of sternocleido astoid uscle and reflect it to"ards tra!e7ius uscle( Identify the accessory nerve lying 3ust dee! to the investing layer seen at the iddle of the !osterior border of sternocleido astoid uscle and across the !osterior triangle to reach the anterior border of tra!e7ius "hich it su!!lies B1ig( :(AC( Define the boundaries. trun's and their branches carefully( )he branches are su!rasca!ular nerve. Note that the infeI rior belly of the omohyoid divides the triangle into upper or ocI cipital and lower or supraclavicular parts.nterior border of tra!e7ius( Inferior or base7 #iddle one-third of clavicle( 6.nother incision is given along the u!!er border of clavicle( )o o!en u! the su!rasternal s!ace a'e a hori7ontal incision 3ust above the sternu ( 2&tend this incision along the anterior border of sternocleido astoid uscle for :-H c ( .

*er.i*al .ator s*a. great auricular.ontents of the Posterior Trian*le )he s.i*ular or the sub*la. )he floor of the !osterior triangle is for ed by the !revertebral layer of dee! cervical fascia. the Posterior Tria"!#e Roo. BdC unna ed arteries derived fro the occi!ital. crosses the sternocleido astoid obli%uely. the argins of the vein get adherent to the fascia( So if the vein gets cut.lexus !ierce the fascia >covering the floor of the triangle. !ass through the triangle and !ierce the dee! fascia at different !oints to beco e cutaneous B1ig( :(6C( 1us*ular bran*hes to the le. transverse cervical and B1ig( :(4C su!rasca!ular arteriesD and BeC ly !h vessels "hich !ierce the dee! fascia to end. the dee! fascia has to be cut( Its tributaries are8 BaC )he !osterior e&ternal 3ugular vein.e e erges a little above the iddle of the !osterior border of the sternocleido astoid( It runs through a tunnel in the fascia for ing the roof of the triangle. and o!ens into the subclavian vein. :(4C( )he four *utaneous bran*hes of the *er. by 3oining the 3 follo"ing !oints( faC )he first 3ooint a little beJo" and behind the angle of the andible( BbC )he second !oint on the clavicle 3ust lateral to the !osterior border of the sternocleido astoid B1ig( :(6C( )he e&ternal 3ugular vein is examine+ to assess the . called the su.ital triangle. and disa!!ears under the anterior border of the tra!e7ius about J c above the clavicle B1igs :(A.enous . .ugular . !ierces the anteroinferior angle of the roof of the !osterior triangle.ulae an+ to the tra. CHC a!!ear about the iddle of the sternocleido astoid( )hose to the levator soon end in itD those to the tra!e7ius run belo" and !arallel to the accessory nerve across the iddle of the triangle( Both nerves lie dee! to the fascia of the floor B1ig( :(9C( .ian triangle B1ig( :(AC( * Co"te"ts o.ressure8 the right atrial !ressure is reflected in it because there are no valves in the entire course of this vein( F#oor B E8ter"a# Nu!u#ar 5ei" Fi*+ '+ : $tructures seen in relation to the fascial roof of the posI terior triangle.inal a**essory ner.e4ius BC:. !assing do"n"ards and laterally. and BbC a s aller lo"er !art.$urface /arking of E ternal Bugular 'ein Lesser o&&i%ita# "er5e Ireat auri&u#ar "er5e A"terior &uta"eous "er5e Su%ra&#a5i&uNar "er5es 1 )he vein is usually visible through the s'in and can I be ade ore !ro inent by blo"ing "ith the outh and nostrils closed( It can be ar'ed. transverse cutaneous and lesser occi!ital nerves. it cannot close and air enters into it and causes air e bolis ( )o !revent this. called the o**i.s>lt !ierces the fascia.esting layer of +ee. in the su!raclavicular nodes( K )he extemal. the Posterior Tria"!#e )hese are enu erated in )able :(1( So e of the contents are considered belo"8 7eleAant Features of the . if not visible.i*al fas*ia) )he su!erficial fascia over the !osterior triangle contains8 BaC )he !latys a. )he roof is for ed by the in.ra*la. BbC the transverse cervical veinD BcC the su!rasca!ular veinD and BdC the anterior 3ugular vein( )he obli%ue 3ugular vein connects the e&ternal 3ugular vein "ith the internal 3ugular vein across the iddle one-third of the anterior border of the sternocleido astoid( It is subdivided by the inferior belly of the o ohyoid into BaC a larger u!!er !art. covering the follo"ing uscles8 BaC S!lenius ca!itisD BbC levator sca!ulaeD BcC scalenus edius B1ig( :(AC and occasionally scalenus !osterior( Di5isio" o.ein7 lilies dee! to the !latys a B1ig( :(6C( It is for ed by union of the !osterior auricular vein "ith the !osterior division of the retro andibular vein( It begins "ithin the lo"er !art of the !arotid gland. BbC the e&ternal 3ugular and !osterior e&ternal 3ugular veinsD BcC !arts of the su!raclavicular.

CAC arises by three roots( )he roots fro CJ and C6 !ierce the scalenus edius and 3oin the root fro CA over the first digitation of the serratus anterior( )he nerve !asses behind the brachial !le&us( It descends over the serratus anterior in the edial "all of the a&illa and gives branches to the digitations of the uscle B1ig( :(9C( .e to the rhomboi+eus BCJC !ierces the scalenus edius and !asses dee! to the levator sca!ulae to reach the bac' "here it lies dee! or anterior to the rho boideus uscles( )he ner. )he ner. -uperior 6ell2 o4 o5oh2oid + -upracia7icular ner7es Dorsal scapulaN ner7e -calenus 5edius 9rans7erse cer7ical arter2 Cut end o4 in4erior 6ell2 o4 o5oh2oid trun! o4 6rachial ple:us Middle trun! o4 6rachial ple:us S Lo1er -te5ocleido5astoid ner7e and arter2 E:ternal Fugular 7ein 9hird part o4 su6cla7ian arter2 o4 6rachial ple:us su6cla7icus er7e to trun! Fi*+ '+(: 2he posterior triangle of neck.e to the serratus anterior BCJ. C6.0reater occipital ner7e Occipital arter2 -te5ocleido5astoid Lesser occipital ner7e -e5ispinalis capitis 9rapeLius -plenius capitis 0reat auricular ner7e -uprascapular Le7ator scapulae and C3 and C? -pinal part o4 accessor2 ner7e H2oid 6one 9rans7erse cutaneous ner7e .

e "hich 3oins the !hrenic nerve in front of the scalenus anterior B1ig( :(AC( )he su.s it runs near the lateral argin of the scalenus anterior. over the first rib( )he subclavian vein !asses in front of the tendon( Ta2#e +. the !hrenic nerve. C6C B1ig( :(AC arises fro the u!!er trun' of the brachial !le&us and crosses the lo"er !art of the !osterior triangle 3ust above and lateral to the brachial !le&us.lexus e erge bet"een the scalenus anterior and edius. and carry the a&illary sheath around the ( )he sheath contains R the brachial !le&us and the subclavian artery B1igs :(1G.9= Co"te"ts o. :(11C( )he trans. C$H 33 er7e to su6cla7ius GC'. the transverse cervical and su!rasca!ular vessels and the clavicle to reach the dee! surface of the subclavius uscle( .ital artery *rosses the a!e& of the !osterior triangle su!erficial to the s!lenius ca!itis( )he su.e BCJ. dee! to the transverse cervical vessels and the o ohyoid( It !asses bac'"ards over the shoulder to reach the sca!ula( It su!!lies the su!ras!inatus and infras!inatus uscles B1ig( :(9C( )hree trun's of the bra*hial . the su!rasca!ular nerve.ras*a.A&&essor6 Lesser o&&i%ita# Ireat auri&u#ar A"terior &uta"eous Su%ra&#a5i&u#ar "er5es nerves Fi*+ '+!: $ome of the right posterior triangle.ras*a. C'. the -upracla7icular nodes and a 4e1 at the upper angle the occipital nodes .ius 2C$. the %osterior tria"!#e !ontents GJigs 33#%33""H (ccipital triangle $ubclavian triangle A3 er7es "3-pinal accessor2 ner7e =3Jour cutaneous 6ranches o4 cer7ical ple:us@ a3 Lesser occipital GC=H 63 0reat auricular GC=. C3H c3 Anterior cutaneous ner7e o4 nec! GC=.erse *er.hreni* ner. CAH B3 Vessels a3 9hird part o4 su6cla7ian arter2 and su6cla7ian 7ein 63 -uprascapular arter2 and 7ein c3 Co55ence5ent o4 trans7erse cer7ical arter2 and ter5ination o4 the corresponding 7ein d3 Lo1er part o4 e:ternal Fugular 7ein A 4e1 5e56ers o4 the -upracla7icular chain C3 L25ph nodes Along the posterior 6order o4 the sternocleido5astoid. and the scalenus edius( . C3H d3 -upracla7icular ner7es GC3. C6C descends in front of the brachial !le&us and the subclavian vessels.i*al artery is a branch of the thyrocervical trun'( It crosses the scalenus anterior. the u!!er trun's of the brachial !le&us. C?H 63 91o s5all 6ranches to the trapeLius GC3. 5ore in the lo1er part. it so eti es gives off the a**essory . C?H 33 Muscular 6ranches@ a3 91o s5all 6ranches'to the le7ator scapulae GC3. 9rans7erse cer7ical arter2 and 7ein 63 Occipital arter2 "39hree trun!s o4 6rachial ple:us =3 er7e to serratus anterior Glong thoracic. )he ner. CAH ?3-uprascapular ner7e GC'. C?H c3 er7e to rho56oideus GC'H ?3 Upper part o4 the 6rachial ple:us a.ular ner. CA.asses behind the tendon of the scalenus anterior.t the anterior border of the levator sca!ulae it divides into su!erficial and dee! branches( )he inferior belly of the o ohyoid crosses the artery( )he o**i.ular artery is also a branch of the thyrocervical trun'( It !asses laterally and bac'"ards behind the clavicle( )he sub*la. but behind the o ohyoid.e to the sub*la. the nerve to the subclavius.ian artery .

and the t"o heads blend belo" the iddle of the nec'( Bet"een the t"o heads there is a s all triangular de!ression of the lesser su!raclavicular fossa. t"o branches fro the occi!ital artery veins follo" the arteries( /eins follo" the arteries( Actions B. su!erior border. ). B:C are !ro!rioce!tive( er7e to serratus anterior Glong thoracic ner7eH -uprascapular 9run!s o4 6rachial ple:us er7e to rho56oideus STERNOCLEIDOMASTOID MUSCLE MSter"o*astoi$T &lood $upply )he sternocleido astoid and tra!e7ius are large su!erficial uscles of the nec'( Both of the are su!!lied by the s!inal root of the accessory nerve( )he tra!e7ius.K: Nerves seen in the posterior triangle of the neck. they fle& the nec' against resistance.i*ular hea+ is usculotendinous and arises fro the edial one-third of the su!erior surface of the clavicle( It !asses dee! to the sternal head.ro*ess. overlying the internal 3ugular vein( .erior nu*hal line of the occi!ital bone( Nerve $upply 2I3 )he s!inal accessory nerve !rovides the otor su!!ly( It !asses through the uscle. and BbC by a thin a!oneurosis into the lateral half of the su. is considered "ith the u!!er li b( )he sternocleido astoid is described belo"( (rigin 1()he . fro its ti! to its . BbC Eith the longus colli. BbC It can also tilt the head to"ards the shoulder( BBCEhen both uscles contract together8 BaC )hey dra" the head for"ards.Fig. because of its ain action on the shoulder girdle.CEhen one sternal hea+ is tendinous and arises fro the su!erolateral !art of the front of the anubriu sterni B1ig( :(AC( F()he *la.nsertion uscle contracts8 BaC It turns the chin to the o!!osite side. as in eating and in lifting the head fro a !illo". BcC )he reverse action hel!s in forced ins!iration( It is inserted BaC by a thic' tendon into the lateral surface of the mastoi+ .rterial su!!lyMone branch each fro su!erior thyroid artery and su!rasca!ular artery and. BFC branches Lesser occipital er7e to su6cla7ius L25ph node -pinal accessor2 Branches 4ro5 C3 to C? to trapeLius 0reat auricular Anterior cutaneous -upracla7icular -u6cla7ian 7ein fro the ventral ra i of CF.

1F(16C( F(/eins8 BaC Internal3ugular. BdC sterno astoid arteries t"o fro the occi!ital artery. ar or chest( )he left su. and BhC transverse cervical B1igs 1F(1J. e(g( the sto ach. BgC su!rasca!ular. Felations )he sternocleido astoid is enclosed in the investing layer of dee! cervical fascia.rteries8 BaC Co S%#e"ius &a%itis on carotid.lthough there are any varieties of torticollis de!ending on the causes the co on ty!es are 8 BaC. 1(Bones and 3oints8 BaC #astoid !rocess above. <odg'in*s disease. 'no"n as signal no+es) Scalene node bio!sy is very hel!ful in the early diagnosis of such alignancies( )his is to be correlated "ith the vast territory drained by the thoracic duct( F( Torti*ollis or 9ryne*kis a defor ity in "hich the head is bent to one side and the chin !oints to the other side( )his is a result of s!as or contracture of the uscles su!!lied by the s!inal accessory nerve. or a cervical rib( Su!raclavicular ly !h nodes are co only enlarged in tuberculosis. BcC e&ternal carotid. BeC !hrenic. BfC s!lenius ca!itis.ra*la. cystic hygro a or ly !hangio a.erfi*ial 1(S'in F(BaC Su!erficial fasciaD and BbC su!erficial la ina of the dee! cervical fascia B1ig( :(:C( :(Platys a( H(2&ternal 3ugular vein. and is !ierced by the accessory nerve and by the four sternocleido astoid arteries( It has the follo"ing relations8 <u. these being the sternocleido astoid and tra!e7ius( . the testis and other abdo inal organs( )hey are. one fro the su!erior thyroid.1(. BbC transverse or anterior cutaneous. BbC internal carotid.efle& torticollis due to infla ed or su!!urating cervical ly !h nodes "hich irritate the s!inal accessory nerve( BcCCongenital torticollis due to birth In3ury( BdCS!as odic torticollis due to central irritation( 3) Blo*k +isse*tion of the nec' for alignant diseases is the re oval of cervical ly !h nodes along "ith other structures involved in the gro"th( )his !rocedure does not endanger those nerves of the !osterior triangle "hich lie dee! to the . 2ra&hia# %#e8us Fi*+ '+#$: $tructures forming the floor of the posterior triangle. $ome related structures are also shown. and in alignant gro"ths of the breast. and BhC !osterior belly of digastric B1ig( :(AC( 1( )he ost co on s9elling in the . and su!erficial cervical ly !h nodes lying along the vein( J(BaC +reat auricular. BfC subclavian.heu atic torticollis due to e&!osure to cold or draught( BbC. BeC occi!ital. dee! cervical( Le5ator s&a%u#ae CLINICAL ANATOM S&a#e"us a"terior Su2&#a5ia" 5ei" S&a#e"us 5edius Su2&#a5ia" arter6 S&a#e"us %osterior Tru"-s o. and BbC sternoclavicular 3oint belo"( F(Carotid sheath B1ig( :(:C( :(#uscles8 BaC Sternohyoid. BgC longissi us ca!itis. !haryngeal !ouch. s"elling in this region ay also be caused by a li!o a. and BcC edial su!raclavicular nerves B1ig( :(9C( 6( )he !arotid gland overla!s the uscle( Dee. and BfC ansa cervicalis( H(@y !h nodes. BbC sternothyroidD BcC o ohyoidD BdC three scaleniD BeC levator sca!ulae. BdC u!!er !art of brachial !le&us. BcC facial and BdC lingual B1ig( 1F(1FC( :(=erves8 BaC /agusD BbC accessory BcC cervical !le&us. BbC anterior3ugular. one fro the su!rasca!ular.i*ular no+es or =ir*ho9's or s*alene no+es are also involved in alignant gro"ths of distant organs.osterior triangleis due to enlarge ent of the su!raclavicular ly !h nodes( . therefore.

cervical rib ay co !ress the subclavian artery( In these cases.hagia lusoria) BaCIn Blalo*k's o.>.!revertebral fascia. O Dorsal scapular ner7e Radial ner7e Ulnar ner7e / Fi*+ '+##: &rachial er7e to su6cla7ius rcoRosPD BRA CHE-)R U S S Lateral pectoral ner7e %%%%%% 3P3 Long thoracic ner7e ]eg ple us... the right subclavian artery is anasto osed end to side to short circuit the !ul onary stenosis( BbC2lective arterial surgery of the co on carotid artery is done for aneurys s. i(e( the brachial and cervical !le&uses and their uscular branches( H( )he clinical anato y of the arteries of the ne*k has been discussed along "ith the arteries concerned( )he follo"ing additional !oints ay be noted( BaC. Medial pectoral ner7e %%%%%%% Medial cutaneous ner7e o4 ar5 Medial cutaneous ner7e o4 4orear5 Median ner7e . Musculocutaneous ner7e O A:illar2 ner7e Lateral root and 5edial root ( ) o4 5edian ner7e %%%% Upper su6scapular ner7e er7e to latissi5us dorsi % Lo1er su6scapular ner7e ). the radial !ulse is di inished or oblit erat ed on tur ning the !at ient *s head u!"ards and to the affected side after a dee! breath 26+son's test3 blood( BbCDys!hagia caused by co !ression of the oeso!hagus by an abnor al subclavian artery is called +ys. . resulting in decreased blood su!!ly to the u!!er li b( ROO9HR -uprascapular ner7e n((() . )))'+' s.eration for 1allot*s tetralogy./flstulae or arteriosclerotic occlusions( It is better to e&!ose the co on carotid artery in its u!!er !art "here it is su!erficial( Ehile ligating the artery care should be ta'en not to include the vagus nerve or the sy !athetic chain( BcCSecond !art of the subclavian artery ay get !ressed by the scalenus anterior uscle..

serratus !osterior su!erior and serratus !osterior inferior uscles( )he s!lenius is the highest of these uscles( It arises fro liga entu nuchae and s!ines of CA and )l-6 vertebrae( It is ade u! of t"o !arts8 BiC S!lenius cervlcis "hich is inserted into the bac' of C1-C: transverse !rocesses. su!erficial branch of transverse cervical artery and ventral ra i of :rd and Hth cervical nerves( @atissi us dorsi has already been e&!osed by the students dissecting the u!!er li b( 0ther"ise e&tend the incision fro )1F s!ineD u!"ards and laterally across 4th rib to the 3unction of u!!er one-third and lo"er t"o-thirds ofhu erus( . BiiC s!lenius ca!itis being inserted into the lo"er !art of astoid !rocess and ad3acent su!erior nuchal line( It is su!!lied by dorsal ra i of C1-C6 nerves( @evator sca!ulae for s !art of the uscular floor of the !osterior triangle( It is !ositioned bet"een scalenus edius belo" and s!lenius ca!itis above( 1ollo" its nerve and blood su!!ly fro dorsal sca!ular nerve and dee! branch of transverse cervical artery res!ectively( + . rho boideus a3or. levator sca!ulae.eflect the s'in laterally along a vertical line dra"n fro the inferior angle of sca!ula( Cut through tra!e7ius uscle vertically at a distance of F c fro the edian !lane( .eflect it laterally and identify the accessory nerve.s such one ust aintain the !osition of the s!ine to be gracious and not 6s!ineless6( )he only triangle of the u!!er ost !art here is the subocci!ital triangle containing the third !art of the vertebral artery.ital ner. any sy !to s a!!ear( INTRODUCTION H //// M/ )he s'in of the na!e or bac' of the nec'. and is distributed only to the uscles bounding the subocci!ital triangle( )he ligamentum nu*hae is a triangular fibrous sheet that se!arates uscles of the t"o sides of the nec'( It is better develo!ed and is ore elastic in %uadru!eds in "ho it has to su!!ort a heavy head( 2&tend theV incision fro e&ternal occi!ital !rotuberance to the s!ine of the seventh cervical s!ine( +ive a hori7ontal incision fro s!ine of Ath -cervical vertebra or vertebra !ro inens till the acro ion( )his "ill e&!ose the u!!er !art and a!e& of !osterior triangle of nec'( @oo' for the occi!ital artery at its a!e& N1ig( H(1C( Close to the edian !lane in the su!erficial fascia are seen the greater occi!ital nerve and occi!ital artery( 2&tend the incision fro vertebra !ro inens to s!ine of lu bar J vertebra( .eflect the s'in and define the argins of broad thin latissi us dorsi( )he second layer co !rises s!lenius uscle.ital ner.e8 C: the thir+ o**i. both of "hich su!!ly the intrinsic uscles of the bac'( )he edial branch in this region su!!lies the s'in as "ell( )he +orsal ramus of Cl does not divide into edial and lateral branches. rho boideus inor.e and CH( 2ach !osterior !ri ary ra us divides into a edial and a lateral branch.9he Bac! o4 the ec! *)>he vertebral colu n at bac' !rovides a edian 0 a&is for the body( )here are big uscles fro the sacru to the s'ull in different strata "hich 'ee! the s!ine straight( . "hich enters the s'ull to su!!ly the brain( If it gets !ressed. and of the bac' of the scal! is su!!lied by edial branches of the dorsal ra i of CF the greater o**i.

inserted into the s!ines.eflect longissi us ca!itis do"n"ards fro the astoid !rocess( Cut through se is!inalis ca!itis and turn it to"ards lateral side( Define the boundaries and contents of the subocci!ital triangle( MUSCLES OF THE BAC' )he mus*les of the entire bac' can be grou!ed into the follo"ing four layers fro su!erficial to the dee!er !lane( I( )ra!e7ius and latissi us dorsi see /ol( I . lu bar and sacral nerves( #uscles of fourth layer are the ultifidus. se is!inalis cervicis and se is!inalis ca!itis( Both these uscles are innervated by the dorsal ra i of cervical. inters!inales.r /3 Hea$ a"$ Ne&- <ubo**i. thoracic. fresh sli!s arising fro the area "here the lo"er sli!s are inserted( Dee! to erector s!inae is the se is!inalis again ade u! of three !arts8 se is!inalis thoracis.ital Triangle E:ternal occipital protu6erance Verte6ra pro5inens 7 Acro5ion -capula Eighth ri6 iii Deltoid tu6erosit2 91el4th ri6 . intertransversii and subocci!ital uscles( It is dee! triangle in the area bet"een the occi!ut and the s!ine of second cervical. inserted into the ribs( 2ach of these divisions are ade of short !arts.ho boideus inor and a3or lie on sa e !lane as levator sca!ulae( Both are su!!lied by dorsal sca!ular nerve BCJC( Dee! to the t"o rho boideus uscles is thin a!oneurotic serratus !osterior su!erior uscle fro s!ines of CA and )1-)F vertebrae to be inserted into F-Jth ribs( Serratus !osterior inferior uscle arises fro )11-)1F s!ines and thoracolu bar fascia and is inserted into 9th. rotatores.1Fth ribs( )he third layer is co !osed of erector s!inae or sacros!inalis "ith its three subdivisions and se is!inalis "ith its three divisions B1ig( H(FC( 2rector s!inae arises fro the dorsal surface of sacru and ascends u! the lu bar region( )here it divides into three subdivisions. the interediate one is longissi us inserted into the transverse !rocesses and the lateral one is iliocostalis. the a&is vertebra( )he dee!est uscles are the uscles of subocci!ital triangle( Cut the attach ents of tra!e7ius fro su!erior nuchal line and reflect it to"ards the s!ine of sca!ula( Cut the s!lenius ca!itis fro its attach ent on the astoid !rocess and reflect it do"n"ards( Clean the su!erficial fascia over the se is!inalis ca!itis edially and longissi us ca!itis laterally( . the edial one is s!inalis.

fro lo"er half of liga entu nuchae and s!ines of u!!er 6 thoracic vertebrae( )hese curve in a half s!iral fashion and se!arate into s!lenius cervicis and s!lenius ca!itis( S!lenius cervicis gets inserted into the !osterior. serratus !osterior su!erior have been studied in /olu e I. serratus !osterior inferior is seen in /olu e II( S!lenius is described briefly here( S!lenius uscles are t"o in nu ber( )hese are s!lenius cervicis and s!lenius ca!itis( )hese cover the dee!er uscles li'e a bandage B1ig( H(FC( 0rigin .%: 5ines of dissection. rho boideus Bt"oC. fro the dorsal seg ent of . 6. II( @evator sca!ulae. tubercles of transverse !rocesses of C1-CH vertebrae( S!lenius ca!itis for s the floor of the !osterior triangle and gets inserted into the astoid !rocess beneath the sternocleido astoid uscle B1ig( H(HC( III( aC 2rector s!inae or sacros!inalis is the true uscle of the bac'.Fig. su!!lied by !osterior ra i of the s!inal nerves( It e&tends fro the sacru to the s'ull B1ig( H(:C( 0rigin fro the bac' of sacru bet"een edian and lateral sacral crests.

. "!# 2hird layer: semispinalis capitis "$m!# and longissimus capitis "5!#.enous . Iliocostalis thoracis and iliocostalis cervicis( )hese are short sli!s and are inserted into angles of the ribs and !osterior tubercles of cervical transverse !rocess( 0rigin of the higher sli!s is edial to the insertion of the lo"er sli!s( BiiC @ongissi us is the iddle colu n and is co !osed of8 @ongissi us thoracis .otatores are the dee!est grou!( )hese !ass fro root of transverse !rocess to the root of the s!inous !rocess( )hese are "ell develo!ed in thoracic region( Inters!inales lie bet"een the ad3acent s!ines of the vertebrae( )hese are better develo!ed in cervical and lu bar regions( Intertransversii connect the transverse !rocesses of the ad3acent vertebrae( Subocci!ital uscles are described belo" in the subocci!ital triangle B1ig( H(HC( In the subocci!ital region bet"een the occi!ut and the s!ine of the a&is vertebra. and gets inserted into the edial area bet"een su!erior and inferior nuchal lines of the occi!ital bone( 2T=3 #ultifidus. $(Psuperior obliQue. )(NPthird occipital nerve. 5ig.inserted into transverse !rocesses of thoracic vertebrae( @ongissi us cervicis -.ital . the four uscular layers are re!resented by8 I( )ra!e7iusD II( s!lenius ca!itisD III( se is!inalis ca!itis and longissi us ca!itisD and I/( the four subocci!ital uscles( )he arteries found in the bac' of the nec' are8 BaC 0cci!ital.(NPgreater occipital nerve.lexus is 'no"n for its e&tensive layout and co !le& connections( SUBOCCIPITAL TRIANILE )he subocci!ital triangle is a uscular s!ace situated dee! in the subocci!ital region( . NPAigamentum nuchae. intertransversii and subocci!ital uscles( #ultifidus is obli%ue dee! uscles( )hese arise fro a illary !rocess of lu bar vertebrae to be inserted into F-: higher s!inous !rocesses( .inserted into transverse !rocess of CF-C6 vertebrae( @ongissi us ca!itis . BcC third !art of the vertebral artery and BdC inute t"igs fro the second !art of the vertebral artery( )he subo**i. "&# $ecI ond layer: splenius capitis "$p!# and levator scapulae "5$#. "A# First layer: trapeMius "2r# and sternocleidomastoid "$/#. (APoccipital artery.Fi*+ 4+&: 2hree layers of muscles covering the suboccipital triangle. longissi us and s!inalis -BiC Iliocostalis is the lateral colu n and co !rised iliocostalis lu boru . BbC dee! cervical.inserted into astoid !rocess B1ig( H(:C( BiiiC S!inalis-is the edial colu n. e&tending bet"een lu bar and cervical s!ines( Its !arts are8 S!inalis lu boru S!inalis thoracis S!inalis cervicis bC )he other uscle of this layer is se is!inalis e&tending bet"een transverse !rocesses and s!ines of the vertebrae( It has three !arts8 Se is!inalis thoracis B1ig( H(HC( Se is!inalis cervicis Se is!inalis ca!itis It only lies in the u!!er half of vertebral colu n( Se is!inalis ca!itis is its biggest co !onent( It arises fro transverse !rocesses of C:-)H vertebrae. !asses u! ne&t to the edian !lane. rotatores. iliac crest and related liga ents( Soon it s!lits into three colu ns8 Iliocostalis. and . inters!inales.(Pinferior obliQue.

the follo"ing layers are reflected B1ig( H(FC( 1()he skin is very thic'( F()he su.e4ius run do"n"ards and laterally over the triangle( )he sternocleido astoid overla!s the region laterally( . E)posure of Suboccipital Trian*le In order to e&!ose the triangle. "ith acco !anying veins( :()he fibres of the tra. and third occi!ital nervesD and BbC the ter inal !art of the occi!ital artery./liocostalis cer7icis -e5ispinalis capitis /liocostalis thoracis Longissi5us capitis Longissi5us cer7icis -pinalis 4horacis liiocostalis lu56oru5 Longissi5us thoracis Erector spinae Longissi5us lu56oru5 Fi*+ 4+': 2he erector spinaeAsacrospinalis muscle with its three columns.erfi*ial fas*ia is fibrous and dense( It contains8 BaC )he greater.

inalis *a.ital triangle) .itis "hich is inserted into the astoid !rocess dee! to the s!lenius( .itis runs u!"ards and laterally for insertion into the astoid !rocess dee! to the sternocleido astoid( F()he semis.lenius *a.1()he s.eflection of the se is!inalis ca!itis e&!oses the subo**i.itis runs vertically u!"ards for insertion into the edial !art of the area bet"een the su!erior and inferior nuchal lines( In the sa e !lane laterally there lies the longissimus *a.

the Ne&- 39 Mu#ti.i$us S%#e"ius &a%itis S%#e"ius &er5i&is Se*is%i"a#is thora&is .o.Ba&.

erolaterally7 Su!erior obli%ue uscle( Interiorly7 Inferior obli%ue uscle( 0aterally7 @ongissi us ca!itis and occasionally the s!lenius ca!itis( 1(Posterior arch of atlas.Se*is%i"a#is &a%itis Se*is%i"a#is &er5i&is Rotatores Le5ator &ostaru* I"tertra"s5ersa#is Fi*+ 4+4: $plenius cervicis and capitis.the multifidus. &oundaries <u. and F(Posterior atlanto-occi!ital e brane( Foof !ontents 1e+ially7 Dense fibrous tissue covered by the se is!inalis ca!itis( 1()hird !art of vertebral artery( F(Dorsal ra us of nerve C1Msubocci!ital nerve( :(Subocci!ital !le&us of veins( . levator costarum and intertransversalis muscles.three parts of semispinalis.erome+ially7 .ectus ca!itis !osterior a3or uscle su!!le ented by the rectus ca!itis !osterior inor B1ig( H(JC( <u.

9= The su2o&&i%ita# *us&#es /uscle " 3 Rectus capitis posterior 5aFor (rigin -pine o4 a:is .+: 5eft suboccipital triangle.Suboccipital . .erAical NerAe It e erges bet"een the !osterior arch of the atlas and the vertebral artery.boundaries. and soon brea's u! into branches "hich su!!ly the four subocci!ital uscles and the se is!inalis ca!itis( )he nerve to the inferior obli%ue gives off a co unicating branch to the greater occi!ital nerve B1igs H(J. H(6C( It is the large edial branch of the dorsal ra us of the second cervical nerve( It is the thic'est cutaneous nerve in the body( It "inds round the iddle of the lo"er border of the inferior obli%ue uscle. and runs u!"ards and edially( It crosses the subocci!ital triangle and !ierces the se is!inalis ca!itis and tra!e7ius uscles to ra ify on the bac' of the head reaching u! to the verte&( It su!!lies the se is!inalis ca!itis in addition to the scal!( Ta2#e .. 6. floor and contents.uscles <reater Occipital NerAe )he subocci!ital uscles are described in )able ()") Dorsal 7a6us of First .nsertion Lateral part o4 the area 6elo1 the in4erior nuchal line Nerve $upply -u6occipital ner7e or dorsal ra5us Cl Actions "3 Mainl2 postural =3 Acting alone it turns =3 Rectus capitis posterior 5inor <osterior tu6ercle o4 atlas 9rans7erse process o4 atlas -pine o4 a:is Medial part o4 the area 6elo1 the in4erior nuchal line Lateral area 6et1een the nuchal lines 9rans7erse process o4 atlas the chin to the sa5e side 33 Acting together the t1o 5uscles e:tend the head "3Mainl2 postural =3E:tend the head "3Mainl2 postural =3E:tend the head 33Jle: the head Laterall2 "3Mainl2 postural =39urns chin to the sa5e side "3O6li8uus capitis superior Gsuperior o6li8ueH =3O6li8uus capitis in4erior Gin4erior o6li8ueH Occipital -ternocleido5astoid -plenius capitis arter2 0reater occipital ner7e -e5ispinalis capitis GinsertionH Rectus capitis posterior 5inor Longissi5us capitis %P Mastoid process O -uperior o6li8ue %))) 9rans7erse processo4 atlas %%%%%%% Verte6ral arter2 DD Dorsal ra5us o4 Cl <osterior arch o4 atlas /n4erior o6li8ue Rectus capitis posterior 5aFor <osterior atlantooccipital 5e56rane <osterior tu6ercle o4 atlas ) -pine o4 a:is Fig.

B:C internal vertebral venous !le&us. and anasto oses "ith the vertebral and dee! cervical arteries( It also gives t"o branches to sternocleido astoid uscle( Deep .o.7: Felationship of the vertebral artery to the atlas vertebra and to the first cervical nerve.s the needle !ierces the !osterior atlanto-occi!ital e brane at a de!th of about H to J c in adults. it ascends edial to the greater occi!ital nerve( It su!!lies the s'in to the bac' of the nec' u! to the e&ternal occi!ital !rotuberance( Dertebral -rtery Verte6ral arter2 It is the first and largest branch of the first !art of the subclavian artery. crossing the carotid sheath. it has a tortuous course( It lies in and around the subocci!ital triangle. Ventral ra5us Third Occipital NerAe It is the slender edial branch of the dorsal ra us of the third cervical nerve( . and BHC condylar e issary vein( It itself drains into the dee! cervical and vertebral !le&us of veins( CLINICAL ANATOM B1CIe*k rigi+ity. grooves the atlas.erAical -rtery are8 Dorsal ra5us It is a branch of the costocervical trun' of the subclavian artery( It !asses into the bac' of the nec' 3ust above the nec' of the first rib( It ascends dee! to the se is!inalis ca!itis and anasto oses "ith the descending branch of the occi!ital artery( Suboccipital Ple)us of Deins It arises fro the e&ternal carotid artery. digastric. H(JC( It runs bac'"ards and u!"ards dee! to the lo"er border of the !osterior belly of the digastric. the su!erior obli%ue and the se is!inalis ca!itis uscles at the a!e& of the !osterior triangle( 1inally. as seen from above. and drains the 8 B1C #uscular veins. longissi us ca!itis( )he artery then crosses the rectus ca!itis lateralis. H(HC( )his !art a!!ears at the fora en transversariu of the atlas. and the accessory and hy!oglossal nerves( =e&t it runs dee! to the astoid !rocess and to the uscles attached to itD the sternocleido astoid. the Ne&3+ <osterior arch o4 atlas -uperior articular 4acet 4or atlas Fig. is due to s!as of the e&tensor uscles( )his is caused by irritation of the nerve roots during their !assage through the subarachnoid s!ace "hich is infected( BFCCistemal .Ba&. the resistance . s!lenius ca!itis. BFC occi!ital veins. needle is introduced in the idline 3ust above the s!ine of the a&is vertebra. destined chiefly to su!!ly the brain( 0ut of its four !arts. and B:C mus*ular) 0ne of the uscular branches is large8 it is called the +es*en+ing bran*h and has su!erficial and dee! branches( )he su!erficial branch anasto oses "ith the su!erficial branch of the transverse cervical arteryD "hile the dee! branch descends bet"een the se is!inalis ca!itis and cervicis. !arallel to an i aginary line 3oining the e&ternal auditory eatus "ith the nasion( .un*ture is done "hen lu bar !uncture fails( )he !atient either sits u! or lies do"n in the left lateral !osition( . only the third !art a!!ears in the subocci!ital triangle( B1igs H(:. and is !assed for"ards and u!"ards.fter !iercing the se is!inalis ca!itis and the tra!e7ius. and leaves the triangle by !assing dee! to the lateral edge of the !osterior atlantoocci!ital e brane( )he artery is se!arated fro the !osterior arch of the atlas by the first cervical nerve and its dorsal and ventral ra i( 1or co !lete descri!tion of the vertebral artery see Cha!ter 1:( Occipital -rtery Its branches in this region B1C 1astoi+. BFC meningeal. it !ierces the tra!e7ius F(J c fro the idline and co es to lie along the greater occi!ital nerve( In the su!erficial fascia of the scal!. o!!osite the origin of the facial artery B1igs H(F. 6. seen in cases "ith eningitis.

is suddenly lost and the ti! of the needle enters the cisterna agna( In this !rocedure. there is danger of in3ury to the edulla "hich lies F(J c anterior to the !osterior atlanto-occi!ital e brane( Such in3ury is fatal( B:C=eurosurgeons a!!roach the !osterior cranial fossa through this region( .

Contents o4 the Verte6ral Canal )) )hen the vertebrae are !ut in a se%uence. trun' and dorsal and ventral !ri ary ra i of the s!inal nerve. valveless. dangerous vertebral venous !le&us connecting veins of the !elvis. abdo en.inal arteries arise fro different sources at different levelsD they enter the vertebral canal through the intervertebral fora ina. !roviding a route for s!read of cancer fro any of the viscera to the brain( CONTENTS canal( It contains8 BaC @oose areolar tissue. and BdC the internal vertebral venous !le&us( )he s. the eninges.ertebral *anal) )his canal contains the three eninges "ith their s!aces and the s!inal cord including the cauda e%uina( )he intervertebral fora ina are a !air of fora ina bet"een the !edicles of the ad3acent vertebrae( 2ach fora en contains dorsal and ventral roots. thora&. their // vertebral fora ina lie one belo" the other for ing a continuous canal "hich is called the . and su!!ly the s!inal cord. the s!inal nerve roots. BbC se ili%uid fat. tough fibrous e brane "hich for s a loose sheath around the s!inal cord B1ig( J(1C( It is continuous "ith the eningeal layer of the cerebral dura ater( )he s!inal dura e&tends 30 . and s!inal vessels( )he vertebral canal also lodges %uiet. the !eriosteu and liga ents( /enous blood fro the s!inal cord drains into the e!idural or internal vertebral !le&us( DISS2C)I0= )he vertebral canal contains the follo"ing structures fro "ithout in"ards( B1ig( J(1C 1(2!idural e&tradural s!ace( F()hic' dura ater or !achy enin&( :(Subdural ca!illary s!ace( H(Delicate arachnoid ater( J(Eide subarachnoid s!ace containing cerebros!inal fluid BCS1C( 6(1ir !ia ater( )he arachnoid and !ia together for the le!to eninges( A(S!inal cord or s!inal edulla and the cauda e%uina( )he s!inal cord is considered along "ith the brain in Cha!ter F:( )he other contents are described belo"( E%i$ura# S%a&e Clean the s!ines and la inae of the entire vertebral colu n by re oving all the uscles attached to the ( )race the dorsal ra i of s!inal nerves to"ards the intervertebral fora ina( Sa" through the s!ines and la inae of the vertebrae carefully and detach the so that the s!inal edullaK s!inal cord encased in the eninges beco es visible( Clean the e&ternal surface of dura ater envelo!ing the s!inal cord by re oving fat and e!idural !le&us of veins( Carefully cut through a s all !art of the dura ater by a fine edian incision( 2&tend this incision above and belo"( See the delicate arachnoid ater( Incise it( Push the s!inal cord to one side and try to identify the liga entu denticulatu ( Define the attach ents of the dorsal and ventral nerve roots on the surface of s!inal cord and their union to for the trun' of the s!inal nerve( S%i"a# Dura Mater 2!idural s!ace lies bet"een the s!inal dura ater. nec' "ith those of the brain. and the !eriosteu and liga ents lining the vertebral S!inal dura ater is a thic'. BcC s!inal arteries on their "ay to su!!ly the dee!er contents.

and the last bet"een t"elfth thoracic and first lu bar s!inal nerves( 2ach !rocess !asses through the arachnoid to the dura bet"een t"o ad3acent s!inal nerves( )he !rocesses sus!end the s!inal cord in the iddle of the Subarachnoid s!ace( )he lilum terminale is a delicate.3^P% O Dorsal ra5us Ventral ra5us nervous syste B1ig( J(FC( Inferiorly.(= its and to 5igamentum denticulatum relationship to the dura the arachnoid mater. although a fe" nerve fibres rudi ents of Fnd . and is also connected to the arachnoid by a fenestrated <ubara*hnoi+ se.len+ens B1ig( J(1C( 0n each side bet"een the ventral and dorsal nerve roots.%: $chematic transverse section showing the spinal meninges. and is in free co unication "ith the ly !h s!aces of the nerves( KAra&h"oi$ Mater IE+C . longitudinal glistening band. and "here the liga entu denticulata are attached to the dura ater3y Su2ara&h"oi$ S%a&e Ventral ner7e root S Liga5entu5 denticulatu5 -u6durai space Linea splendens Fig. Subarachnoid s!ace is a "ide s!ace bet"een the !ia and the arachnoid.ia&intlma "hich is in contact "ith nervous tissue( Bet"een the t"o layers there are any s all blood vessels and also cleft li'e s!aces "hich co unicate "ith the Subarachnoid s!ace( )he !ia ater closely invests the s!inal cord. S!inal !ia ater is thic'er. fir er.rachnoid ater is a thin. it e&tends. and is continued belo" the s!inal cord as the filu ter inale( Posteriorly. containing a thin fil of serous fluid( )his s!ace !er its ove ents of the dura over the arachnoid( )he s!ace is continued for a short distance on to the s!inal nerves. filled "ith cerebros!inal fluid BCS1C( It surrounds the brain and s!inal cord li'e a "ater cushion( )he s!inal Subarachnoid s!ace is "ider than the s!ace around the brain( It is "idest belo" the lo"er end of the s!inal cord "here it encloses the cauda e%uina( 0umbar!uncture is usually done in the lo"er "idest !art of the s!ace. delicate and trans!arent e brane that loosely invests the entire central Liga5entu5 denticulatu5 < U Z%%%%% Dura 5ater . +. called the ligamentum +enti*ulatum) )his is so called because it gives off a series of triangular tooth-li'e !rocesses "hich !ro3ect fro its lateral free border B1ig( J(:C( 2ach liga ent has F1 !rocessesD the first at the level of the fora en agnu .ia&glia or .i&. the !ia is folded into the anterior edian fissure of the s!inal cord( It thic'ens at the outh of the fissure to for a edian.ia containing larger vesselsD and BbC . bet"een third and fourth lu bar vertebrae( S%i"a# Pia Mater fro the fora en agnu to the lo"er border of the second sacral vertebraD "hereas the s!inal cord ends at the lo"er border of first lu bar vertebraWC)he dura gives tubular !rolongations to the dorsal t d ventral nerve roots and to the s!inal nerves as they !ass through the intervertebral fora ina( Su2$urai S%a&e Subdurai s!ace is a ca!illary or !otential s!ace bet"een the dura and the arachnoid. -u6durai apace %% er7e root %Arachnoid 5ater %-u6arachnoid space -pace 4or spinal cord and mater 0. thread-li'e structure about FG c long( It e&tends fro the a!e& of the conus edullaris to the dorsu of the first !iece of the coccy&( It is co !osed chiefly of !ia ater. the !ia is adherent to the !osterior edian se!tu of the s!inal cord. called the linea s. the !ia for s a narro" vertical ridge. but both are ade u! of t"o layers8 BaC an outer e.nteriorly.n inner .tum) . and less vascular than the cerebral !ia. u! to the lo"er border of the second sacral vertebra( It is adherent to the dura only "here so e structures !ierce the e brane. li'e the dura.&A Head and ec! Dura 5ater Arachnoid 5ater <ia 5ater -u6arachnoid space PP Dorsal ner7e root ganglion %% 9run! o4 spinal ner7e .

n intervertebral fora en contains8 BaC )he ends of the nerve roots. and is itself drained at regular intervals by seg ental veinsMvertebral. five lu bar. five sacral. and drains into the subclavian veins( !ommunications and .ntroduction 5igamentum denticulatum. and anterolaterally into the e&ternal vertebral !le&us( :(Fxternal .mplications )he valveless vertebral syste of veins *ommuni*ates7 B1C. BcC the nerve trun'. and the !osterior vessels on the bac' of the vertebral arches and on ad3acent uscles( It is drained by seg ental veins( )he subocci!ital !le&us of veins is a !art of the e&ternal !le&us( It lies in the subocci!ital triangle( It receives the occi!ital veins of the scal!.ertebral bo+ies7 It drains bac'"ards into the e!idural !le&us. lu bar and lateral sacral( F(/lexus 9ithin the . and one coccygeal( 2ach nerve is attached to the cord by t"o roots. t"elve thoracic. co !licated net"or' of veins "ith a longitudinal !attern( It runs !arallel to and anasto oses "ith the su!erior and inferior venae cavae( )his net"or' has three interco unicating subdivisions B1ig( J(HC( 1(The e. and the caval syste of veins( . and the vessels entering the substance of the s!inal cord( S%i"a# Ner5es )he vertebral venous !le&us assu es i !ortance in cases of8 B1C Carcino a of the !rostate causing secondaries in the vertebral colu n and the s'ullD and BFC chronic e !ye a Bcollection of !us in the !leural cavityC causing brain abscess by se!tic e boli( Anatomy of the 'ertebral 'enous Ple us )he s!inal cord gives rise to thirty-one !airs of s. BdC the beginning of the dorsal and ventral ra i. and :rd coccygeal nerves are found adherent to the u!!er !art of its outer surface( )he central canal of the s!inal cord e&tends into it for about J ( )he filu ter inale is subdivided into a !art lying "ithin the dural sheath Bcalled the filu ter inale internu D and a !art lying outside the dural sheath.lexus7 @ies in the vertebral canal outside the dura ater( )he !le&us consists of a !ostcentral and a !rela inar !ortion( 2ach !ortion is drained by t"o vessels( )he !le&us drains the structures in the vertebral canal.e roots unite in the intervertebral fora en to for the ner. is connected "ith the transverse sinus by e issary veins.i+ural .ertebral .bove "ith the intracranial venous sinuses. BeC a s!inal artery. ventral otor and dorsal sensory( 2ach dorsal nerve root bears a ganglion( )he . !osterior intercostal.entral an+ +orsal ner.*a$e 26 the #o<est %ro&ess Li!a*e"tu* denticulatu5 First #u*2ar "er5e Fi*+ 5+': S%i"a# &or$ +ural sheath encloses the ter inal !arts of the roots.inal ner. and is lost by erging "ith the e!ineuriu of the nerve( .ial an+ ara*hnoi+ sheaths e&tend u! to the dura ater( )he )he vertebral venous syste is ade u! of a valveless. and the e&ternu is J c long( /ial sheaths surround the nerve roots crossing the subarachnoid s!ace. and BfC an intervertebral vein B1ig( J(1C( 1ERTEBRAL S STEM OF 1EINS .es7 eight cervical. the !ortal vein. as the s!inal cord is uch shorter than the vertebral colu n( Belo" the ter ination of the s!inal cord at the level of first lu bar vertebra the obli%uity beco es uch ore ar'ed B1ig( J(:C( Belo" the lo"er end of the s!inal cord the roots for a bundle 'no"n as the *au+a e:uina because of its rese blance to the tail of a horse( )he roots of s!inal nerves are surrounded by sheaths derived fro the eninges( )he . continues over the nerve trun'. BbC the dorsal root ganglion. the 1erte2ra# Ca"a# For. and BFCbelo" "ith the !elvic veins.enous .lexus7 It consists of anterior vessels lying in front of the vertebral bodies. belo" the level of the second sacral vertebra called the filu ter inale e&ternu ( )he filu ter inale internu is FG c long.Co"te"ts o.e trunk "hich soon divides into ventral and dorsal rami B1ig( J(1C( )he u!!er ost nerve roots !ass hori7ontally fro the s!inal cord to reach the intervertebral fora ina( @o"er do"n they have to !ass "ith increasing obli%uity.

)he veins are .eless and the blood can flo" in the in either direction( .n increase in intrathoracic .al.

or by an e&tra edullary tu our( deliriu and convulsions. the !rostate. nerve changes in venous !ressure are clinically i !ortant roots-neurofibro aD e!endy a-e!endy o aD because they a'e !ossible the s!read of tu ours and other tissues( . !ressure. often acco !anied by cervical rib.Ne&Venous ple:us 1ithin 7erte6ral 6od2 [%(+'(+W W Verte6ral 6od2 /n4erior 7ena ca7a PPPPPPP% Anterior part o4 e:ternal 7erte6ral 7enous ple:us Basi7erte6ral 7ein Vertical channel o4 epidural ple:us Fig. !yogenic( It is characteri7ed by fever. test +oes not sho" a sudden rise and a sudden and the 'idney( )ubercular infection "ithin the fall of CS1 !ressure by coughing or by brief vertebrae-vertebral caries. for ed in osteoarthritisD by a headache. is si ilarly e&!lained( !ressure over the 3ugular veins( S!inal bloc' can be confir ed by yelogra!hy or C) scan or #. +. nec' rigidity. ay cause blood to flo" in the !le&us a"ay fro the heart. or the syn+rome is seen( )here is yello"ish brain( discolouration of CS1 belo" the level of obstruction( CS1 reveals high level of !rotein )he co on !ri ary sites of tu ours causing but the cell content is nor al Lue*kenste+i's secondaries in vertebrae are the breast. cells fro !elvic. such as is brought about de!ending on the level of co !ression( by coughing and straining.I scan( CLINICAL ANATOM :(Co !ression of the cauda e%uina gives rise to flaccid !ara!legia. its along the distribution of the nerve( !roteins and cell content are increased.!art fro co !ression of or infections( 1or e&a !le.6: 2he vertebral system of veins. and ay ulti ately lodge in lo" belo" the level of lesion( 5roin's the vertebrae. saddle anaesthesia 0e. the s!inal cord. thoracic and breast tu ours ay enter the subarachnoid s!ace so that !ressure of CS1 is the venous syste . ar'ed by osteo!hytes.tomeninges and s!hincter disturbances( )his is called the Infla ation due to infection of le!to eningescauda e%uina syndro e( !ia ater and arachnoid ater is 'no"n as H(Co !ression of roots of s!inal nerves ay eningitis( )his is co only tubercular or be caused by !rola!se of an intervertebral disc. the s!inal cord the tu our causes obstruction of abdo inal. the s'ull. %%%%%-eg5ental 7ein )%%%%%% Dura 5ater or intra- =ertebral Canal 1(Co !ression of the s!inal cord by a tu our Epidural ple:us O <osterior part o4 e:ternal 7erte6ral 7enous ple:us abdo inal gives rise to !ara!legia or %uadri!legia. and sugars and chloride are selectively di inished( . and a changed Such co !ression results in shooting !ain bioche istry of CS1( CS1 !ressure is raised. F(S!inal tu ours ay arise fro dura atereither u!"ards or do"n"ards( Such !eriodic eningio aD glial cells-glio a.

%etrous te*%ora# Fro"ta# air si"usCCCCCCC9. eninges. Note the position of the tentorium 37 . or Cal. !ia. venous sinuses. four !etrosal nerves. s%he"oi$ A"terior &ra"ia# .ossa U%%er *ar!i" o. detach the te !oralis uscle "ith its overlying fascia and reflect these do"n"ards over the !inna( Bemo. the cranial fossae. the highest !laced cavity.ossa C Posterior e$!e o. contains ?^ the brain.aria Dra" a hori7ontal line across the s'ull one centietre above the orbital argins and one centi etre above the inion( Sa" through the s'ull( Be careful in the te !oral region as s'ull is rather thin there( Se!arate the inner table of s'ull fro the fused endosteu and dura ater( Te"toriu* &ere2e##i &ra"ia# . the iddle arachnoid ater.9he Crania Ca7it2 KCranial cavity.ault) It is unifor and s ooth( )he base of the cranial cavity is uneven and !resents three cranial fossae Banterior. !arts of internal carotid artery and a !art of the vertebral artery besides the s!ecial senses( )he anterior branch of iddle eningeal artery lies at the !terion and is ost li'ely to be ru!tured resulting in e&tradural hae orrhage( CRANIAL CA1IT a !otential subdural s!ace( )he arachnoid is se!arated fro the !ia by a "ider subarachnoid s!ace filled "ith cerebros!inal fluid BCS1C( )he arachnoid.F1 =8 Posterior &ra"ia# . iddle and !osteriorC lodging the uneven base of the brain B1ig( 6(1C( )he cranial cavity contains the brain and eningesD the outer dura ater.ossa E C Fora*e" *a!"u* Fi*+ +#: Parasagittal section through the skull to show cerebelli. #esser <i"! o. all cranial nerves.al of <kull Ca. and has a distinct blood su!!ly and nerve su!!ly( )he dura is se!arated fro the arachnoid by Mi$$#e Detach the e!icranial a!oneurosis if not already done laterally till the inferior te !oral line( In the region of the te !le. subarachnoid s!ace and CS1 are dealt "ith the brainD the dura is described after dissection( DISSECTION )he conve& u!!er "all of the cranial cavity is called the . and the inner !ia ater( )he dura ater is the thic'est of the three eninges( It encloses the cranial venous sinuses.

vagus. internal carotid artery. e&ce!t "here the cranial venous sinuses are enclosed bet"een the ( The Endosteal 9ayer or Endocraniu6 1()he endocraniu )he dura ater is the outer ost.. "A#$ection through the tentorial notch "anteriorpart of the fossa#"&#$ection through the middle part of the fossa. and BbC an inner or meningeal layer "hich surrounds the brain( )he eningeal layer is continuous "ith the s!inal dura ater( )he t"o layers are fused to each other at all !laces. abducent.Inner layers of dura 9entoriu5 cere6elli Right trans7erse sinus 9entorial notch Jora5en 5agnu5 %3 -uperior sagittal sinus ater B Jai: cere6ri . i(e( fal& cerebri. 6(:C( Divide the attach ent of tentoriu fro the !etrous te !oral bone( Identify and divide trige inal.)entoriu cerebellr 9rans7erse sinus Jal: cere6elli Occipital sinus Fi*+ +&: !oronal sections through the posterior cranial fossa showI ing folds of dura mater and the venous sinuses enclosed in them. The Cere2ra# Dura Mater s'ull bones.ll these nerves have to be cut first on one side and then on the other side( @astly identify the t"o vertebral arteries entering the s'ull through fora en agnu on each side of the s!inal edulla( Eith a shar! 'nife cut through these structures( )hus the "hole brain "ith the eninges can be gently re oved fro the s'ull( Preserve it in J5 for aldehyde( Cut through the dura ater on the ventral as!ect of brain till the inferolateral borders along the su!erciliary argin( Pull u!"ards the fold of dura ater !resent bet"een the ad3acent edial surfaces of cerebral he is!heres( )his "ill be !ossible till the occi!ital lobe of brain( Pull bac'"ards a si ilar but uch s aller fold bet"een t"o lobes of cerebellu . fal& cerebelli. -traight sinus % 9entoriu5 cere6elii %9rans7ers sinus Jal: cere6elli Occipital sinus -uperior sagittal sinus Jal: cere6ri . C. -traight sinus . facial. B.7: Hea$ a"$ Ne&- Bemo. dia!hrag a sellae including trige inal cave fro the s!eci en "ith the hel! of base of s'ull( #a'e a !a!er odel of these dural folds for reca!itulation( -uperior sagittal sinus Jal: cere6ri /n4erior sagittai sinus O Outer and . "hich ay be lifted fro the underlying anterior cranial fossa( Identify o!tic nerve. !ia ater and brain( @earn about the folds of dura ater.n outer or en+osteal layer "hich serves as an internal !eriosteu or endosteu or endocraniu for the is continuous8 BaC Eith the !eriosteu lining the outside of the s'ull or !ericraniu through the sutures and fora ina. accessory and hy!oglossal nerves( . thic'est and toughest e brane covering the brain BDuraQhardC( )here are t"o layers of dura8 BaC . and vestibulocochlear nerves( )hen cut glosso!haryngeal. infundibulu !assing to"ards hy!o!hysis cerebri( Divide all three structures( Cut through the oculo otor and trochlear nerves in relation to free argin of tentoriu cerebelli B1igs 6(F. i(e( fal& cerebelli( Se!arating the cerebru fro the cerebellu is a double fold of dura ater called tentoriu cerebelli( Pull it out in a hori7ontal !lane( )hus the endosteu and dura ater are !ulled se!arately fro arachnoid ater. and "!# $ection through the posteriorImost part. and BbC "ith the !eriosteal lining of the orbit through the su!erior orbital fissure( F(It !rovides sheaths for the cranial nerves8 the .al of the Brain )o re ove the brain and its envelo!ing eninges the structures leaving or entering the brain through various fora ina of the s'ull have to be carefully detachedKincised( Start fro the anterior as!ect by detaching fal& cerebri fro the crista galli( Put F-: bloc's under the shoulders so that head falls bac'"ards( )his "ill e&!ose the olfactory bulb. tentoriu cerebelli.

sheaths fuse "ith the e!ineuriu s'ull( outside the .

on the base of the s'ull and around the fora en agnu ( The . for ing the roof of the !osterior cranial fossa( It se!arates the cerebellu fro the occi!ital lobes of the cerebru . ..): 2entorium cerebelAi seen from above.-sha!ed and free( )he ends of the *.* are attached anteriorly to the anterior clinoid !rocesses( )his argin bounds the tentorial not*h "hich is occu!ied by the idbrain and the anterior !art of the su!erior ver is( )he outer or atta*he+ margin is conve&( Posterolaterally. and on the !osteroinferior angle of the !arietal bone( . it is attached to the li!s of the transverse sulci on the occi!ital bone.long the attached argin there are the transverse and su!erior !etrosal venous sinuses( )he trigeminal or 1e*kel's *a. BC( 2entorium !erebelli .Cranial Ca7it2 #" 0ver the o!tic nerve. 7.erior sagittal sinus lies along the u!!er arginD the inferior sagittal sinus along the lo"er arginD and the straight sinus along the line of attach ent of the fal& to the tentoriu cerebelli B1ig( 6(F.. it is attached to the su!erior border of the !etrous te !oral bone and to the !osterior clinoid !rocesses( .t !laces. in other "ords. and is attached to the crista galli( BbC )he .CL /n4undi6ulu5 %%%%%%%%%%%%%%%%% Oculo5otor ner7e %%%%%%%%%%%%%%%%%%%%%%% 9rochlear ner7e %%%%%%%%%%%%%%%%%%%% 0reat cere6ral 7ein W_M(' S Attached 5argin o4 tentoriu5 cere6elli 9rans7erse sinus 1ithin la2ers o4 tentoriu5 " Opening o4 superior sagittal sinus Fig. the dura for s a sheath "hich beco es continuous "ith the sclera( :( Its outer surface is adherent to the inner surface of the cranial bones by a nu ber of fine fibrous and vascular !rocesses( )he adhesion is ost ar'ed at the sutures. the eningeal layer of dura ater is folded on itself to for !artitions "hich divide the cranial cavity into co !art ents "hich lodge different !arts of the brain B1ig( 6(FC( )he folds are the 8 . is the !osterior cranial fossa containing the hindbrain and the lo"er !art of the idbrain( )he tentoriu cerebelli has a free argin and an attached argin B1ig( 6(:C( )he anterior free margin is .nterolaterally. and broadly divides the cranial cavity into su!ratentorial and infratentorial co !art ents( )he infratentorial co !art ent. and is attached along the edian !lane to the u!!er surface of the tentoriu cerebelli( )he fal& cerebri has t"o argins8 2a3 )he u.( 1al& cerebri B( )entoriu cerebelli C 1al& cerebelli D( Dia!hrag a sellae )hese are described belo"( Fal !erebri )he fal& cerebri is a large sic'le-sha!ed fold of dura ater occu!ying the edian longitudinal fissure bet"een the t"o cerebral he is!heres B1ig( 6(FC( It has t"o ends8 BaC )he anterior en+ is narro".e is a recess of dura ater !resent in relation to the attached argin of the tentoriu ( It is for ed by evagination of the inferior layer of the tentoriu over the trige inal Diaphrag5a sellae co7ering h2poph2seal 4ossa%%%%%%%%%%%% .er margin is conve& and is attached to the li!s of the sagittal sulcusD BbC the lo9er margin is concave and free( )he fal& cerebri has right and left surfaces each of "hich is related to the edial surface of the corres!onding cerebral he is!here( )he tentoriu cerebelli is a tent-sha!ed fold of dura ater.enin*eal 9ayer )hree i !ortant venous sinuses are !resent in relation to this fold( )he su. Optic ner7e %%%%%%%%%%%%%% .osterior en+ is broad.

I=I %Anterior clinoid process %/nternal carotid arter2 Aperture 4or oculo5otor ner7e O Aperture 4or trochlear ner7e Attached 5argin o4 tentoriu5 cere6elli 2 J >>>B -uperior petrosal sinus%%%%%% Mf L S7S 9entoriu5 cere6elli Jree 5argin o4 tentoriu5 cere6elli .-traight sinus !=>.

hori7ontal fold of dura ater for ing the roof of the hy!o!hyseal fossa( . accessory eningeal. BaC )he anterior *ranial fossa is su!!lied ostly by the anterior eth oidal nerve and !artly by the a&illary nerve. it is continuous "ith the dura ater of the iddle cranial fossa B1ig( 6(JC( )he dia!hrag a has a central a!erture through "hich the stal' of the hy!o!hysis cerebri !asses( Dia%hra!*a se##ae Tri!e*i"a# !a"!#io" . BbC the mi++le *ranial fossa is su!!lied by the a&illary nerve in its anterior half. $ura *ater Petrous te*%ora# 2o"e H6%o%h6sis &ere2ri I""er a"$ outer #a6ers o. and by branches of the andibular nerve and fro the trige inal ganglion in its !osterior half. second and third cervical s!inal nerves and !artly by eningeal branches of the ninth and tenth cranial nerves( 1ENOUS SINUSES OF DURA MATER .7( i !ression on the !etrous te !oral bone( It contains the trige inal ganglion B1ig( 6(HC( )he free and attached argins of the tentoriu cerebelli cross each other near the a!e& of the !etrous te !oral bone( . in the idlineD the straight sinus lies along the line of this attach ent( )he su!erior surface is related to the occi!ital lobes of the cerebru ( )he inferior surfa*e is concave and fits the conve& su!erior surface of the cerebellu ( )he fal& cerebelli is attached to its !osterior !art B1ig( 6(FCC( Fal !erebelli )he outer layer is richly vascular( )he inner eningeal layer is ore fibrous and re%uires little blood su!!ly( 1()he vault or su!ratentorial s!ace is su!!lied by the iddle eningeal artery( F()he anterior cranial fossa and the dural lining is su!!lied by eningeal branches of the anterior eth oidal. !osterior eth oidal and o!hthal ic arteries( :()he iddle cranial fossa is su!!lied by the iddle eningeal.ex of the sic'le is fre%uently divided into t"o !arts "hich are lost on the sides of the fora en agnu ( )he . B#oo$ Su%%#6 Fi*+ +4: Parasagittal section through the petrous temporal bone and meninges to show the formation of the trigeminal cave.erior surfa*e is conve& and slo!es to either side each side. it is attached to the dorsu sellae( 0n dura of the . occi!ital and ascending !haryngeal arteries( Ner5e Su%%#6 1()he )he fal& cerebelli is a s all sic'le-sha!ed fold of dura ater !ro3ecting for"ards into the !osterior cerebellar notch B1ig( 6(FCC( )he base of the sic'le is attached to the !osterior !art of the inferior surface of the tentoriu cerebelli in the edian !lane( )he a.osterior *ranial fossa is su!!lied chiefly by recurrent branches fro first.ault has only a fe" sensory nerves "hich are derived ostly fro the o!hthal ic division of the trige inal nerve( F()he dura of the floor has a rich nerve su!!ly and is %uite sensitive to !ain.C I""er a"$ <B Outer #a6ers o. $ura *ater H6%o%h6sea# .nterior to the !oint of crossing there is a triangular area "hich for s the !osterior !art of the roof of the cavernous sinus. and is !ierced by the third and fourth cranial nerves( )he tentoriu cerebelli has t"o surfaces( )he su.osterior margin is conve& and is attached to the internal occi!ital crest( It encloses the occi!ital sinus( )he anterior margin is concave and free( 9iaphragma $ellae )he dia!hrag a sellae is a s all circular. fro the edian !lane( )he fal& cerebri is attached to this surface.ossa Fi*+ +5: 9iaphragma sellae as seen in a sagittal section through the hypophyseal fossa. and internal carotid arteriesD and by eningeal branches of the ascending !haryngeal artery( H()he !osterior cranial fossa is su!!lied by eningeal branches of the vertebral.CCCCCCC Su%erior %etrosa# si"us CDP)=D B Te"toriu* &ere2e##i CCCCCCC Tri!e*i"a# &a5e P.nteriorly. it is attached to the tuberculu sellae( Posteriorly. BcC the .

)hese are venous s!aces. the "alls of "hich are for ed by dura ater( )hey have an inner lining of .

nterior intercavernous sinus( 6(Posterior intercavernous sinus( A(Basilar !le&us of veins( Ca5er"ous Si"uses 2ach cavernous sinus is a large venous s!ace situated in the iddle cranial fossa.n e&tradural hae orrhage can be dis ti ngui sh ed fro a su bdura l h ae o rrhag e because of the follo"ing differences( 1()he e&tradural hae orrhage is arterial due to in3ury to iddle eningeal arteryD "hereas subdural hae orrhage is venous in nature( F(Sy !to s of cerebral co !ression are late in e&tradural hae orrhage( :()here is no lucid interval in the case of a subdural hae orrhage( In an e&tradural hae orrhage . on either side of the body of the s!henoid bone( Its interior is divided into a nu ber of s!aces or caverns by trabeculae( )he trabeculae are uch less cons!icuous in the living than in the dead B1ig( 6(6C( )he floor of the sinus is for ed by the endosteal dura ater( )he lateral "all. and bones of the s'ull( Cerebros!inal fluid is !oured into so e of the ( Cranial venous sinuses co unicate "ith veins outside the s'ull through emissary .enous sinuses )here is one sinus each on right and left side( 1(Cavernous sinus( F(Su!erior !etrosal sinus( :(Inferior !etrosal sinus( H()ransverse sinus( J(Sig oid sinus( 6(S!heno!arietal sinus( A(Petros%ua ous sinus( 4(#iddle eningeal sinusKveins.Cra"ia# Ca5it6 CLINICAL ANATOM 7+ 1( /ain sensiti. a lucid interval is !resent( )his is a te !orary ! h a s e o f c o n s c i o u s n e s s b e t " e e n t h e e a r l i e r unconsciousness of cerebral concussion and the later unconsciousness of cerebral co !ression( H(In an e&tradural hae orrhage. there is no blood in the CS1D "hile it is a co on feature of subdural hae orrhage( /aire+ . the !rogress of !aralysis is ha!ha7ard( J(In an e&tradural hae orrhage. !aralysis first a!!ears in the face and then s!reads to the lo"er !arts of the body( In a subdural hae orrhage.eins) )hese co unications hel! to 'ee! the !ressure of blood in the sinuses constant( )here are F: venous sinuses. -n. the eninges.e intra*ranial stru*tures are8 BaC)he large cranial venous sinuses and their tributaries fro the surface of the brainD BbCdural arteriesD BcCthe dural floor of the anterior and !osterior cranial fossaeD and BdCarteries at the base of the brain( F( Hea+a*he ay be caused by 8 BaCDilatation of intracranial arteriesD BbCdilatation of e&tracranial arteriesD BcCtraction or distension of intracranial !ain sensitive structuresD BdCinfection and infla ation of intracranial and e&tracranial structures su!!lied by sensory cranial nerves and by cervical nerves( 3) Fxtra+ural an+ sub+ural haemorrhages are both co on( . roof and edial "all are for ed by the eningeal dura ater( DISSECTION Define the cavernous sinuses situated on each side of the body of the s!henoid bone( Cut through it bet"een the anterior and !osterior ends and locate its contents( Define its connections "ith the other venous sinuses and veins( BB<$P66- endotheliu ( )here is no uscle in their "alls( )hey have no valves( /enous sinuses receive venous blood fro the brain.enous sinuses )hese are edian in !osition( 1(Su!erior sagittal sinus( F(Inferior sagittal sinus( :(Straight sinus( H(0cci!ital sinus( J(. of "hich 4 are !aired and A are un!aired( .aire+ .

eriorly7 0!tic tract.6nteriorly. internal carotid artery and anterior !erforated substanceD BbC inferiorly7 fora en laceru and the . olfactory tract. o!tic chias a. the sinus e&tends u! to the edial end of the su!erior orbital fissure and .osteriorly. and 1 c "ide( Relat"on' <tru*tures outsi+e the sinus7 BaC <u. u! to the a!e& of the !etrous te !oral bone( It is about F c long.

( . it divides into su!erior and inferior divisions "hich leave the sinus by !assing through the su!erior orbital fissureD BbC tro*hlear ner. it divides into the lacri al.`3+)' %%%%%% -phenoidal sinus Endotheliu5 ` Oculo5otor ner7e 9rochlear ner7e /nternal carotid arter2 A6ducent ner7e Fig.PPPPPPPP-uper4icial 5iddle cere6ral 7ein . 7.e Do9n9ar+s BaC >*ulomotor ner. 3unction of the body and greater "ing of the s!henoid boneD BcC me+ially7 hy!o!hysis cerebri and s!henoidal air sinus B1ig( 6(6CD BdC laterally7 te !oral lobe "ith uncusD BeC anteriorly7 su!erior orbital fissure and the a!e& of the orbitD Bf3 . A(6CD BdC maxillary ner. fromabo.hannels 5rom the orbit7 BaC )he su!erior o!hthal ic veinD BbC a branch of the inferior o!hthal ic vein or so eti es the vein itselfD BcC the central vein of the retina ay drain either into the su!erior o!hthal ic vein or into the cavernous sinus B1ig( 6(AC( -upraor6ital 7ein -upratrochlear 7ein -phenoparietal sinus %%%%%%%%%%%%% Jrontal and anterior trun! o4 5iddle 5eningeal7ein .e) It leaves the sinus by !assing through the fora en rotundu on its "ay to the !tery- go!alatine fossaD BeC trigeminalganglion) )he ganglion and its dural cave !ro3ect into the !osterior !art of the lateral "all of the sinus B1ig( 6(HC( <tru*tures /assing through the Centre of the <inus BaC Internal *aroti+ artery "ith the venous and sy !athetic !le&us around itD BbC ab+u*ent ner.e) In the anterior !art of the sinus.hthalmi* ner.e) In the anterior !art of the sinus. and enters the orbit through the su!erior orbital fissureD BcC o.#? Head and ec! Meningeal la2er o4 dura 5ater D .osteriorly7 a!e& of the !etrous te !oral and the crus cerebri of the idbrain( <tru*turesin the 0ateral Aall of the <inus. frontal and nasociliary nerves B1igs A(H. it crosses su!erficial to the oculo otor nerve.7: !oronal section through the middle cranial fossa showing the relations of the cavernous sinus.X X ( ( X ( S -Y-YY( M %C%%%%%%%H2poph2sis cere6ri Ophthal5ic ner7e % Ma:illar2 ner7e Mandi6ular ner7e %rEHlF 3.e) In the anterior !art of the sinus. inferolateral to the internal carotid artery( )he structures in the lateral "all and in the centre of the sinus are se!arated fro blood by the endothelial lining( Tributaries or Inco6in* .e.

-uperior ophthal5ic 7ein Central 7ein o4 retina O PPPPPPP /n4erior cere6ral 7eins +%W -uperior petrosal sinus .8: $ide view of the tributaries and communication of the cavernous sinus. 7. .%%%%%%%Ca7ernous sinus 7 * /n4erior petrosal sinus ' E5issar2 7eins /n4erior ophthal5ic 7ein % %Jacial 7ein %) 33333333% Rer2goid 7enous ple:us Deep 4acial 7ein Fig.

and blood can flo" through the in either direction( Factors 4elping E pulsion of &lood from the $inus of the *a.6(11C( So eti es the su!erior sagittal sinus beco es continuous "ith the left transverse Anterior interca7ernous sinus %% -phenoparietal sinus Jrontal or anterior trun! o4 5iddle 5eningeal 7ein /n4undi6ulu5 P`.C Ier. "ith e&o!hthal os due to congestion of the orbital veins( F(. and BdC into the facial vein through the su!erior o!hthal ic vein. and BcC !osition of the head( -uperior -agittal -inus )he su!erior sagittal sinus occu!ies the u!!er conve&. through the fora en caecu ( . the fora en laceru and the e issary s!henoidal fora en B)able 1(1C. fourth and si&th cranial nerves resulting in !aralysis of the uscles su!!lied( BBC /enous sym. cornea and root of the nose. BeC )he right and left cavernous sinuses co unicate "ith each other through the anterior and !osterior intercavernous sinuses and through the basilar !le&us of veins B1ig( 6(4C( .ll these co unications are valveless. and beco es continuous "ith the right transverse sinus B1igs 6(1G. in the nasal cavities.ous sym. BbC into the internal 3ugular vein through the inferior !etrosal sinus and through a !le&us around the internal carotid artery. usually the right. BbC gravity. and in the !aranasal air sinuses( )his gives rise to the follo"ing sy !to s( B. and occasionally "ith the veins of the nose. and BbC inferior cerebral veins fro the te !oral lobe B1ig( 6(4C( 1ro themeninges7 BaC S!heno!arietal sinusD and BbC the frontal trun' of the iddle eningeal vein ay drain either into the !terygoid !le&us through the fora en ovale or into the s!heno!arietal or cavernous sinus( 9raining !hannels or !ommunications CUNICAi.% <osterior interca7arnous sinus PPPPO /n4erior cere6ral 7eins 'PPPPPPPPP Ca7ernous sinus %%%%%%%%-uper4icial 5iddle cere6ral 7ein 33333333333333333 -uperior petrosal sinus /n4erior cere6ral 7eins /n4erior petrosal sinus Basilar ple:us o4 7eins O /nternal Fugular 7ein -ig5oid sinus .Cranial Ca7it2 #' 5rom the brain7 BaC Su!erficial iddle cerebral vein. it beco es !rogressively larger in si7e( It is triangular on crosssection( It ends near the internal occi!ital !rotuberance by turning to one side. attached argin of the fal& cerebri B1ig( 6(9C( Su!erior sagittal sinus is ar'ed by a broad line fro the glabella along the sagittal sulcus till the internal occi!ital !rotuberance( It begins anteriorly at the crista galli by the union of tiny eningeal veins( <ere it co unicates "ith the veins of the frontal sinus.ernous sinus ay be caused by se!sis in the dangerous area of the face. co unication bet"een the cavernous sinus and the internal carotid artery ay be !roduced by head in3ury( Ehen this ha!!ens the eyeball !rotrudes and !ulsates "ith each heart beat( It is called the !ulsating e&o!hthal os( $urface /arking BaC 2&!ansile !ulsations of the internal carotid artery "ithin the sinus.s the sinus runs u!"ards and bac'"ards. ANATOM 1(Thrombosis )he cavernous sinus drains8 BaC Into the transverse sinus through the su!erior !etrosal sinus.toms7 BaC Severe !ain in the eye and forehead in the area of distribution of the o!hthal ic nerveD BbC involve ent of the third.toms7 #ar'ed oede a of the eyelids. BcC into the !terygoid !le&us of veins through the e issary veins !assing through the fora en ovale.

? Occipital sinus%%%%%%%%%%%%%%%%%%% ' CCRI 2R'+%%%%%%%%%%%%%%% 9rans7erse sinus %%%%%%%% Con4luence o4 sinuses Fig.Connection 1ith internal 7enous ple:us% )-* i +' RM. 7. .1: $uperior view of the tributaries and communications of the cavernous sinus.

scal! and di!loe( )his gives rise to 8 BaC . concave free argin of the fal& cerebri( It ends by 3oining the great cerebral vein to for the straight sinus B1ig( 6(9C( Venous lacuna Endosteal dura 5ater E5issar2 7ein Diploic 7ein Meningeai 7ein Su!erior cerebral vein Meningeal dura 5ater %Arachnoid 5ater )) -u6arachnoid space Fig. 7. a vein fro the nose o!ens into the sinus "hen the fora en caecu is !atent( Thrombosis of the su. BbC o!enings of venous lacunae. a s all channel lies in the !osterior t"o-thirds of the lo"er. considerable rise in intracranial tension due to defective absor!tion of CS1D BbC deliriu and so eti es convulsions due to congestion of the su!erior cerebral veinsD and BcC !ara!legia of the u!!er otor neuron ty!e due to bilateral involve ent of the !aracentral lobules of the cerebru "here the lo"er li bs and !erineu are re!resented( I". meningeal and cerebral# veins in its relation. BcC arachnoid villi and granulations !ro3ecting into the lacunae as "ell as into the sinus. the arachnoid villi and granulations. BaC Su!erior cerebral veins "hich never o!en into the venous lacunae B1ig( 6(1GCD BbC !arietal e issary veinsD BcC venous lacunae. and BdC nu erous fibrous bands crossing the inferior angle of the sinus B1ig( 6(1GC( 2ributaries CLINICAL ANATOM )he su!erior sagittal sinus receives these tributaries. usually three on each side.erior sagittal sinus ay be caused by s!read of infection fro the nose.%3: !oronal section through superior sagittal sinus showing arrangement of the meninges. and the various Arachnoid 7illi and granulation "emissary. diploic.erior Sa!itta# Si"us )he inferior sagittal sinus. Occipital sinus 9rans7erse sinuses sinuses.74 Hea$ a"$ Ne&-uperior sagittal sinus /n4erior sagittal sinus -uperior petrosai sinus Fi*+ +": show -phenoparietal sinus )' Ca7ernous sinus /n4erior petrosai sinus -ig5oid sinuses intracranial venous view. 5ateral 3 % Con4luence o4 sinuses 0reat cere6ral 7ein -traight sinus $cheme to the sinus( It generally co unicates "ith the o!!osite sinus( )he 3unction of all these sinuses is called the *onfluen*e of sinuses) )he interior of the sinus sho"s8 BaC 0!enings of the su!erior cerebral veins. and then o!en into the sinusD BdC occasionally. usually three on each side "hich first. <ia 5ater Arachnoid granulation -----1al& cerebri . receive the di!loic and eningeal veins.

eid*s base line BCha!ter 1. situated one in front of the other 1(F c a!art B1ig( 6(11C( BbC)"o si ilar !oints near the !osterior border and 1(F c above the ti! of the astoid !rocess( 2ach sinus right or left is the direct continuation of the transverse sinus( It is S-sha!ed8 hence the na e( It e&tends fro the !osteroinferior angle of the !arietal bone to the !osterior !art of the 3ugular fora en "here it beco es the su!erior bulb of the internal 3ugular vein( It grooves the astoid !art of the te !oral bone. "hich regulates the secretion of CS1( Tra"s5erse Si"us $urface /arking cerebelli( )he right transverse sinus is usually a continuation of the su!erior sagittal sinus. BcC the inferior cerebellar veins.arate+ anteriorly from the mastoi+ antrum an+ mastoi+ air *ells by only )he transverse sinus is ar'ed by t"o !arallel lines 1(F c a!art e&tending bet"een the follo"ing t"o !oints( BaC)"o !oints at the inion.nato ical !osition of s'ullC( )he transverse sinuses are large sinuses( )he right sinus usually larger than the left situated in the !osterior !art of the attached argin of the tentoriu -ig5oid -uperior sagittal sinus sinus 9rans7erse sinus Mastoid process . BbC the inferior cerebral veins. BdC the di!loic B!osterior te !oralC vein. there e&ists a ball valve echanis . and ends at the internal occi!ital !rotuberance by continuing as the transverse sinus usually left B1ig( 6(9C( In addition to the veins for ing it. situated one above the other and 1(F c a!art B1ig( 6(11C( BbC)"o !oints at the base of astoid !rocess. "here it is se.t the ter ination of the great cerebral vein into the sinus. situated one in front of the other 1(F c a!art( )his sinus is conve& u!"ards. and the left sinus a continuation of the straight sinus( 2ach sinus e&tends fro the internal occi!ital !rotuberance to the !osteroinferior angle of the !arietal bone at the base of astoid !rocess "here it bends do"n"ards and beco es the sig oid sinus( Its tributaries are8 BaC )he su!erior !etrosal sinus. it also receives a fe" of the su!erior cerebellar veins( . reaching F c above . . for ed by a sinusoidal !le&us of blood vessels.Cra"ia# Ca5it6 7/ Strai!ht Si"us )he straight sinus lies in the edian !lane "ithin the 3unction of fal& cerebri and the tentoriu cerebelli( It is for ed anteriorly by the union of the inferior sagittal sinus "ith the great cerebral vein. and BeC the inferior anasto otic vein( Si!*oi$ Si"uses $urface /arking )he sig oid sinus is ar'ed by t"o !arallel lines situated 1(F c a!art and e&tending bet"een the follo"ing !oints8 BaC)"o !oints at the base of the astoid !rocess.

0la6ella Fi*+ 7. Jacial 7ein .%%: 'enous sinuses and facial vein.

therefore.eins lies over the clivus of the s'ull( It connects the t"o inferior !etrosal sinuses and co unicates "ith the internal vertebral venous !le&us( )he mi++le meningeal . one in front and the other behind the infundibulu ( Eith the cavernous sinuses they for the circular sinus( )he irregular venous channels belo" the hy!o!hysis cerebri drain into the intercave ous sinuses 25ig) 6) 3) H6%o%h6sis Cere2ri MPituitar6 !#a"$T )he o**i. and drain the cavernous sinus into the su!erior bulb of the internal 3ugular vein( )hey receive8 BaC @abyrinthine veins through the cochlear canaliculus and the a%ueduct of the vestibuleD and BbC veins fro the edulla. right and left lie along the !osterior free argin of the lesser "ing of the s!henoid bone.emous sinuses connect the cavernous sinuses( )hey !ass through the dia!hrag a sellae. 6(9C )he s.etrosal sinuses lie in the anterior !art of the attached argin of the tentoriu cerebelli along the u!!er border of the !etrous te !oral bone( )he sinus crosses the trige inal nerve( It drains the cavernous sinus into the transverse sinus( It receives so e inferior cerebral. one frontal or anterior and one !arietal or !osterior. therefore. cerebellar and ty !anic veins( B1ig( 6(4C( )he inferior . or ii the s!heno!arietal or cavernous sinus( )he .lexus of . and lies in the attached argin of the fal& cerebelli( It begins near the fora en agnu and ends in the confluence of sinuses( B1igs 6(F. "hich acco !any the t"o branches of the iddle Intro+u*tion7 The hy!o!hysis cerebri is a s all endocrine gland situated in relation to the base of the brain( It is often called the aster of the endocrine orchestra because it !roduces a nu ber of hor ones "hich control the secretions of any other endocrine glands of the body B1ig( 6(1FC( /n4undi6ular recess o4 third 7entricle Optic chias5a Ma5illar2 6od2 <ars tu6eralis /n4undi6ulu5 <ars posterior <ars inter5edia %%%%%%% Cle4t Median e5inence Pars a"terior Fig. the !ons and the cerebellu B1ig( 6(9C( )he basilar .%<: Parts of the hypophysis cerebri as seen in a sagittal section.ital sinus is s all. DISSECTION Identify dia!hrag a sellae over the hy!o!hyseal fossa( Incise it radially and locate the hy!o!hysis cerebri lodged in its fossa( )a'e it out and e&a ine it in detail "ith the hand lens B1ig( 6(JC( .erior .arietal sinuses.Head and / a thin . or in the astoid !rocess called the astoiditis( During o!erations on the astoid !rocess one should be careful about the sig oid sinus. and drains into the transverse sinus( )he anterior and !osterior inter*a.halus) Other Si"uses eningeal arterr )he frontal trunk may end either ii the !terygoid !le&us through the fora en ovale.heno.etros:uamous sinus ay or ay not be !resent( It lies in the !etros%ua ous fissure. ore liable to in3ury in fractures of the s'ull( )he . lead to the develo! ent of hydroce!haJus( <u*h a liydroce!halus associated "ith sinus thro bosis follo"ing ear infection is 'no"n as otiti* hy+ro& *e. BbC cerebellar veinsD and BcC the internal auditory vein( CLINICAL ANATOM Thrombosis of the sigmoi+ sin us is al"ays secondary to infection in the iddle ear or otitis edia. and drain into the anterior !art of the cavernous sinus( 2ach sinus ay receive the frontal trun' of the iddle eningeal vein B1ig( 6(4C( )he su. so that it is not e&!osed( S!read of infection or thro bosis fro the sig oid and transverse sinuses to the su!erior sagittal sinus ay cause i !aired CS1 drainage into the latter and ay.eins for t"o ain trun's.arieta trunk usually ends in the !terygoid !le&us through the fora en s!inosu ( )he eningeal veins an nearer to the bone than the arteries.etrosal sinuses right and left lie in the corres!onding !etro-occi!ital fissure. 7. and are.late of bone) Its tributaries are8 BaC )he astoid and condylar e issary veins.

and are carried to their target cells( . e clusively by the portal vessels.osterior) It is s aller than the anterior lobe and lies in the !osterior concavity of the larger anterior lobe( b( Infun+ibular stem.ath'e*s !ouch( c( Tuberal lobe or !ars tuberalis) It is an u!"ard e&tension of the anterior lobe that surrounds and for s !art of the infundibulu ( Neurohypophysis a( /osterior lobe or neural lobe.o. and is connected to the hy!othala us by neural !ath"ays( 1urther subdivisions of each !ail are given belo"( Adenoh ypoph ysis a( 6nterior lobe or !ars anterior.eriorly7 2a3 Dia!hrag a sellaeD BbC o!tic chias aD BcC tuber cineriu D and BdC infundibular recess of the third ventricle( Inferiorly7 BaC Irregular venous channels bet"een the t"o layers of dura ater lining the floor of the hy!o!hyseal fossaD BbC hy!o!hyseal fossaD and BcC s!henoidal air sinuses B1igs 6(6.ars +istalis. . called the trabecular artery( Ca%i##ar6 tu.>'' +OO Capillar2 tu4ts in lo1er in4undi6ulu5 A"asto*osis 2et<ee" su%erior a"$ i"..ts i" *e$ia" e*i"e"&e a"$ i" i". and the short !ortal vessels drain the lo"er infundibulu ( )he !ortal vessels are of great functional i !ortance because they carry the hormone releasing fa*tors fro the hy!othala us to the anterior lobe "here they control the secretory cycles of different glandular cells( 1e"ous Draina*e Short veins e erge on the surface of the gland and drain into neighbouring dural venous sinuses( )he hor ones !ass out of the gland through the venous blood.hysis "hich differ fro each other e bryologically.ars glan+ularis) )his is the largest !art of the gland B1ig( 6(1FC( b( Interme+iate lobe or !ars interme+ia) )his is in the for of a thin stri! "hich is se!arated fro the anterior lobe by an intraglandular cleft. or .o. > Lo"! %orta# 5esse#s @ Q Su%erior h6%o%h6sea# arter5 Tra2e&u#ar arter6 to #o<er i".u"$i2u#u* F4FC+ . BbC the u!!er !art of the infundibulu .Cranial Ca7it2 ## )he gland lies in the hy!o!hyseal fossa or sella turcica or !ituitary fossa( )he fossa is roofed by the dia!hrag a sellae( )he stal' of the hy!o!hysis cerebri !ierces the dia!hrag a sellae and is attached above to the floor of the third ventricle( )he gland is oval in sha!e. and the adenohypophysis.u"$i2u#u* Short %orta# 5esse#s . 6(1F and F9(FC( >n ea*h si+e7 )he cavernous sinus "ith its contents( Su#d"("'"on' )he gland has t"o ain !arts8 6+enohy. 2ach inferior hy!o!hyseal artery divides into edial and lateral branches "hich 3oin one another to for an arterial ring around the !osterior lobe( Branches fro this ring su!!ly the !osterior lobe and also anasto ose "ith branches fro the su!erior hy!o!hyseal artery( )he anterior lobe or !ars distalis is su!!lied e&clusively by . or!hologically and functionally( )he adenohy!o!hysis develo!s as an u!"ard gro"th called the . a re nant of the lu en of .erior h6%o%h6sea# arter6 Fi*+ +#': Arterial supply of the hypophysis cerebri. and easures 4 antero!osteriorly and 1F transversely( It "eighs about JGG g( 7elations <u.hysis and neurohy. and BcC the lo"er !art of the infundibulu through a se!arate long descending branch.essels arising fro ca!illary tufts for ed by the su!erior hy!o!hyseal arteries B1ig( 6(1:C( )he long !ortal vessels drain the edian e inence and the u!!er infundibulu .ath'e*s !ouch fro the ectoder al roof of the sto odeu ( )he neurohy!o!hysis develo!s as a do"n"ard gro"th fro the floor of the dience!halon. . "hich contains the neural connections of the !osterior lobe "ith the hy!othala us( c( 1e+ian eminen*e of the tuber cineriu "hich is continuous "ith the infundibular ste ( -rterial Supply )he hy!o!hysis cerebri is su!!lied by the follo"ing branches of the internal carotid artery( 1(0ne su!erior hy!o!hyseal artery on each side B1ig( 6(1:C( F(0ne inferior hy!o!hyseal artery on each side( 2ach su!erior hy!o!hyseal artery su!!lies8 BaC )he ventral !art of the hy!othala us.erior h6%o%h6sea# arteries I".ars . Note that the neurohypophysis is supplied by the superior and inferior hypophyI seal arteries.ortal .

e) )here are t"o layers of dura belo" the ganglion B1ig( 6(1HC( )he cave is lined by !ia-arachnoid. "ith its conve&ity directed anterolaterally( )he three Identify trige inal ganglion situated on the anterior surface of !etrous te !oral bone near its a!e&( Define the three branches e erging fro its conve& anterior surface( divisions of the trige inal nerve e erge fro this conve&ity( )he !osterior concavity of the ganglion receives the sensory root of the nerve B1ig( 6(1HC( $urface /arking )rige inal ganglion lies a little in front of the !reauricular !oint at a de!th of about J c ( $ituation and /eningeal Felations )his is the sensory ganglion of the fifth cranial nerve( It is ho ologous "ith the dorsal nerve root ganglia of s!inal nerves( . BbC baso!hil adeno a causes Cushing*s syndro e.ressin 26DH3 "hich acts on 'idney tubules.hili* *ells 2$'N3 BaC 6*i+o. and BbC odified neurological cells. BaC .( Ceneral sym. +<C( F(#a otro!hs B!rolactin cellsC8 Secrete lactogenic hor one( :(Corticotro!hs8 Secrete . BcC chro o!hobe adeno a causes effects of hy!o!ituitaris .e*ifi* sym.ath'e*s !ouch tu ours. and BbC oxyto*in "hich !ro otes contraction of the uterine and a ary s ooth uscle( )hese hor ones are actually secreted by the hy!othala us.hils/al. BdC !osterior lobe da age causes diabetes insi!idus. and chro o!hobe cells surrounding asses of colloid aterial( It secretes the elanocyte sti ulating hor one B#S<C( /osterior 0obe It is co !osed of8 BaC . causing a rise in intracranial !ressure( B( <.hobi* *ells $'N re!resent the nonsecretory !hase of the other cell ty!es. and BdC a large tu our ay !ress u!on the third ventricle.ll such ganglia are ade u! of !seudouni!olar nerve cells.itui*ytes) )hey have any dendrites "hich ter inate on or near the sinusoids( )he hy!othala o-hy!o!hyseal tract begins in the !reo!tic and !araventricular nuclei of the hy!othala us( Its short fibres ter inate in relation to ca!illary tufts of !ortal vessels. called the trigeminal or1e*kel's *a. large nu ber of non yelinated fibres-hy!othala o-hy!o!hyseal tract.toms de!ending on the cell ty!e of the tu our. or their !recursors( In terme+ia te 0obe It is ade u! of nu erous baso!hil cells.toms due to !ressure over surrounding structures8 BaC )he sella turcica is enlarged in si7e.=istolo*y and =or6ones CLINICAL ANATOM 6nterior 0obe Chromo. fro "here these are trans!orted through the hy!othala o-hy!o!hyseal tract to the !osterior lobe of the gland( Tri!e*i"a# Ia"!#io" Pituitary tu ours give rise to t"o ain categories of sy !to s8 . on the anterior surface of the !etrous te !oral bone near its a!e&( It occu!ies a s!ecial s!ace of dura ater.ha&*ells8 about H:5 1(So atotro!hs8 Secrete gro"th hor one BS)<. "ith a )*-sha!ed arrange ent of their !rocessD one !rocess arises fro )he ganglion lies on the trigeminal im. called . BbC !ressure over the o!tic chias a causes bite !oral he iano!ia or bite !oral u!!er %uadrantic he iano!iaD BcC !ressure over the hy!othala us ay cause one of the hy!othala ic syndro es li'e obesity of 1rolich*s syndro e in cases "ith . so that the ganglion along "ith the otor root of the trige inal nerve is surrounded by CS1( )he ganglion lies at a de!th of about J c fro the !reauricular !oint( . although the lesion in these cases usually lies in the hy!othala us( the cell body "hich then divides into a central and a !eri!heral !rocess( )he ganglion is crescentic or se ilunar in sha!e. !roviding the !ossibility for a neural control of the secretory activity of the anterior lobe( )he long fibres of the neurosecretory tract !ass to the !osterior lobe and ter inate near vascular sinusoids( )he hor ones related to the !osterior lobe are8 BaC =aso.cido!hil or eosino!hil adeno a causes acro egaly in adults and gigantis in younger !atients.hils/beta&*ells.C)<( BbC Baso.ression. about A5 of cells 1()hyrotro!hs8 Secrete )S<( F(+onadotro!hs8 Secrete 1S<( :(@uteotro!hs8 Secrete @< or ICS<( II( Chromo.

maxillary an+ man+ibular) )he s all motor root of the trige inal nerve is attached to the !ons su!ero edial to the sensory root( It !asses under the ganglion fro its edial to the lateral side.%6: $uperior view of the middle cranial fossa showing some of ifs contents.Felations #edially8 BaC Internal carotid artery. na ely the o. BcC a!e& of the !etrous te !oral bone. 7. and 3oins the andibular nerve at the fora en ovale( &lood $upply )he ganglion is su!!lied by t"igs fro the BaC Internal carotidD BbC iddle eningealD and BcC accessory eningeal arteries and BdC by the eningeal branch of the ascending !haryngeal artery( .eriorly7 Parahi!!oca !al gyrus( Interiorly7 BaC #otor root of trige inal nerve.hthalmi*. Associated Foot and &ranches )he central !rocesses of the ganglion cells for the large sensory root of the trige inal nerve "hich is attached to !ons at its 3unction "ith the iddle cerebellar !eduncle( )he !eri!heral !rocesses of the ganglion cells for three divisions of the trige inal nerve. and BdC the fora en laceru B1ig( 6(1HC( 0reater 1ing o4 sphenoid Mandi6ular ner7e E PPPP% Ma:illar2 ner7e 3O ))) Ophthal5ic ner7e /nternal Ca7ernous sinus carotid arter2 Motor root and sensor2 root o4 trige5inal 9rige5inal ganglion 7 0reater petrosal ner7e Middle 5eningeal arter2 <etrous te5poral 6one -8ua5ous te5poral 6one fig. BbC greater !etrosal nerve. and BbC !osterior !art of cavernous sinus( 0aterally7 #iddle eningeal artery( <u.

given off in the infrate !oral fossa( BCha!ter 1GC D/--EC9/O mm Dissect the iddle eningeal artery "hich enters the s'ull through fora en s!inosu ( It is an i !ortant artery for the su!!ly of endocraniu . BcC and BdC re!resents the anterior or frontal branch( It first runs u!"ards and for"ards Bb-cC and then u!"ards and bac'"ards. !etrosal nerves and fourth !art of vertebral artery( $urface /arking )he artery is ar'ed by 3oining the follo"ing !oints( BaC . internal carotid artery. inner table of s'ull and di!loe( 2&a ine the other structures seen in cranial fossae after re oval of brain( )hese are the cranial nerves. "hich is an acute surgical e ergency B1ig( 6(1HC( >rigin7 )he artery is a branch of the first !art of the a&illary artery. to"ards the !oint *e*( . !oint i ediately above the iddle of the 7ygo a( )he artery enters the s'ull o!!osite this !oint B1ig( 1(9CD BbC a second !oint F c above the first !oint( )he artery divides dee! to this !ointD BcC a third !oint at centre of !terion :(J c behind and 1(J c above the fronto7ygo atic suture( It can also be ar'ed as a !oint H c above the id!oint of the 7ygo atic archD BdC a fourth !oint id"ay bet"een the nasion and inionD BeC a fifth !oint called the la bda 6 c above the e&ternal occi!ital !rotuberance( )he line 3oining !oints BaC and BbC re!resents the ste of the iddle eningeal artery inside the s'ull( )he line 3oining !oints BbC. to"ards the !oint *d*( )he line 3oining !oints BbC and BeC re!resents the !osterior or !arietal branch( It runs bac'"ards and u!"ards.CLINICAL ANATOM Intractable facial !ain due to trige inal neuralgia or carcino atosis ay be abolished by in3ecting alcohol into the ganglion( So eti es cutting of the sensory root is necessary( Congenital cutaneous naevi on the face B!ort "ine stainsC a! out accurately the areas su!!lied by one or ore divisions of the /th cranial nerve( Mi$$#e Me"i"!ea# Arter6 )he iddle eningeal artery is i !ortant to the surgeon because this artery is the co onest source of e&tradural hae orrhage.

and divides into a frontal and !arietal branch B1ig( 6(1HC( H()he frontal or anterior bran*h is larger than the !arietal branch( 1irst it runs for"ards and laterally to"ards the lateral end of the lesser "ing of the s!henoid( )hen it runs obli%uely u!"ards and bac'"ards.!ourse and Felations 1(In the infrate !oral fossa. or near. but the iddle eningeal veins are closer to the bone than the artery( <ere the artery runs for"ards and laterally for a variable distance. the artery runs u!"ards and edially dee! to the lateral !terygoid uscle and su!erficial to the s!heno andibular liga ent( <ere it !asses through a loo! for ed by the t"o roots of the auriculote !oral nerve B1igs 1G(6. giving rise to he i!legia of the o!!osite side( )he anterior division can be a!!roached surgically by a'ing a hole in the s'ull over the !terion. the hole is ade at a !oint H c above and H c behind the e&ternal acoustic eatus( . grooving the s%ua ous te !oral bone. the !arietal or !osterior branch is i !licated.arely. causing contralateral deafness( In this case. and a little in front of the central sulcus of the cerebral he is!here( )hus after crossing the !terion the artery is closely related to the otor area of the cerebral corte&( J()he . the su!erior te !oral sulcus of the cerebru . the artery has an e&tradural course. B"hich also trans its the eningeal branch of the andibular nerve and the !arietal trun' of the iddle eningeal veinC B1ig( 6(1HC( :(In the iddle cranial fossa. 1G(1GC( F(It enters the iddle cranial fossa through the fora en s!inosu . about H c above the level of the 7ygo atic arch( It ends in front of the !osteroinferior angle of the !arietal bone by dividing into branches( Branches )he iddle eningeal artery su!!lies only s all branches to the dura ater( It is !redo inantly a !eriosteaR artery su!!lying bone and red bone arro" in the di!loe( CLINICAL ANATOM )he iddle eningeal artery is of great surgical i !ortance because it can be torn in head in3uries resulting in extra+ural haemorrhage) The frontal or anterior bran*h is co only involved( )he hae ato a !resses on the otor area.arietal or .osterior bran*h runs bac'"ards over. !arallel to. H c above the id!oint of the 7ygo atic arch( .

haryngeal.e !asses through the o!tic canal "ith the o!hthal ic artery( )he thir+ or o*ulomotor and fourth or tro*hlear ner.es !ierce the !osterior !art of the roof of the cavernous sinus for ed by crossing of the free and attached argins of the tentoriu cerebelliD ne&t they run in the lateral "all of the cavernous sinus( )hey enter the orbit through the su!erior orbital fissure B1igs 6(:. four !etrosal nerves and fourth !art of the vertebral artery( .erior tym.etrosal bran*h to the hiatus for the greater !etrosal nerveD B1Ca su.e is seen in the for of 1J to FG fila ents on each side that !ierce the cribrifor !late of the eth oid bone( )he se*on+ or o. Brai" )he structures seen after re oval of the brain are8 1F cranial nerves.enth or a**essory ner. has a large sensory root and a s all otor root( )he roots cross the a!e& of the !etrous te !oral bone beneath the su!erior !etrosal sinus.ti* ner.enth or fa*ial an+ eighth or stato& a*ousti*or vestibulocochlear nerves !ass through the internal acoustic eatus "ith the labyrinthine vessels B1ig( FH(1C( )he ninth or glosso.e.ani* bran*h to the tensor ty !aniD 3 BFCtem. tenth or .Eithin the cranial cavity it gives off8 B1C Canglioni* bran*hes to the trige inal ganglionD BFC a .ranial NerAes )he first or olfa*tory ner.ter Re*o5a# o.e !ierces the lo"er !art of the !osterior "all of the cavernous sinus near the a!e& of the !etrous te !oral bone( It runs for"ards by the side of( the dorsu sellae beneath the !etros!henoidal liga ent to reach the centre of the cavernous sinus B1igs 6(6.oral bran*hes to the te !oral fossaD and B:Canastomoti* bran*h that enters the orbit and 3 anasto oses "ith the lacri al artery( Other Stru&tures See" i" Cra"ia# Fossae a. and then !asses out through the 3ugular fora en B1ig( FH(1C( )he t"o !arts of the t9elfth or hy. to enter the iddle cranial fossa B1ig( 6(1HC( )he sixth or ab+u*ent ner. A(1HC( )he se. cavernous !art of internal carotid artery.agus an+ ele.oglossal ner.e !ierce the dura ater se!arately o!!osite the hy!oglossal canal and then !ass out through it( .es !ierce the dura ater at the 3ugular fora en and !ass out through it( )he s!inal !art of the accessory nerve first enters the !osterior cranial fossa through the fora en agnu . A(HC( Z )he fifth or trigeminal ner.

sy !athetic in nature is a branch of the sy !athetic !le&us around the internal carotid artery( It contains !ostganglionic fibres fro the su!erior cervical sy !athetic ganglion( )he nerve 3oins the greater !etrosal nerve to for the nerve of the !terygoid canal( )he sy !athetic fibres in it are distributed through the branches of the !terygo!alatine ganglion B)able 1(:C( F()he lesser .art7 Eithin the !etrous !art of the te !oral bone. dia!hrag a sellae !ierced by infundibulu . !osterior cerebral artery. cavernous and cerebral !arts of the internal carotid artery together for an *S*-sha!ed figure. !asses out of the s'ull through the fora en ovale.e B1ig( 6(1HC carries gustatory and !arasy !athetic fibres( It arises fro the geniculate ganglion of the facial nerve.art7 )his !art lies at the base of the brain after e erging fro the cavernous sinus B1ig( :1(1C( It gives off the follo"ing arteries8 BaC 0!hthal icD BbC anterior cerebralD BcC iddle cerebralD BdC !osterior co unicatingD and BeC anterior choroidal( 0f these. !alate and !haryn& B1ig( 1J(1:C( )he gustatory or taste fibres do not relay in the ganglion and are distributed to the !alate( 1()he dee! .e. situated 3ust lateral to the hiatus for the greater !etrosal nerve. o!tic nerve.e.art7 Eithin the cavernous sinus B1ig( 6(6C( )his !art of the artery gives off8 Cavernous branches to the trige inal ganglionD and BbC the su!erior and inferior hy!o!hyseal branches to the hy!o!hysis cerebriC ^CereBraG^.etrosal ner. and enters the iddle cranial fossa through the hiatus for the greater !etrosal nerve on the anterior surface of the !etrous te !oral bone( It !roceeds to"ards the fora en laceru . "here it 3oins the dee! !etrosal nerve "hich carries sy !athetic fibres to for the nerve of the !terygoid canal B)able 1(:C( )he nerve of the !terygoid canal !asses through the !terygoid canal to reach the !terygo!alatine ganglion( )he !arasy !athetic fibres relay in this ganglion( Postganglionic !arasy !athetic fibres arising in the ganglion ulti ately su!!ly the lacri al gland and the ucosal glands of the nose. sy !athetic in nature is an inconstant branch fro the sy !athetic !le&us around the iddle eningeal artery to the geniculate ganglion of the facial nerve( Fourth Part o. lesser "ing of s!henoid( Identify follo"ing structures in the iddle cranial fossa8 #iddle eningeal vessels. vestibulocochlear. s all !art of this artery has been seen in Cha!ter H( .e !arasy !athetic in nature is a branch of the ty !anic !le&us. hy!oglossal nerves. accessory. glosso!haryngeal. the o!hthal ic artery su!!lies structures in the orbitD "hile the others su!!ly the brainR i )he curvatures of the !etrous. in the carotid canal( It "ill be studied at a later stage( 6 KCavernous .etrosal ner.etrosal ner. vagus. vertebral arteries.. the 1erte2ra# Arter6 It enters the !osterior cranial fossa through the fora en agnu after !iercing the dura ater near the s'ull( . and ends in the otic ganglion B1ig( 1G(1JC( Postganglionic fibres arising in the ganglion su!!ly the !arotid gland through the auriculo-te !oral nerve B)able 1(:C( :()he external . the carotid si!hon of angiogra s( 1( )he greater .Cra"ia# Ca5it6 9C DISSECTION Petrosal NerAes Identify follo"ing structures in the anterior cranial fossa( Crista galli. internal carotid arteries. cribrifor !late of eth oid.i*al . oculo otor nerves.etrosal ner. orbital !art of frontal bone. deriving its !reganglionic !arasy !athetic fibres fro the ty !anic branch of the glosso!haryngeal nerve( It e erges through the hiatus for the lesser !etrosal nerve.est "ill be studied in Cha!ters 1: and :1( . great cerebral vein( Identify follo"ing structures in the !osterior cranial6 fossa8 1acial.art7 In the nec' it lies "ithin the carotid sheath( )his !art gives no branches B1ig( 4(1FC( /etrous . s!inal root of accessory nerve( I"ter"a# Caroti$ Arter6 MCa5er"ous PartT )he internal carotid artery begins in the nec' as one of the ter inal branches of the co on carotid artery at the level of the u!!er border of the thyroid cartilage( Its course is divided into the follo"ing four !arts( Cer.

es7 0!tic. Illrd. trochlear and abducentD branches of o!hthal ic and a&illary nerves. identify the o!tic canal and su!erior orbital fissure and structures traversing these( Define the orbital fascia and fascial sheath of eyeball( Divide the orbital !eriosteu along the iddle of the orbit antero!osteriorly( Cut through it hori7ontally close to anterior argin of orbit( )he *ontents of the orbit are listed belo"( 1(Fyeball7 It "ill be studied in detail se!arately BCha!ter 19C( F(5as*ia7 0rbital and bulbar( :(1us*les7 2&traocular( It for s the . oculo otor. it is continuous "ith the !eriosteu lining the bones around the orbital argin B1ig( A(1C( )here is a ga! in the !eriorbita over the inferior orbital fissure( )his ga! is bridged by connective tissue "ith so e s ooth uscle fibres in it( )hese fibres constitute the orbitalis uscle( BaC . /lth. and so e sy !athetic fibres are dedicated to the contents of orbit only( =ature has !rovided orbit for the safety of the eyeball( Ee ust also try and loo' after our orbits and their contents( I"tro$u&tio" 1(/essels8 0!hthal ic artery. nerves.Contents o4 the Or6it orbits are bony cavities lodging the eyeballs.sule for s a thin. it is continuous "ith the dura ater and "ith the sheath of the o!tic nerve( . it can be easily stri!!ed( Posteriorly.&is !assing through centres of anterior and !osterior !oles of the eyeball is 'no"n as visual a&is( It a'es an angle of FG-FJ[ "ith the orbital a&is B1ig( 1(F:C.t the u!!er and lo"er argins of the orbit the orbital fascia sends off fla!-li'e continuations into the eyelids( )hese e&tensions for the orbital se. and sy !athetic nerves( :(0a*rimal glan+7 It has already been studied in Cha!ter F( ()>rbitalfat Disual -)is and Orbital -)is i )he orbits are !yra idal cavities. but the lateral "alls are set at right angles to each other( . blood vessels and lacri al gland( 0ut of 1F !airs of cranial nervesD Ilnd. various uscles. su!erior and inferior o!hthal ic veins. situated one on each side of the root of the nose( )hey !rovide soc'ets for rotatory ove ents of the eyeball( )he long a&is of the each orbit !asses bac'"ards and edially( )he edial "alls are !arallel to each other.nteriorly. loose e branous sheath around the eyeball. and ly !hatics( F(Ier.tum8 BaCa !rocess of the fascia holds the fibrous !ulley of the tendon of the su!erior obli%ue uscle in !laceD BbCanother !rocess for s the la*rimal fas*ia "hich bridges the lacri al groove( Fascial Sheath of Eyeball or Bulbar Fascia 1( Tenon's *a. I/th. i(e( o!ening on the face( Orbital Fascia or Periorbita DISSECTION Stri! the endosteu fro the floor of the anterior cranial fossa( +ently brea' the orbital !late of frontal bone for ing the roof of the orbit and re ove it in !ieces so that orbital !eriosteu is clearly visible( #edially the eth oidal vessels and nerves should be !reserved( Posteriorly.eriosteum of the bony orbit( Due to the loose connection to bone. a !art of /th. i(e( line !assing through o!tic canal and centre of base of orbit. e&tending fro ">' .

as&ia Fig.<:I(rbital fascia and fascial sheath of the eyeball as seen in transverse section. BaC .%'S SS : ).ensory ligament of the eye or the sus.a"$ Ne&Or2ita# se%tu* (rbital fascia 1()he sheath is !ierced by8 BaC )he tendons of the Sheath o. . the o!tic nerve to the sclerocorneal 3unction or li bus( It is se!arated fro the sclera by the e!iscleral s!ace "hich is traversed by delicate fibrous bands( )he eyeball can freely ove "ithin this sheath( various e&traocular usclesD and BbC )he ciliary vessels and nerves around the entrance of the o!tic nerve( F()he sheath gives off a nu ber of e&!ansions. 8.ensory ligament of0o*k9oo+ B1ig( A(:C( It is e&!anded in the centre and narro" at its e&tre ities. o%ti& "er5e Or2ita#is *us&#e Or2ita# .SS S SS Q2go5atic 6one -heath o4 lateral rectus' Or6ital 4ascia ` 3* . tubular sheath covers each orbital uscleD BbC the me+ial *he*k ligament is a strong triangular e&!ansion fro the sheath of the edial rectus uscleD it is attached to the lacri al boneD BcC the lateral *he*k ligamentis a strong triangular e&!ansion fro the sheath of the lateral rectus uscleD it is attached to the 7ygo atic bone B1ig( A(FC( :()he lo"er !art of )enon*s ca!sule is thic'ened. 8... and is na ed the sus.3PP Bod2 o4 sphenoid VO -heath o4 optic ner7e Fig. B: (rbital fascia and fasciaA sheath of the eyeball as seen in a parasagittal section. and is slung li'e a ha oc' belo" the eyeball( It is for ed by union of the argins of the sheaths of the inferior rectus and the inferior obli%ue uscles "ith the edial and lateral chec' liga ents( Medial palpe6ral liga5ent 3MrO Lacri5al 4ascia (F Lateral palpe6ral raphe 3 Lateral chec! liga5ent %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% @ O Lacri5al sac ffD Lacri5al 6one Medial chec! liga5ent -heath o4 5edial rectus Or6ital 4ascia + O Eth5oid 6one .

-uperior rectus -uspensor2 liga5ent o4 the e2e 9enon's capsule P Episcleral space Lateral chec! liga5ent % .% Medial chec! liga5ent %%%%%%/n4erior rectus 5uscle O Le7ator palpe6rae superioris )+ /n4erior o6li8ue . . 5uscle Fi*+ (+': FasciaA sheath of the eyeball as seen in coronal section.

anterosu!erior to the o!tic canal and to the origin of the su!erior rectus( . levator !al!ebrae su!erioris and su!erior rectus in the iddle of the orbit and reflect the a!art( Identify the o!tic nerve and other structures crossing it( )hese are nasociliary nerve.nsertion 1()he recti are inserted into the sclera.oluntary 1us*les 1()he su!erior tarsal uscle is the dee!er !ortion of the levator !al!ebrae su!erioris( It is inserted on the u!!er argin of the su!erior tarsus( It elevates the u!!er eyelid( F()he inferior tarsal uscle e&tends fro the fascial sheath of the inferior rectus and inferior obli%ue to the lo"er argin of the inferior tarsus( It !ossibly de!resses the lo"er eyelid( :()he orbitalis bridges the inferior orbital fissure( Its action is uncertain B1ig( A(1C( DISSECTION connecting it to the nasociliary nerve and nerve to inferior obli%ue uscle( @astly. and inferior rectus inferiorly( )he voluntary uscles are iniature ribbon uscles. edial rectus edially. divide frontal nerve. identify the abducent nerve closely adherent to the edial surface of lateral rectus uscle( Incise the inferior fornt& of con3unctiva and !al!ebral fascia( 2levate the eyeball and re ove the fat and fascia to identify the origin of inferior obli%ue uscle fro the floor of the orbit anteriorly( Identify the levator !al!ebrae su!erioris and su!erior rectus above the eyeball.long the lateral "all of the orbit loo' for lacrirnal nerve and artery to reach the su!erolateral corner of the orbit( 1ollo" the tendon of su!erior obli%ue uscle !assing su!erolaterally beneath the su!erior rectus to be inserted into sclera behind the e%uator( . su!ero edial to the o!tic canal( :()he inferior obli%ue arises fro the orbital surface of the a&illa. having short tendons of origin and long tendons of insertion( 1o#u"tar6 Mus&#es Identify and !reserve the trochlear nerve entering the su!erior obli%ue uscle in the su!ero edial angle of the orbit( 1ind the frontal nerve lying in the idline on the levator !al!ebrae su!erioris( It divides into t"o ter inal divisions in the anterior !art of orbit( Beneath the levator !al!ebrae su!erioris is the su!erior rectus uscle( )he u!!er division of oculo otor nerve lies bet"een these t"o uscles. lateral to the lacri al groove( )he uscle is situated near the anterior argin of the orbit( H()he levator !al!ebrae su!erioris arises fro the orbital surface of the lesser "ing of the s!henoid bone. edial J(J D lateral 6(9 B1ig( A(JC( F()he tendon of the su!erior obli%ue !asses through a fibrocartilaginous !ulley attached to the trochlear fossa of the frontal bone( )he tendon then !asses laterally. do"n"ards and bac'"ard belo" the su!erior rectus( It is inserted into the sclera behind the e%uator of the eyeball. lateral rectus laterally. bet"een the su!erior rectus and the lateral rectus( . su!erior obli%ue su!ero edially.fter identification. o!hthal ic artery and su!erior o!hthal ic vein( .Contents o4 the Or6it ">$ E>TRAOCULAR MUSCLES )he e&traocular =oluntary 1us*les uscles are as follo"s( 1(1our recti8 BaC Su!erior rectusD BbC inferior rectusD BcC edial rectusD and BdC lateral rectus( F()"o obli%ui8 BaC Su!erior obli%ueD and BbC inferior obli%ue( :()he levator !al!ebrae su!erioris elevates the u!!er eyelid( In. su!!lying both of the ( . a little !osterior to the li bus( )he average distances of the insertions fro the cornea are8 su!erior A(A D inferior 6(J .long "ith the o!tic nerve find t"o long ciliary nerves and 1F-FG short ciliary nerves( .e ove the orbital fat and loo' carefully in the !osterior !art of the interval bet"een the o!tic nerve and lateral rectus uscle along the lateral "all of the orbit and identify the !in head si7ed ciliary ganglion( )race the roots >rigin 1()he four recti arise fro a *ommon annular ten+on or ten+inous ring) )his ring is attached to the orbital surface of the a!e& of the orbit( It encloses the o!tic canal and the iddle !art of the su!erior orbital fissure B1ig( A(HC( )he lateral rectus has an additional s all tendinous head "hich arises fro the orbital surface of the greater "ing of the s!henoid bone lateral to the tendinous ring( F()he su!erior obli%ue arises fro the body of the s!henoid.

and into the s'in of the u!!er eyelid( )he inferior la ella is inserted into the u!!er argin of the su!erior tarsus B1ig( F(FABC( Nerve $upply ") )he su!erior obli%ue is su!!lied by the I/th cranial or trochlear nerve BS0HC B1ig( A(6C( 1()he inferior obli%ue is fleshy throughout( It . u!"ards and bac'"ards belo" the inferior rectus and then dee! to the lateral rectus( )he inferior obli%ue is inserted close to the su!erior obli%ue a little belo" and !osterior to the latter( F()he flat tendon of the levator s!lits into a su!erior or voluntary and an inferior or involuntary la ellae( )he su!erior la ella of the levator is inserted into the anterior surface of the su!erior tarsus.+: show the obliQue eyeball. /n4erior o6li8ue $cheme to insertion of the muscles of the 3<ulle2 /n4erior rectus !asses laterally.6: Apical part of the orbit showing the origins of the e traocular muscles. -uperior o6li8ue -uperior rectus: Lateral rectus Medial rectus Fig.% Optic ner7e and ophthal5ic arter2 in optic canal /n4erior rectus -uperior or6ital 4issure Fig.reater 1ing o4 sphenoid 9rochlear ner7e S -uperior o6li8ue ` Medial rectus Bod2 o4 sphenoid /. the common tendinous ring and the structures passing through superior orbital fissure.-uperior rectus Lesser 1ing o4 sphenoid Le7ator palpe6rae superioris Co55on tendinous ring % Recurrent 5eningeal 6ranch o4 ophthal5ic arter2 % Lacri5al ner7e %) Jrontal ner7e )))( -uperior ophthal5ic 7ein %))) Upper and lo1er di7isions o4 oculo5otor ner7e asociliar2 ner7e )' == A6ducent ner7e ())) /n4erior ophthal5ic 7ein . 8. 8.

7: supply of the $cheme to show the nerve e traocular muscles. .PPPP % Le7ator palpe6rae superioris PPPPP9rochlear ner7e Lacri5al ner7e -uperior rectus 5uscle 9rochlear ner7e S %%%%%%%%%%%%%%%%%%%%%%%%%%%%%% S Upper ner7e%%%%%% di7ision o4 third ner7e S Jrontal asociEiar2 ner7e%%%%%% Medial rectus Lo1er di7ision o4 third ner7e 9OO S /n4erior /n4erior PPP% -uperior o6li8ue % Optic ner7e Ciliar2 ganglion rectus 5uscle o6li8ue 5uscle Fig. 8.

Co"te"ts o.i+ual mus*les as sho"n in 1igs A(A. inferior and edial rectiD inferior obli%ue and levator !al!ebrae su!erioris are all su!!lied by the Illrd cranial or oculo otor nerve J 6*tions .6C( F()he re aining five e&traocular usclesD su!erior. -uperior rectus t Lateral rectus %[O )E[[a /n4erior o6li8ue 4 / : R R R / /n4erior rectus RMediRil-tlR rectus 2 -uperior o6li8ue Fi*+ (+(B: 2he action of e traocular muscies while looking to the right side. BH Depression A6duction /ntortion =3 /n4erior o6li8ue Ele7ation A6duction E:tortion Onl2 e:tortion Onl2 ele7ation 33 /n4erior rectus GJig3 $3$AH Depression Adduction E:tortion Onl2 depression Onl2 e:tortion . Arrows indicates the direction of movement.osterior axis 1(Intortion( F(2&tortion( )he rotatory ove ents of the eyeball u!"ards.9= A&tio" o. C( <ingle or . "hile o!!osing actions cancel each other enabling !ure ove ents( 1( -.n primary position Abducted eye Onl2 intortion Adducted eye Onl2 depression "3 -uperior o6li8ue GJig3 $3$A.( )he mo.ation7 By the su!erior rectus and the inferior obli%ue( Ta2#e /.ements of the eyeball are as follo"s( I( 6roun+ a trans.erti*al axis 1(#edial rotation or adduction BJG[C( F(@ateral rotation or abduction BJG[C( III( 6roun+ an antero. edially or laterally.9ar+ rotation or ele.. i"$i5i$ua# *us&#es /uscle .!"ard rotation or elevation B::[C( F(Do"n"ards rotation or de!ression B::[C( II( 6roun+ a .erse axis 1(. are defined in ter s of the direction of ove ent of the centre of the !u!il( )he tortions are defined in ter s of the direction of ove ent of the u!!er argin of the !u!il at 1F 0*cloc' !osition( I/( )he ove ents given above can ta'e !lace in various co binations( B( 6*tions of in+i. do"n"ards. -uperior rectus Lateral rectus Medial rectus -uperior o6li8ue /n4erior rectus ABDUCTED RIIHT E E ADDUCTED LEFT E E Fi*+ (+(-: $cheme to show the action of the e traocular muscles.ements are !roduced by co bined actions of uscles( Si ilar actions get added together. 1()he lateral rectus is su!!lied by the /Ith cranial or abducent nerve B@.ure mo. A(AB and )able A(1( /n4erior o6li8ue "= o'cloc!.

"3-uperior rectus Ele7ation Adduction /ntortion Onl2 adduction Onl2 a6duction Onl2 ele7ation Onl2 intortion =3Medial rectus 33Lateral rectus .

or even congenital( F()he anterior *iliary arteries arise fro the uscular branches of o!hthal ic artery( )he uscular arteries are i !ortant in this res!ect( 1( Central 6rtery of Betina )he central artery of retina B1ig( A(9C is the first and ost i !ortant branch of the o!hthal ic artery( It first lies belo" the o!tic nerve( It !ierces the dural sheath of the nerve and runs for"ards for a short distance bet"een these t"o( It then enters the substance of the nerve and runs for"ards in its centre to reach the o!tic disc B1ig( A(4C( <ere it divides into branches that su!!ly the retina B1ig( 19(1GC( )he central artery of the retina is an en+ artery) It does not have effective anasto oses "ith other arteries( 0cclusion of the artery results in blindness( )he intraocular !art of the artery can be seen. "hich ay be conco itant or !aralytic( Con*omitant s:uint is congenitalD there is no li itation of ove ent. through an o!hthal osco!e( 1ESSELS OF THE ORBIT #) Bran*hes 6rising from the 0a*rimal 6rtery BaC Branches are given to the lacri al glandD BbC t"o 7ygo atic branches enter canals in the 7ygo atic bone( 0ne branch a!!ears on the face through the 7ygo aticofacial fora en( )he other a!!ears on the te !oral surface of the bone through the 7ygo aticote !oral fora enD BcC lateral !al!ebral branches su!!ly the eyelidsD BdC a recurrent eningeal O%htha#*i& Arter6 (rigin )he o!hthal ic artery is a branch of the cerebral !art of the internal carotid artery. lying inferolateral to the o!tic nerve( Both the artery and nerve lie in a co on dural sheath( F(In the orbit. A(9C( . the su!erior obli%ue and the inferior obli%ue( H(Intortion7 By the su!erior obli%ue and the su!erior rectus( J(Fxtortion7 By the inferior obli%ue and the inferior rectus( nerve and su!erior o!hthal ic vein( Identify its branches es!ecially the central artery of the retina "hich is an *end artery*( D( Combine+ mo.ements) Con3ugate ove ents are usually hori7ontal or vertical. and crosses above the nerve fro lateral to edial side along "ith the nasociliary nerve( It then runs for"ards along the edial "all of the orbit bet"een the su!erior obli%ue and the edial rectus uscles.ugate o*ular mo.aralyti* s:uint. ascends over the lateral side of the o!tic nerve. and no di!lo!ia( In . ove ents of the t"o eyes are har oniously coordinated( Such coordinated ove ents of both eyes are called *on. given off edial to the anterior clinoid !rocess close to the o!tic canal B1igs A(4. di!lo!ia and vertigo are !resent.1( o!n!ard rotation or depression: B) t!e "nfer"or rectu' and t!e 'u er"or o#l"*ue+ USSECTION F(Medial rotation or adduction: B) t!e med"al rectu'. the artery !ierces the dura ater. and !arallel to the nasociliary nerve( :(It ter inates near the edial angle of the eye by dividing into the su!ratrochlear and dorsal nasal branches B1ig( A(4C( &ranches Ehile still "ithin the dural sheath the o!hthal ic artery gives off the central artery of the retina( . head is turned in the direction of the function of !aralysed uscle. ove ents are li ited. in the living."t! na'ocll"ar) :(0ateral rotation or ab+u*tion7 By the lateral rectus. but obli%ue con3ugate oveents ay also occur( )he dissociated ove ents of the t"o eyes are called as dys3unctive ove ents(vi7(.fter !iercing the dura ater it gives off a large lacri al branch that runs along the lateral "all of the orbit( )he ain artery runs to"ards the edial "all of the orbit giving off a nu ber of branches( )he various branches are described belo"8 1( Eea'ness or !aralysis of a uscle causes s:uin t or strabism us. s'e" deviation( Conclination or antero!osterior ove ents of the eyeballs are also abnor al( Persons are 'no"n "ho could s%uee7e out their eyeballs and ta'e the bac' ?t "ill( CLINICAL ANATOM !ourse and Felations 1()he artery enters the orbit through the o!tic canal. t!e 'u er"or rectu' and t!e -nfer"or rectu'+ Trace t!e o !t!alm"c arter) after "t .ements of the eyes =or ally. and there is a false orientation of the field of vision( 1(Iystagmus is characteri7ed by involuntary.a' 'een to cro'' o(er t!e o t"c ner(e alon/ . rhyth ical oscillatory ove ents of the eyes( )his is due to incoordination of the ocular uscles( It ay be either vestibular or cerebellar.

Middle 5eningeal Anterior ciliar2 arter2 Circulus arteriosus 5aFor Circulus arteriosus 5inor Rectus 5uscle 1ith its arter2 <ia 5ater Arachnoid Long posterior ciliar2 arter2 -hort posterior ciliar2 arter2 Dura 5ater Optic ner7e 5ater -u6arachnoid space Central arter2 o4 retina Fig.1: 2he arteries of the eyeball. 8. 8. branch runs bac'"ards to enter the iddle cranial fossa through the su!erior orbital fissureD BeC .K: &ranches of ophthalmic artery.<osterior eth5oidal -upratrochlear Dorsal nasal -upraor6ital Anterior ciliar2 Q2go5atico%4acial Lacri5al gland PPPP Q2go5atico%te5poral Lacri5al arter2 Anterior eth5oidal <osterior ciliar2 -uperior or6ital 4issure Recurrent 5eningeal 6ranch Central arter2 o4 retina Optic ner7e Ophthal5ic arter2 /nternal carotid Fig.

uscular branches su!!ly the uscles of the orbit( BaC)he su!raorbital and su!ratrochlear branches :( Bran*hes 6rising from the 1ain Trunk BaC )he !osterior Blong and shortC ciliary arteries su!!ly chiefly the choroid and iris( )he eyeball is also su!!lied through anterior ciliary branches "hich are given off fro arteries su!!lying uscles attached to the eyeball B1ig( A(9C( su!!ly the s'in of the forehead( BbC)he anterior and !osterior eth oidal branches enter fora ina in the edial "all of the orbit to su!!ly the eth oidal air sinuses( )hey then enter the anterior cranial fossa( )he ter inal branches of the anterior artery enter the nose and su!!ly !art of it( BcC)he eyelids( edial !al!ebral branches su!!ly the .

for contraction of the !u!il and acco odation( :(+eneral so atic afferent. and 1G intracranial( )he entire nerve is enclosed in three eningeal sheaths( )he subarachnoid s!ace e&tends around the nerve u! to the eyeball B1ig( A(9C( Felations in the (rbit 1(.hthalmi* .erior o. sy!hilis. the o!tic nerve and the retina are a direct !rolongation of the brain( See visual !ath"ays in Cha!ter :G( CLINICAL ANATOM )he ly !hatics drain into the !reauricular !arotid ly !h nodes B1ig( F(FJC( NER1ES OF THE ORBIT BaC>. ence!halitis. and even vita in B deficiency( BbC>. out of "hich about J:5 cross in the o!tic chias a( F()he o!tic nerve is not a nerve in the sl>rict sense( It is actually a tract( It cannot regenerate after it is cut( Develo! entally.t the a!e& of the orbit the nerve is closely behind the eye on ocular ove ents and on !ressure( )he !a!illoede a is less but loss of vision is ore( Ehen the o!tic disc is nor al as seen by an o!hthal osco!y the sa e condition is called retrobulbar neuritis) )he co on causes are de yelinating diseases of the central nervous syste . the lo"er orbital uscles. BdC branches of o!hthal ic and a&illary divisions of the trige inal.ti* ner. out of "hich FJ are intraorbital.hy ay be caused by a variety of diseases( It ay be !ri ary or secondary( O&u#o*otor Ner5e .ein7 It runs belo" the o!tic nerve( It receives tributaries fro the lacri al sac. and BfC sy !athetic nerves( O%ti& Ner5e )he o!tic nerve is the nerve of sight( It is ade u! of the a&ons of cells in the ganglionic layer of the retina( It e erges fro the eyeball : or H nasal to its !osterior !ole( It runs bac'"ards and edially.ti* atro. and drains into the cavernous sinus( It co unicates anteriorly "ith the su!raorbital and angular veins B1igs F(FF.a"$ Ne&- BeC )he dorsal nasal branch su!!lies the u!!er !art of the nose( O%htha#*i& 1ei"s 1()he o!tic nerve is crossed su!eriorly by the The su. BeC abducent. it is in series "ith the I/th.ntroduction )his is the third cranial nerve( It is distributed to the e&traocular as "ell as the intraocular uscles( Since it is a so atic otor nerve. J intracanalicular. any se!tic focus in the teeth or !aranasal sinuses.ti* neuritis is characteri7ed by !ain in and )hese are8 BaC 0!tic. and ends either by 3oining the su!erior o!hthal ic vein or drains directly into the cavernous sinus( It co unicates "ith the !terygoid !le&us of veins by s all veins !assing through the inferior orbital fissure( L6*%hati&s o. eningitis.e has no neurile a sheath. and the eyelids.hthalmi* . and !asses through the o!tic canal to enter the iddle cranial fossa "here it 3oins the o!tic chias a( )he nerve is about H c long.ein7 It acco !anies the o!hthal ic artery( It lies above the o!tic nerve( It receives tributaries corres!onding ta the branches of the artery. !asses through the su!erior orbital fissure. BbC oculo otor "ith ciliary ganglion. /lth and Ollth cranial nerves. for !ro!rioce!tive i !ulses for the uscles of the eyeball( )hese surrounded by the recti uscles( )he ciliary ganglion lies bet"een the o!tic nerve and the lateral rectus B1ig( A(6C( F()he central artery and vein of the retina !ierce the o!tic nerve infero edially about 1(FJ c behind the eyeball B1ig( A(9C( . the Or2it o!hthal ic artery. the nasociliary nerve and the su!erior o!hthal ic vein B1ig( A(4C( F()he o!tic nerve is crossed inferiorly by the nerve to the edial rectus( :(=ear the eyeball the nerve is surrounded by fat containing the ciliary vessels and nerves BCha!ter 19C( $tructure 1()here are about 1(F illion yelinated fibres in each o!tic nerve. and has no !o"er of regeneration( It is a tract and not a nerve( BcC>. BcC trochlear. and also "ith the ventral root of s!inal nerves( Functional !omponents 1(+eneral so atic efferent. F(F:C( The inferior o. for ove ents of the eyeball B1ig( FJ(FC( F(+eneral visceral efferent or !arasy !athetic.

the nerve is attached to the oculo otor sulcus on the edial side of the crus cerebri B1igs A(1G. idbrain lesion causing contralateral he i!legia and i!silateral !aralysis of the third nerve is 'no"n as Eeber*s syn+rome) :(<u. and runs for"ards in the inter!eduncular cistern. the nerve divides into a u!!er and lo"er division B1ig( A(11C( 1()he t"o divisions of the nerve enter the orbit through the iddle !art of the su!erior orbital fissure B1ig( A(HC( In the fissure. the s aller u!!er division ascends on the lateral side of the o!tic nerve. red nucleus and substantia nigra B1ig( FH(1GC( F(6t the base of the brain. i(e( for"ard !ro3ection of the eyeD and BfC di!lo!ia or double vision( F(.aralysis of the third nerve causes loss of con3ugate ove ent of the eyes( PPPPPPPPPPPPPP Mid6rain PPPPPPPPPPPPPP /n4erior colliculus /nterpeduncular cistern % Oculo5otor ner7e 3 9rochlear ner7e % <etrosphenoidal liga5ent % A6ducent ner7e3333 Ca7ernous sinus %Ape: o4 petrous te5poral 6one Basiocciput Ciste5a pontis )) S %%%%%%%%%% 3RBs3 7 % % R %%%%%%%%%% Medulla % Arachnoid 5ater % La2ers o4 dura 5ater Cere6ellu5 . division divides into three branches for the edial rectus. the inferior rectus and the1 inferior obli%ue B1ig( A(11C( )he nerve to the inferior obli%ue is the longest of these( It gives off the otor root to the ciliary ganglion B1ig A(6C( . i(e( droo!ing of the u!!er eyelidD BbC lateral s%uintD BcC dilatation of the !u!ilD BdC loss of acco odationD BeC slight !ro!tosis. and su!!lies the su!erior rectus and the levator !al!ebrae su!erioris( )he larger. FH(1C( 1()he nerve !asses bet"een the su!erior cerebellar and !osterior cerebral arteries. on the lateral side of the !osterior co unicating artery to reach the cavernous sinus( F()he nerve enters the *a.i !ulses are relayed to the the trige inal nerve( Nucleus :W!E\91 esence!halic nucleus of )he oculo otor nucleus is situated in the ventro edial !art of central grey atter of idbrain at the level of su!erior colliculusJ )he fibres for the constrictor !u!illae and for the ciliaris arise fro the 2dinger Eest!hal nucleus "hich for s !art of the oculo otor nuclear co !le&( /entrolaterally it is closely related to the edial longitudinal bundle B1ig( FH(1GC( )he nucleus is connected8 BaC to the !yra idal tracts of both sides "hich for the su!ranuclear !ath"ay of the nerveD BbC to the !retectal nuclei of both sides for the light refle&D BcC to the fourth.ll branches enter the uscles on their ocular surfaces e&ce!t that for the inferior obli%ue "hich enters its !osterior border( CLINICAL ANATOM 1(Co !lete and total .aralysis of the third nerve results in8 BaC !tosis.ranu*lear .ernous sinus by !iercing the !osterior !art of its roof on the lateral side of the 1(In their intraneural *ourse. si&th and eighth nerve nuclei by edial longitudinal bundle for coordination of the eye ove entsD and BdC to the tectobulbar tract for visuo!rotective refle&es( !ourse and 9istribution the nucleus and !ass ventrally through the teg entu . the nasociliary nerve lies in bet"een the t"o divisions "hile the abducent nerve lies inferolateral to the ( F(In the orbit. the fibres arise fro !osterior clinoid !rocess B1ig( 6(:C( it descends to the lateral "all of the sinus "here it lies above the trochlear nerve B1ig( 6(6C( In the anterior !art of the sinus. lo"er.

8. B(: $cheme to show the precavernous courses of the third. . fourth and si th cranial nerves.Fig.

CILIAR IANILION -ensor2 root S6*%atheti& root Motor root er7e to in4erior o6li8ue Constrictor pupillae Cilia ris .4 99.estphal nucleus Fig.%%: (rigin. Optic ner7e -hort ciliar2 ner7e Fig. 8. Hea$ a"$ Ne&-uperior o6li8ue Lateral rectus Ciliar2 ganglion /n4erior rectus Lo1er di7ision Upper di7ision Le7ator palpe6rae superiors -uperior rectus Medial rectus -uperior or6ital 4issure Ca7ernous sinus Oculo5otor ner7e /n4erior o6li8ue ucleus o4 third ner7e Edinger . %<: Foots and branches of ciliary ganglion. course and distribution of oculomotor nerve. 8.

Ci#iar6 Ia"!#io" Definition Ciliary ganglion is a !eri!heral !arasy !athetic ganglion !laced in the course of the oculo otor nerve( It lies near the a!e& of the orbit bet"een the o!tic nerve and the tendon of the lateral rectus uscle( It has otor.atheti* root is a branch fro the internal carotid !le&us( It contains !ostganglionic fibres arising in the su!erior cervical ganglion( )he fibres do not relay in the ciliary ganglion( )hey !ass out of the ganglion in the short ciliary nerves and su!!ly the blood vessels of the eyeball( )hey also su!!ly the dilator !u!illae( . sensory and sy !athetic roots( )he motor root arises fro the nerve to the inferior obli%ue B1ig( A(1FC( It contains !reganglionic fibres that begin in the 2dinger Eest!hal nucleus( )he fibres relay in the ganglion( Postganglionic fibres arising in the ganglion !ass through the short ciliary nerves and su!!ly the s!hincter !u!illae and the ciliaris uscle( )he sensory root co es fro the nasociliary nerve( It contains sensory fibres fro the eyeball( )he fibres do not relay in the ganglion BA(1FC( )he sym.

it !asses edially. above the origin of levator !al!ebrae su!erioris and ends by su!!lying the su!erior obli%ue uscle on its orbital surface( CLINICAL ANATOM Su%erior or2ita# . for !ro!rioce!tive i !ulses fro the lateral rectus uscle( )hese i !ulses are relayed to the . A(1:C( F(<urfa*e atta*hment) )rochlear nerve is attached to the su!erior edullary velu one on each side of the frenulu veil 3ust belo" the inferior colliculus( It is the only cranial nerve "hich e erges on the dorsal as!ect of the brainste B1ig( FH(1C( :()he nerve "inds round the su!erior cerebellar !eduncle and the cerebral !eduncle 3ust above the !ons( It !asses bet"een the !osterior cerebral and su!erior cerebellar arteries to a!!ear ventrally bet"een the te !oral lobe and u!!er border of !ons( H()he nerve enters the *a. it is closely related to the edial longitudinal bundle B1ig( FH(9C( Nu&#eus o. the nerve runs dorsally )his is the fourth cranial nerve( It su!!lies only the su!erior obli%ue uscle of the eyeball B1ig( A(1:C( Functional !omponents 1(+eneral so atic efferent.issure Ca5er"ous si"us Ehen trochlear nerve is da aged. e&ce!t for the !retectal nuclei( !ourse and 9istribution 1(In its intraneural *ourse. It is the si&th cranial nerve "hich su!!lies the lateral rectus uscle of the eyeball B1ig( A(1HC( 0ne nerve fibre su!!lies only si& uscle fibres( Functional !omponents 1(+eneral so atic efferent.ourth "er5e Fi*+ (+#': (rigin. course Nucleus w*Cfav Su%erior o2#i?ue *us&#e and round the central grey atter to reach the u!!er !art of the su!erior or anterior edullary velu "here it decussates "ith the o!!osite nerve to e erge on the o!!osite side B1igs A(1G. and then !ierce the sclera around the entrance of the o!tic nerve( )hey contain fibres fro all the three roots of the ganglion( Tro&h#ear Ner5e )he connections of the nucleus are si ilar to those of the oculo otor nucleus.ntroduction distribution of the trochlear nerve.Co"te"ts o. 6(6C( J()rochlear nerve enters the orbit through the lateral !art of the su!erior orbital fissure( 6(In the orbit. di!lo!ia occurs on loo'ing do"n"ardsD vision is single so long as the eyes loo' above the hori7ontal !lane( A2$u&e"t Ner5e Tro&h#ear "er5e . for lateral ove ent of the eyeball( F(+eneral so atic afferent. the Or2it 990 Bran*hes) The ganglion gives off 4 to 1G short ciliary nerves "hich divide into 1J to FG branches. for lateral ove ent of the eyeball( F(+eneral so atic afferent. it crosses over the oculo otor nerve B1igs 6(:.ernous sinus by !iercing the !osterior corner of its roof( =e&t it runs for"ards in the lateral "all of the cavernous sinus bet"een the oculo otor and o!hthal ic nerves( In the anterior !art of the sinus. . for !ro!rioce!tive i !ulses fro the su!erior obli%ue uscle( )hese i !ulses reach the esence!halic nucleus of the trige inal nerve( B)he trochlear nucleus is situated in the ventro edial !art of the central grey atter of idbrain at the level of inferior colliculusC /entrally.

esence!halic nucleus of the trige inal nerve( .

ernous sinus by !iercing its !osterior "all at a !oint lateral to the dorsu sellae and su!erior to the a!e& of the !etrous te !oral bone( .s the nerve crosses the su!erior border of the !etrous te !oral bone it !asses beneath the !etros!henoidal liga ent. and ends in the lateral !art of the u!!er eyelid( . A(6C( F(In the orbit. for"ards and laterally through the cisterna !ontis and usually dorsal to the anterior inferior cerebellar artery to reach the cavernous sinus( :()he abducent nerve enters the *a.bducent nucleus is situated in the u!!er !art of the floor of fourth ventricle in the lo"er !ons. course and distribution of the abducent nerve.%6: (rigin. and bends shar!ly for"ards B1ig( A(1GC( In the cavernous sinus at first it lies lateral to the internal carotid artery and then inferolateral to it B1ig( 6(6C( 1()he abducent nerve enters the orbit through the iddle !art of the su!erior orbital fissure( <ere it lies inferolateral to the oculo otor and nasociliary nerves B1igs A(H. beneath the facial colliculus( /entro edially. e&ce!t for the !retectal nuclei( !ourse and 9istribution ") In their intraneural *ourse. Nucleus . o!!osite the u!!er end of the !yra id of the edulla B1ig( FH(1C( F()he nerve then runs u!"ards. !asses dee! to the lacri al gland. 8. edial le niscus and basilar !art of !ons to reach the lo"er border of the !ons B1ig( FH(6C( 1()he nerve is attached to the lo"er border of the !ons. it receives co unication fro the 7ygo aticote !oral nerve.nteriorly. it is closely related to the edial longitudinal bundle B1ig( FH(6C( Connections of the nucleus are si ilar to those of the third nerve.Lateral rectus -uperior or6ital 4issure A6ducent ner7e A6ducent ner7e ucleus o4 si:th ner7e Fig. the fibres of the /fth nerve run ventrally and do"n"ards through the tra!e7oid body. the nerve ends by su!!lying only the lateral rectus uscle( It enters the ocular surface of the uscle B1ig( A(1HC( La&ri*a# Ner5e )his is the s allest of the three ter inal branches of the o!hthal ic nerve B1ig( A(1JC( It enters the orbit through the lateral !art of the su!erior orbital fissure B1ig( A(HC and runs for"ards along the u!!er border of the lateral rectus uscle. in co !any "ith the lacri al artery( .

.t the iddle of the orbit it divides into a s all su!ratrochlear branch and a large su!raorbital branch( )he su. the con3unctiva and the u!!er eyelid( Its o"n fibres to the gland are sensory( )he secreto otor fibres to the gland co e fro the greater !etrosal nerve through its co unication "ith the 7ygo aticote !oral nerve B)able 1(:C( Fro"ta# Ner5e surface of the levator !al!ebrae su!erioris( . 8. or even u! to the la bdoid suture( Naso&i#iar6 Ner5e )his is the largest of the three ter inal branches of the o!hthal ic nerve B1ig( A(1JC( It begins in the lateral "all of the anterior !art of the cavernous sinus( It enters the orbit through the lateral !art of the su!erior orbital fissure. to its shar! bend 6over the su!erior border of the !etrous te !oral bone B1ig( A(1GC and the do"n"ard shift of the brainste to"ards the fora en agnu !roduced by raised intracranial !ressure( )he lacri al nerve su!!lies the lacri al gland. the frontal air sinus and the s'in of the forehead and scal! u! to the verte&. the central !art of the u!!er eyelid. F(19C( )he su. the u!!er eyelid.%+: &ranches of ophthalmic nerve. and runs for"ards on the su!erior )his is one of the ter inal branches of the o!hthal ic division of the trige inal nerve B1ig( A(1JC( It begins in the lateral "all of the anterior !art of the cavernous sinus( It enters the orbit through the iddle !art of the su!erior orbital fissure bet"een the t"o divisions of the oculo otor nerve B1ig( A(HC( It crosses above the o!tic nerve fro lateral to edial side along "ith o!hthal ic artery and runs along the edial "all of the orbit bet"een the su!erior obli%ue and the /n4ratrochlear ner7e Lacri5al gland Anterior eth5oidal <osterior eth5oidal Long ciliar2 Optic Ciliar2 ganglion Lacri5al -hort ciliar2 ner7es Branch 4ro5 L2go5atico%te5poral ner7e asociliar2 Jrontal -uperior or6ital 4issure Fig. and a s all area of the s'in of the forehead above the root of the nose B1igs F(J.CLINICAL ANATOM BiC /aralysis of the abducent nerve results in8 BaC edial or Internal or convergent s%uintD and BbC di!lo!ia( BiiC Si&th nerve !aralysis is one of the co onest false locali7ing signs in cases "ith raised intracranial !ressure( Its susce!tibility to such da age is due to its long course in the cisterna !*ontis.raorbital ner.ratro*hlear ner.e e erges fro the orbit through the su!raorbital notch or fora en about t"o fingers breadth fro the edian !lane( It divides into edial and lateral branches "hich runs u!"ards over the forehead and scal!( It su!!lies the con3unctiva.e e erges fro the orbit above the trochlea about one finger breadth fro the edian !lane( It su!!lies the con3unctiva.

and o!hthal ic nerves( .es run on the 2@? edial side of the o!tic nerve.raor2ita# Ner5e 1()he anterior su. and the antero-inferior !art of the nasal cavity C BCha!ter 1JC( F(Terminal bran*hes . the a&illary sinus.ll these sy !athetic nerves are vaso otor in function( Bra"&hes o. or ay be absent( Sy !athetic nerves arise fro the internal carotid !le&us and enter the orbit through the follo"ing sources( 1()he dilator !u!illae of the iris is su!!lied by sy !athetic nerves that !ass through the o!hthal ic nerve.e arises in the infraorbital canal. the iris and the 6 ciliary body( )hey also carry sy !athetic nerves to the dilator !u!illaeCB1ig( A(1JC( 1()he .eolar ner. nasal and labial branches B1ig( F(19C( )he nerve is acco !anied by the infraorbital branch of the third !art of the a&illary artery and the acco !anying vein B1ig( 1G(AC( Branches 1( )he mi++le su. O%htha#*i& Di5isio" o. !le&us surrounds the o!hthal ic artery. and runs along the lateral "all. in the anterior cranial fossa.e "hich su!!lies the s'in of the lo"er half of the nose BCha!ter 1JC( K I". direct branch fro the internal carotid !le&us !asses through the su!erior orbital fissure and 3oins the ciliary ganglion. the 4ygomati*ofa*ial and 4ygomati*otem. "hich contains secretootor fibres to the lacri al gland.erior al. it lies dee! to the nasal bone( It gives off t"o internal nasal bran*hes edial and lateral to the ucosa of the nose( 1inally. the nasociliary nerve.erior al.nterior eth oidal . trochlear.e !asses through the !osterior eth oidal fora en and su!!lies the eth oidal and s!henoidal air sinuses( It is fre%uently absent B1ig( A(1JC( F()he infratro*hlear ner. and its long ciliary branches( F(0ther sy !athetic nerves enter the orbit as follo"s8 BaC . !ierce the sclera. BbC . given off in the !terygo!alatine fossa( It enters the orbit through the lateral end of the inferior orbital fissure. at first in the infraorbital groove and then in the infraorbital canal re aining outside the !eriosteu of the orbit( It e erges on the face through the infraorbital fora en and ter inates by dividing into !al!ebral. BcC 0ther fila ents !ass along the oculo otor.993 Hea$ a"$ Ne&- edial rectus( It ends at the anterior eth oidal fora en by dividing into the infratrochlear and anterior eth oidal nerves( Its branches are as follo"s( 1( . nasal an+ labial su!!ly a large area of s'in on the face( )hey also su!!ly the ucous e brane of the u!!er li! and chee' B1ig( F(19C( R6!o*ati& Ner5e It is a branch of the a&illary nerve. to enter the 7ygo atic bone( Just before or after entering the bone it divides into its t"o ter inal branches. and c(D su!!ly sensory nerves to the cornea.al. and runs in a sinuous canal having a co !licated course in the anterior "all of the a&illary sinus( It su!!lies the u!!er incisor and canine teeth. for a very short distance. ay arise either fro the 7ygo atic or the 7ygo aticote !oral nerve. and su!!lies the u!!er !re olar teeth( It ay be du!licated. it e erges at the lo"er border of the nasal bone as the external nasal ner.e is the s aller ter inal branch of the nasociliary nerve given off at the anterior eth oidal fora en( It e erges fro the orbit belo" the trochlea for the tendon of the su!erior obli%ue and a!!ears on the face above the edial angle of the eye( It su!!lies the con3unctiva. the lacri al sac and caruncle.osterior ethmoi+al ner. and runs in the lateral "all of the orbit BCha!ter FC( S6*%atheti& Ner5es o. the edial ends of the eyelids and the u!!er half of the e&ternal nose B1ig( F(19C( :()he anterior ethmoi+al ner.eoral. Tri!e*i"a# Ner5e 1ollo"ing are the branches of o!hthal ic division of trige inal nerve( 1( 1rontal Su!ratrochlear F( =asociliary Su!raorbital Branch to ciliary ganglion F-: long ciliary nerves Posterior eth oidal Infratrochlear :( @acri al . abducent. runs in the lateral "all of the a&illary sinus.eolar ner.e is the larger ter inal branch of the nasociliary nerve( It leaves the orbit by !assing through the anterior eth oidal fora en( It a!!ears. above the cribrifor !late of the eth oid bone( It then descends into the nose through a slit at the side of the anterior !art of the crista galli( In the nasal cavity.e arises in the infraorbital groove. outside the !eriosteu . *ommuni*ating bran*h to the *iliary ganglion for s the sensory root of the ganglion( It is often i&ed "ith the sy !athetic root B1ig( A(1JC( F( B)"o or three long *iliary ner. the Or2it It is the continuation of the a&illary nerveC It enters the orbit through the inferior orbital fissure( It then runs for"ards on the floor of the orbit or the roof of the a&illary sinus.es "hich su!!ly the s'in of the face and of the anterior !art of the te !le B1ig( F(19C( )he co unicating branch to the lacri al nerve.oral ner.

it is !artially as'ed by the isthmus of the thyroi+ glan+ 9hi*h lies against second to fourth tracheal rings( )he trachea is co only !al!ated in the su. their branches and tributaries for the ost i !ortant contents of the anterior triangle( )he e&ternal carotid artery gives eight branches "hich su!!ly thyroid gland.rominen*e or 6+ams a.. )he anterior triangle of the nec' is bounded8 B1C 6nteriorly by the edian !laneD BFC . !haryn&. and by a line 3oining the angle of the andible to the astoid !rocess( )he a!e& of the triangle lies above the anubriu sterni( -ur4ace Land5ar!s 1()he 1()he man+ible for s the lo"er 3a"( )he lo"er border of its horseshoe-sha!ed body is 'no"n as the base of the man+ible) . uscles of tongue.Anterior 9riangle o4 the ec! anterior triangle of the nec' lies bet"een idline of the nec' and sternocleido astoid uscle( It is subdivided into s aller triangles( Carotid vessels. face.osteriorly by the sternocleido astoid uscleD B:C su. at the 3unction of the nec' "ith the floor of the outh( 0n each side the body of hyoid bone is continuous !osteriorly "ith the greater *omua "hich is overla!!ed in its !osterior !art by the sternocleido astoid uscle( thyroi+ *artilage of the laryn& for s a shar! !rotuberance in the edian !lane 3ust belo" the hyoid bone( )his !rotuberance is called the laryngeal . s!inal root of accessory. vagus.-sha!ed hyoi+ bone can be felt in the edian !lane 3ust belo" and behind the chin.nteriorly.le) It is ore !ro inent in ales( F()he rounded arch of the *ri*oi+ *artilage lies belo" the thyroid cartilage at the u!!er end of the trachea( :()he trachea runs do"n"ards and bac'"ard fro the cricoid cartilage( It is identified by its cartilaginous rings( <o"ever. ear.Clavicle HHBC Ma"u2riu* ste*i Fi*+ B+I: Anterior triangles of the neck showing the pAatysma and the anterior Gugular veins in the superficial fascia. occi!ut.ntroduction Base o4 5andi6le r C Ster"o&#ei$o*astoi$ F A 6 AAAAAAJu!u#ar 5e"ous ar&h P#at6sr"a A"terior Nu!u#ar 5ai" WVbS ---.eriorly by the base of the andible. this base for s the *hin. the trachea ay shift to one side fro the 997 .rastemal not*h "hich lies bet"een the tendinous heads of origin of the right and left sternocleido astoid uscles( In certain diseases. and !osteriorly it can be traced to the angle of the man+ible B1ig( 4(1C( F()he body of the . te !oral region and "ide area around the a&illa( )he carotid body and carotid sinus are situated at the beginning of co on carotid artery and act as che orece!tor and barorece!tor res!ectively( Parts of glosso!haryngeal. hy!oglossal and so e of their branches are seen in relation to the branches of the carotid arteries( .

ll su!erficial nerves and vessels in this area lie dee! to the !latys a B1ig( 4(1C( Anterior Bugular 'ein #a'e edian incision in the s'in fro the chin to the sternu ( 2&tend the u!!er end of the incision along lo"er border of andible for J c on each side( 2&tend the lo"er incision u!"ards along the anterior border of sternocleido astoid uscle by J c ( .eflect the s'in laterally( . the Ne&- )his region includes a stri! F to : c "ide e&tending fro the chin to the sternu ( )he structures encountered fro are listed belo" fro su!erficial to dee!( S8in It is freely ovable over the dee!er structures due to the looseness of the su!erficial fascia( DISSECTION )he s'in over the anterior triangle of the nec' is freely ovable( Its nerve su!!ly is fro anterior cutaneous nerve of nec' BCF. it is a single layer in the edian !lane.ugular .ugular .enous ar*h) )he vein then turns laterally.i&ia# Fas&ia It contains8 BaC )he greater !art of the !latys aD BbC the cervical branch of the facial nerveD BcC the anterior 3ugular vein. but s!lits on each side to enclose the sub andibular salivary gland B1ig( 11(HC( . C:C( Su%er.ugular .edian !lane( )his indicates a shift in the astinu ( Other I6portant land6ar8s 1()he edi- fronto4ygomati* suture can be felt as a de!ression in the u!!er !art of the lateral orbital argin( F()he marginal tuber*le lies a short distance belo" the fronto7ygo atic suture along the !osterior border of the frontal !rocess of the 7ygo atic bone( :()he 5rankfurt .ugal .lane is re!resented by a hori7ontal line 3oining the infraorbital argin to the u!!er argin of the e&ternal acoustic eatus( Posteriorly.eflect the !latys a u!"ards( Identify the structures !resent in the su!erficial fascia and the structures !resent in the anterior edian region of the nec'( Superficial Fascia )his is a s all vein. alongside the e&ternal 3ugular vein( Stru&tures i" the A"terior Me$ia" Re!io" o. runs dee! to the sternocleido astoid 3ust above the clavicle. e&tending fro the head of andible to the !osterior border of the coronoid !rocess( )he notch is 1-F c dee!( S-i" external . beginning in the sub ental region belo" the chin( It descends in the su!erficial fascia about 1 c fro the edian !lane( . and !ossibly hel!s in releasing !ressure of the s'in over the sub3acent su!erficial veins( .oint is the anterior end of the u!!er border of the 7ygo atic arch "here it eets the !rocess of the 7ygo atic bone( J()he man+ibular not*h is re!resented by a line concave u!"ards.eins beginning 3ust above the hyoid bone by the confluence of several su!erficial veins fro the sub andibular region B1ig 4(1CD BcC a fe" s all submental lym. the line !asses through a !oint 3ust belo" the e&ternal occi!ital !rotuberance( H()he . fe" ly !h nodes lie alongside the anterior 3ugular veinD BbC fe" sub ental nodes lie belo" the chinD BcC and a fe" of the lie on the sternocleido astoid.ariable7 BaC It ay be absent on one sideD BbC ay be re!resented by a edian veinD or BcC ay be large in si7e "hen the co on facial vein drains into it( 5ymph Nodes BaC . it !ierces the investing layer of dee! fascia to enter the su!rasternal s!ace "here it is connected to its fello" of the o!!osite side by a transverse channel. and BdC a fe" ly !h nodes( )he !latys a is a subcutaneous uscle for ing a "ide.h no+es lying on the dee! fascia belo" the chin B1ig( 1F(:GCD BdC the ter inal fila ents of the trans. and ends in the It contains8 BaC )he u!!er decussating fibres of the . thin fleshy sheet running u!"ards and edially in the nec' fro the deltoid and !ectoral fasciae to the base of the andible( It is su!!lied by the cervical branch of the facial nerve.bout F(J c above the sternu .latysma for 1 to F c belo" the chinD BbC the anterior .ein at the !osterior border of the sternocleido astoid( )he anterior 3ugular vein is ar'edly .bove the hyoid bone. the .e of the nec' ay be !resent in it( Deep Fascia .erse or anterior *utaneous ner.

ary glan+8 BcC the mylohyoi+ ner.essels8 and BdC the submental bran*h of the fa*ial artery B1igs 4(F. 4(:C( )he anteroinferior !art of the hyoglossus mus*le "ith its su!erficial relations ay also be e&!osed during dissection( Structures lying in this corner are8 BaC )he inter ediate tendon of the +igastri* uscle "ith its fibrous !ulleyD BbC the bifurcated tendon of the stylohyoi+ uscle e bracing the digastric tendonD and BcC the hy.): !oronal section through the floor of the mouth.oglossal ner. P P -u65ental l25ph nodes PPPPPPPPPPPP Anterior 6ell2 o4 digastric Jacial arter2 P P M2loh2oid H2oid 6one %( =erve to ylohyoid M------- -u65ental arter2 % Masseter%%%%%%%%%% Outline o4 su65andi6ular gland O Fig.<: PPPPPPPP H2oglossus $uprahyoid region. 1.C St6#o!#ossus -u6lingual gland CCC Li"!ua# "er5e -u65andi6ular duct M6#oh6oi$ "er5e a"$ arter6 H6%o!#ossa# "er5e CCCCCCIe"io!#ossus M6#oh6oi$ -u65andi6ular gland P Anterior 6ell2 o4 digastric ) Deep 4ascia 0enioh2oid Fig. 1. surface view. 1. the fascia s!lits to enclose the su!rasternal s!ace( Deep Structures 9yin* aboAe the =yoid Bone )he subhyoi+ bursa lies bet"een the !osterior surface of the body of the hyoid bone and the thyrohyoid e brane( It lessens friction bet"een these t"o structures during the ove ents of s"allo"ing B1ig( 4(HC( )he mylohyoi+ mus*le is overla!!ed by8 BaC )he anterior belly of the +igastri*8 BbC the su!erficial !art of the subman+ibular sali.6: $agittal section through the hyoid region of the neck showing the subhyoid bursa and its relations. .Bet"een the hyoid bone and the cricoid cartilage.e an+ . it is a single layer e&tending bet"een the right and left sternocleido astoid uscles( Belo" the cricoid.e) 9rac! o4 th2roglossal duct H6oi$ 2o"e -u6h2oid 6ursa 9h2roh2oid 5e56rane 9h2roid cartilage Fig. %%%%%%%% <osterior 6ell2 o4 digastric %%<ulle2 = -uperior and E 5uscle o4 tongue H6o!#ossus in4erior longitudinal A.

su!erficial !lane containing the infrahyoid uscles.eins lie "ithin the fascia B1igs 1F(F.nsertion into Medial part o4 lo1er 6order o4 h2oid 6one Nerve supply Ansa cer7icalis Actions Depresses the h2oid 6one 4ollo1ing its ele7ation during s1allo1ing and during 7ocal 5o7e5ents =3 $ternothyroid /t lies deep to the -ternoh2oid O6li8ue line on the Ansa cer7icalis Depresses the lar2n: a4ter it has 6een ele7ated in s1allo1ing and in 7ocal 5o7e5ents 33 2hyrohyoid /t lies deep to the -ternoh2oid o4 5anu6riu5 la5ina o4 the sterni th2roid cartilage G6H AdFoining part o4 4irst costal cartilage O6li8ue line o4 th2roid Lo1er 6order o4 the 6od2 and the greater cartilage cornua o4 the th2roid cartilage C" through h2poglossal ner7e GaHDepresses the h2oid 6one@ G6HEle7ates the lar2n: 1hen the h2oid is 4i:ed 62 the suprah2oid 5uscles GaH Depresses the h2oid 6one 4ollo1ing its ele7ation during s1allo1ing or in 7ocal 5o7e5ents ?3 (mohyoid /t has an in4erior 6ell2.rah6oi$ *us&#es /uscle "3 $ternohyoid GJig3 &3'H (rigin from GaH <osterior sur4ace o4 5anu6riu5 sterni G6H AdFoining parts o4 the cla7icle and the posterior sternocla7icular liga5ent GaH <osterior sur4ace .ein and the bra*hio*e. a iddle !lane consisting of the !retracheal fascia and the thyroid gland.9(( Hea$ a"$ Ne&- Structures 9yin* BeloG the =yoid Bone )hese structures ay be grou!ed into three !lanes8 . the left bra*hio*e.ensory ligaments "hich attach the thyroid gland to the cricoid cartilage( )he inferior thyroi+ . !artly covered by the isth us of the thyroid gland fro the second to fourth ringsD BgC *aroti+ sheaths lie on each side of the tracheaD BhC occasionally.sule of the thyroi+ glan+ and the sus. trachea and structures associated "ith the ( Infrahyoi+ mus*les7 BaC SternohyoidD BbC sternothyroidD BcC thyrohyoidD and BdC su!erior belly of o ohyoid( )hese are described in )able 4(1 B1ig( 4(JC( /retra*heal fas*ia7 It for s the false *a. a co55on tendon and a superior 6ell23 /t arises 62 the G6H in4erior 6ell2U and is inserted through the superior 6ell2 GaH Upper 6order o4 scapula near the suprascapular notch AdFoining part o4 suprascapular liga5ent Lo1er 6order o4 6od2 o4 h2oid 6one lateral to the -ternoh2oid 9he central tendon lies on the internal Fugular 7ein at the le7el o4 the cricoid cartilage and is 6ound to the cla7icle 62 a 4ascial pulle2 -uperior 6ell2 62 the superior root o4 the ansa cer7icalisU and in4erior 6ell2 62 ansa cer7icalis .hali* artery ay lie in front of the trachea in the su!rasternal notch B1ig( 4(6C( CLINICAL ANATOM 1()he co on anterior mi+line s9ellings of the nec' are8 BaC 2nlarged sub ental ly !h nodes and sublingual der oid in the sub ental regionD BbC thyroglossal cyst and subhyoid bursitis 3ust belo" the hyoid boneD BcC goitre. and a dee! !lane containing the laryn&.9= I".hali* . carcino a of laryn& and enlarged ly !h nodes in the su!rasternal region( F(Tra*heostomy is an o!eration in "hich the trachea is o!ened and a tube inserted into it to facilitate breathing( It is ost co only done in Ta2#e 3. 1F(HC( Dee! to the !retracheal fascia there are8 BaC )he thyrohyoi+ membrane dee! to the thyrohyoid uscle8 it is !ierced by the internal laryngeal nerve and the su!erior laryngeal vessels B1ig( 4(1GCD BbC thyroi+ *artilage8 BcC *ri*othyroi+ membrane "ith the anasto osis of the cricothyroid arteries on its surfaceD BdC arch of the *ri*oi+ *artilage8 BeC *ri*othyroi+ mus*le su!!lied by the e&ternal laryngeal nerveD BfC tra*hea.

H2oid 6one %Openings 4or internal lar2ngeal ner7e and superior lar2ngeal 7essels Jirst tracheal ring 9h2roid gland Ji4th tracheal ring .O O6li8ue line O5oh2oid G-uperior 6ell2H on th2roid cartilage -te5oth2roid O -ternoh2oid O5oh2oid G/n4erior 6ell2H % Cla7icle /). su!eriorly B1ig( 4(AC( SubdiAisions )he anterior triangle encloses four su!rahyoid and four infrahyoid uscles( )he su!rahyoid uscles H2oid 6one 9h2roid cartilage 9h2roh2oid J.+: 2he infrahyoid muscles. 1. and the trachea seen from the front.9(+ ANTERIOR TRIANILE OF NEC' )he boundaries of the triangle are8 )he anterior edian !lane of the nec' ediallyD sternocleido astoid laterallyD base of the andible and a line 3oining the angle of the andible to the astoid !rocess.7: 2he thyroid gland. and an infrathyroid one is difficult due to the de!th of the trachea and is also dangerous because nu erous vessels lie anterior to the trachea here( :( 'Cut throat' "ounds are ost co only situated 3ust above or 3ust belo" the hyoid bone( )he ain vessels of the nec' usually esca!e in3ury because they are !ushed bac'"ards to a dee!er !lane during voluntary e&tension of the nec'( a"!#e o.the retrothyroid region after retracting the isth us of the thyroid gland( . the Ne&.% Jirst costal cartilage -uperior 6order o4 scapula % Manu6riu5 sterni G. the laryn .P 9h2roh2oid liga5ent O9h2roh2oid 5e56rane OO6li8ue line on th2roid cartilage Fig. O Cricoth2roid 5uscle % % Cricoth2roid 5e56rane Cricoid cartilage . 1. su!rathyroid tracheosto y is liable to stricture.

oin to form the anterior . s all !art of the iddle constrictor uscle of the !haryn&.eins . the sternothyroid. "hich s!lits to enclose the sub andibular salivary gland B1ig( 11(HC( 5loor7 )he floor is for ed by the ylohoid uscle anteriorly.ugular . ") )"o to tour s all submental lym.ass to the subman+ibular nodes( F( S all submental . are the sternohyoid. a!!ears in the floor B1igs 4(4.eins) Digastric 9riangle are the digastric.Inferior belly of o6ohyoid -u65ental 9riangle A"terior tria"!#e %arts= Posterior tria"!#e i Di!astri& tria"!#e Chi" Ha#. su2C*e"ta# tria"!#e Caroti$ tria"!#e Mus&u#ar tria"!#e Su%erior 2e##6 o4 o*oh6oi$ Su%ra&Ka<&uKar %art O&&i%ita# %art )his is a edian triangle( It is bounded as follo"s( 0n each side there is the anterior belly of the corres!onding digastric uscles( Its base is for ed 3 by the body of the hyoid bone( Its a!e& lies at the chin( )he floor of the triangle is for ed by the right i and left ylohyoid uscles and the edian ra!he uniting the B1ig( 4(FC( !ontents Fi*+ !+(: 2he triangles of the neck. "hich for the boundaries of digastric triangle( Identify the inter ediate tendon of digastric after !ulling the sub andibular gland laterally( Clean the stylohyoid uscle "hich envelo!s the tendon of digastric and is lying along "ith the !osterior belly of digastric uscle( Identify the contents of digastric triangle( )he area bet"een the body of the andible and the hyoid bone is 'no"n as the sub andibular region( )he su!erificial structures of this region lie in the sub ental and digastric triangles( )he dee! structures of the floor of outh and root of the tongue "ill be studied se!arately at a later stage under the heading of Sub andibular region BCha!ter 11C( Boun+aries7 )he boundaries of the digastric triangle are as follo"s( 6nteroinferiorly7 . containing8 BaC )he !larys aD BbC the cervical branch of the facial nerveD and BcC the ascending branch of the transverse or anterior cutaneous nerve of the nec'( :(Dee! fascia.e ove the dee! fascia fro anterior bellies of digastric uscles to e&!ose !arts of t"o ylohyoid uscles( Clean the boundaries and contents of the sub ental triangle( Cut the dee! fascia fro the andible and reflect it do"n"ards to e&!ose the sub andibular gland( Identify and clean anterior and !osterior bellies of digastric uscles.eriorly or base7 Base of the andible and a line 3oining the angle of the andible to the astoid !rocess B1ig( 4(AC( Boof7 )he roof of the triangle is for ed by 8 1(S'in( F(Su!erficial fascia. Note that the anterior and posI terior triangles are subdivided by the digastric and inferior belly of omohyoid muscles respectively. the stylohyoid. and by the hyoglossus !osteriorly( . the ylohyoid and the geniohyoid( )he infrahyoid uscles. 4(9C( .nterior belly of digastric( /osteroinferiorly7 Posterior belly of digastric and the stylohyoid( <u. the thyrohyoid and the o ohyoid( )he anterior triangle is subdivided Bby the digastric uscle and the su!erior belly of the o ohyoid into8 BaC Sub entalD BbC digastricD BcC carotidD and BdC uscular triangles B1ig( 4(AC( DISSECTION . already e&a ined.h no+es are situated in the su!erficial fascia bet"een the anterior I bellies of the digastric uscles( )hey drain8 BaC Su!erficial tissues belo" the chinD BbC central !art of the lo"er li!D BcC the ad3oining gu D BdC anterior !art of the floor of the outhD and BeC the ti! of the tongue( Their efferents .

1: Lingual ner7ePPPPPPP ] -t2loh2oid liga5ent %PPP P( !oronal section through the digastric triangle and the submandibular region. 1.Contents 6nterior /art of the Triangle 1(<tru*tures su. and BbC the e&ternal carotid artery before it enters the !arotid gland( F(Dee. !assing bet"een the e&ternal and internal carotid arteries are8 BaC )he styloglossusD BbC the stylo!haryngeusD BcC the glosso!haryngeal nerveD BdC the !haryngeal branch of the vagus nerveD BeC the styloid !rocessD and BfC a !art of the !arotid gland B1ig( 9(HC( H2oglossus 5uscle 0lossophar2ngeal ner7e -t2logossus % -u6lingual gland M2loh2oid line M2loh2oid 5uscle -u65andi6ular duct%%%%%%%%%%% Deep part o4 su65andi6ular gland Middle constrictor o4 phar2n: OOP4.erfi*ial to the hyoglossus seen "ithout disturbing the ylohyoid and the sub andibular gland are8 BaC )he sub andibular salivary gland8 BbC the inter ediate tendon of the digastric and the stylohyoidD and BcC the hy!oglossal nerve B1ig( 11(FC( 0ther relations "ill be studied in the sub andibular region( /osterior /art of the Triangle 1(<u. stru*tures. "' I) S!3tETR' -uper4icial part su65andi6ular gland Lingual arter2 ) W3'F\% : ' S 0reater cornua o4 h2oid 6one % % E S H2pogtossal ner7e /n7esting 4ascia ) )U Co55on tendon o4 digastric 5uscle Fig.erfi*ial to mylohyoi+ are8 BaC Su!erficial !art of the sub andibular salivary gland B1ig( 4(FC( )he facial vein and the sub andibular ly !h nodes are su!erficial to it and the facial artery is dee! to itD BbC sub ental arteryD BcC ylohyoid nerve and vessels( F(<tru*tures su.erfi*ial stru*tures are8 BaC @o"er !art of the !arotid gland. <osterior 6ell2 o4 digastric Middle and in4erior constrictors o4 phar2n: Masseter Jacial arter2 H2oglossus Anterior 6ell2 o4 digastric M2loh2oid .

.H2oid 1ith pulle2 4or tendon o4 digastric 6ellies Fig. 1.K: Floor of the digastric triangle.

es7 B1C )he vagus running vertically do"n"ardsD BFC the su!erior laryngeal branch of the vagus. and BcC the vagus nerve( )he dee! structures "ill be studied "ith the sub andibular region( )he subman+ibular lym. and include the 3ugulodigastric node belo" the !osterior belly of the digastric and the 3ugulo-o ohyoid node above the inferior belly of the o ohyoid B1ig( 1F(F9C( .nterior border of the sternocleidoastoid uscle( DISSECTION Clean the area situated bet"een !osterior belly of digastric and su!erior belly of o ohyoid uscle.9(4 Hea$ a"$ Ne&- :( Dee!est structures include8 BaC )he internal carotid artery. BbC the internal 3ugular vein. nodes( )he efferents fro the sub andibular nodes !ass ostly to the 3ugulo-o ohyoid node and !artly to the 3ugulodigastric node( )hese nodes are situated along the internal 3ugular vein and are e bers of the dee! cervical chain B1igs F(FJ. to e&!ose the three carotid arteries "ith internal 3ugular vein( )race IO.h no+es7 )he dee! cervical ly !h nodes are situated along the internal 3ugular vein. and the floor of the outh( )hey also receive efferents fro the sub ental ly !h. the loo! and inferior root of ansa cervicalis in relation to anterior as!ect of carotid sheath( @ocate the sy !athetic trun' situated !ostero edial to the carotid sheath( Dissect the branches of e&ternal carotid artery( Identify and !reserve internal laryngeal nerve in the thyrohyoid interval( )race it !osterosu!eriorly till vagus( . lingual.o66on . 1F(F9C( Caroti$ Tria"!#e &oundaries Foof 1(S'in( F(Su!erficial fascia containing8 BaC )he !lastys aD BbC the cervical branch of the facial nerveD and BcC the transverse cutaneous nerve of the nec'( :(Investing layer of dee! cervical fascia( Floor It is for ed by !arts of BaC )he thyrohyoid uscleD BbC the hyoglossusD BcC and the iddle and inferior constrictors of the !haryn& B1ig( 4(1GC( !ontents 6nterosu. !articularly "hen its !osterior boundary is retracted slightly bac'"ards( 6rteries7 B1C )he co on carotid artery "ith the( i carotid sinus and the carotid body at its ter inationD 3 BFC internal carotid arteryD and B:C the e&ternal carotid artery "ith its su!erior thyroid. facial. dividing into the e&ternal and internal laryngeal nervesD B:C the s!inal accessory nerve running bac'"ards over the internal 3ugular veinD and the BHC the hy!oglossal nerve running for"ards over the e&ternal and internal carotid arteries( )he hy!oglossal nerve gives off the u!!er root of the ansa cervicalis or descendens hy!oglossi.h no+es are clinically very i !ortant because of their "ide area of drainage( )hey are very co only enlarged( )he nodes lie beneath the dee! cervical fascia on the surface of the sub andibular salivary gland( )hey +rain7 2a3 )he centre of the foreheadD 2b3 the nose "ith the frontal. but ay drain into the co on facial vein( Ier. branches B1ig( 4(11C( /eins8 B1C )he internal3ugularveinD BFC the co on facial vein draining into the internal 3ugular veinD B:C a !haryngeal vein "hich ay end either in the internal 3ugular vein or in the co on facial veinD and BHC the lingual vein "hich usually ter inates in the internal 3ugular vein. a&illary and eth oidal air sinusesD BcC the inner canthus of the eyeD Bd3 the u!!er li! and the anterior !art of the chee' "ith the underlying gu and teethD BeC the outer !art of the lo"er li! "ith the lo"er gu and teeth e&cluding the incisorsD Bf3 the anterior t"o-thirds of the tongue e&cluding the ti!.arotid -rtery )he right co on carotid artery is a branch of the brachioce!halic artery( It begins in the nec' behind the right sternoclavicular 3oint( )he left co on carotid artery is branch of the arch of the aorta( It begins in the thora& in front of the trachea o!!osite a !oint a little to the left of the centre of the . O.lso loo' for e&ternal laryngeal nerve su!!lying the cricothyroid uscle( )he carotid triangle !rovides a good vie" of all the large vessels and nerves of the nec'. ascending !haryngeal and occi!ital. and another branch to the thyrohyoid( BJC )he sy !athetic chain runs B1ig( 4(1FC vertically do"n"ards !osterior to the carotid sheath B1ig( 1F(HC( Caroti+ sheath "ith its contents( 0ym.eriorly7 Posterior belly of the digastric uscleD and the stylohyoid B1ig( 4(AC( 6nteroinferiorly7 Su!erior belly of the o ohyoid( /osteriorly7 . OI and OII nerves in relation to these vessels( Carefully clean and !reserve su!erior root.

Oesophagus ). Ascending phar2ngeal =f O Carotid sinus Outline o4 carotid triangle fig.ressure re*e.RR3 Lateral 6order o4 triangle 4or5ed 62 anterior 6order o4 sternocleido5astoid .( Medial 6order o4 triangle 4or5ed 62 superior 6ell2 o4 o5oh2oid Fig. and the internal Gugular vein.W Styloid !rocess %O Upper 6order o4 triangle 4or5ed 62 posterior 6ell2 o4 digastric %%%%% Middle constrictor i PPPPP 9h2roh2oid 5e56rane G1ith openings 4or internal lar2ngeal ner7e and superior lar2ngeal 7essles Y #KI. but the adventitia is relatively thic' and receives a rich innervation fro the glosso!haryngeal and sy !athetic nerves( )he carotid sinus acts as a barore*e. Recurrent lar2ngeal ner7e )O% /n4erior constrictor ).%%: !arotid arteries.t the level of the u!!er border of the thyroid cartilage the artery ends by dividing into the e&ternal and internal carotid arteries B1ig( 4(1FC( )he ter ination of the co on carotid artery. under cover of the anterior border of the sternocleido astoid( It lies in front of the lo"er four cervical transverse !rocesses( .('' arter2 O Occipital arter2 O /nternal Fugular 7ein Lingual arter2 O -uperior th2roid arter2 % Carotid 6od2 Co55on carotid arter2 . both arteries have a si ilar course( 2ach artery runs u!"ards "ithin the carotid sheath. !arotid $inus anubriu ( It ascends to the bac' of the left sternoclavicular 3oint and enters the nec' B1ig( 1F(11C( In the nec'. the tunica edia is thin.tor and regulates blood !ressure( !arotid &ody Carotid body is a s all. in relation to the carotid triangle. 1. i(uiv\ieiy]^---. 1. -uper4icial te5poral arter2 Ma:illar2 arter2 % E:ternal carotid arter2 Jacial arter2 /nternal carotid <osterior auricular . 'no"n as the carotid sinus( In this region.&f&) )hyrohyoid uscle------/M *D]\ /nsertion o4 sternoh2oid Gon o6li8ue lineH Cricoth2roid 5e56rane%%%%%%%%%%% Cricoid cartilage O% 9rachea%%%%%%%%%%%%% .-t2loh2oid liga5ent H2oglossus M2loh2oid Anterior 9riangle o4 the ec! "=$ .%3: Floor of the carotid triangle. oval reddish-bro"n structure situated behind the bifurcation of the co on carotid artery( It receives a rich nerve su!!ly ainly fro the .tor or . branches of the e ternal carotid artery. or the beginning of the internal carotid artery sho"s a slight dilatation.I.

but also fro the vagus and sy !athetic nerves( It acts as a *hemore*e. and is the chief artery of su!!ly to structures in the front of the nec' and in the face B1igs 4(11.tors are found near the arch of the aorta.arotid -rtery 2&ternal carotid artery is one of the ter inal branches of the co on carotid artery( In general. and the right subclavian artery( )hese are su!!lied by the vagus nerve( E)ternal . it lies anterior to the internal carotid artery.glosso!haryngeal nerve. the ductus arteriosus. 4(1FC( .tor and res!onds to changes in the o&ygen and carbon dio&ide and !< content of the blood( 0ther allie+ *hemore*e.

it is related su!erficially to the retro andibular vein and the facial nerve B1ig( 9(HC( Dee! to the e&ternal carotid artery.scending !haryngeal( Terminal7 2I3 #a&illaryD and BFC su!erficial te !oral B1ig( 4(1FC( <u.erior Thyroi+ 6rtery )he su!erior thyroid artery arises fro the e&ternal carotid artery 3ust belo" the level of the greater cornua of the hyoid bone( It runs do"n"ards and for"ards !arallel and 3ust su!erficial to the e&ternal laryngeal nerve( It !asses dee! to the three long infrahyoid uscles to reach the u!!er !ole of the . stylo!haryngeus. %<: 2he ninth. and lies under cover of the anterior border of the sternocleido astoid( )he artery is crossed su!erficially by the cervical branch of the facial nerve. the e&ternal carotid artery is co !aratively su!erficial. and ter inates behind the nec' of the andible by dividing into the a&illary and su!erficial te !oral arteries( F()he e&ternal carotid artery has a slightly *ur. 1.e+ *ourse. eleventh and twelfth cranial nerves and their branches related to the carotid arteries and to the internal Gugular vein. lingual and su!erior thyroid veins( Dee! to the artery there are8 B1C )he "all of the !haryn&D BFC the su!erior laryngeal nerve "hich divides into the )he e&ternal carotid artery gives off eight branches "hich ay be grou!ed as follo"s( 6nterior7 B1C Su!erior thyroidD BFC lingualD and B:C facial( /osterior7 B1C 0cci!italD and BFC !osterior auricular( 1e+ial7 . in and around the carotid triangle. the hy!oglossal nerve. !haryngeal branch of Oth.e the *aroti+ triangle the e&ternal carotid artery lies dee! in the substance of the !arotid gland( Eithin the gland. $urface /arking )he e&ternal carotid artery is ar'ed by 3oining the follo"ing t"o !oints( BaC. tenth. IOth nerve. !oint on the anterior border of the sternocleido astoid uscle at the level of the u!!er border of the thyroid cartilage( BbC. there are8 BaC )he internal carotid arteryD BbC structures !assing bet"een the e&ternal and internal carotid arteriesD these being styloglossus. na ely the su!erior laryngeal nerve and the su!erior cervical sy !athetic ganglion B1ig( 4(1FC( Branches triangle at the level of the u!!er border of the thyroid cartilage o!!osite the disc bet"een the third and fourth cervical vertebrae( It runs u!"ards and slightly bac'"ards and laterally. and styloid !rocessD and BcC t"o structures dee! to the internal carotid artery. second !oint on the !osterior border of the nec' of the andible( )he artery is slightly conve& for"ards in its lo"er half and slightly concave for"ards in its u!!er half B1ig( 1F(1GC( !ourse and Felations 1()he e&ternal carotid artery begins in the carotid e&ternal and internal laryngeal nervesD and B:C the ascending !haryngeal artery B1ig( 4(1GC( H( 6bo. and anterolateral to the internal carotid artery in its u!!er !art( :(In the *aroti+ triangle. so that it is antero edial to the internal carotid artery in its lo"er !art. and the facial.).E:ternal lar2ngeal ner7e % E:ternal carotid arter2 -t2loid process /nternal carotid arter2 0lossophar2ngeal ner7e +3P <har2ngeal 6ranch o4 7agus%%%%%% -uperior th2roid arter2 O -uperior root o4 ansa cer7icalis H2poglossal ner7e PR Ansa cer7icalis%%%%%%%%%%%%%%%% /nternal lar2ngeal ner7e%%%%%%%%% Accessor2 ner7e R%%%% Occipital arter2 . Outline o4 carotid triangle ))+ -uperior lar2ngeal 6ranch o4 7agus %%%%%%% Vagus ner7e %%%%%%% /n4erior root o4 ansa cer7icalis Fig.

crosses over the u!!er border of the su!erior constrictor and su!!lies the tonsil and the root of the tongue( )he submental bran*h is a large artery "hich acco !anies the ylohyoid nerve. but diverge slightly near the gland( )o avoid in3ury to the nerve.!art fro its ter inal branches to the thyroid gland. H(F.art lies dee! to the hyoglossus along the u!!er border of hyoid bone( It is su!erficial to the iddle constrictor of the !haryn&( )he thir+ . the astoid antru and air cells. the su!erior thyroid artery is ligated as near to the gland as !ossible B1ig( 1F(6C( .alatine artery arises near the origin of the facial artery( It !asses u!"ards bet"een the styloglossus and the stylo!haryngeus. it lies bet"een the genioglossus edially and the inferior longitudinal uscle of the tongue laterally( )he hori7ontal !art of the artery is acco !anied by the lingual nerve( During surgical re oval of the tongue. the se icircular canals. tonsillar. sub ental. 11(4C( )he course and branches of the fa*ial . and su!!lies the sub ental triangle and the sublingual salivary gland( >**i.lateral lobe of the thyroid gland( Its relationshi! to the e&ternal laryngeal nerve. and then hori7ontally for"ards on the undersurface of the tongue as the fourth . and ascends behind the auricle( It su!!lies the bac' of the auricle. and su!!lies the iddle ear. the first !art of the artery is ligated before it gives any branch to the tongue or to the tonsil( 5a*ial 6rtery )he facial artery arises fro the e&ternal carotid 3ust above the ti! of the greater cornua of the hyoid bone( It runs u!"ards first in the nec' as cervical !art and then on the face as facial !art( )he course of the artery in both !laces is tortuous( )he tortuosity in the nec' allo"s free ove ents of the !haryn& during deglutition( 0n the face it allo"s free ove ents of the andible.ital 6rtery )he occi!ital artery arises fro the !osterior as!ect of the e&ternal carotid artery.art of the facial artery have been described "ith the face B1ig( F(F1C( )he cervical !art of the facial artery gives off the ascending !alatine. and the lo"er branch arises near the origin of the occi!ital artery( )he further course of the artery has been described in Cha!ter H B1igs 4(11. H(JC( /os terior 6uri*ular 6rtery )he !osterior auricular artery arises fro the !osterior as!ect of the e&ternal carotid 3ust above the !osterior belly of the digastric( It runs u!"ards and bac'"ards dee! to the !arotid gland. the artery gives t"o sternocleido astoid branches( )he u!!er branch acco !anies the accessory nerve.art is called the arteria !rofunda linguae. and then u! over the base of the andible B1igs 11(A. "hich su!!lies the cricothyroid uscle is i !ortant to the surgeon during thyroid surgeryC )he artery and nerve are close to each other higher u!.erior laryngeal artery "hich !ierces the thyrohyoid e brane in co !any "ith the internal laryngeal nerve B1ig( 4(6C( )he su!erior thyroid artery also gives a sternocleido astoid branch to that uscle and a cricothyroid branch that anasto oses "ith the artery of the o!!osite side in front of the cricovocal e brane B1ig( 1F(6C( 0ingual 6rtery )he lingual artery arises fro the e&ternal carotid artery o!!osite the ti! of the greater cornu of the hyoid bone B1ig( 4(1FC( Its course is divided into three !arts by the hyoglossus uscle( )he first . and the facial nerve B1ig( 4(11C( 6s*en+ing /haryngeal 6rtery )his is a s all branch that arises fro the edial side of the e&ternal carotid artery( It arises very close . or the dee! lingual artery( It runs u!"ards along the anterior border of the hyoglossus.i*al . o!!osite the* origin of the facial artery( It is crossed at its origin by the hy!oglossal nerve( In the carotid triangle.art lies in the carotid triangle( It for s a characteristic u!"ard loo! "hich is crossed by the hy!oglossal nerve B1ig( 11(FC( )he lingual loo! !er its free ove ents of the hyoid bone( )he se*on+ . and over the bac' of the scal!( It is cut in incisions for astoid o!erations( Its stylomastoi+ bran*h enters the stylo astoid fora en. and glandular branches for the sub andibular salivary gland and ly !h nodes( )he as*en+ing .art of the facial artery runs u!"ards on the su!erior constrictor of !haryn& dee! to the !osterior belly of the digastric. "ith the stylohyoid and to the ra us of the andible( It grooves the !osterior border of the sub andibular salivary gland( =e&t the artery a'es an S-bend Bt"o loo!sC first "inding do"n over the sub andibular gland.art) In its vertical course. but su!erficial to the styloid !rocess( It crosses the base of the astoid !rocess. the li!s and the chee' during astication and during various facial e&!ressions( )he artery esca!es traction and !ressure during these ove ents( )he *er. it gives one i !ortant branch. the su. the s'in over the astoid !rocess.

erior root is the continuation of the descending branch of the hy!oglossal nerve( Its fibres are derived fro the first cervical nerve( )his root descends over the internal carotid artery and the co on carotid artery( )he inferior root or descending cervical nerve is derived fro second and third cervical s!inal nerves( . behind the nec' of the andible under cover of the !arotid gland B1igs 9(:.nsa cervicalis8 to the sternohyoid. the auricle and the facial uscles. already studied H2poglossal ner7e Ventral ra5us o4 C" % Co55unication to h2poglossal ner7e 9o 5uscles o4 tongue O Ventral ra5us o4 C= % Ventral ra5us o4 C3 9o genioh2oid%%%%%%%% th2roh2oid O /n4erior root Descendens h2poglossi Gsuperior root o4 ansa cer7icalisH 9o sternoh2oid % o4 ansa cer7icalis Gdescendens cer7icalisH 9o superior 6ell2 o4 o5oh2oid )) i%%%%%%%9o in4erior 6ell2 o4 o5oh2oid 9o sternoth2roid ' Fig.C( BbCIt runs vertically u!"ards. 9(J. 1.oral 6rtery BaCIt is the s aller ter inal branch of the e&ternal carotid artery( It begins. the sternothyroid and the inferior belly of the o ohyoid( =ote that the thyrohyoid and geniohyoid are su!!lied by se!arate branches fro the first cervical nerve through the hy!oglossal nerve B1ig( 4(1:C( Muscular 9riangle &oundaries 6nteriorly7 anterior edian line of the nec' fro hyoid bone to the sternu ( the 1axillary 6rtery )his is the larger ter inal branch of the e&ternal carotid artery( It begins behind the nec' of the andible under cover of the !arotid gland( It runs for"ards dee! to the nec' of the andible belo" the auriculote !oral nerve. the scal!. it "inds round the internal 3ugular vein. the tonsil.erfi*ial Tem. and enters the infrate !oral fossa "here it "ill be studied at a later stage BCha!ter 1GC( <u.s this root descends. and branches of the first . the edial "all of the iddle ear and.to the lo"er end of the e&ternal carotid artery B1ig( 1H(1FC( It runs vertically u!"ards bet"een the side "all of the !haryn&.erse fa*ial artery. :(HBC( 5ormation) It is for ed by a su!erior and an inferior root( )he su. the auditory tube( It sends eningeal branches into the cranial cavity through the fora en laceru . crossing the root of the 7ygo a or !reauricular !oint.bout J c above the 7ygo a it divides into anterior and !osterior branches "hich su!!ly the te !le and scal!( )he anterior branch anasto oses "ith the su!raorbital and su!ra-trochlear branches of the o!hthal ic artery( BcCIn addition to the branches "hich su!!ly the te !le. and then continues anteroinferiorly to 3oint the su!erior root in front of the co on carotid artery B1ig( 4(1FC( 9istribution Su!erior root8 to the su!erior belly of the o ohyoid( .%): Ansa cervicalis. "here its . an+ a mi++le tem.ulsations can be easily felt( .oral artery "hich runs on the te !oral fossa dee! to the te !oralis uscle( Ansa !ervicalis or Ansa 4ypoglossi )his is a thin nerve loo! that lies e bedded in the anterior "all of the carotid sheath over the lo"er !art of the laryn&( It su!!lies the infrahyoid uscles B1igs 4(1:. the !arotid gland. the su!erficial te !oral artery gives off a trans. the 3ugular fora en and the hy!oglossal canal( "ith the face B1ig( #)#"3.

.cervical nerve distributed through the hypogAossaS nerve.

etc(C "ill be studied se!arately at a later stage( are su!!lied by the ventral ra i of first. trachea. su!erficial Bsternohyoid and o ohyoidC and dee! Bsternothyroid and thyrohyoidC B1ig( 4(JC( Identify the infrahyoid uscles on each side of the edian !lane( Cut through the origin of sternocleido astoid uscle and reflect it u!"ards( )race the nerve su!!ly of infrahyoid uscles( )he su!erficial structures in the infrahyoid region are included in this triangle( )he dee!er structures Bthyroid gland./osterosu. oeso!hagus.eriorly7 su!erior belly of the o ohyoid uscle B1ig( 4(AC( /osteroinferiorly7 . second and third cervical s!inal nerves( BbCBecause of their attach ent to the hyoid bone and to the thyroid cartilage.ll of the . they ove these structures( )he s!ecific details of infrahyoid uscles are sho"n in )able 4(1( BaC.nterior border of the sternocleido astoid uscle( !ontents )he infrahyoid uscles are the chief contents of the triangle( )hese uscles ay also be regarded arbitrarily as for ing the floor of the triangle( B1ig( 4(HC( )he infrahyoi+ mus*les are8 B1C )he sternohyoidD BFC the sternothyroidD B:C the thyrohyoidD and BHC the o ohyoid( )hese ribbon uscles have the follo"ing general features( BaC )hey are arranged in t"o layers.

.

re oving the glands in !ieces( Clean the facial nerve already dissected( Study the entire course of facial nerve fro its beginning to the end( 1acial nerve is li'e the %ueen of the face. and !haryngeal glands( It indirectly hel!s in the secreto otor su!!ly to the !arotid gland( 2ven the taste fro the ost of the anterior t"o-thirds of tongue is carried by facial nerve( Since it is too uch for the facial nerve.aroti+. auricle. gives secreto otor branches to the sub andibular. dissect the structures e erging at the !eri!hery of the gland( )race the duct of the !arotid gland anteriorly till the buccinator uscle( )race one or ore of the branches of facial nerve till its trun' in the !osterior !art of the gland( )he trun' can be follo"ed till the srylo astoid fora en( )race its !osterior auricular branch( )race the course of retro andibular vein and e&ternal carotid artery in the gland.nteriorly. the chee's and the li!s( )hese glands !roduce saliva "hich 'ee!s the oral cavity oist. the gland also overla!s the asseter uscle B1ig( 9(1C( .9he <arotid Region Parotid region contains the largest serous salivary gland and the 6%ueen of the face6. scal!. su!!lying all the uscles of facial e&!ression. including those in tongue and floor of outh( It is also secreto otor to glands in the nasal cavity. sub andibular and sublingual( In addition there are nu erous s all glands in the tongue. the facial nerve( Parotid gland contains vertically dis!osed blood vessels and hori7ontally situated facial nerve and its various branches( Parotid gland gets affected by virus of u !s. !art of this for"ard e&tension is often detached. !alatal. the facial nerve nucleus co es close to trige inal nerve nucleus( )he nucleus of facial nerve can act refle&ly in res!onse to sensory i !ulses fro the face( 1acial nerve in3ury causes very ty!ical sy !to s( PAROTID ILAND BPara H arou"$P otic H earT The Sa#i5ar6 !#a"$s I"tro$u&tio" to the Paroti$ I#a"$ )he !arotid is the largest of the salivary glands( It "eighs about 1J g( It is situated belo" the e&ternal acoustic eatus. the !alate. sublingual salivary glands. sublingual. carrying secreto otor fibres to sub andibular. nasal. "hich can e&tend the territory of its attac' u! to gonads as "ell( 0ne ust be careful of the branches of facial nerve "hile incising the !arotid abscess by giving hori7ontal incision( 1acial nerve su!!lies uscles of the face. and is 'no"n as the accessory . !alate and the lacri al gland( It is res!onsible enough for carrying the taste fibres fro anterior t"o-thirds of tongue also e&ce!t fro the vallate !a!illae( 9++ )here are three !airs of large salivary glandsMthe !arotid. so it does not su!!ly the s'in of the face "hich is innervated by trige inal( )o aintain contact "ith trige inal nerve. and it lies bet"een the 7ygo atic arch and the !arotid duct( DISSECTION Carefully cut through the fascial covering of the !arotid gland fro the 7ygo atic arch above to the angle of andible belo"( Ehile re oving tough fascia. and hel!s in che"ing and s"allo"ing( )he saliva also contains en7y es that aid digestion( . bet"een the ra us of the andible and the sternocleido astoid( )he gland overla!s these structures( . lacri al.

Parotid !apsule )he investing layer of the dee! cervical fascia for s a ca!sule for the gland( )he fascia s!lits Bbet"een the angle of the andible and the astoid !rocessC to enclose the gland( )he su!erficial la ina. by 3oining the !oints a-d across the lobule of the ear( Parotid 9uct )o ar' this duct first dra" a line 3oining the follo"ing t"o !oints( asion Duct o4 parotid gland o7er 5asseter <alatine tonsil Fi*+ "+&: $urface marking of parotid. the andible and the ty !anic !late( . e&tending bet"een the styloid !rocess and the andible. !ortion of the dee! la ina. K.%: Position of parotid gland. is attached above to the 7ygo atic arch( )he dee! la ina is thin and is )he !arotid gland is ar'ed by 3oining the follo"ing four !oints "ith each other B1ig( 9(FC( BaC)he first !oint at the u!!er border of the head of the andible( BbC)he second !oint 3ust above the centre of the asseter uscle( BcC)he third !oint !osteroinferior to the angle of the andible( BdC)he fourth !oint on the u!!er !art of the anterior border of the astoid !rocess( )he anterior border of the gland is obtained by 3oining the !oints a-b-cD the !osterior border. is thic'ened to for the styloman+ibular ligament 9hi*h se!arates the !arotid gland fro the sub andibular salivary gland( $urface /arking Outline o4 parotid gland O -ternocleido5astioid Angle o4 5andi6le <arotid duct Masseter Fig.Hea$ a"$ Me Q2go5atic arch E:ternal auditor2 5eatus attached to the styloid !rocess. submandibular H2oid 6one salivary glands and palatine tonsil. . thic' and adherent to the gland. by 3oining the !oints c-dD and the su!erior curved border "ith its concavity directed u!"ards and bac'"ards.

erior surfa*e or base for s the u!!er end of the gland "hich is s all and concave( It is related to8 BaC )he cartilaginous !art of the e&ternal acoustic eatusD BbC the !osterior surface of the te !oroandibular 3ointD BcC the su!erficial te !oral vesselsD and BdC the auriculote !oral nerve B1ig( 9(:C( <urfa*es7 )he su.ex B1ig( 9(:C overla!s the !osterior belly of the digastric and the ad3oining !art of the carotid triangle( )he cervical branch of the facial nerve and the t"o divisions of the retro andibular vein e erge through it( )he su. the !reauricular or su!erficial !arotid ly !h nodes and the !osterior fibres of the !latys a and risoriusD BcC the !arotid fascia "hich is thic' and adherent to the glandD and BdC a fe" dee! !arotid ly !h nodes e bedded in the gland( )he anterome+ial surfa*e B1ig( 9(HC is grooved by the !osterior border of the ra us of the andible( It is related to8 BaC )he asseterD BbC the lateral surface Q2go5atic 6ranch 9rans7erse 4acial arter2 Auriculote5poral ner7e E:ternal auditor2 5eatus <osterior auricular ner7e -uper4icial te5poral arter2 and 7ein <osterior auricular 7ein E:ternal Fugular 7ein O <osterior auricular arter2 Upper 6uccal 6ranch <arotid duct Lo1er 6uccal Fi*+ "+': Cer7ical 6ranch Jacial 7ein $tructures emerging at the periphery of 91o di7sions o4 retro5andi6ular 7ein Marginal 5andi6ular .BaC0ne !oint at the lo"er border of the tragus( BbC.erfi*ial surfa*e is the largest of the four surfaces( It is covered "ith8 BaC S'inD BbC su!erficial fascia containing the anterior branches of the great auricular nerve. second !oint id"ay bet"een the ala of the nose and the red argin of the u!!er li!( )he iddle-third of this line re!resents the !arotid duct( E8ter"a# Features )he gland rese bles a three sided !yra id( )he a!e& of the !yra id is directed do"n"ards( )he gland has four surfaces8 B1C Su!erior Bbase of the !yra idCD BFC su!erficialD B:C antero edialD and BHC !ostero edial( )he surfaces are se!arated by three borders8 B1C .nteriorD BFC !osteriorD and B:C edial( 7elations )he a.

.the parotid gland.

osterior bor+er se!arates the su!erficial surface fro the !ostero edial surface( It overla!s the sternocleido astoid B1ig( 9(1C( )he me+ial e+ge or bor+er se!arates the antero edial surface fro the !ostero edial surface( It is related to the lateral "all of the !haryn& B1ig( 9(HC( Structures Githin the Parotid <land through its antero edial surface( )he su!erficial te !oral vessels e erge at the anterior !art of the su!erior surface( )he !osterior auricular artery ay arise "ithin the gland( 1(=eins7 )he retro andibular vein is for ed "ithin the gland by the union of the su!erficial te !oral and a&illary veins( In the lo"er !art of the gland. the accessory !arotid gland lies on the !arotid duct close to this border B1ig( 9(:C( )he .t the anterior border of the asseter.of the te !oro andibular 3ointD BcC the !osterior border of the ra us of the andibleD BdC the edial !terygoidD and BeC the e erging branches of the facial nerve( )he .6: 4oriMontal section through the parotid gland showing its relations and the structures passing through it. the vein divides into anterior and !osterior divisions "hich e erge at the a!e& Blo"er !oleC of the gland B1ig( 9(J BC( F()he fa*ial ner. BbC the bucco!haryngeal fascia and BcC the buccinator Bobli%uelyC( Because of the obli%ue course of the duct through the buccinator inflation of the duct is !revented during blo"ing( Masseter Branches o4 4acial ner7e PP Medial pter2goid Ra5us o4 5andi6le . it turns r edially and !ierces8 BaC )he buccal !ad of fat.e enters the gland through the u!!er !art of its !ostero edial surface.ccessory !arotid glandD BbC u!!er buccal branch of the facial nerveD and BcC the transverse facial vessels B1ig( 9(:C( Interiorly7 BaC )he lo"er buccal branch of the facial nerve( . and a!!ear on the surface at the anterior border B1ig( 9(J CC( :(Parotid ly !h nodes( Parotid Duct 1ro edial to the lateral side these are as follo"s( 1( 6rteries7 )he e&ternal carotid artery enters the gland through its !ostero edial surface B1ig( 9(J . <arotid gland 3 . "ith structures attached to it( )he e&ternal carotid artery enters the gland through this surface and the internal carotid artery lies dee! to the styloid !rocess B1ig( 9(HC( Bor+ers7 )he anterior bor+er se!arates the su!erficial surface fro the antero edial surface( It e&tends fro the anterior !art of the su!erior surface to the a!e&( )he follo"ing structures e erge at this border8 BaC )he !arotid ductD BbC ost of the ter inal branches of the facial nerveD and BcC the transverse facial vessels( In addition.eriorly7 BaC . "ith the sternocleido astoid and the !osterior belly of the digastricD and BbC the styloid !rocess. and divides into its ter inal branches "ithin the gland( )he branches leave the gland through its antero edial surface.all o4 phar2n: Retro5andi6ular 7ein%%%%%%% B E:ternal carotid arter2%%%%%%% D DMedial D O edge o4 parotid+gland /nternal carotid arter2 . /nternal L6*%h "o$es B Ster"o&#ei$o*astoi$ B 7ein )))O Jacial ner7e A St6#oi$ %ro&ess <ith Fugular atta&he$ *us&#es <osterior 6ell2 o4 digastric Mastoid process Fig.osterome+ial surfa*e is oulded to the astoid and the styloid !rocesses and the structures attached to the ( )hus it is related to8 BaC )he astoid !rocess.C( )he a&illary artery leaves the gland It is thic' "alled and is about J c long( It e erges fro the iddle of the anterior border of the gland( It runs for"ards and slightly do"n"ards on the asseter( <ere its relations are8 <u. K.

Q2go5atic 6ranch 9ran7erse 4acial arter2 Jacial ner7e -uper4icial te5poral arter2

Fi*+ "+5: $tructures within the
Marginal 5andi6ular 6ranch

)he duct runs for"ards for a short distance bet"een the buccinator and the oral ucosa( 1inally, the duct turns edially and o!ens into the vestibule of the outh Bgingivo-buccal vestibuleC o!!osite the cro"n of the u!!er second olar tooth( B1ig( F(F6C(
Blood Supply

parotid gland. "A# Arteries, "&# veins, "!# nerves.

S ' %'+E\'3G 'E 7

V%r

Ma:illar2 arter2 Cer7ical 6ranch
Lo1er 6uccal 6ranch <osterior auricular arter2 E:ternal carotid

S@([ ,5

)he !arotid gland is su!!lied by the e&ternal carotid artery and its branches that arise near the gland( )he veins drain into the e&ternal 3ugular vein(
NerAe Supply
1(Parasy

Upper 6uccal 6ranch

'CCJ&J 'XJ'JY

-uper4icial te5poral 7ein

99R4) Ma:illar2 7ein Retro5andi6ular 7ein <osterior di7ision <osterior auricular 7ein E:ternal Fugular 7ein Anterior di7ision Jacial 7ein

!athetic nerves are secreto otor B1ig( 9(6C( )hey reach the gland through the auriculote !oral nerve( )he !reganglionic fibres begin in the inferior salivatory nucleusD !ass through the glosso!haryngeal 3ierve, its ty !anic branch, the ty !anic !le&us and the lesser !etrosal nerveD and relay in the otic ganglion( )he !ostganglionic fibres !ass through the auriculote !oral nerve and reach the gland( F(Sy !athetic nerves are vaso otor, and are derived fro the !le&us around the e&ternal carotid artery( :(Sensory nerves to the gland co e fro the auriculote !oral nerve, but the !arotid fascia is innervated by the sensory fibres of the great auricular nerve BCFC(
9y6phatic Draina*e

@y !h drains first to the !arotid nodes and fro there to the u!!er dee! cervical nodes(
DeAelop6ent

)he !arotid gland is ectoder al in origin( It develo!s fro the buccal e!itheliu 3ust lateral to the angle of outh( )he outgro"th branches re!eatedly to for the duct syste and acini(
Parotid 9y6ph Nodes

)he !arotid ly !h nodes lie !artly in the su!erficial fascia and !artly dee! to the dee! fascia over the !arotid gland B1ig( 9(HC( )hey drain8 BaC )he te !le, BbC the side of the scal!, BcC the lateral surface of the auricle, BdC the e&ternal acoustic eatus, BeC the iddle car, BfC the !arotid gland, BgC the u!!er !art of the chee', BhC !arts of the eyelids, and BiC the orbit( 2fferents fro these nodes !ass to the u!!er grou! of dee! cervical nodes(

Lesser petrosai ner7e Otic ganglion Auriculote5poral ner7e 925panic ple:us on pro5ontor2 Mandi6ular ner7e G7 H through 4ora5en o7ale

925panic 6ranch 0lossophar2ngeal ner7e

<arotid gland Fig. K.7:

Parasympathetic nerve supply to the parotid gland.

CLINICAL ANATOM

1(/aroti+ s9ellings are very !ainful due to the

unyielding nature of the !arotid fascia( F(#u !s is an infectious disease of the salivary glands Busually the !arotidC caused by a s!ecific virus( :(. !arotid abs*ess aybe caused by s!read of infection fro the outh cavity( .n abscess ay also for due to su!!uration of the !arotid ly !h nodes draining an infected area( H(During surgical re oval of the !arotid gland or !arotidecto y, the facial nerve is !reserved by re oving the gland in t"o !arts, su!erficial and dee! se!arately( )he !lane of cleavage is defined by tracing the nerve fro behind for"ards( J(/iral !arotitis or u !s characteristically does not su!!urate( Its co !lications are orchitis arid !ancreatitis( 6(. !arotid abscess is best drained by hori7ontal incisions 'no"n as <ilton*s ethod( A(1ixe+ .aroti+ tumour is a slo"ly gro"ing lobulated !ainless tu our "ithout any involveent of the facial nerve( #alignant change of such a tu our is indicated by !ain, ra!id gro"th, fi&ity "ith hardness, involve ent of the facial nerve, and enlarge ent of cervical ly !h nodes( AAAAAAAAAAAAAAA FACIAL NER1E AAAAAAAAAAAAAAA )his is the seventh cranial nerve( It is the nerve of the second branchial arch( $urface /arking It is ar'ed by a short hori7ontal line "hich 3oins the

follo"ing t"o !oints B1ig( 1G(1FC( BaC. !oint at the iddle of the anterior border of the astoid !rocess( )he stylo astoid fora en lies F c dee! to this !oint( BbC. second !oint behind the nec' of the andible( <ere the nerve divides into its five branches for the facial uscles(
Fu"&tio"a# Co*%o"e"ts 1(S!ecial visceral or bran*hial efferen t, to

uscles res!onsible for facial e&!ression and for elevation of the hyoid bone( F(Ceneral ,is*eral efferent or !arasy !athetic( )hese fibres are secreto otor to the sub andibular and sublingual salivary glands, the lacri al gland, and glands of the nose, the !alate and the !haryn& B1ig( FJ(FC( :(Ceneral ,is*eral afferent co !onent carries afferent i !ulses fro the above entioned glands( H(<.e*ial ,is*eral afferent fibres carry taste sensations fro the anterior t"o-thirds of the tongue e&ce!t fro vallate !a!illae and fro the !alate( J(Ceneral somati* afferent fibres !robably innervate a !art of the s'in of the ear( )he nerve does not give any direct branches to the ear, but so e fibres ay reach it through co unications "ith the vagus nerve( Pro!rioce!tive i !ulses fro uscles of the face travel through branches of the trige inal nerve to reach the esence!halic nucleus of the nerve(

Nu&#ei
)he fibres of the nerve arise fro four nuclei situated

La62rinthine 7essels Jacial ner7e G5otor rootH %CB'MS nS5 er7us inter5edius ==iGGi==Gr Vesti6ulocochlear ner7e ' R Arachnoid 5ater Fig. K.8: $tructures in the left internal acoustic meatus.

Fig. K.1: $ome features seen on the fundus of the left internal acoustic meatus.

St6#o*astoi$ ,ora*e"

Fi*+ "+": !ourse of facial nerve.

)he facial nerve leaves the s'ull by !assing through the srylo astoid fora en( B3n its extra*ranial *ourse, the facial nerve crosses the lateral side of the base of the styloid !rocess( It enters the !ostero edial surface of the !arotid gland, runs for"ards through the gland crossing the retro andibular vein and the e&ternal carotid artery( Behind the nec' of the andible it divides into its five ter inal branches "hich e erge along the anterior border of the !arotid gland B1ig( !)$C3)3
Bra"&hes a"$ Distri2utio"

.( Eithin the facial canal8 B1C +reater?!etrosal nerye3 BFC the nerve to the sta!ediusD and B:C the chorda ry !ani B1ig( 9(1GC( B( .t its e&it fro the srylo astoid fora en8 B1C Posterior auricularD BFC digastricD and B:C stylohyoid( C( )er inal branches "ithin the !arotid gland8 B1C )e !oralD BFC 7ygo aticD B:C buccalD BHC arginal andibularD and BJC cervical( D( Co unicating branches "ith ad3 acent cranial and s!inal nerves( Creater .etrosal ner,e Bsee Cha!ters 6 and 1JC( )he ner,e to the sta.e+ius arises o!!osite the !yra id of the iddle ear, and su!!lies the sta!edius uscle( )he uscle da !s e&cessive vibrations of the sta!es caused by high-!itched sounds( In !aralysis of the uscle even nor al sounds a!!ear too loud

Lacri5ator2 and superior sali7ator2 nuclei

ucleus o4 tractus solitarius Lacri5al ner7e Lacri5al gland Motor nucleus

-phenopalatine ganglionE <ter2gopalatine ganglion

<osterior 6ell2 o4 digastric -u65andi6ular ganglion -u6lingual gland

-ensor2 root /nternal auditor2 5eatus Marginal 5andi6ular Fig. K.%3: !omponents and distribution of facial nerve.

and is 'no"n as hy!eracusis( )he *hor+a tym.ani arises in the vertical !art of the facial canal about 6 above the stylo astoid
Chorda t25pani -t2lo5astoid 4ora5en

Sub andibular and sublingual salivary glands and taste fibres fro the anterior t"o-thirds of the tongue( )he .osterior auri*ular ner,e arises 3ust belo" the stylo astoid fora en( It ascends bet"een the astoid !rocess and the e&ternal acoustic eatus, and su!!lies8 BaC )he auricularis !osterior, BbC the occi!italis, and BcC the intrinsic uscles on the bac'

fora en( It runs u!"ards and for"ards in a bony canal( It enters the iddle ear and runs for"ards in close relation to the ty !anic e brane B1ig( 14(:C( It leaves the iddle ear by !assing through the !etroty !anic fissure( It then !asses edial to the s!ine of the s!henoid and enters the infrate !oral fossa( <ere it 3oins the lingual nerve through "hich it is distributed B1ig( 1G(1HC( It carries8 BaC Preganglionic secreto otor fibres to the Sub andibular ganglion for su!!ly of the

-u65andi6ular gland

of the auricle( )he +igastri* bran*h, arises close to the !revious nerve( It is short and su!!lies the !osterior belly of the digastric( )he stylohyoi+ bran*h, "hich ay arise "ith the digastric branch, is long and su!!lies the stylohyoid uscle( )he tem.oral bran*hes cross the 7ygo atic arch and su!!ly8 BaC )he auricularis anterior, BbC the auricularis su!erior, BcC the intrinsic uscles on the lateral side of the ear, BdC the frontalis, BeC the orbicularis oculi, and BfC the corrugator su!ercilii B1ig( 9(JCC( )he 4ygomati* bran*hes run across the 7ygo atic bone and su!!ly the orbicularis oculi( )he bu**al bran*hes are t"o in nu ber( )he u!!er buccal branch runs above the !arotid duct and the lo"er buccal branch belo" the duct( )hey su!!ly uscles in that vicinity Bsee Cha!ter FC(

)he marginal man+ibular bran*h runs belo" the angle of the andible dee! to the !latys a( It crosses the body of the andible and su!!lies uscles of the lo"er li! and chin B1ig( F(6C( )he *er,i*al bran*h e erges fro the a!e& of the !arotid gland, and runs do"n"ards and for"ards in the nec' to su!!ly the !latys a B1ig( F(AC( Communi*ating bran*hes) 1or effective coordination bet"een the ove ents of the uscles of the first, second and third branchial arches, the otor nerves of the three arches co unicate "ith each other( )he facial nerve also co unicates "ith the sensory nerves distributed over its otor territory(
Ia"!#ia

CLINICAL ANATOM

1or clinical testing of the facial nerve, and for different ty!es of facial !aralysis Bsu!ranuclear and intranuclearC, Bsee 1ig( F(14C( 1igure 9(11 sho"s the sy !to s according to level of in3ury of facial nerve(

)he ganglia associated "ith the facial nerve are as follo"s( 1( )he geniculate ganglion is located on the first bend of the facial nerve, in relation to the edial "all of the iddle ear( It is a sensory ganglion) )he taste fibres !resent in the nerve are !eri!heral !rocesses

of !seudouni!olar neurons !resent in the geniculate ganglion B1ig( 9(9C( 1()he sub andibular ganglion is a .arasym& .atheti* ganglion for relay of secreto otor fibres to the sub andibular and sublingual glands( It is described in Cha!ter 11 and in )able 1(: B1ig( 11(11C( F()he !terygo!alatine ganglion is also a !arasy !athetic ganglion( Secreto otor fibres eant for the lacri al gland relay in this ganglion( It is described in Cha!ter 1J and in )able 1(:(

9he 9e5poral and /n4rate5poral Regions
)e !oral and infrate !oral regions include nuscles of astication, "hich develo! fro esoder of first branchial arch( 0nly one 3oint, the te !oro andibular 3oint, is !resent to allo" ove ents during s!eech and astication( )he !arasy !athetic ganglion is the otic ganglion, the only ganglion "ith four roots, i(e( sensory, sy !athetic, otor and secreto otor( )he otor root fro the branch to edial !terygoid su!!lies t"o uscles, the tensor veli !alatini and tensor veli ty !ani( )he blood su!!ly of this region is through the a&illary artery( #iddle eningeal artery is its ost i !ortant branch, as its in3ury results in e&tradural hae orrhage( Osteology: in order to understand these regions, the osteology of the te !oral fossa, the infrate !oral fossa and the !terygo!alatine fossa should be studied( )he tem.oral fossa lies on the side of the s'ull, and is bounded by the su!erior te !oral line and the 7ygo atic arch( )he !terion lies in the anterior !art of its floor "here four bones Bfrontal, !arietal, s%ua ous te !oral and greater "ing of s!henoidC eet at an <-sha!ed suture( )he te !oral fossa co unicates "ith the infrate !oral fossa through a ga! dee! to the 7ygo atic arch( )he infratem.oral fossa lies belo" the s'ull B iddle cranial fossaC, behind the body of the a&illa and lateral to the lateral !terygoid !late( It co unicates "ith the !terygo!alatine fossa through the !terygo a&illary fissure( )he .terygo.alatine fossa is a s all s!ace "hich lies bet"een the body of the a&illa and the root of the !terygoid !rocess Bof the s!henoid boneC lateral to the !er!endicular !late of the !alatine bone B1ig( 1G(1C(
LANDMAR'S ON THE LATERAL SIDE OF THE HEAD
Coronal suture Jrontal 6one -phenoid 6one Q2go5atic 6oneES <arietal 6one

)he e&ternal ear or !inna is a !ro inent feature on the lateral as!ect of the head( )he na ed features on

Occipital 6one , -8ua5ous te5poral
Ma8i##a

Mastoid process S Q2go5atic arch * 'Lateral pter2goid plate <ter2go5a:illar2 4issure

Fig. J..: $ome features to be seen on the lateral side of the skull.

the !inna are sho"n in 1ig( 14(1( 0ther land ar's on the lateral side of the head are as follo"s( 1()he 4ygomati* bone for s the !ro inence of the chee' at the inferolateral co er of the orbit( )he 4ygomati* ar*h bridges the ga! bet"een the

eye and the ear( It is for ed anteriorly by the te !oral !rocess of the 7ygo atic bone, and !osteriorly by the 7ygo atic !rocess or 7ygo a of the te !oral bone( )he .reauri*ular .oint lies on the !osterior root of the 7ygo a i ediately in front of the u!!er !art of the tragus( 1()he head of the andible lies in front of the tragus( It is felt best during ove ents of the lo"er 3a"( )he *oronoi+.ro*ess of the andible can be felt belo" the lo"est !art of the 7ygo atic bone "hen the outh is o!ened B1ig( 1G(FC( )he !rocess can be traced do"n"ards into the anterior border of the ramus of the andible( )he !osterior border of the
9.+

Te*%ora# ,as&ia Te*%ora# ,ossa I",rate*%ora# Mi$$#e &ra"ia# ,ossa

n

FF R6!o*ati& ar&h C I",rate*%ora# sur,a&e o, !reater <i"!

&rest o, !reater <i"! o, s%he"oi$ Coro"o#$ %ro&ess o, *a"$i2#e Latera# a"$ E' *e$ia# pter2goid %#ates

Fi*+ #$+&: $cheme to show the outline of the temporal and inI fratemporal fossae .n a coronal section.

suture( Dee! to the !terion lie the anterior branch of the iddle eningeal artery, the iddle eningeal vein, and dee!er still the ste of the lateral sulcus of the cerebral he is!here Bat the <yl,ian .oint3 dividing into three ra i( )he !terion is a co on site for tre!hining B a'ing hole inC the s'ull during o!eration( A( )he 3unction of the bac' of the head "ith the nec' is indicated by the e&ternal occi!ital !rotuberance and the su!erior nuchal lines( )he external o**i.ital .rotuberan*e is a bony !ro3ection felt in the edian !lane on the bac' of the head at the u!!er end of the nuchal furro"( )he su.erior nu*hal lines are indistinct curved ridges "hich e&tend fro the !rotuberance to the astoid !rocesses( )he bac' of the head is called the o**i.ut) )he ost !ro inent edian !oint situated on the e&ternal occi!ital !rotuberance is 'no"n as the inion Bnot onionC( <o"ever, the !osterior ost !oint on the occi!ut lies a little above the !rotuberance(
MUSCLES OF MASTICATION

ra us, though as'ed by the !arotid gland, can be felt through the s'in( )he outer surface of the ra us is covered by the asseter "hich can be felt "hen the teeth are clenched( )he lo"er border of the andible can be traced !osteriorly into the angle of the andible( 1()he .arietal eminen*e is the ost !ro inent !art of the !arietal bone situated far above and a little behind the auricle( F()he mastoi+.ro*ess is a large bony !ro inence situated behind the lo"er !art of the auricle( )he su.ramastoi+ *rest, about F(J c long, begins i ediately above the e&ternal acoustic eatus and soon curves u!"ards and bac'"ards( )he crest is continuous anteriorly "ith the !osterior root of the 7ygo a, and !osterosu!eriorly "ith the te !oral line( :()he inferior tem.oral line for s the u!!er boundary of the te !oral fossa "hich is filled u! by the te !oralis uscle( )he u!!er argin of the contracting te !oralis hel!s in defining this line "hich begins at the 7ygo atic !rocess of the frontal bone, arches !osterosu!eriorly across the coronal suture, !asses a little belo" the !arietal e inence, and turns do"n"ards to beco e continuous "ith the su!ra astoid crest( )he area of the te !oral fossa on the side of the head, above the 7ygo atic arch, is called the te !le or te !oral region( H()he .terion is the area in the te !oral fossa "here four bones Bfrontal, !arietal, te !oral and s!henoidC ad3oin each other across an <sha!ed suture( )he centre of the !terion is ar'ed by a !oint H c above the id!oint of the 7ygo atic arch, falling :(J c behind the fronto7ygo atic

e ove the bone carefully in bet"een these t"o cuts. avoiding in3ury to the underlying structures( )he lateral !terygoid is e&!osed in the u!!er !art and edial !terygoid in the lo"er !art of the dissection( . the lateral !terygoid and the edial !terygoid( )hey develo! fro the esoder of the first branchial arch. the te !oralis.Intro+u*tion7 )he uscles of astication ove the andible during astication and s!eech( )hey are the asseter. and are su!!lied by the andibular nerve "hich is the nerve of that arch( )he uscles are enu erated in )able 1G(1( )e !oral fascia and relations of lateral and edial !terygoid uscles are described( DISSECTION Identify the asseter uscle e&tending fro the 7ygo atic arch to the ra us of the andible( Cut the 7ygo atic arch in front of and behind the attach ent of asseter uscle and reflect it do"n"ards( Divide the nerve and blood vessels to the uscle( Clean the ra us of andible by stri!!ing off the asseter uscle fro it( +ive an obli%ue cut fro the centre of andibular notch to the lo"er end of anterior border of ra us of andible( )urn this !art of the bone including the insertion of te !oralis uscle u!"ards( Stri! the uscle fro the s'ull and identify dee! te !oral nerves and vessels( #a'e one cut through the nec' of the andible( +ive another cut through the ra us at a distance of H c fro the nec'( .

*asti&atio" /uscle " 3 /asseter 8uadrilateral.nsertion GaH -uper4icial la2er@ into lo1er part o4 lateral sur4ace o4 ra5us o4 5andi6le G6H Middle la2er@ into 5iddle part o4 ra5us GcH Deep la2er@ into upper part o4 ra5us and coronoid process o4 the 5andi6le Nerve supply Masseteric ner7e. has three la2ers GJig3 ">33H (rigin GaH $uperficial layer GlargestH@ 4ro5 anterior =E3 o4 lo1er 6order o4 L2go5atic arch and adFoining L2go5atic process o4 5a:illa G6H /iddle layer: 4ro5 anterior =E3 o4 deep sur4ace and posterior "E3 o4 lo1er 6order o4 L2go5atic arch GcH 9eep layer: 4ro5 deep sur4ace o4 L2go5atic arch GaH 9e5poral 4ossa. co7ers lateral sur4ace o4 ra5us o4 5andi6le. / a 6ranch o4 anterior di7ision o4 5andi6ular ner7e Actions Ele7ates 5andi6le to close the 5outh to 6ite =3 2emporalis Jan%shaped. e:cluding L2go5atic 6one G6H 9e5poral 4ascia Fibres GaH -uper4icial 4i6res pass do1n1ards and 6ac!1ards at ?' degrees G6H Middle and deep 4i6res pass 7erticall2 do1n1ards GcH 9hree la2ers are separated posteroin4eriorl2 62 an arter2 and a ner7e . 4ills the te5poral 4ossa GJig3 ">3?H Con7erge and pass through gap deep to L2go5atic arch GaH Margins and deep sur4ace o4 coronoid process3 G6H Anterior 6order o4 ra5us o4 5andi6le 91o deep te5poral 6ranches 4ro5 anterior di7ision o4 5andi6ular ner7e GaH Ele7ates 5andi6le G6H <osterior 4i6res retract the protruded 5andi6le GcH Helps in side to side grinding 5o7e5ent GaH Depress 5andi6le to open 5outh. has upper and lo1er heads GJig3 ">3'H GaH Tpper head Gs5allH@ 4ro5 in4rate5poral sur4ace and crest o4 greater 1ing o4 sphenoid 6one G6H Lo1er head GlargerH@ 4ro5 lateral sur4ace o4 lateral pter2goid plate Ji6res run 6ac!1ards and laterall2 and con7erge 4or insertion GaH <ter2goid 4o7ea on the anterior sur4ace o4 nec! o4 5andi6le G6H Anterior 5argin o4 articular disc and capsule o4 te5poro5andi6ular Foint3 /nsertion is posterolateral and at a slightl2 higher le7el than origin A 6ranch 4ro5 anterior di7ision o4 5andi6ular ner7e ) ?3 /edial pterygoid cuadrilateral. 6ranch o4 the 5ain trun! o4 5andi6ular ner7e . 6ac!1ards and laterall2 Roughened area on the 5edial sur4ace o4 angle and adFoining ra5us o4 5andi6le.9= Mus&#es o. has a s5all super4icial and a large deep head GJig3 ">3'H GaH $uperficial head Gs5all slipH@ 4ro5 tu6erosit2 o4 5a:illa and adFoining 6one G6H Deep head G8uite largeH@ 4ro5 5edial sur4ace o4 lateral pter2goid plate and adFoining process o4 palatine 6one Ji6res run do1n1ards.i%ora# a"$ I". conical.rate*%ora# Re!io"s 9. 6elo1 and 6ehind the 5andi6ular 4ora5en and 52loh2oid groo7e er7e to 5edial pter2goid.0 Ta2#e 9:. 1ith suprah2oid 5uscle G6H Lateral and 5edial pter2goid protrude 5andi6le GcH Le4t lateral pter2goid and right 5edial pter2goid turn the chin to le4t side as part o4 grinding 5o7e5ents GaH Ele7ates 5andi6le G6H Helps protrude 5andi6le GcH Right 5edial pter2goid 1ith le4t lateral pter2goid turn the chin to le4t side 33 5ateral pterygoid -hort.

-uper4icial te5poral line pro7ides attach5ent to te5poral 4ascia 9e5poralis arising 4ro5 te5poral 4ossa Te6poral Fascia /nsertion o4 5asseter on ra5us and coronoid process o4 5andi6le Fig. a branch fro the su!erficial te !oral artery and the 7ygo atico-te !oral nerve( )he su!erficial surface of the te !oral fascia receives an e&!ansion fro the e!icranial a!oneurosis( )his surface gives origin to the auricularis anterior and su!erior. and the te !oral branches of the facial nerve( )he dee! surface of the te !oral fascia gives origin to so e fibres of the te !oralis uscle( )he fascia is e&tre ely dense( In so e s!ecies Be(g(. %3. the auriculote !oral nerve. the te !oral fascia is re!laced by bone( 7elations of 9ateral Ptery*oid )he lateral !terygoid ay be regarded as the 'ey uscle of this region because its relations !rovide a fair idea about the layout of structures in the infrate !oral fossa( )he relations are as follo"s8 <u. $>33@ (rigin and insertion of the masseter muscle.+: 2he lateral and medial pterygoid muscles. and is related to the su!erficial te !oral vessels. the fascia is single layered and is attached to the su!erior te !oral line( Inferiorly.6: (rigin and insertion /nsertion o4 te5poralis on coronoid process and anterior 6order o4 ra5us of the temporalis muscle.erfi*ial7 BaC #asseterD BbC ra us of the andibleD BcC tendon of the te !oralisD and BdC the a&illary artery( Upper head%%%%%%% O3 and lo1er head o4 lateral pter2goid <ter2go5a:illar2 4issure -uper4icial head o4 5edial pter2goid Fi2rous &a%su#e P I I /nsertion o4 lateral pter2goid into pter2goid 467ea Articular disc nead o4 5edial Fig. tortoiseC.Origin o4 5asseter 4ro5 L2go5atic arch Fig. )he te !oral fascia is a thic' a!oneurotic sheet that roofs over the te !oral fossa and covers the te !oralis uscle( Su!eriorly. . %3. it s!lits into t"o layers "hich are attached to the inner and outer li!s of the u!!er border of the 7ygo atic arch B1ig( 1G(FC( )he s all ga! bet"een the t"o layers contains fat.

evise its course and branches fro Cha!ter 6( . and the s!henoniandibular liga ent( 9eep Felations 2&ternal carotid artery divides into its t"o ter inal branches.art runs hori7ontally for"ards. the a&illary artery.cco !anying these branches are the veins and !terygoid venous !le&us and the su!erficial content of infrate !oral fossa( .7 BaC #andibular nerveD BbC iddle eningeal arteryD BcC s!henoniandibular liga entD and BdC dee! head of the edial !terygoid( <tru*tures emerging at the u. % /n4erior al7eolar ner7e and arter2 Lingual ner7e % Buccal ner7e%%%%%%% ner7e and arter2 Fi*+ #$+ : $ome relations of the lateral pterygoid muscle. belo" the auriculo- Deep te5poral ner7es and arteries M2loh2oid Masseteric ner7e and arter2 <ter2go5a:illar2 4issure Lateral pter2goid Middle 5eningeal arter2 %%%%% Ma:illar2 arter2 %%%%% -phenoniandi6ular liga5ent ..Dee. bet9een the t9o hea+s7 BaC )he a&illary artery enters the ga! and BbC the buccal branch of the andibular nerve co es out through the ga!( )he !terygoid !le&us of veins surrounds the lateral !terygoid( 7elations of . .e ove these veins( )ry to see its co unication "ith the cavernous sinus and facial vein( Course a"$ Re#atio"s )he relations are8 BaC )ensor veli !alatiniD BbC su!erior constrictor of !haryn&D BcC styloglossus and BeC stylo!haryngeus attached to the styloid !rocess B1ig( 9(HC( 1or descri!tive !ur!oses the a&illary artery is divided into three !arts Bby the lateral !terygoidC B1ig( 1G(6C( 1( )he first 2man+ibular3 .edial Ptery*oid MA>ILLAR ARTER Intro+u*tion7 )his is the larger ter inal branch of the e&ternal carotid artery.er bor+er7 BaC Dee! te !oral nerves8 BbC asseteric nerve( <tru*tures emerging at the lo9er bor+er7 BaC @ingual nerveD BbC inferior alveolar nerveD BcC the iddle eningeal artery !asses u!"ards dee! to it B1ig( 1G(6C( <tru*tures . first bet"een the nec' of the andible and the s!henoniandibular liga ent. a&illary and su!erficial te !oral on the antero edial surface of the !arotid gland( )he a&illary artery. and su!!lies8 BaC )he e&ternal and iddle ears.assing through the ga. and the auditory tubeD BbC the dura aterD BcC the u!!er and lo"er 3a"sD BdC the uscles of the te !oral and infrate !oral regionsD BeC the nose and !aranasal air sinusesD BfC the !alate and BgC the root of the !haryn& B1ig( 1G(AC( DISSECTIOIE $uperficial Felations )he u!!er !art of the uscle is se!arated fro the lateral !terygoid uscle by8 BaC )he lateral !terygoid !lateD BbC the lingual nerveD BcC the inferior alveolar nerve B1igs 1G(J. 1G(6C( @o"er do"n the uscle is se!arated fro the ra us of the andible by the sa e nerves. given off behind the nec' of the andible B1ig( 1G(6C( It has a "ide territory of distribution. a!!ears in this region( Identify so e of its branches( #ost i !ortant to be identified is the iddle eningeal artery( .

alatine3 .i&ia# te*%ora# 9st %art o.eolar artery runs do"n"ards and for"ards andible edial to the ra us of the acoustic eatus. %ter6!oi$ &a"a# A"terior t6*%a"i& Dee% auri&u#ar Su%er. %3.Dee% te*%ora# Phar6"!ea# arter6 Arter6 o.a)illary -rtery 1()he +ee.art runs u!"ards and for"ards su!erficial to the lo"er head of the lateral !terygoid( F()he thir+ 2.!art fro the eninges it su!!lies structures in the infra-te !oral fossa( .art !asses bet"een the t"o heads of the lateral !terygoid and through the !terygo a&illary fissure.ani* branch su!!lies the iddle ear including the edial surface of the ty !anic e brane( :()he mi++le meningeal artery has been described in Cha!ter 6 and )able 1G(F( H()he accessory meningeal artery enters the cranial cavity through the fora en ovale( . *a8i##ar6 Ireater %a#ati"e Bra"&hes to *a8i##ar6 air si"us a"$ u%%er teeth Mi$$#e su%erior a#5eo#ar ("$ %art o. the ty !anic e brane and the te !oro andibular 3oint B1ig( 1G(AC( F()he anterior tym. te !oral nerve. *a8i##ar6 arter6 Masseteri& arter6 o" #atera# %ter6!oi$ *us&#e Mi$$#e *e"i"!ea# A&&essor6 *e"i"!ea# I".terygoi+3 . to enter the !terygo!alatine fossa "here it lies in front of the !terygo!alatine ganglion( Branches of First Part of the .raor2ita# V K S%he"o%a#ati"e +r$ %art o. *a8i##ar6 arter6 /00000000000 arter) Posterior su%erior a#5eo#ar Buccal Pter6!oi$ arter6 E8ter"a# &aroti$ arter6 Bra"&h to *6#oh6oi$ Fig. and then along the lo"er border of the lateral !terygoid( 1()he se*on+ 2.8: &ranches of ma illary artery.erior a#5eo#ar I". auri*ular artery su!!lies the e&ternal J()he inferior al.terygo.

tem.terygoi+ mus*lesan+ to themasseter)6bu**albran*hsu.a)illary -rtery )hese are ainly uscular( )he +ee.a)illary -rtery 1( )he ..eolar artery arises 3ust before the a&illary artery enters the !terygo a&illary fissure( It descends on the !osterior .oral branches Banterior and !osteriorC ascend on the lateral as!ect of the s'ull dee! to the te !oralis uscle( Branches are also given to the .ties the buccinator uscle( Branches of Third Part of the .osterior su.erior al.to reach the andibular fora en(C Passing through this fora en the artery enters the andibular canal B"ithin the body of the andibleC in "hich it runs do"n"ards and then for"ards( Before entering the andibular canal the artery gives off a lingual branch to the tongueD and a ylohyoid branch that descends in the ylohyoid groove Bon the edial as!ect of the andibleC and runs for"ards above the ylohyoid uscle( Eithin the andibular canal the artery gives branches to the andible and to the roots of the each tooth attached to the bone( It also gives off a ental branch that !asses through the ental fora en to su!!ly the chin( Branches of Second Part of the .

(= Bra"&hes o.eolar branches that enter a!ertures in the a&illa to reach the incisor and canine teeth attached to the bone( . 5iddle ear and tensor t25pani Main distri6ution is e:tracranial to pter2goids Lo1er teeth and 52loh2oid 5uscle 9e5poralis Lateral and 5edial pter2goids Masseter Buccinator Jora5en in the 4loor Gcartilage or 6oneH o4 e:ternal acoustic 5eatus <etrot25panic 4issure Jora5en spinosu5 Jora5en o7ale Mandi6ular 4ora5en "3<osterior superior al7eolar =3/n4raor6ital 330reater palatine ?3<har2ngeal '3Arter2 o4 pter2goid canal A3-phenopalatine Gter5inal partH Al7eolar canals in 6od2 o4 5a:illa /n4erior or6ital 4issure 0reater palatine canal <har2ngeal Gpalato7aginalH canal <ter2goid canal -phenopalatine 4ora5en Upper 5olar and pre5olar teeth and gu5sU 5a:illar2 sinus Lo1er or6ital 5usclesU lacri5al sacU 5a:illar2 sinusU upper incisor and canine teeth -o4t palateU tonsilU palatine glands and 5ucosaU upper gu5s Roo4 o4 nose and phar2n:U auditor2 tu6eU sphenoidal sinus Auditor2 tu6eU upper phar2n:U and 5iddle ear Lateral and 5edial 1alls o4 nose and 7arious air sinuses surface of the a&illa and gives branches that enter canals in the bone to su!!ly the olar and !re olar teeth. *a8i##ar6 arter6 &ranche s A3 (f first part GJig3 ">3$H "3Deep auricular =3Anterior t25panic 33Middle 5eningeal ?3Accessor2 5eningeal '3/n4erior al7eolar B3 (f second part "3Deep te5poral =3<ter2goid 33Masseteric ?3Buccal C3 O4 third part "F*U. first in the infraorbital groove and then in the infraorbital canal to e erge on the face through the infraorbital fora en( It gives off so e orbital branches to structures in the orbit. the nose and the u!!er li!( )he re aining branches of the third !art arise "ithin the !terygo!alatine fossa B1ig( 1G(AC( :( )he greater . and outer sur4ace o4 t25panic 5e56rane /nner sur4ace o4 t25panic 5e56rane -upplies 5ore o4 6one and less o4 5eningesU also 'th and $th ner7es.alatine artery runs do"n"ards in the greater !alatine canal to e erge on the !osterolateral !art of the hard !alate through the greater !alatine fora en( It then runs for"ards near the lateral argin of the !alate to reach the incisive canal Bnear the idlineC through "hich so e ter inal branches enter the nasal cavity( Branches of the artery su!!ly the !alate and gu s( Ehile still "ithin the greater !alatine canal it gives off the lesser . ">3=H Foramina transmitting 9istributio n -!in o4 e:ternal acoustic 5eatus. and the a&illary air sinus( F( )he infraorbital artery also arises 3ust before the a&illary artery enters the !terygo a&illary fissure( It enters the orbit through the inferior orbital fissure( It then runs for"ards in relation to the floor of the orbit.alatine arteries that e erge on the !alate through . the infraorbital artery gives branches to the lacri al sac.Ta2#e 9:. and the anterior su!erior al.fter e erging on the face.

terygoi+ *anal runs bac'"ards in the canal of the sa e na e and hel!s to su!!ly the !haryn&.haryngeal bran*h runs bac'"ards through a canal related to the inferior as!ect of the body of the s!henoid bone B!haryngeal or !alatovaginal canalC( It su!!lies !art of the naso!haryn&.osterolateral nasal branches to the lateral "all of the nose and to the !aranasal sinusesD and . the auditory tube and the ty !anic cavity( :()he S!heno!alatine artery !asses edially through the S!heno!alatine fora en to enter the cavity of the nose( It gives off .osterior se!taR branches to the nasal se!tu ( Pter6!oi$ P#e8us o. and run bac'"ards into the soft !alate and tonsil( 1()he .the lesser !alatine fora ina. the auditory tube and the s!henoidal air sinus( F()he artery of the . 1ei"s It lies around and "ithin the lateral !terygoid uscle( )he tributaries of the !le&us corres!ond to the branches of the a&illary artery( )he !le&us is drained by the a&illary vein "hich begins at the !osterior end of the !le&us and unites "ith the su!erficial te !oral vein to for the retro andibular vein( )hus the a&illary vein acco !anies only the first !art of the a&illary artery( .

c u l a . to the articular tubercle.erior a#5eo#ar "er5e a"$ arter6 t i andible fro the c( @ocate the articular cartilages head of the andible and Fi*+ #$+#$: $uperficial relations of fhe sphenomandibular ligament seen after removal of the lateral pterygoid. *a"$i2#e I". and belo" to the * !osterolateral as!ect of the nec' of the andible( a" F()he s. %# at e lateral or tem.issure 5 ral !terygoid uscle close to its lodge the head of Out#i"e o.sule is attached abo. the circu ference of the andibular fossa and the s%ua oty !anic fissureD d and belo9 to the nec' of the andible( )he ca!sule i is loose above the intra-articular disc.e to the r articular tubercle.rticular e inenceD temporomandi Fora*e" o5a#e 1()he bular Goint. and BbC anterior !art of the andibular fossa B1ig( Ma"$i2u#ar "er5e irFMO Mi$$#e *e"i"!ea# arter6 1G(4C( )he inferior articular surface is for ed by the head of the andible( )he articular surfaces are covered "ith fibrocartilage( )he 3oint cavity is divided into u!!er and lo"er !arts by an intra-articular disc( Mandi6ular 4ossa /ntra% Articular tu6ercle S?ua*ot6*%a"i& ./ 1( )he fibrous *a. and tight s belo" it( )he synovial e brane lines the fibrous c ca!sule and the nec' of the andible B1ig( 1G(9C( Ji6rous capsule )he !le&us co unicates8 BaC Eith the inferior o!hthal ic vein through the inferior orbital fissureD BbC "ith the cavernous sinus through the e issary veinsD and BcC "ith the facial vein through the dee! facial vein( Latera# #i!a*e"t T 6 * %a "i & 9EM<OROMA D/BULAR CO/ 9 )his is a synovial 3oint of the condylar variety( Fi*+ #$+": Fibrous capsule and lateral ligament of the temporomandibular Goint. 1G(11CD and BdC the Articular surfaces of a )he u!!er articular surface is for ed by the follo"ing the left r !arts of the te !oral bone8 BaC . that lies on a dee! !lane a"ay fro 2# the fibrous ca!sule( It is attached su!eriorly to the s!ine of the s!henoid.henoman+ibular ligament is an accessory $i liga ent. and inferiorly to the e lingula of the andibular fora en( It is a re nant of the dorsal !art of #ec'el*s cartilage( )he liga ent is related laterally to8 BaC )he lateral !terygoidD BbC the auriculote !oral nerveD BcC the Articular -ur4aces a&illary artery B1igs 1G(1G.oroman+ibular ligament He reinforces and strengthens the lateral !art of a$ the ca!sular liga ent( Its fibres are directed do"n"ards and bac'"ards( It is attached above o.

s%he"oi$ Fora*e" spinosu5 S Su%er.the \ssa( )a'e out the articular disc as y its sha!e and its role in increasing YY YY( Liga5ents S%i"e o.i&ia# te*%ora# arter6 i Auri&u#oCte*%ora# "er5e S%he"oC*a"$i2u#ar EE #i!a*e"t '+%333V +%+%+ Li"!ua# "er5e 3a ents are the fibrous ca!suleD the lateral ntD the s!heno andibular liga entD and the andibular liga ent( Ma8i##ar6 arter6 .

erior a#5eo#ar "er5e a"$ arter6 Fi*+ %3. and belo" to the angle and !osterior border of the ra us of the andible( Articular Disc )he arti*ular +is* is an oval fibrous !late that divides the 3oint into an u!!er and a lo"er co !art ents( )he u!!er co !art ent !er its gli+ing ove ents. chorda ty !ani nerveD and BcC the "all of the !haryn&( =ear its lo"er end. s%he"oi$CCCCCCC i. anterior thic' band.uriculote !oral nerve and Mo7e5ents )he ove ents at the 3oint can be divided into those bet"een the u!!er articular surface and the articular asseteric nerve( a&illary .$ $@ (bliQue coronal section through the infratemporal fossa showing relations of the sphenomandibular ligament.) ) S%he"o*a"$i2u#ar #i!a*e"tCCCCCCC MC#s Me$ia# %ter6!oi$ *us&#e B M6#oh6oi$ "er5e a"$ arter6CCCCCCCC MCB1. Chor$a t6*%a"i DCCCCC J Phar6"8CCCCCC C. rotatory as "ell as gli+ing ove ents( )he disc has a concavoconve& su!erior surface. "ith the u!!er end of the s!henoandibular liga ent attached to itD BcC the auriculote !oral and chorda ty !ani nervesD BdC iddle eningeal artery B1ig( 1G(11C( 6nterior7 BaC @ateral !terygoidD BbC asseteric nerve and vessels( Posterior 2a"$ I"ter*e$iate Wo"e A"terior 2a"$ F Bi#a*i"ar re!io" T6*%a"i& %#ate Hea$ o. and BdC iddle eningeal vessels( Inferior7 #a&illary artery and vein( Blood -uppl2 Branches fro su!erficial te !oral and arteries( /eins follo" the arteries( er7e -uppl2 . and a concave inferior surface( )he !eri!hery of the disc is attached to the fibrous ca!sule( )he disc is co !osed of an anterior e&tension. 9(:C( <u. /osterior7 BaC )he !arotid gland se!arates the 3oint fro the e&ternal auditory eatusD BbC su!erficial te !oral vesselsD and BcC auriculote !oral nerve B1igs 9(1.E C Te*%ora# 2o"e HHC Te*%oro*a"$i2u#arNoi"t %Auri&u#ote*%ora# "er5e %Ma8i##ar6 arter6 %I".rate*%ora# Re! Mi$$#e &ra"ia# . it is !ierced by the ylohyoid nerve and vessels( H( )he styloman+ibular ligament is another accessory liga ent of the 3oint( It re!resents a thic'ened !art of the dee! cervical fascia "hich se!arates the !arotid and sub andibular salivary glands( It is attached above to the lateral surface of the styloid !rocess. inter ediate 7one.ossa B Mi$$#e *e"i"!ea# arter6 S%i"e o.s*%ora# a"$ I". *a"$i2#e Latera# %ter6!oi$ Fi*+ #$+#&: $ubdivision and attachment of the articular disc of the temporomandibular Goint. and the lo"er. !osterior thic' band and bila ellar region B1ig( 1G(1FC( )he disc re!resents the degenerated !ri itive insertion of lateral !terygoid( Relations o4 9e5poro5andi6ular Coint 0ateral7 BaC S'in and fasciaeD BbC !arotid glandD and BcC te !oral branches of the facial nerve( 1e+ial7 BaC )he ty !anic !late se!arates the 3oint fro the internal carotid arteryD BbC s!ine of the s!henoid.erior7 BaC #iddle cranial fossa.

slightly lo"er and edial to its insertion( During contraction. i(e( enisco andibular co !art ent( #ost ove ents occur si ultaneously at the right and left te !oroandibular 3oints( In for"ard ove ent or !rotraction of the andible.ation is brought about by the asseter.uriculote !oral nerve is ar'ed by a line dra"n first bac'"ards fro the !osterior !art of the andibular notch Bsite of andibular nerveC across the nec' of the andible.erations on the 3oint.ression is brought about ainly by the lateral . or during a convulsion. the head co es to lie under the articular tubercle( )hese ove ents are reversed in closing the outh or elevation of the andible( Che"ing ove ents involve side to side ove ents of the andible( In these ove ents.90( Hea$ a"$ Ne&- disc. the head of BsayC right side glides for"ards along "ith the disc as in !rotraction. i(e( eniscote !oral co !art ent and those bet"een the disc and the head of the andible. it !ulls the articular disc for"ards( So ove ent occurs in both the co !art ents( It is also done !assively by gravity( Fle. the te !oralis. the head of the andible of one or both sides ay sli! anteriorly into the infrate !oral fossa. li'e overclosure or alocclusion( )his gives rise to clic'ing and !ain during ove ents of the 3a"( :(In o.oral Ier.lternate ove ents of this 'ind on the t"o sides result in side to side ove ents of the 3a"( CLINICAL ANATOM 1(Dislo*ation of man+ible) During e&cessive o!ening of the outh. as in !rotraction( . the articular disc glides for"ards over the u!!er articular surface. the head of the andible oves on the undersurface of the disc li'e a hinge( In "ide o!ening of the outh.e #andibular nerve is ar'ed by a short vertical line in the !osterior !art of the andibular notch 3ust in front of the head of the andible( #) 6uri*ulotem. but the head of the left side erely rotates on a vertical a&is( . geniohyoid and ylohyoid uscles hel! "hen the outh is o!ened "ide or against resistance8 )he origin of only lateral !terygoid is anterior.t the end of this ove ent.eduction is done by de!ressing the 3a" "ith the thu bs !laced on the last olar teeth. the head of the andible oving "ith it( )he reversal of this ove ent is called retraction( In slight o!ening of the outh or de!ression of the andible. and at the sa e ti e elevating the chin( F(Derangement of the arti*ular +is* ay result fro any in3ury.e .ements. the digastric and geniohyoid uscles( 0ateral or si+e to si+e mo. it rotates the head andible and o!ens the outh( During "ide o!ening.s a result of this the chin oves for"ards and to left side Bthe side on "hich no gliding has occurredC( .!terygoid( )he digastric. this hinge-li'e ove ent is follo"ed by gliding of the disc and the head of the andible. e(g( turning the chin to left side !roduced by left lateral !terygoid and right edial !terygoid and vice versa( Identify iddle eningeal artery arising fro the a&illary artery and trace it till the fora en s!inosu ( =ote the t"o roots of auriculote !oral nerve surrounding the artery( )race the origin of the auriculote !oral nerve fro andibular nerve B1ig( 1G(1GC( Dissect all the other branches of the nerve( Identify the chorda ty !ani nerve 3oining the lingual branch of andibular nerve( @ift the trun' of andibular nerve laterally and locate the otic ganglion( )race all its connections( . the seventh nerve should be !reserved "ith care( AAAAAAAAA MANDIBULAR NER1EAAAAAAAAAAAA )his is the largest of the three divisions of the trige inal nerve( It has both sensory and otor fibres( It is the nerve of the first branchial arch and su!!lies all structures derived fro the andibular or first branchial arch( $urface /arking Mus&#es Pro$u&i"! Mo5e*e"ts K De. and then u!"ards across the !reauricular !oint B1ig( 1G(1:C( DISSECTION Betra*tion is !roduced by the !osterior fibres of the te !oralis( It ay be resisted by the iddle and dee! fibres of the asseter. as a result of "hich there is inability to close the outh( . and the edial !terygoid uscles of both sides( )hese are antigravity uscles( /rotrusion is done by the lateral and !terygoids( edial ") 1an+ibular Ier.

runs do"n"ards and for"ards. 3) 0ingual Ier.fter a short course. and su!!lies the s'in and ucous e brane related to the buccinator . the ain trun' divides into a s all =erve to edial !terygoid arises close to the otic ganglion and su!!lies the edial !terygoid fro its dee! surface( )his nerve gives a otor root to the otic ganglion "hich does not relay and su!!lies the tensor veli !alatini. and the tensor ty !ani uscles B1ig( 1G(1JC( A f &uccal Nerve Buccal nerve is the only sensory branch of the anterior division of the andibular nerve( It !asses bet"een the t"o heads of the lateral !terygoid.#andibular nerve ner7e /n4raor6ital ./+= $urface marking of some nerves on face.e @ingual nerve is ar'ed by a curved line running do"n"ards and for"ards by 3oining the follo"ing !oints B1ig( 1G(1:C( BaC)he first !oint on the !osterior !art of the andibular notch. the buccal nerveD and BbC otor branches.eolar Inferior alveolar is little belo" and !arallel to the lingual nerve( anterior trun' and a large !osterior trun' B1ig( 1G(1HC( Bra"&hes ) 1ro the ain trun'8 BaC #eningeal branchD and BbC nerve to the edial !terygoid( 1ro the anterior trun'8 BaC . dee! to the lateral !terygoid( . and leaves the cranial cavity through the fora en ovale B1ig( 6(1HC( )he otor root lies dee! to the trige inal ganglion and to the sensory root( It also !asses through the fora en ovale to 3oin the sensory root 3ust belo" the fora en thus for ing the ain trun'( )he ain trun' lies in the infrate !oral fossa.elations #andibular nerve begins in the iddle cranial fossa through a large sensory root and a s all otor root( )he sensory root arises fro the lateral !art of the trige inal ganglion. in line "ith the andibular nerve( BbC)he second !oint a little belo" and behind the last lo"er olar tooth( BcC)he third !oint o!!osite the first lo"er olar tooth( )he concavity in the course of the nerve is ore ar'ed bet"een !oints b and c and is directed u!"ards( H( Inferior 6l. on the tensor veli !alatini.uriculote !oralD BbC lingualD and BcC inferior alveolar nerves( A/eningeal &ranch or Nervus $pinosus #eningeal branch enters the s'ull through the fora en s!inosu "ith the iddle eningeal artery and su!!lies the dura ater of the iddle cranial fossa(C Nerve to /edial Pterygoid Course and .uriculo-te !oral Ath =erve Lingual /n4erior al7eolar Mental Fi*+ 9:. sensory branch. the asseteric and dee! te !oral nerves and the nerve to the lateral !terygoid( 1ro the !osterior trun'8 BaC .

%6: 9istribution of mandibular nerve "')#."'? Head and ec! Lesser petrosal ner7e Otic ganglion Auriculote5poral O /T ner7e Chorda t25pani Lingual ner7e /n4erior al7eolar Mandi6ular ner7e Masseteric Lateral pter2goid Buccal Mental 6ranch -t2loglossus 0enioglossus -u65andi6ular ganglion on h2oglossus M2loh2oid V// ner7e Fig. . %3.

E:ternal carotid arter2 Ma:illar2 arter2 -25pathetic ple:us along 5iddle 5eningeal arter2 Otic ganglion -25pathetic root Auriculote5poral ner7e Base o4 5andi6le . Motor root er7e to tensor 7eli palatini <ostganglionic 4i6res -ensor2 root er7e to 5edial pter2goid %3.%+: Fight otic ganglion seen from medial side.Lesser petrosal ner7e Gsecreto5otor rootH 925panic ple:us 925panic 6ranch 0lossophar2ngeal ner7e er7e to tensor t25pani Mandi6ular ner7e Medial pter2goid Fig.

!asses laterally through the andibular notch in co !any "ith the asseteric vessels. the fibres of the chorda ty !ani Bbranch of facial nerveC "hich is secreto otor to the sub andibular and sublingual salivary glands and gustatory to the anterior t"o-thirds of the tongue. and unite to for a single trun' B1igs 1G(1G. it turns u!"ards and ascends on the te !le behind the su!erficial te !oral vessels( )he auri*ular . encircle the iddle eningeal artery. and enters the dee! surface of the asseter( It also su!!lies the te !oro andibular 3oint B1ig( 1G(6C( 9eep 2emporal Nerves e&ternal acoustic eatus and the ty !anic e brane( B=ote that the lo"er !arts of these regions are su!!lied by the great auricular nerve and the auricular branch of the vagus nerveC( )he tem. Auriculotemporal Nerve @ingual nerve is one of the t"o ter inal branches of the !osterior division of the andibular nerve B1ig( 1G(1:C( It is sensory to the anterior t"o-thirds of the tongue and to the floor of the outh( <o"ever. #asseteric nerve e erges at the u!!er border of the lateral !terygoid 3ust in front of the te !oro andibular 3oint.uriculote !oral nerve arises by t"o roots "hich run bac'"ards.art su!!lies the s'in of the te !le B1ig( F(JC( In a++ition. 1G(11C( )he nerve continues bac'"ards bet"een the nec' of the andible and the s!heno andibular liga ent. are also distributed through the lingual nerve B1ig( 1G(1HC( . the . B1ig( 1G(6C( It also su!!lies the labial as!ect of gu s of olar and !re olar teeth(C /asseteric Nerve. the auriculote !oral nerve also su!!lies the !arotid gland Bsecreto otor and also sensoryC and the te !oro andibular 3oint B)able 1(:C( 5ingual Nerve Dee! te !oral nerves are t"o dee! te !oral nerves.art of the nerve su!!lies the s'in of the tragusD and the u!!er !arts of the !inna. above the a&illary artery( Behind the nec' of the andible.oral .iral and /n4rate5poral Regions "'' 4l. anterior and !osterior( )hey !ass bet"een the s'ull and the lateral !terygoid. and enter the dee! surface of the te !oralis( )he anterior nerve is often a branch of the buccal nerve( )he !osterior nerve ay arise in co on "ith the asseteric nerve( " er7e to 5ateral Pterygoid =erve to lateral !terygoid enters the dee! surface of the uscle( It ay be an inde!endent branch or ay arise in co on "ith the buccal nerve B1ig( 1G(1H.

olar alveolar nerve gives branches that su!!ly the lo"er and tooth teeth and gu s.e e erges at the then bet"ee ental fora en and su!!lies the s'in of the chin.Cou n the oid( <ere it around "inds round the sub andibular rse ra us duct and divides into its ter inal branches. on o!ening s'ull it s B1ig( the outh by the action of the nor al lateral is 1(FAC( !terygoid of the o!!osite side( )he activity of the 3oined It soon !terygoid uscles is tested by as'ing the !atient to by the leaves ove the chin fro side to side( chorda the F(Beferre+ . 1inally. runs in the !alatini ble. the it lies nerve on the runs surface do"n" of the ards geniogl and ossus for"ar dee! to ds the bet"ee ylohy .bout and the herKhis teeth and then feeling for the F c yloh contracting asseter and te !oralis uscles on belo" yoid the t"o sides( If one asseter is !aralysed. over the distribution of the nerve( runs auriculote !oral 2 ergi over ng at the the hyoglo lo"er ssus border dee! to of the the lateral ylohy !teryg oid( oid. and su!!lies the ylohyoid uscle lateral to theand the anterior belly of the digastric B1ig( 1G(11C( BbC !teryg third Ehile running in the andibular canal the inferior oid.division( It arises 3ust before the inferior alveolar nerve enters the tensor the veli andi andibular fora en( It !ierces the s!heno andibular liga ent "ith the ylohyoid artery. BcC )he mental ner. an+ of the relatio andib . !ain radiates to the ear and to the ni and te !oral fossa. bet"ee n theand the s'in and ucous e brane of the lo"er li! n the origins B1ig( 1G(1HC( Its incisive branch su!!lies the labial lateral of theas!ect of gu s of canine and incisor teeth( and su!eri CLINICAL ANATOM edial or !teryg constri 1()he otor !art of the andibular nerve is oids( ctor tested clinically by as'ing the !atient to clench . the the uscle 3a" deviates to the !aralysed side. and the edial ylohyoid groove.ain) In cases "ith cancer of the ty !a gu tongue.nferior Alveolar Nerve ns) It le and Inferior alveolar nerve is the larger ter inal branch begins the of the !osterior division of the andibular nerve B1ig( 1 c edial 1G(1:C( It runs vertically do"n"ards lateral to the belo" !teryg edial !terygoid and to the s!heno andibular the oid( liga ent( It enters the andibular fora en and s'ull( It =e&t it runs in the andibular canal( It is acco !anied by runs lies in the inferior alveolar artery B1ig( 1(FAC( first direct bet"ee contact Bran*hes7 BaC )he mylohyoi+ bran*h contains all n the "ith the otor fibres of the !osterior.

edial to the third olar tooth( In e&traction of al!laced *"isdo * tooth. but functionally it is a !art of the glosso!haryngeal nerve JB1igs 1G(1H. it is inti ately related to the andibular nerve. care ust be ta'en not to in3ure the lingual nerve B1ig( 1(FAC( OTIC IANILION Chorda t25pani SiIe and Situation It is F to : in si7e. and is situated in the infrate !oral fossa. and this is no" the o!eration of choice "hen !ain is confined to the distribution of the a&illary and andibular nerves( During division.Motor root -ensor2 root 0enlculate ganglion o4 4acial ner7e 0reater petrosal ner7e -25pathetic ner7e er7e o4 pter2goid canal OO+ Deep petrosal ner7e /nternal carotid ple:us Co55unication 6et1een chorda t25pani and ner7e o4 pter2goid canal Otic ganglion er7es to parotid gland Co55unication 6et1een otic ganglion and chorda t25pani Lesser petrosal ner7e Middle 5eningeal arter2 Lingual ner7e 925panic ple:us Jacial ner7e Auriculo%te5poral ner7e 0lossophar2ngeal ner7e + #$+# : !onnections of otic ganglion "schematic#. 1G(1JC( . the o!hthal ic fibres that lie in the su!ero edial !art of the root are s!ared. 3ust belo" the fora en ovale( It Introduction Bit is a !eri!heral !arasy !athetic ganglion "hich > B)C relays secreto otor fibres to the !arotid gland( )o!ogra!hically. to !reserve the corneaR refle& thus avoiding da age to the cornea( F(@ingual nerve lies in contact "ith andible. the sensory root of the nerve ay be divided behind the ganglion. Jacial canal nerve( So eti es the lingual nerve is divided to relieve intractable !ain of this 'ind( )his ay be done "here the nerve lies in contact "ith the andible belo" and behind the last olar tooth. covered only by ucous e brane( 1(1an+ibular neuralgia) )rige inal neuralgia of the andibular division is often difficult to treat( In such cases.

the ninth nerve.arasym.onnections and Branches )he motor or . and lateral to the tensor veli !alatini( It surrounds the origin of the nerve to the edial !terygoid B1ig( 1G(1JC( .lies edial to the andibular nerve. its ty !anic branch.atheti* root is for ed by the lesser !etrosal nerve( )he !reganglionic fibres are derived fro the inferior salivary nucleus . the ty !anic !le&us -the lesser !etrosal nerve to reach the ganglion( )he !ostganglionic or secreto otor fibres !ass through the auriculote !oral nerve to the !arotid gland B)able 1(:C( )he sym.atheti* root is derived fro the !le&us on the iddle eningeal artery( It contains !ostganglionic fibres arising in the su!erior cervical ganglion( )he fibres !ass through the ganglion "ithout relay and reach the !arotid gland via the auriculote !oral nerve( )hey are vaso otor in function( )he sensory root co es fro the auriculote !oral nerve and is sensory to the !arotid gland( 0ther fibres !assing through the ganglion are as follo"s( BaC)he nerve to edial !terygoid gives a otor root to the ganglion "hich !asses through it "ithout relay and su!!lies edially !laced tensor veli !alatini and laterally !laced tensor ty !ani uscles( BbC)he chorda ty !ani nerve is connected to the otic ganglion and also to the nerve of the !terygoid canal B1ig( 1G(16C( )hese connections !rovide an alternative !ath"ay of taste fro the anterior t"o-thirds of the tongue( )hese fibres do not !ass through the iddle ear( .

facial and occi!ital arteriesD BcC internal 3ugular veinD BdC vagus. the sub andibular duct. fro "here it is carried by the glosso!haryngeal nerve( . and the vena co itants hy!oglossiD and BbC the genioglossus "ith its su!erficial relations. the dee! !art of the sub andibular salivary gland.erfi*ial7 2a3 #astoid !rocess "ith the sternocleido astoid. ylohyoid.7 BaC <yoglossus "ith its su!erficial relations. 11(:C( 7elations of =yo*lossus <u. na ely the sublingual salivary gland. the sub andibular ganglion. sub andibular duct. sub andibular and sublingual salivary glands and sub andibular ganglion( Chorda ty !ani fro facial nerve !rovides !reganglionic secreto otor fibres to the glands( Chorda ty !ani also carries fibres of sensation of taste fro anterior t"o-thirds of tongue e&ce!t fro the circu vallate !a!illae.ntroduction )his region includes dee!er structures in the area bet"een the andible and hyoid bone including the floor of the outh and the root of the tongue( SUPRAH OID MUSCLES gland "ith retro andibular veinD BdC sub andibular salivary gland and ly !h nodesD BeC angle of the andible "ith the edial !terygoid B1ig( 11(1C( Dee.erfi*ial7 Styloglossus. lingual nerve. accessory and hy!oglossal cranial nervesD and BeC the hyoglossus uscle( Its u!!er border is related to8 BaC )he !osterior auricular artery and BbC the stylohyoid uscle( Its lo"er border is related to the occi!ital artery B1ig( 1F(16C( 7elations of . hy!oglossal nerve and veins acco !anying it( Dee. the hy!oglossal nerve. dee! !art of the sub andibular gland. e&ternal carotid. the lingual artery.7 BaC )ransverse !rocess of the atlas "ith su!erior obli%ue and the rectus ca!itis lateralisD BbC internal carotid. the lingual nerve. sub andibular ganglion. the s!lenius ca!itis and the longissi us ca!itisD BbC the stylohyoidD BcC the !arotid <u. the stylohyoid. na ely the styloglossus.erfi*ial7 BaC .7 BaC Inferior longitudinal uscle of the tongueD BbC genioglossus B1ig( 11(:CD BcC iddle constrictor of 90/ . lingual. stylohyoid. and the hy!oglossal nerve B1igs 11(F. hyoglossus( 7elations of Posterior Belly of Di*astric <u.ylohyoid )he su!rahyoid uscles are the digastric. sub andibular duct. geniohyoid. the lingual nerve. the ylohyoid and the geniohyoid( )hey are described in )able 11(1( DISSECTION Cut the facial artery and vein !resent at the anteroinferior angle of asseter uscle( Se!arate the origin of anterior belly of digastric uscle fro the digastric fossa near the sy !hysis enti( Push the andible u!"ards( Clean and e&!ose the !osterior belly of digastric uscle and its acco !anying stylohyoid uscle( Identify the digastrics.9he -u65andi6ular Region )he sub andibular region contains the su!rahyoid uscles.nterior belly of the digastricD BbC su!erficial !art of the sub andibular salivary glandD BcC ylohyoid nerve and vesselsD and BdC sub ental branch of the facial artery B1ig( 4(FC( Dee.

6et1een 5andi6le and h2oid 6one Anterior sur4ace o4 6od2 o4 h2oid 6one er7e to 52loh2oid GaH Ele7ates 4loor o4 5outh in 4irst stage o4 deglutition G6H Helps in depression o4 5andi6le.9= Su%rah6oi$ *us&#es /uscle (rigin Fibres . it 4i:es the h2oid 6one 33 M2loh2oid GMHH Jlat. H2oglossus3 /t is a 5uscle o4 tongue3 /t 4or5s i5portant land5ar! in this region GJig3 ""3=H /n4erior 5ental spine Ggenial tu6ercleH Runs 6ac!1ards and do1n1ards Cl through h2poglossal ner7e GJig3 &3"3H .nsertion Nerve supply Actions " 3 Digastric GD0H Has t1o 6ellies united 62 an inter5ediate tendon GJigs &3$. being indented by the !osterior border of the ylohyoid "hich divides it into a larger !art su!erficial to the uscle. fro the above do"n"ards8 BaC +losso!haryngeal nerveD BbC stylohyoid liga entD and BcC lingual artery( gland is about the si7e of a "alnut( It is roughly Jsha!ed.ith other h2oid 5uscles. retracts the protruded tongue ?3 0enioh2oid G0HH short and narro1 5uscleU lies a6o7e 5edial part o4 MH GJig3 ""3 =H +.hole length o4 greater cornua and lateral part o4 6od2 o4 h2oid 6one Ji6res run up1ards and 4or1ards -ide o4 tongue 6et1een st2loglossus and in4erior longitudinal 5uscle o4 tongue GJig3 ""3&H H2poglossal GT//H ner7e the !haryn&D BdC glosso!haryngeal nerveD BeC stylohyoid liga entD and BfC lingual artery( Structures !assing dee! to !osterior border of hyoglossus. of the digastric triangle( )he Sub andibular gland is seen in the digastric triangle( 0n !ushing the su!erficial !art of the gland !osteriorly the entire ylohyoid uscle is e&!osed( )he dee! !art of the gland lies on the andi6ular Region . situated in the anterior !art. and ele7ation o4 h2oid 6one GaH Ele7ates h2oid 6one G6H Ma2 depress 5andi6le 1hen h2oid is 4i:ed Depresses tongue 5a!es dorsu5 con7e:. triangular 5uscleU t1o 52loh2oids 4or5 4loor o4 5outh ca7it2. &3#H "a# Anterior 6ell2 GD0AH@ 4ro5 digastric 4ossa o4 5andi6le GaH Anterior 6ell2 runs do1n1ards and 6ac!1ards Both heads 5eet at the inter5ediate tendon 1hich per4orates -H and is held 62 a 4i6rous pulle2 to the h2oid 6one GaH Anterior 6ell2 62 ner7e to 52loh2oid "a# Depresses 5andi6le 1hen 5outh is opened 1idel2 or against resistanceU it is secondar2 to lateral pter2goid G6H Ele7ates h2oid 6one G6H <osterior 6ell2 GD0<H@ 4ro5 5astoid notch o4 te5poral 6one GJig3 #3?H =3 -t2loh2oid G-HH s5all 5uscle. lies on upper 6order o4 D0< GJig3 ""3&H <osterior sur4ace o4 st2loid process G6H <osterior 6ell2 runs do1n1ards and 4or1ards G6H Jacial ner7e 9endon is per4orated 62 D0< tendon Cunction o4 6od2 and greater cornua o4 h2oid 6one Jacial ner7e GaH <ulls h2oid 6one up1ards and 6ac!1ards G6H . and a s all !art lying dee! to the uscleU1ig( 11(:C( DISSECTION SUBMANDIBULAR SALI1AR ILAND Intro+u*tion 7?This is a large salivary gland. deep to D0A GJig3 ""33H M2loh2oid line o4 5andi6le GJig3 "3=$H Ji6res run 5ediall2 and slightl2 do1n1ards GaH <osterior 4i6res@ 6od2 o4 h2oid 6one GJig3 "33=H G6H Middle and anterior 4i6resU 5edian raphe.903 Hea$ a"$ Ne&Ta2#e 99.

%%. muscle. and hy!oglossal nerve running on the hyoglossus uscle fro lateral to the edial side( Dee! !art of gland and its duct are also visible on this surface of hyoglossus uscle B1ig( 11(FC( Carefully release the hyoglossus uscle fro the hyoid bone and reflect it to"ards the tongue( =ote the structures dee! to the uscle.%: Posterior belly of the digastric it. Rectus A capitis lateralis 9rans7erse process o4 atlas S%A 3PP% /nternal Fugular 7ein P % % -pinal accessor2 ner7e R P % I H2poglossal ner7e Vagus ner7e /nternal carotid arter2 I -uperior lar2ngeal ner7e %+% Occipital arter2 %%%%%%%% E:ternal carotid arter2 <osterior 6ell2 o4 digastric 5uscle H2oid 6one 9endon o4 digastric %O Fig. su!erior surface of the uscle( Se!arate the facial artery fro the dee! surface of gland and identify its branches in nec'( )he hyoglossus uscle is recognised as a %uadrilateral uscle lying on dee!er !lane than ylohyoid uscle( Indentify lingual nerve "ith Sub andibular ganglion. e(g( genioglossus uscle. lingual artery.O 0lossophar2ngeal ner7e % H2poglossal ner7e H2oid 6one Deep part o4 -u65andi6ular gland H2oglossus 5uscle Fig."'# Occipital arter2 -ternocleido5astoid O/ -plenius capitis PC Longissu5us capitis %%R SS Mastoid process O -uperior o6li8ue 5uscle E . and structures related to Retro5andi6ular 7ein O7%%\ <arotid gland O% [ Jacial arter2 % -u65andi6ular gland %% Digastric 5uscle Lingual ner7e -u65andi6ular duct Outline o4 su6lingual gland S % -t2loglossus % PPPPPP O -u65andi6uiar ganglion i 0enioglossus 5uscle ?==rGsIC> VPP%? Lingual arter2 0enioh2oid 5uscle C -t2loh2oid liga5ent LB. seen from below. %%. vein and Anterior 6ell2 o4 digastric !haryn&( iddle constrictor of the .<: $ubmandibular region showing the superficial relations of the hyoglossus and genioglossus muscles.

.M2loh2oid . $ $33@ 4oriMontal section through the $ubmandibular region showing the location of the $ubmandibular and sublingual glands. 0enioh2oid 3 0enioglossu s -u6lingual gland -uper4icial part o4 H2oglossus / % Deep part o4 -u65andi6ular gland -u65andi6ular gland N.

i&ia# Part )he inferior surface is covered by8 BaC S'inD BbC !latys aD BcC cervical branch of the facial nerveD BdC dee! fasciaD BeC facial veinD and BfC sub andibular ly !h nodes B1igs 11(J. *a"$i2#e Fig. . )he lateral surface is related to8 BaC )he subandibular fossa on the andibleD BbC insertion of the edial !terygoidD and BcC the facial artery B1igs 11(A.i&ia# #a*i"a o.ossa Ireater &o*ua o.erior %art o. .as&ia Su2*a"$i2u#ar !#a"$CCCCCC 5 >>K BCKB Su2*a"$i2u#ar .7: Felationship of the facial vein to the submandibular gland and to the mandible. 11(6C( Me$ia# %ter6!oi$ J Fa&ia# 5ei" A"teroi". the stylohyoid liga ent. the ninth nerve. *asseter )his !art of the gland fills the digastric triangle( It e&tends u!"ards dee! to the andible u! to the ylohyoid line( It has BaC inferiorD BbC lateralD and BcC edial surfaces( )he gland is !artially enclosed bet"een t"o layers of dee! cervical fascia( )he su!erficial B1ig( 11(HC layer of fascia covers the inferior surface of the gland and is attached to the base of the andible( )he dee! layer covers the edial surface of the gland and is attached to the ylohyoid line of the andible B1ig( 11(HC( Su%er.Sur.a&e Mar-i"! 7elations )his salivary gland is ar'ed by an oval area over the !osterior half of the base of the andible including the !osterior border of the ra us B1ig( 9(:C( )he sub andibular region e&tends 1(J c above the base of the andible and belo" to the greater cornua of the hyoid bone( Su%er. nerve and vessels( BiiC )he iddle !art is related to the hyoglossus. the styloglossus. and the "all of the !haryn&( Inferiorly.as&ia Fig.as&ia M6#oh6oi$ #i"e Dee% #a*i"a o. : %. : %.AAAAA h6oi$ 2o"e ACCCCCC Ma"$i2u#ar &a"a# Su2*a"$i2u#ar !#a"$ I"5esti"! . it overla!s the .6: Fascial covering of the superficial part of the submanI dibular salivary gland. Base o. the lingual nerve the sub andibular ganglion and the hy!oglossal nerve B1ig( 11(9C( BiiiC )he !osterior !art is related to the styloglossus. 11(4C( )he edial surface ay be divided into three !artsD BiC )he anterior !art is related to the ylohyoid uscle.

Bu&&i"ator Su2#i"!ua# !#a"$ Du&t I"tri"si& *us&#es o. to"!ue o.+: !oronal section through the mouth posterior to the molar teeth.i&ia# %art o. su2*a"$i2u#ar !#a"$ Fa&ia# 5ei" P#at6s*a >II "er5e Ie"io!#ossus Li"!ua# arter6 Co**o" te"$o" o. su2*a"$i2u#ar !#a"$ A M6#oh6oi$ Fa&ia# arter6 Li"!ua# "er5e St6#o!#ossus M6o!#ossus Su%er. %%. . $i!astri& Fig.

-u65andi6ular duct 0enioglossus r% 9ongue H2oglossu s% <har2n: It is thin "alled. Anterior 6ell2 o4 digastric S i -u65andi6ular gland S O -!in M2loh2oid . and BcC vaso otor sy !athetic fibres fro the !le&us on the facial artery B1igs 11(1G.'' ERTRR9%VL:2E + Deep 4ascia Cer7ical *G#.%. 9ongue %-t2loglossus H2oglossus R Lingual ner7e P R L3 . at the side of the frenulu of the tongue B1igs 11(4. %%.% It is su!!lied by branches fro the sub andibular ganglion( )hese branches convey8 BaC Secreto otor fibresD BbC sensory fibres fro the lingual nerve..AI**=$:f=B= .t the anterior border of the hyoglossus the duct is crossed by the lingual nerve B1ig( 11(FC( It o!ens on the floor of the outh. and is about J c long( It e erges at the anterior end of the dee! !art of the gland and runs for"ards on the hyoglossus.nandi6ular Region Medial pter2goid stylohyoid and the !osterior belly of the digastric B1igs 11(F.5 .I3333)R=R) /n7esting 4asciaPPPPP E' RR[C 6ranch o4 4acial ner7e .1: $chematic horiMontal section through the submandibuI lar region. 11(11C( )he secre otor !ath"ay begins in the su!erior salivary nucleus( Preganglionic fibres !ass through the sensory root of the facial nerve. %%. 88...8: Felationship of the facial artery to the submandibular gland and to the mandible. -u6lingual gland . i Ei4R2 HAL A ** O-7Hr E E H2poglossal ner7e PP . it e&tends u! to the !osterior end of the sublingual gland B1ig( 11(:C( Su2*a"$i2u#ar Du&t Fig. M 2i o h 2 o i d O P i -u65andi6ular duct %.nteriorly. on the su it of the sublingual !a!illa. 1A(FC( B#oo$ Su%%#6 a"$ L6*%hati& Drai"a!e It is su!!lied by the facial artery( )he veins drain into the co on facial or lingual vein( @y !h !asses to sub andibular ly !h nodes( Ner5e Su%%#6 Digastric Gposterior 6ell2H + -t2loh2oid Jacial arter2 Fig. it is continuous "ith the su!erficial !art round the !osterior border of the ylohyoid( .AL IB==VfGlBI Digastrictendon % %%iF4 E$%R-=Q% H2oid 6one%greater cornua O7Rl. 11(:C( Dee% Part % Jacial arter2 -u65andi6ular gland /n7esting 4ascia )his !art is s all in si7e( It lies dee! to the ylohyoid. bet"een the lingual and hy!oglossal nerves( . the geniculate PPP Bod2 o4 5andi6le P%% Mandi6ular canal % -uper4icial part o4 su65andi6ular gland %% -u65andi6ular l25ph node PLE^. and su!erficial to the hyoglossus and the styloglossus( Posteriorly.

<lat2s5aPPPPP% : -!in JEg3 %%. .K: !oronal section of the submandibular region showing the relations of the superficial part of the submandibular salivary gland.

belo" the ucosa of the floor of the outh.94( Hea$ a"$ Fa&ia# "er5e M1IIT Chor$a 0Lf6PaM -u6lingual gland ucleus o4 tractus solitarius Auriculo%te5poral ner7e -u65andi6ular gland /n4erior al7eolar -uperior sali7ator2 nucle Lingual ner7e -u65andi6ular ganglion Fig.henoi+) )he auriculote !oral nerve su!!lying secreto otor fibres to the !arotid gland is related to lateral as!ect of s!ine of s!henoid( In3ury to s!ine ay involve both these nerves "ith loss of secretion fro all three salivary glands( SUBLINIUAL SALI1AR ILAND )his is s allest of the three salivary glands( It is al ond-sha!ed and "eighs about : to H g( It lies above the ylohyoid. to reach the sub andibular ganglion( Postganglionic fibres e erge fro the ganglion and enter the sub andibular gland B)able 1(:C( CLINICAL ANATOM 2&cision of the sub andibular gland for calculus or tu our is done by an incision belo" the angle of the 3a"( Since the arginal andibular branch of the facial nerve !asses !osteroinferior to the angle of the 3a" before crossing it. the incision ust be !laced ore than F(J c belo" the angle to !reserve the nerve( )he chorda ty !ani su!!lying secreto otor fibres to sub andibular and sublingual salivary glands lies edial to the s.ine of s. and the lingual nerve. ganglion. the chorda tyrn!ani. %5 B(: supply of submandibular and Parasympathetic nerve sublingual glands. the facial nerve. edial to the sublingual fossa of the .

11(J. 11(11C( . 11(4. sus!ended fro the lingual nerve by t"o roots B1ig( 11(1GC( Co""e&tio"s a"$ Bra"&hes 1( )he otor or !arasy !athetic fibres !ass fro the lingual nerve to the ganglion through the !osterior root( )hese are !reganglionic fibres that arise in the su.erior sali. it is connected to the chorda ty !ani branch of the facial nerve Bchorda ty !aniC B)able 1(:C( )he fusifor ganglion lies on the hyoglossus uscle 3ust above the dee! !art of the sub andibular salivary gland. 11(:. it is related to the lingual nerve.bout 1J ducts e erge fro the gland( #ost of the o!en directly into the floor of the outh on the su it of the sublingual fold( .atory nu*leus and !ass through the . fe" of the 3oin the sub andibular duct( )he gland receives its blood su!!ly fro the lingual and sub ental arteries( )he nerve su!!ly is si ilar to that of the sub andibular gland( SUBMANDIBULAR IANILION )his is a !arasy !athetic !eri!heral ganglion( It is a relay station for secreto otor fibres to the sub andibular and sublingual salivary glands( )o!ogra!hically.andible and lateral to the genioglossus B1igs 11(F. but functionally.

and su!!ly vaso otor fibres to the Sub andibular and sublingual glands B1ig( 11(11C( F(Sensory fibres reach the ganglion through the lingual nerve( . PPPPMotor root -u6lingual gland ).andi6ular Region "A3 Lingual ner7e 9ongue Chorda t25pani -ecreto5otor roo4 GpreganglionicH ) 9aste 4i6re Ji6re carr2ing general sensation Fig. %%. the chorda ty !ani and the lingual nerve to reach the ganglion( )he fibres relay in the ganglion( Postganglionic fibres for the Sub andibular gland reach the gland through five or si& branches fro the ganglion( Postganglionic fibres for the sublingual and anterior lingual glands re-enter the lingual nerve through the anterior root and travel to the gland through the distal !art of the lingual nerve B1ig( 11(1GC( sy !athetic fibres are derived fro the !le&us around the facial artery( It contains -u65andi6ular gland !ost-ganglionic fibres arising in the su!erior cervical ganglion( )hey !ass through Sub andibular ganglion "ithout relay. PPPP-ensor2 root R7t O -25pathetic ple:us on 4acial arter2 gi7ing o44 s25pathetic root -u65andi6ular ganglion%%%%%%%% ' 1()he +W% facial nerve.%%: !onnection of the $ubmandibular ganglion.

taste fibres fro !osterior one-third of tongue and circu vallate !a!illae( @astly. the u!!er 1(F c belo" and the lo"er F(J c belo" the arch of the cricoid cartilage B1ig( 1F(1C( 2ach lobe e&tends u! to the iddle of the thyroic cartilage. for better healing and for cos etic reasons( Branches of subclavian artery anasto ose "ith those of a&illary around the sca!ula( =inth nerve is the nerve of third branchial arch and su!!lies the only uscle of that arch. genioglossus and hyoglossus( Scalenus anterior is i !ortant( It ay co !ress the subclavian artery to cause 6scalenus anterior syndro e6( @y !h nodes are clinically i !ortant in deciding the !rognosis and treat ent of alignancies( 1ontent': )here are nu erous dee! structures in the nec'( 1or convenience they ay be grou!ed as follo"s8 . one shrugging uscle. the stylo!haryngeus( It carries sensory fibres fro the !osterior one-third of tongue. vagus. !yra idal. accessory.Deep -tructures in the ec! r )Vhe thyroid gland lies in front of the nec'( S'in -@ incision for its surgery should be hori7ontal. internal 3ugular and brachioce!halic( 2( =erves8 glosso!haryngeal.third. i(e( su!erior longitudinal. hy!oglossal.ccessory nerve co !rises t"o roots M cranial root given to vagus and s!inal root su!!lies t"o uscles of nec'. and !lays an i !ortant role in calciu etabolis ( )he gland consists of right and left lobes that are 3oined to each other by the isthmus) . i(e( styloglossus. carotid sinus and laryngeal branches( )hese are gracefully borro"ed fro cranial root of accessory nerve( /agus gives auricular and cardiac branches as its 6o"n6( )hat is "hy syringing the ear ay cause slo"ing of the heart rate and even its inhibition( /agus is the !arasy !athetic nerve of foregut and idgut( . lobe ay !ro3ect u!"ards fro the isth us Bor fro one of the lobesC( So eti es a fibrous or fibrouscular band or le. belo" till the clavicle. tonsil.atorofthe thyroi+ glan+ descends fro the body of the hyoid bone to the isth us or to the !yra idal lobe( .rteries8 subclavian and carotid( D( /eins8 subclavian. iddle ear. the sternocleido astoid( <y!oglossal su!!lies A out of 4 uscles of tongue. and thoracic duct( +( /iscera8 trachea and oeso!hagus( <( Scalene uscles( I( Cervical !leura and su!ra!leural e brane( J( Styloid a!!aratus( TH ROID ILAND MTh6roi$Qshie#$C#i-eT Introduction )he thyroid is an endocrine gland. inferior longitudinal. situated in the lo"er !art of the front and sides of the nec'( It regulates the basal etabolic rate. and other. the chin turning uscle. e&ce!t !alatoglossus( )he uscles su!!lied are H intrinsic. it !rovides secreto otor fibres to !arotid gland( /agus in nec' gives !haryngeal. !haryn&. transverse and vertical and : e&trinsic. and laterally to bB 94V . sti ulates so atic and !sychic gro"th. sy !athetic chain and cervical !le&us( 1( @y !h nodes.ccessory thyroi+ glan+s are so eti es found as s all detached asses of thyroid tissue in the vicinity of the lobes or above the isth us( -ur4ace /arking )he isth us is ar'ed by t"o transverse !arallel lines Beach 1(F c longC on the trachea. the tra!e7ius.( +lands8 thyroid and !arathyroid( B( )hy us( C( .

2err6 ?% C + C . B Latera# #o2e C First tra&hea# ri"! Isth*us B Fourth tra&hea# ri"! Tra&hea Fi*+ #&+&: $cheme to show the location and subdivisions of the thyroid gland including the false capsule. :.944 DISSECTION BaC2ach lobe e&tends fro Sternocleido astoid uscle has already been reflected laterally fro its origin( Cut the sternothyroid uscle near its origin and reflect it u!"ards( Clean the surface of trachea and identify inferior thyroid vein and re ains of the thy us gland Bdar'er in colour than fatC( 0n the tracheal rings F. C6. but thic' on the inner surface of the gland "here it for s a sus!ensory liga ent Bof BerryC. 1 Le5ator !#a"$ u#ae th6 roi$eae overla!!ed by the anterior border of the sternocleido astoid uscle( )he u!!er !ole of the gland is !ointed. and the lo"er !ole is broad rounded( Situatio" a"$ E8te"t BaC )he gland lies against vertebrae CJ. and further increases in si7e during enstruation and !regnancy( Ca%su#es o. and the isth us 1(F c & 1(F c ( 0n an average the gland "eighs about FJ g( <o"ever.sule is derived fro the !retracheal layer of the dee! cervical fascia B1ig( 1F(FC( It is thin along the !osterior border of the lobes. . e bracing the u!!er !art of the trachea B1ig( 1F(FC( C Th6roi$ &arti#a!e A Cri&oi$ &arti#a!e A@ P6ra*i$a# #o2e . Th6roi$ 1()he true *a. it is larger in fe ales than in ales.sule is the !eri!heral condensation of the connective tissue of the gland( F()he false *a. H lies the isth us of the thyroid gland( Pyra idal lobe if !resent !ro3ects fro the u!!er border of the isth us( 0n each side of isth us are the lateral lobes of the gland( Clean the lobes and identify the vessels of thyroid gland( Identify the recurrent laryngeal nerves tuc'ed bet"een the lateral surfaces of trachea and oeso!hagus( @oo' for beaded thoracic duct !resent on the left of oeso!hagus( )race the su!erior and inferior thyroid arteries( Identify cricothyroid and inferior constrictor uscles lying edial to the lobes of thyroid gland( Thyroi+ Clan+ Cut the isth us of the thyroid gland and turn one of the lobes laterally( @ocate an anasto otic artery bet"een the branches of su!erior thyroid and inferior thyroid arteries su!!lying the gland( Identify the t"o !arathyroid glands 3ust lateral to this anasto otic vessel( Isth*us o. CA and )l. C H6oi$ Ar&h o. "hich connects the lobe to the cricoid cartilage Bsee 1ig( 1F(9C( 1erte2ra# #e5e#s C Li!a*e"t o. &ri&oi$ &arti#a!e =MX-K B H2oid 2o"e Ster"o&#ei$oC *astoi$ 1 5 1 2 Fi*+ #&+#: $urface marking of thyroid gland. th6roi$ !#a"$ 8 the iddle of the thyroid cartilage to the fourth or fifth tracheal ring( BbC)he isth us e&tends fro the second to the fourth tracheal ring( Di*e"sio"s a"$ Lei!ht 2ach lobe easures about J c & F(J c & F(J c .

BcC three surfaces. therefore..n a!e&. lateral. BbC a base. edial and . during !rostatecto y both ca!sules are left behindC B1ig( 1F(:C( Re#atio"s T!e lo#e' are conical in sha!e having8 BaC . dense ca!illary !le&us is !resent dee! to the true ca!sule( )o avoid hae orrhage during o!erations the thyroid is re oved along "ith the true ca!sule( BCo !are "ith the !rostate in "hich the venous !le&us lies bet"een the t"o ca!sules of the glandD and.

e&ternal laryngeal and recurrent laryngeal B1ig( 1F(JC( )he .er bor+er is related to the anasto osis bet"een the right and left su!erior thyroid arteries( 0o9er bor+er) Inferior thyroid veins leave the gland at this border( Arterial -uppl2 )he thyroid gland is su!!lied by the su!erior and inferior thyroid arteries( )he su.osterior surfa*e is related to the second to fourth tracheal rings( It ay be !laced at a higher. with the true and false capsules around these organs. Jalse ca <sule . &#e5a!e OI#a"$ su2sta"&e ZY PROSTATE Fi*+ #&+': $chemes of comparing the relationship of the venous ple uses related to the thyroid gland and to the prostate.fter giving branches to ad3acent structures it !ierces the !retracheal fascia to reach the u!!er !ole of the lobe( <ere it divides -ternocleido5astoid O5oh2oid PPPP -ternoh2oid -ternoth2roid 9rachea P FG AEE Recurrent lar2ngeal ner7e .. inferior constrictor and cricothyroidD and BcC t"o nerves.erior thyroi+ artery is the first anterior branch of the e&ternal carotid artery B1igs 1F(6.i the Ne&.osterior surfa*e is related to the carotid sheath and overla!s the co on carotid artery B1ig( 1F(HC( )he anterior bor+er is thin and is related to the anterior branch of the su!erior thyroid artery B1ig( 1F(6C( )he . or lo"er level B1ig( 1F(FC( )he u. Note the plane of cleavage along which the organ is separated from neighbouring structures during surgical removal. su!erior and inferior( 0ccasionally the isth us is absent( )he anterior surfa*e is covered by8 BaC )he right and left sternothyroid and sternohyoid usclesD BbC the anterior 3ugular veinsD BcC fascia and s'in B1ig( 1F(HC( )he . and is covered by8 BaC )he sternohyoidD BbC the su!erior belly of the o ohyoidD BcC the sternothyroidD and BdC the anterior border of the sternocleido astoid B1ig( 1F(HC( )he me+ial surfa*e is related to8 BaC )"o tubes.94/ TH ROID CCCCCCCFa#se &a%su#e CCCCCCC P#a"e o.osterior bor+er is thic' and rounded and se!arates the edial and !osterior surfaces( It is related to8 BaC )he inferior thyroid arteryD BbC the anasto osis bet"een the su!erior and inferior thyroid arteriesD BcC the !arathyroid glandsD and BdC the thoracic duct only on the left side B1ig( 1F(AC( The isthmus connects the lo"er !arts of the t"o lobes( It has8 BaC )"o surfaces.osterolateral or .erfi*ial surfa*e is conve&. 1F(AC( It runs do"n"ards and for"ards in inti ate relation to the e&ternal laryngeal nerve( . !osterolateralD and BdC t"o borders. anterior and !osteriorD and BbC t"o borders. trachea and oeso!hagusD BbC t"o uscles.ex is directed u!"ards and slightly laterally( It is li ited su!eriorly by the attach ent of the sternothyroid to the obli%ue line of the thyroid cartilage( )he base is on level "ith the Hth or Jth tracheaR ring( )he lateral or su. anterior and !osterior( )he a.. &#e5a!e CCCCCCC True &a%su#e CDD1e"ous %#e8us CCCCCCC I#a"$ su2sta"&e OFa#se &a%su#e O1e"ous %#e8us DJD[ OTrue &a%su#e EECD P#a"e o.

'%%%%%O+%EO3 + Carotid sheath%%%%%% O I d /nternal Fugular 7ein Vagus "er5e '+% -25pathetic trun! .%2 + E .as&ia AA 9h2roid gland%%%%%%%%%% EEP EE Oesophagus O r . .) capsule <osition o4 liga5ent o4 Berr2 /t.= 2ransverse section through the anterior part of the neck at the level of the isthmus of the thyroid gland.. /(.i!.' Pre5erte2ra# .3 <arath2roid gland Co55on carotid arter2 .

P C%%%%%%%%% Outline o4 lo6e o4 th2roid gland 9rachea%%%%%%% E:ternal carotid arter2 Co55on carotid arter2 -uperior th2roid arter2 Cricoth2roid 5uscle Cricoid cartilage E:ternal lar2ngeal ner7e Branches o4 superior th2roid arter2 Anasto5osis 6et1een 6ranches o4 superior th2roid arteries 9rachea Le4t recurrent lar2ngeal ner7e /n4erior th2roid arter2 Le4t 7agus Brachiocephalic trun! -u6cla7ian arter2 Arch o4 aorta Fig. %<. %<.Cricoth2roid 5uscle PP H2oid 6one OP 9h2roh2oid 5e56rane % % O -uperior lar2ngeal ner7e /nternal lar2ngeal ner7e E:ternal lar2ngeal ner7e Oesophagus % /n4erior constrictor 5uscle Recurrent lar2ngeal ner7e 9h2roid cartilage O Cricoid cartilage .3 Outline o4 isth5us o4 th2roid gland P3 Fig.7: Arterial supply of anterior aspect of thyroid gland.+: 9eep relations of the thyroid gland. .

Stru&tures i" the Ne&.947 -uperior th2roid arter2 and its posterior 6ranch -uperior parath2roid Le4t 7agus /n4erior parath2roid Le4t co55on carotid Le4t recurrent lar2ngeal ner7e % Le4t su6cla7ian arter2 Brachiocephalic trun! Fig. and finally do"n"ards to reach the lo"er !ole of the gland( During its course.8: Arterial supply of posterior surface of thyroid gland. the su!erior and inferior thyroid arteries anasto ose freely both on the surface of the gland as "ell as in its substanceD and the territories su!!lied by the t"o arteries overla! considerably( So eti es Bin :5 of individualsC. the thyroid is also su!!lied by the lo9est thyroi+ artery 2thyroi+ea ima artery3 "hich arises fro the brachioce!halic trun' or directly fro the arch of the aorta( It enters the lo"er !art of the isth us( 6**essory thyroi+ arteries arising fro tracheal and oeso!hageal arteries also su!!ly the thyroid( 1e"ous Drai"a!e )he thyroid is drained by the su!erior. %<. then edially. inferior thyroid veins( iddle and . into anterior and !osterior branches( )he anterior bran*h descends on the anterior border of the lobe and continues along the u!!er border of the isth us to anasto ose "ith its fello" of the o!!osite side( )he .os tenor bran*h descends on the !osterior border of the lobe and anasto oses "ith the ascending branch of the inferior thyroid artery B1ig( 1F(AC( )he inferior thyroi+ artery is a branch of the thyrocervical trun' B"hich arises fro the subclavian arteryC( It runs first u!"ards. it !asses behind the carotid sheath and the iddle cervical sy !athetic ganglionD and in front of the vertebral vesselsD and gives off branches to ad3acent structures B1ig( 1F(4C( Its ter inal !art is inti ately related to the recurrent laryngeal nerve( )he artery divides into H to J glandular branches "hich !ierce the fascia se!arately to reach the lo"er !art of the gland( 0ne as*en+ing bran*h anasto oses "ith the !osterior branch of the su!erior thyroid artery. and su!!lies the !arathyroid glands( It is often said that the su!erior thyroid artery su!!lies the u!!er one-third of the lobe and the u!!er half of the isth usD and that the Inferior thyroid artery su!!lies the lo"er t"o-thirds of the lobe and the lo"er half of the isth us( <o"ever.

and drain into the F(/arafolli*ular *ells 2C *ells3 are fe"er and light internal 3ugular vein( cells lie in bet"een the follicles( )hey secrete thyrocalcitonin "hich !ro otes de!osition of calciu salts in s'eletal and other tissues.ein e erges at the u!!er !ole and )he thyroid gland is ade u! of the follo"ing t"o acco !anies the su!erior thyroid artery( It ends ty!es of secretory cells( either in the internal 3ugular vein or in the co on 1(5olli*ular *ells lining the follicles of the gland facial vein( )he mi++le thyroi+ . it ust be noted that in the thyroid Band for caudal to the tuberculu i !ar( )he lo"er end of the that atter in ost other organsC the ly !hatics diverticulu enlarges to for the gland( )he rest of for a !le&us through "hich ly !h ay !ass in any the diverticulu re ains narro" and is 'no"n as direction( the thyroglossal +u*t) #ost of the duct soon disa!!ears( )he !osition of the u!!er end is ar'ed by the fora en caecu of the tongue. "hile in resting and drain into the left brachioce!halic vein( .erior thyroi+ . . L6*%hati& Drai"a!e and tends to !roduce hy!ocalcae ia( )hese @y !h fro the u!!er !art of the gland reaches the effects are o!!osite to those of !arathor one( u!!er dee! cervical ly !h nodes either directly or through the !relaryngeal nodes( @y !h fro the lo"er !art of the gland drains to the lo"er dee! DE1ELOPMENT cervical nodes directly.ein Bof $ocherC ay e erge bet"een the their lu ina( iddle and inferior veins. Anasto5osing 6ranch Outline o4 th2roid gland K 8 A? -uprascapular arter2 ') )he HISTOLOI AND FUNCTION 9h2rocer7ical trun! su.ein is a short.9/: Hea$ a"$ Ne&%%'R E Recurrent lar2ngeal ner7e OO' Middle cer7ical ganglion O -uperior th2roid arter2 . fourth !hase. i Carotid sheath E:ternal lar2ngeal ner7e Anterior 6ranch / PPO <osterior 6ranch Ascending 6ranch o4 in4erior th2roid arter2 -u6cla7ian arter2 PP -calenus anterior lUH/O Verte6ral 7essels Fig. $=3&@ Arterial supply of the O /n4erior th2roid arter2 thyroid gland "lateral view#. 3ust <o"ever.eins e erge at the lo"er border of the gro"th of the individual( During active !hase the isth us( )hey for a !le&us in front of the trachea. and the lo"er Ner5e Su%%#6 end often !ersists as the !yra idal lobe( )he gland =erves are derived ainly fro the iddle cervical beco es functional during third onth of deveganglion and !artly also fro the su!erior and lo! ent( inferior cervical ganglia( )hese are vasoconstrictor( . 9rans7erse cer7ical arter2 8K GG $r. lining of the follicles is colu nar.erti*ulum "hich gro"s do"n in front of the into distinct !arts draining in different directions( nec' fro the floor of the !ri itive !haryn&. and also through the !retracheal and !aratracheal nodes( )he thyroid develo!s fro a me+ian en+o+ermal )he thyroid is so eti es described as being divided thyroi+ +i. "ide secrete triiodothyronin and channel "hich e erges at the iddle of the lobe and tetraiodothyronin Bthyro&inC "hich sti ulate soon enters the internal 3ugular vein( )he inferior basal etabolic rate and so atic and !sychic thyroi+ . it is cuboidal( 1ollicles contain the colloid in thyroi+ .

the !osterior !arts of both lobes are left behind( )his avoids the ris' of si ultaneous re oval of the !arathyroids and also of !osto!erative y&oede a Bcaused by deficiency of thyroid hor onesC( During o!eration the su!erior thyroid artery is ligated near the glan+ to save the e&ternal laryngeal nerveD and the inferior thyroid artery is ligated a9ay from the glan+ to save the recurrent laryngeal nerve( 1(Hy. belo" the inferior thyroid artery and near the lo"er !ole of the thyroid lobeD BFC behind and outside the thyroid ca!sule.arathyroi+ is ore constant in !osition and usually lies at the iddle of the !osterior border of the lobe of the thyroid gland.erior th6roi$ arter6 C I".arathyroi+s are also referred to as . li'e the carotid sheath. "A# 2ransverse section through the left lobe of the thyroid gland.haryngeal . Berr6 JA)B As&e"$i"! 2ra"&h o. IB i".e 1(. "ithin the false ca!sule B1ig( 1F(9C( )he su.ccessory thyroids ay be !resent( CLINICAL ANATOM Capsule Lo2e o.9/9 .arathyroi+ is ore variable in !osition( It ay lie8 B1C Eithin the thyroid ca!sule. th6roi$ !#a"$ C Sus%e"sor6 Su%erior %arath6roi$ Lea. though it ay lie at a higher level( It is usually dorsal to the recurrent laryngeal nerve( )he inferior . the trachea.erior %arath6roi$ Fi*+ #&+": $chemes to show the location of the parathyroid glands. PARATH ROID ILANDS R )hese are t"o !airs Bsu!erior and inferiorC of s all endocrine glands. "&# posterior view of the left lobe of the thyroid gland. that usually lie on the !osterior border of the thyroid gland.Dee% Stru&tures i" the Ne&.othyroi+ism causes cretinis in infants and y&oede a in adults( F(Benign tu ours of the gland ay dis!lace and even co !ress neighbouring structures.erior .arathyroi+ III because they develo! fro the thir+ .ou*h)3 O&O l P? )he !arathyroids secrete the hor one .arathyroi+s.e nants of the thyroglossal duct ay for thyroglossal cysts.ny s"elling of the thyroid gland BgoitreC B AC Su%erior th6roi$ arter6 #i!a*e"t o.ara& thormone "hich controls the etabolis of calciu and !hos!horus along "ith thyrocalcitonin( 2ach !arathyroid gland is oval or lentifor in sha!e. directly or through the inferior thyroid !le&us( Parathyroid activity is controlled by blood calciu levelsD lo" levels sti ulate .artial thyroi+e*tomy. or a thyroglossal fistula( )hyroid tissue ay develo! at abnor al sites along the course of the duct resulting in lingual or retrosternal thyroids( .ou*h) )he inferior . are also *alle+ .erior . etc( #alignant gro"ths tend to invade and erode neighbouring structures( Pressure sy !to s and nerve involve ents are co on in carcino a of the glands( F(.arathyroi+ )/ because they develo! fro the endoder of the fourth . si ilarly.erior th6roi$ arter6 Su%erior %arath6roi$ 3+Nl J C I".%art o. i ediately above the inferior thyroid arteryD it B:C "ithin the substance of the lobe near its !osterior border( It is usually ventral to the recurrent laryngeal nerve( Vascular -uppl2 )he !arathyroid glands receive a rich blood su!!ly fro the inferior thyroid artery and fro the anasto osis bet"een the su!erior and inferior thyroid arteries( )he veins and ly !hatics of the gland are associated "ith those of the thyroid and the thy us( er7e -uppl2 )he anasto otic artery bet"een the su!erior and inferior thyroid arteries is usually a good guide to the glands because they usually lie close to it B1ig( 1F(9C( /aso otor nerves are derived fro the iddle and su!erior cervical ganglia. easuring 6&H&F Bthe si7e of a s!lit !eaC( 2ach gland "eighs about JG g( <osition )he su. &a%su#e oves "ith deglutition( oval of the thyroid Bthyroidecto yC "ith true ca!sule ay be necessary in hy!erthyroidis Bthyroto&icosisC( In .

and high levels inhibit the activity of the glands( .

internal thoracic and inferior thyroid veins( Ner5e Su%%#6 /aso otor nerves are derived fro the stellate ganglion( )he ca!sule is su!!lied by the !hrenic nerve and by the descendens cervicalis( Fu"&tio"s 1()he thy us controls ly !ho!oiesis.s from the en+o+erm of the thir+ .arathyroi+ism ay occur s!ontaneously or fro accidental re oval of the glands during thyroidecto y( )his results in hy!ocalcae ia leading to increased neuro uscular irritability causing uscular s!as and convulsions 2tetany3) TH MUS )he thy us is an i !ortant ly !hoid organ.9/( N Hea$ a"$ Ne&CLINICAL ANATOM 1()u ours of the !arathyroid glands lead to e&cessive secretion of !arathor one Bhy!er!arathyroidis C( )his leads to increased re oval of calciu fro bone a'ing the "ea' and liable to fracture( Calciu levels in blood increase Bhy!ercalcae iaC and increased urinary e&cretion of calciu can lead to the for ation of stones in the urinary tract( F(Hy. situated in the anterior and su!erior ediastina of the thora&. e&tending above into the lo"er !art of the nec'( It is "ell develo!ed at birth. and only 1G g after id-adult life( )hus after !uberty it beco es incons!icuous due to re!lace ent by fat( B#oo$ Su%%#6 )he thy us is su!!lied by branches fro the internal thoracic and inferior thyroid arteries( Its veins drain into the left brachioce!halic.elo. ade u! of t"o !yra idal lobes of une%ual si7e "hich are connected together by areolar tissue( Fa*h lobe +e. continues to gro" u! to !uberty.o. :G-HG g at !uberty. and thereafter undergoes gradual atro!hy and re!lace ent by fat( )he thy us is a bilobed structure. co !etent to react to innu erable antigenic sti uli( F(It controls develo! ent of the !eri!heral ly !hoid tissues of the body during the neonatal . and aintains an effective !ool of circulating ly !hocytes.ou*h) It lies on the !ericardiu .haryngeal . the great vessels of the su!erior ediastinu . and the trachea( S all detached thy ic nodules ay be found in the nec'( )he thy us "eighs 1G-1J g at birth.

etc(C are co itted cells. "hich sti ulates ly !hocyte !roduction both in the corte& of the thy us and in !eri!heral ly !hoid organsD and BbC the *om.oietin. i(e( they can react to any unfa iliar.is. causing hoarseness. oeso!hagus. cough. dys!hagia and cyanosis( AAAAAAAAAAAA SUBCLA1IAN ARTER AAAAAAAAAAA )his is the !rinci!al artery of the u!!er li b( It also su!!lies a considerable !art of the nec' and brain through its branches( . and ove out of the thy us to 3oin the circulating !ool of ly !hocytes "here they act as i unologically co !etent but unco itted cells.olution of the thy us is enhanced by hy!ertro!hy of the adrenal corte&. and the large veins of the nec'. in3ection of cortisone or of androgenic hor one( )he involution is delayed by castration and adrenalecto y( F()hy ic hy!er!lasia or tu ours are often associated "ith myasthenia gra. s!leen.eten*e&in+u*ing fa*tor. directly or indirectly.!eriod( By !uberty. characteri7ed by e&cessive fatiguability of voluntary uscles( )he !recise role of the thy us in this disease is uncertainD it ay influence. ne" antigen( 0n the other hand. the ain ly !hoid tissues are fully develo!ed( 1()he cortical ly !hocytes of the thy us arise fro ste cells of bone arro" origin( #ost B9J5C of the ly !hocytes B) ly !hocytesC !roduced are autoallergic Bact against the host or *self antigensC. i(e( they can ount an i une res!onse only "hen e&!osed to a !articular antigen( )hy ic ly !ho!oiesis. the trans ission at the neuro uscular 3unction( :()hy ic tu ours ay !ress on the trachea. short-lived B:-J daysC and never ove out of the organ( )hey are destroyed "ithin the thy us by !hagocytes( )heir re nants are seen in <assall*s cor!uscles( )he re aining J5 of the ) ly !hocytes are long-lived B: onths or oreC.ho. "hich ay be res!onsible for a'ing ne" ly !hocytes co !etent to react to antigenic sti uli( :(=or ally there are no ger inal centres in the thy ic corte&( Such centres a!!ear in autoi une diseases( )his ay indicate a defect in the nor al function of the thy us( CLINICAL ANATOM 1(In. ly -!holysis and involution are all intrinsically controlled( F()he edullary e!ithelial cells of the thy us are thought to secrete8 BaC 0ym. the other circulating ly !hocytes Bfro ly !h nodes.

the Se&o"$ Part Th6roi$ &arti#a!e Fi*+ #&+#$: $urface marking of subclavian and carotid arteries. 6nterior7 B1C Scalenus anterior( Structures in front of the scalenus anterior are8 BFC right !hrenic nerve dee! to the !revertebral fascia8 233 transverse cervical arteryD BHC su!rasca!ular arteryD BJC subclavian veinD B6C anterior 3ugular veinD and BAC sternocleido astoid B1ig( :(1GC( . second !oint at the iddle of the lo"er border of the clavicle( )he artery rises about F c above the clavicle( )he thoracic !art of the left subclavian artery is ar'ed by a broad vertical line along the left border > P Ar&h o.%%: (rigin and course of the subclavian arteries.t &o**o" &aroti$ arteries Le. aorta /6 Bra&hio&e%ha#i& arter6 Fi*+ %<.!oint on the sternoclavicular 3oint B1ig( 1F(1GC( b( . by 3oining the follo"ing t"o !oints8 a( .t su2&#a5ia" arter6 Ri!ht su2&#a5ia" arter6 It is ar'ed by a broad curved line. and the third !art lateral to the scalenus anterior( S&a#e"us a"terior First ri2 A F AAA Ri!ht a"$ BUA #e. internal thoracic artery and the thyrocervical trun' "ith its branches arising fro the first !art of the artery.#(' Ori*in 0n the right si+e it is branch of the brachioce!halic artery( It arises !osterior to the sternoclavicular 3oint( 0n the left si+e it is a branch of the arch of the aorta( It ascends and enters the nec' !osterior to the left sternoclavicular 3oint( Both arteries !ursue a si ilar course in the nec' B1ig( 1F(AC( DISSECTIO. the second !art !osterior. costocervlcal arising fro second !art and either dorsal sca!ular or none fro the third !art( Surface .ar8in* artery arches laterally fro the sternoclavicular 3oint to the outer border of the first rib "here it ends by beco ing continuous "ith the a&illary artery B1ig( 1F(11C( F()he scalenus anterior uscle crosses the artery anteriorly and divides it into three !arts( )he first !art is edial. Re#atio"s o. the First Part 6nterior7 I ediate relations fro edial to lateral side are8 B1C Co on carotid arteryD BFC ansa subclaviaD 233 cardiac branches of the vagus and of the sy !athetic trun'D BHC vagusD BJC vertebral veinD B6C internal 3ugular veinD BAC left !hrenic nerveD and B4C thoracic duct Bon left side onlyC( #ore su!erficial relations are8 B9C )he sternothyroid and the sternohyoid usclesD B1GC anterior 3ugular veinD and B11C sternocleido astoid B1ig( 1F(1FC( /osterior B!osteroinferiorC8 B1C Su!ra!leural e braneD BFC cervical !leuraD B:C a!e& of lungD BHC ansa subclaviaD and BJC right recurrent laryngeal nerve( Re#atio"s o.+P Stru&tures i" the Ne&. conve& u!"ards.Y of the anubriu a little to the left of the left co carotid artery( Course 1(2ach on Identify scalenus anterior uscle in the anteroinferior !art of the nec'( Subclavian artery gets divided into three !arts by this uscle( Identify vertebral.

/osterior B!osteroinferiorC8 B1C Su!ra!leural e braneD BFC cervical !leura.erior7 . the Thir$ Part 6nterior7 B1C Su!rasca!ular vesselsD BFC nerve to subcalvlus B:C !revertebral fasciaD BHC subclavian veinD BJC e&ternal 3ugular veinD B6C anterior 3ugular veinD BAC transverse cervical veinD B4C Su!rasca!ular veinD B9C investing fasciaD B1GC subclaviusD B11C iddle one-third of the clavicle.!!er and iddle trun's of the brachial !le&us( <u. #u"! er7e to su6cla7ius Su2&#a5ia" arter6 Lo1er trun! o4 6rachial ple:us -calenus 5edius 5 1erte2ra# 5ei" Phre"i& "er5e S&a#e"us a"terior Fig. %<.erior7 B1C . and B1FC the !osterior border of the Sternocleido astoid B1ig( :(AC( /osterior B!osteroinferiorC8 B1C Scalenus ediusD BFC lo"er trun' of brachial !le&usD B:C Su!ra!leural e braneD BHC cervical !leuraD and BJC a!e& of lung( )he subclavian artery usually gives off four branches( )hese are as follo"s8 1(/ertebral artery B1ig( 1F(1:C( F(Internal thoracic artery( :()hyrocervical trun'. %<: $chematic transverse section through the lower part of the neck to show the relations of the left subclavian artery. and B:C a!e& of lung( <u.9rans7erse cer7ical 7ein -uprascapular 7ein /n7esting 4ascia S S Cla7icle -u6cla7ius 3 -u6cla7ian 7ein <re7erte6ral 4ascia Su%ras&a%u#ar arter6 E:ternal Fugular 7ein %-ternocleido5astoid %Anterior Fugular 7ein -ternoth2roid %-te5oh2oid %/nternal Fugular 7ein %Co55on carotid arter2 %Vagus ner7e Ansa su6cla7ia %%-uprapleural 5e56rane OCCCCCC Cer5i&a# %#eura A%i&a# %art o. "hich divides into t"o branches8 BaC Su!erior intercostalD and BbC dee! cervical arteries( J(Dorsal sca!ular arteryMoccasionally( Cer7ical pleura Ape: o4 lung % Deep cer7ical arter2 r 9rans7erse process o4 C$ -uperior intercostal arter2 % ec! o4 4irst ri6 O Jirst posterior intercostal arter2 %Se&o"$ ri2 %-econd posterior intercostal arter2 9h2rocer7ical trun! -u6cla7ian arter2 /nternal thoracic arter2 % % Costo&er5i&a# tru"1erte2ra# arter6 .!!er and iddle trun's of brachial !le&usD and BFC inferior belly of o ohyoid( Inferior7 1irst rib( BRANCHES Re#atio"s o. "hich divides into three branches8 BaC Inferior thyroidD BbC Su!rasca!ularD and BcC transverse cervical arteries( H(Costocervical trun'.

Note that the branches actually arise at different levels. but are shown at one level schematically.%): &ranches of the subclavian artery.Fig. . %<.

/olu e 1C( In addition to branches to surrounding uscles. 1F(A. the artery also su!!lies the clavicle. the sca!ula. su!rasca!ular and transverse cervical arteries( )he inferior thyroi+ artery is described "ith the thyroid gland( In addition to glandular branches Bto the thyroidC it gives8 BaC )he ascending cervical artery "hich runs u!"ards in front of the transverse !rocesses of cervical vertebraeD BbC the inferior laryngeal artery "hich acco !anies the recurrent laryngeal nerve. and enters the laryn& dee! to the lo"er border of the inferior constrictorD and BcC other branches "hich su!!ly the !haryn&. and the shoulder and acro ioclavicular 3oints B1ig( :(11C( )he trans. the trachea. close to the edial border of the scalenus anterior. %<. /olu e F( 2hyrocervical 2runk )hyrocervical trun' is a short.ular artery runs laterally and do"n"ards. B:C the brachioce!halic vein.nteriorly the artery is related to8 B1C )he sternal end of the clavicle. to reach the su!erior border of the sca!ula( It crosses above the su!rasca!ular liga ent and ta'es !art in the anasto osis around the sca!ula BCha!ter A.i*al artery runs laterally above the su!rasca!ular artery( It crosses the scalenus anterior and the !hrenic nerve !assing behind the internal 3ugular vein and the sternocleido astoid( It then crosses the brachial !le&us and the floor of the !osterior triangle to reach the anterior border of tra!e7ius. behind the co on carotid artery. the oeso!hagus and surrounding uscles B1igs 1F(1H. the vertebral vein and the inferior thyroid artery B1ig( 1F(1HC( Details of all the four !arts are described in the section on the !revertebral region BCha!ter 1:C( . the distribution of dee! branch is ta'en over by dorsal sca!ular artery( !ostocervical 2runk Costocervical trun' arises fro the !osterior surface of the second !art of the subclavian artery on the . artery.art e&tends fro its origin to the fora en transversariu of the si&th cervical vertebra Bsee 1ig( 1F(::C( )his !art runs u!"ards and bac'"ards into the angle bet"een the scalenus anterior and the longus colli uscles. and BJC the !hrenic nerve( )he artery enters the thora& by !assing behind the first costal cartilage( 1or course of the artery in the thora& see Cha!ter 1H. 1F(4C( )he su. BHC the first costal cartilage. "ide vessel "hich arises fro the front of the first !art of the subclavian <hrenic ner7e t% -calenus anterior CZO Verte6ral arter2 Longus colli B% /n4erior th2roid arter2 O 9h2rocer7ical trun! arter2 Right co55on carotid arter2 M% Brachiocephalic arter2 ++ /nternal thoracic arter2 -uprascapular arter2 9rans7erse cer7ical arter2 Fig. and bet"een the !hrenic and vagus nerves( It al ost i ediately divides into the inferior thyroid. BFC the internal 3ugular vein. and crosses the scalenus anterior and the !hrenic nerve( It lies behind the internal 3ugular vein and the sternocleido astoid( It then crosses the trun's of the brachial !le&us and runs in the !osterior triangle. behind and !arallel "ith the clavicle.ras*a.erse *er.nternal 2horacic Artery Internal thoracic artery arises fro the inferior as!ect of the first !art of the subclavian artery o!!osite the origin of the thyrocervical trun'( )he origin lies near the edial border of the scalenus anterior B1ig( 1F(1HT(-)he artery runs do"n"ards and edially in front of the cervical !leura( .-tructures in the ec! "$' 'ertebral Artery /ertebral artery is the first and largest branch of the first !art of the subclavian artery( It runs a long course and ends in the cranial cavity by su!!lying the brain( It is divided into four !arts( )he first . "here it divides into a su!erficial and dee! branches( )he su!erficial branch acco !anies the s!inal root of accessory nerve till the lo"er end of the uscle( )he dee! branch !asses dee! to levator sca!ulae and ta'es !art in the anasto osis around the sca!ula( So eti es the t"o branches ay arise se!aratelyD the su!erficial fro thyrocervical trun' and the dee! fro the third !art of subclavian artery( )hen these are na ed as su!erficial cervical and dorsal sca!ular arteries( 9orsal $capular Artery Dorsal sca!ular artery arises occasionally fro the third !art of subclavian artery( If transverse cervical does not divide into su!erficial and dee! branches but continues as su!erficial branch.%6: &ranches of the right subclavian artery.

i*al rib ay co !ress the subclavian artery. "ea'ness. and is covered by8 B1C )he sternocleido astoidD BFC the anterior 3ugular veinD B:C the sternohyoidD BHC )he sternothyroid and the iddle thyroid vein( . and divides into the first and second !osterior intercostal arteries( )he dee! *er.i*al artery is analogous to the !osterior branch of a !osterior intercostal artery( It !asses bac'"ards bet"een the transverse !rocess of the Ath cervical vertebra and the nec' of the first rib( It then ascends bet"een the se i!inalis ca!itis and cervicis u! to the a&is vertebra( It anasto oses "ith the occi!ital and vertebral arteries( CLINICAL ANATOM Internal Caroti+ 6rtery It is ar'ed by a broad line 3oining the follo"ing t"o !oints( BaC. second !oint on the !osterior border of the condyle of the andible( )he origin and course of the co on carotid arteries has been described in Cha!ter 4( )he relations of the artery in the nec' are given8 DISSECTION S1( )he third !art of the subclavian artery can be effe*ti.erior inter*ostal artery descends in front of the nec' of the first rib. and edially in the angle bet"een the sternocleido astoid and the clavicle( 1(6 *er. BC( A"terior Re#atio"s BaC)he co COMMON CAROTID ARTER Surface . bac'"ards. internal 3ugular and brachioce!halic veins( )he co on carotid artery is enclosed in the *aroti+ sheath) )he three contents of the sheath are8 B1C )he co on carotid artery ediallyD BFC the internal 3ugular vein.ely *om. 1F(1HC( )he su. !osteriorly B1ig( :(H. the artery is dee!ly situated. and divides into the su!erior intercostal and dee! cervical arteries at the nec' of the first rib B1igs 1F(1:.ar8in* Common Caroti+ 6rtery It is ar'ed by a broad line along the anterior border of the sternocleido astoid uscle by 3oining the follo"ing t"o !oints( BaC.right sideD but fro the first !art of the artery on the left side( It arches bac'"ards over the cervical !leura.resse+ against the first rib after de!ressing the shoulder( )he !ressure is a!!lied do"n"ards. laterallyD and B:C the vagus in bet"een the artery and the vein. !oint on the anterior border of the sternocleido astoid uscle at the level of the u!!er border of the thyroid cartilage( BbC. di inishing the radial !ulse( F(. second !oint on the anterior border of the sternocleido astoid uscle at the level of the u!!er border of the thyroid cartilage( )he thoracic !art of the left co on carotid artery is ar'ed by a broad line e&tending fro a !oint a little to the left of the centre of the anubriu to the left sternoclavicular 3oint( on carotid artery is crossed by the su!erior belly of the o ohyoid at the level of the cricoid cartilage B1ig( 1F(1JC( BbC. and nu bness in the u!!er li b( )he right subclavian artery ay arise fro the descending thoracic aorta( In that case. !oint on the sternoclavicular 3oint B1ig( 1F(1GC( BbC..t the level of the o ohyoid there are 8 B1C )he sternocleido astoidD BFC the o ohyoidD B:C the sternohyoidD BHC the sternothyroidD and BJC the ansa cervicalis( BdCBelo" the o ohyoid.bove the o ohyoid Bin the carotid triangleC the artery is co !aratively su!erficial.n aneurysm ay for in the third !art of the subclavian artery( Its !ressure on the brachial !le&us causes !ain. dee! to "hich there areD BFC the descendens hy!oglossi nerveD B:C the su!erior thyroid veinD BHC the sternothyroidD and BJC the ansa cervicalis( BcC. and is related to8 B1C )he edial BanteriorC argin of the sternocleido astoid. it !asses !osterior to the oeso!hagus "hich ay be co !ressed and the condition is 'no"n as 2+ys.hagia lusoria3) )he co on carotid artery has been e&!osed in the carotid triangle( Clean it in its entire course( Identify the internal carotid artery and trace it till it leaves the nec'( /eins Identify the tributaries of subclavian.

Posterior Re#atio"s B1C )ransverse !rocess of vertebrae CH.i. "ithin the cavernous sinusD and BdC cerebral !art in relation to the base of the brain( C Cer5i&a# Part 1(It ascends vertically in the nec' fro B1C )hyroid glandD BFC laryn& and !haryn&D trachea. in the nec'D BbC !etrous !art. scalenusanteriorCD BFC the !revertebral fascia covers the usclesD B:C the sy !athetic chain descends on the longus colliD BHC the ascending cervical artery ascends in front of the tuberclesD BJC the inferior thyroid artery crosses edially at the level of the cricoid cartilageD B6C vertebral arteryD BAC on the left side the thoracic duct crosses laterally behind the artery at the level of vertebra CA. %<. "ithin the !etrous te !oral boneD BcC cavernous !art. and ends inside the cranial cavity by su!!lying the brain( )his is the !rinci!al artery of the brain and the eye( It also su!!lies the related bones and eninges( 1or convenience of descri!tion the course of the artery is divided into four !arts8 BaC Cervical !art. 6 and %.resse+ against the carotid tubercle.-uperior 7ein -ternocleido5astoid 6ranch o4 superior th2roid arter2 % th2roid Ascending cer7ical arter2 <re7erte6ral 4ascia =fI 9rans7erse process o4 C? O Longuscolli O/ Descendens h2poglossi % . in front of the vertebral vesselsD B4C on the right side the right recurrent laryngeal nerve crosses edially behind the lo"er end of the artery B1ig( 1F(4C( Me$ia# Re#atio"s CLINICAL ANATOM )he co on carotid artery can be *om. and the uscles attached to their anterior tubercles Blonguscolli. i(e( the anterior tubercle of the transverse !rocess of vertebra C6 "hich lies at the level of the cricoid cartilage( the level of the u!!er border of the thyroid cartilage o!!osite the disc bet"een the third and fourth cervical vertebrae. J..) Co55on carotid arter2 P / 3 -25pathetic trun! Ansa cer7icalis 3 -uperior 6ell2 o4 o5oh2oid Middle th2roid 7ein O Ster"oh6oi$ AA /n4erior th2roid arter2 -te5oth2roid O -ternocleido5astoid O3 O Middle cer7ical ganglion % Verte6ral arter2 +*@@+H 9rans7erse process o4 C$ /n4erior cer7ical ganglion Anterior Fugular 7ein O 9horacic duct p== -UDCla7ia Fig.%+: $chematic sagittal section showing anterior and posterior relations of the common carotid artery. oeso!hagus and recurrent laryngeal nerve B1ig( 1F(JC( 0ateral relation Internal 3ugular vein( /osterolateral relation /agus nerve( INTERNAL CAROTID ARTER )he internal carotid artery is one of the t"o ter inal branches of the co on carotid artery( It begins at its origin to the base of the s'ull to reach the lo"er end of the carotid canal( )his !art is enclosed in the carotid sheath B"ith the internal 3ugular vein and the vagusC( F(=o branches arise fro the internal carotid artery in the nec'( . longusca!itis.

the artery first runs u!"ards. the *aroti+ sinus "hich acts as a barorece!tor BCha!ter 4C( H()he lo"er !art of the artery Bin the carotid triangleC is co !aratively su!erficial( )he u!!er !art. accessory and hy!oglossal nerves at the base of the s'ull( /edial Anterior or $uperficial I( In the carotid triangle8 B1C .nterior border of sternocleido astoidD BFC hy!oglossal nerveD B:C occi!ital arteryD BHC descendens hy!oglossiD BJC co on facial and lingual veinsD and B6C the e&ternal carotid artery is antero edial to it( II( .bove the carotid triangle8 B1C Posterior belly of the digastricD BFC stylohyoidD B:C !osterior auricular arteryD BHC stylo!haryngeusD BJC styloid !rocessD B1C!arotid gland "ith structures "ithin itD BFCglosso!haryngeal nerveD B4C !haryngeal branch of vagus nerveD and B9C the cartilaginous !art of the auditory tube and the tensor veil !alatini Bat the base of the s'ullC B1ig( 1F(16C( 2I3 Pharyn&D BFC ascending !haryngeal arteryD B:C internal and e&ternal laryngeal nervesD BHC the e&ternal carotid is antero edial to it belo" the !arotidD and BJC levator veli !alatini Bat the base of the s'ullC( 5ateral 2I3 Internal 3ugular veinD and BFC the bony !art of the auditory tube.:(Its initial !art usually sho"s a dilatation. and then turns for"ards and edially at /nternal carotid arter2 3R Auditor2 tu6e%%%%%%% 9ensor 7eli palatini%%%%%%% 3 <arotid gland . the styloid a!!aratus. vagus. !osterolateral throughoutD and B4C the glosso!haryngeal. and any other structures( 7elations Posterior 2"3 @ongus ca!itisD BFC !revertebral fasciaD B:C su!erior cervical ganglionD BHC su!erior laryngeal nerveD BJC carotid sheathD B6C !haryngeal veinsD BAC vagus. is dee! to the !arotid gland. CA J ' r %( <har2ngeal 6ranch o4 7agusO'%+'%Ri U ' S E:ternal carotid 'O -uperior cer7ical s25pathetic ganglion 'O <re7erte6ral 4ascia P3 Longus capitis O -uperior lar2ngeal ner7e arter2%%%%%%%%%%%%% %Occipital arter2 -ternocleido5astoid %H2poglossal ner7e %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %Des&e"$e"s h6%o!#ossi * Co55on 4acial 7ein AAAAAAAAAAAAAAAAAAAAAAAAA K K -t2lophar2ngeus O%EiCl %7 D=IP% %(+E t2loh2oid . ty !anic !late and the te !oroandibular 3oint Bat the base of the s'ullC( Petrous Part 1( In the carotid canal. St6#oi$ %ro&ess B 9+i'J. above the !osterior belly of the digastric.

%<osterior 6ell2 o4 digastric 0lossophar2ngeal ner7e G Vagus ner7e E E H2poglossal ner7e E E E E Accessor2 ner7e i l*B.%7: $chematic sagittal section showing the anterior and posterior relations of the internal carotid artery. %<. E Fig. .

in the !osterior "all of the fora en laceru "here it turns u!"ards and edially( 1(Belations7 )he artery is surrounded by venous and sy !athetic !le&uses( It is related to the iddle ear and the cochlea B!osterosu!eriorlyCD the auditory tube and tensor ty !ani BanterolaterallyCD and the trige inal ganglion Bsu!eriorlyC( F(Bran*hes7 2a3 Caroti*otym.terygoi+ bran*h Bs all and inconstantC enters the !terygoid canal "ith the nerve of that canal and anasto oses "ith the greater !alatine artery( Ca5er"ous a"$ Cere2ra# Parts o. and ends at the edial border of the scalenus anterior by 3oining the internal 3ugular vein to for the brachioce!halic vein( It lies8 BaC In front of the subclavian artery. the scalenus anterior and the right !hrenic nerveD BbC behind the clavicle and the subclaviusD and BcC above the first rib and !leura( Its tributaries are8 BaC )he e&ternal 3ugular veinD BbC the dorsal sca!ular vein BcC the thoracic duct on the left sideD and BdC the right ly !hatic duct on the right side( So eti es. $=3$$@ $urface marking of a few veins.ar8in* It is re!resented by a broad line along the clavicle e&tending fro a little edial to its id!oint to the edial end of the bone B1ig( 1F(1AC( Su2&#a5ia" 5ei" /nternal Fugular 7ein E:ternal Fugular 7ein H2oid 6one 9h2roid cartilage Fig.right angles( It e erges at the a!e& of the !etrous te !oral bone. I"ter"a# Caroti$ Arter6 Course It is a continuation of the a&illary vein( It begins at the outer border of the first rib. .ani* branches enter the iddle ear. it ay also receive8 BaC )he anterior 3ugular veinD and BbC a s all branch fro the ce!halic vein "hich crosses the clavicle to reach the subclavian vein( See cranial cavity BCha!ter 6C( SUBCLA1IAN 1EIN INTERNAL JUIULAR 1EIN Surface . and anasto ose "ith the anterior and !osterior ty !anic arteriesD and BbC the .

the su. accessory and hy!oglossal . and ends behind the sternal end of the clavicle by 3oining the subclavian vein to for the brachioce!halic vein( F()he origin is ar'ed by a dilation. vagus.Surface . and the glosso!haryngeal. beneath the floor of the iddle ear cavity( )he ter ination of the vein is ar'ed by the inferior bulb "hich lies beneath the lesser su!raclavicular fossa( Re#atio"s <u.ar8in* It is ar'ed by a broad line by 3oining the follo"ing t"o !oints( a( )he first !oint on the nec' edial to the lobule of the ear B1ig( 1F(1AC( b( )he second !oint at the edial end of the clavicle( )he lo"er bulb of the vein lies beneath the less su!raclavicular fossa bet"een the sternal and clavicular heads of the sternocleido astoid uscle( Course 1(It is a direct continuation of the sig oid sinus( It begins at the 3ugular fora en.erfi*ial7 2I3 Sternocleido astoidD BFC !osterior belly of digastricD B:C su!erior belly of o ohyoidD BHC !arotid glandD BJC styloid !rocessD B6C accessory nerveD BAC !osterior auricular arteryD B4C occi!ital arteryD B9C sternocleido astoid arteriesD B1GC lo"er root of ansa cervicalisD B11C infrahyoid usclesD B1FC anterior 3ugular veinD B1:C dee! cervical ly !h nodesD and B1HC the internal carotid artery.erior bulb "hich lies in the 3ugular fossa of the te !oral bone.

ectus ca!itis lateralisD BFC transverse !rocess of atlasD B:C levator sca!ulaeD BHC scalenus rnediusD BJC cervical !le&usD B6C scalenus anteriorD BAC !hrenic nerveD B4C thyrocervical trun'D B9C inferior thyroid arteryD B1GC first !art of subclavian arteryD and B11C thoracic duct Bon left sideC( 1e+ial7 2I3 Internal carotid arteryD BFC co on carotid arteryD and B:C vagus nerve( 2ributaries CL/ /CAL A A9OMb 1(Dee! B1C Inferior !etrosal sinusD BFC co on facial veinD B:C lingual veinD BHC !haryngeal veinsD BJC su!erior thy ro id veinD B 6C iddle thyroid veinD and BAC so eti es the occi!ital vein B1ig( 1F(14C( )he thoracic duct o!ens into the angle of union bet"een the left internal 3ugular vein and the left subclavian vein( )he right ly !hatic duct o!ens si ilarly on the right side( In the iddle of the nec'. the internal 3ugular vein is easily accessible for recording of venous !ulse tracings( F(In congestive cardiac failure or any other disease "here venous !ressure is raised. during o!eration on such !atients the vein is also resected( behind the u!!er half of the anubriu sterni( )he t"o brachioce!halic veins unite at the lo"er border of the right first costal cartilage to for the su!erior vena cava( H( )he tributaries corres!ond to the branches of the first !art of the subclavian artery( )hese are as follo"s( Bight bra*hio*e. 9horacic duct 3 P % /n4erior petrosal sinus Jacial 7ein % Verte6ral 7ein %%%%%%%%%%%%%% /nternal thoracic 7ein . by the union of the internal 3ugular vein and the subclavian vein( :()he right vein runs vertically do"n"ards( )he left vein runs obli%uely do"n"ards and to the right -uperior 6ul6 o4 internal Fugular 7ein%%%%%%%% /nternal Fugular 7ein Occipital 7ein O%PP <har2ngeal 7ein%%%%%%%%% PR Middle th2roid 7ein Right l25phatic duct` E:ternal Fugular 7ein P Dorsal scapular 7ein O Right su6cla7ian 7ein %% /n4erior th2roid 7eins .cranial nerves Bat the base of the s'ullC _see 1ig( 1F(1FP( /osterior7 N1C . the internal 3ugular vein ay co unicate "ith the e&ternal 3ugular vein through the obli%ue 3ugular vein "hich runs across the anterior border of the sternocleido astoid( BRACH/OCE<HAL/C 1EIN to the lesser su!raclavicular fossa.hali* a( /ertebral b( Internal thoracic c( Inferior thyroid d( 1irst !osterior intercostal 1()he right brachioce!halic vein BF(J c longC is shorter than the left B6 c longC B1ig( 1F(14C( F(2ach vein is for ed behind the sternoclavicular 3oint.>L Right 6rachiocephalic 7ein O -uperior 7ena ca7a O %Lingual 7ein %-uperior th2roid 7ein . the internal 3ugular vein is ar'edly dilated and engorged( :()he dee! cervical ly !h nodes lie on the internal 3ugular vein( )hese nodes often beco e adherent to the vein in alignancy of in tuberculosis( )herefore.hali* a( /ertebral b( Internal thoracic c( Inferior thyroid d( 1irst !osterior intercostal( 0eft bra*hio*e..

%<.%1: 2he veins of the neck. .Jirst -econd and ) 9hird posterior intercostal 7eins Le4t superior intercostal 7ein Le4t 6rachiocephalic 7ein Fig.

tonsil. !haryn&( )he central !rocesses carry ( these sensations to nucleus of s!inal tract of trige inal nerve( Lesser petrosal ner7e Otic ganglion /nternal carotid arter2 <har2ng Middle ear ca7it2 925panic ple:us 925panic 6ranch 0lossophar2ngeal ner7e eal 6ranch 9h2roi d cartila ge st2lop har2n geus Fig.is*eral efferent fibres arise in the nucleus a biguus and su!!ly the stylo!haryngeus uscle( BbCCeneral .is*eral efferent fibres B!reganglionicC arise in the inferior salivary nucleus and travel to the otic ganglion( Postganglionic fibres arising in the ganglion to su!!ly the !arotid gland B)able 1(:C( BcCCeneral . the !osterior one-third of the tongue. touch.%K: Carotid 6ranch % &ranches of the .e( @eft su!erior intercostal f( )hy ic and !ericardial veins ILOSSOPHAR NIEAL NER1E +losso!haryngeal is the ninth cranial nerve( It is the nerve of the third branchial arch( It is otor to the stylo!haryngeusD secreto otor to the !arotid glandD gustatory to the !osterior one-third of the tongue including the circu vallate !a!illae and sensory to the !haryn&.e*ial . carotid body and carotid sinus B1ig( 1F(19C( DISSECTION Fu"&tio"a# Co*%o"e"ts BaC<.e*ial .is*eral afferent fibres are !eri!heral )he course of IO-OII cranial nerves has been seen in different cha!ters( =o" trace these nerves and their branches( <ym. %<. te !eratureC fro !osterior one-third of tongue.atheti* Trunk )he sy !athetic trun' has been identified as lying !ostero edial to the carotid sheath( )race it u!"ards and do"n"ards and locate the three cervical ganglia( Dissect the for ation and branches of the cervical !le&us( Identify the !hrenic nerve on the surface of scalenus anterior uscle behind the !revertebral fascia( !rocesses of cells in the inferior ganglion of the nerve( )hey carry general sensations fro the !haryn&. carotid body and carotid sinus to the ganglion( )he central !rocesses convey these sensations to the nucleus of the solitary tract( BdC<.is*eral afferent fibres are also !eri!heral !rocesses of cells in the inferior ganglion( )hey carry sensations of taste fro the !osterior one-third of the tongue including circu vallate !a!illae to the ganglion( )he central !rocesses convey these sensations to the nucleus of the solitary tract( BeCCeneral somati* afferent fibres are the !eri- !heral !rocesses of the cells in the inferior ganglion of the nerve( )hese carry general sensations B!ain. the tonsil.

glossopharyngeal nerve. <arotid gland -o4t palate .

W. and gives out co unicating and ty !anic branches( 1(In 9ragus 9rans7erse process o4 atlas 0lossophar2ngeal ner7e -pinal accessor2 ner7e %Vagus ner7e H2poglossal ner7e H2oid 6one 9h2roid cartilage 9rapeLius Anterior 6order o4 sternocleido5astoid -tern ocleido5astoid Fi*+ #&+&$: $urface marking of cranial nerves . the nerve descends BiC bet"een the internal 3ugular vein and the internal carotid artery. W. W. bet"een the olivary nucleus and the inferior cerebellar !eduncle. ninth nerve !resents a su!erior and an inferior ganglion( Su!erior ganglion is a detached !art of the inferior. 3ust above the rootlets of the vagus nerve B1ig( FH(1C( their intracra al course the fila ents unite to for a single trun' "hich !asses for"ards and laterally to"ards the 3ugular fora en. and gives no branches( )he inferior ganglion is larger..ugular foramen. dee! to the styloid !rocess and the uscles attached to itD BiiC it then turns for"ards "inding round the lateral as!ect of the stylo!haryngeus.t the base of the brain. and is se!arated fro the vagus and accessory nerves by the inferior !etrosal sinus( In its extra*ranial *ourse. through the reticular for ation of the edulla BCha!ter FHC( F(.Nu&#ei )he three nuclei in the u!!er !art of edulla are na ed belo"8B1C =ucleus a biguus Bbranchio otorC BFC inferior salivary nucleus B!arasy !atheticC B:C nucleus of tractus solitarius BgustatoryC( Surface . the nerve is attached by : to H fila ents to the u!!er !art of the !ostero-lateral sulcus of the edulla.t the base of s'ull.ar8in* Cranial nerve IO is ar'ed by 3oining the follo"ing !oints( BaC)he first !oint on the anteroinferior !art of the tragus B1ig( 1F(FGC( BbC)he second !oint anterosu!erior to the angle of the andible( 1ro !oint *b* the nerve runs for"ards for a short distance along the lo"er border of the andible( )he nerve describes a gentle curve in its course( Course a"$ Re#atio"s 1(In their intraneural *ourse. crossing and grooving the 3ugular tubercle of the occi!ital bone( F()he nerve lea.es the skull by !assing through the iddle !art ofthe . !asses bet"een the e&ternal and internal carotid arteries.. BiiiC It enters the sub andibular region by !assing dee! to the hyoglossus B1ig( 11(FC. . anterior to the vagus and accessory nerves( It has a se!arate sheath of dura ater( :(In the 3ugular fora en. occu!ies notch on the lo"er border of !etrous te !oral. and reaches the side of the !haryn& B1ig( 1H(11C( <ere it gives !haryngeal branches. the fibres of the nerve !ass for"ards and laterally. "here it brea's u! into tonsillar and lingual branches B1ig( 1F(19C( 6( . the nerve is lodged in a dee! groove leading to the cochlear canaliculus. W..

there is refle& contraction of the !haryngeal uscles( =o such contraction occurs "hen the ninth nerve is !aralysed.<%: Felation of cranial nerves . %<. to carotid arteries and internal Gugular vein.ani* ner. in these cases eustachian catarrh should be e&cluded( PPPPPPPPPPPPPPP VA0U. su!erior and inferior( )he su. the astoid antru and air cells( 0ne branch of the !le&us is called the lesser !etrosal nerve( It contains !reganglionic secreto otor fibres for the !arotid gland( 1or detailed course of these fibres see otic ganglion BCha!ter 1GC( F()he *aroti+ bran*h descends on the internal carotid artery and su!!lies the carotid sinus and the carotid body( :()he .W. through the head. /nternal carotid arter2 Cranial root o4 accessor2 ner7e Foining in4erior ganglion o4 7agus E:ternal carotid arter2 0lossophar2ngeal ner7e -pinal accessor2 ner7e <har2ngeal 6ranch o4 7agus -uperior lar2ngeal 6ranch /nternal Fugular 7ein H2poglossal ner7e on lingual arter2 Vagus ner7e /nternal lar2ngeal ner7e -uperior lar2ngeal arter2 -uperior th2roid arter2 E:ternal lar2ngeal ner7e . the auditory tube.ERVEPPPPPPPPPPPPPPP /agus nerve is the tenth cranial nerve( It is so called because of its e&tensive B*vague*C course. the thora& and the abdo en( )he fibres of the cranial root of the accessory nerve are also distributed through it( )he vagus nerve bears t"o ganglia.erior ganglion is rounded and lies in the 3ugular fora en( )he inferior ganglion is cylindrical and lies near the base of the s'ull B1ig( 1F(F1C( Co55on carotid arter2 Fig. along "ith vagal and sy !athetic fibres( )he glosso!haryngeal fibres are distributed to the ucous e brane of the !haryn&( H()he mus*ular bran*h su!!lies the stylo!haryngeus B1ig( 1H(14C( J( )he tonsillar bran*hes su!!ly the tonsil and 3oin the lesser !alatine nerves to for a !le&us fro "hich fibres are distributed to the soft !alate and to the !alatoglossal arches B1ig( 1F(19C( 6( )he lingual bran*hes carry taste and general sensations fro the !osterior one-third of the tongue including the circu vallate !a!illae( 1()he 1()he glosso!haryngeal nerve is tested clinically in the follo"ing "ay8 BaC 0n tic'ling the !osterior "all of the !haryn&. W.Branches and Distri6ution CL/ /CAL A A9OMb tym. ta'es !art in the for ation of the ty !anic !le&us Bon the edial "all of the iddle earC and distributes its fibres to the iddle ear. W5 W.e is a branch of the inferior ganglion of the glosso!haryngeal nerve( It enters the iddle ear through the ty !anic canaliculus. BbC )aste sensibility on the !osterior one-third of the tongue can also be tested( It is lost in ninth nerve lesions( F(Isolated lesions of the ninth nerve are al ost un'no"n( )hey are usually acco !anied by lesions of the vagus nerve( :(Pharyngitis ay cause referred !ain in the ear( <o"ever. the nec'.haryngeal bran*hes ta'e !art in the for ation of the !haryngeal !le&us..

e*ial .a&e Mar-i"! )he nerve runs along the !ostero edial side of the internal 3ugular vein( It is ar'ed by 3oining the follo"ing t"o !oints( BaC)he first !oint at the anteroinferior !art of the tragus B1ig( 1F(FGC( BbC)he second !oint at the edial end of the clavicle( Nu&#ei 1(=ucleus a biguus Bbranchio otorC8 ostly a !art of the cranial root of accessory nerveD !artly of vagus( F(Dorsal nucleus of vagus B!arasy !atheticC8 it is a i&ed nucleus.is*eral efferent fibres arise in the dors al otor nucleus of the va gus( )hes e a re !reganglionic !arasy !athetic fibres( )hey are distributed to thoracic and abdo inal viscera( )he !ostganglionic neurons are situated in ganglia lying close to Bor "ithinC the viscera to be su!!lied( BcCCeneral . oeso!hagus and fro the abdo inal and thoracic viscera( )hese are conveyed by the central !rocesses of the ganglion cells to the nucleus of the tractus solitarius( So e of these fibres ter inate in the dorsal nucleus of the vagus( BdC<.is*eral efferent fibres arise in the H(=ucleus of s!inal tract of trige inal( nucleus a biguus and su!!ly the uscles of the !alate.is*eral afferent fibres are !eri!heral !rocesses of cells located in the inferior ganglion of the nerve( )hey bring sensations fro the !haryn&. laryn&. !haryn& and laryn&( BbCCeneral .Fu"&tio"a# Co*%o"e"ts BaC<. trachea. being both otor Bviscero otor and secreto otorC and sensory BviscerosensoryC( Its fibres for the ain bul' of the nerve( :(=ucleus of tractus solitarius BgustatoryC8 distributed through internal laryngeal nerve to the taste buds of e!iglottis and vallecula( .e*ial .is*eral afferent fibres are also !eri!heral !rocesses of neurons in the inferior ganglion( )hey carry sensations of taste fro the !osterior ost !art of the tongue and fro the e!iglottis( )he central !rocesses of the cells concerned ter inate in the u!!er !art of the nucleus of the tractus solitarius( BeCCeneral somati* afferent fibres are !eri!heral !rocesses of neurons in the su!erior ganglion and are distributed to the s'in of the e&ternal ear( )he central !rocesses of the ganglion cells ter inate in relation to the s!inal nucleus of the trige inal nerve( Sur.

and the internal and co on carotid arteries B ediallyC B1igs :(:. to reach the right side of the trachea( )he left vagus enters the thora& by !assing bet"een the left co on carotid and left subclavian arteries. the su!erior ganglion gives off8 B1C #eningeal. to the !osterolateral sulcus of the edulla( :(In the intracranial course. bet"een the olivary nucleus and inferior cerebellar !eduncle BCha!ter FHC( F()he nerve is attached. the nerve descends "ithin the carotid sheath.Course a"$ Re#atio"s i" Hea$ a"$ Ne&1(In t he intra*rani al *our se. it is 3oined by the cranial root of the accessory nerve( J(@eaving the s'ull. and is connected to hy!oglossal nerve. bet"een the sig oid and inferior !etrosal sinuses( In the fora en. and reaches the 3ugular fora en( H()he nerve lea.ity by !assing through the iddle !art of the 3ugular fora en. su!erior and inferior( )he su. and BFC auricular branches( )he ganglion also gives off co unicating branches to the glosso!haryngeal and cranial root of accessory nerves and to the su!erior cervical sy !athetic ganglion( )he branches arising in the nec' are8 B1C PharyngealD BFC carotidD B:C su!erior laryngealD BHC right recurrent laryngealD and BJC cardiac B1ig( 1F(F1C( . behind the internal 3ugular and brachioce!halic veins( A(/agus bears t"o ganglia. :(H . and then inclining edially behind the brachioce!halic vessels. the rootlets unite to fro a large trun' "hich !asses laterally across the 3ugular tubercle along "ith the glosso!haryngeal and cranial root of accessory nerves. and is connected to glosso!haryngeal and accessory nerves and to su!erior cervical ganglion of sy !athetic chain( )he inferior ganglion is cylindrical BF(J c C and lies near the base of s'ull( It gives !haryngeal. the fib res run for"ards and laterally through the reticular for ation of edulla.erior ganglion is rounded and lies in the 3ugular fora en( It gives eningeal and auricular branches of vagus.t the root of the ne*k. su!erior cervical ganglion and the loo! bet"een first and second cervical nerves( Bra"&hes i" Hea$ a"$ Ne&- In the 3ugular fora en.es the *ranial *a. in bet"een and !osterior to the internal 3ugular vein BlaterallyC. carotid and su!erior laryngeal branches of vagus. by about ten rootlets. the right vagus enters the thora& by crossing the first !art of the subclavian artery. BC( 6(..

e arises fro the inferior 6 ganglion of the vagus.1eningeal bran*h su!!lies dura of the !osterior cranial fossa( )he fibres are derived fro sy !athetic and u!!er cervical nerves( )he auri*ular bran*h arises fro the su!erior ganglion of the vagus( It !asses behind the internal 3ugular vein. etc(C ay refle&ly cause !ersistent cough Bear coughC. and enters the laryn& behind the cricothyroid 3ointflt su!!lies8 BaC . and contains chiefly the fibres of the cranial root of accessory nerve( It !asses bet"een the e&ternal and internal carotid arteries. and enters the astoid canaliculus B"ithin the !etrous te !oral boneC( It crosses the facial canal H above the stylo astoid fora en. and the ty !anic e brane Bouter surfaceC( )he . !ierces the inferior constrictor and ends by su!!lying the cricothyroid uscle( It also gives branches to the inferior constrictor and to the !haryngeal !le&us( '^0 B)he internal laryngeal ner. 1F(4C( t. "inds bac'"ards belo" the artery. e erges through the ty !ano astoid fissure. K ' 2The right re*urrent laryngeal ner. and reaches the iddle constrictor "here it divides into the e&ternal and internal laryngeal nerves>C )he external laryngeal ner. and they runs u!"ards and edially behind the subclavian and co on carotid arteries to reach the tracheo-oeso!hageal groove( In the u!!er !art of the groove. there is no arching.erior laryngeal ner. as the latter crosses the left side of the arch of the aorta( It loo!s around the Idga entu arteriosu and reaches the tracheoSeso!hageal grooveC Its distribution is si ilar to that of the right nerve( It does not have to !ass behind the subclavian and carotid arteriesD and usually it is !osterior to the inferior thyroid artery B1igs 1F(61F(4C( )he *ar+ia* bran*hes are su!erior and inferior( 0ut of the four cardiac branches of the vagi Bt"o on each sideC the left inferior branch goes to the su!erficial cardiac !le&us( )he other three cardiac nerves go to the dee! cardiac !le&us( CLINICAL ANATOM 1()he vagus ner.ll intrinsic uscles of the laryn&.agus in the e&ternal ear Bby ear "a&. vesicles a!!ear on the s'in of the auricle( AAAAAAAAAAAAACCESSOR NER1E .e is teste+ *lini*ally by co !aring the !alatal arches on the t"o sides( 0n the !aralysed side. BbC sensory nerves to the laryn& belo" the level of the vocal cordsD BcC cardiac branches to the dee! cardiac !le&usD G( BaCbranches to the trachea >and oeso!hagusD and BbCto the inferior constrictor(> left re*urrent laryngeal ner.e is thic'( It !asses C do"n"ards and for"ards.e is thin( It acco !anies the su!erior thyroid artery. !ierces the thyrohyoid e brane Babove the su!erior laryngeal vesselsC and enters the laryru>r It su!!lies the ucous e brane of the laryn& u!to the level of the vocal foldsC B1igs 1F(J.ccessory nerve is the eleventh cranial nerve( It has t"o roots. and reaches the u!!er border of the iddle constrictor of the !haryn& "here it ta'es !art in for ing the !haryngeal !le&us( Its fibres are ulti ately distributed to the uscles of the !haryn& and soft !alate Be&ce!t the tensor veli !alatini "hich is su!!lied by the andibular nerveC( )he *aroti+ bran*hes su!!ly the carotid body and carotid sinus( B)he su. so e branches are in front of the nerve. and so e are behind it( )he nerve then !asses dee! to the lo"er border of the inferior constrictor. and is distributed through the branches of the latter( )he s!inal root has a ore inde!endent course B1ig( 1F(FFC( F(/aralysis of the . e&fce!t the cricothyroid. runs do"n"ards and for"ards on the su!erior constrictor dee! to the internal carotid artery. or even death due to sudden cardiac inhibition( F(<timulation of the auri*ular bran*h ay refle&ly !roduce increased a!!etite( :(Irritation of the recurrent laryngeal nerve by enlarged ly !h nodes in children ay also !roduce a !ersistent cough( H(So e fibres arising in the geniculate ganglion of the facial nerve !ass into the vagus through co unications bet"een the t"o nerves( )hey reach the s'in of the auricle through the auricular branch of the vagus( So eti es a sensory ganglion ay have a viral infection Bcalled her!es 7osterC and vesicles a!!ear on the area of s'in su!!lied by the ganglion( In her!es 7oster of the geniculate ganglion. the !osterior half of the e&ternal auditory eatus. and the uvula is !ulled to the nor al side( BaC =asal regurgitation of s"allo"ed li%uidsD BbC nasal t"ang in voiceD BcC hoarseness of voiceD BdC flattening of the !alatal archD BeC cadaveric !osition of the vocal cordD and BfC dys!hagia( 1(Irritation of the auri*ular bran*h of the . syringing. it is related to the inferior thyroid arter" It ay be su!erficial or dee! to the artery( 0ccasionally. cranial and s!inal( )he cranial root is accessory to the vagus. vo iting.haryngeal bran*h arises fro the u!!er !art of the inferior ganglion of the vagus.e arises fro the vagus in front of the right subclavian artery. and ends by su!!lying the concha and root of the auricle. 1F(6.e arises fro the is in the thora&.agus nerve !roduces8 .

Junctional Co5ponents 1()he cranial root is s. and reaches the 3ugular fora en( F(In the 3ugular fora en. e&tending fro C1 to CJ seg ents( It is in line "ith nucleus a biguus( Course and Distri6ution o4 the Cranial Root 1( )he cranial root e erges in the for of H to J rootlets "hich are attached to the !osterolateral 3oin together to for a single trun'( 1(Itruns laterally "ith the glosso!haryngeal vagus and the s!inal accessory nerves. and is distributed sulcus of the edulla( Just belo". and !ossibly the heart( F()he s!inal root is also s!ecial visceral efferent( It arises fro a long s!inal nucleus situated in the lateral !art of the anterior grey colu n of the s!inal cord e&tending bet"een seg ents C1 to CJ( Its fibres su!!ly the sternocleido astoid and the tra!e7ius uscles( =uclei through the branches of the vagus to the uscles of the !alate. the laryn& and !ossibly the heart( )he cranial root arises fro the lo"er !art of the nu*leus ambiguus) )he s!inal root arises fro a long s. the !haryn&.<<: !ourse of the accessory nerve. %<. crosses the 3ugular tubercle. the laryn&. the cranial root unites for a short distance "ith the s!inal root. the rootlets soon .inal nu*leus situated on the lateral !art of anterior grey colu n of s!inal cord.e*ial "*scera^ 2bran*hial3 efferent) It arises fro the lo"er !art of the nucleus a biguus( It is distributed through the branches of the vagus to the uscles of the !alate. and again se!arates fro it as it !asses out of the fora en( :()he cranial root finally fuses "ith the vagus 3ust belo" its inferior ganglion. the !haryn&.Cugular tu6ercle o4 occipital 6one /agus nerve = Cranial part o4 accessor2 ner7e H %4=UO Cugular 4ora5en r4cO -uperior and P in4erior ganglia o4 7agus ner7e Medulla P3 Region o4 4ora5en 5agnu5 % %-pinal root o4 accessor2 ner7e OO -pinal cord Z%%%%%% Vagus incorporating cranial accessor2 ner7e U ) -pinal accessor2 ner7e Fig.

es the skull through the iddle !art of the 3ugular fora en "here it fuses "ith a short length of the cranial root( It soon se!arates fro the latter and !asses out of the fora en( H(In its extra*ranial *ourse.ccessory nerve is ar'ed by 3oining the follo"ing four !oints( BaC)he first !oint at the anteroinferior !art of the tragus B1ig( 1F(FGC( BbC)he second !oint at the ti! of the transverse !rocess of the atlas( BcC)he third !oint at the iddle of the !osterior border of the sternocleido astoid uscle( BdC)he fourth !oint on the anterior border of the tra!e7ius J c above the clavicle( Course and Distri6ution o4 the -pinal Root 1(It arises fro the u!!er five seg ents of the s!inal cord B1ig( 1F(FFC( F(It e erges in the for of a ro" of fila ents attached to the cord id"ay bet"een the ventral and dorsal nerve roots( :(in the . the nerve descends vertically bet"een the internal 3ugular vein and the internal carotid artery dee! to the !arotid and to the styloid !rocess B1igs 1F(16. the nerve runs u!"ards and laterally. crosses the 3ugular tubercle B"ith the ninth and tenth cranial nervesC and reaches the 3ugular fora en( :()he nerve lea.ertebral *anal. 1F(F1C( It reaches a !oint id"ay bet"een the angle of the andible and the . the fila ents unite to taU a sU"`c uUUUU/ U=UUUdU as ute UUU ta o> t' dorsal nerve roots and behind the liga entu denticulatu ( 1()he nerve enters the *ranium through the fora en agnu lying behind the vertebral artery( F(Eithin the craniu .-ur4ace Mar!ing .

e is teste+ *lini*ally7 BaC By as'ing the !atient to shrug his shoulders Btra!e7iusC against resistance and co !aring the !o"er on the t"o sidesD and BbC by as'ing the !atient to turn the chin to the o!!osite side Bsternocleido astoidC against resistance and again co !aring the !o"er on the t"o sides( F(@esions of the accessory nerve are usually acco !anied by lesions of the glosso!haryngeal and vagus nerves because of their close interrelationshi! in the craniu ( :(Irritation of the nerve. by enlarged ly !h nodes. and is surrounded by ly !h nodes( )he nerve !ierces the anterior border of the sternocleido astoid at the 3unction of its u!!er onefourth "ith the lo"er three-fourths.astoid !rocess( )hen it runs do"n"ards and bac'"ards su!erficial to the internal 3ugular vein and dee! to the sternocleido astoid( <ere it is crossed by the occi!ital artery. is acco !anied by the u!!er sternocleido astoid branch of the occi!ital artery. and co unicates "ith second and third cervical "ith s!inal nerves "ithin the uscle( )he nerve enters the !osterior triangle of the nec' by e erging through the !osterior border of the sternocleido astoid a little above its iddle( In the triangle B1ig( 1F(F:C. and ends by su!!lying the tra!e7ius BCha!ter :C( 4( Distribution) )he s!inal accessory nerve su!!lies8 BaC )he sternocleido astoidD and BbC the tra!e7ius( Cervical nerves !rovide a !ro!rioce!tive su!!ly to these uscles( CLINICAL ANATOM 1()he a**essory ner. it runs do"n"ards and bac'"ards e bedded in the fascial roof of the triangle( <ere it lies over the levator sca!ulae( It is related to the su!erficial ly !h nodes( )he nerve leaves the !osterior triangle by !assing dee! to the anterior border of the tra!e7ius J c above the clavicle( 0n the dee! surface of the tra!e7ius the nerve co unicates "ith s!inal nerves C: and CH. ay !roduce torticollis or "ry nec'( AAAAAAAAAAAH POILOSSAL NER1EAAAAAAAAAAA <y!oglossal is the t"elfth cranial nerve( It su!!lies the uscles of the tongue B1ig( 1F(FHC( Fu"&tio"a# Co*%o"e"tsKNu&#ear Co#u*"s 1( +eneral so atic efferent colu n( )he fibres arise fro the hy!oglossal nucleus "hich lies in the i ' L6*%h "o$es 9rans7erse cutaneous ner7e o4 nec! A&&essor6 "er5e Tra%eWius CHi .

Retro5a ndi6ular 7ein Lesser occipital ner7e 0reat auricular ner7e -ternocleido5astoid Fig. %<. E:ternal Fugular 7ein .<): Accessory nerve with branches of cervical ple us. 'eins of the neck also seen.

lies in the floor of fourth ventricle beneath the hy!oglossal triangle( It is divided into !arts for individual uscles innervated( Connection of the nucleus "ith o!!osite !yra idal tract for s su!ranuclear !ath"ay of the nerve( It is also connected to cerebellu . sensory nuclei of Jth nerve. the fibres !ass for"ards lateral to the edial longitudinal bundle. )he hy!oglossal nucleus.St6#o!#ossus Pa#ato!#ossus Ie"io!#ossus >II "er5e 1e"tra# ra*us o. edulla. C9) C() C+ To"!ue 0enioh2oid H6oi$ 2o"e Ster"oh6oi$ I". in the floor of the fourth ventricle dee! to the hy!oglossal triangle( F( +eneral so atic afferent colu n( )he nucleus is s!inal nucleus of cranial nerve / "here !ro!rioce!tive fibres fro tongue end( Nu&#eus the andible and the sy !hysis enti( )he nerve describes a gentle curve in its course( Course a"$ Re#atio"s 1( In their intraneural *ourse. o*oh6oi$ Fi*+ #&+&4: 4ypoglossal nerve and ansa cervicaAis. reticular for ation of edulla.erior 2e##6 o.a&e Mar-i"! <y!oglossal nerve is ar'ed by 3oining the follo"ing !oints( BaC)he first !oint at the anteroinferior !art of the tragus B1ig( 1F(FGC( BbC)he second !oint !osterosu!erior to the ti! of the greater cornua of the hyoid bone( BcC)he third !oint id"ay bet"een the angle of . and the nucleus of tractus solitarius( Sur. F c long.

and the !osterior auricular and occi!ital arteries B1ig( 1F(16C( vfiiiC . hoo's round the lo"er sternocleido astoid branch of the occi!ital artery. and 3oin to for t"o bundles "hich !ierce the dura ater se!arately near the hy!oglossal canal( )he nerve leaves the s'ull through hy!oglossal Banterior condylarC canal( Fxtra*ranial Course BiC )he nerve first lies dee! to the internal 3ugular vein. the . the styloid !rocess.edial le niscus and !yra idal tract. but soon inclines laterally bet"een the internal 3ugular vein and the internal carotid artery. by 1G to 1J rootlets( )he rootlets run laterally Bbehind the vertebral artery. the stylohyoid. crosses the vagus BlaterallyC. and reaches in front of it B1ig( 1F(F1C( BiiC It then descends bet"een the internal 3ugular vein and the internal carotid artery in front of the vagus. dee! to the !arotid gland. bet"een the !yra id and the olive. and edial to the reticular for ation and olivary nucleus BCha!ter FHC( F( )he nerve is attached to the anterolateral sulcus of the edulla. the !osterior belly of the digastric.t the lo"er border of the !osterior belly of the ] digastric it curves for"ards.

a&e Mar-i"! Bra"&hes a"$ Distri2utio" In addition to its o"n fibres.oglossal ner. genioglossus.er) )hey su!!ly the e&trinsic and intrinsic uscles of the tongue. 11(FC( BivC )he nerve then continues for"ards on the hyoglossus and genioglossus. the tongue deviates to o!!osite side( $iMe and $hape )his is the largest of the three ganglia( It is s!indlesha!ed. at a !oint : c above the sternoclavicular 3oint( I"tro$u&tio" )he cervical !arts of the right and left sy !athetic trun's are situated one on each side of the cervical !art of the vertebral colu n.crosses the internal and e&ternal carotid arteries and the loo! of the lingual artery.i*al ganglion lies at the level of the cricoid cartilage. transverse and vertical uscles e&ce!t the !alatoglossus "hich is su!!lied by fibres of the cranial accessory nerve through the vagus and the !haryngeal !le&us B1ig( 1A(:C( Bran*hes of the hy. and about F(J c long( $ituation and Formation It lies 3ust belo" the s'ull.e Cl) )hese fibres 3oin the nerve at the base of the s'ull( 1()he meningeal bran*h Q contains sensory and It is ar'ed by a line 3oining follo"ing !oints8 BaCPoint of the sternoclavicular 3oint B1ig( 1F(FJC( BbC. dee! to the subandibular gland and the ylohyoid. and su!!lies bone and eninges in the anterior !art of the !osterior cranial fossa( F()he +es*en+ing bran*h continues as the descendens hy!oglossi or the u!!er root of the ansa cervicalis( geniohyoid uscles( 6nterior7 BaC Internal carotid arteryD BbC co on carotid arteryD BcC carotid sheathD and BdC inferior thyroid artery( /osterior7 BaC Prevertebral fasciaD BbC longus ca!itis and cervicis usclesD and BcC transverse !rocesses of the lo"er si& cervical vertebrae( Ia"!#ia )heoretically there should be eight sy !athetic ganglia corres!onding to the eight cervical nerves. !oint at the !osterior border of the condyle of the andible( )he su.e !roduces !aralysis of the tongue on that side( If the lesion is infranuclear there is gradual atro!hy of the !aralysed half of the tongue( Su!ranuclear lesions of the hy!oglossal nerve causes !aralysis "ithout "asting( )he tongue oves sluggishly resulting in defective s!eech( 0n !rotrusion. o!!osite the second and third cervical vertebrae. the nerve also carries so e fibres that reach it fro s!inal nerve C1.oglossal ner.erior *er.i*al ganglion. but due to fusion there are only three ganglia.e is teste+ *lini*ally by as'ing the !atient to !rotrude hisKher tongue( =or ally.oglossal ner.e . behind the carotid sheath Bco on carotid and internal carotid arteriesC and in front of the !revertebral fascia( For*atio" )here are no "hite ra i co unicans in the nec' and this !art of the trun' is for ed by fibres "hich e erge fro seg ents )l to )H of the s!inal cord. styloglossus. and enters the substance of the tongue to su!!ly its usclesC B1ig( 1F(FHC( E CER1ICAL PART OF S MPATHETIC TRUN' Sur.erAical <an*lion :(Branches are also given to the thyrohyoid and CLINICAL ANATOM 1()he hy. su!erior longitudinal. inferior longitudinal.ro.e *ontaining fibres of ner.i*al ganglion e&tends fro the transverse !rocess of the atlas to the ti! of the greater cornua of the hyoid bone( )he mi++le *er. and !asses dee! to the !osterior belly of the digastric again to enter the sub andibular region B1igs 1F(FH. the tongue deviates to the !aralysed side( F(. the tongue is !rotruded straight for"ards( If the nerve is !aralysed. and the inferior *er. and then ascend into the nec'( Re#atio"s sy !athetic fibres( It enters the s'ull through the hy!oglossal canal. and are distributed through it( Bran*hes *ontaining fibres of the hy. iddle and inferior B1ig( 1F(F6C( Superior .oglossal ner. su!erior. hyoglossus. lesion of the hy. behind the carotid sheath and in front of the !revertebral fascia Blongus ca!itisC( It is for ed by fusion of the u!!er H cervical ganglia( .

erAical <an*lion $iMe and $hape )his ganglion is very s all( It ay be divided into F to : s aller !arts. %<.Cond2le o4 5andi6le -uperior cer7ical ganglion Middle cer7ical ganglion 9rapeLius <hrenic ner7e across scalenus anterior -calenus anterior H2oid 6one 9h2roid cartilage O Cricoid cartilage /n4erior cer7ical ganglion Fig.ia) &ranches I) +rey ra i co unicans are given to the ventral ra i of the Jth and 6th cervical nerves( . !art of this !le&us su!!lies the dilator !u!illae BCha!ter 19C( So e of these fibres for the dee! !etrosal nerve for !terygo!alatine ganglionD others give fibres along long ciliary nerve for the ciliary ganglion( :()he e&ternal carotid branches for a !le&us around the e&ternal carotid artery( So e of these fibres for the sy !athetic roots of the otic and sub andibular ganglia B)able 1F(1C( H(Pharyngeal branches ta'e !art in the for ation of the !haryngeal !le&us( J()he left su!erior cervical cardiac branch goes to the su!erficial cardiac !le&us "hile the right branch goes to the dee! cardiac !le&us( It lies in the lo"er !art of the nec'. marking and Communi*ations) Eith cranial nerves IO.<+: $urface of cervical sympathetic ganglia phrenic nerve. and "ith the e&ternal and recurrent laryngeal nerves( &ranches 1(+rey . and also through a loo! that "inds round the subclavian artery( )his loo! is called the ansa sub*la. O and OII. behind the carotid sheath Bco on carotid arteryC( Formation It is for ed by fusion of the fifth and si&th cervical ganglia connections( It is connected "ith the inferior cervical ganglion directly. in front of vertebra C6 3ust above the inferior thyroid artery. or ay be absent( $ituation ra i co unicans !ass to the ventral ra i of the u!!er four cervical nerves B1ig( 1F(F6C( F()he internal carotid nerve arises fro the u!!er end of the ganglion and for s a !le&us around the internal carotid artery( .iddle .

erAical <an*lion is also called the stellate ganglion because it is starsha!ed( It is situated bet"een the transverse !rocess of vertebra CA and the nec' of the first rib( It lies behind the vertebral artery.@ Mi$$#e &er5i&a# !a"!#io" 1erte2ra# arter6 )A Su2&#a5ia" arter6 T T P% -uperior cardiac 6ranch J[ A"sa su2&#a5iaCCCCCCCCK TrB I".nferior cervical ganglion Arterial 6ranches GiH Along /nternal carotid arter2 as internal carotid ner7e GiiH Along co55on carotid and e:ternal carotid arteries Along "%? cer7ical ner7es Along cranial ner7es /T.(eR R Oeso%ha!us @. cardiac <har2n:. T/ and T// Along /n4erior th2roid arter2 Along su6cla7ian and 7erte6ral arteries 0re2 ra5i co55unicans Along cranial ner7es Visceral 6ranches Along ' and A cer7ical ner7es Along $ and & cer7ical ner7es 9h2roid. T. FB ( Th6roi$ !#a"$ @.erior &er5i&a# !a"!#io" a"$ i". cervicothoracic ganglion e&tends in front of the nec' of the first rib( &ranches 1(+rey ra It is for ed by fusion of the Ath and 4th cervical ganglia( )his is often fused "ith the first thoracic ganglion and is then 'no"n as the cervicothoracic ganglion( It i co unicans are given to the ventral ra i of nerves CA and C4( F(/ertebral branches for a !le&us around the vertebral artery( . %<.erior &ar$ia& 2ra"&hes C -uper4icial cardiac ple:us Deep cardiac ple:us Fig. Ta2#e 9(. and in front of ra us of s!inal nerve C4( .E8ter"a# &aroti$ arter6 Phar6"8 /nternal carotid ner7e Su%erior &er5i&a# !a"!#io" 1 CAAAQL.@ rB 0re2 ra5i co55unicans to cer7ical 7entral ra5i 9 r a ch e a ` .<7: 2he cervical sympathetic trunks and their branches.9= Bra"&hes o. cardiac Cardiac 1()hyroid branches acco !any the inferior thyroid artery to the thyroid gland( )hey also su!!ly the !arathyroid glands B1ig( 1F(F6C( F()racheal and oeso!hageal branches( :()he iddle cervical cardiac branch is the largest of the sy !athetic cardiac branches( It goes to the dee! cardiac !le&us( Inferior . &er5i&a# s6*%atheti& !a"!#ia $uperior cervical ganglion /iddle cervical ganglion .

n inferior cervical cardiac branch goes to the dee! cardiac !le&us( CLINICAL ANATOM 33 -u6cla7ian 6ranches 4or5 a ple:us around the Position and 7elations of the Ple)us )he !le&us is related8 BaC . the levator sca!ulae and the scalenus ediusD and BbC anteriorly.<8: $cheme to show the position of a cervical nerve relative to the muscles of the region. C:C :()ransverse BanteriorC cutaneous nerve of the nec' BCF. CHC 9eep &ranches !ommunicating &ranches 1(+rey CER1ICAL PLE>US For6ation ra i !ass fro the su!erior cervical ganglion to the roots of C1-CH nerves( F(. to the uscles "hich arise fro the !osterior tubercles of the transverse !rocesses i(e(. BC( 1( )he head and nec' are su!!lied by sy !athetic nerves arising fro the u!!er four thoracic seg ents of the s!inal cord( #ost of these !reganglionic fibres !ass through the stellate ganglion to relay in the su!erior cervical ganglion( F( In3ury to cervical sy !athetic trun' !roduces Horner's syn+rome) It is characteri7ed by8 BaC Ptosis i(e( droo!ing of the u!!er eyelidCD BbC iosis Bi(e( constriction of the !u!ilCD BcC anhydrosis Bi(e( loss of s"eating on that side of the faceCD BdC eno!hthal os Bi(e( retraction of the eyeballCD and BeC loss of the cilios!inal refle& Bi(e( !inching the s'in on the na!e of the nec'C does not !roduce dilatation of the !u!il B"hich nor ally ta'es !laceC( <orner*s syndro e can also be caused by a lesion "ithin thX( scntral nervous syste any"here at or above the first thoracic seg ent of the s!inal cord involving sy !athetic fibres( K Branches $uperficial "!utaneous# &ranches 1(@esser occi!ital BCFC F(+reat auricular BCF. branch fro Cl 3oins the hy!oglossal nerve and carries fibres for su!!ly of the thyrohyoid and geniohyoid uscles BdirectlyC and the su!erior belly of the o ohyoid through the ansa cervicalis B1ig( 1F(FHC( :(.. C:C H(Su!raclavicular BC:. to the !revertebral fascia. branch fro CF to the sternocleido astoid and branches fro C: and CH to the tra!e7ius co unicate "ith the accessory nerve( 1us*ular Bran*hes #uscles su!!lied solely by cervical !le&us8 1(. .ectus ca!itis lateralis fro Cl.ectus ca!itis anterior fro Cl B1ig( 1F(F4BC( F(.subclavian artery( )his !le&us is 3oined by branches fro the ansa subclavia B1ig( 1F(F6C( H( . the internal 3ugular vein and the sternocleido astoid B1ig( 1F(F4. CF( :(@ongus ca!itis fro C1-C:( )he cervical !le&us is for ed by the ventral ra i of the u!!er four cervical nerves( )he ra i e erge bet"een the anterior and !osterior tubercles of the cervical transverse !rocesses. %<.osteriorly. grooving the costotransverse bars( )he four roots are connected "ith one another to for three loo!s B1ig( 1F(FAC( Lon Jora5en trans7ersariu5 Anterior tu6ercle ADO Costotrans7erse 6ar <osterior tu6ercle -uperior articular 4acet Verte6ral arter2 Fig.

gus capitis Longus cer7icis RR -calenus anterior Ventral ra5us R <re7erte6ral 4ascia V -calenus 5edius%%%%%%% Le7ator scapulae%%%%%%% + .

-tructures in the Rectus capitis anterior Longus Rectus capitis lateralis

ec! "#3

11
9rans7erse process o4 atlas Le7ator scapulae

%% -calenus 5edius

))H)C'
trun! o4 6rachial ple:us <hrenic 9rans7erse process o4 !8 7erte6ra%%%%%%%%%%% p. ner7e capitis P Longus colli ,4 C= %C 33333333333333333333 9rans7erse process o4 a:is %%% ' C3%%
"

CH--

9o rectus capitis lateralis and rectus capitis anterior H2poglossal ner7e

G1 B

,` Lesser occipital ner7e 9o sternocleido5astoid 5uscle

%0reat auricular ner7e -uperior %%%%%%%%%%%%%%%%%%%% ansa %Anterior cutaneous ner7e o4 nec!

9o trapeLius, le7ator scapulae, scalenus 5edius <hrenic ner7e EEllSS ) -upracla7icular ner7es 9o in4rah2oid 5uscles

Fig. %<.<1: 2he cervical ple us: "A# Felations and "&# its branches.

H( @o"er root of ansa cervicalis Bdescendens cervicalisC fro CF, C: Bto sternohyoid, sternothyroid and inferior belly of o ohyoid( #uscles su!!lied by cervical !le&us along "ith the brachial !le&us or the s!inal accessory nerve8

1(Sternocleido astoid fro CF along "ith accessory nerve( F()ra!e7ius fro C:, CH along "ith accessory nerve( :(@evator sca!ulae fro C:, CH "ith CJ Bdorsal

sca!ular nerveC(

1(Phrenic nerve fro C:, CH, CJ( F(@ongus colli fro C:-C4( :(Scalenus edius fro C:-C4( H(Scalenus anterior fro CH-C6( J(Scalenus !osterior fro C6-C4( ?
<HRE /C ERVE

)his is a dia!hrag

i&ed nerve carrying otor fibres to the and sensory fibres fro the dia!hrag ,

the !leura, the !ericardiu , and !art of the !eritoneu (
Ori*in

at a higher level and crosses in front of the first !art of the subclavian artery(
TRACHEA

Phrenic nerve arises chiefly fro the fourth cervical nerve but receives contributions fro third and fifth cervical nerves( )he contribution fro CJ ay co e directly fro the root or indirectly through the nerve to the subclavius( In the latter case, the contribution is 'no"n as the a**essory .hreni* ner,e)
.ourse and 7elations in the Nec8
1()he nerve is

for ed at the lateral border of the scalenus anterior, o!!osite the iddle of the sternocleido astoid, at the level of the u!!er border of the thyroid cartilage( F(It runs vertically do"n"ards on the anterior surface of the scalenus anterior( Since the uscle is obli%ue the nerve a!!ears to cross it obli%uely fro its lateral to its edial border( In this !art of its course, the nerve is related anteriorly to the !revertebral fascia B1ig( 1F(FJC, the inferior belly of the o ohyoid, the transverse cervical artery, the su!rasca!ular artery, the internal 3ugular vein, the sternocleido astoid, and the thoracic duct on left side B1igs :(A, 1F(F4., BC( :(.fter leaving the anterior surface of the scalenus anterior, the nerve runs do"n"ards on the cervical !leura behind the co ence ent of the bra-chioce!halic vein( <ere it crosses the internal thoracic artery Beither anteriorly or !osteriorlyC fro lateral to edial side, and enters the thora& behind the first costal cartilage( 0n the left side the nerve leaves BcrossesC the edial argin of the scalenus anterior

)he trachea is a noncolla!sible, "ide tube for ing the beginning of the lo"er res!iratory !assages( It is 'e!t !atent because of the !resence of C-sha!ed cartilaginous *rings* in its "all( )he cartilages are deficient !osteriorly, this !art of the "all being ade u! of uscle BtrachealisC and fibrous tissue( )he soft !osterior "all allo"s e&!ansion of the oeso!hagus during !assage of food(

Clean and define the cervical !arts of the trachea and oeso!hagus( Identify the ly !h nodes in the sub ental, the sub andibular, the !arotid, the astoid and the occi!ital regions including the dee! cervical nodes( Dissect the ain ly !h trun' !resent at the root of the nec'( <*alene 1us*le Scalenus anterior has been seen in relation to subclavian artery( Identify scalenus edius as one of the uscle for ing floor of !osterior triangle of nec'( Scalenus !osterior lies dee! to the edius( Identify the relations of the cervical !leura( Dissect the styloid !rocess and uscles arising fro it(
Di6ensions

CLINICAL ANATOM

)he !hrenic nerve is the sole otor nerve su!!ly to the dia!hrag ( Before the advent of odern treat ents for !ul onary tuberculosis the o!eration of E.hreni* *rushE used to the done to !roduce !aralysis of the corres!onding half of the dia!hrag for a fe" "ee's( )his gave rest to the diseased lung and !ro oted healing( )he accessory .hreni* ner,e is co only a branch fro the nerve to the subclavius( It lies lateral to the !hrenic nerve and descends behind, or so eti es in front of the subclavian vein( It 3oins the ain nerve usually near the first rib, but occasionally the union ay even be belo" the root of the lung( )he accessory !hrenic nerve ay occasionally arise fro s!inal nerves CH or C6 or fro the ansa cervicalis(

)he trachea is about 1G to 1J c long( Its u!!er half lies in the nec' and its lo"er half in the su!erior ediastinu ( )he e&ternal dia eter easures F c in the ale and 1(J c in the fe ale( )he lu en is s aller in the living than in cadavers( It is about : at 1 year of age, and corres!onds to the age in years during childhood, "ith a a&i u of 1F at !uberty(
.erAical Part of Trachea

trachea begins at the lo"er border of the cricoid cartilage o!!osite the lo"er border of vertebra C6( It runs do"n"ards and slightly bac'"ards in front of the oeso!hagus, follo"s the curvature of the s!ine, and enters the thora& in the edian !lane( F(In the nec', the trachea is co !aratively su!erficial and has the follo"ing relations( .nterior8 B1C Isth us of the thyroid gland covering the second and third tracheal ringsD BFC inferior

1()he

thyroid veins belo" the isth usD B:C !retracheal fascia enclosing the thyroid and the inferior thyroid veinsD BHC sternohyoid and sternothyroid usclesD BJC investing layer of the dee! cervical fascia and the su!rasternal s!aceD and B6C the s'in and su!erificial fascia( BAC In children, the left brachioce!halic vein e&tends into the nec' and, then, lies in front of the trachea B1ig( :(:C( /osterior7 B1C 0eso!hagusD BFC longus colliD and B:C recurrent laryngeal nerve in the tracheo-oeso!hageal groove( >n ea*h si+e7 2I3 )he corres!onding lobe of the thyroid glandsD and BFC the co on carotid artery "ithin the carotid sheath B1ig( :(:C(
Dessels and NerAes

)he trachea is su!!lied by branches fro the inferior thyroid arteries( Its veins drain into the left brachioce!halic vein( @y !hatics drain into the !retracheal and !aratracheal nodes( Parasy !athetic nerves Bfro the vagus through the recurrent laryngeal nerveC are sensory and secreto otor to the ucous e brane, and otor to the trachealis uscle( Sy !athetic nerves Bfro the cervical ganglionC are vaso otor(
CLINICAL ANATOM

ediastina of the thora&, and ends by o!ening into the cardiac end of the sto ach in the abdo en( It is about FJ c long( )he cervical !art of the oeso!hagus is relatedD BaC6nteriorly, to the trachea and to the right and left recurrent laryngeal nervesD BbC/osteriorly, to the longus colli uscle and the vertebral colu nD and BcC>n ea*h si+e, to the corres!onding lobe of the thyroid glandD and on the left side, to the thoracic duct B1ig(, :(:C( )he cervical !art of the oeso!hagus is su!!lied by the inferior thyroid arteries( Its veins drain into the left brachioce!halic vein( Its ly !hatics !ass to the dee! cervical ly !h nodes( )he oeso!hagus is narro"est at its 3unction "ith the !haryn&, the 3unction being the narro"est !art of the gastrointestinal tract, e&ce!t for the ver ifor a!!endi&( 1or thoracic !art of oeso!hagus study Cha!ter FG, /olu e 1(

L MPH NODES OF HEAP AND NEC'

1()he

trachea ay be co !ressed by !athological enlarge ents of the thyroid, the thy us, ly !h nodes and the aortic arch( )his causes dys!noea, irritative cough, and often a hus'y voice( F(Tra*heos tomyis an e ergency o!eration done in cases of laryngeal obstruction Bforeign body, di!htheria, carcino a, etc(C( It is co only done in the retrothyroid region after retracting the isth us of the thyroid gland( :(Please read Cha!ter FG, /olu e 1 in "hich the thoracic !art of the trachea is described(
OESOPHAIUS

)he entire ly !h fro the head and nec' drains ulti ately into the dee! cervical nodes either directly or through the !eri!heral nodes( )he dee! cervical nodes for a vertical chain situated along the entire length of the internal 3ugular vein( 1or convenience of descri!tion these are often grou!ed as anterosu!erior, anteroinferior, !osterosu!erior and !osteroinferior, though there is no clear de arcation bet"een the ( )he ;ugulo+igastri* no+e B1ig( 1F(F9C is a e ber of the anterosu!erior grou!( It lies belo" the !osterior
Fa&ia# 5ei"

) Ju!u#o$i!astri& #6*%h "o$e

)he oeso!hagus is a uscular food !assage lying bet"een the trachea and the vertebral colu n( =or ally, its anterior and !osterior "alls are in contact( )he oeso!hagus e&!ands during the !assage of food by !ressing into the !osterior uscular !art of the trachea( )he oeso!hagus is a do"n"ard continuation of the !haryn& and begins at the lo"er border of the cricoid cartilage, o!!osite the lo"er border of the body of vertebra C6( It !asses do"n"ards behind the t r a c he a , t r a v e r s e s t he s u! e r i o r a n d ! o s t e r i o r

Di!astri& *us&#e I"ter"a# Nu!u#ar 5ei" B Ju!u#oC o*oh6oi$ "o$e
O*oh6oi$ *us&#e

Su%ra&#a5i&u#ar "o$es
Fi*+ #&+&": $ome important members of the deep cervical lymph nodes.

974 Hea$ a"$ Ne

belly of the digastric, bet"een the angle of the andible and the anterior border of the sternocleido astoid, in the triangle bounded by the !osterior belly of the digastric, the facial vein and the internal 3ugular vein( It is the ain node draining the tonsil( )he ;ugulo&omohyoi+ no+e is a e ber of the !osteroinferior grou!( It lies 3ust above the interediate tendon of the o ohyoid, under cover of the !osterior border of the sternocleido astoid( It is the ain ly !h node of the tongue( 2fferents of the dee! cervical ly !h nodes 3oin together to for the 3ugular ly !h trun's, one on each side( )he left 3ugular trun' o!ens into the thoracic duct( )he right trun' ay o!en either into the right ly !hatic duct, or directly into the angle of 3unction bet"een the internal 3ugular and subclavian veins( The .eri.heral no+es are arranged in t"o circles, su!erficial and dee!( )he su.erfi*ial *ir*le of *er,i*al lym.h no+es is ade u! of the follo"ing grou!s8 B1C Sub ental B1ig( 1F(:GCD BFC sub andibularD B:C buccal and andibular BfacialCD BHC !reauricular B!arotidCD BJC !ostauricular B astoidCD B6C occi!italD BAC anterior cervicalD and B4C su!erficial cervical nodes( )he +ee. 2inner3 *ir*le of *er,i*al lym.h no+es
Mandi6ular S <reauricular % Occipital <ostauricular
DB Su%er,i&ia# &er5i&a#

relation to the andibular branch of the facial nerve( )hey drain !art of the chee' and the lo"er eyelid( )heir efferents !ass to the anterosu!erior grou! ol dee! cervical nodes(
Postauri&u#ar MMastoi$T No$es

)he !ostauricular nodes lie on the astoid !rocess su!erficial to the sternocleido astoid and dee! to the auricularis !osterior( )hey drain a stri! of scal! 3ust above and behind the auricle, the u!!er half of the edial surface and argin of the auricle, and the !osterior "all of the e&ternal acoustic eatus( )heir efferents !ass to the !osterosu!erior grou! of dee! cervical nodes(
O&&i%ita# No$es

)he occi!ital nodes lie at the a!e& of the !osterior triangle su!erficial to the attach ent of the tra!e7ius( )hey drain the occi!ital region of the scal!( )heir efferents !ass to the su!raclavicular e bers of the !osteroinferior grou! of dee! cervical nodes(
A"terior Cer5i&a# No$es

)he anterior cervical nodes lie along the anterior 3ugular vein and are uni !ortant( )he su!rasternal ly !h node is a e ber of this grou!( )hey drain the s'in of the anterior !art of the nec' belo" the hyoid bone( )heir efferents !ass to the dee! cervical nodes of both sides(
Su%er,i&ia# Cer5i&a# No$es

-u65andi6ular -u65ental 7O Anterior cer7ical S

)he su!erficial cervical nodes lie along the e&ternal 3ugular vein su!erficial to the sternocleido astoid( )hey drain the lobule of the auricle, the floor of the e&ternal acoustic eatus, and the s'in over the lo"er !arotid region and the angle of the 3a"( )heir efferents !ass round both borders of the uscle to reach the u!!er and lo"er dee! cervical nodes(
Pre#ar6"!ea# a"$ Pretra&hea# No$es

Buccal Fig. %<.)3: $uperficial lymph nodes of the neck.

includes the follo"ing8 B1C Prelaryngeal and !retrachealD BFC !aratrachealD and 233 retro!haryngeal nodes( Ealdeyer*s ring is described in Cha!ter 1H( )he sub ental nodes have been described in Cha!ter 4, and the !reauricular B!arotidC nodes in Cha!ter 9( )he other grou!s are considered belo"8
Bu&&a# a"$ Ma"$i2u#ar No$es

)he !relaryngeal and !retrached nodes lie dee! to the investing fascia, the !relaryngeal nodes on the cricothyroid e brane, and the !retracheal in front of the trachea belo" the isth us of the thyroid gland( )hey drain the laryn&, the trachea and the isth us of the thyroid( )hey also receive afferents fro the anterior cervical nodes( )heir efferents !ass to the nearby dee! cervical nodes(
Paratra&hea# No$es

)he buccal node lies on the buccinator, and the andibular node at the lo"er border of the andible near the anteroinferior angle of the asseter, in close

)he !aratracheal nodes lie on the sides of the trachea and oeso!hagus along the recurrent laryngeal nerves( )hey receive ly !h fro the oeso!hagus, the trachea

and the laryn&, and !ass it on to the dee! cervical nodes(
Retrophar2ngeal odes

)he retro!haryngeal nodes lie in front of the !revertebral fascia and behind the bucco!haryngeal fascia covering the !osterior "all of the !haryn&( )hey e&tend laterally in front of the lateral ass of the atlas and along the lateral border of the longus ca!itis( )hey drain the !haryn&, the auditory tube, the soft !alate, the !osterior !art of the hard !alate, and the nose( )heir efferents !ass to the u!!er dee! cervical nodes(
/ain 5ymph 2runks at the Foot of the Neck

1( )he thora*i* +u*t is the largest ly !h trun' of the body( It begins in the abdo en fro the u!!er end of the cisterna chyli, traverses the thora&, and ends on the left side of the root of the nec' by o!ening into the angle of 3unction bet"een the left internal 3ugular vein and the left subclavian vein B1ig( FG(4, /ol( 1C( Before its ter ination, it for s an arch at the level of the transverse !rocess of vertebra CA rising : to H c above the clavicle( )he relations of the arch are 8 6nterior7 2I3 @eft co on carotid arteryD BFC vagusD and B:C internal 3ugular vein( /osterior7 B1C /ertebral artery and veinD BFC sy !athetic trun'D B:C thyrocervical trun' or its branchesD BHC !revertebral fasciaD BJC !hrenic nerveD and B6C scalenus anterior(

.!art fro its tributaries in the abdo en and thora&, the thoracic duct receives Bin the nec'C8 B1C )he left 3ugular trun'D BFC the left subclavian trun'D and B:C the left broncho ediastinal trun'( It drains ost of the body, e&ce!t for the right u!!er li b, the right halves of the head, the nec' and the thora& and the su!erior surface of the liver( 1()he right ;ugular trunk drains half of the head and nec'( F()he right sub*la,ian trunk drains the u!!er li b( :()he bron*home+iastinal trunk drains the lung, half of the ediastinu and !arts of the anterior "alls of the thora& and abdo en( H(0n the right side, the subclavian and 3ugular trun's ay unite to for the righ t lym.h trun' "hich ends in a anner si ilar to the thoracic duct( /ariations in the ode of the ter ination of the 3ugular, subclavian and broncho ediastinal trun's are co on and are ore fre%uent on the right side B1ig( 1F(14C(
SCALENE MUSCLES

)here are usually three scalene uscles, the scalenus anterior, the scalenus edius and the scalenus !osterior( )he scalenus edius is the largest, and the scalenus !osterior the s allest, of three( )hese uscles e&tend fro the transverse !rocesses of cervical vertebrae to the first t"o ribs( )hey can, therefore, either elevate these ribs or bend the cervical !art of the vertebral colu n laterally B1ig( 1F(:1C( )hese uscles are described in )able 1F(F(

% 9rans7erse process o4 atlas % 9rans7erse process o4 a:is %%FR <osterior tu6ercles o4 trans7erse processes O Le7ator scpulae +SPP -calenus 5edius V% -cal enus posterior -ternocleido5astoid -calenus anterior Cla7icle -capula

Ventral ra5us o4 C3 on costotrans7erse 6ar ` -u6cla7ian 7ein%%%%%%% Anterior tu6ercle o4 trans7erse process % Jirst ri6 %))' -econd ri6 %%%%%%%%%%%%%%%%%%%%%

Lo1er trun! o4 6rachial ple:us -u6cla7ian arter2 Fig. %<.)%: 5ateral view of the scalene muscles with a few related structures.

/uscle " 3 $calenus anterior

(rigin from Anterior tu6ercles o4

Ta2#e 9(.(= The s&a#e"e *us&#es .nsertion into -calene tu6ercle and adFoining ridge on the superior sur4ace o4 the 4irst ri6 G6et1een su6cla7ian arter2 and 7einH

Nerve supply Ventral ra5i o4

Actions " 3 Anterolateral

GJig3 "=33"H trans7erse processes o4 cer7ical 7erte6rae, 3, ?, ' and A

ner7es C?%CA 4le:ion o4 cer7ical spine =3 Rotates cer7ical spine to opposite side 33 Ele7ates the 4irst ri6 during inspiration ?3 -ta6iliLes the nec! along 1ith other 5uscles

=3 $calenus medius GaH <osterior GJig3 "=33"H tu6ercles o4 trans7erse processes o4 cer7ical 7erte6rae 3, ?, ', A, $ G6H 9rans7erse process o4 a:is and so5eti5es also o4 the atlas 7erte6ra 33 $calenus posterior GJig3 "=33"H cer7ical 7erte6rae, <osterior tu6ercles o4 trans7erse processes o4 ? ,' , A

-uperior sur4ace o4 the 4irst ri6 6ehind the groo7e 4or the su6cla7ian arter2

Ventral ra5i o4 " 3 Lateral 4le:ion ner7es C3%C& o4 the cer7ical spine3 =3 Ele7ation o4 4irst ri6 33 -ta6iliLes nec! along 1ith other 5uscles Ventral ra5i o4 ner7es CA%C& Ele7ation o4 " 3 Lateral 4le:ion o4 cer7ical spine =3 the second ri6 33 -ta6iliLes nec! along 1ith other 5uscles

Outer sur4ace o4 the second ri6 6ehind the tu6ercle 4or the serratus anterior

-dditional Features of the Scalene ;uscles

eti es a fourth, rudi entary scalene uscle, the s*alenus minimus is !resent( It arises fro the anterior border of the transverse !rocess of vertebra CA and is inserted into the inner border of the first rib behind the groove for the subclavian artery and into the do e of the cervical !leura( )he su.ra.leural membrane is regarded as the flattened tendon of this uscle( Contraction of the scalenus ini us !ulls the do e of the cervical !leura( F(Belations of s*alenus anterior) )he scalenus anterior is a *'ey* uscle of the lo"er !art of the nec' because of its inti ate relations to any i !ortant structures in this region( It is a useful surgical land ar'( Its relations are 8 6nterior7 2I3 Phrenic nerve is covered byD BFC !revertebral fasciaD B:C transverse cervical, su!rasca!ular and ascending cervical arteriesD BHC lateral !art of carotid sheath containing the internal 3ugular veinD BJC descendens cervicalisD B6C inferior belly of o ohyoidD BAC anterior 3ugular veinD B4C subclavian veinD B9C sternocleido astoid branches of su!erior thyroid and su!rasca!ular arteriesD B1GC sternocleido astoidD and B11C clavicle B1ig( 1F(:FC(

1(So

Posterior8 B1C Brachial !le&usD BFC subclavian arteryD B:C scalenus ediusD and BHC cervical !leura covered by the su!ra!leural e brane B1ig( :(1GC( )he me+ial bor+er of the uscle is related8 B1CIn its lo"er !art to an inverted */*-sha!ed interval, for ed by the diverging borders of the scalenus anterior and the longus colli( )his interval contains any i !ortant structures as follo"s8 BaC /ertebral vessels running vertically fro the base to the a!e& of this s!aceD BbC inferior thyroid artery arching edially at the level of the 6th cervical transverse !rocessD BcC sy !athetic trun'D BdC the first !art of the subclavian artery traverses the lo"er !art of the ga!D BeC on the left side the thoracic duct arches laterally at the level of the seventh cervical transverse !rocessD BfC the carotid sheath covers all the structures entioned aboveD and BgC the sternocleido astoid covers the carotid sheath B1igs 1F(::, 1:(F, 1F,4C( BFCIn its u!!er !art, the scalenus anterior is se!arated fro the longus ca!itis by the ascending cervical artery( )he lateral bor+er of the uscle is related to the trun's of the brachial !le&us and the subclavian

-ternocleido5astoid R AL * Descendens cer7icalis PP

S

-calenus 5edius <re7erte6ral 4ascia

( P -calenus anterior -ternocleido5astoid 6ranch o4 superior th2roid arter2 R <hrenic ner7e

9rans7erse cer7ical arter2 P -uprascapular arter2

i @r**> OLl
/ Ci """ ]PP

3P3 Brachial ple:us Costocer7ical trun!

Anterior Fugular 7ein OM, -ternocleido5astoid 6ranch o4 superior th2roid arter2 OUF

lu,
/n4erior 6ell2 o4 o5oh2oid ` 3 Cla7icle O? 'M+MM3' -u6cla7ius%%%%%%%%3F4WU -u6cla7ian 7ein

%%%%% -uprapleural 5e56rane
i

% -u6cla7ian arter2

Fig. %<.)<: $chematic sagittal section through the scalenus anterior to show its relations.

Ascending cer7ical arter2 Zi,, <hrenic ner7e -25pathetic trun! 9rans7erse process o4 CA P3 Middle cer7ical ganglion /n4erior th2roid arter2%%%%%%%%%%%%%% ,, Verte6ral arter2 9rans7erse process o4 C$ Edge o4 longus colli 9horacic duct /n4erior cer7ical ganglion

% 9rans7erse cer7ical arter2 r -uprascapular arter2 `O 9h2rocer7ical trun! %% -u6cla7ian arter2

O Edge o4 scalenus anterior LO /nternal thoracic arter2 Fig. %<.)): $tructures present in the triangular interval between the scalenus anterior and the longus colli.

artery "hich e erges at this border and enter the !osterior triangle B1ig( :(1GC(
CER1ICAL PLEURA

)he cervical !leura covers the a!e& of the lung( It rises into the root of the nec', about J c above the first costal cartilage and F(J c above the edial one-third of the clavicle( )he !leural do e is strengthened on its outer surface by the su!ra!leural

e brane so that the root of the nec' is not !uffed u! and do"n during res!iration BCha!ter 1F, /ol( FC( ;elations of the cervical !leura are as follo"s8 6nterior7 BaC Subclavian artery and its branchesD and BbC scalenus anterior( /osterior7 =ec' of the first rib "ith the follo"ing structures in front of it( B1C Sy !athetic trun'D BFC first !osterior intercostal veinD B:C su!erior intercostal arteryD and BHC the first thoracic nerve B1ig( 1F(1FC(

0ateral7 BaC Scalenus ediusD and BbC lo"er trun' of the brachial !le&us( 1e+ial7 BaC /ertebral bodies8 BbC oeso!hagusD BcC tracheaD BdC left recurrent laryngeal nerveD BeC thoracic duct Bon left sideC and Bf3 large arteries and veins of the nec'(
ST LOID APPARATUS

)he styloid !rocess "ith its attached structures is called the styloid a!!aratus( )he structures attached to the !rocess are the stylohyoid, styloglossus and stylo!haryngeus usclesD and the stylohyoid and stylo andibular liga ents B1ig( 1F(:HC( )he a!!aratus is of diverse origin( )he styloid !rocess, and the stylohyoid liga ent and uscle are derived
B
O fD -t2loh2oid O -t2lophar2ngeus P3 Mandi6le P% 9ongue -t2loglossus

<har2n: -t2lophar2ngeus -t2loh2oid liga5ent O

-t2lo5andi6ular liga5ent
st2 oid process

,

-t2loid process P PP -t2loglossus

'9%R

H2oid 6one

-uperior AIand 5iddle constrictors %)) Fig. %<.)6: 2he styloid apparatus: "A# $uperior view, "&# lateral view.

fro the second branchial archD the stylo!haryngeus fro the third archD the styloglossus fro occi!ital yoto esD and the stylo andibular liga ent fro a !art of the dee! fascia of the nec'( )he fi,e atta*hments resemble the reins of a *hariot) )"o of these reins Bliga entsC are nonad3ustable, "hereas the other three B usclesC are ad3ustable and are controlled each by a se!arate cranial nerve, seventh, ninth and t"elfth nerves( )he styloi+ .ro*ess is a long, slender and !ointed bony !rocess !ro3ecting do"n"ards, for"ards and slightly edially fro the te !oral bone( It descends bet"een the e&ternal and internal carotid arteries to reach the side of the !haryn&( It is inter!osed bet"een the !arotid gland laterally and the internal 3ugular vein edially( )he styloglossus mus*le arises fro the ti! and ad3acent !art of the anterior surface of the styloid !rocess as "ell as fro the u!!er end of the stylohyoid liga ent( It !asses do"n"ards and for"ards and is inserted into the side of the tongue, inter ingling "ith the fibres of the hyoglossus( It is su!!lied by the hy!oglossal nerve( During s"allo"ing, it !ulls the tongue u!"ards and bac'"ards( )he stylo.haryngeus mus*le arises fro the edial surface of the base of the styloid !rocess( .long "ith the glosso!haryngeal nerve it !asses bet"een the e&ternal and internal carotid arteries, enters trie !haryn& through the ga! bet"een the su!erior and iddle constrictors, and is inserted on the !osterior border of the la ina of the thyroid cartilage and the lateral as!ect of the e!iglottis( It is su!!lied by the glosso!haryngeal nerve( It hel!s to lift the laryn& during s"allo"ing and !honation B1ig( 1H(11C( )he styloman+ibular ligament is described in Cha!ter 1G( )he stylohyoi+ ligament e&tends fro the ti! of the styloid !rocess to the lesser cornu of the hyoid bone( Stylohyoid uscle is su!!lied by the facial nerve( Its attach ents are given in )able 11(1(

there is i ediate death due to in3ury to vaso otor centres in edulla oblongata( PRE1ERTEBRAL MUSCLES GAnterior Verte6ral MusclesH )he four !revertebral or anterior vertebral uscles are the longus colli BcervicisC. Fnd and :rd are in the nec'( )he fourth !art !asses through the fora en agnu to reach the subarachnoid s!ace( )he vertebral arteries of t"o sides unite to for a single edian basilar artery "hich gives branches to su!!ly a !art of cerebral corte&. internal ear and !ons( Congenital or ac%uired diseases of cervical vertebrae or their 3oints give rise to lots of sy !to s related to branches of vertebral artery( )he a!ical liga ent of dens is a continuation of notochord( )ransverse liga ent. 'ee!s the dens of a&is in !osition( If this liga ent is in3ured by disease or in 6ca!ital !unish ent6.9he <re7erte6ral Region *)=ie !revertebral region contains four uscles. the longus ca!itis. J? vertebral artery and 3oints of the nec'( /ertebral artery.%: 2he prevertebral Upper o6li8ue part o4 longus colli%%%%%%%%%%% %%%%%%%% Occipital 6one muscles. the rectus ca!itis anterior and the rectus ca!itis lateralis B1ig( 1:(1C( )hese are "ea' fle&ors of the head and nec'( )hey e&tend fro the base of the s'ull to the su!erior ediastinu ( )hey !artially cover the anterior as!ect of the vertebral colu n( )hey are covered anteriorly by the thic' !revertebral fascia( )he uscles are described in )able 1:(1( Rectus capitis anterior S Rectus capitis lateralis /M O Fig. "hich is a !art of cruciate liga ent. a branch of subclavian artery. co !rises four !arts M 1st. (:9 Longus capitis Go7erlapping rectus capitis anterior and upper part o4 longus colliH Lo1er o6li8ue part o4 longus colli%%%%%%%%%%%% Jirst ri6 %%%%%%%%%Vertical part o4 longus colli . cerebellu . %).

it unites "ith its fello" of the o!!osite side to for the basilar artery B1ig( 1:(FC( . the eninges.P3P 9hird part o4 7erte6ral arter2PPPPP PPPPPPP E s Gin su6occipital triangleH Ri O 3%%V'% R -u6cla7ian arter2 /+. C4 B1ig( 1F(1JC( $econd Part -calenusanterior %3PP )he second !art runs through the fora ina transversaria of the u!!er si& cervical vertebrae( Its course is vertical u! to the a&is vertebra( It then runs u!"ards and laterally to reach the fora en transversariu of the atlas vertebra ( Belations7 BaC )he ventral ra i of second to si&th cervical nerves lie !osterior to the vertebral artery B1ig( 1F(1AC( BbC )he artery is acco !anied by a venous !le&us and a large branch fro the stellate ganglion B1ig( 1F(::C( 2hird Part Jirst part o4 7erte6ral arter2%%%%%%%%% Jirst ri6 . it !ierces the dura and the arachnoid. it also su!!lies the s!inal cord.s it ascends it gradually inclines edially to reach the front of the edulla( . -econd part o4 7erte6ral arter2 O P P )he first !art e&tends fro the origin of the artery Bfro the subclavian arteryC to the transverse !rocess of the si&th cervical vertebra( )his !art of the artery runs u!"ards and bac'"ards in the triangular s!ace bet"een the scalenus anterior and the longus colli uscles called as the vertebral triangle B1igs 1F(1:.e ove the scalenus anterior uscle( Identify dee!ly !laced anterior and !osterior intertransverse uscles( Cut through the anterior intertransverse uscles to e&!ose the second !art of vertebral artery( 1irst !art "as seen as the branch arising fro the first !art of the subclavian artery( Its third !art "as seen in the subocci!ital triangle( )he fourth !art lies in the cranial artery( Fourth Part 1()he fourth !art e&tends fro the !osterior atlanto-occi!ital e brane to the lo"er border of the !ons( F(In the vertebral canal.t the lo"er border of the !ons. 1F(::C( Belations) 6nterior7 BaC Carotid sheath "ith co on carotid arteryD BbC vertebral veinD BcC inferior thyroid arteryD and BdC thoracic duct on left side B1ig( 1F(4C( /osterior7 BaC )ransverse !rocess of seventh cervical vertebraD BbC inferior cervical ganglionD and BcC ventral ra i of nerves CA. P )hird !art lies in the subocci!ital triangle( 2 erging fro the fora en transversariu of the atlas. and enters the vertebral canal by !assing dee! to the lo"er arched argin of the !osterior atlanto-occi!ital e brane( Belations) 6nterior7 @ateral ass of atlas( /osterior7 Se is!inalis ca!itis( 0ateral7 . and ends in the cranial cavity by su!!lying the brain B1ig( 1:(FC( )he artery is divided into four !arts( Basilar arter2 % Jourth part o4 7erte6ral arter2 .ectus ca!itis lateralis( 1e+ial7 /entral ra us of the first cervical nerve( Inferior7 BaC Dorsal ra us of the first cervical nerve and BdC the !osterior arch of the atlas B1ig( H(6C( DISSECTION .1ERTEBRAL ARTER First Part .(= $cheme showing parts of the vertebral artery. as seen from the front. and ascends in front of the roots of the hy!oglossal nerve( .ntroduction )he vertebral artery is one of the t"o !rinci!al arteries "hich su!!ly the brain( In addition. 1F(1H. and the surrounding uscles and bones( It arises fro the !osterosu!erior as!ect of the first !art of the subclavian artery near its co ence ent( It runs a long course. the artery "inds edially around the !osterior as!ect of the lateral ass of the atlas( It runs edially lying on the !osterior arch of this bone.

nsertion into GaH Tpper obliQue part: into the anterior tu6ercle o4 the atlas G6H 5ower obliQue part: into the anterior tu6ercles o4 the trans7erse processes o4 'th and Ath cer7ical 7erte6rae GcH >/iddle vertical part: into 6odies o4 =.lies7 BaC Eedge-sha!ed area on the !osterolateral as!ect of the edullaD BbC the lo"er !art of the !onsD and BcC the cerebellu ( F(#edullary arteries are given off to the edulla( C DE1ELOPMENT OF 1ERTEBRAL ARTER Different !arts of vertebral artery develo! in the follo"ing "ays( . C= Jle:es the laterall2 head &ranches of 'ertebral Artery Cer. 4lat 5uscle Anterior tu6ercles o4 trans7erse processes o4 cer7ical 3%A 7erte6rae Ventral ra5i o4 ner7es C"%C3 Jle:es the head Anterior sur4ace o4 lateral 5ass o4 atlas Basilar part o4 the occipital 6one in 4ront o4 the occipital cond2le Ventral ra5 us o4 ner7e C" Jle:es the head Upper sur4ace o4 trans7erse process o4 atlas /n4erior sur4ace o4 Fugular process o4 the occipital 6one Ventral ra5i o4 ner7es C" . 9his 5uscle e:tends 4ro5 the atlas to the third thoracic 7erte6ra3 /t has upper and lo1er o6li8ue parts and a 5iddle 7ertical part (rigin from GaH 9he upper obliQue part: 4ro5 the anterior tu6ercles o4 the trans7erse processes o4 o4 cer7ical 7erte6rae 3.i*al Bran*hes 1(S!inal branches enter the vertebral canal through the intervertebral fora ina. /t o7erlaps the longus colli. "=333.osterior inferior *erebellar artery is the largest branch of the vertebral artery( It arises near the lo"er end of the olive( )he artery first runs bac'"ards and then u!"ards behind the IO and O cranial nerves to reach the lo"er border of the !ons( It then runs do"n"ards along the inferolateral boundary of the fourth ventricle.? cer7ical 7erte6rae /n4erior sur4ace o4 6asilar part o4 occipital 6one Nerve supply Ventral ra5i o4 ner7es C3%C& Actions " 3 Jle:es the nec! =3 O6li8ue parts 4le: the nec! laterall2 33 Lo1er o6li8ue part rotates the nec! to the opposite side =3 5ongus capitis. 9his is a 7er2 short and 4lat 5uscle3 /t lies deep to the longus capitis ?3 Fectus capitis lateralis 9his is a short. and finally laterally into the vallecula of the cerebellu ( It su..3. and su!!ly the s!inal cord.9 = The %re5erte2ra# *us&#es GJigs "=3=$.?.FG: Ta2#e 9+.inal artery arises near the ter ination of the vertebral artery( )he arteries of the t"o sides unite Bat the level of the lo"er end of the oliveC to for a single anterior s!inal artery( It descends in the anterior edian fissure of the s!inal cord( It is reinforced at lo"er levels by s!inal branches of other arteries( It su!!lies the anterior t"o-thirds of the s!inal cord( It also su!!lies !art of the edulla( 1()he . though it ay arise fro the vertebral artery at the side of the edulla( It descends on the !osterolateral as!ect of the s!inal cord( It is reinforced at lo"er levels by s!inal branches of other arteries( It su!!lies the !osterior onethird of the s!inal cord( :()he anterior s. .inal artery is usually a branch fro the !osterior inferior cerebellar artery. "33"H /uscle " 3 5ongus colli "cervicis#. /t is thic! a6o7e and narro1 6elo1 33 Fectus capitis anterior. ' G6H 5ower obliQue part: 4ro5 6odies o4 upper =%3 thoracic 7erte6rae GcH /iddle vertical part: 4ro5 6odies o4 upper 3 thoracic and lo1er 3 cer7ical 7erte6rae .osterior s. the eninges and the vertebrae( F(#uscular branches arise fro the third !art and su!!ly the subocci!ital uscles( Cranial Bran*hes 1(1eningeal branches arise near the fora en agnu and su!!ly bone and eninges of the !osterior cranial fossa( F()he . "=3=&A.

"hile the !osterior border is free and !rovides attach ent to the investing layer of dee! cervical fascia( )he liga ent gives origin to the s!lenius.ital membrane exten+s fro the anterior argin of the fora en agnu above. to the u!!er border of the !osterior arch of the Me56rana tectoria E Cruci4or5 liga5ent Gupper 6andH E E Apical liga5ent %%%%% Occipital 6one Anterior atlantooccipital 5e56rane%%%%%%%%%% Basiocciput PPPPP O I==L=D? Jora5en 5agnu5 %%%%%%%%%% <osterior atlantooccipital 5e56rane )) . /ol( I( )he only additional !oint to be noted is that in the cervical region the su!ras!inous liga ents are re!laced by the liga entu nuchae( )he ligamentum nu*hae is triangular in sha!e( Its a!e& lies at the seventh cervical s!ine and its base at the e&ternal occi!ital crest( Its anterior border is attached to cervical s!ines. !er itting fle&ion and e&tension BnoddingC.osterioratlanto&o**i.art7 1ro s!inal branch of the first cervical interseg ental artery( 5ourth . rho boids and tra!e7ius uscles( S%e&ia# Joi"ts Bet<ee" the At#as) the A8is a"$ the O&&i%ita# Bo"e 1()he atlanto-occi!ital and the atlantoa&ial 3oints . %). to the u!!er border of the anterior arch of the atlas belo" B1ig( 1:(:C( @aterally.sular ligament3 are designed to !er it free ove ents of the head on the nec' Bvertebral colu nC( F()he a&is vertebra and the occi!ital bone are connected together by very strong liga ents( Bet"een these t"o bones.italmembraneexten+s fro the !osterior argin of the fora en agnu above.): /edian section through the foramen magnum and upper two cervical vertebrae showing the ligaments in .art7 1ro a branch of dorsal division of Ath cervical interseg entsR artery( <e*on+ . it is continuous "ith the anterior !art of the ca!sular liga ent. "hich are conve& B1ig( 1:(HC( Belo" 8 )he su!erior articular facets of the atlas vertebra( )hese are concave( )he articular surfaces are elongated. !er itting rotation of the head B1ig( 1:(:C( -tlanto4occipital Ooints 2ype )hese are synoviaR 3oints of the elli!soid variety( Articular $urfaces T6%i&a# Cer5i&a# Joi"ts Bet<ee" the Lo<er Si8 Cer5i&a# 1erte2rae )hese corres!ond in structure to ty!ical intervertebral 3oints already described in Cha!ter 1:. Hea$ a"$ Nee 5irst . the atlas is held li'e a surrounds the 3oint( It is thic' !osterolaterally and thin antero edially( F()he anterior atlanto&o**i.bove 8 )he occi!ital condyles. and are directed for"ards and edially( 5igaments 1()he fibrous *a.art7 1ro !reneural branch of first cervical interseg ental artery( JOINTS OF THE NEC' "asher( )he a&is of ove ent bet"een the atlas and s'ull is transverse.sule 2*a.art7 1ro !ostcostal anasto osis( Thir+ .(:. "hereas the a&is of ove ent bet"een the a&is and the atlas is vertical. and anteriorly it is strengthened by the cord-li'e anterior longitudinal liga ent( :(The. <osterior arch o4 atlas 9rans7erse liga5ent +O%%%%% Cruci4or5 liga5ent Glo1er 6andH Anterior arch o4 atlas 3 P Dens o4 a:is %% Bod2 o4 a:is %Anterior longitudinal liga5ent + /nterspinous liga5ent <osterior longitudinal liga5ent Fig.

.this region.

and the u!!er !art of the tra!e7ius( :( 0ateral ben+ingis !roduced by the rectus ca!itis. Lateral atlantoa:ial Foint %A:is 7erte6ra % atlas belo"( Inferolaterally. its fibres are !rolonged u!"ards to the basiocci!ut and do"n"ards to the body of the a&is.% Lateral 5ass o4 atlas % Lo1er 7ertical 6and o4 cruciate liga5ent Me56rana tectoria Fig. they !er it ove ents around t"o a&es( 1le&ion and e&tension BnoddingC occur around a transverse a&is( Slight lateral fle&ion is !er itted around an antero!osterior a&is( 1(5lexion is brought about by the longus ca!itis and the rectus ca!itis anterior( F(Fxtension is done by the rectus ca!itis !osterior a3or and inor. edian atlantoa&ial 3oint bet"een the dens Bodontoid !rocessC and the anterior arch and transverse liga ent of the atlas( It is a !ivot 3oint( )he 3oint has t"o se!arate synovial cavities. BbC )he !osterior larger !art of the 3oint bet"een the dens and transverse liga ent Boften called a bursaC is often continuous "ith one of the atlanto-occi!ital 3oints( Its ain su!!ort is the transverse liga ent "hich for s a !art of the crucifor liga ent of the atlas B1ig( 1:(:C( )he trans.ertebra) )he transverse liga ent e braces the narro" nec' of the dens. ca!sular liga ent all aroundD BbC the lateral !art of the anterior longitudinal liga entD and BcC the liga entu flavu ( )he edian atlantoa&ial 3oint is strengthened by the follo"ing8 BaC )he anterior s aller !art of the 3oint bet"een the anterior arch of the atlas and the dens is surrounded by a loose ca!sular liga ent. the se is!inalis ca!itis.onnectin* the -)is Gith the Occipital Bone )hese liga ents are the e brana tectoria. and the tra!e7ius B1ig( 1:(JC( -tlantoa)ial Ooints 2ypes and Articular $urfaces )he lateral atlantoa&ial 3oints are su!!orted by8 BaC . the s!lenius ca!itis. the rectus ca!itis !osterior a3or and the s!lenius ca!itis of one side. !air of lateral atlantoa&ial 3oints bet"een the inferior facets of the atlas and the su!erior facets of the a&is( )hese are !lane 3oints( F(.erse ligament B1ig( 1:(HC is attached on each side to the edial surface of the lateral ass of the atlas( In the edian !lane. the se is!inalis ca!itis. it is continuous "ith the !osterior !art of the ca!sular liga ent( Arterial and Nerve $upply 5igaments )he 3oint is su!!lied by the vertebral artery and by the first cervical nerve( Mo7e5ents Since these are elli!soid 3oints. acting "ith the sternocleido astoid of the o!!osite side( 9i*a6ents . the a!ical liga ent of the dens .Pre5erte2ra# Re!io" (:0 Me56rana tectoria %%% Apical liga5ent ` )O='!O O Anterior 5argin o4 4ora5en Alar liga5ent %%L PPPPPPPPPPPPPPPPP 9rans7erse liga5ent R Upper 7ertical 6and o4 cruciate liga5ent 5agnu5 Occipital cond2le . thus for ing the *ru*iform ligament of the atlas . the cruciate liga ent.6: Posterior view of the ligaments connecting the a is with the occipital bone. the s!lenius ca!itis. the sternocleido astoid.. anterior and !osterior( #ove ents at all three 3oints are rotatory and ta'e !lace around a vertical a&is( )he dens for s a !ivot around "hich the atlas rotates Bcarrying the s'ull "ith itC( )he ove ent is li ited by the alar liga ents B1ig( 1:(JC( )he rotatory ove ents are brought about by the obli%uus ca!itis inferior. the obli%uus ca!itis su!erior. %). and !revents its dislocation( /ovements )hese 3oints co !rise8 1(. it has a free argin "hich arches over the vertebral artery and the first cervical nerve( @aterally.

"hich then crushes the s!inal cord and edulla( <o"ever.ertebra) :()he a.and the alar liga ents( )hey su!!ort both the atlantoocci!ital and atlantoa&ial 3oints( 1()he membrana te*toria is an u!"ard continuation of the !osterior longitudinal liga ent( It lies !osterior to the transverse liga ent( It is attached inferiorly to the !osterior surface of the body of the a&is and su!eriorly to the basiocci!ut B"ithin the fora en agnu C B1ig( 1:(HC( F(Cru*iate ligament co !rises transverse and F#e8io" a"$ e8te"sio" Fi*+ #'+5: 'arious movements of the neck. ore co only. it ay occur in the lo"er cervical region( )his causes shooting !ain along the distribution of the cervical nerve !ressed( .i*al ligament of the +ens e&tends fro the a!e& of the dens close to the anterior argin of the fora en agnu behind of the attach ent of the cruciate liga ent( It is the continuation of the notochord( H()he alar ligament. its fibres are !rolonged u!"ards to the basiocci!ut and do"n"ards to the body of the a&is.erse ligament B1ig( 1:(HC is attached on each side to the edial surface of the lateral ass of the atlas( In the edian !lane. dislocated by a fall on the head "ith acute fle&ion of the nec'( In the cervical region. or se!aration of the a&is fro the third cervical vertebra( F(Cer.i*al s. one on each side. thus for ing the *ru*iform ligament of the atlas . e&tends fro the u!!er !art of the lateral surface of the dens to the edial surface of the occi!ital condyles( )hese are strong liga ents "hich li it the rotation and fle&ion of the head( )hey are rela&ed during e&tension( CLINICAL ANATOM 1(Death in e&ecution by hanging is due to dislocation of the dens follo"ing ru!ture of the transverse liga ent of the dens.on+ylosis) In3ury or degenerative changes of old age ay ru!ture the thin !ostero-lateral !arts of the annulus fibrosus Bof the inter-vertebral discC resulting in !rola!se of the nucleus !ul!osus( )his is 'no"n as disc !rola!se or s!ondylosis( .lthough it is co onest in the lu bar region. vertical liga ents( )he trans. direct !osterior !rola!se ay co !ress the s!inal cord( :(Cervical vertebrae ay be fractured or. hanging can also cause fracture through the a&is. the vertebrae can dislocate "ithout any fracture of the articular !rocesses due to their hori7ontal .

!osition( .

containing ucous labial glands and blood vesselsD and BeC ucous e brane( :()he li!s bound the oral fissure) )hey eet laterally at the angles of the outh( )he inner surface of each li! is su!!orted by a frenulum "hich ties it to the gu ( )he outer surface of the u!!er li! !resents a edian vertical groove.ose+ of8 BaC S'inD BbC su!erficial fasciaD BcC the orbicularis oris uscleD BdC the sub ucosa. the vestibule. chee's. li!s. "hen one is su!!osed to be "ise and it is rightly called the 6"isdo 6 tooth( .hati*s of the central !art of the lo"er li! drain to the sub ental nodesD the ly !hatics fro the rest of the lo"er li! !ass to the sub andibular nodes( . and internally.uditory tube connecting the naso!haryn& "ith the iddle ear cavity e%ualises !ressure on the t"o sides of the ty !anic e brane( I$e"ti.i&atio" 1()he . for ing a large !art of each side of the face( )hey are continuous in front "ith the li!s.hee8s BBuccae? 1( )he chee's are fleshy fla!s. s aller !ortion. and are called the frenula of the li.un*tion lines the *edge* of the li!8 !art of the ucosal surface is nor ally seen( F(2ach li! is *om.deciduous and !er anent( )he third olar tooth eru!ts around FGth year. situated on the bucco!haryngeal fascia also o!en into the vestibule B1ig( F(F6C( F(2&ce!t for the teeth. the !hiltru ( H(0ym. and the 3unction is indicated by the nasolabial sul*us 2furro93 "hich e&tends fro the side of the nose to the angle of the outh( (:/ .aroti+ +u*t o!ens on the inner surface of the chee' o!!osite the cro"n of the u!!er second olar tooth( =u erous labial an+ bu**al glan+s B ucousC situated in the sub ucosa of the li!s and chee's o!en into the vestibule( 1our or five molar glan+s B ucousC. the oral cavity !ro!er( Destibule 1()he vestibule of the outh is a narro" s!ace boun+e+ e&ternally by the li!s and chee's. by the teeth and gu s( F(It *ommuni*ates7 BaC Eith the e&terior through the oral fissureD and BbC "ith the outh o!en it co unicates freely "ith the oral cavity !ro!er( 2ven "hen the teeth are occluded a s all co unication re ains behind the third olar tooth( and internally by ucous e brane( )he mu*o*utaneous . the entire vestibule is lined by ucous e brane( )he ucous e brane for s edian folds that !ass fro the li!s to the gu s.s) 9ips 1()he li!s are fleshy folds lined e&ternally by s'in Identify the structures in the oral cavity( Identify the vestibule.nconscious !atients can be fed through this s!ace( )eeth are of t"o ty!es . oral cavity !ro!er and teeth( The Ora# Ca5it6 )he oral or outh cavity is divided into an outer.ll uscles of soft !alate are su!!lied by vagoaccessory co !le& e&ce!t tensor veli !alatini su!!lied by andibular nerve( Collection of ly !hoid tissue at the oro!haryngeal 3unction guards the foreign bodies( #uscles of !haryn& are also su!!lied by vagoaccessory co !le& e&ce!t the stylo!haryngeus su!!lied by glosso!haryngeal nerve( Inferior constrictor of !haryn& receives additional nerve su!!ly fro e&ternal and recurrent laryngeal nerves( . and an inner larger !art.9he Mouth and <har2n: WU )estibule of the outh lies bet"een the teeth and / the chee'( .

ucous olar glands.haryngeal isthmus 2isthmus of fau*es3 "hich is bounded su!eriorly by the soft !alate. and !artly also to the buccal and andibular nodes( Oral .a+ offatis best develo!ed in infants( It lies on the buccinator !artly dee! to the asseter and !artly in front of it( :()he lym. "ith ucous buccal glandsD and BeC ucous e brane( F()he bu**al .illa) 0n the su it of this !a!illa there is the o!ening of the sub andibular duct( S BcC. the cavity co unicates "ith the !haryn& through the oro.a.hati*s fro the anterior !art of the floor of the outh !ass to the sub ental nodes( )hose fro the hard !alate and soft !alate !ass to the retro!haryngeal and u!!er dee! cervical nodes( )he gu s and the rest of the floor drain into the sub andibular nodes B1ig( 1H(9C( <u6s B<in*iAae? 1()he gu s are the soft tissues "hich envelo! the alveolar !rocesses of the u!!er and lo"er 3a"s and surround the nec's of the teeth( )hese are co !osed of dense fibrous tissue covered by stratified s%ua ous e!itheliu ( F(2ach gu has t"o !arts8 BaC )he free !art . and on each side by the !alatoglossal arches( F()he sublingual region !resents the follo"ing features( BaCIn the edian !lane there is a fold of ucosa !assing fro the inferior as!ect of the tongue to the floor of the outh( )his is the frenulum of the tongue B1ig( 1A(FC( BbC0ne each side of the frenulu there is a sublingual . belo" the ti! of the tongue( Posteriorly.aAity Proper 1(It is boun+e+ anterolaterally by the teeth. the !arotid duct.a. and !resents the sublingual region anteriorly. the surrounds the nec' of the tooth li'e a collar. BbC )he atta*he+ . vessels and nervesD BcC the buccinator covered by bucco!haryngeal fascia and !ierced by the !arotid ductD BdC sub ucosa.ose+ of7 BaC S'inD BbC su!er- ficial fascia containing so e facial uscles.hati*s of the chee' drain chiefly into the sub andibular and !reauricular nodes.FG4 Hea$ a"$ Ne&- 1(2ach chee' is *om.art is fir ly fi&ed to the alveolar arch of gu s and the alveolar arches of the 3a"s( )he roof is for ed by the hard and soft !alate( )he floor is occu!ied by the tongue !osteriorly. fe" sublingual ducts o!en on the edge of this fold( :( 0ym.unning laterally and bac'"ards fro the sublingual .illa there is the sublingual fold "hich overlies the sublingual gland( . inferiorly by the tongue.

the 3a"( )he fibrous tissue of the gu is continuous "ith the !eriosteu lining the alveoli B!eriodontal e braneC( 1(Ier. "hereas the !osterior !art drains into the sub andibular nodes( Teeth )he teeth for !art of the asticatory a!!aratus and are fi&ed to the 3a"s( In an. *ro9n.hyo+ont3 in contrast "ith nona alian vertebrates "here teeth are constantly re!laced throughout life 2. iddle and anterior su!erior alveolar nerves( )heir lingual as!ects are su!!lied by anterior or greater !alatine and naso!alatine nerves( )he lo"er gu s on labial as!ect are su!!lied by buccal branch of andibular and incisive branch of ental nerves( )heir lingual as!ect is su!!lied by the lingual nerve( F(0ym. as . !ro3ecting above or belo" the gu D BFC a root. one canine. . and consist of t"o incisors. and t"o olars( )he !er anent teeth are thirty t"o in nu ber.e su. t"o !re olars. or +e*i+uous teeth.ermanent teeth) )he deciduous teeth are t"enty in nu ber( In each half of each 3a" there are t"o incisors.hati*s of the u!!er gu !ass to the sub andibular nodes( )he anterior !art of the lo"er gu drains into the sub ental nodes.oly. and three olars in each half of each 3a"( Parts of a 2ooth 2ach tooth has three !arts8 B1C . bet"een the cro"n and root and surrounded by the gu B1ig( 1H(1C( Ena5el . one canine. e bedded in the 3a" beneath the gu D and B:C a ne*k. and the second set. the teeth are re!laced only once 2+i..%: Parts of a tooth.hyo+ont3) )he teeth of the first set BdentitionC are 'no"n as milk.ly7 )he u!!er gu s on labial as!ect are su!!lied by !osterior. Dentine <ulp ca7it2 Glined 62 odonto6lastsH % 0 u 5 (+( Ce5ent + % <eriodontal 5e56rane Al7eolar 6one %) Apical 4ora5en Fi*+ %6.

erio+ontal membrane 2ligament3 holds the the n root in its soc'et( )his e brane acts as a !eriosteu the to both the ce entu as "ell as the bony soc'et( Form and Function GCro1ns and Foots# 1()he sha!e of year or soon after( )he teeth of the lo"er 3a" eru!t slightly earlier than those of the u!!er 3a"( )he a!!ro&i ate ages of eru!tion are8 @o"er central incisors. 9 yearsD second !re olar. also called a bi*us. "ith the e&ce!tion of the first u!!er !re olar "hich has a bifid root( )he u!!er olars have three roots. of "hich t"o are lateral and one is edial( )he lo"er olars have only t"o roots.ctin dentine covered only by gu ( g in )he . bearing four or five cus!s on their cro"ns( F()he incisors. A onthsD lateral incisors. less co only. nerves and ly !hatics. "hich gro"s into underlying esenchy e and ac%uires a cu!-sha!ed a!!earance.i+tooth) )he molars are grin+ing teeth. the ce entu iGr s. and BJC the !eriodontal e brane( )he .ul. or ual as!ects cro"nD BHC the ce entu surrounding the R a e bedded !art of the dentine. "hile odontoblasts lay dentine on the inner as!ect( @ater a eloblasts disa!!ear "hile odontoblasts re ain( )he root of the tooth is for ed by laying do"n of layers of dentine.arely. 1G yearsD canines. Du ber. canines and !re olars have single roots. is loose fibrous tissue containing vessels. one co only overla!s the cervical end of ena elD or. it ay 3ust eet the ena el( . therefore. iddle su!erior alveolar.remolarhas t"o cus!s and is. 1F yearsD and the third olar B"isdo toothC. occu!ied by the esenchy e( )his esenchy e is of neural crest origin and is called dental !a!illa( )he dental !a!illa together "ith ena el organ is 'no"n as tooth ger ( )his stage is called 6ca! stage6( )he cells of ena el organ ad3acent to dental !a!illa cells get colu nar and are 'no"n as anieloblasts( )he esenchy al cells no" arrange the selves along the a eloblasts and are called odontoblasts( )he t"o cell layers are se!arated by a base ent e brane( )he rest of the esenchy al cells for the 6!ul! of the tooth6( )his is the 6bell stage6( =o" a eloblasts lay ena el on the outer as!ect. 4 yearsD first !re olar. Fyears( )he . and the anterior su!erior alveolar nerves B a&illary nerveC( )he lo"er teeth are su!!lied by the inferior alveolar nerve B andibular nerveC( 9evelopment of 2eeth a tooth is ada!ted to its function( )he in*isors are *utting teeth. 1yearD canines. nor ber( in any nerve su!!ly( 0ver the nec'. 'no"n as -tofthelo"erl odontoblasts "hich are ca!able of re!lacing dentine "hereas theP ti e in life( bu3 )he +entine is a calcified aterial containing s!iral ar nodes( tubules radiating fro the !ul! cavity( 2ach tubule is occu!ied by a !roto!las ic !rocess fro one of the odontoblasts( )he calciu and organic atter are in the sa e !ro!ortion as in bone( re )he enamel is the hardest substance in the body( nonIt is ade u! of crystalline !ris s lying roughly at c [nstantly right angles to the surface of the tooth( he teeth of )he *ementum rese bles bone in structure. "ith chisel-li'e cro"ns( )he u!!er and lo"er incisors overla! each other li'e the blades of a !air of scissors( The *anines are hol+ing an+ tearing teeth. but eth) li'e ena el and dentine it has no blood su!!ly. each tooth is co !osed of8 B1C )he !ul! the centreD BFC the dentine surrounding the !ul!D BB:C D anteric the ena el covering the !ro3ecting !art of dentine. 11 yearsD second olars. "ith s%uare cro"ns. 1A-FJ years or even later( EVer7e $upply of 2eeth )he !ul! and !eriodontal e brane have the sa e nerve su!!ly "hich is different fro that of the overlying gu ( )he u!!er teeth are su!!lied by the !osterior su!erior alveolar. an anterior and a !osterior( Eruption of 2eeth )he +e*i+uous teeth begin to eru!t at about the si&th onth. and all get eru!ted by the end of the second )eeth are for ed in relation to alveolar !rocess( )he e!itheliu thic'ness to for dental la ina( )he cells of dental la ina !roliferate at various sites to for ena el organ. 4-9 onthsD first olar. A yearsD lateral incisors.iture acturally. "ith conical and rugged cro"ns( )hese are better develo!ed in carnivores( 2ach . all of "hich enter the !ul! cavity through the a!ical fora en( )he !ul! is covered Pass to the by a layer of tall colu nar cells. it sto!s short of the ena el B1G5C leaving the cervical . 14 onthsD and second olars. about 6 yearsD edial incisors.ermanent teeth eru!t in the order given belo"8 first olar. about 6 onthsD u!!er central incisors. narro"ing the !ul! s!ace to a canal for the !assage of nerve and blood vessels only( )he dentine in the root is covered by esenchy al cells "hich differentiate into ce entoblasts for laying do"n the ce entu ( 0utside this is the !eriodontal *onne*ting root to the so*ket in the bone) .

lso re ove the ucous e brane over !alatoglossal and !alato!haryngeal arches and sal!ingo!haryngeal fold to visualise the sub3acent uscles( 'essels and Nerves gu s are s"ollen and s!ongy. and is often loo'ed u!on as traffic controller at the crossroads bet"een the food and air !assages B1ig( 1H(FC( )he soft !alate has t"o surfaces.osterior margin gives attach ent to the soft !alate( )he su.alate7 Stri! the uco!eriosteu of hard !alate( <oft . also the sa e teeth are notched. blending on each side "ith the !haryn&( )he inferior border is free and bounds the !haryngeal isth us( 1ro its iddle. t"o curved folds of ucous e brane e&tend laterally and do"n"ards( )he anterior fold is called the .eolaris Bchronic !eriodontitisC( Pyorrhoea is co on cause of foul breath for "hich the !atient hardly ever consults a dentist because the condition is !ainless( H(Decalcification of ena el and dentine "ith 6rteries7 +reater !alatine branch of a&illary artery B1ig( 1G(AC( =eins7 Drain into the !terygoid !le&us of veins( Ier. called the uvula B1ig( 1H(:C( 1ro each side of the base of the uvula. but the notching corres!onds to a large seg ent of a s all circle 2Hut*hinson's teethR) Har$ Pa#ate It is a !artition bet"een the nasal and oral cavies( Its anterior t"o-thirds are for ed by the !alatine !rocesses of the a&illaeD and its !osterior one-third by the hori7ontal !lates of the !alatine bones B1ig( 1H(FC( )he anterolateral margins of the !alate are continuous "ith the alveolar arches and gu s( )he .CLINICAL ANATOM DISSECTION 1(Being the hardest and che ically the ost stable tissues in the body. sus!ended fro the !osterior border of the hard !alate( It se!arates the naso!haryn& fro the oro!haryn&.e ove the ucous e brane of the soft !alate in order to identify its uscles( . the Har+ .hati*s7 )he ly !hatics drain ostly to the u!!er dee! cervical nodes and !artly to the retro!haryngeal nodes( O Introduction SOFT PALATE O conse%uent softening and gradual destruction of the tooth is 'no"n as dental caries( .alatoglossal ar*h or anterior !illar of fauces( It contains the !alatoglossus uscle and reaches the side of the tongue at the 3unction of its oral and !haryngeal !arts( )his fold for s the lateral boundary of the oro!haryngeal isth us or isth us of fauces( )he !osterior fold is called the .i*al abs*ess3 occurs only "hen the !ul! is dead( )he condition can be recogni7ed in a good radiogra!h( 6(Irregular dentition is co on in ri*kets and the u!!er !er anent incisors ay be notched.hilis.yorrhoea al. there hangs a conical !ro3ection. uscular fold. and is continuous su!eriorly "ith the floor of the nasal cavity( )he su. the edges of the gu s are red and bleed easily( :(I !ro!er oral hygiene ay cause gingivitis and su!!uration "ith !oc'et for ation bet"een the teeth and gu s( )his results in a chronic !us discharge at the argin of the gu s( )he condition is 'no"n as . and bleed on touch( In gingivitis.erior surfa*e for s the floor of the nose( )he inferior surfa*e for s the roof of the oral cavity( It is s ovable.es7 +reater !alatine and naso!alatine branches of the !terygo!alatine ganglion sus!ended by the a&illary nerve( 0ym. carious tooth is tender and astication !ainful( J(Infection of a!e& of root 2a.erior bor+er is attached to the !osterior border of the hard !alate.haryngeal arch or !osterior !illar of fauces( It contains the !alato!haryngeus uscle( It for s the !osterior boundary .alato. anterior and !osteriorD and t"o borders. su!erior and inferior( )he anterior 2oral3 surfa*e is concave and is ar'ed by a edian ra!he( )he !osterior surface is conve&.alate7 . the notching corres!onds to a s all seg ent of a large circle( In *ongenital sy. the teeth are selectively !reserved after death and ay be fossili7ed( Because of this the teeth are very hel!ful in edicolegal !ractice for identification of other"ise unrecogni7able dead bodies( )he teeth also !rovide by far the best data to study evolutionary changes and the relationshi! bet"een ontogeny and !hylogeny( F(In scurvy Bcaused by deficiency of vita in CC.

Mouth a"$ Phar6"8 Nasa# &a5it6 Har$ %a#ate Ora# &a5it6 So.erior . and erges interiorly "ith the lateral "all of the !haryn& B1ig( "(663) Structure "l# #otor nerves( .CC U5u#a B Pa#ato%har6"!ea# ar&h EHHH To"si# Pa#ato!#ossa# ar&h )hey are as follo"s( 1()ensor !alati Btensor veli !alatiniC B1ig( 1H(JC F(@evator !alati Blevator veli !alatiniC :(#usculus uvulae H(Palatoglossus J(Palato!haryngeus B1ig( 1H(HBC Details of the uscles are given in )able 1H(1( NerAe Supply HEH To"!ue Fi*+ #4+': Anterior view of the soft palate seen after opening the mouth widely. and so e taste buds are !resent( .ree 2or$er A.t %a#ate Phar6"!ea# o%e"i"! o.t %a#ate Mora# sur. of the tonsillar fossa.uscles of the Soft Palate So. Median raphe To"!ue B Pa#ato%har6"!ea# ar&h H To"si# Ma"$i2#e BiA C Pa#ato!#ossa# ar&h H Oro%har6"8 C E%i!#ottis C Lar6"8 to )he lie on surface 1H(HBC( )he lies on a!oneurosis s!lits enclose the usculus uvulae( levator veli !alatini and the !alato!haryngeus the su!erior of the !alatine a!oneurosis B1ig( !alatoglossus the inferior surface of the AJB Lar6"!o%har6"8 !alatine a!oneurosis( =u erous ucous glands.a&eT @CI". au$itor6 tu2e Fi*+ #4+&: $agittal section through the mouth and pharyn .ll uscles of the soft !alate e&ce!t the tensor veli !alatini are su!!lied by the !haryngeal !le&us( )he fibres of this !le&us are derived fro the cranial !art of the accessory nerve through the vagus( )he tensor veli !alatini is su!!lied by the andibular nerve (U )he soft !alate is a fold of ucous e brane containing the follo"ing !arts8 )he !alatine a!oneurosis "hich is the flattened tendon of the tensor veil !alatini for s the fibrous basis of the !alate( =ear the edian !lane the .

so that breathing is unaffected( F(It se!arates the oro!haryn& fro the naso!haryn& by loc'ing into Passavant*s ridge during the second stage of s"allo"ing. the e!iglottis lies above the level of the soft !alate.erior &o"&ha So.9ensor 7eil palatini Le7ator 7eil palatini uscle "hich o> contraction raises a ridge called the Passavant*s ridge on the !osterior "all of the naso!haryn&( Ehen the soft !alate is elevated it co es in contact "ith this ridge. %6. the blast of air is a!!ro!riately divided and directed through the nasal and oral cavities "ithout da aging the narro" nose( Si ilarly during coughing it directs air and s!utu into the outh and not into the nose( Blood Supply 6rteries B1C+reater !alatine branch of a&illary arteryD BFCascending !alatine branch of facial arteryD and . 2he two are interlocked in closure of the nasopharyngeal isthmus. fe" s!ecific roles are given belo"8 1(It isolates the outh fro the oro!haryn& during che"ing.oAe6ents and Functions of the Soft Palate 1(+eneral sensory nerves are derived fro 8 BaC )he iddle and !osterior lesser !alatine nerves. s!eech. I". the !haryngeal isth us and the oro!haryngeal isth us( It can co !letely close the .t %a#ate M%osterior sur. "hich are branches of the a&illary nerve through the !terygo!alatine ganglion B1ig( 1J(1FC and BbC fro the glosso!haryngeal nerve B1ig( 1F(19C( F(S!ecial sensory or gustatory nerves carrying taste sensations fro the oral surface are contained in the lesser !alatine nerves( )he fibres travel through the greater !etrosal nerve to the geniculate ganglion of the facial nerve and fro there to the nucleus of the solitary tract B1ig( 1F(19C( :(Secreto otor nerves are also contained in the lesser !alatine nerves( )hey are derived fro the su!erior salivatory nucleus and travel through the greater !etrosal nerve B1ig( 9(1GC( PassaAant3s 7id*e So e of the u!!er fibres of the !alato!haryngeus !ass circularly dee! to the ucous e brane of the !haryn&. snee7ing. coughing.orpholo*y of Palatopharyn*eus % <alatophar2ngeus <alatoglossus <alatine aponeurosis Musculus u7ulae Fig. of the passavant. the %uality of voice can be odified and various consonants correctly !ronounced( H(During snee7ing. the laryn& descends and !ulls the s!hincter do"n"ards leading to the for ation of the hu an !alato!haryngeus uscle( <o"ever.s muscle. so e fibres of the s!hincter are left behind and for a s!hincter inner to the su!erior constrictor at the level of the hard !alate( )hese fibres constitute Passavant*s uscle( Passavant*s uscle is best develo!ed in cases of cleft !alate. s"allo"ing. as this co !ensates to so e e&tent for the deficiency in the !alate( . B O Le7ator 7eil palatini O -uperior constrictor %<assa7ant's 5uscle %<alatophar2ngeus B1C1irst read !aragra!h on Passavant*s ridge( BFCIn a als "ith an acute sense of s ell.6A: !oronal section of the soft palate showing the arrangement of its muscles. so that food does not enter the nose( :(By varying the degree of closure of the !haryngeal isth us. and for a s!hincter internal to the su!erior constrictor( )hese fibres constitute Passavant*s )he !alate controls t"o gates.a&eT U7ula Fi*+ #4+4B: Posterior view of the soft palate showing 'Isling oflevators and TIsling. or can regulate their si7e according to re%uire ents( )hrough these ove ents the soft !alate !lays an i !ortant role in che"ing. the t"o together closing the !haryngeal isth us bet"een the naso!haryn& and the oro!haryn& B1ig( 1H(HBC( . and is su!!orted by t"o vertical uscles Bstylo!haryngeus and sal!ingo!haryngeusC and by a s!hincter for ed by !alato!haryngeus( )he !alato!haryngeal s!hincter clas!s the inlet of the laryn&( In an. etc( .

Ta2#e 9.nsertion Muscle descends.all o4 the phar2n: and its 5edian raphe <ulls up the root o4 the tongue.9= Mus&#es o.t %a#ate /uscle " 3 2ensor veli palatini 9his is a thin.hati*s7 Drain into the u!!er dee! cervical and retro!haryngeal ly !h nodes( e$elopment of Palate )he !re a&illa or !ri itive !alate carrying u!!er four incisor teeth is for ed by the fusion of edial nasal folds. and 4lattens out to 4or5 the palatine aponeurosis Aponeurosis is attached to@ GaH <osterior 6order o4 hard palate G6H /n4erior sur4ace o4 palate 6ehind the palatine crest Muscle enters the phar2n: 62 passing o7er the upper conca7e 5argin o4 the superior constrictor. passes through the origin o4 the 6uccinator. to the side o4 the tongue at the Function o4 its oral and phar2ngeal parts Descends in the palato% phar2ngeal arch and spreads out to 4or5 the greater part o4 the longitudinal 5uscle coat o4 phar2n:3 /t is inserted into@ GaH<osterior 6order o4 the la5ina o4 the th2roid cartilage G6H.. runs do1n1ards and 5ediall2 and spreads out in the so4t palate3 /t is inserted into the upper sur4ace o4 the palatine aponeurosis Mucous 5e56rane o4 u7ula Actions "a# 9ightens the so4t palate. chie4l2 the anterior part G6H Opens the auditor2 tu6e to e8ualiLe air pressure 6et1een the 5iddle ear and the nasophar2n: =3 5evator veli palatini 9his is a c2lindrical 5uscle that lies deep to the tensor 7eli palatini GaH /n4erior aspect o4 auditor2 tu6e G6H AdFoining part o4 in4erior sur4ace o4 petrous te5poral 6one GaH Ele7ates so4t palate and closes the phar2ngeal isth5us G6H Opens the auditor2 tu6e. appro:i5ates the palatoglossal arches. triangular 5uscle GJig3 "?3'H (rigin GaH Lateral side o4 auditor2 tu6e G6H AdFoining part o4 the 6ase o4 the s!ull Ggreater 1ing and scaphoid 4ossa o4 sphenoid 6oneH . li!e the tensor 7eli palatini 33 /usculus uvulae 9his is a longitudinal strip placed on one side o4 the 5edian plane. "hich are folds of frontonasal !rocess( )he rest of the !alate is for ed by the shelf-li'e !alatine !rocesses of a&illa and hori7ontal !lates of . the so. and thus closes the orophar2ngeal isth5us <ulls up the 1all o4 the phar2n: and shortens it during s1allo1ing posterior 6order o4 hard palate@ G6H<osterior 4asciculus@ 4ro5 the palatine aponeurosis B:C !alatine branch of ascending !haryngeal artery( =eins7 )hey !ass to the !terygoid and tonsillar !le&uses of veins( 0ym. con7erges to 4or5 a delicate tendon 1hich 1inds round the pter2goid ha5ulus. 1ithin the palatine aponeurosis GaH <osterior nasal spine G6H <alatine aponeurosis <ulls up the u7ula Oral sur4ace o4 palatine aponeurosis '3 Palatopharyngeus /t consists o4 t1o 4asciculi that are separated 62 the le7ator 7eli palatini GAlso see <assa7ant's ridgeH GaHAnterior 4asciculus@ 4ro5 ?3 Palatoglossus Descends in the palatoglossal arch.

thyroid. tongue. internasal suture. it is a !art of the u!!er res!iratory !assages "here infections are co on( )he u!!er !art of the !haryn& trans its only air. the outh and the laryn&( Clinically. inter a&illary sutures. chin. only food. cricoid and tracheal cartilagesD carry the incision through the se!tu of nose. !alatine bone( #ost of the !alate gets ossified to for the hard !alate( )he unossified !osterior !art of fused !alatal !rocesses for s the soft !alate( Soft !alate co !rises e!itheliu .!!er !art is "idest B:(J c C and noncolla!sibleD BbC iddle !art is narro"D and BcC the lo"er end is the narro"est !art of the gastrointestinal tract Be&ce!t for the a!!endi&C( .<. situated behind the nose. hyoid bone.bout 1F c ( Ai+th7 BaC . Hth and 6th branchial arches and accordingly are innervated by andibular and vagoaccessory co !le&( CLINICAL ANATOM 1(Paralysis of the soft !alate in lesions of the vagus nerve !roduces8 BaC =asal regurgitation of li%uidsD BbC nasal t"ang in voice. i(e( naso!haryn&.="? Head and ec! PHAR N> <har2ngot25panic tu6e 9ensor 7alipalatlni S Le7ator7elipalatini )he !haryn& is a "ide uscular tube. and both the !alates( Cut through the centre of the re aining occi!ital bone and cervical vertebrae( )his "ill co !lete the sagittal section of head and nec'( Identify the structures in the interior of three !arts of !haryn&.7: $cheme to show the subdivisions of the pharyn . the defect is confined to the soft !alate( In the ost severe cases. connective tissue and uscles( 2!itheliu is fro the ectoder of a&illary !rocess( )he uscles are derived fro 1st. %6. %6. Musculus u7ulae <alatophar2ngeus Fi*+ #4+5: /uscles of the soft palate. Also see Fig. naso!haryn&. oro!haryn& and laryngo!haryn&( Clean the surfaces of buccinator uscle and ad3oining su!erior constrictor uscles by re oving connective tissue and bucco!haryngeal fascia over these uscles( Detach the edial !terygoid uscle fro its origin and reflect it do"n"ards( )his "ill e&!ose the su!erior constrictor uscle co !letely( 9imensions of pharyn 0ength7 . but the iddle !art is a co on !assage for both air and food B1ig( 1H(6C( asophar2n: Oro phar2n: Mouth ca7it2 Lar2n: %9ongue Cricoid cartilageN O 9rachea Lar2ngophar2n: O Oesophagus Fig. the lo"er !art Bbelo" the inlet of the laryn&C. and BcC flattening of the !alatal arch( 1(Cleft !alate is a congenital defect caused by non-fusion of the right and left !alatal !rocesses( It ay be of different degrees( In the least severe ty!e. the cleft in the !alate is continuous "ith hareli!( 1(Perforation of the hard !alate ay occur in tertiary sy!hilis( 1(2!ignathus is a terato a arising s!ecifically fro the !alate( Cut through the centre of the frontal bone.

BdC Its ucous e brane is su!!lied by the !haiyngeal branch of !terygo!alatine ganglion sus!ended by a&illary branch of trige inal nerve( B=ote8 )he other !arts of the !haryn& are su!!lied by cranial nerves IO and O( )he follo"ing facts ay be noted( 1()he "all of the naso!haryn& is for ed by the . "asa# &a5it6 . s%he"oi$ Mi$$#e &o"&ha A I".CIt co unicates on each side "ith the iddle ear cavity through the auditory tube( BBC)he !haryn& is related on either side to8 BaC )he styloid !rocess and the uscles attached to itD and BbC the co on carotid. including the !osterior !art of the body of the s!henoid and the basilar !art of the occi!ital bone.osterior me+ian . so that the air !assage is 'e!t !atent. and above the lo"er border of the soft !alate( It rese bles the nose structurally as "ell as functionally. BcC It is lined by ciliated colu nar e!itheliu . in front of the !haiyngeal tubercle( Interiorly7 )he !haryn& is continuous "ith the oeso!hagus at the level of the si&th cervical vertebra.haryngobasilar fas*ia and the .eriorly7 Base of the s'ull. oro!haryn&D and BcC the laryngeal !art.C )he !haryn& is attached to8 BaC ) he edia l ! tery go id ! lateD Bb C th e ! tery g oandibular ra!heD BcC the andibleD BdC the tongueD BeC the hyoid boneD and BfC the thyroid and cricoid cartilages( B. BaC It is res!iratory in function. the naso!haryn& co unicates "ith the nasal cavities through the !osterior nasal a!ertures( C Roo. and the cranial n erves related to the ( Parts of the Pharyn) )he cavity of the !haryn& is divided into8 BaC )he nasal !art. and no food nor ally enters it( BbC Its "alls are rigid and noncolla!sible. laryngo!haryn& B1ig 1H(AC( Nasal Part of Pharyn)>Nasopharyn) )his is the u!!er !art of the !haryn& situated behind the nose. internal carotid. and e&ternal carotid arteries.O <osterior 1all o4 phar2n: To"!ue E%i!#ottis B H6oi$ 2o"e C' Th6roi$ &arti#a!e B Cri&oi$ &arti#a!e Tra&heaCCCCCCCCCCCCC .out! and $!ar)n% 235 4 Boundaries <u.erior &o"&haAAAA Fo#$ 26 #e5ator 5e#i %a#ati"i B IB ar&h E S @ Basio&&i%ut Har$ %a#ate B C + Pa#ato!#ossa# PPPP. naso!haryn&D BbC the oral !art. o. S%he"oi$a# si"us C Bo$6 o.haiyngeal ligament or ra!he( F(6nteriorly. the oral cavity and the laryn&( )hus the anterior "all of the !haryn& is inco !lete( 0n ea*h si+e7 B. corres!onding to the lo"er border of the cricoid cartilage( /osteriorly7 )he !haryn& glides freely on the !revertebral fascia "hich se!arates it fro the cervical s!ine( 6nteriorly7 It co unicates "ith the nasal cavity.

. iR " f9= 3 Cricoid la5ina % P Oesophagus Fi*+ #4+(: $agittal section through the pharyn . the mouth and the laryn . A C LC \ ) L 2M3 % 9u6al ele7ation Anterior arch o4 atlas <hai2ngeal recess -alpingophar2ngeal 4old r 3 iL' .0 %O 3 O @ ) -% ?3 scsae(M3% 3 -o4t palate 9onsil <alatophar2ngeal arch Ar2epiglottic 4old Ar2tenoid cartilage r ( S R7 T '3 1i " Cit 9 w / . the nose.

ation bounds the tubal o!ening. and !osteriorly by the !alato!haryngeal arch( )he "all of the oro!haryn& is for ed !osteriorly by the su!erior.haryngeal ornaso.haryngeal fold is a vertical fold of ucous e brane running do"n"ards fro the !osterior argin of the tubal elevation and gradually fading on the side "all of the !haryn&( )he fold is raised by a sli! of uscle. there are several aggregations of ly !hoid tissue that constitute Ealdeyer*s ly !hatic ring B1ig( 1H(9C( )he ost i !ortant aggregations are the right and left !alatine tonsils usually referred to si !ly as the Retro%har6"!ea# "o$e Cugular chain o4 nodes Phar6"!ea# to"si# Cugulodigastric node Fi*+ #4+": Jaldeyer. iddle and inferior constrictors of the !haryn&( :aldeyer3s 9y6phatic 7in* In relation to the oro!haryngeal isth us. it co unicates "ith the oral cavity through the oro!haryngeal isth us or isth us of fauces( Belo9.osterior 9all for a continuous slo!e.1: Path of air and Air AAYC asophar2n: <har2ngeal isth5us Orophar2n: Oesophagus Lar2ngophar2n: pharyn .haryngealtonsil) )here is a s all edian recess in the ucosa covering this tonsil( It is called the . it co Choanae Jood Nose Mouth Bod2 o4 sphenoid Basiocciput Fig.bove.haryngeal re*ess or lateral re*ess. above the u!!er edge of the su!erior constrictor( :()he roof an+ .haryngeal bursa) )he naso!haryngeal tonsil is better develo!ed in children( It is s all or absent in adults( . as it enters the soft !alate.ening of the au+itory tube.unicates "ith the oro!haryn& at the !haryngeal isth us or naso!haryngeal isth us( )he isth us is an o!ening bounded by the lo"er border of the soft !alate and the !osterior "all of the !haryn& for ed by Passavant*s ridge B1ig( 1H(HBC( F()he lateral 9all !resents the follo"ing8 BaC )he !haryngeal o. it is su!!orted by the body of the a&is vertebra and the u!!er !art of the body of the third cervical vertebra( Its lateral . food through the 9all !resents the !alatine tonsil "hich lies in the tonsillar fossa( )his fossa is bounded anteriorly by the !alatoglossal arch. B E -u65andi6ular nodes 9u6al tonsil <alatine tonsil Lingual tonsil -u65ental nodes 0ro!haryn& is the iddle !art of the !haryn& situated behind the oral cavity( 1igure 1H(4 de!icts !ath of air and food( )hese cross at the oro!haryn&( .nder the ucous e brane. behind the tubal o!ening( It is called the tubal tonsil( It is continuous "ith the lateral !art of the !haryngeal tonsil( Oral Part of Pharyn) BOropharyn)? 1(Interiorly. the sal!ingo-!haryngeus( BdC )he levator veli !alatini. it o!ens into the laryngo!haryn& at the level of the u!!er border of the e!iglottis( Behin+. BcC )he sal. at the level of the inferior nasal concha and 1(F c behind it( BbC )he tubal ele. !athologically enlarged !haryngeal tonsil is given the na e a+enoi+s) Its !resence ay a'e nasal breathing al ost i !ossible( . %6. the basiocci!ut.s lymphatic ring. raises a fold of ucous e brane 3ust belo" the tubal o!ening BeC Behind the tubal elevation there is a narro" vertical slit that leads into a flat !oc'et of ucous e brane called the . o!!osite the basiocci!ut. o!!osite the !osterior !art of the body of the s!henoid. or fossa of Bosenmuller) )he recess e&tends side"ays for 1(F c or ore bet"een the auditory tube and !revertebral uscles.nother collection of ly !hoid tissue is !resent in the naso!haryn&. and the anterior arch of the atlas( .ingo. it co unicates "ith the naso!haryn& through the !haryngeal or naso!haryngeal isth us( In front. there is a collection of ly !hoid tissue called the .

li*a triangularis is a triangular vestigial fold of ucous e brane covering the anteroinferior !art of the tonsil( )he !lica se ilunaris.ole is related to the soft !alate. but anteroinferiorly the ca!sule is fir ly adherent to the side of the tongue 3ust in front of the insertion of the !alatoglossus and the !alato!haryngeus uscles( )his fir attach ent 'ee!s the tonsil in !lace during s"allo"ing( )he tonsillar artery enters the tonsil by !iercing the su!erior constrictor 3ust behind the fir attach ent( )he !alatine vein or e&ternal !alatine or !aratonsillar vein descends fro the !alate in the loose areolar tissue on the lateral surface of the ca!sule. Buccophar2ngeal 4ascia Medial pter2goid Angle o4 5andi6le Masseter 0lossophar2ngeal ner7e -t2loglossus Jacial arter2 -u65andi6ular sali7ar2 gland . and inferiorly there is the lingual tonsil over the !osterior !art of the dorsu of the tongue( Palatine Tonsil BThe Tonsil? $urface /arking It is ar'ed by an oval Bal ond-sha!edC area over the asseter 3ust anterosu!erior to the angle of the andible( Features )he !alatine tonsil occu!ies the tonsillar sinus or fossa bet"een the !alatoglossal and !alato!haryngeal arches B1igs 1H(F. is a si ilar se ilunar fold that ay cross the u!!er !art of the tonsillar sinus( )he intratonsillar *left is the largest cry!t of the tonsil( It is !resent in its u!!er !art B1ig( 1H(11C( It is so eti es "rongly na ed the su!ratonsillar fossa( )he outh of the cleft is se ilunar in sha!e and !arallel to the dorsu of the tongue( It re!resents the internal o!ening of the second !haryngeal !ouch( -uperior constrictor <har2ngo6asilar 4ascia 9onsil Capsule o4 tonsil Loose areolar tissue 1ith paratonsillar 7ein Fi*+ #4+#$: 4oriMontal section through the right palatine tonsil showing its deep relations. u!!er and lo"er( )he me+ial surfa*e is covered by stratified s%ua ous e!itheliu continuous "ith that of the outh( )his surface has 1F to 1J cry!ts( )he largest of these is called the intratonsillar *left Jcc3bf *Y * ES PS P )he lateral surfa*e is covered by a sheet of fascia "hich for s the ca!sule of the tonsil( )he ca!sule is an e&tension of the !haryngobasilar fascia( It is only loosely attached to the uscular "all of the !haryn&. for ed here by the su!erior constrictor and by the styloglossus. 1H(:C( It can be seen through the outh( )he tonsil is al ond-sha!ed( It has t"o surfaces edial and lateralD t"o borders. and crosses the tonsil before !iercing the "all of the !haryn&( )he vein ay be in3ured during re oval of the tonsil or tonsillecto y( )he bed of the tonsil is for ed fro "ithin out"ards by8 BaC )he !haryngobasilar fasciaD BbC the su!erior constrictor and !alato!haryngeus usclesD BcC the bucco!haryngeal fasciaD and BdC in the lo"er !art the styloglossus and the BeC glosso!haryngeal nerve ]1ig( 1H(1GC( Still ore laterally there are the facial artery "ith its tonsillar and ascending !alatine branches( )he internal carotid artery is F(J c !osterolateral to the tonsil( )he anterior bor+er is related to the !alatoglossal arch "ith its uscle B1ig( 1H(:C( )he ..tonsils( Posteriorly and above there is the !haryngeal tonsilD laterally and above there are the tubal tonsils.er .osterior bor+er is related to the !alato!haryngeal arch "ith its uscle( )he u. to the tongue( )he . anterior and !osterior and t"o !oles. and the lo"er !ole.

!ierce the su!erior constrictor. or facial veins( 5ymphatic 9rainage 6 abscess or begins in Arterial 2onsil !eritonsillar %uinsy often this cleft( $upply of @y !hatics !ass to the 3ugulodigastric node B1ig( 1F(F9C( Nerve $upply +losso!haryngeal and lesser !alatine nerves( 4istology 1(#ain source8 )onsillar branch of facial artery( F(. . /edial surface of tonsil to show its I"trato"si##ar &#e.% $U the palatine crypts. and 3oin the !alatine.dditional sources8 BaC .t 0ne or ore veins leave the lo"er !art of the dee! surface of the tonsil.i&ia# te*%ora# Ireater %a#ati"e Pa#ati"e to"si# Dorsa# #i"!uae As&e"$i"! %har6"!ea# Fi*+ #4+#&: Arterial supply of the palatine tonsil. !haryngeal. "hich di!s into the underlying tissue to for the cry!ts( )he ly !hocytes lie on the sides of the cry!ts in the for of nodules( )he structure of tonsil is not differentiated into corte& and edulla( 9evelopment )he e!itheliu over the tonsil develo!s fro ventral !art of second !haryngeal !ouch( )he ly !hocytes are esoder al in origin( Ma8i##ar6 To"si##ar 2ra"&hes Su%er.Se&o"$ar6 &r6%ts Pri*ar6 &r6%t 'enous 9rainage Fi*+ %6.scending !alatine branch of facial arteryD BbC dorsal lingual branches of the lingual arteryD BcC ascending !haryngeal branch of the e&ternal carotid arteryD and BdC the greater !alatine branch of the a&illary artery B1ig( 1H(1FC( )he !alatine tonsil is situated at the oro!haryngeal isth us( Its oral as!ect is covered "ith stratified s%ua ous non'eratinised e!itheliu .

%): Anterior wall of the pharyn seen from behind. Co5iculate tu6ercle v A D>D R'n R or5 recess % Mucosa co7ering la5ina o4 cricoid cartilage Orophar2n: Lar2ngophar2n: PPP m JDD Otiii i i R %%. eningitis. 'no"ledge of the relationshi! of the tonsil is of i !ortance to the surgeon( H()onsillecto y is usually done by the guillotine ethod( <ae orrhage after tonsillecto y is chec'ed by re oval of clot fro the ra" tonsillar bed( )his is to be co !ared "ith the ethod for chec'ing !ost!artu hae orrhage fro the uterus( )hese are the only t"o organs in the body "here bleeding is chec'ed by re oval of clots( In other !arts of the body. .% Vallecula FG). iddle and inferior constrictors of the !haryn&( r)he lateral 9all !resents a de!ression called the...CLINICAL ANATOM )hey retrogress after !uberty( F()he tonsils are fre%uently sites of infection. Ar2epiglottic 4old F4 O /nlet o4 lar2n: PP 4.Xo !infor fossa. and !artly by the third and si&th vertebrae( In this region.H.all o4 phar2n: *.dg 4N 9ongue GposteriorendH (g9b4 % Median glossoepiglottic 4old .R.e oval of foreign bodies fro the !irifor fossa ay da age the internal Iaryngeal nerve.OCunei4or5 tu6ercle E+--F. one on each side of the inlet of the laryn&( )he fossa is bounded edially by theB arye!iglottic fold. clot for ation is encouraged( J()onsillitis ay cause referred !ain in the ear as glosso!haryngeal nerve su!!lies both these areas( 6(Su!!uration in the !eritonsillar area is called %uinsy( . Epiglottis *).osterior 9all is su!!orted ainly by the fourth and fifth cervical vertebrae. the !osterior "all of the !haryn& is for ed by the su!erior. f FiK Oesophagus D . !eritonsillar abscess is drained by a'ing an incision in the ost !ro inent !oint of the abscess( A()onsils are often sites of a se!tic focus( Such a focus can lead to serious disease li'e !ul onary tuberculosis.C. leading to anaesthesia in the su!raglottic !art of the laryn&(U $tructure of Pharyn )he "all of the !haryn& is co !osed of the follo"ing five layers fro "ithin out"ards( 2"31u*osa 2#3<ubmu*osa B:C /haryngobasilar fas*ia or !haryngeal a!oneurosis( )his is a fibrous sheet internal to the . s!ecially in children( Infection ay s!read to surrounding tissue for ing a !eritonsillar abscess( :(2nlarged and infected tonsils often re%uire surgical re oval( )he o!eration is called tonsillecto y( . etc( and is often the cause of general ill health( 1()he tonsils are large in children( touth and <har2n: ="# "iaryngeal Part of Pharyn "5aryngopharyn # # '>X rftff# )his is the lo"er !art of the !haryn& situated behind the laryn&( It e&tends fro the u!!er border of the e!iglottis to the lo"er border of the cricoid cartilage( )he anterior 9all !resents8 BaC )he inlet of the laryn&D and BbC the !osterior surfaces of the cricoid and arytenoid cartilages B1ig( 1H(1:C( )he . and laterally by the thyroid cartilage and the thyrohyoid e brane( Beneath the ucosa of fossa there lies the internal Iaryngeal nerve( . -o4t palate Z9% Ca7it2 o4 5outh DM% U7ula ClO asal septu5 Gposterior edgeH "O' asal conchae seen through posterior nasal aperture +VN " ). Opening o4 auditor2 tu6e and salpingophar2ngeal 4old " <alatophar2ngeal arch + R3F]< <alatine tonsil . %6.

c t o r 9h2rophar2ngeal part %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% . $?3%6: $tructure of the pharyn . the !osterior border of the edial !terygoid !late. it is gradually lost dee! to uscles. and the !terygo andibular ra!he( Inferiorly. the !etrous te !oral bone.!haryngeal uscles( It is thic'est in the u!!er !art "here it fills the ga! bet"een the u!!er border of the su!erior constrictor and the base of the s'ull. the fascia is attached to the basiocci!ut. 1H(1JC( Base o4 s!ull -uperior constrictor Upper 4ree e <har2ngot25panic tu6e d g Middle constrictor%%%%%%%% Mucosa <har2ngo6asilar 4ascia e -u65ucosa Middle constrictor o 4 Oesophagus P m&& s u Buccophar2ngeal 4ascia /n4erior constrictor Bod2 o4 sphenoid Medial pter2goid plate <ter2goid ha5ulus <ter2go5andi6ular raphe O 9ongue <art o4 5andi6le p e r i o r c %%%%%%%%%%%%% -t2loh2oid liga5ent PPPPPP% % H2oid 6one o n s 3%%%%%%%%%% O6li8ue line on th2roid cartilage t r i %%%%% 9endinous 6and % Cricoid cartilage Venous ple:us Fig. and hardly e&tend beyond the su!erior constrictor B1igs 1H(1H. the auditory tube. and also !osteriorly "here it for s the !haryngeal ra!he( Su!eriorly.

.-t2loid process O -uperior constrictor O Fig.%+: (rigin of the constrictors of the pharyn . %6.

the bucco!haryngeal fascia is best develo!ed in the u!!er !art of the !haryn&( Bet"een the bucco!haryngeal fascia. and an inner longitudinal layer ade u! of the stylo!haryngeus.alato.nsertion of !onstrictors of Pharyn . i(e( near the lo"er attach ent of the !terygo andibular ra!he B1ig( 1(FAC( d( Side of !osterior !art of tongue( F( )he mi++le *onstri*tor takes origin fro 8 a( )he lo"er !art of the stylohyoid liga ent b( @esser cornua of hyoid bone c( . iddle and inferior( )he origins of the constrictors are situated anteriorly in relation to the !osterior o!enings of the nose. there is a ga! bet"een the base of the s'ull and the u!!er edge of the su!erior constrictor( )his ga! is closed by the !haryngobasilar fascia "hich is thic'ened in this situation B1ig( 1H(1JC( )he lo"er edge of the inferior constrictor beco es continuous "ith the circular uscle of the oeso!hagus( 1( )he su. and the uscular coat there are the !haryngeal !le&uses of veins and nerves B1ig( 1H(1HC( 9etails of (rigin of !onstrictors . as it lies 3ust !osterior to andibular nerve( )he !haryn& has three uscles that run longitudinally( )he stylo.erior *onstri*tor an+ the base of the skullis . and the structures situatedKtraversing through the ga!s bet"een the three constrictor uscles( Identify structures above the su!erior constrictor uscle and belo" the inferior constrictor uscle( Cut through the tensor veli !alatini and reflect it do"n"ards( .B1C)he mus*ular *oat consists of an outer circular layer ade u! of the three constrictors. ho"ever. the fibres of the t"o sides eeting in the iddle line in a fibrous ra!he( )he three constrictors are so arranged that the inferior overla!s iddle "hich in turn overla!s the su!erior( )he fibres of the su!erior constrictor reach the base of the s'ull !osteriorly.haryngeus arises fro the thyroid cartilage( )he other !art the *ri*o.ll the constrictors of the !haryn& are inserted into a edian ra!he on the !osterior "all of the !haryn&( )he u!!er end of the ra!he reaches the base of the s'ull "here it is attached to the !haryngeal tubercle on the basilar !art of the occi!ital bone B1ig( 1H(1AC( 5ongitudinal /uscle !oat of the Pharyn DISSECTION Define the attach ents of iddle and inferior constrictors of !haryn&. tendinous band that crosses the cricothyroid uscle and is attached above to the inferior tubercle of the thyroid cartilage( c( )he inferior cornua of the thyroid cartilage( )he crico!haryngeus arises fro the cricoid carti lage behind the origin of the cricothyroid uscle( .er *on*a.aps &etween Pharyngeal /uscles and $tructures Felated to them I) )he large ga. including the inferior tubercle B1ig( 1H(16C( b( . the outh and the laryn&( 1ro here their fibres !ass into the lateral and !osterior "alls of the !haryn&.haryngeus arises fro the cricoid cartilage( Details of their origin are as follo"s( )he thyro!haryngeus arises fro 8 a( )he obli%ue line on the la ina of the thyroid cartilage.e bor+er of the su.!!er border of the greater cornu of the hyoid bone B1igs 1H(16.e ove the fascia and identify the andibular nerve again "ith otic ganglion edial to it( Identify the branches of the andibular nerve( @ocate the iddle eningeal artery at the fora en s!inosu .uscles of the Pharyn) Preliminary Femarks about the !onstrictors of the Pharyn )he uscular basis of the "all of the !haryn& is for ed ainly by the three !airs of constrictorsM su!erior.haryngeal fas*ia covers the outer surface of the constrictors of the !haryn& and e&tends f or" ards a cr oss t he !te rygo andi bul ar r a!he t o cover the buccinator( @i'e the !haryngobasilar fascia. the sal!ingo!haryngeus and the !alato!haryngeus uscles( )hese uscles are described later( BFC)he bu**o.haryngeus arises fro the styloid !rocess( It !asses through the ga! bet"een the su!erior and iddle constrictors to run do"n"ards on the inner surface of the iddle and inferior constrictors( )he fibres of the .haryngeus descends fro the auditory tube to erge "ith the !alato!haryngeus B1ig( 1H(16C( .erior *onstri*tor ta'es origin fro the follo"ing Bfro above do"n"ardsC8 a( Pterygoid ha ulus B1ig( 1H(1JC( b( Pterygo andibular ra!he( c( #edial surface of the andible at the !osterior end of the ylohyoid line. in the iddle line( 0n the sides.haryngeus descend fro the sides of the !alate and run longitudinally on the inner as!ect of the constrictors B1ig( 1H(JC( )he sal. 1(:FC( :( )he inferior constrictor consists of t"o !arts( 0ne !art the thyro.. bet9een the u.ingo.

% Basisphenoid %% -alpingophar2ngeus -uperior constrictor <har2ngeal tu6ercle (+ <nar2ngo6asilar 4ascia Y % -uperior constrictor -t2loh2oid liga5ent PPPPPPPPPPPPPPP *m % Middle constrictor Middle constrictor /n4erior constrictor 9h2rophar2ngeus part 9h2rophar2ngeal and ' crice<har2ngeal part o4 in4erior constrictor Cricophar2ngeus part -t2loid process %-t2lophar2ngeus3 Median raphe Oesophagus Fig.%7: /uscles of the pharyn .Head and <alatophar2ngeus FigI %6. %6.%8: Jall of the pharyn . . seen from behind.

223 se ilunar and is 'no"n as the sinus of1orgagni) It is closed by the u!!er strong !art of the !haryngobasilar fascia B1ig( 1H(1AC( )he structures !assing through this ga! are8 BaC )he auditory tubeD BbC the levator veli !alatini uscleD and BcC the ascending !alatine artery B1ig( 1H(14C( . Midline Au$itor6 tu2e \ Le5ator 5e#i %a#ati"i -t2loid %ro&ess As&e"$i"! %a#ati"e arter6 St6#o%har6"!eus 0lossophar2ngeal "er5e Su%erior &o"stri&tor *us&#e ECCCCCCCCCCCCC Mi$$#e &o"stri&tor *us&#e I"ter"a# #ar6"!ea# "er5e Su%erior #ar6"!ea# arter6 I". and tends to !roduce a diverticulu ( EVer7e $upply and Actions )he nerve su!!ly of the uscles of the !haryn& is considered belo" Balso see )able 1H(FC( 1or actions see section on deglutition( Nerve $upply ). and !artly through the vagus( <o"ever.erior &o"stri&tor I". bet9een the su. the lo"er !art of the thyro!haryngeus is a single sheet of uscle.s 9ehiscence In the !osterior "all of the !haryn&. not overla!!ed internally by the u!!er and iddle constrictors( )his "ea' !art lies belo" the level of the vocal folds or u!!er border of the cricoid la ina and is li ited inferiorly by the thic' crico!haryngeal s!hincter( )his area is 'no"n as Tillian 's +ehis*en*e) Pharyngeal diverticula are for ed by out!ouching of the dehiscence( Such diverticula are nor al in the !ig( Pharyngeal diverticula are often attributed to )he !haryn& is su!!lied by the !haryngeal !le&us of nerves "hich lies chiefly on the iddle constrictor( )he !le&us is for ed by8 B1C )he !haryngeal branch of the vagus carrying fibres of the cranial accessory nerveD BFC the !haryngeal branches of the glosso!haryngeal nerveD and B:C the !haryngeal branches of the su!erior cervical sy !athetic ganglion( 1otor fibres are derived fro the cranial accessory nerve through the branches of the vagus( )hey su!!ly all uscles of the !haryn&. showing the gaps between pharyngeal muscles and the structures related to them. "er5e Fi*+ #4+#!: $chematic coronal section through the pharyn .erior an+ mi++le *onstri*tors are the Stylo!haryngeus and the glosso!haryngeal nerve( F()he internal laryngeal nerve and the su!erior laryngeal vessels !ierce the thyrohyoid e brane in the ga. branch of facial nerve and through the lesser !alatine branches of the !terygo!alatine ganglion B)able 1(:C( &lood $upply )he arteries su!!lying the !haryn& are as follo"s( B1C . and the s!hincteric crico!haryngeus. by the recurrent laryngeal nerve( If the crico!haryngeus fails to rela& "hen the thyro!haryngeus contracts.hagus) Villlan. by the lesser !alatine and glosso!haryngeal nerves( Taste sensations fro the vallecula and e!iglottic area !ass through the internal laryngeal branch of the vagus( )he !arasy !athetic se*retomotor fibres to the !haryn& are derived fro the greater !etrosal nerve. the bolus of food is !ushed bac'"ards.scending !haryngeal branch of the e&ternal carotid arteryD BFC ascending !alatine and tonsillar branches of the facial arteryD B:C dorsal lingual branches of the lingual arteryD and BHC the greater . bet9een the mi++le an+ inferior *onstri*tors) :()he recurrent laryngeal nerve and the inferior laryngeal vessels !ass through the ga. bet9een the lo9er bor+er of the inferior *onstri*tor an+ the oeso. 1()he structures !assing through the ga. e&ce!t the Stylo!haryngeus "hich is su!!lied by the glosso!haryngeal nerve( )he inferior constrictor receives an additional su!!ly fro the e&ternal and recurrent laryngeal nerves( )he !le&us also su!!lies all uscles of the soft !alate e&ce!t the tensor veli !alatini "hich is su!!lied by the andibular nerve( <ensory fibres or general visceral afferent fro the !haryn& travel ostly through the glosso!haryngeal nerve.erior #ar6"!ea# arter6 CB Re&urre"t #ar6"!ea# neuro uscular incoordination in this region "hich ay be due to the fact that different nerves su!!ly the t"o !arts of the inferior constrictor( )he !ro!ulsive thyro!haryngeus is su!!lied by the !haryngeal !le&us. the naso!haryn& is su!!lied by the a&illary nerve through the !terygo!alatine ganglionD and the soft !alate and tonsil.

tensor 7eil palatini. and hel!s to for the bolus( H(=e&t. es!ecially the su!erior longitudinal and transverse uscles( )he ove ent ta'es !lace fro anterior to the !osterior side( )his !ushes the food bolus into the !osterior !art of the oral cavity( . auricular 5uscles. te5poralis.(= Mesoder5al $eri5ati5es o. the hyoid bone is oved u!"ards and for"ards by the su!rahyoid uscles( )he !osterior !art of the tongue is elevated u!"ards and bac'"ards by the styloglossiD and the !alatoglossal arches are a!!ro&i ated by the !alatoglossi( )his !ushes the bolus through the oro!haryngeal isth us to the oro!haryn&. %har6"!ea# ar&hes Arch /uscles of Arch Nerve of Arch /V Muscles o4 5astication G5asseter.Ta2#e 9. the soft !alate and the !revertebral region( It drains into the internal 3ugular and facial veins( 5ymphatic 9rainage :()he @y !h fro the !haryn& drains into the retro!haryngeal and dee! cervical ly !h nodes( De*lutition BSGalloGin*? soft !alate closes do"n on to the bac' of the tongue.. and the second stage begins( S"allo"ing of food occurs in three stages described belo"( First $tage 1()his stage is voluntary in character( F()he anterior !art of the tongue is raised and !ressed against the hard !alate by the intrinsic uscles of the tongue. stapedius. 5edial and lateral pter2goids. !haryngeal and !terygoid branches of the a&illary artery B1ig( 1H(1FC( )he veins for a !le&us on the !osterolateral as!ect of the !haryn&( )he !le&us receives blood fro the !haryn&. plat2s5a. tensor t25pani 52loh2oid and anterior 6ell2 o4 digastric Muscles o4 4acial e:pression. phar2ngeal 6ranch o4 7agus through 7agoaccessor2 co5ple: Recurrent lar2ngeal 6ranch o4 7agus !alatine. occipito4rontalis. st2loh2oid and posterior 6ell2 o4 digastric -t2lophar2ngeus Cricoth2roid Constrictors o4 phar2n: G3H Le7ator 7eli palatini All other intrinsic 5uscles o4 lar2n: Mandi6ular di7ision o4 trige5inal V/ Jacial ner7e 0lossophar2ngeal ner7e E:ternal lar2ngeal.

and by contraction of t su!erior and iddle constrictors and of the !al to!haryngeus( 2hird $tage 1()his is also involuntary in character( In tl stage. the laryn& and !haryn& are elevati behind the hyoid bone by the longitudinal uscles the !haryn&. to the cloacal e bra caudally( It is divided into four !arts M the !haryP . by gravity.$econd $tage 1(It is involuntary in character( During this the food is !ushed fro the oro!haryn& to the lo"i !art of the laryngo!haryn&( F()he naso!haryngeal isth us is closed 1 elevation of the soft !alate by levator veli !alatini ar tenser veli !alatini and by a!!ro&i ation to it of tl !osterior !haryngeal "all Bridge of PassavantC( )h !revents the food bolus fro entering the nose( :()he inlet of laryn& is closed by a!!ro&i atic of the arye!iglottis folds by arye!iglottic and obli%i arytenoid( )his !revents the food bolus fro enterii the laryn& B1ig( 16(4C( H(=e&t. and the bolus is !ushed do"n over ti !osterior surface of the e!iglottis. the closed inlet the laryn& and the !osterior surface of the arytenc cartilages. food !asses fro the lo"er !art of the !hary to the oeso!hagus( F()his is brought about by the inferior constrictc of the !haryn&( 9evelopment )he !ri itive gut e&tends fro the bucco!haryng e brane cranially.

ya"ning and snee7ing.. the naso!haryn&D iddle !art. 1H(19C( )he cartilaginous !art for s the anterior and edial t"o-thirds of the tube( It is FJ long. by the ty !anic !le&us for ed by glosso!haryngeal nerve B1ig( 1G(1HC( Function )he tube !rovides a co unication of the iddle ear cavity "ith the e&terior. chorda ty !ani.erior7 Canal for the tensor ty !ani B1ig( 14(1GC( BbC 1e+ial7 Carotid canal. auriculote !oral nerve and the te !oro andibular 3oint( CLINICAL ANATOM !artilaginous Part 1(Difficulty dys!hagia( F(Pharyngeal diverticulu 8 see $illian*s dehiscence. BcC 0ateral7 Chorda ty !ani.Bon2 part o4 auditor2 tu6e )%/sth5us + Cartilaginous part o4 9ensor 7eli palatini O -uperior constrictor <alatine aponeurosis )he arterial su!!ly of the tube is derived fro the ascending !haryngeal and iddle eningeal arteries and the artery of the !terygoid canal( )he veins drain into the !haryngeal and !terygoid !le&uses of veins( @y !hatics !ass to the retro!haryngeal nodes( Nerve $upply &ony Part )he bony !art for s the !osterior and lateral onethird of the tube( It is 1F long.Elouth and <har2n: ==' the foregut. and the sal!ingo!haryngeus to lo"er !art near the !haryngeal o!ening B1ig( 1G(1HC( 'ascular $upply Base o4 s!ull Canal 4or tensor t25pani Middle ear %'OMastoid ant55 33333 'RMR$9PC asophar2n:%%%%%% . and is directed do"n"ards. by the !haryngeal branch of the !terygo!alatine ganglion sus!ended by the a&illary nerveD BFC cartilaginous !art. s!ine of the s!henoid. and lies in the sulcus tubae. thus ensuring e%ual air !ressure on both sides of the ty !anic e brane( )he tube is usually closed( It o!ens during s"allo"ing. BaC <u. a groove bet"een the greater "ing of the s!henoid and the a!e& of the !etrous te !oral B1ig( 1H(16C( It is ade u! of a triangular !late of cartilage "hich is curled to for the su!erior and edial "alls of the tube( )he lateral "all and floor are co !leted by a fibrous e brane( )he a!e& of the !late is attached to the edial end of the bony !art( )he base is free and for s the tubal elevation in the naso!haryn&( Belations. by the nervus s!inosus branch of andibular nerveD and B:C bony !art. and lies in the !etrous te !oral bone near the ty !anic !late( Its lateral end is "ide and o!ens on the anterior "all of the iddle ear cavity( )he edial end is narro" Bisth usC and is 3agged for attach ent of the cartilaginous !art( )he lu en of the tube is oblong being "idest fro side to side( 2I3 .t the ostiu . iddle eningeal artery and edial !terygoid !late. the laryngo!haryn&( Belations. above( in s"allo"ing is 'no"n as -uditory Tube It is also 'no"n as the !haryngoty !anic tube or the 2ustachian tube( )he auditory tube is a tru !et-sha!ed channel "hich connects the iddle ear cavity "ith the naso!haryn&( It is about H c long. andibular nerve and its branches. fig. BbC /osterome+ially7 Petrous te !oral and levator veli !alatini( BcC )he levator veli !alatini is attached to its inferior surface. the idgut and the hindgut( )he !haryn& e&tends fro bucco!haryngeal e brane to the tracheobronchial diverticulu ( It is divided into u!!er !art. BaC 6nterolaterally7 )ensor veli !alatini. by the actions of the tensor and levator veli !alatini uscles( . otic ganglion. for"ards and edially( It for s an angle of HJ degrees "ith the sagittal !lane and :G degrees "ith the hori7ontal !lane( )he tube is divided into bony and cartilaginous !arts B1igs 1H(1H. $?3%K: $cheme showing anatomy of left auditory tube. the oro!haryn&D and the lo"er !art. Le7ator 7eli palatini .

due to bloc'age of the tube( Pain is relieved by instillation of decongestant dro!s in the nose. or of sore throat( )his causes !ain into the ear "hich is aggravated by s"allo"ing. "hich hel! to o!en the ostiu ( )he ostiu is co only bloc'ed in children by enlarge ent of the tubal tonsil( .a"$ Ne&CLINICAL ANATOM 1(Infections ay !ass fro the throat to the iddle ear through the auditory tube( )his is ore co on in children because the tube is shorter and straighter in the ( F(Infla ation of the auditory tube B2ustachian catarrhC is often secondary to an attac' of co on cold.

called the e!ista&is( THE NOSE to the level of the su!erior concha( It is thin and less vascular than the res!iratory ucosa( It contains rece!tors called olfactory cells( 1or descri!tive !ur!oses the nose is divided into t"o ain !arts. and is subdivided into right and left halves by the nasal se!tu ( 2ach half has a roof.9he ose and <aranasal -inuses Sense of s ell !erceived in the u!!er !art of nasal cavity by olfactory nerve rootlets ends in olfactory bulb. infratrochlear and infraorbital nerves B1ig( F(19C( Nasal .aAity )he nose !erfor s t"o functions( It is a res!iratory !assage( It is also the organ of s ell( )he rece!tors for s ell are !laced in the u!!er one-third of the nasal cavity( )his !art is lined by olfactory ucosa( )he rest of the nasal cavity is lined by res!iratory ucosa( )he res!iratory ucosa is highly vascular and "ar s the ins!ired air( )he secretions of nu erous serous glands a'e the air oistD "hile the secretions of ucous glands tra! dust and other !articles( )hus the nose acts as an air conditioner "here the ins!ired air is "ar ed. the e&ternal nose and the nasal cavity( E)ternal Nose So e features of the e&ternal nose have been described in Cha!ter F( )he e&ternal nose has a s'eletal fra e"or' that is !artly bony and !artly cartilaginous( )he bones are the nasal bones. "hich is connected to uncus and also to the dorsal nucleus of vagus in edulla oblongata( +ood s ell of food. J-A c in length. and 1(J c in "idth near the floor( )he "idth near the roof is only 1-F ( DISSECTION Dissect and re ove ucous e brane of the se!tu of nose in s all !ieces( )he ucous e brane is covering both surfaces of the se!tu of the nose( Dissect and !reserve the nerves lying in the ucous e brane( . the se!tal cartilage.e ove the entire ucous e brane to see the details in the interior of the nasal cavity( ((/ . "hich for the bridge of the nose. BC( )he s'in over the e&ternal nose is su!!lied by the e&ternal nasal.. and the frontal !rocesses of the a&illae( )he cartilages are the su!erior and inferior nasal cartilages. its integrity ust be aintained and efforts should be ade to see that nose is 6not cut6( +reat ythological "ar has been fought for 6cutting the nose6( 2nviron ental !ollution causes inhalation of un"anted gases and !articles. oistened and cleansed before it is !assed on to the delicate lungs( )he olfa*tory mu*osa lines the u!!er one-third of the nasal cavity including the roof for ed by cribrifor !late and the edial and lateral "alls u! )he nasal cavity e&tends fro the e&ternal nares or nostrils to the !osterior nasal a!ertures. and edial and lateral "alls( 2ach half easures about J c in height. thus sti ulates secretion of gastric 3uice through vagus nerve( #ost of the ucous e brane of the nasal cavity is res!iratory and is continuous "ith various !aranasal sinuses( Since nose is the ost !ro3ecting !art of the face. a floor. res!iratory diseases including asth a( =asal ucous e brane is %uite vascular( So eti es !ic'ing of the nose ay cause bleeding fro 6@ittle*s area6. leading to fre%uent attac's of sinusitis. and so e s all cartilages B1ig( 1J(1.

%: $keleton of the e ternal nose.tum is edian osseocartilaginc !artition bet"een the t"o halves of the nasal cavi 0n each side. nasal bone. %+. it is covered by ucous e brane a for s the edial "all of both nasal cavities( )he bony .art is for ed by B1C the se!l cartilage. both in front and behind( )he iddle hori7ontal !art is -uperior nasal cartilage /n4erior nasal cartilage Ala o4 nose cartilages( )he !os lerior slo!e is for ed by the infe surface of the body of the s!henoid bone( )he floor is about J c long and 1(J c "ide( P for ed by the !alatine !rocess of the a&illa and hori7ontal !late of the !alatine bone( It is cone fro side to side and is slightly higher anteric than !osteriorly B1ig( 1J(FC( Nasal Septu6 for ed by the cribrifor !late of the eth oid( )he anterior slo!e is for ed by the nasal !art of the frontal bone. %+.<: !oronal section through the nasal cavity and the ma illary air sinuses.art is su!!lied by the anterio eth oidal artery B1ig( 1J(HC( Jloor o4 anterior cranial 4ossa Or6it %-uperior concha Eth5oidal sinuses asal septu5 % Middle eth5oidal sinus Ma:illar2 sinus %Jloor o4 nose %Upper tooth Middle concha Ma:illar2 hiatus /n4erior concha <alate 4or5ing roo4 o4 5outh Fig. and BFC the se!tal !rocesses of the inferi nasal cartilages B1ig( 1J( IBC( )he *uti*ular. su!erior. its argins receive contributions fro t nasal s!ine of the frontal bone. inferio8 anterior and !osteriorD and BbC t"o surfaces. the rostru of t s!henoid.erior . !alati and a&illary bones( B1ig( 1J(:C( )he *artilaginous .art or lo"er end is for ed by fibr fatty tissue covered by s'in( )he lo"er argin of tl se!tu is called the colu ella( )he nasal se!tu is rarely strictly edian( I central !art is usually +efle*te+ to one or the othi side( )he deflection is !roduced by overgro"th of or or ore of the constituent !arts( )he se!tu has BaC four borders. . rigP* and left( Arterial $upply 6nterosu.==& Head and ec! Ala o4 nose asal 6one Fig. and BFC the !er!endicular !late of the eth o <o"ever. )he roofis about A c long and F "ide( It slo!es do"n"ards. and the nasal crests of the nasal.art is for ed al ost entirely by B1C t vo er. and the nasal -eptal process o4 in4erior nasal cartilage )he nasal se.

<osterior eth5oidal arter2 Anterior eth5oidal arter2 Little's area -phenopalatine arter2 -uperior la6ial arter2 Fi*+ #5+4: Arterial supply of nasal septum.erior "asa# &arti#a!e Co#u*e##a Fi*+ #5+': Formation of the nasal septum. eth*oi$ Rostru* o. i". eth*oi$ Per%e"$i&u#ar %#ate o.or* %#ate o. "asa# 2o"e Se%ta# &arti#a!e JD Cri2ri.art7 is su!!lied by the s!heno- !alatine artery( . s%he"oi$ 1o*er Se%ta# %ro&ess o.Nose a"$ Para"asa# Si"uses ((7 Nasa# s%i"e o.ro"ta# 2o"e Nasa# &rest o. . /osteroinferior .

e*ial sensory ner. are distributed to "hole of the se!tu B1ig( 1J(JC( 1()he anterosu!erior !art of the se!tu is su!!lied by the internal nasal branch of the anterior eth oidal nerve( F()he !osteroinferior !art is su!!lied by the naso!alatine branch of the !terygo!alatine ganglion( :()he !osterosu!erior !art is su!!lied by the edial !osterior su!erior nasal branches of the !terygo!alatine ganglion II( <. !osteriorly through the s!heno!alatine vein to !terygoid venous !le&us( .erior . and of anterior eth oidal artery( )hese for a large ca!illary net"or' called the $iesselbach*s !le&us( )his is a co on site of bleeding fro the nose or e!ista&is. and is 'no"n a 0ittle's area) Venous 9rainage Nerve $upply I( Ceneral sensory ner. branch of s!heno!alatine artery.es or olfa*tory nerves are confined to the u!!er !art or olfactory area( 5ymphatic 9rainage 6nterior half to the sub andibular nodes( /osterior half to the retro!haryngeal and dee! cervical nodes( )he veins for a !le&us "hich is ore ar'ed in the lo"er !art of the se!tu or @ittle*s area( )he !le&us drains anteriorly into the facial vein.art7 by the su!erior labial branch of facial artery( /osterosu.es. arising fro trige inal nerve.6nteroinferior.art7 by the !osterior eth oidal artery( f )he anteroinferior !art or vestibule of the se!tu contains anasto oses bet"een the se!tal ra us of the su!erior labial branch of the facial artery.

etc( It re%uires surgical correction( 9ateral :all of Nose )he lateral "all se!arates the nose8 BaC 1ro the orbit above. allergic rhinitis. CLINICAL ANATOM 1(@ittle*s area on the se!tu is a co on site of bleeding fro the nose or e!ista&is( F(Pathological deviation of the nasal se!tu is often res!onsible for re!eated attac's of co on cold. sinusitis.(+: Hea$ a"$ Ne&- Ol4actor2 rootlets asopalatine ner7e Medial posterior superior nasal 6ranches Anterior eth5oidal ner7e Fi*+ #5+5: Nerve supply of nasal septum.e ove all the three nasal conchae to e&!ose the eatuses lying belo" the res!ective concha( )his "ill e&!ose the o!enings of the sinuses !resent there( .e ove "ith scissors the anterior !art of inferior nasal concha( )his "ill reveal the o!ening of the nasolacri al duct( Pass a thin !robe u!"ards through the nasolacri al duct into the lacri al sac at the edial angle of the eye( . "ith the eth oidal air sinuses interveningD BbC fro the a&illary sinus belo"D and BcC fro the lacri al groove and nasolacri al canal in front( )he lateral "all of the nose is irregular o"ing to the !resence of three shelf-li'e bony !ro3ections called *on*hae) )he conchae increase the surface area of the nose for effective air-conditioning of the ins!ired air B1ig( 1J(FC( .

curved hairs called vibrissae( BbC)he iddle !art is 'no"n as the atriu of the iddle eatus( BcC )he !osterior !art contains the conchae( S!aces se!arating the conchae are called eatuses B1ig( 1J(6C( )he skeleton of the lateral 9all is !artly bony. stiff. and !artly ade u! only of soft tissues as follo"s( )he bony .art is for ed fro before bac'"ards by the follo"ing bones8 B1C =asalD BFC frontal !rocess of a&illaD B:C lacri alD BHC labyrinth of eth oid "ith su!erior and iddle conchaeD BJC inferior nasal conchaD B6C !er!endicular !late of the !alatine bone together "ith its orbital and s!henoidal !rocessesD and BAC edial !terygoid !late B1ig( 1J(6C( )he *artilaginous .eatuses )he nasal *on*hae are curved bony !ro3ections directed do"n"ards and edially( )he follo"ing three conchae are usually found8 1()he inferior *on*ha is an inde!endent bone( F()he mi++le *on*ha is a !ro3ection fro the edial surface of the eth oidal labyrinth B1ig( 1J(6C( :()he su. !artly cartilaginous. .art is for ed by fibrofatty tissue covered "ith s'in( BaC.erior *on*ha is also a !ro3ection fro the edial surface of the eth oidal labyrinth( )his is .)he lateral "all can be subdivided into three !arts( s all de!ressed area in the anterior !art is called the vestibule( It is lined by odified s'in containing short.honchae and .art is for ed by8 BaC )he su!erior nasal cartilageD BbC the inferior nasal cartilageD and BcC : or H s all cartilages of the ala( )he *uti*ular lo9er .

henoi+al air sinus B1ig( 1J(AC( )he atrium of the mi++le meatus is a shallo" de!ression 3ust in front of the iddle eatus and above the vestibule of the nose( It is li ited above by a faint ridge of ucous e brane. sinus o4 anterior eth5oidal sinus Openings o4@ <osterior eth5oidal sinus Middle eth5oidal sinus . is a rounded elevation !roduced by the underlying iddle eth oidal sinuses. BdC )he o. concha. is a dee! se icircular sulcus belo" the bulla( BcC )he infun+ibulum is a short !assage at the anterior end of the hiatus. "hich runs for"ards and do"n"ards fro the u!!er end of the anterior border of the iddle concha B1ig( 1J(AC( . and is the largest of the three eatuses( )he nasolacri al duct o!ens into it at the 3unction of its anterior one-third and !osterior t"o-thirds( )he o!ening is guarded by the lacri al fold.henoethmoi+al re*ess is a triangular fossa 3ust above the su!erior concha( It receives the o.7: Formation of the lateral wall of the % R W % 3 C O R % % : %%%%%%%% Middle concha nose. %+. Opening o4 4rontal sinus Alar cartilages /n4erior nasal concha Jrontal air sinus %Middle concha GcutH Agger nasi R Atriu5 .osterior ethmoi+al air sinuses) )he s.ening of the frontal air sinus is seen in the anterior !art of the hiatus se ilunaris( BfC )he o.ening of the s.ening of the maxillary air sinus is located in the !osterior !art of the hiatus se ilunaris( It is often re!resented by t"o o!enings. BbC )he hiatus semilunaris. or <asner*s valve( F( )he mi++le meatus lies underneath the iddle concha( It !resents the follo"ing features8 BaC )he ethmoi+al bulla.ening of the mi++le ethmoi+al air sinus is !resent at the u!!er argin of the bulla B1ig( 1J(AC( :( )he su. BgC )he o.erior meatus lies belo" the su!erior concha( )his is the shortest and shallo"est of the three eatuses( It receives the o.PP Hiatus se5ilunaris O+ Vesti6ule Opening o4 nasolacri5al duct S in4erior concha GcutH /n4erior 5eatus '3 $'3$@ 5ateral wall of the nose seen after removing the conchae. the agger nasi.enings of the . * r* DDDD=?= O #1) A PP AA F C F -phenoidal sinus . 7% -uperior concha GcutH the s allest concha situated 3ust above the !osterior !art of the iddle concha( )he meatuses of the nose are !assages beneath the overhanging conchae( 2ach eatus co unicates freely "ith the nasal cavity !ro!er B1ig( 1J(AC( 1( )he inferior meatus lies underneath the inferior .Mose and <aranasal -inuses /n4erior nasal cartilage Jrontal sinus %%%%%%%%%%%%%%%%%%%%%% asal 6one OPPP Jrontal process o4 5a:illa % Lacri5al 6one P`3% Eth5oid 6one ==DD Uncinate process o4 eth5oid R.%% -phenopalatine 4ora5en G%PE Medial pter2goid plate <erpendicular plate o4 palatine 6one Outline o4 opening o4 5a:illar2 sinus Fig. Ma:illar2 in in4undi6ulu5 Opening %i% If= %%% -phenoeth5oidal recess T9) G h * : .

branch of the !terygo!alatine ganglion( 1ollo" the nerve and its acco !anying vessels to the hard !alate( Identify the lesser !alatine nerves and trace the till the soft !alate( EVer7e $upply Branches 4ro5 4acial arter2 Fig.es derived fro the branches of trige inal nerve are distributed to "hole of the lateral "all8 1()he anterosu.1: Arteries supplying the lateral wall of the nose.erior :ua+ran t is su!!lied by the !osterior su!erior lateral nasal branches fro the !terygo!alatine ganglion sus!ended by the a&illary nerve( Anterior eth5oidal ner7e Ol4actor2 rootlets <osterior superior lateral nasal 6ranches Branches o4 anterior palatine ner7e Anterior palatine ner7e Anterior superior al7eolar ner7e Fig.osterosu.erior :ua+rantis su!!lied by the 'enous 9rainage anterior eth oidal artery assisted by the !osterior eth oidal and facial arteries( F()he anteroinferior :ua+rant. branch of a&illary nerve( :()he . %+.erior :ua+rant is su!!lied by the anterior eth oidal nerve branch of o!hthal ic nerve B1ig( 1J(9C( F()he anteroinferior :ua+rant is su!!lied by the anterior su!erior alveolar nerve. %+.(+( Hea$ a"$ Ne&- Arterial $upply of 5ateral Jall 1()he anterosu.osteros u. is su!!lied by the s!heno!alatine artery( H()he . is su!!lied by branches fro the facial and greater !alatine arteries B1ig( 1J(4C( :()he . I( Ceneral sensory ner.osteroinferior :ua+rant is su!!lied by branches fro the greater !alatine artery "hich !ierce the !er!endicular !late of the !alatine bone( Anterior eth5oidal arter2 0reater palatine arter2 '. to the !terygoid !le&us of veins( DISSECTION )race the naso!alatine nerve till the s!heno!alatine fora en( )ry to find fe" nasal branches of the greater !alatine nerve( +ently brea' the !er!endicular !late of !alatine bone to e&!ose the greater !alatine nerve. into the !haryngeal !le&us of veinsD and fro the iddle !art. <osterior eth5oidal arter2 -phenopalatine arter2 )he veins for a !le&us "hich drains anteriorly into the facial veinD !osteriorly.erior :ua+rant.K: Nerve .

supply of lateral wall of nasal cavity. .

osteroinferior :ua+rant is su!!lied by the anterior or greater !alatine branch fro the !terygo!alatine ganglion sus!ended by the a&illary nerve( II( <. to the retro!haryngeal and u!!er dee! cervical nodes( CLINICAL ANATOM Paranasal sinuses are air filled s!aces !resent "ithin so e bones around the nasal cavities( )he sinuses. and to the lacri al a!!aratus through the nasolacri al duct are i !ortant in the s!read of infection( H(<y!ertro!hy of the ucosa over the inferior nasal concha is a co on feature of allergic rhinitis. or even absent at birth( )hey enlarge ra!idly during the ages of si& to seven years. the voice is altered( )he sinuses are rudi entary. s. maxillary. and fro the !osterior half.Nose a"$ Para"asa# Si"uses (++ H( )he .ll of the o!en into the nasal cavity through its lateral "all B1ig( 1J(1GC( )he fun*tion of the sinuses is to a'e the s'ull lighter and add resonance to the voice( In infections of the sinuses or sinusitis.e*ial sensory ner. i(e( ti e of eru!tion of !er anent teeth and then after !uberty( 1ro birth to adult life the gro"th of the sinuses is due to enlarge ent of the bonesD in old age it is due to resor!tion of the surrounding cancellous bone( )he anato y of individual sinuses is i !ortant as they are fre%uently infected( DISSECTION on cold or rhinitis is the co onest infection of the nose( F()he !aranasal air sinuses ay get infected fro the nose( #a&illary sinusitis is the co onest of such infections( :()he relations of the nose to the anterior cranial fossa through the cribrifor !late. "hich is characteri7ed by snee7ing.e ove !art of the roof of the a&illary air sinus so that the a&illary nerve and !terygo!alatine ganglion are identifiable in the !terygo!alatine fossa( )race the infraorbital nerve in the infraorbital canal in the floor of the orbit( )ry to locate the sinuous course of anterior su!erior alveolar nerve into the u!!er incisor teeth( A"terior eth*oi$a# si"uses Posterior etho*oi$a# si"us S%he"oi$a# si"us .es or olfa*tory are distributed to the u!!er !art of the lateral "all 3ust belo" the cribrifor !late of the eth oid u! to the su!erior concha( =ote that the olfactory ucosa lies !artly on the lateral "all and !artly on the nasal se!tu ( 5ymphatic 9rainage PARANASAL SINUSES @y !hatics fro the anterior half of the lateral "all !ass to the sub andibular nodes. are frontal. and loo' for the continuity "ith the ucous e brane of the nose( .e ove the thin edial "alls of the eth oidal air cells.henoi+al an+ ethmoi+al) . nasal bloc'age and e&cessive "atery discharge fro the nose( 1(Co .e ove the edial "all of a&illary air sinus e&tending anteriorly fro o!ening of nasolacri al duct till the greater !alatine canal !osteriorly( =o" a&illary air sinus can be seen( .

./:P 5ateral wall of nasal cavity with location of paranasal sinuses.Fro"ta# air si"us Ma8i##ar6 si"us Fi*+ /0.

erage height. by the lateral "all of the nose( )he a. and is the largest of all the !aranasal sinuses( It is !yra idal in sha!e.ens into the iddle eatus of nose at the anterior end of the hiatus se ilunaris either through the infundibulu or through the frontonasal duct B1ig( 1J(6C( :()he right and left sinuses are usually une%ual in si7eD and rarely one or both ay be absent( )heir a.ex lies in the 7ygo atic !rocess of the a&illa( Features 1()he a&illary sinus lies in the body of the a&illa B1ig( 1J(FC.. but reach full si7e only after !uberty( J(6rterial su. in the su!raorbital notch( 0ym. by the alveolus of the a&illa. the base. "idth and antero!osterior de!th are each about F(J c ( )he sinuses are better develo!ed in ales than in fe ales( H()hey are rudi entary or absent at birth( )hey are "ell develo!ed bet"een seven and eight years of age. and bac'"ards into the edial !art of the roof of the orbit B1ig( 1J(1GP( F(It o.andibular nodes( Ier.. i(e( at the su!raorbital notch( Features 1()he frontal sinus lies in the frontal bone dee! to the su!erciliary arch( It e&tends u!"ards above the edial end of the eyebro". second o!ening is often !resent at the !osterior end of the hiatus( Both o!enings are nearer the roof than the floor of the sinus( .(+.ly7 Su!raorbital artery( =enous +rainage7 Into the anasto otic vein bet"een the su!raorbital and su!erior o!hthal ic veins.ens into the iddle eatus of the nose in the lo"er !art of the hiatus se ilunaris B1ig( 1J(6C( . and the a!e& directed laterally in the 7ygo atic !rocess of the a&illa( F(It o.hati* +rainage7 )o the sub.e su. Hea$ a"$ Nec8 Fro"ta# Si"us $urface /arking It is ar'ed by a triangular area for ed by 3oining the follo"ing three !oints( a( )he first !oint at the nasion( b( )he second !oint F(J c above the nasion( c( )he third !oint at the 3unction of edial one-third and lateral t"o-thirds of the su!raorbital argin. "ith its base directed edially to"ards the lateral "all of the nose.ly7 Su!raorbital nerve( Ma8i##ar6 Si"us $urface /arking )he roof is re!resented by the inferior orbital arginD the floor.

.verag easure ents are8 height.) J(6rterial su. and iD traversed by the infraorbital nerve( )he floor is for ed by the alveolar !rocess of the a&illa. 1J(AC( F(2ach sinus is related su!eriorly to the o!tic chias a and the hy!o!hysis cerebriD and laterally to the internal carotid artery and the cavernous sinus B1ig( 6(6C( :(6rterial su.e <u. infraorbital and greater !alatine arteries( =enous +rainage7 Into the facial vein and the !terygoid !le&us of veins( 0ym.ly7 Posterior eth oidal nerve and orbital branches of the !terygo!alatine ganglion( . the o!ening or hiatus the a&illary sinus is large( <o"ever. t the !er!endicular !late of the !alatine bone B1ia 1J(AC( It is further reduced in si7e by the thic ucosa of the nose( F()he si7e of the sinus is variable . in the inta s'ull the si7e of the o!ening is reduced to : or H as it is overla!!ed by the follo"ing8 BaC 1ro abov by the uncinate !rocess of the eth oid. :(J c D "idth.ly7 Infraorbital. and anterior. :(J c B1ig( 1J(1GC( :(Its roof is for ed by the floor of orbit.ly7 Posterior eth oidal and internal carotid arteries( =enous +rainage7 Into !terygoid venous !le&us and cavernous sinus( 0ym. and tt descending !art of the lacri al boneD BbC fro belo? by the inferior nasal conchaD and BcC fro behind. F(J c and antero!osterior de!th...e su.hati* +rainage7 )o the retro!haryngeal nodes( Ier.1(In an isolated a&illa. anc lies about 1 c belo" the level of the floor of the nose( )he level corres!onds to the level of the lo"er border of the ala of the nose( )he floor is ar'ed by several conical elevations !roduced by the roots of the u!!er olar and !re olar teeth( )he roots ay even !enetrate the bony floor to lie beneath the ucous lining( )he canine tooth ay !ro3ect into the anterolateral "all( H()he a&illary sinus is the first !aranasal sinus to +e.ly7 1acial.. iddle and !osterior su!erior alveolar nerves( S%he"oi$a# Si"us Features 1()he right and left s!henoidal sinuses lie "ithin the body of the s!henoid bone B1ig( 1J(1GC( )hey are se!arated by a se!tu ( )he t"o sinuses are usually une%ual in si7e( 2ach sinus o!ens into the s!henoeth oidal recess of the corres!onding half of the nasal cavity B1igs 1J(6.hati* +rainage7 Into the sub andibular nodes( Ier.elo.

thic'.n o!ening can be ade at the canine fossa through the vestibule of the outh. dee! to the u!!er li! BCald"ell-@uc o!erationC( F( Carcino a of the a&illary sinus arises fro the ucosal lining( Sy !to s de!end on the direction of gro"th( BaC Invasion of the orbit causes !ro!tosis and di!lo!ia( If the infraorbital nerve is involved there 6nterior7 Su!ero edial !art of the !osterior surface of the a&illa( /osterior7 .osterior ethmoi+al sinus consisting of one to seven air cells o!ens into the su!erior eatus of the nose( It is su!!lied by the !osterior eth oidal nerve and vessels and the orbital branches of( the !terygo!alatine ganglion( @y !hatics drain into the retro!haryngeal nodes( is facial !ain and anaesthesia of the s'in over the a&illa( BaCInvasion of the floor ay !roduce a bulging and even ulceration of the !alate( BbC1or"ard gro"th obliterates the canine fossa and !roduces a s"elling of the face( BcCBac'"ard gro"th ay involve the !alatine nerves and !roduce severe !ain referred to the u!!er teeth( BdC+ro"th in a edial direction !roduces nasal obstruction. the sinus is drained surgically by a'ing an artificial o!ening near the floor in one of the follo"ing t"o "ays.nother factor is that cilia in the lining ucosa are destroyed by chronic infection( <ence. e!ista&is and e!i!hora( BeC+ro"th in a lateral direction !roduces a s"elling on the face and a !al!able ass in the labiogingival groove( :( 1rontal sinusitis can !roduce a brain abscess in the frontal lobe( .el than its floor) . !urulent discharge fro the nose( Diagnosis is assisted by transillu ination and radiogra!hy( . BaC .oot of the !terygoid !rocess and ad3oining !art of the anterior surface of the greater "ing of the s!henoid( 1e+ial7 .erior7 .!!er !art of the !er!endicular !late of the !alatine bone( )he orbital and s!henoidal !rocesses of the bone also ta'e !art( 0ateral7 )he fossa o!ens into the infrate !oral fossa through the !terygo a&illary fissure( <u.ntru !uncture can be done by brea'ing the lateral "all of the inferior eatus( BbC . belo" the a!e& of the orbit B1ig( 1J(11C( &oundaries CLINICAL ANATOM 1( Infection of a sinus is 'no"n as sinusitis) It causes headache and !ersistent.ndersurface of the body of the s!henoid( Inferior7 Closed by the !yra idal !rocess of the !alatine bone in the angle bet"een the a&illa and the !terygoid !rocess( !ommunications 6nteriorly7 Eith the orbit through the edial end of the inferior orbital fissure( /osteriorly7 BaC Eith the iddle cranial fossa through the fora en rotundu D BbC "ith the fora en laceru through the !terygoid canalD and BcC "ith the !haryn& through the !alatinovaginal canal( 1e+ially7 Eith the nose through the s!heno!alatine fora en( 0aterally7 Eith the infrate !oral fossa through the !terygo a&illary fissure( . fro behind by the s!henoidal conchae and the orbital !rocess of the !alatine bone. diseased sinus is o!a%ue( )he a&illary sinus is ost co only involved( It ay be infected fro the nose or fro a caries tooth( Drainage of the sinus is +iffi*ult be*ause its ostium lies at a higher le.Eth*oi$a# Si"uses Features 2th oidal sinuses are nu erous s all interco unicating s!aces "hich lie "ithin the labyrinth of the eth oid bone B1ig( 1J(FC( )hey are co !leted fro above by the orbital !late of the frontal bone. si ilar abscess ay result fro eth oiditis( PTER IOPALATINE FOSSA 9efinition )his is s all !yra idal s!ace situated dee!ly. iddle and !osterior grou!s B1ig( 1J(1GC( )he anterior ethmoi+al sinus is ade u! of 1 to 11 air cells( It o!ens into the anterior !art of the hiatus se ilunaris of the nose( It is su!!lied by the anterior eth oidal nerve and vessels( Its ly !hatics drain into the sub andibular nodes( )he mi++le ethmoi+al sinus consisting of one to seven air cells o!en into the iddle eatus of the nose( It is su!!lied by the !osterior eth oidal nerve and vessels and the orbital branches of the !terygo!alatine ganglion( @y !hatics drain into the sub andibular nodes B1ig( 1J(6C( )he . and anteriorly by the lacri al bone( )he sinuses are divided into anterior.

F(FGC( In the !terygo!alatine fossa.=3A Head and ec! Undersur4ace o4 6od2 o4 sphenoid Root o4 pter2goid process /n4erior or6ital 4issure Gleading to or6itH ANTERIOR POSTERIOR <osterior sur4ace o4 5a:illa % -phenopalatine 4ora5en Gon 5edial 1allH Ma:illar2 air sinus <ter2gopalatine 4ossa in OJora5en rotundu5 O<ter2goid canal P% <alatino7aginal canal 0reater palatine canal depth o4 pter2go5a:illar2 4issure <art o4 palatine 6one Lesser palatine canals <2ra5idal process o4 palatine Fig. !alate.atheti* root is also derived fro the nerve of the !terygoid canal( It contains !ostganglionic fibres arising in the su!erior cervical sy !athetic ganglion "hich !ass through the internal carotid !le&us. the facial nerve. 6(1HC( =e&t. motor or . the !alate and the naso!haryn& B1ig( 1J(1FC( F()he sym. the greater !etrosal nerve and the nerve of the !terygoid canal to reach the ganglion( )he fibres relay in the ganglion( Postganglionic fibres arise in the ganglion to su!!ly secreto otor nerves to the lacri al gland and to the ucous glands of the nose. and leaves the iddle cranial fossa by !assing through the fora en rotundu B1igs 6(6. the !aranasal sinuses. 1J(1FC( D/--EC9/O )race the connections. and branches of !terygo!alatine ganglion( It is res!onsible for su!!lying secreto otor fibres to the glands of nasal cavity.atheti* root of the ganglion is for ed by the nerve of the !terygoid canal( It carries !reganglionic fibres that arise fro neurons !resent near the su!erior salivatory and lacri atory nuclei. and gives off the 7ygo atic and !osterior su!erior alveolar nerves( )he !osterior su!erior alveolar nerve enters the !osterior surface of the body of the a&illa. the !aranasal sinuses. 7ygo atic and !osterior su!erior alveolar( :(Pterygo!alatine ganglion and its nu erous branches containing fibres of the a&illary nerve i&ed "ith autono ic nerves( MA>ILLAR ERVE the !alate and !haryn&( )o!ogra!hically. runs for"ards in the lateral "all of the cavernous sinus belo" the o!hthal ic nerve. $'3 $ communications. the nerve crosses the u!!er !art of the !terygo!alatine fossa. and su!!lies the three u!!er olar teeth and the ad3oining !art of the gu ( Pter6!o%a#ati"e Ia"!#io" MS%he"o%a#ati"e Ia"!#io"T Pterygo!alatine is the largest !arasy !athetic !eri!heral ganglion( It serves as a relay station for secreto otor fibres to the lacri al gland and to the ucous glands of the nose. !haryn& and the lacri al gland( It is also called Hay fe. and !ass through the nervus inter edius.onnections 1()he It arises fro the trige inal ganglion. but functionally it is connected to the facial nerve through its greater !etrosal branch( )he flattened ganglion lies in the !terygo!alatine fossa 3ust belo" the a&illary nerve. beyond "hich it is continued as the infraorbital nerve B1igs F(19.arasym. $U $cheme to show the pterygopalatine fossa and its Inferiorly7 Eith the oral cavity through the greater and lesser !alatine canals( !ontents 1()hird !art of the a&illary artery and its branches "hich bear the sa e na es as the branches of the !terygo!alatine ganglia and acco !any all of the ( F(#a&illary nerve and its t"o branches. it is related to the a&illary nerve. the geniculate ganglion. the nerve is inti ately related to the !terygo!alatine ganglion. the dee! !etrosal nerve and the nerve of the !terygoid . in front of the !terygoid canal and lateral to the S!heno!alatine fora en B1igs 1J(11.er ganglion Ballergic sinusitisC( .

canal to reach the ganglion( )he fibres .

e descends through the greater !alatine canal. !ass through the ganglion "ithout relay. the !aranasal sinuses. t"o or three in nu ber su!!ly the !osterior !art of the roof of the nose and of the nasal se!tu 8 the largest of these nerves is 'no"n as the naso.erior nasal ner. i(e( inferior concha and ad3oining eatuses( )he lesser or mi++le an+ .3 3 and s25pathetic rootsH <ter2gopalatine ganglion <har2ngeal ner7e <O-9ER/OR A 9ER/OR <osterior in4erior nasal 6ranch o4 anterior %% Lesser G5iddle and posteriorH palatine ner7es ner7e Fig.es. about si& in nu ber su!!ly the !osterior !arts of the su!erior and iddle conchae B1ig( 1J(9C( )he me+ial . and the orbitalis uscle B1ig( 1J(1FC( bran*hes) The greater or anterior .osterior su.Ma:illar2 ner7e -ensor2 roots asal 6ranches %%%% palatine ner7e Anterior GgreaterH palatine % AL PP`% Q2go5atic ner7e containing lacri5al 6ranch o4 the ganglion %% er7e o4 pter2goid canal Gconstituting paras25pathetic 3 3 . the !alate and the naso!haryn& B)able 1(:C( )he sensory root co es fro the a&illary nerve( Its fibres !ass through the ganglion "ithout relay( )hey e erge in the branches described belo" B1ig( 1J(1FC( &ranches 1(/alatine )he branches of the ganglion are actually branches of the a&illary nerve( )hey also carry !arasy !athetic and sy !athetic fibres "hich !ass through the ganglion( )he branches are as8 1( >rbital bran*hes !ass through the inferior orbital fissure. .alatine ner.es.erior nasal ner. and su!!ly the !eriosteu of the orbit.$.es su!!ly the soft !alate and the tonsil B1ig( 1J(1:C( F(Iasal bran*hes enter the nasal cavity through the s!heno!alatine fora en B1ig( 1J(11C( )he lateral . and su!!lies the hard !alate and the lateral "all of the nose.alatine ner. %<: !onnections of the pterygopalatine ganglion.osterior .e "hich descends u! to the anterior !art of the hard !alate through the incisive fora en B1ig( 1J(JC( ANTERIOR <alpe6ral Lacri5al ner7e l Co55unicating 6ranch 6et1een L2go5atic and lacri5al Ma:illar2 ner7e POSTERIOR Jora5en rotundu5 Jacial ner7e 0eniculate ganglion 0reater petrosal " er7e o4 Deep petrosal E pter2goid canal asal La6ia -phenopalatine 4ora5en <ter2gopalatine ganglion . and su!!ly vaso otor nerves to the ucous e brane of the nose.alatine ner.osterior su.

: /a illary nerve with pterygopalatine ganglion.%).Lacri5al gland /n4raor6ital 4ora5en Lesser palatine 0reater palatine' Fig. %+. .

235 6ead and 7ec8 1()he .haryngeal bran*h !asses through the !alatinovaginal canal and su!!lies the !art of the naso!haryn& behind the auditory tube B1ig( 1J(1FC( F(0a*rimal bran*h) )he !ostganglionic fibres !ass bac' into the a&illary nerve to leave it through its 7ygo atic nerve and its 7ygo aticote !oral 1 a co unicating branch to lacri al nerve to the secreto otor fibres to the lacri al glan 1J(1F. 1J(1:C( )he !reganglionic fibres hav origin in the lacri atory nucleus( .

e ove the lo"er half of la ina of thyroid cartilage including the inferior horn of thyroid cartilage( /isualise the thyroarytenoid uscle in the vocal fold( SiIe . unli'e the oeso!hagus "hich o!ens at the ti e of eating or drin'ing only( .onstitution of 9aryn) )he length of the laryn& is HH in ales and :6 in fe ales( . it lies in front of the third to si&th cervical vertebrae. i(e( Bcricothyroid 3ointC( Define the edian cricothyroid liga ent( Identify thyrohyoid uscle( .buse of the vocal cords by e&cessive tal'ing ay cause singer*s nodules. and acts as a s!hincter at the inlet of the lo"er res!iratory !assages( )he u!!er res!iratory !assages include the nose.ntroduction DISSECTION )he laryn& is the organ for !roduction of voice or !honation( It is also an air !assage. transverse arytenoid and obli%ue arytenoid uscles( .ecurrent laryngeal nerve "as seen to enter laryn& dee! to the inferior constrictor uscle( Identify cricothyroid uscle. "hich is the only intrinsic uscle of laryn& !laced on the e&ternal as!ect of laryn&( . but in children and in the adult fe ale it lies at a little higher level B1ig( 1H(AC( Identify sternothyroid uscle and define its attach ents on the thyroid cartilage( Define the attach ents of inferior constrictor uscle fro both cricoid and thyroid cartilages including the fascia overlying the cricothyroid uscle( Cut through the inferior constrictor uscle to locate articulation of inferior horn of thyroid cartilage "ith cricoid cartilage. thyroe!iglottic and hyoe!iglottic liga ents( Stri! the ucous e brane fro the !osterior surfaces of arytenoid and cricoid cartilages( Identify !osterior cricoarytenoid. and even cancer of the vocal cords( . or teacher*s nodules. liga ents and e branesD and are oved by a nu ber of uscles( )he cavity of the laryn& is lined by ucous e brane( (+7 . an*s language is an 6inde& of intellect6( 0ne s!ea's during the e&!iratory !hase of res!iration( @aryn& is a !art of the res!iratory syste allo"ing t"o-"ay flo" of gases( It is 'e!t !atent because one adult is breathing about 1J ti es !er inute.e ove this uscle to identify thyrohyoid e brane( Identify vessels and nerve !iercing this e brane( Identify e!iglottis.t !uberty the ale laryn& gro"s ra!idly and beco es larger than the fe ale laryn&( )he !ubertal gro"th of the fe ale laryn& is negligible( )he laryn& is ade u! of a s'eletal fra e"or' of cartilages( )he cartilages are connected by 3oints. the naso!haryn& and the oro!haryn&( Situation and E)tent )he laryn& lies in the anterior idline of the nec'. conte !late and s!ea' less according to ti e and need( . e&tending fro the root of the tongue to the trachea( In the adult ale.9he Lar2n: @aryn& or voice bo& is "ell develo!ed in hu ans( Its ca!abilities are greatly enhanced by the large 6vocalisation area6 in the lo"er !art of otor corte&( 0ur s!eech is guided and controlled by the cerebral corte&( +od has given us t"o ears and one outhD to hear ore.

Lar6"8 )he laryn& contains nine cartilages. Cricotracheal liga5ent .artila*e )his cartilage is /-sha!ed in cross-section( It consists of right and left la inae B1ig( 16(1C( 2ach la ina is roughly %uadrilateral( )he la inae are !laced obli%uely relative to the idline8 their !osterior borders are far a!art.rominen*e) )he u!!er !arts of the anterior borders do not eet( )hey are se!arated by the thyroi+ not*h) )he !osterior borders are free( )hey are !rolonged u!"ards and do"n"ards as the su!erior and inferior cornua or horns( )he su!erior cornua is connected "ith the greater cornua of the hyoid bone by the lateral thyrohyoid liga ent in "hich a s all cartilage triticia ay develo!( )he inferior cornua articulates "ith the cricoid cartilage to for the cricothyroid 3oint B1ig( 16(FC( )he inferior border of the thyroid cartilage is conve& in front and concave behind( In the edian !lane. 16(:C( )he right and left argins of the cartilagi !rovide attach ent to the arye!iglottic folds( Iti anterior surfa*e is connected8 BaC )o the tongue byD edian glossoe!iglottic fold B1ig( 1A(1CD and BbC to thi hyoid bone by the hyoe!iglottic liga ent B1ig( 16(HC )he .<: $keleton of the laryn : posterior view..rytenoid F(Corniculate :(Cuneifor Thyroid . it is connected to the cricoid cartilage by the conus elasticus( )he outer surfa*e of each la ina is ar'ed by an obli%ue line "hich e&tends fro the su!erior thyroid tubercle in front of the root of the )his cartilage is sha!ed li'e a ring( It encircles thi laryn& belo" the thyroid cartilage( It is thic'er aiO stronger than the thyroid cartilage( )he ring has a narro" anterior !art called the ar*h. called the lamina B1ig( 16(FC( )he la ina !ro3ects u!"ards behind the thyroid cartilage and articulates su!eriorly "ith the arytenoic cartilages( )he inferior cornua of the thyroid cartilagf articulates "ith the side of the cricoid cartilage at thf 3unction of the arch and la ina( Epi*lottic .artila*e>Epi*lottis )his is a leaf&sha.ricoid . !aired( -n. %7.osterior surfa*e is covered "ith ucous e brane.artila*e )hese are t"o s all . of "hich three are un!aired and three.yrami+&sha. and a broad !osterior !art.e+ cartilage !laced in the anterioi "all of the u!!er !art of the laryn&( Its u. Fig.ex of the arytenoid cartilage ii curved !ostero edially and articulates "ith tb corniculate cartilage( Its base is concave an] Epiglottis %%' H2oid 6one Lateral th2roh2oid liga5ent % % 9h2roh2oid 5e56rane %%%%%% Corniculate cartilage RR Ar2tenoid cartilage R 9h2roid cartilage % O6li8ue line Cricoar2tenoid Foint %%%%%%%%%% Arch and la5ina o4 %%%%%%%%%%%%%%%%%%% cricoid cartilage ) i . %7. i ) ) )) ' O %%%%%%% 9rachea I O Fig.e+ cartilages lyin3 on the u!!er border of the la ina of the cricoit cartilage( )he a.: Hea$ a"$ Ne&- The S-e#eto" or Carti#a!es o.aire+ *artilages 1()hyroid F(Cricoid :(2!iglottic /aire+ *artilages 1(. but the anterior borders a!!roach each other at an angle that is about 9G degrees in the ale and about 1FG degrees in the fe ale( )he lo"er !arts of the anterior borders of the right and left la inae fuse and for a edian !ro3ection called the laryngeal. and !ro3ects u!"ards behind th] hyoid bone and the tongue( )he lo9er en+ or stalkii !ointed and is attached to the u!!er !art of the angli bet"een the t"o la inae of the thyroid cartilage B1igR 16(F.artila*e su!erior cornua to the inferior thyroid tubercle behini the iddle of the inferior border( )he thyrohyoid aiv> the inferior constrictor of the !haryn& are attached ti the obli%ue line( .(. and !resents a tubercle in the lo"er !art( -rytenoid .er en+ is broad and free.%: $keleton of the laryn : anterior view.

and also gliding ove ents in different directions( )he *ri*oarytenoi+ . Fi*+ # +4: !artilages of the laryn as seen in sagittal section. IAAAAAAAAAAAAAAA E%i!#ottis H6oi$ 2o"e Th6roh6oi$ *e*2ra"e O6li8ue #i"e A Th6roi$ &arti#a!e Ar6te"oi$ &arti#a!e Cri&oi$ &arti#a!e Lar2ngeal Fi*+ !artilages view.oint is a synoviaK3oint bet"een the inferior cornua of the thyroid cartilage and the side of the cricoid cartilage( It !er its rotatory ove ents around a transverse a&is. edial and !osterior B1igs 16(F. #ar6"8 1o&a# . cuneifor and !rocesses of the arytenoid are ade of elastic cartilage and do not ossify( cartilage to the hyoid bone( Its edian and lateral !arts are thic'ened to for the edian and lateral thyrohyoid liga ents( )he e brane is !ierced by the internal laryngeal nerves. and by the su!erior laryngeal vessels B1ig( 16(JC( BFC)he hyoe.articulates "ith the lateral !art of the u!!er border of the cricoid la ina( It is !rolonged anteriorly to for the vocal !rocess.o#$ CCo"us C Cri&oi$ &arti#a!e CC Tra&hea . and laterally to for the uscular !rocess Bsee 1ig( 16(1GC( )he surfa*es of the cartilage are anterolateral. and the basal !arts of the arytenoid cartilages are ade u! of hyaline cartilage( )hey ay ossify after the age of FJ years( )he other cartilages of the laryn&. it is interru!ted on each . Note the Quadrate membrane and the conus elasticus. 'no"n as the flbroelasti* membrane of the larynx) )his e brane is !laced 3ust outside the ucous e brane.16(HC( E%i!#ottis \CC Ar6e%i!#otti& .ntrinsic )he intrinsic liga ents are !art of a broad sheet of flbroelastic tissue.or* a"$ Cor"i&u#ate &arti#a!es C Ar6te"oi$ &arti#a!e Si"us o. and also gliding ove ents in all directions B1ig( 16(FC( 5aryngeal 5igaments and /embranes E trinsic B1C)he thyrohyoi+ membrane connects the thyroid !orniculate !artilages )hese are t"o s all conical nodules "hich articulate "ith the a!e& of the arytenoid cartilages. H6oi$ 2o"e CCCCCCC E%i!#ottis CCCCCCCCC H6oe%i!#otti& #i!a*e"t CCCCCCCCCC Th6roh6oi$ *e*2ra"e .)CC Th6roi$ &arti#a!e C Corniculate &arti#a!e &AAA HC Ar6te"oi$ &arti#a!e 4T Cri&oi$ &arti#a!e 5aryngeal Boints )he *ri*othyroi+ . and are directed !ostero edially( )hey lie in the !osterior !arts of the arye!iglottic folds B1ig( 16(JC( !uneiform !artilages )hese are t"o s all rod-sha!ed !ieces of cartilage !laced in the arye!iglottic folds 3ust ventral to the Corniculate cartilages( 4istology of 5aryngeal !artilages )he thyroid and cricoid cartilages.iglotti* ligament connects the u!!er end of the e!iglottic cartilage to the hyoid bone( B:C)he *ri*otra*heal ligament connects the cricoid cartilage to the u!!er end of the trachea B1ig( 16(1C( . %ro*i"e"&e i # +': of the laryn .iaU 3oint bet"een the base of the arytenoid cartilage and the u!!er border of the la ina of the cricoid cartilage( It !er its rotatory ove ents around a vertical a&is. e(g( e!iglottis corniculate.ua$rate *e*2ra"e ) Cu"ei.o#$ C H6oe%i!#otti& #i!a*e"t .o#$ H6oi$ 2o"e C Th6roh6oi$ *e*2ra"e 1esti2u#ar. 16(:.lateral Th6roi$ &arti#a!e e#asti&us ' Fi*+ # +5: 5igaments and membranes of the laryn .oint is also a syno.

entri*le of the laryn&( BcC)he !art belo" the vocal folds is called the infraglotti* .CR )he ri a is the narro"est !art of the laryn&( It is longer BF: C in ales than in fe ales B1A C( :( )he vestibular and vocal folds divide the cavity of the laryn& into three !arts( BaC)he !art above the vestibular fold is called the . therefore.art) The sinus of1orgagni or .fold of ucous e brane( )he ri a.estibule of the laryn&( BbC)he !art bet"een the vestibular and vocalP folds is called the sinus or .ithelium) )he rest of the laryngeal ucous e brane is covered "ith *iliate+ *olumnar e. has an anterior inter e branous !art Bthree-fifthC and aP !osterior intercartilaginous !art Bsee 1ig( 16(11. and the vocal folds are lined by stratifie+ s:uamous e.entri*le of the larynxis a narro" fusifor cleft bet"een the vestibular and vocal folds( )he anterior !art of the sinus is !rolonged u!"ards as a diverticulu bet"een the vestibular fold and the la ina of the thyroid cartilage( )his e&tension is 'no"n as the sa**ule of the larynx) )he saccule contains ucous glands "hich hel! to lubricate the vocal folds B1ig( 16(6C( Mucous Me56rane o4 Lar2n: 1()he anterior surface and u!!er half of the !osterior surface of the e!iglottis. the u!!er !arts of arye!iglottic folds.ithelium) F(The ucous e brane is loosely attached to the cartilages of the laryn& e&ce!t over the vocal liga ents and over the !osterior surface of the e!iglottis "here it is thin and fir ly adherent( Vesti6ular liga5ent Cricoid cartilage %%%%% Vesti6ular4old %Crico7ocal 5e56rane %%%%% iFF O -inus o4 lar2n: % Vocal 4old %%%%%% Ca7it2 o4 lo1er part o4 lar2n: 9h2roh2oid 5e56rane cuadrangular 5e56rane .

7: !oronal section through the laryn . %7. %%%%% 9rachea .% % Epiglottis and its 3 tu6ercle H2oid 6one Ar2epiglottic 4old -accule o4 lar2n: Fig.

"A3">H =32ransverse arytenoid Unpaired 5uscle GJig3 "A3&H Lateral part o4 upper 6order o4 arch o4 cricoid <osterior sur4ace o4 one ar2tenoid Up1ards and 6ac!1ards Muscular process o4 ar2tenoid 9rans7erse <osterior sur4ace o4 another ar2tenoid 33(bliQue arytenoid and aryepiglotticus GJig3 "A3&H A3 2hyroarytenoid and 2hyroepiglottic GJig3 "A3#H Muscular process o4 one ar2tenoid O6li8ue Ape: o4 the other ar2tenoid3 -o5e 4i6res are continued as aryepiglottic 5uscle to the edge o4 the epiglottis 9h2roid angle and adFacent Cricoth2roid liga5ent Bac!1ards and up1ards Anterolateral sur4ace o4 ar2tenoid cartilage3 -o5e 4i6res proFect into the 7ocal 4old and are !no1n as vocails..ricoarytenoid )his is a triangular >rigin uscle B1ig( 16(4C( Its fibres !ass bac'"ards and u!"ards to be inserted into the inferior cornua and lo"er border of the thyroid cartilage( Posterior surface of the la ina of the cricoid cartilage( 0rigin is edial to insertion( Ta2#e 94. but are !lentiful over the anterior surface of the e!iglottis. the #ar6"8 MFi!.:( #ucous glan+s are absent over the vocal cords. around the cuneifor cartilages and in the vestibular folds( )he glands are scattered over the rest of the larynx) /ntrinsic Muscles o4 Lar2n: Ta2#e 94. sternoh2oid 9h2roepiglotticus Ar2epiglotticus <osterior cricoar2tenoid onl2 Lateral cricoar2tenoid trans7erse. 52loh2oid -ternoth2roid. 90.9= I"tri"si& *us&#es o. -o5e o4 the upper 4i6res o4 th2roar2tenoid cur7e up1ards into the ar2epiglottic 4old to reach the edge o4 .(= Mus&#es a&ti"! o" the #ar6"8 /ovement "3Ele7ation o4 lar2n: =3Depression o4 lar2n: 33Opening inlet o4 lar2n: ?3Closing inlet o4 lar2n: '3A6ductor o4 7ocal cords A3Adductor o4 7ocal cords $39ensor o4 7ocal cords &3Rela:or o4 7ocal cords /uscles 9h2roh2oid. o6li8ue ar2tenoids Cricoth2roid 9h2roar2tenoid )he attach ents of intrinsic uscles of laryn& are described these are also !resented in )able 16(1 and their ain action in )able 16(F( !ricothyroid )his is the only intrinsic uscle lying on the e&ternal as!ect of-the laryn& B1ig( 16(AC( >rigin @o"er border and lateral surface of the cricoid cartilage( Insertion Posterior .nsertion /n4erior cornua and lo1er 6order o4 th2roid cartilage "3!ricothyroid 9he onl2 5uscle outside the lar2n: GJig3 "A3$H =3Posterior cricoarytenoid 9riangular 5uscle GJig3 "A3&H <osterior sur4ace o4 the la5ina o4 cricoid Up1ards and laterall2 Muscular process o4 ar2tenoid "35ateral cricoarytenoid GJigs "A3#.T /uscle (rigin Lo1er 6order and lateral sur4ace o4 cricoid Fibres Ji6res pass 6ac!1ards and up1ards .

epiglottis3 9his is !no1n as thyroepiglottic .

Mus&#es .i2resT ObliQue -rytenoid M5erti&a# . origin is lateral to insertion( >rigin 1ro the !osterior as!ect of the angle of the thyroid cartilage and the ad3acent !art of the Cricothyroid liga ent B1ig( 16(9C( Insertion )he fibres run bac'"ards and u!"ards to reach the anterolateral surface of the arytenoid cartilage( Docalis Fi*+ O +!: /uscles of laryn : posterior view.ll intrinsic uscles of the laryn& are su!!lied by the recurrent laryngeal nerve e&ce!t for the Cricothyroid "hich is su!!lied by the e&ternal laryngeal nerve( .ricoaryfenoid )his is ade u! of so e fibres of the obli%ue arytenoid "hich are continued into the arye!iglottic fold to reach the edge of the e!iglottic cartilage( Thyroarytenoid >rigin @ateral !art of the u!!er border of the arch of the cricoid cartilage. Hea$ a"$ Ne&- Insertion Its fibres !ass u!"ards and bac'"ards to the inserted into. the anterior as!ect of uscular !rocess of the arytenoid cartilage( Cricoth2roid TransAerse -rytenoid )his is the only un!aired intrinsic uscle of the laryn&( Its fibres run transversely fro the !osterior surface of one arytenoid cartilage to that of the o!!osite arytenoid cartilage( Mo2#i?ue .i2resT Fi*+ # +(: !ricothyroid muscle. )hese are sli!s of uscle that run obli%uely across the idline crossing each other( 2ach sli! arises fro the uscular !rocess of one arytenoid cartilage and is inserted into the a!e& of the o!!osite arytenoid cartilage B1ig( 16(4C( -ryepi*lotticus Insertion Its fibres !ass u!"ards and laterally and are inserted into !osterior as!ect of uscular !rocess of the arytenoid cartilage( 9ateral . )he vocalis is ade u! of so e fibres of the thyroarytenoid that gain attach ent to the vocal liga ent( K O2#i?ue ar6te"oi$ Thyroepi*lotticus Tra"s5erse ar6te"oi$ Posterior &ri&oar6te"oi$ So e of the u!!er fibres of the thyroarytenoid curve u!"ards into the arye!iglottic fold to reach the edge of the e!iglottis( )hese constitute the thyroe!iglotticus B1ig( 16(9C( Ner5e Su%%#6 o.(..

increasing the distance bet"een t"o attach ents of vocal cords. the inter e branous !art of the ri a is triangular. 6( #uscles "hich o!en the inlet of laryn&8 )hyroe!iglotticus B1ig( 16(9C( Mo5e*e"ts o. 1o&a# Fo#$s #ove ents of the vocal folds affect the sha!e and si7e of the ri a glottidis( 1(During %uiet breathing or condition of rest.or &ri&oth6roi$ Noi"t CCCCCCCCCCCCCCCCCCCCCCCC Cri&oth6roi$ Re&urre"t #ar6"!ea# "er5e Fi*+ # +": /uscles of the laryn : 5ateral view. thus tensing the vocal cords( )he thyroarytenoid !ulls the arytenoid for"ard. resulting in abduction of vocal cords( )his is done by only one !air of uscle.C( F(During !honation or s!eech.I"ter"a# #ar6"!ea# "er5e Th6roe%i!#otti& Latera# &ri&oar6te"oi$ Th6roar6te"oi$ B Cri&oth6roi$ *e*2ra"e Posterior &ri&oar6te"oi$ Fa&et . the glottis is reduced to a chin' by the adduction of the vocal folds B1ig( 16(11 BC( . transverse arytenoid( )he cricothyroid causes roc'ing ove ent of thyroid for"ards. rela&ing the vocal cords B)able 16(FC( 1(#uscles "hich abduct the vocal cords8 0nly !osterior cricoarytenoids( sc-GVV F(#uscles "hich adduct the vocal cords8 B1C @ateral cricoarytenoidsD BFC transverse arytenoidD B:C cricothyroidsD and BHC thyroarytenoids B1ig( 16(1GC( :(#uscles "hich tense the vocal cords8 Cricothyroids( H(#uscles "hich rela& the vocal cords8 B1C )hyroarytenoidsD and BFC vocalis B1ig( 16(9C( J(#uscles "hich close the inlet of the laryn&8 B1C 0bli%ue arytenoidsD and BFC arye!iglotticus( Th6roar6te"oi$ 1o&a#is B 1o&a# &or$ HB Tra"s5erse ar6te"oi$ Posterior &ri&oar6te"oi$ Latera# &ri&oar6te"oi$ Fi*+ # +#$: $cheme to show the direction of pull of some intrinsic muscles of the laryn .ny uscle "hich !ulls the uscular !rocess edially. !ushes the vocal !rocess laterally. the !osterior cricoarytenoid( #uscles "hich !ull the uscular !rocess for"ard and laterally "ill !ush the vocal !rocess edially causing adduction of vocal cords( )his is done by lateral cricoarytenoid. and the intercartilaginous !art is %uadrangular B1ig( 16(11. Actions )he vocal !rocess and uscular !rocesses ove in o!!osite directions( .

Dha. Pa.rticulators 2&!ired air8 . whispering. JhaD Palatal . a branch of the inferior thyroid artery( )he inferior laryngeal vein drains into the inferior thyroid vein( er7e -uppl2 o4 Lar2n: 1otor ner.. =aD @ingual .o*al fol+s7 by the su!erior laryngeal artery. +a. P.=. $ha. both !arts of the ri a are triangular. the inter e branous !art of the ri a glottidis is closed.rticulators8 )hese are for ed by !alate. #. J. )ha. Ja. +ha( B Laterior &ri&oar6te"oi$ C Posterior &ri&oar6te"oi$ Fi*+ # +##: Fima glottidis "a# in Quiet breathing.es7 )he internal laryngeal nerve su!!lies the ucous e brane u!to the level of the vocal folds( )he recurrent laryngeal nerve su!!lies it belo" the level of the vocal folds( L25phatic Drainage @y !hatics fro the !art above the vocal folds drain along the su!erior thyroid vessels to the anterosu!erior grou! of dee! cervical nodes( )he echanis of s!eech involves the follo"ing four !rocesses( 1(2&!ired air fro lungs F(/ibrators :(.C. a branch of the su!erior thyroid artery( )he su!erior laryngeal vein drains into the su!erior thyroid vein( Belo9 the .=?A Head and ec! 1(During forced ins!iration. Ba. "c# "d# during /nter5e56ranous %art I"ter&arti#a!i"ous %art during forced inspiration. Pha. $a. Bha. )a. it !roduces voice( @oudness or intensity of voice de!ends on the force of e&!iration of air( /ibrators8 )he e&!ired air causes vibrations of the vocal cords( Pitch of voice de!ends on the rate of vibration of vocal cords( /o"els are !roduced in the laryn&( . #aD by labiodental-). Da.o*al fol+s7 by the inferior laryngeal artery. 2. tongue. .D. fe" of the drain through the !relaryngeal nodes( Mechanis5 o4 -peech -. so that the entire ri a is lo7enge-sha!edD the vocal folds are fully abducted B1ig( 16(11 CC( F(During "his!ering. . but the inter-cartilaginous !art is "idely o!en B1ig( 16(11 DC( Arterial -uppl2 and Venous Drainage o4 Lar2n: )hose fro the !art belo" the vocal folds drain to the !osteroinferior grou! of dee! cervical nodes( .s the air is forced out of lungs and laryn&.$.esonators H(. to the .esonators8 )he colu n of air bet"een vocal cords and nose and li!s act as resonators( buality of sound de!ends on resonators( 0ne can a'e out change of %uality of voice even on the tele!hone( . teeth and li!s( )hese narro" or sto! the e&haled air( #any of the consonants are !roduced by the intrinsic uscles of tongue( Consonants !roduced by li!s are -B. "b# in phonation or speech.es) See nerve su!!ly of the uscles( <ensory ner. Cha.

and the vocal folds B1ig( 16(1FC( F(Since the laryn& or glottis is the narro"est !art of the res!iratory !assages. the vestibular folds.y38 or indirectly through a laryngeal irror 2in+ire*t laryngos*o.DD Epiglottis and its tu6ercle PPP Vesti6ular 4old PP Vocal 4old Lateral glossoepiglottic 4old Ar2epiglottic 4old : Cunei4or5 tu6ercle : R Co5iculate tu6ercle Rings o4 trachea <iri4or5 recess Fig. in functional !aralysis of laryn&. foreign bo+ies are usually lodged here( :(Infection of the laryn& is called laryngitis) It is characteri7ed by hoarseness of voice( H(0aryngeal oe+ema ay occur due to a variety of causes( )his can cause obstruction to breathing( Median glossoepiglottic 4old + Vallecula . da age to the internal laryngeal nerve !roduces anaesthesia of the ucous e brane in the su!raglottic !art of the laryn& brea'ing the refle& arc so that foreign bodies can readily enter it( F(Da age to the e&ternal laryngeal nerve causes so e "ea'ness of !honation due to loss of the tightening effect of the cricothyroid on the vocal cord( :(Ehen both recurrent laryngeal nerves are interru!ted.. the valleculae. the e!iglottis. the !osterior cricoarytenoids are the first to be !aralysed and the last to recover. %7. the vocal cords lie in the cadaveric !osition in bet"een abduction and adduction and !honation is co !letely lost( Breathing also beco es difficult through the !artially o!ened glottis( Ehen only one recurrent laryngeal nerve is !aralysed. CLINICAL ANATOM 1()he laryn& can be e&a ined either directly es( our nd of he of he of ut ic . . the !irifor fossae. the arye!iglottic folds. aD severe !rotective coughing is e&cited to e&!el the ob3ect( <o"ever. the o!!osite vocal cord co !ensates for it and !honation is !ossible but there is hoarseness of voice( )here is failure of forceful e&!losive !art of voluntary and refle& coughing( In !rogressive lesions of the recurrent laryngeal nerve. the only abductors of the vocal cords. the adductors are the first to be !aralysed( 1(Ehen any foreign ob3ect enters the laryn& through a laryngosco!e 2+ire*t laryngos*o.n to J( . as co !ared to the adductors( )his is called as Se on*s @a"( 0n the other hand.%<: 5aryn as seen through a laryngoscope. ir( si c re /.y3) By these !rocedures one can ins!ect the base of the tongue.

Median glossoepiglottic %8. su!erior constrictor uscles and the intervening !terygo andibular ra!he and reflect these do"n"ards e&!osing the lateral surface of the tongue( @oo' at the su!erior. it should be balanced and hygienic( 6)ongue is barely three inches long. because tongue is anchored to hyoid bone. and a !haryngeal !art that lies in the !haryn&( )he oral and !haryngeal !arts are se!arated by a /-sha!ed sulcus.akori sho!s.7 -ulcus ter5inalis Circu57allate papillae %a%i##ae Jili4or5 papillae . astication and deglutition( It has an oral !art that lies in the outh. O Jora5en caecu5 Pa#ato!#ossa# . the ti! of tongue if !rotruded gets deviated to the !aralysed side8 Introduction )he tongue is a uscular organ situated in the floor of the outh( It is associated "ith the functions of taste. *hat&.9he 9ongue *)/ gue co !rises s'eletal uscle "hich is . etc( are flourishing( 0ne need not be too fussy about the taste of the food( =utritionally.o#$ Fo#iate (. but it can 'ill a !erson si& feet tall(6 )ongue a!!ears very obile. voluntary( )hese voluntary uscles start behaving as involuntary in any classroo . inferior surfaces of your o"n tongue "ith the hel! of hand lens( Vallecula Epiglottis glossoepiglottic 4old E $ Lateral Jungi4or5 papillae Fig. the sulcus ter inalis B1ig( 1A(1C( DISSECTION In the sagittal section. fast food outlets.funny^ )han's to the taste buds that the ulti!le hotels. restaurants. identify fan-sha!ed genioglossus uscle( Cut the attach ents of buccinator. andible and soft !alate( 1our intrinsic and three e&trinsic uscles of tongue are su!!lied by hy!oglossal nerve( 0nly !alatoglossus is su!!lied by vagoaccessory co !le&( In !aralysis of hy!oglossal nerve. 4old <alatophar2ngeal 4old L25phnoid 4ollicles o4 phar2ngeal part o4 the dorsu5 <alatine tonsil epiglottis and palatine tonsil.%: 2he dorsum of the tongue. still it cannot be s"allo"ed li'e food. s!eech.

i&e o.li*a I fimbriata that is directed for"ards and edially to"ards the ti! of the tongue B1ig( 1A(FC( )he . na ed the foliate .hoi+ folli*les that collectively I constitute the lingual tonsil) #ucous glands are also I !resent( )he !osterior ost !art of the tongue is connected to the e!iglottis by three folds of ucous e brane( )hese are the edian glossoe!iglottic fold and the P right and left lateral glossoe!iglottic folds( 0n either side of the edian fold there is a de!ression called the .='> Head and ec! E:ternal Jeatures )he tongue has8 1(.alle*ula B1ig( 1A(1C( )he lateral folds se!arate the vallecula fro the !irifor fossa( <apillae o4 the 9ongue )hese are !ro3ections of ucous e brane or coriu "hich give the anterior t"o-thirds of the tongue its characteristic roughness( )hese are of the follo"ing three ty!es( 1(=allate or *ir*um. I but has any lym.art of the tongue is !laced on the floor of the outh( Its margins are free and in contact "ith the gu s and teeth( Just in front of the !alatoglossal arch each argin sho"s H to J vertical folds. na ed the foramen *ae*um) )hey run laterally and for"ards u! to the !alatoglossal arches( )he fora en caecu re!resents the site fro "hich the thyroid diverticulu gro"s do"n in the e bryo( )he oral and !haryngeal !arts of the tongue differ in their develo! ent.illae are nu erous near the ti! and argins of the tongue. F(. Su2#i"!ua# .a.o#$ o" . but so e of the are also scattered over the dorsu ( )hese are s aller than the vallate !a!illae but larger than the filifor Ori.allate .illae) )he su. root. and BbC a .#oor o. "hich has BaC a curved u!!er surface or dorsu .a.n oral . and to the hyoid bone belo" B1igs 11(F. to"!ue tur"e$ u% $u&t o" su2#i"!ua# %a%i##a Fre"u#u* C Dee% #i"!ua# 5ei" Fi*+ #(+&: 2he inferior floor of surface of the tongue and the mouth. so eti es called I the base of the tongue. and function( )he oral or .haryngeal or lym.illae) )hey are large in si7e 1-F in dia eter and are 4-1F in nu ber( )hey are situated i ediately in front of the sulcus ter inalis( 2ach !a!illa is a cylindrical !ro3ection surrounded by a circular sulcus( )he "alls of the !a!illa are raised above the surface B1ig( 1A(1C( F()he fungiform .i*2riata Ti% o. "hich sho"s a edian fold called the I frenulum linguae) 0n either side of the frenulu there is a !ro inence !roduced by the dee! lingual veins( #ore laterally there is a fold called the .hoi+ . by a faint /-sha!ed groove. body.art of the tongue lies I behind the !alatoglossal arches and the sulcus 1 ter inalis( Its !osterior surface. 1H(FC( Because of these attach ents "e are not able to s"allo" the tongue itself( In bet"een the t"o bones.haryngeal .erior surfa*e of the oral !art sho"s a edian furro" and is covered "ith !a!illae "hich a'e it rough( )he inferior surfa*e is covered "ith a s ooth ucous e brane. structure. ti!.art or !osterior one-third. for s the anterior "all of the oro!haryn&( )he ucous e brane has no !a!illae. and :(. and BbC an inferior surface( )he dorsu is divided into oral and !haryngeal !arts( )he inferior surface is confined to the oral !art only( )he root is attached to the andible and soft !alate above. it is related to the geniohyoid and ylohyoid uscles( )he ti. to!ogra!hy. at rest.a. lies behind the u!!er incisor teeth( )he +orsum of the tongue B1ig( 1A(1C is conve& in all directions( It is divided into8 BaC . of the tongue for s the anterior free end "hich.illary .a. su2*a"$i2u#ar P#i&a .art or anterior t"o-thirds. *outh . the sul*us terminalis) )he t"o li bs of the */ eet at a edian !it.

iddle fibrous se!tu divides the tongue into right and left halves( 2ach half contains four intrinsic and four e&trinsic uscles( Intrinsi* mus*les 1(Su!erior longitudinal F(Inferior longitudinal :()ransverse H(/ertical B1ig( 1A(:C Fxtrinsi* mus*les J(+enioglossus B1ig( 1A(HC 6(<yoglossus. )he intrinsi* mus*les B1ig( 1A(6C occu!y the u!!er !art of the tongue.erse mus*le e&tends fro the edian St6#o!#ossus H6o!#ossus . the To"!ue . h6oi$ arrangement of the intrinsic muscles and e trinsic muscles.a.erior longitu+inal mus*le lies beneath the ucous e brane( It shortens the tongue and a'es its dorsu concave( )he inferior longitu+inal mus*le is a narro" band lying close to the inferior surface of the tongue bet"een the genioglossus and the hyoglossus( It shortens the tongue and a'es its dorsu conve&( )he trans.i2rous se%tu* I".illae cover the !resulcal area of the dorsu of the tongue. and give it a characteristic velvety a!!earance( )hey are the s allest and ost nu erous of the lingual !a!illae( 2ach is !ointed and covered "ith 'eratinD the a!e& is often s!lit into fila entous !rocesses( Mus&#es o. Me$ia" .illae or *oni*al .erior #o"!itu$i"a# *us&#e 1erti&a# *us&#e Su%erior #o"!itu$i"a# *us&#e Tra"s5erse *us&#e Fi*+ #(+5: 4yoglossus and $tyloglossus. B1ig( 1A(JC A(Styloglossus B1ig( 1A(JC 4(Palatoglossus B1ig( 1H(JC Ie"io!#ossus Fi*+ #(+4: .enioglossus. and are attached to the sub ucous fibrous layer and to the edian fibrous se!tu ( )hey alter the sha!e of the tongue( )he su. Fi*+ #(+': section of the Ie"io!#ossus H6o!#ossus !oronal tongue showing St6#o!#ossus Ireater &o*ua o.a.To"!ue (09 !a!illae( 2ach !a!illa consists of a narro" !edicle and a large rounded head( )hey are distinguished by their bright red colour( :( )he filiform .

o4 tongue .ntrinsic muscles of tongue.ier. the iddle fibres into the dorsu . and one vena co itantes I acco !anies the hy!oglossal nerve( )he dee! lingual I vein is the largest and !rinci!al vein of the tongue( It I is visible on the inferior surface of the tongue( It runs bac'"ards and crosses the genioglossus and the hyoglossus belo" the hy!oglossal nerve( )hese veins unite at the !osterior border of the hyoglossus to for the lingual vein "hich ends either in the co on facial vein or in the internal 3ugular vein( L25phatic Drainage Fi*+ #(+ : . se!tu to the argins( It a'es the tongue narro" and elongated( )he .='= Head and ec! <>B>< tS><<BSIiSl><>B>I<< is also su!!lied by the tonsillar and ascendinl !haryngeal arteries B1igs 11(F. the iddle fibres de!ress the tongue. * and the !alate via !alatoglossus( )he genioglossus is described here( )he hyoglossus has been described in Cha!ter 11D the styloglossus in Cha!ter 1F and the !alatoglossus in Cha!ter 1H( )he genioglossus is a fan-sha!ed uscle "hich for s the ain bul' of the tongue( It arises fro the u!!er genial tubercle of the andible( 1ro here the fibres fan out and run bac'"ards( )he u!!er fibres are inserted into the ti!. and the lo"er fibres !ull the !osterior !art of the tongue for"ards and thus !rotrude the tongue fro the outh( )his uscle if !aralysed "ill fall bac' on the oro!haryn& and bloc' the air !assage( During anaesthesia.es) . and the lo"er fibres into the hyoid bone( )he u!!er fibres retract the ti!.ll tne6lntrinsic and e&trinsic uscles.es) )he lingual nerve is the nerve of general sensation and the chorda ty !ani is the nerve of taste for the anterior t"o-thirds of the tongue e&ce!t vallate !a!illae( <osterior "E3 o4 tongue Anterior =E3 -u65ental nodes Cugulo%o5oh2oid l25ph node -u65andi6ular nodes O5oh2oid 5uscle /nternal Fugular 7ein It is chiefly derived fro the lingual artery. are su!!lied by the hy!oglossal nerve( )he !alatoglossus is su!!lied by the cranial root of the accessory nerve through the !haryngeal !le&usy G6> ?<ensory ner. the tongue is !ulled for"ards to clear the air !assage( Arterial -uppl2 o4 9ongue 1()he ti! of the tongue drains bilaterally to the sub ental nodes B1ig( 1A(AC( F()he right and left halves of the re aining !art of the anterior t"o-thirds of the tongue drain unilaterally to the sub andibular nodes( . cce!t the !alatoglossus. 1H(1FC( Venous Drainage 9rans7erse Vertical /n4erior longitudinal )he arrange ent of the vena co itantesKveins of theB tongue is variable( )"o venae co itantes acco !any I the lingual artery. a branch of the e&ternal carotid artery( )he root of the tongue Fig. these are 'no"n as the ly !h nodes of the tongue( f1otor.erti*al mus*le is found at the borders of the anterior !art of the tongue( It a'e the tongue broad and flattened B1ig( 1A(:C( )he extrinsi* mus*les connect the tongue to the andible via genioglossusD to the hyoid bone through> hyoglossusD to the styloid !rocess via styloglossus. fe" central ly !hatics drain bilaterally to the sa e nodes( :()he !osterior one-third of the tongue drains bilaterally to the 3ugulo-o ohyoid nodes. $$3$@ 5ymphatic drainage of tongue.

both ucous and serous lie dee! to the ucous e brane( 23) Taste bu+s are ost nu erous on the sides of the vallate !a!illae. and is adherent to the uscles( 0n the !haryngeal !art of the dorsu . there is gradual atro!hy of the affected half of the tongue or he iatro!hy( #uscular t"itchings are also observed( Infranuclear lesions of the hy!oglossal nerve are seen ty!ically in otor neuron disease and in syringo yelia( Su!ranuclear lesions of the hy!oglossal nerve !roduce !aralysis "ithout "asting( )his is best seen in !seudobulbar !alsy "here the tongue is stiff. and on the "alls of the surrounding sulci( )aste buds are nu erous over the foliate !a!illae and over the !osterior one-third UCf the tongueD and s!arsely distributed on the fungifor !a!illae. it is very rich in ly !hoid follicles( 0n the inferior surface. lined by stratified s%ua ous e!itheliu ( 0n the oral !art of the dorsu . !onnective 2issue bul' of the tongue is ade u! of striated uscles( F()he mu*ous membrane consists of a layer of connective tissue Bcoriu C. To"!ue /3 Epithelium BaC6nterior t9o&thir+s7 fro 1()he )he connective tissue develo!s fro local esenchy e( CLINICAL ANATOM the 1(In3ury t"o lingual s"ellings and one tuberculu i !ar. it is thin. s all and oves very sluggishly resulting in defective articulation( F(+lossitis is usually a !art of generali7ed ulceratlon of the outh cavity or sto atitis( In certain anae ias. the tongue beco es s ooth due to atro!hy of the filifor !a!illae( :()he !resence of a rich net"or' of ly !hatics and of loose areolar tissue in the substance of the tongue is res!onsible for enor ous s"elling of the tongue in acute glossitis( )he tongue fills u! the outh cavity and then !rotrudes out of it( H()he undersurface of the tongue is a good site along "ith the bulbar con3unctiva for observation of 3aundice( Ta2#e 9/. it is thin and s ooth( =u erous glands. "hich arise fro the first branchial arch( )he tuberculu i !ar soon disa!!ears( )herefore. i(e( fro the third arch( )herefore.To"!ue (0+ I )he glosso!haryngeal nerve is the nerve for both general sensation and taste for the !osterior onethird of the tongue including the circu vallate !a!illae( )he !osterior ost !art of the tongue is su!!lied by the>vagus nerve through the internal laryngeal branchJ)able 1A(1C( $c>t>s Histo#o!6 BcC Posterior ost !art fro the fourth arch( )his is therefore su!!lied by the vagus nerve( //3 /uscles )he uscles develo! fro the occi!ital yoto es "hich are su!!lied by the hy!oglossal nerve( ///. the e!iglottis and * the !haryn&( )here are no taste buds on the iddorsal region of the oral !art of the tongue(C De5e#o%*e"t o. for s !a!illae. it is su!!lied by lingual nerve B!ost-tre aticC and chorda ty !ani B!retre aticC( BbC/osterior one&thir+7 fro cranial large !art of the hy!obranchial e inence. it is su!!lied by the glosso!haryngeal nerve B)able 1A(1C( to the hy!oglossal nerve !roduces !aralysis of the uscles of the tongue on the side of lesion( If the lesion is intranuclear. the to"!ue Nerve supply -ensor2 9aste Lingual Chorda t25pani e:cept 7allate papillae Anterior twoIthirds Posterior oneIthird Posterior most part or vallecula /nternal lar2ngeal 6ranch o4 7agus /nternal lar2ngeal 6ranch o4 7agus 0lossophar2ngeal 0lossophar2ngeal including the 7allate papillae .9= Parts o. the soft !alate.

De7elop5ent o4 epitheliu5 Lingual s1ellings o4 / arch3 9u6erculu5 i5par 1hich soon disappears 9hird arch 1hich 4or5s large 7entral part o4 h2po6ranchial e5inence Jourth arch 1hich 4or5s s5all dorsal part o4 h2po6ranchial e5inence Muscles de7elop 4ro5 occipital 52oto5es. so the cranial ner7e T// Gh2poglossal ner7eH supplies all intrinsic and three e:trinsic 5uscles3 Onl2 palatoglossus is supplied 62 cranial root o4 accessor2 through phar2ngeal ple:us and is de7eloped 4ro5 5esoder5 o4 si:th arch3 .

the tongue ay fall bac' and obstruct the air !assages( )his can be !revented either by lying the !atient on one side "ith head do"n Bthe *tonsil !osition*C or by 'ee!ing the tongue out echanically( F(In !atients "ith grand al e!ile!sy. i(e( bloc' dissection of nec' because recurrence of alignant disease occurs in ly !h nodes( Carcino a of the !osterior one-third of the tongue is ore dangerous due to bilateral ly !hatic s!read( .(0. Hea$ a"$ Ne&- 1(In unconscious !atients.ll the dee! cervical ly !h nodes are also re oved. the tongue is co only bitten bet"een the teeth during the attac'( )his can be !revented by hurriedly !utting in a outh gag at the onset of the sei7ure( A( Carcino a of the tongue is %uite co on( )he affected side of the tongue is re oved surgically( .

outer layer is ectoder al. the intrinsi* uscles alter the sha!e of the auricle. besides causing irritation. "hile the extrinsi* uscles ove the auricle as a "hole( )he bloo+ su. $'3$@ Named featured to be seen on the auricle. note the large de!ression called the *on*ha8 it leads into the e&ternal acoustic eatus( Heli: -caphoid 4ossa O3P 9riangular 4ossa%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%% BiE C256a conchae % 9ragus%%%%%%% /ntertragic notch % U E ) Antitragus Lo6ule %' Fig. as the ear.O Concha )he e&ternal ear consists of8 BaC )he auricle or !innaD and BbC the e&ternal acoustic eatus( AuricleE<inna )he auricle is the !art seen on the surface.eading aloud is a %uic'er "ay of e orising.e <u. inner layer is endoder al "hile iddle one is esoder al in origin( )he ossicles of the ear are the only bones fully for ed at birth( #iddle ear is a bo&li'e cavity "ith si& "alls odified accordingly( 0ne hears "ith the ears( )he centre for hearing is in the te !oral lobe of brain above the ear( . the iddle ear and the internal ear( E>TERNAL EAR the lobule for "earing the ear rings( )he rest of the auricle is divided into a nu ber of !arts that are sho"n in 1ig( 14(1( In !articular. PPP Auricular tu6ercle GDar1in's tu6ercleH % Antiheli: .9he Ear and Vesti6ulocochlear er7e )y !anic e brane co !rises all the three bryonic layers -. hy!ertension and obesity( .ly of the auricle is derived fro the !osterior auricular and su!erficial te !oral arteries( )he lym.hati*s drain into the !reauricular.ddiction to )/ "or's out to be e&tre ely e&!ensive in ter s of both health and ti e( )i e anage ent is i !ortant for success on all fronts( )he ear is an organ of hearing( It is also concerned in aintaining the e%uilibriu of the body( It consists of three !arts8 )he e&ternal ear. te !oral lobes and otor s!eech area are also activated( )he labyrinth is also su!!lied by an 6end artery6 li'e the retina( =oise !ollution "ithin the four "alls of the ho es fro the usic albu s and advertise ents e itted fro the television sets cause a lot of da age to the cochlear nerves and te !oral lobes.. the lo"est !art of the auricle is soft and consists only of connective tissue covered by s'in8 )his !art is called In relation to the auricle there are a nu ber of uscles( )hese are vestigeal in an( In lo"er ani als. !ostauricular and su!erficial cervical ly !h nodes( Ier. the !art the lay an calls the ear( )he greater !art of it is ade u! of a single cru !led !late of elastic cartilage "hich is lined on both sides by s'in( <o"ever.ly7 )he u!!er t"o-thirds of the lateral surface of the auricle are su!!lied by the auriculote !oral nerveD and the lo"er one-third by the great auricular nerve( )he u!!er t"o-thirds of the edial surface are su!!lied by the lesser occi!ital nerveD and the lo"er one-third by the great auricular nerve( )he root of the auricle is su!!lied by the auricular branch of the vagus( )he auricular uscles are su!!lied through branches of the facial nerve( (00 ..

bac'"ards and u!"ards( )he inner !art is directed edially. the anterior "all and floor are longer than the !osterior "all and roof( )he canal is oval in section( )he greatest dia eter is vertical at the lateral end.hati*s7 )he ly !hatics !ass to !reauricular. due to the fi&ing of the s'in to the underlying bone and cartilage( :(Irritation of the auricular branch of the vagus in the e&ternal ear by ear "a& or syringing ay refle&ly !roduce !ersistent cough called ear cough. good nu ber of ear traits follo" #endelian inheritance( T6*%a"i& Me*2ra"e )his is a thin. and the inner !art. lies about J fro the ty !anic e brane( )he bony . and antero!osterior at the edial end( )he bony !art is narro"er than the cartilaginous !art( )he narro"est !oint. by the dee! auricular branch of the a&illary artery( 0ym. !ostauricular and su!erficial cervical ly !h nodes( Ier. bac'"ards and slightly laterally( DISSECTION CLINICAL ANATOM 1(. and ceru inous or "a& glands( Ceruminous glan+s are odified s"eat glands( Bloo+ su. grains. for"ards and do"n"ards( )he eatus can be straightened for e&a ination by !ulling the auricle u!"ards. and the lateral one-third or 4 is cartilaginous( Due to the obli%uity of the ty !anic e brane.e su. easuring 9 & 1G ( It is !laced obli%uely at an angle of JJ degrees "ith the floor of the eatus( It faces do"n"ards.art is also C-sha!ed in sectionD and the ga! of the *C* is filled "ith fibrous tissue( )he lining s'in is adherent to the !erichondriu . fir ly adherent to the !eriosteu ( )he *artilaginous . the isthmus. and contains hairs.ly7 )he s'in lining the anterior half of the eatus is su!!lied by the auriculote !oral nerve. ild sti ulation of this nerve ay refle&ly !roduce increased a!!etite( H(. vo iting or even death due to sudden cardiac inhibition( 0n the other hand. sebaceous glands. and that lining the !osterior half.ly7 )he outer !art of the canal is su!!lied by the su!erficial te !oral and !osterior auricular arteries. by the auricular branch of the vagus( already stated. of "hich the edial t"o-thirds or 16 is bony. although fungal infection and foreign bodies should be e&cluded( )roubleso e i !action of large foreign bodies li'e seeds.(04 Hea$ a"$ Ne&- E8ter"a# A&ousti& Meatus )he e&ternal auditory eatus conducts sound "aves fro the concha to the ty !anic e brane( )he canal is S-sha!ed( Its outer !art is directed edially.art is for ed by the ty !anic !late of the te !oral bone "hich is C-sha!ed in crosssection( )he !osterosu!erior !art of the !late is deficient( <ere the "all of the eatus is for ed by a !art of the s%ua ous te !oral bone( )he eatus is lined by thin s'in. for"ards and laterally B1ig( 14(FC( )he e brane has outer and inner surfaces( )he outer surface of the e brane is lined by thin s'in( It is concave( )he inner surface !rovides attach ent to the handle of the alleus "hich e&tends u! to its centre( )he inner surface is conve&( )he !oint of a&i u conve&ity lies at the ti! of the handle of the alleus and is called the umbo) )he e brane is thic'ened at its circu ference . translucent !artition bet"een the e&ternal acoustic eatus and the iddle ear( It is oval in sha!e. in infants. insects is co on( J(Involve ent of the ear in her!es 7oster of the geniculate ganglion de!ends on the connection bet"een the auricular branch of the vagus and the facial nerve "ithin the !etrous te !oral bone( 6(S all !ieces of s'in fro the lobule of the !inna are co only used for de onstration of le!ra bacilli to confir the diagnosis of le!rosy( A(. for"ards and u!"ards( )he iddle !art is directed edially. for e&a ination of th eatus and ty !anic e brane the auricl should be dra"n u!"ards...ccu ulation of "a& in the e&ternal acoustic eatus is often a source of e&cessive itching. the auricle is dra"i do"n"ards and bac'"ards because the canal i only cartilaginous and the outer surface of thi ty !anic e brane is directed ainli do"n"ards( F(Boils and other infections of the e&terna eatus cause little s"elling but are e&tre el3 !ainful. bac'"ards and slightR laterally( <o"ever.s 2&!ose the e&ternal auditory eatus by cutting the tragus of the auricle( Put a !robe into the e&ternal auditory eatus and re ove the anterior "all of cartilaginous and bony !arts of the e&ternal auditory eatus "ith the scissors( Be slo" and careful not to da age the ty !anic e brane( )he eatus or canal is about FH long.

"hich is fi&ed to the ty !anic sulcus of the te !oral .

the anterior and !osterior alleolar folds are !rolonged to the lateral !rocess of the alleus( Ehile the greater !art of the ty !anic e brane is tightly stretched and is. *a##eus Latera# %ro&ess a"$ ha"$#e o. Anterior 5alleolar . Auri&u#ar 2ra"&h o.a&eT ty !anic !late( Su!eriorly. the !art bet"een the t"o alleolar folds is loose and is called the !ars flaccida( )he !ars flaccida is crossed internally by the chorda ty !ani B1ig( 14(:C( )his !art is ore liable to ru!ture than the !ars tensa( )he e brane is held tense by the in"ard !ull of the tensor ty !ani uscle "hich is inserted into the u!!er end of the handle of the alleus( F Fi2rous #a6er Mu&ous #a6er Pars .ar a"$ 1esti2u#o&o&h#ear N Fi*+ #!+&: 5eft tympanic membrane : outer surface. called the !ars tensa. therefore.i2res Auri&u#ote*%ora# "er5e Fi*+ #!+5: Arrangement of fibres in the tympanic membrane and its nerve supply.#a&&i$a Fi*+ #!+4: 2ympanic membrane as seen in section. the sulcus is deficient( <ere the e brane is attached to the ty !anic notch( 1ro the ends of the notch t"o bands.o#$ rC@'rB Hea$ o. t6*%a"i& *e*2ra"e OC Positio" o.i2res C C Ra$ia# . ha"$#e o.o#$ G Pars . *a##eus 3) )he inner mu*ous layer B1ig( 14(6C is lined by a lo" ciliated colu nar e!itheliu ( &lood $upply 1()he Pars te"sa DJC Chor$a t6*%a"i outer surface is su!!lied by the dee! auricular branch of the a&illary artery( F()he inner surface is su!!lied by the anterior ty !anic branch of the a&illary artery and by the !osterior ty !anic branch of the stylo astoid branch of the !osterior auricular artery B1ig( 1G(AC( . 5a!us B Cir&u#ar . Short %ro&ess a"$ 2o$6 o.#a&&i$a bone on the Posterior *a##eo#ar . *a##eus Pars te"sa Mouter sur. *a##eus E8ter"a# a&ousti& *eatus Cuti&u#ar #a6er o. i"&us C Hea$) ) a"terior %ro&ess a"$ ha"$#e o.

i2rous #a6er CCCCCCCCC I""er *u&ous #a6er V%' $tructure )he ty !anic e brane is co !osed of the follo"ing three layers8 1()he outer *uti*ular layer of s'in B1ig( 14(HC( F()he mi++le fibrous layer ma+e u! of su!erficial radiating fibres and dee! circular fibres( )he circular fibres are ini al at the centre and a&i al at the !eri!hery( )he fibrous layer is re!laced by loose areolar tissue in the !ars flaccida B1ig( 14(JC( + Fig.Fi*+ #!+': 5eft tympanic membrane : . U*2o) C C. #!+ : !urvatures of the tympanic membrane.nner surface. B Outer &uti&u#ar #a6er T6*%a"i& %#e8us o. . "er5es CCCCCCCCC Mi$$#e .

lateral to the long !rocess of the incus.1: $cheme to show the three parts of the ear. 'enous 9rainage /eins fro the outer surface drain into the e&ternal 3ugular vein( )hose fro the inner surface drain into the transverse sinus and into the venous !le&us around the auditory tube( 5ymphatic 9rainage acoustic 5eatus canal Middle ear i -econdar2 t25panic 5e56rane Cochlea @y !hatics !ass to the !reauricular and retro!haryngeal ly !h nodes( Nerve $upply Fig. but the other "alls are narro".e ove the dura ater and endosteu fro the floor of the iddle cranial fossa( Identify greater !etrosal nerve e erging fro a canaliculus on the anterior surface of !etrous te !oral bone( )race it as it !asses inferior to trige inal ganglion to reach the carotid canal( Carefully brea' the roof of the iddle ear for ed by teg en ty !ani "hich is a thin !late of bone situated !arallel and 3ust lateral to the greater !etrosal nerve( Cavity of the iddle ear can be visualised( )ry to !ut a !robe in the antero edial !art of the cavity of iddle ear till it a!!ears at the o!ening in the lateral "all of naso!haryn&( Identify the !osterior "all of the iddle ear "hich has an o!ening in its u!!er !art( )his is the aditus to astoid antru "hich in turn connects the cavity to the astoid air cells( . it has to be re e bered that the chorda ty !ani nerve runs do"n"ards and for"ards across the inner surface of the e brane.8: 2he left tympanic membrane seen through the e ternal acoustic meatus.='& Head and ec! <ars 4laccida i Lateral process o4 5alleus %) Long process o4 incus MIDDLE EAR + W++) S SS Ri S Handle o4 5alleus %%%S. and the !osterosu!erior !art by the auricular branch of the vagus nerve( #) Inner surfa*e7 )his is su!!lied by the ty !anic branch of the glosso!haryngeal nerve through the ty !anic !le&us( )he iddle ear is sha!ed li'e a cube( Its lateral and edial "alls are large. but edial to the nec' of the alleus( . /ncisions are gi7en in this 8uadrant % Cone o4 light )he iddle ear is also called the ty !anic cavity. ty !anu ( )he iddle ear is a narro" air filled s!ace situatf in the !etrous !art of the te !oral bone bet"een tl e&ternal ear and the internal ear B1ig( 14(4C( Vesti6ule -e5icircular -tapes ` E:ternal Fig. and H near the floor( DISSECTION CUNICA# ANATOM 1(Ehen the ty !anic e brane is illu inated for e&a ination. %1. the concavity of the e brane Y !roduces a *cone of light* over the anteroinferior %uadrant "hich is the farthest or dee!est %uadrant "ith its a!e& at the u bo B1ig( 14(AC( )hrough the e brane one can see the underlying handle of the alleus and the long !rocess of the incus( F()he e brane is so eti es incised to drain !us !resent in the iddle eVar( )he !rocedure is called yringoto y( )he incision for yringoto y is usually ade in the !osteroinferior %uadrant of the e brane "here the bulge is ost !ro inent( In giving an incision. # in the centre. %1. as the edial and lateral "alls are closest to each other in the centre( )he distances se!arating the are 6 near the roof. because the cube is co !ressed fro side tc side( Its vertical and antero!osterior dia eters are both about 1J ( Ehen seen in coronal section the cavity of the iddle ear is biconcave. $hape and $iMe ") >uter surfa*e7 )he anteroinferior !art is su!!lied by the auriculote !oral nerve.

the roof !resents a ga! at the unossified !etros%ua ous suture "here the iddle ear is in direct contact "ith the eninges( In adults. and !osteriorly "ith the astoid antru and astoid air cells through the aditus to the astoid antru ( )he iddle ear is li'ened to a su ! !it or tra! in the slo!ing course of the aditus to the e!ity !anic recess and the auditory tube B1ig( 14(9C !ontents )he iddle ear contains the follo"ing8 1()hree s all bones or ossicles na ely the alleus.Ear a"$ 1esti2u#o&o&h#ear Ner5e (07 Far ossi*les Identify the bony ossicles( @ocate the tendon of tensor ty !ani uscle !assing fro the alleus to"ards the edial "all of the cavity "here it gets continuous "ith the uscle( )race the tensor ty !ani uscle traversing in a se icanal above the auditory tube( Brea' one "all of the !yra id to visualise the sta!edius uscle( Just su!erior to the attach ent of tendon of tensor ty !ani. the tensor ty !ani and the sta!edius( H(/essels su!!lying and draining the iddle ear( J( =erves8 Chorda ty !ani and ty !anic !le&us( )he ucous e brane lining the iddle ear cavity invests all the contents and for s several Auditor2 tu6e%%%%%%%%3 Middle ear ' ANTERIOR . the suture is ossified and trans its a vein fro the iddle ear to the su!erior !etrosal sinus( The 5loor or Gugular Aall )he floor is for ed by a thin !late of bone "hich se!arates the iddle ear fro the su!erior bulb of the internal 3ugular vein( )his !late is a !art of the te !oral bone B1ig( 14(1GC( =ear the edial "all the floor !resents the ty !anic canaliculus "hich trans its the ty !anic branch of the glosso!haryngeal nerve to the edial "all of the iddle ear( The 6nterior or Caroti+ Aall )he anterior "all is narro" due to the a!!ro&i ation of the edial and lateral "alls. loo' for chorda ty !ani traversing the ty !anic e brane( Parts vascular folds "hich !ro3ect into the cavity( )his gives the cavity a honeyco bed a!!earance( &oundaries )he cavity of the iddle ear can be subdivided into the ty !anic cavity !ro!er "hich is o!!osite the ty !anic e braneD and the e!ity !anic recess "hich lies above the level of the ty !anic e brane( !ommunications The Boof or Tegmental Aall 1()he roof se!arates the iddle ear fro the iddle cranial fossa( It is for ed by a thin !late of bone called the teg en ty !ani( )his !late is !rolonged bac'"ards as the roof of the canal for the tensor ty !ani B1ig( 14(1GC( F(In young children. and because of descent of the roof( )he u!!er ost !art of the anterior "all bears the o!ening of the canal for the tensor ty !ani( )he iddle !art has the o!ening of the auditory tube( )he inferior !art of the "all is for ed by a thin !late of bone "hich for s the !osterior "all of the carotid canal( )he !late se!arates the iddle ear fro the internal carotid artery( )his !late of bone is !erforated by the su!erior and inferior sy !athetic caroticoty !anic nerves and the ty !anic branch of the internal carotid artery B1ig( 14(11C( )he bony se!tu bet"een the canals for the tensor ty !ani and for the auditory tube is continued )he iddle ear co unicates anteriorly "ith the naso!haryn& through the auditory tube. the incus and the sta!es( )he u!!er half of the alleus. and the greater !art of the incus lie in the e!ity !anic recess( F(@iga ents of the ear ossicles( :()"o uscles.

%Mastoid air cells %Mastoid process .K: $cheme to show some relationships of the middle ear cavity. %1.%%% Aditu s to antru5 `%+O Mastoid antru5 POSTERIOR Fig. Note that the cavity resembles a sumpIpit or trap.

POSTERIOR Head o4 5alleus %% Anterior liga5ent o4 5alleus and A O 9ensor t25pani 5uscle 1ithin canal % Bon2 septu5 ) Auditor2 tu6e Anterior canaliculus 4or chorda t25pani petrot25panic 4issure ANTERIOR Chorda t25pani 925panic 5e56rane%%%%%%% Handle o4 5alleus %%%%%%%%% Fig.%%: 5ateral wall of the middle ear viewed from the medial side. %1. conical !ro3ection. there is an o!ening or a+itus through "hich the e!ity !anic recess co unicates "ith the astoid or ty !anic antru B1igs 14(1G.%3: $cheme to show the landmarks on the medial wall of the middle ear. lies near the 3unction of the !osterior and edial "alls( It has an o!ening at its a!e& for !assage of the tendon of the sta!edius uscle( H(@ateral to !yra id and near the !osterior edge of the ty !anic e brane.ani through "hich the nerve enters the iddle ear cavity( .9eg5en t25pani <rocessus cochleari4or5is %3 Canal 4or tensor t25pani % <ro5ontor2 Canal 4or auditor2 tu6e % % <ro5inence o4 lateral + 5icircular canal 925panic antru5 . 14(11C( F()he fossa in*u+is is a de!ression "hich lodges the short !rocess of the incus( :(. there is the .%% Jacial canal %% Jenestra 7esti6uli 333 <2ra5id \%%% -inus t25pani POSTERIOR N%%% Jenestra cochleae /nternal carotid arter2 925panic canaliculus ANTERIOR Cugular 6ul6 3P333333333 %%%%% 3333333/nternal Fugular 7ein Fig.. $ome related structures are aAso shown.yrami+. called the . 9eg5en t25pani%%%%%%%% .ro*essus *o*hleariformis) Its !osterior end for s a !ulley around "hich the tendon of the tensor ty !ani turns laterally to reach the u!!er !art of the handle of the alleus( AAFe /osterior or1astoi+ Aall )he !osterior "all !resents these features fro above do"n"ards( 1(Su!eriorly. %1.osterior *anali*ulus for the *hor+a tym. !osteriorly on the edial "all as a curved la ina called the . Aditus %%%%%%%%%%%%%%%%% <osterior canaliculus 4or chorda t25pani 3.

etrotym. in the region of the e!ity !anic recess( #) =ear the ty !anic notch there are t"o s all a!ertures.e lies either in the fissure or 3ust in front of it( )he nerve leaves the iddle ear through this canaliculus tc e erge at the base of the s'ull( )he 1e+ial or 0abyrinthine Aall )he edial "all se!arates the iddle ear fro the internal ear( It !resents the follo"ing features( .ani* fissure lies in fronl of the u!!er end of the bony ri ( It lodges the anterior !rocess of the alleus and trans its the ty !anic branch of the a&illary artery. BaC )he .aniner. BbC )he anterior *anali*ulus for the *hor+a tym.The 0ateral or 1embranous Aall 1( )he lateral "all se!arates the iddle ear fro the e&ternal acoustic eatus( It is for ed8 BaC #ainly by the ty !anic e brane along "ith the ty !anic ring and sulcus and BbC !artly by the s%ua ous te !oral bone.

#atera# ' se*i&ir&u#ar &a"a# A$itus iH)AAA I iII KSta%es &#osi"! the .ani* membrane) BdC)he sinus tym. Pro&esses &o&h#eari.e"estra 5esti2u#i Pro*o"tor6 <ith t6*%a"i& %#e8us P6ra*i$ Si"us t6*%a"i Fe"estra &o&h#eae Fa&ia# &a"a# Te"$o" o.rominen*e of the fa*ial *anal runs bac'"ards 3ust above the fenestra vestibuli. sta%e$ius Fi*+ #!+#&: Features on the medial wall of the middle ear. o!!osite the a !ulla of the !osterior se icircular canal( BeC)he . to reach the lo"er argin of the aditus( )he canal then descends behind the !osterior "all to end at the stylo astoid fora en( BcC)he fenestra *o*hleae is a round o!ening at the botto of a de!ression !osteroinferior to the !ro ontory( It o!ens into the scala ty !ani of the cochlea.estibuli is an oval o!ening !osterosu!erior to the !ro ontory( It leads into the vestibule of the internal ear and is closed by the foot!late of the sta!es( BbC)he .romontory is a rounded bulging !roduced by the first turn of the cochlea( It Is grooved by the ty !anic !le&us B1ig( 14(1FC( BaC)he fenestra .a"$ 1esti2u#o&o&h#ear Ner BaC )he . 2he .or*is ' Ca"a# . and is closed by the se*on+ary tym.or te"sor t6*%a"i Au$itor6 tu2e Pro*i"e"&e o.ro*essus *o*hleariformis Bsee the anterior "allC( Arterial $upply F( )he !osterior ty !anic branch of the styloastoid branch of the !osterior auricular artery "hich enters through the stylo astoid fora en( S all arteries su!!lying the iddle ear are as follo"s( 1()he su!erior ty !anic branch of the iddle eningeal artery "hich enters through the canal for the tensor ty !ani( F()he inferior ty !anic branch of the ascending !haryngeal artery entering through the ty !anic canaliculus( :()he ty !anic branch of the artery of the !terygoid canal by !assing through the canal for the auditory tube( H()he caroticoty !anic branch of the internal carotid artery entering through the anterior "all( J()he !etrosal branch of the iddle eningeal artery entering through the hiatus for the greater !etrosal nerve( Venous 9rainage /eins fro the iddle ear drain into the su!erior !etrosal sinus and the !terygoid !le&us of the veins( 5ymphatic 9rainage )he ain arteries of the iddle ear are as follo"s( 1( )he anterior ty !anic branch of the a&illary artery "hich enters the iddle ear through the !etroty !anic fissure( @y !hatics !ass to the !reauricular and retro!haryngeal ly !h nodes( stapes and the tendon of the stapedius are also shown.ani is a de!ression behind the !ro ontory.

Nerve $upply )he nerve su!!ly is derived fro the ty !anic !le&us "hich lies over the !ro ontory( )he !le&us is for ed by the follo"ing( 1()he ty !anic branch of the glosso!haryngeal nerve( Its fibres are distributed to the ucous e brane of the iddle ear. and thus transfor s the airborne vibrations fro the ty !anic e brane to li%uid borne vibrations in the internal ear( F()he intensity of the sound "aves is increased ten ti es by the ossicles( It ay be noted that the fre%uency of sound does not change( . the auditory tube. the astoid antru and air cells( It also gives off the lesser !etrosal nerve( F()he su!erior and inferior caroticoty !anic nerves arise fro the sy !athetic !le&us around the internal carotid artery( )hese fibres are vaso otor to the ucous e brane( Functions of the /iddle Ear 1(It trans its sound "aves fro the e&ternal ear to the internal ear through the chain of ear ossicles.

and fits into the fenestra vestibuli( Joi"ts o. causing thro bosis of the sig oid sinus and the internal 3ugular vein. bac'"ards and edially.iddle Ear It is so called because it rese bles an anvil.(4( Hea$ a"$ Ne&CLINICAL ANATOM Jootplate %' Fig.oint is a saddle 3oint( BFC)he in*u+osta.oint is a ball and soc'et . causing astoid abscess and even thro bosis in the sig oid sinus( Chronic otitis edia and astoid abscess are res!onsible for !ersistent discharge of !us through the ear( 0titis edia is ore co on in children than in adults( 1(1racture of the iddle cranial fossa brea's the roof of the iddle ear.ro*ess !ro3ects fro the u!!er end of the handle and !rovides attach ent to the alleolar folds.ll liga ents are e&tre ely elastic B1ig( 14(1:C( . the !ouch is bounded laterally by the !ars flaccida of the ty !anic e braneD edially by the nec' of the alleusD anteriorly and !osteriorly by the alleolar foldsD and su!eriorly by the lateral liga ent of the alleus( Infla atory e&udates in the !ouch often lead to !erforation of the !ars flaccida( THE EAR OSSICLES MALLEUC Hea$ ) Ne&Latera# %ro&ess A"terior %ro&ess . BbC It ay erode the roof and s!read u!"ards. %1.ie*eor base.B Posterior #i*2CCCCCCCC 1( )hroat infections co only s!read to the iddle ear through the auditory tube and cause otitis edia( )he !us fro the iddle ear ay ta'e one of the follo"ing courses8 BaC It ay be discharged into the e&ternal ear follo"ing ru!ture of the ty !anic e brane. BbC )he long . BbC )he ne*k lies against the !ars flaccida and is related edially to the chorda ty !ani nerve( BcC )he anterior .ccessory liga ents are three for the alleus.ro*ess !ro3ects do"n"ards 3ust behind and !arallel "ith the handle of the alleus( Its ti! bears a lentifor nodule directed edially "hich articulates "ith the head of the sta!es( Stapes )his bone is so called because it is sha!ed li'e a stirru!( It is the s allest.ro*ess is connected to the !etroty !anic fissure by the anterior liga ent( BdC )he lateral . and the ost edially !laced ossicle of the ear( It has the follo"ing !arts.? Handle from the medial side. and one each for the incus and the sta!es "hich stabili7e the ossicles( . and at the edial end on the base of the s'ull( )he auditory tube lies 3ust belo" this canal( )he uscle arises fro the "alls of the canal in "hich it . BcC It ay erode the floor and s!read do"n"ards.late. BaC )he bo+y is large and bears an )here are t"o uscles. BaC )he rounded hea+ lies in the e!ity !anic recess( It articulates !osteriorly "ith the body of the incus( It !rovides attach ent to the su!erior and lateral liga ents. the tensor ty !ani and the sta!edius( Both act si ultaneously to da ! do"n the intensity of high-!itched sound "aves and thus !rotect the internal ear( )he tensor tym. !osteriorly.%): (ssicles of the left ear. a foot. to the thin tendon of the sta!edius( BcC T9o limbs or cruraD anterior.uscles of the . is oval in sha!e. BbC )he narro" ne*k !rovides insertion. BaC )he s all hea+ has a concave facet "hich articulates "ith the lentifor nodule of the incus. and the ost laterally !laced ossicle( It has the follo"ing !arts.e+ial . BdC It ay s!read bac'"ards.ani lies in a bony canal that o!ens at its lateral end on the anterior "all of the iddle ear. articular surface that is directed for"ards( It articulates "ith the head of the alleus. BdC )he foot. used by blac's iths( It rese bles a olar tooth and has the follo"ing !arts. ru!ture the ty !anic e brane. and thus cause bleeding through the ear along "ith discharge of CS1( F()he infer ior !ou ch of th e o ute r attic or Prussa'*s !ouch does not drain easily. causing eningitis and brain abscess. the Ossi&#es B1C)he in*u+omalleolar . and is attached to the u!!er half of the ty !anic e brane B1ig( 14(1:C( Incus or -nAil 3oint( Both of the are synoviaR 3oints( )hey are surrounded by ca!sular liga ents( . the shorter and less curvedD and !osterior.alleus )he alleus is so called because it rese bles a ha er( It is the largest. seen / CUBo$6CCCCCCCCCCCCCC Short %ro&ess B Lo"! %ro&ess STAPES Hea$ A Ne&. the longer "hich diverge fro the nec' and are attached to the foot!late. BeC )he han+le e&tends do"n"ards.

e ove the !osterior and su!erior "alls of e&ternal auditory eatus till the level of the roof of astoid antru ( Identify the chorda ty !ani nerve at the !osterosu!erior argin of ty !anic e brane( @oo' for arcuate e inence on the anterior face of !etrous te !oral bone( Identify internal acoustic eatus on the !osterior face of !etrous te !oral bone. and beyond it the te !oral lobe of the cerebru ( F(Interiorly7 #astoid !rocess containing the astoid air cells( :(6nteriorly7 It co unicates "ith the e!ity !anic recess through the aditus( )he aditus is related edially to the a !ullae of the su!erior and lateral se icircular canals.. and !osterosu!eriorly to the facial canal( H(/osteriorly7 It is se!arated by a thin !late of bone fro the sig oid sinus( Beyond the sinus there is the cerebellu ( J(#edially8 Petrous te !oral bone( Clean the astoid te !oral bone off all the uscles and identify su!ra eatal triangle and su!raastoid crest( .eriorly7 )eg en ty !ani. "ith the nerves in it( )ry to brea' off the su!erior !art of !etrous te !oral bone above the internal acoustic eatus( Identify the facial nerve as it !asses to"ards the aditus( Identify the shar! bend of the facial nerve "ith the geniculate ganglion( Identify the facial nerve turning !osteriorly into the edial "all( )race it above the fenestra vestibuli till it turns inferiorly in the edial "all of aditus( Identify facial nerve at the stylo astoid fora en( )ry to brea' the bone vertically along the lateral edge of the fora en to e&!ose the "hole of facial nerve canal( 1acial nerve is described in detail in Cha!ter 9( .Ear a"$ 1esti2u#o&o&h#ear Ner5e (4+ lies( So e fibres arise fro the cartilaginous !art of the auditory tube. they ay e&tend beyond the astoid !rocess into the s%ua ous or !etrous !arts of the te !oral bone( . this canal is continuous "ith the vertical !art of the canal for the facial nerve( . or 1 c in dia eter and has a ca!acity of about one illilitre( Bou"$aries 1(<u. and through the otic ganglion.se a fine chisel to re ove the bone of the triangle till the astoid antru is reached( 2&a ine the e&tent of astoid air cells( . and are confined to the u!!er !art of the astoid !rocess( 0ccasionally.evise it fro there( Brea' off ore of the su!erior surface of the !etrous te !oral bone( . circular.e+ius lies in a bony canal that is related to the !osterior "all of the iddle eary Posteriorly.nteriorly. and so e fro the base of the s'ull( )he uscle ends in a tendon "hich reaches the edial "all of the iddle ear and bends shar!ly around the !rocessus cochlearifor is( It then !asses laterally across the ty !anic cavity to be inserted into the handle of the alleus( )he tensor ty !ani is su!!lied by the andibular nerve( )he fibres !ass through the nerve to the edial !terygoid. but increases in thic'ness at the rate of about 1 !er year u! to a a&i u of about t"elve to 1J ( DISSECTION >tos+erosis So eti es bony fusion ta'es !lace bet"een the foot !late of the sta!es and the argins of the fenestra vestibuli( )his leads to deafness( )he condition can be surgically corrected( T MPANIC OR MASTOID ANTRUM #astoid antru is a s all.e ove the bone gently( 2&a ine the holes in the bone !roduced by se icircular canals and loo' for the se icircular ducts lying "ithin these canals( =ote the branches of vestibulocochlear nerve entering the bone at the lateral end of the eatus( Study the internal ear fro the odels of the useu ( Mastoi$ Air Ce##s #astoid air cells are a series of interco unicating s!aces of variable si7e !resent "ithin the astoid !rocess( )heir nu ber varies considerably( So eti es there are 3ust a fe". "ithout any relay( It develo!s fro the esoder of first branchial arch( YK)he sta. into the !osterior surface of the nec' of the sta!esB)he sta!edius is su!!lied by the facial nerve( It develo!s fro the esoder of the second branchial. air filled s!ace situated in the !osterior !art of the !etrous te !oral bone( It is of adult si7e at birth. and belo".-arch(C CLINICAL ANATOM 6( 0aterally7 It is bounded by !art of the s%ua ous te !oral bone( )his !art corres!onds to the su!ra eatal triangle seen on the surface of the bone( )his "all is F thic' at birth. the canal o!ens on the su it of the !yra id( )he uscle arises fro the "alls of this canal( Its tendon e erges through the !yra id and !asses for"ards to be inserted. si7e of a s all !ea.

lies in the !etrous !art of the te !oral bone( It consists of the bony labyrinth "ithin "hich there is a e branous labyrinth( )he e branous labyrinth is filled "ith a fluid called endoly !h( It is se!arated fro the bony labyrinth by another fluid called the !erily !h( Crus &o**u"e Vesti6ular crest Elliptical A"terior se*i&ir&u#ar &a"a# Lateral se5icircular canal S%heri&a# re&ess Fe"estra &o&h#eae -cala 7esti6uli %.heri*al re*ess in front.ochlea CLINICAL ANATOM #astoid infection is secondary to otitis edia( It is difficult to treat( . and the scala ty !ani belo"( )hese relationshi!s a!!ly to the lo"est !art or basal turn of the cochlea( )he division bet"een the t"o !assages is co !leted by the basilar e brane( )he scala vestibuli co unicates "ith the scala ty !ani at the a!e& of the cochlea by a s all o!ening. S -cala t25pani ')) Opening o4 a8ueduct o4 cochlea .osterior tym.iral lamina.es are derived fro the ty !anic !le&us for ed by the glosso!haryngeal nerve and fro the eningeal branch of the andibular nerve( )he bony labyrinth consists of three !arts8 BaC )he cochlea anteriorlyD BbC the vestibule. the s.eins drain into the astoid e issary vein. !ro3ects fro the odiolus and !artially divides the cochlear canal into the scala vestibuli above. Hea$ a"$ Ne&- 'essels. !ro!er drainage of !us fro the astoid re%uires on o!eration through the su!ra eatal triangle( )he facial nerve can be in3ured during this o!eration( Infection fro the astoid antru and air cells can s!read to any of the structures related to the including the te !oral lobe of the cerebru .. and !resents the s. and the )he internal ear. and the sig oid sinus( )he bony cochlea rese bles the shell of a co on snail( It for s the anterior !art of the labyrinth( It has a conical central a&is 'no"n as the mo+iolus around "hich the cochlear canal a'es t"o and three %uarter turns( )he odiolus is directed for"ards and laterally( Its a!e& !oints to"ards the anterosu!erior !art of the edial "all of the iddle ear and the base to"ards the fundus of the internal acoustic eatus( . or labyrinth. called the heli*otrema) INTERNAL EAR Destibule )his is the central !art of the bony labyrinth( It lies edial to the iddle ear cavity( Its lateral "all o!ens into the iddle ear at the fenestra vestibuli "hich is closed by the foot!late of the sta!es( )hree se icircular canals o!en into its !osterior "all( )he edial "all is related to the internal acoustic eatus.(4. the cerebellu . 5ymphatics and Nerves Bo"6 La26ri"th )he astoid antru and air cells are su!!lied by the . the !osterior auricular vein and the sig oid sinus( 0ym.hati*s !ass to the !ostauricular and u!!er dee! cervical ly !h nodes( Ier. in the iddleD and BcC the se icircular canals !osteriorly B1ig( 14(1HC( . s!iral ridge of the bone.ani* artery derived fro the stylo astoid branch of the !osterior auricular artery( )he .

. %1. 5esti2u#e Co&h#ear re&ess Fig.Posterior se*i&ir&u#ar &a"a# F O%e"i"! o. a?ue$u&t o.%6: $cheme to the show some features of the bony labyrinth "seen from the lateral side#.

ulla) )hree canals o!en into the vestibule by five o!enings( )he anterioror su.ochlea or the Scala .estibular or Beissner's membrane8 and the outer "all by the bony "all of the cochlea( )he basilar e brane su!!orts the s!iral organ of Corti "hich is the end organ for hearing B1ig( 14(1AC( )he organ of Corti is innervated by !eri!heral !rocesses of bi!olar cells located in the s!iral ganglion( )his ganglion is located in the s!iral canal !resent "ithin the odiolus at the base of the s!iral la ina( )he central !rocesses of the ganglion cells for the cochlear nerve( Posteriorly the duct of the cochlea is connected to the saccule by a narro" ductus reuniens( )he sound "aves reaching the endoly !h through the vestibular e brane a'e a!!ro!riate !arts of the basilar e brane vibrate. the saccus endoly !haticus( )he ductus and saccus occu!y the a%ueduct of the vestibule( )he edial "alls of the saccule and utricle are thic'ened to for a ma*ula in each cha ber( )he aculae are end organs that give infor ation about .osterior semi*ir*ular *anal also lies in a vertical !lane !arallel to the long a&is of the !etrous te !oral bone( It is conve& bac'"ards( Its a !ulla lies at its lo"er end( )he u!!er end 3oins the anterior canal to for the crus co une( )he lateral semi*ir*ular *anal lies in the hori7ontal !lane "ith its conve&ity directed !osterolaterally( )he a !ulla lies anteriorly. close to the a !ulla of _ the anterior canal( =ote that the lateral se icircular canals of the t"o sides lie in the sa e !lane. "ithin the vestibuleD and BcC the se icircular ducts the organs of 'inetic balance. !osteriorly B1ig( 14(16C( )he sa**ule lies in the anteroinferior !art of the vestibule. for static balance the aculae. the a%ueduct of the vestibule "hich o!ens at a narro" fissure on the !osterior as!ect of the !etrous te !oral bone. so that different !arts of the organ of Corti are sti ulated by different fre%uencies of sound( )he loudness of the sound de!ends on the a !litude of vibration( Saccule and Rtricle It is in the for of a co !licated.erior semi*ir*ular *anal lies in a vertical !lane at right angles to the long a&is of the !etrous te !oral bone( It is conve& u!"ards( Its !osition is indicated by the arcuate e inence seen on the anterior surface of the !etrous te !oral bone( Its a !ulla is situated anterolaterally( Its !osterior end unites "ith the u!!er end of the !osterior canal to for the crus co une "hich o!ens into the edial "all of the vestibule( )he .ti*al re*ess behind( )he t"o recesses are se!arated by a .elli. 2he lateral canals of the two sides lie in the same plane. and is dilated at one end to for the am. 2he anterior canal of one side lies in the plane of the posterior canal of the other side.estibular crest "hich s!lits inferiorly to enclose the *o*hlear re*ess B1ig( 14(1HC( Just belo" the elli!tical recess there is the o!ening of a diverticulu . !osterior and lateral( )hey lie !osterosu!erior to the vestibule. the e branous labyrinth also consists of three ain !arts8 BaC )he s!iral duct of the cochlea or organ of hearing. and is connected to the basal turn of the cochlear duct by the ductus reuniens( )he utri*le is larger than the saccule and lies in the !osterosu!erior !art of the vestibule( It receives three se icircular ducts through five o!enings( )he duct of the saccule unites "ith the duct of the utricle to for the ductus endoly !haticus( )he ductus endoly !haticus ends in a dilatation.edia )he s!iral duct occu!ies the iddle !art of the cochlear canal bet"een the scala vestibuli and the scala ty !ani( It is triangular in cross-section( )he floor is for ed by the basilar membrane8 the roof by the . !osterolateral to the internal acoustic eatus( It is !lugged in life by the ductus endoly !haticus and a veinD no !erily !h esca!es through it( $emicircular !anals +O3O Lateral Fi*+ #!+#5: 2he semicircular canals.n anterior or su!erior. anteriorlyD BbC the utricle and saccule the organs of static balance. and for 'inetic balance the cristae( @i'e (the bony labyrinth. )here are three bony se icircular canals8 . and that the anterior canal of one side lies in the !lane of the !osterior canal of the other side B1ig( 14(1JC( Me*2ra"ous La26ri"th The Duct of the . and are set at right angles to each other( 2ach canal describes t"o-thirds of a circle. but continuous closed cavity filled "ith endoly !h( Parts of the e!itheliu of the e branous labyrinth are s!eciali7ed to for rece!tors for sound organ of Corti.

there is an end organ called the a !ullary crest or crista( Cristae res!ond to !ressure changes in the endoly !h caused by ove ents of the head( Basi#ar *e*2ra"e #a*i"a K t25pani cells E -cala /nner hair Fig.(44 Hea$ a"$ Ne&- Du&t o.%7: Parts of the membranous labyrinth "as seen from the lateral side#. %1. &o&h#ea Utri&# e Anterior se5icircular duct <osterior se5icircular duct Ductus reunions Endol25phatic duct %and sac P3 Utriculo%saccular duct Lateral se5icircular duct Fig. Vesti6ular 5e56rane Fi2re o. -upporting cells )he three se icircular ducts lie "ithin the corres!onding bony canals( 2ach duct has an a !ulla corres!onding to 9unnel 6et1een rods o4 Corti that of the bony canal( In each a !ulla. &o&h#ear "er5e Cochlear duct Me56rane tectoria Outer hair cells S%ira# -cala 7esti6uli S%ira# !a"!#io" . the !osition of the head( )hey are static balance rece!tors( )hey are su!!lied by !eri!heral !rocesses of neurons in the vestibular ganglion( Se6icircular Ducts .%8: $chematic section through one turn of the cochlea. %1.

Blood Supply of 9abyrinth )he arterial su!!ly is derived ainly fro the labyrinthine branch of the basilar artery "hich acco !anies the vestibulocochlear nerveD and !artly fro the stylo astoid branch of the !osterior auricular artery( )he labyrinthine vein drains into the su!erior !etrosal sinus or the transverse sinus( 0ther inconstant veins e erge at different !oints and o!en se!arately into the su!erior and inferior !etrosal sinuses and the internal 3ugular vein( DeAelop6ent auditory eatus8 Dorsal .ani* re*ess B)able 1(JC( 0ssicles Y #alleus and incus8 1ro "st ar*h *artilage8 Q Sta!es8 1ro #n+ ar*h *artilage) #uscles8 Y)ensor ty !ani8 1ro "st .haryngeal ar*h meso+erm Internal Far #e branous labyrinth fro ectoder al vesicle on each side of hind brain vesicle( 0rgan of Corti -ectoder al( Y2&ternal .art of "st e*to+ermal *left) Y.haryngeal ar*h meso+erm YSta!edius8 5rom #n+ .ening of external au+itory meatus) Y#iddle ear cavity and auditory tube8 Tuboty& m.uricle8 Tuber*les a.earing on "st an+ #n+ bran*hial ar*hes aroun+ the o..

i(e( nerve deafness. both ty!es of conduction are lost( In Binne's test. a cochlear !art concerned "ith hearing B1ig( 14(1AC. are situated !artly in the edulla and !artly in the !ons in relation to the floor of the fourth ventricle( !ochlear Nerve CLINICAL ANATOM rece!tors are the hair cells of the organ of Corti. su!erior.estibular ner. a vibrating tuning for' is held o!!osite the ear and then !laced on the astoid !rocess( )he !atient is as'ed to co !are the relative loudness of the for' in the t"o instances( In Aeber's test. and a vestibular !art concerned "ith e%uilibriu ( Both !arts contain s!ecial so atic afferent nerve fibres( Nuclei cristae of the a !ullae of se icircular ducts. for static balance and the @esions of cochlear nerve cause hearing defects( <earing !o"er can be tested by eans of a "atch in one ear at a ti e( If there is any i !air ent of hearing one ust deter ine "hether it is really due to disease of the nerve. situated in the cochlear duct of the internal ear( F()hey are innervated by !eri!heral !rocesses of bi!olar neurons of the s!iral ganglion "hich are situated in a canal "ithin the odiolus near the base of the s!iral la ina( )he central !rocesses of these neurons for the cochlear nerve "hich ends in the dorsal and ventral cochlear nuclei( )he auditory !ath"ay is described in Cha!ter :G( 'estibular Nerve 1()he auditory )he vestibular rece!tors are the aculae of the saccule and utricle. or erely due to disease of the iddle ear.e7 )he dorsal and ventral cochlear nuclei are situated in relation to the inferior cerebellar !eduncle( >f the .inne*s test and Eeber*s test( )he tests are based on the !rinci!le that nor ally aerial conduction of sound is better than bony conduction( In conductive deafness. edial and lateral. inferior. the vibrating tuning for' is !laced on the centre of the forehead( )he for' is heard better on the side of iddle ear disease than on the nor al side( . for 'inetic balance( )hey are innervated by !eri!heral !rocesses of bi!olar neurons of the vestibular ganglion( )his ganglion is situated in the internal acoustic eatus( )he central !rocesses of these neurons for the vestibular nerve "hich ends in the vestibular nuclei( )he related !ath"ays are described in Cha!ter 3>3 >f the *o*hlear ner.e7 )he four vestibular nuclei.1ESTIBULOCOCHLEAR NER1E MStatoCa&ousti& or Au$itor6 Ner5eT /estibulocochlear is the eighth cranial nerve "hich has t"o distinct !arts. bony conduction beco es better than aerial conduction( In nerve deafness. i(e( conductive deafness( )his is done by .

(47 . !ro3ecting nose and various coats !rotect the !recious retina( 2ach and every co !onent of its three coats is assisting the retina to focus the light !ro!erly( @ots of advances have been ade in correcting the defects of the eye( 2yes can be donated at the ti e of death. Optic ner7e )Dura 5ater ConFuncti7a3 Fi*+ $#3%: $agittal section through the eyeball. in diabetics and in hy!ertensive individuals( .bout AJ5 of afferents reach the brain through the eyes( . the ciliary body and the iris( )he inner or nervous *oat is the retina B1ig( 19(1C( @ight entering the eyeball !asses through several refra*ting me+ia) 1ro before bac'"ards these are the cornea.U Ciliar2 processes ') H %. and 6"ill6 can be !re!ared accordingly( 2ye sees the outside "orld( )he inside of the eyeball can be seen through the o!hthal osco!e "hereby health of s all vessels can be visualised in nor al sub3ects. the lens and the vitreous body( THE OUTER COAT S&#era )he sclera BsEerosQhardC is o!a%ue and for s the !osterior five-si&ths of the eyeball( It is co !osed of Ora serrate Ciliar2 5uscle -clera Choroid -inus 7enosus sclerae +W%O E E) ?L / Anterior cha56er Cornea %Lens O /ris Ob <osterior cha56er O)t -uspensor2 liga5ent ''( .ntroduction )he eyeball is the organ of sight( )he ca era closely rese bles the eyeball in its structure( It is al ost s!herical in sha!e and has a dia eter of about F(J c ( It is ade u! of three concentric coats( )he outer or fibrous *oat co !rises the sclera and the cornea( )he iddle or . the a%ueous hu our.de%uate rest to eye uscles is i !ortant( Could a good !lace for rest be the 6classroo 6 "here !al!ebral !art of orbicularis oculi closes the eyes gently^ .9he E2e6all Sense of sight a!!reciated through retina of the eyeball is one of the five s!ecial senses( Its i !ortance is obvious in the varied "ays of natural !rotection( Bony orbit.as*ular *oat also called the uveal tract consists of the choroid.

it is "ea'est at the entrance of the o!tic nerve( <ere the sclera sho"s nu erous !erforations for !assage of fibres of the o!tic nerve( Because of its sieve-li'e a!!earance this region is called the lamina *ribrosa BcrifoQsieveC( DISSECTION . offering so e resistance( . BcC )he anterior *iliary arteries derived fro uscular arteries to the recti !ierce it near the li bus( BdC 1our .ra*horoi+al lamina or lamina fus*a of the s*lera) )he sclera is continuous anteriorly "ith the cornea I at the s*lero*orneal . and thinnest about 6 behind the sclerocorneal 3unction "here the recti uscles are inserted( <o"ever.e) It !rovides insertion to the e&trinsic uscles of the eyeball8 )he recti in front of the e%uator.se the fresh eyeball of the goats for this dissection( Clean the eyeball by re oving all the tissues fro its surface( Cut through the fascial sheath around the argin of the cornea( Clean and identify the nerve "ith !osterior ciliary arteries and ciliary nerves close to the !osterior !ole of the eyeball( Identify venae vorticosae !iercing the sclera 3ust behind the e%uator( Incise only the sclera at the e%uator and then cut through it all around and carefully stri! it off fro the choroid( .un*tion or limbus B1ig( 19(1C( I )he dee! !art of the li bus contains a circular canal.es an+ arteries !ierce it around the entrance of the o!tic nerve. the ciliary uscles are attached to the sclera. BbC )he *iliary ner.eri*horoi+al s!ace "hich contains a delicate cellular tissue.(/: Hea$ a"$ Ne&- dense fibrous tissue "hich is fir and aintains the sha!e of the eyeball( It is thic'est behind.nteriorly.erior o2#i?ue 1e"a Medial rectus % 5orti&osae .ti* ner. 19(:C( Su%erior o2#i?ue Latera# re&tus Short %osterior &i#iar6 arter6 I".ti* ner. ter ed the su. near the entrance of the o!tic nerve.enosus s*lerae or the *anal of<*hlemm) )he a%ueous hu our drains into the anterior scleral or ciliary veins through thisR sinus( )he sclera is fused !osteriorly "ith the +9al sheath of the o. 3 it is covered by )enon*s ca!sule B1ig( A(:C( Its anterior !art is covered by con3unctiva through "hich it can be seen as the "hite of the eye( )he inner I surfa*e is bro"n and grooved for the ciliary nerves and vessels( It is se!arated fro the choroid by the . and the obli%ue uscles behind the e%uator( )he sclera is !ierced by a nu ber of structures8 BaC )he o.orti*osae or the choroid veins !ass out through the sclera 3ust behind the e%uator B1igs 19(F.enae .e !ierces it a little infero edial to the !osterior !ole of the eyeball. 'no"n as the sinus .s the sclera is steadily se!arated the a%ueous hu our "ill esca!e fro the anterior cha ber of the eye( 0n dividing the o!tic nerve fibres the !osterior !art of sclera can be re oved( )he outer surfa*e of the sclera is "hite and s ooth.

1e"a 5orti&osae Fi*+ #"+&: $tructures piercing the posterior aspect of the eyeball. O%ti& "er5e .

the cornea consists of these layers.un*tion or limbus) DISSECTION )he cornea is ore conve& than the sclera. fro before bac'"ards8 BaC Corneal e. the loose connective tissue bet"een the con3unctiva and sclera called as the e.): $tructures piercing the eyeball seen in a sagittal section. but the curvature di inishes "ith age( It is se!arated fro the iris by a s!ace called the anterior cha ber of the eye( )he cornea is avascular and is nourished by ly !h "hich circulates in the nu erous corneal s!aces( It is su!!lied by branches of the o!hthal ic nerve Bthrough the ciliary ganglionC and the short ciliary nerves( Pain is the only sensation aroused fro the cornea B1ig( A(1JC( =istolo*y Identify the cornea( #a'e an incision around the corneoscleral 3unction and re ove the cornea so that the iris is e&!osed for e&a ination( Identify the choroid. ciliary body and iris dee! to the sclera( @ateral to iris is the ciliary body "ith ciliary uscles and ciliary !rocesses( Stri! off the iris. BbC Bo9man's membrane Banterior elastic la inaC is a structureless ho ogenous layer( It contains no elastic fibres. and alternate bundles cross at right angles( Corneal cor!uscles "hich are .ithelium Bstratified s%ua ous non'eratini7ed ty!eC is continuous "ith that of the con3unctiva. %K.is*lera is vascular( Cor"ea )he cornea is trans!arent( It re!laces the sclera over the anterior one si&th of the eyeball( Its 3unction "ith the sclera is called the s*lero*omeal .e ove the lens and !ut it in "ater( . anterior !art of choroid( .ria consists of bundles of dense collagen fibres se!arated by corneal s!aces( 2ach bundle contains !arallel fibres. BcC )he substantia . )he sclera is al ost avascular( <o"ever.s the lens is re oved the vitreous body also esca!es( 0nly the !osterior !art of choroid and sub3acent retina is left( Structurally.Cornea Ciliar2 6od2 -inus 7enosus sclerae Visual a:is Anterior ciliar2 arter2 Vorticose 7ein -cleral spur Or6ital a:is Jo7ea centralis in the centre o4 5acula lutea H2aloid canal Lo"! %osterior &i#iar6 arter6 Fig.ro. ciliary !rocesses.

radial and circular( )he longitudinal or eridional fibres arise fro a !ro3ection of sclera or scleral s!ur near the li bus( )hey radiate bac'"ards to the su!rachoroidal la ina( )he radial fibres are obli%uely !laced and get continuous "ith the circular fibres( )he circular fibres lie "ithin the anterior !art of the ciliary body and are nearest to the lens( )he contraction of all the !arts rela&es the sus!ensory Bo<*a"'s *e*2ra"e Strati. and !ig ent cells.a"$ N] odified fibroblasts lie bet"een the bundles.t the !eri!heral argin its fibres divide into : grou!s( )he inner fibres turn edially on to the iris and constitute the liga entu !ectinatu ( )he iddle fibres give origin to the ciliary uscle( )he outer fibres are continuous "ith the sclera( BeC Si !le s%ua ous mesothelium lines the !osterior surface of the cornea B1ig( 19(HC( THE MIDDLE COAT Bruch is a thin structureless trans!arent e brane "hich is fir ly adherent to the outer. but contains elastic fibres( . it ends at the ora serrata by erging "ith the ciliary body( Posteriorly.nteriorly. it is !erforated by the o!tic nerve to "hich it is fir ly attached( Its outer surfa*e is se!arated fro the sclera by the su!rachoroidal la ina "hich is traversed by the ciliary vessels and nerves( Its attach ent to the sclera is loose.ie$ s?ua*ous e%ithe#iu* Des&e*et's *e*2ra"e . BdC )he inner basal lamina or la ina vitrea or e brane of Ciliary body is a thic'ened !art of the uveal tract lyin# 3ust !osterior to the corneal li bus( It is continuous anteriorly "ith the iris and !osteriorly "ith the choroid# It sus!ends the lens and hel!s it in acco odation for near vision( 1()he ciliary body is triangular in cross-section( It I is thic' in front and thin behind B1ig( 19(6C( Th1 scleral surface of this body contains the ciliary I uscle( )he !osterior !art of the vitreous surface is I s ooth and blac' B!ars !lanaC( )he anterior !arti# ridged anteriorly B!ars !licataC to for about AG1 ciliary !rocesses( )he central ends of the !rocesses are free and rounded( F(Ciliary 7onule is thic'ened vitreous e brane I fitted to the !osterior surfaces of ciliary !rocesses( I )he !osterior layer lines hyaloid fossa and anterior thic' layer for s the sus!ensory liga ent of the lens B1ig( 19(AC( :()heaA3*ary useAeB1ig( 19(4Cisaringofunstri!ed uscle "hich are longitudinal or eridional. it consists of8 BaC Su!rachoroidal la ina ade of collagen fibres. so that it can be easily stri!!ed( )he inner surfa*e is fir ly united to the retina( Structurally. BcC )he *horio*a. BdC Des*emet's membrane or !osterior elastic la ina is also structureless and ho ogenous.illary lamina for s the ost !ro inent feature of the choroid( It nourishes the rods and cones of the retina by diffusion. the latter being arranged in the for of "horls "hich converge to for H to J venae vorticosae. !ig ented layer of the retina B1ig( 19(JC( Ci#iar6 Bo$6 Choroi$ Choroid is a thin !ig ented layer "hich se!arates the !osterior !art of the sclera fro the retina( . loose areolar tissue. elastic fibres and !ig ent cells. 2b3 =as*ular lamina co !osed of arteries and short !osterior ciliary veins.

)rd edition. &ahl and Vaul: A 2e t &ook of 4istology.arg. !&$ Publishers and 9istributors. New 9elhi#I .Su2sta"tia %ro%ria Posterior e%ithe#iu* Fi*+ #"+4: 4istological structure of the cornea "!ourtesy: .

%K.E2e6all =$3" Chro5atophor es in Vascular la2er ???????((( (((((( ?((?????????????????????? ??????? Choriocapillar2 la2er %% Bruch*s e brane Blood 7essels o4 choroid ) <ig5ent cells o4 Fig. &ahl and Vau. thus divides the anterior seg ent of the eye into anterior and !osterior cha bers. liga ent so that the lens beco es ore conve&( .7: !omponents of ciliary body and iris. Cornea Anterior cha56er /ris Mh*^ Constrictor pupillae Dilator pupillae Ciliar2 5uscle Angle o4 anterior cha56er Lens -uspensor2 liga5ent o4 lens Fig. called the .ll !arts of the uscle are su!!lied by !arasy !athetic nerves( )he !ath"ay involves the 2dinger-Eest!hal nucleus. )rd edition. !&$ Publishers and 9istributors.: A 2e t &ook of 4istology.heral margin is attached to the iddle of the anterior surface of the ciliary body and is se!arated fro the cornea by the iridocorneal angle or angle of the anterior cha ber( )he *entral free margin for ing the boundary of the !u!il rests against the lens( . and thus behaves li'e an ad3ustable dia!hrag B1ig( 19(6C( F( It is !laced vertically bet"een the cornea and the lens. oculo otor nerve and the ciliary ganglion B1ig( A(1FC( 1( )his is the anterior !art of the uveal tract( It for s a circular curtain "ith an o!ening in the centre.arg.il) By ad3usting the si7e of the !u!il it controls the a ount of light entering the eye.u. New 9elhi#. both containing a%ueous hu our( Its .+: 4istological structure of the choroid "!ourtesy: . %K.eri.

hin*ter . 9istributors. and the !osterior surface by a double layer of dee!ly !ig ented cells "hich are C Ci#iar6 %ro&esses continuous "ith those of the ciliary body B1ig( 19(4C( )he ain bul' of the iris is for ed by stro a ade u! of blood vessels and loose connective tissue in i "hich there are !ig ent cells( )he long !osterior and Le"s the anterior ciliary arteries 3oin to for the ma.or* #a6er La6er o.illae is an ill-defined sheet of radial uscle Choroi$ Di#ator %u%i##ae S%hi"&ter %u%i##ae Dou2#e #a6er o. the iris is blue in colour due after vitreous has been removed. delicate inner layer of the eyeball( It is continuous !osteriorly "ith the o!tic nerve( )he outer surface of the retina Bfor ed by !ig ent cellsC is attached to the choroid. &ahl 4istology. %i!*e"te$ e%ithe#iu* Cor"ea fibres !laced near the !osterior surface of the iris( It is su!!lied by sy !athetic nerves 3B1ig( 19(6C( THE INNER COATKRETINA Ci#iar6 *us&#e Ci#iar6 2o$6 Fi*+ #"+!: Epithelium lining the iris. 1( )his is the thin. )rd edition.274 Hea$ a"$ Nee :( )he anterior surface of the iris is covered by a single layer of esotheliu . layers of the retina and Vaul: A 2e t &ook of !&$ Publishers and . ro$s a"$ &o"es I""er %#e8i.arg. !atheticC is si ilar to that of the ciliary uscle( )he +ilator . to the diffusion of light in front of the blac' !osterior surface( 2() )he iris contains a "ell-develo!ed ring of uscle > called the s.or arterial *ir*le at the !eri!hery of the iris( 1ro this circle vessels converge to"ards the free argin of the Ci#iar6 Wo"u#e iris and 3oin together to for the minor arterial *ir*le of the iris B1ig( A(9C( S&#era )he colour of the iris is deter ined by the nu ber of !ig ent cells in its connective tissue( If the Fi*+ #"+(: Anterior part of the inner aspect of the eyeball seen !ig ent cells are absent.u. New 9elhi#.i2res Fi*+ #"+": 4istoiogical "!ourtesy: . "hile the inner surface is in contact "ith the hyaloid e brane Bof the vitreousC( Outer #i*iti"! *e*2ra"e CC Pi!*e"t &e## #a6er Outer P#e8i.or* #a6er CCCCCCCCCCCCC Outer "u&#ear #a6er Ia"!#io" &e## #a6er I""er #i*iti"! *e*2ra"e I""er "u&#ear #a6er C O%ti& "er5e .illae "hich lies near the >U/nargin of the !u!il( Its nerve su!!ly B!arasy i.u.

ot) . ciliary and iridial !arts( )he o. A(9C( A.t the !osterior !ole of the eye : lateral to the o!tic disc there is another de!ression of si ilar si7e. and is the site of a&i u acuity of vision B1ig( 19(:C( F()he rods and cones are the light rece!tors of the eye( )he rods contain a !ig ent called .ti* .hoto.isual .ur.art of the retina contains nervous tissue and is sensitive to light( It e&tends fro the o!tic disc to the !osterior end of the ciliary body( )he anterior argin of the o!tic !art of the retina for s a "avy line called the ora serrata B1ig( 19(1C( Beyond the ora serrata the retina is continued for"ards as a thin.UEOUS HUMOUR )his is a clear fluid "hich fills the s!ace bet"een the cornea in front and the lens behind the anterior seg ent( )his s!ace is divided by the iris irttoanterior and !osterior cha bers "hich freely co unicate "ith each other through the !u!il( )he a%ueous hu our is secreted into the !osterior cha ber fro the ca!illaries in the ciliary !rocesses( It !asses into the anterior cha ber through the !u!il( 1ro the anterior cha ber it is drained into the anterior ciliary veins through the s!aces of the . the outer !ig ented layer re ains attached to the choroid.ision3 and are sensitive to colour( )he fovea centralis has only cones( )heir nu ber di inishes to"ards the !eri!hery of the retina( J( )he retina is co !osed of ten layers8 BaC )he outer !ig ented layerD BbC layer of rods and conesD BcC e&ternal li iting e braneD BdC outer nuclear layerD BeC outer !le&ifor layerD BfC inner nuclear layer Bbi!olar cellsCD BgC inner !le&ifor layerD BhC ganglion cell layerD BiC nerve fibre layerD and B3C the internal li iting e brane B1ig( 19(9C( In detach ent of the retina.le) )hey can res!ond to di light 2s*oto.i* . i(e( it is the .ision3) )he !eri!hery of the retina contains only rods. called the ma*ula lutea) It is avascular and yello" in colour( )he centre of the acula is further de!ressed to for the fo. each giving off nasal and te !oral branches( )he artery su!!lies the dee!er layers of the retina u! to the bi!olar cells( )he rods and cones are su!!lied by diffusion fro the ca!illaries of the choroid( )he retinal veins run "ith the arteries B1igs 19(1G. non-nervous insensitive layer that covers the ciliary body and iris.i* .ti* +is*) It is 1(J in dia eter( #) )he retina di inishes in thic'ness fro behind for"ards and is divided into o!tic. but the fovea has none at all( )he cones res!ond only to bright light 2.ea *entralis) )his is the thinnest !art of the retina( It contains cones only.E6e2a## (/0 0!!osite the entrance of the o!tic nerve Binfero edial to the !osterior !oleC there is a circular area 'no"n as the o. but the re aining layers of the retina se!arate fro the !ig ented layer and are dis!laced in"ards( 6( )he retina is su!!lied by the *entral artery) )his is an end artery( In the o!tic disc it divides into an u!!er and a lo"er branch. for ing the *iliary an+ iri+ial .hysiologi*al blin+ s.arts of the retina) )hese !arts are ade u! of t"o layers of e!ithelial cells B1ig( 19(4C( 1()he de!ressed area of the o!tic disc is called the .hysiologi*al *u.) It contains no rods or cones and is therefore insensitive to light.

%K. . J: 9istribution of central artery ot the retina.-uperior nasal arter2 Optic disc /n4erior nasal arter2 -uperior te5poral arter2 Macula lutea and 4o7ea centralis Macular arter2 /n4erior te5poral arter2 Fig.

to the furro"s bet"een the ciliary !rocesses. lens having a focal length of half eter has a !o"er of t"o dio!tresC( ISSECTI +ive an incision in the anterior surface of lens and "ith a little !ressure of fingers and thu b !ress the body of lens outside fro the ca!sule( )he !osterior surface of the lens is ore conve& than the anterior( )he anterior surface is 'e!t flattened by the tension of the sus!ensory liga ent( Ehen the liga ent is rela&ed by contraction of the ciliary uscle. the cells elongate to !roduce the fibres of the lens( )he fibres are concentrically arranged to for the lens substance( )he centre BnucleusC of the lens is fir Band consists of the oldest fibresC. the anterior surface of the lens is covered by a *a. "hile the arginal circu ference is ter ed the e:uator) )he chief A"terior #e"s &a%su#e E%ithe#ia# &e##s Le"s . #e"s .sular e. and in front to the ora serrataD in bet"een it is free and lies in contact "ith the retina( )he anterior surface of the vitreous body is indented by the lens and ciliary !rocesses B1ig( 19(1C( DeAelop6ent Fi*+ %K. 0!tic vesicle for s o!tic cu!( )he o!tic vesicle is an out !ouching fro the forebrain vesicle( .ensory ligament of the lens Bor the 7onule of LinnC retains the lens in !osition and its tension 'ee!s the anterior surface of the lens flattened( )he liga ent is ade u! of a series of fibres "hich are attached !eri!herally to the ciliary !rocesses.i2res A"terior %o#e Nu&#eus o.i2re It is a colourless. and a fe" behind.t the centre of the anterior surface.oles B1ig( 19(11C( )he line connecting the !oles constitutes the a&is of the lens. the e%uator B1ig( 19(6C( 1ITREOUS BOD )he lens is a trans!arent biconve& structure "hich is !laced bet"een the anterior and !osterior seg ents of the eye( It is circular in outline and has a dia eter of 1 c ( )he central !oints of the anterior and !osterior surfaces are called the anterior and !osterior . the e!itheliu is ade u! of a single layer of cubical cells.sule "hich is thic'est anteriorly near the circu ference( Dee! to ca!sule. dio!tre is the inverse of the focal length in eters( .$ $@ 2he lens. the fibres are attached to the lens. 3ellyli'e trans!arent ass "hich fills the !osterior seg ent B!osterior HKJthC of the eyeball( It is enclosed in a delicate ho ogeneous hyaloi+ membrane) Behind it is attached to the o!tic disc.a"$ N] iridocorneal angle or angle of anterior cha ber Blocated bet"een the fibres of the liga entu !ectinatu C and the canal of Schle B1ig( 19(6C( Interference "ith the drainage of the a%ueous hu our into the canal of Schle results in an increase of intraocular !ressure Bglauco aC( )his !roduces cu!!ing of the o!tic disc and !ressure atro!hy of the retina causing blindness( )he intraocular !ressure is due chiefly to the a%ueous hu our "hich aintains the constancy of the o!tical di ensions of the eyeball( )he a%ueous is rich in ascorbic acid. and to the ora serrata( Centrally. but at the !eri!hery. and nourishes the avascular tissues of the cornea and lens( THE LENS advantage of the lens is that it can vary its dio!tric !o"er( It contributes about 1J dio!tres to the total of J4 dio!tric !o"er of the eye B. the anterior surface beco es ore conve& due to elasticity of the lens substance( )he lens is enclosed in a trans!arent. "hereas the !eri!hery Bcorte&C is soft and is ade u! of ore recently for ed fibres B1ig( 19(11C( )he sus.ithelium) . ostly in front. structureless elastic *a. glucose and a ino acids.

caused by raised intracranial !ressure( @ens beco es o!a%ue "ith increasing age( Since the o!acities cause difficulty in vision. astig ation or !resbyo!ia( .ti* *u. hy!er etro!ia or longsightedness.@ens fro lens .ti* *u.la*o+e 2e*to+ermal3 . lens has to be re!laced( . scleraMmeso+erm CorneaMsurfa*e e*to+erm CUNICAL ANATOM 2ye is a very sensitive organ and even a dust !article gives rise to !ain( Cornea can be grafted fro one !erson to the other.8 nervous layers fro the inner layer of o. one can also e&a ine the o!tic disc for evidence of !a!illoede a. it is an inter-retinal detach ent( 2ye sees everyone( 0ne can see the interior of the eye by o!hthal osco!e( )hrough the o!hthal osco!e one can see the s all vessels in the retina and 3udge the changes in diabetes and hy!ertension( In addition.) Choroid. as it is avascular( In3ury to cornea ay cause o!acities( )hese o!acities ay interfere "ith vision( 0ver!roduction of a%ueous hu our or lac' of its drainage or co bination of both raise the intraocular !ressure( )he condition is called glauco a( It ust be treated urgently( )he central artery of retina is an end-artery( Bloc'age of the artery leads to sudden blindness( Bulbar con3unctiva is vascular( Infla ation of the con3unctiva leads to con3unctivitis( )he loo' of !al!ebral con3unctiva is used to 3udge hae oglobin level( )he antero!osterior dia eter of the eyeball and sha!e and curvature of the cornea deter ine the focal !oint( Changes in these result in yo!ia or short-sightedness.ctually.etinal detach ent occurs bet"een outer single !ig ented layer and inner nine nervous layers( .etinaM !ig ent layer fro the outer layer of o.

vertical line dra"n fro the su!raorbital notch to the base of the andible.oral line for s the u!!er boundary of the te !oral fossa "hich is filled u! by the te !oralis uscle( )he u!!er argin of the contracting te !oralis hel!s in defining this line (/7 . and !osterosu!eriorly "ith the te !oral line B1ig( 1(4C( J()he tem.raorbital margin lies beneath the u!!er argin of the eyebro"( )he su. and corres!onds to the elevation bet"een the t"o eyebro"s( :()he nasion is the !oint "here the internasal and frontonasal sutures eet( It lies a little above the floor of the de!ression at the root of the nose. belo" the glabella B1ig( 1(JC( La"$*ar-s o" the Latera# Si$e o. ace and nec' hel! in surface ar'ing of various structures( )hese land ar's are of i ense value to the clinician for locating the !art to be e&a ined or to be o!erated( SURFACE LANDMAR'S G La"$*ar-s o" the Fa&e So e i !ortant na ed features to be identified on the living face have been described on !age HJ( 0ther land ar's are as follo"s( 1()he su. and !osteriorly by the 7ygo atic !rocess B7ygo aC of the te !oral bone( )he . about F(J c long.ro*ess is a large bony !ro inence situated behind the lo"er !art of the auricle( )he su.arietal eminen*e is the ost !ro inent !art of the !arietal bone. the Hea$ )he e&ternal ear or !inna is a !ro inent feature on the lateral as!ect of the head( )he na ed features on the !inna are sho"n in 1ig( 14(1( 0ther landar's on the lateral side of the head are as follo"s( 1()he 4ygomati* bone for s the !ro inence of the chee' at the inferolateral corner of the orbit( )he 4ygomati* ar*h bridges the ga! bet"een the eye and the ear( It is for ed anteriorly by the te !oral !rocess of the 7ygo atic bone.raorbital not*h is !al!able at the 3unction of the edial one-third "ith the lateral t"o-thirds of the su!raorbital argin Be&ce!t in those cases in "hich the notch is converted into a fora enC( .er*iliary ar*h is a curved bony ridge situated i ediately above the edial !art of each su!raorbital argin( )he glabella is the edian elevation connecting the t"o su!erciliary arches.ro*ess of the andible can be felt belo" the lo"est !art of the 7ygo atic bone "hen the outh is o!ened( )he !rocess can be traced do"n"ards into the anterior border of the ra us of the andible( )he !osterior border of the ra us. though as'ed by the !arotid gland. can be felt through the s'in( )he outer surface of the ra us is covered by the asseter "hich can be felt "hen the teeth are clenched( )he lo"er border of the andible can be traced !osteriorly into the angle of the andible B1ig( 1(4C( :()he . crosses the infraorbital fora en J belo" the infraorbital argin. Radiolog2 and /5aging Anato52 )he bony and soft tissue land ar's on the head. and the ental fora en id"ay bet"een the u!!er and lo"er borders of the andible B1ig( 1(JC( F()he su. situated far above and a little behind the auricle( H()he mastoi+. !assing id"ay bet"een the lo"er t"o !fre olar teeth.oint lies on the !osterior root of the 7ygo a i ediately in front of the u!!er !art of the tragus B1ig( 1(4C( F()he head of the andible lies in front of the tragus( It is felt best during ove ents of the lo"er 3a"( )he *oronoi+ .ramastoi+ *rest. begins i ediately above the e&ternal acoustic eatus and soon curves u!"ards and bac'"ards( )he crest is continuous anteriorly "ith the !osterior root of the 7ygo a.reauri*ular .-ur4ace Mar!ing.

ra*la. arches !osterosu!eriorly across the coronal suture.ein crosses the sternocleido astoid obli%uely. the !osterior ost !oint on the occi!ut lies a little above the !rotuberance B1ig( 1(:C( Land5ar!s on the -ide o4 the ec! 1()he sterno*lei+omastoi+ !arts of the sternocleido astoid( It overlies the internal 3ugular vein( J()he mastoi+ .ro*ess is a large bony !ro3ection behind the auricle BconchaC B1ig( :(1C( uscle is seen !ro inently "hen the face is turned to the o!!osite side( )he ridge raised by the uscle e&tends fro the sternu to the astoid*!rocess B1ig( :(1C( F()he external . te !oral and s!henoidC ad3oin each other across an <sha!ed suture( )he centre of the !terion is ar'ed by a !oint H c above the id!oint of the 7ygo atic arch. running do"n"ards and bac'"ards fro near the auricle to the clavicle( It is better seen in old age B1ig( :(6C( :()he greater su.rotuberan*e is a bony !ro3ection felt in the edian !lane on the bac' of the head at the u!!er end of the nuchal furro"( )he su.=&> Head and ec! "hich begins at the 7ygo atic !rocess of the frontal bone.ra*la.oint3 dividing into three ra i( )he !terion is a co on site for tre!hining B a'ing a hole inC the s'ull during o!eration B1ig( 1(9C( F()he 3unction of the bac' of the head "ith the nec' is indicated by the e&ternal occi!ital !rotuberance and the su!erior nuchal lines( )he external o**i. and dee!er still the ste of the lateral sulcus of the cerebral he is!here Bat the <yl. above the 7ygo atic arch. !arietal.ut) )he ost !ro inent edian !oint situated on the e&ternal occi!ital !rotuberance is 'no"n as the inion) <o"ever.ian .i*ular fossa is a s all de!ression bet"een the sternal and clavicular .i*ular fossa lies above and behind the iddle one-third of the clavicle( It overlies the cervical !art of the brachial !le&us and the third !art of the subclavian artery B1ig( :(JC( H()he lesser su.erior nu*hal lines are indistinct curved ridges "hich e&tend fro the !rotuberance to the astoid !rocesses( )he bac' of the head is called the o**i. the iddle eningeal vein. !asses a little belo" the !arietal e inence. and turns do"n"ards to beco e continuous "ith the su!ra astoid crest( )he area of the te !oral fossa on the side of the head.ugular . is called the tem.terion is the area in the te !oral fossa "here four bones Bfrontal.ital . falling :(J c behind the fronto7ygo atic suture( Dee! to the !terion lie the anterior branch of the iddle eningeal artery.le or te !oral region B1ig( 1(4C( 1()he .

i*al .erse .le) It is ore !ro inent in ales than in fe ales B1ig( 4(1GC( H()he rounded arch of the *ri*oi+ *artilage lies belo" the thyroid cartilage at the u!!er end of the trachea B1ig( 4(6C( J()he trachea runs do"n"ards and bac'"ards fro the cricoid cartilage( It is identified by its cartilagineous rings( <o"ever.ro*ess of the sixth *er. it is !artially as'ed by the isthmus of the thyroi+ glan+ 9hi*h lies against the second to fourth tracheal rings( )he trachea is co only !al!ated in the su.erse .e4ius mus*le I beco es !ro inent on elevation of the shoulder I against resistance B1ig( :(JC( Land5ar!s on the Anterior Aspect o4 the ec! 1()he man+ible for s the lo"er 3a"( )he lo"er border of its horseshoe-sha!ed body is 'no"n as I the base of the man+ible B1ig( 1(F6C( .ertebra can I be felt on dee! !ressure id"ay bet"een the angle I of the andible and the astoid !rocess.i*al trans. this base for s the *hin. dee! to the anterior border of the I sternocleido astoid uscle( F()he anterior bor+er of the tra.i*al trans.I diately anteroinferior to the ti! of the astoid I !rocess( )he fourth *er.ertebra is the largest of all such !rocesses and is called the *aroti+ tuber*le Bof ChassaignacC( )he co on carotid artery can be best !ressed against I this tubercle.-sha!ed hyoi+ bone can be felt in the edian !lane 3ust belo" and behind the 3 chin.ro*ess is 3ust !al!able at the level of the u!!er border of the thyroid cartilageD and the sixth *er. and !osteriorly it can be traced 3 to the angle of the man+ible B1ig( 1(F6C( F()he body of the .ro*ess of the a tlas . the trachea ay shift to one side fro the edian !lane( )his indicates a shift in the ediastinu B1ig( 4(6C( Other /5portant Land5ar!s 1( )he fronto4ygomati* suture can be felt as a slight de!ression in the u!!er !art of the lateral orbital argin( .rastemal not*h "hich lies bet"een the tendinous heads of origin of the right and left sternocleido astoid uscles( In certain diseases.. i e.rominen*e or 6+am's a.1()he trans.erse .erse . at the 3unction of the nec' "ith the floor of the outh( 0n each side the body of hyoid bone is continuous !osteriorly "ith the greater *omua "hich is overla!!ed in its !osterior !art by the sternocleido astoid uscle B1ig( 4(6C( :()he thyroi+ *artilage of the laryn& for s a shar! !rotuberance in the edian !lane 3ust belo" the hyoid bone( )his !rotuberance is called the laryngeal .nteriorly.ro*ess I at the level of the cricoid cartilage( )he anterior tubercle of the trans.

a&e Mar -i"! ) Ra$i o#o! i&& 6.ugal . !oint on the anterior border of the sterno cleido astoid uscle at the level of the u!!er border of the thyroid cartilage( b( .nternal !arotid Artery It is ar'ed by a broad line 3oining these t"o !oints( a( . !oint on the base of the andible at the anterior border of the asseter uscle( b( .lane is re!resented by a hori7ontal line 3oining the infraorbital argin to the centre of the e&ternal acoustic eatus( Posteriorly. the line !asses through a !oint 3ust belo" the e&ternal occi!ital !rotuberance( :()he . !ommon !arotid Artery )he artery is ar'e d by 3oining these t"o !oints( a( . E tern al !aroti d Artery Arteries /3 Facial Artery It is ar'ed on the face by 3oining these three !oints( a( . second !oint on the !osterior border of the condyle of the andible( .oint is the anterior end of the u!!er border of the 7ygo atic arch "here it eets the frontal !rocess of the 7ygo atic bone( H()he man+ibular not*h is re!resented by a curved line concave u!"ards.1()he marginal tuber*le lies a short distance belo" the fronto7ygo atic suture along the !osterior border of the frontal !rocess of the 7ygo atic bone( F()he 5rankfurt . second !oint 1(F c lateral to the angle of the outh( c( . e&tending fro the head of the andible to the anterior end of the 7ygo atic arch( )he notch is 1-F c dee!( SURFACE MAR'INI OF 1ARIOUS STRUCTURES Sur. !oint on the sternoclavicular 3oint( b( . !oint at the edial angle of the eye( )he artery is tortuous in its course and is ore so bet"een the first t"o !oints B1ig( 1(9C( <. second !oint on the anterior border of the sternocleido astoid uscle at the level of the u!!er border of the thyroid cartilage( )he thoracic !art of the left co on carotid artery is ar'ed by a broad line e&tending fro a !oint a little to the left of the centre of the anubriu to the left sternoclavicular 3oint B1ig( 1F(1GC( 33 . ! o i n t o n t h e a n t e r i o r b o r d e r o f t h e s t e r It is ar'ed by a broad line along the anterior border of the sternocleido astoid uscle by 3oining the follo"ing t"o !oints( a( .

third !oint Bcentre of !terionC :(J c behind and 1(J c above the fronto7ygo atic suture( d( . fifth !oint Bla bdaC 6 c above the e&ternal occi!ital !rotuberance( )he line 3oining !oints a and b re!resents the ste of the iddle eningeal artery inside the s'ull( )he line 3oining !oints b. to"ards the !oint *e* B1ig( 1(9C( 1ei"s $3 Facial 'ein It is re!resented by a line dra"n 3ust behind the facial artery( . to"ards the !oint *d*( )he line 3oining !oints b and e re!resents the !osterior B!arietalC branch( It runs bac'"ards and u!"ards. fourth !oint id"ay bet"een the nasion and inion( e( . conve& u!"ards. !oint on the sternoclavicular 3oint( b( . c and d re!resents the anterior BfrontalC branch( It first runs u!"ards and for"ards Bb-cC and then u!"ards and bac'"ards. second !oint on the !osterior border of the nec' of the andible( )he artery is slightly conve& for"ards in its lo"er half and slightly concave for"ards in its u!!er half B1ig( 1F(1GC( '3 $ubclavian Artery " It is ar'ed by a broad curved line. /iddle /eningeal Artery It is ar'ed by 3oining these !oints( a( . second !oint F c above the first !oint( )he artery divides dee! to this !oint( c( . !oint i ediately above the iddle of the 7ygo a( )he artery enters the s'ull o!!osite this !oint( b( . by 3oining these t"o !oints( a( .no cleido astoid uscle at the level of the u!!er border of the thyroid cartilage( b( . second !oint at the iddle of the lo"er border of the clavicle( )he artery rises about F c above the clavicle( )he thoracic !art of the left subclavian artery is ar'ed by a broad vertical line along the left border of the anubriu a little to the left of the left co on carotid artery B1ig( 1F(1GC( 7.

$ubclavian 'ein 1acial nerve is ar'ed by a short hori7ontal linel 3oining these t"o !oints( a( . 2ransverse $inus #andibular nerve is ar'ed by a short vertical line in the !osterior !art of the andibular notch 3ust in front of the head of the andible( 6. Facial Nerve Internal 3ugular vein is ar'ed by a broad line by 3oining these t"o !oints( a( )he first !oint on the nec' edial to the lobule of the ear( b( )he second !oint at the edial end of the clavicle( )he lo"er bulb of the vein lies beneath the lesser su!raclavicular fossa bet"een the sternal and clavicular heads of the sternocleido astoid uscle( 6. and then u!"ards across the !reauricular !oint B1ig( 1G(1:C( ). situated one above the other and 1(F c a!art( b( )"o !oints at the base of the astoid !rocess.lossopharyngeal Nerve Sig oid sinus is ar'ed by t"o !arallel lines situated 1(F c a!art and e&tending bet"een these t"o !oints( +losso!haryngeal nerve is follo"ing !oints( ar'ed by 3oining the . 5ingual and . reaching F c above . 1(F c a!art B1ig( 6(9C( 7. situated one in front of the other and 1(F c a!art( )he sinus is conve& u!"ards. I situated one in front of the other and 1(F c I a!art( b( )"o si ilar !oints near the !osterior border 1 and 1(F c above the ti! of the astoid !rocess( Ner5es %. if not visible.nternal Bugular 'ein a( )"o !oints at the base of the astoid !rocess. $uperior $agittal $inus . /andibular Nerve Su!erior sagittal sinus is ar'ed by t"o lines Bdiverging !osteriorlyC 3oining these t"o !oints( a( 0ne !oint at the glabella( b( )"o !oints at the inion.uriculote !oral nerve is ar'ed by a line dra"n first bac'"ards fro the !osterior !art of the andibular notch Bsite of andibular nerveC across the nec' of the andible.nferior Alveolar Nerves )ransverse sinus is ar'ed by t"o !arallel lines. second !oint behind the nec' of theP andible( <ere the nerve divides into its five a branches to the facial uscles B1ig( 9(JC. E ternal Bugular 'ein )he vein is usually visible through the s'in and can be ade ore !ro inent by blo"ing "ith the outh and nostrils closed( It can be ar'ed. !oint at the iddle of the anterior border of a the astoid !rocess( )he stylo astoidD fora en lies F c dee! to this !oint( b( . 1G(1:C( <.(3( <.eid*s base line B1ig( 6(9C( $3 $igmoid $inus @ingual nerve is ar'ed by a curved line running do"n"ards and for"ards by 3oining these !oints B1ig( 1G(1:C( a( )he first !oint on the !osterior !art of the andibular notch. . 1(F c a!art e&tending bet"een the follo"ing t"o !oints( a( )"o !oints at the inion. in line "ith the andibular nerve( b( )he second !oint a little belo" and behind the last lo"er olar tooth( c( )he third !oint o!!osite the first lo"er olar tooth( )he concavity in the course of the nerve is ore ar'ed bet"een the !oints b and c and is directed u!"ards( Inferior alveolar nerve lies a little belo" and !arallel to the lingual nerve( +. by 3oining these !oints( a( )he first !oint a little belo" and behind the angle of the andible( b( )he second !oint on the clavicle 3ust lateral to the !osterior border of the sternocleido astoid B1ig( :(6C( ). Auriculotemporal Nerve Subclavian vein is re!resented by a broad line along the clavicle e&tending fro a little edial to its id!oint to the edial end of the bone( +. situated side by side. .

second !oint id"ay bet"een the ala of the nose and the red argin of the u!!er li!( )he iddle-third of this line re!resents the !arotid duct( ). the u!!er 1(F c and the lo"er F(J c belo" the arch of the cricoid cartilage( .land . 2hyroid . by 3oining the !oints c-dD and the su!erior curved border "ith its concavity directed u!"ards and bac'"ards. and the inferior *er.r.ccessory nerve s!inal !art is ar'ed by 3oining the follo"ing four !oints( a( )he first !oint at the anteroinferior !art of the tragus( b( )he second !oint at the ti! of the transverse !rocess of the atlas( r( )he third !oint at the iddle of the !osterior border of the sternocleido astoid uscle( d( )he fourth !oint on the anterior border of the tra!e7ius 6 c above the clavicle( i 1. at a !oint : c above the sternoclavicular 3oint B1ig( 1F(FJC( $ $ 3 2rigeminal .i*al ganglion lies at the level of the cricoid cartilage. !oint at the sternoclavicular 3oint( b( )he second !oint at the !osterior border of the condyle of the andible( )he su. by 3oining the !oints a-d across the lobule of the ear B1ig( 9(:C( <. Parotid 9uct Phrenic nerve is ar'ed by a line 3oining the follo"ing !oints( a( .a&e Mar-i"!) Ra$io#o!i&a# a"$ I*a!i"! A"ato*6 (3+ a( )he first !oint on the anteroinferior !art of the tragus( b( )he second !oint anterosu!erior to the angle of the andible( 1ro !oint *b* the nerve runs for"ards for a short distance along the lo"er border of the andible( )he nerve describes a gentle curve in its course B1ig( 1F(FGC( A3 Vagus er7e $>3 !ervical $ympathetic !hain )he nerve runs along the edial side of the internal 3ugular vagus vein( It is ar'ed by 3oining these t"o !oints( a( )he first !oint at the anteroinferior !art of the tragus( b( )he second !oint at the edial end of the clavicle B1ig( 1F(FGC( $3 Accessor2 er7e "$pinal Part# Cervical sy !athetic chain is ar'ed by a line 3oining the follo"ing !oints( a( . 4ypoglossal Nerve <y!oglossal nerve is ar'ed by 3oining these !oints( a( )he first !oint at the anteroinferior !art of the tragus( b( )he second !oint !osterosu!erior to the ti! of the greater cornua of the hyoid bone( c( )he third !oint id"ay bet"een the angle of the andible and the sy !hysis enti( )he nerve describes a gentle curve in its course B1ig( 1F(FGC( #3 Phrenic Nerve Parotid gland is ar'ed by 3oining these four !oints "ith each other( a( )he first !oint at the u!!er border of the head of the andible( b( )he second !oint 3ust above the centre of the asseter uscle( c( )he third !oint !osteroinferior to the angle of the andible( d( )he fourth !oint on the u!!er !art of the anterior border of the astoid !rocess( )he anterior border of the gland is obtained by 3oining the !oints a-b-cD the !osterior border.erior *er.anglion )rige inal ganglion lies a little in front of the !reauricular !oint at a de!th of about H(J c ( I#a"$s $3 Parotid .land )he isth us of thyroid gland is ar'ed by t"o transverse !arallel lines Beach 1(F c longC on the trachea. !oint on the side of the nec' at the level of the u!!er border of the thyroid cartilage and :(J c fro the edian !lane( b( )he second !oint at the edial end of the clavicle B1ig( 1F(FJC( )o ar' this duct first dra" a line 3oining these t"o !oints( a( 0ne !oint at the lo"er border of the tragus( b( .i*al ganglion e&tends fro the transverse !rocess of the atlas to the ti! of the greater cornua of the hyoid bone( )he mi++le *er.i*al ganglion.

loi* .erse sinus ay be seen as a curved dar' shado". e&tending fro the internal occi!ital !rotuberance to the !etrous te !oral( BcC)he +i. i(e( at the su!raorbital notch( <. "or li'e. a congenital hae olytic anae ia. the s'ull !resents large !unched out areas( 1ractures are ore e&tensive in the inner table than in the outer table( :( <utures7 )he coronal and la bdoid sutures are usually visible clearly( )he coronal suture runs do"n"ards and for"ards in front of the central sulcus of the brain( )he la bdoid suture traverses the !osterior ost !art of the s'ull( 0bliteration of sutures begins first on the inner surface Bbet"een :G and HG yearsC and then on the outer surface Bbet"een HG and JG yearsC( . a hereditary disease( Sutures are o!ened u! in children by an increase in intracranial !ressure( H( =as*ular markings) BaC1i++le meningeal . follo"ed by the !osterior !art of the sagittal suture( Pre ature closure of sutures occurs in craniostenosis. locali7ed hy!erostosis ay be seen over a eningio a( In ulti!le yelo a and secondary carcino atous de!osits. icroce!haly.ntero!osterior and obli%ue vie"s for the study of cervical vertebrae( LATERAL 1IEL S'ULL MPLAIN S'IAIRAMT )he radiogra here( is studied syste atically as described 1( <ha. !osterior te !oral and occi!ital di!loic veins( .e the base of the andible. including the lo"er border of the ra us( The areas exten+s ")$ *m abo. shado"s !roduced by the frontal. and belo" to the greater cornua of the hyoid bone( Pa#ati"e To"si# Cra"ia# 1au#t Palatine tonsil is ar'ed by an oval Bal ond-sha!edC area over the asseter 3ust anterosu!erior to the angle of the andible B1ig( 9(:C( Para"asa# Si"uses E3 Frontal $inus 1rontal sinus is ar'ed by a triangular area for ed by 3oining these three !oints( a( )he first !oint at the nasion b( )he second !oint F(J c above the nasion( c( )he third !oint at the 3unction of the edial one-third and lat eral t "o-t hirds of t he su!raorbital argin.land )he sub andibular salivary gland is ar'ed by an oval area over the !osterior half of the base of the andible. s!ecial !osteroanterior vie" Bin Eaters* !ositionC to study the !aranasal sinuses( :(. anterior te !oral. etc( aybi diagnosed( F( <tru*ture of *ranial bones7 )he bones unila ellar during the first three years of life. tables se!arated by di!loe a!!ear during the fe year. /a illary $inus )he roof of a&illary sinus is re!resented by the inferior orbital arginD the floor. belo" to the clavicle. conve& u!"ards. the follo"ing O-ray !ictures of the s'ull are co only used( 1(@ateral vie" for general survey of the s'ull( F(. and the differentiation reaches its a&i v by about 3$ years 9hen +i.essels7 )he anterior branch runs about 1 c behind the coronal suture( )he !osterior branch runs bac'"ards and u!"ards at a lo"er level across the u!!er !art of the shado" of the auricle( BbC)he trans. by the alveolus of the a&illaD the base. hydroce!halus.sually the lo"er !art of the coronal suture is obliterated first. $ubmandibular .e an+ si4e7 It is i !ortant to be fa ilia "ith the nor al sha!e and si7e of the s'ull so tha abnor alities. and the lo"er !ole is broad and rounded B1ig( 1F(1C( ?.loi* .2ach lobe e&tends u! to the iddle of the thyroid cartilage. li'e o&yce!haly Ba ty!e of cranios tenosisC. and laterally to be overla!!ed by the anterior border of the sternocleido astoid uscle( )he u!!er !ole of the lobe is !ointed.enous markings are seen as irregularly anasto osing.eins !roduci characteristic ar'ings in radiogra s( )he sites o the e&ternal occi!ital !rotuberance and frontal bone are nor ally thic'er than the rest of the s'ull( )he s%ua ous te !oral and the u!!er !art of tha occi!ital bone are thin( +enerali7ed thic'ened bones are found in Paget*s disease( )halassae ia. by the lateral "all of the nose( )he a!e& lies on the 7ygo atic !rocess of the a&illa( AAAAAAAARADIOLOIICAL ANATOM AAAAAAAA In routine clinical !ractice. is associated "ith thic'ening and a characteristic sun-ray a!!earance of the s'ull bones( .

arising !articularly fro acido!hil or chro o!hobe cells( F()he s. can be seen( In raised intracranial tension.. fal& cerebri. the nasal cavities.%: 5ateral view of the skull.i*al .hyseal fossa re!resents the age of 1A years( )he !ineal body is located F(J c above and 1(F c behind the e&ternal acoustic eatus( Ehen visible it serves as an i !ortant radiological land ar'( BbC0ther structures "hich ay beco e calcified include the choroid !le&uses.-ur4ace Mar!ing.er *er.etrous . the i !ressions beco e ore !ronounced and !roduce a characteristic sil.er beaten3 a. belo" the anterior cranial fossa( :()he ..oral bone !roduces a argin of the auricle is seen above the !etrous te !oral( F()he frontal sinus !roduces a dar' shado" in the anteroinferior !art of the s'ull vault( Base o4 -!ull 1( )he floor of the anterior *ranial fossa slo!es bac'"ards and do"n"ards( )he shado"s of the t"o dense irregular shado" !osteroinferior to the hy!o!hyseal fossa( Eithin this shado" there are t"o dar' areas re!resenting the e&ternal acoustic eatuses of the t"o sidesD each shado" lies i ediately behind the head of the andible of that side( Si ilar dar' shado"s of the internal acoustic eatuses ay also be seen( )he !osterior !art of the dense shado" erges "ith the astoid air cells !roducing a honeyco b a!!earance( H(In addition to the features entioned above.er beaten for *o.ertebrae H2poph2seal 4ossa Or6ital plates <etrous part o4 the te5poral 6one Mastoid air cells Ma:illar2 air sinus Fi*+ <3. and the eth oidal and a&illary sinuses lie su!eri !osed on one another..henoi+al air sinus lies anteroinferior to the hy!o!hyseal fossa( )he shado"s of the orbit. indicating nor al i !ressions of cerebral gyri. and other dural folds( 1(The auri*le7 )he curved iddle cranial fossa in this vie"( It is overhung anteriorly by the anterior clinoid !rocess Bdirected !osteriorlyC.art of the tem. and !osteriorly by the !osterior clinoid !rocess( It easures 4 vertically and 1H antero-!osteriorly( )he interclinoid distance is not ore than H ( )he fossa is enlarged in cases of !ituitary tu ours.o. Radi ing Anato52 =& )hese ar'ings beco e ore !ro inent in raised intracranial !ressure( 1(Cerebral moul+ing. -phenoidal air sinus . the man+ible lies anteriorly for ing the lo"er !art of the facial s'eleton( )he u. arachnoid granulations.earan*e of the s'ull( F(6ra*hnoi+ granulations ay indent the !arasagittal area of the s'ull to such an e&tent as to si ulate erosion by a eningio a( 3)Iormal intra*ranial *al*ifi*ations7 BaCPineal concretions Bbrain sandC a!!ear by the sides are often seen situated one above the other( )he surface is irregular due to gyral ar'ings( It also for s the roof of the orbit B1ig( FG(1C( 1()he hy.

th6roi$ *us&#es F stra% *us&#es Cugular 7ein Lo"!us colli *us&#es Fi*+ &$+&: Tltrasound scan showing relations of trachea. the ad3acenX inferior articular and su!erior articular !rocessesR and intervertebral fora en are visualised( -ltrasoun+ s*ans B1igs FG(F and FG(:C through the thyroid gland reveal various relations of trachea( Ri!ht #o2e o. th6roi$ Le. th6roi$ Stra% L e. and the a&illary sinuses belo"( )he nor al sinuses )he cervical vertebrae can be visualised inl antero!osterior vie" of the nec' and in obli%ue vie"l of the nec'( In the antero!osterior vie".t to2e o. the body ofl cervical vertebrae.F46 <ead and =ec' lie !osteriorly and are seen as a !illar su!!orting the s'ull( SPECIAL PA 1IEL OF S'ULL FOR PARANASAL SINUSES are clear and radiolucent. the shado" is either ha7y of radio!a%ue( Cer5i&a# 1erte2rae )his !icture is ta'en "ith the head e&tended in such a "ay that the chin rests against the fil and the nose is raised fro it BEaters* !ositionC( )his vie" sho"s the frontal and a&illary sinuses clearly( )he frontal sinuses are seen i ediately above the nose and edial !arts of the orbits( )he nasal cavities are flan'ed on each side by the orbits above. th6roi$ Co**o" &aroti$ arter6 Fi*+ &$+': Tltrasound scan showing thyroid gland and trachea. !edicles an]J s!ines are seen( In the obli%ue vie". Co**o" &aroti$ arter6 Co on carotid artery Co on carotid artery .t #o2e o. intervertebral discs. i(e( they a!!ear dar'( If al sinus is infected. Ri!ht #o2e o.

lateral geniculate body.arts of .ath9ays 1(@esion in retina leads to scoto a.C . lesion on the right side leads to left ho onyous he iano!ia( =uclear colu nsKfunctional co !onents( i( +eneral so atic efferent B+S2C colu nnucleus of oculo otor ii( +eneral visceral efferent B+/2C nucleus of 2dinger-Eest!hal for the su!!ly of intraocular uscles( iii( +eneral so atic afferent B+S. dilation of !u!il. loss of acco odation.Appendi: " CRANIAL NER1ES O&u#o*otor Ner5eKCra"ia# Ner5e III O#.s!inal nucleus of C= /( It receives !ro!rioce!tive i !ulses fro e&traocular uscles( =uclei BiC and BiiC are situated in idbrain at the level of su!erior colliculus( 1ibres of 2dingerEest!hal nucleus 3oin those of the oculo otor nerve( )he nerve is seen at the edial end of crus cerebri of idbrain B1ig( A(1GC( It enters the cavernous sinus and is !laced in its lateral "all ost anteriorly( . inferior rectus and inferior obli%ue uscles( )he nerve to inferior obli%ue gives a branch for the ciliary ganglion( )his branch brings the fibres of 2dinger-Eest!hal nucleus B+/2C to the ganglion for relay( )he !ostganglionic fibres end u! in su!!lying the ciliaris for enhancing the anterior curvature of the lens and the s!hincter !u!illae for narro"ing the si7e of the !u!il( Both these are intraocular uscles re%uired for acco odation( CLINICAL ANATOM Paralysis of oculo otor nerve results in !artial !tosis.etina -\ o!tic nerve M\ o!tic chias a MS o!tic tract -H lateral geniculate body -\ o!tic radiation M\ visual area in occi!ital lobe B1ig( :G(HC( CLINICAL ANATOM Fffe*t of lesions of +ifferent .a&tor6 Path<a6 0lfactory e!itheliu of nose M\ olfactory rootlets M\ olfactory bulb M\ olfactory tract -\ lateral and edial olfactory striae B1ig( F9(4C( @ateral olfactory stria M\ !yrifor lobe Bco !rises uncus and anterior !art of !arahi!!oca !al gyrusC( #edial olfactory stria M\ se!tal nuclei( So e i !ulses fro uncus and se!tal nuclei travel via reticular for ation to the dorsal nucleus of vagus "here it ay increase or decrease gastric secretion according to ty!e of s ell( O%ti&KCra"ia# Ner5e II= 1isua# Path<a6 .a&tor6 KCra"ia# Ner5e I= O#. di!lo!ia and lateral s%uint( (3/ .isual .s it traverses the sinus it divides into its t"o divisions in its anterior !art( Both the divisions !ass through the iddle !art of the su!erior orbital fissure B1ig( A(11C( )he su!erior division turns u!"ards lateral to o!tic nerve and su!!lies su!erior rectus and su!erficially !laced levator !al!ebrae su!erioris( )he inferior division in orbit !asses belo" the o!tic nerve and divides into three branches8 for edial rectus. o!tic radiation or visual corte& of one side results in loss of the o!!osite half of field of vision( J(. that is certain !oints ay beco e blind s!ots( F(0!tic nerve da age results in co !lete blindness of that eye( :(0!tic chais a lesion if central "ill lead to bite !oral he iano!iaD but if !eri!heral on both sides "ill lead to binasal he iano!ia( H(Co !lete destruction of o!tic tract.

Frontal a( Su!ratrochlear8 .nterior eth oidal8 1(#iddle and anterior eth oidal sinuses( F(#edial internal nasal :(@ateral internal nasal H(2&ternal nasal 2&ternal nasal8 S'in of ala of vestibule and ti! of nose( ).nfraorbital !anal 1(#iddle su!erior alveolar F(. 5acrimal @ateral !art of u!!er eyelidD conveys secreto otor fibres fro 7ygo atic nerve to lacri al gland( . scal! till verte& <.bducent nerve only su!!lies the lateral rectus of the eyeball( Paralysis of the nerve results in edial s%uint and di!lo!ia B1ig( A(1HC( . con3unctiva.uricular b( Su!erficial te !oral c( . !atient cannot turn the centre of cornea do"n"ards and laterally( 0n atte !ting to do this action.andibular NerAe *OI= 2runk 1(#eningeal B1ig( 1G(1HC F(=erve to edial !terygoid8 )ensor veli !alatini )ensor ty !ani #edial !terygoid Anterior 9ivision 1(Dee! te !oral F(@ateral !terygoid :(#asseteric H(BuccalMS'in of chee' Posterior 9ivision A( .uriculote !oral a( . the eye rotates edially resulting in di!lo!ia or double vision B1ig( A(1:C( Tri!e*i"a# Ner5eKCra"ia# Ner5e 1 Cranial nerve /Ktrige inal nerve co !rises three branches.n .nterior su!erior alveolar (n Face %) Infraorbital 8 a( Pal!ebral b( @abial c( =asal K .nterior belly of digastric I CLINICAL ANATOM In case of in3ury to o!hthal ic nerve. side of nose. !osterior eth oidal air sinuses B1ig( A(1JC( b( @ong ciliary8 Sensory to eyeball c( =erve to ciliary ganglion d( Infratrochlear8 Both eyelids. lacri al sac e( .Tro&h#ear Ner5eKCra"ia# Ner5e I1 )rochlearKcranial nerve I/ nerve nucleus is situated at the level of inferior colliculus of id brain( )his nerve su!!lies only the su!erior obli%ue uscle of the eyeball( If the nerve is in3ured. there is loss of 6corneal blin' refle&6 In3ury to a&illary nerve causes loss of 6snee7e refle&6 In3ury to andibular nerve results in loss of 63a" 3er' refle&6( A2$u&e"tKCra"ia# Ner5e 1I . u!!er eyelid. Nasoclliary a( Posterior eth oidal8 S!henoidal air sinus. a&illary and andibular( )heir branches are given8 Ophthal6ic NerAe 0!hthal ic nerve is sensory( Its branches are as follo"s( E. lo"er !art of forehead b( Su!raorbital8 1rontal air sinus.a)illary NerAe . o!hthal ic.n /iddle !ranial Fossa ") #eningeal branch .n Pterygopalatine Fossa 1(+anglionic branches B1ig( 1J(1:C F(Lygo atic 8 a( Lygo aticote !oral b( Lygo aticofacial H( Posterior su!erior alveolar .!!er eyelid.rticular to te !oro andibular 3oint d( Secreto otor to !arotid gland( 1(@ingualM+eneral sensation fro anterior t"othirds of tongue F(Inferior alveolarM@o"er teeth and a( =erve to ylohyoid 8 1(#ylohoid > F(. forehead.

uscles of nose and u!!er li!( )heir !aralysis causes dribbling fro the outh( H(#arginal andibular usually runs along the lo"er border of andible( In3ury of this nerve causes !aralysis of de!ressors of lo"er li!( 1G( Cervical lies in the nec' and su!!lies !latys a( CLINICAL ANATOM geniculate ganglion-greater !etrosal nerve Bfro nervus inter ediusC 3oins "ith dee! !etrosal Bsy !athetic fibresC to for nerve of !terygoid canal( F(Branch to sta!edius given off fro facial nerve as it traverses the facial canal( :(Chorda ty !ani nerve M\ also arises fro nervus inter edius 6 above the stylo astoid fora en( )his nerve !asses through !osterior "all -\ lateral "all M\ anterior "all M\ !etroty !anic fissure -> 3oins lingual nerve. disa!!earance of nasolabial fold and loss of "rin'ling of s'in of forehead on the sa e side( F(@esion above the origin of chorda ty !ani nerve "ill sho" sy !to s of Bell*s !alsy !lus loss of taste fro anterior t"o-thirds of tongue e&ce!t vallate !a!illae( :(@esion above the origin of nerve to sta!edius "ill cause sy !to s 1 and F and further causes hy!eracusis( @esions 1.esult is asy etry of corner of outh. only lo"er half of o!!osite side of face is affected( )he u!!er half of face has bilateral re!resentation. i(e( orbicularis oculi. nasal. lies on edial side of s!ine of s!henoid B1ig( 9(1GC( 2&tracranial course 8 )he nerve gives t"o branches nu bered H and J and then enters !ostero edial surface of !arotid gland( It divides 1()hrough the stylo astoid fora en( .!!er otor neuron !aralysis "ill not affect the u!!er !art efface. inability to close the eye. F and : are lo"er otor neuron ty!e( . !haryngeal glands through greater !etrosal nerve B"hich for s nerve to !terygoid canal by 3oining "ith dee! !etrosal nerve Bsy !athetic fibresC and for sub andibular and sublingual salivary glands through chorda ty !ani nerve( =uclei are lacri atory and su!erior salivatory nuclei( :(S!ecial visceral afferent for receiving taste fibres fro anterior t"o-thirds of tongue e&ce!t the circu vallate !a!illae and general visceral afferent fro various glands( =ucleus is tractus solitarius( H(+eneral so atic afferent colu n for receiving !ro!rioce!tive fibres fro uscles of facial e&!ression( =ucleus is s!inal nucleus of / C=( )he ain nerve e erges at the lo"er border of !ons above the olive( )he nervus inter edius co !osed of Fnd and :rd nuclear co !onents 3oin the ain nerve( )hese t"o enter the internal acoustic eatus( )he t"o nerves run laterally in the !etrous te !oral bone "here these fuse to for a single trun'( )hen the nerve for s a bend.Fa&ia# Ner5eKCra"ia# Ner5e 1II It is called facial nerve as this nerve su!!lies all the uscles of facial e&!ression develo!ed fro Fnd !haryngealKbranchial arch( Its various nuclear co !onents are8 1(S!ecial visceral efferent for the su!!ly of uscles of facial e&!ression( =ucleus is at lo"er !ons( F(+eneral visceral efferent for the su!!ly of lacri al. the nerve e&its through the cranial cavity by !assing through the stylo astoid fora en as !urely otor nerve Bsee Cha!ter 9C( . !alatal. "hereas lo"er half has only i!silateral re!resentation( 1esti2u#o&o&h#earKCra"ia# Ner5e 1III Auditory pathway 1(Bells*s !alsy8 Sudden !aralysis of facial nerve at )he auditory rece!tors are the hair cells of the organ of Corti.ntracranial &ranches re3oins and finally e erge as J ain branches( 1(Posterior auricular branch for the su!!ly of auricular uscles and occi!ital belly of occi!itofrontalis uscles( F(#uscular branch "hich su!!lies !osterior belly of digastric and stylohyoid uscles( )hen it !asses through !arotid gland and divides into various branches8 1()e !oral branches e erge fro the u!!er border or base of the gland cross 7ygo atic arch to su!!ly frontalis !art of occi!itofrontalis uscle( F(Lygo atic branches su!!ly orbicularis oculi( Paralysis of this uscle causes e!i!hora and !revents blin'ing( :(Buccal branches usually !ass above and belo" the !arotid duct( )hese su!!ly buccinator. situated around odiolus at the base of s!iral la ina( )he !eri!heral !rocesses are distributed to the organ of Corti. it curves do"n"ards traversing the facial canal( @astly. situated in the cochlear duct of the internal ear( i( )he first sensory neuron lies in the s!iral ganglion of bi!olar cell. "hich is enlarged to for geniculate ganglion( It runs !osteriorly in the edial "all of iddle ear( 1inally. and the central !rocesses .

carotid sinus. it also receives taste fro !osterior one third of tongue and vallate !a!illae( .ll these a sensations reach the inferior ganglion of nerve via the !eri!heral !rocess of the ganglia cells( )heir central !rocess reach the nucleus B tractus solitarius( H( +eneral so atic afferentMcarries !ro!rioce!tiveP i !ulses fro !haryngeal uscle to s!inal tract of/( .ntracranial !ourse )he fibres of the nerve arise fro the res!ective I nuclear colu ns at the level of edulla oblongata( )he nerve fibres !ass bet"een olive and inferior 1 cerebellar !eduncle( It is attached at the base of the brain in theR !osterolateral sulcus bet"een olive and inferior cerebellar !eduncle by :-H rootlets( )he rootlets 3oin to for the nerve "hich enters the iddle !art of the 3ugular fora en in a se!arate sheath of dura ater( E tracranial !ourse )he vestibular nerve innervates the aculae of the utricle and saccule( )hese are sensitive to static changes in e%uilibriu ( )he a !ullae of the se icircular canals are sensitive to dyna ic changes in e%uilibriu ( I !ulses !ass along the vestibular nerve to vestibular nuclei situated at !onto edullary 3unction( 1ibres fro vestibular nuclei !ass via inferior cerebellar !eduncle to the cerebellu ( Damage to vestibular nerve results in vertigo or di77iness and nystag us i(e(. !haryn&. !endular ove ents of the eyes( I#osso%har6"!ea# Ner5eKCra"ia# Ner5e I> )he su!erior ganglion is s all and is a detached !art I of the inferior ganglion( )he inferior ganglion is larger and its central !rocesses carry all the sensory fibres Bgeneral and s!ecial sensationC of the nerve( It curves edially across the stylo!haryngeus uscle and su!!lies it( It enters the !haryn& through the interval bet"een su!erior and iddle constrictor uscles and ends by dividing into its ter inal branches B1ig( 1H(14C( &ranches 1(Co It is na ed so. ediated through tectobulbar and tectos!inal tracts( )he rest of the lateral le niscus relays in edial geniculate body( iv( )he fourth neuron fibres fro edial geniculate body give rise to auditory radiations "hich !ass through sublentifor !art of internal ca!sule and are !ro3ected to auditory corte& of te !oral lobe( Damage to cochlear nerve !roduces tinnitis and sensorineuronal deafness( 'estibular Pathway third of tongue. tonsil. carotid body.for cochlear nerve "hich ends in the dorsal and ventral cochlear nuclei lying in relation to inferior cerebellar !eduncle( ii( )he second neuron fibres start fro the dorsal and ventral cochlear nuclei8 their a&ons for tra!e7oid body and end in dorsal nucleus of tra!e7oid body of the sa e as "ell as the o!!osite side( iii( )he third neuron fibres fro dorsal nuclei of tra!e7oid body ascend as lateral le niscus on both sides( So e of the fibres of lateral le niscus end in the inferior colliculus for auditory refle& activities. auditory tube and gives M\ lesser !etrosal nerve relay in otic ganglion 3oin auriculote !oral nerve M\ !arotid salivary gland B1ig( 1F(19C( b( Sinocarotid nerve for carrying barorece!tor and che orece!tor sensations fro carotid sinus and carotid body res!ectively( c( )onsillary and !alatal branches for the su!!ly of sensory fibres to the !alatine tonsil and soft !alate( . O and su!erior cervical ganglion of sy !athetic chain( F(Distribution to8 a( )y !anic branch enters iddle ear cavity -\ ty !anic !le&us on !ro ontory M\ su!!lies iddle ear. as it su!!lies one uscle of the !haryn&Mthe stylo!haryngeus and carries general sensation and taste fro !osterior one-third of the tongue and vallate !a!illae( It is the nerve of :rd brachial arch( =uclear colu nsKfunctional co !onents8 1(S!ecial visceral efferent Bnucleus a biguusC for the su!!ly only one uscleMthe stylo!haryngeus( F(+eneral visceral efferentMthe inferior salivatory nucleus for the su!!ly of !arotid salivary gland after relay in the otic ganglion( :(+eneral visceral afferent and s!ecial visceral afferent( =ucleus of tractus solitarius as it receives general sensations fro !osterior one- unicating to /.

A%%e"$i8 9 d( @ingual branches for the su!!ly of general sensations and taste fibres fro !osterior onethird of tongue including the circu vallate !a!illae !resent anterior to the sulcus ter inalis of the tongue( e( Pharyngeal branch is sensory to the ucous e brane of !haryn&( f( Stylo!haryngeus uscle( CLINICAL ANATOM H6%o!#ossa# Ner5eKCra"ia# Ner5e >II 0n tic'ling the !osterior "all of !haryn&. transverse and vertical uscles( )he fourth e&trinsic uscle na ely the !alatoglossus is su!!lied by vagoaccessory co !le& B1ig( 1F(FHC( b( It carries fibres of ventral ru us of first cervical "hich gets distributed as eningeal branch. its ti! gets deviated to the affected side( . there is inability to s!ea'. branch to thyrohyoid and geniohyoid uscles( CLINICAL ANATOM If this nerves is in3ured the intrinsic and ost of the e&trinsic uscles of the sa e side to tongue are !aralysed( If !aralysed tongue is !rotruded. !haryn& and laryn&( )he s!inal root su!!lies t"o big uscles of nec'. no such contraction occurs( 1urther taste fro !osterior one-third of tongue and circu vallate !a!illae is not a!!reciated in cranial nerve IO !aralysis( )he cranial nerve IO is ostly !aralysed along "ith cranial nerve O( 1a!usKCra"ia# Ner5e > /agus leaves the cranial cavity through 3ugular fora en( It courses through nec'. the sternocleido astoid and the tra!e7ius B1ig( 1F(FFC( In3ury to s!inal root causes !aralysis of both the above entioned uscles( Paralysis of sternocleido astoid turns the chin to"ards the side of in3ury( Paralysis of tra!e7ius causes li itation in overhead abduction and inability to shrug the shoulder on the affected side( Branches 1(0f co unication "ith vagus. inferior longitudinal. the cranial and s!inal( )he cranial root 3oins vagus to for vagoaccessory co !le& and gets distributed through branches of vagus to soft !alate. Bsu!!lied by andibularCD all uscles of !haryn& e&ce!t Stylo!haryngeus Bsu!!lied by C= IOC and all intrinsic uscles of laryn& B1ig( 1F(F1C( If vagus is da aged the effects are 8 BaCParalysis of uscles of soft !alate resulting in nasal regurgitation of fluids BbC=asal tone of the voice BcC<oarseness of voice /oice beco es onotonous because of !aralysis of e&ternal laryngeal nerve( It both recurrent laryngeal nerves are in3ured. there is refle& contraction of uscles of !haryn&( If cranial nerve IO is !aralysed.s the na e i !lies it is the nerve su!!lying uscles of tongue Bglossal eans tongueC and is !urely otor nerve( 1unctional co !onents or nuclear colu ns8 It belongs to general so atic efferent colu n( Its nucleus is situated in the edulla in the floor of I/ ventricle dee! to hy!oglossal triangle( )he rootlets are attached in the groove bet"een the !yra id and olive( )he rootlets 3oin to for t"o bundles "hich !ierce the dura ater se!arately near the anterior condylar canal or hy!oglossal canal( YIt enters the nec' through anterior condylar canal and is !laced dee!er than cranial nerves IO. genioglossus and hyoglossus and to four intrinsic uscles na ely su!erior longitudinal. su!erficial to hyoglossus "here it ends by dividing into its uscular branches( )he accessory nerve co !rises t"o roots. ventral ra us of first cervical nerve. su!erior li b of ansa cervlcalis. crossing the internal carotid. and dys!noea( A&&essor6KCra"ia# Ner5e >I . O and OI( YIt descends bet"een internal 3ugular vein and internal carotid artery( YIt curves around the vagus nerve as it !asses dee! to !osterior belly of digastric uscle( Y)he hy!oglossal nerve a'es a "ide curve. e&ternal carotid and the loo! of the lingual artery( Y)he nerve !asses above the hyoid bone in sub andibular region. thora& and abdo en and su!!lies organs develo!ed fro foregut and idgut( Since it has too uch to su!!ly it borro"s the cranial root of accessory to su!!ly uscles of soft !alate e&ce!t tensor veli !alatini. lingual nerve and su!erior cervical ganglion of sy !athetic chain( F(0f distribution8 a( )o the three e&trinsic uscles of tongue na ely styloglossus.

"hich su!!lies su!erior belly of o ohyoid and 3oins "ith inferior li b to for ansa( Inferier li b of ansa cervicalis is for ed by ventral ra i of CF. C:. !eritoneu and fibrous !ericardiu ( Infla ation of !eritoneu under dia!hrag causes referred !ain in the area of su!raclavicular nerves su!!ly. !ass u!to su!erior cervical ganglion "here these relay( )he !ostganglionic fibres acco !any internal carotid artery leave the artery to 3oin o!hthal ic nerve. sternothyroid. CH for the cervical !le&us( Cl runs along hy!oglossal and su!!lies geniohyoid and thyrohyoid( It also gives su!erior li b of ansa cervicalis. choroid of eyeball. sy !athetic and secreto otor roots B1igs 1J(1F. es!ecially ti! of the shoulders as their root value is also ventral ra i of C: and CH B1ig( 1F(F4C( <ituation7 )he sub andibular ganglion lieB su!erficial to hyoglossus uscle in the subB andibular regionP 1unctionally. sy !athetic and secreto otor roots( YSensory root is fro the lingual nerve( It im sus!ended by t"o roots of lingual nerve YSy !athetic root is fro the sy !athetic !le&ui around the facial artery( )his !le&us contains I !astganglionic fibres fro the su!erior cervical ganglion of sy !athetic trun'( )hese fibres !ass e&!ress through the ganglion and are vaso otor to the gland YSecreto otor root is fro su!erior salivatory nucleus through nervus inter edius via chorda ty !ani "hich is a branch of cranial nerve /II( Chorda ty !ani 3oins lingual nerve( )he !arasy -1 !athetic fibres get relayed in the sub andibular ganglion Bran*hes7 )he ganglion gives direct branches to the sub andibular salivary gland( So e !ostganglionic fibres reach the lingual nerve to be distributed to sublingual salivary gland( C%ter6!o%a#ati"e Ia"!#io" CER1ICAL PLE>US /entral ra i of Cl. C:C.nhydrosisMloss of s"eating on the head and nec' of the sa e side( H(2no!hthala osMdue to loss of !aralysis of uscle fibres in the orbital cavity su!!lied by sy !athetic nerves( Su2*a"$i2u#ar Ia"!#io" PHRENIC NER1E Phrenic nerve arises !ri arly fro ventral ra i of CH "ith s all contributions fro C: and CJ nerve roots or through nerve to subclavius( It is the only otor su!!ly to its o"n half of dia!hrag and sensory to ediastinal !leura. 1J(1:C( YSensory root is fro a&illary nerve( )he ganglion is sus!ended by F roots of a&illary nerve( YSy !athetic root is fro !ostganglionic !le&us around internal carotid artery( )he nerve is called dee! !etrosal( It unites "ith greater !etrosal to for nerve of !terygoid canal( )he fibres of dee! !etrosal do not relay in the ganglion( YSecreto otor root is fro greater !etrosal nerve "hich arises fro geniculate ganglion of cranial nerve /II( )hese fibres relay in the ganglion( Bran*hes7 )he ganglion gives nu ber of branches( )hese are i( 5or la*rimal glan+7 )he !ostganglionic fibres !ass -\ 7ygo atic branch of a&illary nerve( )hese fibres hitch hi'e through 7ygo aticote !oral nerve into the co unicating branch . CHC and transverse or anterior nerve of nec' BCF. CF. great auricular BCF. inferior belly of o ohyoid( Cervical !le&us also gives four cutaneous branches lesser occi!ital BCFC. nasociliary nerve-long ciliary nerve to su!!ly cornea. su!raclavicular BC:. "hileio!ogra!hically it is connected tol lingual branch of andibular nerve B1ig( 11(11C( 3 Boots7 )he ganglion has sensory. 4(1: and 1F(F4C( <ituation7 Pterygo!alatine or s!heno!alatine is the largest !arasy !athetic ganglion.HORNER'S S NDROME PARAS MPATHETIC IANILIA Preganglionic fibres fro lateral horn of )l seg ent of s!inal cord enter sy !athetic trun' via "hite ra us co unicans of )l. sus!ended by t"o roots of a&illary nerve( 1unctionally it is related to cranial nerve /II( It is called the ganglion of 6<ay fever(6 B Boots7 )he ganglion has sensory. it is connected im facial nerve. C:( Branches fro ansa su!!ly sternohyoid. C:C B1igs :(A. dilator !u!illae and s ooth !art of levator !al!ebrae su!erioris uscle( If these fibres get interru!ted the losses lead to <o er*s syndro e8 1(Constriction of !u!il due to loss of dilator !u!illae( F(Ptosis B!artial droo!ing due to loss of sy !athetic nerve su!!lying !art of levator !al!ebrae su!eriorisC( :(.

the sensory.bet"een 7ygo atico-te !oral and lacri al nerve. !alatine tonsil laterally.roblem7 b Ehat is Ealdeyer*s ly !hatic ring M b 2&!lain the basis of boy*s earache M b Ehat ly !h node "ould li'ely be s"ollen and tender M . it is connected to andibular nerve. sy !athetic and otor( 0nly the otor root fibres relay to su!!ly the intraocular uscles( YSensory root is fro the long ciliary nerve( YSy !athetic root is by the long ciliary nerve fro !le&us around o!hthal ic artery( Y#otor root is fro a branch to inferior obli%ue uscle( )hese fibres arise fro 2dinger-Eest!hal nucleus. 3oin oculo otor nerve and leave it via the nerve to inferior obli%ue.MICAL PROBLEMS 1( . secreto otor and otor roots B1igs 1G(1J. branch of o!hthal ic division of trige inal nerve.alatine ner. bet"een the nerve and the tensor veli !alatini uscle in the infrate !oral fossa. but functionally it is related to oculo otor nerve( )his ganglion has no secreto otor fibres(^ Boots7 It has three roots. tubal tonsil !osterolaterally and !haryngeal tonsil !osteriorly( )he earache is due to infection of the throat reaching the iddle ear( )he !haryngoty !anic tube fro the region of naso!haryn& co unicates "ith the anterior "all of the iddle ear cavity carrying the infection fro !haryn& to the ear causing the earache( )he 3ugulodigastric ly !h node belonging to u!!er grou! of dee! cervical grou! is ost li'ely to be tender and s"ollen.ns( #a3or collections of ly !hoid tissue at the oro!haryngeal 3unction are called the tonsils( )hese lie in a ring for called the Ealdeyer*s ly !hatic ring( )he co !onents of this ring are lingual tonsil anteriorly. to be relayed in the ciliary ganglion B1ig( A(1FC( Bran*hes7 )he ganglion gives 1G-1F short ciliary nerves containing !ostganglionic fibres for the su!!ly of constrictor or s!hincter !u!illae for narro"ing the si7e of !u!il and ciliaris uscle for increasing the curvature of anterior surface of lens re%uired during acco odation of the eye( F\4c Ia"!#io" ) !@ <ituation7 )he otic ganglion lies dee! to the trun' of andibular nerve. sy !athetic. 1F-year-boy co !lained of sore throat and ear ache( <e had 1GF[ 1 te !erature and difficulty in s"allo"ing( <e "as also a outh breather( Clini*oanatomi*al . "hile functionally it is related to cranial nerve Boots7 )his ganglion has sensory. 1G(16C( YSensory root is by the auriculote !oral nerve( YSy !athetic root is by the sy !athetic !le&us around iddle eningeal artery( YSecreto otor root is by the lesser !etrosal nerve fro the ty !anic !le&us for ed by ty !anic branch of cranial nerve IO( 1ibres of lesser !etrosal nerve relay in the otic ganglion( Postganglionic fibres reach the !arotid gland through auriculote !oral nerve( Y#otor root is by a branch fro nerve to edial !terygoid( )his branch !asses unrelayed through the ganglion and divides into t"o branches to su!!ly tensor veli !alatini and tensor ty !ani( %ranches: )he !ostganglionic branches of the I ganglion !ass through auriculote !aral nerve to su!!ly the !arotid gland( )he otor branches su!!ly the t"o uscles I entioned above( / C0iliar2 Ia"!#io" I <ituation7 )he ciliary ganglion is very s all ganglion !resent in the orbit( )o!ogra!hically the ganglion is CLINICOANAT. 3ust distal to the fora en ovale( )o!ogra!hically. then to the lacri al nerve for su!!lying the lacri al gland( il( Iaso.e7 )his nerve runs on the nasal se!tu and ends in the anterior !art of hard !alate( It su!!lies secreto otor fibres to both nasal and !alatal glands( iii( /alatine bran*hes7 )hese are one greater !alatine and F-: lesser !alatine branches( )hese !ass through the res!ective fora ina to su!!ly sensory and secreto otor fibres to ucous e brane and glands of soft !alate and hard !alate( iv( Iasal bran*hes 7 )hese are !osterior su!erior edial for the su!!ly of glands and ucous e brance of nasal se!tu D the largest is na ed naso!alatineD and !osterior su!erior lateral for the su!!ly of glands and ucous e brane of lateral "all of nasal cavity( v( >rbital bran*hes for the orbital !eriosteu ( vi ( Pharyngeal branches for the glands of !haryn&( related to nasociliary nerve. as the ly !hatics fro the tonsil !enetrate the "all of the !haryn& to reach these ly !h nodes( .

roblem7 n Ahy does thyroid s"elling ove u! and do"n during deglutition ^ D Ehy does she co !lain of hoarseness after the o!eration ^ D Ehich other gland can be re oved "ith thyroid ^ .F( .roblem7 D <o" "as the large ly !h node for ed ^ D Ehy did the !atient have dys!hagia ^ D Ehere can the cancer s!read around oeso!hagus ^ . HG-year-"o an co !lained of a s"elling in front of her nec'. there is lot of !ain. the 3 su!rasternal s!ace and the su!raclavicular s!aceD t"o glands.ns( )he thyroid gland is sus!ended fro cricoid cartilage by the !retracheal fascia and liga ent of Berry( So all the s"ellings of thyroid gland ove "ith deglutition( She co !lains of hoarsensess due to in3ury to the recurrent laryngeal nerve as it lies close to the inferior thyroid* artery near the lo"er !ole of the gland( <oarseness can also result fro !osto!erative oede a( )he !arathyoid gland lying on the bac' of thyroid gland can be re oved( Parathyroid controls calciu level in the blood( H( . the cancer can s!read to trachea or any of the !rinci!al bronchi( . giving rise to !ain( )he ly !hatic drainage fro cervical !art of oeso!hagus goes to inferior grou! of dee! cervical ly !h nodes( )he cancer had etastasi7ed to the ly !h node at the anterior border of sternocleido astoid uscle( Since trachea lies 3ust anterior to oeso!hagus.ns( )he e&ternal 3ungular vein "as severed( It !asses across the sternocleido astoid uscle to 3oin the subclavian vein above the clavicle( <er accessory nerve is also in3ured as it crosses the !osterior triangle close to its roof.ns( )he !ain during eating or drin'ing is due to cancer of the oeso!hagus( )he cancer ( obliterates increasing !art of the lu en. the tra!e7ius and the sternocleido astoidD t"o s!aces. and she co !lained of hoarseness after the o!eration( Clini*oana tomi*al . one for the inter ediate tendon of digastric and one for the inter ediate tendon of o ohyoid uscle( J( . she felt difficulty in co bing her hair( :( . iddle-aged "o en had a dee! cut in the iddle of her right !osterior triangle of nec'( )he bleeding "as arrested and "ound "as sutured( )he !atient later felt difficulty in co bing her hair( Clini*oanatomi*al . the !arotid and the subandibular glandsD and for s t"o !ulleys. the fascia gets stretched "hich results in !ain( )he fascia and s'in are su!!lied by the great auricular nerve( Ehile drin'ing le on 3uice.roblem7 D Ehat blood vessel is severed ^ D Ehy did the !atient have difficulty in co bing her hair ^ .roblem7 D Ehere do the ducts of the salivary glands o!en ^ D Ehy did the !ain increase "hile che"ing ^ I D Ehy did the !ain increase "hile drin'ing I le on 3uice ^ . causing !aralysis of tra!e7ius uscle( )he tra!e7ius "ith serratus anterior causes overhead abduction re%uired for co bing the hair( Due to !aralysis of tra!e7ius. young an co !lained of fever and sore throat. an aged JJ years co !lained of dys!hagia in eating solid and even soft food and li%uids( )here "as a large ly !h node felt at the anterior border of sternocleido astoid uscle( )he diagnosis on bio!sy "as cancer of cervical !art of oeso!hagus( Clini*oanatomi*al .s andible oves during che"ing. as the a salivary secretion is sti ulated by the acid of the le on 3uice( )he investing layer of cervical fascia encloses 8 )"o uscles. nervousness and loss of "eight( <er diagnosis "as hy!erthyroidis ( Partial thyroidecto y "as !erfor ed. noted a s"elling and felt !ain on both sides of his face in front the ear( Eithin a fe" days he noted s"ellings belo" his 3a" and belo" his chin( <e suddenly started loo'ing very healthy by facial a!!earance )he !ain increased "hile che"ing or drin'ing le on 3uice( )he !hysician noted enlarge ent of all three salivary glands on both sides of the face( Clini*oanatomi*al .I bular gland o!ens at the !a!illa on the I sublingual fold( )he sublingual gland o!ens by 1G-1F ducts on the sublingual fold( )he investing I layer of cervical fascia encloses both the !arotid I and the sub andibular glands and is attached to the lo"er border of the andible( .ns( )he duct of the !arotid gland o!ens at a I !a!illa in the vestibule of outh o!!osite the I Fnd u!!er olar tooth( )he duct of sub andi.

( If 1.ecurrent d( Su!erior :( Ehich of the follo"ing subdivision of anterior triangle is un!aired8 a( #uscular b( Sub ental c( Digastric d( Carotid H( Ehich !art of internal carotid artery has no branch8 a( Cerebral b( Petrous c( Cervical d( Cavernous J( 0nly one uscle de!resses the one is it^ a( #edial !terygoid b( )e !oralis c( @ateral !terygoid d( #asseter andible( Ehich c( @acri al d( Infraorbital 9( )eg en ty !ani for s the roof of all of the follo"ing e&ce!t8 a( #astoid antru b( )y !anic cavity c( Canal for tensor ty !ani d( Internal acoustic rneatus 1G( By ho" any o!enings do the se icircular canals o!en into the vestibule8 a( : b( J c( H d( F 11( )he a&illary artery is a branch of8 a( 2&ternal carotid artery b( Internal carotid artery c( 1acial artery d( Su!erficial te !oral artery 1F( )he vocal folds are abducted by8 a( Cricothyroid uscle b( @ateral cricoarytenoid uscle c( Posterior cricoarytenoid uscle d( . : are correct B( If 1 and : are correct C( If F and H are correct D( If only H is correct 2( If all are correct . F.C Select the best res!onse8 1( .UESTIONS B.MULTIPLE CHOICE .bducent d( )rochlear 4( Ehich of the follo"ing nerve su!!lies the cornea8 a( Su!raorbital b( =asociliary !oro andibular 3oint is a8 Plane 3oint Condyloid 3oint Ball and soc'et 3oint Saddle-sha!ed 3oint B( 2ach %uestion contains four suggested ans"ers.rye!iglottic 1:( +reater cornua of hyoid bone is develo!ed fro M !haryngeal arch8 a( I b( II c( Ill d( I/ 1H( Stylo!haryngeus a( /II b( IO c( O d( OII IS()e a( b( c( d( uscle is su!!lied by nerve8 6( Ehich uscles ay elevate the laryn&8 a( )hyrohyoid b( Sternothyroid c( Sternohyoid d( 0 ohyoid M inferior belly A( 0ne of the follo"ing nerves does not traverse the su!erior orbital fissure( Ehich one is it^ a( =asociliary b( #a&illary c( . out of "hich one or ore are correct( Choose the ans"er8 .ll of the follo"ing are the branches of e&ternal carotid e&ce!t8 a( 1acial b( 0!hthal ic c( 0cci!ital d( Posterior auricular F( Ehich of the laryngeal nerves acco !anies the inferior thyroid artery8 a( Internal b( 2&ternal c( .

14(. fracture of cranial cavity !assing through 3ugular fora en "ill cause !aralysis of8 1(. 19(2 FG(C 19( )he o!tic nerve is considered a tract because8 1()he sheaths covering the o!tic nerve are derived fro the three eninges( F(Its fibres have no neurile a sheath :(It is attached to forebrain H(It cannot regenerate FG( )he lateral geniculate body receives8 1(Contralateral te !oral retinal fibres F(I!silateral te !oral retinal fibres :(I!silateral nasal retinal fibres H(Contralateral nasal retinal fibres .ccessory nerve F(/agus nerve :(+losso!haryngeal nerve H(1acial nerve 14( )he su!erior colliculus of 1(/isual refle& center F(<igher center for vision :(Situated in idbrain H(/isual relay center idbrain is8 A"s<ers to Mu#ti%#e Choi&e .uestio"s 1(b F(c :(b H(c J(c 6(a A(b 4(b 9(d 1G(b 11(a 1F(c 1:(c 1H(b 1J(b 16(2 1A(.16( )he lesion of oculo otor nerve leads to8 1(Di!lo!ia F(Ptosis :(Dilatation of !u!il H(@ateral s%uint 1A( .

Se&tio" ( BRAIN .

ro*esses of t9o . and a"ay fro the cell body in the a&on( )he neurons are connected to one another by their !rocesses. in so e cases about 1FJ etres !er second( . (77 ./ntroduction to the Brain <u an nervous syste is res!onsible for 3udge ent. for ing the su!!orting BconnectiveC tissue of the C=S( In !eri!heral nervous syste . short. for ing long chains along "hich the Cell 6od2 containing nissl su6stance eurile55a A M2elin sheath ucleus o4 sch1ann cell % A:on Dendrite % Fi*+ =$3$@ A nerve cell. each neuron is s!eciali7ed for sensitivity and conductivity( )he i !ulses can flo" in the "ith great ra!idity. that is !hysical. !sychological and intellectual( It is the ost co !le& syste of the body( I"tro$u&tio" " Neuro" BcC both ty!es of cells are su!!lied "ith blood by abundant blood vessels( =ervous syste is the chief controlling and coordinating syste of the body( It ad3usts the body to the surroundings and regulates all bodily activities both voluntary and involuntary( )he sensory !art of the nervous syste collects infor ation fro the surroundings and hel!s in gaining 'no"ledge and e&!erience. and nerves in the !eri!heral nervous syste ( )he branches of a&ons often arise at right angles and are called the collaterals( 1unctionally.arieties7 BiC Dendrites are any. richly branched and often varicoseD BiiC the a&on is a single elongated !rocess( Collectively the a&ons for tracts B"hite atterC in the C=S.olarity in its !rocesses( )he i !ulse flo"s to"ards the cell body in the dendrites. and ganglia in the !eri!heral nervous syste B1ig( F1(1C( b( Iumerous *ell . these are re!laced by Sch"ann cells and the loose connective tissueD 2ach neuron is ade u! of the follo"ing( a( . cell body( Collectively they for grey atter and the nuclei in the C=S. neuron sho"s +ynami* . intelligence and e ory( =ervous syste is highly evolved at the cost of regeneration( )he activities of nervous syste are lin'ed "ith every as!ect of our lives. "hereas the otor !art is res!onsible for res!onses of the body( CELLULAR ARCHITECTURE )he nervous tissue is ade u! of8 BaC =erve cells or neuronsD BbC neuroglial cells BneurogliaC.

refle& arc is the functional unit of the nervous syste ( In its si !lest for .ll subcortical res!onses are involuntary and therefore are the refle& activities( PARTS OF THE NER1OUS S STEM !entral Nervous $ystem "!N$# 1(Brain( 0ccu!ies cranial cavity( F(S!inal cord( 0ccu!ies u!!er t"o-thirds oft vertebral canal . it survives. into four ty!es( a( 1ulti.i !ulses are conducted( )he site of contact Bcontiguity "ithout continuityC bet"een the nerve cells in 'no"n as *syna!se*( 0ne cell ay establish such contacts through its dendrites "ith as any as 1GGG a&onal ter inals( <o"ever. e(g( the s'inD BbC the sensory neuronD BcC the otor neuronD and BdC the effector. they can for the C=S tu ours( Re. e(g( the uscle( In co !le& for s of the refle& arc. BcC )he distal !art of the cut fibre8 It degenerates co !letely( .estoration of function ay be considerable but rarely co !lete( )he role of neurile al tube as a guiding factor to the regenerating !ro&i al a&on is considered to be of !ara ount i !ortance( )hus a nerve can regenerate because it has a neurile al sheath( . cannot for tu ours( Brain tu ours arise fro the neuroglial cells and the i ature nerve cells( Neuro!#ia# Ce##s If a nerve Ba&onsC is in3ured or cut a series of degenerative and then regenerative changes follo"( )he degenerative changes occur in 8 BaC Cell body8 It undergoes chro atolysis( =issl granules disa!!earD cell beco es s"ollen and roundedD and the nucleus is !ushed to the !eri!hery. "ith short a&on( #ature nerve cells are inca!able of dividing and.strocytes are concerned "ith nutrition of the nervous tissue( b( 0ligodendrocytes are counter!arts of the Sch"ann cells( Sch"ann cells yelinate the !eri!heral nerves( 0ligodendrocytes rnye3inate the tracts( ftyu\dtD f1> c( #icroglia behave li'e acro!hages of the C=S( d( 2!endy al cells are colu nar cells lining the cavities of the C=S( Proliferation of glial cells is called the *gliosis*( . ganglia of eighth cranial nerve.olar neurons) #ost of the neurons in an are ulti!olar( 1or e&a !le. the ti! of the a&on still connected "ith the cell body begins to gro" through the neurile al tube( )he rate of gro"th is about 1F !er day in an( #yelin sheath is refor ed( . as is seen in de yelinating diseases( tissue( Since the glial cells are ca!able of dividing. 1491C( )he i !ulse is trans itted across a syna!se through bioche ical neurotrans itters BacetylcholineC( . and the olfactory ucosa( c( /seu+ouni. "ith long a&on( b( +olgi ty!e II.#e8 Ar& /arious ty!es of neuroglial cells are as follo"s8 a( . C=S lesion heals by gliosis( It re!resents the scar of the nervous tissue( . all otor and internuncial neurons( b( Bi.lassification of Neurons . the internuncial neurons BinterneuronsC are inter!osed bet"een the sensory and motor neurons( . BbC )he !ro&i al !art of the cut fibre8 So long the other cell is intact.olar neurons are !resent in the rnesence!halic nucleus of trige inal nerve and also occur during foetal life( )hese cells are ore co on in lo"er vertebrates( B( .olar neurons are confined to the first neuron of the retina. a tract after de yelination can re yelinate.n involuntary otor res!onse to a sensory 3 sti ulus is 'no"n as the refle& action( 0nly cortical3 res!onses are voluntary in nature( . into t"o ty!es( a( +olgi ty!e I.( .&is cylinder beco es frag entedD yelin sheath brea's u! into fat dro!letsD and the nuclei of Sch"ann cells ulti!ly and fill u! the neurile al tube( During regeneration. s!ontaneous gliosis is an indication of a degenerative change in the nervous . B onosyna!tic refle& arcC it consists of8 BaC a rece!tor. it ust be re e bered that each neuron is an inde!endent unit and the contact bet"een neurons is by contiguity and not by continuity B*neuron theory* of Ealdeyer.ccording to the length of a&on.ccording to the nu ber of their !rocesses. therefore.olar neurons are actually uni!olar to begin "ith but beco e bi!olar functionally and are found in dorsal nerve root ganglia and sensory ganglia of the cranial nerves( d( -ni. and only a !art near the cut end degenerates in a "ay si ilar to the distal !art. tract cannot regenerate because it has no such sheath( <o"ever.

hidden 62 the cere6ru5. and then the !ostganglionic fibres !ass to the effectors( )he ain !arts and their subdivisions are sho"n in )able F1(1 B1ig( F1(FC( )he brainste includes the idbrain. 2rai" Parts $ubdivision s A3 9elencephalon Gcere6ru5H. including the pineal 6od2. su6stantia nigra. and tectu5.9= Parts o. 4ro5 6e4ore 6ac!1ards A3 B3 Metencephalon. the cavity of se!tu !ellucidu is so eti es called as the fifth ventricle( Ta2#e (9.Peripheral Nervous $ystem 1(So Parts o. ha6enular trigone and posterior co55issure e3 -u6thala5us !avity "3 Jore6rain GprosencephalonH Lateral 7entricle B3 9hird 7entricle "3Mid6rain G5esencephalonH Crus cere6ri. Brai" atic Bcerebros!inalC nervous syste ( It is ade u! of 1F !airs of cranial nerves and :1 !airs of s!inal nerves( Its efferent fibres reach the effectors "ithout interru!tion( F(. including the 5edial and lateral geniculate 6odies. !ons and edulla( <indbrain includes !ons. 5ade up o4 t1o cere6ral he5ispheres and the 5edian part in 4ront o4 the inter7entricular 4ora5en Diencephalon Gthala5encephalonH. 5ade up o4 pons and cere6ellu5 M2elencephalon or 5edulla o6longata Cere6ral a8ueduct =3Hind6rain Grho56encephalonH Jourth 7entricle Cere6ral a8ueduct Jourth 7entricle Central canal Lateral 7entricle /nter7entricular 4ora5en 9hird 7entricle . consists o4@ a3 9hala5us 63 H2pothala5us c3 Metathala5us. teg5entu5. edulla and cerebellu ( )he dilated !art of the central canal of s!inal cord "ithin the conus edullaris is 'no"n as the ter inal ventricle( Si ilarly.utono ic Bs!lanchnicC nervous syste ( It consists of sy !athetic and !arasy !athetic syste s( Its efferent fibres first relay in a ganglion. and d3 Epithala5us.

Cere6ellu5 Medulla o6longata Fig. Diencephalon % Mid6rain .<: Parts of brain.CC Cere2ru* % <ons . <%.

it ay be reca!itulated that it is ade u! of t"o layers. "ith the e&ce!tion of the ste of the lateral sulcus( It cannot be identified in the hy!o!hyseal fossa( 7elations It is se!arated fro the dura by the subdural s!ace.Meninges o4 the Brain and Cere6rospinal Jluid )he central nervous syste is highly !rotected d safely secured in the cranial cavity( Its security is enhanced by the three eninges and fluid layers bet"een the ( So the brain al ost floats in the cerebros!inal fluid "ithout !utting 6its "eight6 on the nec'( )he outer ost enin&. and fro the !ia by the subarachnoid s!ace containing cerebros!inal fluid BCS1C( Prolon*ations 1(It )he brain is a very i !ortant but delicate organ( It is !rotected by the follo"ing coverings( 1(Bony covering of the craniu ( F()hree e branous coverings B eningesC8 BaC )he outer dura ater B!achy enin&CD BbC the iddle arachnoid aterD and BcC the inner !ia ater( )he arachnoid and !ia are together 'no"n as the le!to eninges( :()he cerebros!inal fluid fills the s!ace bet"een the arachnoid and the !ia Bsubarachnoid s!aceC and acts as a "ater cushion( !rovides sheaths for the cranial nerves as far as their e&it fro the s'ull( F(. but also !artitions the cerebru fro cerebellu and hy!o!hysis cerebri( In addition. fingerli'e !rocesses of arachnoid tissue. enclosing the cranial venous sinuses bet"een the t"o( )he eningeal layer for s four folds "hich divide the cranial cavity into interco unicating co !art ents for different !arts of the brain B)able FF(1C( )he !ia ater is a thin vascular e brane "hich closely invests the brain. called arachnoid granulations( )hese granulations ay !roduce de!ressions in bone( PIA MATER DURA MATER )he cerebral dura ater has been studied in detail "ith the head and nec' in Cha!ter 6( <o"ever. di!!ing into various sulci and other irregularities of its surface( It is better defined around the brainste ( Prolon*ations 1(It !rovides sheaths for the cranial nerves erging "ith the e!ineuriu around the ( F(It also !rovides !erivascular sheaths for the inute vessels entering and leaving the brain substance( +:+ . it encloses various venous sinuses( )he CS1 for s "atery cushions around the blood vessels to give the shoc'-free environ ent( /ntroduction ARACHNOID MATER )he arachnoid ater is a thin trans!arent e brane that loosely surrounds the brain "ithout di!!ing into its sulci( It bridges all irregularities of the brain. an outer endosteal layer and an inner eningeal layer. the dura ater not only se!arates the right and left cerebral he is!here. !ro3ecting into the cranial venous sinuses( )hey absorb CS1( Eith advancing age the arachnoid villi enlarge in si7e to for !edunculated tufts.rachnoid villi are s all.

9= The *e"i"!ea# #a6er se"$s i"<ar$s .t the base of the brain and around the brainste the subarachnoid s!ace for s interco unicating !ools.ein 2*isterna ambiens3 contains the sa e vein( 6()he *istema *hiasmatis lies belo" and in front of the o!tic chias a( . separates the right 4ro5 le4t cere6ral he5isphere /n4erior sagittal sinus -traight sinus 9entoriu5 cere6elli 9ent%shaped separates the cere6ral he5ispheres 4ro5 hind6rain and lo1er part o4 5id% 6rain Li4ts o44 the 1eight o4 occipital lo6es 4ro5 the cere6ellu5 -5all sic!le shaped 4old partl2 separating t1o cere6ellar he5ispheres -5all horiLontal 4old 9rans7erse sinuses.ontine *istern 2*istema . $ura *ater Folds $hape Attachment s -uperior. called *isterns.e+un*ular *istern 2basal *istern3) contains the circulus arteriosus Bcircle of EillisC( H()he *istern of the lateral sul*us contains the iddle cerebral artery( J()he *istern of the great *erebral . posterior to upper sur4ace o4 tentoriu5 cere6elli Has a 4ree anterior 5argin3 /ts ends are attached to anterior clinoid processes3 Rest is 4ree and conca7e3 <osterior 5argin is attached to the to the lips o4 groo7e containing trans7erse sinuses.o##o<i"! . <osterior attach5ent is to dorsu5 sellaeU laterall2 continuous 1ith dura 5ater o4 5iddle cranial 4ossa 'enous sinuses enclosed . superior petrosal sinuses Jal: cere6elli Occipital sinus Diaphrag5a sellae Anterior and posterior interca7ernous sinuses :( 1olds of !ia ater enclosing tufts of ca!illaries for the tela*horoi+ea) Such !ia ater lined by secretory e!endy a for the choroid !le&us( E>TRADURAL MEPIDURALT AND SUBDURAL SPACES Dilatations )he e&tradural or e!idural s!ace is a !otential s!ace bet"een the inner as!ect of s'ull bone and the endosteal layer of dura ater( )he subdural s!ace is also a !otential s!ace bet"een the dura and arachnoid aters( )hese beco e actual s!aces in !athological conditions( -UBARACH O/D SPACE )his is the s!ace bet"een the arachnoid and the !ia ater( It is traversed by a net"or' of arachnoid trabeculae "hich give it a s!onge-li'e a!!earance( It surrounds the brain and s!inal cord.ontis3 contains the vertebral and basilar arteries( :()he inter. superior petrosal sinuses and to posterior clinoid processes Base is attached to posterior part o4 in4erior sur4ace o4 tentoriu5 cere6elli3 Ape: reaches till 4ora5en 5agnu5 Anterior attach5ent is to tu6erculu5 sellae. -uperior sagittal sinus Jal: cere6ri -ic!le%shaped. "hich f>inyrce the !rotective 3 effect of CS1 on the vital centres situated in the edulla( )he subarachnoid cisterns are as follo"s( 1()he *erebellome+ullary*istern 2*istemamagna3 lies bet"een the edulla and the undersurface of the cerebellu ( It is utili7ed for cisternal !uncture( )he YP CS1 !asses fro the fourth ventricle to this cistern through the edian and lateral a!ertures of the fourth ventricle( F()he .o#$s o.Ta2#e ((. con7e: 5argins are attached to sides o4 the groo7e lodging the superior sagittal sinus /n4erior conca7e 5argin is 4ree3 Anterior attach5ent to crista galli. and large vessels of the brain( Cranial nerves !ass through the s!ace( . and ends belo" at the lo"er border of the second sacral vertebra( )he subarachnoid s!ace contains CS1.

second and eighth cranial nerves( DISSECTION Cut through the fused endosteu and dura ater on the ventral as!ect of brain fro the inferolateral borders e&tending along the su!erolateral argin( Pull u!"ards the endosteu along "ith the fold of dura ater !resent bet"een the ad3acent edial surfaces of cerebral he is!heres. Formation bul' of the CS1 is for ed by the choroid !le&uses of the lateral ventricles. FF(FC( /nter7entricular 4ora5en 1( )he s!ace is !rolonged into the arachnoid sheaths around nerves "here it co unicates "ith the neural ly !hatics. !articularly around the first.nderneath the dura ater and se!arated by a fli sy subdural s!ace is the cob"eb li'e arachnoid ater( It is se!arated fro the underlying !ia ater by the subarachnoid s!ace.. e&tending fro the frontal lobe till the occi!ital lobe( )his is fal& cerebri( Pull bac'"ards a si ilar but uch s aller fold bet"een t"o ad3acent lobes of cerebellu M the fal& cerebelli( Se!arating the cerebru and the cerebellu is another fold of dura ater called the tentoriu cerebelli( Pull it on a hori7ontal !lane( )hus the fused endosteu and dura ater get se!arated fro the underlying subarachnoid ater. and lesser a ounts by the choroid !le&uses of the third and fourth ventricles( F(Possibly. !ia ater and the brain( Identify various venous sinuses bet"een the endosteu and folds of dura ater( . it is also for ed by the ca!illaries on the surface of the brain and s!inal cord( )he total %uantity of CS1 is about 1JG l( It is for ed at the rate of about FGG l !er hour or JGGG l !er day( )he nor al !ressure of CS1 is 6G to 1GG of CS1 Bor of "aterC( !irculation 1()he CS1 !asses fro each lateral ventricle to the third ventricle through the interventricular fora en Bof #onroC( 1ro the third ventricle it !asses to the fourth ventricle through the cerebral a%ueduct( 1ro the fourth ventricle the CS1 !asses to the subarachnoid s!ace through the edian and lateral a!ertures of the fourth ventricle B)able FF(FC( Absorption I) CS1 is absorbed chiefly through the arachnoid villi and granulations. containing cerebros!inal fluid and blood vessels of the brain( Cranial nerves also !ass through this s!ace( =ear the su!erior sagittal sinus.Meninges and C-J 3>' )he arterial !ulsations "ithin the cisterns hel! to force the CS1 fro the cisterns on to the surface of the he is!heres( )he cisterns the selves for cushions around the edulla( !ommunications F( )he s!ace also e&tends into the !ial sheaths around the vessels entering the brain substance B!erivascular s!aceC( )hus CS1 co es into direct contact "ith nerve cells( CEREBROSPINAL FLUID MCSFT )he subarachnoid s!ace co unicates "ith the ventricular syste of the brain at8 BaC . situated in the roof of the fourth ventricle( )he CS1 !asses through these fora ina fro the fourth ventricle to the subarachnoid s!ace B1ig( FA(FC( Prolongations )he cerebros!inal fluid is a odified tissue fluid( It is contained in the ventricular syste of the brain and in the subarachnoid s!ace around the brain and s!inal cord( CS1 re!laces ly !h in the C=S B1igs FF(1. and is thus drained into the cranial venous sinuses( . <<.%: 5ateral view of the ventricular system. edian fora en Bof #agendieCD and BbC t"o lateral fora ina Bof @usch'aC. Central canal Fig. arachnoid ater for s arachnoid villi( )he subarachnoid s!ace is dilated around the brainste and at the base of the brain for ing the subarachnoid cisterns( Cerebros!inal fluid for ed and flo"s through the ventricles of the brain into the subarachnoid s!ace to be absorbed via subarachnoid villi into the su!erior sagittal sinus( Lateral 7entricle P3PPPP Cere6ral a8ueduct 9hird 7entricle Jourth 7entricle *.

<<.<: !irculation of cerebrospinal fluid.Le4t lateral 7entricle Right lateral 7entricle 9hird 7entricle /nter7enticular 4ora5en Jourth 7entricle Median aperture Central canal <ia 5ater % L= 7erte6ra Epidural space Arachnoid -u6arachnoid space Fig. .

second and eighth cranial nerves( F(It is also absorbed by veins related to s!inal nerves( Functions CLINICAL ANATOM 1(CS1 can be obtained by8 BaC @u It is BaC !rotective.1(It is also absorbed !artly by the !erineural ly !hatics around the first. BbC nutritive. and BcC a !ath"ay for etabolites fro the C=S( bar !unctureD BbC cisternal !unctureD or BcC ventricular !uncture( @u bar !uncture is the easiest ethod and is co only used( It is done by !assing a needle in the inters!ace bet"een the third and fourth lu bar s!ines( F(Bioche ical analysis of CS1 is of diagnostic value in various diseases( .

and its s!ontaneous coagulation after "ithdra"al due to a high !rotein content( Bioche ical e&a ination of such fluid reveals that the !rotein content is raised. and raised intracranial !ressure in adults( 1(Drainage of CS1 at regular intervals is of thera!eutic value in eningitis( Certain intractable headaches of un'no"n aetiology are also 'no"n to have been cured by a ere lu bar !uncture "ith drainage of CS1( F(0bstruction in the vertebral canal !roduces 5roin's syn+rome or lo*ulation syn+rome) )his is characteri7ed by yello"ish discolouration of CS1 B&anthochro iaC belo" the level of obstruction.halus in children.#ui$ MCSFT Formation: !irculation : Lateral 7entricles / /nter7entricular 4ora5ina / /llrd 7entricle / A8ueduct o4 5id6rain /Vth 7entricle // 3 apertures in roo4 O one 5edian / t1o lateral open in / / O cere6ello%5edullar2 cisterns and pontine cisterns / 9entorial -u6arachnoid space notch around spinal cord / /n4erior sur4ace and cauda e8uina o4 cere6ru5 / Veins o4 spinal / -uperolateral cord sur4ace o4 cere6ru5 / Arachnoid granulations " A6sorption into / -uperior sagittal sinus Central canal o4 spinal cord . but the cell content is nor al( )his is 'no"n as albumino& *ytologi* +isso*iation) Ta2#e ((.(= Cere2ros%i"a# .sninges and C-J :( 0bstruction to the flo" of CS1 in the ventri cular syste of the brain leads to hy+ro*e.

the cord !resents t"o thic'enings. or the u!!er border of vertebra @F( It is about HJ c long( )he lo"er end is conical and is called the *onus me+ullaris) )he a!e& of the conus is continued do"n as the filum terminals) . it is i !ortant to re e ber that a vertebral s!ine is al"ays lo9er than the corres!onding s!inal seg ent( . the grey atter is divisible into8 BlC)he anterior grey *olumn Bor hornC. res!onsible for establishing contacts bet"een the brain in the cranial cavity and the !eri!heral end organs( )he descending and ascending tracts course through the s!inal cord( It is a centre for refle& activities( Mre$u&tio" )he s!inal cord is the lo"er elongated.i*al an+ lumbar enlargements.9he -pinal Cord S!inal cord is the lo"er !art of central nervous syste . "hich give rise to large nerves for the li bs( )he s!inal cord gives off :1 !airs of s!inal nerves( . cylindrical !art of the C=S( It occu!ies the u!!er t"o-thirds of the vertebral canal( It e&tends fro the level of the u!!er border of the atlas to the lo"er border of I vertebra @I. the *er. the s!inal seg ents do not lie o!!osite the corres!onding vertebrae( In esti ating the !osition of a s!inal seg ent in relation to the surface of the body. and BFC the .long its length.s a rough guide it ay be stated that in the cervical region there is a difference of one seg entD in the u!!er thoracic region there is a difference of t"o seg entsD and in the lo"er thoracic region there is a difference of three seg ents B1ig( F:(1C( Internal Structure Ehen seen in transverse section the grey atter of the s!inal cord for s an <-sha!ed ass( In each half of the cord.s the s!inal cord is uch shorter than the length of the vertebral colu n.

in front by a dee! anterior me+ian fissure8 and behind by the .osterior 9hite *olumn or !osterior funiculusD BiiC the lateral 9hite *olumn or lateral funiculusD and BiiiC the anterior 9hite *olumn or anterior funiculus( )he "hite atter of the right and left sides is continuous across the idline through the "hite co issure "hich lies anterior to the grey co issure B1ig( F:(FC( )he s!inal cord gives attach ent. on either side. lateral being visceral efferent and afferent in function. the head and a dorsal !art.osterior grey *olumn Bor hornC( In so e !arts of the s!inal cord. and !osterior is sensory in function( Nuclei in Anterior .rey !olumn or 4orn )he anterior horn is divided into a ventral !art. the "hite atter is divided into8 BiC )he . a s all lateral grey *olumn is also !resent( )he grey atter of the right and left halves of the s!inal cord is connected across the idline by the grey co issure "hich is traversed by the central canal( )he "hite atter of the s!inal cord is divisible into right and left halves.osterior me+ian se.inal segment) Nuclei of Spinal . the base( )he nuclei in anterior horn innervate the s'eletal uscles( )he cells in the anterior horn are arranged in the follo"ing three ain grou!s( +:7 .tum) In each half.nterior is otor.ord )he grey atter of s!inal cord is arranged in three horns( .nterior Bor ventralCD and BiiC !osterior Bor dorsalC( 2ach root is ade u! of a nu ber of rootlets( )he length of the s!inal cord giving origin to the rootlets for one !air of s!inal nerves constitutes one s.. to a series of s!inal nerves( 2ach s!inal nerve arises by t"o roots8 BiC .

. starting at the ti! of the dorsal horn and oving ventrally into ventral horn B1ig( F:(HC( Postero*ar!i"a# "u&#eus Su2sta"tia !e#ati"osa Nu&#eus %ro%rius Dorsa# "u&#eus I"ter*e$io*e$ia# "u&#eus 1e"tro*e$#a# PostC%ostero#atera# . "!ourtesy: .rius7 It lies sub3acent to the substantia gelatinosa throughout the entire e&tent of cord( It is concerned "ith sensory associative echanis ( BivC =ucleus dorsalis also 'no"n as thoracic nucleus at the edial !art of base of !osterior horn e&tending fro C4 to @: seg ents( It is a relay nuclear colu n for refle& or unconscious !ro!rioce!tive i !ulses to the cerebellu and its a&ons give rise to the !osterior s!inocerebellar tract( 9a6inar Or*anisation in Spinal .(= .ord < h i te / 6 . Phre"i& D A&&essor6 'E I"ter*e$io *e$ia# "u&#eus Ce"tra# &a"a# Fi*+ &'+': Nuclei in the grey matter of spinal cord.ro. Vaul and &ahl: 2e t &ook of Neuroanatomy. !&$ Publishers and 9istributors.rey !olumn 6fferent nu*lear grou. s!inal cord neurons a!!ear to have a la inar BlayeredC arrange ent( )en layers of neurons are recognised. <nd edition. &o#u*" BcC Central grou. Postera#atera# +++ Anteroiateral C.e&ed( )hese are nu bered consecutively by .o an nu erals..9"nal 1 <osterior !re6 &o#u*" Posterior <hite &o#u*" Dr !re6 &o#u*" @@ @@ C A " t e r i o r B5C Latera# <hite &o#u*" (+.7 0nly in u!!er cervical seg ents as !hrenic nerve nucleus and nucleus of s!inal root of accessory nerve( Nuclei in 5ateral 4orn =uclei iri @ateral horn are as follo"s8 BaC Interme+iolateral nu*leus7 )his acts as both efferent and afferent nuclear colu ns( )his nucleus is seen at t"o levels( ( BiC 1ro )l to @F seg ents.nternal structure of spinal Nuclei in Posterior . 'no"n also as @a inae of . *olumn7 )he four ain afferent nuclei are seen in this are8 BiC /osteromarginal nu*leus7 )hin layer of neurons ca!s the !osterior horn( It receives so e of inco ing dorsal root fibres( BiiC <ubstantia gelatinosa7 )his is found at the ti! of !osterior horn through the entire e&tent of s!inal cord( It acts as a relay station for !ain and te !erature fibres and is concerned "ith sensory associative echanis ( Its a&ons give rise to the lateral s!inothala ic tract( BiiiC Iu*leus .i!.t these t"o levels.arg. New 9elhi#. giving rise to !reganglionic sy !athetic fibres Bthoracolu bar outflo"C( BiiC 1ro SF to SH seg ents giving rise to !reganglionic !arasy !athetic fibres chiefly for the !elvic viscera( . cord. the inter ediolateral cell colu n receives visceral afferent fibres( BbC Interme+iome+ial nu*leus7 )his is ostly internuncial neuronal colu n( In thic' sections.

neuroglia and so e neurons in the grey atter surrounding central canal that have !ro!erties of interneurons( DISSECTION Study the s!inal cord after it "as re oved fro vertebral canal and se!arated fro the dura ater and arachnoid ater( Identify the dorsal root due to the !resence of dorsal root ganglion or s!inal ganglion( =ote the !osition of cervical enlarge ent in the u!!er !art and lu bosacral enlarge ent in the lo"er !art( See the nu erous nerve roots surrounding the filu ter inale for ing the cauda e%uina( Cut transverse sections of s!inal cord at cervical. thoracic.tors7 )hese res!ond to sti uli in dee!er tissues that is contraction of uscles. S: and SH( 0amina =III7 Corres!onds to ventral horn in thoracic seg ents but at the level of li b enlargeents of s!inal cord.arg.+9( Brai" A > La*i"a Fi*+ &'+4: 5aminar organisation in the spinal cord. New 9elhi#. 0amina I7 Corres!onds to !ostero arginal nucleus( 0amina II7 Corres!onds to the substantia gelatinosa( 0aminae HI and I/8 Corres!ond to nucleus !ro!rius( 0aminae = an+ =I7 Corres!ond to base of dorsal colu n( 0amina =II7 0ccu!ies the territory bet"een dorsal and ventral horns( )his la ina contains any cells that function as interneurons( )hree clear cells colu ns are recognised "ithin this la ina( )hese are inter ediolateral.rio*e. it lies on the edial as!ect of ventral horn( 0amina IV7 Includes the lateral grou! of nuclei of the ventral horn( )he a&ons of these neurons leave the s!inal cord to su!!ly the striated or s'eletal uscles of li bs( 0amina V7 Surrounds the central canal( It is co !osed of decussating a&ons. <nd edition. lu bar. Vaul and &ahl: 2e t &ook of Neuroanatomy. and sacral regions to note the sha!e and si7e of the horns in relation to "hite atter B)able F:(1C( Sensory 7eceptors )he !eri!heral endings of afferent fibres "hich receive i !ulses are 'no"n as rece!tors( 5un*tional *lassifi*ation7 BiC Fxtero*e. . that is !ain. te !erature. !&$ Publishers and 9istributors. "!ourtesy: . inter edio edial and nucleus dorsalis Bnucleus thoracis or Clar'e*s colu nC( =ucleus dorsalis is !resent on the edial as!ect of dorsal horn fro C4 to @: seg ents( )he sacral autono ic nucleus is an incons!icuous colu n of cells in the lateral !art of la ina /II in seg ents SF. touch and !ressure( BiiC /ro.tors7 )hese res!ond to sti uli fro e&ternal environ ent.

( )he !yra idal or *ortl*os. gland. hearing. !osition and !ressure related to 3oints( )hese are res!onsible for coordination of uscles.9= Sha%e o.inal tra*t descends fro the cerebral corte& to the s!inal cord( It consists of t"o !arts8 1()he lateral corticos!ina3 tract.e*ial sense re*e.estibulos.ere"t se!*e"ts o.. :( )he me+ial an+ lateral reti*ulos. collection of nerve fibres that connects t"o asses of grey atter "ithin the central nervous syste is called a tract( )racts ay be ascending or descending( )hey are usually na ed after the asses of grey atter connected by the ( So e tracts are called fasciculi or le nisci( . blood vessels and s!ecialised structures in the carotid sinus.os. s%i"a# &or$ Posterior 4orn . s ell and taste( TRACTS OF THE SPINAL CORD )he follo"ing tracts are seen in a transverse section through the s!inal cord( )heir location should be identified in B1igs F:(J. hor"s i" $i.S%i"a# Cor$ J+9+ Ta2#e (+. carotid bodies and os orece!tors( BivC <.inal tra*t) Si Le! Ru2ros%i"a# tra&t O#i5os%i"a# tra&t 1esti2u#os%i"a# tra&t Latera# &orti& LZ T1 Tru"Tru". aintenance of body !osture and e%uilibriu ( )hese actions are !erceived at unconscious level( BiiiC Intero*e. $egments of spinal cord 5ateral 4orn Anterior 4orn Cer7ical -lender A6sent Broad in C '%& seg5ents 4or suppl2 o4 upper li56s -lender 9horacic Lu56ar -lender <resent 4or thoraco% lu56ar out4lo1 Bul6ous <resent onl2 in lu56ar "%= seg5ents <resent in sacral =%? seg5ents 4or sacral out4lo1 -acral 9hic! Bul6ous 4or suppl2 o4 lo1er li56s Bul6ous 4or suppl2 o4 lo1er li56s ove ents.inal tra*t) F()he .inal tra*t) :()he te*tos.tors7 )hese are concerned "ith vision.tors7 )hese include rece!tor end-organs in the "alls of viscera. "hich lies in the lateral funiculusD and F()he anterior corticos!inal tract "hich lies in the anterior funiculus B1ig( :G(1C( B( 2&tra!yra idal tracts( )hese are8 1( )he rubros. F:(6C( Des&e"$i"! Tra&ts .inal tra*ts) 1()he oli.D .Ar* %%%%%%%%VO /nterseg .tors/Fntero*e.inal tra*t) F.

<). <nd edition. "!ourtesy: . !&$ Publishers and 9istributors. . New 9elhi#.Dorso#atera# tra&t &orti&os%i"a# Reti&u#os%i"a# A"terior Te&tos%i"a# tra&t Fig. Vaul and &ahl: 2e t &ook of Neuroanatomy.arg.+: 9escending tracts of spinal cord.

:( Beti*ulos.arg. New 9elhi#. idbrain. <ressure.t the lo"er level of edulla oblongata 4G5 of fibres cross to the o!!osite side( )his is 'no"n as !yra idal decussation( )he fibres that have crossed enter lateral colu n of "hite atter of s!inal cord and descend as lateral corticos!inal tract( #ost of these fibres ter inate by syna!sing through the internuncial neurons at the anterior horn cells B1ig( :G(1C( )he FG5 of fibres that do not cross enter anterior "hite colu n of s!inal cord to for anterior BiC )he cerebral corte& controls voluntary oveents of o!!osite half of body through anterior horn cells( BiiC Influence of this tract is su!!osed to be facilitatory for fle&ors and inhibitory for e&tensors. As&e"$i"! Tra&ts 1(@ateral s!inothala ic tract B1ig( F:(6C( F(.inal tra*t7 )his tract is for ed by the a&ons of red nucleus.Deep touch. Vi6ration.nterior s!inothala ic tract B1ig( F:(AC( :(1asciculus gracilis B ediallyC H(1asciculus cuneatus BlaterallyC B1ig( F:(6C( J(Dorsal or !osterior s!inocerebellar tracts( 6(/entral or anterior s!inocerebellar tract A(S!ino-olivary tract( 4(S!inotectal tract( Des&e"$i"! Tra&ts corticos!inal tract( )he fibres of this tract also crossP at a!!ro!riate levels to reach grey atter of the o!!osite half of s!inal cord and syna!se "ith internuncial neurons si ilar to those of lateral corticos!inal tract B1ig( F:(JC( )hus the cerebral corte& through lateral and anterior corticos!inal tracts controls anterior horns cells of o!!osite half of s!inal cord B)able F:(FC( Functional $ignificance Pyra6idal or .orticospinal Tract )he !yra idal or corticos!inal tract is for ed by the a&ons of !yra idal cells !redo inantly lying in the otor area of cerebral corte&( )here is so e contribution to it fro a&on of cells in !re otor area( 1ro here the fibres course through the !osterior li b of internal ca!sule. Mo7e5ent. <nd edition. 3 E)trapyra6idal Tracts ") Bubros.inal tra*ts7 )he edial reticulos!inal tract is for ed by the fibres fro reticular for ation in !ons and descends to the cervical seg ents only( It lies in the anterior "hite colu n . s%i"o&ere2e##ar tra&t I"terse!*e"ta# tra&t S%i"otha#a*i& tra&ts Fi*+ &'+ : Ascending tracts in spinal cord. !ons and edulla oblongata( . situated in the idbrain( )he fibres cross "ith the fibres of the o!!osite side in the teg entu of idbrainD thus constituting the ventral teg ental decussation( )he tract descends through the !ons and edulla oblongata and enters the lateral "hite colu n of s!inal cord( )he fibres ter inate by syna!sing through internuncial neurons "ith anterior horn cells( F. <osition B Fas&i&u#us !ra&i#is Dorso#atera# tra&t B ACCCCCCCCCCCCCC Fas&i&u#us &u"eatus B Posterior s%i"o&ere2e##ar tra&t CC Latera# s%i"otha#a*i& tra&t A"terior s%i"otha#a*i& tra&t B DCCCCCC 1CCCCCCCCCC A"terior . "!ourtesy: . !&$ Publishe/ and 9istributors. Vaul and &ahl: 2e t &ook of Neuroanatomy.

descend to s!inal cord.os. to C' B=3 Medial reticulo% spinal E:trap2ra5idal tract Uncrossed 5ainl2 C" to -' Reticular 4or5a% tion o4 gre2 5atter o4 pons Reticular 4or5ation o4 gre2 5atter o4 5edulla o6longota Anterior gre2 colu5n cells GinterneuronsH Anterior gre2 colu5n cells GinterneuronsH B33 Lateral reticulospinal E:trap2ra5idal tract Crossed C" to -' B?3 Oli7ospinal E:trap2ra5idal tract E44erent path1a2 4or e8uili6rator2 control E44erent path1a2 4or 7isual re4le:es Uncrossed C" to C' /n4erior oli7ar2 nucleus Lateral 7esti% 6ular nucleus Anterior gre2 colu5n cells Anterior gre2 colu5n cells B'3 Vesti6ulospinal Uncrossed C" to -' BA3 9ectospinal Crossed C3.ll these descendi g tracts control the voluntary ove ents of s'eletal uscles of the body through anterior horn cells( As&e"$i"! Tra&ts 1or the sensory !ath"ays the first neuron fibres al"ays start in the dorsal root ganglia "hich has !seudouni!olar cells( )he !eri!heral !rocess of these cells for the sensory fibres of !eri!heral nerves "hich carry various ty!es of sensations fro sensory .inal tra*t7 )he tract is for ed by the a&ons of neurons lying in the su!erior colliculus of the idbrain( )he fibres cross to the o!!osite side thus for ing dorsal teg ental decussation in idbrain( )he tract descends through !ons. to -' Motor area o4 corte: Gupper 5otor neuronsH Red nucleus o4 5id6rain Anterior gre2 colu5n alpha 5otor neurons Anterior gre2 colu5n cells B"3 Ru6rospinal E44erent path1a2 4or cere6ellu5 and corpus stratu5 Crossed C. Name Function Main 5otor tract !rossed uncrossed Crossed $pinal segment C" to -' &eginning Motor area o4 corte: Gupper neuronsH %st termination Anterior gre2 colu5n cells alpha 5otor neurons 2he Ascending 2racts A"3 Lateral corticospinal A=3 Anterior corticospinal Main 5otor tract Uncrossed C. to C' -uperior colliculus Anterior gre2 colu5n of s!inal cord( It has uncrossed fibres( )he lateral reticulos!inal tract originate fro reticular for ation in edulla olongata.Ta2#e (+. edulla and anterior "hite colu n of s!inal cord( )he fibres ter inate on the cells of anterior horn through internuncial neurons( . No. descend u!to thoracic seg ents of s!inal cord( It has both crossed and uncrossed fibres( It lies in the anterolateral "hite colu n of s!inal cord( Both the tracts ter inate by syna!sing "ith the neurons in la inae /II of the s!inal cord( 1(>li.(= The $es&e"$i"! tra&ts s.inal tra*t7 )he fibres arise fro lateral vestibular nucleus lying at !onto edullary 3unction( )he fibres descend uncrossed to s!inal cord( )his tract is situated in the anterior "hite colu n of s!inal cord( )hese fibres syna!se "ith anterior horn cells( 6( Te*tos.inal tra*t7 Its fibres originate fro the inferior olivary nucleus in edulla oblongata. lie in the anterolateral colu n of "hite atter and syna!se "ith the anterior horn cells( F(=estibulos.

inothalami* tra*t7 )his tract carries the sensation of !ain and te !erature( )he first neuron fibres start in the dorsal root ganglia( )hese relay by syna!sing "ith neurons lying in the grey atter of la ina II and III( Pain fibres relay in @a ina II Bsubstantia gelatinosa3( )he second neuron fibres cross i ediately to o!!osite side close to the central canal and ascend as tract in the lateral "hite colu n of s!inal cord( F(6nterior s.inothalami* tra*t7 )his tract carries the fibres for crude touch and !ressure( 1irst neuron fibres are in the dorsal root ganglia( )hese relay in the grey atter of !osterior horn or nucleus !ro!rius B@a inae Ill&T=J) )he second neuron fibres ascend for 1-F seg ents and cross to o!!osite side in the "hite co issure and ascend as a tract in the anterior "hite colu n of s!inal cord( )he anterior and lateral s!inothala ic tracts carry sensations fro the o!!osite half of body( )hese lie in continuity "ith each other in the anterolateral "hite colu n of s!inal cord sho"ing so atoto!ic la ination( )he sensations of !ressure. tactile localisation Bthe ability to locate e&actly the !ro!rioce!tive !art touchedC. li!e the 4inger%nose and heel%!nee tests 4or intention tre5ors Jasciculus cuneatus Dorsal spinocere6ellar Ventral spinocere6ellar eurons o4 posterior horn il . "hereas fro the thala us relayed third neuron fibres are !ro3ected to the sensory areas in the cerebral corte& B)able F:(:C( 1(0ateral s.fter relay in the nuclei second neuron fibres start and ascend to either thala us or cerebellu ( )he cerebellu finally recieves second neurons fibres. te !erature and !ain are lying edial to lateral( Pressure sensations are edial ost near I the anterior edian fissure( Cervical seg ents are facing edially and sacral seg ents face laterally( )he sensations li'e dee! touch. sense of vibration are carried by fasciculus gracilis and fasciculus cuneatus( :( 5as*i*ulus gra*ilis 2tra*t ofColl37 It co ences at the caudal li it of s!inal cord and is co !osed ainly of the long ascending branches of the edial division of fibres of dorsal nerve roots( )hese are the first order neuron fibres fro dorsal root ganglia( )hese run directly u!"ards B"ithout relaying in the s!inal grey atterC in the !osterior colu n of "hite 9a6le =333@ eurons o4 sensor2 tracts %st Lateral spinothala5ic ganglion Dorsal root <nd -u6stantia gelatinosa )rd <osterolateral 7entral nucleus o4 thala5us !linical tests " 3 <ain 1ith pin pric! =3 9e5perature 1ith hot and cold 1ater in the test tu6es "3Coint sense =3Vi6ration sense 339actile localiLation ?39actile discri5ination '3Rho56erg's test A3-tereognosis $3Crude touch &3Crude pressure Anterior spinothala5ic ucleus proprius Jasciculus gracilis ucleus gracilis in 5edulla o6longata ucleus cuneatus in 5edulla o6longata Clar!'s colu5n il All cere6ellar tests.332 end organs( )he central !rocess of the neurons in the dorsal root ganglia enter the s!inal cord through dorsal nerve root and ter inate either by syna!sing "ith cells in !osterior grey colu n of s!inal cord or at higher level in the edulla oblongata "ith the cells of nucleus gracilis and nucleus cuneatus( . !ressure. stereognosis Bability to recognise sha!e of ob3ect held in handC. touch. tactile discri ination Bthe ability to localise t"o se!arate !oints on the s'in that is touchedC.

atter of s!inal cord( . it recieves accession fro each dorsal root( )he fibres "hich enter in the coccygeal and lo"er sacral region are thrust edially by fibres "hich enter at higher levels( 1asciculus gracilis "hich contains fibres derived fro lo"er thoracic.8: E teroceptive and conscious proprioceptive impulses. lu bar.i2re First "euro" .s the tract ascends.or tou&h) %ressure) 5i2ratio") *o5e*e"t %ositio" Fi*+ <).i2re Tha#a*us Se&o"$ "euro" .i2re Lateral spinothala5ic tract or spinal le5niscus S%i"a# #e*"is&us CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC A"terior s%i"otha#a*i& tra&t Foining *e$ia# #e*"is&us i" i" 2rai" ste* Re&e%tors o. %ai") te*%erature) tou&h) %ressure Me$ia# #e*"is&usCCCCCCCCCCCCCCC Fas&i&u#us &u"eatus B Re&e%tors . . sacral and coccygeal seg ents of s!inal cord occu!ies the edial !art of !osterior colu n of u!!er !art of s!inal cord is se!arated fro fasciculus cuneatus by !ostero-inter ediate se!tu N1ig( F:(AC( H( 5as*i*ulus *uneatus 2tra*t of Bur+a*h37 It co ences in id-thoracic region( It derives its fibres fro u!!er thoracic arid cervical seg ents( B B CCCCCCCCCC B B Cere2ra# &orte8 Mse"sor6 areaT i CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC Thir$ "euro" .

Discri5inator2 touch -' to 9$ Dorsal root ganglion cells ucleus gracilis ?3 Jasciculus cuneatus Vi6rator2 sense -tereognosis Uncrossed 9. "3 Lateral spinothala5ic Function uncrossed !rossed $pinal segment C" to -' &eginning -u6stantia gelatinosa o4 posterior gre2 colu5n <osterior gre2 colu5n o4 opposite side %st termination <osterolateral 7entral nucleus o4 thala5us <ain and Crossed te5perature 4ro5 opposite hal4 o4 6od2 =3 Anterior spinothala5ic 9ouch GcrudeH Crossed and pressure 4ro5 opposite hal4 o4 6od2 C. the s%i"a# &or$ s Name No.osterior s..= The as&e"$i"! tra&ts o. to -' <osterior gre2 colu5n Dorsal and 5edial accessor2 oli7ar2 nuclei &3 -pinotectal A44erent li56 o4 re4le: 5o7e5ents o4 e2es and head to1ards source o4 sti5ulation Crossed !% to CA <osterior gre2 colu5n o4 opposite side 9ectu5 or superior colliculus o4 5id%6rain . to 9' Dorsal root ganglion cells ucleus cuneatus '3 <osterior spino% cere6ellar Unconscious Uncrossed proprioception to cere6ellu5 C" to L= 9horacic nucleus o4 posterior gre2 colu5n Ver5is o4 cere% 6ellu5 G7ia in4erior cere% 6ellar peduncleH A3 Anterior spino% cere6ellar Cere6ellu5 Crossed adFust5ents o4 5uscle tone C" to L= <osterior gre2 colu5n sa5e side Ver5is o4 cere% 6ellu5 G7ia superior cere% 6ellar peduncleH 7ia re%crossing $3 -pino%oli7ar2 <ropriocepti7e sense Uncrossed C. to -A <osterolateral 7entral nucleus o4 thala5us 33 Jasciculus gracilis Conscious Uncrossed proprioception.ino*erebellar tra*t7 ItP begins about the level of Fnd or :rd lu bar seg ent of s!inal cord( )he first neuron fibres are the central !rocesses of dorsal root ganglia( )hese relay in the dorsal nucleus Bthoracic or Clar'*s colu nC "hich lies on the edial side of the base of !osterior grey colu n in seg ents( )his relay gives rise to second Ta2#e (+. situated in the edulla oblogata fro "here second neuron fibres ta'e origin( )he refle& !ro!rioce!tive sensations are carried by dorsal and ventral s!inocerebellar tracts( )hey convey to the cerebellu both e&teroce!tive BtouchC and unconscious !ro!rioce!tive i !ulses arising in +olgi tendon organ and uscle s!indle and are essential for the control of !osture B)able F:(HC( J( Dorsal or .Both fasciculi contain first neuron fibres fro central !rocess of dorsal root ganglia and end by syna!sing "ith the neurons in nucleus gracilis and nucleus cuneatus.

!osterior and lateral colu ns of "hite atter of s!inal cord ad3acent to the s!inal cord( Ventral or anterior spinocere6ellar tract passes o7er superior cere6ellar peduncle A44erent 4i6res to cere6ellu5 O%%%%%%% Cere6ellu5 PPPPP Dorsal or posterior spinocere6ellar tract passing through in4erior cere6ellar peduncle %%%%% -econd neuron 4i6res -econd neuron 4i6res S O Jirst neuron 4i6res .neuron fibres "hich for dorsal s!inocerebellar tract( )his uncrossed tract ascends in the lateral colu n of "hite atter of s!inal cord( <ere it is situated as a flattened band at the !osterior region of lateral colu n. "hile the dorsal tract receives infor ation fro trun' and lo"er li bs( A. edially in contact "ith lateral corticos!inal tract( It ascends to the level of edulla oblongata "here its fibres !ass through inferior cerebellar !eduncle to reach the cerebellu B1ig( F:(4C( 6( =entral or anterior s. very fe" fro the i!silateral side( )hese ascend in the lateral "hite colu n of s!inal cord anterior to the fibres of dorsal s!inocerebellar tract to !ass through the edulla oblongata and !ons( )hese fibres finally curve along lateral as!ect of su!erior cerebellar !eduncle. /IC in the lu bar and sacral seg ents( )he second neuron fibres are fro o!!osite side ainly. and recross in the inferior cerebellar co issure to regain their original site of origin( 1unctionally. 4( )he other ascending tracts the s!ino-olivary and s!inotectal. Intersegmental tra*ts7 )hese are for ed of fibres connecting various seg ents of s!inal cord( )hese are !resent in anterior. are res!onsible for visual and !ro!rioce!tive refle&es( .ino*erebellar tra*t7 )he first neuron fibres are the central !rocesses of dorsal root ganglia( )he second neuron fibres are derived fro the large cells of !osterior grey colu n Bla inae /. both s!inocerebellar tracts control the coordination and ove ents of uscles controlling !osture of the body( )he ventral tract conveys uscle and 3oint infor ation fro both u!!er and lo"er li bs.

Fig. <). .1: Path of dorsal and ventral spinocerebellar tracts.

+(: Brai" CLINICAL ANATOM <yringomyelia 7 It is the condition in "hich there is dilatation of central canal of s!inal cord usually beginning in cervical region( Decussating fibres for !ain and te !erature in the grey co issure are interru!ted( )his leads to bilateral loss of !ain and te !erature in the affected region( But touch and !ro!rioce!tion is !resent( )hus !atient has dissociation of sensory loss( .sually the !atient gets severe infections in the fingers due to uncared cuts and bruises( /oliomyelitis 7 It is a viral disease "hich involves anterior horn cells leading to flaccid !aralysis of the affected seg ents( It is lo"er otor neuron !aralysis( 1ollo"ing is the co !arison bet"een u!!er otor neuron and lo"er otor neuron !aralysis8 LMN Para#6sis Muscle tone a6olished Leads to 4laccid paral2sis Muscles atrop2 later UMN Para#6sis Muscle tone increased Leads to spastic paral2sis o atroph2 o4 5uscles 9endon re4le:es e:aggerated E:tensi7e da5age Reaction o4 degeneration seen Reaction o4 degeneration not seen 9endon re4le:es a6sent Li5ited da5age .

nteriorly.yrami+) )he !yra id is ade u! of corticos!inal fibres( In the . to the vallecula of the cerebellu ( . the edulla occu!ies the infratentorial s!ace( E8ter"a# Features 1()he edulla is divided into right and left halves by the anterior and !osterior edian fissures( 2ach half is further divided into anterior. bundle of fibres curving around the lo"er edge of the olive is the *ir*umoli.yrami+al +e*ussation) 1(So e fibres run transversely across the u!!er !art of the !yra id( )hese are the anterior external ar*uate fibres) F()he u!!er !art of the lateral region sho"s an oval elevation. vagus. behind the olive( J()he !osterolateral region lies bet"een the !osterolateral sulcus and the !osterior edian fissure( )he u!!er !art of this region is ar'ed by a /-sha!ed de!ression "hich is the lo"er !art of the floor of the fourth ventricle( Belo" the floor "e see three longitudinal elevations( 1ro edial to lateral side these are the fasciculus gracilis. it is related to the clivus and eningesD and !osteriorly.9he Brainste5 )he brainste connects the s!inal cord to cerebru ( )he various ascending and descending tracts !ass through the three co !onents of the brainste ( #edulla contains the res!iratory and vaso otor centers( In hanging or ca!ital !unish ent.ary nu*leus) . accessory and hy!oglossal nerves( )he brainste consists of the edulla oblongata.e) A()he edulla is divided in t"o !arts8 )he lo"er *lose+ .art "ith a central canalD and the u!!er o. e&tending do"n to the fora en agnu ( . abducent.long "ith other !arts of the hindbrain. there is another elevation the tuber*inerium lateral to the fasciculus cuneatus( It is !roduced by a ass of grey atter called the s. the dens of a&is brea's and stri'es on these centers causing i ediate death( #idbrain contains nuclei of oculo otor and trochlear nerves( Pons has the nuclei of trige inal. the fasciculus cuneatus and the inferior cerebellar !eduncle( )he u!!er ends of the fasciculus gracilis and fasciculus cuneatus e&!and to for the gra*ile an+ *uneate tuber*les) )hese tubercles are for ed by underlying asses of grey atter called the nu*leus gra*ilis and nu*leus *uneatus B1ig( FH(FC( 6(In the lo"er !art of the edulla. i(e( glosso!haryngeal. facial and statoacoustic nerves "hile edulla houses the nuclei of last four cranial nerves.art "here the central canal o!ens out to for the fourth ventricle( THE MEDULLA OBLONIATAAAAAAAAAA )he edulla is the lo"est !art of the brainste . lateral and !osterior regions by the anterolateral and !oste-rolateral sulci B1ig( FH(1C( F()he anterior region is in the for of a longitudinal elevation called the . any fibres of the right and left !yra ids cross in the idline for ing the .inal nu*leus of the trigeminal ner. the !ons and the idbrain( lo"er !art of the edulla.en . the olive( It is !roduced by an underlying ass of grey ater called the inferior oli.ary bun+le) :()he rootlets of the hy!oglossal nerve e erge fro the anterolateral sulcus bet"een the !yra id and the olive( H()he rootlets of the cranial nerves IO and O and of the cranial !art of the accessory nerve e erge through the !osterolateral fissure. e&tending fro the lo"er border of the !ons to a !lane 3ust above the first cervical nerve "here it is continuous "ith the s!inal cord( It lies in the anterior !art of the !osterior cranial fossa.

+(9 .

<6. Cuneate tu6ercle%%%%%% "PPPL 0racile tu6ercle%%%%%%% A O S O O6e:%%%%%% I*D>*>* > .<: $urface features of the brainstem as seen from behind. -uperior colliculus Middle cere6ellar peduncle /n4erior 6rachiu5 /n4erior colliculus Median O Anterolateral sulcus Oli7e e5inence Jacial PRS PPP Vesti6ular area colliculus <2ra5id A6ducent ner7e Jacial ner7e Vesti6ulocochlear ner7e % % lit er7us inter5edius%%%%%%%%%%%% 0lossophar2ngeal ner7e%%%%%%% H2pogiossal ner7e O%P Vagus ner7e%%%%%%% Accessor2 ner7e%%%%%%%% 9rochlear ner7e R -uperior cere6ellar peduncle Middle cere6ellar peduncle /n4erior cere6ellar peduncle -triae 5edullares H2pogiossal triangle Vagal triangle Jasciculus gracilis Jasciculus cuneatus Fig.%: $urface features of the 9rige5inal ner7e brainstem as seen from the front.3== U Brain Colliculi Oculo5otor ner7e ` -u6stantia nlgra <2ra5idal 9rochlear ner7e E% C5s cere6ri decussation Fig. <6.

e ove the s all blood vessels and !ia ater fro the edulla oblongata( Identify its dorsal and ventral surfaces including the attach ents of cranial nerves IO-OII( )he internal structure of edulla oblongata is studied by a'ing sections at the level of8 BaC Pyra idal decussationD BbC sensory decussationD and BcC inferior cerebellar !eduncles( Identify the conve& basilar or ventral surface of !ons "ith the basilar sulcus lodging the basilar artery( Its dorsal surface is overla!!ed by the cerebellu ( )he structure of the basilar !art of !ons is si ilar in its "hole e&tent( )he structure of dorsal or teg ental !art is different in the lo"er and u!!er !art( #a'e sections through the !ons in its u!!er and lo"er !arts and identify its various nuclei and fibre co !onents( #idbrain is the highest !art of the brainste ( Identify the four s"ellings on its dorsal surface( )hese are a !air of inferior and a !air of su!erior colliculi( De arcate the subdivisions of the idbrain( #a'e one transverse section through the idbrain at the level of inferior colliculus and another at the level of su!erior colliculus( )ry to identify fe" !arts of grey and "hite atters( TransAerse Section throu*h the 9oGer Part of the .rey /atter 1()he decussating !yra idal fibres se!arate the anterior horn fro the central grey atter( )he se..% ucleus o4 spinal tract o4 trige5inal ner7e .arate+ anterior horn for s the s!inal nucleus of the accessory nerve laterally and the su!ras!inal nucleus for otor fibres of the first cervical nerve edially( F()he central grey atter B"ith the central canalC is !ushed bac'"ards( :()he nucleus gracilis and the nucleus cuneatus are continuous "ith the central grey atter( H(@aterally. bundle of fibres overlying this nucleus for s the s!inal tract of the trige inal nerve( Jhite /atter /nternal -tructure )he internal structure of the edulla can be studied conveniently by e&a ining transverse sections through it at three levels( 1()he !yra ids. the central grey atter is continuous "ith the nucleus of the s!inal tract of the trige inal nerve( . anteriorly( F()he decussation of the !yra idal tracts for s the ost i !ortant features of the edulla at this level( )he fibres of each !yra id run bac'"ards and laterally to reach the lateral "hite colu n of the s!inal cord "here they for the lateral corticos!inal tract( :()he fasciculus gracilis and the fasciculus cuneatus occu!y the broad !osterior "hite colu n( ucleus gracilis ucleus cuneatus -pinal tract o4 trige5inal ner7e Jasciculus gracilis Jasciculus cuneatus .edulla Passin* throu*h the Pyra6idal Decussation It rese bles a transverse section of the s!inal cord in having the sa e three funiculi and the sa e tracts( Identify the follo"ing in 1ig( FH(:( .

=.): 2ransverse section of medulla oblongata at the level of pyramidal decussation. .BIO Lateral cortico%spinal tract Dorsal%%%%%%%% and 7entral spinocere6ellar tracts%%%%%%%%%% R I -pinal nucleus o4 accessor2 ner7e Lateral spinothala5ic tract 0re2 5atter o4 anterior ho5 separated 4ro5 central gre2 5atter Corticospinal 4i6res G1ithin p2ra5idH <2ra5idal decussation '' Fig. "st cer7ical ner7e nucleus <6.

oglossal nu*leus.es!iratory centre 1()he nuclei of several cranial nerves are seen in are uch larger and are se!arate fro the central grey atter( )he fasciculus gracilis and the fasciculus cuneatus end in these nuclei( F(@ate ral to the cunea te nuc leus "e se e th e a**essory *uneate nu*leus "hich relays unconscious !ro!rioce!tive fibres fro the u!!er li bs( :()he nu*leus of the s. called the me+ial lemnis*us) In the le niscus. in a !ara edian !ositionD BbC the +orsal nu*leus of the . <6.inal tra*t of the trige inal nerve lies in the dorsolateral !art( J()he inferior oli.rey /atter 1()he nucleus gracilis and the nucleus cuneatus Identify the follo"ing in 1ig( FH(J( .ary nu*leus is seen( J()he central grey atter contains the follo"ing8 BaC<y!oglossal nucleus BbCDorsal nucleus of the vagus( BcC=ucleus of tractus solitarius( Jhite /atter 1()he nucleus gracilis and cuneatus give rise to the internal ar*uate fibres) )hese fibres cross to the o!!osite side "here they for a !ara edian band of fibres.ino*erebellar and lateral s. ventrolateral to the dorsal nucleus of the vagusD and BdC the inferior an+ me+ial .inothalami* tra*ts Nand other tractsC lie in the anterolateral area( TransAerse Section throu*h the Rpper Part of the .inal tra*t of the trigeminal ner.iddle of . lateral to the OII nerve nucleusD BcC the nu*leus of the tra*tus solitarius.edulla Bthrou*h the sensory decussation? Identify the follo"ing features in 1ig( FH(H( . Brai" H( )he other features of the "hite si ilar to those of the s!inal cord( atter are H( )he s.6: 2ransverse level of sensory decussation.yrami+al tra*ts lie anteriorly( :()he me+ial longitu+inal bun+le lies !osterior to the edial le niscus( ucleus o4 tractus solitarius Dorsal nucleus o4 7agus % H2poglossal nucleus %/nternal arcuate 4i6res Gsensor2 decussationH /n4erior oli7ar2 nucleus c3 ucleus gracilis ucleus cuneatus ` Accessor2 cuneate nucleus ucleus o4 spinal tract o4 trige5inal ner7e % Medial longitudinal 6undle Lateral spinothala5ic tract Dorsal and 7entral spinocere6ellar tracts Fig. the body is re!resented "ith the head !osteriorly and the feet anteriorly( F()he . section through the medulla oblongata at the <2ra5id .estibular nu*lei. edial to the inferior cerebellar !eduncle( F()he nu*leus ambiguus lies dee! in the reticular for ation of the edulla( It gives origin to otor fibres of the cranial nerves IO.agus.edulla Passin* throu*h the Floor of the Fourth / Dentricle TransAerse Section throu*h the .e is also se!arate fro the central grey atter( H()he lo"er !art of the inferior oli.rey /atter the floor of the fourth ventricle8 BaC )he hy.ary nu*leus is the largest ass of grey atter seen at this level( It is res!onsible for !roducing the elevation of the olive( Its grey atter a!!ears li'e a cru !led !urse( Close to the inferior olivary nucleus there are the edial and dorsal accessory olivary nuclei( 6( )he ar*uate nu*leus lies antero edial to the !yra idal tract( /isceral centres are 8 BiC . O and OI( :()he dorsal and ventral cochlear nuclei lie on the surface of the inferior cerebellar !eduncle( )hese nuclei receive fibres of the cochlear nerve( H()he nu*leus of the s.+(.

artis continuous inferiorly "ith the !yra ids of the edulla.n in3ury to the edulla is. Po"s In transverse sections. eans *bridge*( E8ter"a# Features 1()he .o*erebellar fibres are seen !ro inently in actual sections( )he fibres e erge at the hilu of the inferior olivary nucleus and !ass to the o!!osite inferior cerebellar !eduncle.BiiC Cardiac centre for regulation of heart rate BiiiC /aso otor centre for regulation of blood !ressure Jhite /atter Br&ti"ste* +(0 cerebellar artery. the surface is continuous "ith the iddle cerebellar !eduncle( )he trige inal nerve is attached to this surface at the 3unction of the !ons "ith the !eduncle( )he nerve has t"o roots.as*ular lesions involving the edulla are8 BaC )hro bosis of the !osterior inferior )he !ons has t9o surfa*es. lateral to the fourth ventricle( F()he oli.osterior surfa*e is hidden by the cerebellu . res!ectively( AAAAAAAAAAAAAAAAA THE PONSAAAAAAAAAAAAAAAA It sho"s the follo"ing i !ortant features( 1()he inferior cerebellar !eduncle occu!ies the !osterolateral !art.erior &ere2e##ar %e$u"&#e AFB Me$ia# #o"!itu$i"a# 2u"$#e . on their "ay to the o!!osite half of the cerebellu ( :(<triae me+ullares are seen in the floor of the fourth ventricle( H(Identify the various tracts ascending fro the s!inal cord( )hey lie in the anterolateral !art of the edulla( CLINICAL ANATOM )he !ons is the iddle !art of the brainste .+: 2ransverse section through the olive of medulla oblongata.en tral or an terior s urfa*e is conve& in both directions and is transversely striated( In the edian !lane. and on each side "ith the cerebellu through the iddle cerebellar !eduncle( )he dorsal or teg ental !art is a direct u!"ard continuation of the edulla Be&cluding the !yra idsC( S%i"o&ere2e##ar tra&ts CMe$ia# a"$ $orsa# a&&essor6 o#i5ar6 "u&#ei 1a!us "er5e C S " Z B F@ A A = = . 5a!us Nu&#eus o. it sho"s a vertical basilar sul*us "hich lodges the basilar artery B1ig( FH(1C( @aterally. usually fatal( F(Bulbar .aralysis ay be acute( It is characteri7ed by !aralysis of uscles su!!lied by the last four cranial nerves "hich arise fro the edulla( Paralysis of the res!iratory and vaso otor centres "ould !rove fatal( :(/seu+obulbar . <6. connecting the idbrain "ith the edulla( @iterally. the !ons is seen to be divisible into ventral and dorsal !arts( )he ventral or basilar .^M e=I5 A 1esti2u#ar "u&#ei C C Dorsa# &o&h#ear "u&#eus I".erior o#i5ar6 "u&#eus P . the "ord. . and BbC thro bosis of the vertebral artery( )he t"o lesions cause lateral and edial edullary syndro es. i @ Dorsa# "u&#eus o. tra&tus so#itarius Nu&#eus a*2i!uus B Ru2ros%i"a# tra&t I".04 S%i"a# tra&t o. tri!e*i"a# "er5e B 1e"tra# &o&h#ear "u&#eus C Me$ia# #e*"is&us Latera# s%i"otha#a*i& tra&t HH P6ra*i$ H6%o!#ossa# "er5e CC Ar&uate "u&#eus H6%o!#ossa# "u&#eus i 9ectospinal tract Fig. !ons. ventral and dorsal( )he . a s all otor root "hich lies edial to the uch larger sensory root( )he abducent.ital *entres Bres!iratory and vaso otorC are situated in the lo"er !art of the floor of the fourth ventricle for ed by the edulla( . therefore.alsy is a su!ranuclear ty!e of !aralysis of the bulbar uscles as a result of cerebral arteriosclerosis( H(Co on . and for s the u!!er half of the floor of the fourth ventricle B1ig( FH(FC( I"ter"a# Stru&ture o. facial and vestibulocochlear nerves are attached at the lo"er border of the ventral surface( )he +orsal or .

3ust behind the tra!e7oid body( :()he lateral s!inothala ic tract Bs!inal le niscusC lies lateral to the edial le niscus( .e nu*leus lies beneath the facial colliculus( lying 3ust behind the ventral !art of the !ons( It consists of fibres that arise in the cochlear nuclei of both sides( It is a !art of the auditory !ath"ay Bdescribed in Cha!ter :GC( F()he edial le niscus for s a transverse band on either side of the idline. and to nuclei of the lateral le niscus( )hese fibres for the tra!e7oid body( :()he s!inal nucleus of the trige inal nerve lies in the lateral !art( H(0ther nuclei !resent include the salivatory and lacri atory nuclei Bnot sho"n in figureC( Jhite /atter 1()he tra. and give efferents to the cerebellu BvestibulocerebellarC. !artly in the edulla and !artly in the !ons( )hey are divisible into four !arts.ontine nu*lei "hich are scattered a ong longitudinal and transverse fibres( )he !ontine nuclei for an i !ortant !art of the cortico!ontocerebellar !ath"ay( So e of these nuclei get dis!laced during develo! ent.onto*erebellar fibres beginning fro the !ontine nuclei and going to the o!!osite half of the cerebellu . su!erior. through the iddle cerebellar !eduncle( Te*6entu6 in the 9oGer Part of the Pons Identify the follo"ing in 1ig( FH(6( . the structure of the teg ental !art differs in the u!!er and lo"er !arts of the !ons B1ig( FH(6C( .rey /atter for ation of the !ons( F()he vestibular and cochlear nuclei lie in relation to the inferior cerebellar !eduncle( )he . and give efferents ostly to the su!erior olivary nucleus and !artly to nuclei of the cor!us tra!e7oideu . and BbC the *orti*o. edial and lateral B1ig( FJ(:C( )hey receive the fibres of the vestibular nerve.inal and *orti*onu*lear B!yra idalC tracts.ontine fibres ending in the !ontine nuclei( F()he transverse fibres are . the s!inal cord Bvestibulos!inal tract arising in the lateral vestibular nucleusC and the lateral le niscus( )he dorsal and ventral *o*hlear nu*lei are situated dorsal and ventral to the inferior cerebellar !eduncle( )hey receive the fibres of the cochlear nerve.rey /atter 1()he se. the edial longitudinal bundle.estibular nu*lei lie dee! to the vestibular area in the floor of the fourth ventricle.e4oi+ bo+y is a transverse band of fibres 1( )he sixth ner.enth ner. inferior.Basilar Part of Pons )he basifar !art of the !ons has a unifor structure throughout its length( <o"ever.e nu*leus lies in the reticular It is re!resented by the . and for the arcuate nucleus Bsee edullaC and the !ontobulbar body( 1ibres fro all these nuclei go to the o!!osite half of the cerebellu ( Jhite /atter It consists of longitudinal and transverse fibres( 1()he longitudinal fibres include8 BaC )he *or& ti*os.

1()he inferior cerebellar !eduncle lies lateral to the floor of the fourth ventricle( F()he fibres of the facial nerve follo" a !eculiar course( )hey first !ass bac'"ards and edially to reach the edial side of the abducent nucleus( )hey then for a loo! dorsal to the abducent nucleus( )his loo! is res!onsible for !roducing an elevation.rey /atter )he s!ecial features are the motor an+ su. the s!inal le inscus.e) )he su!erior sensory nucleus( Jhite /atter otor nucleus is edial to the 1( I ediately behind the ventral !art of the !ons "e see a transverse band of fibres that is ade u! Bfro edial to lateral sideC of the edial le niscus. the trige inal le niscus. the facial colliculus. nucleus of tra!e7oid bodyC( F( )he su!erior cerebellar !eduncles lie dorsolateral to the fourth ventricle Bre!lacing the inferior !eduncle seen in the lo"er !art of the !onsC( .erior sensory nu*lei of the trigeminal ner. in the floor of the fourth ventricle( Begmentum in the Tpper Part of Fons Identify the follo"ing in 1ig( FH(A( / . and the lateral le inscus B#)S@C( )he trige inal le inscus contains fibres arising in the s!inal nucleus of the trige inal nerve and travelling to the thala us( )he lateral le inscus is a !art of the auditory !ath"ay( It is for ed by fibres arising in nuclei lying in close relation to the tra!e7oid body Bsu!erior olivary nucleus.

and the !osterior ends of the right and left thala i B1igs F4(J.Crainste5 U 3=$ :( )he edial longitudinal bundle is ade u! of fibres that interconnect the nuclei of the cranial nerves III.LS7 -uperior sensor2 nucleus o4 'V T Basilar part o4 pons %'' Fig. the trochlear nerve.halon) It connects the hindbrain "ith the forebrain( Its cavity is 'no"n as the cerebral a%ueduct8 it connects the third ventricle "ith the fourth ventricle( )he idbrain !asses through the tentorial notch. and the geniculate bodies( .e+un*le) 2ach cerebral !eduncle is subdivided into8 BaC )he crus a'e out the follo"ing a3or subdivisions( Jourth 7entricle -uperior cere6ellar peduncle S trige5inal ner7e Middle cere6ellar peduncle s -uperior 5edullar2 7elu5 P Medial longitudinal 6undle : Lateral le5niscus %-pinal le5niscus %9rige5inal le5niscus Medial le5niscus O : Motor nucleus and . I/. %%%%% 9rige5inal ner7e .( )he te*tum is the !art !osterior to the a%ueduct( It is ade u! of the right and left su!erior and inferior colliculi( B( 2ach half of the idbrain anterior to the a%ueduct is called the *erebral .8: 2ransverse section through the upper part of the pons. /I and /III and the s!inal !art of the accessory nerve( It coordinates ove ents of the head and nec' in res!onse to sti ulation of the cranial nerve /III( <o"ever. the o!tic tracts. it is related to the inter!eduncular structures.nteriorly. the !osterior cerebral artery. F4(1JC( $ubdivisions Ehen "e e&a ine a transverse section through the idbrain "e can . <6. and !osteriorly to the s!leniu of the cor!us callosu . the !ineal body. the a3ority of fibres in the edial longitudinal bundle arise in the vestibular nuclei( AAAAAAAAAAAAAAA THE MIDBRAIN )he idbrain is also called the mesen*e. and is related on each side to the !arahi!!oca !al gyri. the great cerebral vein. the basal vein.

i2res Corti&os%i"a# .idbrain at the 9eAel of Inferior .i2res . are !resent( Tro&h#ear "er5e A I".cerebri. the facial and ocular uscles. and the teeth B1ig( FH(9C( 1()he inferior *olli*ulus receives afferents fro the lateral le niscus. but the available evidence indicates that it hel!s in locali7ing the source of sounds( F()he substantia nigra is a la ina of grey atter ade u! of dee!ly !ig ented nerve cells( It is concerned "ith uscle tone( Fi*+ &4+!: 2ransverse section of the midbrain to show its main subdivisions. !osteriorly B1ig( FH(4C( Su2sta"tia "i!ra ' 1ru' cere#r" ventro edial !artD and BbC the mesen*e. anteriorlyD BbC the substantia nigra.rey /atter I) )he central B!eria%ueductalC grey atter contains8 BaC )he nu*leus of the tro*hlear ner.e+un*les is seen in the edian !lane( BcC)he me+ial longitu+inal bun+le lies in close relation to the trochlear nucleus Bso atic efferent colu nC( BdC)he tectos!inal tract and the rubros!inal tract.e in the tract in the iddleD BbC fronto!ontine fibres in the edial one-si&thD and BcC te !oro!ontine. in the iddleD and BcC the teg entu .olliculi . at the level of the inferior colliculi and at the level of the su!erior colliculi( TransAerse Section of . and lateralC are arranged in the for of a band in "hich they lie in the order entioned Bfro edial to lateral sideC( BbC)he +e*ussation of the su. su%erior &ere2e##ar %e$u"&#es BAAAA Su2sta"tia "i!ra @H Fro"to%o"ti"e .erior &o##i&u#us ) Latera# #e*"is&us / S%i"a# #e*"is&us F )) Tri!e*i"a# #e*"is&us A Me$ia# #e*"is&us B>CA Te&tos%i"a# 'D> CDJC Te*%oro%o"ti"e .hali*nu*leus of the trige inal nerve in the lateral !art( )he esence!halic nucleus is ade u! of uni!olar cells Bfirst neuronC and receives !ro!rioce!tive i !ulses fro the uscles of astication. !arie-to!ontine and occi!ito!ontine fibres in the lateral one-si&th( F()he tegmentum contains ascending tracts as follo"s( BaC)he lemnis*i B edial. ) he e di a l a nd l a t e r a l g e n i c u l a t e b o d i e s B etathala usC are situated on the !osterolateral as!ect of the idbrain( )he su!erior colliculus is connected to the lateral geniculate body by the su!erior brachiu ( @i'e"ise.erior *erebellar . the inferior colliculus is connected to the edial geniculate body by the inferior brachiu B1ig( F4(11C( I"ter"a# Stru&ture o. trige inal. Mi$2rai" Jhite /atter 1()he *rus *erebri contains8 BaC )he corticos!inal It is studied conveniently by e&a ining sections. and gives efferents to the edial geniculate body( In the !ast it has been considered as the centre for auditory refle&es.i2res Mese"&e%ha#i& "u&#eusAAAAA Tro&h#ear "u&#eusCCCCCCCCC Me$ia# #o"!itu$i"a# 2u"$#e BB Ru2ros%i"a#CCCCCCCCCCC De&ussatio" o. s!inal.

.Fi*+ &4+": 2ransver se section of midbrain at the level of inferior colliculus .

hali* nu*leus of the trige inal nerve in the lateral !art( )he oculo otor nuclei of the t"o sides are fused in the edian !lane B1ig( FH(1GC( F()he su.obertson !u!il in "hich the light refle& is lost but acco odation refle& re ains intact BCha!ter :GC( H()he re+ nu*leus is about G(J c in dia eter( It receives afferents fro the su!erior cerebellar !eduncle.idbrain at the 9eAel of Superior .lar la ina cells ulti!ly and fuse to for H colliculi( So e cells also igrate ventrally to for red nucleus and substantia nigra( )he basal la ina for s the crus cerebri( Jrontopontine 4i6res Fig. the globus !allidus.olliculi .rgyll-. and various other centres( It gives efferents to the s!inal cord Btectos!inal tractC( It controls refle& ove ents of the eyes.erior *olli*ulus receives afferents fro the retina BvisualC.rete*tal nu*leus lies dee! to the su!erolateral !art of the su!erior colliculus( It receives afferents fro the lateral roots of the o!tic tract( It gives efferents to the 2dingerEest!hal nuclei of both sides( )he !retectal nucleus is an i !ortant !art of the !ath"ay for the light refle& and the consensual refle&( Its lesion causes .rey /atter 1()he central grey subthala ic nucleus.:( )he trochlear nerve !asses laterally and dorsally round the central grey atter( It decussates in the su!erior edullary velu .%3: 2ransverse section of %-uperior 6rachiu5 %Lateral geniculate 6od2 %-pinal le5niscus 9rige5inal le5niscus Medial le5niscus -u6stantia nigra % 9e5poropontine 4i6res Corticospinal 4i6res midbrain at the level of superior -uperior colliculus OIf <retectal nucleus%%%%%%%%% 3% Y Mesencephalic nucleus o4 trige5inal ner7e%%%%%%%%%% Oculo5otor nucleus%%%%%%%%%% Medial longitudinal 6undle L>>=?LIDorsal teg5ental decussation Red nucleus Ventral teg5ental decussation Go4 ru6rospinal tractH O . and e erges lateral to the frenulurn veli( N TransAerse Section of .e including 2dingerEest!hal nucleus in the ventro edial !art. the subthala ic nucleus and the cerebral corte&( It gives efferents to the s!inal cord 2rubros. the esence!halon( . <6. the olivary nucleus.inal tra*t3. the reticular for ation. the thala us. trige inal and s!inal( @ateral le niscus is absent as it has ter inated in the inferior colliculus( BbC)he decussation of the tectos!inal and tectobulbar tracts for s the dorsal teg ental decussation( BcC)he decussation of the rubros!inal tracts for s the ventral teg ental decussation( BdC#edial longitudinal bundle( BeC2 erging fibres of oculo otor nerve( :( )he te*tum sho"s the !osterior co issure connecting the t"o su!erior colliculi( DE1ELOPMENT 1e+ulla oblongata7 1ro caudal yelence!halic !art of rho bence!halic vesicle( 0livary nucleus is for ed by the igrated cells fro alar la ina( /ons7 1ro cranial esence!halic !art of rho bence!halic vesicle( Cells of alar la ina igrate to for the !ontine nuclei( 1i+brain7 1ro iddle vesicle. the cribed above( F()he tegmentum contains the follo"ing( BaC@e nisci are arranged as edial. and BbC the mesen*e. etc( It has an inhibitory influence on uscle tone( J( )he substantia nigra has already been described( Jhite /atter 1()he *rus *erebri has the sa e tracts as des- atter contains8 BaC the nucleus of the o*ulomotor ner. and of the head and nec' in res!onse to visual sti uli( :()he .

.colliculus.

obertson !u!il8 )his is the condition "hen light refle& is lost but the acco odation refle& re ains intact( )his is generally a result of lesion in the vicinity of !retectal nucleus( Causes include tertiary sy!hilis. B B &: &rainstem sectioned at the level of lowerUP ons3 "34acial ner7e =3a6ducent ner7M o6e: superior 5edullar 2 7elu5 in4erior colliculi superior colliculi oculo5o tor ner7e &4+% <A: &4+#&B: &rainstem sectioned at the level of superior colliculus. and !aralysis of the li bs Bhe i-!legiaC on the o!!osite side Bcrossed he i!legia or #illard +ubler syndro eC( F(. "3in4erior cere6ellar peduncle =35iddle cere6ellar peduncle 33superior cere6ellar peduncle ?3su6stan4ia nigra '3trochlear ner7e . unilateral lesion in the lo"er !art of the !ons results in !aralysis of the facial nerve on the side of lesion. &rainstem sectioned at the level of inferior colliculus. "37agus ner7e =3h2poglossal ner7e 333 oli7e <6. leading to involuntary ove ents( H( @esion in vicinity of cerebral !eduncles leads to oculo otor !aralysis of sa e side but he i!legia of o!!osite side( sectioned at the level of the lower border of the fourth ventricle. diabetes.rgyll-.++: Brai" CLINICAL ANATOM :( @esions of teg entu BaC)hird ay involve the foll"ing( 1(. and ence!halitis( Fi*+&4+OO-: &rainstem nerve leading to !aralysis of e&traocular uscles( BbCSensory tracts8 resulting in loss of sensations( BcCSubstantia nigra and subthala ic nucleus.

"!ourtesy. !&$ Publishers and 9istributers. $ircar. $. New 9elhi#. 9r. /edical Physiology. .

though grey atter for s a co !act fluted colu n in the centre. sight. I/ and /I are efferent to the eye uscles( Statoacoustic nerve is afferent for hearing and balance "hile s!inal root accessory acts as its efferent co !onent for turning the face to the side fro "here sound is heard( /II. OI. it sho"s differentiation into t"o so atic and t"o visceral functional colu ns( )he so atic colu ns are the general so atic efferent B otor or anterior hornC and the general so atic afferent Bsensory or !osterior hornCD they su!!ly structures derived fro so ites( )he visceral colu ns are the general visceral efferent B otorC and the general visceral afferent BsensoryCD these are autono ic colu ns and su!!ly the viscera. laryn& tongue and t"o large uscles of nec'( Besides these are afferent to s!ecial senses li'e s ell. the "hite atter( Soon the antle layer differentiates into a dorsal alar la ina BsensoryC and a ventral basal la ina B otorC. the largest cranial nerve. the "all of the neural tube is ade u! of three layers8 BaC )he inner e!endy al layerD BbC the iddle antle layerD and Bc3 the outer arginal layer( )he antle layer re!resents grey atter and the arginal layer. and cranial root of OI for the uscles of !alate.eticular for ation is diffuse net"or'( It for s 6ascending reticular activating syste 6( #any anaesthetic drugs act through this reticular for ation( 0lfactory ta'es the sense of s ell and sti ulates dorsal nucleus of vagus for enhanced secretion if the s ell is good( C= /. and OII to the edulla B1ig( FJ(1C( )he olfactory and o!tic nerves are connected to the cerebru and "ill be considered "ith it( )he nuclei connected to the re aining nerves are as follo"s( =ote that several cranial nerves are connected to ore than one nucleusD and that so e nuclei contribute fibres to ore than one nerve( E*2r6o#o!6 )here are 1F !airs of cranial nerves( 2ach cranial nerve has a nu ber and a na e as follo"s( I Q 0lfactory II Q 0!tic +( III Q 0culo otor I/ Q )rochlear / Q )rige inal /I Q . O. /II nucleus "inds around /I nucleus so that a refle& arc can be ediated bet"een the afferent and efferent loo!s of the arc( AAAAAAAA NUCLEI OF CRANIAL NER1ES /n Q 1acial /I2 Q /estibulocochlear Bor StatoacousticC DC Q +losso!haryngeal O Q /agus OI Q . /II and /III to the !onsD and the IO. !haryn& and laryn&( . !haryn&. !alate. face. taste and touch( So e nerves for the afferent loo! and others for the efferent loo! of the refle& arc( 0!tic nerve is afferent fro eye "hile III. vessels and glands( ++9 . the t"o are !artially se!arated internally by the sulcus li itans( In the s!inal cord.ccessory O< Q <y!oglossal 0ut of these the I and II nerves are attached to the forebrainD the III and I/ to the idbrainD the /.uclei o4 Cranial er7es and Reticular Jor5ation t"elve !airs of cranial nerves su!!ly uscles of eyeball. IO and O are carrying sensation of taste fro tongue and efferent co !onent is OII nerve for ove ents of tongue and nucleus a biguus "hich gives fibres to IO. hearing. /I. is ainly sensory to the face( )he otor nerve of face is /II nerve( )o co e close to / nerve nucleus. O.bducent During early stages of develo! ent.

na ely the s!ecial visceral BbranchialC efferent and the s!ecial visceral afferentD and one colu n ore for the s!ec ia l senses. the grey atter for s se!arate longitudinal functional c ol u n s. In the brainste . <+.$@ . in its turn. Oculo5otor ner7e % <ons 0lossophar2ngeal ner7e Vagus ner7e Accessor2 ner7e Medulla o6longata 0live /n4erior sur4ace o4 cere6ellu5 Fig.++( Brai" Ol4actor2 tract Or6ital sur4ace o4 4rontal lo6e M 0lfactory bulb Optic chias5a and tract % Ma5illar2 6od2 Uncus O Anterior per4orated su6stance O /n4undi6ulu5%%%%%% 6OEO O 9u6ercineriu5%%%%%%%% 9rochlear ner7e 9rige5inal ner7e %)) Vesti6ulocochlear ner7e +') er7us inter5edius A6ducent ner7e H2poglossal ner7e <2ra5id R Jacial ner7e =V 7 Ys O R %%%%%%%%% )l%%%%%%%% <osterior per4orated su6stance % Cruscere6ri . the alar a nd basal la ina e c o e to lie in the sa e ventral !lane because of stretching of the roof !late Bdorsal "allC of neural tube by !ontine fle&ure( 1urther. na ely the s!ec ia l so atic afferent( )hus a total of seven colu ns B: otor and H sensoryC are for ed( 2ach colu n. there a!!ear t"o ore colu ns Ba otor and a sensoryC for the branc hia l a!!ara tus of the he ad region. "h e re t he o tor co lu ns Bf r o ba sa l la inaC are edial and the sensory colu ns Bfro alar la inaC lateral in !osition( In addition to the four functional colu ns differentiated in the s!inal cord. bre a's u! into s aller fr ag e nts to for nuclei of the cranial nerves( )hese nuclei su!!ly s'eletal uscle of so atic origin( =uclei )he details of the nuclei of cranial nerves are su ari7ed in )able FJ(1( <eneral So6atic Efferent Nuclei B<SE? . !articularly hindbrain.nferior surface of brain with interpeduncuAar fossa and attachment of cranial nerves.

.<: 2ransverse section of the hindbrain of an embryo showI ing the arrangement of functional columns of cranial nerve nuI clei.1()he o*ulomotor nu*leus is situated in the idbrain at the level of the su!erior colliculus( Its fibres enter the oculo otor nerve and su!!ly five e&trinsic uscles of the eyeball e&ce!t the lateral rectus and the su!erior obli%ue B1ig( FJ(FC( F()he tro*hlearn u*leus is situated in the idbrain at the level of the inferior colliculus( It su!!lies the su!erior obli%ue uscle through the trochlear neive( :()he ab+u*ent nu*leus is situated in the lo"er !art of the !ons( It su!!lies the lateral rectus uscle through the abducent nerve( -pecial so5atic a44erent 0eneral so5atic 0eneral 7isceral a44erent A :% S' ' -pecial 7isceral a44erent a44erent 0eneral so5atic e44erent E 0eneral 7isceral e44erent G -pecial 7isceral e44erent Fig. <+.

spinal.eneral 'isceral Efferent Nuclei )hese nuclei give origin to !reganglionic neurons that relay in a !eri!heral autono ic ganglion( Postganglionic fibres arising in the ganglion su!!ly s ooth uscle or glands( 1()he F+inger&Aest.e lies in the lo"er !art of the !ons( It su!!lies the various uscles innervated by the facial nerve( :()he nu*leus ambiguus lies in the edulla( It for s an elongated colu n lying in both the o!en and closed !arts of the edulla( It su!!lies8 BaC)he stylo!haryngeus uscle through the glosso!haryngeal nerveD and BbCthe uscles of the !haryn&. $uperior.atory nu*leus lies in the lo"er !art of the !ons 3ust belo" the su!erior nucleus( It sends fibres through the glosso!haryngeal nerve to the otic ganglion for su!!ly of the !arotid gland( H()he la*rimatory nu*leus lies near the salivatory nuclei Bin the lo"er !onsC( It gives off fibres that !ass through the facial nerve and its branch greater !etrosal nerve to relay in the !terygo!alatine ganglion and su!!ly the lacri al.estphal nucleus 9rochlear nucleus PPP 3'i3% Motor nucleus o4 trige5inal / ')++3 E3)ilN%%9% A6ducent nucleus PPP@tPPPPPP V) Lacri5ator2 nucleus i%'()O?DIO[D -ali7ator2 nuclei 33+' .agus is a long colu n e&tending into the o!en and closed !arts of the edulla( It gives off fibres that !ass through the vagus nerve to be distributed to thoracic and abdo inal viscera( B)he ganglia concerned are !resent in the "alls of the viscera su!!lied(C 0-A colu5n +(' 0VAand -VA colu5n 0-A colu5n O++U3 Mesencephalic nucleus o4 trige5inal Main sensor2 nucleus o4 trige5inal -pinal nucleus o4 trige5inal %R Dorsal cochlear nucleus%%%%%%% I) --A colu5n 3O4O% Ventral cochlear nucleus%%%%%%%%%%% ( Jour 7esti6ular nuclei%%%%%%%% -pinal nucleus o4 trige5inal ucleus o4 solitar2 tract O : "'F3O Oculo5otor nucleus rO Edinger%.). lateral.oglossal nu*leus lies in the edulla( It is elongated and e&tends into both the o!en and closed !arts of the edulla( It su!!lies ost of the uscles of the tongue through the hy!oglossal nerve( / -pecEoE 'isceral EfferentA&ranchial Efferent Nuclei )hese nuclei su!!ly striated uscle derived fro the branchial arches( 1()he motor nu*leus of the trigeminal ner.atory nu*leus lies in the lo"er !art of the !ons( It sends fibres through the facial nerve and its chorda ty !ani branch to the sub.).%%%%%% Jacial nucleus %%%%%%FiO Dorsal nucleus o4 7agus %%%%% [%%%%% ucleus a56iguus ))(+% H2poglossal nucleus 0VE colu5n -VE colu5n -E colu5n $cheme to sho1 the cranial nerve nuclei as proGected on to the posterior surface of brainstem.. the soft !alate and the laryn& through the vagus and the cranial !art of the accessory nerve B1ig( FJ(:C( .andibular ganglion for su!!ly of the sub andibular and sublingual salivary glands( :()he inferior sali. <+. 'estibular nuclei: %. ' ( Fig.Cranial er7e uclei 333 H( )he hy. nasal. 6. !alatal gland( J()he +orsal nu*leus of the .): the .erior sali..hal nu*leus lies in the idbrain in close relation to the oculo otor nucleus( Its fibres !ass through the oculo otor nerve to the ciliary ganglion to su!!ly the s!hincter !u!illae and the ciliaris uscle( F()he su. medial.e lies in the u!!er !art of the !ons( It su!!lies the uscles of astication through the andibular nerve( F()he nu*leus of the fa*ial ner.<.

facial and lingual uscles( Special So6atic -fferent Nuclei )hese are8 1()he *o*hlear nu*lei Bdorsal and ventralC that receive i !ulses of hearing through the cochlear nerve( F()he .e e&tends u!"ards fro the ain sensory nucleus into the idbrain( )hese nuclei receive the follo"ing fibres8 BaC2&teroce!tive sensations Btouch.estibular nu*lei Bsu!erior. including the circu vallate !a!illae( BcC1ro the !osterior ost !art of the tongue and fro the e!iglottis through the vagus nerve( <eneral So6atic -fferent Nuclei )hese are all related to the trige inal nerve( 1()he main or su. the laryn&. carotid body and sinus( BiiC )hrough the vagus nerve. edial . the trachea. fro the !haryn&.inal nu*leus of the trigeminal ner.erior sensory nu*leus of the trigeminal ner.++.e descends fro the ain nucleus into the edulla( It reaches the u!!er t"o seg ents of the s!inal cord( :()he mesen*e.is*eral sensations through8BiC )he glosso!haryngeal nerve. and the !alate e&ce!t circu vallate !a!illae through the facial nerve( BbC1ro the !osterior one-third of the tongue through the glosso!haryngeal nerve. te !eratureC fro the s'in of the face. s!inal. fro the tonsil. through the trige inal nerveD and fro a !art of the s'in of the auricle through the vagus Bauricular branchC and through the facial nerve( BbCPro!rioce!tive sensations fro uscles of astication reach the esence!halic nucleus through the trige inal nerve( )he nucleus is also believed to receive !ro!rioce!tive fibres fro the ocular. !ain.e lies in the u!!er !art of the !ons( F()he s.hali* nu*leus of the trigeminal ner. !haryn& and the !osterior !art of the tongue. Brai" <eneral Disceral -fferent Nucleus and Special Disceral -fferent Nucleus and lateralC that receive fibres fro se icircular the )he only nucleus in this category is the nu*leus of the solitary tra*t) It lies in the edulla and e&tends into both its closed and o!en !arts( It receives general . the oeso!hagus and other thoracic and abdo inal viscera( It also receives sensations of taste Bs!ecial visceral afferentC as follo"s( BaC1ro the anterior t"o-thirds of the tongue.

certain areas of the reticular for ation inhibit voluntary and refle& activities of the . trige inal and auditory !ath"ays to the lateral !arts of the reticular for ation. "hich the selves !ro3ect to the reticular and intrala inar nuclei of the thala us( )hese nuclei. BcochlearC. !ro3ect to "ides!read area of the cerebral corte&( )he autonomi* neurons of the hy!othala us. it is very old8 inl !ri itive vertebrates. visual !ath"ay Btectu C. including the otor. it is best develo!ed in the brainste 3 although it can be traced to all levels of the C=S( 9ocation and Identity 1()he reticular for ation. and e%uilibfatory BvestibularC !ath"ays( In this grou! the as*en+ing reti*ular a*ti.canals. the utricle and the saccule through theP vestibular nerves B)able FJ(1C( RETICULAR FORMATION Introduction )he reticular for ation is a diffuse net"or' of fine nerve fibres inter ingled "ith nu erous !oorly defined nuclei( Phylogenetically.ating system 26B6<3 is of !ri e i !ortance( It is for ed by a great nu ber of collaterals fro the s!inothala ic. auditory !ath"ay. is !laced in the dee! and dorsal !arts of the neural a&is( F(It is very diffuse in its distribution. various asses of grey atter in the brainste including the nuclei of cranial and s!inal nerves( )he sensory neurons of the so esthetic !ath"ays Bcorte&. in turn. li bic syste and the general visceral efferent colu ns( Functions Inhibitory an+ 5a*ilitatory Influen*es )hrough its connections "ith the otor areas of the nervous syste . the basal ganglia.onnections )he reticular for ation is connected to all the !rinci!al 3 !arts of the nervous syste . thala us and s!inal cordC. and has illdefined boundaries( :(It is better defined !hysiologically than anato ically( . it re!resents the largest !art ofl the C=S( In an. I sensory and autono ic !ath"ays "ith their centres( )he connections are reci!rocal Bto and fro the areas to be entionedC !roviding feedbac' echanis s( )hus the reticular for ation is connected to8 )he motor neurons of the cerebral corte&. the cerebellu . in general.

lacri5al gland.Cra"ia# Ner5e Nu&#ei ++0 it% Ta2#e (0. anterior t1o%thirds tongue -ecreto5otor. 4ace and e2e3 9ouch and pressure 4ro5 s!in and 5ucous 5e56rane o4 4acial region <ain and te5perature o4 4ace Lateral 5o7e5ent o4 e2e6all <ropriocepti7e Jacial e:pressions. etc3 <ropriocepti7e Hearing E8uili6riu5 o4 head Mid6rain.# 5ocation Functional Function of the nerve components>> component -5ell -ight e Oculo5otor nucleus 2 n Cf i( /9rochlear nucleus Mid6rain. su65andi6ular and su6lingual sali7ar2 glands -ecreto5otor. le7el o4 superior colliculus 0-E 0VE 0-A( 0-E 0-A( BE 0-A 0-A Mo7e5ents o4 e2e6all Contraction o4 pupil. le7el o4 /n4erior colliculus Upper pons Mid6rain Upper pons //"3 Motor nucleus "3Mesencephalic nucleus =3-uperior sensor2 nucleus 33-pinal nucleus Jro5 upper pons to C= 0-A seg5ent o4 spinal cord3 Lo1er pons 0-E 0-A( BE -VA 0VE 0VE 0-A --A --A V/ A6ducent nucleus V// "3 Motor nucleus "3 ucleus o4 tractus solitarius =3-uperior sali7ator2 nucleus 33Lacri5ator2 nucleus Lo1er pons Lo1er pons Lo1er pons Lo1er pons V/// Cochlear 91o cochlear nuclei dorsal and 7entral Vesti6ular Jour 7esti6ular nuclei superior. C/%' BE Mo7e5ents o4 tongue <ropriocepti7e Medulla 0-E 0-A 9hese co5ponents do not ha7e corresponding nuclei and ter5inate in the nuclei o4 di44erent ner7es3 0-E Y general so5atic e44erentU BE Y 6ranchial e44erentU 0VE Y general 7isceral e44erentU 0VA Y general 7isceral a44erentU -VA Y special 7isceral a44erentU 0-A Y general so5atic a44erentU -VA Y special so5atic a44erent3 . acco55odation <ropriocepti7e Mo7e5ent o4 e2e6all Gsuperior o6li8ue 53H <ropriocepti7e Mo7e5ent o4 5andi6le <ropriocepti7e. 5edial and lateral Cunction o4 5edulla and pons /T "3 ucleus a56iguus =3/n4erior sali7ator2 nucleus 33 ucleus o4 tractus solitarius Medulla BE 0VE -VA 0VA( 0-A( Ele7ation o4 lar2n: -ecreto5otor to parotid gland 9aste posterior one%third o4 tongue -ensations 4ro5 5ucous 5e56rane o4 phar2n: and posterior one%third o4 tongue go to dorsal nucleus o4 7agus G0VAH and spinal nucleus o4 'th ner7e G0-AH Mo7e5ents o4 palate. phar2n: and lar2n: Motor and -ecreto5otor to 6ronchial tree and gutU inhi6itor2 to heart -ensations 4ro5 7iscera 9aste 4ro5 post. ele7ation o4 h2oid 9aste. spinal. 5ost tongue and epiglottis -ensations 4ro5 the s!in o4 e:ternal ear go to the spinal nucleus o4 V ner7e -ternocleido5astoid and trapeLius Medulla T and cranial "3 ucleus a56iguus part o4 T/3 =3 Dorsal nucleus o4 7agus BE 0VE 0VA -VA 0-A( 33 ucleus o4 tractus solitarius -pinal part o4 T/ T// -pinal nucleus o4 accessor2 ner7e H2poglossal nucleus -pinal cord. the &ra"ia# "er5es !ranial nerve Nuclei "n. 5uscles o4 5astication.9= Nu&#ei o. nasal.

irth and laughter( BaCIn brain ste . !artial retention of consciousness during these attac's !rotects the !atient fro har ( BcC. !eriodic inhibition of the reticular for ation( <y!notics and general anaesthetics !roduce their effects by acting on this syste ( Autonomic . rhinence!halon and its !ro3ections( It also de!resses conduction along s!ecific sensory !ath"ays( BvC Pro edol increases the activity of reticular activating syste ( )hrough its autono ic connections and certain s!ecific centres.eneral Awareness and Alertness )he ascending reticular activating syste B. !recise effects of "hich de!end u!on the ty!e of narcotics used and its dosage( =arcotics de!ress the diffuse thala ocortical syste as "ell( BiiC Barbiturates de!ress the afferent i !ulses reaching the reticular-activating !ath"ays( in3uries. behavioral and visceral activities( It also ta'es !art in neuroendocrine regulation and the develo! ent of conditioned and learned refle&es( Action of 9rugs CLINICAL ANATOM 2i3 =arcotics act ore on nons!ecific sensory syste and less on the s!ecific sensory syste ( )heir ain action is de!ression of reticular activating syste . the reticular for ation influences res!iratory and vaso otor activities( )hey are sti ulated or su!!ressed according to the needs( )hrough its connections "ith the li bic syste it !artici!ates in regulating e otional. so that an a!!ro!riate otor res!onse by the body ay be synthesi7ed and actuated( Slee! is a nor al. "hereas certain other areas can facilitate the ( -to4e of Arousal.SC is res!onsible for aintaining the state of "a'efulness and alertness..nother anifestation of disorders of reticular activating syste consists of t"o features8 BiC =ecro!le&y "hich is ar'ed by recurrent attac's of so nolescence and co !ulsive de ands for i ediate slee!( BiiC Cata!le&y consists of !aro&ys al attac's of general uscular "ea'ness during heights of rage. involve ent of reticular activating syste ay result in loss of consciousness or interference in the arousal echanis ( BbCPetit al e!ile!sy is a disorder of reticular activating syste ( It is characterised by attac's of ental confusion. "ith !atient staring ahead "ith o!en eyes. and sti ulates the nons!ecific thala ic syste .nalgesics act by su!!ression of reactions concerned "ith activation of reticular-activating !ath"ays( BivC #or!hine su!!resses the cortico-reticular !ath"ays.nfluences BiiiC .. .++4 Brai" body. by its connections "ith a great nu ber of collaterals fro sensory tracts( )hus sensory !erce!tion of any ty!e is %uic'ly and acutely a!!reciated.

i(e( it is ho oty!ical( Da age to cerebellu gives rise to very ty!ical sy !to s( Introduction DISSECTIO )he cerebellu Blittle brainC is the largest !art of the hindbrain( It is situated in the !osterior cranial fossa behind the !ons and edulla( It is an infratentorial structure that coordinates voluntary ove ents of the body( Felations Identify th