Region Neck

Organ/ Structure Platysma Langer’s lines Investing layer of deep cervical fascia Pretracheal layer

Condition/ Significance Surgical repair Collagen bands of neck Structures covered Structures covered Tumors of thyroid

Description Wrinkles skin If injured in wound of neck, should be sutured so that would will not be distracted by contracting severed muscle Incision across will result in ugly scar after surgery Submandibular and parotid, SCM and trapezius Thyroid, attaches to laryngeal cartilages in midline, inferiorly descends in front of trachea and fuses with fibrous pericardium Attaches to larynx also => move gland with swallowing Tumors of thyroid move with swallowing Attaches from investing to cervical vertebrae Scalene and brachial plexus Common and internal carotids, IJV and vagus nerve Ant divisions of CN II, III and IV, emerging at post border of SCM Innervates post aspect of ear and scalp Both surfaces of lower part of ear Passes ant across SCM 3 of them, medial middle and lateral thirds of clavicle C3/4, supplies skin over ICS 1 and shoulder C3/4 ant rami and supplies motor and sensory to diaphragm Pain impulses appear to be coming from skin than diaphragm because skin is supplied by sensory cortex more than any other structures => shoulder pain due to diaphragmatic irritation Lower border of parotid gland, divide into ant and post Ant -> ant facial vein -> common facial vein Post -> post auricular -> EJV Pierces investing fascia above clavicle and then joins subclavian. Visualized by lowering head and raising intrathroacic pressure by aspiring against closed glottis. - Used to thread catheter thorugh subclavian to SVC and heart. Not ideal route because angle of union makes passage difficult, preferred route is through IJV - If vein severed where pierces fascia, held open by fascia and air sucked into lumen by negative intrathoracic pressure => air embolism Usually severed due to position down the neck from the chin until it joins the EJV Severed during laryngotomy From myloid line to hyoid bone, forms floor of submental triangle (sides formed by hyoid bone and ant bellies of the digastric muscles) Diaphragm of mouth, post border free => lingual nerve, submandibular and hypoglossal nerve enter through here to enter mouth. Only bone to not articular with another, serves as attachment point for many muscles Almost meet at midline and so easier than separating muscles is to separate the fibers of one or the other Restricted because attaches over the upper lobe of the gland and prevents enlargement upward. Attached by tendinous sling to the clavicle is because originally inserted there and during development strayed to the suprascapular notch of the scapula Good landmark for surgery Steady hyoid bone, allowing for opening of the mandible and help control pitch of voice Carotid/subclavian arteries, IJV and subclavian veins, brachial plexus, strap muscles

Prevertebral Carotid sheath Superficial nerves of neck Lesser occipital Greater auricular Transverse cervical Supraclavicular Supraclavicular nerves Phrenic

Structures covered Structures contained Origin Innervation

Origin and innervation Origin and innervation Referred pain from diaphragm Location and drainage Subclavian catheterization Air embolism

Post facial vein EJV

AJV Mylohyoid

Suicidal cutthroat Position and relevance

Hyoid bone Sternohyoids Sternothyroid Omohyoid

Position and relevance Tracheostomy Swelling of thyroid gland Location and development Function Structures covered Accessory nerve

Strap muscles SCM

Function

Thyroid gland

Development

Pyramidal lobe Fibrous remains of thyroid duct Relations to structuresh Arterial supply

Venous supply Tracheostomy Downward enlargement of thyroid Parathyroid glands Function Development Vascular supply

Common carotid

Bifurcation Location and structural relations hemorrhaging Abnormal bifurcation Carotid sinus Tachycardia

Carotid body IC and EC EC Development Branches and supply

Accessory nerve passes obliquely through muscle entering and upper and second quarter junction and leaving at junction of upper and second thirds and makes for trapezius Flex and extend head when acting together Acting along, rotates face to opposite side and bend head to same side Accessory muscle of inspiration From a duct beginning at junction of ant 2/3 and post 1/3 (foramen cecum) and passing down between muscles of tongue to ant surface of hyoid and then follows down behind its post surface deviating either to right or left due to laryngeal prominence At trachea, gives rise to isthmus covering tracheal rings 2,3 and 4, and lateral lobes covering 6th ring to thyroid cartilage Small prominence on sup border of isthmus usually left side May persist and little muscle called levator glandulae thyroideae may be present on it Recurrent and external laryngeal nerves and esophagus and trachea, these may be affected by glandular enlargements Post surface has parathyroid glands Sup thyroid artery (EC) reach apex of lateral lobe Inf thyroid artery (subclavian via thyrocervical trunk) – related closely to recurrent laryngeal nerve Also blood supply from vessels supplying esophagus and trachea => tying off thyroid vessels not very serious Sup thyroid veins, middle thyroid -> IJV needs to be divided to mobilize gland Inf thyroid veins -> brachiocephalic, in danger if tracheostomy done below isthmus of thyroid instead of through it Downward enlargement diagnosed by compression of inf thyroid and brachiocephalic => enlargement showing mediastinal compression Calcium metabolism Upper pair = from fourth pharyngeal pouch Lower pair = from third pouch along with thymus => sometimes migrate along with migrating thymus into sup mediastinum => tumors can be anywhere from thyroid gland to mediastinum Sup/inf thyroid vessels supply At level of upper border of thyroid cartilage bifurcates into EC and IC After escaping covering by SCM nad strap muscles, makes for carotid tubercle of C6 vertebra => can be compressed against it to stop hemorrhage Lies next to trachea and esophagus Much higher than usual => dangerous if cut before bifurcation At bifurcation, is a baroreceptor for controlling intracranial blood pressure, reflexively slows heart (via afferent CN9 (sinus nerve) and efferent CN 10) Cause tachycardia in cases of low blood pressure, alleviated by massaging carotid sinus to slow heart rate If compressed at carotid sinus for too long, faintness due to lowering of heart rate Behind the sinus, detect changes in chemical constitution => chemoreceptor IC from dorsal aorta and EC from ventral, and then goes intracranially and extracranially respectively At birfurcation, IC lies external and deeper than EC Ascending pharyngeal – pharyngeal structures Sup thyroid – moves upon swallowing, supplies larynx through internal laryngeal branch piercing thyrohyoid membrane Lingual – ligated in operations of tongue, hypoglossal crosses loop of lingual, preserved when vessel is dilated (artery deep, nerve superficial) Facial – deep to digastric, enter post border of submandibular and embedded there, at inf border of mandible easily

Maxillary artery

Supply and branches

palpable because escapes gland (tonsillar artery – runs on outer surface and perforates wall of pharynx to supply tonsil Labial – contributes to nasal septal anastomosis – Kiesselbach anastomosis) Post auricular & occipital – muscles and skin of back of neck (come off post surface of EC) Maillary & sup temporal – terminal branches after entering parotid gland External and middle ear Muscles of mastication Orbit (along with ophthalmic artery) Upper teeth and nose Inf dental branch – mandible nad teeth Meningeal branches – middle and large – enter skull through foramen spinosum, extradurally located, supply meninges and skull bones Acessory meningeal – pass through foramen ovale and supplies trigeminal ganglion (one of causes of trigeminal neuralgia) Runs with auriculotemporal nerve in front of tragus of ear and divides into ant and post branches to supply temporal region of scalp Sometimes diseased causing temporal arteritis Deep to post digastric and styloid process, entering through carotid foramen into skull No collateral anastomoses => intracranial collateral circulation used to bypass deficiency = risky Carries sympathetic nerves into cranial cavity from sup cervical ganglion (control caliber of intracranial vessels) Ophthalmic artery is a branch Grouped around are CN IX, X and XI which enter jugular foramen and XII exits just medially Deep to post digastric and stylohyoid muscles Carotid sheath is not thick, is distensible Meets medial quarter of clavicle in notch between heads of SCM Pneumothorax because needle punctured at junction with clavicle may puncture cervical pleura Pharynx, tongue, face, thyroid Common facial vein – ant facial and ant retromandibular Used to pass cannula into IJV for feeding in pediatric patients With inf petrosal sinus which carries intracranial blood when larger intracranial veins are blocked Two bulbs – one superiorly at floor of tympanic antrum Other above bicuspid valve above clavicle Deep cervical chain of lymph nodes surround IJV Have grooves for the large ant rami of nerves on C3-7 vertebrae Large ant rami of lower cervicals lie between scalenus ant and medius Covers scalenes, levator scapulae, longus capitis, longus cervicis Prevent inflated lung with pleura from rising high into neck, runs from inf border of first rib to transverse process of C7 vertebra Subclavians run (between scalenes medius and ant and crosses first rib becoming axillary artery) across sibson’s on way to upper limb Subclavian vein, in front of scalene ant and becomes axillary vein after crossing first rib Vertebral artery – enters suboccipital triangle after making wide curve, which is needed so that fainting does not occur with every rotation of neck If narrowed at origin subclavian steal syndrome => opposite vertebral artery fills by diverting blood away from basilar to fill affected subclavian from above => reduction of blood reaching medullary region of brain with ischemia of upper

Superficial temporal IC

Supply and location Temporal arteritis Location and problems

IJV

Location and relation to IC Carotid sheath Pneumothorax

Branches Junctions and features

Deep neck

Cervical nerves

Transverse processes of cervical vertebrae Prevertebral fascia Suprapleural membrane covering apex of lung

Deep neck muscles Sibson’s fascia

Subclavian artery

Branches of 1st part Subclavian Steal syndrome Coarctation of Aorta Location of inf

cervical/ stellate ganglion

limb/ giddiness resulting Stellate ganglion right below origin of vertebral artery Int thoracic – divides into musculophrenic (diaphragm, adj muscles) and sup epigastric, and pericardiophrenic supplying phrenic nerve Branches to each intercostals, thymus, pleura and pericardium If aorta congenitally narrowed beyond origin of subclavian (coarctation) blood reaches aorta via anastomosis between IC branches of int thoracic and aorta => dilation of IC branches Used in coronary artery occlusive disease – implanted into vessel beyond narrowed segment Thyrocervical trunk – - inf thyroid along inner border of scalenus ant, enters thyroid gland to supply bulk of gland, related closely to recurrent laryngeal nerve supplies parathyroid glands, => if ligated then hypofunction of these glands - transverse cervical & suprascapular – muscles of scapular region, scapular anastomoses which play role in coarctation of aorta - costocervical trunk – sup IC to supply first two IC spaces and anastomose with aorta, and deep cervical to supply deep neck muscles Most of analogous branches of artery If not into subclavian, then drain into EJV or brachiocephalic vein C5/6 form upper trunk, C7 is middle trunk, C8-T1 is lower trunk Sandwiched between scalenes after further subdivisions into ant and post behind clavicle, regroup to from cords in axilla Thoracic outlet syndrome (scalenus ant syndrome, costoclavicular syndrome) – due to subclavian vein, artery and plexus passing between clavicle and first rib, subclavius muscle cushions this compression Radial pulse can be obliterated by bracing down, channel enlarged by either removing scalenus ant, first rib or extra cervical ribs Cervical branches – supply subclavius, suprascapular nerve and serratus anterior (all start with S) Long thoracic nerve which supplies serratus ant is from C5 but has fibers from C6 and C7 too (rhomboids receive supply from own branch of C5 not from brachial plexus) C4 in both brachial and cervical Mostly behind scalenus medius Phrenic – C345, curve around lateral edge of scalenus ant, mixed sensory and motor From everywhere except right chest arm head and neck and lower half of right lung Malignant cells pass from rest of body to venous system, pass from cervical part to neighboring supraclavicular nodes Spongy bone between inner and outer tables of skull bones, responsible for making blood cells and also deposition site of secondary tumors Initially membranous and ossify with passing years Fetus able to compress its head to smallest possible size Sutures overlap during delivery – molding, if excessive molding due to tight fit, then damage to intracranial structures Suture between frontal bones that disappears in 90 % of skulls Supraorbital nerve passes through supraorbital foramen and anesthetic at this notch will anesthetize substantial area of scalp Lacrimal gland slightly above junction of the zygomatic process to form zygomatic arch

Branches of 2nd part

Subclavian vein Cervical nerves

Drainage Brachial plexus Thoracic outlet syndrome Cervical branches

Cervical plexus

Thoracic duct

Drainage Malignancy Function and location Sutures Molding

Head

Diploe Skull bones

Frontal bones

Metopic suture Features

Frontal air sinus Parietal bones Features

Occipital bone

Features

Temporal bone

Features McEwan’s triangle Mastoiditis

Sphenoid bone

Features

Foramena

Ethmoid

Features Ethmoiditis

Zygomatic Nasal, lacrimal, maxillary

Features Features

Palatine Vomer Mandible

Features Features Features

Trochlea, spine by the articulation of frontal with nasal bone, attaches pully for sup oblique muscle of eye Superciliary ridges become larger in elderly Frontal tuberosity more pronounced in child Frontal air sinuses separated by a not so median septum Filled with pus etc. and if fractures of frontal bone pass into frontal air sinus then can get infected and enter cranial cavity Asterion at the junction of occipital parietal and temporal bones To each side of the sagital-lambdoidal junction are grooves for the emissary veins between scalp and sagittal sinus Made up of four bones that are separate at birth and soon fuse Foramen magnum transmits – spinal cord with meninges, spinal roots of accessory nerves, vertebral vessels and sympathetic plexuses and spinal vessels and apical ligament Ext auditory meatus mostly tympanic plate of temporal bone Medially fuses with petrous part of temporal Triangle is formed by line down from ext acoustic meatus, supramastoid crest, suprameatal spine to the zygomatic process is the McEwan’s triangle Beneath triangle is mastoid antrum, prolongation of middle ear and commonly involved in middle ear infections Mastoid process is post and inf to the antrum, and develops starting when baby begins lifting head Cavity prolonged into process by intercommunicating air cells, which allows spread of middle ear infections to cause Mastoiditis Styloid process – formed from second pharyngeal arch cartilage Mastoid – from petrous Separated by deviated septum like frontal bones Tuberculum sellae site where ant lobe of pituitary passes form origin in oral cavity to interior of skull Tumors migrate from pharynx to cranium – craniopharyngeomas, dorsum sellae over sella turcica Optic chiasma ant to tuberculum sellae Post surface united to occipital with a cartilaginous joint Sup orbital fissure between greater and lesser wings of sphenoid Pterygoid processes attach muscles of palate and upper pharynx, medial pterygoid ends in hamulus which hooks tensor palatine muscle Rotundum – maxillary nerve Ovale – mandibular nerve Spinosum – middle meningeal vessels Sup orbital fissure - ophthlamic Crista galli on perpendicular process, attaches falx cerebri Cribriform plate – passage of olfactory nerve rootlets Two lateral masses of ethmoid honeycombed by air cells – ant and middle post sinuses Infection of air sinuses – ethmoiditis Forms prominence of cheek and inf boundary of orbit Maxillary process in orbit articulates with lacrimal bone and contains the lacrimal sac – absorbs tears that are produced by lacrimal gland after flowing across eye Maxillary air sinus, infraorbital foramen where terminal part of maxillary nerve exits to face are features of maxillary bone Has a vertical portion wedged between pterygoid process of sphenoid and maxilla Articulates with bones forming roof and floor of nose Coronoid process and condyle Attachment for temporalis muscle and articulation with mandibular fossa for the TMJ respectively Notch between where the muscular branch (masseteric) of mandibular nerve passes over mandible Mental foramen for passage of mental nerve

Base of skull

Features Cleft palate/ hare lip Torus palatinus

Fossae

Clinical aspects

Supraorbital and mental foramina lie in same vertical line next to space between two premolar teeth Lingula in the mandibular fossa landmark for anesthetizing the dental nerve which supplies the teeth of the lower jaw Premaxilla contains the four incisor teeth, and is joined to maxilla by a suture which then fuses When maxillary bones do not fuse – cleft lip When premaxillary bones also do not fuse – hare lip because lip also involved Torus palatinus – when a large lump found at junction of palatine plates of maxilla and palatine bones Foramen lacerum – on undersurface of petrous temporal, posterolateral to it lies the carotid foramen admitting int carotid artery, closed by cartilage in life (Int carotid so convoluted so as to reduce impact of a pulsatile inflow into a rigid cavity) Jugular fossa – accommodates the jugular bulb a dilatation of the IJV Digastric fossa for attachment of digastric Medial to this is groove for occipital artery Stylomastoid foramen – admits CN VII Condylar canal in front of condyle through which hypoglossal nerve emerges Ant – fracture of cribriform plate of ethmoid or orbital plate of frontal bone will cause bleeding into nose and/or orbit When fracture of roof of nose involves meninges, CSF leaks into nose – cerebrospinal rhinorrhea, may spread as meningitis from nose to meninges, olfactory nerve usually damaged because runs through cribriform plate => anosmia Subconjunctival hemorrhage in fracture eof orbital plate, cause bulging of eyeball or paralysis of eye muscle when blood flows from orbit and beneath conjunctiva Middle – tegmen tympani fracture (roof of middle ear) causes bleeding into middle ear => bluish bulge of tympanic membrane May involve meninges and causes leakage of CSF into ear – otorrhea Post – if basilar part of occipital bone fractured where it forms roof of pharynx, bleeding will occur into pharynx and usually regurgitates into mouth Vault and sides – membranous Base – cartilaginous Mandible fuse in year 2, frontals later Ossification of parietal and frontal bones begins at prominent tuberosities and spreads throughout bones later Fontanelles – ant useful for sampling ventricles or blood from sup sagittal sinus (closes by end of second year) Bulging indicates increased intracranial pressure and depression means dehydration Mastoid process does not develop completely until SCM fully active => stylomastoid foramen is near the surface in infant skull and nerve may be damaged External acoustic meatus very short in child because tympanic bone grows later from an incomplete ring at birth. Face is small in child because of: - rudimentary air sinuses (grows at age 7/8 and puberty) - lack of development of teeth and therefore of mandible Failure of fusion of skull usually at ant and post extremities and protrusion of meninges with or without brain tissue might occur Easy to diagnose at occipital because bulging at coughing or crying => increased intracranial pressure

Skull

Development

Scalp

Features Sebaceous cysts Gaping wounds Black eyes Cephalhematoma

Lymphatic drainage

Arterial supply

Venous drainage

Innervation

Face

Features

TMJ

Features

At nasal region will bulge into nose but may be removed in place of a polyp. Due to blockage of sebaceous glands at hair follicles Inflammatory lesions extremely painful because connective tissue layer which contains nerves and blood vessels is dense, also infiltration of anesthetic is difficult as a result. Dense fibrous tissue holds blood vessels open causing profuse bleeding Aponeurotic layer stretches between occipitalis and frontalis and laterally to zygomatic arch and so wounds here gape because pulled open by two muscles Black eye affecting upper lid and lower lid due to blood accumulation in areolar layer of injury to scalp gravitates inferiorly to eyelids Cephalhematoma – collection of blood under pericranium of bone following excessive molding, usually affecting parietal bone (most mobile) No lymph nodes on scalp so drains to nodes at base of scull Main supply for skull bones is from meningeal vessels internally and vessels supply muscles attached to eh skull externally NOT from scalp vessels EC and IC Ophthalmic -> supratrochlear and supraorbital EC branches – facial and superficial temporal and posterior auricular and occipital supply skin of the head -Facial - IC cutaneous and EC facial anastomose at inner angle of eye. Increased pulse amplitude within facial artery indicates blockage of IC (Facial crosses body of mandible in front of masseter muscle and then up to inner angle of eye) -Sup temporal - palpable in front of tragus of ear – biopsies taken here might include auriculotemporal nerve -Occipital – anastomosed to facial in cases of intracranial ischemia - Facial more superficlaly and straighter than artery Facial -> deep facial -> pterygoid plexus over buccinator muscle -> cavernous sinus So two venous connections between face and cavernous sinus and allow infected facial lesion to spread => area around side of nose and upper lip = dangerous area of face - Mastoid emissary: intracranial sigmoid sinus -> post auricular also allow for extracranial lesions to spread intracranially - Facial nerve – opththalmic – side of nose, upper eyelid, scalp upto vertex Maxillary – area of cheek Mandibular – area of lower jaw Three areas meet at angle of mouth - Cervical: post scalp – greater and lesser occipital – post and ant rami of C2 Skin over angle of mandible – greater auricular – ant ramus of C2 No deep fascia so muscles insert into bone or skin Infection and injury accompanied by swelling Muscles – innervated by terminal branches of facial nerve So facial nerve paralysis => cannot close eyes or mouth Articular eminence and postglenoid fossa – mandibular fossa Clicking of jaw – loose articular disc Mumps – glenoid lobule of parotid passes between tympanic plate and condyle of mandible => opening and closing jaw is painful Dislocation – due to sudden contractions sending condyle forward over eminence into the infratemporal fossa. Neighboring muscles go into spasm to prevent painful movement so condyle pulled upward by masseter and medial pterygoid Reduction – by pulling mandible downward to overcome spasm and then backward push

Muscles

Salivary glands

Parotid

Capsule and disc attachment get looser with each succeeding dislocation Temporalis and masseter – elevate Digastric, mylohyoid, geniohyoid – depression Lateral pterygoid – protrusion Medial pterygoid – retraction Muscles of mastication – motor root of mandibular nerve Buccinator – passing food from vestibule into mouth for proper mastication – CN VII, drooling if inactive Lies in contact with masseter, medial pterygoid, SCM and disgastirc because of their relationships to the mandible and mastoid foramen respectively Duct palpable crossing the contracted masseter, pierces buccinator opposite third molar to enter mouth – oblique passage prevents refliux into duct form mouth From most superficial to deepest: - Facial nerve s- splits into two terminal divisions to supply facial muscles => swelling with paralysis of nerve - retromandibular vein – leaves at lower border and ant -> facial, post -> EJV - EC enters gland and bifurcates into internal maxillary and sup temporal Important lymph nodes – parotid mass could be primary tumor in pharynx spreading to parotid lymph node Auriculotemporal nerve – close to parotid, joins sup temporal artery on side of face Serous secretion => no calculi For removal: - Incision made well below lower border of mandible to avoid severing mandibular branch of facial as it turns up over mandible - Grasped and freed from mylohyoid (has a free post border around which the gland hooks) and quadrilateral hyoglossus on a slightly deeper plane - Facial artery buries itself in post portion of gland before turning up between gland and lower border of mandible which it crosses - hyoglossus has (1) large lingual nerve with PSNS secretory branches, (2) submandibular duct behind post border of mylohyoid which could get entangled with lingual nerve, (3) hypoglossal nerve with accompanying vein Usually removed to remove diseased submandibular lymph nodes, or if stone blocks duct of Wharton whose orifice can be seen lateral to frenulum Mostly mucous secretion, problems rare From a shelf of epithelium from which ingrowths pass deeply to form primitive tooth buds Mandibular appear before maxillary 1st molar at 6th year – first permanent tooth, second permanent molar at 12, from 18 wisdom tooth (sometimes may stay impacted in mandible => trouble) Upper premolar and molars project into floor of maxillary air sinus Sometimes only mucous membrane separates – hard to distinguish between sinusitis and tooth abcesses Second and third molars of lower jaw lie below mylohyoid line => root abscesses from these teeth present in neck, those of others present in mouth Maxillary – terminal branches of maxillary nerve Mandibular – terminal branches of mandibular nerve, ear also innervated => toothache may present as earache Same for sixth year molar eruption which may cuase ear ache. From first and third arches and muscle from occipital myotomes Second arch – buried in substance of tongue Ant 2/3 covered by thick mucous membrane with projecting

Submandibular

Teeth

Sublingual Development

Roots

Nerve supply

Tongue

Development and features

Muscles

Vascular Lymphatics Innervation

Pituitary gland

Function and structure

Disease

Nasal passage s, pharynx and larynx

Nose

Functions and structure

Innervation Arterial supply Paranasal air sinuses Venous drainage Bones involved and location

Pharynx

Structure

filiform and fungiform papillae Filiform – roughness Fungiform – small pink spots Vallate – in front of sulcus terminalis Foramen cecum – origin of thyroglossal duct at apex of sulcus terminalis Ant 2/3 is flat, Post 1/3 has lingual tonsil Intrinsic – shape, extrinsic – position (genio, hyo and styloglossus) Genio – protrudes, hyo – downward and sideways, stylo – retracts Mylohyoid - elevates Lingual artery which loops allowing for protrusion Ant 2/3 drains to submandibular Post 1/3 draines to deep cervical Post 1/3 and area near midline – drain bilaterally Ant 2/3 – general - lingual branch of mandibular Taste – chorda tympani of CN VII Post 1/3 incl. vallate papillae – glossopharyngeal Motor – CN XII – every muscle except palatoglossus CN X and IX – palatoglossus CN V – lingual branch has sensation to ear, and also earaches arise from lesions on tongue Facial nerve lesion – lose taste from ant 2/3 Hypoglossal lesion – that half would be paralyzed Controls secretion of all other endocrine organs Ant lobe passes from buccal cavity through base of skull to reach intracranial cavity Post lobe is a downgroth of base of brain, and between two lobes is pars intermedia Infundibulum connects it to base of brain through the dorsum sellae Either excessive or insufficient secretion, or enlargement of gland which compresses surrounding structures Laterally: cavernous sinuses where III IV V2/3 VI and IC lie, and often involved in pituitary tumor Ant lies optic chiasma and if involved in tumor, visual defect occurs Sup compress base of brain and inf excavates sella trucica and encroaches on sphenoidal sinus => seen radiographically Reach fosa to remove tumor via nasal cavity and sphenoid sinus and avoid nasal contents by staying in a plane deep to mucous membrane Warm humidify filter inspired air, using columnar ciliated cells interspersed with goblet cells. Vascular plexus heats air. Sneeze reflex removes objectionable material Deviated septums are common due to trauma Chonae are bones that create meatuses – upper two are processes of ethmoid and inf is an independent bone V1 V2 Maxillary artery post and facial artery ant, anastomosis at region of vestibule Submucosal plexus of veins Sphenoidal – drains into sphenoethmoidal recess above superior concha Ethmoidal – lateral mass of ethomoid and consists of ant middle and post air cells, drain into middle meatus Ethmoidal sinusitis due to inflammation Frontal – deep under superciliary ridges, frontonasal duct drains into middle meatus. Frontal sinusitis presents with frontal headache with tenderness over sinus and pus in middle meatus. Maxillary – opening into middle meatus is near upper part of sinus near its roof, also roots of some upper teeth esp bicuspids and molars project into floor of maxillary sinus Squamous mucous membrane except for nasal area where it is ciliated with submucous glands

Innervation

Nsaopharynx

Relations

Diseases

Oropharynx

Structure nad location Palatine tonsils

Innervation Laryngopharynx Features

Palate

Hard palate

Soft palate and muscles

Innervation

Inf constricter acts as sphincter, area between transverse and oblique fibers of this muscle called the dehiscence of Killian is weakened by strong propulsive effects and may cause a diverticulum but may be so symptomatic as to require removal Pharyngeal nerve plexus mainly CN XI fibers carried in pharyngeal branch of X with some of sup cervical ganglion and ext and recurrent laryngeal nerves Diseases of X or XI lead to paresis of constrictor muscles – difficulty swallowing also called bulbar palsy. Phyrngeal opening of pharyngotympanic tube lies 1cm behind and just below post end of inf nasal concha Posterosup. is tubal elevation (torus) caused by shape of underlying tubal cartilage and collection of lymphoid tissue Lymphoid tissue may swell in addition to torus and cause blockage of tube => deafness during cold Nasopharyngeal tonsil atrophies at puberty and reappears in elderly causing an increase in retropharyngeal space => diagnosis of enlarged nasopharyngeal tonsil Behind mouth between soft palate and tip of epiglottis, palatoglossal and palatopharyngeal arches separate the arches form the cavity. Tonsillar pits Sup constricter muscle lies outside and is pierced by several tonsillar arteries esp tonsillar branch of facial artery Veins pass to pharyngeal venous plexus  post-tonsillectomy hemorrhage Drains to upper deep cervical nodes esp tonsillar (jugulodigastric) node at junction of common facial vein and IJV, commonly results after sore throat V and IX really diffuse – local infiltration via local infiltration instead of regional block Waldeyer’s ring – lingual, palatines, adenoid, tubal Piriform fossa on either side hiding place for tumors Palatopharygeus form hard palate, salpingopharyngeus from Eustachian tube, stylopharyngeus from styloid process outside constrictors and passing between upper two to join the other muscles Elevators of pharynx Maxillae and palatine bones Mucous membrane strongly adherent and imp in cleft palate operation Small salivary glands so salivary gland tumors may present here Tensor palatine muscle closely related to Eustachian tube so contraction opens the tube allowing air to pass between nose and middle ear Levator palatini main function is to elevate the soft palate but also opens up Eustachian tube Both together abolish aircraft deafness Palatopharyngeus and palatoglossus help close off oral cavity from oropharynx Musculus uvulae nerve supply interruption – displacement of uvula to opposite side Naso: V esp V2 and V3, pharyngeal branch of maxillary Oro: IX Laryngo: X Motor: tenosr palatini by V via otic ganglion All others by pharyngeal plexus from XI which enters X and distributed by pharyngeal branch Phonation and deglutition: nasopharynx sealed off by elevating soft palate against sup constrictor Phonation Criocoid – only completely circular one, bears arytenoids Arytenoids – ant projection for vocal cord and laterl for muscles and sup for corniculate cartilage

Larynx

Function and cartilages

ligaments

Muscles

Thyroid – laryngeal prominence in male Corniculate and epiglottis– yellow elastic along with epiglottis, does not calcify with age Whole larynx in adult: C3-6, in child: C3-4 Cricovocal – free border is vocal cord Quadrangular – upper free border is areepiglottic fold Lower is vestibular fold or false vocal cord Thyrohyoid – small bursa between membrane and hyoid bone = subhyoid bursa facilitates laryngeal movement, pierced by sup laryngeal artery and int laryngeal nerve Intrinsic: Cricothyroid – tilds thyroid forward or cricoid backward, to separate them so vocal cord lengthened Thyroarytenoid – shortens vocal cord Post cricoarytenoid – more oblique with descent and so upper horizontal and lower vertical, former rotate, latter separate arytenoids (dilator of larynx) Lateral cricoarytenoid – adductor of cords Interarytenoid – connect the two arytenoids, pulls epiglottis and arytenoids together & closes laryngeal inlet Extrinsic: Elevators: mylo, stylo, geniohyoid, stylo, salpingo, palatopharyngeus Depressors: strap muscles ant to laryngeal skeleton Mainly columnar ciliated with scattered goblet cells Squamous – vocal folds and laryngeal inlet Vocal fold – no submucosa, minimal blood vessels => whitish Laryngeal edema – submucous tissues swell markedly, swelling may continue downwards and result in complete laryngeal obstruction and asphyxiation During mouth to mouth head should be fully extended to bring oral cavity in line with larynx Vallecula – between lateral glossoepiglottic folds of mucous membrane where neoplasms may hide and foreign bodies impact Saccule – projects from ventricle between false cord and lamina of thyroid cartilage and secretes mucus Aryepiglottis and interarytenoids contract and close sphincter Expiration of air through vocal cords vary intensity and pitch of sound Above folds – sup laryngeal branch of sup thyroid Below – inf laryngeal branch of inf thyroid Above – int laryngeal branch of vagus – sensory and secretomotor Below - recurrent laryngeal nerve All muscles except cricothyroid (ext laryngeal branch of sup laryngeal) – recurrent laryngeal First cricothyroid innervated pulling cords on stretch stimulating other muscles to act => tuning fork of larynx Deep cervical nodes as they lie along jugular vein, upper half to upper and lower half to lower Involved in laryngeal disease Some also to prelaryngeal and pretracheal nodes Occipital - most post, between mastoid process and inion post auricular – on mastoid process behind pinna drain scalp back of pinna and ext auditory meatus preauricular – immediately in front of tragus of ear and superficial to parotid, drains outer side of pinna parotid – more superficial for eyes front of scalp and ext auditory meatus, deeper ones for nasopharynx and back of nose facial – on buccinator below orbit and over facial vessels as they cross mandible, drain conjunctiva eyelids nose and cheek submandibular – same fascial capsule as submandibular glands submental – drain central part of lower lip, floor of mouth tip

Mucosa

Other structures

Functional movements Arterial supply Innervation

Lymphatics

Lymph nodes of head and neck

Chains

Circular

Vertical

Clinical approach

Ear

External ear

Features Innervation

External auditory meatus

Features

Innervation

Middle ear

Features

Problems

Middle and ext ear

Development

of tongue and incisor area of mandible Superficial – ant cervical in midline draining larynx and trachea Deep – along recurrent laryngeal called paratracheal Lymph node of tonsil in angle between IJV and common facial Lymph node of tongue between at bifurfaction of common carotid involved in tongue lesions Supraomohyoid above point where ant belly of omohyoid crosses carotid sheath Final drainage – into jugular lymph trunk leaving inf deep cervical and enter junction of subclavian and IJV on R and thoracic duct on L - No lymph nodes on cranium - Nodes in lower third enlarge due to diseases below clavicle eg. virchow-troisier enlargement from stomach cancer - middle third enlarged node emanates from thyroid gland disease - upper third due to disease of head and upper neck - ant submental drain central wedge of tissue in floor of mouth including tip of tongue floor of mouth gums lower lip opposite four lower incisor teeth - post submandibular drain lateral part of lower lip all upper lip and ext nose and ant 2/3 of tongue , also from paranasal sinuses and ant half of walls of nasal cavity - Most post drain structures not drained by aforementioned - more post higher to which they drain i.e. highest jugular for pharyngeal tonsils Cellulites unlikely due to lack of subcutaneous fat Ant to tragus is preauricular lymph node and pulse of superficial temporal artery Sensory – greater auricular to lower part Auriculotemporal and lesser occipital to facial and cranial surfaces Short meatus of child Thick hairs and sebaceous and wax glands on cartilaginous part and smooth of bony Inflammatory lesions common in meatus Proximal to tympanic membrane is depression where foreign bodies can hide Skin is closely adherent to underlying cartilage or bone Auricular branch of vagus for post half Auriculotemporal for ant half => elderly patients may faint as result of cardiac syncope if syringing out ear due to vagal innervation, same with coughing and gagging Intraoral structure pain referred to ear eg. Pain from erupting tooth Tympanic membrane so oblique in child almost horizontal Fibrous tissue lined by skin ext and mucous membrane int Cartilaginous part 2x as long as bony part of Eustachian tube Aditus into upper part of tympanic antrum leads to mastoid air cells so infections spread from aditus into tympanic antrum and mastoid air cells Auditory ossicles only bones which are full sized at birth Conductive defect - diagnosed if easier to hear tuning fork placed on mastoid process than near ext ear Occlusion of auditory tube – absorption of iar, potential vacuum prevented by outpouring of sticky fluid => glue ear Destructive lesions of middlear can damage facial nerve as it passes through Pinna – series of tubercles around margins of first branchial groove Ext meatus – remains of first ext branchial groove or cleft Middle ear – first pharyngeal pouch from lateral recess of pharynx Auditory tube and tympanic cavity – ectoderm of ext diverticulum Tympanic antrum well developed but not mastoid process at

Inner ear

Features

Orbit

Orbit

Features

Contents

Globe

Muscles

Fascial sheath (Tenon)

Arterial supply

Venous drainage

Eyelids

Features

Tarsal plates Eyelashes

Lacrimal apparatus

Features

birth => infections of tympanic antrum common in first two years due to wide short Eustachian and frequent upper respiratory tract infections VIII reaches walls of semicircular canals and cochlea and consists of cochlear division for cochlea for hearing and vestibular division to utricle saccule and semicircular canals for equilibrium Protect globe by root of nose and supraorbital margin Medial - Small depression with trochlea on medial wall for attachment of tendon of sup oblique, also related to ethmoidal sinus via ethmoid bone Floor – infraorbital terminal branch of maxillary nerve Lateral – zygomatic withstand molar masticatory force if fractured will result in depression of orbital floor and dropping of eyeball with consequent diplopia (double vision) Optic canal transmits optic nerve with meningeal coverings => eye is an extension of the brain => better to enucleate eye from capsule than sever optic nerve to avoid meningitis Outer layer of dura becomes periostium of orbit Outer fibrous, middle vascular, inner nervous continued as optic nerve Post 5/6 – sclera, ant 1/6 – cornea Corneal scarring – impaired vision Corneal transplantion – successful due to lack of vasculature Rectus muscles from common tendinous ring Sup rectus – elevation/adduction, inf – depression/abduction lateral rectus – abduction, medial – adduction Sup oblique – muscle of tramp – down and out Levator palpebrae sup – probably was once same as sup rectus because lie over each other and share nerve supply Smooth muscle – muller’s muscle of eyelid – SNS Horner’s syndrome – drooping of upper lid due to loss of nerve supply to these muscles Blend with sclera and composed of areolar tissue to allow for movement of eyeball Check ligaments – fascial extensions of lateral and medial recti allowing for movement of eyeball via the suspensory ligament of the eye, facia bulbi forms a socket for a glass eye when eye is removed Infraorbital branch of maxillary (and opththalmic artery), passes through optic canal below opththalmic nerve Central artery of retina pierces optic nerve to reach retina before dividing into branches Sup vein accompanies ophthalmic artery and communicates with ant facial vein Inf vein communicates with pterygoid plexus through inf orbital fissure Both drain into cavernous sinus allowing for infections of head and neck to spread to cavernous sinus No subcutaneous fat and easily fills up with fluid Orbicularis oculi – two parts palpebral part from medial palpebral ligament and lacrimal sac and orbital portion running over forehead and check in concentric loops Have tarsal glands visible through conjunctiva Medial palpebral ligament joins palpebral fascia to each bony crest, helps in locating the lacrimal sac Sweat and sebaceous glands related to and opening ducts near hairs When infected => stye forms and when tarsal glands get blocked – meimobian cyst develops Orbital and palpebral parts of lacrimal gland Mucous membrane thrown into folds preventing substances from entering eye via the lacimal apparatus Corneal reflex: involuntary blinking upon irritation via orbicularis oris (VII) and sensation via cornea (V)

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