SternocleidomastoidMuscle

ScalenusAnteriorMuscles
AnteriorTriangleoftheNeck
PosteriorTriangleoftheNeck
ThyroidGland
CommonCarotidArtery
ExternalCarotidArtery
InternalCarotidArtery(CervicalPart)
SubclavianArtery
InternalJugularVeins
CervicalPlexus
PhrenicNerve(CervicalPart)
CervicalPartofSympathetictrunk
Trachea(CervicalPart)
LymphaticDrainageoftheHead&Neck
Scalp
FacialArtery
FacialNerve
DuraMateroftheBrain
CranialFossae
CavernousSinus
SuperiorSagittalSinus
MiddleMeningealArtery
TypesofIntracranialHemorrhage
CerebralHemorrhage
InternalCarotidArtery(Petrous,Cavernous&CervicalParts)
TrigeminalGanglion
StructureoftheEyeball
MovementsoftheEyeball
OphthalmicArtery
LacrimalApparatus
VertebralArtery
ParotidGland
TemporomandibularJoint
MovementsoftheMandible
MaxillaryArtery
MaxillaryNerve
MandibularNerve
PterygopalatineGanglion
SubmandibularGland
LingualNerve
NasalCavity:Relations,Openings&Branches
Tongue:Features&Muscles
InnervationoftheTongue
ConstrictorMusclesofPharynx
Nasopharynx
MechanismofSwallowing

AuditoryTube
MiddleEarCavity
PterygopalatineFossa
CutaneousInnervationofFace
th
GlossopharyngealNerve(9 CranialNerve)
VagusNerve(10thCranialNerve)
th
AccessoryNerve(11 CranialNerve)
HypoglossalNerve(12thCranialNerve)
ParanasalSinuses
OralCavity
Palate
Pharynx
Oropharynx
Laryngopharynx
ExternalEar
Larynx

LifernsAnatomy:Head&Neck

SternocleidomastoidMuscle
Thesternocleidomastoidis1ofthe2large,supfmusclesoftheneck

Origin
sternalhead tendinous
arisesfromsuperolatpartoffrontofmanubriumsterni
clavicularhead musculotendinous
arisesfrommed1/3ofuppersurfaceofclavicle

Insertion
Itisinsertedby:
1. atendonintomastoidprocessofthetemporalbone
2. athinaponeurosisintolatpartofsupnuchallineofoccipitalbone

NerveSupply
spinalpartofaccessoryn motor
ventralramiofC2&C3 sensory(proprioceptive)

BloodSupply
bybranchesfromoccipitalartery

Actions
Whenbothmusclescontract: 1.extendheadatatlantooccipitaljt
2.flexcervicalpartofvertebralcolumn
When1musclecontracts: 1.tilttheheadtowardstheshoulder
2.rotatesheadsothatthefacelooks
upwardsontheopposide
Iftheheadisfixed,the2musclescanalsoactasaccessorymusclesofinspiration

Relations
Supf 1. skin
2. fascia&platysma
3. extjugularvein(EJV)
4. greatauricular,tnvscut&medsupraclavicularnerves
5. supfcervicalLNalongEJV
6. parotidgland
Dee 1. carotidsheath&itscontents:common&ICA,IJV&vagusn
p 2. muscles: sternohyoid,sternothyroid,omohyoid,scaleniant,med&post
levatorscapulae,spleniuscapitis&postbellyofdigastric
3. besidescommoncarotidart(CCA)&intcarotidart(ICA)
therearealso 1.extcarotidart(ECA)
2.occipitalart
3.subclavianart&suprascapularart
4. besidesintjugularvein(IJV),therearealso 1.antjugularvein
2.facialvein
3.lingualvein
5. besidesvagusnervetherealso: 1.accessorynerve
2.cervicalplexus
3.upperpartofbrachialplexus
4.phrenicn&ansacervicalis
6. deepcervicalLN

ClinicalNotes
1. thesternocleidomastoiddividestheneckintoant&posttriangles
2. congenitaltorticollis
3. spasmodictorticollis

ScalenusAnteriorMuscles
Thescalenusanteriorisanimptmuscleofthelowerpartoftheneck
becauseofitsrelationswiththeimptstructuresinthatregion

Origin
fromtheanttuberclesofthetnvsprocessesofCV3,4,5&6

Insertion
Thefibresareinsertedinto
1. scalenetubercleoninnerborderof1st
rib
st
2. ridgeonuppersurfaceof1 rib

Innervation
fromventralramiofC4,5&6

Action
1. assistselevating1st
rib
2. whenactingfrombelow,itlaterallyflexes&rotatescervicalpartofvertebral
column

Relations
Anteriorly Posteriorly Medially Laterally
1. prevertebral 1. subclaviana rt 1. vertebrala rt&v 1. rootsofbrachial
layerofdeep 2. brachialplexus 2. infthyroida rt plexus
cervicalfascia 3. cervicald ome 3. thyrocervical 2. subclaviana rt
2. phrenicn ofpleura trunk 3. rootsofphrenicn
3. supfc ervical& 4. symptrunk
suprascapulara rt 5. ontheleftside,
4. IJV& thoracicduct
subclavianvein

AnteriorTriangleoftheNeck
Thesternocleidomastoidmuscdividestheneckintoananttriangle&aposttriangle

Boundaries
Anteriorly antmedianlineofneck
Posteriorl antb orderofsternocleidomastoid
y
Superiorly infborderofmandible&alinedrawnfromangleofmandibleto
mastoidprocess
Inferiorly theapexofthetriangleliesatthemanubriumsterni

Subdivision
Itissubdividedbythedigastric&supbellyofomohyoidinto
a. submental
b. digastric
c. carotid
d. musculartriangles

a) SubmentalTriangle
base hyoidcore
oneachside antbellyofdigastric

b) DigastricTriangle
anteroinferiorly antbellyofdigastric
posteroinferiorly postbellyofdigastric
superiorly(base) infborderofmandible

c) CarotidTriangle
anteriorly supbellyofomohyoid
posteriorly antborderofsternocleidomastoid
superiorly postbellyofdigastric

d)MuscularTriangle
anteriorly antmedianlineofneck
posterosuperiorly supbellyofomohyoid
posteriorinferiorl antborderofsternocleidomastoid
y

Roof
Theroofisformedby 1.skin
2.fascia
3.platysma

Floor
Triangle formedby
Submental mylohyoidmuscles
Digastric 1. mylohyoid
2. hyoglossus
Carotid 1. thyrohyoid
2. hyoglossus
3. inf&middleconstrictorsofpharynx
Muscular 1. sternohyoid
2. sternothyroid
3. thyrohyoid
ie.infrahyoidmuscles

Contents
Triangle Contents
Submental 1. LN
2. veins
Digastric 1. submandibulargld
2. facialart&vein
3. portionsofparotidgld
4. ECA
situatedmoredeeply
5. ICA
6. IJV
7. glossopharyngealn
8. vagusn
Carotid 1. CCA,ECA&ICA(moredeeply)
2. branchesofECA
3. IJV&someofitstributaries
4. portionsofX,XI&XIIcranialn
5. larynx&pharynx
6. int&extlaryngealn
Muscular 1. thyroidgld
2. trachea&larynx
3. esophagus

PosteriorTriangleoftheNeck
Thesternocleidomastoidmuscledividestheneckintoananttriangle&apost
triangle
Theposttriangleissituatedbhdthemuscle

Boundaries
Anteriorly postborderofsternocleidomastoid
Posteriorly antborderoftrapezius
Inferiorly uppersurfaceofmiddle1/3ofclavicle
Superiorly apexliesonthesupnuchallinelinewhere
thesternocleidomastoid&trapeziusmeet

Subdivisions
Theinfbellyoftheomohyoiddividesitinto
1. largeupperpart:occipitaltriangle
2. smallerlowerpart:supraclavicular(subclavian)triangle

Roof
Theroofisformedby 1.skin
2.fascia
3.platysma
ThefasciaispiercedbytheEJV&supraclavicularn

Floor
Thefloorisformedby 1.semispinaliscapitis(inconstant)
2.spleniuscapitis
3.levatorscapulae
4.scalenuspost
5.scalenusmedius
6.scalenusant(inconstant)
7.1st
digitationsofserratusant
Thesemusclesarecoveredbyprevertebrallayeroffascia

Contents
Occipital 1. spinalpartofaccessoryn
Triangle 2. 4cutaneousbranchesofcervicalplexus
a. lesseroccipital
b. greatauricular
c. tnvscervical
d. 3supraclavicularn
3. dorsalscapularn(torhomboids)
4. upperpartofbrachialplexus
5. tnvscervicalart&vein
6. occipitalartfromECA
7. lymphnodes :alongpostborderofsternocleidomastoid
:supraclavicularnodes
:occipitalnodes
Subclavian 1. 3trunksofbrachialplexus
Triangle 2. longthoracicn(toserratusant)
3. nervetosubclavius
4. suprascapularn
5. 3rdpartofsubclavianart&subclavianvein
6. suprascapularart&vein
7. tnvscervicalart&vein
8. lowerpartofEJV
9. afewsupraclavicularLN

ClinicalNotes
1. enlargementofsupraclavicularLNduetomalignanciesetc
2. brachialplexuscanbeanaesthetizedbyinjectionoflocalanaestheticbtw1st
rib&
skinaboveclavicle

ThyroidGland
Thethyroidgldisanendocrineorganwhichregulatesbasalmetabolicrate&
stimulatesgrowth

Shape
roughlyHshaped

Parts
2lobes:R&L
isthmus,whichconnectsthelobes
sometimesapyramidallobeispresent

Position
ThegldliesatthelevelofCV5,6,7
eachlobeextendsfrommiddleofthyroidcartilageto4th
or5thtrachealring
isthmusextendsfrom2nd to3rd
trachealring

Capsules(Coverings)
fibrouscapsules adherenttounderlyinggld
falsecapsules exttofibrouscapsule
derivedfrompretracheallayerofdeepcervicalfascia
formsuspensoryligtoanchorthegldtothethyroid&
cricoidcartilages&tothetrachea

RelationsoftheLobes
Anterolat 1. sternothyroid
2. sternohyoid
3. supbellyofomohyoid
4. antborderofsternocleidomastoid
Posterolat carotidsheath&itscontents: 1.CCA
2.IJV
3.vagusn
Medially 1. larynx
2. trachea
3. infconstrictorofpharynx
4. esophagus
Associatedwiththesestructuresare
5. cricothyroid
6. extlaryngealn
7. recurrentlaryngealn(ingroovebtwtrachea&esophagus)
Postborderofthe 1. sup&infparathyroidglds
2lobesisrounded 2. anastomosisbtwsup&infthyroidart
&relatedto 3. ontheLside,thoracicduct

10

RelationsoftheIsthmus
Anteriorly 1. sternothyroid
2. sternohyoid
3. antjugularvein
4. fascia&skin
Posteriorly 2 ,3 &4th
nd rd
trachealrings
Superiorly terminalbranchesofthesupthyroidart
anastomosealongitsupperborder

ArterialSupply
supthyroidart fromECA
infthyroidart fromthyrocervicaltrunk
thyroideaima frombrachiocephalicart/archofaorta

VenousDrainage
supthyroidvein intoIJV
middlethyroidvein intoIJV
infthyroidvein anastomosewithLbrachiocephalicvein

LymphaticDrainage
Thelymphaticsfollowthearteries&drainmainlyinto:
1. deepcervicalLN
2. afewlymphvslspasstoparatrachealnodes

NerveSupply
nervesderivedmainlyfrommiddlecervicalganglion
alsopartlyfromsup&infcervicalganglia
thenervesarevasoconstrictor

ClinicalNotes
1. goitre= anyenlargementofthyroidgld
Causes:eg iodinedef
puberty(pubertygoitre)
tumours,etc
2. hyperthyroidism
hypothyroidism
3. becauseoftherelationsofthethyroidtoimptstructures
a. thyroidectomymaycausedamagetothestructures
b. enlargementofthegldmaydisplace&compressthestructures
egtrachea

11

CommonCarotidArtery
Origin
RightCCA branchofbrachiocephalicart(trunk)
beginsinneckbhdRsternoclavicularjt
LeftCCA branchofaorticarch
beginsinthorax&passesbhdL
sternoclavicularjt

Course
runsincarotidsheathalongwithIJV&vagusn
passesupwards&backwardsintheneck,
fromsternoclavicularjttoupperborderofthyroidcartilage
endsbydividingintoECA&ICA(noothernamedbranches)

SpecialFeatures
carotidsinus localiseddilatationatterminalpartofCCA(orbeginningofICA)
innervatedbyglossopharyngeal&sympn
actasbaroreceptortoregulatebldpressure
carotidbody smallreddishbrownstructuresituatedbhdbifurcationofCCA
innervatedmainlybyglossopharyngealn
actsaschemoreceptor
ie.respondtochangesinconcnofO2 &CO2inbld

Relations
Anterolat 1. skin,supffascia,platysma,investinglayerofdeepcervicalfascia
2. sternocleidomastoidoverlapsit
3. sternohyoid
4. sternothyroid
5. supbellyofomohyoid
Embeddedinantwallofcarotidsheath
6. descendenshypoglossi
7. ansacervicalis
Crossingtheart,
8. sup&middlethyroidveins
9. antjugularveins
Posteriorly 1. tnvsprocessesoflower4cervicalvertebral
2. longuscapitis&longuscolli
3. originofscalenusant
4. symptrunk
inthelowerpartoftheneck
5. vertebralvsls
6. infthyroidart
OntheLside
7. thoracicduct
BhdtheterminationofCCA=carotidbody

12

13

 Medially 1. larynx&pharynx
2. trachea
3. esophagus
4. lobeofthyroidgld
5. infthyroidgld
6. recurrentlaryngealn
Laterally 1. IJV
2. vagusliesposterolat

SurfaceAnatomy
ptA: sternoclavicularjt
ptB: antborderofsternocleidomastoidatlevelofupperborderofthyroidcartilage
Joiningthese2ptswillsurfacemarktheartintheneck

ClinicalNotes
1. ligatureoftheCCAon1side
collateralcirculationisestbtw
1)sup&infthyroidart(infthyroid&deepcervicalfromsubclavian)
2)descbranchesofoccipital&deepcervicalart
3)vertebralart
Note: (1)and(2)areoutsidecranialcavity
(3)isinsidecranialcavity
2. bifurcationofCCA:carotidpulsemaybefelt
3. theartcanbecompressedonanttubercleoftnvsprocessofCV6(carotid
tubercle)

14

ExternalCarotidArtery
TheECAisoneofthe2terminalbranchesoftheCCA
&isthechiefartofsupplytoantstructuresintheneck&face

Origin
beginsincarotidtriangle\
atlevelofupperborderofthyroidcartilage(ie.btwCV3&4)

Course
runsupwards,slightlybackwards&laterally
enterssubstanceofparotidgld
terminatesbhdneckofmandiblebydividingintothe
maxillary&supftemporalart
Note: atfirstitliesmedialtoICA.
Itthenpassesbackwards&laterallytolielattoICA

Branches
Thereare8branches
1. supthyroid
2. ascpharyngeal
3. lingual
4. facial
5. occipital
6. postauricular
7. supftemporal
8. maxillary

15

Relations
Anterolat(Supf) 1. sternocleidomastoidoverlapsitatitsbeginning
Abovethislevel,itisrelativelysupf&iscoveredby
2. skin&supffascia
3. cervicalbranchoffacialn
4. tnvscutaneousn
5. investinglayerofdeepcervicalfascia
Itiscrossedby
6. hypoglossaln
7. facial&lingualveins
8. postbellyofdigastric
9. stylohyoidmuscles
Withinparotidgld,itiscrossedby
10. facialn&retromandibularvein
Note:TheIJVfirstlieslattotheart,thenposttoit
Medially 1. wallofpharynx
2. styloidprocess
3. ICA
PassingbtwtheECA&ICA
4. stylopharyngeus
5. glossopharyngealn
6. pharyngealbranchofvagusn
7. portionofparotidgld

SurfaceAnatomy
ptA: ptonantborderofsternocleidomastoid
atlevelofupperborderofthyroidcartilage
ptB: ptbhdneckofmandible
midwaybtwmastoidprocess&angleofmandible
Joiningthese2ptsgivesthesurfacemarkingofECA

ClinicalNotes
Ligatureofartof1side
collateralcirculationismaintainedbtwthebranchesoftheECA
withthoseoftheopposide

16

InternalCarotidArtery(CervicalPart)
TheICAisoneofthe2terminalbranchesoftheCCA
Itistheprincipalarttothebrain&eye
Itscourseisdividedinto4parts
a)cervicalpart
b)petrouspart
c)cavernouspart
d)cerebralpart
Thecervicalpartisdiscussedhere

Origin
beginsinthecarotidtriangle
atlevelofupperborderofthyroidcartilage(iebtwCV3&4)

Course
enclosedincarotidsheathtogwithIJV&vagusn
ascverticallyinthenecktolowerendofcarotidcanalinpetroustemporalbone
lowerpart(incarotidtriangle)iscomparativelysupf
afterascendingdeeptopostbellyofdigastric,itliesdeeptoparotidgld,styloid
process&manyotherstructures
itdoesnotgiveanynamedbranchesintheneck

SpecialFeatures
TheICAmaypresent2structuresatitscommencement
carotidsinus localiseddilatationatterminalpartofCCA(orbeginningofICA)
innervatedbyglossopharyngeal&sympn
actasbaroreceptor(regulatebldpressure)
carotidbody smallreddishbrownstructuresituatedbhdbifurcationofCCA
innervatedmainlybyglossopharyngealn
actsaschemoreceptor(detectchangesinbldO2 &CO2)

17

Relations
Anterolat Belowdigastric
(Supf) 1. skin,supffascia,platysma,investinglayerofdeepcervicalfasica
2. tnvscutaneousn
3. antborderofsternocleidomastoid
4. lingual&facialn
5. hypoglossaln&itsdescendingbranch
6. occipitalart
Abovedigastric
7. postauricularart
8. stylohyoid&stylopharyngeus
9. styloidprocess
10. glossopharyngealn
11. pharyngealbranchofvagusn
12. parotidgld&itscontents :facialn
:retromandibularvein
:ECA
Posteriorl 1. suplaryngealn
y 2. cervicalpartofsymtrunk&supcervicalganglion
3. longuscapitis&prevertebrallayerofdeepcervicalfascia
4. tnvsprocessesofupper3cervicalvertebrae
Medially 1. pharynx
2. suplaryngealn
3. ext&intlaryngealn
4. ascpharyngealart
Laterally 1. IJV
2. vagus

SurfaceAnatomy
pt1: antborderofsternocleidomastoidatlevelofupperborderofthyroidcartilage
pt2: postborderofcondyleofmandible
Joiningthese2ptsgivesthesurfacemarkingoftheICA

ClinicalNotes
atherosclerosiscauses 1.impairmentofvision
2.cerebraldisorders

18

SubclavianArtery
Thisistheprincipalarteryoftheupperlimb
butalsosuppliespartoftheneck&brainthroughitsbranches

Origin
Rsubclavianart arisesfrombrachiocephalicart(trunk)
bhdRsternoclavicularjt
Lsubclavianart arisesfromarchofaortabhdLCCA
asctobackofLsternoclavicularjt

Course
Fordescriptivepurposes,thesubclavianartisdividedinto3partsbythepresenceof
thescalenusant
1stPart archesupwards&latfrombhdsternoclavicularjttomedborderof
scalenusant
2ndPart liesbhdscalenusantmuscle
3rdPart extendsfromlatborderofscalenusanttoouterborderof1st rib
whereitcontinuesasaxillaryart
supf&canbecompressedagainst1strib

Branches
1stPart 1. vertebralart
2. thyrocervicaltrunk
a)infthyroid
b)tnvscervical
c)suprascapular
3. intthoracicart
2ndPart costocervicaltrunk
a)supICart
b)deepcervicalart
3rdPart descending(dorsal)scapularart

Relationsof1st
Part
Anteriorly Frommedtolat
1. CCA
2. ansasubclavia
3. vagusn
4. IJV
5. vertebralveins
6. onLside=thoracicduct
Inaddition
7. cardiacbranchesofvagus&sympn
Posteriorly 1. domeofcervicalpleura&suprapleuralmbm
2. apexoflung
3. ansasubclaviawhichencirclestheart
4. symptrunk&infcervicalganglion

19

 5. ontheRside=Rrecurrentlaryngealn

Relationsofthe2nd
Part
Anteriorly 1. scalenusant
2. sternocleidomastoid
3. subclavianvein(sepbyscalenusant)
4. onRside=Rphrenicn
Posteriorly 1. domeofcervicalpleura&suprapleuralmbm
2. apexoflung
3. scalenusmedius

Relationsof3rd
Part
Anteriorly 1. skin,supffascia,platysma,investinglayerofdeepcervicalfascia
2. supraclavicularn
3. EJV&itstributaries :antjugularvein
:tnvscervical
:suprascapular
4. suprascapularart
5. ntosubclavius
6. clavicle&subclavius
Posteriorly 1. scalenusmedius
2. lowertrunkofbrachialplexus
Superiorly upper&middletrunksofbrachialplexus
Inferiorly uppersurfaceof1st
rib

SurfaceAnatomy
pt1: onsternoclavicularjt
pt2: atmiddleoflowerborderofclavicle
Theartismarkedbyacurvedline,
convexupwardstoabt2cmabovetheclavicle,joiningthe2pts

ClinicalNotes
1. 3rdpartofsubclavianartmaybecompressedagainst1st ribtostopbleedingin
upperarm
2. aneurysmsmayformin3rd partofartery
exertpressureonbrachialplexus&resultsin
pain,weakness&numbnessinupperlimb
3. cervicalribartiskinkedasitpassesoverrib,causingocclusion

20

InternalJugularVeins
TheIJVdrainsthebrain,neck&face

Origin
beginsatjugularforamenatbaseofskull
itisacontinuationofthesigmoidsinus

Course
descendsincarotidsheath
passesdownwards&anteriorly
endsbhdmedendofclaviclebyjoiningwithsubclavianvein
toformbrachiocephalicvein

SpecialFeatures
1. supbulb:dilatationatisorigin
2. infbulb:dilatationnearitstermination
3. Theveinpossess1bicuspidvalvedirectlyaboveinfbulb

Relations
Anterolat 1. skin,supffascia,platysma,investinglayerofdeepc ervicalfascia
2. sternocleidomastoid
3. postbellyofdigastric
4. parotidsalivarygldsepfromitbystyloidprocess&stylopharyngeus
Itslowerpartisc overedby
5. sternohyoid,sternothyroid&omohyoid
Crossingthevein
6. ansac ervicalis
7. stylohyoid
8. posta uricular&occipitala rt
9. spinalpartofa ccessoryn
Alsosupfa re
10. facialn
11. antjugularvein
12. Thedeepc ervicalLNruna longsidetheIJV
Posteriorly 1. tnvsprocessesofc ervicalvertebrae
2. levatorscapulae
3. scalenusa nt&medius
4. cervicalplexus
5. phrenicn
6. thyrocervicaltrunk
7. vertebralvein
8. 1stpartofsubclaviana rt
9. domeofc ervicalpleura
10. ontheL=thoracicduct
Medially Below,
1. vagusn
2. CCA
Atbaseofskull

21

 3. ICA
4. 9th,10th,11th&12thc ranialn

Tributaries
1. infpetrosalsinus
2. facialvein
3. lingualvein
4. pharyngealveins
5. supthyroidvein
6. middlethyroidvein
7. sometimes,occipitalvein
Note: ThoracicductopensintoangleofunionbtwleftIJV&Lsubclavianvein
Therightlymphaticductopenssimilarlyontherside

SurfaceAnatomy
pt1: onneck,medtolobuleofear
pt2: atmedendofclavicle
Joiningthese2ptswillsurfacemarktheIJV

ClinicalNotes
1. Incongestiveheartfailureoranydiseasewherevenouspressureisraised,theIJV
ismarkedlydilated,engorged
2. DeepcervicalLNliealongtheIJV.
Inmalignanciesinvolvingthesenodes,theveinisusuremovedtogwiththenodes
inasurgicalprocedurecalledblockdissectionofthecervicalnodes

22

CervicalPlexus
Thecervicalplexussuppliestheskinatthebackofthehead,theneck&shoulderas
wellascertainmusclesofthenecktogwiththediaphragm

Formation
byventralramiofC1toC4
ther amiarejoinedbyconnectingbranchestoformaseriesof3loopsfromwhich
thebranchesarise

Position&Relations
Anteriorly 1. Itiscoveredantbyprevertebrallayerofdeepcervicalfascia
Itisalsorelatedto
2. IJVincarotidsheath
3. sternocleidomastoid
Posteriorly Itliesinfrontoftheoriginsof
1. levatorscapulae
2. scalenusmedius

Branches
Supf(Cut)Branches 1. Lesseroccipital(C2)
2. greatauricular(C2,3)
3. tnvscut(cervical)(C2,3)
4. med,intermediate&latsupraclavicular(C3,4)
Thecutaneousbranchesallemergenearmiddleofpostborder
ofsternocleidomastoid
DeepBranches CommunicatingBranches
1. Eachofthe4ramireceiveGRCfromthesupcervical
ganglionofthesymptrunk
2. branchfromC1tohypoglossaln
3. otherbranchestovagus&accessoryn
MuscularBranchesto:
1. prevertebralmuscles
2. sternocleidomastoid
3. levatorscapulae
4. scaleniant,medius&post
5. trapezius
Italsosupplies:
6. diaphragmviaphrenicn
7. infrahyoidmuscles(exceptthyrohyoid)viaansacervicalis
Ansacervicalis
liessupfto(orinthesubstanceof)thecarotidsheath
formedby 1.descbranchofhypoglossaln(C1)
2.descendingcervicaln(C2,3)
whichunitetoformaloop
supplyomohyoid,sternohyoid&sternothyroid
(ThyrohyoidissupplieddirectlyviaC1fibreswithin

23

 hypoglossaln)

24

PhrenicNerve(CervicalPart)
Thephrenicnisamixedncarryingmotorfibrestothediaphragm&sensory
fibresfromthepleura,pericardium,peritoneum&diaphragm
Italsocarriessympfibres
Itistheonlymotorsupplyofthediaphragm

Origin
fromC3,C4&C5(mainlyC4)
atlatb
orderofscalenusantatlevelofcircoidcartilage
ThecontributionfromC5maycomeviantosubclavius,inwhichcaseitiscalled
accessoryphrenicn

Course
runsdownwardsverticallyonantsurfaceofscalenusant(bhdprevertebralfascia)
sincescalenusantisoblique,phrenicncrossesitfromlattomedborder
crossesintthoracicartfromlattomedside
entersthoraxbypassinginfrontofsubclavianart&bhdbeginningof
brachiocephalicvein
itdoesnotgiveanybranchesintheneck

Relations
Anteriorly 1. prevertebrallayerofdeepfascia
2. IJV
3. supfcervical&suprascapularart
4. beginningofbrachiocephalicvein
5. ontheL:thoracicduct
Posteriorly 1. scalenusant
2. subclavianart
3. cervicaldomeofpleura

SurfaceAnatomy
pt1: onsideofneckatlevelofupperborderofthyroidcartilage&
3.5cmfrommedianplane
pt2: medendofclavicle
Joiningthese2ptswillsurfacemarkthecourseofthephrenicnintheneck

ClinicalNotes
surgicalinterruptionofthephrenicnonthescalenusantissometimesperfomedtoaid
incollapseofalung
ie. diaphragmonaffectedsideisparalysed&isthereforeelevated,leadingto
collapseofthelung
Thisgivesresttoadiseasedlung&promoteshealing

25

CervicalPartofSympathetictrunk
Thisisaganglionatedchainlocatedoneoneachsideofthecervicalpartofthe
vertebralcolumn
Fromitcomesthesympsupplytothevariousstructuresofthehead&neck

Formation
byfibres(PreGN)arisingfromsegmentsT1toT4ofspinalcord
thesefibrespasstothoracicpartofsymptrunk&thenascendintotheneck

Extent
upwardstobaseofskull
downwardstoneckof1st
ribwhereitbecomescontinuouswiththoracicpartof
symptrunk

Relations
Itisprevertebral&isrelatedto
Anteriorly 1. carotidsheath
2. CCA&ICA
3. infthyroidart
Posteriorly 1. prevertebralfascia
2. longuscapitis&cervicis
3. tnvsprocessesoflower6CV

26

Ganglia
Thereare3ganglia:sup,middle&inf
TheascPreGNfibressynapseintheseganglia,
fromwhichPGNfibresarisetosupplytheSM,BV&gldsofthehead&neck
Cervical Remarks Branches
Ganglion
Superior largestofthe3ganglia 1. GRCtoC1toC4(ventralrami)
formedbythefusionoftheupper 2. branchesto9th ,10th&12thc ranialn
4ganglia 3. intc arotidnintc arotidplexus
liesjustbelowskulla tlevelof 4. arterialbranchestoCCA&ECA
CV1toCV3bhdICA&infront 5. pharyngealbranches
oflongusc apitis pharyngealplexus(withbranches
of9th
&10thc n)
6. supc ervicalbranch
c ardiacplexusinthorax
Middle verysmall 1. GRCtovenralramiofC5&C6
formedbyfusionof5th
&6th 2. thyroidbranchesthyroidgld
cervicalganglia 3. middlec ardiacbranch
liesinlowerpartofneckinfront c ardiacplexusinthorax
ofCV6a bovea rchformedbyinf
thyroida rt
Inferior ratherlarge,irregular& 1. GRCtoa ntramiofC7&C8
starshaped 2. arterialbranches
formedbyfusionof7th &8th subclavian&vertebrala rt
cervicalganglia,&oftenwith1 st 3. infc ardiacbranch
thoracicganglia c ardiacplexusinthorax
stellateganglion
liesbtwtnvsprocessofCV7&
neckof1st ribbhdvertebrala rt

ClinicalNotes
1. injurytocervicalpartofsymptrunkproducedHornerssyndrome
2. stellateganglioncanbeblockedbyanesthetic

27

Trachea(CervicalPart)
Thetracheaisamobile,noncollapsibletubeformingthebeginningofthelower
resppassages
ItiskeptpotentbyanterolatCshapedcartilaginousrings
Itspostmembranouspartpermitsexpansionoftheesophagusduringpassageof
food

Origin
beginsatlowerborderofcriccoidcartilageoflarynx(atlevelofCV6)inthemiddline

Course
runsdownwards&slightlybackwardsinthemidline
entersthoraxinmedianplane

Relations
Anteriorly 1. skin&fascia
2. isthmusofthyroidgld(infrontof2nd,3rd&4th
rings)
3. infthyroidveins
4. jugulararch
5. thyroideaimaart(ifpresent)
6. sternothyroids&sternohyoids
7. Lbrachiocephalicveininthechild
Posteriorly 1. R&Lrecurrentlaryngealn
2. esophagus
3. vertebralcolumn&someprevertebralmuscles
Laterally 1. lobesofthyroidgld
(oneachside) 2. carotidsheath&CCA

BloodSupply
mianlyfrominfthyroidarteries

VenousDrainage
veinsdrainintoLbrachiocephalicvein

LymphaticDrainage
Lymphaticspassto 1.pretrachealnodes
2.paratrachealnodes

NerveSupply
1.psymp: vagus&recurrentlaryngealn
sensory&secretomotortomucousmbm
motortotrachealismuscle
2.symp: frommiddlecervicalganglionofsymptrunks
vasomotor

28

ClinicalNotes
1. tracheamaybecompressedbypathologicalenlargementofthyroid,thymus,LN
&aorticarch
2. tracheostomyisusudoneaftercuttingtheisthmusofthyroidgld

29

LymphaticDrainageoftheHead&Neck
Thelymphaticsystemofthehead&neckconsistsof 1.LN
2.lymphvsls

LymphNodes
Thelymphnodesofthehead&neckaremadeupofano.ofperipheralgps,&a
terminalgp
Theterminalgpreceivesallthelymphaticsofthehead&neck,
eitherdirectlyorindirectlyviaoneoftheperipheralgps

PeripheralGroupsofLymphNodes
Thesearearrangedin2gps:supf&deep
a. Thesupfgpconsistof
Nodes Remarks
1 occipitalnodes locatedoveroccipitalboneatapexofposttriangleofneck
receivelymphfrombackofscalp
efferentstodeepcervicalnodes
2 retroauricular locatedoverlatsurfaceofmastoidprocessoftemporal
(mastoid)nodes bone
receivelymphfromscalpaboveauricle&
frompostwallofextauditorymeatus
efferentstodeepcervicalnodes
3 parotidnodes locatedon/withinparotidgld
receivelymphfromscalp,auricle,face,extacousticmeatus
&middleear
efferentstodeepcervicalLN
4 buccalnodes locatedoverbuccinatormuscleclosetofacialvein
liealongcourseoflymphvsls
iereceivesfromseveralnodes
efferentstosubmandibularcervicalLN
5 submandibular locatedonsurfaceofsubmandibulargld
nodes receivelymphfromwidearea
efferentstodeepcervicalnodes
6 submental locatedinsubmentaltrianglebtwantbelliesofdigastric
nodes receivelymphfromlowerlip,tongue&supfneck
efferenttosubmandibular&deepcervicalnodes

These6gpsofLNformacollaratthejnoftheheadwiththeneckcalled
pericervicalcollar
Thesupftissuesofthehead&neckdrainintothesenodes,aswellas2othergps
7 antcervical locatedalongcourseofantjugularvein
nodes receivelymphfromsupftissueoffrontofneck
efferenttodeepcervicalnodes
8 supfcervical locatedalongthecourseofEJV
nodes receivelymphfromsmallpartofface&extear
efferentstodeepcervicalnodes

30

b.

31

 ThedeepgpofperipheralLNare:
9 retropharyngeal fdinintervalbtwpharyngealwall&prevertebralfascia
nodes ieretropharyngealspace
10 laryngealnodes fdinfrontoflarynxoncricothyroidlig
11 paratrachealnodes fdlattotrachea
12 pretrachealnodes fdinfrontoftrachea

TerminalGroupofLymphNodes
Thesearethedeepcervicalnodes
fdinachainalongthecourseofIJV
embeddedinfasciaofcarotidsheath
receivealllymphofhead&neck
efferentsjointoformjugularlymphtrunkswhichdrainsintothoracicductorR
lymphaticduct
Note:2ofthenodesarereferredtoclinically: 1.jugulodigastricnode
2.juguloomohyoidnode

LymphVessels
supfvslsfollowsupfveins
deepvsls followarteries&sometimesdeepveins

ClinicalNotes
1. enlargementofnodesmayindicateinfectionofitsareaofdrainage
2. spreadofcancerthroughthelymphatics
3. blockdissectionofcervicalnodes
ie removalofcervicalnodes,IJV,submandibulargld&fasica
maybeperformedinsomecasesofcancer

32

Scalp
Softtissuescoveringthecranialvaultformthescalp

Extent
Anteriorly supraorbitalmargins
Posteriorly extoccipitalprotuberance&supnuchallines
Laterally suptemporallinesoneachside
Hairlinedoesnotcorrespondtoboundariesofscalp
hairisdeficientoverfrontpartofscalp
hairoverlapsupperpartofbackofneck

Structure
Thescalpconsistsof5layers,the1st
3ofwhichareintimatelyconnected&moveasa
unit.Thelayersare:
Skin thick,hairbearing&containssebaceousglds
Connectivetissue fibrofattylayerbeneaththeskincontaininganastomosesof
arteries&veins
Aponeurosisof
occipitofrontalis
muscles
Looseareolartissue liesbelowtheaponeurosisinthesubaponeuroticspace
containsemissaryveins
Pericranium periosteumcoveringoutersurfaceofskullbones

BloodSupply
Thescalphasaveryrichbldsupply smallcutstendtobleedprofusely
Infrontoftheauricle,itissuppliedfrombeforebackwardsby
1 supratrochlear branchesofophthalmicart(brofICA)
2 supraorbital branchesofophthalmicart(brofICA)
3 supftemporal terminalbranchofECA
Behindtheauricle,itissuppliedfrombeforebackwardsby:
4 postauricular branchesofECA
5 occipital branchesofECA

VenousDrainage
1. supratrochlear uniteatmedmarginoforbittoformfacialvein
2. supraorbital uniteatmedmarginoforbittofromfacialvein
3. supftemporalvein
4. postauricularvein
5. occipitalvein suboccipitalvenousplexuses
Theveinsofthescalpanastomosewithdiploicveins
Theyareconnectedtotheintracranialvenoussinusesbyemissaryveins

LymphaticDrainage
partofscalp drainsinto

33

 antpartofscalp preauricular(parotid)nodes
postpartofscalp mastoid&occipitalnodes

NerveSupply
a. SensoryInnervation
Fromanttopostbybranchesof
1.ophthalmicn from5th cranialn
2.maxillaryn from5th
cranialn
th
3.mandibularn from5 cranialn
4.cervicalplexus
5.dorsalramiofcervicalspinaln
b. MotorInnervation
branchesoffacialn temporalbranchtofrontalbelly
postauricularbranchtooccipitalbelly

ClinicalNotes
1. scalpbleedsprofuselywheninjuredduetorichbldsupply
2. emissaryveinsinlooseareolartissue(subaponeurotic)areinvinspreadof
infectionfromscalptointracranialregions
Thustheareaiscalleddangerarea

34

FacialArtery
Thefacialarteryisthechiefarteryoftheface

Origin
branchofECA
givenoffincarotidtriangleintheneck

Course
briefcourseintheneck
windsroundlowerborderofmandibleatantmarginofmasseter
proceedsupwards&forwardsontheface
endsatmedangleoftheeyewhereitanastomoseswithbranchesofophthalmic
art
Thefacialartisverytortuous&takespartinnumerousanastomoses,including
someacrossmedianplane
Tortuouscoursepermitsfreemovementofthemandible,lips&cheeks

VenousDrainage
Facialvein connectstocavernoussinus&pterygoidplexus
Thusspreadofinfectionfromfaceintocranialcavity

Branches
Intheneck: 1.ascpalatineart
2.tonsillarbranch
3.glandularbranchtosubmandibulargld
Inthefaceitsuppliesthelips&extnosevia: 1.submentalart
2.inflabialart
3.suplabialart
4.latnasalart

ClinicalNotes
There.isrichanastomosis
collateralcirculationcanbeestafterligatureoftheCCAorECAon1side

Otherarteriessupplyingtheface
1 supftemporalart fromECA
2 tnvsfacialart fromsupftemporalart
3 supraorbital fromophthalmicart
4 supratrochlear fromophthalmicart

35

FacialNerve
Thefacialnisthe7th
Itisalsothenervetothe2nd
Itis 1.motortotheface
2.secretomotortosubmandibular&sublingualsalivaryglds&lacrimalglds
3.specialsensory(taste)toant2/3ofthetongue
Nuclei&FunctionalComponents
1 motornucleus
2 supsalivatorynucleus
3 lacrimatorynucleus
4 nucleusofsolitarytract
5 spinalnucleusofV
Course
IntracranialCourse
ExtracranialCourse
Branches
a) IntracranialBranches
withinfacialcanal:
4.
b) ExtracranialBranches
Atexitfromstylomastoidformen:
36
cranialnerve.
branchialarch
SVE
GVE
GVE
SVA
GSA
startsoffas2roots motor
sensory(nervusintermedius)
&secretomotor
leavebrainatlowerborderofpons
enterintacousticmeatus
enterfacialcanaloftemporalbone
Abovepromontoryofmedwallofmiddleear,itforms
geniculateganglion(containingcellsoftastefibres)
emergesfromskullatstylomastoidforamen
crosseslaterallythebaseofstyloidprocess
entersposteromedsurfaceofparotidgld
runsforwardwithinthegld,supftoretromandibularvein
&ECA
bhdneckofmandibleitdividesintoits5terminal
branches,whichemergeattheantborderofthegld
1.greaterpetrosaln
2.ntostapedius
3.chordatympani(joinslingualn)
1.postauricular
2.muscularbranchestodigastric&
stylohyoid

c) TerminalBranches
1.temporal
2.zygomatic
3.buccal
4.mandibular
5.cervical
Theseariseinthesubstanceoftheparotidgld&emegefromitsantborder
Thefacialnsuppliesallthemusclesoffacialexpression
Itdoesnotsupplytheskin
d) CommunicatingBranches
communicatewithadjcranial&spinaln

SurfaceAnatomy
pt1: atmiddleofantborderofmastoidprocess
=positionofstylomastoidforamen
pt2: bhdneckofmandible
=ptofdivisionintoterminalbranches
Joiningthese2ptswillgiveextracranialcourseoffacialn

ClinicalNotes
1. Lesionsofthefacialnbelow/atthelevelofthemotornucleusresultsin
lowermotorneuronlesion
Possiblecauses: 1.infectionofmiddleear
2.surgery,etc
Result:paralysisofentirefacialmusculatureonaffectedside
Features :displacementofmouthaccompaniedbydrooping
:ptosis,&inabilitytocloseeyes
:nowrinklesonforehead
2. Lesionsofthefacialnabovelevelofthemotornucleusresultsin
uppermotorneuronlesion
Possiblecauses: 1.tumours
2.surgery,etc
Result :Lowerhalfoffaceofopposideparalysed
:orbicularisoculi&frontalismusclessparedbecause
theyarecontrolledbyfibresfrombothsidesofcerebralcortex
Features :displacement&droopingofmouthcontralaterally
Howeverthepatientisabletowrinklehisforehead

DistributionofFacialNerve
4modalitiescarriedbynerve
Motor 1. tomusclesoffacialexpression
2. stylohyoid,digastric
3. stapedius
SpecialSenses tastefibrestoant2/3oftongue
Pysmp secretomotorto submandibular,sublingualglds
lacrimalgld
parotidgld
Sensory smallareaofextmeatus,auricle
37

38

DuraMateroftheBrain
Theduramateristheoutermost,thickest&toughestmbmcoveringthebrain
Itiscontinuouswiththeduraofthespinalcord

LayersoftheDuraMater
Ithas2layers
1. outerlayer/endosteallayerservesasanintperiosteumtothecranialbones
2. innerlayer/meningeallayerprovidestheprotectivembmtothebrain
The2layersarefusedexceptatplaceswherecranialvenoussinusesareenclosedbtw
them

ProcessesoftheDuraMater
Themeningeallayersends4foldsinternallywhichdividethecranialcavityinto
manyfreelycommunicatingcompartmentshousingdifferentpartsofthebrain
1 FalxCerebri large,sickleshapedfold
occupiesmedianlongitudinalfissurebtwthe2cerebral
hemispheres
attachments: anteriorlytocristagalli
posteriorlytotentoriumcerebelli
upperconvexbordercontainssupsagittalsinus
lowerconcavebordercontainsinfsagittalsinus
2 Tentorium tentshapedfoldformingroofofpostcranialfossa
Cerebelli supportsoccipitallobeabove&sepitfromcerebellumbelow
anteriorlyitshowsasgap
tentorialnotch,forpassageofthemidbrain
Thus,ithas2borders:
1.antfreeborderformingtentorialnotch
whichisattachedonbothsidestoantclinoidprocess
2.outerattachedborderwhichisattachedto
postclinoidprocess
outerattachedborderenclosessuppetrosal&tnvssinuses
uppersurfaceenclosesstraightsinus
3 Falx smallsickleshapedfoldlyingbelowtentoriumcerebelli
Cerebelli
4 Diaphragma smallcircularhorizfoldformingroofofhypophysealfossa
Sellae

BloodSupply
outerlayerisrichlyvascular
innerlayerismorefibrous&requireslittlebloodsupply
Theduraissuppliedbynumerousmeningealbranchesfrom
1.ICA
2.maxillaryascpharyngealart
3.occipitalart
4.vertebralart
Themostimptismiddlemeningealart

39

VenousDrainage
bymeningealveinsintopterygoidplexusofveinsorsphenoparietalsinus

NerveSupply
Theduraissuppliedbybranchesofthetrigeminal&cervicalnerves
antcranialfossa ophthalmicn
middlecranialfossa maxillary&mandibularn
postcranialfossa branchesofvagus&hypoglossaln
aswellasbranchesfromC1toC3
Thenervesupplyis
a)sensorytothedura
b)autonomictotheBV

ClinicalNotes
1. headacheusuimplicatesthedura&thestructurescontainedinitbecausethebrain
itselfisnormallyquiteinsensitive
2. intracranialhemorrhages

40

CranialFossae
interiorofthebaseoftheskullisdividedinto3cranialfossae:
anteriorcranialfossa
middlecranialfossa
posteriorcranialfossa

Boundaries
AnteriorCranialFossa MiddleCranialFossa PosteriorCranialFossa
Ant innersurfaceoffrontalbone lesserwingsofsphenoid supborderofpetrous
(withfalxc erebriinmidline) partoftemporalbone
Post sharplesserwingof supbordersofpetrous internalsurfaceof
sphenoid partsoftemporalbone squamouspartof
grooveforopticc hiasma occipitalbone
Lat squamouspartsof
temporalbone
greaterwingsofsphenoid
parietalbones
Floor lat:orbitalplatesoffrontal greaterwingofsphenoid basilar,c ondylar&
bone squamousa ndpetrous squamouspartsof
med:c ribiformplateof partsoftemporalbone occipitalbone
ethmoid mastoidpartoftemporal
bone

MajorForaminaoftheCranialFossae
Openinginskull Boneofskull Structurestransmitted
Ant perforationsin ethmoid olfactoryn
Cranial cribiformplate
Fossa
Middle 1.opticc anal lesserwingofsphenoid opticn
Cranial 2.supopticfissure b/wlesser&greater lacrimal,frontal,trochlear,
Fossa wingsofsphenoid oculomotor,nasociliary&
abducentn
supophthalmicvein

3.foramenrotundum greaterwingofsphenoid maxillarydivisionofthe
trigeminaln

4.foramenovale greaterwingofsphenoid mandibulardivisionofthe
trigeminaln,lesserpetrosaln

5.foramenspinosum greaterwingofsphenoid middlemeningeala rt
6.foramenlacerum b/wpetrouspartof ICA
temporala ndsphenoid
Post 1.formenmagnum occipital MO,sppartofa ccn,R&L
Cranial vertebrala rt
Fossa 2.h ypoglossalc anal occipital hypoglossaln

3.jugularforamen b/wpetrouspartof glossopharyngeal,vagus&
temporal&c ondylarpart accnsigmoidsinusIJV

41

 ofoccipital
4.inta cousticmeatus petrouspartoftemporal vestibulocochlear&facialn

42

CavernousSinus
Itisalargevenousspacebtwthe2layersofduramater
Itissituatedinthemiddlecranialfossa,oneoneithersideofthebodyofthe
sphenoidbone

Formation
floorisbyendostealduramater
latwall,roof&medwall=meningealduramater

Extent&Size
abt2cmlong&1cmwide
anteriorly:extendsuptomedendofsuporbitalfissure
posteriorly:extendsuptoapexofpetroustemporal

Relations
a. StructuresOutsidetheSinus
Superiorly 1. optictract
2. ICA
Inferiorly 1. foramenlacerum
2. jnofbody&greaterwingofsphenoidbone
Anteriorly suporbitalfissure&apexoforbit
Posteriorly apexofpetroustemporal
Medially 1. hypophysiscerebri=pit
2. sphenoidalairsinuses
Laterally temporallobeofcerebralhemisphere
b. StructuresinLateralWalloftheSinus
fromabovedownwards: 1.occulomotorn
2.trochlearn
3.ophthalmicn
4.maxillaryn
5.trigeminalganglion
c. StructuresPassingThroughtheSinus
1.ICAtogetherwithitsvenous&sympplexuses
2.abducentn

Tributaries
fromtheorbit 1. sup&infophthalmicveins
2. centralveinofretina
fromthebrain 1. supfmiddlecerebralvein
2. infcerebralveins
fromthemeninges 1. sphenoparietalsinus
2. middlemeningealvein(sometimes)

43

Drainage
Thecavernoussinusdrainsinto
1. tnvssinusviasuppetrosalsinus
2. IJVviainfpetrosalsinus
3. pterygoidplexusofveinsviaemissaryveins
Thecavernoussinusesonbothsidescommunicatewitheachothervia
ant&postintercavernoussinuses

Factorswhichhelptoexpelbldfromthesinusare:
a)pulsationsoftheICA&
b)gravity

ClinicalNotes
1. infectionoffacemayspreadviafacialveinintocavernoussinus
thrombosisofcavernoussinus
2. carotidcavernoussinusaneurysms

44

SuperiorSagittalSinus
Itislocatedintheupperconvexmarginofthefalxcerebri

Course
beginsanteriorlyatcristagallibyunionofmeningealveins
runsupwards&backwards,becomingprogressivelylargerinsize
endsnearintoccipitalprotuberancebydeviatingto1side
usutotheright(continuesasRtnvssinus)

SpecialFeatures
Thesinuscommunicateswith2or3small,irregularlyshapedvenouslacunaeon
eachside
Arachnoidvilli&granulationsprojectintothelacunae

Tributaries
Thesinusreceivesbldfrom 1.diploic&meningealveinsviathelacunae
2.emissaryveins
3.supcerebralveins

Drainage
Itdrainsintotheconfluenceofsinuses&
henceintothetnvssinuses&occipitalsinus,aswellasstraightsinus

SurfaceAnatomy
Itextendsfromaboverootofthenose,overvaultofskullinmedianplane,
toextoccipitalprotuberance

ClinicalNotes
1.thrombosiscausedbyspreadofinfectionfromnose,scalp&diploe

45

MiddleMeningealArtery
Thisarteryisclinicallyimptbecauseitisthechiefsourceofextraduralhemorrhage

Origin
branchofmaxillaryart
arisesininfratemporalfossadeeptoramusofmandible

Course&Relations
ininfratemporalfossaitrunsupwards&medially
deeptolatpterygoid
passesbtw2rootsofauriculotemporaln
entersmiddlecranialfossathroughforamenspinosum
inmiddlecranialfossaithasanextraduralcourse,runningforward&laterally
relatedtomiddlemeningealveins
dividesatavariableptintoant&postbranches

Branches
Thebranchesariseinthemiddlecranialfossa
Theycontributetothesupplyof 1.trigeminalganglion
2.tympaniccavity
3.orbit
Theterminalbranchesare
1.ant(frontal)branch groovesthesphenoid&parietalbones
suppliesantportionofdura
2.post(parietal)branch groovesthetemporal&parietalbones
suppliespostportionofdura

SurfaceMarking
Pt1: atmidptofzygomaticarch =entryofarteryintoskull
=ptofdivisionofartery
Pt2: 2cmabovept1
Pt3: centreofpterion
Pt4: midptbtwnasion&inion
Pt5: atlambdasinus
Joiningpt1&2 stemofartery
Joiningpt2,3,&4 antbranch
Joiningpt2&5 postbranch

ClinicalNotes
Injuriestothesideofheadfractureofhead
Thismayresultintearingofarteryormorecommonlyviaintbranchleadingto
extraduralhemorrhage

46

TypesofIntracranialHemorrhage
Intracranialhemorrhagesrefertobleedinginsidethecranialcavity
Theymayresultfromtraumaorvascularlesions
Thereare4mainvarieties 1.extradural
2.subdural
3.subarachnoid
4.cerebral

ExtraduralHemorrhage
resultsfrominjuriestothemeningealarteriesorvein
mostcommonarterytobedamaged=antbranchofmiddlemeningealart
Itisusutornbyablowtosideoftheheadresultinginfractureoftheskullaround
theanteroinfregionofparietallobe
bleedingoccurs&ahematomaforms
theintracranialpressurerises&thebldclotexertslocalpressureonunderlying
areaonprecentralgyrus(mayresultinoppohemiplegia)
bldalsopassesoutwardsthroughthefracturelinetoformasoftswellingunder
temporalismuscle

SubduralHemorrhage
resultsfromtearingofsupcerebralveinsattheirptofentranceintosupsagittal
sinus
usucausedbyblowtothefrontorbackofthehead
causingexcessiveanteropostdisplacementofthebrainwithintheskull
oncetheveinistorn,bldunderlowerpressurebeginstoaccumulateinthe
potentialspacebtwthedura&arachnoid
In1/2thecases,theconditionisbilateral
dependingonthespeedofaccumulationofblood,theclinicalconditioncanbe
acuteorchronic
Inbothcasesthebldclodwillpressagainstthebrim,producingdiffpressure
symptomsdependingonthelocationoftheclot

SubarachnoidHemorrhage
resultsfromleakageorruptureofacongenitalaneurysmonthecerebralarterial
cicle(ofWillis)orlesscommonlyfromanangioma
thesymptomsaresuddeninonset&include:
1.severeheadache
2.stiffneck
3.lossofconsciousness
Itisdiagnosedbyalumbarpuncture,
whereCSFiswithdrawnisheavilybldstained

47

CerebralHemorrhage
generallyduetoruptureoflenticulostriateartery,
whichisabranchofmiddlecerebralart
invcorticolubar&corticospinalfibresininternalcapsule
produceshemiplegiaonoppoisideofbody
thepatientimmediatelylosesconsciousness&paralysisisevidentwhen
consciousnessisregained

48

InternalCarotidArtery(Petrous,Cavernous&Cervical
Parts)
ThecervicalpartoftheICAentersthecarotidcanalinthepetrouspartofthe
temporalbone,tocontinueasthepetrouspart

Petrous runsinthecarotidcanal
Part closelyrelatedtocochlea,middleear&auditorytube,aswellas
trigeminalganglion
attheforamenlacerumitasctoaptmedtolingualofsphenoidbone
enterscavernoussinustocontinueasthecavernouspart
givesbranchestotympaniccavity
Cavernou runsforwardinthesinusalongsideofsellaturcica
sPart sepfrombldinthesinusbyendothelialliningofthesinus
asc&piercesduralroofofsinusbtwant&postclinoidprocessesto
continueascerebralpart
givesbranchestothemeningesaswellasinfhypophysealbranch
Cerebral turnsbackwardinsubarachnoidspacebelowopticn
Part asc&atmedendoflatsulcusdividesintoant&middlecerebralart

BranchesofCerebralPart
1. suphypophpysealart
2. ophthalmicart
3. postcommnunicatingart
4. antchoroidart(choroidplexusoflatventricle)
5. antcerebralartterminalbranch
6. middlecerebralartterminalbranch

ClinicalNotes
1. Ifcollateralcirculationisgood,theICAon1sidecanbeligatedoroccluded
withoutanyeffect
2. Inant&middlecerebralarteriesareoccluded
variousneuraldefectsbecausetheysupplypartsofthebrain

49

TrigeminalGanglion
Thisisthesensoryganglionofthe5th
cranialn(trigeminaln)
Itismadeupofpseudounipolarncells,eachwith
aperipheral&acentralprocess

Location
liesonthetrigeminalimpressiononantsurfaceofpetroustemporalnearitsapex
occupiesaspecialspaceintheduramatercalledtrigeminal(orMerkel)cave

Shape
cresenteric/semilunarinshape
convexityisdirectlyanterolaterally,
wherethe3divisionsofthetrigeminalnemerge
concavityispost&receivessensoryrootofthenerve

Relations
Superiorly parahippocampalgyrus
Inferiorly 1. motorrootof5th
n
2. greaterpetrosaln
3. apexofpetroustemporal
4. foramenlacerum
Medially 1. ICA
2. postpartofcavernoussinus
Laterally middlemeningealartery

Roof
formedbycentralprocessesofganglioncells
sensoryroottotrigeminaln
attachedtoponsatitsjnwithmiddlecerebellarpeduncle

Branches
=3divisionsofthetrigeminaln
1.ophthalmicn
2.maxillaryn
3.mandibularn
Theseareformedbytheperipheralprocessesoftheganglioncells

BloodSupply
twigsfrom 1.ICA
2.middlemeningeal
3.accessorymeningeal&
4.meningealbranchesofascpharyngealarteries

ClinicalNotes
1. ganglioncanbeblockedbypassinganeedlethroughthemandibularnotch&

50

 foramenovale&injectingananesthetic
2. thesensoryrootmaybesurgicallysectionedinthemiddlecranialfossatorelieve
facialpainduetotrigeminalneurolgiaorcarcinomatosis

51

StructureoftheEyeball
Theeyeballconsistsof3coats:
1. ext,protectivefibrouscoat
2. middle,vascularpigmentedcoat&
3. intnervouscoat
Itcontainstheaqueoushumour,lens&vitreousbody

CoatsoftheEyeball
a. ExternalFibrousCoat
Thisismadeupofan anttransparentpart:thecornea
&apostopaquepart,thesclera
Cornea largelyresponsibleforrefractionoflight
itstransparencydependsonitshydration
avascularnourishedbypermeation
suppliedbyophthalmicnviaciliarybranches
Sclera composedofdensefibroustissue&iswhiteincolour
piercedbyciliaryarteries&nerves
posteriorly,piercedbyopticn(atlaminacribosa)
receivestendonsofmusclesoftheeyeball

b. MiddleVascularCoat
Thiscomprises,frombhdforwards,thechoroid,ciliarybody&iris
Choroid browncoatliningthegreaterpartofthesclera
consistsofouterpigmentedlayer&innervascularlayer
Ciliary connectsthechoroidstotheiris
Body composedof 1.ciliaryring
2.ciliarymuscles
3.ciliaryprocesses
Note:ciliarymuscles suppliedbypsympfibresfromciliaryganglion
theircontractionresultsinthelensbecoming
moreconvex
highrefractivepowerofthelens
Iris circularpigmenteddiaphragm,itsapertureknowasthepupil
liesinfrontofthelens
dividesspacebtwcornea&lensintoant&postchambers,
bothofwhicharefilledwithaqueoushumour
containmusclesfibresforming
1.sphincterpapillae(suppliedbypsympfibresfromocculomotor
n)
2.dilatorpapillae(suppliedbysympfibresfromLCplexus)

c.

52

 InternalNervousCoat
Thisiscalledtheretina
consistsof: outerpigmentedlayer
innernervouslayer
antportionisnonreceptive&issepfrompostpartbytheoraserrata
postparthasthefollowingfeatures
1.maculalutea(yellowspot)
2.foveacentralis=centralpitinthemaculalutea
3.opticdisc,wheretheopticnleavestheretina
Thisiscalledtheblindspotbecauseoflackofreceptors
Theopticdiscispiercedbythecentralarteryoftheretina

ContentsoftheEyeball
Thisconsistsoftheaqueoushumour,lens&vitreousbody
Aqueous fillsant&postchambersofeye
Humour compositionisapproxthatofproteinfreeplasma
formedbyciliaryprocesses
functions 1.supportwallofeyeballbyexertingpressure
2.nourisheslens&removeproductsofmetabolism
Lens transparent&biconvex
situatedbhdiris&infrontofvitreousbody
consistof 1.elasticcapsule
2.cuboidalepithelium
3.lensfibres
capsuleisattachedtociliarybodybysuspensoryligofthelens
contractionofciliarymusclesofciliarybodywillalterthe
shapeofthelens
VitreousBody transparentgelatinousmassenclosedbyvitreousmbm
fillstheeyeballbhdthelens
functions 1.supportspostsurfaceoflens
2.contributetomagnifyingpowerofeye

SensoryNerveSupply
short&longciliarynfromnasociliaryn

BloodSupply
Ophthalmicart

VenousDrainage
intocavernoussinus

53

MovementsoftheEyeball
Themovementsoftheeyeballarecommonlyresolvedintothosetakingplace
around3primaryaxes: 1.verticalaxis
2.tnvsaxis
3.anteropostaxis
1position
Thepositionofrestisthatinwhichthegazeisstraightahead
Equilibriumismaintainedbyalltheeyeballmuscles,
whichpracticallydonotactalonebutasagp
Movementsoftheeyesarebroughtabtby
anincreaseintonein1setofmuscles&
adecreaseintoneoftheantagonisticmuscles

MovementaroundVerticalAxis
Thereferenceptisthecentreofthecornea,
&themovementsareabduction&adduction,
bothrotatorymovementsoftheeyeball
Abduction centreofcorneamoveslaterally
musclesacting: 1.latrectus
2.supoblique
3.infoblique
Adduction centreofcorneamovesmedially
musclesacting: 1.medrectus
2.suprectus
3.infrectus

MovementaroundTransverseAxis
Thereferenceptisagainthecentreofthecornea,
&themovementsareelevation&depression,
bothalsorotatorymovements
Elevation centreofcorneamovesupward
muscleacting 1.suprectus
2.infoblique
Depression centreofcorneamovesdownward
musclesacting 1.infrectus
2.supoblique

MovementaroundAnteroposteriorAxis
Thereferenceptisnowthetoppartofthecornea
&themovementsareintorsion&extorsion
bothalsorotatorymovements
Extorsion toppartofcorneamoveslaterally
musclesinv 1.infrectus
2.infoblique
Intorsion toppartofcorneamovesmedially
musclesinv 1.suprectus
2.supoblique

54

55

ClinicalNotes
Paralysisofamuscleoftheeyeballisnotedby
1. limitationofeyemovementinthefieldofactionofparalysedmuscle
2. productionof2images(diplopia)whichareseparatedmaximallywhenanattempt
ismadetousetheparalysedmuscle

Innervation
Occulumotorn suppliesallextraocularmusclesexceptLR&SO
damageresultsin
1. ptosis(paralysisoflevatorpalpebraesup)
2. abduction(unoppoactionofLR&SO)
3. limitationofmovement
4. doublevision=diplopia
5. dilatationofpupil(paralysisofsphincter)
6. inabilitytoaccommodate(paralysisofciliarymuscles)
Trochlearn suppliessupoblique
Damageresultsinlimitationofmovement&diplopia
whenthesubjectisaskedtolookdownwardswitheyeadducted
Abducentn supplieslatrectus
Damageresultsininabilitytoabducttheeye
beyondthemiddleofthepalpebralfissure

56

OphthalmicArtery
Thisisthemainbldsupplyoftheorbit

Origin
branchofcerebralpartofICA
givenoffmedtoantclinoidprocess

Course&Relations
entersorbitthroughorbitalcanal
inferolattoopticn
runsforward atfirstlattooptic
thencrossesthenervefromabovetogwithnasociliaryn
runsalongmedwalloforbit
terminatesnearmedangleofeye
bydividingintosupratrochlear&dorsalnasalbranches

Branches
Branches Supply
centralarteryoftheretina retina
postciliaryarteries ciliarybody&iris
muscularbranches iris&ciliarybody
(givesrisetoantciliaryarteries)
lacrimalartery lacrimalgld
supraorbitalartery uppereyelid&scalp
supratrochlearartery forehead&scalp
dorsalnasalartery root&lacrimalsac

ClinicalNotes
Occlusionofophthalmicartery/centralarteryofretinaleadstoblindness

57

LacrimalApparatus
Thestructuresconcernedwithsecretion&drainageoftearsconstitutethelacrimal
apparatus
Itismadeupof 1.lacrimalgld&itsducts
2.lacrimalcanaliculi
3.lacrimalsac
4.nasolacrimalduct
LacrimalGland
locatedinfossaonanterolatangleofroofoforbit
restsonlatrectus&levatorpalpebraesup
consistsof2parts:orbitalpart
palpebralpart
whicharecontinuouswitheachotheraroundthelatborderofaponeurosisofthe
levatorpalpbraesup
1 2lacrimalductswhichopenintothesupfornixofthe
itisdrainedby
conjunctiva
NerveSupply
Psymp PreGNfibresderivedfromlacrimalnucleusoffacialnerve
Supply travelinpetrosaln
synapseinpterygopalatineganglion
PGNfibresjoinmaxillaryn
thenpassintoz ygomaticbranch&z ygomaticotemporaln
reachthelacrimalgldwithinlacrimaln
Symp fibresfromsupc ervicalganglion
Supply reachthegldbywayoflacrimaln

LacrimalCanaliculi
1ineacheyelid,1 cmlong
beginsaslacrimalpunctum
passmedially
openintolatwalloflacrimalsac

LacrimalSac
locatedinafossaatmedmarginoforbit,btwant&postlacrimalcrests
1to11/2cminlength
relatedto anteriorlytomedpalpebrallig
posteriorlytolacrimalpartoforbicularisoculi
laterallytoethmoidalaircells&middlemeatus

NasolacrimalDuct
2cmlong
extendsfromlowerendoflacrimalsactoinfmeatusofnose
situatedinabonycanal
itsopeningisguardedbyafoldofmucousmbm=lacrimalfold

ClinicalNotes
overflowoftears&dischargeofpus
Inflammationoflacrimalsac

58

59

VertebralArtery
Thisis1ofthe2principalarteriessupplyingthebrain
Inaddition,italsosuppliesthespinalcord,meninges,&thesurroundingmuscles
&bones

Origin
branchof1stpartofsubclavianart

Course&Relations
Thecourseiscomplicated&canbeconsideredin4parts
Cervical(1st) extendsfromorigintotnvsprocessofCV7
Part entersforamenintnvsprocessofCV6
antrelations 1.carotidsheath&CCA
2.vertebralvein
3.infthyroidartery
4.onLside:thoracicduct
postrelations 1.tnvsprocessofCV7
2.stellateganglion
3.ventralramiofCV7,8
nd
Vertebral(2 ) extendsfromtnvsprocessesofCV6toCV1
Part ie. runsthroughtheforaminaoftheupper6CV
emergefromtnvsprocessofatlas
rd
Suboccipital(3 ) windsmediallybhdlatmassofatlas
Part entersvertebralcanalafterpiercingduramater&arachnoid
mater
passesthroughforamenmagnum thenmakesasharploop
Intracranial(4th) ascmediallyinfrontofmedullaoblongata
Part atlowerborderofpons,thevertebralarteries
unitetoformthebasilarartery

Branches
CervicalBranches 1. spinal
2. muscular
CranialBranches 1. meningealbranches
2. postspinalartery
3. medullaryarteries

ClinicalNotes
1. thrombosisofvertebralartery(occlusion)
2. lesionofantspinalartery
3. lesionofpostinfcerebellarartery

60

SuboccipitalTriangle
deeptosemispinaliscapitis&spleniuscapitis
Boundaries
med rectuscapitispostmajor
superolat obliquecapitissup
inferolat obliquecapitisinf
contents: 1.vertebralvenousplexus
2.3rd
partofvertebralart(ingrooveofpostarchofatlas)
3.suboccipitaln(beneathvertebralart)
Greateroccipitaln liesonroofoftriangle
beforepiercingsemispinaliscapitis
tobedistributedtoskinofoccipitalregion

61

ParotidGland
Thisisthelargestofthesalivaryglds.Itisalmostentirelyserousinnature

Location
situatedbelowextauditorymeatus
liesindeephollowbhdramusofmadible&infrontofthesternocleidomastoid

Shape&PartsoftheGland
Shape: roughlywedgeshaped,
withthebaseabove&theapexbhdangleofthemandible
Parts: facialndividesthegldinto: 1.supflobe
2.deeplobe

Processes
1. glenoidprocess
2. facialprocess
3. pterygoidprocess

Capsules
2capsules:innerfibrouscapsule
outercapsulederivedfrominvestinglayerofdeepcervicalfascia
Aportionoffasciabtwstyloidprocess&mandibleisthickenedtoformthe
stylomandibularlig

Relations
Forpurposesofdescription,therelationsaredividedintosupf,sup,posteromed&
anteromed
Superficial 1. parotidlymphnodes
2. greata uricularn
3. supffascia&skin
Superior 1. exta uditorymeatus
2. postsurfaceoftemporomandibularjt
Glenoidprocessisdirectlyrelatedtoa uriculotemporaln
Posteromed 1. mastoidprocess
2. sternocleidomastoid
3. postbellyofdigastric
4. styloidprocess&itsa ttachedmuscles stylohyoid
stylopharyngeus
styloglossus
5. carotidsheathw ithICA,IJV&vagus
6. IX,X I&X IIc ranialn
7. facialn
Anteromed 1. postborderoframusofmandible
2. temporomandibularjt
3. masseter
4. medpterygoid

62

 5. terminalbranchesoffacialn
6. stylomandibularlig
Attheunionofanteromed&posteromedsurfacesthegldliesincontactwith
pharyngealwall
Theantborderofthegldisformedbyunionofsupf&anteromedsurfaces
Fromtheborderseveralstructuresemerge
1.parotidduct
2.terminalbranchesoffacialn
3.tnvsfacialvsls

StructuresWithintheGland
Fromlattomed,theseare:
1. facialn&terminalbranches
2. retromandibularvein antdivisionfacialvein
IJV
postdivisionjoinspostauricularveinEJV
3. ECA supftemporalart
maxillaryart
4. somemembersofparotidgpoflymphvsls

ParotidDuct
emergesfromfacialprocessofthegld
passesforwardoverlatsurfaceofmasseter
atantborderofmasseter,itturnsmedially
topiercebuccalpadoffat&buccinator
runsforwardbrieflybtwbuccinator&oralmucousmbm
opensintovestibuleofmouthoppositeupper2nd molartooth
Note:itsobliquecourseactsasavalvetopreventinfectionoftheductduring
chewing

BloodSupply
ECA&itsterminalbranches supftemporalart
maxillaryart

VenousDrainage
facial&EJV
intoretromandibularvein

LymphaticDrainage
deepcervicalnodes
intoparotidlymphnodes

63

NerveSupply
a. Psymp=secretomotor
PreGNfibres arisefrominfsalivatorynucleus
travelvia9th
cranialn
synapseinoticganglion
PGNfibres passthroughauriculotemporaln
reachthegld

b. Symp=vasomotor
derivedfromplexusaroundECA
c. Sensory
fromauriculotemporaln
also,parotidfasciaissuppliedbysensoryfibresfromgreatauricularn

ClinicalNotes
1. parotidfasciaisunyieldingparotidswellingsarepainful
2. viralinfectionmumps
3. inflammationofretrogradbacterialinfectionfromparotidduct
4. tumourofparotidgld
ifmalignant,usuinvthefacialnunilatfacialparalysis
5. penetratingwoundsofparotidthatdamageauriculotemporal&greatauricularn
Freyssyndrome
iesweatingoverparotidregionwhenpatienteats

64

TemporomandibularJoint

Type
Itisasynovialjt

Articulation
btw 1.articulartubercle&antpartofmandibularfossa
oftemporalboneabove
2.headofmandiblebelow
articularsurfacescoveredwithfibrocartilage

Capsule
surroundsthejt
attachments: abovetoarticulartubercle&marginofmandibularfossa
belowtoneckofmandible

Ligaments
lattemporomandibularlig lat
sphenomandibularlig med
stylomandibularlig posteromed
articulardisc dividesthejtintoupper&lowercompartments

SynovialMembrane
linesthecapsuleinbothcompartments

BloodSupply
1. supftemporalartery
2. maxillaryartery
(BothfromECA)

NerveSupply
branchesofmandibularn: 1.auriculotemporal
2.masseteric
3.deeptemporal

Relations
Anteriorly 1. mandibularnotch
2. massetericn&artery
Posteriorly 1. tympanicplateofextauditorymeatus
2. glenoidprocessofparotidgld
Medially 1. maxillaryart&vein
2. auriculotemporaln
Laterally 1. parotidgld
2. fascia&skin

65

66

Movements
Inthepositionofrest,theupper&lowerteethareseparatedbyaslightinterval
Themovementsare
Movements Musclesinvolved
1 depressionofmandible 1. latpterygoids
(openingofmouth) 2. digastrics
3. geniohyoids&mylohyoids
2 elevationofmandible 1. masseter
(closureofmouth) 2. temporalis
3. medpterygoids
3 Protusionofmandible 1. latpterygoids
2. medpterygoids
4 Retractionofmandible 1. postfibresoftemporalis
5 Lateralmovements med&latpterygoidsofeachsideacting
(sidetosidechewingmovements) alternatively

ClinicalNotes
1. Dislocationofmandible
2. detachmentofarticulardiscclickingsoundswhenthejawismoved

67

MovementsoftheMandible
Themovementsofthemandiblearecontrolledmorebytheplayofmusclesthan
byeithertheshapeofthearticularsurfacesortheligaments
Inthepositionofrest,theteethoftheupper&lowerjawsslightlyapart.On
closureofthejawstheteethcomeintocontact
Thechiefmovementsare 1.depression
2.elevation
3.protrusion
4.retraction
5.lateralmovement

Movements
Movements Resultsin Mechanism Musclesinv
ofthe
Mandible
Depression openingof headofmandiblerotatesa roundhoriz 1. latpterygoids
themouth axisunderthea rticulardisc 2. digastrics
bothhead&disca rethenpulled 3. geniohyoids&
forwardssothatthediscnowmoves mylohyoids
ontoa rticulartubercle
headnowa rticulateswithmosta nt
partofdisc
Elevation Closingof headofmandible&a rticulardisc 1. masseter
themouth movesbackwards 2. temporalis
headthenrotatesunderthea rticular 3. medpterygoids
disc
oppositemovementfrom
depression
Protrusion Lower articulardiscpulledforwardontoa nt 1. latpterygoids
teeth tubercletogwithheadofmandible 2. medpterygoids
drawn Thusa movementoccursinupper
forwards compartmentofjt
beyond
upperteeth
Retraction Mandible articulardisc&headofmandiblea re 1. postfibresof
drawn pulledbackwardintomandibularfossa temporalis
backwards 2. maybe
topostion assistedby
ofrest masseter
Lateral bya lternatelyprotruding&retracting 1. medpterygoid
Chewing themandibleone achside 2. latpterygoid
Forthistotakeplace,a c ertaina mt
ofrotationoccurs&themuscles
responsibleonbothsideswork
alternatively&notinunison

ClinicalNotes
Dislocationofthemandiblesometimesoccurswhenthemandibleisdepressed

68

Theheadofthemandibleon1orbothsidesslipsanteriorlyintoinfratemporalfossa
inabilitytoclosemouth

69

MaxillaryArtery
Themaxillaryarteryhasanextensivedistributiontotheupper&lowerjaws,muscles
ofmastication,thepalate&thenose

Origin
ItisthelargerterminalbranchofECA
arisesinparotidgldbhdneckofmandible

Course&Relations
Fordescriptivepurposesthearteryisdividedinto3partsbythelatpterygoid
Mandibular(1st)Part fromitsoriginitrunsforward
liesbtwneckofmandible&sphenomandibularlig
reaches&runsalonglowerborderoflatpterygoid
nd
Pterygoid(2 )Part fromlowerborderofpterygoid,
itrunsupwards&forwards
eithersupfordeeptolowerheadoflatpterygoid
Pterygopalatine(3rd)Part passesbtwthe2headsoflatpterygoid
thenthroughpterygomaxillaryfissure
toenterthepterygopalatinefossa
breaksupintobranches,ofwhichthe
sphenopalatineartisconsideredtheterminal
branch

Branches
From1stPart givesoff5branchesofwhichthemostimptis
middlemeningealart&infalveolarart
From2ndPart branchessupplythemusclesofmasticationaswellasthebuccinator
From3rdPart themoreimptare:
1.infraorbitalart
2.greaterpalatine
3.pharyngeal
4.spenopalatine

ClinicalNotes
1. middlemeningealarteryinvinintracranialhemorrhages
2. sphenopalatinearteryinvinnosebleeds

70

MaxillaryNerve
Themaxillarynerveisthe2nd
divisionofthetrigeminaln

Origin
arisesfromtrigeminalganglion
liesind
uralattocavernoussinus

Course&Relations
fromorigin,itpassesthroughforamenrotundum
enterspterygopalatinefossa
continuesasinfraorbitaln
entersorbitthroughinforbitalfissure
runsininfraorbitalgroovethencanal
passesthroughinfraorbitalforamen
emergesontothefacewhereitendsbydividingintoseveralbranches

Branches
1 meningealbranch inmiddlecranialfossa
2 postsupalveolarbranches inpterygopalatinefossa
3 zygomaticn
4 middle&antsupalveolarbranch ininfraorbitalcanal
5 infpalpebralbranches onface
6 nasalbranches
7 suplabialbranches

ClinicalNotes
Inthepterygopalatinefossa,thenervecanbeblockedbypassinganeedlethroughthe
mandibularnotch&injectingalocalanesthetic

71

MandibularNerve
Themandibularnisthe3rd
&largestofthe3divisionofthetrigeminaln
Ithasbothsensory&motorfibres

Origin
beginsinthemiddlecranialfossaasalargesensoryroot&asmallmotorroot
sensoryrootarisesfromtrigeminalganglion
motorrootarisesfrommotornucleusofVinpons

Course&Relations
sensoryrootliesabovemotorroot&bothpassoutoftheskullthroughforamen
ovaletoenterinfratemporalfossa
the2rootsunitejustbelowtheforamentoformasinglemaintrunk
liesontensorpalatini,deeptolatpterygoid
themaintrunksoondividesintoasmallant&largepostdivision

Branches
1.FromMainTrunk
1.meningealbranch
2.ntomedpterygoid
From Sensory Motor
2. AnteriorTrunk/Division buccaln 1.massetericn
2.deeptemporaln
3.ntolatpterygoid
3. PosteriorTrunk/Division 1.auriculotemporaln infalveolarn
2.lingualn

ClinicalNotes
1. mandibularnblockcarriedoutintraorallyforextractionofteeth
2. painfromdiseaseofthetoothsometimesgetsreferredalongtheauriculotemporal
ntotheear

72

PterygopalatineGanglion
Thisisalargerpsympperipheralganglion
Itservesasarelaystationforthesecretomotorfibrestothe
lacrimalgld&mucousgldsofthenose,paranasalsinuses,palate&pharynx

Location
liesinpterygopalatinefossa belowmaxillaryninfrontofpterygoidcanal
closetosphenopalatineforamen

Connections(Roots)
a. Motor(psymp)root=secretomotor
formedby 1.greaterpetrosaln
2.nofpterygoidcanal
PreGNfibres arisefromlacrimalnucleus
passthroughnervousintermediusoffacialn
synapseintheganglion
PGNf ibres passtolacrimalgldviamaxillary,zygomatic&lacrimaln
alsopasstonasal&palatineglds

b. Symproot=vasomotor
formedby 1.deeppetrosaln
2.nofpterygoidcanal
fibresderivedfromICAplexus&theyarePGNfibreshavingcomefromsup
cervicalganglion
thesefibrespassthroughganglionwithoutsynapsing
theyaredistributedwiththepsympfibres
c. Sensoryroot
frommaxillaryn
passthroughtheganglionwithoutsynapsing

Branches
Thesearebranchesofthemaxillarynwhichalsoincorporatepsymp&sympfibres
1. orbitalbranches
2. palatinebranches(greater&lesser)
3. nasalbranches
4. pharyngealbranches

ClinicalNotes
Theganglioncanbeinjectedthroughthemandibularnotch&pterygopalatinefossa

73

SubmandibularGland
Thesubmandibulargldisalargesalivarygldandhasamixtureofserousandmucous
acini.

Location
itliesintheantpartofdigastrictriangle
partlyundercoverofbodyofmandible

Shape&PartsoftheGland
roughlyJshaped
dividedinto 1.largesupfpart(supftomylohyoid)
2.smalldeeppart(deeptomylohyoid)
The2partsarecontinuouswitheachotheraroundpostborderofmylohyoid

Capsules
2capsulescoverthegld:
1.intfibrouscapsule
2.extcapsulederivedfrominvestinglayerofdeepcervicalfascia
Partoffasciaextendsbtwstyloidprocess&angleofmandible
stylomandibularlig

SuperficialPartofGland
liesindigastrictriangle,partlyundercoverofmandible
posteriorlyitisseparatedfromparotidgldbystylomandibularlig
Relations
anteriorly antbellyofdigastric
posteriorly 1. stylohyoid
2. postbellyofdigastric
3. stylomandibularlig,whichsepitfrom
4. parotidgld
medially 1. mylohyoid
2. mylohyoidn&vsls
3. hyoglossus
4. lingual&hypoglossaln
laterally 1. submandibularfossaonmedsurfaceofmandible
2. cervicalbranchoffacialn
3. facialvein
4. submandibularlymphnodes
5. fascia,platysma&skininferolaterally

74

DeepPartoftheGland
extendsforwardtointervalbtw: mylohyoid(below&lat)
&hyoglossus&styloglossus(med)
postendiscontinuouswithsupfpartofgldaroundpostborderofmylohyoid
muscle
antendreachesasfarassublingualgld
Relations
anteriorly sublingualgld
posteriorly 1. stylohyoid
2. postbellyofdigastric
3. stylomandibularlig
4. parotidgld
superiorly 1. lingualn
2. submandibularganglion
3. Itiscoveredbymucousmbmoffloorofthemouth
inferiorly hypoglossaln
medially hyoglossus&styloglossus
laterally 1. mylohyoid
2. supfpartofthegld

SubmandibularDuct
emergesfromantendofdeeppartofgld
passesforwardalongsideofthetongue,beneathmucousmbmoffloorofmouth
opensintothemouthonthesummitofasmallpapillasituatedatthesidesofthe
frenulumofthetongue

BloodSupply
branchesof 1.facialart&
2.lingualart

VenousDrainage
1.facialvein
2.lingualvein

LymphaticDrainage
submandibularnodesdeepcervicalnodes

NerveSupply
Psymp secretomotor
c ranialnPreGN
fibresfromsupsalivatorynucleusof7th
passviac hordatympanilingualnsynapseinsubmandibularganglion
PGNfibresreachglddirectlyfromtheganglion
Symp fromplexusonfaciala rt
Sensory fromlingualn

ClinicalNotes
1. commonsiteforformationofc alculus(stones)

75

2. excisionofgld

76

SublingualGland
Thisisthesmallestofthe3mainsalivaryglands
Itcontainsbothserous&mucousacini,withmucouspredominating

Location&Shape
lies beneathmucousmbmoffloorofmouth
closetomidlin
roughlyalmondshaped

Relations
Anteriorly gldonoppositeside
Posteriorly deeppartofsubmandibulargld
Medially 1. genioglossus
2. lingualn
3. submandibularduct
Laterally sublingualfossaonmedsurfaceofmandible
Superiorly mucousmbmoffloorofthemouth
elevatedtoformsublingualfold
Inferiorly mylohyoidmuscle

SublingualDucts
820innumber
majorityopenintomouthonsummitofsublingualfold
somemayopenintosubmandibularduct

BloodSupply
branchesof 1.facialart
2.lingualart

VenousDrainage
1.facialvein
2.lingualvein

LymphaticDrainage
deepcervicalnodes
submandibular

NerveSupply
Psymp PreGNfibresfromsupsalivarynucleusof7th cranialn
chordatympani lingualnsubmandibularganglion
PGNfibres lingualnsupplythegld
Symp fromplexusaroundfacial&lingualarteries
Sensory fromlingualn

ClinicalNotes
1. infection&enlargementofgld
77

2. cysts
blockageofoneofthesublingualducts

78

LingualNerve
Thelingualnissensorytotheant2/3ofthetongue&fibreofthemouth
Inadditionitalsoreceivesfibresfromthechordatympanibranchofthefacialn
1.secretomotor(psymp)tosubmandibular&sublingualsalivaryglds
2.tastefibrestoant2/3oftongue

Origin
1ofthe2terminalbranchesofpostdividisionofmandibularn
beginsslightlybelowskull(stylomandibularlig)

Course&Relations
runsdownwardonmedsurfaceoflatpterygoid
thenonlatsurfaceofmedpterygoid
joinedbychordatympani
emergesatlowerborderoflatpterygoid&continuesdownwardsbtwramusof
mandible&medpterygoid
nextitpassesforward&mediallybeneathlowerborderofsupconstrictorof
pharynx
mediallyitisrelatedtostyloglossus
laterallyitisrelatedtolower3rd
molartooth
passesforwardonlatsurfaceofhyoglossus
atantmarginofhyoglossus,itwindsroundsubmandibularductfromlattomed&
liesongenioglossus
dividesintoterminalbranches

Branches
ganglionic PreGNpsympfibrespassingtosubmandibularganglion
branches Thesefibresarisefromsupsalivatorynucleusoffacialn
travelviachordatympani lingualn
sensorybranches toant2/3ofthetongue,floorofmouth&lingualsurfaceofgums
communicating tohypoglossaln
branches

ClinicalNotes
Closerelationoflingualnto3rd
molartooth
maybedamagedduringtoothextraction

79

NasalCavity:Relations,Openings&Branches
Thenasalcavityextendsfromthenostrils(nares)infronttothechoanaebhd
Itisdividedinto2halvesbythenasalseptum

Relations
Superiorly 1. frontalsinus
2. antcranialfossa
3. sphenoidalsinus
4. middlecranialfossa
Inferiorly 1. hardpalate,whichsepitfrom
2. oralcavity
Posteriorly communicateswithnasopharynxwhich
canberegardedasthebackofthecavity
Laterally 1. exterior(frontpartofcavity)
2. orbit
3. maxillary&ethmoidsinuses
4. pterygopalatine&pterygoidfossae

Openings
Theopeningsthatleadintooroutofthenasalcavityare:
1. nostrils
2. choanae
3. openingsofmaxillary,frontal,sphenoidal&ethmoidalairsinuses,&
4. openingofnasolacrimalduct

Nostrils antaperturesofthenose
perforateextnosetocommunicatewithexterior
bounded mediallybynasalseptum
laterallybyalaofthenose
Choanae postapertureofthenose,largerthanthenostrils
communicatewithnasopharynx
bounded superiorlybybodyofsphenoid
inferiorlybyhorizplateofpalatinebone
mediallybyvomer&
laterallybymedpterygoidplate
OpeningsofParanasalAir
Sinuses
1.maxillarysinus opensintomiddlemeatusofnasalcavitythrough
hiatussemilunaris
2.frontalsinus opensintomiddlemeatusviainfundibulum
3.sphenoidalsinus opensintosphenoethmoidalrecess
4.ethmoidalsinuses ant&middlegpsopenintomiddlemeatus
postgpopensintosupmeatus
OpeningofNasolacrimal opensintoinfmeatusofnasalcavity
Duct openingisguardedbyafoldofmucousmbm
=lacrimalfold

80

81

Boundaries
eachhalfofthenasalcavityhasaroof,floor,med&latwalls
Formation Remark
Roof 1. nasalcartilages theroofisnarrow&slopes
2. nasalbone downwards
3. frontalbone
4. cribiformplateofethmoidbone
5. bodyofsphenoid
(fromanttopost)
Floor 1. palatineprocessofmaxilla(ant) separatesnasalcavityfromoral
2. horizplateofpalatinebone(post) cavity
uppersurfaceofhardpalate
Medial 1. septalcartilage consistsofnasalseptum
Wall 2. perpendicularplateofethmoid usudeviatedtooneside
3. vomer(fromanttopost)
Lateral 1. nasalbone
Wall 2. maxillabone
3. lacrimalbone
4. ethmoid(labryrinth&concave)
5. infnasalconcha
6. perpendicularplateofpalatine
7. medpterygoidplatesphenoid

BloodSupply
maxillaryartsphenopalatineart
ophthalmicartantethmoidalart

VenousDrainage
Veinsfollowthearteries

LymphaticDrainage
deepcervicalnodes

NerveSupply
1. Psympfrompterygopalatineganglion
2. Sympfromsupcervicalganglion

82

Features
1. 3projections
supchoncha partofethmoidbone
middlechoncha partofethmoidbone
infchoncha sepbonebyitself
2. areabeloweachchonchaiscalledmeatus
supmeatus liesbelow&lattosupchoncha
receivesopeningofpostgpofethmoidalsinuses
middle liesbelow&lattomiddlechoncha
meatus ethmoidalbulla=openingofmiddleethmoidalsinuses
hiatussemilunaris=openingofmaxillarysinus
ethmoidalinfundibulum= openingoffrontalsinus&
antethmoidalsinuses
infmeatus liesbelow&lattoinfchoncha
receivesopeningsofnasolacrimalduct,guardedbyan
imperfectvalve,thelacrimalfold

ClinicalNotes
1. fractureofnasalbones&nasalseptumduetofrontalblows
2. spreadofinfectionfromnasalcavityintointracranialregions
3. epistaxis/nosebleed
invsphenopalatine&facialvsls

83

Tongue:Features&Muscles
Thetongueisamuscularorganinthefloorofthemouth
Itisattachedbymusclestothehyoidbone,mandible,stylodprocesses&pharynx
Itisimptintaste,mastication,swallowing&speech

SurfaceFeatures
Thetongueiscomposedchieflyofskeletalmuscle&coveredbymucousmbm
Itsant2/3liesinthemouth&post2/3inthepharynx
Itpresents 1.tip&margin
2.dorsum
3.infsurface
4.root
a. Tip&Margin
Thetip/apexofthetongueusurestsagainsttheincisorteeth
Themarginofthetongueisrelatedoneachsidetothegums&theteeth
b. Dorsum
situatedpartlyinoralcavity&partlyinoropharynx
ThisisdemarcatedbyaVshapedgroove=sulcusterminalis
whichdividesitinto ant2/3inoralcavity
post1/3inoropharynx
apexofsulcusterminalisprojectsbackwards
&ismarkedbyasmallpit=foramencecum
OralPartofTongue 1. dividedintoL&Rhalvesbyshallow
mediangroove
2. exhibitlingualpapillaeofthe3types
a.filiformpapillae
b.fungiformpapillae
c.vallatepapillae
PharyngealPartofTongue containslymphaticnodules=lingualtonsils
=antwallofpharynxdevoid
ofpapillae
c. InferiorSurface
smooth&devoidofpapillae
connectedtofloorofmouthbyafoldofmucousmbm=frenulumoftongue
deeplingualveincanbeseenbesidefrenulum
lattoveinmucousmbmformsafold=plicafimbriatia
d. Root
restsonfloorofmouth,ie.geniohyoid&mylohyoid
attachedbymusclestomandible&hyoidbone
nerves,vsls&extrinsicmusclesenterorleavethetonguethroughitsroot

84

MusclesoftheTongue
Thesemusclesofthetongueareof2types 1.intrinsic
2.extrinsic
Allthemusclesarebilateral,thoseon1sidebeingpartiallyseparatedfromthose
oftheoppositesidebyamedianseptum
Intrinsic Thesemusclesareconfinedtothetongueitself&arenot
Muscles attachedtobone
Theyarearrangedinseveralplanes&aregenerallyclassified
as
1.sup&inflongitudinal
2.tnvs
3.vertical
Theiractionsaretoaltertheshapeofthetongue
Extrinsic Thesemusclesthatarisefromnearbyparts&areinsertedinto
Muscles thetongue
Theyare: 1.genioglossus
2.hyoglossus
3.styloglossus
4.palatoglossus
Theiractionsaretomovethetongue

MovementsoftheTongue
1 protrusion broughtabtbygenioglossusofbothsidesactingtog
2 retraction producedbystyloglossus&hyoglossusofbothsidesactingtog
3 depression producedbyhyoglossus&genioglossusofbothsidesactingtog
Theshapeofthetongueismodifiedbytheactionoftheintrinsicmuscles

BloodSupply
1. lingualart
2. tonsillarbranchoffacialart
3. ascpharyngealart

LymphaticDrainage
tip submentalnodes
ant2/3 submandibular deepcervicalnodes
post1/3 deepcervicalnodes

85

InnervationoftheTongue
Thenervesupplyofthetongueis2fold:
1.motorsupplytothemuscles
2.sensorytothemucousmbm

MotorSupply
Allintrinsicmusclesaresuppliedbyhypoglossaln
Alle xtrinsicmusclesarealsosuppliedbyhypoglossaln
exceptpalatoglossuswhichissuppliedbycranialpartofaccessoryn
Thusthenervesconcernedwithmotorsupplytothetonguearethe11th&12th
cranialn

Sensory
Ant2/3ofTongue suppliedbylingualn(abranchofmandibularn)
1.
forgeneralsensation
2. suppliedbychordatympani(abranchoffacialn)
fortaste
Note:chordatympanirunsinlingualn
Post1/3ofTongue 1. suppliedbylingualbranchofglossopharyngealn
forbothgeneralsensation&taste
2. smallcontributionfromintlaryngealbranchofvagusn
forbothgeneralsensation&taste
Thusthenervesconcernedwithsensorysupplycomefrom:
1. 5thcranialn =generalsensation
th
2. 7 cranialn =taste
th
3. 9 cranialn =both
4. 10thcranialn =both

ClinicalNotes
1. lesionofhypoglossaln paralysisofipsilatsideoftongue
2. lossoftastesensationonant2/3oftongue
lesionoffacialn

86

ConstrictorMusclesofPharynx
Thewallofthepharynxiscomposedlargelyof2layersofmuscles
Theinternal,chieflylongitudinallayerconsistsof2levatormuscles:
1.palatopharyngeus
2.stylopharyngeus
Theoutercircularlayerconsistsof3constrictors
1.supconstrictors
2.middleconstrictors
3.infconstrictors
Theconstrictorshavetheirfixedptsinfront,
wheretheyareattachedtobones&cartilage,
whereastheyexpandbhd&overlaponeanotherfrombelowupwards.
Theyendinamediantendinousrapheposteriorly

TheConstrictorMuscles
SuperiorConstrictor MiddleConstrictor InferiorConstrictor
Origin 1. postborderofmed 1. lowerpartof 1. obliquelineonlaminaon
pterygoidplate stylohyoidlig thyroidcartilage
2. pterygoidhamulus 2. lesser&greater 2. tendinousband
3. postendofmylohyoidline cornusofhyoid connectingthyroid
onmandible bone cartilagetocricoid
4. sideoftongue cartilage
3. sideofcricoidcartilage
Insertio 1. upperfibrecurvemed& intomedian Intomediantendinous
n upwards tendinousraphe raphe
pharyngealtubercleof Supfibres Supfibresoverlaplat
occipitalbone overlaplat surfaceofmiddle
2. middlefibresmedian surfaceofsup constrictormuscle
tendinousraphe constrictor Inffibresrunhorizontally
3. lowerfibrescurvemed&
inffibresare med&arecontinuous
downwardmedian
overlapped withcircularfibresof
tendinousraphe
laterallybyinf esophagusbelow
Theyareoverlappedby
constrictor
middleconstrictors
Nerve pharyngealplexus pharyngealplexus pharyngealplexus
Supply

ActionofConstrictorMuscles
Duringprocessofswallowing,
1. upperfibresofsupconstrictorcontract&pullthepostpharyngealwallforward
aidspalateinclosingoffupperpartofpharynx(nasopharygnx)
2. successivecontractionofthesup,middle&infconstrictormusclespropelsthe
bolusoffooddownintotheesophagus
3. thelowestfibresofinfconstrictor(sometimescalledcricopharyngeusmuscle)
exertasphinctericeffectonlowerendofpharynx
prevententryofairintoesophagusbtwtheactsofswallowing.

ClinicalNotes
Thepharyngealplexuswhichsuppliesthemusclesismadeupfromfibres
travellinginthevagusn(pharyngealbranch)
However,thesefibresoriginatefromcranialpartofaccessoryn
87

 paralysisofconstrictors
Lesionofvagusn
Thusthepatientmayhavedifficultyswallowing

88

Nasopharynx
Thephaynxextendsfrombaseofskulldowntolowerborderofcricoidcartilage
(oppositeCV6),whereitbecomescontinuouswiththeesophagus
Itcanbedividedinto3parts
nasophaynx bhdnasalcavity
oropharynx bhdoralcavity
laryngopharynx bhdlarynx

Nasopharynx:Introduction
liesbhdthenasalcavities,abovethesoftpalate
Thussometimesregardedasbackpartofnasalcavity
whenswallowing,softpalateisraised&postpharyngealwalldrawnforward
nasophaynxisshutofffromoropharynx
nasopharynxhas: roof&floor
ant&postwalls
latwalls

Roof
supportedby 1.bodyofsphenoid
2.basilarpartofoccipitalbone
submucosaofthisregioncontainsacollectionoflymphoidtissue
=pharyngealtonsil

Floor
formedbyslopinguppersurfaceofsoftpalate
opening=pharyngealisthmus
btwfreeedgesofsoftpalate&postpharyngealwall
enablesnasopharynxtocommunicatewithoropharynx
duringswallowing,thisopeningisclosedbyraisingthesoftpalate
&pullingforwardthepostpharyngealwall

AnteriorWall
formedbypostnasalapertures(choanae)separatedbypostedgeofnasalseptum
communicatedwithnasalcavityanteriorlythroughthechoanae

PosteriorWall
formsacontinuousslopingsurfacewiththeroof
supportedbyantarchofatlas

89

LateralWall
openingofauditorytube
tubalelevation postmarginofauditorytubeformsanelevation
salpingopharyngealfold salpingopharyngeusmuscle(attachedtolower
marginoftube)
formsaverticalfoldofmucousmbm
pharyngealrecess bhdtubalelevationisasmalldepression
tubaltonsil bhdopeningofauditorytubeisacollectionof
lymphoidtissueinthesubmucosa

BloodSupply
ascpharyngealart(fromECA)

VenousDrainage
venousplexusesbelowmucosa

LymphaticDrainage
deepcervicalnodes

NerveSupply
pharyngealplexus

ClinicalNotes
1. infection hypertrophyofpharyngealtonsil enlarged
Thisisknownasadenoids&isremovedbyadenoidectomy
2. closerelationshipofinfectedtonsiltoauditorytubemaycausedeafness
3. nasopharynxmaybeexaminedbyamirrorpassedthroughthemouth

90

MechanismofSwallowing
Afterfoodentersthemouth,itisusuallybrokendwonbythegrindingoftheteeth
&ismixedwithsaliva
Thethoroughlymixedfoodisnowformedintoabolusonthedorsumofthe
tongue&theprocessofswallowingbegins
Thisprocesshasavoluntary&involuntaryphase

VoluntaryPhase
antpartoftongueisraised&pressedagainsthardpalatebyintrinsicmusclesof
thetongue
pushesbolusoffoodintopostpartoforalcavity
Thisisfollowedbystyloglossusmusclescontracting
pullsrootoftongueupwards&backwards
palatoglossusalsocontract
squeezebolusoffoodbackwardintooropharynx

InvoluntaryPhase
elevationofsoftpalate
pullingforwardofpostpharyngealwallbysupconstrictors
&contractionofpalatopharyngeus
closureofnasopharyngealisthmus
ie.nasopharynxclosedofffromoropharynx
larynx&laryngealpartofpharynxnowelevated
larynxisclosedtoprevententryoffoodbolus
thebolusmovesdownwardovertheepiglottis&closedentranceoflarynx
reacheslowerpartofpharynxasresultofsuccessivecontractionofsup,middle&
infconstrictormuscles&bygravity
finally,thelowerfibresofinfconstrictormuscle(cricopharyngeusmuscle)relax
bolusenterstheesophagus

ClinicalNotes
difficultyinswallowing=dysphagia
canbecausedbyparalysisoftheconstrictorsmusclesduetolesionofvagusn

91

AuditoryTube
Thisisatrumpetshapedchaneelwhichconnectsthenasopharynxwiththemiddle
earcavity
Itsfunctionistomaintainatmpressureinthemiddleearcavitysothattheair
pressuresonbothsidesofthetympanicmbmareequal

Length&Direction
34cmlong
extendsbackward,laterally&upwardsfromnasopharynx

Parts
post1/3 =bony
ant2/3 =cartilaginous
CartilaginousPart abt23cmlong,attachedtomedendofbonypart
liesinagroovebtwgreaterwingofsphenoid&apexof
petroustemporal
sup&medwall=cartilage
lat&infwalls=fibrousmbm
relations
a.anterolat: 1.tensorvelipalatini
2.mandibularn
3.middlemeningealart
b.posteromed: 1.levatorvelipalatini
2.pharyngealrecess
BonyPart abt1cmlong
liesinpetroustemporalbone,neartympaniplate
opensintomiddleearcavity
latendiswider
medendisnarrow(isthmus) attachtocartilaginouspart
relations
a.superiorly 1.canalfortensortympani
b.anterolat 1.tympanicportionoftemporalbone
c.posteromed 1.carotidcanal

MucosalLining
incartilaginouspart mainlypseudostrcolumnarciliatedepith
containsmanymucousglds
inbonypart mainlyflattenedcuboidalnonciliatedepith
=mucoperiosteum

BloodSupply
from: 1.ascpharyngeal
2.middlemeningeal
3.artofpterygoidcanal

92

VenousDrainage
into: 1.pharyngealvein
2.pterygoidplexusesofveins

LymphaticDrainage
intoretropharyngealnodesdeepcervicalnodes

NerveSupply
cartilaginouspart bybranchfrommandibularn
bonypart bytympanicplexus(9thn)
Alsobypharyngealbranchofpterygopalatineganglion

ClinicalNotes
1. cold/sorethroatmayleadtoinflammationofauditorytube
2. throatinfectionsmaybetransmittedviathetubetomiddleearcavity

93

MiddleEarCavity
Themiddleearconsistslargelyofanairspace
Itisalsocalledthetympaniccavity

Location
situatedinpetrouspartoftemporalbone
btwext&intears

Communications
withnasopharynxanteriorlyviaauditorytube
withm astoidantrum&aircellsposteriorlyviatheaditustotheantrum

Parts
Itconsistsof
1.tympaniccavityproperwhichliesoppositethetympanicmbm
2.epitympanirecesswhichliesabovethelevelofthetympanicmbm
Itcontainsupperpartofmalleus&greaterpartofincus

Boundaries
Themiddleearhas6sides
Roof formedbya portionofpetroustemporalc alledtegmentympani
(TegmentalWall) sepmiddlee arfrommiddlec ranialfossa
Floor formedbyjugularfossaoftemporalbone
(JugularWall) sepmiddlee arfromsupbulbofIJV
Anterior sepmiddlee arfromICA&sympplexus
(Carotid)Wall consistsof3parts 1.openingofc analfortensortympanisup
2.openingofa uditorytubeinthemiddle&
3.postwallofc arotidc analinf
Posterior upperparthaslargeopening=a ditustothemastoida ntrum
(Mastoid)Wall belowthea ditusisa smallprojection=pyramid
c ontainsstapediusmuscle
LaterallWall sepmiddlee arfrome xta cousticmeatus
(Membranous) formedby tympanimbmbelow
squamouspartoftemporalbonea bove
aboveleveloftympanicmbmisthee pitympanicrecess
MedialWall sepmiddlee arfrominte ar
(Labyrinthine) thiswallpresentsthefollowingfeaturesfroma bovedownwards:
1.prominenceoflatsemicircularc anal
&prominenceoffacialnc anal
2.ovalwindow(fenestravestibule)=c losedbybaseofstapes
&processusc ochleariformis(abonyprominencea bovethe
window)
3.promontory
formedbybasalturnofc ochlea&c overedbytympanicplexus
4.fenestrac ochleae(roundwindow)
c losedbymucousmbmofmiddlee ar

94

95

Contents
Contents Remarks
1 3earossicles malleus
incus
stapes
2 ligsofearossicles
3 2muscles tensortympani
stapedius
4 vslssupplying&drainingmiddleear
5 nerves chordatympani
tympanicplexus
6 air
Themiddleearislinedbymucousmbm

BloodSupply
1. stylomastoidartery(fromECA)
2. anttympanicart(frommaxillaryartery)
3. manysmallervslscontribute

VenousDrainage
1. suppetrosalsinus
2. pterygoidplexusofveins

LymphaticDrainage
preauricular&retropharyngealnodsdeepcervicalnodes

NerveSupply
fromtympanicplexuswhichisformedby
1.auriculotemporaln(5thcranialn)
2.tympanicn(9thcranial)
3.auricularbranch(10thcranialn)
Note:AlsobynervesfromsympplexusaroundECA

ClinicalNotes
1. otoscopicexaminationoftympanicmbm
2. infectionofnasopharynxmayspreadviaauditorytubetomiddleear
3. infectionofmiddleeariscalledottismedia
Thiscanspreadtoallitssurroundingrelationstocausevarioussymptoms

FunctionalConsiderations
1. Sound Soundwavesinmiddleearcavity
tympanicmbmvibrates
ossiclesvibrate stapescausevibrationoffenestravestibuli
2. fenestracochleaevibratesinoppositedirection
Thus,soundvibrationsaretransmittedintoinnerearby:
1.auditoryossicles&fenestravestibuli
2.airintympaniccavity&fenestracochleae
3.boneconduction

96

Disease=otosclerosisofmedwall

97

PterygopalatineFossa
smallpyramidalspacebhd&beloworbitalcavity

Boundaries
ant postsurfaceofmaxilla
post greaterwinofsphenoid&rootofpterygoidprocess
med upperpartofperpendicularplatewithorbital&sphenoidalprocesses
withpalatinebone
lat open(pterygomaxillaryfissure)
sup bodyofsphenoid
inf pyramidalprocess&palatinebone

Communications
relations communicateswith through
ant orbit inforbitalfissure
post 1. middlecranialfossa foramenrotundum
2. pterygoidcanal foramenlacerum
3. pharynx palatovaginalcanal
med nose sphenopalatineforamen
lat infratemporalfossa pterygomaxillaryfissure
inf oralcavity a.greaterpalatinecanals
b.lesserpalatinecanals

Contents
1. Maxillaryart3rd
part&branch
2. Maxillarynerve&2branches(zygomatic,postalveolar)
3. Pterygopalatineganglion&branches containingfromwhichmaxillaryn
mixedwithautonomicn

98

CutaneousInnervationofFace
skinoffacesuppliedbybranchesofthe3divisionsofthetrigeminaln
exceptforthesmallareaovertheangleofmandibleandtheparotidgld
whichissuppliedbythegreatauricularn
Theoverlapofthe3divisionsofthetrigeminalnisslightincomparisiontothe
considerableoverlapofadjdermatomesofthetrunkandlimbs

EmbryologicalDevelopment
ophthalmicn regiondevfromthefrontonasalprocess
maxillaryn regiondevfromthemaxillaryprocessofthe
1stpharyngealarch
mandibularn regiondevfromthemandibularprocessofthe
1stpharyngealarch

OphthalmicNerve
suppliestheskinoftheforehead,uppereyelid,conjunctivaandsideofthenose
downtoandincludingthetip
Branches Course Supply
lacrimaln 1. skin
2. conjunctivaoflatuppereyelid
supraorbitaln windsaroundtheupper 1. skin
marginoftheorbitatthe 2. conjunctivaonthecentralpartof
supraorbitalnotch uppereyelid
3. skinoftheforehead
supratrochlearn windsaroundtheupper 1. skin
marginoftheorbit 2. conjunctivaonthemedpartofthe
medialtothesupraorbital uppereyelid
n 3. skinoverthelowerpartof
foreheadclosetothemedianplane
infratrochlearn leavesorbitbelowthe 1. skin
pulleyofthesupoblique 2. conjunctivaonmedpartofthe
musc uppereyelid
3. adjoiningpartofthesideofthe
nose
extnasaln leavesnosebyemergeing skinonsideofnosedowntothetip
btwnasalboneandupper
nasalcartilage

99

MaxillaryNerve
suppliestheskinonthepostpartofthesideofthenose,thelowereyelid,the
cheek,theupperlips,andthelatsideoftheorbitalopening
Branches Course Supply
infraorbitaln directcontinuationofmaxillaryn 1. skinoflowereyelid
entersorbitandappearsonthe andcheek
facethroughtheinfraorbital 2. skinofsideofnose
foramen 3. skinofupperlip
zygomaticofaci passesontothefacethroughasmall skinovertheprominence
aln foramenonthelatsideofthe ofcheek
zygomaticbone
zygomaticotem emergesinthetemporalfossathrough skinoverthetemple
poraln asmallforamenonthepostsurfaceof
zygomaticbone

MandibularNerve
suppliesskinofthelowerlip,thelowerpartoftheface,thetemporalregionand
partoftheauricle
thenpassesupwardstothesideofthescalp
Branches Course Supply
mentaln emergesfromthemental skinofthelowerlipand
foramenofthemandible chin
buccaln emergesfrombeneaththeant skinoverasmallareaofthe
borderofthemassetermusc cheek
auriculotemporaln ascfromtheupperborderofthe 1. skinoftheauricle
parotidgldbtwthesupf 2. extauditorymeatus
temporalvslsandtheauricle 3. outersurfaceofthe
tympanicmbm
4. skinofthescalpabove
theauricle

100

GlossopharyngealNerve(9thCranialNerve)
motorandsensorynerve
motorfibres stylopharyngeus
psympsecretomotorfibres parotidsalivarygld
sensoryfibres(includingtastefibres) post1/3oftongue&pharynx

Course
emergesfromantsurfaceofupperMO
by3or4rootletsalongthegroovebtwolive&infcbllarpenduncle
passesforward&latbeneathcbllminpostcranialfossa
leavesskullbypassingdownwardthrucentralpartofjugularforamen
descintheneckwithinthecarotidsheath
windsforwardaroundthestylopharyngeusmusc
&passesbtwthesup&middleconstrictormusc
lingualbranchofnentersthesubmandibularregion

Branches
Branch Course Supply
tympanicbr arisesbelowjugularforamen liningoftympcavity
passesthryflooroftympcavity givesofflesserpetrosaln
groovessurfaceofpromontory (withsecretomotorfibres
splitsintobranches tymp forparotidgld)
plexus
carotidbr carotidsinus&carotidbody
musclularbr stylopharyngeusmusc
pharyngealbr uniteonoutersurfaceofmiddle sensoryfibresto
constrictormuscwith 1. mucousmbmofpharynx
pharyngealbrofvagus& 2. tonsil
pharyngealbrofsymptrunk 3. softpalate
pharyngealplexus
lingualbr enterstonguebelowstyloglossus generalsensory&special
musc tastefibresto
1. mucousmbmofpost1/3
oftongue
2. circumvallatepapillae
regionofanttongue

101

VagusNerve(10thCranialNerve)
composedofbothmotorandsensoryfibres

Origin
originatesinMO
leavesthes kullthrumiddleofthejugularforamentogwith9th
&11thcn

SensoryGanglia
SuperiorGanglion rounded
onnwithinthejugularforamen
InferiorGanglion cylindrical
liesonnjustbelowforamen
belowthisganglion,cranialpartofaccnjoinsthevagusn
andisdistributedmainlyinitspharyngealandrecurrent
pharyngealbr

CourseintheNeck
passesverticallydowntheneckwithinthecarotidsheath
liesat1stbtwtheIJV&ICA
andthenbtwIJVandCCA
AtrootoftheneckaccompaniestheCCA
&liesantto1st
partofthesubclavianart

102

BranchesofVagusNerveintheNeck
Branches Ganglion Course Supply
Inv
Meningeal sup duramaterinpostfossaof
br ganglion skull
Auricular sup passesthroughbonyc analof medsurfaceofa uricle
br ganglion skulltoe mergebhdtheEAM floorofEAM
adjpartoftympmbm
pharyngeal inf passesforwardbtwtheICA& allthemuscofpharynx
br ganglion, ECAtoreachthepharyngeal (except
contains wall stylopharyngeus,byIX)
motor joinsbranchesfromtheIXn& allmuscofsoftpalate
fibresfr symptrunktoformthe (excepttensorveli
cranial pharyngealplexus palatini,bymandibular
partof divisionofVc n)
accn
sup inf runsdownward&mediallybhd
laryngealn ganglion ICA
dividesintoint&e xtlaryngeal
n
inf piercesthyrohyoidmbm(with sensoryn
laryngealn intlaryngeala rt) floorofpiriformfossa
mucousmbmoflarynx
downtovocalfolds
ext desctogwithsupthyroidgld cricothyroidmusc
laryngealn passesdeeptothyroidgld
2/3c ardiac arisefromvagusa sitdescthru
br neck
joinora ccompanyc ardiacbrof
symptrunk
endinc ardiacplexusinthorax
Rrecurrent arisesfromvagusa sitc rosses allmuscoflarynx
laryngealn 1stpartofsubclaviana rt exceptc ricothyroid
hooksbackward&upwardbhd mucousmbmoflarynx
art belowvocalfolds
ascingroovebtwtrachea& mucousmbmofupper
esophagus paroftrachea
passesdeeptolobeofthyroid
gld&c omesc losetoinf
thyroida rt
crossese itherinfrontoforbhd
artormaypassbtwits
branches
passesbeneathlowerborderof
infc onstrictormusc
Lrecurrent arisesfromvagusa sitc rosses
laryngealn archofa ortainthorax
hooksa roundbeneatha rchbhd
liga rt

103

 ascintoneckingroovebtw
trachea&e sophagus

104

AccessoryNerve(11thCranialNerve)
composedofmotorfibres

Origin
formedbyunionofcranial&spinalroots
cranialrootissmaller&arisesintheMO
spinalrootsa risefromC1C5segmentsofspcord

CourseinNeck
spinalrootsunitetoformatrunkthatascinvertebralcanaltoentertheskull
throughforamenmagnum
Boththecranial&spinalrootscometog&passthroughthemiddleofjugular
foramen

CourseofCranialRoot
sepfromsproot&joinsthevagusatinfganglion
distributedmainlyinthepharyngeal&recurrentlaryngealbranches

CourseofSpinalRoot
runsdownward&lat&crossestheIJV
thenentersthedeepsurfaceofsternocleidomastoid,whichitsupplies
emergesabovethemiddleofpostborderofsternocleidomastoid&crossesthe
posttriangleofneckonthelevscaptosupplythetrapeziusmusc

105

HypoglossalNerve(12thCranialNerve)
motornervetotonguemuscles

Origin
arisesinMO

Course
leavestheskullthruhypoglossalcanalintheoccipitalbone
comesincloserelationshipwith9th ,10th,&11thcn,ICAandIJV
descbtwICA&IJVuntilitreachesthelowerborderofpostbellyofdigastric
musc
runsforward&med
nerveloopsaroundoccipitalart&crossesICA&ECA&loopofligualart
(justabovetipofgreatercornuofhyoidbone)
passesforward&upward,deeptodigastric,stylohyoid,postmarginofmylohyoid
musc
inupperpartofitscourse,joinedbysmallbrfromcervicalplexus
(C1&sometimesC2)
ThisbrlaterleavesXIInasits descbr
ntothyrohyoid
ntogeniohyoid
Runsforwardonlatsurfaceofhyoglossusmusc
&onmedsurfaceofmylohyoidmusc
liesbelowdeeppartofsubmandibulargld,submandibularduct&lingualn
endsbycurvingupwardtowardtipoftongue

BranchesinNeck
Branches Origin&Course Supply
MeningealBr arisesfrnasittraversesthe meningesinpostcranial
hypoglossalcanal fossa
DescBr arisesfrnasitcurvesforward Branchesofloop:
(C1fibres) belowthepostbellyofdigastric omohyoid
descinfrontofECA&CCA, sternohyoid
withincarotidsheath sternothyroid
joinedbydesccervicaln(C2&3)
frcervicalplxtoformaloop(ansa
cervicalis)

106

BranchesinTongue
Branches Origin&Course Supply
ntothyrohyoid arisesfrnasitpassesdeepto thyrohyoidmusc
(C1fibres) mylohyoidmusc
ntogeniohyoid givenoffonsideoftongue geniohyoidmusc
(C1fibres)
Communicatingbr withlingualnonsideoftongue
Alsomuscularbranchestoallmuscoftongue
exceptpalatoglossus(bypharyngealplexus)
Thussupplies styloglossus
hyoglossus
genioglossus
intrinsicmuscoftongue

107

ParanasalSinuses
cavitiesfdinintofmaxilla,frontal,sphenoid&ethmoidbones
linedwithmucoperiosteum,filledwithair
communicatewithnasalcavitythrusmallapertures

MucousMembrane
havegldswhichproducesmucus
mucusmovedbyciliaryactionofcolumnarcells
drainageofmucus:bysiphonactioncreatedbyblowingofnose

Function
1. actasresonatorstovoice
2. reduceweightofskull
Thuswhensinusesblocked,orfilledwithfluid,qualityofvoicechanged

MaxillarySinus
foundwithinbodyofmaxilla
pyramidalinshape
base formslatwallofnose
apex inzygomaticprocessofmaxilla
roof formedbyflooroforbit
floor formedbyalveolarprocess
Rootsof1st &2nd
premolars&3rdmolar&sometimes,rootofcanine,projectup
intomaxsinus
opensintomiddlemeatusofnosethruhiatussemilunaris
clinically: openingofmaxsinustomiddlemeatusishigh
sinusaccumulatesfluid
frontal&antethsinusesdrainintoinfundibulum,intohiatus
infectionfromthesesinusesmayspreadtomaxsinus
nervesupplyofmucousmbm: supalveolarn
infraorbitaln

FrontalSinuses
containedwithinfrontalbone
separatedfromeachotherbybonyseptum(freqdeviatedfrommedianplane)
roughlytriangularinshape extendupwardabovemedendofeyebrow
backwardintomedpartofroofoforbit
opensintomiddlemeatusofnosethruinfundibulum
nervesupplyofmucousmbm:supraorbitaln

SphenoidalSinuses
liewithinbodyofsphenoidbone
opensintospenoethmoidalrecessabovesupconcha
nervesupplyofmucousmbm:postethmoidaln

108

EthmoidalSinuses
containedwithinethmoidbone(btwnose&orbit)
sepfromorbitbythinplateofbone
infectioncanspreadfromsinusesintoorbit
dividedinto3groups:ant,middle,post
Sinus antgp middlegp postgp
Opening infundibulum middlemeatus supmeatus
nervesupplyofmucousmbm:ant&postethmoidaln

109

OralCavity
Extent
fromlipstooropharyngealisthmus(jnofmouthwithpharynx)

Subdivision
vestibule Externally: liesbtwlips&cheeks
Internally: liesbtwgums&teeth
Mouthcavityproper: lieswithinalveolararches,gums&teeth

Vestibule
slitlikespacethatcommunicateswith
1.theextthuoralfissure
2.mouthproperbhdthe3rd molartoothoneachsidewhenjawsareclosed
Boundaries
Sup&inf limitedbyreflectionofmucousmbm
fromlips&cheeksontogums
laterally cheek
(madeupofbuccinatormusc,coveredext
bybuccopharyngealfascia&skin&
linedbymucousmbm)
Papillaoppositeupper2nd molartoothonthemucousmbm
=openingofductofparotidsalivarygld

MouthProper
Roof Infront:hardpalate
Behind:softpalate
Floor ant2/3oftongue
reflectionofmucousmbmfromsidesoftongueto
gumonmandible
Midline frenulumoftongue(foldofmucousmbm)
connectstheundersurfaceoftonguetofloorofmouth
ductofsubmandibulargld: summitofsmallpapilla
oneachsideoffrenulum
Sublingualfold prodbyunderlyingsublingualgld
aroundedridgeofmucousmbm
extendsbackward&laterallyfrompapilla

SensoryNerveSupplyofMucousMbmofMouth
Supply
Roof greaterpalatine&nasopalatinen
nfibrestravelinmaxn
Floor lingualn(brofmandn)
tastefibrestravelinchordatympanin(broffacialn)
Cheek buccaln(brofmandn)

110

111

Palate
formsroofofmouth
dividedinto2parts: 1.hardpalateinfront
2.softpalatebehind

A.HardPalate
formedby 1.palatineprocessesofmaxillae
2.horizontalplatesofpalatinebones
formsfloorofnasalcavities
undersurface: mucoperiosteum
withamedianridge(oneitherside,corrugatedmucousmbm)
Boundary
alveolararches
bhd,continuouswithsoftpalate

MucousMbm:coveredbystrsqepith
post,numerousmucousglds

B.SoftPalate
mobilefoldattachedtopostborderofhardpalate
sidescontinuouswithlatwallofpharynx

Contents
aponeurosis,musclefibres,lymphoidtissue,glds,vsls&n
uvulamidlineconicalprojectiononpostborder
composedof
1.mucousmbm coversupper&lowersurfaceofsoftpalate
coveredmainlywithstrsqepith
numerousmucousgldspresentonbothsurfaces
submucosa:collectionsoflymphoidtissue
2.palatineaponeurosis
fibroussheetattachedtopostborderofhardpalate
expandedtendonoftensorvelipalatini
&splitstoenclosethemusculusuvulae
3.muscles: a)tensorvelipalatini
b)levatorvelipalatini
c)palatoglossus
d)palatopharyngeus
e)musculusuvulae

112

Movements
Raisesoftpalate
toclosethepharyngealisthmus,
tocloseoffnasalpartofpharynxfromoralpart
(communicatingchannelbtwnasal&oralpartsofpharynx)
occursduringproductionofexplosiveconsonantsinspeech
bycontractionof 1.levvelipalatinioneachside
2.upperfibresofsupconstrictormusc
pullpostpharyngealwallforward
3.palatopharyngeusmusconbothsides
pullpalatopharyngealarchesmedially

113

Pharynx
situatedbhdthenasalcavities,themouth,&thelarynx
funnelshaped: upper,wideendunderskull
lower,narrowendbecomingcontinuouswithesophagus
oppositeCV6
musculomembranouswall defant
herereplacedby
1.postnasalapertures
2.oropharyngealisthmus(openingintomouth)
3.inletoflarynx
canbedividedinto3parts
nasopharynx bhdnasalcavity
oropharynx bhdoralcavity
laryngopharynx bhdlarynx
wallhas3layersmucous,fibrous,muscular

MucousMembrane
continuouswiththatof 1.nasalcavities
2.mouth
3.larynx
4.tympaniccavity(byauditorytubes)
upperpart: ciliatedcolumnarepith
lowerpart: strsqepith
transitionalzonewherethe2areascometog

FibrousLayer
liesbtwmucousmbm&musclelayer
Above:thicker(stronglyconnectedtobaseofskull)
Below:continuouswithsubmucosalcoatofesophagus

MuscularLayer
1. supconstictormuscle
2. middleconstrictormuscle fibresrunin>or<circulardirection
3. infconstrictormuscle
4. stylopharyngeus fibresrunina>or<longitudinaldirection
5. salpingopharyngeus

NerveSupply
mainlyfrompharyngealplexus(brofglossopharyngeal,vagus&sympn)
MotorNerveSupply SensoryNerveSupply(tomucousmbm)
fromcranialpartofaccn nasopharynx:maxn
(viabrofvagustopharyngealpl) oropharynx:glossopharyngealn
suppliesallmusclesofpharynx aroundentrance:intlaryngealbrofvagus
exceptstylopharyngeus(byIXn) nintolarynx

114

ArterialSupply
frombrof 1.ascpharyngealart
2.ascpalatineart
3.facialart
4.maxart
5.lingualart

VenousDrainage
intopharyngealvenousplexus(intoIJV)

LymphaticDrainage
LVfrompharynxdraineither
1.directlyintodeepcervicalLN
2.indirectlyviaretropharyngealorparatrachealnodes

115

Oropharynx
liesbhdthemouthcavity
extendsfromsoftpalatetoupperborderofepiglottis
has roof&floor
ant&postwall
latwall

Roof
formedbyundersurfaceofsoftpalate&pharyngealisthmus
smallcollectionsoflymphoidtissuepresentinsubmucosaonundersurfaceofsoft
palate

Floor
formedby 1.post1/3oftongue(almostvertical)
2.intervalbtwtongue&antsurfaceofepiglottis
mucousmbmonpost1/3oftongue
devoidofpapillae
irregularinappearance(duetopresenceofunderlyinglingualtonsil)
reflectedfromtongueontoepiglottis
medianglossoepiglotticfold midlineelevation
oneachsideisvallecula(depression)
2latglossoepiglotticfolds

AnteriorWall
opensintomouththrutheoropharyngealisthmus
belowthisopeningpharyngealpartoftongue

PosteriorWall
supportedby 1.thebodyofCV2
2.upperpartofbodyofCV3

LaterallWalls
consistsof 1.palatoglossal&palatopharyngealarchesorfolds
2.tonsillarsinus(triangularrecess)containingthepalatinetonsils
1.Palatoglossalarch
foldofmucousmbmcoveringunderlyingpalatoglossusmuscle
intervalbtw2palatoglossalarchesistheoropharyngealisthmus
(boundarybtwmouth&oralpharynx)
2.Palatopharyngealarch
foldofmucousmbmonlatwalloforopharynxbhdpalatoglossalarch
coversunderlyingpalatopharynguesmuscle

116

3.PalatineTonsils
2massesoflymphoidtissuelocatedinlatwallsoforopharynxintonisllarsinuses
coveredbymucousmbm
freemedsurface projintocavityofpharynx
surfacepittedbynumeroussmallopenings
(leadintotonsilarcrypts)
upperparthasadeepintratonsillarcleft
latsurfacecoveredbycapsule(layeroffibroustissue)
reachesmaxsizeduringearlychildhood
butafterpubertydiminishedinsizeconsiderably
relations
ant palatoglossalarch(mayextendforshortdistbeneath)
post palatopharyngealarch
sup softpalate
here,tonsilbecomescontinouswithlymphoidtissueon
undersurfaceofsoftpalate
inf post1/3oftongue
here,tonsilbecomescontinuouswithlingualtonsil
med cavityoforopharynx
lat 1. capsulesepartedfrom
2. supconstrictormuscbylooseareolartissue
3. extpalatineveindescfromsoftpalateintheLCTtojoin
pharyngealvenouspl
4. styloglossus&loopsoffacialart(lattosupconstrictormusc)
5. ICAlies1inchbhd&lattotonsil
artsupply:tonsilarart(broffacialart)
veins piercesupconstrictormusc
&jointheextpalatine,thepharyngealorfacialveins
LV joinupperdeepcervicalLN
espjugulodigastricnode(below&bhdangleofmandible)

117

Laryngopharynx
liesbhdopeningintolarynx&postsurfaceoflarynx
extendsbtwupperborderofepiglottis&lowerborderofcircoidcartilage
has antwall&postwall
latwall

AnteriorWall
formedby 1.inletoflarynx
2.mucousmbmcoveringpostsurfaceoflarynx

PosteriorWall
supportedbybodiesofCV3,4,5,6

LateralWall
supportedbythyroidcartilage&thyrohyoidmbm
piriformfossa grooveinmucousmbmoneachsideoflaryngealinlet
leadobliquelydownward&backward
fromregionofbackoftonguetoesophagus
bounded med: aryepiglottisfold
lat: laminaofthyroidcartilage&
thyrohyoidcartilage

118

ExternalEar
consistsofauricle&extauditorymeatus
outer1/3:elasticcartilage
inner2/3:bone(tympanicmbm)
linedbyskin
outer1/3has: 1.hairs
2.sebaceousglds
3.ceruminousglds modifiedsweatglds
secreteyellowishbrownwax
hairs&waxprovidestickybarrierthatpreventstheentranceofforeignbodies

Auricle
characteristicshape
servestocollectairvibrations
consistsofathinplateofelasticcartilagecoveredbyskin
hasbothextrinsic&intrinsicmuscles(suppliedbyfacialn)

ExternalAuditoryMeatus
sinuoustubethatleadsfromauricletotympanicmbm
Fn:toconductsoundwavesfromtheauricletothetympanicmbm
isthmusnarrowest(abt5mmfromtympanicmbm)
anteroinfwalllongest(becauseofobliquityoftympanicmbm)

SensoryNerveSupplytoliningskin
from 1.auriculotemporaln
2.auricularbrofvagusn

LymphaticDrainage
to 1.supfparotidLN
2.mastoidLN
3.supfcervicalLN

119

Larynx
providesaprotectivesphincterattheinletofairpassages
responsibleforvoiceproduction
above: opensintolaryngopharynx
below: continuouswithtrachea
framework:cartilagesconnectedbymbms&ligs,movedbymuscles
linedbymucousmbm

Cartilages
thyroid 2laminaeofhyalinecartilagemeetinginmidline(inprominentV
cartilage angleofAdamsapple)
postborderofeachlaminaisdrawn upward supcornu
downward infcornu
obliqueline onoutersurfaceofeachlamina
forattachmentof sternothyroid
thyrohyoid
infconstrictormusc
cricoid formedfromcompleteringofhyalinecartilage
cartilage signetringshape
liesbelowthyroidcartilage
consistsof narrowantarch
broadpostlamina
sideoflatsurfacecirculararticularfacet infcornuofthyroid
cartilage
sideofupperborderarticularfacet baseofarytenoidcartilage
(alljointsaresynovialjoints)
arytenoid 2,smallpyramidal
cartilage fdatbackoflarynxonlatpartofupperborderoflaminaofcricoid
cartilage
consistsof apex above
supportscorniculatecartilage
base below
articulateswithcricoidcartilage
projects2processes
1.vocalprocess
projhorizforward
givesattachmenttovocallig
2.muscularprocess
projlat
givesattachmenttopost&
latcricoarytenoidmusc
corniculate 2smallnodules
cartilage articulatewithapicesofarytenoidscartilages
giveattachmenttoaryepiglotticcartilages
cuneiform 2small,rodshapedpiecesofcartilage
cartilage placedoneineacharyepiglotticfold
serveassupportsforthefolds

120

 epiglottis leafshapedelasticcartilage
fdbhdrootoftongue
connections:
1.infrontbodyofhyoidbone
2.bystalkbackofthyroidcartilage
3.sidesarytenoidcartilagesbyaryepiglotticfolds
upperedgefree
coveringofmucousmbm
reflectedforwardontopostsurfaceoftongue
medianglossoepiglotticfold
lateralpharyngoepiglotticfolds
valleculae(depressionsofmucousmbmon
eithersideofglossoepiglotticfolds)

Membranes&LigamentsoftheLarynx
thyrohyoid connects
membrane uppermarginofthyroidcartilagebelowto
uppermarginofpostsurfaceofbody&greatercornuof
hyoidboneabove
medaianthyrohyoidligmbmthickenedinmidline
latthyrohyoidligthickenedpostborders
piercedbysuplaryngealvsls&intlaryngealnoneachside
cricotracheal connects lowermarginofcricoidcartilageto
ligament 1stringoftrachea
fibroelastic beneathmucousmbmliningthelarynx
membraneof quadrangularmbmupperportionofmbm
larynx extendsbtwepiglottis&arytenoidcartilages
cricothyroidliglowerpartofmbm
antpartthick
connects cricoidligto
lowermarginofthyroidcartilage
latpartisthin,
attachedbelowtouppermarginofcricoidcatilage
supmarginascwithinthyroidcartilageonitsmed
surface
uppermarginthickened
formesimptvocalligoneachside
vocalligantenddeepsurfaceofthyroid
cartilage
vocalprocessofthe
postend
arytenoidcartilage
hypoepiglottic attachestoepiglottistohyoidbone
ligament
thryoepiglotti attachedtoepiglottistothyroidcartilage
cligament

121

InletofLarynx
looksbackward&upwardintolaryngopharynx
boundariesofopening
infront uppermarginofepiglottis
lat aryepiglotticfoldofmucousmbm
connectsepigloittistoarytenoidcartilage
posteroinf mucousmbmstretchingbtwarytenoidcartilages
corniculatecartilage(onapexofarytenoidcartilage)&
cuneiformcartilage(smallbar)produce
asmallelevationonupperborderofeacharyepiglotticfold

CavityoftheLarynx
extendsfrominlettolowerborderofcricoidcartilage
maybedividedinto3parts: 1.upperpart=vestibule
2.middlepart
3.lowerpart

1.VestibuleofLarynx
extendsfrominlettovestibularfolds
vestibularfolds2thickfoldsofmucousmbmthatcovervestibularlig
hasant,post&latwall
antwall postsurfaceofepiglottis(coveredbymucousmbm)
postwall arytenoidcartilages&
interarytenoidfoldofmucousmbm(containingtnvsarytenoidmusc)
latwalls aryepiglotticfolds(containthearyepiglotticmusc)
below,narrowedbypinkvestibularfolds(projmedially)
rimavestibuli gapbtwvestibularfolds
vestibularlig lieswithineachvestibularfold
thickenedloweredgeofquadrangularmbm
stretchesfromthyroidcartilagetosideofarytenoidcartilage

2.MiddlePartofLarynx
extendsfromlevelofvestibularfoldstolevelofvocalfolds
vocalfoldswhiteincolour
containvocallig
vocallig thickenedupperedgeofcricothyroidlig
stretchesfrom
thyroidcartilageinfrontto
vocalprocessesofarytenoidcartilagebhd
rimaglottisgapbtw vocalfoldsinfront&
vocalprocessesofarytenoidscartilagebhd
sinusoflarynx smallrecessbtwvestibular&vocalfoldsoneachside
linedwithmucousmbm
diverticulumfrommucousmbm:sacculeofthelarynx
passesupwardbtwvestibularfold&thyroidcartilage

122

3.LowerPartofLarynx
extendsfromthelevelofvocalfoldstolowerborderofcricoidcartilage
wallsformedbyinnersurfaceofcricothyroidlig&cricoidcartilage

MucousMembrane
linescavity
coveredwithciliatedcolumnarepith
onvocalfolds:coveredwithstrsqepith
mucousmbmsubjecttorepeatedtraumaduringphonation
mucousgldswithinmucousmbm,espinsaccules
wheresecretionpoursdownontouppersurfaceofvocalfolds&lubricatesthem
duringphonation

NerveSupply
Sensorynsupply
tomucousmbmoflarynx
a)abovevocalfolds intlaryngealbrofsuplaryngealbrofvagus
b)belowlevelofvocalfolds recurrentlaryngealn
Motornsupply
tointrinsicmuscoflarynx recurrentlaryngealn
Note: exceptforcricothyroidmusc.
byextlaryngealbrofsuplaryngealbrof
vagus

BloodSupply
upper1/2oflarynx: suplaryngealbrofsupthyroidart
lower1/2oflarynx: inflaryngealbrofinfthyroidart

LymphaticDrainage
LVdrainintodeepcervicalgroupofnodes

123