HEAD AND NECK

Crisle Dychingco, MD, DPBS Department of Anatomy AUFSOM

Skeleton of the Head
• • •

• • • • • •

Mastoid process Styloid process External auditory/ acoustic meatus (ear opening) Ear drum Hyoid bone Epiglottis Thryroid cartilage Cricoid cartilage Tracheal rings

Neck
• • •

Neck is anatomically complex Vertebral compartment – cervical (=neck) vertebrae and muscles Visceral compartment – parts of respiratory and digestive tracts, and some endocrine organs Vascular compartments – major blood vessels of head and neck

Anterior and posterior triangles of neck
• •

Aid regional description of anatomy Anterior and posterior triangles separated by sternocleidomastoid

Platysma muscle
• •

Muscle of facial expression in superficial fascia (subcutaneous) Supplied by facial nerve (CN VII), cervical branch

Netter 21, Moore&Agur 597

Dermatomes of neck

• •

Dermatome: area of skin supplied by cutaneous branches derived from a single spinal nerve C2-C4, also C5 posteriorly Adjacent dermatomes overlap Netter 150, 155

Spinal nerves branch into dorsal and ventral rami Posteriorly: dorsal rami of spinal nerves C2 or C3 - C5 Anteriorly: branches of cervical plexus from ventral rami of C2 - C4

Cutaneous nerves of neck

Lesser occipital, great auricular, transverse cervical, supraclavicular

Netter 18, 156

Deep fascia of neck
• • • • •

Investing (superficial) layer Visceral (pretracheal/buccopharyngeal) layer Prevertebral layer Carotid sheath Retropharyngeal space

Netter 30

Posterior triangle of neck
• • • •

Borders: SCM, trapezius, middle 1/3 of clavicle Roof: investing layer of deep cervical fascia Floor: prevertebral fascia and deep muscles of neck Surface anatomy: supraclavicular fossa, CN XI

Netter 18 Backhouse 57

Sternocleidomastoid muscle

• •

Individually: laterally flexes (abducts) head/neck to same side, laterally rotates head/neck to opposite side Together: flexes head/neck

Netter 23, Devinsky 41, 43

Trapezius muscle
• •

Elevate, retract, depress shoulder girdle Lateral rotation of scapula (aids abduction of upper limb)

Netter 160, Devinsky 45

Innervation of SCM and trapezius: CN XI

(spinal) accessory nerve (CN XI)

Netter 121, Fix 19

Floor of posterior triangle of neck
• •

Splenius, levator scapulae, scalenes (posterior, middle, anterior) Anterior to anterior scalene: phrenic n, subclavian v, IJV, inferior belly of omohyoid Between anterior and middle scalenes: brachial plexus (ventral rami, trunks), subclavian artery

Netter 22, 28

Anterior triangle of neck
• • •

Borders: SCM, midline, mandible Roof: investing layer of deep cervical fascia Floor: pretracheal fascia over viscera of neck

Netter 22,23

Subtriangles in anterior triangle of neck
• •

Submandibular, submental, carotid, muscular Additional borders: digastric, omohyoid muscles; hyoid bone Netter 22,23

Submandibular, submental triangles
• • • •

Hyoid bone Netter 22,63 Digastric, stylohyoid muscles Mylohyoid - floor of mouth Submandibular salivary gland, facial and lingual aa,vv, hypoglossal n

Infrahyoid (strap) muscles
• •

Sternohyoid, omohyoid; sternothyroid, thyrohyoid Action: depress hyoid and larynx after swallowing, help stabilise hyoid bone Carotid ∆

Common carotid bifurcation; IJV Viscera of neck

Muscular ∆

Netter 24

Contents of carotid sheath

• • • •

Location: in carotid triangle superiorly, deep to SCM inferiorly Netter 30, 24 Common (and internal) carotid artery Internal jugular vein Vagus nerve Deep cervical lymph nodes

Vagus nerve - in carotid sheath Sympathetic chain: superior and middle cervical ganglia, cervicothoracic (stellate) ganglion

Autonomic nerves in neck

Netter 30, 124

Viscera of neck
• • •

Larynx (thyroid, cricoid cartilages) and trachea Pharynx and oesophagus Thyroid and parathyroid glands

Netter 30, 68b

Thyroid, parathyroid glands
• •

Thyroid: isthmus (midline), right and left lobes, pyramidal lobe Parathyroids: superior and inferior, on posterior surface of thyroid

Netter 26, 68,70

Blood supply to thyroid, parathyroids
• • •

Superior, inferior thyroid artery Superior, middle, inferior thyroid veins Note relationships to laryngeal nerves

Netter 68,69

Common Carotid Artery

Right Common Carotid Artery

from brachiocephalic a behind R sternoclavicular joint from arch of aorta

Left Common Carotid Artery

Both run upward through the neck in the carotid sheath Under cover by anterior border of SCM Divides into ICA and ECA at the upper border of thyroid cartilage Laterally: internal jugular vein (vagus n between)

Posterior View

Common Carotid Artery

Carotid Sinus
– – – – –

– –

Localized dilatation of CCA Located at point of division Bulbous 2 cm long Supplied by glossopharyngeal n (sinus nerve of Hering) Pressoreceptor, baroreceptor Assists in regulation of BP

Common Carotid Artery

Carotid Body

– –

Small neurovascular structure posterior to point of division Supplied by glossopharyngeal n Chemoreceptor Sensitive to excess CO2 and reduced O2 tension in blood Assists in regulating heart and respiratory rates

Branches of the CCA
EXTERNAL CAROTID ARTERY • one of terminal branches of CCA • from the level of upper border of thyroid cartilage • ascends to terminate in parotid gland behind neck of mandible • divides into superficial temporal and maxillary aa INTERNAL CAROTID ARTERY • ascends with internal jugular v and vagus n • passes deep into parotid gland • enters cranial cavity via carotid canal in petrous part of temporal bone • terminate by dividing into anterior and middle cerebral aa

External Carotid Artery
• •

• • • •

Superior thyroid artery Ascending pharyngeal artery Lingual artery Facial artery Occipital artery Posterior auricular artery Superficial temporal artery Maxillary artery

"Some Angry Lady Figured Out PMS" Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Maxillary Superificial temporal

SUPERIOR THYROID ARTERY
Curves downward to upper pole of thyroid gland Accompanied by external laryngeal nerve (cricothyroid m)
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ASCENDING PHARYNGEAL ARTERY
Click to edit Master text styles ascends along and Second level supplies the ● Third level pharyngeal wall ● Fourth level ● Fifth level

LINGUAL ARTERY
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loops upward and forward Crossed superficially by hypoglossal nerve

FACIAL ARTERY
loops upward on lateral surface of pharynx close to the tonsil tunnels the submandibular gland bends around lower border of mandible ascends close to anterior border of masseter ascends lateral to mouth terminates at medial angle of orbit pulsations felt against the mandible branches supply: tonsil, submandibular gland, muscles and skin of face

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OCCIPITAL ARTERY

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supplies the back of the scalp POSTERIOR AURICULAR ARTERY auricle and scalp SUPERFICIAL TEMPORAL ARTERY ascends over zygomatic arch palpated in front of auricle accompanied by auriculotemporal nerve supplies the scalp

MAXILLARY ARTERY
Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level Runs forward medial to neck of mandible Splits into branches that follow maxillary branches of trigeminal nerve Supply upper and lower jaws, muscles of mastication, nose, palate and meninges

MAXILLARY ARTERY
Middle meningeal artery
ascends between roots of auriculotemporal nerve to enter skull via foramen spinosum Runs laterally within skull and divides into anterior and posterior branches Anterior branch
lies close to motor area of cerebral cortex alongside its vein, grooves the upper part of greater wing of sphenoid bone and anteroinferior angle of parietal bone (prone to trauma) lie between meningeal layer and periosteal layer (extradural hemorrhage)

Weakest part of skull….middle meningeal artery runs beneath it…. risk of extradural haematoma

Internal Carotid Artery
Begins at level of upper border of thyroid cartilage Ascends within carotid sheath with IJV and Vagus n Passes deep to parotid gland Branches
No branches in the neck Ophthalmic artery Posterior communicating artery Anterior cerebral artery Middle cerebral artery

Ophthalmic Artery
Arises from ICA as it leaves cavernous sinus Passes through orbital cavity to optic canal Gives off central artery of retina Enters optic nerve to enter eyeball End artery Only blood supply to retina

Posterior Communicating Artery
Runs backward to join posterior cerebral artery

Anterior Cerebral Artery
Terminal branch of ICA Passes forward between cerebral hemispheres Winds around corpus callosum Supply medial and superolateral surfaces of cerebral hemispheres Joined to artery of opposite side by anterior communicating artery

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Middle Cerebral Artery
Largest terminal branch of ICA Runs laterally in lateral cerebral sulcus Supplies lateral surface of cerebral hemisphere except
narrow strip along superolateral margin (supplied by anterior cerebral a) Occipital pole and inferolateral surface of hemisphere (posterior cerebral a)

Supplies all motor area of cerebral cortex except leg area Gives off central branches that supply masses of gray matter and the internal capsule

Subclavian Arteries
Right subclavian artery Arises from brachiocephalic behind R sternoclavicular joint Arches upward and laterally over pleura and scalenus anterior and medius muscles Becomes axillary artery at outer border of first rib

Subclavian Arteries
Left Subclavian Artery Arises from the arch of aorta Ascends to root of neck then arches laterally Scalenus anterior muscle used to divide the subclavian artery into 3 parts

First Part of the Subclavian Artery
Extends from the origin of subclavian a to medial border of scalenus anterior muscle Branches Vertebral a Thyrocervical trunk Internal thoracic a

Vertebral Artery
Click to edit Master text styles Second level Passes medially above posterior ● Third level arch of atlas then through foramen ● Fourth level magnum into the skull ● Fifth level Joins vessel from the opposite side
Ascends through foramina of transverse processes of C1-C6 to form basilar artery on the anterior surface of medulla Basilar artery
Ascends on the groove anterior to the pons Gives off branches to pons, cerebellum, internal ear Divides into 2 posterior cerebral arteries

Vertebral Artery
Posterior Cerebral a
Curves laterally and backward around the midbrain Cortical branches supply inferolateral surfaces of temporal lobe and visual cortex on lateral and medial surfaces of occipital lobe Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Thyrocervical Trunk
Short trunk that gives off 3 terminal branches Inferior thyroid artery
Ascends to reach posterior surface of thyroid gland Closely related to recurrent laryngeal n supplies thyroid and inferior parathyroid glands

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Superficial cervical artery
Runs laterally over phrenic nerve and crosses brachial plexus

Suprascapular artery
Follows suprascapular n into supraspinous fossa of scapula Takes part in anastomosis around scapula

Internal Thoracic Artery
Enters thorax behind first costal cartilage and in front of pleura Descends vertically one fingerbreadth lateral to the sternum Divides into superior epigastric and musculophrenic aa in the 6th ICS Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Second Part of Subclavian Artery
Lies behind scalenus anterior muscle Branches
Costocervical trunk

Runs backward over dome of pleura Divides into…

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Superior intercostal a Supplies 1st and 2nd ICS Deep cervical a
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Supplies deep muscles of neck

Third Part of Subclavian Artery
From lateral border of scalenus anterior m across posterior triangle of neck to lateral border of 1st rib Surrounded by axillary sheath of fascia with nerves of brachial plexus Branches
Usually no branches Occasionally, superficial cervical aa, scapular aa or both arise

Veins of the Head and Neck
Divided into Veins of the brain, venous sinuses, diploic veins and emissary veins Veins of scalp, face and neck

Veins of the Brain
Thin-walled Valveless Cerebral veins, cerebellar veins and veins of brain stem Drain into neighboring venous sinuses

Venous Sinuses
Situated between periosteal and meningeal layers of dura mater With thick fibrous walls Valveless Receive tributaries from brain, skull bones, orbit and internal ear Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Venous Sinuses
Superior Sagittal Sinus
Lies in upper fixed border of falx cerebri Runs backward becomes continuous with right transverse sinus Communicates on each side with venous lacunae Numerous arachnoid villi and granulations project into the lacunae

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Venous Sinuses
Inferior Sagittal Sinus
Lies in lower free margin of falx cerebri Runs backward and joins the great cerebral vein to form straight sinus

Straight Sinus
Lies at junction of falx cerebri and tentorium cerebelli Formed by union of inferior sagittal sinus and great cerebral vein Drains into left tranverse sinus

Venous Sinuses
Transverse Sinuses
R transverse sinus begins as continuation of superior sagittal s Left transverse continuation of straight sinus End on each side by becoming sigmoid sinus Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Venous Sinuses
Sigmoid Sinuses
Direct continuation of the transverse sinuses Click to edit Master text styles Second level ● Third level Each curves downward ● Fourth level behind the mastoid antrum ● Fifth level Leaves skull through jugular foramen to become IJV

Venous Sinuses
Occipital Sinus
Lies in the attached margin of falx cerebelli Click to edit Master text styles Second level ● Third level Communicates with ● Fourth level vertebral veins through ● Fifth level foramen magnum and with transverse sinuses

Venous Sinuses
Cavernous sinuses
Each cavernous sinus lies on lateral side of the body of sphenoid bone Receives inferior ophthalmic v and central v of retina anteriorly Drains posteriorly into transverse sinus through superior petrosal sinus Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Important Structures Associated with the Cavernous Sinuses
ICA and CN6 travel through it CN3 and CN4, ophthalmic and maxillary divisions of CN5 laterally
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Dangerous Area of the Face
Triangular area bounded by root of nose and angles of mouth Venous drainage enters angular vein (facial vein) at medial angle of eye Communicates with cavernous sinus via superior ophthalmic v Infections may lead to cavernous sinus thrombosis

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Venous Sinuses
Superior and Inferior Petrosal Sinuses
Run along the upper and lower border of the petrous part of the temporal bone Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Diploic Veins
Occupy channels within bones of the vault of the skull

Emissary Veins
Valveless veins that pass through skull bones Connect veins of scalp to venous sinuses Route for spread of infection

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Veins of the Face and Neck
Facial Vein
Formed at the medial angle of the eye by union of supraorbital and supratrochlear vv Connected through ophthalmic veins with the cavernous sinus Descends down with facial artery, passes lateral to the mouth Crosses the mandible Joined by retromandibular v and drains into IJV

Veins of the Face and Neck
Superficial Temporal Vein
Formed on the side of the scalp Follows superficial temporal a and auriculotemporal n Enters parotid gland Joins maxillary v to form the retromandibular v Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Veins of the Face and Neck
Maxillary Vein
Formed in the infratemporal fossa from pterygoid venous plexus Joins the superficial temporal v to form the retromandibular v Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level

Veins of the Face and Neck
Retromandibular Vein
Formed by the union of the superficial temporal and maxillary vv On leaving parotid gland, divides into anterior and posterior branch Anterior joins facial v Posterior joins posterior auricular v to form EJV

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Veins of the Face and Neck
External Jugular Vein
Formed behind the angle of the jaw Union of posterior auricular v and retromandibular v Descends across SCM muscle and beneath platysma muscle Drains into subclavian v behind the middle 3rd of clavicle

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Tributaries oftoEJV text styles Click edit Master
Posterior external jugular vein from the back of the scalp Superficial cervical vein from skin and fascia over posterior triangle Suprascapular vein from suprascapular fossa Anterior jugular vein Second level ● Third level ● Fourth level ● Fifth level

Veins of the Face and Neck
Anterior Jugular Vein
Descends in the neck close to the midline Joined to opposite vein by jugular arch above the sternum Anterior jugular v joins external jugular v deep to the SCM muscle

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Veins of the Face and Neck
Internal Jugular Vein
Large vein that drains blood from the brain, face, scalp and neck Starts as continuation of sigmoid venous sinus Leaves the skull through jugular foramen Descends through neck in the carotid sheath Lateral to the vagus n and internal and common carotid aa Ends by joining subclavian v to form brachiocephalic v behind medial end of clavicle Closely related to deep cervical lymph nodes throughout its course

Tributaries of IJV
Inferior petrosal sinus Facial vein Pharyngeal veins Lingual vein Superior thyroid vein Middle thyroid vein
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Click edit Subclavian Vein tolevel Master text st Second

Continuation of axillary v at the outer border of 1st rib Joins IJV to form brachiocephalic v Receives external jugular v Receives thoracic duct on the left and right lymphatic duct on the right

Third level ● Fourth level ● Fifth level

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Lymphatic Drainage of the Head and Neck
Lymph nodes are arranged in 2 groups
Regional group

surrounds neck below chin like a collar embedded in carotid sheath

Deep vertical group

Lymphatic Drainage of Head and Neck
Regional Lymph Nodes
Occipital nodes

Apex of posterior triangle Drains back of scalp Over mastoid process Scalp above ear, auricle and external auditory meatus On or within parotid gland Scalp above parotid, eyelids, auricle, external auditory meatus

Mastoid nodes
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Parotid nodes
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Regional Lymph Nodes
Buccal nodes

Lymphatic Drainage of Head and Neck

On buccinator muscle Face and anterior part of scalp Pass lymph to submandibular nodes Superficial to submandibular gland below body of mandible Front of scalp, nose, cheek, upper and lower lip (except central part of lower lip); frontal, maxillary and ethmoid sinuses; upper and lower teeth (except lower incisors); anterior 2/3 of tongue (except tip); floor of the mouth, vestibule, gums

Submandibular nodes
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Regional Lymph Nodes
Submental nodes

Lymphatic Drainage of Head and Neck

Submental triangle just below chin Tip of tongue, floor of anterior part of the mouth, lower incisors, central part of lower lip, skin over chin Along course of AJV Skin of front of the neck Along EJV Skin over angle of jaw, lower part of parotid and ear lobe

Anterior cervical nodes
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Superficial cervical nodes
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Regional Lymph Nodes
Retropharyngeal nodes

Lymphatic Drainage of Head and Neck

Between pharynx and vertebral column Nasopharynx, auditory canal, vertebral column In front Larynx Alongside trachea Trachea and thyroid gland

Laryngeal nodes
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Tracheal (paratracheal) nodes
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Lymphatic Drainage of Head and Neck
Deep Cervical Lymph Nodes
Arranged in vertical chain along course of IJV within carotid sheath Receive lymph from all regional nodes Efferent lymph vessels from deep cervical nodes join to form jugular trunk which drains into thoracic duct or right lymphatic duct

Jugulodigastric nodes
Behind angle of jaws Drains the tonsil

Jugulo-omohyoid node
Approximately halfway down the neck Drainage of the tongue

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Eye Movements, the Extrinsic Muscles

Eye Movements, the Extrinsic Muscles

Extrinsic Eye Muscles
Muscle Medial Rectus Lateral Rectus Movement Medial Test Lateral Nerve Supply Occulomotor (III) Abducens (VI) Origin Common Tendinous Ring Insertion Sclera, anterior half of eye (5mm behind corneal margin)

Lateral

Medial

Superior Rectus Inferior Rectus Superior Oblique Inferior Oblique

Superior and medial (adduction) Inferior and medial (adduction) Inferior and lateral (abduction) Superior and lateral (abduction)

Lat and dwn

Occulomotor (III) Occulomotor (III) Trochlear Body of sphenoid (IV) Occulomotor Orbital surface of (III) maxilla Post/Superior Quadrant via trochlear Post/inferior quadrant

Lat and up

Med and dwn

Med and dwn

Extrinsic Eye Muscles
Muscle Medial Rectus Movement Medial Nerve Supply Occulomotor (III) Origin Insertion

Isolated Muscle
Lateral Rectus Lateral Abducens (VI) Occulomotor (III) Occulomotor (III) Trochlear (IV)

Common Sclera, anterior half Tendinous eye (5mm behind Actions of corneal margin) Ring

Superior Superior and Rectus medial Inferior Rectus Inferior and medial Superior Inferior and Oblique lateral Inferior Oblique Superior and lateral

Body of sphenoid Orbital surface of maxilla

Post/Superior Quadrant via trochlear Post/inferior quadrant

Occulomotor (III)

Testing Eye Movements

Third nerve palsy Accompanied by double vision (PS fibres run with III)

Parts of the Ear
• • •

External ear Middle ear Inner ear

External Ear

Auricle (pinna)
– –

Elastic cartilage Skin

External Auditory Meatus
– –

S-shaped canal Inner bony, outer cartilaginous Ceruminous glands

Middle Ear
Tympanic Cavity • Lateral - tympanic membrane • Medial - lateral wall of internal ear
– – – –

Promontory Fenestra vestibuli Fenestra cochlea Facial canal prominence

• • • •

Anterior - eustachian tube Posterior - mastoid antrum to mastoid air cells Roof - tegmen tympani to cranial cavity Floor - adjacent to jugular bulb

Middle Ear
Contents • Auditory ossicles
– – –

Malleus Incus Stapes

Muscles
– –

Tensor tympani (CN V) Stapedius (CN VII)

Internal Ear
Bony (osseus) Labyrinth

Contains perilymph
– –

Transudate from blood vessels Fluid spaces around CN VII and possibly CSF Vestibule Semicircular canals Cochlea

Composed of
– – –

Bony Labyrinth of the Internal Ear

Semicircular canals
– – –

Superior (anterior) Lateral (horizontal) posterior

Bony Labyrinth of the Internal Ear
Cochlea • 2 1/2 turns around mediolus • Scala vestibuli and scala tympani connect at helicotrema • Oval window opens into scala vestibuli • Round window closed by secondary tympanic membrane, expands with excessive movement of perilymph in scala tympani

Internal Ear
Membranous Labyrinth • Contains endolymph

Secreted at stria vascularis Utricle and saccule Semicircular ducts Cochlear duct Vestibular membrane

Composed of
– – – –

Membranous Labyrinth of the Inner Ear

Utricle and saccule (vestibule)
Maculae
• •

sensory area of utricle and saccule macula utriculi, macula sacculi receptors for static equilibrium

Membranous Labyrinth of the Inner Ear

Semicircular ducts (canals)

Cristae ampullares
sensory area of semicircular ducts at ampullae receptors for kinetic equilibrium

Membranous Labyrinth of the Inner Ear

Cochlear duct or scala media (cochlea)

Organ of Corti
sensory area of cochlear duct lies on basilar membrane receptor for hearing

– –

Membranous Labyrinth of the Inner Ear

Vestibular (Reissner’s membrane)

Separates scala vestibuli from scala media (or cochlear duct)

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