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Crisle Dychingco, MD, DPBS

Department of Anatomy
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 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 Cutaneous
• Posteriorly: dorsal rami of spinal nerves of neck
nerves C2 or C3 - C5
• Anteriorly: branches of cervical plexus
from ventral rami of C2 - C4
– 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
Netter 18
• Borders: SCM, trapezius, middle 1/3 of clavicle Backhouse 57
• Roof: investing layer of deep cervical fascia
• Floor: prevertebral fascia and deep muscles of neck
• Surface anatomy: supraclavicular fossa, CN XI
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 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 Netter 22,23
• Floor: pretracheal fascia over viscera of neck
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
• Digastric, stylohyoid muscles Netter 22,63
• 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
• Carotid ∆
– Common carotid
bifurcation; IJV
• Muscular ∆
– Viscera of neck

Netter 24
Contents of carotid sheath
• Location: in carotid triangle superiorly, deep to SCM
Netter 30, 24
• Common (and internal) carotid artery
• Internal jugular vein
• Vagus nerve
• Deep cervical lymph nodes
Autonomic nerves in neck
• Vagus nerve - in carotid
• Sympathetic chain: superior
and middle cervical ganglia,
cervicothoracic (stellate)
Netter 30, 124
Viscera of neck
• Larynx (thyroid, cricoid cartilages) and trachea
• Pharynx and oesophagus
Netter 30, 68b
• Thyroid and parathyroid glands
Thyroid, parathyroid glands
• Thyroid: isthmus (midline), right and left lobes,
pyramidal lobe
• Parathyroids: superior and inferior, on posterior
surface of thyroid

Netter 26,
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
• Left Common Carotid Artery
– from arch of aorta

• Both run upward through the neck in

the carotid sheath
• Under cover by anterior border of
• 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
– Assists in regulating heart
and respiratory rates
Branches of the CCA
• one of terminal • ascends with internal
branches of CCA jugular v and vagus n
• from the level of upper • passes deep into
border of thyroid parotid gland
cartilage • enters cranial cavity via
• ascends to terminate in carotid canal in petrous
parotid gland behind part of temporal bone
neck of mandible • terminate by dividing
• divides into superficial into anterior and middle
temporal and maxillary cerebral aa
External Carotid Artery
• Superior thyroid artery
• Ascending pharyngeal
• Lingual artery
• Facial artery
• Occipital artery
• Posterior auricular
• Superficial temporal
• Maxillary artery
"Some Angry Lady Figured Out PMS"
Superior thyroid
Ascending pharyngeal
Posterior auricular
Superificial temporal
Curves downward to
upper pole of thyroid Click to edit Master text styles
gland Second level
● Third level

Accompanied by ● Fourth level

external laryngeal ● Fifth level

nerve (cricothyroid m)

Click to edit Master text styles ascends along and

Second level supplies the
● Third level

● Fourth level
pharyngeal wall
● Fifth level
Click to edit Master text styles
Second level
● Third level
loops upward and
● Fourth level forward
● Fifth level
Crossed superficially
by hypoglossal nerve
loops upward on lateral surface of
pharynx close to the tonsil
tunnels the submandibular gland
Click to edit Master text styles
bends around lower border of mandible
Second level
● Third level
ascends close to anterior border of
● Fourth level
● Fifth level
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
Click to edit Master text styles supplies the back of the scalp
Second level
● Third level
● Fourth level
auricle and scalp
● Fifth level

ascends over zygomatic arch
palpated in front of auricle
accompanied by auriculotemporal
supplies the scalp

Runs forward medial to

neck of mandible
Click to edit Master text styles
Second level Splits into branches that
● Third level
follow maxillary branches
● Fourth level
of trigeminal nerve
● Fifth level

Supply upper and lower

jaws, muscles of
mastication, nose, palate
and meninges
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
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
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

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

Anterior Cerebral Artery

Terminal branch of ICA Click to edit Master text styles

Passes forward between Second level
● Third level
cerebral hemispheres
● Fourth level

Winds around corpus ● Fifth level

Supply medial and
superolateral surfaces of
cerebral hemispheres
Joined to artery of opposite
side by anterior
communicating artery
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
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

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
Vertebral a
Thyrocervical trunk
Internal thoracic a
Vertebral Artery
Ascends through foramina of Click to edit Master text styles
transverse processes of C1-C6
Second level
Passes medially above posterior ● Third level
arch of atlas then through foramen
magnum into the skull ● Fourth level

● Fifth level
Joins vessel from the opposite side
to form basilar artery on the anterior
surface of medulla
Basilar artery
Ascends on the groove anterior to the
Gives off branches to pons, cerebellum,
internal ear
Divides into 2 posterior cerebral arteries
Vertebral Artery

Posterior Cerebral a Click to edit Master text styles

Second level
Curves laterally and ● Third level
backward around the ● Fourth level
midbrain ● Fifth level

Cortical branches supply

inferolateral surfaces of
temporal lobe and visual
cortex on lateral and
medial surfaces of
occipital lobe
Thyrocervical Trunk
Short trunk that gives off 3 terminal
Inferior thyroid artery Click to edit Master text styles
Ascends to reach posterior surface of thyroid Second level
gland ● Third level

● Fourth level
Closely related to recurrent laryngeal n
● Fifth level
supplies thyroid and inferior parathyroid
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 Click to edit Master text styles

costal cartilage and in Second level
● Third level
front of pleura
● Fourth level
Descends vertically one ● Fifth level
fingerbreadth lateral to the
Divides into superior
epigastric and
musculophrenic aa in the
6th ICS
Second Part of Subclavian Artery

Lies behind scalenus Click to edit Master text styles

anterior muscle Second level
● Third level
● Fourth level
Costocervical trunk ● Fifth level
● Runs backward over dome
of pleura
● Divides into…
– Superior intercostal a
● Supplies 1st and 2nd
– Deep cervical a
● 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
Surrounded by axillary sheath of fascia with
nerves of brachial plexus
Usually no branches
Occasionally, superficial cervical aa, scapular aa or both
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

Cerebral veins, cerebellar veins and veins
of brain stem
Drain into neighboring venous sinuses
Venous Sinuses

Situated between Click to edit Master text styles

periosteal and meningeal Second level
layers of dura mater ● Third level

● Fourth level
With thick fibrous walls
● Fifth level

Receive tributaries from
brain, skull bones, orbit
and internal ear
Click to edit Master text sty
Second level
Venous Sinuses ● Third level

● Fourth level

● Fifth level

Superior Sagittal Sinus

Lies in upper fixed border of falx
Runs backward becomes
continuous with right transverse
Communicates on each side
with venous lacunae
Numerous arachnoid villi and
granulations project into the
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 Click to edit Master text styles
as continuation of superior Second level
sagittal s ● Third level

Left transverse ● Fourth level

continuation of straight ● Fifth level

End on each side by
becoming sigmoid sinus
Venous Sinuses

Sigmoid Sinuses
Direct continuation of theClick to edit Master text styles
transverse sinuses Second level
● Third level
Each curves downward
behind the mastoid antrum ● Fourth level

● Fifth level
Leaves skull through
jugular foramen to become
Venous Sinuses

Occipital Sinus
Lies in the attached Click to edit Master text styles
margin of falx cerebelliSecond 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 Click to edit Master text styles
on lateral side of the body Second level
of sphenoid bone ● Third level

Receives inferior ● Fourth level

ophthalmic v and central v ● Fifth level

of retina anteriorly
Drains posteriorly into
transverse sinus through
superior petrosal sinus
Important Structures Associated
with the Cavernous Sinuses

Click to edit Master text styles

ICA and CN6 travel Second level
through it ● Third level

● Fourth level

● Fifth level

CN3 and CN4,

ophthalmic and
maxillary divisions
of CN5 laterally
Dangerous Area of the Face
Triangular area bounded by
root of nose and angles of
Venous drainage enters Click to edit Master text styles
angular vein (facial vein) at Second level
medial angle of eye ● Third level

● Fourth level
Communicates with
cavernous sinus via ● Fifth level

superior ophthalmic v
Infections may lead to
cavernous sinus thrombosis
Click to edit Master text styles
Second level
● Third level

● Fourth level

● Fifth level
Venous Sinuses

Superior and Inferior

Petrosal Sinuses Click to edit Master text styles
Second level
Run along the upper and ● Third level

lower border of the ● Fourth level

petrous part of the ● Fifth level

temporal bone
Diploic Veins
Occupy channels within bones of
the vault of the skull Click to edit Master text styles
Second level
● Third level
Emissary Veins ● Fourth level

Valveless veins that pass through ● Fifth level

skull bones
Connect veins of scalp to venous
Route for spread of infection
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 Click to edit Master text styles

Vein Second level
● Third level

Formed on the side of the ● Fourth level

scalp ● Fifth level

Follows superficial
temporal a and
auriculotemporal n
Enters parotid gland
Joins maxillary v to form
the retromandibular v
Veins of the Face and Neck

Maxillary Vein Click to edit Master text styles

Second level
Formed in the ● Third level

infratemporal fossa from ● Fourth level

pterygoid venous plexus ● Fifth level

Joins the superficial

temporal v to form the
retromandibular v
Veins of the Face and Neck
Click to edit Master text styles
Second level
● Third level
Retromandibular Vein
● Fourth level

Formed by the union of the ● Fifth level

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

External Jugular Vein Click to edit Master text styles

Formed behind the angle of the
Second level
● Third level
● Fourth level

Union of posterior auricular v ● Fifth level

and retromandibular v
Descends across SCM muscle
and beneath platysma muscle
Drains into subclavian v behind
the middle 3rd of clavicle
edit Master text styles
Second level
● Third level

● Fourth level
Posterior external jugular
● Fifth level
vein from the back of the
Superficial cervical vein
from skin and fascia over
posterior triangle
Suprascapular vein from
suprascapular fossa
Anterior jugular vein
Veins of the Face and Neck
Click to edit Master text styles
Anterior Jugular Vein Second level
● Third level

Descends in the neck close to ● Fourth level

the midline ● Fifth level

Joined to opposite vein by

jugular arch above the sternum
Anterior jugular v joins external
jugular v deep to the SCM
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 Click to edit Master text styles

Second level
Facial vein ● Third level

● Fourth level
Pharyngeal veins ● Fifth level

Lingual vein
Superior thyroid vein
Middle thyroid vein
Subclavian Vein
Click to edit Master text st
Second level
● Third level
● Fourth level
Continuation of axillary v at ● Fifth level

the outer border of 1st rib

Joins IJV to form
brachiocephalic v
Receives external jugular v
Receives thoracic duct on Click to edit Master text styles
the left and right lymphatic Second level
● Third level
duct on the right ● Fourth level

● Fifth level
Lymphatic Drainage of the
Head and Neck
Lymph nodes are arranged in 2
Regional group
● surrounds neck below chin like a collar
Deep vertical group
● embedded in carotid sheath
Lymphatic Drainage of
Head and Neck
Regional Lymph Nodes
Occipital nodes
Click to edit Master text styles
Apex of posterior triangle
Second level

Drains back of scalp

● Third level

Mastoid nodes ● Fourth level

● Over mastoid process ● Fifth level
● Scalp above ear, auricle and
external auditory meatus
Parotid nodes
● On or within parotid gland
● Scalp above parotid, eyelids,
auricle, external auditory meatus
Lymphatic Drainage of
Head and Neck
Regional Lymph Nodes
Buccal nodes
● On buccinator muscle
● Face and anterior part of scalp
● Pass lymph to submandibular nodes
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
Lymphatic Drainage of
Head and Neck
Regional Lymph Nodes
Submental nodes
● 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
Anterior cervical nodes
● Along course of AJV
● Skin of front of the neck
Superficial cervical nodes
● Along EJV
● Skin over angle of jaw, lower part of parotid and ear lobe
Lymphatic Drainage of
Head and Neck
Regional Lymph Nodes
Retropharyngeal nodes
● Between pharynx and vertebral column
● Nasopharynx, auditory canal, vertebral column
Laryngeal nodes
● In front
● Larynx
Tracheal (paratracheal) nodes
● Alongside trachea
● Trachea and thyroid gland
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
Click to edit Master text styles
Second level
● Third level

● Fourth level

● Fifth level
Eye Movements,
the Extrinsic Muscles
Eye Movements,
the Extrinsic Muscles
Extrinsic Eye Muscles
Muscle Movement Test Nerve Supply Origin Insertion

Medial Medial Lateral Occulomotor Common Sclera,

Rectus (III) Tendinous anterior half
Ring of eye
Lateral Lateral Medial Abducens (5mm behind
Rectus (VI) corneal margin)

Superior Superior and Lat and dwn Occulomotor

Rectus medial (III)
Inferior Inferior and Lat and up Occulomotor
Rectus medial (III)
Superior Inferior and Med and dwn Trochlear Body of sphenoid Post/Superior
Oblique lateral (IV) Quadrant via
(abduction) trochlear
Inferior Superior and Med and dwn Occulomotor Orbital surface of Post/inferior
Oblique lateral (III) maxilla quadrant
Extrinsic Eye Muscles
Muscle Movement Nerve Supply Origin Insertion

Medial Rectus Medial Occulomotor (III) Common Sclera, anterior half

Tendinous of eye (5mm behind
Isolated Muscle Actions
Ring corneal margin)

Lateral Rectus Lateral Abducens (VI)

Superior Superior and Occulomotor (III)

Rectus medial
Inferior Rectus Inferior and Occulomotor (III)
Superior Inferior and Trochlear (IV) Body of Post/Superior
Oblique lateral sphenoid Quadrant via
Inferior Oblique Superior and Occulomotor (III) Orbital Post/inferior
lateral surface of quadrant
Testing Eye
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
– 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
• 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
• Composed of
– Vestibule
– Semicircular canals
– Cochlea
Bony Labyrinth of the Internal
• Semicircular canals
– Superior (anterior)
– Lateral (horizontal)
– posterior
Bony Labyrinth of the Internal
• 2 1/2 turns around mediolus
• Scala vestibuli and scala
tympani connect at
• 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
• Composed of
– Utricle and saccule
– Semicircular ducts
– Cochlear duct
– Vestibular membrane
Membranous Labyrinth of the
Inner Ear
– Utricle and
– Maculae
• sensory area of
utricle and saccule
• macula utriculi,
macula sacculi
• receptors for static
Membranous Labyrinth of the
Inner Ear
• Semicircular
ducts (canals)
– Cristae
– sensory area of
semicircular ducts at
– receptors for kinetic
Membranous Labyrinth of the
Inner Ear
• Cochlear duct or
scala media
– Organ of Corti
– sensory area of cochlear
– lies on basilar membrane
– receptor for hearing
Membranous Labyrinth of the
Inner Ear
• Vestibular
– Separates scala
vestibuli from scala
media (or cochlear