HEAD & NECK

COL SUSHIL KUMAR

Professor & Head
Dept of Anatomy
AFMC
Pune- 411040
drsushilkumar@rediffmail.com

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 INDEX
HEAD & NECK

1. Scalp
2. Cervical fascia
3. Face
4. Posterior triangle of neck
5. Suboccipital triangle
6. Anterior aspect of neck
7. Thyroid gland
8. Lymphatic drainage of head & neck
9. Arteries of head & neck
10. Veins of head & neck
11. Parotid gland
12. Temporal & infratemporal fossae
13. Temporomandibular joint
14. Submandibular gland
15. Pharynx
16. Soft palate and Palatine tonsil
17. Nasal cavity
18. Tongue
19. Larynx
20. Orbit
21. Ear
22. Eye
23. Cranial nerves
24. Parasympathetic ganglia of head & neck
25. Bones of head and neck

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 CHAPTER- 1

SCALP
Introduction
It is the soft tissue covering the skull vault. It extends from eyebrows to highest nuchal lines. Laterally it
extends to superior temporal lines. Forehead is common to both face and scalp.
Scalp has five layers (from superficial to deep):
 S - Skin
 C - Connective tissue (dense)
 A - Aponeurosis (Galea aponeurotica)
 L - Loose connective tissue
 P - Pericranium
Abundant fibrous strands in dense CT layer anchor skin to aponeurotic layer. Thus, dense connective
tissue layer is inseparable. It contains blood vessels and nerves.

Scalp and its layers

Occipitofrontalis muscle
It covers skull from highest nuchal lines to eyebrows. It consists of occipital and frontal bellies; connected
by epicranial aponeurosis. Occipitalis arises from outer part of highest nuchal line and inserted in galea
aponeurosis. Frontalis is adherent to superficial fascia (without bony attachments) of eyebrows. Its medial
fibres blend with corrugator supercilii and orbicularis oculi. It is inserted in epicranial aponeurosis.
Nerve supply
 Occipitalis- posterior auricular branch of facial nerve
 Frontalis- temporal branches of facial nerve
Actions of frontalis
 Acting from above, frontalis raise eyebrows and skin over root of nose (expression of surprise,
horror or fright)
 Acting from below, it draw scalp forwards to cause transverse wrinkles in the forehead
Actions of occipitalis
 Occipitalis draws scalp backwards
 Acting alternately, occipitalis and frontalis can move scalp backwards and forwards

Epicranial aponeurosis
It forms a continuous fibromuscular sheet that extends from occiput to eyebrows.
Attachments:
Posteriorly - external occipital protuberance and highest nuchal line
Anteriorly - splits to enclose frontalis
On each side - thin and continues over temporal fascia; attached to zygomatic arch.
Over skull vault, it is adherent to skin by fibrous septa but loosely attached to pericranium by areolar
tissue. Thus, aponeurosis can move freely over pericranium along with the skin of the scalp.

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Blood supply
Branches of internal carotid artery (ICA) and external carotid artery (ECA) supply scalp. Scalp is one of
the sites of anastomosis between ICA and ECA.

Nerve supply
Ten nerves supply each half of scalp. These are four sensory and one motor, each in front and behind the
auricle. The motor branches of facial nerve (VII CN) supply fronto-occipitalis.

Scalp: Arterial and nerve supply

Scalp & Face: Venous return

CLINICAL ANATOMY
Open wounds of scalp bleed profusely
Scalp has rich blood supply with numerous anastomoses between branches of ICA & ECA. Cut ends of
vessels are prevented from retraction by the fibrous strands that anchor vessel walls. The bleeding is
stopped effectively by applying firm pressure against the underlying bone for some time.

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Scalp swellings are painful
Fibrous stands of dense connective tissue layer restrict expansion of swelling or subcutaneous
haemorrhage. Hence, swelling is tensile and presses on nerve endings.

Sebaceous cysts
Sebaceous glands are associated with hair follicles. Any blockade in the extrusion of secretions of
sebaceous glands may lead to formation of sebaceous cyst. Scalp is the commonest site for sebaceous cyst.

Emissary veins connect intracranial dural venous sinuses to the veins of scalp. These are valve-less and
blood can flow in either direction. Infection of scalp can spread via these veins and which may cause
meningitis and dural venous sinus thrombosis.

Black eye
Direct black eye is due to local blow to eye causing blackish discolorations of both eyelids simultaneously
within 1-2 hours due to subcutaneous haemorrhage.
Indirect black eye is due to haemorrhage in subaponeurotic layer. The haemorrhage fills subaponeurotic
space upto highest nuchal liner posteriorly; superior temporal line laterally and slowly gravitates under
frontalis to upper eyelid first followed by lower eyelid causing their discoloration. This takes 1-2 days to
appear.

Safely valve hematoma

The fracture of vault may tear dura and pericranium. This results in collection of intracranial haemorrhage
in sub-aponeurotic layer through fracture line. No signs of brain compression develop until sub-
aponeurotic space is completely filled with blood. After this, signs of cerebral compression develop
rapidly. This collection of blood is safety valve hematoma.

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 CHAPTER- 2

CERVICAL FASCIA

Superficial cervical fascia

It is a thin fascia, which contains platysma.

DEEP CERVICAL FASCIA

It invests the muscles and other structures of the neck. It consists of following layers:
Investing fascia
Behind it is attached to ligamentum nuchae and spine of 7th cervical vertebra. It covers trapezius and
continues forwards as a single layer over posterior triangle (forms roof) to posterior border of
sternocleidomastoid; splits and encloses sternocleidomastoid. At anterior margin of SCM, it becomes
single layer and forms roof of anterior triangle of neck. It reaches forwards to midline and meets
corresponding layer from the opposite side.
Above, it is attached to superior nuchal line, mastoid process and base of mandible. Between mandible
and mastoid process, it encloses parotid gland. The superficial layer over gland extends upwards as
parotid fascia, which is attached to zygomatic arch. From deep layer to gland, stylomandibular ligament
passes to styloid process.
Below, it is attached to acromion process, clavicle and manubrium sterni. Just above manubrium, it splits
into superficial and deep layers. Between two layers is suprasternal space (of Bern).
In lower part of posterior triangle, investing fascia splits and both laminae are attached to clavicle to form
supraclavicular space.

Deep cervical fascia: Vertical disposition

Prevertebral fascia
It is formed by splitting of investing fascia under SCM. It passes in front of prevertebral muscles and
forms fascial floor of posterior triangle. Subclavian artery and brachial plexus emerge from behind
scalenus anterior they carry a sleeve (derived from prevertebral fascia) called axillary sheath.
Superiorly prevertebral fascia is attached to base of skull. Inferiorly it descends into superior mediastinum
where it blends with anterior longitudinal ligament at T-4 level. Anteriorly prevertebral fascia is separated
from pharynx by retropharyngeal space.

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 Deep cervical fascia: Horizontal disposition
Carotid sheath
It is a condensation of deep cervical fascia around common and internal carotid arteries, internal jugular
vein, vagus nerve and ansa cervicalis. It is thicker around arterial side than venous side.

Pretracheal fascia
It is formed by splitting of investing fascia under SCM. It passes in front of trachea and oesophagus.
Above it is attached to arch of cricoid cartilage and below it continues into superior mediastinum. It
provides fascial sheath for thyroid gland.

CLINICAL ANATOMY
The investing layer of deep cervical fascia opposes spread of abscesses towards the surface and pus
beneath it migrates laterally. If the pus is present in anterior triangle, it may go into mediastinum, anterior
to pretracheal fascia. Pus behind prevertebral fascia may extend laterally and points in posterior triangle. It
may perforate this layer and buccopharyngeal fascia and bulge into pharynx as retropharyngeal abscess.

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 CHAPTER- 3

FACE
CRANIOFACIAL MUSCLES
Topographically and functionally, these muscles are grouped as:
 Epicranial
 Circumorbital
 Nasal
 Buccolabial
Branches of facial nerve (VII CN) innervate these muscles
Epicranial group
 Occipitofrontalis and temporoparietalis
Circumorbital group
 Orbicularis oculi
 Corrugator supercilii
 Levator palpebrae superioris (LPS)

Facial muscles

ORBICULARIS OCULI
This muscle surrounds circumference of orbit. Its parts are orbital, palpebral and lacrimal.
Nerve supply- Temporal & zygomatic branches of facial nerve
Actions
 Sphincter muscle of eyelids
 Palpebral part- closes eyelids gently (in sleep) or reflexly (protectively in blinking).
 Orbital part is activated under voluntary control

Nasal muscles
 Procerus
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  Nasalis
 Depressor septi

Buccolabial group
Elevators, retractors & evertors of upper lip
 Levator labii superioris alaeque nasi
 Levator labii superioris
 Zygomaticus major and minor
 Levator anguli oris
 Risorius
Depressors, retractors & evertors of lower lip
 Depressor labii inferioris
 Depressor anguli oris
 Mentalis
Compound sphincter
 Orbicularis oris
 Incisivus superior and inferior

Facial muscles

BUCCINATOR
It occupies space between maxilla & mandible in the cheek. It is attached to outer surfaces of alveolar
processes of maxilla and mandible opposite molar teeth.
Nerve supply- Lower buccal branch of facial nerve
Actions
 It compresses cheeks against the teeth and gums
 During mastication, assist tongue in directing food between molar teeth
 It expel air from the cheeks between the lips (blowing muscle)

ORBICULARIS ORIS
This muscle consists of four quadrants (upper, lower, left and right). These parts are apposed along lines
that correspond to the junction between the red-lip and the skin.
Nerve supply- Lower buccal and mandibular marginal branches of facial nerve

Action of facial muscles

Actions are primarily to regulate the openings of three openings- orbit, nose and mouth. Thus, their names
convey actions that these muscles perform. In addition, these muscles of facial expression by virtue of
their insertion on to skin manifest as various facial expressions.

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Blood supply of face

Arterial supply

Venous drainage

Lymphatic drainage

Lymphatic drainage of face

Cutaneous innervation of face

The face develops from above downwards by three processes: frontonasal, maxillary and mandibular. The
cutaneous innervation for these processes is derived from branches of Trigeminal nerve (V-CN). These
branches are ophthalmic, maxillary and mandibular nerves respectively.

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 Cutaneous innervation of face

CLINICAL ANATOMY
Bleeding from face
The face has a very rich blood supply because of anastomoses between the branches of two facial arteries
in midline and anastomoses of posterior branches with branches that run along the various branches of
trigeminal nerve. Because of these extensive anastomoses, any arterial cut would lead to bleeding from
both cut ends.

Palpation of facial artery

Facial artery enters face at anteroinferior angle of masseter; made prominent by asking the individual to
clinch his teeth. At anteroinferior angle of masseter, facial artery is palpated.

Clinical testing of facial nerve

To assess facial nerve involvement, facial muscles are tested clinically by asking patient to perform
frowning, closing of eyes, showing of teeth, whistling and smiling.

Dangerous area of face includes upper lip, lower part of nose and nasal septum. Any infection in this
area may cause spread of infection to cut ends of healthy venules. Factors facilitating spread of infection:
 Difficulty in immobilizing this part of face
 absence of deep fascia fails to restrict infection
 veins are valve-less
The infection incites thrombus formation, which may occlude facial vein and open up alternative passage
of venous return. Along these alternative pathways, infection may enter cavernous sinus leading to
cavernous sinus thrombosis.

Dangerous area of face

Bell's palsy is the paralysis of facial nerve. This may result from trauma, nerve compression by a
tumour or infection. The person may not be able to close an eye or control salivation on the affected side.

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 CHAPTER- 4

POSTERIOR TRIANGLE OF NECK

Boundaries
In front - posterior border of SCM
Below - middle third of clavicle
Behind - anterior border of trapezius
Its apex (between SCM and trapezius) is blunt. Inferior belly of omohyoid divides posterior triangle into
upper larger occipital triangle and lower smaller supraclavicular triangle.

Posterior triangle: Boundaries and subdivisions

OCCIPITAL TRIANGLE
Boundaries
In front - posterior border of SCM
Below – inferior belly of omohyoid
Behind - anterior border of trapezius
Floor (from above downwards): semispinalis capitis, splenius capitis, levator scapulae, scalenus medius &
posterior.
The accessory nerve pierces SCM; passes obliquely downwards and backwards to enter trapezius.
Cutaneous and muscular branches of cervical plexus emerge at posterior border of SCM.
Below, supraclavicular nerves, transverse cervical vessels and upper part of brachial plexus cross the
triangle.
Lymph nodes are arranged along the posterior border of SCM; extend from mastoid process to root of
neck.

SUPRACLAVICULAR TRIANGLE
Boundaries
In front - posterior border of SCM
Below - middle third of clavicle
Behind - inferior belly of omohyoid
Floor contains 1st rib, Scalenus medius and first slip of serratus anterior.
Floor- from above downwards floor is formed by splenius capitis, semispinalis capitis, levator scapulae
and three scaleni (posterior, medius & anterior; covered by prevertebral fascia.

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 Posterior triangle: Muscular floor

Contents of posterior triangle

Third part of subclavian artery crosses first rib and enters axilla; subclavian vein (behind clavicle), does
not appear in triangle.
Brachial plexus is partly above and behind subclavian artery.
Suprascapular vessels pass transversely behind the clavicle; at higher-level, transverse cervical vessels are
present.
External jugular vein descends behind posterior border of SCM; opens in subclavian vein.
Occipital artery Occipital nodes

Great auricular nerve

Lesser occipital nerve

Transverse cervical nerve

Supraclavicular nerves
XI CN
OH (inferior belly)
Dorsal scapular nerve

Suprascapular nerve Subclavian Vs

Phrenic nerve
Trunks of BP Long thoracic nerve
Nerve to subclavius
Posterior triangle: Contents

CLINICAL ANATOMY
Torticollis (wryneck)
Here, neck is flexed to same side and head & face is turned to opposite side due to contraction of SCM of
that side. It may be congenital or acquired.
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Enlargement of lymph nodes along XI CN in posterior triangle would lead to irritation of the nerve
causing spasm of SCM and trapezius resulting in wry neck. Birth injuries resulting in damage to SCM
fibers would give rise to congenital torticollis.

Torticollis (wryneck)

Air embolism
External jugular vein (EJV) enters subclavian vein by piercing investing fascia an inch above the medial
end of clavicle. A cut here would prevent the vein from collapsing leaving its opening patent where from
air may be sucked in during inspiration. This may cause fatal air embolism.

Cervical rib
The costal element of C-7 vertebra at times enlarges to form various grades of cervical rib. A fully formed
cervical rib is anchored close to anterior end of first rib. In such situation, lower trunk of brachial plexus
overrides cervical rib causing its stretching leading to neurological symptoms. Subclavian artery is also
likely to be compressed causing various vascular symptoms.

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 CHAPTER- 5

SUBOCCIPITAL TRIANGLE
Boundaries
Above & medially - Rectus capitis posterior major
Above & laterally - Superior oblique
Below & laterally - Inferior oblique capitis
Floor- posterior atlanto-occipital membrane & posterior arch of atlas
Contents
 Vertebral artery (3rd part)
 C-1 nerve (dorsal ramus)

Boundaries & contents

Suboccipital venous plexus

Suboccipital venous plexus (in and around sub-occipital triangle) drains into vertebral venous plexus &
deep cervical vein. It presents alternative routes for venous drainage

Suboccipital muscles
These include
 Rectus capitis posterior major and minor
 Superior oblique capitis
 Inferior oblique capitis
These muscles cause
Extension of head at atlanto-occipital joints: Recti capitis posterior major & minor
Rotation of head and atlas on the axis: Superior oblique & inferior oblique
Nerve supply
All muscles are supplied by dorsal ramus of C-1 nerve

CLINICAL ANATOMY
This region is important for neurosurgeons, physicians & orthopedic surgeons. To approach posterior
cranial fossa, neurosurgeon gives “cross bow incision of Cushing”. This gives access to cerebellum,
cerebellopontine angle (commonest site of brain tumour), fourth ventricle, medulla, upper part of spinal
cord.

Cisternal puncture
In this procedure, a needle is inserted into cerebellomedullary cistern to withdraw cerebrospinal fluid
(CSF) for examination. Subarachnoid space of cerebellomedullary cistern is tapped by inserting a needle
in the sub-occipital region. The needle pierces posterior atlanto-occipital membrane and enters
cerebellomedullary cistern.

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 CHAPTER- 6

ANTERIOR ASPECT OF NECK

MIDLINE STRUCTURES IN THE NECK

The midline structures in the neck are divided into suprahyoid & infrahyoid structures
Suprahyoid structures
In submental triangle: submental lymph nodes and mylohyoid raphe
Infrahyoid structure
 Hyoid bone (C-3)
 Thyrohyoid membrane
 Notch of thyroid cartilage (C-4)
 Cricothyroid cartilage (C-6)
 Tracheal rings
 Isthmus of thyroid gland in front of 2nd, 3rd, 4th tracheal rings
 Suprasternal notch (disc between T-1 & T-2)
Sternocleidomastoid (SCM) divides side of neck into anterior & posterior triangles.

ANTERIOR TRIANGLE
Boundaries
In front - midline structures of neck
Above - base of mandible
Behind - anterior border of SCM
It is subdivided into:
 Muscular triangle
 Carotid triangle
 Digastric triangle
 Submental triangle

Muscular triangle
Boundaries
Median line from hyoid to sternum
Inferoposteriorly - anterior margin of SCM
Posterosuperiorly - superior belly of omohyoid

Carotid triangle
Boundaries
Posteriorly - SCM
Anteroinferiorly - superior belly of omohyoid
Superiorly - stylohyoid & posterior belly of digastric
Roof- skin, superficial fascia, platysma and deep fascia
Floor- thyrohyoid, hyoglossus, inferior and middle pharyngeal constrictors
Contents
 CCA and its divisions- ECA & ICA
 Branches of ECA
o superior thyroid artery
o lingual artery
o facial artery
o occipital artery
o ascending pharyngeal artery
 IJV
 Hypoglossal nerve (XII CN)
 Internal laryngeal nerve
 External laryngeal nerve

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 Internal jugular vein (IJV)
 Deep cervical lymph nodes
 Vagus nerve

Facial artery
Digastric (AB)

2 1 Masseter Mylohyoid

Hyoglossus
3 Digastric (PB)

OH
8

SH
4 7
6
5 XII CN
4

XI CN
1. Submental E I
2. Digastric C 2 C
3. Carotid A A RLN
4. Muscular 3 I
1. Superior thyroid J
2. Ascending pharyngeal V
1 C X CN
3. Lingual
4. Facial C Ansa cervicalis
5. Occipital
A A
6. Post auricular V
7. Maxillary
8. Superficial temporal Vagus nerve

Anterior triangle of neck: Boundaries & subdivisions

Digastric triangle
Boundaries
Above - base of mandible
Posteroinferiorly - posterior belly of digastric & stylohyoid
Anteroinferiorly - anterior belly of digastric
Roof - skin, superficial fascia, platysma & deep fascia
Floor - mylohyoid and hyoglossus
Contents
In anterior region
 Submandibular gland
 Facial vessels
 Submental artery
 Mylohyoid artery and nerve
 Submandibular gland
 Submandibular lymph nodes
In posterior region
 Lower part of parotid gland
 External carotid artery
ECA is superficial to ICA and crosses it posterolaterally. ICA, IJV and 10th cranial nerve are deeply
placed; separated from ECA by styloglossus and stylopharyngeus

Submental triangle
The submental triangle is unpaired.
Boundaries
Anterior bellies of both digastric muscles
Apex - at chin
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Base - body of hyoid
Floor - mylohyoid muscles
Contents
 Lymph nodes
 Small veins uniting to form anterior jugular vein

Anterior region of neck

STERNOCLEIDOMASTOID MUSCLE (SCM)

It forms common boundary of triangles of neck. It arises by two heads.
 Sternal head - upper part of anterior surface of manubrium sterni
 Clavicular head - superior surface of medial third of clavicle
It is inserted into mastoid process and lateral half of superior nuchal line.
Accessory nerve (XI CN) passes deep to sternocleidomastoid. It pierces (and supplies) it and reappears
just above the middle of the posterior border.

Nerve supply
 Spinal accessory nerve (XI CN)
 Branches from ventral rami of 2nd to 4th cervical nerves

Actions
 Acting alone, one SCM tilts head towards same shoulder and simultaneously rotates head so that face
turns towards opposite side (sideways glance)
 Acting together from below, muscles draw head forwards, helping longus colli to flex cervical part of
vertebral column (common in feeding)
 Two muscles are used to raise head when the body is supine
 When head is fixed, they help to elevate thorax in forced inspiration
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 CHAPTER- 7

THYROID GLAND

Introduction
This (vascular organ, weighing 30 grams) secretes thyroxin hormone; part of endocrine system. It is
situated in the lower part of the front of neck. It surrounds trachea and sides of larynx. It is enclosed in
pretracheal fascia, which anchors it to oblique line of thyroid cartilage and arch of cricoid cartilage. The
pretracheal fascia forms outer false capsule of gland. This makes it move up and down with deglutition.
The outer condensation of gland forms true capsule. The venous plexus is under true capsule.

Features
The gland has two lateral lobes joined by isthmus. The isthmus overlies second, third and fourth tracheal
rings. It presents pyramidal lobe (15-30%) from upper border of isthmus. The pyramidal lobe may be
connected to hyoid by a fibromuscular band called levator glandulae thyroidae.
Each lateral lobe is pyriform shaped with its apex directed upwards. Its dimensions are 2 x 1 x 1 inches.
Each lobe extends superiorly upto oblique line on thyroid cartilage under sternothyroid.

Thyroid gland: Features

Relations
Anterolateral - infrahyoid strap muscles and SCM
Posterior- carotid sheath and its contents
Medial
 Two cartilages -Thyroid & Cricoid
 Two muscles -Cricothyroid & Cricopharyngeus
 Two tubes -Trachea & Oesophagus
 Two nerves -External & Recurrent laryngeal nerves

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 Thyroid gland: Relations

Arterial supply
 Superior thyroid artery (branch of ECA)
 Inferior thyroid artery (branch of thyrocervical trunk)
 Thyroidea ima (occasionally) from brachiocephalic trunk or aortic arch
These arteries form numerous anastomoses.

Venous return
Features of thyroid veins:
 Short in course
 Wide lumen
 Absence of valve
 Do not accompany the arteries
Three pairs of veins
 Superior & middle thyroid veins open into IJV
 Inferior thyroid vein opens into brachiocephalic vein

Thyroid gland: Blood supply

Lymphatic drainage
Thyroid gland is drained by:
 Prelaryngeal nodes – upper half of isthmus joint parts of lateral lobes
 Pretracheal nodes – lower half of isthmus and adjoining parts of lateral lobes
 Anterosuperior group (deep cervical nodes) – upper lateral half of lateral lobe
 Posteroinferior group (deep cervical nodes) – lower lateral half of lateral lobe

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 Thyroid gland: Blood supply & lymphatic drainage

CLINICAL ANATOMY
Thyroid swellings
The line of least resistance for thyroid swelling to grow is along its posteromedial border. These swellings
compress structures that are in close proximity namely trachea, oesophagus and recurrent laryngeal
nerves. The presenting symptoms for these involvements include dyspnoea, dysphagia and hoarseness of
voice.
All thyroid swellings move with deglutition as ligament of Berry (slip of pretracheal fascia) attaches each
lateral lobe to cricoid cartilage.

Anatomical considerations during thyroidectomy

Ligation of thyroid arteries- To avoid accidental ligation of superior laryngeal nerve, superior thyroid
artery is ligated close to upper pole. The inferior thyroid artery is ligated away from the gland to avoid
accidental ligation of recurrent laryngeal nerve.
Ligation of external laryngeal nerve leads to weak and monotonous voice with hoarseness. Ligation of
recurrent laryngeal nerve leads to hoarseness of voice.
Mobilization of gland- Cutting of ligament of Berry releases the gland.
Thyroid capsules- Thyroid gland has two capsules. The outer (false) capsule is derived from pretracheal
fascia while inner (true) capsule is the condensation of peripheral part of gland. The thyroid venous plexus
is deep to true capsule. In thyroidectomy, gland is removed along with both capsules to avoid bleeding
from venous plexus, situated deep to true capsule. This is contrary to prostatectomy where both capsules
are retained.

Thyroidectomy and Prostatectomy

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Parathyroid glands-Thyroidectomy is subtotal in which some part of thyroid gland is preserved to avoid
post-operative hypothyroidism. In thyroidectomy, parathyroid glands are preserved which are along the
posterior border of thyroid gland.

Compressions of structures in carcinoma of thyroid

Carcinoma of thyroid may appear as symptoms due to compression of related structures that are likely to
be involved:
 Dyspnoea - compression of trachea
 Dysphagia - compression of esophagus
 Hoarseness of voice - involvement of recurrent laryngeal nerve
 Horner’s syndrome - involvement of cervical sympathetic chain
 Haemorrhage - erosion of carotid sheath

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 CHAPTER- 8

LYMPHATIC DRAINAGE OF THE HEAD AND NECK

The lymph nodes draining head and neck and face region are arranged in superficial and deep groups.

Superficial group
In this group, lymph nodes are in a circular manner.
 Preauricular node- in front of tragus
 Parotid lymph nodes- embedded in parotid gland
 Submental lymph nodes- in submental triangle
 Submandibular lymph nodes- in submandibular triangle
 Superficial cervical nodes- on outer surface of SCM around EJV
 Anterior cervical nodes- near midline in front of larynx and trachea
 Occipital lymph nodes- between mastoid process and external occipital protuberance
 Posterior auricular nodes- over mastoid process behind pinna

Superficial lymph nodes of head & neck

Deep group
These nodes are placed vertically along the carotid sheath. They are Jugulodigastric & Juguloomohyoid
nodes. These nodes are enlarged in pathological conditions of the region that they drain.

Deep lymph nodes of head & neck

Thoracic duct in neck

This largest lymph duct starts from cisterna chyli in the upper lumbar region.
It drains left half of body above diaphragm and both halves between diaphragm except right lobe of liver
and upper right quadrant of anterior abdominal wall
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It enters thorax through aortic opening and ascends in posterior mediastinum along oesophagus. It enters
root of neck on the left side to reach transverse process of C-7. It then turns laterally between vertebral
artery (posteriorly) and carotid artery (anteriorly).
Before termination, it runs across the apex of left pleura and crosses first part of left subclavian artery. It
terminates into jugulosubclavian junction.

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 CHAPTER- 9

ARTERIES OF THE HEAD AND NECK

Arteries of head and neck

SUBCLAVIAN ARTERY
It arises from brachiocephalic trunk on the right and arch of aorta on left. It arches over upper surface of
first rib to become axillary artery. It is in close contact with the apex of lung and lies behind scalenus
anterior at the root of neck.
Branches
Vertebral artery runs upwards and enters foramen transversarium of C-6 vertebra. It passes through
transversarium foramina of other cervical vertebra to reach upper surface of atlas. It turns medially in a
groove and then enters cranial cavity through foramen magnum where it joins opposite artery to form
basilar artery. It gives anterior and posterior spinal arteries that supply spinal cord, and posterior inferior
cerebellar artery, which supplies cerebellum & medulla. The basilar artery passes forwards on medulla &
pons. It gives anterior inferior cerebellar artery, branches to brainstem and inner ear (internal auditory
artery). It ends by dividing into superior cerebellar and posterior cerebral arteries.
Costocervical trunk passes backward to supply muscles of back. It gives superior thoracic artery.
Thyrocervical trunk gives superficial cervical and suprascapular arteries. It then passes medially as
inferior thyroid artery across the vertebral artery to reach middle of posterior border of thyroid. It has a
variable relation to recurrent laryngeal nerve, lying in front or behind them.
Dorsal scapular artery descends along the medial border of scapula. It may arise in common with
superficial cervical artery.

25
 Subclavian artery and its branches

Arteries of head and neck

COMMON CAROTID ARTERY

The right and left carotid arteries differ in length and origin.
Right common carotid artery has cervical part only. It arises from brachiocephalic trunk behind the right
sternoclavicular joint.

26
Left common carotid artery has thoracic and cervical parts. It originates from aortic arch posterolateral
to brachiocephalic trunk.
Thoracic part of left CCA ascends upto left sternoclavicular joint where it enters neck. At first, it is in
front of trachea, and then it inclines to left.

Cervical part of CCA

Both have similar course. This part ascends upto upper border of thyroid cartilage, where it divides into
ECA and ICA.
At its division, artery shows a dilatation called carotid sinus. It contains receptor endings of
glossopharyngeal nerve. The sinus is responsive to changes in arterial blood pressure. It acts as a
baroreceptor for control of intracranial pressure.
Carotid body (small, reddish-brown structure) is situated behind CCA bifurcation; acts as chemoreceptor.
CCA is contained in carotid sheath. This sheath also encloses IJV and vagus nerve.
Anterolaterally at cricoid cartilage, artery is crossed by intermediate tendon of omohyoid. Above
omohyoid, artery is superficial. It is covered by platysma, deep cervical fascia and medial border of SCM.
In front of carotid sheath, superior root of ansa cervicalis joins inferior root derived from C-2 & C- 3
nerves.
Below C-6 vertebra, artery lies in an angle between scalenus anterior and longus colli. It is anterior to
vertebral vessels, inferior thyroid and subclavian arteries, sympathetic trunk. On the left thoracic duct is
located.

Common Carotid Artery: Relations

EXTERNAL CAROTID ARTERY

This begins lateral to upper border of thyroid cartilage (between C-3 & C-4). It passes upwards between
tip of mastoid process and angle of mandible. In parotid gland, it divides into superficial temporal and
maxillary arteries (behind neck of mandible).
At its origin, it is in carotid triangle, anteromedial to internal carotid artery. It becomes anterior and then
lateral to ICA as it ascends.
Branches
 Superior thyroid artery
 Ascending pharyngeal artery
 Lingual artery
 Facial artery
 Occipital artery
 Posterior auricular artery
 Superficial temporal artery

27
 Maxillary artery

Superior thyroid artery arises from the front of ECA just below greater cornu of hyoid. It divides into
terminal branches at the apex of lateral lobe of thyroid gland. It supplies adjacent muscles and thyroid
gland. It anastomoses with opposite artery and inferior thyroid artery.

Ascending pharyngeal artery ascends between ICA and pharynx to base of cranium. It anastomoses
with ascending palatine branch of facial artery. Its branches are pharyngeal arteries, inferior tympanic
artery and meningeal branches.

Lingual artery (main supply to tongue and floor of mouth) arises opposite the tip of greater cornu of
hyoid between superior thyroid and facial arteries. It ascends forwards and passes medial to posterior
border of hyoglossus and then deep to it. It courses forwards on the inferior surface of tongue up to its tip.
The artery has three parts: First part (in carotid triangle) ascends medially, and then descends to the level
of hyoid. Second part passes along the upper border of hyoid deep to hyoglossus, tendons of digastric and
stylohyoid, lower part of submandibular gland and posterior part of mylohyoid. Third part turns upwards
near the anterior border of hyoglossus. It passes forwards close to inferior surface of tongue near the
frenulum accompanied by lingual nerve. Near the tip of tongue, it anastomoses with opposite artery.

Lingual artery
FACIAL ARTERY
It arises in carotid triangle superior to lingual artery above the greater cornu of hyoid. It arches upwards
and grooves posterior aspect of submandibular gland. It reaches surface of mandible where it curves round
its inferior border, anterior to masseter to enter face. On face, it ascends the side of nose and ends at
medial palpebral commissure. It ends by supplying lacrimal sac and joins dorsal nasal branch of
ophthalmic artery. The artery is tortuous throughout its course. Over face, facial vein is posterior to artery.
Cervical branches
Ascending palatine artery ascends between styloglossus and stylopharyngeus to the side of pharynx.
Along pharynx, it ascends between superior constrictor and medial pterygoid towards the base of cranium.
It supplies tonsil and pharyngotympanic tube.
Tonsillar artery (main supply to tonsil) ascends between medial pterygoid and styloglossus. At upper
border of styloglossus, it pierces superior constrictor and supplies tonsil.
Glandular branches (three or four) supply submandibular salivary gland.
Submental artery (largest cervical branch) arises below the mandible. It supplies surrounding muscles and
anastomoses with sublingual branch of lingual artery.
Facial branches
Inferior labial artery arises near buccal angle. It pierces orbicularis oris and supplies mucous membrane
and muscles. It anastomoses with opposite artery.

28
Superior labial artery courses along the upper lip and anastomoses with opposite artery. It supplies upper
lip. It gives a septal branch, which ramifies in nasal septum.
Lateral nasal artery ascends side of nose. It supplies ala of nose. It anastomoses with opposite artery.

External carotid artery & its branches

Occipital artery arises from posterior aspect of ECA. At origin, it is crossed by hypoglossal nerve. It
courses backwards, upwards and deep to posterior belly of digastric. It crosses ICA, IJV, XII CN, X CN
and XI CN. It ascends tortuously in superficial fascia of scalp.

Posterior auricular artery arises from posterior aspect of ECA just above digastric and stylohyoid. It
ascends between auricular cartilage and mastoid process. It divides into auricular and occipital branches. It
supplies digastric, stylohyoid, sternocleidomastoid, and parotid gland.

Superficial temporal artery (smaller terminal branch of ECA) given in parotid gland behind neck of
mandible. It crosses zygomatic process of temporal and divides into anterior and posterior branches. This
artery supplies parotid gland and temporomandibular joint.

MAXILLARY ARTERY
It (larger terminal branch of ECA) arises behind the neck of mandible in parotid gland. It passes medial to
neck of mandible to reach pterygopalatine fossa. It has three parts:
 First (mandibular) part
 Second (pterygoid) part
 Third (pterygopalatine) part

29
 Maxillary artery: Parts and Branches

First part passes between neck of mandible and sphenomandibular ligament. Second part ascends
forwards superficial to lower head of lateral pterygoid. Third part passes through pterygomaxillary
fissure into pterygopalatine fossa.
Distribution- Maxillary artery supplies mandible, maxilla, teeth, muscles of mastication, palate, nose and
cranial dura mater.

Branches of first part

Deep auricular artery ascends in parotid gland behind TM joint. It pierces external acoustic meatus and
supplies tympanic membrane and TM joint.
Anterior tympanic artery enters tympanic cavity through petrotympanic fissure; supplies interior of
tympanic membrane.
Middle meningeal artery passes between two roots of auriculotemporal nerve and enters cranial cavity
through foramen spinosum. In cranium, it divides into frontal and parietal branches. It supplies dura mater
and cranium. Clinical anatomy- middle meningeal artery may be torn in fractures of temporal bone and
injuries separating dura mater from bone, followed by haemorrhage between them. Trephining may be
required to reduce cerebral compression.
Accessory meningeal artery enters cranial cavity through foramen ovale; supplies trigeminal ganglion and
dura mater.
Inferior alveolar artery enters mandibular foramen. Its mylohyoid branch pierces sphenomandibular
ligament and descends with mylohyoid nerve. The inferior alveolar artery traverses mandibular canal with
inferior alveolar nerve and divides into incisor & mental branches near first premolar. Incisor branch
continues towards midline, where it anastomoses with artery of opposite side. In mandibular canal,
arteries supplies mandible, tooth sockets and teeth. The mental branch exit through mental foramen and
supplies chin.

Branches of second part

Branches are distributed to muscles of mastication.
Deep temporal branches (anterior & posterior) ascend between temporalis and bone; supply temporalis.
Pterygoid branches supply pterygoid muscles.
Masseteric artery (with masseteric nerve) passes behind tendon of temporalis through mandibular notch to
deep surface of masseter.
Buccal artery runs forwards with buccal nerve between medial pterygoid and attachment of temporalis;
supplies buccinator.

Branches of third part

Posterior superior alveolar artery divides into branches that enter alveolar canals to supply molar and
premolar teeth and maxillary sinus.

30
Infraorbital artery enters orbit through inferior orbital fissure. It runs in infraorbital groove and canal with
infraorbital nerve and emerges on the face through infraorbital foramen. It supplies lower teeth and
mucous membrane of maxillary sinus.
Descending palatine artery descends in palatine canal. It gives two or three lesser palatine arteries that
pass through lesser palatine canals to supply soft palate and tonsil. It then continues as greater palatine
artery. It emerges on the oral surface of palate by passing through greater palatine foramen. It supplies
gingivae, palatine glands and mucous membrane of hard palate
Pharyngeal artery runs through palatovaginal canal; supplies nasopharynx, sphenoidal air sinus and
auditory tube.
Artery of pterygoid canal passes in pterygoid canal; supplies upper pharynx, pharyngotympanic tube and
tympanic cavity.
Sphenopalatine artery (continuation of maxillary artery) passes through sphenopalatine foramen into nasal
cavity. It supplies frontal, maxillary, ethmoidal and sphenoidal sinuses.

31
 CHAPTER- 10

VEINS OF THE HEAD AND NECK

EXTERNAL VEINS OF HEAD & FACE

Supratrochlear vein starts on the forehead, which descends near the midline. The vein joins supraorbital
vein to form facial vein near medial canthus.
Supraorbital vein pierces orbicularis oculi and joins supratrochlear vein near medial canthus.

Facial vein
It is formed by union of supraorbital and supratrochlear veins near the medial canthus of eye. After
formation, it descends obliquely near the side of nose and passes downwards behind the facial artery. It
descends on to anterior border and surface of masseter. It crosses body of mandible and runs obliquely
backwards superficial to submandibular gland. At anteroinferior angle of mandible, it joins anterior
division of retromandibular vein to form common facial vein. It enters IJV near greater cornu of hyoid.
Connections
 near its commencement, facial vein is connected to superior ophthalmic vein
 via supraorbital vein, it is connected to cavernous sinus
It receives
 deep facial vein from pterygoid venous plexus
 superior and inferior labial veins

Superficial veins of face and neck

Superficial temporal vein (joined by middle temporal vein) enters parotid gland and joins maxillary vein
to form retromandibular vein.
Pterygoid venous plexus (between two heads of lateral pterygoid) is connected to facial vein by deep
facial vein and cavernous sinus through foramen ovale & foramen lacerum.
Maxillary vein accompanies first part of maxillary artery; formed by pterygoid venous plexus. It joins
superficial temporal vein to form retromandibular vein.
Retromandibular vein after formation, it descends in parotid gland. It divides into anterior division that
joins facial vein to form common facial vein and posterior division, which joins posterior auricular vein to
form EJV.
Posterior auricular vein descends behind the auricle to join posterior division of retromandibular vein
below the parotid gland to form EJV.
Occipital vein begins in a venous network in scalp. In suboccipital triangle, it joins deep cervical and
vertebral veins. It terminates in IJV.
32
 Veins of head and neck
External jugular vein
It is formed by union of posterior division of retromandibular vein and posterior auricular vein near the
angle of mandible below parotid gland. It drains scalp and face.
It descends from angle of mandible to mid-clavicle. It passes obliquely, superficial to SCM. In subclavian
triangle, it pierces investing fascia to terminate in subclavian vein.
Tributaries
 Posterior external jugular vein
 Transverse cervical vein
 Suprascapular vein
 Anterior jugular vein
Anterior jugular vein starts near the hyoid by union of superficial submandibular veins. In lower neck, it
joins lower end of EJV. Two anterior jugular veins joined just above the manubrium by jugular venous
arch.

Internal jugular vein

This large vein collects blood from skull, brain, superficial parts of face & neck. It begins at the base of
cranium in jugular foramen by continuation of sigmoid sinus. It descends in carotid sheath and joins
subclavian vein to form brachiocephalic vein. Its lower dilated end is inferior bulb. Deep cervical lymph
nodes are along the vein.
Tributaries
 Inferior petrosal sinus
 Facial vein
 Lingual vein
 Pharyngeal vein
 Superior and middle thyroid veins
 Occipital vein (sometimes)
Thoracic duct opens near the union of left subclavian vein and IJV.
Inferior petrosal sinus exits cranium through jugular foramen and opens into IJV.
Dorsal lingual veins (drain dorsum and sides of tongue) near greater cornu of hyoid join IJV.
Deep lingual vein begins near the tip and runs backwards near mucous membrane on the inferior surface
of tongue. It joins facial vein, IJV or lingual vein.
33
Pharyngeal veins start in pharyngeal plexus; receive meningeal veins and end in IJV.
Superior thyroid vein receives superior laryngeal and cricothyroid veins; terminates in IJV.
Middle thyroid vein drains lower part of gland and receives veins from larynx; ends in IJV.

IJV: Formation, tributaries and termination

IJV: Relations

34
Vertebral vein enters foramen transversarium in transverse process of atlas; forms plexus around
vertebral artery, which descends through successive foramina. The vertebral vein descends behind IJV in
front of first part of subclavian artery. It opens into brachiocephalic vein.

CLINICAL ANATOMY
Carotid pulse is felt in carotid triangle in front of anterior border of SCM at the level of laryngeal
prominence.

Jugular venous pressure

The pressure in right atrium with veins are in direct communication affects pressure in jugular veins. In
conditions of heart where there is venous stasis in right atrium, jugular venous pressure rises, which is
observed as engorged neck veins.

Tracheostomy is a surgical operation to establish airway. It is an opening into trachea through which an
indwelling tube is inserted.
Indications:
 laryngeal obstruction
 for prolonged continuous artificial respiration

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 CHAPTER- 11

PAROTID GLAND
Parotid space
Extent
Anteroposteriorly - overlaps masseter anteriorly & SCM posteriorly
Superoinferiorly - from external auditory meatus to below and behind angle of mandible

Parotid gland: Extent

PAROTID GLAND
It (largest salivary gland) is at the side of face just below and in front of external ear. The gland has
superficial and deep parts.
The superficial part lies between ramus of mandible, mastoid process and SCM. It reaches up to
zygomatic arch and inferiorly it tapers near angle of mandible. The gland is enclosed in a capsule that
continues with deep cervical fascia.

Parotid capsule

Structures forming parotid bed

Posteromedial structures
 Mastoid process with SCM and posterior belly of digastric
 Stylomastoid foramen with emerging facial nerve
 Styloid apparatus
 Carotid sheath
36
  Spine of sphenoid with middle meningeal artery
 Foramen ovale and its contents
 Scaphoid fossa with tensor palati
Anteromedial structures
 Rumus of mandible with masseter
Parotid space is bounded anteriorly by posterior margin of ramus of mandible and posteriorly by anterior
border of SCM.

Parotid bed

Parotid duct
The parotid duct (Stenson’s) emerges at anterior border of parotid gland. It courses forwards over masseter
where it can be palpated. At anterior border of masseter, parotid duct turns medially and pierces (from
superficial to deep) buccal pad of fat, buccopharyngeal fascia, buccinator, pharyngobasilar fascia and
mucous membrane of cheek.
It pierces mucous membrane to open obliquely in the vestibule of mouth opposite the crown of upper
second motor toot

Parotid duct: Course and opening

37
Relations

Superficial relations

Relations of anteromedial & posteromedial surfaces

38
Structures within parotid gland
From superficial to deep these are facial nerve, retromandibular vein and external carotid artery and its
terminal branches.

Structures embedded in parotid gland

Retromandibular vein

Secretomotor pathway for parotid gland

Preganglionic parasympathetic impulses arise in inferior salivatory nucleus. These are carried
subsequently in glossopharyngeal (IX CN) nerve, recurrent branch of IX CN (Jacobson’s nerve),
tympanic plexus and lesser petrosal nerve, to end in otic ganglion.
Postganglionic parasympathetic impulses reach parotid gland through posterior root of auriculotemporal
nerve.

39
 Parasympathetic secretomotor pathway for parotid gland

CLINICAL ANATOMY
Incisions in parotid surgery
Facial nerve within parotid gland divides and forms anastomosis; terminal branches arise from this
anastomosis. These emerge along superior and anterior borders of parotid gland. Surgical intervention
of parotid swelling requires adequate care to avoid injury to branches of facial nerve as well as parotid
duct. Hence, horizontal incisions are given. A vertical incision is likely to cut branches of facial nerve
and parotid duct.

Mumps
This acute viral infection is characterized by parotid gland swelling. The parotid swelling is very painful
as it causes stretching of parotidomasseteric fascia where nerve endings are stimulated. This is because of
unyielding nature of parotidomasseteric fascia (deep fascia).

40
 CHAPTER- 12

TEMPORAL AND INFRATEMPORAL FOSSAE

Infratemporal region
It is under base of skull, behind the maxilla, between lateral wall of pharynx and ramus of mandible.
Boundaries
Anterior - posterior surface of body of maxilla
Posterior - styloid process and tympanic plate
Lateral - temporalis & masseter (attached to coronoid process & ramus of mandible)
Medial - lateral pterygoid plate, superior constrictor and tensor & levator palati
Superior (roof) - infratemporal surface of greater wing of sphenoid
Inferior - continues with sides of pharynx

Boundaries of infratemporal fossae

Communications
Superiorly - with temporal fossa
With cranial cavity- via foramen ovale & foramen spinosum
Anteriorly - with pterygopalatine fossa through pterygomaxillary fissure
Superficial contents
Muscles- medial and lateral pterygoids
Vessels- pterygoid venous plexus, maxillary artery and its branches of first & second parts
Ligament- sphenomandibular ligament
Deep contents
Muscles - tensor palati
Nerves- mandibular nerve, chorda tympani and maxillary nerve
Ganglion - otic ganglion

Lateral pterygoid muscle: Relations

41
 Medial pterygoid muscle: Medial relations

Pterygoid venous plexus

Pterygoid venous plexus

PTERYGOPALATINE FOSSA
Boundaries
Medial wall- pterygoid process & perpendicular plate of palatine bone
Superior wall- body of sphenoid
Anterior wall- maxilla
Inferior- fusion of anterior & posterior walls
Lateral is open, into infratemporal fossa

Connections
Pterygomaxillary fissure transmits maxillary artery & nerves supplying posterosuperior teeth
Inferior orbital fissure: connection with orbital cavity
Sphenopalatine foramen (pterygopalatine) transmits sphenopalatine artery and posterior nasal nerve to
nasal cavity
Foramen rotundum: connection with middle cranial fossa
Greater & lesser palatine foramina connect with oral cavity via greater & lesser palatine canals- transmit
greater & lesser palatine nerves and descending palatine artery
Pterygoid canal: connection with outer surface of skull. At the root of medial plate of pterygoid process, it
goes into pterygopalatine fossa- transmits great petrosal nerve to pterygopalatine fossa

42
 CHAPTER- 13

TEMPOROMANDIBULAR JOINT

Bones taking part

From above - articular tubercle and anterior part of mandibular fossa of temporal bone
From below - head of mandible
Articular surfaces are covered with fibrocartilage.

Temporomandibular joint: Formation

Classification
Synovial- condylar variety
Right and left joints form bicondylar articulation
Articular disc divides joint into upper and lower compartments:
 Upper (meniscotemporal) compartment
 Lower (meniscomandibular) compartment

Temporomandibular joint: Compartments

Ligaments
Fibrous capsule- above it is attached to articular tubercle and edges of mandibular fossa and below to
neck of mandible.
Lateral ligament extends from tubercle on root of zygoma to lateral surface and posterior border of
neck of mandible.
Sphenomandibular ligament extends from spine of sphenoid to lingula of mandibular foramen. At its
lower end mylohyoid, nerve and vessels pierce ligament.
Stylomandibular ligament (thickening of investing fascia) extends from styloid process to angle of
mandible and posterior border.
Articular disc (fibrocartilaginous plate) divides joint cavity. Its upper surface is concavo-convex to fit
articular tubercle and fossa while its inferior concave surface is applied to head of mandible.
Anteromedially tendon of lateral pterygoid is attached.

Synovial membrane lines capsule, above and below the disc (does not cover disc). Thus, on each side
it lines non-articular surfaces of both superior and inferior synovial compartments.

43
 Temporomandibular joint: Ligaments

Blood supply
 Superficial temporal artery
 Maxillary artery

Nerve supply
 Auriculotemporal nerve
 Masseteric branches of mandibular nerve

Relations

Temporomandibular joint: Relations

44
Movements & muscles
Food bolus has to be chewed properly. Movements of lower jaw achieve this by muscles of mastication.
These movements are elevation and depression of lower jaw, protraction and retraction of lower jaw and
side to side movement of lower jaw
These movements take at both temporomandibular joints.

Temporomandibular joint: Movements

Protrusion
 Lateral & medial pterygoids
Retraction
 Temporalis (posterior fibres)
 Middle and deep parts of masseter
 Digastric
 Geniohyoid
Elevation
 Temporalis
 Masseter
 Medial pterygoid of both sides
Depression
 Lateral pterygoids
 Digastric
 Geniohyoid
 Mylohyoid
Side to side movement
 Medial and lateral pterygoid of each side, acting alternately

Temporomandibular joint: Movements and Muscles

45
APPLIED ANATOMY
Dislocation of temporomandibular joint
It occurs only in forward direction. When the mouth is open, mandibular condyles are on articular
eminences and sudden violence, even muscular spasm (convulsive yawn), may displace one or both into
infratemporal fossa. Reduction involves depressing jaw posteriorly and at the same time elevating the
chin. Downward pressure overcomes spasm in masseter, temporalis and pterygoids while elevation of
chin forces condyles backwards.

Referred pain from diseased tooth

The teeth of lower jaw are supplied by inferior alveolar nerve, which is a branch of mandibular nerve.
Thus, it is common to have pain from diseased tooth referred to external acoustic meatus, which is
innervated by auriculotemporal nerve (branch of mandibular nerve).

Pterion is an important bony landmark where four bones meet namely, anteroinferior angle of parietal,
squamous part of temporal, greater wing of sphenoid and frontal bone. It is two fingers-breaths above
zygomatic arch and two finger-breaths behind orbital margin. Deep to it in cranium, anterior branch of
middle meningeal vessels are related. This site is preferred for cerebral decompression by making a
trephine hole.

46
 CHAPTER- 14

SUBMANDIBULAR REGION & SUBMANDIBULAR GLAND

Salivary glands

Submandibular region is between the mandible and hyoid under body of mandible. Its lower part
includes submental & digastric triangles.

Contents
Structures in superficial fascia
 fat
 platysma
 cervical branch of facial nerve
 anterior cutaneous nerve of necks (from cervical plexus)
 submental lymph nodes
 anterior jugular vein
Structures deep to investing layer of deep cervical fascia
Muscles
 digastric (both bellies & intermediate tendon)
 stylohyoid
 mylohyoid
 geniohyoid
 genioglossus
 styloglossus muscles of tongue
 hyoglossus
Ligament: stylohyoid ligament
Salivary glands
 submandibular gland
 sublingual gland
Arteries
 facial artery and its branches

47
  lingual artery and its branches
Nerves
 nerve to mylohyoid
 lingual with submandibular ganglion
 glossopharyngeal nerve
 hypoglossal nerve
Lymph nodes: submandibular lymph nodes

SUBMANDIBULAR GLAND
This walnut-sized mixed salivary gland (secretes mucus & serous fluid) is in the submandibular triangle.
It extends from anterior belly of digastric to stylomandibular ligament (separates submandibular and
parotid glands) and superiorly under mandible. It extends as deep process anteriorly above mylohyoid
muscle. The upper part of superficial surface of gland lies partly against submandibular depression on
inner surface of mandible and partly on medial pterygoid. The lower part is covered by skin, superficial
fascia, platysma and deep cervical fascia.

Submandibular triangle with submandibular gland

Submandibular gland

48
 Submandibular gland: Capsule

Relations

Tongue

Hyoglossus

Lingual N & Ganglion

XII CN
Facial artery Lingual artery
SMG
Platysma Hyoid
Digastric (Ant belly)
Superficial fascia Investing fascia
Skin
Cervical br of VII CN
Submandibular gland: Relations

The submandibular duct (Wharton’s duct) is 5 cm long. It starts at the deep surface of the gland. It runs
between sublingual gland and genioglossus and opens on a small papilla at the side of frenulum linguae.

Submandibular gland: Deep part and duct

49
SUBLINGUAL GLAND
This almond-shaped paired salivary gland is under mucous membrane of the floor of mouth, beneath the
tongue. It is a mucus gland. Sublingual duct opens in the flour of mouth.

Relations
Inferiorly- mylohyoid
Posteriorly- submandibular gland
Laterally- mandible
Medially- genioglossus

SUBMANDIBULAR GANGLION
This parasympathetic ganglion provides secretomotor innervation to submandibular, sublingual and
anterior lingual glands.
Topographically, it is related to lingual nerve (V-3) and functionally to VII CN.
Preganglionic parasympathetic impulses arise from superior salivatory nucleus; carried successively
in nervous intermedius, chorda tympani and lingual nerve.
Postganglionic parasympathetic impulses are carried to submandibular gland via direct branches
from the ganglion. For sublingual gland, impulses run in one of the roots of lingual nerve.

Submandibular ganglion

MUSCLE IN THE REGION

Mylohyoid- Muscles of both sides form floor of mouth (diaphragm of oral cavity). It arises from
mylohyoid line of mandible and inserted into hyoid; supplied by mylohyoid nerve (branch of mandibular
nerve). It raises hyoid and tongue.
Digastric- Anterior belly arises from digastric fossa of mandible and inserted into hyoid; supplied by
nerve to mylohyoid. It opens jaw and draws hyoid forward. Posterior belly arises from mastoid notch of
temporal bone and inserted into hyoid; supplied by facial nerve. It draws back and raises hyoid.
Geniohyoid arises from symphysis menti and inserted into body of hyoid; branch of C-1 nerve supplies it.
It draws hyoid and tongue forward.
Stylohyoid arises from styloid process and inserted into hyoid; supplied by facial nerve. It draws hyoid up
and back.

CLINICAL ANATOMY
Submandibular calculi
The mucoid secretion causes sluggish flow in the duct. This with course of duct may result in formation of
calculi. The calculus in duct is felt in the floor of mouth bimanually.

50
 CHAPTER- 15

PHARYNX AND SOFT PALATE

PHARYNX
This fibromuscular tube (lined with mucous membrane) extends from base of skull to lower border of
cricoid cartilage (C-6). It is 12-14 cm long. It is situated in front of cervical vertebrae. At lower border of
cricoid, it continues with oesophagus.
Pharynx functions as a passage for respiratory and digestive tracts.
It presents:
 Openings of auditory tubes
 Openings of two posterior nares
 Opening into larynx
 Opening into oesophagus
It also contains pharyngeal tonsils, palatine tonsils and lingual tonsils.
Pharynx is divided into:
 Nasopharynx
 Oropharynx
 Laryngopharynx

Sagittal section of head & neck

NASOPHARYNX
It is a part of respiratory tract, situated posterior to nasal cavity above and behind the soft palate. It
communicates through pharyngeal isthmus with oropharynx. In lateral wall, it shows opening of
pharyngotympanic tube about half inch behind inferior nasal concha; opening is guarded by tubal
elevation. Salpingopharyngeal fold is a ridge of mucous membrane that extends from posterior margin of
tubal elevation to sidewall of pharynx downwards. This fold contains salpingopharyngeus. Behind
salpingopharyngeal fold is a narrow vertical depression called pharyngeal recess. The roof and posterior

51
wall of nasopharynx form a continuous slope. Under mucous membrane is nasopharyngeal tonsil
(lymphoid tissue).

OROPHARYNX
This is common to both respiratory and digestive systems; situated behind mouth and tongue. The
oropharyngeal isthmus communicates it with oral cavity. Its posterior wall is smooth and lateral walls
shows palatine tonsils placed between palatoglossal and palatopharyngeal arches.

LARYNGOPHARYNX
It lies behind larynx. Its upper part is common to digestive and respiratory tracts while lower part
continues with oesophagus. The anterior and posterior walls are approximated except when food is
passing. Anterior wall from above downwards presents epiglottis, arytenoids and cricoid, aryepiglottic
folds, inlet of larynx and pyriform fossa.

Muscles of pharynx
They differ from rest of musculature of gastrointestinal tract:
 are skeletal muscles
 longitudinal muscles are placed inside
 circular muscles (constrictors) are incomplete anteriorly; arranged in three layers overlapping each
other
Longitudinal muscles
The longitudinal muscles of pharynx are stylopharyngeus, salpingopharyngeus and palatopharyngeus;
attached to posterior border of thyroid cartilage. They help in second stage of deglutition by lifting the
pharynx.

Pharyngeal muscles

The constrictors of pharynx are superior, middle and inferior.

Superior constrictor is attached to pharyngeal tubercle while lowest fibers reach up to level of vocal
cords. The space between base of skull and upper fiber (space of Morgagni) is occupied by auditory
tube and tensor and levator palati.
Middle constructor arises from stylohyoid ligament, lesser & greater cornu of hyoid. The fibres
overlap superior constrictor and reach upto level of vocal cords. Stylopharyngeus and IX CN pass
between superior constrictor and middle constrictor.
52
Inferior constrictor has thyropharyngeus & cricopharyngeus parts. Thyropharyngeus overlaps middle
constrictor. Cricopharyngeus continues with other side. Superior laryngeal nerve and vessels appear in
the space between middle constrictor and inferior constrictor. The space between inferior constrictor and
oesophagus is occupied by recurrent laryngeal and inferior laryngeal vessels.

Constrictors of pharynx

Longitudinal muscles of pharynx and spaces between them

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 CHAPTER- 16

SOFT PALATE AND PALATINE TONSIL

SOFT PALATE
This musculomembranous structure separates nasopharynx from oropharynx. Anteriorly, it continues with
hard palate while its posterior border is free. In the middle from its posterior border, uvula hangs.
Laterally it blends with sidewalls of pharynx.
Structure
From oral surface to pharyngeal surface, it consists of
 mucous membrane with stratified squamous epithelium
 mucous glands
 layer of muscle (palatoglossus)
 palatine aponeurosis
 layer of muscles (levator palati and palatopharyngeus)
 mucous membrane (respiratory type)
Oropharyngeal isthmus is bounded by:
Above - soft palate
Below - tongue
Sides - palatoglossal arch

Sagittal section: Head & neck

Pharyngeal tonsil (lymphoid tissues) are on the posterior wall of nasopharynx behind posterior nares.
During childhood, these often enlarge and block passage of air from nasal cavity into pharynx. This
prevents child from breathing through the nose.

PALATINE TONSIL
These paired lymphoid tissues are between palatoglossal and palatopharyngeal arches on each side of
fauces. These (covered with mucous membrane) contain numerous lymphoid follicles and many crypts.

54
 Palatine tonsil

Tonsil: Deep relations

Blood supply of palatine tonsil

Palatine tonsil has rich blood supply from neighbouring arteries.
 anteriorly – dorsal lingual
 inferiorly – facial
 posteriorly – ascending pharyngeal
 superiorly – lesser palatine
 laterally – facial
The venous return is by venous plexus placed on the capsule laterally. The veins drain into lingual vein;
some connected to pharyngeal venous plexus. Paratonsillar vein runs down from soft palate; pierces
superior constrictor in the tonsillar bed and joins pharyngeal plexus. It may be the chief source of bleeding
in tonsillectomy.

55
 Arterial supply of tonsil

DEGLUTITION
Swallowing (deglutition) is completed in three stages:
First stage is voluntary; intrinsic muscles of tongue push bolus against hard palate towards oropharynx.
Second stage: later part of this stage is involuntary. To prevent regurgitation of food into nasopharynx:
 Nasopharyngeal isthmus is narrowed by raising of soft palate by tensor palati and levator palati
climbing on palatopharyngeal fold
 Oropharyngeal isthmus is narrowed by raising of posterior part of tongue by styloglossus and
palatoglossus
 Closure of laryngeal inlet- epiglottis is raised and bends to prevent descent of bolus into posterior
part of laryngopharynx. Aryepiglotticus and longitudinal muscles of pharynx cause change in the
position of epiglottis.
Third stage is involuntary. It permits ford bolus to enter oesophagus by rhythmic contractions of
constrictions of pharynx. Propulsive action of thyropharyngeus helps in entry of bolus into oesophagus.

APPLIED ANATOMY
Peritonsillar abscess (Quinsy)
It is an infection of tissue between tonsil and pharynx results usually after acute follicular tonsillitis.
Quinsy is drained by an incision in the most prominent part of abscess.

Tonsillitis

Cleft palate
Palate develops by fusion of two horizontal plates of maxillary process and frontonasal process. Any
derangement in this fusion can lead to different grades of cleft lip and cleft palate.

56
Cleft lip (Hare lip)
It is a congenital anomaly consisting of one or more clefts in the upper lip. This results from failure of
fusion of maxillary and median nasal processes in the embryonic life.

Killian’s dehiscence & pharyngeal diverticulum

Posteriorly between thyropharyngeus and cricopharyngeus of inferior constrictor, there is a gap called
killian’s dehiscence. Through this gap, mucosa of pharynx may protrude posterolaterally called
pharyngeal diverticulum. It is because of neuromuscular incoordination.

Pharyngeal pouch

Retropharyngeal abscess
Acute abscess arise from enlarged retropharyngeal lymph nodes. Hence, acute abscess in front of
prevertebral fascia would appear as paramedian swelling. Chronic retropharyngeal abscess usually
originates from tuberculosis of cervical vertebrae. The swelling is behind the prevertebral fascia and
appears as midline swelling. Subsequently abscess gravitates under prevertebral fascia in posterior
triangle, superior mediastinum or axilla (along axillary sheath).

Adenoids
At the junction of roof and posterior wall of nasopharynx, collection of lymphoid tissue in the midline is
pharyngeal tonsil; part of Waldayer’s ring. Its enlargement in children causes obstruction of posterior
nasal aperture, reflected as adenoid facies.

Tonsillitis & tonsillectomy

Infections of tonsil (tonsillitis) are common in children. Repeated episodes of tonsillitis may lead to
paratonsillar abscess. Tonsillectomy is indicated in chronic tonsillitis. Tonsils can be removed by
guillotine or dissection method.

57
 CHAPTER- 17

NASAL CAVITY
NASAL SEPTUM
It is formed by:
Bones - perpendicular plate of ethmoid and vomer
Cartilages - septal cartilages
Cuticular part - fibrofatty tissue
The epithelium in upper part is olfactory and remaining is respiratory (pseudostratified).

Nasal septum
Nerve supply
Olfactory region - olfactory nerve
Anterosuperior part - anterior ethmoidal nerve  nasociliary  V-1
Posteroinferior part- branches of maxillary nerve V-2
Anteroinferior part - infraorbital branch of maxillary nerve V-2
Thus, branches of maxillary nerve predominantly supply nasal septum.

Blood supply
Anterosuperior part - anterior ethmoidal artery
Anteroinferior part - septal branches of facial artery
Posteroinferior part - greater palatine and sphenopalatine arteries

Nasal septum
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LATERAL WALL OF NOSE
It is formed by bones, cartilage and fibrofatty tissue.
Bones - maxilla, ethmoid with superior & middle nasal conchae and inferior nasal concha
Cartilages - upper and lower nasal cartilage and alar cartilage
Cuticular part by fibrofatty tissue
The mucosa is highly vascular to humidity and warm inspired air. The conchae (turbinates) help to
regulate flow of air. The lateral wall comprises from anterior to posterior: vestibule, atria and region of
meati.

Lateral wall of nose: Features

Nerve supply
Above superior concha - olfactory nerve
Anterosuperiorly - anterior ethmoidal  nasociliary  V-1
Anteroinferiorly - anterior superior alveolar  V-2
Posterosuperiorly - branches from pterygopalatine ganglion
Posteroinferiorly - branches from pterygopalatine ganglion

Blood supply
Lateral wall receives blood supply mainly from branches of maxillary artery.
Anterosuperior - anterior ethmoidal  ophthalmic artery
Anterosuperior- alar branch of facial artery & branch from greater palatine artery
Posterosuperior - sphenopalatine artery  maxillary (third part)
Posteroinferior - greater palatine artery  maxillary (third part)
The venous plexus lies over inferior and middle conchae; connected to cerebral vein via ethmoidal vein,
pterygoid venous plexus and anterior facial vein.
59
 Lateral wall of nose

PARANASAL AIR SINUSES

Developmentally, paranasal sinuses are out pouches from the lateral wall of nose, which open in the
lateral wall of nose. These sinuses are frontal sinus, sphenoidal sinus, ethmoidal group of sinuses and
maxillary sinus
After puberty, these sinuses enlarge. These bilateral sinuses are lined by mucous membrane.

PARANASAL AIR SINUSES: SUMMARY

Arterial supply Venous return Lymphatics Nerve supply Opening
FRONTAL Supraorbital Diploic veins SM nodes Supraorbital Summit of
Supratrochlear Superior Supratrochlear infundibulum by
Ant ethmoidal ophthalmic V frontonasal duct
in middle meatus
SPHENOIDAL Post ethmoidal Corresponding Retropharyngeal Post ethmoidal Sphenoethmoidal
Sphenopalatine veins LNs Brs from PPG recess above
superior concha
ETHMOIDAL Supraorbital Corresponding SM nodes Supraorbital Ant group-
GROUP OF Ant ethmoidal veins Retropharyngeal Ant ethmoidal anterior wall of
SINUSES Post ethmoidal LNs Post ethmoidal infundibulum
Sphenopalatine Lat post sup Post group-
nasal superior meatus
Middle group-
bulla ethmoidale
in middle meatus
MAXILLAY Brs from facial Facial vein SM nodes Sup alveolar Floor of hiatus
Infraorbital Pterygoid (post, middle & semilunaris in
Greater palatine venous plexus ant) middle meatus
Greater palatine Additional
Infraorbital opening in post
part of hiatus
semilunaris

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 Paranasal air sinuses

Functions of PNS
• Growth is important: alters size & shape of face during infancy & childhood
• Impart resonance to voice
• Insulators to regulate temperature of inhaled air
• Humidify inspired air
• By their shape they help to determine position of orbital cavities & hence eyes
• May contribute in reducing skull weight

Maxillary sinus (largest) is present since birth (all other sinuses start appearing after 6th year of life).
Osteum of Maxillary sinus is reduced by
• From above: ethmoidal (uncinate) process
• From front: lacrimal bone (descending part)
• From below: inferior nasal concha
• From behind: palatine bone (perpendicular plate)

Openings of paranasal sinuses

Sphenoidal air sinus - sphenoethmoidal recess
Posterior ethmoidal sinus - superior meatus
Middle & anterior ethmoidal sinuses - middle meatus under bulla ethmoidale
Maxillary sinus - hiatus semilunaris of middle meatus
Frontal sinus - infundibulum of middle meatus
The inferior meatus receives nasolacrimal duct.

CLINICAL ANATOMY

Little’s area and epistaxis

At anteroinferior part of nasal septum, lies Little’s area (Kieselbach’s area). This area has rich
anastomosis; formed by anterior ethmoidal artery, sphenopalatine artery, septal branch of superior labial
branch of facial artery and greater palatine artery. The bleeding through nose (epistaxis) result because of
rupture of vessels due to various causes, namely, sudden rise in blood pressure, high temperature and high
attitude.
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Sinusitis
Inflammation of mucosal lining of paranasal sinuses is sinusitis. The swelling of nasal mucous membrane
blocks openings of sinuses to nasal cavity. This results in an accumulation of sinus secretions. Maxillary
sinusitis requires surgical intervention to drain stagnated inflammatory exudates by making an opening
through incisive fossa called Caldwel Luc operation. Drainage of maxillary sinus is via enlarging its
opening (hiatus semilunaris) is antrum puncture.

Deviated septum
Here there is a shift in the partition (nasal septum) of nasal cavity. Severe deflection of septum obstructs
nasal passage; may result in sinusitis, breathlessness and recurrent epistaxis. It is corrected by septoplasty.

Nasal polyp is rounded and elongated mucosal mass projecting into the nasal cavity. It is an important
cause of nasal obstruction.

Nasogastric intubation is placement of a nasogastric tube through the nose into stomach to relieve
gastric distention by removing gas or gastric secretions or instill medication, food or fluids. This is used in
conditions where the person is able to digest food but not able to eat.

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 CHAPTER- 18

TONGUE

Tongue is composed of muscles (extrinsic & intrinsic), fat & glands with covering of mucous
membrane. A thin median fibrous septum divides the tongue into right and left halves.

Tongue: Gross features

Gross features
The tongue is consists of root, tip and the body.
Root (formed by muscles & mucous membrane) is fixed to hyoid, mandible, pharynx, epiglottis and
palate.
Body has pharyngeal and oral parts. Oral part is rough; caused by papillae. Sulcus terminalis (V shaped
groove) separates oral part from the pharyngeal part. The apex of groove points backwards and shows
foramen caecum. The inferior surface of free part of tongue has smooth mucous membrane. Frenulum
connects it to the floor of mouth in the midline. On either side of frenulum, deep lingual vein is seen
through the mucous membrane. Still laterally fringed fold called fimbriated fold is present under which
deep lingual artery is located. Pharyngeal part is directed backwards into the pharynx. Its mucous
membrane is smooth and presents lingual tonsil. It is connected to epiglottis by median glossoepiglottic
fold (fold of mucous membrane). Apex and margins of tongue are free; are in contact with teeth.

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 Tongue: Features

Extrinsic muscles move tongue- styloglossus, hyoglossus, genioglossus & palatoglossus.

Intrinsic muscles alter shape of tongue- superior & inferior longitudinal, vertical & transverse.

Tongue: Extrinsic muscles

Papillae of tongue
The sulcus terminalis divides dorsum of tongue into anterior two third and posterior one third. The
anterior two third (oral part) presents following papillae:
Filiform are arranged posteriorly in rows parallel to sulcus terminalis; irregularly placed anteriorly
Foliate (five or six vertical folds) are along the margins in front of palatoglossal arch
Fungiform are numerous; found mainly at apex and margins
Circumvallate are about ten; placed anterior and parallel to sulcus terminalis. Taste buds line its walls.

Blood supply
Lingual artery is main artery; arises from ECA in carotid triangle. It runs deep to hyoglossus. It divides
into branches, supplies tongue and surrounding muscles. Branches of lingual artery are suprahyoid,
dorsal lingual, sublingual and deep lingual.
Deep lingual vein is formed by dorsal lingual veins, which drain into IJV.

Lymphatic drainage
From tip & lower surface - submental nodes
From margins - submandibular lymph nodes

64
From posterior one third, lymph vessels drain into jugulodigastric nodes
From dorsum of tongue, lymph vessels drain into submandibular nodes
Juguloomohyoid nodes receive lymphatics from submandibular lymph node, which receives lymph from
submental lymph nodes.

Tongue: Blood supply & lymphatic drainage

Nerve supply
Motor - All muscles (except palatoglossus) are supplied by hypoglossal nerve (XII CN).
Sensory –
Anterior two third- general sensations are carried in lingual nerve and taste sensations are carried by
chorda tympani.
Posterior one third including circumvallate papillae-general and taste sensations are carried in
glossopharyngeal nerve (IX CN).
Posteriormost part is supplied by internal laryngeal nerve - branch of vagus (X CN).

Tongue: Nerve supply

65
APPLIED ANATOMY
Thromboses of anterior spinal artery may involve:
 12th nerve nucleus- LMN ipsilateral paralysis
 Medial lemniscus- loss of conscious proprioceptive sensations on contralateral side
 Pyramid- UMN paralysis on contralateral side

Unilateral lesion of XII CN

Action of contralateral, unparalyzed genioglossus is unopposed. Thus, tongue deviates toward the side
of nerve lesion on protrusion.

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 CHAPTER- 19

LARYNX
Introduction
This (air passage) connect pharynx with trachea. It is also the organ of voice production. Functionally it
is concerned with passage of air, phonation and in third stage of deglutition. It forms lower part of
anterior wall of pharynx. It extends from C-4 to C-6 vertebrae. It is higher in female and during
childhood. Anterolaterally it is related to thyroid gland and infrahyoid strap muscles.

Larynx: Gross features

Structure
Cartilages form framework of larynx. Membranes & ligaments join cartilages. They have joints to
permit movement, carried by laryngeal muscles. It is lined by mucous membrane.
Cartilages
 three unpaired: epiglottis, thyroid & cricoid
 three paired: arytenoid, corniculate & cuneiform

67
 Larynx: Cartilages

Ligaments & membranes

Extrinsic ligaments are thyrohyoid membrane and cricothyroid membrane.
Intrinsic ligaments are quadrate ligament and conus elasticus

Thyrohyoid membrane

Quadrate ligament - Anterolaterally, it is attached to margins of epiglottis and posteriorly to arytenoid

cartilage. It bounds vestibule of larynx laterally.
Conus elasticus extends between vocal folds and upper margin of cricoid cartilage. It is anchored
anteriorly to thyroid cartilage and cricothyroid membrane and posteriorly to base of arytenoid cartilage.
Internally it bounds cavity of larynx.

Interior of larynx
It shows two pairs of shelf like projections- upper vestibular and lower vocal folds.

68
 Laryngeal cavity
Components of larynx
 Vestibule is above vestibular folds (supraglottic)
 Ventricle (glottic) is a narrow space between vestibular and vocal folds; extends laterally as sinus
of larynx
 Cavity of larynx (infraglottic) lies below vocal folds
Rima glottidis- space between two vocal folds having intermembranous and intercartilaginous parts.
Rima vestibuli- space between two vestibular folds

Larynx: interior

69
 Laryngeal cavity

Muscles of larynx
Extrinsic muscles move larynx as a whole.
Muscles pull up hyoid & thyroid cartilage
 Digastric (both bellies)
 Mylohyoid
 Geniohyoid
 Thyrohyoid
 Stylohyoid
Muscles pull up thyroid cartilage
 Thyrohyoid
 Stylopharyngeus
 Palatopharyngeus
 Salpingopharyngeus
Muscles depress larynx
 Sternohyoid
 Sternothyroid
 Superior belly of omohyoid

Extrinsic muscles of larynx

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Intrinsic muscles bring change in position of vocal cords.
Lengthening of vocal cords
 Cricothyroid
 Vocalis
Abduction of vocal cords
 Posterior cricoarytenoid
Adduction of vocal cords
 Thyroarytenoid
 Lateral cricoarytenoid
They reduce intermembranous part of rima glottidis; intercartilaginous part of rima glottidis is widened.
Interarytenoids (transverse & oblique) reduces intermembranous and intercartilaginous parts of rima
glottidis
Depression of epiglottis
 Aryepiglotticus
 Thyroepiglotticus

Laryngeal muscles

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 Larynx: Intrinsic muscles
True vocal cord are two bands of yellow elastic tissue enclosed by vocal folds. These extend from
angle of thyroid cartilage to vocal process of arytenoid cartilage.
False vocal cords are folds of mucous membrane that separate ventricle from vestibule. Each fold
encloses ventricular ligament.

Rima glottidis
Joints of larynx
Cricothyroid joint is between inferior horn of thyroid cartilage and lateral aspect of cricoid cartilage. It
is hinge variety of synovial joint. The movements occur in transverse axis. There is tilting of cricoid
cartilage backwards; caused by cricothyroid, which is tensor of vocal cord.
Cricoarytenoid joint is between base of arytenoid cartilage and lamina of cricoid cartilage. It is plane
variety synovial joint. The movements are in vertical axis. Rotation of arytenoid cartilage causes change
in dimension of intercartilaginous part of rima glottidis. Muscles are posterior & lateral cricoarytenoids.
Gliding of arytenoid cartilage over lamina of cricoid cartilage causes tensing of vocal cords; caused by
vertical fibers of posterior cricoarytenoid. The arytenoid cartilages are approximated by interarytenoids
to reduce intercartilaginous gap of rima glottidis (adduction).

Larynx: Joints
Piriform fossa is a depression of mucosa lateral to vestibule of larynx. Laterally it is bounded by
thyroid cartilage and thyrohyroid membrane. Medially aryepiglottic fold and epiglottis separate it from

72
laryngeal orifice. This fossa is a potential space for foreign bodies. An attempt to remove foreign body
from this fossa can cause damage to internal laryngeal nerve, which is deep to it. Damage to internal
laryngeal nerve may predispose to aspiration pneumonia, as sensations are lost in supraglottic part of
larynx.

Nerve & blood supply

Vocal cords demarcates area of arterial supply and sensory nerve supply
Above the vocal folds
Arterial supply- superior laryngeal artery (branch of superior thyroid artery)
Venous return- superior laryngeal vein (tributary of superior thyroid vein)
Nerve supply- internal laryngeal nerve (superior laryngeal nerve branch of XCN)

Below the vocal folds

Arterial supply- inferior laryngeal artery (inferior thyroid artery)
Venous return- inferior laryngeal vein (tributary of superior thyroid vein)
Nerve supply- recurrent laryngeal nerve branch of vagus (X CN)

All the intrinsic muscles of larynx are supplied by recurrent laryngeal nerve except cricothyroid-
innervated by external laryngeal nerve.

Lymphatic drainage
This is demarcated by vocal folds.
Above vocal folds lymphatics travel along superior laryngeal artery to drain into anterosuperior group of
deep cervical nodes
Below vocal folds lymphatics pierce thyrohyroid membrane and drain into posteroinferior group of deep
cervical nodes

CLINICAL ANATOMY

Laryngeal oedema
It is caused by fluid accumulation in larynx; usually inflammatory which may result from an infection,
injury, or inhalation of toxic gases. In infections (diphtheria), there is accumulation of inflammation
exudates, under mucous membrane of vestibular folds. This oedema can approximate vestibular folds
and cause difficulty in breathing.

Laryngoscopy
To view interior of larynx is laryngoscopy. Indirect laryngoscopy is OPD procedure. Here, image of
larynx is seen in a mirror indirectly. Structures visualized from above downwards are posterior 1/3 of
tongue, valleculae, epiglottis, laryngeal inlet, interior of larynx, piriform fossa and posterior pharyngeal
wall. Direct laryngoscopy is by laryngoscope; performed under general anesthesia.

Cafe coronary phenomenon

Eating and talking at the same time can cause entry of food bolus into the larynx. It leads to choking
symptoms like coughing and difficulty in breathing. It may prove fatal. Since such an episode is
commonly seen in at an eating-place, called coronary phenomenon. It is a misnomer as there is no
primary cardiac lesion.

Singer’s nodule (Vocal cord nodule) is a small inflammatory or fibrous growth that develops on
the vocal cords of people who constantly strain their voices. These are bilateral and usually affect
singers.

Heimlich maneuver
Foreign bodies may get lodged in rima glottidis to cause laryngeal obstruction. The individual gets
asphyxiated. It requires an emergency procedure to dislodge foreign body. Compression of abdomen
raises diaphragm, which compresses lungs, thereby expelling air from lungs up the trachea to dislodge
foreign body from rima glottidis called Heimlich maneuver.
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 CHAPTER- 20

ORBIT

The bony orbit is a four-sided pyramid. The medial walls are parallel to each other while lateral walls
are at right angle.
Boundaries
Base is towards the face; bounded by orbital margin. It is formed by frontal, zygomatic and maxilla
Apex is in the depth and medial to superior orbital fissure
Roof - orbital plate of frontal and lesser wing of sphenoid
Lateral wall - greater wing of sphenoid and frontal process of zygomatic bone
Medial wall - frontal process of maxilla, lacrimal, orbital plate of ethmoid and side of body of sphenoid

Openings in orbit
Inferior orbital fissure - between lateral wall and floor
Superior orbital fissure - between roof and lateral wall
Optic canal - between roof and medial wall

Superior orbital fissure

Contents
Eye-ball with its extraocular muscles and associated nerves and vessels
Nerves: II, III, IV and VI cranial nerves
Vessels: ophthalmic artery and its branches, superior & inferior ophthalmic vein
Fat
Fascial sheath, cheek ligaments and suspensory ligaments
Lacrimal apparatus
Ciliary ganglion

Extra-ocular muscles
These are four recti, two obliqui and levator palpabrae superioris (LPS). The eyeball moves in three
axes. All muscles except medial rectus (MR) and lateral rectus (LR) act on all the three axes. Medial
and lateral recti act only in vertical axis.
Abduction & adduction take place in vertical axis. Abductors are MR, superior rectus (SR) and inferior
rectus (IR). Abductors are LR, superior oblique (SO) and inferior oblique (IO).
Elevation & depression take place in horizontal axis. The elevators are SR and IO. The depressors are
IR and SO.
Intorsion & extorsion take place in anteroposterior axis. In intorsion cornea rotates from 12 O’clock
position to 3 O’clock and its opposite movement is extorsion. Intorsion is caused by SO and SR while
extorsion is caused by IO and IR.

74
 Actions of extraocular muscles

Frontal air sinus

Superior oblique

Superior rectus
Optic nerve
Lateral rectus Cornea
Sclera
Inferior rectus Inferior oblique

Extraocular muscles of eyeball

75
 Medial rectus
Lateral rectus

Trochlea

Axis of centre of eye

Superior rectus
Superior oblique

Inferior rectus
Medial rectus

Lateral rectus
LPS

Optic nerve

Extraocular muscles of eyeball

Venous drainage of orbit

Superior and inferior ophthalmic veins are connected to cavernous sinus. Over the face, they receive
supraorbital, supratrochlear and angular vein. Thus, these act as emissary veins, capable of transmitting
superficial infection of face to cavernous sinus causing cavernous sinus thrombosis, which may prove
fatal.

CLINICAL ANATOMY
Squint (Strabismus)
Here one eye deviates from the fixation point. In convergent squint, unopposed action of medial rectus
causes cornea to direct medially. In divergent squint, unopposed action of lateral rectus causes
abduction of eyeballs. Paralytic squint results from inability of ocular muscles to move eye because of
neurologic deficit or muscular dysfunction. Nonparalytic squint is a defect in the position of two eyes in
relation to each other.

Pulsating eyeball
A communication between internal carotid artery (ICA) and cavernous sinus (carotid cavernous
aneurysm) leads to pulsating and bulging eye-ball.

Ptosis
The eyelid droops because of a congenital or acquired weakness of levator palpabrae superioris muscle
or paralysis of III CN (oculomotor nerve). Partial ptosis may be caused by disorder of sympathetic part
of autonomic nervous system.

Argyll Robertson pupil

It is characterized by pupil constriction on accommodation but not in response to light; seen in advanced
neurosyphilis.

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Cavernous sinus thrombosis
It is generally secondary to infections near the eye or nose. This is characterized by palsy of III, IV and
VI cranial nerves, which supply extraocular muscles, resulting in ophthalmoplegia.

Horner’s syndrome
It is seen after cervical sympathectomy for improving blood flow to distal parts of upper limbs
(Raynaud’s disease). The symptoms are also observed in klumpke’s paralysis where lower trunk of
brachial plexus is affected.
Symptoms:
Flushing of face due to dilatation of cutaneous blood vessels
Anhidrosis due to loss of secretions of sweat glands of face
Ptosis is drooping of upper eyelid marginally because of paresis of smooth muscle part of levator
palpabrae superioris (LPS)
Enophthalmos (sinking of eyeball in orbit) is due to paralysis of Muller’s muscle- supplied by
sympathetic fibres
Miosis (constriction of pupil) is due to interruption in nerve supply to dilator pupillae

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 CHAPTER- 21

THE EAR

The ear comprises external ear, middle ear & internal ear

Ear: Parts
EXTERNAL EAR
It consists of pinna (auricle) and external acoustic meatus.

External ear

External ear

External auditory canal

External ear: parts

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External acoustic meatus is one inch long. Its lateral one-third is cartilaginous; medial two-third is
bony. It shows two bends: lateral bend is at the junction of cartilaginous and osseous part; medial bend
is 5 mm from lateral wall of middle ear (tympanic membrane). In infants, external acoustic meatus is
very short and narrow.
It is supplied by great auricular nerve, auriculotemporal nerve and X CN.

MIDDLE EAR
Middle ear is a six-walled cavity in petrous temporal bone. Its lateral wall separates it from external
ear. Medial wall is related to internal ear. Anterior wall is connected to pharynx through auditory tube.
Posteriorly it opens into mastoid antrum leading into mastoid air cells. Roof is formed by tegmen
tympani separating it from meninges covering temporal bone. Floor has ICA anteriorly placed and bulb
of IJV posteriorly.
Dimensions:
 Height & length: 15 mm
 Roof & floor: 6 mm & 4 mm respectively
 In middle: 2 mm wide
Contents:
 Tympanic ossicles (malleus, incus & stapes)
 Ligaments and muscles attach to ossicles
 Chorda tympani and tympanic plexus
Epitympanic recess (above level of tympanic membrane) contains greater part of incus and upper half of
malleus.

Ear ossicles
Features:
 their size remain constant
 they show presence of marrow cavity
 they help in conduction of sound
Malleus (8 mm long) has head (lies in epitympanic recess), neck, lateral process, handle and anterior
process that give attachment to anterior ligament of malleus. Incus- Its body is large (lies in
epitympanic recess) gives posteriorly short crus and inferiorly continuous as long crus. Stapes has head,
neck, crus and a footplate. Stapedius is attached on the posterior surface of neck.

Ear ossicles and their joints

Muscles acting on ear ossicles
Tensor tympani tenses tympanic membrane by pulling it medially
Stapedius pulls the stapes laterally; deepens the sound

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 Malleus

Incus

Epitympanic recess

Stapedius
Stapes
Tensor tympani
Tympanic membrane

Auditory tube

Tympanic membrane
Tympanic membrane
This pearl grey coloured membrane is one cm in diameter with 50-degree angle with external acoustic
meatus. Its periphery is attached to bony sulcus except in upper part. The handle and lateral process of
malleus are embedded in it. The mallear folds extend from lateral process to tympanic sulcus. Its parts
are pars flaccida (enclosed by mallear folds) and pars tensa. The tympanic membrane has outer cuticular
layer, middle fibrous layer and inner patchy ciliated layer.
Nerve supply
Lateral surface - auriculotemporal nerve and branch from vagus nerve
Medial surface - tympanic branch of glossopharyngeal nerve and chorda tympani

Pharyngotympanic tube (auditory tube/Eustachian tube)

This trumpet shaped tube (1.5 inch long) is directed forwards, downwards and medially. It extends from
anterior wall of tympanic cavity to opens in the lateral wall of nasopharynx. It has bony and
cartilaginous parts. Osseous part (half inch long) is in temporal bone. Cartilaginous part (one inch
long) is in the groove between greater wing of sphenoid and petrous temporal bone. The tensor palati
arises from its anterolateral surface. The posteromedial surface gives attachment to levator palati. At its
pharyngeal orifice is pharyngeal tonsil.
Nerve supply- tympanic plexus and branches from pterygopalatine ganglion
Function- During deglutition, tube in opened by muscles attached to it. This equalizes pressure
between nasopharynx and tympanic cavity.

INTERNAL EAR
The spiral organ (of Corti) is composed of supporting cells; interspersed with hair cells (sensory end
organs).
The hair cells are in rows of inner and outer hair cells. The free surface of each hair cell is covered with
clumps of hair. The ends of hairs are embedded in tectorial membrane.
The wave of perilymph through scala induces movement in basilar membrane. Vibrations of basilar
membrane cause a pull on hair cells attached to tectorial membrane. This action transforms mechanical
energy into electric impulses. This stimulates fibres of cochlear nerve (of VIII CN) to produce action
potentials. This action potential is responsible for transmission of nerve impulses to the brain. Hair cells
transmitting specific frequencies are arranged together.
Each hair cell is supplied by at least one nerve fibre. A single neuron supplies ten outer hair cells while
each inner hair cell is supplied by twenty neurons. This overlap of nerve connections is important for
functional flexibility and allows compensation for damage to single hair cells or certain neurons.

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 ICA Auditory tube
Cochlea

Cochlear N.

Facial N. Lat. Semicircular canal

Ant. Semicircular canal

Post. Semicircular canal

Vestibular N.
Vestibule

Internal ear

Ear: Schematic diagram

Semicircular canals
Vestibular nerve

Cochlear nerve
Ear ossicles

TM 8th CN
Ext. auditory meatus

Cochlea
Vestibule
Int. acoustic meatus

Internal ear and vestibulocochlear nerve

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CLINICAL ANATOMY
Tympanic reflex
It is the reflection of a beam of light shining on the tympanic membrane. In normal ear, a bright wedge-
shaped reflection is seen with its apex is at the end of malleus and its base is at anterior inferior margin
of tympanic membrane. In diseases of middle ear or tympanic membrane, this shape is distorted.

Syringing
The wax like ear secretion gets hardened to block external acoustic meatus thus causing hearing
impairment. To remove this hardened wax, lukewarm water is injected slowly into external auditory
meatus. This is to avoid stimulation of vagus nerve, which may cause vaso-vagal attack.

Myringotomy (Tympanotomy)
It is making an opening in tympanic membrane. This is carried out to drain collected pus in middle ear.
Incision is given in posteroinferior quadrant of tympanic membrane.

Otitis media
It is the infection of middle ear; common in children. It is often preceded by upper respiratory tract
infection. The infection may spreads to meninges causing meningitis.

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 CHAPTER- 22

THE EYE

This organ of special sense is almost spherical (one inch in diameter); situated in the anterior part of
orbit.

Fascia bulbi (Tenon's capsule)

It envelops eyeball from optic nerve to ciliary region; allows eyeball to move freely. It has a smooth
inner surface pierced by vessels and nerves. It fuses with sheath of optic nerve and sclera. The lower
part of membrane thickens into suspensory ligament (checks ligaments) which attaches to zygomatic
arch and lacrimal bones.

Orbital fascia

Check ligaments & suspensory ligament

Structure of eyeball
It has three coats:
Outer fibrous coat is composed of sclera and cornea.
Middle vascular coat comprises choroid, ciliary body and iris.
Inner nervous coat consists of retina.
Refracting media from anterior to posterior are cornea, aqueous humour, lens and vitreous body.

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 Eyeball: Structure

Optic & orbital axes

Cornea is half-inch wide convex and transparent layer. Anterior chamber separates it from iris. It is
avascular; nourished by lymph and has rich nerve supply. Its junction with sclera is limbus.
Sclera is white part of eye is covered with conjunctiva. It provides attachments to tendons of recti and
obliqui. It is pierces by numerous nerves and vessels.
Choroid lines sclera and separates it from retina. It consists of pigmented tissue containing nerve
plexuses, network of capillaries, arteries and superficially veins.
Ciliary body connects choroid with iris. It is made up of ciliary processes (internally) and ciliary
muscle (externally). Ciliary processes are radially arranged folds that lie behind the periphery of iris.
They form a flat ring with free and rounded central ends.

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Ciliary muscle is a muscular ring placed deep to anterior part of sclera. It is made up of radial and
circular fibres. The ciliary muscle is brought into action during accommodation e.g. it slackens
suspensory ligament of lens and make it move convex as is required for near vision.
Iris is behind the cornea and in front of lens. It is a circular, colored and contractile curtain. Its central
aperture is pupil whose margins rest on lens while its peripheral margin continues with ciliary body. It is
made up of smooth muscle called sphincter pupillae and dilator pupillae.
Retina has two components. Pigmented layer (external layer) is attached to choroid and continues over
ciliary body to iris. Retina proper (internal layer) is in contact with vitreous. Ora serrata divides it into
posterior optic part and anterior ciliary part.
Ora serrata is a wavy border behind the ciliary body. Posterior to this, retina contains nervous elements
while anterior to this there is thin layer of columnar cells over ciliary body to iris.
Macula lutea is a small yellowish spot at posterior pole of eyeball on retina. It presents fovea centralis.
Optic disc- Here, optic nerve fibers converge to leave eyeball; 1 mm below and 3 mm medial to
posterior pole. Its circumference is raised while its centre is depressed called optic cup. The disc is the
blind spot of eye as it lacks nervous elements.
Lens is transparent and circular. It is 10 mm in diameter and 4 mm thick. It is biconvex placed on
vitreous anteriorly; behind the iris and pupil.
Anterior chamber is the space between cornea anteriorly & iris and central part of lens posteriorly.
Posterior chamber is behind iris and suspensory ligament and adjoining part of lens posteriorly. The
two chambers communicate through pupil; filled with a clear fluid called aqueous humour.
Vitreous humour (vitreous body) is transparent and jelly like substance that fills posterior 4/5 of eyeball.
It is enclosed in a transparent membrane (hyaloid membrane). It consists of aqueous humour and loose
vitreous fibrous stroma. The vitreous humour is concave anteriorly to accommodate lens and closely
applied to retina around the wall of eyeball.

CLINICAL ANATOMY
Cataract
It is abnormal progressive condition of lens characterized by loss of transparency. This results in a gray-
white opacity in the lens; most caused by degenerative changes in lens after 50 years of age. Congenital
cataracts are hereditary; may be caused by viral infection during first trimester of gestation. Senile
cataracts are uncomplicated cataracts of old age. Vision is lost if cataracts are not treated.

Retinal detachment
It is the separation of retina from choroid. It results from internal changes in the vitreous chamber
associated with aging of interior of eye. The retina does not contain sensory nerves; thus, condition is
painless. Detachment begins at the thin peripheral edge of retina and extends gradually beneath thicker
central areas. If retinal detachment is not checked, it results in blindness.

Corneal grafting (keratoplasty)

It is the surgical procedure of transplantation of cornea; performed to improve vision in corneal scarring,
distortion or perforation.

Glaucoma
It is an abnormal condition of elevated intraocular pressure because of obstruction of outflow of
aqueous humour.
Acute (narrow angle) glaucoma occurs if the pupil with a narrow angle between the iris and cornea
dilates markedly. This causes folded iris to block the exit of aqueous humour from anterior chamber.
Chronic (wide-angle) glaucoma is more common; often bilateral. The obstruction is in canal of
Schlemm.

Corneal reflex
It is a protective mechanism for eye where eyelids close when cornea is touched. The reflex is mediated
by ophthalmic division of 5th cranial nerve (sensory) and 7th cranial nerve (motor). This reflex is used as
test for integrity of those nerves.

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 CHAPTER- 23

CRANIAL NERVES

Frontal lobe

Olfactory bulb

Olfactory nerve: 1st CN

Olfactory tract Temporal lobe

Optic nerve: 2nd CN
Olfactory trigone
Optic chiasma
Optic tract
Oculomotor nerve: 3rd CN
Trochlear nerve: 4th CN
Pituitary stalk
Pons Trigeminal nerve: 5th CN
Mamillary body
Abducent nerve: 6th CN
Facial nerve: 7th CN
Vestibulocochlear nerve: 8th CN

Glossopharyngeal: 9th CN
Vagus: 10th CN
Cerebellum Accessory: 11th CN
Medulla
Hypoglossal nerve: 12th CN

Cranial nerves: Attachments to base of brain

NERVE COMPONENTS OF CRANIAL NERVES

Motor modalities
• Somatic efferent
• Special visceral efferent (Branchial efferent)
• General visceral efferent
Sensory modalities
• General somatic afferent
• General visceral afferent
• Special visceral afferent
• Special somatic afferent
Each functional component has:
• Nucleus of origin (efferent)
• Nucleus of termination (afferent)
Nuclei of components are in vertical columns in grey matter related to floor of 4th ventricle in sequence
• Each half of floor of ventricle is divided into medial & lateral parts by sulcus limitans
• Basal lamina (medial part) for efferent nuclei
• Alar lamina (lateral part) for afferent nuclei
• In each part visceral nuclei are closer to sulcus than somatic nuclei
• Within subgroup, general nucleus is nearer to sulcus than special nucleus

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 Cranial nerve components

1. General somatic efferent fibres supply striated muscles developing from somites
2. Special visceral (branchial) efferent fibres supply striated muscles of branchial arches:
Muscles of face, mastication, palate, pharynx & larynx
3. General visceral efferent fibres supply glands & smooth muscles of vessels & viscera-
form cranial outflow of PNS
4. General visceral afferent- sensations (distention & ischaemia) from viscera, viz. lung,
heart & upper par GIT & associated glands
5. Special visceral (branchial) afferent fibres- taste sensation from tongue
6. General somatic afferent- general sensations (pain, touch, temperature from skin) &
proprioceptive sensations (vibration, muscle & joint sense)
7. Special somatic afferent fibres- sensations of hearing & equilibrium

Cranial nerve components

FIRST CRANIAL NERVE: OLFACTORY NERVE

It is the nerve of smell. The olfactory nerve is composed of many filaments that ramify in the mucous
membrane of olfactory area of lateral wall and nasal septum.
The fibres of olfactory nerve pass through cribriform plate of ethmoid and unite to form olfactory bulb.
The olfactory bulb continues as olfactory tract.

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 Frontal lobe of cerebrum

Olfactory tract
Olfactory bulb
Cribriform plate of ethmoid

Olfactory rootlets

Nasal mucosa
Olfactory nerve

SECOND CRANIAL NERVE: OPTIC NERVE

It is the nerve of sight. It consists of myelinated fibres that arise in ganglion layer of retina, traverse
thalamus, and connect with visual cortex.
At optic chiasma, fibres from inner (nasal half) of retina cross to optic tract of opposite side. The fibres
from outer (temporal) half of each retina are uncrossed and pass to visual cortex on the same side.
The visual cortex functions in the perception of light and shade and objects.
Optic radiations conduct impulses from lateral geniculate bodies in cerebral hemispheres to visual
cortices.
Parts of optic nerve:
Intraocular part (1 mm long) contains unmyelinated fibers that become myelinated after passing through
lamina cribosa.
Orbital part (25 mm long) is invested by dura, arachnoid and pia mater (meninges).
Within optic canal, nerve lies superior to ophthalmic artery. The meninges covering the nerve are fused to
each other, to nerve and to periosteum of bone. This secures nerve.
Intracranial part is on anterior portion of cavernous sinus in close proximity with ICA.
The optic nerve develops from a diverticulum of lateral portion of forebrain. The optic nerve fibres
therefore correspond to a tract of fibres within the brain.

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 Eyeball

Retina

Optic nerve

Optic chiasma

Optic tract

Lat. Geniculate body

Optic radiation

Visual cortex

Optic pathway

Visual pathways and effects of lesions

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THIRD CRANIAL NERVE: OCULOMOTOR NERVE
Nerve components
Somatic efferent- all extrinsic muscles of eyeball along LPS are supplied except lateral rectus (LR) and
superior oblique (SO).
General visceral efferent- constrictor pupillae & ciliaris

Nerve components

Nuclei
Somatic efferent- motor nucleus is in midbrain.
General visceral efferent (Edinger Westphal nucleus) - through ciliary ganglion it supplies constrictor
pupillae and ciliaris
Sup. division

LPS Midbrain
SR
3rd CN
MR
PONS

IO IR

Inf. division

Ciliary ganglion

Oculomotor nerve: Distribution

Course
Intraneural course- axons from nuclei run through red nucleus; descend to reach lower level of crus
cerebri.
Intracranial course- nerve comes out in interpeduncular cistern and runs laterally between posterior
cerebral and superior cerebellar arteries. It reaches free margin of tentorium cerebelli, pieces it and enter
cavernous sinus. It then runs along the lateral wall of cavernous sinus. It runs forwards to enter superior
orbital fissure where it divides into upper and lower divisions.
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Extracranial course- upper division gives branches to LPS and SR while lower division supplies MR, IR
and IO.

Course in cavernous sinus

Course in superior orbital fissure

Accommodation reflex
This requires two actions:
 Convergence of eyeball by contraction of medial rectus
 Constriction of pupil
To elicit this, individual is asked to look at a distant object and thereafter to look at object/ finger placed
close to eyes. Afferent impulses are carried in neurons as:
Rods & cones

Optic nerve

Optic chaisma

Optic tract

Lateral geniculate body (LGB)


Optic radiation (retrolentiform part of internal capsule)
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Occipital cortex

By superior longitudinal fasciculus to frontal eye-field

FOURTH CRANIAL NERVE: TROCHLEAR NERVE

It is a motor cranial nerve.
Peculiarities:
 Only CN to arise from dorsal aspect of brain
 Only CN to cross / decussate
 Most slender CN
 Has longest intracranial course
Nerve component- somatic efferent for superior oblique (SO)
Nucleus- is at the level of inferior colliculus in central grey matter

Nerve component
Superior oblique

Midbrain
4th CN

Sup. orbital fissure

Trochlear nerve: Distribution

Course
Intraneural course- it runs laterally and then backwards to decussate within inferior colliculus. It comes
out at lower border of inferior colliculus
Intracranial course- from lower pole of inferior colliculus it winds round midbrain and reaches
interpeduncular cistern superior to pons. It runs forwards under free margin of tentorium cerebelli and
pierces arachnoid and dura to enter middle cranial fossa. It runs along lateral wall of cavernous sinus to
reach superior orbital fissure.
Extracranial course- it is outside the tendinous ring. It runs medially over SR and LPS to supply SO along
its outer surface.

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FIFTH CRANIAL NERVE: TRIGEMINAL NERVE
It is a mixed nerve with motor and sensory roots.
Nerve components
Branchial efferent- nerve of first branchial arch; supplies muscles of mastication and anterior belly of
digastric and mylohyoid
Somatic afferent-
 Pain & temperature sensations from face & scalp, from mucous membrane of nose and paranasal
air sinuses, oral cavity, gums and teeth and anterior two third of tongue
 Discriminatory touch from face
 Proprioceptive impulses from muscles of mastication, facial muscles and extrinsic muscles of eye
Nuclei
Branchial efferent
 motor nucleus is in pons
Somatic afferent
 spinal nucleus for pain & temperature in pons & medulla
 main sensory nucleus for discriminatory touch in pons
 mesencephalic nucleus for proprioception in whole length of midbrain

Nerve components
Course
Intraneural course- axons from nuclei ascend or descend to come out in the middle of anterolateral aspect
of basilar part of pons.
Intracranial course- motor and sensory roots pass together below tentorium cerebelli to trigeminal cave.
The nerve crosses upper border of petrous temporal near its apex and enters middle cranial fossa.

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 V1
Supraorbital &
supratrochlear
Gassarian ganglion
V2 Pons
SENSORY DISTRIBUTION
Infraorbital V3
Sup. alveolar
Ant. Trunk for
muscles of mastication
Lingual Temporalis Lat. pterygoid
Inf. alveolar
Med. pterygoid

Masseter

Ant. belly of digastric

MOTOR DISTRIBUTION
Trigeminal nerve: Distribution

OPHTHALMIC NERVE

Ophthalmic nerve & its branches

MANDIBULAR NERVE
Mandibular nerve (mixed nerve) enters infratemporal region by leaving cranium through foramen ovale.
In infratemporal region, trunk divides into anterior and posterior divisions.
Branches & distribution
From the trunk- one motor and one sensory branch are given. Motor branch is nerve to medial pterygoid;
also supplies tensor tympani & tensor palati. Sensory branch is nervous spinosus. It enters, middle cranial
fossa through foramen spinosum; supplies due mater in middle cranial fossa.
From anterior division- This predominantly motor division has motor branches for muscle of mastication
and one sensory branch. Motor branches are deep temporal nerves (for temporalis), masseteric branch (for
masseter) and nerve to lateral pterygoid. Sensory branch is buccal nerve
From posterior division-This is predominantly sensory with three sensory branches and one motor branch.
Motor fibers (nerve to mylohyoid) are contained in inferior alveolar nerve. Sensory branches:
Auriculotemporal nerve innervates skin of scalp, temple and pinna. Lingual nerve (mixed nerve) carries
general and taste sensations from anterior two third of tongue and secretomotor impulses to

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submandibular and sublingual glands. Inferior alveolar nerve is for gum and teeth of lower jaw. Its
terminal branch (mental nerve) emerges through mental foremen to supply adjoining skin.

Mandibular nerve & its branches

Chorda tympani (mixed nerve) arises from geniculate ganglion of facial nerve (VII CN) within petrous
temporal bone. It emerges through petrotympanic fissure to join lingual nerve in infratemporal region. It
carries secretomotor impulses to submandibular ganglion. It carries taste sensations from anterior two
third of tongue excluding circumvallate papillae.

SIXTH CRANIAL NERVE: ABDUCENT NERVE

It is a motor nerve- supplies lateral rectus (LR)
Nerve component- somatic efferent for lateral rectus
Nucleus- is in lower pons surrounded by fibres of VII CN, causing an elevation called facial colliculus in
the floor of fourth ventricle

Nerve component

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 Midbrain

LR

Sup. orbital fissure 6th CN

Medulla

Abducent nerve: Distribution

Course
Intraneural course- nerve axons run downwards to reach the junction of pons and medulla
Intracranial course- nerve emerges at lower border of pons and enters cisterna pontis. It turns upwards
between anterior inferior cerebellar artery and labyrinthine artery. It pierces arachnoid and dura mater on
the clivus, runs between two layers of dura mater and reaches apex of petrous temporal bone. It then
bends forwards under petro-clenoid ligament to enter cavernous sinus. It runs lateral to ICA to reach
superior orbital fissure and enters tendinous ring below inferior division of III CN.
Extracranial course- nerve passes within cone of muscles to supply lateral rectus.

SEVENTN CRANIAL NERVE: FACIAL NERVE

It is a mixed cranial nerve
Nerve components
Branchial efferent- nerve of II branchial arch; supplies facial muscles, occipitofrontalis, platysma,
buccinator, stapedius, stylohyoid and posterior belly of digastric
General visceral efferent- through pterygopalatine ganglion it supplies lacrimal gland and nasal,
palatine and pharyngeal glands
Special visceral efferent- carries taste sensations from anterior 2/3 of tongue and palate
Somatic afferent- carries sensations from external acoustic meatus and proprioceptions from facial
muscles

Facial nerve components

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Nuclei
Branchial efferent- motor nucleus of facial (in lower pons)
General visceral efferent- lacrimatory nucleus (in pons) and superior salivatory nucleus (in pons)
Special visceral efferent- nucleus of tractus solitarius (in open part of medulla)
Somatic afferent- spinal nucleus of trigeminal (in open part of medulla and lower pons) and
mesencephalic nucleus (in midbrain)
The ventral motor nucleus receives fibres from both cerebral cortices and supplies upper face. The dorsal
nucleus receives fibres from opposite cerebral cortex and supplies lower face.
The nucleus is in three parts. Medial part is for stapedius, stylohyoid and posterior belly of digastric.
Lateral part supplies buccinator. The intermediate part supplies face.

Facial nerve nuclei

Course
Intraneural course- axons either ascend or descend from respective nuclei to reach the pontomedullary
junction and appear between olive and inferior cerebellar peduncle.

Intraneural course

Intracranial course (common for motor and sensory roots)- motor and sensory roots run along VIII CN.
Both roots pass laterally in the cisterna pontis. Both roots with VIII CN enter internal acoustic meatus
with a sleeve of dura mater.

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Relation at internal acoustic meatus: sensory root is between motor root and VIII CN; hence called nervus
intermedius.
Course of motor root: under the geniculate ganglion, it runs (within petrous temporal) laterally,
backward and downwards. After entering facial canal, it descends along the medial and posterior walls of
middle ear. It comes out through the stylomastoid foramen. Two branches are given in the facial canal.
Opposite the pyramid of middle ear, motor root gives branch to stapedius. About 6 mm proximal to
stylomastoid foramen, chorda tympani leaves facial canal and runs upwards and forwards in a bony canal.

Intracranial course of motor and sensory roots

Extracranial course of motor root- after emerging from stylomastoid foramen it gives branches to
stylohyoid, posterior belly of digastric and posterior auricular nerve (for occipitalis). The motor root then
enters parotid gland through its posteromedial surface. Within the parotid, it divides into upper
(zygomaticotemporal) and lower (cervicofacial) trunks. The branches from these trunks form a plexus
called pes anserinus. This divides parotid into superficial and deep parts. The terminal braches emerge
along the superior and anterior borders of the gland. The terminal branches are temporal, zygomatic,
buccal, mandibular and cervical branches.

Extracranial course of motor root

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Intracranial course of sensory root- within petrous temporal it forms geniculate ganglion. From it, greater
superficial petrosal nerve and chorda tympani arise.

Greater superficial petrosal nerve

Intracranial course- it appears at anterior pole of the ganglion and comes out through its hiatus. It then
runs under trigeminal ganglion. It joins deep petrosal nerve to form nerve of the pterygoid canal (Vidian’s
nerve). The nerve runs in pterygoid canal and reaches pterygopalatine fossa.
Extracranial course- Vidian’s nerve joins pterygopalatine ganglion. Branches issued from the ganglion
supply lacrimal, nasal, palatine and pharyngeal glands.

Extracranial course of greater superficial petrosal nerve

Chorda tympani
Intracranial course- it arises from the posterior pole of the geniculate ganglion. It runs along the motor
root in the facial canal. About 6 mm proximal to stylomastoid foramen, it leaves facial canal. It then runs
along the tympanic membrane close to the handle of malleus. Through petrotympanic fissure, it comes out
in infratemporal fossa.
Extracranial course- it joins lingual nerve from its posterior aspect. Further, it runs along the lingual nerve
to reach the submandibular ganglion. Branches given from it supply submandibular and sublingual
salivary glands. It then continues with lingual nerve and carries taste sensations from the anterior 2/3 of
the tongue.

Extracranial course of chorda tympani

APPLIED ANATOMY
Supranuclear lesion of facial nerve
UMN type
Causes
1. Thrombosis of cerebral cortex
2. Haemorrhage in internal capsule
Supranuclear fibres
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Ventral nucleus is connected to both cerebral cortices and innervates forehead thru branches from ZT
trunk.
Dorsal nucleus is connected to opposite cerebral cortex and innervates lower part of forehead thru brs
from CF trunk.
Clinical picture
1. Contralateral hemiplegia (uncrossed corticonuclear fibres)
2. Paresis of forehead (B/L representation-sparing)
3. Contralateral paralysis of lower face(because input to dorsal nucleus is affected)

Nuclear lesion of facial nerve

LMN type because of tumour
Clinical picture
1. Ipsilateral complete paralysis of ½ face
2. May include nuclei in pons

Infranuclear lesion of facial nerve (Bell’s palsy)

LMN type
Factors within or outside petrous temporal
Clinical picture
When both roots involve
1. Ipsilateral LMN paralysis
2. Loss of taste (geniculate ganglion)
3. Loss of secretions (greater superficial petrosal nerve & chorda tympani)
When only motor root involved
• Beyond stylomastoid foramen
• Common in children (mastoid pr is small)
• Exposure to cold /viral infection leads to oedema of facial nerve
It causes ipsilateral transient weakness called Bell’s palsy.

Testing of VII CN
Ask patient to
 Frown: occipitofrontalis
 Shut the eyes: Orbicularis oculi
 Show clinched teeth: Zygomaticus
 Inflate cheeks: Buccinator
Observe patient for
 Loss of wrinkles on forehead: frontalis
 Inability to close eyes: orbicularis oculi
 Drooling of saliva: orbicularis oris
 Accumulation of food in vestibule with inability to inflate cheeks: buccinator
 Flattening of nasolabial fold: Levator labii superioris alaque nasi
 Social smile id drawn to one side: zygomaticus
 Emotional smile (B/L) because of connections with basal ganglia

NINTH CRANIAL NERVE: GLOSSOPHARYNGEAL NERVE

It is a mixed cranial nerve
Nerve components
Branchial efferent- nerve of III branchial arch; supplies stylopharyngeus
General visceral efferent- through otic ganglion it supplies parotid gland
General visceral afferent- carries general sensations from palate, tongue, tonsil and oropharynx
Special visceral afferent- carries taste sensation from posterior 1/3 of tongue including circumvallate
papillae
Somatic afferent- carries sensations from tympanic membrane

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 Glossopharyngeal nerve components

Nuclei
Branchial efferent- nucleus Ambiguus (in open part of medulla)
General visceral efferent- inferior salivatory nucleus (in open part of medulla)
General visceral afferent- dorsal nucleus of vagus (in open part of medulla)
Special visceral efferent- nucleus of tractus solitarius (in open part of medulla)
Somatic afferent- spinal nucleus of trigeminal (in open part of medulla and lower pons)

Glossopharyngeal nerve nuclei

Course
Intraneural course- axons from various nuclei run laterally and emerge at posterolateral sulcus between
olive and inferior cerebellar peduncle.

Intraneural course

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Intracranial course-3 to 4 rootlets join to form trunk under flocculus of cerebellum and enters jugular
foramen.
Extracranial course- after emerging from jugular foramen it passes forwards between IJV and ICA. It
descends in front of ICA upto lower border of stylopharyngeus. It runs deep to ECA and ascends under
hyoglossus to enter tongue.

Extracranial course
Branches
Tympanic branch - parotid gland
Motor - stylopharyngeus
Other branches:
 Pharyngeal - oropharynx
 Lingual - posterior 1/3 of tongue including circumvallate papillae
 Auricular -tympanic membrane

Branches and distribution

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CLINICAL ANATOMY
Gag reflex (Pharyngeal reflex)
It is a normal neural reflex elicited by touching soft palate or posterior pharynx. The normal response will
be elevation of palate, retraction of tongue and contraction of pharyngeal muscles. This reflex tests vagus
and glossopharyngeal nerves.

TWELTH CRANIAL NERVE: HYPOGLOSSAL NERVE

It is a motor nerve. It supplies tongue muscles except palatoglossus supplied by vagoaccessory complex.
Proprioceptive impulses from tongue are carried in mesencephalic nucleus of trigeminal nerve.

Nerve component
Somatic efferent- is in the line with nuclei of 3rd, 4th & 6th cranial nerves

Hypoglossal nerve components

Nucleus- is in open part of medulla in the floor of IV ventricle called hypoglossal triangle.

Nucleus and intraneural course

Course
Intraneural course- fibers run anterolaterally to emerge at anterolateral sulcus between pyramid and olive
Intracranial course- ten to twelve rootlets join to form a trunk that pierces dura mater to enter hypoglossal
canal.

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 Intracranial course
Extracranial course- it comes out of condylar canal and runs laterally. It descends along X CN over ICA
and reaches lower border of posterior belly of digastric. It runs forwards over ICA, ECA, middle
constrictor and hyoglossus. The nerve runs under cover of posterior belly of digastric, stylohyoid and
mylohyoid. The nerve ends end in genioglossus.

Extracranial course and relations

Branches
Meningeal- branch of C-1, which supplies dura of posterior cranial fossa
Muscular- styloglossus, hyoglossus, genioglossus, geniohyoid (through C-1) & thyrohyoid
Omohyoid (superior belly), sternohyoid, sternothyroid and omohyoid (inferior belly)- supplied by
descends hypoglossi through C-2, 3.

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 Branches and distribution

CLINICAL ANATOMY

Testing of 12th nerve

Patient is asked to protrude the tongue. In paralysis, it deviates to affected side due to hemiatrophy of
tongue and unopposed action of normal genioglossus.

Dorsal of tongue as indicator of clinical conditions

In pernicious anemia, tongue appears smooth and red while in central cyanosis it will appear bluish.

In unconscious patient
Tongue should be pulled out manually to prevent choking.

Bleeding from tongue

It can be stopped temporarily by pulling tongue out. In this first aid maneuver, lingual artery is
compressed against the tip of greater cornu of hyoid.

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 CHAPTER- 24

PARASYMPATHETIC GANGLIA OF HEAD AND NECK

Introduction
 All smooth muscles except of blood vessels are supplied by parasympathetic nerves
 All glands except sweat glands are supplied by parasympathetic nerves
 Excluding head, neck and face, parasympathetic supply to body is by vagus nerve and sacral
parasympathetic for pelvis and perineum
Parasympathetic innervation of head, neck and face is by 3rd, 7th, and 9th cranial nerves through peripheral
ganglia. These are Ciliary, Pterygopalatine, Otic and Submandibular ganglia.
All ganglia have three roots: Secretomotor, Sensory & Sympathetic.
All ganglia give mixed branches that carry following impulses:
 Postganglionic parasympathetic
 Postganglionic sympathetic
 Sensory / motor
Ciliary ganglion is placed on nasociliary nerve- branch of ophthalmic division of V cranial nerve;
functionally connected to oculomotor nerve (III CN)
Otic ganglion is placed on mandibular division of trigeminal nerve (IX CN)
Pterygopalatine ganglion (Sphenopalatine ganglion) is placed on maxillary division of trigeminal
nerve; functionally related to facial nerve (VII CN)
Submandibular ganglion is placed on lingual nerve (mandibular division of V CN); functionally
connected to facial nerve (VII CN)

CILIARY GANGLION
This pinhead-sized ganglion is between optic nerve and lateral rectus close to apex of orbit. It has three
roots:
Sensory- connected to nasociliary nerve
Sympathetic- sympathetic plexus around ophthalmic artery
Parasympathetic- arises from nerve to inferior oblique- branch of inferior division of III CN

Ciliary ganglion: Formation and distribution

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About 8 - 10 short ciliary nerves arise from ganglion, pierce sclera around the entrance of optic nerve.
They carry sensory, postganglionic sympathetic and postganglionic parasympathetic impulses. From
cornea and conjunctiva, sensory impulses travel in long ciliary nerves.
Postganglionic sympathetic impulses search dilator pupillae muscle. Postganglionic parasympathetic
impulses are carried to sphincter pupillae & ciliaris muscle.

PTERYGOPALATINE GANGLION (SPHENOPALATINE GANGLION)

This parasympathetic ganglion carries secretomotor fibres from superior salivary and lacrimatory nuclei to
lacrimal, palatine, nasal and pharyngeal glands.
It is in pterygopalatine fossa with three roots:
Sensory root is connecting to maxillary nerve
Parasympathetic / secretomotor root is nerve of pterygoid canal; formed by:
Greater superficial petrosal nerve (mixed) carries secretomotor impulses to gland and afferent of taste
sensation. Deep petrosal nerve carries postganglionic sympathetic impulses
Sympathetic root is formed by plexus around ICA. Deep petrosal nerve arises from this plexus, joins
greater superficial petrosal nerve to form nerve of pterygoid canal (Vidian’s nerve).
The nerve enters pterygopalatine fossa to reach pterygopalatine ganglion.
Branches from ganglion:
 nasal
 palatine
 pharyngeal
Branch to lacrimal gland runs in zygomatico-temporal branch of maxillary nerve to join lacrimal nerve
(ophthalmic nerve: V-1) to innervate lacrimal gland.

Pterygopalatine ganglion: Formation & distribution

Taste sensations from palate are carried in peripheral process of geniculate ganglion. These peripheral
processes are represented by palatine branch  pterygopalatine ganglion (without relay)  Vidian’s
nerve  greater superficial petrosal nerve. The central process of geniculate ganglion carries taste
sensations to nucleus of tractus solitaries.

OTIC GANGLION
This parasympathetic ganglion carries secretomotor fibres to parotid gland.
Preganglionic parasympathetic impulses arise in inferior salivatory nucleus, carried subsequently in
glossopharyngeal (IX CN) nerve, recurrent branch of IX CN (Jacobson’s nerve), tympanic plexus and
lesser petrosal nerve, to end in otic ganglion.
Postganglionic parasympathetic impulses reach parotid gland through posterior root of
auriculotemporal nerve.

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 Otic ganglion: Formation & distribution

SUBMANDIBULAR GANGLION
It is a parasympathetic ganglion for secretomotor innervation to submandibular, sublingual and anterior
lingual glands. Topographically it is related to lingual nerve (V-3) and functionally to VII CN.
Preganglionic parasympathetic impulses arise from superior salivatory nucleus. These are carried
successively in nervous intermedius, chorda tympani and lingual nerve.
Postganglionic parasympathetic impulses are carried to submandibular gland via direct branches
from the ganglion. For sublingual gland, impulses run in one of the roots of lingual nerve.

Submandibular ganglion : Formation & distribution

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 CHAPTER- 25

BONES OF HEAD & NECK

SKULL
Skull is composed of many separate bones, which are united by sutures (fibrous immovable joints).Skull
can be divided into two parts: cranium and facial skeleton.

Skull viewed from front

Functions of skull
Various parts of skull have specific and different functions:
 cranium protects brain
 bony eye sockets provide eyes with protection against injury and give attachment to muscle that
moves the eyes
 temporal bone protects ear
 sinuses give resonance to the voice
 bone of face form walls of posterior part of nasal cavities and form upper part of air passages
 maxilla and mandible provide alveolar ridges in which teeth are embedded
 chewing of food is performed by mandible, controlled by muscles of lower face

CRANIUM
Many flat and irregular bones that provide protection for the brain form the cranium. In mature skull, joints
(sutures) between bones are immovable (fibrous).The bones of the cranium are:
Frontal bone is the bone of forehead. It forms part of the orbital cavities (eye sockets). Within the bone,
there are two air-filled sinuses, which open into the nasal cavity. The coronal suture joins the frontal and
parietal bones.
Parietal bones form sides and roof of skull. They articulate with each other at sagittal suture, with frontal
bone at coronal sutures, with occipital bone at lambdoid suture and with temporal bones at squamous
sutures.
Temporal bones (one on each side of head) form fibrous joints with parietal, occipital, sphenoid and
zygomatic bones. The squamous part articulates with parietal bone. The zygomatic process articulates with
zygomatic bone to form zygomatic arch (cheek-bone).
Occipital bone forms back of head and part of base of skull. It forms fibrous joints with parietal, temporal
and sphenoid bones. It has two articular condyles that form condyloid joints with atlas; permits nodding
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movements of head. Between the condyles is foramen magnum through which spinal cord passes.
Sphenoid bone occupies middle portion of base of skull. It articulates with occipital, temporal, parietal and
frontal bones. Its superior surface in the middle of bone shows a saddle- shaped depression called
hypophyseal fossa, which lodges pituitary gland. Its body contains sphenoidal air sinuses, which open into
the nasal cavity.
Ethmoid bone occupies anterior part of skull base. It helps to form orbital cavity, the nasal septum and
lateral walls of nasal cavity. On each side are two projections into the nasal cavity, called superior and
middle conchae. It contains many air sinuses, which open into the nasal cavity. Its cribriform plate forms
roof of nasal cavity. It has numerous small foramina through which nerve fibres of olfactory nerve (nerve
of smell) pass from nasal cavity to the brain. Its perpendicular plate forms upper part of nasal septum.

Skull viewed from lateral side

FACE
Skeleton of face is formed by 13 bones besides frontal bone. These are:
Zygomatic (cheek) bones form prominences of cheeks and part of the floor and lateral walls of orbital
cavities.
Maxilla (upper jawbone) forms upper jaw, anterior part of roof of mouth, lateral walls of nasal cavity and
part of floor of orbital cavities. The alveolar process bears sockets for upper teeth. It contains large
maxillary sinus, which opens into nasal cavity.
Nasal bones are two small bones that form major part of lateral and superior surfaces of nasal bridge.
Lacrimal bones are small bones are behind the nasal bones and form part of medial walls of orbital
cavities.
Vomer is a thin flat bone that extends upwards from the middle of hard palate to form most of the nasal
septum. It articulates with perpendicular plate of ethmoid bone.
Palatine bones are two small L-shaped bone. The horizontal parts unit to form posterior part of hard palate
and perpendicular parts form part of lateral walls of nasal cavity. They also form part of the orbital cavities.
Inferior nasal concha is an independent bone that forms part of lateral wall of nasal cavity. The superior
and middle conchae are from ethmoid bone. The conchae increase the surface area in nasal cavity to
allowing warm and humidify inspired air more effectively.
Mandible (lower jawbone) is the only movable bone of skull. It develops in two parts that unite at
midline. Each half consists of a curved body with alveolar process containing sockets for lower teeth and a
ramus, which projects upwards at right angle to posterior end of body. Ramus divides into condylar process
(articulates with temporal bone to form temporomandibular joint) and coronoid process, which provides
attachment to temporalis. The point where ramus joins body is angle of mandible.

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 Mandible: Outer aspect

Mandible: Inner aspect

Hyoid bone is horseshoe-shaped bone in the neck just above the larynx and below the mandible. It does
not articulate with any other bone. It is suspended by muscles and ligaments. It supports larynx.

FONTANELLES OF FOETAL SKULL

At birth, ossification of cranial sutures is incomplete. Where three or more bones meet, there are
membrane-filled areas called fontanelles. Two largest fontanelles are anterior fontanelle, which persists
until 18 months, and posterior fontanelle persists until 3 months after birth.

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 Fontanelles of foetal skull

BONES OFNECK
Seven cervical vertebrae form cervical region. These are divided into:
 Atypical cervical vertebrae
 Typical cervical vertebrae
Atypical cervical vertebrae- First, second & seventh cervical vertebrae are atypical.

First cervical vertebra (atlas)

It differs from typical vertebrae, as it has no body and no spine. It consists of a ring of bone with two short
transverse processes.

First cervical vertebra

Second cervical vertebra (axis)
It shows presence of dens (odontoid process- thick tooth like projection from upper part of body). The
odontoid process fits into the space between anterior arch of atlas and its transverse ligament to form
median atlanto-occipital joint. The movement at this joint is to turn head from side to side.

Seventh cervical vertebra (vertebra prominens)

It possesses a long spinous process, felt at the base of neck.

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NORMA BASALIS

Norma basalis: Demarcations and openings

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