Preface

Agam is a group of budding medicos, who are currently doing their under graduation in
various Medical Colleges across Tamil Nadu and Pondicherry. The group was initiated on 18th
November 2017, in the vision of uniting medicos for various social and professional causes.

We feel delighted to present you Agam Anatomy notes prepared by Agam Divide and Rule
2020 Team to guide our fellow medicos to prepare for university examinations.

This is a reference work of 2017 batch medical students from various colleges. The team
took effort to refer many books and make them into simple notes. We are not the authors of the
following work. The images used in the documents are not copyrighted by us and is obtained from
various sources.

Dear readers, we request you to use this material as a reference note, or revision note, or
recall notes. Please do not learn the topics for the 1st time from this material, as this contain just the
required points, for revision.
Acknowledgement

On behalf of the team, Agam would like to thank all the doctors who taught us Anatomy. Agam
would like to whole heartedly appreciate and thank everyone who contributed towards the making
of this material. A special thanks to Srivardhany Bhaskar and M. Snaha, who took the responsibility
of leading the team. The following are the name list of the team who worked together, to bring out
the material in good form.

1. A. Sowmiya Parameshwari
2. Ajithvas VC
3. Aathira Sunilkumar
4. Lehak Agarwal
5. Shaziya Mohsin
6. Thamizhazhagan G
7. Rhifkaa J
8. Amrutha Sivakumar
9. Kirthana R
10. Sri kamali G
11. Ram Girythar VRS
12. Suvitha ??
13. Srivardhany
14. Yashi Awasthi
15. Harsha M
16. Sanjana singh
17. Prassana Pandian
18. Varshni R
19. Geethik ??
20. Ashiq Ahamed Jawid Nazir
21. Karthika Devi S
22. Barani
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HEAD AND NECK ESSAYS

SR. QUESTION NAME PAGE NO.

NO.

1. PAROTID GLAND 2

2. FACIAL NERVE 6

3. CAVERNOUS SINUS 11

4. TONGUE 17

5. THYROID GLAND 24

6. CAROTID TRIANGLE 34

7. SUBMANDIBULAR SALIVARY GLAND 44

8. TEMPOROMANDIBULAR JOINT 49

9. EXTRAOCULAR MUSCLES 55

10. INTRACRANIAL DURAL VENOUS SINUSES 59

11. ABDUCENT NERVE 65

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1. PAROTID GLAND

INTRODUCTION:
The parotid gland is the largest of all salivary glands. It weighs about
25g. It is a serous type of gland.

LOCATION:
It is situated below the external acoustic meatus between ramus of
mandible and sternocleidomastoid.

PARTS:
The gland resembles a three-sided pyramid.
The gland has 4 surfaces:
A) Superior
B) Superficial
C) Anteromedial
D) Posteromedial
The surfaces are separated by 3 borders:
A) Anterior
B) Posterior
C) Medial

RELATIONS:

Overlaps posterior belly of digastric

Appears in carotid triangle

APEX
Structures emerging near the apex:
1. Cervical branch of facial nerve
2. Two divisions of retromandibular vein

Cartilaginous part of external acoustic meatus

Posterior surface of tmj

SUPERIOR
Superficial temporal vessels
SURFACE
Auricotemporal nerve

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Skin

Superficial fascia containing lymph nodes, anterior

branches of Auricotemporal nerves, posterior fibres
of platysma & risorius
SUPERFICIAL
Parotid fascia
SURFACE
Deep parotid lymph nodes

Masseter

Lateral surface of TMJ

ANTEROMEDIAL
Posterior border of ramus of the mandible
SURFACE
Medial pterygoid

Emerging branches of fascial nerve

Mastoid process

POSTEROMEDIAL Styloid process

SURFACE External carotid artery

Facial nerve

Separates superficial surface from anteromedial

surface
ANTERIOR
BORDER Structures emerging from this border:
Parotid duct &Terminal branches of facial nerve
Transverse facial vessels

Separates superficial surface from posteromedial

POSTERIOR surface
BORDER
Overlaps sternocleidomastoid

Separates anteromedial surface from posteromedial

MEDIAL BORDER surface

Related to lateral wall of pharynx

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COVERINGS/CAPSULE:
Investing layer of deep
cervical fascia forms the
capsule.
The fascia splits between
the angle of mandible and
the mastoid process to
enclose the gland.
SUPERFICIAL LAMINA
[thick] = attached above
to the zygomatic arch.
DEEP LAMINA [thin] =
attached to styloid
process + tympanic plate
+ angle & posterior border
of ramus of mandible
A portion of deep lamina thickens to form the stylomandibular
ligament which separates parotid from the submandibular gland.

NERVE SUPPLY:
The gland is under PARASYMPATHETIC REGULATION.
It receives these fibers via the lesser petrosal nerve, which is a branch
of the GLOSSOPHARYNGEAL NERVE (CN IX) beginning from the
inferior salivatory nucleus.
CN IX synapses on the otic ganglion.
The postganglionic secretomotor fibers that emerge from the otic
ganglion reach the parotid gland via the auriculotemporal nerve (a
branch of the mandibular division of the trigeminal nerve [CN V3]).
The SYMPATHETIC SUPPLY is derived from the adjacent sympathetic
plexus of the carotid sheath.

Inferior salivatory nucleus IX nerve Tympanic branch Tympanic

plexus Lesser petrosal nerve Relay in otic ganglion Postganglionic
fibres through auriculotemporal nerve Parotid gland

APPLIED ANATOMY:
1. A PAROTID ABSCESS may be caused by spread of infection from
the opening of the parotid duct in the mouth cavity.
2. PAROTIDECTOMY is the removal of the parotid gland.

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3. FREY'S SYNDROME is a RARE NEUROLOGICAL DISORDER resulting

from damage to or near the parotid glands responsible for making
saliva, and from damage to the auriculotemporal nerve often from
surgery.
4. PAROTID CALCULI may get formed in the parotid gland or in
duct.

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2. FACIAL NERVE
7th cranial nerve
Mixed nerve
Nerve of second pharyngeal arch - Supplies muscles of facial
expression
Most commonly injured Cranial nerve
Cranial nerve with longest interosseous course

FUNCTIONAL COMPONENTS OF FACIAL NERVE

A. SPECIAL VISCERAL EFFERENT - Supply muscles of facial

expression
B. GENERAL VISCERAL EFFERENT - Supply glands
Submandibular and sublingual salivary glands, lacrimal gland,
nasal and palatine glands
C. SPECIAL VISCERAL AFFERENT - Carries taste sensation from
anterior two third of tongue (except vallate papillae)

NUCLEI OF FACIAL NERVE

A. MOTOR NUCLEUS OF FACIAL NERVE

Located on lower pons
Fibres arising supplies muscles of second arch
B. SUPERIOR SALIVATORY NUCLEUS
Located in pons
Supply submandibular and sublingual salivary glands through
submandibular ganglion
C. LACRIMATORY NUCLEUS
Located in pons
Supply lacrimal gland through pterygopalatine ganglion
D. NUCLEUS TRACTUS SOLUTARIUS
Located in medulla
Receives taste sensation from anterior two third of tongue

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ORIGIN
Formed by 2 roots -
a. LARGER MOTOR root;
b. SMALLER SENSORY root (nervus intermedius)
Emerges at pontomedullary junction

COURSE
Passes through internal acoustic meatus along with vestibuli cochlear
nerve (8th CN) and labyrinthine artery and enters inner ear
From inner ear, enters medial wall of middle ear, passes through
oblique part of facial canal
Runs through vertical part of facial canal in the posterior wall of middle
ear
Comes out of skull through stylomastoid foramen
Enter parotid gland through posteromedial surface

GENU OF FACIAL NERVE

INTERNAL GENU - Facial colliculus (Facial nerve fibres winding

around abducent nucleus in the floor of fourth ventricle)
EXTERNAL GENU - Geniculate ganglion (Gives greater petrosal
nerve)

TERMINATION
Within parotid gland, it divides into five terminal branches (Branching
pattern - PES ANSERINUS)

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BRANCHES AND DISTRIBUTION

A. GREATER PETROSAL NERVE

First branch of facial nerve from Geniculate ganglion
Greater Petrosal Nerve + Deep Petrosal Nerve

Nerve to

Pterygopalatine Ganglion

Post-Ganglionic Fibres

Lacrimal Gland + Nasal Gland + Palatine Gland

B. NERVE TO STAPEDIUS - Supplies stapedius muscle

C. CHORDA TYMPANI NERVE

Carries Taste sensation from anrerio two third of tongue (except
vallate papillae)
Secretomotor fibres to submandibular and sublingual salivary
glands
Chorda Tympani Nerve + Lingual Nerve

Preganglionic Fibres

Submandibular Ganglion

Submandibular + Sublingual Salivary Glands

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D. POSTERIOR AURICULAR NERVE - supplies occipitalis muscle

E. NERVE TO STYLOHYOID - supplies stylohyoid and posterior belly
of digastric

F. TERMINAL BRANCHES
TEMPORAL BRANCH - Frontalis, orbicularis oculi
ZYGOMATIC BRANCH - Lower part of orbicularis oculi
UPPER BUCCAL BRANCH - Zygomatic major, zygomatic minor
LOWER BUCCAL BRANCH - Buccinator, orbicularis Oris
MARGINAL MANDIBULAR BRANCH - Mentalis, risorius
CERVICAL BRANCH Platysma

DIAGRAM: SHOWING THE COURSE OF THE FACIAL NERVE

**(NOTE: ZOOM FOR CLARITY) **

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CLINICAL ANATOMY

BELL'S PALSY
Lower motor neuron type of facial nerve palsy
Cause - idiopathic

CLINICAL PRESENTATION MUSCLES PARALYSED

Facial asymmetry (face pulled All muscles of facial expression
towards healthy side)
Loss of transverse wrinkles of Frontalis
forehead
Inability to close eyes, epiphora Orbicularis Oculi

Loss of nasolabial fold, drooling Levator anguli Oris

of saliva from angle of mouth
Accumulation of food in Buccinator
vestibule of mouth
Usual site of lesion - just below stylomastoid foramen

RAMSAY HUNT SYNDROME

Involvement of Geniculate ganglion in herpes zoster infection

CLINICAL PRESENTATION NERVE INVOLVED

Hyperacusis Nerve to stapedius

Loss of lacrimation Greater petrosal nerve

Loss of taste sensation from anterior Chorda tympani nerve

two third of tongue
Ipsilateral facial palsy (Bell's palsy) Terminal branches

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3. CAVERNOUS SINUS
INTRODUCTION
The cavernous sinus (2 cm long, 1 cm wide) is a large venous space.
Its interior is divided into a number of small spaces (caverns) by
trabeculae, hence the name cavernous sinus

LOCATION:
situated on either side of the body of the sphenoid and Sella turcica
in the middle cranial fossa.

BOUNDARIES:

FLOOR: endosteal layer

Lateral wall, roof, and medial wall: meningeal layer.
MEDIALLY: roof is continuous with the diaphragm sellae
POSTERIORLY: roof has a triangular depression between the
attached margin (edge) of tentorium cerebelli to the posterior
clinoid process and ridge raised by the free margin (edge) of
tentorium cerebelli as it extends forward to gain attachment on the
anterior clinoid process.
The oculomotor and trochlear nerves pierce this triangle to enter
the cavernous sinus.

EXTENT:

ANTERIORLY: up to the medial end of superior orbital fissure

POSTERIORLY: up to apex to the petrous temporal bone.

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RELATIONS

SUPERIOR:
1. Optic chiasma
2. Optic tract
3. Internal carotid artery
4. Anterior perforated substance

INFERIOR
1. Foramen lacerum
2. Junction of the body and the greater wing of the sphenoid

MEDIAL
1. Pituitary gland (hypophysis cerebri)
2. Sphenoid air sinus.

LATERAL
1. Temporal lobe (uncus) of the cerebral hemisphere.
2. Cavum trigeminale containing the trigeminal ganglion.

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ANTERIOR
1. Superior orbital fissure.
2. Apex of the orbit.

POSTERIOR
1. Crus cerebri of midbrain.
2. Apex of the petrous temporal bone.

STRUCTURES PRESENT IN THE LATERAL WALL OF THE SINUS

FROM ABOVE DOWNWARD:
1. Oculomotor nerve.
2. Trochlear nerve.
3. Ophthalmic nerve.
4. Maxillary nerve.
STRUCTURES PASSING THROUGH CAVERNOUS SINUS:

1. INTERNAL CAROTID ARTERY surrounded by the sympathetic

plexus of nerves.
2. ABDUCENT NERVE (it enters the sinus by passing below the
petrosphenoid ligament and accompanies the artery on its
inferolateral aspect).

TRIBUTARIES OF THE CAVERNOUS SINUS

FROM ORBIT
1. Superior ophthalmic vein.
2. Inferior ophthalmic vein.
3. Central vein of retina (sometimes).

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FROM MENINGES
1. Sphenoparietal sinus.
2. Anterior (frontal) trunk of the middle meningeal vein.
FROM BRAIN
1. Superficial middle cerebral vein.
2. Inferior cerebral veins (only few).

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COMMUNICATIONS OF CAVERNOUS SINUS

1. Transverse sinus via superior petrosal sinus.
2. Internal jugular vein via inferior petrosal sinus.
3. Pterygoid venous plexus via emissary veins which pass through
foramen ovale, foramen lacerum, and emissary sphenoidal foramen.
4. Facial vein via two routes:
a. Superior ophthalmic vein angular vein facial vein
b. Emissary veins pterygoid venous plexus deep facial vein facial
vein
5. Opposite cavernous sinuses via anterior and posterior intercavernous
sinuses.
6. Superior sagittal sinus via superficial middle cerebral vein and superior
anastomotic vein.
7. Internal vertebral venous plexus, via basilar venous plexus.

APPLIED ANATOMY

1. CAVERNOUS SINUS THROMBOSIS:

The septic thrombosis of cavernous sinus may be caused by its
numerous communications.
The commonest cause of thrombosis is the passage of septic
emboli from the dangerous area of the face the through facial
vein deep facial vein pterygoid venous plexus emissary vein.
SIGNS AND SYMPTOMS:
Severe pain in the eye and forehead, due to involvement of the
ophthalmic nerve.
Ophthalmoplegia (paralysis of ocular muscles) due to
involvement of the 3rd, 4th, and 6th cranial nerves.
Marked edema of eyelids with exophthalmos, due to congestion
of orbital veins following obstruction of ophthalmic veins.

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2. ARTERIOVENOUS COMMUNICATION:
If the internal carotid artery is ruptured in the fracture base of the
skull, an arteriovenous communication/fistula is established
between the artery and cavernous sinus.
Consequently, arterial blood rushes into the cavernous sinus,
enlarging it and forcing blood into the connecting veins.
SIGNS AND SYMPTOMS:
Pulsating exophthalmos; the eyeball protrudes and pulsates with
each heartbeat.
A loud bruit (loud systolic murmur) is easily heard over the eye.
Ophthalmoplegia due to involvement of the 3rd, 4th, and 6th
cranial nerves.
Marked orbital and conjunctival edema due to raised venous
pressure in the cavernous sinus.

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4. TONGUE
SITUATION:
The tongue is a mobile muscular organ in the oral cavity, which bulges
upwards from the floor of the mouth and its posterior part forms the
anterior wall of the oropharynx.
The tongue is conical in shape being elongated postero- anteriorly and
flattened dorsoventrally.

PARTS:
The tongue exhibits the following external features:
a. Root
b. Tip
c. Body
ROOT
The root of the tongue is attached to the mandible and hyoid bone by
muscles.
It is because of these attachments that the tongue is not swallowed
during deglutition.
The nerve and vessels of the tongue enter through its root.

TIP
It is the anterior free end of the tongue, which comes into contact with
the central incisors.

BODY
The bulk of tongue between the root and tip is called body.
It has dorsal and ventral surfaces and right and left lateral margins.

DORSAL SURFACE:
The dorsal surface is convex on all the sides.
It is divided by a V-shaped sulcus, the sulcus terminalis into two parts,
viz.
1. ANTERIOR two-third or oral part.

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Dorsal surface is covered by mucous membrane. Containing

filiform, fungiform, and circumvallate.
2. POSTERIOR one-third or pharyngeal part
It forms the anterior wall of the oropharynx.
Laterally its mucous membrane is continued onto the palatine tonsils
and pharyngeal wall.
Posteriorly the mucous membrane is reflected onto the epiglottis.
Folds namely a median and two lateral glossoepiglottic folds are
formed and the depressions formed between the folds are called
vallecula.
The apex of the sulcus terminalis is marked by a blind foramen, the
foramen caecum, which indicates the point of origin of the median
thyroid diverticulum (thyroglossal duct) in the embryonic life.

VENTRAL SURFACE:
The mucous on inferior surface is smooth
It is connected to floor of oral cavity and gums.
FRENULUM is the midline fold of mucous membrane connecting
tongue to the floor of the oral cavity.
The DEEP LINGUAL VEIN, lies lateral to the frenulum on either side.
The PLICA FIMBRIATA, is a folded mucosal ridge lying lateral to the

vein.

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BLOOD SUPPLY:
The tongue is supplied by the following arteries:
a. Branches of lingual artery (chief artery of tongue); the deep lingual
arteries to the anterior part and dorsal lingual arteries to the
posterior part.
b. Tonsillar branch of the facial artery.
c. Ascending pharyngeal artery.

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LYMPHATIC DRAINAGE:
The lymphatics emerging from the tongue are grouped into the
following four sets:
APICAL VESSELS: They drain the tip and inferior surface of the tongue
into submental lymph nodes after piercing the mylohyoid muscle. Their
efferent go to the submandibular nodes mainly, some cross the hyoid
bone to reach the jugulo-omohyoid nodes.

MARGINAL VESSELS: They drain the marginal portions of the anterior

two-third of the tongue unilaterally into submandibular lymph nodes and
then to the lower deep cervical lymph nodes, including jugulo-omohyoid.

CENTRAL VESSELS: They drain the central portion of the anterior

two-third of the tongue (i.e., area within 0.5 inch on either side of
midline). They pass vertically downwards in the midline of the tongue
between the genioglossus muscles and then drain bilaterally into the
deep cervical lymph nodes.

BASAL VESSELS: They drain the root of the tongue and posterior one-
third of the tongue bilaterally into upper deep cervical lymph nodes,
including jugulodigastric.

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HISTOLOGY:
Made of mucous and muscular layers.
Mucous layer is adherent to muscular coat
MUCOUS LAYER:

EPITHELIUM: Mucous membrane is lined by stratified squamous

epithelium.

It is non-keratinized in the posterior part of the tongue and keratinized

over filiform papillae
The lamina propria contains dense fibrous tissue, elastic fibres, nerve
and lymph plexus, blood vessels and lingual glands.
The mucous membrane projects I the dorsal surface to form papillae.
There are 4 types of papillae
a. Filiform
b. Fungiform
c. Vallate
d. Foliate
Taste buds are present in all papillae except filiform papillae

MUSCULAR COAT: Made of skeletal muscles arranged as irregular

bundles.

DEVELOPMENT OF THE TONGUE

The tongue develops from the floor of the primitive pharynx in relation
to the pharyngeal arches.

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DEVELOPMENT OF MUCOUS MEMBRANE OF THE TONGUE

The mucous membrane of the anterior two-third of tongue develops
from the fusion of a pair of lingual swellings with the tuberculum
impar.
The lingual swellings appear as endodermal thickenings at the anterior
ends of the first pharyngeal arches.
The tuberculum impar appears as a median swelling just behind the
lingual swellings between the 1st and 2nd pharyngeal arches.
The tuberculum impar soon disappears; thus, the oral part is mostly

bilateral in origin.

The lingual swellings fuse in the midline forming a median sulcus.

The mucous membrane of posterior one-third of the tongue develops
from the cranial part of hypobranchial eminence.
The hypobranchial eminence (copula of His) appears as a median
swelling due to thickening of endoderm connecting the ventral ends of
2nd, 3rd, and 4th pharyngeal arches.
It soon divides into two parts: a cranial part related to the 2nd and 3rd
arches and a caudal part related to the 4th arch.
The 3rd arch endoderm grows forwards over the 2nd arch to fuse with
the lingual swellings and tuberculum impar and gives rise to the
mucous membrane of the posterior one-third of the tongue.

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The 3rd arch grows forwards in a V-shaped manner and fuses with the
anterior two-third of the tongue.
The line of fusion is indicated by sulcus terminalis.
The mucous membrane of the posterior most part of the tongue is
derived from the 4th pharyngeal pouch.
The foramen caecum represents the site of development of
thyroglossal duct forming thyroid gland in the embryo.
DEVELOPMENT OF MUSCLES OF THE TONGUE
The muscles of tongue develop from occipital myotomes, which at
first are closely related to developing hindbrain and later migrates
anteroinferiorly around the pharynx and enter the tongue. The
migrating myotomes carry with them their nerve supply the 12th
cranial nerve.
CORRELATION OF NERVE SUPPLY OF THE TONGUE WITH ITS
DEVELOPMENT MOTOR INNERVATION:
Muscles of the tongue are supplied by the hypoglossal nerve because
they develop from occipital myotomes (occipital myotomes are formed
by the fusion of precervical somites).
SENSORY INNERVATION:

1. ANTERIOR TWO-THIRD develops from the 1st pharyngeal arch, and

therefore, supplied by: (a) lingual nerve, the post-traumatic nerve of the
1st arch, and (b chorda tympani nerve, the pre-traumatic nerve of the 1st
arch.

2. POSTERIOR ONE-THIRD develops from the 3rd pharyngeal arch,

hence supplied by the glossopharyngeal nerve, the nerve of the 3rd arch.

3. POSTERIORMOST PART develops from the 4th arch, hence supplied

by the internal laryngeal nerve, the nerve of the 4th arch.

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5. THYROID GLAND
LOCATION AND PARTS
The thyroid gland is located in the lower part of the front and side of
the neck opposite to the C5, C6, C7, and T1 vertebrae clasping the
upper part of the trachea.
It is H-shaped and consisting of vertical right and left lateral lobes and
a horizontal isthmus connecting them across the midline. Sometimes
a small pyramidal lobe projects upwards from the isthmus usually to
the left of the midline.
It is connected to the body of the hyoid bone by a fibrous or
fibromuscular band called levator glandulae thyroideae.
Each lateral lobe of the gland extends upwards to the oblique line of
the thyroid cartilage and below up to the 5th or 6th tracheal ring.
The isthmus extends across the midline in front of the 2nd, 3rd, and
4th tracheal rings.

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COVERINGS
The thyroid gland is invested by two capsules: an inner true capsule
and an outer false capsule.
TRUE CAPSULE:
It is formed by the peripheral condensation of the fibrous stroma of
the gland.
FALSE CAPSULE:
It is derived from the splitting of the pretracheal fascia. The important
features of the false capsule are:
a. It is thin along the posterior border of the lateral lobe.
b. It is thick on the medial surface of the lateral lobe.
c. On the medial surface, it thickens to form the suspensory ligament of
Berry, which connects the lobe to the cricoid cartilage. The dense
venous lies deep to true capsule. To avoid hemorrhage during
thyroidectomy, the thyroid gland is removed along with the true
capsule. (prostate gland is removed leaving behind both capsules)

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RELATIONS OF THE THYROID LOBES

Each thyroid lobe is roughly pyramidal and presents apex, base, three
surfaces (lateral, medial, and posterolateral), and two borders (anterior
and posterior):

APEX:
It extends up to the oblique line of thyroid cartilage, limited above by
the attachment of sternothyroid muscle. The apex is sandwiched
between the inferior constrictor medially and sternothyroid laterally.
BASE:
The base extends up to the 5th or 6th tracheal ring. It is related to
inferior thyroid artery and recurrent laryngeal nerve.

LATERAL SURFACES:
It is convex and is covered by
a. 3 strap muscles (sternothyroid, sternohyoid, superior belly of
omohyoid)
b. anterior border of sternocleidomastoid.

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MEDIAL SURFACE

It is related to:
(a) two tubes: trachea and esophagus,
(b) two muscles: inferior constrictor and cricothyroid
(c) two cartilages: cricoid and thyroid.

POSTEROLATERAL SURFACE
It is related to carotid sheath and its contents (common carotid artery,
internal jugular vein and vagus nerve).
The Ansa-cervicalis is embedded in the anterior wall of the sheath
while cervical sympathetic chain lies posterior to sheath in front of
prevertebral fascia.
ANTERIOR BORDER
It is thin and separates superficial and medial surfaces. It is related to
anterior branch of the superior thyroid artery.

POSTERIOR BORDER
It is thick and rounded. It is related to
a. superior and inferior thyroid arteries
b. parathyroid glands.

RELATIONS OF ISTHMUS
The isthmus is horizontal and presents two surfaces anterior and
posterior and two borders superior and inferior.
ANTERIOR SURFACE is related to strap muscles (sternohyoid and
sternothyroid) and anterior jugular veins.

POSTERIOR SURFACE is related to 2nd, 3rd, and 4th tracheal rings.

SUPERIOR BORDER is related to anastomosis between the anterior

branches of two superior thyroid arteries.

INFERIOR BORDER, inferior thyroid vein emerges and thyroideae

ima artery (when present) enters.

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BLOOD SUPPLY

1. SUPERIOR THYROID ARTERY:

It is a branch of the external carotid artery. It runs downwards and
forwards in company with the external laryngeal nerve. At the apex of
the lobe, it divides into anterior and posterior branches.
The anterior branch first descends along the anterior border of the
lobe and then continues along the upper border of the isthmus to
anastomose with its fellows of opposite side.
The posterior branch descends along the posterior border of the lobe
to anastomose with the ascending branch of the inferior thyroid artery.
Superior thyroid artery supplies the upper one-third of the lobe and
upper half of the isthmus.

2. INFERIOR THYROID ARTERY:

It is a branch of thyrocervical trunk from the first part of the subclavian
artery. It first runs upwards and then passes medially behind the
carotid sheath to reach the back of the thyroid lobe, where it is
intimately related to the recurrent laryngeal nerve.
The recurrent laryngeal nerve may pass behind or in front of the loop of
the artery or between the branches of the artery. The artery gives 4 or
5 branches.
One ascending branch anastomoses with the posterior branch of the
superior thyroid artery. The inferior thyroid artery supplies lower two-
third of the lobe and lower half of the isthmus.

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3. THYROIDEA IMA ARTERY (in 30% cases):

It is a branch of the brachiocephalic trunk or may arise directly from
the arch of aorta. It enters the isthmus from below.
4. ACCESSORY THYROID ARTERIES:
They arise from tracheal and esophageal arteries.

VENOUS DRAINAGE:

1. SUPERIOR THYROID VEIN: It emerges at the upper pole of the

thyroid lobe, runs upwards and laterally, and drains into the internal
jugular vein.
2. MIDDLE THYROID VEIN: It emerges at the middle of the lobe and
drains into the internal jugular vein.
3. INFERIOR THYROID VEIN/VEINS: They emerge at the lower border
of the isthmus, form plexus in front of the trachea and then run
downwards to drain into the left brachiocephalic vein.
4. Sometimes a fourth vein, the THYROID VEIN (OF KOCHER)
emerges between the middle and inferior thyroid veins to drain into
the internal jugular vein.

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LYMPHATIC DRAINAGE:
The lymph vessels draining the thyroid gland are upper and lower
group.
1. The UPPER GROUP drains into the prelaryngeal (lying in front of
the larynx) and upper deep cervical (jugulodigastric) lymph nodes.
2. The LOWER GROUP drains into pretracheal and lower deep
cervical lymph nodes and group of lymph nodes along the recurrent
laryngeal nerves. Those from lower part of isthmus drain into
retrosternal or brachiocephalic nodes lying in the superior
mediastinum.
The upper lymphatics follow superior thyroid artery and lower
lymphatics follow the inferior thyroid arteries.

HISTOLOGY
The thyroid gland has two types of cells: follicular and parafollicular.
A. FOLLICULAR CELLS
They are cuboidal epithelial cells forming the wall of spherical
thyroid follicles. They secrete two hormones: thyroxine and
triiodothyronine.
These hormones are essential for normal growth and
development, specially of the skeletal and nervous system.

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B. PARAFOLLICULAR CELLS OR C-CELLS

It lie mainly between the basement membrane and the follicular
cells. Some of them also lie in the spaces between the follicles.
They secrete a hormone called thyrocalcitonin/calcitonin.
It reduces the blood calcium level by reducing the reabsorption
of the calcium by the renal tubules. Its effects are opposite to
that of parathormone.

DEVELOPMENT
The thyroid gland begins to develop as endodermal thickening in the
midline of the floor of the pharynx immediately behind the tuberculum
impar during 3rd week of intrauterine life.
This thickening forms a diverticulum called thyroglossal duct.
This duct grows downwards, descends in front of hyoid bone, becomes
retrohyoid and finally descends below the hyoid with slight inclination
to the left to reach its definitive position (by the end of the 7th week)
where its tip bifurcates and proliferates to form the bilateral terminal
swellings, which expand to form the thyroid gland.
A portion of the duct near its tip sometimes forms the pyramidal lobe.
The remaining duct disappears.
The site of origin of thyroglossal duct is marked by foramen caecum at
the junction of the anterior two-third and posterior one-third of the
tongue in adults.
The thyroid is the earliest glandular tissue to develop and becomes
functional during the 3rd month.

APPLIED ANATOMY

GOITRE:
Any enlargement of the thyroid gland except that during menstruation
and lactation is called goitre.
It may be associated with hypofunction or hyperfunction of the gland.

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HYPOTHYROIDISM

It occurs when there is insufficient secretion of the T3 and T4. The

decreased levels of T3 and T4 cause increased secretion of TSH.
Hypothyroidism causes cretinism in children and myxedema in adults.

HYPERTHYROIDISM occurs due to excess secretion of T3 and T4. It

clinically presents as: tachycardia, tremors, and systolic bruit due to
increased BMR.

SIMPLE GOITRE/PUBERTY GOITRE:

It occurs due to deficiency of iodine in diet. The decreased levels of T3
and T4 lead to increased secretion of TSH from the pituitary gland
which causes hyperplasia of the thyroid gland.
Simple goitre commonly occurs in females at the age of puberty.
(puberty goitre)
The thyroid gland can enlarge backwards or downwards but it cannot
enlarge upwards due to attachment of its fascial sheath and
sternothyroid muscle.
The backward enlargement is common because the thyroid capsule is
relatively thin posteriorly. In backward enlargement, the gland buries
itself around the sides of trachea and esophagus.
This results in three characteristic pressure symptoms, DYSPNEA
(difficulty in breathing), due to pressure on trachea, DYSPHAGIA
(difficulty in swallowing) due to pressure on esophagus and
DYSPHONIA (hoarseness of voice) due to pressure on the recurrent
laryngeal nerve, which lies in the tracheoesophageal groove.
The downward expansion behind the sternum is called retrosternal
goitre. It can compress trachea leading to dangerous dyspnea. It can
also cause severe venous compression.

THYROIDECTOMY:
The superior thyroid artery and the external laryngeal nerve diverge
from each other near the apex, the artery lies superficial and the
nerve lies deep to the apex.
Therefore, during thyroidectomy, the superior thyroid artery should be
ligated close to the apex of thyroid lobe to avoid injury to the external
laryngeal nerve.

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The recurrent laryngeal nerve lies very close to the inferior thyroid
artery near the base of the thyroid lobe. Therefore, during
thyroidectomy, the inferior thyroid artery should be ligated away from
the base of the thyroid lobe to avoid injury to the recurrent laryngeal
nerve.
BENIGN TUMORS may compress or also displace the neighboring
structures whereas malignant growth tends to invade surrounding
structures.
CONGENITAL ANOMALIES: The development of the thyroid gland
may account for the following common congenital anomalies:
a. THYROGLOSSAL CYST/FISTULA: Thyroglossal duct may
persist and lead to formation of thyroglossal cyst and fistula.
b. ECTOPIC THYROID: The Thyroid gland (thyroid tissue) may be
found at an abnormal position anywhere along the course of
thyroglossal duct
(a) at the base of the tongue just beneath the foramen caecum,
and if large, it may cause difficulty in swallowing by the infant
(lingual thyroid)
(b) above, behind or below the hyoid bone (suprahyoid,
retrohyoid, or infrahyoid thyroid).
One of the lobes may be absent.
Isthmus may be absent.

DESCENT OF THE THYROGLOSSAL DUCT

It may go beyond the definitive position in the neck to superior

mediastinum (retrosternal thyroid).

THYROID TISSUE

It may be situated away from the normal course of the thyroglossal

duct, viz. in relation to carotid sheath, in the mediastinum, in the
pericardium (aberrant thyroid).

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6. CAROTID TRIANGLE

INTRODUCTION
The major contents of carotid triangle are common carotid artery,
internal carotid artery, external carotid artery, internal jugular vein, and
last three cranial nerves, all overlapped by sternocleidomastoid.

BOUNDARIES:

A. ANTEROSUPERIORLY
a. Posterior belly of Digastric
b. Stylohyoid

B. ANTEROINFERIORLY
a. Superior belly of omohyoid

C. POSTERIORLY
a. Anterior border of Sternocleidomastoid

D. ROOF
It is formed by investing layer of deep cervical fascia.
The superficial fascia over the roof contains platysma, cervical branch
of facial nerve and transverse facial nerve.

E. FLOOR
It is formed by the following four muscles:
a. Thyrohyoid.
b. Hyoglossus.
c. Middle constrictor.
d. Inferior constrictor.

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CONTENTS:
1. CAROTID ARTERIES
a. Common carotid artery
b. Internal carotid artery
c. External carotid artery and its first five branches.

2. CAROTID SINUS AND CAROTID BODY.

3. INTERNAL JUGULAR VEIN.
4. LAST THREE CRANIAL NERVES
a. Vagus nerve
b. Spinal accessory nerve
c. Hypoglossal nerve.

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5. CAROTID SHEATH
6. ANSA CERVICALIS.
7. CERVICAL PART OF THE SYMPATHETIC CHAIN.
8. DEEP CERVICAL LYMPH NODES

FEATURES OF THE CONTENTS OF THE CAROTID TRIANGLE

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COMMON CAROTID ARTERY

It ascends from just behind the inferior angle of the carotid triangle in
the carotid sheath under cover of anterior border of
sternocleidomastoid and in front of lower 4 cervical transverse
processes and AT THE LEVEL OF THE UPPER BORDER OF THE
THYROID CARTILAGE divides into external and internal carotid
arteries.
The common carotid artery gives no other branches in the neck

INTERNAL CAROTID ARTERY

It runs straight upwards as the continuation of the common carotid
artery.

EXTERNAL CAROTID ARTERY

It ascends anteromedial to the internal carotid artery and gives the
following five branches in the triangle:
1. Ascending pharyngeal artery (first branch).
2. Superior thyroid artery.
3. Lingual artery.
4. Facial artery.
5. Occipital artery.
1. ASCENDING PHARYNGEAL ARTERY:
It is a slender artery that arises from the medial aspect of
external carotid artery near its lower end.
It ascends in the deeper plane on the side of the pharynx.
2. SUPERIOR THYROID ARTERY:
It arises from the front and descends downwards and forwards
to pass deep to the infrahyoid muscles to reach the upper part of
the thyroid gland.
3. LINGUAL ARTERY:
It arises from the front aspect of external carotid artery,
opposite the tip of greater cornu of hyoid bone.
It then runs upwards and forwards forming a characteristic loop
over the greater cornu of the hyoid and disappear deep to the
hyoglossus muscle.
Before disappearing, it gives rise to suprahyoid artery, which
runs superficial to hyoglossus above the hyoid

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4. FACIAL ARTERY
It arises from the front aspect of external carotid artery just
above the lingual artery and runs upwards on the superior
constrictor deep to digastric and stylohyoid muscles.
5. OCCIPITAL ARTERY
It arises from the posterior aspect of external carotid artery at
the lower border of posterior belly of digastric muscle and runs
backwards superficial to internal carotid artery, internal jugular
vein, and last three cranial nerves along the lower border of
posterior belly of digastrics
HYPOGLOSSAL NERVE
It descends between the internal jugular vein and internal carotid
artery.
Then just above the level of greater cornu of hyoid bone, it hooks
around the origin of the occipital artery, runs forwards, crossing in
front of internal carotid artery, external carotid artery, and loop of
lingual artery to run on the hyoglossus muscle above the hyoid bone.
It gives off the SUPERIOR ROOT OF ANSA CERVICALIS (also called
descendens hypoglossi), which descends on the anterior wall of the
internal and common carotid arteries and becomes embedded in the
anterior wall of the carotid sheath.

DEEP CERVICAL LYMPH NODES

They lie on and along the internal jugular vein
INTERNAL JUGULAR VEIN
It is partly hidden by the posterior edge of the sternocleidomastoid.
It descends posterolateral to common and internal carotid arteries and
receives the following three veins in the region of carotid triangle:
a. The LINGUAL VEIN lies just below and parallel to the hypoglossal
nerve, crosses external and internal carotid arteries to join the
internal jugular vein.
b. The COMMON FACIAL VEIN after crossing the digastric triangle,
crosses the upper part of carotid triangle to drain into the internal
jugular vein.
c. The SUPERIOR THYROID VEIN crosses the lower part of the
triangle to end into the internal jugular vein.

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VAGUS NERVE
It descends vertically downwards, first between the internal carotid
artery and internal jugular vein and then between common carotid
artery and internal jugular vein.
It gives the two branches
a. PHARYNGEAL BRANCH: It runs lnferomedially between the
external and internal carotid arteries to join the pharyngeal plexus
on the superior constrictor of the pharynx.
b. SUPERIOR LARYNGEAL NERVE: It runs on a deep plane, deep
to both internal and external carotid arteries, where it divides into
internal and external laryngeal nerves.

The INTERNAL LARYNGEAL NERVE (sensory) passes forwards to

disappear deep to thyrohyoid muscle; there it pierces the thyrohyoid
membrane to supply the laryngeal mucosa.

The EXTERNAL LARYNGEAL NERVE (motor) descends to supply

the inferior constrictor and cricothyroid muscles after passing deep to
the superior belly of the omohyoid.

ACCESSORY NERVE
It runs downwards and backwards across the upper part of the
triangle, superficial to the internal jugular vein to enter the
sternocleidomastoid muscle.

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CAROTID SHEATH
It is a facial sheath which encloses
Internal jugular vein, and
Internal and common carotid arteries.
The vagus nerve lies in between the vein and the artery on a deeper
plane.
The ANSA CERVICALIS is embedded in its anterior wall
The CERVICAL SYMPATHETIC CHAIN lies just deep to its posterior wall
on the prevertebral fascia

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CAROTID SINUS
It is a fusiform dilatation at the terminal end of common carotid artery
or at the beginning of internal carotid artery.
It has rich innervation from IX, X cranial nerves and sympathetic
nerves.
The carotid sinus acts as a baroreceptor (pressure receptor) and
regulates the blood pressure in the cerebral arteries.
CAROTID BODY
It is a small oval structure situated behind the bifurcation of the
common carotid artery.
It is reddish-brown and receives rich nerve supply from
glossopharyngeal, vagus, and sympathetic nerves.
It acts as a chemoreceptor and responds to the changes in the oxygen
and carbon dioxide content of the blood.
The excess of CO2 and reduced O2 tension in blood stimulates it
causing increase in blood pressure and heart rate.
ANSA CERVICALIS:
The Ansa cervicalis (Ansa hypoglossi) is a U-shaped nerve loop present
in the region of the carotid triangle embedded in the anterior wall of
the carotid sheath.
It is derived from ventral rami of C1, C2, and C3 spinal nerves.
It supplies all the infrahyoid muscles except thyrohyoid, which is
supplied by nerve to thyrohyoid (C1) from hypoglossal nerve.

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ROOT FORMATION SUPPLY

SUPERIOR It is formed by the descending branch of the Superior belly
ROOT hypoglossal nerve carrying C1 spinal nerve of omohyoid
fibres.
It descends downwards over internal and
common carotid arteries.

INFERIOR It is derived from C2 and C3 spinal nerves. Sternohyoid,

ROOT As this root descends, it first winds round Sternothyroid
(descendens the internal jugular vein and then continues Inferior belly
of omohyoid
cervicalis) anteroinferiorly to join the superior root in
front of the common carotid artery at the
level of cricoid cartilage.

CLINICAL ANATOMY:
1. CAROTID SINUS SYNDROME:
In an individual with carotid sinus hypersensitivity, pressure on
carotid sinuses can cause enough slowing of heart rate, fall in
blood pressure, and cerebral ischemia that will lead to fainting
(syncope).
patient will have sudden attacks of syncope on rotation of head
especially when wearing a shirt with tight collar or a tie with tight
knot, condition called CAROTID SINUS SYNDROME.
Symptoms can be relieved by periarterial neurectomy.

2. CAROTID TUBERCLE:
The common carotid artery can be compressed against the
prominent anterior tubercle of transverse process of the 6th
cervical vertebra called CAROTID TUBERCLE by pressing
medially and posteriorly with the thumb.

3. CAROTID PULSE:
The common carotid artery can be pulsated against the anterior
border of the sternocleidomastoid in the carotid triangle

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7. SUBMANDIBULAR SALIVARY GLAND:

INTRODUCTION:
Partly below & partly deep to the posterior half of the mandible
10-20 g
Mixed (mucus and predominantly serous)

PARTS:
a. LARGE SUPERFICIAL PART (lies superficial to mylohyoid)
b. SMALL DEEP PART (lies deep to mylohyoid)
Both meet at posterior end of mylohyoid

SUPERFICIAL PART & ITS RELATION:

Anterior Fills the anterior part of the digastric triangle extending
upwards up to the mylohyoid line.
Has 2 ends and 3 surfaces

ENDS:

a. ANTERIOR END-extends upto the anterior belly of the digastric

muscle
b. POSTERIOR END extends upto the stylomandibular ligament
Separates the submandibular gland from the parotid gland

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RELATIONS:

SUPERFICIAL OR LATERAL
MEDIAL SURFACE
INFERIOR SURFACE SURFACE
Skin Submandibular ANTERIOR PART:
Superficial fascia fossa Mylohyoid muscle
(platysma and Medial pterygoid Submental branch of facial artery
cervical branch of muscle Mylohyoid nerve and vessels
fascial nerve) Facial artery MIDDLE PART:
Deep fascia
Hyoglossus & styloglossus muscle
Facial vein
Lingual and hypoglossal nerves
Submandibular
Submandibular ganglion
lymph nodes
POSTERIOR PART:
Styloglossus muscle
Stylohyoid ligament
Glossopharyngeal nerve
Wall of pharynx

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DEEP PART & ITS RELATION:

a. Posteriorly it is continuous with the superficial part
b. Anteriorly it extends upto the sublingual salivary gland

RELATIONS:

MEDIAL: hyoglossus

LATERAL: mylohyoid

SUPERIOR: lingual nerve and submandibular ganglion

INFERIOR: hypoglossal nerve

accompanied by a pair of veins

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5 cm long
Emerges at the anterior end of the deep part
COURSE:
Runs forward on the hyoglossus (btw lingual and hypoglossal nerves)
At anterior border of hyoglossus, crossed by the lingual nerve
Runs between the sublingual gland and genioglossus
Opens in to the oral cavity on the summit of the sublingual papilla.

BLOOD SUPPLY:
By sublingual and submental arteries
Drained by the common facial and lingual veins

NERVE SUPPLY:
1. PARASYMPATHETIC + SYMPATHETIC + SENSORY
2. Parasympathetic (stimulation produces watery secretion)
3. Preganglionic fibres arise from the superior salivatory nucleus
Facial Nerve
Chorda tympani
Lingual nerve
RELAY STATION: submandibular ganglion from where the post
ganglionic fibres arise
SYMPATHETIC (stimulation produces sticky mucus rich secretion):
PREGANGLIONIC FIBRES arise from the T1 segment
Enter the cervical sympathetic trunk
Relay station: superior
cervical sympathetic ganglion
SENSORY: by lingual nerve

LYMPHATIC DRAINAGE:
Drain into the submandibular
lymph nodes and subsequently
into the jugulodigastric lymph
nodes

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CLINICALS:
Formation of calculi in the submandibular gland is more common than
in the parotid duct because:
a. Its secretion is more viscid
b. Its duct is torturous and has upward course
Excision of the submandibular gland for calculus or tumor is done by
skin incision below the angle of mandible
Swellings of the gland is palpated bimanually

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8. TEMPOROMANDIBULAR JOINT
TYPE OF JOINT = Synovial joint of condylar variety.
ARTICULAR SURFACES:
Joint is divided into upper and lower parts by an intra-articular disc.
A. UPPER ARTICULAR SURFACE:
Formed by:
a. Articular fossa
b. Articular eminence or tubercle of temporal bone
c. Posterior non-articular part formed by tympanic plate
Surface is concavo convex from behind forwards
B. LOWER ARTICULAR SURFACE:
Formed by head of mandible
Surface is elliptical in shape
Both surfaces are covered by fibrocartilage and joint is hence an
atypical synovial joint.
ARTICULAR DISC:
It is an oval plate of fibrocartilage.
It consists mainly of collagen fibres with few cartilage cells.
Congruent with both articular surfaces.
Periphery of disc is firmly attached to fibrous capsule.
Disc has a thick margin, the peripheral annulus and a central
depression on its inferior surface.
In sagittal section - Disc appears to possess a thin intermediate zone &
thickened anterior and posterior bands.
ANTERIOR BAND Extends anteriorly through capsule continuous
w/tendon of lateral pterygoid.
POSTERIOR BAND Splits into 2 laminae upper & lower.
UPPER LAMINA - Composed of fibroelastic tissue attached to
squamotympanic fissure.
LOWER LAMINA Composed of fibrous non-elastic tissue
attached to back of condyle.
Bilaminar region contains a venous plexus.
Central part of disc is avascular.
Elastic fibers in posterior part of disc bring back the disc in the
articular fossa when open mouth is closed.
Prevents friction between articulating surfaces.

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Acts as a cushion and helps in shock absorption.

Stabilizes condyle by filling up space between articulating surfaces.
Proprioceptive fibre
It is present in disc help regulate movements of joint.
Disc increases area of contact to help distribute weight across TMJ.

PARTS:
a. Anterior extension
b. Anterior thick band
c. Intermediate zone
d. Posterior thick band
e. Posterior bilaminar zone

LIGAMENTS:
1) FIBROUS CAPSULE:
Attached
a. Above Articular tubercle
b. In front Circumference of mandibular fossa
c. Behind Squamotympanic fissure
d. Below Neck of mandible
Capsule is loose above intra-articular disc
Capsule is tight below intra-articular disc
Synovial membrane lines the fibrous capsule and the neck of the
mandible.

2) LATERAL (TEMPOROMANDIBULAR) LIGAMENT:

Reinforces and strengthens lateral part of capsular ligament.
Fibers are directed downwards and backwards.
Attached
a. Above - Articular tubercle
b. Below Posterolateral aspect of neck of mandible

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3) SPHENOMANDIBULAR LIGAMENT:
Accessory ligament.
Lies on a deep plane away from fibrous capsule.
Attached
a. Superiorly Spine of sphenoid
b. Inferiorly Lingula of mandibular foramen
Related
Laterally
a. Lateral pterygoid muscle
b. Auriculotemporal nerve
c. Maxillary artery
Medially
a. Chorda tympani nerve
b. Wall of pharynx
Near its lower end, it is pierced by mylohyoid nerve and vessels.

4) STYLOMANDIBULAR LIGAMENT:
Accessory ligament
Represents a thickened part of deep cervical fascia.
Separates parotid and submandibular salivary glands.

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ATTACHED
a. ABOVE Lateral surface of styloid process
b. BELOW angle and adjacent part of posterior border of ramus of
mandible

MOVEMENTS OCCURRING AT TMJ:

1) DEPRESSION:
Lowering of jaw to open mouth
MUSCLES:
a. Lateral pterygoid
b. Digastric
c. Geniohyoid
d. Mylohyoid
Head of mandible along with an articular disc glide forward in the
upper menisco-temporal compartment on both sides by
contraction of lateral pterygoid muscle.
At the same time head rotates forward underneath the articular
disc by contraction of suprahyoid muscles Digastric, Geniohyoid
and Mylohyoid.
Gravity also helps in opening the mouth.
2) ELEVATION:
Elevating of jaw to close mouth
MUSCLES:
a. Masseter
b. Medial pterygoid
c. Temporalis
Movements take place in a reverse order to depression

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First the head of mandible along with an articular disc glide

backward in the upper menisco-temporal compartment by
Temporalis, Masseter, and Medial pterygoid.
Head then rotates backward on the lower surface of disc by
posterior fibers of temporalis.
3) PROTRACTION/PROTRUSION:
MUSCLES:
a. Medial pterygoid
b. Lateral pterygoid
c. Masseter
Mandibular teeth move forward in front of maxillary teeth.
Head of mandible along with articular disc glide forwards in the
upper menisco-temporal compartment on both sides by
simultaneous action of Medial and Lateral pterygoids on both sides.
4) RETRACTION:
MUSCLES:
a. Posterior fibers of Temporalis
b. Middle and deep fibers of Masseter
c. Middle and deep fibers of Digastric
d. Middle and deep fibers of Geniohyoid
Head of mandible along with articular disc glide backwards in upper
menisco-temporal compartment by the contraction of posterior
fibers of temporalis muscle.
This brings the joint to resting position.
Forceful retraction is assisted by deep fibers of Masseter, Digastric,
and Geniohyoid muscles.
At the end of this movement head of mandible comes to lie
underneath the articular tubercle.
5) SIDE TO SIDE (CHEWING) MOVEMENTS:
Movements occur alternately in right and left TMJ
MUSCLES:
a. Medial pterygoid
b. Lateral pterygoid
Head of mandible on one side glides forwards along with disc.
Head of mandible on opposite side rotates on the vertical axis.
Chin moves forward and to one side, i.e., towards the side on which
no gliding has taken place.

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Medial & lateral pterygoids of one side contract alternatively with

those of opposite sides.

APPLIED ANATOMY:
DISLOCATION OF MANDIBLE:
Mandible is dislocated anteriorly only.
When the mouth is open, mandibular condyles move forward and lie
underneath the articular eminences.
This is the most unstable position of TMJ.
In this position, if there is excessive opening of mouth as during
yawning, sudden violence or convulsive spasm of lateral pterygoid
muscles, the head of mandible on one or both sides may slip anteriorly
and get locked into infratemporal fossa.
Mouth cannot be closed anymore.
Any passive effort to close mouth will fracture neck of mandible on one
or both sides.
To reduce dislocation, condyle must be lowered and pushed back
behind the summit of articular eminence into the articular fossa.
Thus, the reduction is done by depressing jaw with thumb placed on
the last molar teeth and simultaneously elevating the chin.

TEMPOROMANDIBULAR JOINT SYNDROME:

Consists of group of symptoms arising from TMJs and associated
masticatory muscles.
Typical presenting symptoms:
- Diffuse facial pain due to spasm of masseter
- Headache due to spasm of temporalis
- Jaw pain due to spasm of lateral pterygoid
Symptoms associated w/clicking and pain in joint.
Clicking audible during chewing
Occurs when posterior attachment of disc becomes stretched or
detached.
Allows disc to become temporarily or permanently trapped anteriorly.
Derangement of articular disc results from an overclosure or
malocclusion.
In operations on TMJ, VII nerve & auriculotemporal nerve, branch of
mandibular division of V nerve should be preserved with care.

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9. EXTRAOCULAR MUSCLES OF EYE:

TWO TYPES:

1. VOLUNTARY MUSCLES
a. Four recti muscles Superior rectus, Inferior rectus, Medial rectus,
Lateral rectus
b. Two oblique muscles Superior oblique, inferior oblique
c. One levator palpebrae Superior
2. INVOLUNTARY MUSCLES
a. Superior tarsal muscle / Muller's muscle
b. Inferior tarsal muscle
c. Orbitalis

NERVE
MUSCLES ORIGIN INSERTION
SUPPLY
Muscle is divided into 3 lamellae

1. UPPER LAMELLA consists of

skeletal muscle inserts into
skin of upper eyelid.
LEVATOR 2. INTERMEDIATE LAMELLA
Lesser wing of consists of smooth muscle Oculomotor
PALPEBRAE
sphenoid inserts onto upper border of nerve
SUPERIORIS
Superior tarsal plate
3. LOWER LAMELLA consists of
connective tissue inserts
onto superior fornix of
conjunctiva

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Upper medial
portion of
SUPERIOR Upper part of sclera in front of Oculomotor
common
RECTUS tendinous ring-
equator 8mm from limbus nerve

Annulus of Zinn

Lower part of
INFERIOR Lower part of sclera in front of Oculomotor
common
RECTUS tendinous ring
equator- 6mm from limbus nerve

Upper and lower

LATERAL head in lateral Lateral side of sclera in front of Abducent
RECTUS part of common equator 7mm from limbus nerve
tendinous ring

Medial part of
MEDIAL Medial side of sclera in front of Oculomotor
common
RECTUS tendinous ring
equator 5mm from limbus nerve

SUPERIOR Lesser wing of Posterosuperior quadrant of Trochlear

OBLIQUE sphenoid eyeball nerve

Antero medial
INFERIOR Posterolateral part of eyeball Oculomotor
part of orbital
OBLIQUE floor
behind the eyeball nerve

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FUNCTIONS OF EXTRAOCULAR MUSCLES:

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10. INTRACRANIAL DURAL VENUS SINUSES:

The Dural venous channels are formed by two ways,
1. By the separation of two layers of cranial dura.
2. By the reduplication of the meningeal layer of dura.
The Dural venous sinuses are lined by endothelium which becomes
continuous with endothelial lining of the veins.
FEATURES:
Lie between the layers of dura mater.
Are devoid of smooth muscle fibres in their walls.
Devoid of valves in their lumen blood can flow in either direction in
the sinuses.
Receive venous blood and CSF and finally drain into internal jugular
veins.
Have cerebral, diploic, some meningeal veins as their tributaries.
Receive emissary veins which regulate blood flow and maintain
equilibrium of the skull.

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CLASSIFICATION:
There are about 21 sinuses. They are classified into paired and
unpaired.

UNPAIRED:
1. Superior sagittal sinus
2. Inferior sagittal sinus
3. Straight sinus
4. Anterior intercavernous sinus
5. Posterior intercavernous sinus
6. Occipital sinus

PAIRED:
1. Superior petrosal sinuses
2. Inferior petrosal sinuses
3. Sphenoparietal sinuses
4. Petrosquamous
5. Cavernous sinus
6. Transverse sinuses
7. Sigmoid sinuses

CAVERNOUS SINUS:
The cavernous sinus is located on either side of the body of sphenoid
bone and Sella turcica in the middle cranial fossa.
Anteroposterior length = 2 cm
Transverse length = 1 cm

RELATIONS:

SUPERIOR:
a. Optic chiasma
b. Optic tract
c. U shaped loop of internal carotid artery forming carotid siphon
INFERIOR:
a. Foramen lacerum
b. Junction of body and the greater wing of the sphenoid.
MEDIAL:
a. Pituitary gland
b. Sphenoid air sinus.

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LATERAL:
a. Uncus of temporal lobe
b. Cavum trigeminale
ANTERIOR:
a. Superior orbital fissure
b. Apex of orbit
POSTERIOR:
a. Crus cerebri
b. Apex of petrous temporal bone

STRUCTURES PRESENT IN THE LATERAL WALL OF SINUS:

From below upwards, [MOTO]

a. Maxillary nerve
b. Ophthalmic nerve
c. Trochlear nerve
d. Oculomotor nerve.

STRUCTURES PASSING THROUGH CAVERNOUS SINUS:

a. Internal carotid artery
b. Abducens nerve
Pulsation of internal carotid artery help in expelling blood from the
sinus.

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TRIBUTARIES OF CAVERNOUS SINUSES:

It receives blood from three sources,

FROM ORBIT:
a. Superior ophthalmic vein
b. Inferior ophthalmic vein when it does not end in Superior ophthalmic
vein
c. Central vein of retina sometimes when it fails to drain into Superior
ophthalmic vein
FROM MENINGES:
a. Sphenoparietal sinus
b. Anterior trunk of middle meningeal vein when it fails to drain into
pterygoid venous plexus

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FROM BRAIN:
a. Superficial middle cerebral vein
b. Inferior cerebral veins

COMMUNICATIONS OF CAVERNOUS SINUS:

IT COMMUNICATES WITH THE,

Internal jugular vein via inferior petrosal sinus.
Transverse sinus via superior petrosal sinus.
Superior sagittal sinus through superficial middle cerebral vein and
Superior anastomotic vein
Pterygoid venous plexus via emissary vein.
Facial vein via two routes
Emissary vein pterygoid venous plexus deep facial vein facial vein
Superior ophthalmic Opposite cavernous sinus via anterior and
posterior intercavernous sinuses.
Internal vein angular vein facial vein
vertebral venous plexus via basilar venous plexus.

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CLINICAL:
CAVERNOUS SINUS THROMBOSIS:
It may be caused by its numerous communications.
The commonest pathway is through facial vein -- emissary vein.
SYMPTOMS ARE:
a. Severe pain in eye
b. Ophthalmoplegia
c. Edema of eyelids with exophthalmos.

ARTERIOVENOUS COMMUNICATION:
If the internal carotid artery is ruptured within cavernous sinus, an
arteriovenous communication is established
It enlarges the sinus and increase the force of blood in connecting
veins
SYMPTOMS ARE:
a. Pulsating exophthalmos (bulging eye pulsates in synchrony with
radial pulse)
b. Ophthalmoplegia (due to paralysis of abducens nerve)
c. Orbital and conjunctival engorgement (chemosis) due to raised
venous pressure.

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11.ABDUCENT NERVE
INTRODUCTION:
6th cranial nerve
Purely motor and supplies only one muscle (lateral rectus of eyeball)
Named so as it abducts the eyeball
Also called as NERVE because in ancient times, boys
used to call girls from a gathering by sending signal through the
action of this muscle.
UNIQUE FEATURES:
Most susceptible to damage of all the cranial nerves during increased
intracranial pressure
FUNCTIONAL COMPONENTS AND NUCLEI:
A. GSE FIBRES
Arise from abducent nucleus in pons
Supply the lateral rectus of eyeball
B. GSA FIBRES
Carry proprioceptive sensations from lateral rectus
Terminate in mesencephalic nucleus of trigeminal nerve

COURSE, RELATIONS, AND DISTRIBUTION:

The abducent nerve arises at the lower border of the pons opposite
to the pyramid of the medulla.
The nerve runs upward, forward, and laterally dorsal to the anterior
cerebellar artery and pierces the dura mater over the clivus
inferolateral to the dorsumsellae.
It then passes through the medial wall of the inferior petrosal sinus
and arches forward directly over the sharp ridge of the petrous
temporal bone, under the petroclinoid ligament and enters the fibro-
osseous canal ( canal) formed by the apex of the petrous
temporalboneand thepetroclinoid ligament( ligament).
The nerve then enters the cavernous sinus by piercing the posterior
wall close to the floor of the sinus.

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In the cavernous sinus, it

runs forward inferolateral
to the internal carotid
artery.
The nerve enters the orbit
through the superior
orbital fissure within the
tendinous ring lateral to 2
divisions of oculomotor
and nasociliary nerves.
In the orbit, it runs
forward, towards the
lateral side to enter the
orbital surface of the
lateral rectus muscle,
which it supplies.

CLINICAL ANATOMY:
LESIONS OF ABDUCENT NERVE:
- The abducent nerve is generally damaged during increased
intracranial pressure.
- Duringincreasedintracranialpressure, thenerveis stretcheddue to
the descent of brainstem.
- Consequently, the nerve is cut by the sharp bony edge of the petrous
temporal bone.
- The paralysis of lateral rectus muscle following the injury of the
abducent nerve leads to:
a. Convergent squint due to the unopposed action of medial
rectus
b. Inability to abduct the eye, and
Diplopia (double vision) with maximum separation of two images while
looking towards the paralyzed side.

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HEAD AND NECK SHORT ANSWERS

PAGE
SR. NO. QUESTION
NO.

1. 73

2. WALDEYER'S RING 74

STRUCTURE RELATED TO LATERAL WALL OF

3. 75
CAVERNOUS SINUS

4. MENTION THE BRANCHES OF OPHTHALMIC NERVE 75

5. NAME THE BRANCHES OF FACIAL ARTERY IN FACE 76

6. TONSILLAR BED 76

7. FORMATION AND TERMINATION OF EJV 76

8. NERVE SUPPLY OF PINNA: 77

9. SUPERIOR ORBITAL FISSURE: 78

10. BRANCHES OF ICA: 79

11. DANGEROUS AREA OF FACE: 80

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12. TRIGEMINAL NEURALGIA: 81

INTRINSIC MUSCLES OF LARYNX AND ITS NERVE

13. 81
SUPPLY

14. NAMES OF BONES MEETING AT PTERION: 82

15. MUSCLES ATTACHED TO CRICOID CARTILAGE 82

STRUCTURES PASSING THROUGH INTERNAL ACOUSTIC

16. 83
MEATUS

17. PARTS OF ORBICULARIS OCULI 83

18. LINGUAL PAPILLA 83

19. VENOUS SINUSES RELATED TO FALX CEREBRI 84

20. SIGNIFICANCE OF PYRIFORM FOSSA 84

21. MUSCLES OF MASTICATION 84

22. NERVE SUPPLY OF LARYNX- 85

23. STRUCTURES PASSING THROUGH FORAMEN OVALE 86

24. BONES FORMING NASALSEPTUM 86

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25. STRUCTURE PASSING THROUGH FORAMENSPINOSUM 86

26. PARTS OF LACRIMAL APPARATUS 86

27. INFRAHYOID MUSCLES 86

28. NAME THE TERMINAL BRANCHES OF FACIAL NERVE: 87

29. NAME THE UNPAIRED CARTILAGE OF LARYNX: 87

30. EMISSARY VEIN: 87

31. LACUS LACRIMALIS: 88

32. LYMPHATIC DRAINAGE OF FACE: 88

33. 89

34. BONES DERIVED FROM THE FIRST PHARYNGEAL ARCH: 89

35. ENUMERATE MUSCLES OF PALATE: 89

36. TWO FEATURES OF NASO-PHARYNX: 89

37. BOUNDARIES OF SUBMENTAL TRIANGLE: 90

38. NAME THE UNPAIRED DURAL VENOUS SINUSES: 90

39. FALX CEREBELLI: 90

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40. MIDDLE CERVICAL GANGLION: 91

41. PAROTID DUCT: 91

42. FENESTRA VESTIBULI: 91

43. EPICRANIAL APONEUROSIS: 92

44. BRANCHES OF ECA: 92

45. TENTORIUM CEREBELLI: 93

46. MIDDLE EAR BONES: 93

47. SUBOCCIPITAL NERVE: 94

48. LARNGYNEAL INLETS: 94

49. STRUCTURE PIERCED BY PAROTID DUCT 94

50. ORIGIN AND BRANCHES - MIDDLE MENINGEAL ARTERY 95

51. ARTERIAL SUPPLY- PITUITARY GLAND 95

52. OPENING OF MAXILLARY SINUS (MAXILLARY HIATUS) 96

53. AUDITORY TUBE OPENING 96

54. BLOOD SUPPLY -TONSILS 97

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55. NERVE SUPPLY AND ACTION - CRICOTHYROID MUSCLE 97

56. VOCAL CORDS 98

FORMATION AND TERMINATION OF INTERNAL JUGULAR

57. 98
VEIN

58. PIRIFORM FOSSA: 98

59. TRIBUTARIES OF CARNVEROUS SINUS: 98

60. CAVERNOUS SINUS COMMUNICATES WITH: 99

61. 100

62. CAROTID SHEALTH: 100

FORMATION AND DISTRIBUTION OF FINAL PART OF

63. 101
ACCESSORY NERVE:

64. TORTICOLLIS 101

65. CAROTID TRIANGLE 102

66. DEEP CARDIAC PLEXUS 105

67. EPISTAXIS 106

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68. SECRETOMOTOR PATHWAY TO PAROTID GLAND 107

69. INFRAHYOID MUSCLES 109

70. MAXILLARY SINUS (ANTRUM OF HIGHMORE) 112

71. CAROTID TRIANGLE 116

72. OESOPHAGUS 119

73. CAVERNOUS SINUS 121

RECURRENT LARYNGEAL NERVE- (NERVE OF 6TH

74. 125
ARCH):

75. MIDDLE EAR: 128

76. PTERYGOPALATINE GANGLION: 132

77. HYOGLOSSUS (A FLAT QUADRILATERAL MUSCLE): 136

78. ANSA CERVICALIS: 136

79. CILIARY GANGLION: 138

80. FACIAL ARTERY 140

81. SUBCLAVIAN TRIANGLE: 141

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82. TYMPANIC MEMBRANE: 144

83. STYLOID APPARATUS 146

84. DUCT: 147

85. VOCAL CORDS: 148

86. VENOUS DRAINAGE OF FACE 150

87. MIDDLE MEATUS OF NOSE 152

88. ATLANTO-OCCIPITAL JOINT 154

89. HYOGLOSSUS MUSCLE 155

90. BLOOD SUPPLY OF THYROID GLAND 157

91. LYMPH DRAINAGE OF TONGUE 161

92. CONTENTS OF POSTERIOR TRIANGLE 165

93. EXTRINSIC MUSCLES OF TONGUE 166

94. BRACHIOCEPHALIC VEIN 168

95. PTERION 170

96. BLOOD AND NERVE SUPPLY OF SCALP 171

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97. TONGUE MUSCLES - NERVE SUPPLY AND ACTION. 174

98. DIGASTRIC TRIANGLE: 178

99. INTRINSIC MUSCLES OF LARYNX 181

100. MEDIAN NASAL SEPTUM: 182

101. EXTERNAL ACOUSTIC MEATUS 185

102. SAGITTAL SECTION OF EYE BALL 188

103. PARANASAL AIR SINUS 189

104. MIDDLE EAR CAVITY 193

105. EAR OSSICLES 198

106. FACIAL ARTERY IN FACE: 201

107. LATERAL PTERYGOID MUSCLE: 202

108. SURFACE AND BORDERS OF THYROID GLAND: 205

109. ISTHMUS: 206

110. STERNOCLEIDOMASTOID MUSCLE. 211

111. SUPERIOR SAGITTAL SINUS 216

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112. LATERAL WALL OF NOSE 219

113. ORBICULARIS OCULI 224

114. BLOOD SUPPLY OF THYROID GLAND & DEVELOPMENT 227

115. BOUNDARIES & CONTENT OF SUBOCCIPITAL TRIANGLE 230

116. EUSTACHIAN TUBE 232

117. INFERIOR CONSTRICTOR 235

118. LACRIMAL APPARATUS 237

119. SUPERIOR LARYNGEAL NERVE 241

120. MUSCLES OF MASTICATION 242

121. TROCHLEAR NERVE 244

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1.

It is about 5cm long.

Emerges at the anterior end of deep part.
Runs forwards on the hyoglossus between the lingual and hypoglossal
nerves.
Near the anterior border of hyoglossus, it is crossed by lingual nerve.
Continues running forward between sublingual gland and
genioglossus.
Lies just deep to the mucus membrane of the oral cavity.
Opens into oral cavity on summit of sublingual papilla at the side of
frenulum of tongue.

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2. WALDEYER'S RING

Aggregations of lymphoid tissue underneath the epithelial lining of

pharyngeal wall called TONSILS surround commencement of air and
food passages.
These aggregations together constitute an interrupted circle called
.
This forms the special feature of interior of pharynx.

Formed by:
1. POSTEROSUPERIORLY Nasopharyngeal tonsil
2. ANTERIORLY Lingual tonsil
3. LATERALLY Tubal and palatine tonsils

Prevents invasion of microorganisms from entering the air and food

passages and this helps in the defense mechanism of respiratory and
alimentary system

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3. STRUCTURE RELATED TO LATERAL WALL OF

CAVERNOUS SINUS

1) OCULOMOTOR NERVE:
Gives superior and inferior divisions in anterior part of sinus.
Leave sinus by passing through superior orbital fissure.
2) TROCHLEAR NERVE:
Crosses superficial to oculomotor nerve in the anterior part of sinus.
Enters the orbit through superior orbital fissure.
3) OPHTHALMIC NERVE:
In the anterior part, divides into:
1. Lacrimal nerve
2. Frontal nerve
3. Nasociliary nerve
4) MAXILLARY NERVE:
Passes through foramen rotundum
Leaves sinus
Reaches pterygopalatine fossa
5) TRIGEMINAL GANGLION:
Ganglion and its Dural cave may project into the posterior part of
lateral wall of sinus

4. MENTION THE BRANCHES OF OPHTHALMIC NERVE

Lacrimal
Frontal
Nasociliary
Sensory root to ciliary ganglion
Long ciliary nerves
Posterior ethmoidal nerve
Anterior ethmoidal nerve
Infratrochlear nerve

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5. NAME THE BRANCHES OF FACIAL ARTERY IN FACE

A. FROM CERVICAL PART

1. Ascending palatine artery
2. Tonsillar artery
3. Glandular branches
4. Submental artery
B. FROM FACIAL PART
1. Inferior labial artery
2. Superior labial artery
3. Lateral nasal artery
4. Muscular branches

6. TONSILLAR BED

Formed by:
1. Pharyngobasilar fascia
2. Superior constrictor muscle
3. Buccopharyngeal fascia

7. FORMATION AND TERMINATION OF EJV

Begins just below angle of mandible by union of posterior division of

retromandibular vein and posterior auricular vein.
Runs across Sternocleidomastoid under cover of platysma.
Pierce deep cervical fascia in anteroinferior angle of posterior triangle
about 2.5 cm above clavicle along posterior border of
sternocleidomastoid.
Enters supraclavicular space.
Terminates in subclavian vein after passing through space.

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8. NERVE SUPPLY OF PINNA:

LATERAL SURFACE OF AURICLE:
1. Upper 2/3rd is supplied by auriculotemporal branch of Vth cranial
nerve.
2. Lower 1/33rd is supplied by Great auricular nerve.
MEDIAL SURFACE OF AURICLE:
1. Upper 2/3rd is supplied by Lesser occipital nerve.
2. Lower 1/3rd is supplied by Great auricular branch of vagus nerve.
ROOT OF AURICLE is supplied by Auricular branch of vagus.
AURICULAR MUSCLES are supplied by Facial nerve.

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9. SUPERIOR ORBITAL FISSURE:

It is an elongated triangular fissure in front and lateral to foramen
rotundum.
Structures passing through superior orbital fissure:

IN PART PRESENT WITHIN COMMON TENDINOUS RING:

1. Superior and inferior division of oculomotor nerve
2. Nasociliary nerve
3. Abducent nerve
4. Sympathetic root of ciliary ganglion.

STRUCTURE PRESENT ABOVE THE COMMON TENDINOUS RING:

1. Trochlear nerve
2. Frontal nerve
3. Lacrimal nerve
4. Lacrimal artery
5. Recurrent meningeal branch of lacrimal artery

STRUCTURES PRESENT BLW THE COMMON TENDINOUS RING:

1. Inferior ophthalmic vein.

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10. BRANCHES OF ICA:

MNEMONIC:

1. A: Anterior choroidal artery (C7)

2. V: Vidian artery (C2)
3. I: Inferolateral trunk (C4)
4. P: Posterior communicating artery (C7)
5. S: Superior hypophyseal artery (C6)
6. C: Caroticotympanic artery (C2)
7. O: Ophthalmic artery (C6)
8. M: Meningohypophyseal trunk (C4)
9. M: Middle cerebral artery (C7)
10. A: Anterior cerebral artery (C7)

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11. DANGEROUS AREA OF FACE:

Facial veins that are devoid of valves communicates with the

cavernous sinus through emissary veins.
Infections in the region of upper lip, lower part of nose and adjacent
cheek area are prone to spread in backward direction via the valveless
facial vein to cause thrombus in cavernous sinus.
So, this area is called the DANGEROUS AREA OF FACE.

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12. TRIGEMINAL NEURALGIA:

A condition in which one or more of the three divisions of trigeminal

nerve is involved causing, paroxysmal episodes of severe pain and
burning sensation for short duration, along the area of distribution of
affected nerve.
Pain will be removed by:
1. Injecting 90% alcohol in affected nerve division
2. Sectioning the sensory root of affected nerve
3. Or performing medullary tractomy.

13. INTRINSIC MUSCLES OF LARYNX AND ITS NERVE

SUPPLY
1. Cricothyroid
2. Posterior cricoarytenoid
3. Lateral cricoarytenoid
4. Transverse arytenoid
5. Oblique arytenoid
6. Aryepiglottic
7. Thyroepiglottic
8. Thyroarytenoid
9. Vocalis

All intrinsic muscles of larynx are supplied by RECURRENT

LARYNGEAL NERVE except Cricothyroid which is supplied by external
laryngeal nerve.

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14. NAMES OF BONES MEETING AT PTERION:

A. Frontal bone
B. Parietal bone
C. Squamous part of temporal bone
D. Greater wing of sphenoid

15. MUSCLES ATTACHED TO CRICOID CARTILAGE

1. Lateral cricoarytenoid muscles
2. Posterior cricoarytenoid muscles
3. Cricothyroid muscles

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16. STRUCTURES PASSING THROUGH INTERNAL

ACOUSTIC MEATUS
1. Vestibulocochlear nerve (CN VIII)
2. Facial nerve (CN VII)
3. Labyrinthine artery (an internal auditory branch of the anterior
inferior cerebellar artery)
4. Vestibular ganglion.

17. PARTS OF ORBICULARIS OCULI

1. Orbital part
2. Palpebral part

18. LINGUAL PAPILLA

1. Circumvallate (vallate)
2. Filiform
3. Fungiform
4. Foliate

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19. VENOUS SINUSES RELATED TO FALX CEREBRI

1. Frontal sinus
2. Ethmoidal sinus
3. Superior sagittal sinus
4. Inferior sagittal sinus

20. SIGNIFICANCE OF PYRIFORM FOSSA

PYRIFORM SINUS recess on either side of laryngeal orifice

Deep to the mucous membrane of the pyriform fossa lie the recurrent
laryngeal nerve as well as the internal laryngeal nerve, a branch of
the superior laryngeal nerve.
The INTERNAL LARYNGEAL NERVE supplies sensation to the area, and
it may become damaged if the mucous membrane is inadvertently
punctured.
The pyriform sinus is a SUBSITE OF THE HYPOPHARYNX.
This distinction is important for head and neck cancer staging and
treatment.

21. MUSCLES OF MASTICATION

Masseter
Temporalis
Lateral
pterygoid
Medial pterygoid

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22. NERVE SUPPLY OF LARYNX-

MOTOR- All intrinsic muscles- rec. laryngeal nerve Except cricothyroid-
externalbranchofsuperior laryngeal nerve

SENSORY-ABOVE VOCAL CORDS-internal branch of superior laryngeal

nerve

BELOW VOCALCORDS- Recurrent Laryngeal Nerve

Recurrent laryngeal nerve arises from trunk of vagus
Superior laryngeal nerve arises from Inferior Ganglion of vagus.

FOUR BRANCHES OF 1ST PART OF MAXILLARY ARTERY-

a. Sphenopalatine artery
b. Descending palatine artery
c. Infraorbital artery
d. Posterior superior alveolarartery

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23. STRUCTURES PASSING THROUGH FORAMEN OVALE

1. Mandibular nerve
2. Accessory meningeal nerve
3. Lessor petrosal nerve (br. of glossopharyngeal nerve)
4. Emissary vein

24. BONES FORMING NASAL SEPTUM

1. Perpendicular plate of ethmoid bone
2. Vomer bone
3. Crest of maxillary bone
4. Crest of palatine bone

25. STRUCTURE PASSING THROUGH FORAMEN

SPINOSUM
1. Middle meningeal artery
2. Middle meningeal vein
3. Nervus spinosus

26. PARTS OF LACRIMAL APPARATUS

1. Lacrimal gland
2. Lacrimal canaliculi
3. Lacrimal sac
4. Nasolacrimal duct
5. Meibomian glands

27. INFRAHYOID MUSCLES

1. SUPERFICIAL PLANES- omohyoid and sternohyoid muscles
2. DEEP PLANE- sternothyroid and thyrohyoid muscles

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28. NAME THE TERMINAL BRANCHES OF FACIAL

NERVE:
The terminal branches of the facial nerve are temporal branch,
zygomatic branch, buccal branch, mandibular branch and the cervical
branch.
In the substance of the parotid gland the facial nerve divides into two
trucks, the cervicofacial and the temporofacial.
The cervicofacial trunk gives the cervical, mandibular and the buccal
(upper buccal and lower buccal branches).
The temporofacial trunk gives the temporal and zygomatic branch.

29. NAME THE UNPAIRED CARTILAGE OF LARYNX:

The thyroid cartilage, the cricoid cartilage and the epiglottis are the
unpaired cartilages of the larynx.

30. EMISSARY VEIN:

They are the veins connecting the veins of the scalp
(EXTRACRANIAL) with the Dural venous sinuses (INTRACRANIAL).
They pass through the foramina present in the skull bone
There are mainly two sets of emissary veins
1. Parietal emissary vein
2. Mastoid emissary vein
The parietal emissary vein passes through the parietal foramen, it
drains into the superior sagittal sinus
The mastoid emissary vein passes through the mastoid foramen, it
drains into the sigmoid sinus

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31. LACUS LACRIMALIS:

It is a triangular space in the medial part of the eye, it can be seen when
the eye is open.
In its centre is a reddish fleshy elevation called LACRIMAL CARUNCLE.

32. LYMPHATIC DRAINAGE OF FACE:

The face is divided into three territories in order to study the

lymphatics.
1. UPPER TERRITORY
It CONSISTS of most of the parts of the forehead, lateral half of
eyelids and conjunctiva, parotid area and the cheek.
It DRAINS in preauricular lymph nodes.
2. MIDDLE TERRITORY
It CONSISTS of the central part of forehead (other than the area
coming under the upper territory), medial half of the eyelids,
external nose, upper lip and lateral part of lower lip, medial part of
the cheek (other than the region of upper territory), and greater
part of the lower jaw.
It DRAINS into the submandibular lymph nodes.
3. LOWER TERRITORY:
It CONSISTS of the medial part of the lower lip and chin.
It DRAINS into submental lymph nodes.

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33.
This is caused due to an injury to the cervical sympathetic trunk.
The main features are MAP: M- Miosis, A- anhydrosis, P-partial ptosis.

MIOSIS- constriction of pupil (due to paralysis of dilator pupillae)

ANHYDROSIS- loss of sweating, it is due to the sudomotor and
vasoconstrictor denervation.
PARTIAL PTOSIS- partial drooping of the upper eyelid, it is due to
paralysis of smooth part of levator palpebrae superioris muscles

34. BONES DERIVED FROM THE FIRST PHARYNGEAL

ARCH:
1. Malleus
2. Incus
3. Mandible
4. Maxilla
5. Zygomatic bone
6. Palatine
7. Part of temporal bone

35. ENUMERATE MUSCLES OF PALATE:

1. Tensor palati
2. Levator palati
3. Palatoglossus
4. Palatopharyngeus
5. Musculus uvulae

36. TWO FEATURES OF NASO-PHARYNX:

1. Nasopharyngeal tonsil
2. Opening of the eustachian tube
3. Tubal elevation
4. Pharyngeal recess

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37. BOUNDARIES OF SUBMENTAL TRIANGLE:

1. APEX: chin, symphysis menti
2. BASE: body of hyoid bone
3. ON EACH SIDE: anterior belly of digastric muscle

38. NAME THE UNPAIRED DURAL VENOUS SINUSES:

1. Superior sagittal sinus
2. Inferior sagittal sinus
3. Straight sinus
4. Occipital sinus
5. Anterior intercavernous
6. Posterior intercavernous
7. Basilar venous plexus

39. FALX CEREBELLI:

It is a fold of the meningeal layer of the dura matter
It is sickle shaped
It is superiorly attached to the inferior surface of the tentorium
cerebellum, from the internal occipital protuberance, posteriorly
attached to the internal occipital crest, inferiorly to the posterior
margin of the foramen magnum.
Its anterior concave margin is free and is lodged between the two
lateral hemispheres of the cerebellum
The occipital sinus runs in this fold.

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40. MIDDLE CERVICAL GANGLION:

It is very small, mostly absent
Location: in front of transverse process of C6
Formation: fusion of 5th and 6th primitive cervical ganglia
BRANCHES:
1. Grey rami communicates to ventral rami of C5 and C6 spinal nerves
2. Thyroid branches to form plexus around the inferior thyroid artery
3. Middle cervical cardiac nerve
4. Tracheal branches
5. Esophageal branches

41. PAROTID DUCT:

It is five cm long
It emerges from anterior border of the gland runs on masseter
muscle between upper and lower buccal branches of facial nerve
bends medially at the level of anterior border of masseter pierces the
3Bs, buccal pad of fat, buccopharyngeal fascia and buccinator muscle
bends forward and runs over buccal mucosa turns medially
opens into vestibule of mouth opposite to upper second molar tooth.

42. FENESTRA VESTIBULI:

1. The oval window (or FENESTRA VESTIBULI) is a kidney-shaped aperture
in the medial wall of the mesotympanum of the middle ear, providing
communication with vestibule of inner ear.
2. Footplate of stapes is attached to its rim by annular ligament.
3. Sound waves cause vibration of tympanic membrane and ossicles
transmit those vibrations to the oval window, which leads to movement
of fluid within cochlea and activation of receptors for hearing.
4. It connects middle ear to the cochlea of the inner ear.

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43. EPICRANIAL APONEUROSIS:

It is the third layer of scalp
Formed by Occipitofrontalis muscle and its aponeurosis.
The greater part of this layer is formed by aponeurosis called
APONEUROTIC LAYER.
The aponeurosis of Occipitofrontalis muscle is also called
EPICRANIAL APONEUROSIS or GALEA APONEUROTICA.
The wounds of the scalp do not gape unless epicranial aponeurosis is
cut transversely because aponeurosis is under tension in
anteroposterior direction by the tone of Occipitofrontalis muscle.

44. BRANCHES OF ECA:

ANTERIOR:
Superior thyroid
Lingual
Facial
POSTERIOR:
Occipital,
Posterior auricular
MEDIAL:
Ascending pharyngeal
TERMINATING BRANCHES:
Maxillary
Superficial temporal arteries.

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45. TENTORIUM CEREBELLI:

CEREBELLAR TENTORIUM or TENTORIUM CEREBELLI is an extension
of dura mater.
Separates cerebellum from inferior portion of occipital lobe.
It divides the cranial cavity into supratentorial and infratentorial
compartments.
Anterior free margin of tentorium is U shaped and free and attached to
anterior clinoid process.
Attached margin is convex and posterolaterally related to lip of
transverse sulci.

46. MIDDLE EAR BONES:

1. MALLEUS:
It is the largest and has following parts:
1. Round head
2. Neck
3. Anterior and lateral process
4. Handle

2. INCUS:
Incus or anvil bone has the following parts:
1. Body
2. Long process

3. STAPES:
It is smallest and has following parts:
1. Small head
2. Neck
3. Two crura (Anterior & Posterior)
4. Footplate or base

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47. SUBOCCIPITAL NERVE:

Dorsal primary ramus of C1.
Supplies muscles of suboccipital triangle
1. Rectus capitis posterior major
2. Rectus capitis posterior minor
3. Obliquus capitis superior
4. Obliquus capitis inferior

48. LARNGYNEAL INLETS:

Triangular opening
BOUNDARIES:
1. ANTERIOR: Epiglottis
2. POSTERIOR: Arytenoid and corniculate cartilage
3. LATERAL: Mucous membrane enclosing ligamentous and muscular
fibres

49. STRUCTURE PIERCED BY PAROTID DUCT

PAROTID DUCT - During courses it pierces following structure,
1. Buccal pad of fat
2. Buccopharyngeal fascia
3. Buccinator muscle

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50. ORIGIN AND BRANCHES - MIDDLE MENINGEAL

ARTERY

ORIGIN- First part of maxillary artery, gives off in infratemporal fossa

BRANCHES -Supplies duramater, bones and red marrow in the diploe (by
periosteal artery)
In cranial cavity, it gives
1. Ganglionic branches to trigeminal ganglion
2. Petrosal branches
3. Superior tympanic branches
4. Temporal branches
5. Anastomotic branch with lacrimal artery

51. ARTERIAL SUPPLY- PITUITARY GLAND

Mainly supply by Internal Carotid Artery
1. Superior hypophyseal artery
2. Inferior hypophyseal artery
SUPERIOR HYPOPHYSEAL ARTERY INFERIOR HYPOPHYSEAL ARTERY
Supplies - upper and lower part of It divides medial and lateral branches
infundibulum (lower part through form arterial ring around posterior
trabecular artery) lobe.
It gets anastomoses with superior
hypophyseal artery

Anterior lobe supply by portal vessel (formed by capillary tuft of

superior hypophyseal artery.

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52. OPENING OF MAXILLARY SINUS (MAXILLARY

HIATUS)
Present at base of maxillary sinus
Hiatus of maxillary sinus reduced in size by
1. ABOVE- uncinate process of ethmoid
2. FRONT- descending part of lacrimal bone
3. BELOW -inferior nasal concha
4. BEHIND -perpendicular plate of palatine bone

53. AUDITORY TUBE OPENING

It also known as PHARYNGOTYMPANIC TUBE

Mucous lined osseocartilaginous channel
Connects nasopharynx with tympanic cavity (middle ear).
ENDS OF THE TUBE - tympanic and pharyngeal end.
1. TYMPANIC END - situated in anterior wall of middle ear.
2. PHARYNGEAL END-situated in lateral wall of pharynx, about
1.25 cm behind the posterior end of inferior nasal concha.

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54. BLOOD SUPPLY -TONSILS

1. ARTERIAL SUPPLY-
Tonsillar branch of facial artery
Ascending palatine branch of facial artery
Dorsal lingual branches of lingual artery
Ascending pharyngeal artery of external carotid artery
Greater palatine branch of maxillary artery

2. VENOUS DRAINAGE -
One or more vein leaves the lower part of deep surface of tonsil, pierce
the superior constrictor and join the palatine, pharyngeal or facial vein.

55. NERVE SUPPLY AND ACTION - CRICOTHYROID

MUSCLE
Nerve supply - External laryngeal nerve
Action
1. Tensor of vocal cord and modulation of voice
2. Rocking movement of thyroid forward and downward at the
cricothyroid joint.

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56. VOCAL CORDS

Lower folds produced within the laryngeal cavity by vocal ligaments and
vocalis muscle is called vocal folds or true vocal cords.
Extend from middle of thyroid angle to vocal processes of arytenoids.
The space between right and left vocal folds is called RIMA GLOTTIDIS
(narrowest part of laryngeal cavity)

57. FORMATION AND TERMINATION OF INTERNAL

JUGULAR VEIN

Continuation of sigmoid sinus at base of skull below jugular foramen

Terminate posteriorly to the sternal end of clavicle by merging with the
ipsilateral subclavian vein and forming brachiocephalic vein.

58. PIRIFORM FOSSA:

Deep depression in the wall of laryngopharynx lying lateral to the orifice of

larynx.
BOUNDARIES
1. MEDIAL: Aryepiglottic fold
2. LATERAL: Thyroid cartilage
Clinical significance
1. Common site for lodgment of foreign objects
2. Perforation by endoscopy

59. TRIBUTARIES OF CARNVEROUS SINUS:

TRIBUTARIES
A. FROM ORBIT
1. Superior ophthalmic vein
2. Inferior ophthalmic vein
3. Central vein of retina

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B. FROM MENINGES
1. Sphenoparietal sinus
2. Anterior trunk of the middle meningeal vein
C. FROM BRAIN
1. Superficial middle cerebral vein
2. Inferior cerebral veins

60. CAVERNOUS SINUS COMMUNICATES WITH:

A. TRANSVERSE SINUS via superior petrosal sinus

B. INTERNAL JUGULAR VEIN via inferior petrosal sinus
C. PTERYGOID VENOUS PLEXUS via emissary veins which pass
through foramen ovale, foramen lacerum, and emissary sphenoidal
foramen
D. FACIAL VEIN via two routes:
a. Superior ophthalmic vein angular vein facial vein
b. Emissary veins pterygoid venous plexus deep facial vein
facial vein
E. OPPOSITE CAVERNOUS SINUSES via anterior and posterior
intercavernous sinuses
F. SUPERIOR SAGITTAL SINUS via superficial middle cerebral vein
and superior anastomotic vein.
G. INTERNAL VERTEBRAL VENOUS PLEXUS, via basilar venous
plexus

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61.

Area in the anteroinferior part of nasal septum just above vestibule

Highly vascular
Septal branches of the following arteries anastomose to form a vascular
plexus called .
1. Anterior ethmoidal
2. Sphenopalatine
3. Greater palatine
4. Superior labial
COMMONEST SITE OF EPISTAXIS (nose bleeding) in children and
young adults usually due to finger nail trauma following picking of nose

62. CAROTID SHEALTH:

Tubular condensation of deep cervical fascia around:

1. Common carotid and internal carotid arteries
2. Internal jugular vein
3. Vagus nerve.
Carotid sheath is wedged between three layers of deep cervical fasci
(i.e. investing layer, pretracheal fascia, and prevertebral fascia) and
attached to all these layers by loose areolar tissue.
It is thick around common and internal carotid arteries but thin over
internal jugular vein in order to allow its expansion during increased
venous return.
Extends from base of skull above to arch of aorta below.

RELATIONS:
1. Ansa cervicalis is embedded in anterior wall of carotid sheath
2. Cervical sympathetic chain is closely related to posterior wall

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63. FORMATION AND DISTRIBUTION OF FINAL PART OF

ACCESSORY NERVE:

The spinal root arises by a number of rootlets from lateral aspect of

spinal cord (upper five cervical spinal segments) along a vertical line
between ventral and dorsal roots of spinal nerves.
The spinal root of accessory nerve supplies:
1. Sternocleidomastoid along with C2 and C3 spinal nerves.
2. Trapezius muscle along with C3 and C4 spinal

64. TORTICOLLIS:
Deformity in which head is bent to one side and chin points to other
side.
Spasm or contracture of muscles supplied by the spinal accessory
nerve.
Sternocleidomastoid and trapezius.

TYPES:

a. RHEUMATIC TORTICOLLIS due to exposure to cold or draught.

b. REFLEX TORTICOLLIS due to inflamed or suppurating cervical
lymph node which irritate the spinal accessory nerve.
c. CONGENITAL TORTICOLLIS due to birth injury.

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65. CAROTID TRIANGLE

BOUNDARIES:

ANTEROSUPEIORLY: posterior belly of digastric muscle and stylohyoid

ANTEROINFERIORLY: Superior belly of omohyoid

POSTERIORLY: Anterior border of sternocleidomastoid muscle

ROOF:
a. Skin
b. superficial fascia with platysma, cervical branch of fascial nerve and
transverse cutaneous neve of the neck
c. investing layer of deep cervical fascia

FLOOR:
a. Middle constrictor of pharynx
b. inferior constrictor of pharynx
c. thyrohyoid membrane

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CONTENTS:
a. Common carotid Artery
b. Internal Carotid Artery
ARTERIES
c. External Carotid Artery with Superior Thyroid, Lingual,
Fascial, Ascending Pharyngeal and Occipital Branches
a. Internal Jugular Vein
b. Common Facial Vein
VEINS
c. Pharyngeal Vein
d. Lingual Vein
a. Vagus Nerve
b. Superior Laryngeal Nerve
c. Spinal Accessory Nerve
NERVES
d. Hypoglossal Nerve
e. Sympathetic Chain
f. Carotid Sheath Contents

LYMPH a. Deep Cervical Lymph Nodes

b. Jugulodigastric Node
NODES
c. Jugulo Omohyoid Node

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66. DEEP CARDIAC PLEXUS

Situated in front of bifurcation of trachea
Behind the arch of aorta is situated

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67. EPISTAXIS
LITTLES AREA in anteroinferior part of vestibule.
Highly vascular.
Septal branch of superior labial branch of facial artery, sphenopalatine
artery and anterior ethmoidal artery.
It forms larger capillary plexus called KIESSELBACH PLEXUS.
Common site of bleeding of nose or epistaxis.

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68. SECRETOMOTOR PATHWAY TO PAROTID GLAND

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APPLIED:
FREY'S SYNDROME (AURICULOTEMPORAL NERVE SYNDROME):
Sometimes penetrating wounds of the parotid gland may damage
auriculotemporal and great auricular nerves.
The auriculotemporal nerve contains parasympathetic (secretomotor),
sensory, and sympathetic fibres. The great auricular nerve contains
sensory and sudomotor fibres.
When these nerves are cut, during regeneration the secretomotor
fibres grow into endoneurial sheaths of fibres supplying cutaneous
receptors for pain, touch and temperature, and sympathetic fibres
supplying sweat glands and blood vessels.
Thus, a stimulus intended for salivation evokes cutaneous
HYPERESTHESIA, SWEATING, AND FLUSHING.

a. When a person eats, the ipsilateral cheek (parotid region) becomes

red, hot, and painful. It is associated with beads of perspiration
(GUSTATORY SWEATING).
b. When a person shaves, there is CUTANEOUS HYPERESTHESIA
in front of the ear.

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69. INFRAHYOID MUSCLES

GENERAL FEATURES OF INFRAHYOID MUSLCES:

Two layers are present:

a. SUPERFICIAL: Sternohyoid and Omohyoid
b. DEEP - sternothyroid and thyrohyoid
Supplied by Ansa cervicalis except thyrohyoid.
Because of their attachment to hyoid and thyroid cartilage they move
these structured.
Anterior surface of isthmus of thyroid gland is covered by right and left
sternothyroid and sternohyoid.

STERNOHYOID (thin narrow strap muscle)

ORIGIN:
Posterior surface of manubrium and adjoining part of clavicle, and
posterior sternoclavicular ligament.

INSERTION:
Medial part of the lower border of the hyoid bone.

ACTIONS:
Depresses hyoid bone following its elevation during swallowing.

STERNOTHYROID (shorter and wider than sternohyoid)

ORIGIN;
Posterior surface of the manubrium and adjoining part of the first
costal cartilage.

INSERTION:
Oblique line on the lamina of thyroid cartilage.

ACTIONS
Depresses the larynx following its elevation during swallowing.

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THYROHYOID (It is an upward extension of the sternothyroid being

broken by the oblique line on the thyroid lamina)

ORIGIN
Oblique line on the lamina of thyroid cartilage

INSERTION:
Lower border of the greater cornu and adjoining part of the body of the
hyoid bone

ACTIONS
Depresses the hyoid bone during swallowing
ELEVATES THE LARYNX when hyoid bone is fixed by suprahyoid
muscles

OMOHYOID consists of inferior and superior bellies united by an

intermediate tendon

ORIGIN:
Inferior belly from upper border of scapula near the suprascapular
notch and occasionally from superior transverse scapular ligament
Superior belly proceeds upwards from the intermediate tendon almost
vertically upwards near the lateral border of sternohyoid

INSERTION:
Lower border of the body of the hyoid bone lateral to the sternohyoid.
The intermediate tendon is bound to the clavicle by a fascial pulley
derived from investing layer of deep cervical fascia

ACTIONS
Depresses the hyoid bone following its elevation during swallowing

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APPLIED ANATOMY:

1. TRACHEOSTOMY: It is operation in which trachea is opened and tube

is inserted to facilitate breathing. It commonly done in retrothyroid
after retracting the isthmus of thyroid gland which is covered by
sternohyoid and sternothyroid

2. ANTERIOR MIDLINE SWELLING: Thyroglossal cyst and inflamed

subhyoid bursa just below the hyoid bone

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70. MAXILLARY SINUS (ANTRUM OF HIGHMORE)

INTRODUCTION:
It is the largest of paranasal air sinuses and is present in the body of
maxilla.
It drains into the hiatus semilunaris (posterior part) of the middle
meatus.

DEVELOPMENT
The maxillary sinus is first to develop.
It appears about the 4th month of intrauterine life as an out-pouching
from the mucous membrane lining the lateral wall of the nasal cavity.
Becomes fully developed at puberty after the eruption of permanent
teeth.

MEASUREMENTS
a. Vertical: 3.5 cm.
b. Transverse: 2.5 cm.
c. Anteroposterior: 3.25 cm.

SHAPE
It is PYRAMIDAL in shape
a. The base directed medially towards the lateral wall of the nose
b. Apex laterally towards the zygomatic bone.
ROOF
It is formed by the floor of the orbit.
The infraorbital nerve and artery traverse the roof in a bony canal.

FLOOR
It is formed by the alveolar process of maxilla and lies about 1.25 cm
below the floor of the nasal cavity.
The level of the floor corresponds to the level of the ala of nose.

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BASE
It is formed by the lateral wall of the nose.
It possesses the opening or ostium of the sinus in its upper part, i.e.,
close to the roof, a disadvantageous position for natural drainage.

In the DISARTICULATED SKULL, the base of maxillary sinus (medial

surface of the body of maxilla) presents a large opening the maxillary
hiatus, which is reduced in size by the following bones
a. Uncinate process of ethmoid, from above.
b. Descending process of lacrimal, from in front.
c. Ethmoidal process of inferior nasal concha, from below.
d. Perpendicular plate of palatine from behind.

APEX:
It extends into the zygomatic process of maxilla.
ANTERIOR WALL
It is formed by the anterior surface of the body of maxilla and is related
to INFRAORBITAL PLEXUS OF NERVES. Within this wall runs the
anterior superior alveolar nerve in a curved bony canal called CANALIS
SINUOSUS

POSTERIOR WALL
It is formed by the infratemporal surface of the maxilla, separating the
sinus from the infratemporal and pterygopalatine fossae.
It is pierced by the POSTERIOR SUPERIOR ALVEOLAR NERVES and
VESSELS.

OPENING
Maxillary sinuses open in the HIATUS SEMILUNARIS OF MIDDLE
MEATUS near the roof of the sinus.

ARTERIAL SUPPLY
It is by the anterior, middle, and posterior superior alveolar arteries
from maxillary and infraorbital arteries.

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LYMPHATIC DRAINAGE
The sinus drains into submandibular lymph nodes.
NERVE SUPPLY
Maxillary sinuses are supplied by the anterior, middle, and posterior
superior alveolar nerves from the maxillary and infraorbital nerves.

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APPLIED ANATOMY:
MAXILLARY SINUSITIS:
Maxillary sinus is most commonly infected of all the sinuses due to
following reasons:
Infection can reach into this sinus from infected nose (viral rhinitis),
carious upper premolar and molar teeth, especially molars, and infected
frontal and anterior ethmoidal sinuses.
Being MOST DEPENDENT PART, it acts as a secondary reservoir for pus
from frontal air sinus through frontonasal duct and hiatus semilunaris.
Pain of maxillary sinusitis is referred to the upper teeth and infraorbital
skin due to common innervation by the maxillary nerve.

DRAINAGE OF MAXILLARY SINUS:

The opening of this sinus is unfortunately located in the UPPER PART
OF THE LATERAL WALL OF NOSE, which is a disadvantageous site for
adequate natural drainage. Surgically, maxillary sinus is drained in the
following two ways:

CALDWELL LUC
ANTROSTOMY
OPERATION
Antral puncture by using trocar and Fenestrating the antrum through
cannula, which are passed below canine fossa in the gingivolabial
the inferior nasal concha in an sulcus.
outward and backward direction.

CARCINOMA OF MAXILLARY SINUS:

It arises from the mucous lining of the sinus.

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71. CAROTID TRIANGLE

BOUNDARIES:

ANTEROSUPERIORLY:
Posterior belly of Digastric
Stylohyoid

ANTEROINFERIORLY:
Superior belly of omohyoid

POSTERIORLY:
Anterior border of Sternocleidomastoid

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ROOF:
It is formed by investing layer of deep cervical fascia.
The superficial fascia over the roof contains platysma, cervical branch
of facial nerve and transverse facial nerve.

FLOOR:
It is formed by the following four muscles:
a. Thyrohyoid.
b. Hyoglossus.
c. Middle constrictor.
d. Inferior constrictor.

CONTENTS:

1. Carotid Arteries
a. Common carotid artery
b. Internal carotid artery
c. External carotid artery and its first five branches.

2. Carotid sinus and carotid body.

3. Internal jugular vein.
4. Last three cranial nerves
a. Vagus nerve
b. Spinal accessory nerve
c. Hypoglossal nerve.

5. Carotid sheath
6. Ansa cervicalis.
7. Cervical part of the sympathetic chain.
8. Deep cervical lymph nodes.

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CLINICAL ANATOMY:
a. CAROTID PULSE: Common carotid artery can be palpated at the
anterior border of sternocleidomastoid muscle in carotid triangle.
b. CAROTID SINUS SYNDROME: Sudden rotation of head may cause
slowing of heart.
c. CAROTID SINUS MASSAGE: supraventricular tachycardia may be
controlled by carotid sinus massage due to inhibitory effects of
vagus nerve

72. OESOPHAGUS
INTRODUCTION
25cm long muscular tube, connects pharynx and stomach.
Kept collapsed anteroposteriorly between trachea and vertebral
column.

COURSE:
Begins as a continuation of pharynx at the lower border of cricoid
cartilage opposite the lower border of C6 vertebra.
Passes downwards in front of vertebral column behind trachea
Traverses superior and posterior mediastina of thorax
Passes through the esophageal opening of diaphragm
Ends at the cardiac orifice of the stomach in the abdomen about 2.5cm
to the left of the medial plane.
DIVIDES into 3 parts: cervical, thoracic, abdominal

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A. CERVICAL PART
BLOOD SUPPLY = inferior thyroid arteries
VENOUS DRAINAGE = Veins from this part drain into inferior
thyroid veins and left brachiocephalic vein.
LYMPHATIC DRAINAGE = pretracheal and deep cervical lymph
nodes

B. THORACIC PART
BLOOD SUPPLY = oesophageal branches of aorta
VENOUS DRAINAGE = azygous vein
LYMPHATIC DRAINAGE = posterior mediastinal nodes

C. ABDOMINAL PART
BLOOD SUPPLY = oesophageal branch of left gastric artery
VENOUS DRAINAGE = left gastric vein and vena azygos via
hemiazygos vein.
LYMPHATIC DRAINAGE = left gastric nodes

CONGENITAL ANOMALIES

1. OESOPHAGEAL ATRESIA:
It occurs due to failure of recanalization of the developing esophagus.
The oesophageal atresia is often associated with tracheoesophageal
fistula.
It is produced by extreme posterior deviation of tracheoesophageal
septum.
2. OESOPHAGEAL STENOSIS
3. TRACHEOESOPHAGEAL FISTULA
4. ACHALASIA CARDIA

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73. CAVERNOUS SINUS

LOCATION
It is 2cm long, 1cm wide, large venous space situated on either side of
the body of the sphenoid and stella turcica in the middle cranial fossa.
FLOOR
It is formed by endosteal layer, lateral and medial wall is of meningeal
layer.
Medially the roof is continuous with diaphragm stella.
Posteriorly, roof has a triangular depression between the attached
margin of tentorium cerebelli to the posterior clinoid process and ridge
raised by the free margin of tentorium cerebelli as it extends forward to
gain attachment on the anterior clinoid process.
The oculomotor and trochlear nerve pierces this triangle to enter the
cavernous sinus.

EXTENT
It is upto the medial end of superior orbital fissure and posteriorly upto
apex to the petrous temporal bone.
A. SUPERIOR
1. Optic chiasma.
2. Optic tract.
3. Internal carotid artery.
4. Anterior perforated substance.
B. INFERIOR
1. Foramen lacerum.
2. Junction of the body and the greater wing of the sphenoid.
C. MEDIAL
1. Pituitary gland (hypophysis cerebri).
2. Sphenoid air sinus.
D. LATERAL
1. Temporal lobe (uncus) of the cerebral hemisphere.
2. Cavum trigeminale containing the trigeminal ganglion.

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E. ANTERIOR
1. Superior orbital fissure.
2. Apex of the orbit.
F. POSTERIOR
1. Crus cerebri of midbrain.
2. Apex of the petrous temporal bone.
STRUCTURES PRESENT IN THE LATERAL WALL OF THE SINUS
From above downward these are as follows:
1. Oculomotor nerve.
2. Trochlear nerve.
3. Ophthalmic nerve.
4. Maxillary nerve.
STRUCTURES PASSING THROUGH CAVERNOUS SINUS

1. INTERNAL CAROTID ARTERY surrounded by the sympathetic

plexus of nerves.
2. ABDUCENT NERVE (it enters the sinus by passing below the
petrosphenoid ligament and accompanies the artery on its
inferolateral aspect).
It is believed that the pulsations of the internal carotid artery help in
expelling blood from the sinus

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TRIBUTARIES OF THE CAVERNOUS SINUS

FROM ORBIT
1. Superior ophthalmic vein.
2. Inferior ophthalmic vein.
3. Central vein of retina (sometimes).

FROM MENINGES
1. Sphenoparietal sinus.
2. Anterior (frontal) trunk of the middle meningeal vein.

FROM BRAIN
1. Superficial middle cerebral vein.
2. Inferior cerebral veins (only few).
The cavernous sinus communicates with the:
1. Transverse sinus via superior petrosal sinus.
2. Internal jugular vein via inferior petrosal sinus.
3. Pterygoid venous plexus via emissary veins which pass through
foramen ovale, foramen lacerum, and emissary sphenoidal foramen.
Facial vein via two routes:
1. Superior ophthalmic vein angular vein facial vein
2. Emissary veins pterygoid venous plexus deep facial vein
facial vein.
Opposite cavernous sinuses via anterior and posterior intercavernous
sinuses.
Superior sagittal
sinus via superficial
middle cerebral vein
and superior
anastomotic vein.
Internal vertebral
venous plexus, via
basilar venous
plexus.

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CLINICAL

CAVERNOUS SINUS THROMBOSIS:

The septic thrombosis of cavernous sinus may be caused by its
numerous communications.
The commonest cause of thrombosis is the passage of septic emboli
from the dangerous area of the face the through facial vein deep facial
vein pterygoid venous plexus emissary vein.

SIGNS AND SYMPTOMS-

1. SEVERE PAIN in the eye and forehead, due to involvement of the

ophthalmic nerve.
2. OPHTHALMOPLEGIA (paralysis of ocular muscles) due to
involvement of the 3rd, 4th, and 6th cranial nerves.
3. MARKED EDEMA OF EYELIDS with exophthalmos, due to
congestion of orbital veins following obstruction of ophthalmic veins.

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74. RECURRENT LARYNGEAL NERVE- (NERVE OF 6TH

ARCH):
On the RIGHT SIDE, it arises in the root of the neck from the vagus
nerve as it crosses in front of the subclavian artery, winds around the
first part of the subclavian artery, and then ascends up (in a recurrent
direction) in the tracheoesophageal groove.
On the LEFT SIDE, it arises in the superior mediastinum from the
vagus nerve as it crosses the arch of the aorta (lateral aspect). It hooks
below the arch of the aorta on the left side of ligamentum arteriosum
behind the arch of aorta on its way to the tracheoesophageal groove.

FUNCTION:
Provides MOTOR INNERVATION to all the intrinsic muscles of the larynx
(except the cricothyroid which is supplied by the external laryngeal
nerve) and sensory innervation to the mucous membrane of laryngeal
cavity up to the vocal cord.
Each recurrent laryngeal nerve passes deep to the inferior constrictor
muscle to enter the laryngeal cavity deep to the cricothyroid joint. Now
it is called the INFERIOR LARYNGEAL NERVE.

RELATIONS OF THYROID GLAND

RELATIONS OF THE THYROID LOBE- each lobe is roughly pyramidal

and has apex, base, three surfaces (lateral, medial, and posterolateral), and
two borders (anterior and posterior)

APEX: directed upwards and slightly laterally. Extends up to the oblique

line of thyroid cartilage where it is limited above by the attachment of
sternothyroid muscle. The apex is sandwiched between the inferior
constrictor medially and sternothyroid laterally

BASE: extends up to the 5th or 6th tracheal ring. It is related to inferior

thyroid artery and recurrent laryngeal nerve.

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LATERAL (SUPERFICIAL) SURFACES: It is convex and is covered by:

1. Three strap muscles (sternothyroid, sternohyoid, and superior belly
of omohyoid)
2. Anterior border of sternocleidomastoid overlapping it inferiorly.
MEDIAL SURFACE:

1. TWO TUBES: trachea and esophagus

2. TWO MUSCLES: inferior constrictor and cricothyroid
3. TWO CARTILAGES: cricoid and thyroid

POSTEROLATERAL SURFACE is related to carotid Sheath

CONTENTS
1. Common Carotid Artery
2. Internal Jugular Vein
3. Vagus Nerve
The Ansa-cervicalis is embedded in the anterior wall of the sheath while
cervical sympathetic chain lies posterior to sheath in front of
prevertebral fascia.
ANTERIOR BORDER is thin and separates superficial and medial
surfaces. It is related to anterior branch of the superior thyroid artery.
POSTERIOR BORDER is thick and rounded. It separates the medial
and the posterior surfaces. It is related to
1. Longitudinal arterial anastomosis between superior and inferior
thyroid arteries, and
2. Parathyroid glands.

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RELATIONS OF ISTHMUS
The isthmus is horizontal and presents
1. Two surfaces anterior and posterior
2. Two borders superior and inferior.
Anterior surface is related to:
1. strap muscles (sternohyoid and sternothyroid) and
2. anterior jugular veins.
Posterior surface is related to 2nd, 3rd, and 4th tracheal rings.
Superior border is related to anastomosis between the anterior
branches of two superior thyroid arteries.
Inferior border. Along this border inferior thyroid vein emerge and
thyroideae ima artery (when present) enters.

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75. MIDDLE EAR:

The middle ear is called tympanic cavity or tympanum.
It is a narrow air-filled space situated in the petrous part of temporal
bone.

COMMUNICATION:

1. ANTERIORLY: with nasopharynx through pharyngotympanic tube.

2. POSTERIORLY: with mastoid antrum and mastoid air cells through
aditus to antrum called aditus ad antrum.
The mucous membrane lining the middle ear cavity gives the cavity a
honeycombed appearance.

CONTENTS:

INSIDE THE MUCOUS LINING:

1. Air

OUTSIDE THE MUCOUS LINING:

1. Three small bones called ear ossicles: malleus, incus, and stapes.
2. Two muscles: tensor tympani and stapedius.
3. Two nerves: chorda tympani and tympanic plexus.
4. Vessels supplying and draining the middle ear.
5. Ligaments of the ear ossicles.
PARTS:
It is divided into three parts:
1. EPITYMPANUM (attic), a part above the tympanic membrane
containing head of malleus, body, and short process of the incus.
2. MESOTYMPANUM, a part opposite to tympanic membrane
containing handle of the malleus, long process of incus, and stapes.
It is the narrowest part of the middle ear.
3. HYPOTYMPANUM, a part below the tympanic membrane.

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BOUNDARIES:
It has SIX WALLS i.e.:
1. Roof
2. Floor
3. Anterior wall
4. Posterior wall
5. Medial wall
6. Lateral wall

ROOF:
It is formed by a thin plate of bone called tegmen tympani. It separates
the tympanic cavity from the middle cranial fossa.

FLOOR:
The floor is formed by a thin plate of bone, which separates the
tympanic cavity from the jugular bulb.
The tympanic branch of glossopharyngeal nerve pierces the floor
between the jugular fossa and lower opening of the carotid canal and
enters the tympanic cavity to take part in the formation of tympanic
plexus.

ANTERIOR WALL:
The upper part of the anterior wall bears two opening, a canal for tensor
tympani on the upper part and the opening of auditory canal on the
lower part.
Inferior part of the wall formed by a thin plate of bone forms the
posterior wall of the carotid canal.
The bony partition between the two canals for the tensor tympani and
for the auditory tube extends backwards along the medial wall as a
curved lamina called PROCESSUS COCHLEARIFORMIS.

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POSTERIOR WALL:
The posterior wall separates the tympanic cavity from mastoid antrum
and mastoid air cells.
It presents the following features:
1. ADITUS, an opening in the upper part through which tympanic cavity
communicates with the mastoid antrum.
2. FOSSA INCUDIS, a small depression lodging the short process of the
incus.
3. PYRAMID, lies near the junction of posterior and medial wall and has
an opening for the passage of tendon of stapedius muscle.
4. POSTERIOR CANALICULUS FOR CHORDA TYMPANI, a small aperture
through which the nerve enters the middle ear cavity.

MEDIAL WALL:
It separates the tympanic cavity from the internal ear. The medial wall
presents the following features:
1. PROMONTORY, a rounded prominence in the centre produced by
first (basal) turn of the cochlea. It is grooved by the tympanic plexus.
2. OVAL WINDOW (fenestra vestibuli): it leads into the vestibule of
the internal ear. It is closed by the base of stapes and annular
ligament.
3. ROUND WINDOW (fenestra cochleae) is a small round opening below
and behind the promontory and is closed by fibrous secondary
tympanic membrane.
4. SINUS TYMPANI is a depression behind the promontory, opposite
the ampulla of the posterior semicircular canal.
5. PROMINENCE OF OBLIQUE PART of the facial canal.
6. PROMINENCE OF LATERAL SEMICIRCULAR CANAL of the internal
ear: a small ridge high up in the angle between the medial and
posterior walls.

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LATERAL WALL:
Most of the lateral wall is formed by
1. Tympanic membrane, which separates the tympanic cavity from the
external auditory meatus.
2. Partly by squamous temporal bone.
TWO SMALL APERTURES: petrotympanic fissure lies in the front of
the upper end of bony rim.
ANTERIOR CANALICULUS for the chorda tympani nerve lies in the
fissure or in front of it.

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76. PTERYGOPALATINE GANGLION:

It is the largest parasympathetic peripheral ganglion.
LOCATION:
It is located deeply in the upper part of the pterygopalatine fossa,
suspended from maxillary nerve by two short roots.
RELATIONS:

A. BEHIND: Pterygoid canal.

B. MEDIAL: Sphenopalatine foramen.
C. IN FRONT: Perpendicular plate of palatine.
D. ABOVE: Maxillary nerve.
ROOTS:

1. MOTOR OR PARASYMPATHETIC ROOT:

It is derived from the nerve of pterygoid canal.
It carries preganglionic parasympathetic fibres from superior
salivatory nucleus (located in the lower part of the pons).
These fibres relay in the ganglion.
The postganglionic fibres arise from the cells in the ganglion and
supply secretomotor fibres to the lacrimal gland, glands of the
nose, palate, nasopharynx, and paranasal sinuses.
2. SYMPATHETIC ROOT:
It is derived from sympathetic plexus around internal carotid
artery via nerve of pterygoid canal.
It contains postganglionic fibres from superior cervical
sympathetic ganglion.
These fibres pass through the ganglion without relay and provide
vasomotor supply to the mucus membrane of the nose, palate,
pharynx, and paranasal air sinuses.
3. SENSORY ROOT: derived from maxillary nerve

ORBITAL BRANCHES:
It supplies orbital periosteum, ethmoidal air sinuses, and secretomotor
fibres to the lacrimal gland.

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PALATINE BRANCHES:
It includes greater and lesser palatine nerves.
The greater palatine nerve passes through greater palatine canal and
foramen to supply posteroinferior quadrant of the lateral wall of the
nose.
The lesser palatine nerves pass through lesser palatine canals and
foramina to supply secretomotor fibres to mucus membrane and glands
on the inferior surface of soft palate and hard palate.

NASAL BRANCHES:
It passes through the sphenopalatine foramen to enter the nasal cavity.
These are called posterior superior nasal nerves.
These are divided into two sets lateral and medial.
The longest branch of medial set is called nasopalatine/ sphenopalatine
nerve.

PHARYNGEAL BRANCH:
It passes through palatovaginal canal and supply the nasopharynx.

LACRIMAL BRANCHES:

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CLINICAL ANATOMY:
The pterygopalatine ganglion if irritated or infected can cause
congestion of the glands of palate and nose including the lacrimal gland
producing running nose and lacrimation.
The condition is called hay fever. The ganglion is called ganglion of hay
fever

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77. HYOGLOSSUS (A FLAT QUADRILATERAL MUSCLE):

MUSCLE ORIGIN INSERTION ACTION

SIDE OF TONGUE
Greater cornu
(posterior half) between 1. Depresses the
and adjacent side of the tongue
HYOGLOSSUS styloglossus laterally
part of the body 2. Make the dorsal
and inferior longitudinal
of hyoid surface convex
muscle medially

78. ANSA CERVICALIS:

It is a thin nerve loop embedded wall of carotid sheath over the lower
part of the lower part of the larynx.

FORMATION:
Formed by the superior and inferior root.
A. SUPERIOR ROOT:
1. It is the continuation of the branch of hypoglossal nerve.
2. Its fibres are derived from the first cervical nerve.
3. It descends over the common carotid artery and internal carotid
artery.

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B. INFERIOR ROOT:
1. Inferior root or descending root is derived from the second and
third spinal nerve.
2. It winds around the internal jugular vein and continues to join the
superior root in front of the common carotid artery.

DISTRIBUTION:

1. SUPERIOR ROOT: to the superior belly of omohyoid.

2. ANSA CERVICALIS: to the sternohyoid and sternothyroid.
3. INFERIOR ROOT: to the inferior belly of omohyoid.

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79. CILIARY GANGLION:

It is a peripheral parasympathetic ganglion, connected with the
nasociliary nerve.
LOCATION
It lies near the apex of orbit between the optic nerve and lateral rectus
muscle.
ROOTS:
There are three roots:
A. MOTOR (PARASYMPATHETIC) ROOT:
It is derived from nerve to inferior oblique
It contains preganglionic parasympathetic fibres from Edinger
Westphal nucleus. These fibres relay in the ganglion.
The postganglionic parasympathetic fibres pass through short
ciliary nerves to supply the ciliary muscle and sphincter pupillae.
B. SENSORY ROOT:
It comes from nasociliary nerve.
It consists of sensory fibres from eyeball, which pass through the
ciliary ganglion without relay.
C. SYMPATHETIC ROOT:
It is a branch from internal carotid plexus.
It contains postganglionic sympathetic fibres from superior
cervical sympathetic ganglion.
The fibres pass through the ganglion without relay and further
pass through short ciliary nerves to supply the dilator pupillae and
blood vessels of the eyeball.

BRANCHES:
The branches of ciliary ganglion are short ciliary nerves (8 10) which
divides into 15 to 20 branches.
Then it pierces the sclera around the entrance of optic nerve.

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80. FACIAL ARTERY

It is main artery of the face and it arises from the external carotid artery
just above the greater cornu of the hyoid bone.
It has TWO PARTS:
A. FACIAL PART
B. CERVICAL PART

CERVICAL PART:
Cervical part of the artery ascends deep to digastric and stylohyoid
muscles, passes deep to the ramus of mandible where is grooves the
submandibular gland.
It makes a S shaped bending over the submandibular gland and then up
to the base of the mandible.

BRANCHES (in the neck):

1. ASCENDING PALATINE ARTERY arises from facial artery and

accompanies the levator palati and supplies the palate.
2. TONSILLAR ARTERY is the main artery of the tonsil
3. GLANDULAR BRANCHES supply the submandibular gland.
4. SUBMENTAL ARTERY is a large artery that supplies the
mylohyoid muscle and submandibular and sublingual salivary gland.
FACIAL PART:
Facial part of facial artery begins where it winds around the lower
border of body of the mandible at the anteroinferior angle of the
masseter.
The terminal part of the facial artery is called angular artery.

BRANCHES FROM FACIAL ARTERY:

Three sets of branches are:

1. INFERIOR LABIAL ARTERY to supply labial artery.

2. SUPERIOR LABIAL ARTERY to supply the upper lip.
3. LATERAL NASAL ARTERY to supply ala and dorsum of the nose.

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APPLIED ASPECT:
The tortuosity of facial artery prevents its walls from being unduly
stretched during movements of mandible, lip, cheeks.
The pulsation of the facial artery can be felt at two sites:
1. At the base of mandible close to anteroinferior angle of masseter
2. About 1.25 cm lateral to angle of the mouth.

81. SUBCLAVIAN TRIANGLE:

The smaller lower part of the posterior triangle is the subclavian
triangle.

CONTENTS SUBCLAVIAN TRIANGLE

1. Root and trunk of brachial plexus

2. Nerve to serratus anterior (c5-C7)
NERVES
3. Nerve to subclavius(C5-C6)
4. Suprascapular nerve

1. Third part of subclavian artery and vein

2. Suprascapular artery and vein
VESSELS
3. Lower part of external jugular vein
4. Transverse cervical artery

LYMPH NODE 1. Few members of supra clavicular chain.

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All the muscles of tongue (intrinsic and extrinsic) are supplied by the
hypoglossal nerve except palatoglossus which is supplied by cranial root
of accessory via pharyngeal plexus.

SENSORY SUPPLY:

ANTERIOR TWO-THIRD OF THE TONGUE is supplied by:

1. Lingual nerve carrying general sensations, and
2. Chorda tympani nerve carrying special sensations of taste.

POSTERIOR ONE-THIRD OF THE TONGUE is supplied by:

1. Glossopharyngeal nerve, carrying both general and special
sensations of taste, and
2. Posterior most part (base of the tongue), supplied by the internal
laryngeal branch of the superior laryngeal carrying special
sensations of taste.

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NERVES CARRYING TASTE SENSATIONS FROM THE TONGUE

ARE AS FOLLOWS:

Chorda tympani nerve (a branch of the facial nerve) from anterior two-
third of the tongue.
Glossopharyngeal from posterior one-third of the tongue.
Internal laryngeal nerve from superior laryngeal branch of the vagus
nerve, from posterior most part of the tongue.

REFERRED PAIN OF CANCER TONGUE:

The patients with cancer tongue often complains of pain in ear,

temporomandibular joint, temporal fossa, and/or lower teeth.
This is due to referred pain. It is important to note that pain is
frequently referred from one branch of the mandibular nerve to the
other.
Carcinoma commonly involves anterior 2/3rd of tongue. Thus, if the
sensations carried from anterior 2/3rd of the tongue by the lingual
nerve are referred to auriculotemporal nerve, the patient feels pain in
the ear, TMJ, and temporal fossa.
On the other hand, if the pain from lingual nerve is referred to the
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82. TYMPANIC MEMBRANE:

It is a thin translucent partition between external acoustic meatus and
middle ear.
Oval in shape, makes an angle of 55o with the floor of meatus.
Faces downwards forwards laterally
2 surfaces outer and inner surfaces.
Outer surface lined by skin, concave.
Inner surface convex, provides attachment to handle of malleus.
Point of maximum convexity umbo
The membrane is fixed to tympanic sulcus of temporal bone but
superiorly it is attached to tympanic notch.
From the notch anterior and posterior malleolar folds prolong to
the lateral process of malleus.
The whole tympanic membrane is divided into
1. PARS FLACCIDA it is the part between anterior and
posterior malleolar fold. It is crossed by chorda tympani
internally.
2. PARS TENSA it is tightly stretched and forms the greater
part of the tympanic membrane.
It is held tense by tensor tympani muscle.

STRUCTURE:
It is composed of 3 layers:
1. OUTER cuticular layer of skin
2. MIDDLE fibrous layer made of superficial radiating fibres and
deep circular fibres. In pars flaccida fibrous layer is replaced by
loose areolar tissue.
3. INNER mucous layer lined by ciliated columnar epithelium.

ARTERIAL SUPPLY:
OUTER SURFACE deep auricular branch of maxillary artery.

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INNER SURFACE
a. anterior tympanic branch of maxillary artery.
b. Posterior tympanic branch of stylomastoid branch of posterior
auricular artery.

VENOUS DRAINAGE:
1. OUTER SURFACE drain into external jugular vein
2. INNER SURFACE transverse sinus, venous plexus.

LYMPHATIC DRAINAGE:
Lymphatics pass to preauricular and retropharyngeal lymph nodes.

NERVE SUPPLY:
OUTER SURFACE
1. ANTEROINFERIOR PART auriculotemporal nerve
2. POSTEROSUPERIOR PART auricular branch of vagus nerve with
communicating branch of facial nerve
INNER SURFACE tympanic branch of glossopharyngeal nerve through
tympanic plexus.

CLINICAL ANATOMY:
Any disease in pars flaccida should be treated carefully as chorda
tympani lies behind it.
To drain pus in middle ear sometimes the tympanic membrane is
incised. This procedure is called MYRINGOTOMY.
It is incised in posteroinferior quadrant where the bulge is prominent.
Incision must be given remembering that the chorda tympani is
present on the inner surface of tympanic membrane.

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83. STYLOID APPARATUS:

It is styloid process with its attachments
The structures are

3 MUSCLES
Stylohyoid
Styloglossus
Stylopharyngeus

2 LIGAMENTS
Stylohyoid
Stylomandibular

STYLOID PROCESS
long pointed bony process medially from temporal bone.
Descends between external and internal carotid arteries to reach the
side of pharynx

STYLOGLOSSUS MUSCLE
Originate from anterior surface of styloid process
Inserted into the side of tongue

STYLOPHARYNGEUS MUSCLE
Arise from medial surface of base of styloid process
Inserted into posterior border of lamina of thyroid cartilage

STYLOHYOID MUSCLE
Arise from posterior surface of styloid process
Splits at the lower end to get inserted into hyoid bone.

STYLOMANDIBULAR LIGAMENT
from laterally from styloid process
Attached to the angle of mandible below.

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STYLOHYOID LIGAMENT
From tip of styloid process to lesser cornu of hyoid bone

FEATURES:
External carotid artery crosses tip of styloid process superficially and
pierces stylomandibular ligament.
Facial nerve crosses base of styloid process laterally

84. DUCT:
It is a thick-walled duct which emerges from the middle of anterior
border of the gland.

RELATIONS:
SUPERIOR
a. Accessory parotid gland
b. Transverse facial vessels
c. Upper buccal branch of facial nerve
INFERIOR
a. Lower buccal branch of facial nerve

At the anterior border of masseter, it turns medially and pierces

1. Buccal pad of fat
2. Buccopharyngeal fascia
3. Buccinator
Because of oblique course through buccinator it is not inflated during
blowing
Finally, it opens into gingivobuccal vestibule opposite the crown of
upper 2nd molar tooth.

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CLINICAL ANATOMY:
Parotid calculi may get formed in duct and can be located
by injecting radio-opaque dye into the vestibule of mouth. This
procedure is called SIALOGRAM.
The duct can be examined by a spatula or bidigital examination.

85. VOCAL CORDS:

There are 2 folds of mucous membrane on each side in the cavity of
larynx.
1. UPPER FOLD vestibular fold
2. LOWER FOLD vocal fold/vocal cord
RIMA VESTIBULI space between 2 vestibular folds
RIMA GLOTTIDIS space between 2 vocal folds.
The Rima is longer in males(23mm) than females(17mm).
The vocal cords are composed of mucous membrane infoldings that
stretch horizontally across the middle laryngeal cavity.
The vocal folds are located within the larynx at the top of the trachea.
They are attached posteriorly to the arytenoid cartilages, and
anteriorly to the thyroid cartilage.
The male vocal cords are longer than females and it is much shorter in
children.

MOVEMENTS OF VOCAL CORDS:

CRICOTHYROID JOINT
It allows rotatory movement around a transverse axis passing
between 2 cricothyroid joints permitting tension and relaxation of
vocal cords.
Muscles which tense vocal cord cricothyroid
Muscles which relax vocal cords
a. Thyroarytenoids
b. Vocalis

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CRICOARYTENOID JOINT
It permits rotatory movement around a vertical axis allowing the
abduction adduction of vocal cords
Muscles that abduct vocal cord posterior cricoarytenoids (safety
muscle of larynx)
Muscles that adduct vocal cord
a. Lateral cricoarytenoid
b. Transverse arytenoid
c. Cricothyroid (tuning fork of larynx)
d. Thyroarytenoids

MOVEMENTS OF THE VOCAL FOLDS AFFECT THE SHAPE AND

SIZE OF THE RIMA GLOTTIDIS

DURING QUIET BREATHING or CONDITION OF REST, the inter-

membranous part of the Rima is triangular, and the
intercartilaginous part is quadrangular
DURING PHONATION or SPEECH, the glottis is reduced to a chink by
the adduction of the vocal folds
DURING FORCED INSPIRATION, both parts of the Rima are
triangular, so that the entire Rima is lozenge- shaped; the vocal
folds are fully abducted
DURING WHISPERING, the intermembranous part of the Rima
glottidis is closed, but the intercartilaginous part is widely open

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86. VENOUS DRAINAGE OF FACE

FACIAL VEIN

BEGINS as an angular vein (supraorbital + supratrochlear veins)

continues at the lower margin of the orbital margin into the facial
vein.
RECEIVES tributaries corresponding to the branches of the
facial artery & also receives the infraorbital & deep facial veins.
DRAINS either directly into the internal jugular vein or by joining
the anterior branch of the retromandibular vein to form the

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common facial vein, which then enters the internal jugular vein.
COMMUNICATES with the superior ophthalmic vein & thus with
the cavernous sinus, allowing a route of infection from the face
to the cranial Dural sinus.

RETROMANDIBULAR VEIN

FORMED by superficial temporal + maxillary veins behind the mandible.

DIVIDES into an anterior branch, which joins the facial vein to
form the common facial vein, & a posterior branch, which joins
the posterior auricular vein to form the external jugular vein.

CLINICAL

DANGER AREA OF THE FACE

It is near the nose drained by the facial veins.
PUSTULES (pimples) or boils or other skin infections, particularly on
the side of the nose & upper lip, may spread to the cavernous
venous sinus via the facial vein, pterygoid venous plexus, &
ophthalmic veins.
SEPTICEMIA (blood infection) is a systemic disease caused by the
presence of pathogenic organisms or their toxins in the
bloodstream & is often associated with severe infections, leading to
meningitis & cavernous sinus thrombosis, both of which may cause
neurologic damage & may be life-threatening.

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87. MIDDLE MEATUS OF NOSE

Meatuses are the passages (recesses) beneath the overhanging
conchae.
They are visualized once conchae are removed.
Middle meatus lies underneath the middle concha. It presents
following features:

A. ETHMOIDAL BULLA (bulla ethmoidalis), a round elevation

produced by the underlying middle ethmoidal sinuses.
B. HIATUS SEMILUNARIS, a deep semicircular sulcus below the bulla
ethmoidalis.
C. INFUNDIBULUM, a short passage at the anterior end of middle
meatus.

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NERVE SUPPLY OF LACRIMAL GLAND

The sensory innervation to the lacrimal gland is via the lacrimal
nerve. This is a branch of the ophthalmic nerve (in turn derived from
the trigeminal nerve).
The lacrimal gland also receives autonomic nerve fibres:

PARASYMPATHETIC:
Preganglionic fibres are carried in the greater petrosal nerve
(branch of the facial nerve) and then the nerve of pterygoid
canal, before synapsing at the pterygopalatine ganglion.
Postganglionic fibres travel with the maxillary nerve, and finally
the zygomatic nerve.
Stimulates fluid secretion from the lacrimal gland

SYMPATHETIC
Fibres originate from the superior cervical ganglion, and are
carried by the internal carotid plexus and deep petrosal nerve.
They join with the parasympathetic fibres in the nerve of pterygoid
canal, and follow the same route to supply the gland.
Inhibits fluid secretion from the lacrimal gland.

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88. ATLANTO-OCCIPITAL JOINT

TYPE: Atlantoaxial joint complex; Synovial joint; biaxial

ARTICULAR SURFACES

A. MEDIAN ATLANTOAXIAL JOINT: dens of axis (C2),

osteoligamentous ring (anterior arch of atlas [C1], transverse
ligament of atlas)

B. LATERAL ATLANTOAXIAL JOINTS: inferior articular

surface of lateral mass for axis, superior articular facet of atlas

LIGAMENTS: Cruciform ligament (transverse ligament of atlas, superior

and inferior longitudinal bands), tectorial membrane, alar ligaments, apical
ligament of dens
INNERVATION:
Ventral primary ramus of the second cervical spinal nerve
BLOOD SUPPLY:
Deep cervical, occipital, vertebral arteries
MOVEMENTS
Principal movement; axial rotation, Limited
flexion, extension, lateral flexion

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89. HYOGLOSSUS MUSCLE

ORIGIN
Hyoglossus is a flat quadrilateral muscle of tongue
It arises from upper surface of hyoid bone. (Greater cornu and lateral part
of body)
INSERTION
Fibres run upwards, forwards into side of tongue.

RELATIONS OF HYOGLOSSUS

A. Superficial Relations
B. Deep Relations

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SUPERFICIAL RELATIONS
In upper part Lingual nerve.
In lower part Hypoglossal nerve.
In between lies the deep part of submandibular gland and its duct.
Submandibular ganglion between lingual nerve and submandibular gland.
Styloglossus muscle.
Mylohyoid muscle.

DEEP RELATIONS
Lingual artery- second part
Glossopharyngeal nerve
Stylohyoid ligament
Inferior longitudinal muscle
Genioglossus
Middle constrictor of pharynx

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STRUCTURES RELATED TO POSTERIOR BORDER OF

HYOGLOSSUS
Glossopharyngeal nerve
Stylohyoid ligament
Lingual artery
NERVE SUPPLY
Hypoglossal nerve

ACTIONS
Depresses tongue
Retraction of protruded tongue

90. BLOOD SUPPLY OF THYROID GLAND

ARTERIAL SUPPLY = Highly vascularized gland
ARTERIES FROM

1. SUPERIOR THYROID ARTERY from External carotid artery.

2. INFERIOR THYROID ARTERY from Thyrocervical trunk branch from 1st
part of Subclavian artery.
3. THYROIDEA IMA ARTERY from brachiocephalic trunk or from arch of
aorta.
4. ACCESSORY THYROID ARTERIES from tracheal and oesophageal
arteries.

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SUPERIOR THYROID ARTERY

Runs downward, forwards near upper pole of thyroid lobe
Near apex divides to anterior and posterior branches
ANTERIOR BRANCH descends along Anterior border of thyroid lobe and
continues along upper border of isthmus
Anastomose with superior thyroid artery of opposite side
POSTERIOR BRANCH descends along posterior border of thyroid lobe,
continues along lower border of isthmus
Anastomose with ascending branch of inferior thyroid artery
Thus, the superior thyroid artery supplies -upper 1/3 rd. of thyroid lobe
and upper ½ of isthmus
Superior thyroid artery is related closely to External laryngeal nerve away
from apex of thyroid lobe

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INFERIOR THYROID ARTERY

Runs upwards, enters thyroid from below, ascends up.
One ascending branch Anastomoses with Posterior branch of Superior
thyroid artery
Thus, the inferior thyroid artery supplies -lower 2/3 rd. of thyroid lobe and
lower ½ of isthmus
Inferior thyroid artery is related closely to Recurrent laryngeal nerve near
base of thyroid lobe

THYROIDEA IMA ARTERY

From brachiocephalic vein ascends upwards enters isthmus from below

APPLIED ANATOMY

LIGATION OF THYROID ARTERIES DURING THYROIDECTOMY

1. As superior thyroid artery is closely related to External laryngeal nerve
away from apex of thyroid lobe. During thyroidectomy, it should be
ligated close to apex of thyroid lobe to avoid injury to External
laryngeal nerve
2. As inferior thyroid artery is closely related to Recurrent laryngeal nerve
close to base of thyroid lobe. During thyroidectomy, it should be ligated
away from base of thyroid lobe to avoid injury to Recurrent laryngeal
nerve

VENOUS DRAINAGE

1. SUPERIOR THYROID VEIN-Internal jugular vein

2. MIDDLE THYROID VEIN-Internal jugular vein
3. INFERIOR THYROID VEIN-Left brachiocephalic vein
4. VEIN OF KOCHER-Internal jugular vein

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SUPERIOR THYROID VEIN

Emerges at upper pole, runs upwards laterally
Drains into Internal jugular vein

MIDDLE THYROID VEIN

Emerges at middle
Drains into internal jugular vein

INFERIOR THYROID VEIN

Emerges at lower border of isthmus
Runs downwards
Drains into left brachiocephalic vein

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VEIN OF KOCHER
Emerge between middle and inferior thyroid veins
Drains into internal jugular vein

91. LYMPH DRAINAGE OF TONGUE

Chief lymph node of tongue is Jugulo-omohyoid nodes

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APPLIED ANATOMY OF LYMPH DRAINAGE OF TONGUE

Rich anastomoses of lymphatics of posterior 1/3 rd of tongue and midline
lymphatics of tongue.
Thus, cancer metastasizes to ipsilateral and contralateral sides.
Little cross communication of lymphatics of anterior 2/3 rd of tongue 0.5
inches away from midline does not metastasize to contralateral nodes
Cancer of posterior 1/3 rd of tongue has poor prognosis

REFERRED PAIN
Due to involvement of pain fibres pain in tongue is referred to ear,
temporal Fossa, Temporomandibular joint in lower teeth.

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92. CONTENTS OF POSTERIOR TRIANGLE

IN OCCIPITAL TRAINGLE (ABOVE INFERIOR BELLY OF OMOHYOID)
1. Spinal accessory nerve
2. C3, C4 spinal nerves providing branches levator scapulae and trapezius
3. Dorsal scapular nerves(C5)
4. 4 cutaneous branches of cervical plexus
5. Superficial transverse cervical artery & Occipital artery

IN SUBCLAVIAN /SUPRACLAVICULAR TRIANGLE (BELOW

INFERIOR BELLY OF OMOHYOID)
1. Third part of subclavian artery
2. Subclavian vein and Terminal part of External jugular vein
3. Trunks of Brachial plexus
4. Superficial. Transverse cervical, suprascapular, Dorsal scapular
arteries
5. Lymph nodes

APPLIED ASPECT

BRACHIAL PLEXUS BLOCK

Injection of local anesthetic between first rib and skin above clavicle
causes brachial block.
This procedure is performed sometimes during surgical procedure in
upper limb.

PULSATIONS OF SUBCLAVIAN ARTERY

Felt at root of neck by pressing behind clavicle at posterior border of
sternocleidomastoid.
SWELLING IN POSTERIOR TRIANGLE
Enlargement of lymph nodes in posterior triangle
CAUSES: Tuberculosis of supraclavicular nodes, disease,
malignant growth of breast, arm, chest.

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93. EXTRINSIC MUSCLES OF TONGUE

These muscles take origin from structures outside the tongue and enter
the tongue to be inserted in it.
These muscles move the tongue (protrusion, retraction and side-to-side
movements).
Each half of the tongue has four extrinsic muscles, these are as follows:
1. Genioglossus (tongue to the mandible)
2. Hyoglossus (tongue to the hyoid)
3. Styloglossus (tongue to the styloid process)
4. Palatoglossus (tongue to the palate)

All these are supplied by HYPOGLOSSAL NERVE.

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GENIOGLOSSUS (FAN SHAPED)

ORIGIN: From superior genial tubercle of mandible.

INSERTION: Radiating, from tip to base of tongue and body of hyoid, Body of
hyoid bone.

ACTION: Along with its counterpart protrudes the tongue.

HYOGLOSSUS (FLAT QUADRILATERAL MUSCLE)

ORIGIN: Greater cornu and adjacent part of body of hyoid

INSERTION: Side of tongue between Styloglossus (laterally) and inferior

longitudinal muscle(medially)

ACTION: Depressed the side of the tongue and makes the dorsal surface
convex.

STYLOGLOSSUS (ELONGATED SLIP)

ORIGIN: Tip of styloid process and adjacent part of stylohyoid ligament.

INSERTION: Side of tongue interdigitating posteriorly with the fibres of

hyoglossus.

ACTION: Draws the side of tongue upwards and backwards.

PALATOGLOSSUS (SLENDER SLIP)

ORIGIN: Oral surface of palatine aponeurosis of palate.

INSERTION: Side of tongue (at the junction of its oral and pharyngeal parts)

ACTIONS: Pulls up the root of the tongue and approximates palatoglossal

arches.

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94. BRACHIOCEPHALIC VEIN

There are two Brachiocephalic veins: Right and Left.
Each of them is formed behind the sternoclavicular joint by the union of
corresponding internal jugular and Subclavian veins.
They unite to form the Superior Vena Cava (SVC). Both are devoid of
valves.

RIGHT BRACHIOCEPHALIC VEIN:

It is short (2.5 cm), vertical course (runs vertically from the right
sternoclavicular joint to the lower margin of the right first costal cartilage)

TRIBUTARIES:
1. Right vertebral vein
2. Right internal thoracic vein
3. Right inferior thyroid vein
4. First right posterior intercostal vein

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LEFT BRACHIOCEPHALIC VEIN:

It is long (6 cm), oblique course (runs obliquely across the superior
mediastinum from the left sternoclavicular joint to the lower margin of the
right costal cartilage)

TRIBUTARIES:
1. Left vertebral vein
2. Left internal thoracic vein
3. Left inferior thyroid vein
4. First left posterior intercostal vein
5. Left superior intercostal vein

LYMPHATIC DRAINAGE FOLLOWS VEINS

LT LYMPHATICS Lt jugular trunk Lt thoracic duct Lt jugulo

subclavian angle (Beginning of Lt Brachiocephalic vein)

RT LYMPHATICS Rt jugular trunk Rt lymphatic duct Rt jugulo

subclavian angle (beginning of Rt Brachiocephalic vein)

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95. PTERION
Pterion is the region in the
anterior part of the temporal
fossa where four bones (frontal,
parietal, squamous temporal and
greater wing of Sphenoid) meet to
form an H-shaped suture.
Deep to pterion lies the Anterior
division of middle Meningeal
artery.
It is situated 4 cm above the
midpoint of the zygomatic arch.

It can be located by placing the thumb behind the frontal process of

zygomatic bone and two fingers above the zygomatic arch.
The angle between the thumb and upper finger represents the site of
pterion (Stile's method).

APPLIED:
If a blow occurs in the pterion,
the anterior division of middle
Meningeal artery ruptures to
form an extradural hematoma
(clot between the skull bone and
the duramater).
If the clot is big, may compress the brain leading to unconsciousness or
even death.
Therefore, it should be removed as early as possible by trephination or
craniotomy.

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96. BLOOD AND NERVE SUPPLY OF SCALP

The term Scalp is applied to the soft tissues covering the vault of skull.
The scalp consists of five layers.

ARTERIAL SUPPLY:
The scalp has rich blood supply. On each side of midline, it is supplied by
FIVE arteries: three in front of the auricle and two behind the auricle.

IN FRONT OF AURICLE (FROM BEFORE BACKWARDS)

1. SUPRATROCHLEAR, a branch of ophthalmic artery from internal carotid

artery.
2. SUPRAORBITAL, a branch of ophthalmic artery from internal carotid
artery.
3. SUPERFICIAL TEMPORAL, a branch of external carotid artery.

BEHIND THE AURICLE (FROM BEFORE BACKWARDS)

4. POSTERIOR AURICULAR ARTERY, a branch of external carotid artery.

5. OCCIPITAL ARTERY, a branch of external carotid artery.

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NERVE SUPPLY

SENSORY SUPPLY:
The scalp on each side of midline is supplied by eight sensory nerves: four
in front and four behind the auricle.
The nerves in front of the auricle are derived from trigeminal nerve,
whereas those behind the auricle are derived from the 2nd and 3rd cervical
nerves.
IN FRONT OF AURICLE (FROM BEFORE BACKWARDS):

SUPRATROCHLEAR, a branch of frontal nerve from ophthalmic division of

trigeminal nerve

SUPRAORBITAL, a branch of frontal nerve from ophthalmic division of

trigeminal nerve.

ZYGOMATICOTEMPORAL, a branch of zygomatic nerve from maxillary

division of trigeminal nerve.

AURICULOTEMPORAL, a branch of mandibular division of trigeminal

nerve.

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BEHIND THE AURICLE (FROM BEFORE BACKWARDS)

POSTERIOR DIVISION OF GREAT AURICULAR, derived from vertical

Rami of 2nd and 3rd cervical nerves.

LESSER OCCIPITAL, derived from ventral ramus of 2nd cervical nerve.

GREATER OCCIPITAL, derived from dorsal ramus of 2nd cervical nerve.

THIRD OCCIPITAL, derived from dorsal ramus of 3rd cervical nerve.

MOTOR SUPPLY:
The scalp on each side of the midline is supplied by two motor nerves: one
in front of the ear and one behind the ear - both these nerves are derived
from facial nerve.

Nerve in front of ear is TEMPORAL BRANCH OF FACIAL NERVE - it

supplies frontal belly of Occipitofrontalis muscle.
Nerve behind the ear is POSTERIOR AURICULAR BRANCH OF
FACIAL NERVE - It supplies occipital belly of Occipitofrontalis.

APPLIED:

SCALP WOUNDS BLEED PROFUSELY BUT HEAL QUICKLY: Due to

high vascularity. The avulsed portions of scalp, therefore should not be cut
away rather they should be placed in position and stitched.

CONTROL OF SCALP HEMORRHAGE: Since all the superficial arteries

supplying the scalp ascend from face and neck. Therefore, life-threatening
scalp hemorrhage can be stopped as a first aid measure, by encircling the
head just above the ears and eyebrows with a string or string-strap of cotton
and tied toughly.

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97. TONGUE MUSCLES - NERVE SUPPLY AND ACTION.

The muscles of tongue is divided into 4 intrinsic muscles and 4
extrinsic muscles on each right & left half divided by the middle fibrous
septum.
INTRINSIC MUSCLES
They are attached to the submucous fibrous layer and to the median fibrous
septum. Arranged in several planes. They alter the shape of tongue.

SUPERIOR LONGITUDINAL:
LOCATION: Lies beneath the mucous membrane of dorsum.
ORIGIN:
Fibrous tissue deep to mucous membrane on dorsum.
Midline lingual septum.
INSERTION: Overlying mucous membrane of root of tongue posteriorly.
ACTION:
Shortens the tongue.
Makes dorsum concave.

INFERIOR LONGITUDINAL:
LOCATION: lies between genioglossus and hyoglossus.
ORIGIN:
Fibrous tissue beneath the mucous membrane from tip to root of tongue
longitudinally.
INSERTION: Mucous membrane of the tongue dorsum.
ACTION:
Shortens the tongue.
Makes dorsum convex.

TRANSVERSE:
LOCATION: lies in plane deep to superior longitudinal and superficial to
genioglossus.
ORIGIN: Fibrous lingual septum.

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INSERTION: Submucous fibrous tissue at lateral margins of the tongue.

ACTION: Makes tongue narrow and elongated.

VERTICAL:
LOCATION: lies at borders of the anterior part of the tongue.
ACTION: Makes tongue broader.

EXTRINSIC MUSCLES
It originates from structures outside the tongue. They responsible for
the movement of tongue.

GENIOGLOSSUS (LIFE SAVING MUSCLE): Fan shaped bulky muscle.

ORIGIN: Upper genial tubercle of mandible.

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INSERTION:
Upper fibres tip of tongue.
Middle fibres dorsum
Lower fibres hyoid bone.
ACTION: Protrudes the tongue.
PALATOGLOSSUS:
ORIGIN: Oral surface of palatine aponeurosis.
INSERTION:
Descends in the palatoglossal arch to the side of tongue at the junction of
oral and pharyngeal parts.
ACTION: Elevates the tongue.
HYOGLOSSUS:
ORIGIN: Greater cornu and lateral part of hyoid bone.
INSERTION: Side of tongue between styloglossus and inferior longitudinal
muscle.
ACTION: Depresses the tongue.
STYLOGLOSSUS:
ORIGIN: Tip and part of anterior surface of styloid process.
INSERTION: Into the side of tongue.
ACTION: Retracts the tongue.

NERVE SUPPLY
All the intrinsic and extrinsic muscles except the palatoglossus, are
supplied by the HYPOGLOSSAL NERVE. (XII nerve).

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Palatoglossus is supplied by cranial roots of accessory nerve through

pharyngeal plexuses.

CLINICAL ANATOMY
SAFETY MUSCLE OF TONGUE / LIFE- SAVING MUSCLE:
GENIOGLOSSUS muscle prevent the falling back of tongue on
oropharynx and blockage of air passage.
During anesthesia tongue pulled forward for this reason.
PARALYSIS OF HYPOGLOSSAL NERVE:
Genioglossus used to check the hypoglossal nerve.
On protrusion of tongue the tip of the tongue deviates towards the side
of paralysis.

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98. DIGASTRIC TRIANGLE:

BOUNDARIES
ANTEROINFERIORLY: Anterior belly of Digastric muscle.
POSTEROINFERIORLY: Posterior belly of Digastric muscle and stylohyoid.
FLOOR: Mylohyoid and hyoglossus.

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ROOF:
Investing layer of deep cervical fascia (enclosing the submandibular gland)
Superficial fascia with platysma muscle, cervical branch of facial nerve
and ascending branch of transverse cutaneous nerve of neck.
BASE: Formed by the base of the mandible and imaginary line joining the
angle of the mandible to the mastoid process.
CONTENTS
The digastric triangle is divided into anterior and posterior parts by the
stylomandibular ligament.
ANTERIOR PART
1. Submandibular salivary gland
2. Submandibular lymph nodes
3. Hypoglossal nerve
4. Facial vein
5. Facial artery
6. Submental artery
7. Mylohyoid nerve and vessels
POSTERIOR PART
A. SUPERFICIAL STRUCTURES:
1. External Carotid artery
2. Lower part of parotid gland
B. DEEP STRUCTURES:
1. A part of parotid gland.
2. Styloid process
3. Styloglossus
4. Stylopharyngeus
5. Glossopharyngeal nerve
6. Pharyngeal branch of Vagus nerve
C. DEEPEST STRUCTURES:
1. Internal carotid artery
2. Internal jugular vein
3. Vagus nerve

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99. INTRINSIC MUSCLES OF LARYNX

CRICOTHYROID:
ORIGIN: Anterolateral part of arch of cricoid cartilage.
INSERTION: Fibres pass backwards and upwards to be inserted into Inferior
cornu and Jacent part of lower border of lamina of thyroid cartilage.

OBLIQUE ARYTENOIDS:
ORIGIN: Muscular process of one arytenoid cartilage.
INSERTION: Apex of opposite arytenoid cartilage.

ARYEPIGLOTTICUS:
ORIGIN: Muscular process of arytenoid cartilage.
INSERTION: Margins of epiglottis

TRANSVERSE ARYTENOID
ORIGIN: Posterior surface of one arytenoid.
INSERTION: Posterior surface of another arytenoid.

LATERAL CRICOARYTENOID (A TRIANGULAR MUSCLE):

ORIGIN: Lateral part of upper border of cricoid arch
INSERTION: Front of muscular process of arytenoid cartilage.

POSTERIOR CRICOARYTENOID (A TRIANGULAR MUSCLE):

ORIGIN: Posterior surface of cricoid lamina lateral to median ridge.
INSERTION: Back of muscular process of the arytenoid cartilage.

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THYROARYTENOID:
ORIGIN: Posterior aspect of angle of the thyroid cartilage
INSERTION: Anterolateral surface of the arytenoid cartilage.
THYROEPIGLOTTICUS:
ORIGIN: Posterior aspect of angle of thyroid cartilage.
INSERTION: Margin of epiglottis.
ACTIONS OF MUSCLES

MUSCLES THAT OPEN OR CLOSE THE LARYNGEAL INLET.

a. Oblique arytenoids (close the inlet of larynx)
b. Aryepiglotticus (close the inlet of larynx)
c. Thyroepiglotticus (opens the inlet of larynx)

MUSCLES THAT ABDUCT OR ADDUCT THE VOCAL CARD.

a. Posterior cricoarytenoids (abduct vocal cords)
b. Lateral cricoarytenoids (adduct the vocal cords)
c. Transverse arytenoid (adduct the vocal cords)

100. MEDIAN NASAL SEPTUM:

The Nasal septum is an osseocartilaginous partition between the left and
right nasal cavities. It is usually deviated a little to the right side.
It has 2 PARTS; i) Bony part, ii) Cartilaginous part
A. BONY PART FORMATION
a. Perpendicular plate of ethmoid (posterosuperior part).
b. Vomer (Posteroinferior part).

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B. CARTILAGINOUS PART FORMATION

a. Septal cartilage.
b. Septal process of the 2 major alar cartilages.
APPLIED ANATOMY OF NASAL SEPTUM
DEVIATED NASAL SEPTUM:
It is an important cause of nasal obstruction and can be caused due to
trauma, developmental error.
It can cause difficulty breathing, headache, sinusitis.
Corrected by Submucous resection.

DESTRUCTION OF NASAL SEPTUM

The nasal septum supports the dorsum and anterior 2/3rd of nose.
Destruction of nasal septum leads to supra-tip depression of the external
nose.

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ARTERIAL SUPPLY OF NASAL SEPTUM

The nasal septum is supplied by the following arteries:
1. SEPTAL BRANCH OF THE ANTERIOR ETHMOIDAL ARTERY (a branch of
ophthalmic artery).
2. SEPTAL BRANCH OF THE POSTERIOR ETHMOIDAL ARTERY (a branch
of ophthalmic artery).
3. SEPTAL BRANCH OF THE SPHENOPALATINE ARTERY (a branch of
maxillary artery).
4. SEPTAL BRANCH OF THE GREATER PALATINE ARTERY (a branch of
maxillary artery).
5. SEPTAL BRANCH OF THE SUPERIOR LABIAL ARTERY (a branch of
facial artery).

NERVE SUPPLY OF NASAL SEPTUM:

The nasal septum receives supply from the following nerves:
1. OLFACTORY NERVES supply the upper part (one-third) just below the
cribriform plate.
2. INTERNAL NASAL BRANCH OF THE ANTERIOR ETHMOIDAL NERVE, a
branch from nasociliary supplies the anterosuperior part.
3. NASOPALATINE NERVE, a branch of pterygopalatine ganglion
supplies the posteroinferior part.
4. MEDIAL POSTERIOR SUPERIOR NASAL BRANCHES OF
PTERYGOPALATINE GANGLION supply the posterosuperior part.
5. NASAL BRANCH OF GREATER PALATINE NERVE supplies the
posterior part.
6. ANTERIOR SUPERIOR ALVEOLAR NERVE, a branch of maxillary nerve
supplies the anteroinferior part.

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101. EXTERNAL ACOUSTIC MEATUS

FEATURES
Extends from the bottom of the concha to the tympanic membrane
Not a straight tube but it has a typical S-shaped course.
Its outer part is directed medially, forwards & upwards.
Middle part is directed medially, backwards & upwards.
Inner part is directed medially, forwards & downwards.
Measures about 24 mm long, of which medial 2/3rd is bony & lateral 1/3rd is
cartilaginous.
Narrowest point isthmus lies about 5mm from tympanic membrane.
PARTS
A. CARTILAGINOUS PART
Forms the outer one-third (8 mm) of the meatus.
Contains hair, sebaceous and ceruminous glands.
B. BONY PART
Forms the inner two-third (16 mm) of the external auditory meatus.
Formed by tympanic plate of temporal bone
Lined by thin skin, firmly adherent to periosteum.
It is devoid of hair and ceruminous glands.

BLOOD SUPPLY
OUTER PART superficial temporal & posterior auricular arteries
INNER PART deep auricular branch of maxillary artery

LYMPHATICS
Preauricular, postauricular & superficial cervical lymph nodes.

NERVE SUPPLY
ANTERIOR HALF of meatus - the auriculotemporal nerve.
POSTERIOR HALF - the auricular branch of vagus.

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TYMPANIC MEMBRANE
thin, translucent partition between external acoustic meatus & middle ear
oval- shaped, 9 x 10mm, placed obliquely at an angle of 55 degrees with
floor of meatus
faces downwards, forwards & laterally
has 2 surfaces: outer concave surface lined by skin and inner convex
surface which provides attachment to handle of malleus.

STRUCTURE
Composed of:
1. Outer cuticular layer of skin
2. Middle fibrous layer made of superficial radiating fibres & deep circular
fibres
3. Inner mucous layer lined by low ciliated columnar epithelium

ARTERIAL SUPPLY
Outer surface-deep auricular branch of maxillary artery
Inner surface-anterior tympanic branch of maxillary artery & posterior
tympanic branch of stylomastoid branch of posterior auricular artery

VENOUS DRAINAGE
outer surface drain into external jugular vein
inner surface drain into transverse sinus & venous plexus around
auditory tube

LYMPHATICS
Preauricular & retropharyngeal lymph nodes

NERVE SUPPLY
outer surface- anteroinferior part by auriculotemporal nerve &
posterosuperior part by auricular branch of vagus nerve with
communicating branch from facial nerve
inner surface-tympanic branch of glossopharyngeal nerve through
tympanic plexus

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DEVELOPMENT
The external auditory meatus develops as an ectodermal invagination of
first pharyngeal cleft.
It becomes filled with ectodermal cells forming a solid mass
called MEATAL PLUG, which is canalized before birth.

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The auricle develops from six mesodermal tubercles around the external
opening of the first pharyngeal cleft.
The failure of canalization of meatal plug results in atresia of the external
auditory meatus, while failure of fusion of tubercles will give rise
to accessory auricles.

CLINICAL CORRELATION:
The infection and boils cause very little swelling but are very painful
because the skin lining is firmly adhered to underlying cartilage and bone.

EAR WAX:
- Prevents injury of lining epithelium from water
- Prevents damage of tympanic membrane by trapping insects.
- Excess of ear wax is removed by syringing
- Irritation of auricular branch of vagus during syringing may cause ear
cough, vomiting and even death due to sudden cardiac inhibition.
Sometimes the anterior wall of bony part presents foramen of Huschke.
This permits infection back and forth from parotid gland.

102. SAGITTAL SECTION OF EYE BALL

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103. PARANASAL AIR SINUS

The paranasal air sinuses are air-containing cavities in the paranasal
bones, i.e., bones around the nasal cavity.
Their function is to make skull lighter & add resonance to the voice

FRONTAL SINUS
The frontal air sinus (two in number) lies between the inner and outer
tables of the frontal bone deep to the superciliary arch.
The right and left sinuses are usually unequal in size.

OPENING
drains into the anterior part of the hiatus semilunaris of the middle
meatus through infundibulum or frontonasal duct.

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RELATIONS
Anterior wall is related to: Superciliary arch of forehead.
Posterior wall is related to: Meninges and frontal lobe of the brain.
Inferior wall is related to: Roof of nose, roof of orbit (medial part) and
ethmoidal air cells.
It extends upwards above the medial end of eyebrow

ARTERIAL SUPPLY: Supraorbital artery

VENOUS DRAINAGE: Into supraorbital & superior ophthalmic veins
LYMPHATICS: Submandibular nodes
NERVE SUPPLY: Supraorbital nerve.
CLINICAL CORRELATION: Frontal sinusitis

MAXILLARY SINUS (antrum of Highmore)

It is the largest of paranasal air sinuses and is present in the body of
maxilla.
It is pyramidal in shape, with its base directed medially towards lateral wall
of nose & apex directed laterally in the zygomatic process of maxilla.
The maxillary sinus is the first paranasal sinus to develop.

OPENING
Drains into middle meatus of nose in lower part of hiatus semilunaris. The
opening is nearer the roof.

RELATIONS
ROOF is formed by the floor of the orbit & traversed by infraorbital nerve.
FLOOR is formed by the alveolar process of maxilla and lies about 1 cm
below the floor of nose.
Normally, the roots of upper molar & premolar teeth project into the floor
producing elevations.
Sometimes roots of teeth are separated from the sinus only by a thin layer
of mucous lining.
BASE is formed by the lateral wall of the nose.

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In the disarticulated skull, the base of maxillary sinus (medial surface of

the body of maxilla) presents a large opening the maxillary hiatus, which
is reduced in size by the following bones:
Uncinate process of ethmoid & descending part of lacrimal bone,
from above.
Inferior nasal concha, from below.
Perpendicular plate of palatine bone, from behind.
APEX extends into the zygomatic process of maxilla.
ANTERIOR WALL is formed by the anterior surface of the body of maxilla
and is related to infraorbital plexus of nerves.
POSTERIOR WALL is formed by the infratemporal surface of the maxilla,
separating the sinus from the infratemporal and pterygopalatine fossae.
ARTERIAL SUPPLY: Facial, infraorbital & greater palatine arteries.
VENOUS DRAINAGE: Into facial vein & pterygoid plexus of veins.
LYMPHATIC DRAINAGE: Submandibular lymph nodes.
NERVE SUPPLY: Posterior superior alveolar nerves from maxillary, and
anterior & middle superior alveolar nerves from infraorbital
CLINICAL CORRELATION
Maxillary sinusitis
Drainage by Caldwell Luc operation and Antrostomy
Carcinoma may also occur

ETHMOIDAL SINUSES
The ethmoidal air sinuses are numerous small intercommunicating spaces
present within the labyrinth of ethmoidal bone.
They are divided into the following three groups:
- Anterior, consisting of 1-11 cells.
- Middle, consisting of 1 7 cells.
- Posterior, consisting of 1 7 cells.

OPENING
ANTERIOR GROUP anterior part of hiatus semilunaris of nose
MIDDLE GROUP middle meatus of nose
POSTERIOR GROUP superior meatus of nose

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RELATIONS
ABOVE: completed by orbital plate of frontal bone
BEHIND: sphenoidal conchae & orbital process of palatine bone
ANTERIOR: lacrimal bone
BLOOD & NERVE SUPPLY
ANTERIOR GROUP anterior ethmoidal nerve & vessels
MIDDLE GROUP anterior ethmoidal nerve & vessels, and orbital
branches of pterygopalatine ganglion
POSTERIOR GROUP posterior ethmoidal nerve & vessels, and orbital
branches of pterygopalatine ganglion
LYMPHATICS: Anterior & middle group drains into submandibular nodes,
posterior into retropharyngeal nodes.
CLINICAL CORRELATION: Ethmoidal Sinusitis

SPHENOIDAL SINUSES
The right and left sphenoidal sinuses lie within the body of the sphenoid
bone.
They are separated from each other by a bony septum.
The two sinuses are usually asymmetrical.
OPENING
Each sinus drains into the sphenoethmoidal recess of corresponding half
of the nasal cavity.

RELATIONS
ABOVE: Pituitary gland and optic chiasma.
BELOW: Roof of the nasopharynx.
LATERAL: Cavernous sinus and internal carotid artery (on each side).
BEHIND: Pons and medulla oblongata.
IN FRONT: Sphenoethmoidal recess.
ARTERIAL SUPPLY: posterior ethmoidal & internal carotid arteries

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VENOUS DRAINAGE: into pterygoid venous plexus & cavernous sinus

LYMPHATICS: retropharyngeal nodes
CLINICAL CORRELATION: Sphenoidal Sinusitis

104. MIDDLE EAR CAVITY

The middle ear (synonym for tympanum, tympanic cavity) is a narrow slit-
like air-filled cavity within the petrous part of the temporal bone between
external ear & internal ear.
It contains three auditory ossicles
They transmit sound vibrations from tympanic membrane in its lateral wall
to the internal ear via its medial wall.
The tympanic cavity is really the intermediate portion of a blind
diverticulum from the respiratory mucous membrane of the nasopharynx.
From front to back, the diverticulum consists of pharyngotympanic tube,
tympanic cavity and mastoid antrum.

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COMMUNICATIONS:
1. ANTERIORLY: with nasopharynx through pharyngotympanic tube.
2. POSTERIORLY: with mastoid antrum and mastoid air cells.

CONTENTS OF THE MIDDLE EAR

INSIDE THE MUCOUS LINING: Air
OUTSIDE THE MUCOUS LINING:
1. TWO MUSCLES: tensor tympani and stapedius.
2. TWO NERVES: chorda tympani and tympanic plexus.
3. VESSELS supplying and draining the middle ear.
4. LIGAMENTS of the ear ossicles.
5. THREE SMALL BONES called ear ossicles: malleus, incus and stapes.

SUBDIVISIONS OF THE MIDDLE EAR

The tympanic cavity extends much beyond the limits of tympanic
membrane, which forms its lateral boundary.
It is divided into three parts, namely

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1. EPITYMPANUM (attic), a part above the tympanic membrane

containing head of malleus, body and short process of incus.
2. MESOTYMPANUM, a part opposite to tympanic membrane containing
handle of malleus, long process of incus and stapes. It is the narrowest
part of the middle ear.
3. HYPOTYMPANUM, a part below the tympanic membrane.

BOUNDARIES
1. ROOF OR TEGMENTAL WALL
It is formed by a thin plate of bone called TEGMEN TYMPANI.
It separates the tympanic cavity from the middle cranial fossa.
The tegmen tympani also extend posteriorly to form the roof of aditus
ad antrum.
2. FLOOR OR JUGULAR WALL
The floor is also formed by a thin plate of bone, which separates the
tympanic cavity from the jugular bulb.
Sometimes it is congenitally deficient and the jugular bulb then
projects into the middle ear, being separated from cavity only by
mucosa.
The tympanic branch of glossopharyngeal nerve pierces the floor
between the jugular fossa and lower opening of the carotid canal and
enters the tympanic cavity to take part in the formation of tympanic
plexus.
3. ANTERIOR OR CAROTID WALL
It is formed by a thin plate of bone.
In the lower part, it separates the cavity from internal carotid artery.
The upper part of anterior wall presents two openings or canals, the
upper one for the tensor tympani muscle and the lower one for the
auditory tube.
The bony partition between the two canals extends backwards along
the medial wall in the tympanic cavity as a curved lamina
called PROCESSES COCHLEARIFORMIS.

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4. POSTERIOR OR MASTOID WALL

The posterior wall separates the tympanic cavity from mastoid antrum
and mastoid air cells
Aditus ad antrum, an opening in the upper part through which tympanic
cavity communicates with the mastoid antrum.
Fossa incudis, a small depression close to the aditus, lodging the short
process of the incus.
Pyramid, a hollow conical bony projection below the aditus containing
stapedius muscle whose tendon appears through its summit, passes
forwards to be attached to the neck of the stapes.
Vertical part of facial canal runs in the posterior wall just behind the
pyramid and descends up to the stylomastoid foramen.
Posterior canaliculus for chorda tympani, a small aperture for
emergence of this nerve.

5. MEDIAL OR LABRYNTHINE WALL

It separates the tympanic cavity from the internal ear; thus, it is
actually formed by the bony lateral wall of the internal ear.
PROMONTORY, a rounded prominence in the centre produced by first
(basal) turn of the cochlea.
The tympanic branch of the glossopharyngeal nerve ramifies on it to
form tympanic plexus.
OVAL WINDOW (fenestra vestibuli), a reniform aperture located above
and behind the promontory.
It is closed by the base of stapes and annular ligament.
ROUND WINDOW (fenestra cochleae), a small round opening below and
behind the promontory
Closed by fibrous secondary tympanic membrane.
The SECONDARY TYMPANIC MEMBRANE separates the middle ear from
the Scala tympani.
SINUS TYMPANI, a depression behind the promontory between
fenestra vestibuli and fenestra cochleae, which indicates the position
of ampulla of the posterior semicircular canal.
Prominence of oblique part of the facial canal that extends backwards
and downwards above the oval window until it joins the vertical part of
the facial canal in the posterior wall of the tympanic cavity.

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Sometimes the bony covering of the facial nerve may be absent, thus
exposing the nerve for injuries and infection.
Prominence of lateral semicircular canal of the internal ear, which is
seen as a small ridge high up in the angle between the medial and
posterior walls.

6. LATERAL OR MEMBRANOUS WALL

Most of the lateral wall is formed by tympanic membrane, which
separates the tympanic cavity from the external auditory meatus.
The CHORDA TYMPANI NERVE, a branch of facial nerve passes across
the tympanic membrane lying lateral to the long process of the incus
and medial to the handle of the malleus.
It enters the tympanic cavity through the posterior canaliculus in the
posterior wall and leaves through the anterior canaliculus medial to the
petrotympanic fissure.

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105. EAR OSSICLES

The three ear ossicles (malleus, incus and stapes) within the middle ear
are connected to one another by synovial joints and form a bony chain that
extend across the tympanic cavity from the tympanic membrane to the
oval window.
They CONDUCT SOUND VIBRATIONS from tympanic membrane to the oval
window and subsequently to the inner ear fluid.

MALLEUS INCUS STAPES

RESEMBLANCE Hammer Anvil Stirrup

1st pharyngeal arch 1st pharyngeal 2nd pharyngeal arch

DEVELOPMENT
cartilage arch cartilage cartilage

MUSCLE
Tensor tympani None Stapedius
ATTACHED
Incudomalleolar &
JOINT (S) Incudomalleolar Incudostapedial
Incudostapedial

INTRATYMPANIC MUSCLES

NERVE
MUSCLE ORIGIN INSERTION ACTION
SUPPLY

Medial aspect
Cartilaginous part Tenses
TENSOR of upper end Mandibular
of auditory tube tympanic
TYMPANI and sulcus
of handle of nerve (V3)
membrane
malleus

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Draws
Interior of hollow stapes
pyramidal Posterior laterally thus
Facial nerve
STAPEDIUS eminence on aspect of neck
(CN VII)
tilting
posterior wall of of stapes footplate in
tympanic cavity the oval
window

ARTERIAL SUPPLY
1. Anterior tympanic branch of the maxillary artery.
2. Posterior tympanic branch of stylomastoid branch of the posterior
auricular artery.

VENOUS DRAINAGE
1. Pterygoid venous plexus, via squamotympanic fissure.
2. Superior petrosal sinus, through subarcuate fossa.

LYMPHATIC DRAINAGE
1. Retropharyngeal lymph nodes.
2. Preauricular lymph nodes

NERVE SUPPLY = Derived from tympanic plexus. Plexus is formed by:

1. TYMPANIC BRANCH OF GLOSSOPHARYNGEAL NERVE:

It provides sensory supply to the lining of middle ear, antrum,
auditory tube and air cells.
It gives off lesser petrosal nerve.

2. SUPERIOR AND INFERIOR CAROTICOTYMPANIC NERVES:

They are vasomotor to mucous membrane.
derived from sympathetic plexus around the internal carotid artery.

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DEVELOPMENT
MASTOID ANTRUM develops as a backward extension of tympanic cavity
and assumes the full adult size at birth.

PHARYNGOTYMPANIC TUBE
The pharyngotympanic tube (auditory tube) is an osseocartilaginous
tube, which connects the nasopharynx with tympanic cavity (middle
ear).
It is directed downwards, forwards and medially from the tympanic
cavity to the nasopharynx.
The AUDITORY TUBE MAINTAINS EQUILIBRIUM OF AIR PRESSURE on
either side of the tympanic membrane for its proper vibration.

DEVELOPMENT OF THE MIDDLE EAR

The auditory tube and middle ear develop from endodermal tubotympanic
recess, which arises from the first pharyngeal pouch (and partly from
second pharyngeal pouch).
The mastoid antrum develops as an extension of the middle ear cavity into
the mastoid process.

CLINICAL CORRELATION:
1. Otitis media infection of middle ear
2. Hyperacusis
3. Otosclerosis
4. Mastoid abscess

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106. FACIAL ARTERY IN FACE:

CHIEF ARTERY of face
Branch of ECA, given of in carotid triangle just above the greater cornu of
hyoid bone.
Passes through the submandibular region
Winds around the lower border of mandible
Pierces the investing layer of deep cervical fascia
Enters the face at the anteroinferior angle of masseter.
Here it is called as ANAESTHETIST ARTERY.
Runs upwards, 1.25cm lateral to the angle of the mouth.
Ascends by the side of nose till the medial angle of the eyes.
Terminates by supplying the lacrimal gland.
ANASTOMOSE with the dorsal nasal branch of the ophthalmic artery.
FEATURES:
very tortuous, prevents stretching of arterial walls during movements of
mandible, lips, cheeks.
lies between superficial and
deep muscles of the face.

BRANCHES:

1. INFERIOR LABIAL
ARTERY, supplies
lower lip.
2. SUPERIOR LABIAL
ARTERY, supplies
upper lip.
3. LATERAL NASAL
ARTERY, supplies ala
and dorsum of the nose.
4. MUSCULAR
BRANCHES arise from
the posterior aspect of the artery.

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ANASTOMOSIS:

1. LARGE ANTERIOR BRANCHES anastomose with similar branches

of the opposite side.
2. SMALL POSTERIOR BRANCHES anastomose with transverse facial
and infraorbital artery.
3. TERMINAL BRANCHES anastomose with ophthalmic artery.

CLINICAL ANATOMY:

PALPATION OF FACIAL ARTERY at base of mandible (Anesthetist

artery) and 1.25cm lateral to angle of the mouth.

107. LATERAL PTERYGOID MUSCLE:

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UPPER HEAD: from infratemporal surface and crest of

greater wing of sphenoid bone.
ORIGIN
LOWER HEAD: frame lateral surface of lateral pterygoid plate.

Original is medial to insertion

UPPER HEAD: pterygoid fovea on the anterior surface of neck

of mandible

INSERTION LOWER HEAD: anterior margin of articular disc and capsule of

temporomandibular joint.

INSERTION is posterolateral and at a higher level than origin

NERVE SUPPLY A branch from ANTERIOR DIVISION OF MANDIBULAR NERVE

DEPRESS MANDIBLE to open mouth, with suprahyoid

muscles.
ACTIONS
PROTRUDES MANDIBLE

Right lateral pterygoid turns the chin to the left.

Masseter

SUPERFICIAL Ramus of the mandible

RELATIONS Tendon of temporalis

Maxillary artery

Mandibular nerve

Middle meningeal artery

DEEP RELATIONS
Sphenomandibular ligament

Deep head of medial pterygoid

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STRUCTURES Deep temporal nerves

EMERGING AT
Masseteric nerve
UPPER BORDER
Lingual nerve and artery
STRUCTURES
Inferior alveolar nerve
EMERGING AT THE
LOWER BORDER Middle meningeal and accessory meningeal artery pass deep
to it

STRUCTURES
PASSING Maxillary artery enters the gap
THROUGH THE GAP Buccal branch of mandibular nerve comes out through the
BETWEEN THE gap
TWO HEAD

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108. SURFACE AND BORDERS OF THYROID GLAND:

LATERAL OR SUPERFICIAL SURFACE
Convex
Covered by
1. Sternohyoid
2. Superior belly of omohyoid
3. Sternothyroid
4. Anterior border of sternocleidomastoid

MEDIAL SURFACE
1. Trachea
2. Oesophagus
3. Inferior constrictor
4. Cricothyroid
5. External laryngeal nerve
6. Recurrent laryngeal nerve

POSTEROLATERAL SURFACE
1. Carotid sheath
2. Overlaps common carotid artery

ANTERIOR BORDER
1. Thin
2. Anterior branch of superior thyroid artery
POSTERIOR BORDER
1. Thick, rounded
2. Inferior thyroid artery
3. Anastomosis between posterior branch of superior thyroid artery and
ascending branch of inferior thyroid artery
4. Parathyroid glands
5. Thoracic duct on the left

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109. ISTHMUS:
ANTERIOR SURFACE
Right and left sternothyroid and sternohyoid muscles.
Anterior jugular veins
Fascia and skin

POSTERIOR SURFACE
2nd -4th tracheal rings
UPPER BORDER
Anterior branch of right and left superior thyroid artery

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LOWER BORDER
Inferior thyroid veins leaves the gland

MUSCLES OF TONGUE:

INTRINSIC ACTION
LOCATION
MUSCLES
SUPERIOR Beneath the mucous Shortens the tongue, makes
LONGITUDINAL membrane the dorsum concave

Close to the inferior surface of

INFERIOR Shortens the tongue, makes
tongue between genioglossus
LONGITUDINAL and hyoglossus the dorsum convex

Extends from median septum Makes the tongue narrow and

TRANSVERSE elongated
to margins

At the border of anterior part of Makes the tongue broad and

VERTICAL flattened
the tongue

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EXTRINSIC ACTION
ORIGIN INSERTION
MUSCLES
Pulls up the root
Descends in the
of tongue,
palatoglossal
approximates the
Oral surface arch to the side
palatoglossal
PALATOGLOSSUS of palatine of the tongue at
arches & thus
aponeurosis the junction of
closes the
oral and
oropharyngeal
pharyngeal parts
isthmus
Side of tongue
Whole length Depresses
between
of greater tongue, makes
styloglossus and
HYOGLOSSUS cornu dorsum convex,
inferior
Lateral part retracts the
longitudinal
of hyoid bone protruded tongue
muscle of tongue

Tip and part

of anterior Pulls the tongue
Into the side of
STYLOGLOSSUS surface of upwards &
tongue
styloid backwards
process

Retracts the
tongue
Upper fibre into
Depresses the
the tip of tongue
Upper genial tongue
Middle fibre into
GENIOGLOSSUS tubercle of Pulls the
the dorsum
mandible posterior part of
Lower fibre into
tongue forwards
the hyoid bone
and protrude the
tongue forwards.

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MOVEMENTS OF TONGUE MUSCLES

PROTRUSION GENIOGLOSSUS

RETRACTION STYLOGLOSSUS

DEPRESSION HYOGLOSSUS

ELEVATION PALATOGLOSSUS

CHANGE IN SHAPE INTRINSIC MUSCLES

ARTERIAL SUPPLY:
LINGUAL ARTERY, branch of ECA
TONSILLAR ARTERY, branch of facial artery
ASCENDING PHARYNGEAL ARTERY, branch of ECA

VENOUS DRAINAGE:
DEEP LINGUAL VEIN
2 Venae comitants accompanying lingual artery
1 Vena comitants accompanying hypoglossal nerve

LYMPHATIC DRAINAGE
Tip of tongue- SUBMENTAL NODES
Right and left half of anterior 2/3rdof tongue-SUBMANDIBULAR
(unilaterally) and DEEP CERVICAL NODES (bilaterally).
Posterior most part & posterior 1/3rd of tongue-upper deep cervical
lymph nodes
Whole lymph drains into JUGULO-OMOHYOID NODES.

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NERVE SUPPLY

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110. STERNOCLEIDOMASTOID MUSCLE.

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KEY MUSCLE OF NECK

extends obliquely across side of neck.
Divides neck into anterior & posterior triangle.

ORIGIN
STERNAL HEAD: Superolateral part of front of Manubrium Sterni.
(Tendinous)
CLAVICULAR HEAD: medial rd of superior surface of the clavicle.
(Musculotendinous)

INSERTION
Lateral surface of MASTOID PROCESS, by a thick tendon.
Lateral half of SUPERIOR NUCHAL LINE OF OCCIPITAL BONE, by a thin
aponeurosis.

NERVE SUPPLY
MOTOR: spinal accessory nerve.
PROPRIOCEPTIVE: branches from ventral rami of C2 & C3.

BLOOD SUPPLY

ARTERIAL SUPPLY:
UPPER PART occipital & posterior auricular arteries.
MIDDLE PART superior thyroid artery.
LOWER PART suprascapular artery.

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VENOUS DRAINAGE: by veins following the arteries.

ACTIONS
A. ONE MUSCLE CONTRACTION:
Turns chin to opposite side.
Head towards shoulder of same side.
B. BOTH MUSCLE CONTRACTION:
Draw head forwards.
With longus Colli, flex the neck against resistance.
Forced inspiration.

RELATIONS
The sternocleidomastoid is enclosed in the investing layer of deep cervical
fascia, and is pierced by the accessory nerve and by the four
sternocleidomastoid arteries. It has the following relations -

SUPERFICIAL:
Skin
Superficial fascia
Superficial lamina of the deep cervical fascia
Platysma
External jugular vein, and superficial cervical lymph nodes lying along the
vein.
Nerves -
Great auricular
Transverse or anterior cutaneous
Medial supraclavicular nerves
Lesser occipital nerve
The parotid gland overlaps the muscle.

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DEEP:
BONES AND JOINTS:
A. Mastoid process-above
B. Sternoclavicular joint-below.
CAROTID SHEATH.
MUSCLES:
1. Sternohyoid
2. Sternothyroid
3. Omohyoid
4. Three scaleni
5. Levator scapulae
6. Splenius capitis
7. Longissimus capitis
8. Posterior belly of digastric.
ARTERIES:
1. Common carotid
2. Internal carotid
3. External carotid
4. Sternocleidomastoid arteries, two from the occipital artery, one
from the superior thyroid, one from the suprascapular
5. Occipital
6. Subclavian
7. Suprascapular
8. Transverse cervical
VEINS:
1. Internal jugular
2. Anterior jugular
3. Facial
4. Lingual

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NERVES:
1. Vagus
2. Parts of IX, XI, XII
3. Cervical plexus
4. Upper part of brachial plexus
5. Phrenic
6. Ansa cervicalis
LYMPH NODES: deep cervical.

CLINICAL ANATOMY

TORTICOLLIS:
Head is bend to one side and chin points to the opposite side.
Spasm or contracture of muscle supplied by spinal accessory nerve.
1. Sternocleidomastoid
2. Trapezius
Common types
1. RHEUMATIC torticollis: exposure to cold or draught.
2. REFLEX torticollis: inflamed or suppurating cervical lymph nodes.
3. CONGENITAL torticollis: birth injury.

STERNOCLEIDOMASTOID TUMOR:
Due to edema& ischemic necrosis caused by birth trauma.
LESSER SUPRACLAVICULAR FOSSA:
Small triangular gap.
Terminal part of internal jugular vein is entered at this site by needle or
catheter.
WRY NECK:
Shortening of muscle fibres due to intravascular clotting of veins within
muscle, usually occurs during difficult delivery of baby.

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111. SUPERIOR SAGITTAL SINUS

LOCATION:
Intra cranial.
The upper convex, attached margin of the falx cerebri.

COURSE:
Begins anteriorly at the crista gall.
Communicates with veins of frontal sinus & veins of nose via foramen
caecum.
Runs upwards & backwards (becomes progressively large).
Ends near internal occipital protuberance.
Becomes continuous with the right transverse sinus.

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INTERIOR OF SINUS:
Openings of superior cerebral veins.
Openings of venous lacunae.
Arachnoid villi and granulations.
Numerous fibrous bands crossing the inferior angel of the sinus.
TRIBUTARIES:
Superior cerebral veins.
Parietal emissary veins.
Venous lacunae.
Occasionally, a vein from the nose opens into sinus when the foramen
caecum is patent.

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CLINICAL ANATOMY:

THROMBOSIS OF SUPERIOR SAGITTAL SINUS:

CAUSE: infection spread from nose, scalp and diploe.
LEADS TO:
1. Intracranial pressure increases.
2. Delirium, sometimes convulsions.
3. Paraplegia of upper motor neuron type. (Involvement of paracentral
lobules of cerebrum.)

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112. LATERAL WALL OF NOSE

Irregular due to shelf - like projections called Conchae.
It is formed by number of bones and cartilages
The lateral wall separates the nose:
From orbit above, with ethmoidal air sinuses intervening
From maxillary sinus below
From lacrimal groove & nasolacrimal canal in front
BONES
NASAL
1. Frontal process of maxilla
2. Lacrimal
3. Conchae and labyrinth of ethmoid
4. inferior nasal conchal
5. Perpendicular plate of palatine
6. medial pterygoid plate of Sphenoid

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CARTILAGES
1. Lateral nasal cartilage (upper nasal)
2. Major alar cartilage (lower nasal)
3. Three to four tiny cartilage of alae

FEATURES
3 AREAS: The lateral wall is subdivided into 3 parts.
1. Anterior Part
2. Middle Part
3. Posterior Part.
ANTERIOR PART
Has a small depressed part called "Vestibule "
Skin Contain "Vibrissae"
MIDDLE PART
atrium of middle meatus
Junction between atrium and Vestibule is "limen nasi"
POSTERIOR PART
Has "Chonchae"
Spaces separating the Conchae are called meatuses"

ARTERIAL SUPPLY
1. ANTEROSUPERIOR QUADRANT -anterior ethmoidal artery (also
Posterior ethmoidal artery)
2. ANTEROINFERIOR QUADRANT - Facial artery branches and greater
Palatine arteries
3. POSTEROSUPERIOR QUADRANT Sphenopalatine
4. POSTEROINFERIOR QUADRANT- greater Palatine artery.

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VENOUS DRAINAGE
Veins form a plexus which drains into
1. FACIAL VEIN -anteriorly
2. PHARYNGEAL PLEXUS -Posteriorly
3. PTERYGOID PLEXUS- middle part

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LYMPHATIC DRAINAGE
1. From anterior half of Lateral Wall -SUBMANDIBULAR NODES
2. Posterior half - RETROPHARYNGEAL and UPPER CERVICAL NODES
NERVE SUPPLY
GENERAL SENSORY Branches of Trigeminal
1. ANTEROSUPERIOR QUADRANT - anterior ethmoidal nerve (Ophthalmic
nerve)
2. ANTEROINFERIOR QUADRANT anterior superior alveolar nerve
(Infraorbital)
3. POSTEROSUPERIOR QUADRANT - Lateral Posterior Superior nasal
branches (Pterygopalatine ganglion)

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4. POSTEROINFERIOR QUADRANT -anterior Palatine branch

(Pterygopalatine ganglion)
SPECIAL SENSORY /OLFACTORY NERVES- Supply upper Part of lateral
wall just below cribriform plate of ethmoid up to the superior concha.

CLINICAL ANATOMY
1. HYPERTROPHY of inferior nasal Concha's mucosal lining is common
feature of allergic rhinitis. It is characterized by
o sneezing
o Nasal blockage
o excessive Watery discharge
2. RHINOSCOPY: Examination of Nasal Cavity,
Through nostril-anterior rhinoscopy
Through pharynx - Posterior rhinoscopy

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113. ORBICULARIS OCULI

It is one of the important facial muscle that is present around eye
It acts as sphincter and dilator for the orifice of eye
It contains three parts.
1. Orbital part
2. Palpebral part
3. lacrimal part

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ORBITAL PART:
ORIGIN:
1. Medial part of medial palpebral ligament
2. Frontal process of maxilla
3. Nasal part of frontal bone.
INSERTION: Concentric rings return to the point of origin
ACTION:
1. Winking
2. Closure of eye tightly

PALPEBRAL PART: (in the eye lids)

ORIGIN: Lateral part of medial palpebral ligament and runs laterally on upper
and lower eyelid.
INSERTION: lateral palpebral raphe
ACTION: gentle closure of eyelid (as in blinking & sleeping)

LACRIMAL PART: (lateral & deep to lacrimal sac)

ORIGIN: Lacrimal fascia and posterior lacrimal crest forming sheath for
lacrimal sac
INSERTION: lateral palpebral raphe
ACTION: Dilation of lacrimal sac for sucking of lacrimal fluid into sac, directs
lacrimal puncta into lacus lacrimalis, supports lower lid.

NERVE SUPPLY:
1. MOTOR: Temporal and zygomatic branch of facial nerve.
2. SENSORY: Trigeminal nerve

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BLOOD SUPPLY: Facial artery and facial vein.

CLINICAL ANATOMY:

CROW'SFOOT:
Skin folds from the lateral angle of the eye.
On contraction of entire muscle.
Permanent feature in old people called crow's foot

ECTROPION:
ECTROPION drooping of lower eyelid (paralysis of orbicularis oculi).
EPIPHORA spilling of tear on the cheek (due to Ectropion).

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114. BLOOD SUPPLY OF THYROID GLAND & DEVELOPMENT

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DEVELOPMENT OF THYROID GLAND

Begins as an endodermal thickening in the midline of pharynx behind the
tuberculum impar in the 3rd week of IUL.
The endodermal thickening forms a diverticulum which extends downward
to form the THYROGLOSSAL DUCT.
The thyroglossal duct descends in front of the neck and hyoid bone. It
winds under the hyoid and descends by inclining toward one side and
reaches its definitive position by 7th week of IUL.
Here the tip of the Thyroglossal duct bifurcates into 2 bilateral swellings
which develop into the thyroid gland.
The ultimobranchial bodies of the 5th pharyngeal pouch and neural crest
cells also get incorporated into the two lobes to form the parafollicular
cells or C-cells.
Sometimes the tip of the thyroglossal duct develops into the pyramidal
lobe.
The rest of the thyroglossal duct disappears except for its origin at
junction of the anterior 2/3 and posterior 1/3 of the tongue called
FORAMEN CECUM.

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115. BOUNDARIES & CONTENT OF SUBOCCIPITAL

TRIANGLE

BOUNDARIES

SUPEROMEDIAL: SUPEROLATERAL:
Rectus capitis posterior major. Obliquus capitis superior
Rectus capitis posterior minor
INFERIOR: ROOF:
Obliquus capitis inferior Dense fibrous tissue
Semispinalis capitis (medially)
Longissimus capitis and splenius
capitis (laterally)
FLOOR:
Posterior Arch of atlas
Posterior atlanto-occipital membrane

CONTENTS
1. Suboccipital plexus of veins
2. Greater occipital nerve
3. Dorsal ramus of 1st cervical nerve
4. 3rd part of vertebral artery

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116. EUSTACHIAN TUBE

It is an osseocartilaginous channel which connects the nasopharynx and
the tympanic cavity. It traverses downward, forwards and medially.

PARTS

1. BONY PART:
a. Forms posterior 1/3rd (12mm) of eustachian tube.
b. Lies between the tympanic and petrous part of the temporal bone.
2. CARTILAGINOUS PART:
a. Forms anterior 2/3rd (36mm) of Eustachian tube

FEATURES OF EUSTACHIAN TUBE:

The NARROWEST PART of the tube is called ISTHMUS (junction of
cartilaginous and bony part)
The CARTILAGINOUS PART is made of a folded fibrocartilage which
forms the floor, medial wall, roof and part of the lateral wall of the tube
The REST OF THE LATERAL WALL is formed by fibrous membrane.

ENDS OF THE EUSTACHIAN TUBE

TYMPANIC END: It is a small opening in the anterior wall of the
tympanic cavity just above the floor.
PHARYNGEAL END: it is a slit like opening in the lateral wall of
nasopharynx about 1.25cm posterior to the inferior nasal concha.

LINING OF EUSTACHIAN TUBE

It is lined by pseudo-stratified ciliated columnar epithelium
It also shows cilia which beat in the direction of nasopharynx.

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FUNCTIONS OF EUSTACHIAN TUBE

MAINTAINS EQUILIBRIUM of pressure on either side of tympanic
membrane
DRAINS THE SECRETIONS of the tympanic cavity into the nasopharynx by
the beating action of cilia.
PROTECTS THE MIDDLE EAR from High pressure sound waves of
nasopharynx

DIFFERENCES IN ADULT AND INFANT EUSTACHIAN TUBE

INFANT ADULT

LENGTH 18mm 36mm

ANGULATION No angulation Angulation present

Horizontal (10° angle Oblique, downwards, forward,

DIRECTION
with horizontal) medially (45° angle with horizontal)

APPLIED ANATOMY

BLOCKAGE OF EUSTACHIAN TUBE:

Lack of equilibrium on either side of tympanic membrane.
Air in the tympanic cavity is absorbed into the blood via the mucosal lining
of tympanic cavity.
Pressure drops inside the tympanic cavity.
Retraction of tympanic membrane.
Hearing disturbance and severe ear-ache.

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117. INFERIOR CONSTRICTOR

The inferior constrictor is a part of the three constrictor muscles of the
pharynx.
It has 2 parts
1. Thyropharyngeus
2. Cricopharyngeus

THYROPHARYNGEUS

ORIGIN:
Oblique line on the lamina of the thyroid cartilage
Tendinous band between the thyroid tubercle and cricoid cartilage.

INSERTION: Median Fibrous Raphe

NERVE SUPPLY
Pharyngeal plexus
External laryngeal nerve

ACTION = Helps in Deglutition

CRICOPHARYNGEUS

ORIGIN = Cricoid cartilage

INSERTION = Median Fibrous raphe

NERVE SUPPLY = Recurrent laryngeal nerve

ACTION = Closes off entrance to Oesophagus

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118. LACRIMAL APPARATUS

Structures concerned with secretion and drainage of lacrimal fluid
together form the lacrimal apparatus.

CONTENTS:
1. Lacrimal gland
2. Ducts of lacrimal gland
3. Conjunctival sac
4. Lacrimal puncta
5. Lacrimal canaliculi
6. Lacrimal sac
7. Nasolacrimal duct

LACRIMAL GLAND It is a J-shaped serous gland. It has two parts: orbital

and palpebral part.

1. ORBITAL PART Located in lacrimal fossa in anterolateral part of

roof of bony orbit.
2. PALPEBRAL PART It is smaller and is situated in the lateral part of
upper eyelid.

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DUCTS OF LACRIMAL GLAND They are 12 in number, 4 or 5 from orbital

part and 6-8 from palpebral part. They convey the lacrimal fluid into the
conjunctival sac.

FUNCTIONS OF LACRIMAL FLUID

1. FLUSHES CONJUNCTIVA and keep cornea moist.
2. PROVIDES NOURISHMENT to cornea
3. Serves to EXPRESS EMOTIONS
4. PREVENTS INFECTION
ARTERIAL SUPPLY Lacrimal br. of ophthalmic artery
VENOUS DRAINAGE ophthalmic veins
NERVE SUPPLY = PARASYMPATHETIC PATHWAY

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SYMPATHETIC PATHWAY

CONJUCTIVAL SAC Space between palpebral and bulbar conjunctiva.

LACRIMAL PUNCTA Small openings on the lid margins.
LACRIMAL CANALICULI 2 in no.: superior (in upper eyelid) and inferior
(in lower eyelid). Each canaliculus is 10 mm in length and begins at lacrimal
punctum and open into lacrimal sac.

LACRIMAL SAC Upper dilated end of the nasolacrimal duct. It is situated

in the deep lacrimal groove enclosed in the lacrimal fascia. It is divisible into
three parts; fundus, body and neck. Relations

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NASOLACRIMAL DUCT
Membranous canal about 18 mm long.
It extends from neck of lacrimal sac to anterior part of inferior meatus of
nose.
It has a lower opening called LACRIMAL FOLD OR VALVE OF HASNER; it
prevents the air from blowing the duct into the eye.

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119. SUPERIOR LARYNGEAL NERVE

It is the nerve of fourth arch.
It arises from inferior ganglion.
In the middle constrictor it divides into external and internal laryngeal
nerves.

EXTERNAL LARYNGEAL NERVE (MOTOR)

It accompanies superior thyroid vessels.
It supplies cricothyroid muscle.
INTERNAL LARYNGEAL NERVE (SENSORY)
It passes b/w middle and inferior constrictors.
Piercing thyrohyoid membrane enters larynx.
It supplies - mucous membrane of larynx above vocal cord and mucous
membrane of pharynx, epiglottis, vallecula, posterior most part of tongue.

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120. MUSCLES OF MASTICATION

The muscles of mastication are concerned with movements of mandible at
the temporomandibular joints during mastication.

PRINCIPAL MUSCLES
All are located in or around the infratemporal fossa.
All are inserted into the ramus of the mandible.
All are innervated by the mandibular division of the trigeminal nerve.
All are concerned with movements of the mandible on the
temporomandibular joints.
All develop from mesoderm of the first pharyngeal arch. They are:
a. Temporalis
b. Masseter
c. Lateral pterygoid
d. Medial pterygoid.

ACCESSORY MUSCLES
(a) Digastric
(b) Buccinator
(c) Mylohyoid
(d) Geniohyoid

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NERVE
MUSCLES ORIGIN INSERTION ACTION
SUPPLY

Tip, anterior Elevation of

border and medial mandible by
surface of anterior and
TEMPORALIS coronoid process middle fibres
Floor of
temporal fossa
(fan shaped) Temporal fascia Anterior border Retraction
of of mandible
by posterior
ramus of
mandible fibres

Lateral surface Elevation of

Zygomatic arch of ramus of
adjoining mandible to
MASSETER
part of mandible occlude the
zygomatic Mandibular
(quadrilateral) teeth for
process of Coronoid division of
maxilla process trigeminal forceful bite
nerve
Depression
Upper head Pterygoid fovea
from of
infratemporal on anterior
LATERAL surface and surface of neck of mandible by
PTERYGOID crest of greater pulling the
wing of mandible
(short, thick sphenoid neck of
Lower head Articular disc mandible
and conical) from lateral and capsule of forward
surface of
lateral TMJ
pterygoid plate Protraction
Superficial head Medial surface of
MEDIAL from tuberosity Elevation of
of maxilla angle adjoining mandible
PTERYGOID Deep head from ramus of
(quadrilateral) medial surface Protraction
of lateral mandible
pterygoid plate

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121. TROCHLEAR NERVE

Trochlear nerve is the 4th cranial nerve.
It is purely motor and supplies only one muscle the superior oblique
muscle of the eyeball.
It is the only cranial nerve which emerges on the dorsal aspect of the brain.
It is the most slender of all the cranial nerves.
It is the smallest cranial nerve.
It is the only cranial nerve whose nuclear fibres decussate before
emerging on the surface of the brain.

FUNCTIONAL COMPONENTS AND NUCLEI -

General somatic efferent fibres arise from the trochlear nucleus in the
midbrain.
They supply the superior oblique muscle of the eyeball.

COURSE, RELATIONS, DISTRIBUTION -

It arise from the dorsal aspect of the midbrain, one on either side of
frenulum veli.
It winds round the superior cerebellar peduncle and cerebral peduncle just
above the pons.
It passes between the posterior cerebral and superior cerebellar arteries.
It lies medial to and below the free margin to tentorium cerebelli.
The nerve enters the cavernous sinus by piercing the posterior corner of
its roof.
In the cavernous sinus, it runs forward in its lateral wall between the
oculomotor and ophthalmic nerves.
It enters orbit through the superior orbital fissure superolateral to the
tendinous ring.
It runs medially above the levator palpebrae superioris to enter the orbital
surface of the superior oblique.
Supplies the superior oblique.

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