HEAD & NECK  Apex of the gland overlaps the posterior belly of digastrics
muscle
State the boundaries of the infratemporal fossa (40)
 Roof – greater wing of sphenoid(infratemporal surface)
(extra; squamous temporal bone )
 Floor –open
 Lateral wall – ramus of mandible
 Medial wall – lateral pterygoid plate / side wall of pharynx
o (extra; pyramidal process of palatine bone)
 Posterior wall – open
 Anterior wall – posterior surface of maxilla
o (extra; medial surface of zygomatic bone)
 Anterior and medial wall are separated by pterygomaxillary
fissure
 Communicate with the pterygopalatinefossa , temporal
fossa and orbit
Give a brief account on relations of the parotid gland (60)
 Situated below the external acoustic meatus
 Between the ramus of the mandible and
 Sternocleidomastoid muscle
 Anteriorly gland overlaps the masseter [below zygomatic
arch]
 Deep cervical fascia split into 2 layers
 Encloses the gland
 Deep lamina of the fascia forms the stylomandibular
ligament,
 And separates the parotid gland from submandibular gland
 Cervical branch of facial nerve,
 2 divisions of the retromandibular vein,
 Emerge from the apex
 Superior surface of the gland related to the
temperomandibular joint,
 Superficial temporal vessels,
 Auriculotemporal nerve
 Skin
 Superficial fascia
 And parotid fascia overlaps the superficial surface of the
gland
 Anteromedial surface is grooved by the ramus of the
mandible
 External carotid artery enters the gland through the
posteromedial surface of the gland
 And divided into its terminal maxillary and
 Superficial temporal branches
 Within the substance of the gland
 Behind the neck of mandible
 Parotid duct emerges from the anterior surface of the gland
 Run forwards over the masseter muscle
 Then pierce the buccal fat pad and buccinatormauscle
 And opened into vestibule of mouth opposite crown of
upper 2nd molar tooth
 Facial nerve enter into the gland through the posteromedial
surface of the gland
 And crosses the vessels superficially within the gland
  And divided into its terminal 5 branches
 Nerve is separated from the artery by the vein during its
course inside the gland
 Temporal, zygomatic, buccal, marginal mandibular branches
 Leave the gland through its anteromedial surface
 Retromandibular vein is formed inside the gland
 By the union of the maxillary and
 Superficial temporal vein
 Lymph nodes and lymphatics are closely related to the
gland
Describe the macroscopic anatomy of the thyroid gland. (60)
 Butterfly shaped/shield like endocrine gland
Extent and location
 In the lower part of the front and side of the neck
 gland lies against C5,C6,C7 & T1 vertebrae/ each lobe
extend from middle of the side of the thyroid cartilage to
the 4th& 5th tracheal rings
 gland has2 lobes joined by an isthmus/conical lobes are
connected with each other by an isthmus in its lower part
 isthmus overlies 2nd to 4th tracheal rings
 [an inconstant pyramidal lobe may project upward dfrom
the isthmus]
 Have 2 capsules
 Peripheral condensation of the connective tissue forms the
true capsule
 False capsule is derived from the pretracheal fascia which
encloses it
 Inner surface of the gland connected to the cricoids by
thicken pretrachealfascial layer called suspensory ligament
[of Berry]
Blood supply
 By superior thyroid artery – a branch from of external
carotid artery
 By inferior thyroid artery – a branch of thyrocervical trunk
 Additional supply is by thyroideaima artery and esophageal
and tracheal branches
 Superior thyroid artery reach the upper pole of the gland
and [anastomose with the opposite artery along the upper
border of isthmus]
 Inferior thyroid artery reach the lower pole
 Superior thyroid vein emerges from the upper pole of the
gland drains into internal jugular vein
 Middle thyroid vein also drain into internal jugular vein
 Inferior thyroid veins emerge from the lower border of the
isthmus to be drained into brachiocephalic vein
 Dense capillary plexus present deep to the true capsule
 Lymph from the upper part of the gland drains into upper
deep cervical lymph nodes
Relations
 Superficially gland is covered by strap muscle of
neck/sternothyroid, sternohyoid, superior belly of
omohyoid overlapped by sternoclastomastoid
 Anterior jugular vein course over the isthmus
 On the deep aspect lie the larynx and trachea, pharynx and
esophagus
 Behind the carotid sheath on the either side
  Recurrent laryngeal nerve coursing on the
tracheoesophageal groove
 Closely related to the inferior thyroid artery
 And external laryngeal nerve is closely related to the
superior thyroid artery
 Sympathetic fibres are mainly derived from the middle
cervical ganglia/ cervical sympathetic trunk.
Briefly describe the embryological development of the thyroid
gland. (25)
 Epithelium of endodermal origin
 Begins proliferating in the floor of the ventral portion of the
pharynx
 [the site is later known as foramen ceacum/ between the
tuberculumimpar and copula]
 Descend as blobbed diverticulum
 In front of the pharyngeal gut/hyoid bone& forms a
recurrent loop
 Laryngeal cartilage
 In the midline
 But remain connected to the tongue by thyroglossal duct
 Later it disappears. (in the 7th week of development)
 Acquired 2 lateral lobes and a small median lobe
 Parafollicular cells are derived from the ultimo branchial
body of the 4thbranchial pouch
Give the briedf account of microscopic appearance of the thyroid
follicle. (15)
 Functional unit of the thyroid gland are thyroid follicles
 Spherical structures
 Composed of single layer of simple cuboidal epithelium
bounded by a basement membrane. (secrete thyroxin
&triiodothyronine)
 The size of the follicle and their lining cells vary according to
state of activity (actively secreting – small follicles, less
active – large follicles)
 Parafollicular cells are found within the basement
membrane (secrete calcitonin)
 Contain large amount of pink stained stored colloid material
inside the follicle.
Briefly describe the relations of the cavernous sinus. (45)
 Large venous sinus/space located in the middle cranial fossa
 On either side of the body of the sphenoid
 sinus is located within the dura mater
 lateral medial walls and roof is formed by the meningeal
layer of the dura mater
 and the floor is formed by the endosteal layer of dura
 anteriorly sinus is extends up to medial end of the superior
orbital fissure
 posteriorly to the apex of the petrous temporal bone
 cavernous sinus is related superiorly to the optic tract
 optic chiasma, internal carotid artery, internal carotid
artery, olfactory tract
 inferiory to the sinus is foramen lacerum, junction between
body and the greater wing of the sphenoid
 medially to the sphenoidal air sinus
 and to pituitary gland/hypophysiscerebri
  laterally, temporal lobe of the cerebrum
 lateral wall related to the occulomotor
 trochlear
 ophthalmic
 maxillary nerves above downwards
 (extra- trigeminal ganglion also related to the lateral wall)
 Internal carotid artery
 Abducent nerve runs medially (nerve is inferolateral to the
artery)
 Above nerves are separated from the sinus by a thin
endothelial cell layer
Name communications of the cavernous sinus
 Into the transverse sinus through the superior petrosal sinus
 Into the internal jugular vein through the inferior petrosal
 Into the pterygoid plexus through the emissary veins
 Into the facial vein through the superior ophthalmic vein
 Intercavernous connection
Describe the layers of the scalp. (60)
 The SCALP is made up of 5 layers. Superficial to deep they
are,
 Skin
 Superficial fascia
 Epicranialaponeurosis/galeaaponeurotica
 Loose areolar tissue
 Pericranium
 Skin is thick
 Hairy & rich in sebaceous glands
 Superficial fascia is fibrous & has lobules of fat
 Arranged in tight compartments divided by fibrous septa
 Blood vessels running to the skin lies in this layer
 Skin is firmly adherent to the underlying
epicranialaponeurosis via superficial fascia
 Epicranialaponeurosis is fibrous over the dome of the skull
but
 Receives insertion of frontalisanterioly& of occipitalis
posteriorly
 Aponeurosis is attached posteriorly to the external occipital
protuberance, superior nuchel line &
 Superior temporal line on either side. [sends down a thin
expansion passing over temporal fasia]
 Loose areolar tissue extend anteriorly into eyelids. (because
frontalis does not have a bony attachment)
 Posteriorly attached to superior/highest necheal lines,
 & superior temporal lines on either sides
 Due to its loose nature, aponeurosis& overlying layers are
freely movable
 Pericranium is loosely adherent to bony surface
 Except at sutures
 Where it tightly attached to endocranium [via sutural
ligament]
 (aponeurosis is tensed by the tone of occipitofrontalis)
Describe the relations of the submandibular gland
 Is a mixed mucous and seroud in type
 The mylohyoid divide gland into superficial and deep parts
 Superficial part is triangular in shape
 Its inferior/superficial surface is related to the
o skin,
o platysma,superficial fascia,
o investing layer of deep fascia,
o submandibular lymph nodes, (within the substance)
o the facial vein &
o the cervical branch of facial nerve (extra -
sometimes to marginal mandibular branch as well)
 the lateral surface is related to the submandibular fossa &
medial pterygoid muscle(insertion)
 the medial surface lies against the mylohyoid and behind it
on the hyoglossus, lingual nerve, hypoglossal nerve and its
accompanied veins
 the facial artery is at first deep to the gland, and then
grooves posterosuperior part as it hooks over the top of the
gland on to its lateral surface
 deep part of the gland extend forwards for variable distance
 between mylohyoid and hyoglossus, below the lingual nerve
and above the hypoglossal nerve
 the submandibular duct emerges from the medial surface of
the superficial part of the gland near the posterior part of
the mylohyoid
 it runs with the deep part, forward, slightly upwards
 first between mylohyoid and hyoglossus
 then between sublingual gland &genioglossus
 to open into the floor of the mouth beside the frenulum
 as it lies on hyoglossus, the duct is crossed laterally by the
lingual nerve & turns under the duct to pass medially
A cricket player received a blow on the temple. He was diagnosed
to have a extradural hemorrhage.
What is the artery damage?
Anterior division of the middle meningeal artery
What is the commonest site it would be damage? How would you
surface mark it?
 Pterion
 2 finger breath posterior to the lateral orbital margin or
 1 thumbs breath posterior to the lateral orbital margin
How would you differentiate between an extradural & subdural
hemorrhage?
 Extradural hemorrhage is arterial in nature& subdural
hemorrhage is venous
 In extradural hemorrhage paralysis first appear from face
and then spreads to the lower part of the body,
 In subdural hemorrhage the progress of paralysis is
haphazard
 In extradural hemorrhage there is no blood in CSF; while it
is a common feature in subdural hemorrhage
 Symptoms of cerebral compression are late in extradural
hemorrhage
Describe the sign & symptoms observed in increased intracranial
pressure
 Medial squint – damage to abducent nerve as it winds over
superior border of the apex of the petrous temporal bone
 Dilatation of pupil – compression of the occulomotor nerve
over the edge of tentorium cerebelli
 Papilloedema – at the subarachnoid space extends around
the optic nerve up to the eye ball, increased pressure in this
space compress the retinal vaeins causing papilloedema
 Contralateral hemiplegia – due to compression of crus
cerebri of the midbrain (by the herniated uncus)