CLINICAL ANATOMY OF HEAD AND NECK 2022

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Clinical Anatomy Cause Sign/Symptom
Anterior Cranial Fossa - Cranial nerve I, Nasal Cavity
Fracture of Nasal septum continuous with Blow to nose; fracture Leakage of CSF from
cribriform plate crista galli of ethmoid bone; produces continuity nose ('runny nose');
of ethmoid Olfactory nerve passes between Decreased sense of
bone through cribriform plate of subarachnoid space smell (hyposmia)
ethmoid bone and nasal cavity
Middle Cranial Fossa - Cranial nerves II-VI Orbit, Eye Movements, Face
Rapid loss of Central artery of retina (branch Occlusion of Central Sudden onset blindness
vision in one of Ophthalmic artery from Int. Artery of Retina in one eye (one eye only,
eye Carotid) is an normally an end sign: artery occlusion
artery with no functional visible through
anastomoses (exception: ophthalmoscope)
Chorioretinal anatomoses)
Slow loss of Dura mater and subarachnoid Communicating Decreased visual
vision in one continue over optic nerve; hydrocephalus (many function both eyes; sign:
eye Optic nerve function causes) papilledema in
affected by CSF pressure ophthalmoscope view;
also other signs of
increased intracranial
pressure (headache,
etc.)
Abducens Abducens nerve innervates Damage Abducens Diplopia and Medial
nerve palsy only Lateral Rectus muscle nerve VI (causes ex. strabismus
(action: abduction of eye) increased intracranial
pressure, Cavernous
sinus thrombosis)
Trochlear nerve Trochlear nerve innervates Damage Trochlear Inability to look down
palsy only Superior Oblique muscle nerve (ex. trauma) and out (difficulty
(action: abduct, depress and walking down stairs);
medially rotate eye) Head tilted toward side
opposite lesion
Oculomotor Oculomotor nerve innervates Damage Oculomotor Lateral strabismus,
nerve palsy Superior, Medial and Inferior nerve (frequently dilated pupil, ptosis;
Rectus and Inferior Oblique; idiopathic) also loss of
part of Levator palpebrae accommodation (near
superioris; also provides vision) due to paralysis
parasympathetics to pupillary of ciliary muscles
constrictor, ciliary muscles

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Clinical Anatomy
Horner's Sympathetics in head
Syndrome innervate smooth muscle part
(Dr. Salisbury of Levator Palpebrae
Lecture) Superioris; Pupillary Dilator
muscle; sweat glands of skin;
Pathway: pre-ganglionic
neurons out cord at T1,2;
ascend in chain; post-
ganglionics in Sup. Cerv.
Ganglion; distributed with
arteries (ex. Ophthalmic A.)
Cavernous Branches of cranial nerves (III,
sinus IV, V1, V2, VI) and Internal
thrombosis Carotid artery pass through
wall of Cavernous sinus;
Cavernous sinus drains
ophthalmic veins which
anastomose with branches of
Facial Vein; veins have no
valves
Epidural Middle Meningeal artery
Hematoma (branch of Maxillary artery that
passes through foramen
spinosum) supplies bone of
calvarium
Subdural Bridging veins link Superficial
Hematoma cerebral veins on surface of
brain and Superior Sagittal
sinus (also other venous
sinuses)
Communicating CSF produce in choroid
Hydrocephalus plexus; reabsorbed from
due to subarachnoid space at
decreased CSF arachnoid villi into venous
reabsorption sinuses
Cause Sign/Symptom
Block conduction in Ptosis (drooping eyelid
Sympathetics to head from smooth muscle part
(tumors, etc) of Levator Palpebrae
Superioris);
Constricted pupil
(miosis due to paralyze
Dilator pupillae);
Anhydrosis of forehead
(denervate sweat glands)
ex. Infection in cav. Diplopia (blurred vision)
sinus spread from due to disruption of eye
infection of face movements; increased
(Facial Vein has venous pressure
no/few valves) (angle produces engorgement
of nose or upper lip in veins of retina (view
particularly dangerous) in ophthalmoscope)
+other symptoms
Blow to side of head Patient conscious after
(fracture skull in accident; loses
region of pterion) consciousness within
hours; coma, death
(Note: hematoma is
lens-shaped on CT)
Blow to head; in Slow onset of
elderly can occur neurological symptoms,
without distinct event headache (often hours to
days)
(Note: hematoma is
crescent-shaped on CT)
In elderly, Headache, papilledema
Calcification of
arachnoid villi
(arachnoid
granulations)
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CLINICAL ANATOMY OF HEAD AND NECK

Clinical Anatomy Cause Sign/Symptom

Posterior Cranial Fossa - Cranial Nerves VII-XII, face, ear, pharynx, tongue (cont.)
Loss of IX is major sensory nerve to Tumor at Jugular Difficulty in swallowing;
function of IX pharynx (oropharynx); Foramen Absence of Gag Reflex;
and X X is motor to all muscles of (Gag reflex - IX sensory,
pharynx except X motor)
Stylopharyngeus; all muscles Uvula deviates away
of palate (except Tensor from side of lesion
palati)
Hoarse voice X is motor to all muscles of Damage Recurrent Hoarse voice due to
after thyroid larynx; also sensory to larynx; Laryngeal nerve unilateral paralysis of
surgery Recurrent Laryngeal nerve during Thyroid all laryngeal muscles
passes posterior to Thyroid surgery (except Cricothyroid)
gland with Inf. Thyroid artery;
motor to all laryngeal muscles
except Cricothyroid
Torticollis XI innervates Torticollis can be Contracture of
Sternocleidomastoid and congenital or acquired Sternocleidomastoid -
Trapezius head is rotated with face
directed to opposite side
(Note: Trapezius -
clinical test for XI -
shrug shoulders)
Paralysis of XII is motor to all muscles of XII hypoglossal nerve Atrophy of muscles of
muscles of tongue (no sensory palsy tongue on one side;
tongue component) protruded tongue
deviates toward side of
lesion due to
Genioglossus) in
Lower Motor Neuron
Lesion

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Clinical Anatomy
Middle Cranial Fossa - Cranial nerves II-VI Orbit, Eye Movements, Face
Numbness of V is major sensory nerve of
regions of face face and head; Sensory
neuron cell bodies are in
Semilunar (Trigeminal)
Ganglion; V1 above lateral
margin eyelids; V2 eyelids to
upper lip; V3 below lateral
margins of lips
Pain in external Skin of ear and external
auditory auditory meatus receive
meatus following sensory innervation from V,
Facial paralysis VII, IX and X
Weakness of Muscles mastication
muscles innervated by V3; Lateral
mastication Pterygoid opens mouth; all
other muscles Mastication
close mouth
Facial paralysis CN VII and VIII exit post.
(with effect on cranial fossa via Internal
VIII) auditory meatus; VIII ends in
temporal bone; VII enters
facial canal and gives off
branches in temporal bone; 1)
parasymp. to Lacrimal gland,
mucous glands of nose, palate; 2)
Nerve to Stapedius muscle; 3)
Chorda tympani - taste to ant. 2/3
of tongue; parasymp. to
Submandibular, Sublingual
salivary glands
Facial paralysis Facial nerve exits skull via
(no effect on Stylomastoid foramen; only has
VIII) motor branches after leaving skull
Cause Sign/Symptom
Many; ex. Trigeminal Numbness in specific
Anesthesia region can be correlated
with specific division of
V
Bell's palsy Ear ache (following or
accompanying Facial
paralysis)
ex. Tumor at foramen When open mouth, jaw
ovale deviates toward
paralyzed side
Acoustic neuroma Loss or reduction of
hearing in one ear;
Full Facial nerve palsy
(Bell's palsy) symptoms:
1) Facial paralysis and
loss of Corneal reflex
(V1 sensory, VII motor)
2) Loss of taste to ant.
2/3 of tongue
3) Decreased secretion
tears and saliva
4) Hyperacousia
Parotid tumor Facial paralysis; Loss of
corneal reflex but no
loss of taste or
decrease in tears or
saliva; no hypercousia
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3) SPINAL REFLEXES AND DIAGNOSIS OF UPPER AND LOWER MOTOR NEURON LESIONS
REFLEX STIMULUS/SENSE RESPONSE CLINICAL/ABNORMAL
ORGAN(S) EXCITED RESPONSES
Stretch Rapid Stretch of Stretched muscle contracts Hyporeflexia - decrease in stretch
(Myotatic, muscle (test: tap on rapidly (monosynaptic reflexes occurs in Lower
Deep muscle tendon) connection); also excite synergist Motoneuron Diseases, Muscle
Tendon) Excites Muscle Spindle and Inhibit antagonist atrophy etc.
Reflex Primary (Ia) and Note: Gamma motor neurons can Hyperreflexia - (increase) -
Secondary (II) sensory enhance stretch reflexes (Gamma characteristic of Upper Motor
neurons (NOT Golgi dynamic motor neurons Neuron lesions (ex. spinal cord
Tendon Organ) specifically enhance Ia injury, damage Corticospinal
sensitivity; tell patient to relax tract); note: Clonus =
before test) hyperreflexia with repetitive
contractions to single stimulus
Autogenic Large force on tendon Muscle tension decreases; Clasped Knife Reflex - occurs in
Inhibition excites Golgi Tendon Also inhibit synergist muscles; Upper Motor Neuron lesions -
(Inverse Organ Ib (test: pull on excite antagonist muscles forceful stretch of muscle is first
Myotatic muscle when resisted) resisted then collapses
Reflex)
Flexor Sharp, painful Limb is rapidly withdrawn from Babinski sign- toes extend
Reflex stimulus, as in stimulus; protective reflex; also (dorsiflex) to cutaneous stimulus
stepping on nail; inhibit extensors of same limb of sole of foot (normally plantar
Excites - Cutaneous and excite extensors of opposite flex); characteristic of Upper
and pain receptors limb (Crossed Extensor Reflex) Motor Neuron lesion

LOWER AND UPPER MOTOR NEURON LESIONS

Lesion Structure Affected Symptoms Examples
Lower Motor Lower Motor Muscle is effectively denervated: 1) Compression of spinal nerve
Neuron Neurons = Alpha 1) Decrease Stretch (Deep Tendon) 2) Poliomyelitis - viral infections
Lesion Motor neurons Reflexes affecting motor neurons
(Flaccid with axons that 2) Decreased Muscle Tone
Paralysis) innervate skeletal 3) Muscle atrophy; Fasciculations
muscles (twitches) precede atrophy
4) No Babinski sign
Upper Motor Upper Motor Disrupt voluntary control and 1) Damage to Corticospinal
Neuron Neurons = All regulation of reflexes (remove (corticobulbar) tracts - can occur at
Lesion descending inhibition): all levels from cortex to spinal cord
(Spastic neurons that 1) Increase Stretch (Deep Tendon) (including brainstem)
Paralysis) affect Lower Reflexes
Motor Neurons 2) Increased Muscle Tone
(ex. Corticospinal 3) No Fasciculations
Reticulospinal 4) Babinski sign
neurons) 5) Clasped Knife Reflex
Note: Some diseases produce both Upper and Lower Motor Neuron Symptoms - (ex. ALS Amyotrophic Lateral Sclerosis)

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REFLEXES OF CRANIAL NERVES
REFLEX STIMULUS SENSORY RESPONSE CLINICAL
Pupillary Light Test: Shine light Light detected by Excite Constrictor of Extensively used to check
Reflex (II to III) in eye Optic Nerve pupil of eye (III Short CN II; Absence of
Ciliary nerves (Ciliary Pupillary Light Reflex can
Ganglion, indicate catastrophe
parasympathetic) (brain herniation)
Corneal Reflex Touch cornea of Touch detected by Close eye (VII to Absence of Corneal
(V to VII) eye with cotton Long Ciliary Orbicularis Oculi Reflex; Test for damage to
nerves (V1), muscle) V1 sensory, VII motor
Somatic sensory Branchiomotor
Gag Reflex (IX Test: Touch Excites Visceral Excite muscles of Other symptoms of Vagus
to X) posterior Sensory endings pharynx, palate; Vagus damage (X);
tongue, in N. (X), Branchiomotor Patient Say's Ahh: soft
oropharynx; Glossopharyngeal palate not elevated on
N. (IX) ipsilateral side (paralyze
Levator Palati); uvula
deviated away from side
of lesion
Jaw Jerk Test: tap down Excites Muscle Contract muscles that Hyporeflexia - indicates
Reflex Stretch on mandible; Spindle sensory elevate mandible Trigeminal nerve damage
(Deep Tendon) Stretch muscles neurons in Motor - V3
Reflex of mastication Trigeminal nerve
(V to V) (ex. Masseter) (V)

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CLINICAL EMBRYOLOGY OF HEAD AND NECK

Clinical Normal development Abnormal Signs/ Treatment

Condition Symptoms
Cleft Lip Fusion of medial nasal and maxillary Failure of Cleft at Surgical
(cheiloschisis) processes forms upper lip fusion of philtrum of repair
medial upper lip
nasal and
maxillary
processes
Cleft Palate Anterior - Fusion of medial nasal Failure of Anterior - Treatment:
(palatoschisis) processes (Primary palate) and fusion Cleft anterior Surgical
maxillary processes (Secondary to Incisive repair
Palate); foramen;
Posterior - Secondary palate formed Posterior -
by fusion of Maxillary processes of two Cleft
sides posterior to
Incisive
foramen
Malformation Duct forms as cord between maxillary Cord fails Continuous Surgical
of nasolacrimal and frontonasal processes; extends to canalize flow of tears repair
duct from lacrimal sac (at medial canthus of over lower lid
(dacryostenosis) eye) to nasal cavity (inferior meatus) onto face
First Arch First brachial arch forms skeletal Neural 1) Mandibular Some surgical
(Treacher elements: crest cells hypoplasia repair
Collins) 1) malleus, incus do not 2) Conductive
Syndrome 2) contributes to mandible (Meckel's migrate hearing loss
cartilage) into Arch 1 4) Facial
malformation
Thyroglossal Thyroid forms as evagination at Glandular Mass in Surgical
duct cysts foramen cecum of tongue; tissue tissue or midline of removal
migrates ant. to Hyoid bone in midline cysts neck (remove tract
of neck to location below Cricoid develop to tongue)
cartilage anywhere
along path
of
migration
Abnormal Normally posterior to thyroid gland or Can be Normally no Treat calcium
location/ embedded in it; develop from branchial located symptoms; imbalance
Accidental pouches 3 and 4 within calcium pharmaco-
Removal of Inferior parathyroid - pouch 3 thyroid imbalance If logically, etc.
parathyroid Superior parathyroid - pouch 4 gland or accidentally
glands ectopic remove (
during thyroid
surgery)

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BRANCHIAL ARCHES AND DERIVATIVES

ARCH (NERVE) SKELETAL LIGAMENTS MUSCLES

First (V) 1) Malleus 1) Ant. ligament of 1) Muscles of Mastication
2) Incus malleus 2) Tensor tympani
2) Spheno- 3) Tensor palati
mandibular ligament 4) Mylohyoid
5) Ant. belly of Digastric
Second (VII) 1) Stapes Stylohyoid ligament 1) Muscles of Facial
2) Styloid process Expression
3) Hyoid bone - lesser 2) Stapedius
horn, upper half of body 3) Stylohyoid
4) Post. belly of Digastric
Third (IX) Hyoid bone - greater horn, ---------- Stylopharyngeus
lower half of body
Fourth (X) Cartilages of Larynx ---------- 1) All muscles of Larynx
2) All muscles of Pharynx
(except Stylopharyngeus)
3) All muscles of Soft Palate
(except Tensor palati)
Sixth (XI) ---------- ---------- 1) Sternocleidomastoid
2) Trapezius

STRUCTURES DERIVED FROM BRANCHIAL POUCHES, CLEFT AND MEMBRANE: BRANCHIAL 'CLEFT'
CYSTS (FISTULI = channels from pharynx to skin)

POUCH FORMS CLINICAL

First 1) Auditory tube First Branchial 'Cleft' cyst - tract to external auditory
2) Tympanic cavity meatus or auditory tube

Second Lining (crypts) of palatine Second Branchial 'Cleft' cyst - tract to tonsillar fossa
tonsils (palatine tonsils) - MOST COMMON CYST

Third 1) Inferior parathyroid gland Third Branchial 'Cleft' cyst - tract to thyrohyoid
2) Thymus membrane or piriform recess

Fourth 1) Superior parathyroid gland Rare

2) C-cells of Thyroid
Note: Pouch 3 structures migrate below (caudal) to Pouch 4 structures.
Note: Location of Cysts and Fistuli - in lateral neck, anterior to Sternocleidomastoid muscle
Note: First Branchial Cleft forms Ext. Auditory Meatus; First Branch. Membrane = Tympanic Membrane