Sakaj Sog by HJ

‫ن‬
‫رس و رگد ی‬
‫ی‬ ‫زجء‬
‫ی‬ ‫شک ا یز‬
‫ن ی‬‫رسرگدا ی‬
The High Yield Head & Neck Book
Hamzah Jehanzeb
‫اکسج وسگ‬
HJ’s HY H&N
Hamzah Jehanzeb
3 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Preface
The author in his true form and natural habitat (Credits: M. Ali Akbar Khan)
Anatomy is a discipline that ought to be easy to grasp, but is dealt a horrible injustice by
a lack of good resources. This problem gets especially compounded in the head and
neck module, where the “big books” (KLM and Gray’s) offer way too much detail, little
of which is exam-relevant, while the “short books” (BRS, HY Anatomy, and TMA),
although providing a good overview of the topics, tend to be lacking in terms of content
and good, explanatory diagrams. While one could easily get away with only doing the
clinical correlates in MSK, that’s not an option for head and neck since the anatomy
tends to get tested in its pure form in this module. Thus, I began my quest to compile a
high-yield book of my own.
My motivations for writing this book were as follows:

1. The resources for this module were too scattered, making last-minute
reviewing difficult.
2. The high-yield resources had a lot of irrelevant content and were extremely
lacking when it came to certain topics.
3. Being a connoisseur of the high-yield arts, I would often get asked by
concerned batchmates as to which high-yield resources would be the most
ideal. The problem I encountered here was that most people don’t realize that
not all information in high-yield resources is high-yield for the summative, and
so they would end up wasting a lot of time and effort trying to memorize
irrelevant information while completely neglecting important information.
4. There was a lot of confusion regarding which video resources to use.
And so, I wrote this book as a distillate of all the high-yield facts from BRS, TMA, Gray’s
and KLM, including all the important diagrams from the aforementioned resources.
Additionally, at the beginning of each chapter, I have included recommended video
resources, which I highly recommend you check out. Although I have tried my level
best to only include exam-relevant content, I have included a few low-yield points,

purely for concept-building purposes. Despite this, I still strongly believe that this book
is the most complete high-yield resource out there.
The way this book is structured to be used is as follows: watch whichever

recommended video suits you. This will help give you an initial overview of the topic.
Then go through the text in this book, which will hopefully contain all the relevant
information. If there are any missing points, I have left a wide margin on the right side
of the page for annotations (if only Fermat had such a wide margin….). Additionally, in
the left side margin you can find important review questions you should be asking
yourself while revising. This was inspired by the format of Cornell notes, and is meant
for active recall-based learning.
A few random facts regarding the book: the main title in Urdu, as seen on the front
page, means “remover of difficulties of the head and neck module”. This long,
convoluted name has been abbreviated to “Sakaj Sog”, which is the preferred name for
the book, and is completely nonsensical. The long version of the name is a satirical take
on the titles of texts from medieval Persianate societies. Thought it might pique
someone’s interest. Additionally, all the images used in the chapter covers, as well as
the image on the front page, were generated using AI text-to-image programs. The
ones I used were Dall-E mini and Dall-E Flow. Each image is meant to evoke a certain
art style. Let’s see if you can guess what those art styles are. I’ll include the answers at
the end of the book. Additionally, I’ve designed the book so that the page numbering
on the pages and the pdf page numbers coincide. In the process of writing this book, I
also developed an index for determining which resources would be the most effective
to use for any particular module, and the results were pretty spot-on. I was hoping I
could include the equation and graphs in this book, but I was too lazy to do so.
A big shoutout to Dr. Ali Aahil for his amazing module guide, which helped me
determine which topics and diagrams to include. Be sure to check it out.
Lastly, I hope this book makes this module easier for everyone. It sure has done that for
me. I hate to see my batchmates struggling because they don’t know what information
is important, and end up scoring lower than they should, just because a lot of their
effort was wasted on low-yield facts. If you truly find this book useful, bus dil sai dua
karo meray liyay. Or just get me a cocomo, either one works.
End of Rant

Dedicated to the Batch of 2025
Regardless of how med school goes, you’ll all make amazing doctors someday,
although I can’t guarantee that all of you will be good people (just kidding, itnay jaldi
sokhta tau na ho)
high-yield
‫ن آدمی‬
‫وت رباےئ ولص رکد ی‬
‫ن آدمی‬
‫صف رکد ی‬
‫ی‬ ‫ےن رباےئ‬
low-yield
‫م‬
‫ الجلادلنی رو ی‬-
“If the yield is low, let it go.”

Table of Contents
1. The Skull and Cranial Foramina .................................................................................................. 9
Bones of the Skull..................................................................................................................... 11
Cranial Foramina ...................................................................................................................... 27
Cranial Fossae........................................................................................................................... 33
2. The Meninges and Dural Venous Sinuses ................................................................................ 37
The Meninges ........................................................................................................................... 38
Dural Venous Sinuses ............................................................................................................... 40
3. The Scalp, Muscles of Facial Expression & Muscles of Mastication......................................... 45
The Scalp .................................................................................................................................. 46
Muscles of Facial Expression .................................................................................................... 50
Muscles of Mastication ............................................................................................................ 53
4. The Infratemporal Fossa, Pterygopalatine Fossa, and TMJ ..................................................... 55
Infratemporal Fossa ................................................................................................................. 57
Pterygopalatine Fossa .............................................................................................................. 61
The Temporomandibular Joint ................................................................................................. 67
5. The Oral Cavity ......................................................................................................................... 69
Structure of the Oral Cavity ..................................................................................................... 71
The Palate................................................................................................................................. 73
The Tongue............................................................................................................................... 77
The Salivary Glands .................................................................................................................. 84
The Oropharyngeal Triangle..................................................................................................... 93
6. The Nose and Paranasal Sinuses .............................................................................................. 95
The Nasal Skeleton & External Nose ........................................................................................ 97
The Nasal Cavity ....................................................................................................................... 99
The Paranasal Sinuses ............................................................................................................ 111
7. The Orbit and the Eye ............................................................................................................ 119
The Bony Orbit ....................................................................................................................... 121
The Eyelids and Lacrimal Apparatus ...................................................................................... 124
The Extraocular Muscles ........................................................................................................ 127
The Eyeball ............................................................................................................................. 132
8. The Ear.................................................................................................................................... 141
The External Ear ..................................................................................................................... 143
The Middle Ear ....................................................................................................................... 147
The Inner Ear .......................................................................................................................... 154
9. Vasculature of the Head and Neck ......................................................................................... 161
Arteries of the Head & Neck .................................................................................................. 163
Veins of the Head & Neck ...................................................................................................... 170
Lymphatics of the Head & Neck ............................................................................................. 172
10. Cranial Nerves ...................................................................................................................... 175
Cranial Nerve Modalities ........................................................................................................ 177
The Olfactory Nerve (CN I) ..................................................................................................... 178
The Optic Nerve (CN II) .......................................................................................................... 180
The Oculomotor Nerve (CN III)............................................................................................... 183
The Trochlear Nerve (CN IV) .................................................................................................. 186
The Trigeminal Nerve (CN V) .................................................................................................. 188
The Abducens Nerve (CN VI) .................................................................................................. 200
The Facial Nerve (CN VII) ........................................................................................................ 202
The Vestibulocochlear Nerve (CN VIII) ................................................................................... 208
The Glossopharyngeal Nerve (CN IX) ..................................................................................... 210
The Vagus Nerve (CN X) ......................................................................................................... 213
The Accessory Nerve (CN XI) .................................................................................................. 218
The Hypoglossal Nerve (CN XII) .............................................................................................. 220
11. The Neck ............................................................................................................................... 223
Cervical Fascia ........................................................................................................................ 225
Muscles of the Neck ............................................................................................................... 230
Triangles of the Neck.............................................................................................................. 237
12. The Pharynx.......................................................................................................................... 247
Subdivisions of the Pharynx ................................................................................................... 249
Muscles of the Pharynx .......................................................................................................... 252
13. The Larynx ............................................................................................................................ 257
Overview of the Larynx .......................................................................................................... 259
Laryngeal Cartilages ............................................................................................................... 260
Laryngeal Ligaments and Folds .............................................................................................. 263
Muscles of the Larynx ............................................................................................................ 267
Laryngeal Cavity ..................................................................................................................... 272
Neurovascular Supply of the Larynx ...................................................................................... 276

Chapter 1
The Skull and Cranial

Foramina
1. The Skull and Cranial Foramina
Recommended Videos
Sam Webster:
• “Labelled skull bones”
o Runtime: 17:28
o (https://youtu.be/uxmD2XMaBM8)
• “Labelled cranial foramina anatomy”
o Runtime: 22:51
o (https://youtu.be/97sWvuPXGLI)
The Noted Anatomist:

• “The Skull”
o Runtime: 13:09
o (https://youtu.be/mrMDXZgpByI)
• “Skull bones, sutures and landmarks”
o Runtime: 39:23
o (https://youtu.be/_In46sgXzBM)
AnatomyZone:
• “Foramina of the Skull | Skull Anatomy”
o Runtime: 8:42
o (https://youtu.be/BW19nGC4g_U)

Bones of the Skull

(https://teachmeanatomy.info/head/osteology/skull/)
• The skull is divided into the braincase (neurocranium, or sometimes simply

referred to as the cranium) and the facial skeleton (viscerocranium).
Neurocranium:
• The cranium (also known as the neurocranium) is formed by the superior

aspect of the skull.
• It encloses and protects the brain, meninges, and cerebral vasculature.
• Anatomically, the cranium can be subdivided into a roof (calvarium) and a base:
Bones forming o Cranial roof (calvarium) – comprised of the:
the calvarium? ▪ Frontal
▪ Occipital
▪ two Parietal bones.
o Cranial base – comprised of six bones:
Bones forming ▪ frontal
the cranial ▪ sphenoid
base? ▪ ethmoid
▪ occipital
▪ parietal
▪ temporal.
o The bones forming the cranial base articulate with the 1st cervical
vertebra (atlas), the facial bones, and the mandible (jaw).
• Mnemonic for the bones of the neurocranium: STEP OF
Bones forming o Sphenoid, Temporal, Ethmoid, Parietal, Occipital and Frontal bones
the
neurocranium?
Fig 1 – Bones of the calvarium and cranial base.

Neurocranium
• Frontal bone:
Fontal bone
• Parietal bone:
Parietal bone

• Temporal bone:
Parts of the o Squamous part
temporal ▪ is external to the lateral surface of the temporal lobe of the
bone?
brain.
o Petrous part
▪ encloses the internal and middle ears
o Mastoid part
▪ contains mastoid air cells
o Tympanic part
▪ houses the external auditory meatus and the tympanic cavity
o Zygomatic process
▪ Forms part of the zygomatic arch
o Styloid process
▪ acts as an attachment point for muscles and ligaments
Fig 1 – Lateral view of the skull. The temporal bone has been highlighted.
Fig 1.1 – The constituent parts of the temporal bone.
Fig 1.2 – Coronal section of temporal bone, showing the mastoid air cells in more detail

Infections can
spread to the
mastoid air • Clinical Correlate: Mastoiditis:
cells from?
o Middle ear infections (otitis media) can spread to the mastoid air cells.
Where can
they spread to ▪ Due to their porous nature, they are a suitable site for
from the air pathogenic replication.
cells? o The mastoid process itself can get infected
▪ this can spread to the middle cranial fossa, and into the brain,
causing meningitis.
Nerve that can o If mastoiditis is suspected, the pus must be drained from the air cells.
be damaged ▪ When doing so, care must be taken not the damage the
when draining
pus from the
nearby facial nerve.
mastoid air • Clinical Correlate: Temporal Bone Fractures:
cells? o It has a varied presentation.
o Ear-related disorders are commonly seen, such as vertigo or hearing
loss.
Symptoms of o As the facial nerve travels through the temporal bone, it can be
temporal bone
damaged, with paralysis resulting.
fracture?
o Other symptoms include bleeding from the ear and bruising around the
mastoid process.
• Occipital bone:
o Encloses the foramen magnum and forms the cerebral and cerebellar
fossae.
Occipital bone
• Sphenoid bone:
o Said to be ‘butterfly-shaped‘
o Consists of:
▪ the body (which houses the sphenoid sinuses and sella turcica),
▪ the greater and lesser wings
▪ the pterygoid process, which projects inferiorly from the
cranium.
o Chiasmatic groove – a sulcus formed by the optic chiasm (where the
optic nerves partially cross).

o The sella turcica is surrounded by the anterior and posterior clinoid

processes.
▪ serve as attachment points for the tentorium cerebelli
Fig 2 – Foramina and bony landmarks of the sphenoid wings and pterygoid process.
Fig 3 – Bony landmarks of the sphenoid body.
• Ethmoid bone:
o Is located between the orbits
o Consists of:
▪ the cribriform plate through which the olfactory nerves enter
the skull
▪ perpendicular plate which contributes to the nasal septum
▪ two lateral masses enclosing ethmoid air cells, known as
ethmoidal labyrinths
o Projecting superiorly from the cribriform plate is the crista galli, which
provides an attachment point for the falx cerebri.

Ethmoid bone
Fig 2 – The ethmoid bone within the nasal cavity.

Viscerocranium:
Bones
comprising the • Consists of 14 bones, which fuse to house the orbits of the eyes, the nasal and
viscerocranium
?
oral cavities, and the sinuses.
• The frontal bone, typically a bone of the calvaria, is sometimes included as part
of the facial skeleton.
• Zygomatic (2):
Unpaired o forms the cheek bones of the face
bones of the o articulates with the frontal, sphenoid, temporal and maxilla bones.
viscerocranium o The most important feature of the zygomatic bone is the zygomatic
?
arch.
▪ This arch is formed by the zygomatic process of the temporal
bone and the temporal process of the zygomatic bone.
Zygomatic arch
Zygomatic bone
• Lacrimal (2):
o the smallest bones of the face.
o They form part of the medial wall of the orbit.
o The main function of the lacrimal bone is to provide support for the
structures of the lacrimal apparatus.
Lacrimal bone

• Nasal (2):
o two slender bones that are located at the bridge of the nose.
Nasal bone
• Inferior nasal conchae (2):

o located within the nasal cavity.
o These bones increase the surface area of the nasal cavity, thus increasing
the amount of inspired air that can come into contact with the cavity
walls.
Inferior nasal concha
• Palatine (2):
o Situated at the rear of oral cavity.
o Forms part of the hard palate.
Palatine bone

• Maxilla (2):
o Comprises part of the upper jaw and hard palate.
o The maxilla is the central, paired bone of the viscerocranium.
o The left and right maxilla fuse in the midline to form the upper jaw.
o Between the two maxillae lies a cranial suture called the intermaxillary
suture.
o Important features of the maxilla include the infraorbital
foramen, maxillary sinus, and incisive foramen.
o The main function of the maxilla is to hold the upper teeth in place.
Maxilla
• Vomer:
o Forms the posterior aspect of the nasal septum.
o One of the two unpaired bones of the viscerocranium.
o The superior two-thirds of the bony nasal septum is formed by the
perpendicular plate of the ethmoid bone, while the inferior third is
formed by the vomer.
Vomer

• Mandible (jaw):
o articulates with the base of the cranium at the temporomandibular
joint (TMJ).
o Largest bone of the viscerocranium.
o Unpaired (the only other unpaired bone of the viscerocranium is the
vomer)
o Head – situated posteriorly, and articulates with the temporal bone to
form the temporomandibular joint.
o Coronoid process – site of attachment of the temporalis muscle
Mandible
Fig 2 – Internal surface of the mandible and its bony landmarks

Fig 3 – Anterior view of the face, showing some of the bones of the nasal skeleton. The vomer, palatine and
inferior conchae bones lie deep within the face.
• Clinical Correlate: Le Fort fractures:

Le Fort o Fractures of maxillae and associated bones
fractures? o Le Fort I fracture:
▪ wide variety of horizontal fractures of the maxillae
▪ passing superior to the maxillary alveolar process (i.e., to the
roots of the teeth)
▪ crossing the bony nasal septum and possibly the pterygoid
plates of the sphenoid.
o Le Fort II fracture:
▪ passes from the posterolateral parts of the maxillary sinuses
▪ supero-medially through the infra-orbital foramina, lacrimals, or
ethmoids to the bridge of the nose.
▪ As a result, the entire central part of the face, including the hard
palate and alveolar processes, is separated from the rest of the
cranium.
o Le Fort III fracture:
▪ horizontal fracture that passes through the superior orbital
fissures and the ethmoid and nasal bones
▪ extends laterally through the greater wings of the sphenoid and
the frontozygomatic sutures.

▪ Concurrent fracturing of the zygomatic arches causes the

maxillae and zygomatic bones to separate from the rest of the
cranium.
Sutures of the Skull:
• Sutures are a type of fibrous joint that are unique to the skull.
Sutures of the • They are immovable and fuse completely around the age of 20.
skull? • These joints are important in the context of trauma, as they represent points
of potential weakness in the skull.
• The main sutures in the adult skull are:
o Coronal suture – fuses the frontal bone with the two parietal bones.
o Sagittal suture – fuses both parietal bones to each other.
o Lambdoid suture – fuses the occipital bone to the two parietal bones.
• In neonates, the incompletely fused suture joints give rise to membranous gaps
between the bones, known as fontanelles.
• The two major fontanelles are:
Frontanelles? o Frontal fontanelle – located at the junction of the coronal and sagittal
sutures
o Occipital fontanelle – located at the junction of the sagittal and
Junctions of lambdoid sutures
cranial • Junctions of the cranial sutures:
sutures? o Lambda
▪ Intersection of the lambdoid and sagittal sutures.
o Bregma
▪ Intersection of the sagittal and coronal sutures.
o Pterion
▪ A craniometric point at the junction of the frontal, parietal, and
temporal bones and the greater wing of the sphenoid bone.
• Clinical Correlate: The pterion overlies the middle meningeal artery, and
fractures in this area may injury the vessel.
o Blood can accumulate between the skull and the dura mater, forming an
epidural hematoma.
Bregma
Lambda
Fig 5 – The major fontanelles and sutures of the skull
Fig 2 – Lateral view of the skull, showing the path of the meningeal arteries. Note the pterion, a weak point
of the skull, where the anterior middle meningeal artery is at risk of damage.

• Clinical Correlate: Skull fractures

Fracture of the o Fracture at the pterion may rupture the middle meningeal artery, and a
petrous portion depressed fracture may compress the underlying brain.
of the temporal
bone?
o A fracture of the petrous portion of the temporal bone may cause blood
or cerebrospinal fluid (CSF) to escape from the ear, hearing loss, and
facial nerve damage.
Fracture of the o Fracture of the anterior cranial fossa causes anosmia, periorbital
anterior cranial bruising (raccoon eyes), and CSF leakage from the nose (rhinorrhea).
fossa? o A blow to the top of the head may fracture the skull base with related
cranial nerve (CN) injury, CSF leakage from a dura-arachnoid tear, and
dural sinus thrombosis.
Fracture of the o Tripod fracture is a facial fracture involving the three supports of the
skull base?
zygomatic (cheek or malar) bone, including the zygomatic processes of
the temporal, frontal and maxillary bones.
Tripod
fracture?



Cranial Foramina
(https://teachmeanatomy.info/head/osteology/cranial-foramina/)
Cranial Nerve Foramina:
• Cribriform Foramina:
Cribriform o Numerous perforations in the cribriform plate of the ethmoid bone.
foramina? o They connect the anterior cranial fossa with the nasal cavity.
o Allow the passage of axons of the olfactory nerve from the olfactory
epithelium of the nose into the anterior cranial fossa where they
communicate with the olfactory bulb.
• Optic Canal and Foramen:
Optic canal? o Permits the passage of the optic nerve (CN II) and the ophthalmic artery
into the bony orbit.
o Bounded medially by the body of the sphenoid, and laterally by the
lesser wing of the sphenoid bone.
• Superior Orbital Fissure:
Superior orbital o Cleft that opens anteriorly into the orbit, and enables communication
fissure? between the cavernous sinus and the apex of the orbit.
o Bordered superiorly by the lesser wing and inferiorly by the greater
wing of the sphenoid bone.
o Transmits several structures that are listed below (from superior to
inferior):
▪ Lacrimal nerve (branch of the ophthalmic nerve, the first division
of the trigeminal nerve)
▪ Frontal nerve (branch of the ophthalmic nerve, the first division
of the trigeminal nerve)
▪ Superior ophthalmic vein
▪ Trochlear nerve (CN IV)
▪ Superior division of the Oculomotor nerve (CN III)
▪ Nasociliary nerve (branch of the ophthalmic nerve, the first
division of the trigeminal nerve)
▪ Inferior division of the Oculomotor nerve (CN III)
▪ Abducens nerve (CN VI)
▪ A branch of the Inferior ophthalmic vein
• Foramen Rotundum:
Foramen o Provides a connection between the middle cranial fossa and
rotundum? the pterygopalatine fossa.
o The maxillary nerve (branch of the trigeminal nerve, CN V) passes
through this foramen.

• Foramen Ovale:
Foramen o Positioned posterolateral to the foramen rotundum within the middle
ovale? cranial fossa.
o It conducts the mandibular nerve (branch of the trigeminal nerve, CN
V) and the accessory meningeal artery.
Fig 2 – Foramina and bony landmarks of the sphenoid wings and pterygoid process.
• Internal Acoustic Meatus:

Internal o Bony passage located within the petrous part of the temporal bone.
acoustic o The canal connects the posterior cranial fossa and the inner ear,
meatus?
transporting neurovascular structures to the auditory and vestibular
apparatus.
o The facial and vestibulocochlear nerves pass through the internal
acoustic meatus, alongside the vestibular ganglion and labyrinthine
artery.
• Jugular Foramen:
Jugular o Formed anteriorly by the petrous part of the temporal bone and
foramen? posteriorly by the occipital bone.
o Can be considered as three separate compartments with their respective
contents:
▪ Anterior – contains the inferior petrosal sinus (a dural venous
sinus).
▪ Middle – transmits the glossopharyngeal nerve, vagus nerve and
cranial part of the accessory nerve.
▪ Posterior – contains the sigmoid sinus and transmits meningeal
branches of occipital and ascending pharyngeal arteries.
• Hypoglossal Canal:
Hypoglossal o Located in the occipital bone, through which the hypoglossal nerve (CN
canal? XII) passes to exit the posterior cranial fossa.

Fig 3 – The bony landmarks and foramina of the posterior cranial fossa.
Figure 1 – Superior view of the skull base showing the foramina and which cranial nerves pass through
them.

Other Foramina:
• Foramen Magnum:
Foramen o The largest of the cranial foramina.
magnum? o Lies in the occipital bone within the posterior cranial fossa
o Allows the passage of:
▪ the medulla and meninges
▪ the vertebral arteries
▪ the anterior and posterior spinal arteries
▪ the dural veins
▪ The spinal division of the accessory nerve, which ascends
through the foramen magnum to join the cranial division. Once
combined, the completed nerve exits through the jugular
foramen as described above.
• Foramen Spinosum:
Foramen o Located within the middle cranial fossa, laterally to the foramen ovale.
spinosum? o It allows the passage of:
▪ the middle meningeal artery
▪ the middle meningeal vein
▪ the meningeal branch of CN V3
• Foramen cecum:
Foramen o In the anterior cranial fossa
cecum? o Carries an occasional small emissary vein from nasal mucosa to superior
sagittal sinus.
• Anterior and posterior ethmoidal foramina:
Ant. and Pos. o In the anterior cranial fossa
ethmoidal o Carries the anterior and posterior ethmoidal nerves, arteries, and veins.
foramina?
• Foramen lacerum:
o Nothing passes through this foramen (may be filled with cartilage)
o but the upper part is traversed by the internal carotid artery and
Foramen greater and deep petrosal nerves en route to the pterygoid canal.
lacerum?
• Carotid canal:
o Internal carotid artery and sympathetic nerves (carotid plexus).
Carotid canal?

Hiatus of facial
canal? • Hiatus of facial canal:
o Greater petrosal nerve.
• Condyloid foramen:
Condyloid o Condyloid emissary vein.
foramen?
• Mastoid foramen:
Mastoid o Branch of occipital artery to dura mater and mastoid emissary vein.
foramen?

• Summary:

Cranial Fossae (Brief Overview)

Anterior Cranial Fossa:
(https://teachmeanatomy.info/head/areas/cranial-fossa/anterior/)
• Most shallow and superior of the three cranial fossae.

• It lies superiorly over the nasal and orbital cavities.
• The fossa accommodates the anteroinferior portions of the frontal lobes of the
brain.
Fig 1 – The bones of the base of the skull. The anterior cranial fossa has been outlined.
Fig 2 – Bony landmarks of the anterior cranial fossa.

Middle Cranial Fossa:

(https://teachmeanatomy.info/head/areas/cranial-fossa/middle/)
• Said to be “butterfly shaped”

• middle part accommodating the pituitary gland
• two lateral parts accommodating the temporal lobes of the brain
Fig 1.0 – The bones of the cranial floor. The middle cranial fossa has been highlighted.
Fig 1.3 – The foramina of the middle cranial fossa.

Posterior Cranial Fossa:

(https://teachmeanatomy.info/head/areas/cranial-fossa/posterior/)
• most posterior and deep of the three cranial fossae.

• It accommodates the brainstem and cerebellum.
Fig 1 – The bones of the cranial floor. The posterior cranial fossa has been outlined.Fig 1.0 – The bones of
the cranial floor. The posterior cranial fossa has been outlined.
Fig 2 – The bony landmarks and foramina of the posterior cranial fossa.

(Blank)

Chapter 2
The Meninges and Dural

Venous Sinuses
2. The Meninges and Dural Venous Sinuses
The Meninges
(https://teachmeanatomy.info/neuroanatomy/structures/meninges/)
• have two major functions:

o Provide a supportive framework for the cerebral and cranial
vasculature.
o Acting with cerebrospinal fluid to protect the CNS from mechanical
damage.
Dura Mater:
Structure,
vascular supply • Outermost layer of the meninges
and
innervation of • located directly underneath the bones of the skull and vertebral column.
the dura • It is thick, tough, and inextensible.
mater? • Consists of two layered sheets of connective tissue:
o Periosteal layer – lines the inner surface of the bones of the cranium.
o Meningeal layer – located deep to the periosteal layer. It is continuous
with the dura mater of the spinal cord.
• The dural venous sinuses are located between the two layers of dura mater.
• Receives its own vascular supply – primarily from the middle meningeal artery
and vein.
• It is innervated by the trigeminal nerve (V1, V2 and V3).
• Dural reflections:
o Falx cerebri – projects downwards to separate the right and left cerebral
hemispheres.
o Tentorium cerebelli – separates the occipital lobes from the cerebellum.
It contains a space anteromedially for passage of the midbrain – the
tentorial notch.
o Falx cerebelli – separates the right and left cerebellar hemispheres.
o Diaphagma sellae – covers the hypophysial fossa of the sphenoid bone.
It contains a small opening for passage of the stalk of the pituitary gland.
Arachnoid Mater:
Structure,
vascular supply • Middle layer of the meninges, lying directly underneath the dura mater.
and
innervation of
• Filmy, transparent layer that is connected to the pia mater by arachnoid
the arachnoid trabeculae.
mater? • Is avascular, and does not receive any innervation.
• Separated from the pia mater by the subarachnoid space, which contains
cerebrospinal fluid (CSF) and enlarges at several locations to form subarachnoid
cisterns.

• The arachnoid projects arachnoid villi (collections of which are called arachnoid
granulations) into the cranial venous sinuses, which serve as sites where CSF
diffuses into the venous blood.
Pia Mater:
Structure of the
pia mater? • Located underneath the sub-arachnoid space.
• It is very thin, and tightly adhered to the surface of the brain and spinal cord.
• It is the only covering to follow the contours of the brain (the gyri and fissures).
• Like the dura mater, it is highly vascularised, with blood vessels perforating
through the membrane to supply the underlying neural tissue.
Fig 1 – Overview of the meninges, and their relationship to the skull and brain.
Fig 3 – Coronal section of the skull, meninges and cerebrum. An arachnoid granulation is visible in the
centre.

Dural Venous Sinuses

(https://teachmeanatomy.info/neuroanatomy/vessels/venous-drainage/)
• Lie between the periosteal and meningeal layers of the dura mater.
• They are best thought of as collecting pools of blood, which drain the central
nervous system, the face, and the scalp.
• All the dural venous sinuses ultimately drain into the internal jugular vein.
• Unlike most veins of the body, the dural venous sinuses do not have valves.
• The straight, superior, and inferior sagittal sinuses are found in the falx
Drainage cerebri of the dura mater.
patter of the o They converge at the confluence of sinuses (overlying the internal
dural venous
occipital protuberance).
sinuses?
o The straight sinus is a continuation of the great cerebral vein and the
inferior sagittal sinus.
o The superior sagittal sinus is the main location of CSF return via
Dural venous arachnoid granulations.
sinus that is the o Superior sagittal sinus is located along the superior aspect of the falx
main location cerebri, while the inferior sagittal sinus is located along the inferior
of CSF return?
aspect (free edge) of the falx cerebri.
• From the confluence, the transverse sinus continues bi-laterally and curves into
the sigmoid sinus to meet the opening of the internal jugular vein.
• The cavernous sinus drains the ophthalmic veins and can be found on either
side of the sella turcica. From here, the blood returns to the internal jugular vein
via the superior or inferior petrosal sinuses.
Figure 1 – Sagittal section showing the dural venous sinuses and the great cerebral vein

Cavernous Sinus:
(https://teachmeanatomy.info/neuroanatomy/vessels/cavernous-sinus/)
• The cavernous sinus is a paired dural venous sinus located within the cranial
cavity.
• It is divided by septa into small ‘caves’ – from which it gets its name.
• Located on either side of the Sella turcica of the sphenoid bone
• Receive venous blood from:
The cavernous o the facial vein
sinus receives o superior ophthalmic vein
venous return o inferior ophthalmic vein
from?
o pterygoid plexus of veins
o central vein of the retina
o each other via the intercavernous sinuses
▪ pass anterior and posterior to the hypophyseal stalk.
▪ Infections can spread from one side to the other through the
intercavernous sinuses.
• They drain venous blood into:
The cavernous o the superior petrosal sinus → transverse sinus
drains into? o the inferior petrosal sinus → internal jugular vein.
• The superior orbital fissure is located anteriorly to the cavernous sinus.
• Several important structures pass through the cavernous sinus to enter
Structures the orbit. They can be sub-classified by whether they travel through the sinus
passing itself, or through its lateral wall:
through the
cavernous
sinus?

• A useful mnemonic to remember the contents and their relation to one another
is: O TOM CAT, where OTOM (oculomotor nerve, trochlear nerve, ophthalmic
branch, maxillary branch) refers to the lateral wall contents from superior to
inferior, and CAT (internal carotid artery, abducens nerve, trochlear nerve) refers
to the horizontal contents, from medial to lateral.
• The cavernous sinus is the only site in the body where an artery (internal
carotid) passes completely through a venous structure.
o Carotid artery-cavernous sinus fistula can result in a headache, orbital
pain, diplopia, arterialization of the conjunctiva, and ocular bruit.
• Poor drainage of the cavernous sinus may result in exophthalmos and edema of
the eyelids and conjunctiva.
• It is important to note that the superior ophthalmic vein forms an anastomosis
with the facial vein. Therefore, the ophthalmic veins represent a potential route
by which infection can spread from an extracranial to an intracranial site.
Fig 1 – Coronal section demonstrating the borders of the right cavernous sinus.
Fig 3 – Schematic of the dural venous system relating to the cavernous sinus. Note the anastomosis
between the ophthalmic veins and the facial vein.

Fig 2 – Coronal section demonstrating the contents of the right cavernous sinus.

(Blank)

Chapter 3
The Scalp, Muscles of

Facial Expression &
Muscles of Mastication
3. The Scalp, Muscles of Facial Expression & Muscles of Mastication
The Scalp
(https://teachmeanatomy.info/head/areas/scalp/)
• The scalp consists of five layers.
• The first three layers are tightly bound together and move as a collective
structure.
• The mnemonic ‘SCALP’ can be a useful way to remember the layers of the scalp:
Layers of the o Skin
scalp? o Dense Connective Tissue
o Epicranial Aponeurosis
o Loose Areolar Connective Tissue
o Periosteum
• Skin – contains numerous hair follicles and sebaceous glands (thus a common
site for sebaceous cysts).
• Dense Connective tissue
o Connects the skin to the epicranial aponeurosis.
o It is richly vascularised and innervated.
o The blood vessels within the layer are highly adherent to the connective
tissue.
▪ This renders them unable to constrict fully if lacerated – and so
the scalp can be a site of profuse bleeding.
• Epicranial Aponeurosis
o Is a tendinous sheet that covers the vault of the skull.
o Unites the occipital and frontal bellies of the occipitofrontal muscles.
o Wounds superficial to this layer of the scalp do not gape or bleed
excessively because the strength of the aponeurosis epicranialis holds
the margins of the wound together.
Occipitofrontalis

• Loose Areolar Connective Tissue

o A thin connective tissue layer that separates the periosteum of the skull
from the epicranial aponeurosis.
o Forms the loose and scanty subaponeurotic space.
o It contains numerous blood vessels, including emissary veins which
connect the veins of the scalp to the diploic veins and intracranial
venous sinuses.
o Is known as the dangerous area of the scalp because infection can
spread easily in this layer to the intracranial sinuses by way of emissary
veins.
• Pericranium – Is the periosteum over the surface of the skull.
Figure 1.0. The five layers of the scalp. Note – The three layers below the periosteum are the meninges.

• The scalp receives a rich arterial supply via the external carotid artery and the
Arterial supply ophthalmic artery (a branch of the internal carotid).
of the scalp?
• There are three branches of the external carotid artery involved:
o Superficial temporal – supplies the frontal and temporal regions
o Posterior auricular – supplies the area superiorly and posteriorly to the
auricle.
o Occipital – supplies the back of the scalp
• Anteriorly and superiorly, the scalp receives additional supply from two
branches of the ophthalmic artery – the supraorbital and supratrochlear
arteries.
Fig 1.1 – Three key arterial branches supplying the scalp. Note, the maxillary artery supplies the deep
structures of the face, not the scalp.
• The scalp receives cutaneous innervation from branches of the trigeminal nerve
or the cervical nerve roots.
• Clinical Correlate: Danger Area of the Scalp
Danger area of o The loose connective tissue layer is considered the “danger area” of the
the scalp? scalp.
o This is because it contains the emissary veins – these are valveless veins
which connect the extracranial veins of the scalp to the intracranial dural
venous sinuses.
o The emissary veins are a potential pathway for the spread of infection
from the scalp to the intracranial space.
▪ Can lead to meningitis or septicemia.
• Clinical Correlate: Scalp Lacerations
Why do deep o Deep lacerations to the scalp tend to bleed profusely for several
lacerations to reasons. These are:
the scalp bleed ▪ The pull of the occipitofrontalis muscle prevents the closure of
profusely?
the bleeding vessel and surrounding skin.
▪ The blood vessels to the scalp are adhered to dense connective
tissue, preventing the vasoconstriction that normally occurs in
response to damage.
▪ The blood supply to the scalp is made up of many anastomoses,

which contribute to profuse bleeding.
o Scalp hemorrhage results from laceration of arteries in the dense
connective tissue layer that is unable to contract or retract and thus
remain open, leading to profuse bleeding.
o Deep scalp wounds gape widely when the epicranial aponeurosis is
lacerated in the coronal plane because of the pull of the frontal end
occipital bellies of the epicranius muscle in opposite directions.

Muscles of Facial Expression

(https://teachmeanatomy.info/head/muscles/facial-expression/)
• They are the only group of muscles that insert into skin.
• These muscles have a common embryonic origin – the 2nd pharyngeal
arch. They migrate from the arch, taking their nerve supply with them.
o As such, all the muscles of facial expression are innervated by the facial
nerve.
• Can broadly be split into three groups: orbital, nasal and oral.
Orbital Group:
Orbital group
and actions? • Orbicularis oculi:
o Surrounds the eye socket and extends into the eyelid.
o Actions:
▪ Palpebral part – gently closes the eyelids.
▪ Lacrimal part – involved in the drainage of tears.
▪ Orbital part – tightly closes the eyelids.
• Corrugator supercilia:
o A much smaller muscle and is located posteriorly to the orbicularis oculi.
o Actions – Acts to draw the eyebrows together, creating vertical
wrinkles on the bridge of the nose.
Fig 2 – The two orbital muscles of facial expression.

Nasal Group:
Nasal group
and actions? • Nasalis:
o It is split into two parts: transverse and alar.
o Actions: The two parts have opposing functions. The transverse part
compresses the nares, and the alar part opens the nares.
• Procerus:
o Most superior of the nasal muscles.
o Contraction of this muscle pulls the eyebrows downward to produce
transverse wrinkles over the nose.
• Depressor Septi Nasi:
o This muscle assists the alar part of the nasali in opening the nostrils.
o Actions: It pulls the nose inferiorly, opening the nares.
Fig 3 – The nasal muscles of facial expression. Note the nasalis muscle is comprised of two parts.
Oral Group:
Oral group and
actions?
• Orbicularis Oris:
o The fibres of the orbicularis oris enclose the opening to the oral cavity.
o Action: Purses the lips.

• Buccinator:
o This muscle is located between the mandible and maxilla, deep to the
other muscles of the face.
o Actions: The buccinator pulls the cheek inwards against the teeth,
preventing accumulation of food in that area
• Other Oral Muscles
Fig 4 – The main oral muscles of facial expression. Note how the fibers of buccinator and obicularis oris
blend together

Muscles of Mastication
(https://teachmeanatomy.info/head/muscles/mastication/)
• There are four muscles:

Muscles that o Masseter
open and close o Temporalis
the jaw?
o Medial pterygoid
o Lateral pterygoid
• The jaws are opened by the lateral pterygoid muscle and are closed by the
temporalis, masseter, and medial pterygoid muscles.
• The muscles of mastication develop from the first pharyngeal arch. Thus, they
Innervation of are innervated by a branch of the trigeminal nerve (CN V), the mandibular
the muscles of nerve (V3).
mastication?
• Masseter:
o The masseter muscle is the most powerful muscle of mastication.
o It is quadrangular in shape.
Actions of the o Has two parts: deep and superficial.
masseter? o The entirety of the muscle lies superficially to the pterygoids and
temporalis, covering them.
o Actions: Elevates the mandible, closing the mouth.
Fig 1 – The masseter muscle. Only the superficial head is visible

• Temporalis:
Actions of the o Originates from the temporal fossa.
temporalis? o Actions: Elevates the mandible, closing the mouth. Also retracts the
mandible, pulling the jaw posteriorly.
Fig 2 – The temporalis muscle.
• Medial Pterygoid:
Actions of the o Has a quadrangular shape with two heads: deep and superficial.
medial o It is located inferiorly to the lateral pterygoid.
pterygoids? o Actions: Elevates the mandible, closing the mouth.
• Lateral Pterygoid:
o Has a triangular shape with two heads: superior and inferior.
Actions of the o It has horizontally orientated muscle fibres
lateral ▪ Thus is the major protractor of the mandible.
pterygoids?
o Actions:
▪ Acting bilaterally, the lateral pterygoids protract the mandible,
pushing the jaw forwards.
▪ Unilateral action produces the ‘side to side’ movement of the
jaw.
▪ Note: Contraction of the lateral pterygoid will produce lateral
movement on the contralateral side. For example, contraction of
left lateral pterygoid will deviate the mandible to the right.
Fig 3 – The medial and lateral pterygoids.

Chapter 4
The Infratemporal Fossa,

Pterygopalatine Fossa,
and TMJ
4. The Infratemporal Fossa, Pterygopalatine Fossa, and TMJ
Recommended Videos
Sam Webster:
• ‘Infratemporal fossa (anatomy)’
o Runtime: 15:32
o (https://youtu.be/jLrkUTIqsAM)

• ‘Infratemporal fossa’
o Runtime: 8:32
o (https://youtu.be/z2GlluoOtMY)
About Medicine:
• ‘Pterygopalatine Fossa - Anatomy, Contents and Borders’
o Runtime: 6:18
o (https://youtu.be/o_JbDynMZjo)
Anatomy Knowledge:
• ‘Pterygopalatine Fossa - Boundaries, Communications & Contents’
o Runtime: 5:51
o (https://youtu.be/QacrWgdmzdY)
Watching the videos is highly recommended.

Although this is a low-yield topic, it’s still important for understanding the courses of
the cranial nerves.
Since it’s low-yield, less effort was put into the notes. Use the videos to orient
yourself.

Infratemporal Fossa
(https://teachmeanatomy.info/head/areas/infratemporal-fossa/)
• The infratemporal fossa is a complex area located at the base of the skull, deep
to the masseter muscle.
• It is closely associated with both the temporal and pterygopalatine fossae and
acts as a conduit for neurovascular structures entering and leaving the cranial
cavity.
• Can be said to have a wedge shape.
• The fossa is closely associated with both the pterygopalatine fossa, via the
Relations and pterygomaxillary fissure, and also communicates with the temporal fossa,
borders of the which lies superiorly
infratemporal
fossa?
Borders:
• It is located deep to the masseter muscle and zygomatic arch (to which the
masseter attaches).
• The boundaries of this complex structure consists of both bone and muscle:
o Lateral – condylar process and ramus of the mandible bone
o Medial – lateral pterygoid plate; tensor veli palatine, levator veli
palatine and superior constrictor muscles
o Anterior – posterior border of the maxillary sinus
o Posterior – carotid sheath
o Roof – greater wing of the sphenoid bone
o Floor – medial pterygoid muscle
• The roof of the infratemporal fossa, formed by the greater wing of the sphenoid
bone, provides an important passage for the neurovascular structures
transmitted through the foramen ovale and spinosum.
o Among these are the mandibular branch of the trigeminal nerve and
the middle meningeal artery.
Fig 1 – The bony features of the infratemporal fossa. The ramus of the mandible has been removed in this
image.

Contents:
• The infratemporal fossa acts as a pathway for neurovascular structures passing

to and from the cranial cavity, pterygopalatine fossa and temporal fossa.
• It also contains some of the muscles of mastication.
o In fact, the lateral pterygoid splits the fossa contents in half – the
branches of the mandibular nerve lay deep to the muscle, while the
maxillary artery is superficial to it.
• Muscles:
Muscles of the o The medial and lateral pterygoids are located within the fossa itself.
infratemporal
fossa?
Fig 2 – The medial and lateral pterygoids.

• Nerves:
o Mandibular nerve – a branch of the trigeminal nerve (CN V).
Nerves of the
infratemporal ▪ It enters the fossa via the foramen ovale, giving rise to motor
fossa? and sensory branches.
▪ The sensory branches continue inferiorly to provide innervation
to some of the cutaneous structures of the face.
o Auriculotemporal, buccal, lingual and inferior alveolar nerves – sensory
branches of the trigeminal nerve.
o Chorda tympani – a branch of the facial nerve (CN VII). It follows the
anatomical course of the lingual nerve and provides taste innervation to
the anterior 2/3 of the tongue.
o Otic ganglion – a parasympathetic collection of neuronal cell bodies.
Nerve fibres leaving this ganglion ‘hitchhike’ along the auriculotemporal
nerve to reach the parotid gland.
• Vasculature:
Vasculature of o Maxillary artery – the terminal branch of the external carotid artery. It
the travels through the infratemporal fossa.
infratemporal
▪ Within the fossa, it gives rise to the middle meningeal artery,
fossa?
which passes through the superior border via the foramen
spinosum.
o Pterygoid venous plexus – drains the eye and is directly connected to
the cavernous sinus.
▪ It provides a potential route by which infections of the face can
spread intracranially.
o Maxillary vein
o Middle meningeal vein

Fig 3 – Some of the contents of the infratemporal fossa.
Infratemporal fossa


Pterygopalatine Fossa
(https://teachmeanatomy.info/head/areas/pterygopalatine-fossa/)
• The pterygopalatine fossa is a bilateral, cone-shaped depression extending

deep from the infratemporal fossa all the way to the nasal cavity via the
sphenopalatine foramen.
Borders:
Borders of the
pterygopalatine • The borders of the pterygopalatine fossa are formed by the palatine, maxilla
fossa?
and sphenoid bones:
o Anterior: Posterior wall of the maxillary sinus.
o Posterior: Pterygoid process of the sphenoid bone.
o Inferior: Palatine bone and palatine canals.
o Superior: Inferior orbital fissure of the eye.
o Medial: Perpendicular plate of the palatine bone
o Lateral: Pterygomaxillary fissure
Fig 1.0 – Left infratemoporal fossa demonstrating the opening of the pterygopalatine fossa (circled in red).
Note: the zygomatic arch has been removed in this image.
Contents:
• Maxillary Nerve:
Course of the o It passes from the middle cranial fossa into the pterygopalatine fossa
maxillary nerve through the foramen rotundum.
and its branches
through the
o The main trunk of the maxillary nerve leaves the pterygopalatine fossa
pterygopalatine via the infraorbital fissure.
fossa?

▪Here, it enters the infraorbital canal of the maxilla and exits

below the orbit in the infraorbital foramen to contribute to the
sensory innervation of the face.
o While in the pterygopalatine fossa, the maxillary nerve gives of
numerous branches including the infraorbital, zygomatic, nasopalatine,
superior alveolar, pharyngeal and the greater and lesser palatine
nerves.
o The maxillary nerve also communicates with the pterygopalatine
ganglion via two small trunks, the pterygopalatine nerves.
Fig 2.0 – The main trunk of the maxillary nerve (CNV2); showing the origin at the trigeminal nerve and its
path to external facial structures.
Fig 2.1 – The branches of the pterygopalatine ganglion and the maxillary nerve. Note: For simplicity, this
schematic does not show: the contribution of the facial nerve (CNVII) to the pterygopalatine ganglion, the
posterior superior alveolar nerves, or the nerve of the pterygoid canal.

• Pterygopalatine Ganglion:
Nerves received o It is the largest parasympathetic ganglion related to branches of the
and sent out by maxillary nerve (via pterygopalatine branches)
the
o Is predominantly innervated by the greater petrosal branch of the facial
pterygopalatine
ganglion? nerve (CNVII).
o Postsynaptic parasympathetic fibres leave the ganglion and distribute
with branches of the maxillary nerve (CNV2).
▪ These fibres are secretomotor in function, and
provide parasympathetic innervation to the lacrimal gland, and
muscosal glands of the oral cavity, nose and pharynx.
Fig 3.0 – The pterygopalatine ganglion and its branches.
• Maxillary Artery:
Course of the o The maxillary artery is a terminal branch of the external carotid artery.
maxillary artery o The terminal portion of the maxillary artery lies within the
and its branches pterygopalatine fossa.
through the
pterygopalatine
o Here, it separates into several branches which travel through other
fossa? openings within the fossa to reach the regions they supply.
o These branches include, but are not limited to:
▪ Sphenopalatine artery (to the nasal cavity).
▪ Descending palatine artery – branches into greater and lesser
palatine arteries (hard and soft palates).
▪ Infraorbital artery (lacrimal gland, and some muscles of the eye).
▪ Posterior superior alveolar artery (to the teeth and gingiva).
o At their terminal ends, the sphenopalatine and greater palatine arteries
anastomose at the nasal septum.

Fig 4.0 – Branches of the maxillary artery and their related foramina and cavities.
Foramina:
• Pterygomaxillary Fissure:
Pterygomaxillary o The pterygomaxillary fissure connects the infratemporal fossa with the
fissure? pterygopalatine fossa.
o It transmits two neurovascular structures:
▪ Posterior superior alveolar nerve – a branch of the maxillary
nerve. It exits through the fissure into the infratemporal fossa,
where it goes on to supply the maxillary molars.
▪ Terminal part of the maxillary artery – enters the
pterygopalatine fossa via the fissure.
• Foramen Rotundum:
Foramen o The foramen rotundum connects the pterygopalatine fossa to
rotundum? the middle cranial fossa.
o It is one of three openings in the posterior boundary of the
pterygopalatine fossa.
o It conducts a single structure, the maxillary nerve.
• Pterygoid and Pharyngeal Canals:
Pterygoid o These two canals, along with the foramen rotundum, are the three
canal? openings in the posterior wall of the pterygopalatine fossa:
▪ Pterygoid canal – runs from the middle cranial fossa and through
the medial pterygoid plate. It carries the nerve, artery and vein
Pharyngeal of the pterygoid canal.
canal? ▪ Pharyngeal canal – communicates with the nasopharynx. It
carries the pharyngeal branches of the maxillary nerve and
artery.
• Inferior Orbital Fissure:
Inferior orbital o The inferior orbital fissure forms the superior boundary of the
fissure? pterygopalatine fossa and communicates with the orbit.
o It is a space between the sphenoid and maxilla bones.
o The zygomatic branch of the maxillary nerve and the infraorbital artery
and vein pass through the inferior orbital fissure.
• Greater Palatine Canal:
Greater o The greater palatine canal lies in the inferior boundary of the
palatine canal? pterygopalatine fossa.
o Communicates with the oral cavity.
o Branching from the greater palatine canal are the accessory lesser
palatine canals.
o The greater palatine canal transmits the descending palatine artery and
vein, the greater palatine nerve and the lesser palatine nerve.
• Sphenopalatine Foramen:
Sphenopalatine o This foramen is the only opening in the medial boundary.
foramen? o It connects the pterygopalatine fossa to the nasal cavity – specifically
the superior meatus.
o The sphenopalatine foramen transmits the sphenopalatine artery and
vein, as well as the nasopalatine nerve (a large branch of the
pterygopalatine ganglion – CNV2).


The Temporomandibular Joint

(https://teachmeanatomy.info/head/joints/temporomandibular/)
Articulating Surfaces:
Articulating
surfaces of the • The temporomandibular joint consists of articulations between three surfaces;
TMJ?
the mandibular fossa and articular tubercle (from the squamous part of
the temporal bone), and the head of mandible.
• This joint has a unique mechanism; the articular surfaces of the bones never
come into contact with each other – they are separated by an articular disk.
• The presence of such a disk splits the joint into two synovial joint cavities, each
lined by a synovial membrane.
Fig 1 – The osteology of the temporomandibular joint
Ligaments:
Ligaments of
the TMJ? • There are three extracapsular ligaments. They act to stablise the
temporomandibular joint.
o Lateral ligament – runs from the beginning of the articular tubule to the
mandibular neck. It is a thickening of the joint capsule, and acts to
prevent posterior dislocation of the joint.
o Sphenomandibular ligament – originates from the sphenoid spine, and
attaches to the mandible.
o Stylomandibular ligament – a thickening of the fascia of the parotid
gland. Along with the facial muscles, it supports the weight of the jaw.

Fig 2 – The joint capsule and accessory ligaments of the temporomandibular joint.
Movements:
Movements
around the TMJ • Movements at this joint are produced by the muscles of mastication, and the
and associated
muscles?
hyoid muscles.
• Protrusion and Retraction:
o The upper part of the joint allows protrusion and retraction of the
mandible – the anterior and posterior movements of the jaw.
o The lateral pterygoid muscle is responsible for protrusion (assisted by
the medial pterygoid).
o The posterior fibres of the temporalis perform retraction.
o A lateral movement (i.e. for chewing and grinding) is achieved by
alternately protruding and retracting the mandible on each side.
• Elevation and Depression:
o The lower part of the joint permits elevation and depression of the
mandible; opening and closing the mouth.
o Depression is mostly caused by gravity.
▪ However, if there is resistance, the digastric, geniohyoid, and
mylohyoid muscles assist.
o Elevation is very strong movement, caused by the contraction of
the temporalis, masseter, and medial pterygoid muscles.
• Clinical Correlate: Temporomandibular Joint Dislocation
Nerves that o A dislocation of the temporomandibular joint can occur via a blow to the
can be side of the face, yawning, or taking a large bite.
damaged in a o The head of the mandible ‘slips’ out of the mandibular fossa, and is
TMJ
pulled anteriorly.
dislocation?
o The patient becomes unable to close their mouth.
o The facial and auriculotemporal nerves run close to the joint, and can
be damaged if the injury is high-energy.

Chapter 5
The Oral Cavity

5. The Oral Cavity
Recommended Videos
Noted Anatomist:
• ‘Oral cavity’
o Runtime: 6:13
o (https://youtu.be/egpicHMYwU4)
• ‘Parotid gland’
o Runtime: 3:17
o (https://youtu.be/Zb6pZMF-rMM)
Sam Webster:
• ‘Oral cavity anatomy’
o Runtime: 14:58
o (https://youtu.be/9xVGxuUB3P0)
• ‘Muscles of the tongue (anatomy)’
o Runtime: 21:43
o (https://youtu.be/lATWhP0wJ5c)
• ‘Cranial nerves of the tongue’
o Runtime: 12:15
o (https://youtu.be/lQrCSYqJBX4)
• ‘Salivary glands (anatomy)’
o Runtime: 19:50
o (https://youtu.be/gdq8mjsWRkk)
Anatomy Knowledge:
• ‘Muscles of the Tongue | Anatomy tutorial’
o Runtime: 3:42
o (https://youtu.be/umNW_PvKsPE)

5. The Oral Cavity
Structure of the Oral Cavity

(https://teachmeanatomy.info/head/organs/oral-cavity/)
• It has three major functions:

o Digestion – receives food, preparing it for digestion in the stomach and
small intestine.
o Communication – modifies the sound produced in the larynx to create a
range of sounds.
o Breathing – acts as an air inlet in addition to the nasal cavity.
• The oral cavity spans between the oral fissure (anteriorly – the opening
between the lips), and the oropharyngeal isthmus (posteriorly – the opening of
the oropharynx).
Divisions:
• It is divided into two parts by the upper and lower dental arches (formed by the
teeth and their bony scaffolding).
• The two divisions of the oral cavity are the vestibule and the mouth cavity
proper.
• Vestibule:
o It is the space between the lips/cheeks, and the gums/teeth.
o The vestibule communicates with the mouth proper via the space
behind the third molar.
• Mouth Proper:
Borders of the o The mouth proper lies posteriorly to the vestibule.
mouth proper? o It is bordered by a roof, a floor, and the cheeks.
o Roof: The roof of the mouth proper consists of the hard and soft
palates.
o Cheeks: are formed by the buccinator muscle.
▪ Innervated by the buccal branches of the facial nerve (CN VII).
o Floor: The floor of the oral cavity consists of several structures:
▪ Muscular diaphragm – comprised of the bilateral mylohyoid
muscles. It provides structural support to the floor of the mouth,
and pulls the larynx forward during swallowing.
▪ Geniohyoid muscles – pull the larynx forward during swallowing.
▪ Tongue – connected to the floor by the frenulum of the tongue, a
fold of oral mucosa.
▪ Salivary glands and ducts.

5. The Oral Cavity
Fig 1 – The two divisions of the oral cavity are the vestibule and oral cavity proper.
Fig 2 – Structures of the oral cavity floor.

5. The Oral Cavity
The Palate
(https://teachmeanatomy.info/head/other/palate/)
• The palate divides the nasal cavity and the oral cavity.
• The hard palate positioned anteriorly and the soft palate posteriorly.
• It forms both the roof of the mouth and the floor of the nasal cavity.
• Reflecting this, the superior and inferior palatal surfaces have different mucosal
linings:
o Superior aspect of palate (nasal cavity) – respiratory epithelium.
o Inferiorly aspect of palate (oral cavity) – oral mucosa, populated by
secretory salivary glands.
Fig 1 – The palate separates the nasal cavity from the oral cavity
The Hard Palate:
• The hard palate forms the anterior aspect of the palate.

Bones and • The underlying bony structure is composed of:
foramina of the o Palatine processes of the maxilla
hard palate?
o Horizontal plates of the palatine bones.
• There are three main foramina/canals in the hard palate:
o Incisive canal – located in the anterior midline, transmits the
nasopalatine nerve.
o Greater palatine foramen – transmits the greater palatine nerve and
vessels
o Lesser palatine foramina – transmits the lesser palatine nerve.

5. The Oral Cavity
Fig 2 – The hard palate is formed by the contributions from the maxilla and palatine bones.
The Soft Palate:
• The soft palate is located posteriorly.

• It is mobile, and comprised of muscle fibres covered by a mucous membrane.
• It acts as a valve that can lower to close the oropharyngeal isthmus, and
elevate to separate the nasopharynx from the oropharynx.
• Anteriorly, it is continuous with the hard palate and with the palatine
aponeurosis.
• The posterior border of the soft palate is free (i.e. not connected to any
structure)
o It has a central process that hangs from the midline – the uvula.
• The soft palate also forms the roof of the fauces; an area connecting the oral
cavity and the pharynx.
• Two arches bind the palate to the tongue and pharynx;
Arches of the o the palatoglossal arches
soft palate? ▪ anteriorly
o the palatopharyngeal arches
▪ posteriorly
• Between these two arches lie the palatine tonsils, which reside in the tonsillar
fossae of the oropharynx.

5. The Oral Cavity
Fig 3 – Location of the palatine tonsil in the oropharynx
Muscles of the Soft Palate:

Muscles of the
soft palate and
• They are all innervated by the pharyngeal branch of the vagus nerve (CN X)
actions?
o APART from Tensor veli palatini
▪ is innervated by the medial pterygoid nerve (a branch of CN V3).
• Tensor Veli Palatini
o Tenses the soft palate.
• Levator Veli Palatini
o Elevation of the soft palate.
• Palatoglossus
o Pulls the soft palate towards the tongue.
• Palatopharyngeus
o Tenses soft palate and draws the pharynx anteriorly on swallowing.
• Musculus Uvulae
o Shortens the uvula.

5. The Oral Cavity
• Clinical Correlate: Cleft Lip and Cleft Palate

What causes a o A cleft refers to a gap/split in the upper lip or palate. It results from a
cleft lip and defect during development of face and palate:
cleft palate? ▪ Cleft lip – occurs when the medial nasal prominence and
maxillary prominence fail to fuse.
▪ Cleft palate – can occur in isolation when the palatal shelves fail
to fuse in the midline, or in combination with cleft lip.
Fig 4 – Cleft palate and cleft lip.

5. The Oral Cavity
The Tongue
(https://teachmeanatomy.info/head/muscles/tongue/)
• Is attached by muscles to the hyoid bone, mandible, styloid process, palate, and
pharynx.
• Is divided into two parts by a V-shaped sulcus terminalis - an anterior two-thirds
and a posterior one-third-which differ developmentally, structurally, and in
innervation.
• The foramen cecum is located at the apex of the "V" and indicates the site of
origin of the embryonic thyroglossal duct.
• A fold of tissue called the lingual frenulum extends from the floor of the mouth
to the inferior surface of the tongue.
• The lingual tonsil is a collection of nodular masses of lymphoid follicles on the
posterior one-third of the dorsum of the tongue.
Lingual Papillae:
Types of lingual
papillae? • Are small, nipple-shaped projections on the anterior two-thirds of the dorsum
of the tongue.
• Are divided into the vallate, fungiform, filiform, and foliate papillae.
• Vallate papillae:
o Are arranged in the form of a “V” in front of the sulcus terminalis.
o Are studded with numerous taste buds and are innervated by the
glossopharyngeal nerve.
• Fungiform papillae:
o Are mushroom-shaped projections with red heads.
o Are scattered on the sides and the apex of the tongue.
• Filiform papillae:
o Are numerous, slender, conical projections.
o Are arranged in rows parallel to the sulcus terminalis.
• Foliate papillae:
o Are found in certain animals but are rudimentary in humans.

5. The Oral Cavity

5. The Oral Cavity
Intrinsic Muscles of the Tongue:

Intrinsic
muscles of the • The intrinsic muscles only attach to other structures in the tongue.
tongue and
actions? • There are four paired intrinsic muscles of the tongue and they are named by the
direction in which they travel: the superior longitudinal, inferior longitudinal,
transverse and vertical muscles of the tongue.
• These muscles affect the shape and size of the tongue – for example, in tongue
rolling – and have a role in facilitating speech, eating and swallowing.
• Motor innervation for the intrinsic muscles of the tongue is via the hypoglossal
nerve (CNXII).
• Superior longitudinal:
o Shortens tongue
o Curls apex and sides of tongue
• Inferior longitudinal:
o Shortens tongue
o Uncurls apex and turns it downward
• Transverse:
o Narrows and elongates tongue
• Vertical:
o Flattens and widens tongue
Extrinsic Muscles of the Tongue:

Extrinsic
muscles of the
• All of the intrinsic and extrinsic muscles are innervated by the hypoglossal
tongue:
innervation nerve (CN XII)
and actions? o EXCEPT for the palatoglossus, which has vagal innervation (CN X).
• Genioglossus:
o Inferior fibres protrude the tongue, middle fibres depress the tongue,
and superior fibres draw the tip back and down

5. The Oral Cavity
• Hyoglossus:
o Depresses and retracts the tongue
• Styloglossus:
o Retracts and elevates the tongue
• Palatoglossus:
o Elevates the posterior aspect of the tongue
o ONLY muscle of the tongue not to be innervated by the hypoglossal
nerve (CNXII). It receives motor innervation via the vagus nerve (CNX)

5. The Oral Cavity
Fig 1 – The extrinsic muscles of the tongue. Note the palatoglossus muscle is not included in this
illustration.
Sensory Innervation of the Tongue:

Sensory
innervation of • The anterior two-thirds of the tongue receives:
the tongue?
o Somatic sensory innervation from the lingual nerve, a branch of
the mandibular nerve (CN V3).
o Taste sensation from the chorda tympani.
▪ In the petrous part of the temporal bone, the facial nerve gives
off three branches, one of which is chorda tympani.
▪ This travels through the middle ear, and continues on to the
tongue.
▪ Joins the lingual nerve in the infratemporal fossa
• The posterior one-third of the tongue and the vallate papillae receive both
somatic and taste innervation via the glossopharyngeal nerve.
• The epiglottic region of the tongue and the epiglottis receive both somatic and
taste innervation from the internal laryngeal branch of the vagus nerve.
Vasculature:
Vasculature of
the tongue? • The lingual artery (branch of the external carotid) does most of the supply.
• Drainage is by the lingual vein.
o Nitroglycerin, a vasodilator used in cases of angina pectoris is absorbed
via the deep lingual veins, located on the side of frenulum linguae

5. The Oral Cavity
Fig 1.2 – The lingual nerve provides sensory innervation to the to the 2/3 of the tongue.
Lymphatic Drainage:
Lymphatic
drainage of the
• Anterior two thirds – initially into the submental and submandibular nodes,
tongue?
which empty into the deep cervical lymph nodes
• Posterior third – directly into the deep cervical lymph nodes

5. The Oral Cavity
• Clinical Correlate: Prognosis of Tongue Cancer

Cancer in o Cancer in the posterior one-third has a poor prognosis
which part of o This is because there is rich anastomosis across the midline between
the tongue has
a poor
the lymphatics of the posterior one-third of the tongue
prognosis, and ▪ therefore, a cancer on one side readily metastasizes to ipsilateral
why? as well as the contralateral lymph nodes.

5. The Oral Cavity
The Salivary Glands

(https://teachmeanatomy.info/head/organs/salivary-glands/)
The Parotid Gland:
• It produces serous saliva, a watery solution rich in enzymes.

Type of saliva • Displays a lobular and irregular morphology.
produced by
the parotid?
• Anatomically, it can be divided into deep and superficial lobes, which are
separated by the facial nerve.
• It is invested with a dense fibrous capsule, the parotid sheath, derived from the
investing layer of the deep cervical fascia.
• Anatomical position:
Anatomical o occupies the region superficial to the ramus of the mandible and the
position of the retromandibular space posterior to the ramus and in front of the
parotid?
mastoid process and sternocleidomastoid muscle.
o It lies within a deep hollow, known as the parotid region. The parotid
region is bounded as follows:
▪ Superiorly – Zygomatic arch.
▪ Inferiorly – Inferior border of the mandible.
▪ Anteriorly – Masseter muscle.
▪ Posteriorly – External ear and sternocleidomastoid.
• Parotid duct:
Course of the o The secretions of the parotid gland are transported to the oral cavity by
parotid duct?
the Stensen duct.
o It arises from the anterior surface of the gland, traversing
the masseter muscle.
o The duct then pierces the buccinator, moving medially.
o It opens out into the oral cavity near the second upper molar.
Fig 1.0 – Position of the parotid gland and borders of the parotid region.

5. The Oral Cavity
• Anatomical relationships:
Anatomical o The facial nerve (cranial nerve VII), gives rise to five terminal branches
relationships of within the parotid gland.
the parotid?
▪ These branches innervate the muscles of facial expression.
o The external carotid artery (ECA) ascends through the parotid gland.
▪ Within the gland, the ECA gives rise to the posterior auricular
artery.
▪ The ECA then divides into its two terminal branches – the
maxillary artery and superficial temporal artery.
o The retromandibular vein is formed within the parotid gland by the
convergence of the superficial temporal and maxillary veins.
▪ It is one of the major structures responsible for venous drainage
of the face.
• Innervation:
Innervation of o The parotid gland receives sensory and autonomic innervation.
the parotid?
o The autonomic innervation controls the rate of saliva production.
▪ Secretes copious watery saliva with parasympathetic stimulation
and produces a small amount of viscous saliva when under
sympathetic control
o Sensory innervation is supplied by the auriculotemporal nerve (gland)
and the great auricular nerve (fascia).
o The parasympathetic innervation to the parotid gland has a complex
path.
▪ It begins with the glossopharyngeal nerve (cranial nerve IX).

5. The Oral Cavity
▪ This nerve synapses with the otic ganglion (a collection of

neuronal cell bodies).
▪ The auriculotemporal nerve then carries parasympathetic fibres
from the otic ganglion to the parotid gland.
o Parasympathetic stimulation causes an increase in saliva production.
o Sympathetic innervation originates from the superior cervical ganglion,
part of the paravertebral chain.
▪ Fibres from this ganglion travel along the external carotid artery
to reach the parotid gland.
o Increased activity of the sympathetic nervous system inhibits saliva
secretion, via vasoconstriction.
Fig 1.2 – Path of the parasympathetic fibres to the parotid gland.
• Clinical Correlate: Surgical Excision of Parotid Gland Tumours

o During this procedure, it is critical to identify and preserve the facial
nerve and its branches.
o Damage to facial nerve or its branches will cause paralysis of the facial
muscles.
• Clinical Correlate: Parotitis
Referred pain o Parotitis refers to inflammation of the parotid gland, usually as a result
from parotitis? of an infection.
o The parotid gland is enclosed in a tough fibrous capsule.
▪ This limits swelling of the gland, producing pain.
o The pain produced can be referred to the external ear.
▪ This is because the auriculotemporal nerve provides sensory
innervation to the parotid gland and the external ear.

5. The Oral Cavity
The Submandibular Gland:

Type of saliva
produced by • Mixed serous and mucous salivary secretions.
the
submandibular • Anatomical position:
gland? o The submandibular gland is located within the anterior part of
the submandibular triangle. The boundaries of this triangle are:
▪ Superiorly: Inferior body of the mandible.
Anatomical ▪ Anteriorly: Anterior belly of the digastric muscle.
position and ▪ Posteriorly: Posterior belly of the digastric muscle.
structure of the • Anatomical structure:
submandibular
gland?
o Structurally, the submandibular glands are a pair of elongate, flattened
hooks which have two sets of arms; superficial and deep.
o The positioning of these arms is in relation to the mylohyoid muscle,
which the gland hooks around.
o Superficial arm – comprises the greater portion of the gland and lies
partially inferior to the posterior half of the mandible, within an
impression on its medial aspect (the submandibular fossa).
▪ It is situated outside the boundaries of the oral cavity.
o Deep arm – hooks around the posterior margin of mylohyoid through a
triangular aperture to enter the oral cavity proper.
▪ It lies on the lateral surface of the hyoglossus, lateral to the root
of the tongue.
• Submandibular duct:
Course of the o Secretions from the submandibular glands travel into the oral cavity via
submandibular
the submandibular duct (Wharton’s duct).
duct?
o Emerges anteromedially from the deep arm of the gland between the
mylohyoid, hypoglossus and genioglossus muscles.
o The duct ascends on its course to open as 1-3 orifices on a
small sublingual papilla (caruncle) at the base of the lingual frenulum
bilaterally.
o Passes medial to and then superior to the lingual nerve.
• Relationship with nerves:

Nerves o Lingual nerve:
associated with ▪ Loops beneath the duct.
the
submandibular
o Hypoglossal nerve:
gland? ▪ Lies deep to the submandibular gland and runs superficial to
hyoglossus and deep to digastric muscle.
o Facial nerve (marginal mandibular branch):
▪ Curves down inferior to the submandibular gland.

5. The Oral Cavity
• Clinical Correlate: Submandibular Gland Excision

Nerve damage o As discussed previously, the gland and its duct lie in close proximity to
in excision of three principal nerves, so the surgeon must be acutely aware of this
the
submandibular
regional anatomy. Consequences of the three nerve injuries are:
gland? ▪ Lingual nerve: Immediate post-operative ipsilateral parathesia
and loss of taste from the anterior two-thirds of the tongue.
▪ Hypoglossal nerve: Ipsilateral paresis or paralysis of the intrinsic
muscles of the tongue leading to dysarthria and deviation of
tongue to side of the lesion.
▪ Facial nerve (marginal mandibular branch): Ipsilateral paresis or
paralysis of the muscles supplying the lower lip and chin,
including depressor labii inferioris, which characteristically
presents as drooping of the lower lip.
• Innervation:
Innervation of o Parasympathetic innervation originates from the superior
the
submandibular
salivatory nucleus through pre-synaptic fibres, which travel via the
gland? chorda tympani branch of the facial nerve (CNVII).
▪ The chorda tympani then unifies with the lingual branch of the
mandibular nerve (CNViii) before synapsing at the
submandibular ganglion and suspending it by two nerve
filaments.
▪ Increased parasympathetic drive promotes saliva secretion.
o Sympathetic innervation originates from the superior cervical ganglion,
where post-synaptic fibres travel as a plexus on the internal
and external carotid arteries, facial artery and finally the
submental arteries to enter each gland.
▪ Reduces glandular blood flow through vasoconstriction and
decreases the volume of salivary secretions, resulting in a more
mucus and enzyme-rich saliva.
Fig 4 – The parasympathetic innervation to the submandibular gland

5. The Oral Cavity
• Clinical Correlate: Salivary Duct Calculi

Why is the o A calculus or sialolith is a calcified deposit which can block the lumen of
submandibular a duct.
duct
o The submandibular duct is the most susceptible to calculi out of all the
susceptible to
calculi? salivary ducts.
o This is thought to be due to the:
▪ Torturous length of the duct
▪ Ascending secretory pathway
▪ Nature of salivary secretion
o The submandibular glands and the patency of the ducts can be examined
by direct injection of a contrast medium. This is known as a sialogram,
which is a special type of radiograph.
The Sublingual Gland:

Type of saliva
produced by • The sublingual glands are the smallest of the three paired salivary glands.
the sublingual
gland? • Produce mixed secretions which are predominately mucous in nature.
• The sublingual glands are almond-shaped and lie on the floor of the oral cavity.
o between the mucous membrane above and the mylohyoid muscle
Anatomical below.
position of the • Surrounds the terminal portion of the submandibular duct.
sublingual • Both sublingual glands unite anteriorly and form a single mass through a
gland?
horseshoe configuration around the lingual frenulum.
o The superior aspect of this U-shape forms an elevated, elongate crest of
mucous membrane called the sublingual fold.
Drainage of
saliva from the • Empties mostly into the Door of the mouth along the sublingual fold by 12 short
sublingual ducts, some of which enter the submandibular duct.
gland? • A major sublingual duct (of Bartholin) can be present in some people.
o Adheres to the passing submandibular duct.
o Drainage then follows the submandibular duct out through
Innervation of the sublingual papillae.
the sublingual • Is supplied by postganglionic parasympathetic (secretomotor) fibers from the
gland?
submandibular ganglion either directly or through the lingual nerve.
• Sympathetic innervation originates from the superior cervical ganglion.
o Enters the gland via the sublingual and submental arteries.
Why is the
sublingual • Clinical Correlate: Ranula
gland prone to o A ranula is a type of mucocele (mucous cyst) that occurs in the floor of
developing the mouth inferior to the tongue.
ranulas? o It is the most common disorder associated with the sublingual glands
due to their higher mucin content in secretions compared to other
salivary glands.

5. The Oral Cavity
Fig 4 – A right sided ranula.
Fig 1 – The sublingual gland, viewed from the right side
Fig 2 – The sublingual folds and papillae.

5. The Oral Cavity

5. The Oral Cavity

5. The Oral Cavity
The Oropharyngeal Triangle

• A major route by which structures in the upper neck and infratemporal fossa of
Borders of the the head pass to and from structures in the floor of the oral cavity.
oropharyngeal
triangle? • Borders formed by:
o The free posterior border of the mylohyoid
o Superior Constrictor Muscle
o Middle Constrictor Muscle
Borders of the
oropharyngeal
• Most structures that pass through the aperture are associated with the tongue
Contents
triangle? of the and include:
oropharyngeal o Muscles (hyoglossus, styloglossus)
triangle?
o Vessels (lingual artery and vein)
o Nerves
Borders of the
oropharyngeal ▪ lingual
Borders
triangle?of the ▪ hypoglossal [XII]
oropharyngeal
▪ glossopharyngeal [IX]
triangle?
o Lymphatics
Borders of the
o The submandibular gland
oropharyngeal ▪ Is “hooked” around the free posterior margin of the mylohyoid
Borders
triangle?of the muscle and therefore also passes through the opening.
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
triangle?
5. The Oral Cavity
(Blank)

Chapter 6
Chapter 6
Chapter 6
Chapter 6
Chapter 6
Chapter 6
Chapter 6
Chapter 6
The Nose and Paranasal

Sinuses
6. The Nose and Paranasal Sinuses
Recommended Videos
Sam Webster:
• ‘Nose bones’
o Runtime: 16:56
o (https://youtu.be/tgxb9-jyPkQ)
• ‘Paranasal air sinuses’
o Runtime: 17:32
o (https://youtu.be/nLDEt0JzyyI)

• ‘Nasal cavity’
o Runtime: 7:00
o (https://youtu.be/ukTum1NBJ7E)
Armando Hasudungan:
• ‘Clinical Anatomy - Nasal Cavity and Sinuses’
o Runtime: 7:54
o (https://youtu.be/iwwFPQk7SJU)

The Nasal Skeleton & External Nose

(https://teachmeanatomy.info/head/osteology/nasal-skeleton/)
• formed by three types of tissue; bone, cartilage and fibro-fatty tissue.

• The external skeleton extends the nasal cavities onto the front of the face
o partly formed by the nasal and maxillary bones, which are situated
superiorly.
• The inferior portion of the nose is made up of hyaline cartilages; lateral, major
alar, minor alar, and the cartilaginous septum.
Figure 1 – Lateral view of the external nasal skeleton
The Nasal Septum:
• The bones that contribute to the nasal septum can be divided into:
o Paired bones: Nasal, maxillary and palatine bones
o Unpaired bones: Ethmoid and vomer bones.
• In addition to the bones of the nose, the septal and greater alar cartilages also
constitute part of the nasal septum.
• The floor of the nasal cavity is formed by the hard palate
• The cribriform plate of the ethmoid bone forms the roof of the nasal cavity.

Structures
forming the
nasal septum?
Figure 2 – Lateral view of the side of the nasal septum.
The External Nose:

(https://teachmeanatomy.info/head/organs/the-nose/external-nose/)
Fig 1 – Surface appearance of the nose.
• Whilst the skin over the bony part of the nose is thin, that overlying the
cartilaginous part is thicker with many sebaceous glands.
o This skin extends into the vestibule of the nose via the nares. Here there
are hairs which function to filter air as it enters the respiratory system.

The Nasal Cavity

(https://teachmeanatomy.info/head/organs/the-nose/nasal-cavity/)
• Functions:
Functions of o Warms and humidifies the inspired air.
the nasal o Removes and traps pathogens and particulate matter from the inspired
cavity? air.
o Responsible for sense of smell.
o Drains and clears the paranasal sinuses and lacrimal ducts.
• Has three divisions:
Divisions of the o Vestibule – the area surrounding the anterior external opening to the
nasal cavity? nasal cavity.
o Respiratory region – lined by a ciliated psudeostratified epithelium,
interspersed with mucus-secreting goblet cells.
o Olfactory region – located at the apex of the nasal cavity. It is lined by
olfactory cells with olfactory receptors.
• Opens on the face through the anterior nasal apertures (nares or nostrils) and
communicates with the nasopharynx through a posterior opening, the choanae.
Fig 1 – Sagittal section of the nasal cavity. Conchae are present on the lateral walls

• Projecting out of the lateral walls of the nasal cavity are curved shelves of bone.
Bones forming They are called conchae (or turbinates).
the conchae? o There are three conchae – inferior, middle and superior.
o inferior nasal concha is formed by an independent bone (of the same
name, inferior concha).
o superior and middle nasal conchae arise from the perpendicular plate of
the ethmoid bone.
• They project into the nasal cavity, creating four pathways for the air to flow.
These pathways are called meatuses:
o Inferior meatus – between the inferior concha and floor of the nasal
cavity.
o Middle meatus – between the inferior and middle concha.
o Superior meatus – between the middle and superior concha.
o Spheno-ethmoidal recess – superiorly and posteriorly to the superior
concha.
• The function of the conchae is to increase the surface area of the nasal cavity –
Functions of this increases the amount of inspired air that can come into contact with the
the conchae? cavity walls.
o They also disrupt the fast, laminar flow of the air, making it slow and
turbulent.
o The air spends longer in the nasal cavity, so that it can be humidified.
Fig 2 – Coronal section of the anterior nasal cavity. The spheno-ethmoidal recess is located posteriorly,and
not visible on this diagram
100 | H J ’ s H Y H & N | ‫اکس جی وس گی‬


Inferior nasal meatus Middle nasal meatus
Superior nasal meatus Sphenoethmoidal recess
• The paranasal sinuses drain into the nasal cavity.

Specific site of o The frontal, maxillary and anterior ethmoidal sinuses open into the
drainage for middle meatus.
structures ▪ The location of this opening is marked by the semilunar hiatus, a
draining into
the nasal
crescent-shaped groove on the lateral walls of the nasal cavity.
cavity? o The middle ethmoidal sinuses empty out onto a structure called
the ethmoidal bulla (located in the middle meatus).
▪ This is a bulge in the lateral wall formed by the middle ethmoidal
sinus itself.
o The posterior ethmoidal sinuses open out at the level of the superior
meatus.

o The only structure not to empty out onto the lateral walls of the nasal
cavity is the sphenoid sinus. It drains onto the posterior roof (in the
spheno-ethmoidal recess).
• In addition to the paranasal sinuses, other structures open into the nasal cavity:
o Nasolacrimal duct – acts to drain tears from the eye. It opens into the
inferior meatus.
o Auditory (Eustachian) tube – opens into the nasopharynx at the level of
the inferior meatus.
▪ It allows the middle ear to equalise with the atmospheric air
pressure.
• Clinical Correlate: As the auditory tube connects the middle ear and upper
respiratory tract, it is a path by which infection can spread from the upper
respiratory tract to the ear.
o Infection of the auditory tube causes swelling of the mucous linings, and
the tube becomes blocked. This results in diminished hearing.
Fig 3 – The conchae have been removed, showing the various openings on the lateral wall of the nasal
cavity.

• Gateways to the Nasal Cavity: As well as openings for the drainage of

“Gateways” to structures, nerves, vasculature and lymphatics need to be able to access the
the nasal nasal cavity.
cavity? What
o The cribriform plate is part of the ethmoid bone.
structures do
they transmit? ▪ Forms a portion of the roof of the nasal cavity.
▪ Contains very small perforations, allowing fibres of the olfactory
nerve to enter and exit,
o At the level of the superior meatus, the sphenopalatine foramen is
located.
▪ This hole allows communication between the nasal cavity and
the pterygopalatine fossa.
▪ The sphenopalatine artery, nasopalatine and superior nasal
nerves pass through here.

o The incisive canal is a pathway between the nasal cavity and the incisive
fossa of the oral cavity.
▪ It transmits the nasopalatine nerve and greater palatine artery.
o Other routes by which vessels and nerves get into and out of the nasal
cavity include the nares and small foramina in the lateral wall.
• The nose has a very rich vascular supply

o this allows it to effectively change humidity and temperature of inspired
air.
• The nose receives blood from both the internal and external carotid arteries.
Vascular supply • Internal carotid branches:
of the nose? o Anterior ethmoidal artery
o Posterior ethmoidal artery
o The ethmoidal arteries are branch of the ophthalmic artery.
o They descend into the nasal cavity through the cribriform plate
• External carotid branches:
o Sphenopalatine artery
▪ Branches from the maxillary artery
▪ Enters the nasal cavity via the sphenopalatine foramen
o Greater palatine artery
▪ A terminal branch of the maxillary artery
▪ Passes through the greater palatine foramen and travels along
the hard palate to enter the nasal cavity by way of the incisive
canal

o Superior labial artery

▪ The facial artery gives off the superior labial artery
▪ The septal branch enters the nasal cavity through the nares and
joins the anastomoses in Little’s area.
o Lateral nasal arteries
▪ NOT a part of Kiesselbach’s Plexus
• In addition to the rich blood supply, these arteries form anastomoses with each
other.
o This is particularly prevalent in the anterior portion of the nose.
Kiesselbach’s Plexus:
• Kiesselbach’s plexus is an integral anastomosis of five branches converging in

the anterior inferior quadrant of the nasal septum (over the septal cartilage).
o The area has been referred to as Little’s Area, Kiesselbach’s Triangle or
Kiesselbach’s Area.
o Little’s area is a common site of epistaxis (nose bleeds) in both
paediatric and adult cases.
o Branches involved:
Arteries ▪ Anterior ethmoidal artery (from the ophthalmic artery).
forming ▪ Posterior ethmoidal artery (from the ophthalmic artery).
Kiesselbach’s ▪ Sphenopalatine artery (from the maxillary artery).
plexus?
▪ Greater palatine artery (from the maxillary artery).
▪ Septal branch of the superior labial artery (from the facial
artery).
• Clinical Correlate: Epistaxis is the medical term for a nosebleed.
o Due to the rich blood supply of the nose, this is a common occurrence.
o It is most likely to occur in the anterior third of the nasal cavity – this
area is known as the Kiesselbach area.
o The cause can be local (such as trauma or infection), or systemic (such
as hypertension).
o Nose bleeds from Little’s area are best controlled by vascular
compression (pressing down the ala on the septum).
▪ In a clinical setting, packing the affected cavity with cotton wool
can control the bleeding.
▪ In extreme cases, where bleeding is persistent, cauterization of
the vessels is a suitable option for management of the bleeding.
• The veins of the nose tend to follow the arteries.
Venous o They drain into the pterygoid plexus, facial vein or cavernous sinus.
drainage of the o In some individuals, a few nasal veins join with the sagittal sinus (a dural
nose? venous sinus).
▪ This represents a potential pathway by which infection can
spread from the nose into the cranial cavity.

Fig 4 – Little’s area and the arterial supply to the nose.

anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
Septal and lateral nasal branches of posterior ethmoidal artery Greater palatine artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
Sphenopalatine artery artery
Superior labial artery

• The innervation of the nose can be functionally divided into special (SVA) and
Innervation of general innervation (GSA).
the nose? o Special sensory innervation refers to the ability of the nose to smell.
▪ This is carried out by the olfactory nerves.
▪ The olfactory bulb, part of the brain, lies on the superior surface
of the cribriform plate, above the nasal cavity.
▪ Branches of the olfactory nerve run through the cribriform plate
to provide special sensory innervation to the nose.
o General sensory innervation to the septum and lateral walls is delivered
by the:
▪ nasopalatine nerve (branch of maxillary nerve)
▪ nasociliary nerve (branch of the ophthalmic nerve).
▪ Innervation to the external skin of the nose is supplied by
the trigeminal nerve.
o parasympathetic control of nasal mucous glands is via branches of the
facial nerve
• Clinical Correlate: A fracture of the cribriform plate can occur as a result of
nose trauma.
o A fractured cribriform plate can penetrate the meningeal linings of the
brain, causing leakage of cerebrospinal fluid.
▪ Exposing the brain to the outside environment like this increases
the risks of meningitis, encephalitis and cerebral abscesses.
o The olfactory bulb lies on the cribriform plate and can be damaged
irreversibly by the fracture.
▪ In this case, the patient may present with anosmia (loss of
smell).
Fig 5 – Lateral view of the nasal septum. Note the close relationship of the olfactory bulb and
cribriform plate

Miscellaneous:
• Boundaries of the nasal cavity:

Boundaries of o Roof – houses the cribriform plate
the nasal o Floor – hard palate
cavity? o Medial wall – nasal septum
o Lateral Wall – houses the conchae and meatuses
• Apertures of the nasal cavity:
o Anterior – nostrils
o Posterior - nasopharynx (choanae)
o Superior - cribriform plate
o Inferior - Incisive canal
o Posterosuperior - sphenopalatine foramen
• Bones of the nasal cavity:
Bones of the o nasal, maxilla, sphenoid, vomer, palatine, lacrimal, ethmoid
nasal cavity? o (Mnemonic: Nerdy Medical Students are often Very PaLE)

The Paranasal Sinuses

(https://teachmeanatomy.info/head/organs/the-nose/paranasal-sinuses/)
• The paranasal sinuses are air-filled extensions of the nasal cavity.

• There are four paired sinuses – named according to the bone in which they are
located – maxillary, frontal, sphenoid and ethmoid.
• Each sinus is lined by a ciliated pseudostratified epithelium, interspersed with
mucus-secreting goblet cells.
• Functions:
Functions of o Lightening the weight of the head
the paranasal
o Supporting immune defence of the nasal cavity
sinuses?
o Humidifying inspired air
o Increasing resonance of the voice
• The paranasal sinuses are formed during development by the nasal
Development cavity eroding into the surrounding bones.
of the o All the sinuses therefore drain back into the nasal cavity.
paranasal
o The maxillary and ethmoid sinuses are the first to develop and are
sinuses?
present at birth.
o The frontal and sphenoid sinuses develop more slowly.
o From Dr. Khalid Hameed’s lecture slides:
▪ All sinuses are present at birth except? → Frontal air sinuses
(develop by 2 to 4 years)
▪ First sinus that can be visualized radiologically after birth →
Maxillary (4-5 months)
Fig 1 – Location of the paranasal sinuses.

Frontal Sinuses:
• There are two frontal sinuses located within the frontal bone of the skull.
Drainage of the o They are the most superior of the paranasal sinuses.
frontal sinuses? o Are triangular in shape.
o Drainage is via the frontonasal duct.
▪ It opens out at the hiatus semilunaris, within the middle meatus.
o Sensation is supplied by the supraorbital nerve (a branch of the
ophthalmic nerve)
o arterial supply is via the anterior ethmoidal artery (a branch of the
ophthalmic artery from the internal carotid).
• Clinical Correlate: Frontal sinusitis is an inflammation in the frontal sinus that
Spread of may erode the thin bone of the anterior cranial fossa, producing meningitis or
frontal brain abscess.
sinusitis?
Sphenoid Sinuses:
• The sphenoid sinuses are situated within the body of the sphenoid bone.
Drainage of the o They open out into the nasal cavity in an area supero-posterior to the
sphenoid superior concha – known as the spheno-ethmoidal recess.
sinuses?
o They are innervated by the posterior ethmoidal nerve (a branch of the
ophthalmic nerve), and branches of the maxillary nerve.
o They are vascularized by the posterior ethmoidal arteries, branches of
the ophthalmic artery
o Are closely related to important structures of the brain including the:
Structures ▪ optic nerves and optic chiasm
closely related
to the sphenoid
▪ pituitary gland
sinuses? ▪ internal carotid arteries
▪ cavernous sinuses

• Clinical Correlate: Transsphenoidal Surgery:

o The sphenoid bone shares a close anatomical relationship with
the pituitary gland.
o The pituitary can be accessed surgically by passing instruments through
the sphenoid bone and sinus.
o This type of surgery is known as endoscopic trans-sphenoidal
surgery (ETSS).
▪ Is the usual treatment of choice for pituitary adenomas.
▪ Care must be taken not to damage the cavernous sinus and the
internal carotid artery.
• Clinical Correlate: Sphenoidal sinusitis is an infection in the sphenoidal sinus
Spread of that may spread to or from the nasal cavity or the nasopharynx
sphenoidal o may erode the sinus walls to reach the cavernous sinuses, pituitary
sinusitis? gland, optic nerve or brain stem.
Fig 2 – The transsphenoidal approach to pituitary surgery.
Ethmoidal Sinuses:
• The ethmoidal sinuses, or commonly known as ethmoidal cells, are small spaces
Drainage of the located in the ethmoid bone.
ethmoidal o Consists of numerous ethmoidal air cells, which are numerous small
sinuses? cavities within the ethmoidal labyrinth
o They are located between the nasal cavity and the orbit.
o These cells can be divided into three groups:
Drainage of the ▪ The anterior ethmoidal cells: are drained to the middle nasal
ethmoidal meatus via the ethmoidal infundibulum.
sinuses?
Drainage of the
ethmoidal
▪ The middle ethmoidal cells are drained into the middle nasal
meatus. Form a bulge on the middle nasal meatus (ethmoidal
bulla)
▪ The posterior ethmoidal cells are drained into the superior nasal
meatus.
o Innervated by the anterior and posterior ethmoidal branches of the
nasociliary nerve, the branches of the ophthalmic nerve (CN V1).
o The blood supply is provided via the anterior and posterior ethmoidal
arteries.
• Clinical Correlate: Ethmoidal sinusitis is an inflammation in the ethmoidal
Spread of sinuses that may erode the medial wall of the orbit, causing an orbital cellulitis
ethmoidal that may spread to the cranial cavity.
sinusitis?
Ethmoidal air cells
Maxillary Sinuses:
• The maxillary sinuses are the largest and the most inferior of the paranasal
sinuses.
o They are situated deep in the bodies of the maxillae.
o Each maxillary sinus is drained by one or more openings (maxillary ostia)
Drainage of the into the middle nasal meatus.
maxillary ▪ Similar to the frontal sinuses, the maxillary sinuses are also
sinuses? drained at the semilunar hiatus.
▪ They drain underneath the frontal sinus opening at the
semilunar hiatus. This is a potential pathway for spread of
infection – fluid draining from the frontal sinus can enter the
maxillary sinus.
o Is the only paranasal sinus that may be present at birth.
o innervated by the anterior, middle, and posterior superior alveolar
nerves, branches of the maxillary nerve (CN V2).
o The blood supply comes from the superior alveolar branches of the
maxillary artery.
• Clinical Correlate: Maxillary sinusitis mimics the clinical signs of maxillary tooth
Why is the abscess
maxillary sinus o The maxillary sinus is the paranasal sinus that is most commonly
prone to
affected by sinusitis
sinusitis?
▪ This is because their ostia (openings) are commonly small and
are located high on their superomedial walls.
o In most cases, it is related to an infected tooth.
o Infection may spread from the maxillary sinus to the upper teeth and
Spread of irritate the nerves to these teeth, causing toothache.
maxillary ▪ The maxillary nerve supplies both the maxillary sinus and
sinusitis? maxillary teeth, and so inflammation of that sinus can present
with toothache.
o It may be confused with toothache because only a thin layer of bone
separates the roots of the maxillary teeth from the sinus cavity.
• Clinical Correlate: Caldwell-Luc operation, or Radical antrostomy, is an
operation to remove irreversibly damaged mucosa of the maxillary sinus.
o The approach is mainly from the anterior wall of the maxilla bone.
o The maxillary sinus is entered from two separate openings, one in the
canine fossa to gain access to the antrum and other in the naso antral
wall for drainage.
Maxillary sinus

• Clinical Correlate: Chronic sinusitis: The Ostiomeatal complex is a key factor in

Significance of the pathogenesis of chronic sinusitis
the o Final common pathway for drainage and ventilation of ethmoid,
ostiomeatal maxillary, and frontal sinuses → obstruction of this small area, can
complex?
block all above.


(Blank)

Chapter 7
The Orbit and the Eye

7. The Orbit and the Eye
Recommended Videos
Sam Webster:
• ‘Bones of the orbit’
o Runtime: 17:26
o (https://youtu.be/s6j50KNzATE)
• ‘Muscles of the eye - extraocular muscles and movements’
o Runtime: 24:50
o (https://youtu.be/lDGCT9e-MWg)

• ‘Orbital anatomy tutorial’
o Runtime: 8:39
o (https://youtu.be/BVENPmTQYt8)
• ‘Extraocular muscles tutorial’
o Runtime: 7:07
o (https://youtu.be/u3BcgOIjbGA)
• ‘Clinical testing extraocular muscles tutorial’
o Runtime: 4:04
o (https://youtu.be/3J2UZiLVZKA)
AnatomyZone:
• ‘Eyeball Anatomy’
o Runtime: 9:54
o (https://youtu.be/7lBtlGvS1Gc)
• ‘Eyeball | Blood Supply’
o Runtime: 3:23
o (https://youtu.be/_aGL9dU-Lnk)
• ‘Orbit | Eye Anatomy’
o Runtime: 7:05
o (https://youtu.be/HKEA4p5k66U)
• ‘Extraocular Muscles | Eye Anatomy’
o Runtime: 10:13
o (https://youtu.be/f_rb6FMVHPk)

The Bony Orbit

(https://teachmeanatomy.info/head/organs/eye/bony-orbit/)
• The bony orbit is a pyramid-shaped cavity surrounded by a shell of bone to

Bones forming protect the eyeball.
the bony orbit? o Apex – Located at the opening to the optic canal, the optic foramen.
o Base – Opens out into the face, and is bounded by the eyelids. It is also
known as the orbital rim.
• The roof of the orbit is formed by the frontal bone and the lesser wing of the
sphenoid bone.
o The frontal bone separates the orbit from the anterior cranial fossa.
• The medial wall is formed by the ethmoid bone and lacrimal bone.
o The ethmoid bone separates the orbit from the ethmoid sinus.
• The lateral wall is formed by the zygomatic bone and the greater wing of the
sphenoid bone.
• The floor of the orbit is formed by the maxilla bone and the palatine bone.
o The maxilla separates the orbit from the underlying maxillary sinus.
Fig 1 – The anterior and lateral views of the bony orbit.
Contents:
• The bony orbit contains the eyeballs and their associated structures.
• Extra-ocular muscles – They are responsible for the movement of the eyeball
and superior eyelid.
• Eyelids – These cover the orbits anteriorly.
• Nerves: Several cranial nerves supply the eye and its
structures; optic, oculomotor, trochlear, trigeminal and abducens nerves.
• Blood vessels: The eye receives blood primarily from the ophthalmic artery.
Venous drainage is via the superior and inferior ophthalmic veins.
• Any space within the orbit that is not occupied is filled with orbital fat.
o This tissue cushions the eye, and stabilises the extraocular muscles.

Pathways into the Orbit:

Pathways into
the orbit?
• Optic canal – transmits:
o the optic nerve
o ophthalmic artery.
• Superior orbital fissure – transmits:
o the lacrimal,
o frontal,
o trochlear (CN IV),
o oculomotor (CN III),
o nasociliary and
o abducens (CN VI) nerves.
o It also carries the superior ophthalmic vein.
• Inferior orbital fissure – transmits:
o the zygomatic branch of the maxillary nerve,
o the inferior ophthalmic vein, and
o sympathetic nerves.
• There are other minor openings into the orbital cavity.
o The nasolacrimal canal, which drains tears from the eye to the nasal
cavity, is located on the medial wall of the orbit.
o The supraorbital foramen and infraorbital canal – they carry small
neurovascular structures.

• Clinical Correlate: Fractures of the Bony Orbit

o ‘Blowout’ fracture – This refers to partial herniation of the orbital
contents through one of its walls.
▪ This usually occurs via blunt force trauma to the eye.
▪ The medial and inferior walls are the weakest, with the contents
herniating into the ethmoid and maxillary sinuses respectively.

The Eyelids and Lacrimal Apparatus

The Eyelids:
• The interior surface of the eyelid is a mucous membrane called the palpebral
conjunctiva.
o The palpebral conjunctiva is reflected onto the eyeball, where it is then
called the bulbar conjunctiva.
o The bulbar conjunctiva is continuous with the corneal epithelium.
o The palpebral and bulbar conjunctiva enclose a space called the
conjunctival sac.
• There are three important muscles associated with the eyelid, which include the
Muscles of the following:
eyelid and
o Levator palpebrae superioris muscle:
innervation?
▪ This skeletal muscle is located in the upper eyelid and attaches
to the skin of the upper eyelid
▪ This muscle is innervated by CN III and its function is to keep the
eye open (main player).
o Superior tarsal muscle:
▪ This smooth muscle is located in the upper eyelid.
▪ This muscle is innervated by postganglionic sympathetic neurons
that follow the carotid arterial system
▪ Its function is to keep the eye open (minor player).
o Orbicularis oculi muscle (palpebral portion).
▪ This skeletal muscle is located in the upper and lower eyelids.
▪ This muscle is innervated by CN VII
▪ Its function is to close the eye.

Fig 2 – Sagittal section of the orbit, demonstrating the layers of the eyelid.
The Lacrimal Apparatus:
Fig 1 – The anatomical position of the lacrimal gland.
Fig 2 – The lacrimal apparatus of the eye.

• Parasympathetic innervation:
Parasymp. o The preganglionic parasympathetic neuronal cell bodies are located in
Innervation of superior salivatory nucleus and lacrimal nucleus.
the lacrimal
gland?
o Preganglionic axons from the superior salivatory nucleus and the
lacrimal nucleus run with CN VII (by way of the nervus intermedius,
greater petrosal nerve, and the nerve of the pterygoid canal) and enter
the pterygopalatine ganglion, where they synapse with post-ganglionic
parasympathetic neurons.
o Postganglionic axons leave the pterygopalatine ganglion and run with
the zygomaticofacial branch of CN V2 and the lacrimal branch of CN V1
to innervate the lacrimal gland.
Fig 3 – The pterygopalatine ganglion and its branches.

The Extraocular Muscles

(https://teachmeanatomy.info/head/organs/eye/extraocular-muscles/)
Note: Watch the Sam Webster and Noted Anatomist videos to understand the concepts
behind the movements produced by each muscle and the concepts underlying
extraocular muscle testing.
• They act to control the movements of the eyeball and the superior eyelid.
o Responsible for eye movement – Recti and oblique muscles.
o Responsible for superior eyelid movement – Levator palpebrae
superioris.
• Levator Palpebrae Superioris:
o Only muscle involved in raising the superior eyelid.
o A small portion of this muscle contains a collection of smooth muscle
fibres – known as the superior tarsal muscle.
▪ In contrast to the LPS, the superior tarsal muscle is innervated by
the sympathetic nervous system.
o Actions:
▪ Elevates the upper eyelid.
o Innervation: The levator palpebrae superioris is innervated by
the oculomotor nerve (CN III).
▪ The superior tarsal muscle (located within the LPS) is innervated
by the sympathetic nervous system.
Fig 1 – Attachment of the levator palpebrae superiors to the superior tarsal plate.
• Recti Muscles:
o These muscles characteristically originate from the common tendinous
ring.
▪ This is a ring of fibrous tissue, which surrounds the optic canal
and the medial part of the superior orbital fissure at the back of
the orbit.
o From their origin, the muscles pass anteriorly to attach to the sclera of
the eyeball.
• Superior Rectus:
Superior rectus: o Actions:
actions and
▪ Main movement is elevation.
innervation?
▪ Also contributes to adduction and medial rotation of the eyeball.
o Innervation: Oculomotor nerve (CN III).
• Inferior Rectus:
Inferior rectus: o Actions:
actions and ▪ Main movement is depression.
innervation?
▪ Also contributes to adduction and lateral rotation of the eyeball.
• Medial Rectus:
Medial rectus:
actions and
o Actions:
innervation? ▪ Adducts the eyeball.
• Lateral Rectus:
Lateral rectus: o Actions:
actions and ▪ Abducts the eyeball.
innervation?
o Innervation: Abducens nerve (CN VI).
• Oblique muscles:
o From their origin, the oblique muscles take an angular approach to the
eyeball (in contrast to the straight approach of the recti muscles).
o They attach to the posterior surface of the sclera.
o Unlike the recti group of muscles, they do not originate from the
common tendinous ring.
• Superior Oblique:
Superior o Its tendon passes through a trochlea and then attaches to the sclera of
oblique: the eye, posterior to the superior rectus.
actions and
o Actions:
innervation?
▪ Depresses,
▪ abducts and
▪ medially rotates the eyeball.
o Innervation: Trochlear nerve (CN IV).

• Inferior Oblique:
Inferior o Actions:
oblique: ▪ Elevates,
actions and
innervation?
▪ abducts and
▪ laterally rotates the eyeball.
Fig 2 – Lateral view of the extraocular muscles.

• Clinical Correlate: Cranial Nerve Palsies
Effects of o Oculomotor nerve (CN III) – A lesion of the oculomotor nerve affects
cranial nerve
most of the extraocular muscles.
palsies on the
extraocular ▪ The affected eye is displaced laterally by the lateral rectus and
muscles? inferiorly by the superior oblique.
▪ The eye adopts a position known as ‘down and out’.
o Trochlear nerve (CN IV) – A lesion of CN IV will paralyse the superior
oblique muscle.
▪ There is no obvious effect on the resting orientation of the
eyeball.
▪ However, the patient will complain of diplopia (double vision),
and may develop a head tilt away from the site of the lesion.
o Abducens nerve (CN VI) – A lesion of CN VI will paralyse the lateral
rectus muscle.
▪ The affected eye will be adducted by the resting tone of the
medial rectus.
Fig 3 – Right oculomotor nerve palsy, characterised by the ‘down and out’ dilated pupil with ipsilateral
ptosis

Clinical testing
of extraocular
muscle
function?


The Eyeball
(https://teachmeanatomy.info/head/organs/eye/eyeball/)
• Anatomically, the eyeball can be divided into three parts –

the fibrous, vascular and inner layers.
Fibrous Layer:
• The fibrous layer of the eye is the outermost layer.

• It consists of the sclera and cornea, which are continuous with each other.
o Their main functions are to provide shape to the eye and support the
deeper structures.
• The sclera comprises the majority of the fibrous layer (approximately 85%).
o It provides attachment to the extraocular muscles – these muscles are
responsible for the movement of the eye.
o It is visible as the white part of the eye.
• The cornea is transparent and positioned centrally at the front of the eye.
o Light entering the eye is refracted by the cornea.
• Corneoscleral Junction (Limbus):
Flow of o The limbus is the junction of the transparent cornea and the opaque
aqueous sclera.
humor?
o The limbus contains a trabecular network and the canal of Schlemm,
which are involved in the flow of aqueous humor.
o The flow of aqueous humor follows this route: Posterior chamber →
anterior chamber → trabecular network → canal of Schlemm →
aqueous veins → episcleral veins.
o An obstruction of aqueous humor flow will increase intraocular pressure,
causing a condition called glaucoma.
Fig 1.0 – The cornea and sclera of the eye.

Vascular Layer:
• The vascular layer of the eye lies underneath the fibrous layer.
• It consists of the choroid, ciliary body and iris:
• Choroid – layer of connective tissue and blood vessels.
o The choroid is a pigmented vascular bed that lies immediately deep to
the corneoscleral tunic.
o It provides nourishment to the outer layers of the retina.
o The profound vascularity of the choroid is responsible for the “red eye”
that occurs with flash photography.
• Ciliary body – comprised of two parts – the ciliary muscle and ciliary processes.
o The ciliary muscle consists of a collection of smooth muscles fibres.
▪ Is circularly arranged around the entire circumference of the
ciliary body
▪ These are attached to the lens of the eye by the ciliary processes.
o The ciliary body controls the shape of the lens, and contributes to the
formation of aqueous humor.
o The ciliary muscle is innervated by the parasympathetic nervous system.
Innervation of ▪ The preganglionic parasympathetic neuronal cell bodies are
the ciliary located in the Edinger-Westphal nucleus of CN III.
muscle? ▪ Preganglionic axons from the Edinger-Westphal nucleus travel
with CN III and enter the ciliary ganglion, where they synapse
with postganglionic parasympathetic neurons.
▪ Postganglionic axons leave the ciliary ganglion, where they travel
with the short ciliary nerves to innervate the ciliary muscle.
o Accommodation is the process by which the lens becomes rounder to
Action of the focus a nearby object or flatter to focus a distant object.
ciliary muscle in ▪ For close vision (e.g., reading), the ciliary muscle contracts,
accommodation? which reduces tension on the zonular fibers attached to the lens
and thereby allows the lens to take a rounded shape.
▪ For distant vision, the ciliary muscle relaxes, which increases
tension on the zonular fibers attached to the lens and thereby
allows the lens to take a flattened shape.

o Epithelium of the Ciliary Body: The ciliary epithelium secretes aqueous

humor and produces the zonular fibers that attach to the lens.
• Iris – circular structure, with an aperture in the centre (the pupil).
o The diameter of the pupil is altered by smooth muscle fibres within the
iris, which are innervated by the autonomic nervous system.
o It is situated between the lens and the cornea.
o Dilator pupillae muscle: is radially arranged around the entire
Sympathetic circumference of the iris
innervation of ▪ Is innervated by the sympathetic nervous system.
the iris?
▪ The preganglionic sympathetic neuronal cell bodies are located in
the gray matter of the T1-L2/L3 spinal cord.
▪ Preganglionic axons project from this area, enter the
paravertebral chain ganglia, and ascend to the superior cervical
ganglion, where they synapse with postganglionic sympathetic
neurons.
▪ Postganglionic axons leave the superior cervical ganglion and
follow the carotid arterial system into the head and neck, where
they travel with the long ciliary nerves to in-nervate the dilator
pupillae muscle, which dilates the pupil.
▪ Any pathology that compromises this sympathetic pathway will
result in Horner syndrome.
o Sphincter pupillae muscle: is circularly arranged around the entire
Parasymp. circumference of the iris
innervation of ▪ Is innervated by the parasympathetic nervous system.
the iris?
▪ The preganglionic parasympathetic neuronal cell bodies are
located in the Edinger-Westphal nucleus of CN III.
▪ Preganglionic axons from the Edinger-Westphal nucleus enter the
ciliary ganglion, where they synapse with postganglionic
parasympathetic neurons.
▪ Postganglionic axons leave the ciliary ganglion, where they travel
with the short ciliary nerves to innervate the sphincter pupillae
muscle, which constricts the pupil (or miosis).
▪ Lesions involving CN III will result in a fixed and dilated pupil.

Fig 1.1 – The vascular layer of the eye.
Inner Layer:
• The inner layer of the eye is formed by the retina; its light detecting component.
• The retina is composed of two layers:
o Pigmented (outer) layer
▪ Formed by a single layer of cells.
▪ It is attached to the choroid and supports the choroid in
absorbing light (preventing scattering of light within the eyeball).
▪ It continues around the whole inner surface of the eye.
o Neural (inner) layer
▪ Consists of photoreceptors, the light detecting cells of the retina.
▪ It is located posteriorly and laterally in the eye.
• The intraretinal space separates the outer pigment epithelium from the inner
neural retina.
o Although the intraretinal space is obliterated in the adult, it remains a
weakened area prone to retinal detachment.

• Anteriorly, the pigmented layer continues but the neural layer does not
o This is part is known as the non-visual retina.
o Posteriorly and laterally, both layers of the retina are present. This is
the optic part of the retina.
• The optic part of the retina can be viewed during ophthalmoscopy.
Structures • The centre of the retina is marked by an area known as the macula.
visible on o It is yellowish in colour.
funduscopy?
o Lateral (temporal side) to the optic disc along the visual axis.
• The macula contains a depression called the fovea centralis, which has a high
concentration of light detecting cells.
o It is the area responsible for high acuity vision.
o The fovea centralis contains only cones (no rods or capillaries) that are
arranged at an angle so that light directly impinges on the cones
without passing through other layers of the retina and is linked to a
single ganglion, both of which contribute to visual acuity.
• The area that the optic nerve enters the retina is known as the optic disc
o The optic disc lacks rods and cones and is therefore a blind spot.
o The central artery and vein of the retina pass through the optic disc.
Fig 1.1 – The optic part of the retina.

Contents of the globe:
• The globe is divided into two cavities by the lens: The anterior cavity and
Divisions of the posterior cavity.
globe? o The anterior cavity consists of the anterior chamber (the area between
the cornea and iris) and the posterior chamber (the area between the
iris and lens).
▪ These chambers are filled with the watery aqueous humor that is
secreted by the epithelium of the ciliary body.
▪ Aqueous humor a clear plasma-like fluid that nourishes and
protects the eye.
▪ The aqueous humor is produced constantly, and drains via the
trabecular meshwork, an area of tissue at the base of the
cornea, near the anterior chamber.
o The posterior cavity consists of the vitreous chamber (the area between
the lens and retina).
▪ The vitreous chamber is filled with the vitreous body (a jelly-like
substance) and vitreous humor (a watery fluid), which hold the
retina in place and support the lens.
• Vitreous Body:
o The vitreous body is a transparent gel which fills the posterior cavity of
the eyeball (the area posterior to the lens).
o It is marked by a narrow canal which runs from the optic disc to the lens
– the hyaloid canal.
▪ This is a fetal remnant.
o The vitreous body has three main functions:
▪ Contributes to the magnifying power of the eye
▪ Supports the lens
▪ Holds the layers of the retina in place
• Lens:
o The lens of the eye is located anteriorly, between the vitreous humor
and the pupil.
o The shape of the lens is altered by the ciliary body, altering its refractive
power.
Fig 1.3 – Anterior and posterior chambers of the eye.

Note:
• The globe of the eye consists of three concentric tunics that make up the wall of
Layers of the the eye:
globe? o Corneoscleral Tunic
▪ This is the outermost fibrous tunic.
▪ Consists of the cornea, sclera, and corneoscleral junction
(limbus).
o Uveal Tunic
▪ This is the middle vascular tunic.
▪ Consists of the choroid, stroma of the ciliary body, and stroma
of the iris.
o Retinal Tunic
▪ This is the innermost tunic.
▪ Consists of the outer pigment epithelium and the inner neural
retina (posteriorly), the epithelium of the ciliary body
(anteriorly), and the epithelium of the iris (anteriorly).
• Clinical Correlate: Glaucoma

Types of o Glaucoma is the obstruction of aqueous humor flow that results in an
glaucoma? increased intraocular pressure.
o This increased pressure causes impaired retinal blood flow producing
retinal ischemia; degeneration of retinal cells, particularly at the optic
disc; defects in the visual field; and blindness.
o There are two types of glaucoma; open-angle and closed-angle
glaucoma.
o Open-angle Glaucoma:
▪ Most common
▪ Occurs when the trabecular network is open but the canal of
Schlemm is obstructed.
▪ It causes a gradual reduction of the peripheral vision, until the
end stages of the disease.
o Closed-angle Glaucoma
▪ Occurs when the trabecular network is closed usually due to an
inflammatory process of the uvea (uveitis) (e.g., infection by
cytomegalovirus).
▪ It is an ophthalmic emergency, which can rapidly lead to
blindness.
Vasculature:
• The eyeball receives arterial blood primarily via the ophthalmic artery.
Arterial supply o This is a branch of the internal carotid artery.
of the eye? • The ophthalmic artery gives rise to many branches, which supply different
components of the eye:
o Central artery of the retina
▪ Is the most important branch of the ophthalmic artery.
▪ Travels in the optic nerve; it divides into superior and inferior
branches to the optic disk,
▪ Is a terminal artery that does not anastomose with other
arteries, and, thus, its occlusion results in blindness.
o Long posterior ciliary arteries
▪ Pierce the sclera and run between the sclera and the choroid
layers.
▪ Form the circulus arteriosus major around the iris, which run
inwards to form a smaller circle of arteries (the circulus
arteriosus minor).
▪ Supply the ciliary body and the iris.
o Short posterior ciliary arteries
▪ Pierce the sclera at the back of the eye and run between
the sclera and choroid.
▪ Supply the choroid.
o Anterior ciliary arteries
▪ Pass forwards to the anterior aspect of the eyeball, where they
pierce the sclera, near the cornea.
▪ Terminate in the circulus arteriosus major, that surrounds the
iris.

Blood vessels of the eyeball
• Venous drainage of the eyeball is carried out by the:

Venous o Superior ophthalmic vein
drainage of the ▪ Ultimately drains into the cavernous sinus.
eye?
▪ Superior ophthalmic vein → cavernous sinus.
o Inferior ophthalmic vein
▪ Communicates with the pterygoid venous plexus.
▪ Empties into the superior ophthalmic vein.
▪ Inferior ophthalmic vein → superior ophthalmic vein →
cavernous sinus.

Chapter 8
The Ear
8. The Ear
Recommended Videos
Sam Webster:
• ‘Ear anatomy introduction’
o Runtime: 7:18
o (https://youtu.be/ZQcZkhLQ_tg)
• ‘Cochlea (ear anatomy)’
o Runtime: 26:53
o (https://youtu.be/A85IfgDjkcQ)
• ‘Vestibular apparatus (inner ear anatomy)’
o Runtime: 24:27
o (https://youtu.be/cv5Fnvn7sPE)
Armando Hasudungan:
• ‘Anatomy - Ear Overview’
o Runtime: 5:18
o (https://youtu.be/qYv9V2qna6I)
• ‘Understanding Ear Pain - Otalgia (Innervation of ear, mechanism of ear pain
and causes)’
o Runtime: 8:11
o (https://youtu.be/hW2_ZcofmNg)
• ‘Anatomy - Middle Ear’
o Runtime: 7:23
o (https://youtu.be/-OuFKmZSZoY)
Dr.G Bhanu Prakash Animated Medical Videos:

• ‘Gross Anatomy of the Middle Ear - Boundaries ,Contents and Functions (
Animation )’
o Runtime: 13:42
o (https://youtu.be/unDpXRE_PPA)

8. The Ear
The External Ear

(https://teachmeanatomy.info/head/organs/ear/external-ear/)
• The ear can be divided into three parts; external, middle and inner.
• The external ear can be divided functionally and structurally into two parts; the
auricle (or pinna), and the external acoustic meatus – which ends at the
tympanic membrane.
Fig 1 – Overview of the ear

8. The Ear
The Auricle:
• It functions to capture and direct sound waves towards the external acoustic
meatus.
• It is a mostly cartilaginous structure, with the lobule being the only part not
supported by cartilage.
• The cartilaginous part of the auricle forms an outer curvature, known as
the helix.
• A second innermost curvature runs in parallel with the helix – the antihelix.
o The antihelix divides into two cura; the inferoanterior crus, and the
superoposterior crus.
• In the middle of the auricle is a hollow depression, called the concha.
o It continues into the skull as the external acoustic meatus.
o The concha acts to direct sound into the external acoustic meatus.
• Immediately anterior to the beginning of the external acoustic meatus is an
elevation of cartilaginous tissue – the tragus.
• Opposite the tragus is the antitragus.
Fig 2 – Anterior surface of the auricle of the external ear.

8. The Ear
Sensory Innervation of the Auricle:

Sensory
innervation of • The outer more superficial surfaces of the auricle are supplied by:
the auricle?
o The great auricular nerve
▪ Anterior and posterior inferior portions
▪ From the cervical plexus
o The lesser occipital nerve
▪ Posterosuperior portion
▪ From the cervical plexus
o The auriculotemporal branch of the mandibular nerve [V3]
▪ Anterosuperior portion
• The deeper parts of the auricle are supplied by:
o The vagus nerve [X]
▪ The auricular branch
▪ Some individuals can complain of an involuntary cough when
cleaning their ears – this is due to stimulation of the auricular
branch of the vagus nerve (the vagus nerve is also responsible for
the cough reflex).
o The facial nerve [VII]
▪ Sends a branch to the auricular branch of the vagus nerve [X].
The External Acoustic Meatus:
• The external acoustic meatus is a sigmoid shaped tube that extends from the
deep part of the concha to the tympanic membrane.

8. The Ear
The Tympanic Membrane:
• The tympanic membrane lies at the distal end of the external acoustic meatus.
• It is a connective tissue structure, covered with skin on the outside and a
mucous membrane on the inside.
• The membrane is connected to the surrounding temporal bone by a
fibrocartilaginous ring.
• The translucency of the tympanic membrane allows the structures within the
middle ear to be observed during otoscopy.
• On the inner surface of the membrane, the handle of malleus attaches to the
tympanic membrane, at a point called the umbo of tympanic membrane.
Fig 3 – The tympanic membrane of the ear.

8. The Ear
The Middle Ear

(https://teachmeanatomy.info/head/organs/ear/middle-ear/)
• The middle ear lies within the temporal bone.

• Extends from the tympanic membrane to the lateral wall of the inner ear.
• The main function of the middle ear is to transmit vibrations from the tympanic
membrane to the inner ear via the auditory ossicles.
Parts of the Middle Ear:
• Tympanic cavity – located medially to the tympanic membrane.

o It contains three small bones known as the auditory ossicles: the
malleus, incus and stapes.
▪ They transmit sound vibrations through the middle ear.
• Epitympanic recess – a space superior to the tympanic cavity.
o Lies next to the mastoid air cells.
o The malleus and incus partially extend upwards into the epitympanic
recess.
Fig 2 – The middle ear. The two main parts of the middle ear have been labelled.

8. The Ear
Borders:
• The middle ear can be visualised as a rectangular box, with a roof and floor,
medial and lateral walls and anterior and posterior walls.
• Roof:
Roof of the o Known as the tegmental wall.
middle ear? o Formed by a thin bone from the petrous part of the temporal bone
(known as the tegmen tympani).
o It separates the middle ear from the middle cranial fossa.
• Floor:
Floor of the o Known as the jugular wall.
middle ear? o It consists of a thin layer of bone, which separates the middle ear from
the internal jugular vein.
• Lateral wall:
Lateral wall of o Known as the membranous wall.
the middle ear?
o Made up of the tympanic membrane and the lateral wall of the
epitympanic recess.
• Medial wall:
Medial wall of o Known as the labyrinthine wall.
the middle ear? o Formed by the lateral wall of the internal ear.
o A prominent structure on this wall is a rounded bulge (the promontory)
produced by the cochlea.
▪ Associated with the promontory is the tympanic plexus.
▪ Consists primarily of contributions from the tympanic branch of
the glossopharyngeal nerve [IX] and branches from the internal
carotid plexus.
▪ Additionally, a branch of the tympanic plexus, the lesser petrosal
nerve, leaves the promontory and the middle ear.
o Other structures associated with the labyrinthine wall are two openings:
▪ The oval window is the point of attachment for the base of the
stapes. Transfers vibrations initiated by the tympanic membrane
to the cochlea of the internal ear.
▪ The round window: is closed by the mucous membrane of the
middle ear and accommodates pressure waves transmitted to
the perilymph of the scala tympani.
o Contains a prominent bulge (the prominence of the facial canal),
produced by the facial nerve as it travels nearby in its canal.
o Also contains the prominence of the lateral semicircular canal,
produced by the lateral semicircular canal
• Anterior wall:
Anterior wall of o A thin bony plate with two openings; for the auditory tube and the
the middle ear? tensor tympani muscle.
o It separates the middle ear from the internal carotid artery.

8. The Ear
o The foramen for the exit of the chorda tympani nerve is also associated
with this wall.
• Posterior wall:
Posterior wall o Known as the mastoid wall.
of the middle o It consists of a bony partition between the tympanic cavity and the
ear?
mastoid air cells.
▪ Superiorly, there is a hole in this partition, allowing the two areas
to communicate. This hole is known as the aditus to the mastoid
antrum.
o Associated with the mastoid wall are:
▪ The pyramidal eminence, a small elevation through which the
tendon of the stapedius muscle enters the middle ear.
▪ The opening through which the chorda tympani nerve, a branch
of the facial nerve [VII], enters the middle ear.

8. The Ear
The Auditory Ossicles:
Ossicles? • The bones of the middle ear are the auditory ossicles – the malleus, incus and
stapes.
• They are connected in a chain-like manner, linking the tympanic membrane to
the oval window of the internal ear.
• Sound vibrations cause a movement in the tympanic membrane which then
creates movement, or oscillation, in the auditory ossicles.
o This movement helps to transmit the sound waves from the tympanic
membrane of external ear to the oval window of the internal ear.
• The malleus:
o Is the largest and most lateral of the ear bones, attaching to the
tympanic membrane.
o Articulates with the next auditory ossicle, the incus.
• The incus:
o The body articulates with the malleus
o The long limb joins the last of the ossicles; the stapes.
• The stapes:
o Is the smallest bone in the human body.
o It joins the incus to the oval window of the inner ear.
o It is stirrup-shaped.
Fig 1.1 – Bones of the middle ear.
The Mastoid Air Cells:
• The mastoid air cells are located posterior to the epitympanic recess.
• They are a collection of air-filled spaces in the mastoid process of
the temporal bone.
• The air cells are contained within a cavity called the mastoid antrum.

8. The Ear
• The mastoid antrum communicates with the middle ear via the aditus to the
mastoid antrum.
• The mastoid air cells act as a ‘buffer system’ of air – releasing air into the
tympanic cavity when the pressure is too low.
Fig 1.2 – Coronal section of temporal bone, showing the mastoid air cells in more detail
• Clinical Correlate: Mastoiditis

o Middle ear infections (otitis media) can spread to the mastoid air cells.
o Due to their porous nature, they are a suitable site for
pathogenic replication.
o The mastoid process itself can get infected, and this can spread to
the middle cranial fossa, and into the brain, causing meningitis.
o If mastoiditis is suspected, the pus must be drained from the air cells.
▪ When doing so, care must be taken not to damage the
nearby facial nerve.
Fig 1.3 – Mastoiditis

8. The Ear
Muscles of the Middle Ear:

Muscles of the
middle ear: • There are two muscles which serve a protective function in the middle ear; the
actions and
innervation?
tensor tympani and stapedius.
• They contract in response to loud noise, inhibiting the vibrations of the
malleus, incus and stapes, and reducing the transmission of sound to the inner
ear.
o This action is known as the acoustic reflex.
• Tensor Tympani Muscle:
o The tensor tympani muscle inserts on the handle of the malleus.
o The tensor tympani muscle draws the tympani membrane medially and
tightens it in response to a loud noise
▪ Thereby reducing the vibration of the tympanic membrane.
o The tensor tympani muscle is innervated by CN V3.
• Stapedius Muscle:
o The stapedius muscle inserts on the neck of the stapes.
o The stapedius muscle pulls the stapes posteriorly and reduces excessive
oscillation
▪ Thereby protecting the inner ear from injury from a loud noise.
o The stapedius muscle is innervated by CN VII.
The Auditory Tube:
• The auditory tube (eustachian tube) is a cartilaginous and bony tube that
connects the middle ear to the nasopharynx.
• It acts to equalise the pressure of the middle ear to that of the external
auditory meatus.

8. The Ear
• It extends from the anterior wall of the middle ear, opening onto the lateral wall
of the nasopharynx.
• In joining the two structures, it is a pathway by which an upper respiratory
infection can spread into the middle ear.
o The tube is shorter and straighter in children, therefore middle ear
infections tend to be more common in children than adults.
• The auditory tube can be opened by the contraction of the tensor veli palatini
Muscles that and the salpingopharyngeus muscles.
open the
auditory tube?

8. The Ear
The Inner Ear

(https://teachmeanatomy.info/head/organs/ear/inner-ear/)
• The inner ear is the innermost part of the ear, and houses the vestibulocochlear
organs.
• It has two main functions:
o To convert mechanical signals from the middle ear into electrical signals,
which can transfer information to the auditory pathway in the brain.
o To maintain balance by detecting position and motion.
• The inner ear is located within the petrous part of the temporal bone.
• It lies between the middle ear and the internal acoustic meatus, which lie
laterally and medially respectively.
• The inner ear has two main components – the bony labyrinth and membranous
labyrinth.
o Bony labyrinth – consists of a series of bony cavities within the petrous
part of the temporal bone.
▪ It is composed of the cochlea, vestibule and three semi-circular
canals.
▪ All these structures are lined internally with periosteum and
contain a fluid called perilymph.
o Membranous labyrinth – lies within the bony labyrinth.
▪ It consists of the cochlear duct, semi-circular ducts, utricle and
the saccule.
▪ The membranous labyrinth is filled with fluid called endolymph.
• The inner ear has two openings into the middle ear, both covered by
membranes:
o The oval window lies between the middle ear and the vestibule.
o The round window separates the middle ear from the scala tympani.

8. The Ear
The Bony Labyrinth:

Components of
the bony • The bony labyrinth is a series of bony cavities within the petrous part of
labyrinth?
the temporal bone.
• It consists of three parts:
o The cochlea
o Vestibule
o The three semi-circular canals
• Vestibule:
Structure of the o The vestibule is the central part of the bony labyrinth.
vestibule? o It is separated from the middle ear by the oval window.
o Communicates anteriorly with the cochlea and posteriorly with the semi-
circular canals.
o Two parts of the membranous labyrinth; the saccule and utricle, are
located within the vestibule.
• Cochlea:
Structure of the o The cochlea houses the cochlear duct of the membranous labyrinth –
cochlea? the auditory part of the inner ear.
o It twists upon itself around a central portion of bone called
the modiolus, making two-and-a-half turns and producing a cone shape.
o Extending outwards from the modiolus is a ledge of bone known
as spiral lamina, which attaches to the cochlear duct, holding it in
position.
o The presence of the cochlear duct creates two perilymph-filled
chambers above and below:

8. The Ear
▪ Scala vestibuli: Located superiorly to the cochlear duct. As its

name suggests, it is continuous with the vestibule.
▪ Scala tympani: Located inferiorly to the cochlear duct. It
terminates at the round window.
o The scala tympani communicates with the scala vestibule through the
helicotrema, a small opening at the apex of the cochlea.
• Semi-circular canals:
Structure of the o There are three semi-circular canals:
semi-circular ▪ Anterior
canals?
▪ Lateral
▪ Posterior
▪ They contain the semi-circular ducts.
• Are responsible for balance (along with the utricle and
saccule).
o The canals are situated superoposterior to the vestibule, at right angles
to each other.
o They have a swelling at one end, known as the ampulla.
Fig 2 – The three parts of the bony labyrinth.

8. The Ear
The Membranous Labyrinth:
• The membranous labyrinth is a continuous system of ducts filled

with endolymph.
• It lies within the bony labyrinth, surrounded by perilymph.
• It is composed of the:
Components of o Cochlear duct
the o Three semi-circular ducts
membranous o Saccule
labyrinth?
o Utricle
• The cochlear duct is situated within the cochlea and is the organ of hearing.
• The semi-circular ducts, saccule and utricle are the organs of balance (also
known as the vestibular apparatus).
• Cochlear duct:
Structure of the o The cochlear duct is located within the bony scaffolding of the cochlea.
cochlear duct? o It is held in place by the spiral lamina.
o The presence of the duct creates two canals above and below it –
the scala vestibuli and scala tympani respectively.
o The cochlear duct can be described as having a triangular shape:
▪ Lateral wall – Formed by thickened periosteum, known as the
spiral ligament.
▪ Roof – Formed by a membrane which separates the cochlear
duct from the scala vestibuli, known as the Reissner’s
membrane.
▪ Floor – Formed by a membrane which separates the cochlear
duct from the scala tympani, known as the basilar membrane.
o The basilar membrane houses the epithelial cells of hearing – the Organ
of Corti.
Fig 3 – Structure of the cochlea, and borders of the cochlear duct.

8. The Ear
• Saccule and Utricle:

Structure and o The saccule and utricle are two membranous sacs located in the
function of the vestibule.
saccule and o House sense organs called maculae.
utricle?
▪ They are organs of balance which detect movement or
acceleration of the head.
▪ The macula of the utricle detects horizontal acceleration.
▪ The macula of the saccule detects vertical acceleration.
o The utricle is the larger of the two.
▪ Receives the three semi-circular ducts.
o The saccule is globular in shape.
▪ Receives the cochlear duct.
o Endolymph drains from the saccule and utricle into
the endolymphatic duct.
▪ The duct travels through the vestibular aqueduct to the posterior
aspect of the petrous part of the temporal bone.
▪ Here, the duct expands to a sac where endolymph can be
secreted and absorbed.
Structure of the
• Semi-circular ducts:
semi-circular o The semi-circular ducts are located within the semi-circular canals, and
ducts? share their orientation.

8. The Ear
o Consists of anterior (superior), lateral, and posterior ducts, and their

dilated ends called ampullae.
o They contain sensory organs (epithelial areas), the cristae ampullaris,
which detect rotational or angular acceleration of the head.
▪ The cristae ampullaris contain neuroepithelial cells, the hairs of
which project into a gelatinous mass (cupula).
o Upon movement of the head, the flow of endolymph within the ducts
changes speed and/or direction.
▪ Sensory receptors in the ampullae of the semi-circular canals
detect this change, and send signals to the brain, allowing for the
processing of balance.
Fig 4 – The components of the membranous labyrinth.

8. The Ear
Transmission of Sound:
Transmission of
sound within • Sound waves entering the external auditory meatus induce vibration of the
the ear?
tympanic membrane.
• These waves, in turn, vibrate the ossicles, which amplify the intensity of the
sound waves.
o Transfer of a large-amplitude, low-force, airborne wave that vibrates
the tympanic membrane into a small-amplitude, high-force vibration of
the oval window.
• The vibrations of the stapes against the oval window transmit the sound
waves to the perilymph in the scala vestibule and then in the scala tympani
through the helicotrema.
• Soundwaves are also transmitted across the vestibular (Reissner) membrane to
the endolymph of the cochlear duct.
• Vibrations or pressure waves of the perilymph and of endolymph stimulate
oscillatory movements of the basilar membrane and hence hair calls in the
organ of Corti on the basilar membrane, which convert (transduce) sound
waves to nerve impulses that travel via the cochlear nerve to the brain.
• Clinical Correlate: Meniere’s Disease

o Meniere’s disease is a disorder of the inner ear, characterised by
episodes of vertigo, low-pitched tinnitus, and hearing loss.
o The symptoms are thought to be caused by an excess accumulation
of endolymph within the membranous labyrinth, causing progressive
distension of the ducts.
o The resulting pressure fluctuations damage the thin membranes of the
ear that detect balance and sound.

Chapter 9
Vasculature of the Head

and Neck
9. Vasculature of the Head and Neck
Recommended Videos
AnatomyZone:
• ‘External Carotid Branches - 3D Anatomy Tutorial’
o Runtime: 8:20
o (https://youtu.be/K-qtoLS3L4w)
Anatomy Knowledge:
• ‘ANATOMY Tutorial - External Carotid Artery Branches’
o Runtime: 9:25
o (https://youtu.be/Anfq88W1gJ8)
• ‘MAXILLARY ARTERY and its Branches - Anatomy Tutorial’
o Runtime: 9:50
o (https://youtu.be/pTkfjC9xMZk)
• ‘Facial Artery - Origin, course, branches | Anatomy Tutorial’
o Runtime: 2:24
o (https://youtu.be/CBNIK2MpMzw)
• ‘Anatomy Tutorial - Veins of the Head and Neck’
o Runtime: 5:07
o (https://youtu.be/HL16Ge1gv4M)

• ‘Arteries of the neck’
o Runtime: 11:05
o (https://youtu.be/NGoVMXz8SLU)

Arteries of the Head & Neck

Subclavian Artery:
Subclavian
artery: origin • Is a branch of the brachiocephalic trunk on the right but arises directly from the
and branches?
arch of the aorta on the left.
• Branches:
o Vertebral artery
o Thyrocervical trunk
o Internal thoracic artery
o Costocervical trunk
• Vertebral Artery:
o Ascends through the transverse foramina of vertebrae C1 to C6.
o Passes through the foramen magnum into the posterior cranial cavity.
• Thyrocervical Trunk:
o Branches into the:
▪ Inferior thyroid artery
▪ Transverse cervical artery
▪ Suprascapular artery
Common Carotid Artery:

Common
carotid artery: • Have different origins on the right and left sides:
origin and
course? o The right common carotid artery begins at the bifurcation of the
brachiocephalic artery.
o The left common carotid artery, which arises from the aortic arch.
• Ascend within the carotid sheath and divide at the level of the upper border of
the thyroid cartilage into the external and internal carotid arteries.
• Carotid body: Lies at the bifurcation of the common carotid artery. Is a
chemoreceptor
• Carotid sinus: Is a dilatation located at the origin of the internal carotid artery,
which functions as a baroreceptor.

Internal Carotid Artery:

Internal carotid
artery: course • Has no branches in the neck.
and banches?
• Ascends within the carotid sheath in company with the vagus nerve and the
internal jugular vein.
• Enters the cranium through the carotid canal.
• In the middle cranial fossa, it gives rise to the ophthalmic artery and the
anterior and middle cerebral arteries.
o It participates in the formation of the circle of Willis.
External Carotid Artery:

External
carotid artery:
course and
• Extends from the superior aspect of the thyroid cartilage to the neck of the
branches? mandible, where it divides in the parotid gland into the maxillary and
superficial temporal arteries.
• Has eight named branches:
o Superior thyroid artery
o Ascending pharyngeal artery
o Lingual artery
o Facial artery
o Occipital artery
o Posterior auricular artery
o Maxillary artery
o Superficial temporal artery
• Mnemonic for branches:
Some Anatomists Like Freaking Out Poor Medical Students

• Facial Artery:
Facial artery: o Hooks around the lower border of the mandible.
course and o Branches:
branches?
▪ Ascending palatine
▪ Tonsilar
▪ Submental
▪ Glandular
▪ Inferior labial
▪ Superior labial
▪ Lateral nasal
▪ Angular
o Mnemonic for branches: Anna, PLS SIT (Ascending palatine
artery, Premasseteric artery, Lateral nasal artery, Submental
artery, Superior labial artery, Inferior labial artery, Tonsillar artery)
o The angular artery is the final and terminal branch of the facial artery.

• Maxillary Artery:
Maxillary o Is the larger terminal branch of the external carotid artery.
artery: course o Runs deep to the neck of the mandible and enters the infratemporal
and branches?
fossa.
o Breaks into its terminal branches at the pterygopalatine fossa.
o Branches:
▪ Deep auricular artery
▪ Anterior tympanic artery
▪ Middle meningeal artery
▪ Inferior alveolar artery
▪ Accessory meningeal artery
▪ Masseteric artery
▪ Pterygoid artery
▪ Deep temporal artery
▪ Buccinator artery
▪ Sphenopalatine artery
▪ Descending palatine artery
▪ Infraorbital artery
▪ Posterior superior alveoar artery
▪ Middle superior alveolar artery
▪ Pharyngeal artery
▪ Anterior superior alveolar artery
▪ Artery of the pterygoid canal (Vidian artery)
o Mnemonic for branches: DAMn I AM Piss Drunk But Stupid Drunk I
Prefer, Must Phone Alcoholics Anonymous

o The Middle meningeal artery passes straight upwards through the

Courses of the foramen spinosum.
branches of the o The inferior alveolar artery enters the mandibular foramen.
maxillary
artery?
▪ The artery runs further anteriorly in the mandible, supplying the
pulps of the mandibular teeth (with its dental branches) and
the body of the mandible.
▪ Its other branch, the mental branch, emerges from the mental
foramen.
o The accessory meningeal artery passes upwards through the foramen
ovale.
o The sphenopalatine artery passes through the sphenopalatine foramen
in the pterygopalatine fossa and enters the nasal cavity.
o The descending palatine artery descends through the greater palatine
canal from the pterygopalatine fossa.
▪ It terminates by dividing into the greater and lesser palatine
arteries.
o The infraorbital artery passes forwards from the pterygopalatine fossa
through the inferior orbital fissure, along the floor of the orbit and
infraorbital canal to emerge from the infraorbital foramen.
o The artery of the pterygoid canal (Vidian artery) runs into the pterygoid
canal from the pterygopalatine fossa.

The Circle of Willis and the Vertebrobasilar System:

Arteries of the
Circle of Willis Note: This section is only for review purposes, hence only diagrams have been provided.
&
vertebrobasilar
It is assumed that this topic has already been covered in detail in neuro. Regardless, it is
system? still high-yield for head and neck.

Blood supply to
the cerebral
cortex?

Veins of the Head & Neck

Retromandibular Vein:
Retromandibular
vein: origin and • Is formed by the superficial temporal and maxillary veins.
branches?
o Via the maxillary vein, the retromandibular vein is connected to
the pterygoid venous plexus of the infratemporal fossa.
• Divides into:
o An anterior branch, which joins the facial vein to form the common
facial vein.
o A posterior branch, which joins the posterior auricular vein to form the
external jugular vein.
External Jugular Vein:

External
jugular vein: • Is formed by the union of the posterior auricular vein and the posterior branch
origin and
course?
of the retromandibular vein.
• Ends in the subclavian vein.
• Receives the suprascapular; transverse cervical, and anterior jugular veins.
Internal Jugular Vein:

Internal jugular
vein: origin and • Begins in the jugular foramen as a continuation of the sigmoid sinus.
course?
• Descends in the carotid sheath.
• Ends in the brachiocephalic vein.
• Receives the inferior petrosal sinus in the jugular foramen and then the facial,
lingual, and superior and middle thyroid veins in the neck.

• Clinical Correlate: Danger area of the face

Danger area of o Danger area of the face is the area of the face near the nose drained by
the face? the facial veins.
o Pustules (pimples), boils, or other skin infections, particularly on the side
of the nose and upper lip, may spread to the cavernous venous sinus via
the facial vein, pterygoid venous plexus, and ophthalmic veins.
o Consists of the area from the corners of the mouth to the bridge of the
nose, including the nose and maxilla.

Lymphatics of the Head & Neck

• The lymphatic vessels of the head and neck can be divided into two major
Pattern of groups; superficial vessels and deep vessels.
lymphatic
drainage in the
o The superficial vessels drain lymph from the scalp, face and neck into
head & neck? the superficial ring of lymph nodes at the junction of the neck and head.
o The deep lymphatic vessels of the head and neck arise from the deep
cervical lymph nodes. They converge to form the left and right jugular
lymphatic trunks.
• The lymph nodes of the head and neck can be divided into two groups;
Groups of a superficial ring of lymph nodes, and a vertical group of deep lymph nodes.
superficial o Superficial lymph nodes ultimately drain into the deep lymph nodes.
lymph nodes of
the head &
They include the following groups of lymph nodes:
neck? ▪ Occipital
▪ Mastoid
▪ Pre-auricular
▪ Parotid
▪ Submental
▪ Submandibular
▪ Facial
▪ Superficial Cervical
o The deep (cervical) lymph nodes receive all of the lymph from the head
and neck – either directly or indirectly via the superficial lymph nodes.
▪ The nodes can be divided into superior and inferior deep cervical
lymph nodes.
▪ They are numerous in number, but include groups such as the
prelaryngeal, pretracheal, paratracheal, retropharyngeal nodes
etc.
Fig 1 – The superficial and deep lymph nodes of the head and neck.

Waldeyer’s Ring:
Waldeyer’s
ring? • Waldeyer’s tonsillar ring refers to the collection of lymphatic tissue surrounding
the superior pharynx.
• This lymphatic tissue responds to pathogens that may be ingested or inhaled.
• The tonsils that make up the ring are as follows:
o Lingual tonsil
▪ Located on the posterior base of the tongue.
▪ Form the antero-inferior part of the ring.
o Palatine tonsils
▪ Located on each side between the palatoglossal and
palatopharyngeal arches.
▪ These are the common ‘tonsils’ that can be seen within the oral
cavity.
▪ They form the lateral part of the ring.
o Tubal tonsils
▪ These are located where each Eustachian tube opens into the
nasopharynx.
▪ Form the lateral part of the ring.
o Pharyngeal tonsil
▪ Also called the nasopharyngeal/adenoid tonsil.
▪ Located in the roof of the nasopharynx, behind the uvulva
▪ Forms the postero-superior part of the ring.
Fig 1 – The four tonsils that comprise Waldeyer’s ring.

(Blank)

Chapter 10
Cranial Nerves
10. Cranial Nerves
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10. Cranial Nerves
Cranial nerve Cranial Nerve Modalities

modalities?

10. Cranial Nerves
The Olfactory Nerve (CN I)

(https://teachmeanatomy.info/head/cranial-nerves/olfactory-cni/)
• It is a special visceral afferent (SVA) nerve, which transmits information relating

Modalities of to smell.
CN I?
• They pass through the foramina in the cribriform plate of the ethmoid bone
and synapse in the olfactory bulb.
The Olfactory Tract:

Olfactory
tract? • The olfactory tract travels posteriorly on the inferior surface of the frontal lobe.
• As the tract reaches the anterior perforated substance (an area at the level of
the optic chiasm) it divides into medial and lateral stria:
o Lateral stria – carries the axons to the primary olfactory cortex, located
within the uncus of temporal lobe.
o Medial stria – carries the axons across the medial plane of the anterior
commissure, where they meet the olfactory bulb of the opposite side.
• The primary olfactory cortex sends nerve fibres to many other areas of the
brain, notably the piriform cortex, the amygdala, olfactory tubercle and the
secondary olfactory cortex.
o These areas are involved in the memory and appreciation of olfactory
sensations.
Lateral olfactory stria

10. Cranial Nerves
Olfactory nerve

10. Cranial Nerves
The Optic Nerve (CN II)

(https://teachmeanatomy.info/head/cranial-nerves/optic-cnii/)
• Is formed by the axons of ganglion cells of the retina, which converge at the
Modalities of optic disc.
CN II?
• These fibers of the optic nerve are covered by a membrane continuous with the
dura, and the myelin of the optic nerves is formed by oligodendroglia, just like
CNS tracts.
• These nerves carry SSA fibers for vision from the retina to the brain.
• CNII leaves the middle cranial fossa to enter the orbit through the optic canal.
• The optic chiasma contains fibers from the nasal retina that cross over to the
opposite side of the brain.
The Visual Pathway:

Visual
pathway? • Within the middle cranial fossa, the optic nerves from each eye unite to form
the optic chiasm.
• At the chiasm, fibres from the nasal (medial) half of each retina cross over to
the contralateral optic tract, while fibres from the temporal (lateral) halves
remain ipsilateral.
o Left optic tract – contains fibres from the left temporal (lateral) retina,
and the right nasal (medial) retina.
o Right optic tract – contains fibres from the right temporal retina, and
the left nasal retina.
Fig 2 – The nasal retinal fibres crossing over at the optic chiasm.

10. Cranial Nerves
• Each optic tract travels to its corresponding cerebral hemisphere to reach

the lateral geniculate nucleus (LGN), a relay system located in the thalamus.
o The fibres synapse here.
• Axons from the LGN then carry visual information via a pathway known as
the optic radiation. The pathway itself can be divided into:
o Upper optic radiation
▪ Carries fibres from the superior retinal quadrants (corresponding
to the inferior visual field quadrants).
▪ It travels through the parietal lobe to reach the visual cortex.
o Lower optic radiation
▪ Carries fibres from the inferior retinal quadrants (corresponding
to the superior visual field quadrants).
▪ It travels through the temporal lobe, via a pathway known as
Meyers’ loop, to reach the visual cortex.
Fig 3 – The optic pathway.

10. Cranial Nerves
• Clinical Correlate: Visual Field Defects

Visual field
defects?

10. Cranial Nerves
The Oculomotor Nerve (CN III)

• The oculomotor nerve is the third cranial nerve and is purely motor.
Modalities of o The GSE component arises from the oculomotor nucleus of the rostral
CN III and their midbrain. It innervates the:
functions?
▪ medial rectus
▪ superior rectus
▪ inferior rectus
▪ inferior oblique
▪ levator palpebrae superioris
o The GVE component consists of preganglionic parasympathetic fibers
from the accessory oculomotor nucleus (Edinger–Westphal nucleus)
that project to the ciliary ganglion.
▪ The ciliary ganglion projects postganglionic parasympathetic
fibers to the sphincter pupillae (miosis) and the ciliaris
(accommodation).
Anatomical Course:
• The oculomotor nerve originates from the oculomotor nucleus at the level of
Anatomical
course of the the superior colliculus in the midbrain.
GSE o The oculomotor nucleus is located ventral to the periaqueductal grey
component of matter.
CN III? • Fibers from the oculomotor nucleus pass through the red nucleus then pass
through the medial part of the substantia nigra, exiting through the
interpeduncular fossa.
• On emerging from the midbrain, the oculomotor nerve passes between the
posterior cerebral artery, located superior to the nerve, and superior cerebellar
artery, located below the nerve.
• The nerve enters the lateral wall of the cavernous sinus, traversing it in its
superior part.
• Before leaving the lateral wall of the cavernous sinus, the oculomotor nerve
splits into a superior division and an inferior division.
o Those two divisions will enter the orbit via the superior orbital fissure.
o The superior division is smaller and supplies the superior rectus muscle
and the levator palpebrae superioris muscle.
o The inferior division of the oculomotor nerve, the larger one, divides
Anatomical into three branches, supplying the medial rectus, inferior rectus, and
course of the the inferior oblique muscle.
GVE • The oculomotor nerve also contains parasympathetic fibers.
component of
CN III?
• The preganglionic parasympathetic fibers originate in the Edinger-Westphal
nucleus, located in the midbrain at the level of the superior colliculus, just
posterior to the oculomotor nucleus.
10. Cranial Nerves
• These parasympathetic fibers will travel within the oculomotor nerve, and will
then follow the course of the inferior division of the nerve.
• They then follow the branch to inferior oblique, finally arriving at the ciliary
ganglion via a communicating branch between the branch to inferior oblique
and the ganglion.
o This communicating branch is called the parasympathetic root of the
ciliary ganglion.
• The ciliary ganglion is located behind the eye, and lateral to the optic nerve and
contains parasympathetic postganglionic neurons.
• The parasympathetic postganglionic fibers will reach the posterior pole of the
eye via the short ciliary nerves.
• The postganglionic parasympathetic fibers then pass forward on the inner
surface of the sclera and are distributed to the ciliary muscle and the sphincter
pupillae.
• Clinical Correlate: Oculomotor Paralysis

Symptoms of o Denervation of the levator palpebrae superioris causes ptosis (i.e.,
CN III drooping of the upper eyelid).
paralysis?
o Denervation of the extraocular muscles innervated by CN III causes the
affected eye to look “down and out”.
▪ Occurs as a result of the unopposed action of the lateral rectus
and superior oblique.
▪ The superior oblique and lateral rectus are innervated by CNs IV
and VI, respectively.
o Oculo-motor palsy results in diplopia (double vision) when the patient
looks in the direction of the paretic muscle.

10. Cranial Nerves
o Interruption of parasympathetic innervation (internal ophthalmoplegia)

results in a dilated, fixed pupil and paralysis of accommodation
(cycloplegia).

10. Cranial Nerves
The Trochlear Nerve (CN IV)

• Pure motor nerve. Somatic motor fibers (GSE) supply the superior oblique
Modalities of
CN IV and their
muscle.
functions? • This is the smallest of all cranial nerves and the only CN that emerges from the
dorsal aspect of the brainstem.
Anatomical Course:
Anatomical
course of CN • The axons of the trochlear nerve originate in the trochlear nucleus.
IV?
o Located in the tegmentum of the midbrain at the level of the inferior
colliculus, and ventrolateral to the periaqueductal gray matter.
• Axons arising from the trochlear nucleus course dorsally around the
periaqueductal grey matter, and cross the midline.
• The crossed axons emerge from the dorsal aspect of the midbrain just caudal to
the inferior colliculus to form cranial nerve IV.
• The nerve curves ventrally around the cerebral peduncle to pass between the
posterior cerebral and superior cerebellar arteries.
• The trochlear nerve enters the lateral wall of the cavernous sinus, where it is
situated between oculomotor and ophthalmic nerves.
• It leaves the cavernous sinus and enters the orbit through the superior orbital
fissure, above the tendinous ring.
• The nerve then courses medially, close to the roof of the orbit, and runs
diagonally above the levator palpebrae superioris muscle to reach its target, the
superior oblique muscle.
o Here the nerve divides into branches that enter the superior oblique
muscle along its proximal third.

10. Cranial Nerves
• Clinical Correlate: CN IV Paralysis

Symptoms of o CN IV paralysis results in the following conditions:
CN IV ▪ Extorsion of the eye and weakness of downward gaze.
paralysis?
▪ Vertical diplopia, which increases when looking down.
▪ Head tilting to compensate for extorsion (may be misdiagnosed
as idiopathic torticollis).

10. Cranial Nerves
The Trigeminal Nerve (CN V)

• The largest cranial nerve.
Embryology of
CN V? • Connects to the brainstem at the pons.
• The nerve of the first pharyngeal arch (mandibular nerve).
• Contains sensory (general somatic afferent [GSA]) and motor (special visceral
Modalities and efferent [SVE] fibers.
functions of CN o The SVE component arises from the trigeminal motor nucleus. It
V?
innervates:
▪ The muscles of mastication (i.e., temporalis, masseter, lateral,
and medial pterygoids)
▪ Tensors tympani
▪ Tensor veli palatini
▪ The mylohyoid
▪ The anterior belly of the digastric
o The GSA component provides sensory innervation, including
proprioception from muscles.
• Provides sensory innervation to the face and oral and nasal cavity.
• Innervates the dura mater of the anterior and middle cranial fossae.
• Innervates the muscles of mastication.
• Consists of a large ganglion that gives rise to three major divisions: ophthalmic,
maxillary, and mandibular.
o The trigeminal ganglion occupies the trigeminal impression at the apex
of the petrous portion of the temporal bone in the middle cranial fossa.
o The ganglion itself is housed in a pouch webbed with arachnoid between
two layers of dura (Meckel cave).
Trigeminal ganglion

10. Cranial Nerves
Trigeminal Nuclei:
Trigeminal
nuclei? • Chief (Principal, Main) Sensory Nucleus:
o Located in the rostral pontine tegmentum at the level of the trigeminal
motor nucleus.
o Receives fine touch from the face (GSA).
• Spinal Trigeminal Nucleus:
o Located in the spinal cord (C1—C3), medulla, and pons.
o Receives pain and temperature inputs from the face and oral cavity
(GSA).
• Mesencephalic Nucleus:
o Subserves GSA proprioception from the head.
o Receives inputs from muscle spindles and pressure and joint receptors.
o Projects to the trigeminal motor nucleus to mediate the muscle stretch
(jaw jerk) reflex and regulate the force of bite.
• Trigeminal Motor Nucleus:
o SVE
o Located in the rostral pontine tegmentum at the level of the chief
sensory nucleus.
o Innervates the muscles of mastication (temporalis, masseter, medial
and lateral pterygoids), tensor tympani, tensor veli palatini, anterior
belly of digastric and mylohyoid.

10. Cranial Nerves
The Ophthalmic Nerve (CN V1):
• The ophthalmic nerve is the first branch of the trigeminal nerve.

Ophthalmic • Provides somatic sensory innervation to the eyeball, tip of the nose, and skin of
nerve: function
and anatomical
the face above the eye.
course? • Soon after it splits from the trigeminal ganglion, the ophthalmic nerve enters
through the lateral wall of the cavernous sinus.
o At this level, superior to the ophthalmic nerve are the 3rd and 4th cranial
nerves.
o Before entering the cavernous sinus, it gives off a meningeal branch.
• In the cavernous sinus, it divides into three branches:
o Nasociliary
o Lacrimal
o Frontal
• All these branches enter the orbit through the superior orbital fissure.
• The lacrimal nerve:
o In the orbit, the lacrimal nerve communicates with the zygomatic nerve.
o It provides sensory innervation to the lacrimal gland, conjunctiva, and
the lateral upper eyelids.
o By the way of the communicating branch with the zygomatic nerve, the
lacrimal nerve will receive parasympathetic postganglionic fibers for the
lacrimal gland.
• The frontal nerve:
o The frontal nerve is the largest branch of the ophthalmic nerve, and may
be regarded both from its size and direction as the continuation of the
nerve.
o It runs forward and divides into two branches: the supraorbital nerve
and supratrochlear nerve.
o It provides the sensory innervation to the skin of the forehead, mucosa
of the frontal sinus, and the skin of the upper eyelid.
• The nasociliary nerve:
o The nasociliary nerve runs obliquely to the medial wall of the orbital
cavity.
o Passing through the orbit, it gives rise to the communicating branch of
the ciliary ganglion, the long ciliary nerves, and the posterior and
anterior ethmoidal nerves, and terminates as the infratrochlear nerve.
o The anterior ethmoidal nerve, after entering through the anterior
ethmoidal foramen, will soon lie on the cribriform plate.
▪ At this level, after giving off a meningeal branch, it enters the
nasal slit and appears in the nasal cavity.
▪ Here it supplies branches to the mucous membrane of the nasal
cavity and finally emerges between the inferior border of the

10. Cranial Nerves
nasal bone and the upper lateral nasal cartridge as the external
nasal branch.
▪ The external nasal branch ultimately innervates skin on the
lateral side of the nose and the tip of the nose.
• The ophthalmic nerve itself does not contain any autonomic fibres. However,
nerves from the sympathetic and parasympathetic system ‘hitchhike’ on CNV1:
o Sympathetic fibres (from the superior cervical ganglion) hitchhike on
branches of the nasociliary nerve (long ciliary nerves) to reach the
dilator pupillae in the eye.
o Parasympathetic fibres (from the pterygopalatine ganglion) hitchhike
along the zygomatic branch of the maxillary nerve (CNV2) and then the
lacrimal branch of the ophthalmic nerve (CNV1) to reach the lacrimal
gland.

10. Cranial Nerves
Overview of the ophthalmic nerve and its branches (lateral-left view)
The Maxillary Nerve (CN V2):

Maxillary
nerve: function • The maxillary nerve is a sensory nerve and arises from the trigeminal ganglion.
and anatomical
course?
o Somatic sensory fibers provide innervation to the face below the eyes
and to the upper lip, palate, paranasal sinuses, and maxillary teeth.
• It enters the lateral wall of the cavernous sinus where it occupies the lowest
position and leaves the cranial fossa through the foramen rotundum.
• It then crosses the pterygopalatine fossa and enters the orbit through the
inferior orbital fissure as the infraorbital nerve.
o The infraorbital nerve courses through the infraorbital groove and then
the infraorbital canal, finally emerging on the face through the
infraorbital foramen.
• Before exiting the skull through for foramen rotundum, the maxillary nerve
gives off a meningeal branch, which will supply the dura mater in the middle
cranial fossa.
• In the pterygopalatine fossa, the pterygopalatine ganglion is attached to the
maxillary nerve.
• In the pterygopalatine fossa, the zygomatic nerve arises directly from the
maxillary nerve and enters the orbit through the infraorbital fissure, along with
the infraorbital nerve.
o The zygomatic nerve gives off a communicating branch to the lacrimal
nerve.
10. Cranial Nerves
• The maxillary nerve also gives off the posterior superior alveolar nerves.
o They enter the alveolar canals of the maxilla.
o These nerves supply the maxillary sinus and gingival and dental
branches to each molar tooth.
• The infraorbital nerve also gives off the middle superior alveolar nerve and
anterior superior alveolar nerve.
• The maxillary nerve also gives off the following nerves via the pterygopalatine
ganglion:
o The Nasopalatine Nerve
▪ It enters the nasal cavity through the sphenopalatine foramen
and runs obliquely downward on the lower part of the septum.
▪ It descends to the roof of the mouth through the incisive canal
and communicates with the greater palatine nerve.
o The Greater Palatine Nerve
▪ It descends through the greater palatine canal, emerges upon
the hard palate through the greater palatine foramen and passes
forward.
▪ It supplies the gums, the mucous membrane and glands of the
hard palate.
o The Lesser Palatine Nerve
▪ Descends through the greater palatine canal and emerges
through the lesser palatine foramen.
▪ It supplies the soft palate, tonsil and uvula.
o The Pharyngeal Nerve
• The Nerve of the Pterygoid Canal:
o Also called the vidian nerve.
o It is formed by the junction of the greater petrosal nerve and the deep
petrosal nerve within the pterygoid canal.
o It then enters the pterygopalatine fossa and joins the pterygopalatine
ganglion.
o Contents of the vidian nerve are:
▪ Parasympathetic preganglionic fibers from the facial nerve
contained within the greater petrosal nerve, which synapse in
the pterygopalatine ganglion.
▪ Sympathetic postganglionic fibers from the deep petrosal nerve
which do not synapse in the pterygopalatine ganglion.
o The preganglionic parasympathetic fibres of the greater petrosal nerve
upon synapsing in the pterygopalatine ganglion redistribute to the nose,
palate, and lacrimal gland through the various nerves leaving the
pterygopalatine fossa.
▪ For example, the most important parasympathetic pathway from
the pterygopalatine ganglion are the parasympathetic
postganglionic fibers which will follow the course of the maxillary
nerve, then the zygomatic nerve, and via the communicating
10. Cranial Nerves
branch of zygomatic with lacrimal nerve will supply the lacrimal

gland.
Overview of the maxillary nerve (lateral-left view)

10. Cranial Nerves
The Mandibular Nerve (CN V3):

Maxillary
nerve: function • The large sensory root and the small motor root of the nerve arise from the
and anatomical
course?
lateral pontine region.
o It is the sensory root that bears the large trigeminal ganglion.
▪ Is the equivalent of the dorsal root ganglion of a spinal nerve.
▪ Gives rise to the three great branches of the nerve.
▪ Somatic sensory innervation to the lower part of the face,
including the lower lip, anterior ear and chin as well as the
mandibular teeth, and anterior two-thirds of the tongue.
o The motor root blends neither with the sensory root nor with the
ganglion.
▪ Passes deep to the ganglion to accompany the mandibular
division and joins just outside the foramen ovale.
▪ Supply motor fibers to the muscles from the first branchial arch,
including the tensor veli palatini, tensor tympani, anterior belly
of the digastric, and mylohyoid muscle as well as the muscles of
mastication (temporalis, masseter, and lateral and medial
pterygoid).
• The mandibular nerve as it leaves through the foramen ovale, consists of two
rootlets: a large sensory one which contains fibers derived from the trigeminal
ganglion and the motor root which is the direct continuation of the motor root.
o As these two parts emerge through the foramen ovale in intimate
contact, they unite to form the mandibular nerve, which is a very short
trunk.
• Soon after it exits through the foramen ovale, it splits up into an anterior and a
posterior division.
• Medially to the mandibular nerve, the otic ganglion is located.
• The anterior division of the mandibular nerve: This division gives off the
following branches:
o The deep temporal nerves which innervate the temporalis muscle.
o The buccal nerve:
▪ Contains all the sensory fibers from the anterior division of the
mandibular nerve.
▪ This nerve will innervate the skin and the mucous membrane
related to the chin.
o The nerve to the lateral pterygoid. This nerve will innervate the lateral
pterygoid muscle.
o The masseteric nerve: this nerve will innervate the masseteric muscle.

10. Cranial Nerves
• Branches from the main trunk of the mandibular nerve: Two branches arise
from the main trunk:
o A sensory branch, which is the nervus spinosus
▪ Enters the cranial cavity through foramen spinosum together
with the meningeal artery.
▪ Supplies the dura mater of the middle cranial fossa.
o The nerve to the medial pterygoid is the other branch from the main
trunk and is a motor branch
▪ Traverses the otic ganglion and supplies the medial pterygoid.
▪ In addition to the medial pterygoid, it also supplies the tensor
veli palatini and tensor tympani muscles.
• Branches from the posterior division of the mandibular nerve: In contrast to the
anterior division of the mandibular nerve, the posterior division is mainly
sensory and it contains only a few motor fibers. The posterior division gives off
three branches:
o The lingual nerve: is the smaller terminal branch of the posterior division
of the mandibular nerve.
▪ It is sensory to the mucous membrane of the anterior 2/3 of the
tongue.
▪ This nerve winds around the submandibular duct, first above,
then lateral, then below, and finally medial to the duct, and
divides into its terminal branches.
▪ It also carries preganglionic secretomotor (parasympathetic)
fibers to the submandibular and sublingual salivary glands.
o The inferior alveolar nerve: it is the larger terminal branch of the
posterior division of the mandibular nerve.
▪ This nerve will enter the mandibular foramen in company with
inferior alveolar artery, traverses the mandibular canal as far as
the mental foramen, where it terminates.
▪ The mental nerve emerges out through the mental foramen to
supply skin of the chin and skin and mucous membrane of the
lower lip.
o Arising from the inferior alveolar nerve before it enters the mandibular
canal is the mylohyoid nerve.
▪ Carries all the motor fibers from the posterior division of the
mandibular nerve.
▪ It supplies the mylohyoid and the anterior belly of the digastric
muscle.
o The auriculotemporal nerve:
▪ This nerve arises from two roots, which after encircling the
middle meningeal artery unite to form the single trunk.
▪ It runs backwards to enter the temple.
▪ The auriculotemporal nerve is a sensory nerve.

10. Cranial Nerves
• Secretomotor Innervation of the Parotid Gland:

Parasymp. o The glossopharyngeal nerve carries the parasympathetic preganglionic
innervation of fibers which originate in the inferior salivatory nucleus.
the parotid
gland?
o Those fibers will leave the glossopharyngeal nerve at the level of its
inferior ganglion and will travel along with the tympanic nerve.
o The tympanic nerve arises from the inferior ganglion of glossopharyngeal
and ascends to the tympanic cavity through a small canal, the inferior
tympanic canaliculus.
o In the tympanic cavity, it divides into branches which form the tympanic
plexus.
o From the tympanic plexus, parasympathetic secretory fibers continue as
the lesser petrosal nerve which will enter the otic ganglion.
o Here, the preganglionic fibers will synapse with the postganglionic
neurons.
o From the otic ganglion, the parasympathetic postganglionic fibers will
pass to the auriculotemporal nerve via communicating branches.
o From the auriculotemporal nerve, the parasympathetic fibers will reach
the parotid gland.
• Parasympathetic Innervation to the Submandibular and Sublingual Salivary
Parasymp. Glands:
Innervation of o The fibers originate in the superior salivatory nucleus located in the
the subman.
and subling. pons.
glands? o The preganglionic parasympathetic fibres take the route of nervus
intermedius.
o At the level of the geniculate ganglion, some of the parasympathetic
fibers will continue along with the facial nerve.
o Then, the preganglionic parasympathetic fibers will pass to the chorda
tympani nerve which branches from the facial nerve.
o The corda tympani nerve will anastomose with the lingual nerve.
o Thus, the preganglionic parasympathetic fibers will reach the lingual
nerve and from this nerve the fibers will arrive at the submandibular
ganglion.
o In the submandibular ganglion, the preganglionic fibers synapse with the
postganglionic neurons, and the parasympathetic postganglionic fibers
will go to the submandibular and sublingual glands.

10. Cranial Nerves
Origin and course of the mandibular nerve

10. Cranial Nerves
• Clinical Correlate: Neurologic Deficits in Lesions of the Trigeminal Nerve

Lesions of CN o Loss of general sensation (hemianesthesia) from the face and mucous
V? membranes of the oral and nasal cavities.
o Loss of the corneal reflex (afferent limb, CN V1).
o Flaccid paralysis of the muscles of mastication.
▪ Deviation of the jaw to the weak side as a result of the
unopposed action of the opposite lateral pterygoid muscle.
o Paralysis of the tensor tympani muscle, which leads to hypoacusis
(partial deafness to low-pitched sounds).
o Trigeminal neuralgia (tic douloureux), which is characterized by
recurrent paroxysms of sharp, stabbing pain in one or more branches of
the nerve.
Fig 4 – Cutaneous innervation to the head and neck.

10. Cranial Nerves
The Abducens Nerve (CN VI)

• The abducens nerve is the 6th cranial nerve. It is purely motor (GSE) and
Modalities of supplies only one muscle—the lateral rectus of the eyeball.
CN VI? • Its general somatic efferent fibres arise from the abducens nucleus in the pons.
• Inside the pons, fibers from the facial motor nucleus of the facial nerve loop
over the abducens nucleus. Thus, the facial colliculus is formed.
Anatomical o The facial colliculus is an elevated area located on the pontine
course of CN
VI?
tegmentum in the floor of the fourth ventricle.
• The abducens nerve arises at the lower border of the pons.
• At this level, medially to the nerve is the basilar artery, and also closely related
to the nerve is the anterior inferior cerebellar artery, which originates from the
inferior part of the basilar artery.
• The nerve runs over the clivus, approaching the tip of the petrous part of the
temporal bone.
• It then arches forward directly over the sharp ridge of the petrous temporal
bone, under the petroclinoid ligament and enters a fibro-osseous canal called
Dorrello's canal.
o This canal is formed by the apex of the petrous temporal bone and the
petroclinoid ligament.
o In Dorello’s canal, the abducens nerve is accompanied by the inferior
petrosal sinus which feeds into the cavernous sinus.
• The nerve then enters the cavernous sinus.
o In the cavernous sinus, it runs forward inferolateral to the internal
carotid artery.
• The nerve enters the orbit through the superior orbital fissure.
• In the orbit, it runs forward to supply the lateral rectus muscle.

10. Cranial Nerves
• Clinical Correlate: CN VI Paralysis

CN VI o It is the most common isolated palsy that results from the long
paralysis? peripheral course of the nerve.
o It is seen in patients with meningitis, subarachnoid hemorrhage, late-
stage syphilis, and trauma.
o Abducent nerve paralysis results in the following defects:
▪ Convergent (medial) strabismus (esotropia) with inability to
abduct the eye.
▪ Horizontal diplopia with maximum separation of the double
images when looking toward the paretic lateral rectus.

10. Cranial Nerves
The Facial Nerve (CN VII)

• The facial nerve is the 7th cranial nerve. It is a mixed nerve, but predominantly
Embryological it is motor.
origin of CN
VII? • It is the nerve of the second pharyngeal arch.
• Exits the brainstem at the cerebellopontine (CP) angle.
• Four nuclei are related to the fibers which travel with within the facial nerve:
Nuclei of CN
o The motor nucleus of facial nerve
VII? ▪ Located in the pons
▪ SVE
o The superior salivatory nucleus
▪ GVE
o The spinal nucleus of the trigeminal nerve
▪ GSA
o The nucleus solitarius
▪ SVA
• The facial nerve has four functional components which are related to these four
Modalities of nuclei.
CN VII and their
o SVE component (innervates the muscles of facial expression, the
functions?
stylohyoid, the posterior belly of the digastric, and stapedius.)
o GVE component (Parasympathetic component that innervates the
lacrimal, submandibular, and sublingual glands)
o GSA component (innervates the posterior surface of the external ear)
o SVA component (innervates the taste buds from the anterior two-thirds
of the tongue)
The Branchial Motor Component (Special Visceral Efferent Fibers) (SVE):

Course of the
SVE component • Innervates:
of CN VII?
o The muscles of facial expression
o The stylohyoid
o The posterior belly of the digastric
o The stapedius
• Motor fibers from the motor nucleus of facial nerve loop around the abducens
nucleus to form a slight bulge in the floor of the fourth ventricle, called the
facial colliculus.
o The loop itself is the internal genu of the facial nerve.
• These fibers then turn medially to emerge as the facial nerve proper on the
ventrolateral aspect of the brain stem at the caudal border of the pons.
• Further on, the facial nerve carrying these special visceral efferent fibers enters
the internal auditory meatus and then the facial canal.

10. Cranial Nerves
• The facial canal has three parts:

o The labyrinthine segment lies above the vestibule of bony labyrinth and
bends to reach the anterosuperior part of the medial wall of the middle
ear.
▪ Here, the canal bends sharply backwards.
▪ The facial nerve coursing through the labyrinthine segment of
facial canal also makes a sharp bend called the external genu of
the facial nerve which possesses the geniculate ganglion.
o The tympanic segment of the facial canal runs horizontally backward in
the medial wall of the middle ear till it reaches the junction of the medial
and posterior wall of the middle ear.
o The mastoid segment begins at the junction of the medial and posterior
wall of the middle ear and passes vertically downwards in the posterior
wall of the middle ear till it reaches the stylomastoid foramen at the
base of the skull.
• As it travels through the mastoid segment of the facial canal, the facial nerve
gives off a small branch called nerve to stapedius which will innervate the
stapedius muscle.
• The facial nerve comes out of cranial cavity through stylomastoid foramen.
• Upon emerging from the stylomastoid foramen, the facial nerve gives rise to the
posterior auricular nerve.
o This branch supplies the posterior auricular muscle the occipitalis
muscle.
• Another two small branches arise from the facial nerve soon after emerging
from the stylomastoid foramen:
o The branch to stylohyoid muscle and the branch to posterior belly of
the digastric muscle.
• Within the substance of the parotid gland, five major, terminal branches arise
from the facial nerve, which innervate all the muscles of facial expression.
• These branches, from top to bottom are as follows:
Terminal o The temporal branch
branches of CN o The zygomatic branch
VII?
▪ Supplies the orbicularis occuli muscle
▪ An injury to the zygomatic branch would alter the function of the
ipsilateral oribularis occuli muscle, the eyelids would be unable to
close, and thus inflammation, dryness, ulceration or even
blindness may occur in extreme cases.
o The buccal branch
o The marginal mandibular branch
o The cervical branch
o Mnemonic for branches: "To Zanzibar By Motor Car"
o AKU version: “Tum Zyadah Bakwas Mat Caro”
▪ (Me whenever someone starts talking low-yield)

10. Cranial Nerves
Fig 3 – Innervation to the muscles of facial expression via the facial nerve (CN VII)
The Nervus Intermedius:

Nervus
intermedius? • The remaining three functional components of facial nerve are:
o Visceral motor or general visceral efferent fibers
o General sensory or general somatic afferent fibers
o Special sensory or special visceral afferent fibers
• These last three functional components emerge from the brain stem as the
nervus intermedius of Wrisberg separately from the facial nerve proper which
contains only the branchial motor component.
General Visceral Efferent (GVE) Fibers:

Course of the
GVE • A parasympathetic component that innervates:
component of
o The lacrimal gland
CN VII?
o The submandibular gland
o The sublingual gland
• These types of fibers represent the preganglionic parasympathetic fibers from
the superior salivatory nucleus.
• They travel in the nervus intermedius to reach the external genu of the facial
nerve.
• Here, they divide into two groups.
• One group becomes the greater petrosal nerve.
o Exits the petrous portion of the temporal bone via the greater petrosal
foramen to enter the middle cranial fossa.
o Further on, before entering the pterygoid canal, the greater petrosal
nerve unites with the deep petrosal nerve to form the Vidian nerve.
▪ The deep petrosal nerve is sympathetic and is derived from the
sympathetic plexus around the internal carotid artery.
10. Cranial Nerves
o Further on, the preganglionic fibers, by way of the Vidian nerve, arrive at
the pterygopalatine ganglion in the pterygopalatine fossa.
▪ Here the preganglionic fibers synapse with the postganglionic
neurons within the ganglion.
▪ The pterygopalatine ganglion is attached to the maxillary
division of trigeminal nerve.
o Some of the postganglionic parasympathetic fibers from the
pterygopalatine ganglion jump to the maxillary nerve and then to the
zygomatic nerve, a branch of the maxillary nerve.
o From the zygomatic nerve, by way of a communicating branch with the
lacrimal nerve, the postganglionic parasympathetic fibers arrive at the
lacrimal gland to supply it.
o The remaining postganglionic fibers continue forward via ganglionic
branches of maxillary nerve to reach the mucous glands in the mucousa
of the nasal and oral cavities.
• The other group of fibers travel together with the facial nerve proper and exits
the mastoid segment of facial canal as the corda tympani nerve to arrive in the
middle ear cavity.
o The corda tympani nerve exits the middle ear by way of the
petrotympanic fissure.
o Further on this nerve unites with the lingual nerve, which is a branch of
the mandibular division of the trigeminal nerve, and thus the
preganglionic parasympathetic fibers arrive at the submandibular
ganglion which is suspended from lingual nerve.
▪ Here, the preganglionic fibers synapse in the ganglion with the
postganglionic neurons.
o From here, the postganglionic fibers continue to the submandibular and
sublingual glands and to minor glands in the floor of the mouth.
General Sensory Component (GSA):

Course of the
GSA • Cutaneous nerve endings can be found around the skin of the concha of the
component of
CN VII? external ear and in a small area behind the ear.
o Innervation via the posterior auricular branch of the facial nerve.
• The nerve cell bodies of these sensory fibers are located in the geniculate
ganglion.
o The neurons in the geniculate ganglion are pseudounipolar, having a
peripheral projection and a central projection.
• The peripheral projections which gather sensory information arrive at the
geniculate ganglion by way of the facial nerve.
• From the geniculate ganglion the central projections travel in the nervus
intermedius to reach the spinal nucleus of trigeminal nerve where they
synapse.

10. Cranial Nerves
Special Sensory Component (Special Visceral Afferent Fibers) (SVA):

Course of the
SVA • Special sensory fibers of cranial nerve VII carry information from taste buds on
component of
the anterior two thirds of the tongue and the hard and soft palates.
CN VII?
• The cell bodies of the special sensory neurons for taste are located in the
geniculate ganglion.
• Peripheral projections of these cells for taste run with the lingual nerve and
then separate from it in the chorda tympani nerve.
• From the geniculate ganglion, the central projections travel in the nervus
intermedius to reach the nucleus solitarius, where they synapse.
o The nucleus solitarius is sometimes referred to as the gustatory nucleus.

10. Cranial Nerves
• Clinical Correlate: Lesions of CN VII

Lesions of CN o Flaccid paralysis of the ipsilateral muscles of facial expression (upper
VII? and lower face)
▪ UMN lesion is spastic and only affects the lower face
o Loss of the corneal (blink) reflex (efferent limb), which may lead to
corneal ulceration (keratitis paralytica)
o Loss of taste (ageusia) from the anterior two-thirds of the tongue
o Hyperacusis (increased acuity to sounds) due to stapedius paralysis

10. Cranial Nerves
The Vestibulocochlear Nerve (CN VIII)

• Maintains balance and mediates hearing.
Modalities of • Consists of two functional divisions: the vestibular nerve and the cochlear
CN VIII?
nerve.
• A purely SSA nerve.
• Exits the brainstem at the cerebellopontine angle.
Course of CN
VIII? • Enters the internal auditory meatus.
• Vestibular Nerve:
o Plays a role in equilibrium and balance.
o Has first-order sensory bipolar neurons in the vestibular (Scarpa’s)
ganglion of the internal auditory meatus.
o Projects peripheral processes to the hair cells of the cristae ampullares
of the semicircular ducts and into hair cells of the utricular and saccular
maculae.
o Projects central processes to the four vestibular nuclei (Superior,
Inferior, Medial and Lateral) of the brainstem and to the
flocculonodular lobe of the cerebellum.
o Conducts efferent fibers to hair cells from the brainstem to decrease the
sensation of movement; failure results in motion sickness.
• Cochlear Nerve:
o Serves audition (hearing).
o Has first-order sensory bipolar neurons in the cochlear (spiral) ganglion
of the modiolus of the cochlea, within the temporal bone.
o Projects peripheral processes to the hair cells of the organ of Corti.
o Projects central processes to the dorsal and ventral cochlear nuclei of
the brainstem.
o Conducts efferent fibers to the hair cells from the brainstem.
• Clinical Correlate: Rinne and Weber Test
Rinne and
Weber tests?

10. Cranial Nerves
Vestibulocochlear nerve

10. Cranial Nerves
The Glossopharyngeal Nerve (CN IX)

• The glossopharyngeal nerve or the 9th cranial nerve is a mixed nerve and has
Nuclei of CN four related nuclei located in the medulla.
IX?
o The nucleus ambiguous
▪ SVE
o The inferior salivatory nucleus
▪ GVE
▪ GSA
o The solitary nucleus
▪ GVA and SVA
• It is the nerve of the third pharyngeal arch.
Embryology of • The glossopharyngeal nerve arises from the upper part of the lateral aspect of
CN IX? the medulla between the olive and the inferior cerebellar peduncle.
• It leaves the skull by way of the jugular foramen.
• Two ganglia are located on the nerve:
o The superior ganglion which lies within the jugular foramen.
o The inferior ganglion which lies just below the jugular foramen.
• The Glossopharyngeal nerve carries 5 different types of fibers:
Modalities of o SVE
CN IX and their ▪ Innervates the stylopharyngeus
functions?
o GVE
▪ A parasympathetic component that innervates the parotid gland.
o GVA
▪ Innervates the baroreceptors of the carotid sinus and
chemoreceptors of the carotid body.
o SVA
▪ Innervates the taste buds of the posterior third of the tongue.
o GSA
▪ Pain, temperature, and touch from the auditory tube, internal
surface of the tympanic membrane, upper pharynx (soft palate),
tonsil and the posterior one-third of the tongue.
The Branchial Motor Fibers (SVE):

Course of SVE
component of • The motor neurons for these fibers are located in the nucleus ambiguus.
CN IX?
• Axons from these neurons are carried within the glossopharyngeal nerve to
innervate the stylopharyngeus muscle.
o The stylopharyngeus muscle is the only muscle innervated by the
glossopharyngeal nerve.

10. Cranial Nerves
General Visceral Efferent (GVE) Fibers:

Course of GVE
component of • Preganglionic neurons of the parasympathetic motor fibers are located in the
CN IX?
inferior salivatory nucleus.
• Axons from the inferior salivatory nucleus join the other components of the
glossopharyngeal nerve and exit with them through the jugular foramen.
• These preganglionic parasympathetic fibers leave the glossopharyngeal nerve at
the level of its inferior ganglion as the tympanic nerve of Jacobson.
• The tympanic nerve reaches the tympanic cavity where it forms the tympanic
plexus which lies on the medial wall of middle ear.
• From the plexus emerges the lesser petrosal nerve which finally leaves the
cranial cavity through for foramen ovale to synapse in the otic ganglion.
• From the otic ganglion, the postganglionic parasympathetic fibers jump to the
auriculotemporal nerve to supply secretomotor fibers to the parotid gland.
General Visceral Afferent (GVA) Fibers:

Course of GVA
component of • Chemoreceptors from the carotid body monitor oxygen levels in circulating
CN IX?
• Baroreceptors in the carotid sinus monitor arterial blood pressure.
• These sensations are relayed in the carotid sinus nerve towards the inferior
ganglion where the nerve cell bodies are located.
• From these neurons, central processes are carried within the glossopharyngeal
nerve to reach the nucleus solitarius.
Special Visceral Afferent (SVA) Fibers:

Course of SVA
component of • The sensation from the posterior one third of the tongue is carried by special
CN IX?
sensory processes towards neurons in the inferior glossopharyngeal ganglion.
• Central processes from these neurons are carried further within the
glossopharyngeal nerve to reach the nucleus solitarius.
General Somatic Afferent (GSA) Fibers:

Course of GSA
component of
CN IX?
• General sensory axons for pain, touch and temperature from the mucous
membrane of the pharynx, tonsil, soft palate and the posterior one third of the
tongue.
• Have their nerve cell bodies in the superior glossopharyngeal ganglion.
• The tympanic nerve is also carrying these types of fibers from the middle ear,
inner surface of the tympanic membrane and part of external ear.
• Central processes from the neurons of superior glossopharyngeal ganglion
travel further in the Glossopharyngeal nerve to synapse in the spinal nucleus of
the trigeminal nerve.

10. Cranial Nerves
• Clinical Correlate: CN IX Lesion

CN IX lesion? o Loss of the gag (pharyngeal) reflex (interruption of the afferent limb).
o Hypersensitive carotid sinus reflex (syncope).
o Loss of general sensation in the pharynx, tonsils, fauces, and back of
the tongue.
o Loss of taste from the posterior one-third of the tongue.
o Glossopharyngeal neuralgia, which is characterized by severe stabbing
pain in the root of the tongue.

10. Cranial Nerves
The Vagus Nerve (CN X)

• The vagus nerve is the 10th cranial nerve and is a mixed nerve.
• It is the nerve of the fourth (superior laryngeal) and sixth (recurrent laryngeal)
Embryology of pharyngeal arches.
CN X?
• Its field of distribution extends beyond the head and neck—to the thorax and
abdomen.
Components/Modalities:
Modalities of
CN X and their • GSA:
functions?
o Innervates:
▪ The infratentorial dura
▪ Posterior surface of the external ear
▪ External auditory meatus
▪ Tympanic membrane
o Has cell bodies in the superior (jugular) ganglion.
o Projects its central processes to the spinal trigeminal tract and nucleus.
• GVA:
o Innervates the mucous membranes of the pharynx, larynx, esophagus,
trachea, and thoracic and abdominal viscera (to the mid-transverse
colon).
o Has cell bodies in the inferior (nodose) ganglion.
o Projects its central processes to the solitary tract and nucleus.
• SVA:
o Innervates the taste buds over the epiglottis and soft palate.
o Has cell bodies in the inferior (nodose) ganglion.
o Projects its central processes to the solitary tract and nucleus.
• SVE:
o Provides motor innervation to the majority of the muscles of the:
▪ Pharynx (notable exception: stylopharyngeus, innervated by CN
IX)
▪ Soft palate (notable exception: tensor veli palatini, innervated
by CN V3)
▪ Larynx
▪ Also innervates the palatoglossus of the tongue.
o Arises from the nucleus ambiguus in the lateral medulla.
o Provides the efferent limb of the gag reflex.
• GVE:
o Innervates the viscera of the neck and the thoracic and abdominal
cavities as far as the mid-transverse colon.

10. Cranial Nerves
o Consists of preganglionic parasympathetic neurons in the dorsal motor

nucleus of the vagus, which project to the intramural ganglia of the
viscera.
Nuclei:
Nuclei of CN X?
• Dorsal nucleus
o Sends parasympathetic fibers to the intestines
• Nucleus ambiguus
o Sends efferent motor fibres
o Also sends parasympathetic fibers to the heart.
• Solitary nucleus
o Receives special gustatory afferent from the tongue
o Receives visceral afferent fibers from organs
• Spinal trigeminal nucleus
o Receives general sensory afferent fibers
Anatomical Course:
Anatomical
course of CN X? • The vagus nerve arises from the lateral aspect of the medulla between the olive
and inferior cerebellar peduncle.
• It exits the skull through the jugular foramen.
• Its two sensory ganglia, the superior (jugular) ganglion and the inferior
(nodose) ganglion, are located on the nerve.
• As the vagus continues below the inferior ganglion, it is joined by the motor
fibers from the nucleus ambiguus that have travelled briefly with the cranial
root of accessory nerve.
• The vagus has four related nuclei located in the medulla:
o The nucleus ambiguus
o The dorsal nucleus of vagus
o The nucleus solitarius
• Its meningeal branch arises from the superior ganglion
o Takes a recurrent course, and enters the cranial cavity through the
jugular foramen
o Supplies the dura mater of the posterior cranial fossa.
• The Auricular branch or the Arnold’s nerve arises from the superior ganglion
o Enters the mastoid canaliculus on the lateral wall of the jugular fossa,
and emerges through the tympanomastoid fissure just behind the
external auditory meatus
o Supplies the skin on the back of the meatus and adjoining part of the
auricle, the floor of the meatus and the tympanic membrane.

10. Cranial Nerves
• The pharyngeal branch

o Is the principal motor nerve of the pharynx
o Traverses the inferior ganglion
o Enters the pharynx at the upper border of the middle constrictor
o It then breaks up into the pharyngeal plexus to supply all of the muscles
of the pharynx and soft palate
▪ EXCEPT for the stylopharyngeus and tensor veli palatini.
• The superior laryngeal nerve arises from the inferior ganglion or just below it
o Passes downward and forward to reach the middle constrictor where it
divides into internal and external laryngeal nerves.
o The internal laryngeal nerve is a sensory nerve
▪ Pierces the thyrohyoid membrane
▪ Supplies the mucous membrane of the: pharynx, epiglottis,
vallecula, and the posterior most part of the tongue and also the
mucous membrane of the larynx above the vocal cords.
o The external laryngeal nerve is motor
▪ Runs downward to supply the cricothyroid muscle and part of
the inferior constrictor.
• There are two cervical cardiac branches from the vagus nerve.
o The superior cardiac branch
o The inferior cardiac branch
o They enter the thorax through the thoracic inlet and carry preganglionic
parasympathetic cardio-inhibitory fibres to the heart.
• The recurrent laryngeal nerve
o There are two recurrent laryngeal nerves, right and left and are not
symmetrical
▪ The left nerve loops under the aortic arch
▪ The right nerve loops under the right subclavian artery
o It then travels upwards to reach the tracheoesophageal groove.
o Each recurrent laryngeal nerve passes deep to the inferior constrictor
muscle to enter the laryngeal cavity just posterior to the cricothyroid
joint.
o The recurrent laryngeal nerve is a mixed nerve
▪ Provides motor innervation to all the intrinsic muscles of the
larynx EXCEPT the cricothyroid (supplied by the external
laryngeal nerve)
▪ Sensory innervations to the mucous membrane of laryngeal
cavity bellow the vocal cords.

10. Cranial Nerves
Overview of the Major Branches of the Vagus Nerve

10. Cranial Nerves
• Clinical Correlate: Lesions of CN X

CN X lesion? o Ipsilateral paralysis of the soft palate, pharynx, and larynx
▪ Leads to dysphonia (hoarseness), dyspnea, dysarthria, and
dysphagia
▪ Uvula deviation (towards the opposite side of the lesion)
o Loss of the gag (palatal) reflex (efferent limb)
o Anesthesia of the pharynx and larynx, leading to unilateral loss of the
cough reflex.
o Aortic aneurysms and tumors of the neck and thorax frequently
compress the vagal nerve.

10. Cranial Nerves
The Accessory Nerve (CN XI)

• The accessory nerve is the 11th cranial nerve and is purely motor.
Modalities of o Contains SVE fibers.
CN XI and their o Mediates head and shoulder movement. (Additionally, the cranial root
functions?
has SVE distribution with the vagus to the muscles supplied by the
vagus)
• It has two roots: a cranial root and a spinal root.
Anatomical • Fibers of the spinal root of accessory nerve originate in the spinal accessory
course of CN nucleus
XI?
o It is a cluster of neurons located in the lateral aspect of the anterior horn
of the spinal cord, stretching from C1 to C5 spinal levels.
o Axons from these motor neurons emerge from the lateral part of spinal
cord between the anterior root and posterior root of spinal nerve.
o The fibers then ascend through vertebral canal to enter the skull by way
of the foramen magnum as the spinal root of the accessory nerve.
• The motor neurons of the cranial root of accessory nerve are located in the
nucleus ambiguus.
o The axons of these neurons emerge from the medulla just posterior to
the olive.
• Both cranial and spinal roots of accessory nerve unite with each other to leave
the skull by way of jugular foramen.
• Immediately after coming out of the cranial cavity, the two roots separate
again.
• The cranial root joins the vagus nerve just below its inferior ganglion
o It is distributed through the branches of the vagus to the muscles of the
palate (except for the tensor veli palati), muscles of pharynx (except for
the stylopharyngeus), and muscles of the larynx (basically all the muscles
that receive SVE innervation from the vagus).
o Note: According to KLM, the cranial root is now considered to be a part
of the vagus and not the accessory nerve.
• The spinal root of accessory nerve after detaching from the cranial part of
accessory nerve continues alone and heads backwards and downwards to
supply two muscles in the neck: The sternocleidomastoid muscle and the
trapezius muscle.
o The spinal root of accessory nerve after detaching from the the cranial
part is called the spinal accessory nerve.

10. Cranial Nerves
• Clinical Correlate: CN XI Lesion

CN XI lesion? o Paralysis of the sternocleidomastoid
▪ Results in difficulty in turning the head to the side opposite the
lesion.
o Paralysis of the trapezius
▪ results in a shoulder droop.
▪ results in the inability to shrug the ipsilateral shoulder.

10. Cranial Nerves
The Hypoglossal Nerve (CN XII)

• Hypoglossal nerve is the 12th cranial nerve and is purely motor.
Modalities of o A pure GSE nerve.
CN XII and their
functions?
o Mediates tongue movement.
• Its fibers arise from the hypoglossal nucleus located in the medulla.
• The hypoglossal nerve arises on the ventral aspect of the medulla between the
pyramid and the olive.
Anatomical
o It is related at this level with the vertebral artery which is located
course of CN
XII? anterior to the nerve.
• Further on the hypoglossal nerve exits the cranial cavity via the hypoglossal
canal.
• At the level of angle of mandible, the nerve curves forward crossing in front of
the internal and external carotid arteries, and the loop of the 1st part of the
lingual artery to reach the posterior margin of the hyoglossal muscle.
• Now it runs on the superficial surface of the hypoglossus.
• It then gives off branches to:
o Three of the four extrinsic muscles of the tongue:
▪ Hyoglossus muscle
▪ Styloglossus muscle and
▪ Genioglossus muscle
o It also gives off branches to all the intrinsic muscles of the tongue.
• (The aforementioned are the branches of the hypoglossal nerve proper).
• Additionally, the hypoglossal nerve carries also fibers from the C1 spinal nerve.
o These fibers travel along the hypoglossal nerve to supply the geniohyoid
muscle and the thyrohyoid muscle.
o Some fibers from the C1 spinal nerve have a recurrent course traveling
along the hypoglossal nerve to enter the cranial cavity via the
hypoglossal canal as the meningeal branch
▪ Supplies the dura mater of the posterior cranial fossa.
• Lastly, as the hypoglossal nerve crosses the internal carotid artery it gives off
the superior root of ansa cervicalis.
• Clinical Correlate: Lesions of CN XII
CN XII lesion? o Hemiparalysis of the tongue results.
o The tongue points toward the weak side due to the unopposed action
of the opposite genioglossus upon protrusion.

10. Cranial Nerves

10. Cranial Nerves
(Blank)

Chapter 11
The Neck
11. The Neck
Recommended Videos
Sam Webster:
• ‘Fascia of the neck (anatomy)’
o Runtime: 26:43
o (https://youtu.be/tNVDtpuLMns)

• ‘Cervical fascia’
o Runtime: 16:39
o (https://youtu.be/iGx2kMUf178)
• ‘Muscles of the neck’
o Runtime: 12:37
o (https://youtu.be/IxInfkIfn0E)
• ‘Triangles of the Neck’
o Runtime: 11:08
o (https://youtu.be/IhGkSWyzfwo)
AnatomyZone:
• Guide recommended the entire playlist on the neck

11. The Neck
Cervical Fascia
• The cervical fascia consists of concentric layers of fascia that compartmentalize
structures in the neck.
• These fascial layers are defined as the superficial fascia and the deep fascia,
with sublayers within the deep fascia.
Superficial Fascia:
Superficial
fascia?
• The superficial cervical fascia is the subcutaneous layer of the skin in the neck.
• Contains the platysma muscle, cutaneous nerves from the cervical plexus, and
superficial vessels and lymph nodes.
Deep Fascia:
Deep fascia?
• The deep cervical fascia is deep to the superficial fascia.
• Contains muscles and viscera in compartments to enable structures to slide
over each other, and to serve as a conduit for neurovascular bundles.
• Forms the following sublayers:
o Deep investing fascia
o Pretracheal fascia
o Prevertebral fascia
o Carotid sheath
Deep Investing Fascia:

Deep investing
fascia? • Completely encircles the neck.
• Splits to enclose the sternocleidomastoid and trapezius muscles.
• Forms the roof of the anterior and posterior triangles of the neck.
Fig 2 – Transverse section of the neck, with the investing layer of fascia highlighted in blue.

11. The Neck
Pretracheal Fascia:
Pretracheal
fascia? • Forms a tubular sheath in the anterior part of the neck.
• Extends from the hyoid bone inferiorly into the thorax to blend with the fibrous
pericardium.
• Muscular part – encloses the infrahyoid muscles.
• Visceral part – encloses the:
o Thyroid gland
o Parathyroid glands
o Trachea
o Esophagus
• Buccopharyngeal fascia:
o The name of the posterior portion of the pretracheal fascia.
Fig 3 – Transverse section of the neck, showing the pretracheal fascia in red.
Prevertebral Fascia:
Prevertebral
fascia? • Forms a tubular sheath around the vertebral column.
• Forms the floor of the posterior triangle of the neck.
• Contents:
o Sympathetic trunk
o Phrenic nerve
o Brachial plexus
o Cervical vertebrae
o Prevertebral muscles (i.e., longus colli, longus capitis and scalene
muscles).
• Alar fascia:
o The anterior lamina of prevertebral fascia has two layers; the anterior
layer is referred to as alar fascia.
o Axillary sheath:
▪ The prevertebral fascia extends laterally as the axillary sheath,
which surrounds the axillary vessels and branchial plexus.

11. The Neck
Fig 4 – The carotid sheath and prevertebral fascia of the neck.
Carotid Sheath:
Carotid
sheath? • A tube of fascia that extends from the cranial base to the root of the neck.
• Formed by the investing, pretracheal, and prevertebral layers of fascia.
• Contents:
o Common and internal carotid arteries
o Internal jugular vein
o Vagus nerve
o Deep cervical lymph nodes
o Carotid sinus nerve
Retropharyngeal Space:
Retropharyng-
eal space? • Located between the buccopharyngeal and alar fascia
• Extends from the skull base to the upper thoracic vertebrae.
• It is a potential space where normally nothing fills it. However, an abscess can
spread easily in this location.
• Function: Permits superior and inferior movements of the larynx, pharynx, and
esophagus during swallowing relative to the cervical vertebrae.
Pharyngobasilar Fascia:
Pharyngobasil-
ar fascia? • Forms the submucosa of the pharynx and blends with the periosteum of the
base of the skull
• Lies internal to the muscular coat of the pharynx; these muscles are covered
externally by the buccopharyngeal fascia.

11. The Neck
• Clinical Correlate: Retropharyngeal Abscess

Retropharyng- o Abscesses within the retropharyngeal space may bulge anteriorly and
eal abscess?
compress the pharynx (swallowing compromised) and trachea
(breathing compromised) or spread inferiorly into the mediastinum.
• Clinical Correlate: Danger Space
Danger space
o A potential space located between the alar fascia (anterior lamina of
of the neck?
prevertebral fascia) and deep lamina of prevertebral fascia.
o This potential space extends from the skull base to the diaphragm.
▪ Provides a route for the spread of infection directly to the
thorax.

11. The Neck

11. The Neck
Muscles of the Neck

Suboccipital Muscles:
Occipital
muscles: • The suboccipital muscles are a group of four muscles situated underneath the
function and
innervation?
occipital bone.
• All the muscles in this group are innervated by the suboccipital nerve (posterior
ramus of C1).
• They collectively act to extend and rotate the head.
Fig 1 – The left occipital muscles, which lie underneath the deep muscles of the back.
Platysma Muscle:
Platysma
muscle:
• Located in the superficial cervical fascia.
function and
innervation? • Depresses the mandible and wrinkles the skin of neck.
• Is innervated by the cervical branch of the facial nerve (CN VII).
Fig 1 – The platysma muscle, located within the superficial cervical fascia.

11. The Neck
Sternocleidomastoid Muscle:
SCM: function
and • Located within the deep investing fascia.
innervation?
• Named according to its bony attachments (sternum, clavicle, and mastoid
process)
• Forms a primary border for the anterior and posterior cervical triangles.
• Actions:
o Singly: turns face toward opposite side
o Together: flexes the head, raises the thorax
• Innervated by the spinal accessory nerve (CN XI).
Trapezius Muscle:
Trapezius:
function and • Located within the deep investing fascia.
innervation?
• Elevates, retracts, depresses, and superiorly rotates the scapula.
• Innervated by the spinal accessory nerve (CN XI).
Prevertebral Muscles:
Prevertebral
muscles:
• The prevertebral muscles are located between the prevertebral fascia and the
names and
functions? cervical vertebrae.
• Longus colli and capitis muscles
o The longus colli and longus capitis muscles help stabilize the cervical
vertebrae and flex the neck.
• Scalene muscles
o anterior, middle, and posterior scalenes
o Elevate the ribs during breathing and laterally flex the neck.
o The cervical and brachial plexuses exit the vertebral column between
the anterior and middle scalenes.

11. The Neck
Suprahyoid Muscles:
Suprahyoid
muscles:
• These muscles raise the hyoid bone during swallowing because the mandible is
names,
functions and stabilized.
innervation? • Digastric muscle:
o A two-bellied muscle attached to the mastoid process (posterior belly)
and mandible (anterior belly) and connected by a central tendon at the
hyoid bone.
o Because of the two bellies, the digastric muscle can raise the hyoid bone
or open the mouth.
o Originates embryologically from both the first and second pharyngeal
arches and as such has dual innervation
▪ Anterior belly from CN V-3
▪ Posterior belly from CN VII

11. The Neck
• Stylohyoid muscle:
o Elevates the hyoid bone and is innervated by CN VII.
• Mylohyoid muscle:
o Forms the floor of the mouth
o Elevates the floor of the mouth
o Innervated by CN V-3
• Geniohyoid muscle:
o Elevates the hyoid bone and is innervated by the cervical plexus (C1 via
the hypoglossal nerve)
Fig 1 – Anterior view of the neck with the suprahyoid muscles highlighted.
Fig 2 – Lateral view of the neck with three of the suprahyoid muscles highlighted (digastric, mylohyoid and
stylohyoid)
Infrahyoid Muscles:
Infrahyoid
muscles:
• Composed of four pairs of muscles inferior to the hyoid bone (hence the name).
names,
functions and • Each muscle is innervated by the ansa cervicalis from the cervical plexus
innervation? (ventral rami C1-C3).
• Collectively, these muscles function to depress the hyoid bone and larynx
during swallowing and speaking.

11. The Neck
• They receive their names according to their attachments:

o Sternothyroid muscle. Sternum and thyroid cartilage.
o Sternohyoid muscle. Sternum and hyoid bone.
o Thyrohyoid muscle. Thyroid cartilage and hyoid bone.
o Omohyoid msucle. Superior border of the scapula (“omo” for shoulder)
and hyoid bone.
Fig 1 – Lateral view of the infrahyoid muscles of the neck.
Fig 2 – Anterior view of the infrahyoid muscles of the neck.

11. The Neck

11. The Neck
• Clinical Correlate: Torticollis

Torticollis? o Torticollis (wryneck) is a spasmodic contraction or shortening of the
neck muscles.
o Produces twisting of the neck, with the chin pointing upward and to the
opposite side.
o It is due to injury to the sternocleidomastoid muscle or avulsion of the
accessory nerve at the time of birth and unilateral fibrosis in the
muscle, which cannot lengthen with the growing neck (congenital
torticollis).
• Clinical Correlate: Eagle Syndrome

Eagle o Eagle syndrome (styloid, stylohyoid or styoloid-stylohyoid syndrome) is
syndrome?
an elongation of the styloid process or excessive calcification of the
styloid process and/or stylohyoid ligament.
o Causes neck, throat or facial pain and dysphagia (difficulty in
swallowing).
▪ The pain may occur because of compression of the
glossopharyngeal nerve, which winds around the styloid process
or stylohyoid ligament as it descends to supply the tongue,
pharynx, and neck.
▪ The pain may also be caused by pressure on the internal and
external carotid arteries by a deviated and elongated styloid
process.
o Treatment is styloidectomy.

11. The Neck
Triangles of the Neck

Anterior Triangle of the Neck:
Anterior
triangle of the
neck: borders?
• The anterior triangle is situated at the front of the neck. It is bounded by:
o Superiorly – inferior border of the mandible (jawbone).
o Laterally – anterior border of the sternocleidomastoid.
o Medially – sagittal line down the midline of the neck.
o Investing fascia covers the roof of the triangle
o Visceral fascia covers the floor.
• It can be subdivided further into four triangles
• The contents of the anterior triangle include muscles, nerves, arteries, veins
Anterior and lymph nodes.
triangle of the • The common carotid artery bifurcates within the triangle into the external and
neck: contents?
internal carotid branches.
• The internal jugular vein can also be found within this area.
• The cranial nerves in the anterior triangle are the facial [VII], glossopharyngeal
[IX], vagus [X], accessory [XI], and hypoglossal [XII] nerves.
• Contents:
o Muscles: thyrohyoid, sternothyroid, sternohyoid muscles
o Organs: thyroid gland, parathyroid glands, larynx, trachea,
esophagus, submandibular gland, caudal part of the parotid gland
o Arteries: superior and inferior thyroid, common carotid, external
carotid, internal carotid artery (and sinus), facial, submental, lingual
arteries
o Veins: anterior jugular veins, internal jugular, common facial, lingual,
superior thyroid, middle thyroid veins, facial vein, submental vein,
lingual veins
o Nerves: vagus nerve (CN X), hypoglossal nerve (CN XII), part
of sympathetic trunk, mylohyoid nerve
Fig 1.0 – Borders of the anterior triangle of the neck.

11. The Neck
Fig 2 – The extracranial anatomical course of the hypoglossal nerve, through the anterior triangle of the
neck.

11. The Neck
Carotid Triangle:
• Subdivision of the anterior triangle.

• The carotid triangle of the neck has the following boundaries:
Carotid o Superior – posterior belly of the digastric muscle.
triangle: o Lateral – medial border of the sternocleidomastoid muscle.
boundaries?
o Inferior – superior belly of the omohyoid muscle.
• The main contents of the carotid triangle are:
o The common carotid artery (which bifurcates within the carotid triangle
into the external and internal carotid arteries)
o The internal jugular vein
o The hypoglossal and vagus nerves.
• Contents:
Carotid o Tributaries to common facial vein
triangle: o Cervical branch of facial nerve [VII]
contents?
o Common carotid artery; external and internal carotid arteries
o Superior thyroid; ascending pharyngeal; lingual, facial, and occipital
arteries (branches of the external carotid)
o Internal jugular vein
o Vagus [X]
o Accessory [XI]
o Hypoglossal [XII]
o Superior and inferior roots of ansa cervicalis
o Transverse cervical nerve
Fig 3 – Carotid triangle of the neck

11. The Neck
Submental Triangle:
• Division of the anterior triangle.

• Borders:
Submental o Inferiorly – hyoid bone.
triangle: o Medially – midline of the neck.
boundaries?
o Laterally – anterior belly of the digastric.
o The floor of the submental triangle is formed by the mylohyoid muscle.

11. The Neck
• Contents:
Submental o Submental lymph nodes
triangle: o Tributaries forming the anterior jugular vein
contents?
Fig 4 – The submental triangle of the neck.
Submandibular (Digastric) Triangle:

• The boundaries of the submandibular triangle are:
Submandibular o Superiorly – body of the mandible.
triangle: o Anteriorly – anterior belly of the digastric muscle.
boundaries?
o Posteriorly – posterior belly of the digastric muscle.
o Floor – Formed by mylohyoid (anteriorly), hyoglossus, and small part of
the middle constrictor (posteriorly).
o Roof – formed by investing layer of deep cervical fascia.
• It contains the submandibular gland (salivary), and lymph nodes.
• The facial artery and vein also pass through this area.
• Contents:
Submandibular o Submandibular gland
triangle: o Submandibular lymph nodes
contents? o Hypoglossal nerve [XII]
o Mylohyoid nerve
o Facial artery and vein

11. The Neck
Fig 5 – Lateral view of the neck, showing the submandibular triangle

11. The Neck
Muscular (Omotracheal) Triangle:

• It is a slightly ‘dubious’ triangle, in reality having four boundaries.
• Boundaries:
Muscular o Superiorly – hyoid bone.
triangle: o Medially – imaginary midline of the neck.
boundaries?
o Supero-laterally – superior belly of the omohyoid muscle.
o Infero-laterally – inferior portion of the sternocleidomastoid muscle.
• The muscular triangle contains some muscles and organs –
the infrahyoid muscles, the pharynx, and the thyroid, parathyroid glands.
• Contents:
Muscular o Sternohyoid, omohyoid, sternohyoid, and thyrohyoid muscles
triangle: (infrahyoid muscles)
contents?
o Thyroid and parathyroid glands
o Pharynx
Fig 6 – Muscular triangle of the neck.
Posterior Triangle of the Neck:
• The posterior triangle of the neck is an anatomical area located in the lateral
aspect of the neck.
• Its boundaries are as follows:
Posterior o Anterior – posterior border of the sternocleidomastoid.
triangle: o Posterior – anterior border of the trapezius muscle.
boundaries?
o Inferior – middle 1/3 of the clavicle.
o The posterior triangle of the neck is covered by the investing layer of
fascia.
o The floor is formed by the prevertebral fascia.

11. The Neck
• Contents:
Posterior o Vessels:
triangle: ▪ The third part of the subclavian artery
contents?
▪ Suprascapular and transverse cervical branches of the
thyrocervical trunk
▪ External jugular vein
▪ Lymph nodes
o Nerves:
▪ Accessory nerve (CN XI)
▪ The trunks of the brachial plexus
▪ Fibers of the cervical plexus
o A number of vertebral muscles (covered by prevertebral fascia) form
the floor of the posterior triangle:
▪ Splenius capitis
▪ Levator scapulae
▪ Anterior, middle and posterior scalenes
• The omohyoid muscle splits the posterior triangle of the neck into two:
o The larger, superior part is termed the occipital triangle.
o The inferior triangle is known as the subclavian triangle. It is also known
as the omoclavicular or supraclavicular triangle.
Fig 1 – The borders and floor of the posterior triangle of the neck.
Figure 2 – Nerves within the posterior triangle of the neck.

11. The Neck
Fig 3 – The posterior triangle is divided by the inferior belly of the omohyoid into the occipital and
subclavian triangles.

11. The Neck
Occipital Triangle:
• Division of the posterior triangle.

Occipital • Boundaries:
triangle:
boundaries?
o Anterior - posterior margin of sternocleidomastoid muscle
o Posterior - anterior margin of trapezius muscle
o Inferior - inferior belly of omohyoid muscle
• Contents:
Occipital o Part of external jugular vein
triangle: o Posterior branches of cervical plexus of nerves
contents? o Spinal accessory nerve (CN XI)
o Trunks of brachial plexus
▪ Note: almost every other source included the trunks of the
brachial plexus in the omoclavicular triangle, but since the faculty
LOVE KLM, and KLM said occipital triangle, I just went with that.
o Cervicodorsal trunk
o Cervical lymph node
Supraclavicular/Subclavian/Omoclavicular Triangle:
• Division of the posterior triangle.

Subclavian • Boundaries:
triangle:
o Superior - inferior belly of omohyoid muscle
boundaries?
o Anterior - posterior edge of sternocleidomastoid muscle
o Inferior – clavicle
• Contents:
Subclavian o Subclavian artery (third part)
triangle: o Part of subclavian vein (sometimes)
contents?
o Suprascapular artery
o Supraclavicular lymph nodes

Chapter 12
The Pharynx
12. The Pharynx
Recommended Videos
Dr. Umar Azizov:
• ‘The Pharynx’
o Runtime: 15:24
o (https://youtu.be/_aqiaY1Uc70)

12. The Pharynx
Subdivisions of the Pharynx

• The pharynx is a muscular tube that connects the oral and nasal cavity to
the larynx and esophagus.
• It begins at the base of the skull and ends at the inferior border of the cricoid
cartilage (C6).
• The pharynx is comprised of three parts (superior to inferior):
o Nasopharynx
o Oropharynx
o Laryngopharynx
Nasopharynx:
Structure of the
nasopharynx?
• The nasopharynx is posterior to the nasal cavity and superior to the soft
palate.
• During swallowing, the soft palate elevates and the pharyngeal wall contracts
anteriorly to form a seal, preventing food from refluxing into the nasopharynx
and nose.
• Choanae: Arched openings that enable communication between the nasal
cavity and nasopharynx.
• Auditory tubes (Pharyngotympanic/Eustachian tubes): Open into the lateral
walls of the nasopharynx and communicate with the middle ear.
o The auditory tubes enable middle ear pressure to equalize with
atmospheric pressure.
• Pharyngeal tonsil (adenoids): Lymphatic tissue in the posterosuperior
nasopharynx; traps and destroys pathogens that enter from the air.
Oropharynx:
Structure of the
oropharynx? • The oropharynx is the region of the pharynx located between the soft palate
and the epiglottis, and communicates with the oral cavity.
• Palatoglossal arches: Arches formed by the palatoglossal muscles
o Mark the boundary between the oral cavity anteriorly and the
oropharynx posteriorly.
• Palatine tonsils
Laryngopharynx:
Structure of the
laryngopharynx
?
• The laryngopharynx extends between the epiglottis and the cricoid cartilage,
with the larynx forming the anterior wall.
• The laryngopharynx serves as a common passageway for food and air.

12. The Pharynx
• The laryngopharynx communicates:

o Anteriorly with the larynx, where air is conducted in and out of the lungs
during breathing.
o Posteriorly with the esophagus, where food and fluids to the stomach
pass.
• Contains the piriform recess, one on each side of the opening of the larynx, in
which swallowed foreign bodies may be lodged.

12. The Pharynx

12. The Pharynx
Muscles of the Pharynx

• There are two main groups of pharyngeal muscles; longitudinal and circular.
• The muscles of the pharynx are mostly innervated by the vagus nerve.
o The only exception being the stylopharyngeus (glossopharyngeal
nerve).
Circular Muscles:
Circular
muscles of the
• There are three circular pharyngeal constrictor muscles; the superior, middle,
pharynx:
names, and inferior pharyngeal constrictors.
functions and • They are stacked like glasses, which form an incomplete muscular circle as they
innervation? attach anteriorly to structures in the neck.
• The circular muscles contract sequentially from superior to inferior to constrict
the lumen and propel the bolus of food inferiorly into the oesophagus.
• All pharyngeal constrictors are innervated by the vagus nerve (CN X).
• The inferior pharyngeal constrictor is split into two parts; the thyropharyngeus
and the cricopharyngeus.
o This area between the two is a weak area in the mucosa, and a
diverticulum can form here.

12. The Pharynx
Fig 4 – Lateral view of the deep structures of the pharynx. Visible are the circular muscles of the pharynx,
and the stylopharyngeus.
Fig 3 – Pharyngeal diverticulum.

12. The Pharynx
Longitudinal Muscles:
Longitudinal
muscles of the • The longitudinal muscles are the:
pharynx:
names,
o Stylopharyngeus
functions and o Palatopharyngeus
innervation? o Salpingopharyngeus
• They act to shorten and widen the pharynx, and elevate the larynx during
swallowing.
• The names of these muscles identify their origins and insertions.
• The salpingopharyegeus muscle attaches to the auditory tube and the
pharyngeal wall.
o It widens the opening of the pharyngotympanic tube during swallowing,
which equalizes the pressure between the auditory canal and the
nasopharynx.
• The palatopharyngeus and salpingopharyngeus are innervated by CN X,
whereas the stylopharyngeus is innervated by CN IX.
o The stylopharyngeus is the only muscle derived from the third
pharyngeal arch.

12. The Pharynx
Fig 5 – Posterior view of the pharynx. The pharynx has been split down the midline and opened, to show
the longitudinal muscles.
Pharyngeal Plexus:
Pharyngeal
plexus?
• Pharyngeal nerves from CN IX and X and a small contribution from CN V-2 form
the pharyngeal plexus.
• The plexus lies along the middle pharyngeal constrictor muscle.
• It is responsible for sensory and motor innervation.
Swallowing Action:
Swallowing
action? • The tongue pushes the bolus of food back toward the oropharynx.
• The palatoglossus and palatopharyngeus muscles contract to squeeze the
bolus backward into the oropharynx.
o The tensor veli palatini and levator veli palatini muscles elevate and
tense the soft palate to close the entrance into the nasopharynx.
• The palatopharyngeus, stylopharyngeus, and salpingopharyngeus muscles
elevate the walls of the pharynx in preparation to receive the food.
o The suprahyoid muscles elevate the hyoid bone and the larynx to close
the opening into the larynx, thus preventing the food from entering the
respiratory passageways.
• The sequential contraction of the superior, middle, and inferior pharyngeal
constrictor muscles moves the food through the oropharynx and the
laryngopharynx into the esophagus, where the bolus of food is propelled via
peristalsis.

12. The Pharynx

Chapter 13
The Larynx
13. The Larynx
Recommended Videos
Sam Webster:
• ‘Larynx anatomy’
o Runtime: 22:48
o (https://youtu.be/mtqpyzS48zA)
AnatomyZone:
• ‘Larynx - Cartilages - 3D Anatomy Tutorial’
o Runtime: 12:20
o (https://youtu.be/Z3S2dD9BrSY)
• ‘Larynx - Ligaments, Membranes, Vocal Cords - 3D Anatomy Tutorial’
o Runtime: 13:14
o (https://youtu.be/jqTKSorDRJo)
• ‘Mucosa of the Larynx and Vocal Cords - 3D Anatomy Tutorial’
o Runtime: 15:04
o (https://youtu.be/fBHr1RjqLHA)
• ‘Muscles of the Larynx - Part 1 - 3D Anatomy Tutorial’
o Runtime: 8:28
o (https://youtu.be/lqeDLsP1ISE)
• ‘Muscles of the Larynx - Part 2 - 3D Anatomy Tutorial’
o Runtime: 10:44
o (https://youtu.be/GEMquo7qxpg)

13. The Larynx
Overview of the Larynx

• The larynx (voice box) is an organ located in the anterior neck.
• It is a component of the respiratory tract, and has several important functions,
including phonation, the cough reflex, and protection of the lower respiratory
tract.
• The structure of the larynx is primarily cartilaginous, and is held together by a
series of ligaments and membranes.
• The larynx is located in the anterior compartment of the neck, suspended from
Anatomical the hyoid bone.
location of the
• It spans between C3 and C6.
larynx?
• It is continuous inferiorly with the trachea, and opens superiorly into the
laryngeal part of the pharynx.
• The larynx is formed by a cartilaginous skeleton, which is held together
by ligaments and membranes.
• The interior surface of the larynx is lined by pseudostratified ciliated columnar
epithelium.
o An important exception to this is the true vocal cords, which are lined by
a stratified squamous epithelium.

13. The Larynx
Laryngeal Cartilages
• There are nine cartilages located within the larynx; three unpaired, and six
Cartilages of paired. They form the laryngeal skeleton.
the larynx? o The three unpaired cartilages are the epiglottis, thyroid and cricoid
cartilages.
o The three paired cartilages are the arytenoid, corniculate and
cuneiform cartilages.
Thyroid Cartilage:
• The thyroid cartilage is a large, prominent structure which is easily visible in

adult males.
• It is composed of two sheets (laminae), which join anteriorly to form
the laryngeal prominence (Adam’s apple).
• The posterior border of each sheet project superiorly and inferiorly to form
the superior and inferior horns (also known as cornu).
o The superior horns are connected to the hyoid bone via the lateral
thyrohyoid ligament.
o The inferior horns articulate with the cricoid cartilage.
Cricoid Cartilage:
• The cricoid cartilage is a complete ring of hyaline cartilage.

o Consisting of a broad sheet posteriorly and a much narrower arch
anteriorly (said to resemble a signet ring in shape).
• It articulates with the paired arytenoid cartilages posteriorly, as well as
providing an attachment for the inferior horns of the thyroid cartilage.

13. The Larynx
Epiglottis:
• The epiglottis is a leaf shaped plate of elastic cartilage which marks the
entrance to the larynx.
• Its ‘stalk’ is attached to the back of the anterior aspect of the thyroid cartilage.

13. The Larynx
Arytenoid Cartilages:
• The arytenoid cartilages are pyramidal shaped structures that sit on

the cricoid cartilage.
• They consist of an apex, base, three sides and two processes, and provides an
attachment point for various key structures in the larynx:
o Apex – articulates with the corniculate cartilage.
o Base – articulates with the superior border of the cricoid cartilage.
o Vocal process – provides attachment for the vocal ligament.
o Muscular process – provides attachment for the posterior and lateral
cricoarytenoid muscles.
Corniculate Cartilages:
• They articulate with the apices of the arytenoid cartilages.
Cuneiform Cartilages:
• Are located within the aryepiglottic folds.

13. The Larynx
Laryngeal Ligaments and Folds

• The extrinsic ligaments act to attach the components of the larynx to external
structures (such as the hyoid and the cricoid cartilage).
• The intrinsic ligaments are responsible for holding the cartilages of the larynx
together as one functional unit internally.
Extrinsic Ligaments:
Extrinsic
ligaments of
• Thyrohyoid membrane – Spans between the superior aspect of the thyroid
the larynx and
their structure? cartilage and the hyoid bone.
o It is pierced laterally by the superior laryngeal vessels and internal
laryngeal nerve (branch of the superior laryngeal nerve).
o Median thyrohyoid ligament – Anteromedial thickening of the
membrane.
o Lateral thyrohyoid ligaments – Posterolateral thickenings of the
membrane.
• Hyo-epiglottic ligament – Connects the hyoid bone to the anterior aspect of the
epiglottis.
• Cricotracheal ligament – Connects the cricoid cartilage to the trachea.
• Median cricothyroid ligament – Anteromedial thickening of the cricothyroid
ligament (also known as the cricovocal membrane), connecting the thyroid and
cricoid cartilages.

13. The Larynx
Fig 1 – Some of the major laryngeal membranes and ligaments. Note that the upper free edge of the
cricothyroid ligament is not demonstrated in this image.
Fig 2 – The external ligaments of the larynx.
Intrinsic Ligaments:
• The quadrangular membrane and conus elasticus are the superior and inferior
parts of the submucosal fibro-elastic membrane of the larynx.
• Conus Elasticus (Cricovocal Membrane)
Structure of the o Attached to the arch of cricoid cartilage and extends superiorly to end in
cricovocal a free upper margin within the space enclosed by the thyroid cartilage.
ligament? o On each side, this upper free margin attaches:
▪ Anteriorly to the thyroid cartilage
▪ Posteriorly to the vocal processes of the arytenoid cartilages.
o The free margin between these two points of attachment is thickened to
form the vocal ligament, which is under the vocal fold (true vocal cord)
of the larynx.
o The conus elasticus is also thickened anteriorly in the midline to form a
distinct median cricothyroid ligament.
13. The Larynx
• Quadrangular Membrane
Structure of the o The quadrangular membrane on each side runs between the lateral
quadrangular margin of the epiglottis and the anterolateral surface of the arytenoid
ligament?
cartilage on the same side.
o Each quadrangular membrane has a free upper margin, and a free lower
margin.
o The free superior margin of the quadrangular membrane forms the
aryepiglottic ligament, which is covered with mucosa to form the
aryepiglottic fold.
▪ The corniculate and cuneiform cartilages appear as small
nodules in the posterior part of the aryepiglottic folds.
o The free lower margin is thickened to form the vestibular ligament
under the vestibular fold (false vocal cord) of the larynx.
▪ The vestibular ligament is attached posteriorly to the arytenoid
cartilage and anteriorly to the thyroid cartilage.
o On each side, the vestibular ligament of the quadrangular membrane is
separated from the vocal ligament of the cricothyroid ligament below by
a gap.

13. The Larynx

13. The Larynx
Muscles of the Larynx

• The muscles of the larynx can be divided into two groups; the extrinsic muscles
and the intrinsic muscles.
o The extrinsic muscles act to elevate or depress the larynx during
swallowing.
o In contrast, the intrinsic muscles act to move the
individual components of the larynx – playing a vital role in breathing
and phonation.
Extrinsic Muscles:
• The extrinsic muscles act to move the larynx superiorly and inferiorly.
• They are comprised of the suprahyoid and infrahyoid groups, and the
stylopharyngeus (a muscle of the pharynx).
• The supra- and infrahyoid muscle groups attach to the hyoid bone. This, in turn,
is bound to the larynx by strong ligaments; allowing the whole of the larynx to
be moved as one unit.
• As a general rule, the suprahyoid muscles and the stylopharyngeus elevate the
larynx, whilst the infrahyoid muscles depress the larynx.
Intrinsic Muscles:
Intrinsic
muscles of the
• Their main functions are to:
larynx: names,
functions and o Open or close the laryngeal inlet
innervation? o Adduct and abduct the vocal cords
o Increase or decrease the tension of the vocal cords.
• All the intrinsic muscles of the larynx (except the cricothyroid) are innervated by
the inferior laryngeal nerve – the terminal branch of the recurrent laryngeal
nerve, itself a branch of the vagus nerve.
o The cricothyroid is innervated by the external branch of the superior
laryngeal nerve – again derived from the vagus nerve.
• Muscles that Open or Close the Laryngeal Inlet:
o Aryepiglotticus
▪ Closes the inlet of larynx.
o Thyroepiglotticus
▪ Opens the inlet of larynx.

13. The Larynx
• Muscles that Abduct or Adduct the Vocal Cords:

o Posterior cricoarytenoids
▪ Abduct the vocal cords.
▪ Are the sole abductors of the vocal folds
o Lateral cricoarytenoids
▪ Adduct the vocal cords.
o Transverse and Oblique arytenoid:
▪ Adduct the vocal cords.
• Muscles that Increase or Decrease the Tension of Vocal Cords:
o Cricothyroid
▪ Tenses the vocal cords.
o Vocalis
▪ Produce minute adjustments of the vocal ligaments, selectively
tensing and relaxing the anterior and posterior parts,
respectively, of the vocal folds during animated speech and
singing.
▪ Relaxes posterior vocal ligament while maintaining (or
increasing) tension of anterior part
o Thyroarytenoid
▪ Relaxes the vocal cords.

13. The Larynx

13. The Larynx
Variations in the Shape of the Rima Glottidis:
• The shape of the rima glottidis, the aperture between the vocal folds, varies
Rima glottidis
during normal according to the position of the vocal folds.
respiration? • During normal respiration:
o The laryngeal muscles are relaxed and the rima glottidis assumes a
narrow, slit-like position.
• During a deep inhalation:
Rima glottidis
during deep o The vocal ligaments are abducted by contraction of the posterior
inhalation? cricoarytenoid muscles, opening the rima glottidis widely into an
inverted kite shape.
• During phonation:
Rima glottidis o The arytenoid muscles adduct the arytenoid cartilages at the same time
during that the lateral cricoarytenoid muscles moderately adduct.
phonation?
o Air forced between the adducted vocal ligaments produces tone.
o Stronger contraction of the same muscles seals the rima glottidis
(Valsalva maneuver).
• During whispering:
Rima glottidis o The vocal ligaments are strongly adducted by the lateral cricoarytenoid
during
muscles, but the relaxed arytenoid muscles allow air to pass between
whispering?
the arytenoid cartilages (intercartilaginous part of rima glottidis), which
is modified into toneless speech.
o No tone is produced.
• Note:
o Tensing the vocal cords (cricothyroid) raises the pitch of the voice,
o Relaxing the vocal cords (thyroarytenoid) lowers the pitch.

13. The Larynx

13. The Larynx
Laryngeal Cavity
• The laryngeal cavity extends from the laryngeal inlet, through which it
communicates with the laryngopharynx, to the level of the inferior border of
the cricoid cartilage, where the laryngeal cavity is continuous with the cavity of
the trachea.
• Larygeal inlet:
o Its anterior border is formed by mucosa covering the superior margin of
the epiglottis.
o Its lateral borders are formed by mucosal folds (aryepiglottic folds),
which enclose the superior margins of the quadrangular membranes.
▪ Two tubercles on the more posterolateral margin on each side
mark the positions of the underlying cuneiform and corniculate
cartilages.
o Its posterior border in the midline is formed by a mucosal fold that
forms a depression (interarytenoid notch) between the two corniculate
tubercles.
• The laryngeal cavity includes the:
Divisions of the o Laryngeal vestibule: Between the laryngeal inlet and the vestibular
laryngeal
folds.
cavity?
o Middle part of the laryngeal cavity: the central cavity (airway) between
the vestibular and vocal folds.
▪ Laryngeal ventricle: recesses extending laterally from the middle
part of the laryngeal cavity between vestibular and vocal folds.
▪ The laryngeal saccule is a blind pocket opening into each
ventricle.
o Infraglottic cavity: the inferior cavity of the larynx between the vocal
folds and the inferior border of the cricoid cartilage, where it is
continuous with the lumen of the trachea.
• The vocal folds are the sharp-edged folds of mucous membrane overlying and
incorporating the vocal ligaments, vocalis muscles and the thyro-arytenoid
muscles.
o They are the source of the sounds (tone) that come from the larynx.
o The vocal folds also serve as the main inspiratory sphincter of the larynx
when they are tightly closed.
o The rima glottidis is the aperture between the vocal folds.
• The vestibular folds play little or no part in voice production; they are
protective in function.
o They consist of two thick folds of mucous membrane enclosing the
vestibular ligaments.
o The space between these ligaments is the rima vestibuli.
• Both the rima glottidis and the rima vestibuli can be opened and closed by
movement of the arytenoid cartilages and associated fibro-elastic membranes.
13. The Larynx
Structures
visible in
laryngoscopic
view?

13. The Larynx
Laryngoscopic
view during
different
actions?

13. The Larynx

13. The Larynx
Neurovascular Supply of the Larynx

Arterial Supply:
Arterial supply
of the larynx?
• The laryngeal arteries, branches of the superior and inferior thyroid arteries,
supply the larynx.
• The superior laryngeal artery accompanies the internal branch of the superior
laryngeal nerve through the thyrohyoid membrane.
o Branches to supply the internal surface of the larynx.
o Originates from the superior thyroid branch of the external carotid
artery.
• The cricothyroid artery, a small branch of the superior thyroid artery, supplies
the cricothyroid muscle.
• The inferior laryngeal artery, a branch of the inferior thyroid artery from the
thyrocervical trunk of the subclavian artery.
o Accompanies the inferior laryngeal nerve (terminal part of the
recurrent laryngeal nerve)
o Supplies the mucous membrane and muscles in the inferior part of the
larynx.

13. The Larynx
Venous Drainage:
Venous
drainage of the • The laryngeal veins accompany the laryngeal arteries.
larynx?
• The superior laryngeal vein usually joins the superior thyroid vein and through
it drains into the IJV.
• The inferior laryngeal vein joins the inferior thyroid vein, which empties into
the left brachiocephalic vein.
Lymphatic Drainage:
Lymphatic
drainage of the
• The laryngeal lymphatic vessels superior to the vocal folds accompany the
larynx?
superior laryngeal artery through the thyrohyoid membrane and drain into the
superior deep cervical lymph nodes.
• The lymphatic vessels inferior to the vocal folds drain into the pretracheal or
paratracheal lymph nodes, which drain into the inferior deep cervical lymph
nodes.

13. The Larynx
Innervation:
Innervation of
the larynx? • Superior laryngeal nerve
o Is a branch of the vagus nerve.
o Divides into the internal and external laryngeal branches.
o Internal laryngeal nerve:
▪ Innervates the mucous membrane superior to the vocal cord
and taste buds on the epiglottis.
▪ Is accompanied by the superior laryngeal artery and pierces the
thyrohyoid membrane.
o External laryngeal nerve:
▪ Innervates the cricothyroid and inferior pharyngeal constrictor
(cricopharyngeus part) muscles.
▪ Is accompanied by the superior thyroid artery.
• Recurrent laryngeal nerve
o Innervates all of the intrinsic muscles of the larynx except the
cricothyroid, which is innervated by the external laryngeal branch of the
superior laryngeal branch of the vagus nerve.
o Supplies sensory innervation below the vocal cord.
o Has a terminal portion within the larynx, superior to the lower border of
the cricoid cartilage called the inferior laryngeal nerve.
▪ Accompanies the inferior laryngeal artery.

13. The Larynx
• Clinical Correlate: Lesion of the Internal Laryngeal Nerve

Lesion of the o Results in loss of sensation in the larynx superior to the vocal cord and
internal loss of taste on the epiglottis.
laryngeal
nerve? • Clinical Correlate: Lesion of the External Laryngeal Nerve
o May occur during thyroidectomy because the nerve accompanies the
superior thyroid artery.
Lesion of the o It causes paralysis of the cricothyroid muscle, resulting in paralysis of
external the laryngeal muscles and thus inability to lengthen the vocal cord and
laryngeal loss of the tension of the vocal cord.
nerve?
▪ Such stresses to the vocal cord cause a fatigued voice and a weak
hoarseness.
• Clinical Correlate: Lesion of the Recurrent Laryngeal Nerve
Lesion of the o Can occur accidentally during thyroidectomy or cricothyrotomy or by
Recurrent
laryngeal aortic aneurysm.
nerve? o May cause respiratory obstruction, hoarseness, inability to speak, and
loss of sensation below the vocal cord.

Chapter Object Style Tool Used
Cover Neurovasculature of the head Abstract art DALL·E Mini

page and neck
1. Skull on a beach Ukiyo-e DALL·E Mini
2. Meninges of the brain Renaissance DALL·E Flow

painting
3. Muscles of the face Mughal painting DALL·E Flow
4. Skull from the side view Matisse oil painting DALL·E Flow
5. Oral cavity Roman mosaic DALL·E Flow
6. Nasal cavity Surrealist painting DALL·E Mini
7. Eye Andy Warhol DALL·E Flow
8. Ear van Gogh DALL·E Flow
9. Arteries of the head and neck Stained glass DALL·E Flow

mosaic
10. The brain vaporwave DALL·E Flow
11. Man with a long neck 16-bit retro art DALL·E Flow
12. The pharynx Cyberpunk art style DALL·E Flow
13. The larynx Soviet communist DALL·E Flow

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‫ن‬

3 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

My motivations for writing this book were as follows:

4 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

The way this book is structured to be used is as follows: watch whichever

5 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

“If the yield is low, let it go.”

6 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

8 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

The Skull and Cranial

The Noted Anatomist:

10 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Bones of the Skull

• The skull is divided into the braincase (neurocranium, or sometimes simply

• The cranium (also known as the neurocranium) is formed by the superior

Fig 1 – Bones of the calvarium and cranial base.

11 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

12 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Fig 1.1 – The constituent parts of the temporal bone.

13 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

14 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

o The sella turcica is surrounded by the anterior and posterior clinoid

Fig 3 – Bony landmarks of the sphenoid body.

15 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Fig 2 – The ethmoid bone within the nasal cavity.

16 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

17 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

• Inferior nasal conchae (2):

Inferior nasal concha

18 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

19 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Fig 2 – Internal surface of the mandible and its bony landmarks

20 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

• Clinical Correlate: Le Fort fractures:

21 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

▪ Concurrent fracturing of the zygomatic arches causes the

Sutures of the Skull:

Fig 5 – The major fontanelles and sutures of the skull

23 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

• Clinical Correlate: Skull fractures

24 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

25 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

26 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Cranial Nerve Foramina:

27 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

• Internal Acoustic Meatus:

28 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

29 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

30 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

31 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

32 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Cranial Fossae (Brief Overview)

• Most shallow and superior of the three cranial fossae.

Fig 2 – Bony landmarks of the anterior cranial fossa.

33 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Middle Cranial Fossa:

• Said to be “butterfly shaped”

Fig 1.3 – The foramina of the middle cranial fossa.

34 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

Posterior Cranial Fossa:

• most posterior and deep of the three cranial fossae.

35 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

36 | H J ’ s H Y H & N | ‫اکس ج ی وس گی‬

The Meninges and Dural