1
Q
mvmts @ TMJ: protrusion
A
protrude chin:
- lateral pterygoid (prime)
- masseter
- medial pterygoid
2
Q
•Muscular triangle
A
–Bounded by anterior border of SCM, superior belly of omohyoid, midline of neck
–Contains infrahyoid muscles, thyroid and parathyroid glands
3
Q
mucus membrane of larynx
A
respiratory epith
- except over true/aryepiglottic folds = stra-squa
4
Q
pons
A
ant region of posterior cranial cav
4th ventricle
5
Q
mylohyoid
A
N: N to mylohyoid - from inferior alveolar N - from CN V3 (madibular)
A: elevate hyoid, floor of mouth, tongue during swallow and speak
6
Q
contents of infratemporal fossa
A
- Inferior part of the temporalis muscle.
- Lateral and medial pterygoid muscles.
- Maxillary artery.
- Pterygoid venous plexus.
- Mandibular, inferior alveolar, lingual, buccal, and chorda tympani nerves
- Otic ganglion.
7
Q
boundaries Anterior Triangle of neck
A
- Lateral—anterior border of SCM
- Anterior—anterior midline of neck
- Superior—inferior mandible
8
Q
Pretracheal Layer of Deep Cervical fascia
A
Thin layer: muscular and visceral parts
laryngeal cartilages + hyoid bone –> (thorax) fib pericaridium
- Blends laterally with carotid sheaths
Encloses:
- thyroid
- parathyroid
- infrahyoid muscles
9
Q
sensory and motor innervation of larynx
A
sensory
- above vocal folds: internal laryngeal (branch of superior)
- below vocal folds: inferior laryngeal (branch of recurr)
motor
- external –> circothyroid
- recurrent –> rest of intrinsic
10
Q
dorsal scapular A
A
from either 2nd or 3rd part
passes backwards to supply levator scpulae, rhomboids
11
Q
Thyroid cartilage
A
two flat laminae
- upper 1/3 = superior thyroid notch
- lower 2/3 = fused –> laryngeal prominence (Adam’s apple)
posterior horns
- Superior horns/laminae attach to hyoid bone by thyrohyoid membrane
12
Q
Pharynx
A
M tube post to nasal and oral cav: continuous with esop and larynx
ant to C1-C6, prevert M
retropharyngeal space: potential space b/w pharynx and prevert fascia
3 parts: naso, oro, laryngo
13
Q
•Vertebral arteries
A
1st branche of subclavian –> txverse foramen (c1-c6) –> pierce dura –> foramen magnum –> basilar A –> clivus –> 2 posterior cerebral arteries –> circle of Willis
connect to anterior cerebral A via posterior commun A
vasc supply to cerv-SC and neck
14
Q
Cutaneous branches of the cervical plexus
A
posterior SCM
loop formed b/w anterior rami C2, C3
- –Lesser occipital (C2) to skin of neck and scalp posterior to auricle
–Great auricular (C2 and C3) to skin over parotid gland, mastoid process, auricle, and between angle of mandible and mastoid process
–Transverse cervical nerve (C2 and C3) to skin over anterior cervical region
•Supraclavicular nerves
- –Arise from C3–C4 loop
–Emerge from under SCM
–Supply skin over clavicle, superior thoracic wall, and shoulder
15
Q
Cervical plexus block
A
posterior SCM @ around C2-C3
16
Q
jugular foramen
A
b/w temporal & occipital
IX, X, XI
sigmoid sinus
inferior petrol sinus
posterior meningeal A
17
Q
vertebral A
A
runs cranially in tx formaina of cerv-vert –> circle of wilis
18
Q
Optic canal
A
lesser wing sphenoid
stuctures:
- optic N
- opthalmic A
- sympathetic plexus
19
Q
Ventricular system
A
ECF in brain: like blood but less protein & diff [ion]
formed by choroid plexus in 4 ventricles of brain
- lateral ventricles –> intervent foramina –> 3rd ventricle –> cerebral aqueduct –> 4th ventricle –> apertures (2 lat, 1 midline) –>subarachnoid space
absorbed via arachnoid granulations (villi) into venous blood in dural venous sinuses
approx 400 mL/day CSF –> venous circ
20
Q
general larynx
A
fx: phonation, sphincter guarding lower respir-tract
connects oropharynx with trachea
ant to prevert M, C3-C6 vert
21
Q
otic ganglion
A
PNS
- pre: (glossopharyngeal N) –> otic ganglion
- post: –> auriculotemporal N –> parotid
location:
- infratemporal fossa
- inferior: foramen ovale
- medial: CN V3
- post: medial pterygoid
22
Q
Cervical Ligaments
A
Stylohyoid:
- styloid process –> lesser cornu of hyoid
Stylomandibular:
- styloid process –> angle of mandible
Sphenomandibular:
- spine of sphenoid –> lingula of mandible
Pterygomandibular:
- hamular process of medial pterygoid plate –> posterior end of mylohyoid line of mandible
- attachment to superior constrictor & buccinator muscles
23
Q
thyrohyoid membrane
A
txverse superior border and superior horns of thryoid cartilage
pierced by superior larngeal vessels, interal laryngeal N
24
Q
geniohyoid
A
N: C1 via CN XII (hypoglossal)
A:
- pull hyoid ant-sup
- shortens mouth floor
- widens pharynx
25
soinus drainage
26
Laryngeal skeleton
Unpaired cartilages
Epiglottis
Thyroid
Cricoid cartilage
Paired cartilages
Arytenoid
Corniculate
Cuneiform
27
joints of larynx
circothyroid
* gliding/rotation of thyroid cart
* changes length of vocal folds
circoarytenoid
* slide/rotate/tilting of arytenoid on circoid
28
posterior triangle of neck
## Footnote
•Boundaries:
•Boundaries:
–Posterior—anterior border of trapezius
–Anterior—posterior border of SCM
–Inferior—meddle 1/3 of the clavicle
–Roof—investing layer of deep cervical fascia
–Floor—muscles and prevertebral layer of the deep fascia
29
Torticollis/ Wry neck
•1.Congenital torticollois
–Malposition in utero
–Birth injury
–SCM tumor
•2. Acquired
–Tumors of skull base
–Trauma
–Transient spasm
•3.Spasmodic
–Cervical dystonia
30
Vasculature of duramater
middle menin A --\> ant/post branch
veins accompany: --\> foramen spinosum --\> pterygoid venous plexus
31
Temporalis M
O: temporal fossa (broad)
I: coronoid process/anterior ramus of mandible (narrow)
N: CN V3 (deep temporal branhces)
A: elevates mandible, close jaws, primary retractors
32
mvmts @ TMJ: lateral mvmts
grind/chew
* ipsi temporalis
* contralat pterygoids
* masseter
33
innervation of scalp
anterior --\> auricle: CN V (trigeminal): ophthalmic, max, mandibular divisions
posterior --\> auricle: cutaneous branches of C2-3 spinal N
34
Veins of the face
•Supratrochlear vein
* desc forehead to nose --\> + supraorbital --\> angular
•Supraorbital vein
* forehead --\> medial --\> supratrochlear
* branch --\> through supraorbital notch --\> superior ophthalmic vein
•Facial vein
* Two veins = main venous drainage of face
* Follows facial artery
* Drain directly or indirectly into internal jugular vein
* --\> superior ophthalmic vein --\> pterygoid venous plexus and cavernous sinus
•Superficial temporal vein
* Drains scalp and forehead --\> + maxillary --\> retromandibular
•Retromandibular vein
* Descends through parotid gland
* branch to facial vein
* + posterior auricular --\> external jugular vein
35
Lymphatic drainage of larynx
Above folds: to deep cervical nodes
Below folds: to paratracheal nodes to deep cervical nodes
36
Vocal folds
paired
contains:
* vocal lig: medial free edge of lateral cricothyroid ligament (conus elasticus)
* Vocalis muscle—medial fibers of thyroid arytenoids muscle
37
facial expressions and M pic
38
Scalene muscle
O: TP c2-c7
I: 1-2 ribs (lateral vertebral M)
A: accessory M of respiration
* anterior, middle: elevate 1st rib
* posterior: elevate 2nd rib
N: c4-c6
39
•Submental triangle
–Between body of hyoid bone and right and left anterior bellies of the digastric muscles
–Apex is mandibular symphysis
–Contains submental lymph nodes
40
arteries of face
facial - major
from external carotid: cross mandible --\> medial angle of eye
branches to lips & nose
* superficial temporal
* term branch external carotid --\> temporal fossa --\> ends in scalp
* txverse facial
* from superficial temporal --\> below zygomatic arch
41
digastric
N: N to mylohyoid, CN VII (facial)
A: works with infrahyoid M
* depress mandible against resistance
* elev, steadies hyoid during swallow, speak
42
Prevertebral Layer of Deep Cervical fascia
thick tubular sheath for v-column & muscles
* Behind pharynx & esophagus
* longuses, scalenes & deep cervical muscles
* Fixed to cranial base superiorly
* Cervical part of sympathetic trunk
Fascial floor of posterior triangle
forms axillary sheath
* ax A
* brachial plexus
43
piriform recess
small depressions on either side of laryngeal inlet sep by aryepiglottic folds
bounded medial: throid cart, thyrohyoid memb
food:
* sharp food: may injure internal laryngeal N (groove adj to recess)
* anesthesai of laryngeal muc-memb as far inferior as vocal folds
44
Triangles of the Neck
SCM: each side into 2 triangles
## Footnote
–Anterior
•Lies in the anterior cervical region
–Posterior
•Lies in the lateral cervical region
45
carotid sinus massage
46
medulla oblongata
posterior cranial fossa
contin with SC
inferior portion of 4th ventricle
47
Superior orbital fissure
both wings sphenoid
structures:
* V1
* III, IV, VI
* superior opthalmic vein
48
thyroid A
•Superior thyroid artery (from external carotid)
–Descends to superior poles
•Inferior thyroid artery (from thyrocerv trunk)
–Superomedially posterior to carotid sheath – posterior inferior poles
•10% thyroid ima –
–arises from brachiocephalic trunk , arch of aorta or right common carotid , subclavian or internal thoracic
–supplies anterior trachea and isthmus
49
maxillary artery: 2nd part
Mnemonic: muscles of mastication which are also derivatives of the 1st arch.
Deep temporal artery (ant/post): Temporalis
Pterygoid artery: Lateral and medial pterygoids
Masseteric artery: --\> mand notch --\> Masseter, TMJ
Buccal of Buccinator artery: Buccinator, runs with N
50
Oropharynx
soft palate --\> superior epiglottis
boundary:
* anterior: oropharyn opening, posterior 1/3 tongue epiglottis
* lateral: palatoglossal and palatopharyngeal arches (containing palatoglossus and palatopharyngeus muscles)
* superior: soft palate
* posterior: sup/middle constrictor M
contents:
* palatine tonsils (b/w arches)
* tonsilar bed: superior constrictor M & paryngobasilar fascia
* epiglottis
* attached to tongue via median/lat glossoepiglottic folds
* epiglottic valleculae: depression b/w medial/lateral folds
51
52
•Subarachnoid space
b/w arachnoid and pia: with CSF (ventricles) = cushion brain
53
Innervation to the dura
supratentorial: trigeminal (V1-3)
infratentorial: upper cerv
54
thyroid lymph
prelaryngeal, pretracheal, and paratracheal lymph nodes
Superior cervical nodes ---inferior cervical nodes---inferior deep cervical nodes
55
Blood supply to the Pharynx
artery:
* upper
* •tonsillar from facial
* Ascending pharyngeal from external carotid
* Ascending and descending palatine from maxillary
* lingual
* lower
* inferior thyroid
vein:
* External palatine → pharyngeal plexus → IJV
56
Rima glottidis
space b/w vocal folds
normal breathing: narrow wedge
forced respiration: wide apart
* abduct via contraction of posterior crico-arytenoid
phonation: slit-like
* adduct arytenoid cart, moderate adduct lateral crico-arytenoid M
* stronger contraction = close rima glottidis: valsalva
whispering:
* strong adduct lateral crico-arytenoid M of vocal ligaments
* relaxed arytenoid M
* allow air to pass --\> toneless speech
57
laryngeal cavity
laryngeal inlet --\> tracheal cavity (inferior border of cricoid)
parts:
* vestibule: recess ext lateral
* infraglottic cav: b/w vocal folds and inferior border of cricoid
58
•Subarachnoid cisterns
where pia & arachnoid are widely separated: pools of CSF usu @ brain base
cerebellomedullary:
* largest: b/w cerebellum & medulla
pontocerebellar:
* "pontine cistern" ventral to pons, contin infer with subarachnoid space
interpeduncular:
* "basal" b/w cerebral peduncles of midbrain
chiasmatic:
* @ cross of optic chiasm: inf/ant
quadrigeminal:
* b/w corpus callosum and cerebellum
ambient:
* lateral midbrain, contin post with quadrigeminal cistern
59
brain A pic
60
Temporal Region
superior to zygomatic arch
boundaries:
* sup/post: squamous suture
* ant: frontal, sphenoid, zygomatic bones
* lat: zygomatic arch
* inf: infratemporal crest
61
circle of Willis
subarach space
formed by:
* anterior: commun, cerebral
* ICA
* posterior: commun, cerebral
62
Swallowing
3 stages:
1st
* voluntary: 1-2s
* breathing via nasopharynx
* bolus food aga hard palate --\> paltoglossal folds relax --\> M of tongue and soft palate push bolus into oropharynx
2nd
* involun/reflexive via glossopharyngeal N
* nasopharynx closed by elevation of soft palate
* tensor veli palatine & levator veli palatine M
* suprahyoid & longitudinal pharyngeal M contract
* elevate larynx, close epiglottis, propel bolus
3rd
* involun via peristalsis (all 3 constrictors)
* high P @ distal end --\> relax circophrayngeus M (sup esop sphinctor) --\> bolus to oesophagus --\> P drops --\> sphinctor closes --\> normal positions of larynx and epiglottis
63
Carotid Sheath
cranial base --\> root of neck
* •Blends anteriorly with investing & pretracheal layers of fascia
* •Blends posteriorly with prevertebral layer of fascia
•Contents:
–Common & internal carotid arteries & plexuses
–Internal jugular vein
–Vagus nerve CN X
\*Ansa Cervicalis Nerve – embedded in the carotid sheath
–Some deep cervical lymph nodes
–Carotid sinus nerve
–Sympathetic nerve fibers
free communication: superior mediastinum --\> cranial cavity
* potential pathways for spread of infection & blood
64
Muscles related to the nose
nasalis
* compressor naris: compresses
* dilator naris: flares
procerus
* forehead --\> bridge of nose
* medial eyebrow inferior
* txverse wrinkles over nose (frown)
65
pharynx fascia
• reinforces the pharyngeal wall where muscles are missing
§Fascia splits to enclose muscles
§Buccopharyngeal outer surface
§Pharyngobasilar covers the inner surface
•
•
66
epiglottis
Leaf-shaped elastic cartilage
location: b/w hyoid/tongue and laryngeal inlet
* overlays laryngeal inlet during **swallow**
attachements:
* superior: broad & free = aryepiglottic fold
* inferior: thyroepiglottic ligament --\> midline thyroid cart
* lateral: quadragular memb --\> arytenoid
67
Corniculate and cuneiform cartilages
Nodules in posterior aryepiglottic folds
Cuneiforms do not attach to other cartilages
Corniculates attach to apices of arytenoids
68
Hypoglossal canal
occipital bone
## Footnote
CN XII (same name)
69
Venous drainage of temporal region
pterygoid venous plexus
* partly b/w temporalis & pterygoids
* drain most veins along maxillary A
* anast
* ant: --\> deep facial vein --\> facial vein
* sup: emissary veins --\> caverous sinus
70
•Lower molar dental infections
medially spread:
* mandible --\> submand & masticatory spaces --\> push tongue fwd & up
downwards spread --\> visc space
* edema vocal cords
* airway obstruction
71
Deep Cervical Fascia
3: Investing, Pretracheal, Prevertebral
support
* thyroid gland, muscles, vessels & deep lymph nodes
condenses around carotid sheath
forms natural cleavage planes:
* tissues may be separated during sx
* limit spread of abscesses from infections
* allows slipperiness = structures in neck to move & pass over one another without difficulty - swallowing & turning head & neck
72
temporal fossa
occupied primarily by upper portion of temporalis M
* fascia attaches sup to temporal line, inferior splits to lateral/medial zygomatic arches
floor = 4 bones: frontal, pariental, temporal, greater wing of sphenoid
temporal A:
* superficial: from external carotid
* deep from maxillary
deep temporal N: from trigeminal (mandibular division)
zygomaticotermporal N: from trigeminal (maxillary branch)
73
face
highly vasc
sensory branches of CN V (trigeminal), upper cerv spinal N, motor branches of CN VII (facial)
skin ligaments (retiacula cutis)
74
Gaps in Pharyngeal Wall
b/w superior constrictor and base of skull: **ALE**
* Ascending palatine artery
* levator veli palitini
* eustacian tube
b/w superior and middle constrictor: **LMN**
* *Stylo*hyoid ligament
* Stylo*pharyng*eus M
* Glossopharyngeal N
b/w middle and inferior constrictor:
* Superior laryngeal artery and vein
* Internal laryngeal nerve
below inferior constrictor:
* inferior laryngeal artery
* recurrent laryngeal N
75
Foramen ovale
greater wing sphenoid
## Footnote
V3
lesser petrosal N
76
posterior triangle of neck: subdivisions
* Subdivided by inferior belly of omohyoid into:
* Occipital triangle:
* Larger
* occipital artery at its apex
* superiorly crossed by Accessory nerve
•Supraclavicular/ subclavian triangle:
* Smaller inferior
* external jugular vein, suprascapular artery, and subclavian artery
77
Laryngopharynx
superior epiglottis --\> inferior cricoid cartilage
stra-sqam
boundary:
–Inferiorly: continuous with esophagus
–Superiorly: continuous with oropharynx
–Anteriorly: larynx
–Posteriorly: middle and inferior constrictor muscles deep: Bodies of C4–C6 vertebrae
–Laterally: middle and inferior constrictor muscles
78
middle constrictor
O: upper border greater cornu of hyoid, lesser cornu, stylohyoid lig
and then....
* upper: ascend & overlap superior constrictor
* middle: txverse
* lower: descend beneath inferior constrictor
I: post-median raphe
79
vocalis M
\*subsidiary of thyroarytenoid M
O: vocal proc os artenoid cart
I: vocal lig
N: recurr laryngeal
A: relax post vocal lig, tense ant vocal lig
blood: sup/inf thyroid
80
Thyroid - nerves
from superior , middle ,inferior cervical sympathetic ganglia through cardiac ,superior and inferior thyroid periarterial plexus - vasomotor
81
Internal acoustic meatus
temporal bone
## Footnote
VII, VIII
labyrinthine
82
stylohyoid
N: CN VIII (facial)
A: elev, retract hyoid --\> elong mouth floor
83
Foramen lacerum
b/w temporal & sphenoid bone
## Footnote
pterygoid: A, N
84
Internal carotid arteries: supply to brain
from common carotid @ upper border of thyroid cartilage
**no branches to face/neck**
carotid canal (temporal bone) --\> carotid sinus (sphrenoid) --\> ant/mid cerebral A
united to posterior cerebral A --\> circle of willis (around interpeduncular fossa)
85
Inferior constrictor
2 parts:
* thyropharyngeal
* obliq line
* cricopharyngeal
* b/w Cricothyreoideus (front) & inferior cornu (behind)
fibers spread back and medial to opposide side M of fibrous pharyngeal raphe
**external laryngeal N**
86
thyroarytenoid M
O: post thyroid cartilage
I: M process of arytenoid cart
N: recurr laryngeal
A: shorten/relax VC
blood: sup/inf thyroid
87
lingual nerve
anterior to inferior alveolar N
sensory --\> ant 2/3 tongue, mouth floor, lingual gingiva
* joined by chorda tympani N (CN VII - taste fibers) infratemporal fossa
* secretomotor fiber from sub-mand/lingual salivary glands
88
vessels of neck
* External jugular vein
* Subclavian vein
* Third part of subclavian artery and its branches
* Occipital artery (from external carotid)
Veins:
* external jugular
* subclavian
* superficial temporal & maxillary --\> retromandibular --\> anterior & posterior
* anterior: joins facial --\> comm facial 00\> IJV
* posterior: joins auricular --\> external jugular --\> subclavian
89
Muscles related to the orbit
•Orbicularis oculi
* three parts:
* lacrimal: draws eyelids/lacrimal puncta med to drain tears
* palpebral: (inner) blink (gentle close)
* orbital: (outer) squint (tightly close)
•Corrugator supercilii
* Draws medial end of eyebrow medially and inferiorly for a concerned look
* Wrinkles skin of forehead (furrowing eyebrows)
Frontalis portion of occipitofrontalis
* Elevates the eyebrows (surprised)
* Wrinkles the forehead
90
thyrocervical trunk
short
divides into inferior throid, suprascapular, tx cerv
91
Arterial supply to larynx
upper = superior laryngeal A (from superior thyroid)
* thru gap in thyrohyoid memb
* accomp by sup laryngeal N
lower = inferior laryngeal A ( from inferior thyroid)
* accomp by recurrent laryngeal N
92
cerebellum
dorsal to pons/medulla, inf to posterior cerebrum
2 lateral hemis conn by vermis (midline)
fx:
* balance, posture, coord
* timing/strength of M contraction
93
Motor innervation to face
facial: sole motor supply to M of facial expression
5 branches: named to areas they supply
* •Temporal
* Zygomatic
* Buccal
* Mandibular
* Cervical
94
Internal jugular vein
signoid sinus --\> jugular foramen (begin) --\> desc carotid sheath --\> joins subclavian to form brachiocephanic
•Tributaries
–Inferior petrosal sinus
–Pharyngeal vein
–Common facial vein
–Lingual vein
–Superior & middle thyroid vein
95
Muscles related to mouth and lips
## Footnote
* Orbicularis oris
* Buccinator
* Levator labii superioris alaeque nasi
Levator anguli oris
Depressor anguli oris
Mentali
* Levator labii superioris
* Depressor labii inferioris
* Risorius
* Zygomaticus major
* Zygomaticus minor
* Platysma
•Orbicularis oris
* Sphincter of the mouth
* speech, holding food between the teeth, whistling, blowing
•Buccinator
* smiling
* Holds food between teeth during chewing
* whistling, sucking, and horn blowing
•Levator labii superioris alaeque nasi
* Elevates nose and upper lip
Levator anguli oris
* Elevates corner of mouth
Depressor anguli oris
* Depresses angle of mouth
Levator labii superioris
* Lifts and everts upper lip
Depressor labii inferioris
* Draws lip down and laterally (impatience)
Risorius
* Draws corner of mouth laterally (grinning)
Zygomaticus major
* Draws angle of mouth up and laterally (smiling and laughing)
Zygomaticus minor
* Raises upper lip (contempt)
Platysma
* Depresses mandible
* Draws corners of mouth down
* grimacing
Mentalis
* Wrinkles skin on chin
96
innervation to pharynx
Motor = pharyngeal plexus:
* Pharyngeal branches of X, IX
* External laryngeal = **inferior constrictor**
sensory
* •Nasophaynx by maxillary (2nd division of trigeminal CN V)
* Oropharynx by glossopharyngeal CN IX - upper pharynx
* Laryngopharynx by vagus CN X - lower pharynx
97
•Muscles of facial expression
in superficial fascia: most from bone --\> skin
sphincters/dilators around face
N: 1 of 5 main branches of CN VII (facial)
* occipitalis N by posterior auricular branch
98
cerebral hemispheres
largest: ant/middle cranial fossa, sep by cerebral fissure
connected via corpus callosum
cavity = ventricle
4 lobes:
* frontal: high mental fx, speech/lang
* parietal: init mvmt, perception
* temporal: mem, hearing, speech
* occipital: vision
99
vestibular folds
false VC
thyroid --\> arytenoid cart
fx: protection
100
Skin of Neck
Natural lines of cleavage of skin:
* constant
* run almost horizontally around neck
Important clinically: incisions
* along a cleavage: narrow scar
* crosses lines = wide or heaped-up scar
101
•Falx cerebelli
vertical fold: partially separates hemispheres
attached to internal occipital crest, inferior to tentorium cerebelli
102
maxillary A: 1st part
Mnemonic: Remember the branches with the mnemonic “DAMIA”
* Deep auricular artery: External acoustic meatus, TMJ
* Anterior tympanic artery: internal tympanic membrane
* Middle meningeal artery: --\> foramen spinosum --\> attaches to auric-temp N
* dura mater and Skull bones
* gang: trigem, geniculate
* CN VII
* tymp-cav & tensor tympani
* Inferior alveolar artery: --\> mandibular foramen --\> Mandible
* 3 branches: dental, mental, mylohyoid
* runs alongside N
* Accessory meningeal artery: --\> foramen ovale --\> infratemp-fossa
* otic gang
* mandibular N
Clinical significance: Middle meningeal artery injury results in Extradural hematoma (EDH).
103
cerebral A
**supplies cerebral hemisphere**
anterior:
* medial/upper lat
* frontal
middle:
* lower/lateral
* temporal
posterior:
* inferior surf
* occipital
104
TMJ bones
•superior: mandibular fossa and articular tubercle of the temporal bone
inferior: mandible head
* capsule attaches to the margins of the articular cartilage on the temporal bone and around the neck of the mandible
* Joint cavity is divided into two compartments by Articular disc
* upper: gliding (protrusion/retrusion/retraction)
* lower: hinge (depress/elevate), rotate, pivot
105
Venous drainage of larynx
Superior laryngeal vein → superior thyroid vein → IJ → BC
Inferior laryngeal vein → inferior thyroid vein/plexus → BC
106
diencephalon
–Composed of
* Epithalamus
* Thalamus
* Hypothalamus
–Surrounds third ventricle of brain between right and left halves
107
Retropharyngeal Space
•Largest & most important space in neck
* between prevertebral fascia & buccopharyngeal fascia surrounding pharynx
* spread down to superior mediastinum
•extent:
* –Superiorly: base of skull
* –Inferiorly: superior mediastinum
* –Laterally : carotid sheath
108
TMJ ligaments
stylomandibular: not significant to strength of joint
sphenomadibular: primary passive support of mandible
* swinging hinge
lateral ligament (thickened part of joint capsule)
* + postglenoid tuberle ---\> **prevents posterior dislocation of jt**
109
Parotid gland
largest of 3 paired salivary glads
contains parotid plexus of CN VII (facial)
parts:
* bed: ant/inf to external acoustic meatus b/w madible ramus & mastoid process
* apex: posterior to mandible angle
* base: zygomatic arch
* duct: pierces buccinator --\> oral cav through small hole opposite 2nd max molar tooth
110
lymph drainage of pharynx
tonsillar tissue --\> mandible nodes & tonsilar (jugulodigastric) node --\> generally to deep cervical
111
Suprasternal space of Burns
investing layer of deep cervical fascia remains divided into two layers -
* Inferiorly between sternal heads of SCMs
* superior to manubrium
encloses:
* ends of jugular veins & arch
* fat
* deep lymph nodes
112
Midbrain (mesencephalon)
@ jxn of middle and posterior cranial fossa
contains cerebral aqueduct
113
Pus spread in the neck
abscess post to prevert layer --\> ext lat --\> swell post to SCM
may perf prevert layer --\> retropharyngeal space --\> bulge in pharynx
* retropharyngeal abscess
* Causes difficulty in swallowing - dysphagia & speaking - dysarthria
114
post cricoarytenoid M
O: post cricoid cartilage
I: M process of arytenoid cart
N: recurr laryngeal
A: abduct vocal fold
blood: sup/inf thyroid
115
Lateral pterygoid
O: 2 heads: infratemp surf & sphenoid, lateral pterygoid plate
I: joint capsule of TMJ, pteryoid fovea on condyloid process of mandible
A: bilateral = protract mandible & depress chin, unilat = contralat jaw swinging for chewing mvmts
N: lateral pterygoid
116
Fascial Spaces
loose connective tissue forms potential spaces
* Visceral
* Retropharyngeal
* Submandibular
* Masticatory
infections spread: touch fascia = detm path
117
Mode of distribution of the Ansa cervicalis to the hyoid muscles
118
Modified parts of investing layer: fascia
encloses via splitting:
* submandibular gland: inf to mandible
* parotid gland: post to mandible
Stylomandibular ligament = thickened mod
119
HORNERS SYNDROsME
•Damage to the sympathetic nervous system
ptosis, Anhydrosis, miosis, enopthalmos, loss of ciliospinal reflex
* Ptosis: dmg superior tarsal muscle (muller muscle): eyelid droop
* anhydrosis: lack of sweat
* miosis: constrict pupil
* enopthalmos: posterior displace eyeball
* ciliospinal reflex: dilate ipsi pupil with pain to: face, neck, upper trunk
120
cricothyroid M
O: anterior cricoid cartilage
I: inferior border/horn thyroid
N: superior laryngeal
A: lengthen/tense vocal lig
blood: sup/inf thyroid
121
Arytenoid cartilages
paired
* articulates with lat/sup cricoid lamina
3 processes:
* apex (superior)
* attacehd to aryepiglottic fold
* corniculate cartilage sits sup
* vocal (anterior)
* posterior VC attachement
* muscular (lateral)
* post/lat cricoarytenoid M
122
Medial pterygoid M
O: 2 heads: lateral pteryoid plate & palatine bone, maxilla tuberosity
I: mandible ramus below foramen - mirror img of masseter (2 M flanking the ramus)
N: CN V3 (mandibular N)
A: with masseter to elev mandible, protrustion, smaller lateral chewing mvmts than lateral pterygoid
123
extrinsic M of larynx
attached to hyoid
infrahyoid: lower larynx & hyoid
* sterno/omo/thyro-hyoid
* sternothyroid
suprahyoid: fix hyoid/elevate hyoid & larynx
* stylo/mylo-hyoid
* disgastric
stylopharyngeus: elev hyoid bone & larynx
124
Vascular supply of parotid
artery
* main = txverse facial
* branches of external carotid
veins
* --\> ext/internal jugular
* maxillary + superficial temporal --\> retromandibular
* **in parotid gland but od not drain it**
lymph: mainly pre-auricular lymph nodes
125
Inferior orbital fissure
b/w zygo & greater wing of sphenoid
structures: **INFRA**ORBITAL
* VAN
126
Masseter
O: maxillary process of zygomatic bone & zygomatic arch
I: mandible ramus
N: CN V3 (masseteric N)
A: elevates mandible, closes jaw, some protrustion of mandible
127
Infratemporal fossa boundaries
* Laterally: mandible the
* Medially: lateral pterygoid plate.
* Anteriorly: maxilla
* Posteriorly: tympanic plate, mastoid and styloid processes
* Superiorly: the inferior (infratemporal) surface of the greater wing of the sphenoid.
* Inferiorly: where the medial pterygoid muscle attaches to the mandible
128
Lymphatic drainage of the face
superfical with veins
deep with arteries
lateral --\> parotid
upper lip/lateral lower lip --\> sybmandibular
chin/central lowerlip --\> submental
**all --\> deep cerv**
129
neck lymph nodes
130
Foramen rotundum
greater wing sphenoid
structure: V2
131
Foramen magnum
occipital bone
## Footnote
medulla
accessory N spinal roots
vert A
132
nasopharynx lymph
roof of nasopharynx = tonsils: incomplete ring
roof/posterior wall = adenoid
opening of auditory tube = tubal
133
Cervical plexus location and characteristics
anterior rami C1-C4
deep to SCM, ant-med to levator scuplae and middle scalene
loops & branches off
134
maxillary A: 3rd part
Mnemonic:
* Posterior superior alveolar: Maxilla
* Infraorbital: --\> inferior orb fissure --\> infraorb region & incisors
* Descending palatine: --\> greater and lesser --\> hard and soft palate respectively
* Pharyngeal: --\> palatovag canal --\> pharynx
* Pterygoid canal: Upper pharynx and tympanic cavity
* Sphenopalatine: nasal cavity (term branch)
* common cause of posterior epistaxis (nosebleed)
135
costcervical trunk
splits into highest intercosstal & deep cerv
136
longitudinal pharyngeal wall M
\* shortens and widens pharynx and larynx during swallowing and speaking
salpingopharyngeus
* auditory tube cartilage --\> palatophyngeus M
* CN XI (accessory) via **vagus** to pharyngeal plexus
palatophyngeus
* superior: hard palate/palatine aponeur, inferior: lat pharynx wall --\> thryoid cart/lateral pharynx wall
* CN XI (accessory) via **vagus** to pharyngeal plexus
stylopharyngeus:
* styloid process --\> thryoid cart
* **CN IX**
137
Thyroid - Veins
* Three pairs form thyroid plexus of veins, anterior to thyroid gland
* Superior thyroid vein- accompany superior thyroid artery, drain superior pole
* Middle thyroid vein – drain middle lobe
* Inferior thyroid vein – drain the inferior lobe
* Superior and middle drain into IJV
* Inferior drain into brachiocephalic veins
138
Vasculature of scalp
rich blood supply --\> profuse bleeding
external carotid: posterior auricular, occipital, superficial temporal
intenral carotid: supra-trachlear/orbital
veins = same name as A
* deep scalp --\> deep temporal --\> pterygoid venous plexus
139
Innervation of larynx
vagus:
* superior laryngeal --\> internal (sensory) & external (motor)
* from inferior vagal ganglion
* **cricothyroid**
* inferior laryngeal
* continuation of recurrent laryngeal
* enter larynx deep to inferior pharyngeal constrictor
* anterior branch
* thyro-arytenoid, vocalis, ary- epiglottic and thyro-epiglottic muscles
* posterior branch
* posterior crico- arytenoid, transverse and oblique arytenoid muscles
* sens fib to infraglottic cav
140
Dura mater
thick fibrous: 2 (v 1 of SC)
* outer periosteal: inner surf of calvaria
* inner meningeal: contious with dura of SC
folds:
* Falx cerebri (cerebral falx).
* Tentorium cerebelli (cerebellar tentorium).
* Falx cerebelli (cerebellar falx).
* Diaphragma sellae (sellar diaphragm).
141
Cervical Subcutaneous Tissue & Platysma
Cervical subQ-
* fatty connective tissue
* between dermis & investing layer of deep cervical fascia
* Usually thinner than in other regions - especially anteriorly
contents:
* cutaneous nerves
* bv
* lymph v, superficial lymph nodes
* ant/lat: platysma
142
TEMPOROMANDIBULAR JOINT:
type of joint
mvmts possible
* modified hinge type of synovial joint
* Movments possible
– gliding (translation)
– rotation (pivoting)
–Flexion (elevation) and extension (depression)
143
suprahyoid M
hyoid --\> mandible/mastoid process
\_\_\_\_\_hyoid
* mylo
* genio
* stylo
digastric
144
Paralysis of Platysma
cervical branch of facial nerve (CN VII)
* important not to cut during sx
= skin to fall away from neck in slack folds
145
Anterior Triangle divisions
4 smaller triangles:
* submand
* submental
* carotid
* digastric
146
Prevertebral Layer of Deep Cervical fascia splits ______ to form...
inferior
alar fascia - which blends with buccopharyngeal fascia
‘true’ prevertebral fascia
fuses with ALL @ T3 & extends into superior mediastinum
147
DURAL VENOUS SINUSES
empty large veins of brain surf
endothelium lined: b/w periosteal @ meningeal layers of dura
148
Subclavian artery in the neck
3 parts
1st:
* origin --\> medial border anterior scalene
* brancheses: vertebral, internal thoracic, thyrocervical
2nd:
* behind anterior scalene
* costocervical trunk
3rd:
* b/w lateral border anterior scalene --\> outer border 1st rib
* dorsal scapular
149
nasopharynx
post to nose, above soft palate
ciliated epith
boundary:
* anterior: choanae (contin with nasal cav)
* roof/posterior: sphenoid, base of occipital bone
* lateral: superior constrictor M
150
Vessels in the anterior triangle
* Common carotid artery
* Internal & External carotid artery and its branches
* Internal jugular vein
151
internal thoracic A
runs behind ribs --\> superior epigastric, musculophrenic
gives off anterior intercostal A & perforating vessels to breast
152
FASCIA OF NECK
* Structures in neck are surrounded by a layer of subcutaneous tissue - superficial fascia & are compartmentalized by layers of deep cervical fascia
* Fascial planes determine direction in which an infection in neck may spread
153
thyroid gland
location:
* deep to sterno-thyroid/hyoid M
* C5-T1
* 2nd/3rd tracheal rings
154
C-6 level is important
* Level of cricoid cartilage
* Pharynx and larynx end
* Esophagus and trachea begins
* Vertebral artery enters the foramen transversarium at this level
* Carotid artery is palpated against transverse process of C6
155
Pharyngeal Wall: Muscles
constrictors: sup, middle, inferior
paired via midline raphe - attaches to pharyngeal tub of occiptal bone
palatopharyn sphinctor: M from soft palate --\> superior constrictor
N: vagus , **inferior constrictor = external laryngeal N ( & cricothyroid - larynx)**
156
scalp
sup nuchal line --\> sup orbital ridge, ext acoustic meatus --\> zygomatic arch
5 layers:
\*first 3 layers adhered to skull: move as one
1. skin: sweat/seb glands, hair follicles, well-vasc
2. dense connective tissues: well-vasc & innerv
3. aponeur of oppicitofrontalis M: tendinous sheet: connects ocipitalis, frontalis, superior auricular M
4. loose connective issue: emissary veins
* scanty subaponeu space: collects fl in injury/infection
* moves freely over first 3 layers
5. external periosteum of calvaria (skullcap): firmly attached to bone
* most tightly bound @ suture line
157
Muscles that form the floor of the posterior triangle
splenius capitis
Levator scapulae
scalene: anterior, middle, posterior
158
•Falx cerebri
largest of infoldings
longitudinal fissure: sep R and L hemisphere
* medial plane: crista galli & frontal crest ---\> internal occipital protuberance
159
Cavernous sinus
receives:
* sup/inf ophthalmic veins --\> sup orbital fissure
* superficial cortical veins
* basilar plexus
contains:
* internal carotid A (carotid siphon)
* CN: (w/in lateral wall of sinus) superior to inferior
* III, oculomotor
* IV, trochlear
* V, trigeminal (V1: ophthalmic, V2: maxillary)
* VI, abducens: **runs in middle of sinus along internal carotid A**
many anast --\> infection from face --\> bad
drains into:
* sup/inf petrosal sinus --\> --\> internal jugular
160
Emissary veins
connect dural venous sinuses with veins outside cranium
**valveless: bidirectional flow** (but usually blood away from brain)
veins:
* frontal (children/some adults) - superior sag sinus --\> frontal sinus
* parietal: --\> parietal foramen: superior sag sinus --\> scalp veins
* mastoid: --\> mastoid foramen: sigmoid sinus --\> occipital/posterior auricular vein
* posterior condyloid: condylar canal: sigmoid sinus --\> suboccipital venous plexus
161
•Arachnoid mater
–Thin, nonvascular membrane
–Loosely attached to dura mater
–Separated from pia mater by subarachnoid space
162
Quadrangular membrane
Inelastic connective tissue
* extends from thyroid cart --\> arytenoid cart
* Attaches lateral aspects of arytenoids and epiglottis
borders:
* upper = aryepiglottic fold/ligament
* lower = vestibular ligament/fold (false vocal cord) - above VC
163
•Diaphragma sella
smallest dural infolding: circular - partial roof of hypophyseal fossa
164
nasopharynx cavities
lateral: opening to ear canal (pharyngotympanic tube)
Torus tubarius:fold covering pharyngotympanic tube
retropharyngeal recess behind torus tubarious
Salpingopharyngeal fold – salpingopharyngeal m
Torus levatorius mucosa overlying levator palatini m
165
Parathyroid glands
external to thyroid capsule
usually 4
* sup @ lvl of cricoid
* inferior @ inferior poles of thyroid
A: inferior thyroid
V: parathyroid --\> thyroid venous plexus
same lymph and N as thyroid
166
emb origin of platysma
mesenchyme: 2nd phaaryngeal arch
167
M related to ear
ant/sup/post auricular
168
•Ludwig's angina
–Acute infection of submandibular fascial space & is commonly secondary to dental infection
169
superior constrictor
4 parts:
* Pterygopharyngeal: lower 1/3 post-medial pterygoid plate & its hamulus
* Buccopharyngeal: pterygomandibular raphe
* Myolopharyngeal: alveolar process of the mandible above posterior mylohyoid line
* Glossopharyngeal: side of tongue
inserts into median raphe, enlong by aponeuro to pharyngeal spine (base of occiput)
170
instrinsic M of larynx pic
171
mandibular nerve
from trigeminal ganglin in middle cranial fossa
* immed gets motor root of trigeminal N
--\> foramen ovale --\> infratemporal fossa
branches:
* buccal
* auriculotemporal --\> send postsynap PNS to parotid (encuirc mid-mening A)
* mental
* inferior alveolar --\> mand foramen
* lingual --\> tongue: joined by chorda tympani (taste) @ intratemp fossa
supplies 4 M of mastication
172
innervation of parotid gland
**parotid plexus does not supply gland**
PNS -inferior salivatory nucleus: PNS input (from CN IX: glossopharyngeal)
* presynap -- otic ganglion
* auriculutemporal N (from ganglion): post synap
Stimulation of the parasympathetic fibers produces a thin, watery saliva
SNS = cerv gang --\> external carotid plexus on ECA = dec secr from gland
great auricular (from cerv plexus - C2/C3) = sheath
173
•Pia mater
–Adherent to brain and spinal cord
–Highly vascular connective tissue
174
txverse/ obliq arytenoid M
\*subsidiary of thyroarytenoid M
O: arytenoid cart
I: opposite arytenoid cart
N: recurr laryngeal
A: close rima glottis
blood: sup/inf thyroid
175
N of neck
* Accessory nerve (cranial nerve [CN] XI)
* Ventral rami (roots) of brachial plexus
* Suprascapular nerve
* Cervical plexus
176
Thoracic outlet syndrome
compression subclav A, V, trunks of brachial plexus --\> arm pain
* A: pallor, cold
* V: swelling (also lymph)
* plexus: parethesia
common cause = C7 cerv rib presence
177
neck regions: central & lateral
•Central region:
–Respiratory system: larynx & trachea
–Alimentary system: pharynx & esophagus
•Lateral sides:
–Carotid arteries, internal jugular veins, vagus nerve & deep cervical lymph nodes
178
inferior alveolar nerve
--\> mandibular foramen
* inferior dental plexus --\> ipsilat teeth
* --\> mental N --\> thru mental foramen:
* lower lip
* chin skin
* gingiva of incisors
179
•Submandibular triangle
–Between inferior mandible and anterior and posterior bellies of the digastric muscle
–submandibular gland, duct, lymph
180
deep branches cerv plexus innervate prevertebral muscles like
* Scalenes
* Longus capitis
* Longus coli
* Rectus capitis anterior
* Rectus capitis lateralis
181
Clinical relevance of parotid
Parotitis (Mumps)
Salivary duct calculi
Pleomorphic adenoma, Warthin’s tumor: benign tumors
182
Cricoid cartilage
Signet ring shaped, signet (lamina) facing posteriorly
* Strong, thick, complete circle of cartilage
lig:
* median & lateral (conus elasticus) cricothyroid ligament --\> inferior thyroid
* lateral (conus elasticus) free edge = vocal ligaments (true VC)
* cricotracheal ligament --\> 1st tracheal ring
183
lateral cricoarytenoid M
O: arch of cricoid cartilage
I: M process of arytenoid cart
N: recurr laryngeal
A: adduct vocal fold
blood: sup/inf thyroid
184
mvmts @ TMJ: depression
open mouth:
* lateral ptergoid
* supra/infra-hyoid
* **prime mover = gravity: M are mainly active aga resistance**
185
INVESTING LAYER OF DEEP CERVICAL FASCIA
•Most superficial part of deep fascial layer
* •Deep to skin & subcutaneous tissue
* •Surrounds entire neck
•Splits to enclose trapezius & SCM muscles
186
PLATYSMA
Broad, thin sheet of muscle in subQ
Dev: mesenchyme - 2nd pharyngeal arch
N: branches of CN VII
External jugular vein
* angle of mandible --\> middle of clavicle
* deep to platysma
Main cutaneous nerves of neck = deep to platysma
187
carotid triangle
–Bounded by anterior belly of omohyoid, posterior belly of digastric, and anterior border of SCM
–Contains carotid sheath
* common carotid artery
* internal jugular vein
* vagus nerve
–Carotid sinus
–Carotid body
188
•Tentorium cerebelli
2nd largest infolding
cresent-shaped: sep cerebrum from cerebellum
attachment:
* ant: clinoid processes of sphenoid
* post/lat: occipital/parietal/temporal bones
* falx cerebri: suspends tentorium
189
ECA branches
●Superior thyroid artery
●Lingual artery
●Posterior auricular artery
●Facial artery
●Occipital artery
●Ascending pharyngeal artery
●Maxillary
●Superficial temporal
●Stany Lobo’s Pretty Face Often Attracts Medical Students
190
mvmts @ TMJ: elevation
close mouth:
* temporalis
* masseter
* medial pterygoid
191
Infrahyoid muscles
**TOSS:**
thryohyoid
* N: C1 via CN XII (hypoglossal)
* A: depress hyoid, elev larynx
omohyoid
* N: C1-C3 (ansa cervicalis)
* A: depress, retract, steady hyoid
sternohyoid
* N: C1-C3 (ansa cervicalis)
* A: depress hyoid after swallowing evel
sternothyroid
* N: C2, C3 (ansa cervicalis)
* A: depress hyoid, larynx
192
mvmts @ TMJ: retrusion
retrude chin:
* temporalis (posterior oblique)
* massester
193
auriculotemporal nerve
encirc middle meningeal A
largest branch --\> sensory fibers to its name
--\> sensory to TMJ
--\> postsynap PNS secretomotor from otic ganglion --\> parotid gland
194
Innervation of the face
•Cutaneous branches of the cervical nerves
* From cervical plexus
* posterior neck, ear, and area over parotid gland
Trigeminal nerve (CN V)
* Sensory for face
* Motor for mastication
* Branches of ophthalmic nerve—CN V1
* Nasociliary → external nasal nerve to skin on dorsum of nose
* Nasociliary → infratrochlear nerve to skin and lower eyelid
* Frontal → supratrochlear nerve to skin in midforehead
* Frontal → supraorbital nerve to skin of forehead and upper eyelid
Branches of maxillary nerve—CN V2
* Infraorbital nerve to skin of cheek, lower lid, lateral nose and mouth, upper lip
* Zygomaticotemporal nerve to skin over anterior temple
* Zygomaticofacial nerve to skin over zygomatic arch
Branches of mandibular nerve—CN V3
* Auriculotemporal —skin of external ear, posterior temple, anterior ear
* Buccal —skin of cheek
* Mental —skin of chin and lower lip
Anatomy Year 1
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