Gross Anat. Block B

• junction of greater wing of the sphenoid, squamous temporal, frontal  & parietal bones
• overlies course of anterior division of middle meningeal artery

point on calvaria at junction of lambdoid and sagittal sutures

point on calvaria at junction of coronal and sagittal sutures

• superior point of neurocranium
• in middle with the cranium oriented in anatomical plane

• star shaped
• located at junction of three sutures: parietomastoid, occipitomastoid & lamboid

• smooth prominence
• most marked in males
• on the frontal bones superior to the root of nose
• most anterior projecting part of forehead

most prominent point of external occipital protuberance

point on cranium where frontonasal & internasal sutures meet

• skin
• connective tissue (dense)
• aponeurosis (galea aponeurotica)
• loose connective tissue (danger area)
• periosteum

• extends from superior part of neck posteriorly to the eyebrows anteriorly & to the zygomatic arches laterally
• covers the calvaria

• first 3 layers
• skin, dense connective tissue, aponeurosis

• contains many hair follicles, sebaceous glands & sweat glands
• sebaceous glands may become obstructed leading to sebaceous cysts (more common in scalp than anywhere else)

• richly vascularized & innervated
• many collagenous & elastic fibers which attach to the skin and to the deeper galea aponeurosis

• most common type of head injury requiring surgical care
• bleed profusely
• profuse blood supply from multiple sources from multiple directions with large number of anastomoses
• blood vessels not allowed to contract because they are imbedded in the dense cCT

tend to remain superficial because of the density of the fibrous tissue

• epicranial aponeurosis
• galea aponeurosis

• epicranius
• frontalis
• occipitalis

• "danger area"
• limits of the loose CT space or subaponeurotic space is important in the spread of infection

infection is unable to spread into the neck because the galea aponeurosis is attached to the superior nuchal line

infection is unable to spread beyond the zygomatic arches because the galea aponeurosis is continuous here with the temporal fascia

fluid or pus can enter the eyelids and the root of the nose because the frontalis is inserted into the skin & dense subcutaneous tissue

• the periosteum of the skull
• a thin, fibrous sheet which is only loosely attached to the bone apart from along the sutures
• continuous with the periosteal layer of the dura (endocranium) on the inside of the calvaria at the sutures & foramina

will be confined to the limits of the bone underlying that portion of periosteum

• superficial musculo-aponeurotic system of fascia
• superficial fascia of face & neck - invests facial muscles
• extends from platysma m. to galea aponeurotica
• continuous with temporopartietal fascia & galea aponeurotica
• connected to dermis by vertical septa

• all innervated by VII (facial nerve) - nerve of 2nd pharyngeal arch
• occipitofrontalis
• procerus
• nasalis
• depressor septi nasi
• orbicularis oculi - orbital & palpebral parts
• corrugator supercilii
• auricular - superior, anterior, posterior
• orbicularis oris
• depressor anguli oris
• risorius
• zygomaticus minor
• zygomaticus major
• levator labi superioris
• levator labi superioris alaeque nasi
• depressor labi inferioris
• levator anguli anis
• buccinator
• mentalis

• opthalmic (V1): sensory; innervates the skin of the forehead, upper eyelids & nose
• maxillary (V2): sensory; innervates the skin of the lower eyelid, cheek, & upper lip
• mandibular (V3): sensory & motor; sensory innervation of the skin of lower face & part of side of head; motor innervation of the muscles of mastication

• posterior auricular branch: passes posterior to the ear
• temporal branch: crosses the zygomatic arch
• zygomatic branch: crosses the zygomatic bone
• buccal branches: cross the superficial surface of the masseter muscle
• mandibular branch: parallels the inferior margin of the mandible
• cervical branch: cross the angle of the mandible to enter the neck

• sudden loss of control of the muscles of facial expression on one side of the face
• caused by injury to the facial nerve
• presentation - drooping of mouth & inability to close eyelid on affected side

• Tic douloureux
• patient experiences excruciating pain along the distribution of the maxillary, mandibular or opthalmic divisions of the trigeminal nerve
• spontaneous firing of the trigeminal nerve endings

• scalp is innervated by both cranial nerves & spinal nerves
• dorsal spinal nerve rami: greater occipital (C2) and third occipital (C3)
• ventral spinal nerve rami: great auricular (C2, C3) and lesser occipital (C2,C3)
• CN V: trigeminal nerve (V1, V2, V3)

innervates the skin of the back of the head as far superiorly as the vertex

innervates the skin behind the ear

innervates the skin of the lower part of the ear and skin over the angle of the mandible and lower part of parotid gland

• opthalmic division of trigeminal nerve
• sensory innervation of skin of forehead, upper eyelids, and nose
• branches: supraorbital nerve, supratrochlear nerve, palpebral branch of lacrimal nerve, infratrochlear nerve

• maxillary division of trigeminal nerve
• sensory innervation of skin of lower eyelid, cheek & upper lip
• branches: infraorbital nerve, zygomaticofacial nerve, zygomaticotemporal nerve

• mandibular division of trigeminal nerve
• sensory innervation to skin of lower face and part of side of head
• motor innervation to muscles of mastication
• branches: mental nerve, buccal nerve, auriculotemporal nerve

• external carotid branches: occipital artery, posterior auricular artery, superficial temporal artery
• internal carotid branch: opthalmic artery (divides into supraorbital artery & supratrochlear artery)

• go between the dural venous sinuses and superficial veins on the outside of the skull
• valveless but flow is usually away from the brain
• infections can spread from the internal skull in dural venous sinuses to the meninges and cavernous sinuses (cavernous sinus thrombosis)

• run within flat bones of the skull
• do not penetrate all the way through bone, but travel in and through diploe
• may make connections with emissary veins

sensory ganglion of trigeminal nerve

• herpes zoster
• area of V1
• virus lies latently in trigeminal ganglion

• accumulation of blood between the skull & dura mater
• pterion overlies middle meningeal artery
• fractures along skull can tear artery

• area of the face near the nose drained by the facial veins
• facial veins have no valves, so blood can go in either direction
• clotted blood & infectious material can travel to cavernous venous sinus in the skull from facial veins, pterygoid venous plexus & opthalmic veins

• serous salivary gland
• wraps around behind mandible right in front of ear
• contains facial nerve, retromandibular vein & external carotid artery

• goes across masseter muscle
• pierces the buccinator muscle
• opens up into the vestibule of the oral cavity opposite the second maxillary molar

• sympathetic: preganglionic neurons from IMLCC of T1-T4 synapse in superior cervical ganglion; unmyelinated postganglionic fibers travel out through the external carotid plexus to go to parotid
• parasympathetic: inferior salivatory nucleus of CN IX (GVE) will synapse on otic ganglion, then go to parotid gland

facial nerve

• facial nerve
• external carotid artery
• retromandibular vein

• supraorbital artery
• supraorbital nerve

supratrochlear nerve

• Infraorbital nerve (branch of V2)
• infraorbital artery

mental nerve

• lies deep to pterion
• damage will cause epidural or extradural hematoma
• largely responsible for multiple small impressions on the inside of the skull

• located superior to the infratemporal fossa
• provides area of origin for temporalis m.
• houses the pterion - area between frontal, parietal, temporal and sphenoid bones; covers middle meningeal artery

• lateral: ramus of mandible
• medial: lateral pterygoid plate of sphenoid bone
• anterior: posterior aspect of maxilla
• posterior: tympanic plate, mastoid process & styloid process of temporal bone
• superior/roof: greater wing of sphenoid bone
• inferior/floor: attachment of medial pterygoid muscle to mandible (medial aspect of angle

• oval shape; anterior to foramen spinosum
• Mandibular division of trigeminal nerve (V3)
• Accessory meningeal artery
• Lesser petrosal nerve

• posterior to & smaller than foramen ovale
• Middle meningeal artery & vein
• Meningeal branch of mandibular nerve (V3) - Recurrent meningeal nerve

• accumulation of blood between the skull & dura mater
• ex. middle meningeal artery damaged

• accumulation of blood in the potential space between the dura mater and the arachnoid mater
• ex. damage to bridging veins

Maxillary division of trigeminal nerve (V2)

• Oculomotor nerve (CN III)
• Trochlear nerve (CN IV)
• Ophthalmic branch of trigeminal nerve (V1) – frontal , lacrimal, & nasociliary
• Abducent nerve (CN VI)
• Superior ophthalmic vein
• Sympathetic fibers

• Medulla oblongata & Meninges
• Vertebral arteries & meningeal branches of vertebral arteries
• Dural veins
• Anterior & posterior spinal arteries
• Spinal roots of accessory nerve (CN XI)

• Glossopharyngeal nerve (CN IX)
• Vagus nerve (CN X)
• Accessory nerve (CN XI)
• Superior bulb of internal jugular vein
• Inferior petrosal sinus
• Sigmoid sinus
• Posterior meningeal artery

• temporomandibular joint
• ligaments of TMJ
• muscles of mastication
• branches of V3
• chorda tympani (CN VII)
• lesser petrosal nerve (CN IX)
• otic ganglion
• branches of maxillary artery
• superficial temporal vein
• pterygoid venus plexus
• maxillary vein
• deep facial vein
• retromandibular vein

• temporalis
• masseter
• medial pterygoid
• lateral pterygoid

first pharyngeal arch

trigeminal nerve (V3)

• ramus of the mandible
• lateral pterygoid plate
• posterior aspect of maxilla
• tympanic plate, mastoid process & styloid process of temporal bone
• infratemporal surface of greater wing of sphenoid
• attachment of medial pterygoid muscle (medial aspect of mandibular angle) 

• intrinsic: joint capsule & lateral ligament
• extrinsic: sphenomandibular & stylomandibular

• mandibular fossa of temporal bone
• articular tubercle of temporal bone
• condyle of mandible

continuous with middle ear cavity

• modified hinge joint (gliding hinge)
• two separate cavities separated by fibrocartilaginous disc
• upper cavity allows protrusion & retrusion
• lower cavity allows elevation & depression

• condyle sits anterior to temporal bone
• pain transmitted by trigeminal nerve

• origin: floor of temporal fossa & deep surface of temporalis fascia
• insertion: coronoid process & anterior border of ramus of mandible
• action: elevate & retrude mandible
• innervation: anterior & posterior deep temporal nerves

• branches of trigeminal nerve (V3)
• auriculotemporal nerve
• masseteric nerve

• origin: inferior border & medial surface of maxillary process of zygomatic bone; zygomatic arch
• insertion: angle & lateral surface of ramus of mandible
• action: elevate mandible; close jaw
• innervation: masseteric nerve

• superficial origin: tuberosity of maxilla & pyramidal process of palatine bone
• deep origin: medial surface of lateral pterygoid plate
• insertion: medial surface of ramus of mandible
• action: elevate mandible (close jaw); lateral mandibular movements
• innervation: nerve to medial pterygoid

• superior origin: infratemporal surface & crest of greater wing of sphenoid
• inferior origin: lateral surface of lateral pterygoid plate
• insertion: joint capsule & articular disc of TMJ; pterygoid fovea
• action: protrudes mandible; initiates jaw opening (with GRAVITY); lateral manidibular movements
• innervation: nerve to lateral pterygoid

• opthalmic
• maxillary
• mandibular

• GSA: sensory innervation to most of the face
• SVE: motor to muscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani, tensor veli palatini
• other fibers may "hitch a ride" but did NOT originate from trigeminal nerve

• muscles of mastication: masseter, temporalis, medial & lateral pterygoid
• mylohyoid
• anterior belly of digastric
• tensor tympani
• tensor veli palatini

• dura
• skull
• TMJ
• outer tympanic membrane
• mandibular teeth
• skin of temporal region
• skin of auricle
• skin of external auditory meatus
• skin of cheek
• skin of lower lip
• skin of lower face
• mucosa of cheek
• anterior 2/3 of tongue
• floor of mouth
• mastoid air cells
• gingiva of mandible
• lower lip

• masseteric nerve: motor to masseter; sensory to TMJ
• deep temporal nerve: motor to temporalis m.
• nerve to lateral pterygoid: motor
• long buccal nerve: sensory to skin & mucosa of cheek

• nerve to mylohyoid: motor to mylohyoid & anterior belly of digastric
• auriculotemporal nerve: sensory; splits around middle meningeal artery
• lingual nerve: sensory; joins with chorda tympani of facial nerve
• inferior alveolar nerve: sensory; enters mandibular foramen
• mental nerve: sensory; terminal branch of inferior alveolar nerve; emerges from mental foramen

• portion of facial nerve
• carries fibers to lingual nerve - GVE (parasympathetic) & SVA (special sensory taste fibers)

• branch of anterior division of CN V3
• motor to masseter
• little bit of sensory to TMJ

• branch of anterior division of CN V3
• sensory to skin & mucosa of cheek

• branch of posterior division of CN V3
• motor to mylohyoid & anterior belly of digastric

• branch of posterior division of CN V3
• sensory to TMJ, tympanic membrane, skin over parotid gland, skin of temporal region, skin of auricle, skin of external auditory canal
• splits around middle meningeal artery

• branch of posterior division of CN V3
• sensory to anterior 2/3 of tongue, floor of mouth & gingiva of mandible
• functional components - GSA
• joins with chorda tympani (GVE & SVA)

• branch of posterior division of  CN V3
• sensory to mandible, mandibular teeth, & gingiva of mandible
• enters mandibular foramen

• branch of posterior division of CN V3
• terminal branch of inferior alveolar nerve
• sensory to skin of chin, lower lip, mucosa of lower lip & gingiva of mandible
• emerges from mental foramen

• SVA: taste to anterior 2/3 of tongue
• GVE: motor to submandibular gland, sublingual gland & mucosa of floor of mouth

cell bodies of preganglionic parasympathetic fibers from CN VII (facial nerve)

houses cell bodies of postganglionic parasympathetic fibers of facial nerve (CN VII) that innervate submandibular & sublingual glands

cell body origin of all sensory fibers (esp. special sensory taste SVA)

reinforces articular capsule surrounding the TMJ

• runs from styloid process of temporal bone to posterior aspect of mandible
• support/accessory ligament
• some prevention of anterior dislocation
• essentially a thickening of cervical fascia

• runs from spine of sphenoid to lingula of mandible
• main ligament of TMJ: thick & strong
• serves as check ligament - prevents excessive motion of the mandible

• arises from CN IX (glossopharyngeal)
• GVE: parasympathetic motor fibers; controls secretions of parotid gland

cell bodies of preganglionic parasympathetic fibers of CN IX (glossopharyngeal nerve)

postganglionic parasympathetic fibers from glossopharyngeal nerve (CN IX) to parotid gland (via auriculotemporal nerve)

• mandibular: 5 branches
• pterygoid: 4 branches
• pterygopalatine: 6 branches

• superior thyroid a.
• ascending pharyngeal a.
• lingual a.
• facial a.
• occipital a.
• posterior auricular a.
• maxillary a.
• superficial temporal a.

• deep auricular a.
• anterior tympanic a.
• inferior alveolar a.
• middle meningeal a.
• accessory meningeal a.

• deep temporalis aa.
• pterygoid branches
• masseteric a.
• buccal a.

• posterior superior alveolar a.
• infraorbital a.
• artery of pterygoid canal
• pharyngeal branch
• descending palatine a. - greater palatine a. & lesser palatine a.
• sphenopalatine a.

• communicates with cavernous sinus, orbital veins, pharyngeal venous plexus & facial vein
• drains into maxillary vein then retromandibular vein

• airway
• breathing
• circulation

• agitation
• obtundation - disorientation/blacked out
• tachypnea - fast breathing
• chest retractions - chest muscle sinks due to attenuated breathing
• cyanosis - blue discoloration

• ability to talk & respond
• noisy breathing and stridor
• silence - NOT GOOD

air movement

• chin lift
• jaw thrust
• oral airway
• nasal airway
• ventilate - mask/mouth to mouth

• secure the airway with intubation
• use laryngoscope to intubate patient with long flexible plastic tube
• step is taken before utilization of surgical airway

• stenosis
• foreign body
• tumor
• trauma
• inflammation
• infection

• jet ventilation via needle cricothyroidotomy - requires special equipment in hospital
• cricothryoidotomy
• tracheotomy - done in controlled hospital settings or EXTREME emergencies

• palpate cricothyroid space
• stabilize thryroid cartilage
• horizontal incision
• spread or retract opening
• insert tube
• inflate endotracheal tube & bag
• confirm placement & stabilize tube

• pyramid
• base: orbit
• apex: optic canal
• medial walls: parallel to each other
• lateral walls: diverge at 45 degrees
• closed space except at base
• space occupying infections or tumors within orbit may cause the eyeball to bulge anteriorly

anterior protrusion of the eyeball

• frontal bone: supraorbital foramen, zygomatic process, nasal process, orbital process
• ethmoid bone: lamina papyrecea (thin orbital plate)
• sphenoid: lesser & greater wing
• maxilla: frontal aspect, orbital process
• lacrimal bone: anterior & posterior lacrimal crest
• palatine bone: orbital process
• zygomatic bone: orbital process

• optic canal
• superior orbital fissure
• inferior orbital fissure

• lateral margin: strongest part of orbital margin
• superior margin: roof of orbit
• medial rim: not prominent, surgically important (lacrimal sac)
• infraorbital margin: inferior palpebral

• lateral margin: most injuries occur from the temporal side
• superior margin: may damage trochlea & produce symptoms of superior oblique paralysis

sharp objects may easily penetrate the roof of the orbit & enter the anterior cranial fossa and/or the frontal paranasal sinuses

• anterior cranial fossa
• meninges
• frontal lobes of brain
• frontal paranasal sinus
• lesser wing of sphenoid
• orbital plate of frontal

• ethmoid paranasal sinuses
• sphenoid paranasal sinuses
• lacrimal bone
• orbital plate of ethmoid bone
• body of sphenoid bone
• ethmoidal air cells

• infections/tumors of the ethmoid paranasal sinuses may erode through thin medial wall
• common route through which sinus infections may produce orbital cellulitis
• vulnerable to operative procedure

inflammation of cellular or connective tissue

• temporal fossa
• temporalis muscle (ant.)
• middle cranial fossa
• meninges
• temporal lobe of the brain (post.)
• greater wing of sphenoid
• ONLY WALL NOT ASSOCIATED WITH A PARANASAL SINUS

• maxillary sinus
• infraorbital nerve & vessels
• pterygopalatine fossa
• temporal fossa
• zygomatic bone
• orbital surface of maxilla
• orbital process of palatine

• Orbit hit with something too large to penetrate orbit
• Transmits force to floor of orbit
• Contents of orbit end up in maxillary sinus
• Accompanied by areas of parasthetia (nerves running through infraorbital canal)

• blowout fractures
• malignant tumors of the maxillary sinus can easily invade the orbit
• necrosis of the bone from chronic inflammation of the maxillary sinus

• bruising around the eye
• diplopia - double vision
• proptosis - anterior protrusion of the eye
• numbness - damage to infraorbital nerve

• physician anesthesizes eye, grabs eye & tries to manually elevate eye
• unable to elevate eye - entrapment of inferior rectus muscle

• rounded opening at the apex of the orbit
• surrounded by the body & lesser wing of sphenoid bone
• connects middle cranial fossa with orbital cavity
• lies almost directly posterior along the medial wall of the orbit

• optic nerve
• opthalmic artery
• sympathetic plexus
• meninges
• extension of subarachnoid space

• located in upper lateral angle of apex of the orbit
• between the greater & lesser wings of the sphenoid
• connects the middle cranial fossa with the orbital cavity

• derivative of periorbital fascia
• surround both the optic canal & part of the superior orbital fissure

• lacrimal nerve (branch of V1)
• frontal nerve (branch of V1)
• superior opthalmic vein (danger zone)
• trochlear nerve (CN IV)

• upper & lower divisions of oculomotor nerve (CN III)
• nasociliary nerve (branch of V1)
• abduscens nerve (CN VI)
• inferior opthalmic vein

• oculomotor nerve (CN III)
• trochlear nerve (CN IV)
• opthalmic division of trigeminal nerve (CN V1) - frontal, lacrimal & nasociliary nerves
• abducens nerve (CN VI)
• sympathetic nerves
• opthalmic veins

• infraorbital nerve & artery
• communication between inferior opthalmic vein & pterygoid venous plexus
• orbital & zygomatic branches of maxillary division of trigeminal nerve (CN V2)

• supraorbital artery
• supraorbital nerve

anterior ethmoidal artery, vein & nerve

posterior ethmoidal artery, vein & nerve

• infraorbital nerve from CN V2
• infraorbital artery

• periosteum of orbit
• loosely attached
• continuous through various foramina of the orbit with the periosteum on outside of the skull
• continuous through inner surface of the skull with periosteal layer of dura (endocranium)
• with meninges, attached to dural sheath of optic nerve at optic canal
• tightly attached at suture lines

• annular tendon: posterior periosteal thickening
• orbital septa: enters eyelids; give upper & lower eylids continuity

• continuation of subarachnoid space  from inside cranial vault to posterior aspect of eye
• where optic nerve attaches

• disruption of normal pattern of retinal artery & vein distribution
• indicative of increased intracranial (CSF) pressure

• AKA Tenon's capsule or bulbar sheath
• separates eyeball from surrounding fat & other contents of orbit
• attached to sclera at entrance of optic nerve
• barrier to spread of infection or hemorrhage between eyeball & retroocular space
• socket for prosthesis

• meibomian (tarsal) glands
• lacrimal aruncle
• lacrimal papilla
• lacrimal puncta - open to lacrimal canaliculi to drain tears
• skin continuous with conjunctiva
• sebaceous glands associated with eyelashes
• orbicularis oculi muscle - orbital & palpebral portions

• hordeolum of lower lid
• infectionof sebaceous glands associated with cilia at edge of lid
• highly innervated space - painful

infection of meibomian (tarsal) glands at mid-upper lid

• largest component of lacrimal apparatus
• occupies lacrimal fossa on the superiolateral aspect of orbit
• subdivided by lateral horn of levator palpebrae superioris muscle aponeurosis
• two portions: orbital & palpebral
• dumps tears into orbit through lacrimal foramina

• extends down into upper lid
• yellowish visible portion of gland

found against the orbital process of the frontal bone in the roof of the orbit

• tears from lacrimal gland are extruded from lacrimal foramina into superior fornix of conjunctiva
• tears collect in lacrimal lake, enter lacrimal canaliculi
• through superior & inferior lacrimal punctum
• lacrimal canaliculi dump into lacrimal sac, which occupies the lacrimal fossa (medial orbital wall)
• tears drain down the nasolacrimal duct and into the inferior meatus of the nose

• closes lacrimal canaliculi
• tears will overflow lower lid

• common in newborns
• nasolacrimal sac has not yet canalized

• facial nerve lesion
• lack of nasal lacrimal groove
• cannot smile properly (half does not elevate)
• cannot tightly close eyes

• levator palpebrae superioris
• superior tarsal muscle (Muller's muscles)
• superior rectus muscle
• inferior rectus muscle
• lateral rectus muscle
• medial rectus muscle
• superior oblique muscle
• inferior oblique muscle

• vertical: ADduction & ABduction
• horizontal: elevation & depresseion
• anterior/posterior: rotation (intorsion & extorsion)

pupil moves towards nose (medial)

pupil moves towards ear (lateral)

medial rotation of the pupil

lateral rotation of the pupil

• superior rectus m.
• medial rectus m.
• inferior rectus m.

• inferior oblique m.
• lateral rectus m.
• superior oblique m.

• inferior oblique m.
• superior rectus m.

• superior oblique m.
• inferior rectus m.

• inferior oblique m.
• inferior rectus m.

• superior oblique m.
• superior rectus m.

• ask patient to follow finger tip away from nose & back towards nose
• when one eye is adducting, the other should be abducting
• testing integrity of muscle-nerve connection
• medial rectus m: inferior division of CN III (oculomotor)
• lateral rectus m: abducens nerve (CN VI)

• have patient fully ABduct eye
• test elevation & depression
• superior rectus m: superior division of oculomotor (CN III)
• inferior rectus m: inferior division of CN III (oculomotor)

• have patient fully ADduct eye
• test elevation & depression
• superior oblique m: trochlear nerve (CN IV)
• inferior oblique m: inferior division of CN III (oculomotor)

• lateral strabismus: eye is down & out (loss of IR, MR, IO, SR)
• dilated pupil: loss of constrictor pupilae m. (parasympathetic innervation); unopposed sympathetic stimulation
• ptosis: can't elevate lid (levator papebrae superioris m. innervated by superior division of CN III)
• loss of accomodation: loss of ciliary muscle (parasympathetics through short ciliary nerves)

• paralyzed superior oblique m.
• affected eye is elevated & adducted
• difficulty reading & going down stairs

• paralyzed lateral rectus m.
• affected eye is medially deviated
• cannot ABduct eye

• Bell's palsy
• can't smile or wink

• ciliary
• pterygopalatine
• otic
• submandibular

causes by interruption of sympathetic innervation to the head & neck

• ptosis of the lid: due to lack of innervation to the superior tarsal muscle
• myosis: constriction of the pupil due to lack of innervation to dilator pupillae muscle
• red face: due to dilation of superficial blood vessels (loss of sympathetic constriction of blood vessels)
• dry face: due to inactive sweat glands (anhidrosis)

• in mesencephalon
• location of preganglionic parasympathetic cell bodies associated with CN III (occulomotor)

made up of postganglionic parasympathetic cell bodies of neural crest cell origin

• bright light stimulus causes bilateral pupil constriction
• direct response in ipsilateral eye
• consentual response in contralateral eye

• afferent limb: CN II (optic nerve) fibers leave the optic tracts to enter the midbrain; synapse in Edinger-Westphal nucleus
• efferent limb: CN III parasympathetic fibers from Edinger-Westphal nucleus synapse in ciliary ganglion; travel down short ciliary nerves to iris sphincters

• different sized pupils
• the pupil on the affected size is larger than the normal pupil
• CN III lesion (parasympathetic interruption)

• CN III palsy: cannot open eye (orbicularis oculi)
• CN VII paralysis: cannot close eye (levator palpebrae superioris acts unopposed)

• frontal n: supratrochlear & supraorbital
• lacrimal n: sensory fibers to lacrimal gland
• nasociliary n: sensory ramus to ciliary ganglion, long ciliary nerves, posterior ethmoidal nerve, anterior ethmoidal, meningeal, nasal, medial palpebral nerves

• touch stimulation of cornea = blink
• afferent limb: sensation from cornea via CN V1
• efferent limb: blink via CN VII

• angular vein of the face
• superior & inferior ophtalmic veins
• cavernous sinus

• danger zone of face
• valveless
• communicates with superior opthalmic vein (ABOVE annular tendon)

• internal carotid artery (cavernous portion)
• abducens nerve (CN VI)

• CN III: oculomotor nerve
• CN IV: trochlear nerve
• CN V1: opthalmic division of trigeminal nerve
• CN V2: maxillary division of trigeminal nerve

• late complication of an infection of the central face or paranasal sinuses
• other causes - bacterial infection of the ear or maxillary teeth; trauma
• marked eyelid edema
• bluish purple discoloration: impeded venous drainage

• C2: superior cervical ganglion
• C3: hyoid bone
• C4: common carotid artery bifurcation & superior border of thyroid cartilage
• C5: rest of thyroid cartilage
• C6: vertebral artery enters transverse formen of C6; cricoid cartilage; middle cervical ganglion; larynx becomes trachea; pharynx become esophagus
• C7: inferior cervical ganglion

• inferior cervical ganglion
• fused with first thoracic ganglion near spinal nerve C8

• superficial musculo-aponeurotic system
• contains platysma muscle
• continuous with temporal fascia & galea aponeurotica

• investing fascia: wraps around trapezius & sternocleidomastoid
• prevertebral fascia: wraps around vertebrae & deep back muscles; continues as axillary sheath around brachial plexus
• pretracheal fascia: covers anterior aspect of trachea; splits into visceral & buccopharyngeal fascia
• carotid sheath: surrounds common carotids (bifurcate at C4)
• alar fascia: surrounds retropharyngeal space

• retropharyngeal: between buccopharyngeal & prevertebral fascia
• lateral pharyngeal: lateral to pharynx
• submandibular: below mandible

• medial border: posterior border of sternocleidomastoid
• lateral border: anterior borders of trapezius
• inferior border: intermediate 1/3 of clavicle
• roof: platysma & investing layer of deep cervical fascia

• accessory nerve
• cutaneous branches of the cervical plexus
• external jugular vein
• transverse cervical vessels
• suprascapular vessels
• subclavian vein & artery
• posterior belly of omohyoid m.
• roots & trunks of branchial plexus
• nerve to subclavius
• dorsal scapular nerve
• suprascapular nerve
• long thoracic nerve

• common insertion of nerves on posterior border of sternocleidomastoid
• lesser occipital n.
• greater auricular n.
• transverse cervical n.
• lateral, intermediate & middle supraclavicular nn.

• carotid triangle
• muscular triangle
• submandibular/digastric triangle
• submental triangle

• lateral border: anterior border of sternocleidomastoid
• medial border: anterior midline of nec
• superior border: inferior mandible
• roof: platysma & investing layer of deep cervical fascia

• lateral border: anterior border of SCM
• medial border: anterior belly of omohyoid
• superior border: posterior belly of digastric

• lateral: anterior border of SCM
• medial: midline of neck
• superior: anterior belly of omohyoid

• STRAP muscles
• sternohyoid, sternothyroid, thyrohyoid, omohyoid

• lateral: posterior belly of digastric
• medial: anterior belly of digastric
• superior: inferior mandible

• lateral: right & left anterior bellies of digastric
• superior: inferior mandible
• inferior: hyoid bone

detect changes in blood pressure

detect hypoxia & hypercapnia

• dilation of the proximal part of the internal carotid artery
• GVA sensation from CN IX (glossopharyngeal)
• contains baroreceptors

• small epitheliod body within the bifurcation of the common carotid artery
• GVA sensation from CN IX (glossopharyngeal)
• uses chemoreceptors to detect hypoxia & hypercapnia
• will elicit hormonal response to increase respiration, heart rate & blood pressure

• internal carotid plexus
• external carotid plexus
• gray rami communicans (C1-C4)
• pharyngeal plexus branches
• superior cervical cardiac nerve

• gray rami communicans (C5-C6)
• branches to thyroid
• middle cervical cardiac nerve

• gray rami communicans (C7-C8)
• inferior cervical cardiac nerve

NONE

• superior thyroid a.
• ascending pharyngeal a.
• lingual a.
• facial a.
• occipital a.
• posterior auricular a.
• maxillary a.
• superficial temporal a.

• vertebral artery
• thyrocervical trunk
• internal thoracic artery
• costocervical trunk
• dorsal scapular artery

• small deep pyramidal shaped space
• posterior to the maxilla
• posterior & inferior to apex of the orbit
• between the pterygoid process of the sphenoid bone & the perpendicular plate of the palatine bone

• medial wall: perpendicular plate of palatine bone
• roof: greater wing of sphenoid
• anterior border: posterior aspect of the maxilla
• posterior border: pterygoid process of the sphenoid bone

• palatine bone
• maxilla
• sphenoid bone

• infraorbital fissure
• sphenopalatine foramen
• foramen rotundum
• pterygoid canal
• pharyngeal canal
• palatine canal
• alveolar foramen
• pterygomaxillary fissure

• anteriorly to floor of the orbit through inferior orbital fissure
• posteriorly to the middle cranial fossa through the foramen rotundum and to the pharynx through the pharyngeal canal
• laterally to the infratemporal fossa through the pterygomaxillary fissure
• medially to the nasal cavity through the sphenopalatine foramen
• inferiorly to hard palate through the greater & lesser palatine foramina

• allows communication of the pterygopalatine fossa laterally with infratemporal fossa
• located between the back of the maxilla & the pterygoid process of sphenoid bone
• transmits 3rd part of maxillary artery

• allows communication of pterygopalatine fossa posteriorly with middle cranial fossa
• transmits maxillary nerve (V2) - courses through superior part of pterygopalatine fossa

• connects the superior part of foramen lacerum with the pterygopalatine fossa
• transmits the nerve of the pterygoid canal & artery of the pterygoid canal

• enters posterior aspect of pterygopalatine fossa
• between horizontal plate of palatine bone & vaginal processes
• transmits pharyngeal nerve & artery to the roof of the pharynx

• located at inferior aspect of pterygopalatine fossa at junction of anterior and posterior walls
• ends inferiorly in the greater & lesser palatine foramina at level of hard palate
• transmits greater & lesser palatine nerves and arteries

• on medial wall of pterygopalatine fossa between sphenoid bone & perpendicular plate of the palatine bone
• communicates medially with the nasal cavity
• transmits the sphenopalatine artery & the nasopalatine nerve

• pterygopalatine ganglion
• branches of the maxillary nerve
• nerves arising from the pterygopalatine ganglion
• branches of the third part of the maxillary artery
• accompanying veins

• fibromuscular aerodigestive tube
• extends from base of skull to the base of the cricoid cartilage at the level of the 6th cervical vertebra

• superior: body of sphenoid & basilar occipital bone
• inferior: esophageal inlet

• two nasal cavities through posterior choanae
• two tympanic cavities through pharyngotympanic tube
• mouth
• larynx through laryngeal aditus
• esophagus (direct communication at level of C6)

• nasopharynx
• oropharynx
• laryngopharynx

• posterior to the two nasal cavities
• communicates with nasal cavities via posterior nasal choanae
• inferior to the base of the skull (basisphenoid & basioccipital bones)
• above the level of the soft palate

• posterior to the oral cavity or the mouth
• anterior wall represented by the posterior 1/3 of the tongue
• inferior to the soft palate
• superior to the laryngeal aditus

• lies inferior to the oropharynx
• posterior to the larynx
• extends from the laryngeal aditus to the level of C6

ethmoid bone covered in mucosa

• isthmus of fauces/oropharyngeal isthmus
• narrowing of the pharynx at level of soft palate
• separates the nasopharynx from the oropharynx

• anteriorly & posteriorly border palatine tonsils
• palatoglossal fold: anterior pillar of the fauces
• palatopharyngeal fold: posterior pillar of the fauces

• anterior pillar of the fauces
• boundary between the oral cavity & the oropharynx
• formed by the palatoglossus m. covered by mucosa
• runs from palatine aponeurosis to the posterolateral surface of the tongue
• innervated by CN X

• posterior pillar of the fauces
• formed the palatopharyngeus m. covered with mucosa
• runs from the hard palate & the palatine aponeurosis to the posterior border of the lamina of the thyroid cartilage & the side of the pharynx and esophagus

• pharyngeal tonsils
• lymphoid tissue in nasopharynx

• mucosa: ciliated in nasopharynx; stratified squamous epithelium in oropharynx & laryngopharynx; tightly attached to the pharyngobasilar fascia
• pharyngobasilar fascia: lines the inside of the pharynx between the muscle of the mucosa
• muscular wall: superior, middle & inferior constrictors of the pharynx
• buccopharyngeal fascia: external to the muscles of the pharyngeal wall above the C6 vertebral level

• superior constrictor
• middle constrictor
• inferior constrictor

space between prevertebral & buccopharyngeal fascia

• stylopharyngeus
• salpingopharyngeus
• palatopharyngeus

• area devoid of muscle
• fusion of pharyngobasilar fascia & mucosa
• most posterior/superior aspect of the pharynx
• AKA sinus of Morgagni or fossa of Rosenmuller

• CN IX - glossopharyngeal: GVA fibers to mucosa of pharynx; SVE fibers to stylopharyngeus muscle
• CN X - vagus: SVE to muscles of pharynx & soft palate; GVE to glands of pharyngeal mucosa
• Sympathetics: GVE to blood vessels in the pharyngeal mucosa

• afferent pathway: glossopharyngeal n (CN IX)
• efferent pathway: vagus n (CN X) from nucleus ambiguus

• Tonsillar branch of lesser palatine artery
• Tonsillar branch of ascending pharyngeal
• Tonsillar branch of ascending palatine artery
• Tonsillar branch of facial artery
• Tonsillar branch of facial artery

ring of lymph tissue protecting the pharyngeal body

connects the palatine, pharyngeal, and lingual tonsils

• swallowing
• process by which a bolus of food  or liquid is transferred from the mouth to the stomach
• pattern-elicited response: both voluntary & reflex component
• controlled by central program generator in the swallowing center of the medulla

• oral preparatory phase
• oral transit phase
• pharyngeal phase
• esophageal phase

• voluntary control: process of mastication
• muscles of mastication (CN V3)
• labial musculature, orbicularis oris, buccinator (CN VII)
• tongue holds bolus against hard palate (CN XII)
• taste (CN VII, IX)
• temperature, touch, proprioception (CN V2, V3, IX)

• voluntary phase controlled by cerebral cortex through corticobulbar tracts
• manipulation of bolus to central portion of tongue & toward pharynx (CN VII & XII)

• involuntary rapid reflex in which bolus moves through pharynx
• triggered when bolus reaches palatoglossal fodl
• CN VII, IX & X
• swallowing reflex prevents interuption of posterior movement of the bolus
• retraction of tongue  (CN XII)
• tension (CN V3) & elevation (CN X) of palate
• elevation of larynx (C1, CN V3, VII, IX, X)

• stylohyoid - VII
• digastrics - V3 (anterior belly); VII (posterior belly)
• geniohyoid - C1
• thyrohyoid - C1
• mylohyoid - V3
• stylopharyngeus - IX
• salpingopharyngeus - X
• palatopharyngeus - X

• final phase of swallowing process
• under direct control of brain stem & myenterix plexus (CN X)
• peristaltic wave beginning in pharynx pushes bolus from cervical esophagus through esophageal gastric sphincter & into stomach

• lies in the anterior neck in front of C3-C6 (disc of C7)
• smaller & more superior placed in females & children
• extends from laryngeal aditus to lower border of cricoid cartilage
• lies between carotid sheaths
• is covered by lops of the thyroid gland & infrahyoid muscles
• continuous with trachea at level of C6 vertebra

• passageway for air
• production of sound
• protective mechanism - prevents things from entering respiratory tree

opening located between the epiglottis & superior aspect of the lamina of the cricoid cartilage

posterior protection during cricothyroidotomy

• made up of cartilages
• free cartilages: thyroid, cricoid, epiglottic
• paired cartilages: arytenoid, corniculate, cuneiform

• maintain patency of the airway
• serve as attachment for muscles

• two laminae - quadrangular shapes
• laryngeal prominence: laminae fuse in anterior midline; "Adam's apple"
• superior thryoid notch
• superior horn/cornu
• inferior horn/cornu
• oblique line: attachment for sternothryoid, thyrohyoid & inferior constrictor muscles
• attaches to the hyoid bone by thyrohyoid membrane and  median & lateral thyrohyoid ligaments

• internal branch of superior laryngeal nerve
• superior laryngeal artery

• attaches thyroid cartilage to hyoid bone by suspending the thryoid cartilage inferiorly
• pierced by internal branch of superior laryngeal nerve & superior laryngeal artery

thickening in the midline of the thyrohyoid membrane

• thickenings on either side of the thyrohyoid membrane
• attach the superior horn of the thyroid cartilage to the hyoid bone

small cartilaginous nodule frequently found in lateral thyrohyoid ligament

• "signet ring" shaped
• forms the interior parts of the anterior & lateral walls of the larynx
• anterior arch
• posterior lamina
• articulates with inferior cornu of thyroid cartilage via a synovial joint

• AKA cricothryoid membrane, cricovocal membrane
• connects cricoid cartilage to thyroid cartilage
• extends up medially and inserts on interior lamina of thyroid cartilage

• superior extension of the cricothyroid membrane
• superior free edge: forms vocal ligament
• attaches posteriorly to vocal processes of arytenoids

• paired cartilages on either side of the median plane on the upper border of the lamina of the cricoid cartilage
• forms a synovial joint with the lamina of the cricoid cartilage
• vocal process: where vocal ligaments attach
• muscular process: point of attachment of intrinsic muscles of the larynx
• apex: apical process
• base
• cricoarytenoid joint

synovial joint between superior aspect of lamina of cricoid cartilage and base of arytenoid cartilage

• AKA Santorini's cartilages
• wedge-shaped yellow elastic cartilage
• located at apex of arytenoid cartilage
• unknown function

• yellow elastic cartilage
• rod-like cartilages in the aryepiglottic folds

• spoon-shaped yellow elastic cartilage
• forms the anterior wall of the laryngeal aditus
• small glands present (look like pits)
• hooked onto posterior aspect of hyoid bone by hyoepiglottic ligament
• closes off opening to larynx

• cartilages become ossified with age & may be fractured during boxing, karate, or by a shoulder strap (seatbelt) in a car accident
• the thyroid cartilage begins to ossify ~20 yrs

• attach epiglottis to arytenoid cartilages
• forms the wall between the piriform recess & the larynx
• partially bind the laryngeal aditus (opening to larynx)
• cuneiform & corniculate tubercles present

connects thebody of the hyoid & the anterior surface of the epiglottis

• extends from anterior surface of arytenoid cartilage to posterior aspect of epiglottis
• superior free edge: form aryepiglottic fold
• inferior free edge: forms vestibular ligament/ false vocal cords

• thickened superior edge of the conus elasticus
• extend between the vocal processes of the arytenoid cartilages to the inside of the thyroid cartilage

vocal ligaments covered with epithelium/mucosa

• anterior: epiglottis
• lateral: aryepiglottic folds
• posterior: corniculate cartilages & arytenoideus muscles

• median glossoepiglottic fold: epiglottis to root of tongue
• lateral glossoepiglottic fold: epiglottis to sides of tongue (2)

• lateral depressions on either side of median glossoepiglottic fold between posterior aspect of tongue and anterior aspect of epiglottis
• place to look for foreign bodies (swallowed or aspirated)

• on either side of larynx posterior to laryngeal aditus
• subdivisions of laryngopharynx/hypopharynx

• triangular cavity posterior to the epiglottis & superior to the vestibular folds
• extends from the laryngeal aditus to the vestibular folds
• quadrangular membrane + mucosa

narrow aperture between true vocal cords

• appear pink in the living; contained within the vestibule
• superior to true vocal folds

free inferior edge of the quadrangular membrane

opening between the vestibular folds

• AKA ventricle of Morgagni, laryngeal sinus
• diverticulum between the vestibular & vocal folds

• appendix of the laryngeal ventricle
• diverticulum from the anterior end of the ventricle upward between the vestibular fold & inner surface of the thyroid cartilage

• concerned with phonation
• appear white in the living
• formed by vocal ligament (anterior 3/5) & vocal processes of arytenoid cartilages (posterior 2/5)

vocal folds (true vocal cords and mucosa) + rima glottidis (aperature between true vocal folds)

continuous inferiorly with the trachea

move the larynx as a whole (elevate or depress) because the hyoid bone is attached to the thryoid cartilage

• omohyoid, sternohyoid, sternothyroid & thyrohyoid
• in general, depressors of the larynx (NOT thyrohyoid)

• stylohyoid, digastric, geniohyoid, mylohyoid
• elevate the larynx w/ thyrohyoid, stylopharyngeus, salpingpharyngeus & palatopharyngeus

concerned with movements of laryngeal parts & alterations in the length & tension of the vocal folds

• stylohyoid
• digastric
• geniohyoid
• mylohyoid
• sternohyoid
• thyrohyoid
• sternothyroid
• omohyoid

• cricothyroid
• posterior cricoarytenoid
• lateral cricoarytenoid
• thryoarytenoid
• transverse arytenoid
• oblique arytenoid
• vocalis

• abduction of vocal folds: posterior cricoarytenoid
• adduction of vocal folds: lateral cricoarytenoid & transverse arytenoid
• tension of vocal ligaments: cricothyroid
• relaxation of vocal ligaments: vocalis

superior laryngeal a. & inferior laryngeal a.

• branch of superior thyroid artery
• accompanies superior laryngeal nerve
• penetrates thyrohyoid membrane

• branch of inferior thyroid artery from thyrocervical trunk
• passes with the inferior laryngeal nerve deep to lower border of inferior constrictor
• supplies the mucosa & musculature

• superior laryngeal nerve: largely sensory & secretory
• external branch of superior laryngeal nerve - innervates the cricothyroid muscle
• internal branch of superiro laryngeal nerve - penetrates thyrohyoid membrane along with superior laryngeal artery; innervates mucosa down as far as the vocal folds
• recurrent/inferior laryngeal nerve: sensory & secretory fibers; voluntary motor to all intrinsic muscles of the larynx except the cricothyroid; innervates mucosa below level of vocal folds

• radical neck dissection
• block dissection of cervical nodes
• removal of all ipsilateral cervical lymph node groups from levels I through V together with spinal accessory nerve, SCM & IJV

inflammation of lymph vessels

inflammation of the lymph nodes

spread of malignant (cancer) cells through lymphatic vessels

• lie along external jugular vein
• are in the superficial fascia
• are superficial or external to the SCM

• where scalp, including forehead, drains into ring of lymph nodes at junction of the head & neck
• horizontal chain
• occipital, mastoid/retromandibular, superficial parotid, mandibular, submental

drain lymphatic vessels from forehead, lateral parts of both eyelids, part of external nose

drain lymphatic vessels from the medial corner of the eye, most of the external nose, and lower part of face

drain occipital region

• located between the anterior bellies of the digastric muscle
• range from one to three nodes

• drain facial nodes of the face & submental node
• are the primary nodes for lateral part of tongue
• recirculate lymph fluid from nose, cheek, hard palate, upper lip, part of lower lip & floor of mouth

• lie within the parotid gland
• drain the face anterior to the gland & some of the pharynx

• anterior to the ear; located superficial to the parotid gland
• drainage from the lymph plexus of the skin

• usually only one on either side
• located on mastoid process or posterior external ear
• carries lymph from skin & scalp and drains into superior deep cervical nodes

• found along the course of the occipital artery
• recirculates lymph from occipital region & drains into the superior cervical nodes

• embedded in & around the CT of  the carotid sheath
• associated with the internal jugular vein
• upper (superior) deep cervical nodes: nodes lying above the level at which the omohyoid muscle crosses the carotid artery & the jugular vein
• lower (inferior) deep cervical nodes: nodes lying below the level of the omohyoid

• related to the internal jugular vein under the SCM
• jugulodigastric node: where the posterior belly of the digastric crosses the IJV & ICA
• jugulo-omohyoid node: where the omohyoid crosses the IJV & ICA
• bounded by anterior & posterior triangles of the neck
• made more apparent for examination by turning patient's head
• lymph nodes lie deep to the superior aspect of the muscle

• posterior lateral nodes associated with the subclavian vessels & the brachial plexus
• supraclavicular nodes
• retroauricular nodes

6-10 nodes may be found in lower portion of posterior triangle

• lie inferior to the omohyoid muscle
• receive lymph vessels descending from the superior deep cervical nodes, larynx, trachea & scalp
• last group of nodes through which lymph passes before entering the thoracic duct

• median glossoepiglottic fold: midline of tongue drain bilaterally
• lateral tongue: drains ipsilaterally
• lymphatics of base/root of tongue drain to jugulodigastric node
• lymphatics from middle of tongue drain to submandibular nodes
• lymphatics from lateral parts of tongue drain into submandibular nodes
• lymphatics from medial tip of tongue drain bilaterally into submental nodes

• infection mononucleosis (kissing disease)
• non-hodgkin's lymphoma
• persistant generalized lymphadenopathy
• cat scratch disease
• metastatic carcinoma

• anterior & posterior bellies of digastric
• mylohyoid
• stylohyoid
• geniohyoid

• superficial part of submandibular gland
• submandibular & submental lymph nodes
• facial a & v
• submental a & v
• mylohyoid a & v
• mylohyoid n.
• branches of CN VII

• lingual n.
• CN XII
• submandibular ganglion
• deep part of submandibular gland
• submandibular duct
• sublingual gland

• lingual artery
• deep lingual vv.
• CN IX

• circumvallate: in front of terminal sulcus; taste buds
• fungiform: numerous on sides & tip; taste buds
• foliate: on margin; taste buds
• filiform: most numerous; NO taste buds

• styloglossus
• genioglossus
• hyoglossus
• palatoglossus

• anterior 2/3 tongue
• posterior 1/3 tongue
• soft palate
• portion of tongue just anterior to epiglottis
• epiglottis
• aryepiglottic fold

• palatoglossus
• palatopharyngeus
• musculus uvulae
• levator veli palatini
• tensor veli palatini

• facial a. - tonsillar a & ascending palatine a.
• lingual a. - dorsal lingual a.
• ascending pharyngeal a.
• maxillary a. - descending palatine a. - lesser palatine a.

• frontal: middle meatus
• anterior ethmoidals: middle meatus
• middle ethmoidals: middle meatus
• posterior ethmoidals: superior meatus
• maxillary: middle meatus
• sphenoid: sphenoethmoidal recess

supraorbital n.

anterior ethmoidal branches of nasociliary n.

• posterior ethmoidal branches of nasociliary n.
• orbital branches of V2

• posterior ethmoidal branches of nasociliary n.
• orbital branches & pharyngeal branches of V2

anterior, middle & posterior superior alveolar nn.