-
pterion
- junction of greater wing of the sphenoid, squamous temporal, frontal & parietal bones
- overlies course of anterior division of middle meningeal artery
-
lambda
point on calvaria at junction of lambdoid and sagittal sutures
-
bregma
point on calvaria at junction of coronal and sagittal sutures
-
vertex
- superior point of neurocranium
- in middle with the cranium oriented in anatomical plane
-
asterion
- star shaped
- located at junction of three sutures: parietomastoid, occipitomastoid & lamboid
-
glabella
- smooth prominence
- most marked in males
- on the frontal bones superior to the root of nose
- most anterior projecting part of forehead
-
inion
most prominent point of external occipital protuberance
-
nasion
point on cranium where frontonasal & internasal sutures meet
-
layers of scalp
- skin
- connective tissue (dense)
- aponeurosis (galea aponeurotica)
- loose connective tissue (danger area)
- periosteum
-
boundaries of scalp
- extends from superior part of neck posteriorly to the eyebrows anteriorly & to the zygomatic arches laterally
- covers the calvaria
-
scalp proper
- first 3 layers
- skin, dense connective tissue, aponeurosis
-
scalp: skin
- contains many hair follicles, sebaceous glands & sweat glands
- sebaceous glands may become obstructed leading to sebaceous cysts (more common in scalp than anywhere else)
-
scalp: dense CT
- richly vascularized & innervated
- many collagenous & elastic fibers which attach to the skin and to the deeper galea aponeurosis
-
scalp lacerations
- 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
-
superficial infections of the scalp
tend to remain superficial because of the density of the fibrous tissue
-
scalp: aponeurosis
- epicranial aponeurosis
- galea aponeurosis
-
muscles of the scalp aponeurosis
- epicranius
- frontalis
- occipitalis
-
scalp: loose connective tissue
- "danger area"
- limits of the loose CT space or subaponeurotic space is important in the spread of infection
-
scalp: posterior loose CT
infection is unable to spread into the neck because the galea aponeurosis is attached to the superior nuchal line
-
scalp: lateral loose CT
infection is unable to spread beyond the zygomatic arches because the galea aponeurosis is continuous here with the temporal fascia
-
scalp: anterior loose CT
fluid or pus can enter the eyelids and the root of the nose because the frontalis is inserted into the skin & dense subcutaneous tissue
-
pericranium
- 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
-
bleeding under the periosteum
will be confined to the limits of the bone underlying that portion of periosteum
-
SMAS
- 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
-
muscles of facial expression
- 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
-
divisions of trigeminal nerve
- 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
-
branches of the facial nerve
- 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
-
Bell's palsy
- 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
-
trigeminal neuralgia
- 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
-
nerves of the scalp
- 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)
-
greater occipital nerve
innervates the skin of the back of the head as far superiorly as the vertex
-
lesser occipital nerve
innervates the skin behind the ear
-
great auricular nerve
innervates the skin of the lower part of the ear and skin over the angle of the mandible and lower part of parotid gland
-
CN V1
- 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
-
CN V2
- maxillary division of trigeminal nerve
- sensory innervation of skin of lower eyelid, cheek & upper lip
- branches: infraorbital nerve, zygomaticofacial nerve, zygomaticotemporal nerve
-
CN V3
- 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
-
superficial arteries of face & scalp
- external carotid branches: occipital artery, posterior auricular artery, superficial temporal artery
- internal carotid branch: opthalmic artery (divides into supraorbital artery & supratrochlear artery)
-
emissary veins
- 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)
-
diploic veins
- 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
-
trigeminal ganglion
sensory ganglion of trigeminal nerve
-
shingles of face
- herpes zoster
- area of V1
- virus lies latently in trigeminal ganglion
-
epidural hematoma
- accumulation of blood between the skull & dura mater
- pterion overlies middle meningeal artery
- fractures along skull can tear artery
-
danger area of the face
- 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
-
parotid gland
- serous salivary gland
- wraps around behind mandible right in front of ear
- contains facial nerve, retromandibular vein & external carotid artery
-
parotid duct
- goes across masseter muscle
- pierces the buccinator muscle
- opens up into the vestibule of the oral cavity opposite the second maxillary molar
-
autonomic innervation to parotid gland
- 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
-
motor innervation to muscles of facial expression
facial nerve
-
structures found within parotid gland
- facial nerve
- external carotid artery
- retromandibular vein
-
supraorbital foramen: contents
- supraorbital artery
- supraorbital nerve
-
supratrochlear notch: contents
supratrochlear nerve
-
infraorbital canal: contents
- Infraorbital nerve (branch of V2)
- infraorbital artery
-
mental foramen
mental nerve
-
middle meningeal artery
- lies deep to pterion
- damage will cause epidural or extradural hematoma
- largely responsible for multiple small impressions on the inside of the skull
-
temporal fossa
- 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
-
borders of infratemporal fossa
- 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
-
foramen ovale
- oval shape; anterior to foramen spinosum
- Mandibular division of trigeminal nerve (V3)
- Accessory meningeal artery
- Lesser petrosal nerve
-
foramen spinosum
- posterior to & smaller than foramen ovale
- Middle meningeal artery & vein
- Meningeal branch of mandibular nerve (V3) - Recurrent meningeal nerve
-
epidural hematoma
- accumulation of blood between the skull & dura mater
- ex. middle meningeal artery damaged
-
subdural hematoma
- accumulation of blood in the potential space between the dura mater and the arachnoid mater
- ex. damage to bridging veins
-
foramen rotundum: contents
Maxillary division of trigeminal nerve (V2)
-
superior orbital fissure: contents
- 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
-
foramen magnum: contents
- Medulla oblongata & Meninges
- Vertebral arteries & meningeal branches of vertebral arteries
- Dural veins
- Anterior & posterior spinal arteries
- Spinal roots of accessory nerve (CN XI)
-
jugular foramen: contents
- 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
-
contents of infratemporal fossa
- 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
-
muscles of mastication
- temporalis
- masseter
- medial pterygoid
- lateral pterygoid
-
embryologic origin of muscles of mastication
first pharyngeal arch
-
motor innervation of muscles of mastication
trigeminal nerve (V3)
-
bony landmarks of infratemporal fossa
- 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)
-
ligaments of TMJ
- intrinsic: joint capsule & lateral ligament
- extrinsic: sphenomandibular & stylomandibular
-
bones of TMJ
- mandibular fossa of temporal bone
- articular tubercle of temporal bone
- condyle of mandible
continuous with middle ear cavity
-
movements of TMJ
- modified hinge joint (gliding hinge)
- two separate cavities separated by fibrocartilaginous disc
- upper cavity allows protrusion & retrusion
- lower cavity allows elevation & depression
-
dislocation of TMJ
- condyle sits anterior to temporal bone
- pain transmitted by trigeminal nerve
-
temporalis m.
- 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
-
innervation of TMJ
- branches of trigeminal nerve (V3)
- auriculotemporal nerve
- masseteric nerve
-
masseter m.
- 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
-
medial pterygoid
- 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
-
lateral pterygoid m.
- 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
-
branches of trigeminal nerve
- opthalmic
- maxillary
- mandibular
-
functional components of CN V
- 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
-
CN V3: motor
- muscles of mastication: masseter, temporalis, medial & lateral pterygoid
- mylohyoid
- anterior belly of digastric
- tensor tympani
- tensor veli palatini
-
CN V3: sensory
- 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
-
anterior division of V3
- 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
-
posterior division of V3
- 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
-
chorda tympani
- portion of facial nerve
- carries fibers to lingual nerve - GVE (parasympathetic) & SVA (special sensory taste fibers)
-
masseteric nerve
- branch of anterior division of CN V3
- motor to masseter
- little bit of sensory to TMJ
-
long buccal nerve
- branch of anterior division of CN V3
- sensory to skin & mucosa of cheek
-
nerve to mylohyoid
- branch of posterior division of CN V3
- motor to mylohyoid & anterior belly of digastric
-
auriculotemporal nerve
- 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
-
lingual nerve
- 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)
-
inferior alveolar nerve
- branch of posterior division of CN V3
- sensory to mandible, mandibular teeth, & gingiva of mandible
- enters mandibular foramen
-
mental nerve
- 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
-
functional components of CN VII
- SVA: taste to anterior 2/3 of tongue
- GVE: motor to submandibular gland, sublingual gland & mucosa of floor of mouth
-
superior salivary nucleus
cell bodies of preganglionic parasympathetic fibers from CN VII (facial nerve)
-
submandibular ganglion
houses cell bodies of postganglionic parasympathetic fibers of facial nerve (CN VII) that innervate submandibular & sublingual glands
-
geniculate ganglion
cell body origin of all sensory fibers (esp. special sensory taste SVA)
-
lateral ligament of TMJ
reinforces articular capsule surrounding the TMJ
-
stylomandibular ligament
- 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
-
sphenomandibular ligament
- 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
-
lesser petrosal nerve
- arises from CN IX (glossopharyngeal)
- GVE: parasympathetic motor fibers; controls secretions of parotid gland
-
inferior salivary nucleus
cell bodies of preganglionic parasympathetic fibers of CN IX (glossopharyngeal nerve)
-
otic ganglion
postganglionic parasympathetic fibers from glossopharyngeal nerve (CN IX) to parotid gland (via auriculotemporal nerve)
-
divisions of maxillary artery
- mandibular: 5 branches
- pterygoid: 4 branches
- pterygopalatine: 6 branches
-
branches of external carotid artery
- superior thyroid a.
- ascending pharyngeal a.
- lingual a.
- facial a.
- occipital a.
- posterior auricular a.
- maxillary a.
- superficial temporal a.
-
branches of first part of maxillary artery
- deep auricular a.
- anterior tympanic a.
- inferior alveolar a.
- middle meningeal a.
- accessory meningeal a.
-
branches of second part of maxillary artery
- deep temporalis aa.
- pterygoid branches
- masseteric a.
- buccal a.
-
branches of third part of maxillary artery
- posterior superior alveolar a.
- infraorbital a.
- artery of pterygoid canal
- pharyngeal branch
- descending palatine a. - greater palatine a. & lesser palatine a.
- sphenopalatine a.
-
pterygoid venous plexus
- communicates with cavernous sinus, orbital veins, pharyngeal venous plexus & facial vein
- drains into maxillary vein then retromandibular vein
-
ABCs of trauma
- airway
- breathing
- circulation
-
what to look for when checking airway
- agitation
- obtundation - disorientation/blacked out
- tachypnea - fast breathing
- chest retractions - chest muscle sinks due to attenuated breathing
- cyanosis - blue discoloration
-
what to listen for when checking airway
- ability to talk & respond
- noisy breathing and stridor
- silence - NOT GOOD
-
what to feel for when checking airway
air movement
-
manuevers to assist a patient's breathing
- chin lift
- jaw thrust
- oral airway
- nasal airway
- ventilate - mask/mouth to mouth
-
definitive airway
- secure the airway with intubation
- use laryngoscope to intubate patient with long flexible plastic tube
- step is taken before utilization of surgical airway
-
airway obstructions: larynx
- stenosis
- foreign body
- tumor
- trauma
- inflammation
- infection
-
surgical airways
- jet ventilation via needle cricothyroidotomy - requires special equipment in hospital
- cricothryoidotomy
- tracheotomy - done in controlled hospital settings or EXTREME emergencies
-
cricothyroidotomy: procedure
- palpate cricothyroid space
- stabilize thryroid cartilage
- horizontal incision
- spread or retract opening
- insert tube
- inflate endotracheal tube & bag
- confirm placement & stabilize tube
-
eye orbit
- 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
-
proptosis/exophthalmos
anterior protrusion of the eyeball
-
bones of eye orbit
- 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
-
foramen of eye orbit
- optic canal
- superior orbital fissure
- inferior orbital fissure
-
orbital margins
- lateral margin: strongest part of orbital margin
- superior margin: roof of orbit
- medial rim: not prominent, surgically important (lacrimal sac)
- infraorbital margin: inferior palpebral
-
orbital fractures
- lateral margin: most injuries occur from the temporal side
- superior margin: may damage trochlea & produce symptoms of superior oblique paralysis
-
orbital roof injuries
sharp objects may easily penetrate the roof of the orbit & enter the anterior cranial fossa and/or the frontal paranasal sinuses
-
orbital roof relationships
- anterior cranial fossa
- meninges
- frontal lobes of brain
- frontal paranasal sinus
- lesser wing of sphenoid
- orbital plate of frontal
-
orbital medial wall relationships
- ethmoid paranasal sinuses
- sphenoid paranasal sinuses
- lacrimal bone
- orbital plate of ethmoid bone
- body of sphenoid bone
- ethmoidal air cells
-
orbital medial wall injuries
- 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
-
orbital cellulitis
inflammation of cellular or connective tissue
-
orbital lateral wall relationships
- 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
-
orbital floor relationships
- maxillary sinus
- infraorbital nerve & vessels
- pterygopalatine fossa
- temporal fossa
- zygomatic bone
- orbital surface of maxilla
- orbital process of palatine
-
blowout fractures
- 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)
-
orbital floor injuries
- blowout fractures
- malignant tumors of the maxillary sinus can easily invade the orbit
- necrosis of the bone from chronic inflammation of the maxillary sinus
-
symptoms of a blowout fracture
- bruising around the eye
- diplopia - double vision
- proptosis - anterior protrusion of the eye
- numbness - damage to infraorbital nerve
-
forced duction test
- physician anesthesizes eye, grabs eye & tries to manually elevate eye
- unable to elevate eye - entrapment of inferior rectus muscle
-
optic canal
- 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
-
contents of optic canal
- optic nerve
- opthalmic artery
- sympathetic plexus
- meninges
- extension of subarachnoid space
-
superior orbital fissure
- 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
-
annular tendon
- derivative of periorbital fascia
- surround both the optic canal & part of the superior orbital fissure
-
structures outside the annular tendon
- lacrimal nerve (branch of V1)
- frontal nerve (branch of V1)
- superior opthalmic vein (danger zone)
- trochlear nerve (CN IV)
-
structures within the annular tendon
- upper & lower divisions of oculomotor nerve (CN III)
- nasociliary nerve (branch of V1)
- abduscens nerve (CN VI)
- inferior opthalmic vein
-
contents of superior orbital fissure
- 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
-
contents of inferior orbital fissure
- infraorbital nerve & artery
- communication between inferior opthalmic vein & pterygoid venous plexus
- orbital & zygomatic branches of maxillary division of trigeminal nerve (CN V2)
-
supraorbital foramen
- supraorbital artery
- supraorbital nerve
-
anterior ethmoidal foramen
anterior ethmoidal artery, vein & nerve
-
posterior ethmoidal foramen
posterior ethmoidal artery, vein & nerve
-
infraorbital canal
- infraorbital nerve from CN V2
- infraorbital artery
-
periorbita
- 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
-
derivatives of periorbita
- annular tendon: posterior periosteal thickening
- orbital septa: enters eyelids; give upper & lower eylids continuity
-
optic papilla
- continuation of subarachnoid space from inside cranial vault to posterior aspect of eye
- where optic nerve attaches
-
papilledema
- disruption of normal pattern of retinal artery & vein distribution
- indicative of increased intracranial (CSF) pressure
-
fascia bulbi
- 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
-
features of eyelid
- 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
-
sty
- hordeolum of lower lid
- infectionof sebaceous glands associated with cilia at edge of lid
- highly innervated space - painful
-
chalazion
infection of meibomian (tarsal) glands at mid-upper lid
-
lacrimal gland
- 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
-
palpebral lacrimal gland
- extends down into upper lid
- yellowish visible portion of gland
-
orbital lacrimal gland
found against the orbital process of the frontal bone in the roof of the orbit
-
lacrimial apparatus
- tears from lacrimal gland are extruded from lacrimal foramina into superior fornix of conjunctiva
- tears collect in lacrimal lake, enter lacrimal canaliculithrough 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
-
epiphera
- closes lacrimal canaliculi
- tears will overflow lower lid
-
infected tear duct
- common in newborns
- nasolacrimal sac has not yet canalized
-
Bell's palsy
- facial nerve lesion
- lack of nasal lacrimal groove
- cannot smile properly (half does not elevate)
- cannot tightly close eyes
-
extraocular muscles
- 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
-
axes of eye movement
- vertical: ADduction & ABduction
- horizontal: elevation & depresseion
- anterior/posterior: rotation (intorsion & extorsion)
-
adduction of eye
pupil moves towards nose (medial)
-
abduction of eye
pupil moves towards ear (lateral)
-
intorsion
medial rotation of the pupil
-
extorsion
lateral rotation of the pupil
-
adductors of the eye
- superior rectus m.
- medial rectus m.
- inferior rectus m.
-
abductors of the eye
- inferior oblique m.
- lateral rectus m.
- superior oblique m.
-
elevators of the eye
- inferior oblique m.
- superior rectus m.
-
depressors of the eye
- superior oblique m.
- inferior rectus m.
-
lateral rotators of the eye
- inferior oblique m.
- inferior rectus m.
-
medial rotators of the eye
- superior oblique m.
- superior rectus m.
-
clinical testing of medial & lateral rectus muscles
- 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)
-
clinical testing of superior & inferior rectus muscles
- 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)
-
clinical testing of superior & inferior oblique muscles
- have patient fully ADduct eye
- test elevation & depression
- superior oblique m: trochlear nerve (CN IV)
- inferior oblique m: inferior division of CN III (oculomotor)
-
CN III lesion
- 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)
-
CN IV lesion
- paralyzed superior oblique m.
- affected eye is elevated & adducted
- difficulty reading & going down stairs
-
CN VI lesion
- paralyzed lateral rectus m.
- affected eye is medially deviated
- cannot ABduct eye
-
CN VII lesion
- Bell's palsy
- can't smile or wink
-
parasympathetic ganglion of the head & neck
- ciliary
- pterygopalatine
- otic
- submandibular
-
Horner's syndrome
causes by interruption of sympathetic innervation to the head & neck
-
symptoms of Horner's syndrome
- 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)
-
Edinger Westphal nucleus
- in mesencephalon
- location of preganglionic parasympathetic cell bodies associated with CN III (occulomotor)
-
ciliary ganglion
made up of postganglionic parasympathetic cell bodies of neural crest cell origin
-
pupillary light response
- bright light stimulus causes bilateral pupil constriction
- direct response in ipsilateral eye
- consentual response in contralateral eye
-
pupillary light reflex
- 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
-
anisocoria
- different sized pupils
- the pupil on the affected size is larger than the normal pupil
- CN III lesion (parasympathetic interruption)
-
CN III palsy vs. CN VII paralysis
- CN III palsy: cannot open eye (orbicularis oculi)
- CN VII paralysis: cannot close eye (levator palpebrae superioris acts unopposed)
-
branches of opthalmic division of trigeminal nerve (CN V1)
- 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
-
corneal reflex
- touch stimulation of cornea = blink
- afferent limb: sensation from cornea via CN V1
- efferent limb: blink via CN VII
-
drainage of the head
- angular vein of the face
- superior & inferior ophtalmic veins
- cavernous sinus
-
angular vein
- danger zone of face
- valveless
- communicates with superior opthalmic vein (ABOVE annular tendon)
-
structures within cavernous sinus
- internal carotid artery (cavernous portion)
- abducens nerve (CN VI)
-
structures in lateral wall of cavernous sinus
- CN III: oculomotor nerve
- CN IV: trochlear nerve
- CN V1: opthalmic division of trigeminal nerve
- CN V2: maxillary division of trigeminal nerve
-
cavernous sinus thrombosis
- 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
-
important vertebral levels of the neck
- 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
-
stellate ganglion
- inferior cervical ganglion
- fused with first thoracic ganglion near spinal nerve C8
-
SMAS
- superficial musculo-aponeurotic system
- contains platysma muscle
- continuous with temporal fascia & galea aponeurotica
-
deep fascia of the neck
- 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
-
spaces within fascia of the neck
- retropharyngeal: between buccopharyngeal & prevertebral fascia
- lateral pharyngeal: lateral to pharynx
- submandibular: below mandible
-
borders of posterior triangle of the neck
- 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
-
contents of posterior triangle of the neck
- 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
-
Erb's point
- common insertion of nerves on posterior border of sternocleidomastoid
- lesser occipital n.
- greater auricular n.
- transverse cervical n.
- lateral, intermediate & middle supraclavicular nn.
-
anterior cervical region/ anterior triangle
- carotid triangle
- muscular triangle
- submandibular/digastric triangle
- submental triangle
-
boundaries of anterior 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
-
boundaries of carotid triangle
- lateral border: anterior border of SCM
- medial border: anterior belly of omohyoid
- superior border: posterior belly of digastric
-
boundaries of muscular triangle
- lateral: anterior border of SCM
- medial: midline of neck
- superior: anterior belly of omohyoid
-
contents of muscular triangle
- STRAP muscles
- sternohyoid, sternothyroid, thyrohyoid, omohyoid
-
boundaries of submandibular triangle
- lateral: posterior belly of digastric
- medial: anterior belly of digastric
- superior: inferior mandible
-
boundaries of submental triangle
- lateral: right & left anterior bellies of digastric
- superior: inferior mandible
- inferior: hyoid bone
-
baroreceptors
detect changes in blood pressure
-
chemoreceptors
detect hypoxia & hypercapnia
-
carotid sinus
- dilation of the proximal part of the internal carotid artery
- GVA sensation from CN IX (glossopharyngeal)
- contains baroreceptors
-
carotid body
- 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
-
branches of superior cervical ganglion (sympathetic)
- internal carotid plexus
- external carotid plexus
- gray rami communicans (C1-C4)
- pharyngeal plexus branches
- superior cervical cardiac nerve
-
branches of middle cervical ganglion (sympathetic)
- gray rami communicans (C5-C6)
- branches to thyroid
- middle cervical cardiac nerve
-
branches of inferior cervical ganglion (sympathetic)
- gray rami communicans (C7-C8)
- inferior cervical cardiac nerve
-
branches of internal carotid artery in neck
NONE
-
branches of external carotid artery
- superior thyroid a.
- ascending pharyngeal a.
- lingual a.
- facial a.
- occipital a.
- posterior auricular a.
- maxillary a.
- superficial temporal a.
-
branches of subclavian artery
- vertebral artery
- thyrocervical trunk
- internal thoracic artery
- costocervical trunk
- dorsal scapular artery
-
pterygopalatine fossa
- 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
-
borders of the pterygopalatine fossa
- 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
-
bones that form the pterygopalatine fossa
- palatine bone
- maxilla
- sphenoid bone
-
foramina of the pterygopalatine fossa
- infraorbital fissure
- sphenopalatine foramen
- foramen rotundum
- pterygoid canal
- pharyngeal canal
- palatine canal
- alveolar foramen
- pterygomaxillary fissure
-
communication of pterygopalatine fossa
- 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 forameninferiorly to hard palate through the greater & lesser palatine foramina
-
pterygomaxillary fissure
- 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
-
foramen rotundum
- allows communication of pterygopalatine fossa posteriorly with middle cranial fossa
- transmits maxillary nerve (V2) - courses through superior part of pterygopalatine fossa
-
pterygoid canal
- connects the superior part of foramen lacerum with the pterygopalatine fossa
- transmits the nerve of the pterygoid canal & artery of the pterygoid canal
-
pharyngeal 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
-
greater palatine canal
- 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
-
sphenopalatine foramen
- 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
-
contents of the pterygopalatine fossa
- pterygopalatine ganglion
- branches of the maxillary nerve
- nerves arising from the pterygopalatine ganglion
- branches of the third part of the maxillary artery
- accompanying veins
-
pharynx
- fibromuscular aerodigestive tube
- extends from base of skull to the base of the cricoid cartilage at the level of the 6th cervical vertebra
-
boundaries of the pharynx
- superior: body of sphenoid & basilar occipital bone
- inferior: esophageal inlet
-
communication of the pharynx
- two nasal cavities through posterior choanae
- two tympanic cavities through pharyngotympanic tube
- mouth
- larynx through laryngeal aditus
- esophagus (direct communication at level of C6)
-
divisions of the pharynx
- nasopharynx
- oropharynx
- laryngopharynx
-
nasopharynx
- 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
-
oropharynx
- 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
-
laryngopharynx
- lies inferior to the oropharynx
- posterior to the larynx
- extends from the laryngeal aditus to the level of C6
-
conchae
ethmoid bone covered in mucosa
-
pharyngeal isthmus
- isthmus of fauces/oropharyngeal isthmus
- narrowing of the pharynx at level of soft palate
- separates the nasopharynx from the oropharynx
-
pillars of fauces
- anteriorly & posteriorly border palatine tonsils
- palatoglossal fold: anterior pillar of the fauces
- palatopharyngeal fold: posterior pillar of the fauces
-
palatoglossal fold
- 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
-
palatopharyngeal fold
- 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
-
adenoids
- pharyngeal tonsils
- lymphoid tissue in nasopharynx
-
layers of the pharyngeal wall
- 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
-
pharyngeal constrictors
- superior constrictor
- middle constrictor
- inferior constrictor
-
retropharyngeal space
space between prevertebral & buccopharyngeal fascia
-
longitudinal pharyngeal muscles
- stylopharyngeus
- salpingopharyngeus
- palatopharyngeus
-
pharyngeal recess
- area devoid of muscle
- fusion of pharyngobasilar fascia & mucosa
- most posterior/superior aspect of the pharynx
- AKA sinus of Morgagni or fossa of Rosenmuller
-
contributions to the pharyngeus plexus
- 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
-
gag reflex
- afferent pathway: glossopharyngeal n (CN IX)
- efferent pathway: vagus n (CN X) from nucleus ambiguus
-
blood supply to tonsils
- 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
-
Waldeyer's tonsillar ring
ring of lymph tissue protecting the pharyngeal body
-
lateral pharyngeal bands
connects the palatine, pharyngeal, and lingual tonsils
-
degluttition
- 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
-
phases of normal swallowing
- oral preparatory phase
- oral transit phase
- pharyngeal phase
- esophageal phase
-
oral prepatory 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)
-
oral transit phase
- voluntary phase controlled by cerebral cortex through corticobulbar tracts
- manipulation of bolus to central portion of tongue & toward pharynx (CN VII & XII)
-
pharyngeal phase
- 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)
-
elevation of larynx (muscles & CN)
- stylohyoid - VII
- digastrics - V3 (anterior belly); VII (posterior belly)
- geniohyoid - C1
- thyrohyoid - C1
- mylohyoid - V3
- stylopharyngeus - IX
- salpingopharyngeus - X
- palatopharyngeus - X
-
esophageal phase
- 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
-
larynx
- 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
-
function of larynx
- passageway for air
- production of sound
- protective mechanism - prevents things from entering respiratory tree
-
laryngeal aditus
opening located between the epiglottis & superior aspect of the lamina of the cricoid cartilage
-
lamina of cricoid cartilage
posterior protection during cricothyroidotomy
-
laryngeal skeleton
- made up of cartilages
- free cartilages: thyroid, cricoid, epiglottic
- paired cartilages: arytenoid, corniculate, cuneiform
-
function of laryngeal cartilages
- maintain patency of the airway
- serve as attachment for muscles
-
thyroid cartilage
- 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
-
structures that pierce the thryohyoid membrane
- internal branch of superior laryngeal nerve
- superior laryngeal artery
-
thyrohyoid membrane
- attaches thyroid cartilage to hyoid bone by suspending the thryoid cartilage inferiorly
- pierced by internal branch of superior laryngeal nerve & superior laryngeal artery
-
median thryohyoid ligament
thickening in the midline of the thyrohyoid membrane
-
lateral thyrohyoid ligaments
- thickenings on either side of the thyrohyoid membrane
- attach the superior horn of the thyroid cartilage to the hyoid bone
-
triticea
small cartilaginous nodule frequently found in lateral thyrohyoid ligament
-
cricoid cartilage
- "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
-
cricothyroid ligament
- AKA cricothryoid membrane, cricovocal membrane
- connects cricoid cartilage to thyroid cartilage
- extends up medially and inserts on interior lamina of thyroid cartilage
-
conus elasticus
- superior extension of the cricothyroid membrane
- superior free edge: forms vocal ligament
- attaches posteriorly to vocal processes of arytenoids
-
arytenoid cartilages
- 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
-
cricoarytenoid joint
synovial joint between superior aspect of lamina of cricoid cartilage and base of arytenoid cartilage
-
corniculate cartilages
- AKA Santorini's cartilages
- wedge-shaped yellow elastic cartilage
- located at apex of arytenoid cartilage
- unknown function
-
cuneiform cartilages
- yellow elastic cartilage
- rod-like cartilages in the aryepiglottic folds
-
epiglottic cartilage
- 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
-
calcified laryngeal cartilages
- 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
-
aryepiglottic folds
- 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
-
hyoepiglottic ligament
connects thebody of the hyoid & the anterior surface of the epiglottis
-
quadrangular membrane
- 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
-
vocal ligament
- thickened superior edge of the conus elasticus
- extend between the vocal processes of the arytenoid cartilages to the inside of the thyroid cartilage
-
vocal cord
vocal ligaments covered with epithelium/mucosa
-
boundaries of laryngeal aditus
- anterior: epiglottis
- lateral: aryepiglottic folds
- posterior: corniculate cartilages & arytenoideus muscles
-
folds that attach epiglottis to tongue
- median glossoepiglottic fold: epiglottis to root of tongue
- lateral glossoepiglottic fold: epiglottis to sides of tongue (2)
-
epiglottic valleculae
- 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)
-
piriform recess
- on either side of larynx posterior to laryngeal aditus
- subdivisions of laryngopharynx/hypopharynx
-
vestibule
- triangular cavity posterior to the epiglottis & superior to the vestibular folds
- extends from the laryngeal aditus to the vestibular folds
- quadrangular membrane + mucosa
-
rima glottidis
narrow aperture between true vocal cords
-
vestibular/false vocal cords
- appear pink in the living; contained within the vestibule
- superior to true vocal folds
-
vestibular ligament
free inferior edge of the quadrangular membrane
-
rima vestibuli
opening between the vestibular folds
-
ventricle of the larynx
- AKA ventricle of Morgagni, laryngeal sinus
- diverticulum between the vestibular & vocal folds
-
laryngeal saccule
- appendix of the laryngeal ventricle
- diverticulum from the anterior end of the ventricle upward between the vestibular fold & inner surface of the thyroid cartilage
-
vocal folds/ true vocal cords
- concerned with phonation
- appear white in the living
- formed by vocal ligament (anterior 3/5) & vocal processes of arytenoid cartilages (posterior 2/5)
-
glottis
vocal folds (true vocal cords and mucosa) + rima glottidis (aperature between true vocal folds)
-
infraglottic compartment
continuous inferiorly with the trachea
-
function of extrinsic muscles of the larynx
move the larynx as a whole (elevate or depress) because the hyoid bone is attached to the thryoid cartilage
-
infrahyoid strap muscles
- omohyoid, sternohyoid, sternothyroid & thyrohyoid
- in general, depressors of the larynx (NOT thyrohyoid)
-
suprahyoid strap muscles
- stylohyoid, digastric, geniohyoid, mylohyoid
- elevate the larynx w/ thyrohyoid, stylopharyngeus, salpingpharyngeus & palatopharyngeus
-
function of intrinsic muscles of the larynx
concerned with movements of laryngeal parts & alterations in the length & tension of the vocal folds
-
extrinsic muscles of the larynx
- stylohyoid
- digastric
- geniohyoid
- mylohyoid
- sternohyoid
- thyrohyoid
- sternothyroid
- omohyoid
-
intrinsic muscles of the larynx
- cricothyroid
- posterior cricoarytenoid
- lateral cricoarytenoid
- thryoarytenoid
- transverse arytenoid
- oblique arytenoid
- vocalis
-
movements of the vocal cords
- abduction of vocal folds: posterior cricoarytenoid
- adduction of vocal folds: lateral cricoarytenoid & transverse arytenoid
- tension of vocal ligaments: cricothyroid
- relaxation of vocal ligaments: vocalis
-
blood supply to the larynx
superior laryngeal a. & inferior laryngeal a.
-
superior laryngeal artery
- branch of superior thyroid artery
- accompanies superior laryngeal nerve
- penetrates thyrohyoid membrane
-
inferior laryngeal artery
- 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
-
innervation of the larynx
- 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
-
hemimandibulectomy
- 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
-
lymphangitis
inflammation of lymph vessels
-
lymphadenitis
inflammation of the lymph nodes
-
lymphogenous metastasis
spread of malignant (cancer) cells through lymphatic vessels
-
superficial cervical lymph nodes
- lie along external jugular vein
- are in the superficial fascia
- are superficial or external to the SCM
-
superficial cervical collar nodes
- 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
-
superficial parotid nodes
drain lymphatic vessels from forehead, lateral parts of both eyelids, part of external nose
-
buccal & mandibular nodes
drain lymphatic vessels from the medial corner of the eye, most of the external nose, and lower part of face
-
occipital nodes
drain occipital region
-
submental nodes
- located between the anterior bellies of the digastric muscle
- range from one to three nodes
-
submandibular 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
-
parotid nodes
- lie within the parotid gland
- drain the face anterior to the gland & some of the pharynx
-
preauricular nodes
- anterior to the ear; located superficial to the parotid gland
- drainage from the lymph plexus of the skin
-
postauricular nodes
- 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
-
occipital nodes
- found along the course of the occipital artery
- recirculates lymph from occipital region & drains into the superior cervical nodes
-
deep 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
-
superior deep cervical nodes
- 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
-
inferior deep cervical nodes
- posterior lateral nodes associated with the subclavian vessels & the brachial plexus
- supraclavicular nodes
- retroauricular nodes
-
supraclavicular nodes
6-10 nodes may be found in lower portion of posterior triangle
-
retroauricular nodes
- 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
-
lymphatic drainage of the tongue
- 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
-
diseases that may cause lymphadenopathy
- infection mononucleosis (kissing disease)
- non-hodgkin's lymphoma
- persistant generalized lymphadenopathy
- cat scratch disease
- metastatic carcinoma
-
suprahyoid muscles
- anterior & posterior bellies of digastric
- mylohyoid
- stylohyoid
- geniohyoid
-
structures related to inferior surface of mylohyoid
- superficial part of submandibular gland
- submandibular & submental lymph nodes
- facial a & v
- submental a & v
- mylohyoid a & v
- mylohyoid n.
- branches of CN VII
-
structures between mylohyoid & hyoglossus mm.
- lingual n.
- CN XII
- submandibular ganglion
- deep part of submandibular gland
- submandibular duct
- sublingual gland
-
structures located deep to hyoglossus m.
- lingual artery
- deep lingual vv.
- CN IX
-
papillae of tongue
- 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
-
extrinsic tongue musculature
- styloglossus
- genioglossus
- hyoglossus
- palatoglossus
-
where are there taste buds?
- anterior 2/3 tongue
- posterior 1/3 tongue
- soft palate
- portion of tongue just anterior to epiglottis
- epiglottis
- aryepiglottic fold
-
muscles of the soft palate
- palatoglossus
- palatopharyngeus
- musculus uvulae
- levator veli palatini
- tensor veli palatini
-
arterial supply to palatine tonsils
- facial a. - tonsillar a & ascending palatine a.
- lingual a. - dorsal lingual a.
- ascending pharyngeal a.
- maxillary a. - descending palatine a. - lesser palatine a.
-
drainage of paranasal sinuses
- frontal: middle meatus
- anterior ethmoidals: middle meatus
- middle ethmoidals: middle meatus
- posterior ethmoidals: superior meatus
- maxillary: middle meatus
- sphenoid: sphenoethmoidal recess
-
nerve supply to frontal sinus
supraorbital n.
-
nerve supply to anterior & middle ethmoidal sinuses
anterior ethmoidal branches of nasociliary n.
-
nerve supply to posterior ethmoidal sinus
- posterior ethmoidal branches of nasociliary n.
- orbital branches of V2
-
nerve supply to sphenoidal sinuses
- posterior ethmoidal branches of nasociliary n.
- orbital branches & pharyngeal branches of V2
-
nerve supply to maxillary sinus
anterior, middle & posterior superior alveolar nn.
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