OSTEOLOGY, SCALP, FACE AND TRIANGLES OF NECK BONES OF HEAD AND NECK St i is Foramen ovale (Mnemonic MALE) :- Mandibular nervel!" "M2 "9087%, accessory meningeal artery, lesser poirosal nerve, emissary vein" "(connecting cavernous sinus with pterygoid venous plexus'®™"™"*7) ‘Occasionally anterior trunk of middle meningeal vein is also transmitted. «0 Foramen spinosum (Mnemonic MEN) - Middle meningeal artery and vein (postertor trunk)", emissary ‘vein, nervus spinosus (meningeal branch" of mandibular nerve). Foramen lacerum - Meningeal branch of ascending pharyngeal artery and emissary vein pass through whole length ICA with sympathetic plexus and venous plexus around traverses partially through foramen lacerum. Greater petrosal ‘nerve unites with deep petrosal nerve to form nerve of pterygoid canal ‘9 Carotid canal - Internal carotid artery with sympathetic plexus around it, emissary vein (connecting cavernous sinus with IV). ‘9 Foramen rotundum :- Maxillary nerve". 0 Pterygoid canal - Vidian nerve“®""* (nerve of pterygoid canal), vidian artery (artery of pterygoid canal). 0 Stylomastoid foramen :- Facial nerve, stylomastoid branch of posterior auricular artery. 6 Jugular foramen :-Itmay be divided into three parts- |) Anterior part:-Inferlor petrosal sinus”, ii) Middle part: Glossopharyngea! (IX) nerve“!""”, vagus (X) nerve”, accessory (XT) nerve”, ii) Posterior part:-Sigmoid sinus continues as internal jugular vein (Sigmoid simus- BV junction), meningeal branch of occipital artery. Internal auditory (acoustic) meatus :-Facial nerve, nervus intermedius of wrisberg”""™"", vestibulocochlear (6%) nervl"0H2 8878.2 gbrynthine vessels. The internal acoustic canal is divided by transverse crest (or Faleiform ‘rest into a superior and inferior part. The superior partis divided by vertical crest or Bill's bar‘! into anterior and posterior pars. : «6 Hypoglosal canal (anterior condylar eanal :- Bypoglossa nerve, meningeal branch of hypoglossal nerve, meningeal branch of ascending pharyngeal artery, emissary vein (connecting sigmoid sinus to UV). © Posterior condylar ean :- Emissary vein (connecting sigmoid sinus with suboceipital venous plexus), ‘9 Mastoid canalieulus - Auricular branch of vagus nerve (entery), ‘ ‘Tympanomastoid fissure - Auricularbranch of vagus nerve(exi) © Greater palatine foramen :-Greater palatine vessels, anterior palatine nerve. o Lesser palatine foramen :- Middle and posterior palatine nerves. o Incisive foramen :- Greater palatine vessels, nasopalatine nerve. o Tympanic canaliculus ~ Tympani branch of glossopharyngeal (IX) nerve (Jacobson nerve). © Foramen magnum :-Itis divided into following parts- i) Amrior part: Apical ligament of dens, membrana tetova, vertical band of cruciate ligament it) Posterior part :- Lowest part of medulla oblongata three meninges (dura, arachnoid and pia mater). ii) Subarachnoid space :-Spinal accessory nerves!" "24050, vertebral artery! 870% ie AMID and ‘sympathetic plexus around it, posterior spinal arteries, anterior spinal arteries. © Mastoid eanaliculus - Aurleular branch of vagus!" (Arnold’snerve or Akderman’s nerve!®!7, © Foramen of Vesalius (Emissary sphenoidal foramen) :- Emissary vein connecting cavernous sinus with pterygoid venous plexus" 440), © Optic canal (foramen) :-Optic nerve, opthalmic artrery with sympathetic plexus around it, o Superior orbital fissure :Itis divided into 3 pats by common tendinous ring of Zinn - ) Middle part (within the ring) :- Upper and lower division of oculomotor nerve™* 1, nasoctliary nerve", abducent nerve", ii) Lateral part (above the ring) :- Trochlear nerve "#44, frontal nerve and lacrimal nerves Home #5, ‘superior ophthalmic vein, recurrent menigeal branch of lacrimal artery, orbital branch of middle meningeal artery and sometimes meningeal branch of ophthalmic artery. ‘i) Medial part (below the ring) :~ inferior ophthalmic vein, sympathetic nerves around ICA. « Inferior orbital fissure - Zygomatic branch of maxillary nerve”, infraobital nerveand vessels, rami of pterygoid ganglion, communicating vein between inferior opthalmic vein and pterygoid plexus of veins. 6 Anterior ethmoidal eanal - Anterior ethmoidal nerve (branch of nasociliary nerve), anterior ethioidal vessels. © Posterior ethamoidal eanal = Posterior ethmoidal nerve (branch of nasociliary nerve), posterior ethmoidal vessels. ‘© Mastold foramen :- Meningeal branch of occipital artery, emissary vein, foramen :- Supraorbital nerve and artery, frontal diploie vein «© Infraorbital foramen :-Infraorbital nerve and vessels.OSTEOLOGY, SCALP, FACE AND TRIANGLES OF NECK [252] IMPORTANT FACTS ABOUT OSTEOLOGY OF HEAD AND NECK ‘9 The skull forms the cranial end ofthe axial skeleton. Itis composed of 22 bones”? of which 8 bones are present in calvaria (brain case) and 14 bones in facial skeleton. (Note - Some people also consider ear osccles : malleus, incus, ‘and stapes as skull bones. According to them there are 28 bones in skal). © Greater wing of sphenoid presents following foramina:- foramen rotundumy! "80, foramen ovale" ‘etm00, foramen spinosum 7-8, conaliculus innominatus, and emissary sphenoidal foramen (Foramen of vvesatius). ‘9 Optic eanal (foramen) is enclosed by tesser wing of sphenold and body of sphenoid(*™, co Eimmisary veins pass through - 1) Foramen ovate"? and foramen of vesalies"@”H0"9 (emissary sphenotdsl foramen) Connecting ‘caveraozs sinus with pterygoid venous plexus?@”24007%, i) Foramen coecum :- From nasal mucosa to superior sagittal sinus. ii) Anterior condylar canal (hypoglosal canal) and earotid canal :- Conwecting sigmoid sinus with UV. iv) Posterior conéylar canal :- Connecting sigmoid sinus with suboccipital venous plexus. ¥)_ Mastoid foramen :- Connecting sigmoid sinus with posterior auricular or occipital vein. vi) Parietal foramen :- Conncets superior sagitial sinus with scalp veins. vii) Foramen lacerum :- Connects cavernous sinus with pharyngeal venous plexus. ‘9 Maxillary nerve passes through foramen rotundum, pterygopalatine fossa and inferior orbital fissure to reach the orbit ‘9 Arcuate eminence in petrons part of cemporal bone is caused by superior semicireular canal”, © A coronal plane drawn downward through internal acoustic meats i related tothe last six cranial nerves :~7* and, 84 nerves in internal acoustic meatus; , 10° and 11 nerves in jugular foramen: and 12" nerve in hypoglossal cana, ‘9 Cartilaginous part of auditory tube (eustachian tube) lies inferior to spheno-petrosal synchondrosis“™"*9, ‘9 Sternberg’s canals persistent lateral eraniopharyngeal cana”, lies anteromedial” to foramen rotandum. It ‘can communicate with sphenoid sinus to create a potenial path of spread of infection to sphenoid sinus. Congenital {intra-sphenoid meningocele and encephalocele may arise through this canal’, © Craniofacial angle is 130%", © Dorelio canal is an opening to cavernous sinus that transmit abducent nerye!"@™, © Anterior fontanelle (bregma) is closed by 18 months and posterior fontanelle (lambda) by 2-6 months”, © Cranial vault of aduleis bilamellar, ie. consists of an outer table of compact bone and an inner table of compact bone. Jn betyeen these two tables of compact bone there is intervenning cancellous and vascular portion called diploe. Veins draining the dipole are called diptote veins, which are valveless"®, with very thin walt of endothelium supported by some elastic tissue”. Cranial vant in unilamellar at birth without any diploe and diploic vein“, ‘The diploie veins start to eppear at around 2 years of age with the diploe. The outer-inner tables and intervening Aiploe appears at around 4" years and gets maximally differentiated by 35 years of age, ORBIT © Orbits are pyramidal bony cavities, situated one on each side of the root of nase. They provide sockets for rotatory ‘movements of eye ball. Orbit is four-side pyramide with an apex, a base and following four walls: ‘Walls Formation Roof (Orbital plate of frontal (mainly) Lesser wing of sphenoid Lateral wall Anterior surface of greater wing of sphenol Orbital surface of frontal process of zygomatic hone Floor Orbital surface of msxitia (mainly)"@*" ‘Orbital surface of zygomatic” Orbital process of palatine bone Medialwall Frontal process of maxilla!"™1™4"e0 Lacrimal bone! Orbital plate of ethmoia”” Body of sphenoia?™™-470 © Medial wall is the weakest wail” and lateral wall is thickest,OSTEOLOGY, SCALP, FACE AND TRIANGLES OF NECK [253] Inferior orbital fissure oceuples the posterior part of function between lateral wall and floor”. 0 Superior orbital fissure occupies the posterior part of the junction between the roof and lateral wall 0 Optic canal lies at the junction of roof and medial wall, and is enclosed by lesser wing and body of sphenoid/@"™*”, SCALP AND FACE Sealy «The scalp is sof tissue which covers the calvaia of skull. It consists of five Jayers and can be memorised by @ smemonic using the initial letters of the word, SCALP :-(a) Skin; (b) Close network of connective tissue (superficial fascia) (€) Aponeurosis (galea aponeurotica) with occiptofrontalis muscles; (2) Loose areolar (subaponcurotic) tissue; (e)Perieranium (outer periostoum of sll). First three layers are intimately connected and move as one unit, and are called surgical layers of sealp or scalp proper © Connective tissue (superficial fscia) contains large blood vessels and nerves of the scalp. The walls ofthe vessels tare adherent tothe fibrous network so that wien the vessels are tom in an open wound they are unable to retract and produce profuse bleeding. Bleeding can be arrested by pressure against the underlying bone”, « Loose suibaponcuroti areolar tissue (4® layer) is called dangerous area of scalp!” because it contains emissary veins through which infection in subaponeurotic space may spread readily to intracranial venous sinuses. 6 Arterial supply of cap i as follows =~ }) Infrontofauvicle -Supratrochlear and supraorbital branches of ophthalmic artery (abranch of CA); and superficial temporal artery, a branch of ECA. i) Behing auricle: Posterior auricular artery and dccipitl artery, both are branches of ECA. «© Therefore scalp isthe ste of free anastomosis between the branches of external and internal carotid arteries. 6 Nerve supply i as follows: 3) Injron of auricle :- Supratrochlear (sensory), supracrbital (sensory), zygomaticotemporal"™"”:" (sensory), auriculotemporal”“"""" (sensory) and temporal branch of facial nerve (motor). i) Behind auricle :- Posterior branch of great auricular”*'™”.; CxC; (sensory), lesser occipital’™”” : C2 (sensory), greater occipital : C (sensory), third occipital C: (sensory), and posterior aurieular branch of facial nerve (motor), FACE 0 The face is provided with mouth, eyes and nose. The face is limited above by hair line of scalp, below by chin and base of mandible, and on each side by auricle Eacial muscles ‘o Muscles of facial expression are subcutaneous muscles and bring about different facial expressions, These muscles Muscle of scalp Occipitoftontals. i) Muscles of auricle (around ear) - Auricularis anterior, superior and posterior. ii) Muscles of eyelids :-Orbicularis ocul,corrugator supereili, levator palpebrae superiors. iv) Muscles of nose Procerus, compressor naris, dilator nari, depressor septi ¥) Muscles around mouth :- Orbiculars ois, becinato, levator abi superiors alague nasi, zygomaticus major, levator labii superiors, levator angul oris, 2ygomaticus minor, depressor anguli ori, depressor lai inferior, metals, risorius®22, vi) Muscles ofneck:-Platysm. «These muscles bring sbout different facial expressionsOSTEOLOGY, SCALP, FACE AND TRIANGLES OF NECK [254] “Muscles of facial expressions (Factal muscles of emotional expression) ‘Smiling & laughing -> Zygomaticus major | ‘Sadness ~> Levatorlabii superioris and levator angularis, Grief Depressor anguli Anger ~> Dilator naris and depressor sept Frowning —» Corrugstor supercilii and procerus. Horror, terror and fright — Plstysma, ‘Surprise => Frontalis Doubs —> Mental Grinning — Risorius 22, Contempt > Zygomaticus minor. Closing the mouth —» Orbiculatis eris. ©. Whistling ~> Buccinator and orbicularis oris. © Functionally, most of these muscles may be regarded primarily as regulators of three openings situated on face := palpebral fissure (eye openings), nostrils and oral fissure (mouth opening). Opening, ‘Functional groups of facial muscles Sphincter Dilators ‘A. Palpebral fissure Orbicularisoculi 1. Levator palpebrae superioris B. Oral fissure © Nostils Nerve supply 2.Frontalis part of occipitofrontalis Orbicularisoris All the muscles around the mouth, except the orbicularis oris the sphineter, and the mentalis which does not mingle with orbicularis Compressornaris 1. Dilstornaris 2.Depressor septi 3, Medial lip of levator labii superiorisalaeque nasi. © Each half of the face is supplied by fourteen nerves, one is motor and the rest are sensory, Motor supply is derived from facial (74) nerve which suppliesall facial muscles except levator palpeprae sperioris™, whichis supplied by sympathetic fibers and 3” cranial nerve. Eleven sensosry nerves are derived from branches of trigeminal (5%) nerve and only two sensory are derived from great auricular nerve and transverse (anterior) cutaneous nerve of neck. Art © Face is supplied by facial artery (chief artery of face), transverse facial artery and arteries that accompany cutaneous Facial artery isthe chief artery of face. It arises from external carotid artery""*9 above the level of tip of greater comu of hyoid bone, in carotid triangle. The facial artery enters the face by winding around the base of the mandible and by piercing the deep cervical fascia, tthe anterioinferior angle of messeter. It can be palpated here and is called anaesthetist artery. Branches of facial artery are () inferior labial, (i) superioir labial, (ii) lateral nasal , and (iv) posterior (unnamed) brnaches. Transverse facial artery isa branch of superficial temporal artery, emerges from parotid gland, It supplies parotid land, overlying skin, masseter, and ends by anastomosing with neighbouring arteries. Veins of face © The facial vein isthe largest vein of the face with no valves. It begins as the angular vein at the medial angle of the eye. Angular vein is formed by the union of supraorbital and supratrochlear veins. The angular vein continues as facial veins, Which joins the anterior division of reromandubular vein (i.e. deep facial vein) below the angle of the ‘mandible to form common fa fal vein. Common facial vein drains into the internal jugular vein.a eile) © Facial vein communicates with cevernous sinus through deep connections - 1. communication between supraorbital and superior ophhthalamic veins™"""™"™, 2. With the pterygoud plexus through deep facial vein. Therefore, infection from the face can spread in retrograde direction and cause eavernus sinus thrombosis (CVD). This is especially likely to occur in the presence of infection inthe upper lip and in lower part of the nose. This arenis, therfore, called dangerous area of the face. ad 2S a) ‘9 The face possesses three areas from which lymphatic drainage is as follows :- ') Upper area, comparising greater part of forehead, lateral % of eyelids, conjunctiva, lateral part of cheek and parotid area, drains into preauricular (superficial) parotid nodes. i) Middle area, comprising central part of forehead, external nose, upper lip, lateral part of lower lip, medial halves of eyelids, medial part of cheek, and greater part of lower jaw, drains into submandibular nodes. ii) Lower area, including central part of lower lip“?*” and the chin, drains into submental nodes", ‘TRIANGLES OF NECK © Anterolateral aspect (side) of neck is divided by stemocleidomastoid muscle into anterior triangle in front of the ‘muscle and posterior triangle, behind the muscle. POSTERIOR TRIANGLE © Posterior triangle is situated behind stenocleidamastoid muscle, Anterior border is formed by posterior border of sternocleidomastoid’"!* ==, Posterior border is formed by anterior margin of trapezius”, Bases, formed by superior surface of middle third of elavicle™”! "9, Apex lies on superior nuchal line at junction of ‘trapezius and stemocleidomastoid, Roof is formed by investing layer of deep cervical fascia, ski and superficial ‘fascia (containing platysma; external jugular veins; parts of supraclavicular, great auricular, transverse cutaneous ‘and lesser occipital nerves; unnamed arteries from occipital, transverse cervical and supraclavicular arteries; and lymph vessels). Floor is formed by prevertebral layer of deep cervical fascia covering following muscles: splenius capitis, levator scapula, scalenus medius and semispinalis capitis. «6 Posterior triangle is subdivided into an larger upper occipital triangle and smaller lower supraclavicular (subclavian) triangle by inferior belly of omobyoid.BB, Vessels 1. Transverse cervical artery and vein OSTEOLOGY, SCALP, FACE AND TRIANGLES OF NECK [256] Contents ofthe posterior triangle Contents Occipital triangle Subelavian triangle ANerves 1, Spinal accessory nerve 1. Three teunks of brachial plexus 2, Four eutancous branches of 2. Nerve to serratus anterior (long thoracic. cervial plexus C5, C6, C79 1) Lesser ocsipital (C2) 7 3. Nerve to subclavius (C5, C6) ) Great auricular (C2, C3ysr0" 9 4. Suprascapalar nerve (C5, C6) ©) Anterior cutaneous nerve of neck (C2, C3) &) Supraclavieular nerves (C3, C479 3. Muscular branches 8) Two small branches to the levator seapulae (C3, ca) 'b) Two small branches to the trapezius (C3, C4) ©) Nerve to shomboideus (proprioceptive) (C3) 4. C5, C6 roots of the brachial plexus 1 Third part of subclavian artery and subclavian vein 2. Occipital artery” 2, Suprascapularacery and vein 3. Commencement of transverse cervical artery and termination ofthe corresponding vein 4: Lower part of extemal jugular vein Lymph Along the posterior border of the a sternoceido- ‘A few members of the supraclavicular chan, ‘nodes. mastoid more in the lower part-the supraclavicular ‘nodes and a few atthe upper angle-the ocepltal odes © Spinal accessory nerve (XI eranial nerve) runs along te levator scapulae to supply trapezius. Because ilies close to the roof, the nerve may be damage by a aceratng injury or during inesion and drainage of abcess in posterior triangle! “= equsing paralysis of trapezius which results in drooping of shoulder and difficulty in overhead abduetion“"® and difficulty in shrugging of shoulder‘™™s7s1H209, Deep cervical ‘9 Deep fascia of neck is condensed to form the following layers = 1) Investing layer :-Itis deep to platysma and surrounds neck like @ collar. Itforms the roof of the posterier triangle ‘ofneck. Investing layer of deep cerival fascia splits to enclose :() trapezius and sternocletdomastoid muscles; (ii) parortid and submandibular glands; and (iii) suprasternal and supraclavicular spaces. 2). Pretracheal fascia :- encloses and suspends the thyroid gland and formas its false capsule, On either side of {thyroid glands, it forms suspensory ligament for thyroid gland known as ligament of Berry which fixes thyroid gland to cricoid eartilage™, 3) Prevertebral fascia :-It lies in front of prevertebral muscles!" and forms the loor of posterior tringle of lexus! and “axillary sheath” ace derived from prevertebral fascia. tis formed on anterior aspect by pretracheal fascia and posteriorly by prevertebral fascia, It ternal earotid artery", internal jugular vein™="""®, vagus nerve™"!%"6!8, and in upper part IX, XE, XII nerves. Ansa cervicalis is embedded in the anterior wall of carotid sheath", 5) Buceopharyngeal fascia :- This fascia covers superior constrictor muscle externally and extends on to the superficial aspect of buceinator muscle. 6) Pharyngobasilar fascia :-It lies doop to pharyngeal muscles between upper border of superior constrictor and base of skull. 4 ANTERIOR TRIANGLE © The anterior triangle les between the anterior border of stcmocleidomastoid (posterior boundry of triangle), midline of neck (anterior boundry of triangle) and lower border of mandible (base of triangle). This triangle is further subdivided into 4 parts by superior belly of omohyoid and digasttie muscles ;- (i) Submental triangle" (ii) digastrie triangle'”°"™, (jf) Carotid triangle"™, and (jv) museular triangle", Submental triangle © Itis a median triangle. Base is formed by body of hyoid bone. Apex is formed by symphiysis menti ofthe mandible. Oneither side, there is anterior belly of corresponding digastric muscles**7*, Floor is formed by right and left mylohyoid™* "#9 and median raphe uniting them. Contents of submental triangle are submental lymph nodes, submental vessels and begining of anterior jugular vein. Submental lymph nodes drain superficial tissues belowOSTEOLOGY, SCALP, FACE AND TRIANGLES OF NECK [257] chin, central part oflower lip”, adjoining gums, anterior partof the floor of mouth", and tip of tongue". Submental nodes, themselves, drain into submandibular nodes Digastric triangle © This triangle is bounded () above by base of mandible and line extending its angle to mastoid; (i) below and in front by anterior belly of digastric; and (ji below and behind by posterior belly of digastric and stylohyoid. Floor is formed by mylohyoid’™""?"2.%-29 and byoglassus*er**9 on™, Iss contents ae = j) Inanterior part:-Submandibular gland”, facial artery ©”, facial vein, submental artery, mylohyoid nerve and vessels*##4"#8<"™, hypoglossal nerve" and submandibular lymph nodes. ll these structures are superficial to mylohyoid“#* P8447, 4) In posterior part:- Lower pole of parotid gland, ECA and its posterior auricular branch, glossopharyngeal nerve, siyloglossus and stylopharyngeus muscles, ICA, vagus nerve and LV. arotid triangle ‘© Boundaries of carotid triangle are : (i) anterlosuperiorly :- posterior belly of digastric and stylohyoid; (i) anteroinferiorly- Superior belly of omohyoid: and (ii) posteriorly - Anterior border of sternocieidomastoid™* ‘99@64.17896.088 8), Figor is formed by middle and inferior constrictors of pharynx, and thyrohyoid membrane. Contents of carotid tiangle are 1) _ Arteries - Common carotid artery with carotid sinus and carotid body, ICA, and ECA with its superior thyroid, lingual, facial, ascending pharyngeal and occipital branches. 2) Veins: DV, common facial vein, pharyngeal vein and lingual vein. 3) Nerves - Vagus, superior laryngeal with ts bifurcation into intemal and extemal aryngeal nerves, spinal accessory, hypoglossal", ansa cervicalis (upper part) and branch to thyrohyoid. 4) ‘Lymph nodes - Deep cervical nodes along UV Gugulodigastic and jugulo-omohyoid nodes). Muscular 9 This triangle is bounded :- (i) Anterosupertorty = Posterior belly of digastric and stylohyoid i) Anteroinferorly Superiorbelly ofomohyoid, and (i) Posteriory anterior border of stemocleidomustoid. Muscular triangle con infrahyoid ribbon muscles", These infrahyoid muscles are sternohyoid, sternothyro‘d, thyrohyoid, and comohyoid. SUBOCCIPITAL TRIANGLE 6 Itlies more deeply in upper part of back of neck just below the occipital bone. tis bounded (i) Superomedially:- rectus capitis posterior major and minor; (ii) Superolaterally - Obliques capitis superior; and inferolaterally - Obligues capitis inferior. Floor is formed by posterior atlantooceipital membrane and posterior arch of atlas. Its contents are 3" part of vertebral artery, suboccipital nerve (dorsal ramus of C1), and suboceipital venous plexus”,