Applied aspects of Head & Neck (KLM)

Scalp
1. Anatomical feature: Scalp proper / surgical layers of scalp (Skin, superficial fascia
& epicranial aponeurosis). These 3 layers are regarded as a single layer because they
don’t separate. Nerves and vessels of the scalp enter inferiorly and ascend through loose
connective tissue (layer 2) to reach the skin

Applied aspects:

Scalp proper remain together during accidental injury and also during craniotomy. Surgical
pedicle scalp flaps are made so they remain attached inferiorly to preserve the nerves and vessels
& promote good healing

2. Anatomical feature: scalp arteries are not responsible to supply the calvaria

Applied aspects:

There will be no effect or necrosis of calvarial bones even in the case of loss of scalp

3. Anatomical feature: strength of epicranial aponeurosis

Applied aspects:

Superficial wounds of scalp: do not gape because of strong aponeurosis so there is no need of
deep sutures.

Deep wounds of scalp: Gape widely because of pull of occipitofrontalis muscle in opposite
direction

4. Anatomical feature: Scalp has arterial supply with abundant anastomosis between
the arteries.

Applied aspect:

Due to this anastomosis, scalp wounds bleed profusely.

Moreover, arteries do not retract and held open because of connective tissue. This bleeding can
lead to spasm of occipitofrontalis muscle & then gaping of scalp wounds (reason for gaping of
deep scalp wounds).

5. Anatomical feature: Loose connective tissue (layer 4 of scalp)

Applied aspect:

It is considered as dangerous layer of scalp because pus or blood spreads easily in it. This
infection can spread to intracranial structures via emissary veins.

6. Anatomical feature: epicranial aponeurosis has attachment of occipitofrontalis

muscle on anterior & posterior margins respectively (see figure).

Occipitalis part (posterior): attached to occipital & mastoid bone.

Laterally: via temporal fascia on the zygomatic arches.

Frontalis part (anterior): attached to skin & subcutaneous tissue of forehead. Thus, this part
has no bony attachment.

Applied aspect:

Black eye/ peri-orbital ecchymosis

It can result from an injury to the scalp or forehead. Spread of infection or fluid is possible into
the eyelids and root of nose because of

a. Frontalis part of occipitofrontalis has no bony attachment.

b. Thin skin and loose nature of subcutaneous tissue within eyelids.

7. Anatomical feature: Calvarial bones are supplied by periosteal arteries

Applied aspect:
Rupture of these periosteal arteries after difficult birth can lead to accumulation of blood
between the pericranium (5th layer of scalp) and calvaria (skull cap) mostly over the parietal
bone. This condition is called as cephalhematoma (figure).

Face
Anatomical feature: Absence of deep fascia & loose subcutaneous tissue in the face

Applied aspects:

1. Due to these two factors, the facial lacerations tend to gape, so should be stitched
carefully to avoid scarring.
2. Enables fluid and blood to accumulate easily in loose connective tissue responsible for
facial swelling

Aging effect: Wrinkles develop in the skin perpendicular to the direction of facial muscles
(Langer lines)

Applied aspect:

Skin incisions in these lines heal with minimal scarring

 Facial artery applied aspect:
Pulsation of facial artery: Clench the teeth and feel the inferior border of the mandible
immediately anterior to the masseter muscle for pulsation.

Facial artery compression: The bleeding from facial artery can be occluded by applying
pressure against the mandible where the vessel crosses it. Because of numerous anastomosis of
facial artery and its branches, the pressure should be applied on both sides. For example, in lip
lacerations, pressure is applied on both sides to stop bleeding.

Facial nerve (motor supply of face)

Motor: muscles of facial expression and scalp, middle ear muscle (stapedius), stylohoid,
posterior belly of digastric

Special senses: Taste from anterior two third of tongue and palate

Parasympathetic: secretion from sublingual, submandibular gland, lacrimal gland, glands of

nose and palate

Branches of facial nerve along its course:

Before its exit from Nerve to stapedius, taste fibers for anterior 2/3rd of tongue,
stylomastoid foramen of lacrimation fibers, salivary glands secretions
skull

Posterior auricular (occipital

After its exit from Before entering the parotid belly of occipitofrontalis
stylomastoid foramen of gland muscle, auricularis posterior),
skull nerve to posterior belly of
digastric & stylohyoid

Within parotid gland Temporal, zygomatic, buccal,

marginal mandibular, cervical

Applied aspects:

Facial nerve paralysis:

Causes:

a. Inflammation of facial nerve after a viral infection

 b. Fracture of temporal bone
c. Idiopathic, usually after exposure to cold (riding in a car with an open window)
d. Iatrogenic (parotidectomy; parotid gland surgery)
e. Other causes include dental manipulation, vaccination, pregnancy, HIV infection, lyme
disease & middle ear infections. (less common)
f. After a stab wound or injury at birth (less common)

Signs & symptoms:

a. Sagging of affected area

b. Distorted facial expression (looks like sad face)
c. Eversion of lower eyelid. This thing prevents lacrimal fluid to spread over the cornea.
Thus reducing adequate lubrication and hydration of the cornea- corneal ulceration-
leading to visual impairment.
d. Accumulation of food in the oral vestibule during chewing (paralysis of buccinator &
orbicularis oris). The patient uses finger to remove food from mouth.
e. Drooping of corners of mouth resulting into food and saliva drippling out of the side of
mouth (paralysis of sphincters & dilators of mouth)
f. Weakened lip muscles ( speech problems & inability to produce labial sounds (B, M, P &
W alphabets)
g. Inability to whistle or blow a wind instrument
h. Constantly uses handkerchief to wipe the fluid from eyes and mouth

Clinical scenario… Any patient with distorted facial expression giving appearance of sad face,
with drooping of lower eyelid and angle of mouth, unable to whistle and blow a wind instrument,
having speech problems, using handkerchief to wipe fluid from mouth and eyes, absence of
wrinkles from forehead is having facial nerve paralysis.

Do prepare supranuclear and infranuclear injury difference from BD.

Trigeminal nerve (sensory innervation of face)

How to check the functions of trigeminal nerve?

a. Ask the patient to close his both eyes and respond when type of touch is felt
b. Skin of the forehead (ophthalmic division), cheek(maxillary division), lower
jaw(mandibular division) are assessed to check all three branches of trigeminal nerve
c. Sensation to assess include: touch, temperature and pain sensations
d. Touch sensation is checked by gently stroking the dry gauze piece on the skin of face
e. Temperature is assessed by using cold or warm instrument
f. Pain is checked by gentle touch of sharp pin

Trigeminal neuralgia/tic douloureux:

It occurs due to demyelination of axons of trigeminal nerve or some pathology in the neurons of
trigeminal ganglion.

Mostly occur in middle aged or elderly persons. Sudden attacks of excruciating pain lasts for 15
minutes or more. Most commonly maxillary division of trigeminal nerve get involved, then
mandibular and least frequently ophthalmic division.

Trigger zone: tip of nose or cheek

Attacks usually set off by touching face, chewing, brushing the teeth and shaving

Not so important: (just give a read) Treatment to relieve pain: infra orbital nerve block using
alcohal (when pain is in the area supplied by maxillary division)

Radiofrequency selective ablation of parts of trigeminal ganglion

Rhizotomy (partial cutting of sensory root of trigeminal nerve)

Tractotomy (sectioning of spinal tract of trigeminal nerve): after this procedure, there will be loss
of all sensation of face. Patient will be unable to identify food on the lip or mouth or feel it in the
mouth.

Squamous cell carcinoma of lip:

Causes: overexposure to sunshine or chronic irritation due to pipe smoking

Usually involves lower lip

Carcinoma spread can occur to submental lymph node if it involves central part of lower lip,
flour of mouth or apex of tongue

Spread occurs to submandibular lymph nodes in case of lateral part of lower lip

*Correlate it with lymphatic drainage of face

Thrombophlebitis of facial vein

Facial vein has connections with cavernous sinus through superior opthalmic vein and with
pterygoid venous plexus through inferior ophthamic vein and deep facial vein.

As facial vein has no valve so blood can spread to opposite direction and venous blood from face
can enter cavernous sinus.

Inflammtion of facial vein with clot formation – infected clot can extend into cavernous sinus-
leading to thromboplebitis of cavernous sinus.
Nose lacerations or squeezing the pustule on side of nose and upper lip are most common sites of
infection spread. So regarded as dangerous trinangle of face.

Dangerous trinagle of face: From the upper lip to the bridge of nose

UQ from face and scalp

Q1. Draw and label cutenous innervation of face.

Q2. During surgery for a parotid malignant tumor in a 69 years old woman, the temporal branch
of “ facial nerve” is lacerated.

a. Name the muscles which will be paralyzed

b. Give origin, insertion and actions of orbilculris oculi muscle.

Q3. What is dangerous triangle of face? Describe the anatomical basis of danger? (3)

A patient complains of dryness of eyes. Tarce the secremotor fibers of lacrimal gland. (2)

Q4. Enumerate the nuclei of facial nerve with its location (not part of this substage)
Describe the course and distribution of facial nerve (only extra cranial course of facial nerve in
this substage).
What are the eefcts of branches of facial nerve due to deep laceration of face?

Q5. With the knowledge of attachemnt of layers of scalp, explain the follwing conditions.

Gaping of scalp wounds

Danegrous area of scalp
Black eye
Q6. Scalp wounds bleed profusely. Give the anatomical justification of this statement. Enlist the
arteries supplying scalp and in which layer of scalp do they run.