72.

Skull & Scalp

Cranial Malformations
[A] Scaphocephaly: premature closure
of the sagittal suture, in which the
anterior fontanelle is small or absent,
results in a long, narrow, wedge-shaped
cranium.
[C] Oxycephaly: premature closure of the
coronal suture results in a high, tower-
like cranium.
When premature closure of the coronal or
the lambdoid suture occurs on one side
only, the cranium is twisted and
asymmetrical, a condition known as
plagiocephaly [B].

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 Layers of the scalp

1. Skin - sebaceous cysts

2. Dense Connective tissue - superficial
scalp
lacerations do not gape and result in
severe bleeding
3. Aponeurosis (Epicranial) - lacerations
throw 3 superficial layers gape widely
because of contraction frontalis and
occipitalis parts of occipitofrontalis muscle
4. Loose areolar tissue - dangerous area
of the scalp. It contains potential spaces
capable of being distended with fluid
resulting from injury or infection
5. Pericranium - Bleeding between
pericranium and calvaria during a difficult
birth results in cephalhematoma
(typically limited by borders of parietal
bone)

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 73. Cranial fosses
Anterior cranial fossa:
contains Frontal lobe [1] 1
dura matter is supplied by V1 and 2
anterior meningeal a. (from ethmoidal
3
a.)
Middle cranial fossa:
contains Temporal lobe [2]
dura matter is supplied by V2 & V3 and
middle meningeal a. (from maxillary a.)
Posterior cranial fossa:
contains Cerebellum [3]
dura mater is supplied by spinal nerves
(via CNX & CNXII) and posterior
meningeal aa. (from ascending
pharyngeal and occipital aa.)

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 74. Fracture of the
anterior cranial fossa
Fracture of the anterior cranial fossa
(Cribriform plate of the Ethmoid bone)
is suggested by anosmia, periorbital
bruising (raccoon eyes), and CSF
leakage from the nose (rhinorrhea).

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 75. Epidural hematoma
Skull fracture near pterion often
causes epidural hematoma from torn
middle meningeal artery (foramen
spinosum).
Unconsciousness and death are
rapid because the bleeding dissects
a wide space as it strips the dura
from the inner surface of the skull,
which puts pressure on the brain.
An epidural hematoma forms a
characteristic biconvex pattern on
computed tomography images.

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 76. Cavernous sinus infection
Dangerous triangle of the face
The middle third of the face is a
"danger area“ because infection
2 there may produce thrombophlebitis
of the facial (angular) vein [1] that
3 can spread to the cavernous sinus
via superior ophthalmic vein [2]:
Facial vein - Superior ophthalmic vein
- Cavernous sinus.
Septicemia leads to meningitis and
cavernous sinus [3] thrombosis,
both of which can cause neurological
damage and are life-threatening.
5 4 Second possible root of the
1 infection: it can spread from upper
molars via pterygoid venous plexus
[4] through inferior ophthalmic vein
[5]: Pterygoid plexus - Inferior
ophthalmic vein - Cavernous sinus.

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 Cavernous sinus thrombosis
Structures which may be
affected by cavernous
sinus thrombosis:
Structures that pass
through sinus directly:
1. Internal carotid artery (in
case of laceration -
arteriovenous fistula)
2. Abducens nerve CN VI
(in case of lesion - internal
squint)

Structures on lateral wall

of sinus:
1. Oculomotor nerve (CN III)
2. Trochlear nerve (CN IV)
3. Ophthalmic nerve V1
4. Maxillary nerve V2

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 Key:
77. Cranial Nerves S = sensory
M = somatomotor
P = parasympathetic,
Smart table 8 secretomotor

CN, Type, Foramina, Function Lesion

Associated Ganglia
I Olfactory, S, Cribriform Smells Anosmia
plate
II Optic, S, Optic canal Vision Visual deficits (anopsia)
Loss of light rf (+CNIII)
III Oculomotor, M+P, Raises eyelid, moves External strabismus
Superior orbital fissure, eyeball in all directions, +Ptosis +Dilated pupil
Ciliary ganglion constricts pupil, Loss of light rf (+CNII)

IV Trochlear , M,
accommodates
Depresses &
tens Trouble reading & going
Superior orbital fissure abducts eyeball down stairs
VI Abducens, M, Abducts eyeball Internal strabismus
Superior orbital fissure

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 CN, Type, Foramina, Function
Associated Ganglia
V Trigeminal,
Trigeminal ganglion
V1 Ophthalmic, S, General sensation (touch,
Superior orbital fissure pain, temperature) of
forehead/scalp/cornea/nose
V2 Maxillary, S, General sensation of
foramen rotundum palate/nasal cavity/ maxillary
face/upper teeth
V3 Mandibular, S+M, General sensation of anterior
foramen ovale 2/3 of tongue/ mandibular
face/ lower teeth Motor to 4
muscles of mastication/ 2 oral
floor / 2 tensors
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Lesion
Trigeminal neuralgia
Loss of general sensation
in skin of
forehead & nose
Loss of blink rf (+CNVII)
Loss of general sensation
in skin over
maxilla, upper teeth
Loss of general sensation
in skin over mandible,
lower teeth, ant. 2/3 of the
tongue. Weakness in
chewing: jaw deviation
toward weak side
 CN, Type, Foramina, Function Lesion
Associated Ganglia
VII Facial, M+S+P, To muscles of facial Bell palsy,
Internal auditory expression, stapedius Hypcracusis
meatus, Geniculate (1) Taste of ant. 2/3 of the Loss of blink rf (+CNV)
Submandibular (2) & tongue (1) Loss of taste ant. 2/3
Pterygopalatine (3) gg. Secretomotor for Eye dry and red
submandibular, sublingual
glands (2) / lacrimal gland,
nasal & palaline glands (3)
VIII Vestibulocochlear, Hearing (1) Sensorineural hearing
S, Internal auditory Linear & angular acceleration loss
meatus, Spiral (1) & (2) Loss of balance
Vestibular (2) gg.
IX Glossopharyngeal, Stylopharyngeus m. Loss of gag rf (+CNX)
M+S+P, Jugular General & taste senses (1) for
foramen, Sup. & Inf. gg, post. 1/3 of the tongue/
(1), Otic g. (2) pharynx/ carotid sinus/body
Secretomotor for parotid
gland (2)

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 CN, Type, Foramina, Function
Associated Ganglia
X Vagus, M+S+P, To muscles of larynx, palate
Jugular foramen, Sup. & pharynx (except tensor
& Inf. gg, (1), Terminal palati (V) & stylopharyngeus
gg. (2) (IX))
Sensation in larynx and
laryngopharynx (1)
(2) To foregut and midgut
smooth muscle and glands
XI Accessory, M, Turns head to opposite side
Jugular foramen (sternocleidomastoid)
Elevates and rotates scapula
(trapezius)
XII Hypoglossal, M, To muscles of the tongue &
Hypoglossal canal infrahyoid (ansa cervicalis)
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Lesion
Dysphagia, palate droop
Uvula pointing away from
the lesion side
Hoarseness/loss of vocal
cord abduction
Loss of gag rf (+CNIX)
Loss of cough rf
Shoulder droop the same
side
Deviation of the tongue
toward the lesion
side on protrusion
 78. Pituitary gland tumors and
transsphenoidal operation
2 1
Pituitary tumors [1] may extend
superiorly through opening in the
diaphragma sella, producing
disturbances in endocrine system.
Superior extension of a tumor may
cause visual deficit owing to pressure on
the optic chiasm [2], the place where
the optic nerve fibers cross.
The transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphenoidal sinus [3]. This surgical
approach provides the best exposure of
the tumor at the lowest risk.
3

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 Hormones of the pituitary gland
Releasing and inhibiting factors from
neurosecretory cells of the
hypothalamus reach pituitary gland
thought special capillary network –
hypophyseal portal system and
control the production of
adenohypophyseal hormones
(ACTH, FSH, LH, TSH, prolactin
and somatotropin).
Hormones of neurohypophysis
(ADH and Oxytocin) are secreted in
hypothalamus and transported
through axons to pituitary gland.

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 Leer prosection
for more details

79. Trigeminal nerve

Skin of face
supplied by
branches of the
three divisions of
the [1]
TRIGEMINAL
NERVE (CN V)
1
Except for a small
area over the
angle of the
Infraorbital mandible which is
foramen supplied by the [2]
great auricular
nerve (C2-C3) –
cervical plexus
2

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 80. Bell's palsy
It is idiopathic unilateral facial
paralysis.
Terminal branches of CN VII may
be injured by parotid cancer or
inflammation (parotitis) by surgery
to remove a parotid tumor
(stylomastoid foramen).

Manifestations:
unable to close lips and eyelids on affected side
eye on affected side is not lubricated (dry eye)
unable to whistle, blow a wind instrument, or chew effectively
facial distortion due to contractions of unopposed contralateral facial
muscles

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 81. Epistaxis
HEE
Epistaxis (nosebleed)
most often occurs from
the anterior nasal septum
(Kiesselbach's area),
where branches of the
sphenopalatine, anterior
ethmoidal, greater
palatine, and superior
labial (from facial)
arteries converge.

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 Lateral wall of nasal cavity
Sphenoethmoidal recess
receives the opening of the
sphenoidal air sinus
1. Superior meatus
1. Receives opening of posterior
ethmoidal air cells
2. Middle meatus
1. Infundibulum, ethmoidal bulla and
semilunar hiatus
2. Receives openings of frontal and
maxillary sinuses and anterior
and middle ethmoidal air cells
3. Inferior meatus
Receives opening of
nasolacrimal duct

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 82.Ethmoiditis
Infection in the ethmoidal
sinuses can erode the medial
wall of the orbit, resulting in
orbital cellulites that can spread
to the cranial cavity.
In orbital cavity infection may
erode structures related to the
medial orbital wall:
Medial rectus muscle
Superior oblique muscle
Nasociliary nerve

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 83. Cheeks
Form the lateral, movable walls of the
oral cavity and the zygomatic
prominences of the cheeks over the
zygomatic bones.
1 Buccinator [1] – principal muscle of the
cheek.
Buccal pad of fat – encapsulated
2 collection of fat superficial to buccinator.
3 Parotid duct [2] from Parotid gland [3]
perforate buccinator and opens in inner
surface of the cheek right opposite 2nd
upper molar tooth

Long buccal N. also pierces

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 84. Movements at the TMJs

All 4 muscles of
mastication are
innervated by V3:
1.Temporalis –
elevation & retraction
2.Masseter -
elevation
3.Medial pterygoid -
elevation
4.Lateral pterygoid
- protrusion
Note: In case of Mandibular nerve (V3)
damage mandible (when it is protruded)
deviate toward the side of lesion because
opens
jaw
of Lateral pterygoid weakness.

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 85. Innervation of the tongue
1. Sensory anterior 2/3: general – lingual n. (V3), taste

2.
– chorda tympani (CNVII)
Facial
Sensory posterior 1/3: general and taste –
glossopharyngeal (CNIX)
3. Motor – hypoglossal (CNXII)
A lesion of the chorda tympani – lose of the taste
sensation anterior 2/3 of the tongue
A lesion of the lingual nerve – lose of both general
and taste sensation anterior 2/3 of the tongue
A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation and atrophy of the tongue).

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 86. Palatine tonsils
Receives main blood supply
from tonsillar branch of facial
artery
Drained by external palatine
vein to facial vein
Lymph drainage mainly to
jugulodigastric lymph node,
which is body's most frequently
enlarged lymph node
Nerve supply: tonsillar plexus of
nerves formed by branches of CN
IX and CN X

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 Tonsillitis
During palatine tonsillectomy, the
peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
If the glossopharyngeal nerve is
injured, taste and general sensation
from the posterior 1/3 of the tongue are
lost.
Hemorrhage may occur, usually from
the external palatine vein or tonsillar
branch of the facial artery
If the superior constrictor is
penetrated, a high facial artery or
tortuous internal carotid artery may
be injured.

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 Gag reflex
Touching the posterior part of the
pharynx results in muscular
contraction of each side of the
pharynx - gag reflex:
Afferent limb: CN IX
Efferent limb: CN X
Injury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative gag
reflex

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 87. Muscles of Soft Palate
1. Tensor veli palatini and
2. Levator veli palatini – elevates the
soft palate during swallowing to
prevent food entering to the
nasopharynx
in 3. Palatoglossus and
4. Palatopharyngeus – depress soft
palate and pulls walls of pharynx
superiorly
5. Uvular muscle – shortens uvula
and pulls it superiorly

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 88. Lymph drainage from the
head
1. Preauricular (parotid ) (on front of
auricle) receive lymph from
anteriolateral part of scalp and
lateral face
2. Submandibular (in digastric or
submandibular Δ) – from all air
1 sinuses, nose and adjacent
cheek, upper lip and lateral parts
of lower lip.
4
5 3. Submental (in submental Δ) – from
the chin, tip of the tongue and
3
2 central part of the lower lip.
4. Mastoid (behind the auricle) –
adjacent region of the head.
5. Occipital (occipital region).

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 Hingham
89. Blow-out fracture
we
A blow-out fracture of the orbital
floor typically is not involve the
orbital rim and is caused by blunt
trauma to the orbital contents (e.g.,
by a handball). Content of orbital
cavity blow-out in maxillary sinus.
Blow-out fractures may damage:
1. Inferior rectus muscle
2. Infraorbital nerve (from
maxillary V2)
3. Infraorbital artery
(hemorrhaging).

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 90. Lips and palate congenital
defects
The intermaxillary segment forms when
the two medial nasal prominences fuse
together at the midline and gives rise to the
philtrum of the lip, four incisor teeth, and
primary palate of the adult. It forms anterior
to the incisive foramen.
Secondary palate (2 shelves) derivate from
maxillary prominences.
Maxillary prominences have fused with the
medial nasal prominences (intermaxillary
segment).
In case of failure of this process, cleft of the
lip or palate will develop.

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 91. Strabismus
Smart table 9: Muscles of the orbit
Muscle Action Testing CN
Superior Up and medially Look laterally, CN III
rectus then up
Inferior rectus Down and Look laterally, CN III
medially then down

Medial rectus Adducts pupil Look medially CN III

Lateral Abducts pupil Look laterally CN VI
rectus
Superior Down and Look medially, CN IV
oblique laterally then down
Inferior Up and laterally Look medially, CN III
oblique then up
Levator Elevates upper CN III
pulpebra eyelid
superior

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 Oculomotor Nerve Palsy
External squint affects most of the extraocular
muscles
Manifestations: Ptosis, Fully dilated pupil, Eye is
fully depressed and abducted (“down and out”)
due to unopposed actions of superior oblique and
lateral rectus, respectively.

Trochlear nerve palsy

CNIII
It cause paralysis of the superior oblique and
impair the ability to turn the affected eyeball infero-
medially (“up and out”)
The characteristic sign of trochlear nerve injury is
diplopia (double vision) when looking down (e.g.,
when going down stairs or reading)
CNIV Abducens Nerve Palsy
Internal squint because of injury to abducens nerve
→ paralysis of lateral rectus → inability to abduct
the affected eye
Affected eye is fully adducted by the unopposed
CNVI action of the medial rectus that is supplied by CN III

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 92. Horner syndrome
Penetrating injury to the neck,
Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
interrupting ascending preganglionic
sympathetic fibers anywhere between
their origin in the T1 segment (IML) of
spinal cord and their synapse in the
Superior cervical ganglion.
It includes the following signs:
Constriction of the pupil (miosis)
Drooping of the superior eyelid

surfing't
(ptosis),
Redness and increased temperature
of the skin (vasodilation)
Absence of sweating (anhydrosis)

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 93. Otitis Media
Complications:
1. Hearing is diminished because of
pressure on the eardrum and
reduced movement of the ossicles.
2. Taste may be altered because the
chorda tympani is affected.
3. Infection spreading posteriorly
cause mastoiditis.
4. Infection that spreads to the
middle cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.

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 Perforation of the tympanic
membrane
May result from otitis media and is one of
several causes of middle ear (conduction)
deafness
Causes: foreign bodies in external
acoustic meatus, excessive pressure (as in
diving), trauma
Because chorda tympani directly relates
to the posterior surface of the tympanic
membrane it may be damaged and
resulting in loss of taste over anterior 2/3
of the tongue and secretion of the
sublingual and submandibular glands
Minor perforation heal spontaneously; large
ones require surgical repair

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 94. Inner ear
It contains the vestibulocochlear organ
concerned with reception of sound and
maintenance of balance (CNVIII).
Cochlea: spiral organ (of Corti) –
receptors for hearing (located along the
basilar membrane)
Vestibule: utricle and saccule are parts
of the balancing apparatus (static
position)
Semicircular canals: receptors of
angular acceleration (kinetic)
Anterior – in coronal plane
Posterior - in sagittal plane
Lateral – in horizontal plane

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 95. Thyroid and parathyroid
glands
Hormones:
The thyroid gland is the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4), which
controls the rate of metabolism (increase the
temperature of the body), and calcitonin, a hormone
controlling calcium metabolism (reduce blood calcium
Ca2+).
After total thyroidectomy may develop lower
temperature of the body and hypercalcemia.

The hormone produced by the parathyroid glands,

parathormone (PTH), controls the metabolism of
phosphorus and calcium in the blood (increase Ca2+
level).

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 Variation of parathyroid glands
position

The superior parathyroid

glands, more constant in position
than the inferior ones.
The inferior parathyroid glands
are usually near the inferior
poles of the thyroid gland, but
they may lie in various positions
In 1-5% of people, an inferior
parathyroid gland is deep in the
superior mediastinum inside the
thymus because of common
embryonic origin.

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 Anatomical relations of the
thyroid gland

Anterolateral –
infrahyoid muscles
1 Posterolateral –
COMMON CAROTID
ARTERY [1]
Medial – larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
1 nerve [3]
Ht Posterior –
parathyroid glands
1 [4]
3

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 CS of the neck

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 96. Cervical cysts
Median cervical cyst
Usually presents as a painless
midline mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during swallowing
together with thyroid gland because of
relation with pretracheal layer of
cervical fascia and infrahyoid muscles
of the neck.
Remanent of the thyroglossal canal
(thyroid gland originally from
epithelium of the tongue).
Treatment: surgical excision

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 Lateral cervical cysts
(Branchial cysts)

Lateral cervical cysts are

remnants of 2nd, 3rd, and 4th
grooves and filled up by
ectoderm
There are painless cysts located
on the lateral neck along the
anterior border of the
sternocleidomastoid muscle
They do NOT move during
swallowing (difference with
median cysts)
Treatment: surgical excision

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 97. Larynx
3

Cavity of the Larynx -

2 Folds:
1
2 Vestibular folds
[1] (false vocal
cords)
Vocal folds [2]
(true vocal cords)
Rima vestibuli – gap between the
vestibular folds
Rima glottidis [3] – gap between the
vocal folds anteriorly and vocal
1 processes of the arytenoid cartilages
posteriorly is most narrow place in the
larynx (it limits size of intubation tube
2
during endotrachial anaesthesia)

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 Muscles of the Larynx
Abductors
Posterior
cricoarytenoid –
abducts vocal folds (the
only abductors of the
vocal folds)
Opensthe rime
It is innervated by gl titis
recurrent laryngeal
nerve (CNX vagus).
Interruption of recurrent
laryngeal nerve results
in hoarseness because
the corresponding vocal
fold does not abduct and
deviate toward the
midline.

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 98. Cricothyrotomy
A cricothyrotomy is an emergency
procedure that relieves an airway
obstruction (e.g. swallowed foreign
bodies or abnormal tissue growths).
A hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage (needle
cricothyrotomy).
More frequently, a small incision is
made in the skin over the
Cricothyroid membrane, and
another one is made through the
membrane between the cricoid
and thyroid cartilage. A tube that
enables breathing is inserted
through the incision.

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 99. Retropharyngeal space
It is interval between pharynx
(Bucco-pharyngeal fascia) and
prevertebral fascia
May provide a passageway of
infection from pharynx to
posterior mediastinum
(mediastinitis ≈  90%  mortality  
rate).

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 100. Neck
Axillary sheath
Derived from the prevertebral
fascia
Encloses the subclavian artery
and brachial plexus as they
emerge in the interval between the
scalenus anterior and medius
muscles (Interscalenus space)
Extends into the Axilla

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 Torticollis
Congenital torticollis
most commonly caused by a fibrous
tissue tumor in the SCM
head turns to the side and the face to
turn away from the affected side
surgical release may be necessary
Spasmodic torticollis
may involve any bilateral combination
of lateral neck muscles, usually SCM
and trapezius
involuntary shifting of head laterally or
anteriorly
shoulder usually elevated and anteriorly
displaced on the side on which chin
turns

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 Posterior triangle of the neck
CN XI
CN XI (accessory nerve) supply:
Veins – external jugular vein,
subclavian vein.
Arteries – occipital artery.
Nerves – Accessory nerve (XI),
trunks of the brachial plexus,
branches of cervical plexus, phrenic
nerve.
Lymph nodes – superficial cervical
nodes along external jugular vein.
Sternocleidomastoid muscle - face
looks upward to the opposite side
Trapezius - superior fibers elevate,
middle fibers retract, and inferior
fibers depress scapula.

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