Riyadh et al.

Notes

GENERAL:
1- Embryology of Pharyngeal Apparatus
2- Skull and Facial Bones Anatomy
3- Cervical Muscles Anatomy
4- Vessels and Lymphatics Anatomy
5- Cranial Nerves Anatomy
6- Trigeminal Nerve Anatomy
7- Facial Nerve Anatomy
8- Anatomy of Pharynx
9- Physiology of Pharynx
10- Pharyngitis
11- Tonsils
12- Adenoid
13- Velopharyngeal Insufficiency
14- Snoring and Obstructive Sleep Apnea (OSA)
15- Cervical Fascia and Deep Neck Infections
16- Pharyngeal Pouch
17- Esophageal Anatomy and Disorders
18- Angioedema
19- Neck Trauma

2
The phrenic nerve originates in the phrenic motor nucleus in the ventral horn of the cervical spinal cord. It
descends obliquely with the internal jugular vein across the anterior scalene, deep to the prevertebral layer of
deep cervical fascia and the transverse cervical and suprascapular arteries. On the left, the phrenic nerve
crosses anterior to the first part of the subclavian artery. On the right, it lies on the anterior scalene muscle and
crosses anterior to the 2nd part of the subclavian artery. On both sides, the phrenic nerve runs posterior to the
subclavian vein as it enters the thorax where it runs anterior to the root of the lung and between the fibrous
pericardium and mediastinal face of the parietal pleura
pharyngeal apparatus

1st Arch - Nerves: Trigeminal (V2 and V3).

- Cartilage: Meckel’s cartilage: head of malleus, body and short process of incus, maxilla and premaxilla, mandible, Seqaumous
portion of temporal bone, Zygoma )
- Ligaments: Anterior ligament of malleus, Sphenomandibular Ligament
- Muscles: Muscles of Mastication, Tensor tympani, Tensor palati, Mylohyoid, Ant. belly of Digastric.
- EAR: Hillock of His: 1st (tragus), 2nd (crus of helix), 3rd (helix)
- artery: involutes
- others: anterior 2/3 tongue, salivary glands

1st pouch tubotympanic recess, tympanic membrane, mastoid antrum , EAC, ET, tympanic cavity

2nd arch - Nerve: Facial Nerve (VII)

- Cartilage: Reichert’s cartilage: long process of incus, handle " manubrium" of malleus, stapes superstructure and tympanic surface
of footplate, hyoid bone ( lesser horn, upper half of body.)
- Muscles: Muscles of Facial Expression, Platysma, Stapedius, Stylohyoid, Post. belly of Digastric.
- Ligament: Stylohyoid ligament
- Artery: 2nd Arch artery (stapedial artery); Involutes (may persist in 2% of adults).
- Ear: Hillock of His: 4th (antihelix), 5th (scapha), 6th (antitragus and lobule).]

2nd pouch Palatine Tonsiles, tonsiler fossa, epithelium of tonsil

3rd arch - Nerve: Glossopharyngeal Nerve (IX)

- Cartilage: hyoid bone: ( Lower ½ Body and Greater Horn )
- Muscles: Stylopharyngeus.
- Artery: Common carotid artery, internal carotid artery.
- others: posterior 1/3 tongue,

3rd pouch ventral: thymus, dorsal: inferior parathyroid

4th arch - Nerve: superior laryngeal nerve (X).

- Cartilage: Thyroid cartilage, epiglottis
- Muscles: cricothyroid, All Muscles of Soft Palate (EXCEPT Tensor Veli Palatini):( Levator Veli Palatini, Musculus uvulae, PalatoGlossus,
PalatoPharyngeus.) , All Muscles of Pharynx (EXCEPT StyloPharyngeus):( Superior Constrictor, Middle Constrictor, Inferior Constrictor,
SalpingoPharyngeus, PalatoPharyngeus.)
- Artery: Rt. Side: Proximal Subclavian artery, Lt. Side: Arch of Aorta.
- others: root of tongue.

4th pouch dorsal: superior parathyroid, ventral: ultimobranchial body which forms the parafollicelar cell C-Cells of the thyroid gland

6th arch - Nerve: Recurrent Laryngeal branch nerve (X)

- Cartilage: cricoid cartilage, arytenoid cartilage, corniculat cartilage, Cuniform cartilage
- Muscles: All Intrinsic Muscles of Larynx (EXCEPT CricoThyroid):( Thyroarytenoid Muscle, Thyroepiglotticus Muscle, Lateral
Cricoarytenoid Muscle, Transverse Arytenoid Muscle, Oblique Arytenoid Muscle, Posterior Cricoarytenoid muscle.)
- Artery: Rt. Side: Rt. Pulmonary artery, Lt. Side: Ductus arteriosus and Lt. pulmonary aretery.
Riyadh et al. Notes
chapter 1
Embryology

- Head and Neck are formed by:

1. Paraxial mesoderm
2. Lateral plate mesoderm
3. Neural crest
4. Ectodermal placodes

- Pharyngeal (branchial) apparatus appear in embryo by 4thweek.

- It consist of:
1- Pharyngeal Arches (6)
2- Pharyngeal Pouches (4)
3- Pharyngeal Groove (1)
4- Pharyngeal Membrane (1)

Pharyngeal Arches:

- Early in the 4th week, neural crest cells

migrate to develop it.
- 1st pharyngeal arch pair (premordium
jaws) elevates lateral to develop
pharynx.
- Then other arches appear.
- By end of 4th week, 4 pairs of arches
are visible externally.
- 5th and 6th pharyngeal arches are
rudimentary and not visible.
- Pharyngeal arches separated by fissures
(grooves).

- 1st pharyngeal arch (Mandibular Arch) Develop 2 prominences:

1- Maxillary prominence.
2- Mandibular prominence.

3
 Riyadh et al. Notes

- 2nd pharyngeal arches (Hyoid Arch).

- Arches support lateral wall of primordial pharynx which is derived from
cranial part of the foregut.

buccopharyngeal membrane

- Primordial mouth or stomodeum appears as a slight depression of the

surface ectoderm. Mcq
- It is separated from the cavity of primordial pharynx by a bilaminar
membrane, Oropharyngeal membrane (composed of ectoderm and
endoderm).
- Rupture at about 26 days and communicate pharynx and foregut with
amniotic cavity

4
Riyadh et al. Notes

- Components of Pharyngeal Arch:

1. Externally ectoderm.
2. Core mesenchyme (embryonic connective tissue)
3. Internally endoderm.

Head and Neck mesenchyme is derived from:

1. Mesoderm (Original Mesenchyme) gives rise to:
o Skeletal musculature
o Vascular endothelia.
2. Cranial neural crest mesenchyme (Ectomesenchyme) Gives rise to:
o Most Head and neck myesenchyme.

- All the mesenchyme of head and neck derived from neural crest cells
EXCEPT skeletal musculature and vascular endothelia which derived
from original mesenchyme.

Fate of Pharyngeal Arches:

- Face, nasal cavity, mouth, pharynx, larynx and neck.
- By 5th week:
o 2nd pharyngeal Arch Overgrows the 3rd and 4th arches, forming
Cervical sinus.
- By the 7th week:
o 2nd, 3rd, 4th Grooves + Cervical sinus have disappeared.

- Typical Pharyngeal Arch contains:

1- Nerve.
2- Skeletal Structures.
3- Muscular component .
4- Aortic arch:
o Arise from Truncus arteriosis pass around pharynx and enter
Dorsal aorta

5
Riyadh et al. Notes

6
Riyadh et al. Notes

Derivatives of Pharyngeal Arch Nerves:

- 1st Arch:
o Trigeminal Nerve (CN-V):
1. Maxillary Nerve (V2)
2. Mandibular Nerve (V3)
- 2nd Arch:
o Facial Nerve (CN-VII)

- 3rd Arch:
o Glossopharyngeal Nerve (CN-IX)

- 4th Arch:
o Vegus Nerve (CN-X):
o Superior Laryngeal Nerve
- 5th Arch:
o No Derivatives.

- 6th Arch:
o Vegus Nerve (CN-X):
o Recurrent Laryngeal Nerve

7
MCQ
Riyadh et al. Notes

- Derivatives of Pharyngeal Arches Skeletal Structures:

- 1st Arch (Meckel Cartilage):

1. Malleus.
2. Incus.
3. Seqaumous portion of temporal bone.
4. Zygoma.
5. Maxilla.
6. Mandible.
7. Anterior ligament of malleus.
8. Sphenomandibular Ligament

- 2nd Arch (Reichert Cartilage):

1. Stapes supra structures.
2. Styloid Process
3. Lesser cornu of Hyoid.
4. Superior part of body of Hyoid.
5. Stylohyoid ligament

- 3rd Arch:
1. Greater cornu of Hyoid.
2. Inferior part of body of Hyoid.

- 4th Arch:
1. Epiglottis.
2. Thyroid Cartilage.

- 5th Arch:
o No Derivatives.

- 6th Arch:
1. Arytenoid Cartilage.
2. Corniculate Cartilage.
3. Cuneiform Cartilage.
4. Cricoid Cartilage.

8
 MCQp
Riyadh et al. Notes

- Derivatives of Pharyngeal Arches Muscles

- 1st Arch: (Trigeminal Nerve)

1. Muscles of Mastication
1. Temporalis.
MCQ 2. Masseter.
3. Medial Pterygoid.
4. Lateral Pterygoid.
2. Tensor Tympani.
3. Tensor Veli Palatini.
4. MyloHyoid.
5. Anterior belly of Digastric.

- 2nd Arch: (Facial Nerve)

1. Muscles of Facial Expression.
MCQ 2. Stapedius.
3. StyloHyoid.
4. Posterior belly of Digastric.

- 3rd Arch: (Glossopharyngeal Nerve)

1. StyloPharyngeus muscle.

- 4th Arch: (Superior Laryngeal Nerve)

MCQp 1. CricoThyroid (Tensor).
2. All Muscles of Pharynx (EXCEPT StyloPharyngeus):
1. Superior Constrictor.
2. Middle Constrictor.
3. Inferior Constrictor.
4. SalpingoPharyngeus.
5. PalatoPharyngeus.
3. All Muscles of Soft Palate (EXCEPT Tensor Veli Palatini):
1. Levator Veli Palatini.
2. Musculus uvulae.
3. PalatoGlossus
4. PalatoPharyngeus.
- 5th Arch:
o No Derivatives.

- 6th Arch: (Recurrent Laryngeal Nerve)

1. All Intrinsic Muscles of Larynx (EXCEPT CricoThyroid):
1. Postereior CricoArytenoid (Abdcutor)
2. Lateral CricoArytenoid. (Addcutor)
3. InterArytenoid (Addcutor)
4. ThyroArytenoid (Addcutor)
5. Vocalis (Tensor)
6. ThyroEpiglottis (Opens the laryngeal inlet)
7. AryEpiglottis (Closes the laryngeal inlet)

9
Riyadh et al. Notes

10
Riyadh et al. Notes

- Derivatives of Pharyngeal Arches Arteries (Aortic Arches):

- 1st Arch:
o Disappear early in life, but the remnant forms:
1- Maxillary Artery.

- 2nd Arch:
1. Stapedial Artery.
o Disappear early in fetal life.
o Originate from ICA.
o Pass between Stapedial crura.
rd
- 3 Arch:
1. Internal Carotid Artery.

- 4th Arch:
o Right:
1- Right Subclavian Artery.
o Left:
1- Arch of Aorta.
- 5th Arch:
o No Derivatives.

- 6th Arch:
o Right:
1. Proximal: Right Pulmonary Artery
2. Distal: Degenerates
o Left:
1. Proximal: Left Pulmonary Artery
2. Distal: Ductus Arteriosum.

- This explain why the course of the recurrent laryngeal nerves differ on
the two sides:
o Right side: hooks around Right subclavian artery
MCQp
o Left side: hooks around Ligmentum Arteiosum (Remenant of
Ductus Arteriosum).

11
Riyadh et al. Notes

- Hillock of His Embryology:

- 1st Arch:
Mcq
1. Tragus
2. Helical crus
3. Helix
- 2nd Arch:
1. Anti-Hilex.
2. Scapha.
3. Lobule

12
Riyadh et al. Notes

13
Riyadh et al. Notes

- Pharyngeal Pouches:
- Primordial Pharynx derived from Foregut.
- Widens cranially and joins Primordial mouth (Stomodeum)
- Narrows caudally and joins Esophagus.
- Endoderm of pharynx lines internal aspect of Pharyngeal Arches
- Pharyngeal Pouches forms from Endodermal invagination.

14
 Riyadh et al. Notes

- Pharyngeal Pouches:

- 1st Pouch:
1. Tubotympanic Recess:
MCQp 1. Tympanic Cavity.
2. Mastoid Antrum.
2. Eustachian Tube.

- 2nd Pouch:
1. Tonsilar Fossa.
2. Epithelium of Tonsils

- 3rd Pouch:
1. Ventral Part:
1. Thymus.
2. Dorsal Part:
2. Inferior Parathyroid glands.

- 4th Pouch:
1. Ventral Part:
1. UltimoPharyngeal Body  Parafollicular Cells.
2. Dorsal Part:
2. Superior Parathyroid glands.

15
Riyadh et al. Notes

- UltimoPharyngeal Body:
- Last of the series of structures from the pouches.
- From neural crest cells that migrate from 4th pouch (5th pouch which
become part of 4th helps also to form ultimopharyngeal body)
- Gives Parafollicular cells (C cells) and fuses with thyroid gland
- Produce Calcitonin.

16
Riyadh et al. Notes

- Pharyngeal Groove (Cleft):

- Grooves formed from Ectoderm.
- Initially, 4 Pharyngeal Grooves.
- Later on 2nd, 3rd, 4th Pharyngeal Grooves normally obliterated by
overgrowth of 2nd Pharyngeal Arch.
- Only One Pharyngeal Groove contributes to postnatal structure.
- 1st Pharyngeal Groove:
1. External Auditory Meatus.

- Pharyngeal Membrane:
- Composed of:
1. External Ectoderm of Pharyngeal Grooves.
Mcq 2. Mesoderm and Neural crest in the core.
3. Internal Endoderm of Pharyngeal Pouches.

- Only One Pharyngeal Membrane contributes to postnatal structure.

- 1st Pharyngeal Membrane:
1. Tympanic Membrane.

17
Riyadh et al. Notes

- Embryology of Adenoid:
- Formed between 3rd and 7th month.
- Arise from subepithelial infiltrations of lymphocytes
- Present at birth

- Anomalies of Head and Neck:

- Congenital auricular sinuses and cysts
- Branchial sinuses, fistula or cysts
- Branchial vestiges (cartilaginous and bony remnant which should have
disappeared)
- 1st ach syndrome (Treacher collins syndrome, Pierre robin syndrome)
- Accessory thymic tissue and variation of thymus
- Ectopic parathyroid and abnormal number

18
Riyadh et al. Notes
chapter 2
Skull and Facial Bones:

- Most complicated bony structure in the human body.

- 22 bones make up the skull:
o 8 Paired bones:
1. Parietal
2. Temporal
3. Zygomatic
4. Maxilla
5. Palatine
6. Nasal
7. Lacrimal
8. Inferior Turbinate

o 6 Single bones:
1. Frontal
2. Ethmoid
3. Sphenoid
4. Vomer
5. Mandible
6. Occipital

- Most important function: to protect the brain

- Also protects the 5 organs of special sense:
o Olfaction
o Vision
o Taste
o Vestibular function
o Auditory function

- Skull is divided into:

1. Mandible (lower jaw)
2. Cranium (skull without the mandible)
o Cranium is further divided into:
 Cranial vault: Upper portion of skull.
 Cranial base: Inferior portion of skull.
 Cranial cavity: Interior of skull.
 Facial skeleton: Bones that make up the face
 Acoustic skeleton: Ear ossicles.

- Cranial cavity divisions:

1. Anterior cranial fossa:
o Contains Frontal lobe of the brain.
2. Middle cranial fossa:
o Contains Temporal lobe of the brain.
3. Posterior cranial fossa:
o Contains Cerebellum.

19
Riyadh et al. Notes

- FRONTAL BONE
- Single bone.
- Contains Frontal Sinuses
- 3 Parts:
1. Squamous Portion:
o Largest part.
o Forms majority of forehead.
o Forms supra-orbital margin and superciliary arch.
o Zygomatic process of frontal bone extends from posterior
part of supra-orbital margin.
2. Orbital Portion:
o Forms roof of the orbit and floor of Anterior cranial fossa.
3. Nasal Portion:
o Trochlea of orbit articulates with the orbital portion.
o Articulates with Nasal bones and Frontal process of
Maxilla to form Root of the nose.

20
Riyadh et al. Notes

- PARIETAL BONE
- Paired bone.
- Forms majority of Cranial vault (roof and sides).
- Provides attachment of Temporalis muscle.

21
Riyadh et al. Notes

- OCCIPITAL BONE
- Single bone.
- Forms posterior part of Cranial vault.
- Articulates with Atlas.
- 3 Parts:
1. Squamous portion:
o Largest portion of Occipital bone.
o Posterior and superior to Foramen magnum.
o Articulates with Temporal and Parietal bones.
o External occipital protuberance (more pronounced in
males).
o Superior and Inferior nuchal lines.

2. Lateral portion:
o Lateral to Foramen magnum.
o Articulates with Temporal bone.
o Occipital condyle articulates with Atlas.
o Contains Hypoglossal canal.
o Forms a portion of Jugular foramen.

22
Riyadh et al. Notes

3. Basilar portion:
o Immediately Anterior to Foramen magnum.
o Articulates with Petrous and sphenoid bones.
o Pharyngeal tubercle provides attachment for superior
constrictor.
o Internal surface of Basilar portion is called Clivus, and
part of the brainstem lies against it.

- TEMPORAL BONE
- Paired bone.
- Form part of base and lateral walls of Skull.
- House Auditory and Vestibular apparatuses.
- Contain Mastoid air cells.
- 4 parts:
1. Squamous part of Temporal bone:
o Largest Part.
o 3 portions:
1. Temporal:
o Thin large area on Squamous part of
temporal bone.
o On the internal surface of temporal portion
lies a groove for Middle meningeal Artery.
2. Zygomatic process:
o Extends laterally and anteriorly from the
squamous portion
o Articulates with Temporal process of
zygomatic bone to make Zygomatic arch.
3. Glenoid fossa:
o Inferior and medial to Zygomatic process.
o Articulates with Mandibular condyle forming
Temporomandibular joint.

23
Riyadh et al. Notes

2. Petrous part of Temporal bone:

o The solid portion of Temporal bone.
o Extends Anteriorly and Medially.
o Auditory and Vestibular apparatuses are located within
petrous part.
o Separate Temporal and Occipital lobes of the brain.
o Medial part articulates with sphenoid bone to form
Foramen lacerum.
o Internal Acoustic Meatus (IAM) is observed on the medial
side of petrous part.
o Carotid canal lies on Inferior part of Petrous part.
o Petrotympanic fissure lies between Petrous and Tympanic
parts of Temporal bone.
o On the posterior inferior surface lies Jugular fossa.
o Between Jugular fossa and Carotid canal is Tympanic
canaliculus.
o Mastoid process extends posteriorly and has large
mastoid air cells.

24
Riyadh et al. Notes

3. Tympanic part of Temporal bone:

o A plate of bone forming Anterior, Posterior and Inferior
portions of External acoustic meatus.
o Anterior part forms Posterior portion of Glenoid fossa.

4. Styloid process:
o A projection from the temporal bone.
o Stylomastoid foramen lies posterior to this process.

25
Riyadh et al. Notes

- SPHENOID BONE
- Single bone.
- Forms majority of Middle portion of Cranial base.
- Forms majority of Middle Cranial fossa.
- Contains Sphenoid Sinus.

- 4 Parts:
1. Body of Sphenoid:
o Center of sphenoid.
o Anterior portion forms part of nasal cavity.
o Sella turcica:
 Superior part of sphenoid body.
 Saddle shaped and possesses the Anterior and
posterior clinoid processes.
 Hypophyseal fossa, the deepest part of Sella
turcica, houses Pituitary gland.
o Dorsum sellae is a square-shaped part of bone that lies
posterior to sella turcica.
o Clivus is the portion that slopes posterior to the body.
o Body contains sphenoid paranasal sinuses.
o Lateral portion of the body is covered by Cavernous sinus.
o Optic canal is found in the body of the sphenoid.

2. Greater wing:
o Extends Laterally and Anteriorly from posterior portion of
the body.
o Endocranial portion helps form a large part of the middle
cranial fossa.
o Lateral portion is the infratemporal surface.
o Anterior portion lies in the orbit.
o Contains 3 foramina:
1. Foramen spinosum
2. Foramen rotundum
3. Foramen ovale

26
Riyadh et al. Notes

3. Lesser wing:
o Extends Laterally and Anteriorly from the superior portion
of the body.
o Separated from the greater wing by Superior orbital
fissure.

4. Pterygoid process:
o Arises from Inferior surface of the body.
o 2 Pterygoid processes, each has:
1. Lateral pterygoid plate
2. Medial pterygoid plate
o Pterygoid hamulus extends from Medial pterygoid plate.
o Two canals are associated with Pterygoid process:
1. Pterygoid canal
2. Pharyngeal canal

27
Riyadh et al. Notes

28
Riyadh et al. Notes

29
 Riyadh et al. Notes

- ETHMOID BONE
- Single porous bone.
- Forms the major portion of middle part of Face between the orbits.
- Helps form Orbit, Nasal cavity, Septum and Anterior cranial fossa.
- 3 Parts:
1. Perpendicular plate:
o Flat plate descends from Cribriform plate to form part of
Nasal septum.
o Articulates with the vomer inferiorly.
MCQ
2. Cribriform plate:
o Horizontal bone forms Superior surface of Ethmoid.
o Contains numerous foramina for Olfactory nerve.
o Crista galli is a vertical plate extends superiorly from
cribriform plate providing attachment for Falx cerebri of
meninges.
o Associated with a small foramen cecum.
3. Ethmoid labyrinth:
o Largest part of Ethmoid bone.
o Descends inferiorly from the cribriform plate.
o Ethmoid sinuses are located within the ethmoid labyrinth.
o Ethmoid labyrinth forms 2 major structures within Nasal
cavity:
1. Superior Nasal Turbinate
2. Middle Nasal Turbinate
o Ethmoid bulla is the large elevation of bone located by the
middle ethmoid paranasal sinuses
o Uncinate process is a curved piece of bone.
o Between Ucinate process and Ethmoid bulla is the Hiatus
semilunaris.

30
Riyadh et al. Notes

31
Riyadh et al. Notes

- MAXILLA
- Paired bone.
- Forms majority of skeleton of Face and upper jaw.
- Contains Maxillary sinus.
- Articulates with:
o Opposite Maxilla
o Frontal bone
o Sphenoid bone
o Nasal bone
o Vomer bone
o Ethmoid bone
o Inferior Nasal Turbinate
o Palatine bone
o Lacrimal bone
o Zygomatic bone
o Septal cartilages

32
Riyadh et al. Notes

- 5 Parts:
1. Body of Maxilla:
o Major part of the bone.
o Shaped like a pyramid.
o Contains Maxillary sinus.
o 4 different regions:
 Orbit
 Nasal cavity
 Infratemporal fossa
 Face
o Infraorbital canal and foramen pass from the orbit region
to the face region.

2. Frontal Process:
o Extends Superiorly.
o Articulate with:
 Nasal bone
 Frontal bone
 Ethmoid bone
 Lacrimal bone
o Forms the posterior boundary of Lacrimal fossa

3. Zygomatic Process:
o Extends Laterally.
o Articulates with Maxillary process of Zygomatic bone.

4. Palatine Process:
o Extends Medially.
o Form Majority of Hard palate.
o Articulates with:
 Palatine process of opposite Maxilla
 Horizontal plate of Palatine bone
o Incisive foramen is located in the Anterior portion.

5. Alveolar Process:
o Extends Inferiorly.
o Supports all Maxillary teeth.
o Each maxilla contains:
 5 primary teeth.
 8 permanent teeth.
o Alveolar bone is resorbed when a tooth is lost.

33
Riyadh et al. Notes

- PALATINE BONE
- Paired L-shaped bone
- Forms part of Lateral wall of Nasal cavity and Hard palate.
- 3 Parts:
1. Perpendicular Plate:
o Vertical rectangle shape.
o On the superior border is a notch articulates with the
sphenoid bone, forming Sphenopalatine foramen.
o Small orbital process helps form part of the orbit.
o Forms part of wall of the Pterygopalatine fossa and
Lateral wall of Nasal cavity.
o Lateral wall articulates with Maxilla to form palatine canal.
2. Horizontal Plate:
o Forms Posterior portion of Hard palate.
o Superior to horizontal plate is Nasal cavity.
o Posterior nasal spine is located on the medial part and
formed by both of the horizontal plates.
o Greater palatine foramen is located on this plate.
3. Pyramidal Process:
o Extends posteriorly and inferiorly from junction of
Perpendicular and Horizontal plates of palatine bone.
o Lesser palatine foramina are located here.

34
Riyadh et al. Notes

35
Riyadh et al. Notes

- LACRIMAL BONE
- Paired bone.
- Small and rectangular in shape.
- Very thin and fragile.
- Forms a small portion of:
o Medial wall of Orbit.
o Lateral wall of Nasal cavity.
- Articulates with:
o Frontal process of Maxilla
o Orbital plate of Ethmoid bone
o Frontal bone
o Inferior Nasal Turbinate
- The region that articulates with Frontal process of Maxilla forms
Lacrimal fossa, the location of the Lacrimal Sac.

- NASAL BONE
- Paired bone.
- Inferior portion forms Superior margin of Nasal aperture.
- Forms bridge of Nose.
- Articulates with:
o Nasal bone of opposite side
o Nasal portion of Frontal bone
o Frontal process of Maxilla
o Perpendicular plate of Ethmoid
- Inferior portion of the nasal bones attaches with Lateral nasal
cartilages and septal cartilage.

36
Riyadh et al. Notes

- VOMER
- Single bone.
- Shaped like a “plough”.
- Forms Posterior inferior part of Nasal septum.
- Articulates with:
o Perpendicular plate of Ethmoid
o Maxilla
o Palatine
o Sphenoid bone
o Septal cartilage
- Posterior border does not articulate with any other bone.

- INFERIOR NASAL CONCHA

- Paired curved bone.
- Forms part of Lateral wall of Nasal cavity.
- Lies within a curve in Lateral wall of Nasal cavity.
- Articulates with:
o Maxilla
o Perpendicular plate of Palatine
o Lacrimal bone
o Ethmoid bone

37
Riyadh et al. Notes

- ZYGOMATIC BONE (ZYGOMA)

- Paired bone.
- Forms Majority of skeleton of Cheek.
- Provides for attachment of Masseter.
- Three foramina in Zygoma:
1. Zygomatico-orbital foramen
2. Zygomaticofacial foramen
3. Zygomaticotemporal foramen

- 3 Parts:
1. Frontal Process:
o Articulates with Zygomatic process of Frontal bone to help
form Orbit.
2. Temporal Process:
o Articulates with Zygomatic process of Temporal bone to
form Zygomatic Arch.
3. Maxillary Process:
o Articulates with Zygomatic process of Maxillary bone to
help form Orbit.

38
Riyadh et al. Notes

- MANDIBLE
- Single horseshoe shaped bone.
- Forms Lower jaw.
- All muscles of Mastication attach to Mandible.
- 5 Parts:
1. Body of Mandible:
o Mental foramen lies on Anterior part of Lateral surface of
the body.
o External oblique line located on Lateral side of Body.
o Mylohyoid line located on Medial side of Body
o Mylohyoid line helps divide Sublingual from
Submandibular fossa.
o Posterior border of Mylohyoid line provides attachment of
Pterygomandibular raphe.
o At the midline on the medial side are the superior and
inferior genial tubercles, as well as Digastric fossa.

2. Ramus of Mandible:
o Meets body of Mandible at the Angle on each side.
o Lateral side of Ramus:
 Attachment of Masseter muscle.
o Medial side of Ramus:
 Attachment of Medial pterygoid muscle.
 Mandibular foramen.
o Superior part of Ramus divides into:
 Coronoid Process (Anteriorly)
 Condylar Process (Posteriorly)
 Separated by Mandibular notch.

39
Riyadh et al. Notes

3. Coronoid Process:
o Anterior superior extension of each Ramus.
o Attachment of Temporalis muscle.

4. Condylar Process:
o Posterior superior extension of each Ramus.
o Articulates with Temporal bone in TM joint.
o Has a neck that forms a condyle superiorly.
o Attachment of Lateral pterygoid muscle into pterygoid
fovea on the Neck.

5. Alveolar Process:
o Extends superiorly from the body.
o Created by a thick buccal and a thin lingual plate of bone
o Supports the mandibular teeth
o Each side of the mandible contains:
 5 primary teeth.
 8 permanent teeth.
o Alveolar bone is resorbed when a tooth is lost.

40
Riyadh et al. Notes

41
 Riyadh et al. Notes

- Major Skull Foramina and Fissures:

o Cribriform Plate:
- Formed by:
o Ethmoid bone.
- Contents:
1. Olfactory Nerve (CN-I).

o Anterior Ethmoid Foramen:

- Formed by:
o Between Frontal and Ethmoid
bone
- Contents:
1. Anterior Ethmoid Nerve.
2. Anterior Ethmoid Vessels.

o Posterior Ethmoid Foramen:

- Formed by:
o Between Frontal and Ethmoid
bone
- Contents:
1. Postrior Ethmoid Nerve.
2. Postrior Ethmoid Vessels.

o Optic Canal:
- Formed by:
Mcq o Sphenoid bone
- Contents:
1. Optic Nerve (CN-II)
2. Ophthalmic Artery.

The ophthalmic artery is inferolateral to the optic nerve

o Superior Orbital Fissure:

- Formed by:
o Between Greater and Lesser wings of Sphenoid.
- Contents:
1. Oculomotor (CN-III) (Upper+Lower)
2. Trochlear Nerve (CN-IV).
3. Ophthalmic Nerve (V1)
(Frontal+Lacrimal+Nasocilliary)
4. Abducens Nerve (CN-VI)
5. Ophthalmic vein (Superior+Inferior).

42
Riyadh et al. Notes

o Foramen Rotundum:
- Formed by:
o Sphenoid.
- Contents:
1. Maxillary Nerve (V2)

o Foramen Ovale:
- Formed by:
o Sphenoid.
- Contents:
1. Mandibular Nerve (V1)
2. Accessory Meningeal Artery.
3. Lesser Petrosal Nerve.
4. Emissary Veins.

o Foramen Spinosum:
- Formed by:
o Sphenoid.
- Contents:
1. Middle Meningeal Vessels.
2. Meningeal branch of Mandibular
Nerve (V1)

o Foramen Lacerum:
- Formed by:
o Articulation of Greater wing and
body of Sphenoid + Petrous
portion of Temporal + Basilar
portion of Occipital bone
- No Contents

o Carotid Canal:
- Formed by:
o Petrous portion of Temporal Bone.
- Contents:
1. Internal Carotid Artery.
2. Internal Carotid Plexus (Sympathetics).

43
 Riyadh et al. Notes

o Internal Acoustic Meatus:

- Formed by:
o Petrous portion of Temporal Bone.
- Contents:
1. Facial Nerve (CN-VII)
2. Vestibulocochlear Nerve (CN-VIII)
3. Labyrinthine Artery.

o Jugular Foramen:
- Formed by:
o Petrous portion of Temporal Bone
+ Occipital.

- Anterior-medial compartment:
1. Inferior Petrosal Sinus
- Intermediate compartment:
1. Glossopharyngeal Nerve (CN-IX)
MCQ 2. Vagus Nerve (CN-X)
3. Spinal Accessory Nerve (CN-XI)
- Posterior-lateral compartment:
1. Sigmoid Sinus
2. Posterior Meningeal Artery.
- The jugular foramen is usually described as being divided into
two parts by a fibrous or bony septum, called the jugular spine,
into:
- the pars nervosa: anteromedial and smaller (inferior petrosal
sinus and glossopharyngeal cranial nerve (CN IX)
- the pars vascularis: posterolateral and larger ( jugular bulb,
vagus nerve (CN X) and spinal accessory nerve (CN XI)

o Hypoglossal Canal:
- Formed by:
o Occipital Bone.
- Contents:
1. Hypoglossal Nerve (CN-XII)

o Foramen Magnum:
- Formed by:
o Occipital Bone.
- Contents:
1. Medulla oblongata
2. Vertebral Arteries
3. Spinal roots of Spinal Accessory Nerve (CN-XI)

44
Riyadh et al. Notes

o Incisive Foramen:
- Formed by:
o Palatine Process of Maxilla.
- Contents:
1. Nasopalatine Nerve.
2. Sphenopalatine Artery.

o Tympanic Canaliculus:
- Formed by:
o Temporal bone.
- Contents:
1. Tympanic branch of
Glossopharyngeal Nerve (CN-IX)

o Petrotympanic Fissure:
- Formed by:
o Temporal bone.
- Contents:
1. Chorda Tympani Nerve.
2. Anterior Tympanic Artery.

o Stylomastoid Foramen:
- Formed by:
o Temporal bone.
- Contents:
1. Facial Nerve (CN-VII)
2. Stylomastoid Artery.

45
Riyadh et al. Notes

o Supraorbital Foramen:
- Formed by:
o Frontal bone.
- Contents:
1. Supraorbital Nerve.
2. Supraorbital Vessels

o Infraorbital Fissure:
- Formed by:
o Between Greater wing of
sphenoid and Maxilla and
Orbital postion of Palatine
bone.
- Contents:
1. Maxillary Nerve (V2).
2. Zygomatic Nerve.
3. Infraorbital Vessels.

o Zygomaticfacial Foramen:
- Formed by:
o Zygomatic bone.
- Contents:
1. Zygomaticofacial Nerve.
2. Zygomaticofacial Vessels.

o Infraorbital Foramen:
- Formed by:
o Maxilla bone.
- Contents:
1. Infraorbital Nerve
2. Infraorbital Vessels

o Mental Foramen:
- Formed by:
o Mandible bone.
- Contents:
1. Mental Nerve.
2. Mental Vessels.

46
Riyadh et al. Notes
chapter 3
Anatomy of Cervical Muscles:

Platysma:

 Platysma is a broad sheet arising from the fascia covering the upper parts of
the Pectoralis major and Deltoid.
 Superficial Fascia of the neck is a thin lamina investing the Platysma.
 Platysma fibers cross the clavicle, and proceed obliquely upward and
medialward along the side of the neck.
 Anterior fibers interlace, below and behind the symphysis menti, with the
fibers of the opposite side; the posterior fibers cross the mandible, inserted
into the bone below the oblique line, into the skin and subcutaneous tissue of
the lower part of the face.
 Under Platysma, the external jugular vein descends from the angle of the
mandible to the clavicle.
 Variations occur in the extension over the face and over the clavicle and
shoulder; it may be.
 Nerve: supplied by the cervical branch of the facial nerve.
 Actions: When the entire Platysma is in action it produces a slight wrinkling
of the surface of the skin of the neck in an oblique direction. Its anterior
portion, the thickest part of the muscle, depresses the lower jaw; it also
serves to draw down the lower lip and angle of the mouth in the expression
of sadness.

47
Riyadh et al. Notes

Sternocleidomastoid muscle:

 Medial (sternal) head, tendinious, arises from the upper part of the anterior
surface of the manubrium sterni. Lateral (clavicular) head, fleshy, arises from
the superior border and anterior surface of the medial third of the clavicle.
 Inserted, by a strong tendon, into the lateral surface of the mastoid process,
and by a thin aponeurosis into the lateral half of the superior nuchal line of
the occipital bone.
 Nerves: Spinal accessory nerve (CN XI) and branches from C2 and C3.
 Actions: it draws the head toward the shoulder of the same side, rotates the
face toward the opposite side. Acting together, the muscles will flex the neck.
If the head be fixed, the two muscles assist in elevating the thorax in forced
inspiration.

48
Riyadh et al. Notes

Trapezius:

 It arises from: external occipital protuberance and medial third of the

superior nuchal line of the occipital bone, ligamentum nuchæ, spinous
process of the seventh cervical, and spinous processes of all the thoracic
vertebræ.
 Inserted into posterior border of the lateral third of the clavicle; acromion,
and spine of scapula.
 Nerve: Spinal accessory nerve (CN XI) and branches from C3 and C4.
 Action: it elevates shoulder, rotates scapula, and draws head to one side .

49
Riyadh et al. Notes

Suprahyoid muscles:

1. Digastric muscle:

 Posterior belly, longer than the anterior, arises from the mastoid notch and
passes downward and forward.
 Anterior belly arises from a depression on the inner side of the lower border
of the mandible, close to the symphysis, and passes downward and
backward.
 The two bellies end in an intermediate tendon which is connected with body
of the hyoid bone by a broad aponeurotic layer (suprahyoid aponeurosis).
 Nerves:
 Posterior belly: (Facial Nerve)
 Anterior belly: (Myelohyoid branch of inferior alveolar N, of V3).

2. Stylohyoid muscle:

 It arises from lateral surface of styloid process, near the base.

 Passing downward and forward, in front of, and above the posterior belly of
the Digastric.
 Inserted into body of the hyoid bone.
 Stylohyoid Ligament is a fibrous cord, which is attached to the tip of the
styloid process and the lesser cornu of the hyoid bone. It frequently contains
a little cartilage in its center, which is often partially ossified.
 Nerves: Facial Nerve.

50
Riyadh et al. Notes

3. Mylohyoid muscle:

 It arises from the mylohyoid line of the mandible (extending from the
symphysis in front to the last molar tooth behind).
 Forms, with its fellow of the opposite side, a muscular floor (diaphragm) for
the oral cavity.
 Posterior fibers inserted into body of the hyoid bone, while anterior fibers
inserted into a median fibrous raphé extending from the symphysis menti to
the hyoid bone.
 Nerves: Myelohyoid branch of inferior alveolar N, of V3.

4. Geniohyoid muscle:

 Narrow muscle, situated above the medial border of the Mylohyoid.

 It arises from the back of the symphysis menti (inferior mental spine).
 Inserted into the anterior surface of the body of the hyoid bone.
 Nerves: Hypoglossal N. (CN XII).
 Actions: Suprahyoid muscles arise the hyoid (with base of the tongue)
during the act of deglutition. When the hyoid bone is fixed by its depressors
and those of the larynx, they depress the mandible.

51
Riyadh et al. Notes

52
Riyadh et al. Notes

Infrahyoid muscles (Strap muscles):

1. Sternohyoid muscle:
- Arises from posterior sternoclavicular ligament, and upper and posterior part
of manubrium.
- Inserted into the lower border of the body of the hyoid bone.

2. Sternothyroid muscle:
- Arises from the posterior surface of the manubrium.
- Inserted into the oblique line on the lamina of the thyroid cartilage.

3. Thyrohyoid muscle:
- Arises from the oblique line on the lamina of the thyroid cartilage.
- Inserted into the lower border of the greater cornu of the hyoid bone.

4. Omohyoid muscle:
- Inferior belly arises from upper border of the scapula, runs forward and
upward. Behind the Sternocleidomastoid, it becomes tendinous and changes
its direction, forming an obtuse angle with superior belly, which passes
almost vertically upward, to be inserted into the lower border of the body of
the hyoid bone.
- Central tendon varies much in length, and is held in position by a process of
the deep cervical fascia, which sheaths it.

- Nerve supply to strap muscles: Ansa Hypoglossi:

- C1, and C2 give a branch that joins the hypoglossal (CN XII) trunk, runs with
it some distance, and sends off a branch to the Thyreohyoid; it then leaves
the hypoglossal to form the descendens hypoglossi and unites with the
communicantes cervicalis from C3 to form ansa hypoglossi from which
nerves pass to the other infrahyoid muscles.

53
Riyadh et al. Notes

Anterior Vertebral Muscles:

1. Longus colli:
- Between the atlas and the third thoracic vertebra.

2. Longus capitis:
- Between occipital bone and sixth cervical vertebra.

3. Rectus capitis anterior & lateralis:

- Short muscles, lies behind longus capitis, runs from atlas to occipital bone.

- Nerves: C1, C2, C3.

- Actions: They act as direct antagonists of the muscles at the back of the
neck, serving to restore the head to its natural position. These muscles also
flex the head.

54
Riyadh et al. Notes

Lateral Vertebral Muscles:

1. Scalenus anterior, and medium, and posterior:

- From transverse processes of cervical vertebræ (3-6) to the scalene tubercle
on the inner border of the first rib.
2. Splenius capitis.
3. Levator scapulæ

- Nerves: C2 – C7.
- Actions: elevate the first rib, and are, therefore, inspiratory muscles.

55
 Mcq

Riyadh et al. Notes

Muscles of Mastication: Mcq

1. Masseter:

 Superficial portion, arises by a thick, tendinous aponeurosis from the

zygomatic process of the maxilla, and the zygomatic arch; and it is inserted
into the lower part of lateral surface of the ramus of the mandible.
 Deep portion, is inserted into the upper half of the ramus and the lateral
surface of the coronoid process.

2. Temporalis:

 It arises from the whole of the temporal fossa.

 Its fibers end in a tendon, which passes deep to the zygomatic arch and is
inserted into the coronoid process, and the anterior border of the ramus of
the mandible.

3. Lateral pterygoid:

 Upper head: arises from lower part of the lateral surface of the great wing of
the sphenoid, and lower head from the lateral surface of the lateral pterygoid
plate.
 Its fibers pass backward and lateralward, to be inserted in front of neck of
the mandibular condyle.

4. Medial pterygoid:

 It arises from the medial surface of the lateral pterygoid plate.

 Its fibers pass downward, lateralward, and backward, and are inserted into
the lower medial surface of the ramus (it forms, with its facial envelop and
the ramus of mandible, the lateral boundery of the parapharyngeal space).
 Nerves: V3.
 Actions: raise the mandible against the maxilla, and draw forward the
mandible.

56
Riyadh et al. Notes

57
Riyadh et al. Notes

Triangles of the Neck

Anterior Triangle:

 Bounded, in front, by the midline of the neck; behind, by the anterior margin
of the Sternocleidomast; its base, directed upward, is formed by the lower
border of the body of the mandible, and a line extending from the angle of
the mandible to the mastoid process; its apex is below, at the sternum.
 This space is subdivided into four smaller triangles by the digastric above,
and the superior belly of the Omohyoid below.

58
Riyadh et al. Notes

1. Carotid Triangle:
- Bounded, behind by the Sternocleidomastoid; below, by the superior belly of
the Omohyoideus; and above, by the Stylohyoid and the posterior belly of
the Digastric.
- Its floor is formed by parts of the Thyrohyoid, Hyoglossus, and the middle
and inferior constrictores.
- Contains:
o Arteries: common carotid artery, which bifurcates opposite the upper
border of the thyroid cartilage into the external, internal carotid
(external being the more anterior), branches of external carotid
(superior thyroid, lingual, external maxillary, occipital, ascending
pharyngeal).
o Veins: internal jugular, (lateral to common and internal carotid
arteries), and veins corresponding to branches of the external carotid.
o Nerves: descendens hypoglossi (in front of carotid sheath),
hypoglossal nerve (crosses both the internal and external carotids),
vagus nerve (within the sheath, between the artery and vein, and
behind both), accessory nerve (on lateral side of sheath, before it
pierces the Sternocleidomast), internal branch of superior laryngeal
nerve (on the medial side of the external carotid, just below the hyoid
bone), and external branch of superior laryngeal nerve (more
inferiorly).
o Viscera: upper portion of the larynx and lower portion of the pharynx.

2. Muscular Triangle:
- Bounded, in front, by the medline of the neck; behind, by the anterior margin
of the Sternocleidomastoid; above, by the superior belly of the Omohyoid.
- Floor is formed by Sternohyoid and Sternothyreoid,
- Contains:
o Carotid sheath (covered by sternomastoid) ansa hypoglossi (infront of
sheath); inferior thyroid artery, recurrent laryngeal nerve, and
sympathetic trunk(all behind sheath).

3. Submandibular (Digastric) Triangle:

- Bounded, above, by the lower border of the body of the mandible, and a line
drawn from its angle to the mastoid process; below, by the posterior belly of
the Digastric and the Stylohyoid; in front, by the anterior belly of the
Digastric.
- Its floor is formed by the Mylohyoid, Hyoglossus, and superior constrictor.
- It is divided by stylomandibular ligament into:
o Anterior part:
 Contains submandibular gland, superficial to which is anterior
facial vein, beneath the gland, facial (external maxillary) artery
and its glandular branches; on the surface of the Mylohyoid, are
the submental artery and mylohyoid artery and nerve.
o Posterior part:
 Related to the tail of parotid gland with its piercing structures.

59
Riyadh et al. Notes

4. Submental (Suprahyoid) Triangle:

- Limited behind by the anterior belly of the Digastric, in front by the middle
line of the neck between the mandible and the hyoid bone; below, by the
body of the hyoid bone; its floor is formed by the Mylohyoideus. It contains
one or two submental lymph glands and some small veins; the latter unite
to form the anterior jugular vein.

60
Riyadh et al. Notes

Posterior Triangle:

 Bounded, in front, by the Sternocleidomastoid; behind, by the anterior

margin of the Trapezius; its base is formed by the middle third of the
clavicle; its apex, by the occipital bone.
 Crossed, about 2.5 cm. above the clavicle, by the inferior belly of the
Omohyoideus, which divides it into two triangles, an upper or occipital, and
a lower or subclavian.

1. Occipital Triangle,
o Its floor is formed from above downward by the Splenius capitis,
Levator scapulæ, and the Scaleni medius and posterior.
o Accessory nerve is directed obliquely across the space from the
substance of Sternocleidomastoid, to the under surface of the
Trapezius. Below, transverse cervical vessels and the upper part of the
brachial plexus cross the space. A chain of lymph glands is also found
running along the posterior border of the Sternocleidomastoideus,
from the mastoid process to the root of the neck.
2. Subclavian Triangle:
o Its floor is formed by the first rib and Serratus anterior.
o Crossed by supraclavicular nerves, third portion of the subclavian
artery across the first rib, to the axilla.

61
Riyadh et al. Notes
chapter 4
- Blood Supply of Head and Neck:
- Major arteries of Neck are:
o Common Carotid Artery
o Subclavian Artery

- Common Carotid Artery:

- Right Common Carotid Artery:
o Begins at bifurcation of
Brachiocepahlic (innominate)
Artery behind Sternoclavicular
joint.
- Left Common Carotid Artery:
o Arises directly from Arch of Aorta.

- Ascend obliquely upward within Carotid

Sheath to Upper border of Thyroid cartilage, where it divides into
External and Internal Carotid Arteries.
- Carotid Sinus:
o Baroreceptor located in Dilation of proximal part of Internal
carotid.
o receives its sensory innervations from Glossopharyngeal nerve
(CN-IX)
o Reacts to changes in Arterial blood pressure.
- Carotid Body:
o Chemoreceptor lies at Bifurcation of Common carotid.
o Monitors level of Oxygen in blood

- Carotid sheath encloses:

1. Common Carotid artery (Medial)
2. Vagus nerve (CN-X) (Middle + Posterior)
3. Internal Jugular vein. (Lateral)

62
Riyadh et al. Notes

- Relations of Common Carotid Artery in Neck:

- Crossed by:
1. Sternocleidomastoid branch of Superior Thyroid Artery.
2. Superior and Middle thyroid veins which end in the internal
jugular.
3. Anterior jugular vein just above the clavicle.
4. Inferior thyroid artery crosses behind the lower part of the
vessel.
- Sympathetic trunk interposed posteriorly between the artery and
anterior vertebral muscles.
- Superior root of Ansa Cervicalis nerve descends in front of its sheath.

- Braches of Common Carotid Artery in Neck:

o NO Branches.

63
Riyadh et al. Notes

Mcq
- External Carotid Artery:
- One of terminal braches of Common Carotid Artery.
- Begins:
o At level of Upper thyroid Cartilage.
- Course:
o Passes upward and forward.
o Medial to Internal Carotid artery.
o External to the carotid sheath
- Terminates:
o Behind Neck of mandible
o Dividing into Superficial temporal artery and Maxillary Artery.
- Supplies:
o Supplies most structures External to cranium Except (Orbit,
Part of forehead and scalp supplied by Opthalmic artery of
internal carotid)

- Relations of External Carotid Artery:

- Crossed by:
1. Lingual vein
2. Common facial vein
3. Superior thyroid vein
4. Hypoglossal nerve
5. Digastric and Stylohyoid.
- Lies deep to:
1. Retromandibular vein
2. Facial nerve
3. External jugular vein.

64
Riyadh et al. Notes

- Braches of External Carotid Artery:

1. Superior Thyroid Artery.
2. Ascending Pharyngeal Artery.
3. Lingual Artery.
4. Facial Artery.
5. Occipital Artery.
6. Posterior Auricular Artery.
7. Maxillary Artery.
8. Superficial Temporal Artery.

65
Riyadh et al. Notes

- Superior Thyroid Artery:

- 1st branch of External Carotid Artery.
- Arises just below Greater cornu of Hyoid
- Passes inferiorly along Inferior constrictor muscle to reach upper pole
of Thyroid gland.
- Branches:
1. Superior Laryngeal Artery:
o Prices Thyrohyoid membrane to supply the larynx.
o Accompanied with Internal branch of Superior laryngeal nerve.

- Ascending Pharyngeal Artery:

- Smallest branch of External carotid Artery.
- Arises from Posterior portion of External carotid Artery.
- Ascends superiorly between Pharynx and Internal Carotid Artery.
- Supplies Pharyngeal Muscles.

- Lingual Artery:
- Arises in Carotid Triangle.
- Passes superiorly and medially toward Greater cornu of Hyoid.
- Loops by passing anteriorly and inferiorly while traveling superficial to
Middle constrictor muscle.
- Crossed superficially by Hypoglossal nerve (CN-XII).
- Supplies the Tongue.

- Facial Artery:
- Arises in Carotid Triangle.
- Passes superiorly immediately deep to posterior belly of Digastric and
Stylohyoid muscles.
- Passes along Submandibular gland.
- Passes superiorly over Body of Mandible at Masseter mucle in a
tortuous pattern.
- Passes forward and upward, immediately beneath Platysma (deep to
SMAS).
- Cross Cheek to Angle of mouth and ascends along side of nose.
- Ends at Medial commissure of the eye as Angular artery.
- Supplies the Face.
- Branches in Neck:
- Tonsillar (perforating superior constrictor) – Glandular – Submental.
- Branches in Face:
- Inferior Labial - Superior Labial - Lateral Nasal – Angular -Muscular.
- Branches:

- Occipital Artery:
- Arises in Carotid Triangle.
- Opposite to Facial Artery.
- Passes upward and reaches Back of Scalp.
- The terminal part of the artery is accompanied by Greater occipital
nerve.

66
Riyadh et al. Notes

67
Riyadh et al. Notes

- Posterior Auricular Artery:

- Arises high above the Digastric.
- Ascends posterior to the parotid gland.
- Between Auricle and Mastoid process
- Divides into its auricular and occipital branches.

- Superficial Temporal Artery:

- Smallest Terminal branch of External Carotid
Artery.
- Begins in Parotid gland, behind Neck of Mandible.
- Runs in front of Auricle.
- Corsses over root of Zygomatic process of
Temporal bone.
- Crossed by Temporal and Zygomatic branches of
Facial nerve (CN-VII).
- Accompanied by Auriculotemporal nerve (V3)
- About 5 cm above Zygomatic process, it divides
into two terminal branches:
1. Frontal branch.
2. Parietal branch.
- Branches:
1. Transverse Facial Artery:
o Arises within the parotid gland
o Passes transversely over Masetter muscle
across the side of the face.
o Accompanied by one or two branches of the facial nerve.
o Passes between Parotid (Stenone) duct and Zygomatic Arch.

68
Riyadh et al. Notes

- Maxillary Artery:
- Largest Terminal branch of External Carotid Artery.
- Begins in Parotid gland, behind Neck of Mandible.

- 1st Portion (Mandibular):

- Passes horizontally forward between Ramus of Mandible and
Sphenomandibular ligament
- Runs along lower border of Lateral Ptyregoid Muscle.
- Branches:
- Anterior Tympanic Artery:
o Enters tympanic cavity via petro-tympanic fissure.
o Anastmose with Inferior tympanic branch of Ascending
Pharyngeal Artery, Stylomastoid branch of Posterior Auricular
Artery, Pterygoid canal Artery and with Caroticotympanic
branch from Internal carotid artery.
- Deep Auricular Artery:
o Pierces cartilaginous or bony wall of External Acoustic
Meatus.
o Supplies its cuticular lining and the outer surface of the
tympanic membrane.
o Gives a branch to TMJ.
- Inferior Alveolar Artery:
o Descends with Inferior Alveolar Nerve along Mandibular canal
o Opposite 1st Premolar tooth divides into two branches,
incisor and mental.

69
Riyadh et al. Notes

- 2nd Portion (Pterygoid):

- Runs forward and upward under Ramus of the mandible
- Passes between two heads of Temporalis
- Passes through Ptyrego-maxillary fissure to enter Ptyregopalatine
Fossa.
- Branches:
- Muscular (Deep Temporal - Masseteric - Pterygoid – Buccinator).

- 3rd Portion (Pterygopalatine):

- Lies in Ptyregopalatine Fossa.
- Rrelated to Sphenopalatine ganglion.
- Branches:
- Posterior Superior Alveolar - Artery of the Pterygoid Canal –
Infraorbital –Descending Palatine - Sphenopalatine.

- Posterior Superior Alveolar Artery:

o Enters alveolar canals (begin on posterior suface of maxilla)
o Supply the molar and premolar teeth and the lining of the
maxillary sinus.

- Infraorbital Artery:
o Runs along Inferior orbital Fissure with Infraorbital Nerve
o Emerges on face through Infraorbital foramen
o While in the canal, it gives off:
(a) Obital branches
(b) Anterior superior alveolar branches.

70
Riyadh et al. Notes

- Descending (Greater) Palatine Artery:

o Descends through Pterygopalatine canal with Anterior
Palatine branch of Sphenopalatine ganglion.
o Emerges from Greater palatine foramen.
o Runs forward in a groove on medial side of alveolar border of
Hard palate to Incisive canal.
o Passes upward through Incisive canal to anastomose with
Sphenopalatine artery.
o In Pterygopalatine canal, gives off Lesser Palatine Artery
which descend in lesser palatine canals to supply the soft
palate and palatine tonsil.

71
Riyadh et al. Notes

- Artery of the Pterygoid Canal (Vidian Artery):

o Passes backward along pterygoid (Vidian) canal
o Gives branches to ET and Tympanic cavity.

- Sphenopalatine Artery (Nasopalatine Artery):

o Terminal branch of Maxillary artery.
o Passes through Sphenopalatine Foramen into Cavity of nose,
at Posterior part of Superior meatus.
o Gives off its posterior lateral nasal branches which spread
forward over the conchæ and meatuses, anastomose with
Ethmoidal arteries and Nasal branches of Descending
palatine Artery.
o Crosses face of sphenoid.
o Ends on nasal septum as the posterior septal branches which
anastomose with Ethmoidal arteries and Septal branch of
Superior labial.
o One branch descends in a groove on the vomer to the
incisive canal and anastomoses with Descending palatine
artery.

72
Riyadh et al. Notes

- Blood supply of Face:

1. Facial Artery.
2. Transverse facial artery (Superficial
Temporal Artery).
3. Frontal artery (Superficial Temporal Artery).
4. Supraorbital Artery (Ophthalmic Artery).
5. Supratrochlear artery (Ophthalmic Artery).
6. Dorsal nasal artery (Ophthalmic Artery).
7. Zygomatico-facial & Zygomatico-temporal
artery (Ophthalmic Artery).
8. External nasal artery (Anterior Ethmoid
Artery).
9. Infraorbital artery (Maxillary artery).

- Skin of midface is supplied by muscular cutaneus branches from these

arteries that forms subdermal plexus.

73
Riyadh et al. Notes

- Internal Carotid Artery

- One of terminal braches of Common Carotid Artery.
- Supplies Cranium, Orbit and Part of Forehead and scalp.
-
- Begins:
o At level of Upper thyroid Cartilage.
- Course:
o Ascends in the neck to base of skull.
o Enclosed within Carotid sheath.
o Gives NO branches in the Neck
o Enters Cranial cavity through Carotid Canal in Petrous portion
of Temporal bone.
- Supplies:
o Supplies Cranium, Orbit and Part of Forehead and scalp.

- Divided into 4 Portions:

- 1st Portion of ICA (Cervical):
- Begins at level of Upper thyroid Cartilage.
- Ascends in the neck to base of skull.
- Enclosed within Carotid sheath.
- Gives NO branches in the Neck.
- Enters Cranial cavity through Carotid Canal in Petrous portion of
Temporal bone.

74
Riyadh et al. Notes

- Relations:
- Posteriorly:
o Superior cervical ganglion of the sympathetic trunk.
- Laterally:
o Internal jugular vein
o Vagus nerve.
- Medially:
o Pharynx.
- At the base of the skull:
o CNs-IX ,X , XI, XII lie between Internal Carotid Artery and
Internal jugular vein.
o Separated from External carotid Artery by styloid apparatus.

- 2nd Portion of ICA (Petrous):

- Starts from inferior aperture of the carotid canal located in the
temporal bone.
- Ascends a short distance, then curves forward and medialward, and
again ascends through top of Foramen Lacerum to enter Skull.
- Lies in front of Cochlea and Tympanic cavity.
- Branch:
1. Caroticotympanic artery.
o Enters Tympanic cavity through a minute foramen in the carotid
canal, and anastomoses with other tympanic vessels.

75
Riyadh et al. Notes

- 3rd Portion of ICA (Cavernous):

- Artery is situated between the layers of the dura mater forming the
cavernous sinus, but covered by the lining membrane of the sinus.
- First ascends toward Posterior clinoid process.
- Passes forward by the side of Body of Sphenoid bone.
- Curves upward on Medial side of Anterior clinoid process.
- Perforates Dura mater forming Roof of the sinus.
- On its lateral side is Abducent nerve.
- Branches:
- Hypophyseal - Anterior Meningeal - Ophthalmic.

76
Riyadh et al. Notes

- Ophthalmic Artery:
- Aarises from Internal carotid Artery, just as that vessel is emerging
from the cavernous sinus.
- Enters Orbital cavity through Optic foramen (below and lateral to the
optic nerve).
- Passes over Optic nerve to reach Medial wall of Orbit.
- Divides into two terminal branches,
1. Frontal (supratrochlear) Artery
2. Dorsal nasal Artery
- Orbital branches:
- Lacrimal, Supraorbital, Anterior & Posterior Ethmoidal, Medial
Palpebral, Frontal, Dorsal Nasal.
- Ocular branches:
- Central Artery of the Retina, Short Posterior Ciliary, Long Posterior
Ciliary, Anterior Ciliary, Muscular.

77
Riyadh et al. Notes

- 4th Portion of ICA (Cerebral):

- Starts after emergence through Dural roof.
- Passes between Optic (CN-II) and Oculomotor (CN-III) Nerves.
- Gives off its terminal cerebral branches.
- Branches:
- Anterior Cerebral - Middle Cerebral - Posterior Communicating -
Choroidal Artery.

- Circle of Willis:
- Circulatory anastomosis that
supplies brain and surrounding
structures.

- Anterior circulation:
1. Internal Carotid Artery
(ICA)
2. Anterior cerebral Artery
(ACA)
3. Anterior communicating
Artery (ACOM).

- Posterior circulation:
1. Basilar artery
2. Posterior cerebral artery
(PCA)
3. Posterior
communicating Artery
(PCOM).

Mcq

78
Riyadh et al. Notes

- Subclavian Artery:
- Right Subclavian Artery:
o Branch of Right Brachiocepahlic (innominate) Artery.
- Left Subclavian Artery:
o Arises directly from Arch of Aorta.

- Travel lateral to trachea into the root of Neck

- Passes between Anterior and Middle Scalene Muscles.

- Divides into 3 parts:

- 1st Part of Subclavian Artery:
- Extends from beginning of Subclavian to Medial border of Anterior
scalene Muscle.
- Most of branches of Subclavian Artery arise from the 1st part

- 2nd Part of Subclavian Artery:

- Located posterior to Anterior scalene Muscle.
- Gives rise to Left Costocervical trunk.

- 3rd Part of Subclavian Artery:

- Starting from Lateral border of Anterior scalene Muscle to Lateral
border of 1st rib, where it becomes Axillary Artery.

79
Riyadh et al. Notes

- Braches of Subclavian Artery in Neck:

1. Thyrocervical Trunk.
2. Vertebral Artery.
3. Costocervical Trunk.
4. Dorsal scapular Artery.

- Thyrocervical Trunk:
- Branch of 1st part of Subclavian Artery.
- Immediately divides into 3 branches:
- Inferior thyroid Artery:
o Travels along Medial border of Anterior Scalene Muscle to
Thyroid gland.
o Runs Posterior to Carotid sheath and Anterior to Vertebral
Artery.
o Accompanied by Recurrent laryngeal Nerve
- Suprascapular Artery:
o Travels inferior and laterally across Anterior Scalene Muscle and
Phrenic nerve deep to SCM muscle.
o Crosses Posterior triangle of Neck to reach Scapula.
- Transverse cervical Artery:
o Travels across Posterior triangle of neck to reach Anterior border
of Trapezius muscle.

- Vertebral Artery:
- Branch of 1st part of Subclavian Artery.
- Ascends to enter Foramen transversarium transverse process of C1-6
- Passes through Foramen magnum to enter the skull.
- Unites with the opposite vertebral artery to form Basilar Artery along
the ventral surface of Pons.

- Costocervical Trunk:
- Branch of 1st part of Right Subclavian and 2nd part of Left Subclavian.
- Divides into 2 branches:
- Deep cervical:
o Supplies Posterior deep cervical muscles.
- Supreme intercostal:
o Supply the 1st and 2nd intercostal spaces.

- Dorsal scapular Artery:

- Branch of 2nd or 3rd part of Subclavian Artery.
- Travel across Posterior triangle of neck to reach the anterior border of
trapezius muscle.

80
Riyadh et al. Notes

- Venous Drainage of Brain:

- Dural venous sinuses:

- Venous channels found between layers of dura mater in the brain.
- Receive blood from internal and external veins of the brain.
- Receive cerebrospinal fluid (CSF) from the subarachnoid space.
- Ultimately empty into Internal jugular vein through Sigmoid Sinus.

- Cavernous Sinus:
- Large paired reticulated venous structure on the lateral body of the
sphenoid bone.
- Receives blood via Superior and Inferior Ophthalmic veins through the
Superior orbital fissure.
- Infection from face reach Cavernous sinus through its many
anastomotic connections, with severe consequences.
- Drains by two channels: Superior and Inferior Petrosal Sinuses,
ultimately into Internal jugular vein via Sigmoid sinus.

81
Riyadh et al. Notes

- Lateral wall of Cavernous sinus

contains:
1. Oculomotor Nerve (CN-III)
2. Trochlear Nerve (CN-IV)
3. Ophthalmic Nerve (V1)
4. Maxillary Nerve (V2)

- Middle of Cavernous sinus

contains:
1. Internal Carotid Artery.
2. Abducens Nerve (CN-VI).

- All these nerves pass through Cavernous sinus to enter Orbital Apex
through Superior Orbital Fissure Except Maxillary Nerve (V2) which
travels through Lower portion of sinus and exits via Foramen
Rotundum.

- Optic Nerve (CN-II) lies just above and outside Cavernous sinus,
Superior and lateral to Pituitary gland on each side, and enters the
Orbital Apex via Optic canal.

- Cavernous sinus receives tributaries from:

1. Superior and inferior ophthalmic veins.
2. Sphenoparietal sinus.
3. Superficial middle cerebral veins.

- Cavernous sinus drains into:

1. Superior and Inferior Petrosal Sinuses to Sigmoid sinus
2. Emissary veins to veins outside skull.

- Danger triangle of Face:

- Area from corners of mouth to bridge of nose, including
nose and maxilla.
- facial vein is connected to Cavernous sinus via Superior
Ophthalmic vein.
- Risk of retrograde spread of infections from nasal area to
cavernous sinus from an external facial injury, especially
likely as facial vein has no valves, allowing blood to pass in
both directions.
- In patients with thrombophlebitis of the facial vein, pieces
of the clot may break off and enter the cavernous sinus,
forming a cavernous sinus thrombosis.
- From there the infection may spread to the dural venous sinuses.

82
Riyadh et al. Notes

- Sigmoid Sinus:
- Two areas beneath the brain which allow blood to drain inferiorly from
the posterior center of the head.
- Continuation of Transverse sinuses on the same side.
- Follows an S-shaped course to Jugular foramen.
- Sigmoid sinus becomes continuous with Internal jugular vein .

- Venous Drainage of Head and Neck:

- Supratrochlear vein:
- Superficial vein.
- Begins on the forehead.
- Communicates with Frontal tributary of Superficial temporal vein.
- Passes inferiorly along the forehead parallel with the vein of the
opposite side
- Joins Supraorbital vein at Medial angle of Orbit to form Angular
vein.
- Drain Anterior part of scalp and forehead.

- Supraorbital vein:
- Superficial vein.
- Begins on the forehead.
- Communicates with Frontal tributary of Superficial temporal vein.
- Passes inferiorly superficial to the frontalis muscle.
- Joins Supratrochlear vein at Medial angle of Orbit to form Angular
vein.
- Drain Anterior part of scalp and forehead.

83
Riyadh et al. Notes

- Superior Ophthalmic vein:

- Communicating vein.
- Receives blood from roof of orbit and scalp.
- Travels posteriorly to communicate with Pterygoid plexus and
cavernous sinus.

- Inferior Ophthalmic vein:

- Communicating vein.
- Receives blood from floor of orbit.
- Travels posteriorly with Infraorbital vein and passes through the
Inferior Orbital Fissure.
- Communicate with Pterygoid plexus and cavernous sinus.

- Infraorbital vein:
- Communicating vein.
- Receives blood from Midface via the lower eyelid, lateral aspect of the
nose, and the upper lip.
- Travels posteriorly with Inferior ophthalmic vein and passes through
the Inferior Orbital Fissure.
- Cmmunicates with Pterygoid plexus.

84
Riyadh et al. Notes

- Angular vein:
- Superficial vein.
- Begins at root of nose.
- Forms from union of Supraorbital and Supratrochlear veins along
medial part of the eye
- Travels along Lateral aspect of the nose to become Facial vein at
inferior orbital margin.
- Drain Anterior part of scalp and forehead and eye lids.

- Facial vein:
- Superficial vein.
- Begins at lower orbital margin as continuation of Angular vein.
- Passes inferiorly along side of Nose, receiving the lateral nasal vein.
- Continues posteroinferiorly across the angle of the mouth to the
cheek, receiving Superior and Inferior labial veins.
- While passing toward the mandible, the deep facial vein connects it to
the pterygoid plexus
- Joins Anterior branch of Retromandibular vein in Submandibular
triangle to form Common Facial vein which terminates in Internal
Jagular Vein at level of hyoid.
- Drains Anterior part of scalp and forehead, eye lids, external nose,
anterior cheek, lips, chin and submandibular gland.
- Has no valves that can allow blood to backflow.

- Superficial temporal vein:

- Superficial vein.
- Begins at sides of scalp on along zygomatic arch.
- Descends posterior to the zygomatic root of temporal bone alongside
Auriculotemporal nerve.
- Enter parotid gland
- Joins Maxillary vein posterior to Neck of Mandible to form
Retromandibular vein.
- Drains side of scalp and External ear.

- Retromandibular vein:
- Superficial vein.
- Begins Anterior to ear by union of Superficial temporal and
Maxillary veins.
- Runs posterior deep to Ramus of Mandible through Parotid gland.
- Divides into two branches:
o Anterior branch joins Facial vein to form Common Facial
vein.
o Posterior branch joins Posterior Auricular vein to form
External jugular vein.
- Drains Parotid gland and Masseter muscle.

85
Riyadh et al. Notes

- Pterygoid plexus:
- Extensive network of veins that parallels 2nd and 3rd parts of
maxillary Artery.
- Receives branches that correspond to the maxillary artery's branches
- Tributaries of the pterygoid plexus eventually converge to form
Maxillary vein.
- Communicates with cavernous sinus, pharyngeal venous plexus, Facial
vein via Deep facial vein and ophthalmic vein.

86
Riyadh et al. Notes

- Lingual vein:
- Passes with Lingual artery deep to the Hyoglossus muscle.
- Ends in Internal Jugular vein.

- Superior and Middle thyroid vein:

- Forms a venous plexus on the thyroid gland with
the middle and inferior thyroid veins.
- Drains into Internal jugular vein.

- Inferior thyroid vein:

- Forms a venous plexus on the thyroid gland with
the middle and inferior thyroid veins.
- Drains into Left Brachiocephalic vein.

- Occipital vein:
- Begins on Posterior portion of Scalp at vertex.
- Passes from superficial to deep by passing through the attachment of
SCM muscle.
- Termination is variable, joins Posterior Auricular vein to reach External
Jugular vein or join Internal Jugular vein.

- Anterior jugular vein:

- Begins near Hyoid bone.
- Arises by joining of a series of superficial veins in Submental region.
- Descends anterior to SCM muscle then deep to it.
- Drains into External Jugular vein or directly into Subclavian vein.
- Venous jugular arch:
o Transverse trunk communicate both Anterior jugular veins just
above the sternum
o Receive tributaries from the inferior thyroid veins.

87
Riyadh et al. Notes

- External jugular vein:

- Formed by Combination of Posterior branch of Retromandibular
and Posterior Auricular veins in Parotid gland just behind Angle of
Mandible.
- Descends Obliquely.
- Superficial to SCM muscle.
- Deep to Platysma muscle.
- Passes into Posterior triangle of Neck.
- Pierces deep facia.
- Drains into Subclavian vein immediately lateral to Anterior scalene
muscle.
- Tributaries:
o Posterior Auricular vein.
o Posterior branch of Retromandibular vein.
o Anterior Jugular vien.
o Transverse cervical vein.
o Suprascapular vein.

- Internal Jugular vein:

- Begins in at a dilation (superior bulb) in
Postero-lateral compartment of Jugular
foramen.
- Continuation of Sigmoid sinus.
- Runs down the side of Neck in a vertical direction.
- Lying Postero-lateral to Internal Carotid Artery (and common carotid)
and behind CN-IX, X, XI.
- Travels within Carotid sheath lateral to Internal carotid artery and
Anterior to Vagus nerve (CN-X).
- Lower down, CN-IX and CN-XII pass forward between Internal
Jugular Vein and Internal Carotid Artery.
- 2nd dilation (Inferior bulb) located above its termination.
- Joins Subclavian vein to form Brachiocephalic (innominate) vein
at root of Neck.
- Tributaries:
o Inferior petrosal sinus.
o Facial vein.
o Pharyngeal vein.
o Lingual vein.
o Superior and Middle thyroid vein.

- Vertebral vein:
- Begins as a plexus in Suboccipital triangle.
- Descends through the Foramen transversarium of all of Cervical
vertebrae.
- Drains into Subclavian or more commonly, Brachiocephalic vein.

88
Riyadh et al. Notes

- Lymphatics of Head and Neck:

- Superficial Lymph Node of Head:

1. Occipital LN:
o Located at back of Head close to margin of Trapezius.
o Afferents: from Occipital region of scalp
o Efferents: to Superior deep cervical LN.

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Riyadh et al. Notes

2. Posterior Auricular LN:

o Located at Mastoid insertion of SCM muscle.
o Afferents: from posterior part of Temporoparietal region, Upper
part of cranial surface of Auricle and back of EAC.
o Efferents: to Superior deep cervical LN.

3. Preauricular (superficial parotid) LN:

o Located immediately in front of the tragus.
o Afferents: from lateral surface of Auricle and skin of adjacent
part of Temporal region.
o Efferents: to Superior deep cervical LN.

4. Parotid LN:
o Imbedded in the substance of the gland.
o Afferents: from Root of the nose, Eyelids, Fronto-temporal
region, EAC and Tympanic cavity
o Efferents: to Superior deep cervical LN.

5. Facial LN:
o Three Groups:
i. Infraorbital LN
ii. Buccinator LN
iii. Supramandibular LN

- Waldeyer`s Ring:
1. Pharyngeal Tonsil (Adenoid):
o Located in the Nasopharynx.
o No Afferents.
o Efferents: Retropharyngeal and
Parapharyngeal LN.
2. Tubal Tonsils:
o Located posterior to opening of ET in
Nasopharynx.
3. Palatine Tonsil:
o Located in the Oropharnyx.
o No Afferents.
o Efferents: to Jugulodigastric and
Superior deep cervical LN.
4. Lingual Tonsil:
o Located in dorsal surface at base of
tongue.

 Retropharyngeal LN:
o Deep LN (Not part of Waldeyer`s Ring)
o Located in the buccopharyngeal fascia, behind the upper part of
the pharynx.
o Afferents: from Posterior Nasal cavity, Nasopharynx and ET.
o Efferents: to Superior deep cervical LN.

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Riyadh et al. Notes

- Regions of Lymph Nodes of the Neck:

1. Level I:
 Level Ia: Submental LN
o Bounded by bilateral Anterior bellies of
digastric muscles and Hyoid bone.
o Drains Floor of mouth, Anterior tongue,
Anterior mandibular alveolar ridge, and
Lower Lip.
 Level Ib: Submental LN
o Bounded by Anterior and Posterior bellies
of digastric and body of Mandible.
o Drains oral cavity, Anterior Nasal Cavity,
soft tissue structures of the mid face, and
Submandibular gland.

2. Level II: Upper Jugular LN (Jugulodigastric)

o Related to upper third of Internal jugular vein.
o Clinical Landmark: From Skull base to Hyoid bone.
o Surgical Landmark: From Skull base to Carotid bifurcation.
o Drains the oral cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx, and parotid gland.
o Spinal Accessory Nerve (CN-XI) travels obliquely across this
area.
 Level IIa: LN Anterior to Spinal Accessory Nerve (CN-XI)
 Level IIb: LN Posterior to Spinal Accessory Nerve (CN-XI)

3. Level III: Middle Jugular LN

o Related to Middle third of Internal jugular vein.
o Clinical Landmark: From Hyoid bone to C
o ricothyroid notch.
o Surgical Landmark: From Carotid bifurcation to Omohyoid.
o Drains the oral cavity, nasopharynx, oropharynx, hypopharynx,
and larynx.

4. Level IV: Lower Jugular LN

o Related to Lower third of Internal jugular vein.
o From Omohyoid mucle to Clavicle.
o Drains larynx, hypopharynx, thyroid, and cervical esophagus.

91
Riyadh et al. Notes

5. Level V: Posterior Triangle LN

o Located along lower half of the spinal
accessory nerve and the transverse cervical
artery.
o Extends from Apex of Convergence of SCM
and trapezius muscle to Clavicle.
o Drains nasopharynx, oropharynx, and skin of
the posterior scalp and neck.
 Level Va: LN Associated with Spinal accessory
nerve (CN-XI)
 Level Vb: LN Associated with Transverse
Cervical and supraclavicular nodes.

6. Level VI: Central Compartment LN

o Extend in midline from hyoid bone superiorly
to Suprasternal notch inferiorly.
o Drains Thyroid gland, subglottic larynx, cervical trachea,
hypopharynx, and cervical esophagus.
o Paratracheal LN: Located in Tracheoesophageal groove.
o Pretracheal LN: Located in front of the trachea
o Parathyroidal LN: Located around the thyroid gland
o Precricoid or Delphian LN: Located on Cricothyroid membrane.

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Riyadh et al. Notes

- Thoracic Duct:
- Left lymphatic duct.
- Common trunk of all lymphatic vessels of the body Except:
o Right side of Head, Neck, thorax, Right upper limb, Right lung,
Right side of Heart.
o Drained by Right lymphatic duct.
- Length in adult: 40-45 cm
- Begins in Abdomen by a dilatation (Cisterna chili) in front of L2.
- Extends to the root of the neck posterior to Left Carotid artery and left
Internal jugular vein.
- Passing into the neck it forms an arch above clavicle and crosses
Anterior to Subclavian artery.
- Passes in front Scalenus
Anterior.
- Ends in Left Subclavian
vein.

- Right lymphatic duct:

- Length in adult: 40-45 cm
- Courses along Medial border
of Scalenus Anterior at Root of
Neck.
- Ends in Right Subclavian
vein.
- Drains Right side of Head,
Neck, thorax, Right upper
limb, Right lung, Right side of
Heart.

93