Scalp

Layers:-
1- Skin
2- Connective tissue
3- Aponeurosis of occipito-frontalis muscle = Epicranial aponeurosis
4- Loose areolar C.T.
5- Pericranium = Periosteum of skull

Arterial supply:-
A- In front of the auricle:-
1- Supratrochlear artery:- branch of ophthalmic A. from I.C.A.
2- Supra-orbital artery:- branch of ophthalmic A. from I.C.A.
3- Superficial temporal artery:- One of the 2 terminal branches of E.C.A.

B- Behind the auricle:-

1- Posterior auricular artery:- Of E.C.A.
2- Occipital artery:- Of E.C.A.

Venous drainage:-
1- Supratrochlear V.:- Unites with …… to form anterior facial V.
2- Supra-orbital V.:- Unites with …… to form anterior facial V.
3- Superficial temporal V.:- unites with maxillary V. to form posterior facial V.
4- Posterior auricular V.:- unites with posterior division of posterior facial V.
(just below parotid gland) to form E.J.V.
5- Occipital V.:- Drains into either
a- sub-occipital venous plexus → drains into vertebral vein
b- I.J.V.

1
Nerve supply:-
A- In front of the auricle:- 5 nerves (4 sensory & 1 motor)
1- Sensory nerves:- From trigeminal nerve
a- Supra-trochlear:- From ophthalmic division
b- Supra-orbital:- From ophthalmic division
c- Zygomatico-temporal:- From maxillary division
d- Auriculo-temporal:- From mandibular division
2- Motor nerve:- Temporal branch of facial N. that supplies frontal belly of
occipitofrontalis

B- Behind the auricle:- 5 nerves (4 sensory & 1 motor)

1- Sensory nerves:- From cervical nerves
a- Great auricular N. (C2, 3):- From cervical plexus
b- Lesser occipital N. (C2):- From ** **
c- Greater occipital N. (C2):- From posterior ramus of C2
d- Third occipital N. (C3):- From ** ** of C3
2- Motor nerve:- Posterior auricular branch of facial N. that supplies occipital
belly of occipitofrontalis

Dangerous area of scalp

- It is the layer of loose areolar C.T. = Sub-aponeurotic space
- Named so because if there is an infection in this layer → can extend into skull
bones & cranial cavity through the emissary veins that connect the veins of this
layer with the diploic Vs. of skull & intra-cranial venous sinuses
- Blood or pus may collect in it
- Limited by
a- Orbital margin
b- Nuchal lines
c- Temporal lines

2
 Occipitofrontalis
Origin:-
1- Frontal bellies arise from skin and superficial fascia of eyebrows
2- Occipital bellies arise from highest nuchal line
Insertion:- Into the epicranial aponeurosis
Action:-
1- Elevation of eyebrows by frontal bellies
2- Wrinkling of the forehead
Nerve supply:- By facial N.
1- Frontal bellies- Supplied by temporal branch of facial N.
2- Occipital bellies:- Supplied by posterior auricular branch of facial N.

N.B.
1- Emissary veins of scalp:-
- In the layer of loose areolar C.T.
- Valveless
- Connect the superficial Vs. of scalp with the diploic Vs. of skull & with intracranial
venous sinuses
2- Sutural ligaments connect the periosteum with endosteum
3- Superficial temporal A. is accompanied by auriculo-temporal N.
4- Occipital A. is accompanied by greater occipital N.
5- Great auricular N. supplies
a- Scalp behind the auricle
b- Lower parts of both surfaces of the auricle
c- Postero-inferior part of the face
6- Lesser occipital N. Supplies the occipital part of scalp & medial surface of auricle
7- Galea aponeurotica = epicranial aponeurosis
8- Wounds of scalp bleed profusely because of
a- Rich arterial supply
b- Rich venous anastomoses
c- Walls of the arteries are attached to the fibrous septa in subcutaneous tissue →
Cannot contract or retract → No clotting

3
 Face
Arterial supply of the face
1- Branches from facial A.:-
a- Inferior labial A. c- Lateral nasal A.
b- Superior labial A. d- Submental A.
2- Branches from maxillary A.:-
a- Infra-orbital b- Buccal c- Mental
3- Branches from ophthalmic A.:- Supply the forehead
a- Supra-orbital
b- Supratrochlear
4- Transverse facial A. that is a branch from superficial temporal A.

Venous drainage of the face

By anterior facial V.:-
A- Course:- Begins at the medial angle of the eye by the union of supra-
trochlear & supra-orbital veins → Descends behind facial A. → Reaches the
lower border of mandible → Crosses superficial to submandibular gland →
Joins the anterior division of retromandibular V. to form the common facial V.
→ Ends into the I.J.V.

B- Communications:-
1- With cavernous sinus through superior ophthalmic V.
2- With pterygoid plexus of veins through deep facial V.
C- Tributaries:-
a- Inferior labial V. c- Lateral nasal V.
b- Superior labial V. d- Submental V.

4
 Dangerous area of the face
- Bounded by the lines between corners of the mouth & bridge of the nose
- Called so because the infection can be transmitted from it into the cavernous
sinus
- Includes maxilla & nose because these regions are drained by facial vein that
has connections with the cavernous sinus through
1- Superior ophthalmic vein → Cavernous sinus
2- Deep facial vein → pterygoid plexus → Emissary Vs. → Cavernous sinus

Lymph drainage of the face

A- Lateral part of face including lateral part of eyelids:- To parotid L.Ns.

B- Forehead & anterior part of face:- To submandibular L.Ns & (Buccal

L.Ns. if present present)

C- Central part of lower lip & chin:- To Submental L.Ns.

Motor innervation of the face

- By the terminal branches of facial nerve:-
1- Temporal:- Supplies
a- Anterior & superior auricular muscles
b- Frontal belly of occipito-frontalis
c- Orbicularis oculi
2- Zygomatic:- Supplies orbicularis oculi
3- Buccal:- Supplies
a- Buccinator
b- Upper lip muscles
c- Nostril muscles
4- Mandibular:- Supplies lower lip muscles
5- Cervical:- Supplies platysma

5
 Sensory innervation of the face

A- Branches from ophthalmic nerve:-

1- Supratrochlear:- Supplies the medial part of upper eyelid (skin & conjunctiva) + Lower
part of forehead close to midline

2- Supra-orbital:- Supplies the central part of upper eyelid (skin & conjunctiva) + Forehead

3- Infra-trochlear:- Supplies the medial part of upper eyelid (skin & conjunctiva) + Side
of the nose

3- Lacrimal:- Supplies lateral part of upper eyelid (skin & conjunctiva)

4- External nasal branch:- Supplies side of the nose till the tip

B- Branches from maxillary nerve:-

1- Infra-orbital:- Appears through infra-orbital foramen & divides into
a- Palpebral branch:- Supplies cheek & lower eyelid
b- Nasal branch:- Supplies side of nose
c- Labial branch:- Supplies upper lip

2- Zygomatico-facial:- Supplies the skin of prominence of cheek

3- Zygomatico-temporal:- Supplies the skin of temple

C- Branches from mandibular nerve:-

1- Auriculo-temporal:- Supplies the skin of auricle, scalp, E.A.M. & outer surface of T.M.

2- Buccal:- Supplies part of the skin of cheek

3- Mental:- Supplies the skin of lower lip & chin

6
 Buccinator
A- Origin:-
1- Alveolar process of maxilla above the 3 molar teeth
2- Alveolar process of mandible below the 3 molar teeth
3- Pterygomandibular raphe

B- Insertion:- Blends with orbicularis oris

1- The upper fibers into the upper lip
2- The lower fibers into the lower lip
3- The intermediate fibers decussate so
a- their upper part inserted into the lower lip
b- their lower part inserted into the upper lip

C- Nerve supply:- Buccal branch of facial nerve

D- action:-
1- Prevents accumulation of food in the vestibule of mouth by compressing the
cheeks & lips against teeth.
2- Blowing
3- Suckling
4- Assistant muscle of mastication

Orbicularis oculi
A- Orbital part:-
- arises from the medial end of medial palpebral ligament & adjacent bone
B- Palpebral part:-
- originates from medial palpebral ligament
- inserted into lateral palpebral raphe
C- lacrimal part:-
- originate from lacrimal bone & fascia covering lacrimal sac
- inserted into upper & lower eyelids
- behind lacrimal sac

Nerve supply:- Temporal & zygomatic branches of facial N.

Actions:-
1- Orbital part:- Closes eyelids forcibly
2- Palpebral part:- Closes eyelids gently
4- Lacrimal part:- Helps in drainage of tears
7
N.B.
1- Angular artery = The terminal part of facial artery = The facial artery after giving its
superior labial branch
2- No deep fascia in the face
3- Muscles of the face:-
a- Inside superficial fascia
b- Originate from skull
c- Inserted into skin
4- Sphincter of eyelids = Orbicularis oculi
5- Muscles of nostrils:-
a- Dilator naris
b- Constrictor naris = Sphincter of naris
6- Orbicularis oris
a- Sphincter of mouth
b- Action:- Whistling expression
c- Nerve supply:- Buccal & mandibular branches of facial N.
7- Pterygo-mandibular raphe separates buccinator from superior constrictor of pharynx
8- Buccinator is pierced by parotid duct
9- Highest & lowest fibers of buccinators form part of orbicularis oris
10- Sensory innervation of the face is by trigeminal N. except the area over angle of
mandible & parotid gland (Supplied by great auricular N.)
11- Submental A. arises from facial A. as it is curving around lower border of mandible
12- Superior labial A. supplies upper lip and ala & septum of nose
13- Lateral nasal A. supplies ala & dorsum of nose
14- Lateral nasal A. anastomoses with
a- Lateral nasal A. of the opposite side
b- Septal & alar branches of superior labial A.
c- Dorsal nasal branch of ophthalmic A.
d- Infra-orbital branch of maxillary A.
15- Transverse facial A.:-
a- Arises from superficial temporal A. inside parotid gland
b- Passes anteriorly above parotid duct

8
 Parotid gland
Shape:- Wedge shaped
a- Its base directed superiorly
b- Its apex behind the angle of mandible

Position:-
a- Below external auditory meatus
b- Wedged between
1- Ramus of mandible anteriorly
2- Sternomastoid posteriorly

Surface anatomy:- P.G. is drawn between 4 points that are

a- Upper border of head of mandible
b- Upper part of anterior border of mastoid process
c- 2 cm postero-inferior to the angle of mandible
d- Above the center of masseter
1- Upper border:- Concave line drawn between 2 points a & b
2- Anterior border:- Line drawn between 3 points a, d & c
3- Posterior border:- Line drawn between 2 points b&c

Structures inside:- from lateral to medial

1- Facial nerve:- Gives its terminal branches inside P.G.
2- Retromandibular vein:- Begins & ends inside P.G.
3- External carotid artery and its terminal branches

Arterial supply:- From inside

1- External carotid A.
2- Superficial temporal A.
3- Maxillary A.

Venous drainage:- Retromandibular V.

Lymph drainage:-
1- Parotid L.Ns.
2- Deep cervical L.Ns.

9
Nerve supply:-

A- Parasympathetic = Secretomotor:- The secretomotor fibers arise

from the inferior salivary nucleus of glosso-pharyngeal N. → Pass in
glossopharyngeal nerve → Pass in tympanic branch of glossopharyngeal
nerve → reach tympanic cavity → forms tympanic plexus → Recollect to form lesser petrosal nerve →
Leave tympanic cavity as lesser petrosal N. → pass through foramen oval → Relay in
otic ganglion → postganglionic fibers are carried by auriculotemporal
nerve into parotid gland.

B- Sympathetic:- From plexus around E.C.A.

A- Sensory:- By
1- Auriculotemporal N.
2- Great auricular N.

Parotid duct
Course:- Arises from facial process of parotid gland → passes anteriorly
on the lateral surface of masseter → at the anterior border of masseter, it
turns medially to pierce buccal pad of fat & buccinator → Passes forwards
between buccinator & mucous membrane → opens in the vestibule of the
mouth opposite the upper 2nd molar tooth.

Length:- 5 cm

Surface anatomy:- Represented by the middle 1/3 of a line drawn

between 2 points that are
1- Tragus of the ear
2- A point on the upper lip midway between ala nasi and the angle of mouth

11
 Relations of parotid gland
A- Apex:-
1- Overlaps posterior belly of digastric
2- Cervical branch of facial N. exits through the apex
3- The 2 divisions of posterior facial V. exit through the apex
B- Superior surface:-
1- Cartilaginous part of E.A.M.
2- Posterior surface of temporo-mandibular joint
3- Superficial temporal vessels
4- Auriculo-temporal N.
C- Superficial surface:-
1- Skin
2- Superficial fascia containing
a- branches of great auricular N.
b- pre-auricular (superficial parotid) L.Ns.
c- posterior fibers of platysma
3- Parotid fascia
4- Few deep parotid L.Ns. embedded in the gland
D- Antero-medial surface:-
1- Masseter
2- Temporo-mandibular joint
3- Ramus of mandible
4- Medial pterygoid
5- Branches of facial N.
E- Postero-medial surface:-
1- Mastoid process with 2 muscles attached to it
a- sternomastoid
b- posterior belly of digastric
2- Styloid process & structures attached to it
3- Facial N.
4- Carotid sheath with its contents
a- I.C.A.
b- I.J.V.
c- last 4 cranial Ns.
F- Anterior border:- Allows for the emergence of
1- Parotid duct
2- Most of terminal branches of facial N.
3- Transverse facial vessels
G- Posterior border:- Overlaps sterno-mastoid
H- Medial border:- Related to lateral wall of pharynx

11
N.B.
1- Facial N. divides parotid gland into superficial & deep lobes
2- Processes of parotid gland:-
a- Glenoid process = Extension from the upper margin behind temporo-mandibular joint
to the mandibular fossa
b- Pterygoid process = Extension from the deep part between ramus of mandible &
medial pterygoid muscle
c- Facial process = Extension from the anterior margin superficial to masseter
3- Accessory P.G. = Accessory part of P.G. = Part of facial process become separated
from P.G. = Lies above parotid duct close to the anterior border of P.G.
4- Capsules of parotid gland:-
a- C.T. capsule
b- Fibrous capsule. Derived from deep fascia
5- Stylo-mandibular ligament intervenes between parotid & submandibular glands
6- The oblique passage of parotid duct between buccinator & M.M. → Valve like mechanism
→ Prevents inflation of parotid duct during blowing
7- E.C.A. enters P.G. through its postero-medial surface
8- Maxillary A. leaves P.G. through its antero-medial surface
9- E.C.A. ends inside P.G. at the level of neck of mandible
10- Some parotid L.Ns. may lie inside P.G.
11- Parotid bed = Structures on deep surface of P.G.

Sterno-mastoid
Origin:-
A- Sternal head:- From anterior surface of manubrium sterni
B- Clavicular head:- From medial 1/3 of upper surface of clavicle
Insertion:-
1- Mastoid process
2- Lateral 1/3 of superior nuchal line
Nerve supply:-
A- Motor:- Spinal part of accessory N.
B- Sensory = Proprioceptive:- C2, 3

12
Action:-
1- On both muscles →
a- Posterior fibers → Extend the head at atlanto-occipital joint
b- Anterior fibers → Flex cervical spine
c- Protraction of the head
2- On one side →
a- Wryneck position = Torticollis that consist of
- The ear pulled down to tip of shoulder of same side
- Rotation of the head → The face looking to the opposite side
b- Rotation of the face to opposite side
3- Accessory muscle of inspiration

Relations of sterno-mastoid
I- Superficial relations
1- Skin
2- Superficial fascia containing platysma
3- E.J.V.
4- Lower part of P.G.
5- Great auricular N.
6- Transverse cervical N.

II- Deep relations

A- Upper part:- Related to
1- Posterior belly of digastric
2- Occipital A.
3- Spinal part of accessory N.
B- Middle part:- Related to
1- Carotid sheath containing I.C.A., I.J.V. & vagus N.
2- D.C.L.Ns.
C- Lower part:- Related to
1- Sterno-clavicular joint
2- Sternohyoid
3- Sternothyroid
4- Intermediate tendon of omohyoid
D- The posterior border overlaps brachial & cervical plexuses

13
 Posterior triangle
Boundaries:-
A- Anteriorly:- Posterior border of sternocleidomastoid
B- Posteriorly:- Anterior border of trapezius
C- Inferiorly = Base of the triangle:- Middle 1/3 of clavicle
D- Apex:- Meeting of sterno-mastoid & trapezius
E- Roof:-
1- Skin
2- Superficial fascia
3- Platysma
4- Investing layer of deep fascia
F- Floor:- 5 muscles covered by prevertebral layer of deep fascia. From above
downwards,
1- Semi-spinalis capitis
2- Splenius capitis
3- Levator scapulae
4- Scalenus medius
5- Scalenus anterior

Contents:-
A- Arteries:-
1- 3rd part of subclavian A.
2- Suprascapular A.
3- Superficial cervical A. = Transverse cervical A.
4- Occipital A.
B- Veins:-
1- E.J.V. & its tributaries
2- Subclavian V.
C- Nerves:-
1- Brachial plexus:- Roots & trunks
2- Cutaneous Branches of cervical plexus:- Great auricular, lesser occipital,
transverse cutaneous & supra-clavicular Ns.
3- Spinal part of accessory N.
D- Muscles:- Inferior belly of omohyoid

14
N.B.
1- Supraclavicular Ns. Pass in the roof of posterior triangle
2- Inferior belly of omohyoid divides posterior triangle into 2 triangles
1- Occipital
2- Supraclavicular
3- E.J.V. pierces the deep fascia just above clavicle
4- Branches from the roots & trunks of brachial plexus inside posterior triangle
A- Branches from the roots:-
1- Dorsal scapular N. 2- Long thoracic N.
B- Branches from trunks:-
1- Suprascapular N. 2- Nerve to subclavius
5- Divisions of brachial plexus are formed in supraclavicular triangle

Divisions of anterior triangle

1- Digastric triangle 2- Carotid
3- Muscular 4- Submental

Digastric triangle = Submandibular triangle

Boundaries:-
A- Anteriorly:- anterior belly of digastric
B- Posteriorly:-
1- posterior belly of digastric
2- stylohyoid muscle
C- Superiorly:- lower border of the body of mandible
D- Floor:- By 3 muscles
1- Mylohyoid anteriorly
2- Hyoglossus posteriorly
3- Superior constrictor of the pharynx posteriorly
Contents:-
1- Submandibular salivary gland
2- Submandibular lymph nodes
3- Facial A. & V.
4- Hypoglossal N.
5- Nerve & vessels to mylohyoid
6- Lower part of parotid gland
15
 Carotid triangle
Boundaries:-
A- Posteriorly:- sternomastoid
B- Superiorly:- posterior belly of digastric
C- Inferiorly:- superior belly of omohyoid
D- Floor:- By 4 muscles
1- Thro-hyoid
2- Hyoglossus
3- Middle constrictor of pharynx
4- Inferior constrictor * **

Contents:-
1- Carotid sheath containing:-
a- end of C.C.A.
b- beginning of I.C.A.
c- I.J.V.
d- vagus nerve
3- External carotid artery
4- Some branches of external carotid artery
a- superior thyroid c- facial
b- lingual d- ascending pharyngeal

5- Tributaries of I.J.V.
6- Hypoglossal nerve & its descending branch
7- Accessory nerve
8- Internal & external laryngeal Ns.

Submental triangle
Boundaries:-
A- Anteriorly:- Anterior bellies of digastrics
B- Inferiorly:- Body of hyoid bone
C- Floor:- Mylohyoid muscle
Contents:-
1- Submental L.Ns.
2- Submental vessels
3- Beginning of anterior jugular vein
16
 Muscular triangle

Boundaries:-
A- Anteriorly:- Midline of the neck
B- Superiorly:- Superior belly of omohyoid
C- Inferiorly:- Sternomastoid
D- Floor:- 2 infrahyoid muscles (Sterno-hyoid & Sterno-thyroid)

Contents:- Infrahyoid muscles that are

1- sternohyoid
2- sternothyroid
3- thyrohyoid
4- omohyoid

Infrahyoid muscles
A- Superficial layer
1- omohyoid
2- sternohyoid
B- Deep layer
1- sternothyroid
2- thyrohyoid

Nerve supply of infrahyoid muscles

Ansa cervicalis (C1,2 & 3) except thyrohyoid that is supplied by nerve to
thyrohyoid that is a branch from hypoglossal N. and consists of fibers from C1.

17
 Omohyoid
Origin:-
A- Inferior belly:- From upper border of scapula
B- Superior belly:- From the intermediate tendon
Insertion:-
A- Inferior belly:- Intermediate tendon
B- Superior belly:- Body of H.B.
Action:- Depression of H.B.

Sternohyoid
Origin:-
1- Back of manubrium sterni
2- Medial part of clavicle
Insertion:- Body of H.B.
Action:- Depression of H.B.

Sternothyroid
Origin:- Back of manubrium sterni
Insertion:- Oblique line of thyroid cartilage
Action:- Depression of larynx

Thyrohyoid
Origin:- Oblique line of thyroid cartilage
Insertion:- Body of H.B.
Action:-
1- Depression of H.B.
2- Elevation of larynx
N.S.:- The exception

18
 Platysma
Origin:- Deep fascia covering upper parts of deltoid & pectoralis major
Insertion:-
1- Lower border of mandible
2- Blends with muscles at the angle of mouth
Action:-
1- Depression of mandible
2- Depression of the lower lip & angle of mouth
N.S.:- Cervical branch of facial N.

Midline structures of the neck

1- Symphysis menti
2- Mylo-hyoid raphe
3- body of H.B.
4- Median thyro-hyoid ligament
5- Thyroid cartilage
6- Crico-thyroid ligament
7- Cricoid cartilage
8- Crico-tracheal ligament
9- First tracheal ring
10- Isthmus of thyroid gland

Meninges
1- Three layers; from superficial to deep
a- Dura mater
b- Arachnoid mater
c- Pia mater
2- Dura mater consists of 2 layers; endosteal (Outer) & meningeal layers
3- Dura mater of spinal cord begins at foramen magnum as a continuation
from only the meningeal layer of dura around brain
4- Dural venous sinuses = Lines of separation between the 2 layers of dura
5- Dural folds = Extensions from the meningeal layer of dura between the
different parts of brain

19
 Dural folds
1- Falx cerebri
2- Falx cerebelli
3- Tentorium cerebelli
4- Diaphragma sellae

Falx cerebri
Shape:- Sickle shaped
Site:- Between the 2 cerebral hemispheres. In the midline
Attachment:-
1- Anterior end:- attached to internal frontal crest + crista galli
2- Posterior end:- attached to upper surface of tentorium cerebelli
Contents:-
1- S.S.S. runs in the upper fixed border
2- I.S.S. runs in the lower free border
3- Straight sinus runs along its attachment with tentorium cerebelli

Falx cerebelli
Shape:- Sickle shaped
Site:- Between the 2 cerebellar hemispheres
Attachment:-
1- To the internal occipital crest
2- Inferior surface of tentorium cerebelli
Contents:- Occipital sinus runs in the posterior border

21
 Tentorium cerebelli
Shape:- Crescent shaped
Site:- Covers the upper surface of cerebellum
Attachment:-
1- Its peripheral border is attached to
a- Posterior clinoid processes
b- Upper border of petrous part of temporal bone
c- Margins of the groove for transverse sinus
d- Internal occipital protuberance
2- Its inner border
- Free border
- Surrounds the tentorial notch
- Midbrain passes through the tentorial notch
- Crosses the attached border → Then gets attached to the anterior
clinoid process
- Trochlear N. pierces dura mater at the point where the 2 borders cross
each other
Contents:-
1- Straight sinus runs along its attachment to falx cerebri
2- Superior petrosal sinus runs along attachment with petrous part of
temporal bone
3- Transverse sinus runs along its attachment to occipital bone

Nerve supply of dura

Branches from
1- Trigeminal N.
2- Vagus N.
3- Upper 3 cervical Ns.
4- Sympathetic trunk
Arterial supply of dura
Branches from
1- Middle meningeal A.:- The most important
2- I.C.A.
3- maxillary A.
4- Ascending pharyngeal A.
5- Occipital A.
6- Vertebral A.
21
 Dural venous sinuses
Paired:-
1- Spheno-parietal sinus
2- Cavernous sinus
3- Superior petrosal sinus
4- Inferior petrosal sinus
5- Transverse sinus
6- Sigmoid sinus

Single:-
1- Superior sagittal sinus
2- Inferior sagittal sinus
3- Straight sinus
4- Basilar plexus of sinuses
5- Intercavernous sinuses
6- Occipital sinus

Cavernous sinus
Position:-
1- In the middle cranial fossa on each side of hypophyseal fossa
2- On Body of sphenoid
3- Extends from superior orbital fissure to apex of petrous part of temporal bone

Contents:-
1- On the lateral wall:- From above downwards
a- Oculo-motor N.
b- Trochlear N.
c- Ophthalmic N.
d- Maxillary N.
2- On the medial wall:-
a- I.C.A. surrounded by sympathetic plexus
b- Abducent N.

22
Communications:-
1- Anteriorly:-
a- Superior & inferior ophthalmic Vs.
b- Spheno-parietal sinus
c- Central vein of the retina
d- With facial V. through superior ophthalmic V.
2- Posteriorly:- Superior & inferior petrosal sinuses
3- Superiorly:-
a- Superficial middle cerebral V.
b- Inferior cerebral Vs.
4- Inferiorly:- With pterygoid plexus of Vs. through emissary Vs. passing
through foramen ovale
5- Medially:- With opposite cavernous sinus through intercavernous sinuses
(Anterior, posterior & inferior)

Relations:-
1- Medially:-
a- Pituitary gland
b- Sphenoid air sinus
2- Laterally:-
a- Trigeminal cave
b- Uncus of brain
3- Superiorly:- I.C.A.
4- Inferiorly:- Body of sphenoid
5- Anteriorly:- Superior orbital fissure
6- Posteriorly:- Apex of petrous bone
Tributaries:-
1- Superior ophthalmic vein
2- Inferior ophthalmic vein
3- Sphenoparietal sinus
4- Superficial middle cerebral vein

Drainage:- by 2 sinuses
1- Superior petrosal sinus to the transverse sinus
2- Inferior petrosal sinus to the internal jugular vein

23
 Superior sagittal sinus
Position:- Upper fixed border of falx cerebri
Beginning:- Foramen caecum
End:- At internal occipital protuberance by continuation as right transverse
sinus

Tributaries:-
1- Arachnoid villi & granulations project into the lacunae
2- Diploic & meningeal Vs. drain into the lacunae
3- Superior cerebral Vs.

Inferior sagittal sinus

Position:- In the lower border of falx cerebri
End:- Unites with the great cerebral vein to form the straight sinus

Straight sinus = Tentorial sinus

1- At the line of meeting of falx cerebri with tentorium cerebelli
2- Begins by the union of I.S.S. & great cerebral V.
3- Ends at internal occipital protuberance by continuation as the left transverse
sinus

Superior petrosal sinus

1- On the superior border of petrous part of temporal bone
2- Arises from the cavernous sinus
3- Ends into the transverse sinus

Inferior petrosal sinus

1- On the inferior border of petrous part of temporal bone
2- Arises from the cavernous sinus
3- Ends into I.J.V.

24
 Transverse sinus
Beginning:- At the internal occipital protuberance
1- The right is a continuation of the superior sagittal sinus
2- The left is a continuation of the straight sinus
Site:- in the attached border of tentorium cerebelli
End:- by continuation as sigmoid sinus
Tributaries:-
1- Superior petrosal sinus
2- Inferior cerebral V.
3- Cerebellar Vs.
4- Occipital diploic Vs.

Sigmoid sinus
Beginning:- as a continuation of the transverse sinus
End:- by passing through the jugular foramen to continue as I.J.V.

Occipital sinus
Site:- Along the attachment of falx cerebelli with internal occipital crest
Beginning:- From either
1- Beginning of one of the transverse sinuses
2- Confluence of sinuses
End:- Divides into 2 divisions → Skirt the margins of foramen magnum →
End into sigmoid sinuses

25
 Basilar plexus of sinuses
1- On clivus of skull
2- Communicates with inferior petrosal sinuses on both sides

N.B.
1- Stalk of hypophysis cerebri passes through the central opening in
diaphragm sellae
2- Dural venous sinuses are valveless
3- Dural venous sinuses drain into I.J.V.
4- Contents of cavernous sinus lie between dura mater & endothelial
lining of cavernous sinus = The contents are separated from the blood by
the endothelial lining
5- The cavity of cavernous sinus is spongy due to the presence of many
trabeculae
6- Anterior & posterior intercavernous sinuses pass through diaphragm
sellae in front of & behind pituitary stalk respectively
7- Inferior intercavernous sinus
- May be absent
- If present, passes below pituitary gland
8- Around foramen magnum, the divisions of occipital sinus communicate
with the internal venous plexus (Outside spinal cord)
9- S.S.S. communicates with 3 irregular venous spaces called lacunae
10- S.S.S. dilates at internal occipital protuberance → Forms confluence of
sinuses

26
 Pituitary gland
Position:- In sella turcica of sphenoid bone
Lobes:-
A- Anterior lobe = Adenohypophysis:- Divided into 2 parts
1- pars anterior = pars distalis
2- pars intermedia
B- Posterior lobe = Neurohypophysis
Arterial supply:- Superior & inferior hypophyseal As. From I.C.A.
Venous drainage:- Into the intercavernous sinuses

Relations:-
A- anteriorly:-
1- Ethmoid air sinuses
2- Sphenoid air sinus
3- Tuberculum sellae
B- Posteriorly:-
1- Dorsum sellae
2- Basilar artery
3- Pons
C- Superiorly:-
1- Diaphragma sellae
2- Optic chiasma
D- Inferiorly:-
1- Body of sphenoid
2- Sphenoid air sinus
3- Inferior intercavernous sinus
E- Laterally:- Cavernous sinus and its contents
N.B.
1- Pars tuberalis arise from pars anterior and surround pituitary stalk
2- Diaphragma sellae separates pituitary gland from optic chiasma
3- Pituitary gland is suspended to the floor of 3rd ventricle by infundibulum

27
 Emissary veins

1- Parietal emissary V.:-

- Passes through parietal foramen
- Connects scalp Vs. with S.S.S.
2- Mastoid emissary V.:-
- Passes through mastoid foramen
- Connects posterior auricular V. with sigmoid sinus
3- Posterior condylar emissary V.:-
- Passes through posterior condylar canal
- Connects sub-occipital plexus with sigmoid sinus
4- Emissary Vs. connecting cavernous sinus with pterygoid plexus by passing through
a- Foramen ovale
b- Foramen spinosum
c- Foramen lacerum
d- Emissary sphenoidal foramen
5- Emissary V. through hypoglossal canal:- Connects I.J.V. with sigmoid sinus
6- Emissary V. through foramen caecum:- Connects S.S.S. with nasal Vs.
7- Occipital emissary V.:- Connects confluence of sinuses with occipital V.
8- Superior ophthalmic V.:- Acts as emissary V. by connecting facial V. with
cavernous sinus
9- Venous plexus around I.C.A. in carotid canal:- Connects cavernous sinus with I.J.V.

N.B. Emissary veins

1- Valveless
2- Their function:- Communicate intra-cranial with extra-cranial Vs. → Maintain
equilibrium of intracranial venous pressure
3- Can transmit infection from extra-cranial to intra-cranial Vs.
4- Some of them are constant & others are variable

28
 Orbit
Margins:-
1- Upper margin:- Formed by frontal bone
2- Lower:- By Zygomatic bone & maxilla
3- Lateral:- By frontal & zygomatic bone
4- Medial:- By processes of maxilla & frontal bone

Boundaries:-
1- Roof:- By orbital plate of frontal bone
3- Floor:- Orbital plate of maxilla
2- Medial wall:- From before backwards
a- Frontal process of maxilla
b- Lacrimal bone
c- Orbital plate of ethmoid
d- Body of sphenoid
4- Lateral wall:-
a- Zygomatic bone
b- Greater wing of sphenoid

Communications
1- With middle cranial fossa through optic canal & superior orbital fissure
2- With infra-temporal & pterygo-palatine fossae through inferior orbital
fissure
3- With nasal cavity through naso-lacrimal duct

Structures passing through superior orbital fissure

1- Abducent nerve
2- Trochlear nerve
3- Divisions of oculomotor nerve:- a- superior b- inferior
4- Divisions of ophthalmic nerve:- a- frontal b- lacrimal c- nasociliary
5- Superior and inferior ophthalmic veins
Structures passing through inferior orbital fissure
1- Maxillary nerve 3- Infra=orbital artery
2- Zygomatic branch of maxillary nerve 4- Infra-orbital vein
Structures passing through optic canal
1- Optic nerve 2- Ophthalmic artery 3- Sympathetic plexus around ophthalmic A.

29
 Layers of eyelids
1- Skin
2- Subcutaneous tissue
3- Orbicularis oculi
4- Orbital septum & tarsal plates
6- Palpebral conjunctiva

Extra-ocular muscles
1- Levator palpebrae superioris
2- Four recti:-
a- superior b- inferior c- medial d- lateral
3- Two oblique muscles:-
a- superior b- inferior

Levator palpebrae superioris

Origin:- Inferior surface of lesser wing of sphenoid
Insertion:- By 2 lamellae
1- Superior lamella:- Into skin & front of tarsal plate of upper lid
2- Inferior lamella (Contains smooth muscle fibers):- Into upper margin of
superior tarsal plate
Nerve supply:-
1- Superior division of oculomotor N.
2- The smooth muscle fibers are innervated by sympathetic fibers from
superior cervical ganglion

Attachment of recti muscles

Origin:- From common tendinous ring
Insertion:- Into the sclera. 6 – 8 mm behind corneo-scleral junction

31
 Attachment of superior oblique
Origin:- Body of sphenoid
Insertion:- Passes through the trochlea → Inserted into sclera behind the coronal
equator & below superior rectus

Attachment of inferior oblique

Origin:- Anterior part of the floor of orbit
Insertion:- Inserted into sclera behind the coronal equator

Action of the extra-ocular muscles

1- Superior rectus:- Directs the cornea upward & medially
2- Inferior rectus:- * * * downward & *

3- Medial rectus:- Directs the cornea medially = Adduction

4- Lateral rectus:- * * * laterally = Abduction

5- Superior oblique:- Directs the cornea downward & laterally

6- Inferior oblique:- * * * upward & *

Nerve supply of the extra-ocular muscles

1- Trochlear N.:- Supplies superior oblique
2- Abducent N.:- Supplies lateral rectus
3- Oculomotor N.:- Divides into 2 divisions
A- Superior division:- Supplies
1- Levator palpebrae superioris
2- Superior rectus
B- Inferior division:- Supplies
1- Inferior oblique
2- Inferior rectus
3- Medial rectus

31
N.B.
1- Orbital plate of maxilla separates the orbit from maxillary sinus
2- Orbital plate of ethmoid separates the orbit from ethmoid sinuses
3- Openings for zygomatico-temporal & zygomatico-facial Ns. are on the lateral wall of
orbit
4- Anterior & posterior ethmoidal foramina are on the medial wall of orbit along the upper
margin of ethmoid bone
5- Meibomian glands = Tarsal glands:-
a- Modified sebaceous glands
b- In the back of tarsal plates
c- Open behind the eyelashes
6- Orbital septum:-
a- Continuous with periosteum
b- Thickened at the margins of eyelids → Form tarsal plates
7- Tarsal plates are attached to the medial & lateral palpebral ligaments
8- Parts of orbital fascia:-
a- Peri-orbita = Periosteum of the orbit
b- Bulbar fascia = Tenon’s capsule
c- Orbital septum
9- Periorbita:-
- Continuous with dura through superior orbital fissure
- Forms the lacrimal sac
10- Tenon’s capsule:-
- Encapsulates the eyeball
- Separated from the eye ball by the episcleral space
- Attached to corneo-scleral junction
11- Paralysis of the involuntary part of levator palpebrae superioris leads to ptosis
12- Lateral rectus originates by 2 heads from the common tendinous ring
13- Common tendinous ring:-
- Thickening of periosteum
- Fibrous ring
- Surrounds optic canal & part of superior orbital fissure
14- Equator of eyeball = An imaginary line encircling the eyeball equidistant from the
anterior & posterior poles
15- There are no lymph vessels in the orbit

32
 Lacrimal apparatus
Parts:-
1- Lacrimal gland:-
- In the superolateral part of the orbit
- Divided by levator palpebrae superioris into 2 parts (Orbital & palpebral)
2- Conjunctiva:- Lines the inner aspect of eyelids & Covers the anterior part
of sclera
3- Superior & inferior lacrimal canaliculi:- Drain tears into the
lacrimal sac
4- Lacrimal sac:-
- In the lacrimal groove at the medial wall of the orbit
- Covered by lacrimal part of orbicularis oculi
5- Nasolacrimal duct:- Drains tears from lacrimal sac to nasal cavity (into
the anterior part of inferior meatus)

Lacrimal gland
Site = Position:- Lacrimal fossa in the supero-lateral part of orbit
Arterial supply:- Lacrimal branch of the ophthalmic artery
Venous drainage:- Into the ophthalmic veins

Parts of lacrimal gland

It is divided by levator palpebrae superioris into 2 parts:-
A- Orbital part:-
- larger
- in the lacrimal fossa of frontal bone
B- Palpebral part:-
- smaller
- in the supero-lateral part of upper eye lid

33
 Nerve supply of lacrimal gland
A- Parasympathetic = secretomotor:- The secretomotor fibers
arise from lacrimal nucleus of facial nerve → Pass through nervus
intermedius → Through the greater petrosal nerve → unites with deep
petrosal nerve to form the nerve of pterygoid canal → Relay in pterygo-
palatine ganglion → Postganglionic fibers join maxillary nerve → To its
zygomatic branch → To its zygomatico-temporal branch → These
secretomotor fibers leave the zygomatico-temporal nerve and join the
lacrimal branch of ophthalmic nerve → Into L.G.

B- Sympathetic:- From plexus around I.C.A.

- Post-ganglionic sympathetic fibers arise from the superior cervical ganglion → Pass in the internal carotid nerve → plexus around ……..
→ pass in the deep petrosal nerve → unites with .................. …………… ………. To form ………. Of ……………. → pass through
pterygo-palatine ganglion without relay → join maxillary nerve → ………

C- Sensory:- By lacrimal branch of ophthalmic nerve

N.B.
1- The 2 parts of lacrimal gland are continuous together around the lateral edge of the
aponeurosis of levator palpebrae superioris
2- Lacrimal gland opens by 12 ducts into the lateral part of superior fornix of conjunctiva
3- Upper & lower conjunctival fornices are the sites of reflection
4- Lacrimal canaliculi start at the lacrimal puncta
5- Lacrimal sac is behind the medial palpebral ligament
6- Length of nasolacrimal duct = 13 mm = 0.5 inch
7- Lacrimal fold = Mucosal fold guarding the opening of nasolacrimal duct.
8- Lacrimal fold prevents the passage of air into nasolacrimal duct during blowing the nose

34
 Ciliary ganglion

Type:- Parasympathetic

Site:-
- In the posterior part of orbit
- Lateral to optic N.

Afferents = Roots:-

1- Preganglionic parasympathetic fibers:- From oculo-motor nerve through

nerve to inferior oblique

2- Sympathetic fibers from plexus around I.C.A.:- Without relay

3- Sensory fibers:- From nasociliary N.

Efferents = Branches:-

1- Postganglionic parasympathetic fibers:- Through the short ciliary nerves to

a- sphincter pupillae
b- ciliary muscles

2- Short ciliary nerves to B.Vs. & dilator pupillae:- Sympathetic

3- Short ciliary nerves to cornea, iris & choroid:- Sensory

35
 Boundaries (Skeleton) of the nose

A- Roof:- From anterior to posterior

1- Sloping anterior part:- Frontal + nasal bones
2- Horizontal middle part:- Cribriform plate of ethmoid
3- Sloping posterior part:- Body of sphenoid + ala of vomer

B- Floor:- By hard palate

1- Palatine processes of maxilla
2- Horizontal plates of palatine bones

C- Medial wall = Nasal septum:-

1- Superiorly = Perpendicular plate of ethmoid
2- Anteriorly = Septal nasal cartilage
3- Posteriorly = Vomer

D- Lateral wall:-
1- Superiorly = Labyrinth of ethmoid
2- Anteriorly = Medial surface of maxilla
3- Posteriorly = Perpendicular plate of palatine bone

Divisions of lateral wall of nose

Divided by 3 projections (superior, middle and inferior conchae) into

1- Spheno-ethmoidal recess = above the superior concha

2- Superior meatus = below superior concha
3- Middle meatus = below middle concha
4- Inferior meatus = below inferior concha

36
 Features in middle meatus
1- Bulla ethmoidalis = Ethmoidal bulla:-
- Rounded prominence
- Produced by the underlying middle ethmoidal cells
- Middle ethmoidal cells open on bulla ethmoidalis or just above it
2- Hiatus semilunaris:-
- Curved gutter below ethmoidal bulla
- Its anterior end forms the ethmoidal infundibulum
- Maxillary sinus opens into hiatus semilunaris
- Frontal sinus & anterior ethmoidal cells are drained by frontonasal duct →
Into ethmoidal infundibulum → Into anterior end of hiatus semilunaris
3- Ethmoidal infundibulum

Arterial supply of the nose

1- Anterior and posterior ethmoidal As.:- From ophthalmic A.
2- Sphenopalatine A.:-
- From maxillary artery
- It is the main arterial supply of nose
3- Branches of superior labial A. (from facial A.)
4- Greater palatine A.:- From maxillary A.

Venous drainage of the nose

1- Pterygoid plexus of Vs.
2- Facial V.
3- Maxillary V.

Lymph drainage
1- The vestibule:- Drained by submandibular L.Ns.
2- The remainder:- Drained by U.D.C.L.Ns.

37
 Nerve supply of nasal epithelium
A- Olfactory nerve
- Passes through cribriform plate of ethmoid
- From olfactory mucosa to olfactory bulb

B- General sensory nerves

A- Anterior part:- By anterior ethmoidal N. (From ophthalmic N.)
B- Posterior part:- By branches of maxillary N. via pterygopalatine ganglion
1- Nasal branches
2- Nasopalatine N.
3- Nasal branches of greater palatine N.

C- Secretomotor and sympathetic

- By branches of spheno-palatine ganglion
- Secretomotor:- from greater petrosal nerve that is a branch from ………. Nerve
- Sympathetic:- from deep petrosal nerve that is a branch from the ………. Around ………. ……….. artery

Little’s area
Site:- Anterior part of nasal septum

Characters = why it is the commonest site for epistaxis:-

1- Rich in arterial supply because it is a site for anastomosis between 4 arteries that are
a- septal branch of superior labial artery
b- anterior ethmoidal artery
c- greater palatine artery
d- sphenopalatine artery
2- Thin mucous membrane

Q 1:- Mention arterial supply of lateral wall of the nose

Q 2:- Mention arterial supply of nasal septum

Openings into the lateral wall of nose

1- Sphenoid air sinus:- Into spheno-ethmoidal recess
2- Posterior ethmoidal cells:- Into superior meatus
3- Middle ethmoidal cells:- On bulla ethmoidalis or just above it
4- Anterior ethmoidal:- Into anterior end of H.S.L. through infundibulum
5- Maxillary:- Into H.S.L.
6- Frontal:- Into anterior end of H.S.L. through infundibulum
7- Nasolacrimal duct:- Into anterior end of inferior meatus

38
 Relations of maxillary air sinus
1- Roof (supero-lateral surface):- Related to orbit
4- Antero-lateral surface:- Related to
a- Roots of upper molar & premolar teeth
b- Face
5- Posteriorly:- Related to infratemporal fossa

Arterial & nerve supply of air sinuses

Sphenoidal Ethmoidal Maxillary Frontal

As. Branches of ophthalmic Branches of Anterior

A. maxillary A. ethmoidal As.
From
1- Anterior ethmoidal A. 1- Infra-orbital A. ophthalmic A.
2- Superior
2- Posterior ethmoidal A. alveolar As.

Ns. Posterior 1- Anterior & posterior Branches of

ethmoidal ethmoidal branches of maxillary N.
branch of nasociliary N. from Supra-orbital
ophthalmic ophthalmic N. 1- Infraorbital N. N. from
N. ophthalmic N.
2- Orbital branches of 2- Superior
maxillary N. through alveolar Ns.
pterygo-palatine ganglion

N.B.
1- Spheno-palatine A. anastomoses with septal branch of superior labial A. in the vestibule
→ Common site for epistaxis
2- Olfactory mucosa lines
a- Roof of nose c- Upper surface of superior concha
b- Spheno-ethmoidal recess d- Upper part of nasal septum
3- Ethmoid air cells lie in ethmoidal labyrinth
4- Ethmoid cells are separated from the orbit by orbital plate of ethmoid
5- Orbital plate of ethmoid is thin → So, infection can spread from sinuses to orbit

39
 Ages of eruption of milk teeth
1- Central incisors:- 6 – 8 months
2- Lateral incisors:- 8 – 10
3- First molars:- 12 – 16
4- Canines:- 16 – 20
5- Second molars:- 20 – 30

Ages of eruption of permanent teeth

1- First molars:- 6 – 7 years
2- Central incisors:- 6–8
3- Lateral incisors:- 7–9
4- Canines:- 9 – 12
5- 1st & 2nd premolars:- 10 – 12
6- Second molars:- 11 – 13
7- Third molars:- 17 – 21

Boundaries of mouth cavity proper

Anterolaterally:- Alveolar arches, gums & teeth
Posteriorly:- Communicates with pharynx through oropharyngeal isthmus
Roof:- Palate
Floor:- Anterior 2/3 of tongue

Tongue
Arterial supply:-
1- Lingual A.
2- Tonsillar branch of facial A.
3- Ascending pharyngeal A.
Venous drainage:- Lingual V. → Drains into I.J.V.
Lymph drainage:-
A- Tip:- Submental L.Ns.
B- Sides of the anterior 2/3:- Submandibular & deep cervical L.Ns.
C- Posterior 1/3:- Deep cervical L.Ns.

41
 Nerve supply of the tongue
Motor:-
1- All muscles are supplied by hypoglossal nerve except palatoglossus
2- Palatoglossus is supplied by the cranial part of accessory nerve through
pharyngeal plexus

Sensory:-
A- General sensation:-
1- Anterior 2/3 except the area of vallate papillae:- By lingual N.
2- Posterior 1/3 & the area of vallate papillae:- By glossopharyngeal N.
3- Root:- By internal laryngeal nerve (branch from superior laryngeal N. that
is a branch from vagus N.)
B- Taste sensation:-
1- Anterior 2/3 except the area of vallate papillae:- By chorda tympani N.
2- Posterior 1/3 & the area of vallate papillae:- By glossopharyngeal N.
3- Root:- By internal laryngeal nerve (branch from superior laryngeal N. that
is a branch from vagus N.)

Muscles of the tongue

A- Intrinsic Ms.:- 4 pairs
- Consist of longitudinal, transverse & vertical fibers
- Action:- Alter the shape of tongue

B- Extrinsic Ms.:-
1- Styloglossus
2- Genioglossus
3- Palatoglossus
4- Hyoglossus

41
 Extrinsic muscles of the tongue
Origin Insertion Action

Styloglossus Tip of styloid Retracts the tongue upwards

process & backwards

Palatoglossus Undersurface 1- Elevation of the posterior

of palatine part upwards & backwards
aponeurosis
Side of the 2- Adduction of
tongue palatoglossal arches to close
or narrow the oropharyngeal
isthmus

Hyoglossus Greater horn &

body of hyoid
bone
Depresses the tongue
Chondroglossus Lesser horn &
body of H.B.

Genioglossus Superior genial Whole length 1- On both sides →

tubercle of of tongue Protrusion of tongue
mandible
2- On one side → Pushes the
protruded tongue to the
opposite side

3- One of the safety muscles

= Prevents the tongue from
falling backwards and
suffocation

N.B.
1- Parts of oral cavity:-
a- Vestibule of the mouth
b- Mouth cavity proper
2- Boundaries of vestibule of the mouth:-
a- Externally:- Lips & cheeks
b- Internally:- Gum & teeth
42
3- Parotid duct opens into vestibule of the mouth opposite the upper 2nd molar tooth
4- Frenulum labia = Mucosal fold connecting the lip with the gum
5- Frenulum of the tongue = Mucosal fold connecting the undersurface of the tongue with
the floor of mouth
6- Lingual V. can be seen on the inferior surface of tongue lateral to the frenulum
7- Plica fimbriata = Mucosal fold lateral to lingual vein
8- Sublingual papilla:- In the floor of mouth on both sides of the frenulum of tongue
9- Sublingual fold:-
- Extends posteriorly from sublingual papilla
- Produced by sublingual gland
- Shows the openings of sublingual ducts
10- Submandibular duct opens on the summit of sublingual papilla
11- Deciduous teeth = Milk teeth
12- Oropharyngeal isthmus = Isthmus of fauces
13- Oropharyngeal isthmus = Isthmus of fauces = The interval between palatoglossal
arches
14- Mylohyoid supports the floor of mouth
15- Sulcus terminalis divides the upper surface of tongue into
a- Oral part = Anterior 2/3
b- Pharyngeal part = Posterior 1/3
16- Foramen cecum is at the apex of sulcus terminalis
17- Lingual papillae:-
- On the anterior 2/3 of upper surface
- 3 types; Filiform, Fungiform & Vallate
18- Fungiform papillae:-
- Fewer than filiform papillae
- On the sides
- Mushroom shaped
19- Vallate papillae:-
- The largest papillae
- 10 – 12 in number
- Immediately in front of sulcus terminalis
20- Lingual tonsil = Lymphatic nodules below the mucosa of posterior 1/3
21- The tongue is divided into right & left halves by a median fibrous septum
22- In cases of unilateral paralysis of genioglossus → The protruded tongue deviates to the
paralyzed side

43
 Palate
Arterial supply:-
1- Greater palatine artery:- from maxillary artery
2- Ascending palatine artery:- from facial artery
3- Ascending pharyngeal A.:- from E.C.A.
Venous drainage:- Pharyngeal & pterygoid plexuses of veins
Lymph drainage:-
1- Submandibular L.Ns
2- Upper deep cervical L.Ns.
Nerve supply of hard palate:-
1- Greater palatine N.:- Passes through greater palatine foramen
2- Nasopalatine N.:- Passes through incisive foramen

Nerve supply of soft palate:-

A- Motor:- All muscles of palate are supplied by cranial part of
accessory nerve through pharyngeal branch of vagus nerve and pharyngeal
plexus except tensor palati that is supplied by nerve to medial pterygoid
that is a branch from the trunk of mandibular nerve
B- Sensory:-
I- General sensations:- By
1- Greater palatine N..
2- Lesser palatine N.
3- Nasopalatine N.
4- Glossopharyngeal N.
II- Taste sensations:- By greater superficial petrosal N. that is a branch
from facial N.

Muscles:-
1- Palatoglossus
2- Palatopharyngeus
3- Levator palate
4- Tensor palate
5- Musculus uvulae
44
 Palatopharyngeus
Origin:- Palatine aponeurosis
Insertion:- Posterior border of thyroid cartilage
Action:-
1- Shortens the pharynx during deglutition
2- Closes the pharyngeal isthmus during deglutition
Levator palate
Origin:-
1- Apex of petrous part of temporal bone
2- Medial wall of the cartilaginous part of auditory tube
Insertion:- Upper surface of palatine aponeurosis
Tensor palate
Origin:-
1- Spine of sphenoid
2- Scaphoid fossa
3- Lateral wall of the cartilaginous part of auditory tube
Insertion:- Palatine aponeurosis
Nerve supply = the exception
Musculus uvulae
Origin:- Posterior nasal spine
Insertion:- Mucosa of uvula
Action:- Retraction & elevation of uvula

N.B.
1- Pharyngeal isthmus is between the soft palate & posterior pharyngeal wall
2- Tensor palati pierces buccinators & hooks around pterygoid hamulus
3- Hard palate = The anterior 2/3 of the palate
4- Hard palate consists of
a- Palatine processes of maxilla = The anterior 2/3 of hard palate
b- Horizontal plates of palatine bone

45
 Pharynx
Beginning:- At the base of skull

End:- At the level of 6th cervical vertebra = lower border of cricoid cartilage =
by continuation with esophagus

Length = 12 cm

Arterial supply:-
1- Ascending pharyngeal A.
2- Ascending palatine A.
3- Pharyngeal branch of maxillary A.
4- Tonsillar A.
5- Lingual A.

Venous drainage:- Pharyngeal plexus of veins → Drains into the I.J.V.

Lymph drainage:- Deep cervical L.Ns.

Nerve supply:-
A- Motor:-

1- All muscles are supplied by cranial part of accessory N. through

pharyngeal branch of vagus and pharyngeal plexus except stylopharyngeus
2- Stylopharyngeus is supplied glosso-pharyngeal N.
B- Sensory:-
1- Nasopharynx:- by maxillary nerve
2- Oropharynx:- by glossopharyngeal N.
3- Laryngopharynx:- by internal laryngeal branch of vagus N.

46
Muscles of the pharynx are:-
1- Palatopharyngeus 2- Stylopharyngeus 3- Salpingopharyngeus
4- Three constrictors (superior, middle and inferior)

Salpingopharyngeus
Origin:- Cartilaginous part of auditory tube
Insertion:- Wall of pharynx
Action:-
1- Elevates larynx during deglutition
2- Opens Eustachian tube during swallowing

Stylopharyngeus
Origin:- Medial side of styloid process
Insertion:- Posterior border of thyroid lamina
Action:- Elevates larynx during swallowing

The 3 constrictors of pharynx

Origin:-
1- Superior constrictor = from
a- posterior border of medial pterygoid plate
b- pterygoid hamulus
c- pterygomandibular raphe
d- posterior end of mylohyoid line
e- side of the tongue
2- Middle constrictor = from
a- lower part of stylohyoid ligament
b- lesser & upper part of greater horns of hyoid bone
3- Inferior constrictor = from
a- oblique line of thyroid cartilage (Thyro-pharyngeus part)
b- cricoid cartilage (Crico-pharyngeus part)

Insertion:- Into pharyngeal raphe

47
 Structures passing in relation to the constrictors
A- At the upper border of superior constrictor:-
1- cartilaginous part of auditory tube
2- levator veli palatini = levator palati
3- ascending palatine A.
4- pharyngeal branch of ascending pharyngeal A.

B- At the upper border of middle constrictor:-

1- glossopharyngeal nerve
2- stylopharyngeus muscle
3- stylohyoid ligament

C- At the upper border of inferior constrictor:-

1- superior laryngeal artery
2- internal laryngeal nerve

D- At the lower border of inferior constrictor:-

1- inferior laryngeal artery
2- recurrent laryngeal nerve

Pharyngeal plexus
Site:- On the outer surface of pharynx (Outer surface of middle constrictor)
Roots:-
1- Motor root:- Pharyngeal branch of vagus
2- Sensory root:- Pharyngeal branch of glosso-pharyngeal N.
3- Sympathetic root:- Pharyngeal branch of superior cervical ganglion
Motor distribution:-
1- Supplies all muscles of palate except tensor palati
2- Supplies all muscles of pharynx except stylopharyngeus

48
 Boundaries of nasopharynx
Anteriorly:- Posterior nasal aperture
Posteriorly:- Anterior arch of atlas
Roof:- Body of sphenoid + Basilar part of occipital bone
Floor:- Soft palate + Pharyngeal isthmus
Lateral wall:- shows the following features
1- Pharyngeal opening of auditory tube
2- Tubal elevation:- Formed by the posterior margin of auditory tube
3- Salpingo-pharyngeal fold:- Extends inferiorly from the tubal elevation
4- Pharyngeal recess:- Behind the tubal elevation
5- Tubal tonsil:- In submucosa behind the opening of auditory tube

Boundaries of oropharynx
Anteriorly:-
1- Oropharyngeal isthmus
2- Pharyngeal part of the tongue
Posteriorly:- Body of 2nd + Upper part of the body of 3rd cervical vertebrae
Roof:- Soft palate + Pharyngeal isthmus
Floor:-
1- Posterior 1/3 of tongue
2- The interval between the tongue & anterior surface of epiglottis
Lateral wall:- Faucial pillars = Faucial folds
1- Palatoglossal arches
2- Palatopharyngeal arches

Boundaries of laryngo-pharynx
A- Anteriorly:-
1- Inlet of larynx
2- Mucous membrane on the back of larynx
B- Posteriorly:- bodies of 3rd, 4th, 5th and 6th cervical vertebrae
C- Lateral wall:- Supported by
1- Thyroid cartilage
2- Thyrohyoid membrane

49
N.B.
1- Pharyngo-esophageal junction is the narrowest & least dilatable part of G.I.T.

2- Layers of pharynx
a- Mucous coat
b- Fibrous coat = Pharyngobasilar fascia
c- Muscular coat
d- Areolar tissue

3- Pharyngobasilar fascia is
a- Attached superiorly to the base of skull
b- Posteriorly, forms the pharyngeal raphe

4- Pharyngeal raphe = Median fibrous band that is attached superiorly to the

pharyngeal tubercle

5- Piriform fossa is a common site for the lodging of ingested sharp bodies

6- Buccopharyngeal fascia covers the outer surface of buccinators & pharyngeal muscles

7- Adenoids = Enlarged pharyngeal tonsil = In the submucosa of roof of pharynx

8- Oropharynx extends from the soft palate to upper border of epiglottis

9- Mucous membrane of the posterior 1/3 of tongue is irregular due to the presence
of lingual tonsil

10- Glosso-epiglottic folds

- Median & 2 lateral
- Mucosal folds (Reflections) between the tongue & epiglottis

11- Vallecula = Depressions between the glosso-epiglottic folds

12- Laryngopharynx extends from the upper border of epiglottis to the lower
border of cricoid cartilage

13- Piriform fossa is on both sides of laryngeal inlet

14- Boundaries of piriform fossa

a- Medially:- Ary-epiglottic fold
b- Laterally:- Thyroid lamina + Thyrohyoid membrane

51
 Palatine tonsil
Position:- In the tonsillar sinus in the lateral wall of oropharynx

Relations:-
A- Anteriorly:- palatoglossal arch
B- Posteriorly:- Palatopharyngeal arch
C- Superiorly:- Soft palate
D- Inferiorly:- Posterior 1/3 of the tongue
E- Medially:- Cavity of oropharynx
F- Laterally:- From medial to lateral
1- Tonsillar capsule
2- Loose areolar C.T.
3- Superior constrictor
4- External palatine V. = Paratonsillar V.
5- I.C.A. (One inch posterolateral to the tonsil)

Arterial supply:-
1- Tonsillar branch of facial A.:- From facial A.
2- ~ ~ of ascending palatine A.:- From facial A.
3- ~ ~ of ascending pharyngeal A.:- From E.C.A.
4- ~ ~ of descending palatine A.:- From maxillary A.
5- ~ ~ of dorsal lingual A.:- From lingual A.

Venous drainage:- The veins pierce the superior constrictor → Join the
external palatine V. → Ends into the pharyngeal plexus of Vs.

Sensory nerve supply:-

1- Lesser palatine nerve:- from maxillary nerve
2- Glossopharyngeal nerve

Lymph drainage:- Upper deep cervical L.Ns. (Jugulo-digastric L.Ns.)

below & behind the angle of mandible

N.B. Intratonsillar crypt = Cleft in the upper part of the medial surface of tonsil
51
 Larynx
Position:- Opposite the 3rd – 6th cervical vertebrae

Arterial supply:-
1- Superior laryngeal A. that is a branch of superior thyroid A.
2- Inferior ………… A. that is a branch of ……... ………. A.

Venous drainage:-
1- Superior laryngeal V. that drains into superior thyroid V.
2- Inferior ………… V. that drains into ……... …….… V.

Lymph drainage:- To infrahyoid, prelaryngeal & pretracheal L.Ns. → Then

drain into upper & lower deep cervical L.Ns.

Sensory nerve supply of mucosa:-

A- Above the vocal cords:- By internal laryngeal N.
B- Below the vocal cords:- By recurrent laryngeal N.

Motor innervation of the intrinsic muscles:-

1- Recurrent laryngeal nerve:- supplies all the intrinsic muscles except
cricothyroid that is supplied by external laryngeal N.
2- External laryngeal N. that is a branch of superior laryngeal N.:- supplies
cricothyroid muscle

Parts of laryngeal cavity

1- Vestibule:- Between the laryngeal inlet & vestibular folds
2- Middle part:- Between the vestibular folds & vocal cords
3- Lower compartment:- Between the vocal cords & lower border of cricoid C.

52
 Boundaries of laryngeal inlet
1- Anteriorly:- Upper border of epiglottis
2- Posteriorly:- Mucous membrane between arytenoid cartilages
3- Laterally:- Ary-epiglottic folds

Rima glottidis = Rima glottis

Definition:- It is the space between the 2 vocal folds anteriorly & between the
2 arytenoid cartilages posteriorly

Parts:-
1- Intermembranous part = Between the 2 vocal folds
2- Intercartilaginous part = Between the 2 arytenoid cartilages

Anteroposterior length:-
1- In males = 23 mm
2- In females = 17 mm

Cartilages of larynx

A- Single cartilages:-
1- Thyroid
2- Cricoid
3- Epiglottis
B- Paired cartilages:-
1- Arytenoid
2- Corniculate
3- Cuneiform

53
 Thyroid cartilage
1- Right and left laminae
2- Laryngeal prominence = Adam's apple
3- Superior thyroid notch:- Median notch above Adam’s apple
4- Superior and inferior horns (Cornua) = upward and downward projections from the
posterior borders of thyroid laminae
5- Thyrohyoid membrane = Between the upper border & hyoid bone
6- Oblique line = oblique ridge on the outer surfaces of thyroid laminae = Between
superior & inferior thyroid tubercles

Cricoid cartilage
1- Shape = signet shaped
2- Level = at the level of 6th cervical vertebra
3- Parts =
a- narrow arch anteriorly
b- broad lamina posteriorly

Epiglottis
1- Shape:- Leaf shaped
2- Ligaments attached:-
a- Hyo-epiglottic ligament
b- Thyro-epiglottic ligament
c- 3 glosso-epiglottic ligaments (one median and 2 lateral)
d- Ary-epiglottic folds (Right & left)

Arytenoid cartilage
1- Shape = Pyramid
2- Vocal process:- the anterior angle of the base
3- Muscular process:- the Posterolateral angle of the base

54
 Joints of larynx
Articular parts Type

1- Crico-thyroid J. 1- Lateral surface of cricoid C.

2- Inferior cornu of thyroid C. Synovial

2- Crico-arytenoid J. 1- Upper border of cricoid C.

2- Base of arytenoid C.

3- J. between the apex of arytenoid & corniculate Cs. Cartilaginous but

sometimes synovial

Extrinsic muscles of larynx

I- Elevators of larynx
1- Digastric 3- Stylopharyngeus 5- Stylohyoid 7- Mylohyoid
2- Palatopharyngeus 4- Salpingopharyngeus 6- Geniohyoid
II- Depressors of larynx
1- Sternohyoid 2- Sternothyroid 3- Omohyoid

Intrinsic muscles of larynx

I- Muscles modifying laryngeal inlet
1- Narrowing the inlet:-
a- Oblique arytenoid
b- Ary-epiglottic muscle
2- Widening the inlet:- Thyro-epiglottic muscle

II- Muscles acting on vocal cords

1- Tensing V.Cs.:- Cricothyroid
2- Relaxing V.Cs.:- Vocalis = Thyroarytenoid
3- Adducting V.Cs.:-
a- Transverse arytenoid
b- Lateral crico-arytenoid
4- Abducting V.Cs.:- Posterior cricoarytenoid

55
 Cricothyroid
Origin:- Side of cricoid C.
Insertion:- Lower border & inferior horn of thyroid cartilage
Action:- Tenses the vocal cords
Nerve supply:- The exception

Thyro-arytenoid = Vocalis
Origin:- Inner surface of thyroid C.
Insertion:- Antero-lateral surface of arytenoids cartilage
Action:- Relaxes the vocal cords
N.S.:-

Lateral and posterior crico-arytenoid

Origin Insertion Action

Lateral Upper border of cricoid Muscular process Adduction of vocal cords

of arytenoids
Posterior Back of cricoid lamina cartilage Abduction of vocal cords

Transverse and oblique arytenoids

Origin Insertion Action

Oblique Muscular process of Apex of opposite Narrowing of

arytenoids C. arytenoids C. laryngeal inlet
Transverse Back & medial surface of Back & medial Closes the posterior
arytenoid C. surface of opposite part of Rima glottis
arytenoids C.

56
 Membranes & ligaments of larynx

I- Extrinsic ligaments

1- Thyro-hyoid membrane:-
- Attached to the upper border of thyroid C. & upper border of the back of hyoid bone
- Separated from the back of hyoid bone by hyoid bursa → Facilitates laryngeal ascent
during swallowing
- Thickened in the midline → Median thyrohyoid ligament
- Thickened at its posterior borders → Lateral thyrohyoid ligaments
- Pierced by
a- Superior laryngeal A.
b- Superior laryngeal V.
c- Internal laryngeal N.
2- Thyro-epiglottic ligament:- Connects the lower end of epiglottis with the inner
surface of thyroid cartilage
3- Hyo-epiglottic ligament
4- Cricotracheal ligament:- Connects the cricoid C. with the 1st tracheal ring

II- Intrinsic ligaments = Fibro-elastic membrane

1- Upper part = Quadrangular membrane:-

- Between epiglottis & arytenoid C.
- Its thickened inferior margin is called vestibular ligament
2- Lower part = Crico-thyroid ligament:-
- Between the upper border of cricoid C. & medial surface of thyroid C.
- Thickened anteriorly → median cricothyroid ligament
- Thinned laterally → cricothyroid or cricovocal membranes
- Its upper edges are thickened → vocal ligaments

Waldeyer’s ring = Tonsillar ring

1- Pharyngeal tonsil:- In the postero-superior wall of pharynx
2- Lingual tonsils:- On the dorsum of the posterior 1/3 of tongue
3- Palatine tonsils:- On each side of oropharyngeal isthmus
4- Tubal tonsils:- Behind the pharyngeal opening of eustachian tube

57
N.B.
1- Corniculate cartilages articulate with the apices of arytenoid cartilages

2- Cuneiform cartilage is in front of corniculate cartilage

3- Corniculate & cuneiform cartilages are in the posterior part of ary-epiglottic fold

4- The vestibular ligaments are covered by vestibular folds

5- Rima vestibuli = The gap between the 2 vestibular folds

6- Rima glottidis is the narrowest part of larynx

7- Sinus of larynx = Recess between the vestibular & vocal folds

8- Saccule = Upward diverticulum from mucous membrane = Between the vestibular

fold & thyroid C.

9- Function of saccule = Secretion of mucus → Lubrication of vocal folds

10- Fibro-elastic membrane of larynx lies deep to the mucous membrane

11- Cricothyroid ligament is crossed by cricothyroid As.

12- Attachment of vocal ligament

a- Anteriorly:- Dorsum of thyroid angle
b- Posteriorly:- Vocal process of arytenoid C.

13- Conus elasticus = Either

a- Cricothyroid ligamentous complex
b- Anterior part of cricothyroid ligamentous complex

58
 Pterygo-palatine ganglion
Site:- Pterygo-palatine fossa below maxillary N.
Roots:-
1- Parasympathetic R.:- From nerve of pterygoid canal
- Preganglionic fibers arise from lacrimal nucleus in pons → Pass through
facial nerve → geniculate ganglion → Greater petrosal N. → Vidian N. → Relay
on pterygopalatine ganglion → Postganglionic secretory fibers to lacrimal gland
2- Sympathetic R.:- From nerve of pterygoid canal
- Postganglionic fibers arise from superior cervical ganglion → Plexus around
I.C.A. → Deep petrosal N. → Vidian N. → Pass through pterygopalatine
ganglion without relay → Distributed through orbital, nasal, palatine &
pharyngeal branches of the ganglion
3- Sensory root:- From maxillary N.
- Ganglionic branches of maxillary N. → Pass through the ganglion without relay

Branches:-
1- Orbital branches:- Enter the orbit through inferior orbital fissure
2- Naso-palatine N. = Long spheno-palatine N.:- Enters the nasal cavity through
spheno-palatine foramen → Enters the mouth through incisive canal → Supplies palate
around the upper incisors & canine and part of nasal septum & lateral wall of nose
3- Greater palatine N.:- Passes in greater palatine canal → Supplies gum & palate
4- Lesser palatine N.:- Passes through lesser palatine canal →
a- Supplies uvula, tonsil & soft palate
b- Carries taste from soft palate
5- Nasal branches:- Enter the nose through spheno-palatine foramen
6- Pharyngeal branch:- Passes through palato-vaginal canal → Supplies nasopharynx

N.B.
1- Spheno-palatine ganglion = Pterygo-palatine ganglion
2- Vidian nerve = Nerve of pterygoid canal
3- Naso-palatine N. communicates with naso-palatine N. of the opposite side & with
greater palatine N.
4- Palato-vaginal canal
a- Synonymous to pharyngeal canal
b- Between sphenoid & palatine bones
c- Connects nasopharynx with pterygo-palatine fossa

59
 Ear
External auditory meatus
Length:- One inch
Parts & direction:-
A- Lateral 1/3:-
- Cartilaginous
- Directed upwards, backwards & medially
B- Medial 2/3:-
- Bony
- Directed downwards, forwards & medially
Constrictions:-
1- At the junction between cartilaginous & bony parts
2- Isthmus; 5 mm from T.M.
Nerve supply:-
1- Auriculotemporal N.
2- Auricular branch of vagus N.

Tympanic membrane
Shape:- Circular
Diameter:- One cm
Nerve supply:-
A- Outer surface:- By
1- Auriculotemporal N.
2- Auricular branch of vagus N.
B- Inner surface:- By tympanic branch of glossopharyngeal N.
Layers:-
1- Outer layer = Skin
2- Middle layer = Fibrous tissue. Absent in pars flaccida
3- Inner layer = Mucous membrane
Parts:-
1- Pars flaccida:-
- Small upper part
- Consists of 2 layers only; skin & mucous membrane
- Bounded by anterior & posterior malleolar folds
2- Pars tensa
61
 Boundaries of middle ear
A- Roof:- Tegmen tympani that separates M.E. from middle cranial fossa
B- Floor:- Bone plate separating M.E. from superior bulb of I.J.V.
C- Anterior wall = Carotid wall:-
1- Upper part:- Opening for tensor tympani
2- Middle part:- Opening of auditory tube
3- Lower part:- Bony plate separating M.E. from carotid canal
D- Posterior wall:-
1- Upper part:- Aditus to mastoid antrum
2- Lower part:- Pyramid
E- Lateral wall:-
1- Upper part:- Squamous part of temporal bone
2- Lower part:- T.M.
F- Medial wall:- Formed by the lateral wall of inner ear and shows
1- Promontory = bulge formed by 1st turn of cochlea
2- Oval window = Fenestra vestibuli:- above and behind the promontory
3- Rounded opening = Fenestra cochleae:- below and behind promontory
4- Horizontal part of facial canal

Communications of M.E.
A- Anteriorly:- With naso-pharynx through eustachian tube
B- Posteriorly:- With mastoid air cells through mastoid antrum

Contents of middle ear

A- Air
B- Ossicles:- 1- Malleus 2- Incus 3- Stapes
C- Muscles:- 1- Tensor tympani 2- Stapedius
D- Nerves:- 1- Nerve to stapedius 2- Chorda tympani

61
 Muscles of M.E.
Tensor tympani Stapedius

Origin 1- Wall of auditory tube Pyramid

2- Its own canal

Insertion Handle of malleus Neck of stapes

N.S. Mandibular N. Facial N.

Action 1- Pulls the handle of malleus 1- Pulls the neck of stapes during
→ Tenses T.M. → Dampens loud sounds → Dampens down the
down the vibrations of T.M. vibrations of stapes →
→

2- Protect the inner ear from loud sounds

Parts of inner ear

A- Parts of bony labyrinth:- from anterior to posterior
1- Cochlea
2- Vestibule
3- Semicircular canals
B- Parts of membranous labyrinth:-
1- Cochlear duct = inside the cochlea
2- Utricle and saccule = inside the vestibule
3- Semicircular ducts = inside the semicircular canals

Vestibulo-cochlear nerve
A- Vestibular N.:-
- Related to vestibular ganglion
- Supplies utricle, saccule & ampullae of semicircular ducts
B- Cochlear N.:-
- Related to spiral ganglion inside the modiolus
- Supplies the organ of Corti
62
 Eustachian tube
Length:- 36 mm
Function:-
1- Equalizes air pressure on both sides of T.M.
2- Connects the M.E. with nasopharynx
Parts:-
1- Lateral 1/3 is bony
2- Medial 2/3 are cartilaginous
Isthmus (Narrowest part):- Between bony & cartilaginous parts

Mastoid antrum
Site:- In petrous part of temporal bone
Communications:-
A- Anteriorly:- With epitympanic recess
B- Postero-inferiorly:- With mastoid air cells

Relations:-
Anteriorly:- Communicates with M.E. through the aditus of antrum
Posteriorly:-
1- Sigmoid sinus
2- Cerebellum
Lateral wall:- Floor of suprameatal triangle
Medial wall:- Posterior semicircular canal
Superior wall:- Tegmen tympani separates the M.E. from
1- Meninges of middle cranial fossa
2- Temporal lobe of brain
Inferior wall:- Communicates with mastoid air cells

63
N.B
1- Parts of external ear:-
a- Auricle
b- External auditory meatus
c- T.M.
2- T.M. is convex towards the middle ear & concave towards E.A.M.
3- Umbo = Point of deepest concavity of T.M.
4- Umbo is produced by the tip of handle of malleus
5- T.M. is extremely sensitive to pain
6- T.M. is fixed in the tympanic sulcus
7- Tympanic sulcus is deficient superiorly
8- Myringotomy incision is done in antero-inferior or postero-inferior quadrants for 2 reasons
a- because the lower ½ is less vascular than the upper ½
b- to avoid injury of chorda tympani N. & auditory ossicles
9- Parts of tympanic cavity:-
a- Tympanic cavity proper = Opposite T.M.
b- Epitympanic recess = Above the level of T.M.
10- Oval window is closed by the base of stapes
11- Round window is closed by 2ry T.M.
12- Auditory tube = Eustachian tube = Pharyngo-tympanic tube
13- Mastoid air cells:-
a- Inside mastoid process
b- Lined with mucous membrane
14- Middle ear, inner ear & mastoid antrum lie in petrous part of temporal bone
15- Endolymph:- Inside membranous labyrinth
16- Perilymph:- Outside membranous labyrinth = Inside bony labyrinth
17- The sensory organ inside the cochlear duct is the organ of Corti
18- Cochlea:- Consists of 2.5 turns around the modiolus
19- Semicircular canals:-
a- Number:- 3 (superior, posterior and lateral)
b- Ampullae of S.C.Cs.:- Each semicircular canal has one dilated end

64
 Lymph nodes of head & neck
I- Regional groups
A- Superficial groups:-
1- Occipital
2- Retro-auricular = Mastoid
3- Parotid
4- Buccal
5- Submandibular
6- Submental
7- Anterior cervical
8- Superficial cervical
B- Deep groups
1- Retro-pharyngeal
2- Lingual
3- Laryngeal
4- Tracheal
II- Terminal = Deep cervical L.Ns.
- Along I.J.V.
- Receive afferents from superficial & deep regional L.Ns.
- Their efferent lymphatics collect to form jugular lymph trunk →
a- Right jugular lymph trunk → Drains into right lymphatic duct
b- Left jugular lymph trunk → Drains into thoracic duct
- Divided by inferior belly of omohyoid into upper & lower D.C.L.Ns.
A- U.D.C.L.Ns.:-
- Along the upper part of I.J.V.
- Include jugulo-digastric L.N. (Lies in the angle between I.J.V. & posterior belly
of digastric)
B- L.D.C.L.Ns.:-
- Along the lower part of I.J.V.
- Include jugulo-omohyoid L.N. (Lies along the intermediate tendon of omohyoid)
N.B. Collectively:- Lymph drainage of head & neck = The tissues are drained by
the regional L.Ns. → Deep cervical L.Ns. → Jugular lymph trunk →
a- right jugular lymph trunk → Drains into right lymphatic duct
b- left jugular lymph trunk → Drains into thoracic duct

65
 Temporal fossa
Boundaries:-
A- Superiorly:- Superior and inferior temporal lines
B- Inferiorly:- Zygomatic arch
C- Anteriorly:-
1- Zygomatic bone
2- Zygomatic processes of frontal bone & maxilla
D- Roof:- Temporal fascia.
E- Floor:- The Part of the skull that includes the pterion

Contents:-
1- Temporalis muscle
2- Deep temporal vessels
3- Deep temporal nerves
4- Superficial temporal A.
5- Auriculo-temporal nerve

Infratemporal fossa
Boundaries:-
A- Medially:- By
1- Tensor palati
2- Levator palati
3- Superior constrictor of pharynx
4- Lateral pterygoid plate
5- Pterygo-maxillary fissure
B- Laterally:-
1- Ramus of mandible
2- Coronoid process of mandible
C- Anteriorly:- Back of maxilla
D- Posteriorly:- Styloid process
E- Superiorly = The roof:- By
1- Infratemporal surface of greater wing of sphenoid
2- Infra-temporal crest of greater wing of sphenoid
3- Squamous part of temporal bone
4- Space deep to zygomatic arch

66
Contents:-
1- Medial & lateral pterygoid muscles
2- Insertion of temporalis
3- Maxillary A. & its branches
4- Mandibular N. & its branches
5- Pterygoid plexus of veins
6- Otic ganglion
7- Chorda tympani
8- Posterior superior alveolar branches of maxillary N.

Communications:-
1- With temporal fossa through the space deep to zygomatic arch
2- With the orbit through the inferior orbital fissure
3- With the middle cranial fossa through foramen ovale and spinosum
4- With the pterygo-palatine fossa through the pterygo-maxillary fissure.

N.B.:-
1- The infratemporal surface of greater wing of sphenoid is bound laterally by the
infratemporal crest
2- The superior and inferior temporal lines extend from the frontal process of zygomatic bone to the supramastoid crest of temporal bone

Muscles of mastication
1- Temporalis
2- Lateral pterygoid
3- Medial pterygoid
4- Masseter
Temporalis
Origin:-
1- Floor of temporal fossa
2- Deep surface of fascia covering temporalis
Insertion:-
1- Coronoid process of mandible
2- Anterior border of ramus of mandible down to retromolar fossa
Action:-
1- Anterior & Superior fibers:- Elevation of mandible
2- Posterior fibers:- Retraction of mandible
Nerve supply:- Deep temporal nerves that are branches of mandibular N.

67
 Masseter
Origin:-
1- Lower border and inner surface of zygomatic arch
2- Zygomatic process of maxilla
Insertion:- Lateral surface of ramus of mandible
Action:-
1- Elevation of mandible:- By deep fibers
2- Protraction of mandible:- By superficial fibers
3- Clenches the teeth
Nerve supply:- Mandibular nerve

Lateral pterygoid
Origin:-
1- Upper head = from the infratemporal crest and infratemporal surface of greater wing
of sphenoid
2- Lower head = from the lateral surface of lateral pterygoid plate
Insertion:-
1- Front of the neck of the mandible (pterygoid fovea)
2- Capsule of temporo-mandibular joint
3- Articular disc of temporo-mandibular joint
Action:-
1- Depression & protraction of the mandible = Pulls the neck of the mandible forward
during opening the mouth
2- With the medial pterygoid on both sides → protrusion of the mandible → opening of
the mouth
3- With the medial pterygoid on one side → rotation of the mandible to the opposite side =
side to side movement of the mandible = chewing movement
Nerve supply:- Mandibular N.

Medial pterygoid
Origin:-
1- Superficial head:- from tuberosity of maxilla
2- Deep head:- from medial surface of lateral pterygoid plate
Insertion:- Medial surface of ramus & angle of mandible
Action:-
1- Elevation of the mandible
2- Protraction of mandible
3- Side to side movement of the mandible = chewing movement
Nerve supply:- Mandibular N.

68
N.B.
Temporalis tendon descends deep to zygomatic arch -c
2- Direction of the fibers of temporalis:-
a- Anterior fibers are vertical
b- Posterior fibers are horizontal
c- Middle fibers are oblique

3- All muscles of mastication close the mouth except lateral pterygoid (Opens it)
4- All muscles of mastication protract mandible except temporalis (Retracts it)
5- Temporal fascia:-
a- Means fascia covering temporalis
b- Perforated by middle temporal vessels
c- Superficial temporal vessels & auriculotemporal N. run on it and don not pierce it
d- Attached to
1- Superiorly:- To superior temporal line
2- Inferiorly:- To zygomatic arch

Temporomandibular joint
Type:- Synovial. With articular disc dividing the joint into 2 cavities
Articular parts:-
1- Head of the mandible
2- Articular tubercle & anterior part of mandibular fossa of temporal bone
Capsule attachment:- to
1- Articular tubercle & margins of mandibular fossa
2- Neck of mandible
Nerve supply:-
1- Auriculo-temporal N.
2- Masseteric N. from mandibular N.
Ligaments:-
1- Lateral temporo-mandibular ligament:- Attached to
a- Tubercle of the root of zygoma
b- Lateral aspect of neck of mandible
2- Spheno-mandibular ligament:- Attached to
a- Spine of sphenoid
b- Lingula of mandibular foramen
3- Stylomandibular ligament:- Attached to
a- Apex of styloid process
b- Angle of mandible

69
Movements:-
A- Protraction:- By
1- Medial pterygoid
2- Lateral pterygoid
3- Masseter
B- Retraction:- By Posterior fibers of temporalis
C- Side to side movement = Chewing:- By
1- Temporalis
2- Pterygoids of opposite side
D- Elevation:- By
1- Medial pterygoid
2- Temporalis
3- Masseter
E- Depression:- By
1- Lateral pterygoid
2- Digastric
3- Infra-hyoid muscles

Relations:-
A- Anteriorly:-
1- Mandibular notch
2- Masseteric N.
3- Masseteric A.
B- Posteriorly:-
1- Tympanic plate of E.A.M.
2- Glenoid process of parotid gland
C- Laterally:-
1- Skin & fascia
2- Parotid gland
D- Medially:-
1- Maxillary vessels
2- Auriculo-temporal N.
N.B.
1- Condyloid process of mandible = Head of mandible
2- Articular disc of temporomandibular joint:-
a- Moves with protraction & retraction of mandible
b- Has concavoconvex upper surface
c- Has concave lower surface
3- Lateral temporo-mandibular ligament:-
a- Runs downward & backward → Limits backward movement of mandible → Protects the
E.A.M.
4- Spheno-mandibular ligament is a remain of 1st pharyngeal arch

71
 Mylohyoid
Origin:- Mylohyoid line of the mandible
Insertion:-
1- Anterior fibers:- Into the mylohyoid raphe
2- Posterior fibers:- Into the body of hyoid bone.
Action:-
1- Depression of mandible = opening of the mouth
2- Elevates H.B. and floor of mouth during 1st stage of swallowing
Nerve supply:- Mylohyoid nerve that is a branch from inferior alveolar N.

Relations of mylohyoid
A- Superficial relations:-
1- Superficial part of submandibular gland
2- Anterior belly of digastric
3- Mylohyoid N.
4- Mylohyoid A.
5- Submental L.Ns.
6- Skin
7- Superficial fascia containing platysma
8- Mandibular division of facial N.
B- Deep relations:-
1- Muscles:-
a- Geniohyoid
b- Genioglossus
c- Hyoglossus
2- Nerves:-
a- Lingual N.
b- Hypoglossal N.
3- Vessels:- Sublingual vessels
4- Salivary glands:-
a- Sublingual salivary gland
b- Deep part of submandibular gland
c- Sublingual & submandibular ducts

71
 Geniohyoid
Origin:- From inferior mental spine
Insertion:- Into body of hyoid bone
Action:-
1- Elevation of H.B. upward & forward
2- Depression of mandible
Nerve supply:- First cervical nerve through hypoglossal N.

Stylohyoid
Origin:- Back of styloid process
Insertion:- Junction between body & greater cornu of H.B.
Action:- Elevation of H.B.
N.S.:- Facial N.

Digastric
Origin:-
1- Anterior belly:- from digastric fossa of mandible
2- Posterior belly:- from mastoid notch on the medial surface of mastoid process
Insertion:-
1- The 2 bellies are inserted into the intermediate tendon
2- The intermediate tendon is connected to the junction between body and greater
cornu of H.B. by a loop of deep fascia.
Action:-
1- Depression of mandible
2- Elevation of H.B.
Nerve supply:-
1- Anterior belly:- By nerve to mylohyoid that is a branch of inferior
alveolar N. from mandibular N.
2- Posterior belly:- By facial N.

72
 Relations of anterior belly of digastric
A- Superficial relations:-
1- Skin
2- Superficial fascia containing platysma
2- Superficial part of submandibular gland
3- Submental L.Ns.

B- Deep relations:- Mylohyoid muscle.

Relations of posterior belly of digastric

A- Superficial relations:-
1- Skin
2- Superficial fascia containing platysma
3- Sternomastoid
4- Lower part of parotid
5- Common facial vein

B- Deep relations:-
1- Arteries:-
a- I.C.A
b- E.C.A.
c- facial A.
d- lingual A.
e- posterior auricular A. is deep to its upper border
f- occipital A. is deep to its lower border
2- Veins:- I.J.V.
3- Nerves:-
a- vagus
b- hypoglossal N.
c- accessory N.
4- Bones:-
a- Styloid process
b- Transverse process of atlas

73
 Scalene muscles
1- Scalenus anterior
2- Scalenus medius
3- Scalenus posterior

Anterior Medius Posterior

Origin 3rd – 6th cervical 2 – 7 cervical Lower 2 or 3 cervical

transverse processes transverse processes transverse processes
Insertion Scalene tubercle of 1st Upper surface of 1st Outer surface of 2nd rib
rib rib behind the groove
for subclavian A.
N.S. Anterior rami of 4th – 6th Anterior rami of Anterior rami of lower
cervical Ns. cervical Ns. cervical Ns.
Action 1- Elevation of 1st rib 1- Elevation of 2nd rib
2- Lateral flexion & rotation of neck 2- Lateral flexion &
rotation of neck

Relations of scalenus anterior

Anterior relations:-
1- Prevertebral fascia 5- I.J.V.
2- Phrenic N. 6- Subclavian V.
3- Superficial cervical A. 7- Sternomastoid
4- Suprascapular A. 8- Skin & fascia
Posterior relations:-
1- Subclavian A. (2nd part) 4- Cervical dome of pleura
2- Roots of brachial plexus 5- Suprapleural membrane
3- Scalenus medius
Medial relations:-
1- Vertebral vessels 4- Thoracic duct on the left side
2- Thyrocervical trunk 5- Sympathetic trunk
3- Inferior thyroid A.
Lateral relations:-
1- Roots of phrenic N. unite at the lateral border
2- Roots of brachial plexus & subclavian A. emerge from behind lateral border of scalenus
anterior → To enter posterior triangle

74
N.B.
1- Mylohyoid raphe is attached to symphysis menti & body of H.B.
2- Stylohyoid runs along upper border of posterior belly of digastric
3- Stylohyoid is pierced near its insertion by digastric tendon
4- Scalenus posterior may be absent
5- Prevertebral fascia binds phrenic N. to the anterior surface of scalenus anterior
6- Roots of phrenic N. unite
a- At the lateral border of scalenus anterior
b- At the level of cricoid cartilage

Otic ganglion
Site:-
- Just below foramen ovale = In the infratemporal fossa
- Between mandibular N. & tensor palati
Type:- Parasympathetic
Roots = Afferents:-
1- Parasympathetic preganglionic fibers:-
- From lesser petrosal N.
- Relay on otic ganglion
2- Sympathetic postganglionic fibers:-
- From plexus around middle meningeal A.
- Pass without relay
3- Motor:-
- Nerve to medial pterygoid
- Pass without relay
Branches = Efferents:-
1- Post-ganglionic secretomotor fibers:- Join auriculotemporal N. → To P.G.
2- Postganglionic sympathetic fibers:- Join auriculotemporal N. → To B.Vs. of P.G.
3- Nerves to tensor palati & tensor tympani

N.B.
1- Otic ganglion is related anatomically to mandibular N. but functionally related to
glossopharyngeal N.
2- Parasympathetic ganglia in head & neck:-
a- Otic c- Submandibular
b- Ciliary d- Pterygo-palatine

75
 Common carotid artery

Beginning:-
A- On the right side:- Behind the right sternoclavicular joint as one of the 2
terminal branches of brachiocephalic artery.
B- On the left side:- In the superior mediastinum of thorax as a branch from aortic
arch. → Enters the neck by passing behind left sterno-clavicular joint

End:- Opposite the upper border of thyroid cartilage (Intervertebral disc between
C3 & C4) by dividing into E.C.A. and I.C.A.

Course:-
1- Beginning:- …………..
2- Ascends in the carotid sheath with
a- I.J.V. lateral to it
b- Vagus nerve Posterolateral to it
3- End:- ……………

Relations:- Ascends in the carotid sheath with

a- I.J.V. lateral to it
b- Vagus nerve Posterolateral to it

Branches:-
1- E.C.A.
2- I.C.A.

76
 External carotid artery

A- Beginning:- At the level of upper border of thyroid cartilage

(Intervertebral disc between C3 & C4) as one of the 2 terminal divisions of
C.C.A.

B- End:- Inside parotid gland behind the neck of mandible by dividing into
1- superficial temporal A.
2- maxillary A.

C- Branches:-

1- From the anterior aspect:-

a- superior thyroid A.
b- lingual A.
c- facial A.

2- From posterior aspect:-

a- occipital A.
b- posterior auricular A.

3- From the deep (medial) surface:- ascending pharyngeal A.

4- Terminal divisions:-
a- Superficial temporal A.
b- maxillary A.

77
 Relations of E.C.A.

A- Anteriorly:-
1- Anterior border of sternomastoid:- Overlaps the beginning of E.C.A.
2- Skin
3- Superficial fascia
4- Cervical branch of facial N.
5- Transverse cutaneous N.
6- Investing layer of deep cervical fascia
7- Hypoglossal N.
8- Facial N. inside P.G.
9- Facial V.
10- Lingual V.
11- I.J.V.:- Lateral then posterior to E.C.A.
12- Posterior belly of digastric
13- Stylohyoid

B- Medially:-
1- Pharynx
2- I.C.A.
3- Styloid process

Structures crossing anterolateral to E.C.A.

A- 2 veins
1- Facial
2- Lingual
B- 2 nerves
1- Hypoglossal
2- Facial:- In parotid gland
C- 2 muscles
1- Posterior belly of digastric
2- Stylohyoid

78
 Superior thyroid artery
Course:-
- Arises from the anterior surface of E.C.A. near its origin → Descends
vertically (Superficial & parallel to external laryngeal N.) → Reaches the upper
pole of thyroid gland
- Accompanied by external laryngeal N.

Branches:-
1- Branch to sternomastoid
2- Infrahyoid A.
3- Cricothyroid A.
4- Superior laryngeal A.
5- Glandular branches

Lingual artery
Course:-
1- Begins as a branch from the anterior surface of E.C.A. just below the tip of
greater cornu of H.B.
2- Passes forward → Forms an upward loop → Passes forward deep to
hyoglossus → Turns upward to supply tip of tongue

Branches:-
1- Suprahyoid A.
2- Dorsal lingual branches:- 2 - 3 branches to the dorsal surface of the tongue
3- Sublingual A.:- To sublingual gland & adjacent structures
4- Lingual branches:- To the anterior part of the tongue

Lingual veins
1- Dorsal lingual Vs. unite to form lingual V.
2- Deep lingual V. unites with sublingual V. → Form a vein that accompanies
hypoglossal N.
3- All veins drain into I.J.V.
79
 Facial artery

Course:-
1- Begins from the anterior surface of E.C.A. just above the level of the tip of greater
cornu of H.B.
3- Passes deep to the posterior belly of digastric and stylohyoid muscles to reach the
digastric triangle
4- Ascends in the groove on the posterior border of submandibular gland deep to the mandible
5- Then descends between the medial surface of mandible and S.M.G.
6- Hooks around lower border of mandible at the anterior margin of masseter →
Enters the face → Ascends toward the angle of mouth → Ascends deep to zygomaticus
muscles → Ascends along the side of nose → Reaches the medial angle of eye → Ends
at the medial angle of eye by anastomosis with the terminal branches of ophthalmic A.

Branches:-
A- In the submandibular region:-
1- Ascending palatine
2- Tonsillar:- To palatine tonsil
3- Glandular branches to the submandibular gland
4- Submental artery:- To the chin & lower lip
B- In the face:-
1- Inferior labial A.
2- Superior labial A.
3- Lateral nasal A.
Site of feeling pulsation:- At the lower border of mandible at the anterior margin
of masseter while winding around the lower border of mandible

Facial vein
Begins at the medial angle of eye by the union of Supratrochlear & supra-orbital Vs. →
Form the anterior facial V. → Descends in the face behind facial A. → Crosses the lower
border of mandible → Joins the anterior division of retro-mandibular V. → Form the
common facial V. → Crosses the loop of lingual A. → Drains into I.J.V.

81
 Occipital artery
Course:-
Arises from the posterior surface of E.C.A. opposite facial A. → ascends upward and
backward along the lower border of posterior belly of digastric → Passes through the apex
of posterior triangle → Reaches the posterior part of scalp
Branches:-
1- Two branches to sterno-mastoid
2- Terminal branches:- supply the back of the scalp

Posterior auricular artery

Course:-
Arises from the posterior surface of E.C.A. at the level of upper border of posterior belly
of digastric → Ascends upward and backward along the upper border of posterior belly of
digastric deep to P.G. → Reaches the groove between the auricle & back of scalp
Branches:-
1- Branches to the skin over mastoid process
2- Auricular branch:- To ear pinna
3- Stylo-mastoid branch:- Passes through stylo-mastoid foramen and supplies
- Facial N.
- Inner surface of T.M.
- Gives the stapedial A. to stapedius

Ascending pharyngeal A.
Course:- Arises from the deep surface of E.C.A. just above its beginning → Ascends
between I.C.A. & pharynx
Branches:-
1- Branches to pharynx
2- Branches to soft palate
3- Meningeal branches:- Pass through
a- Foramen lacerum
b- Jugular foramen
c- Hypoglossal canal

81
 Superficial temporal A.
Course:- Begins inside P.G. behind the neck of mandible as one of the 2 terminal
branches of E.C.A. → Emerges from the upper border of P.G. behind temporomandibular
joint → Crosses superficial to zygomatic arch in front of auriculotemporal N. → Ascends
to the scalp → Divides into anterior & posterior divisions
Branches:-
1- Transverse facial A.:- Passes just above parotid duct
2- Anterior auricular branches:- To the auricle, lobule & E.A.M.
3- Zygomatico-orbital A.:- To orbicularis oculi
4- Middle temporal A.:- Ascends deep to temporalis
5- Anterior branch:- Supplies the frontal part of scalp
6- Posterior branch:- Supplies the parietal part of scalp

Site of feeling pulsation:- While crossing superficial to the root zygomatic arch in
front of the auricle

Maxillary artery
Course:- Begins inside P.G. behind the neck of mandible as one of the 2 terminal
branches of external carotid artery → Passes forwards & winds around deep to the neck of
mandible → Reaches the infratemporal fossa → Passes along the lower border of lateral
pterygoid → Ascends upwards and forwards superficial or deep to the lower head of
lateral pterygoid → Leaves the infra-temporal fossa by passing through pterygomaxillary
fissure to reach the Pterygopalatine fossa → Ends by passing through spheno-palatine
foramen & continues as spheno-palatine A.

2- Divided by lateral pterygoid muscle into 3 parts:-

1- First part = Before the muscle
2- Second part = On the muscle
3- Third part = Beyond the muscle

82
 Branches of maxillary artery

From the 1st part:-

1- Inferior alveolar A.:- Enters the mandibular canal to supply the mandible & lower
gum and teeth. Gives mental branch to the chin & lower lip (skin & muscles)
2- Middle meningeal A.:- Reaches the cranial cavity by passing through foramen
spinosum → Supplies skull bones
3- Accessory meningeal A.:- Reaches the cranial cavity by passing through foramen
ovale → Supplies the dura of middle cranial fossa & trigeminal (Meckel’s) cave
4- Deep auricular A.:- To the E.A.M.
5- Anterior tympanic A.:- Passes through petro-tympanic fissure → To tympanic cavity
→ Shares in circular anastomosis around T.M.

From 2nd part:- muscular branches

1- Muscular branches:- To pterygoids & masseter
2- Deep temporal branches:- 2 arteries supplying temporalis
3- Buccal artery:- Accompanies buccal N.

From 3rd part:-

1- Posterior superior alveolar A.:- supplies the upper molars and maxillary sinus
2- Greater palatine A.:- Passes through greater palatine canal → supplies the palate
3- Pharyngeal A.:- passes through palato-vaginal canal
4- Artery of pterygoid canal
5- Infra-orbital A.:- passes through the inferior orbital fissure → Through infra-orbital
groove → Through infraorbital canal → Through infraorbital foramen → Reaches the face
6- Sphenopalatine A.:- Passes through sphenopalatine foramen → Enters the posterior
part of superior meatus → Gives posterior lateral nasal branches → Ends by dividing into
posterior septal branches → Anastomose with branches of greater palatine A.

83
 Middle meningeal artery
Course:-
Begins in the infratemporal fossa as a branch from the 1 st part of maxillary A. →
Enters the cranial cavity by passing through foramen spinosum → Passes between
the 2 layers of dura in a groove on the greater wing of sphenoid & squamous part of
temporal bone → Divides into anterior and posterior divisions →
A- Anterior division:- Grooves the parietal bone → Ascends towards the
pterion → Ascends towards the vertex over the precentral gyrus
B- Posterior division:-
- Grooves the squamous part of temporal bone
- Lies over the superior temporal gyrus (Contains the auditory area)

Branches:-
1- Ganglionic branches:- To semilunar ganglion & dura mater
2- Superficial petrosal branch:-
- Enters facial canal → Supplies facial N.
- Anastomoses with the stylomastoid branch of posterior auricular A.
3- Superior tympanic A.:-
- Runs in canal of tensor tympani
- Supplies tensor tympani & the lining of its canal
4- Orbital branches:- Anastomose with lacrimal or other branches of ophthalmic A.
5-Temporal branches:- Reach the temporal fossa → Anastomose with deep temporal As.

Surface anatomy:-
A- Frontal division:-
1- Related to the pterion:-
- 3 cm above the midpoint of zygomatic arch
- 3.5 cm behind & 1.2 cm above the frontozygomatic suture
2- At foramen spinosum:- Just above the articular eminence at the posterior root of
zygomatic arch

B- Posterior division:- Runs backwards parallel to upper border of zygomatic arch

& supramastoid crest

Maxillary vein
- Drains the posterior end of pterygoid plexus → Passes backwards deep to neck of mandible →
Enters P.G. → Unites with superficial temporal V. to form the retromandibular V.
84
 Pterygoid venous plexus
Site:- Surrounds lateral pterygoid muscle
Tributaries:- …… … … … … … …. …….
Drainage:- Its posterior end is drained by maxillary V.
Communications:-
1- With anterior facial vein:- Through deep facial vein
2- With cavernous sinus:- Through emissary veins passing through foramen oval
3- With inferior ophthalmic V. through inferior orbital fissure
4- With pharyngeal plexus of veins

N.B.
1- Site of feeling pulsations of E.C.A.:- At its beginning inside carotid triangle
2- Relations of E.C.A. to I.C.A.:- E.C.A. lies medial then postero-lateral to I.C.A.
3- Carotid sinus = Dilatation at the end of C.C.A. & beginning of I.C.A.
4- Carotid body lies posterior to the bifurcation of C.C.A.
5- Carotid sinus & body are supplied by glossopharyngeal N.
6- Carotid sinus contain pressoreceptors
7- Carotid body contains chemoreceptors
8- Thyrohyoid membrane is pierced by:-
a- Superior laryngeal vessels b- Internal laryngeal N.
9- The loop of lingual A. is crossed by hypoglossal N. & common facial V.
10- Suprahyoid A. runs along upper border of H.B.
11- Facial A. has a tortuous course
12- Tonsillar A. pierces the superior constrictor of pharynx
13- The terminal part of occipital A. accompanies the branches of greater occipital N.

14- Middle temporal A. grooves the squamous part of temporal bone

15- Maxillary A. is the larger terminal branch of E.C.A.
16- All branches of 1st & 3rd parts of maxillary A. pass through bony foramina
17- Accessory meningeal A. is the main arterial supply for trigeminal ganglion
19- Naso-palatine A. = Spheno-palatine A.
20- Hemorrhage from the anterior division of M.M.A. compresses the precentral gyrus →
Compresses motor area
21- Hemorrhage from the posterior division of M.M.A. compresses the auditory area →
Contralateral deafness
22- Diploic veins:-
- In the diploe of skull
- They are frontal, anterior temporal, posterior temporal & occipital
- Communicate with meningeal Vs., dural sinuses & pericranial Vs.
23- Posterior division of retromandibular V. unites with posterior auricular V. just below P.G. → Form
E.J.V. → Drains into subclavian V.

85
 I.C.A.

Course:-
A- Cervical part:-
- Beginning at the level of upper border of thyroid cartilage (Intervertebral disc between
3rd & 4th cervical vertebra) as one of the 2 terminal branches of C.C.A.
- Ascends in carotid sheath
- Ends at lower end of carotid canal by continuation as the petrous part

B- Petrous part:-
- Passes anteromedially inside carotid canal → Reaches the upper foramen lacerum →
Passes upward → Pierces the dura → Enter the cranial cavity
- Surrounded by
1- Venous plexus
2- Carotid autonomic plexus:- Derived from internal carotid branch of superior cervical
ganglion

C- Cavernous part:-
- Passes anteromedially inside cavernous sinus → Passes upward → Pierces the roof of
cavernous sinus medial to the anterior clinoid process → Continues as the cerebral part
- Surrounded by the cavernous plexus that is a sympathetic plexus derived from internal
carotid branch of superior cervical ganglion

D- Cerebral part:-
- Passes backward above the roof of cavernous sinus → Turns upwards → Pierces
arachnoid mater → Enters the interpeduncular fossa → Ends by dividing into anterior &
middle cerebral arteries

86
Branches:-
A- Cervical part:- No branches
B- Petrous part:- Gives 2 branches
a- Pterygoid A. → To pterygoid canal
b- Carotico-tympanic → To tympanic cavity
C- Cavernous part:- Gives 3 branches
1- Hypophyseal (Superior & inferior):- To pituitary gland
2- Meningeal:- To dura of anterior cranial fossa
3- Cavernous:- To trigeminal ganglion, walls of cavernous sinus & walls of inferior
petrosal sinus
D- Cerebral part:- Gives 5 branches
a- Ophthalmic
b- Anterior choroidal
c- Posterior communicating
d- Anterior cerebral
e- Middle cerebral

Relations of the 1st part of I.C.A.

Anterolaterally:-
A- Below digastric:-
1- Skin, superficial fascia & investing layer of deep fascia
2- Platysma & transverse cutaneous N. in superficial fascia
3- Anterior border of sternomastoid
4- Lingual V. 6- Occipital A.
5- Facial V. 7- Hypoglossal N. & its descending branch
B- Above digastric:-
1- Posterior auricular A. 5- Glossopharyngeal N.
2- Styloid process 6- Pharyngeal branch of vagus
3- Stylohyoid muscle 7- P.G. & its contents that are ………..
4- Stylopharyngeus muscle
Posteriorly:-
1- Superior laryngeal N. 3- Cervical part of sympathetic trunk
2- Longus capitis muscle 4- Upper 3 cervical transverse processes
Medially:-
1- Superior laryngeal N. 2- Pharynx
Laterally:-
1- I.J.V. 2- Vagus

87
 Structures between I.C.A. & E.C.A.
1- Styloid process
2- Stylopharyngeus muscle
3- Glossopharyngeal N.
4- Pharyngeal branch of vagus
5- Deep part of P.G.
6- Styloglossus (??????????)

Sites of anastomosis between I.C.A. & E.C.A.

1- In the scalp:- Between
a- Supra-orbital & supra-trochlear As. (From I.C.A.)
b- Superficial temporal A. (From E.C.A.)
2- In the face:- Between
a- Dorsal nasal A. (I.C.A.)
b- Angular A. = Terminal part of facial A. (E.C.A.)
3- In nasal septum:- Between
a- Anterior & posterior ethmoidal As. (I.C.A.)
b- Greater palatine A. (E.C.A.)
4- Between
a- Zygomatico-temporal A.:- From lacrimal branch of ophthalmic A. (I.C.A.)
b- Deep temporal A. (E.C.A.)
5- Between
a- Zygomatico-facial A.:- From lacrimal branch of ophthalmic A. (I.C.A.)
b- Transverse facial A. (E.C.A.)
c- Zygomatico-orbital A.:- From superficial temporal A. (E.C.A.)
6- Between
a- Recurrent meningeal A.:- From lacrimal branch of ophthalmic A. (I.C.A.)
b- M.M.A. (E.C.A.)

7- Between
a- Carotico-tympanic A. (I.C.A.)
b- Anterior tympanic A.:- From maxillary A. (E.C.A.)
c- Posterior tympanic A:- From stylomastoid A. that is a branch of posterior
auricular A. (E.C.A.)

88
 Ophthalmic artery
Course:- Begins as the 1st branch of the 4th part of I.C.A. → Passes through
optic canal inferolateral to optic N. → Then above optic N. → Reaches the medial
wall of orbit
Branches:-
1- Central artery of the retina
2- Ciliary As.
- Anterior & Posterior
- Supply choroid, iris & sclera
3- Lacrimal A.:- Supplies lacrimal gland, conjunctiva & eyelids
4- Supra-orbital & supra-trochlear As.:- To skin of forehead
5- Anterior ethmoidal A.:- Passes through anterior ethmoidal foramen to supply
a- Anterior & middle ethmoidal cells
b- Frontal sinus
c- Nasal cavity
d- Skin of dorsum of nose
6- Posterior ethmoidal A.:- Passes through posterior ethmoidal foramen → Supplies
posterior ethmoidal sinus
7- Medial palpebral A.:- To eyelids
8- Dorsal nasal A.
9- Muscular As.:- To the extra-ocular muscles

Ophthalmic Vs.
1- Superior & inferior ophthalmic Vs.
2- Pass through superior orbital fissure → Into cavernous sinus
3- Superior ophthalmic V. communicates with facial V.
4- Inferior ophthalmic V. communicates with pterygoid venous plexus through inferior
orbital fissure

N.B.
1- Carotid canal is inside the petrous part of temporal bone
2- Ophthalmic A. is the 1st branch of the 4th part of I.C.A.
3- Optic N, is crossed by
a- Ophthalmic A.
b- Nasociliary N.
4- Central A. of the retina pierces the optic N. → Enters the eye ball at the center of optic disc
5- Lacrimal A. runs above lateral rectus
6- Intra-cranial part of I.C.A. = The petrous, cavernous & cerebral parts

89
 Subclavian artery
Course:-
1- Beginning:-
A- On the right side:- At the root of neck behind the right sternoclavicular joint as one of
the 2 terminal branches of brachiocephalic A.
B- On the left side:- In the superior mediastinum of thorax as a branch of aortic
arch. → Enters the neck by passing behind left sterno-clavicular joint
2- Passes supero-laterally behind scalenus anterior muscle
3- End:- At the outer border of 1st rib by continuation as axillary A.

Parts:-
1- First part:- From the origin to the medial border of scalenus anterior
2- Second part:- Behind scalenus anterior
3- Third part:- From the lateral border of scalenus anterior to the outer border
of 1st rib

Branches:-
A- From the 1st part:-
1- Vertebral A.
2- Internal thoracic A. = Internal mammary A.
3- Thyrocervical trunk
B- From the 2nd part:- Costocervical trunk
C- 3rd part:- Dorsal scapular A..

N.B.:- In some cases there are no superficial cervical nor dorsal scapular As.,
in these cases there is transverse cervical A. arising from 2nd part of S.C.A. →
Divides into
1- Superficial branch = Superficial cervical
2- Deep branch = Dorsal scapular A.

91
 Relations of subclavian artery
1- 1st part
A- Anteriorly:-
1- C.C.A.
2- Ansa subclavia
3- Vagus N. & its cardiac branches
4- I.J.V.
5- Vertebral V.
6- Three muscles:-
a- sternomastoid b- sternohyoid c- sternothyroid
7- Skin & fascia
8- Left phrenic N.:- In front of 1st part of left S.C.A.
B- Postero-inferiorly:-
1- Lung apex
2- Dome of cervical pleura
3- Ansa subclavia
4- Right R.L.N.:- Behind the 1st part of right subclavian A.
N.B.:- L.R.L.N. hooks around aortic arch → Then ascends medial to left S.C.A.
2- 2nd part
A- Anteriorly:-
1- Scalenus anterior
2- Sternomastoid
3- Skin & fascia
4- Right phrenic N.:- In front of 2nd part of right S.C.A.

B- Postero- inferiorly:-
1- Lung apex
2- Dome of cervical pleura
3- Supra-pleural membrane.

3- 3rd part
A- Anteriorly:-
1- Skin & fascia 4- Subclavian V.
2- Clavicle 5- E.J.V.
3- Subclavius muscle. 6- Supraclavicular N.
B- Postero-inferiorly:-
1- Lower trunk of brachial plexus.
2- Scalenus medius

91
 Vertebral artery

Course:-
1- Beginning:- In the neck as a branch from the 1st part of S.C.A.

2- Parts:-
a- First part = cervical part:-
- Ascends between longus colli & scalenus anterior
- Passes in front of 7th cervical transverse process
b- 2nd part = Vertebral part:- Ascends in the foramina of upper 6 cervical transverse
processes
c- 3rd part = Suboccipital part:- Curves on the upper surface of posterior arch of atlas
→ Pierces the posterior atlanto-occipital membrane → Pierces dura mater → Enters the
vertebral canal.
d- 4th part = Cranial part:- Ascends through foramen magnum → Enters the skull

3- Termination:- At the lower border of pons by joining its opposite fellow to

form basilar A.

Branches:-
A- In the neck:-
1- Spinal branches to the cervical part of spinal cord
2- Muscular branches

B- Cranial branches:-
1- Meningeal As.
2- Medullary As.
3- Anterior spinal A.
4- Posterior spinal A.
5- Posterior inferior cerebellar A.

92
 Relations of vertebral artery
A- Anteriorly:-
1- C.C.A. 3- Inferior thyroid A.
2- Vertebral V. 4- Thoracic duct
B- Posteriorly:-
1- 7th cervical transverse process
2- Cervicothoracic ganglion = Stellate ganglion
3- Anterior rami of cervical Ns.

Thyrocervical trunk
Beginning:- From the front of 1st part of subclavian A.
End and branches:- Ends at the medial border of scalenus anterior by dividing into 3
branches
1- Inferior thyroid artery
2- Suprascapular artery
3- Superficial cervical artery

Inferior thyroid A.
Course:- Originates from thyrocervical trunk → Ascends along the medial border of
scalenus anterior till the level of cricoid cartilage → Turns infero-medially behind vagus
& C.C.A. and in front of vertebral vessels & sympathetic trunk → Passes beside R.L.N. to
reach the posterior border of thyroid gland →
Branches:-
1- Muscular branches 5- Tracheal branches
2- Inferior laryngeal A. 6- Esophageal branches
3- Ascending cervical A. 7- Pharyngeal branches
4- Glandular branches:- To thyroid and parathyroid glands

Costocervical trunk
Beginning:- From the back of 2nd part of S.C.A.
Course:- Passes backwards above the pleura
End:- At the neck of the 1st rib by dividing into 2 branches
a- Superior intercostal A.:- to 1st & 2nd intercostal spaces
b- Deep cervical A.:- To the muscles of back of neck

N.B.
1- Inferior thyroid A. is closely related to R.L.N.
2- Suprascapular & dorsal scapular As. share in anastomosis around scapula

93
 Internal jugular vein
Course:-
1- Beginning:- At jugular foramen as a continuation of sigmoid sinus.
2- Descends in carotid sheath
3- End:- Behind the medial end of clavicle by uniting with subclavian vein to
form the brachiocephalic V.

Bulbs = dilatations:-
1- Superior bulb:- At the upper end = just below jugular foramen
2- Inferior bulb:- Near the lower end

Tributaries:-
1- Inferior petrosal sinus.
2- Pharyngeal plexus of Vs..
3- Common facial V.
4- Lingual V..
5- Superior thyroid V.
6- Middle thyroid V.
7- Occipital V.:- Occasionally drains into I.J.V.

N.B.
1- I.J.V. has a bicuspid valve just above its inferior bulb
2- Inferior petrosal sinus → Drains cavernous sinus → Passes through jugular foramen →
Drains into I.J.V. at the superior bulb or just below it
3- Pharyngeal plexus of Vs. → Drained by pharyngeal Vs. → Drain into either
a- Facial V.
b- Lingual V.
c- I.J.V.
4- Common facial V. is formed by the union of ……. & ….. → crosses the hypoglossal N.,
loop of lingual A., E.C.A. & I.C.A. → Joins I.J.V.
5- Lingual & superior thyroid Vs. drain into either facial V. or I.J.V.
6- Middle thyroid V. drains into I.J.V. at the level of cricoid cartilage

94
 Subclavian vein
Beginning:- At the outer border of the first rib as a continuation of the
axillary vein
End:- At the medial border of scalenus anterior by joining I.J.V. to form the
brachiocephalic V.
Tributaries:- E.J.V.

External jugular vein

Course:- Begins behind the angle of mandible by the union of posterior
auricular V. & posterior division of retromandibular V. → Descends superficial to
sternomastoid → Pierces the deep fascia just above the clavicle → Ends into S.C.V

Tributaries:-
1- Posterior auricular V.
2- Posterior division of retromandibular V.
3- Posterior external jugular V.
4- Anterior jugular V.
5- Supra-scapular V.
6- Transverse cervical V.

N.B.:-
1- E.J.V. descends parallel to spinal accessory N.
2- Posterior E.J.V. drains the posterior part of scalp & neck

Anterior jugular vein

Course:- Begins just below the chin in Submental triangle by the union of small Vs.
(Submental Vs.) → Descends in the neck close to midline → Just above suprasternal notch,
the 2 A.J.Vs. are interconnected by jugular arch → Passes laterally deep to sternomastoid →
Ends into E.J.V.

95
 N.B.
1- Superficial Vs. of the neck include
a- E.J.V. b- Posterior E.J.V. c- A.J.V.
2- Deep Vs. of the neck include:-
a- I.J.V. b- S.C.V.
3- Thoracic duct opens into the angle between left I.J.V. & S.C.V.
4- Level of C6
a- Junction between pharynx & esophagus
b- Junction between larynx & trachea
c- R.L.N. enters the larynx
d- C.C.A. can be compressed against C6 transverse process
e- 3 cm above thyroid isthmus
f- Inferior thyroid vessels. reach the posterior border of thyroid gland

Trachea
Length:- 10 cm (5 cm in the neck)
Beginning:- At the lower border of cricoid cartilage (Level of C6)
Termination:- In thorax at the level of sternal angle (I.V.D. between 4th & 5th thoracic
vertebrae) by dividing into right & left bronchi
Arterial supply:- Inferior thyroid As.
Venous drainage:- Inferior thyroid Vs.
Lymph drainage:- Pretracheal & paratracheal L.Ns.
Nerve supply:-
1- Vagi
2- R.L.Ns.
3- Sympathetic trunks

Relations:-
Anteriorly:-
1- Skin & fascia 5- Inferior thyroid Vs.
2- Sternothyroid & sternohyoid 6- Thyroidea ima A.
3- Thyroid isthmus 7- Jugular arch
4- Anastomosis between the 2 superior thyroid As.
Posteriorly:-
1- Right & left R.L.Ns. 2- Esophagus 3- Vertebral column
Laterally:-
1- Thyroid lobes 2- Carotid sheath

96
 Esophagus
Length:- 10 inches = 25 cm
Commencement:- At the lower border of cricoid cartilage (Level of C6)
Arterial supply:- Inferior thyroid As.
Venous drainage:- Inferior thyroid Vs.
Lymph drainage:- D.C. L.Ns.
Nerve supply:-
1- R.L.Ns.
2- Sympathetic trunks

Relations:-

Anteriorly:-
1- Trachea
2- R.L.Ns.

Posteriorly:-
1- Longus colli
2- Vertebral column
3- Prevertebral layer of deep fascia

Laterally:-
1- Thyroid lobe
2- Carotid sheath
3- Thoracic duct:- On the left side

N.B.
1- Commencement = Beginning
2- Commences = begins
3- Esophagus begins in midline then inclines to the left

97
 Thyroid gland
Parts:- 2 lobes and an isthmus in between

Arterial supply:-
1- Superior thyroid A.:- from external carotid A.
2- Inferior thyroid A.:- from thyrocervical trunk that is a branch of the 1st part
of subclavian A.
3- Thyroidea ima A.:-
- From either aortic arch or innominate A.
- Supplies the isthmus
- May be absent

Venous drainage:-
1- Superior thyroid Vs.:- Drains into I.J.Vs.
2- Middle thyroid Vs.:- Drains into I.J.Vs.
3- Inferior thyroid Vs.:-
- Drain the isthmus & lower part of the lobes
- Right & left inferior thyroid Vs. anastomose together
- Drains into left brachiocephalic vein.

Lymphatic drainage:-
1- Lymphatics from the upper pole → Accompany superior thyroid A. → Into the
anterosuperior group of D.C.L.Ns.
1- Lymphatics from the lower pole → Accompany inferior thyroid A. → Into postero-
inferior group of D.C.L.Ns.
3- Few lymphatics accompany Thyroidea ima A. → To pretracheal L.Ns.

Nerve supply:- Sympathetic vasoconstrictor fibers

1- Sympathetic fibers derived from middle cervical ganglion → Pass along inferior
thyroid A. → Reach the gland
2- Some sympathetic fibers derived from superior cervical ganglion → Pass along
superior thyroid A. → Reach the gland

98
 Relations of thyroid gland

A- Superficial (Lateral) surface:-

1- Sternomastoid
2- Sternohyoid
3- Sternothyroid
4- Superior belly of omohyoid
5- Skin & fascia

B- Medial surface:-
1- 2 tubes above
a- larynx b- pharynx
2- 2 tubes below
a- trachea b- esophagus
3- 2 muscles
a- cricothyroid
b- inferior constrictor of pharynx
4- 2 nerves
a- external laryngeal N. that supplies ………………… muscle
b- recurrent laryngeal N.

C- Posterior surface:- Overlaps carotid sheath containing

1- C.C.A.
2- I.J.V.
3- Vagus N.

D- Posterior border:-
1- Parathyroid glands (Superior & inferior)
2- Anastomosis between superior & inferior thyroid As.

E- Relations of the isthmus:-

1- Anteriorly:-
a- Sternothyroid
b- Sternohyoid
c- Anterior jugular V.
d- Skin & fascia
2- Posteriorly:-
a- 2nd, 3rd and 4th tracheal rings
b- Terminal branches of superior thyroid As. anastomose on the upper border

99
 Parathyroid glands
Site:-
- Related to the lower part of posterior border of thyroid gland
- Parathyroid glands lie within the fascial capsule of thyroid gland. But the inferior
occasionally lie outside the fibrous sheath
- Superior parathyroid G. is At the middle of posterior border of thyroid G.
Arterial supply:- Inferior thyroid As.
Venous drainage:- Inferior thyroid Vs.
Nerve supply:- Sympathetic vasoconstrictor fibers
N.B.
1- Sheath of thyroid gland
- Surrounds thyroid gland completely
- Derived from the pretracheal layer of deep fascia
- Attaches thyroid gland to larynx & trachea
2- Pyramidal lobe is on the upper border of isthmus. Usually to the left
3- Levator glandulae thyroidae
- Connects the pyramidal lobe to hyoid bon
- Fibrous band but may contain muscle fibers
4- External laryngeal N. accompanies the superior thyroid A.
5- Recurrent L.N. accompanies the inferior thyroid A.
6- The apex of thyroid lobe reaches the oblique line of thyroid cartilage
7- The base of thyroid lobe reaches the 6th tracheal ring
8- Thyroid isthmus is in front of 2nd, 3rd & 4th tracheal rings
9- Shape of thyroid lobe = Pear-shaped

Submandibular region
Site:- Between the mandible and hyoid bone
Contents:-
A- Muscles:-
1- Digastric 4- Geniohyoid
2- Mylohyoid 5- Genioglossus
3- Hyoglossus 6- Styloglossus
B- Salivary glands:- 1- Submandibular gland 2- Sublingual gland
C- Parasympathetic ganglion:- Submandibular ganglion
D- Lymph nodes:- Submandibular L.Ns.
E- Vessels:- 1- Facial A. 3- Lingual A.
2- * V. 4- * V.
F- Nerves:- 1- Lingual N. 2- Hypoglossal N. 3- Glossopharyngeal N.

111
 Submandibular gland
Parts:-
1- Superficial part:- Larger
2- Deep part

Position:-
A- Superficial part:-
- In digastric triangle
- Superiorly, extends deep to the body of mandible
- Anteriorly, extends to the anterior belly of digastric
- Posteriorly, separated from P.G. by stylomandibular ligament
B- Deep part:- Lies between
1- Infero-laterally:- Mylohyoid
2- Medially:- Hyoglossus & styloglossus
Capsules:- 2 capsules
1- C.T. capsule
2- Fibrous capsule
Course of submandibular duct:-
Emerges from the deep part of S.M.G. → Passes anteriorly beside the tongue (Deep to the
mucosa of the floor of mouth) → Crossed laterally by lingual N. → Passes between
genioglossus and sublingual gland → Opens in the floor of mouth on the summit of
sublingual papilla

Relations of the superficial part of S.M.G.

A- Infero-lateral surface:-
1- Skin 4- Facial V.
2- Investing layer of deep cervical fascia 5- Cervical branch of facial N.
3- Platysma 6- Submandibular L.Ns.
7- Superficial fascia

A- Lateral surface:-
1- Mandible (Submandibular fossa of mandible) 3- Facial A.
2- Medial pterygoid muscle
B- Medial surface:-
1- Anterior:- Mylohyoid (Separated from it by mylohyoid N. & vessels)
2- Intermediate:- Hyoglossus (Separated from it by lingual N., submandibular
ganglion & hypoglossal N.)
3- Posterior:-
a- Styloglossus b- Stylohyoid ligament c- Glossopharyngeal N.
111
 Relations of the deep part
A- Anteriorly:- Sublingual gland
B- Posteriorly:-
1- Stylohyoid 3- Stylomandibular ligament
2- Posterior belly of digastric 4- P.G.
E- Medially:-
1- Hyoglossus 2- Styloglossus
F- Laterally:-
1- Mylohyoid 2- Superficial part of S.M.G.
C- Superiorly:-
1- Lingual N.
2- Submandibular ganglion
3- Mucosa of the floor of mouth
D- Inferiorly:- Hypoglossal N.

Sublingual gland
Position:-
- Below the mucous membrane of the floor of mouth
- Near the midline

Ducts:-
- 8 – 20 in number
- Open on the summit of sublingual fold
- Few of them may open into the submandibular duct

Relations:-
A- Posteriorly:- Deep part of S.M.G.
B- Medially:-
1- Lingual nerve
2- Submandibular duct
3- Genioglossus muscle (separated from the gland by lingual N. and Submandibular duct)
C- Laterally:- Sublingual fossa of mandible
D- Superiorly:- Mucous membrane of the floor of mouth
E- Inferiorly:- Mylohyoid muscle

112
 Submandibular and sublingual glands
Arterial supply:-
1- Branches of facial A.
2- Branches of lingual A.
Venous drainage:- To
1- Facial V.
2- Lingual V.
Lymph drainage:-
1- Submandibular L.Ns.
2- D.C.L.Ns.

Nerve supply:-
A- Parasympathetic secretomotor:- Secretomotor fibers arise from
superior salivary nucleus in pons → Pass in facial N. → Pass in chorda
tympani branch → Join lingual N. in the infratemporal fossa → Leave lingual N. to relay
on submandibular ganglion → Postganglionic fibers reach submandibular
and sublingual salivary glands.
B- Postganglionic sympathetic:- The fibers arise from superior cervical
ganglion → Form plexus around E.C.A. → Plexus around facial & lingual As.
→ Reaches the glands
C- Sensory:- From lingual N.

N.B.
1- The 2 parts of submandibular gland are continuous together around the posterior border
of mylohyoid muscle
2- Length of submandibular duct = 5 cm
3- Wharton’s duct = Submandibular duct
4- Sublingual papilla lies beside the frenulum of the tongue
5- Sublingual fold is an elevation formed by sublingual gland
6- Submandibular & sublingual glands consist of mucous & serous acini
a- Submandibular G. is mainly serous
b- Sublingual G. is mainly …………..
7- The anterior end of the deep part of S.M.G. reaches the sublingual G.

113
 Submandibular ganglion
Type:- Parasympathetic
Site:-
1- On the lateral surface of hyoglossus
2- Below lingual N.
3- Above the deep part of S.M.G.

Roots = Afferent fibers:-

1- Preganglionic parasympathetic fibers:- The fibers arise from superior
salivary nucleus in pons → Pass in facial N. → Pass in chorda tympani
branch → Join lingual N. in the infratemporal fossa → Leave lingual N. to synapse in
submandibular ganglion
2- Sympathetic fibers:- The fibers arise from the cells of superior cervical
ganglion → Form plexus around E.C.A. → Plexus around facial → Reaches
the glands → Pass through the ganglion without relay
3- Sensory:- The fibers arise from trigeminal ganglion → Reach the ganglion
through lingual N.

Branches:-
1- Postganglionic secretomotor fibers:-
a- Most of fibers:- Pass directly to submandibular & sublingual glands
b- Few fibers:- Join lingual N. → To sublingual gland & small salivary glands of mouth
2- Postganglionic sympathetic fibers:- Vasomotor to submandibular & sublingual
glands
3- Sensory fibers:- To the mucous membrane of cheek
N.B.
1- Submandibular ganglion is
a- Anatomically:- Related to lingual N.
b- Functionally:- Related to facial N. (Chorda tympani branch of facial N.)
2- Submandibular ganglion is suspended to lingual N.

114
 Investing layer of deep cervical fascia

1- The most superficial deep fascial layer

2- Surrounds the structures of neck

3- Covers the anterior & posterior triangles

4- Continuous posteriorly with:-

a- Periosteum of last cervical spine
b- Ligamentum nuchae

5- Splits into superficial & deep layers to enclose

a- Trapezius
b- Sternomastoid
c- P.G.
d- S.M.G.

6- Just above the sternum → Splits around the anterior & posterior surfaces of
manubrium sterni → Forms the suprasternal space that contains the A.J.Vs.

7- Attachment:-
A- Superiorly:- Attached to
1- Superior nuchal line
2- Cervical spines
3- Ligamentum nuchae
4- Mastoid process
5- Zygomatic arch
6- Lower border of mandible
7- Hyoid bone

B- Inferiorly:- Attached to
1- Manubrium
2- Clavicle
3- Acromion

115
 Prevertebral layer of deep cervical fascia
1- Extends from the base of skull to the 3rd thoracic vertebra
= From skull base to T3
2- Below T3, it blends with the anterior longitudinal ligament of vertebral column
3- Covers the floor of posterior triangle
4- Retropharyngeal space = The space between pharynx & prevertebral fascia
5- Extends laterally → Forms the axillary sheath (Surrounds axillary vessels, brachial
plexus & sympathetic trunks)

Pretracheal fascia
A- Attachment :-
1- Superiorly:- Attached to thyroid & cricoid cartilages
2- Inferiorly:- Blends with fibrous pericardium
3- Laterally:- Blends with carotid sheath & investing layer of deep cervical fascia
B- Encloses
1- Thyroid gland
2- Parathyroid glands
3- Infrahyoid muscles (Invests infrahyoid muscles)

N.B.
1- Derivatives of deep cervical fascia include
1- Investing layer of deep cervical fascia
2- Pretracheal fascia
3- Prevertebral fascia
4- Stylomandibular ligament
5- Carotid sheath
2- Ligamentum nuchae = Extension of supraspinous ligament
3- Pretracheal fascia forms a sheath around thyroid gland & connects it to larynx → So,
thyroid G. moves with swallowing
4- Contents of carotid sheath:-
1- C.C.A. inferiorly
2- I.C.A. superiorly
3- I.J.V.
4- Vagus
5- Glossopharyngeal, accessory & hypoglossal Ns. pass through the upper part of
carotid sheath
6- D.C.L.Ns.
7- Ansa cervicalis

116
 Cervical ganglia
Position
A- Superior ganglion:-
- Below the base of skull
- Opposite 2nd and 3rd cervical vertebrae
B- Middle:-
- Opposite 6th cervical vertebrae
- At the level of cricoid cartilage
- Between C.C.A. (Anteriorly) & loop of inferior thyroid A. (Posteriorly)
C- Inferior:- Between the last cervical transverse process and the neck of 1st rib

Branches
Superior Middle Inferior

1- Gray rami communicans to the 1- Gray rami 1- Gray rami

anterior rami of upper 4 cervical Ns. communicans to the communicans
anterior rami of 5th & 6th to the anterior
cervical Ns. rami of 7th &
8th cervical
Ns.
2- Superior cardiac branch to cardiac 2- Middle cardiac branch 2- Inferior
plexus to cardiac plexus cardiac branch
to cardiac
plexus
3- Internal carotid N.:- Postganglionic 3- Ansa subclavia:-
branches that form internal carotid plexus - Crosses in front of 1st
around I.C.A. part of subclavian A.
- Joins the middle &
inferior cervical ganglia
4- Arterial branches:- 4- Thyroid branches:- 3- Arterial
- Form plexuses around C.C.A. & Accompany inferior branches:- To
E.C.A. thyroid A. → To thyroid subclavian &
- Pass along branches of E.C.A. gland vertebral As.
th th
5- Cranial nerve branches:- Join 9 , 10
& 12th cranial Ns.
6- Pharyngeal branch:- Unites with
pharyngeal branches of 9th & 10th cranial
N.s → Form pharyngeal plexus

117
N.B.:-
1- Cervical part of sympathetic trunk:-
a- Consists of the superior, middle & inferior cervical ganglia
b- Extends from the base of skull to the neck of 1st rib
c- Behind the internal & common carotid As.
2- Inferior cervical ganglion usually fuses with 1st thoracic ganglion → Form stellate
ganglion = Cervico-thoracic ganglion

Cervical plexus
Formation:- By the anterior rami of upper 4 cervical nerves

Relations:-
A- Anteriorly:- I.J.V. inside carotid sheath
B- Posteriorly:-
1- Origin of scalenus medius
2- Origin of levator scapulae

Branches:-
A- Cutaneous:-
1- Great auricular ( C2 & 3 )
2- Lesser occipital ( C2 )
3- Transverse cutaneous N. ( C2 & 3 )
4- Supraclavicular N. ( C3 & 4 )
B- Communicating:-
1- Branches from C1 & 2 to vagus & hypoglossal Ns.
2- Branches from C2, 3 & 4 to accessory N.
3- Receives branches from superior cervical sympathetic ganglion to C1, 2, 3 & 4
C- Muscular:-
1- Prevertebral muscles
2- Sternocleidomastoid (Proprioceptive C2 & 3)
3- Trapezius (Proprioceptive C3 & 4 )
4- Levator scapula ( C3 & 4 )
5- Descending cervicalis:- Shares in ansa cervicalis
6- Phrenic N. to diaphragm

118
 Phrenic nerve
Course:- Begins at the lateral border of scalenus anterior at the level of
cricoid cartilage by the union of its roots (From C3, 4 & 5 roots of cervical
plexus) → Crosses in front of scalenus anterior from lateral to medial →
Enters the thorax
A- Right phrenic N. enters the thorax by passing in front of scalenus
anterior
B- Left phrenic N. enters the thorax by passing in front of the 1st part of
subclavian A.

Type of fibers:-
1- Motor to diaphragm
2- Sensory
3- Sympathetic

Relations:-
A- Anteriorly:-
1- I.J.V.
2- Superficial cervical A.
3- Suprascapular A.
4- Prevertebral fascia
5- Thoracic duct & left brachiocephalic V. anterior to left phrenic N.
B- Posteriorly:-
1- Scalenus anterior
2- S.C.A.
3- Cervical dome of pleura

N.B. Scalenus anterior separates phrenic N. from subclavian A.

119
 CRANIAL NERVES
2- Optic nerve
1- Enters the orbit through optic canal
2- Surrounded by the 3 meninges
3- Central artery and vein of retina are inside the optic nerve
N.B. Nasociliary N. & ophthalmic A. cross over optic N.

3- Oculomotor nerve
Course:- Arises from midbrain → Passes through the lateral wall of cavernous sinus →
Divides into superior & inferior divisions → Pass through superior orbital fissure inside the
tendinous ring → Enters the orbit

Distribution:-
A- The superior division supplies:-
1- Superior rectus
2- Levator palpebrae superioris
B- The inferior division supplies:-
1- Medial rectus
2- Inferior rectus
3- Inferior oblique
4- The nerve to inferior oblique gives parasympathetic root of ciliary ganglion → Supplies
constrictor pupillae & ciliary muscles
Nuclei:- 1- Motor nucleus 2- Edinger Westphal nucleus (Parasympathetic)

4- Trochlear nerve
Course:- From midbrain → Passes through lateral wall of cavernous sinus → Through
superior orbital fissure outside the tendinous ring → enters the orbit → ends in superior oblique
muscle
Distribution:- Supplies superior oblique only

6- Abducent nerve
Course:- From the pons → Passes through medial wall of cavernous sinus → Through
superior orbital fissure inside the tendinous ring → enters the orbit → ends in lateral rectus
Distribution:- Supplies lateral rectus only

111
 5- Trigeminal nerve
1- Has 3 divisions:-
a- ophthalmic (pure sensory) = the smallest
b- maxillary (pure sensory)
c- mandibular (mixed = motor and sensory) = the largest
2- Has 2 roots:-
a- sensory = the larger
b- motor = the smaller

Ophthalmic nerve
Course:- Arises from trigeminal nerve → Passes through lateral wall of cavernous sinus →
Divides into 3 branches (Frontal, lacrimal & nasociliary) → Pass through the superior orbital
fissure → Enter the orbit

Branches:-
A- Frontal:- Divides into
1- Supratrochlear
2- Supra-orbital
- Passes through supra-orbital notch or foramen
- Supplies the forehead & frontal air sinus
B- Lacrimal:-
- Passes above lateral rectus
- Supplies sensory fibers to lateral part of upper eye lid, conjunctiva & lacrimal gland
- Joined by a branch from zygomatico-temporal N. (Parasympathetic secretomotor to lacrimal
gland)

C- Naso-ciliary:- Gives the following branches

1- Communicating branch to ciliary ganglion
2- Long ciliary Ns. (2-3):- Sympathetic to dilator pupillae
3- Posterior ethmoidal N.:- To sphenoid & ethmoid air sinuses
4- Anterior ethmoidal nerve:-
- Supplies ethmoid air sinuses, nasal cavity & skin of nose
- Appears on the face as the external nasal branch
5- Infratrochlear:- Supplies the medial part of upper eyelid & adjacent part of the nose

N.B.
1- Terminal branches of nasociliary N. = Anterior ethmoidal & infratrochlear
2- Nasociliary N. passes through the tendinous ring

111
 Maxillary nerve
Type:- Pure sensory
Course:-
Originates from trigeminal ganglion in the middle cranial fossa → Through lateral wall of
cavernous sinus → Through foramen rotundum → Reaches pterygopalatine fossa → Through pterygomaxillary
fissure → Reaches the infratemporal fossa → Enters the orbit by passing through inferior orbital fissure
(Continues as the infra-orbital N.) → Through infraorbital groove → Through infraorbital canal
→ Through infraorbital foramen to reach the face → Ends in the face by dividing into nasal, labial
and palpebral branches.

Branches:-
1- Meningeal branch:- In the middle cranial fossa
2- Two ganglionic branches to pterygo-palatine ganglion:- Contain
a- Sensory fibers → Pass through pterygo-palatine ganglion without relay → Supply the
nose, palate & pharynx
b- Postganglionic parasympathetic fibers to lacrimal gland
3- Zygomatic nerve:- Enters the orbit then divides into
a- Zygomatico-facial N.
b- Zygomatico-temporal N.
4- Posterior superior alveolar N.:- Supplies
a- Maxillary sinus
b- Upper molars & adjacent parts of upper gum & cheek
5- Middle superior alveolar N.:-
- Arises from infra-orbital N. in the infra-orbital groove
- Supplies upper premolars & adjacent parts of upper gum & cheek
6- Anterior superior alveolar N.:-
- Arises from infra-orbital N. in the infra-orbital canal
- Supplies the upper canine, upper incisors & part of the nose
7- Infra-orbital nerve:- Is the terminal part of maxillary N. → Passes through infra-
orbital foramen to supply
a- Lower eyelid
b- Upper lip
c- Side of nose
d- Cheek
Mandibular nerve
112
Type:- mixed
Roots:-
1- Sensory root:- From the trigeminal ganglion
2- Motor root:-
Course:- Begins just below foramen ovale by the union of its sensory & motor
roots → Descends between lateral pterygoid & tensor palati → Ends by dividing
into
a- Anterior division:- Smaller & mainly motor
b- Posterior division:- Larger & mainly sensory

Branches:-
A- From the trunk (1 motor & 1 sensory):-
1- Nerve to medial pterygoid.:- Supplies 3 muscles
a- Supplies medial pterygoid
b- Gives the motor root of otic ganglion → Passes without relay to supply
tensor palati & tensor tympani
2- Nervus spinosus = Meningeal recurrent N.:-
- Passes through foramen spinosum (Or foramen ovale)
- Supplies
a- Meninges of middle cranial fossa
b- Mastoid antrum & mastoid air cells
c- Cartilaginous part of auditory tube

B- From anterior division (3 motor & 1 sensory):-

1- Two deep temporal Ns.:- To temporalis
2- Masseteric N.
3- Nerve to lateral pterygoid
4- Buccal N. Supplies
a- Skin and mucous membrane of the cheek
b- Lower gum opposite molars & 2nd premolar

C- From posterior division:-

1- Auriculo-temporal nerve
2- Lingual nerve
3- Inferior alveolar nerve
Auriculo-temporal nerve
113
Course:- Arises by 2 roots (Embrace the M.M.A.) from posterior division of
mandibular N. → Passes posteriorly (Between the neck of mandible & sphenomandibular
ligament) → Passes through P.G. → Crosses the root of zygomatic arch → Ascends
behind temporomandibular joint & in front of auricle (Accompanied by superficial
temporal vessels)
Distribution:- Sensory fibers to
1- Auricular part:- Supplies
a- Tragus
b- Upper part of pinna
c- E.A.M.
d- Outer surface of T.M.
2- Temporal part:- To the skin of temple
3- P.G.:-
a- Sensory to P.G.
b- Receives postganglionic secretomotor fibers from otic ganglion to P.G.
4- Temporo-mandibular joint

Inferior alveolar nerve

Course:- Arises from the posterior division of mandibular N. → appears at the
lower border of lateral pterygoid (behind lingual N.) → enters the mandibular
canal through mandibular foramen → Ends by dividing into mental & incisive
Ns.
Branches:-
1- Communicating branch:- To lingual N.
2- Nerve to mylohyoid:-
- arises from inferior alveolar N. just before the mandibular foramen
- supplies 2 muscles ( ……………….. and …………..………)
3- Inside mandibular canal:- Supplies the lower molars & premolars
4- At the end of mandibular canal: Divides into mental & incisive Ns.
a- Mental N. supplies the skin & mucous membrane of lower lip
b- Incisive N. supplies the canine & 2 incisors

114
 Lingual nerve
Course:-
Arises from the posterior division of mandibular N. → Descends anterior to inferior
alveolar N. at the lower border of lateral pterygoid → Descends antero-inferiorly between
the ramus of mandible & medial pterygoid → Passes antero-medially below superior
constrictor → Enters the mouth → Passes behind then below the lower 3rd molar tooth →
Passes superficial to hyoglossus → Winds around submandibular duct → Enters the
tongue

Distribution:-
1- Sensory branches:-
a- Carries general sensations from
1- anterior 2/3 of the tongue
2- floor of mouth
3- lingual surface of lower gum
b- Taste fibers of chorda tympani carry taste sensations from the anterior 2/3
of the tongue
2- Ganglionic branches:- Parasympathetic secretomotor fibers of chorda
tympani → Relay on submandibular ganglion → Postganglionic secretomotor
fibers reach submandibular and sublingual salivary glands
3- Communicating branches:- Connect lingual & hypoglossal Ns.
N.B.
1- Sensory root of mandibular N is larger than the motor root
2- Course of buccal N.:- Arises from anterior division of mandibular N. → Passes
between the 2 heads of lateral pterygoid → Passes on the outer surface of buccinator
(Supplies the skin of cheek) → Pierces buccinator (Supplies the mucous membrane of
cheek & lower gum
3- Chorda tympani joins lingual N. at the lower border of lateral pterygoid
4- Mylohyoid N. pierces the sphenomandibular ligament
5- Ganglionic branches of maxillary N. hold up the pterygo-palatine ganglion in pterygo-
palatine fossa
6- Inside pterygo-palatine fossa, maxillary N gives
a- ganglionic branches
b- zygomatic N.
c- posterior superior alveolar N.
7- Zygomatic N. arises from maxillary N. inside pterygo-palatine fossa → Enters the orbit
through inferior orbital fissure → Divides into ………… & ………..

115
 7- Facial nerve
Roots:-
1- Motor
2- Sensory = nervus intermedius
Nuclei:-
1- Motor nucleus
2- Superior salivatory nucleus
3- Nucleus of tractus solitarius:- Receives taste sensation
4- Lacrimal nucleus

Course:-
The 2 roots arise from the lower border of pons → Enter the internal acoustic meatus → Enters
facial canal (Here it expands to form the geniculate ganglion) → Passes backwards in the medial
wall of middle ear → Descends in the posterior wall of M.E. → Exits through stylo-mastoid
foramen → Reaches the neck → Enters P.G. → Ends in P.G. by dividing into 5 terminal branches

Branches:-
1- From geniculate ganglion:-
a- Greater petrosal N.:- Contains
1- Secretomotor fibers to lacrimal gland
2- Secretomotor fibers to nasal & palatine glands
3- Taste fibers from the palate
b- Communicating branch with lesser petrosal N.
c- External petrosal N.:- Join the sympathetic plexus around M.M.A.
2- Inside facial canal:-
a- Nerve to stapedius
b- Chorda tympani
3- At the exit from stylo-mastoid foramen:- 3 muscular branches
a- Posterior auricular N. to posterior belly of occipito-frontalis
b- Nerve to posterior belly of digastric
c- Nerve to stylohyoid
4- In the face:- Terminal branches arising in parotid gland
a- Temporal
b- Zygomatic
c- Buccal
d- Mandibular
e- Cervical

116
 Chorda tympani nerve

Course:- Arises from facial N. Just above the stylomastoid foramen → Passes
between the inner & middle layers of T.M. → Crosses over the handle of malleus
→ Passes through petrotympanic fissure → Reaches the infratemporal fossa →
Joins lingual N.

Type of fibers & distribution:-

1- Secretomotor (Parasympathetic) fibers to submandibular & sublingual glands
2- Taste fibers from the anterior 2/3 of tongue

N.B.
1- Facial N. enters P.G. through its postero-medial surface
2- Inside P.G., facial N. divides → Rejoins → Divides to 5 terminal branches

pharyngeal plexus

Site:- on the surface of middle constrictor of pharynx

Roots:-
1- Motor = Pharyngeal branch of vagus
2- Sensory = pharyngeal branches of glossopharyngeal nerve
3- Sympathetic = pharyngeal branch of sympathetic trunk.

Branches:- motor and sensory branches to pharynx

117
 9- Glossopharyngeal nerve
Course:- Arises from medulla oblongata → Emerges through jugular foramen →
Descends between I.J.V. and I.C.A. (In the upper part of carotid sheath) → Passes between
I.C.A. & E.C.A. (With stylopharyngeus) → Passes on the upper border of middle
constrictor → Passes deep to hyoglossus muscle → Reaches the tongue
Branches:-
1- Tympanic branch = Jacobson’s N.:- Carries
a- Sensory fibers to
1- middle ear
2- inner aspect of T.M.
3- bony part of auditory tube
b- Secretomotor fibers to
1- P.G.
2- glands of the vestibule of mouth
2- Muscular branch to stylopharyngeus
3- Carotid branch to carotid sinus & carotid body
4- Pharyngeal branches to pharyngeal plexus:- Carry sensations from pharynx, tonsil &
soft palate.
5- Tonsillar branch:- Sensory to palatine tonsil
6- Lingual branch:- Carries general and taste sensations from
a- Posterior 1/3 of the tongue
b- Region of circumvallate papillae = The posterior part of the anterior 2/3

Course of Jacobson’s nerve

Arises from the inferior ganglion of glossopharyngeal N. → Passes through tympanic
canaliculus → Enters the M.E. → Forms tympanic plexus → The parasympathetic fibers
form the lesser petrosal N. → Relay on otic ganglion → Postganglionic fibers are carried
on auriculo-temporal N. → Into P.G.
Nuclei = in medulla oblongata:-
1- Motor = upper part of nucleus ambiguous:- For stylopharyngeus
2- Parasympathetic = inferior salivary nucleus:- For parotid gland
3- Special sensory = nucleus solitarius:- For taste
4- Spinal nucleus of trigeminal N.:- For general sensations

N.B.
1- Glossopharyngeal N. winds around stylopharyngeus
2- Tonsillar branch of glossopharyngeal N. anastomoses with lesser petrosal N.
3- Tympanic canaliculus lies between carotid & jugular foramina

118
 10- Vagus nerve

Course:-
Arises from medulla oblongata → Passes through jugular foramen → descends inside carotid
sheath behind and between I.C.A. & I.J.V. then between C.C.A. & I.J.V. → Enters the
mediastinum by passing in front of subclavian A.

Branches in the neck = Distribution in the neck:-

1- Meningeal branch:-
- Arises from superior ganglion
- Supplies the dura of posterior cranial fossa
2- Auricular branch:-
- Arises from superior ganglion
- Supplies
a- Medial surface of auricle
b- Floor of E.A.M.
c- Lower part of the outer surface of T.M.
3- Pharyngeal branch:-
- Arises from inferior ganglion
- Contains motor fibers from the cranial part of accessory N.
- Supplies
a- all muscles of pharynx except stylopharyngeus
b- all muscles of soft palate except tensor palati
4- Superior laryngeal nerve:-
- Arises from inferior ganglion
- Divides into 2 divisions
a- Internal laryngeal N. carries sensations from
- larynx above the vocal cords
- piriform fossa
b- External laryngeal N. supplies cricothyroid muscle.
5- Right recurrent laryngeal nerve:- gives the following branches
a- motor fibers to all intrinsic muscles of larynx except ………
b- sensory fibers to
1- laryngeal mucosa below vocal cords
2- Mucosa of upper part of trachea
6- Carotid branch:- To carotid body & carotid sinus
7- Cervical cardiac branches ( 2 - 3 ):- To the cardiac plexus

119
 Course of recurrent laryngeal nerve
A- On right side:- arises from vagus N. in the neck → hooks around 1st part of
subclavian artery →

B- On the left side:- arises from vagus N. in chest → hooks around aortic arch →

Then
→ Ascends in the groove between esophagus and trachea → passes deep to thyroid gland
→ enters the larynx by passing deep to the lower border of inferior constrictor →
Distribution ………..

Ganglia of vagus N.:-

A- Superior ganglion:-
- Inside jugular foramen
- Gives the meningeal & auricular branches
B- Inferior ganglion:-
- Just below jugular foramen
- Its cells give all of the sensory fibers

Nuclei = in medulla oblongata:-

1- Nucleus ambiguous (Motor)
2- Dorsal motor N. (Parasympathetic)
3- Nucleus of tractus solitarius:- For taste from palate & Root of tongue
4- Spinal nucleus of trigeminal N.:- For general sensations from the skin of E.A.M.

N.B.

1- Pharyngeal branch of vagus contains fibers from cranial accessory = Originates from
the cells of nucleus ambiguus

2- R.L.N. is closely related to inferior thyroid A.

121
 11- Accessory nerve
Roots:-
1- Cranial = arises from Posterolateral sulcus of medulla oblongata
2- Spinal = from the upper 5 cervical segments
Type:- pure motor

Course:-
The spinal root arises from the upper 5 cervical segments → ascends through
foramen magnum → reaches the cranial cavity → unites with the cranial root
that arises from medulla oblongata → form the accessory nerve → exits
through jugular foramen → just below jugular foramen divides again into
spinal and cranial parts →

a- Cranial part:- Joins vagus N. at or just below the inferior ganglion → Distributed
through pharyngeal & recurrent laryngeal branches of vagus
b- Spinal part:- Supplies sternomastoid → passes through posterior triangle → Ends
deep to trapezius by supplying it.

Distribution:-
A- Cranial part:- Supplies
1- All muscles of palate except tensor palati
2- All muscles of pharynx except stylopharyngeus
3- All muscles of larynx except crico-thyroid

B- Spinal part:- supplies

1- Sternomastoid
2- Trapezius.
N.B.:- The spinal part of accessory N. is larger than its cranial part

121
 12- Hypoglossal nerve
Course:-
Arises from medulla oblongata → Passes through hypoglossal canal → Joined
by motor fibers from C1 ( And sometimes from C2) → Passes between I.C.A.
& I.J.V. → Passes superficial to I.C.A., E.C.A. & loop of lingual A., →
Passes deep to stylohyoid & intermediate tendon of digastric → Passes
superficial to hyoglossus → Passes between hyoglossus & mylohyoid → At
the anterior border of hyoglossus, turns upwards → Enters the tongue

Distribution:-
1- Meningeal branch:-
- Consists of sensory fibers from C2
- Supplies meninges of posterior cranial fossa
2- Descendens hypoglossi:-
- Consists of fibers from C1
- Joins descendens cervicalis (C2 & 3) to form ansa cervicalis that supplies
a- Omohyoid
b- Sternohyoid
c- Sternothyroid
3- Nerve to thyrohyoid:- Consists of fibers from C1
4- Nerve to geniohyoid:- Consists of fibers from C1
5- Muscular branches to all muscles of the tongue except palatoglossus:- Supply
a- genioglossus
b- Hyoglossus
c- Chondroglossus
d- Styloglossus
e- Intrinsic muscles of the tongue
6- Communicating branch:- Communicates with lingual N. on the side of the
tongue
N.B. Hypoglossal N. is pure motor (Type of fibers)

122