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Sakaj Sog by HJ
Sakaj Sog by HJ
Sakaj Sog by HJ
رس و رگد ی
ی زجء
ی شک ا یز
ن یرسرگدا ی
The High Yield Head & Neck Book
Hamzah Jehanzeb
اکسج وسگ
HJ’s HY H&N
Hamzah Jehanzeb
The author in his true form and natural habitat (Credits: M. Ali Akbar Khan)
Anatomy is a discipline that ought to be easy to grasp, but is dealt a horrible injustice by
a lack of good resources. This problem gets especially compounded in the head and
neck module, where the “big books” (KLM and Gray’s) offer way too much detail, little
of which is exam-relevant, while the “short books” (BRS, HY Anatomy, and TMA),
although providing a good overview of the topics, tend to be lacking in terms of content
and good, explanatory diagrams. While one could easily get away with only doing the
clinical correlates in MSK, that’s not an option for head and neck since the anatomy
tends to get tested in its pure form in this module. Thus, I began my quest to compile a
high-yield book of my own.
And so, I wrote this book as a distillate of all the high-yield facts from BRS, TMA, Gray’s
and KLM, including all the important diagrams from the aforementioned resources.
Additionally, at the beginning of each chapter, I have included recommended video
resources, which I highly recommend you check out. Although I have tried my level
best to only include exam-relevant content, I have included a few low-yield points,
A few random facts regarding the book: the main title in Urdu, as seen on the front
page, means “remover of difficulties of the head and neck module”. This long,
convoluted name has been abbreviated to “Sakaj Sog”, which is the preferred name for
the book, and is completely nonsensical. The long version of the name is a satirical take
on the titles of texts from medieval Persianate societies. Thought it might pique
someone’s interest. Additionally, all the images used in the chapter covers, as well as
the image on the front page, were generated using AI text-to-image programs. The
ones I used were Dall-E mini and Dall-E Flow. Each image is meant to evoke a certain
art style. Let’s see if you can guess what those art styles are. I’ll include the answers at
the end of the book. Additionally, I’ve designed the book so that the page numbering
on the pages and the pdf page numbers coincide. In the process of writing this book, I
also developed an index for determining which resources would be the most effective
to use for any particular module, and the results were pretty spot-on. I was hoping I
could include the equation and graphs in this book, but I was too lazy to do so.
A big shoutout to Dr. Ali Aahil for his amazing module guide, which helped me
determine which topics and diagrams to include. Be sure to check it out.
Lastly, I hope this book makes this module easier for everyone. It sure has done that for
me. I hate to see my batchmates struggling because they don’t know what information
is important, and end up scoring lower than they should, just because a lot of their
effort was wasted on low-yield facts. If you truly find this book useful, bus dil sai dua
karo meray liyay. Or just get me a cocomo, either one works.
End of Rant
high-yield
ن آدمی
وت رباےئ ولص رکد ی
ن آدمی
صف رکد ی
ی ےن رباےئ
low-yield
م
الجلادلنی رو ی-
Recommended Videos
Sam Webster:
• “Labelled skull bones”
o Runtime: 17:28
o (https://youtu.be/uxmD2XMaBM8)
• “Labelled cranial foramina anatomy”
o Runtime: 22:51
o (https://youtu.be/97sWvuPXGLI)
AnatomyZone:
• “Foramina of the Skull | Skull Anatomy”
o Runtime: 8:42
o (https://youtu.be/BW19nGC4g_U)
Neurocranium:
Neurocranium
• Frontal bone:
Fontal bone
• Parietal bone:
Parietal bone
• Temporal bone:
Parts of the o Squamous part
temporal ▪ is external to the lateral surface of the temporal lobe of the
bone?
brain.
o Petrous part
▪ encloses the internal and middle ears
o Mastoid part
▪ contains mastoid air cells
o Tympanic part
▪ houses the external auditory meatus and the tympanic cavity
o Zygomatic process
▪ Forms part of the zygomatic arch
o Styloid process
▪ acts as an attachment point for muscles and ligaments
Fig 1 – Lateral view of the skull. The temporal bone has been highlighted.
Fig 1.2 – Coronal section of temporal bone, showing the mastoid air cells in more detail
Infections can
spread to the
mastoid air • Clinical Correlate: Mastoiditis:
cells from?
o Middle ear infections (otitis media) can spread to the mastoid air cells.
Where can
they spread to ▪ Due to their porous nature, they are a suitable site for
from the air pathogenic replication.
cells? o The mastoid process itself can get infected
▪ this can spread to the middle cranial fossa, and into the brain,
causing meningitis.
Nerve that can o If mastoiditis is suspected, the pus must be drained from the air cells.
be damaged ▪ When doing so, care must be taken not the damage the
when draining
pus from the
nearby facial nerve.
mastoid air • Clinical Correlate: Temporal Bone Fractures:
cells? o It has a varied presentation.
o Ear-related disorders are commonly seen, such as vertigo or hearing
loss.
Symptoms of o As the facial nerve travels through the temporal bone, it can be
temporal bone
damaged, with paralysis resulting.
fracture?
o Other symptoms include bleeding from the ear and bruising around the
mastoid process.
• Occipital bone:
o Encloses the foramen magnum and forms the cerebral and cerebellar
fossae.
Occipital bone
• Sphenoid bone:
o Said to be ‘butterfly-shaped‘
o Consists of:
▪ the body (which houses the sphenoid sinuses and sella turcica),
▪ the greater and lesser wings
▪ the pterygoid process, which projects inferiorly from the
cranium.
o Chiasmatic groove – a sulcus formed by the optic chiasm (where the
optic nerves partially cross).
Fig 2 – Foramina and bony landmarks of the sphenoid wings and pterygoid process.
• Ethmoid bone:
o Is located between the orbits
o Consists of:
▪ the cribriform plate through which the olfactory nerves enter
the skull
▪ perpendicular plate which contributes to the nasal septum
▪ two lateral masses enclosing ethmoid air cells, known as
ethmoidal labyrinths
o Projecting superiorly from the cribriform plate is the crista galli, which
provides an attachment point for the falx cerebri.
Ethmoid bone
Viscerocranium:
Bones
comprising the • Consists of 14 bones, which fuse to house the orbits of the eyes, the nasal and
viscerocranium
?
oral cavities, and the sinuses.
• The frontal bone, typically a bone of the calvaria, is sometimes included as part
of the facial skeleton.
• Zygomatic (2):
Unpaired o forms the cheek bones of the face
bones of the o articulates with the frontal, sphenoid, temporal and maxilla bones.
viscerocranium o The most important feature of the zygomatic bone is the zygomatic
?
arch.
▪ This arch is formed by the zygomatic process of the temporal
bone and the temporal process of the zygomatic bone.
Zygomatic arch
Zygomatic bone
• Lacrimal (2):
o the smallest bones of the face.
o They form part of the medial wall of the orbit.
o The main function of the lacrimal bone is to provide support for the
structures of the lacrimal apparatus.
Lacrimal bone
• Nasal (2):
o two slender bones that are located at the bridge of the nose.
Nasal bone
• Palatine (2):
o Situated at the rear of oral cavity.
o Forms part of the hard palate.
Palatine bone
• Maxilla (2):
o Comprises part of the upper jaw and hard palate.
o The maxilla is the central, paired bone of the viscerocranium.
o The left and right maxilla fuse in the midline to form the upper jaw.
o Between the two maxillae lies a cranial suture called the intermaxillary
suture.
o Important features of the maxilla include the infraorbital
foramen, maxillary sinus, and incisive foramen.
o The main function of the maxilla is to hold the upper teeth in place.
Maxilla
• Vomer:
o Forms the posterior aspect of the nasal septum.
o One of the two unpaired bones of the viscerocranium.
o The superior two-thirds of the bony nasal septum is formed by the
perpendicular plate of the ethmoid bone, while the inferior third is
formed by the vomer.
Vomer
• Mandible (jaw):
o articulates with the base of the cranium at the temporomandibular
joint (TMJ).
o Largest bone of the viscerocranium.
o Unpaired (the only other unpaired bone of the viscerocranium is the
vomer)
o Head – situated posteriorly, and articulates with the temporal bone to
form the temporomandibular joint.
o Coronoid process – site of attachment of the temporalis muscle
Mandible
Fig 3 – Anterior view of the face, showing some of the bones of the nasal skeleton. The vomer, palatine and
inferior conchae bones lie deep within the face.
• Sutures are a type of fibrous joint that are unique to the skull.
Sutures of the • They are immovable and fuse completely around the age of 20.
skull? • These joints are important in the context of trauma, as they represent points
of potential weakness in the skull.
• The main sutures in the adult skull are:
o Coronal suture – fuses the frontal bone with the two parietal bones.
o Sagittal suture – fuses both parietal bones to each other.
o Lambdoid suture – fuses the occipital bone to the two parietal bones.
• In neonates, the incompletely fused suture joints give rise to membranous gaps
between the bones, known as fontanelles.
• The two major fontanelles are:
Frontanelles? o Frontal fontanelle – located at the junction of the coronal and sagittal
sutures
o Occipital fontanelle – located at the junction of the sagittal and
Junctions of lambdoid sutures
cranial • Junctions of the cranial sutures:
sutures? o Lambda
▪ Intersection of the lambdoid and sagittal sutures.
22 | H J ’ s H Y H & N | اکس ج ی وس گی
1. The Skull and Cranial Foramina
o Bregma
▪ Intersection of the sagittal and coronal sutures.
o Pterion
▪ A craniometric point at the junction of the frontal, parietal, and
temporal bones and the greater wing of the sphenoid bone.
• Clinical Correlate: The pterion overlies the middle meningeal artery, and
fractures in this area may injury the vessel.
o Blood can accumulate between the skull and the dura mater, forming an
epidural hematoma.
Bregma
Lambda
Fig 2 – Lateral view of the skull, showing the path of the meningeal arteries. Note the pterion, a weak point
of the skull, where the anterior middle meningeal artery is at risk of damage.
Tripod
fracture?
Cranial Foramina
(https://teachmeanatomy.info/head/osteology/cranial-foramina/)
• Cribriform Foramina:
Cribriform o Numerous perforations in the cribriform plate of the ethmoid bone.
foramina? o They connect the anterior cranial fossa with the nasal cavity.
o Allow the passage of axons of the olfactory nerve from the olfactory
epithelium of the nose into the anterior cranial fossa where they
communicate with the olfactory bulb.
• Optic Canal and Foramen:
Optic canal? o Permits the passage of the optic nerve (CN II) and the ophthalmic artery
into the bony orbit.
o Bounded medially by the body of the sphenoid, and laterally by the
lesser wing of the sphenoid bone.
• Superior Orbital Fissure:
Superior orbital o Cleft that opens anteriorly into the orbit, and enables communication
fissure? between the cavernous sinus and the apex of the orbit.
o Bordered superiorly by the lesser wing and inferiorly by the greater
wing of the sphenoid bone.
o Transmits several structures that are listed below (from superior to
inferior):
▪ Lacrimal nerve (branch of the ophthalmic nerve, the first division
of the trigeminal nerve)
▪ Frontal nerve (branch of the ophthalmic nerve, the first division
of the trigeminal nerve)
▪ Superior ophthalmic vein
▪ Trochlear nerve (CN IV)
▪ Superior division of the Oculomotor nerve (CN III)
▪ Nasociliary nerve (branch of the ophthalmic nerve, the first
division of the trigeminal nerve)
▪ Inferior division of the Oculomotor nerve (CN III)
▪ Abducens nerve (CN VI)
▪ A branch of the Inferior ophthalmic vein
• Foramen Rotundum:
Foramen o Provides a connection between the middle cranial fossa and
rotundum? the pterygopalatine fossa.
o The maxillary nerve (branch of the trigeminal nerve, CN V) passes
through this foramen.
• Foramen Ovale:
Foramen o Positioned posterolateral to the foramen rotundum within the middle
ovale? cranial fossa.
o It conducts the mandibular nerve (branch of the trigeminal nerve, CN
V) and the accessory meningeal artery.
Fig 2 – Foramina and bony landmarks of the sphenoid wings and pterygoid process.
Fig 3 – The bony landmarks and foramina of the posterior cranial fossa.
Figure 1 – Superior view of the skull base showing the foramina and which cranial nerves pass through
them.
Other Foramina:
• Foramen Magnum:
Foramen o The largest of the cranial foramina.
magnum? o Lies in the occipital bone within the posterior cranial fossa
o Allows the passage of:
▪ the medulla and meninges
▪ the vertebral arteries
▪ the anterior and posterior spinal arteries
▪ the dural veins
▪ The spinal division of the accessory nerve, which ascends
through the foramen magnum to join the cranial division. Once
combined, the completed nerve exits through the jugular
foramen as described above.
• Foramen Spinosum:
Foramen o Located within the middle cranial fossa, laterally to the foramen ovale.
spinosum? o It allows the passage of:
▪ the middle meningeal artery
▪ the middle meningeal vein
▪ the meningeal branch of CN V3
• Foramen cecum:
Foramen o In the anterior cranial fossa
cecum? o Carries an occasional small emissary vein from nasal mucosa to superior
sagittal sinus.
• Anterior and posterior ethmoidal foramina:
Ant. and Pos. o In the anterior cranial fossa
ethmoidal o Carries the anterior and posterior ethmoidal nerves, arteries, and veins.
foramina?
• Foramen lacerum:
o Nothing passes through this foramen (may be filled with cartilage)
o but the upper part is traversed by the internal carotid artery and
Foramen greater and deep petrosal nerves en route to the pterygoid canal.
lacerum?
• Carotid canal:
o Internal carotid artery and sympathetic nerves (carotid plexus).
Carotid canal?
Hiatus of facial
canal? • Hiatus of facial canal:
o Greater petrosal nerve.
• Condyloid foramen:
Condyloid o Condyloid emissary vein.
foramen?
• Mastoid foramen:
Mastoid o Branch of occipital artery to dura mater and mastoid emissary vein.
foramen?
• Summary:
Fig 1 – The bones of the base of the skull. The anterior cranial fossa has been outlined.
Fig 1.0 – The bones of the cranial floor. The middle cranial fossa has been highlighted.
Fig 1 – The bones of the cranial floor. The posterior cranial fossa has been outlined.Fig 1.0 – The bones of
the cranial floor. The posterior cranial fossa has been outlined.
Fig 2 – The bony landmarks and foramina of the posterior cranial fossa.
(Blank)
The Meninges
(https://teachmeanatomy.info/neuroanatomy/structures/meninges/)
Dura Mater:
Structure,
vascular supply • Outermost layer of the meninges
and
innervation of • located directly underneath the bones of the skull and vertebral column.
the dura • It is thick, tough, and inextensible.
mater? • Consists of two layered sheets of connective tissue:
o Periosteal layer – lines the inner surface of the bones of the cranium.
o Meningeal layer – located deep to the periosteal layer. It is continuous
with the dura mater of the spinal cord.
• The dural venous sinuses are located between the two layers of dura mater.
• Receives its own vascular supply – primarily from the middle meningeal artery
and vein.
• It is innervated by the trigeminal nerve (V1, V2 and V3).
• Dural reflections:
o Falx cerebri – projects downwards to separate the right and left cerebral
hemispheres.
o Tentorium cerebelli – separates the occipital lobes from the cerebellum.
It contains a space anteromedially for passage of the midbrain – the
tentorial notch.
o Falx cerebelli – separates the right and left cerebellar hemispheres.
o Diaphagma sellae – covers the hypophysial fossa of the sphenoid bone.
It contains a small opening for passage of the stalk of the pituitary gland.
Arachnoid Mater:
Structure,
vascular supply • Middle layer of the meninges, lying directly underneath the dura mater.
and
innervation of
• Filmy, transparent layer that is connected to the pia mater by arachnoid
the arachnoid trabeculae.
mater? • Is avascular, and does not receive any innervation.
• Separated from the pia mater by the subarachnoid space, which contains
cerebrospinal fluid (CSF) and enlarges at several locations to form subarachnoid
cisterns.
• The arachnoid projects arachnoid villi (collections of which are called arachnoid
granulations) into the cranial venous sinuses, which serve as sites where CSF
diffuses into the venous blood.
Pia Mater:
Structure of the
pia mater? • Located underneath the sub-arachnoid space.
• It is very thin, and tightly adhered to the surface of the brain and spinal cord.
• It is the only covering to follow the contours of the brain (the gyri and fissures).
• Like the dura mater, it is highly vascularised, with blood vessels perforating
through the membrane to supply the underlying neural tissue.
Fig 1 – Overview of the meninges, and their relationship to the skull and brain.
Fig 3 – Coronal section of the skull, meninges and cerebrum. An arachnoid granulation is visible in the
centre.
• Lie between the periosteal and meningeal layers of the dura mater.
• They are best thought of as collecting pools of blood, which drain the central
nervous system, the face, and the scalp.
• All the dural venous sinuses ultimately drain into the internal jugular vein.
• Unlike most veins of the body, the dural venous sinuses do not have valves.
• The straight, superior, and inferior sagittal sinuses are found in the falx
Drainage cerebri of the dura mater.
patter of the o They converge at the confluence of sinuses (overlying the internal
dural venous
occipital protuberance).
sinuses?
o The straight sinus is a continuation of the great cerebral vein and the
inferior sagittal sinus.
o The superior sagittal sinus is the main location of CSF return via
Dural venous arachnoid granulations.
sinus that is the o Superior sagittal sinus is located along the superior aspect of the falx
main location cerebri, while the inferior sagittal sinus is located along the inferior
of CSF return?
aspect (free edge) of the falx cerebri.
• From the confluence, the transverse sinus continues bi-laterally and curves into
the sigmoid sinus to meet the opening of the internal jugular vein.
• The cavernous sinus drains the ophthalmic veins and can be found on either
side of the sella turcica. From here, the blood returns to the internal jugular vein
via the superior or inferior petrosal sinuses.
Figure 1 – Sagittal section showing the dural venous sinuses and the great cerebral vein
Cavernous Sinus:
(https://teachmeanatomy.info/neuroanatomy/vessels/cavernous-sinus/)
• The cavernous sinus is a paired dural venous sinus located within the cranial
cavity.
• It is divided by septa into small ‘caves’ – from which it gets its name.
• Located on either side of the Sella turcica of the sphenoid bone
• Receive venous blood from:
The cavernous o the facial vein
sinus receives o superior ophthalmic vein
venous return o inferior ophthalmic vein
from?
o pterygoid plexus of veins
o central vein of the retina
o each other via the intercavernous sinuses
▪ pass anterior and posterior to the hypophyseal stalk.
▪ Infections can spread from one side to the other through the
intercavernous sinuses.
• They drain venous blood into:
The cavernous o the superior petrosal sinus → transverse sinus
drains into? o the inferior petrosal sinus → internal jugular vein.
• The superior orbital fissure is located anteriorly to the cavernous sinus.
• Several important structures pass through the cavernous sinus to enter
Structures the orbit. They can be sub-classified by whether they travel through the sinus
passing itself, or through its lateral wall:
through the
cavernous
sinus?
• A useful mnemonic to remember the contents and their relation to one another
is: O TOM CAT, where OTOM (oculomotor nerve, trochlear nerve, ophthalmic
branch, maxillary branch) refers to the lateral wall contents from superior to
inferior, and CAT (internal carotid artery, abducens nerve, trochlear nerve) refers
to the horizontal contents, from medial to lateral.
• The cavernous sinus is the only site in the body where an artery (internal
carotid) passes completely through a venous structure.
o Carotid artery-cavernous sinus fistula can result in a headache, orbital
pain, diplopia, arterialization of the conjunctiva, and ocular bruit.
• Poor drainage of the cavernous sinus may result in exophthalmos and edema of
the eyelids and conjunctiva.
• It is important to note that the superior ophthalmic vein forms an anastomosis
with the facial vein. Therefore, the ophthalmic veins represent a potential route
by which infection can spread from an extracranial to an intracranial site.
Fig 1 – Coronal section demonstrating the borders of the right cavernous sinus.
Fig 3 – Schematic of the dural venous system relating to the cavernous sinus. Note the anastomosis
between the ophthalmic veins and the facial vein.
Fig 2 – Coronal section demonstrating the contents of the right cavernous sinus.
(Blank)
The Scalp
(https://teachmeanatomy.info/head/areas/scalp/)
• The scalp consists of five layers.
• The first three layers are tightly bound together and move as a collective
structure.
• The mnemonic ‘SCALP’ can be a useful way to remember the layers of the scalp:
Layers of the o Skin
scalp? o Dense Connective Tissue
o Epicranial Aponeurosis
o Loose Areolar Connective Tissue
o Periosteum
• Skin – contains numerous hair follicles and sebaceous glands (thus a common
site for sebaceous cysts).
• Dense Connective tissue
o Connects the skin to the epicranial aponeurosis.
o It is richly vascularised and innervated.
o The blood vessels within the layer are highly adherent to the connective
tissue.
▪ This renders them unable to constrict fully if lacerated – and so
the scalp can be a site of profuse bleeding.
• Epicranial Aponeurosis
o Is a tendinous sheet that covers the vault of the skull.
o Unites the occipital and frontal bellies of the occipitofrontal muscles.
o Wounds superficial to this layer of the scalp do not gape or bleed
excessively because the strength of the aponeurosis epicranialis holds
the margins of the wound together.
Occipitofrontalis
Figure 1.0. The five layers of the scalp. Note – The three layers below the periosteum are the meninges.
• The scalp receives a rich arterial supply via the external carotid artery and the
Arterial supply ophthalmic artery (a branch of the internal carotid).
of the scalp?
• There are three branches of the external carotid artery involved:
o Superficial temporal – supplies the frontal and temporal regions
o Posterior auricular – supplies the area superiorly and posteriorly to the
auricle.
o Occipital – supplies the back of the scalp
• Anteriorly and superiorly, the scalp receives additional supply from two
branches of the ophthalmic artery – the supraorbital and supratrochlear
arteries.
Fig 1.1 – Three key arterial branches supplying the scalp. Note, the maxillary artery supplies the deep
structures of the face, not the scalp.
• The scalp receives cutaneous innervation from branches of the trigeminal nerve
or the cervical nerve roots.
• Clinical Correlate: Danger Area of the Scalp
Danger area of o The loose connective tissue layer is considered the “danger area” of the
the scalp? scalp.
o This is because it contains the emissary veins – these are valveless veins
which connect the extracranial veins of the scalp to the intracranial dural
venous sinuses.
o The emissary veins are a potential pathway for the spread of infection
from the scalp to the intracranial space.
▪ Can lead to meningitis or septicemia.
• Clinical Correlate: Scalp Lacerations
Why do deep o Deep lacerations to the scalp tend to bleed profusely for several
lacerations to reasons. These are:
the scalp bleed ▪ The pull of the occipitofrontalis muscle prevents the closure of
profusely?
the bleeding vessel and surrounding skin.
▪ The blood vessels to the scalp are adhered to dense connective
tissue, preventing the vasoconstriction that normally occurs in
response to damage.
48 | H J ’ s H Y H & N | اکس ج ی وس گی
3. The Scalp, Muscles of Facial Expression & Muscles of Mastication
• They are the only group of muscles that insert into skin.
• These muscles have a common embryonic origin – the 2nd pharyngeal
arch. They migrate from the arch, taking their nerve supply with them.
o As such, all the muscles of facial expression are innervated by the facial
nerve.
• Can broadly be split into three groups: orbital, nasal and oral.
Orbital Group:
Orbital group
and actions? • Orbicularis oculi:
o Surrounds the eye socket and extends into the eyelid.
o Actions:
▪ Palpebral part – gently closes the eyelids.
▪ Lacrimal part – involved in the drainage of tears.
▪ Orbital part – tightly closes the eyelids.
• Corrugator supercilia:
o A much smaller muscle and is located posteriorly to the orbicularis oculi.
o Actions – Acts to draw the eyebrows together, creating vertical
wrinkles on the bridge of the nose.
Nasal Group:
Nasal group
and actions? • Nasalis:
o It is split into two parts: transverse and alar.
o Actions: The two parts have opposing functions. The transverse part
compresses the nares, and the alar part opens the nares.
• Procerus:
o Most superior of the nasal muscles.
o Contraction of this muscle pulls the eyebrows downward to produce
transverse wrinkles over the nose.
• Depressor Septi Nasi:
o This muscle assists the alar part of the nasali in opening the nostrils.
o Actions: It pulls the nose inferiorly, opening the nares.
Fig 3 – The nasal muscles of facial expression. Note the nasalis muscle is comprised of two parts.
Oral Group:
Oral group and
actions?
• Orbicularis Oris:
o The fibres of the orbicularis oris enclose the opening to the oral cavity.
o Action: Purses the lips.
• Buccinator:
o This muscle is located between the mandible and maxilla, deep to the
other muscles of the face.
o Actions: The buccinator pulls the cheek inwards against the teeth,
preventing accumulation of food in that area
• Other Oral Muscles
Fig 4 – The main oral muscles of facial expression. Note how the fibers of buccinator and obicularis oris
blend together
Muscles of Mastication
(https://teachmeanatomy.info/head/muscles/mastication/)
• Temporalis:
Actions of the o Originates from the temporal fossa.
temporalis? o Actions: Elevates the mandible, closing the mouth. Also retracts the
mandible, pulling the jaw posteriorly.
• Medial Pterygoid:
Actions of the o Has a quadrangular shape with two heads: deep and superficial.
medial o It is located inferiorly to the lateral pterygoid.
pterygoids? o Actions: Elevates the mandible, closing the mouth.
• Lateral Pterygoid:
o Has a triangular shape with two heads: superior and inferior.
Actions of the o It has horizontally orientated muscle fibres
lateral ▪ Thus is the major protractor of the mandible.
pterygoids?
o Actions:
▪ Acting bilaterally, the lateral pterygoids protract the mandible,
pushing the jaw forwards.
▪ Unilateral action produces the ‘side to side’ movement of the
jaw.
▪ Note: Contraction of the lateral pterygoid will produce lateral
movement on the contralateral side. For example, contraction of
left lateral pterygoid will deviate the mandible to the right.
Recommended Videos
Sam Webster:
• ‘Infratemporal fossa (anatomy)’
o Runtime: 15:32
o (https://youtu.be/jLrkUTIqsAM)
About Medicine:
• ‘Pterygopalatine Fossa - Anatomy, Contents and Borders’
o Runtime: 6:18
o (https://youtu.be/o_JbDynMZjo)
Anatomy Knowledge:
• ‘Pterygopalatine Fossa - Boundaries, Communications & Contents’
o Runtime: 5:51
o (https://youtu.be/QacrWgdmzdY)
Infratemporal Fossa
(https://teachmeanatomy.info/head/areas/infratemporal-fossa/)
• The infratemporal fossa is a complex area located at the base of the skull, deep
to the masseter muscle.
• It is closely associated with both the temporal and pterygopalatine fossae and
acts as a conduit for neurovascular structures entering and leaving the cranial
cavity.
• Can be said to have a wedge shape.
• The fossa is closely associated with both the pterygopalatine fossa, via the
Relations and pterygomaxillary fissure, and also communicates with the temporal fossa,
borders of the which lies superiorly
infratemporal
fossa?
Borders:
• It is located deep to the masseter muscle and zygomatic arch (to which the
masseter attaches).
• The boundaries of this complex structure consists of both bone and muscle:
o Lateral – condylar process and ramus of the mandible bone
o Medial – lateral pterygoid plate; tensor veli palatine, levator veli
palatine and superior constrictor muscles
o Anterior – posterior border of the maxillary sinus
o Posterior – carotid sheath
o Roof – greater wing of the sphenoid bone
o Floor – medial pterygoid muscle
• The roof of the infratemporal fossa, formed by the greater wing of the sphenoid
bone, provides an important passage for the neurovascular structures
transmitted through the foramen ovale and spinosum.
o Among these are the mandibular branch of the trigeminal nerve and
the middle meningeal artery.
Fig 1 – The bony features of the infratemporal fossa. The ramus of the mandible has been removed in this
image.
Contents:
Infratemporal fossa
Pterygopalatine Fossa
(https://teachmeanatomy.info/head/areas/pterygopalatine-fossa/)
Borders:
Borders of the
pterygopalatine • The borders of the pterygopalatine fossa are formed by the palatine, maxilla
fossa?
and sphenoid bones:
o Anterior: Posterior wall of the maxillary sinus.
o Posterior: Pterygoid process of the sphenoid bone.
o Inferior: Palatine bone and palatine canals.
o Superior: Inferior orbital fissure of the eye.
o Medial: Perpendicular plate of the palatine bone
o Lateral: Pterygomaxillary fissure
Fig 1.0 – Left infratemoporal fossa demonstrating the opening of the pterygopalatine fossa (circled in red).
Note: the zygomatic arch has been removed in this image.
Contents:
• Maxillary Nerve:
Course of the o It passes from the middle cranial fossa into the pterygopalatine fossa
maxillary nerve through the foramen rotundum.
and its branches
through the
o The main trunk of the maxillary nerve leaves the pterygopalatine fossa
pterygopalatine via the infraorbital fissure.
fossa?
Fig 2.0 – The main trunk of the maxillary nerve (CNV2); showing the origin at the trigeminal nerve and its
path to external facial structures.
Fig 2.1 – The branches of the pterygopalatine ganglion and the maxillary nerve. Note: For simplicity, this
schematic does not show: the contribution of the facial nerve (CNVII) to the pterygopalatine ganglion, the
posterior superior alveolar nerves, or the nerve of the pterygoid canal.
• Pterygopalatine Ganglion:
Nerves received o It is the largest parasympathetic ganglion related to branches of the
and sent out by maxillary nerve (via pterygopalatine branches)
the
o Is predominantly innervated by the greater petrosal branch of the facial
pterygopalatine
ganglion? nerve (CNVII).
o Postsynaptic parasympathetic fibres leave the ganglion and distribute
with branches of the maxillary nerve (CNV2).
▪ These fibres are secretomotor in function, and
provide parasympathetic innervation to the lacrimal gland, and
muscosal glands of the oral cavity, nose and pharynx.
• Maxillary Artery:
Course of the o The maxillary artery is a terminal branch of the external carotid artery.
maxillary artery o The terminal portion of the maxillary artery lies within the
and its branches pterygopalatine fossa.
through the
pterygopalatine
o Here, it separates into several branches which travel through other
fossa? openings within the fossa to reach the regions they supply.
o These branches include, but are not limited to:
▪ Sphenopalatine artery (to the nasal cavity).
▪ Descending palatine artery – branches into greater and lesser
palatine arteries (hard and soft palates).
▪ Infraorbital artery (lacrimal gland, and some muscles of the eye).
▪ Posterior superior alveolar artery (to the teeth and gingiva).
o At their terminal ends, the sphenopalatine and greater palatine arteries
anastomose at the nasal septum.
Fig 4.0 – Branches of the maxillary artery and their related foramina and cavities.
Foramina:
• Pterygomaxillary Fissure:
Pterygomaxillary o The pterygomaxillary fissure connects the infratemporal fossa with the
fissure? pterygopalatine fossa.
o It transmits two neurovascular structures:
▪ Posterior superior alveolar nerve – a branch of the maxillary
nerve. It exits through the fissure into the infratemporal fossa,
where it goes on to supply the maxillary molars.
▪ Terminal part of the maxillary artery – enters the
pterygopalatine fossa via the fissure.
• Foramen Rotundum:
Foramen o The foramen rotundum connects the pterygopalatine fossa to
rotundum? the middle cranial fossa.
o It is one of three openings in the posterior boundary of the
pterygopalatine fossa.
o It conducts a single structure, the maxillary nerve.
• Pterygoid and Pharyngeal Canals:
Pterygoid o These two canals, along with the foramen rotundum, are the three
canal? openings in the posterior wall of the pterygopalatine fossa:
▪ Pterygoid canal – runs from the middle cranial fossa and through
the medial pterygoid plate. It carries the nerve, artery and vein
Pharyngeal of the pterygoid canal.
canal? ▪ Pharyngeal canal – communicates with the nasopharynx. It
carries the pharyngeal branches of the maxillary nerve and
artery.
• Inferior Orbital Fissure:
Inferior orbital o The inferior orbital fissure forms the superior boundary of the
fissure? pterygopalatine fossa and communicates with the orbit.
o It is a space between the sphenoid and maxilla bones.
64 | H J ’ s H Y H & N | اکس ج ی وس گی
4. The Infratemporal Fossa, Pterygopalatine Fossa, and TMJ
o The zygomatic branch of the maxillary nerve and the infraorbital artery
and vein pass through the inferior orbital fissure.
• Greater Palatine Canal:
Greater o The greater palatine canal lies in the inferior boundary of the
palatine canal? pterygopalatine fossa.
o Communicates with the oral cavity.
o Branching from the greater palatine canal are the accessory lesser
palatine canals.
o The greater palatine canal transmits the descending palatine artery and
vein, the greater palatine nerve and the lesser palatine nerve.
• Sphenopalatine Foramen:
Sphenopalatine o This foramen is the only opening in the medial boundary.
foramen? o It connects the pterygopalatine fossa to the nasal cavity – specifically
the superior meatus.
o The sphenopalatine foramen transmits the sphenopalatine artery and
vein, as well as the nasopalatine nerve (a large branch of the
pterygopalatine ganglion – CNV2).
Articulating Surfaces:
Articulating
surfaces of the • The temporomandibular joint consists of articulations between three surfaces;
TMJ?
the mandibular fossa and articular tubercle (from the squamous part of
the temporal bone), and the head of mandible.
• This joint has a unique mechanism; the articular surfaces of the bones never
come into contact with each other – they are separated by an articular disk.
• The presence of such a disk splits the joint into two synovial joint cavities, each
lined by a synovial membrane.
Ligaments:
Ligaments of
the TMJ? • There are three extracapsular ligaments. They act to stablise the
temporomandibular joint.
o Lateral ligament – runs from the beginning of the articular tubule to the
mandibular neck. It is a thickening of the joint capsule, and acts to
prevent posterior dislocation of the joint.
o Sphenomandibular ligament – originates from the sphenoid spine, and
attaches to the mandible.
o Stylomandibular ligament – a thickening of the fascia of the parotid
gland. Along with the facial muscles, it supports the weight of the jaw.
Fig 2 – The joint capsule and accessory ligaments of the temporomandibular joint.
Movements:
Movements
around the TMJ • Movements at this joint are produced by the muscles of mastication, and the
and associated
muscles?
hyoid muscles.
• Protrusion and Retraction:
o The upper part of the joint allows protrusion and retraction of the
mandible – the anterior and posterior movements of the jaw.
o The lateral pterygoid muscle is responsible for protrusion (assisted by
the medial pterygoid).
o The posterior fibres of the temporalis perform retraction.
o A lateral movement (i.e. for chewing and grinding) is achieved by
alternately protruding and retracting the mandible on each side.
• Elevation and Depression:
o The lower part of the joint permits elevation and depression of the
mandible; opening and closing the mouth.
o Depression is mostly caused by gravity.
▪ However, if there is resistance, the digastric, geniohyoid, and
mylohyoid muscles assist.
o Elevation is very strong movement, caused by the contraction of
the temporalis, masseter, and medial pterygoid muscles.
• Clinical Correlate: Temporomandibular Joint Dislocation
Nerves that o A dislocation of the temporomandibular joint can occur via a blow to the
can be side of the face, yawning, or taking a large bite.
damaged in a o The head of the mandible ‘slips’ out of the mandibular fossa, and is
TMJ
pulled anteriorly.
dislocation?
o The patient becomes unable to close their mouth.
o The facial and auriculotemporal nerves run close to the joint, and can
be damaged if the injury is high-energy.
Recommended Videos
Noted Anatomist:
• ‘Oral cavity’
o Runtime: 6:13
o (https://youtu.be/egpicHMYwU4)
• ‘Parotid gland’
o Runtime: 3:17
o (https://youtu.be/Zb6pZMF-rMM)
Sam Webster:
• ‘Oral cavity anatomy’
o Runtime: 14:58
o (https://youtu.be/9xVGxuUB3P0)
• ‘Muscles of the tongue (anatomy)’
o Runtime: 21:43
o (https://youtu.be/lATWhP0wJ5c)
• ‘Cranial nerves of the tongue’
o Runtime: 12:15
o (https://youtu.be/lQrCSYqJBX4)
• ‘Salivary glands (anatomy)’
o Runtime: 19:50
o (https://youtu.be/gdq8mjsWRkk)
Anatomy Knowledge:
• ‘Muscles of the Tongue | Anatomy tutorial’
o Runtime: 3:42
o (https://youtu.be/umNW_PvKsPE)
Divisions:
• It is divided into two parts by the upper and lower dental arches (formed by the
teeth and their bony scaffolding).
• The two divisions of the oral cavity are the vestibule and the mouth cavity
proper.
• Vestibule:
o It is the space between the lips/cheeks, and the gums/teeth.
o The vestibule communicates with the mouth proper via the space
behind the third molar.
• Mouth Proper:
Borders of the o The mouth proper lies posteriorly to the vestibule.
mouth proper? o It is bordered by a roof, a floor, and the cheeks.
o Roof: The roof of the mouth proper consists of the hard and soft
palates.
o Cheeks: are formed by the buccinator muscle.
▪ Innervated by the buccal branches of the facial nerve (CN VII).
o Floor: The floor of the oral cavity consists of several structures:
▪ Muscular diaphragm – comprised of the bilateral mylohyoid
muscles. It provides structural support to the floor of the mouth,
and pulls the larynx forward during swallowing.
▪ Geniohyoid muscles – pull the larynx forward during swallowing.
▪ Tongue – connected to the floor by the frenulum of the tongue, a
fold of oral mucosa.
▪ Salivary glands and ducts.
Fig 1 – The two divisions of the oral cavity are the vestibule and oral cavity proper.
The Palate
(https://teachmeanatomy.info/head/other/palate/)
• The palate divides the nasal cavity and the oral cavity.
• The hard palate positioned anteriorly and the soft palate posteriorly.
• It forms both the roof of the mouth and the floor of the nasal cavity.
• Reflecting this, the superior and inferior palatal surfaces have different mucosal
linings:
o Superior aspect of palate (nasal cavity) – respiratory epithelium.
o Inferiorly aspect of palate (oral cavity) – oral mucosa, populated by
secretory salivary glands.
Fig 1 – The palate separates the nasal cavity from the oral cavity
Fig 2 – The hard palate is formed by the contributions from the maxilla and palatine bones.
The Tongue
(https://teachmeanatomy.info/head/muscles/tongue/)
• Is attached by muscles to the hyoid bone, mandible, styloid process, palate, and
pharynx.
• Is divided into two parts by a V-shaped sulcus terminalis - an anterior two-thirds
and a posterior one-third-which differ developmentally, structurally, and in
innervation.
• The foramen cecum is located at the apex of the "V" and indicates the site of
origin of the embryonic thyroglossal duct.
• A fold of tissue called the lingual frenulum extends from the floor of the mouth
to the inferior surface of the tongue.
• The lingual tonsil is a collection of nodular masses of lymphoid follicles on the
posterior one-third of the dorsum of the tongue.
Lingual Papillae:
Types of lingual
papillae? • Are small, nipple-shaped projections on the anterior two-thirds of the dorsum
of the tongue.
• Are divided into the vallate, fungiform, filiform, and foliate papillae.
• Vallate papillae:
o Are arranged in the form of a “V” in front of the sulcus terminalis.
o Are studded with numerous taste buds and are innervated by the
glossopharyngeal nerve.
• Fungiform papillae:
o Are mushroom-shaped projections with red heads.
o Are scattered on the sides and the apex of the tongue.
• Filiform papillae:
o Are numerous, slender, conical projections.
o Are arranged in rows parallel to the sulcus terminalis.
• Foliate papillae:
o Are found in certain animals but are rudimentary in humans.
• Hyoglossus:
o Depresses and retracts the tongue
• Styloglossus:
o Retracts and elevates the tongue
• Palatoglossus:
o Elevates the posterior aspect of the tongue
o ONLY muscle of the tongue not to be innervated by the hypoglossal
nerve (CNXII). It receives motor innervation via the vagus nerve (CNX)
Fig 1 – The extrinsic muscles of the tongue. Note the palatoglossus muscle is not included in this
illustration.
Vasculature:
Vasculature of
the tongue? • The lingual artery (branch of the external carotid) does most of the supply.
• Drainage is by the lingual vein.
o Nitroglycerin, a vasodilator used in cases of angina pectoris is absorbed
via the deep lingual veins, located on the side of frenulum linguae
Fig 1.2 – The lingual nerve provides sensory innervation to the to the 2/3 of the tongue.
Lymphatic Drainage:
Lymphatic
drainage of the
• Anterior two thirds – initially into the submental and submandibular nodes,
tongue?
which empty into the deep cervical lymph nodes
• Posterior third – directly into the deep cervical lymph nodes
Fig 1.0 – Position of the parotid gland and borders of the parotid region.
• Anatomical relationships:
Anatomical o The facial nerve (cranial nerve VII), gives rise to five terminal branches
relationships of within the parotid gland.
the parotid?
▪ These branches innervate the muscles of facial expression.
o The external carotid artery (ECA) ascends through the parotid gland.
▪ Within the gland, the ECA gives rise to the posterior auricular
artery.
▪ The ECA then divides into its two terminal branches – the
maxillary artery and superficial temporal artery.
o The retromandibular vein is formed within the parotid gland by the
convergence of the superficial temporal and maxillary veins.
▪ It is one of the major structures responsible for venous drainage
of the face.
• Innervation:
Innervation of o The parotid gland receives sensory and autonomic innervation.
the parotid?
o The autonomic innervation controls the rate of saliva production.
▪ Secretes copious watery saliva with parasympathetic stimulation
and produces a small amount of viscous saliva when under
sympathetic control
o Sensory innervation is supplied by the auriculotemporal nerve (gland)
and the great auricular nerve (fascia).
o The parasympathetic innervation to the parotid gland has a complex
path.
▪ It begins with the glossopharyngeal nerve (cranial nerve IX).
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
oropharyngeal
Borders
triangle?of the
oropharyngeal
triangle?
Borders of the
93 | H J ’ s H Y H & N | اکس ج ی وس گی
oropharyngeal
triangle?
5. The Oral Cavity
(Blank)
Recommended Videos
Sam Webster:
• ‘Nose bones’
o Runtime: 16:56
o (https://youtu.be/tgxb9-jyPkQ)
• ‘Paranasal air sinuses’
o Runtime: 17:32
o (https://youtu.be/nLDEt0JzyyI)
Armando Hasudungan:
• ‘Clinical Anatomy - Nasal Cavity and Sinuses’
o Runtime: 7:54
o (https://youtu.be/iwwFPQk7SJU)
• The bones that contribute to the nasal septum can be divided into:
o Paired bones: Nasal, maxillary and palatine bones
o Unpaired bones: Ethmoid and vomer bones.
• In addition to the bones of the nose, the septal and greater alar cartilages also
constitute part of the nasal septum.
• The floor of the nasal cavity is formed by the hard palate
• The cribriform plate of the ethmoid bone forms the roof of the nasal cavity.
Structures
forming the
nasal septum?
• Whilst the skin over the bony part of the nose is thin, that overlying the
cartilaginous part is thicker with many sebaceous glands.
o This skin extends into the vestibule of the nose via the nares. Here there
are hairs which function to filter air as it enters the respiratory system.
• Functions:
Functions of o Warms and humidifies the inspired air.
the nasal o Removes and traps pathogens and particulate matter from the inspired
cavity? air.
o Responsible for sense of smell.
o Drains and clears the paranasal sinuses and lacrimal ducts.
• Has three divisions:
Divisions of the o Vestibule – the area surrounding the anterior external opening to the
nasal cavity? nasal cavity.
o Respiratory region – lined by a ciliated psudeostratified epithelium,
interspersed with mucus-secreting goblet cells.
o Olfactory region – located at the apex of the nasal cavity. It is lined by
olfactory cells with olfactory receptors.
• Opens on the face through the anterior nasal apertures (nares or nostrils) and
communicates with the nasopharynx through a posterior opening, the choanae.
Fig 1 – Sagittal section of the nasal cavity. Conchae are present on the lateral walls
• Projecting out of the lateral walls of the nasal cavity are curved shelves of bone.
Bones forming They are called conchae (or turbinates).
the conchae? o There are three conchae – inferior, middle and superior.
o inferior nasal concha is formed by an independent bone (of the same
name, inferior concha).
o superior and middle nasal conchae arise from the perpendicular plate of
the ethmoid bone.
• They project into the nasal cavity, creating four pathways for the air to flow.
These pathways are called meatuses:
o Inferior meatus – between the inferior concha and floor of the nasal
cavity.
o Middle meatus – between the inferior and middle concha.
o Superior meatus – between the middle and superior concha.
o Spheno-ethmoidal recess – superiorly and posteriorly to the superior
concha.
• The function of the conchae is to increase the surface area of the nasal cavity –
Functions of this increases the amount of inspired air that can come into contact with the
the conchae? cavity walls.
o They also disrupt the fast, laminar flow of the air, making it slow and
turbulent.
o The air spends longer in the nasal cavity, so that it can be humidified.
Fig 2 – Coronal section of the anterior nasal cavity. The spheno-ethmoidal recess is located posteriorly,and
not visible on this diagram
o The only structure not to empty out onto the lateral walls of the nasal
cavity is the sphenoid sinus. It drains onto the posterior roof (in the
spheno-ethmoidal recess).
• In addition to the paranasal sinuses, other structures open into the nasal cavity:
o Nasolacrimal duct – acts to drain tears from the eye. It opens into the
inferior meatus.
o Auditory (Eustachian) tube – opens into the nasopharynx at the level of
the inferior meatus.
▪ It allows the middle ear to equalise with the atmospheric air
pressure.
• Clinical Correlate: As the auditory tube connects the middle ear and upper
respiratory tract, it is a path by which infection can spread from the upper
respiratory tract to the ear.
o Infection of the auditory tube causes swelling of the mucous linings, and
the tube becomes blocked. This results in diminished hearing.
Fig 3 – The conchae have been removed, showing the various openings on the lateral wall of the nasal
cavity.
o The incisive canal is a pathway between the nasal cavity and the incisive
fossa of the oral cavity.
▪ It transmits the nasopalatine nerve and greater palatine artery.
o Other routes by which vessels and nerves get into and out of the nasal
cavity include the nares and small foramina in the lateral wall.
Kiesselbach’s Plexus:
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
Septal and lateral nasal branches of posterior ethmoidal artery Greater palatine artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
artery
anterior ethmoidal
Sphenopalatine artery artery
• The innervation of the nose can be functionally divided into special (SVA) and
Innervation of general innervation (GSA).
the nose? o Special sensory innervation refers to the ability of the nose to smell.
▪ This is carried out by the olfactory nerves.
▪ The olfactory bulb, part of the brain, lies on the superior surface
of the cribriform plate, above the nasal cavity.
▪ Branches of the olfactory nerve run through the cribriform plate
to provide special sensory innervation to the nose.
o General sensory innervation to the septum and lateral walls is delivered
by the:
▪ nasopalatine nerve (branch of maxillary nerve)
▪ nasociliary nerve (branch of the ophthalmic nerve).
▪ Innervation to the external skin of the nose is supplied by
the trigeminal nerve.
o parasympathetic control of nasal mucous glands is via branches of the
facial nerve
• Clinical Correlate: A fracture of the cribriform plate can occur as a result of
nose trauma.
o A fractured cribriform plate can penetrate the meningeal linings of the
brain, causing leakage of cerebrospinal fluid.
▪ Exposing the brain to the outside environment like this increases
the risks of meningitis, encephalitis and cerebral abscesses.
o The olfactory bulb lies on the cribriform plate and can be damaged
irreversibly by the fracture.
▪ In this case, the patient may present with anosmia (loss of
smell).
Fig 5 – Lateral view of the nasal septum. Note the close relationship of the olfactory bulb and
cribriform plate
Miscellaneous:
Frontal Sinuses:
• There are two frontal sinuses located within the frontal bone of the skull.
Drainage of the o They are the most superior of the paranasal sinuses.
frontal sinuses? o Are triangular in shape.
o Drainage is via the frontonasal duct.
▪ It opens out at the hiatus semilunaris, within the middle meatus.
o Sensation is supplied by the supraorbital nerve (a branch of the
ophthalmic nerve)
o arterial supply is via the anterior ethmoidal artery (a branch of the
ophthalmic artery from the internal carotid).
• Clinical Correlate: Frontal sinusitis is an inflammation in the frontal sinus that
Spread of may erode the thin bone of the anterior cranial fossa, producing meningitis or
frontal brain abscess.
sinusitis?
Sphenoid Sinuses:
• The sphenoid sinuses are situated within the body of the sphenoid bone.
Drainage of the o They open out into the nasal cavity in an area supero-posterior to the
sphenoid superior concha – known as the spheno-ethmoidal recess.
sinuses?
o They are innervated by the posterior ethmoidal nerve (a branch of the
ophthalmic nerve), and branches of the maxillary nerve.
o They are vascularized by the posterior ethmoidal arteries, branches of
the ophthalmic artery
o Are closely related to important structures of the brain including the:
Structures ▪ optic nerves and optic chiasm
closely related
to the sphenoid
▪ pituitary gland
sinuses? ▪ internal carotid arteries
▪ cavernous sinuses
Ethmoidal Sinuses:
• The ethmoidal sinuses, or commonly known as ethmoidal cells, are small spaces
Drainage of the located in the ethmoid bone.
ethmoidal o Consists of numerous ethmoidal air cells, which are numerous small
sinuses? cavities within the ethmoidal labyrinth
o They are located between the nasal cavity and the orbit.
o These cells can be divided into three groups:
Drainage of the ▪ The anterior ethmoidal cells: are drained to the middle nasal
ethmoidal meatus via the ethmoidal infundibulum.
sinuses?
113 | H J ’ s H Y H & N | اکس جی وس گی
Drainage of the
ethmoidal
6. The Nose and Paranasal Sinuses
▪ The middle ethmoidal cells are drained into the middle nasal
meatus. Form a bulge on the middle nasal meatus (ethmoidal
bulla)
▪ The posterior ethmoidal cells are drained into the superior nasal
meatus.
o Innervated by the anterior and posterior ethmoidal branches of the
nasociliary nerve, the branches of the ophthalmic nerve (CN V1).
o The blood supply is provided via the anterior and posterior ethmoidal
arteries.
• Clinical Correlate: Ethmoidal sinusitis is an inflammation in the ethmoidal
Spread of sinuses that may erode the medial wall of the orbit, causing an orbital cellulitis
ethmoidal that may spread to the cranial cavity.
sinusitis?
Maxillary Sinuses:
• The maxillary sinuses are the largest and the most inferior of the paranasal
sinuses.
o They are situated deep in the bodies of the maxillae.
o Each maxillary sinus is drained by one or more openings (maxillary ostia)
Drainage of the into the middle nasal meatus.
maxillary ▪ Similar to the frontal sinuses, the maxillary sinuses are also
sinuses? drained at the semilunar hiatus.
▪ They drain underneath the frontal sinus opening at the
semilunar hiatus. This is a potential pathway for spread of
infection – fluid draining from the frontal sinus can enter the
maxillary sinus.
o Is the only paranasal sinus that may be present at birth.
o innervated by the anterior, middle, and posterior superior alveolar
nerves, branches of the maxillary nerve (CN V2).
o The blood supply comes from the superior alveolar branches of the
maxillary artery.
114 | H J ’ s H Y H & N | اکس جی وس گی
6. The Nose and Paranasal Sinuses
• Clinical Correlate: Maxillary sinusitis mimics the clinical signs of maxillary tooth
Why is the abscess
maxillary sinus o The maxillary sinus is the paranasal sinus that is most commonly
prone to
affected by sinusitis
sinusitis?
▪ This is because their ostia (openings) are commonly small and
are located high on their superomedial walls.
o In most cases, it is related to an infected tooth.
o Infection may spread from the maxillary sinus to the upper teeth and
Spread of irritate the nerves to these teeth, causing toothache.
maxillary ▪ The maxillary nerve supplies both the maxillary sinus and
sinusitis? maxillary teeth, and so inflammation of that sinus can present
with toothache.
o It may be confused with toothache because only a thin layer of bone
separates the roots of the maxillary teeth from the sinus cavity.
• Clinical Correlate: Caldwell-Luc operation, or Radical antrostomy, is an
operation to remove irreversibly damaged mucosa of the maxillary sinus.
o The approach is mainly from the anterior wall of the maxilla bone.
o The maxillary sinus is entered from two separate openings, one in the
canine fossa to gain access to the antrum and other in the naso antral
wall for drainage.
Maxillary sinus
(Blank)
Recommended Videos
Sam Webster:
• ‘Bones of the orbit’
o Runtime: 17:26
o (https://youtu.be/s6j50KNzATE)
• ‘Muscles of the eye - extraocular muscles and movements’
o Runtime: 24:50
o (https://youtu.be/lDGCT9e-MWg)
AnatomyZone:
• ‘Eyeball Anatomy’
o Runtime: 9:54
o (https://youtu.be/7lBtlGvS1Gc)
• ‘Eyeball | Blood Supply’
o Runtime: 3:23
o (https://youtu.be/_aGL9dU-Lnk)
• ‘Orbit | Eye Anatomy’
o Runtime: 7:05
o (https://youtu.be/HKEA4p5k66U)
• ‘Extraocular Muscles | Eye Anatomy’
o Runtime: 10:13
o (https://youtu.be/f_rb6FMVHPk)
Contents:
• The bony orbit contains the eyeballs and their associated structures.
• Extra-ocular muscles – They are responsible for the movement of the eyeball
and superior eyelid.
• Eyelids – These cover the orbits anteriorly.
• Nerves: Several cranial nerves supply the eye and its
structures; optic, oculomotor, trochlear, trigeminal and abducens nerves.
• Blood vessels: The eye receives blood primarily from the ophthalmic artery.
Venous drainage is via the superior and inferior ophthalmic veins.
• Any space within the orbit that is not occupied is filled with orbital fat.
o This tissue cushions the eye, and stabilises the extraocular muscles.
• The interior surface of the eyelid is a mucous membrane called the palpebral
conjunctiva.
o The palpebral conjunctiva is reflected onto the eyeball, where it is then
called the bulbar conjunctiva.
o The bulbar conjunctiva is continuous with the corneal epithelium.
o The palpebral and bulbar conjunctiva enclose a space called the
conjunctival sac.
• There are three important muscles associated with the eyelid, which include the
Muscles of the following:
eyelid and
o Levator palpebrae superioris muscle:
innervation?
▪ This skeletal muscle is located in the upper eyelid and attaches
to the skin of the upper eyelid
▪ This muscle is innervated by CN III and its function is to keep the
eye open (main player).
o Superior tarsal muscle:
▪ This smooth muscle is located in the upper eyelid.
▪ This muscle is innervated by postganglionic sympathetic neurons
that follow the carotid arterial system
▪ Its function is to keep the eye open (minor player).
o Orbicularis oculi muscle (palpebral portion).
▪ This skeletal muscle is located in the upper and lower eyelids.
▪ This muscle is innervated by CN VII
▪ Its function is to close the eye.
Fig 2 – Sagittal section of the orbit, demonstrating the layers of the eyelid.
• Parasympathetic innervation:
Parasymp. o The preganglionic parasympathetic neuronal cell bodies are located in
Innervation of superior salivatory nucleus and lacrimal nucleus.
the lacrimal
gland?
o Preganglionic axons from the superior salivatory nucleus and the
lacrimal nucleus run with CN VII (by way of the nervus intermedius,
greater petrosal nerve, and the nerve of the pterygoid canal) and enter
the pterygopalatine ganglion, where they synapse with post-ganglionic
parasympathetic neurons.
o Postganglionic axons leave the pterygopalatine ganglion and run with
the zygomaticofacial branch of CN V2 and the lacrimal branch of CN V1
to innervate the lacrimal gland.
Note: Watch the Sam Webster and Noted Anatomist videos to understand the concepts
behind the movements produced by each muscle and the concepts underlying
extraocular muscle testing.
• They act to control the movements of the eyeball and the superior eyelid.
o Responsible for eye movement – Recti and oblique muscles.
o Responsible for superior eyelid movement – Levator palpebrae
superioris.
• Levator Palpebrae Superioris:
o Only muscle involved in raising the superior eyelid.
o A small portion of this muscle contains a collection of smooth muscle
fibres – known as the superior tarsal muscle.
▪ In contrast to the LPS, the superior tarsal muscle is innervated by
the sympathetic nervous system.
o Actions:
▪ Elevates the upper eyelid.
o Innervation: The levator palpebrae superioris is innervated by
the oculomotor nerve (CN III).
▪ The superior tarsal muscle (located within the LPS) is innervated
by the sympathetic nervous system.
Fig 1 – Attachment of the levator palpebrae superiors to the superior tarsal plate.
• Recti Muscles:
o These muscles characteristically originate from the common tendinous
ring.
▪ This is a ring of fibrous tissue, which surrounds the optic canal
and the medial part of the superior orbital fissure at the back of
the orbit.
o From their origin, the muscles pass anteriorly to attach to the sclera of
the eyeball.
127 | H J ’ s H Y H & N | اکس جی وس گی
7. The Orbit and the Eye
• Superior Rectus:
Superior rectus: o Actions:
actions and
▪ Main movement is elevation.
innervation?
▪ Also contributes to adduction and medial rotation of the eyeball.
o Innervation: Oculomotor nerve (CN III).
• Inferior Rectus:
Inferior rectus: o Actions:
actions and ▪ Main movement is depression.
innervation?
▪ Also contributes to adduction and lateral rotation of the eyeball.
o Innervation: Oculomotor nerve (CN III).
• Medial Rectus:
Medial rectus:
actions and
o Actions:
innervation? ▪ Adducts the eyeball.
o Innervation: Oculomotor nerve (CN III).
• Lateral Rectus:
Lateral rectus: o Actions:
actions and ▪ Abducts the eyeball.
innervation?
o Innervation: Abducens nerve (CN VI).
• Oblique muscles:
o From their origin, the oblique muscles take an angular approach to the
eyeball (in contrast to the straight approach of the recti muscles).
o They attach to the posterior surface of the sclera.
o Unlike the recti group of muscles, they do not originate from the
common tendinous ring.
• Superior Oblique:
Superior o Its tendon passes through a trochlea and then attaches to the sclera of
oblique: the eye, posterior to the superior rectus.
actions and
o Actions:
innervation?
▪ Depresses,
▪ abducts and
▪ medially rotates the eyeball.
o Innervation: Trochlear nerve (CN IV).
• Inferior Oblique:
Inferior o Actions:
oblique: ▪ Elevates,
actions and
innervation?
▪ abducts and
▪ laterally rotates the eyeball.
o Innervation: Oculomotor nerve (CN III).
Fig 3 – Right oculomotor nerve palsy, characterised by the ‘down and out’ dilated pupil with ipsilateral
ptosis
Clinical testing
of extraocular
muscle
function?
The Eyeball
(https://teachmeanatomy.info/head/organs/eye/eyeball/)
Fibrous Layer:
Vascular Layer:
• The vascular layer of the eye lies underneath the fibrous layer.
• It consists of the choroid, ciliary body and iris:
• Choroid – layer of connective tissue and blood vessels.
o The choroid is a pigmented vascular bed that lies immediately deep to
the corneoscleral tunic.
o It provides nourishment to the outer layers of the retina.
o The profound vascularity of the choroid is responsible for the “red eye”
that occurs with flash photography.
• Ciliary body – comprised of two parts – the ciliary muscle and ciliary processes.
o The ciliary muscle consists of a collection of smooth muscles fibres.
▪ Is circularly arranged around the entire circumference of the
ciliary body
▪ These are attached to the lens of the eye by the ciliary processes.
o The ciliary body controls the shape of the lens, and contributes to the
formation of aqueous humor.
o The ciliary muscle is innervated by the parasympathetic nervous system.
Innervation of ▪ The preganglionic parasympathetic neuronal cell bodies are
the ciliary located in the Edinger-Westphal nucleus of CN III.
muscle? ▪ Preganglionic axons from the Edinger-Westphal nucleus travel
with CN III and enter the ciliary ganglion, where they synapse
with postganglionic parasympathetic neurons.
▪ Postganglionic axons leave the ciliary ganglion, where they travel
with the short ciliary nerves to innervate the ciliary muscle.
o Accommodation is the process by which the lens becomes rounder to
Action of the focus a nearby object or flatter to focus a distant object.
ciliary muscle in ▪ For close vision (e.g., reading), the ciliary muscle contracts,
accommodation? which reduces tension on the zonular fibers attached to the lens
and thereby allows the lens to take a rounded shape.
▪ For distant vision, the ciliary muscle relaxes, which increases
tension on the zonular fibers attached to the lens and thereby
allows the lens to take a flattened shape.
Inner Layer:
• The inner layer of the eye is formed by the retina; its light detecting component.
• The retina is composed of two layers:
o Pigmented (outer) layer
▪ Formed by a single layer of cells.
▪ It is attached to the choroid and supports the choroid in
absorbing light (preventing scattering of light within the eyeball).
▪ It continues around the whole inner surface of the eye.
o Neural (inner) layer
▪ Consists of photoreceptors, the light detecting cells of the retina.
▪ It is located posteriorly and laterally in the eye.
• The intraretinal space separates the outer pigment epithelium from the inner
neural retina.
o Although the intraretinal space is obliterated in the adult, it remains a
weakened area prone to retinal detachment.
• Anteriorly, the pigmented layer continues but the neural layer does not
o This is part is known as the non-visual retina.
o Posteriorly and laterally, both layers of the retina are present. This is
the optic part of the retina.
• The optic part of the retina can be viewed during ophthalmoscopy.
Structures • The centre of the retina is marked by an area known as the macula.
visible on o It is yellowish in colour.
funduscopy?
o Lateral (temporal side) to the optic disc along the visual axis.
• The macula contains a depression called the fovea centralis, which has a high
concentration of light detecting cells.
o It is the area responsible for high acuity vision.
o The fovea centralis contains only cones (no rods or capillaries) that are
arranged at an angle so that light directly impinges on the cones
without passing through other layers of the retina and is linked to a
single ganglion, both of which contribute to visual acuity.
• The area that the optic nerve enters the retina is known as the optic disc
o The optic disc lacks rods and cones and is therefore a blind spot.
o The central artery and vein of the retina pass through the optic disc.
• The globe is divided into two cavities by the lens: The anterior cavity and
Divisions of the posterior cavity.
globe? o The anterior cavity consists of the anterior chamber (the area between
the cornea and iris) and the posterior chamber (the area between the
iris and lens).
▪ These chambers are filled with the watery aqueous humor that is
secreted by the epithelium of the ciliary body.
▪ Aqueous humor a clear plasma-like fluid that nourishes and
protects the eye.
▪ The aqueous humor is produced constantly, and drains via the
trabecular meshwork, an area of tissue at the base of the
cornea, near the anterior chamber.
o The posterior cavity consists of the vitreous chamber (the area between
the lens and retina).
▪ The vitreous chamber is filled with the vitreous body (a jelly-like
substance) and vitreous humor (a watery fluid), which hold the
retina in place and support the lens.
• Vitreous Body:
o The vitreous body is a transparent gel which fills the posterior cavity of
the eyeball (the area posterior to the lens).
o It is marked by a narrow canal which runs from the optic disc to the lens
– the hyaloid canal.
▪ This is a fetal remnant.
o The vitreous body has three main functions:
▪ Contributes to the magnifying power of the eye
▪ Supports the lens
▪ Holds the layers of the retina in place
• Lens:
o The lens of the eye is located anteriorly, between the vitreous humor
and the pupil.
o The shape of the lens is altered by the ciliary body, altering its refractive
power.
Note:
• The globe of the eye consists of three concentric tunics that make up the wall of
Layers of the the eye:
globe? o Corneoscleral Tunic
▪ This is the outermost fibrous tunic.
▪ Consists of the cornea, sclera, and corneoscleral junction
(limbus).
o Uveal Tunic
▪ This is the middle vascular tunic.
▪ Consists of the choroid, stroma of the ciliary body, and stroma
of the iris.
o Retinal Tunic
▪ This is the innermost tunic.
▪ Consists of the outer pigment epithelium and the inner neural
retina (posteriorly), the epithelium of the ciliary body
(anteriorly), and the epithelium of the iris (anteriorly).
o Closed-angle Glaucoma
▪ Occurs when the trabecular network is closed usually due to an
inflammatory process of the uvea (uveitis) (e.g., infection by
cytomegalovirus).
▪ It is an ophthalmic emergency, which can rapidly lead to
blindness.
Vasculature:
• The eyeball receives arterial blood primarily via the ophthalmic artery.
Arterial supply o This is a branch of the internal carotid artery.
of the eye? • The ophthalmic artery gives rise to many branches, which supply different
components of the eye:
o Central artery of the retina
▪ Is the most important branch of the ophthalmic artery.
▪ Travels in the optic nerve; it divides into superior and inferior
branches to the optic disk,
▪ Is a terminal artery that does not anastomose with other
arteries, and, thus, its occlusion results in blindness.
o Long posterior ciliary arteries
▪ Pierce the sclera and run between the sclera and the choroid
layers.
▪ Form the circulus arteriosus major around the iris, which run
inwards to form a smaller circle of arteries (the circulus
arteriosus minor).
▪ Supply the ciliary body and the iris.
o Short posterior ciliary arteries
▪ Pierce the sclera at the back of the eye and run between
the sclera and choroid.
▪ Supply the choroid.
o Anterior ciliary arteries
▪ Pass forwards to the anterior aspect of the eyeball, where they
pierce the sclera, near the cornea.
▪ Terminate in the circulus arteriosus major, that surrounds the
iris.
The Ear
8. The Ear
Recommended Videos
Sam Webster:
• ‘Ear anatomy introduction’
o Runtime: 7:18
o (https://youtu.be/ZQcZkhLQ_tg)
• ‘Cochlea (ear anatomy)’
o Runtime: 26:53
o (https://youtu.be/A85IfgDjkcQ)
• ‘Vestibular apparatus (inner ear anatomy)’
o Runtime: 24:27
o (https://youtu.be/cv5Fnvn7sPE)
Armando Hasudungan:
• ‘Anatomy - Ear Overview’
o Runtime: 5:18
o (https://youtu.be/qYv9V2qna6I)
• ‘Understanding Ear Pain - Otalgia (Innervation of ear, mechanism of ear pain
and causes)’
o Runtime: 8:11
o (https://youtu.be/hW2_ZcofmNg)
• ‘Anatomy - Middle Ear’
o Runtime: 7:23
o (https://youtu.be/-OuFKmZSZoY)
• The ear can be divided into three parts; external, middle and inner.
• The external ear can be divided functionally and structurally into two parts; the
auricle (or pinna), and the external acoustic meatus – which ends at the
tympanic membrane.
The Auricle:
• It functions to capture and direct sound waves towards the external acoustic
meatus.
• It is a mostly cartilaginous structure, with the lobule being the only part not
supported by cartilage.
• The cartilaginous part of the auricle forms an outer curvature, known as
the helix.
• A second innermost curvature runs in parallel with the helix – the antihelix.
o The antihelix divides into two cura; the inferoanterior crus, and the
superoposterior crus.
• In the middle of the auricle is a hollow depression, called the concha.
o It continues into the skull as the external acoustic meatus.
o The concha acts to direct sound into the external acoustic meatus.
• Immediately anterior to the beginning of the external acoustic meatus is an
elevation of cartilaginous tissue – the tragus.
• Opposite the tragus is the antitragus.
• The external acoustic meatus is a sigmoid shaped tube that extends from the
deep part of the concha to the tympanic membrane.
• The tympanic membrane lies at the distal end of the external acoustic meatus.
• It is a connective tissue structure, covered with skin on the outside and a
mucous membrane on the inside.
• The membrane is connected to the surrounding temporal bone by a
fibrocartilaginous ring.
• The translucency of the tympanic membrane allows the structures within the
middle ear to be observed during otoscopy.
• On the inner surface of the membrane, the handle of malleus attaches to the
tympanic membrane, at a point called the umbo of tympanic membrane.
Fig 2 – The middle ear. The two main parts of the middle ear have been labelled.
Borders:
• The middle ear can be visualised as a rectangular box, with a roof and floor,
medial and lateral walls and anterior and posterior walls.
• Roof:
Roof of the o Known as the tegmental wall.
middle ear? o Formed by a thin bone from the petrous part of the temporal bone
(known as the tegmen tympani).
o It separates the middle ear from the middle cranial fossa.
• Floor:
Floor of the o Known as the jugular wall.
middle ear? o It consists of a thin layer of bone, which separates the middle ear from
the internal jugular vein.
• Lateral wall:
Lateral wall of o Known as the membranous wall.
the middle ear?
o Made up of the tympanic membrane and the lateral wall of the
epitympanic recess.
• Medial wall:
Medial wall of o Known as the labyrinthine wall.
the middle ear? o Formed by the lateral wall of the internal ear.
o A prominent structure on this wall is a rounded bulge (the promontory)
produced by the cochlea.
▪ Associated with the promontory is the tympanic plexus.
▪ Consists primarily of contributions from the tympanic branch of
the glossopharyngeal nerve [IX] and branches from the internal
carotid plexus.
▪ Additionally, a branch of the tympanic plexus, the lesser petrosal
nerve, leaves the promontory and the middle ear.
o Other structures associated with the labyrinthine wall are two openings:
▪ The oval window is the point of attachment for the base of the
stapes. Transfers vibrations initiated by the tympanic membrane
to the cochlea of the internal ear.
▪ The round window: is closed by the mucous membrane of the
middle ear and accommodates pressure waves transmitted to
the perilymph of the scala tympani.
o Contains a prominent bulge (the prominence of the facial canal),
produced by the facial nerve as it travels nearby in its canal.
o Also contains the prominence of the lateral semicircular canal,
produced by the lateral semicircular canal
• Anterior wall:
Anterior wall of o A thin bony plate with two openings; for the auditory tube and the
the middle ear? tensor tympani muscle.
o It separates the middle ear from the internal carotid artery.
o The foramen for the exit of the chorda tympani nerve is also associated
with this wall.
• Posterior wall:
Posterior wall o Known as the mastoid wall.
of the middle o It consists of a bony partition between the tympanic cavity and the
ear?
mastoid air cells.
▪ Superiorly, there is a hole in this partition, allowing the two areas
to communicate. This hole is known as the aditus to the mastoid
antrum.
o Associated with the mastoid wall are:
▪ The pyramidal eminence, a small elevation through which the
tendon of the stapedius muscle enters the middle ear.
▪ The opening through which the chorda tympani nerve, a branch
of the facial nerve [VII], enters the middle ear.
Ossicles? • The bones of the middle ear are the auditory ossicles – the malleus, incus and
stapes.
• They are connected in a chain-like manner, linking the tympanic membrane to
the oval window of the internal ear.
• Sound vibrations cause a movement in the tympanic membrane which then
creates movement, or oscillation, in the auditory ossicles.
o This movement helps to transmit the sound waves from the tympanic
membrane of external ear to the oval window of the internal ear.
• The malleus:
o Is the largest and most lateral of the ear bones, attaching to the
tympanic membrane.
o Articulates with the next auditory ossicle, the incus.
• The incus:
o The body articulates with the malleus
o The long limb joins the last of the ossicles; the stapes.
• The stapes:
o Is the smallest bone in the human body.
o It joins the incus to the oval window of the inner ear.
o It is stirrup-shaped.
• The mastoid air cells are located posterior to the epitympanic recess.
• They are a collection of air-filled spaces in the mastoid process of
the temporal bone.
• The air cells are contained within a cavity called the mastoid antrum.
• The mastoid antrum communicates with the middle ear via the aditus to the
mastoid antrum.
• The mastoid air cells act as a ‘buffer system’ of air – releasing air into the
tympanic cavity when the pressure is too low.
Fig 1.2 – Coronal section of temporal bone, showing the mastoid air cells in more detail
• The auditory tube (eustachian tube) is a cartilaginous and bony tube that
connects the middle ear to the nasopharynx.
• It acts to equalise the pressure of the middle ear to that of the external
auditory meatus.
• It extends from the anterior wall of the middle ear, opening onto the lateral wall
of the nasopharynx.
• In joining the two structures, it is a pathway by which an upper respiratory
infection can spread into the middle ear.
o The tube is shorter and straighter in children, therefore middle ear
infections tend to be more common in children than adults.
• The auditory tube can be opened by the contraction of the tensor veli palatini
Muscles that and the salpingopharyngeus muscles.
open the
auditory tube?
• The inner ear is the innermost part of the ear, and houses the vestibulocochlear
organs.
• It has two main functions:
o To convert mechanical signals from the middle ear into electrical signals,
which can transfer information to the auditory pathway in the brain.
o To maintain balance by detecting position and motion.
• The inner ear is located within the petrous part of the temporal bone.
• It lies between the middle ear and the internal acoustic meatus, which lie
laterally and medially respectively.
• The inner ear has two main components – the bony labyrinth and membranous
labyrinth.
o Bony labyrinth – consists of a series of bony cavities within the petrous
part of the temporal bone.
▪ It is composed of the cochlea, vestibule and three semi-circular
canals.
▪ All these structures are lined internally with periosteum and
contain a fluid called perilymph.
o Membranous labyrinth – lies within the bony labyrinth.
▪ It consists of the cochlear duct, semi-circular ducts, utricle and
the saccule.
▪ The membranous labyrinth is filled with fluid called endolymph.
• The inner ear has two openings into the middle ear, both covered by
membranes:
o The oval window lies between the middle ear and the vestibule.
o The round window separates the middle ear from the scala tympani.
Transmission of Sound:
Transmission of
sound within • Sound waves entering the external auditory meatus induce vibration of the
the ear?
tympanic membrane.
• These waves, in turn, vibrate the ossicles, which amplify the intensity of the
sound waves.
o Transfer of a large-amplitude, low-force, airborne wave that vibrates
the tympanic membrane into a small-amplitude, high-force vibration of
the oval window.
• The vibrations of the stapes against the oval window transmit the sound
waves to the perilymph in the scala vestibule and then in the scala tympani
through the helicotrema.
• Soundwaves are also transmitted across the vestibular (Reissner) membrane to
the endolymph of the cochlear duct.
• Vibrations or pressure waves of the perilymph and of endolymph stimulate
oscillatory movements of the basilar membrane and hence hair calls in the
organ of Corti on the basilar membrane, which convert (transduce) sound
waves to nerve impulses that travel via the cochlear nerve to the brain.
Recommended Videos
AnatomyZone:
• ‘External Carotid Branches - 3D Anatomy Tutorial’
o Runtime: 8:20
o (https://youtu.be/K-qtoLS3L4w)
Anatomy Knowledge:
• ‘ANATOMY Tutorial - External Carotid Artery Branches’
o Runtime: 9:25
o (https://youtu.be/Anfq88W1gJ8)
• ‘MAXILLARY ARTERY and its Branches - Anatomy Tutorial’
o Runtime: 9:50
o (https://youtu.be/pTkfjC9xMZk)
• ‘Facial Artery - Origin, course, branches | Anatomy Tutorial’
o Runtime: 2:24
o (https://youtu.be/CBNIK2MpMzw)
• ‘Anatomy Tutorial - Veins of the Head and Neck’
o Runtime: 5:07
o (https://youtu.be/HL16Ge1gv4M)
• Facial Artery:
Facial artery: o Hooks around the lower border of the mandible.
course and o Branches:
branches?
▪ Ascending palatine
▪ Tonsilar
▪ Submental
▪ Glandular
▪ Inferior labial
▪ Superior labial
▪ Lateral nasal
▪ Angular
o Mnemonic for branches: Anna, PLS SIT (Ascending palatine
artery, Premasseteric artery, Lateral nasal artery, Submental
artery, Superior labial artery, Inferior labial artery, Tonsillar artery)
o The angular artery is the final and terminal branch of the facial artery.
• Maxillary Artery:
Maxillary o Is the larger terminal branch of the external carotid artery.
artery: course o Runs deep to the neck of the mandible and enters the infratemporal
and branches?
fossa.
o Breaks into its terminal branches at the pterygopalatine fossa.
o Branches:
▪ Deep auricular artery
▪ Anterior tympanic artery
▪ Middle meningeal artery
▪ Inferior alveolar artery
▪ Accessory meningeal artery
▪ Masseteric artery
▪ Pterygoid artery
▪ Deep temporal artery
▪ Buccinator artery
▪ Sphenopalatine artery
▪ Descending palatine artery
▪ Infraorbital artery
▪ Posterior superior alveoar artery
▪ Middle superior alveolar artery
▪ Pharyngeal artery
▪ Anterior superior alveolar artery
▪ Artery of the pterygoid canal (Vidian artery)
o Mnemonic for branches: DAMn I AM Piss Drunk But Stupid Drunk I
Prefer, Must Phone Alcoholics Anonymous
Blood supply to
the cerebral
cortex?
Fig 1 – The superficial and deep lymph nodes of the head and neck.
Waldeyer’s Ring:
Waldeyer’s
ring? • Waldeyer’s tonsillar ring refers to the collection of lymphatic tissue surrounding
the superior pharynx.
• This lymphatic tissue responds to pathogens that may be ingested or inhaled.
• The tonsils that make up the ring are as follows:
o Lingual tonsil
▪ Located on the posterior base of the tongue.
▪ Form the antero-inferior part of the ring.
o Palatine tonsils
▪ Located on each side between the palatoglossal and
palatopharyngeal arches.
▪ These are the common ‘tonsils’ that can be seen within the oral
cavity.
▪ They form the lateral part of the ring.
o Tubal tonsils
▪ These are located where each Eustachian tube opens into the
nasopharynx.
▪ Form the lateral part of the ring.
o Pharyngeal tonsil
▪ Also called the nasopharyngeal/adenoid tonsil.
▪ Located in the roof of the nasopharynx, behind the uvulva
▪ Forms the postero-superior part of the ring.
(Blank)
Cranial Nerves
10. Cranial Nerves
Recommended Videos
Anatomy Knowledge:
• ‘Oculomotor Nerve - Anatomy Tutorial | Made easy!’
o Runtime: 3:34
o (https://youtu.be/6oEn5m3-2sE)
• ‘Trochlear Nerve | Anatomy Tutorial’
o Runtime: 2:36
o (https://youtu.be/C4K2rwre_kg)
• ‘Trigeminal Nerve Anatomy - The Ophthalmic Nerve’
o Runtime: 3:13
o (https://youtu.be/V77L711iFfI)
• ‘Trigeminal Nerve Anatomy - The Maxillary nerve’
o Runtime: 5:47
o (https://youtu.be/Dk8wKym8FCc)
• ‘Trigeminal nerve Anatomy - The Mandibular nerve’
o Runtime: 11:55
o (https://youtu.be/Z-sAzQK4u9Q)
• ‘Abducens Nerve - Anatomy Tutorial’
o Runtime: 2:44
o (https://youtu.be/qbrv5EcQDic)
• ‘Facial nerve - Origin, Function, Pathway & Branches | Anatomy Tutorial’
o Runtime: 10:57
o (https://youtu.be/2fVAJ0JaCGs)
• ‘Glossopharyngeal Nerve | Cranial Nerve IX | Anatomy Tutorial’
o Runtime: 5:00
o (https://youtu.be/53Nb8KchqzM)
• ‘Vagus Nerve | Cranial nerve X - Head & Neck Anatomy Tutorial’
o Runtime: 5:06
o (https://youtu.be/fcnvbFQuI7w)
• ‘Accessory nerve | Cranial Nerve XI | Anatomy Tutorial’
o Runtime: 2:37
o (https://youtu.be/nIgMg1jwuks)
• ‘Hypoglossal Nerve | Course & Branches | Anatomy Tutorial’
o Runtime: 2:21
o (https://youtu.be/ToGTJCefcy4)
Olfactory nerve
• Is formed by the axons of ganglion cells of the retina, which converge at the
Modalities of optic disc.
CN II?
• These fibers of the optic nerve are covered by a membrane continuous with the
dura, and the myelin of the optic nerves is formed by oligodendroglia, just like
CNS tracts.
• These nerves carry SSA fibers for vision from the retina to the brain.
• CNII leaves the middle cranial fossa to enter the orbit through the optic canal.
• The optic chiasma contains fibers from the nasal retina that cross over to the
opposite side of the brain.
Fig 2 – The nasal retinal fibres crossing over at the optic chiasm.
• Axons from the LGN then carry visual information via a pathway known as
the optic radiation. The pathway itself can be divided into:
o Upper optic radiation
▪ Carries fibres from the superior retinal quadrants (corresponding
to the inferior visual field quadrants).
▪ It travels through the parietal lobe to reach the visual cortex.
o Lower optic radiation
▪ Carries fibres from the inferior retinal quadrants (corresponding
to the superior visual field quadrants).
▪ It travels through the temporal lobe, via a pathway known as
Meyers’ loop, to reach the visual cortex.
Anatomical Course:
• The oculomotor nerve originates from the oculomotor nucleus at the level of
Anatomical
course of the the superior colliculus in the midbrain.
GSE o The oculomotor nucleus is located ventral to the periaqueductal grey
component of matter.
CN III? • Fibers from the oculomotor nucleus pass through the red nucleus then pass
through the medial part of the substantia nigra, exiting through the
interpeduncular fossa.
• On emerging from the midbrain, the oculomotor nerve passes between the
posterior cerebral artery, located superior to the nerve, and superior cerebellar
artery, located below the nerve.
• The nerve enters the lateral wall of the cavernous sinus, traversing it in its
superior part.
• Before leaving the lateral wall of the cavernous sinus, the oculomotor nerve
splits into a superior division and an inferior division.
o Those two divisions will enter the orbit via the superior orbital fissure.
o The superior division is smaller and supplies the superior rectus muscle
and the levator palpebrae superioris muscle.
o The inferior division of the oculomotor nerve, the larger one, divides
Anatomical into three branches, supplying the medial rectus, inferior rectus, and
course of the the inferior oblique muscle.
GVE • The oculomotor nerve also contains parasympathetic fibers.
component of
CN III?
• The preganglionic parasympathetic fibers originate in the Edinger-Westphal
nucleus, located in the midbrain at the level of the superior colliculus, just
posterior to the oculomotor nucleus.
183 | H J ’ s H Y H & N | اکس جی وس گی
10. Cranial Nerves
• These parasympathetic fibers will travel within the oculomotor nerve, and will
then follow the course of the inferior division of the nerve.
• They then follow the branch to inferior oblique, finally arriving at the ciliary
ganglion via a communicating branch between the branch to inferior oblique
and the ganglion.
o This communicating branch is called the parasympathetic root of the
ciliary ganglion.
• The ciliary ganglion is located behind the eye, and lateral to the optic nerve and
contains parasympathetic postganglionic neurons.
• The parasympathetic postganglionic fibers will reach the posterior pole of the
eye via the short ciliary nerves.
• The postganglionic parasympathetic fibers then pass forward on the inner
surface of the sclera and are distributed to the ciliary muscle and the sphincter
pupillae.
Anatomical Course:
Anatomical
course of CN • The axons of the trochlear nerve originate in the trochlear nucleus.
IV?
o Located in the tegmentum of the midbrain at the level of the inferior
colliculus, and ventrolateral to the periaqueductal gray matter.
• Axons arising from the trochlear nucleus course dorsally around the
periaqueductal grey matter, and cross the midline.
• The crossed axons emerge from the dorsal aspect of the midbrain just caudal to
the inferior colliculus to form cranial nerve IV.
• The nerve curves ventrally around the cerebral peduncle to pass between the
posterior cerebral and superior cerebellar arteries.
• The trochlear nerve enters the lateral wall of the cavernous sinus, where it is
situated between oculomotor and ophthalmic nerves.
• It leaves the cavernous sinus and enters the orbit through the superior orbital
fissure, above the tendinous ring.
• The nerve then courses medially, close to the roof of the orbit, and runs
diagonally above the levator palpebrae superioris muscle to reach its target, the
superior oblique muscle.
o Here the nerve divides into branches that enter the superior oblique
muscle along its proximal third.
Trigeminal ganglion
Trigeminal Nuclei:
Trigeminal
nuclei? • Chief (Principal, Main) Sensory Nucleus:
o Located in the rostral pontine tegmentum at the level of the trigeminal
motor nucleus.
o Receives fine touch from the face (GSA).
• Spinal Trigeminal Nucleus:
o Located in the spinal cord (C1—C3), medulla, and pons.
o Receives pain and temperature inputs from the face and oral cavity
(GSA).
• Mesencephalic Nucleus:
o Subserves GSA proprioception from the head.
o Receives inputs from muscle spindles and pressure and joint receptors.
o Projects to the trigeminal motor nucleus to mediate the muscle stretch
(jaw jerk) reflex and regulate the force of bite.
• Trigeminal Motor Nucleus:
o SVE
o Located in the rostral pontine tegmentum at the level of the chief
sensory nucleus.
o Innervates the muscles of mastication (temporalis, masseter, medial
and lateral pterygoids), tensor tympani, tensor veli palatini, anterior
belly of digastric and mylohyoid.
nasal bone and the upper lateral nasal cartridge as the external
nasal branch.
▪ The external nasal branch ultimately innervates skin on the
lateral side of the nose and the tip of the nose.
• The ophthalmic nerve itself does not contain any autonomic fibres. However,
nerves from the sympathetic and parasympathetic system ‘hitchhike’ on CNV1:
o Sympathetic fibres (from the superior cervical ganglion) hitchhike on
branches of the nasociliary nerve (long ciliary nerves) to reach the
dilator pupillae in the eye.
o Parasympathetic fibres (from the pterygopalatine ganglion) hitchhike
along the zygomatic branch of the maxillary nerve (CNV2) and then the
lacrimal branch of the ophthalmic nerve (CNV1) to reach the lacrimal
gland.
• The maxillary nerve also gives off the posterior superior alveolar nerves.
o They enter the alveolar canals of the maxilla.
o These nerves supply the maxillary sinus and gingival and dental
branches to each molar tooth.
• The infraorbital nerve also gives off the middle superior alveolar nerve and
anterior superior alveolar nerve.
• The maxillary nerve also gives off the following nerves via the pterygopalatine
ganglion:
o The Nasopalatine Nerve
▪ It enters the nasal cavity through the sphenopalatine foramen
and runs obliquely downward on the lower part of the septum.
▪ It descends to the roof of the mouth through the incisive canal
and communicates with the greater palatine nerve.
o The Greater Palatine Nerve
▪ It descends through the greater palatine canal, emerges upon
the hard palate through the greater palatine foramen and passes
forward.
▪ It supplies the gums, the mucous membrane and glands of the
hard palate.
o The Lesser Palatine Nerve
▪ Descends through the greater palatine canal and emerges
through the lesser palatine foramen.
▪ It supplies the soft palate, tonsil and uvula.
o The Pharyngeal Nerve
• The Nerve of the Pterygoid Canal:
o Also called the vidian nerve.
o It is formed by the junction of the greater petrosal nerve and the deep
petrosal nerve within the pterygoid canal.
o It then enters the pterygopalatine fossa and joins the pterygopalatine
ganglion.
o Contents of the vidian nerve are:
▪ Parasympathetic preganglionic fibers from the facial nerve
contained within the greater petrosal nerve, which synapse in
the pterygopalatine ganglion.
▪ Sympathetic postganglionic fibers from the deep petrosal nerve
which do not synapse in the pterygopalatine ganglion.
o The preganglionic parasympathetic fibres of the greater petrosal nerve
upon synapsing in the pterygopalatine ganglion redistribute to the nose,
palate, and lacrimal gland through the various nerves leaving the
pterygopalatine fossa.
▪ For example, the most important parasympathetic pathway from
the pterygopalatine ganglion are the parasympathetic
postganglionic fibers which will follow the course of the maxillary
nerve, then the zygomatic nerve, and via the communicating
193 | H J ’ s H Y H & N | اکس جی وس گی
10. Cranial Nerves
• Branches from the main trunk of the mandibular nerve: Two branches arise
from the main trunk:
o A sensory branch, which is the nervus spinosus
▪ Enters the cranial cavity through foramen spinosum together
with the meningeal artery.
▪ Supplies the dura mater of the middle cranial fossa.
o The nerve to the medial pterygoid is the other branch from the main
trunk and is a motor branch
▪ Traverses the otic ganglion and supplies the medial pterygoid.
▪ In addition to the medial pterygoid, it also supplies the tensor
veli palatini and tensor tympani muscles.
• Branches from the posterior division of the mandibular nerve: In contrast to the
anterior division of the mandibular nerve, the posterior division is mainly
sensory and it contains only a few motor fibers. The posterior division gives off
three branches:
o The lingual nerve: is the smaller terminal branch of the posterior division
of the mandibular nerve.
▪ It is sensory to the mucous membrane of the anterior 2/3 of the
tongue.
▪ This nerve winds around the submandibular duct, first above,
then lateral, then below, and finally medial to the duct, and
divides into its terminal branches.
▪ It also carries preganglionic secretomotor (parasympathetic)
fibers to the submandibular and sublingual salivary glands.
o The inferior alveolar nerve: it is the larger terminal branch of the
posterior division of the mandibular nerve.
▪ This nerve will enter the mandibular foramen in company with
inferior alveolar artery, traverses the mandibular canal as far as
the mental foramen, where it terminates.
▪ The mental nerve emerges out through the mental foramen to
supply skin of the chin and skin and mucous membrane of the
lower lip.
o Arising from the inferior alveolar nerve before it enters the mandibular
canal is the mylohyoid nerve.
▪ Carries all the motor fibers from the posterior division of the
mandibular nerve.
▪ It supplies the mylohyoid and the anterior belly of the digastric
muscle.
o The auriculotemporal nerve:
▪ This nerve arises from two roots, which after encircling the
middle meningeal artery unite to form the single trunk.
▪ It runs backwards to enter the temple.
▪ The auriculotemporal nerve is a sensory nerve.
Fig 3 – Innervation to the muscles of facial expression via the facial nerve (CN VII)
o Further on, the preganglionic fibers, by way of the Vidian nerve, arrive at
the pterygopalatine ganglion in the pterygopalatine fossa.
▪ Here the preganglionic fibers synapse with the postganglionic
neurons within the ganglion.
▪ The pterygopalatine ganglion is attached to the maxillary
division of trigeminal nerve.
o Some of the postganglionic parasympathetic fibers from the
pterygopalatine ganglion jump to the maxillary nerve and then to the
zygomatic nerve, a branch of the maxillary nerve.
o From the zygomatic nerve, by way of a communicating branch with the
lacrimal nerve, the postganglionic parasympathetic fibers arrive at the
lacrimal gland to supply it.
o The remaining postganglionic fibers continue forward via ganglionic
branches of maxillary nerve to reach the mucous glands in the mucousa
of the nasal and oral cavities.
• The other group of fibers travel together with the facial nerve proper and exits
the mastoid segment of facial canal as the corda tympani nerve to arrive in the
middle ear cavity.
o The corda tympani nerve exits the middle ear by way of the
petrotympanic fissure.
o Further on this nerve unites with the lingual nerve, which is a branch of
the mandibular division of the trigeminal nerve, and thus the
preganglionic parasympathetic fibers arrive at the submandibular
ganglion which is suspended from lingual nerve.
▪ Here, the preganglionic fibers synapse in the ganglion with the
postganglionic neurons.
o From here, the postganglionic fibers continue to the submandibular and
sublingual glands and to minor glands in the floor of the mouth.
Vestibulocochlear nerve
Components/Modalities:
Modalities of
CN X and their • GSA:
functions?
o Innervates:
▪ The infratentorial dura
▪ Posterior surface of the external ear
▪ External auditory meatus
▪ Tympanic membrane
o Has cell bodies in the superior (jugular) ganglion.
o Projects its central processes to the spinal trigeminal tract and nucleus.
• GVA:
o Innervates the mucous membranes of the pharynx, larynx, esophagus,
trachea, and thoracic and abdominal viscera (to the mid-transverse
colon).
o Has cell bodies in the inferior (nodose) ganglion.
o Projects its central processes to the solitary tract and nucleus.
• SVA:
o Innervates the taste buds over the epiglottis and soft palate.
o Has cell bodies in the inferior (nodose) ganglion.
o Projects its central processes to the solitary tract and nucleus.
• SVE:
o Provides motor innervation to the majority of the muscles of the:
▪ Pharynx (notable exception: stylopharyngeus, innervated by CN
IX)
▪ Soft palate (notable exception: tensor veli palatini, innervated
by CN V3)
▪ Larynx
▪ Also innervates the palatoglossus of the tongue.
o Arises from the nucleus ambiguus in the lateral medulla.
o Provides the efferent limb of the gag reflex.
• GVE:
o Innervates the viscera of the neck and the thoracic and abdominal
cavities as far as the mid-transverse colon.
Nuclei:
Nuclei of CN X?
• Dorsal nucleus
o Sends parasympathetic fibers to the intestines
• Nucleus ambiguus
o Sends efferent motor fibres
o Also sends parasympathetic fibers to the heart.
• Solitary nucleus
o Receives special gustatory afferent from the tongue
o Receives visceral afferent fibers from organs
• Spinal trigeminal nucleus
o Receives general sensory afferent fibers
Anatomical Course:
Anatomical
course of CN X? • The vagus nerve arises from the lateral aspect of the medulla between the olive
and inferior cerebellar peduncle.
• It exits the skull through the jugular foramen.
• Its two sensory ganglia, the superior (jugular) ganglion and the inferior
(nodose) ganglion, are located on the nerve.
• As the vagus continues below the inferior ganglion, it is joined by the motor
fibers from the nucleus ambiguus that have travelled briefly with the cranial
root of accessory nerve.
• The vagus has four related nuclei located in the medulla:
o The nucleus ambiguus
o The dorsal nucleus of vagus
o The nucleus solitarius
o The spinal nucleus of the trigeminal nerve
• Its meningeal branch arises from the superior ganglion
o Takes a recurrent course, and enters the cranial cavity through the
jugular foramen
o Supplies the dura mater of the posterior cranial fossa.
• The Auricular branch or the Arnold’s nerve arises from the superior ganglion
o Enters the mastoid canaliculus on the lateral wall of the jugular fossa,
and emerges through the tympanomastoid fissure just behind the
external auditory meatus
o Supplies the skin on the back of the meatus and adjoining part of the
auricle, the floor of the meatus and the tympanic membrane.
(Blank)
The Neck
11. The Neck
Recommended Videos
Sam Webster:
• ‘Fascia of the neck (anatomy)’
o Runtime: 26:43
o (https://youtu.be/tNVDtpuLMns)
AnatomyZone:
• Guide recommended the entire playlist on the neck
Cervical Fascia
• The cervical fascia consists of concentric layers of fascia that compartmentalize
structures in the neck.
• These fascial layers are defined as the superficial fascia and the deep fascia,
with sublayers within the deep fascia.
Superficial Fascia:
Superficial
fascia?
• The superficial cervical fascia is the subcutaneous layer of the skin in the neck.
• Contains the platysma muscle, cutaneous nerves from the cervical plexus, and
superficial vessels and lymph nodes.
Deep Fascia:
Deep fascia?
• The deep cervical fascia is deep to the superficial fascia.
• Contains muscles and viscera in compartments to enable structures to slide
over each other, and to serve as a conduit for neurovascular bundles.
• Forms the following sublayers:
o Deep investing fascia
o Pretracheal fascia
o Prevertebral fascia
o Carotid sheath
Fig 2 – Transverse section of the neck, with the investing layer of fascia highlighted in blue.
Pretracheal Fascia:
Pretracheal
fascia? • Forms a tubular sheath in the anterior part of the neck.
• Extends from the hyoid bone inferiorly into the thorax to blend with the fibrous
pericardium.
• Muscular part – encloses the infrahyoid muscles.
• Visceral part – encloses the:
o Thyroid gland
o Parathyroid glands
o Trachea
o Esophagus
• Buccopharyngeal fascia:
o The name of the posterior portion of the pretracheal fascia.
Fig 3 – Transverse section of the neck, showing the pretracheal fascia in red.
Prevertebral Fascia:
Prevertebral
fascia? • Forms a tubular sheath around the vertebral column.
• Forms the floor of the posterior triangle of the neck.
• Contents:
o Sympathetic trunk
o Phrenic nerve
o Brachial plexus
o Cervical vertebrae
o Prevertebral muscles (i.e., longus colli, longus capitis and scalene
muscles).
• Alar fascia:
o The anterior lamina of prevertebral fascia has two layers; the anterior
layer is referred to as alar fascia.
o Axillary sheath:
▪ The prevertebral fascia extends laterally as the axillary sheath,
which surrounds the axillary vessels and branchial plexus.
Carotid Sheath:
Carotid
sheath? • A tube of fascia that extends from the cranial base to the root of the neck.
• Formed by the investing, pretracheal, and prevertebral layers of fascia.
• Contents:
o Common and internal carotid arteries
o Internal jugular vein
o Vagus nerve
o Deep cervical lymph nodes
o Carotid sinus nerve
Retropharyngeal Space:
Retropharyng-
eal space? • Located between the buccopharyngeal and alar fascia
• Extends from the skull base to the upper thoracic vertebrae.
• It is a potential space where normally nothing fills it. However, an abscess can
spread easily in this location.
• Function: Permits superior and inferior movements of the larynx, pharynx, and
esophagus during swallowing relative to the cervical vertebrae.
Pharyngobasilar Fascia:
Pharyngobasil-
ar fascia? • Forms the submucosa of the pharynx and blends with the periosteum of the
base of the skull
• Lies internal to the muscular coat of the pharynx; these muscles are covered
externally by the buccopharyngeal fascia.
Fig 1 – The left occipital muscles, which lie underneath the deep muscles of the back.
Platysma Muscle:
Platysma
muscle:
• Located in the superficial cervical fascia.
function and
innervation? • Depresses the mandible and wrinkles the skin of neck.
• Is innervated by the cervical branch of the facial nerve (CN VII).
Fig 1 – The platysma muscle, located within the superficial cervical fascia.
Sternocleidomastoid Muscle:
SCM: function
and • Located within the deep investing fascia.
innervation?
• Named according to its bony attachments (sternum, clavicle, and mastoid
process)
• Forms a primary border for the anterior and posterior cervical triangles.
• Actions:
o Singly: turns face toward opposite side
o Together: flexes the head, raises the thorax
• Innervated by the spinal accessory nerve (CN XI).
Trapezius Muscle:
Trapezius:
function and • Located within the deep investing fascia.
innervation?
• Elevates, retracts, depresses, and superiorly rotates the scapula.
• Innervated by the spinal accessory nerve (CN XI).
Prevertebral Muscles:
Prevertebral
muscles:
• The prevertebral muscles are located between the prevertebral fascia and the
names and
functions? cervical vertebrae.
• Longus colli and capitis muscles
o The longus colli and longus capitis muscles help stabilize the cervical
vertebrae and flex the neck.
• Scalene muscles
o anterior, middle, and posterior scalenes
o Elevate the ribs during breathing and laterally flex the neck.
o The cervical and brachial plexuses exit the vertebral column between
the anterior and middle scalenes.
Suprahyoid Muscles:
Suprahyoid
muscles:
• These muscles raise the hyoid bone during swallowing because the mandible is
names,
functions and stabilized.
innervation? • Digastric muscle:
o A two-bellied muscle attached to the mastoid process (posterior belly)
and mandible (anterior belly) and connected by a central tendon at the
hyoid bone.
o Because of the two bellies, the digastric muscle can raise the hyoid bone
or open the mouth.
o Originates embryologically from both the first and second pharyngeal
arches and as such has dual innervation
▪ Anterior belly from CN V-3
▪ Posterior belly from CN VII
• Stylohyoid muscle:
o Elevates the hyoid bone and is innervated by CN VII.
• Mylohyoid muscle:
o Forms the floor of the mouth
o Elevates the floor of the mouth
o Innervated by CN V-3
• Geniohyoid muscle:
o Elevates the hyoid bone and is innervated by the cervical plexus (C1 via
the hypoglossal nerve)
Fig 1 – Anterior view of the neck with the suprahyoid muscles highlighted.
Fig 2 – Lateral view of the neck with three of the suprahyoid muscles highlighted (digastric, mylohyoid and
stylohyoid)
Infrahyoid Muscles:
Infrahyoid
muscles:
• Composed of four pairs of muscles inferior to the hyoid bone (hence the name).
names,
functions and • Each muscle is innervated by the ansa cervicalis from the cervical plexus
innervation? (ventral rami C1-C3).
• Collectively, these muscles function to depress the hyoid bone and larynx
during swallowing and speaking.
Fig 2 – The extracranial anatomical course of the hypoglossal nerve, through the anterior triangle of the
neck.
Carotid Triangle:
Submental Triangle:
• Contents:
Submental o Submental lymph nodes
triangle: o Tributaries forming the anterior jugular vein
contents?
• The posterior triangle of the neck is an anatomical area located in the lateral
aspect of the neck.
• Its boundaries are as follows:
Posterior o Anterior – posterior border of the sternocleidomastoid.
triangle: o Posterior – anterior border of the trapezius muscle.
boundaries?
o Inferior – middle 1/3 of the clavicle.
o The posterior triangle of the neck is covered by the investing layer of
fascia.
o The floor is formed by the prevertebral fascia.
• Contents:
Posterior o Vessels:
triangle: ▪ The third part of the subclavian artery
contents?
▪ Suprascapular and transverse cervical branches of the
thyrocervical trunk
▪ External jugular vein
▪ Lymph nodes
o Nerves:
▪ Accessory nerve (CN XI)
▪ The trunks of the brachial plexus
▪ Fibers of the cervical plexus
o A number of vertebral muscles (covered by prevertebral fascia) form
the floor of the posterior triangle:
▪ Splenius capitis
▪ Levator scapulae
▪ Anterior, middle and posterior scalenes
• The omohyoid muscle splits the posterior triangle of the neck into two:
o The larger, superior part is termed the occipital triangle.
o The inferior triangle is known as the subclavian triangle. It is also known
as the omoclavicular or supraclavicular triangle.
Fig 1 – The borders and floor of the posterior triangle of the neck.
Fig 3 – The posterior triangle is divided by the inferior belly of the omohyoid into the occipital and
subclavian triangles.
Occipital Triangle:
Supraclavicular/Subclavian/Omoclavicular Triangle:
The Pharynx
12. The Pharynx
Recommended Videos
Dr. Umar Azizov:
• ‘The Pharynx’
o Runtime: 15:24
o (https://youtu.be/_aqiaY1Uc70)
Nasopharynx:
Structure of the
nasopharynx?
• The nasopharynx is posterior to the nasal cavity and superior to the soft
palate.
• During swallowing, the soft palate elevates and the pharyngeal wall contracts
anteriorly to form a seal, preventing food from refluxing into the nasopharynx
and nose.
• Choanae: Arched openings that enable communication between the nasal
cavity and nasopharynx.
• Auditory tubes (Pharyngotympanic/Eustachian tubes): Open into the lateral
walls of the nasopharynx and communicate with the middle ear.
o The auditory tubes enable middle ear pressure to equalize with
atmospheric pressure.
• Pharyngeal tonsil (adenoids): Lymphatic tissue in the posterosuperior
nasopharynx; traps and destroys pathogens that enter from the air.
Oropharynx:
Structure of the
oropharynx? • The oropharynx is the region of the pharynx located between the soft palate
and the epiglottis, and communicates with the oral cavity.
• Palatoglossal arches: Arches formed by the palatoglossal muscles
o Mark the boundary between the oral cavity anteriorly and the
oropharynx posteriorly.
• Palatine tonsils
Laryngopharynx:
Structure of the
laryngopharynx
?
• The laryngopharynx extends between the epiglottis and the cricoid cartilage,
with the larynx forming the anterior wall.
• The laryngopharynx serves as a common passageway for food and air.
Circular Muscles:
Circular
muscles of the
• There are three circular pharyngeal constrictor muscles; the superior, middle,
pharynx:
names, and inferior pharyngeal constrictors.
functions and • They are stacked like glasses, which form an incomplete muscular circle as they
innervation? attach anteriorly to structures in the neck.
• The circular muscles contract sequentially from superior to inferior to constrict
the lumen and propel the bolus of food inferiorly into the oesophagus.
• All pharyngeal constrictors are innervated by the vagus nerve (CN X).
• The inferior pharyngeal constrictor is split into two parts; the thyropharyngeus
and the cricopharyngeus.
o This area between the two is a weak area in the mucosa, and a
diverticulum can form here.
Fig 4 – Lateral view of the deep structures of the pharynx. Visible are the circular muscles of the pharynx,
and the stylopharyngeus.
Longitudinal Muscles:
Longitudinal
muscles of the • The longitudinal muscles are the:
pharynx:
names,
o Stylopharyngeus
functions and o Palatopharyngeus
innervation? o Salpingopharyngeus
• They act to shorten and widen the pharynx, and elevate the larynx during
swallowing.
• The names of these muscles identify their origins and insertions.
• The salpingopharyegeus muscle attaches to the auditory tube and the
pharyngeal wall.
o It widens the opening of the pharyngotympanic tube during swallowing,
which equalizes the pressure between the auditory canal and the
nasopharynx.
• The palatopharyngeus and salpingopharyngeus are innervated by CN X,
whereas the stylopharyngeus is innervated by CN IX.
o The stylopharyngeus is the only muscle derived from the third
pharyngeal arch.
Fig 5 – Posterior view of the pharynx. The pharynx has been split down the midline and opened, to show
the longitudinal muscles.
Pharyngeal Plexus:
Pharyngeal
plexus?
• Pharyngeal nerves from CN IX and X and a small contribution from CN V-2 form
the pharyngeal plexus.
• The plexus lies along the middle pharyngeal constrictor muscle.
• It is responsible for sensory and motor innervation.
Swallowing Action:
Swallowing
action? • The tongue pushes the bolus of food back toward the oropharynx.
• The palatoglossus and palatopharyngeus muscles contract to squeeze the
bolus backward into the oropharynx.
o The tensor veli palatini and levator veli palatini muscles elevate and
tense the soft palate to close the entrance into the nasopharynx.
• The palatopharyngeus, stylopharyngeus, and salpingopharyngeus muscles
elevate the walls of the pharynx in preparation to receive the food.
o The suprahyoid muscles elevate the hyoid bone and the larynx to close
the opening into the larynx, thus preventing the food from entering the
respiratory passageways.
• The sequential contraction of the superior, middle, and inferior pharyngeal
constrictor muscles moves the food through the oropharynx and the
laryngopharynx into the esophagus, where the bolus of food is propelled via
peristalsis.
The Larynx
13. The Larynx
Recommended Videos
Sam Webster:
• ‘Larynx anatomy’
o Runtime: 22:48
o (https://youtu.be/mtqpyzS48zA)
AnatomyZone:
• ‘Larynx - Cartilages - 3D Anatomy Tutorial’
o Runtime: 12:20
o (https://youtu.be/Z3S2dD9BrSY)
• ‘Larynx - Ligaments, Membranes, Vocal Cords - 3D Anatomy Tutorial’
o Runtime: 13:14
o (https://youtu.be/jqTKSorDRJo)
• ‘Mucosa of the Larynx and Vocal Cords - 3D Anatomy Tutorial’
o Runtime: 15:04
o (https://youtu.be/fBHr1RjqLHA)
• ‘Muscles of the Larynx - Part 1 - 3D Anatomy Tutorial’
o Runtime: 8:28
o (https://youtu.be/lqeDLsP1ISE)
• ‘Muscles of the Larynx - Part 2 - 3D Anatomy Tutorial’
o Runtime: 10:44
o (https://youtu.be/GEMquo7qxpg)
Laryngeal Cartilages
• There are nine cartilages located within the larynx; three unpaired, and six
Cartilages of paired. They form the laryngeal skeleton.
the larynx? o The three unpaired cartilages are the epiglottis, thyroid and cricoid
cartilages.
o The three paired cartilages are the arytenoid, corniculate and
cuneiform cartilages.
Thyroid Cartilage:
Cricoid Cartilage:
Epiglottis:
• The epiglottis is a leaf shaped plate of elastic cartilage which marks the
entrance to the larynx.
• Its ‘stalk’ is attached to the back of the anterior aspect of the thyroid cartilage.
Arytenoid Cartilages:
Corniculate Cartilages:
Cuneiform Cartilages:
• Are located within the aryepiglottic folds.
Extrinsic Ligaments:
Extrinsic
ligaments of
• Thyrohyoid membrane – Spans between the superior aspect of the thyroid
the larynx and
their structure? cartilage and the hyoid bone.
o It is pierced laterally by the superior laryngeal vessels and internal
laryngeal nerve (branch of the superior laryngeal nerve).
o Median thyrohyoid ligament – Anteromedial thickening of the
membrane.
o Lateral thyrohyoid ligaments – Posterolateral thickenings of the
membrane.
• Hyo-epiglottic ligament – Connects the hyoid bone to the anterior aspect of the
epiglottis.
• Cricotracheal ligament – Connects the cricoid cartilage to the trachea.
• Median cricothyroid ligament – Anteromedial thickening of the cricothyroid
ligament (also known as the cricovocal membrane), connecting the thyroid and
cricoid cartilages.
Fig 1 – Some of the major laryngeal membranes and ligaments. Note that the upper free edge of the
cricothyroid ligament is not demonstrated in this image.
Intrinsic Ligaments:
• The quadrangular membrane and conus elasticus are the superior and inferior
parts of the submucosal fibro-elastic membrane of the larynx.
• Conus Elasticus (Cricovocal Membrane)
Structure of the o Attached to the arch of cricoid cartilage and extends superiorly to end in
cricovocal a free upper margin within the space enclosed by the thyroid cartilage.
ligament? o On each side, this upper free margin attaches:
▪ Anteriorly to the thyroid cartilage
▪ Posteriorly to the vocal processes of the arytenoid cartilages.
o The free margin between these two points of attachment is thickened to
form the vocal ligament, which is under the vocal fold (true vocal cord)
of the larynx.
o The conus elasticus is also thickened anteriorly in the midline to form a
distinct median cricothyroid ligament.
264 | H J ’ s H Y H & N | اکس جی وس گی
13. The Larynx
• Quadrangular Membrane
Structure of the o The quadrangular membrane on each side runs between the lateral
quadrangular margin of the epiglottis and the anterolateral surface of the arytenoid
ligament?
cartilage on the same side.
o Each quadrangular membrane has a free upper margin, and a free lower
margin.
o The free superior margin of the quadrangular membrane forms the
aryepiglottic ligament, which is covered with mucosa to form the
aryepiglottic fold.
▪ The corniculate and cuneiform cartilages appear as small
nodules in the posterior part of the aryepiglottic folds.
o The free lower margin is thickened to form the vestibular ligament
under the vestibular fold (false vocal cord) of the larynx.
▪ The vestibular ligament is attached posteriorly to the arytenoid
cartilage and anteriorly to the thyroid cartilage.
o On each side, the vestibular ligament of the quadrangular membrane is
separated from the vocal ligament of the cricothyroid ligament below by
a gap.
Extrinsic Muscles:
• The extrinsic muscles act to move the larynx superiorly and inferiorly.
• They are comprised of the suprahyoid and infrahyoid groups, and the
stylopharyngeus (a muscle of the pharynx).
• The supra- and infrahyoid muscle groups attach to the hyoid bone. This, in turn,
is bound to the larynx by strong ligaments; allowing the whole of the larynx to
be moved as one unit.
• As a general rule, the suprahyoid muscles and the stylopharyngeus elevate the
larynx, whilst the infrahyoid muscles depress the larynx.
Intrinsic Muscles:
Intrinsic
muscles of the
• Their main functions are to:
larynx: names,
functions and o Open or close the laryngeal inlet
innervation? o Adduct and abduct the vocal cords
o Increase or decrease the tension of the vocal cords.
• All the intrinsic muscles of the larynx (except the cricothyroid) are innervated by
the inferior laryngeal nerve – the terminal branch of the recurrent laryngeal
nerve, itself a branch of the vagus nerve.
o The cricothyroid is innervated by the external branch of the superior
laryngeal nerve – again derived from the vagus nerve.
• Muscles that Open or Close the Laryngeal Inlet:
o Aryepiglotticus
▪ Closes the inlet of larynx.
o Thyroepiglotticus
▪ Opens the inlet of larynx.
• The shape of the rima glottidis, the aperture between the vocal folds, varies
Rima glottidis
during normal according to the position of the vocal folds.
respiration? • During normal respiration:
o The laryngeal muscles are relaxed and the rima glottidis assumes a
narrow, slit-like position.
• During a deep inhalation:
Rima glottidis
during deep o The vocal ligaments are abducted by contraction of the posterior
inhalation? cricoarytenoid muscles, opening the rima glottidis widely into an
inverted kite shape.
• During phonation:
Rima glottidis o The arytenoid muscles adduct the arytenoid cartilages at the same time
during that the lateral cricoarytenoid muscles moderately adduct.
phonation?
o Air forced between the adducted vocal ligaments produces tone.
o Stronger contraction of the same muscles seals the rima glottidis
(Valsalva maneuver).
• During whispering:
Rima glottidis o The vocal ligaments are strongly adducted by the lateral cricoarytenoid
during
muscles, but the relaxed arytenoid muscles allow air to pass between
whispering?
the arytenoid cartilages (intercartilaginous part of rima glottidis), which
is modified into toneless speech.
o No tone is produced.
• Note:
o Tensing the vocal cords (cricothyroid) raises the pitch of the voice,
o Relaxing the vocal cords (thyroarytenoid) lowers the pitch.
Laryngeal Cavity
• The laryngeal cavity extends from the laryngeal inlet, through which it
communicates with the laryngopharynx, to the level of the inferior border of
the cricoid cartilage, where the laryngeal cavity is continuous with the cavity of
the trachea.
• Larygeal inlet:
o Its anterior border is formed by mucosa covering the superior margin of
the epiglottis.
o Its lateral borders are formed by mucosal folds (aryepiglottic folds),
which enclose the superior margins of the quadrangular membranes.
▪ Two tubercles on the more posterolateral margin on each side
mark the positions of the underlying cuneiform and corniculate
cartilages.
o Its posterior border in the midline is formed by a mucosal fold that
forms a depression (interarytenoid notch) between the two corniculate
tubercles.
• The laryngeal cavity includes the:
Divisions of the o Laryngeal vestibule: Between the laryngeal inlet and the vestibular
laryngeal
folds.
cavity?
o Middle part of the laryngeal cavity: the central cavity (airway) between
the vestibular and vocal folds.
▪ Laryngeal ventricle: recesses extending laterally from the middle
part of the laryngeal cavity between vestibular and vocal folds.
▪ The laryngeal saccule is a blind pocket opening into each
ventricle.
o Infraglottic cavity: the inferior cavity of the larynx between the vocal
folds and the inferior border of the cricoid cartilage, where it is
continuous with the lumen of the trachea.
• The vocal folds are the sharp-edged folds of mucous membrane overlying and
incorporating the vocal ligaments, vocalis muscles and the thyro-arytenoid
muscles.
o They are the source of the sounds (tone) that come from the larynx.
o The vocal folds also serve as the main inspiratory sphincter of the larynx
when they are tightly closed.
o The rima glottidis is the aperture between the vocal folds.
• The vestibular folds play little or no part in voice production; they are
protective in function.
o They consist of two thick folds of mucous membrane enclosing the
vestibular ligaments.
o The space between these ligaments is the rima vestibuli.
• Both the rima glottidis and the rima vestibuli can be opened and closed by
movement of the arytenoid cartilages and associated fibro-elastic membranes.
272 | H J ’ s H Y H & N | اکس جی وس گی
13. The Larynx
Structures
visible in
laryngoscopic
view?
Laryngoscopic
view during
different
actions?
Venous Drainage:
Venous
drainage of the • The laryngeal veins accompany the laryngeal arteries.
larynx?
• The superior laryngeal vein usually joins the superior thyroid vein and through
it drains into the IJV.
• The inferior laryngeal vein joins the inferior thyroid vein, which empties into
the left brachiocephalic vein.
Lymphatic Drainage:
Lymphatic
drainage of the
• The laryngeal lymphatic vessels superior to the vocal folds accompany the
larynx?
superior laryngeal artery through the thyrohyoid membrane and drain into the
superior deep cervical lymph nodes.
• The lymphatic vessels inferior to the vocal folds drain into the pretracheal or
paratracheal lymph nodes, which drain into the inferior deep cervical lymph
nodes.
Innervation:
Innervation of
the larynx? • Superior laryngeal nerve
o Is a branch of the vagus nerve.
o Divides into the internal and external laryngeal branches.
o Internal laryngeal nerve:
▪ Innervates the mucous membrane superior to the vocal cord
and taste buds on the epiglottis.
▪ Is accompanied by the superior laryngeal artery and pierces the
thyrohyoid membrane.
o External laryngeal nerve:
▪ Innervates the cricothyroid and inferior pharyngeal constrictor
(cricopharyngeus part) muscles.
▪ Is accompanied by the superior thyroid artery.
• Recurrent laryngeal nerve
o Innervates all of the intrinsic muscles of the larynx except the
cricothyroid, which is innervated by the external laryngeal branch of the
superior laryngeal branch of the vagus nerve.
o Supplies sensory innervation below the vocal cord.
o Has a terminal portion within the larynx, superior to the lower border of
the cricoid cartilage called the inferior laryngeal nerve.
▪ Accompanies the inferior laryngeal artery.
4. Skull from the side view Matisse oil painting DALL·E Flow
11. Man with a long neck 16-bit retro art DALL·E Flow