cap si gat

The skull bones(111) house the brain (surrounded by the meninges and cerebrospinal fluid (CSF)) and the organs of special sense, hearing (plus balance), smell, sight and taste. The nasal and oral cavities are the com- mencement of the respiratory and gastro-intestinal sys- tems, respectively. The mandible (10) articulates with the skull at the synovial temporomandibular joints (12) for mouth opening and mastication.

On the skull base, the maxillae house the upper teeth and form much of the hard palate. They also contribute to the face, nasal cavity and orbit.

Inside the skull the brain, like the spinal cord, is sur- rounded by the three meninges. The thin, hardly visi- ble membrane of pia mater (1) clothes the brain. The arachnoid mater (2) covers the brain but does not dip into the fissures and sulci. It more closely follows the contours of the overlying dura mater (3) and skull.

The internal carotid artery (22) emerges from the petrous temporal bone and bends to pass anteriorly within the cavernous sinus. It then curves back upon itself, gives off its first branch, the ophthalmic artery and divides into the middle (23) and anterior (24) cerebral arteries. The left and right vertebral arteries (25) fuse to form the basilar artery (26). They supply the spinal cord, the cerebellum and pons. The basilar artery divides into the posterior cerebral arteries (27). Posterior communicating arteries (28) pass from the posterior cerebrals to the middle cerebrals and the anterior communicating artery (29) links the two anterior cerebrals. This arrangement creates the anas- tomotic arterial Circle (of Willis) (Illustration D) to supply the brain. The arteries lie within the CSF.

Olfactory nerve (I) is for the sense of smell and arises from the olfactory bulb (1) at the distal end of the olfactory tract (2). Optic nerve (II) (3) is for the sense of sight. The nerves converge at the optic chiasma (4) just above and in front of the

pituitary gland (5).

Oculomotor nerve (III) (6) supplies all but two of the muscles that move the eye, and carries parasympa- thetic fibres to constrict the pupil.

Trochlear nerve (IV) (9) supplies the superior oblique muscle.

Trigeminal nerve (V) (10) passes anteriorly to reach its ganglion (11) in an invagination of dura mater just under the posterior end of the cavernous sinus. It has three divisions, ophthalmic (V1) (12), maxillary (V2) (13) and mandibular (V3) (14). It is the sensory nerve of much of the head, face and orbital, nasal and oral cavities.

Facial nerve (VII) (17) is the motor supply to the muscles of facial expression.

Vestibulocochlear (VIII) (18) supplies the organs responsible for hearing and balance.

Glossopharyngeal (IX) (19) supplies one muscle (stylopharyngeus) and carries general sensation and taste from the posterior one-third of the tongue, the oropharynx and the pala- tine tonsil. It also carries parasympathetic fibres that run with its tympanic branch, which supplies sensa- tion to the middle ear.

Vagus (X) (20) supplies the musculature of the pharynx and larynx, and is the parasympathetic nerve to the heart, lungs and much of the intestinal tract.

Accessory (XI) (21) is actu- ally a spinal nerve arising from C15 segments of the spinal cord. It ascends up the spinal canal and through the foramen magnum to pass through the jugular foramen to supply sternocleidomastoid and trapezius.

Hypoglossal nerve (XII) is a totally motor nerve to the tongue muscles.

The two nasal cavities are the uppermost parts of the respiratory tract and contain the olfactory receptors.

The smaller anterior regions of the cavities are enclosed by the external nose whereas the larger posterior regions are more central within the skull. The anterior apertures of the nasal cavities are the nares, which open onto the inferior surface of the nose. The posterior apertures are the choanae, which open into the nasopharynx.

The nasal cavities are separated: from each other by a midline nasal septum; from the oral cavity below by the hard palate; from the cranial cavity above by parts of the frontal, ethmoid, and sphenoid bones. Lateral to the nasal cavities are the orbits. Each nasal cavity has a floor, roof, medial wall, and lateral wall

Regions Each nasal cavity consists of three general regions-the nasal vestibule, the respiratory region, and the olfactory region (Fig. 8.219). the nasal vestibule is a small dilated space just internal to the naris that is lined by skin and contains hair follicles; the respiratory region is the largest part of the nasal cavity, has a rich neurovascular supply, and is lined by respiratory epithelium composed mainly of ciliated and mucous cells; the olfactory region is small, is at the apex of each nasal cavity, is lined by olfactory epithelium, and contains the olfactory receptors. In addition to housing receptors for the sense of smell (olfaction), the nasal cavities adjust the temperature and humidity of respired air, and trap and remove particulate matter from the airway.

Skeletal framework Bones that contribute to the skeletal framework of the nasal cavities include: the unpaired ethmoid, sphenoid, frontal bone, and vomer; the paired nasal, maxillary, palatine and lacrimal bones, and inferior conchae. Of all the bones associated with the nasal cavities, the ethmoid is a key element.

Paranasal sinuses There are four paranasal air sinuses-the ethmoidal cells, and the sphenoidal, maxillary, and frontal sinuses (Fig. 8.222A and 8.222B). Each is named according to the bone in which it is found.

The ear, for hearing and balance, comprises the auri- cle (pinna), external acoustic meatus (1), tympanic membrane (2), middle ear and inner ear. Much of the ear is housed within the temporal bone and is closely related to the sigmoid venous sinus, middle cranial fossa and internal carotid artery.

The middle ear is like a biconcave lens. It is filled with air and houses the malleus, incus and stapes, which transmit sound waves from the tympanic mem- brane to the cochlea. Tensor tympani (V3) and stapedius (VII) attach to these ossicles to dampen excessive vibration. The auditory tube (middle ear to nasopharynx) equalizes air pressure on either side of the tympanic membrane. Patency of the tube is essen- tial for normal ear function.

The inner ear houses the bony labyrinth, itself lined by the fluid-filled membranous labyrinth, and subdi- vided into the cochlea (hearing) and semicircular canals with utricle and saccule (balance).

Nasopharynx The nasal cavity continues posteriorly into the nasopharynx (1), which is also lined by respiratory epithelium and is held open by the pharyngobasilar fascia that arises from the bones of the skull base.

Auditory tube Equalization of pressure in the mid- dle ear occurs via the auditory (Eustachian) tube (2) that connects the middle ear to the nasopharynx. The tube has a bony part that passes through the petrous temporal bone and a
cartilaginous part that lies between the greater wing of sphenoid and the petrous temporal bone.

Tonsils Clusters of lymphoid tissue are gathered under the mucous membrane on the posterior wall of the nasopharynx and around the opening of the auditory tube. These are the pharyngeal
(adenoid) (7) and tubal (3) tonsils, which may enlarge following chronic inflammation to obstruct the nasopharynx and auditory tube. The latter may result in recurrent and chronic middle ear infections.

Muscles of mastication (all supplied by V3)

Lateral pterygoid is the only primary muscle of mastication that opens the mouth. Muscles passing upward from the hyoid to the mandible, in particular digastric (6), may assist it.

Closing the mouth. The three other primary muscles of mastication elevate the mandible in biting, chewing and grinding.

Temporalis (7,8) arises from the temporal fossa and overlying fascia.

Masseter (10) passes from the zygomatic arch (11) to the lateral aspect of the mandibular ramus. Medial pterygoid (12) is a deeper, almost mirror image of masseter. It arises from the lateral pterygoid plate, but from its medial aspect.

Five layers of the scalp

1 The skin (1) has hair and associated sebaceous glands, which may form cysts.

2 The subcutaneous tissue connects the skin to the underlying aponeurosis. It is dense, thick tissue with a rich blood supply. The arteries anastomose freely from both sides and from branches of both the internal and external carotids. The rich anastomosis and dense con- nective tissue that tends to hold open a lacerated artery means scalp wounds bleed profusely.

3 Occipitalis (2) has a muscle belly on each side that arises from the skull and inserts into the epicranial aponeurosis (3). The aponeurosis gives origin to frontalis (4), which anteriorly attaches to the skin of the eyebrow. Laterally the aponeurosis thins and blends with the fascia over temporalis (6).

4 The loose connective tissue beneath the aponeuro- sis allows the scalp movement described above.

5 The periosteum (7) adheres to the bone and is continuous with the periosteal layer of dura mater at the foramina and via the sutures.

Salivary glands

Saliva wets and lubricates food; it also contains enzymes to commence digestion. Small salivary glands are scat- tered under the mucous membrane of the lips and cheeks, and the sublingual glands (Illustration G) lie under the tongue, on the floor of the mouth. The parotid (Illustration F) secretes serous saliva, and the sub- mandibular (Illustration E) secretes seromucous saliva.

The parotid lies between the mastoid process and the mandibular ramus. It overlaps sternocleido- mastoid (15) and masseter, and extends medially as far as the styloid process (16).

The submandibular gland lies inferior to the body of the mandible, between it and mylohyoid

From this deeper part of the gland, the submandibular duct (21) passes for- ward (surrounded by the sublingual gland (22) and receiving its ducts) to open on the sublingual papilla (40) on the lingual frenulum.

The soft palate (1) is tensed during swallowing and elevated to lie in a socket (created by a few circular fibres of palatopharyngeus) and separate the orophar- ynx (2) from the nasopharynx (3). It is formed by the aponeuroses of the tensor palati muscles.

Tonsils

The lingual tonsil (6) lies under the mucous mem- brane of the posterior one-third of the tongue. The palatine tonsil (7) lies in the fossa behind palatoglos- sus, but in front of palatopharyngeus (8). Tonsils are clusters of lymphocytes, but the overly- ing mucous membrane dips into the tonsillar tissue to form crypts. The lingual, palatine, pharyngeal and tubal tonsils form a protective lymphoid ring around the entries to the respiratory and digestive tracts.

The tongue and floor of the mouth

The tongue consists of a buccal and a pharyngeal portion separated by a V-shaped groove on its dorsal surface, the sulcus terminalis.

The under aspect of the tongue bears the median frenulum linguae; the mucosa is thin on this surface and the lingual veins can thus be seen on either side of the frenulum. The lingual nerve and the lingual artery are medial to the vein but not visible.

The thick stratified squamous mucosa of the dorsum of the tongue bears papillae over the anterior two-thirds back as far as the sulcus terminalis. These papillae (particularly the vallate) bear the taste buds. The posterior one-third has no papillae but carries numerous lymphoid nodules which, with the palatine tonsils and adenoids, make up the lymphoid ring of Waldeyer.

The tongue is divided by a median vertical fibrous septum, as indicated on the dorsum by a shallow groove. On each side of this septum are the intrinsic and extrinsic muscles of the tongue

whole. They pass to the tongue from the symphysis of the mandible, the hyoid, styloid process and the soft palate, respectively the genioglossus, hyoglossus, styloglossus andpalatoglossus. The functions of the individual extrinsic muscles can be deduced from their relative positions (Fig. 197). Genioglossus protrudes the tongue, styloglossus retracts it and hyoglossus depresses it. Palatoglos- sus is, in fact, a palatal muscle and helps to narrow the oropharynx in swallowing.

Blood is supplied from the lingual branch of the external carotid artery.

Nerve supply
The anterior two-thirds of the tongue receives its sensory supply from the lingual branch of V which also transmits the gustatory fibres of the chorda tympani (VII). Common sensation and taste to the posterior one-third, including the vallate papillae, are derived from IX. A few fibres of the superior laryngeal nerve (X) carry sensory fibres from the posterior part of the tongue. All the muscles of the tongue except palatoglossus are supplied by XII; palatoglossus, a muscle of the soft palate, is innervated by the pharyngeal branch of X.

Pharynx

The pharynx is for the passage of air from the nasal cavity to the larynx and trachea, and for food from the oral cavity to the laryngopharynx (9) and oesophagus.

Superior constrictor (11) arises from the medial pterygoid plate and the pterygomandibular raphe, which ensures continuity between it and buccinator. Middle constrictor (12) arises from the hyoid bone and stylohyoid ligament. Inferior constrictor arises from the thyroid and cricoid cartilages: thyropharyngeus (13) and cricopharyngeus (14). The constrictors sweep around the pharynx and fuse in the pharyngeal raphe

The three constrictor muscles on each side are major contributors to the structure of the pharyngeal wall (Fig. 8.189 and Table 8.17) and their names indicate their position-superior, middle, and inferior constrictor muscles. Posteriorly, the muscles from each side are joined together by the pharyngeal raphe. Anteriorly, these muscles attach to bones and ligaments related to the lateral margins of the nasal and oral cavities and the larynx.

The constrictor muscles overlap each other in a fashion resembling the walls of three flower pots stacked one on the other. The inferior constrictors overlap the lower margins of the middle constrictors and, in the same way, the middle constrictors overlap the superior constrictors. Collectively, the muscles constrict or narrow the pharyngeal cavity.

All of the constrictors are innervated by the pharyngeal branch of the vagus nerve [X].

Nasopharynx

The nasopharynx is behind the posterior apertures (choanae) of the nasal cavities and above the level of the soft palate (Fig. 8.192). Its ceiling is formed by the sloping base of the skull and consists of the posterior part of the body of the sphenoid bone and the basal part of the occipital bone. The ceiling and lateral walls of the nasopharynx form a domed vault at the top of the pharyngeal cavity that is always open. The cavity of the nasopharynx is continuous below with the cavity of the oropharynx at the pharyngeal isthmus. The position of the pharyngeal isthmus is marked on the pharyngeal wall by a mucosal fold caused by the underlying palatopharyngeal sphincter, which is part of the superior constrictor muscle. Elevation of the soft palate and constriction of the palatopharyngeal sphincter close the pharyngeal isthmus during swallowing and separate the nasopharynx from the oropharynx.

Oropharynx

The oropharynx is posterior to the oral cavity, inferior to the level of the soft palate, and superior to the upper margin of the epiglottis (Fig. 8.192). The palatoglossal folds (arches), one on each side, that cover the palatoglossal muscles, mark the boundary between the oral cavity and the oropharynx. The arched opening between the two folds is the oropharyngeal isthmus. Just posterior and medial to these folds are another pair of folds (arches), the palatopharyngeal folds, one on each side, that overlie the palatopharyngeus muscles.

Laryngopharynx

The laryngopharynx extends from the superior margin of the epiglottis to the top of the esophagus at the level of vertebra CVI

The cavity of the laryngopharynx is related anteriorly to a pair of mucosal pouches (valleculae), one on each side of the midline, between the base of the tongue and epiglottis. The valleculae are depressions formed between a midline mucosal fold and two lateral folds that connect the tongue to the epiglottis. There is another pair of mucosal recesses (piriform fossae) between the central part of the larynx and the more lateral lamina of the thyroid cartilage. The piriform fossae form channels that direct solids and liquids from the oral cavity around the raised laryngeal inlet and into the esophagus.

LARYNX

The larynx is both a valve (or sphincter) to close the lower respiratory tract, and an instrument to produce sound. It is composed of: three large unpaired cartilages (cricoid, thyroid, and epiglottis); three pairs of smaller cartilages (arytenoid, corniculate, and cuneiform); a fibroelastic membrane and numerous intrinsic muscles.

The larynx is suspended from the hyoid bone above and attached to the trachea below by membranes and ligaments. It is highly mobile in the neck and can be moved up and down and forward and backward by the action of extrinsic muscles that attach either to the larynx itself or to the hyoid bone.

Cavity of the larynx The central cavity of the larynx (Fig. 8.208) is tubular in shape and is lined by mucosa. Its architectural support is provided by the fibro-elastic membrane of larynx and by the laryngeal cartilages to which it is attached.

The inferior opening of the laryngeal cavity is continuous with the lumen of the trachea, is completely encircled by the cricoid cartilage, and is horizontal in position unlike the laryngeal inlet, which is oblique and points posterosuperiorly into the pharynx. In addition, the inferior opening is continuously open whereas the laryngeal inlet can be closed by downward movement of the epiglottis.

Two pairs of mucosal folds, the vestibular and vocal folds, which project medially from the lateral walls of the laryngeal cavity, constrict it and divide it into three major regions-the vestibule, a middle chamber, and the infraglottic cavity

the vestibule is the upper chamber of the laryngeal cavity between the laryngeal inlet and the vestibular folds, which enclose the vestibular ligaments and associated soft tissues; the middle part of the laryngeal cavity is very thin and is between the vestibular folds above and the vocal folds below. the infraglottic space is the most inferior chamber of the laryngeal cavity and is between the vocal folds (which enclose the vocal ligaments and related soft tissues) and the inferior opening of the larynx;

How to outline the anterior and posterior triangles of the neck

The eye and lacrimal apparatus

Major features of the eye include the sclera, cornea, iris, and pupil (Fig. 8.277). The cornea is continuous with the sclera and is the clear circular region of the external covering of the eye through which the pupil and iris are visible. The sclera is not transparent and is normally white.