Superficial Neck

Clinical Anatomy II
Spring
Rutland
 Neck
Can you draw where the spinal
accessory nerve travels?

Gilroy,
 Triangles of the Neck
Name the borders
of the posterior
triangle/ anterior
triangle

What might you

find under each
border if you
removed the
muscles? Use your
x-ray vision to see.

Gray’s Fig 8.157, p. 1000

 Which triangle?

Gilroy, p.636, Fig 45.29

What do you find in
the submandiular
triangle?

Name the borders of the

carotid(anterior) triangle
SCM, Digastric, Sternohyoid

Borders of posterior triangle(occipital)

Scm, UT, Clavicle
Gilroy, pg 636; Fig. 45.29B
What lies in the
carotid sheath?
1. Carotid artery
Neck – Cross Section
2. Vagus n
3. Internal jugular
vein
 External Jugular Vein Through which
triangle does the
external jugular
exit?

Gray’s Fig 8.181, p. 1024

Find Grandma
ms! Muscles of Triangles List all the
muscles that
border the
levator

Gray’s Fig 8.188, p. 1033

Neck Mm.
in Anterior
Triangle of
Neck
1.Digastric
2.Mylohyoid
3. Stylohyoid

4. Sternohyoid
5. Omohyoid
6. Thyrohyoid
7.Sternothyroid

Gilroy Fig 45.5A, p. 621

 1. Digastric
2. Mylohyoud
3. Geniohyoid(not Suprahyoid Muscles
pictured
4. Stylohyoid
Hyoglossus is attached to
hyoid, but considered ms
of mouth

Gilroy Fig 45.5A, p. 621

INFRAHYOID MS
“STRAP MS”

Gilroy Fig
45.5A, p. 621
 Suprahyoid Mm. Mylohyoid
Digastric
Stylohyoid

Function: affects tongue: assist with Gives base for tongue to function,
chewing, swallowing, sucking on a elevates hyoid and larynx to allow
straw, singing, and speaking swallowing and tone production
ELEVATE HYOID
Gilroy Fig 45.5A, p. 621
Anterior Digastric
 Notice sling of
mylohyoid and ms
superior to it.
Which
jt?

Which ms lies
here?

Geniohyoid M. Gilroy Fig 45.5A, p. 621

Function: assists with drinking,
swallowing, speaking (opposing Try tightening ms of ant
action with suprahyoids), Infrahyoid
tightens tissue of anterior neck
“strap ms”
Mm. neck with isometric
when threatened contraction.
DEPRESS HYOID and LARYNX

Gilroy Fig 45.5A, p. 621

 Suprahyoid and Infrahyoid muscles
Muscles
(p.620)
Proximal attach Distal Attach Nerve FUNCTION

Digastric Mastoid mandible V3/facial n

process
Stylohyoid Styloid process Facial n

Mylohyoid V3(mylohyoid)

Geniohyoid C1

Omohyoid Ana cervicalis (C1-3)

Sternohyoid Ansa Cervicalis C1-3

Sternothyroid Ansa Cervicalis C2-3

Pg 590 Gilroy
Thyrohyoid C1
 WHICH MS?
• Which suprahyoid ms resembles an infrahyoid
ms with 2 bellies?

• Explain to your neighbor the difference

between the suprahyoid and infrahyoid ms.
Gilroy Fig 45.8, p. 624
 Infrahyoid Mm.
What spinal level is
the hyoid bone? c3
C3

Gilroy Fig 45.5A, p. 621

Spinal levels
 “Adam’s apple”= laryngeal prominence= C4
Hyoid bone= Body of C3
Cricoid cartilage= C6 (tracheotomy usually performed below this)
• https://www.cancer.gov/images/cdr/live/CDR786385.jpg
 What lies in the Carotid sheath?
• I See 10 CC's in the IV
– I See (I.C.) = Internal Carotid artery
– 10 = CN 10 (Vagus nerve)
– CC = Common Carotid artery
– IV = Internal Jugular Vein
 Common Carotid Aa. - Origin

Arch of aorta → Left CCA

Right CCA ABCS
Arch of aorta → Brachiocephalic trunk
Right Subclavian a.

Gilroy Fig 8.4A, p. 80

External Carotid A.
Track blood flow from
aorta to L facial artery-
aorta arch-L common
carotid artery –ext
carotid artery- facial
artery

NOTICE ARTERIES OFF OF

EXTERNAL CAROTID

1. Superior thyroid a
2. Lingual artery
3. Facial
4. Mandibul ar

Gilroy Fig 40.4B, p. 547

Superior Thyroid A.

Superior thyroid a .
from external
carotid a.

What arteries
supply the thyroid?
1. Glandular
branches
2. Inferior thyroid

Gilroy Fig 45.8, p. 624

 Arteries off
Ext carotid
from distal Lingual and Facial Aa.
to proximal

1.

Gilroy Fig 40.4p. 547

 Internal Jugular V.

1.S ______
2. F
_______

Gilroy Fig 45.9, p. 625

 Internal Jugular Vein

I I
S S
B B

Grandparent?____________ Parent? _____________ of internal jugular v.

 VENOUS DRAINAGE

Chronic lung dx; mediastinal tumors, infection can impede blood flow to R heart and blood
can dam up into superior vena cava- jugular veins. Gilroy, p 625
 Jugular Vein Distention
• Can be due to:
– R heart failure
– Pulmonary hypertension
– Tricuspid valve stenosis
– Superior vena cava
obstruction
– Constrictive pericarditis
– Cardiac tamponade
Grays
Hypoglossal n. Cervical Plexus
What ms is
innervated by
Hypoglossal n.

Loop of nerve
fibers from
C1-C3
innervating
strap ms.
What cranial
nerve does
the superior
ansa cervicalis
arise from?

Gilroy Fig 45.15, p. 629

 Vagus N.

Gilroy Fig 45.31, p. 639

Submandibular Glands
Parotid gland

Gilroy Fig 45.33

pg. 641
 Submandibular/Sublingual Glands
Helps with
digestion and a
healthy mouth.
Saliva has enzymes
that break down
food, moistens food
to slip down throat.

Gilroy Fig 44.25C, p. 611

 Submandibular Duct

Fib 44.21, p. 609

Posterior Triangle of Neck, Gilroy p.636

Gray’s Fig 8.180, p. 1025

Sensory Branches – Cervical Plexus

Fig 45.14, p. 629

Which
nerves exit
the
posterior
triangle?

Posterior
Triangle of Neck
Gilroy Fig 45.35B, p.643
 Erb’s point
• landmark of brachial plexus on
upper trunk, about 1 inch
above clavicle at C6 level.
• Point: location of angle
between posterolateral border
of SCM muscle and clavicle
where nerves exit
– Spinal accessory found 1
cm above Erb’s point
• Electrical stimulation at Erb's
point causes contractions of
the biceps, deltoid, etc.

Gilroy Fig 45.35B, p.643

Posterior
Triangle

Gilroy Fig 45.35B, p.643

Posterior Triangle - Muscles

Gray’s Fig 8.173

Deep Cervical mm.
Name those “deep
flexors“ muscles
Action:

Attachments to C1
transverse process:
_____________
________
Which ms attaches to
anterior body of C1
Which ms(s) attaches
to transverse
processes of cervical
vertebrae?
________________
_________________

Gilroy fig 45.7, pg 623

Cervical Plexus

Gray’s Fig 8.177

 Brachial Plexus
Subclavian A.
Scalene Mm.
Between which scalenes does
the brachioplexus arise?

Note proximal attachments of

scalenes

Gilroy Fig -----C

 Tumor Metastasis
• Lymph from all of body
goes to Jugulosubclavian
junctions (red circles) .
– -Gastric carcinoma may
metastasize to L
supraclavicular lymph
nodes
• Clinical: look for
enlargement of lymph
glands in your pts

Gilroy, pg 627, 45.2

 Superficial Cervical Lymph Nodes

Gilroy, pg 627, Fig.

45.11
Note lymph drainage- posterior
to jugular vein.

Note lymph glands

submandibular and submental
that you will find as you dissect

Gilroy Fig 45.12,p. 627

Can you name the structures?
Answers
 Anterior Neck questions
Muscle Nerve Innervation Function
     
     
     
     
     
     
     

•List the suprahyoid ms. What are the functions of these

muscles? _______________________
•List the infrahyoid ms. What are the functions of these muscles?
_________________________
•Can you palpate any of the above muscles? _____________
Neck II – Deep Structures

Clinical Anatomy II
Spring
Rutland
 Cervical Disectomy/ Fusion
• http://www.youtube.com/watch?v=Ks0tYTzHU
9w
anterior

• http://www.youtube.com/watch?v=dinevg_S4
iU
posterior

• http://www.youtube.com/watch?v=r04wNmX
7rm4
 By the end of dissection, you should recognize CRANIAL
nerves that pass through the anterior triangle :

• Facial nerve(VII): goes to

– platysma, posterior belly digastric, and stylohyoid
• Glossopharyngeal Nerve(IX)
– Supplies sensory branches to pharynx; goes to base of tongue
• Vagus Nerve(X): runs in carotid sheath with _____ & _____
– Branch supplies motor branch to pharynx, superior laryngeal nerve
• Spinal Accessory Nerve(XI): most posterior of the cranial nerves
exiting through jugular foramen (Posterior triangle)
– No branches given off in anterior neck
• Hypoglossal Nerve (XII): supplies the tongue ms
• Cervical sympathetic trunk-ganglion: part of Cervical plexus
form anterior rami of C2-C3
Review what you have dissected
 As you evaluate deep neck
• Look for 1st rib: Ms attaching there?
– S______ _________
– S_______ ________
– S________ ____________
– S________
– Intercostal
– Does Pec minor?
– Pec major?
 Why
Which nerves
important?
make the Ansa
Cervicalis ? Ansa Cervicalis
• What is it?
– Loop of nerve fibers
from cervical nerve
C1-C3 that innervate
strap muscles in
anterior neck
• Omohyoid
• Sternohyoid
Sternothryoid
– Begins as branches
off of C1, joins
hypoglossal nerve,
then leaves and
forms superior root
 Cervical Sympathetic Trunk
Phrenic n.
arises off of
__, __, ___ .
Upon which
ms do you Look for
find the cervical
phrenic n ganglion
lying? when
_________ dissecting

Gray’s Fig 8.185, p. 1029

 Cervical
Sympathetic
Trunk
Which sympathetic ganglion
nerve root innervates the
carotid plexus ? _________
Nerve root level? ________
Middle cervical ganglion
from C__ and C __

Which cervical sympathetic

trunk supplies the vertebral
artery? _M__________
Middle cervical ganglion: at
level of C6 vertebra

Inferior Cervical Ganglion Vertebral a.

Subclavian a. ______ Subclavian a.
Nerve root level? C7-C8 Gray’s Fig 8.190, p. 1036
 Superior Cervical Ganglion
Superior cervical
Which vessels
ganglion: part of
supply the
sympathetic trunk –
thyroid gland?
lies anterior to C1
and C2 vertebral
bodies

Gilroy Fig 45.34, p. 641

Drawing by Nick Love, PhD, 2nd yr med student at Stanford University, 2017
 Where does lymph

Lymph Nodes drainage for head

go?
________
________
Tonsils drain
Deep cervical into______
nodes Tongue drains into
(jugulodigastric and ________
jugulo-omohyoid
nodes) receive
lymphatic drainage
from head and
neck.

Jugulodigastric:
receives drainage
from TONSILS

Jugulo-omohyoid:
receives drainage
from tongue

Gray’s Fig 8.193, p. 1038

 Lymph Nodes
• Infective nodes:
– A) soft
– B) tender &
– C) inflamed
 LYMPH NODES
• Lymphoma:
– multinodular large volume rubbery nodes
– Ie: Hodgkin’s Lymphoma
Thoracic Duct
Thoracic ducts:
transports lymph &
drains into venous
system. Note location
of posterior to internal
jugular v.

Gray’s Fig 8.191, p. 1037

Purpose of
thyroid?
Thyroid Gland

Thyroid:part of
endocrine system;
produces, stores,
& releases
Triiodothyronine
(T3) &, Thyroxine
(T4)

Gilroy Fig 45.37, p. 639

Thyroid Gland: Superior thyroid
a. comes off
blood supply: from ext carotid ______ Carotid a.
artery

Notice ms

Isthmus:
normally Inferior
covers 2-4th thyroid a
tracheal ring comes
Gilroy Fig 45.31c, p. 639 off_S_____
 Diseases of the
thyroid
• Thyroidectomy performed for
– Multinodular goiter: diffuse
irregular enlargement of thyroid
gland
– Thyroid cancer
National cancer Institute . http://seer.cancer.gov/statfacts/html/thyro.html . Accessed 2-6-15
 Parathyroid Glands
Usually 4 parathyroid glands:
small ,brownish bodies (3-5 mm
diameter-size of rice) found on
posterior surface of thyroid
gland.

Purpose: assists in controlling

body’s calcium levels to level
between 9.0 to 10.1 (most in mid
9 range)

Gilroy Fig 44.28, p. 615

 Pharynx
Circle the
pharynx areas

See the
CROSS

Gilroy Fig 44.23, p. 610

 Larynx
The hyoid bone
serves as a
protection to
what structure?
____________
BE CAREFUL with
dissection-DON’T
just cut or your
will cut off the
epiglottis!

Tracheal rings

Gilroy Fig 45.16A, p. 630

Glossopharyngeal N.
CRANIAL NERVE IX
Innervates: which muscle?
Stylo______________________

Function: Sensory to posterior

tongue(touch, pain, taste),
pharynx (touch, pain)
Autonomic: parotid gland
Important for swallowing

Hyoglossus: Hypoglossal n

Gray’s Fig 8.163, p. 962

 Gag reflex:
• Brisk/ brief elevation of • Glossopharyngeal
soft palate & • Vagus n.
contraction of
pharyngeal ms
• Can also be from
sensory of trigeminal
Gilroy pg. 608, fig 44.20
Vagus N.(X)
-pharyngeal br.
-superior laryngeal n.

Can the vagus

nerve affect our
ability to speak?
___________

Gray’s Fig 8.164, p. 962

Recurrent
Laryngeal Nn.
Note laryngeal (recurrent)
nerves(off of VAGUS). If
impaired with
thyroidectomy, paralysis of
laryngeal muscles occurs.

Which muscles innervated

by this?
Intrinsic laryngeal ms.
Posterior cricoarytenoid
Lateral cricoarytenoid
Arytenoid
Thyroarytenoid

Gilroy Fig 44.31, p. 617

Note the exit of Spinal Accessory N.
the nerve.
Which structure
does it lie
anterior to?
_____________
Which bony
structure is near
the n. ?
____________

Gray’s Fig 8.165, p. 963

Cr 12: arises off brainstem
Innervates T______ ms
Motor or sensory nerve or
Hypoglossal N.
both?

Which ms are
innervated by the
hypoglossal
n_________
Would you lose
function of
swallowing if you
damaged the
hypoglossal n?

Hypoglossal shares
nerve pathway
with _____
Name those “strap”
ms? Gilroy Fig 44.17, p. 607
 Cranial nerves involved in swallowing

Erman et al. Disorders of Cr N. IX and X. Semin Neurolo. 2009;29(1):85-92.

 Rahman S, Ganesh V, Hakim M (2019) Vertebral Artery Dissection Following Tonic Clonic
Seizure. J Neurol Neurosci Vol.10 No.3:298. DOI: 10.36648/2171-6625.10.3.29
 Review questions
• Which cranial nerve is found in the carotid sheath running
along with the common carotid artery and internal jugular
vein? ____________

• Which cranial nerve is found running along the internal

jugular vein and under the hyoglossal ms?
___________________

• Which cranial nerve is found running below the SCM and

upper trap? ___________

• Which cranial nerve shares a pathway with C1? __________

Name all anterior cervical muscles
• Superior:

• Inferior:

• What action does the omohyoid perform?

– Depression of hyoid bone
 Eye and Ear

Clinical Anatomy II –Spring

Rutland
Which
nerves
affect the
nose?

Eyes?

Ear?
Bony Orbit
3 bones make the eye
orbit?
1. Frontal process of maxilla
2. Frontal bone
3. Zygomatic bone

What other bones make up

the full eye socket?
Sphenoid
Ethmoid
Lacrimal
Palintine

So how many bones?

MZLFESP

Gray’s Fig 8.73, p. 927

• Thin layer of Skin
connective tissue/
loose
arrangement---
leads to
accumulation of
fluid (blood)around
skin of eyelids

Do you have swelling

in your eyes after
crying?
 EYELIDS
• With which motion
of the eyes do pts
with Bell’s Palsy have
difficulty?
– difficulty with closing
eye or opening eye?
• Bell’s Palsy often
caused by Herpes
Simples or Herpes
Zoster virus
(shingles)
Which part of this muscle
Orbicularis Oculi M.
performs a tight squeeze
of the eyelid? ______
Light squeeze?palperbral

Gray’s Fig 8.75, p. 929

Attaches
to
sphenoid Eyelids
Note tendon of the
levator palpebrae
superioris ms. – open
eye

Gray’s Fig 8.76, p 929

 Levator Palpebrae Superioris Ms
• Innervated by Oculomotor(Cr n III)
• Elevates and retract the upper eye lid
• Ptosis(“Greek word for fall) can develop:
Droopy eyelid ( “student syndrome”)
 Loss of :
• Inability to close eyelids
• Facial n:
– Orbicularis Oculi
tightly and lower eyelid
droops away with
spillage of tears

• Oculomotor n: • Inability to open superior

– Levator palpebrae eyelid voluntarily, leads
superioris
to complete ptosis

• Superior tarsal muscle: • Constant partial ptosis

– Sympathetic fibers
 Glands
• Tarsal gland can be • Eyelid sebaceous gland
blocked and inflamed- and sweat glands: stye
Chalazion (benign,
painless nodule on inner
surface of eyelid
 Lacrimal Apparatus
Where does the
nasolacrimal
duct drain?
____________

Note location
of lacrimal
gland

Gilroy Fig 41.15, p. 575

Lacrimal Gland of eye
 Superior Orbital Fissure - Contents

Which cranial
nerves affect
the eye?

Gray’s Fig 8.86, p. 934

 Which cranial nerves affect the eye?
• Cr N _2__
• Cr N __3_
• Cr N _4__
• Cr N (5) V1-2-3
• Cr N _6__
• Cr N _7__
Extra-ocular Mm.
Superior
view

Gilroy Fig 41.2B, p. 568

Extra-ocular Mm.
How many
extraocular ms?
____

Gilroy Fig 41.2A, p. 568

 Cranial nn. III, IV, VI in Orbit
Look for these in
the cranium
today

Gilroy Fig 39.6A, p. 529

Cut window
into cranium
to see
muscles and
nerves

Try this
dissection on
one eye

Gilroy Fig 39.5C, p. 529

Extra-ocular Mm.

Circle the
nerves

Gilroy Fig 39.6B, p. 529

Moore’s eye chart*****
 MUSCLE /NERVE MOVEMENT
Medial rectus Oculomotor (III) IN (ADDUCTION)
Lateral rectus Abducens (VI) OUT (ABDUCTION)
Inferior rectus Oculomotor (III) DOWN and IN
Superior rectus Oculomotor (III) UP and IN
Inferior oblique Oculomotor (III) UP and OUT
Superior oblique Trochlear (IV) DOWN and OUT

http://www.youtube.com/watch?v=vd7OOJ7c1q4
Cr N III: Oculomotor PALSY
“Down and Out”
• NOT WORKING:
– Superior rectus
– Inferior rectus
– Medial rectus
– Inferior oblique

– Causes: DM, HTN,

Aneurysms
Cr N IV:Trochlear nerve palsy
• Superior oblique not
PALSY
working
– S.O. ms. moves eye DOWN
and OUT
– So with palsy: up and in
• Only ms it innervates
• Causes: DM, HTN, Trauma,
congenital, tumor
• Tend to tilt head away
from lesion
 Cr N. VI: Abducens nerve palsy:
• Lateral rectus not working
on L
– Not able to abduct eye(L)
(paralysis of lateral rectus)
– COMPLETE LESION OF VI: eye
will rest medially due to
unopposed medial rectus
• Can be caused by Diabetes,
HTN, high intracranial
pressure affects 6th n.
• Follow pencil in circle
 (LR SO )3
6 4

LAST
Ophthalmic Division of Trigeminal
Supplies sensory nerve
N.
(V1) supply to cornea, ciliary
body, iris, lacrimal gland,
conjunctiva, mucous
membrane of nasal cavity
and skin to eyelids,
eyebrow, forehead, and
nose

Gilroy Fig 39.9D, p. 531

 Trigeminal N. in Orbit (branch of V₁)
Frontal n=V1 Ophthalmic n.-
sensation to eyelid

Gilroy Fig 41.12A, p. 573

Internal
Carotid A.
-ophthalmic
a.
Parent of the
ophthalmic a.
_______________
Grandparent?
_____________

Gilroy Fig 41.7, p. 570

Eye - Sagittal

Gilroy Fig 41.13, p. 574

 Eyeball

Gilroy , 41.16, p. 576

Cornea, Iris, Lens

Gilroy Fig 40.18, p. 578

Where would you dissect to find
the bones of the ear?
Ear
Which CR nerve
affects the ear? ___

Gilroy Fig 43.3, p. 588

 Do ears grow as you age?
– Earlobes elongate due to gravity
– Bones do not grow

• The facial nerve travels through the internal

acoustic meatus. In which bone of the skull is
this located?
a. Temporal
b. Parietal
c. Occipital
d. Sphenoid
 External Ear

Gilroy Fig 43.4, p. 588

 Does the facial n supply
Middle Ear anything to the ear?
Supplies motor function to stapedius ms in
middle ear
If someone has facial n. disorder, they may
have pain in ear and sensitivity to loud
sounds.

“The
“Drum”

Gilroy Fig 43.10, p. 591

Facial nerve

By Patrick J. Lynch, medical illustrator - Patrick J. Lynch, medical illustrator, CC BY 2.5,

https://commons.wikimedia.org/w/index.php?curid=1498075
Hair cells in
inner ear
http://www.nidcd.nih.gov/health/hearing/pages/otosclerosis.aspx
Middle Ear Ossicles
 Barotrauma • Increased pressure or fluid on ear from air
travel/ scuba diving / weather frontal
systems
• Pressure builds causing eardrum to be pulled
inward.
Common symptoms of ear barotrauma include:
• Ear pain
• A sensation that the ears are stuffed
• A need to "pop" your ears by swallowing,
yawning or chewing gum
• More severe signs include:
Extreme pain in the ear
• Dizziness (vertigo)
• Bleeding or fluid coming from the ear, which
can mean you have a ruptured eardrum
• Hearing loss

https://www.health.harvard.edu/a_to_z/barotrauma-a-to-z
Nasal and Oral Cavities
Pharynx and Larynx
Clinical Anatomy II-Spring
Rutland
 Terminology
• Adenoids=
enlargement of tonsils
• Pharynx- to
esophagus(P-E)
• Larynx= voice box; has
vocal folds.
– Larynx (top part of
trachea, which goes to
lungs(L –T- L)
Tracheostomy: hole in trachea and tube
inserted in lower neck. Strap ms deviated
laterally, Usually around 2nd-3rd tracheal rings.

Note ligament that connects hyoid bone thyroid

cartilage and cricothyroid cartilage
 Performed between
the 2nd and 3rd
tracheal ring

Tracheotomy: incision into

trachea

Tracheostomy: temporary
or permanent opening in
trachea
What happens at the hyoid
with swallowing? raises
 Which muscles/ n. assist with
deglutition(swallowing)?
• Oral phase
• Pharyngenal Phase
• Esophageal phase
Review
 Oral phase
-Opening of mouth: ( nerve ) DR 1-3
-Digastric
-Mylohyoid
-Lateral pterygoid can assist
-Geniohyoid
-Closing of mouth: (nerve ) Trigeminal
- Temporalis
- Masseter
- Medial pterydoid
-
Which muscles close the lips to chew?
Cr. N 7
Chewing of food:
V3 muscles ____________
Buccinator( Cr n. ___) helps contain food against teeth
Lingual nerve of tongue(V3)
 Pharyngeal phase
• Nasopharynx and Larynx
– Involuntary NM control
– Chewing, breathing, coughing and vomiting inhibited
during this phase.
• Can you swallow and chew at the same time?
– Cr n. IX, X work during this phase (pharyngeal
constrictors)
• The efferent motor fibers of Cr n. IX supply stylopharyngeus
muscle which helps elevate larynx and expand pharynx during
swallowing
• Cr n. X supplies pharyngeal ms.
– The opening of the auditory tube happens with this(chew
gum when flying)?
 Esophageal Phase
• Involuntary NM control
• Bolus of food passes slower
• Pharyngeal constrictor muscles (Cr n. X )push
bolus of food from esophagus to stomach
– May see difficulty with patients who CVA
(dysphagia)
 Which bones make up the nasal cavity?
• Maxilla
• Palatine (roof of the
mouth) & maxilla make
the majority of the floor
of the nasal cavity
• Nasal
• Ethmoind” determines
the shape of the nose
– Vomer perpendicular
plate of ethmoid (vomer
bone looks like a plow)
 Muscles of nose?
• Elevate nose?
– Procerus
– Levator labii Superioris
Alaeque nasi
– Nasalis
• Depress nose?
– Alar nasalis
– Depressor septi nasi
• Compress nose?
– Transverse nasalis
• Dilate nose?
– Alar nasalis
 Which bone Nasal Cartilages
makes the
anterior nasal
spine? maxilla

Which
bones
touch
the
Nasal
bone?
Facial
Maxilla

Gilroy Fig 42.1A, p. 580

Nasal Cavity - External

Gilroy Fig 36.1B, p. 550

 Nasal Septum

Gray’s Fig 8.224, p. 1020

List at least 4
sinuses: Paranasal Sinuses

Gray’s Fig 8.223A,B, p. 1018

Note where the
pituitary gland sits in
relation to the nose Paranasal Sinuses

Gray’s Fig 223C,D, p. 1019

List the sinuses of
the nose
Paranasal Sinuses

Gilroy Fig 42.5B, p. 583

 Nasal Cavity – Nasal Conchae
Which cranial
fossa sits
superior to
the nose?
________

Which bones
are in the
anterior air
passageway?
frontal
ethmoid

Gilroy Fig 42.2B, p. 581

 Nasal Cavity – Sinus Openings

Gray’s Fig 8.227C, p. 1023

Nasal Cavity – Nasal Conchae
Which bones make
the superior and
middle concha?
ethmoid

Gray’s Fig 8.227B, p. 1023

 Nasal Conchae

Gray’s Fig 8.229, p. 1025

When hit on
the nose,
which artery
Nasal Cavity Blood Supply
may bleed?
ethmoid

Gray’s Fig 8.231, p. 1026

Olfactory n. fibers pass through the cribiform plate of the ethmoid innervating nose with
sense of smell
In which
conchae Innervation of Nasal Cavity
does Cr I exit
in the nose?
Superior
V1 and V2
conchae

Gray’s Fig 8.233, p. 1028

 Oral Cavity
Which
structures are
anterior of C5?
Vocal
cords/esophagu
s, thyroid
cartilage
The dens is in
alignment with
_____________
The epiglottis is
at which cervical
level? c4
5

Gilroy Fig 42.23, p. 610

Oral Cavity

Gray’s Fig 8.247, p. 1041

 FUNCTION OF TONGUE
• Assists with: • Nerves affecting the motor
– Mastication(chewing) and sensory function of the
– Taste tongue:
– Deglutition(swallowing) • All motor function of
– Articulation (speech) tongue: CNXII
– Oral cleansing – Except L palatoglossus(Cr X)
– Anterior 2/3 tongue:
sensation supplied by
V3(lingual n)
– Taste mainly from Facial n.
(chorda tympani n.)
Oral Cavity
Sublingual Region
Can you curl your tongue
lengthwise?

Do you have a gland in

your tongue?

Name all the glands we

have seen

Gilroy Fig 44.21A, p. 609

Oral Cavity
Which ns. affect the oral cavity?

-Lingual n.(V3)
-Hypoglossal n.
-Facial n.
-Glossopharyngeal n.

Lingual a.

Gilroy Fig 8.248, p. 1042

 The cranial nerves that affect the tongue
include:
• Cr n 7
• Cr n 5
• Cr n 9
• CN10
• Cr n 12
– All of the motor of the tongue is hypoglossal
 Tongue
• Average length of tongue: 10 cm
• Average weight: 60g(F), 70g (M)
• Anchored to the hyoid bone
• Assist with chewing and swallowing food as
well as speech
• Common tastes: sweet, sour, bitter, salty, and
5th: umami(tasting glutamate)
• 8 muscles control tongue
 Intrinsic ms
– Intrinsic: change shape of tongue
• Superior longitudinal ms
• Inferior Longitudinal ms
• Vertical Muscle
• Transverse ms
 Extrinsic ms of tongue:
Tongue- a mobile muscular organ
Anchored to bone
• Function: Change
position of tongue
• Genioglossus
• Hyoglossus
• Styloglossus
• Palatoglossus
Teeth
-Incisors
-Canines
-Premolars
-Molars

Gray’s Fig 8.265, p. 1056

The superior
and inferior
alveolar n is
Nerve Supply to Teeth
supplied by Superior and Inferior Alveolar Nn.
which
Nerve(s)?
Trigeminal

Gray’s Fig 8.268, p. 1059

 Pharynx

Gilroy Fig 44.23A, p. 610

Find your
1) cricothyroid ms
2) Inferior pharyngeal
constrictors
3) Hyoglossus
4) Middle pharyngeal
constrictors
5) Superior
pharyngeal ms

Pharyngeal Muscles

Gilroy Fig 44.28A, p. 614

Pharynx
-pharyngeal
constrictor mm.
Nerve innervation:
Vagus nerve (X)

Gilroy Fig 44.28, p. 614

Function of
Pharyngeal
constrictors?
____________
When?
__________

Pharynx -
Posterior
Gilroy Fig 44.29 p. 615
 Tonsils • Pharyngeal (aka
adenoids- nasal cavity-
disappear by adulthood)
• Palatine- most common
to be removed
• Lingual
Tonsils : part of
lymphatic system- help
fight infx

Gray’s Fig 8.193A, p. 992

Pharynx
Posterior

Uvula: “small bunch of

grapes”.

gag if touch?
Cr. N. IX
afferent for
Gilroy Fig 44.29, p. 615
gag reflex
 Larynx
-hyoid bone
-thyroid cartilage
-epiglottis
-cricoid cartilage

Gilroy Fig 45.16, p. 630

https://www.researchgate.net/figure/Com
putational-model-of-the-oral-pharynx-
larynx-trachea-airway-adopted-from- Vocal cord is vocal
Cheng_fig4_282905171 fold
https://www.dummies.com/education/science/anatomy/the-pharynx-larynx-and-trachea/
 Notice tongue- is it
Larynx attached to hyoid?

-hyoid bone
-thyroid cartilage
-cricoid cartilage
-Epiglottis
-vocal fold

Gilroy Fig 45.23, p. 633

 Both vocalis and
Larynx cr____t_____ help
with phonation and
-Vocalis m. pitch
Vocalis: part of the upper portion
of thyroarytenoid ms: produces
speech(reduce tension on vocal
cords during speech to decrease
pitch
Lateral cricoarytenoid ms: closed
vocal cords

Gilroy Fig 45.22, p. 632

Larynx
Posterior
-Intrinsic mm.
N to these ms? VAGUS
Purpose of posterior
cricoarytenoid ms: open
vocal cords- abduct vocal
cords

Transverse/Oblique arytenoid:
close larynx when swallowing/
cough
Gilroy Fig 45.22, p. 632
 Pharynx and Larynx Innervation
Which Cr n.
affect pharynx
and larynx?
Cr N 5
Cr N 9
Cr N 10

Gray’s Fig 8.196A, p. 996

 Which nerve supplies?
• Motor and sensory innervation of larynx?
VAGUS
• Nerve to cricothyroid? VAGUS
• Nerve to posterior ms of larynx? ( artyenoid
muscles) VAGUS
 Review of CrANial nerves +
Autonomic Nervous System

Rela-a-a-x-x or RUN!!!

Clinical Anatomy II-Spring

Gray’s pp. 41- 49
Gilroy, 648-649
 Before we start: CNS
• Somatic= body(Greek): skin, most skeletal ms derived from somites
in embryo
– Responds to info from external environment
– Originate in ventral grey, myelinated, synapse of skeletal ms . Releases
acetylcholine
– Polio destroyed the somatic body
– Neurogenic- skeletal ms depends upon the nerve supply
• Visceral= guts(Greek): innervates organ systems in body and other
visceral elements
– Responds to info from internal environment
– Has 2 types of nervous innervation-
• sympathetic(stress)
• parasympathetic (rest state= rest and digest)
 PNS: SAME

http://antranik.org/peripheral-nervous-system-cranial-nerves/
Cranial Nerves 1-6
Cr Nerve I: OLFACTORY (SENSORY)
 CR NERVE II: OPTIC (SENSORY)

Optic nerve:
sensory nerve of
vision.
-Carry info all
way to occipital
lobe
 CR NERVE III, IV and VI
Oculomotor, Trochlear and ABDUCENS ( ALL MOTOR)

• All 3 Cr n.
move the eye

• Which one
controls the
most eye ms?
• oculomotor
 CR N. V: Trigeminal
sensory and motor
Which muscles are
innervated by Cr N V?
CR N. VII-XII
Homunculus
Facial n: sensory and motor
CR N VIII: vEstibulocochlear n.
sensory n. of hearing and balance

Vestibular
portion

Hearing
portion
 CR N IX: GLOSSOPHARYNGEAL n.
Motor & sENSORY
-Innervates structures of
tongue (glosso) &
pharynx(pharyngeal=swa
llow)
-Provides somatic motor
and taste, respectively. 
Visceral sensory
function: innervates O2
and CO2 chemoreceptors
in carotid body and BP
sensor baroreceptors in
carotid sinus
-Its visceral motor
function is salivation
through the parotid
gland

Which nerve makes you salivate?

 cr. N 10: VAGUS
Parasympathetic SYSTEM
“REST and digest”
 CR n. XI: Accessory nerve:
motor only
Which ms
functions
might be weak
or lost if this
nerve was
damaged?
CR N. XII: HYPOGLOSSAL N:
Motor only
 Review

https://helpcampus.wordpress.com/2014/12/17/cranial-nerves-should-i-know-them/
 Before we progress
– Which Cr Ns. have motor and sensory functions?
• Cr N ___
• Cr N ___
• Cr N ___
• Cr N ___

V, VII, IX, X
 CLINICAL CASE
• 25yo M c/o of central
abdominal pain, which is
diffuse and colicky. After 3
hrs, pain localized to R
iliac fossa and became
constant. He was referred
to abdominal surgeon,
who removed a grossly
inflamed appendix.
• Can you explain the pain
pathways???
Where’s the pain coming from?
 Referred pain
• 1) Occurs when sensory info comes to spinal cord from one
location, but is interpreted by CNS as coming from another
location innervated by same spinal cord level.
• Happens when pain info comes from a region with low
amount of sensory input(gut)
• Afferents converge on neurons at same spinal level from
skin where high amount of sensory output occurs. Pain
from low output region interpreted as coming from
normally high output region
• Ie: pain from visceral region at same spinal cord level as
somatic side of nervous system
 REVIEW: REFERRED PAIN
• 2) Pain can refer from one somatic region to another
• EX: Pt c/o of pain on top of R shoulder, but could come from irritation of
peritoneum on inferior surface of diaphragm (innervated by phrenic
nerve)
 MYOTOMES
Somatic motor nerves

Most skeletal ms are

innervated by more than 1
spinal cord level

Ex: C5-6 in deltoid region

Can you name a ms that

only has 1 level spinal cord
innervation?
 DERMATOMES
Specific nerve region of
posterior SC at a specific
level . Area of skin supplied
by single spinal cord level
or one side .

Belly button- 10
Nipple line= ___
CUTANEOUS and DERMAL SENSORY PATTERNS
 Visceral (Autonomic ) Nervous System
Consists of sensory and motor components:
• Sensory – arise from neural crest cells
• Neuron cell bodies are in sensory ganglia
• Processes grow centrally into SC;
• Peripheral processes go to internal organs of
cardiac, pulmonary, digestive, and genitourinary
systems
• For chemoreception, mechanoreception, pain,
and stretch sensation
• Travel with motor fibers to same organ
 Autonomic Nervous System
Motor – innervate cardiac muscle, smooth
muscle, and glands
• Different organization than somatic motor
neurons
• Two neuron pathway from spinal cord to target
organs
• Synapse occurs in ganglia
• Preganglionic neurons arise in CNS
• Postganglionic neurons are in ganglia
– Postganglionic neurons come from neural crest cells
Autonomic Nervous System

Sensory

Motor

Gray’s Fig 1.41, p. 41

From where do the
2 parts of the ANS
develop?
Autonomic Nervous System
Visceral motor system subdivided into two parts:

• Parasympathetic – craniosacral outflow of preganglionic

axons “Brake” (Cr n. 3(Oculomotor),7
(facial),9(Glossopharyngeal),10 (Facial) have
parasympathetic as well as motor function)
– “Rest and Digest”

• Sympathetic – thoracolumbar outflow of preganglionic

axons “ Accelerator” (only nerves in thoracic-lumbar levels)
– “Fight or Flight” …”Epi and norepi”
Purpose is to REST and ________
 Stress: from ___________ System
(? Parasympathetic or sympathetic? )

• Fight (competing)
• Fright
• Flight (running) or exercising, or emotionally
running
• Prepare body for

• WHICH system for REST AND DIGEST?

– _________________________________
 Autonomic
Nervous System

Origin of preganglionic
motor neurons

A cranial sacral therapist affects which

system?

Gray’s Fig 1.43, p. 42

 Can an organ be innervated by both
parasympathetic and sympathetic ?

• Heart
• Iris of eye
• Lacrimal glands
• Salivary glands
• Airways of lungs
• Stomach
• Spleen
• Kidneys
• Adrenal gland
• Small Intestine
• Large Intestine
• Urinary Bladder
 Sympathetic Nervous System
Sympathetic motor system supplies innervation
to:
1. Peripheral - smooth muscle to blood vessels
and arrector pili mm; sweat glands; pupillary
dilator smooth muscle,
-TO the limbs (OPPOSITE for Parasympathetic- doesn’t
go to limbs)
2. Visceral - organs in head, thorax, abdomen,
and pelvis
Sympathetic
Nervous
System T1

L2
Preganglionic axons

Post-ganglionic axons

Gray’s Fig 1.44, p. 43

 Sympathetic Nervous System

Sympathetic trunks – contain the post-

ganglionic sympathetic neuron cell bodies
– paraspinal sympathetic ganglia
• Found on either side of spine from upper
cervical region to lower sacral levels
• Pre-ganglionic neuron axons travel from spinal
nerve to sympathetic trunk via whitewhite
communicating rami (myelinated)
Sympathetic
Trunks

Gray’s Fig 4.122, p. 342

 Spinal Nerve

Sympathetic trunk
Gray ramus
communicans
Sympathetic
ganglion

White ramus
communicans

Gray’s Fig 1.42, p. 42

 Sympathetic Nervous System
Innervation of Peripheral Regions

• Pre-ganglionic (myelinated) axons leave the

spinal nerve and enter the white
communicating ramus at that spinal level
• Post-ganglionic (unmyelinated) axons may do
one of two things:
1. may re-enter spinal nerve at same level and
travel to target organs
2. may re-enter spinal nerve at different level and
travel to target organs
 Sympathetic Nervous System
• Pre- and post-ganglionic
axons all stay at the
same spinal cord level
• Pre-ganglionic axons
synapse with post-
ganglionic neurons in
sympathetic ganglion

Gray’s Fig 1.45, p. 44

 Sympathetic Nervous System
For those post-ganglionic axons that will re-enter a
spinal nerve at different level:
Once pre-ganglionic sympathetic neuron axon
reaches sympathetic ganglion via white
communicating ramus, it can do either:
1. Synapse with a post-ganglionic neuron at that
level
- post-ganglionic axon will travel up or down
sympathetic trunk and exit at a different spinal
cord level through a gray ramus
 Sympathetic Nervous System
2. Can ascend or descend to another spinal
level and synapse with post- ganglionic
neuron at that different level
- post-ganglionic axon will leave the
sympathetic trunk at that level and re-enter
spinal nerve at that level through a gray
communicating ramus
 Sympathetic Nervous System

1
1

2
preganglionic
postganglionic
Gray’s Fig 1.46, p. 45
 PARA SYMPATHETIC
(see previous page)
• FUNCTION:
• Cr 3(Oculomotor): ________________
• Cr 7 (Facial): _____________________
• Cr 9 (Glossopharyngeal)
_____________________
• Cr 10 (Vagus) :
____________________________
 Sympathetic Nervous System
Innervation of Internal Organs
Thorax – Heart and Lungs
• Pre-ganglionic axons enter sympathetic trunk
and synapse at that level, or travel to a
different level and synapse at that ganglion
• Post-ganglionic sympathetic nerves leave the
sympathetic ganglia and form named nerves
to those organs, the cardiac nerves
 Sympathetic Nervous System
Innervation of
Thoracic Organs

preganglionic
postganglionic

Gray’s Fig 1.47, p. 46

 Sympathetic Nervous System
Abdominal and Pelvic Organs
Pre-ganglionic axons pass through the ganglion
without synapsing, and leave the ganglion at
that level, or travel up and down the chain
before passing out, and:
• The preganglionic sympathetic axons (from T5
–L2) will form splanchnic nerves that travel to
abdominal and pelvic regions
 Splanchnic nn.
Sympathetic
Nervous
System

Prevertebral ganglia
What forms the
splanchnic nerves?

Gray’s Fig 1.48, p. 47

 Sympathetic Nervous System
Abdominal and Pelvic Organs
• The preganglionic sympathetic axons synapse
at prevertebral ganglia in the abdomen and
pelvis

• The postganglionic neurons travel with the

blood vessels going to the abdominal and
pelvic organs
Sympathetic Nervous System

Gray’s Fig 4.154, p. 375

Where are white
and gray
communicating rami Sympathetic Nervous System
found?

Differences between
them? White
communicating rami
• Found at T1 – L2 spinal nerve levels
• Contain preganglionic sympathetic neurons
• Myelinated fibers

Gray Communicating rami

• Found at all spinal nerve levels
• Contain postganglionic fibers
• Unmyelinated fibers

White rami usually found lateral to gray rami

 Parasympathetic Nervous System
Cranial-Sacral Outflow
Cranial - Preganglionic parasympathetic neurons are
found in cranial nerve nuclei (III, VII, IX, X)
• Pre-ganglionic parasympathetic axons travel with
cranial nerves to the target organ
• Supply innervation to :
– salivary, mucous, and lacrimal glands;
– pupillary sphincter
– ciliary muscles in the eye
• Vagus n. supplies:
– thoracic and abdominal organs (large intestine to transverse
colon)
What do the pre and post
ganglionic neurons in the
PARASYMPATHETIC chain release?
A____________

What do the postganglionic

neurons in the sympathetic
nervous system release?
Nor_______________

Norepinephrine
Acetylcholine
 Parasympathetic Nervous System
• Sacral – Preganglionic parasympathetic neurons:
– Found in spinal cord at levels S2-S4
• Preganglionic parasympathetic axons from sacral
outflow travel with pelvic splanchnic nerves to
target organ

• Pelvic splanchnic nerves innervate:S2-S4

– GI tract from transverse colon down,
– reproductive organs
– urinary tract
Parasympathetic Nervous System
• All preganglionic parasympathetic axons
travel to the target organ before synapsing
• Ganglia are found :
– wall of, or in connective tissue surrounding or very
near to, the target organ
• Post-ganglionic parasympathetic axons:
– very short
– innervate the smooth muscle, cardiac muscle, or
glands in the organ in the vicinity of the ganglia
Parasympathetic
Nervous System
(top and bottom-
Cranial-Sacral)

Gray’s Fig 1.49, p. 48

Parasympathetic
Nervous System
Nerve plexuses in
wall of GI tract

Gray’s Fig 1.50, p. 50

Parasympathetic Nervous System
Myenteric Plexus
 SIMPLE
way TO REMEMBER
Which system? ( Cranial-Sacral)
_____________________
Constriction of
eye
Sympathetic CHAIN
 SYMPATHETIC DIVISON (T1-L2)
opposite of parasympathetic :
• Pupil dilation
• Inhibit tear, nasal mucus, saliva production
• Skin blood vessel constriction (shunt blood away from skin and to
vital organs)
• Sweat
• Increase heartrate and bloodflow to heart muscle
• Bronchodilation
• Liver/gallbladder: release glucose
• Inhibit rest of digestive system
• Inhibit defecation and urination
• Ejaculation
SYMPATHETIC
 PARASYMPATHETIC
• The sacral outflow comes from spinal nerves S2 -S4 and innervates:
– 2nd half of large intestine (smooth muscle)
– Urinary bladder and ureters (smooth muscle)
– Reproductive organs/erectile tissues of external genitalia (smooth muscle)

• The cranial outflow is made up of CN and innervates

– III (Oculomotor) constriction of pupils
– VII (Facial) lacrimal gland (tears), nasal mucus glands, salivary glands
– IX (Glossopharyngeal) parotid gland (which is a salivary gland)
– X (Vagus) heart (cardiac muscle), lungs (bronchi smooth muscle),
liver/gallbladder (glands), stomach (smooth muscle and secretions),
pancreas (gland), small intestine and 1st half of large intestine (smooth
muscle and secretions)
 Questions ?
• What cranial nerves are involved with the Sympathetic chain?
Parasympathetic chain?
– Explain how they affect actions.
• Can you explain why a patient following mobilization of the thoracic
region may feel lightheaded following treatment or following
cervical traction?
• From where do the 2 chains of the ANS develop?
– Demonstrate differences between parasympathetic chain and sympathetic
chain.
• Explain why a patient might have referred musculoskeletal pain
when an organ might be irritated.
• Describe the differences between dermatomes, myotomes,
referred pain.
• Compare and contrast the 2 chains (pg 648 in Gilroy)
THORACIC WALL

CLINICAL ANATOMY II
Spring
Rutland
 Thorax – Thoracic Wall and Lungs
What is so
important about the
superior thoracic
aperature?

Location?

What concerns do
you have with dry
needling in this Inferior thoracic
region? aperature:
The anatomical thoracic
outlet, bounded by:
-T12 vertebra
posteriorly
Superior: open
-11th/12th pairs of ribs
Inferior: closed posterolaterally
by diaphragm -costal margin
anterolaterally
-xiphisternal joint
anteriorly

Gray’s Fig 3.1, p. 123

 Bony Thorax

With which 3
structures does the
manubrium
articulate?
________
________
________

Did you know that

the sternum is a
common site for
needle puncture to
obtain bone marrow
for study?
Gilroy Fig 671A, p. 56
What level is…. ?
Notice ribs 7-10- share same cartilage
attachment
 Vertebral body LEVEL ???
• T3-4: Manubrium
• T4 (T5)( T4-5 disc)
(level of 2nd costal cartilage: Sternal
4
Angle (Angle of Louis)
• T5-10: Sternal body
• T 10 (at epigastric fossa or “pit of
8
stomach): Xiphoid process
10
• Palpate these on yourself/friend
• 1st rib? Last rib?
Thoracic region
Radiographs
A: Nl lungs B: Pneumonia C. Scoliosis
C.
Where is the trachea?
 Ribs

Gilroy Fig 7.3, p. 57

Ribs
-Head
-Neck
-Tubercle
-Angle Body (shaft)

-Body (shaft)
-Costal cartilage

Gray’s Fig 3.21, p. 145

 Ribs
Ribs 1 & 2 –
shorter
more concave

First rib: has shallow

groove for subclavian
vein. Forms part of the
thoracic inlet .
2nd rib: longer than first

Ribs 11 and 12 –
shorter,
less curved
No tubercles
God even put his Note where
love with the shape Serratus anterior
of the ribs! attaches- which
Gilroy Fig 7.5C, p. 59
ribs?
 Ribs

Can you
palpate the 1st
rib?
location? To
clavicle?
Gilroy Fig 7.5A, p. 59
Cervical Rib!!!!
 Sternocostal Joints
Which ligament may be
strained anteriorly ?

Gilroy Fig 7.7, p. 61

Rib Movement

Gilroy Fig 7.6D, p. 60

Movement of
Upper Ribs and
Sternum

How would you mobilize a R

T6 rib in a patient whose rib
is elevated from lifting a
heavy load on the R?

Gray’s Fig 3.34, p. 158

Intercostal Ms.
Which anterior neck
ms attach on 1st rib?
_______________
_______________

2nd rib?
______________

Other muscles attach

to ribs and affect their
function?
_______________
_______________
_______________

Gilroy Fig 7.10, p. 63

Name muscles that affect(attach
directly) to the first rib?
Serattus Anterior
Scalene Middle
Scalene Anterior
Subclavius
Levator Costae
Which ms attach to ribs?
Which ms attach to ribs?
Which ms attach to ribs?
Which ms attach to ribs?
Which ms attach to ribs?
 Food for thought
• What happens to the first rib when someone
is very stressed (shoulders elevated, small
breathes)?
– Elevates ( scalenes and possibly UT)
• What muscles can directly affect the ribs?
What exercises can you do to help facilitate rib
movement?
Intercostal
Mm.
Describe the
difference in ms
orientation between
the ext (inspire) and
int intercostals
(expiration)
Ext intercostals:
assist with rib
elevation in
inspiration. What
other ms would help
with this?
____________

Gilroy Fig 7.11, p. 63

Transversus thoracis m.
INSIDE THORACIC WALL:
What is the function of the
transversus thoracis ms?

It assists with forcible

expiration to lower the
ribcage

DEPRESSS RIBS with

exhalation:
1. Internal oblique
2. Innermost______
3. Transverse thoracis

Gilroy Fig 7.11, p. 63

 RIBS
• Muscles that elevate • Muscles that depress
ribs (inspiration) ribs(and help expiration)
– 1.Scalenes A • 1.Internal Intercostal m
– 2. External Innercostal • 2.Innermost Intercostal m
– 3. S _____ M
• 3.Subcostal m
– 4. S ______P
• 4. Transversus thoracis m
 -Posterior
Intercostal Aa.
-Subcostal A.
Parent of these arteries?
aorta

Grant’s Atlas
of Anatomy
 Posterior Intercostal
Anterior intercostal a:
Aa.
Describe the arterial supply supplies anterior thoracic
for the ribs, with the artery, wall
parent and child Posterior intercostal a:
supplies SC and posterior
thoracic wall, lateral
thoracic wall

Gilroy Fig 7.18, p. 68

Posterior Intercostal Aa.
Describe the parent of the
posterior intercostal artery.
Compare to the parent of
the internal thoracic artery

Posterior intercostal
a. anastomoses with
anterior intercostal a
to supply thoracic
wall. Posterior
arises from thoracic
aorta, except 1st and
2nd- come off
costocervical trunk

Gray’s Fig 3.29, p. 155

 Internal
Thoracic A.

It branches off of
the subclavian
a
Intercostal Spaces
Where is the
NAV located
for the
intercostal ms?
Inferior and
superior
aspect of rib

So where
would the
surgeon
perform
surgery?

Gray’s Fig 3.27, p. 153

Intercostal Nn. From where does the
intercostal nerve
originate ?
Straight off posterior
Rami

Can pain in the ribs be

affected by
mobilization of the
spine?

Gray’s Fig 3.32, p. 159

 Thoracic duct
• Largest lymph drainage
system in body
• Drains 75% of body’s
lymph drainage
• Lymph vessels of
thoracic wall drain
mainly into
– 1)internal thoracic
arteries
– 2) head and neck of ribs
– 3) diaphragm
• Superficial regions of
thoracic wall drain into
axillary lymph nodes
Created by Nick Love, PhD, a 2nd yr med
student at Stanford University, 2017
 Lymphatic drainage
• Enlargement of neck
lymph nodes (cervical
lymphadenopathy)
– Common symptom of
diseases of head/ neck
– Common symptom for
other dz: lymphoma,
sarcoidosis, viral infx
glandular fever, HIV infx)
– Soft tender and inflamed
lymph nodes: acute
inflammatory process

Gray’s . 3rd edition. Pg. 1038, Fig. 8.193

Enlarge Lymph nodes
 Pectus Excavatum
• Congenital deformity in anterior
thoracic wall
• Can impair cardiac/respiratory
function
• 40% of pectus ex. Pts have 1 or
more family members with
condition.
• M>F: 1 out of every 300-400
White M births
• Seen more in Marfan Syndrome,
Scoliosis, those with Rickets,
loose connective tissue
15yoM undergoing Nuss procedure for
Pectus excavatum
• https://www.youtube.c
om/watch?
v=z6U9CBbyVmE&featu
re=youtu.be
 MUSCLES THAT ASSIST with:
• INSPIRATION
– External oblique
– Diaphram
– SCM
– Scalene Anterior
– Scalene Middle
– Scalene Posterior
– Levator Costarum
– Subclavius
– Pec Minor
– Seratus Anterior
– Serratus Posterior Superior
– Upper Traps
Which is more difficult- Gilroy, pg. 148- abd ms attachments
inspiration or expiration?
• EXPIRATION
– Transverse Thoracis
– Internal Innercostals
– Innermost Iinternal intercostals
– Subcostal
– Quadratus Lumborum
– Serratus Posterior inferior
– Latissimus Dorsi
– Erector spinae
– Transverse Abdominis
– Rectus Abdominum
– External Oblique
– Internal Oblique
 Muscles attached to
• RIBS
• Sternum/Manubrium/ – Pec major?
– Pec Minor __,__,__
xiphoid – Serratus Ant__-____
– SCM – T_____T_____
– Diaphragm
– Sternohyoid – QL______
– S_____A
– Sternothyroid – S_____M
– S___P
– T________T_______ Serratus Posterior _____
Serratus Posterio _______
– Pec______M_______ -Rectus Abd_______

– Re_______A_______
Transverse Abdom______
External Obliques______

– Diaphragm Internal Obliques______

Lats Dorsi____
Internal intercostals
External Intercostals
By the end of lab, be able to identify muscles
affect the ribs directly
• 1.
• 2.
3.
• 4.
• 5.
• 6.
• 7…..
 By the end of the lab, be able to name all
muscles that affect the sternum/manubrium
• 1.
• 2.
• 3.
• 4.
• 5.
• 6.
 By the end of the lab, be able to locate all
muscles attaching to the 1st rib
• 1.
• 2.
• 3.
• 4.
What it will look like when you take the
ribcage off…
BE ABLE TO LABEL:
C7
L1
Thoracic bodies
Clavicle
Pedicles
Transverse processes
Spinous processes
Costotransverse
joints

Note on ID list
where certain tanks
will review
structures before
leaving today!
Locate items on ID list and the following:

• Intervascular bundle
• Transversus thoracic ms (originates from
sternum and upward to 2-6th rib)
• Internal thoracic artery and vein
– Held in place by transversus thoracic ms
– Artery arises from subclavian artery and
anastomoses with superior epigastric artery
– Vein continues from superior epigastric vein
upward to brachiocephalic vein
 LAB : Follow chapter 5 in lab manual lab 5.1-
5.19
• 1. Review origins of pec major/ minor/ serratus anterior
• 2. Locate the external intercostal muscles (11 pairs extending from tubercles of
ribs posterior to costochondral junction anteriorly)
• 3. Remove the external IC ms from several IC spaces to expose the underlying
internal IC ms(11 prs)
• 4. Remove anterior thoracic wall. Use bone saw and bone shears, cutting
through the mid-axillary line down to the inferior margins of ribs above
diaphragm .
• 5. Continue to cut from mid axillary line along 2nd IC space through lower
aspect of manubrium. Don’t cut too deep – don’t cut into lungs or pleural
linings
• Release the diaphragm across lower margins of ribs.
• Reflect the anterior chest wall downward toward the groin.Remove or reflect
from superior region and leave attached to the abdominal muscles