Head and Neck 2

THE HEAD AND NECK LECTURES
By
ANAS IBRAHIM YAHAYA
MBBS, M.Sc., ADCTA, PhD (London)
What are the objectives of the
lecture today?
Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

The objectives are to know:
1. What is head and what are
the structures in it?
2. What is neck and what the
structures in it?
3. What are functions of those
structures in either head or
neck?
The head
Structures?
Two: Internal & external
Internal = Brain and others
External = Bones, muscles &
neurovascular bundles

The bones of the head
The skull, which consists of the

cranium, the facial skeleton and
other associated bones

 The skull: it is part of the axial skeleton
 It consist of 2 set of bones
– 8 cranial bones
– 14 facial bones
 Bones associated with the skull:
– 6 auditory ossicles
– the hyoid bone
 The skull functions
 Protection of the brain
 Entrances to respiratory system
 Entrance to digestive system

The Skull
The Orbital Complex
The Orbital and ear Complexes.

The nasal Complex
Posterior view of the Skull
Superior view of the Skull
Lateral view of the Skull

Anterior view of the Skull

Inferior view of the Skull

Internal aspect of the Skull
Nomenclature of the skull
 The cranial bones that

form the
neurocranium, which
lodges the brain.
 The facial bones, which
form the
viscerocranium. The
bones of the visceral
cranium form the
orbits, the oral cavity
and nasal one.
Topographical areas of the skull
 Frontal area
 Parietal area
 Occipital area
 Temporal area
 Infratemporal
area
Shapes of the skull
The shape of the skull is oval and the volume is from 1400 to 1600cm³.
According to its capacity the following types of the skull can be
distinguished:
 Microcephalic cranium,
Brain <1300cm³ Australian and some African tribes.
 Mesocephalic cranium,
Brain capacity =1300 cm³- 1450cm³Africans and Chinese.
 Megacephalic cranium
Brain capacity >1450cm³ European and Japanese.
 Hydrocephalic cranium = very voluminous skull (abnormal) due

to pathological condition of the brain.
 Dolichocephalic
skull – the skull
has an oval
shape.
 Brachycephalic
skull – it
means a
spheroid shape
of the skull.
 Mesocephalic
skull – an
intermediate
shape between
the previous
two forms.
Facial skeleton
 Superficial Facial Bones

 Maxillae = maxillary bones
 Lacrimal
 Nasal
 Zygomatic
 Mandible
 Deep Facial Bones
 Palatine bones
 Inferior nasal conchae
 Vomer
Sinuses and sutures
 Sinuses
 Cavities that decrease the weight of the skull
 Lined with mucous membranes
 Protect the entrances of the respiratory system
 Sutures
 The immovable joints of the skull
 The four major sutures
 Lambdoid suture
 Coronal suture
 Sagittal suture
 Squamous suture
Regions of the head and neck
Regions Lateral View Cont.
Development of the skull
(skull develops from 3 different sources)
 The membranous
neurocranium or
desmocranium
develops from
mesenchyme,
which derives
from mesoderm.
Median fontanelles of the skull
 Anterior fontanelle  Posterior fontanelle

The cartilaginous neurocranium
(chondrocranium) is formed by separate
cartilages, which further by enchondral
ossification will form the bones of the
base of the skull.
The visceral cranium – develops from

the first and second visceral arches.
a)the first or mandibular arch,
b)the second or the hyoid arch.
Abnormalities of the skull
Plagiocephaly –
premature closure of
the sutures and
fontanelles only from
one side.
Abnormalities of the skull
 Scaphocephaly –
earlier ossification of
the sagittal suture,
being a condition of
appearance of a
long and narrow
skull.
 Acrocephaly –
closure of the
coronary suture.
 Anancephaly– this term isn't
correct, because the absence
of the cerebral extremity of the
trunk, does not permit the
development of the embryo at
all.
 Meningoencephalocoele
 Craniostenosis – premature
ossification of the fontanelles
and of the sutures.
Fontanelles
 The Infant Skull

 Grows rapidly
 Is large compared to the body
 Has many ossification centers
 Fusion is not complete at birth

 Two frontal bones
 Four occipital bones
 Several sphenoidal and temporal elements

Fontanelles
 Fontanelles (sometimes spelled fontanels)
 Are areas of fibrous connective tissue (soft spots)
 Cover unfused sutures in the infant skull
 Allow the skull to flex during birth
 Anterior fontanelle:
– frontal, sagittal, and coronal sutures
 Occipital fontanelle:
– lambdoid and sagittal sutures
 Sphenoidal fontanelles:
– squamous and coronal sutures
 Mastoid fontanelles:
– squamous and lambdoid sutures
Fontanelles
Fontanelles
 CALVARIA has:
 Spongy substance which is
referred to as diploe,
 It means that the spongy
substance is placed between
two plates of compact bone
tissue
=outer (lamina externa)
=inner (lamina interna).
Meningeal arterial marks
Cont. Important openings &structures
passing through them( Base of skull)
Some bones of the skull are called pneumatic
bones, because they have inside air cavities,
named sinuses
AIR SINUSES (in

pneumatic bones)
 Frontal sinus
 Sphenoid sinus
 Ethmoid sinus
 Maxilla sinus
Bones of the Neck Region
 The Cervical Vertebrae
 Small body (support only head)
 Large vertebral foramen (largest part of spinal cord)
 Concave superior surface
 Slopes posterior to anterior
 C1 (atlas) has no spinous process
 All others have short spinous processes
 tip of each spinous process
is notched (bifid)
Vertebral Regions

 Transverse processes
 Are fused to costal processes
 Which encircle transverse foramina
(protect arteries and veins)
 Atlas (C1)
 Articulates with occipital condyles
 Has no body or spinous process
 Has a large, round foramen
 Axis (C2)
 Supports the atlas
 Has heavy spinous process
 To attach muscles of head and neck
 Dens = fused bodies of c1 & c2
 Vertebra prominens (C7)
 Has a long spinous process with a broad tubercle
 Has large transverse processes
 Ligamentum nuchae (elastic ligament) extends from C7 to skull

Vertebral Regions
Inter-vertebral disc:
B/w vertebral bones
Secondary cartilaginous joints
2 parts = annulus, nucleus pulposus
Herniation

Ligaments of the cervical
vertebrate

Structures in the neck:
Pharynx
Oesophagus
Larynx
Trachea
Thyroid gland/parathyroid glands
Muscles
Fasciae
NVB
55
 The pharyngo-esophageal
junction appears as a
constriction produced by the
cricopharyngeal part of the
inferior pharyngeal
constrictor muscle (the
superior esophageal
sphincter) and is the
narrowest part of the
esophagus.
Gross anatomy of Pharynx
 The pharynx is the continuation of the digestive system

from the oral cavity
 It is a funnel-shaped fibromuscular tube that serve as
common route for both food and air
 The phraynx extends from cranial base to the inferior
boarder of the of the cricoid cartilage at level of C6
 The pharynx is located posterior to the nasal and oral
cavities and the larynx
 It is widest above (5cm) and narrowest (1.5cm) at its
inferior where it is continious with esophagus
Pharyngeal wall
 Mucosal layer
 Submucosa
 Pharyngobasilar fascia
 Pharyngeal Muscle layer
 Buccopharyngeal fascia
 Mucosal layer
 Nasopharynx – Ciliated columnar epithelium
 Oropharynx – Stratified squamous epithelium
 Laryngopharynx - Stratified squamous epithelium
 Submucous layer
Fibrous layer
Thick in the upper part where the
muscular layer is deficient
Muscular Layer
 Consist of circular muscles

Superior, Middle and Inferior constrictor muscle
 Of the three pharyngeal constrictor muscles, the inferior muscle
overlaps the middle one and the middle one overlaps the
superior one, All three muscles form a common median
pharyngeal raphe posteriorly
 Longitudinal muscles
Palatopharyngeus
Stylopharyngeus
Salpingopharyngues
Function of the muscles
 External circular muscles: Constrict walls

of pharynx during swallowing
 Internal longitudinal muscles: Elevate
(shorten and widen) the pharynx during
swallowing
 ESOPHAGUS
 Muscular tube, length at birth = 10cm, in adult = 25 cm
 Diameter = varies on food item swallowed, at rest = 2cm
 Collapsed at rest (flat in upper 2/3) & rounded in lower 1/3
 Begins at C6, but in newborn = C4 or C5
 Has 2-3 slight curvatures (within the thorax only)
 At C6 & root of the neck (midline)
 Oesophagus has three constrictions:
 15 cm from incisor teeth is crico-
pharyngeus sphincter
 25 cm from incisor teeth = aortic arch
and left main bronchus indent it
 40 cm from incisor teeth = it pierces the
diaphragm and therefore narrow here
 Esophagus relations in the neck
 Trachea = anteriorly
 Posteriorly = vertebral column and
Longus coli muscle
 Laterally = common carotid artery,
part of the lateral lobes of the thyroid
gland; the recurrent laryngeal nerves
Site of impaction =
constriction areas
1.Cricopharyngeus
2.Others in the thorax

 Esophagus at the thoracic inlet
= most common site of oesophageal
impaction
= the site of anatomical change from the
skeletal muscle to the smooth muscle
=The cricopharyngeus slings at C6 and
foreign body can lodge here
Histological features of Esophagus
1. Mucosa (3 layers): 2. Submucosa: loose

I. Epithelium = stratified areolar tissue
sqamous non-
keratinized contains;Serous and
II. Lamina propria: fibrous mucous glands, Blood
tissue, lymphocytes
III. Muscularis mucosae:
vessels, Lymphatic
channels, Meissner's
3. Muscularis externa: nerve plexus
-Outer longitudinal muscle 4. Adventitia: Layer of
-Inner circular muscle loose supportive fibrous
Auerbach's nerve tissue, Conducts major
plexus lies b/w them vessels & nerves
Larynx
 The larynx consists of 4 main structures:
- A cartilaginous skeleton
- Membranes and ligaments
- Intrinsic and extrinsic muscles
- Mucosal lining
The Cartilages
• The cartilaginous skeleton are:
 Un-paired Cartilages:
 Thyroid
 Cricoid
 Epiglottis
 Paired Cartilages:
 Arytenoid
 Corniculate
 Cuneiform
 All the cartilages, except the epiglottis,
are of hyaline type.
 Epiglottis is formed of elastic cartilage
 The cartilages are:
 Connected by joints, membranes &
ligaments
 Moved by muscles
Thyroid Cartilage
 Has 2 laminae, meet in the midline
and form a prominent angle, called
laryngeal prominence (Adam’s apple)
 Has thyroid notch
 Posterior border of each lamina =
superior & inferior cornu (horns)
 Outer surface of each lamina =
superior
oblique line for attachment to 3 cornu
Oblique
muscles line
-thyrohyoid
-sternothyroid
-inferior constrictor of the pharynx
 The superior border gives attachment inferior
to the thyrohyoid membrane cornu
Cricoid Cartilage
 Is a complete ring below the
thyroid cartilage
 Has narrow anterior arch & a
broad posterior lamina
 Has an articular facet on its:
• Lateral surface for articulation
with inferior cornu of the
thyroid cartilage (a synovial
joint)
• Upper border for articulation
with base of arytenoid
cartilage (a synovial joint)
Arytenoid Cartilages
 Small, pyramidal cartilage
 Base articulates with the upper
border of the cricoid cartilage
• Apex supports the corniculate
cartilage
• It has 2 processes: vocal
process projects forward, & gives
attachement to the vocal ligament
• A muscular process projects
laterally, & gives attachment to
muscles
Un-paired Cartilages
Corniculate Cartilages
 Small nodules
 Articulate with the apices of arytenoid E
cartilages
Cuneiform Cartilages
V
 Small rod shaped, placed in each CU F
aryepiglottic fold, producing a small
CO
elevation
 Do not articulate with any other cartilage
but serve as support for the ary-epiglottic fold
Epiglottis
 Leaf shaped, situated behind the root of the
tongue
 Connected:
 In front to the body of hyoid bone by the
hyoepiglottic ligament
 By its stalk to the back of thyroid cartilage
by the thyroepiglottic ligament
 Upper edge is free.
 Laterally gives attachment to aryepiglottic fold
 Anteriorly mucosa is reflected onto the tongue
forming three glossoepiglottic folds &
valleculae
Membranes & Ligaments
 Thyrohyoid membrane, thickens to form:
median & lateral thyrohoid ligaments
 Median cricothyroid ligament
 Cricotracheal membrane
 Hyoepiglottic ligament
 Thyroepiglottic ligament
 Quadrangular membrane:
 Extends between the epiglottis and
the arytenoid cartilages
 Its lower free margin forms the
vestibular ligament that lies within
the vestibular fold
 Cricothyroid membrane (conus
elasticus):
 Lower margin is attached to upper
border of cricoid cartilage
 Upper free margin forms vocal
ligament that is attached anteriorly to
deep surface of thyroid cartilage &
posteriorly to the vocal process of
arytenoid cartilage
Laryngeal Inlet
 Faces backward and upward and
opens into the laryngeal part of the
pharynx
 The opening is bounded:
• Anteriorly: by the upper margin of
epiglottis
• Posteriorly & below by arytenoid
cartilages
• Laterally by aryepiglottic folds
CU
CO
AEF
A
Laryngeal Cavity
 Extends from laryngeal
inlet to lower border of
the cricoid cartilage
 Narrow in the region of Rima
vestibu
the vestibular folds (rima li
vestibuli)
 Narrowest in the region
of the vocal folds (rima
glottidis)
Rima
glottidi
s
Laryngeal Cavity cont’d
 Divided into 3 parts:
1. Supra-epiglottic
part, the part above
the vestibular folds,
is called the
vestibule
2. The part between
A
the vestibular & the
vocal folds, is B
called the ventricle
C
3. Infra-epiglottic part,
the part below the
vocal folds
 Vestibular Part:
 Extends from the inlet to the vestibular
fold
 Below it becomes narrow as the
vestibular folds project medially.
 Each vestibular fold contains
vestibular ligament, the lower free
margin of the quadrangular membrane
stretching from thyroid cartilage to the
arytenoid cartilage
 Lower Part:
 Extends from vocal folds to lower
border of cricoid cartilage
 Walls formed by the inner surface of
the cricothyroid ligament and the
cricoid cartilage
Mucous Membrane
 The cavity = lined with ciliated columnar epithelium
 The surface of vocal folds, because it is exposed to continuous trauma during
phonation, is covered by stratified squamous epithelium
 Contains many mucous glands, more numerous in the saccule (for lubrication of
vocal folds)
 LARYNGEAL MUSCLES (2 GROUPS)
:
 Extrinsic muscles (2 groups):
• Elevators of the larynx
• Depressors of the larynx
 Intrinsic muscles (2 groups):
• Muscles controlling the laryngeal inlet
• Muscles controlling the movements of the vocal cords
 EXTRINSIC MUSCLES
ELEVATORS
 The Suprahyoid Muscles
 Digastric
 Stylohyoid
 Mylohyoid
 Geniohyoid
 The Longitudinal Muscles of the
Pharynx
 Stylopharyngeus
 Salpingopharyngeus
 Palatopharyngeus
DEPRESSORS
 The Infrahyoid Muscles
 Sternohyoid
 Sternothyroid
 Omohyoid
Muscles Controlling the Laryngeal Inlet
 Oblique arytenoid
 Aryepiglottic muscle
Movements of the Vocal Cords
 Adduction
 Abduction
Glottis (space between

Folds closed (adducted) Folds open folds)
(abducted) (View from above)
Adductors of the Vocal Cords
 Lateral cricoarytenoid
 Transverse arytenoid
Abductor of the Vocal Cords
 Posterior cricoarytenoid
THYROID AND PARATHYROID
GLANDS
INTRODUCTION
 The thyroid gland = the largest endocrine

gland; it has a weight of 20 to 25 g
 It receives one of the body’s highest rates of
blood flow per gram of tissue
Thyroid gland
Isthmus
Trachea
EMBRYOLOGY OF THYROID GLAND
 Floor of the pharynx
 Tuberculum impar and the copula
 Foramen cecum
 Thyroid descends in front of the pharynx
as a bilobed diverticulum
 Connected to tongue by thyroglossal
ducts
 This duct later disappears.
 Descends in front of the hyoid bone and
the laryngeal cartilages
 It reaches its final position in front of the
trachea in the 7th week of IUTL
 Functions end of 3rd month, at which time

the first follicles containing colloid
become visible
EMBRYOLOGY OF PARATHYROID
GLANDS
 Inferior parathyroid glands = parathyroid

III , = proliferation of endodermal cells in the
3rd pharyngeal pouch on each side.
 As the thymic diverticulum on each side
grows inferiorly in the neck, it pulls the inferior
parathyroid with it, so that it finally comes to
rest on the posterior surface of the lateral
lobe of the thyroid gland near its lower pole
and becomes completely separated from the
thymus
 Superior parathyroid glands =
parathyroid IV , = proliferation of
endodermal cells in the 4th pharyngeal
pouch on each side.
 These loses their connection with the
pharyngeal wall and take up their final
position on the posterior aspect of the
lateral lobe of the thyroid gland on each
sides.
GROSS ANATOMY OF THYROID GLAND
 Parts: two lobes , isthmus.

Sometimes there is pyramidal
lobe on the upper border
of the isthmus.
 Pyramidal lobe may be
connected to the hyoid bone
by a band of connective tissue
(remnant of thyroglossal duct).
RELATIONS OF THE THYROID GLAND
 Each lobe is pyramidal

In shape, has an apex, base
and three surfaces.
 Apex- extends up to the
oblique line of thyroid
cartilage.
 Base- is at the level of 5th
tracheal ring.
 Lateral surface-
covered by infrahyoid
and sternocleidomastoid
muscle.
 Posterior surface –
related to carotid sheath
and contents.
 Medial surface –
is related to trachea,
esophagus, cricoid
and thyroid cartilages,
recurrent and external
laryngeal nerves.
ISTHMUS OF THE THYROID GLAND
Connects two lobes.

Lies in front of the 2nd, 3rd tracheal rings
(sometimes 4th).
Covered by infrahyoid muscles.
Inferior thyroid vein emerges from its lower

border.
BLOOD SUPPLY
ARTERIAL SUPPLY :
Superior thyroid artery, a
branch of external
carotid artery.
Inferior thyroid artery –

branch of thyrocervical
artery (branch of subclavian
artery).
 Thyroidea ima from

arch of aorta( occasional).
VENOUS DRAINAGE
 Superior thyroid vein –

drains into internal
jugular vein.
 Middle thyroid vein –
drains into internal
jugular veins.
 Inferior thyroid vein –
drains into the left
brachiocephalic vein
in the thorax.
 Last two veins are not
accompanied by
arteries
LYMPHATIC DRAINAGE
Prelaryngeal
Pretracheal
Paratracheal nodes.
Some accompany
superior thyroid vein
to end in the lower
deep cervical nodes.
Nerve supply;
Is by superior, middle and inferior cervical
sympathetic ganglia.
PARATHYROID GLANDS
Ovoid bodies measuring about 6mm long in

their greatest diameter.
They are four in number and are
closely related to the posterior border of
the
thyroid gland, lying within its fascial
capsule
 The two superior parathyroid glands
are more constant in position and lie at
the level of the middle of the posterior
border of
the thyroid gland.
 The two inferior parathyroid glands
usually lie close to the inferior poles of the
thyroid gland.
 They may lie within the fascial sheath,

embedded in the thyroid substance, or
outside the fascial sheath.
Blood Supply:
The arterial supply
It’s from the superior and inferior thyroid
arteries.
The venous drainage
It’s into the superior, middle, and inferior
thyroid veins.
Lymph Drainage:
Is by Deep cervical and paratracheal lymph
nodes
Nerve Supply:
Is by superior or middle cervical
sympathetic ganglia.
MICROSCOPIC STRUCTURE OF
THYROID GLAND
 The thyroid gland is covered by fibrous

capsule
 The septum extending into the glands
from the capsule divide it into a number
of lobules
 Each lobule is made up of aggregation
of follicles
 Each follicles is lined by follicular cells
 They rest on the basement membrane
 The follicles have a cavity filled with
homogeneous material called colloid
 The space between the follicles are filled
by stroma made up of delicate connective
tissue containing numerous capillaries and
lymphatics.
 The capillaries are in close contact with
the walls of the follicles
 The parafollicular cells are larger than the
follicular cells
 They intervene between the follicular cells
and the basement membrane
 They also lie between the follicles.
 They secrete calcitonin which regulates
the level of calcium in the blood.
 HISTOLOGY OF
PARATHYROIDS
 Each gland has a connective
tissue capsule from which septal
extends into the gland substance
 The cells of parathyroid glands
are of two types
 Chief cells (principal cells)
 Oxyphils cells or Eosinophils
cells.
 CLINICAL ANATOMY OF THYROID
GLAND
 A thyroglossal cyst may lie at any

point along the migratory pathway of
the thyroid gland but is always near or
in the midline of the neck. As
indicated by its name, it is a cystic
remnant of the thyroglossal duct.
Thyroglossal cyst
LINGUAL THYROID
Thyroglossal duct sinus
 Swelling of Thyroid Glands (Goiter):
Absence and Hypoplasia of the
Parathyroid
Glands
Agenesis or incomplete development of the

parathyroid glands has been demonstrated
in an individuals with idiopathic
hypoparathyroidism.
Ectopic Parathyroid Glands:
The close relationship between the parathyroid III
and the developing thymus explains the frequent
finding of parathyroid tissue in the superior
mediastinum of the thorax.
If the parathyroid glands remain attached to
the thymus, they may be pulled inferiorly into the
lower part of the neck or thoracic cavity.
Moreover, this also explains the variable position of
the inferior parathyroid glands in relation to the
lower poles of the lateral lobes of the thyroid
gland.
ECTOPIC TISSUE
Ectopic thyroid tissue
 Extra thyroid tissue may
be present anywhere
along the migratory path of thyroglossal
duct.
Blood Supply of
Head & Neck
Objectives
• Enlist the major arteries supplying head and neck.
• How common carotid arteries take origin.
• Enlist important relations of common carotid arteries.
• Describe the relations and branches of external carotid
artery.
• Describe the relations and branches of subclavian
artery.
• Enlist the major veins supplying head and neck.
• Discuss the formation of external and internal jugular
veins.
• Describe the tributaries of external and internal jugular
veins.
Arteries of Head & Neck
• Common Carotid Artery
• External Carotid Artery
• Internal Carotid Artery
• Subclavian Artery
Common Carotid Arteries
Right Common Carotid Artery:
 Arises from brachiocephalic artery
(Behind right sternoclavicular joint)
Left Common Carotid Artery:
 Arises from Arch of Aorta
 Runs upwards in the neck from sternoclavicular
joint to upper border of thyroid cartilage
Relations of Common Carotid Artery
Anterolaterally:
 Sternocleidomastoid
 Sternohyoid
 Sternothyroid
 Superior belly of omohyoid
Posteriorly:
 Prevertebral muscles
Medially:
 Larynx
 Pharynx
Laterally:
 Internal jugular vein
Branches of Common Carotid Artery
 External Carotid Artery
 Internal Carotid Artery

External Carotid Artery
 Begins at the level of upper border of thyroid cartilage
 Terminates in the substance of the parotid gland behind
the neck of mandible by dividing into:
 Superficial temporal artery
 Maxillary artery
Supply of External Carotid Artery
 Neck
 Face
 Scalp
 Tongue
 Maxilla
Branches of External Carotid Artery
 Superior thyroid artery
 Ascending pharyngeal artery
 Lingual artery
 Facial artery
 Occipital artery
 Posterior auricular artery
 Superficial temporal artery
 Maxillary artery
Internal Carotid Artery
 Begins at the level of upper border of thyroid

cartilage
 No branches in the neck
 Through carotid canal enters into cranial cavity
 Supplies brain, eyes, forehead and part of the nose
Subclavian Artery
Right Subclavian Artery:
 Arises from brachiocephalic artery
(Behind right sternoclavicular joint)
 At outer border of 1st rib it becomes Axillary Artery
Left Subclavian Artery:
 Arsis from Arch of Aorta in the thorax
 Runs upwards to the root of the neck & arches
laterally
 At outer border of 1st rib it becomes Axillary Artery
Subclavian Artery
Scalenus Anterior muscle passes anterior to the
artery on each side and divides it into 3 parts.
1. 1st part of subclavian artery
2. 2nd part of subclavian artery
3. 3rd part of subclavian artery

1st part of Subclavian Artery
Extends from the origin of the subclavian artery to
the medial border of the Scalenus anterior muscle.
Branches:
1. Vertebral artery
2. Thyrocervical Trunk
3. Internal thoracic artery

Branches:
1. Vertebral artery
 Spinal and muscular branches in neck
 Branches in skull
Branches:
2. Thyrocervical Trunk
 Inferior thyroid artery
 Superficial cervical artery
 Suprascapular artery
Branches:
3. Internal thoracic artery

 Superior epigastric artery
 Musculophrenic artery
2nd part of Subclavian Artery
Lies behind the Scalenus anterior muscle.
Branches:
1. Costocervical trunk
 Superior intercostal artery

 Deep cervical artery
3rd part of Subclavian Artery
Extends from the lateral border of the Scalenus
anterior muscle to the lateral border of 1 st rib.
Branches: (Occasional)
1. Superficial cervical artery
2. Suprascapular artery
Subclavian Artery
Branches of Subclavian Artery
Veins of Head & Neck
• Veins of Brain
• Venous Sinuses
• Veins of Face and Neck

Veins of Face and Neck
 Facial vein
 Superficial temporal vein
 Maxillary vein
 Retromandibular vein
 External jugular vein
 Anterior jugular vein
 Internal jugular vein
 Subclavian vein
Veins supplying Head and Neck
Facial Vein
Formed at medial
angle of eye by
the union of
supraorbital and
supratrochlear veins.
It joins anterior
division of
retromandibular vein
Superficial temporal Vein
Formed on the side of the scalp. Enters parotid gland.
It joins maxillary vein to form Retromandibular vein.
Maxillary Vein
Formed in the Infratemporal fossa from the Pterygoid venous plexus.
It joins superficial temporal vein to form Retromandibular vein.
Retromandibular Vein
 Formed by the union of maxillary vein and superficial
temporal vein.
 Leaving parotid gland divides into anterior branch and
posterior branch.
 Anterior branch joins facial vein.
 Posterior branch joins posterior auricular vein to form
external jugular vein.
External jugular Vein
 Formed behind the angle of jaw by the union of
Posterior branch of retromandibular vein with
posterior auricular vein.
 It drains into subclavian vein
 Tributaries:
 Posterior external jugular
 Transverse cervical
 Suprascapular
 Anterior jugular
Internal jugular Vein
 Receives blood from brain, face and neck.
 Continuation of sigmoid sinus and leave the skull from
jugular foramen.
 Ends by joining subclavian vein to form brachiocephalic
vein.
 Tributaries:
 Facial vein
 Pharyngeal vein
 Lingual vein
 Superior thyroid vein
 Middle thyroid vein
Subclavian Vein
 Continuation of axillary vein at the outer border of 1 st rib.

 Joins internal jugular vein to form brachiocephalic vein.
Tributaries:
 External jugular vein
Brachiocephalic Veins & SVC
SCALENE & PREVERTEBRAL
MUSCLES
CERVICAL PLEXUS
Scalenus Anterior Muscle
 The scalenus anterior muscle is a key

muscle in understanding the root of the
neck
 It is deeply placed
 It descends almost vertically from the

vertebral column to the first rib
Anterior Relation
 Related to the carotid arteries, the vagus

nerve, the internal jugular vein, and the
deep cervical lymph nodes
 The transverse cervical and suprascapular

arteries and the prevertebral layer of deep
cervical fascia bind the phrenic nerve to
the muscle
Posterior Relation
 Related to the pleura, the origin of the

brachial plexus, and the second part of the
subclavian artery
 The scalenus medius muscle lies behind

the scalenus anterior muscle
Medially
 Related to the vertebral artery and vein

and the sympathetic trunk
 On the left side, the medial border is

related to the thoracic duct
Laterally
 Related to the emerging branches of the

cervical plexus, the roots of the brachial
plexus, and the third part of the subclavian
artery
Scalenus Anterior Muscle
Origin:
 Transverse processes of third, fourth, fifth, and
sixth cervical vertebrae
Insertion:
 First rib
Action:
 Elevates first rib, laterally flexes and rotates
cervical part of vertebral column
Scalenus Medius
 It lies behind the scalenus anterior
 It extends from the transverse process of the atlas and

the transverse processes of the next five cervical
vertebrae
 Inserted into the upper surface of the first rib behind the
groove for the subclavian artery
 The muscle lies behind the roots of the brachial plexus

and the subclavian artery
Scalenus Posterior
Origin:
 Transverse processes of lower cervical
vertebrae
Insertion:
 Second rib
Action:
 Elevates second rib, laterally flexes and
rotates cervical part of vertebral column
Longus Colli Muscle
Origin:
 Anterior tubercle of C1, bodies of C1 to C3 and
transverse processes of C3 to C6 vertebrae
Insertion:
 Bodies of C5 to T3 vertebrae, transverse
processes of C3 to C5 vertebrae
Action:
 Flexes neck with rotation to opposite side
Longus Capitis Muscle
Origin:
 Basilar part of occipital bone
Insertion:
 Anterior tubercles of C3 to C6 transverse
processes
Action:
 Flexes the head
Rectus Capitis Anterior
Origin:
 Base of the skull, just anterior to the occipital
condyle
Insertion:
 Anterior surface of lateral mass of atlas
Action:
 Flexes the head
Rectus Capitis Lateralis
Origin:
 Jugular process of occipital bone
Insertion:
 Transverse process of atlas
Action:
 Flexes head and helps stabilize it
Splenius Capitis
Origin:
 Inferior half of nuchal ligament and spinous processes of
superior 6 thoracic vertebrae
Insertion:
 Lateral aspect of mastoid process and lateral third of
superior nuchal line
Action:
 Laterally flexes and rotates head and neck to same side,
extend head and neck
Cervical Plexus
 The cervical plexus is formed by the

anterior rami of the first four cervical
nerves
 The rami are joined by connecting

branches, which form loops that lie in front
of the origins of the levator scapulae and
the scalenus medius muscles
Cervical Plexus
 The plexus is covered in front by the

prevertebral layer of deep cervical fascia
 Is related to the internal jugular vein within the

carotid sheath
 The cervical plexus supplies the skin and the

muscles of the head, the neck, and the
shoulders
Cutaneous Branches
The lesser occipital nerve (C2):

 Supplies the back of the scalp and the auricle
The greater auricular nerve (C2 and3):

 Supplies the skin over the angle of the mandible
The transverse cervical nerve (C2 and 3):

 Supplies the skin over the front of the neck
Cutaneous Branches
The supraclavicular nerves (C3 and 4)

 The medial, and intermediate, and lateral
branches supply the skin over the
shoulder region
 These nerves are important clinically,
because pain may be referred along them
from the phrenic nerve (gallbladder
disease)
Muscular Branches
 Prevertebral muscles, sternocleidomastoid (proprioceptive, C2 and

3), levator scapulae (C3 and 4), and trapezius (proprioceptive, C3
and 4)
 A branch from C1 joins the hypoglossal nerve
 Some of these C1 fibers later leave the hypoglossal as the
descending branch, which unites with the descending cervical nerve
(C2 and 3), to form the ansa cervicalis
Muscular Branches
 The first, second, and third cervical nerve

fibers within the ansa cervicalis supply the
omohyoid, sternohyoid, and sternothyroid
muscles
 Other C1 fibers within the hypoglossal

nerve leave it as the nerve to the
thyrohyoid and geniohyoid
Phrenic Nerve
 It arises in the neck from the third, fourth, and

fifth cervical nerves of the cervical plexus
 It runs vertically downward across the front of

the scalenus anterior muscle
 Enters the thorax by passing in front of the

subclavian artery
Phrenic Nerve
 The phrenic nerve is the only motor nerve

supply to the diaphragm
 It also sends sensory branches to the

pericardium, the mediastinal parietal
pleura, and the pleura and peritoneum
covering the upper and lower surfaces of
the central part of the diaphragm
MUSCLES AND TRIANGLES OF THE
NECK
 The anterolateral part of the neck is
quadrilateral area which is divided by
sternomastoid muscle into 2 large
triangular areas ( anterior and posterior ) .
 The investing layer of deep fascia roofs
both triangles .
• Sternomastoid muscle :
• 1- action :when one muscle acts alone , it bends
the head to its same side and rotates it to the
opposite side ( the face looks to the opposite
side
• As you want to approximate the mastoid process
to the manubrium of the sternum ).
• When the two muscles act together , they flex the
head .
• 2-Nerve supply : 1- the spinal root of the
accessory nerve (motor )
• 2- the cervical nerves C2&C3 (proprioceptive )
Omohyoid
Sternomastoid
muscle
muscle
Relations of the sternomastoid
 1- superficial relations :
 1- the lower end of the parotid gland .
 2- the great auricular nerve .
 3- anterior cutaneous nerve of the neck .
 4- external jugular vein .
Parotid
gland
Great
auricular
nerve
Transverse
cutaneous nerve of
the neck
External
jugular vein
• Deep relations :
• A- Deep relations to its upper half :
• 1- posterior belly of digastric muscle .
• 2- spinal accessory nerve .
• 3- splenius capitis
• 4- occipital artery
• B- Deep relations to its lower half :
• 1- intermediate tendon of omohyoid muscle .
• 2- transverse cervical artery .
• 3- suprascapular artery
• 4- anterior jugular vein
• 5- scalenous anterior
• 6- phrenic nerve
• 7- carotid sheath and its contents
• Stucture emerging from its posterior
border (they appear in the posterior
triangle )
• 1- branches of the cervical plexus
• 2- trunks of brachial plexus
• 3- spinal accessory nerve
• 4- transverse cervical artery &suprascapular
arteries
• 5- the 3rd part of subclavian artery
• 6- deep cervical lymph nodes
 Clinical importance of the sternomastoid
muscle :
 1- congenital torticollis : (wry neck ), it is a
fibrous tissue tumour or injuiry of the
muscle during birth .
 2- spasmodic torticollis : abnormal tonicity
in the muscle .
apex
trapezius
muscle
Investing
Sternomastoid
layer of
muscle
deep fascia
roof
Middle
1/3 of
clavicle –
base
The posterior triangle
• the posterior triangle lies behind the sternomastoid

muscle , it has an apex , base and 2 borders .
• The outlines of the posterior triangle :
• 1- the posterior border of the sternomastoid
muscle . (infront )
• 2- the anterior border of trapezius muscle(behind )
• 3- the middle one third of the clavicle forms the
base of the triangle .
• 4- the meeting of the sternomastoid muscle and
trapezius muscle forms the apex of the triangle .
• Roof :
• It consists of the following layers (from outwards
inwards )
• 1-the skin
• 2- the superficial fascia containing :
• 1- the platysma muscle (very thin sheet of muscle
layer )
• 2- the external jugular vein
• 3- the deep fascia of the roof ( part of the general
investing layerof the deep fascia of the neck ) .
• Floor :
• The deep fascia of the floor ( prevertebral
fascia ) which cover the muscles of the floor .
• The muscles of the floor ( arranged from
below upwards )
• 1- scalenus medius
• 2- levator scapulae
• 3- splenius capitis
• 4- semi- spinalis capitis ( at the apex of the
triangle )
 The posterior triangle is subdivided by the
inferior belly of omohyoid into 2 smaller
triangles :
 1- the occipital triangle ( above )
 2- the subclavian triangle ( below )
Contents of the posterior triangle
 1- nerves, remember that the main

contents of the posterior triangle are
nerves .
 2- vessels ( arteries and veins )
 3- the inferior belly of the omohyoid
muscle
Spinal
part of
accessory
nerve
• Cervical plexus :
• It is formed by the anterior rami of the upper
4 cervical nerves .
• It gives off 4 muscular branches :
• 1- nerve to sternomastoid muscle ( C2&C3
proprioceptive)
• 2- nerve to trapezius muscle ( C3&C4
proprioceptive)
• 3- nerve to levator scapulae muscle ( C3&C4)
• 4- roots to the phrenic nerve . (C3&C4 & C5)
 Cutaneous branches of the cervical plexus
:
 1- lesser occipital nerve (C2)
 2- great auricular nerve (C2&C3).
 3- transverse cervical nerve (C2&C3)
 4- supraclavicular nerves (C3&C4)
 Arteries :
 1- 3rd part of subclavian artery .
 2- two branches which come from the 1st part
of the subclavian artery ( transverse cervical
artery and suprascapular artery )
 Veins :
 1- subclavian vein
 2- transverse cervical vein
 3- suprascapular vein
The anterior triangle of the neck
• It lies in front of the sternomastoid muscle .

• It is bounded by :
• 1- anterior border of sternomastoid muscle .
(behind)
• 2- anterior midline of the neck ( in front )
• 3- lower border of the mandible (base )
• It is subdivided into 4 triangles by means of
the superior belly of omohyoid muscle , the
anterior and posterior bellies of digastric
muscle as follows :
 1- Digastric triangle
 2- carotid triangle
 3- Muscular triangle
 4- Submental triangle
Posterior
belly of
digastric
Stylohyoid Anterior belly of

digastric muscle
Sternohyoid
muscle
Digastric triangle
• Outlines :
• Above : the lower border of the mandible
• Below & infront : the anterior belly of Digastric
muscle
• Below & behind : the posterior belly of
Digastric and stylohyoid muscles .
• Floor :
• Anteriorly : the mylohyoid muscle
• Posteriorly : part of hyoglossus muscle
Contents of the Digastric triangle
• 1- submandibular salivary gland

• 2- the submandibular lymph nodes lie on
the surface of the gland
• 3- facial artery deep to posterior end of
submandibular salivary gland
• 4- facial vein lies superficial to
submandibular salivary gland
• 5- hypoglossal nerve
• 6- nerve to mylohyoid muscle
Anterior belly
d
of digastric
Digastric triangle
Posterior
belly of
digastric
Carotid triangle
Mylohyoid
muscle
forms the Muscular triangle
floor of
the mouth
Carotid triangle
• Outlines :
• Behind : the sternomastoid muscle
• Infront and above : the posterior belly of digastric
muscle
• Infront and below : the superior belly of omohyoid
muscle
• Floor : infont : the hyoglossus muscle ( above )
and the thyrohyoid muscle (below)
• Behind: the middle constrictor muscle of the
pharynx (above ) and the inferior constrictor
muscle of the pharynx (below )
Internal
carotid
artery
External carotid
artery
Common carotid
artery
Contents of the Carotid triangle
 1- The carotid sheath and its contents :

 - common carotid artery : in the lower part
of the triangle .
 - internal carotid artery : in the upper part
of the triangle .
 Internal jugular vein : lateral
 Vagus nerve : between the artery and the
vein but in a more posterior plane .
 2- the external carotid artery : gives most of
its branches in the carotid triangle ( superior
thyroid artery ,lingual artery ,facial artery ,
ascending pharyngeal artery and occipital artery
)
 3- hypoglossal nerve
 4- Descendes cervicalis (C2,3) anterior to
carotid sheath.
 5- sympathetic trunk adherent to the posterior
wall of carotid sheath
Muscular triangle
 Outlines :
 Infront : midline of the neck
 Behind and above :superior belly of
omohyoid muscle
 Behind and below : the sternomastoid
muscle
Contents of the Muscular triangle
 It contains the infrahyoid muscle

Submental triangle
 Outlines :
 Infront : symphysis menti of the mandible
 On each side : the anterior belly of
digastric muscle
 Behind ( base ) : the hyoid bone
 Floor : parts of the mylohyoid muscles as
they meet each other in the median plane
Contents of the Submental triangle
 1- submental lymph nodes

 2- beginning of the anterior jugular vein
The infrahyoid muscles
• They are strap like muscles occupy each side

of the midline of the neck , from the hyoid
bone to the manubrium sterni .
• They consist of 4 muscles arranged into 2
layers :
• 1- superficial layer : a- sternohyoid
• B- omohyoid
• 2- deep layer: a- sternothyroid
• B- thyrohyoid
The Hyoid Bone
• The only bone that does

not articulate with another
bone
• Serves as a moveable
base for the tongue
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

The infrahyoid muscles
 Nerve supply :
 All The infrahyoid muscles are supplied by
 Ansa cervicalis except
thyrohyoid muscle supplied by fibres
from C1 through hypoglossal nerve .
Ansa cervicalis
 Ansa = loop
 It is a loop of cervical nerve fibres derived
from C1,2,3 which lies below the carotid
sheath below the middle of the neck .
 It consists of 2 roots :
 1- descendes hypoglossi C1: derived from
hypoglossal nerve
 2- descendes cervicalis : C2,3 : from the
cervical plexus
Action of the infrahyoid muscles
 1- superficial layer : a- sternohyoid :

depress the hyoid bone after it has been
elevated during swallowing .
 B- omohyoid : depresses , retracts and
steadies the hyoid bone .
 2- deep layer: a- sternothyroid : depress the
hyoid bone and the larynx
 B- thyrohyoid : depress the hyoid bone and
elevate the larynx
Suprahyoid muscles
 1- digastric muscle
 2- mylohyoid muscle
 3- hyoglossus muscle
 4- geniohyoid muscle
 5- stylohyoid muscle
Geniohyoid
muscle
Hyoglossus
Digastric muscle
• It consists of 2 bellies anterior and posterior , that

connected together by an intermediate tendon .
• Nerve supply :
• 1- anterior belly : from nerve to mylohyoid which is
a branch of mandibular nerve .
• 2- posterior belly : the facial nerve
• Action :
• When the mandible is fixed , it raises the hyoid
bone during swallowing .
• When the hyoid bone is fixed , the anterior belly
can depress the mandible
• mylohyoid muscle :
• Formed of superoir and inferior bellies .
• Nerve supply : nerve to mylohyoid , which is
a branch of the mandibular nerve .
• Action :
• When the 2 bellies contract they elevate the
hyoid bone and the floor of the mouth as well
as the root of the tongue during swallowing .
• If the hyoid bone is fixed , the 2 bellies
depress the mandible and open the mouth .
Hyoglossus muscle
 Nerve supply :
 Hypoglossal nerve ( 12th cranial nerve )
 Action :
 It draws the tongue downwards and thus
help suckling .
 Geniohyoid muscle :
 Nerve supply :
 Hypoglossal nerve ( via fibres from C1 )
 Action :
 It pulls the hyoid bone upwards and
forwards , if the hyoid bone is fixed , it
depresses the mandible .
 Stylohyoid muscle
 Nerve supply :
 Facial nerve
 Action :
 Raises the hyoid bone upwards

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THE HEAD AND NECK LECTURES

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

The skull, which consists of the

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

The Orbital and ear Complexes.

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

 The cranial bones that

 Hydrocephalic cranium = very voluminous skull (abnormal) due

 Superficial Facial Bones

 Anterior fontanelle  Posterior fontanelle

The visceral cranium – develops from

 The Infant Skull

 Is large compared to the body

 Has many ossification centers

 Fusion is not complete at birth

 Four occipital bones

 Several sphenoidal and temporal elements

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

AIR SINUSES (in

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Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

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Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

 The pharynx is the continuation of the digestive system

 Consist of circular muscles

 External circular muscles: Constrict walls

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

1. Mucosa (3 layers): 2. Submucosa: loose

Glottis (space between

 The thyroid gland = the largest endocrine

 Functions end of 3rd month, at which time

 Inferior parathyroid glands = parathyroid

 Parts: two lobes , isthmus.

 Each lobe is pyramidal

Connects two lobes.

Covered by infrahyoid muscles.

Inferior thyroid vein emerges from its lower

Inferior thyroid artery –

 Thyroidea ima from

 Superior thyroid vein –

Ovoid bodies measuring about 6mm long in

 They may lie within the fascial sheath,

 The thyroid gland is covered by fibrous

 A thyroglossal cyst may lie at any

Agenesis or incomplete development of the

• Common Carotid Artery

• External Carotid Artery

• Internal Carotid Artery

 External Carotid Artery

 Internal Carotid Artery

 Begins at the level of upper border of thyroid

1. 1st part of subclavian artery

2. 2nd part of subclavian artery

3. 3rd part of subclavian artery