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20- Posterior Triangle of Neck

Sternocleidomastoid m.

Trapezius m.

Omohyoid m. Superior belly Inferior belly

1. 2. 3. 4. 5.

Hyoid: u-shaped bone at C3 level Thyroid cartilage: (C4/5) Laryngeal prominence (Adams apple) Arch of cricoid: only complete trachea ring Rings of trachea: C-shaped, membrane in posterior Temporal bone: a. Mastoid process: SCM attachment b. Styloid process: stylohyoid m. attachment, attached to hyoid b. in front of EAM 6. Occipital bone: attachment for trapezius a. External occipital protuberance: midline b. Nuchal lines: two ridges 7. Mandible: upper border of neck a. Body: horizontal; Ramus: vertical portion the two meet at the Angle b. Head: forms part of TMJ 8. Cervical vertebrae: have 7 cervical vertebrate, but 8 cervical nerves: i. C1 C7 pass above correspondingly numbered vertebrae ii. C8 passes below C7 vertebrae b. Transverse foramina: transmit subclavian branches which ascend to skull base i. Atlanto-occipital joint: flexion & extension of head on C1 c. Atlanto-occipital membrane: closes space between skull & atlas; penetration of vertebral arteries through foramen magnum d. Atlas (C1): two depressions articulate with occipital condyles & supports skull; no vertebral body present space for dens i. Atlanto-axial joint: rotation of atlas & skull together around dens ii. Jefferson Fracture: fracture of C1 anterior arch; from falling on head e. Axis (C2): dens (Odontoid process) projects into atlas to allow pivoting i. Hangmans Fracture: bilateral fracture posterior arch of C2 with anterior subluxation of C2 on C3; hyperextension/distraction injury

f. Transverse ligament: posterior to dens to prevent atlas anterior displacement g. Alar ligaments: prevent excessive rotation from side to side h. Internal Craniocervical ligaments: i. Cruciate l.: Superior & inferior longitudinal + Transverse ligament ii. Anterior longitudinal l.: prevents excessive extension 1. Tear Drop Fracture: neck hyperextension sudden pull of A.L.Lig on anterior inferior vertebral body C2 fracture iii. Posterior longitudinal l.: prevents excessive flexion i. Nuccal ligament: prevents skull flexion; divides back m.s into right & left sides j. Herniated disks in cervical region: pain in neck & upper limbs 9. Facial Layers of Neck: a. Superficial layer: nerves, blood vessels, fat, Platysma m. b. Investing fascia: (deeper) splits twice to surround Trapezius and then SCM c. Pre-vertebral fascia: compartmentalizes neck muscles i. Danger space: open space between Alar & Pre-vertebral fascia extending into posterior mediastinum; infection spread route to heart ii. Anterior: splits into Alar fascia which crosses midline from one transverse process to another iii. Retropharyngeal space: closed space between Alar & Visceral fascia d. Visceral fascia: tube around trachea, esophagus, thyroid e. Carotid sheath: condensation of other layers, surrounds carotid a., internal jugular v. & vagus 10. Muscles: ! a. Platysma: thin m. facial expression in superficial fascia; fibers extend over clavicle &
under mandible to blend in with facial muscles; leaves midline gap

Retropharyngeal Space

Danger Space

i. Nerve supply: Cervical branch of Facial n. 1. Depresses mandible, draws down lower lip & angle of mouth b. Sternocleidomastoid (SCM): two heads (sternal & clavicular) join to form flat strap muscle that attaches to mastoid process i. Motor - Spinal Accessory n. (CNXI) 1. Both m.: extend head at atlanto-occipital joint, flex cervical column 2. One m.: rotates the face to the opposite side ii. Proprioceptive - Ventral rami of C2-3 iii. Torticollis (Wry Neck): shortening of SCM head tilts towards affected side & turns towards unaffected side; caused by: 1. Congenital: excessive stretching of SCM during labor 2. Spasmodic: usually psychogenic 3. Injury to spinal part of accessory nerve, brachial plexus, nerve to platysma, or pleura & lung injuries in the root of neck c. Trapezius: acts on shoulder i. Upper part elevates, Middle part retracts, Lower part depresses ii. Also acts with serratus anterior to rotate shoulder superiorly iii. Nerve supply: Spinal Accessory n. (CNXI)

d. Scalene muscles: i. Anterior & Middle scalene: first rib to transverse processes for lateral bending 1. Brachial Plexus is sandwiched between anterior & middle s.m. ii. Posterior scalene: off second rib, inserts on lower cervical vertebrae e. Levator scapulae: attaches to superior scapula angle; elevates scapula (w/ trapezius) f. Splenius capitis: (bandage) extends & laterally rotates skull to same side 11. Vessels: a. External jugular vein: origin near mandible from confluence of posterior auricular & posterior retromandibular v.s (superficial temporal + maxillary v.s) runs superficial to SCM, empties into subclavian v. i. External Jugular Vein Distension: from elevated central venous pressure (CVP) right heart failure; tricuspid stenosis 1. Hepatojugular reflux: hepatic pressure increases EJVD b. Subclavian branches: i. Transverse cervical a.: deep to trapezius ii. Supracapular artery a.: through scapula notch 12. Nerves: a. Dorsal primary rami: facet joint sensation b. Suboccipital n.: C1 dorsal ramus; no sensory i. Motor to positional muscles which help in extension (nodding) & lateral skull rotation 1. Rectus capitus posterior (major & minor) 2. Obliquius capitus (superior & inferior) c. Greater occipital: C2 dorsal ramus; sensation from back of skull d. Cervical plexus (C1-C4 Ventral primary rami):
Sensation only; cutaneous branches emerge at nerve point of the neck; loops formed between adjacent primary rami

ii. iii. iv. v.


1. Nerve point of the neck: half way up posterior edge of SCM location of Cervical plexus block Lesser occipital (C2,3): skin right behind ear & auricle; travels anterior Trapezius Great auricular (C2,3): skin from mastoid process to lower ear & mandible angle; runs travels external jugular vein Transverse cervical (C2,3): anterior triangle skin Supraclavicular (C3,4): above clavicle; 3 trunks: medial, intermediate, lateral 1. Phrenic nerve shares spinal segments with cutaneous innervation of Supraclavicular - - referred pain to shoulder from diaphragm irritation **C1 has no area of sensation on outside of head/neck

21- Anterior Triangle of Neck

1. Anterior Triangle: a. Submandibular triangle: below mandible b. Submental triangle: between two anterior bellies of digastric i. Small veins give rise to Anterior Jugular v. (superficial to muscular t.) ii. Submental lymph nodes: enlarged with infected tongue tip, lower lip, chin c. Carotid triangle: bounded by posterior belly of digastric & SCM; location of i. IJV: lateral to Common Carotid; Vagus n. (between & posterior to both) d. Muscular triangle: bounded by superior belly omohyoid, extending to SCM; location of infrahyoid m., trachea, thyroid, & larynx
Digastric Anterior belly

Sternothyroid m. Anterior J.V.


2. Muscles: a. Suprahyoid m.s: raises oral cavity floor i. Digastric: two bellies connect to hyoid {sling}; elevates hyoid bone 1. Posterior belly: attaches to deep surface of mastoid a. Cervical n. branch of Facial n. 2. Anterior belly: N. to Mylohoid (br. Inferior alveolar n. (V )) ii. Mylohyoid: deep to digastric anterior belly; extends towards midline to attach to raphae; shortens & pulls towards hyoid bone, pushing tongue to roof of mouth; N. to Mylohoid iii. Stylohyoid: styloid process (temporal b.), splits in two, to hyoid b. a. Cervical n. branch of Facial n. iv. Geniohyoid: attaches near mandible bend; pulls hyoid bone forward a. Branch of C1 (which piggybacks along hypoglossal n.) b. Infrahyoid (strap) muscles: anterior to larynx, trachea, thyroid; raise larynx & depresses hyoid during speech & swallowing i. Sternohyoid: attached to side of thyroid cartilage can depress it ii. Omohyoid (superior belly): depress hyoid bone iii. Sternothyroid: depresses hyoid bone towards myoid iv. Thyrohyoid: from side of thyroid cartilage to undersurface of hyoid a. Branch of C1 (which piggybacks along hypoglossal n.)


Innervation SUPRAHYOID MUSCLES N. To mylohyoid (br. of inferior alveolar n. CN V3) C1 via Hypoglossal n Cervical br. Facial n. N. To mylohyoid Cervical br. Cn VII INFRAHYOID MUSCLES Ansa cervicalis Ansa cervicalis Ansa cervicalis *C1 via Hypoglossal


Mylohyoid Geniohyoid Stylohyoid Digastric anterior belly Digastric posterior belly Sternohyoid Sternothyroid Omohyoid Thyrohyoid*

Elevates hyoid, depresses mandible Pulls hyoid superiorly Elevates & retracts hyoid Depresses mandible Elevates hyoid Depresses hyoid Depresses thyroid cartilage Depresses, retracts hyoid Depresses hyoid, elevates thyroid cartilage

3. Brachiocephalic a. Common carotid: C4/5 bifurcation a. Carotid artery Stenosis: i. TIA: brief periods of inadequate perfusion in portion of middle cerebral a.
temporary & focal loss of neurological function (hand, vision sx.)

ii. Stroke/Infarction: sudden insufficiency of arterial supply due to emboli or thrombi macroscopic brain necrosis b. INTERNAL CAROTID: (posterior) no branches in neck; enters through carotid foramen to supply brain i. Arterial Circle of Willis: base of brain around pituitary gland & optic chiasm ii. Opthalmic a.: supply eyeball & muscles and forehead 1. Supraorbital: anastamose w/ superficial temporal a. iii. Carotid sinus: dilated part of internal carotid c. EXTERNAL CAROTID: (anterior) supply neck (SALFOPSMax) i. Superior thyroid: down to supply upper thyroid gland 1. Superior laryngeal: ii. Ascending pharyngeal: iii. Lingual: floor of oral cavity, tongue iv. Facial: deep to mandible, supplies skin & muscles of facial expression 1. Submental: v. Occipital: deep to SCM & post. belly digastric vi. Posterior auricular: vii. Superficial temporal (terminal br.): scalp & skin above ear viii. Maxillary (terminal br.): infratemporal fossa & deep head (nasal cavity, palate, floor of orbit); courses transversely medial to mandible condyle neck

4. Veins: a. Internal jugular: drains brain & neck; valve before joining subclavian to prevent blood from flowing back into brain b. At the root of the neck, joins Subclavian vein 5. Lymph: a. Deep Cervical Lymph Nodes: drain deep parts of head b. Superficial Cervical Lymph Nodes: drains scalp; lie along fascia of posterior triangle & EJV; join lymph nodes along IJV to empty into Thoracic duct c. Jugulo-digastric node: behind mandible angle; enlarged in Tonsilitis & Pharynx infections d. Supraclavicular (Sentinal) node: enlarged with tumors, cancer, infections of thorax/abdomen e. Virchows node: left side enlarged in abdominal (stomach fundus) cancer 6. Nerves: a. Ansa cervicalis: motor innervation infrahyoid m.s i. Descendens hypoglossi (C1): superior root ii. Descendens cervicalis (C2, 3): inferior root b. C1 (thyrohyoid & geniohyoid): piggybacks along hypoglossal n. c. Sympathetic trunk: cervical portion: Superior cervical ganglion: postganglionic sympathetic cell bodies that piggyback blood vessels (carotid artery & branches) 7. TracheoStomy: permanent or semi-permanent trachea opening a. Placed in lower trachea, between tracheal rings b. Indications: foreign body, vocal cord paralysis, upper airway tumors or trauma c. Need to be careful not to puncture brachiocephalic a. or left brachio. v. 8. Cricothyrotomy: Emergency surgical airway incision of cricothyroid membrane a. Safer alternative - avoid vocal cords, thyroid gland & associated vessels

22- Intro to Skull

1. BONES OF THE SKULL: a. Frontal: unpaired bone making skeleton of forehead & superior orbit margin i. Supraorbital foramen: transmits Supraorbital n. (V1) for sensation b. Coronal suture: between frontal & parietal c. Parietal: top to back of skull i. Sagittal suture: down the paired parietal bones d. Lambdoid suture: between parietal & occipital e. Occipital: lower back of skull f. Squamous suture: between parietal & temporal g. Temporal: lateral sides i. External acoustic meatus: from the auricle to the tympanic membrane ii. Temporal Fossa: located above the zygomatic arch. 1. Superior, Inferior temporal lines: Temporalis m. originates
between the two lines & attaches to mandible for jaw clenching

iii. Zygomatic process/ridge: sutures with zygomatic bone iv. Infratemporal fossa: irregular space inferior to zygomatic arch 1. Contains: muscles of mastication, maxillary a. branches, pterygoid venous plexus, CN V3 branches v. Petrous part: pyramidal wedge between the sphenoid and occipital 1. Internal acoustic meatus: where facial n. enters skull h. Zygomatic: cheek-bone, part of zygomatic arch i. Sphenoid: i. Superior orbital fissure: slit between Greater & Lesser wings; passage for nerves from middle c fossa to orbit ii. Body: depression for pituitary gland
iii. Lateral & Medial pterygoid plates: Pterygoid m.s attachments

j. Nasal: nose ridge k. Lacrimal: orbit medial wall; most fragile facial bone l. Maxilla: upper jaw & medial inferior orbit margin i. Alveoli: sockets for upper teeth ii. Infraorbital foramen: transmits Infraorbital n. (V2) iii. Pterygopalatine fossa: between maxilla & lateral pterygoid plate 1. Pterygopalatine ganglion: suspended from Maxillary n a. PNS root: i. Preganglionic via G. Petrosal (Facial n.) ii. Postganglionic supplies lacrimal, nasal, & palatine glands b. SNS root: sympathetic efferent (postganglionic) fibers from the superior cervical ganglion
2. Passages that connect with other parts of the skull: a. Foramen rotundum middle cranial fossa b. Vidian canal Foramen lacerum c. Splenopalatine foramen nasal cavity d. Inferior orbital fissure orbit e. Pterygomaxillary fissue infratemporal fossa f. Greater palatine canal oral cavity

m. Mandible: i. Mandibular foramen: entrance for Inferior alveolar n. ii. Mental foramen: Mental n. (Inferior alveolar V3 br.) n. Pterion: suture point of frontal, GWS, parietal, temporal; Middle meningeal a. branches lie deep to pterion and run in dura layers i. Area thin & susceptible to fractures Epidural Hematoma o. Basilar Skull Fracture: (skull base) swelling of soft tissue i. Battle sign: bruising & redness behind ear from vessel hemorrhage p. Paranasal sinuses: air-filled spaces developed from excavation of bone by air-filled sacs (pneumatic diverticula) from the nasal cavity i. Maxillary sinuses: surround nasal cavity 1. Opening is high in the sinus wall, so head must be tipped to opposite side to drain fluid can accumulate causing infection ii. Frontal sinuses: above eyes iii. Ethmoidal sinuses: between the eyes iv. Sphenoidal sinuses: behind the ethmoids 1. Anterior approach through nasal cavity to sella turcica, used when operating on pituitary gland v. Sinusitis: infection, often precipitated by earlier upper resp. infection 1. Often accompanied by headaches, pain, pressure in head, and referred pain to upper teeth because sinuses are supplied by sensory fibers from Trigeminal n. (V2 Superior alveolar n.)

2. INFANT SKULL GROWTH: sutures allow skull expansion brain develops a. Metopic suture: down frontal bone i. Metopid ridge: metopic suture fuses early skull & forehead deformities b. Anterior fontanelle: between frontal & parietal c. Posterior fontanelle: between parietal & occipital d. Mastoid fontanelle: between occipital & temporal e. Sphenoid fontanelle: between GWS & parietal f. Craniosynostosis: one or more fibrous sutures in infant skull prematurely fuses; may be inherited, associated with other problems of facial development i. Prominent forehead, swelling on one side of head ii. Increased pressure on brain; developmental delays iii. Surgery used to separate the fused sutures and to reshape the skull

3. MENINGES: a. Epidural space: between dura & skull i. Epidural Hematoma: arterial origin (torn br. middle meningeal a.); lens-shaped blood accumulation between; pterion swelling, headache b. Dura mater: i. Tentorium cerebelli: infolding of dura that separates occipital from cerebellum; brainstem can be pushed & cut by TC in Epidural Hematoma ii. Two layers: Periosteal layer (skull contact) & Meningeal layer (deeper) iii. Between the two layers is 1. Middle meningeal a. (& v.): runs in infratemporal fossa a. Br. of Maxillary a. (term. br. External Carotid a.) b. Small branch enters skull through foramen spinosum 2. Also supplying blood to duraMeningeal br.s of Occipital & Ascending Pharyngeal a.s 3. Superior sagittal sinus: drainage of cerebral v.s; located at superior edge of Falx cerebri

iv. Falx cerebri: midline projection of dura between cerebral hemispheres 1. Inferior sagittal sinus: runs at inferior edge of Falx cerebri;
a. Joins Great Cerebral v. to form Straight Sagittal sinus

b. Joins Superior sagittal sinus to form Transverse sinus flow to Sigmoid sinus
& through Jugular foramen

v. Cavernous sinus: at sphenoid body; receives v. blood from orbit & face 1. CN II, IV, VI, V1 (V2) pass through 2. Cav.Sinus infection (from face) double vision, headache, eye pain 3. ICA Aneurysm can also affect CN VI (supplies lateral rectus m.) affecting lateral eye movement double vision (diplopia) a. Unable to supply the retina (since central a. of the retina is a branch of the ophthalmic a. & thus ICA) blindness

c. d.




4. Cavernous carotid AV fistula: enlarged cavernous sinus & dilated superior ophthalmic v. orbital pain, chemosis, exophthalmos; tx with embolization vi. Pterygoid plexus: below orbit in infratemporal fossa Maxillary v. Cerebral veins: between dura & arachnoid; to superior sagittal sinus & IJV Subdural space: between dura & arachnoid; potential space i. Subdural Hemorrhage (SDH): venous origin; head trauma where brain moves within skull; forms crescent shape Arachnoid mater: i. Arachnoid granulations (villi): small arachnoid protrusions through dura into v. sinuses - CSF exits sub-arachnoid to enter blood stream ii. Hydrocephalus: CSF resorption blockage 1. Sx of increased intracranial pressure: headaches, vomiting, nausea, papilledema (optic disc swelling), sleepiness, coma Subarachnoid space: true space with CSF circulation & cerebral a.s i. Basilar Tip Aneurysm: associated with subarachnoid hemorrhage ii. Subarachnoid Hemorrhage: arterial origin (ruptured intracranial aneurysm); also associated with trauma; blood mixes with CSF and can diffuse widely irregular in space, may cause a lot of pain Pia mater: thin fibrous tissue impermeable to fluid, surrounding brain & spinal cord

23- Face and Parotid

1. LeFort Fractures: a. Type I: horizontal maxillary fracture, separating teeth from upper face i. Fracture line passes through alveolar ridge, lateral nose, & inferior wall of maxillary sinus b. Type II: pyramidal fracture; teeth at pyramid base, nasofrontal suture at apex i. Fracture arch passes through posterior alveolar ridge, lateral maxillary sinus walls, inferior orbital rim, & nasal bones c. Type III: craniofacial disjunction i. Fracture line passes through nasofrontal suture, maxilla-frontal suture, orbital wall, & zygomatic arch 2. FACE: a. Aging of facial skin: Tensor lines (Langers lines) corresponding to direction of collagen & elastin fibers; loss of elastic fibers causes permanent wrinkles b. Botox: blocks release of ACh which triggers contractions that create wrinkles 3. Sensory & Motor Facial innervation comes from different cranial nerves due to organizing principle head structures are derived from Five Primitive Pharyngeal Arches: each contains cartilaginous & muscular component, aortic arch, and a nerve a. Arch I: CN V (Maxillary & Mandibular n.s) b. Arch II: CN VII (Facial n.) c. Arch III: CN IX (Glossopharyngeal n.) d. Arch IV/VI: CN X (Superior laryngeal br. & Recurrent laryngeal br. of Vagus) e. *Arch V develops and quickly regresses

4. THE CRANIAL CAVITY: is divided into 3 fossa

Superior Orbital Fissure

Foramen Ovale

Jugular Foramen

Internal Acoustic Meatus

5. Facial Expression muscles: covered by superficial but not deep fascia; br.s Facial n. a. Occipitofrontalis: raises eyebrows b. Orbicularis oculi: acts as sphincter to close eye c. Zygomaticus major: smile d. Buccinator: cheek i. Motor: Buccal n. (br. Facial n. - CNVII) ii. Sensation: Long buccal n. (V3) e. Levator labii superioris: elevate upper lip f. Orbicularis oris: lip pursing g. Depressor anguli inferioris: frown h. Platysma: frown

i. Bells Palsy: weakness or paralysis of facial expression m.{ one side} due to Facial n. trauma; 85% have complete recovering in a year
i. ii. iii. iv. v. vi. Pain behind or in front of ear on affected side Sounds seem louder on same side (affects N. to Stapedius m.) Loss of taste anterior tongue Drooling mouth corner on affected side (paralysis of buccinators m.) Difficult closing eye (paralysis of orbicularis oculi m.) Changes in amount of tears or saliva

6. Muscles of Mastication: attach to mandible; Mandibular n. (only V3 division with motor) a. Temporalis: closes/clenches jaw; fan-shaped m., attaches to coronoid process b. Masseter: closes jaw (pulls mandible up); from zygomatic arch to mandible angle c. Medial Pterygoid: elevates mandible, pulls jaw to opposite side (grinding); originates on medial surface of lateral pterygoid & tuberosity of maxilla d. Lateral Pterygoid: mandible protrusion (pulls forward); two heads 7. Tempero-mandibular joint: synovial joint between mandiblular condyle & mandibular fossa j. Articular eminence: prevents displacement of jaw forward k. Upper compartment: sliding movement, disc moves with mandible; can lock l. Lower compartment: hinge motion m. Branches of Auriculotemporal n.: sensation from TMJ n. TMJ disorders: aching pain in/around ear & face, recurrent headache, jaw tenderness, clicking/grating, joint locking difficult to open & close mouth 8. PAROTID GLAND: largest salivary gland all salivary g.s under autonomic control a. Parotid duct: from gland, across masseter, pierces buccinators & opens in cheek mucosa along 2nd maxillary (upper) molar tooth - delivers saliva to oral cavity b. Structures within the Parotid Gland: External carotid a.; Retromandibular v.s. i. Auricotemporal n. branches (V3); Terminal motor branches of VII 1. Parotid tumors can compress Facial n. branches pain anterior to left
ear, accentuated when chewing, food collects in space between cheek & teeth, and dribbling out mouth corner; left lower eyelid & mouth droop

c. Glossopharyngeal (CNIX) br.: parasympathetic innervation & secretomotor 2. Herpes Zoster (Shingles): chicken pox (varicella) infects trigeminal ganglion; once activated, travels along
afferent axons to skin where forms painful rash; often has a typical dermatomal presentation

3. Trigeminal Neuralgia: intense facial pain lasting few seconds to several min/hours; enlarged blood vessel
(superior cerebellar a.)

is compressing/ throbbing against microvasculature of trigeminal n. near connection with pons

4. Facial vein: i. Danger triangle of Face: infections on face may pass retrogradely into skull via facial v. Opthalmic veins Cavernous sinus Dural sinuses brain a. External carotid artery:
i. Facial artery: deep to mandible, through submandibular gland a. Superior & Inferior labial: upper & lower lips b. Lateral nasal: c. Angular: medial/lower eye Superficial temporal artery: a. Transverse facial artery: 12


24- Cranial Nerves

CNs originate from the nuclei within the brainstem (except CN I & II forebrain extensions) a. Travel within subarachnoid space, in CSF, pierce dura to exit cranial cavity
b. c. d. e.

i. Except CN I & II - considered tracts (extension of brain covered by meninges) MOTOR ONLY (may be all somatic motor or both somatic & visceral motor) = III, IV, VI, XI, XII SENSORY ONLY (special sensory) = I, II, VIII MIXED (may be somatic & visceral motor and somatic & special sensory) = V, VII, IX, X PARASYMPATHETICS (visceral motor to glands & smooth/cardiac m.) = III, VII, IX, X

1. CN I Olfactory: special sensory only a. Nerves pass through foramen in ethmoid bone (cribiform plate), through olfactory tract and synapse with neurons (mitral cells) in olfactory bulb 2. CN II Optic: special sensory only a. Optic nerve (tract covered by meninges), pass through Optic Canals within sphenoid lesser wing (along with Opthalmic a. & periarterial plexus of postganglionic sympathetic n.s), crosses at chiasm, back to occipital pole b. Retinal ganglion cells in back of the retina collectively form the optic nerve i. Glaucoma: death of retinal ganglion cells 3. CN III Oculomotor: all motor (somatic & visceral) a. Travels through superior orbital fissure (between lesser & greater wings) & tendonous ring (muscles attached), divides into superior & inferior divisions b. Edinger-Westphal nucleus (accessory Oculomotor nucleus) Pregang. PS synapse in Ciliary ganglion (orbit) Short ciliary post-ganglionic nerves: i. Constrictor pupillae m.: constricts iris (pupillary light reflex) 1. Loss/slowness of reflex may indicate brainstem damage and/or bleeding that compresses CN III against petrous ridge ii. Ciliaris m.: rounds up lens for near vision (accommodation) iii. Absence of adequate PS stimulation pupil dilation, difficulty near focusing c. Innervates extraocular muscles: Superior, Medial, & Inferior rectus; Inferior oblique; Levator palpebrae superioris i. *Two are not innervated by CNIII (LR6SO4) 1. Lateral rectus: CN VI; Superior oblique: CN IV

4. CV IV Trochlear: Superior oblique m. (medial side of eye) a. Travels through superior orbital fissure 5. CN V Trigeminal: sensory to face & head outside
(& including) dura mater

a. Trigeminal ganglion: sensory; no synapses; sits near ICS & Vidian nerve (middle cranial fossa) b. Opthalmic division (V1): superior orbital fissure; all somatic sensory i. Frontal: cornea, skin of: upper eyelid, nose bridge, forehead 1. Supraorbital: supraorbital foramen onto forehead 2. Supratrochlear: medially; sensation to forehead between eyebrows ii. Nasociliary: sensory 1. Infratrochlear: sensation angle of eye, lateral to nose bridge 2. Long & Short ciliaries: sensation from cornea a. Long = sensory + sympathetic b. Short = sensory + sympathetic + parasympathetic c. Corneal (Blink) Reflex: eye is closed by orbicularis oculi m. (supplied by Facial n. CN VII) i. Afferent limb: CN V1 (long & short ciliary = sensory) ii. Efferent limb: CN VII (blink) iii. Lacrimal: lacrimal gland, upper eyelid skin c. Maxillary division (V2): in pterygopalatine fossa; passes through foramen rotundum i. Zygomatic: lateral nose ii. Infraorbital: infraorbital foramen; upper lip, lower eyelid iii. Posterior superior alveolar: upper teeth & maxillary sinus iv. Pterygopalatine ganglion: PSN ganglion hanging off maxillary n. stimulates lacrimation (tears & nasal cavity muscosa) d. Mandibular division (V3): foramen ovale; contains motor & sensory i. Sensory: 1. Long Buccal: cheek 2. Lingual: sensory anterior 2/3 tongue, mouth floor a. Submandidibular ganglion: PNS ganglion suspended from Lingual n; receives fibers from Chorda Tympani n 3. Auriculotemporal: sensation from TMJ ii. Motor: Mandibular: muscles (& accessory m.) of mastication iii. Motor & Sensory: 1. Inferior alveolar: mandibular foramen; right mandible, lower teeth a. N. to Mylohoid: mylohyoid & anterior belly digastric i. Pushes tongue to roof; Raises oral cavity floor b. Mental: mental foramen (mandible) Sensory: chin, lower lip

6. CN VI Abducent: Lateral rectus m. (abducts {laterally moves} pupil) a. ICA Aneurysm can affect CN VI & lateral eye movement eye medial deviation 7. CN VII Facial: motor (somatic & visceral) and sensory (special & general) i. Internal acoustic meatus: entrance to facial canal b. Motor: i. Cervical branch exits via Stylomastoid foramen muscles of facial expression + stylohyoid, posterior belly digastric, stapedius 1. Depresses mandible, draws down lower lip & angle of mouth 2. Raises oral cavity ii. Buccal branch: muscles of facial expression c. Sensory: Geniculate ganglion (petrous part temporal b.) i. Skin around EA.meatus ii. Proprioceptive to skeletal muscles d. Superior salivatory nucleus: preganglionic parasymp. fibers of Greater Pet.n e. Parasympathetic & Sensory branches: i. Chorda tympani: travels through tympanic cavity (middle ear) 1. Secretomotor: PS submandibular & sublingual glands 2. Preganglionic synapse in Submandibular ganglion 3. Sensory: taste anterior 2/3 tongue
a. Travels along Lingual n.; exits through petrotympanic fissure

Greater petrosal: parasympathetic to lacrimal & mucosal glands {nasal cavity, soft palate} 1. Preganglionic synapse in pterygopalatine ganglion iii. GPN at Geniculate ganglion meets up with sympathetic fibers from the Deep Petrosal n. to form the Vidian n. travels to pterygopalatine fossa where parasympathetic fibers synapse fibers travels along V1 & V2 to reach Lacrimal gland 1. Vidian: mixed pregang. parasymp.; postgang. sympathetic f. N. to stapedius: origin in tympanic canal



Greater Petrosal n. loose secretion of palatine, nasal, & lacrimal glands (DRY EYE)

Loose motor parts of VII (Bells Palsy), secretion of lower salivary glands, taste on anterior 2/3 tongue Chorda tympani n. loose special sense on tongue & secretion of lower two salivary glands


8. CN VIII Vestibulocochlear: special sensory; enter internal acoustic meatus with CN VII a. Vestibular system balance b. Cochlea hearing 9. CN IX Glossopharyngeal: motor (somatic & visceral) & sensory (general & special) i. Exits cranial cavity at jugular foramen (beginning of IJV) a. Motor: stylopharyngeus m. only b. Sensory (general): pharynx, carotid body, carotid sinus (n. to Carotid sinus) c. Sensory (general & special): posterior 1/3 tongue (taste & sensory Gag reflex) d. Parasympathetic: to parotid glands for secretion i. Preganglionic fibers in Inferior salivatory nucleus travel with CN XI ii. Tympanic n. of Jacobson: joins with sympathetic (from superior cervical ganglion) to form iii. Lesser petrosal n. (IX & VII) emerges from middle ear iv. Synapse at Otic ganglion (infratemporal fossa) v. Postganglionic fibers follow Auriculotemporal (V3) to parotid 10. CN X Vagus: motor (somatic & visceral) & sensory (general & special) a. Motor: pharyngeal constrictors, laryngeal & palatal muscles i. Superior laryngeal n.: motor (crichothyroid) & sensory (vocal cords) 1. Important for cough reflex b. Motor + Sensory: Recurrent laryngeal nerve: between trachea & esophagus; motor to esophagus, larynx muscles; sensory to trachea i. Damaged during Thyroid Removal (proximity to a.) hoarse voice c. Parasympathetic: GI tract, heart, lungs {thorax} 11. CN XI Spinal Accessory: somatic motor i. Trunks enter foramen magnum and then out through jugular foramen a. Spinal Part i. Motor: SCM (extend head, flex column, rotate face to opposite side) & trapezius (rotate shoulder superiorly) f. Cranial Part joins Vagus n. i. Motor: larynx & pharynx muscles 1. Salpingopharyngeal m.: elevates pharynx b. Torticollis (Wry Neck): shortening of SCM head tilts towards affected side & turns towards unaffected side 12. CN XII - Hypoglossal: somatic motor only to tongue a. Innervates muscles: genioglossus, hyoglossus, styloglossus 1. Mandible fracture: damage to left CN XII affects genioglossus tongue deviates to left when protruded (pushes tongue to affected side due to action of m. on unaffected side) 2. Still have sensation in cheek (V3 Long Buccal n.) & lower teeth a. Seen between the olives & pyramids; exits through hypoglossal canal b. C1 fibers join hypoglossal and then become part of ansa cervicalis superior root


25- Orbit
1. Orbital surfaces a. Medial: Lacrimal bone {very thin} i. Medial Blow-out fracture: fracture through ethmoid b. showing orbital
emphysema & herniation of fat into ethmoid air cells, caused by sneezing

b. Floor: Maxillary & Zygomatic {& lateral wall} bones i. Inferior Blow-out fracture: fracture of orbit floor; orbit contents into
maxillary sinus; affects inferior rectus m. unable to elevate eye; double vision

2. FORAMINA: most structures enter orbit from middle cranial fossa a. Optic canal: in base of sphenoid lesser wing i. Contains optic n. & ophthalmic a. RIGHT ORBIT b. Superior orbital fissure: between sphenoid greater & lesser wings i. Contains CN III, IV, V1, VI, & ophthalmic v. Frontal c. Inferior orbital fissure: slit below sup. orb.
fissure; between sphenoid & maxillary i. Contains Infraforbital & Zygomatic n., a.

Anterior & Posterior Ethmoidal foramina

ii. Connects pterygopalatine fossa & infratemporal fossa with orbit d. Orbit serves as a passageway for nerves & vessels to face, scalp, nasal cavity i. Supraorbital notch: frontal b. 1. Contains Supraorbital n. ii. Infraorbital foramen: maxilla b.
1. Contains Infraorbital n. (V2) & a.





L a c r i m a l


Supraorbital notch/foramen Opening of Nasolacrimal Duct

Infraorbital foramen ZygomaticoFacial foramen

iii. Zygomatico-Facial foramen: 1. Contains zygomatico-facial n. from V2 Important for transmitting autonomic innervation to lacrimal gland iv. Anterior & Posterior Ethmoidal foramina: between ethmoid & frontal bones; connect orbit & nasal cavities 1. Contains Ant & Post Ethmoidal n., a., & v. (V1 & Opthalmic a.) v. Nasolacrimal duct opening: in maxillary, lacrimal bones & inf. nasal concha 3. EYELIDS: protect & keep eyes moist a. Glands of Zeis: unilobar sebaceous glands on margin of eyelid; produce oily substance through excretory ducts into middle of eyelash hair follicle i. Hordeolum (external stye): glans infected when eyelashes not kept clean b. Tarsal Plates: fibrous connective tissue eyelid skeleton, deep to orbital septum i. Meibomian glands: sebaceous gland at eyelid rims deep to tarsal plate 1. Meibum: oily substance that prevents evaporation of eyes tear film & tear spillage; also makes closed lids airtight 2. Dysfunctional meibomian glands dry eyes 3. Obstruction by thick secretions Chalazion (internal stye)

c. Conjunctive: membrane inside lid; fuses to sclera, reflected to cornea of eye i. Conjunctivitis: conjunctive inflammation viral, bacterial, allergic d. Blepharitis: inflammation of eyelids (bacterial staphylococcal) stypes e. Lacrimal gland: located above & lateral to eye i. Lacrimal caruncle: small pink nodule at inner corner (medial angle) of the eyes; made of skin covering sebaceous & sweat glands ii. Parasympathetic {pregang.} fibers from CN VII (Greater petrosal n.) join {postgang.} sympathetic fibers of deep petrosal n. to form Vidian n. 4. EYE: a. Fibrous layer: sclera, cornea; Vascular layer: iris, ciliary body, choroid b. Retina: light-sensitive cells where light is focused; Retinal a. (br. Opthalmic a.) c. Tenons capsule: fascial sheath surrounding back of eye; separates from periorbital fat i. Thickenings Medial & Lateral check ligaments: prevent excessive rotation ii. Periorbital fascia: lines orbit & reflects over extraocular m.s d. Graves Disease Exophthalmos: upper eyelid retraction, swelling, redness, conjunctivitis, proptosis (bulging eyes) {hyperthyroidism} i. AutoAbs target eye muscle fibroblasts - differentiate into fat cells 5. Extraoccular Extrinsic muscles: voluntary muscles which move eyeball a. Levator palpebrae superioris: elevates upper eyelid; attaches to tarsal plate (CNIII) b. Recti = straight, named for attachment sides; also attach to Tendinous Ring (of Zinn): ring of CT surrounding optic canal & superior orbital fissure 1. Passing through ring is CN II, III, V1 2. Passing above ring is CN IV ii. Rectus Superioris: elevates & medially rotates iii. Medial rectus: medial deviation iv. Lateral rectus: lateral deviation of eye (CN VI) (LR6SO4) 1. Strabismus: eyes not properly aligned; disorder of brain in coordinating eyes or 1 or more of muscles power or direction a. Medial deviation left eye = weak lateral rectus m. v. Inferior rectus: depresses & medially rotates c. Superior oblique: by itself, moves eye down & out (depresses & intorts) i. Acts through pulley (trochlea) (CN IV) ii. To clinically test Trochlear n. (CN IV), have pt look IN then DOWN d. Inferior oblique: pulls eye up & out; attaches to orbit floor e. Pure elevation = superior rectus + inferior oblique together f. Pure depression = inferior rectus + superior oblique together


6. Autonomic innervation of eye - Oculomotor nerve (CN III): a. Pupillary Light reflex: i. Dark - Dilation = sympathetic activation of dilator m. 1. Superior cervical ganglion: pregang symp fibers T1-2 2. Postgang fibers travel with ICA to enter orbit via ophthalmic a. & travel with Nasociliary n ii. Light - Constriction = PS CN III activation sphincter m. 1. Edinger-Westphal nucleus: preganglionic PS fibers 2. Ciliary ganglion: postganglionic PS fibers travel to constrictor pupillary & ciliary muscles via Short Ciliary nerves b. Accommodation: lens rounding for near vision by tightening ciliary m. = PS CN III c. Horners Syndrome: interruption of sympathetic inn. to head i. Miosis (constricted pupil) ii. Ptosis (drooping eyelid) due to weakness of smooth (Muellers) m. in levator palpabrae superioris iii. Anhydrosis (lack of sweating on face) iv. Vasodilation dilated blood vessels in face

Sympathetic fibers Parasympathetic fibers Zonular fiber relaxation (PS) lens rounding (accommodation)

7. Vessels: a. Ophthalmic artery: first branch off internal carotid; accompanies optic n. through optic canal i. Supraorbital & Supratrochlear a.: forehead ii. Central a. of the retina: pierces the 3 meninges layers & travels with the optic n. to supply inner cells of retina 1. No anastomosis blindness can occur quickly with emboli iii. Ciliary a.s: sclera & deeper retina in choroid iv. Lacrimal a.: v. Anterior & Posterior Ethmoidal a.s.:


8. VISION: a. Papilledema: swollen optic nerves, blurriness of optic disc; can be caused by i. Increased intracranial pressure (prevents back-flow from r. veins) ii. Venous drainage obstruction from compressive lesions (tumors, vascular disorders, optic nerve ischemia/infarction) b. Glaucoma: death of retinal cells; risk factor is increased intraocular pressure i. Intraocular pressure is a function of aqueous humor production by the ciliary body (c. processes in anterior chamber) and its drainage through the trabecular network (canal of Schlemm: venous plexus) c. Macular Degeneration: (age-related) results in loss of vision in macula because of damage to the retina i. DRY AMD: more common; vision loss gradual
1. Retinal pigment epithelium is disrupted by cellular debris (drusen)

ii. WET AMD: vision loss is rapid & severe 1. Choroidal blood vessels form underneath the retina & leak blood/fluid detach retina & blur central vision
Pituitary Tumor

Loose vision from right eye

Loose peripheral (temporal) field of vision

Loose left field of vision (Left nasal field & Right temporal)

26- Oral Cavity/Pharynx

1. ORAL CAVITY: a. Vestibule: anteriormost portion - space between cheek/lips and teeth b. Oral cavity proper: the space within the area bounded by the teeth c. Pillars of the fauces: anterior pillar: separate the oral cavity from the pharynx d. Floor of the mouth: oral cavity that is located beneath the tongue
i. On each side: slight fold (sublingual papilla) which ducts of submandibular open

e. Mylohyoid m.: elevates hyoid bone & floor of mouth to aid in swallowing i. Nerve to Mylohyoid (V3)

2. Structures of NASOPHARYNX: directly behind nasal cavities a. Torus tubarius: protrusion on nasopharynx lateral wall marking the pharyngeal end of the cartilaginous part of the eustachian tube b. Opening for auditory tube: on lateral wall of nasal part of pharynx c. Pharyngeal recess: location of Pharyngeal Tonsil; wide, slitlike lateral extension in nasopharynx wall, cranial & dorsal to pharyngeal orifice of AT i. Adenoids: inflamed pharyngeal tonsils can compress eustachian tube and block ear secretions lead to Otitis media: middle ear infections d. Salpingopharyngeal fold & m.: elevates pharynx, opens auditory tube during swallowing i. Cranial part of the accessory nerve 3. Muscles of the SOFT PALATE*: a. Levator palati: pulls soft palate up and back b. Tensor veli palatine*: elevates and tenses soft palate i. Prevents regurgitation of food & fluids from oral to nasal cavity ii. Paralysis (CN V3 damage) results in uvula deviation to opposite side (CN right side damage deviation to left side) c. Musculus uvulae: moves the uvula upwards and laterally d. *All muscles supplied by CNs X & XI (motor br.s of pharyngeal plexus), except tensor veli palatini, which is supplied by CN V 4. Structures of OROPHARYNX: between soft palate & epiglottis, behind oral cavity a. Posterior pillar (palatopharyngeus fold and muscle): b. Tonsillar bed (Palatine tonsils): located between palatoglossus & palatopharyngeus m.s., contains sensory branches of CN IX 5. Structures of LARYNGOPHARYNX: low pharynx between epiglottis & esophagus a. Piriform recess (fossa): tear shaped pocket in laryngopharynx mucosa through which food travels so as to avoid larynx and enter esophagus 6. Muscles of the PHARYNX*: connects nasal cavity, oral cavity & laryngeal area to trachea & esophagus a. Longitudinal muscles: elevate pharynx during swallowing i. Palatopharyngeus & Salpingopharyngeus: ii. Stylopharyngeus*: between superior & middle constrictors iii. Gag reflex: touching posterior 1/3 tongue pharyngeal m. activated causing pharynx to constrict & elevate 1. Sensory (afferent): CN IX 2. Motor (efferent): CN X (along with CN IX for stylopharyngeus) b. Circular muscles: horizontal constrictors insert on base of the skull i. Superior constrictor: from pterygomandibular raphe to pharyngeal tubercle ii. Middle constrictor: from hyoid bone iii. Inferior constrictor: from thyroid & cartilages; continues as esophagus c. *Muscles supplied by CN X, except stylopharyngeus supplied by CN IX


7. TONGUE: a. Surface landmarks: i. Foramen cecum: depression on tongue dorsum posterior end midline groove ii. Sulcus terminalis: v-shaped near back, splits it into oral & pharyngeal parts iii. Lingual tonsil: lymphatic tissue in tongue root in oropharynx floor b. Extrinsic muscles*: i. Genioglossus: pulls tongue forward, sticking tongue out 1. Mandible fracture: damage to left CN XII affects genioglossus tongue deviates to left when protruded (pushes tongue to affected side due to action of m. on unaffected side)
a. Still have sensation in cheek (V3 Long Buccal n.) & lower teeth

ii. Hyoglossus: draws tongue down (flattens) iii. Palatoglossus*: elevates tongue floor; shuts oral cavity from oropharynx iv. Styloglossus: draws tongue up and back to aid swallowing food c. Sensory innervation: i. Lingual nerve : general sensation from anterior 2/3 ii. Chorda tympani: taste from anterior 2/3 iii. Glossopharyngeal nerve: general sensation & taste from posterior 1/3 iv. Vagus: taste from vallecular
(where tongue reflects onto epiglottis)

d. *All extrinsic (& intrinsic) m. supplied by CN XII, except palatoglossus by CN X i. Paralysis of XII on one side causes tongue to deviate to ipsilateral side 8. Lymphatic drainage: a. Tip of tongue: to Submental nodes b. Lateral aspect of anterior 2/3 thirds: to Submandibular nodes of same side c. Posterolateral aspect: to Superior Deep Cervical nodes of same side d. Midline tongue: to Inferior Deep Cervical nodes of same side i. Deep cervical lymph nodes lie around the ICV e. Central portion of tongue: to Deep Cervical nodes of BOTH sides