Lecture Objectives on Head and Neck

TOPIC: Neck and Cervical Viscera

Overview
Begin with an overview of the general relationships of the neck structures, including the skeleton
of the neck. Be able to identify the hyoid bone, the thyroid and cricoid cartilages, and the
cervical vertebrae. Know the surface anatomy landmarks including the thyroid notch, jugular
notch, and supraclavicular fossa. Observe that the anterior neck houses 3 layers of cervical
viscera (see below). Note that the structures in this region are compartmentalized by cervical
fascia.

Fasciae of Neck

ƒ Superficial cervical fascia (subcutaneous) containing the platysma m. (CN VII)

ƒ Deep cervical fascia: investing, pretracheal, prevertebral

ƒ Carotid sheath: carotid a.; internal jugular v.; vagus n (CN X).
ƒ Buccopharyngeal fascia
ƒ Retropharyngeal space: A potential space between the prevertebral fascia and the
buccopharyngeal fascia - the largest and most important interfascial space in the neck since it
permits movement of the pharynx, esophagus, larynx and trachea relative to the vertebral column
during swallowing. Abscesses in this space can cause difficulty in swallowing and speaking.

Triangles of the Neck

Posterior (SCM, trapezius, clavicle)

ƒ Subdivided into occipital and supraclavicular triangles
ƒ Splenius and Levator Scapulae muscles found in floor of triangle
ƒ Spinal accessory nerve (CN XI) motor to SCM and trapezius
ƒ Scalene muscles
• Anterior scalene – separates subclavian artery from vein
phrenic nerve on anterior border; brachial plexus roots at posterior border
• Middle and posterior scalene
ƒ Cervical plexus (C1-C4): sensory nerves radiating out from behind SCM
ƒ Arterial branches from thyrocervical trunk (from subclavian artery)
ƒ External jugular vein

Anterior (SCM, mandible, midline of neck)

ƒ Subdivided into carotid, submandibular, submental, & muscular triangles
ƒ Suprahyoid muscles
• Mylohyoid, geniohyoid, stylohyoid, digastric
ƒ Infrahyoid muscles (ansa cervicalis) (
• Omohyoid, sternohyoid, sternothyroid, thyrohyoid
Note: Supra- and infrahyoid muscles used mainly during swallowing and speaking.
ƒ Ansa cervicalis and hypoglossal nerve (CN XII)
ƒ Common carotid artery → external and internal carotid
ƒ Most veins in anterior triangle are tributaries of the internal jugular (IJV).

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Vasculature
Arteries
o Common, External, and Internal Carotid artery
The common carotid artery is found in the carotid triangle (SCM, digastric, omohyoid), a
subdivision of the anterior triangle. The artery divides into internal and external carotid
arteries at the superior border of the thyroid cartilage. The external carotid is the only carotid
artery that gives off branches in the neck.
Know the following:
• Carotid sinus (int. carotid) – baroreceptor – CN IX
• Carotid body – chemoreceptor (oxygen and CO2) – CN IX and X
• Know the 6 major branches of the external carotid: superior thyroid, lingual, facial,
occipital, maxillary, superficial temporal

o Subclavian artery. Gives off vertebral, thyrocervical trunk, and internal thoracic arteries.
• Veins
o External and Internal jugular (EJV and IJV)
o Subclavian
ƒ The subclavian and internal jugular veins are commonly used clinically as entry
points into the venous system. Introducing a needle into this area can puncture the
parietal pleura, which rises superior to the medial clavicle, causing a pneumothorax.
ƒ High venous pressure, which occurs during heart failure, distends the EJV and causes
it to become prominent and noticeable throughout its course in the neck.

• Lymphatics
o Superficial structures are drained by lymphatic vessels that enter superficial cervical lymph
nodes (along EJV). Lymph from these nodes and from all the head and neck drains into the
inferior deep cervical nodes, the main group of which lies alongside the IJV.
o The thoracic duct arches into the left side of the root of the neck to drain into the junction of
the IJV and subclavian vein. A right lymphatic trunk may occur on the right side.

Three layers of cervical viscera

• Endocrine (thyroid/parathyroid glands)

• Respiratory (larynx and trachea)
• Alimentary (pharynx and esophagus)

Thyroid and parathyroid glands

• Highly vascular glands. The thyroid gland has 2 lobes connected by an isthmus that is usually
found anterior to 2nd and 3rd tracheal rings. About 50% of thyroid glands have a pyramidal lobe.
Around 10% of people have a midline thyroidea ima artery.
• During embryonic development, the future thyroid gland begins in the floor of the pharynx at a
site indicated by the foramen cecum in the tongue. The gland descends, in the form of a narrow
thyroglossal duct, through the tongue and into the neck, passing anterior to the hyoid bone and
thyroid cartilages. Although the duct normally disappears, remnants of it may remain and form
cysts at any point along its original path.
• Thyroid surgery can put the recurrent laryngeal nerves at risk.

(The anatomy of the larynx and pharynx will be covered in subsequent lectures.)

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Deep Structures in Neck

ƒ Important deep structures of the neck include: brachial plexus; subclavian arteries; EJV, IJV and
thoracic duct; vagus (CN X), recurrent laryngeal and phrenic nerves; the prevertebral muscles
and cervical vertebrae; the sympathetic trunk. Damage to the cervical sympathetic trunk results
in Horner’s syndrome (constricted pupil; drooping upper eyelid; loss of sweat gland function).

ƒ By definition, the root of the neck is the junctional area between the thorax and neck. It is
bounded by the 1st pair of ribs, the manubrium, and the body of T1. All the structures that pass
from the thorax into the head and vice versa travel through the superior thoracic aperture.
Thoracic outlet syndrome refers to the compression of the brachial plexus and/or subclavian
artery by attached muscles in the region of the first rib and clavicle; it can be caused by a
cervical rib.

TOPIC: Face & Skull.

Overview of Head and Cranial Nerves

Know the 12 cranial nerves – both name and number.

Bones and landmarks of the Skull

*****The following structures are best studied and understood in the laboratory*****

• Chief bones of the skull: frontal; occipital; parietal; temporal; sphenoid; ethmoid; maxillary;
zygomatic; nasal; lacrimal; palatine; vomer; inferior conchae; mandible
• coronal, sagittal, and lambdoidal sutures
• the pterion
• the calvaria
• entrance to the external acoustic meatus (ear canal)
• mastoid and styloid processes
• supraorbital, infraorbital, mental, and stylomastoid foramina
• ramus and body of mandible; mandibular notch and foramen
• the temporomandibular joint (TMJ)
• the medial and lateral pterygoid plates
• the openings for the carotid canal (base of skull)
• the foramen magnum
• occipital condyles
• oral cavity – bony palate: incisive and palatine foramina (these structures will be presented in a
subsequent lecture)
• nasal cavity – superior, middle and inferior conchae (turbinates), vomer, ethmoid bones (these
structures will be presented in a subsequent lecture)
• infratemporal fossa
• pterygopalatine fossa

- Know the definition of a fontanelle, and the site of the anterior fontanelle in the newborn
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- Understand how the infratemporal fossa, the pterygopalatine fossa, and the nasal cavity connect
within the skull. For optional details, read about the pterygopalatine fossa on pp. 570-574 in your text.

Face
Muscles
Know the differences between the muscles of facial expression and the muscles of
mastication.

Facial expression Mastication

Occipitofrontalis Temporalis
Orbicularis oculi (orbital and palpebral parts) Masseter
Orbicualris oris Medial pterygoid
Buccinator Lateral pterygoid
Platysma
Zygomatic major
Depressor anguli oris

Scalp (p.502-503)
• 5 layers (Fig. 7.4); top 3 are the scalp proper; vessels and nerves in layer 2
• layer 4 is the “dangerous area” because it provides pathway for spread of infection,
etc
• motor innervation from CN VII (nerve to muscles of facial expression)
• sensory innervation from trigeminal (anterior) and occipital (posterior) nerves
• arteries from external and internal carotid branches – multiple anastomoses
• scalp lacerations bleed profusely – most common head injury requiring surgical
care

Nerves
Muscles of facial expression: facial nerve (CN VII) (Table 7.3 in text)
Muscles of mastication: trigeminal nerve (CN V3) (Table 7.8, 7.9 in text)
Sensory innervation of the face: trigeminal nerve (V1, V2, V3) (Table 7.4 in text)

Bell’s palsy (p. 524) is facial nerve palsy that occurs without a known cause. Realize that the
absence of the mastoid process in a neonate exposes the facial nerve to potential injury,
especially during forceps delivery. Understand the significance of trigeminal neuralgia (tic
douloureux) (p. 524).

Trigeminal Nerve (CN V). The 3 divisions of this nerve can be found in the orbit (V1), the
pterygopalatine fossa (V2) and the infratemporal fossa (V3). Read about trigeminal neuralgia
(p. 524 and 660)

Muscles of Mastication and the Temporomandibular Joint (TMJ) (p. 555-557)

Movement of the TMJ occurs primarily via the 4 muscles of mastication. Appreciate the
movement in this joint as the mouth is opened and closed and the importance of the articular
tubercle. Understand how this joint can become dislocated. Note that the lateral pterygoid m.
attaches to this joint.

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Face and Scalp Vasculature
Know the six major branches of the external carotid artery (Fig. 7.44)

Understand that the principal venous drainage of the face eventually routes blood to the large
internal jugular vein and smaller external jugular vein. Know the general course of the facial
vein, superficial temporal vein, and retromandibular vein (Fig. 7.18, 7.19 & 7.44 ) and the
location of the pterygoid plexus of veins in the infratemporal fossa.

Lymphatic vessels in the face travel with the veins. General drainage is toward the deep cervical
lymph nodes (Fig. 7.20).

Parotid gland and duct (Stensen’s duct)

Parotid ducts open into the vestibule of the mouth opposite upper 2nd molars. Realize that
facial nerve branches, the retromandibular vein and the external carotid artery travel
through this gland.

TOPIC: Imagery of Head and Neck

Objectives:
1. Become familiar with the general features of the neck and facial regions when viewed by current
imaging modalities

2. Be familiar with the major structures of the neck in cross section.

3. Be familiar with the appearance carotid arteries of the neck and branches of the external carotid
artery in the neck and face when viewed via arteriography.

TOPIC: Brain, Meninges, Cranial Nerves, and Cranial Fossae

Overview 
The brain is that part of the CNS that lies within the cranial cavity. Within this cavity, the brain
is covered by the same 3 meningeal layers found around the spinal cord (dura, arachnoid, pia). Review
the bones (e.g., frontal, parietal, temporal, occipital and sphenoid) and sutures that make up the walls
and floor of the cavity. Note that the bones of the cranial vault contain inner and outer compact layers
separated by diploё, through which course the diploic veins (no arteries).
Removal of the calvaria reveals the outer dura mater and the prominent middle meningeal artery
(MMA) and vein. The MMA actually provides the bulk of its blood to the bone (not the meninges), and
the artery and vein can become deeply imbedded in the bone with advancing age. The large anterior
branch of the MMA courses across the pterion. Consequently, fractures in this region can easily tear
this artery, producing an extradural (or epidural) hematoma.
Removal of the calvaria in a dry, bony specimen reveals that the floor of the cranial cavity is
separated into 3 cranial fossae: anterior, middle, and posterior. The principal bones, which form these
fossae, are the frontal, ethmoid, sphenoid, temporal and occipital. Note that the pituitary gland resides
in a fossa within the sphenoid bone (hypophysial fossa) – the surrounding bony mass is referred to as
the sella turcica (Turkish saddle). It is an important landmark and point of orientation. The cranial
fossae are covered by tightly adherent dura mater, and the cranial nerves and cranial blood vessels
course through this dura and through several different foramina in the fossae.

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Gross anatomy of the brain  
• Gyri, sulci, and fissures
• Cerebral hemispheres
ƒ frontal, parietal, temporal, occipital lobes
• Cerebellum
• Brainstem (midbrain, pons, medulla oblongata)
• Hypothalamus and pituitary
• Pineal gland
• Cranial Nerves (located on the ventral surface of the brain and brainstem)

Meninges
• Dura Mater (Dura mater = pachymenix)
ƒ Falx Cerebri and other cerebral folds
ƒ Middle meningeal arteries (from maxillary artery through foramen spinosum)
• Laceration produces epidural hematoma
ƒ Dural venous sinuses
• Superior sagittal
• Confluence
• Transverse
• Sigmoid
• Cavernous (on either side of the sella turcica)
• Arachnoid mater (Arachnoid + pia mater = leptomeninges)
ƒ Covers gyri and sulci
ƒ Cerebral veins - Laceration produces subdural hematoma
ƒ Subarachnoid space contains cerebrospinal fluid (CSF)
• Pia mater
ƒ Helps form choroid plexus which produces CSF
The ventricular system and CSF circulation
ƒ Lateral ventricles / Third ventricle / Cerebral aqueduct / Fourth ventricle
ƒ Choroid plexus produces the CSF
ƒ CSF drains into the venous sinuses through arachnoid granulations (Pacchionian bodies)
ƒ Hydrocephalus

Blood supply to brain

• Derived from two major arterial sources
ƒ internal carotid (through carotid canal across foramen lacerum)
ƒ vertebral arteries (through foramen magnum) – form single basilar artery
• 3 cerebral arteries
ƒ anterior
ƒ middle
ƒ posterior
• anterior arteries connect via the anterior communicating artery
• the internal carotid is connected to the posterior cerebral artery by the
posterior communicating artery
• anterior artery stays in the midline of the cerebrum; middle artery courses
laterally; posterior artery travels posteriorly
• Circle of Willis (CN II is inside circle)
• 3 major cerebellar arteries
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Clinical Points 
¾ Emissary veins are important valveless connections between scalp and intracranial venous
sinuses. They provide a potential route for infections of the scalp to travel to the intracranial
dural venous sinuses – especially the superior sagittal sinus.
¾ Rupture of a cerebral artery aneurysm often results in a subarachnoid hemorrhage (blood in the
CNS). Severe headaches and a stiff neck follow the resultant meningeal irritation.
¾ The internal carotid arteries and the vertebral arteries carry sympathetic nerve fibers from the
cervical sympathetic trunk into the cranial cavity.

Cranial Nerves and their foramina

I. Olfactory (cribriform plate)

II. Optic (optic canal)
III. Oculomotor (superior orbital fissure)
IV. Trochlear (superior orbital fissure)
V. Trigeminal (V1-superior orbital fissure; V2-f. rotundum; V3-f. ovale)
VI. Abducent (superior orbital fissure)
VII. Facial (internal acoustic meatus → stylomastoid foramen)
VIII. Auditory or vestibulocochlear (internal acoustic meatus)
IX. Glossopharyngeal (jugular foramen)
X. Vagus (jugular foramen)
XI. Accessory (jugular foramen)
XII. Hypoglossal (hypoglossal canal)

These foramina and the bony landmarks of the cranial fossa listed below are best studied in the lab.

Cranial cavity   
• Bony landmarks
ƒ Crista galli
ƒ Greater and lesser wings of sphenoid
ƒ Sella turcica and hypophyseal fossa (for pituitary)
ƒ Petrous temporal bone and petrous ridge
• Foramina
Anterior Cranial Fossa
• Cribriform plate
Middle Cranial Fossa
• Optic canals
• Superior orbital fissures
• Foramen rotundum
• Foramen ovale
• Foramen spinosum (for middle meningeal artery)
• Foramen lacerum (associated with internal carotid a. & sympathetic
plexus)
Posterior Cranial Fossa
Foramen magnum Internal acoustic meatus
Jugular foramen Hypoglossal canal

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Clinically important anatomical relationships you should remember:

ƒ The optic chiasm lies directly over the pituitary gland. Tumors of the pituitary that expand
superiorly typically cause distinct visual disturbances.

ƒ The cavernous sinus completely encloses a segment of the internal carotid artery.

TOPIC: Eyeball & Orbit

Following this lecture, you will be expected to:

1. Identify the gross anatomy and features of the bony orbit:

a. Frontal, Ethmoid, Lacrimal, Sphenoid, & Zygomatic bones

b. Maxilla
c. Supraorbital & Infraorbital foramina (what structures travel through here?)
d. Superior orbital & Inferior orbital fissures (what structures travel through here?)
e. Optic canal (what structures travel through here?)

2. Describe the components and parts of the eyeball.

a. Outer fibrous layer (sclera/cornea)
b. Middle vascular layer (uvea: choroid, ciliary body, iris)
c. Inner layer (retina)

3. Know the arterial supply of the orbit.

4. Know the extra-ocular muscles of the orbit, including function and nerve distribution.

5. Explain the rationale behind the clinical testing of the extra-ocular muscles.

6. Identify the lacrimal gland and related components of the lacrimal apparatus.

7. Identify the gross anatomy of the eyelids.

8. Learn the sympathetic and parasympathetic components of the orbit and eyeball.

9. Explain the pupillary and corneal reflexes

.
10. Clinical points:
a. Relate clinical symptoms to specific lesions of the cranial and/or autonomic nerves supplying
the orbital muscles and eyeball.
b. Describe what happens with a blowout fracture.
c. Explain the anatomic basis of the ocular manifestations of Horner’s syndrome
d. Know the definition and anatomical basis for certain pathological conditions related to the
orbit, such as: (1) papilledema, (2) macular degeneration, (3) detachment of the retina, (4)
glaucoma.

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HANDOUT: Eyeball & Orbit

Use the following points as a study guide.

Overview of the orbit

Pyramidal bony cavity into which the optic canal, superior and inferior orbital fissures open
Thin medial and inferior walls may be fractured by indirect trauma (“blowout” fracture)
Eyelids and Lacrimal Apparatus
Inner covering is palpebral conjunctiva (continuous at fornix with bulbar conjunctiva over
eyeball)
“Skeleton” of eyelids formed by tarsal plates of connective tissue – these contain tarsal glands
Eyelids meet at angle of the eye (canthus) – also referred to as palpebral commissures
Facial nerve damage can paralyze orbicularis oculi – prevents eye from closing fully
Lacrimal gland is in superior lateral orbit. Lacrimal papillae, punctum, canaliculi, sac and
nasolacrimal duct are medial.
Nasolacrimal duct drains into inferior meatus
Lacrimal gland receives autonomic innervation via parasympathetics from facial nerve
Three layers of the eyeball
Outer fibrous layer – sclera and cornea
Middle vascular layer (uvea) – choroid, ciliary body, ciliary processes, iris (and pupil)
Inner layer – retina
Optic disc or papilla (blind spot); swelling = papilledema
Macula lutea and foveola centralis (area of maximally acute vision)
Central artery and vein of retina travel through optic nerve
Refractive media of the eyeball
cornea – avascular, sensory innervation from CN V1
aqueous humor - secreted by ciliary processes, drains through canal of Schlemm
- problems with drainage can lead to glaucoma
lens – anchored by suspensory ligaments to ciliary body; action of ciliary muscle changes shape
- for near vision, parasympathetics contract ciliary m. causing lens to round up
(accommodation)
- cataracts are opacities in the lens
vitreous humor in vitreous body – helps hold retina in place and supports lens
Orbital muscles
Levator palpebrae superioris – CN III
Superior rectus – CN III Lateral rectus – CN VI (abducent)
Inferior rectus – CN III Superior oblique – CN IV (trochlear)
Medial rectus – CN III
Inferior oblique – CN III
Innervation of orbital structures
• sensory: branches of CN V1; sympathetic: from int. carotid artery plexus; parasympathetic:
from CN III via ciliary ganglion
• Ciliary m. and sphincter pupillae m. are parasympathetic; dilator pupillae m. is sympathetic
• Blink reflex involves CN V1 (sensory); CN VII (motor to orbicularis oculi); CN III (motor to
levator palp.)
• Direct light reflex involves CN II (sensory) and parasympathetics (to constrictor pupillae muscle)
Vasculature - arterial branches from ophthalmic artery which arises from internal carotid a.
- ophthalmic veins drain into cavernous sinus but have connections with facial veins

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Note ‐ CNIII damage, Horner syndrome, and extraocular muscle paralysis.  Remember these key points: 
• Sympathetics, carried in with internal carotid artery, are responsible for pupillary dilation.
• Parasympathetics carried in CN III are responsible for pupillary constriction and
accommodation.
• Ptosis of the eyelid can be caused by sympathetic damage (Horner’s syndrome) or by damage to
CN III which innervates the levator palpebrae

TOPIC: Retropharyngeal Space and Pharynx

Following this lecture, you will be expected to:

1. Explain the relevance of the retropharyngeal space.

2. Know the boundaries, divisions and landmarks of the pharynx

a. 3 parts of the pharynx: (1) nasopharynx, (2) oropharynx, (3) laryngopharynx
b. Pharyngotympanic tube, pharyngeal recess, choanae
c. Arches of the soft palate, oropharyngeal isthmus
d. Laryngeal inlet, piriformis

3. Know the pharyngeal muscles, including function

a. External layer
i. Superior constrictor
ii. Middle constrictor
iii. Inferior constrictor
b. Internal layer
i. Palatopharyngeus
ii. Stylopharyngeus
iii. Salpingopharyngeus

4. Know the nerve distribution of the pharynx.

5. Know what forms the pharyngeal plexus of nerves.

6. Know the arterial supply of the pharynx.

7. Identify the tonsillar ring of the pharynx

a. Pharyngeal tonsil
b. Palatine tonsil
c. Lingual tonsil

8. Identify the lacrimal gland and related components of the lacrimal apparatus.

9. Know the relationship of the pharynx to the esophagus.

Pharyngoesophageal junction

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 10. Clinical points:
a. Describe the spread of infection in the neck.
b. Know the definition and anatomical basis of adenoiditis.
c. What is a tonsillectomy?

TOPIC: Nasal Cavity

Following this lecture, you will be expected to:

1. Identify the gross anatomy and features of the external nose

a. Nasal cartilages
b. Dorsum of the nose (root & apex)
c. Nares (or nostrils, anterior nasal apertures)
d. Ala of the nose
e. Nasal septum

2. Know the bony parts of the nose

a. Nasal bones
b. Frontal processes of maxillae
c. Nasal part of frontal bone & its nasal spine
d. Bony part of nasal septum

3. Know the parts of the nasal septum: nasal conchae

a. Superior nasal conchae
b. Middle nasal conchae
c. Inferior nasal conchae

4. Describe how the nasal cavity communicates with its surroundings

a. Choanae
b. Sphenoethmoidal recess
c. Frontonasal duct & ethmoidal infundibulum
d. Ethmoidal bulla
e. Maxillary ostium
f. Nasolacrimal duct

5. Know the nerve distribution of the nasal cavity, nasal septum and nasal mucosa.

6. Know the artery supply of the nasal cavity, nasal septum and nasal mucosa.

7. Identify the paranasal sinuses (ethmoid, frontal, maxillary, and sphenoidal)

8. Clinical points:
a. Describe the clinical symptoms of a nasal fracture.
b. Define epistaxis.
c. Explain what rhinitis and sinusitis are. What structures are involved?

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HANDOUT: Craniovertebral Joints, Pharynx and Nasal Cavity

• This material will cover three topic areas relating to the head and neck, the craniovertebral joints,
the pharyngeal region, and the nasal cavity. The latter two are continuous and constitute the
upper portion of the airways. The craniovertebral joints are important in understanding the
movements of the head.

• Craniovertebral joints. This complex is composed of the atlas (C1) and axis (C2) and the
articulating surfaces of the occipital bone, occipital condyles, and thus is made of the atlanto-
axial and the atlanto-occipital joints. The atlas and axis are modified forms of cervical vertebrae.
The superior facets of the atlas are modified for articulation with the occipital condyles to
produce flexion and extension of the head. The atlas has no body or spinous process functions in
rotation around the dens (odontoid process) of the axis to produce right and left directed
movement of the head. The dens is the vertebral body of the atlas, which has fused with the axis.
The atlas then articulates in a normal manner with the C3 vertebra. The primary ligaments hold
the bones together and limit motion at the joints. The alar ligaments found between the dens and
occipital condyles limit rotation. The apical ligament connects the superior aspect of the dens
with the anterior border of the foramen magnum and thus binds the occipital bone and dens. The
cruciate ligament connects the lateral aspects of the atlas and binds the dens to the anterior arch
of the atlas. The cruciate ligament has a much weaker vertical component connecting the dens
with the foramen magnum.

• Pharyngeal Region. The pharynx is a funnel shaped region divided into three regions,
nasopharynx, oropharynx, and laryngopharynx. Each is located behind the respective region.
The posterior wall is formed by pharyngeal constrictors: superior, middle, and inferior. They
originate on the 1) pterygoid plate, and mandible, 2) hyoid bone, and 3) thyroid cartilage and
insert at the midline at a median raphe. The entire complex is innervated by the pharyngeal
plexus made up of fibers from the vagus and spinal accessory nerves. The small stylopharyngeus
muscle is also found on the lateral wall adjacent to the superior constrictor (innervated by
glossopharyngeal).

• The lateral wall of the nasopharynx contains the opening of the auditory tube with the opening
guarded by the cartilage of the torus tubarius, which maintains its patency. The
salpingopharyngeal fold extends inferiorly from this structure. Posterior to the opening is the
pharyngeal tonsils whose inflammation (adenoid) can cause recurrent infections . The
oropharynx is bounded anteriorly by the opening of the oral cavity and the palate. Along its
lateral wall are two folds, the palatoglossal and palatopharyngeal folds. Each fold has a small
muscle that makes up the core of the fold. Between these folds lie the "tonsilar bed" that
contains the palatine tonsils. The posterior tongue also contains tonsilar tissue termed lingual
tonsils. Posterior and lateral to the tongue is a space termed the vallecula that separates the
tongue and epiglottis. The laryngeal part of the pharynx lies behind the opening of the larynx
and the larynx itself. The piriform recess lies along the lateral wall between the thyroid cartilage
and the upper portion of the laryngeal cartilages.

• Prevetebral Region. The region anterior to the cervical vertebral column contains the
prevertebral muscles. They include the longus coli and longus capitus muscles that project
superiorly to attach to the atlas and occipital bone, respectively. The inferiorly located
prevertebral muscles are the scalenes that run downward to attach to the upper 1-2 ribs. The
prevertebral region is lined anteriorly by the prevertebral layer of the deep cervical fascia. The
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 ventral primary rami of the cervical nerves pierce the prevertebral fascia laterally forming the
cervical plexus of nerves superiorly and brachial plexus inferiorly. The transverse processes of
the first cervical vertebrae (atlas) are most prominent laterally and serve as effective levers for
muscle attachments. The vertebral artery enters the transverse foramen of the 2nd cervical
vertebra in the co-called "vertebral triangle" formed by the longus coli and anterior scalene. As a
review the brachial plexus and subclavian artery emerge from the interscalene triangle between
the anterior and middle scalene muscles.

• The retropharynx is the space/plane behind the pharynx and in front of the prevertebral region.
The clinical significance is that it is a fascia-lined pathway or pouch to the superoior
mediastinum for the potential spread of infectious agents from the deep structures of the neck to
the thorax. For simplification, the anterior fascial plane of this space is the fascia of the posterior
pharyngeal wall termed the buccopharyngeal fascia. The posterior fascial sheet is the
prevertebral fascia that lines the anterior cervical vertebral region.

• Nasal Cavity. The nasal cavity extends from the vestibule located behind the nares to the
choanae, which open into the nasopharynx. It is divided by a nasal septum in the middle and has
superior, middle and inferior conchae (or turbinates) that extend from the lateral wall. Beneath
each of these is their respective meatus. The palatine processes of the maxillary bone form the
floor. In the middle meatus is a rounded prominence, the ethmoid bulla, caused by the bulging
ethmoid air cells. Below it lays the hiatus semilunaris. The opening of the maxillary sinus is in
the anterior hiatus. The frontal sinuses open into the infundibulum area anterior to the middle
meatus. The opening of the nasolacrimal duct is found in the anterior aspect of the inferior
meatus. The olfactory mucosa lines the surface of the superior conchae. Sensory cells in the
mucosa send fibers through the cribriform plate to synapse with cells in the olfactory bulb. The
rest of the surface is lined with respiratory mucosa that contains numerous blood vessels and
mucous glands to warm and moisten the air as it passes through. The sensory nerves are derived
from the ophthalmic and maxillary divisions of the trigeminal nerve. Stimulation for secretion of
the mucous glands is from parasympathetic nerves from the pterygopalatine ganglion coming
originally from the greater petrosal branch of the facial nerve. The blood supply is from
branches of the maxillary artery, primarily the sphenopalatine branch. There is a rich plexus of
veins in the mucosa that drain the area.

• Paranasal sinuses are important structures that function to reduce the weight of the head and give
resonance to the voice. They are named for the bones in which they are found. They are lined
with mucous membranes and contain a rich blood supply. One major sinus is the paired
sphenoid sinus that is superior to the nasal cavity and drains above the superior conchae. The
frontal sinuses lie above the orbit and drain into the infundibulum of the middle meatus. The
ethmoidal sinuses (anterior, middle, and posterior) form a honeycomb network along the lateral
wall of the nasal cavity adjacent to the orbits. They drain by numerous small ducts into the
infundibulum, middle meatus, and superior meatus. The maxillary sinuses are large chambers in
the maxillary bone that extend from the floor of the orbit to the alveolar bone of the upper jaw.
Roots of the teeth can protrude into this space. It opens into the middle meatus that is near the
upper portion of the sinus thus ciliary action is necessary to remove material from this cavity. It
is easy to see why this sinus accumulates fluid and mucous and becomes full and painful during
allergic reactions or sinusitis.

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TOPIC: Oral Region

Oral Cavity and vestibule

Parotid duct openings in vestibule

Teeth and gingivae (gums)

Deciduous and permanent teeth
Palate
Hard palate
Incisive foramen; Greater & Lesser Palatine Foramina
Soft Palate and Uvula
Muscles and Nerves
Palatoglossus – pharyngeal plexus CN X – exception to CN XII
Palatopharyngeus – pharyngeal plexus (CN X)
- palatine tonsil sits between these two muscles

Levator palati – pharyngeal plexus (CN X)

Tensor palati – CN V
Musculus Uvulae – pharyngeal plexus
Vasculature: Vessels accompany nerves
Tongue
Surface features
Papillae / taste buds / foramen cecum / sulcus terminalis (terminal groove)

Muscles
Extrinsic – paired: move entire tongue
Genioglossus protrudes tongue
Hyoglossus retracts and depresses tongue
Styloglossus retracts and elevates tongue
Intrinsic – change shape of tongue
All tongue muscles are innervated by CN XII except palatoglossus (X)

Nerves
Motor – all muscles CN XII except palatoglossus m.(CN X)
Sensory
General sensory (touch, temperature, vibration)
V – anterior 1/3
IX – posterior 1/3
X – small area near epiglottis
Nerves (continued)
Special sensory (taste)
VII (chorda tympani) – anterior 2/3 of tongue
IX - posterior 1/3
X – small area near epiglottis
Vasculature
Lingual artery
Dorsal and deep lingual veins – all drain into IJV

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 Lymph
Regional drainage into several different nodes

Salivary Glands
Parotid – parasympathetics from IX via otic ganglion
- ducts open into oral vestibule opposite upper 2nd molar tooth
Submandibular – parasympath. from VII via chorda tympani and submandibular ganglion
- ducts open on either side of frenulum of tongue
Sublingual – parasympath. from VII via chorda tympani and submandibular ganglion
- ducts open directly into oral cavity beneath tongue

Swallowing (Deglutition)
First stage: voluntary – food bolus moves from oral cavity to oropharynx
Second stage: involuntary – nasopharynx sealed, larynx elevated, pharynx opened
Third stage: involuntary – pharyngeal muscles contract sequentially, bolus enters esophagus.

TOPIC: Larynx

1. Oropharynx and laryngopharynx

2. Deglutition – swallowing
3. Larynx – regional description
4. Cartilage skeleton
5. Muscles and actions
6. Innervation

This lecture will cover the structure and function of the larynx and how it relates to other features of the
cervical region.
The laryngeal apparatus provides both voice production and a protective sphincter at the inlet of the air
passage. It is composed of several hyaline cartilage components connected by muscles and ligaments.

Spaces and Folds:

Vestibule - space extending from behind the epiglottis which narrows as approaches the false vocal
folds. This is also termed the inlet to the larynx.

False Vocal Folds - two folds of mucous membrane which border the first narrowed area of the airway.

Ventricle - space between the true and false vocal folds.

True Vocal Fold - two thin folds of mucous membrane that are also called the vocal cords and resonate
with the passage of air to create the sounds necessary for speaking.

Rima glottidis - space of varying width between the true vocal folds.

Cartilages:
Thyroid cartilage - large shield shaped structure that makes of the laryngeal prominence

Cricoid cartilage - signet ring shaped structure below the thyroid cartilage.
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Arytenoid cartilage - small pyramidal shaped structures – attachments for the vocal ligaments.

Epiglottis - large cartilage 'flap' attached behind the thyroid cartilage that serves to divert swallowed
materials.

Membranes & Ligaments: Thyrohyoid membrane - extends from hyoid bone to thyroid cartilage.
Cricothyroid membrane - connects thyroid and cricoid cartilages
Quadrangular membrane - extends from epiglottis to arytenoid cartilages and forms wall of vestibule.

Muscles: Extrinsic - cervical muscles that control position of the laryngeal apparatus, e.g., thyrohyoid,
sternothryoid.
Intrinsic - muscles that move components of the larynx.
1. cricothyroid**, 2. thyroarytenoid*, 3. posterior cricoarytenoid*, 4. lateral cricoarytenoid*
5. arytenoid*

Innervation: The larynx is innervated by branches of the vagus nerve (CN X). The recurrent branch of
vagus travels superiorly in the groove between the esophagus and trachea. As it approaches the larynx it
is referred to as the inferior laryngeal nerve (same nerve just new name). It passes into the deep
posterior part of the larynx and divides to innervate most of the intrinsic muscles of the larynx* and is
sensory to the mucous surface up to the vocal cords. The superior laryngeal nerve passes through the
thyrohyoid membrane and becomes the internal laryngeal nerve and supplies sensory innervation to the
mucosal surface down to the level of the vocal cords. Thus, the sensory innervation is separated at the
vocal cords. **The cricothyroid muscle is innervated by a small branch of the superior laryngeal
called external laryngeal nerve.

Vasculature: It is supplied by branches of the superior and inferior thyroid arteries

Functions: The rima glottitis is the narrowest part of the airway and can be opened or closed depending
on need. It is narrowed and air is expelled in a controlled manner to create sound with vibration of the
vocal cords. It can be closed as a sphincter to increase thoracic and abdominal pressure and then
released quickly as in coughing. Since it is the narrowest stricture is it where foreign objects are most
often lodged and can be forcibly expelled by coughing. It can be opened wide during deep breathing.
The vocal cords are controlled by the contraction of the laryngeal muscle pulling on the cartilages. The
posterior cricoarytenoid is the only muscle to abduct the vocal cords. Both the lateral cricoarytenoid and
arytenoid muscles adduct the vocal cords. The thyroarytenoid with its vocalis component relaxes the
vocal ligaments and changes the pitch of the sound produced. The cricothryoid muscle changes the tilt
between cricoid and thyroid cartilages and acts to tense the vocal cords.

TOPIC: Ear

External ear
Auricle, concha, ear lobe, tragus, intertragic notch
External acoustic meatus (ear canal)
ƒ About 1 inch long in adults; lateral third is cartilaginous, medial two-thirds bony
ƒ S-shaped canal that must be straightened to visualize tympanic membrane
ƒ Cerumen is wax produced by glands within the canal
ƒ Sensory branches from CN V and X
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 Tympanic membrane (eardrum)
ƒ Superior half is more vascular and is crossed by chorda tympani
Note: pain (or increased pain) upon moving the auricle usually signals otitis externa. However,
in young children, the external meatus is entirely cartilaginous, and movements of the cartilage of the
auricle can be transmitted to the eardrum, which can be painful if otitis media is present.

Middle ear (tympanic cavity)

Ossicles: malleus, incus, stapes
malleus - attached to tympanic membrane
incus – bridges the cavity and transmits movement
footplate of stapes - attached to oval window on medial wall
tensor tympani muscle (CN V) – attached to malleus
stapedius muscle (CN VII) – attached to stapes - central damage to CN VII can cause
hyperacusis
chorda tympani nerve (branch of CN VII) crosses superior eardrum – supplies taste fibers to
anterior 2/3 of tongue
Tympanic plexus of nerves (from CN IX) - sensory to wall of cavity
Pharyngotympanic tube (auditory or Eustachian tube) – closed except during
yawning/swallowing
Mastoid air cells – communicate with cavity via antrum on posterior wall
Nearby structures
ƒ Internal carotid artery passes close to front wall of tympanic cavity
ƒ Internal jugular vein passes close to floor of cavity
ƒ Bony canal for facial nerve (CN VII) passes just posterior to cavity
ƒ Cochlea of inner ear forms “promontory” on medial wall of cavity

Inner ear (Labyrinth)

Vestibulocochlear organ located within the temporal bone. Footplate of stapes is placed in the
oval window and movement is then conducted to sensory nerves of cochlea
• Cochlea – organ of hearing: receives cochlear portion of CN VIII
• Vestibule and semicircular canals – maintenance of balance: receive vestibular
portion of CN VIII

Clinical notes
o Hearing loss can be conductive (problems with external or middle ear) or sensorineural
(problems with the cochlea, with CN VIII, or within the brain).
o Tinnitus (buzzing or ringing noises in the ear) can be caused by nerve damage within the
cochlea, or by middle ear problems.
o Vertigo (dizziness) can be caused by damage to CN VIII or problems with the
semicircular ducts.

TOPIC: Imaging of the Head and Brain (Tegrity Only)

1. Become familiar with the general features of the different modalities used to image the brain and
cranium
2. Know the different windows commonly used in CT of the skull (brain and bone windows)
3. Understand the utility of the 2 modalities used in MRI (T1 and T2)
4. Know the difference between standard imaging and functional imaging of the brain; be able to
list major functional imaging methods or modalities.
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