SKULL

The skull is formed of the cranium and the mandible. The cranium is
composed of the calvaria (the part enclosing the brain) and the skeleton of
the face. The calvaria is divided into the skull cap (the vault of the skull) and
the base of the skull.
Most of the bones of the skull are joined by sutures. The sutures are a
type of fibrous joints in which two bony edges are connected by minimal
fibrous tissue called the sutural ligament. After 40-50 years, these ligaments
begin to ossify from inside outwards.

NORMA VERTICALIS
Frontal bone

Coronal suture

Bregma

Sagittal suture

Parietal bone

Parietal emissary
foramen

Lambdoid suture
Lambda

Occipital bone

Bones appearing in the norma:

The squamous part of the frontal bone, the two parietal bones and the
squamous part of the occipital bone.

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Features:
- Coronal suture: It connects the frontal and the two parietal bones.
- Sagittal suture: It connects the two parietal bones.
- Lambdoid suture: It connects the two parietal bones to the occipital
bone.
- Bregma: It is the point of meeting of the sagittal and coronal sutures.
- Lambda: It is the point of meeting of the sagittal and lambdoid
sutures.
- Parietal emissary foramina: They lie on the sides of the sagittal suture
about 3.5 cm above the lambda.
- Parietal eminences: They are the most prominent parts of the parietal
bones. They indicate the sites of the primary centers of ossification of
the parietal bones.
- Metopic suture (may be present): It is the persistent interfrontal suture
which begins normally to disappear at 2 years and disappears
completely at 8 years.

NORMA OCCIPITALIS

Sagittal suture

Parietal emissary Highest nuchal line

foramen

Lambdoid suture Superior nuchal line

External occipital
protuberance
Mastoid bone External occipital crest
Mastoid emissary
foramen Inferior nuchal line

Bones appearing in the norma:

The two parietal bones, the squamous part of the occipital bone and the
mastoid parts of the temporal bones.

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 Features:
- The posterior part of the sagittal suture with the parietal emissary
foramina on its sides.
- The lambdoid suture and lambda.
- The external occipital protuberance: It lies in the median plane
midway between the foramen magnum and the lambda. Its center is
called the inion.
- The external occipital crest (the median nuchal crest): It extends from
the external occipital protuberance to the foramen magnum.
- The superior nuchal lines: They extend laterally from the external
occipital protuberance.
- The inferior nuchal lines: They extend laterally from the middle of the
external occipital crest.
- The highest nuchal lines: They are ill-defined ridges about one finger
above the superior nuchal lines.
- Mastoid emissary foramina: They lie on the mastoid parts of the
temporal bones.

NORMA FRONTALIS
Glabella
Superciliary arch Frontal eminence
Supraorbital foramen

Frontozygomatic suture
Nasal bone
Zygomaticofacial foramen

Anterior nasal spine

Infraorbital foramen Intermaxillary suture

Canine eminence

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Bones appearing in the norma:
Frontal bone, two maxillae, two zygomatic bones two nasal bones.

Features:
1- Features on the frontal bone:
- Superciliary arches: They are rounded elevations above the medial
parts of the supraorbital margins. The two arches meet in a median
prominence called the glabella above the root of the nose.
- Frontal eminences: They are the most prominent parts of the
frontal bone. They indicate the sites of the primary centers of
ossification of the frontal bone.
- Nasion: It is the point of meeting of the internasal and frontonasal
sutures.
- Supraorbital margin: It shows the supraorbital notch or foramen at
the meeting of its medial 1/3 and lateral 2/3.
- Zygomatic process of the frontal bone which articulates with the
frontal process of the zygomatic bone at the frontozygomatic
suture.
2- Features on the maxilla:
- The anterior surface of the body of the maxilla shows:
a. Canine eminence caused by the root of the canine.
b. Canine and incisive fossae lateral and medial to the eminence.
c. Infraorbital foramen which lies at the upper part of the canine
fossa below the infraorbital margin.
- Intermaxillary suture and the anterior nasal spine.
- Frontal, zygomatic and alveolar processes of maxilla.
3- Features on the zygomatic bone:
- Zygomaticofacial foramen: Lies on the anterior surface of the body
of zygomatic bone.
- Frontal, maxillary and temporal processes of zygomatic bone.
4- Features on the nasal bone:
The nasal bone is connected medially with the other nasal bone at the
internasal suture. Laterally, it is connected with the frontal process of
the maxilla at the nasomaxillary suture. Above, it is connected with
the frontal bone at the frontonasal suture. The point of meeting of the
internasal and frontonasal sutures is called the nasion. The lower
border of the nasal bone is free and gives attachment to the nasal
cartilage

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 NORMA LATERALIS

Inferior temporal
Coronal suture line
Frontal bone

Temporal line
Squamous part
of temporal bone

Nasal bone Greater wing of

sphenoid

Anterior nasal spine Supramastoid

crest

Mastoid process

Bones appearing in the norma:

Frontal bone, parietal bone, occipital bone, maxilla, zygomatic bone, greater
wing of sphenoid bone and temporal bone.

Features:
1. Temporal line: It starts at the zygomatic process of the frontal bone,
divides into superior temporal line which rapidly fades away, and
inferior temporal line which passes backwards then downwards and
forwards to end at the supramastoid crest.
2. Temporal fossa:
- Boundaries: Temporal line, inferior temporal line, supramastoid
crest, zygomatic arch, frontal process of zygomatic bone and
zygomatic process of frontal bone.

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 - Floor: Frontal bone, parietal bone, squamous part of temporal bone
and greater wing of sphenoid. These bones meet at H-shaped
sutures.
- Features
a. Pterion: It is a circular area at the meeting of the 4 bones that
form the floor of the temporal fossa. The center of the pterion
lies on the horizontal limb of the H-shaped sutures and lies
about 3.5 cm above the midzygomatic point and 3.5 cm behind
the frontozygomatic suture. The anterior branch of the middle
meningeal artery traverses the inner aspect of the pterion.
b. Asterion: A circular area at the meeting of the parietal, occipital
and temporal bones. It corresponds to the end of the transverse
sinus.
c. Zygomaticotemporal foramen: Lies on the temporal surface of
the zygomatic bone.
d. Posterior superior alveolar foramen: Lies on the temporal
surface of the maxilla.

3. Infratemporal fossa:
- Boundaries:
. Anteriorly: Back of maxilla.
. Posteriorly: Tympanic bone.
. Medially: Lateral surface of lateral pterygoid plate.
. Laterally: Ramus of mandible.
. Above: Infratemporal surface of the greater wing of sphenoid.
- Communications:
. With temporal fossa: Through the space deep to zygomatic arch.
. With orbit: Through the inferior orbital fissure.
. With pterygopalatine fossa: Through the pterygomaxillary
fissure.
. With middle cranial fossa: Through foramina ovale and
spinosum.
4. Pterygopalatine fossa:
- Boundaries:
. Anteriorly: Back of maxilla.
. Posteriorly: Pterygoid process.
. Medially: Vertical plate of palatine bone.
. Laterally: It communicates with the infratemporal fossa.
. Above: Body of sphenoid.
. Below: It is closed by union of the maxilla and pterygoid process.

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 - Communications:
. With the orbit: Through the inferior orbital fissure.
. With the infratemporal fossa: Through the pterygomaxillary
fissure.
. With the middle cranial fossa: Through foramen rotundum.
. With the nose: Through the sphenopalatine foramen.
. With the region of the palate: Through the greater and lesser
palatine foramina
. With the region of the pharynx: Through the palatovaginal and
pterygoid canals
5. Features on the temporal bone (4 parts of this bone appear in this
norma)
a. Squamous part:
It gives a zygomatic process which articulates with the temporal
process of the zygomatic bone to form together the zygomatic
arch.
b. Mastoid part:
It has the following features:
. Mastoid process which is a nipple-like projection.
. Mastoid emissary foramen.
. Supramastoid crest.
c. Tympanic part:
. It forms the anterior wall, floor and the lower half of the
posterior wall of the external acoustic meatus.
. It covers the root of the styloid process.
d. Styloid process:
Its root is covered by the tympanic bone then it projects
downwards and forwards
e. Suprameatal triangle:
- Boundaries:
. Above: The supramastoid crest.
. Anteriorly: The posterosuperior margin of the external
acoustic meatus.
. Posteriorly: A line along the anterior border of the mastoid
process.
- This triangle forms the lateral wall of the tympanic antrum
which communicates with the tympanic cavity and the
mastoid air cells.

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 NORMA BASALIS EXTERNA

Greater palatine foramen

Palatine crest
Pterygoid fossa
Posterior nasal spine
Foramen ovale
Pterygoid hamulus
Foramen spinosum
Vomer
Scaphoid fossa Articular tubercle

Foramen lacerum Styloid process

Petrous bone Carotid foramen

Tympanic bone
Occipital condyle

Jugular foramen
Condylar fossa

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 Traced from before backwards, it shows the following features:

1) The alveolar margin of the alveolar process of the maxilla:

- It carries the sockets of the upper teeth.
- A maxillary tuberosity lies at each end of the margin.
2) Hard palate:
- It is formed of:
. The anterior 3/4 are formed of the palatine processes of the maxillae.
. The posterior 1/4 is formed of the horizontal plates of palatine bones.
- Features:
a. Incisive fossa: It includes 4 incisive foramina or canals; 2
lateral (right and left) and 2 median (anterior and posterior). All
these canals connect the region of the palate with the nose.
b. Greater and lesser palatine foramina with the palatine crest in
between. These foramina connect the region of the palate with
the pterygopalatine fossa.
c. Grooves for greater palatine nerve and vessels: They lie on the
sides of the palate between the incisive fossa and the greater
palatine foramina.
d. The posterior nasal spine: Lies at the middle of the posterior
border of the hard palate.

Incisive fossa

Groove for greater Palatine process of maxilla

palatine nerve and
vessels

Greater palatine
foramen
Horizontal plate of palatine
bone
Lesser palatine foramen
Maxillary tuberosity

3) The posterior nasal openings (the posterior choana): They are separated
from each other by the vomer whose upper border has two ala.

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 4) Pterygoid processes (parts of the sphenoid bone):
- Each process is formed of medial and lateral plates with a pterygoid
fossa in between.
- The medial pterygoid plate:
. It ends below by a hook-like process called the pterygoid hamulus
whose tip can be felt in the living behind the last upper molar tooth.
. Above, the posterior border of the plate splits bounding the scaphoid
fossa. A medial extension from the upper part of the plate , called
the vaginal process, articulates with the ala of the vomer. The
vaginal process articulates with the sphenoidal process of the
palatine bone with a canal in between called the palatovaginal canal.
The upper part of the medial pterygoid plate contains also a canal
called the pterygoid canal. Both the palatovaginal and pterygoid
canals connect the region of nasopharynx with the pterygopalatine
fossa.
5) Basilar part of occipital bone:
- It extends from the foramen magnum till the body of the sphenoid.
The spheno-occipital junction remains cartilaginous till 18-25 years.
- About 1 cm in front of foramen magnum, it has a tubercle called the
pharyngeal tubercle.
6) Infratemporal surface of the greater wing of the sphenoid:
It presents foramen ovale, foramen spinosum and the spine of sphenoid.
7) Parts of the temporal bone:

Squamous part of Supramastoid crest

temporal bone
Mastoid part of
temporal bone

Zygomatic process Tympanic part of

temporal bone
Mandibular fossa

External acoustic Mastoid process

meatus

Styloid process

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 1. Petrous part:
- It is a pyramidal-shaped mass of bone that lies between the
greater wing of the sphenoid and the basilar part of the occipital
bone.
- At its apex there is the foramen lacerum which is closed below
with cartilage.
- On its lower surface there is the carotid foramen which is the
lower opening of the carotid canal that lies inside the petrous.
- On its medial side between it and the occipital bone there is the
jugular foramen.
- On its lateral side there are two fissures:
a) Squamotympanic fissure which is divided by a small
ridge on the under surface of the petrous into:
. Petrotympanic fissure that lodges the chorda tympani
nerve and the anterior tympanic artery.
. Petrosquamous fissure that gives attachment to the
capsule of the temporomandibular joint.
b) Petrosphenoidal fissure that lodges the cartilaginous
part of the Eustachian tube.
2. Squamous part:
- It has the mandibular fossa which articulates with the head of the
mandible.
- In front of the fossa there is an elevation called the articular
tubercle or eminence
3. Tympanic part:
- It forms the anterior wall, floor and the lower half of the posterior
wall of the external acoustic meatus.
- It covers the root of the styloid process.
4. Styloid process:
It is separated from the mastoid process by the stylomastoid
foramen.
5. Mastoid part:
It has the mastoid process with the digastric notch on its medial side
and a groove for the occipital artery further medially.
8) Foramen magnum, occipital condyles, anterior condylar or hypoglossal
canal and condylar fossa which may be perforated by the posterior
condylar canal.
9) External occipital protuberance and crest and the nuchal lines.

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 NORMA BASALIS INTERNA
(CRANIAL CAVITY)

Crista galli
Orbital plate of frontal
bone

Groove for the anterior Cribriform plate of

ethmoidal nerve ethmoid

Lesser wing of sphenoid Jugum sphenoidale

Optic groove
Anterior clinoid process
Tuberculum sellae
Foramen rotundum Hypophyseal fossa
Posterior clinoid process
Foramen ovale
Dorsum sellae
Foramen spinosum
Foramen lacerum
Clivus
Arcuate eminence
Trigeminal depression

Jugular tubercle
Tegmen tympani
Hypoglossal canal
Transverse sulcus

Internal occipital
protuberance Jugular foramen

Superior sagittal sulcus

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Anterior cranial fossa
- Bones forming the floor of the fossa:
Cribriform plate of ethmoid, anterior part of the body of sphenoid (jugum
sphenoidale), orbital plates of the frontal bone and the lesser wings of the
sphenoid.
- Features
1. Frontal crest: Projects from the frontal bone in the median plane.
2. Cribriform plate of ethmoid shows the crista galli and many foramina
for the olfactory filaments. On each side of the crista galli there is a
slit-like groove for the anterior ethmoidal nerve.
3. Foramen coecum: Lies between the frontal crest and the crista galli.
4. Anterior clinoid processes: Lie at the medial ends of the lesser wings
of the sphenoid.

Middle cranial fossa

- Bones forming the floor of the fossa:
Upper surface of the body of sphenoid, greater wings of sphenoid,
squamous parts of the temporal bones and the anterior surface of the
petrous parts of the temporal bones.
- Features
1. Features on the body of the sphenoid:
a. Chiasmatic (optic) groove that ends on each side by the optic
canal.
b. Sella turcica: It is formed of :
. Tuberculum sellae anteriorly.
. Pituitary (hypophyseal) fossa in the middle.
. Dorsum sellae ending by posterior clinoid processes
posteriorly.
c. Carotid groove on either side of the body of sphenoid.
2. Foramina and fissures related to the greater wing of the sphenoid:
a. Superior orbital fissure: It lies between the lesser and greater
wings of sphenoid and it leads to the orbit.
b. Foramen rotundum: It leads to the pterygopalatine fossa.
c. Foramen ovale and foramen spinosum lead to the infratemporal
fossa.
d. Foramen lacerum: It lies between the apex of the petrous bone
and the greater wing and the body of the sphenoid.

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Jugum sphenoidale
Lesser wing

Optic canal Greater wing

Foramen ovale

Foramen spinosum
Optic groove
Spine of sphenoid

Superior orbital
fissure

Foramen rotundum

Pterygoid process

3. Features on the anterior surface of the petrous part of the temporal

bone:
a. Trigeminal depression: Lies just behind the apex of the petrous.
It is caused by the trigeminal (Gasserian) ganglion.
b. Arcuate eminence: It is an elevation posterolateral to the
trigeminal depression caused by the superior semicircular canal
in the internal ear.
c. Tegmen tympani: A thin plate of bone lateral to the arcuate
eminence and forms the roof of the middle ear cavity.
d. Greater and lesser petrosal foramina and grooves.

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Posterior cranial fossa
- Bones forming the floor of the fossa:
Dorsum sellae, clivus (sloping fused body of sphenoid and the basilar
part of the occipital bone), posterior surface of the petrous bone, mastoid
part of temporal bone and squamous part of occipital bone.
- Features
a. Jugular tubercle: It lies on each side of the foramen magnum
above the hypoglossal canal.
b. Features on the posterior surface of the petrous bone:
- Superior petrosal sulcus: Lies along the superior border.
- Inferior petrosal sulcus: Lies along the inferior border.
- Sigmoid sulcus: Lies along the posterior border.
- Jugular foramen: Lies between the petrous and occipital
bones.
- Internal auditory meatus.
c. Features on the internal surface of the squamous part of the
occipital bone:
- Internal occipital protuberance.
- Internal occipital crest: Extends from the protuberance till
the foramen magnum.
- Transverse sulcus: Extends laterally from the protuberance
till continues with the sigmoid sulcus.
- The end of the superior sagittal sulcus: It continues with one
of the transverse sulci usually the right.
- Cruciate eminence: It is formed of the internal occipital
crest, the two transverse sulci and the end of the superior
sagittal sulcus. The internal occipital protuberance lies at its
center.
- Four fossae bounded by the cruciate eminence. The upper
two fossae house the occipital poles of the cerebral
hemispheres, while the lower two house the cerebellar
hemispheres.

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 ORBIT

Formation of the orbit

- Orbital margin:
a. Superior orbital margin:
Formed of the frontal bone.
b. Inferior orbital margin:
Formed of the maxilla and zygomatic bone.
c. Lateral orbital margin:
Formed of the zygomatic process of the frontal bone and the
frontal process of the zygomatic bone.
d. Medial orbital margin:
Formed of the maxillary process of the frontal bone and the
frontal process of the maxilla.
- Medial wall:
Formed of the frontal process of maxilla. Lacrimal bone, orbital plate
of ethmoid.
- Lateral wall:
Formed of the orbital surfaces of zygomatic bone and greater wing of
sphenoid
- Roof:
Formed of the orbital plate of the frontal bone and the lesser wing of
sphenoid.
- Floor:
Formed of the orbital surfaces of the maxilla and the zygomatic bones.

Features in the orbit

1. Features on the roof:
- Lacrimal fossa for the lacrimal gland: On the anterolateral part of
the roof.
- Trochlear fossa where a fibrous pulley called the trochlea is
attached: On the anteromedial part of the roof.
- Optic canal: Lies in the posterior part of the roof between the two
roots of the lesser wing of the sphenoid.
2. Between the roof and the lateral wall there is a fissure called the
superior orbital fissure which connects the orbit with the middle
cranial fossa. It is wider medially and its lower border has a small
projection for the attachment of the common tendinous ring.

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3. Features on the lateral wall: There are two openings on the orbital
surface of the zygomatic bone that transmit the zygomaticotemporal
and zygomaticofacial nerves.
4. Between the lateral wall and the floor there is the inferior orbital
fissure that connects the orbit with the infratemporal and
pterygopalatine fossae.
5. Features on the floor: Infraorbital groove and infraorbital canal that
leads to the infraorbital foramen seen in norma frontalis.
6. On the medial wall there is the lacrimal groove between the anterior
and posterior lacrimal crests. The groove contains the lacrimal sac and
is connected with the nose by the nasolacrimal canal in which a duct
called the nasolacrimal duct descends from the lacrimal sac to the
nose to discharge tears.
7. Between the medial wall and the roof there are the anterior and
posterior ethmoidal foramina.

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 NASAL CAVITY
Superior concha Frontal sinus Vertical plate
of ethmoid
Middle concha Nasal bone
Sphenoidal
sinus

Vomer

Hard palate
Inferior concha

Lateral wall of the nose Nasal septum

The nasal cavity has a roof, floor, lateral wall and a medial wall (nasal
septum).
a. The roof is formed of:
- Anterior sloping part formed of nasal bone.
- Middle horizontal part formed of the cribriform plate of ethmoid
bone.
- Posterior sloping part formed of the body of sphenoid.
b. The floor is the hard palate.
c. The lateral wall is formed of:
- The nasal surface of the maxilla to which the inferior concha
articulates.
- The vertical plate of the palatine bone
- The nasal surface of the lateral mass of ethmoid (ethmoid labyrinth)
from which the superior and middle conchae project.
d. The nasal septum is formed of:
- Vertical plate of ethmoid.
- Vomer.
- Nasal cartilage.

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 MANDIBLE

Condyloid process
Coronoid process

Mandibular notch

Oblique line
Mental foramen

Mental protuberance
Angle

Mandibular foramen

Lingula

Mylohyoid groove

Mylohyoid line

Description of the mandible

The mandible is formed of a body and two rami
A- Body of the mandible: It has two borders and two surfaces.
1. Upper border: Carries the sockets of the lower teeth.
2. Lower border: Has a digastric fossa on each side of the midline.
3. Outer surface: Shows the following features:
- Symphysis menti: A ridge at the junction of the two halves of
the body.
- Mental protuberance at the lower part of the symphysis menti.

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 - Mental foramen: It lies midway between the upper and lower
border between the 1st and 2nd premolars.
- Oblique line: It extends from the anterior border of the ramus
towards the mental foramen.
4. Inner surface: Shows the following features:
- Upper and lower genial tubercles on each side of the midline.
- Mylohyoid line: Extends from little behind the last molar to the
genial tubercles.
- Sublingual fossa above the mylohyoid line and submandibular
fossa below the mylohyoid line.
- Groove for lingual nerve just below the last molar.
B- Rami of the mandible: Each ramus has 3 borders and 2 surfaces:
1. Anterior border: It is thin and continuous with the oblique line.
2. Posterior border: It is thick and continuous with the lower border of
the body at the angle of the mandible. The inner surface of the angle
if rough.
3. Superior border: Has the following features:
- Coronoid process anteriorly: It is thin and triangular.
- Condyloid process posteriorly: It carries the head and neck of
the mandible. The neck has an anteromedial and a posterolateral
surfaces.
- Mandibular notch: Between the coronoid and condyloid
processes.
4. Outer surface: Flat.
5. Inner surface: Has the following features:
- Mandibular foramen.
- Lingula: A tongue-like process that overlaps the mandibular
foramen anteriorly.
- Mylohyoid groove: Extends from the mandibular foramen
forwards.
Structures related to the mandible
A. Muscles:
1. Insertion of all muscles of mastication and the platysma:
- Masseter:
Inserted into the outer surfaces of the ramus and coronoid
process
- Temporalis:
Inserted into the tip, anterior border and inner surface of the
coronoid process.
- Lateral pterygoid:

20
 Inserted into the anteromedial surface of the neck.
- Medial pterygoid
Inserted into the rough inner surface of the angle.
- Platysma:
Inserted into the lower border of the mandible
2. Origin of the following muscles:
- Mylohyoid:
From the mylohyoid line
- Superior constrictor of the pharynx:
From the posterior part of the mylohyoid line.
- Genioglossus and geniohyoid:
From the upper and lower genial tubercles respectively.
- Anterior belly of digastric:
From the digastric fossa.
- Buccinator:
From the outer surfaces of the sockets of the molars.
B. Ligaments:
1. Temporomandibular ligament: Extends from the posterior part
of the zygomatic arch to the outer surface of the neck of the
mandible.
2. Stylomandibular ligament: Extends from the styloid process to
the posterior border of the angle of the mandible.
3. Sphenomandibular ligament: Extends from the spine of
sphenoid to the lingual of the mandible.
4. Pterygomandibular ligament: Extends from the pterygoid
hamulus to the posterior part of the mylohyoid line,

C. Nerves:
1. Two nerves related to foramina:
- Inferior alveolar nerve: Enters the mandibular foramen.
- Mental nerve: Comes out of the mental foramen.
2. Two nerve related to grooves:
- Nerve to mylohyoid: Passes in the mylohyoid groove.
- Lingual nerve: Passes in the grooves below the last molar.
3. Two nerves related to the superior border of the ramus:
- Nerve to masseter: Passes in the mandibular notch.
- Auriculotemporal nerve Crosses the inner surface of the
neck.
4. Two nerves related to the ramus:

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 - Buccal branch of mandibular nerve: Passes deep to the
ramus.
- Buccal branch of facial nerve: Passes superficial to the
ramus.
5. One nerve related to the lower border:
The mandibular branch of facial nerve.

Determination of the age of the mandible

1. Young mandible:
- The mental foramen is nearer to the lower border.
- The angle is obtuse (about 170o at birth & 145o at 4 years)
2. Adult mandible:
- The mental foramen is midway between the upper and lower borders.
- The angle is about 120o .
3. Old mandible:
- The mental foramen is nearer to the upper border.
- The angle is obtuse (about 145o )

The age of the mandible can be also determined by the time of eruption of
the teeth:
1. Milk (deciduous) teeth:
- Central incisor: 6-8 months.
- Lateral incisor: 8-10 months
- First molar: 10-12 months.
- Canine: 16-20 months.
- Second molar: 20-30 months.
2. Permanent teeth:
- First molar: 6-7 years.
- Central incisor: 6-8 years.
- Lateral incisor: 8-10 years.
- Canine: 9-12 years.
- First and second premolars: 10-12 years.
- Second molar: 11-13 years.
- Third molar: 17-21 years.
The upper teeth usually erupt earlier than the lower teeth.

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 HYOID BONE

Greater horn

Body Lesser horn

• It is a U-shaped bone that consists of:

- Body anteriorly
- Two greater horns that extend backwards from the body.
- Two small lesser horns that extend upwards at the junction of the
body and greater horns.
• Muscles attached:
- It gives origins to: middle constrictor of the pharynx and hyoglossus
and superior belly of omohyoid.
- It gives insertions to: geniohyoid, mylohyoid, stylohyoid, sternohyoid
and thyrohyoid.
• Ligaments attached:
- Hyoepiglottic ligament.
- Thyrohyoid membrane.
- Stylohyoid ligament.

23
 CERVICAL VERTEBRAE

Typical cervical vertebrae (third, fourth, fifth and sixth

cervical vertebrae)
Upper surface of the body

Later tubercle of the body

Anterior and posterior Pedicle

tubercles of the
transverse process Superior articular process

Vertebral canal
Foramen transversorium
Lamina

Spine

Anterior and posterior

tubercles on the lower
surface of the body

It consists of:
1. Body anteriorly:
- It is small in relation to the larger vertebral canal.
- The upper surface shows two lateral tubercles that prevent the side to
side dislocation of the vertebrae.
- The lower surface shows anterior and posterior tubercles that prevent
the anteroposterior dislocation of the vertebrae.
2. Neural arch formed of 2 pedicles and 2 laminae. The body and the neural
arch enclose a large triangular vertebral canal. Above and below each

24
 pedicle there are notches. The notches of successive vertebrae form
intervertebral foramina for the exit of the cervical spinal nerves.
3. Spine: It is short, bifid and directed backwards.
4. Transverse processes: They are perforated by foramina transversoria for
the vertebral vessels. Each ends laterally by anterior and posterior
tubercles.
5. Superior and inferior articular processes that share in the formation of the
intervertebral joints.
Atlas (first cervical vertebra)

A tubercle for attachment

of the transverse ligament
of atlas

Upper concave
articular surface

Groove for vertebral

artery

It has the following features:

- It has neither body nor spine.
- It looks like a ring with two lateral masses connected by short anterior
and longer posterior arches.
- The lateral mass has the following features:
a. Upper concave, kidney-shaped surface which articulates with
the occipital condyles forming the atlanto-occipital joint.
b. Lower flat, nearly circular surface which articulates with the
upper articular surfaces of the axis.
c. A tubercle on the medial aspect of the lateral mass for the
attachment of the transverse ligament of atlas. This ligament
together with the anterior arch of the atlas form a ring that
receives the odontoid process of the axis.
- The anterior arch has a small tubercle in front and a smooth surface
posteriorly for articulation with the odontoid process of the axis.
- On the upper surface of the posterior arch just behind the lateral mass,
there is a groove for the vertebral artery.

25
Axis (second cervical vertebra)
Odontoid process

Its most characteristic feature is the presence of the odontoid process

projecting from the upper surface of its body. The atlas, carrying the skull
rotates around the odontoid process during rotation of the head.

Vertebra prominens (seventh cervical vertebra)

It differs from the typical cervical vertebra in the following features:
- Its foramina transversoria are small as they transmit the vertebral veins
only while the other foramina transmit the vertebral vessels.
- Its spine is long and not bifid.

26
 FEATURES OF FETAL SKULL
AND
THE CHANGES AFTER BIRTH

Frontal bone Anterior fontanelle

Interfrontal suture

Coronal suture

Parietal bone Sagittal suture

Lambdoid suture Posterior fontanelle

Features of the fetal skull

1. The mandible is formed of two halves.
2. The face is small in size due to:
- Incomplete development of the maxilla and maxillary air sinus.
- Non eruption of teeth.
3. The frontal bone is formed of two halves with interfrontal suture in
between.
4. Absent or rudimentary paranasal air sinuses.
5. The tympanic bone is represented by only a ring so external auditory tube
is formed of cartilage only and the drum is more superficial and may be
more easily injured.
6. The mastoid process is not well developed, thus the stylomastoid
foramen and the facial nerve are more exposed.

27
7. The basilar part of the occipital bone and the body of sphenoid are
separated by cartilage.
8. Fontanelles:
a. Anterior fontanelle: It is a large, diamond-shaped membrane between
the two parietal and the two halves of the frontal bone. Normally, it
closes at 1.5-2 years. It gives a chance for the growth and
development of the brain in the first two years. It sinks down in case
of dehydration and bulges in increased intracranial tension. It may be
a site for intravenous injection into the superior sagittal sinus.
b. Posterior fontanelle: It is a smaller triangular membrane between the
two parietal bones and the occipital bone. It closes at 6 months.
c. Anterolateral (sphenoidal) fontanelle: At the region of the pterion. It is
very small and closes at 3 months.
d. Posterolateral (mastoidal) fontanelle: At the region of the asterion. It
is very small and closes at 3 months

Changes which occur in the skull after birth

1. At 3 months: The anterolateral and posterolateral fontanelles are closed.
2. At 6 months: The posterior fontanelle is closed.
3. At 12 months: The symphysis menti is ossified.
4. At 18 months: The anterior fontanelle is closed.
5. At 24 months: The mastoid process starts to develop.
Fusion of the two halves of the frontal bone begins.
6. At 5 years: Complete development of the tympanic bone.
7. At 7 years: Well development of upper part of nasal cavity, orbit and
frontal air sinus.
8. At 8 years: The two halves of the frontal bone completely fuse.
9. At 18-25 years: Fusion of the body of sphenoid and basilar part of
occipital bone.
10. At 30 years: Obliteration of the inner sides of the sutures.
11. At 40-50 years: Obliteration of the sutures.
12. At older age: Loss of teeth leading to a smaller face

28
 SCALP
Boundaries
- In front: Supraorbital margin.
- Behind: Highest nuchal lines.
- Laterally: Temporal line and superior temporal line.
Layers

Skin
Connective tissue
Aponeurosis
Loose areolar tissue
Skull bone Periosteum
Endosteum

1. Skin: It is rich in hair follicles and sebaceous glands.

2. Connective tissue: It is rich in fat and fibrous septa that connect the skin
to the underlying aponeurosis. Numerous arteries and veins, that freely
anastomose, are found in this layer and thus scalp wound leads to marked
bleeding.
3. Aponeuorsis (epicranial aponeurosis): It is a fibrous band attached
anteriorly (through the frontal bellies of the occipitofrontalis muscle) to
the skin over the superciliary arches, and attached posteriorly (through
the occipital bellies of the occipitofrontalis muscle) to the highest nuchal
lines and a part of the aponeurosis extends between the occipital bellies
to be attached to the external occipital protuberance. On each side, the
aponeurosis is attached to the superior temporal line.
Occipitofrontalis muscle:
- Origin:
Frontal bellies: From the skin over the superciliary arches.
Occipital bellies: From the highest nuchal lines.
- Insertion: Into the epicranial aponeurosis.

29
 - Nerve supply:
Frontal bellies: Temporal branch of facial nerve.
Occipital bellies: Posterior auricular branch of facial nerve.
- Action: Transversely corrugates the skin of the forehead (expression
of surprise)

Frontal bellies of
occipitofrontails

Epicranial
aponeurosis

Highest nuchal line

Occipital bellies of
occipitofrontails

External occipital
protuberance

4. Loose areolar connective tissue: It allows movement of the above three

layers on the periosteum of the skull. It contains few emissary veins that
connect the scalp veins to intracranial venous sinuses.
5. Periosteum: It is adherent to the skull bones. At the suture lines, it
becomes continuous with the endosteum.

30
 Nerves of the scalp

Supraorbital nerve

Greater occipital nerve Supratrochlear nerve

Auriculotemporal nerve
Third occipital nerve
Zygomaticotemporal nerve

Lesser occipital nerve

Great auricular nerve

Sternomastoid

A. Nerves in front of the auricle (4 sensory & 1 motor):

1. Supratrochlear nerve:
- One of the two terminal branches of the frontal nerve which is a
branch from the ophthalmic division of the trigeminal nerve.
- Comes out of the orbit one finger breadth from the midline.
- Supplies the medial 1/3 of the upper eyelid and the skin of the
forehead above the root of the nose.
2. Supraorbital nerve:
- The other terminal branch of the frontal nerve.
- Comes out of the orbit through the supraorbital foramen two
fingers breadth from the midline.

31
 - Supplies the middle 1/3 of the upper eyelid and the skin of the
scalp as far back as the lambdoid suture.

3. Zygomaticotemporal nerve:
- One of the two terminal branches of the zygomatic nerve which is
a branch from the maxillary division of the trigeminal nerve.
- Comes out of the orbit from the zygomaticotemporal foramen.
- Supplies the skin of the temporal region and a small area of the
scalp above the temporal region.
4. Auriculotemporal nerve:
- A branch from the posterior division of the mandibular branch of
the trigeminal nerve.
- Appears in the scalp just in front of the auricle.
- Supplies the skin of the scalp above the auricle & the upper 2/3 of
the outer surface of the auricle and a part of the external auditory
tube and ear drum.
5. Temporal branch of facial nerve (motor):
Supplies the frontal belly of the occipitofrontalis muscle.
B. Nerves behind the auricle (4 sensory & 1 motor):
1. Lesser occipital nerve:
- Arises from the ventral ramus of C2
- Appears at the middle of the posterior border of sternomastoid then
passes upwards and backwards.
- Supplies the skin of the scalp behind the auricle and the upper 1/3
of the inner surface of the auricle.
2. Great auricular nerve:
- Arises from the ventral rami of C2&3.
- Appears at the middle of the posterior border of sternomastoid then
passes upwards and forwards superficial to the muscle. It divides
into two branches that pass in front and behind the auricle.
- Supplies the skin over the angle of the mandible, a small area of
scalp behind the auricle, lower 1/3 of the outer and the lower 2/3 of
the inner surfaces of the auricle as well as the capsule of the
parotid gland.
3. Greater occipital nerve:
- Arises from the dorsal ramus of C2.
- Appears near the external occipital protuberance.
- Supplies a large area of the skin of the back of the scalp.
4. Third occipital nerve:
- Arises from the dorsal ramus of C3.

32
 - Appears in the back of the scalp below the greater occipital nerve.
- Supplies an area of the skin of the back of the scalp as well as the
back of the neck.
5. Posterior auricular branch of facial nerve (motor):
Supplies the occipital belly of the occipitofrontalis muscle.

Arteries of the scalp

Supraorbital artery

Supratrochlear artery

Superficial temporal
artery Zygomaticoorbital artery

Middle temporal artery

Transverse facial artery

Posterior auricular artery Maxillary artery

Parotid gland

Occipital artery

External carotid artery

The scalp has a rich blood supply so a small wound in the scalp may lead to
marked bleeding. The arteries enter from the periphery of the scalp and
ramify and freely anastomose in the center. The anterior part of the scalp is
supplied by branches from the internal carotid artery, while the largest pat is

33
supplied by branches from the external carotid artery. There are 5 arteries on
each half of the scalp: two in front of the auricle (supraorbital and
supratrochlear), two behind the auricle (posterior auricular and occipital) and
one in the middle part of the scalp (superficial temporal).
1. Supratrochlear and supraorbital arteries:
They are branches of ophthalmic artery which is a branch from the
internal carotid artery. They accompany the corresponding nerves.
2. Posterior auricular artery:
Arises from the posterior aspect of the external carotid artery, passes
backwards along the upper border of the posterior belly of digastric to
supply the skin of the scalp behind the auricle.
3. Occipital artery:
Arises from the posterior aspect of the external carotid artery, passes
backwards along the lower border of the posterior belly of digastric. Then
it passes in a groove on the medial side of the mastoid process deep to the
sternomastoid muscle. It appears at the apex of the posterior triangle. It
passes deep to then pierces the trapezius to ramify on the posterior part of
the scalp lateral to the greater occipital nerve.

34
 Posterior belly of
digastric
Posterior auricular
artery

Occipital artery
External carotid
artery

Sternomastoid
Trapezius

4. Superficial temporal artery:

- One of the two terminal branches of the external carotid artery inside
the parotid gland at the level of the neck of the mandible.
- It emerges from the upper border of the parotid gland to enter the
scalp where it divides into terminal anterior and posterior branches.
- Branches:
a. Transverse facial artery: It emerges from the anterior border of the
parotid to share in the arterial supply of the face.
b. Middle temporal artery: Supplies the temporalis muscle.
c. Zygomaticoorbital artery: It arises from the superficial temporal
artery after it leaves the parotid. It crosses the zygomatic arch
towards the orbit. It shares in the arterial supply of the face.
d. The frontal and parietal terminal branches supply the middle part
of the scalp.

35
 FACE
Important muscles of the face
1. Orbicularis oculi
It is formed of 3 parts: orbital, palpebral and lacrimal.
- Origin and insertion:
a. Orbital part:
Arises from the upper part of the medial palpebral ligament and
the adjoining bone. The fibers run around the orbital margin to be
attached to the lower part of medial palpebral ligament.
The medial palpebral ligament is about ½ cm in length, attached
to the frontal process of maxilla and divides into upper and lower
parts each attached to the tarsus of the corresponding lid.
a. Palpebral part:
Arises from the upper and lower parts of the medial palpebral
ligament. The fibers pass in both lids to interlace with each other
at the lateral angle of the eye forming the lateral palpebral raphe.
b. Lacrimal part:
Arises from the lacrimal bone and the fascia covering the
lacrimal sac. The fibers pass in both lids where most of the fibers
insert into the tarsi of the lids, while few fibers continue till the
lateral angle of the eye and share in the lateral palpebral raphe.

- Nerve supply: Temporal and upper zygomatic branches of facial

nerve.
- Action:
a) Contraction of the whole muscle draws the skin of the eyelids
medially helping the flow of tears towards the lacrimal canaliculi.
b) Contraction of the orbital part performs firm closure of the eye.
c) Contraction of the palpebral part performs gentle closure of the
eye.
d) Contraction of the lacrimal part distends the lacrimal fascia so
dilates the lacrimal sac and thus helps in absorption of tears.

36
Orbicularis oculi

Orbital part

Palpebral part

Buccinator

Orbicularis oris

2. Buccinator
- Origin:
a. Upper fibers: From the outer surfaces of the sockets of upper
molars.
b. Lower fibers: From the outer surfaces of the sockets of lower
molars.
c. Middle fibers: From the Pterygomandibular ligament.
- Insertion:
The fibers converge towards the angle of the mouth. The upper and
lower fibers run in the corresponding lip while the middle fibers
decussate.
- Nerve supply: Buccal branch of facial nerve.
- Action:
It presses the cheek to the gums, so its paralysis leads to accumulation
of food in the vestibule of the mouth and dribbling of saliva.

37
3. Orbicularis oris
- It lies in the lips and formed mainly by the two buccinators.
- Nerve supply: Buccal branch of facial nerve.
- Action: Compresses the lips together.

Nerves of the face

Motor supply of the face: Facial nerve
The extra cranial course and branches of facial nerve:
- The facial nerve leaves the skull through the stylomastoid foramen.
- It gives two branches:
1. Posterior auricular branch to supply the occipital belly of
occipitofrontalis muscle.
2. A branch to the posterior belly of digastric and stylohyoid
muscle.
- Then it curves upwards around the styloid process to enter the parotid
gland through its posteromedial surface.
- Inside the parotid, it ends by dividing into 5 terminal branches:
1. Temporal: Supplies the frontal belly of occipitofrontalis and the
upper part of orbicularis oculi.
2. Zygomatic:
- Upper zygomatic: Supplies the lower part of orbicularis oculi.
- Lower zygomatic: Supplies the nasal muscles.
3. Buccal: Supplies the buccinator, orbicularis oris and other muscle
of the mouth except those of the lower lip.
4. Mandibular: Supplies the muscles of the lower lip.
5. Cervical Supplies the platysma.

38
 Temporal

Upper and
lower
zygomatic
Posterior auricular
Buccal

Mandibular
Nerve to posterior
belly of digastric and
stylohyoid Cervical

Sensory supply of the face

The trigeminal nerve supplies all the skin of the face except the skin over the
angle of the mandible which is supplied by the great auricular nerve. The
trigeminal nerve supplies the face by branches of its 3 divisions:
1. From the ophthalmic division of trigeminal
a. From the frontal nerve:
- Supratrochlear nerve: Supplies the medial 1/3 of the upper
eyelid.
- Supraorbital nerve: Supplies the middle 1/3 of the upper
eyelid.
b. From the lacrimal nerve:
The palpebral nerve which is the continuation of the lacrimal
nerve supplies the lateral 1/3 of the upper eyelid.
c. From the nasociliary nerve:

39
 - The external nasal nerve supplies the lower ½ of the dorsum
of the nose.
- The infratrochlear nerve which is the continuation of the
nasociliary nerve supplies the upper 1/2 of the dorsum of the
nose and the adjoining part of the lower eyelid.
2. From the maxillary division of trigeminal
a. Zygomaticofacial nerve: Supplies the skin over the bony cheek.
b. Infraorbital nerve (the continuation of the maxillary nerve):
- Palpebral branch: Supplies the skin of the lower eyelid.
- Nasal branch: Supplies the skin of the side of the nose.
- Labial branch: Supplies the skin of the upper lip.
3. From the mandibular division of trigeminal
a. Buccal nerve: Supplies the skin of the cheek.
b. Mental nerve: Supplies the skin of the lower lip.

Area supplied by ophthalmic

nerve

Area supplied by maxillary

nerve

Area supplied by mandibular

nerve

Area supplied by great

auricular nerve

40
 6
1. Trigeminal nerve (sensory root)
2. Trigeminal ganglion
3. Ophthalmic nerve
4. Superior orbital fissure 8
5
5. Lacrimal nerve
9
6. Palpebral nerve 4
7. Frontal nerve 14
8. Supraorbital nerve
9. Supratrochlear nerve 7 11
10. Nasociliary nerve
11. Anterior ethmoidal nerve 13
12. Internal nasal nerve 12
13. External nasal nerve
2 10
3 18 19
20
1
16 17 P
15
22 N 26

L
23
21 24
27
25
14. Infratrochlear nerve
15. Maxillary nerve 28
16. Foramen rotundum
17. Zygomatic nerve
18. Inferior orbital fissure
19. Zygomaticotemporal nerve 31
20. Zygomaticofacial nerve 30
21. Posterior superior alveolar nerve
22. Infraorbital nerve 36
23. Middle superior alveolar nerve 29
24. Anterior superior alveolar nerve
25. Infraorbital canal
26. Palpebral, nasal and labial branches 32
35
27. Mandibular nerve
28. Foramen ovale
29. Posterior division of mandibular
30. Anterior division of mandibular
31. Auriculotemporal nerve
32. Inferior alveolar nerve 34
33. Mental nerve
33
34. Lingual nerve
35. Branches to muscles of mastication
36. Buccal nerve

41
Arteries of the face
1. Facial artery:
• Course:
- It arises from the anterior aspect of the external carotid artery
just above the level of the greater horn of the hyoid bone.
- It runs upwards on the side of the pharynx first on the middle
then the superior constrictor of the pharynx.
- Then it ascends deep to the posterior belly of digastric, makes a
deep groove on the posterior part of submandibular salivary
gland. Then it curves downwards and forwards between the
lateral surface of the gland and the ramus of the mandible.
- It turns around the lower border of the mandible at the inferior
angle of the masseter to reach the face.
- In the face, it takes a tortuous course, passes upwards till a
point 1 cm behind the angle of the mouth, then continues
upwards on the side the nose till the medial angle of the eye.
• Branches:
a. Ascending palatine artery: Ascends on the wall of the pharynx
then curves forwards to reach the palate.
b. Tonsillar artery: It pierces the superior constrictor of the
pharynx to supply the palatine tonsil.
c. Glandular artery: Supplies the submandibular salivary gland.
d. Submental artery: Passes along the lower border of the
mandible, supplies the skin of chin and lower lip.
e. Inferior labial artery: Supplies the lower lip, anastomoses with
that of the opposite side.
f. Superior labial artery: Supplies the upper lip, anastomoses with
that of the opposite side. It gives a septal branch to supply the
nasal septum.
g. Lateral nasal artery: Supplies the skin of the side and dorsum of
the nose.
h. Angular artery: It is the continuation of the facial artery after
giving its lateral nasal branch.
2. Transverse facial and zygomaticoorbital arteries which are braches of
the superficial temporal artery.
3. Buccal and infraorbital arteries which are branches of the maxillary
artery.

42
 Facial artery

Posterior belly of
digastric

External carotid Submandibular

artery salivary GLAND

Hyoid bone

Veins of the scalp and face

1. Supraorbital and supratrochlear veins:
They unite at the medial angle of the eye to form the anterior facial vein.
2. Anterior facial vein:
- It is formed at the medial angle of the eye by union of the supraorbital
and supratrochlear veins.
- It accompanies and lies behind the facial artery in the face till it
reaches the anterior inferior angle of the masseter, then it descends in
the neck superficial to the submandibular salivary gland. It ends by
joining the anterior branch of the posterior facial vein to form the
common facial vein which drains into the internal jugular vein.

43
 - Communications:
a. At its beginning it receives the ophthalmic veins which are
connected to the cavernous sinus through the superior orbital
fissure.
b. Along its course it receives veins corresponding to the branches of
the facial artery.
c. While crossing the buccinator it is connected with the pterygoid
venous plexus through the deep facial vein that passes deep to the
ramus of the mandible. The pterygoid venous plexus is connected
to the cavernous sinus through emissary veins passing through
foramen ovale.
Infection in the triangular area of the face between the two anterior
facial veins (dangerous area of the face) can lead to cavernous
sinus thrombosis by two ways:
. Anterior facial vein — ophthalmic veins — cavernous sinus.
. Anterior facial vein — deep facial vein — pterygoid venous
plexus — emissary veins through ovale — cavernous sinus.
3. Superficial temporal vein:
It enters the parotid gland through its upper end. Inside the gland it is
joined with the maxillary vein and form together the posterior facial
(retromandibular) vein which leaves the gland through its lower end and
divides into anterior and posterior branches.
4. Posterior auricular vein:
It drains the posterior part of the scalp, joins the posterior branch of the
posterior facial vein to form the external jugular vein. The external
jugular vein descends vertically on the surface of the sternomastoid,
pierces the deep fascia above the clavicle to end in the subclavian vein
5. Occipital vein:
It accompanies the occipital artery and usually ends in the suboccipital
venous plexus in the back of the neck.

44
 Supraorbital vein

Supratrochlear
vein

Superficial temporal
vein

Parotid
gland
Anterior facial
vein

Posterior auricular
vein
Maxillary vein
Retromandibular
vein

Common facial
vein

External jugular vein Internal jugular

vein

Sternomastoid

Subclavian vein

45
 PAROTID GLAND
It is the largest salivary gland composed mainly of serous acini.

• Site
It lies on the side of the head filling the gap between the mandible and
the mastoid process. It extends above till the zygomatic arch and the
external acoustic meatus. Below, it extends till a point 1 cm below and
behind the angle of the mandible. Anteriorly, it overlaps the posterior
border of the masseter. Posteriorly, it overlaps the mastoid process and
the anterior border of the sternomastoid.

Accessory part of
parotid

Tragus Parotid duct

Postglenoid part
of parotid

Parotid gland Buccinator

Sternomastoid

Masseter

46
• Shape
- It is wedge-shaped with the base of the wedge outwards while the
narrow part of the wedge is deep and faces the styloid process and the
side wall of the pharynx.
- The gland has 3 surfaces:
1. Upper surface: It is concave and related to the cartilaginous part of
the external auditory tube.
2. Superficial (lateral surface).
3. Medial surface: It is divided by the medial border of the gland into
anteromedial and posteromedial surfaces.
Posteromedial
surface
Anteromedial
surface Mastoid process

Sternomastoid

Superficial surface

Upper surface

Superficial surface

47
 - The gland has 4 borders:
1. Upper border: Concave.
2. Anterior border: Convex forwards. The duct of the gland emerges
at the junction of the upper 1/3 and lower 2/3 of this border.
3. Posterior border: Straight.
4. Medial border: Rounded border that separates the anteromedial
from the posteromedial surface.
- The gland has 4 parts:
1. Superficial part: The main part of the gland.
2. Deep part: Lies close to the styloid process.
3. Postglenoid part: A small part that lies behind the
temporomandibular joint.
4. Accessory part: A small detached part that lies above the duct.
- The gland has 2 ends or poles:
1. Upper end: More pointed, lies in front of the external acoustic
meatus.
2. Lower end: It lies between the angle of the mandible and the
sternomastoid .

• Surface anatomy
1. Upper border:
Draw a curved line below the external auditory meatus connecting a
point in front of the tragus with a point at the middle of the anterior
border of the mastoid process.
2. Anterior border:
Draw a line connecting 3 points: A point in front of the tragus, a point
at the middle of the mandibular notch, and a point 1 cm below and
behind the angle of the mandible.
3. Posterior border:
Draw a line from a point 1 cm below and behind the angle of the
mandible till a point at the middle of the anterior border of the
mastoid process.

• Capsule
- It has no true fibrous capsule but it is surrounded by a fascial capsule
formed by splitting of the investing fascia of the neck at the lower end
of the parotid into two laminae.
- The superficial lamina is attached to the zygomatic arch.
- The deep lamina which extends from the styloid process till the angle
of the mandible is thickened and forms the stylomandibular ligament.

48
• Relations
- Upper surface: Related to the cartilaginous part of the external
auditory tube and the temporomandibular joint.
- Superficial surface: Related to the skin, superficial fascia containing
the anterior branch of the great auricular nerve, deep fascia and
parotid (preauricular) group of lymph nodes.
- Anteromedial surface: It is concave and surrounds the posterior border
of the ramus of the mandible. It is related to the posterior border of the
ramus of the mandible, medial pterygoid, masseter and it pierced by
the maxillary vessels.
- Posteromedial surface: Related to the following structures:
a. Styloid process and the structures attached to it:
. Three muscles: Stylohyoid, styloglossus and stylopharyngeus.
. Two ligaments: Stylohyoid and Stylomandibular.
b. Mastoid process, anterior border of sternomastoid and posterior
belly of digastric.
c. Internal carotid artery.
d. Internal jugular vein
e. Lower 4 cranial nerves.
f. The facial nerve pierces this surface.
- Structures inside the parotid:
1. Facial nerve:
It enters the parotid through its posteromedial surface and ends
inside the gland into 5 terminal branches. It is the most superficial
structure inside the gland.
2. Retromandibular (posterior facial) vein:
It is formed inside the upper of the gland by union of the
superficial temporal and maxillary veins. It descends in the
substance of the gland between the facial nerve and the external
carotid artery. It divides into anterior and posterior branches which
leave the parotid through its lower end.
3. External carotid artery:
It is the deepest structure inside the gland, ends at the level of the
neck of the mandible by dividing into superficial temporal and
maxillary arteries.

49
 Posteromedial
surface
External carotid Anteromedial
artery surface

Retromandibular
vein

Branches of
facial nerve

Superficial surface
4. Auriculotemporal nerve:
It is embedded in the upper part of the gland.
- Structures related to the anterior border:
1. Parotid duct.
2. Transverse facial artery.
3. Zygomatic, Buccal and mandibular branches of facial nerve.
- Structures related to the upper end:
1. Superficial temporal vessels.
2. Temporal branch of facial nerve.
3. Auriculotemporal nerve.
- Structures related to the lower end:
1. External carotid artery.
2. Cervical branch of facial nerve.
3. Anterior and posterior branches of the retromandibular vein.

50
 Temporal branch of facial
Auriculotemporal nerve

Superficial temporal vein

Upper zygomatic branch of
Superficial temporal artery facial

Lower zygomatic branch of

facial

Transverse facial artery

Parotid duct
Retromandibular vein Buccal branch of facial

Mandibular branch of facial

External carotid artery Maxillary vessels

Cervical branch of facial

• Parotid duct

- Course:
It arises from the anterior border of the gland, passes forwards on the
masseter. It pierces the buccinator and opens in the vestibule of the
mouth opposite the upper 2nd molar tooth.
- Surface anatomy
It is represented by the middle 1/3 of a line connecting the tragus and
a point midway between the ala of the nose and the red margin of the
upper lip.

51
 • Nerve supply
- Sensory supply to the capsule:
From the great auricular and Auriculotemporal nerves.
- Parasympathetic secretomotor fibers:
. The preganglionic fibers arise from the inferior salivary nucleus of
the glossopharyngeal nerve.
. The fibers leave the nerve as its tympanic branch that enters the
petrous bone to reach the middle ear where it shares in the formation
of the tympanic plexus.
. The lesser superficial petrosal nerve arises from the tympanic plexus,
passes through the lesser petrosal foramen to reach the middle
cranial fossa. Then it passes through foramen ovale to reach the
infratemporal fossa where it relays in the otic ganglion.
. Postganglionic parasympathetic fibers arise from the otic ganglion,
join the Auriculotemporal nerve to reach the parotid gland.
Lesser
Inferior salivary nucleus superficial
petrosal nerve Auriculotemporal
nerve
Tympanic plexus
Foramen
ovale

Jugular foramen
Middle ear

Tympanic branch
of Otic
glossopharyngeal ganglion

52
 CRANIAL CAVITY
The cranial cavity contains the brain and the surrounding cerebral meninges; pia
mater, arachnoid mater and dura mater. This chapter will concern with the study of
the cerebral dura mater.
The cerebral dural mater is formed of two layers: an inner layer called the dura mater
proper or the meningeal layer, and an outer layer called the endosteal layer.
The inner layer of the dura is reduplicated in certain places to form dural folds
which restrict the displacements of the brain.
Endothelial-lined tubes containing venous blood are present in certain places either
between the outer and inner layers of the dura or between the two layers of a dural
fold. These tubes are called the dural venous sinuses. These sinuses receive venous
blood and cerebrospinal fluid (CSF) from the brain, and they drain into the internal
jugular veins.

Skull

Superior sagittal sinus

Inner layer of dura

Falx cerebri

Inferior sagittal sinus

53
 DURAL FOLDS
1. Falx cerebri
• Shape and position
It is sickle-shaped lying in the sagittal plane between the two cerebral
hemispheres.
• Attachments
- Apex: Attached to the crista galli and the frontal crest.
- Base: Attached to the peak of the tentorium cerebelli.
- Upper convex border: Attached to the margins of the superior sagittal
sulcus.
- Lower free border.
• Related sinuses
- Superior sagittal sinus: Lies along the upper border.
- Inferior sagittal sinus Lies along the posterior 2/3 of the inferior border.
- Straight sinus: Lies between the base of the falx cerebri and the peak of the
tentorium cerebelli.

Falx cerebri

Tentorium
cerebelli

2. Tentorium cerebelli
• Shape and position
It is tent-like stretching horizontally across the posterior cranial fossa
separating the posterior parts of the cerebral hemispheres from the cerebellum.

54
 • Attachments
- Peak: Attached to the base of the falx cerebri.
- Free border: It is U-shaped enclosing a tentorial notch that encloses the
midbrain. It is attached to the anterior clinoid processes.
- Attached border: Attached to the posterior clinoid process, margins of
superior petrosal and transverse sulci. It is crossed by the free border and
three cranial nerve pierce the dura in relation to the site of crossing:
a. In front of the crossing: Oculomotor nerve (3rd cranial nerve).
b. At the site of crossing: Trochlear nerve (4th cranial nerve).
c. Behind the crossing: Trigeminal nerve (5th cranial nerve).
• Related sinuses
- Straight sinus: Lies between the base of the falx cerebri and the peak of the
tentorium cerebelli.
- Transverse sinuses: Lie along transverse sulci.
- Superior petrosal sinuses: Lie along the superior petrosal sulci.

Free border

Attached border

Tentorium
cerebelli

55
3. Falx cerebelli
• Shape and position
It is a small triangular fold in the posterior cranial fossa below the tentorium
cerebelli projecting in the posterior notch of the cerebellum.

Falx cerebri

Tentorium cerebelli
Straight sinus

Falx cerebelli

• Attachments
- Base: Attached to the posterior part of the peak of the tentorium cerebelli.
- Attached border: Attached to the internal occipital crest.
- Free border: Projects in the posterior notch of the cerebellum.
- Apex: Reaches the posterior boundary of foramen magnum.
• Related sinuses
- Occipital sinus: Lies along the attached border.
- The posterior part of the straight sinus: Lies along its base.
4. Diaphragma sellae
A small circular fold of dura that forms a roof for the sella turcica. A small
opening in its center allows passage of the stalk of the pituitary gland.

56
 DURAL VENOUS SINUSES
A. Single dural venous sinuses
1. Superior sagittal sinus
- It begins at the foramen coecum and ends usually in the right transverse
sinus. Occasionally it ends in the left transverse sinus and rarely in the
confluence of sinuses on the internal occipital protuberance.
- It receives:
a. Superior cerebral veins.
b. Cerebrospinal fluid.
c. Emissary veins:
. Through parietal emissary foramina: Connect the sinus with the
occipital venous plexus.
. Through the foramen coecum: Connect the sinus with nasal veins.
- Drainage:
Blood passes in the sinus from before backwards to end usually in the right
transverse sinus, occasionally in the left transverse sinus and rarely in the
confluence of sinuses.
2. Inferior sagittal sinus
- It lies in the posterior 2/3 of the lower free border of the falx cerebri.
- It receives inferomedial cerebral veins.
- Drainage:
It unites with the great cerebral vein to form the straight sinus.
3. Straight sinus
- Lies between the base of the falx cerebri and the peak of the tentorium
cerebelli.
- It is formed by union of the Inferior sagittal sinus and the great cerebral
vein
- Drainage
It usually drains into the left transverse sinus, occasionally in the right
transverse sinus and rarely in the confluence of sinuses.
4. Occipital sinus
- It lies along the internal occipital crest at the attached border of the falx
cerebelli.
- It receives veins from the cerebellum.
- It drains into the internal vertebral venous plexus.

57
 Inf.sagittal sinus
Great cerebral vein

Sup. sagittal sinus

Rt. transverse sinus

Cavernous sinus

Lt. transverse sinus

Ophthalmic vein

Sphenoparietal sinus

Sup. Petrosal sinus

Straight sinus
Sigmoid
Inf. petrosal sinus sinus

Internal jugular vein

Sphenoparietal sinus

Ophthalmic vein

Cavernous sinus

Sup. Petrosal sinus

Inf. petrosal sinus

Rt. transverse
sinus

Internal jugular vein

Sup. sagittal sinus Sigmoid sinus

58
B. Paired dural venous sinuses
1. Transverse sinus
- It occupies the transverse sulcus along the attached border of the
tentorium cerebelli.
- It receives:
a. The right sinus usually receives the superior sagittal sinus and
the left sinus usually receives the straight sinus.
b. Superior petrosal sinus.
c. Inferolateral cerebral veins.
d. Cerebellar veins.
- Drainage: Into the sigmoid sinus.
2. Sigmoid sinus
- In the sigmoid sulcus.
- It receives:
a. Transverse sinus.
b. Emissary veins through the mastoid emissary foramen connecting the
sinus with the occipital venous plexus.
- Drainage: Into the internal jugular vein.
3. Cavernous sinus
- It Lies on the side of the body of the sphenoid between the outer
and inner layers of dura mater. Its anterior end lies immediately
behind the medial end of the superior orbital fissure, and its
posterior end extends till the apex of the petrous part of the
temporal bone.
- Relations:
a. Medially: Pituitary gland and sphenoidal air sinus.
b. Laterally: Temporal lobe of the brain and trigeminal ganglion.
c. Embedded in the lateral wall from above downwards:
. Oculomotor nerve (3)
. Trochlear nerve (4)
. Ophthalmic division of trigeminal (5)
. Maxillary division of trigeminal (5)
d. Inside the sinus:
. Internal carotid artery.
. Abducent nerve (6) on the lateral side of the artery.

59
 Cavernous
sinus
Diaphragma sellae

Pituitary gland
3
Inner layer of dura
4
Outer layer of dura
Ophthalmic

Body of sphenoid Maxillary

6
Sphenoidal air Internal carotid
sinuses artery

- Communications:
a. Anteriorly: Ophthalmic veins and sphenoparietal sinus.
b. Posteriorly: Superior and inferior petrosal sinuses.
c. Superiorly: Superficial middle cerebral vein.
d. Inferiorly:
. Emissary veins through foramen ovale: They connect the
sinus with the pterygoid venous plexus.
. Emissary veins through foramen lacerum and carotid canal:
They connect the sinus with the pharyngeal venous plexus.
e. Medially: It is connected to the opposite cavernous sinus by
anterior and posterior intercavernous sinuses which pass in the
diaphragma sellae in front and behind the pituitary stalk.
- Drainage: Into the superior and inferior petrosal sinuses.

60
 Ophthalmic vein

Superficial middle
cerebral vein

Sphenoparietal
Intercaverno sinus
us sinus

Foramen ovale

Sup. petrosal sinus Pterygoid

venous plexus

Inf. Petrosal sinus

Carotid canal

Pharyngeal
plexus

4. Superior petrosal sinus

- Lies in the superior petrosal sulcus along the attached border of
the tentorium cerebelli.
- It receives blood from the cavernous sinus.
- It is drained into the transverse sinus.

5. Inferior petrosal sinus

- It lies in the inferior petrosal sulcus.
- It receives blood from the cavernous sinus.

61
 - It passes through the anterior part of the jugular foramen to end in
the internal jugular vein just below the skull.
6. Sphenoparietal sinus
- A small sinus that lies along the lesser wing of sphenoid.
- It receives some parietal cerebral veins.
- It is drained into the cavernous sinus.

NERVE AND ARTERIAL SUPPLY OF THE DURA

Nerve supply of the dura
Supratentorial dura : (5)
- Ethmoidal nerves which are branches of the nasociliary of the ophthalmic nerve
- Meningeal branch of maxillary nerve
- Meningeal branch of mandibular nerve (nervus spinosus)
Tentorium cerebelli: (5)
Meningeal branches of the ophthalmic nerve
Infratentorial dura: (9) (10) (C1) (C2)
Meningeal branches of glossopharyngeal (9), vagus (10) and 1st , 2nd cervical nerves
Arterial supply of the dura
1. Anterior and posterior ethmoidal arteries: They are branches of the ophthalmic
artery which is a branch of the internal carotid artery.
2. Meningeal branches of the internal carotid artery.
3. Vertebral artery which is a branch of the first part of subclavian artery.
4. Middle meningeal artery which is a branch of the maxillary artery.
5. Accessory meningeal artery which is a branch of the maxillary artery.
6. Ascending pharyngeal artery which is a branch of the external carotid artery.
7. Occipital artery which is a branch of the external carotid artery.

EMISSARY VEINS
- They are valveless veins that connect dural venous sinuses with extracranial
veins through emissary foramina.
- They equalize the venous pressure inside and outside the skull. However,
infection may spread from outside to inside the skull through the emissary veins.
- Types:
1. Veins connected to the superior sagittal sinus:

62
 - Through the parietal emissary foramina: To the occipital venous plexus.
- Through foramen coecum: To nasal veins.
2. Veins connected to the sigmoid sinus:
- Through the mastoid emissary foramina: To the occipital venous plexus.
- Through the posterior condylar canal: To the suboccipital venous plexus.
3. Veins connected to the cavernous sinus:
- Through foramen ovale: To the pterygoid venous plexus.
- Through foramen lacerum and the carotid canal: To the pharyngeal venous
plexus.

RELATIONS OF THE PITUITARY GLAND

Anteriorly: Optic chiasma.
Posteriorly: Dorsum sellae, basilar artery and pons.
On each side: Cavernous sinus.
Superiorly: Diaphragma sellae and hypothalamus.
Inferiorly: Sphenoidal air sinus.

63
 TEMPORAL
AND INFRATEMPORAL
FOSSAE

Muscles of mastication
Temporalis
- Origin:
a. Inferior temporal line.
b. Temporal fossa.
c. Deep surface of temporal fascia. The temporal fascia is attached above to the
superior temporal line and below to the zygomatic arch.
- Insertion:
a. The inner surface, apex and anterior and posterior borders of the coronoid
process of the mandible.
b. The anterior border of the ramus of the mandible.
- Nerve supply:
Deep temporal nerves from the anterior division of mandibular nerve.
- Action:
a. The anterior fibers elevate the mandible.
b. The posterior fibers retract the protracted mandible.
Masseter
- Origin:
From the lower border (superficial fibers) and inner surface (deep fibers) of the
zygomatic arch.
- Insertion:
Into the outer surface of the ramus of the mandible and the outer surface of the
coronoid process. The superficial fibers pass downwards and backwards, while
the deep fibers descend vertically downwards.
- Nerve supply:
Nerve to masseter from the anterior division of mandibular nerve.
- Action:
a. Elevates the mandible.
b. The superficial fibers can protract the mandible.

64
Temporalis

Masseter

65
Lateral pterygoid
- Origin:
a. Upper small head: From the infratemporal surface of the great wing of
sphenoid.
b. Lower larger head: From the lateral surface of the lateral pterygoid plate.
- Insertion:
a. The anteromedial surface of the neck of the mandible.
b. The capsule of temporomandibular joint.
c. The intra-articular disc of the temporomandibular joint.
Nerve to masseter
Deep temporal nerves

Buccal nerve
Lateral pterygoid

Lingual nerve

Med. pterygoid

Inferior alveolar nerve

- Nerve supply:
Nerve to lateral pterygoid from the anterior division of mandibular nerve.
- Action:
a. It assists in opening the mouth by pulling the head of the mandible and the
intra-articular disc forwards, and at the same time it rotates the head on the
lower surface of the disc.
b. When the 4 pterygoids act, they protrude the mandible.
c. When the lateral and medial pterygoids of one side act, they protrude the
mandible on the opposite side. Alternative actions of the pterygoids on the
two sides perform a side to side movement.
- Relations
1. Superficial:
- Second part of maxillary artery.

66
 - Pterygoid venous plexus.
- Ramus of mandible.
2. Deep:
- Mandibular nerve and its anterior and posterior divisions.
- Otic ganglion.
- Chorda tympani.
- Tensor palate.
- Wall of the pharynx.
- Middle and accessory meningeal arteries.
3. Along its upper border:
- Deep temporal nerves and vessels.
- Nerve to masseter.
4. Along its lower border:
- Lingual nerve.
- Inferior alveolar nerve.
5. Between its two heads:
- Maxillary artery.
- Buccal nerve.

Medial pterygoid
- Origin:
a. Superficial small head: From the maxillary tuberosity.
b. Deep larger head: From the medial surface of the lateral pterygoid plate. The
two heads embrace the lower head of the lateral pterygoid.
- Insertion: Into the inner surface of the angle of the mandible.
- Nerve supply:
Nerve to medial pterygoid from the main trunk of mandibular nerve.
- Action:
a. It elevates the mandible.
b. When the 4 pterygoids act, they protrude the mandible.
c. When the lateral and medial pterygoids of one side act, they protrude the
mandible on the opposite side. Alternative actions of the pterygoids on the
two sides perform a side to side movement.
- Relations
1. Superficial:
- Lateral pterygoid.
- Maxillary artery.
- Lingual nerve.
- Inferior alveolar nerve.
- Ramus of the mandible.

67
 2. Deep:
- Wall of the pharynx.
- Tensor palati.

Mandibular nerve
Origin and course
- It has two roots; a large sensory root which is one of the three divisions of the
trigeminal ganglion, and a smaller motor root from the motor nucleus of the
trigeminal nerve in the pons.
- The two roots pass through foramen ovale and join together just below the
skull to form a short trunk deep to the lateral pterygoid. The trunk
immediately divides into anterior and posterior divisions. The otic ganglion is
suspended from the medial side of the trunk.

Branches
From the main stem
1. Meningeal branch (Nervus spinosus): It enters the skull with the middle
meningeal artery through foramen spinosum to supply the dura mater.
2. Nerve to medial pterygoid: It supplies the medial pterygoid and gives a branch
that passes through the otic ganglion (without relay) to supply the tensor tympani
and tensor palati muscles.
From the anterior division (mainly motor)
1. Muscular branches:
a. Two deep temporal nerves: They appear at the upper border of the lateral
pterygoid to supply the temporalis muscle.
b. Nerve to masseter: It appears at the upper border of the lateral pterygoid then
passes in the mandibular notch to reach the masseter.
c. Nerve to lateral pterygoid.
2. Buccal nerve:
It passes between the two heads of the lateral pterygoid, runs downwards and
forwards to supply the skin and mucous membrane of the cheek.

68
 Sensory root of Motor root of
trigeminal trigeminal

Foramen
ovale Tensor tympani
Middle meningeal
artery
Tensor palate

Otic ganglion
Nervus spinosus Medial pterygoid

1
Auriculotemporal
nerve 2
3

Buccal
Anterior nerve
Posterior division division

1= Lateral pterygoid
Inferior 2= Masseter
alveolar 3= Temporalis
nerve

Lingual nerve

Nerve to
mylohyoid

Mylohyoid
Mandibular
foramen Mental
Anterior belly of
Mental nerve
digastric
foramen

69
From the posterior division (mainly sensory)
1. Auriculotemporal nerve:
- Course:
It arises by two roots that surround the middle meningeal artery. It passes
backwards between the Sphenomandibular ligament and the neck of the
mandible, then passes laterally behind the temporomandibular joint, then
upwards through the upper part of the parotid gland. It appears at the upper
end of the parotid behind the superficial temporal vessels and ascends in front
of the auricle to the scalp.
- Supplies:
The skin of the scalp above the auricle & the upper 2/3 of the outer
surface of the auricle and a part of the external auditory tube and ear
drum.

2. Lingual nerve:
- Course:
• Deep to the lateral pterygoid, it receives the chorda tympani which is a
branch of the facial nerve.
• It runs downwards and forwards to appear at the lower border of the lateral
pterygoid to lie on the surface of the medial pterygoid in front of the
inferior alveolar nerve.
• Then it lies in a groove just below the last lower molar tooth where it
becomes liable to injury during extraction of the last lower molar tooth.
• Then it continues forwards in the submandibular region where it runs on
the lateral surface of the hyoglossus immediately above the deep part of the
submandibular gland and its duct and the submandibular ganglion
suspends from it.
• At the anterior border of the hyoglossus it curves lateral, below then
medial to the submandibular duct (a triple relation).
• Then both the nerve and the duct pass deep to the sublingual salivary gland
just deep to the mucous membrane of the floor of the mouth where the
lingual nerve divides into terminal branches.

70
 Tongue

Lingual nerve

Deep part of
submandibular
salivary gland Sublingual salivary gland

Hyoglossus Submandibular duct

Hyoid bone

- Supplies:
• General sensation to the anterior 2/3 of the tongue and the adjacent part of
the mucous membrane of the floor of the mouth.
• Through the chorda tympani, it supplies:
- Taste sensation to the anterior 2/3 of the tongue.
- Preganglionic parasympathetic fibers to the submandibular ganglion.
3. Inferior alveolar nerve:
- Course:
• At its origin it lies deep to the lateral pterygoid.
• It runs downwards and forwards to appear at the lower border of the lateral
pterygoid to lie on the surface of the medial pterygoid behind the lingual
nerve.

71
 •Before entering the mandibular foramen it gives the mylohyoid nerve
which runs in the mylohyoid groove and ends by supplying the mylohyoid
muscle and the anterior belly of digastric.
• In the mandibular canal it gives alveolar branches to the lower teeth.
• It ends by passing through the mental foramen as the mental nerve which
supplies the skin of the chin and lower lip.
- Supplies:
• Motor supply to the mylohyoid muscle and the anterior belly of digastric.
• Sensory supply to the lower teeth, skin of chin and lower lip.

Maxillary nerve
Origin and course
- It is one of the three divisions of the trigeminal ganglion.
- It passes forwards on the lateral side of the body of the sphenoid embedded in the
lower part of the lateral wall of the cavernous sinus.
- It passes through the foramen rotundum to reach the pterygopalatine fossa. A
parasympathetic ganglion, called the sphenopalatine ganglion, is suspended from
the nerve while lying in the pterygopalatine fossa.
- Then it leaves the pterygopalatine fossa by passing through the inferior orbital
fissure to reach the orbit.
- The continuation of the maxillary nerve in the orbit, which is called the
infraorbital nerve, runs through the infraorbital groove and canal in the floor of
the orbit.
- It emerges from the infraorbital foramen to divide in the face into three terminal
branches (palpebral, nasal and labial).
Branches
1. In the cranial cavity it gives meningeal branches that supply the dura mater.
2. In the pterygopalatine fossa it gives:
a. Two ganglionic branches that suspend the sphenopalatine ganglion. They are
formed of the sensory branches of the sphenopalatine ganglion that convey
sensations from different areas and join the maxillary nerve.
b. Zygomatic: Enters the orbit through the inferior orbital fissure. It divides into
zygomaticotemporal and zygomaticofacial branches that pass through special
canals to reach the scalp and face.
c. Posterior superior alveolar (posterior superior dental); It passes through the
posterior superior alveolar foramen on the back of the maxilla that leads to a
canal in the posterior wall of the maxilla. It supplies the upper molars.

72
 3. In the orbit it gives:
a. Middle superior alveolar (middle superior dental): It arises from the
infraorbital nerve while lying in the infraorbital groove. It runs in a bony
canal in the lateral wall of the maxilla. It supplies the upper premolars.
b. Anterior superior alveolar (anterior superior dental): It arises from the
infraorbital nerve while lying in the infraorbital canal. It runs in a bony canal
in the anterior wall of the maxilla. It supplies the upper canine and incisors.
4. Terminal branches:
a. Palpebral: To the skin of the lower eyelid.
b. Nasal: To the ala of the nose.
c. Labial: To the upper lip.

5. Indirect branches which form the sensory branches of the sphenopalatine

ganglion. These nerves descend from the maxillary nerve, pass through the
ganglion to carry sensations from different areas.

Meningeal Foramen Zygomatic

branches rotundum nerve

Inferior orbital
fissure

1
2 3
Infraorbital
Trigeminal Sphenopalatine canal
ganglion ganglion

Maxillary
nerve

1= Posterior superior alveolar nerve Premolars Incisors

2= Middle superior alveolar nerve Molars and canine
3= Anterior superior alveolar nerve

73
 Sphenopalatine ganglion
(Pterygopalatine ganglion)
Site
In the pterygopalatine fossa suspended from the maxillary nerve by two
rami (the ganglionic branches of the maxillary nerve)

Roots or branches
1. Parasympathetic root
- Preganglionic parasympathetic fibers come from the geniculate ganglion of
the facial nerve in the internal ear as the greater superficial petrosal nerve. The
greater superficial petrosal nerve leaves the internal ear and the petrous bone
through the greater petrosal foramen on the anterior surface of the petrous and
it unites with the deep petrosal nerve, which is a sympathetic nerve that comes
from the sympathetic plexus around the internal carotid artery, to form
together the nerve of pterygoid canal (vidian nerve). This nerve passes
through the pterygoid canal to reach the pterygopalatine fossa where the
greater superficial petrosal nerve relays in the sphenopalatine ganglion.
- Postganglionic parasympathetic fibers arise from the ganglion to supply the
lacrimal gland and mucous glands of the nose, mouth and palate.
2. Sympathetic root
The deep petrosal nerve, which is a branch from the sympathetic plexus around
the internal carotid artery, reach the pterygopalatine fossa via the vidian nerve. It
enters the ganglion and leaves it without relay to supply the lacrimal gland and
mucous glands of the nose, mouth and palate.

74
Facial nerve Greater petrosal foramen Sphenopalatine
ganglion
Greater superficial petrosal
Geniculate nerve
ganglion

Internal
carotid artery Deep petrosal Pterygoid Vidian
nerve canal nerve
Sympathetic
plexus

3. Sensory root
These nerves descend from the maxillary nerve, pass through the ganglion then
emerge from the ganglion to carry sensations from different areas (orbit, nose,
palate and nasopharynx).
a. Orbital branch:
Descends from the ganglion, passes through the inferior orbital fissure to carry
sensation from the periosteum of the orbit.
b. Pharyngeal branch:
Descends from the ganglion, passes through the palatovaginal canal to carry
sensation from the mucous membrane of the nasopharynx.
c. Greater palatine nerve:
Descends from the ganglion, passes through the greater palatine foramen to
reach the hard palate where it passes forwards in a groove on the side of the
palate. Then it passes through the lateral incisive foramen to reach the nose
where it passes backwards on the lateral wall of the nose. It carries sensation
from the mucous membranes of the hard palate and the lateral wall of the
nose.
d. Lesser palatine nerve:

75
 Descends from the ganglion, passes through the lesser palatine foramen, then
passes backwards in the soft palate from which it carries sensation.
e. Long sphenopalatine nerve:
Descends from the ganglion, passes through the sphenopalatine foramen to
reach the nose where it runs forwards on the nasal septum. Then it passes
through a median incisive foramen (the left through the anterior foramen and
the right through the posterior foramen) to reach the anterior part of the hard
palate. It carries sensation from the mucous membrane of the nasal septum
and the anterior part of the hard palate.
f. Short sphenopalatine nerve:
Descends from the ganglion, passes through the sphenopalatine foramen to
reach the nose where it carries sensation from its mucous membrane.

1
Orbit 3
Naso
4 pharynxx

14 15 2
Nose
10 5
13
8
Pterygopalatine fossa

12 7 9
11

Hard palate Soft palate

1= Maxillary nerve 9= Lesser palatine canal

2= Sphenopalatine ganglion 10= Lesser palatine nerve
3= Inferior orbital fissure 11= Lateral incisive canal
4= Orbital nerve 12= Median incisive canal
5= Palatovaginal canal 13= Long sphenopalatine nerve
6= Pharyngeal nerve 14= Sphenopalatine foramen
7= Greater palatine canal 15= Short sphenopalatine nerve
8= Greater palatine nerve

76
 Otic ganglion
Site
In the infratemporal fossa just below foramen ovale. It is suspended by two rami
from the main trunk of the mandibular nerve.
Roots or branches
1. Parasympathetic root
. The preganglionic fibers arise from the inferior salivary nucleus of the
glossopharyngeal nerve.
. The fibers leave the nerve as its tympanic branch that enters the petrous
bone to reach the middle ear where it shares in the formation of the
tympanic plexus.
. The lesser superficial petrosal nerve arises from the tympanic plexus,
passes through the lesser petrosal foramen to reach the middle cranial
fossa. Then it passes through foramen ovale to reach the infratemporal
fossa where it relays in the otic ganglion.
. Postganglionic parasympathetic fibers arise from the otic ganglion, join
the Auriculotemporal nerve to reach the parotid gland.
2. Sympathetic root
A branch from the sympathetic plexus around the middle meningeal artery enters
the ganglion and leaves it without relay to accompany the parasympathetic fibers
to the parotid gland.
3. Sensory root
Some of the sensory fibers of the Auriculotemporal nerve join the otic ganglion
without relay.
Otic
ganglion
Mandibular
nerve

Auriculotemporal
nerve

77
4. Motor root
A branch from the nerve to medial pterygoid, which is a branch from the main
trunk of the mandibular nerve, enters the ganglion then leaves it without relay to
supply the tensor tympani and tensor palati muscles.

Maxillary artery
Origin
It is the larger of the two terminal branches of the external carotid artery inside the
parotid gland at the level of the neck of the mandible.
Course
Its course is divided by the lateral pterygoid muscle into three parts:
- First part: Leaves the parotid gland through its anteromedial surface, passes
forwards deep to the neck of the mandible to reach the lower border of the lateral
pterygoid.
- Second part: Passes upwards and forwards on the surface of the lateral pterygoid.
- Third part: Dips between the two heads of the lateral pterygoid then passes
through the pterygomaxillary fissure to reach the pterygopalatine fossa. It
accompanies the maxillary nerve and both the artery and the nerve pass through
the inferior orbital fissure to reach the orbit. In the orbit they are called the
infraorbital artery and nerve and they pass through the infraorbital groove and
canal and then emerge from the infraorbital foramen to reach the face.

Branches
Branches of the first part
1. Deep auricular artery: Supplies the external auditory tube and the ear drum.
2. Anterior tympanic artery: Supplies the middle ear.
3. Inferior alveolar artery: Accompanies the inferior alveolar nerve.
4. Accessory meningeal artery: Enters the cranial cavity through foramen ovale to
share in the blood supply of the dura mater.
5. Middle meningeal artery:
• Course:
- It ascends deep to the lateral pterygoid between the two roots of the
auriculotemporal nerve to enter the cranial cavity through foramen
spinosum.
- It ascends extradurally for about 2 cm then divides into anterior and
posterior branches that share in the blood supply of the dura mater.

78
 - The anterior branch runs up to the pterion, then passes upwards and
backwards to a midpoint between the nasion and inion. During its
extradural course, it runs opposite the motor area of the brain.
- The posterior branch passes backwards towards the lambda.
• Surface anatomy:
- The main stem: Represented by a line between the midzygomatic point
and a point 2cm above it.
- The anterior branch: Represented by a line connecting 3 points: the first
is 2 cm above the midzygomatic point, the second is at the center of the
pterion, and the third is midway between nasion and inion.
- The posterior branch: Represented by a line connecting a point 2 cm
above the midzygomatic point and a point opposite the lambda which lies
about 3 cm above the inion.
Branches of the second part
1. Muscular branches to the muscles of mastication.
2. Buccal artery: Accompanies the Buccal nerve.
Branches of the third part
1. Posterior superior alveolar artery: Accompanies the corresponding nerve. It
supplies the upper molars and premolars.
2. Anterior superior alveolar artery from the infraorbital artery which is the
continuation of the third part of the maxillary artery. It supplies the upper canine
and incisors.
3. Zygomatic artery: Accompanies the corresponding nerve and divides into
zygomaticotemporal and zygomaticofacial arteries.
4. Greater palatine artery: It passes through the greater palatine foramen to the hard
palate, then passes forwards to reach the nose through the lateral incisive
foramen. It supplies the mucous membrane of the hard palate and nose. It also
gives 2-3 lesser palatine branches to the soft palate
5. Sphenopalatine artery: Passes through the sphenopalatine foramen to the nose.
6. Pharyngeal branch: Accompanies the pharyngeal branch of the sphenopalatine
ganglion to share in the supply of the nasopharynx.
7. Orbital branch: Accompanies the orbital branch of the sphenopalatine ganglion
to share in the supply of the periosteum of the orbit. It also gives supply to the
inferior rectus and inferior oblique muscles
8. Artery of pterygoid canal: Passes backwards in the canal to share in the supply of
the nasopharynx
9. The termination of the infraorbital shares in the arterial supply of the face.

79
 Deep auricular artery

Middle meningeal artery

Anterior tympanic Accessory meningeal artery
artery

Artery to masseter
Artery to lateral pterygoid
Artery to temporalis

Superficial Lateral pterygoid

temporal
artery

Artery to medial
pterygoid

Buccal artery
Maxillary
artery

Inferior alveolar artery

External carotid artery

Medial pterygoid

80
 Pterygoid venous plexus

Site
It lies on the surface of the lateral pterygoid muscle.
Tributaries
It receives veins that accompany the branches of the maxillary artery.
Drainage
It is drained by the maxillary vein which enters the parotid gland through its
anteromedial surface to join the superficial temporal vein to form together the
retromandibular or posterior facial vein.
Communications
1. With the anterior facial vein through the deep facial vein which passes through
the fat covering the buccinator muscle.
2. With the ophthalmic veins through the inferior orbital fissure.
3. With the cavernous sinus through emissary veins passing through foramen ovale.

Superficial temporal Cavernous Ophthalmic

vein sinus vein

Foramen
ovale

Inferior orbital fissure

Deep facial Anterior facial

vein vein

Maxillary vein

Retromandibular
vein

81
 ORBIT
Eye ball
Iris
Cornea
Anterior chamber
Ciliary muscle

Sclera

Ciliary body
Retina
Suspensory ligaments of
the lens
Choroid
Lens
Optic nerve

The eye ball consists of three coats:

1. Outer fibrous coat:
- The cornea which is transparent forms the anterior 1/5 of this coat.
- The sclera which is formed of dense fibrous tissue and is white in
colour forms the posterior 4/5 of this coat.
2. Middle vascular pigmented coat:
a. Choroid: Formed of an outer pigmented layer and an inner highly
vascular layer.
b. Ciliary body: It has many processes called the ciliary processes which
are connected to the suspensory ligaments of the lens. The ciliary
muscle lies on the outer surface of the processes. The muscle arises
from the corneoscleral junction and is inserted in the posterior part of
the ciliary body. Contraction of the ciliary muscle pulls the ciliary
body forwards thus the suspensory ligaments of the lens become
relaxed and the elastic lens becomes more convex.

82
 c. Iris: It is a thin pigmented membrane with a central opening called the
pupil. It contains circular
smooth muscle fibers called the sphincter pupillae and radial smooth
muscle fibers called the dilator
pupillae. The iris divides the space between the
cornea and lens into anterior and posterior chambers
which are filled with clear fluid called the aqueous humor.
3. Inner nervous coat: (Retina):
The retina consists of an outer pigmented layer and an inner nervous layer.
The inner surface of the retina is in contact with the vitreous body which is a
transparent gel which fills the eye ball behind the lens.

Fascial sheath of the eye ball

- It surrounds the eye ball from the optic nerve to the corneoscleral
junction. It is perforated by the tendons of the orbital muscles and
reflected on each of them as a tubular sheath.
- The sheaths of the tendons of the medial and lateral recti are attached to
the medial and lateral walls by medial and lateral check ligaments.
- The lower part of the fascial sheath is thickened and called the
suspensory ligament of the eye that connects the two check ligaments.

83
 Lacrimal apparatus
Lacrimal gland
- Site:
. Its larger (orbital) part lies in the lacrimal fossa in the anterolateral
part of the roof of the orbit.
. Its smaller (palpebral) part lies in the upper lid deep to the
conjunctiva.
- Ducts:
About 8-10 ducts arise from the palpebral part of the gland, pierce the
upper fornix of the conjunctiva to open in the conjunctival sac.
- Parasympathetic (secretomotor) supply:
Some of the postganglionic fibers of the sphenopalatine ganglion join
the zygomatic nerve then transmitted to the lacrimal nerve through a
communicating branch between the zygomatic and lacrimal nerves.
The lacrimal nerve carries them to the gland.

Lacrimal canaliculus

Lacrimal sac

Lacrimal gland Lacrimal

punctum Nasolacrimal duct

84
 Greater
superficial
petrosal Maxillary nerve
nerve

Facial nerve Pterygoid Zygomatic nerve

canal

Geniculate
ganglion
Lacrimal nerve

Vidian nerve
Lacrimal
Sphenopalatine ganglion gland

Lacrimal sac
- It lies in the lacrimal groove in the medial wall of the orbit.
- It receives the tears through two lacrimal canaliculi which open on the
margins of the lids by lacrimal puncti. Tears pass from the lacrimal
gland to the sac by the muscular action of the orbicularis oculi.
Nasolacrimal duct
It descends from the lacrimal sac through the nasolacrimal canal to open in
the inferior meatus of the nose

Extraocular muscles
Origin and insertion
1. Levator palpebrae superioris
Origin:
From the roof of the orbit just in front of the optic canal.
Insertion:
It runs forwards on the upper surface of the superior rectus to be inserted
in the skin and tarsus of the upper lid as well as the upper fornix. The
deep part of the muscle is formed of smooth muscle fibers.

85
 Levator palpebrae superiosis

Skin of upper lid

Conjunctiva of
upper lid

Deep smooth part

2. Recti
Origin:
a. Superior rectus
From the upper part of the common tendinous ring which is a
fibrous ring attached to the upper, medial and lower margins of the
optic foramen and to a spin e on the lower margin of the superior
orbital fissure.
b. Inferior rectus
From the lower part of the common tendinous ring
c. Medial rectus
From the medial part of the common tendinous ring

d. Lateral rectus: Arises by two heads:

- Upper head: From the lateral part of the common tendinous ring
- Lower head: From the lower part of the common tendinous ring
in common with the inferior rectus.
Insertion:
They are inserted in the sclera at variable distances from the
corneoscleral junction:
Superior rectus: At 7.7 mm from the corneoscleral junction.
Medial rectus: At 5.5 mm from the corneoscleral junction.
Inferior rectus: At 6 mm from the corneoscleral junction.
Lateral rectus: At 7 mm from the corneoscleral junction.

86
 Optic canal
Superior orbital fissure LPS

SR
SO

MR

LR

IR

3. Obliques
Trochlea

IO

SO

Superior oblique
Origin
From the roof of the orbit just above the optic canal.
Insertion
It runs forwards on the medial wall of the orbit above the medial
rectus. Its tendon passes through the trochlea, passes backwards
and laterally above the eye ball to be inserted in the lateral side of

87
 the sclera midway between the corneoscleral junction and the exit
of the optic nerve.
Inferior oblique
Origin
From the anteromedial part of the floor of the orbit.
Insertion
It passes backwards and laterally below the inferior rectus to be
inserted in the lateral side of the sclera midway between the
corneoscleral junction and the exit of the optic nerve.

Nerve supply
- The Oculomotor nerve (3rd cranial nerve) supplies 7 of the 10 ocular
muscles: 5 extraocular muscles (levator palpebrae superioris, superior
rectus, inferior rectus, medial rectus and inferior oblique) and 2
intraocular muscles (sphincter pupillae and ciliary muscles)
- The trochlear nerve (4th cranial nerve) supplies the superior oblique.
- The Abducent nerve (6th cranial nerve) supplies the lateral rectus.
- The dilator pupillae and the deep part of the levator palpebrae
superioris receive sympathetic supply.
Action

IO SR

MR
LR

SO
IR

88
 - Levator palpebrae superioris: Elevation of the upper eye lid.
Stimulation of the sympathetic innervation results in further elevation
of the lid. Injury of the oculomotor nerve leads to drooping of the
upper lid (ptosis). Cervical sympathetic paralysis (Horner’s syndrome)
also leads to ptosis.
- Lateral rectus: Abduction of the eye.
- Medial rectus: Adduction of the eye.
- Superior rectus: Adduction and elevation of the eye.
- Inferior rectus: Adduction and depression of the eye.
- Superior oblique: Abduction and depression of the eye.
- Inferior oblique: Abduction and elevation of the eye.

For pure depression, the inferior rectus and superior oblique should act
together. Similarly, for pure elevation, the superior rectus and inferior
oblique should act together.

Orbital nerves
Oculomotor nerve (3rd cranial nerve)
- It pierces the dura in front of the crossing of the two borders of the
tentorium cerebelli.
- Then it passes in the lateral wall of the cavernous sinus.
- Then it divides into superior and inferior divisions which pass through
the superior orbital fissure between the two heads of the lateral rectus.
- The superior division supplies the levator palpebrae superioris and
superior rectus. The inferior division supplies the medial rectus, the
inferior rectus and the inferior oblique. The branch to the inferior
oblique carries preganglionic parasympathetic fibers to the ciliary
ganglion from which postganglionic fibers supply the sphincter
pupillae and the ciliary muscle.

89
 LPS

SR
Somatic motor fibers

MR

Parasympathetic fibers
IR

IO Ciliary
ganglion
Sphincter pupillae

Ciliary muscle

Trochlear nerve (4th cranial nerve)

- It pierces the dura at the point of crossing of the two borders of the
tentorium cerebelli.
- Then it passes in the lateral wall of the cavernous sinus.
- It passes through the superior orbital fissure lateral to the common
tendinous ring.
- It supplies the superior oblique.
Abducent nerve (6th cranial nerve)
- It ascends on the clivus, pierces the dura lateral to the dorsum sellae.
- It passes inside the cavernous sinus lateral to the internal carotid
artery.
- It enters the orbit by passing through the superior orbital fissure
between the two heads of the lateral rectus.
- It supplies the lateral rectus.
Optic nerve (2nd cranial nerve)
- It is formed by collection of the axons of the ganglion cell layer of the
retina. It leaves the eye ball about 3mm medial to its posterior pole.
The area of the sclera that is pierced by the fibers of the optic nerve is
called lamina cribrosa which is a relatively weak area. If the

90
 intraocular pressure rises, the lamina cribrosa will bulge outward
producing a cupped disc.
- It leaves the orbit through the optic canal, ends at the optic chiasma
where there is decussation of the nasal fibers of the optic nerves. The
nerve is slightly longer than the distance in which it lies to allow easy
movements of the eye ball.
- The central retinal artery passes inside the optic nerve.
- The optic nerve has no neurolemmal sheath so it can not be
regenerated after injury.
- The optic nerve is covered by the three meninges. Increased pressure
of the CSF in the subarachnoid space presses on the central retinal
vein inside the optic nerve causing oedema of the optic disc which is
the site of the retina corresponding to the exit of the optic nerve.
Ophthalmic division of trigeminal (5th cranial) nerve
It passes in the lateral wall of the cavernous sinus, divides into three
branches which pass through the superior orbital fissure to reach the orbit.
Frontal nerve
It runs forwards above the levator palpebrae superioris just beneath the roof
of the orbit. It divides into supraorbital and supratrochlear nerves.
Lacrimal nerve
It runs forwards on the lateral wall of the orbit above the lateral rectus. It
supplies the lacrimal gland by both sensory fibers and secretomotor
parasympathetic fibers which originate from the sphenopalatine ganglion
and join the nerve through a communication with the zygomatic nerve.
Nasociliary nerve
- It enters the orbit through the superior orbital fissure between the two
heads of the lateral rectus between the superior and inferior divisions of
the Oculomotor nerve.
- It runs forwards and medially crossing above the optic nerve parallel to
the ophthalmic artery to reach the medial wall of the orbit where it passes
forwards between the superior oblique and the medial rectus.
- Branches:
1. Sensory twigs to the ciliary ganglion. These fibers emerge from the
ganglion to supply the cornea and they form the sensory part of the
corneal reflex.
2. Two long ciliary nerves: They arise from the nasociliary nerve as it
crosses the optic nerve. They pass forwards with the optic nerve and
pierce the sclera. They pass deep to the sclera to reach the ciliary body
then the iris. It supplies sympathetic fibers to the dilator pupillae

91
 muscle. These sympathetic fibers originate from the plexus around the
internal carotid artery and join the nasociliary nerve.
3. Posterior ethmoidal nerve: It supplies the sphenoidal and posterior
ethmoidal air sinuses.
4. Anterior ethmoidal nerve: It passes through the anterior ethmoidal
foramen to reach the anterior cranial fossa then descends to the nose
through the cribriform plate of ethmoid. In the nose it is called the
internal nasal nerve, then it emerges between the nasal bone and
cartilage to reach the face as the external nasal nerve.
5. Infratrochlear nerve: It is the continuation of the nasociliary nerve in
the face.

Supratrochlear Supraorbital
nerve nerve
nerve

Palpebral nerve
Infratrochlear nerve

Lacrimal gland

Anterior ethmoidal nerve

Posterior ethmoidal nerve Lacrimal nerve

Frontal nerve
Long ciliary nerves

Nasociliary nerve Ciliary ganglion

Superior orbital
fissure
Optic nerve

92
 Ciliary ganglion
Site
It lies near the apex of the orbit between the optic nerve and the lateral rectus
muscle.
Roots
1. Sensory
Sensory twigs to the ciliary ganglion. These fibers emerge from the
ganglion to supply the cornea and they form the sensory part of the
corneal reflex.
2. Parasympathetic
The preganglionic fibers come from the branch of the inferior division of
oculomotor that supplies the inferior oblique. The postganglionic fibers
supply the ciliary and sphincter pupillae muscles
3. Sympathetic
Sympathetic fibers arise from the internal carotid plexus, join the
nasociliary nerve then enter the ciliary ganglion. The fibers leave the
ganglion without relay to supply the deep part of the levator palpebrae
superioris and the smooth muscle of the blood vessels of the orbit.

Nasociliary nerve

Oculomotor nerve

I.C.A

To deep part of L.P.S

To ciliary muscle

To smooth muscles of blood

vessels of the orbit To sphincter pupillae

Cornea

93
 Nasociliary nerve

Long ciliary nerves

to dilator pupillae
Ciliary
ganglion
L.P.S
Lacrimal nerve
I.C.A B. Vs
Lacrimal gland

Zygomatic nerve

Maxillary nerve

Sphenopalatine ganglion

Orbital vessels

Ophthalmic artery
- It arises from the internal carotid artery as it leaves the cavernous sinus.
- It passes forwards, with the optic nerve, through the optic canal to reach
the orbit. In the orbit it runs below then lateral to the optic nerve, then it
crosses above the nerve from lateral to medial with the nasociliary nerve.
It ends by two terminal branches: supratrochlear and dorsal nasal.
- Branches:
1. Lacrimal artery: it runs on the lateral wall of the orbit, supplies the
lacrimal gland. It gives a lateral palpebral branch which anastomoses
with the medial palpebral branch of the supratrochlear artery.
2. Anterior and posterior ciliary arteries: The anterior ciliary arteries
pierce the sclera near the corneoscleral junction, while the posterior
arteries pierce the sclera near the optic nerve.
3. Central retinal artery: It is an end artery that pierces the optic nerve.
4. Supraorbital artery which shares in the arterial supply of the scalp.

94
 5. Anterior and posterior ethmoidal arteries: They supply the sphenoidal
and ethmoidal air sinuses.
6. Muscular arteries.
7. Two terminal branches: Supratrochlear and dorsal nasal.

Lateral palpebral artery

Dorsal nasal artery

Supratrochlear artery
Lacrimal gland
Medial palpebral artery

Supraorbital artery

Anterior ethmoidal artery

Posterior ethmoidal artery

Lacrimal artery

Ciliary arteries
Nasociliary nerve

Central retinal artery

Optic nerve

Internal carotid artery

Ophthalmic veins
- There are superior and inferior ophthalmic veins above and below the
optic nerve respectively.
- They communicate anteriorly with the anterior facial vein. Posteriorly
they pass through the superior orbital fissure to end in the cavernous
sinus.
- The inferior ophthalmic vein is connected to the pterygoid venous plexus
through the inferior orbital fissure.

95
 Superior
ophthalmic vein
Superior
orbital
fissure

Cavernous sinus
Anterior
facial vein

Foramen ovale

Inferior orbital
fissure
Deep facial
vein
Pterygoid
Inferior venous
ophthalmic vein plexus

N.B: Structures passing through the superior orbital fissure:

Live: Lacrimal nerve. Lateral to the common tendinous ring.
Free: Frontal nerve. Lateral to the common tendinous ring.
To: Trochlear nerve. Lateral to the common tendinous ring.
See: Superior division of Oculomotor nerve. Within the ring.
No: Nasociliary nerve. Within the ring.
Insult: Inferior division of Oculomotor nerve. Within the ring.
At: Abducent nerve. Within the ring.
All: Ophthalmic veins. Below the ring

F I

T A

N
A

96
 DEEP FASCIA OF
THE NECK
Investing layer
Attachments
- Above: To the external occipital protuberance, superior nuchal lines,
mastoid processes, lower border of mandible and symphysis menti.
- Below: To the 7th cervical spine, spines of scapulae, acromion
processes of scapulae, clavicles and the upper border of the sternum.
- Posteriorly: To the ligamentum nuchae.
- Anteriorly: To symphysis menti, hyoid bone, thyroid cartilage, cricoid
cartilage and upper border of sternum.
Splittings
- Between the mastoid process and the angle of the mandible to enclose
the parotid gland
- At the lower border of the mandible to enclose the submandibular
salivary gland.
- To enclose the sternomastoid.
- To enclose the trapezius.
- Above the sternum where the splitting forms the suprasternal space
that contains:
1. The tendon of the sternal origin of the sternomastoid.
2. Interclavicular ligament.
3. Terminals of anterior jugular veins.
4. Jugular arch which is a small vein that connects the terminals of
the anterior jugular veins.
5. Suprasternal lymph node.
Carotid sheath
- It is a tube of fascia that extends from the base of the skull above to
the superior mediastinum of the thorax below. It is connected
medially to the prevertebral and pretracheal fasciae.
- It contains:
1. Common and internal carotid arteries.
2. Internal jugular vein.
3. Vagus nerve.

97
 4. The upper part of the sheath contains the lower four cranial nerves.
However, all leave the sheath except the vagus which continues
between the carotids and the internal jugular vein.
5. The sympathetic chain is embedded in the posterior wall of the
sheath.
6. The ansa cervicalis is embedded in the anterior wall of the sheath.
Prevertebral fascia
- It covers the prevertebral muscles and continues posteriorly to form
the fascia of the floor of the posterior triangle.
- It blends with the carotid sheath and the investing fascia on the deep
surface of the trapezius.
Pretracheal fascia
- It covers the front of the trachea and thyroid gland.
- Attachments:
1. Above: To the thyroid cartilage.
2. Below: Extends to the superior mediastinum.
3. On each side: It blends with the carotid sheath.
Buccopharyngeal fascia
- It covers the constrictors of the pharynx, buccinator muscles as well as
the oesophagus.
- A narrow space, called the retropharyngeal space, is enclosed between
the prevertebral and buccopharyngeal fasciae. It contains a lymph
node that drains the nasopharynx.

Investing fascia

Thyroid gland Pretracheal fascia

Trachea
Sternomastoid Buccopharyngeal fascia
Oesophagus
Carotid sheath
Retropharyngeal space
Prevertebral fascia
Prevertebral muscles

Trapezius

98
 POSTERIOR TRIANGLE
Boundaries
- Anteriorly: The posterior border of the sternomastoid.
Sternomastoid
+ Origin:
1. Sternal head (tendinous): the upper part of the anterior surface
of the manubrium.
2. Clavicular head (fleshy): Medial 1/3 of the upper surface of the
clavicle.
+ Insertion: The outer surface of the mastoid process.
+ Nerve supply:
1. Spinal accessory nerve (motor).
2. Fibers from C2 (proprioceptive).
+ Action:
1. When one muscle acts it bends the head to the same side and
rotates the head so that the face becomes directed upwards and
to the opposite side.
2. When both muscles act they can flex the head forwards.
3. It acts as an accessory muscle during forced inspiration.
- Posteriorly: The anterior border of the trapezius.
- Base (below): The middle 1/3 of the clavicle.
- Apex (above): Meeting of the anterior and posterior borders.
Roof
- Skin
- Superficial fascia: It contains the following structures:
1. Platysma:
• Origin: It is a thin muscle that arises from the deep fascia
covering the pectoralis major and deltoid.
• Insertion: Into the lower border of the mandible.
• Nerve supply: Cervical branch of facial nerve.
• Action: It assists in depressing the mandible.
2. External jugular vein.
3. Cutaneous branches of the cervical plexus:
a. Lesser occipital nerve (C2).
b. Great auricular nerve (C2&3).
c. Transverse cutaneous nerve of the neck (C2&3).

99
 d. Supraclavicular nerves (medial, lateral and intermediate)
(C3&4): They supply the skin of the front of the chest and
over the upper half of the deltoid.
- Deep fascia
• It is a part of the investing layer of the deep fascia of the neck.
• It is pierced by the external jugular vein and the cutaneous
branches of the cervical plexus.
• The spinal accessory nerve is embedded in the deep fascia of the
roof. It emerges from the middle of the posterior border of the
sternomastoid, passes downwards and laterally to enter the
trapezius.
Floor: Splenius capitis, levator scapulae and scalenus medius covered by
prevertebral fascia.
Splenius capitis
+ Origin: Lower part of ligamentum nuchae and spine of C7.
+ Insertion: Posterior border of the mastoid process.
+ Nerve supply: Dorsal ramus of C1.
+ Action: Extension and lateral rotation of the head.
Levator scapulae
+ Origin: Transverse processes of upper 4 cervical vertebrae.
+ Insertion: Upper part of dorsal surface of the medial border of the
scapula.
+ Nerve supply:
1. Dorsal scapular nerve (motor).
2. Fibers from C3&4 (proprioceptive).
+ Action
1. Elevation of the medial border of the scapula
2. Downward rotation of the scapula.
Scalenus medius
+ Origin: Anterior tubercles of transverse processes of lower 6
cervical vertebrae.
+ Insertion: Upper surface of first rib.
+ Nerve supply:
Ventral rami of the cervical nerves.
+ Action
1. Bends the neck to the sane side.
2. Helps to raise the first rib during forced inspiration.

100
 Sternomastoid

Trapezius

Splenius capitis

Levator scapulae

Scalenus medius

101
Contents
1. Nerves:
a) The three trunks of the brachial plexus.
b) All the branches of the roots and trunks of the brachial plexus:
- Nerve to rhomboids.
- Nerve to subclavius.
- Suprascapular nerve.
- Nerve to serratus anterior.
c) All the cutaneous branches of the cervical plexus.
d) Some of the muscular branches of the cervical plexus:
- Nerve to levator scapulae.
- Nerve to trapezius
- Nerve to sternomastoid
a) The spinal accessory nerve: It is usually embedded in the deep fascia
of the roof.
2. Arteries:
a) The third part of the subclavian artery.
b) Transverse cervical and suprascapular arteries which are branches of
the thyrocervical trunk of the first part of the subclavian artery.
c) Occipital artery: Near the apex of the triangle.
3. Veins:
a) Subclavian vein.
b) The lower part of the external jugular vein:
- The external jugular vein is formed below the angle of the
mandible by union of the posterior auricular vein and the posterior
division of the retromandibular vein.
- It descends vertically crossing the sternomastoid then in the
superficial fascia of the roof of the posterior triangle. It pierces the
deep fascia one inch above the clavicle to end in subclavian vein.
- It receives:
a. Anterior jugular vein: It is formed by union of small Submental
veins, descends in the front of the neck till the upper border of
the sternum where it turns laterally deep to the tendon of the
sternomastoid to end in the external jugular vein.
b. Transverse cervical vein.
c. Suprascapular vein.
4. Muscle: The inferior belly of omohyoid. The posterior triangle is
sometimes divided by the inferior belly of omohyoid into
subclavian triangle below and occipital triangle above.
5. Lymph nodes: Occipital and supraclavicular groups of lymph nodes.

102
Sternomastoid

Trapezius

Lesser occipital
nerve

Great auricular
External jugular vein
nerve
Transverse cutaneous
nerve of the neck
Spinal accessory
nerve

Supraclavicular
nerve
Upper trunk of
brachial plexus

Transverse cervical
artery
Inferior belly of
omohyoid Suprascapular artery

Subclavian artery Subclavian vein

103
Occipital artery

Splenius capitis

Trapezius
Sternomastoid

Levator scapulae
Scalenus medius

Scalenus anterior

Thyrocervical trunk

First part of subclavian

artery

Suprascapular artery
Transverse cervical artery

104
 ANTERIOR TRIANGLE
It is bounded posteriorly by the anterior border of the sternomastoid,
anteriorly by the midline and the base which lies above is the lower border
of the mandible. It is divided by the digastric muscle and the superior belly
of omohyoid into 3 ½ triangles: Digastric, carotid, muscular and half of the
Submental triangle on each side.

Digastric triangle
Trapezius

Posterior belly of Anterior belly of

digastric digastric

Sternomastoid Submental triangle

Carotid triangle

Superior belly of
omohyoid

Muscular triangle

Inferior belly of
omohyoid

105
 Digastric triangle
• Boundaries:
- Above: The lower border of the mandible.
- Below: The two bellies of digastric muscle.
• Floor:
- In front: Mylohyoid muscle.
- Behind: Hyoglossus muscle.

Mylohyoid
Posterior belly of digastric
Anterior belly
Hyoglossus of digastric

• Contents:
1. Submandibular salivary gland and
2. Submandibular lymph nodes.
3. Anterior facial vein.
4. Facial artery.
5. Hypoglossal nerve.

106
Posterior belly of
digastric Facial artery

Submandibular lymph
nodes
Hypoglossal nerve

Anterior facial vein

Carotid triangle
• Boundaries:
- Behind: The anterior border of the sternomastoid.
- Above: The posterior belly of digastric and a part of the hyoid bone.
- In front: The superior belly of omohyoid.
• Floor:
- In front: Thyrohyoid and hyoglossus muscles.
- Behind: Middle and inferior constrictors of the pharynx.
• Contents:
1. Carotid sheath: It contains the common and internal carotid arteries,
the internal jugular vein and the vagus nerve. The sympathetic chain is
embedded in the posterior wall of the sheath. The ansa cervicalis is
partially embedded in the anterior wall of the sheath.
2. Three of the tributaries of the internal jugular vein: Common facial,
lingual and superior thyroid veins.
3. External carotid artery and all its branches except three: Posterior
auricular, maxillary and superficial temporal arteries.
4. Lower three cranial nerves
5. Lymph nodes.

107
 Hyoglossus
Middle
constrictor of
the pharynx

Thyrohyoid

Superior belly
Inferior of omohyoid
constrictor of
the pharynx

108
 Facial artery
Occipital
artery Hypoglossal
nerve

Internal jugular vein

Spinal accessory
nerve

Lingual artery

Vagus nerve Superior thyroid artery

Common carotid
artery Ansa cervicalis

109
Muscular triangle
• Boundaries:
- Above: Superior belly of omohyoid.
- Posteriorly: The anterior border of the sternomastoid.
- Anteriorly: The midline of the neck.
• Floor (or contents):
The infrahyoid group of muscles. They are arranged in two groups:
Superficial group: Sternohyoid and omohyoid.

Superior belly Thyrohyoid

of omohyoid

Sternothyroid

Sternohyoid

Sternohyoid
- Origin: Inner surface of the upper part of the manubrium.
- Insertion: Lower border of the body of the hyoid bone.
- Nerve supply: Ansa cervicalis.
- Action: Depresses the hyoid bone.

110
 Omohyoid
- Origin: Superior belly: Lower border of the body of the hyoid bone.
Inferior belly: Upper border of the scapula.
- Insertion: The two bellies are connected by a central tendon deep to the
sternomastoid.
- Nerve supply: Ansa cervicalis.
- Action: Depresses the hyoid bone.
Sternothyroid
- Origin: Inner surface of the manubrium.
- Insertion: Oblique line of the thyroid cartilage.
- Nerve supply: Ansa cervicalis.
- Action: Depresses the thyroid cartilage.
Thyrohyoid
- Origin: Oblique line of the thyroid cartilage.
- Insertion: Lower border of the body of the hyoid bone.
- Nerve supply: Fibers from C1 through the hypoglossal nerve.
- Action: Depresses the hyoid bone or elevates the thyroid cartilage.

Submental triangle
• Boundaries: Anterior bellies of digastric and the body of hyoid bone.
• Floor: The two mylohyoid muscles with a median raphe in between.
• Contents: Submental veins and Submental lymph nodes.

Anterior belly of Mylohyoid

digastric

Mylohyoid
raphe

111
 SUBMANDIBULAR
REGION
Submandibular muscles
Digastric muscle
- Origin:
Anterior belly: From the digastric fossa on the lower border of the
body of the mandible.
Posterior belly: From the digastric notch on the medial side of the
mastoid process.
- Insertion:
The two bellies are connected by an intermediate tendon which is
attached to the hyoid bone by a fibrous pulley.
- Nerve supply:
Anterior belly: Nerve to mylohyoid from the inferior alveolar nerve.
Posterior belly: Facial nerve.
- Action:
Can raise the hyoid bone or depress the mandible.
- Relations:
A. Relations of the anterior belly:
1. Superficial relations: Skin, superficial fascia, platysma, deep
fascia and it is overlapped by the submandibular gland.
2. Deep relations: Mylohyoid muscle.
B. Relations of the posterior belly:
1. Superficial relations:
a. Mastoid process.
b. Sternomastoid muscle.
c. Parotid gland.
d. Angle of the mandible.
e. Submandibular salivary gland.
f. Anterior facial vein.

112
 2. Deep relations:
a. Three large vessels: External and internal carotid arteries
and Internal jugular vein.
b. Two smaller arteries: Facial and occipital arteries.
c. The lower three cranial nerves.
d. The sympathetic chain
Internal carotid artery
External carotid artery

Internal jugular vein

Posterior auricular artery

Stylohyoid muscle

Facial artery Occipital artery

Hyoglossus
Spinal accessory nerve
Anterior belly
of digastric Hypoglossal nerve
Ansa cervicalis
Mylohyoid

Lingual artery Vagus nerve

Superior thyroid artery

Hyoglossus
- Origin:
From the body and greater horn of the hyoid bone.
- Insertion:
Into the posterior half of the side of the tongue.
- Nerve supply:
Hypoglossal nerve.
- Action:
Depresses the posterior half of the tongue. This action is purely done
during suckling, so it is called the muscle of suckling.
- Relations
A. Superficial relations:
1. Lingual nerve.
2. Submandibular ganglion.

113
 3. Deep part of the submandibular salivary gland.
4. Submandibular duct.
5. Hypoglossal nerve.
6. Vena comitans nervi hpoglossi.
7. Suprahyoid artery.
8. Mylohyoid muscle.
9. Central tendon of digastric.
10. Insertion of styloglossus muscle.
B. Deep relations:
1. Stylohyoid ligament.
2. Stylopharyngeus muscle.
3. Glossopharyngeal nerve.
4. Second part of lingual artery and its dorsal lingual branches.
5. Middle constrictor of the pharynx.
6. Genioglossus muscle.
C. Anterior relations:
1. Third part of lingual artery and its sublingual branch.
2. Deep lingual vein.
3. Geniohyoid.
4. Genioglossus.
5. Sublingual salivary gland.
D. Structures passing deep to its posterior border:
1. Stylohyoid ligament.
2. Stylopharyngeus muscle.
3. Glossopharyngeal nerve.
4. First part of lingual artery.
5. Middle constrictor of the pharynx.

114
 Deep lingual vein
Styloglossus Lingual nerve

Sublingual salivary gland

Stylohyoid ligament.
Stylopharyngeus Genioglossus
Glossopharyngeal nerve
Geniohyoid
Middle constrictor of the
pharynx Hypoglossal nerve
Hyoglossus

Lingual artery Submandibular ganglion

Suprahyoid artery
Deep part of submandibular
Mylohyoid salivary gland
- Origin:
Mylohyoid line of the mandible.
- Insertion:
Most of the fibers are inserted into a fibrous raphe that extends from
the symphysis menti to the body of the hyoid bone. The most
posterior fibers are inserted into the body of the hyoid bone.
- Nerve supply:
Nerve to mylohyoid from the inferior alveolar nerve.
- Action:
It raises the floor of the mouth at the beginning of the first stage of
deglutition.
- Relations:
A. Superficial relations:
1. Submental veins.
2. Submental lymph nodes.
3. Nerve to mylohyoid.
4. Anterior belly of digastric.
5. Superficial part of submandibular salivary gland.
B. Deep relations:
The hyoglossus + its superficial relations + its anterior relations.

115
Stylopharyngeus
- Origin:
Medial surface of the base of the styloid process.
- Insertion:
Posterior border of the lamina of thyroid cartilage.
- Nerve supply:
Glossopharyngeal nerve.
- Action:
Raises the larynx during 2nd stage of deglutition.
Stylohyoid
- Origin:
Posterior border of the styloid process.
- Insertion:
Hyoid bone at the junction of the body and the greater horn.
- Nerve supply:
Facial nerve.
- Action:
Raises the hyoid bone during 2nd stage of deglutition.
Styloglossus
- Origin:
Tip of the styloid process.
- Insertion:
Whole length of the side of the tongue.
- Nerve supply:
Hypoglossal nerve.
- Action:
Elevates posterior part of the tongue during the 1st stage of deglutition.
Styloglossus
Styloid process

Stylohyoid

Hyoglossus Stylopharyngeus

Hyoid bone
Posterior belly of
digastric
Thyroid cartilage

116
Geniohyoid
- Origin:
Lower genial tubercle of the mandible.
- Insertion:
Body of hyoid bone.
- Nerve supply:
Fibers of C1 through the hypoglossal nerve.
- Action:
Can raise the hyoid bone or depress the mandible.
Genioglossus
- Origin:
Upper genial tubercle of the mandible.
- Insertion:
The fibers radiate as a fan to be inserted into the whole length of the
tongue from the root to the tip. It forms the main musculature of the
tongue.
- Nerve supply:
Hypoglossal nerve.
- Action:
1. Protrusion of the tongue: If both muscle act together, the tongue
will be protruded without deviation. If one muscle only acts, the
tongue will be protruded to the opposite side.
2. Can depress the tongue.

Genioglossus Upper genial tubercle

Lower genial tubercle

Geniohyoid

117
 Submandibular salivary gland
Site
In the digastric triangle overlapping its boundaries.
Surface anatomy
Draw slightly curved lines that connect the following 4 points:
1. A point on the angle of the mandible.
2. A point on the lower border of the mandible midway between the angle
and the symphysis menti.
3. A point 1.5 cm above the lower border of the mandible midway between
the previous two points.
4. A point at the tip of the greater horn of the hyoid bone.
Shape
It is formed of a large superficial part and a smaller deep part. The two parts
are connected to each other around the posterior border of the mylohyoid.
The superficial part has three surfaces: Inferolateral, lateral, and medial
surfaces.
Capsule
In addition to the true fibrous capsule, the gland is partially covered by a
fascial capsule formed by splitting of the investing fascia at the lower border
of the mandible. The superficial layer is attached to the lower border of the
mandible, and the deep layer is attached to the mylohyoid line.
Relations
A. Relations of the superficial part:
1. Relations of the Inferolateral surface:
- Skin.
- Superficial fascia including: platysma, cervical branch of facial
nerve and the anterior facial vein.
- Deep fascia.
- Submandibular lymph nodes.
2. Relations of the lateral surface:
- Submandibular fossa of the mandible.
- Medial pterygoid muscle.
- Facial artery.
3. Relations of the medial surface:
a. Its anterior part:
- Mylohyoid muscle and mylohyoid nerve.
- Submental veins.
- Anterior belly of digastric

118
 b. Its middle part:
Hyoglossus + its superficial relations.
c. Its posterior part:
- Stylohyoid ligament.
- Stylopharyngeus muscle.
- Glossopharyngeal nerve.
- Posterior belly of digastric.
- The facial artery makes a deep groove on the posterior part of
the gland.
B. Relations of the deep part:
- Superficial: Mylohyoid.
- Deep: Hyoglossus.
- Above: Lingual nerve and submandibular duct.
- Below: Hypoglossal nerve.
Submandibular duct
- Arises from the deep part of the gland.
- passes forwards between the mylohyoid and hyoglossus where it lies
below the lingual nerve. At the anterior border of the hyoglossus, the
nerve twists around the lateral, lower then medial side of the duct.
- Then the duct passes between the sublingual gland and the Genioglossus
to open in the floor of the mouth at the apex of the sublingual papilla on
the side of the frenulum of the tongue.
Nerve supply:
- Sensory fibers to the capsule: From the lingual nerve.
- Parasympathetic secretomotor fibers: From postganglionic fibers from
the submandibular ganglion. The preganglionic fibers come from the
chorda tympani which is a branch of facial nerve.

Sublingual salivary gland

Site
In the sublingual fossa of the mandible below the mucous membrane of the
mouth which is elevated by the gland forming the sublingual fold on the side
of the frenulum of the tongue.
Relations
- Above : The mucous membrane of the mouth.
- Below: Mylohyoid muscle.
- Laterally: Sublingual fossa of the mandible.
- Medially: Genioglossus, lingual nerve and submandibular duct.

119
 Tongue

Sublingual
gland

Submandibular
duct Lingual Genioglossus Mylohyoid
nerve
Nerve supply:
- Sensory fibers to the capsule: From the lingual nerve.
- Parasympathetic secretomotor fibers: From postganglionic fibers from
the submandibular ganglion. The preganglionic fibers come from the
chorda tympani which is a branch of facial nerve.

Submandibular ganglion
Site
On the lateral surface of the hyoglossus muscle suspended by two rami from
the lingual nerve.
Roots:
1. Parasympathetic:
Chorda tympani which is a branch of the facial gives the preganglionic
fibers to the ganglion. It reaches the ganglion via the lingual nerve. The
postganglionic fibers supply the submandibular and sublingual salivary
glands.
2. Sympathetic:
They come from the sympathetic plexus around the facial artery. They
leave the ganglion without relay to reach the submandibular and
sublingual salivary glands.
3. Sensory:
Sensory fibers from the lingual nerve pass through the ganglion to reach
the capsules of the submandibular and sublingual salivary glands.

120
 Chorda tympani

Lingual nerve

Facial nerve
Submandibular
ganglion

Facial artery
Sublingual gland

Submandibular gland

Lingual artery
- Origin:
From the anterior aspect of the external carotid artery just below the tip
of the greater horn of the hyoid bone.
- Course and relations:
Its course is divided by the hyoglossus into three parts:
1. First part: Behind the hyoglossus. It forms a loop above the tip of the
greater horn of hyoid. It lies on the middle constrictor of the pharynx
and is crossed by the hypoglossal nerve.
2. Second part: Lies deep to the hyoglossus.
3. Third part: Ascends along the anterior border of the hyoglossus then
runs forwards on the lower surface of the tongue and ends by
anastomosing with that of the opposite side at the tip of the tongue.
- Branches:
1. Suprahyoid artery: Arises from the first part, runs superficial to the
hyoglossus along the upper border of the hyoid bone.
2. Two or three dorsal lingual arteries: They arise from the second part,
ascend deep to the hyoglossus to supply the posterior part of the
tongue.
3. Sublingual artery: Arises from the third part, supplies the sublingual
salivary gland.

121
 Dorsal lingual
arteries

Sublingual artery
External
carotid artery Lingual artery

Veins of the tongue

1. Dorsal lingual veins:
They drain the dorsum and sides of the tongue, end in the lingual vein
which passes backwards deep to the hyoglossus accompanying the
second part of the lingual artery. It ends in the internal jugular vein.
2. Deep lingual vein:
It begins at the tip of the tongue, runs backwards on its under surface
on the side of the midline. It unites with the sublingual vein to form
the vena comitans nervi hpoglossi which accompanies the hypoglossal
nerve, passes backwards on the surface of the hyoglossus. It ends
either in the lingual vein, common facial vein of directly into the
internal jugular vein.
Dorsal lingual veins

Common facial vein

Deep lingual vein

Sublingual vein
Internal jugular vein

vena comitans nervi

Lingual vein hpoglossi

122
 THYROID GLAND
Site
In the lower part of the front of the neck with its isthmus opposite 2,3,4
tracheal rings. The apex of the lobe reaches the oblique line of thyroid
cartilage and the base of the lobe reaches the 5th or 6th tracheal rings.

1st tracheal ring

Lobe

Isthmus

th
6 tracheal ring
Shape
- It is formed of two lobes connected together by an isthmus of
glandular tissue.
- Each lobe is conical in shape with an apex directed upwards and
laterally, a base directed downwards and 3 surfaces: superficial
(lateral), medial and posterior surfaces.
- A small lobe, called the pyramidal lobe, may be connected to the
upper border of the isthmus usually on the left side. If present, the
pyramidal lobe is usually connected to the hyoid bone by a
fibromuscular band called the levator glandulae thyroidae.

123
Levator
glandulae
thyroidae

Pyramidal lobe

Capsule:
In addition to its true fibrous capsule, the gland is surrounded by an outer
fascial capsule of pretracheal fascia. The fascial capsule is attached to the
oblique line of thyroid cartilage and to the cricoid cartilage so the gland
moves up and down with the movements of the larynx during swallowing.
Posteriorly the capsule blends with the carotid sheath.

Relations
1. Relations of the lobe:
a. Relations of the superficial surface:
- Skin, superficial fascia and deep fascia.
- Sternomastoid.
- Sternohyoid, superior belly of omohyoid and sternothyroid.

b. Relations of the medial surface:

- Larynx (thyroid cartilage, cricoid cartilage, cricothyroid muscle
and external laryngeal nerve).
- Pharynx (inferior constrictor of the pharynx).
- Trachea.
- Oesophagus.
- Recurrent laryngeal nerve.
c. Relations of the posterior surface:
- Prevertebral muscles.

124
 - Medial part of carotid sheath including the common carotid artery.
- Two parathyroid glands are embedded in the posterior surface of
each lobe.
2. Relations of the isthmus:
- Superficial: Skin, superficial fascia, deep fascia, sternohyoid and
sternothyroid.
- Deep: 2,3,4 tracheal rings.
- Its upper border is related to an anastomotic artery between the two
superior thyroid arteries. A pyramidal lobe may be present usually on
the left side.
- Its lower border is related to the inferior thyroid veins and thyroidea
ima artery

Inferior constrictor
of the pharynx
Sternohyoid
External laryngeal
Superior nerve
belly of
Sternothyroid omohyoid

Cricothyroid
muscle

Recurrent
laryngeal nerve

Oesophagus
Sternomastoid Trachea

Common
carotid artery

Carotid sheath

Prevertebral
muscles

125
Arterial supply
1. Superior thyroid artery:
- It arises from the anterior aspect of the external carotid artery.
- It enters the gland through the apex of the lobe. The arteries of the two
sides are connected by an anastomotic artery that passes along the
upper border of the isthmus.
- It supplies the upper 1/3 of the lobe and the upper 1/2 of the isthmus.
- It accompanies the external laryngeal nerve, but as they approach the
gland they leave each other. During thyroidectomy the artery should
be ligated as near as possible to the gland to avoid injury of the
external laryngeal nerve.
2. Inferior thyroid artery:
- It arises from the thyrocervical trunk which is a branch from the first
part of the subclavian artery.
- It enters the gland at the middle of the border separating the medial
and posterior surfaces of the lobe.
- It supplies the lower 2/3 of the lobe and the lower 1/2 of the isthmus.
- Near the gland it accompanies the recurrent laryngeal nerve. During
thyroidectomy the artery should be ligated as far as possible from the
gland to avoid injury of the recurrent laryngeal nerve.
3. Thyroidea ima artery (may be present and if present it is single)
It arises either from the brachiocephalic artery, arch of aorta or the left
common carotid artery. It ascends in front of the trachea to reach the
isthmus.
4. The gland is richly supplied by adjacent arteries (aberrant thyroid
arteries) which supply the oesophagus and the trachea. These arteries
maintain good supply to the gland if the big arteries are ligated.

Venous drainage
1. Superior thyroid vein:
- Emerges from the apex of the lobe.
- Ends in the internal jugular vein.
2. Middle thyroid vein:
- Emerges from the base of the lobe.
- Ends in the internal jugular vein.
3. Inferior thyroid vein:
- Emerges from the lower border of the isthmus
- Ends in the left innominate (brachiocephalic) vein.

126
 External carotid artery Internal carotid artery

Internal laryngeal nerve

Vagus nerve

Superior laryngeal nerve

External laryngeal nerve

Superior thyroid artery

Cricothyroid muscle
Inferior thyroid artery

Thyrocervical trunk Subclavian artery

Arch of aorta
Right recurrent laryngeal nerve

Left recurrent laryngeal nerve

Superior thyroid vein

Internal jugular vein

Middle thyroid vein

Inferior thyroid vein

left innominate vein

127
 Lymphatic drainage
1. The upper part of the gland is drained into the upper deep cervical lymph
nodes.
2. The lower part of the gland is drained into the lower deep cervical lymph
nodes. Some lymphatics are interrupted in the pretracheal and
paratracheal lymph nodes. Some lymphatics from the lower part of the
gland descend to the thorax to drain into the innominate lymph nodes.

Upper deep cervical lymph

nodes.

Lower deep cervical lymph

nodes

Innominate lymph nodes

128
 LARGE VESSELS
OF
HEAD AND NECK
SUBCLAVIAN ARTERY
Origin
- Right subclavian artery arises from the innominate (brachiocephalic artery)
- Left subclavian artery arises from the arch of aorta.
Scalenus anterior
Right common carotid artery

Left subclavian artery

Right subclavian artery

Clavicle

First rib Left common carotid artery

Arch of aorta

Course:
The subclavian artery enters the neck deep to the sternoclavicular joint. It
makes a curve in the root of the neck behind the scalenus anterior muscle. It
ends at the outer border of the first rib by becoming the axillary artery. The
subclavian artery is divided by the scalenus anterior muscle into 3 parts:
first part medial to the muscle, second part deep to the muscle and third part
lateral to the muscle. The subclavian vein lies anteroinferior to the artery
being separated from it by the scalenus anterior muscle.

129
 Scalenus anterior
Subclavian artery

First rib Subclavian vein

Scalenus anterior
- Origin:
Anterior tubercles of transverse processes of C3&4&5&6.
- Insertion:
Scalene tubercle of the first rib.
- Nerve supply:
Ventral rami of C4&5&6.
- Action:
1. Flexion of the neck forwards and laterally.
2. Helps to elevate the first rib during forced inspiration.

Relations
Posterior relations:
- The cervical pleura and the apex of the lung lie posterior to all parts of
both subclavian arteries.
- The right recurrent laryngeal nerve hooks around and ascends behind the
first part of the right subclavian artery.
- The upper surface of first rib and the lower trunk of the brachial plexus
lie behind the third parts of both subclavian arteries.
Anterior relations:
- Anterior to the first part:
1. Sternomastoid, sternohyoid and sternothyroid.
2. Vagus nerve and the cervical cardiac branches of both the vagus and
the sympathetic chain and the ansa subclavia.
3. Internal jugular vein.

130
 4. The left phrenic nerve and the thoracic duct lie in front of the first part
of the left subclavian artery.
- Anterior to the second part:
1. Sternomastoid.
2. Scalenus anterior.
3. The right phrenic nerve lies anterior to the second part of right
subclavian artery.
- Anterior to the third part:
1. Skin, superficial fascia and deep fascia..
2. External jugular vein.
3. Clavicle. Vagus nerve Left phrenic
nerve
Scalenus anterior

External jugular vein

Trunks of brachial plexus

Subclavian artery

Subclavian vein
Sternothyroid

Right phrenic Right recurrent Sternohyoid

nerve laryngeal nerve
Branches Sternomastoid
Branches of the first part
1. Vertebral artery:
- Course: The course of the artery is divided into 4 parts:
1. First part:
It ascends in the inverted V-shaped space (vertebral triangle)
between the scalenus anterior laterally and the longus colli
medially, ascends in front of the transverse process of C7 to enter
the foramen transversorium of the C6. During its course it lies deep
to the common carotid artery and is crossed on both sides by the

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 inferior thyroid artery and on the left side by the thoracic duct and
the sympathetic chain lies along its medial side.
2. Second part:
Ascends through the foramina transversoria from C6 to C1.
3. Third part:
Arches backwards behind the lateral mass of atlas making a groove
on the upper surface of its posterior arch.
4. Fourth part:
Ascends through the foramen magnum, passes upwards and
medially in front of the medulla till the lower border of the pons
where it ends by union with the other vertebral artery to form the
basilar artery.

N.B: The vertebral vein emerges from the foramen transversorium of

C7 to end in the corresponding innominate vein.
- Branches:
1. From the 2nd part:
- Spinal branches: Enter the vertebral canal to supply the cervical
part of the spinal cord and the covering meninges.
- Muscular branches: Supply the prevertebral and scalene
muscles.
2. From the 4th part:
- Anterior and posterior spinal arteries.
- Posterior inferior cerebellar artery.
- Medullary branches.

Pons
Pons

Posterior inferior
cerebellar artery
Foramen magnum
Vertebral artery
Posterior spinal
Anterior spinal artery
artery

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2. Thyrocervical trunk:
It is a short trunk that divides immediately into inferior thyroid,
transverse cervical and suprascapular arteries.
A. Inferior thyroid artery:
- Course:
It ascends along the medial border of the scalenus anterior till the
level of C6 where it curves medially behind the carotid sheath and
the sympathetic chain crossing the vertebral vessels. It reaches the
posterior border of the thyroid gland where it becomes closely
related to the recurrent laryngeal nerve. It enters the gland at the
middle of its posterior border.
- Branches:
a. Inferior laryngeal and pharyngeal branches.
b. Esophageal and tracheal branches.
c. Glandular branches to the lower 2/3 of the lobe of the thyroid
gland and the lower 1/2 of its isthmus.
B. Transverse cervical artery:
It passes laterally undercover of the internal jugular vein and the
sternomastoid crossing the scalenus anterior muscle, then crosses the
floor of the posterior triangle till the anterior border of the levator
scapulae where it divides into superficial and deep branches. The
superficial branch passes between the levator scapulae and the
trapezius supplying both muscles. The deep branch descends deep to
the levator scapulae to share in the anastomosis around the scapula.
C. Suprascapular artery:
It passes laterally undercover of the internal jugular vein and the
sternomastoid crossing the scalenus anterior muscle. It accompanies
the inferior belly of omohyoid to reach the scapula where it shares in
the anastomosis around the scapula.
3. Internal mammary (thoracic) artery:
It descends to the thorax where it passes deep to the upper 6 costal
cartilages.

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 Internal jugular vein Common carotid artery

Scalenus medius

Phrenic nerve
Thyroid lobe (reflected)

Scalenus anterior Vertebral artery

Transverse cervical artery Sympathetic chain

Suprascapular artery

Trunks of Inferior thyroid artery

brachial plexus Right recurrent laryngeal nerve
Vagus nerve
Longus colli
Brachiocephalic artery
Subclavian vein

Internal mammary artery

Subclavian artery

Branches of the second part: Costocervical trunk.

The costocervical trunk arches backwards above the cervical pleura to reach
the neck of the first rib where it divides into deep cervical and superior
intercostal arteries. The deep cervical artery ascends deep to the trapezius to
anastomose with the descending branch of the occipital artery. The superior
intercostal artery descends to the thorax where it gives the first and second
posterior intercostals arteries.
Branches of the third part
Usually no branches arise from the third part. Occasionally, this part of the
artery gives either the suprascapular artery or the transverse cervical artery.

N.B: Relations of scalenus anterior muscle

A. Anteriorly
- Phrenic nerve.
- Prevertebral fascia.
- Transverse cervical artery.
- Suprascapular artery.
- Internal jugular vein.

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 - Subclavian vein.
- Inferior belly of omohyoid.
- Sternomastoid.
B. Posteriorly
- Roots of brachial plexus.
- Second part of subclavian artery.
- Scalenus medius.
- Apex of the lung and cervical pleura.
C. Laterally
- Trunks of brachial plexus.
- Third part of subclavian artery.
D. Medially
- First part of subclavian artery.
- Vertebral artery.
- Inferior thyroid artery.
- Thoracic duct (on the left side): It is a lymphatic trunk that ascends
from the thorax to the neck along the left border of the oesophagus. At
the level of the transverse process of C7, it curves laterally in front of
the vertebral vessels then descends along the medial border of the
scalenus anterior to end at the beginning of the left innominate vein.

Scalenus anterior

Internal jugular vein

Common carotid artery

Thoracic duct

Subclavian vein

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 SUBCLAVIAN VEIN
Course
It starts at the outer border of the first rib as continuation of the axillary vein.
It ends deep to the sternoclavicular joint by union with the internal jugular
vein to form the innominate vein.
Relations
Anteriorly: Sternomastoid.
Clavicle.
Posteriorly: Scalenus anterior and phrenic nerve.
Apex of the lung and cervical pleura.
First rib.
Tributaries
The only tributary is the external jugular vein

COMMON CAROTID ARTERY

Origin
- The left common carotid artery arises from the arch of aorta.
- The right common carotid artery arises from the innominate
(brachiocephalic) artery.
Course
It ascends in the neck inside the carotid sheath to end at the level of the
upper border of thyroid cartilage (C3/C4) by dividing into external and
internal carotid arteries.
Relations
- Anteriorly:
1. Sternomastoid, sternohyoid, sternothyroid and superior belly of
omohyoid.
2. Posterior surface of thyroid lobe.
3. Ansa cervicalis.
- Posteriorly:
1. Transverse processes of the lower 4 cervical vertebrae separated
from them by prevertebral muscles and sympathetic chain.
2. Vertebral artery.
3. Inferior thyroid artery.
4. The right recurrent laryngeal nerve is posterior to the right
common carotid artery.

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 5. The thoracic duct is posterior to the left common carotid artery.
- Medially:
1. Oesophagus, trachea and recurrent laryngeal nerve.
2. Larynx and pharynx.
- Laterally:
Internal jugular vein and vagus nerve inside the carotid sheath.

Branches
The external and internal carotid arteries.

EXTERNAL CAROTID ARTERY

Course
It arises as one of the two terminal branches of the common carotid artery at
the level of the upper border of thyroid cartilage (C3/C4). It ends inside the
parotid gland at the level of the neck of the mandible by dividing into
superficial temporal and maxillary arteries.
Relations
- Superficial relations:
1. In the carotid triangle: (Page 109)
a. Skin, superficial fascia and deep fascia.
b. Hypoglossal nerve.
c. Common facial vein.
d. Lingual vein.
e. Posterior belly of digastric and stylohyoid muscle.
2. Inside the parotid gland: (Page 50)
a. Posterior facial (retromandibular) vein.
b. Terminal branches of facial nerve.
- Deep relations
1. In the carotid triangle:
The artery lies on the wall of the pharynx with the following
structures in between:
a. Ascending pharyngeal artery.
b. External and internal laryngeal nerves.
2. Inside the parotid gland:
The artery is separated from the internal carotid artery that lies deep to
the gland by the following structures:
a. The styloid process and stylopharyngeus muscle.

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 b. Glossopharyngeal nerve.
c. Pharyngeal branch of vagus nerve.
d. Part of the parotid gland.

Styloid process External carotid artery

Part of parotid gland

Vagus nerve
Internal carotid artery

Pharyngeal branch Stylopharyngeus muscle

of vagus
Glossopharyngeal nerve

Ascending
pharyngeal artery
Branches
Superficial temporal artery
Occipital artery Maxillary artery
Posterior auricular Facial artery
artery
Lingual artery

Superior thyroid artery

Inferior thyroid artery

Deep cervical artery

Common carotid artery
Costocervical trunk

Superior intercostals artery

Subclavian artery

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 Superficial temporal artery

Transverse facial artery

Maxillary artery
Sternomastoid
Posterior auricular artery
Posterior belly of
Occipital artery
digastric
Facial artery
Lingual artery
Stylohyoid

Superior thyroid artery

External carotid artery

1. Superior thyroid artery:

Arises from the anterior aspect of the external carotid artery. It runs
downwards and forwards accompanying the external laryngeal nerve to
reach the apex of the thyroid lobe. It gives the following branches:
a. Muscular branches to the infrahyoid muscles, cricothyroid muscle and
sternomastoid.
b. Superior laryngeal artery: It accompanies the internal laryngeal nerve
and both pierce the thyrohyoid membrane to enter the larynx.
c. A branch which anastomoses with the other superior thyroid artery
along the upper border of the thyroid isthmus.
d. Glandular branches that supply the uppe1/3 of the thyroid lobe and the
upper 1/2 of the isthmus
Internal laryngeal nerve
Superior laryngeal nerve
Thyrohyoid membrane
Vagus nerve
Superior laryngeal artery
Common carotid artery
Cricothyroid muscle

Inferior laryngeal Anastomotic artery between

artery the inferior thyroid arteries

External laryngeal
nerve

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2. Ascending pharyngeal artery:
Arises from the medial aspect of the external carotid artery. It ascends on
the wall of the pharynx and gives the following branches:
a. Pharyngeal branches to supply the pharynx.
b. Inferior tympanic artery to supply the middle ear.
c. Meningeal branches which enter the skull through the hypoglossal
canal, jugular foramen and foramen lacerum.

Inferior tympanic artery

Meningeal branches

Pharyngeal branches

Ascending pharyngeal artery

External carotid artery

3. Lingual artery:
Arises from the anterior aspect of the external carotid artery (See page
121)
4. Facial artery:
Arises from the anterior aspect of the external carotid artery (See page
42)
5. Occipital artery:
- Course: It arises from the posterior aspect of the external carotid
artery at the level of the facial artery. It runs backwards and upwards
along the lower border of the posterior belly of digastric then deep to
it. Then it runs deep to the sternomastoid and the mastoid process,
traverses the apex of the posterior triangle and continues deep to the
trapezius. Lateral to the external occipital protuberance, it pierces the
trapezius to reach the back of the scalp.
- Branches

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 a. Muscular branches to the sternomastoid, posterior belly of
digastric and the trapezius.
b. Descending branch: It descends deep to the trapezius to
anastomose with the deep cervical artery which is a branch of the
costocervical trunk of the second part of the subclavian artery.
c. Terminal branches to the back of the scalp.

Posterior belly of digastric

Occipital artery
External carotid artery

Trapezius Sternomastoid

6. Posterior auricular artery:

- Course: It arises from the posterior aspect of the external carotid
artery just above the posterior belly of digastric... It runs backwards
and upwards along the upper border of the posterior belly of digastric.
It ends by terminal branches to the area of the back of the scalp behind
the auricle.
- Branches
a. Muscular branches to the sternomastoid, posterior belly of
digastric.
b. Stylomastoid artery that enters through the stylomastoid foramen
to supply the middle ear.
c. Terminal branches to area of the back of the scalp behind the
auricle.

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Posterior auricular artery

External carotid artery

7. Superficial temporal artery: (See page 35)

8. Maxillary artery: (See page 78)

INTERNAL CAROTID ARTERY

Course
It arises as one of the two terminal branches of the common carotid artery at
the level of the upper border of thyroid cartilage (C3/C4). Its course can be
divided into 4 parts:
1. Cervical part:
The artery ascends vertically upwards inside the carotid sheath.
2. Petrous part:
The artery passes through the carotid foramen on the lower surface of the
petrous bone and passes forwards in the carotid canal inside the petrous.
3. Cavernous part:
The artery emerges from the apex of the petrous bone, crosses foramen
lacerum then passes forwards inside the cavernous sinus grooving the
side of the body of the sphenoid.
4. Cerebral part:
It leaves the cavernous sinus by passing upwards. Then it curves
backwards above the cavernous sinus then upwards again to reach just

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 below the anterior perforated substance where it ends by dividing into
anterior and middle cerebral arteries.
The internal carotid artery takes a tortuous course (carotid siphon) in side
the skull with 6 bendings. This tortuous course diminishes the cerebral
blood pressure.

Relations of the cervical part

- Superficial relations:
1. In the carotid triangle: (Page 109)
a. Skin, superficial fascia and deep fascia.
b. Sternomastoid.
c. Hypoglossal nerve.
d. Descendens hypoglossi
e. Common facial vein.
f. Lingual vein.
g. Posterior belly of digastric and stylohyoid muscle.
2. Near the base of the skull:
The external carotid artery lies superficial to the internal carotid artery
but separated from it by the following structures:
a. The styloid process and stylopharyngeus muscle.
b. Glossopharyngeal nerve.
c. Pharyngeal branch of vagus nerve.
d. Part of the parotid gland.
- Deep relations
1. In the carotid triangle:
The artery lies on the wall of the pharynx with the superior laryngeal
nerve in between.
2. Near the base of the skull:
The internal jugular vein is separated from the artery by the lower 4
cranial nerves.

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 Part of parotid gland

Glossopharyngeal nerve
Internal jugular vein
Stylopharyngeus muscle
Vagus nerve

Hypoglossal nerve
External carotid artery
Spinal accessory Pharyngeal branch of vagus

Facial artery

Hypoglossal nerve

Lingual artery

Superior thyroid artery

Descendens cervicalis

Descendens hypoglossi

Branches
1. Cervical part: No branches.
2. Petrous part:
- Caroticotympanic branch to the middle ear.
- Pterygoid artery(inconstant): It enters the pterygoid canal and ends by
anastomosing with the greater palatine artery.
3. Cavernous part:
- Superior and inferior hypophyseal arteries to the pituitary gland.
- Meningeal branches.
4. Cerebral part:
- Ophthalmic artery.

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 - Anterior choroid artery.
- Posterior communicating artery.
- Anterior cerebral artery.
- Middle cerebral artery.

INTERNAL JUGULAR VEIN

Course
It begins at the jugular foramen as the continuation of the sigmoid sinus. It
descends vertically in the neck inside the carotid sheath. It ends behind the
medial end of the clavicle by union with the subclavian to form the
innominate (brachiocephalic) vein. It has a bulb at its beginning called the
superior bulb, and another one at its termination called the inferior bulb.
Relations
- Superficial relations:
1. Near the base of the skull:
The internal carotid artery is superficial to the vein but separated
from it by the lower 4 cranial nerves.
2. In the parotid region:
It lies deep to the parotid gland separated from it by the following
structures:
a. Styloid process and the muscles attached to it (stylohyoid,
styloglossus and stylopharyngeus).
b. Posterior belly of digastric.
c. Spinal accessory nerve.
3. In the carotid triangle: (Page 109)
a. Skin, superficial fascia and deep fascia.
b. Sternomastoid. Sternohyoid, sternothyroid and superior belly of
omohyoid
c. Descendens cervicalis.
d. Upper and lower deep cervical lymph nodes.
- Deep relations:
a. Transverse processes of cervical vertebrae and muscles attached to
them (scalenus anterior, scalenus medius and levator scapulae).
b. Cervical plexus and its branches
c. Phrenic nerve.
d. First part of subclavian artery.
e. Vertebral vessels.
f. Thyrocervical trunk and its branches.

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 g. Apex of the lung and cervical pleura.
h. Thoracic duct (on left side).

Tributaries
1. Inferior petrosal sinus.
2. Pharyngeal veins.
3. Common facial vein.
4. Lingual vein.
5. Superior thyroid vein.
6. Middle thyroid vein.

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 IMPORTANT NERVES
OF
HEAD AND NECK
A- CRANIAL NERVES
Olfactory nerve (first cranial nerve)
- Olfactory filaments arise from the nasal mucosa and pass through the
foramina on the cribriform plate of ethmoid to join the olfactory pathway
in the brain. The details of the olfactory pathway will be studied in the
course of neuroanatomy.
- Integrity of the olfactory nerve is tested by applying substances with
different odors to each nostril.

Optic nerve (second cranial nerve)

See pages 90 and 91. The details of the visual pathway will be studied in the
neuroanatomy.

Oculomotor nerve (third cranial nerve)

See page 89.
Injury of the oculomotor nerve can be detected by the following tests:
- At rest the eye looks laterally (by lateral rectus and superior oblique) and
downwards (by superior oblique).
- The patient can not move the eye upwards and medially (due to paralysis
of superior, inferior and medial recti and the inferior oblique).
- Drooping of the upper lid (due to paralysis of levator palpebrae
superioris).
- The pupil is dilated (due to paralysis of the sphincter pupillae muscle).

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- There is no accommodation for near vision (due to paralysis of the ciliary
muscle).

Trochlear nerve (Fourth cranial nerve)

See page 90.
Injury of the trochlear nerve can be detected by asking the patient to look
downwards (reading position), the eye will deviate medially (due to
paralysis of the superior oblique).

Trigeminal nerve (Fifth cranial nerve)

- The trigeminal nerve arises from the pons by two roots: a large sensory
and a small motor root. The sensory root has a ganglion (trigeminal or
Gasserian ganglion) that lies on the anterior surface of the petrous bone
in the trigeminal depression, while the motor root lies below the
ganglion. Three branches arise from the ganglion: ophthalmic, maxillary
and mandibular nerves. The motor root of the trigeminal joins the
mandibular nerve. For the detailed course of these nerves see pages 68-73
& 91 and 92.
- Injury of the trigeminal nerve can be detected by the following tests:
a. Test for the sensation in the face. See figure in page 40.
b. The patient is unable to clench the teeth (due to paralysis of
temporalis and masseter).
c. Perform the trigeminal reflexes:
1. Corneal reflex: (5 – 7)
Touching the cornea → Nasociliary branch of ophthalmic nerve →
Main sensory nucleus of trigeminal in the pons → Facial motor
nucleus in the pons → Orbicularis oculi → Closure of the eye.
2. Lacrimal reflex: (5 – 7)
Touching the cornea → Nasociliary branch of ophthalmic nerve →
Main sensory nucleus of trigeminal in the pons → Superior
salivary nucleus of the facial nerve in the pons → greater
superficial petrosal nerve → Lacrimal gland → Lacrimation.
3. Masseteric reflex (jaw jerk): (5 – 5)
Tapping the masseter muscle → Stimulation of the muscle spindles
in the masseter → Mesencephalic nucleus of trigeminal in the
midbrain → Motor nucleus of trigeminal in the pons → Mylohyoid
and anterior belly of digastric → Opening of the mouth.

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- Mandibular nerve block:
Mandibular nerve block is used to extract teeth from the lower jaw. With
the patient’s mouth open, the anterior margin of the ramus of the
mandible is palpated, and the Pterygomandibular ligament is felt. The
syringe needle is inserted through the mucous membrane just lateral to
the ligament, and the inferior alveolar nerve is infiltrated with a local
anesthetic solution.
- Analgesia of the infraorbital nerve:
The infraorbital nerve may be readily blocked by injection of local
anesthetic solution. The needle is introduced in the upper labial vestibule
over the premolar teeth in line with the pupil and directed upwards and
backwards to enter the foramen. One finger should be kept on the
infraorbital rim to ensure that the needle does not pass the mark.
Abducent nerve (Sixth cranial nerve)
See page 90.
Injury of the Abducent nerve can be detected by Presence of internal squint
due to paralysis of the lateral rectus) .

Facial nerve (Seventh cranial nerve)

- The facial nerve arises from the pons by two roots:
a. Motor root.
b. Nervus intermedius which carries sensory and parasympathetic fibers.
- The roots join each others and the facial nerve passes through the internal
auditory meatus on the posterior surface of the petrous bone to reach the
internal ear.
- It passes laterally above the vestibule of the internal ear where it has a
ganglion called the geniculate ganglion.
- Then it passes through the facial canal that extends backwards inside the
medial wall of the middle ear then vertically downwards inside the
posterior wall of the middle ear to leave the skull through the
stylomastoid foramen.

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 Lingual nerve
Petrous bone
Chorda tympani
Middle ear

Tongue Sphenopalatine
ganglion

Greater superficial
petrosal nerve
Submandibular
ganglion Facial nerve

Nerve to stapedius
Internal auditory
meatus

Stylomastoid foramen Internal ear

- The extra cranial course of facial nerve: See page 38.

- Branches of the facial nerve during its intrapetrous part:
1. Greater superficial petrosal nerve (parasympathetic): See page 74.
2. Chorda tympani:
• It arises from the facial nerve while lying in the vertical part of the
facial canal inside the posterior wall of the middle ear.
• It enters the cavity of the middle ear through an opening in its
posterior wall called the posterior canaliculus. It runs forwards on
the inner surface of the drum above the handle of malleus, then it
emerges from the anterior wall of the middle ear through an
opening called the anterior canaliculus. Then it leaves the skull
through the Petrotympanic fissure. It passes forwards to reach the
infratemporal fossa where it joins the lingual nerve deep to the
lateral pterygoid.
• It supplies taste sensation to the anterior 2/3 of the tongue and
preganglionic parasympathetic fibers to the submandibular
ganglion.
3. Nerve to stapedius muscle in the middle ear.
- Extracranial branches of the facial nerve: See page 38.
- Injury of the facial nerve can be detected by the following tests:
1. Inability to close the eye (due to paralysis of orbicularis oculi).
2. Inability to raise the eye brows (due to paralysis of occipitofrontalis).

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 3. Drooping of the angle of the mouth (due to paralysis of levator anguli
oris).
4. Accumulation of the food between the gums and cheek and dribbling
of saliva (due to paralysis of buccinator).
5. Hyperacusis (due to paralysis of stapedius).
6. Loss of sensation over the anterior 2/3 of the tongue.
7. Loss of lacrimation (due to injury of greater superficial petrosal nerve)
8. Loss of corneal and lacrimation reflexes.

Vestibulocochlear nerve (statoacoustic nerve)

(Eighth cranial nerve
- It is formed of two parts: vestibular part for equilibrium and cochlear
part for hearing. The hearing and equilibrium pathways will be
studied in the neuroanatomy.
- The vestibular function of the nerve is tested by presence of dizziness
(vertigo) and nystagmus (uncontrollable pendular movement of the
eye). The cochlear function of the nerve is tested by the degree of
hearing using a tuning fork.

Glossopharyngeal nerve (ninth cranial nerve)

- It emerges by many rootlets through the posterolateral fissure of the
medulla. It carries sensory, motor and parasympathetic fibers. It leaves
the skull through the jugular foramen. Just below the foramen it has two
sensory ganglia: superior and inferior.
- It descends between the internal carotid artery and the internal jugular
vein inside the upper part of the carotid sheath. Then it leaves the sheath
by passing forwards between the internal and external carotid arteries
accompanying the stylopharyngeus muscle (see figure in page 138). Both
the nerve and muscle pass deep to the hyoglossus (see figure in page 115)
where the nerve ends by terminal branches to the posterior 1/3 of the
tongue.

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 Glossopharyngeal nerve
Internal jugular vein

Spinal accessory nerve

Hypoglossal nerve
Mylohyoid

Vagus nerve
Hyoglossus

- Branches:
1. Meningeal branch (sensory) to the dura mater.
2. Carotid branch (sensory) to the carotid sinus and body.
3. Pharyngeal branch (sensory): It gives the sensory root of the
pharyngeal plexus that supplies the pharynx and palate.
4. Lingual branches (sensory): They supply the posterior wall of the
tongue by both general and taste sensations.
5. Tympanic branch ( mainly parasympathetic): To the parotid gland
(see page 52). It also carries sensory fibers from the inner surface of
the drum, so one may feel pain in his ear when any part supplied by
the glossopharyngeal nerve is inflamed.
6. Nerve to stylopharyngeus (motor).

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 Meningeal branch

Carotid branch
Pharyngeal plexus

Stylopharyngeus

Tympanic branch

Tongue

- Injury of the glossopharyngeal nerve can be detected by:

1. Testing the general and taste sensation on the posterior 1/3 of the
tongue.
2. Loss of gag and palatal reflexes: (9 – 10): Touching the posterior wall
of the pharynx (in gag reflex) or the soft palate (in palatal reflex) →
Elevation of either the pharynx or soft palate.

Vagus nerve (tenth cranial nerve)

- It emerges by many rootlets through the posterolateral fissure of the
medulla. It carries parasympathetic, motor and sensory fibers. It leaves
the skull through the jugular foramen. Just below the foramen it has two
sensory ganglia: superior and inferior and it receives the cranial
accessory nerve.
- It descends between the internal carotid artery and the internal jugular
vein then between the common carotid artery and the internal jugular
inside the carotid sheath. At the root of the neck it crosses the first part of
subclavian artery to reach the thorax.

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- Branches:
1. Meningeal branch (sensory) to the dura mater. It arises from the
superior ganglion.
2. Auricular branch (Arnold’s nerve) (sensory): It arises from the
superior ganglion. It supplies the floor of the external auditory meatus
and the lower part of the ear drum.
3. Pharyngeal branch (motor): It arises from the inferior ganglion and
descends between the external and internal carotid arteries and gives
the motor root of the pharyngeal plexus that supplies all the muscles
of the pharynx except the stylopharyngeus and all muscles of the
palate except the tensor palati. The pharyngeal plexus is formed of:
a. Pharyngeal branch of vagus (motor).
b. Pharyngeal branch of glossopharyngeal (sensory).
c. Pharyngeal branch of superior cervical sympathetic ganglion
(sympathetic)
4. Superior laryngeal (mixed: sensory and motor): It arises from the
inferior ganglion and descends deep to the internal carotid artery then
divides into internal and external laryngeal branches that pass deep to
the external carotid artery. The internal laryngeal nerve (sensory)
accompanies the superior laryngeal artery and both pierce the
thyrohyoid membrane to enter the larynx (see figure in page 139). It
supplies the upper part of the mucous membrane of the larynx above
the vocal cords. The external laryngeal nerve (motor) accompanies the
superior thyroid artery and ends by supplying the cricothyroid muscle
(see figure in page 139).
5. Two cardiac branches (parasympathetic): They descend with the
vagus nerve to reach the thorax where they share in the formation of
the cardiac plexuses.
6. The right vagus gives the right recurrent laryngeal nerve (mixed:
sensory and motor): as it crosses the first part of right subclavian
artery. On the other hand, the left recurrent laryngeal nerve arises
from the left vagus in the thorax as it crosses the arch of aorta (see
figure in page 127). Both nerves ascend between the trachea and
oesophagus. Near the thyroid gland, the nerves are intimately related
to the inferior thyroid arteries. They enter the larynx by passing deep
to the inferior constrictor of the pharynx. They supply:
a. All muscles of the larynx except the cricothyroid.
b. The lower part of the mucous membrane of the larynx.
c. Cardiac branches to share in the formation of the cardiac plexuses.

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 d. Branches to the trachea, oesophagus and the inferior constrictor of
the pharynx.

Meningeal branch

Superior laryngeal branch

Auricular branch

Internal laryngeal nerve

Pharyngeal branch
External laryngeal nerve

Cricothyroid muscle

Right recurrent Cardiac branches

laryngeal

- Injury of the vagus nerve can be detected by:

1. Loss of gag and palatal reflexes: (9 – 10).
2. Asking the patient to say ah, the soft palate is not elevated.
3. Hoarseness of voice and paralysis of the vocal cord.

Accessory nerve (eleventh cranial nerve)

- It is a motor nerve that consists of two parts:
1. Cranial part; Emerges from the anterior surface of the medulla.
2. Spinal part: Arises from the anterior horn cells of the upper 5 cervical
segments of the spinal cord.
The spinal part ascends in the vertebral canal beside the spinal cord and
enters the skull through the foramen magnum to join the cranial part. The
two parts unite and descend through the jugular foramen. Just below the
foramen the two parts separate. The cranial accessory joins the vagus
nerve and is distributed through its pharyngeal and superior and recurrent
laryngeal branches. The spinal accessory nerve descends between the

155
 internal jugular vein and the internal carotid artery within the upper part
of the carotid sheath. Then it leaves the sheath and curves backwards
crossing the internal jugular vein then pierces the sternomastoid and
emerges from the middle of its posterior border. Then it traverses the
posterior triangle embedded in the deep fascia of its roof to end finally in
the trapezius. It supplies the sternomastoid and the trapezius.
Cranial accessory
Spinal accessory
Vagus nerve

Jugular foramen
Foramen magnum
Sternomastoid

Trapezius

- Injury of the spinal accessory nerve can be detected by:

1. Test the sternomastoid by rotating the head upwards and to the
opposite side.
2. Test the trapezius by shrugging the shoulders.

Hypoglossal nerve (twelfth cranial nerve)

- It is a motor nerve that emerges from the anterior surface of the medulla
by many rootlets. It leaves the skull through the anterior condylar
(hypoglossal) canal. It descends between the internal carotid artery and
the internal jugular vein accompanying 9, 10,11 nerves within the upper
part of the carotid sheath. At the lower border of the posterior belly of
digastric it curves forwards crossing the internal carotid artery, the
external carotid artery and the first part of the lingual artery. In the
digastric triangle it passes superficial to the hyoglossus then disappears
deep to the mylohyoid where it divides into terminal branches. Fibers
from C1 join the hypoglossal nerve then leave in certain branches (see
figure in page 109).

156
 Hypoglossal nerve

Thyrohyoid
C1
Geniohyoid
C2
C3
Descendens hypoglossi

Descedens cervicalis

- Branches:
1. It supplies all the intrinsic muscles of the tongue.
2. It supplies all muscles of the tongue except the palatoglossus.
3. Branches from C1 through the hypoglossal nerve:
a. Nerve to thyrohyoid and geniohyoid.
b. Descedens hypoglossi: It unites with the descendens cervicalis that
arises from C2,3 to form the ansa cervicalis which is embedded in
the anterior wall of the carotid sheath and supplies all the
infrahyoid group of muscles except the thyrohyoid (see figure in
page 109).
- Injury of the hypoglossal nerve can be detected by asking the patient to
protrude his tongue, the tongue will deviate to the paralyzed side.

157
 B- SYMPATHETIC CHAIN
It lies vertically in the neck embedded in the posterior wall of the carotid
sheath behind the carotid arteries and medial to the vagus nerve. It has 3
ganglia: superior, middle and inferior.

Cervical plexus Longus

Superior ganglion colli
Levator scapulae

Scalenus medius
Middle ganglion
Ansa subclavia
Ansa subclavia
Scalenus anterior

First thoracic
ganglion
Inferior
ganglion

Phrenic nerve

Superior cervical sympathetic ganglion

- Site and size:
It lies opposite the 2nd and 3rd cervical vertebra. It is the largest of the
three cervical ganglia.
- Branches:
1. Gray rami communicantes to the upper 4 cervical nerves.
2. Superior cardiac branch.

158
 3. Arterial branches: Form plexus around the internal and external
carotid arteries.
4. Pharyngeal branch that forms the sympathetic root of the pharyngeal
plexus
5. Communicating branches to 9, 10 and 12 cranial nerves.
Middle cervical sympathetic ganglion
- Site and size:
It lies opposite the 6th cervical vertebra. It is the smallest of the three
cervical ganglia.

- Branches:
1. Gray rami communicantes to 5th and 6th cervical nerves.
2. Middle cardiac branch.
3. Arterial branches: Form plexus around the inferior thyroid artery.
4. Ansa subclavia: It is a part of the sympathetic chain that connects the
middle and inferior ganglia and hooks around the 1st part of
subclavian artery.

Inferior cervical sympathetic ganglion

- Site:
It lies between the transverse process of C7 and the neck of the 1st rib. It
may fuse with the 1st thoracic ganglion forming the cervicothoracic
(stellate) ganglion which lies in front of the neck of the 1st rib.
- Branches:
1. Gray rami communicantes to 7th and 8th cervical nerves.
2. Inferior cardiac branch.
3. Arterial branches: Form plexus around the subclavian and vertebral
arteries.

159
 C- CERVICAL PLEXUS
Formation
Formed by the ventral rami of the upper 4 cervical nerves. The rami are
connected by 3 loops.

Lesser occipital

Great auricular

Transverse cutaneous
nerve of the neck

Supraclavicular

Phrenic

Site
It lies on the surface of the scalenus medius muscle deep to the prevertebral
fascia, internal jugular vein and sternomastoid.
Branches
A. Muscular branches:
1. Twigs that supply scalene muscles, prevertebral muscles.
Sternomastoid, trapezius and levator scapulae.
2. Descedens hypoglossi (C1) and descedens cervicalis (C2&3) form the
ansa cervicalis that supplies the sternohyoid, omohyoid and
sternothyroid muscles. Other fibers of C1 that join the hypoglossal
nerve form the nerve to thyrohyoid and geniohyoid.
3. Phrenic nerve:
- It arises from C3&4&5 mainly from C4.
- It descends vertically downwards in front of the scalenus anterior
deep to the prevertebral fascia, internal jugular vein, transverse
cervical and suprascapular arteries. On the left side it crosses the
first part of the subclavian artery, while on the right side it is

160
 separated from the second part of subclavian artery by the scalenus
anterior. It enters the thorax by passing deep to the beginning of
the brachiocephalic vein.
- It supplies motor fibers to the diaphragm and sensory fibers to the
pleura, pericardium and peritoneum.
B. Cutaneous branches:
1. Lesser occipital nerve (C2): See page 32.
2. Great auricular nerve (C2&3): See page 32.
3. Transverse cutaneous nerve of the neck (C2&3):
It appears at the middle of the posterior border of sternomastoid,
passes forward across the muscle (figure, page 103) to supply the skin
of the front of the neck.
4. Supraclavicular nerve (C3&4):
It emerges from beneath the posterior border of the sternomastoid,
divides into medial, intermediate and lateral branches ((figure, page
103) that supply the skin of the front of the chest down to the sternal
angle and the skin over the upper half of the deltoid muscle.

161
D- PARASYMPATHETIC GANGLIA
Spheno- Otic Ciliary Subman-
palatine dibular
Site In the pterygopalatine In the Near the apex of On the surface
fossa suspended by 2 infratemporal the orbit between of the
rami from the fossa suspended the optic nerve hyoglossus
maxillary nerve. by 2 rami from and the lateral suspended by 2
the Mandibular
rectus suspended rami from the
nerve
by 2 rami from lingual nerve.
the nasociliary
nerve.
Parasym- Greater superficial Lesser superficial Nerve of inferior Chorda tympani
petrosal branch of petrosal branch oblique which is a branch of facial
pathetic facial nerve. of branch of nerve That
root Glossopharyngea Oculomotor reaches the
l nerve.
nerve. ganglion
through the
lingual nerve.
Sympa- From the sympathetic From the From the From the
plexus around the sympathetic sympathetic sympathetic
thetic ICA. plexus around the plexus around the plexus around
root middle meningeal ICA. the facial artery.
artery.
Sensory Some of the Sensory twigs to Sensory fibers
1- Orbital nerve. sensory fibers of the cornea to to the capsules
root 2- Pharyngeal nerve. the form the sensory of
3- Greater palatine Auriculotemporal root of the submandibular
nerve nerve join the
corneal reflex and sublingual
4- Lesser palatine otic ganglion.
salivary glands.
nerve.
5- Short
sphenopalatine nerve.
6- Long
sphenopalatine nerve.
Motor - A branch from - -
the nerve to
root medial pterygoid
to supply the
tensor tympani
and tensor palati.

162
 MOUTH CAVITY
Parts of the mouth cavity
1. Vestibule of the mouth:
- It is the space between the cheeks and gums externally and the teeth
and gums internally.
- It receives the ducts of the parotid glands opposite the upper 2nd
molar teeth.
2. Mouth cavity proper:
- It lies behind the teeth and gums and extends till the oropharyngeal
isthmus which is bounded by the soft palate above, the dorsum of the
tongue below and the palatoglossal arches on the sides.

Palatoglossal arch

Palatine tonsil

Palatopharyngeal arch

- The roof of the mouth cavity proper is formed of the hard palate
anteriorly and the soft palate posteriorly.
- The floor of the mouth cavity proper is formed of mucous membrane
that has the following features:
a. Frenulum of the tongue:
A fold of mucous membrane that connects the under surface of the
tongue to the floor of the mouth.
b. Sublingual folds:

163
 They lie on the sides of the frenulum and caused by the sublingual
salivary glands. On the summit of each fold there is the opening of
the submandibular duct.
c. Many minute openings of the ducts of the sublingual salivary
glands.

Sensory supply of the mucous membrane of the mouth

1. The roof is supplied by the greater palatine and long sphenopalatine
nerves.
2. The floor is supplied by the lingual nerve.
3. The cheek is supplied by the buccal branch of mandibular nerve.

Tongue
- The tongue is a mass of striated muscles covered with mucous
membrane. Its anterior 2/3 which look upwards lie in the mouth cavity,
while its posterior 1/3 which looks backwards lie in the pharynx.
- Muscles of the tongue:
1. Intrinsic muscles:
a. Superior longitudinal.
b. Inferior longitudinal.
c. Vertical.
d. Transverse.
2. Extrinsic muscles:
a. Hyoglossus. See page 113.
b. Styloglossus. See page 116
c. Genioglossus. See page 117.
d. Palatoglossus: It arises from the palatine aponeurosis and inserted
in the posterior part of the side of the tongue. It raises the mucous
membrane causing the palatoglossal arch.
- Mucous membrane of the tongue:
1. Mucous membrane of the dorsum (upper surface) of the tongue:
- Sulcus terminalis: It is a V-shaped sulcus at the junction of the
anterior 2/3 and the posterior 1/3 of the tongue. A small depression
is found at its apex called the foramen coecum.
- Three types of papillae that carry taste buds are found on the upper
surface of the anterior 2/3 of the tongue:
a. Vallate papillae: They are 8-10 and lie in front of the sulcus
terminalis.

164
 b. Fungiform papillae: They are found at the tip and margins of
the tongue.
c. Filiform papillae: They are the smallest papillae and are
distributed on the dorsum of the anterior 2/3 of the tongue.
- The mucous membrane covering the posterior 1/3 of the dorsum of
the tongue is devoid of papillae but has a nodular irregular surface
caused by underlying lymphoid follicles called the lingual tonsils.
Small number of solitary taste buds are found in the mucous
membrane of the posterior 1/3 of the dorsum of the tongue.
2. Mucous membrane of the ventral side (lower surface) of the tongue:

- Frenulum of the tongue: A fold of mucous membrane that connects

the under surface of the tongue to the floor of the mouth.
- The deep lingual veins are seen through the mucous membrane on
the sides of the frenulum.
- Plica fimbriate: It is a fold of mucous membrane lateral to the deep
lingual vein.

Plica fimbriate

lingual tonsils Deep lingual vein

Frenulum of the
Sulcus terminalis tongue

Vallate papillae Sublingual fold

Fungiform papillae Opening of

submandibular duct
Filiform papillae

- Nerve supply of the tongue:

1. Motor supply: All the intrinsic muscles and the extrinsic muscles
except the palatoglossus are supplied by the hypoglossal nerve. The
palatoglossus is supplied by the pharyngeal plexus whose motor root
is the pharyngeal branch of vagus including fibers of cranial
accessory.
2. Sensory supply:
a. General sensation:

165
 - From the anterior 2/3: Lingual nerve.
- From the posterior 1/3: Glossopharyngeal nerve.
b. Taste sensation:
- From the taste buds on anterior 2/3 (except from the buds the
vallate papillae): chorda tympani branch of facial nerve through
the lingual nerve.
- From the solitary taste buds on the posterior 1/3 as well as those
on the vallate papillae: Glossopharyngeal nerve.

- Blood supply of the tongue:

1. Arterial supply: Lingual artery. See page 121.
2. Venous drainage Deep and dorsal lingual veins: See page 122.

- Lymphatic drainage of the tongue:

a. The tip of the tongue: To Submental lymph nodes of both sides.
b. The margins of the anterior 2/3: To submandibular lymph nodes of the
same side.
c. The central part of the anterior 2/3: mainly to the submandibular
lymph nodes of both sides. However the lymphatics from the area in
front of sulcus terminalis pass to the deep cervical lymph nodes of
both sides.
d. Lymphatics from the posterior 1/3 of the tongue pass to the deep
cervical lymph nodes of both sides.

Deep cervical nodes Deep cervical nodes

Deep cervical nodes Deep cervical nodes

Submandibular nodes Submandibular nodes

Submandibular nodes Submandibular nodes

Submental nodes
Submental nodes

166
 PALATE
The palate is formed of the hard palate which separates the oral and nasal
cavities, and the mobile soft palate which is attached to the posterior border
of hard palate and when elevated it separates the nasopharynx from the
oropharynx. At the center of the free border of the soft palate, there is a
conical projection called the uvula. The soft palate is composed of mucous
membrane, palatine muscles and the palatine aponeurosis which is a fibrous
sheet attached to the posterior border of the hard palate.
Palatine muscles:
1. Tensor palati:
- Origin: Scaphoid fossa, lateral wall of Eustachian tube and spine of
sphenoid.
- Insertion: Its tendon winds around the pterygoid hamulus to be
inserted into the palatine aponeurosis.
- Action: Tenses the soft palate and dilates the Eustachian tube.
2. Levator palati:
- Origin: Lower surfaces of petrous bone and Eustachian tube.
- Insertion: Upper surface of palatine aponeurosis.
- Action: Raises the soft palate and dilates the Eustachian tube.
3. Palatoglossus:
- Origin: Lower surface of palatine aponeurosis.
- Insertion: Descends in front of the palatine tonsil in the palatoglossal
arch to be inserted into the posterior part of the side of the tongue.
- Action: The two muscles pull the tongue upwards and approximate
the palatoglossal arches thus help to close the oropharyngeal isthmus
at the end of the first stage of deglutition.
4. Palatopharyngeus:
- Origin: Palatine aponeurosis.
- Insertion: Descends behind the palatine tonsil in the palatopharyngeal
arch to be inserted into the posterior border of thyroid cartilage. The
upper fibers of the muscle, called the muscle of Passavant, pass
backwards on the side of the pharyngeal isthmus and blend with the
fibers of the superior constrictor of the pharynx.
- Action: Helps to pull the larynx upwards and to shorten the pharynx
during the second stage of deglutition. The muscle of Passavant helps
to close the pharyngeal isthmus during the second stage of deglutition.

167
5. Musculus uvulae:
- Origin: Posterior nasal spine.
- Insertion: Into the mucous membrane of the uvula.
- Action: Shortens the uvula.
Nerve supply of the palate.
- Motor: All the muscles of the palate are supplied by the pharyngeal
plexus whose motor root is the pharyngeal branch of vagus including
fibers of cranial accessory except the tensor palati which is supplied
by the nerve of medial pterygoid of the mandibular division of the
trigeminal nerve.
- Sensory supply: The mucous membrane of the hard palate is supplied
by both greater palatine and long sphenopalatine nerves, while that of
the soft palate is supplied by the lesser palatine nerve.
Blood supply of the palate:
- Arterial supply: Greater palatine branch of maxillary artery, ascending
palatine branch of facial artery and ascending pharyngeal branch of
external carotid artery
- Venous drainage: The draining veins end in the pterygoid and pharyngeal
venous plexuses.
Lymphatic drainage of the palate:
Into the deep cervical lymph nodes.

168
 NOSE AND PARANASAL
AIR SINUSES
The nasal cavity has a roof, a floor and two lateral walls and is divided into
right and left cavities by the nasal septum ( See page 18).

Features on the lateral wall of the nose

- The lateral wall of the nose has 3 projections called conchae: superior,
middle and inferior conchae.

Frontal air sinus

Sphenoethmoidal recess
Superior concha
Sphenoidal air sinus
Middle concha
Superior meatus

Inferior concha Middle meatus

Inferior meatus

- The small space of the nose above the superior concha is called the
sphenoethmoidal recess which receives the opening of the sphenoidal air
sinus.
- The small space of the nose between the superior and middle conchae is
called the superior meatus which receives the opening of the posterior
ethmoidal air sinus.
- The space of the nose between the middle and inferior conchae is called
the middle meatus. It has a rounded bulge called the bulla ethmoidalis
caused by the underlying middle ethmoidal air sinus. The groove below
the bulla ethmoidalis is called the hiatus semilunaris. Anterior to the

169
 hiatus semilunaris there is a groove called the infundibulum. The middle
ethmoidal air sinus opens into the bulla ethmoidalis. The maxillary air
sinus opens into the posterior part of the hiatus semilunaris, while the
anterior ethmoidal air sinus opens into its anterior part. The frontal air
sinus opens into the infundibulum.
- The inferior meatus which lies below the inferior concha receives the
opening of the nasolacrimal duct.
Superior concha
Sphenoethmoidal
recess

Sphenoidal air sinus

Middle concha

Bulla ethmoidalis

Opening of maxillary
Inferior concha sinus

Inferior meatus

Opening of anterior ethmoidal air

Mucous membrane of the nose
The upper part of the mucous membrane of the nose is called the olfactory
mucosa that has specialized olfactory nerve cells. The rest of the mucous
membrane is called the respiratory mucosa which is responsible to warm,
moisten and clean the inspired air.

Nerve supply of the nasal cavity

1. Smell: Olfactory nerve.
2. General sensations:
- Nasal septum: Anterior ethmoidal, short sphenopalatine and long
sphenopalatine nerves.
- Lateral wall: Anterior ethmoidal, short sphenopalatine and greater
palatine nerves.

170
Blood supply of the nasal cavity
- The following arteries share in the arterial supply of the nose:
1. Sphenopalatine branch of maxillary artery.
2. Greater palatine branch of maxillary artery.
3. Septal branch of the superior labial branch of facial artery.
4. Anterior ethmoidal branch of ophthalmic artery.
5. Posterior ethmoidal branch of ophthalmic artery.
These arteries from extensive anastomoses with each other. This is
particularly evident in the anteroinferior part of the nasal septum where
there is an anastomoses between the sphenopalatine artery, the septal
branch of the superior labial artery and greater palatine artery, and where
the vessels are relatively close to the surface. This area is the major site
of epistaxis (bleeding per nose)
- The veins form a rich plexus in the submucosa. The plexus is drained by
veins that accompany the arteries. Infection from the nose may spread to
the superior sagittal sinus through emissary veins via the foramen
coecum.

Lymphatic drainage of the nasal and paranasal air sinuses:

- The anterior part of the nasal cavity is drained into the submandibular
lymph nodes.
- The posterior part of the nasal cavity and the paranasal air sinuses drain
into the upper deep cervical lymph nodes. However, some lymphatics
from the frontal, maxillary, anterior and middle ethmoidal air sinuses
stop first in the submandibular lymph nodes.

Paranasal air sinuses

- They are cavities lined with ciliated mucous membranes found inside the
bones around the nose (maxilla, frontal, sphenoid and ethmoid bones)
and open in the cavity of the nose. Drainage of mucous from these
sinuses into the nose is achieved by the ciliary action.
- Functions:
1. Resonance of voice.
2. Reduction of the weight of the skull.
3. Conditioning of the inspired air.
- Maxillary air sinus:
• It is the largest one of the paranasal air sinuses.
• It is pyramidal in shape with:
a. Base: Lateral wall of the nose.

171
 b. Apex: Zygomatic process of maxilla.
c. Roof: Floor of the orbit.
d. Floor: Alveolar process of maxilla carrying the premolars and
molars.
• Opening: Into the middle meatus of the nose in the posterior part of
the hiatus semilunaris.
• Nerves supply: It is supplied by all the related nerves (superior
alveolar nerves and infraorbital nerve).
• Clinically important points:
a. Infection of the sinus may lead to pain in the upper teeth and in the
face due to irritation of the related nerves.
b. Infected upper premolar or molar can produce maxillary sinusitis.
c. Extraction of an upper premolar or molar can be complicated by
maxillary fistula.
d. The opening of the sinus is in the upper part of the medial wall of
the nose; a position which does not allow free drainage of any
collection in the sinus. This is the main cause for the chronicity
and the frequent recurrence of the maxillary sinusitis.
e. Infection may spread to the maxillary sinus from the other sinuses
that open in the middle meatus (frontal, anterior and middle
ethmoidal sinuses).
- Frontal air sinus:
• They are two in number and lie within the frontal bone behind the
superciliary arches. The two sinuses are separated by a septum which
usually deviated from the midline.
• It opens in the middle meatus in the infundibulum.
• Nerve supply: Supraorbital nerve.
- Sphenoidal air sinus:
• They are two in number and lie within the body of sphenoid.
• It opens in the sphenoethmoidal recess.
• Nerve supply: Posterior ethmoidal nerve.
- Ethmoidal air sinus:
• They are three groups (anterior, middle and posterior) that lie within
the ethmoid labyrinth.
• The anterior group opens into the anterior part of the hiatus
semilunaris. The middle group opens into the bulla ethmoidalis. The
posterior group opens into the superior meatus of the nose.
• Nerve supply: Anterior and posterior ethmoidal nerves.

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 EAR
External ear

1. Auricle
- Structure:

Scaphoid fossa
Helix
Concha
Antihelix
Tragus

Antitragus
Lobule

- Nerve supply:
a. Great auricular nerve: Supplies the lower 1/3 of the outer surface
and the lower 2/3 of the inner surface of the auricle.
b. Auriculotemporal nerve: Supplies the upper 2/3 of the outer
surface of the auricle.
c. Lesser occipital nerve: Supplies the upper 1/3 of the inner surface
of the auricle.
d. Auricular branch of vagus nerve: Supplies the upper part of the
auricle.
- Arterial supply:
a. Deep auricular branch of the 1st part of maxillary artery.
b. Posterior auricular branch of external carotid artery.

2. External auditory (acoustic) tube (meatus)

- It is about 24 mm in length. Its outer 1/3 is cartilaginous and is
directed upwards and backwards while its inner 2/3 is bony and is
directed downwards and forwards. During examination of the ear
drum, you must pull the auricle upwards and backwards so as to
straighten the external auditory tube.

173
 - Nerve supply:
a. Auriculotemporal nerve.
b. Auricular branch of vagus nerve.
- Arterial supply:
a. Deep auricular branch of the 1st part of maxillary artery.
b. Posterior auricular branch of external carotid artery.

3. Ear drum (tympanic membrane)

- It is an oval membrane (10mm X 8mm) that separates the external ear
from the middle ear. It is obliquely set so that its outer surface looks
downwards, forwards and laterally so that the floor and the anterior
wall of the external auditory tube are longer than the roof and the
posterior wall. It is convex towards the middle ear, gives attachment
to the handle of malleus. Its outer surface is concave. It is formed of
two parts:
a. Pars flaccida: A small triangular part at the upper part of the
membrane limited by the anterior and posterior malleolar folds.
b. Pars tensa: Below the malleolar folds. Below the malleolar folds,
the fibers are arranged radially towards the handle of malleus.

Pars flaccida

Malleolar fold Malleolar folds

Pars tensa

Handle of
malleus

- Nerve supply:
a. Auriculotemporal nerve.
b. Auricular branch of vagus nerve.
- Arterial supply:
a. Deep auricular branch of the 1st part of maxillary artery.
b. Posterior auricular branch of external carotid artery.

Middle ear (tympanic cavity)

174
Site, shape and size:
The middle ear lies inside the petrous part of the temporal bone. It looks like
a biconcave lens with equal anteroposterior and transverse diameters, each
about 1.5 cm. The transverse diameter is about 6mm, 2mm and 4mm from
above downwards.

Boundaries:
It has a roof, floor and 4 walls: lateral, medial, anterior and posterior walls.
1. Roof: Formed of Tegmen tympani that separates the middle ear from the
middle cranial fossa and the temporal lobe of the brain.
2. Floor: Formed of a thin plate of bone that separates the middle ear from
the bulb of the internal jugular vein. It has a small opening for the
tympanic branch of the glossopharyngeal nerve.
3. Lateral wall: It is formed mainly by the drum. The part of the middle ear
cavity above the level of the drum is called the epitympanic recess.
4. Medial wall: It has the following features:
a. Promontory: A rounded bulge caused by the first turn of cochlea
b. Oval window above and behind the promontory. It is closed by the
foot of the stapes.
c. Round window below and behind the promontory. It is closed by the
secondary tympanic membrane.
d. Horizontal part of facial canal: It passes backwards above the
promontory and oval window.
5. Anterior wall: It has the following features from above downwards:
a. Opening of the canal for tensor tympani.
b. Opening of the pharyngotympanic tube.
c. Anterior canaliculus for the exit of the chorda tympani.
d. A plate of bone that separated the middle ear from the internal carotid
artery in the carotid canal.

175
 6. Posterior wall: It has the following features:
a. Opening connecting the epitympanic recess with the tympanic antrum.
b. Pyramid: It is a hollow conical projection that contains the stapedius
muscle. The tendon of the stapedius passes forwards through apex of
the pyramid to be inserted into the neck of the stapes
c. Vertical part of facial canal: It lies medial to the opening of tympanic
antrum and ends by the stylomastoid foramen.
d. Posterior canaliculus: It lies lateral to the pyramid and transmits the
chorda tympani.
Horizontal part of facial canal
Posterior canaliculus Tensor tympani
epitympanic recess

Mastoid air
cells
Ear
drum

Eustachian tube Medial

wall of
Pyramid middle
Oval window ear
Vertical part of facial canal
Internal Round window
Tympanic branch of 9th nerve carotid Promontory
Anterior
canaliculus artery
Internal jugular vein

Structures inside the middle ear:

1. Three ossicles: Malleus, incus and stapes.

176
 Head Head
Anterior Facet
Posterior limb For
limb incus

Anterior
Short Facet process
Foot limb For
malleus

Facet for Long

head of limb Handle
stapes

Stapes Incus Malleus

2. Two muscles: Tensor tympani and stapedius:

a. Tensor tympani:
- Origin: From the cartilaginous part of the Eustachian tube, passes
through a small canal above the tube.
- Insertion: Into the handle of malleus.
- Nerve supply: Nerve to medial pterygoid.
- Action: Tenses the tympanic membrane to damp down the
intensity of high pitched sound.
b. Stapedius:
- Origin: From the inner wall of the pyramid.
- Insertion: Into the neck of the stapes.
- Nerve supply: Facial nerve.
- Action: Draws the neck of the stapes downwards to damp down
the intensity of high pitched sound.
3. One nerve: Chorda tympani.

Structures related to the middle ear

1. Pharyngotympanic (Eustachian tube):
- It connects the middle ear and the nasopharynx.
- It is about 36 mm long. Its posterior 1/3 is bony while its anterior 2/3
is cartilaginous.
- It gives origin to: Levator palati, tensor palati. Tensor tympani and
salpingopharyngeus muscle.
2. Tympanic antrum and mastoid air cells:
- The tympanic antrum is about the size of pea situated in the posterior
part of the petrous bone. It opens anteriorly into the tympanic cavity.

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 The Suprameatal triangle forms the lateral wall of the tympanic
antrum.
- Mastoid air cells: They are many cells inside the mastoid part of the
temporal bone. They communicate directly or indirectly with the
mastoid antrum.

Internal ear (Labyrinth)

It is situated inside the petrous bone medial to the middle ear.

Bony labyrinth
It consists of three parts: cochlea, vestibule and semicircular canals. The
cavity of these structures contains a clear fluid called the perilymph in which
the membranous labyrinth is suspended.
a. Cochlea:
- It is the anterior part of the bony labyrinth. It consists of a coiled tube
that makes two and half spiral turns, each successive turn is of
decreasing radius so that the whole tube looks conical in shape with
the apex of the cone directed laterally and the base is directed
medially.
- The first basal turn of the cochlea is responsible for the promontory
seen on the medial wall of the middle ear.
- An osseous spiral lamina extends from the outer surface of the
cochlear canal and projects into the interior of the canal. Basilar and
vestibular membranes stretch from the free edge of the lamina to the
bony wall. The cavity of the cochlea is divided into scala vestibuli
above the vestibular membrane, scala tympani below the basilar
membrane and cochlear canal between the two membranes. The
perilymph in the scala vestibuli is separated from the middle ear by
the foot of the stapes at the oval window, while the perilymph in the
scala tympani is separated from the middle ear by the secondary
tympanic membrane at the round window.

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 Vestibular membrane

Cochlear canal
Scala
vestibuli
Osseous spiral lamina
Organ of Corti

Scala
Cochlear nerve tympani

Spiral Basilar membrane

ganglion

b. Vestibule:
- It lies between the cochlea anteriorly and the semicircular canals
posteriorly.
- Its lateral wall has the oval window which is closed by the foot of the
stapes and the round window which is closed by the secondary
tympanic membrane.
c. Semicircular canals (Superior, posterior and lateral):
- The superior canal is vertical and at right angle to the long axis of
petrous. The posterior canal is vertical and parallel to the long axis of
petrous. The lateral canal is set in a horizontal position.
- They open in the posterior part of the vestibule.
- Each canal has a swelling at one end called the ampulla.

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 Superior semicircular canal
Vestibule

Lateral semicircular canal

Posterior semicircular canal

Cochlea

Oval window Round window

Scala vestibuli

Scala tympani

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Membranous labyrinth
It lies within the bony labyrinth. It contains a fluid called the endolymph and
is surrounded by the perilymph. It consists of:
a. Cochlear duct:
It lies inside the cochlear canal and is connected to the saccule. It
contains the organ of Corti that lies on the basilar membrane and contains
the sensory receptors for hearing from which nerve fibers pass to the
spiral ganglion whose axons form the cochlear nerve.
b. Utricle and saccule:
They lie inside the vestibule and their walls contain specialized receptors
sensitive to the orientation of the head to the gravity. They receive
terminals of the vestibular nerve.
c. Semicircular ducts:
They lie inside the semicircular canals and their ampullae contain
specialized receptors sensitive to the orientation of the head to the
gravity. They receive terminals of the vestibular nerve.

Saccule
Utricle

Semicircular ducts

Cochlear duct

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 LARYNX
Structure of the larynx
A. Laryngeal cartilages
1. Thyroid cartilage:
It is formed of two quadrilateral laminae of hyaline cartilage fused
anteriorly at an angle (thyroid angle) forming the laryngeal
prominence (Adam’s apple) at the upper part of which there is the
thyroid notch. Posteriorly the two laminae are separate and the
posterior border of each lamina has superior and inferior horns. The
outer surface of each lamina has an oblique ridge.

Thyroid cartilage

2. Cricoid cartilage:
It lies below the thyroid cartilage and is formed of a complete ring of
hyaline cartilage looking like a signet ring with a narrow anterior arch
and a broad posterior lamina. The lateral surface of the side of the
cricoid articulates on each side with the inferior horn of the thyroid
cartilage at a synovial joint. The upper border of the lamina articulates
with the bases of the arytenoids at synovial joints.

Arch Lamina

Cricoid cartilage
3. Epiglottis:

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 It is a leaf-like plate of elastic cartilage. Its upper end is free and
rounded. Its lower end is tapering and is attached to the inner surface
of the thyroid angle by thyroepiglottic ligament. Its anterior surface is
attached to the hyoid bone by a Hyoepiglottic ligament and to the
tongue by three mucous folds called median and two lateral
glossoepiglottic ligaments. The fossae between the median and lateral
glossoepiglottic ligaments are called the valeculae.

Epiglottis

4. Two arytenoids cartilages:

They are small pyramidal-shaped cartilages situated on the upper
border of the cricoid lamina. It looks like a three-sided pyramid with:
- Apex: It looks upwards and backwards.
- Three surfaces: Medial, posterior and anterolateral surfaces.
- Base: It articulates with the upper border of the cricoid lamina. It
has a vocal process anteriorly and a muscular process laterally.

Arytenoid cartilage

Muscular process

Vocal process
Cricoid lamina

5. Two corniculate and two cuneiform cartilages:

These are small cartilages that articulate with the apices of the
arytenoids.

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 Epiglottis

Hyoid bone

Thyrohyoid
membrane

Arytenoid
cartilage Thyroid Arytenoid
cartilage cartilage
Cricoid
cartilage

B. Laryngeal membranes and ligaments

1. Thyrohyoid membrane:
- It connects the upper borders of thyroid cartilage and hyoid bone.
A hyoid bursa lies between the membrane and the posterior surface
of the hyoid bone.
- In the midline it is thickened to form the median thyrohyoid
ligament.
- The posterior borders of the membrane are thickened to form the
lateral thyrohyoid ligament.
- It is pierced by the superior laryngeal artery and internal laryngeal
nerve.
2. Cricotracheal membrane:
Connects the lower margin of cricoid to the first tracheal ring.

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 Hyoid bone
Median thyrohyoid ligament Lateral thyrohyoid ligament

Thyrohyoid membrane

Thyroid cartilage

Cricothyroid ligament
Cricotracheal membrane
Cricoid cartilage

3. Fibroelastic membrane:
- It lies beneath the mucous membrane of the larynx.
- Its upper part is called the quadrangular membrane. It extends
between the epiglottis and the arytenoid cartilages. Its lower
margin is thickened forming the vestibular ligament.
- Its lower part is called the cricothyroid ligament or the cricovocal
membrane. Its anterior part is thickened and connects the upper
border of the anterior arch of the cricoid to the lower border of
thyroid cartilage. The rest of the ligament extends upwards and
medially and its upper border is thickened forming the vocal
ligaments which are attached to the inner surface of the angle of
thyroid and posteriorly to the vocal processes of arytenoids.

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 Epiglottis

Quadrahgular Thyroid cartilage

membrane

Vestibular
ligament Cricothyroid ligament

Vocal ligament

Arytenoid
cartilage Cricoid lamina

4. Hyoepiglottic, thyroepiglottic and glossoepiglottic ligaments.

C. Mucous membrane of the larynx
1. The mucous membrane consists of ciliated columnar epithelium
except that covering the vocal cords which consists of stratified
squamous epithelium.
2. Aryepiglottic fold: A mucous fold between the epiglottis and the
arytenoid on each side.
3. Interarytenoid fold: A mucous fold between the two arytenoids.
4. Vestibular fold: Encloses the vestibular ligament.
5. Vocal fold: Encloses the vocal ligament. The vocal ligament and the
covering mucosa are called the vocal cord which appears white
because the mucosa is firmly adherent to the ligament without
submucosa.

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 Tongue

Hyoid bone

Epiglottis

Vesibular fold
Vestibular fold

Transverse
arytenoid

Vocal fold Vocal fold

Cricoid lamina

D. Cavity of the larynx

1. Inlet of the larynx:
- It is bounded by the upper border of the epiglottis anteriorly, the
upper borders of the aryepiglottic folds on the sides and the upper
border of the interarytenoid fold posteriorly.
- It is directed upwards and backwards.
2. Vestibule of the larynx:
It is the upper part of the laryngeal cavity that extends from the inlet
to the vestibular folds.
3. Sinus (ventricle) of the larynx:
It is the part of the laryngeal cavity between the vestibular and vocal
folds. A small diverticulum called the saccule of the larynx extends
upwards between the vestibular fold and the thyroid cartilage.
4. Rima vestibuli:
It is the part of the laryngeal cavity between the two vestibular folds
5. Rima glottidis:

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 It is the part of the laryngeal cavity between the two vocal cords. It is
formed of intermembranous part between the two cords and
intercartilaginous part between the two arytenoids.
6. Lower part of the laryngeal cavity.

Epiglottis
Greater horn of hyoid

Thyrohyoid membrane

Vestibule of larynx

Thyroid cartilage
Vestibular fold

Sinus of larynx

Vocal fold
Cricothyroid ligament
Lower part of laryngeal
cavity Cricoid cartilage

E. Muscles of the larynx

A. Extrinsic muscles:
1. Elevators of the larynx:
Digastric, stylohyoid, geniohyoid, mylohyoid, stylopharyngeus,
palatopharyngeus and salpingopharyngeus.
2. Depressors of the larynx:
Sternohyoid, sternothyroid and omohyoid.
B. Intrinsic muscles:
1. Sphincters of laryngeal inlet:
a. Transverse arytenoid muscle:

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 It extends between the posterior surfaces of the arytenoids.
b. Oblique arytenoid muscles:
Each extends from the back of the muscular process of one
arytenoid to the apex of the other arytenoid. The two muscles
cross each other and run superficial to the transverse arytenoids.
c. Aryepiglottic muscles:
Each extends from the apex of an arytenoid to the edge of the
epiglottis. It is considered as continuation of the oblique
arytenoid.

Thyroid lamina
Aryepiglottic

Oblique arytenoid Transverse

arytenoid

Posterior
cricoarytenoid

2. Muscles acting on the vocal cords:

a. Cricothyroid (Tensor of the cords):

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 Extends from the upper border of the cricoid arch to the lower
border of thyroid cartilage.
b. Thyroarytenoid (Relaxant of the cords)
Extends from the inner surface of the thyroid angle below the
vocal ligament to the anterolateral surface of arytenoid. Some
fibers of the thyroarytenoid, called vocalis muscle, are inserted
anteriorly to the vocal ligament and posteriorly to the vocal
process of the arytenoids. The vocalis muscle can produce
tension of the anterior part and relaxation of the posterior part
of the cord.

Thyroid cartilage
Thyroarytenoid

Vocalis

Base of arytenoid

c. Posterior cricoarytenoid (Abductor of the cords)

It is the largest of the laryngeal muscles. It extends from the
posterior surface of the cricoid lamina to the back of the
muscular process of the arytenoid.
d. Lateral cricoarytenoid (Adductor of the cord)
It extends from the upper border of the cricoid arch to the
anterior aspect of the muscular process of the arytenoid.

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 Vocal cords

Lateral cricoarytenoid Base of arytenoid

Posterior cricoarytenoid

Abduction by posterior Adduction by lateral

cricoarytenoid cricoarytenoid

Nerve supply of the larynx

- The vagus nerve supplies the larynx by both sensory and motor fibers:
1. Motor
All laryngeal muscles are supplied by the recurrent laryngeal nerve
except the cricothyroid which is supplied by the external laryngeal
nerve.
2. Sensory
The upper part of the mucous membrane above the level of the
cords is supplied by the internal laryngeal nerve, and the lower part
is supplied by the recurrent laryngeal nerve.
- Injury of the laryngeal nerves:

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 The laryngeal nerves may be injured during thyroid operations or may
be involved in bronchial or esophageal carcinoma or malignant
deposits in mediastinal or deep cervical lymph nodes.
1. Section of the external laryngeal nerve: Produces low pitched
sound because the cords can not be tensed.
2. Unilateral complete section of the recurrent laryngeal nerve: The
vocal cord on the affected side takes the cadaveric position
(midway between abduction and adduction). Inspiration is not
affected and speech is not greatly affected because the healthy cord
compensates by moving toward the affected cord.
3. Bilateral complete section of the recurrent laryngeal nerve: Both
cords take the cadaveric position. Inspiration is affected because
rima glottidis is narrowed. Speech is lost with hoarseness.
4. Unilateral partial section of the recurrent laryngeal nerve: The
abductors are affected more than the adductors (Semon’s law) so
the affected cord assumes adducted midline position. Inspiration is
markedly affected while speech is not so much affected.
5. Bilateral partial section of the recurrent laryngeal nerve: This
leads to bilateral adduction of the cords leading to acute dyspnea
and stridor and in this case tracheostomy is indicated.
Arterial supply of the larynx
1. Superior laryngeal artery which is a branch of the superior thyroid artery.
2. Inferior laryngeal artery which is a branch of the inferior thyroid artery.

Lymphatic drainage of the larynx

The upper part of the larynx is drained into the upper deep cervical lymph
nodes, and the lower part to the lower deep cervical lymph nodes. Some
lymphatics are interrupted in the prelaryngeal and pretracheal lymph nodes.

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 PHARYNX
It is a musculomembranous tube that extends from the base of the skull to
the level of C6 where it becomes continuous with the oesophagus. It extends
be hind the nasal cavities (nasopharynx), mouth cavity (oropharynx) and
larynx (laryngopharynx).
Structure of the pharynx
It is formed of 3 layers from inside outwards: mucous layer,
pharyngobasilar fascia and muscle layer .
A. Mucous layer (interior of the pharynx)
1. Nasopharynx
- Boundaries:
Anteriorly: Posterior nasal openings.
Posteriorly and the roof: Body of sphenoid.
Below: The elevated soft palate. Behind the soft palate there is a
space called the pharyngeal isthmus which is bounded by the
posterior border of the soft palate anteriorly, the posterior wall of
the pharynx posteriorly and the palatopharyngeal fold on each side.
A band of muscle called the muscle of Passavant sweeps
backwards from the upper part of the palatopharyngeus muscles
and form a mucous ridge around the pharyngeal isthmus. This
ridge is seen when the palate is elevated.
- Features:
a. Opening of Eustachian tube at the level of the inferior concha.
b. Tubal elevation above and behind the opening of Eustachian
tube caused by tubal tonsil.
c. Salpingopharyngeal fold: Extends downwards from the tubal
elevation
d. Pharyngeal recess: A recess of mucous membrane behind the
tubal elevation.
e. Nasopharyngeal tonsil: A mass of lymphoid tissue causing a
bulge in the roof of the nasopharynx. If this tonsil is enlarged it
is called adenoids.

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 Nasopharyngeal tonsil

Tubal elevation
Pharyngeal recess

Eustachian tube

Salpingopharyngeal
fold

2. Oropharynx
- Boundaries:
Anteriorly: Oropharyngeal isthmus.
Posteriorly: Axis vertebra.
Above: Elevated soft palate.
Below: The upper border of epiglottis.
- Features: Palatine tonsil:
- Site: The tonsil lies in the Tonsillar fossa between the
palatoglossal and palatopharyngeal folds.
- Its lateral surface lies on the superior constrictor of the pharynx
separated from it by a fibrous capsule and a loose areolar tissue.
The superior constrictor separates the tonsil from the following
vessels: facial artery, ascending palatine artery, paratonsillar
vein which descends from the palate and internal carotid artery
which lies about 2.5 cm behind and lateral to the tonsil.
- Its medial surface has about 12 crypts. The upper crypt is large
and called the crypta magna.

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 Palatopharyngeal fold

Palatine tonsil

Palatoglossal fold

3. Laryngopharynx
- Boundaries:
Anteriorly: Inlet of larynx, interarytenoid fold and back of cricoid
lamina.
Posteriorly: Bodies of 3,4,5,6 vertebrae
- Features: Piriform fossa:
The piriform fossa is a groove in the mucous membranes that lies
outside the aryepiglottic fold. Its lateral wall is formed by the
mucous membrane covering the inner surface of the thyroid lamina
and thyrohyoid membrane. Its medial wall is the mucous
membrane covering the outer surface of the aryepiglottic fold. As
these fossae lie on the sides of the inlet of the larynx, a lodged
foreign body may enter the larynx.

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 Aryepiglottic muscle

Piriform fossa

Thyroid lamina

B. Pharyngobasilar fascia
It is attached above to the base of the skull, medial pterygoid plate and
Pterygomandibular ligament. Inferiorly it gets thinner and gradually
disappears. Posteriorly it is thickened forming the pharyngeal raphe
which is attached above to the pharyngeal tubercle.
C. Muscles of the pharynx
1. Constrictors of the pharynx:
- Origin:
a. Superior constrictor:
- Posterior border of medial pterygoid plate.
- Pterygoid hamulus.
- Pterygomandibular ligament.
- Posterior part of mylohyoid line.

196
 b. Middle constrictor:
- Stylohyoid ligament.
- Greater and lesser horns of hyoid bone.
c. Inferior constrictor:
- Thyropharyngeus part: Oblique line of thyroid cartilage.
- Cricopharyngeus part: Side of cricoid cartilage.
- Insertion: All are inserted in the pharyngeal raphe.
- Gaps in the wall of the pharynx:
a. Superior gap: It lies between the skull and the superior
constrictor. It is pierced by tensor and levator palati muscles
and the Eustachian tube.
b. Middle gap: It lies between the superior and middle
constrictors. It is pierced by the stylopharyngeus muscle and the
glossopharyngeal nerve.
c. Inferior gap: It lies between the middle and inferior constrictors.
It is crossed by the internal laryngeal nerve and superior
laryngeal vessels.
2. Small muscles of the pharynx:
a. Stylopharyngeus: See the submandibular region.
b. Palatopharyngeus: See the palate.
c. Salpingopharyngeus: It arises from the end of the Eustachian tube,
descends through the wall of the pharynx raising the
salpingopharyngeal fold to be inserted in the posterior border of
thyroid lamina. It raises the larynx during deglutition.

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Superior gap

Styloid process Pterygoid process

Stylopharyngeus

Superior constrictor Buccinator

Middle constrictor Pterygomandibular

ligament

Middle gap

Inferior gap

Inferior constrictor Hyoid bone

Thyroid cartilage

Nerve supply of the pharynx

- Motor:
All the muscles of the pharynx except the stylopharyngeus are supplied
by the pharyngeal branch of vagus and cranial accessory through the
pharyngeal plexus. The stylopharyngeus is supplied by the
glossopharyngeal nerve. The inferior constrictor receives additional
supply from the recurrent laryngeal nerve.
- Sensory:

198
 a. Nasopharynx: Pharyngeal branch of maxillary nerve through the
sphenopalatine ganglion.
b. Oropharynx: Pharyngeal branch of glossopharyngeal nerve through
the pharyngeal plexus.
c. Laryngopharynx: Internal and recurrent laryngeal branches of vagus.
Blood supply of the pharynx
- Arteries: Ascending pharyngeal, ascending palatine and tonsillar
branches of facial artery, pharyngeal branch of 3rd par of maxillary artery
and pharyngeal branch of inferior thyroid artery.
- Veins: It is drained into the pharyngeal plexus which is drained by the
internal jugular vein.
Lymphatic drainage of the pharynx
Into the upper and lower deep cervical lymph nodes. Some lymphatics are
interrupted in the retropharyngeal and paratracheal lymph nodes.
Mechanism of deglutition
The act of deglutition can be divided into two stages: Voluntary or oral stage
and involuntary or pharyngeal stage.
The voluntary (Oral stage):
• It includes the passage of the bolus of food above the tongue; between
the dorsum of the tongue and the hard palate.
• This stage is voluntary so that it can be stopped by will at any time.
• The muscles involved are:
1. The intrinsic muscles of the tongue particularly the superior
longitudinal and the transverse muscles:
Their successive alternative contraction and relaxation push the bolus
of food backwards above the dorsum of the tongue.
2. The mylohyoid muscles:
Their contraction elevates the floor of the mouth to press the dorsum
of the tongue against the hard palate.
3. The styloglossus and palatoglossus muscles:
Contraction of these muscles allows the bolus to pass through the oro-
pharyngeal isthmus. Contraction of the styloglossi elevates the
posterior part of the tongue upwards and backwards, while contraction
of the palatoglossi approximates the palatoglossal arches. These
actions direct the bolus backwards through the oropharyngeal isthmus
The involuntary (Pharyngeal stage):
• It includes the passage of the bolus of food through the pharynx to reach
the esophagus.

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• This stage is involuntary so that it cannot be stopped by will and once the
bolus passes through the oro-pharyngeal isthmus, it is reflexely pushed
through the pharynx to reach the esophagus.
• This stage includes the following events:
1. Closure of the inlet of the larynx:
- This action protects against the passage of the bolus of food into
the respiratory passages.
- The muscles involved are:
1. Oblique arytenoids muscles.
2. Aryepiglottic muscles.
3. Transverse arytenoids muscles.
2. Elevation of the larynx and hyoid bone:
- This action pushes the bolus of food downwards and backwards
above the posterior surface of the epiglottis and the closed
laryngeal inlet
- The muscles involved are
1. Stylopharyngeus & palatopharyngeus and
salpingopharyngeus.
2. Stylohyoid & mylohyoid and geniohyoid
3. Elevation and tension of the soft palate:
- This action protects against the passage of the bolus of food into
the nasal cavity.
- The muscles involved are the levator and tensor palati.
4. Closure of the pharyngeal isthmus:
- This action separates the nasopharynx from the oropharynx
completely to protect against the passage of the bolus into the nasal
cavity.
- The muscles involved are:
1. Superior constrictor of the pharynx.
2. Palatopharyngeal sphincter (Muscle of Passavant): It is the
upper fibers of the palatopharyngeus muscle that pass
backwards on the side of the pharyngeal isthmus and blend
with the fibers of the superior constrictor.
5. Passage of the bolus through the pharynx:
- This action is mediated by both alternative contraction and
relaxation of the constrictors and upward pull of the pharyngeal
wall above the bolus of food.
- The muscles involved are:
1. Superior & middle and inferior constrictors of the pharynx.
2. Stylopharyngeus, palatopharyngeus and salpingopharyngeus.

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 TRACHEA
IN THE NECK
- The trachea begins at the level of the lower border of cricoid cartilage
(C6) as continuation of the larynx. It extends downwards in the midline
of the neck then descends in the thorax to end at the level of the sternal
angle (T4/5) by dividing into two bronchi. It is about 10-12 cm long.
- Relations
1. Anteriorly:
Skin, superficial fascia containing the platysma, deep fascia,
sternohyoid and sternothyroid muscles, thyroid isthmus, inferior
thyroid vessels, thyroidea ima artery, anterior jugular veins and
jugular arch, pretracheal lymph nodes.
2. Posteriorly:
Oesophagus and recurrent laryngeal nerves.
3. Laterally:
Carotid sheath and thyroid lobe.
- Nerve supply: Recurrent laryngeal nerves and sympathetic chains.
- Blood supply in the neck: Inferior thyroid vessels.

OESOPHAGUS
IN THE NECK
- The oesophagus begins at the level of the lower border of cricoid
cartilage (C6) as continuation of the pharynx. It descends in the thorax
then passes through the diaphragm to end at the cardiac opening of the
stomach. It is about 10 inches long.
- Relations:
1. Anteriorly:
Trachea and recurrent laryngeal nerves.
2. Posteriorly:
Cervical vertebrae and prevertebral muscles and fascia.

201
 3. Laterally:
Carotid sheath, thyroid lobe and thoracic duct on the left side.
- Nerve supply: Recurrent laryngeal nerves and sympathetic chains.
- Blood supply in the neck: Inferior thyroid vessels.

LYMPHATIC DRAINAGE
OF HEAD AND NECK
Most of the lymphatics from the head and neck are drained into small groups
of lymph nodes which are arranged in two circles. Efferents from these small
nodes pass to larger groups of lymph nodes called the deep cervical lymph
nodes. However, some lymphatics pass directly to the deep cervical lymph
nodes. Efferents from the deep cervical lymph nodes collect to form the
jugular lymph trunk. The left jugular lymph trunk ends in the thoracic duct,
while the right one ends usually in the right lymphatic trunk.

Deep cervical lymph nodes

- They are arranged into two groups; upper and lower deep cervical lymph
nodes which are arranged around the upper and lower parts of the internal
jugular vein respectively. Each group is furtherly subdivided into two
subgroups; anterior and posterior according to the relation to the internal
jugular vein.
- Jugulodigastric group:
It is the largest of the upper deep cervical group. It lies below the angle of
the mandible between the posterior belly of digastric and the anterior
border of the sternomastoid and lies anterior to the internal jugular vein.
- Juguloomohyoid group:
It is the largest of the lower deep cervical group. It lies above the inferior
belly of omohyoid under cover of the posterior border of the
sternomastoid and behind the internal jugular vein.

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 Juguloomohyoid
Jugulodigastric

The two circles of small lymph nodes

A. Outer circle:
1. Submental lymph nodes:
- Site:
In the superficial fascia of the submental triangle.
- Afferents:
Central part of the lower lip, chin, tip of the tongue. Gum of the
lower incisors and the anterior part of the floor of the mouth.
- Efferents:
To submandibular nodes but few lymphatics pass directly to the
juguloomohyoid lymph group.
2. Submandibular lymph nodes:
- Site:
Beneath the deep fascia on the Inferolateral surface of the
submandibular salivary gland.
- Afferents:
Efferents from the Submental lymph nodes, central part of
forehead, anterior part of the nose and nearby cheek, some

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 lymphatics from the frontal, maxillary, anterior and middle
ethmoidal air sinuses, upper lip, lateral parts of lower lip, gums
except that of lower incisors, upper and lower teeth and the
anterior 2/3 of the tongue except its tip.
- Efferents:
To upper and lower deep cervical lymph nodes.
3. Buccal and mandibular lymph nodes:
- Site:
The Buccal group lies on the buccinator, while the mandibular
group lies on the lower border of the mandible at the anterior
inferior angle of the masseter
- Afferents:
Cheek and the lower eye lid.
- Efferents:
To the upper deep cervical lymph nodes.
4. Preauricular (Parotid) lymph nodes:
- Site:
Beneath the fascial capsule of the parotid gland.
- Afferents:
Anterior part of the scalp except the central part of the forehead,
temporal region, eye lids, orbit, external auditory meatus, outer
surface of the auricle and the parotid gland.
- Efferents:
To the upper deep cervical lymph nodes.
5. Posterior auricular (Mastoid) lymph nodes:
- Site:
Behind the auricle on the mastoid process.
- Afferents:
Middle part of the scalp and inner surface of the auricle.
- Efferents:
To the upper deep cervical lymph nodes.
6. Superficial cervical lymph nodes:
- Site:
Superficial to the upper part of the sternomastoid below the lobule
of the ear.
- Afferents:
Lobule of the ear.
- Efferents:
To the upper deep cervical lymph nodes.
7. Occipital lymph nodes:

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 - Site:
At the apex of the posterior triangle.
- Afferents:
The posterior part of the scalp.
- Efferents:
To the lower deep cervical lymph nodes.

Preauricular

Posterior auricular Buccal

Occipital Mandibular

Superficial cervical Submental

Submandibular

Preauricular (Parotid) lymph nodes

Submandibular lymph nodes

Submental lymph nodes

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 B. Inner circle:
1. Prelaryngeal & pretracheal and paratracheal lymph nodes:
- Site:
The prelaryngeal: In front of the cricothyroid membrane.
The pretracheal: In front of the trachea.
The paratracheal: on the sides of the trachea.
- Afferents:
Lower part of the larynx, trachea and thyroid isthmus.
- Efferents:
The prelaryngeal: To the upper deep cervical lymph nodes.
The pretracheal and paratracheal: To the lower deep cervical
lymph nodes.

2. Retropharyngeal lymph nodes:

- Site:
Behind the pharynx in the retropharyngeal space.
- Afferents:
Pharynx, palate.
- Efferents:
To the upper deep cervical lymph nodes.

Upper deep cervical nodes

Lower deep cervical nodes

Paratracheal nodes

Pretracheal nodes
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 TEMPOROMANDIBULAR JOINT
- Type: Both joints are involved together in all movements so they are
considered together as synovial bicondylar joint.
- Articular surfaces of each joint:
Head of the mandible & mandibular fossa and articular tubercle.
- Capsule:
It is a weak capsule attached above to the margins of the mandibular
fossa and in front of the articular tubercle. Below, it is attached to the
neck of the mandible. There is an opening in the anterior part of the
capsule for the tendon of lateral pterygoid.
- Ligaments related:
1. Lateral temporomandibular ligament:
It looks like an inverted triangle whose base is attached to the
posterior part of the zygomatic arch and its apex is attached to the
lateral surface of the neck of the mandible.
2. Sphenomandibular ligament:
It is attached to the spine of sphenoid above and the lingula of the
mandible below.
3. Stylomandibular ligament:
It is attached to the apex of the styloid process above and the angle of
the mandible below
- Synovial membrane:
It lines all the intracapsular structures except the articular surfaces.
- Intra-articular disc:
It is a plate of fibrocartilage that divides the joint cavity into upper and
lower cavities. It is attached to the capsule of the joint and to lateral and
medial ends of the head of the mandible by fibrous bands, however. It is
attached in front to the tendon of the lateral pterygoid. The upper surface
of the disc is concavoconvex to fit the shape of the articular tubercle and
the mandibular fossa, while its lower surface is concave to fit the head of
the mandible.
- Movements:
1. Protraction of the mandible:
- The articular disc together with head of the mandible moves
forwards on the articular tubercle, so the movement takes place in
the upper cavity of the joint.
- The movement is done by the pterygoids and the superficial fibers
of masseter.

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 2. Retraction of the protracted mandible:
- The articular disc together with head of the mandible move
backwards into the mandibular fossa, so the movement takes place
in the upper cavity of the joint.
- The movement is done by the posterior fibers of temporalis.
3. Depression of the mandible:
- The head of the mandible rotates on the under surface of the disc.
At the same time the head of the mandible together with the disc
are pulled downwards and forwards on the articular tubercle. The
rotation movement occurs in the lower cavity of the joint while the
pulling movement takes place in the upper cavity of the joint.
- The rotation movement is done by the lateral pterygoid while the
pulling movement is done by the digastrics, mylohyoids,
geniohyoids and lateral pterygoids.
4. Elevation of the mandible
- The mechanics of movements in depression of the mandible are
reversed.
- The movement is done by the temporalis, masseter and medial
pterygoid.
5. Side to side movement
- Alternative protraction of the mandible on each side.
- The movement is done by alternative action of the pterygoids on
each side.
- Nerve supply:
Nerve to masseter and auriculotemporal nerve.
- Stability and dislocation:
• The joint is stable only in the position of closure of the mouth when the head
of the mandible and the disc lie in the mandibular fossa.
• When the mouth is open with the head of the mandible and the disc lie below
the articular tubercle, anterior dislocation can occur by a blow on the chin or
even excessive opening of the mouth as in yawing.
• Reduction of the dislocation is achieved by downward pressure of the last
molars to overcome the spasmodic contraction of the masseter and temporalis,
then elevation of the chin with backward pressure to draw the condyles
backwards.

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