Head/Neck Anatomy Flashcards
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√Four parasympathetic ganglions in the head/neck
- Otic
- Ciliary
- Submandibular
- Pterygopalatine
√What are the four nuclei of the trigeminal nerve?
The trigeminal nerve originates from three sensory nuclei (mesencephalic, principal sensory, spinal nuclei of trigeminal nerve) and one motor nucleus (motor nucleus of the trigeminal nerve) extending from the midbrain to the medulla.
- Spinal trigeminal nuclei: pain, touch, temperature
- Trigeminal motor nucleus: Mastication
- Mesencephalic nucleus: Proprioception
- Pontine nucleus: chief sensory nucleus
https://teachmeanatomy.info/wp-content/uploads/Anatomy-of-the-Origin-of-the-Trigeminal-Nerve-Nuclei-and-Ganglia.jpg
√Name and describe the 4 brainstem nuclei of the facial nerve
- Facial motor nucleus
- Sends special visceral efferent to muscles of facial expression, stylohyoid, posterior digastric, stapedius - Nucleus Tractus Solitarius
- Receives special sensory taste afferents from oral tongue - Superior Salivatory nucleus
- Sends general visceral efferents (parasympathetic) to lacrimal, sublingual, submandibular, and nasal glands and hard palate - Spinal nucleus of Trigeminal
- General sensory afferents from EAC/conchal skin
https://prod-images-static.radiopaedia.org/images/53508827/Brainstem_images.003_gallery.jpeg
Name the 5 main branches of the extratemporal facial nerve
- Temporal
- Zygomatic
- Buccal
- Marginal mandibular
- Cervical
√Name and describe the 4 nuclei of the glossopharyngeal nerve
- Spinal trigeminal
- Sensation to the posterior 1/3 of the tongue and EAC - Nucleus of tracus solitarius
- Taste to the posterior 1/3 of the tongue - Motor (nucleus ambiguous)
- Stylopharyngeus efferent - Inferior salivatory nucleus
- Parasympathetic to the parotid
https://prod-images-static.radiopaedia.org/images/57518870/0._gallery.jpeg
Name and describe the 4 nuclei of the vagus nerve
- Spinal Trigeminal Nucleus
- Sensation to the meninges, ear, and larynx - Nucleus of tractus solitarius
- Taste to the laryngeal surface of the epiglottis
- Chemoreceptors to the aortic arch - Nucleus ambiguous (motor)
- Motor to pharyngeal constrictors, palatoglossal, palatopharyngeus - Dorsal vagal motor nucleus
- Smooth muscle of pharynx and larynx
https://pbs.twimg.com/media/E0occVVX0AQSxGk?format=png&name=900x900
What are the structures that pass through the foramen ovale?
Foramen ovale is posterolateral to pterygoid plates
- V3
- Accessory meningeal artery
- Emissary vein
- Lesser superficial petrosal nerve (LSPN)
What are the structures that pass through the Foramen rotundum?
- V2 (maxillary)
- Infraorbital nerve
- Inferior ophthalmic vein
- Sphenopalatine ganglion branches
What are the structures that pass through the Jugular foramen?
- CNIX-XI
- Inferior petrosal sinus
- Junction of sigmoid sinus with internal jugular vein
- Meningeal branch of ascending pharyngeal artery
- Occipital artery
- Emissary veins
What are the structures that pass through the foramen spinosum?
- Middle meningeal artery
- Middle meningeal vein
- Meningeal branch of the mandibular nerve
https://prod-images-static.radiopaedia.org/images/19299087/b46d875e609e5eca70cc5753d19632_gallery.jpeg
What are the structures that pass through the foramen lacerum? 4
- Ascending pharyngeal artery
- Artery of the pterygoid canal
- Greater and deep petrosal nerve
https://upload.wikimedia.org/wikipedia/commons/8/81/Gray193.png
List the cranial nerve foramina in order from anterior to posterior and list all the cranial nerves that exit them.
Draw a picture of the skull base
- Cribriform plate
- Olfactory nerve (CNI) - Optic canal
- Optic nerve (CNII) - Superior orbital fissure
- Oculomotor nerve (CNIII)
- Trochlear nerve (CNIV)
- Ophthalmic nerve branch of trigeminal (CNV-1)
- Abducens nerve (CNVI) - Foramen Rotundum
- Maxillary nerve branch of trigeminal (CNV-2) - Foramen Ovale
- Mandibular nerve branch of trigeminal (CNV-3) - Internal acoustic meatus
- Facial nerve (CNVII)
- Vestibulocochlear nerve (CNVIII) - Jugular foramen
- Glossopharyngeal nerve (CNIX)
- Vagus nerve (CNX)
- Accessory nerve (CNXI) - Hypoglossal canal
- Hypoglossal nerve (CNXII)
Vancouver Page 49
Kevan Otology
Describe the length and course of Stenson’s duct
4-7cm
Course:
1. Anterior from superior parotid
2. Crosses superficial to masseter muscle halfway between the zygoma and angle of the mouth
3. At the anterior border of the masseter muscle, the duct turns
4. Duct then pierces through the buccinator after the anterior border of masster
5. Papilla exists near second molar
6. Zygomatic and buccal branches of facial nerve fun with the duct
https://www.parotidsurgerymd.com/education/articles/parotid-salivary-gland-info/img/parotid-gland-info.jpg
https://ars.els-cdn.com/content/image/3-s2.0-B9780123813619000081-f08-03-9780123813619.jpg
Describe the length and course of Wharton’s duct
~5cm
- Runs along the floor of the mouth between the mylohygoid and the hyoglossus/genioglossus muscles
- Then goes medial to the sublingual gland, to end in a small orifice at the base of the lingual frenulum
Relationship between lingual nerve and Wharton’s duct:
- Lingual nerve descends lateral to the submandibular duct, passes inferior to it, and ascends medial to it
https://medicoapps.org/wp-content/uploads/2018/10/1526205507.jpg
https://openbooks.uct.ac.za/images/Chapter%2025%20-%20Sialolithiasis%20and%20sialendoscopy/Fig%205.JPG
Where do the sublingual ducts end?
Ducts of Rivinus (too small for eye to see)
~10 ducts along the floor of mouth
https://anatomy-medicine.com/uploads/posts/2015-05/1431364369_salivary_glands.jpg
Describe the sympathetic innervation to the face
- ECA plexus (superficial/superior sympathetic cervical ganglion)
- V2/3 from ECA plexus
- V1 from ICA plexus
https://www.researchgate.net/publication/313886720/figure/fig1/AS:1086510044586072@1636055589547/Diagram-demonstrating-the-sympathetic-innervation-to-the-face-with-possible-lesion-sites.jpg
Describe the sympathetic innervation to the salivary glands and the nasal cavity
- Originate in nuclei of lateral horn in cervical horn
- Travel within Sympathetic chain (T1-5), to
- Synapses at Superior cervical ganglion, to either ECA/ICA
ECA:
3. Parotid post-ganglionic fibers travel with the ECA
4. Submandibular post-ganglionic fibers travel with facial artery/IMAX
5. Sublingual postganglionic fibers run with lingual artery
6. Minor salivary glands fibers run with lingual artery/Palatal branches of IMAX
ICA:
3. ICA plexus, branches to
4. Deep petrosal nerve, to
5. Carotid canal/foramen lacerum; meets
6. Greater superficial petrosal nerve (from CNVII); which combines with deep petrosal nerve
7. DPN + GSPN = Vidian nerve; goes to
8. Pterygopalatine fossa (no synapse); to
9. Sphenopalatine nerve; to
10. Nasal cavity
https://radiopaedia.org/cases/35928/studies/37483?lang=us&referrer=%2Farticles%2Fgreater-superficial-petrosal-nerve%3Flang%3Dus%23image_list_item_631
https://upload.wikimedia.org/wikipedia/commons/thumb/e/e1/Gray844.png/250px-Gray844.png
Describe the parasympathetic innervation to the parotid gland
- Inferior salivatory nucleus; to
- Glossopharyngeal nerve; through jugular foramen, to
- Jacobsen’s nerve (inferior tympanic canaliculus); to
- Tympanic plexus (over promontory); to
- Lesser (small) superficial petrosal nerve (hiatus);
- Travels along the petrous bone through foramen ovale; to
- Otic ganglion synapse
- Post-sympanic to auriculotemporal nerve; to
- Parotid
Pre-ganglionic fibres
- Originate in the inferior salivatory nucleus
- Glossopharyngeal nerve (makes a U-turn in the jugular foramen) via Jacobsen’s nerve in tympanic plexus (enters the middle ear via the inferior tympanic canaliculus - exits via the superior tympanic canaliculus)
- Emerges out of skull base via foramen ovale and synapses at the otic ganglion via lesser superficial petrosal nerve
Post-ganglionic fibres
- Emerges from otic ganglion and travel within the auriculotemporal branch of V3 (enters the infra temporal fossa via the foramen oval)
- Innervates the parotid gland
https://i.ytimg.com/vi/K3JL0Wp19mI/maxresdefault.jpg
Describe the parasympathetic innervation to the submandibular/sublingual gland
- Superior salivatory nucleus; to
- Nervus Intermedius (CNVII); to
- Chorda tympani; travels with lingual branch of V3, to
- Lingual nerve; to
- Submandibular ganglion (synapse);
- Submandibular/sublingual gland
The lingual nerve, she took a curve, on
stylohyoglossus. Said Warthn’s duct, well I’ll be fucked the bastards double crossed us.
Pre-ganglionic Fibers
- Originate in superior salivatory nucleus
- Nervus intermedius to CNVII
- Enter the chords tympani, which exits skull through the petrotympanic fissure, then exits via infratemporal fossa
- Travel with the lingual branch of V3, then travels between medial pterygoid muscle and ramus of the mandible, then goes to submandibular ganglion
Post-ganglionic fibres
- Emerge from submandibular ganglion and enters the submandibular and sublingual glands
https://www.researchgate.net/publication/256100308/figure/fig1/AS:616376234426379@1523966954968/Model-of-parasympathetic-and-sympathetic-innervation-of-the-adult-major-salivary-glands.png
Describe the parasympathetic innervation of the minor salivary glands
- Superior salivatory nucleus
- Nucleus intermedius
- Geniculate ganglion (bypass)
- Enters the Greater Superficial petrosal nerve
- Merge with deep petrosal nerve to form Vidian nerve
- Synapse at the pterygopalatine ganglion
- Post-ganglionic travels with zygomatic branch of V2
- Innervates lacrimal gland, gr/lesser palatine nerves/sphenopalatine nerve (nasal cavity)
- Provides innervation to 600-1000 minor salivary glands
Pre-ganglionic fibres
- Originates in the superior salivary nucleus
- Nervus intermedius to CNVII
- Enter the greater superior petrosal nerve from the geniculate
- Merge with the deep petrosal nerve to form the Vidian nerve
- Synapse in the pterygopalatine ganglion
Post-ganglionic Fibers
- With zygomatic branch of V2
- Emerge from pterygopalatine ganglion via palatine nerves and inner minor salivary acini
Describe the artery and vein supplying the parotid, submandibular, and sublingual glands
PAROTID GLAND
- Arterial Supply: External carotid > superficial temporal artery > transverse facial artery
- Venous drainage: Superficial temporal vein joins the maxillary vein to form the posterior facial (retromandibular vein)
– This should be deep to the facial nerve
– This joins the post-auricular vein to form the external jugular vein
– The posterior facial vein ALSO joins the anterior facial vein to form the common facial vein > drainage into the internal jugular vein
SUBMANDIBULAR GLAND
- Arterial Supply: Facial artery
- Venous drainage: Anterior facial vein (marginal mandibular nerve is superficial to this) > internal jugular vein
SUBLINGUAL GLAND
- Arterial supply: Sublingual branch of lingual artery and submental branch of facial artery
- Venous drainage: Lingual vein and anterior facial vein
Describe the afferent taste pathway
- Anterior 2/3 tongue (Fungiform papillae)
- Lingual nerve
- Chorda tympani (enters through Hugier canal)
- Middle ear
- Iter Chordae posterior
- Facial nerve
- Genicular ganglion (anterior cell bodies)
- Nervus intermedius
- Nucleus tractus solitarius (pons)
- Ventroposteriomedial nucleus of the thalamus
- Operculum/anterior dorsal insula (cortex)
What are the most common cranial nerve injuries?
In order: 1, 8, 10, 7
CN 6 - longest nerve (abducens)
What is Meckel’s cave?
Dural diverticulum (outpouching) with subarachnoid at the petrous ridge of Middle Cranial Fossa, houses the trigemical ganglion
What are the 3 branches of V1?
What do they pass through?
What do they innervate?
FRONTAL BRANCH
- Enters the Superior orbital fissure lateral to Tendon of Zinn
- Divides into supratrochlear and supraorbital nerves
- Supply forehead and scalp
LACRIMAL BRANCH
- Enters the superior orbital fissure lateral to tendon of Zinn
- Supplies lacrimal gland (postsynaptic autonomic efferent) and lateral eyelid
NASOCILIARY BRANCH
- Enters the superior orbital fissure medial to tendon of Zinn
- Divides into posterior ethmoidal nerve, anterior ethmoidal nerve (tip of nose), and infratrochlear nerve (root of nose)
- Supplies tip of nose through external branch of anterior ethmoidal nerve, root of nose through infratrochlear nerve, and corneal surface sensation
https://www.earthslab.com/wp-content/uploads/2018/01/Anterior-Ethmoidal-Nerve.jpg
What are the branches of V2 (Maxillary division of Trigeminal)? 13
V2 goes from Foramen Rotundum, through PPF (where it also branches to pterygopalatine ganglion) and then exist the infra-orbital canal (among other canals are its branches)
IN THE CRANIUM:
1. Middle meningeal nerve (in the meninges)
FROM THE PTERYGOPALATINE FOSSA:
1. Infraorbital nerve (through infraorbital canal)
2. Zygomatic nerve – branches to Zygomaticotemporal and Zygomaticofacial (through inferior orbital fissure)
3. Nasal branches/nasopalatine (through Sphenopalatine foramen)
4. Superior alveolar nerves - posterior superior alveolar & middle superior alveolar
5. Palatine nerves - Greater palatine and lesser palatine nerve
6. Pharyngeal nerve
IN THE INFRAORBITAL CANAL:
1. Anterior superior alveolar nerve
2. Infraorbital nerve
ON THE FACE (All branches of the infraorbital nerve)
1. Inferior palpebral nerve
2. Internal nasal nerve
3. External nasal nerve
4. Superior labial nerve
Vancouver page 50
What are the 3 divisions and 13 branches of the mandibular division of the trigeminal (V3).
UNDIVIDED NERVE
1. Meningeal (nervus spinosus up through foramen spinosum)
2. Medial pterygoid
3. Tensor veli palatini
4. Tensor tympani
ANTERIOR DIVISION
1. Buccal nerve
2. Lateral pterygoid
3. Masseteric
4. Anterior deep temporalis
5. Posterior deep temporalis
POSTERIOR DIVISION
1. Auriculotemporal nerve
2. Lingual nerve
3. Inferior alveolar nerve (mental)
4. Nerve to mylohyoid and anterior belly of digastric
Vancouver Page 51
https://d45jl3w9libvn.cloudfront.net/jaypee/static/books/9788184487015/Chapters/images/47-1.jpg
https://www.earthslab.com/wp-content/uploads/2017/07/070417_0934_MandibularN1.jpg
√What are the boundaries of the Infratemporal Fossa?
Anterior = Posterior surface of the maxilla
Posterior = Articular tubercle of temporal bone, sphenoid spine
Superior = Greater wing of the sphenoid bone, foramen ovale and spinosum
Inferior = Alveolar border of the maxilla
Medial = Lateral pterygoid plate, pterygomaxillary fissure
Lateral = Coronoid process and ramus of the mandible
Vancouver Page 51
What are the contents of the infratemporal fossa? 6
- Branches of V3 mandibular nerve
- Chorda tympani
- Internal maxillary artery (1st and 2nd parts)
- Pterygoid muscles
- Pterygoid venous plexus
- Sphenomandibular ligament
√Regarding the parapharyngeal space, discuss:
1. What are the borders?
2. What are the connections?
3. What are the contents?
BORDERS:
- Superior: Skull base along the sphenoid
- Inferior: Greater cornu of the hyoid
- Lateral: Fascia covering the ramus of the mandible, deep surface of the parotid
- Medial: Buccopharyngeal fascia covering the superior constrictor
- Anterior: Pterygomandibular raphe
- Posterior: Posterolateral carotid sheath, Posteromedial retropharyngeal space
CONNECTIONS:
1. Paralingual
2. Parotid
3. Carotid
4. Masticator
5. Retropharyngeal
6. Submandibular spaces
CONTENTS:
- Tensor-vascular styloid (aponeurosis of Zuckerkandl and Testut) fascia running from styloid process to Tensor Veli palatini divides space into two compartments
PRE-STYLOID (Between medial pterygoid and superior constrictor)
1. Fat
2. Deep lobe of parotid
3. Internal maxillary artery
4. Branches of Mandibular nerve V3 (lingual, inferior alveolar, auriculotemporal)
5. Lymph nodes
6. Ectopic minor salivary glands
POST-STYLOID
1. CN IX-XII
2. IJV
3. ICA
4. Sympathetic chain
Nadia PPS lecture Grand Rounds 2023
√What are the boundaries of the pterygopalatine fossa?
ANTERIOR = Posterior wall of the maxilla
POSTERIOR = Sphenoid bone, base of pterygoid process, inferior portion of anterior aspect of the greater wing
MEDIAL = Perpendicular plate of palatine bone
LATERAL = Pterygomaxillary fissure
SUPERIOR: Undersurface of sphenoid bone and orbital process of palatine bone, opens into inferior orbital fissure
INFERIOR = Palatine bone and palatine canals
Vancouver Rhinology 409
https://www.youtube.com/watch?v=o_JbDynMZjo
√List the 8 openings of the pterygopalatine fossa and their connections, where applicable
- Inferior orbital fissure = orbit
- Pterygomaxillary fissure = Infratemporal fossa
- Sphenopalatine foramen = Nose
- Foramen rotundum = Middle cranial fossa
- Pterygoid canal (Vidian nerve)
- Pharyngeal canal
- Greater palatine canal = oral cavity
- Lesser palatine canal = oral cavity
√What are the contents of the pterygopalatine fossa?
- Predominantly innervated by the great petrosal nerve (CNVII)
- Post-synaptic fibers leave the ganglion and travel with V2 to provide secromotor parasympathetic innervation to the lacrimal gland and mucosal glands (oral cavity, nose, pharynx)
- Vidian nerve is made up of GSPN + Deep petrosal nerves
Vancouver Rhinology Pg 409
√What are the segments of the internal carotid artery?
- C1 = Cervical
- C2 = Petrous
- C3 = Lacerum
- C4 = Cavernous
- C5 = Clinoid
- C6 = Ophthalmic
- C7 = Communicating
“C’mon Please Let Children Consume Our Candy”
Vancouver Page 52
√What are the branches of the external carotid artery?
- Superior thyroid
- Ascending pharyngeal
- Lingual
- Facial
- Occipital
- Posterior auricular
- Maxillary (internal maxillary)
- Superficial temporal
“Some anatomists like freaking out poor med students”
√What are the branches of the internal maxillary artery (IMAX)?
FIRST PART (5): Lies medial to the mandible, all branches go through foramina
1. Deep auricular
2. Anterior tympanic
3. Middle meningeal
4. Inferior alveolar
5. Accessory meningeal
SECOND PART (5): Lies lateral to lateral pterygoid, all branches supply muscles
1. Masseteric artery
2. Pterygoid branches (medial/lateral)
3. Anterior Deep temporal
4. Posterior Deep temporal
5. Buccal artery
THIRD PART (6): Lies within pterygomaxillary fossa
1. Sphenopalatine
2. Descending palatine (Forms greater and lesser palatine)
3. Infraorbital
4. Pharyngeal
5. Posterior superior alveolar
6. Vidian/Artery of the pterygoid canal
“DAM I AM Piss Drunk But Stupid Drunk I Prefer, must phone VPd”
Vancouver Page 53
What are 8 muscles that arise from the 1st branchial arch?
- Masseter
- Temporalis
- Medial Pterygoid
- Lateral Pterygoid
- Anterior belly of digastric
- Tensor tympani
- Tensor veli palatini
- Mylohyoid
These are all supplied by V3
What are the boundaries of the oral cavity?
ANTERIOR = Vermillion border
POSTERIOR = Posterior border of the hard palate, intersection of retromolar trigone and anterior pillar, circumvallate line of the tongue
What are 8 functions of the oral cavity?
- Mastication
- Taste
- Deglutition
- Oral competence
- Articulation
- Respiration
- Airway protection
- Oral hygiene
What are the 5 muscles of the soft palate, and their innervations?
- Palatoglossus (X)
- Palatopharyngeus (X)
- Musculus uvulae (X)
- Levator veli palatini (X)
- Tensor veli palatini (V)
What are the pharyngeal constrictor muscles, and what are their attachments?
- SUPERIOR CONSTRICTOR
- Suspended from skull base, pterygomandibular raphe, transverse process C-spine, mylohyoid line, lateral tongue - MIDDLE CONSTRICTOR
- Stylohyoid ligament, hyoid bone, transverse process of C-spine - INFERIOR CONSTRICTOR
- Thyroid and cricoid cartilages, transverse process of C-spine
All three muscles insert with the corresponing opposite muscle in the midline at the pharyngeal raphe
https://teachmeanatomy.info/wp-content/uploads/Circular-Muscles-of-the-Pharynx-and-the-Stylopharyngeus..png
What is the sinus of Morgagni?
Defect space between the base of skull and superior constrictor.
Allows for communication between the nasopharynx and middle ear
What are 5 anatomic structures running between the skull base and superior constrictor?
- Tensor veli palatini
- Levator veli palatini
- Eustachian tube
- Ascending pharyngeal artery (runs under stylopharyngus, supplies stylopharyngeus and pharyngeal constrictors)
- Ascending palatine artery (branch of facial), runs between the styloglossus/pharyngeus
TELAA
What are the anatomic structures that run between the superior and middle pharyngeal constrictor?
- Glossopharyngeal nerve (IX)
- Stylopharyngeus
- Stylohyoid ligament
- Lingual artery
What are the anatomic structures that run between the middle and inferior constrictors?
Space enclosed by the thyrohyoid membrane
1. Superior laryngeal artery and vein
2. Internal branch of the superior laryngeal nerve
What are the anatomic structures between the inferior constrictor and the esophagus?
- Recurrent laryngeal nerve
- Inferior laryngeal artery and vein
Vancouver page 54
What is the origin and insertion of the medial and lateral pterygoid muscles?
MEDIAL PTERYGOID:
- Consists of two heads: deep head (majority of the muscle) and superficial head (smaller)
- Deep head origin: Medial surface of lateral pterygoid plate
- Superficial head origin: Palatine bone
- Insertion: Both insert into medial angle of the mandible
LATERAL PTERYGOID:
1. Also consists of two heads, superior (upper) and inferior (lower, larger)
2. Superior Head:
- Origin: Infratemporal crest of the greater sphenoid wing
- Insertion: Articular disc and fibrous capsule of the TMJ
3. Inferior Head:
- Origin: Lateral surface of the lateral pterygoid plate
- Insertion: Neck of the mandibular condylar process
Vancouver Page 54
Kevan Gen #24
Describe the 9 layers of the cheek from medial to lateral
- Mucosa
- Pharyngobasilar fascia
- Buccinator muscle
- Buccopharyngeal fascia
- Buccinator fat pad
- Masseter muscle
- SMAS/muscles of facial expression
- Subcutaneous tissue
- Skin
https://maryannreynolds.com/wp-content/uploads/2018/07/screen-shot-2018-06-27-at-8-56-00-am.png
https://musculoskeletalkey.com/wp-content/uploads/2016/12/fig-ch26-04.jpg
What are the boundaries of the oropharynx?
SUPERIOR = plane through hard palate
INFERIOR = Plane through the hyoid
ANTERIOR = Circumvallate papillae
What are the boundaries of the hypopharynx?
SUPERIOR = Horizontal plane through the hyoid
INFERIOR = Horizontal plane through inferior margin of cricoid
What is the one nerve that supplies the sensory innervation of the hypopharynx?
Internal branch of the superior laryngeal nerve
What 3 arteries supply the hypopharynx?
- Ascending pharyngeal (posterior)
- Superior thyroid (post-cricoid/pyriform); branches to superior laryngeal artery –> pharyngeal branch of the superior laryngeal artery supplies it
- Inferior thyroid (post-cricoid/pyriform); branches to inferior laryngeal artery –> pharyngeal branch of inferior laryngeal artery supplies it
Name 5 structures that cross over the internal carotid artery lateral to it
NERVES:
1. Glossopharyngeal nerve (on stylopharyngeus)
2. Pharyngeal branch of vagus
3. Superior laryngeal branch of vagus
4. Hypoglossal nerve (between carotid artery and internal jugular vein)
ARTERIES:
1. Posterior aruticular artery
2. Occipital artery and its lower SCM branch
MUSCLES:
1. Posterior belly of the digastric
2. Stylo-everything (Stylopharyngeus, styloglossus, stylohyoid muscle, and stylohyoid ligament (split ICA/IJV)
“GOSH PPPS”
Vancouver pg 55
Name the 5 structures that run between the external and internal carotid arteries
PSSSP
- Pharyngeal branch of the glossopharyngeal nerve
- Pharyngeal branch of the vagus
- Stylopharngeus
- Styloglossus
- Stylohyoid ligament (NOT the muscle)
https://d45jl3w9libvn.cloudfront.net/jaypee/static/books/9789350251089/Chapters/images/362-1.jpg
What are the 6 main branches of the vagus nerve in the neck and its subdivisions?
- Meningeal
- Auricular (Arnold’s nerve, exists tympanomastoid suture line and supplies inferior EAC+lower TM, causes referred otalgia)
- Pharyngeal (from Nodose ganglion - inferior ganglion of vagus nerve; runs between ICA + ECA, to join pharyngeal branch of CNIX)
- Superior laryngeal nerve, below nodose ~36mm (external and internal laryngeal nerves)
- Cervical cardiac (sympathetics to cardiac plexus in upper and lower neck)
- Recurrent laryngeal nerve
“MAP Some Cardiac Routes”
https://www.earthslab.com/wp-content/uploads/2017/07/Vagus-nerve-course-and-connections.jpg
What are the branches of the glossopharyngeal nerve? 4
- Tympanic branch (Jacobsen’s nerve)
- Pharyngeal branches
- Lingual branches
- Carotid branches
What are the four cutaneous branches of the cervical plexus?
What is defined as Erb’s point?
- Lesser Occipital (C2-3)
- Greater auricular (C2-3)
- Transverse cervical (C2-3)
- Supraclavicular (C3-4, divided into anterior, middle, and posterior)
Punctum nervosum, also known as Erb’s point or the nerve point of the neck, is a point half way along the posterior border of the sternocleidomastoid muscle from which all cutaneous branches of the cervical plexus converge and become superficial.
Vancouver pg 55
https://osmose-it.s3.amazonaws.com/nmL3PALgTPyjod74qk-5SvJMQcKBh-A2/_.jpg
Describe 4 landmark based methods of finding the accessory nerve
- Transverse process of the atlas (C1)
- 10.7mm ± 6.3mm above great auricular point (Erb’s point) mid SCM, posterior border
- 51.3mm ± 17mm above clavicule along the trapezius
- SCM branch - ~4mm from mastoid tip
- Relation to the IJV: 80% anterior, 17% posterior, 1-3% through
- Travels along Levator Scapulae
Discuss 4 referred pain pathways of the head and neck
- TRIGEMINAL referred pain (mouth, mandible, TMJ) –> V3 –> Gasserian Ganglion –> Trigeminal nucleus –> lAuriculotemporal nerve –> Tragus
- GLOSSOPHARYNGEAL referred pain (NP, BOT, tonsil) –> IX –> Petrosal/jugular ganglion –> IX nucleus –> Jacobsen’s nerve –> Tympanic plexus/external ear
- VAGUS referred pain (larynx, piriform, epiglottis) –> SLN –> Nodosum –> Sensory X –> Arnold’s nerve –> EAC/posterior TM
- CERVICAL PLEXUS referred pain (C2/C3) –> Greater auricular nerve –> Gray matter spinal cord –> Lesser occipital/greater auricular –> Pinna/mastoid area
Discuss the venous drainage of the superficial head and neck
- Retromandibular vein (posterior facial vein)
- Formed from the junction of the superficial temporal and pterygoid plexus veins
- Splits to join the external jugular and the common facial vein - Common facial vein
- Formed from junction of anterior facial vein and branch from retromandibular vein
- Drains into internal jugular vein at the level of the hyoid - Pterygoid plexus + Superficial temporal vein = Anterior retromandibular vein
- Posterior auricular vein + posterior retromandibular vein = drains into EJV
Vancouver pg 56
Label the distal arterial branches of the face
Inferior face:
Facial artery –> inferior and superior labial artery –> angular artery –> lateral nasal artery
Superior face:
Transverse facial artery
Superficial temporal artery
Supraorbital artery
Supratrochlear artery
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√Discuss the layers of the fascial planes of the neck
A. SUPERFICIAL CERVICAL FASCIA (SCF)
- Boundaries: Deep to dermis, superficial to the superficial layer of the deep cervical fascia, from zygoma to axillae, clavicles, deltopectoral region
- Contents: Invests platysma, facial mimetic muscles, contiguous with SMAS
- Potential space between SCF and SLDCF contents: Superficial nodes, sensory nerves (e.g. Great Auricular nerve), Vessels (e.g. External jugular vein)
B. DEEP CERVICAL FASCIA (DCF) PLANES:
- SUPERFICIAL/INVESTING LAYER (SLDCF): From nuchal line, vertebral spinous process and mandible to clavicles
- Splits to form suprasternal space of Burns inferiorly
- Superior to inferior boundaries: Zygome to hyoid, clavicle, acronium, scapular spine
- Muscles: envelops trapezius, SCM, strap muscles, and muscles of mastication (masseter, temporalis, and pterygoids)
- Bones: Attaches to hyoid, mandible, and zygomatic arches
- Glands: Parotid and Submandibular Gland
- Other points: Forms the stylomandibular ligament (separates parotid and SMG), contributes to anterolateral aspect of carotid sheath - MIDDLE LAYER (MLDCF): Muscular layer and Visceral Layer
MUSCULAR LAYER:
- Boundaries: Superior: hyoid and thyroid cartilage, inferior: sternum and clavicle
- Contents: Surrounds straps
VISCERAL LAYER:
- Boundaries: Superior: skull base; Anterior: hyoid, strap muscles; Inferior: extends into thorax covering trachea, esophagus, pericardium
- Subdivisions = Pre-tracheal fascia, Buccopharyngeal fascia
- Pre-tracheal fascia surrounds larynx, trachea, pharynx (constrictors), esophagus, thyroid and parathyroid
- Buccopharyngeal fascia forms midline raphe adherent to prevertebral fascia, and pterygomandibular raphe in the lateral pharynx, superiorly ensheaths/contains pharyngeal constrictors and buccinator muscle; anterior border of retropharyngeal space; contributes to medial aspect of carotid sheath
- DEEP LAYER (DLDCF): Divided into prevertebral division and alar division
ALAR LAYER:
- Boundaries: Lies between prevertebral (anterior to prevertebral fascia) and visceral layer of middle cervical fascia (deep to buccopharyngeal fascia; superior - skull base; inferior - fuses with MLDCF at T2 level; Lateral - from carotid sheath to carotid sheath (transverse process to transverse process)
- Contents: Posterior wall of retropharyngeal space, anterior wall of danger space, contributes to post/med/lat aspects of carotid sheath
PREVERTEBRAL LAYER:
- Boundaries: Superior - skull base; Inferior - coccyx; Lateral - Vertebral bodies to transverse process (complete ring)
- Bone and Muscle contents: Invests vertebrae, deep neck muscles (paraspinous, vertebral, scales, longus coli, splenius capitus, etc.)
- Contributes to posterior aspect of carotid sheath
Vancouver Pg 58
Kevan Gen #36
√Describe the Canine space and its borders, and abscess presentation. What is the danger with abscesses in this space?
- Potential space between infraorbital and zygomatic heads of levator labii superioris, the levator anguli oris muscle, and the caninus muscle (roots extends above this)
- Important in anterior superior and bicuspid (premolar) infection
CANINE SPACE BORDER
- Anterior: Nasal cartilages, orbicularis oris
- Posterior: Buccal space / buccinator
- Superior and Superficial: Levator labii superioris muscle, infraorbital foramen/zygoma
- Inferior: Oral mucosa
- Deep: Levator anguli oris muscle, maxilla
ABSCESS PRESENTATION:
- Medial cheek swelling
- Loss of nasolabial fold
- V2 pain
- Eyelid swelling
- CAN SPREAD UP TO ORBIT
Treatment of infection: Dental extraction/root canal, dependent drainage
Which spaces run the entire length of the neck?
- Carotid
- Retropharyngeal
- Danger
- Prevertebral spaces
√Define the buccal space boundaries, contents, and sources of infection
BOUNDARIES:
- Medial: Buccinator and buccopharyngeal fascia
- Lateral: Cheek skin
- Superior: Zygomatic arch
- Inferior: Inferior border of mandible
- Anterior: Lip muscles
- Posterior: Pterygomandibular raphe (Hamulus to mylohyoid muscle, connecting the buccinator to the superior constrictor)
Muscular boundaries:
- Superficial: Temporalis muscle
- Deep: Buccinator muscle
- Posterior: Masseter muscle
CONTENTS:
- Buccal fat pad (fat-filled space)
ABSCESS PRESENTATION:
- Lateral cheek swelling
- May spread to temporal, masticator, or submandibular spaces
- Note: Urgent external drainage as can spread to orbit, cavernous sinus, and intracranially via angular veins
Important in maxillomandibular bicuspid and molar infection
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What are the primary oral cavity spaces?
- Submental: between digastrics, mylohyoid and skin
- Sublingual: Anterior teeth, bicuspids, 1st molar
- Submandibular: 2nd and 3rd molars
Site and spread of infection determined by level/height of tooth roots in relation to mylohyoid line
Vancouver Pg 57
What are the boundaries of the retromolar trigone? 6
- Coronoid
- Maxillary tuberosity
- Tonsillar pillar
- Alveolus
- 3rd molar
- Buccal mucosa
√What are the boundaries of the mandibular spaces? ie. Submandibular and Sublingual spaces (aka. Submaxillary)
What are the divisions?
How does an abscess in this space typically present?
BOUNDARIES:
- Anterior = mylohyoid/anterior belly of digastric
- Superior = FOM mucosa
- Posterior = Stylomandibular ligament/posterior belly of digastric
- Inferior = Investing fascia of hyoid/digastric (superficial layer of the deep cervical fascia)
- Medial: hyoglossus/styloglossus/genioglossus/mylohyoid/geniohyoid
- Lateral: Plastyma and mandible
DIVISIONS:
- Mylohyoid divides into submandibular and sublingual spaces
- Sublingual space is above the mylohyoid line (inferior border of the space is the mylohyoid)
- Submanidbular space is inferior, below the mylohyoid line (superior border is mylohyoid)
- Intrinsic tongue muscles separate into bilateral sublingual spaces
ABSCESS PRESENTATION:
- Teeth anterior to 2nd molar (= superior to mylohyoid line) = submental swelling (sublingual space)
- bilateral SL + SM spaces = Ludwig’s angina - risk airway obstruction from FOM swelling
√What are the contents within the sublingual space? 5
- Sublingual gland
- Wharton’s duct
- Ducts of rivinus
- Lingual and hypoglossal nerves
√What are 7 contents within the submandibular space?
- Submandibular gland
- Wharton’s duct
- Facial artery
- Lingual nerves
- Hypoglossal nerves
- Fat
- Lymph nodes
√Describe the Masticator space and its contents. How does an abscess typically present here?
Delineated by the superficial layer of the deep cervical fascia:
- At lower mandible splits into two
- Inner layer: Deep to medial pterygoid, attaches to skull base
- Outer layer: Covers the masseter muscle, attaches to zygomatic arch and then contineus superiorly to encase the temporalis muscle
Boundaries:
- Lateral: Superficial temporal fascia/zygoma/masseter
- Medial: Sphenoid/pterygoid plates
- Superior: Attachment of superficial temporal fascia to skull base
- Inferior: Mandible
- Anterior: Pterygopalatine fossa
- Posterior: Mandibular ramus
Contains:
- Mastication muscles
- Ramus of mandible
- Mandibular nerve
- Inferior alveolar nerve/vein/artery
- IMAX
Subdivisions:
1. Superficial temporal space: between superior temporal fascia + temporalis muscle
2. Infratemporal space (aka Deep temporal): between temporalis muscle/deep temporal fascia + sphenoid (temporal bone)
3. Pterygomandibular space: between medial pterygoid muscle and mandible
4. Masseteric space: between masseter and mandible
Other components:
- Foramen ovale opens into the space
- Trismus hallmark symptom
- Important in infections of maxillomandibular molar origin
- Can be subdivided into: Masseteric space, pterygomandibular, superficial temporal deep temporal and infratemporal spaces
Abscess presentation:
- Usually odontogenic, cheek swelling, trismus
- Contiguous with parapharyngeal space
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Vancouver Page 58
√Regarding the parotid space, discuss:
1. What are the boundaries?
2. What are its contents?
3. What is it divided into?
4. How does an abscess here typically present?
BOUNDARIES:
- Formed by SLDCF as it splits to enclose parotid –> superomedial portion unencapsulated and opens to prestyloid space
CONTENTS:
1. Parotid gland
2. Facial nerve
3. Lymphatics
4. External carotid artery
5. Retromandibular vein
6. Posterior facial vein
DIVISIONS:
1. Superficial (nerve): Auriculotemporal nerve, great auricular nerve, facial nerve
2. Mid (venous): Superficial temporal vein, IMAX, posterior facial vein
3. Deep (arterial): ECA/ICA, superficial temporal artery
No true upper medial covering: communicates with the pterygopalatine fossa
Abscess Presentation:
1. Cheek swelling
2. NO trismus
√What are the borders of the mental space, and how does an abscess here typically present?
Subperiosteal space on anterior mandible/symphysis beneath mentalis muscle
BOUNDARIES:
1. Anterior: mentalis muscle
2. Posterior: mandible
3. Superior: orbicularis oris
4. Inferior: Depressor labii inferioris
5. Lateral: Depressor anguli oris
ABSCESS PRESENTATION:
- Tender chin swelling
√Describe the borders of the posterior neck spaces
RETROPHARYNGEAL SPACE:
1. Superior: skull base
2. Inferior: Superior mediastinum (to level of the carina - T3/4)
3. Anterior: Buccopharyngeal fascia
4. Posterior: Alar fascia
5. Lateral: Carotid sheath
Retropharyngeal Contents: Fat, 1-3 lymph nodes
DANGER SPACE:
- Found between alar layer and prevertebral layer of deep fascia
- Lateral: carotid sheaths/cervical transverse processes
- Superior: skull base
- Inferior: Descends to diaphragm (T10)
- Abscess presentation: Potential for rapid spread to mediastinum from retropharyngeal/parapharyngeal/prevertebral spaces
PREVERTEBRAL SPACE:
- Found posterior to prevertebral fascia, descends to sacrum
- RIsk of osteomyelitis ± vertebral instability with infections
Vancouver pg 58
Describe the borders of the visceral space
Superior: Hyoid
Inferior: Mediastinum
Posterior: Retropharyngeal space
Lateral: Carotid sheath
Contains: Pharynx, esophagus, larynx, trachea, thyroid
√What are the boundaries of the peritonsillar space? What are its connections?
BOUNDARIES:
1. Lateral - Superior constrictor muscle
2. Medial: Tonsillar capsule
3. Superior - Soft palate
4. Inferior - Base of tongue
5. Anterior - Anterior tonsillar pillar (palatoglossus)
6. Posterior - Posterior tonsillar pillar (palatopharyngeus)
CONNECTIONS:
1. Parapharyngeal space
Name all 6 components of Waldeyer’s ring
- Lingual tonsil
- Palatine tonsils (x2)
- Adenoid
- Gerlach’s tonsils (Tubal, posterior to ET opening)
- Lateral bands
Describe the blood supply to the adenoids (5)
- Pharyngeal branch of the IMAX (major supply)
- Ascending pharyngeal artery
- Ascending palatine branch of the facial artery
- Ascending cervical branch of the thyrocervical trunk
- Artery of the pterygoid canal (vidian)
What is the innervation to the adenoids?
CN IX and X
What is the histology of the adenoids?
- Ciliated pseudostratified columnar epithelium; and
- Stratified squamous epithelium
- Transitional epithelium
- Inflammation increases specialized squamous epithelium proportion and decreased respiratory proportion
What are the four zones of antigen processing in adenotonsillar tissue?
- Specialized squamous epithelium (Dendritic cells)
- Extrafollicular area (T-cells)
- Mantle zone of lymphoid follicle (Mature B-lymphocytes)
- Germinal centre of follicle (active B-cells) - antigen specific cells –> secrete IgA
“GEMS”
Vancouver Pg 59
Describe the blood supply for the tonsil 5
LOWER POLE:
1. Lingual artery - dorsal lingual branches
2. Facial artery - Tonsillar branch + Ascending palatine branch
UPPER POLE:
1. IMAX - Descending palatine artery, branches into lesser ± greater palatine artery
2. Ascending pharyngeal artery - tonsillar branches
Vancouver Pg 59
Describe the efferent lymphatics of the tonsils and adenoids - 2
T + A: Upper deep cervical nodes
A only: Retropharyngeal LN
No afferent lymphatics for T+A
What muscles attach to the medial surface of the mandible? 8
- Genioglossus
- Mylohyoid
- Geniohyoid
- Anterior belly of digastric
- Medial pterygoid
- Lateral pterygoid (condyle)
- Temporalis (coronoid proceess)
- Superior constrictor
Kevan Gen #23
What muscles attach to the lateral surface of the mandible? 6
- Mentalis
- Depressor labii inferioris
- Depressor anguli oris
- Platysma
- Buccinator
- Masster
Kevan Gen #24
What are two possible abscesses than can be formed due to extension of a prevertebral abscess? 2
- Potts abscess = TB spinal abscess
- Psoas abscess = Rare posterior extension/spread from a vertebral abscess (anterior is more common)
What are the contents of the Foramen Magnum (8)
Vertebral artery
Anterior Spinal artery
Meningeal branches of cervical nerves
Posterior spinal arteries
Spinal part of the accessory nerve
Alar and apical ligaments
Tectorial membrane
Medulla Oblongata / Brainstem/
VAMPires Sing AT Midnight
