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neuro 2019 Exam 3 > Pterygopalatine Fossa and Palate > Flashcards

Pterygopalatine Fossa and Palate Flashcards

1
Q

General Features of Pterygopalatine fossa

A

A. The PPF is a bony space located deeply within the skull; it is located postero-inferiorly to the apex of the orbit, posterior to the maxillary sinus, and deep (medial to) the infratemporal region.

B. The PPF contains multiple nerves, arteries, and veins, which distribute to deep and superficial portions of the head and face. The PPF also contains an important parasympathetic ganglion called the pterygopalatine ganglion. This ganglion will receive preganglionic parasympathetic fibers from the facial nerve and distribute postganglionic parasympathetic fibers via branches of V2 to the lacrimal gland and to most of the mucous-secreting glands of the head.

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2
Q

CLINICAL CORRELATION – Transantral access to PPF

A

The PPF can be accessed via the maxillary sinus. The upper lip is elevated and the maxillary sinus is entered anteriorly. This approach can be utilized to remove tumors from the PPF or to ligate a sphenopalatine artery in cases of chronic epistaxis (nose bleeding).

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3
Q

PPF general contents

A
  1. Maxillary artery – third (pterygopalatine) portion
  2. Maxillary branch of trigeminal nerve (V2)
  3. Pterygopalatine ganglion
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4
Q

Boundaries of Pterygopalatine fossa

A

A. Lateral – pteygomaxillary fissure
B. Superior – greater wing of sphenoid bone
C. Anterior – maxilla
D. Medial – palatine bone
E. Inferior – open via pterygopalatine canal
F. Posterior – pterygoid process of sphenoid bone

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5
Q

Openings of Pterygopalatine fossa

A 
pterygomaxillary fissure
inferior orbital fissure
sphenopalatine foramen
pterygopalatine canal
foramen rotundum
pterygoid canal
pharyngeal canal
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6
Q

Openings of Pterygopalatine fossa: Pterygomaxillary fissure

A
  1. Lateral
  2. Communicates with infratemporal fossa
  3. Transmits – maxillary a.; posterior superior alveolar a.v.n
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7
Q

Openings of Pterygopalatine fossa: inferior orbital fissure

A
  1. Anterior
  2. Communicates with orbit
  3. Transmits – infraorbital a.v.n.; zygomatic a.v.n.
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8
Q

Openings of Pterygopalatine fossa: sphenopalatine foramen

A
  1. Medial
  2. Communicates with nasal cavity
  3. Transmits – sphenopalatine a.; nasopalatine n.; post sup lateral nasal n.
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9
Q

Openings of Pterygopalatine fossa: pterygopalatine canal

A
  1. Inferior
  2. Communicates with palate and oral cavity
  3. Transmits – descending palatine a.; greater and lesser palatine nn.
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10
Q

Openings of Pterygopalatine fossa: Foramen rotundum

A
  1. Posterior
  2. Lateral-most of the three posterior openings
  3. Communicates with middle cranial fossa
  4. Transmits – V2
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11
Q

Openings of Pterygopalatine fossa: pterygoid canal

A
  1. Posterior
  2. Middle of the three posterior openings
  3. Communicates with middle cranial fossa near foramen lacerum
  4. Transmits – nerve and artery of pterygoid canal
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12
Q

Openings of Pterygopalatine fossa: pharyngeal canal

A
  1. Posterior
  2. Medial-most of the three posterior openings
  3. Communicates with nasopharynx
  4. Transmits – pharyngeal a.v.n.
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13
Q

Contents of pterygopalatine fossa

A

Maxillary artery
Maxillary nerve
Pterygopalatine ganglion

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14
Q

The maxillary artery in the pterygopalatine fossa

A

A. Maxillary artery
1. The maxillary artery courses through the infratemporal fossa; its third portion then enters the PPF through the pterygomaxillary fissure.

  1. Branches of pterygopalatine portion of maxillary artery
    a. Posterior superior alveolar a.
  2. Enters un-named foramen on maxillary bone.
  3. Supplies maxillary teeth and gingiva and maxillary sinus

b. Infraorbital a.
1. Exits the PPF anteriorly via the inferior orbital fissure.
2. Courses through the floor of orbit in the infraorbital canal
3. Exits to face via infraorbital foramen
4. Supplies floor of orbit, maxillary sinus, maxillary teeth, and the skin of the face via the following branches:
a. Zygomatic artery
b. Middle superior alveolar a.
c. Anterior superior alveolar a.
d. Nasal branches
e. Superior labial branches

c. Descending palatine a.
1. Exits the PPF inferiorly via the pterygopalatine canal.
2. Supplies the palate, nasal cavity, and palatine tonsil via the following branches:
a. Greater palatine a.
b. Lesser palatine a.

d. Artery of pterygoid canal
1. Exits the PPF posteriorly via the pterygoid canal.
2. Supplies nasopharynx, auditory tube, tympanic cavity.

e. Pharyngeal a.
1. Exits the PPF posteriorly via the pharyngeal canal.
2. Pharyngeal canal courses through the medial wall of the sphenoid sinus to open into the nasopharynx.
3. Supplies nasopharynx, sphenoid sinus, and auditory tube.

f. Sphenopalatine a.
1. Exits the PPF medially via the sphenopalatine foramen
2. Supplies nasal cavity

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15
Q

Maxillary nerve (V2)

A
  1. V2 exits the middle cranial fossa via the foramen rotundum to enter the PPF.
  2. V2 is sensory (GSA) to the middle dermatome of the face, nasal cavity; paranasal sinuses; maxillary teeth.
  3. Distributes parasympathetic innervation from the pterygopalatine ganglion.
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16
Q

Branches of V2

A
  1. Branches of V2
    a. Meningeal branch to dura of middle cranial fossa.

b. Zygomatic n.
1. Exits PPF anteriorly via the inferior orbital fissure.
2. Courses through floor and lateral wall of the orbit and then divides into the following two nerves which supply GSA innervation to the face:
a. Zygomaticofacial n.
b. Zygomaticotemporal n.
1. Gives rise to communicating branch to lacrimal nerve of V1
2. NOTE: Route for autonomic fibers to the lacrimal gland.

c. Posterior superior alveolar n.
1. Enters un-named foramen on maxillary bone.
2. Supplies maxillary teeth and gingiva and maxillary sinus

d. Infraorbital n.
1. Exits PPF anteriorly via the inferior orbital fissure.
2. Courses through floor of orbit in infraorbital canal and exits to face via infraorbital foramen.
3. Supplies floor of orbit, maxillary sinus, maxillary teeth, skin of face via:
a. Middle and anterior superior alveolar n.
b. Inferior palpebral nn.
c. External nasal branches
d. Superior labial branches

e. Pterygoplatine nn. (2)
1. Suspend the pterygopalatine ganglion to V2
2. Carry parasympathetic nerves to pterygopalatine ganglion.

f. Greater palatine n.
1. Exits PPF inferiorly via the pterygopalatine canal to oral cavity.
2. Supplies hard palate
3. Also supplies the nasal cavity via the:
a. Posterior inferior lateral nasal n.

g. Lesser palatine n.
1. Exits PPF inferiorly via the pterygopalatine canal to oral cavity.
2. Supplies soft palate and tonsillar bed.

h. Posterior superior lateral nasal n.
1. Exits PPF medially via sphenopalatine foramen to enter nasal cavity.
2. Supply lateral wall of nasal cavity

i. Pharyngeal n.
1. Exits PPF posteriorly via the pharyngeal canal to nasopharynx.
2. Supplies nasopharynx

j. N. of pterygoid canal
1. Enters PPF posteriorly via the pterygoid canal.
2. Carries autonomics to PPG (see below)

k. Nasopalatine n.
1. Exits PPF via the sphenopalatine foramen to nasal cavities.
2. Supplies nasal cavity
3. Then passes through incisive foramen to supply anterior hard palate

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17
Q

CLINICAL CORRELATION: Nerve Blocks

A

a. Nasopalatine nerve block – anesthetic injected near incisive foramen.
b. Greater palatine nerve block – anesthetic injected near greater palatine foramen.

18
Q

Pterygopalatine ganglion (PPG)

A
  1. The PPG is suspended from V2 by pterygopalatine nn. It contains cell bodies of postganglionic parasympathetic neurons. The PPG receives preganglionic fibers from facial n (greater petrosal n) and postganglionic fibers from the deep petrosal nerve. These autonomic fibers then distribute via various branches of V2 to the mucus glands of the deep head (nasal and paranasal cavities, palate, pharynx) and to the lacrimal gland.
19
Q

Nerve of the pterygoid canal

A

a. Carries parasympathetic (pre) and sympathetic (post) to PPG.
b. Composed of greater petrosal nerve and deep petrosal nerve.

c. Greater petrosal nerve
1. Pathway of parasympathetic fibers concerned with PPG
2. Preganglionic cell bodies located in brainstem in salivatory nucleus.
3. Preganglionic fibers travel with CN VII → greater petrosal nerve → nerve of pterygoid canal → pterygopalatine ganglion.
4. Postganglionic fibers then distribute via branches of the maxillary nerve.

d. Deep petrosal nerve
1. Pathway of sympathetic innervation to (through) PPG
2. Preganglionic cell bodies located in the IMLCC from T1/T4.
3. Preganglionic fibers travel within sympathetic chain to the superior cervical sympathetic ganglion (SCG).
4. Postganglionic cell bodies are located in the SCG.
5. Postganglionic fibers form internal carotid nerve → deep petrosal nerve → nerve of pterygoid canal → pass through PPG without synapsing.
6. Postganglionic fibers then distribute via branches of the maxillary nerve.

20
Q

III. Autonomic Innervation to Lacrimal Gland : Parasympathetic innervation

A
  1. Preganglionic cell bodies located in the salivatory nucleus in brainstem.
  2. Preganglionic fibers travel with the greater petrosal nerve (CN VII).
  3. Postganglionic cell bodies in pterygopalatine ganglia.
  4. Postganglionic fibers travel with the zygomatic (V2) and lacrimal (V1) nerves.
  5. Increase lacrimal gland secretions.
21
Q

Autonomic Innervation to Lacrimal Gland: Sympathetic innervation

A
  1. Preganglionic cell bodies located in upper thoracic spinal levels (T1-T4).
  2. Preganglionic fibers enter sympathetic chain and ascend.
  3. Postganglionic cells bodies in superior cervical sympathetic ganglia; fibers distributed via internal carotid nerve (deep petrosal nerve).
  4. Greater and deep petrosal nerves merge to form the nerve of the pterygoid canal.
  5. Postganglionic fibers distribute with the zygomatic (V2) and lacrimal (V1) nerves.
  6. Vasomotor; creates more watery lacrimal fluid
22
Q

Autonomic innervation to mucous-secreting glands of head : Parasympathetic

A
  1. Preganglionic cell bodies – salivatory nucleus in brainstem
  2. Preganglionic fibers travel with facial n.
  3. Facial n provides greater petrosal branch which exits temporal bone via the hiatus for the greater petrosal n.
  4. Now in the middle cranial fossa, the greater petrosal nerve joins the deep petrosal nerve to form the nerve of the pterygoid canal.
  5. N. of pterygoid canal travels in pterygoid canal to pterygopalatine fossa.
  6. Postganglionic cell bodies – pterygopalatine ganglion
  7. Postganglionic fibers travel with branches of V2 to distribute to the nasal cavities and paranasal sinuses.
23
Q

Autonomic innervation to mucous-secreting glands of head: Sympathetic

A
  1. Preganglionic cell bodies – T1-T4
  2. Postganglionic cell bodies – superior cervical ganglion
  3. Postganglionic fibers form the internal carotid nerve → deep petrosal n.
  4. Deep and greater petrosal nerve form nerve of the pterygoid canal.
  5. Postganglionic fibers travel with branches of V2 to distribute to the nasal cavities and paranasal sinuses.
24
Q

General Features of Palate

A

A. Consists of hard (ossified) and soft (musculofascial) portions.
B. Forms boundary between nasal and oral cavities.
C. Superior (nasal) surface is covered with a respiratory mucosa.
D. Inferior (oral) surface is covered with a typical oral mucosa.

25
Q

Structure of the palate: hard palate

A
  1. Anterior 2/3rds of palate.
  2. Bony, internal skeleton formed by:
    a. Palatine processes of maxillary bones
    b. Horizontal plate of palatine bones
  3. Foramina
    a. Incisive foramen – passage of nasopalatine n. and greater palatine a.
    b. Greater palatine foramine – passage of greater palatine a.v.n
    c. Lesser palatine foramina – passage of lesser palatine a.v.n
  4. Mucosa
    a. Palatine glands – mucous-secreting.
    b. Transverse palatine folds
    c. Palatine raphe
26
Q

Clinical correlation: anesthetic injection at the hard palate

A

anesthetic injection is very painful here because the mucosa is very tightly adhered to the underlying bone, thus anesthetic agent is typically injected into superior gingiva mucosa.

27
Q

Structure of the palate: soft palate

A
  1. Posterior 1/3rd of palate.
  2. Mobile; assists with swallowing.
    a. Presses against tongue to hold food in oral cavity
    b. Presses against roof of pharynx to prevent food from passing into nasal cavity
  3. Composed of palatine aponeurosis and overlying mucosa with palatine glands.
  4. Ends in posterior projection called the uvula.
28
Q

Fauces

A
  1. Fauces = passage from oral cavity to pharynx.
  2. Bounded by:
    a. Superior – palate
    b. Inferior – base of tongue
    c. Lateral – faucial pillars
  3. Palatoglossal arch – fold of mucosa overlying palatoglossus muscle
  4. Palatopharyngeal arch – fold of mucosa overlying palatopharyngeus muscle
  5. Isthmus of the fauces – constricted portion of fauces bounded by palatoglossal pillars.
29
Q

Tonsillar bed/ fossa

A
  1. Depression between palatoglossal and palatopharyngeal folds
  2. Houses palatine tonsil
  3. Structures forming tonsillar bed:
    a. Superior constrictor
    b. Hyoglossus
    c. Middle constrictor
    d. Glossopharyngeal n
    e. Tonsillar vessels
30
Q

Palatine tonsil

A
  1. Lymphoid tissue
  2. Arterial supply
    a. Facial a.
    b. Palatine branch of ascending pharyngeal a.
    c. Ascending palatine a.
    d. Dorsal lingual a.
    e. Lesser palatine a.
  3. Venous drainage
    a. Tonsillar plexus
    b. Pharyngeal plexus of veins
31
Q

Muscles of palate

A 
palatoglossus
palatopharyngeus
musculus uvulae
tensor veli palatini
levator veli palatini

all except tensor veli palatini are innervated by vagus n.

32
Q

Palatoglossus

A
  1. Origin – soft palate via palatine aponeurosis
  2. Insertion – tongue
  3. Innervation – vagus n
  4. Function – pulls tongue and soft palate together during swallowing
33
Q

Palatopharyngeus

A
  1. Origin – soft palate via palatine aponeurosis
  2. Insertion – thyroid cartilage
  3. Innervation – vagus n
  4. Function – swallowing
34
Q

Musculus uvulae

A
  1. Origin – soft palate via palatine aponeurosis
  2. Insertion – uvula
  3. Innervation – vagus n.
  4. Function – shortens and elevates uvula
35
Q

Tensor veli palatini

A
  1. Origin – lateral side of cartilaginous auditory tube; membranous auditory tube; medial pterygoid plate; scaphoid fossa; spine of sphenoid bone.
  2. Insertion – attaches to palatine aponeurosis via a tendon which passes inferior to the pterygoid hamulus.
  3. Innervation – trigeminal n (V3) * only muscle of palate not innervated by CN X
  4. Function – tenses palate; functions during mastication and swallowing; opens membranous portion of auditory tube.
36
Q

Levator veli palatini

A
  1. Origin – medial side of cartilaginous auditory tube; petrous portion of temporal bone
  2. Insertion – passes between base of skull and superior constrictor to attach to the palatine aponeurosis.
  3. Innervation – vagus n.
  4. Function – elevate palate; pull against roof of pharynx
37
Q

CLINICAL CORRELATION: With paralysis of CN X

A

the soft palate and the faucial pillars will sag. Also, the uvula will deviate to the unaffected side.

38
Q

tensor veli palatini’s innervation

A

CN V3

39
Q

Vasculature of palate

A 
IV.	Vasculature of Palate
A.	Arterial
1.	Maxillary artery (3rd portion) 
a.	Greater palatine
b.	Lesser palatine
2.	Facial artery 
a.	Ascending palatine a.

B. Venous Drainage of Palate

  1. Pterygoid plexus of veins
  2. To maxillary vein
40
Q

Sensory innervation of Palate

A

A. Trigeminal nerve (V2)

  1. Nasopalatine n.
  2. Greater palatine n.
  3. Lesser palatine n.

B. NOTE: These branches of V2 also distribute autonomic fibers to the blood vessels and glands of the palate

neuro 2019 Exam 3 (17 decks)

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