ENT Head and Neck Radiology Seminar

16-17 July 2010

Hospital Ampang

ASSOC PROF DR BAHARUDIN ABDULLAH

Dept of Otorhinolaryngology-Head & Neck
Surgery
School Of Medical Sciences
Universiti Sains Malaysia

Thin, flat muscles which are

connected to the dermis by
fasciocutaneous ligaments
and osteocutaneous
ligaments (zygoma and
mandible)
Innervated by the facial nerve
These muscles may often
blend into each other
Relaxed skin tension lines
run perpendicular to the
direction of muscle fibers
During tumor extirpation,
significant loss is required
before a functional deficit is
appreciated.

The face is supplied by branches of the external

carotid and the internal carotid artery
Two main branches of the external carotid:Facial
artery and superficial temporal artery
Main branches of the internal carotid that supplies
the medial upper face and scalp is the
ophthalmic artery

Most veins in the face run parallel with their

corresponding arteries
These veins lack valves and therefore allow
bidirectional blood flow
The facial vein can communicate with the
cavernous sinus through the ophthalmic vein or
the pterygoid plexus (which drain the paranasal
area and the upper lip)
Wound infections in this area have the
potential to gain access to the cavernous sinus

 Innervates

muscles of facial expression

Exits stylomastoid foramen and travels
through through parotid gland where it
divides into its five major
branches:Temporal, Zygomatic, Buccal,
Marginal Mandibular, Cervical
Posterior auricular branch arises proximal
to parotid
There is significant variability in the
course and arborization of this nerve from
patient to patient.

 Temporal

and Marginal Mandibular

Branches are most at risk during skin
cancer surgery
Zygomatic and Buccal branches are at
less risk because :
-There are often many anastomoses
between zygomatic and buccal branches
-The proximal trunks of these nerves are
located relatively deep to the surface of
the skin

 Main

branch runs from 0.5 cm below the

tragus to 1.5 cm above the lateral brow
The zone between a line connecting the
ear lobe and the brow and another line
connecting the ear lobe and most lateral
portion of the highest forehead crease will
contain most of the temporal branches
Area over the zygoma is the most
vulnerable

 The

marginal mandibular branch exits the

parotid and runs along the mandible
where it is covered by the platysma.
At the anterior border of the masseter it
passes superficial to the facial artery and
vein and runs along the mandible.
At a point 2 cm from the oral commissure
it takes a more superficial position, but is
still protects as long as the underlying
muscles have not been violated.

Anterior triangles
Posterior cervical triangle

Trapezius

Sternocleidomastoid

Investing layer of deep cervical fascia

Sternocleidomastoid

Pretracheal fascia
(visceral part)

Carotid sheath
T
E

Buccopharyngeal fascia

Alar fascia

Prevertebral fascia

Trapezius

Pretracheal
fascia
(muscular
part)

Deep Cervical Fascia

 deep

fascia of neck condenses to form

four layers:
1) investing
2)pretracheal
3)prevertebral
4)carotid sheath

 surrounds

neck like collar

splits to enclose two muscles (trapezius &
sternocleidomastoid), two salivary glands
(parotid & submandibular) and two spaces
(suprasternal & supraclavicular)

 between

angle of mandible and mastoid

process, it splits into two laminae to
enclose parotid gland, superficial lamina
(parotid fascia) extends to zygomatic arch
deeper lamina (between angle of
mandible and styloid process) forms
stylomandibular ligament
forms roof of anterior and posterior
triangles of neck

 lies

deep to infrahyoids
splits to enclose thyroid, trachea and
oesophagus

 situated

in front of prevertebral muscles

of neck (surrounds cervical vertebrae and
associated muscles)
forms floor of post. triangle of neck
cervical and prox. brachial plexuses are
deep to this fascia
axillary sheath is extension of this fascia

 encloses

common carotid and internal

carotid arteries, internal jugular vein,
and vagus nerve
ansa cervicalis embedded in ant wall
sympathetic chain lies post, outside
sheath
runs from base of skull to sup
mediastinum

triangular area in neck enclosed between

sternocleidomastoid and trapezius
Boundaries:
base: mid 1/3 of clavicle
apex: lies on sup. nuchal line
ant: post border of sternocleidomastoid
post: ant border of trapezius
roof: investing layer of cervical fascia
floor: prevertebral fascia fascia covering splenius
capitus, levator scapulae, scalenus medius, and
scalenus posterior

 spinal

accessory, cervical plexus,phrenic,

brachial plexus
accessory n. (CN XI) divides post triangle
into sup and inf parts, runs between
sternocleidomastoid and trapezius
(supplying both), enters at 1/3 way down
sternocleidomastoid
lesser occipital n. (C2) ascends short
distance along sternocleidomastoid before it
divides to supply skin of neck and scalp post
to auricle, and sup auricle

 greater

auricular n. (C2-3) curves over

post sternocleidomastoid, supplies
branches to skin of neck, divides into ant
& post branch to supply inf auricle, and
area from mastoid to mandible
transverse cervical n. (C2-3) curves
around the post border of
sternocleidomastoid near its middle,
passes transversely across it, supplies
skin of ant triangle of neck

 supraclavicular

nn. (C3-4) arise as single

trunk, which divides into med,
intermediate and lat branches
phrenic n. (C3-5) curves around lat
border of scalenus ant, descends
obliquely across ant surface, deep to
transverse cervical and suprascapular
art, enters thorax by crossing origin of
internal thoracic art between subclavian
art and vein

 Innervates

trapezius and
sternocleidomastoid muscles
Most vulnerable when it enters posterior
triangle of the neck at Erbs point
Other nerves at risk near Erbs point:
-Greater Auricular
-Transverse Cervical
-Lesser Occipital
-Supraclaviular

 Draw

a horizontal line from the thyroid

notch across the neck
Nerve exit SCM 2 cm superior to the line
and enters trapezius 2 cm inferior to the
line (King and Mott, 1983)
Draw a line from the Mastoid process to
the angle of the mandible. Then drop a
perpendicular line at the mid point. This
line will intersect the posterior border of
the SCM.
The nerve emerges within a short
distance above this point (Salasche and
Bernstein, 1988).

Arteries
subclavian (3rd part), transverse cervical,
suprascapular, occipital
Veins
external jugular
lymph nodes
muscles

 anterior

triangle - triangular area in front

of neck
Boundaries:
ant: midline
post: ant border of sternocleidomastoid
base: lower border of mandible, line
drawn from angle of mandible to mastoid
process
apex: jugular notch

 muscles:

1)suprahyoid muscles: mylohyoid (floor

of mouth), geniohyoid (reinforce floor
of mouth), stylohyoid, digastric
(straplike, two bellies, intermediate
tendon joined to hyoid)
2)infrahyoid muscles: omohyoid (two
bellies), sternohyoid, sternothyroid
(deep to sternohyoid), thyrohyoid (sup
continuation of sternothyroid)

Arteries

common carotid, internal carotid, external carotid +

branches

Veins

ant jugular, int jugular + tributaries

Nerves

IX, X, XI , XII, ansa cervicalis, sympathetic trunk

viscera: pharynx, oesophagus, larynx, trachea

glands: parotid, submandibular, thyroid, parathyroid

submandibular fills most of digastric triangle

submandibular duct (5 cm) passes from deep process of

gland to open on sublingual papilla

 Common

Carotid Arteries
-begins at bifurcation of brachiocephalic
- arises from arch of aorta
(post to sternoclavicular joints)
-ascends within carotid sheath to level of
sup border of thyroid cartilage where it
terminates by dividing into int & ext
carotid art.

Internal Carotid Artery

-has no branches in neck, but are
two of four major art. that
supply blood to brain
-each passes vertically upwards
from common to enter carotid
canal in petrous part of
temporal bone, accompanied
by plexus of sympathetic fibres
-during course through neck, lies
deep to sternocleidomastoid
m and parotid gland
-enters middle cranial fossa
through the superior part of
foramen lacerum
-supplies pituitary, orbit and
most of supratentorial part of
brain

External Carotid Artery

-extends between C3/C4
vertebra to the neck of the
mandible
-runs midway between
mastoid process and angle
of mandible within the
parotid gland
-terminates by dividing into
two branches, maxillary a.
and superficial temporal a.

Post.
auricular

Superficial temporal
Maxillary

Facial

Int.
carotid

Digastric
Lingual

Ext. carotid
Sup. thyroid
Sup. laryngeal

Ascending
pharyngeal

Omohyoid

Common carotid

Internal Jugular Vein

-largest vein in neck (usually larger on right side than
left)
-drains blood from brain and superf part of face and
neck
-course corresponds to line drawn from external
acoustic meatus to med end of clavicle
-commences at jugular foramen in post cranial fossa,
as direct continuation of sigmoid sinus, from
dilation at origin (sup bulb of int jugular v.)
-it runs in carotid sheath, leaves ant triangle by
passing deep to sternocleidomastoid and unites with
subclavian post to med clavicle

Lymph Node Groups of the Neck

Level

Lymph Node Group

Submental and
submandibular nodes

II

Upper jugular nodes (skull

base to level of carotid
bifurcation/hyoid bone)

III

Middle jugular nodes

(carotid bifurcation to
omohyoid muscle)

IV

Lower jugular nodes

(omohyoid muscle to
clavicle)

Posterior triangle nodes

VI

Anterior compartment
lymph nodes
(paratracheal/perithyroidal)

funnel-shaped fibromuscular tube

located post to nasal cavity, mouth and larynx
divided into three parts: nasopharynx,
oropharynx, and laryngopharynx
it is about 15 cm in length, extends from base of
skull to inf border of cricoid cartilage
widest (~5cm) opposite hyoid bone, narrowest
(~1.5cm) at inf end
post wall lies against prevertral fascia, with
potential retropharyngeal space in between

pharyngeal wall composed of five layers

-mucous membrane
-submucosa
-pharyngobasilar fascia (attached to skull)
-2 muscular layers composed of inner longitudinal
(stylopharyngeus, palatopharyngeus and
salpingopharyngeus) and outer circular fibres (sup,
middle and inf constrictors)
-loose connective tissue layer forming buccopharyngeal
fascia
supplied mainly by pharyngeal plexus of nn. (formed by
CN IX (sensory) and X (motor));
nasopharynx receives its sensory supply mainly from CN V3

measures ~ 5 cm in length

located in front of C3-C6 vertebrae below the hyoid bone

cartilages: 3 single (epiglottis, thyroid, cricoid); 3 paired

(arytenoid, corniculate, cuneiform)

Epiglottis

Epiglottis

Hyoid

Hyoid
Thyroid cart.

Thyroid cart.
Arytenoid
cart.

Arytenoid
cart.
Cricoid cart.

Anterior view

Vocal Cord
Cricoid cart.

Posterior view

Sagittal Section

 membranes

and ligaments:
1)extrinsic: thyrohyoid membrane,
cricotracheal membrane
2)intrinsic: quadrangular membrane
(extends between epiglottis and
vestibular folds)
3)cricovocal membrane (extends between
vocal ligament and upper border of
cricoid cartilage)

 Cavity

divided into three parts:

-upper (vestibular) part
-middle (ventricular) part: between
vestibular and vocal folds
-lower (infraglottic/subglottic) part
rima glottidis: is the aperture
between the two vocal folds.

 extrinsic

muscles that move the larynx

up and down during deglutition:
1)elevators of larynx : digastric,
stylohyoid, mylohyoid, and geniohyoid
muscles
2)depressors of larynx : sternohyoid,
sternothyroid, and omohyoid muscles
instrinsic muscles: alterations in the
length and tension of vocal folds in the
production of voice, and in changing the
size of rima glottidis

 sensory

nerve supply (to the mucosa) :

above vocal fold: internal laryngeal nerve
vocal fold: recurrent laryngeal nerve
motor nerve supply (to intrinsic muscles) :
recurrent laryngeal nerve, except for
cricothyroid (supplied by external laryngeal
nerve)

largest of endocrine glands

consists of two lateral lobes, isthmus and
occasionally pyramidal lobe
isthmus overlies 2nd, 3rd and 4th tracheal rings
med lat lobe overlies larynx, trachea,
oesophagus, inf. constrictor of pharynx and
cricothyroid muscles
post surface of lat lobe extends over carotid
sheath
infrahyoid muscles cover gland anteriorly
levator glandulae thyroideae attaches pyramidal
lobe to hyoid bone, embryological remnant of
thyroglossal duct

Parathyroids are situated are situated on post

border, along line of sup and inf thyroid art
anastomoses
arteries:
sup thyroid a. (from ext carotid a.); inf thyroid a.
(from thyrocervical trunk); and occasionally
thyroid ima a.(from arch of aorta).
Veins:
sup and middle thyroid vv.(empty into int jug v);
inf thyroid vv (empty into brachiocephal v)

 lies

between body of mandible and hyoid

bone
superficial part includes submental and
digastric triangles
deeper parts include root of tongue and
floor of mouth

Structures
1)muscles: digastric, stylohyoid, mylohyoid, hyoglossus
2)submandibular gland
-mixture of serous and mucous acini
-two parts: superficial and deep
-superficial: in digastric triangle, reaching upward under
cover of mandible, separated post from parotid gland by
stylomandibular lig
-deep: extends forwards in interval between mylohyoid and
hyoglossus, post end continuous with superf part of gland,
while ant end reaches as far as sublingual gland
-coverings: inner ct capsule and outer fibrous capsule
(derived from deep cervical fascia)

 submandibular

duct: runs from ant deep

submandibular gland, forward between
mylohyoid and hyglossus
blood supply: branches of lingual and
facial, veins follow aa.
nerve supply: derived from
submandibular ganglion (receives
parasympathetic fibres from chorda
tympani, lingual and sympathetic trunk)

largest

of salivary glands
(serous acini)
covered by a capsule and a
dense fibrous tissue sheath
(parotid fascia) formed by deep
cervical fascia
divided into two (superficial
and deep) parts by facial n.

lies in fossa post to ramus of mandible

extends from external acoustic meatus to upper
part of carotid triangle
med, extends to styloid process and around
neck of mandible
post, overlaps sternocleidomastoid and extends
ant over masseter
portion of facial part often detached and called
accessory parotid gland
wedge-shaped (base above, apex behind angle
of mandible)
sup: extends upward behind TM joint into post
mandibular fossa, called glenoid process
ant: extends forwards superf to masseter

 Parotid

Duct
5 cm long, 5mm wide
passes horizontally from ant edge, turns
med at ant masseter and pierces
buccinator, and enters oral cavity
opposite crown of 2nd upper molar tooth
Structures within the Gland
facial n (superf)
retromandibular v
external carotid a. (deep)

 Nerve

and blood Supply

supplied by branches of external carotid
a., drains by tributaries of
retromandibular v.
secretomotor (parasympathetic): from
glossopharyngeal n. (IX), via otic ganglion
sensory: branches from greater auricular
and auriculo-temporal nn.

ENT Head and Neck Radiology Seminar

16-17 July 2010
Hospital Ampang