Head bones ................................................................................................................................

3
Temporal bone ................................................................................................................................................................................ 3
Ethmoid bone ................................................................................................................................................................................... 4
Sphenoid bone ................................................................................................................................................................................. 5
Mandible ............................................................................................................................................................................................ 5
Teeth – molars, premolars, incisors, canines...................................................................................................................... 6
Temporomandibular joint .......................................................................................................................................................... 7
Hyoid bone ........................................................................................................................................................................................ 8
Ear ossicles........................................................................................................................................................................................ 9
Orbital anatomy .........................................................................................................................9
Orbital margin ...................................................................................................................................................................................... 9
Walls of the orbital cavity ........................................................................................................................................................ 10
Spinal vertebrae ....................................................................................................................... 11
Cervical vertebrae characteristics........................................................................................................................................ 11
Thoracic vertebrae ..................................................................................................................................................................... 13
Lumbar vertebrae ....................................................................................................................................................................... 13
Ligamentous supports of vertebral column ..................................................................................................................... 13
Intervertebral joints ................................................................................................................................................................... 14
Cranial fossa foramina.............................................................................................................. 15
Superior view ................................................................................................................................................................................ 15
Inferior view .................................................................................................................................................................................. 15
Fascial layers ............................................................................................................................ 17
Muscles of the neck and head .................................................................................................. 20
Large neck muscles..................................................................................................................................................................... 20
Facial expression muscles ....................................................................................................................................................... 20
Hyoid bone muscles ................................................................................................................................................................... 20
Muscles of mastication .............................................................................................................................................................. 22
Pharyngeal constrictor muscles ............................................................................................................................................ 22
Tongue muscles ........................................................................................................................................................................... 23
Extra ocular eye muscles.......................................................................................................................................................... 24
CNS core concepts .................................................................................................................... 24
Embryology.................................................................................................................................................................................... 24
Basal ganglia (nuclei)................................................................................................................................................................. 25
Lobes, sulci and gyri ................................................................................................................................................................... 27
Cerebellum .................................................................................................................................................................................... 28
CSF production ......................................................................................................................... 29
CNS circulation ......................................................................................................................... 29
Vertebrobasilar artery .............................................................................................................................................................. 29
Internal carotid artery................................................................................................................................................................... 30
External carotid artery.............................................................................................................................................................. 31
Common carotid artery and bifurcation ............................................................................................................................ 31
Venous drainage ...................................................................................................................... 33
CNS and cranial sinuses ............................................................................................................................................................ 33
Cavernous sinus ........................................................................................................................................................................... 33
Internal jugular vein .................................................................................................................................................................. 34
Vertebral vein ............................................................................................................................................................................... 35
Cranial nerves .......................................................................................................................... 37
Development with pharyngeal arches ................................................................................................................................ 35
Oculomotor nerve ....................................................................................................................................................................... 37
Trochlear nerve (IV) .................................................................................................................................................................. 39
Clinic trochlear .................................................................................................................................................................................. 40
Trigeminal nerve (V) ................................................................................................................................................................. 41
Ophthalmic nerve (V1).............................................................................................................................................................. 42
Maxillary nerve division of trigeminal nerve (V2) ......................................................................................................... 43
Mandibular nerve (V3) ............................................................................................................................................................. 44
Abducens ........................................................................................................................................................................................ 46
Facial nerve (VII) ......................................................................................................................................................................... 46
Glossopharyneal (IX) ................................................................................................................................................................. 49
Vagus (X) ......................................................................................................................................................................................... 50
Accessory XI................................................................................................................................................................................... 51
Hypoglossal XII............................................................................................................................................................................. 52
Pharyngeal plexus ............................................................................................................................................................................ 52
Cervical plexus.............................................................................................................................................................................. 53
Spinal Cord............................................................................................................................... 53
Spinal cord anatomy .................................................................................................................................................................. 54
Spinal cord venous drainage .................................................................................................................................................. 56
Vertebral venous plexus ........................................................................................................................................................... 56
Spinal cord dura ........................................................................................................................................................................... 57
Respiratory system................................................................................................................... 57
Nasal cavity .................................................................................................................................................................................... 57
Oral cavity ...................................................................................................................................................................................... 59
Pharynx ........................................................................................................................................................................................... 60
Larynx .............................................................................................................................................................................................. 61
Viscera of the head and neck .................................................................................................... 63
Thyroid ............................................................................................................................................................................................ 63
Lymphatic drainage of neck ...................................................................................................... 65
Superficial ring of lymph nodes............................................................................................................................................. 65
Deep vertical chain of lymph nodes..................................................................................................................................... 65
Regions .................................................................................................................................... 65
Temporal fossa ............................................................................................................................................................................. 66
Infratemporal fossa .................................................................................................................................................................... 66
Parotid region ............................................................................................................................................................................... 66
Anterior triangle .......................................................................................................................................................................... 68
Submandibular triangle ............................................................................................................................................................ 68
Sublingual region......................................................................................................................................................................... 68
Head bones
Calvarium is the skullcap = Frontal, occipital and two parietal bones

Facial bones
 Zygomatic – two cheek bones
 Maxilla – Upper jaw and hard palate
 Mandible – Jaw, articulating with the temporal bone
 Lacrimal – groove within the orbit which supports the lacrimal duct
 Nasal – two slender bones forming the bridge of the nose
 Palatine – Rear of the oral cavity forming part of the hard palate
 Vomer – posterior aspect of the nasal septum
 Inferior nasal conchae – Increase surface area of the nasal cavity to increase air touching
the cavity walls
 Superior nasal conchae is formed by ethmoid bone

Sutures of the skull – Coronal, saggital, lambdoid sutures

Pterion: Coronal suture (frontal and parietal), Sphenofrontal,
sphenoparietal, squamous (squamous portion of temporal bone against
parietal and sphenoid)
 Anterior branch of middle meningeal artery embedded in bone


Temporal bone

Squamous portion – Forms the upright bulk of the bone (red) and
lateral wall of the meddle cranial fossa, is convex laterally
 Temporalis muscle attaches to its lower portion
 Articulates with sphenoid anterior, parietal bone posteriorly
(forms part of pterion)
 Mandibular fossa forms below the zygomatic process within the
squamous bone

Petrous portion – Wedges between sphenoid and occipital bones at the base of the skull and
forms the base of the middle cranial fossa along with the sphenoid bone
Zygomatic process – Blue, merges with zygomatic bone
forming zygomatic arch (cheek bones)
 Masseter attaches some fibers to the zygomatic arch

Petromastoid process – Purple section behind ear. Mastoid

externally, petrous internally.
 SCM attaches here
 Mastoid air cells exist within the bones of the wall to
equalize pressure. Risk of infection

Styloid process – Attachment for ligaments for TMJ

Tympanic – Surrounds the external auditory meatus

Ethmoid bone

Crysta galli – Upward projection of bone for attachment of falx

cerebri
Cribiform plate – The horizontal flat plate of the ethmoid bone
which forms part of the base of the anterior cranial fossae
Ethmoidal labrynths – Two projections inferiorly off the
cribiform plate which contain ethmoidal air cells and the
superior and middle nasal conchae
Perpendicular plate – runs inferiorly between the two
labrynths, attaches to septal cartilage of the nose, forms part of
nasal septum
Sphenoid bone

Four sections
1. Body – Anteriorly: Contributes to the nasal cavity. Laterally: Builds the medial wall of
optic canal. Superiorly: Forms the sella turcica for the pituitary gland and is bordered
by the anterior and posterior clinoid processes.
2. Greater wing – form part of lateral orbital wall posteriorly.
a. Foramen rotundrum – maxillary nerve
b. Foramen ovale – mandibular nerve + accessory meningeal artery
c. Foramen spinosum – Middle meningeal vessels + spinous nerve (branch of
mandibular)
3. Lesser wing – projects superiorly
4. Pterygoid process – Extensions from the base of sphenoid. Contain two canals
a. Pterygoid canal (major petrosal nerve -> deep petrosal -> vessel for pterygoid
canal).
b. Palatovaginal (pharyngeal) canal - Pharyngeal nerve
c. Pterygoid processes undergo intramembranous ossification, rest of sphenoid is
endochondral

Superior orbital fissure: Live Frankly To See Absolutely No Insult (Lacrimal, frontal,
Trochlear, Superior OM, abducens, nasociliary, Inferior OM)

Mandible
Body – runs parallel to floor when standing
 Mental foramen – mental nerve and vessels exit from inside mandible
 Digastric fossa (posterior inferior anterior surface)

Ramus – attaches to cranium at an angle of 110. Divides into two processes separated by
mandibular notch. Coronoid process (red) and condylar process posteriorly
 Mandibular foramen – medial side of ramus, transmits inferior alveolar nerve
 Pterygoid fovea – the ‘neck’ of the anterior condylar process
 Lateral attachments: masseter and temporalis (to coronoid
process).
 Medial attachments: Medial pterygoid, sphenomandibular
ligament

Alveolar processes – Holds teeth with joint mechanism known as

gomphosis

Important components of medial side of the mandible

Digastric fossa – attachment of digastric muscle middle anteroirly
Mylohyoid line – attachment of mylohyoid muscle. Divides the submandibular and
sublingual lines
-Lingula at the end of mylohyoid
line, gives rise to the
pterygomandibular raphe
-Pterygomandibular raphe –
Thickening of fascia, which is
attachment the inner surface
behind the third molar tooth, has
buccinator and superior
constrictor attached

Nerves and vessels in close proximity to mandible

Inferior alveolar nerve – runs into the mandible through the mandibular foramen inside the
bone then exits out of mental foramen
Lingual nerve – In contact behind the posterior end of the mylohyoid line
Masseteric nerve – Passes through mandibular notch to reach the masseter on the lateral
surface of ramus
Auriculotemporal nerve – runs on the medial side of the neck of the mandible
Mylohyoid nerve – Lies in mylohyoid groove, branch of inferior alveolar
Mental nerve – out of the mental foramen, continuation of inferior alveolar

Facial artery – Runs superficial to mandible at the inferior angle of masseter

Teeth – molars, premolars, incisors, canines

The first molar is the one adjacent to the premolar. The third molar is the wisdom tooth, at the
posterior most section
Upper jaw
 Three molars are supplied by posterior superior alveolar nerve
 Premolars supplied by the middle superior alveolar nerve
 Incisors and canines supplied by the anterior superior alveolar nerve
Lower jaw
 All molars and premolars supplied by the inferior alveolar nerve
 Incisors and canines supplied by its continuation, the inferior incisor nerve

Clinical
-In the lower jaw, the mylohyoid line lies below the apex of all the teeth except the second and
third molars. Note, apex is the base, crown is top.
 This means that an abscess of the first molar or incisors will point towards the mouth
cavity, as the mylohyoid is below
 An apical abscess of the second and third molar will have an abscess pointing towards the
neck

Temporomandibular joint
 Synovial
 Condylar type
 Atypical (fibrocartilage on surface)
 Disc attachments
 Anterior: head of mandible
 lateral pterygoid plate

1. A and B represent sphenomandibular ligament (spine of

sphenoid + lingual of mandible). Distance must remain constant.
Lingula is axis of movement
2. First few degrees, gravity drops mandible and rotates anteriorly
at condylar axis initially to maintain distance of A->B
3. Major opening – anterior displacement and further rotation
around new axis which is B via lateral pterygoid muscle
4. Last few degrees are further rotation around condylar process

Supports of TMJ

(More deep)
Lateral TMJ lig – from zygomatic arch to neck and ramus of mandible. Fuses with joint
capsule
Stylomandibular lig – from styloid process mandible
Sphenomandibular lig– from spine of sphenoid to lingual of mandible. Superficial to deep at
sphenomandibular ligament: Mandible, lateral pterygoid, sphenomandibular ligament,
inferior alveolar nerve, medial pterygoid

Pterygomandibular raphe (ligament)

Medial: Oral mucosa
Lateral: adipose and mandible
Posterior: superior constrictor
Anterior: Buccinator

Hyoid bone
 Shaped like a horseshow.
 Situated between the chin and the thyroid cartilage.
 Rests at the base of the mandible anterior to C3.
 No articulations, only attached by ligaments and muscles
 Supplied by the lingual artery from the tongue
 Suprahyoid branch runs across the body to supply muscles

Horns (cornu)
 Greater project posteriorly from the body
 Bony tubercle at the end connects to the lateral thyrohyoid
ligament
 Multiple muscles attach to superior and inferior surface
 Derived from the third pharyngeal arch
 Lesser cornu project superiorly and come from the angle formed by body and greater
cornu
 Stylohyoid ligament and chondroglossus arise from it
 Derived from second pharyngeal arch

Mnemonic from lateral to medial. First is superior attachment, second is inferior attachments
Christ He Didn’t Screw Girls Much. That’s Obvious Stupid.
 Constictor (middle) -
 Hypoglossus
 Digastric
 Stylohyoid
 Geniohyoid
 Mylohyoid
 Thyrohyoid
 Omohyoid
  Sternohyoid

Palatine

Vomer

Nasal bone

Ear ossicles
 Order from lateral to medial – MISO: Malleus,
incus, stapes, oval window
 Synovial joints

Malleus – looks like a dancing astronaut with a head,

neck. Handle is feet, anterior process is arm
Incus – Body with short fat and long slender limb
Stapes – Base is attached to oval window. head
attaches to long limb of incus

Orbital anatomy
 Orbital cavity is pear shaped
 Medial edge runs straight anteroposterior in the saggital plane
 Lateral edge diverges at 45 degrees
 Bones of the orbital cavity include: Many friendly zebras enjoy lazy summer picnics
 Maxilla
 Frontal
 Zygomatic
 Ethmoidal
 Lacrimal
 Sphenoid
 Palatine

Orbital margin
Bony margin when looking at
someone’s’ eyes
 Supraorbital margin: Frontal bone. Supraorbital notch passes vessels and nerve
 Infraorbital margin: Zygomatic laterally and maxilla medially.
 Lateral margin: Strongest margin of orbit. Frontal part of zygomatic bone and zygomatic
part of frontal bone.
 Medial margin: Maxillary process of the frontal bone and lacrimal crest of the frontal
process of the maxilla
 Upper part is indistinct, lower margin easily felt

Walls of the orbital cavity

Walls are lined by periosteum. The apex is formed by the end of the superior orbital fissure

Roof: Frontal bone and lesser wing of sphenoid posteriorly

 Anteromedially, invaded by the frontal air sinus
 Anteriolaterally has a depression named the lacrimal fossa, formed for the orbital part
of the lacrimal gland.
 Medial to the supraorbital notch and 4mm posterior is a spine for the pulley of the
superior oblique muscle.
The roof separates the orbit from the anterior cranial fossa and frontal lobe

Floor: Maxilla and zygomatic with piece of palatine bone.

 Separates orbital cavity from the maxillary sinus (paranasal sinus that drains into middle
meatus of nose)
 Inferior orbital fissure separates the orbital floor from the lateral wall posteriorly, but it is
continuous anteriorly.
 Inferior orbital foramen runs through the inferior orbital canal of the maxilla, to the
inferior orbital groove, which is medial to the inferior orbital fissure.
 Infraorbital vessels pass through here

Lateral wall: Zygomatic anterior 1/3 and greater wing of sphenoid for posterior 2/3
 Thickest wall
 Anterior third is the zygomatic bone, separates it from the temporal fossa
 Temporal fossa = depression in side of skull
 Posterior two thirds is from the greater wing of sphenoid
 Separates orbit from temporal lobe of the brain in the middle cranial fossa
 Lateral wall is continuous with the roof anteriorly, separated by inferior orbital fissure
posteriorly

Medial wall: From anterior to posterior, Maxilla, lacrimal, ethmoid, sphenoid

 Ethmoidal bone separates orbital cavity from ethmoid sinus
 Lacrimal groove is formed by the lacrimal bone posteriorly and frontal process of
maxilla anteriorly. This groove is continuous with the nasolacrimal canal
 Lamina papricia – paper thin wall, part of ethmoid bone, likely to fracture

Clinical
-Most common is orbital floor fracture of the maxilla, termed ‘blow-out fracture’
-Can develop inferior rectus entrapment
-Operation required if eye movement severely limited or globe pushed back after 14 day
waiting period

Spinal vertebrae
Common features amongst all vertebrae
 All have a body S
 All have a neural arch around the vertebral foramen which
collectively form the vertebral canal
L T
 Lamina – posterior aspect of the vertebral arch
 Pedicle – lateral aspects of arch A
P VF
 Pars interarticularis – between the P and L sort of.
 Intervertebral foramen – formed between the pedicles of the
overlying and underlying vertebrae B
 Three processes from each vertebrae: Transverse x2 + spinous
 Four articular processes: Two above (face back) and two below
(face forward)
 Synovial joint

S
Cervical vertebrae characteristics
 Atlas and axis are unique L
 Has a transverse foramen formed by a double edged
P A
transverse process
 Has two tubercles at the base of the foramen, which VF
attach scalene muscles
 Has a bifid spinous process TP
 Has a triangular vertebral foramen TF
B
 C3-T1 have an uncinate process on the side edges of top of
the bodies that for uncovertebral joints (of luschka)
 Has a small body that has a saddle shape (concave top, convex bottom)
 Most mobile – flex, extens, lat flex, med flex, rotation from atlantooccipital joint

Atlas PA

 Has no body – just an anterior arch and posterior arch

 Two lateral masses with arches enclose large foramen
 Posterior foramen for spinal cord
 Anterior foramen for odontoid process of axis O
 Has 2x kidney shaped articular process with the occipital LM
bone
AA
Axis
 Odontoid process is the axis with which the atlas and head move
upon. It is the missing body of the atlas
 Transverse ligament of the atlas holds the odontoid process in
place posteriorly, with bone holding it anteriorly and laterally O
 Two alar ligaments attach posteriorly to do same
 Has a flat, large facet joint
 Nerve roots emerge posterior to the vertebral artery and transverse
foramina and divide into ventral and dorsal lateral to the artery

Atlantooccipital + atlantoaxial membranes

Anterior: Is a continuation of the anterior

longitudinal ligament
-Runs anterior vertebral bodies
-Runs over anterior vertebral body of axis + over
anterior dens
-Runs from anterior dens to anterior arch of atlas (atlantoaxial)
-Runs from anterior arch of atlas to occipital bone

Posterior:
-Connected to posterior foramen magnum of occipital bone and to the upper border of the
posterior arch of the atlas
 Has a defect on each side of entrance of the vertebral artery
-Connected from the posterior arch of the atlas to the lamina of the axis

Supports for the dens

Cruciform ligaments (A) – superior, inferior and transverse

Transverse ligament: Arches across atlas ring to hold axis’ dens in B
position
Alar ligaments – Connects dens to occipital condyle

Tectorial membrane
A (Cont post long lig)

Greater
occipital
Suboccipital nerve
Nerves and arteries at the atlas nerve (C2
dorsal)
 Vertebral artery swings posteriorly and medially +Lesser
occipital
after emerging through C1 transverse foramina nerve
(also
dorsal)

C1 ventral ramus
 C1 nerve ventral ramus passes anteriorly between facet joint and vertebrael artery
 Suboccipital nerve (posterior ramus of C1) passes under vertebral artery
 This nerve supplies capitis and spinal muscles in suboccipital triangle
 C2 dorsal ramus passes posteriorly under vertebral artery – This is the lesser occipital
nerve

Thoracic vertebrae

 Articulates in two positions with the twelve ribs

 At the transverse process lies a facet joint
 Where the pedicle meets the body
 Transverse processes point laterally
 Spinous processes point downwards, overlapping one below
 Bodies grows progressively larger
 Minimal movements due to overlying spinous processes and articulation with ribs
 Some rotation

Lumbar vertebrae
 Massive body
 Transverse processes small
 Spinous processes broad and points straight back
 No rotation due to facet joints facing inwards and outwards (upper and lower)

Ligamentous supports of vertebral column

Anterior longitudinal ligament – anterior vertebral
body, from basiocciput to sacrum. Poorly attached to
disks, broadens distally
Posterior longitudinal ligament – from C2 to upper
sacral canal. Is continued above C2 as tectorial
membrane. Broadens over disks, narrow over bodies,
narrows lower, where the majority of disc herniations
occur.
 Inferiorly, PLL is very weak, ½ the strength of ALL

Ligamentum flavum – Attached from one lamina below to the other

lamina above. The bottom section of ligament attached posteriorly,
the top section attaches to lamina anteriorly. Is yellow

Interspinous ligaments - Between spinous processes (weak)

Intertransverse processes (weak)
Supraspinous – strong!
Intervertebral joints
Zygapophyseal joints – Synovial, supplied by nerve roots from above and below
Uncovertebral joints (of Luschka) – Between C3-T1.
 They are small and located on the lateral side of the body between uncincate process and
side of body
 Prevent the vertebrae from sliding backwards + limits lateral flexion
Cranial fossa foramina
Superior view
5 = Foramina of cribiform plate / foramen caecum (CNI) + superior
sagittal sinus origin
7 = Optic canal (CNII)
8 = SOF (CN V1), CN IV, CN VI
9 = Foramen rotundum – CN V2
10 = Foramen ovale – Otic ganglion, CN V3, accessory meningeal artery,
Lesser petrosal nerve, Emmisary vein (OVALE)
11 = Foramen spinosum –Middle meningeal artery, emissary vein,
Nervus spinosus meningeal branch of mandibular nerve (MEN)
12 = Foramen lacerum (ICA, greater petrosal nerve, meningeal branch
of ascending pharyngeal artery, emissary vein (MEIG)
14 = Internal acoustic (auditory) meatus = facial nerve (VII) and
vestibulocochlear (VIII)
15 = Jugular foramen – CN IX, X, XI
16 = Hypoglossal canal (CN XII)
17 = Foramen magnum – Brainstem,
meninges, vertebrals, spinal root of CN XI
12
Inferior view
1=Mastoid foramen 13
2=Condylar foramen – 14
3= Stylomastoid foramen 10
4=Foramen spinosum 8
9
5=Foramen ovale
6=Foramen lacerum (not always visible)
7=Carotid canal
8=Inferior orbital fissure 5
6 11
9=Lesser palatine foramen 4
10=Greater palatine foramen
7
11 = Sphenooccipital suture
12 = Incisive foramen
3
13=Median palatine suture
14=Transverse palatine suture 2
15=external occipital crest
16=Superior nuchal line 1
17=inferior nuchal line
15 17

Mastoid foramen
Transmits posterior meningeal artery 16
(from occipital artery) to dura + mastoid
emissary vein to sigmoid sinus
Incisive foramen
Receives the nasopalatine nerves and sphenopalatine artery

1
Fascial layers
Skin
Superficial fascia – invests outerlayer of neck and contains nerves, vessels of the skin and
platysma

Platysma
 Origin: Fascia of deltoid and pectoralis major, crossing over the clavicle
 Insertion: Mental symphysis anteriorly, oblique line (anterior surface of mandible) + skin
and subcutaneous tissue of the face.
 Action: Draws lips down weakly, draws jaw down weakly
 Innervation: Facial nerve
 Part of the panniculus carnosus – superficial layers of muscle deep to the panniculus
adiposus – same as palmaris brevis and dartos

Deep cervical fascia – multiple layers, lies underneath platysma.

Investing layer: Surrounds all structures of the neck, but splits to enclose trapezius,
sternocleidomastoid, muscles of mastication and parotid + submandibular glands

Attachment
From the stylomandibular ligament upwards, the
fascia splits to enclose the parotid gland and masseter.
The superficial layer attaches to zygomatic arch

Superficial attachments:
 External occipital protuberance, nuchal line
 Spinous processes of all cervical vertebrae
 Mastoid process + zygomatic arches
 Inferior border of mandible + Hyoid bone
 Sylomandibular ligament

Inferior attachment:
 Acromion, spine of scapula, spine of C7, clavicle
 Splits to enclose the sternal manubrium, forming a
suprasternal space (of burns)

Roof - Posterior and anterior triangle of neck

Encloses
 Sternocleidomastoid
 Trapezius
 Omohyoid
 Muscles of mastication??? Maybe
 Parotid and submandibular glands

Apertures for cervical plexus

 Lessor occipital nerve
 Greater auricular nerve
 transverce cervical nerve
 Suprascapular nerve
 External jugular vein
 Lymphatics

Prevertebral layer
 Extends from base of skull to body of T3 (base of longus coli)
 Encloses the prevertebral muscles (scalenes, levator, longus coli)
in the posterior triangle of the neck
 Blends with the anterior longitudinal ligament posteriorly
 Has the third part of subclavian artery (that whish is lateral to scalene anterior) lying deep
to the fascia – i.e, the Prevertebral fascia extends over it after encompassing scalene
anterior. It then becomes prolonged over the artery under the clavicle and above the first
rib as the axillary sheath
 Does not enclose subclavian vein or axillary vein
 Also encloses brachial plexus
 Provides a fixed base for the trachea, oesophagus and carotid
sheath to slide against Phr

Symp
Superficial / lying on the fascia
-Sympathetic chain
-Spinal root of accesory nerve
-Lymph nodes

Deep to it
-Phrenic nerve
-3rd part of subclavian artery
-Trunks of brachial plexus
-Cervical plexus

Piercing through it
 Branches of cervical plexus (great auricular, lesser occipital,
transverse cervical and supraclavicular)

Pretracheal
-Lies deep to the infrahyoid strap muscles. Therefore:
 Attached to inferior hyoid bone in midline
 Attaches to oblique line of thyroid cartilage + cricoid
cartilage
 Laterally to the carotid sheath and Prevertebral fascia
 Inferiorly to the fibrous pericardium

-Splits to enclose thyroid gland, only attached over isthmus and 2-4th tracheal rings
-Hold parathyroids and thymus posterior
-Pierced by thyroid vessels
-Fusses with the front layer of carotid sheath laterally / some say that the carotid sheath is a
posterolateral extension of the Pretracheal fascia
-Blends with adventitia of aorta and pericardium

Carotid sheath
Superiorly
-Attaches to the base of skull at the margins of the carotid canal
-Blends with the deep layer of the parotid fascia
-Upper sheath has nerves escaping from it: CN IX -> XII (9->12)
-Anterior is infratemporal fossa, medially is pharynx, laterally is deepest part of
parotid gland. Posterior = sympathetic trunk lying on top of prevertebral fascia

Inferiorly
-Blends with pretracheal fascia and investing fascia under SCM 446
-Blends with adventitia of the aortic arch

Buccopharyngeal fascia – the posterior portion of the Pretracheal fascia, which forms a
retropharyngeal space between the posterior Pretracheal and anterior prevetrebral

Summary of muscle positions in the neck relative to fascia

Trap and SCM -> enclosed in investing fascia
Sternohyoid, omohyoid, thyrohyoid -> all under deep investing but superficial to pretracheal
fascia
Scalene anterior, medius, levator scapulae, longus capitis -> Under Prevertebral

Tracking of infection in neck tissue spaces

Prevertebral space
 Behind the prevertebral fascia
 Closed space which can only be breached by a perforation
in the fascia
 Extends down to T3 vertebral body
 Can track into axillary sheath (3rd part of subclavian +
axillary artery + brachial plexus but not axillary vein)
 Continuation of prevertebral fascia that encloses the axillary artery and brachial plexus
as it passes under clavicle deep to scalenus anterior

Retropharyngeal space (Anterior to Prevertebral fascia,

essentialy between the investing fascia)
 Anterior to prevertebral space, posterior to buccopharygneal
fascia
 Extends below behind oesophagus to diaphragm via superior then posterior mediastinum
 Can also spread laterally behind carotid sheath to the posterior triangle

Submandibular space
 Between hyoid and mandible to floor of mouth
 On the superficial to the mylohyoid muscle between anterior and posterior bellies of
digastric
 Corresponds to the submandibular triangle in the neck bound by:
body of mandible, posterior belly of digastric below and anterior belly
of digastric
 Gives rise to ludwigs angina

Muscles of the neck and head

Large neck muscles

Sternocleidomastoid
 Origin: Manubrium and middle third of clavicle
 Insertion: Mastoid process and anterior half of superior nuchal line
 Action: Rotates head to opposite side. Lateral flexion to same side. Helps with forced
inspiration by moving sternum up Protracts the head

Facial expression muscles

Buccinator
 Origin: Both jaws opposite the molar teeth a and pterygomandibular raphe
 Interdigitates with superior constrictor
 Tidbits: Pierced by buccal sensory nerve from trigeminal. Pierced by parotid gland duct
opposite the upper 3rd molar tooth
 Innervated by facial nerve buccal branch (proprioception from buccal branch of trigeminal

Hyoid bone muscles

 All muscles attaching superior hyoid elevate the bone to initiate swallowing

Mnemonic from lateral to medial. First is superior, second is inferior

Christ He Didn’t Screw Girls Much. That’s Obvious Stupid.
Constictor (middle) – Arises from entire length of greater cornu, some lesser cornu and
stylohyoid ligament. See constrictor section
Hyoglossus (landmark for oral cavity. Hypoglossal nerve)
Digastric – Two muscle bellies connected via a tendon to hyoid held in by a fibrous sling. Can
sometimes perforate stylohyoid.
 Attaches anteriorly to digastric fossa of mandible
 Posteriorly to mastoid process of temporal bone
 Has a sling located on hyoid bone
 Depresses mandible and elevates the hyoid bone
 Innervation:
o Anterior belly from inf alveolar nerve(V3) -> nerve to mylohyoid
o Posterior belly by nerve to stylohyoid (facial nerve VII)
Stylohyoid – Styloid process of temporal bone. Pulls hyoid posterior and
superiorly
 Innervation: CN VII nerve to stylohyoid
Geniohyoid – Deep to the mylohyoid muscle, from mandible. Depresses
mandible, elevates hyoid.
 Innervation: C1 nerve roots running with hypoglossal nerve
Mylohyoid – Broad and triangular, forms floor of oral cavity. Originates
from mandible mylohyoid line
 Elevates the floor of the mouth and hyoid bone
 Innervation: Inferior alveolar nerve (V)

Inferior hyoid
Thyrohyoid – Deep to omohyoid and sternohyoid. Continuation of sternothyroid muscle.
 Origin from thyroid cartilage of larynx, ascends to hyoid bone
 Depresses hyoid or, if hyoid fixed, raises larynx
 Innervation: C1 via hypoglossal nerve
Omohyoid – Two bellies much like digastric.
 Inferior belly: Scapula to clavicle
 Superior belly: Continuation upwards and medially to attach to
SCM and move to hyoid bone
 Action: Depresses hyoid
 Innervation: C1-3 via ansa cervicalis
Sternohyoid – Descriptive name. Depresses hyoid. Innervation:
Anterior rami of C1-3, carried by branch of ansa cervicalis
Sternothyroid – Wider and deeper than sternohyoid, becomes the
thyrohyroid. From sternum to thyroid cartilage

Muscles innervated by hypoglossal nerve: Thyrohyoid, Geniohyoid

Muscles by ansa cervicalis: Omohyoid, sternohyoid
Muscles by V3 inferior alveolar nerve: Mylohyoid, Digastric
Muscles innervated by VII: stylohyoid
Muscles of mastication
Originate from first pharyngeal arch, therefore all CN V3
mandibular division
All elevate the mandible, closing the mouth except lateral
pterygoid

Masseter – Quadrangular and most powerful

 Superficial: Origin at maxillary process of zygomatic bone
 Deep: Zygomatic arch of temporal bone
 Both heads attach to ramus of mandible

Temporalis – Temporal fossa to coronoid process of mandible

 Retracts the mandible, pulling it posteriorly

Medial pterygoid –
 Medial side of lateral pterygoid plate of sphenoid bone.
 Attaches to pterygoid tuberosity of the ramus of mandible
 Lies deep to sphenomandibular ligament
 Lies deep to inferior alveolar nerve (nerve runs on top of it)

Lateral pterygoid – Only one to open mouth via protraction of mandible

 Superior head from greater wing of sphenoid / base of skull
 Inferior head from lateral pterygoid plate of sphenoid
 Two heads converge on tendon which attaches to TMJ joint / condylar process
 Action: Bilateral moves the mandible forward (protracts), unilateral action allows it to
glide side to side
 Lies superficial to sphenomandibular ligament

Summary points:
 Masseter and medial pterygoid have superficial and deep parts and function along the
same line of action, one inside and one outside mandible
 Lateral pterygoid has superior and inferior heads
 All close except lateral pterygoid opens and moves side to side
 Temporalis closes but also retracts
 All supplied by mandibular division of trigeminal nerve (V)

Pharyngeal constrictor muscles

Pharyngobasilar fascia – lies deep to the constrictors, between

muscles and mucous membranes of pharynx. Palatine tonsils lie on
the upper base of this fascia
-Attached to the basilar portion of the occipital bone at a point known as the
pharyngeal tubercle

External circular layers / constrictors

All constrictors meet at the pharyngeal raphe posteriorly
 Superior – Circular around pharynx (green)
 Attaches from pterygomandibular raphe, which runs from pterygoid plate to alveolar
process of mandible
 Attaches to pharyngeal raphe
 Middle – orange
 Hyoid bone anteriorly, pharyngeal raphe posteriorly
 Inferior – “Cricopharyngeus” – upper oesophageal sphincter +
“Thyropharyngeus – closes the glottis etc. Together when working,
it encourages food to slider either side of the epiglottis and also
opens the oesophagus. Attachments:
 From oblique thyroid line around to the pharyngeal raphe
 From cricoid cartilage anteriorly to the raphe + inferior cornu of
thyroid cartilage articulation

All constrictors are innervated by the pharyngeal plexus

 Motor fibers from vagus nerve (?Nucleus ambiguous)
 Sensory fibers from glossopharyngeal nerve
 Motor fibers from cranial accessory nerve
 Superior cervical ganglion sympathetic fibers

Internal longitudinal layers

 Stylopharyngeus (yellow) – Passes between superior and middle pharyngeal constrictor
 Only internal muscle to be supplied by glossopharyngeal nerve (IX)
 Palatopharyngeus
 Salphingopharyngeus

Tongue muscles
Intrinsic
Horizontal, vertical, transverse

Extrinsic
Genioglossus – Protrudes tongue and responsible for
successful jaw thrust effect
Hyoglossus - Depresses and retracts tongue (dorsal
surface becomes convex)
Styloglossus – Draws the sides of the tongue to create a
trough for swallowing
Palatoglossus – Elevates dorsum of tongue and draws
soft palate inferiorly

Rules:
 All innervated by XII (hypoglossal nerve) except
palatoglossus which is X (vagus)
Extra ocular eye muscles

SR: Elevates eye in abduction, incyclotorsion

IR: Depresses eye in abduction, excyclotorsion
SO: Depresses eye in adduction, incyclotorsion
IO: Elevates eye in abduction, excyclotorsion
LR and MR do as expected.

CNS core concepts

Embryology

Cranial side of neural tube develops three swellings

(vesicles) which have further subdivisions
1. Forebrain (prosencephalon)
a. Telencephalon – cortex, rapidly
develops around diencephalon
b. Diencephalon – becomes enclose in
telencephalon
2. Midbrain (mesencephalon)
3. Hindbrain (rhombencephalon)
a. Metencephalon
b. Myelencephalon

Diencephalon

Thalamus – two large mounds of grey matter sitting on top and

lateralof midbrain

Has third ventricle between the two thalami. Cerebral

aqueduct commenced at the start of midbrain and runs down
to the fourth ventricle, which bulges into cerebellum

Epithalamus = combination of pineal gland and the two

habenula nuclei and their tract (habenular commissure)
 Posterior to the third ventricle is the pineal gland
(green)
 Posterior superior corners of the lateral ventricle is
the habenular nuclei (red stars)
 Habenular commissure connects the two habenular
nuclei
Subthalamus – two sheets of grey matter sitting under thalamus
Hypothalamus – anterior most part of third ventricle (orange)
 The optic tracts border the hypothalamus on either side of its floor
 Median eminence descends from central floor of third ventricle
 Posterior pituitary – extension of hypothalamus from mediam eminence
 ANTERIOR PITUITARY NOT PART OF DIENCEPHALON. Part of the nasopharynx
epithelium which detaches and forms a pouch (Ruthke’s pouch) and moves up to lay
adjacent to posterior pituitary
 Mamillary bodies – floor of third ventricle, when the midbrain ends, two only visible from
underneath
 Lateral geniculate body – on the lateral surface of thalamus for eyes
 Medial geniculate body on the medial posterior surface of thalamus for ears

Intraventricular foramen – two windows present in the upper left and right walls of the
middle of the third ventricle between the thalamus and hypothalamus, leading into the lateral
ventricles

Anterior commissure – anterior limit of third ventricle, connects to temporal lobes

Mesencephalon (midbrain)

 Tectal nuclei
 Communication between tectal nuclei = posterior commisure
 Superior and inferior colliculus
 Cerebral aqueduct
 Periaqueductal grey matter (PAG)
 Substantia nigra
 Crus cerebri
 Superior cerebellar peduncle

Pons

Medulla

Other brainstem terms

Tegmentum: Everything that lies behind the cerebral
peduncles, the basilar pons and the pyramids

Basal ganglia (nuclei)

Basal ganglia components are in orange, the rest is for
architecture description
1. Thalamus (not part of basal ganglia), adjacent to third ventricle
2. Caudate nucleus – the rat shaped object, its head rests adjacent to lateral ventricle and is
most anterior. It rests against lentiform nucleus. Its body rests over thalamus and tail
around laterally and posteriorly
a. Amygdala – Exists as a bulge on the rats tail
3. Internal capsule – white matter separating
thalamus from lentiform nucleus
4. Lentiform nucleus – two parts
a. Putamen
b. Globus pallidus – Internal + external
5. External capsule – white matter hugging the
outside of lentiform
6. Claustrum – grey matter

Lentiform nuclei = putamen and globus pallidus

Functional groups of basal ganglia (nomenclature)

Corpus striatum: All three, caudate nucleus, putamen and globus pallidus
Neostriatum: Caudate nucleus + putamen (also called just striatum)
 Same embryological origin
 Have very similar functions
Paleostriatum: Internal and external parts of the globus pallidus

Physiological functions
Neostriatum – receives input from the cortex
for motor movements

Internal globus pallidus – Output neurons of

basal ganglia circuit projecting to the
ipsilateral motor thalamus, which later get
crossed. Therefore, basal ganglia control the
contralateral motor movements of the body

Beyond the scope of my study for GSSE but

important for USMLE
Lobes, sulci and gyri

Central sulcus
 Separates frontal and parietal lobes
 Bordered by pre and postcentral gyri
 Motor and sensory cortex respectively
 Only sulcus to pass to medial side of
hemispheres
 Does not run directly into the lateral sulcus

Lateral sulcus (fissure of sylvius)

 Separates frontal and temporal lobes
 Has a main posterior sulcus and two ‘sort
sulci’: Ascending and anterior rami
 These form parts of the inferior
frontal gyri
 Orbital, triangular and opercular
gyri
 Broca’s motor area is the parts
triangularis and pars orbitalis of the
dominant frontal lobe hemisphere
 Wernicke’s area is parietal lobe at
posterior section of superior temporal
gyrus (around supramarginalis on our picture) at end of sylvian fissure

Frontal lobe
 Divided into superior, middle and inferior gyri, orbital triangular and opercular gyri by the
superior and inferior frontal sulci
 Orbital gyrus, triangular gyrus and opercular gyrus
 Bet
ween
anterior,
ascending
and
posterior
rami of
lateral
sulcus
Temporal lobe
 Anterior commissure: Connects the two temporal lobes
 Temporal operculum sits at the lateral sulcus and covers the insula
 Divided into superior, middle and inferior gyri by superior and inferior temporal gyri

Parietal lobe
 Somatosensory cortical area of the brain
 Between central sulcus and postcentral sulcus
 Posterior parietal cortex – behind the postcentral sulcus
 Superior parietal lobule divided from inferior parietallobule by intraparietal sulcus
 Supramarginal gyrus anterior to angular gyrus

Insula
 Hidden underneath the frontal, parietal and temporal lobes
 Has a central sulcus of its own, which divides short (anterior) and
Central sulcus
long (posterior) gyri

Cingulate sulcus Cingulate sulcus

 Separates frontal and parietal lobes on the medial surface of the
brain
 Is intercepted by the central sulcus
 On radiographs of the brain in transverse views, look for cingulate sulcus to identify
central sulcus

Cerebellum
 Two hemispheres united in the midline
by vermis
 Anterior lobe lie superiorly
 Posterior lobe lies inferiorly

Horizontal fissure – Runs vertically dividing

it into halves
Primary fissure – separates anterior and
posterior lobes

Venous drainage
From surface of cerebellum to nearest venous sinus.
Superior and posterior surface = straight and transverse sinus
Inferior surface = inferior petrosal sinus, sigmoid and occipital sinus
Superior vermis drains into the great cerebral vein
CSF production

Third ventricle – has anterior commissural fibers running through its anterior wall

CNS circulation

Vertebrobasilar artery
Divided into six segments, with seventh segment terminal branch
1. Root of neck: enters C6 tranversarium foraminum (transverse
foramina) between scalenus anterior and longus coli
a. IJV, vertebral veins, inferior thyroid are anterior
2. Travels up through 6 transverse foramen
a. Sits in front of the trunks of cervical nerves
3. Moves from C2, entering C1 and bending medially and posteriorly
to pierce the posterior atlantooccipital membrane
a. Gives off a dura branch which lies between endosteal
and fibrous dural layers of posterior cranial fossa
4. Travels up foramen magnum and pierces dura mater and arachnoid mater to lie in
subarachnoid space converging at the pontomedullary junction

Branches are sent off as two arteries converge over anterior medulla
 Anterior spinal artery – the penis of Willis, originating anterior to medulla
 Posterior spinal artery – can arise directly or from PICA
 Posterior inferior cerebellar artery (PICA) - also supplies lateral medulla
 Arises below XII rootlets and then between IX and X
 Supplies choroid plexus of 4th vent
Basilar artery forms at the pontomedullary junction
 Anterior inferior cerebellar artery (AICA)
(supplies lateral pons)
 Sits below VI, VII and above IX nerves
 Labrynthine artery – sometimes off vertebral
artery (15%), or AICA, moves through internal
acoustic meatus of the posterior cranial fossa to
go to ear canal (petrous bone)
 Pontine artery
 Superior cerebellar
 Gives off posterior choroidal artery
 Winds around cerebral peduncle below IV
nerve
 Posterior cerebral artery – bends around
cerebral peduncles above CNIII at midbrain to
supply posterior hemispheres including visual
cortex

Internal carotid artery

 Common carotid bifurcates at C4 / thyroid cartilage
 Continues up behind posterior belly of digastric
 Enters carotid canal (temporal bone), turns 90 degrees anteriorly
and medially, then again 90 degrees upwards and exits via foramen
lacerum
 Runs into cavernous sinus then up top medial to anterior clinoid
process it pierces dura and runs in subarachnoid space
 Bends backwards and divides into branches MCA
 Ophthalmic artery – optic canal with CRA
 Posterior communicating artery
 Anterior choroidal artery – to lateral ventricles
 Striate artery to deep structures via anterior perforated
substance
 Middle cerebral – Moves into lateral fissure. Supplies lateral PCA
segment of frontal, parietal, temporal, including head and arms of
Choroidal and
motor cortex striate arteries
 Anterior cerebral – moves upwards and backwards around
corpus callosum. Will supply the motor cortex to lower limb
External carotid artery
Some anatomists life freaking out poor medical students (SALFOPMS)

Superior thyroid - Anterior

Ascending pharyngeal – Posterior, runs on pharynx deep to internal carotid
Lingual – Anterior above superior thyroid, deep to hyoglossus
Facial – Above lingual (often common trunk), on superior constrictor deep to submandibular
gland
Occipital – Arises opposite facial and runs posteriorly deep to posterior belly of digastric
Posterior auricular – Above digastric, over styloid process t oscalp
Maxillary – Runs deep to neck of the mandible, has three parts, many branches
1. Before lateral pterygoid
2. On lateral pterygoid
3. After lateral pterygoid
Superficial temporal – Behind TMJ to scalp

Specific knowledge on external carotid branches

Lingual artery
 Runs superior to hyoid bone
 Runs under hyoglossus (originating from hyoid
bone)
 Gives off a dorsal lingual artery and a branch to
sublingual gland
 Hypoglossal nerve runs nearby
 Doesn’t travel with lingual nerve, which comes
from V3 from foramen ovale

Facial artery
 Arises above lingual artery (sometimes shares a trunk)
 Runs on superior constrictor and under digastric and stylohyoid muscles
 Runs deep to submandibular gland and indents it
 Makes S bend looping under the margin of maxilla to arise anterior to it
 Gives off a submental artery
 Sends off a inferior and superior labial artery above and below lips, which anastomose
with other side
 Travels near lip and up towards external eye to form angular artery + lateral nasal
branches

Common carotid artery and bifurcation

Lies anterior to: Cervical sympathetic chain, prevertebral fascia, cervical transverse processes,
inferior thyroid artery
-Divides at C4

Common carotid divides like a two-pronged fork.

Between the prongs: Tongue/pharynx related

 Styloid process with styloglossus, stylopharyngeus
 Glossopharyngeal nerve with branch to
stylopharyngeus
 Pharyngeal branch of vagus nerve
 Branchial fistula if present will also pass through
here
 Portion of parotid gland

Anterior to arteries: Hyoid related structures

 Stylohyoid muscle and ligament
 Posterior belly of digastric
 Branches from the ECA: SALFOP
 Hypoglossal nerve

Deep to internal carotid: Larynx related

 Superior laryngeal nerve and both branches

Maxillary artery
Divided into three sections by the lateral ptyerygoid
 5 arteries before: All go into bone
 5 within, infront, or behind: 4/5 go to soft itssue
 Beyond / lateral: 5/6 branches named with nerves


DAM I AM Piss Drunk But Stupid Drunk I prefer Must Phone Alcoholics Anonymous
 Deep auricular
 Anterior tympanic
 Middle meningeal
 Inferior alveolar
 Accessory meningeal
 Masseteric
 Pterygoid
 Deep temporal
 Buccinator
 Sphenopalatine
 Descending palatine
 Infraorbital
 Posterior superior alveolar
 Middle superior alveolar
 Anterior superior
 Artery of the pterygoid canal

Meningeal artery
Branch off first part of maxillary artery, has the
auriculotemporal nerve form a ring around it and enters
into cranial cavity via foramen spinosum.
 Ganglionic branch to trigeminal ganglion
 Anterior (frontal) branch: Runs 3cm above midpoint of zygomatic process – under pterion.
Causes extradural haemorrhage
 Posterior (parietal) branch: Can also cause extradural at a line drawn vertically from
mastoid process and horizontally from orbit

Venous drainage

CNS and cranial sinuses

Superior saggital
Inferior sagittal
Straight connects two saggital
Transverse x 2 – Run along inferior surface of
occipital bone, draining from confluence of sinuses
Sigmoid into internal jugular
Super +inferior petrosal - Into cavernous sinus

Basilar plexus
 Lies between the endosteal and visceral layers of dura on inner surface of clivus
 Connects: Inferior petrosal, cavernous, intercavernous, superior petrosal, internal
vertebral venous plexus and marginal sinus (around margins of foramen magnum)

Cavernous sinus
Incoming
Facial vein, supraorbital vein and supertrochlear vein  superior and inferior ophthalmic
vein  cavernous sinus
*Risk of spread of infection, cavernous sinus thrombosis

Exiting
 Superior petrosal sinus
  Leaves the top of the posterior wall of cavernous sinus
 Runs along upper border of petrous bone between the two layers at the attached
margin of the tentorium cerebelli
 Enters sigmoid sinus at termination of transverse sinus
 Inferior petrosal sinus
 Larger, empties bulk of blood
 Leaves posterior wall between petroclinoid ligament (stretched band between apex of
petrous bone and the side of the dorsum sellae

 Emissary veins via foramen ovale to pterygoid plexus
 Emissary veins via carotid canal to internal jugular

O TOM CAT
Wall of sinus
Occulomotor nerve
Trochlear nerve
Ophthalmic nerve
Maxillary nerve

Within the sinus

Carotid artery
Abducens nerve

Internal jugular vein

 Begins below jugular foramen from combination of inferior
petrosal sinus and sigmoid sinus
 Runs behind ICA then laterally
 Has vagus between ICA and IJV
 Runs under SCM
 Joins subclavian vein to become brachiocephalic vein

Venous drainage of face

Anterior
 Supraorbital and supratrochlear veins pass to medial canthus
uniting to form the angular vein which becomes the facial vein
 Facial vein follows facial artery to a point at angle of mandible in
which it pierces the deep investing layer
 Is joined by the anterior branch of the retromandibular vein
 These join the internal jugular vein, along with the lingual vein

Lateral
 Temple drains into superficial temporal veins which are joined
 by maxillary veins from the pterygoid plexus
 The union forms the retromandibular vein
 Passes downwards through substance of parotid posterior to the facial nerve and after its
lower border, divides into anterior and posterior retromandibular
 Anterior branch joins the facial vein at mandible angle which empties into internal
jugular
 Posterior again pierces investing layer of deep fascia (to become superficial) and is
joined by the posterior auricular to form the external jugular vein
 External jugular vein has a valve 4cm above the clavicle

Anterior jugular vein

 Begins below chin by confluence of superficial submaxillary
veins
 Descends between anterior border of SCM and median line
 Drains into subclavian or into external jugular
 Has a venous arch connecting the two anterior jugular veins
below the thyroid
 Pierces deep fascia at suprasternal notch

Summary of veins
-Supraorbital + supratrochlear vein = angular vein = facial vein
-Superficial temporal + maxillary vein = retromandibular vein
-Below parotid, retromandibular vein has anterior and posterior
branches
-Anterior branch goes to facial vein then ito IJV
-Posterior branch + posterior auricular = external jugular (superficial on top of SCM) -> right
subclavian

Vertebral vein
 Formed from a plexus of veins that come together in the suboccipital triangle from
surrounding musclulature
 Exists only in the neck, doesn’t enter skull like vertebral artery
 Descends in the transverse foramina along with the vertebral artery
 One two vertebral veins emerge on EACH side, one emerges from transverse process of C6
along with vertebral artery, another emerges from C7 by itself.
 Also drains the vertebral venous plexus
 Both enter brachiocephalic

Branchial arches
Development with pharyngeal arches
 There are 5 pharyngeal arches (1, 2, 3, 4, 6)
 Each arch has a blood supply, cartilage (mesoderm) and a nerve supply (CN)
 Outside is lined by ectoderm and between them form four pharyngeal ‘grooves’
 Inside is lined by endoderm and form four pharyngeal ‘pouches’
 The substance itself is made up of mesoderm
 Ectoderm = skin, nervous system. Mesoderm = connective tissue, I
genetalia, kidneys, endothelial cells. Endoderm = Endocrine organs V X
X
3
(thyroid, pancreas), gastrointestinal tract, respiratory tract, thyroid X
and thymus, urinary bladder

1st arch = CN V2 and V3. Blood supply = first aortic arch which persists as V
I
maxillary artery
 Muscles of mastication + tensor veli palatini + tensor tympani +
anterior belly of digastric + mylohyoid
 Maxilla, mandible (model for), malleus, incus, sphenomandibular ligament,
 Meckels cartilage
 Maxillary artery, external carotid artery

2nd = CN VII. Blood supply = Second aortic arch which persists as

stapedial artery in animals, atrophies in humans
 Muscles of facial expression + Stapedes + stylohyoid + posterior
digastric
 Stapes bone, styloid process and part of hyoid bone (lesser horn
and upper body)

3rd = CN IX. Blood supply = Common carotid -> internal carotid

 Glossopharyngeal: Stylopharyngeus muscle – elevates pharynx
 Body and greater horn of hyoid bone, thymus

4th = CN X. Blood supply: Right = subclavian, left = aortic arch

 All intrinsic muscles of palate, pharynx except levator veli
palatine (V3), one laryngeal muscle – cricothyroid.
 Thyroid cartilage, epiglottic cartilage

6th = CN X recurrent laryngeal nerve

 Loops around aorta (left) and subclavian (right) then works back
to the larynx (recurrent laryngeal nerve)
 Except the cricothyroid muscle, which is the external branch
of the superior laryngeal nerve
 Arteries: Right = R pulmonary artery, left = L pulmonary artery and ductus ateriosis

Silly way of remembering things I have devised

Groove is outside with ectoderm ectopically (outside) – blue in the picture
Pouch is inside with endoderm inside – yellow in the pouch
Mesoderm lies in the middle of the two

39C = 3rd IXth nerve, carotid

40S = 4th Xth nerve, subclavian
60P = 6th Xth nerve, Pulmonary artery
Endoderm
 Likes to form glands
 Thyroid gland forms superiorly and migrates inferiorly

Fate of the grooves (ectoderm)

1: Invaginates to form external ear
2, 3 and 4: Invaginate and to form an external cervical sinus, which
then closes off. External cervical cyst can persist, infront of SCM and
communicate with external environment or larynx (prone to infection)

Fate of the Pouches

1: Also invaginates to form inner ear in conjunction with groove 1
2: Forms the tonsilar bed, which the palatine tonsil rests upon
3: Forms dorsal and ventral ‘extensions’. The dorsal extension forms the inferior parathyroid,
the ventral extension forms the thymus which migrates to superior mediastinum
4: Also forms dorsal and ventral extensions. The dorsal extension becomes superior
parathyroid, the ventral extension becomes ultimobranchial body (last thing to come from the
neck). Produces the C cells of the thyroid gland to make calcitonin to lower blood calcium,
through increased bone deposition

Cranial nerves

Oculomotor nerve
Nuclei
Oculomotor nucleus arises in midbrain at the level of
the superior colliculus, anterior to the cerebral
aqueduct
EWN – parasympathetic nucleus for iris sphincter
muscle and ciliary muscle

Course
1. Moves anteriorly through red nucleus and
emerges from anterior brainstem, medial to cerebral peduncles
2. Passes between posterior cerebral and superior cerebellar, moving anterior adjacent
to posterior communicating artery
3. Pierces dura mater on lateral side of posterior clinoid process
4. Enters wall of cavernous sinus (receives sensory communicating branch from facial
nerve and sympathetic from carotid plexus)
5. Through superior orbital fissure as two branches – superior and inferior
 6. Super division passes medially over optic nerve – LPS and superior rectus
7. Inferior division medially under ON – IR, MR, IO,
a. Branch from IO going to ciliary ganglion, to then supply the sphincter pupillae
muscle of iris

Outgoing motor innervations of oculomotor nucleus

 Levator palpebrae superioris of both sides is supplied by the central caudate nucleus
(which sits behind and on top of the oculomotor nucleus complex
 MR, IR, IO, ciliary muscle and sphincter are supplied by the ipsilateral oculomotor nucleus,
with ciliary muscle and sphincter through the parasympathetic EWN via IO branch of
inferior oculomotor nerve -> ciliary ganglion

Summary of functions
 Motor to SR, IR, IO, MR
 Motor to LPS (central caudate nucleus supplies both)
 Parasympathetic to ciliary body for accommodation (EWN)
 Parasympathetic to constrictor (EWN)
 NOTE: Dilator pupillae is sympathetic and travels via ICA -> Nasociliary branch of V1

Clinical syndromes
Oculomotor nerve palsy:
 Patient will look down and out (unopposed SO and lateral
rectus)
 Ptosis (due to inactivity of LPS)
 Pupil will be dilated (due to inactivity of sphincter pupillae)

Cranial lesions causing this

 Cavernous sinus: Thrombosis or ICA aneurysm
compression
 Retrobulbar glioma or meningioma from optic nerve, as the
oculomotor nerve lies within the muscle cone. Can be compressed
 Interpeduncular fossa – where CN III emerges from the brainstem, it lies between
posterior cerebral and superior cerebellar and is adjacent to posterior communicating.
Aneurysm can compress here

Midbrain lesions
 Benedikts syndrome – CNIII lesions and contralateral cerebellar tremor, i.e from
posterior circulation stroke, lesion at red nucleus
 Webers syndrome – CNIII lesions and contralateral limb weakness, lesion with
corticospinal tract. E.G posterior cerebral artery stroke
 Nothnagel’s syndrome – CNIII and cerebellar ataxia (cerebellar peduncle lesion) e.g
tumour of midbrain

BT’s (Benedkits tremor), WW (Webers weak), NA (nothnagels ataxia)

Trochlear nerve (IV)
Most slender nerve
Decussates and supplies the other side
Has the longest intracranial portion

Nucleus of trochlear nerve Sup

cerebellar
 Situated at anterior part of grey matter surrounding cerebral peduncle
aqueduct
 Lies at level of inferior colliculus, below oculomotor nerve
 Forms part of a column along the branstem, continuation
of general somatic efferent of skeletal muscles
 IIIrd, IVth, VIth and XIIth nerve all in column as well
 Fibers pass posterior around central grey matter where they
decussate near the structured named superior medullary velum

 Receives corticobulbar fibres from both cerebral hemispheres
 Tectobulbar fibres from superior colliculus, info from visual cortex
 MLF fibres connect it to 3rd, 6th and 8th cranial nerves. MLF is located inferior to the
inferior colliculus

Course of trochlear
 Exit posterior brainstem and wrap around brainstem anteriorly to emerge between
posterior cerebral and superior cerebellar
 Pierces arachnoid and dura mater below the free border of the tentorium cerebelli near
posterior clinoid process
 Lateral wall of cavernous sinus initially above oculomotor nerve, later below oculomotor
nerve
 Enters SOF in lateral section outside tendinous ring
 Passes medially above origin of levator palpebrae superioris and enters SO on its superior
/ medial side.

Clinical
 SO direction of pull is down and out and intorsion
 Only nerve to pull eye down when eye is adducted
 When there is a palsy, it can not intort, inferior oblique extorts and patient gets diplopia
 Patient then tilts head. EG in right sided trochlear palsy, R eye is extorting. If patient
motilts head left, R eye’s extorsion will make visual axis vertical, left eye must intort
and patient will be happy
 It patient doesn’t tilt head, they get vertical diplopia
 Patient will alsk tilt head down to keep visual axis above horizontal as the superior
oblique isn’t working to depress eye
Clinic trochlear
 Longest intracranial neve. Liable to damage in trauma
Paralysis of trochlear nerve causes diplopia and hypertropia, I.E the SO moves the eye down
and out. When this is no longer happening, unopposed IO moves the eye up and out, making
the visual axis higher in one eye = hypertropia of affected eye
 Patient tilts head to non-involved side to make the eyes even (e.g R sided hypertropia,
tiliting head to left will make left eye come up and in to compensate
 Chin depressed

Subarachnoid space lesion

 Head injuries causes stretching or bruising of trochlear nerve in SAS
 Damaged at the site were it exits or the dorsal surface of the superior medullary velum, or
as it passes lateral to the brainstem to enter into the cavernous sinus
Midbrain lesion
 Same as oculomotor nerve, an infarct to the posterior cerebral artery will cause an
ipsilateral III’rd nerve palsy and a contralateral IV’th nerve palsy

VIth ventricle
Pituitary

Clivus
Trigeminal nerve (V)

Trigeminal nuclei (4)

 Mesencephalic trigeminal – Situated in lateral
part of grey matter around cerebral aqueduct in
midbrain
 Receives proprioception
 Pontine nucleus of trigeminal - Main sensory
nucleus, lateral to motor nucleus, in middle pons
 Receives fine touch equivalent of dorsal
medial leminiscus)
 Spinal nucleus – Extends from the main sensory
nucleus to the spinal cord at level of C2.
 Inferior receives pain+temp (equivalent of
spinothalamic)
 Superior receives cornea sensation
 Motor nucleus – medial to sensory nucleus in
middle pons (muscles of first branchial arch i.e mastication)
Course of sensory fibres within nuclei
 Incoming sensory fibers enter pons and either:
 Descend to ‘spinal tract’ to spinal nucleus
 Enter central pontine nucleus
 Ascend to mesencephlaic nucleus
 Then move to brainstem in two tracts
 Ventral tract: Pain and temperature from spinal nucleus
 Dorsal tract: Fine touch and proprioception from pontine sensory nucleus and mesencephalic nucleus
 Fibers then all converge to form the trigeminal leminiscus, which contains both ventral and dorsal systems
 This tract travels upwards to the ventral posteriomedial nucleus of the thalamaus (VPM)

Reflex pathways

Corneal reflex
 Long ciliary nerves (from nasociliary) communicate via V1 to brainstem central pontine
nucleus of trigeminal nerve.
 Communicates with motor nuclei of facial nerve
 Through the temporal and zygomatic nerves, orbicularis oculi is innervated and you blind

Lacrimation reflex
 Upper conjunctiva is through V1 (frontal and lacrimal nerves)
 Lower conjunctiva is through V2 (intraorbital nerve)
 Transmits to central pontine nucleus and communicates with superior salivatory nucleus
(parasympathetic nucleus)
 Superior salivatory nucleus leaves as nervus intermedius, into middle ear geniculate
ganglion, then passes into middle cranial fossa as greater petrosal nerve
 Through foramen lacerum, receives deep petrsal sympathetic nerve from carotid artery,
then through vidian canal as vidian nerve
 Through pterygopalatine ganglion, jump on to the zygomatic branch of V2 through inferior
orbital fissure, then to lacrimal gland

First, second and third order neurons of trigeminal system – unfinished due to relevance
Pain, temperature and fine touch
 First order neurons are in trigeminal ganglion
 Form spinal tracts within brainstem then converge on
 Second order neurons within the spinal nucleus
 Then form Ventral tracts towards brain and cross to opposite side
 Third order neurons are in ventral posteromedial thalamus
Proprioception for mastication and EOM
 First order neurons for proprioception are in mesencephalic nucleus

Trigeminal trunks from brainstem

 Arises above mid-level of pons on lateral surface with two branches
 Motor trunk (smaller) and sensory trunk
 Motor trunk is separate and passes through the foramen ovale – goes on to supply muscles
of mastication
 Sensory trunk ascends to groove on upper border of petrous and pierces dura under
attached tentorial border (containing superior petrosal sinus)
 Here fans out to form the trigeminal ganglion located in ‘Meckel’s cave’ double layer of
dura mater in petrous bone, under posterior part of cavernous sinus
 Contains lots of sensory fibers, and motor to: tensors and anterior digastric and
mylohyoid

Ophthalmic nerve (V1)

 Largest of three parts of trigeminal
 Passes into cavernous sinus lateral wall and
picks up sympathetic internal carotid plexus for
dilator pupillae
 Also given proprioceptive fibres for CN III, IV
and VI
 Divides into three branches which all enter in
through SOF. Lacrimal, frontal and nasociliary
Lacrimal
 Runs on top of lateral rectus into lacrimal gland
 Receives the zygomaticotemporal branch of the zygomatic branch of the maxillary
nerve (CN VII)
 Contains parasympathetic secretory fibers from facial nerve of the superior
lacrimatory nucleus
 Sends off multiple branches within lacrimal gland
 Pierces the orbital septum and joins with filaments of facial nerve
 Innervates conjunctiva and upper eyelid laterally
Frontal – largest branch
 Runs on top of LPS
 Divides mid-way through orbit into Supraorbital (big) and supratrochlear (small)
 Supraorbital – Leaves orbit through superior orbital notch.
 Innervates upper eyelid, conjunctiva, skin of forehead, branch to mucous membrane of
frontal sinus (pierces frontal bone)
 Supratrochlear – Moves medially above trochlea. Communicates with infratrochlear
branch of nasociliary nerve
 Innervates – Skin of medial forehead, skin of upper eyelid and conjunctiva (medially)
Nasociliary
 Arises inside tendinous ring, lateral to ON
 Immediately gives off ramus communicans to ciliary ganglion
 Sensory fibers from eyeball reach the ganglion via the short ciliary nerves. Pass without
interruption through the ganglion to reach the ramus
 Gives off two long ciliary nerves as it crosses medially over ON with ophthalmic artery.
Innervate ciliary body, iris and cornea
 Sympathetic postganglionic fibres to dilator pupillae (from carotid plexus)
 Sensor fibres from the cornea
 Runs on upper border of MR below SO
 Gives off ethmoidal nerve as it passes into
anterior ethmoidal foramen
 There is a corresponding posterior
ethmoidal nerve (post eth. foramen) but
absent sometimes
 Runs anterior into nasal cavity, gives off
two inferior nasal nerves
 Terminates as external nasal nerve as it
exits the nasal cavity between lateral
nasal cartilage and nasal bone.
 Innervates skin on dorsum of nose
 Infratrochlear nerve arises close to anterior
ethmoidal foramen
 Joined by a branch of supratrochlear
 Passes beneath the trochlear and pierces
orbital septum and orbicularis oculi
 Innervates lacrimal sac, conjunctiva and
skin on medial upper and lower eyelids,
upper part of lateral aspect of nose.

Maxillary nerve division of trigeminal nerve (V2)

 Intermediate in size of the three nerves
 Leaves ganglion to enter lower lateral part of cavernous sinus
 Gives off meningeal branch to supply dura in middle cranial fossa
 Leaves skull through foramen rotundum to enter pterygopalatine fossa
Within the pterygopalatine fossa, these things happen:

Ganglionic branch connect to the pterygopalatine ganglion and suspend it on the inferior
border of the maxillary nerve.
 Contains sensory from periosteum, nose, palate
 Also contain postganglionic parasympathetic fibers from the facial neve which pass to
the lacrimal gland via the zygomatic nerve

Zygomatic nerve arises in pterygopalatine fossa.

 Enters orbit through inferior orbital fissure running in lateral wall
 Divides into two branches
 Zygomaticotemporal, sends branch to lacrimal nerve (postganglionic
parasympathetic to lacrimal gland)
 Zygomaticotemporal foramen to exit the skull from the zygomatic bone, towards
the temporal bone.
 Innervates skin on lateral side of forehead
 Zygomaticofacial, goes through zygomaticofacial foramen to supply skin of cheek

Posterior superior alveolar nerve appears in pterygopalatine fossa

 Passes laterally to the pterygomaxillary fissure into the infratemporal fossa.
 Descends via infratemporal surface of maxilla into mouth to supply maxillary molars
Anterior superior alveolar nerve supplies incisors and canines
Middle superior alveolar nerve supplies two premolars

Pharyngeal nerve – palatovaginal canal, innervates mucous membranes of nasal part of

phaynx

Infraorbital nerve – continuation of maxillary nerve, through infraorbital

fissure, infraorbital canal and emerging from infraorbital foramen. Divides into three
branches
 Nasal – skin of nasal ala
 Inferior palpebral - skin of lower lid and conjunctiva
 Labial – skin of upper lip
 Receives innervation from sensory communicating branches of facial nerve for
proprioception information on muscles of
expression

*Fracture of inferior orbital wall = numbness of

inferior conjunctiva, upper lip, nasal ala, gum of
upper incisors and canines

Mandibular nerve (V3)

Inf alv
 Passes through foramen ovale in medial middle
cranial fossa, under the posterior edge of
Lingual
cavernous sinus, along with the motor trunk of
trigeminal nerve
Mylohyoid
 Outside of skull, the motor and sensory branches combine then give off three main
branches

Main trunk branches

 Nerve to medial pterygoid (fibers from motor nucleus)
 Nerve to tensor tympani
 Nerve to tensor veli palatini

Anterior division, all motor except one

 Masseteric nerve
Lingual
 Deep temporal nerve (anterior + posterior)
 Buccal nerve (sensory)
 Lateral pterygoid nerve

Posterior division, all sensory except one

Auriculotemporal nerve has sensory and motor
 Runs between neck of mandible and sphenomandibular
ligament
 Encircles the middle meningeal artery.
 It runs with superficial temporal artery
 Somatosensory to auricle, outer tympanic
membrane, TMJ and temporal region skin
 Post-ganglionic fibers for motor to parotid
gland (pre-ganglionic from CN IX)
Lingual nerve - Passes between:
 Tensor veli palatine medially
 Lateral pterygoid laterally
 Medial pterygoid medially
 Hyoglossus medially
 Mylohyoid laterally
 Enters mouth passing between superior
and middle constrictor
Inferior alveolar nerve (motor and sensory)
 Gives motor Nerve to mylohyoid (also supplies anterior digastric), pierces
sphenomandibular ligament, also supplies anterior belly of digastric
 Supplies lower three molars and two premolars
 Continuesas a terminal incisor branch which
supplies the remaining teeth

Greater
Occipital
C2-3
Sensory distribution of trigeminal nerve
Lesser
 V3 does sensation to all lower teeth Occipital
 V3 does majority of temporal region including C2
middle cranial fossa (meningeal branch from Greater
main trunk) Auricular
C2-3

Transverse
Cutaneous
Neck C2-3
 V2 does inferior eyelid (infraorbital nerve continuation)
including the palpebral conjunctiva
 V2 does lateral nose, V1 does median nose
 V1 extends right to tip of crown, behind which is occipital

Auriculotemporal = V3
Auricular branch of vagus = X
Lesser occipital nerve = C2-3
Greater auricular nerve = C2-3 – ear lobe

Abducens

Facial nerve (VII)

Nuclei
 Has three nuclei in brainstem: Motor, parasympathetic and
sensory
 M: Branchial motor nucleus of facial nerve
 P: Superior salivatory nucleus
 S: Nucleus of tractus solitarius
Motor: supplies muscle of face, scalp, auricle of ear, posterior digastric and stylohyoid. Not
muscles of mastication (V3)
 Upper facial muscles receives efferent from both hemispheres (via precentral gyrus ->
corticobulbar tracts)
 Lower facial muscles receives efferent from precentral gyrus of contralateral precentral
gyrus only
Parasympathetic: Nerves to submandibular and sublingual salivary glands and lacrimal
gland
 Receives efferent from hypothalamus for emotional crying
 Lies posteriolateral to main motor nucleus within pons
Sensory: Taste from anterior 2/3 tongue, inferior mouth as well as touch, pain and
temperature of external ear
 Receives fibers from any cranial nerve that is involved with taste (glossopharyngeal for
posterior 1/3 tongue)
 Receives sensory afferent for touch pain and temperature from ear
Course of motor and sensory from brainstem to middle ear
 Motor branches – travel posteriorly towards cerebellum, then loops around VIth nerve
and travel anteriorly again.
 Leaves anterior brainstem at base of pons
 Nerve is called ‘facial nerve proper’
 Sensory and parasympathetic leave anteriorly, and form a combined bundle named
nervus intermedius
 Travel through internal auditory meatus (from posterior cranial fossa, through petrous
part of temporal bone) – all fibers joint together at geniculate ganglion
 Enter the middle ear on the anterior superior part of the medial wall
 Shares the canal with vestibulocochlear nerve (VIII)
 Forms a ganglion called geniculate ganglion at the entrance to middle ear

Motor nerve pathway through middle ear out stylomastoid foramen

 Pass through geniculate ganglion without synapse
 Turn posteriorly along the medial wall of anterosuperior bony canal known as facial
canal
 Bony canal runs to posterior superior border of medial wall of middle ear then runs
downwards through a foramen between mastoid
process and styloid process
 Called stylomastoid foramen
 Before exiting stylomastoid foramen, gives off a
nerve to innervate stapes muscle. Stops stapes from
excessively vibrating.
*Salivatory fibers from superior salivatory nucleus follow
these motor nerves through facial canal (lacrimatory do not) Retromandibular
vein + branch
– but do not come out at stylomastoid foramen, instead jump
into middle ear

Motor Outside stylomastoid foramen

-Initial branches include posterior auricular nerve and nerve to stylohyoid
 Posterior auricular nerve – Runs up anterior to mastoid process and supplies occipitalis
muscle
 Stylohyoid = also supplies posterior belly of digastric
-Moves into parotid gland and gives off two main trunks followed by five branches
 Temporal branch: Frontalis and procerus
 Zygomatic – two subsequent branches. Top =
Orbicularis oculi bottom = mid-face and smile
 Buccal – Buccinator and upper lip
 Marginal mandibular – Lower lip and
orbicularis oris
 Cervical – Platysma
*Proprioception is supplied by trigeminal nerve
Clinical note for GSSE
 20% of patients have a marginal mandibular nerve that enters the neck along the inferior
border of mandible
 Surgical incisions to get to submandibular gland can ligate the marginal mandibular nerve
causing ugly lower lip droop. Incision must be done 4cm below mandible

Lacrimal fibers course from geniculate ganglion

 Become known as greater petrosal nerve
 Moves through canal to middle cranial fossa
 Enter foramen lacerum and receives sympathetic fibers
from carotid artery through a branch called deep
petrosal nerve
 Pass through the pterygoid (vidian) canal to get to the
pterygopalatine fossa. Combined Greater and Deep
petrosal nerve is called nerve to pterygoid canal (vidian
nerve)
 Synapse in pterygopalatine ganglion hanging off the maxillary nerve
 Postganglion fibers jump off of the vidian nerve and join the zygomatic branch of the
maxillary nerve (which entered the fossa through foramen rotundum)
 Passes through the inferior orbital fissure to orbit and merge with lacrimal nerve of
ophthalmic division of trigeminal nerve
 The motor segments divides into two nerves, zygomaticotemporal and
zygomaticofacial, which exit lateral orbital wall via two foramen named after the
nerves to supply sensory to skin
The parasympathetic fibers also go to nasal canal, sphenoid and maxillary sinus etc

Salivatory fibers course from posterior canaliculus

 Jump from facial canal (posterior wall of middle ear) through posterior canaliculus to
middle ear
 Pass anterior through middle ear through pterygotympanic fissure to join lingual nerve
 Mandibular division of trigeminal nerve passes through foramen ovale
 Divides into anterior and posterior nerves. Branch of posterior division is lingual nerve
 Lingual nerve collects touch, pain and temperature from anterior 2/3 tongue
 Leave lingual nerve to synapse at submandibular ganglion
 Postganglionic fibers go to submandibular and sublingual glands

Taste fibers from tractus solitarius

 Follow the exact same pathway as the salivatory fibers
 But they synapse at geniculate ganglion
 Do not leave lingual nerve to go to submandibular ganglion
 Instead travel to tongue for taste of anterior 2/3
 Touch pain and temperature travel with lingual nerve through foramen rotundrum to
trigeminal ganglion
Summary of pathways and function
1. Muscles of facial expression + posterior digastric + stylohyoid + stapedes: Motor nucleus -
> around 6th nerve nucleus -> pontomedullary junction -> internal acoustic foramen ->
geniculate ganglion (no synapse) -> facial canal -> stylomastoid foramen -> parotid gland -
> branches
2. Lacrimatory fibers -> Superior salivatory nucleus -> pontomedullary junction -> internal
acoustic canal -> geniculate ganglion (no synapse) – middle cranial fossa -> foramen
lacerum -> vidian canal -> pterygopalatine ganglion synapse -> zygomatic branch of
mandibular nerve -> inferior orbital fissure -> lacrimal nerve
3. Salivatory fibers -> same as lacrimatory -> geniculate ganglion no synapse -> facial canal -
> posterior canaliculus -> becomes chorda tympani through middle ear ->
pterygotympanic fissure -> lingual nerve -> submandibular ganglion -> submandibular
gland and sublingual gland
4. Taste to anterior 2/3 of tongue – lingual nerve – chorda II
tympani – pterygotympanic fissure – posterior
canaliculus – facial canal – internal acoustic canal –
pontomedullary junction – tractus solitarius

III

For understanding of CN IX-XII:

GSA = general somatic afferent = touch pain and IV
temperature
GSE = general somatic efferent = motor to muscles V
GVA = general visceral afferent = Touch pain and
VI
temperature to viscera (e.g tongue, endoderm derived) VII
GVA = Specialised visceral afferent = taste, chemoreceptors, VIII
XII
baroreceptors
GVE = Motor to viscera IX
Pyramid

XI
Glossopharyngeal (IX)

Nuclei
Spinal nucleus of trigeminal nerve for GSA
Tractus solitarius for GVA
Inferior salivatory nucleus for secretion to parotid
Nucleus ambiguus

*The stem of glossopharyngeal nerve arises from the

post-olivary sulcus below CN VIII

Summary of courses
 Spinal nucleus of trigeminal -> GSA -> jugular foramen -> branches to pharynx, tonsils, soft
palate, middle ear, larynx above vocal cord
 Tractus solitarius -> GVE + SVE -> jugular foramen -> Posterior 1/3 tongue taste and
T+P+T, carotid sinus for baro and carotid body for chemoreceptor
 Inferior salivatory nucleus -> GVE -> jugular foramen -> tympanic cannaliculus (for IX
exclusively) -> lesser petrosal nerve through foramen ovale -> otic ganglion ->
auriculotemporal nerve of VII -> parotid
gland
 Nucleus ambiguus -> GSE -> jugular
foramen -> motor to stylopharyngeus

Position in oral cavity

Lies under the hyoglossus muscle

Gag reflex
 Posterior wall of pharynx irritation leads to
gag
 Sensory pathway is through the IXth nerve
 Motor pathway is through Xth nerve
Lesions to either causes loss of gag reflex

Vagus (X)
Inferior to 9th nerve, arises from post-olivary sulcus

Nuclei

Spinal nucleus of trigeminal -> GSA (touch, pain,

temperature) -> Jugular foramen -> auricular branch of
vagus nerve to ear and meningeal branch of vagus nerve to
posterior cranial fossa
 Crude touch pain and temperature to ear canal + tragus
 Supplies dura of posterior cranial fossa
 Sensation to larynx below the true vocal cord
Tractus solitarius -> GVA + SVA -> Jugular foramen ->
 Taste to epiglottic region
 Baroreceptor / chemoreceptor to arch of aorta
 Mechanoreceptors and chemoreceptors to viscera of abdomen and thorax
 Sensory to ear
Dorsal nucleus of vagus -> Parasympathetic GVE +
GVA -> jugular foramen -> viscera of thorax and
abdomen up until mid part of transverse colon
Nucleus ambiguus -> GSE -> branchiomotor to
pharynx, larynx, upper oesophagus
 Pharyngeal muscles: Superior, middle and inferior
pharyngeal constrictors, Levator veli palatine,
Palatoglossus
 Skeleton of soft palate
Pharyngeal

Laryngeal
 Laryngeal muscles
 Superior laryngeal nerve -> cricothyroid muscle + cartilages
 Recurrent laryngeal nerve -> inferior laryngeal nerve = posterior cricoarytenoid

Summary of course
 Exits jugular foramen with jugular ganglion of vagus nerve superficial
 Sends off auricular branch of vagus nerve to join auricular branch of glossopharyngeal
for external ear and tragus GSA, joins V3
 Is joined by cranial XI in its lower ganglia
 Passes down carotid sheath between ICA and IJV
 Root of neck
 Into thorax behind lung
 To oesophagus and abdomen as vagal trunks
 Gives off branches
 Pharynx – branchiomotor with contribution from XI
 Cardiac
 Superior laryngeal
 Recurrent laryngeal – loops around aorta / subclavian (L + R)

Reflexes are generally all mediated by nucleus of tractus solitarius

Bainbridge reflex: Increase in heart rate in response to increased fluid volume in the atria /
central venous pressure
Cough reflex: Sensation for respiratory center dependent on the vagus nerve.

Accessory XI
Accessory nerve has two components
1. Spinal accessory nerve
a. The spinal arises from lower down in spinal cord from C1-5
b. It passes up through foramen magnum into skull
c. Joints the cranial accessory and passes through jugular foramen
d. Then separates from the combined accessory nerve to be an independent spinal
accessory nerve again
e. Passes deep to styloid process and posterior belly of diagstric
f. Pierces SCM then travels over levator scapulae to supply trapezius
2. Cranial accessory nerve
a. Arises from the anterior surface of medulla between olive and inferior
cerebellar peduncle
b. Joins with spinal, leaves through jugular foramen, separates from spinal
c. Goes to join the vagus nerve, which it then helps to supply muscles of the
pharynx and larynx -> pharyngeal plexus
i. Palatoglossus
ii. Levator palate
iii. Palatopharyngeus
iv. Assists with motor fibers to the recurrent laryngeal nerves as well
Surface marking: Draw a line a third of the way down posterior border of SCM and a third of
the way up the anterior border of trapezius – this is the course of the nerve
 In front of levator scapulae and scalenus medius

Hypoglossal XII
 Has a central medullary nucleus that lies anterior
to 4th ventricle
 Arises from post-pyramidal sulcus (medial to live,
lateral to pyramid), superior to XI rootlets
 Passes through hypoglossal canal
 Is joined by C1 fibers
 Arises and passes superficial / lateral to ICA,
ECA and lingual artery
Within tongue:
 Lies medial to mylohyoid and lateral to runs
along lower margin of hyoglossus (cf lingual
runs along superior margin of hyoglossus)

Pharyngeal plexus
Located on the surface of the middle pharyngeal constrictor. Consists of:
 Sensory: Pharyngeal branches of glossopharyngeal nerve
 Motor: Pharyngeal branch of vagus nerve (X) + cranial part of accessory nerve (XI)
 Sympathetic: Superior cervical ganglion
Things supplied by pharyngeal plexus
1. Motor: All the muscles of the pharynx except stylopharyngeus (innervated bi IX)
a. Palatopharyngeus
b. Palatoglossus
c. Musculus uvulae
d. Pharyngeal constrictors
e. Salpingopharyngeus
 2. Sensory: Oropharynx, laryngopharynx. Not the nasopharynx above the which is
supplied by V2
3. The muscles of the larynx are not pharyngeal plexus. They instead are vagus
exclusively

Cervical plexus
 C1-4 nerve roots, receive a grey ramus from the superior cervical ganglion
 Lies in a series with brachial plexus

Muscular branches
 C1 loop to hypoglossal nerve which helps innervate geniohyoid and thyrohyoid
 C2 and 3 to SCM
 C3 and 4 to trapezius – motor supplied by accessory, but some evidence that it can
maintain motor function from C3 and 4 nerve roots
 Phrenic nerve – Mainly from C4, but some from 3 and 5
 Passes from lateral scalenus anterior to medial border of scalenus anterior under
prevertebral fascia
 Passes behind the subclavian vein into mediastinum
 Can descend in front of the subclavian vein or even pierce it
 Right passes through the vena caval hiatus, left passes through left crus
 Contains afferent fibers to the pericardium, pleura and peritoneum as well as its motor
to half the diaphragm

Cutaneous branches
Lesser occipital nerve (C2) – Runs along posterior border of SCM after hooking around
accessory nerve
Greater auricular nerve (C2-3) – Passes vertically upwards over SCM to supply skin below
external acoustic meatus, over parotid and over mastoid
Transverse cervical (C2-3) – Some distance from transverse cervical artery. Pierces
investing fascia in posterior triangle and moves medially over SCM to supply skin from chin to
sternum via many branches
Supraclavicular (C3-4) – Divides quickly into three groups, medial, intermediate, lateral.

Spinal Cord
Denticulate ligament attaches the pia matter to the dura mater by piercing the arachnoiud
mater between exit sites for the nerve
 Present from C1 to T12 in triangular slits
 Spinal accessory nerve roots (C1-5) and dorsal sensory roots emerge dorsal to the
ligament, motor emerges ventral

Grey matter is the cell bodies of neurons

White matter is axons of cell bodies traveling along the CNS. There are three different
bundles of white matter in the CNS
1. Rostral and caudal (ascending and descending) axon
bundles are referred to as tracts
2. Ventral and dorsal (anterior to posterior) axon
bundles are called association fibers
3. Lateral (left to right) axon bundles are called
commissures
a. Corpus callosum – Rostrum front below, genu
(knee) at front, trunk middle, splenium at back
b. Anterior commissure (temporal lobe) at anterior
limit of 3rd ventricle
c. Posterior commissure (tectal area of midbrain)
d. Habenular commissure (superoposterior third
ventricle with pineal gland)

*All tracts are organised into a three neuron pathway

Spinal cord tracts

White mater = myelinated
Grey mater = unmyelinated

Dorsal column medial leminiscus

pathway – Fine touch, proprioception,
vibration
1. From limb receptor to dorsal root
ganglion adjacent to spinal cord
a. Gracilus tract carry information
about lower limb
b. Cuneate tract carry information
about upper limb
2. Fibers ascend and decussate in
superior medulla via internal
arcuate fibers and ascend further
to ventral posterlateral nucleus of
thalamus
3. Project to the postcentral gyrus

Spinothalamic tract – Pain,

temperature and crude touch
1. From receptor to dorsal root ganglion adjacent to spinal cord, enters into Lissauer’s
fasciculus
a. Ascends or descends 1-2 levels in lissauer’s fasciculus
b. Then synapses with the dorsal horn of grey matter, an area known as substantia
gelatinosa.
2. From dorsal horn grey matter, axons decussated immediately through the anterior white
commisure, then ascends via the spinothalamic fasciculus to synapses in thalamus (hence
name)
3. Then projects to the postcentral gyrus

Corticospinal (pyramidal) tract – Motor for axial and limbs

1. Primary motor cortex through internal capsule into brainstem down to medulla
pyramids, then down to spinal cord.
a. 75-90% of fibers decussate into the lateral corticospinal tract (for limbs) located in
the inferior medulla
b. Fibers that don’t decussate are axial muscles, remain in and decussate in the cervical
/ upper thoracic via the anterior white commisure
2. These described descending upper motor neurons synapse at the ventral horn of the gray
matter
3. From ventral horn of grey matter, axons travel to final muscle (3rd order)

*Corticobulbar are also motor pathways that pertain to face muscles, same as above except
they only descend to the brainstem nuclei and have bilateral input (except lower facial nerve
and hypoglossal nerve which is contralateral only)

*The most superior decussation is the ‘sensory decussation’ which pertains to the gracilis and
cuneate tracts for proprioception. These decussate in the superior medulla pyramids
*Next comes the Corticospinal tract in the inferior pyramid
*The spinothalamic tracts decussate low down in spinal cord, often 1-2 levels above or below
where the dorsal nerve root enters the cord

Spinal cord arterial supply

 Anterior spinal artery (from vertebral) supply the anterior 2/3 of spinal cord
 Posterior spinal artery (paired) (from vertebral OR PICA) supply
Post
posterior 1/3 of spinal cord Spinal a.
 Anastomosis between two is called arterial
vasocorona, supplies lateral aspect
 Discontinuous and therefore, reinforced by radicular
arteries. Enter via intervertebral foramen
 Ascending and deep cervical arteries
 Intercostal arteries (beginning at T4)
 Lumbar arteries (Beginning at L2)
 Great medullary artery of Adamkiewicz, most Radicular
important, Arising usually from the left posterior
intercostal artery around T10-11
 Supplies lower 2/3 of spinal cord via the anterior spinal artery
 Lateral sacral artery from internal iliac supplies the iliolumbar which is the ‘5th lumbar
artery – also goes on to provide individual sacral branches
 Internal thoracic and lateral thoracic arteries can provide additional flow to radicular
arteries during aortic surgery due to anastomoses with the anterior intercostal artery
anastomoses
 T4 and L2 are areas where the anterior spinal artery has trickle flow and are susceptible
to infarction
 Immediately proximal where the radicular arteries begin entering in thorax and
lumbar region is reduced blood flow

Spinal cord venous drainage

 Paired anterior and posterior spinal arteries
 Anastomose freely with eachother
 Communicate freely with both the vertebral venous
plexus and the segmental veins of the trunk
 Vertebral veins in neck
 Azygos in thoraic
 Lumbar veins in abodmen
 Lateral sacral in pelvis
 At foramen magnum, communication is with veins of medulla

Vertebral venous plexus

Three components. All valveless
1. Internal vertebral venous plexus – Within spinal column, outside of the dura (epidural
space). One anterior (behind body) and two posterior (anterior to lamina)
2. External vertebral venous plexus – longitudinal outside of vertebra, one anterior to body,
one posterior to ligamentum flavum
3. Basivertebral veins –horizontally through the vertebral body, drained by anterior
internal venous plexus.

Spinal cord dura

 Spinal cord ends at L1-2 at the cona medullaris (conical shaped
conclusion of spinal cord)
 Corda equine extends further down to C1
 Filum terminale is a fibrous stand of tissue 20cm in length that extends
from cona medullaris to the back of C1 – the inferior end referred to as
the coccygeal ligament
 Dura finishes at S2
 Pia can be considered to finish at C1 as the filum terminale is a
continuation of it

Respiratory system

Nasal cavity
 Drains lacrimal ducts and paranasal sinuses
 Humidifies air
 Traps pathogens
 Responsible for olfaction
Conchae
Vestibule - opening through nares (nostril)
Olfactory region - top of nasal cavity, contains olfactory receptors and
hairs Meatus
Respiratory region - Main passageway, surface area increased by the
three conchae (or turbinates)
Conchae - The inferior conchae is its own bone, whereas the
top two are part of the ethmoid bone. They slow the passage of
air and increase surface area for warming

Boundaries and nasal septum

Roof – cribiform plate
Floor = hard palate (maxilla palatine process as well as the horizontal plate of the palatine
bone)
Lateral wall – Conchae and meatus (formed by ethmiod bone and inferior nasal concha bone,
lacrimal bone
Medial wall is the septum, composed of: Perpendicular plate of ethmoid bone, vomer, nasal
cartilage, crest of maxillary bone, crest of palatine bone

Apertures
Middle meatus – opening to the frontal, maxillary and anterior ethmoidal air sinuses,
marked by the semilunar hiatus on the lateral wall
Superior meatus – Opening for the posterior ethmoidal sinus behind semilunar hiatus
Spheno-ethmoidal recess – Posterior superior wall, marks the opening to the sphenoid
sinus
Nasolacrimal duct – drains into inferior meatus (below inferior nasal conchae)
Auditory tube – Opens directly into nasopharynx at level of inferior meatus allowing
equalization of pressure

Cribiform plate perforations – for

olfactory nerve
Sphenopalatine foramen – at level of
superior meatus, passes to the
pterygopalatine fossa, transmiting the
sphenopalatine artery, nasopalatine and
superior nasal nerves
Incisive canal – Between nasal cavity
and oral cavity, transmits nasopalatine
nerve and greater palatine artery

Sinus air cells drainage summary recap

Middle meatus (at the hiatus semilunaris) = Anterior ethmoidal, frontal and maxillary sinuses
Superior meatus = Posterior ethmiodal
Inferior meatus = Nasolacrimal duct opening
Sphenoidethmoidal recess = Sphenoid air cells

Blood supply of nose (Kiesselbach’s plexus / Little’s area)

Epistaxis is most likely to occur in the anterior third of the nasal cavity Kiesselbach’s plexus).
Trauma or hypertension can cause it epistaxis

Ophthalmic artery branches

 Anterior ethmoidal artery
 Posterior ethmoidal artery (superior meatus
opening), meets with sphenopalatine artery
Maxillary artery branches
 Sphenopalatine artery – Passes through
sphenopalatine foramen from pterygopalatine
fossa into the superior meatus
 Greater palatine artery – Descending palatine artery branches from maxillary artery
within pterygopalatine fossa, descends through greater palatine canal to supply hard
palate, then moves through incisive canal to anastomose with sphenopalatine
 Superior labial arteries – Branch off facial artery, moves up lip and deep into the nose

*Tidbits
-The anterior and middle ethmiodal air cells open into middle meatus, along with frontal and
maxillary air cells
-The posterior ethmiodal air cells open into superior meatus, along with sphenoid air cells

Oral cavity
Oropharyngeal isthmus – passage to oropharynx
Vestible: Between lips and cheek (buccinators muscle) plus gums and teeth. Diameter of the
oral fissure controlled by orbicularis oris
Parotid duct opening – opposite upper second molar tooth, from the cheek. Pierces
buccinators to get there

Roof
Hard palate – Formed from maxillary bone’s palatine crest and the maxillary process of the
palatine bone
Soft palate – Muscular structure that forms a
valve to open and close the oropharyngeal
isthmus and elevate to separate the
nasopharynx from the oropharynx

Floor
 Muscular diaphragm – mylohyoid
muscles, pulls larynx forward during
swallowing
 Geniohyoid muscles – Pulls larynx
forward during swallowing
 Tongue – Connected to floor by frenulum.
Extrinsic muscles include genioglossus
and hyoglossus
 Salivary glands and ducts
 Sublingual gland
 Deep and superficial submandibular glands (around mylohyoid)

Important anatomical relations of oral cavity

Hyoglossus muscle important is landmark

-Hypoglossal nerve crosses lower part of muscle from behind forwards
-Lingual nerve crosses upper part from behind worwards
-Glossopharyngeal nerve passes deep to posterior part of hyoglossus muscle
-Submandibular gland lies deep to hyoglossus,
duct runs superficial
-Lingual artery runs deep to hyoglossus after
wrapping above hypoglossal nerve

Innervation
General sensory
 Soft and hard palate by nasopalatine and
greater palatine nerves from V2
 Floor of oral cavity from lingual nerve from V3
 Taste
 Anterior two thirds of tongue = Chorda tympani branch of VII
 Posterior one third = glossopharyngeal (IX)

Motor
 All tongue muscles innervated by XII (hypoglossal
nerve) except palatoglossus which is X (accessory)
via pharyngeal arch
 Mylohyoid innervated by inferior alveolar nerve
(from V3)
 Geniohyoid innervated by C1 nerve roots running
with hypoglossal nerve
 Buccinator innervated by buccal nerve (From VII)

Pharynx
Starts at C1 base of skull and extends to C6
Choana – opening into the nasopharynx

Pharyngeal tonsil (Adenoids) - located at back of

nasopharynx – can obstruct the Eustachian tube when
chronically inflamed. This can cause chronic otitis media
(glue ear)

Palatine tonsils – Tonsillar fossa between

palatoglossus and palatopharyngeal arch of oral
cavity
 Superior constrictor lies lateral to the tonsils
 Drains directly to jugulo-digastric nodes
 Innervation
-Lesser palatine nerve from maxillary (V2)
-Tonsilar branches of glossopharyngeal

Blood supply
1. Dorsal lingual artery (Lingual artery - EC)
2. Ascending palatine (Facial artery - EC)
3. Tonsilar branch of facial artery – EC
a. Most likely to bleed post tonsillectomy
4. Ascending pharyngeal artery
5. Lesser palatine – branch of descending palatine artery from
maxillary artery

ant wall gone

Larynx

Piriform recess: Either side of the laryngeal orifice

Cartilages
Unpaired
 Epiglottis – Leaf shaped plate. Entrance to larynx. Lays on anterior part of
Thyroid post thyroid cartilage’s posterior surface. Moves towards the arytenoid cartilage to
close off larynx
 Thyroid – Two sheets joining together to form the adam’s apple (laryngeal
prominence). Superior horn has thickened tendon to suspend it from hyoid bone. Inferior
horn articulates with cricoid cartilage
 Cricoid – Complete ring of hyaline cartilage, thin anteriorly and thicker posteriorly.
Makes the inferior border of larynx at C6. Articulates with the paired arytenoid cartilage
posteriorly
Cricoid post

Paired
 Arytenoid – Pyramidal shape. Sit on cricoid cartilage
 Apex: articulates with corniculate cartilage
 Base: Articulates with superior border of cricoid cartilage
 Vocal process – attachment of vocal cord
 Muscular process – Attachment for posterior and lateral cricoarytenoid
muscles
 Corniculate – Minor, articular with arytenoid superiorly
 Cuneiform – Within the quadrangular membrane
Ligaments
 Thyrohyoid membrane – suspends from hyoid bone to thyroid cartilage.
 Thickened in the middle – median thyrohyoid
ligament
 Thickened laterally – lateral thyrohyoid ligament
 Contains a hole laterally superior laryngeal
nerve and vessels
 Cricothyroid membrane – From anterior arch of
cricothyroid cartilage to thyroid cartilage inner
surface + arytenoid cartilage.
 Thickened midline = median cricothyroid
ligament
 Thickened and free upper border = vocal
ligament
 Cricothyroid membrane also known as conus
elasticus
 Quadrangular membrane – lateral surface of epiglottis to arytenoid cartilage + thyroid
cartilage above area where the vocal cord attaches
 Free lower margin between arytenoid and thyroid cartilage =
vestibular ligament (false vocal cord)

*The mucosa of the pharynx folds around the vestibular fold and the
vocal fold

Intrinsic muscles

Cricothyroid
 Attaches from cricoid to thyroid. Moves thyroid forward and down
 This puts tension on vocal cords to raise the pitch
 External branch of superior laryngeal nerve
Posterior cricoarytenoid muscle
 Move the arytenoid cartilages laterally - Only abductor of cords
 From posterior cricoid cartilage to arytenoid cartilage
Transverse arytenoid– Adducts arytenoid cartilage
Thyroarytenoid– Relaxes the vocal cord
Lateral cricoarytenoid – Adducts vocal cord

Innervation from vagus nerve root

 Inferior laryngeal nerve (terminal branch of recurrent laryngeal nerve) innervates all
except cricothyroid
 Cricothyroid is innervated by the external branch of the superior laryngeal nerve
Viscera of the head and neck

Thyroid
Embryology
 ‘Tubercular impar’ is the substance that gives rise to the tongue
 Begins in the oropharynx and descends via the thyroglossal duct (foramen
caecum), at posterior 1/3 and anterior 2/3 of tongue is point of descent
 Descends anterior to hyoid bone
 At the base of descent it forms the pyramidal lobe
 Can be attached to hyoid bone via ‘levator glandulae thyroidae’
 Fourth pharyngeal arch gives rise to ‘ultimobranchial body’ – c cells of the thyroid
 Ectopic thyroid tissue can remain: Linual thyroid, cervical thyroid or anywhere along path
of descent

Anatomy
 Bilobed, lobulated, 5cm long. Forms two triangles in cross section
 Inferior pole extends to 6th tracheal ring, isthmus overlies rings 2, 3 and 4
 Lies on carotid sheath
 Lateral (superficial) side is under sternohyoid and sternothyroid, with SCM overlapping
inferiorly. Sternothyroid limits its upwards expansion (attached to oblique line of thyroid
cartilage)
 Medial surface is against the lateral larynx and upper trachea. Has cricothyroid muscle and
inferior pharyngeal constrictor medial relations
 Posterior: Overlaps the medial surface of carotid sheath
 Always lies behind the pretracheal fascia and behind the cricothyroid
joint (as it passes up covered by inferior constrictor)
 Suspensory ligament of berry: Connects the posterior surface of
thyroid gland with the trachea (is a thickening of the pretracheal fascia
 Makes the thyroid gland move with swallowing as it is attached to
the trachea and inferior constrictor

Blood supply
 Superior thyroid artery from above (external carotid)
 Pierces pretracheal fascia as a single vessel to reach the summit of
the upper pole
 External laryngeal nerve immediately behind it, so during thyroidectomy, it is ligated
at the thyroid (not distance form it)
 Divides into anterior and posterior branches, anastomosing with the inferior thyroid
atery
 Inferior thyroid artery from the thyrocervical trunk of first part subclavian
 Divides outside the pretracheal fascia into four or five branches
 Pierces separately to reach the lower pole
 The recurrent laryngeal nerve lies behind the
pretracheal fascia

Innervation
 External laryngeal nerve from above
 Runs 1mm behind superior thyroid artery
 Passes medial to upper pole
 Recurrent laryngeal nerve from below
 Travels up the medial surface lying in front of the groove between trachea and
oesophagus
 Left side: likely behind thyroid artery
 Right side: Equal chance of being behind or in front of thyroid artery
 Often divides into two at the isthmus, in which the anterior branch is
motor and the smaller posterior is sensory
 Occasionally the R side has a non recurrent laryngeal nerve
 Passes into larynx below inferior constrictor

Venous drainage
 Superior and middle thyroid veins drain to IJV. Superior vein follows the
superior artery
 Inferior thyroid vein drains to R and L subclavian medial to the internal jugular branch

Clinical summary
The superior thyroid artery should be ligated close to the gland as it moves away from the
superior laryngeal nerve
The inferior thyroid artery should be ligated away from the gland as it moves towards the
recurrent laryngeal nerve at the level of the gland

Salivary glands

 Parotid gland
 Serous secretions only
 Submandibular gland
 Serous and mucus secretions
 Superficial lobe lies above the mylohyoid line (larger part)
 Deep lobe lies below the mylohyoid line (smaller part)
 65% of saliva contribution, decreasing on stimulation of the parotid
 Chorda tympani innervation
 80% of calculi come from this gland
 Sublingual gland
 Mucus secretions only
 Only unencapsulated gland
 3-5% salivary volume
 Lies above the mylohyoid line
 Chorda tympania innervation
 Duct drainage
 8-20 separate small ducts of Rivinus drain to the plica sublingualis
 Sublingual duct of Bartholin joins the submandibular duct to drain sublingual
caruncle
Lymphatic drainage of neck

Superficial ring of lymph nodes

Drain from scalp, face and neck into superficial ring at the junction of head and neck. Nodes
follow veins
 Occipital: 1-3
 Mastoid: 2, also known as post-auricular, lie at
insertion of SCM, posterior neck, upper ear and
back of external auditor meatus
 Pre-auricular: 1-3, anterior to the ear,
superficial face and temporal region
 Parotid: superficial to parotid gland, collect
lateral orbit, nose, nasopharynx
 Submental: Superficial to mylohyoid, lymph
from lower lip, floor of mouth, apex of tongue
 Submandibular: 3-6, Cheeks, lateral nose, upper lip
 Superficial cervical – along external jugular

Deep vertical chain of lymph nodes

Receive all lymph from superficial lymph nodes
 Upper Jugulo-digastric trunk: Close proximity to the internal jugular
vein within carotid triangle
 Lower jugulo-omoyhyoid / supraclavicular
 Root of neck, posterior triangle

Converge to form left and right jugular lymphatic trunks

 Left jugular trunk joins thoracic duct
 Right jugular trunk drains to right lymphatic duct at root of neck

Regions
Temporal fossa
Located under temporalis muscle attached to inferior temporal line
Roof: Temporalis fascia
Floor: Calvarium including pterion and the bones that constitue it
Inferior: Zygomatic arch
Anterior: Zygoma, zygomatic process of frontal and maxilla
Contents:
 Superficial temporal artery
 Auriculotemporal nerve / deep temporal branch of auriculotemporal nerve
 Deep temporal arteries of maxillary artery

Infratemporal fossa
Located at the base of skull between ramus of mandible and pharynx
Roof: Infratemporal crest (greater wing of sphenoid) + squamous bone
Posterior: Carotid sheath
Anterior: Maxilla / infraorbital fissure
Lateral wall; Ramus of mandible + coronoid process
Medial wall: Superior constrictor, tensor palate, Lateral pterygoid plate, Pterygomaxillary
fissure (passage of Superior alveolar nerves)

Contents:
 Medial and lateral pterygoid muscles
+temporalis muscle tendon
 Nerves
 Mandibular nerve
 Posterior superior alveolar nerve
 Otic ganglion
 Chorda tympani
 Pterygoid venous plexu
 Arteries: Maxillary artery and branches

Parotid region
Superior: Zygomatic arch
Inferior: Inferior border of mandible
Anterior: Masseter muscle
Posterior: External ear and sternocleidomastoid
Parotid gland: Lies between the mastoid, styloid
process and ramus of mandible
Parotid gland
Innervation
 Secretomotor: Inferior salivatory nucleus ->
IX -> geniculate ganglion -> lesser petrosal
nerve -> foramen ovale -> otic ganglion ->
auriculotemporal nerve
 GVA: Auriculotemporal -> V3 -> spinal
nucleus of trigeminal

Contents within gland

 FATE GP
 Facial nerve branches
 Auriculotemporal nerve – branch off V3 main trunk, engulfes middle meningeal artery
 Temporal artery and vein (continuation of ECA)
 External carotid artery
 Great auricular nerve – from C2 and C3, supplies sensation to skin over parotid and and
mastoid process
 Parotid (stenson’s) duct

Posterior triangle
Posterior: trapezius
Anterior: SCM
Inferior: Middle 1/3 clavicle
Floor: Prevertebral fascia with items lying deep to it:
 Third part of subclavian artery
 Cervical plexus trunks
 Cervical plexus
Roof: Investing fascia with items lying superficial to it
 External jugular vein superficial to deep fascia, but then
passing into deep fascia in subclavian triangle
 Platysma
Contents: Veins, arteries, nerves, lymphatics
 Accessory nerve passing transversely between top 1/3
of posterior SCM and bottom 1/3 of trapezius.
 Nerves from the cervical plexus which pierce fascia:
 Greater auricular
 Transverse cervical
 Supraclavicular nerve
 Greater occipital (C2)
 Arteries
 Suprascapular artery anterior to scalenus anterior
 Transverse cervical artery (branch of thyrocervical trunk)
  Occipital artery up top
 Muscles
 Scalenus anterior ,medius, levator, omohyoid
 Lymph nodes: Occipital, supraclavicularposterior

Anterior triangle
Lateral: Medial sternocleidomastoid
Medial: midline
Superior: Inferior mandible
Floor: Suprahyoid muscles and sternohyoid
Contents from lateral to medial
 Vagus
 Hypoglossal nerve
 Ansa cervicalis
 Carotid sheath
 Trachea, oesophagus, etc

Submandibular triangle
Lingual N

Sublingual region
Lateral: Mandible body
Medial: Hyoglossus
Inferior: Mylohyoid
Superior: Oral cavity
Contents:
 Deep = submandibular gland + duct
 Sublingual gland Inf
 Lingual nerve and XII Alv
 Submandibular ganglion