Human Anatomy Head and Neck - BD Chaurasia - Human Anatomy, 3, 8, 2020 - CBS Publishers & Distributors PVT LTD - Anna's Archive

Volume 3
Eighth
BD Chaurasia’s Edition
Human
Anatomy
Regional and Applied Dissection and Clinical
As per Medical Council of India: Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018
Head and Neck

Dr BD Chaurasia (1937–1985)
was Reader in Anatomy at GR Medical College, Gwalior.
He received his MBBS in 1960, MS in 1965 and PhD in 1975.
He was elected fellow of National Academy of Medical Sciences (India) in 1982.
He was a member of the Advisory Board of the Acta Anatomica since 1981,
member of the editorial board of Bionature, and in addition
member of a number of scientific societies.
He had a large number of research papers to his credit.
Volume 3
Eighth
BD Chaurasia’s Edition
Human
Anatomy
Regional and Applied Dissection and Clinical
As per Medical Council of India: Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018
Head and Neck

Chief Editor
Krishna Garg
MBBS MS PhD FIMSA FIAMS FAMS FASI
Member and Fellow, Academy of Medical Sciences
Fellow, Indian Academy of Medical Specialists
Fellow, International Medical Science Academy
Fellow, Anatomical Society of India
Lifetime Achievement Awardee
DMA Distinguished Service Awardee
Ex-Professor and Head, Department of Anatomy

Lady Hardinge Medical College
New Delhi
Editors
Pragati Sheel Mittal MBBS MS Mrudula Chandrupatla MBBS MD

Associate Professor, Department of Anatomy Professor and Head, Department of Anatomy
Government Institute of Medical Sciences Apollo Institute of Medical Sciences
Greater Noida, UP Hyderabad, Telangana
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to
my teacher
Shri Uma Shankar Nagayach
— BD Chaurasia
This human anatomy is not systemic but regional
Oh yes, it is theoretical as well as practical
Besides the gross features, it is chiefly clinical
Clinical too is very much diagrammatical.
Lots of tables for the muscles are provided

Even methods for testing are incorporated
Improved colour illustrations are added
So that right half of brain gets stimulated
Tables for muscles acting on joints are given

Tables for branches of nerves and arteries are given
Hope these volumes turn highly useful
Editors’ hardwork under Almighty’s guidance prove fruitful
Preface to the Eighth Edition
T he Seventh edition was published in 2016. The newly added fourth volume on brain–neuroanatomy
received an excellent response from the students and the teachers alike.
The Eighth edition also brings new changes, surprises, modifications and highlights. It has been designed
as per MCI BoG Syllabus 2018 featuring the text and headings following the “Competency based
Undergraduate Curriculum for the Indian Medical Graduate, 2018”, prescribed by Medical Council of
India.
Many readers and teachers gave a feedback of retaining the cranial nerves in Volume 3, therefore,
a brief description of all the cranial nerves has been given in the appropriate chapters.
Text, along with the illustrations, has been thoroughly updated. Many new diagrams have been
added and the earlier ones modified for easy comprehension. Some selected diagrams from the very
first edition have been adapted, recreated and incorporated in these volumes.
Quite a few radiographs and MRIs have been added to keep up with the new developments. Extensive
editing, especially developmental editing, has been done.
Extensive research has decoded the molecular control of development of organ tissues of the body.
An attempt has been made to introduce molecular regulation of development of some organs in the
book. Hope the teachers would explain them further for better understanding of the interesting aspect
of embryology. It is known that many of the adult diseases have a foetal origin.
The text provides essential and relevant information to all the students. For still better and detailed
learning, some selected bibliographic references have been given for inquisitive students.
The cadaveric dissection is the ‘real/actual anatomy’. Since some of these were introduced in the
seventh edition, more diagrams of dissection have been added for the undergraduate students, so
they will not miss carrying out the dissections (due to lack of cadavers).
For testing the knowledge acquired after understanding the topic, Viva Voce questions have been
added. These would prove useful in theory, practical, viva voce and grand viva voce examinations.
Since so much has been added to these holistic volumes, the size would surely increase, though making
the text as compatible with the modern literature as is possible. Most of it is visual and anatomy as a
basic component of medicine remains a subject of practical exploration.
We have satisfactorily modified text to suit requirements of horizontal and vertical integrations of
anatomy with other preclinical, paraclinical and clinical subjects as per BoG NMC (erstwhile MCI)
guidelines.
Happy Reading.
Krishna Garg
Chief Editor
email: [email protected]
Preface to the First Edition (Excerpts)
T he necessity of having a simple, systematized and complete book on anatomy has long been felt.
The urgency for such a book has become all the more acute due to the shorter time now available
for teaching anatomy, and also to the falling standards of English language in the majority of our
students in India. The national symposium on ‘Anatomy in Medical Education’ held at Delhi in 1978
was a call to change the existing system of teaching the unnecessary minute details to the
undergraduate students.
This attempt has been made with an object to meet the requirements of a common medical
student. The text has been arranged in small classified parts to make it easier for the students to
remember and recall it at will. It is adequately illustrated with simple line diagrams which can be
reproduced without any difficulty, and which also help in understanding and memorizing the
anatomical facts that appear to defy memory of a common student. The monotony of describing
the individual muscles separately, one after the other, has been minimised by writing them out in
tabular form, which makes the subject interesting for a lasting memory. The relevant radiological and
surface anatomy have been treated in separate chapters. A sincere attempt has been made to
deal, wherever required, the clinical applications of the subject. The entire approach is such as to
attract and inspire the students for a deeper dive in the subject of anatomy.
The book has been intentionally split in three parts for convenience of handling. This also makes a
provision for those who cannot afford to have the whole book at a time.
It is quite possible that there are errors of omission and commission in this mostly single-handed
attempt. I would be grateful to the readers for their suggestions to improve the book from all angles.
I am very grateful to my teachers and the authors of numerous publications, whose knowledge has
been freely utilised in the preparation of this book. I am equally grateful to my professor and colleagues
for their encouragement and valuable help. My special thanks are due to my students who made
me feel their difficulties, which was a great incentive for writing this book. I have derived maximum
inspiration from Prof. Inderbir Singh (Rohtak), and learned the decency of work from Shri SC Gupta
(Jiwaji University, Gwalior).
I am deeply indebted to Shri KM Singhal (National Book House, Gwalior) and Mr SK Jain (CBS
Publishers & Distributors, Delhi), who have taken unusual pains to get the book printed in its present
form. For giving it the desired get-up, Mr VK Jain and Raj Kamal Electric Press are gratefully
acknowledged. The cover page was designed by Mr Vasant Paranjpe, the artist and photographer
of our college; my sincere thanks are due to him. I acknowledge with affection the domestic assistance
of Munne Miyan and the untiring company of my Rani, particularly during the odd hours of this work.
BD Chaurasia
Acknowledgements
F oremost acknowledgement is the extreme gratefulness to almighty for ‘All Time Guidance’ during the
preparation of the Eighth edition. All the editors are sincerely obliged to Dr VG Sawant, Dr NA
Faruqi, Dr Gayatri Rath, Dr Ritesh Shah, Dr SN Kazi, Dr N Vasudeva, Dr Sabita Mishra, Dr Mangla Kohli,
Dr Satyam Khare, Dr Nisha Kaul, Dr Azmi Mohsin, Dr Medha Joshi and Dr Surbhi Garg for making this
edition noteworthy.
The suggestions provided by Dr DC Naik, Dr Ved Prakash, Dr Mohini Kaul, Dr Indira Bahl, Dr SH Singh,
Dr Rewa Choudhary, Dr Shipra Paul, Dr Anita Tuli, Dr Shashi Raheja, Dr Sneh Aggarwal, Dr RK Suri,
Dr Vadana Mehta, Dr Veena Bharihoke, Dr Mahindra Nagar, Dr Renu Chauhan, Dr Sunita Kalra, Dr RK
Ashoka, Dr Vivek Parashar, Mr Buddhadev Ghosh, Mr Kaushik Saha, Dr Dinesh Kumar, Dr AK Garg,
Dr Archana Sharma, Dr Shipli Jain, Dr Poonam Kharab, Dr Mahindra K Anand, Dr Daisy Sahni, Dr Kiran
Vasudeva, Dr Rashmi Bhardwaj, Dr Arqam Miraj, Dr Joseph, Dr Harsh Piumal, Dr Yogesh Sontakke, HA
Buch, Umang Sharma, Dr Nikha Bhardwaj and many friends and colleagues are gratefully
acknowledged. They have been providing help and guidance to sustain the responsibility of upkeeping
the standard of these volumes.
Videos of bones and soft parts of human body prepared at Kathmandu University School of Medical
Sciences were added in the CDs along with the Frequently Asked Questions. I am grateful to Dr R Koju,
CEO of KUSMS and Dhulikhel Hospital, for his generosity. This material is now available at our mobile
App CBSiCentral.
The moral support of the family members is appreciated. The members are Dr DP Garg, Mr Satya
Prakash Gupta, Mr Ramesh Gupta, Dr Suvira Gupta, Dr JP Gupta, Mr Manoj, Ms Rekha, Master Shikhar,
Mr Sanjay, Mrs Meenakshi, Kriti, Kanika, Dr Manish, Dr Shilpa, Meera and Raghav. Dr Shilpa Mittal and
Dr Sushant Rit, Mr Rishabh Malhotra have been encouraging and inspiring us in the preparation of the
volumes.
The magnanimity shown by Mr SK Jain (Chairman) and Mr Varun Jain (Director), CBS Publishers &
Distributors Pvt Ltd, has been ideal and always forthcoming.
The unquestionable support of Mr YN Arjuna (Senior Vice President—Publishing, Editorial and Publicity) and his entire
team comprising Ms Ritu Chawla (GM—Production), Mr Sanjay Chauhan (graphic artist) with his untiring
efforts on drawings, Ms Jyoti Kaur (DTP operator), for excellent formatting, Mr Surendra Jha (copyeditor),
Mr Neeraj Sharma (copyeditor), Ms Meena Bhaskar (typing) and Mr Neeraj Prasad (graphic artist) for layout
and cover designing have done excellent work to bring out the eighth edition. I am really obliged to
all of them.
Krishna Garg
Chief Editor
Thus spoke the cadaver
Handle me with little love and care

As I had missed it in my life affair
Was too poor for cremation or burial
That is why am lying in dissection hall
You dissect me, cut me, section me

But your learning anatomy should be precise
Worry not, you would not be taken to court
As I am happy to be with the bright lot
Couldn't dream of a fridge for cold water

Now my body parts are kept in refrigerator
Young students sit around me with friends
A few dissect, rest talk, about food, family and movies
How I enjoy the dissection periods
Don't you? Unless you are interrogated by a teacher
When my parts are buried post-dissection

Bones are taken out for the skeleton
Skeleton is the crown glory of the museum
Now I am being looked up by great enthusiasm
If not as skeletons as loose bones

I am in their bags and in their hostel rooms
At times, I am on their beds as well
Oh, what a promotion to heaven from hell
I won't leave you, even if you pass anatomy

Would follow you in forensic medicine and pathology
Would be with you even in clinical teaching
Medicine line is one where dead teach the living
One humble request I'd make

Be sympathetic to persons with disease
Don't panic, you'll have enough money
And I bet, you'd be singularly happy
Contents
Preface to the Eighth Edition vii

Preface to the First Edition (Excerpts) viii
Index of Competencies xix
1. Introduction and Osteology 3 Maxilla 36

Side Determination 36
Introduction 3 Features 36
Functions of Head and Neck 3 Articulations of Maxilla 39
Skull 4 Ossification 39
Bones of the Skull 4 Age Changes 39
Anatomical Position of Skull 5 Parietal Bone 40
Peculiarities of Skull Bones 5 Side Determination 40
Exterior of the Skull 6 Features 40
Norma Verticalis 6 Occipital Bone 40
Clinical Anatomy 6 Anatomical Position 40
Norma Occipitalis 7 Features 40
Norma Frontalis 8 Frontal Bone 41
Clinical Anatomy 10 Anatomical Position 41
Norma Lateralis 10 Temporal Bone 42
Clinical Anatomy 13 Side Determination 42
Norma Basalis 13 Features 42
Interior of the Skull 21 Sphenoid Bone 45
Internal Surface of Cranial Vault 22 Body of Sphenoid 45
Internal Surface of the Base of Skull 22 Greater Wings 45
Clinical Anatomy 23 Lesser Wings 46
Clinical Anatomy 25 Pterygoid Processes 47
Clinical Anatomy 26 Ethmoid Bone 47
Attachments and Relations: Interior of the Skull 26 Cribriform Plate 47
Principles Governing Fractures of the Skull 27 Perpendicular Plate 47
The Orbit 28 Labyrinths 47
Foetal Skull/Neonatal Skull 30 Vomer 48
Dimensions 30 Inferior Nasal Conchae 48
Structure of Bones 30 Zygomatic Bones 48
Ossification 30 Nasal Bones 49
Postnatal Growth of Skull 31 Lacrimal Bones 49
Clinical Anatomy 31 Palatine Bones 50
Sex Differences in the Skull 31 Hyoid Bone 50
Craniometry 31 Attachments on the Hyoid Bone 51
Mandible 32 Development 51
Body 33 Clinical Anatomy 51
Ramus 33 Cervical Vertebrae 51
Attachments and Relations of the Mandible 34 Identification 51
Foramina and Relations to Nerves and Vessels 34 Typical Cervical Vertebrae 51
Ossification 35 Ossification 52
Age Changes in the Mandible 35 First Cervical Vertebra 53
Structures Related to Mandible 35 Ossification 54
Clinical Anatomy 36 Second Cervical Vertebra 54
xii HUMAN ANATOMY—HEAD AND NECK
Seventh Cervical Vertebra 55 Skin 84

Ossification 55 Superficial Fascia 85
Clinical Anatomy 55 Dissection 85
Ossification of Cranial Bones 56 Clinical Anatomy 86
Development of Neurocranium 57 Deep Cervical Fascia (Fascia Colli) 86
Foramina of Skull Bones and their Contents 58 Investing Layer 86
Mnemonics 59 Clinical Anatomy 88
Facts to Remember 60 Pretracheal Fascia 89
Clinicoanatomical Problem 60 Clinical Anatomy 89
Further Reading 60 Prevertebral Fascia 89
Frequently Asked Questions 61 Clinical Anatomy 89
Multiple Choice Questions 61 Carotid Sheath 90
Viva Voce 61 Buccopharyrgeal Fascia 90
Pharyngobasilar Fascia 90
2. Scalp, Temple and Face 62 Pharyngeal Spaces 90
Introduction 62 Retropharyngeal Space 90
Surface Landmarks 62 Lateral Pharyngeal Space 90
Scalp and Superficial Temporal Region 63 Sternocleidomastoid Muscle (Sternomastoid) 91
Scalp 63 Clinical Anatomy 92
Dissection 63 Posterior Triangle 93
Superficial Temporal Region 65 Dissection 93
Clinical Anatomy 66 Clinical Anatomy 94
Face 67 Contents of the Posterior Triangle 95
Dissection 68 Clinical Anatomy 96
Skin 68 Mnemonics 97
Superficial Fascia 68 Facts to Remember 97
Facial Muscles 68 Clinicoanatomical Problem 97
Nerve Supply of Face 71 Further Reding 97
Clinical Anatomy 73 Frequently Asked Questions 98
Clinical Anatomy 74 Multiple Choice Questions 98
Arteries of the Face 75 Viva Voce 98
Dissection 75
Facial Artery 75 4. Anterior Triangle of the Neck 99
Veins of the Face 76 Introduction 99
Clinical Anatomy 76 Surface Landmarks 99
Lymphatic Drainage of the Face 77 Structures in the Anterior Median Region
Eyelids or Palpebrae 78 of the Neck 100
Dissection 78 Dissection 101
Lacrimal Apparatus 79 Anterior Triangle 103
Components 79 Boundaries 103
Dissection 79 Subdivisions 103
Clinical Anatomy 80 Submental Triangle 103
Development of Face 81 Digastric Triangle 103
Molecular Regulation 81 Dissection 104
Mnemonics 81 Carotid Triangle 105
Facts to Remember 81 Dissection 105
Clinicoanatomical Problems 81 Muscular Triangle 107
Further Reading 82 Dissection 107
Frequently Asked Questions 83 Ansa Cervicalis or Ansa Hypoglossi 107
Multiple Choice Questions 83 Common Carotiol Artery 109
Viva Voce 83 Clinical Anatomy 109
External Carotid Artery 109
3. Side of the Neck 84 Branches 110
Introduction 84 Potential Tissue Spaces in Head and Neck 112
Landmarks 84 Mnemonics 112
Boundaries 84 Facts to Remember 112
CONTENTS xiii
Clinicoanatomical Problem 112 7. Submandibular Region 142

Further Reading 113
Introduction 142
Frequently Asked Questions 113
Suprahyoid Muscles 142
Multiple Choice Questions 113
Dissection 144
Viva Voce 113 Submandibular Salivary Gland 146
Dissection 146
5. Parotid Region 114
Submandibular Duct/Wharton’s Duct 147
Introduction 114 Sublingual Salivary Gland 147
Salivary Glands 114 Submandibular Ganglion 148
Parotid Gland 114 Histology 149
Dissection 114 Comparison of the Three Salivary Glands 149
Relations 115 Facts to Remember 151
Parotid Duct/Stenson’s Duct 119 Clinicoanatomical Problem 151
Further Reading 151
Clinical Anatomy 120
Histology 120
Development 120 Viva Voce 152
Facts to Remember 120
Clinicoanatomical Problem 120 8. Structures in the Neck 153
Further Reading 121
Introduction 153
Frequently Asked Questions 122 Glands 153
Multiple Choice Questions 122 Thyroid Gland 153
Viva Voce 122 Dissection 153
6. Temporal and Infratemporal Regions 123 Histology 158
Introduction 123 Development 158
Temporal Fossa 123 Parathyroid Glands 159
Infratemporal Fossa 123 Histology 160
Landmarks on the Lateral Side of the Head 124
Thymus 160
Muscles of Mastication 124
Features 124
Histology of Thymus 161
Temporal Fascia 124
Development of Thymus and Parathyroid
Dissection 124
Glands 161
Relations of Lateral Pterygoid 126
Blood Vessels of the Neck 162
Relations of Medial Pterygoid 127
Subclavian Artery 162
Dissection 162
Maxillary Artery 127
Dissection 127 Common Carotid Artery 165
Branches of Maxillary Artery 128 Dissection 165
Pterygoid Venous Plexus 130 Internal Carotid Artery 166
Temporomandibular Joint 130 Subclavian Vein 167
Dissection 130 Internal Jugular Vein 168
Mandibular Nerve 134 Brachiocephalic Vein 169
Dissection 134 Nerves of the Neck 169
Otic Ganglion 137 Glossopharyngeal Nerve—IX Nerve 169
Clinical Anatomy 138 Vagus Nerve—X Nerve 169
Mnemonics 139 Accessory Nerve—XI Nerve 169
Facts to Remember 139 Cervical Part of Sympathetic Trunk 171
Clinicoanatomical Problem 139 Formation 171
Further Reading 140 Dissection 171
Frequently Asked Questions 141 Ganglia 172
Multiple Choice Questions 141 Clinical Anatomy 172
Viva Voce 141 Lymphatic Drainage of Head and Neck 173
xiv HUMAN ANATOMY—HEAD AND NECK
Dissection 173 Frequently Asked Questions 205

Superficial Group 173 Multiple Choice Questions 205
Deep Group 174 Viva Voce 205
Deepest Group 175
Main Lymph Trunks at the Root of the Neck 175 11. Contents of Vertebral Canal 206
Clinical Anatomy 176 Introduction 206
Styloid Apparatus 176 Contents 206
Development of the Arteries 177 Dissection 206
Mnemonics 177 Clinical Anatomy 208
Facts to Remember 178 Spinal Nerves 209
Further Reading 178 Vertebral System of Veins 209
Frequently Asked Questions 178 Facts to Remember 210
Multiple Choice Questions 179 Clinicoanatomical Problem 210
Viva Voce 179 Further Reading 210
Frequently Asked Question 211
9. Prevertebral and Paravertebral Regions 180 Multiple Choice Questions 211
Introduction 180 Viva Voce 211
Prevertebral Muscles 180
Vertebral Artery 180 12. Cranial Cavity 212
Dissection 180 Introduction 212
Scalenovertebral Triangle 181 Conterts of Cranial Cavity 212
Development of Vertebral Artery 183 Dissection 212
Trachea 183 Cerebral Dura Mater 213
Oesophagus 184 Venous Sinuses of Dura Mater 216
Clinical Anatomy 184 Cavernous Sinus 216
Joints of the Neck 184 Dissection 216
Paravertebral Region 188 Superior Sagittal Sinus 219
Scalene Muscles 188 Clinical Anatomy 220
Dissection 188 Straight Sinus 220
Cervical Pleura 190 Transverse Sinuses 220
Cervical Plexus 190 Sigmoid Sinuses 220
Phrenic Nerve 192 Clinical Anatomy 220
Clinical Anatomy 193 Hypophysis Cerebri (Pituitary Gland) 221
Facts to Remember 193 Dissection 221
Clinicoanatomical Problems 193 Subdivisions/Parts and Development 222
Further Reading 194 Molecular Regulation 222
Frequently Asked Questions 194 Histology 222
Multiple Choice Questions 194 Clinical Anatomy 223
Viva Voce 195 Trigeminal Ganglion 224
Dissection 224
10. Back of the Neck 196
Introduction 196 Middle Meningeal Artery 225
Nerve Supply of Skin 197 Clinical Anatomy 226
Muscles of the Back 197 Other Structures Seen in Cranial Fossae after
Suboccipital Region 201 Removal of Brain 226
Suboccipital Muscles 201 Internal Carotid Artery 226
Eeposure of Suboccipital Triangle 202 Cranial Nerves 226
Clinical Anatomy 203 Petrosal Nerves 227
Mnemonics 203 Mnemonics 228
Facts to Remember 204 Facts to Remember 228
Clinicoanatomical Problem 204 Clinicoanatomical Problem 229
Further Reading 204 Further Reading 229
CONTENTS xv
Frequently Asked Questions 229 Pharynx 257

Multiple Choice Questions 230 Dissection 258
Viva Voce 230 Parts of the Pharynx 258
Waldeyer’s Lymphatic Ring 258
13. Contents of the Orbit 231 Clinical Anatomy 258
Introduction 231 Palatine Tonsil (The Tonsil) 259
Orbits 231 Clinical Anatomy 261
Dissection 231 Histology 261
Orbital fascia or Periorbita 231 Development 261
Facial Sheath of Eyeball or Bulpar Fascia 232 Laryngeal Part of Pharynx (Laryngopharynx) 261
Extraocular Muscles 232 Structure of Pharynx 262
Dissection 232 Muscles of the Pharynx 263
Involuntary Muscles 233 Structures in between Pharyngeal Muscles 264
Vessels of the Orbit 237 Killians’ Dehiscence 265
Ophthalmic Artery 237 Clinical Anatomy 265
Dissection 237 Nerve Supply of Pharynx 265
Clinical Anatomy 239 Blood Supply of Pharynx 266
Ophthalmic Veins 239 Lymphatic Drainage of Pharynx 266
Nerves of the Orbit 239 Deglutition (Swallowing) 266
Optic Nerve 239 Development 266
Clinical Anatomy 240 Pharyngo Tympanic Tube 267
Ciliary Ganglion 240 Clinical Anatomy 268
Oculomotor Nerve 240 Mnemonics 268
Trochlear Nerve 241 Facts to Remember 268
Abducent Nerve 241 Clinicoanatomical Problem 268
Branches of Ophthalmic Division of Trigeminal Further Reading 268
Nerve 241 Frequently Asked Questions 269
Some Branches of Maxillary Division of Trigeminal Multiple Choice Questions 269
Nerve 243 Viva Voce 270
Sympathetic Nerves of the Orbit 244
Mnemonics 244 15. Nose, Paranasal Sinuses and Pterygopalatine
Facts to Remember 244 Fossa 271
Clinicoanatomical Problem 244 Introduction 271
Further Reading 244 Nose 271
Frequently Asked Questions 245 External Nose 271
Multiple Choice Questions 245 Nasal Cavity 271
Viva Voce 245 Clinical Anatomy 272
Nasal Septum 273
14. Mouth and Pharynx 246 Dissection 273
Oral Cavity 246 Clinical Anatomy 274
Vestibule 246 Lateral Wall of Nose 274
Oral Cavity Proper 247 Conchae and Meatuses 275
Nerve Supply of Gums 248 Dissection 276
Teeth 248 Olfactory Nerve—1st Nerve 277
Stages of Development of Deciduous Teeth 250 Paranasal Sinuses 277
Molecular Regulation of Teeth Develop- Dissection 277
ment 251 Clinical Anatomy 279
Hard Palate 252 Pterygopalatine Fossa 280
Dissection 252 Maxillary Nerve 280
Soft Palate 252 Pterygopalatine Ganglion/Spheno-palatine
Muscles of the Soft Palate 254 Ganglion/Ganglion of Hay Fever/Meckel’s
Clinical Anatomy 257 Ganglion 281
Development of Palate 257 Dissection 282
xvi HUMAN ANATOMY—HEAD AND NECK
Clinical Anatomy 283 External Acoustic Meatus 310

Summary of Pterygopalatine Fossa 283 Dissection 311
Facts to Remember 283 Tympanic Membrane 311
Further Reading 284 Middle Ear 314
Frequently Asked Questions 285 Dissection 314
Multiple Choice Questions 285 Functions of Middle Ear 318
Viva Voce 285 Tympanic or Mastoid Antrum 318
Dissection 318
16. Larynx 286 Clinical Anatomy 319
Introduction 286 Internal Ear 320
Constitution of Larynx 286 Bony Labyrinth 320
Dissection 286 Membranous Labyrinth 321
Cartilages of Larynx 287 Vestibulocochlear Nerve 323
Laryngeal Joints 289 Clinical Anatomy 324
Laryngeal Ligaments and Membranes 289 Development 324
Cavity of Larynx 290 Molecular Regulation 324
Mucous Membrane of Larynx 290 Reasons of Earache 324
Clinical Anatomy 291 Mnemonics 324
Intrinsic Muscles of Larynx 291 Facts to Remember 324
Clinical Anatomy 294 Clinicoanatomical Problem 325
Movements of Vocal Folds 295 Noise Pollution 325
Infant’s Larynx 295 Further Reading 325
Mechanism of Speech 296 Frequently Asked Questions 326
Facts to Remember 296 Multiple Choice Questions 326
Clinicoanatomical Problem 296
Viva Voce 326
Further Reading 297
Frequently Asked Questions 298 19. Eyeball 327
Viva Voce 298 Introduction 327
Outer Coat 327
17. Tongue 299 Sclera 327
Dissection 328
Introduction 299
Cornea 329
Dissection 299
Dissection 329
Parts of Tongue 299 Clinical Anatomy 329
Clinical Anatomy 300 Middle Coat 330
Papillae of the Tongue 300 Choroid 330
Muscles of the Tongue 301 Ciliary Body 330
Hypoglossal Nerve—XII Nerve 303 Iris 330
Histology 304 Inner Coat/Retina 331
Development of Tongue 305 Clinical Anatomy 332
Taste Pathway 306 Aqueous Humour 333
Facts to Remember 306 Lens 333
Clinicoanatomical Problem 307 Dissection 334
Further Reading 307
Vitreous Body 334
Development 335
Molecular Regulation 335
Viva Voce 308 Facts to Remember 335
Clinicoanatomical Problem 335
18. Ear 309
Further Reading 335
Introduction 309 Frequently Asked Questions 336
External Ear 309 Multiple Choice Questions 336
Auricle/Pinna 309 Viva Voce 336
CONTENTS xvii
20. Surface Marking and Radiological Anatomy 337 Appendix: Parasympathetic Ganglia, Arteries,
Introduction 337 Pharyngeal Arches and Clinical Terms 350
Surface Landmarks 337 Introduction 350
Landmarks on the Face 337 Cervical Plexus 350
Phrenic Nerve 350
Landmarks of the Lateral Side of the Head 338
Sympathetic Trunk 350
Landmarks on the Side of the Neck 339 Parasympathetic Ganglia 350
Landmarks on the Anterior Aspect of the Submandibular Ganglion 350
Neck 340 Pterygopalatine Ganglion 351
Other Important Landmarks 341 Otic Ganglion 352
Surface Marking of Various Structures 342 Ciliary Ganglion 353
Arteries 342 Arteries of Head and Neck 354
Pharyngeal Apparatus 356
Veins/Sinuses 343
Structures Derived from Components of
Nerves 344 Pharyngeal Arches 356
Glands 345 Derivatives of Endodermal Pouches 356
Paranasal Sinuses 346 Derivatives of Ectodermal Clefts 356
Radiological Anatomy 347 Clinical Terms 357
Lateral View of Skull (Plain Skiagram) 347 Molecular Regulation of Pharyngeal Arches 357
Spots 359
Special PA View of Skull for Paranasal Sinuses 348
Answers of Spots 360
Carotid Angiogram 349
Further Reading 349 Index 361
Ethical Aspects of Cadaveric Dissection
T he cadaver, the dead body, that we dissect, plays an important role in the teaching of anatomy to medical
students. The cadaver and the bones become an important part of our life as medical students as some
academics have even referred to the cadaver as the ‘first teacher’ in the medical school.
We must pay due respect to the cadavers and bones kept in the dissection hall or museum. In some
medical schools it is mandatory to take an ‘oath’ before beginning the cadaveric dissection which aims to
uphold the dignity of the mortal remains of the departed soul while other medical schools help the student to
undertake dissection in a proper manner and empathise with the families of the donor. During the course of
dissection the student is constantly reminded of the sanctity of the body he/she is studying so that the noble
donation of someone's body is used only as a means of gaining scientific knowledge/progress. Each and every
dissected part afterwards is disposed or cremated with full dignity.
Honour of the donor and his/her family is the prime responsibility of the health professional. ‘The dead teach
the living’, and the living pledge to use this knowledge for the upliftment of humankind.
Three-dimensional models and computer simulations cannot replace the tactile appreciation achieved
by cadaveric dissection and we should always be grateful to those who have donated their bodies and strive
to respect them. We have the privilege to study the human being through a body of a fellow human and have
to be humble and carry forward the legacy of nobility and selflessness in our careers.
(Contributed by Dr Puneet Kaur)
Head and Neck
1. Introduction and Osteology 3

2. Scalp, Temple and Face 62
3. Side of the Neck 84
4. Anterior Triangle of the Neck 99
5. Parotid Region 114
6. Temporal and Infratemporal Regions 123
7. Submandibular Region 142
8. Structures in the Neck 153
9. Prevertebral and Paravertebral Regions 180
10. Back of the Neck 196
11. Contents of Vertebral Canal 206
12. Cranial Cavity 212
13. Contents of the Orbit 231
14. Mouth and Pharynx 246
15. Nose, Paranasal Sinuses and Pterygopalatine Fossa 271
16. Larynx 286
17. Tongue 299
18. Ear 309
19. Eyeball 327
20. Surface Marking and Radiological 337
Anatomy
Appendix: Parasympathetic Ganglia, Arteries, 350
Pharyngeal Arches and Clinical Terms
Ichchak dana, bichchak dana, dane upar dana
Hands naache, feet naache, brain hai khushnama Ichhak dana
Teen inch lambi hai, pink aur khurdari hai,
chat pakori, pizza hut chalte iske bal se
Soch vichar express hote hai iske dum se,
achha bolna, thoda bolna, sukh se reh jana
Kehna hai aasan, magar mushkil hai nibhana
Ichhak dana
Bolo kya—tongue, bolo kya—tongue
1
Introduction and Osteology
Uneasy lies the head that wears the crown .
—Shakespeare
INTRODUCTION blood vessels. Brain is the highest seat of intelligence.

Face is the anterior aspect of head and the muscles Human is the most evolved animal so far, as there is
present here express facial movements. Scalp overlies maximum nervous tissue. To accommodate the
the lateral, posterior and superior aspects of skull. increased volume of nervous tissue, the cranial cavity
had to enlarge. Correspondingly, the lower jaw or
Compartments of Neck mandible had to retract. The eyes also had come more
1 Posterior or vertebral compartment contains 7 anteriorly, on each side of the nose. The external nose
cervical vertebrae with their muscles. also got prominent. During the course of evolution,
2 Anterior/visceral compartment contains glands like external ear becomes vestigeal and chin is pushed
thyroid, parathyroid, thymus and parts of digestive forwards to accommodate the broad tongue. Tongue,
and respiratory tracts. the organ for speech, is securely placed in the oral cavity
3 Two lateral vascular compartments, one on each side, for articulation of words, i.e. speech. In human, the
containing major arteries, veins, lymph vessels and vocalisation centre is quite big to articulate various
lymph nodes. words and speak distinctly. Speech is a special and chief
Neck also contains pharynx and larynx. Pharynx is characteristic of the human.
a musculofascial tube with openings in anterior wall, Skull comprises a number of bones, and their
two posterior nasal openings, one opening of mouth respective regions are:
and lowest is opening of inlet of larynx. These parts Frontal region: Lies in front of skull.
are called nasopharynx, oropharynx and laryngo-
pharynx, respectively. Parietal region: Lies on top of skull, formed chiefly by
Larynx or voice box is a part of respiratory system. the parietal bones. It is seen from the top.
It lies between hyoid bone and trachea. A number of Occipital region: Forms back of skull.
cartilages and membranes form the skeleton of larynx.
Temporal region: It is the area above the ears. The sense
There are two lateral vocal folds projecting towards
of hearing and balance is appreciated and understood
each other from sides of laryngeal cavity. Muscles of
in the temporal lobe of brain situated on its inner aspect.
larynx move the vocal folds. Function of larynx is to
give passage to food and produce speech. Ocular region: It is the region around the large orbital
openings, containing the precious eyeball, muscles to
FUNCTIONS OF HEAD AND NECK move the eyeball, nerves and blood vessels to supply
those muscles. There are accessory structures like the
1 Protection to brain, endocrine glands and special
lacrimal apparatus and protective eyelids.
senses.
2 Gives passage to food and air and connects their Auricular region: The region of the external ear with
upper parts to respective lower parts. external auditory meatus comprises the auricular
3 Produces voice for communication. region. Air waves enter the ear through the meatus
Head and neck is the uppermost part of the body. which change into fluid waves and finally into nerve
Head comprises skull and lodges the brain covered by impulses to be received in the temporal lobe of the
meninges, hypophysis cerebri, special senses, teeth and cerebrum.
3
HEAD AND NECK
4
Nasal region: The region of the external nose, its muscles attention, concentration, judgement, and intellect are
and the associated cavity comprise the nasal region. because of the brain that we possess and its proper use.
Sense of smell is perceived from this region.
Oral region: Comprises upper and lower lips and the SKULL
angle of the mouth, where the lips join on each side.
Numerous muscles are present here, to express the Terms
feelings and emotions. These are parts of the muscles The skeleton of the head is called the skull. It consists
of facial expression. They show the feelings, without of several bones that are joined together to form the
words. cranium. The term skull also includes the mandible or
Oral cavity: It houses the organ of speech and taste. lower jaw which is a separate bone. However, the two
Tongue is not swallowed, though everything put on terms, skull and cranium, are often used synonymously.
the tongue passes downwards. It is held in position by The skull can be divided into two main parts:
extrinsic muscles arising from surrounding bones. It a. The calvaria or brain box/neurocranium is the upper
says so much and manages to hide inside the oral cavity part of the cranium which encloses the brain. It
to be protected by 32 teeth in adult. consists of a skull cap/vault (upper part) and a
base (lower part).
Parotid region: Lies on the side of the face. It contains
b. The facial skeleton/viscerocranium constitutes the
the biggest serous parotid salivary gland, which lies
rest of the skull and includes the mandible.
around the external auditory meatus.
Head is followed by the tubular neck which Bones of the Skull
continues downwards with chest or thorax. The skull consists of the 28 bones which are named as
Each half of the neck comprises two triangles between follows.
anterior median line and posterior median line. a. The calvaria or brain case is composed of 14 bones
Posterior triangle: Lies between sternocleidomastoid, the including three paired ear ossicles.
neck and chin turning muscle; trapezius, the shrugging
muscle and middle one-third of the clavicle. It contains Paired Unpaired
proximal parts of the important brachial plexus, 1. Parietal (2) 1. Frontal (1)
subclavian vessels with its branches and tributaries. Its 2. Temporal (2) 2. Occipital (1)
apex is above and base is below. 3. Malleus (2) 3. Sphenoid (1)
4. Incus (2) 4. Ethmoid (1)
Anterior triangle: Lies between the anterior median line
5. Stapes (2)
and the anterior border of sternocleidomastoid muscle.
3, 4, 5 are described in Chapter 18.
Its apex is in lower part of neck, close to sternum and
base above. It contains the common carotid artery and b. The facial skeleton is composed of 14 bones.
its numerous branches. Isthmus of thyroid gland lies
in the lower part of the triangle. Paired Unpaired
1. Maxilla (2) 1. Mandible (1)
Competency achievement: The student should be able to: 2. Zygomatic (2) 2. Vomer (1)
Head and Neck
AN 26.1 Demonstrate anatomical position of skull, identify and 3. Nasal (2)

locate individual skull bones in skull.1 4. Lacrimal (2)
5. Palatine (2)
Bones of head and neck include the skull, i.e. cranium 6. Inferior nasal concha (2)
with mandible, seven cervical vertebrae, the hyoid, and
six ossicles of the ear. Skull Joints
The skull cap is formed by frontal, parietal, The joints in the skull are mostly sutures, a few primary
squamous, temporal and a part of occipital bones. These cartilaginous joints and three pairs of synovial joints.
develop by intramembranous ossification, being a Two pairs of synovial joints are present between the
quicker one stage process. ossicles of middle ear. One pair is the largest temporo-
The base of the skull in contrast ossifies by intra- mandibular joint. This mobile joint permits us to speak,
cartilaginous ossification which is a two-stage process eat, drink and laugh.
(membrane–cartilage–bone).
Skull lodges the brain, teeth and also special senses Sutures are:
like cochlear and vestibular apparatus, retina, olfactory Plane – internasal suture
mucous membrane, and taste buds. Serrate – coronal suture
The weight of the brain is not felt as it is floating in the Denticulate – lambdoid suture
cerebrospinal fluid. Our personality, power of speech, Squamous – parietotemporal suture
INTRODUCTION AND OSTEOLOGY
5
Anatomical Position of Skull b. Internal surface of the cranial base which shows
The skull can be placed in proper orientation by a natural subdivision into anterior, middle and
considering any one of the two planes. posterior cranial fossae.
1 Reid’s base line is a horizontal line obtained by The skull can also be studied as individual bones.
joining the infraorbital margin to the centre of Mandible, maxilla, ethmoid and zygomatic, etc. have
external acoustic meatus, i.e. auricular point. been described.
2 The Frankfurt’s horizontal plane of orientation is Peculiarities of Skull Bones
obtained by joining the infraorbital margin to
the upper margin of the external acoustic meatus 1 Base of skull ossifies in cartilage, while the skull cap
(Fig. 1.1). ossifies in membrane.
2 At birth, skull comprises one table only. By 4 years
Methods of Study of the Skull or so, two tables are formed. Between the two tables,
The skull can be studied as a whole. there are diploes (Greek double), i.e. spaces containing
The whole skull can be studied from the outside or red bone marrow forming RBCs, granular series of
externally in different views: WBCs and platelets. Four diploic veins drain the
a. Superior view or norma verticalis formed blood cells into neighbouring veins.
b. Posterior view or norma occipitalis 3 At birth, the 4 angles of parietal bone have
c. Anterior view or norma frontalis membranous gaps or fontanelles. These allow
d. Lateral view or norma lateralis overlapping of bones during vaginal delivery, if
e. Inferior view or norma basalis required. These also allow skull bones to increase in
The whole skull can be studied from the inside or size after birth, for housing the delicate brain.
internally after removing the roof of the calvaria or skull 4 Some skull bones have air cells in them and are called
cap: pneumatic bones, e.g. frontal, maxilla.
a. Internal surface of the cranial vault. a. They reduce the weight of skull.
b. They maintain humidity of inspired air.
c. They give resonance to voice.
d. These may get infected resulting in sinusitis.
5 Skull bones are united mostly by sutures.
6 Skull has foramina for ‘emissary veins’ which
connect intracranial venous sinuses with extracranial
veins. These try to relieve raised intracranial
pressure. Infection may reach through the emissary
veins into cranial venous sinuses as these veins are
valveless (Table 1.1).
7 Petrous temporal is the densest bone of the body. It
lodges internal ear, middle ear including three
ossicles, i.e. malleus, incus and stapes. Ossicles are
‘bones within the bone’ and are fully formed at birth.
Head and Neck

Fig. 1.1: Anatomical position of skull 8 Skull lodges brain, meninges, CSF, glands like
hypophysis cerebri and pineal, venous sinuses, teeth,
Competency achievement: The student should be able to: special senses like retina of eyeball, taste buds of
AN 27.2 Describe emissary veins with its role in spread of infection tongue, olfactory epithelium, cochlear and vestibular
from extracranial route to intracranial venous sinuses.2
nerve endings.
Table 1.1: The emissary veins of the skull

Name Foramen of skull Veins outside skull Venous sinus
1. Parietal emissary vein Parietal foramen Veins of scalp Superior sagittal sinus
2. Mastoid emissary vein Mastoid foramen Veins of scalp Sigmoid sinus
3. Emissary vein Hypoglossal canal Internal jugular vein Sigmoid sinus
4. Condylar emissary vein Posterior condylar foramen Suboccipital venous plexus Sigmoid sinus
5. 2–3 emissary veins Foramen lacerum Pharyngeal venous plexus Cavernous sinus
6. Emissary vein Foramen ovale Pterygoid venous plexus Cavernous sinus
7. Emissary vein Foramen caecum Veins from upper part of nose Superior sagittal sinus
HEAD AND NECK
6
Competency achievement: The student should be able to: Some other Named Features
AN 26.2 Describe the features of norma frontalis, verticalis, 1 Vertex is the highest point on sagittal suture.
occipitalis, lateralis and basalis.3 2 Vault of skull is the arched roof for the dome of skull.
3 Bregma is the meeting point between the coronal and
EXTERIOR OF THE SKULL sagittal sutures. In the foetal skull, this is the site of
a membranous gap, called the anterior fontanelle,
which closes at 18 to 24 months of age. It allows
NORMA VERTICALIS
growth of brain (Fig. 1.3).
Shape 4 The lambda is the meeting point between the sagittal
When viewed from above, the skull is usually oval in and lambdoid sutures. In the foetal skull, this is the
shape. It is wider posteriorly than anteriorly. The shape site of the posterior fontanelle which closes at birth—
may be more nearly circular. 2 to 3 months of age.
5 The parietal tuber (eminence) is the area of maximum
Bones convexity of the parietal bone. This is a common site
1 Upper part of frontal bone—anteriorly. of fracture of the skull.
2 Uppermost part of occipital bone—posteriorly. 6 The parietal foramen, one on each side, pierces the
3 A parietal bone—on each side. parietal bone near its upper border, 2.5 to 4 cm in
front of the lambda. The parietal foramen transmits
Sutures an emissary vein from the veins of scalp to superior
1 Coronal suture: This is placed between the frontal and sagittal sinus (Fig. 1.2).
the two parietal bones. The suture crosses the cranial 7 The obelion is the point on the sagittal suture between
vault from side-to-side and runs downwards and the two parietal foramina.
forwards (Fig. 1.2). 8 The temporal lines begin at the zygomatic process of
2 Sagittal suture: It is placed in the median plane the frontal bone, arch backwards and upwards, and
between the two parietal bones. cross the frontal bone, the coronal suture and the
3 Lambdoid suture: It lies posteriorly between the parietal bone. Over the parietal bone, there are two
occipital and the two parietal bones, and it runs lines—superior and inferior. Traced anteriorly, they
downwards and forwards across the cranial vault. fuse to form a single line. Traced posteriorly, the
4 Metopic (Latin forehead) suture: This is occasionally superior line fades out over the posterior part of the
present in about 3 to 8% individuals. It lies in the parietal bone, but the inferior temporal line continues
median plane and separates the two halves of the downwards and forwards with zygomatic arch.
frontal bone. Normally, it fuses at 6 years of age.
Head and Neck
Fig. 1.3: Fontanelles of skull
CLINICAL ANATOMY
• Fontanelles are sites of growth of skull, permitting

growth of brain and help to determine age.
Fig. 1.2: Norma verticalis
7
• If fontanelles fuse early, brain growth is stunted; NORMA OCCIPITALIS

such children are less intelligent. Norma occipitalis is convex upwards and on each side,
• If anterior fontanelle is bulging, there is raised and is flattened below.
intracranial pressure. If anterior fontanelle is
depressed, it shows decreased intracranial Bones
pressure, mostly due to dehydration. 1 Posterior parts of the parietal bones—above.
• Bones override at the fontanelle helping to 2 Upper part of the squamous part of the occipital
decrease size of head during vaginal delivery. bone—below (Fig. 1.5).
• Caput succedaneum is soft tissue swelling on any 3 Mastoid part of the temporal bone—on each side.
part of skull due to rupture of capillaries during
delivery. Skull becomes normal within a few days Sutures
in postnatal life (Fig. 1.4). 1 The lambdoid suture lies between the occipital bone
and the two parietal bones. Sutural or wormian bones
are common along this suture.
2 The occipitomastoid suture lies between the occipital
bone and mastoid part of the temporal bone.
3 The parietomastoid suture lies between the parietal
bone and mastoid part of the temporal bone.
4 The posterior part of the sagittal suture is also seen.
Other Features
1 Lambda, parietal foramina and obelion have been
examined in the norma verticalis.
2 The external occipital protuberance is a median
prominence in the lower part of this norma. It marks
the junction of the head and the neck. The most
Fig. 1.4: Caput succedaneum prominent point on this protuberance is called the
inion.
Head and Neck
Fig. 1.5: Norma occipitalis

HEAD AND NECK
8
3 The superior nuchal lines are curved bony ridges of absence of highest nuchal lines, these structures
passing laterally from the protuberance. These also are attached to superior nuchal lines.
mark the junction of the head and the neck. The area
below the superior nuchal lines will be studied with NORMA FRONTALIS
the norma basalis. The norma frontalis is roughly oval in outline, being
4 The highest nuchal lines are not always present. They wider above than below.
are curved bony ridges situated about 1 cm above
the superior nuchal lines. They begin from the upper Bones
part of the external occipital protuberance and are 1 Frontal bone forms the forehead. Its upper part is
more arched than the superior nuchal lines. smooth and convex, but the lower part is irregular
5 The occipital point is a median point, a little above and is interrupted by the orbits and by the anterior
the inion. It is the point farthest from the glabella. bony aperture of nose (Fig. 1.7).
6 The mastoid (Greek breast) foramen is located on the 2 The right and left maxillae form the upper jaw.
mastoid part of the temporal bone at or near the occi- 3 The right and left nasal bones form the bridge of the
pitomastoid suture. Internally, it opens at the nose.
sigmoid sulcus. The mastoid foramen transmits an 4 The zygomatic (Greek yoke) bones form the bony
emissary vein (Table 1.1) and the meningeal branch prominence of the superolateral part of the cheeks.
of the occipital artery. 5 The mandible forms the lower jaw.
7 The interparietal bone (inca bone) is occasionally The norma frontalis can be studied under the
present. It is a large triangular bone located at the following heads.
apex of the squamous occipital. This is not a sutural a. Frontal region
or accessory bone, but represents the membranous b. Orbital openings
part of the occipital bone which has failed to fuse c. Anterior piriform-shaped bony aperture of the
with the rest of the bone. nose
d. Lower part of the face.
Attachments
1 The upper part of the external occipital protuberance Frontal Region
gives origin to the trapezius, and the lower part gives The frontal region presents the following features:
attachment to the upper end of the ligamentum 1 The superciliary arch is a rounded, curved elevation
nuchae (Fig. 1.14). situated just above the medial part of each orbit. It
2 The medial one-third of the superior nuchal line gives overlies the frontal sinus and is better marked in
origin to the trapezius, and the lateral part provides males than in females.
insertion to the sternocleidomastoid above and to the 2 The glabella is a median elevation connecting the two
splenius capitis below. superciliary arches. Below the glabella, the skull
3 The highest nuchal lines, if present, provide recedes to frontonasal suture at root of the nose.
attachment to the epicranial aponeurosis medially, 3 The nasion is a median point at the root of the nose
and give origin to the occipitalis or occipital belly of where the internasal suture meets with the
Head and Neck
occipitofrontalis muscle laterally (Fig. 1.6). In case frontonasal suture.

4 The frontal tuber or eminence is a low rounded
elevation above the superciliary arch—one on each
side. It is more prominent in females and in children.
Orbital Openings
Each orbital (Latin circle) opening is quadrangular in
shape and is bounded by the following four margins.
1 The supraorbital margin is formed by the frontal bone.
At the junction of its lateral two-thirds and its medial
one-third, it presents the supraorbital notch or
foramen (Fig. 1.7).
2 The infraorbital margin is formed by the zygomatic
bone laterally, and maxilla medially.
3 The medial orbital margin is ill-defined. It is formed
by the frontal bone above, and by the lacrimal crest
Fig. 1.6: Attachments of the occipitofrontalis muscle of the frontal process of the maxilla below.
9
Fig. 1.7: Norma frontalis: Walls of orbit and nasal aperture. Inset showing apertures
4 The lateral orbital margin is formed mostly by the 3 Rhinion is the lowermost point of the internasal
frontal process of zygomatic bone, but is completed suture.
above by the zygomatic process of frontal bone.
Frontozygomatic suture lies at their union. Lower Part of the Face
Maxilla
Anterior Bony Aperture of the Nose
Maxilla contributes a large share in the formation of
The anterior bony aperture is pear-shaped, being wide the facial skeleton. The anterior surface of the body of
below and narrow above. the maxilla presents:
Head and Neck

a. The nasal notch medially;
Boundaries
b. The anterior nasal spine;
Above: By the lower border of the nasal bones. c. The infraorbital foramen, 1 cm below the infraorbital
Below: By the nasal notch of the body of maxilla on each margin;
side. d. The incisive fossa above the incisor teeth, and
e. The canine fossa lateral to the canine eminence.
Features: Note the following:
1 Articulations of the nasal bone: In addition, three out of four processes of the maxilla
a. Anteriorly, with the opposite bone at the internasal are also seen in this norma.
suture. a. The frontal process of the maxilla is directed
b. Posteriorly, with the frontal process of the maxilla. upwards. It articulates anteriorly with the nasal
c. Superiorly, with the frontal bone at the frontonasal bone, posteriorly with the lacrimal bone, and
suture. superiorly with the frontal bone (Fig. 1.7).
d. Inferiorly, the upper nasal cartilage is attached to it. b. The zygomatic process of the maxilla is short but stout
2 The anterior nasal spine is a sharp projection in the and articulates with the zygomatic bone.
median plane in the lower boundary of the piriform c. The alveolar process of the maxilla bears sockets for
aperture (Fig. 1.7). the upper teeth.
HEAD AND NECK
10
Zygomatic Bone (Malar Bone) 9 The incisivus muscle arises from an area just below
Zygomatic bone forms the prominence of the cheek. the depressor septi. It forms part of orbicularis oris.
The zygomaticofacial foramen is seen on its surface. 10 The zygomaticus major and minor arise from the
surface of the zygomatic bone (see Fig. 2.9).
Mandible (Lower Jaw Bone) The zygomaticus minor muscle arises below the
Mandible (Latin to chew) forms the lower jaw. zygomaticofacial foramen. The zygomaticus major
The upper border or alveolar arch lodges the lower arises lateral to the minor muscle (see Fig. 2.9).
teeth. 11 Buccinator arises from maxilla and mandible
The lower border or base is rounded. opposite molar teeth (see Fig. 2.10) and from
The middle point of the base is called the mental point pterygomandibular raphe. It also forms part of
or gnathion. orbicularis oris.
The point on the angle of mandible is called gonion.
Structures Passing through Foramina
The anterior surface of the body of the mandible
presents: 1 The supraorbital notch or foramen transmits the
a. The symphysis menti, the mental protuberance and supraorbital nerves and vessels (see Fig. 2.5).
the mental tubercles, anteriorly (Fig. 1.7). 2 The external nasal nerve emerges between the nasal
b. The mental foramen below the interval between the bone and upper nasal cartilage (see Fig. 2.16).
two premolar teeth, transmitting the mental nerve 3 The infraorbital foramen transmits the infraorbital nerve
and vessels. and vessels (see Fig. 2.16).
c. The oblique line runs upwards and backwards from 4 The zygomaticofacial foramen transmits the nerve of
the mental tubercle to the anterior border of the the same name, a branch of maxillary nerve.
ramus (Latin branch) of the mandible. 5 The mental foramen on the mandible transmits the
mental nerve and vessels (see Fig. 2.16).
Sutures of the Norma Frontalis
• Internasal (Fig. 1.7) CLINICAL ANATOMY
• Frontonasal
• Nasomaxillary The nasal bone is one of the most commonly fractured
• Lacrimomaxillary bones of the face. Mandible and parietal eminence are
• Frontomaxillary the next bones to be fractured (Fig. 1.8).
• Intermaxillary
• Zygomaticomaxillary
• Zygomaticofrontal
Attachments
1 The medial part of the superciliary arch gives origin
to the corrugator supercilii muscle.
Head and Neck
2 The procerus muscle arises from the nasal bone near

the median plane (see Fig. 2.9).
3 The orbital part of the orbicularis oculi arises from
the frontal process of the maxilla and from the nasal
part of the frontal bone (see Fig. 2.9).
4 The medial palpebral ligament is attached to the
frontal process of the maxilla between the frontal
and maxillary origins of the orbicularis oculi. Fig. 1.8: Fractured nasal bone and position of anterior division
5 The levator labii superioris alaeque nasi arises from of middle meningeal artery against the pterion
the frontal process of the maxilla in front of the
orbicularis oculi (see Fig. 2.9).
NORMA LATERALIS
6 The levator labii superioris arises from the maxilla
between the infraorbital margin and the infraorbital Bones
foramen (see Fig. 2.9). 1 Frontal
7 The levator anguli oris arises from the canine fossa. 2 Parietal (Fig. 1.9a)
8 The nasalis and the depressor septi arise from the 3 Occipital
surface of the maxilla bordering the nasal notch. 4 Temporal (Figs 1.9b and c)
11
Figs 1.9a to c: (a) Norma lateralis with facial angle; (b) Bones forming norma lateralis; (c) Tympanic plate forming margins of
Head and Neck

external acoustic meatus
5 Sphenoid Zygomatic Arch or Zygoma

6 Zygomatic The zygomatic arch is a horizontal bar on the side of the
7 Mandible head, in front of the ear, a little above the tragus. It is
8 Maxilla formed by the temporal process of the zygomatic bone
9 Nasal in anterior one-third and the zygomatic process of the
temporal bone in posterior two-thirds. The zygomatico-
Features temporal suture crosses the arch obliquely downwards
Temporal Lines and backwards.
The temporal lines have been studied in the norma Above the zygomatic arch is temporal fossa, which
verticalis. The inferior temporal line, in its posterior is filled by temporalis muscle. Attached to lower margin
part, turns downwards and forwards and becomes of zygomatic arch is masseter muscle; contraction of
continuous with the supramastoid crest on the squamous both temporalis and masseter may be felt by clenching
temporal bone near its junction with the mastoid the teeth.
temporal. This crest is continuous anteriorly with the The arch is separated from the side of the skull by a
posterior root of the zygomatic arch (Fig. 1.9b). gap which is deeper in front than behind. Its lateral
HEAD AND NECK
12
surface is subcutaneous. The anterior end of the upper during the second year of life. The tympanomastoid
border is called the jugal point. The posterior end of the fissure is placed on the anterior aspect of the base of
zygomatic arch is attached to the squamous temporal the mastoid process. The mastoid foramen lies at or near
bone by anterior and posterior roots. The articular tubercle the occipitomastoid suture (Fig. 1.5).
of the root of the zygoma lies on its lower border, at the
junction of the anterior and posterior roots. The anterior Styloid Process
root passes medially in front of the articular fossa. The The styloid (Latin pen) process is a needle-like thin, long
posterior root passes backwards along the lateral projection from the temporal bone seen in norma basalis
margin of the mandibular or articular fossa, then above situated anteromedial to the mastoid process. It is
the external acoustic meatus to become continuous with directed downwards, forwards and slightly medially.
the supramastoid crest. Two projections are visible in Its base is partly ensheathed by the tympanic plate. The
relation to these roots. One is articular tubercle at its apex or tip is usually hidden from view by the posterior
lower border. Another tubercle is visible just behind border of the ramus of the mandible.
the mandibular or articular fossa and is known as
postglenoid tubercle. Temporal Fossa
Boundaries
External Acoustic Meatus
1 Above, by the superior temporal line.
The external acoustic meatus opens just below the
2 Below, by the upper border of the zygomatic arch
posterior part of the posterior root of zygoma. Its
laterally, and by the infratemporal crest of the greater
anterior and inferior margins and the lower part
wing of the sphenoid bone medially. Through the
of the posterior margin are formed by the tympanic
gap deep to the zygomatic arch, temporal fossa
plate, and the posterosuperior margin is formed
communicates with the infratemporal fossa.
by the squamous temporal bone. The margins are
roughened for the attachment of auricular cartilage. 3 The anterior wall is formed by the zygomatic bone
The suprameatal triangle (trianlge of McEwen) is a small and by parts of the frontal and sphenoid bones. This
depression posterosuperior to the meatus. It is bounded wall separates the fossa from the orbit.
above by the supramastoid crest, in front by the Floor: The anterior part of the floor is crossed by an H-
posterosuperior margin of the external meatus, and shaped suture where four bones—frontal, parietal,
behind by a vertical tangent to the posterior margin of greater wing of sphenoid and temporal adjoin each
the meatus. The suprameatal spine may be present on other. This area is termed the pterion. It lies 4 cm above
the anteroinferior margin of the triangle. The triangle the midpoint of the zygomatic arch and 2.5 cm behind
forms the lateral wall of the tympanic or mastoid the frontozygomatic suture. Deep to the pterion lie, the
antrum (Fig. 1.9c). middle meningeal vein, the anterior division of the middle
meningeal artery, and the stem of the lateral sulcus of brain
Mastoid Part of the Temporal Bone (Sylvian point) (Fig. 1.8).
The mastoid part of the temporal bone lies just behind the On the temporal surface of the zygomatic bone
external acoustic meatus. It is continuous antero- forming the anterior wall of the fossa, there is the
Head and Neck
superiorly with the squamous temporal bone (Fig. 1.9c). zygomaticotemporal foramen.
A partially obliterated squamomastoid suture may be
visible in front of and parallel to the roughened area Attachments
for muscular insertion. 1 The temporal fascia is attached to the superior
The mastoid temporal bone articulates postero- temporal line and to the area between the two
superiorly with the posteroinferior part of the parietal temporal lines. Inferiorly, it is attached to the outer
bone at the horizontal parietomastoid suture, and and inner lips of the upper border of the zygomatic
posteriorly with the squamous occipital bone at the arch.
occipitomastoid suture. These two sutures meet at the 2 The temporalis muscle arises from the whole of the
lateral end of the lambdoid suture. The asterion is the temporal fossa, except the part formed by the
point where the parietomastoid, occipitomastoid and zygomatic bone (Fig. 1.14). Beneath the muscle, there
lambdoid sutures meet. In infants, the asterion is the lie the deep temporal vessels and nerves. The middle
site of the posterolateral or mastoid fontanelle, which closes temporal vessels produce vascular markings on the
by 12 months (Fig. 1.3). temporal bone just above the external acoustic
The mastoid process is a breast-like projection from meatus (Fig. 1.9b).
the lower part of the mastoid temporal bone, postero- 3 The medial surface and lower border of the
inferior to the external acoustic meatus. It appears zygomatic arch give origin to the masseter.
13
4 The lateral ligament of the temporomandibular joint

is attached to the tubercle of the root of the zygoma
(see Chapter 6).
5 The sternocleidomastoid, splenius capitis and
longissimus capitis are inserted from before
backwards on the posterior part of the lateral surface
of the mastoid process (Fig. 1.14). Posterior belly of
digastric arises from mastoid notch. The groove
obliquely placed behind mastoid notch is due to
occipital artery (see Fig. 7.3).
6 The gap between the zygomatic arch and the side of
the skull transmits:
a. Tendon of the temporalis muscle Fig. 1.10: Extradural haemorrhage
b. Deep temporal vessels
c. Deep temporal nerves.
Anterior Part of Norma Basalis
Infratemporal Fossa Alveolar Arch
Boundaries and the contents are described in Chapter 6. Alveolar arch bears sockets for the roots of the upper
teeth.
Pterygopalatine Fossa
Pterygopalatine fossa is described in Chapter 15. Hard Palate
1 Formation:
Structures Passing through Foramina
a. Anterior two-thirds, by the palatine processes of
1 The tympanomastoid fissure on the anterior aspect of the maxillae.
the base of the mastoid process transmits the auricular
branch of vagus nerve. b. Posterior one-third, by the horizontal plates of the
2 The mastoid foramen transmits: palatine.
a. An emissary vein connecting the sigmoid sinus with 2 Sutures: The palate is crossed by a cruciform suture
the posterior auricular vein (Table 1.1). made up of intermaxillary, interpalatine and
b. A meningeal branch of the occipital artery. palatomaxillary sutures.
3 The zygomaticotemporal foramen transmits the nerve 3 Dome:
of the same name and a minute artery (see Fig. 2.16). a. It is arched in all directions.
b. Shows pits for the palatine glands.
CLINICAL ANATOMY
4 The incisive foramen is a deep fossa situated anteriorly
Pterion site of anterolateral fontanelle is the thin part of in the median plane (Fig. 1.12).
skull. In roadside accidents, the anterior division of Two incisive canals, right and left, pierce the walls of
Head and Neck

middle meningeal artery at pterion (Fig. 1.8) may be the incisive foramen, usually one on each side, but
ruptured, leading to clot formation between the skull occasionally in the median plane, the left being
bone and dura mater or extradural haemorrhage. The anterior and the right, posterior.
clot compresses the motor area of brain, leading to
paralysis of the opposite side. The clot must be 5 The greater palatine foramen, one on each side, is
sucked out at the earliest by trephining (Fig. 1.10). situated just behind the lateral part of the palato-
The head must be protected by a helmet during maxillary suture. A groove leads from the foramen
driving a two-wheeler. towards the incisive fossa (Fig. 1.11a).
6 The lesser palatine foramina, two or three in number
NORMA BASALIS on each side, lie behind the greater palatine foramen,
and perforate the pyramidal process of the palatine
For convenience of study, the norma basalis is divided
bone (Fig. 1.11a).
arbitrarily into anterior, middle and posterior parts. The
anterior part is formed by the hard palate and the 7 The posterior border of the hard palate is free and
alveolar arches. The middle and posterior parts are presents the posterior nasal spine in the median plane.
separated by an imaginary transverse line passing 8 The palatine crest is a curved ridge near the posterior
through the anterior margin of the foramen magnum border. It begins behind the greater palatine foramen
(Figs 1.11a–c). and runs medially (Fig. 1.12).
HEAD AND NECK
14
Head and Neck
Figs 1.11a to c: (a) Norma basalis showing passage of main nerves and arteries; (b) Three parts of norma basalis; (c) Infratemporal
surface of greater wing of sphenoid
Middle Part of Norma Basalis b. A broad bar of bone formed by fusion of the posterior
The middle part extends from the posterior border of part of the body of sphenoid and the basilar part
the hard palate to the arbitrary transverse line passing of occipital bone (Fig. 1.13).
through the anterior margin of the foramen magnum. 2 The vomer separates the two posterior nasal
apertures. Its inferior border articulates with the
Median Area bony palate. The superior border splits into two alae
1 The median area shows: and articulates with the rostrum of the sphenoid bone
a. The posterior border of the vomer. (Fig. 1.13).
15
2 The pterygoid process projects downwards from the

junction of greater wing and the body of sphenoid
behind the third molar tooth.
Inferiorly, it divides into the medial and lateral
pterygoid plates which are fused together anteriorly,
but are separated posteriorly by the V-shaped
pterygoid fossa.
The fused anterior borders of the two plates articulate
medially with the perpendicular plate of the palatine
bone, and are separated laterally from the posterior
surface of the body of the maxilla by the
pterygomaxillary fissure.
The medial pterygoid plate is directed backwards. It
Fig. 1.12: Anterior part of the norma basalis has medial and lateral surfaces and a free posterior
border.
The upper end of posterior border divides to enclose
a triangular depression called the scaphoid fossa. The
lower end of the posterior border is prolonged
downwards and laterally to form the pterygoid
hamulus.
The lateral pterygoid plate is directed backwards and
laterally. It has medial and lateral surfaces and a free
posterior border. The lateral surface forms the medial
wall of the infratemporal fossa. Its lateral and medial
surfaces give origin to muscles.
The posterior border sometimes has a projection at
its middle called the pterygospinous process which
projects towards the spine of the sphenoid.
3 The infratemporal surface of the greater wing of the
Fig. 1.13: Posterior view of a coronal section through the sphenoid is pentagonal.
posterior nasal aperture showing the formation of the
a. Its anterior margin forms the posterior border of
palatinovaginal and vomerovaginal canals
the inferior orbital fissure (Fig. 1.11c).
b. Its anterolateral margin forms the infratemporal crest.
3 Palatinovaginal canal: The inferior surface of the c. Its posterolateral margin articulates with the
vaginal process of the medial pterygoid plate is squamous temporal.
marked by an anteroposterior groove which is d. Its posteromedial margin articulates with petrous
converted into the palatinovaginal canal by the upper temporal.
Head and Neck

surface of the sphenoidal process of the palatine e. Anteromedially, it is continuous with the pterygoid
bone. The canal opens anteriorly into the posterior process and with the body of the sphenoid bone.
wall of the pterygopalatine fossa (see Fig. 15.14). The posteriormost point between the posterolateral
4 Vomerovaginal canal: The lateral border of each ala of and posteromedial margins projects downwards to
the vomer comes into relationship with the vaginal form the spine of the sphenoid.
process of the medial pterygoid plate, and may Along the posteromedial margin, the surface is
overlap it from above to enclose the vomerovaginal pierced by the following foramina.
canal (Fig. 1.13). a. The foramen ovale is large and oval in shape. It is
5 The broad bar of the bone is marked in the median situated posterolateral to the upper end of the
plane by the pharyngeal tubercle, a little in front of posterior border of lateral pterygoid plate
the foramen magnum (Fig. 1.11a). (Figs 1.11a and c).
b. The foramen spinosum is small and circular in
Lateral Area shape. It is situated posterolateral to the foramen
1 The lateral area shows two parts of the sphenoid ovale, and is limited posterolaterally by the spine
bone—pterygoid process and greater wing. Also of sphenoid (Figs 1.11a and c).
seen are three parts of the temporal bone, i.e. petrous c. Sometimes, there is the emissary sphenoidal foramen
temporal, tympanic plate and squamous temporal. or foramen of Vesalius. It is situated between the
HEAD AND NECK
16
foramen ovale and the scaphoid fossa. Internally, Internally: The tympanic plate is fused to the petrous
it opens between the foramen ovale and the temporal bone.
foramen rotundum. 6 The squamous part of the temporal bone forms:
d. At times, there is a canaliculus innominatus situated a. The anterior part of the mandibular articular fossa
between the foramen ovale and the foramen which articulates with the head of the mandible
spinosum. to form the temporomandibular joint.
The spine of the sphenoid may be sharply pointed or b. The articular tubercle which is continuous with
blunt (Figs 1.11a and c). the anterior root of the zygoma.
The sulcus tubae is the groove between the postero- c. A small posterolateral part of the roof of the
medial margin of the greater wing of the sphenoid infratemporal fossa.
and the petrous temporal bone. It lodges the
cartilaginous part of the auditory tube. Posteriorly, the Posterior Part of Norma Basalis
groove leads to the bony part of the auditory tube Median Area
which lies within the petrous temporal bone The median area shows from before backwards:
(Figs 1.11a and c). a. The foramen magnum
4 The inferior surface of the petrous (Greek rock) part b. The external occipital crest
of the temporal bone is triangular in shape with its c. The external occipital protuberance
apex directed forwards and medially. d. Nuchal lines.
It lies between the greater wing of the sphenoid and a. The foramen magnum (Latin great) is the largest
the basiocciput. Its apex is perforated by the upper foramen of the skull. It opens upwards into the
end of the carotid canal, and is separated from the posterior cranial fossa, and downwards into the
sphenoid by the foramen lacerum. The inferior surface vertebral canal. It is oval in shape, being wider
is perforated by the lower end of the carotid canal behind than in front where it is overlapped on each
posteriorly. side by the occipital condyles (Figs 1.11b and 1.14).
The carotid canal runs forwards and medially within b. The external occipital crest begins at the posterior margin
the petrous temporal bone. of the foramen magnum and ends posteriorly and above
The foramen lacerum is a short, wide canal, 1 cm long. at the external occipital protuberance (Fig. 1.11).
Its lower end is bounded posterolaterally by the apex c. The external occipital protuberance is a projection located
of the petrous temporal, medially by the basiocciput at the posterior end of the crest. It is easily felt in the
and the body of the sphenoid, and anteriorly by the living, in the midline, at the point where the back of
root of the pterygoid process and the greater wing the neck becomes continuous with the scalp (Fig. 1.11a).
of the sphenoid bone. d. Nuchal lines: The superior nuchal lines begin at the
A part of the petrous temporal bone, called the tegmen external occipital protuberance and the inferior
tympani, is present in the middle cranial fossa. It has nuchal lines at the middle of the crest. Both of them
a down turned edge which is seen in the curve laterally and backwards and then laterally and
squamotympanic fissure and divides it into the forwards.
posterior petrotympanic and anterior petrosquamous Highest nuchal line is faded and seen above superior
fissures (Fig. 1.11a).
Head and Neck
nuchal line (occasionally).

5 The tympanic part of the temporal bone, also called the
tympanic plate, is a triangular curved plate which lies Lateral Area
in the angle between the petrous and squamous parts. The lateral area shows:
Its apex is directed medially and lies close to the spine • The condylar part of the occipital bone.
of the sphenoid. • The squamous part of the occipital bone.
The base or lateral border is curved, free and roughened.
• The jugular foramen between the occipital and
Its anterior surface forms the posterior wall of the
petrous temporal bones.
mandibular fossa. The posterior surface is concave and
forms the anterior wall, floor, and lower part of the • The styloid process of the temporal bone.
posterior wall of the bony external acoustic meatus • The mastoid part of the temporal bone.
(Fig. 1.9c). a. The condylar or lateral part of the occipital bone
Its upper border bounds the petrotympanic fissure. presents the following.
The lower border is sharp and free. i. The occipital condyles are oval in shape and are
Medially: It passes along the anterolateral margin of situated on each side of the anterior part of
the lower end of the carotid canal. the foramen magnum. Their long axis is
Laterally: It forms the anterolateral part of the sheath directed forwards and medially (Fig. 1.11).
of the styloid process. They articulate with the superior articular
17
Fig. 1.14: Muscles attached to the base of skull with their nerve supply
facets of the atlas vertebra to form the atlanto- It is placed at the posterior end of the petro-
occipital joints. occipital suture (Fig. 1.11a).
Head and Neck

ii. The hypoglossal or anterior condylar canal pierces At the posterior end of the foramen, its anterior
the bone anterosuperior to the occipital wall (petrous temporal) is hollowed out to form
condyle, and is directed laterally and slightly jugular fossa which lodges the superior bulb of the
forwards. internal jugular vein. The fossa is larger on
iii. The condylar or posterior condylar canal is the right side than on the left.
occasionally present in the floor of a condylar The lateral wall of the jugular fossa is pierced by
fossa present behind the occipital condyle. a minute canal, the mastoid canaliculus.
Superiorly, it opens into the sigmoid sulcus. Near the medial end of the jugular foramen, there
iv. The jugular process of the occipital bone lies is the jugular notch. At the apex of the notch, there
lateral to the occipital condyle and forms is an opening that leads into the cochlear canaliculus.
the posterior boundary of jugular foramen The tympanic canaliculus opens on or near the thin
(Fig. 1.11). edge of bone between the jugular fossa and the
b. Squamous part of occipital bone is marked by the lower end of the carotid canal.
superior and inferior nuchal lines mentioned d. Styloid process is described in Chapter 8.
above (Fig. 1.5). The stylomastoid foramen is situated posterior to the
c. The jugular foramen is large and elongated, root of the styloid process, at the anterior end of
with its long axis directed forwards and medially. the mastoid notch.
HEAD AND NECK
18
e. The mastoid process, a component of mastoid part tuberosity and the adjoining part of the pyramidal
is a large conical projection located posterolateral process of the palatine bone (Fig. 1.14).
to the stylomastoid foramen. It is directed 6 The infratemporal surface of the greater wing of the
downwards and forwards. It forms the lateral sphenoid gives origin to the upper head of the lateral
wall of the mastoid notch (Fig. 1.5). pterygoid muscle, and is crossed by the deep
temporal and masseteric nerves.
Attachments on Exterior of Skull 7 The spine of the sphenoid is related laterally to the
1 The posterior border of the hard palate provides auriculotemporal nerve, and medially to the chorda
attachment to the palatine aponeurosis. The tympani nerve and auditory tube (Fig. 1.11c).
posterior nasal spine gives origin to the musculus Its tip provides attachment to the (i) sphenomandi-
uvulae (Fig. 1.14). bular ligament, (ii) anterior ligament of malleus, and
2 The palatine crest provides attachment to a part of (iii) pterygospinous ligament.
the tendon of tensor veli palatini muscle (Fig. 1.14). Its anterior aspect gives origin to the most posterior
fibres of the tensor veli palatini and tensor tympani
3 The attachments on the inferior surface of the
muscles.
basiocciput are as follows:
8 The inferior surface of petrous temporal bone gives
a. The pharyngeal tubercle gives attachment origin to the levator veli palatini (Fig. 1.14).
to the raphe which provides insertion to the 9 The margins of the foramen magnum provide
upper fibres of the superior constrictor muscle attachment to:
of the pharynx (Fig. 1. 14). a. The anterior atlanto-occipital membrane,
b. The area in front of the tubercle forms the roof of anteriorly (see Fig. 9.11d).
the nasopharynx and supports the pharyngeal b. The posterior atlanto-occipital membrane,
tonsil. posteriorly.
c. The longus capitis is inserted lateral to the c. The alar ligaments on the roughened medial
pharyngeal tubercle (Fig. 1.14). surface of each occipital condyle (see Fig. 9.12).
d. The rectus capitis anterior is inserted a little 10 The ligamentum nuchae is attached to the external
posterior and medial to the hypoglossal canal occipital protuberance and crest.
(Fig. 1.14). 11 The rectus capitis lateralis is inserted into the inferior
4 The attachments on the medial pterygoid plate are surface of the jugular process of the occipital bone
as follows: (Fig. 1.14).
a. The pharyngobasilar fascia is attached below to 12 The following are attached to the squamous part of
the processus tuberis. the occipital bone (Fig. 1.14).
Processus tuberis/pterygospinous process is a • The area between the superior and inferior nuchal
lines provides insertion medially to the
triangular projection which is present at the
semispinalis capitis, and laterally to the superior
middle of the posterior border of medial
oblique muscle.
pterygoid plate. It supports the medial end of
• The area below the inferior nuchal line provides
cartilaginous part of auditory tube.
insertion medially to the rectus capitis posterior
b. The lower part of the posterior border and the
Head and Neck
minor, and laterally to the rectus capitis posterior

pterygoid hamulus give origin to the superior major (Fig. 1.14).
constrictor of the pharynx. 13 The mastoid notch gives origin to the posterior belly
c. The upper part of the posterior border is notched of digastric muscle (Fig. 1.14).
by the auditory tube.
d. The pterygomandibular raphe is attached to the Structures Passing through Foramina
tip of the pterygoid hamulus at one end and to the 1 Each incisive foramen transmits:
mandible behind 3rd molar tooth at the other end. a. The terminal parts of the greater palatine vessels
e. The pterygospinous process which is present at from the palate to the nose.
the middle of medial pterygoid plate gives b. The terminal part of the nasopalatine nerve from
attachment to the ligament of same name. the nose to the palate (Fig. 1.11a).
5 The attachments on the lateral pterygoid plate are 2 The greater palatine foramen transmits:
as follows: a. The greater palatine vessels (Fig. 1.12).
a. Its lateral surface gives origin to the larger lower b. The anterior palatine nerve, both of which run
head of lateral pterygoid muscle (Fig. 1.14). forwards in the groove that passes forwards from
b. Its medial surface gives origin to the deep head the foramen.
of the medial pterygoid. The small, superficial 3 The lesser palatine foramina transmit the middle and
head of this muscle arises from the maxillary posterior palatine nerves.
19
4 The palatinovaginal canal transmits: sympathetic plexuses around it. In the anterior part
a. A pharyngeal branch from the pterygopalatine of the foramen, the greater petrosal nerve unites with
ganglion (see Fig. 15.16a). the deep petrosal nerve to form the nerve of the pterygoid
b. A small pharyngeal branch of the maxillary artery. canal (Vidian’s nerve) which leaves the foramen by
5 The vomerovaginal canal (if patent) transmits entering the pterygoid canal in the anterior wall of
branches of the pharyngeal branch from pterygo- the foramen lacerum (Figs 1.15a and b).
palatine ganglion and vessels. 12 The medial end of the petrotympanic fissure
6 The foramen ovale transmits (mnemonic—MALE) (Fig. 1.11a) transmits the chorda tympani nerve,
a. The mandibular nerve (Fig. 1.11) anterior ligament of malleus and the anterior
b. The accessory meningeal artery tympanic artery.
c. The lesser petrosal nerve 13 The foramen magnum (Fig. 1.16a) transmits the
d. An emissary vein connecting the cavernous sinus following.
with the pterygoid plexus of veins. Through the narrow anterior part:
e. Anterior trunk of middle meningeal vein a. Apical ligament of dens
(occasionally). b. Vertical band of cruciate ligament
7 The foramen spinosum transmits the middle meningeal c. Membrana tectoria
artery (Fig. 1.11a), the meningeal branch of the Through wider posterior part:
mandibular nerve or nervus spinosus, and the a. Lowest part of medulla oblongata
posterior trunk of the middle meningeal vein. b Three meninges.
8 The emissary sphenoidal foramen (foramen of Vesalius) Through the subarachnoid space pass:
transmits an emissary vein connecting the cavernous a. Spinal accessory nerves
sinus with the pterygoid plexus of veins. b. Vertebral arteries
9 When present the canaliculus innominatus transmits c. Sympathetic plexus around the vertebral arteries
the lesser petrosal nerve (in place of foramen ovale). d. Posterior spinal arteries
10 The carotid canal transmits the internal carotid artery, e. Anterior spinal artery.
and the venous and sympathetic plexuses around the 14 The hypoglossal or anterior condylar canal transmits
artery (Fig. 1.11a). the hypoglossal nerve, the meningeal branch of the
11 The structures passing through the foramen lacerum: hypoglossal nerve (These are the sensory fibres of
During life, the lower part of the foramen is filled first cervical spinal nerve supplying the dura mater
with cartilage, and no significant structure passes of posterior cranial fossa.), the meningeal branch of
through the whole length of the canal, except for the ascending pharyngeal artery, and an emissary
the meningeal branch of the ascending pharyngeal vein connecting the sigmoid sinus with the internal
artery and an emissary vein from the cavernous jugular vein (Table 1.1).
sinus. 15 The posterior condylar canal transmits an emissary
However, the upper part of the foramen is traversed vein connecting the sigmoid sinus with suboccipital
by the internal carotid artery with venous and venous plexus (Table 1.1).
Head and Neck
Fig. 1.15a: Structures related to the foramen lacerum

HEAD AND NECK
20
Fig. 1.15b: Portion of right norma basalis showing foramina of middle and posterior parts
Head and Neck
Fig. 1.16a: Structures passing through foramen magnum
16 The jugular foramen transmits the following structures:

i. Through the anterior part:
a. Inferior petrosal sinus (Fig. 1.16b).
b. Meningeal branch of the ascending pharyngeal
artery.
ii. Through the middle part: IX, X and XI cranial nerves.
iii. Through the posterior part:
a. Internal jugular vein (Fig. 1.11a, also see Fig. 4.46,
of BD Chaurasia’s Human Anatomy, Volume 4).
b. Meningeal branch of the occipital artery.
The glossopharyngeal notch near the medial end of
the jugular foramen lodges the inferior ganglion of
the glossopharyngeal nerve. Fig. 1.16b: Jugular foramen (CN, cranial nerve)
21
17 The mastoid canaliculus (Arnold’s canal) in the lateral 2 The thickness of the cranial vault is variable. The
wall of the jugular fossa transmits the auricular branch bones covered with muscles, i.e. temporal and
of the vagus (Arnold’s nerve). The nerve passes posterior cranial fossae, are thinner than those
laterally through the bone, crosses the facial canal, and covered with scalp. Further, the bones are thinner in
emerges at the tympanomastoid fissure. The nerve is females than in males, and in children than in adults.
extracranial at birth, but becomes surrounded by bone 3 Most of the cranial bones consist of:
as the tympanic plate and mastoid process develop a. An outer table of compact bone which is thick,
(also called Alderman’s nerve). resilient and tough (Fig. 1.17b).
18 The tympanic canaliculus on the thin edge of partition b. An inner table of compact bone which is thin and
between the jugular fossa and carotid canal brittle.
transmits the tympanic branch of glossopharyngeal
c. The diploe which consists of spongy bone filled
nerve (Jacobson’s nerve) to the middle ear cavity.
with red marrow, in between the two tables.
19 The stylomastoid foramen transmits the facial nerve
and the stylomastoid branch of the posterior The skull bones derive their blood supply mostly
auricular artery. from the meningeal arteries from inside and very little
from the arteries of the scalp. Blood supply from the
outside is rich in those areas where muscles are
INTERIOR OF THE SKULL attached, e.g. the temporal fossa and the suboccipital
Before beginning a systematic study of the interior, the region. The blood from the diploes is drained by four
following general points may be noted. diploic veins on each side draining into venous sinuses
1 The cranium is lined internally by endocranium which (Table 1.2 and Fig. 1.17a).
is continuous with the pericranium through the Many bones, like vomer (Latin plowshare), pterygoid
foramina and sutures. plates, do not have any diploe.
Table 1.2: Diploic veins

Vein Foramen Drainage
1. Frontal diploic vein Supraorbital foramen Drain into supraorbital vein
2. Anterior temporal or parietal diploic vein In the greater wing of sphenoid Sphenoparietal sinus or in anterior
deep temporal vein
3. Posterior temporal or parietal diploic vein Mastoid foramen Transverse sinus
4. Occipital diploic vein (largest) Foramen in occipital bone Occipital vein or confluence of sinuses
5. Small unnamed diploic veins Pierce inner table of skull close to the Venous lacunae
margins of superior sagittal sinus
Head and Neck
Figs 1.17a to c: (a) Diploic veins in an adult; (b) Section of cranial bone showing its structure; (c) Internal surface of the skull cap
HEAD AND NECK
22
INTERNAL SURFACE OF CRANIAL VAULT Floor

The shape, the bones present, and the sutures uniting In the median plane, it is formed anteriorly by the
them have been described with the norma verticalis. cribriform plate of the ethmoid bone, and posteriorly by
The following features may be noted. the superior surface of the anterior part of the body of
a. The inner table is thin and brittle. It presents the sphenoid or jugum sphenoidale.
markings produced by meningeal vessels, venous On each side, the floor is formed mostly by the orbital
sinuses, arachnoid granulations, and to some plate of the frontal bone, and is completed posteriorly by
extent by cerebral gyri. It also presents raised the lesser wing of the sphenoid.
ridges formed by the attachments of the dural
folds. Other Features
b. The frontal crest lies anteriorly in the median 1 The cribriform plate of the ethmoid bone separates the
plane. It projects backwards. anterior cranial fossa from the nasal cavity. It is
c. The sagittal sulcus runs from before backwards in
quadrilateral in shape (Fig. 1.18a).
the median plane. It becomes progressively wider
posteriorly. It lodges the superior sagittal sinus. a. Anterior margin articulates with the frontal bone
d. The granular foveolae are deep, irregular, large, pits at the frontoethmoidal suture which is marked in the
situated on each side of the sagittal sulcus. They median plane by the foramen caecum. This foramen
are formed by arachnoid granulations. They are is usually blind, but is occasionally patent.
larger and more numerous in aged persons. b. Posterior margin articulates with the jugum
e. Vascular markings: The groove for the anterior sphenoidale. At the posterolateral corners, we see
branch of the middle meningeal artery, and the the posterior ethmoidal canals.
accompanying vein runs upwards 1 cm behind
c. Its lateral margins articulate with the orbital plate
the coronal suture. Smaller grooves for the
of the frontal bone: The suture between them
branches from the anterior and posterior branches
of the middle meningeal vessels run upwards and presents the anterior ethmoidal canal placed behind
backwards over the parietal bone (Fig. 1.17c). the crista galli (Fig. 1.18a).
f. The parietal foramina open near the sagittal Anteriorly, the cribriform plate has a midline
sulcus 2.5 to 3.75 cm in front of the lambdoid projection called the crista galli (Latin cock’s comb).
suture (Fig. 1.2). On each side of the crista galli, there are foramina
g. The impressions for cerebral gyri are less distinct. through which the anterior ethmoidal nerve and vessels
These become very prominent in cases of raised pass to the nasal cavity. The plate is also perforated
intracranial tension. by numerous foramina for the passage of olfactory
nerve rootlets.
Competency achievement: The student should be able to:
AN 26.3 Describe cranial cavity, its subdivisions, foramina and 2 The jugum sphenoidale separates the anterior cranial
structures passing through them.4 fossa from the sphenoidal sinuses.
AN 30.1 Describe the cranial fossae and identify related structures.5 3 The orbital plate of the frontal bone separates the
Head and Neck
anterior cranial fossa from the orbit. It supports the

INTERNAL SURFACE OF THE BASE OF SKULL orbital surface of the frontal lobe of the brain, and
The interior of the base of skull presents natural presents reciprocal impressions. The frontal air sinus
subdivisions into the anterior, middle and posterior may extend into its anteromedial part. The medial
cranial fossae. The dura mater is firmly adherent to the margin of the plate covers the labyrinth of the
floor of fossae and is continuous with pericranium ethmoid; and the posterior margin articulates with the
through the foramina and fissures (Fig. 1.18a). lesser wing of the sphenoid.
4 The lesser wing of the sphenoid is broad medially where
Anterior Cranial Fossa (refer to BDC App)
it is continuous with the jugum sphenoidale and tapers
Boundaries laterally. The free posterior border fits into the stem of
Anteriorly and on the sides, by the frontal bone (Fig. 1.18b). the lateral sulcus of the brain. It ends medially as a
In the median plane is frontal crest. prominent projection, the anterior clinoid process. Infe-
Posteriorly, it is separated from the middle cranial riorly, the posterior border forms the upper boundary
fossa by the free posterior border of the lesser wing of the of the superior orbital fissure. Medially, the lesser wing
sphenoid, the anterior clinoid process, and the anterior is connected to the body of the sphenoid by anterior
margin of the sulcus chiasmaticus. and posterior roots, which enclose the optic canal.
23
Head and Neck
Figs 1.18a and b: (a) All three cranial fossae; (b) Divisions of skull into three fossae
CLINICAL ANATOMY through the nose. It may also cause a condition called
black eye which is produced by seepage of blood into
Fracture of the anterior cranial fossa may cause
the eyelid, as frontalis muscle has no bony origin
bleeding and discharge of cerebrospinal fluid
(see Fig. 2.8).
HEAD AND NECK
24
Middle Cranial Fossa (refer to BDC App) and behind by the two roots of the lesser wing, and
It is deeper than the anterior cranial fossa, and is shaped medially by the body of sphenoid.
like a butterfly, being narrow and shallow in the middle; 3 Sella turcica (pituitary fossa or hypophyseal fossa): The
and wide and deep on each side. upper surface of the body of the sphenoid is
hollowed out in the form of a Turkish saddle, and is
Boundaries known as the sella turcica. It consists of the tuberculum
Anterior sellae in front, the hypophyseal fossa in the middle and
1 Posterior border of the lesser wing of the sphenoid the dorsum sellae behind (Fig. 1.19).
2 Anterior clinoid process The tuberculum sellae separates the optic groove from
3 Anterior margin of the sulcus chiasmaticus the hypophyseal fossa. Its lateral ends form the middle
Posterior clinoid process which may join the anterior clinoid
1 Superior border of the petrous temporal bone process.
2 The dorsum sellae of the sphenoid The hypophyseal fossa lodges the hypophysis cerebri.
Lateral Beneath the floor of fossa lie the sphenoidal air sinuses.
1 Greater wing of the sphenoid The dorsum sellae is a transverse plate of bone
2 Anteroinferior angle of the parietal bone projecting upwards; it forms the back of the saddle. The
3 The squamous temporal bone superolateral angles of the dorsum sellae are expanded
to form the posterior clinoid processes.
Floor
Floor is formed by body of sphenoid in the median Lateral area
region and by greater wing of sphenoid, squamous 1 The lateral area is deep and lodges the temporal lobe
temporal and anterior surface of petrous temporal on of the brain.
each side. 2 It is related anteriorly to the orbit, laterally to the
temporal fossa, and inferiorly to the infratemporal
Other Features fossa.
Median area: The body of the sphenoid presents the 3 The superior orbital fissure opens anteriorly into the
following features. orbit. It is bounded above by the lesser wing, below
1 The sulcus chiasmaticus or optic groove leads, on each by the greater wing, and medially by the body of
side, to the optic canal. The optic chiasma does not the sphenoid (see Fig. 13.4).
occupy the sulcus, it lies at a higher level well behind The medial end is wider than the lateral.
the sulcus. The long axis of the fissure is directed laterally,
2 The optic canal leads to the orbit. It is bounded upwards and forwards. The lower border is marked
laterally by the lesser wing of the sphenoid, in front by a small projection, which provides attachment
Head and Neck
Fig. 1.19: Features of the middle cranial fossa

25
to the common tendinous ring of Zinn. The ring divides c. The seventh and eighth cranial nerves may be
the fissure into three parts. damaged, if the fracture also passes through the
4 The greater wing of the sphenoid presents the following internal acoustic meatus. If a semicircular canal is
features. damaged, vertigo may occur.
a. The foramen rotundum leads anteriorly to the
pterygopalatine fossa containing pterygopalatine
ganglia (see Fig. 15.15). Posterior Cranial Fossa (refer to BDC App)
b. The foramen ovale lies posterolateral to the foramen This is the largest and deepest of the three cranial fossae.
rotundum and lateral to the lingula. It leads The posterior cranial fossa contains the hindbrain which
inferiorly to the infratemporal fossa (Figs 1.18a consists of the cerebellum behind and the pons and medulla
and 1.19). in front.
c. The foramen spinosum lies posterolateral to the
foramen ovale. It also leads, inferiorly, to the Boundaries
infratemporal fossa (Figs 1.18a and 1.19). Anterior
d. The emissary sphenoidal foramen or foramen of 1 The superior border of the petrous temporal bone
Vesalius carries an emissary vein. 2 The dorsum sellae of the sphenoid bone (Fig. 1.18a)
5 The foramen lacerum lies at the posterior end of the
carotid groove, posteromedial to the foramen ovale. Posterior: Squamous part of the occipital bone.
6 The anterior surface of the petrous temporal bone presents On each side
the following features.
1 Mastoid part of the temporal bone
a. The trigeminal impression lies near the apex, behind
the foramen lacerum. It lodges the trigeminal 2 The mastoid angle of the parietal bone
ganglion within its dural cave (see Fig. 12.4).
Floor
b. The hiatus and groove for the greater petrosal nerve
are present lateral to the trigeminal impression. Median area
They lead to the foramen lacerum (Fig. 1.36). 1 Sloping area behind the dorsum sellae or clivus in
c. The hiatus and groove for the lesser petrosal nerve lie front
lateral to the hiatus for the greater petrosal nerve. 2 The foramen magnum in the middle
They lead to the foramen ovale or to canaliculus 3 The squamous occipital behind
innominatus to relay in otic ganglion (Fig. 1.36).
d. Still more laterally there is the arcuate eminence Lateral area
produced by the superior semicircular canal. 1 Condylar or lateral part of occipital bone
e. The tegmen tympani is a thin plate of bone 2 Posterior surface of the petrous temporal bone
anterolateral to the arcuate eminence. It forms a 3 Mastoid temporal bone
continuous sloping roof for the tympanic antrum, 4 Mastoid angle of the parietal bone
for the tympanic cavity and for the canal for the
tensor tympani. Other Features
The lateral margin of the tegmen tympani is turned
Head and Neck

Median area
downwards, it forms the lateral wall of the bony
1 The clivus is the sloping surface in front of the foramen
auditory tube.
magnum. It is formed by fusion of the posterior part
Its lower edge is seen in the squamotympanic fissure
of the body of the sphenoid including the dorsum
and divides it into the petrosquamous and
sellae with the basilar part of the occipital bone or
petrotympanic fissures.
basiocciput. It is related to the basilar plexus of veins,
7 The cerebral surface of the squamous temporal bone is
and supports the pons and medulla (Fig. 1.18a).
concave. It shows impressions for the temporal lobe
and grooves for branches of the middle meningeal On each side, the clivus is separated from the petrous
vessels. temporal bone by the petro-occipital fissure which is
grooved by the inferior petrosal sinus, and is
CLINICAL ANATOMY
continuous behind with the jugular foramen.
2 The foramen magnum lies in the floor of the fossa. The
Fracture of the middle cranial fossa produces: anterior part of the foramen is narrow because it is
a. Bleeding and discharge of CSF through the ear. overlapped by the medial surfaces of the occipital
b. Bleeding through the nose or mouth may occur condyles.
due to involvement of the sphenoid bone. 3 The squamous part of the occipital bone shows the
following features.
HEAD AND NECK
26
a. The internal occipital protuberance lies opposite 1 cm long and runs transversely in a lateral
the external occipital protuberance. It is related direction. It is closed laterally by a perforated plate
to the confluence of sinuses, and is grooved on of bone known as lamina cribrosa which separates
each side by the beginning of transverse sinuses. it from the internal ear (Figs 1.18a and 1.20).
b. The internal occipital crest runs in the median plane b. The orifice of the aqueduct of the vestibule is a narrow
from the internal occipital protuberance to the slit lying behind the internal acoustic meatus.
foramen magnum where it forms a shallow c. The subarcuate fossa lies below the arcuate
depression, the vermian fossa (Fig. 1.20). eminence, lateral to the internal acoustic meatus.
c. The transverse sulcus is quite wide and runs 3 The jugular foramen lies at the posterior end of the
laterally from the internal occipital protuberance petro-occipital fissure. The upper margin is sharp
to the mastoid angle of the parietal bone where it and irregular, and presents the glossopharyngeal notch.
becomes continuous with the sigmoid sulcus. The The lower margin is smooth and regular.
transverse sulcus lodges the transverse sinus. The 4 The mastoid part of the temporal bone forms the lateral
right transverse sulcus is usually wider than the wall of the posterior cranial fossa just behind the
left and is continuous medially with the superior petrous part of the bone. Anteriorly, it is marked by
sagittal sulcus (Fig. 1.20). the sigmoid sulcus which begins as a downward
d. On each side of the internal occipital crest, there continuation of the transverse sulcus at the mastoid
are deep fossae which lodge the cerebellar angle of the parietal bone, and ends at the jugular
hemispheres (Fig. 1.20). foramen. The sigmoid sulcus lodges the sigmoid sinus
which become the internal jugular vein at the jugular
Lateral area
foramen (Figs 1.18a and 1.20). The sulcus is related
1 The condylar part of the occipital bone is marked by the anteriorly to the tympanic antrum. The mastoid foramen
following. opens into the upper part of the sulcus.
a. The jugular tubercle lies over the occipital condyle.
b. The hypoglossal canal (anterior condylar canal)
pierces the bone posteroanterior to the jugular CLINICAL ANATOMY
tubercle and runs obliquely forwards and laterally Fracture of the posterior cranial fossa causes bruising
along the line of fusion between the basilar and over the mastoid region extending down over the
the condylar parts of the occipital bone. sternocleidomastoid muscle.
c. The condylar canal (posterior condylar canal) opens
in the lower part of the sigmoid sulcus which
ATTACHMENTS AND RELATIONS: INTERIOR OF THE SKULL
indents the jugular process of occipital bone.
2 The posterior surface of the petrous part of the temporal Attachment on Vault
bone forms the anterolateral wall of the posterior 1 The frontal crest gives attachment to the falx cerebri
cranial fossa. The following features may be noted. (see Fig. 12.2).
a. The internal acoustic meatus opens above the 2 The lips of the sagittal sulcus give attachment to the
anterior part of the jugular foramen. It is about falx cerebri (see Fig. 12.2).
Head and Neck
Fig. 1.20: Features of the posterior cranial fossa

27
Anterior Cranial Fossa foramen, hypoglossal canal, and posterior condylar

1 The crista galli gives attachment to the falx cerebri. canal. Additional foramina seen in the cranial fossae
2 The orbital surface of the frontal bone supports the are as follows.
frontal lobe of the brain. 1 The foramen caecum in the anterior cranial fossa is
3 The anterior clinoid processes give attachment to the usually blind, but occasionally it transmits a vein from
free margin of the tentorium cerebelli (see Fig. 12.3). the upper part of nose to the superior sagittal sinus.
2 The posterior ethmoidal canal transmits the vessels of
Middle Cranial Fossa the same name. Note that the posterior ethmoidal
1 The middle cranial fossa lodges the temporal lobe of nerve does not pass through the canal as it terminates
the cerebral hemisphere. earlier.
2 The tuberculum sellae provides attachment to the 3 The anterior ethmoidal canal transmits the corres-
diaphragma sellae (see Fig. 12.5). ponding nerve and vessels.
3 The hypophyseal fossa lodges the hypophysis cerebri. 4 The optic canal transmits the optic nerve and the
4 Upper margin of the dorsum sellae provides ophthalmic artery.
attachment to the diaphragma sellae, and the 5 The three parts of the superior orbital fissure (see
posterior clinoid process to anterior end of the Fig. 13.4) transmit the following structures.
attached margin of tentorium cerebelli and to the Lateral part
petrosphenoidal ligament (see Fig. 12.3). a. Lacrimal nerve
5 One cavernous sinus lies on each side of the body of b. Frontal nerve
the sphenoid. The internal carotid artery passes c. Trochlear nerve
through the cavernous sinus (see Fig. 12.6). d. Superior ophthalmic vein
6 The superior border of the petrous temporal bone is Middle part
grooved by the superior petrosal sinus and provides a. Upper and lower divisions of the oculomotor
attachment to the attached margin of the tentorium nerve (Table 1.4)
cerebelli. It is grooved in its medial part by the b. Nasociliary nerve in between the two divisions of
trigeminal nerve (trigeminal impression). the oculomotor
c. The abducent nerve, inferolateral to the foregoing
Posterior Cranial Fossa
nerves (see Fig. 13.4)
1 The posterior cranial fossa contains the hindbrain
which consists of the cerebellum behind, and the Medial part
pons and medulla in front. a. Inferior ophthalmic vein
2 The lower part of the clivus provides attachment to b. Sympathetic nerves from the plexus around the
the apical ligament of the dens near the foramen internal carotid artery
magnum, upper vertical band of cruciate ligament 6 The foramen rotundum transmits the maxillary nerve
and to the membrana tectoria just above the apical (see Fig. 15.15).
ligament (Fig. 1.16a). 7 The internal acoustic meatus transmits the seventh and
eighth cranial nerves and the labyrinthine vessels.
Head and Neck

3 The internal occipital crest gives attachment to the
falx cerebelli.
4 The jugular tubercle is grooved by the ninth, tenth PRINCIPLES GOVERNING FRACTURES OF THE SKULL
and eleventh cranial nerves as they pass to the jugular 1 Fractures of the skull are prevented by:
foramen. a. Its elasticity
5 The subarcuate fossa on the posterior surface of b. Rounded shape
petrous temporal bone lodges the flocculus of the c. Construction from a number of secondary elastic
cerebellum. arches, each made up of a single bone
Competency achievement: The student should be able to: d. The muscles covering the thin areas.
AN 30.2 Describe and identify major foramina with structures passing 2 Since the skull is an elastic sphere filled with the
through them.6 semifluid brain, a violent blow on the skull
produces a splitting effect commencing at the site of
Structures Passing through Foramina the blow and tending to pass along the lines of least
The following foramina seen in the cranial fossae have resistance.
been dealt with under the norma basalis: Foramen 3 The base of the skull is more fragile than the vault, and
ovale, foramen spinosum, emissary sphenoidal is more commonly involved in such fractures,
foramen, foramen lacerum, foramen magnum, jugular particularly along the foramina.
HEAD AND NECK
28
4 The inner table is more brittle than the outer table. 2 It is completed posteriorly by the lesser wing of the
Therefore, fractures are more extensive on the inner sphenoid (Fig. 1.22a).
table. Occasionally, only the inner table is fractured
and the outer table remains intact. Relations
5 The common sites of fracture in the skull are: 1 It separates the orbit from the anterior cranial fossa.
a. The parietal area of the vault 2 The frontal air sinus may extend into its anteromedial
b. The middle cranial fossa of the base. This fossa is part.
weakened by numerous foramina and canals.
The facial bones commonly fractured are: Named Features
a. The nasal bone 1 The lacrimal fossa, placed anterolaterally, lodges the
b. The mandible. lacrimal gland (Fig. 1.22a).
2 The optic canal lies posteriorly, at the junction of the
THE ORBIT roof and medial wall (Figs 1.22a and b).
3 The trochlear fossa lies anteromedially. It provides
The orbits are pyramidal bony cavities, situated one attachment to the fibrous pulley or trochlea for the
on each side of the root of the nose. They provide tendon of the superior oblique muscle (Fig. 1.22a).
sockets for rotatory movements of the eyeballs. They
also protect the eyeballs (refer to BDC App). Lateral Wall
This is the thickest and strongest of all the walls of the
Shape and Disposition
orbit. It is formed:
Each orbit resembles a four-sided pyramid. Thus, it has: 1 By the anterior surface of the greater wing of the
• An apex situated at the posterior end of orbit at the sphenoid bone, posteriorly (Fig. 1.22b).
medial end of superior orbital fissure.
• A base seen as the orbital opening on the face. 2 By the orbital surface of the frontal process of the
• Four walls: Roof, floor, lateral and medial walls. zygomatic bone, anteriorly.
The long axis of the orbit passes backwards and Relations
medially. The medial walls of the two orbits are parallel
1 The greater wing of the sphenoid separates the orbit
and the lateral walls are set at right angles to each other
from the middle cranial fossa.
(Fig. 1.21).
2 The zygomatic bone separates it from the temporal
Roof fossa.
It is concave from side-to-side. It is formed:
Named Features
1 Mainly by the orbital plate of the frontal bone.
1 The superior orbital fissure occupies the posterior part
of the junction between the roof and lateral wall.
2 The foramen for the zygomatic nerve is seen in the
Head and Neck
zygomatic bone.
3 Whitnall’s or zygomatic tubercle is a palpable elevation
on the zygomatic bone just within the orbital margin.
It provides attachment to the lateral check ligament
of eyeball (Fig. 1.22a).
Floor
It slopes upwards and medially to join the medial wall.
It is formed:
1 Mainly by the orbital surface of the maxilla (Fig. 1.22b).
2 By the lower part of the orbital surface of the
zygomatic bone, anterolaterally.
3 The orbital process of the palatine bone, at the
posterior angle.
Fig. 1.21: Diagram comparing the orientation of the orbital axis Relation
and the visual axis It separates the orbit from the maxillary sinus.
29
Fig. 1.22a: The orbit seen from the front (schematic)
Head and Neck

Fig. 1.22b: The orbit seen from the front
Named Features Medial Wall

1 The inferior orbital fissure occupies the posterior part It is very thin. From before backwards, it is formed by:
of the junction between the lateral wall and floor. 1 The frontal process of the maxilla
Through this fissure, the orbit communicates with 2 The lacrimal bone (Fig. 1.21)
the infratemporal fossa anteriorly and with the 3 The orbital plate of the ethmoid
pterygopalatine fossa posteriorly (Figs 1.22a and b). 4 The body of the sphenoid bone.
2 The infraorbital groove runs forwards in relation to
the floor. Relations
3 A small depression on anteromedial part of the floor 1 The lacrimal groove, formed by the maxilla and the
gives origin to inferior oblique muscle. lacrimal bone, separates the orbit from the nasal cavity.
HEAD AND NECK
30
2 The orbital plate of the ethmoid separates the orbit STRUCTURE OF BONES
from the ethmoidal air sinuses. The bones of cranial vault are smooth and unilamellar;
3 The sphenoidal sinuses are separated from the orbit there is no diploe. The tables and diploes appear by
only by a thin layer of bone. fourth year of age (Fig. 1.17a and Table 1.2).
Named Features
Bony Prominences
1 The lacrimal groove lies anteriorly on the medial
wall. It is bounded anteriorly by the lacrimal crest of 1 Frontal and parietal tubera are prominent.
the frontal process of the maxilla, and posteriorly by 2 Glabella, superciliary arches and mastoid processes
the crest of the lacrimal bone. The floor of the groove are not developed.
is formed by the maxilla in front and by the lacrimal
bone behind. The groove lodges the lacrimal sac Paranasal Air Sinuses
which lies deep to the lacrimal fascia bridging the These are rudimentary or absent.
lacrimal groove. The groove leads inferiorly, through
the nasolacrimal duct, to the inferior meatus of the Temporal Bone
nose (see Fig. 2.22). 1 The internal ear, tympanic cavity, tympanic antrum,
2 The anterior and posterior ethmoidal foramina lie on the and ear ossicles are of adult size.
frontoethmoidal suture, at the junction of the roof 2 The tympanic part is represented by an incomplete
and medial wall. tympanic ring.
3 Mastoid process is absent, it appears during the later
Foramina in Relation to the Orbit part of second year.
1 The structures passing through the optic canal and 4 External acoustic meatus is short and straight. Its
through the superior orbital fissure have been bony part is unossified and represented by a fibro-
described in cranial fossae (see Fig. 13.4). cartilaginous plate.
2 The inferior orbital fissure transmits: 5 Tympanic membrane faces more downwards than
a. The zygomatic nerve, laterally due to the absence of mastoid process.
b. The orbital branches of the pterygopalatine ganglion, 6 Stylomastoid foramen is exposed on the lateral
c. The infraorbital nerve and vessels, and the surface of the skull because mastoid portion is flat.
communication between the inferior ophthalmic
7 Styloid process lies immediately behind the
vein and the pterygoid plexus of veins (Fig. 1.22a).
tympanic ring and has not fused with the remainder
3 The infraorbital groove and canal transmit the of the temporal bone.
corresponding nerve and vessels.
8 Mandibular fossa is flat and placed more laterally,
4 The zygomatic foramen transmits the zygomatic nerve.
and the articular tubercle has not developed.
5 The anterior ethmoidal foramen transmits the corres-
9 The subarcuate fossa is very deep and prominent.
ponding nerve and vessels.
6 Posterior ethmoidal foramen only transmits vessels of 10 Facial canal is short.
Head and Neck
same name (Fig. 1.22a).

Orbits
These are large. The germs of developing teeth lies close
FOETAL SKULL/NEONATAL SKULL to the orbital floor. Orbit comprises base or an outer
opening with upper, lower, medial and lateral walls.
DIMENSIONS Its apex lies at the optic foramen/canal. It also has
1 Skull is large in proportion to the other parts of superior and inferior orbital fissures.
skeleton.
2 Facial skeleton is small as compared to calvaria. In
foetal skull, the facial skeleton is 1/7th of calvaria; OSSIFICATION
in adults, it is half of calvaria. The facial skeleton is
small due to rudimentary mandible and maxillae, • Two halves of frontal bone are separated by
non-eruption of teeth, and small size of maxillary metopic suture.
sinus and nasal cavity. The large size of calvaria is • The mandible is also present in two halves. It is a
due to precocious growth of brain. derivative of first branchial arch.
3 Base of the skull is short and narrow, though internal • Occipital bone is in four parts (squamous one,
ear is almost of adult size, the petrous temporal has condylar two, and basilar one).
not reached the adult length.
31
• The four bony elements of temporal bone are CLINICAL ANATOMY

separate, except for the commencing union of the
tympanic part with the squamous and petrous • Fontanelles help to determine the age in 1–2 years
parts. The second centre for styloid process has of child.
not appeared. • Help to know the intracranial pressure. In case of
• Unossified membranous gaps, a total of 6 increased pressure, bulging is seen and in case
fontanelles at the angles of the parietal bones are of dehydration, depression is seen at the site of
present (Fig. 1.3). fontanelles.
• Squamous suture between parietal and squamous
temporal bones is present. Thickening of Bones
1 Two tables and diploe appear by fourth year.
Differentiation reaches maximum by about 35 years,
POSTNATAL GROWTH OF SKULL when the diploic veins produce characteristic
The growth of calvaria and facial skeleton proceeds at marking in the radiographs.
different rates and over different periods. Growth of 2 Mastoid process appears during second year, and
calvaria is related to growth of brain, whereas that of the mastoid air cells during sixth year.
the facial skeleton is related to the development of
dentition, muscles of mastication, and of the tongue. Obliteration of Sutures of the Vault
The rates of growth of the base and vault are also 1 Obliteration begins on the inner surface between 30
different. and 40 years, and on the outer surface between 40
and 50 years.
Growth of the Vault 2 The timings are variable, but it usually takes place
1 Rate: Rapid during first year, and then it slows up to first in the lower part of the coronal suture, next in
the seventh year when it is almost of adult size. the posterior part of the sagittal suture, and then in
2 Growth in breadth: This growth occurs at the sagittal the lambdoid suture.
suture, sutures bordering greater wings, occipito-
In Old Age
mastoid suture, and the petro-occipital suture at the
base. The skull generally becomes thinner and lighter but
3 Growth in height: This growth occurs at the fronto- in small proportion of cases, it increases in thickness and
zygomatic suture, pterion, squamosal suture, and weight. The most striking feature is reduction in the size
asterion. of mandible and maxillae due to loss of teeth and
absorption of alveolar processes. This causes decrease in
4 Growth in anteroposterior diameter: This growth occurs the vertical height of the face and a change in the angles
at the coronal and lambdoid sutures.
of the mandible which become more obtuse.
Growth of the Base
SEX DIFFERENCES IN THE SKULL
Head and Neck

The base grows in anteroposterior diameter at three
There are no sex differences until puberty. The
cartilaginous plates situated between the occipital and
postpubertal differences are listed in Table 1.3.
sphenoid bones, between the pre- and post-sphenoids,
and between the sphenoid and ethmoid. Wormian or Sutural Bones
Growth of the Face

These are small irregular bones found in the region
of the fontanelles, and are formed by additional
1 Growth of orbits and ethmoid is completed by ossification centres.
seventh year.
They are most common at the lambda and at the
2 In the face, the growth occurs mostly during first
year, although it continues till puberty and even asterion; common at the pterion (epipteric bone); and
later. rare at the bregma (OS Kerckring). Wormian bones are
common in hydrocephalic skulls.
Closure of Fontanelles
CRANIOMETRY
Anterior fontanelle (bregma) closes by 18 months,
mastoid fontanelle by 12 months, posterior fontanelle Cephalic Index
(lambda) by 2–3 months and sphenoidal fontanelle also It expresses the shape of the head, and is the proportion
by 2–3 months (Fig. 1.3). of breadth to length of the skull. Thus:
HEAD AND NECK
32
Table 1.3: Sex differences in the skull

Features Males Females
1. Weight Heavier Lighter
2. Size Larger Smaller
3. Capacity Greater in males 10% less than males
4. Walls Thicker Thinner
5. Muscular ridges, glabella, More marked Less marked
superciliary arches, temporal
lines, mastoid processes,
superior nuchal lines, and
external occipital protuberance
6. Tympanic plate Larger and margins are more roughened Smaller and margins are
less roughened
7. Supraorbital margin More rounded Sharp
8. Forehead Sloping (receding) Vertical
9. Frontal and parietal tubera Less prominent More prominent
10. Vault Rounded Somewhat flattened
11. Contour of face Longer due to greater depth of the jaws. Chin is bigger Rounded, facial bones are
and projects more forwards. In general, the skull is smoother, and mandible
more rugged due to muscular markings and and maxillae are smaller.
processes; and zygomatic bones are more massive
of man, it is larger in lower races, and still larger in

Breadth
Cephalic index = × 100 anthropoids.
Length
The length or longest diameter is measured from the Abnormal Crania
glabella to the occipital point, the breadth or widest Oxycephaly or acrocephaly, tower-skull, or steeple-skull
diameter is measured usually a little below the parietal is an abnormally tall skull. It is due to premature closure
tubera. of the suture between presphenoid and postsphenoid
Human races may be: in the base, and the coronal suture in skull cap, so that
a. Dolichocephalic or long-headed when the index is the skull is very short anteroposteriorly. Compensation
75 or less. is done by the upward growth of skull for the enlarging
b. Mesaticephalic when the index is between 75 and 80. brain.
c. Brachycephalic or short-headed or round-headed Scaphocephaly or boat-shaped skull is due to
Head and Neck
when the index is above 80. premature synostosis in the sagittal suture, as a result
d. Dolichocephaly is a feature of primitive races, like the skull is very narrow from side-to-side but greatly
Eskimos, Negroes, etc. elongated.
e. Brachycephaly through mesaticephaly has been a
continuous change in the advanced races, like the Competency achievement: The student should be able to:
Europeans. AN 26.4 Describe morphological features of mandible.7
Facial Angle
This is the angle between two lines drawn from the MANDIBLE
nasion to the basion or anterior margin of foramen
magnum and a line drawn from basion to the prosthion The mandible, or the lower jaw, is the largest and the
or central point on upper incisor alveolus (Fig. 1.9). strongest bone of the face. It develops from the first
Facial angle is a rough index of the degree of pharyngeal arch. It has a horseshoe-shaped body which
development of the brain because it is the angle between lodges the teeth, and a pair of rami which project
facial skeleton, i.e. viscerocranium, and the calvaria, i.e. upwards from the posterior ends of the body. The
neurocranium, which are inversely proportional to each rami provide attachment to the muscles of mastication
other. The angle is the smallest in the most evolved races (refer to BDC App).
33
BODY
Each half of the body has outer and inner surfaces, and
upper and lower borders.
The outer surface presents the following features.
a. The symphysis menti is the line at which the right
and left halves of the bone meet each other. It is
marked by a faint ridge (Fig. 1.23a).
b. The mental protuberance (mentum = chin) is a
median triangular projecting area in the lower part
of the midline. The inferolateral angles of the
protuberance form the mental tubercles.
c. The mental foramen lies below the interval between
the premolar teeth (Table 1.4).
d. The oblique line is the continuation of the sharp
anterior border of the ramus of the mandible. It
runs downwards and forwards towards the
mental tubercle.
e. The incisive fossa is a depression that lies just below Fig. 1.23b: Inner surface of right half of the mandible
the incisor teeth.
RAMUS
The inner surface presents the following features.
a. The mylohyoid line is a prominent ridge that runs The ramus is quadrilateral in shape and has:
obliquely downwards and forwards from below • Two surfaces—lateral and medial
the third molar tooth to the median area below • Four borders—upper, lower, anterior and posterior
the genial tubercles (see below) (Fig. 1.23b). • Two processes—coronoid and condyloid.
b. Below the mylohyoid line, the surface is slightly The lateral surface is flat and bears a number of oblique
hollowed out to form the submandibular fossa, ridges.
which lodges the submandibular gland. The medial surface presents the following.
c. Above the mylohyoid line, there is the sublingual 1 The mandibular foramen lies a little above the centre
fossa in which the sublingual gland lies. of ramus at the level of occlusal surfaces of the
d. The posterior surface of the symphysis menti is teeth. It leads into the mandibular canal which
marked by four small elevations called the superior descends into the body of the mandible and opens
and inferior genial tubercles. at the mental foramen (Fig. 1.23b).
e. The mylohyoid groove (present on the ramus) 2 The anterior margin of the mandibular foramen
extends onto the body below the posterior end of is marked by a sharp tongue-shaped projection
the mylohyoid line. called the lingula. The lingula is directed towards
The upper or alveolar border bears sockets for the teeth. the head or condyloid process of the mandible.
Head and Neck

The lower border of the mandible is also called the 3 The mylohyoid groove begins just below the
base. Near the midline, the base shows an oval mandibular foramen, and runs downwards and
depression called the digastric fossa. forwards to be gradually lost over the submandi-
bular fossa.
The upper border of the ramus is thin and is curved
downwards forming the mandibular notch.
The lower border is the backward continuation of the
base of the mandible. Posteriorly, it ends by becoming
continuous with the posterior border at the angle of the
mandible.
The anterior border is thin, while the posterior border
is thick.
The coronoid (Greek crow’s beak) process is a
flattened triangular upward projection from the
anterosuperior part of the ramus. Its anterior border is
continuous with the anterior border of the ramus. The
Fig. 1.23a: Outer surface of right half of the mandible posterior border bounds the mandibular notch.
HEAD AND NECK
34
The condyloid (Latin knuckle like) process is a strong 10 The platysma is inserted into the lower border
upward projection from the posterosuperior part of the (Fig. 1.24).
ramus. Its upper end is expanded from side-to-side to 11 Whole of the lateral surface of ramus except the
form the head. The head is covered with fibrocartilage posterosuperior part provides insertion to the
and articulates with the temporal bone to form the masseter muscle (Fig. 1.24).
temporomandibular joint. The constriction below 12 Posterosuperior part of the lateral surface is covered
the head is the neck. Its anterior surface presents a by the parotid gland.
depression called the pterygoid fovea. 13 Sphenomandibular ligament is attached to the
lingula (Fig. 1.23b).
ATTACHMENTS AND RELATIONS OF THE MANDIBLE 14 The medial pterygoid muscle is inserted on the
1 The oblique line on the lateral side of the body gives medial surface of the ramus, on the roughened area
origin to the buccinator as far forwards as the below and behind the mylohyoid groove (Fig. 1.25).
anterior border of the first molar tooth. In front of 15 The temporalis is inserted into the apex and medial
this origin, the depressor labii inferioris and the surface of the coronoid process. The insertion
depressor anguli oris arise from the oblique line extends downwards on the anterior border of the
below the mental foramen (Fig. 1.24). ramus (Fig. 1.24).
2 The incisive fossa gives origin to the mentalis and 16 The lateral pterygoid muscle is inserted into the
mental slips of the orbicularis oris. pterygoid fovea on the anterior aspect of the neck
(Fig. 1.24).
3 The parts of both the inner and outer surfaces just 17 The lateral surface of neck provides attachment to
below the alveolar margin are covered by the the lateral ligament of the temporomandibular joint
mucous membrane of the mouth. (see Fig. 6.9).
4 Mylohyoid line gives origin to the mylohyoid
muscle (Fig. 1.23b). FORAMINA AND RELATIONS TO NERVES AND VESSELS
5 Superior constrictor muscle of the pharynx arises 1 The mental foramen transmits the mental nerve and
from an area above the posterior end of the vessels (Fig. 1.24).
mylohyoid line.
2 The inferior alveolar nerve and vessels enter the
6 Pterygomandibular raphe is attached immediately mandibular canal through the mandibular foramen, and
behind the third molar tooth in continuation with run forwards within the canal.
the origin of superior constrictor. 3 The mylohyoid nerve and vessels lie in the mylohyoid
7 Upper genial tubercle gives origin to the genioglossus, groove (Fig. 1.25).
and the lower tubercle to geniohyoid (Fig. 1.25). 4 The lingual nerve is related to the medial surface of
8 Anterior belly of the digastric muscle arises from the ramus in front of the mylohyoid groove (Fig. 1.25).
the digastric fossa (Fig. 1.25). 5 The area above and behind the mandibular foramen
9 Deep cervical fascia (investing layer) is attached to is related to the inferior alveolar nerve and vessels and
the whole length of lower border. to the maxillary artery (Fig. 1.25).
Head and Neck
Fig. 1.24: Muscle attachments and relations of outer surface of the mandible
35
Fig. 1.25: Muscle attachments and relations of inner surface of the mandible
6 The masseteric nerve and vessels pass through the 2 At birth, the mental foramen opens below the sockets
mandibular notch (Fig. 1.24). for the two deciduous molar teeth near the lower
7 The auriculotemporal nerve and superficial temporal border. This is so because the bone is made up only
artery are related to the medial side of the neck of of the alveolar part with teeth sockets. The mandibular
mandible (Fig. 1.25). canal runs near the lower border. The foramen and
8 Facial artery is palpable on the lower border of
canal gradually shift upwards.
mandible at anteroinferior angle of masseter (Fig. 1.24).
3 The angle is obtuse. It is 140° or more because the
9 Facial and maxillary arteries are not accompanied
by respective nerves. The lingual nerve does not get head is in line with the body. The coronoid process
company of its artery. is large and projects upwards above the level of the
condyle.
OSSIFICATION
In Adults
The mandible is the second bone, next to the clavicle, to 1 The mental foramen opens midway between the
ossify in the body. Its greater part ossifies in membrane. upper and lower borders because the alveolar and
The parts ossifying in cartilage include the incisive sub-alveolar parts of the bone are equally developed.
part below the incisor teeth, the coronoid and condyloid The mandibular canal runs parallel with the mylo-
processes, and the upper half of the ramus above the hyoid line.
Head and Neck

level of the mandibular foramen. 2 The angle reduces to about 110° or 120° because the
Each half of the mandible ossifies from only one ramus becomes almost vertical (Fig. 1.26b).
centre which appears at about the sixth week of
In Old Age
intrauterine life in the mesenchymal sheath of Meckel’s
cartilage near the future mental foramen. Meckel’s 1 Teeth fall out and the alveolar border is absorbed,
cartilage is the skeletal element of first pharyngeal so that the height of body is markedly reduced
arch. (Fig. 1.26c).
2 The mental foramen and the mandibular canal are close
At birth, the mandible consists of two halves to the alveolar border.
connected at the symphysis menti by fibrous tissue. 3 The angle again becomes obtuse about 140° because
Bony union takes place during the first year of life. the ramus is oblique.
AGE CHANGES IN THE MANDIBLE STRUCTURES RELATED TO MANDIBLE

In Infants and Children Salivary glands: Parotid, submandibular and sublingual
(Figs 1.23a and b).
1 The two halves of the mandible fuse during the first
year of life (Fig. 1.26a). Lymph nodes: Parotid, submandibular and submental.
HEAD AND NECK
36
Figs 1.26a to c: Age changes in the mandible
Arteries: Maxillary, superficial temporal, masseteric, MAXILLA

inferior alveolar, mylohyoid, mental and facial
(Fig. 1.24). Maxilla (cheek) is the second largest bone of the face,
Nerves: Lingual, auriculotemporal, masseteric, inferior the first being the mandible. The two maxillae form the
alveolar, mylohyoid and mental (Fig. 1.25). whole of the upper jaw, and each maxilla forms a part
each in the formation of face, nose, mouth, orbit, the
Muscles of mastication: Insertions of temporalis, infratemporal and pterygopalatine fossae.
masseter, medial pterygoid and lateral pterygoid.
Ligaments: Lateral ligament of temporomandibular SIDE DETERMINATION
joint, stylomandibular ligament, sphenomandibular 1 Anterior surface ends medially into a deeply concave
and pterygomandibular raphe (Fig. 1.25). border, called the nasal notch. Posterior surface is
convex (Fig. 1.28).
CLINICAL ANATOMY 2 Alveolar border with sockets for upper teeth faces
downwards with its convexity directed outwards.
• The mandible is commonly fractured at the canine Frontal process is the longest process which is
socket where it is weak (Fig. 1.27). Involvement directed upwards.
of the inferior alveolar nerve in the callus may 3 Medial surface is marked by a large irregular
cause neuralgic pain, which may be referred to opening, the maxillary hiatus/antrum of Highmore
the areas of distribution of the buccal and for maxillary air sinus.
auriculotemporal nerves. If the nerve is paralysed,
the areas supplied by these nerves become FEATURES
Head and Neck
insensitive.
• The next common fracture of the mandible occurs Each maxilla has a body and four processes—the
at the angle and neck of mandible (Fig. 1.27). frontal, zygomatic, alveolar and palatine.
Body
The body of maxilla is pyramidal in shape, with its base
directed medially at the nasal surface, and the apex
directed laterally at the zygomatic process. It has four
surfaces and encloses a large cavity, the maxillary sinus
described in Chapter 15.
The surfaces are:
• Anterior or facial,
• Posterior or infratemporal,
• Superior or orbital, and
• Medial or nasal.
Fig. 1.27: Fracture of the mandible at the neck, at the angle Anterior or Facial Surface
and at canine fossa
1 Anterior surface is directed forwards and laterally.
37
Fig. 1.28: Lateral aspect of maxilla with muscular attachments
2 Above the incisor teeth, there is a slight depression, 5 Above the maxillary tuberosity, the smooth surface
the incisive fossa, which gives origin to depressor forms anterior wall of pterygopalatine fossa, and is
septi. Incisivus arises from the alveolar margin below grooved by maxillary nerve.
the fossa, and the nasalis superolateral to the fossa
along the nasal notch. Superior or Orbital Surface
3 Lateral to canine eminence, there is a larger and 1 Superior surface is smooth, triangular and slightly
deeper depression, the canine fossa, which gives concave, and forms the greater part of the floor of
origin to levator anguli oris. orbit.
4 Above the canine fossa, there is infraorbital foramen, 2 Anterior border forms a part of infraorbital margin.
which transmits infraorbital nerve and vessels (Fig. 1.28). Medially, it is continuous with the lacrimal crest of
5 Levator labii superioris arises between the infraorbital the frontal process.
margin and infraorbital foramen. 3 Posterior border is smooth and rounded, it forms most
6 Medially, the anterior surface ends in a deeply of the anterior margin of inferior orbital fissure. In
concave border, the nasal notch, which terminates the middle, it is notched by the infraorbital groove.
below into process which with the corresponding
4 Medial border presents anteriorly the lacrimal notch
process of opposite maxilla forms the anterior nasal
which is converted into nasolacrimal canal by the
spine. Anterior surface bordering the nasal notch
descending process of lacrimal bone. Behind the
Head and Neck

gives origin to nasalis and depressor septi.
notch, the border articulates from before backwards
Posterior or Infratemporal Surface with the lacrimal, labyrinth of ethmoid, and the orbital
process of palatine bone (Fig. 1.29).
1 Posterior surface is convex and directed backwards
and laterally. 5 The surface presents infraorbital groove leading
forwards to infraorbital canal which opens on the
2 It forms the anterior wall of infratemporal fossa, and anterior surface as infraorbital foramen. The groove,
is separated from anterior surface by the zygomatic canal and foramen transmit the infraorbital nerve and
process and a rounded ridge which descends from vessels. Near the midpoint, the canal gives off laterally
the process to the first molar tooth. a branch, the canalis sinuous, for the passage of
3 Near the centre of the surface open two or three anterior superior alveolar nerve and vessels.
alveolar canals for posterior superior alveolar nerve and 6 Inferior oblique muscle of eyeball arises from a
vessels. depression just lateral to lacrimal notch at the
4 Posteroinferiorly, there is a rounded eminence, the anteromedial angle of the surface.
maxillary tuberosity, which articulates superomedially
with pyramidal process of palatine bone, and gives Medial or Nasal Surface
origin laterally to the superficial head of medial 1 Medial surface forms a part of the lateral wall of
pterygoid muscle. nose.
HEAD AND NECK
38
Fig. 1.29: Medial aspect of intact maxilla
2 Posterosuperiorly, it displays a large irregular opening 7 More anteriorly, an oblique ridge forms the conchal
of the maxillary sinus, the maxillary hiatus (Fig. 1.30). crest for articulation with the inferior nasal concha.
3 Above the hiatus, there are parts of air sinuses which 8 Above the conchal crest, the shallow depression
are completed by the ethmoid and lacrimal bones. forms a part of the atrium of middle meatus of nose.
4 Below the hiatus, the smooth concave surface forms
a part of inferior meatus of nose. Processes of Maxilla
5 Behind the hiatus, the surface articulates with Zygomatic Process
perpendicular plate of palatine bone, enclosing the The zygomatic process is a pyramidal lateral projection
greater palatine canal which runs downwards and on which the anterior, posterior, and superior surfaces
forwards, and transmits greater palatine vessels and of maxilla converge. In front and behind, it is
the anterior, middle and posterior palatine nerves (Fig. 1.12). continuous with the corresponding surfaces of the
6 In front of the hiatus, there is nasolacrimal groove, body, but superiorly it is rough for articulation with
which is converted into the nasolacrimal canal by the zygomatic bone.
articulation with the descending process of lacrimal bone
and the lacrimal process of inferior nasal concha. The Frontal Process
canal transmits nasolacrimal duct to the inferior meatus 1 The frontal process projects upwards and backwards
of nose. to articulate above with the nasal margin of frontal
Head and Neck
Fig. 1.30: Medial aspect of disarticulated left maxilla

39
bone, in front with nasal bone, and behind with 3 Superior surface is concave from side-to-side, and
lacrimal bone. forms greater part of the floor of nasal cavity.
2 Lateral surface is divided by a vertical ridge, the 4 Medial border is thicker in front than behind. It is
anterior lacrimal crest, into a smooth anterior part and raised superiorly into the nasal crest.
a grooved posterior part. Groove between the nasal crests of two maxillae
The lacrimal crest gives attachment to lacrimal fascia receives lower border of vomer; anterior part of the
and the medial palpebral ligament, and is continuous ridge is high and is known as incisor crest which
below with the infraorbital margin. terminates anteriorly into the anterior nasal spine
(Fig. 1.28).
The anterior smooth area gives origin to the orbital Incisive canal traverses near the anterior part of the
part of orbicularis oculi and levator labii superioris medial border.
alaeque nasi. The posterior grooved area forms the 5 Posterior border articulates with horizontal plate of
anterior half of the floor of lacrimal groove (Fig. 1.45). palatine bone.
3 Medial surface forms a part of the lateral wall of nose. 6 Lateral border is continuous with the alveolar process.
The surface presents following features:
a. Uppermost area is rough for articulation with ARTICULATIONS OF MAXILLA
ethmoid to close the anterior ethmoidal sinuses. 1 Superiorly, it articulates with three bones—the nasal,
b. Ethmoidal crest is a horizontal ridge about the frontal and lacrimal.
middle of the process. Posterior part of the crest 2 Medially, it articulates with five bones—the ethmoid,
articulates with middle nasal concha, and the ante- inferior nasal concha, vomer, palatine and opposite
rior part lies beneath the agger nasi (see Fig. 15.8). maxilla.
c. The area below the ethmoidal crest is hollowed 3 Laterally, it articulates with one bone—the zygomatic.
out to form the atrium of the middle meatus.
d. Below the atrium is the conchal crest which OSSIFICATION
articulates with inferior nasal concha.
e. Below the conchal crest, there lies the inferior Maxilla ossifies in membrane from three centres, one
meatus of the nose with nasolacrimal groove for the maxilla proper, and two for os incisivum or
ending just behind the crest (see Fig. 15.8). premaxilla. The centre for maxilla proper appears
above the canine fossa during sixth week of intra-
Alveolar Process uterine life.
1 The alveolar process forms half of the alveolar arch, Of the two premaxillary centres, the main centre
and bears sockets for the roots of upper 8 teeth. In appears above the incisive fossa during seventh week
adults, there are eight sockets: Canine socket is deepest; of intrauterine life. The second centre (paraseptal or
molar sockets are widest and divided into three minor prevomerine) appears at the ventral margin of nasal
sockets by septa; the incisor and second premolar sockets septum during tenth week and soon fuses with the
are single; and the first premolar socket is sometimes palatal process of maxilla. Though premaxilla begins
divided into two. to fuse with alveolar process almost immediately
Head and Neck

2 Buccinator arises from the posterior part of its outer after the ossification begins, the evidence of
surface up to the first molar tooth (Fig. 1.28). premaxilla as a separate bone may persist until the
3 A rough ridge, the maxillary torus, is sometimes pre- middle decades.
sent on the inner surface opposite the molar sockets.
AGE CHANGES
Palatine Process 1 At birth:
1 Palatine process is a thick horizontal plate projecting a. The transverse and anteroposterior diameters are
medially from the lowest part of the nasal surface. It each more than the vertical diameter.
forms a large part of the roof of mouth and the floor b. Frontal process is well marked.
of nasal cavity (Fig. 1.30). c. Body consists of a little more than the alveolar
2 Inferior surface is concave, and the two palatine process, the tooth sockets reaching to the floor of
processes form anterior three-fourths of the bony orbit.
palate. It presents numerous vascular foramina and d. Maxillary sinus is a mere furrow on the lateral wall
pits for palatine glands. of the nose.
Posterolaterally, it is marked by two anteroposterior 2 In the adult: Vertical diameter is greatest due to
grooves for the greater palatine vessels and anterior development of the alveolar process and increase in
palatine nerves. the size of the sinus.
HEAD AND NECK
40
3 In the old: The bone reverts to infantile condition. Its Borders

height is reduced as a result of absorption of the 1 Superior or sagittal
alveolar process. 2 Inferior or squamosal
3 Anterior or frontal
PARIETAL BONE 4 Posterior or occipital
Two parietal bones form a large part of the roof and Angles
sides of vault of skull. Each bone is roughly quadrilateral 1 Anterosuperior or frontal
in shape with its convexity directed outwards (Fig. 1.31). 2 Anteroinferior or sphenoidal
3 Posterosuperior or occipital
SIDE DETERMINATION
4 Posteroinferior or mastoid
Outer surface is convex and smooth, inner surface is
concave and depicts vascular markings. At each of the four angles, are four fontanelles. These
Anteroinferior angle is pointed and shows a groove are:
for anterior division of middle meningeal artery. 1 One anterior fontanelle—closes at 18 months.
2 One posterior fontanelle—closes at 3 months
FEATURES 3 Two anterolateral or sphenoidal fontanelles—close
Parietal bone has two surfaces, four borders, and four at 3 months.
angles. 4 Two posterolateral or mastoid fontanelles—close at
about 12 months of life.
Surfaces Details can be studied from norma verticalis and norma
1 Outer convex lateralis and inner aspect of skull cap.
2 Inner concave (Fig. 1.32)
OCCIPITAL BONE
Single occipital bone occupies posterior and inferior
parts of the skull (Fig. 1.33).
ANATOMICAL POSITION
It is concave forwards and encloses the largest foramen
of skull, foramen magnum, through which cranial
cavity communicates with the vertebral canal.
On each side of foramen magnum is the occipital
condyle which articulates with atlas vertebra.
Head and Neck
FEATURES
Fig. 1.31: Outer surface of left parietal bone Occipital bone is divided into three parts:
1 Squamous part—above, below and behind foramen
magnum.
2 Basilar part—lies in front of foramen magnum.
3 Condylar or lateral part—on each side of foramen
magnum.
Squamous Part
Comprises two surfaces, three angles and four borders.
Surfaces: External convex surface and internal concave
surface.
Angles: One superior angle and two lateral angles.
Borders: Two lambdoid borders in upper part and two
Fig. 1.32: Inner surface of left parietal bone mastoid borders in lower part.
41
Fig. 1.33: Inner surface of occipital bone
Basilar Part Outer Surface

The basilar part of occipital bone is called basiocciput. It is smooth and shows:
It articulates with basisphenoid to form the base of 1 Frontal tuberosity
skull. It is quadrilateral in shape and comprises two 2 Superciliary arches
surfaces and four borders. 3 Glabella
Surfaces are superior and inferior.
4 Frontal air sinus is a cavity within outer and inner
Borders are anterior, posterior and lateral, on each side.
tables of frontal bone, divided by a bony septum
Condylar Part into two parts
It comprises: 5 Metopic suture
• Superior surface 6 Upper or parietal border: Articulates with parietal
• Inferior surface which shows occipital condyles and bone
hypoglossal canal. 7 Lower or orbital border: Free, presents supra-orbital
The details can be read from descriptions of norma notch foramen
Head and Neck

occipitalis and posterior cranial fossa. 8 Zygomatic process
9 Temporal line and temporal surfaces
FRONTAL BONE
Inner Surface
Frontal bone forms the forehead, most of the roof of It is concave and presents:
orbit, and most of the floor of anterior cranial fossa. Its 1 Sagittal sulcus
parts are squamous, orbital and nasal bones (Fig. 1.34). 2 Frontal crest
ANATOMICAL POSITION Orbital Parts (Plates)

Squamous part is vertical and is convex forwards. Orbital plates are separated from each other by a wide
Two orbital plates are horizontal thin plates gap—the ethmoidal notch.
projecting backwards. Orbital or inferior surface of the plate is smooth and
Nasal part is directed forwards and downwards. presents lacrimal fossa, anterolaterally and trochlear
spine, anteromedially.
Squamous Part Ethmoidal notch is occupied by cribriform plate of
The squamous part presents two surfaces, two borders ethmoid bone. On each side of notch are small air spaces
and encloses a pair of frontal air sinuses. which articulates with the labyrinth of ethmoid to
HEAD AND NECK
42
Fig. 1.34: Frontal bone from below
complete ethmoidal air sinuses. At the margins are SIDE DETERMINATION

anterior and posterior ethmoidal canals. • Plate-like squamous part is directed upwards and
Nasal Part laterally.
• Strong zygomatic process is directed forwards.
Lies between two supraorbital margins. • Petrous part, triangular in shape, is directed medially.
The margins of the nasal notch on each side articulate • External acoustic meatus, enclosed between squa-
with nasal, frontal process of maxilla and lacrimal bones. mous and tympanic parts, is directed laterally.
Details can be studied from descriptions of norma
frontalis, norma lateralis, inner aspect of skull cap and FEATURES
anterior cranial fossa.
It comprises following parts:
TEMPORAL BONE a. Squamous part (Fig. 1.35)
b. Petromastoid part
Temporal bones are situated at the sides and base of c. Tympanic part
skull. d. Styloid process
Head and Neck
Fig. 1.35: Outer aspect of left temporal bone

43
Squamous Part Borders

Two surfaces: Outer and inner Superior border: Articulates with parietal bone.
Two borders: Superior and anteroinferior Anteroinferior border: Articulates with greater wing of
sphenoid bone.
Surfaces
Outer or temporal Petromastoid Part
It is smooth and forms a part of temporal fossa. Mastoid Part
Above external acoustic meatus, there is a groove Mastoid (Greek breast) part forms posterior part of
for middle temporal artery. temporal bone. It has:
Its posterior part presents supramastoid crest. • Two surfaces—outer and inner
• Two borders—superior and posterior, and enclose the
Below the anterior end of supramastoid crest and
mastoid air cells. (The outer surface forms a downwards
posterosuperior to external acoustic meatus, there is
projecting conical process, the mastoid process.)
suprameatal triangle.
Zygomatic process springs forwards from the outer Surfaces
surface of squamous part. Its posterior part comprises Outer: The outer surface gives attachment to occipitalis
superior and inferior surfaces. The inferior surface is muscle. Mastoid foramen opens near its posterior
bounded by two roots which converge at the tubercle border and transmits an emissary vein and a branch of
of root of the zygoma. Anterior root projects as the occipital artery.
articular tubercle in front of mandibular fossa. Mastoid process appears at the end of 2nd year.
Posterior root begins above the external acoustic Lateral surface gives attachment to sternocleidomastoid,
meatus. splenius capitis, and longissimus capitis (Fig. 1.14).
Mandibular fossa lies behind articular tubercle and Medial surface of the process shows a deep mastoid
consists of anterior articular part formed by squamous notch for the origin of posterior belly of digastric.
part of temporal bone and a posterior non-articular Medial to this notch is a groove for the occipital artery.
portion formed by tympanic plate. Inner: The inner surface is marked by a deep sigmoid
sulcus (Fig. 1.36).
Inner or cerebral
Borders
It is concave and shows grooves for the middle
meningeal vessels. Its superior border articulates with Superior border: Articulates with parietal bone at asterion.
the lower border of parietal bone. Its anteroinferior Posterior border: Articulates with occipital bone at
border articulates with the greater wing of sphenoid. occipitomastoid suture.
Head and Neck
Fig. 1.36: Inner aspect of the left temporal bone

HEAD AND NECK
44
Petrous Part
Petrous (Latin rock) part is triangular in shape. It has a
base, an apex, three surfaces—anterior, posterior and
inferior; and three borders—superior, anterior and
posterior.
Base is fused with squamous and mastoid parts.
Apex is irregular and forms posterolateral boundary
of foramen lacerum.
Surfaces
Anterior:
• Trigeminal impression
• Part forming roof of anterior part of carotid canal.
• Arcuate eminence
• Tegmen tympani lying most laterally. In the anterior
part of tegmen tympani are hiatus and groove for
greater petrosal nerve and a smaller hiatus and
groove for the lesser petrosal nerve.
Posterior: Internal acoustic meatus is present here.
Aqueduct of vestibule lies behind internal acoustic
meatus.
Inferior: Forms part of norma basalis. It shows lower
opening of carotid canal (refer to norma basalis for
details). Jugular fossa lies behind carotid canal
(Fig. 1.37).
Borders
a. Superior: It is grooved by superior petrosal sinus.
Margins of the groove provide attachment to Fig. 1.37: Inferior view of the temporal bone
tentorium cerebelli.
b. Anterior: Medial part articulates with greater wing Upper and lower borders, which in its lateral part,
of sphenoid. Lateral part joins squamous part of split to enclose the root of styloid process.
petrosquamosal suture.
c. Posterior: Medial part forms a sulcus for inferior External Acoustic Meatus
petrosal sinus with a similar sulcus on occipital bone. Bony part of meatus is about 16 mm long.
The lateral part forms anterior boundary of jugular Its anterior wall, floor and lower part of posterior
foramen whose posterior boundary is formed by wall are formed by tympanic part. Its roof and upper
Head and Neck
jugular notch of occipital bone. half of the posterior wall are formed by the squamous
Tympanic Part part (Fig. 1.35).
Its inner end is closed by tympanic membrane.
It is a curved plate of bone below squamous part and
in front of mastoid process. It comprises two surfaces, Styloid Process
three borders and an external acoustic meatus.
Styloid (Greek pillar form) process is long pointed
Surfaces process directed downwards, forwards and medially
between parotid gland and internal jugular vein
Anterior and posterior concave part forming anterior
(Fig. 1.36).
wall, floor and lower part of the posterior wall of
external acoustic meatus. • Its base is related to facial nerve
• Its apex is crossed by external carotid artery.
Borders • It gives attachment to three muscles and two
Lateral border forms the margin of external acoustic ligaments (see Chapter 8) (refer to norma lateralis for
meatus. details).
45
SPHENOID BONE Opening of sphenoidal air sinus is seen (Fig. 1.39b).

Sphenoidal conchae close the sphenoid air sinuses
Sphenoid (Greek wedge) bone resembles a bat with out- leaving the openings. Each half of anterior surface has
stretched wings. It comprises: two parts—superolateral and inferomedial.
• A body in the centre (Fig. 1.38). The superolateral depression articulates with
• Two lesser wings from the anterior part of body. labyrinth of ethmoid to complete the posterior
• Two greater wings from the lateral part of body. ethmoidal air sinuses. The inferomedial smooth tri-
• Two pterygoid (wing-like) processes, directed down- angular area forms the posterior part of the root of the
wards from the junction of body and greater wings. nose.
Posterior Surface
BODY OF SPHENOID
It articulates with basilar part of occipital bone.
It comprises six surfaces and enclose a pair of
sphenoidal air sinuses. Lateral Surfaces
Carotid sulcus, a broad groove curved like letter ‘f’ for
Superior or Cerebral Surface
lodging cavernous sinus and internal carotid artery.
It articulates with ethmoid bone anteriorly and basilar Below the sulcus, it articulates with greater wing of
part of occipital bone posteriorly. It shows: sphenoid laterally and with pterygoid process which
1 Jugum sphenoidale is directed downwards.
2 Sulcus chiasmaticus
3 Tuberculum sellae Sphenoidal Air Sinuses
4 Sella turcica These are asymmetrical air sinuses in the body of
5 Dorsum sellae sphenoid, and are closed by sphenoidal conchae. The
6 Clivus sinus opens into the lateral wall of nose in the spheno-
Refer to middle cranial fossa for details. ethmoidal recess above the superior concha.
Inferior Surface GREATER WINGS

1 Rostrum of sphenoid (Fig. 1.39a) These are two strong processes which curve laterally
2 Sphenoid conchae (Fig. 1.39b) and upwards from the sides of the body. It has three
surfaces.
3 Vaginal processes of medial pterygoid plate
Refer to norma basalis for details. Superior or Cerebral Surface
It forms the floor of middle cranial fossa and presents
Anterior Surface from before backwards:
Sphenoidal crest articulates with perpendicular plate 1 Foramen rotundum (Fig. 1.39a)
of ethmoid to form a small part of septum of nose. 2 Foramen ovale
Head and Neck
Fig. 1.38: Superior view of the sphenoid bone

HEAD AND NECK
46
Figs 1.39a and b: (a) Posterior view of sphenoid; (b) Greater and lesser wings of sphenoid
3 Emissary sphenoidale foramen LESSER WINGS

4 Foramen spinosum Lesser wings are two triangular plates projecting
laterally from the anterosuperior part of the body. It
Lateral Surface comprises:
Head and Neck
A horizontal ridge, the infratemporal crest divides • A base forming medial end of the wing. It is connected
this surface into upper or temporal surface and a to the body by two roots which enclose the optic canal.
lower or infratemporal surface. It is pierced by • Tip forms the lateral end of the wing.
foramen ovale and foramen spinosum. Its posterior • Superior surface forming floor of anterior cranial fossa.
part presents spine of sphenoid. • Inferior surface forming upper boundary of superior
Refer to norma basalis for details. orbital fissure.
• Anterior border articulates with the posterior border
Orbital Surface
of orbital plate of frontal bone.
Forms the posterior wall of the lateral wall of orbit. • Posterior border is free and projects into the stem of
Its medial border bears a small tubercle for lateral sulcus of brain. Medially, it terminates into
attachment of a common tendinous ring for the origin the anterior clinoid process.
of recti muscles of the eyeball. Below the medial end of
superior orbital fissure, the grooved area forms the Superior Orbital Fissure
posterior wall of the pterygopalatine fossa and is It is a triangular gap through which middle cranial fossa
pierced by foramen rotundum (Fig. 1.39b). communicates with the orbit. The structures passing
Borders are surrounding the greater wing of through it are put in list of foramina and structures
sphenoid. passing through them (see Fig. 13.4).
47
PTERYGOID PROCESSES Ethmoid bone comprises:

One pterygoid (Greek wing) process on each side projects 1 Cribriform plate (Fig. 1.40b)
downwards from the junction of the body with the 2 Perpendicular plate
greater wing of sphenoid (Fig. 1.38). 3 A pair of labyrinth
Each pterygoid process divides inferiorly into the CRIBRIFORM PLATE
medial and lateral pterygoid plates. The plates are fused
together in their upper parts, but are separated in their It is a horizontal perforated bony lamina, occupying
lower parts by the pterygoid fissure. Posteriorly, the ethmoidal notch of frontal bone. It contains foramina
pterygoid plates enclose a ‘V-shaped interval’, the for olfactory nerve rootlets.
pterygoid fossa. The medial pterygoid plate in its upper Crista Galli
part presents a scaphoid fossa.
Crista galli is a median, tooth-like upward projection
Refer to norma basalis for medial and lateral pterygoid in the floor of anterior cranial fossa. Foramen
plates. transmitting anterior ethmoidal nerve to nasal cavity
is situated by the side of crista galli.
ETHMOID BONE PERPENDICULAR PLATE
Ethmoid (Greek sieve) is a very light cuboidal bone It is a thin lamina projecting downwards from the under-
surface of the cribriform plate, forming upper part of
situated in the anterior of base of cranial cavity between
nasal septum.
the two orbits. It forms:
1 Part of medial orbital walls LABYRINTHS
2 Part of nasal septum (Fig. 1.40a) These are two light cubical masses situated on each side
3 Part of medial wall of orbit of the perpendicular plate, suspended from the
4 Lateral walls of the nasal cavity undersurface of the cribriform plate (Fig. 1.40c).
Head and Neck
Figs 1.40a to c: (a) Articulations of perpendicular plate of ethmoid bone; (b) Posterior view of the ethmoid bone; (c) Ethmoid bone
articulating with neighbouring bones
HEAD AND NECK
48
Each labyrinth also encloses large number of ‘air INFERIOR NASAL CONCHAE
cells’ arranged in three groups—the anterior, middle
and posterior ethmoidal air sinuses. Its surfaces are:
The inferior nasal conchae are two curved bony
• Anterior surface articulates with frontal process of
laminae, these are horizontally placed in the lower part
maxilla to complete anterior ethmoidal air cells.
of lateral walls of the nose. Between this concha and
• Posterior surface articulates with sphenoidal concha
floor of the nose lies the inferior meatus of the nose. It
to complete posterior ethmoidal air cells.
comprises two surfaces, two borders and two ends.
• Superior surface articulates with orbital plate of
• Medial convex surface is marked by vascular
frontal bone.
grooves.
• Inferior surface articulates with nasal surface of
maxilla. • Lateral concave surface forms the medial wall of
• Lateral surface forms medial wall of orbit. inferior meatus of the nerve.
• Medial surface presents small superior nasal concha, • Superior border is irregular and articulates with
middle nasal concha, superior meatus below lacrimal, maxilla, ethmoid and palatine bones (Fig. 1.42).
superior concha, and middle meatus below middle • Inferior border is free, thick and spongy.
concha. • Posterior end is more pointed than the anterior end.
VOMER
Vomer (Latin plough share) is a single thin, flat bone

forming posteroinferior part of the nasal septum. It
comprises:
• Right and left surfaces marked by nasopalatine
nerves which course downwards and forwards.
• Superior border splits into two alae with a groove is
occupied by rostrum of sphenoid (Fig. 1.41).
• Inferior border articulates with nasal crests of
maxillae and palatine bones. Fig. 1.42: Lateral view of the left inferior nasal concha
• Anterior, longest border, articulates with per-
pendicular plate of ethmoid above and with septal
cartilage below. ZYGOMATIC BONES
• Posterior border is free and separates the two
posterior nasal openings. These are two small quadrilateral bones present in the
upper and lateral part of face. The bone forms
prominence of the cheeks. Each bone takes part in the
formation of:
• Floor and lateral wall of the orbit
Head and Neck
• Walls of temporal and infraorbital fossae.

Zygomatic bone comprises three surfaces, five
borders and two processes.
Surfaces
1 Lateral surface presenting zygomaticofacial foramen
(Fig. 1.43a).
2 Temporal surface is smooth and concave and
presents zygomaticotemporal foramen (Fig.1.43b).
3 Orbital surface is also smooth and concave one or
two zygomatico-orbital foramen on this surface and
this leads to zygomaticofacial and zygomatico-
temporal foramina (Fig. 1.22a).
Borders
1 Anterosuperior or orbital
Fig. 1.41: Vomer forming posteroinferior part of the nasal 2 Anteroinferior or maxillary
septum with its various borders 3 Posteroinferior or temporal border
49
Surfaces
1 The outer surface is convex from side-to-side.
2 The inner surface is concave from side-to-side and
is traversed by a vertical groove for anterior
ethmoidal nerve.
Borders
1 Superior border is thick and serrated and articulates
with nasal part of frontal bone.
2 Inferior border is thin and notched and articulates
with lateral nasal cartilage.
3 Medial border articulates with opposite nasal bone.
4 Lateral border articulates with frontal process of
maxilla.
LACRIMAL BONES
Lacrimal bones are extremely delicate and smallest of

the skull bones. These form the anterior part of the
medial part of the orbit. Each lacrimal bone comprises
two surfaces and four borders.
Figs 1.43a and b: Features of the left zygomatic bone: (a) Outer
view; (b) Inner view Surfaces
1 Lateral or orbital surface is divided by posterior
4 Posteroinferior border lacrimal crest into anterior and posterior parts. The
5 Posteromedial border anterior grooved part forms posterior half of the floor
of lacrimal groove for lacrimal sac. The posterior
Processes smooth part forms part of medial wall of orbit.
1 Frontal process, which is directed upwards. 2 Medial or nasal surface forms a part of middle
2 Temporal process, which is directed backwards. meatus of the nose (Fig. 1.45).
Borders
NASAL BONES
1 Anterior border articulates with frontal process of
Nasal bones are two small oblong bones, which form maxilla.
the bridge of the nerve. 2 Posterior border with orbital plate of ethmoid.
Each nasal bone has two surfaces and four borders 3 Superior border with frontal bone.
(Fig. 1.44). 4 Inferior border with orbital surface of maxilla.
Head and Neck
Fig. 1.44: Inner view of the left nasal bone Fig. 1.45: Lateral surface of the left lacrimal bone
HEAD AND NECK
50
PALATINE BONES HYOID BONE
Palatine bones are two L-shaped bones present in the The hyoid (Greek U-shaped) bone is U-shaped.
posterior part of nasal cavity. Each bone forms: It develops from second and third branchial arches.
• Lateral wall and floor of nasal cavity (Fig. 1.46a). It is situated in the anterior midline of the neck between
• Roof of mouth cavity the chin and the thyroid cartilage (refer to BDC App).
• Floor of the orbit
At rest, it lies at the level of the third cervical vertebra
• Parts of pterygopalatine fossa
behind and the base of the mandible in front.
Each palatine bone has two plates and three processes.
It is kept suspended in position by muscles and
Plates ligaments.
1 Horizontal plate forms posterior one-fourth part The hyoid bone provides attachment to the muscles
of bony palate. It has two surfaces and four borders of the floor of the mouth and to the tongue above, to
(Fig. 1.46b). the larynx below, and to the epiglottis and pharynx
2 Perpendicular plate of palatine bone is oblong in behind (Fig. 1.47).
shape and comprises two surfaces and four borders The bone consists of the central part, called the
(refer to norma basalis). body, and of two pairs of cornua—greater and lesser.
Processes Body
Pyramidal It has two surfaces—anterior and posterior, and two
Pyramidal process projects downwards from the borders—upper and lower.
junction of two plates. Its inferior surface is pierced by The anterior surface is convex and is directed forwards
lesser palatine foramina. and upwards. It is often divided by a median ridge into
two lateral halves.
Orbital The posterior surface is concave and is directed
Orbital process projects upwards and laterally from backwards and downwards.
the perpendicular plate. Its orbital surface is triangular Each lateral end of the body is continuous posteriorly
and forms the posterior part of the floor of the orbit with the greater horn or cornua. However, till middle
(Fig. 1.46b). life, the connection between the body and greater
cornua is fibrous.
Sphenoidal
Sphenoidal process projects upwards and medially Greater Cornua
from the perpendicular plate. Its lateral surface These are flattened from above downwards. Each
articulates with medial pterygoid plate. cornua tapers posteriorly, but ends in a tubercle. It has
Head and Neck
Figs 1.46a and b: (a) Medial view of the left palatine bone; (b) Various processes of palatine bone
51
Fig. 1.47: Anterosuperior view of the left half of hyoid bone showing its attachments (Inset: Hyoid bone)
two surfaces—upper and lower, two borders—medial muscle arises from its posterolateral aspect extending
and lateral and a tubercle. onto the greater cornua (see Fig. 14.21).
Lesser Cornua DEVELOPMENT

These are small conical pieces of bone which project Upper part of body and lesser cornua develop from
upwards from the junction of the body and greater second branchial arch, while lower part of body and
cornua. The lesser cornua are connected to the body greater cornua develop from the third arch.
by fibrous tissue. Occasionally, they are connected to
the greater cornua by synovial joints which usually
persist throughout life, but may get ankylosed. CLINICAL ANATOMY
In a suspected case of murder, fracture of the hyoid
ATTACHMENTS ON THE HYOID BONE bone strongly indicates throttling or strangulation.
The anterior surface of the body provides insertion to
the geniohyoid and mylohyoid muscles and gives Competency achievement: The student should be able to:
origin to a part of the hyoglossus which extends to the AN 26.5 Describe features of typical and atypical cervical vertebrae
greater cornua (Fig. 1.47). (atlas and axis).8
The upper border of the body provides insertion to
the lower fibres of the genioglossi and attachment to
Head and Neck

the thyrohyoid membrane. CERVICAL VERTEBRAE
The lower border of the body provides attachment to
IDENTIFICATION
the pretracheal fascia. In front of the fascia, the
sternohyoid is inserted medially and the superior belly The cervical vertebrae are identified by the presence of
of omohyoid laterally. foramina transversaria.
Below the omohyoid, there is the linear attachment There are seven cervical vertebrae, out of which the
of the thyrohyoid, extending back to the lower border third to sixth are typical, while the first, second and
of the greater cornua. seventh are atypical (Figs 1.48a and b) (refer to BDC App).
The medial border of the greater cornua provides
attachment to the thyrohyoid membrane, stylohyoid TYPICAL CERVICAL VERTEBRAE
muscle and digastric pulley. Body
The lateral border of the greater cornua provides 1 The body is small and broader from side-to-side than
insertion to the thyrohyoid muscle anteriorly. The from before backwards.
investing fascia is attached throughout its length. 2 Its superior surface is concave transversely with
The lesser cornua provides attachment to the upward projecting lips on each side. The anterior
stylohyoid ligament at its tip. The middle constrictor border of this surface may be bevelled.
HEAD AND NECK
52
3 The superior and inferior articular processes form

articular pillars which project laterally at the junction
of pedicle and the lamina. The superior articular
facets are flat. They are directed backwards and
upwards. The inferior articular facets are also flat
but are directed forwards and downwards.
4 The transverse processes are pierced by foramina
transversaria. Each process has anterior and posterior
roots which end in tubercles joined by the costo-
transverse bar. The costal element is represented by the
anterior root, anterior tubercle, the costotransverse bar
and the posterior tubercle. The anterior tubercle of the
sixth cervical vertebra is large and is called the carotid
tubercle because the common carotid artery can be
compressed against it.
Figs 1.48a and b: Cervical vertebrae: (a) Anterior view; (b) Lateral 5 The spine is short and bifid. The notch is filled up by
view the ligamentum nuchae (Fig. 1.49).
Attachments and Relations

3 The inferior surface is saddle-shaped, being convex
from side-to-side and concave from before 1 The anterior and posterior longitudinal ligaments are
backwards. The lateral borders are bevelled and form attached to the upper and lower borders of the body
synovial joints with the projecting lips of the next in front and behind, respectively. On each side of
lower vertebra. The anterior border projects the anterior longitudinal ligament, the vertical part
downwards and may hide the intervertebral disc. of the longus colli is attached to the anterior surface.
4 The anterior and posterior surfaces resemble those of The posterior surface has two or more foramina for
other vertebrae (Fig. 1.49). passage of basivertebral veins.
2 The upper borders and lower parts of the anterior
Vertebral Foramen surfaces of the laminae provide attachment to the
Vertebral foramen is larger than the body. It is ligamenta flava.
triangular in shape because the pedicles are directed 3 The foramen transversarium transmits the vertebral
backwards and laterally. artery, the vertebral veins and a branch from the inferior
cervical ganglion. The anterior tubercles give origin to
Vertebral Arch the scalenus anterior, the longus capitis, and the
1 The pedicles are directed backwards and laterally. The oblique part of the longus colli.
superior and inferior vertebral notches are of equal size. 4 The costotransverse bars are grooved by the anterior
primary rami of the corresponding cervical nerves.
2 The laminae are relatively long and narrow, being
5 The posterior tubercles give origin to the scalenus
thinner above than below.
medius, scalenus posterior, the levator scapulae and
Head and Neck
insertion to the splenius cervicis, the longissimus

cervicis, and the iliocostalis cervicis (see Fig. 10.3).
6 The spine gives origin to the deep muscles of the back
of the neck—interspinales, semispinalis thoracis and
cervicis, spinalis cervicis, and multifidus (see Figs 10.2
and 10.4).
OSSIFICATION
A typical cervical vertebra ossifies from three
primary and six secondary centres. There is one
primary centre for each half of the neural arch during
9 to 10 weeks of foetal life and one for the centrum in
3 to 4 months of foetal life. The two halves of the
neural arch fuse posteriorly with each other during
the first year. Synostosis at the neurocentral
synchondrosis occurs during the third year.
Fig. 1.49: Typical cervical vertebra seen from above
53
The secondary centres, two for the annular backwards. It articulates with the corresponding
epiphyseal discs for the peripheral parts of the upper facet on the axis vertebra to form an atlantoaxial
and lower surfaces of the body, two for the tips of joint.
the transverse processes, and two for the bifid spine, c. The medial surface of the lateral mass is marked
appear during puberty, and fuse with the rest of the by a small roughened tubercle.
vertebrae by 25 years. d. The transverse process projects laterally from the
lateral mass. It is unusually long and can be felt
FIRST CERVICAL VERTEBRA on the surface of the neck between the angle of
It is called the atlas (Tiltan, who supported the heaven). mandible and the mastoid process. Its long length
It can be identified by the following features. allows it to act as an effective lever for rotatory
movements of the head. The transverse process is
1 It is ring-shaped. It has neither a body nor a spine
pierced by the foramen transversarium.
(Fig. 1.50).
2 The atlas has a short anterior arch, a long posterior Attachments and Relations
arch, right and left lateral masses, and transverse
1 The anterior tubercle provides attachment (in the
processes.
median plane) to the anterior longitudinal ligament,
3 The anterior arch is marked by a median anterior and provides insertion on each side to the upper
tubercle on its anterior aspect. Its posterior surface oblique part of longus colli.
bears an oval facet which articulates with the dens 2 The upper border of the anterior arch gives
(Fig. 1.50). attachment to the anterior atlanto-occipital membrane.
4 The posterior arch forms about two-fifths of the ring 3 The lower border of the anterior arch gives attachment
and is much longer than the anterior arch. Its to the lateral fibres of the anterior longitudinal ligament.
posterior surface is marked by a median posterior 4 The posterior tubercle provides attachment to the
tubercle. The upper surface of the arch is marked ligamentum nuchae in the median plane and gives
behind the lateral mass by a groove. origin to the rectus capitis posterior minor on each
side (Fig. 1.50).
Each lateral mass shows the following important 5 The groove on the upper surface of the posterior arch
features. is occupied by the vertebral artery and by the first
a. Its upper surface bears the superior articular facet. cervical nerve. Behind the groove, the upper border
This facet is elongated (forwards and medially), of the posterior arch gives attachment to the posterior
concave, and is directed upwards and medially. atlanto-occipital membrane (see Fig. 10.5).
It articulates with the corresponding condyle to 6 The lower border of the posterior arch gives
form an atlanto-occipital joint. attachment to the highest pair of ligamenta flava.
b. The lower surface is marked by the inferior articular 7 The tubercle on the medial side of the lateral mass
facet. This facet is nearly circular, more or less flat, gives attachment to the transverse ligament of the
and is directed downwards, medially and atlas.
Head and Neck
Fig. 1.50: Atlas vertebra seen from above

HEAD AND NECK
54
8 The anterior surface of the lateral mass gives origin Body and Dens
to the rectus capitis anterior. 1 The superior surface of the body is fused with the dens,
9 The transverse process gives origin to the rectus and is encroached upon on each side by the superior
capitis lateralis from its upper surface anteriorly, the articular facets. The dens articulates anteriorly with
superior oblique from its upper surface posteriorly, oval fact on posterior surface of the anterior arch
the levator scapulae from its lateral margin and lower of the atlas, and posteriorly with the transverse
border, scalenus medius from its lower surface of the ligament of the atlas.
tip and insertion to inferior oblique and splenius
2 The inferior surface has a prominent anterior margin
cervicis from the posterior tubercle of transverse
which projects downwards.
process.
3 The anterior surface presents a median ridge on each
side of which there are hollowed out impressions.
OSSIFICATION
Atlas ossifies from three centres, one for each lateral Vertebral Arch
mass with half of the posterior arch, one for the 1 The pedicles are concealed superiorly by the superior
anterior arch. The centres for the lateral masses articular processes. The inferior surface presents a
appear during seventh week of intrauterine life and deep and wide inferior vertebral notch, placed in front
unite posteriorly at about 3 years. The centre for of the inferior articular process. The superior
anterior arch appears at about first year and unites vertebral notch is very shallow and is placed on the
with the lateral mass at about 7 years. upper border of the lamina, behind the superior
articular process.
SECOND CERVICAL VERTEBRA 2 The laminae are thick and strong.
This is called the axis (Latin axile). It is identified by 3 Articular facets: Each superior articular facet occupies
the presence of the dens or odontoid (Greek tooth) the upper surfaces of the body and of the massive
process which is a strong, tooth-like process projecting pedicle. Laterally, it overhangs the foramen
upwards from the body. The dens is usually believed transversarium. It is a large, flat, circular facet which
to represent the centrum or body of the atlas which has is directed upwards and laterally. It articulates with
fused with the centrum of the axis (Figs 1.51a and b). the inferior facet of the atlas vertebra to form the
atlantoaxial joint. Each inferior articular facet lies
posterior to the transverse process and is directed
downwards and forwards to articulate with the third
cervical vertebra.
4 The transverse processes are very small and represent
the true posterior tubercles only. The foramen
transversarium is directed upwards and laterally
(Fig. 1.51).
Head and Neck
5 The spine is large, thick and very strong. It is deeply

grooved inferiorly. Its tip is bifid, terminating in two
rough tubercles.
Attachments
1 The dens provides attachment at its apex to the apical
ligament, and on each side, below the apex to the
alar ligaments (see Fig. 9.12).
2 The anterior surface of the body receives the insertion
of the longus colli. The anterior longitudinal ligament
is also attached to the anterior surface.
3 The posterior surface of the body provides attach-
ment, from below upwards, to the posterior
longitudinal ligament, the membrana tectoria and the
vertical limb of the cruciate ligament.
Figs 1.51a and b: The axis vertebra: (a) Posterosuperior view; 4 The laminae provide attachment to the ligamenta
(b) Lateral view flava.
55
5 The transverse process gives origin by its tip to the OSSIFICATION

levator scapulae, the scalenus medius anteriorly and
the splenius cervicis posteriorly. The intertransverse Its ossification is similar to that of a typical cervical
muscles are attached to the upper and lower surfaces vertebra. In addition, separate centre for each costal
of the process. process appears during sixth month of intrauterine
6 The spine gives attachment to the ligamentum nuchae, life and fuses with the body and transverse process
the semispinalis cervicis, the rectus capitis posterior during fifth to sixth years of life.
major, the inferior oblique, the spinalis cervicis, the
interspinalis and the multifidus (see Chapter 10).
CLINICAL ANATOMY
AN 26.7 Describe the features of the 7th cervical vertebra.9 • The costal element of seventh cervical vertebra
may get enlarged to form a cervical rib (Fig. 1.53).
SEVENTH CERVICAL VERTEBRA • A cervical rib is an additional rib arising from the
It is also known as the vertebra prominens because of its C7 vertebra and usually gets attached to the 1st
long spinous process, the tip of which can be felt rib near the insertion of scalenus anterior. If the
through the skin at the lower end of the nuchal furrow. rib is more than 5 cm long, it usually displaces
Its spine is thick, long and nearly horizontal. It is the brachial plexus and the subclavian artery
not bifid, but ends in a tubercle (Fig. 1.52). upwards (Fig. 1.54).
The transverse processes are comparatively large in The symptoms are tingling pain along the inner
size, the posterior root is larger than the anterior. The border of the forearm and hand including weakness
anterior tubercle is absent. The foramen transversarium and even paralysis of the muscles of the palm.
is relatively small, sometimes double, or may be entirely • The intervertebral foramina of the cervical
absent. It does not transmit the vertebral artery. vertebrae lie anterior to the joints between the
articular processes. Arthritic changes in these joints,
Attachments
if occur, cause tiny projections or osteophytes.
1 The tip of the spine provides attachment to the
ligamentum nuchae, trapezius, rhomboid minor,
serratus posterior superior, splenius capitis,
semispinalis thoracis, spinalis cervicis, interspinales,
and the multifidus (see Fig. 10.3).
2 Transverse process: The foramen transversarium usually
transmits only an accessory vertebral vein. The
posterior tubercle provides attachment to the
suprapleural membrane. The lower border provides
attachment to the levator costarum.
The anterior root of the transverse process may
Head and Neck

sometimes be separate. It then forms a cervical rib of Fig. 1.53: Bilateral cervical ribs
variable size.
Fig. 1.54: Cervical rib causing pressure on the lower trunk of

the brachial plexus
Fig. 1.52: Seventh cervical vertebra seen from above
HEAD AND NECK
56
Fig. 1.56: Fracture of the odontoid process during hanging
Fig. 1.55: Pressure on the cervical nerve due to bony changes
These osteophytes may press on the anteriorly

placed cervical spinal nerves in the foramina
causing pain along the course and distribution of
these nerves (Fig. 1.55).
• The joints in the lateral parts of adjacent bodies of
cervical vertebrae are called Luschka’s joints. The
osteophytes commonly occur in these joints. The
cervical nerve roots lying posterolateral to these
joints may get pressed causing pain along their
distribution (Fig. 1.55).
• The vertebral artery coursing through the foramen
transversarium lies lateral to Luschka’s joints. The
osteophytes of Luschka’s joints may cause distortion
of the vertebral artery leading to vertebrobasilar
insufficiency. This may cause vertigo, dizziness, etc.
Fig. 1.57: Types of the fractures of the skull
• Prolapse of the intervertebral disc occurs at the
junction of different curvatures. So, the common • Fractures of skull may be depressed, linear and
site is lower cervical and upper lumbar vertebral basilar (Fig. 1.57).
Head and Neck
regions. In the cervical region, the disc involved • Hangman’s fracture occurs due to fracture of the
is above or below 6th cervical vertebra. The nerve pedicles of axis vertebra. As the vertebral canal
roots affected are C6 and C7. There is pain and gets enlarged, the spinal cord does not get pressed.
numbness along the lateral side of forearm and
hand. There may be wasting of muscles of thenar
eminence. Competency achievement: The student should be able to:
• During judicial hanging, the odontoid process AN 26.6 Explain the concept of bones that ossify in membrane.10
usually breaks to hit upon the vital centres in the
medulla oblongata (Fig. 1.56).
• Atlas may fuse with the occipital bone. This is called OSSIFICATION OF CRANIAL BONES
occipitalization of atlas and this may at times compress
the spinal cord which requires surgical decompression. Intramembranous ossification of skull bones is one
• The pharyngeal and retropharyngeal inflamma- stage quicker process of ossification. Bones forming
tions may cause decalcification of atlas vertebra. cap of skull, i.e. frontal, parietal, squamous temporal
This may lead to loosening of the attachments of and upper part of occipital ossify in membrane as
transverse ligament which may eventually yield, these cover and protect the vital brain.
causing sudden death from dislocation of dens.
57
Frontal: It ossifies in membrane. Two primary centres for medial pterygoid plates appear during
centres appear during eighth week near frontal ninth week and the remaining portion of the
eminences. At birth, the bone is in two halves, greater wings and lateral plates ossify in
separated by a suture, which soon start to fuse. But membrane from the centres for the root of greater
remains of metopic suture may be seen in about wing only.
3–8% of adult skulls. Ethmoid: It ossifies in cartilage. Three centres
Parietal: It also ossifies in membrane. Two centres appear in cartilaginous nasal capsule. One centre
appear during seventh week near the parietal appears in perpendicular plate during first year
eminence and soon fuse with each other. of life. Two centres, one for each labyrinth,
Occipital: It ossifies partly in membrane and appear between fourth and fifth months of intra-
partly in cartilage. The part of the bone above uterine life.
highest nuchal line ossifies in membrane by two Mandible: Each half of the body is ossified in
centres which appear during second month of membrane by one centre which appears during sixth
foetal life, it may remain separate as interparietal week near the mental foramen. The upper half of
bone. ramus ossifies in cartilage. Ossification spreads in
The following centres appear in cartilage: condylar and coronoid processes above the level of
• Two centres for squamous part below highest the mandibular foramen.
nuchal line appear during seventh week. One Inferior nasal concha: It ossifies in cartilage. One
Kerckring centre appears for posterior margin of centre appears during fifth month in the lower border
foramen magnum during sixteenth week. of the cartilaginous nasal capsule.
• Two centres, one for each of the lateral parts,
Palatine: One centre appears during eighth
appear during eighth week. One centre appears
week in perpendicular plate. It ossifies in mem-
for the basilar part during sixth week.
brane.
Temporal: Squamous and tympanic parts ossify
Lacrimal: It ossifies in membrane. One centre
in membrane. Squamous part by one centre
appears during twelfth week.
which appears during seventh week. Tympanic
part from one centre which appears during third Nasal: It also ossifies in membrane from one
month. centre which appears during third month of intra-
Petromastoid and styloid parts ossify in cartilage. uterine life.
Petromastoid part is ossified by several centres which Vomer: It ossifies in membrane. Two centres
appear in cartilaginous ear capsule during fifth appear during eighth week on either side of midline.
month. Styloid process develops from cranial end of These fuse by twelfth week.
second branchial arch cartilage. Two centres appear Zygomatic: It ossifies in membrane by one centre
in it. Tympanohyal before birth and stylohyal after which appears during eighth week.
birth.
Head and Neck

Maxilla: It also ossifies in membrane by three
Sphenoid: It ossifies in two parts: centres. One for main body which appears during
• Presphenoidal part which lies in front of tuberculum sixth week above canine fossa.
sellae and lesser wings ossifies from six centres in Two centres appear for premaxilla during seventh
cartilage: Two for body of sphenoid during ninth week and fuse soon.
week; two for the two lesser wings during ninth Various foramina of anterior, middle and
week; two for the two sphenoidal conchae during posterior cranial fossae and other foramina with their
fifth month. contents are shown in Table 1.4.
• Postsphenoidal part consisting of posterior part of
body, greater wings and pterygoid processes DEVELOPMENT OF NEUROCRANIUM
ossifies from eight centres: Two centres for two 1 Membranous part: From mesenchyme around
greater wings during eighth week forming the root developing brain. Mesenchyme is derived from:
only; two for postsphenoidal part of body during i. Neural crest cells forming roof and sides of cranial
fourth month; two centres appear for the two vault.
pterygoid hamulus during third month of foetal ii. Para-axial mesoderm forming small part in
life. These six centres appear in cartilage. Two occipital region. Ossification is membranous
ossification.
HEAD AND NECK
58
Table 1.4: Foramina of skull bones and their contents (refer to BDC App)
Foramina/apertures Contents
ANTERIOR CRANIAL FOSSA

Groove for superior sagittal sinus Superior sagittal sinus
Foramen caecum Emissary vein to superior sagittal sinus from upper part of nose
Anterior ethmoidal foramen Anterior ethmoidal nerve and vessels
Foramina of cribiform plate Olfactory nerve rootlets
Posterior ethmoidal foramen Posterior ethmoidal vessels
MIDDLE CRANIAL FOSSA

Optic canal Optic nerve and ophthalmic artery
Superior orbital fissure:
• Lateral part Lacrimal and frontal nerves (branches of ophthalmic nerve); trochlear nerve; superior
ophthalmic vein; meningeal branch of lacrimal artery; anastomotic branch of middle
meningeal artery, which anastomoses with recurrent branch of lacrimal artery.
• Middle part Upper and lower divisions of oculomotor nerve (CN III), nasociliary nerve, abducent
nerve (CN VI)
• Medial part Inferior ophthalmic vein; sympathetic nerve from plexus around internal carotid artery.
Foramen rotundum Maxillary nerve (CN V2)
Foramen ovale Mandibular nerve (CN V3); accessory meningeal artery; lesser petrosal nerve;
emissary vein connecting cavernous sinus with pterygoid plexus (MALE)
Foramen spinosum Middle meningeal artery and vein, meningeal branch of mandibular nerve (CN V3)
Emissary sphenoidal foramen Emissary vein connecting cavernous sinus with pterygoid plexus of veins
Foramen lacerum (Fig. 1.15) During life, the foramen is filled with cartilage
No significant structure passes through it; internal carotid artery and nerve plexus pass
across its superior end; nerve to pterygoid canal passes through its anterior wall;
meningeal branch of ascending pharyngeal artery and emissary vein pass through it.
Carotid canal Internal carotid artery and nerve plexus (sympathetic)
Groove for lesser petrosal nerve Lesser petrosal nerve
Groove for greater petrosal nerve Greater petrosal nerve
POSTERIOR CRANIAL FOSSA

Foramen magnum (Fig. 1.16) Lowest part of medulla oblongata and three meninges; vertebral arteries; spinal roots
of CN XI; anterior and posterior spinal arteries; apical ligament; vertical band of cruciate
Head and Neck
ligament and membrana tectoria.

Jugular foramen CN IX; X; XI; inferior petrosal and sigmoid sinuses; meningeal branches of ascending
pharyngeal and occipital arteries.
Hypoglossal canal/anterior condylar canal CN XII
Internal acoustic meatus CN VII; VIII and labyrinthine vessels
External opening of vestibular aqueduct Endolymphatic duct
Posterior condylar canal Emissary vein connecting sigmoid sinus with the suboccipital venous plexus
Mastoid foramen Mastoid emissary vein and meningeal branch of occipital artery
OTHER FORAMINA
External acoustic meatus Air waves
External nasal foramen External nasal nerve
(Contd...)
59
Table 1.4: Foramina of skull bones and their contents (Contd...)

Foramina/apertures Contents
Greater palatine foramen Greater palatine vessels; anterior palatine nerve
Incisive canal Greater palatine vessels; terminal part of nasopalatine nerve
Inferior orbital fissure Zygomatic nerve; orbital branches of pterygopalatine ganglion; infraorbital nerve and
vessels
Infraorbital foramen Infraorbital nerve and vessels
Lesser palatine foramen Middle and posterior palatine nerves
Mandibular foramen/canal Inferior alveolar nerve and vessels
Mandibular notch Masseteric nerve and vessels
Mastoid canaliculus Auricular branch of vagus nerve
Mental foramen Mental nerve and vessels
Palatinovaginal canal Pharyngeal branch from pterygopalatine ganglion; pharyngeal branch of maxillary
artery
Parietal foramen Emissary vein from scalp to superior sagittal sinus
Petrotympanic fissure Chorda tympanic nerve and anterior tympanic artery
Pterygoid canal Nerve to pterygoid canal and vessels
Pterygomaxillary fissure Maxillary nerve
Pterygopalatine fossa Pterygopalatine ganglion
Stylomastoid foramen Facial nerve; stylomastoid branch of posterior auricular artery.
Supraorbital foramen Supraorbital nerve and vessels
Tympanic canaliculus Tympanic branch of glossopharyngeal nerve
Tympanomastoid fissure Auricular branch of vagus nerve
Vomerovaginal canal Branch of pharyngeal nerve and vessels
Zygomatic foramen Zygomatic nerve
Zygomaticofacial foramen Zygomaticofacial nerve
Zygomaticotemporal foramen Zygomaticotemporal nerve
2 Mesenchyme formed directly into bone. Membranous

Mnemonics
bones are: Frontal, parietal, squamous temporal and
Head and Neck

interparietal part of occipital bones. These bones are Nerves related to mandible M3LIA
united by sutures and fontanels.
M3—masseteric nerve, mental nerve, nerve to
Cartilaginous part: Neural crest cells form mylohyoid
mesenchyme which form cartilaginous models; these L—lingual nerve
get replaced by bone. Bones thus formed are: Ethmoid, I—inferior alveolar nerve
most of sphenoid, base of occipital pre-petrous A—auriculotemporal nerve
temporal.
Development of viscerocranium: Viscerocranium Arteries related to mandible—M4IFS
includes bones of face. Some bones have membranous M4—masseteric artery, maxillary, mental and
ossification while others have cartilaginous. These are artery to mylohyoid
formed by first pharynegeal arch cartilage—maxillary I—inferior alveolar artery
process  Maxilla, zygomatic, part of temporal. F—facial artery
Mandibular process—mandible, malleus, incus. S—superficial temporal artery
Second arch <Dorsal end—stapes, styloid process,
lesser cornua and upper part of body of hyoid bone.
HEAD AND NECK
60
• Why are thenar muscles getting weaker?

FACTS TO REMEMBER
Ans: There is no obvious injury in the hand or
• Eight bones in the calvaria and 14 facial bones make forearm. These symptoms are nervous in nature. One
up the skull. has to look for the nerve root which supplies this
• Most of the joints are ‘suture’ type of joints. The area. The nerve root is C6. Feel the cervical spine for
joint between teeth and gums is gomphosis. There any pain. An X-ray/CT scan may reveal prolapse of
is a pair of temporomandibular joints, which is of the intervertebral disc between C5 and C6 vertebrae
synovial variety. compressing the C6 nerve root. These roots form part
• The bony ossicles are malleus, incus and stapes and of lateral cutaneous nerve of forearm, and median
are ‘bone within bone’, as these are present in the nerves. Since median nerve (C6) supplies thenar
petrous temporal bone. Between these three muscles, there is wasting/weakness of these muscles.
ossicles are two synovial joints. As lateral cutaneous nerve of forearm is pressed,
• Diploe veins contain manufactured RBCs, there is numbness on lateral side of forearm and
granulocytes and platelets. These drain into the hand.
neighbouring veins.
• Paranasal sinuses give resonance to the voice, FURTHER READING
besides humidifying and warming up the inspired • Lahr MM. The Evolution of Modern Human Diversity: A
air. study of Cranial Variation. Cambridge: Cambridge
University Press. 1996.
• Tuli A, Choudhry R, Choudhry S, Raheja S, Agarwal S.
CLINICOANATOMICAL PROBLEM Variation in shape of the lingula in the adult human
mandible. J Anat 2000;197:313–17.
A young woman complains of pain and numbness • Tubbs RS, Salter EG, Oakes WJ. Artificial deformation of the
along the lateral side of forearm and hand, with human skull: A review Clin Anat 2006;19:372–77.
wasting of the muscles of thenar eminence. An excellent text when considering the extent of human variation
• Why is there pain in forearm and hand with no and diversity.
injury to the affected area? An excellent review article that highlights the incredible plasticity
of the human skull.
1–10
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
Head and Neck
61
1. Enumerate the muscles attached to the hyoid bone. b. Pterion bones meeting at this point and its clinical
Give their nerve supply. importance.
2. Name the structures traversing foramen magnum. c. Attachments of muscles on mastoid process with
Depict these with the help of a diagram. their nerve supply.
3. Write short notes/enumerate: d. Ligaments/membranes attached to atlas vertebra.
a. Structures passing though superior orbital e. Structure passing through jugular foramen.
fissure. 4. Name paired bones of cranium and face.
1. Which of the following structures does not pass 3. Which is the thickest boundary of the orbit?
through foramen magnum? a. Lateral b. Medial
a. Accessory pharyngeal artery c. Roof d. Floor
b. Vertebral artery 4. Which bone is not a ‘bone within the bone’ in
petrous temporal bone?
c. Spinal accessory nerve
a. Malleus b. Hyoid
d. Vertical band of cruciate ligament
c. Incus d. Stapes
2. Which of the following nerves does not pass through 5. Which of the parasympathetic ganglia does not
jugular foramen? have a secretomotor root?
a. Vagus b. Hypoglossal a. Submandibular b. Pterygopalatine
c. Glossopharyngeal d. Accessory c. Otic d. Ciliary
1. a 2. b 3. a 4. b 5. d
• Name the paired and unpaired (brain case) bones of • What is pterion? Give its importance.
Head and Neck

cranium. • Name the structures passing through foramen
• Name the paired and unpaired bones of facial magnum.
skeleton. • Name the structures traversing inferior orbital fissure.
• Name the fontanelles of the skull. When do these • Name the structures passing through superior orbital
close? fissure in order.
• Name the ‘bones within the bone’. • Enumerate the nerves related to mandible.
• Which is the last fontanelle to be closed and at what • Enumerate the arteries related to mandible.
age does it close? What are the functions of fontanelle? • What is type of atlantoccipital joint?
• Name the diploic veins. • What is type of median atlantoaxial joint?
• Name the emissary veins, what are their functions • Name the muscles attached to styloid process
and clinical anatomy? including their nerve supply.
HEAD AND NECK
62
2
Scalp, Temple and Face
Kiss is the anatomical juxtaposition of two orbicularis oris in a state of contraction .
—Anonymous
INTRODUCTION
Face is the most prominent part of the body. Facial
muscles, being the muscles of facial expression, express
a variety of emotions like happiness, joy, sadness, anger,
frowning, grinning, etc. The face, therefore, is an index
of mind. One’s innerself is expressed by the face itself
as it is controlled by the higher centres.
SURFACE LANDMARKS
1 The forehead is the part of the face between the
hairline of adolescent’s scalp and the eyebrows. The
superolateral prominence of the forehead is known
as the frontal eminence.
2 Identify the following in relation to the nose: The
prominent ridge separating the right and left halves
of the nose is called the dorsum. The upper narrow
end of the nose, just below the forehead, is the root of
the nose. The lower end of the dorsum is in the form
of a somewhat rounded tip. At the lower end of the
nose, we see the right and left nostrils or anterior nares.
The two nostrils are separated by a soft median parti-
Head and Neck
tion called the columella. This is continuous with the

Figs 2.1a and b: (a) Some features to be seen on the face around
nasal septum which separates the two nasal cavities. the left eye; (b) Parts of the pinna
Each nostril is bounded laterally by the ala.
3 The palpebral fissure is an elliptical opening between the inner surfaces of the lids is the palpebral conjunc-
the two eyelids. The lids are joined to each other at tiva. The space between the two is the conjunctival
the medial and lateral angles or canthi of the eye. sac. The line along which the bulbar conjunctiva
The free margin of each eyelid has eyelashes or cilia becomes the palpebral conjunctiva is known as the
arranged along its outer edge (Fig. 2.1a). conjunctival fornix.
Through the palpebral fissure following are seen. 4 The oral fissure or mouth is the opening between the
upper and lower lips. It lies opposite the cutting edges
a. The opaque sclera or white of the eye
of the upper incisor teeth. The angle of the mouth
b. The transparent circular cornea through which the usually lies just in front of first upper premolar tooth.
coloured iris and the dark circular pupil can be seen. Each lip has a red margin at mucocutaneous junction
The eyeballs are lodged in bony sockets, called the orbits. and a dark margin, with a non-hairy thin skin inter-
The conjunctiva is a moist, transparent membrane. vening between the two margins. The lips normally
The part which covers the anterior surface of the close the mouth along their red margins. The philtrum
eyeball is the bulbar conjunctiva, and the part lining is the median vertical groove on the upper lip.
62
SCALP, TEMPLE AND FACE
63
5 The external ear is made up of two parts: A superficial DISSECTION

projecting part, called the auricle or pinna; and a deep
Place 2–3 wooden blocks under the head to raise it
canal, called the external acoustic meatus. The mobile
about 10–12 cm from the table. Figure 2.2a shows a
auricle helps in catching the sound waves, and is a
median incision in the skin of scalp extending from root
characteristic feature of mammals (Fig. 2.1b). Lobule
of the nose (i), to the prominent external occipital
is the lower, smaller soft part of the auricle. The
protuberance (ii). Give a coronal incision across the
upper larger stiff part shows: (a) Helix, the outer
previous incision from root of one auricle to the other
rolled margin; (b) A Y-shaped antihelix which is
(iii). Extend the incision from the auricles to the mastoid
surrounded, except inferiorly, by the arched helix.
process posteriorly (iv), and to root of zygoma anteriorly
The upper forked end of the antihelix encloses the
(v). Reflect the skin in four flaps. Usually, the skin is so
triangular fossa. Antihelix is separated from the helix
adherent to the subjacent connective tissue and
posterosuperiorly by the scaphoid fossa and
aponeurotic layers that these all come off together.
anteroinferiorly by the cymba conchae. (c) Concha
Dissect the layers, including the nerves, vessels,
leads into external acoustic meatus. It is bounded
lymphatics and identify these structures in the cadaver
anteriorly by tragus, inferiorly by the intertragic
(refer to BDC App).
notch and the antitragus, posteriorly by the curved
anterior end of the helix. The auricle is situated at The scalp is made up of five layers (mnemonic
the level of the eyebrow above and the nostrils below SCALP)
and is nearer the occiput than the face. a. Skin
6 The supraorbital margin lies beneath the upper margin
b. Superficial fascia (Connective tissue)
of the eyebrow. The supraorbital notch is palpable
at the junction of the medial one-third with the lateral
two-thirds of the supraorbital margin. A vertical line
drawn from the supraorbital notch to the base of the
mandible, passing midway between the lower two
premolar teeth, crosses the infraorbital foramen
5 mm below the infraorbital margin, and the mental
foramen midway between the upper and lower
borders of the mandible.
7 The superciliary arch is a curved bony ridge situated
immediately above the medial part of each
supraorbital margin. The glabella is the median
elevation connecting the two superciliary arches, and
corresponds to elevation between the two eyebrows.

AN 27.1 Describe the layers of scalp, its blood supply, its nerve
Head and Neck

supply and surgical importance.1
SCALP AND SUPERFICIAL TEMPORAL REGION
SCALP
The soft tissues covering the cranial vault form the scalp
(Fig. 2.3).
Extent of Scalp
Anteriorly, supraorbital margins; posteriorly, external
occipital protuberance and superior nuchal lines; and
on each side, the superior temporal lines (Fig. 2.26).
Structure
Conventionally, the superficial temporal region is
studied with the scalp, and the following description,
therefore, will cover both the regions. Figs 2.2a and b: Lines of dissection for scalp, face and eyelids
HEAD AND NECK
64
Figs 2.3a to c: (a) and (b) Layers of the scalp; (c) Layers of superficial temporal region
c. Deep fascia in the form of the epicranial

aponeurosis or galea aponeurotica with the
occipitofrontalis muscle
d. Loose areolar tissue
e. Pericranium (Figs 2.3a–c).
The skin is hairy. It is adherent to the epicranial
aponeurosis through the dense superficial fascia. It has
more number of sweat glands and sebaceous glands.
The subcutaneous or superficial fascia is more fibrous
and dense in the centre than at the periphery of the
head. It contains many blood vessels.
It binds the skin to the subjacent aponeurosis, and
provides the proper medium for passage of vessels and
nerves to the skin.
Head and Neck
Fig. 2.4a: Bellies of the occipitofrontalis muscle

The occipitofrontalis muscle has two bellies, occipital
or occipitalis and frontal or frontalis, both of which are overlying and adherent skin and fascia (Figs 2.3a and
inserted into the epicranial aponeurosis. The occipital 2.9). Anteriorly, it receives the insertion of the frontalis,
bellies are small and separate. Each arises from the posteriorly, it receives the insertion of the occipitalis
lateral two-thirds of the superior nuchal line, and is and is attached to the external occipital protuberance,
supplied by the posterior auricular branch of the facial and to the highest/superior nuchal lines in between
nerve (Fig. 2.4a). the occipital bellies. On each side, the aponeurosis is
The frontal bellies are longer, wider and partly united attached to the superior temporal line, but sends down
in the median plane. Each arises from the skin of the a thin expansion which passes over the temporal fascia
upper eyelid and forehead, mingling with the and is attached to the zygomatic arch (Fig. 2.3c).
orbicularis oculi and the corrugator supercilii. It is First three layers of scalp are called surgical layers of
supplied by the temporal branch of the facial nerve (see the scalp. These are called scalp proper also.
Fig. 1.6). The fourth layer of the scalp is made up of loose
The muscle raises the eyebrows and causes areolar tissue. It extends anteriorly into the eyelids
horizontal wrinkles in the skin of the forehead. (Fig. 2.4b), because the frontalis muscle has no bony
The epicranial aponeurosis, or galea aponeurotica is attachment; posteriorly to the highest and superior
freely movable on the pericranium along with the nuchal lines; and on each side to the superior temporal
65
1 Skin
2 Superficial fascia
3 Thin extension of epicranial aponeurosis which gives
origin to extrinsic muscles of the auricle
4 Temporal fascia
5 Temporalis muscle
6 Pericranium.
Tempus means time. Greying of hair first starts here.
Arterial Supply of Scalp and
Superficial Temporal Region
In front of the auricle, the scalp is supplied from before
backwards by the:
• Supratrochlear
• Supraorbital
Fig. 2.4b: Schematic section through the scalp and upper eyelid
to show how fluids can pass from the subaponeurotic space or • Superficial temporal arteries (Fig. 2.5).
layer of loose areolar tissue of the scalp into the eyelid, and into The first two are branches of the ophthalmic artery
the subconjunctival area. Note that this is possible because the which in turn is a branch of the internal carotid artery.
frontalis muscle has no bony attachment The superficial temporal is a branch of the external
carotid artery.
lines. It gives passage to the emissary veins which
connect extracranial veins to intracranial venous sinuses Behind the auricle, the scalp is supplied from before
(Fig. 2.3a). backwards by the:
The fifth layer of the scalp, called the pericranium, • Posterior auricular
is loosely attached to the surface of the bones, but is • Occipital (tortuous) arteries, both of which are
firmly adherent to their sutures where the sutural branches of the external carotid artery.
ligaments bind the pericranium to the endocranium Thus, the scalp has a rich blood supply derived from
(Fig. 2.3a). both the internal and the external carotid arteries, the
two systems anastomosing over the temple.
SUPERFICIAL TEMPORAL REGION
It is the area between the superior temporal line and Venous Drainage
the zygomatic arch. This area contains the following The veins of the scalp accompany the arteries and have
6 layers (Fig. 2.3c): similar names. The supratrochlear and supraorbital veins
Head and Neck
Fig. 2.5: Arterial and nerve supply of scalp and superficial temporal region
HEAD AND NECK
66
Fig. 2.6: The veins of the scalp, face and their deep connections with the cavernous sinus and the pterygoid plexus of veins
unite at the medial angle of the eye forming the angular either into the occipital vein, or into the transverse sinus
vein which continues down as the facial vein. near the median plane (see Table 1.2).
The superficial temporal vein descends in front of the
tragus, enters the parotid gland, and joins the maxillary Competency achievement: The student should be able to:
vein to form the retromandibular vein. This vein divides AN 28.5 Describe cervical lymph nodes and lymphatic drainage of
into two divisions. scalp, face and neck.2
The anterior division of the retromandibular vein
unites with the facial vein to form the common facial Lymphatic Drainage
vein which drains into the internal jugular vein. The anterior part of the scalp drains into the pre-
The posterior division of the retromandibular vein auricular or parotid lymph nodes, situated on the
unites with the posterior auricular vein to form the surface of the parotid gland. The posterior part of the
external jugular vein which ultimately drains into the
scalp drains into the posterior auricular or mastoid and
subclavian vein. The occipital veins terminate in the
occipital lymph nodes.
suboccipital venous plexus (Fig. 2.6).
Emissary veins connect the extracranial veins with
Head and Neck
the intracranial venous sinuses to equalise the pressure. Nerve Supply

These veins are valveless. The parietal emissary vein The scalp and temple are supplied by 10 nerves on each
passes through the parietal foramen to enter the side. Out of these, five nerves (four sensory and one
superior sagittal sinus. The mastoid emissary vein passes motor) enter the scalp in front of the auricle. The
through the mastoid foramen to reach the sigmoid remaining five nerves (again four sensory and one
sinus. Remaining emissary veins are shown in Table 1.1. motor) enter the scalp behind the auricle (Fig. 2.5 and
Extracranial infections may spread through these veins Table 2.1).
to intracranial venous sinuses.
Diploic veins start from the cancellous bone within
the two tables of skull. These carry the newly formed CLINICAL ANATOMY
blood cells into the general circulation. These are four • Wounds of the scalp gape when the epicranial
veins on each side (see Fig. 1.17a). aponeurosis is divided transversely.
The frontal diploic vein emerges at the supraorbital • Because of the abundance of sebaceous glands, the
notch open into the supraorbital vein. Anterior temporal scalp is a common site for sebaceous cysts (Fig. 2.7).
diploic vein ends in anterior deep temporal vein or • Wounds of the scalp bleed profusely because the
sphenoparietal sinus. Posterior temporal diploic vein ends vessels are prevented from retracting by the fibrous
in the transverse sinus. The occipital diploic vein opens
67
Table 2.1: Nerves of the scalp and superficial temporal

region
In front of auricle Behind the auricle
Sensory nerves Sensory nerves
• Supratrochlear, branch of • Posterior division of great
the frontal nerve (ophthalmic auricular nerve (C2, C3)
division of trigeminal nerve) from cervical plexus
• Supraorbital, branch of • Lesser occipital nerve
frontal nerve (ophthalmic (C2), from cervical plexus
division of trigeminal nerve)
• Zygomaticotemporal, • Greater occipital nerve
branch of zygomatic nerve (C2, dorsal ramus)
(maxillary division of
trigeminal nerve)
• Auriculotemporal branch of • Third occipital nerve Fig. 2.8: Right eye—black eye due to injury to the scalp
mandibular division of (C3, dorsal ramus)
trigeminal nerve which course here, may transmit infection from the
scalp to the cranial venous sinuses (Fig. 2.3a).
Motor nerve Motor nerve • Collection of blood in the layer of loose connective
• Temporal branch of facial • Posterior auricular branch tissue causes generalised swelling of the scalp. The
nerve of facial nerve blood may extend anteriorly into the root of the
nose and into the eyelids (as frontalis muscle has
no bony origin) resulting in black eye. The
posterior limit of such haemorrhage is not seen
(Fig. 2.8). If bleeding is due to local injury, the
posterior limit of haemorrhage is seen.
• Because of the spread of blood, compression of brain
is not seen and so this layer is also called safety layer.
• Since the blood supply of scalp and superficial
temporal region is very rich; avulsed portions need
not be cut away. They can be replaced in position
and stitched: They usually take up and heal well.
FACE
Features
Head and Neck

The face, or countenance, extends superiorly from the
adolescent position of hairline, inferiorly to the chin
Fig. 2.7: Bilateral sebaceous cysts and the base of the mandible, and on each side to the
auricle. The forehead is, therefore, common to both the
face and the scalp.
fascia. Bleeding can be arrested by applying
pressure at the site of injury by a tight cotton SKIN
bandage against the bone.
1 The facial skin is very vascular. Rich vascularity makes
• Because of the density of fascia, subcutaneous haemorr-
the face blush and blanch. Wounds of the face bleed
hages are never extensive, and the inflammations
profusely but heal rapidly. The results of plastic
in this layer cause little swelling but much pain.
surgery on the face are excellent for the same reason.
• Because the pericranium is adherent to sutures,
collections of fluid deep to the pericranium known 2 The facial skin is rich in sebaceous and sweat glands.
as cephalhaematoma take the shape of the bone Sebaceous glands keep the face oily, but also cause
concerned when there is fracture of particular bone. acne in young adults. Sweat glands help in regulation
• The layer of loose areolar tissue is known as the of the body temperature.
dangerous area of the scalp because the emissary veins, 3 Laxity of the greater part of the skin facilitates rapid
spread of oedema. Renal oedema appears first in the
HEAD AND NECK
68
DISSECTION Table 2.2: Functional groups of facial muscles

Give a median incision from the root of nose, across Opening Sphincter Dilators
the dorsum of nose, centre of philtrum of upper lip, to A. Palpebral Orbicularis 1. Levator palpebrae
centre of lower lip to the chin (vi). Give a horizontal fissure oculi superioris
incision from the angle of the mouth to posterior border 2. Frontalis part of
of the mandible (vii). Reflect the lower flap towards and occipitofrontalis
up to the lower border of mandible (Fig. 2.2a; line with B. Oral fissure Orbicularis All the muscles around the
dots). Direct and reflect the upper flap till the auricle. oris mouth, except the orbicularis
oris, the sphincter, and the
Subjacent to the skin, the facial muscles are directly
mentalis which does not
encountered as these are inserted in the skin. Identify mingle with orbicularis oris
the various functional groups of facial muscles.
C. Nostrils Compressor 1. Dilator naris
Trace the various motor branches of facial nerve
naris 2. Depressor septi
emerging from the anterior border of parotid gland to 3. Medial slip of levator labii
supply these muscles. Amongst these motor branches superioris alaeque nasi
on the face are the sensory branches of the three
divisions of the trigeminal nerve. Try to identify all these
with the help of their course given in the text (Fig. 2.16) Morphologically, they represent the best remnants of
(refer to BDC App). the panniculus carnosus, a continuous subcutaneous
muscle sheet seen in some animals. All of them are
eyelids and face before spreading to other parts of inserted into the skin.
the body. Topographically, the muscles are grouped under the
4 Boils in the nose and ear are acutely painful due to following six heads.
the fixity of the skin to the underlying cartilages. Functionally, most of these muscles may be regarded
5 Facial skin is very elastic and thick because the facial primarily as regulators of the three openings situated
muscles are inserted into it. The wounds of the face, on the face, namely the palpebral fissures, the nostrils
therefore, tend to gape. and the oral fissure. Each opening has a single sphincter,
and a variable number of dilators. Sphincters are
SUPERFICIAL FASCIA naturally circular and the dilators radial in their
arrangement. These muscles are better developed around
It contains: (i) The facial muscles, all of which are
the eyes and mouth than around the nose (Table 2.2).
inserted into the skin, (ii) the vessels and nerves, to the
muscles and to the skin, and (iii) a variable amount of Muscle of the Scalp
fat. Fat is absent from the eyelids, but is well developed
Occipitofrontalis—described in scalp.
in the cheeks, forming the buccal pads that are very
prominent in infants in whom they help in sucking. Muscles of the Auricle
The deep fascia is absent from the face, except over the
Situated around the ear:
parotid gland where it forms the parotid fascia, and
1 Auricularis anterior
over the buccinator where it forms the buccopharyngeal
Head and Neck
fascia. 2 Auricularis superior

3 Auricularis posterior
Competency achievement: The student should be able to: These are vestigeal muscles.
AN 28.1 Describe and demonstrate muscles of facial expression and
their nerve supply.3 Muscles of the Eyelids/Orbital Openings
AN 28.6 Identify superficial muscles of face, their nerve supply and 1 Orbicularis oculi (Fig. 2.9 and Table 2.3)
actions.4 2 Corrugator (Latin to wrinkle) supercilii (Fig. 2.9 and
Table 2.3)
FACIAL MUSCLES 3 Levator palpebrae superioris (an extraocular muscle,
The facial muscles are subcutaneous muscles. Since supplied by sympathetic fibres and the third cranial
these muscles are inserted into skin, these bring out nerve) is described in Chapter 13, see Fig. 2.21 as well.
various facial expressions. So, these are secondarily
known as muscles of facial expression. These have small Muscles of the Nose
motor units. 1 Procerus (Fig. 2.9)
Embryologically, they develop from the mesoderm of 2 Compressor naris
the second branchial arch, and are, therefore, supplied 3 Dilator naris
by the facial nerve. 4 Depressor septi
69
Fig. 2.9: The facial muscles
Muscles around the Mouth 3 Levator labii superioris alaeque nasi (Fig. 2.10)
1 Orbicularis oris (Fig. 2.9) 4 Zygomaticus major (Fig. 2.9)
2 Buccinator (Latin cheek) (Fig. 2.10) 5 Levator labii superioris (Fig. 2.9)
Head and Neck
Fig. 2.10: Some facial muscles

HEAD AND NECK
70
Table 2.3: The facial muscles

Name Origin Insertion Actions
Muscles of eyelid/orbital opening
1. Corrugator supercilii Medial end of superciliary arch Skin of mid-eyebrow Vertical lines in forehead,
(Fig. 2.9) as in frowning
2. Orbicularis oculi (Fig. 2.9) Medial part of medial palpe- Concentric rings return to Protects eye from bright light,
a. Orbital part, on and bral ligament, frontal process the point of origin wind and rain. Cause forceful
around the orbital of maxilla and nasal part of closure of eyelids
margin frontal bone
b. Palpebral part, in the lids Lateral part of medial Lateral palpebral raphe Closes lids gently as in
palpebral ligament blinking and sleeping
c. Lacrimal part, lateral and Lacrimal fascia and posterior Pass laterally in front of Dilates lacrimal sac for
deep to the lacrimal sac lacrimal crest, forms tarsal plates of both the sucking of lacrimal fluid into
sheath for lacrimal sac eyelids the sac, directs lacrimal
puncta into lacus lacrimalis;
supports the lower lid
Muscles around nasal opening
3. Procerus Nasal bone and upper part Skin of forehead Causes transverse wrinkles
of lateral nasal cartilage between eyebrows and on
bridge of the nose
4. Compressor Maxilla just lateral to nose Aponeurosis across Nasal aperture compressed
naris dorsum of nose
5. Dilator naris Maxilla over the lateral incisor Alar cartilage of nose Nasal aperture dilated
6. Depressor Maxilla over the medial incisor Lower mobile part of Nose pulled inferiorly
septi nasal septum
Mucles around the lips
7. Orbicularis oris Superior incisivus, from Angle of mouth Closes lips and protrudes lips,
a. Intrinsic part, deep maxilla; inferior incisivus, numerous extrinsic muscles
stratum, very thin sheet from mandible make it most versatile for
various types of grimaces
b. Extrinsic part, two Thickest middle stratum, Lips and the angle of the
strata, formed by derived from buccinator; thick mouth
converging muscles superficial stratum, derived
(Fig. 2.9) from elevators and depressors
of lips and their angles
8. Buccinator, the muscle of 1. Upper fibres, from maxilla 1. Upper fibres, straight to Flattens cheek against gums
Head and Neck
the cheek (Fig. 2.10) opposite molar teeth the upper lip and teeth; prevents accumu-
lation of food in the vestibule.
Pierced by This is the whistling muscle
a. Parotid duct and 2. Lower fibres, from 2. Lower fibres, straight to
b. Buccal branch of mandible, opposite molar the lower lip
mandibular nerve teeth
3. Middle fibres, from pterygo- 3. Middle fibres decussate
mandibular raphe
9. Levator labii Frontal process of maxilla Upper lip and alar Lifts upper lip and dilates
superioris cartilage of nose the nostril
alaeque nasi
10. Zygomaticus Posterior aspect of lateral Skin at the angle of the Pulls the angle upwards and
major surface of zygomatic bone mouth laterally as in smiling
11. Levator labii Infraorbital margin Skin of upper lateral Elevates the upper lip,
superioris (Fig. 2.10) of maxilla half of the upper lip forms nasolabial groove
12. Levator anguli Maxilla just below Skin of angle of the Elevates angle of mouth,
oris infraorbital foramen mouth forms nasolabial groove
(Contd...)
71
Table 2.3: The facial muscles (Contd...)

Name Origin Insertion Actions
13. Zygomaticus Anterior aspect of lateral Upper lip medial to Elevates the upper lip
minor surface of zygomatic bone its angle
14. Depressor Oblique line of mandible Skin at the angle of mouth Draws angle of mouth
anguli oris below first molar, premolar and fuses with orbicularis downwards and laterally
and canine teeth oris
15. Depressor Anterior part of oblique line Lower lip at midline, fuses Draws lower lip downward
labii inferioris of mandible with muscles from opposite
side
16. Mentalis Mandible inferior to incisor Skin of chin Elevates and protrudes
teeth lower lip as it wrinkles skin
on chin
17. Risorius Fascia on the masseter Skin at the angle Retracts angle of mouth
muscle of the mouth
Muscles of the neck

18. Platysma Upper parts of pectoral and Anterior fibres, to the base Releases pressure of skin on
(Fig. 2.9) deltoid fasciae of the mandible; posterior the subjacent veins; depres-
Fibres run upwards and fibres, to the skin of the ses mandible; pulls the angle
medially lower face and lip, and of the mouth downwards as
may be continuous with in horror or fright
the risorius
Modiolus: It is a compact, mobile fibromuscular structure present at about 1.25 cm lateral to the angle of the mouth opposite the
upper second premolar tooth. The five muscles interlacing to form the modiolus are: zygomaticus major, buccinator, levator anguli
oris, risorius and depressor anguli oris.
6 Levator anguli oris

7 Zygomaticus minor
AN 28.4 Describe and demonstrate branches of facial nerve with
8 Depressor anguli oris (Fig. 2.10) distribution.5
9 Depressor labii inferioris
10 Mentalis (Latin chin)
11 Risorius (Latin laughter) NERVE SUPPLY OF FACE
Motor Nerve Supply

Muscles of the Neck
The facial nerve is the motor nerve of the face. Its five
Head and Neck

Platysma (Greek broad)
terminal branches, temporal, zygomatic, buccal,
Details of the these muscles are given in Table 2.3. marginal mandibular and cervical emerge from the
A few of the common facial expressions and the muscles parotid gland and diverge to supply the various facial
producing them are given below (Fig. 2.11). muscles as follows.
1 Surprise: Frontalis Temporal—frontalis, auricular muscles, orbicularis
2 Dislike: Corrugator supercilii and procerus oculi (Fig. 2.12a).
3 Anger: Dilator naris and depressor septi Zygomatic—orbicularis oculi (lower eyelid part).
4 Smiling and laughing: Zygomaticus major Buccal—muscles of the cheek and upper lip.
5 Grinning: Risorius Marginal mandibular—muscles of lower lip.
6 Sadness: Levator labii superioris and levator
Cervical—platysma.
anguli oris
Branches of facial nerve can be simulated by putting
7 Grief: Depressor anguli oris
your right wrist on the right ear and spreading five
8 Closing the mouth: Orbicularis oris digits: The thumb over the temporal region, the index
9 Whistling/kissing: Buccinator, and orbicularis oris finger on the zygomatic bone, middle finger on the
10 Doubt: Mentalis upper lip, the ring finger on the lower lip and the little
11 Horror, terror and fright: Platysma finger over the neck (Fig. 2.12b).
HEAD AND NECK
72
Fig. 2.11: Some common facial expressions

Head and Neck
Figs 2.12a and b: Terminal branches of the facial nerve

AN 28.7 Explain the anatomical basis of facial nerve palsy.6
73
CLINICAL ANATOMY The affected side is motionless. Wrinkles disappear

• The facial nerve is examined by testing the from the forehead. The eye cannot be closed
following facial muscles (Fig. 2.13). leading to keratitis. Any attempt to smile draws the
a. Frontalis: Ask the patient to look upwards with- mouth to the normal side. During mastication, food
out moving his head, and look for the normal accumulates between the teeth and the cheek.
horizontal wrinkles on the forehead (Fig. 2.13a). Articulation of labials is impaired. Tears flow out
b. Dilators of mouth: Showing the teeth (Fig. 2.13b). from the eye. Saliva flows down from the angle of
c. Orbicularis oculi: Tight closure of the eyes mouth.
(Fig. 2.13c). • In supranuclear lesions of the facial nerve; usually
d. Buccinator: Puffing the mouth and then blowing a part of hemiplegia, with injury of corticonuclear
forcibly as in whistling (Fig. 2.13d). fibres, only the lower quarter of the opposite side of
• Infranuclear lesion (Fig. 2.14) of the facial nerve, at face is paralysed. The upper quarter with the frontalis
the stylomastoid foramen is known as Bell’s palsy, and orbicularis oculi escapes due to its bilateral repre-
upper and lower quarters of the face on the same sentation in the cerebral cortex (Fig. 2.15). Only
side get paralysed. voluntary movements are affected and emotional
The face becomes asymmetrical and is drawn up expressions remain normal as there are separate
to the normal side. pathways for voluntary and emotional movements.
Figs 2.13a to d: (a) Test for frontalis; (b) Test for dilators of mouth; (c) Test for orbicularis oculi; (d) Test for buccinator
Head and Neck
Fig. 2.14: Infranuclear lesion of right facial nerve or Bell’s palsy Fig. 2.15: Supranuclear lesion of left facial nerve
HEAD AND NECK
74
Table 2.4: Cutaneous nerves of the face

Source Cutaneous nerve Area of distribution
a. Ophthalmic division of 1. Supratrochlear nerve 1. Upper eyelid and forehead
trigeminal nerve 2. Supraorbital nerve 2. Upper eyelid, frontal air sinus, scalp
3. Lacrimal nerve 3. Lateral part of upper eyelid
4. Infratrochlear nerve 4. Medial parts of both eyelids
5. External nasal nerve 5. Lower part of dorsum and tip of nose
b. Maxillary division of 6. Infraorbital nerve 6. Lower eyelid, side of nose and upper lip
trigeminal nerve 7. Zygomaticofacial nerve 7. Upper part of cheek
8. Zygomaticotemporal nerve 8. Anterior part of temporal region
c. Mandibular division of 9. Auriculotemporal nerve 9. Upper two-thirds of lateral side of
trigeminal nerve 10. Buccal nerve auricle, temporal region
11. Mental nerve 10. Skin of lower part of cheek
11. Skin over chin
d. Cervical plexus 12. Anterior division of great auricular nerve 12. Skin over angle of the jaw and over
(C2, C3) the parotid gland
13. Upper and lower divisions of transverse 13. Lower margin of the lower jaw and upper
(anterior) cutaneous nerve of neck (C2, C3) part of neck
14. Lesser occipital 14. Back of auricle
15. Supraclavicular 15. Front of thorax till 2nd costal cartilage and
skin over upper ½ of deltoid muscle

AN 28.2 Describe sensory innervation of face.7
Sensory Nerve Supply

The trigeminal nerve through its three branches is the
chief sensory nerve of the face (Fig. 2.16 and Table 2.4).
The skin over the angle of the jaw and over the parotid
gland is supplied by the great auricular nerve (C2, C3).
In addition to most of the skin of the face, the sensory
distribution of the trigeminal nerve is also to the nasal
cavity, the paranasal air sinuses, the eyeball, the mouth
cavity, palate, cheeks, gums, teeth and anterior two-
Head and Neck
thirds of tongue and the supratentorial part of the dura

mater, including that lining the anterior and middle
cranial fossae (Fig. 2.16).
CLINICAL ANATOMY
• The sensory distribution of the trigeminal nerve

explains why headache is a uniformly common
symptom in involvements of the nose (common
cold, boils), the paranasal air sinuses (sinusitis),
infections and inflammations of teeth and gums,
refractive errors of the eyes, and infection of the Fig. 2.16: The sensory nerves of the face and neck. (1) Supra-
meninges as in meningitis. trochlear, (2) supraorbital, (3) palpebral branch of lacrimal,
• Trigeminal neuralgia may involve one or more of (4) infratrochlear, (5) external nasal, (6) infraorbital, (7) zygomatico-
the three divisions of the trigeminal nerve. It facial, (8) zygomaticotemporal, (9) auriculotemporal, (10) buccal,
causes attacks of very severe burning and scalding (11) mental, (12) great auricular, (13) transverse cutaneous nerve
of neck, (14) lesser occipital, and (15) supraclavicular
75
pain along the distribution of the affected nerve. DISSECTION

Pain is relieved either: (a) By injecting 90% alcohol Tortuous facial artery enters the face at the lower border
into the affected division of the trigeminal of mandible. Dissect its course from the anteroinferior
ganglion, or (b) by sectioning the affected nerve, angle of masseter muscle running to the angle of mouth
the main sensory root, or the spinal tract of the till the medial angle of eye, reflecting off some of the
trigeminal nerve which is situated superficially in facial muscles, if necessary (Fig. 2.17).
the medulla. The procedure is called medullary Straight facial vein runs on a posterior plane than
tractotomy. the artery.
Identify buccopharyngeal fascia on the external
ARTERIES OF THE FACE surface of buccinator muscle. Clean the deeply placed
buccinator muscle situated lateral to the angle of mouth.
Features
Identify parotid duct, running across the cheek 2 cm
The face is richly vascular. It is supplied by: below the zygomatic arch. The duct pierces buccal pad
1 The facial artery, of fat, buccopharyngeal fascia, buccinator muscle,
2 The transverse facial artery, and mucous membrane of the mouth to open into its
3 Arteries that accompany the cutaneous nerves, which vestibule opposite second upper molar tooth (Fig. 2.20).
are small branches of ophthalmic, maxillary and
superficial temporal arteries. Course
1 It enters the face by winding around the base of the
mandible, and by piercing the deep cervical fascia,
AN 28.3 Describe and demonstrate origin/formation, course,
at the anteroinferior angle of the masseter muscle. It
branches/tributaries of facial vessels.8
can be palpated here and is called ‘anaesthetist’s artery’.
2 First it runs upwards and forwards to a point 1.25 cm
Facial Artery (Facial Part) lateral to the angle of the mouth. Then it ascends by
The facial artery is the chief artery of the face (Fig. 2.17). the side of the nose up to the medial angle of the
It is a branch of the external carotid artery given off in eye, where it terminates by supplying the lacrimal
the carotid triangle just above the level of the tip of the sac; and by anastomosing with the dorsal nasal
greater cornua of the hyoid bone. In its cervical course, branch of the ophthalmic artery.
it passes through the submandibular region, and finally 3 The facial artery is very tortuous. The tortuosity of
enters the face. the artery prevents its walls from being unduly
Head and Neck
Fig. 2.17: Arteries of the face

HEAD AND NECK
76
stretched during movements of the mandible, the lips vein continues as the facial vein, running down-
and the cheeks. wards and backwards behind the facial artery, but
4 It lies between the superficial and deep muscles of with a straighter course. It crosses the anteroinferior
the face. angle of the masseter, pierces the deep fascia,
The course of the artery in the neck is described in crosses the submandibular gland, and joins the
submandibular region. anterior division of the retromandibular vein below
the angle of the mandible to form the common facial
Branches vein. It latter drains into the internal jugular vein.
The anterior branches on the face are large and named. It is represented by a line drawn just behind the
They are: facial artery. The other veins drain into neighbour-
1 Inferior labial, to the lower lip. ing veins.
2 Superior labial, to the upper lip and the anteroinferior 4 Deep connections of the facial vein include:
part of the nasal septum. a. A communication between the supraorbital and
3 Lateral nasal, to the ala and dorsum of the nose. superior ophthalmic veins.
b. Another connection with the pterygoid plexus
The posterior branches are small and unnamed.
through the deep facial vein which passes
Anastomoses backwards over the buccinator. The connection
between facial vein and cavernous sinus is shown
1 The large anterior branches anastomose with similar
in Flowchart 2.1.
branches of the opposite side and with the mental
artery. In the lips, anastomoses are large, so that cut Flowchart 2.1: Connection between facial vein and cavernous
arteries spurt from both ends. sinus
2 Small posterior branches anastomose with the
transverse facial and infraorbital arteries.
3 At the medial angle of the eye, terminal branches of
the facial artery anastomose with branches of the
ophthalmic artery. This is, therefore, a site for
anastomoses between the branches of the external
and internal carotid arteries.
Transverse Facial Artery

This small artery is a branch of the superficial temporal
artery. After emerging from the parotid gland, it runs
forwards over the masseter between the parotid duct
and the zygomatic arch, accompanied by the upper Dangerous Area of Face
buccal branch of the facial nerve. It supplies the parotid The facial vein communicates with the cavernous sinus
gland and its duct, masseter and the overlying skin, through emissary veins. Infections from the face can
and ends by anastomosing with neighbouring arteries
Head and Neck
spread in a retrograde direction and cause thrombosis

(Fig. 2.17). of the cavernous sinus. This is specially likely to occur
in the presence of infection in the upper lip and in the
lower part of the nose. This area is, therefore, called
AN 28.8 Explain surgical importance of deep facial vein.9
the dangerous area of the face (Fig. 2.18).
VEINS OF THE FACE

CLINICAL ANATOMY
1 The veins of the face accompany the arteries and
drain into the common facial and retromandibular The facial veins and its deep connecting veins are
veins. They communicate with the cavernous sinus. devoid of valves, making an uninterrupted passage
2 The veins on each side form a ‘W-shaped’ arrangement. of blood to cavernous sinus. Squeezing the pustules
Each corner of the ‘W’ is prolonged upwards into or pimples in the area of the upper lip or side of nose
the scalp and downwards into the neck (Fig. 2.6). or even the cheeks may cause infection which may
3 The facial vein is the largest vein of the face with no be carried to the cavernous sinus leading to its
valves. It begins as the angular vein at the medial thrombosis. So the cheek area may also be included
angle of the eye. It is formed by the union of the as the dangerous area (Fig. 2.18).
supratrochlear and supraorbital veins. The angular
77
Fig. 2.18: Dangerous area of the face (stippled). Spread of

Fig. 2.19: The lymphatic territories of the face. Area A drains into
infection from this area can cause thrombosis of the
the preauricular nodes, area B drains into the submandibular
cavernous sinus
nodes, and area C drains into the submental nodes
LYMPHATIC DRAINAGE OF THE FACE

3 Lower territory, including the central part of the lower
The face has three lymphatic territories: lip and the chin, drains into the submental nodes
1 Upper territory, including the greater part of the (Fig. 2.19).
forehead, lateral halves of eyelids, conjunctiva, lateral
part of the cheek and parotid area, drains into the Labial, Buccal and Molar Mucous Glands
preauricular parotid nodes. The labial and buccal mucous glands are numerous.
2 Middle territory, including a strip over the median They lie in the submucosa of the lips and cheeks. The
part of the forehead, external nose, upper lip, lateral molar mucous glands, four or five, lie on the
part of the lower lip, medial halves of the eyelids, buccopharyngeal fascia around the parotid duct. All
medial part of the cheek, and the greater part of lower these glands open into the vestibule of the mouth
jaw, drains into the submandibular nodes. (Fig. 2.20).
Head and Neck
Fig. 2.20: Scheme of coronal section showing structures in the cheek. The parotid duct pierces buccal pad of fat, buccopharyngeal
fascia, buccinator muscle and the mucous membrane to open into the vestibule of mouth opposite the crown of the upper second
molar tooth
HEAD AND NECK
78
EYELIDS OR PALPEBRAE DISSECTION

Give a circular incision around the roots of eyelids
Features (Fig. 2.2a—viii and ix). This will separate the orbital part
The space between the two eyelids is the palpebral of orbicularis oculi from the palpebral parts. Carefully
fissure. The two lids are fused with each other to form reflect the palpebral part towards the palpebral fissure.
the medial and lateral angles or canthi of the eye. At Identify the structures present beneath the muscle as
the inner canthus, there is a small triangular space, the given in the text.
lacus lacrimalis. Within it, there is an elevated lacrimal The upper and lower eyelids are movable curtains
caruncle, made up of modified skin and skin glands. which protect the eyes from foreign bodies and bright
Lateral to the caruncle, the bulbar conjunctiva is light. They keep the cornea clean and moist. The upper
pinched up to form a vertical fold called the plica eyelid is larger and more movable than the lower eyelid
semilunaris (Fig. 2.1a). (Figs 2.21a and b).
Each eyelid is attached to the margins of the orbital
opening. Its free edge is broad and has a rounded outer 3 The palpebral fascia of the two lids forms the orbital
lip and a sharp inner lip. The outer lip presents two or septum. Its thickenings form tarsal plates or tarsi in
more rows of eyelashes or cilia, except in the boundary the lids and the palpebral ligaments at the angles. Tarsi
of the lacus lacrimalis. At the point where eyelashes are thin plates of condensed fibrous tissue located near
cease, there is a lacrimal papilla on the summit of which the lid margins. They give stiffness to the lids
there is the lacrimal punctum (Fig. 2.1a). Near the inner (Müller’s muscles) (Fig. 2.21a).
lip of the free edge, there is a row of openings of the The palpebral fascia (orbital septum) is pierced by:
tarsal glands. (a) Palpebral part of lacrimal gland, (b) fibres of
levator palpebral superioris, (c) vessels and nerves
The free margin of both the eyelids is subdivided entering the face from the orbit.
into: Lateral 5/6th, the ciliary part with eyelashes and
The upper tarsus receives two tendinous slips from
medial 1/6th, the lacrimal part, which lacks cilia. the levator palpebrae superioris, one from voluntary
part and another from involuntary part or Müller’s
Structure muscle (Fig. 2.21b). Tarsal glands or meibomian
Each lid is made up of the following layers from without glands are embedded in the posterior surface of the
inwards: tarsi; their ducts open in a row behind the cilia.
1 The skin is thin, loose and easily distensible by 4 The conjunctiva lines the posterior surface of the tarsus.
oedema fluid or blood. Apart from the usual glands of the skin, and mucous
2 The superficial fascia is without any fat. It contains glands in the conjunctiva, the larger glands found in
the palpebral part of the orbicularis oculi. Deep to the lids are:
the muscle is loose areolar tissue which is continuous a. Large sebaceous glands also called Zeis glands at
with loose areolar tissue of the scalp. the lid margin associated with cilia.
Head and Neck
Figs 2.21a and b: (a) Orbital septum; (b) Sagittal section of the upper eyelid
79
b. Modified sweat glands or Moll’s glands at the lid hard and painful, and the whole of the lid is
margin closely associated with Zeis glands and oedematous. The pus points near the base of one
cilia. of the cilia.
c. Sebaceous or tarsal glands are also known as • Blepharitis is inflammation of the eyelids, specially
meibomian glands. of the lid margin.
Blood Supply
The eyelids are supplied by:
AN 31.4 Enumerate components of lacrimal apparatus.10
1 The superior and inferior palpebral branches of the
ophthalmic artery.
2 The lateral palpebral branch of the lacrimal artery. LACRIMAL APPARATUS
They form an arcade in each lid.
The veins drain into the ophthalmic and facial veins. COMPONENTS
Nerve Supply The structures concerned with secretion and drainage of
The upper eyelid is supplied by the lacrimal, the lacrimal or tear fluid constitute the lacrimal
supraorbital, supratrochlear and infratrochlear nerves apparatus. It is made up of the following parts:
from lateral to medial side. 1 Lacrimal gland and its ducts (Fig. 2.22).
The lower eyelid is supplied by the infraorbital and 2 Conjunctival sac
infratrochlear nerves (Fig. 2.16). 3 Lacrimal puncta and lacrimal canaliculi
4 Lacrimal sac
Lymphatic Drainage 5 Nasolacrimal duct.
The medial halves of the lids drain into the submandi-
Lacrimal Gland
bular nodes, and the lateral halves into the preauricular
nodes (Fig. 2.19). It is a serous gland situated chiefly in the lacrimal fossa
on the anterolateral part of the roof of the bony orbit
and partly on the upper eyelid. Small accessory lacrimal
CLINICAL ANATOMY glands are found in the conjunctival fornices. These are
also called as Krause’s gland.
• The Müller’s muscle or involuntary part of levator
palpebrae superioris is supplied by sympathetic DISSECTION
fibres from the superior cervical ganglion.
Paralysis of this muscle leads to partial ptosis. This On the lateral side of the upper lid, cut the palpebral
is part of the Horner’s syndrome. fascia. This will show the presence of the lacrimal gland
• The palpebral conjunctiva is examined for deep in this area. Its palpebral part is to be traced in
anaemia and for conjunctivitis; the bulbar the upper eyelid. On the medial ends of both the eyelids,
conjunctiva for jaundice. look for lacrimal papilla. Palpate and dissect the medial
Head and Neck

palpebral ligament binding the medial ends of the
• Conjunctivitis is one of the commonest diseases eyelids. Try to locate the small lacrimal sac behind this
of the eye. It may be caused by infection or by ligament.
allergy.
• Foreign bodies are often lodged in a groove
situated 2 mm from the edge of each eyelid.
• Chalazion is inflammation of a tarsal gland,
causing a localised swelling pointing inwards.
• Ectropion is due to eversion of the lower lacrimal
punctum. It usually occurs in old age due to laxity
of skin.
• Trachoma is a contagious granular conjunctivitis
caused by the trachoma virus. It is regarded as
the commonest cause of blindness.
• Stye or hordeolum is a suppurative inflammation
of one of the glands of Zeis. The gland is swollen,
Fig. 2.22: Components of lacrimal apparatus
HEAD AND NECK
80
The gland is ‘J’ shaped, being indented by the tendon The lacrimal fluid secreted by the lacrimal gland
of the levator palpebrae superioris muscle. It has: flows into the conjunctival sac where it lubricates the
a. An orbital part which is larger and deeper, and front of the eye and the deep surface of the lids. Periodic
b. A palpebral part smaller and superficial, lying blinking helps to spread the fluid over the eye. Most of
within the eyelid (Fig. 2.22). the fluid evaporates. The rest is drained by the lacrimal
canaliculi. When excessive, it overflows as tears.
About a dozen of its ducts pierce the conjunctiva of
the upper lid and open into the conjunctival sac near Conjunctival Sac
the superior fornix. Most of the ducts of the orbital part The conjunctiva lining the deep surfaces of the eyelids
pass through the palpebral part. Removal of the latter is called palpebral conjunctiva and that lining the front
is functionally equivalent to removal of the entire gland. of the eyeball is called bulbar conjunctiva. The potential
After removal, the conjunctiva and cornea are space between the palpebral and bulbar parts is the
moistened by accessory lacrimal glands. conjunctival sac. The lines along which the palpebral
The gland is supplied by the lacrimal branch of the conjunctiva of the upper and lower eyelids is reflected
ophthalmic artery and by the lacrimal nerve. The nerve onto the eyeball are called the superior and inferior
has both sensory and secretomotor fibres. Flowchart 2.2 conjunctival fornices.
shows the secretomotor fibres for lacrimal gland. The palpebral conjunctiva is thick, opaque, highly
vascular, and adherent to the tarsal plate. The bulbar
conjunctiva covers the sclera. It is thin, transparent, and
Flowchart 2.2: Secretomotor fibres for lacrimal gland loosely attached to the eyeball. Over the cornea, it is
represented by the anterior epithelium of the cornea.
Lacrimal Puncta and Canaliculi
Each lacrimal canaliculus begins at the lacrimal punctum,
and is 10 mm long. It has a vertical part which is 2 mm
long and a horizontal part which is 8 mm long. There
is a dilated ampulla at the bend. Both canaliculi open
close to each other in the lateral wall of the lacrimal sac
behind the medial palpebral ligament.
Lacrimal Sac
It is a membranous sac, 12 mm long and 5 mm wide,
situated in the lacrimal groove behind the medial
palpebral ligament. Its upper end is blind. The lower
end is continuous with the nasolacrimal duct.
The sac is related anteriorly to the medial palpebral
ligament and to the orbicularis oculi. Medially, the
lacrimal groove separates it from the nose. Laterally, it
Head and Neck
is related to the lacrimal fascia and the lacrimal part of

the orbicularis oculi.
Nasolacrimal Duct
It is a membranous passage, 18 mm long. It begins at
the lower end of the lacrimal sac, runs downwards,
backwards and laterally, and opens into the inferior
meatus of the nose. A fold of mucous membrane, called
the valve of Hasner, forms an imperfect valve at the lower
end of the duct.
CLINICAL ANATOMY
• Inflammation of the lacrimal sac is called dacro-
cystitis.
• The ducts of lacrimal gland open through its
palpebral part into the conjunctival sac. Because
81
of this arrangement, the removal of palpebral part Loss of taste in anterior two-thirds of tongue
necessitates the removal of the orbital part as well. Sudden onset
• Excessive secretion of the lacrimal fluid over- Palsy of muscles of facial expression (unilateral)
flowing on the cheeks is called epiphora. Epiphora Five branches of the facial nerve (VII)
may result due to obstruction in the lacrimal fluid (Ten Zebras Bit My Cat)
pathway, either at the level of punctum or Temporal
canaliculi or nasolacrimal duct. Zygomatic
Buccal
Marginal mandibular
Competency achievement: The student should be able to: Cervical
AN 43.4 Describe the development and developmental basis of
congenital anomalies of face, palate, tongue, branchial apparatus, SCALP
pituitary gland, thyroid gland and eye.11 (Development of face is From superficial to deep:
given here. For the development of other structures, please refer Skin
to respective chapters.) Connective tissue
Aponeurosis
DEVELOPMENT OF FACE Loose areolar tissue
Five processes of face, one frontonasal, two maxillary Pericranium
and two mandibular processes form the face.
Frontonasal process forms the forehead, the nasal
septum, philtrum of upper lip and premaxilla bearing FACTS TO REMEMBER
upper four incisor teeth. • Forehead is common to both the scalp and the face.
Maxillary process forms whole of upper lip except • There are 5 layers in scalp and 6 layers in the
the philtrum and most of the hard and soft palate except superficial temporal region.
the part formed by the premaxilla. • Impulses from skin of the face reach the three
Mandibular process forms the whole lower lip. branches of trigeminal nerve, whereas the muscles
Cord of ectoderm gets buried at the junction of of facial expression are supplied by the facial nerve.
frontonasal and maxillary processes. Canalisation of To establish the reflex arc, nucleus of VII nerve
ectodermal cord of cells gives rise to nasolacrimal comes closer to the spinal nucleus of V nerve at the
duct. level of lower pons. This is called ‘neurobiotaxis’.
• Facial nerve though courses through the parotid
Molecular Regulation gland, does not give any branch to the largest
Face develops from pharyngeal arches. Facial skeleton salivary gland.
develops from neural crest cells which migrate into the • Buccinator is an accessory muscle of mastication,
pharyngeal arches. In hindbrain, the segments are as it prevents food entering the vestibule of mouth.
rhombomeres. From the rhombomeres, crest cells • Part of the face between anterior nares and upper
migrate to pharyngeal region. Genes responsible are: lip is called ‘dangerous area of face’ as the facial
Head and Neck

First arch is HOX negative. It expresses OTX2, a vein communicates with cavernous venous sinus
homeodomain containing transcription factor. situated in the cranial cavity. Any infection from
Second arch expresses HOX-A2. this part of face can infect the intracranial venous
Third to sixth arches express HOX-A3, HOX-B3 and sinus, i.e. cavernous sinus.
HOX-D3. • Levator palpebrae superioris is supplied partly by
Following signaling molecules play an important oculomotor nerve and partly by sympathetic fibres.
part in development of face. • The facial muscles are subcutaneous in position
• BMP7—Bone morphogenetic protein and represents morphologically remnants of
• FGF8—Fibroblast growth factor 8 panniculus carnosus.
• SHH—Sonic hedgehog proteins
Mnemonics CLINICOANATOMICAL PROBLEMS

Bell’s palsy Case 1
Blink reflex abnormal A man of about 30 years comes to OPD with inability
Ear ache to close his left eye, tears overflowing on the left cheek
Lacrimation (deficient) and saliva dribbling from his left angle of the mouth.
HEAD AND NECK
82
• What is the reason for his sad condition? few days, she noticed severe weakness in her eye
• What is the nerve damaged and how is the muscles.
integrity of the nerve tested? • How are the pustules connected to nerves
Ans: The reason for the patient’s sad condition is supplying eye muscles?
paralysis of his left facial nerve at the stylomastoid
foramen. It is called Bell’s palsy. It is treated by Ans: Infection from pustules travels via facial vein,
physiotherapy and medicines. deep facial vein, pterygoid venous plexus, emissary
Facial nerve is tested by: vein to cavernous venous sinus and III, IV and VI
Asking the patient: cranial nerves related in its lateral wall. Since the
i. To look upwards without moving his head, nerves are infected, the extraocular muscles get weak
and look for the normal horizontal wrinkles and may get paralysed.
on the forehead.
ii. To show the teeth
iii. Tightly close the eyes to test the orbicularis FURTHER READING
oculi muscle. • Choudhry R, Raheja S, Gaur U, Choudhry S, Anand C.
iv. Puffing the mouth and then blowing out air Mastoid canals in adult human skulls. J Anat 1996;188:217–
19.
forcibly to test the buccinator muscle.
• Wilkinson C, Rynn C. Craniofacial Identification. Cambridge:
Case 2 Cambridge University press. 2012.
A teenage girl with infected acne tried to drain the Forensic facial reconstruction is an area that requires an equal
pustules on her upper lip with her bare hands. After a amount of scientific and artistic talent. This text addresses this
complex subject in an approachable manner.
1–11
Head and Neck
83
1. Describe the arterial supply and venous drainage 3. Write short notes/enumerate:
of the face, add a note on its clinical impor- a. Buccinator muscle
tance. b. Sensory nerve supply of face
c. Components of lacrimal apparatus
2. Enumerate the layers of the scalp. Give its blood d. Features of Bell’s palsy
supply, nerve supply and clinical importance. e. Emissary veins
1. Nasolacrimal duct opens into: c. Inferior oblique

a. Anterior part of inferior meatus d. Levator palpabrae superioris
b. Vestibule of nose 4. Infection in dangerous area of face usually leads
c. Middle meatus to:
d. Superior meatus a. Superior sagittal sinus thrombosis
2. Dangerous area of face is named because of b. Transverse sinus thrombosis
connection of cavernous sinus with facial vein c. Cavernous sinus thrombosis
through which vein?
d. Brain abscess
a. Maxillary
b. Anterior ethmoidal 5. Supraorbital artery is a branch of:
c. Posterior ethmoidal a. Maxillary b. External carotid
d. Deep facial c. Ophthalmic d. Internal carotid
3. Which of the following muscles separates the orbital 6. Which of the following nerves ascends along with
and palpebral parts of the lacrimal gland? occipital artery in the scalp?
a. Superior oblique a. Greater occipital b. Lesser occipital
b. Superior rectus c. Third occipital d. Suboccipital
1. a 2. d 3. d 4. c 5. c 6. a
• Name the sensory and motor nerves supplying the • Enumerate the parts of lacrimal apparatus. Head and Neck
scalp. • Why is buccinator muscle an accessory muscle of
• How is the external jugular vein formed? mastication?
• What is air-embolism? • Name the branches of facial nerve given on the face.
• Name the parts of orbicularis oculi muscle.
• What is the sensory nerve supply of the face?
• Name the muscles attached to the modiolus.
• What is the effect of supranuclear lesion of left facial • What are the structures piercing the buccinator
nerve? muscle?
• Which is the dangerous area of face? • Name the layers of upper eyelid.
• Why is this area of face called dangerous? • What are the effects of left Bell’s palsy on the face?
• Name the nerves supplying levator palpebrae • Which arteries are called ‘an anaesthetist’s arteries’
superioris muscle. and why?
HEAD AND NECK
84
3
Side of the Neck
Life is a continuous process of adjustment .
—Indira Gandhi
INTRODUCTION mandible and the mastoid process, immediately

The beauty of the neck lies in its deep or cervical fascia anteroinferior to the tip of the mastoid process.
(Fig. 3.1a). The sternocleidomastoid is an important 7 The fourth cervical transverse process is just palpable
landmark between the anterior and posterior triangles. at the level of the upper border of the thyroid
The posterior triangle contains the spinal root of cartilage; and the sixth cervical transverse process at
accessory nerve deep to its fascial roof and the roots the level of the cricoid cartilage.
and trunks of brachial plexus deep to its fascial floor. 8 The anterior tubercle of the transverse process of
It also contains a part of the subclavian artery, which the sixth cervical vertebra is the largest of all such
continues as the axillary artery for the upper limb. processes and is called the carotid tubercle of
Arteries, like the rivers, are named according to the Chassaignac. The common carotid artery can be best
regions they pass through. Congestive cardiac failure pressed against this tubercle, deep to the anterior
can be seen at a glance by the raised jugular venous border of the sternocleidomastoid muscle.
pressure. This external jugular vein lies in the 9 The anterior border of the trapezius muscle becomes
superficial fascia and if cut, leads to air embolism, prominent on elevation of the shoulder against
unless the deep fascia pierced by the vein is also cut resistance.
to collapse the vein.
BOUNDARIES
LANDMARKS The side of the neck is roughly quadrilateral in outline.
1 The sternocleidomastoid muscle is seen prominently It is bounded anteriorly, by the anterior median line;
when the neck and chin are turned to the opposite side. posteriorly, by the anterior border of trapezius;
Head and Neck
The ridge raised by the muscle extends from the superiorly, by the base of mandible, a line joining angle
clavicle and sternum to the mastoid process (Fig. 3.1b). of the mandible to mastoid process, and superior nuchal
2 The external jugular vein crosses the sterno- line; and inferiorly, by the clavicle.
cleidomastoid obliquely, running downwards and This quadrilateral space is divided obliquely by the
backwards from near the auricle to the clavicle. It is sternocleidomastoid muscle into the anterior and
better seen in old age. posterior triangles (Fig. 3.1b).
3 The greater supraclavicular fossa lies above and behind
the middle one-third of the clavicle. It overlies the SKIN
cervical part of the brachial plexus and the third part The skin of the neck is supplied by the second, third
of the subclavian artery. and fourth cervical nerves. The anterolateral part is
4 The lesser supraclavicular fossa is a small depression supplied by anterior primary rami through the
between the sternal and clavicular parts of the sterno- (i) anterior cutaneous, (ii) great auricular, (iii) lesser
cleidomastoid. It overlies the internal jugular vein. occipital, and (iv) supraclavicular nerves. A broad band
5 The mastoid process is a large bony projection behind of skin over the posterior part is supplied by dorsal or
the auricle. posterior primary rami (see Fig. 2.16).
6 The transverse process of the atlas vertebra can be felt First cervical spinal nerve has no cutaneous
on deep pressure midway between the angle of the distribution. Cervical fifth, sixth, seventh, eighth and
84
SIDE OF THE NECK
85
thoracic first nerves supply the upper limb through the along the superior nuchal line till the external occipital
brachial plexus; and, therefore, do not supply the neck. protuberance.
The territory of fourth cervical nerve extends into the One incision is given along the upper border of
pectoral region through the supraclavicular nerves and clavicle (Fig. 3.1a). Reflect only the skin up towards the
meets second thoracic dermatome at the level of the anterior border of trapezius muscle.
second costal cartilage. Platysma, a part of the subcutaneous muscle is
visible. Reflect the platysma towards the mandible.
SUPERFICIAL FASCIA
Identify the anterior or transverse cutaneous nerve of
Superficial fascia contains areolar tissue with platysma the neck in the upper part of superficial fascia. Anterior
(see Table 2.3). Lying deep to platysma are cutaneous jugular vein running vertically close to the median plane
nerves (Fig. 3.6), superficial veins (see Fig. 2.6), lymph is also encountered. Remove the superficial fascia till
vessels, lymph nodes and small arteries. the deep fascia of neck is seen (Fig. 3.1a).
External jugular vein is seen above the clavicle.
DISSECTION To open up the suprasternal space, make a horizontal
Give a median incision from the chin downwards incision just above the sternum. Extend this incision
towards the suprasternal notch situated above the along the anterior border of sternocleidomastoid muscle
manubrium of sternum. for 3–4 cm. Reflect the superficial lamina to expose the
Make one incision in the skin of base of mandible. suprasternal space and identify its contents.
Continue it by oblique incision along posterior border Define the attachments of investing layer, pretracheal
of ramus of mandible up to mastoid process and further layer, prevertebral layer and carotid sheath.
Head and Neck
Figs 3.1a to c: (a) Lines of dissection; (b) Side of neck divided into anterior and posterior triangles; (c) Parts of posterior and
anterior triangles
HEAD AND NECK
86
CLINICAL ANATOMY Attachments

Superiorly
The surgeon has to stitch platysma muscle separately
so that skin does not adhere to deeper neck muscles, a. External occipital protuberance
otherwise the skin will get an ugly scar. b. Superior nuchal line
c. Mastoid process, styloid process
Competency achievement: The student should be able to: d. External acoustic meatus, tympanic plate
AN 35.1 Describe the parts, extent, attachments, modifications e. Base of the mandible.
of deep cervical fascia.1 Between the angle of the mandible and the mastoid
process, the fascia splits to enclose the parotid gland
(Fig. 3.4a).
DEEP CERVICAL FASCIA (FASCIA COLLI) The superficial lamina, named parotid fascia, is thick
and dense, and is attached to the zygomatic arch. The deep
The deep fascia of the neck is condensed to form the lamina is thin and is attached to the styloid process, the
following layers: tympanic plate and the mandible. Between the styloid
1 Investing layer (Fig. 3.2) process and the angle of the mandible, the deep lamina
2 Pretracheal fascia is thick and forms the stylomandibular ligament which
3 Prevertebral fascia separates the parotid gland from the submandibular
4 Carotid sheath gland, and is pierced by the external carotid artery.
5 Buccopharyngeal fascia At the base of mandible, it encloses submandibular
6 Pharyngobasilar fascia. gland. The superficial lamina is attached to lower
border of body of mandible and deep lamina to the
INVESTING LAYER mylohyoid line (Fig. 3.4b).
It lies deep to the platysma, and surrounds the neck
like a collar. It forms the roof of the posterior triangle Inferiorly
of the neck (Fig. 3.3). a. Spine of scapula,
Head and Neck
Fig. 3.2: Vertical extent of the first three layers of the deep cervical fascia
SIDE OF THE NECK
87
Fig. 3.3: Transverse section through the neck at the level of the seventh cervical vertebra
Head and Neck
Figs 3.4a and b: Investing layer enclosing: (a) Parotid gland; (b) Submandibular gland
b. Acromion process, The fascia splits to enclose the suprasternal and

c. Clavicle, and supraclavicular spaces (Fig. 3.5), both of which are
d. Manubrium. described as follows.
HEAD AND NECK
88
The suprasternal space or space of Burns contains:

• The sternal heads of the right and left sterno-
cleidomastoid muscles (Fig. 3.5),
• The jugular venous arch,
• A lymph node, and
• The interclavicular ligament.
The supraclavicular space is traversed by:
• The external jugular vein (Fig. 3.6),
• The supraclavicular nerves, and
• Cutaneous vessels, including lymphatics.
2 It also forms pulleys to bind the tendons of the
digastric and omohyoid muscles (Fig. 3.1c).
3 Forms roof of anterior and posterior triangles.
4 Forms stylomandibular ligament (Fig. 3.4a) and
Fig. 3.5: Contents of suprasternal space parotidomasseteric fascia.
Posteriorly
CLINICAL ANATOMY
a. Ligamentum nuchae, and
b. Spine of seventh cervical vertebra. • Parotid swellings are very painful due to the
unyielding nature of parotid fascia.
Anteriorly
• While excising the submandibular salivary gland,
a. Symphysis menti the external carotid artery should be secured
b. Hyoid bone. before dividing it, otherwise it may retract through
Both above and below the hyoid bone, it is the stylomandibular ligament and cause serious
continuous with the fascia of the opposite side. bleeding (Fig. 3.4a). This figure also shows the
superior attachment of investing layer of deep
Other Features
cervical fascia to tympanic plate and styloid process.
1 The investing layer of deep cervical fascia splits to • Division of the external jugular vein in the supra-
enclose: clavicular space may cause air embolism and
a. Muscles: Trapezius and sternocleidomastoid consequent death because the cut ends of the
(Fig. 3.3). vein are prevented from retraction and closure
b. Salivary glands: Parotid and submandibular by the fascia, attached firmly to the vein (Fig. 3.6
(Fig. 3.4).
and inset).
c. Spaces: Suprasternal and supraclavicular.
Head and Neck
Fig. 3.6: Structures seen in relation to the fascial roof of the posterior triangle and structures seen in supraclavicular space
SIDE OF THE NECK
89
PRETRACHEAL FASCIA layer is attached to the anterior longitudinal ligament

and to the body of the fourth thoracic vertebra.
The importance of this fascia is that it encloses and
suspends the thyroid gland and forms its false capsule Anteriorly
(Fig. 3.2). It is continuous with buccopharyngeal fascia. It is separated from the pharynx and buccopharyngeal
Attachments fascia by the retropharyngeal space containing loose
areolar tissue. In the lower part of neck, prevertebral
Superiorly and buccopharyngeal fasciae fuse (Fig. 3.3 and see
1 Hyoid bone in the median plane Fig. 8.4). Lymph nodes lie in the retropharyngeal space.
2 Oblique line of thyroid cartilage—laterally
3 Cricoid cartilage—more laterally Laterally
It lies deep to the trapezius and is attached to fascia of
Inferiorly sternocleidomastoid muscle.
Below the thyroid gland, it encloses the inferior thyroid
veins, passes behind the brachiocephalic veins, and Other Features
finally blends with the arch of the aorta and fibrous 1 The cervical and brachial plexuses lie behind the
pericardium. prevertebral fascia. The fascia is pierced by the four
cutaneous branches of the cervical plexus (Fig. 3.6).
On Either Side
2 As the trunks of the brachial plexus and the subclavian
It forms the front of the carotid sheath, and fuses with artery pass laterally through the interval between the
the fascia deep to the sternocleidomastoid (Fig. 3.3). scalenus anterior and the scalenus medius, they carry
Other Features with them a covering of the prevertebral fascia known
as the axillary sheath which extends into the axilla
1 The posterior layer of the thyroid capsule is thick.
(Fig. 3.7). The subclavian and axillary veins lie outside
On either side, it forms a suspensory ligament for the
the sheath and as a result they can dilate during
thyroid gland known as ligament of Berry (see Fig. 8.4).
increased venous return from the limb.
The ligaments are attached chiefly to the cricoid carti-
lage, and may extend to the thyroid cartilage. They 3 Fascia provides a fixed base for the movements of
support the thyroid gland, and do not let it sink into the pharynx, the oesophagus and the carotid sheaths
the mediastinum. The capsule of the thyroid is very during movements of the neck and during swallowing.
weak along the posterior borders of the lateral lobes.
2 The fascia provides a slippery surface for free CLINICAL ANATOMY
movements of the trachea during swallowing. • Neck infections behind the prevertebral fascia
arise usually from tuberculosis of the cervical
CLINICAL ANATOMY vertebrae or cervical caries. Pus produced as a
• Neck infections in front of the pretracheal fascia result may extend in various directions. It may
may bulge in the suprasternal area or extend down pass forwards forming a chronic retropharyngeal
into the anterior mediastinum. abscess which may form a bulging in the posterior
Head and Neck

• The thyroid gland and all thyroid swellings move wall of the pharynx, in the median plane (Fig. 3.7).
with deglutition because the thyroid is attached The pus may extend laterally through the axillary
to cartilages of the larynx by the suspensory sheath and point in the posterior triangle, or in
ligaments of Berry. the lateral wall of the axilla. It may extend
downwards into the superior mediastinum, where
PREVERTEBRAL FASCIA its descent is limited by fusion of the prevertebral
fascia to the fourth thoracic vertebra.
It lies in front of the prevertebral muscles, and forms • Neck infections in front of the prevertebral fascia
the floor of the posterior triangle of the neck (Fig. 3.2). in the retropharyngeal space usually arise from
Attachments and Relations suppuration, i.e. formation of pus in the retro-
pharyngeal lymph nodes. The pus forms an acute
Superiorly
retropharyngeal abscess which bulges forwards
It is attached to the base of the skull (Fig. 3.2). in the paramedian position due to fusion of the
Inferiorly
buccopharyngeal fascia to the prevertebral fascia
in the median plane. The infection may extend
It extends into the superior mediastinum where it splits down through the superior mediastinum into the
into anterior and posterior layers. Anterior layer/alar posterior mediastinum (Fig. 3.3).
fascia blends with buccopharyngeal fascia and posterior
HEAD AND NECK
90
Fig. 3.7: Axillary sheath showing extent of tuberculosis of Figs 3.8a and b: Right carotid sheath with its contents: (a) Surface
cervical vertebrae view; (b) Sectional view
CAROTID SHEATH skull. It lies deep to the pharyngeal muscles (see Figs 14.14
It is a condensation of the fibroareolar tissue around and 14.21).
the main vessels of the neck.
Formation: It is formed on anterior aspect by pre-
AN 35.10 Describe the fascial spaces of neck/pharynx.2
tracheal fascia and on posterior aspect by prevertebral
fascia.
Contents: The contents are the common or internal PHARYNGEAL SPACES
carotid arteries, internal jugular vein and the vagus
nerve. It is thin over the vein (Figs 3.8a and b). In the RETROPHARYNGEAL SPACE
upper part of sheath, there are IX, XI, XII nerves also. Situation: Dead space behind pharynx.
These nerves pierce the sheet at different points. Function: Acts as a bursa for expansion of
Relations: pharynx during deglutition
1 The ansa cervicalis lies embedded in the anterior wall Boundaries: Anterior: Buccopharyngeal fascia
of the carotid sheath (Figs 3.8a and b). Posterior: Prevertebral fascia. The two
2 The cervical sympathetic chain lies behind the sheath, get fused.
plastered to the prevertebral fascia. Sides: Carotid sheath (Fig. 3.3)
Head and Neck
3 The sheath is overlapped by the anterior border of Superior: Base of skull

the sternocleidomastoid, and is fused to the layers Inferior: Open and continuous with superior
of the deep cervical fascia. mediastinum.
Contents: Retropharyngeal lymph nodes,
BUCCOPHARYNGEAL FASCIA pharyngeal plexus of vessels and
This fascia covers all the constrictor muscles externally nerves, loose areolar tissue.
and extends onto the superficial aspect of the buccinator Clinical Pus collection due to lymph node
muscle (see Fig. 14.14) and is attached to pharyngeal anatomy: abscess which lies in paramedian
tubercle. Retropharyngeal space lies posterior to postion. It should be differentiated
buccopharyngeal fascia. Alar fascia is an ancillary layer from cold abscess of spine of cervical
of deep cervical fascia which divides retropharyngeal vertebrae which is seen in median
space into two parts. The posterior space between alar plane.
and prevertebral fasciae is the ‘dangerous space in neck’.
LATERAL PHARYNGEAL SPACE
PHARYNGOBASILAR FASCIA Situation: Side of pharynx
This fascia is especially thickened between the upper Boundaries: Medial: Pharynx
border of superior constrictor muscle and the base of the Posterolateral: Parotid gland
SIDE OF THE NECK
91
Anterolateral: Medial pterygoid b. It can also tilt the head towards the shoulder of
Posterior: Carotid sheath same side.
Contents: Branches of maxillary artery 2 When both muscles contract together:
Fibrofatty tissue a. They draw the head forwards, as in eating and in
Clinical Pus collection/Ludwig’s angina. lifting the head from a pillow.
anatomy: b. With the longus colli, they flex the neck against
resistance.
Competency achievement: The student should be able to: c. It also helps in forced inspiration.
AN 29.1 Describe and demonstrate attachments, nerve supply,
relations and actions of sternocleidomastoid.3 Relations
The sternocleidomastoid is enclosed in the investing
layer of deep cervical fascia, and is pierced by the
STERNOCLEIDOMASTOID MUSCLE accessory nerve and by the four sternocleidomastoid
(STERNOMASTOID) arteries. It has the following relations.
The sternocleidomastoid and trapezius are large super- Superficial
ficial muscles of the neck. Both of them are supplied by
1 Skin
the spinal root of the accessory nerve. The trapezius, is
2 a. Superficial fascia
described in Chapter 10. The sternocleidomastoid is
b. Superficial lamina of the deep cervical fascia
described below.
(Fig. 3.3)
Origin 3 Platysma
1 The sternal head is tendinous and arises from the 4 External jugular vein, and superficial cervical lymph
superolateral part of the front of the manubrium nodes lying along the vein (Fig. 3.6).
sterni (Fig. 3.1c). 5 a. Great auricular
b. Transverse or anterior cutaneous
2 The clavicular head is musculotendinous and arises
c. Medial supraclavicular nerves (Fig. 3.6)
from the medial one-third of the superior surface of
d. Lesser occipital nerve
the clavicle. It passes deep to the sternal head, and
6 The parotid gland overlaps the muscle.
the two heads blend below the middle of the neck.
Between the two heads, there is a small triangular Deep
depression of the lesser supraclavicular fossa, 1 Bones and joints:
overlying the internal jugular vein. a. Mastoid process—above (Fig. 3.1c)
Insertion b. Sternoclavicular joint—below.
2 Carotid sheath (Fig. 3.8)
It is inserted:
3 Muscles:
1 By a thick tendon into the lateral surface of mastoid
a. Sternohyoid (Fig. 3.3)
process, from its tip to superior border.
b. Sternothyroid
Head and Neck

2 By a thin aponeurosis into the lateral half of the c. Omohyoid
superior nuchal line of the occipital bone.
d. Three scaleni
Nerve Supply e. Levator scapulae (Fig. 3.9b)
f. Splenius capitis (Fig. 3.10)
1 The spinal accessory nerve provides the motor
g. Longissimus capitis (see Fig. 7.3)
supply. It passes through the muscle (Fig. 3.10).
h. Posterior belly of digastric (see Fig. 4.10).
2 Branches from the ventral rami of C2 and C3 are pro-
4 Arteries:
prioceptive.
a. Common carotid (Fig. 3.8)
Blood Supply b. Internal carotid (see Fig. 8.4)
Arterial supply—one branch each from superior c. External carotid
thyroid artery and suprascapular artery and, two d. Sternocleidomastoid arteries, two from the
branches from the occipital artery supply the big occipital artery, one from the superior thyroid, one
muscle. Veins follow the arteries (see Fig. 4.14). from the suprascapular
e. Occipital
Actions f. Subclavian
1 When one muscle contracts: g. Suprascapular
a. It turns the chin to the opposite side. h. Transverse cervical (Fig. 3.9)
HEAD AND NECK
92
Figs 3.9a and b: (a) Boundaries; (b) Contents of posterior triangle
5 Veins: CLINICAL ANATOMY

a. Internal jugular (Fig. 3.8)
b. Anterior jugular • Figure 3.5 shows inferior attachment of investing
Head and Neck
c. Facial layer of deep cervical fascia. Fascia of supra-

clavicular space is pierced by external jugular vein
d. Lingual
to drain into subclavian vein (Fig. 3.6).
6 Nerves:
a. Vagus • Torticollis is a deformity in which the head is bent
to one side and the chin points to the other side.
b. Parts of IX, XI, XII. Spinal root of XI leaves the
This is a result of spasm or contracture of the
SCM at middle of its posterior border to lie in
muscles supplied by the spinal accessory nerve,
posterior triangle (Figs 3.8 and 3.10)
these being the sternocleidomastoid and trapezius.
c. Cervical plexus Although there are many varieties of torticollis
d. Upper part of brachial plexus (Fig. 3.10) depending on the causes, the common types are:
e. Phrenic (Fig. 3.10)
a. Rheumatic torticollis due to exposure to cold
f. Ansa cervicalis or draught.
7 Lymph nodes, superficial and deep cervical (see
b. Reflex torticollis due to inflamed or suppura-
Figs 8.28 and 8.29).
ting cervical lymph nodes which irritate the
Competency achievement: The student should be able to: spinal accessory nerve.
AN 29.3 Explain anatomical basis of wry neck.4
SIDE OF THE NECK
93
Fig. 3.10: The boundaries of posterior triangle of neck with its contents
c. Congenital torticollis due to birth injury. of this muscle. Trace it both ways. Deep to this muscle
Wry neck: Shortening of the muscle fibres due to is the upper or supraclavicular part of brachial plexus.
intravascular clotting of veins within the muscle. It Identify the roots, trunks and their branches carefully.
usually occurs during difficult delivery of the baby. The branches are suprascapular nerve, dorsal scapular
nerve, long thoracic nerve, nerve to subclavius
(Fig. 3.10). Medial to the brachial plexus locate the third
POSTERIOR TRIANGLE part of subclavian artery (refer to BDC App).
Follow the terminal part of external jugular vein
Features through the deep fascia into the deeply placed
subclavian vein (Fig. 3.6). Identify suprascapular artery
The posterior triangle is a space on the side of the neck running just above the clavicle (Fig. 3.9b).
situated behind the sternocleidomastoid muscle.
Define the attachments and relations of sternocleido-
Head and Neck

DISSECTION mastoid muscle. To expose scalenus anterior muscle,
cut across the clavicular head of sternocleidomastoid
Try to dissect and clean the cutaneous nerves (Fig. 3.6)
muscle and push it medially. Scalenus anterior muscle
which pierce the investing layer of fascia at the middle
covered by well-defined prevertebral fascia can be
of posterior border of sternocleidomastoid muscle.
identified. Clean the subclavian artery and upper part
Demarcate the course of external jugular vein. Cut
of brachial plexus deep to the scalenus anterior muscle.
carefully the deep fascia of posterior border of sterno-
cleidomastoid muscle and reflect it towards trapezius
Boundaries
muscle. Identify the accessory nerve lying just deep to
the investing layer seen at the middle of the posterior Anterior
border of sternocleidomastoid muscle and across the Posterior border of sternocleidomastoid (Figs 3.1b and
posterior triangle to reach the anterior border of c).
trapezius which it supplies (Fig. 3.10).
Posterior
Define the boundaries, roof, floor, divisions and
contents of the posterior triangle (Fig. 3.1c). Anterior border of trapezius.
Identify and clean the inferior belly of omohyoid. Find Inferior or Base
the transverse cervical artery along the upper border
Middle one-third of clavicle.
HEAD AND NECK
94
Apex Floor
Lies on the superior nuchal line where the trapezius The floor of the posterior triangle is formed by the
and sternocleidomastoid meet. prevertebral layer of deep cervical fascia, covering the
following muscles:
Roof 1 Splenius capitis
The roof is formed by the investing layer of deep cervical 2 Levator scapulae
fascia. The superficial fascia over the posterior triangle 3 Scalenus medius (Fig. 3.9)
contains: 4 Semispinalis capitis may also form part of the floor.
1 The platysma
Division of the Posterior Triangle
2 The external jugular and posterior external jugular
It is subdivided by the inferior belly of omohyoid into:
veins
1 A larger upper part, called the occipital part.
3 Parts of the supraclavicular, great auricular, 2 A smaller lower part, called the supraclavicular part
transverse cutaneous and lesser occipital nerves or subclavian part (Fig. 3.9a).
(Fig. 3.6)
4 Unnamed arteries derived from the occipital, Competency achievement: The student should be able to:
transverse cervical and suprascapular arteries. AN 29.4 Describe and demonstrate attachments of: 1) inferior belly
of omohyoid, 2) scalenus anterior (see Chapter 9), 3) scalenus
5 Lymph vessels which pierce the deep fascia to end medius (see Chapter 9) and 4) levator scapulae (see Chapter 10).5
in the supraclavicular nodes.
External jugular vein: It lies deep to the platysma Contents of the Posterior Triangle
(Fig. 3.6). It is formed by union of the posterior auricular These are enumerated in Table 3.1. Some of the contents
vein with the posterior division of the retromandibular are considered below.
vein. It begins within the lower part of the parotid
gland, crosses the sternocleidomastoid obliquely, Relevant Features of the Contents of Posterior Triangle
pierces the anteroinferior angle of the roof of the 1 The spinal root of accessory nerve emerges a little
posterior triangle, and opens into the subclavian vein above the middle of the posterior border of the
(see Fig. 2.6). sternocleidomastoid. It runs through a tunnel in the
fascia forming the roof of the triangle, passing
Its tributaries are: downwards and laterally, and disappears under the
a. The posterior external jugular vein anterior border of the trapezius about 5 cm above
b. The transverse cervical vein the clavicle (Figs 3.9 and 3.10). It is the only structure
beneath the roof of triangle. It supplies both
c. The suprascapular vein sternocleidomastoid and trapezius muscles.
d. The anterior jugular vein. 2 The four cutaneous branches of the cervical plexus
The oblique jugular vein connects the external pierce the fascia covering the floor of the triangle,
jugular vein with the internal jugular vein across the pass through the triangle and pierce the deep fascia
middle one-third of the anterior border of the at different points to become cutaneous (Fig. 3.6).
Head and Neck
sternocleidomastoid. a. Transverse cutaneous nerve: Arises from ventral

rami of C2 and C3 nerves runs transversely across
the sternocleidomastoid to supply skin of neck,
CLINICAL ANATOMY till the sternum.
b. Supraclavicular nerves: Formed from ventral rami
• The right external jugular vein is examined to assess of C3 and C4 nerves. Emerges at posterior border
the venous pressure; the right atrial pressure is of sternocleidomastoid. It descends downwards
reflected in it because there are no valves in the and diverges into three branches. Medial one
entire course of this vein and it is straight. supplies the skin over the manubrium till
• As external jugular vein pierces the fascia, the manubriosternal joint. Intermediate nerve crosses
margins of the vein get adherent to the fascia. So the clavicle to supply skin of first intercostal space
if the vein gets cut, it cannot close and air is sucked till the second rib. Lateral nerve runs across the
in due to negative intrathoracic pressure. That lateral side of clavicle and acromion to supply
causes air embolism. To prevent this, the deep skin over the upper half of the deltoid muscle.
fascia has to be cut. c. Great auricular nerve: It is the largest ascending
branch of cervical plexus. Arises from ventral
rami of C2 and C3 nerves. Ascends on the
SIDE OF THE NECK
95
Table 3.1: Contents of the posterior triangle

Contents Occipital triangle Subclavian triangle
A. Nerves 1. Spinal accessory nerve (Figs 3.9 and 3.10) 1. Roots and trunks of brachial plexus
2. Four cutaneous branches of cervical plexus (Fig. 3.6): 2. Nerve to serratus anterior (long thoracic, C5–C7)
a. Lesser occipital (C2) 3. Nerve to subclavius (C5, C6)
b. Great auricular (C2, C3) 4. Suprascapular nerve (C5, C6)
c. Anterior cutaneous nerve of neck (C2, C3)
d. Supraclavicular nerves (C3, C4)
3. Muscular branches:
a. Two small branches to the levator scapulae
(C3, C4)
b. Two small branches to the trapezius (C3, C4)
c. Nerve to rhomboids (proprioceptive) (C5)
B. Vessels 1. Transverse cervical artery and vein 1. Third part of subclavian artery and subclavian vein
2. Occipital artery 2. Suprascapular artery and vein
3. Commencement of transverse cervical artery and
termination of the corresponding vein
4. Lower part of external jugular vein
C. Lymph nodes Along the posterior border of the sternocleidomastoid, A few members of the supraclavicular chain
more in the lower part—the supraclavicular nodes
and a few at the upper angle—the occipital nodes
sternocleidomastoid muscle to reach parotid where it lies deep or anterior to the rhomboid
gland, where it divides into anterior and muscles (Fig. 3.10).
posterior branches. Anterior branch supplies 6 The nerve to the serratus anterior (C5–C7) arises by
lower one-third of skin on lateral surface of pinna three roots. The roots from C5 and C6 pierce the
and skin over the parotid gland and connects the scalenus medius and join the root from C7 over the
gland to the auriculotemporal nerve. This cross- first digitation of the serratus anterior. The nerve
connection is the anatomical basis for Frey’s passes behind the brachial plexus. It descends over
syndrome. Posterior branch supplies lower one- the serratus anterior in the medial wall of the axilla
third of skin on medial surface of the pinna. and gives branches to the digitations of the muscle
d. Lesser occipital: Arises from ventral ramus of C2 (Fig. 3.11).
segment of spinal cord. Seen at the posterior 7 The nerve to the subclavius (C5, C6) (Fig. 3.9b) descends
border of sternocleidomastoid muscle. It then in front of the brachial plexus and the subclavian
winds around and ascends along its posterior vessels, but behind the omohyoid, the transverse
border to supply skin of upper two-thirds of cervical and suprascapular vessels and the clavicle
medial surface of pinna adjoining part of the scalp. to reach the deep surface of the subclavius muscle.
Head and Neck

3 Muscular branches to the levator scapulae and to the As it runs near the lateral margin of the scalenus
trapezius (C3, C4) appear about the middle of the anterior, it sometimes gives off the accessory phrenic
sternocleidomastoid. Those to the levator scapulae nerve which joins the phrenic nerve in front of the
soon end in it; those to the trapezius run below and scalenus anterior.
parallel to the accessory nerve across the middle of 8 The suprascapular nerve (C5, C6) arises from the
the triangle. Both nerves lie deep to the fascia of the upper trunk of the brachial plexus and crosses the
floor. lower part of the posterior triangle just above and
4 Three trunks of the brachial plexus emerge between lateral to the brachial plexus, deep to the transverse
the scalenus anterior and medius, and carry the axil- cervical vessels and the omohyoid. It passes
lary sheath around them. The sheath contains the backwards over the shoulder to reach the scapula.
brachial plexus and the subclavian artery. These It supplies the supraspinatus and infraspinatus
structures lie deep to the floor of posterior triangle. If muscles (Fig. 3.9b).
prevertebral fascia is left intact, all these structures are 9 The subclavian artery passes behind the tendon of the
safe (Fig. 3.9). scalenus anterior, over the first rib (Fig. 3.12).
5 The nerve to the rhomboid or dorsal scapular nerve is 10 The transverse cervical artery is a branch of the
from C5 root, pierces the scalenus medius and thyrocervical trunk. It crosses the scalenus anterior,
passes deep to the levator scapulae to reach the back the phrenic nerve, the upper trunks of the brachial
HEAD AND NECK
96
Fig. 3.11: Brachial plexus
plexus, the nerve to the subclavius, the supras- nodes. While doing biopsy of the lymph node, one
capular nerve, and the scalenus medius. At the must be careful in preserving the accessory nerve
anterior border of the levator scapulae, it divides which may get entangled amongst enlarged
into superficial and deep branches. The inferior belly lymph nodes (Fig. 3.10).
of the omohyoid crosses the artery (Fig. 3.10). • Supraclavicular lymph nodes are commonly
11 The suprascapular artery is also a branch of the enlarged in tuberculosis, Hodgkin’s disease, and
thyrocervical trunk. It passes laterally and back- in malignant growths of the breast, arm or chest.
wards behind the clavicle (Fig. 3.10). • Block dissection of the neck for malignant diseases
Head and Neck
12 The occipital artery crosses the apex of the posterior is the removal of cervical lymph nodes along with
triangle superficial to the splenius capitis (Fig. 3.9). other structures involved in the growth. This
13 The subclavian vein passes in front of the tendon of procedure does not endanger those nerves of the
scalenus anterior muscle. posterior triangle which lie deep to the
14 Inferior belly of omohyoid arises from upper border prevertebral fascia, i.e. the brachial and cervical
of scapula near suprascapular notch, passes deep plexuses and their muscular branches.
to trapezius and appears on its upper border in the • A cervical rib may compress the second part of sub-
posterior triangle. It courses through posterior clavian artery. In these cases, blood supply to upper
triangle, dividing it in two parts, lies deep to sterno- limb reaches via anastomoses around the scapula.
cleidomastoid and continues as superior belly till • Dysphagia caused by compression of the oesophagus
hyoid bone. by an abnormal subclavian artery is called
dysphagia lusoria.
• Elective arterial surgery of the common carotid
CLINICAL ANATOMY artery is done for aneurysms, AV fistulae or
arteriosclerotic occlusions. It is better to expose
• The most common swelling in the posterior triangle the common carotid artery in its upper part where
is due to enlargement of the supraclavicular lymph it is superficial. While ligating the artery, care
SIDE OF THE NECK
97
should be taken not to include the vagus nerve or • Cold abscess of caries spine, can track down to the
the sympathetic chain. posterior triangle or axilla.
• Second part of the subclavian artery may get • Occipital part of posterior triangle contains the
pressed by the scalenus anterior muscle, resulting spinal root of accessory nerve as the most
in decreased blood supply to the upper limb. If important constituent.
the muscle is divided, the effects are abolished • Supraclavicular part of posterior triangle contains
(Fig. 3.12). roots, trunks, branches of brachial plexus and third
part of subclavian artery.
• Sternocleidomastoid divides the side of neck into
anterior and posterior triangles.
CLINICOANATOMICAL PROBLEM
A middle-aged woman had a deep cut in the

middle of her right posterior triangle of neck. The
bleeding was arrested and wound was sutured.
The patient later felt difficulty in combing her
hair.
• What is the blood vessel severed?
• Why did the patient have difficulty in combing
her hair?
Ans: The external jugular vein was severed. It passes
across the sternocleidomastoid muscle to join the
Fig. 3.12: Second part of subclavian artery narrowed by the
subclavian vein above the clavicle. Her accessory
short scalenus anterior nerve is also injured as it crosses the posterior triangle
close to its roof, causing paralysis of trapezius
muscle. The trapezius with serratus anterior causes
Mnemonics overhead abduction required for combing the hair.
Due to paralysis of trapezius, she felt difficulty in
Arrangement of the important nerves “GLAST”: combing her hair.
Great auricular
Lesser occipital FURTHER READING
Head and Neck

Accessory nerve pops out between L and S • Berkoviz BKB, Moxham BJ. Color Atlas of the Skull, London:
Supraclavicular Mosby-Wolfe. 1994.
Transverse cervical An excellent atlas that gives a clear illustration of the different
components of the skull.
• Guidera, AK Daws PJD, Stringer MD. Cervical fascia: A
terminological pain the neck. ANZ Surg 2012;82:786–91.
A review that provides a critical appraisal of the terms used to
FACTS TO REMEMBER
describe the cervical fascia in order to achieve consensus and
Investing layer of deep cervical fascia encloses uniformitiy.
two muscles, two salivary glands; forms two pulleys; • Guidera AK, Dawes PJD, Fong A, et al. Head and neck fascia
encloses two spaces and forms roof of posterior and compartments: No space for spaces. Head Neck 2014;
triangle. 36:1058–68.
• Prevertebral fascia forms the axillary sheath. A comprehensive review of the fascia of the head and neck and its
associated compartments aiding the understanding of the variable
• Pretracheal fascia suspends the thyroid gland. and, at times, misleading terminology.
1–5
HEAD AND NECK
98
1. Describe the cervical fascia under following 2. Enumerate the boundaries and contents of posterior
headings: triangle of neck. How is external jugular vein
formed and what is its clinical importance?
a. Attachments and structures enclosed by
investing layer of cervical fascia 3. Write short notes/enumerate:
a. Sternocleidomastoid muscle
b. Clinical importance of pretracheal fascia b. Contents of suprasternal space
c. Contents of carotid sheath c. Suspensary ligament of Berry
1. All of the following structures are seen in the 4. All the following nerves are present in the posterior
posterior triangle of neck, except: triangle, except:
a. Spinal accessory nerve a. Spinal accessory
b. Transverse cervical artery b. Lesser occipital
c. Middle trunk of brachial plexus c. Greater occipital
d. Superior belly of omohyoid d. Great auricular
2. Spinal root of accessory nerve innervates: 5. Investing layer of cervical fascia encloses all, except:
a. Serratus anterior a. Two muscles
b. Stylohyoid
b. Two salivary glands
c. Styloglossus
c. Axillary vessels
d. Sternocleidomastoid
d. Two spaces
3. Suprasternal space contains all, except:
6. Ligament of Berry is formed by:
a. Sternal heads of right and left sternocleido-
mastoid muscles a. Investing layer of cervical fascia
b. Jugular venous arch b. Pretracheal layer
c. Interclavicular ligament c. Prevertebral layer
d. Sternohyoid muscles d. Buccopharyngeal fascia
Head and Neck
1. d 2. d 3. d 4. c 5. c 6. b
• Enumerate the contents of suprasternal space. • Which are the muscles supplied by spinal root of XI
• Name the structures enclosed by investing layer of nerve?
cervical fascia. • Name the arteries supplying the sternocleidomastoid
• What is the function of ligament of Berry. muscle.
• Name the contents of carotid sheath. • Traction of which muscle may result in narrowing
• Which layer of cervical fascia forms the axillary of the subclavian artery?
sheath? • Name the nerves arising from upper trunk of brachial
• What are the boundaries of posterior triangle of plexus.
neck? • What is the root value of ‘nerve to serratus anterior’?
4
Anterior Triangle of the Neck
One picture is worth more than thousand words .
—Anonymous
INTRODUCTION 2 The body of the U-shaped hyoid bone can be felt in

The anterior triangle of the neck lies between midline the median plane just below and behind the chin, at
of the neck and sternocleidomastoid muscle. It is the junction of the neck with the floor of the mouth.
subdivided into smaller triangles. On each side, the body of hyoid bone is continuous
posteriorly with the greater cornua which is over-
lapped in its posterior part by the sternocleidomastoid
SURFACE LANDMARKS muscle.
1 The mandible forms the lower jaw (Fig. 4.1). The lower 3 The thyroid cartilage of the larynx forms a sharp
border of its horseshoe-shaped body is known as the protuberance in the median plane just below the
base of the mandible. Anteriorly, this base forms the hyoid bone. This protuberance is called the laryngeal
chin, and posteriorly it can be traced to the angle of prominence or Adam’s apple. It is more prominent in
the mandible. males.
Fig. 4.1: Surface landmarks of neck
99
HEAD AND NECK
100
4 The rounded arch of the cricoid cartilage lies below

the thyroid cartilage at the upper end of the trachea.
5 The trachea runs downwards and backwards from
the cricoid cartilage. It is identified by its carti-
laginous rings. However, it is partially masked by
the isthmus of the thyroid gland which lies against
second to fourth tracheal rings. The trachea is
commonly palpated in the suprasternal notch which
lies between the tendinous heads of origin of the right
and left sternocleidomastoid muscles. In certain
diseases, the trachea may shift to one side from the
median plane. This indicates a shift in the medi-
astinum.
STRUCTURES IN THE ANTERIOR

MEDIAN REGION OF THE NECK Fig. 4.2: Anterior triangles of the neck showing the platysma
and the anterior jugular veins in the superficial fascia
Features
This region includes a strip 2 to 3 cm wide extending (Fig. 4.2). The vein then turns laterally, runs deep to
from the chin to the sternum. The structures encountered the sternocleidomastoid just above the clavicle, and
are listed below from superficial to deep. ends in the external jugular vein at the posterior border
of the sternocleidomastoid.
Skin 3 A few small submental lymph nodes lye on the deep
It is freely movable over the deeper structures due to fascia below the chin (Fig. 4.3).
the looseness of the superficial fascia. 4 The terminal filaments of the transverse or anterior
cutaneous nerve of the neck may be present in it.
Superficial Fascia
It contains: Deep Fascia
1 The upper decussating fibres of the platysma for 1 to Above the hyoid bone, the investing layer of deep fascia
2 cm below the chin. is a single layer in the median plane, but splits on
2 The anterior jugular veins beginning in the submental each side to enclose the submandibular salivary gland
region below the chin. It descends in the superficial (see Fig. 3.4).
fascia about 1 cm from the median plane. About Between the hyoid bone and the cricoid cartilage, it
2.5 cm above the sternum, it pierces the investing is a single layer extending between the right and left
layer of deep fascia to enter the suprasternal space sternocleidomastoid muscles.
where it is connected to its fellow of the opposite Below the cricoid, the fascia splits to enclose the
Head and Neck
side by a transverse channel, the jugular venous arch suprasternal space (see Fig. 3.5).
Fig. 4.3: Suprahyoid region, contents of submental and digastric triangles also shown
ANTERIOR TRIANGLE OF THE NECK
101
Fig. 4.4: Coronal section through the floor of the mouth
Deep Structures Lying above the Hyoid Bone

The mylohyoid muscle is overlapped by:
a. Anterior belly of digastric above the hyoid bone.
b. Superficial part of the submandibular salivary gland
(Figs 4.3 and 4.4).
c. Mylohyoid nerve and vessels.
d. Submental branch of the facial artery.
The anteroinferior part of the hyoglossus muscle with
its superficial relations may also be exposed during
dissection. Structures lying in this corner are:
a. The intermediate tendon of the digastric muscle
with its fibrous pulley (Fig. 4.3). Fig. 4.5: Sagittal section through the hyoid region of the neck
b. The bifurcated tendon of the stylohyoid muscle showing the subhyoid bursa and its relations
embracing the digastric tendon (Fig. 4.10).
The subhyoid bursa lies between the posterior 3 Deep to the pretracheal fascia, there are:
surface of the body of the hyoid bone and the a. The thyrohyoid membrane deep to the thyrohyoid
thyrohyoid membrane. It lessens friction between these muscle: It is pierced by the internal laryngeal nerve
two structures during the movements of swallowing and the superior laryngeal vessels (Fig. 4.7).
(Fig. 4.5). b. Thyroid cartilage.
Head and Neck

c. Cricothyroid membrane with the anastomosis of the
Structures Lying below the Hyoid Bone cricothyroid arteries on its surface.
These structures may be grouped into three planes: d. Arch of the cricoid cartilage.
(1) Superficial plane containing the infrahyoid muscles, e. Cricothyroid muscle supplied by the external
(2) a middle plane consisting of the pretracheal fascia laryngeal nerve.
and the thyroid gland, and (3) a deep plane containing f. Trachea, partly covered by the isthmus of the
the larynx, trachea and structures associated with them. thyroid gland from the second to fourth rings.
1 Infrahyoid muscles: g. Carotid sheaths lie on each side of the trachea
a. Sternohyoid (see Fig. 3.8).
b. Sternothyroid
c. Thyrohyoid DISSECTION
d. Superior belly of omohyoid. The skin over the anterior triangle has already been
These are described in Table 4.1 and Fig. 4.6. reflected following dissection in Chapter 3. Platysma is
2 Pretracheal fascia: It forms the false capsule of the thyroid also reflected upwards. Identify the structures present
gland and the suspensory ligaments of Berry which in the superficial fascia and structures present in the
attach the thyroid gland to the cricoid cartilage anterior median region of neck.
(see Fig. 8.4).
HEAD AND NECK
102
Fig. 4.6: The infrahyoid muscles
retrothyroid region after retracting the isthmus of

the thyroid gland (Fig. 4.8). A suprathyroid tracheo-
stomy is liable to stricture, and an infrathyroid one
is difficult due to the depth of the trachea and is
also dangerous because numerous vessels lie
anterior to the trachea here.
• Cut throat wounds are most commonly situated
just above or just below the hyoid bone. The main
vessels of the neck usually escape injury because
they are pushed backwards to a deeper plane
during voluntary extension of the neck.
• Skin incisions to be made parallel to natural
creases or Langer’s lines (Fig. 4.9).
• Ludwig’s angina is the cellulitis of the floor of the
mouth. The infection spreads above the mylo-
Head and Neck
Fig. 4.7: The thyroid gland, the larynx and the trachea seen
from the front
CLINICAL ANATOMY
• The common anterior midline swellings of the

neck are:
a. Enlarged submental lymph nodes and
sublingual dermoid in the submental region.
b. Thyroglossal cyst and inflamed subhyoid bursa
just below the hyoid bone (Fig. 4.5).
c. Goitre, carcinoma of larynx and enlarged
lymph nodes in the suprasternal region.
• Tracheostomy is an operation in which the trachea
is opened and a tube inserted into it to facilitate
breathing. It is most commonly done in the Fig. 4.8: Tracheostomy tube in position
103

AN 32.2 Describe and demonstrate boundaries and contents of
digastric and submental triangles.2
SUBMENTAL TRIANGLE
This is a median triangle. It is bounded as follows.
On each side, there is the anterior belly of the
corresponding digastric muscles. Its base is formed by
the body of the hyoid bone. Its apex lies at the chin.
The floor of the triangle is formed by the right and left
mylohyoid muscles and the median raphe uniting them
(Fig. 4.3).
Contents
1 Two to four small submental lymph nodes are situated
in the superficial fascia between the anterior bellies
of the digastric muscles (Fig. 4.3). They drain:
a. Superficial tissues below the chin
b. Central part of the lower lip
c. The adjoining gums
d. Anterior part of the floor of the mouth
e. The tip of the tongue.
Their efferents pass to the submandibular nodes.
2 Small submental veins join to form the anterior
Figs 4.9a and b: Langer’s lines in the neck
jugular veins.
hyoid forcing the tongue upwards. Mylohyoid is DIGASTRIC TRIANGLE

pushed downwards. There is swelling within the The area between the body of the mandible and the
mouth as well as below the chin. hyoid bone is known as the submandibular region. The
superficial structures of this region lie in the submental
and digastric triangles. The deep structures of the floor
Competency achievement: The student should be able to: of the mouth and root of the tongue will be studied
AN 32.1 Describe boundaries and subdivisions of anterior triangle.1 separately at a later stage under the heading ‘sub-
mandibular region’ in Chapter 7.
Head and Neck

ANTERIOR TRIANGLE Boundaries
BOUNDARIES
The boundaries of the digastric triangle are as follows.
The boundaries of the anterior triangle of neck are: The Anteroinferiorly: Anterior belly of digastric.
anterior median plane of the neck medially; Posteroinferiorly: Posterior belly of digastric and the
sternocleidomastoid laterally; base of the mandible and stylohyoid.
a line joining the angle of the mandible to the mastoid
Superiorly or base: Base of the mandible and a line
process, superiorly (Fig. 4.10).
joining the angle of the mandible to the mastoid process
(Fig. 4.10).
SUBDIVISIONS
The anterior triangle is subdivided (by the digastric Roof
muscle and the superior belly of the omohyoid) into: The roof of the triangle is formed by:
a. Submental, 1 Skin
b. Digastric, 2 Superficial fascia, containing:
c. Carotid, and a. The platysma
d. Muscular triangles (Fig. 4.10). b. The cervical branch of the facial nerve
HEAD AND NECK
104
Fig. 4.10: The triangles of the neck. The anterior triangle is subdivided by digastrics and superior belly of omohyoid. Posterior
triangle is subdivided by inferior belly of omohyoid
c. The ascending branch of the transverse or anterior DISSECTION

cutaneous nerve of the neck.
3 Deep fascia, which splits to enclose the submandi- Remove the deep fascia from anterior bellies of digastric
muscles to expose parts of two mylohyoid muscles. Clean
bular salivary gland (see Fig. 7.6).
the boundaries and contents of the submental triangle.
Floor Cut the deep fascia from the mandible and reflect it
The floor is formed by the mylohyoid muscle anteriorly, downwards to expose the submandibular gland. Identify
and by the hyoglossus posteriorly. A small part of the and clean anterior and posterior bellies of digastric
middle constrictor muscle of the pharynx appears in muscles, which form the boundaries of digastric triangle.
the floor (Fig. 4.11). Identify the intermediate tendon of digastric after pulling
the submandibular gland laterally. Clean the stylohyoid
muscle which envelops the tendon of digastric and is
Head and Neck
lying along with the posterior belly of digastric muscle

(Fig. 4.10). Identify the contents of digastric triangle (refer
to BDC App).
Contents
Anterior Part of the Triangle
Structures superficial to mylohyoid are:
1 Superficial part of the submandibular salivary gland
(Fig. 4.3).
2 The facial vein and the submandibular lymph nodes
are superficial to it and the facial artery is deep to it.
3 Submental artery
4 Mylohyoid nerve and vessels (Fig. 4.4)
5 The hypoglossal nerve.
Other relations will be studied in the submandibular
Fig. 4.11: Floor of the digastric triangle region.
105
Posterior Part of the Triangle DISSECTION

1 Superficial structures are: Clean the area situated between posterior belly of digastric
a. Lower part of the parotid gland. and superior belly of omohyoid muscle, to expose the
b. The external carotid artery before it enters the three carotid arteries with internal jugular vein. Trace IX,
parotid gland. X, XI and XII nerves in relation to these vessels (Fig. 4.10).
2 Deep structures, passing between the external and Identify middle and inferior constrictors of pharynx
internal carotid arteries, are: and thyrohyoid membrane forming its floor (Fig. 4.12).
Carefully clean and preserve superior root, the loop
a. The styloglossus
and inferior root of ansa cervicalis in relation to anterior
b. The stylopharyngeus aspect of carotid sheath. Locate the sympathetic
c. The glossopharyngeal nerve (Fig. 4.13) trunk situated posteromedial to the carotid sheath (see
d. The pharyngeal branch of the vagus nerve Fig. 3.8b). Dissect the branches of external carotid artery
e. The styloid process (Figs 4.13 and 4.16).
f. A part of the parotid gland. Identify and preserve internal laryngeal nerve in the
thyrohyoid interval. Trace it posterosuperiorly till vagus.
3 Deepest structures include:
Also look for external laryngeal nerve supplying the
a. The internal carotid artery (Fig. 4.13) cricothyroid muscle (Fig. 4.13).
b. The internal jugular vein The carotid triangle provides a good view of all the
c. The vagus nerve (see Fig. 3.8b). large vessels and nerves of the neck, particularly when
Most of these structures will be studied later. its posterior boundary is retracted slightly backwards.
Competency achievement: The student should be able to: Anteroinferiorly: Superior belly of the omohyoid.
AN 32.2 Describe and demonstrate boundaries and contents of
Posteriorly: Anterior border of the sternocleidomastoid
muscular, carotid triangles.3
muscle.
CAROTID TRIANGLE Roof

Boundaries 1 Skin
Anterosuperiorly: Posterior belly of the digastric muscle; 2 Superficial fascia containing:
and the stylohyoid (Fig. 4.12). a. The plastysma
Head and Neck
Fig. 4.12: Floor of the carotid triangle

HEAD AND NECK
106
Fig. 4.13: The ninth, tenth, eleventh and twelfth cranial nerves and their branches related to the carotid arteries and to the internal
jugular vein, in and around the left carotid triangle
Head and Neck
Fig. 4.14: Dissection of muscular triangle

107
b. The cervical branch of the facial nerve Posterosuperiorly: Superior belly of the omohyoid muscle
c. The transverse cutaneous nerve of the neck. (Fig. 4.10).
3 Investing layer of deep cervical fascia. Posteroinferiorly: Lower part of anterior border of the
sternocleidomastoid muscle (Fig. 4.14).
Floor
It is formed by parts of: DISSECTION
a. The middle constrictor of pharynx
Identify the infrahyoid muscles on each side of the
b. The inferior constrictor of the pharynx (Fig. 4.12) median plane. Cut through the origin of sternocleido-
c. Thyrohyoid membrane. mastoid muscle and reflect it upwards. Trace the nerve
Contents supply of infrahyoid muscles.
The superficial structures in the infrahyoid region
Arteries are included in this triangle. The deeper structures
1 The common carotid artery with the carotid sinus (thyroid gland, trachea, oesophagus, etc.) will be studied
and the carotid body at its termination separately at a later stage.
2 Internal carotid artery
3 The external carotid artery with its superior thyroid, Contents
lingual, facial, ascending pharyngeal and occipital
The infrahyoid muscles are the chief contents of the
branches (Fig. 4.12).
triangle. These muscles may also be regarded arbitrarily
Veins as forming the floor of the triangle (Fig. 4.6).
1 The internal jugular vein The infrahyoid muscles are:
2 The common facial vein draining into the internal a. Sternohyoid
jugular vein. b. Sternothyroid
3 A pharyngeal vein which usually ends in the internal c. Thyrohyoid
jugular vein. d. Omohyoid.
4 The lingual vein which usually terminates in the These ribbon muscles have the following general
internal jugular vein. features.
Nerves a. They are arranged in two layers—superficial
(sternohyoid and omohyoid) and deep (ster-
1 The vagus running vertically downwards.
nothyroid and thyrohyoid) (Fig. 4.6).
2 The superior laryngeal branch of the vagus, dividing
into the external and internal laryngeal nerves. b. All of them are supplied by the ventral rami of
3 The spinal accessory nerve running backwards over first, second and third cervical spinal nerves.
the internal jugular vein. c. Because of their attachment to the hyoid bone
4 The hypoglossal nerve running forwards over the and to the thyroid cartilage, they move these
external and internal carotid arteries. The hypo- structures.
glossal nerve gives off the upper root of the ansa d. Sternohyoid, superior belly of omohyoid, and
Head and Neck

cervicalis or descendens hypoglossi, and another sternothyroid lie superficial to the lateral or
branch to the thyrohyoid (Fig. 4.15). superficial convex surface of the thyroid gland (see
5 Sympathetic chain runs (see Fig. 3.8b) vertically Fig. 8.4).
downwards posterior to the carotid sheath. e. The anterior surface of isthmus of thyroid gland
6 Carotid sheath with its contents (see Fig. 3.8). is covered by right and left sternothyroid and
sternohyoid muscles (see Fig. 3.3).
Lymph Nodes The specific details of infrahyoid muscles are shown
The deep cervical lymph nodes are situated along the in Table 4.1.
internal jugular vein, and include the jugulodigastric
node below the posterior belly of the digastric and the ANSA CERVICALIS OR ANSA HYPOGLOSSI
jugulo-omohyoid node above the inferior belly of the
This is a thin nerve loop that lies embedded in the
omohyoid (see Fig. 8.31).
anterior wall of the carotid sheath over the lower part of
the larynx. It supplies the infrahyoid muscles (Fig. 4.15).
MUSCULAR TRIANGLE
Boundaries Formation
Anteriorly: Anterior median line of the neck from the It is formed by a superior and an inferior root. The
hyoid bone to the sternum. superior root is the continuation of the descending
HEAD AND NECK
108
Table 4.1: Infrahyoid muscles

Muscle Proximal attachment Distal attachment Nerve supply Actions
1. Sternohyoid a. Posterior surface Medial part of lower Ansa cervicalis Depresses the hyoid
(Fig. 4.6) of manubrium border of hyoid bone C1–C3 bone following its
sterni elevation during
b. Adjoining parts of swallowing and during
the clavicle and vocal movements
the posterior
sternoclavicular
ligament
2. Sternothyroid: a. Posterior surface Oblique line on the Ansa cervicalis Depresses the larynx
It lies deep to the of manubrium sterni lamina of the thyroid C1–C3 after it has been elevated
sternohyoid b. Adjoining part of cartilage in swallowing and in
first costal cartilage vocal movements
3. Thyrohyoid: Oblique line of thyroid Lower border of the C1 through a. Depresses the hyoid
It lies deep to the cartilage body and the greater hypoglossal nerve bone
sternohyoid cornua of the hyoid b. Elevates the larynx
bone when the hyoid is fixed
by the suprahyoid
muscles
4. Omohyoid: It has a. Upper border of Lower border of body of Superior belly by Depresses the hyoid
an inferior belly, a scapula near the hyoid bone lateral to the the superior root of bone following its
common tendon and suprascapular sternohyoid. The central the ansa cervicalis, elevation during
a superior belly. It notch tendon lies on the and inferior belly by swallowing or in vocal
arises by the inferior b. Adjoining part of internal jugular vein at inferior root of movements
belly, and is inserted suprascapular the level of the cricoid ansa cervicalis
through the superior ligament cartilage and is bound
belly to the clavicle by a
fascial pulley
branch of the hypoglossal nerve. Its fibres are derived

Head and Neck
from the first cervical nerve. This root descends over

the internal carotid artery and the common carotid
artery.
The inferior root or descending cervical nerve is
derived from second and third cervical spinal nerves.
As this root descends, it winds around the internal
jugular vein, and then continues anteroinferiorly to join
the superior root in front of the common carotid artery
(Fig. 4.15).
Distribution
Superior root: To the superior belly of the omohyoid.
Ansa cervicalis: To the sternohyoid, the sternothyroid.
Inferior root: To the inferior belly of the omohyoid.
Note that the thyrohyoid and geniohyoid are
supplied by separate branches from the first cervical Fig. 4.15: Ansa cervicalis, and branches of the first cervical
nerve through the hypoglossal nerve (Fig. 4.17). nerve distributed through the hypoglossal nerve
109
COMMON CAROTID ARTERY CLINICAL ANATOMY

The right common carotid artery is a branch of the
brachiocephalic artery. It begins in the neck behind the • The carotid sinus is richly supplied by nerves. In
right sternoclavicular joint (Fig. 4.16, also see Fig. 8.17). some persons, the sinus may be hypersensitive.
The left common carotid artery is branch of the arch of In such persons, sudden rotation of the head may
cause slowing of heart. This condition is called
the aorta.
‘carotid sinus syndrome’.
• The supraventricular tachycardia may be
Carotid Sinus controlled by carotid sinus massage, due to
The termination of the common carotid artery, or the inhibitory effects of vagus nerve on the heart.
beginning of the internal carotid artery shows a slight • The necktie should not be tied tightly, as it may
dilatation, known as the carotid sinus. In this region, compress both the internal carotid arteries,
the tunica media is thin, but the adventitia is relatively supplying the brain.
thick and receives a rich innervation from the
glossopharyngeal and sympathetic nerves. The carotid EXTERNAL CAROTID ARTERY
sinus acts as a baroreceptor or pressure receptor and
External carotid artery is one of the terminal branches
regulates blood pressure.
of the common carotid artery. In general, it lies anterior
to the internal carotid artery, and is the chief artery of
Carotid Body
supply to structures in the front of the neck and in the
Carotid body is a small, oval reddish brown structure face (Fig. 4.16, also see Fig. 8.17).
situated behind the bifurcation of the common carotid
artery. It receives a rich nerve supply mainly from the Course and Relations
glossopharyngeal nerve, but also from the vagus 1 The external carotid artery begins in the carotid
and sympathetic nerves. It acts as a chemoreceptor and triangle at the level of the upper border of the thyroid
responds to changes in the oxygen, carbon dioxide cartilage opposite the disc between the third and
and pH content of the blood. fourth cervical vertebrae. It runs upwards and
Other allied chemoreceptors are found near the arch of slightly backwards and laterally, and terminates
the aorta, the ductus arteriosus, and the right subclavian behind the neck of the mandible by dividing into
artery. These are supplied by the vagus nerve. the maxillary and superficial temporal arteries.
Head and Neck
Fig. 4.16: Right carotid arteries including branches of the external carotid artery
HEAD AND NECK
110
2 The external carotid artery has a slightly curved course, Anterior

so that it is anteromedial to the internal carotid artery 1 Superior thyroid (Fig. 4.16)
in its lower part, and anterolateral to the internal 2 Lingual (Fig. 4.17)
carotid artery in its upper part (see Fig. 20.11). 3 Facial
3 In the carotid triangle, the external carotid artery is
comparatively superficial, and lies under cover of Posterior
the anterior border of the sternocleidomastoid. The 4 Occipital
artery is crossed superficially by the cervical branch 5 Posterior auricular
of the facial nerve, the hypoglossal nerve (Fig. 4.13) Medial
and the facial, lingual and superior thyroid veins.
Deep to the artery, there are: 6 Ascending pharyngeal
a. The wall of the pharynx Terminal
b. The superior laryngeal nerve which divides into the 7 Maxillary
external and internal laryngeal nerves (Fig. 4.16).
8 Superficial temporal (Fig. 4.16).
c. The ascending pharyngeal artery.
4 Above the carotid triangle, the external carotid artery Superior Thyroid Artery
lies deep in the substance of the parotid gland. Within The superior thyroid artery arises from the external
the gland, it is related superficially to the retro- carotid artery just below the level of the greater cornua
mandibular vein and the facial nerve (see Fig. 5.4). of the hyoid bone.
Deep to the external carotid artery, there are: It runs downwards and forwards parallel and just
a. The internal carotid artery. superficial to the external laryngeal nerve. It passes
b. Structures passing between the external and internal deep to the three long infrahyoid muscles to reach the
carotid arteries; these being styloglossus, stylo- upper pole of the lateral lobe of the thyroid gland.
pharyngeus both arising from the styloid process, Its relationship to the external laryngeal nerve, which
IX nerve, pharyngeal branch of X nerve (Fig. 4.13). supplies the cricothyroid muscle is important to the
c. Two structures deep to the internal carotid artery, surgeon during thyroid surgery. The artery and nerve
namely the superior laryngeal nerve (Fig. 4.13) are close to each other higher up, but diverge slightly
and the superior cervical sympathetic ganglion. near the gland. To avoid injury to the nerve, the superior
thyroid artery is ligated as near the gland as possible
Branches (see Fig. 8.7).
The external carotid artery gives off eight branches Apart from its terminal branches to the thyroid gland,
which may be grouped as follows. Though small parts it gives one important branch, the superior laryngeal artery,
of 1–4 and 6th branches lie in carotid triangle, these which pierces the thyrohyoid membrane in company
have been described completely. with the internal laryngeal nerve (Fig. 4.7). The superior
Head and Neck
Fig. 4.17: Lingual artery

111
thyroid artery also gives a sternocleidomastoid branch close to angle of mouth, side of nose till medial angle
to that muscle and a cricothyroid branch that of eye. It is described in Chapter 2.
anastomoses with the artery of the opposite side in front The cervical part of the facial artery gives off the
of the cricovocal membrane. ascending palatine, tonsillar, submental, and glandular
branches for the submandibular salivary gland and
Lingual Artery lymph nodes.
The lingual artery arises from the external carotid artery The ascending palatine artery arises near the origin of
opposite the tip of the greater cornua of the hyoid bone. the facial artery. It passes upwards between the
It is tortuous in its course (Fig. 4.17). styloglossus and the stylopharyngeus, crosses over the
Its course is divided into three parts by the upper border of the superior constrictor and supplies
hyoglossus muscle. the tonsil and the root of the tongue.
• The first part lies in the carotid triangle. It forms a The submental branch is a large artery which
characteristic upward loop which is crossed by the accompanies the mylohyoid nerve, and supplies the
hypoglossal nerve. The lingual loop permits free submental triangle and the sublingual salivary gland
movements of the hyoid bone. (Fig. 4.3).
• The second part lies deep to the hyoglossus along the
upper border of hyoid bone. It is superficial to the Occipital Artery
middle constrictor of the pharynx.
• The third part is called the arteria profunda linguae, The occipital artery arises from the posterior aspect of
or the deep lingual artery. It runs upwards along the the external carotid artery, opposite the origin of the
anterior border of the hyoglossus, and then facial artery.
horizontally forwards on the undersurface of the It is crossed at its origin by the hypoglossal nerve.
tongue as the fourth part. In its vertical course, it lies In the carotid triangle, the artery gives two
between the genioglossus medially and the inferior sternocleidomastoid branches. The upper branch
longitudinal muscle of the tongue laterally. The accompanies the accessory nerve, and the lower branch
horizontal part of the artery is accompanied by the arises near the origin of the occipital artery.
lingual nerve. The further course of the artery in scalp has been
It gives branches: Suprahyoid, dorsal lingual, described in Chapter 10 (see Fig. 10.5).
sublingual.
During surgical removal of the tongue, the first part Posterior Auricular Artery
of the artery is ligated before it gives any branch to the
The posterior auricular artery arises from the posterior
tongue or to the tonsil.
aspect of the external carotid just above the posterior
belly of the digastric (Fig. 4.16).
Facial Artery
It runs upwards and backwards deep to the parotid
The facial artery arises from the external carotid just
gland, but superficial to the styloid process. It crosses
above the tip of the greater cornua of the hyoid bone.
the base of the mastoid process, and ascends behind
It runs upwards first in the neck as cervical part and
Head and Neck

the auricle.
then on the face as facial part. The course of the artery
in both places is tortuous. The tortuosity in the neck It supplies the back of the auricle, the skin over the
allows free movements of the pharynx during mastoid process, and over the back of the scalp. It is
deglutition. On the face, it allows free movements of cut in incisions for mastoid operations. Its stylomastoid
the mandible, the lips and the cheek during mastication branch enters the stylomastoid foramen, and supplies
and during various facial expressions. The artery the middle ear, the mastoid antrum and air cells, the
escapes traction and pressure during these movements. semicircular canals, and the facial nerve.
The cervical part of the facial artery runs upwards on
Ascending Pharyngeal Artery
the superior constrictor of pharynx deep to the posterior
belly of the digastric, stylohyoid and to the ramus of This is a small branch that arises from the medial side
the mandible. of the external carotid artery. It arises very close to the
It grooves the posterior end of the submandibular lower end of external carotid artery (Fig. 4.16).
salivary gland. Next the artery makes an S-bend (two It runs vertically upwards between the side wall of
loops) first winding down over the submandibular gland, the pharynx, and the tonsil, medial wall of the middle
and then up over the base of the mandible (see Fig. 7.7). ear and the auditory tube. It sends meningeal branches
The facial part of the facial artery enters the face at into the cranial cavity through the foramen lacerum,
anteroinferior angle of masseter muscle, runs upwards the jugular foramen and the hypoglossal canal.
HEAD AND NECK
112
Maxillary Artery
Superior thyroid (anterior)
This is the larger terminal branch of the external carotid
Ascending pharyngeal (medial)
artery. It begins behind the neck of the mandible under
cover of the parotid gland. It runs forwards deep to Lingual (anterior)
the neck of the mandible below the auriculotemporal Facial (anterior)
nerve, and enters the infratemporal fossa where it will Occipital (posterior)
be studied at a later stage (see Chapter 6). Posterior auricular (posterior)
Superficial Temporal Artery Maxillary (terminal)
1 It is the smaller terminal branch of the external carotid Superficial temporal (terminal)
artery. It begins, behind the neck of the mandible
under cover of the parotid gland (see Fig. 5.5a).
2 It runs vertically upwards, crossing the root of the
zygoma or preauricular point, where its pulsations FACTS TO REMEMBER
can be easily felt. About 5 cm above the zygoma, it • Apex of anterior triangle of neck is close to the
divides into anterior and posterior branches which sternum, while that of posterior triangle is close
supply the temple and scalp. The anterior branch to the mastoid process.
anastomoses with the supraorbital and supra- • Submental triangle is half on each side of the
trochlear branches of the ophthalmic artery. midline.
3 In addition to the branches which supply the temple,
the scalp, the parotid gland, the auricle and the facial • Maximum blood vessels are present in the carotid
muscles, the superficial temporal artery gives off a triangle.
transverse facial artery, already studied with the face, • Superficial temporal artery can be palpated at the
and a middle temporal artery which runs on the preauricular point.
temporal fossa deep to the temporalis muscle. • The necktie should not be tied tightly, as it may
compress both the internal carotid arteries,
POTENTIAL TISSUE SPACES IN HEAD AND NECK supplying the brain.
Submental space: Lies below inferior border of mandible.
Corresponds to submental triangle. It communicates
with submandibular spaces of both sides. CLINICOANATOMICAL PROBLEM
Submandibular space: Lies between anterior and
posterior bellies of digastric muscle and inferior border A patient is undergoing abdominal surgery.
of mandible. It communicates with sublingual and Anaesthetist is sitting at the head end of the table
submental spaces. and monitoring patient’s pulse by palpating arteries
Parotid space: Localized around parotid gland behind in the head and neck region
ramus of mandible, communicates with retro- • What is the artery anaesthetist palpating?
pharyngeal space and even mediastinum.
Head and Neck
• Name the other palpable arteries in the body.

Parapharyngeal space: Lies in suprahyoid region of
neck, lateral to pharynx. It is continuous with Ans: The anaesthetist has been monitoring the pulse
retropharyngeal space. by palpating the common carotid artery at the
Retropharyngeal space: Lies between anteriorly placed anterior border of sternocleidomastoid muscle. He
buccopharyngeal fascia and posteriorly placed need not get up to feel the radial pulse repeatedly.
prevertebral fascia. It communicates with peritonsillar Other palpable arteries in head and neck are
space, submental spaces and may reach mediastinum. superficial temporal and facial. In upper limb,
Peritonsillar space: Lies between anterior and posterior palpable arteries are third part of axillary artery,
fauces of the palatine tonsil. It communicates with brachial artery and radial pulse.
sublingual space.
In abdomen, one can feel abdominal aorta
pulsation when one lies supine.
Mnemonics
Palpable arteries in lower limb are femoral at head
External carotid artery branches of femur, popliteal, dorsalis pedis and posterior
tibial.
Some Anatomists Like Freaking Out Poor Medical
Students
113
FURTHER READING • Barker BCW, Davies PL. The applied anatomy of the
pterygomandibular space. Br J Surg 1972;10:43–55.
• Borges AE, Alexander JE. Relaxed skin tension lines, Z-
A description of the relationships of the structures within the
plastics on scars, and fusiform excision of lesions. Br J Plast
plerygomandibular space, with particular reference to anaesthesia
Surg 1962;15:242–54.
associated with an inferior alveolar nerve block.
A paper that provides the anatomical basis for every incision made
on the face.
1–3
1. Describe carotid triangle under following headings: 3. Write short notes/enumerate:

a. Boundaries a. Branches of external carotid artery
b. Contents b. Infrahyoid muscles
c. Nerves c. Ansa cervicalis
d. Arteries d. Facial artery—cervical part
2. Describe the boundaries and contents of digastric e. Lingual artery
triangle.
1. Only medial branch of external carotid artery is: 4. Hyoid bone develops from:
a. Superior thyroid a. 1st and 2nd arches b. 2nd and 3rd arches
b. Lingual c. 3rd and 4th arches d. 1st, 2nd and 3rd arches
c. Ascending pharyngeal 5. Which of the following is not a palpable artery in
d. Maxillary head and neck?
2. All the following are branches of external carotid a. Facial artery
artery, except: b. Superficial temporal artery
a. Posterior ethmoidal c. Lingual artery
b. Occipital d. Common carotid artery
c. Lingual 6. Which of the following is not a infrahyoid muscle?
d. Facial a. Sternohyoid b. Sternothyroid
3. All are the muscles forming boundaries of carotid c. Thyrohyoid d. Omohyoid—inferior belly
triangle, except: 7. Which of the following nerves runs with vagus
Head and Neck

a. Posterior belly of digastric between internal carotid artery and internal jugular
b. Superior belly of omohyoid vein till the angle of the mandible?
c. Inferior belly of omohyoid a. Hypoglossal b. Accessory
d. Sternocleidomastoid c. Glossopharyngeal d. Maxillary
1. c 2. a 3. c 4. b 5. c 6. d 7. a
• Name the contents of submental triangle. • How is ansa cervicalis formed? What are its branches?
• Enumerate the boundaries of carotid triangle. Name • Name the main contents of digastric triangle. How
the structures piercing the thyrohyoid membrane. does hyoid bone develop?
• Name the branches of external carotid artery given • What are the arteries related to posterior belly of
off in the carotid triangle. digastric muscle?
5
Parotid Region
Eat, drink and feel no sorrow; For there may not be a tomorrow .
—Anonymous
INTRODUCTION
Parotid region contains the largest serous salivary gland
and the ‘queen of the face’, the facial nerve. Parotid
gland contains vertically disposed blood vessels and
horizontally situated facial nerve and its various
branches. Parotid gland gets affected by virus of
mumps, which can extend the territory of its attack up
to gonads as well. One must be careful of the branches
of facial nerve while incising the parotid abscess by
giving horizontal incision. Facial nerve is described in
detail in Chapter 4, BD Chaurasia’s Human Anatomy,
Volume 4. Its extracranial course is given in this chapter.
SALIVARY GLANDS Fig. 5.1: Position of parotid gland
There are three pairs of large salivary glands—the

DISSECTION
parotid, submandibular and sublingual. In addition,
there are numerous small glands in the tongue, the Carefully cut through the fascial covering of the parotid
palate, the cheeks and the lips. These glands produce gland from the zygomatic arch above to the angle of
saliva which keeps the oral cavity moist, and helps in mandible below. While removing tough fascia, dissect
chewing and swallowing. The saliva also contains the structures emerging at the periphery of the gland
(refer to BDC App).
enzymes that aid digestion.
Trace the duct of the parotid gland anteriorly till the
Competency achievement: The student should be able to: buccinator muscle (see Fig. 2.20). Trace one or more
AN 28.9 Describe and demonstrate the parts, borders, surfaces,
of the branches of facial nerve till its trunk in the posterior
contents, relations and nerve supply of parotid gland with course part of the gland. The trunk can be followed till the
of its duct and surgical importance.1 stylomastoid foramen. Trace its posterior auricular
branch. Trace the course of retromandibular vein and
external carotid artery in the gland, removing the glands
PAROTID GLAND in pieces. Clean the facial nerve already dissected.
Study the extracranial course of facial nerve.
Features Facial nerve is the main nerve of the face, supplying
(Para = around; otic = ear) all the muscles of facial expression, carrying
The parotid gland is the largest of the salivary glands. secretomotor fibres to submandibular, sublingual salivary
It weighs about 25 g. It is situated below the external glands, including those in tongue and floor of mouth. It
acoustic meatus, between the ramus of the mandible is also secretomotor to glands in the nasal cavity, palate
and the sternocleidomastoid. The gland overlaps these and the lacrimal gland. It is responsible enough for
structures. Anteriorly, the gland also overlaps the carrying the taste fibres from anterior two-thirds of tongue
masseter muscle (Fig. 5.1). Skin over the gland is also except from the vallate papillae (see Chapter 4 of
supplied by great auricular nerve (C2, C3). BD Chaurasia’s Human Anatomy, Volume 4).
114
PAROTID REGION
115
Capsule of Parotid Gland the parotid gland from the submandibular salivary
The investing layer of the deep cervical fascia forms a gland. The ligament is pierced by the external carotid
capsule for the gland (Fig. 5.2). It is supplied by great artery (see Fig. 3.4a).
auricular nerve. The fascia splits (between the angle of
the mandible and the mastoid process) to enclose the
gland. The superficial lamina/parotidomasseteric CLINICAL ANATOMY
fascia, thick and adherent to the gland, is attached above • Parotid swellings are very painful due to the
to the zygomatic arch. The deep lamina is thin and is unyielding nature of the parotid fascia.
attached to the styloid process, tympanic plate, the angle • Mumps is an infectious disease of the salivary
and posterior border of the ramus of the mandible. A glands (usually the parotid) caused by a specific
portion of the deep lamina, extending between the virus. Viral parotitis or mumps characteristically
styloid process and the mandible, is thickened to does not suppurate. Its complications are orchitis
form the stylomandibular ligament which separates and pancreatitis.
External Features
The gland resembles a three-sided pyramid.
The apex of the pyramid is directed downwards
(Figs 5.3a and b).
The gland has four surfaces:
a. Superior (base of the pyramid)
b. Superficial (Fig. 5.3a)
c. Anteromedial
d. Posteromedial (Fig. 5.4a).
The surfaces are separated by three borders:
a. Anterior (Fig. 5.4b)
b. Posterior
c. Medial/pharyngeal edge
Relations
The apex (Fig. 5.3a) overlaps the posterior belly of the
Fig. 5.2: Capsule of the parotid gland digastric and the adjoining part of the carotid triangle.
Head and Neck
Fig. 5.3a: Structures emerging at the periphery of the parotid gland

HEAD AND NECK
116
Fig. 5.3b: Parotid gland
The cervical branch of the facial nerve and the two d. The medial pterygoid
divisions of the retromandibular vein emerge near the e. The emerging branches of the facial nerve.
apex. The posteromedial surface (Fig. 5.4a) is moulded to the
Surfaces mastoid and the styloid processes and the structures
The superior surface or base forms the upper end of the attached to them. Thus, it is related to:
gland which is small and concave. It is related to: a. The mastoid process, with the sternocleido-
a. The cartilaginous part of the external acoustic mastoid and the posterior belly of the digastric.
meatus. b. The styloid process, with structures attached to
b. The posterior surface of the temporomandibular it.
joint (Fig. 5.3b). c. The external carotid artery and facial nerve enter
c. The superficial temporal vessels. the gland through this surface. The internal carotid
artery lies deep to the styloid process (Fig. 5.4a).
d. The auriculotemporal nerve (Fig. 5.3a).
The superficial surface is the largest of the four Borders
Head and Neck
surfaces. It is covered with: The anterior border separates the superficial surface from
a. Skin the anteromedial surface (Fig. 5.4b). It extends from the
b. Superficial fascia containing the anterior branches anterior part of the superior surface to the apex. The
of the great auricular nerve, the preauricular or following structures emerge at this border.
superficial parotid lymph nodes and the posterior a. The parotid duct
fibres of the platysma and risorius. b. Most of the terminal branches of the facial nerve
c. The parotid fascia which is thick and adherent to c. The transverse facial vessels.
the gland (Fig. 5.2). In addition, the accessory parotid gland lies on
d. A few deep parotid lymph nodes embedded in the parotid duct close to this border (Fig. 5.3a).
the gland. The posterior border separates the superficial surface
The anteromedial surface (Fig. 5.4a) is grooved by the from the posteromedial surface. It overlaps the
posterior border of the ramus of the mandible. It is sternocleidomastoid (Fig. 5.4b).
related to: The medial edge or pharyngeal border separates the
a. The masseter anteromedial surface from the posteromedial
b. The lateral surface of the temporomandibular joint surface. It is related to the lateral wall of the pharynx
c. The posterior border of the ramus of the mandible (Fig. 5.4a).
PAROTID REGION
117
Figs 5.4a and b: (a) Horizontal section through the parotid gland showing its relations and the structures passing through it;
(b) Gross features of parotid gland
Structures within the Parotid Gland anteromedial surface. The superficial temporal artery
From medial to lateral side, these are as follows. gives transverse facial artery and emerges at the
1 Arteries: The external carotid artery enters the gland anterior part of the superior surface.
through its posteromedial surface (Fig. 5.5a). The 2 Veins: The retromandibular vein is formed within the
maxillary artery leaves the gland through its gland by the union of the superficial temporal and
Head and Neck
Figs 5.5a to e: Structures within the parotid gland: (a) Arteries; (b) Veins; (c) Branches of facial nerve at its exit; (d) Two parts of the
parotid gland are separated by isthmus; (e) Five terminal branches of facial nerve
HEAD AND NECK
118
maxillary veins. In the lower part of the gland, the iv. The marginal mandibular branch runs below
vein divides into anterior and posterior divisions the angle of the mandible deep to the
which emerge close to the apex (lower pole) of the platysma. It crosses the body of the mandible
gland (Fig. 5.5b). and supplies muscles of the lower lip and chin.
3 Facial nerve is the nerve of the second branchial arch. v. The cervical branch emerges from the apex of
The facial nerve leaves the skull by passing through the parotid gland, and runs downwards and
the stylomastoid foramen. forwards in the neck to supply the platysma.
In its extracranial course, the facial nerve crosses Bell's palsy: Sudden paralysis of facial nerve at the
the lateral side of the base of the styloid process. Then stylomastoid foramen, results in asymmetry of corner
the nerve enters the posteromedial surface of the of mouth, inability to close the eye, disappearance
parotid gland, runs forwards through the gland of nasolabial fold and loss of wrinkling of skin of
crossing the retromandibular vein and the external forehead on the same side (see Fig. 2.20).
carotid artery. Behind the neck of the mandible, it Patey’s faciovenous plane
divides into two branches—temporofacial and
The gland is composed of a large superficial and a small
cervicofacial. Temporofacial gives temporal and deep part, the two being connected by an ‘isthmus’ around
zygomatic branches. Cervicofacial gives buccal, which facial nerve divides (Fig. 5.5d).
marginal mandibular and cervical branches. These
five terminal branches emerge along the anterior Accessory processes of parotid gland
border and apex of the parotid gland (Fig. 5.5e). • Facial process—along parotid duct. It lies between
zygomatic arch and the parotid duct (Fig. 5.3a).
Branches at its exit from the stylomastoid foramen • Pterygoid process—between mandibular ramus and
i. Communicating branches with adjacent medial pterygoid.
cranial and spinal nerves. • Glenoid process—between external acoustic meatus
ii. The posterior auricular nerve arises just below and temporomandibular joint
the stylomastoid foramen. It ascends between • Poststyloid process
the mastoid process and the external acoustic
meatus, and supplies: Blood Supply
a. Auricularis posterior The parotid gland is supplied by the external carotid
b. Occipitalis artery and its branches that arise within the gland. The
c. Intrinsic muscles on the back of auricle. veins drain into the external jugular vein and internal
iii. The digastric branch, arises close to the jugular vein.
previous nerve. It is short and supplies the
posterior belly of the digastric. Nerve Supply
iv. The stylohyoid branch, arises with the 1 Parasympathetic nerves are secretomotor (Fig. 5.6).
digastric branch, is long and supplies the They reach the gland through the auriculotemporal
stylohyoid muscle. nerve.
Terminal branches The preganglionic fibres begin in the inferior
Head and Neck
salivatory nucleus; pass through the glossopharyngeal

i. Temporal branches cross the zygomatic arch
nerve, its tympanic branch, the tympanic plexus and
and supply:
the lesser petrosal nerve; and relay in the otic
a. Auricularis anterior
ganglion.
b. Auricularis superior
c. Intrinsic muscles on the lateral side of the The postganglionic fibres pass through the auriculo-
ear temporal nerve and reach the gland. This is shown
d. Frontalis in Flowchart 5.1.
e. Orbicularis oculi 2 Sympathetic nerves are postganglionic, vasomotor,
f. Corrugator supercilii. and are derived from the plexus around the middle
ii. The zygomatic branches run across the meningeal artery. These fibres start from lateral horn
zygomatic bone and supply the orbicularis of T1 segment of spinal cord. These synapse in
oculi. superior cervical ganglion. Postganglionic fibres
iii. The buccal branches are two in number. The travel along branches of external carotid, maxillary
upper buccal branch runs above the parotid arteries and their branches.
duct and the lower buccal branch below the 3 Sensory nerves to the gland come from the auriculo-
duct. They supply muscles in that vicinity temporal nerve, but the parotid fascia is innervated by
especially the buccinator. the sensory fibres of the great auricular nerve (C2, C3).
PAROTID REGION
119
Fig. 5.6: Parasympathetic nerve supply to the parotid gland
Flowchart 5.1: Tracing nerve supply of parotid gland h. Parts of the eyelids and orbit.
Efferents from these nodes pass to the upper group
of deep cervical nodes.
Parotid Duct/Stenson’s Duct

(Dutch Anatomist, 1638–86)
Parotid duct is thick-walled and is about 5 cm long. It
emerges from the middle of the anterior border of the
gland (Fig. 5.1). It runs forwards and slightly down-
wards on the masseter. Here its relations are.
Superiorly
1 Accessory parotid gland
2 The transverse facial vessels (Fig. 5.3a)
3 Upper buccal branch of the facial nerve
Inferiorly
The lower buccal branch of the facial nerve.
Head and Neck

At the anterior border of the masseter, the parotid
duct turns medially and pierces:
Lymphatic Drainage a. The buccal pad of fat
Lymph drains first to the parotid nodes and from there b. The buccopharyngeal fascia
to the upper deep cervical nodes. c. The buccinator (obliquely)
Parotid Lymph Nodes Because of the oblique course of the duct through
the buccinator, inflation of the duct is prevented during
The parotid lymph nodes lie partly in the superficial
blowing.
fascia and partly deep to the deep fascia over the parotid
gland (Fig. 5.4). They drain: The duct runs forwards for a short distance between
a. Temple the buccinator and the oral mucosa. Finally, the duct
b. Side of the scalp turns medially and opens into the vestibule of the
c. Lateral surface of the auricle mouth (gingivobuccal vestibule) opposite the crown of
d. External acoustic meatus the upper second molar tooth (Fig. 5.8).
e. Middle ear
f. Parotid gland
AN 28.10 Explain the anatomical basis of Frey's syndrome.2
g. Upper part of the cheek
HEAD AND NECK
120
CLINICAL ANATOMY in the region supplied by auriculotemporal nerve.

So, it is also called ‘auriculotemporal syndrome’.
• A parotid abscess may be caused by spread of
• During surgical removal of the parotid gland or
infection from the opening of parotid duct in the
parotidectomy, the facial nerve is preserved by
mouth cavity (Fig. 5.7).
removing the gland in two parts—superficial and
• A parotid abscess is best drained by horizontal
deep separately. The plane of cleavage is defined
incision/making many small holes known as
by tracing the nerve from behind forwards.
Hilton’s method (Fig. 5.8) below the angle of
• Mixed parotid tumour is a slow growing lobulated
mandible.
painless tumour without any involvement of the
• Parotidectomy is the removal of the parotid gland.
facial nerve. Malignant change of such a tumour
After this operation, at times, there may be
is indicated by pain, rapid growth, fixity with
aberrant regeneration of the secretomotor fibres
hardness, involvement of the facial nerve, and
in the auriculotemporal nerve which join the great
enlargement of cervical lymph nodes.
auricular nerve. This causes stimulation of the
• The parotid calculi may get formed within the
sweat glands and hyperaemia in the area of its
parotid gland or in its Stenson’s duct. These can
distribution, thus producing redness and sweating
be located by injecting a radio-opaque dye through
in the area of skin supplied by the nerve. This
its opening in the vestibule of the mouth. The
clinical entity is called Frey’s syndrome. Whenever,
procedure is called ‘Sialogram’. The duct can be
such a person chews there is increased sweating
examined by a spatula or bidigital examination.
HISTOLOGY
Histology of parotid gland is given in Chapter 7.
DEVELOPMENT
The parotid gland is ectodermal in origin. It develops
from the buccal epithelium just lateral to the angle of
mouth. The outgrowth branches repeatedly to form the
duct system and acini. The mesoderm forms the
intervening connective tissue septa.
FACTS TO REMEMBER
Fig. 5.7: Openings of salivary glands • Facial nerve courses through the parotid gland,
without supplying any structure in it.
• Skin over the parotid gland is supplied by great
auricular nerve, C2, C3.
Head and Neck
• Deepest structure in the substance of parotid gland

is the external carotid artery.
• Otic ganglion is the only parasympathetic ganglion
with four roots, including a motor root.
• Facial nerve divides into temporofacial and
cervicofacial branches. The former gives temporal
and zygomatic branches. The latter gives buccal,
marginal mandibular and cervical branches.
• Facial nerve passes through two foramina of skull,
i.e. internal acoustic meatus and stylomastoid
foramen.
Fig. 5.8: Horizontal incision for draining parotid abscess.
Branches of facial nerve also seen. Te—temporal; Zy—zygomatic, A young man complained of fever and sore throat,
Bu—buccal; Mm—marginal mandibular; C—cervical noted a swelling and felt pain on both sides of his
PAROTID REGION
121
face in front of the ear. Within a few days, he noted While drinking lemon juice, there is a lot of pain,
swellings below his jaw and below his chin. He as the salivary secretion is stimulated by the acid
suddenly started looking very healthy by facial present in the lemon juice.
appearance. The pain increased while chewing or The investing layer of cervical fascia encloses: Two
drinking lemon juice. The physician noted muscles—the trapezius and the sternocleidomastoid;
enlargement of all three salivary glands on both sides two spaces—the suprasternal space and the supra-
of the face. clavicular space; two glands—the parotid and the
• Where do the ducts of salivary glands open? submandibular; and forms two pulleys—one for the
intermediate tendon of digastric muscle and other
• Why did the pain increase while chewing?
for the intermediate tendon of omohyoid muscle.
• Why did the pain increase while drinking lemon
juice?
FURTHER READING
Ans: The duct of the parotid gland opens at a papilla • Mitz V, Peyronie M. The superficial musculo-aponeurotic
in the vestibule of mouth opposite the 2nd upper system (SMAS) in the parotid and cheek area. Plast
molar tooth. The duct of submandibular gland opens Reconstruct Surg 1976;58:80–88.
at the papilla on the sublingual fold. The sublingual A paper that provides the anatomical basis for all invasive aesthetic
gland opens by 10–12 ducts on the sublingual fold. and reconstructive facelift surgery.
• Ziarah HA, Atkinson ME. The surgical anatomy of the
The investing layer of cervical fascia encloses both
mandibular distribution of the facial nerve. Br J Oral Surg
the parotid and the submandibular glands and is 1981;19:159–70.
attached to the lower border of the mandible. As An outline of how the mandibular branch of the facial nerve is at
mandible moves during chewing, the fascia gets risk in all incisions at the lower border of the mandible, in
stretched which results in pain. The fascia and skin submandibular gland excision, incision of space-occupying dental
are supplied by the great auricular nerve. infections, and neck dissection. A detailed knowledge of this
structure is essential.
1–2
Head and Neck

HEAD AND NECK
122
1. Describe parotid gland under the following headings: 2. Describe briefly the structures present within the
a. Gross anatomy parotid gland.
b. Structures emerging at various borders, apex and 3. Write short notes on/enumerate:
base
c. Nerve supply a. Parotid duct
d. Clinical anatomy b. Histology of parotid gland
1. Nerve carrying postganglionic parasympathetic 5. All of the following are peripheral parasympathetic
fibres of the parotid gland is: ganglia, except:
a. Facial b. Auriculotemporal a. Otic b. Ciliary
c. Inferior alveolar d. Buccal c. Pterygopalatine d. Geniculate
2. Somata of postganglionic secretomotor fibres to 6. Which artery is not inside the parotid gland?
parotid gland lie in:
a. External carotid
a. Ciliary ganglion
b. Internal carotid
b. Pterygopalatine ganglion
c. Superficial temporal
c. Otic ganglion
d. Maxillary
d. Submandibular ganglion
7. Which one of the following nerves is not related to
3. Which of the following arteries passes between the
parotid gland?
roots of the auriculotemporal nerve?
a. Maxillary a. Temporal branch of facial
b. Middle meningeal b. Zygomatic branch of facial
c. Superficial temporal c. Buccal branch of facial
d. Accessory meningeal d. Posterior superior alveolar branch of maxillary
4. Vein formed by union of posterior division of 8. Pes anserinus is the arrangement in which of the
retromandibular and posterior auricular vein is: following nerves?
a. Internal jugular b. External jugular a. Vagus b. Trigeminal
c. Common facial d. Anterior jugular c. Facial d. Glossopharyngeal
Head and Neck
1. b 2. c 3. b 4. b 5. d 6. b 7. d 8. c
• Enumerate the structures emerging from the anterior • What is the histological structure of parotid gland?
border of parotid gland. • What are the structures pierced by parotid duct and
• What structures lie within the parotid gland? where do they open?
• Trace the secretomotor nerve supply of the parotid • Name the areas drained by parotid lymph nodes.
gland. • What is Hilton’s method of drainage of parotid abscess?
Temporal and 6
Infratemporal Regions
Best physicians are: Doctor Quiet, Doctor Rest, Doctor Diet and Doctor Merryman .
—Regimen of Salerno
INTRODUCTION
Temporal and infratemporal regions include muscles
of mastication, which develop from mesoderm of first
branchial arch. The muscles of mastication are
innervated by mandibular branch of trigeminal nerve.
Only one joint, the temporomandibular joint, is present
on each side between the base of skull and mandible to
allow movements during speech and mastication.
The parasympathetic ganglion is the otic ganglion,
the only ganglion with four roots, i.e. sensory, sym-
pathetic, motor and secretomotor or parasympathetic.
The blood supply of this region is through the
maxillary artery. Middle meningeal artery is its most
Fig. 6.1: Some features seen on the lateral side of the skull
important branch, as its injury results in extradural
haemorrhage (see Fig. 1.10).
Competency achievement: The student should be able to: Contents
AN 33.1 Describe and demonstrate extent, boundaries and contents 1 Temporalis muscle
of temporal and infratemporal fossae.1 2 Middle temporal artery (branch of superficial
temporal artery) (see Chapter 4)
TEMPORAL FOSSA 3 Zygomaticotemporal nerve and artery
In order to understand these regions, the osteology of 4 Deep temporal nerves for supplying temporalis
the temporal fossa, and the infratemporal fossa should muscle
be studied. The temporal fossa lies on the side of the skull, 5 Deep temporal artery, branch of maxillary artery
and is bounded by the superior temporal line and the
zygomatic arch. INFRATEMPORAL FOSSA
It is an irregular space below zygomatic arch.
Boundaries
Anterior: Zygomatic and frontal bones (Fig. 6.1) Boundaries
Posterior: Inferior temporal line and supramastoid crest Anterior: Posterior surface of body of maxilla
Superior: Superior temporal line Roof: Infratemporal surface of greater wing of sphenoid
Inferior: Zygomatic arch
Medial: Lateral pterygoid plate and pyramidal process
Floor: Parts of frontal, parietal, temporal and greater of palatine bone
wing of sphenoid. Temporalis muscle is attached to the
floor and inferior temporal line. Lateral: Ramus of mandible (Fig. 6.2)
123
HEAD AND NECK
124
6 The junction of the back of the head with the neck is

indicated by the external occipital protuberance and
the superior nuchal lines.

AN 33.2 Describe and demonstrate attachments, direction of fibres,
nerve supply and actions of muscles of mastication.2
MUSCLES OF MASTICATION
FEATURES
The muscles of mastication move the mandible during
mastication and speech. They are the masseter, the
temporalis, the lateral pterygoid and the medial
pterygoid. They develop from the mesoderm of the first
branchial arch, and are supplied by the mandibular
nerve which is the nerve of that arch. The muscles are
enumerated in Table 6.1 and shown in Figs 6.3 to 6.5.
Temporal fascia and relations of lateral and medial
Fig. 6.2: Scheme to show the outline of the temporal and pterygoid muscles are described.
infratemporal fossae in a coronal section
TEMPORAL FASCIA
Contents The temporal fascia is a thick aponeurotic sheet

that roofs over the temporal fossa and covers the
1 Lateral pterygoid muscle temporalis muscle. Superiorly, the fascia is single
2 Medial pterygoid muscle layered and is attached to the superior temporal line.
3 Mandibular nerve with its branches, otic ganglion Inferiorly, it splits into two layers which are attached
4 Maxillary nerve with posterior superior alveolar to the inner and outer lips of the upper border of the
nerve (see Chapter 15) zygomatic arch. The small gap between the two layers
5 Chorda tympani, branch of VII nerve contains fat, a branch from the superficial temporal
6 1st and 2nd parts of maxillary artery with their artery and the zygomaticotemporal nerve.
branches
7 Posterior superior alveolar artery, branch of 3rd part DISSECTION
of maxillary artery Identify the masseter muscle extending from the
8 Accompanying veins zygomatic arch to the ramus of the mandible (Fig. 6.3).
Cut the zygomatic arch in front of and behind the
Head and Neck
LANDMARKS ON THE LATERAL SIDE OF THE HEAD attachment of masseter muscle and reflect it
The external ear or pinna is a prominent feature on the downwards. Divide the nerve and blood vessels to the
lateral aspect of the head. muscle. Clean the ramus of mandible by stripping off
the masseter muscle from it (refer to BDC App).
1 The zygomatic bone forms the prominence of the cheek
at the inferolateral corner of the orbit. The zygomatic Give an oblique cut from the centre of mandibular
arch bridges the gap between the eye and the ear. notch to the lower end of anterior border of ramus of
mandible. Turn this part of the bone including the
2 The head of the mandible lies in front of the tragus.
insertion of temporalis muscle upwards. Strip the muscle
It is felt best during movements of the lower jaw.
from the skull and identify deep temporal nerves and
3 The mastoid process is a large bony prominence
vessels.
situated behind the lower part of the auricle.
Make one cut through the neck of the mandible. Give
4 The superior temporal line forms the upper boundary another cut through the ramus at a distance of 4 cm
of the temporal fossa which is filled up by the from the neck. Remove the bone carefully in between
temporalis muscle. these two cuts, avoiding injury to the underlying
5 The pterion is the area in the temporal fossa structures. The lateral pterygoid is exposed in the upper
where four bones (frontal, parietal, temporal and part and medial pterygoid in the lower part of the
greater wing of sphenoid) adjoin each other across dissection (Fig. 6.5).
an H-shaped suture (Fig. 6.1).
Table 6.1: Muscles of mastication
Muscle Origin Fibres Insertion Nerve supply Actions
1. Masseter a. Superficial layer a. Superficial fibres pass a. Superficial layer into Masseteric nerve, a a. Elevates mandible to
Quadrilateral, covers (largest): From anterior downwards and the lower part of the branch of anterior close the mouth to bite
lateral surface of two-thirds of lower backwards at 45° lateral surface of division of mandibular b. Superficial fibres cause
ramus of mandible, border of zygomatic ramus of mandible nerve protrusion
has three layers arch and adjoining
(Fig. 6.3) zygomatic process of
maxilla
b. Middle layer: From lower b. Middle fibres pass b. Middle layer into the
border of posterior vertically downwards central part of ramus
one-third of zyomatic of the mandible
arch
c. Deep layer: From deep c. Deep fibres pass c. Deep layer into rest
surface of zygomatic vertically downwards of the ramus of
arch the mandible
2. Temporalis a. Temporal fossa, Anterior fibres run vertically, a. Margins and deep Two deep temporal a. Elevates mandible
Fan-shaped, fills the excluding zygomatic middle obliquely and surface of coronoid branches from anterior b. Helps in side-to-side
temporal fossa bone posterior horizontally. All process. division of mandibular grinding movement
(Fig. 6.4) b. Temporal fascia converge and pass through b. Anterior border nerve c. Posterior fibres retract
gap deep to zygomatic arch of ramus of the the protruded mandible
mandible
3. Lateral pterygoid a. Upper head (small): Fibres run backwards a. Pterygoid fovea on A branch from anterior a. Depress mandible to
Short, conical, has From infratemporal and laterally and the anterior surface division of mandibular open mouth, with
upper and lower surface and crest of converge for insertion of neck of mandible nerve suprahyoid muscles.
heads (Fig. 6.5) greater wing of b. Anterior margin of It is indispensible for
sphenoid bone articular disc and actively opening the
b. Lower head (larger): capsule of temporo- mouth
From lateral surface of mandibular joint. b. Protrudes mandible
lateral pterygoid plate. Insertion is postero- c. Right lateral pterygoid
Origin is medial to lateral and at a turns the chin to left
insertion slightly higher level side
than origin
4. Medial pterygoid a. Superficial head Fibres run downwards, Roughened area on the Nerve to medial a. Elevates mandible
Quadrilateral, has a (small slip): From backwards and laterally. medial surface of angle pterygoid, branch of b. Helps protrude
small superficial and tuberosity of maxilla The two heads embrace and adjoining ramus of the main trunk of mandible
a large deep head and adjoining bone part of the lower head mandible, below and mandibular nerve c. Right medial pterygoid
(Fig. 6.5) b. Deep head (quite of lateral pterygoid behind the mandibular with right lateral
large): From medial (Fig. 6.5) foramen and mylohyoid pterygoid turn the chin
surface of lateral groove to left side as part of
TEMPORAL AND INFRATEMPORAL REGIONS
pterygoid plate and grinding movements

adjoining process of
palatine bone
125
Head and Neck

HEAD AND NECK
126
Fig. 6.3: Origin and insertion of the masseter muscle
Fig. 6.5: The lateral and medial pterygoid muscles
Superficial Relations
1 Masseter
2 Ramus of the mandible
3 Tendon of the temporalis
4 The maxillary artery (Fig. 6.6)
Deep Relations
1 Mandibular nerve
2 Middle meningeal artery (Fig. 6.11)
3 Sphenomandibular ligament
4 Deep head of the medial pterygoid
Fig. 6.4: Origin and insertion of the temporalis muscle Structures Emerging at the Upper Border
Head and Neck
1 Deep temporal nerves (Fig. 6.6)

The superficial surface of the temporal fascia receives 2 Masseteric nerve
an expansion from the epicranial aponeurosis (see
Fig. 2.3). This surface gives origin to the auricularis Structures Emerging at the Lower Border
anterior and superior, and is related to the superficial 1 Lingual nerve and artery
temporal vessels, the auriculotemporal nerve, and the 2 Inferior alveolar nerve
temporal branch of the facial nerve (see Fig. 5.3a). The 3 The middle meningeal and accessory meningeal
deep surface of the temporal fascia gives origin to some arteries pass upwards deep to it (Fig. 6.6).
fibres of the temporalis muscle.
The fascia is extremely dense. In some species (e.g. Structures Passing through
tortoise), the temporal fascia is replaced by bone. the Gap between the Two Heads
1 The maxillary artery enters the gap
RELATIONS OF LATERAL PTERYGOID
2 The buccal branch of the mandibular nerve comes
The lateral pterygoid may be regarded as the key
out through the gap (Fig. 6.6).
muscle of this region because its relations provide a
fair idea about the layout of structures in the infra- The pterygoid plexus of veins surrounds the lateral
temporal fossa. The relations are as follows: pterygoid.
127
Fig. 6.6: Some relations of the lateral pterygoid muscle and branches of maxillary artery
RELATIONS OF MEDIAL PTERYGOID

MAXILLARY ARTERY
The superficial and deep heads of medial pterygoid
enclose the lower head of lateral pterygoid muscle Features
(Fig. 6.5). This is the larger terminal branch of the external carotid
Superficial Relations artery, given off behind the neck of the mandible. It
The upper part of the muscle is separated from the has a wide territory of distribution, and supplies:
lateral pterygoid muscle by: 1 The external and middle ears, and the auditory tube
1 The lateral pterygoid plate (Fig. 6.7)
2 The lingual nerve (Fig. 6.5) 2 The dura mater
3 The inferior alveolar nerve. 3 The upper and lower jaws with their teeth
Lower down the muscle is separated from the ramus 4 The muscles of the temporal and infratemporal
of the mandible by the lingual and inferior alveolar regions
Head and Neck

nerves, the maxillary artery, and the sphenomandibular 5 The nose and paranasal air sinuses
ligament. 6 The palate
7 The root of the pharynx.
Deep Relations
The relations are: DISSECTION
1 Tensor veli palatini External carotid artery divides into its two terminal
2 Superior constrictor of pharynx branches, maxillary and superficial temporal on the
3 Styloglossus anteromedial surface of the parotid gland (see Fig. 5.5a).
4 Stylopharyngeus attached to the styloid process. The maxillary artery, appears in this region. Identify
some of its branches. Most important to be identified is
CLINICAL ANATOMY the middle meningeal artery. Learn its course and
branches given in Chapter 12. Accompanying these
Temporalis and masseter muscles are palpated by branches are the veins and pterygoid venous plexus
requesting the person to clench the teeth. Medial and and the superficial content of infratemporal fossa.
lateral pterygoid muscles can be tested by requesting Remove these veins. Try to see its communication with
the person to move the lower jaw from one side to the cavernous sinus and facial vein.
other side.
HEAD AND NECK
128
Fig. 6.7: Branches of three parts of the maxillary artery
Course and Relations 1 The first (mandibular) part runs horizontally forwards,
For descriptive purposes, the maxillary artery is divided first between the neck of the mandible and the
into three parts (Fig. 6.7 and Table 6.2). sphenomandibular ligament, below the auriculo-
Table 6.2: Branches of maxillary artery (Figs 6.6 and 6.7)

Branches Foramina transmitting Distribution
A. Of first part
1. Deep auricular Foramen in the floor (cartilage or bone) of Skin of external acoustic meatus, and outer surface
external acoustic meatus of tympanic membrane
2. Anterior tympanic Petrotympanic fissure Inner surface of tympanic membrane
3. Middle meningeal Foramen spinosum Supplies more of bone and less of meninges; also
5th and 7th nerves, middle ear and tensor tympani
4. Accessory meningeal Foramen ovale Main distribution is extracranial to pterygoids
5. Inferior alveolar Mandibular foramen Lower 8 teeth and mylohyoid muscle
Head and Neck
B. Of second part
1. Masseteric — Masseter
2. Deep temporal — Temporalis (two branches)
3. Pterygoid — Lateral and medial pterygoids
4. Buccal — Skin of the cheek
C. Of third part
1. Posterior superior Alveolar canals in body of maxilla Upper molar and premolar teeth and gums;
alveolar maxillary sinus
2. Infraorbital Inferior orbital fissure Lower orbital muscles; lacrimal sac; maxillary
sinus; upper incisor and canine teeth
3. Greater palatine Greater palatine canal Soft palate; tonsil; palatine glands and mucosa of
upper gums
4. Pharyngeal Pharyngeal (palatovaginal) canal Roof of nose and pharynx; auditory tube; sphenoidal
sinus
5. Artery of pterygoid canal Pterygoid canal Auditory tube; upper pharynx and middle ear
6. Sphenopalatine Sphenopalatine foramen Lateral and medial walls of nose and various air
(terminal part) sinuses (artery of epistaxis)
129
temporal nerve, and then along the lower border of Branches of Third Part of the Maxillary Artery
the lateral pterygoid. 1 The posterior superior alveolar artery arises just before
2 The second (pterygoid) part runs upwards and forwards the maxillary artery enters the pterygomaxillary
superficial to the lower head of the lateral pterygoid. fissure. It descends on the posterior surface of the
3 The third (pterygopalatine) part passes between the maxilla and gives branches that enter canals in the
two heads of the lateral pterygoid and through the bone to supply the molar and premolar teeth, and
pterygomaxillary fissure, to enter the pterygopalatine the maxillary air sinus.
fossa. 2 The infraorbital artery also arises just before the
maxillary artery enters the pterygomaxillary fissure.
Branches of First Part of the Maxillary Artery It enters the orbit through the inferior orbital fissure.
1 The deep auricular artery supplies the external acoustic It then runs forwards in relation to the floor of the
meatus, the tympanic membrane and the temporo- orbit, first in the infraorbital groove and then in
mandibular joint (Fig. 6.7). the infraorbital canal to emerge on the face through
2 The anterior tympanic branch supplies the middle ear the infraorbital foramen. It gives off some orbital
including the medial surface of the tympanic branches, for structures in the orbit; middle superior
membrane. alveolar branch for premolar teeth and the anterior
3 The middle meningeal artery is described in Chapter 12. superior alveolar branches that enter apertures in the
It lies between lateral pterygoid and spheno- maxilla to reach the incisor and canine teeth attached
mandibular ligaments, then between two roots of to the bone.
auriculotemporal nerve, enters the skull through After emerging on the face, the infraorbital artery
foramen spinosum to reach middle cranial fossa. It gives branches to the lacrimal sac, the nose and the
divides into a large frontal branch which courses upper lip.
towards the pterion and a smaller parietal branch The remaining branches of the third part arise within
(Fig. 6.11, also see Fig. 12.14). the pterygopalatine fossa (Fig. 6.7).
4 The accessory meningeal artery enters the cranial cavity 3 The greater palatine artery runs downwards in the
through the foramen ovale. Apart from the meninges, greater palatine canal to emerge on the posterolateral
it supplies structures in the infratemporal fossa. part of the hard palate through the greater palatine
5 The inferior alveolar artery runs downwards and foramen. It then runs forwards near the lateral
forwards medial to the ramus of the mandible to margin of the palate to reach the incisive canal (near
reach the mandibular foramen. Passing through this the midline) through which some terminal branches
foramen, the artery enters the mandibular canal enter the nasal cavity (see Fig. 1.12).
(within the body of the mandible) in which it runs Branches of the artery supply the palate and gums.
downwards and then forwards. While still within the greater palatine canal, it gives
Before entering the mandibular canal, the artery gives off the lesser palatine arteries that emerge on the palate
off a lingual branch to the tongue; and a mylohyoid through the lesser palatine foramina, and run
branch that descends in the mylohyoid groove (on the backwards into the soft palate and tonsil.
Head and Neck

medial aspect of the mandible) and runs forwards 4 The pharyngeal branch runs backwards through a
above the mylohyoid muscle (see Fig. 1.25). canal related to the inferior aspect of the body of the
Within the mandibular canal, the artery gives sphenoid bone (pharyngeal or palatinovaginal
branches to the mandible and to the roots of the each canal). It supplies part of the nasopharynx, the
tooth attached to the bone. auditory tube and the sphenoidal air sinus.
It also gives off a mental branch that passes through 5 The artery of the pterygoid canal runs backwards in
the mental foramen to supply the chin (see Fig. 1.24). the canal of the same name and helps to supply the
pharynx, the auditory tube and the tympanic cavity.
Branches of Second Part of the Maxillary Artery 6 The sphenopalatine artery passes medially through the
These are mainly muscular. These are: sphenopalatine foramen to enter the cavity of the
nose. It gives off posterolateral nasal branches to
1 Masseteric the lateral wall of the nose and to the paranasal
2 Deep temporal (anterior and posterior) sinuses; and posteromedial branches to the nasal
3 Laterior pterygoid septum. Sphenopalatine artery is the artery of
4 Buccal for skin of cheek. ‘epistaxis’ (see Fig. 15.5).
HEAD AND NECK
130
CLINICAL ANATOMY DISSECTION

Cut the lateral pterygoid muscle close to its insertion.
• The anterior branch of middle meningeal artery Dislodge the head of mandible from the articular disc.
is likely to be injured at the pterion in roadside Locate the articular cartilages covering the head of the
accidents. It leads to extradural haemorrhage (see mandible and the mandibular fossa. Take out the
Fig. 1.10). The clot must be sucked out at the earliest, articular disc as well and study its shape and its role in
otherwise it may compress the motor area of brain. increasing the varieties of movements.
• Bleeding from lower teeth is from branches of
inferior alveolar artery (1st part of maxillary
artery) and from upper teeth is from branches of Articular Surfaces
3rd part of maxillary artery. These are posterior The upper articular surface is formed by the following
superior alveolar and infraorbital arteries. parts of the temporal bone.
• Sphenopalatine is the terminal branch of 3rd part 1 Articular tubercle
of maxillary artery. It anastomoses with neighbou- 2 Anterior part of mandibular fossa (Fig. 6.8).
ring vessels to form large capillary plexus called
3 Posterior non-articular part formed by the tympanic
Kiesselbach’s plexus at the anteroinferior angle of
the nasal septum. It is a common site of bleeding plate.
from nose or epistaxis and is known as Little’s The inferior articular surface is formed by the head
area. So sphenopalatine artery is called ‘the artery of the mandible.
of epistaxis’. The articular surfaces are covered with fibrocartilage.
The joint cavity is divided into upper and lower parts
Competency achievement: The student should be able to: by an intra-articular disc.
AN 33.4 Explain the clinical significance of pterygoid venous plexus.3
Ligaments
PTERYGOID PLEXUS OF VEINS The ligaments are the fibrous capsule, the lateral
temporomandibular ligament, the sphenomandibular
It lies around and within the lateral pterygoid muscle. ligament, the stylomandibular ligament and pterygo-
The tributaries of the plexus correspond to the branches mandibular ligament.
of the maxillary artery. The plexus is drained by the
1 The fibrous capsule is attached above to the articular
maxillary vein which begins at the posterior end of the
tubercle, the circumference of the mandibular fossa
plexus and unites with the superficial temporal vein to
in front and the squamotympanic fissure behind, and
form the retromandibular vein. Thus, the maxillary vein
accompanies only the first part of the maxillary artery. below to the neck of the mandible. The capsule is loose
above the intra-articular disc, and tight below it. The
The plexus communicates: synovial membrane lines the fibrous capsule and the
a. With the inferior ophthalmic vein through the neck of the mandible (Fig. 6.9).
inferior orbital fissure. 2 The lateral temporomandibular ligament reinforces and
b. With the cavernous sinus through the emissary strengthens the lateral part of the capsular ligament.
Head and Neck
veins. Its fibres are directed downwards and backwards. It

c. With the facial vein (FV) through the deep facial
vein.
FV communicates with inferior ophthalmic vein.
Thus infection from FV/inferior ophthalmic vein can
reach cavernons sinus causing its thrombosis and palsy
of cranial nerves in the sinus.

AN 33.3 Describe and demonstrate articulating surface, type and
movements of temporomandibular joint.4
TEMPOROMANDIBULAR JOINT
Type of Joint Fig. 6.8: Subdivisions and attachments of the articular disc of
This is a synovial joint of the condylar variety. temporomandibular joint (TMJ)
131
4 The stylomandibular ligament is another accessory

ligament of the joint. It represents a thickened part
of the deep cervical fascia which separates the parotid
and submandibular salivary glands. It is attached
above to the lateral surface of the styloid process,
and below to the angle and adjacent part of posterior
border of the ramus of the mandible (Fig. 6.11).
5 Pterygomandibular ligament is attached above to
pterygoid hamulus at lower end of medial pterygoid
plate and below to inner aspect of mandible just
behind 3rd molar tooth.
Articular Disc
Fig. 6.9: Fibrous capsule and lateral ligament of the temporo- The articular disc is an oval predominantly fibrous plate
mandibular joint that divides the joint into an upper and a lower
compartments. The upper compartment permits gliding
is attached above to the articular tubercle, and below movements, and the lower, rotatory as well as gliding
to the posterolateral aspect of the neck of the mandible. movements.
3 The sphenomandibular ligament is an accessory ligament, The disc has a concavoconvex superior surface, and
that lies on a deep plane away from the fibrous capsule. a concave inferior surface. The periphery of the disc is
It is attached superiorly to the spine of the sphenoid, attached to the fibrous capsule. The disc is composed
and inferiorly to the lingula of the mandibular foramen. of an anterior region, anterior thick band, intermediate
It is a remnant of the dorsal part of Meckel’s cartilage. region, posterior thick band and bilaminar region (Fig.
The ligament is related laterally to: 6.8) containing venous plexus. The disc represents the
a. Lateral pterygoid muscle (Fig. 6.10) degenerated primitive insertion of lateral pterygoid.
b. Auriculotemporal nerve The disc prevents friction between the articulating
c. Maxillary artery (Fig. 6.11). surfaces.
The ligament is related medially to: It acts as a cushion and helps in shock absorption. It
a. Chorda tympani nerve stabilises the condyle by filling up the space between
b. Wall of the pharynx. articulating surfaces.
Near its lower end, it is pierced by the mylohyoid The proprioceptive fibres present in the disc help to
nerve and vessels. regulate movements of the joint.
Head and Neck
Fig. 6.10: Articular surfaces of the right temporomandibular joint

HEAD AND NECK
132
Figs 6.11a to c: (a and b) Superficial relations of the sphenomandibular ligament seen after removal of the lateral pterygoid; Medial
relations of temporomandibular joint also seen; (c) Shows other relations of the joint
The disc helps in distribution of weight across the 2 Superficial temporal vessels
TMJ by increasing the area of contact. 3 Auriculotemporal nerve (see Fig. 5.3a)
Relations of Temporomandibular Joint Superior
Lateral 1 Middle cranial fossa
1 Skin and fasciae 2 Middle meningeal vessels
2 Parotid gland (Fig. 6.11c)
3 Temporal branches of the facial nerve Inferior
Head and Neck
Maxillary artery and vein

Medial
1 The tympanic plate separates the joint from the Blood Supply
internal carotid artery. Branches from superficial temporal and maxillary
2 Spine of the sphenoid, with upper end of the spheno- arteries. Veins follow the arteries.
mandibular ligament attached to it (Fig. 6.11b).
3 Auriculotemporal and chorda tympani nerves. Nerve Supply
4 Middle meningeal artery (Fig. 6.11a). Auriculotemporal nerve and masseteric nerve.
Anterior Movements
1 Lateral pterygoid 1 Depression (open mouth) (Figs 6.12a–c)
2 Elevation (closed mouth)
2 Masseteric nerve and artery (Fig. 6.11c).
3 Protrusion (protraction of chin)
Posterior 4 Retrusion (retraction of chin)
1 The parotid gland separates the joint from the 5 Lateral or side-to-side movements during chewing
external auditory meatus. or grinding.
133
Figs 6.12a to c: Movements in lower and upper compartments during opening of the mouth
Movements of this joint can be palpated by putting disc as in protraction, but the head of the left side merely
finger at preauricular point or into external auditory rotates on a vertical axis. As a result of this, the chin
meatus. The movements at the joint can be divided into moves forwards and to left side (the side on which no
those between the upper articular surface and the gliding has occurred). Alternate movements of this kind
articular disc, i.e. meniscotemporal (upper) compart- on the two sides result in side-to-side movements of
ment and those between the disc and the head of the the jaw. Here the mandible rotates around an imaginary
mandible, i.e. meniscomandibular (lower) compartment. axis running along the mid-sagittal plane.
Most movements occur simultaneously at the right and
left temporomandibular joints. Muscles Producing Movements
In forward movement or protraction of the mandible,  depression is brought about mainly by the lateral
the articular disc with the head of the mandible glides pterygoid. The digastric, geniohyoid and mylohyoid
forwards over the upper articular surface. Movement muscles help when the mouth is opened wide or against
occurs in meniscotemporal compartment. In retraction, resistance.
the articular disc glides backwards over the upper The origin of only lateral pterygoid is anterior,
articular surface taking the head of mandible with it. slightly lower and medial to its insertion. During
Head and Neck

Mandible rotates around a horizontal axis extending contraction, it rotates the head of mandible and opens
from left to right condyle. the mouth. During wide opening, it pulls the articular
In slight opening of the mouth or depression of the disc forwards. So, movement occurs in both the
mandible, the head of the mandible moves on the compartments. It is also done passively by gravity
undersurface of the disc like a hinge in lower compart- (Figs 6.10 and 6.13).
ment (Fig. 6.12b). The movement occurs around a  elevation is brought about by the masseter, the
vertical axis passing through the condyle and posterior anterior vertical, middle oblique fibres of temporalis,
border of the ramus of mandible. In wide opening of and the medial pterygoid muscles of both sides. These
the mouth, this hinge-like movement is followed by are antigravity muscles.
gliding of the disc and the head of the mandible in  protrusion is done by the lateral and medial
upper compartment, as in protraction. At the end of pterygoids and superficial oblique fibres of masseter.
this movement, the head comes to lie under the articular retraction is produced by the posterior horizontal
tubercle (Fig. 6.12c). These movements are reversed in fibres of the temporalis and deep vertical fibres of
closing the mouth or elevation of the mandible. masseter.
Chewing movements involve side-to-side Lateral or side-to-side movements, e.g. chewing from
movements of the mandible. In these movements, the left side produced by right lateral pterygoid, right
head of (say) right side glides forwards along with the medial pterygoid which push the chin to left side.
HEAD AND NECK
134
• Derangement of the articular disc may result from

any injury, like overclosure or malocclusion. This
gives rise to clicking and pain during movements
of the jaw.
• In operations on the temporomandibular joint, the
VII nerve and auriculotemporal nerve, branch of
mandibular division of V nerve should be
preserved with care (Fig. 6.15).
Fig. 6.13: Movements of temporomandibular joint (arrows) by

muscles of mastication
Then left temporalis (anterior fibres), left masseter

(deep fibres) () chew the food. Chewing from right
side involves left lateral pterygoid, left medial
pterygoid, right temporalis and right masseter. Since,
so many muscles are involved, chewing becomes tiring.

AN 33.5 Describe the features of dislocation of temporomandibular
joint.5
Fig. 6.15: Close relation of the two nerves to the temporo-
mandibular joint
CLINICAL ANATOMY
• Dislocation of mandible: During excessive opening

of the mouth, the head of the mandible of one or MANDIBULAR NERVE
both sides may slip anteriorly into the
infratemporal fossa, as a result of which there is This is the largest mixed branch of the trigeminal nerve.
inability to close the mouth. Reduction is done by It is the nerve of the first branchial arch and supplies
all structures derived from that arch. Otic and
depressing the jaw with the thumbs placed on the
submandibular ganglia are associated with this nerve
last molar teeth, and at the same time elevating
(Fig. 6.16).
Head and Neck
the chin (Fig. 6.14).

Course and Relations
Mandibular nerve begins in the middle cranial fossa
through a large sensory root and a small motor root.
DISSECTION
Identify middle meningeal artery arising from the
maxillary artery and trace it till the foramen spinosum.
Note the two roots of auriculotemporal nerve
surrounding the artery. Trace the origin of the auriculo-
temporal nerve from mandibular nerve (Fig. 6.11).
Dissect all the other branches of the nerve. Identify the
chorda tympani nerve joining the lingual branch of
mandibular nerve. Lift the trunk of mandibular nerve
laterally and locate the otic ganglion (refer to BDC App).
Fig. 6.14: Dislocation of the head of mandible Trace all connections of the otic ganglion.
135
Fig. 6.16: Distribution of mandibular nerve (V3)
The sensory root arises from the lateral part of the palatini, deep to the lateral pterygoid. After a short
trigeminal ganglion, and leaves the cranial cavity course, the main trunk divides into a small anterior
through the foramen ovale (Fig. 6.17). trunk and a large posterior trunk (Fig. 6.16).
The motor root lies deep to the trigeminal ganglion
and to the sensory root. It also passes through the Branches
foramen ovale to join the sensory root just below the From the main trunk:
foramen thus forming the main trunk. The main trunk a. Meningeal branch
lies in the infratemporal fossa, on the tensor veli b. Nerve to the medial pterygoid.
Head and Neck
Fig. 6.17: Right otic ganglion seen from medial side

HEAD AND NECK
136
From the anterior trunk: mandible, it turns upwards and ascends on the temple
a. A sensory branch—the buccal nerve behind the superficial temporal vessels.
b. Motor branches—the masseteric and deep temporal The auricular part of the nerve supplies the skin of the
nerves and the nerve to the lateral pterygoid. tragus; and the upper parts of the pinna, the external
From the posterior trunk: acoustic meatus and the tympanic membrane. (Note
a. Auriculotemporal, that the lower parts of these regions are supplied by the
b. Lingual, and great auricular nerve and the auricular branch of the
c. Inferior alveolar nerves. vagus nerve.) The temporal part supplies the skin of
the temple (see Fig. 2.5). In addition, the auriculotemporal
Meningeal Branch or Nervus Spinosus nerve also supplies the parotid gland (secretomotor
Meningeal branch enters the skull through the foramen and also sensory, Fig. 6.17) and the temporomandibular
spinosum with the middle meningeal artery and joint (see Table A.2).
supplies the dura mater of the middle cranial fossa. Lingual Nerve
Nerve to Medial Pterygoid Lingual nerve (Table 6.3) is one of the two terminal
Nerve to medial pterygoid arises close to the otic branches of the posterior division of the mandibular
ganglion and supplies the medial pterygoid from its nerve (Fig. 6.16). It is sensory to the anterior two-thirds
deep surface. This nerve gives a motor root to the otic of the tongue and to the floor of the mouth. However,
ganglion which does not relay and supplies the tensor the fibres of the chorda tympani (branch of facial nerve)
veli palatini, and the tensor tympani muscles (Fig. 6.17). which is secretomotor to the submandibular and
sublingual salivary glands and gustatory to the anterior
Buccal Nerve two-thirds of the tongue, are also distributed through
Buccal nerve is the only sensory branch of the anterior the lingual nerve (Fig. 6.18).
division of the mandibular nerve. It passes between the Course
two heads of the lateral pterygoid, runs downwards
Lingual nerve begins 1 cm below the skull. About 2 cm
and forwards, and supplies the skin of cheek and
below skull, it is joined by chorda tympani nerve at an
mucous membrane related to the buccinator (Fig. 6.6).
acute angle. Then it lies in contact with mandible medial
It also supplies the labial aspect of gums of molar and
to 3rd molar tooth. Finally, it lies on surface of hyoglossus
premolar teeth.
and genioglossus to reach the tongue.
Masseteric Nerve
Relations
Masseteric nerve emerges at the upper border of the It begins 1 cm below the skull. It runs first between the
lateral pterygoid just in front of the temporomandibular tensor veli palatini and the lateral pterygoid, and then
joint, passes laterally through the mandibular notch in between the lateral and medial pterygoids.
company with the masseteric vessels, and enters the About 2 cm below the skull, it is joined by the chorda
deep surface of the masseter. It also supplies the tympani nerve (Fig. 6.18).
temporomandibular joint (see Fig. 1.24).
Head and Neck
Emerging at the lower border of the lateral pterygoid,

Deep Temporal Nerves the nerve runs downwards and forwards between
the ramus of the mandible and the medial pterygoid.
Deep temporal nerves are two nerves—anterior and
Next it lies in direct contact with the mandible, medial
posterior. They pass between the skull and the lateral
pterygoid, and enter the deep surface of the temporalis.
Table 6.3: Branches of the mandibular nerve (CN V3)
Nerve to Lateral Pterygoid Muscular Sensory Others
Nerve to lateral pterygoid enters the deep surface of Temporalis and masseter Meningeal Carries
Auriculotemporal taste
the muscle.
fibres
Auriculotemporal Nerve Medial and lateral pterygoids Inferior alveolar Carries
and mental secreto-
Auriculotemporal nerve arises by two roots which run motor fibres
backwards, encircle the middle meningeal artery, and
Tensor veli palatini and Lingual Articular
unite to form a single trunk (Figs 6.11, 6.16 and 6.17). tensor tympani
The nerve continues backwards between the neck of
Mylohyoid and digastric Buccal —
the mandible and the sphenomandibular ligament, (anterior belly)
above the maxillary artery. Behind the neck of the
137
Fig. 6.18: Connections of otic ganglion (schematic)
to the third molar tooth between the origins of the 3 The mental nerve emerges at the mental foramen and
superior constrictor and the mylohyoid muscles (see supplies the skin of the chin, and the skin and
Fig. 1.25). mucous membrane of the lower lip (Fig. 6.16).
It soon leaves the gum and runs over the hyoglossus 4 Its incisive branch supplies the labial aspect of gums
deep to the mylohyoid. Finally, it lies on the surface of of canine and incisor teeth.
the genioglossus deep to the mylohyoid. Here it winds
around the submandibular duct and divides into its OTIC GANGLION
terminal branches (see Fig. 7.4).
It is a peripheral parasympathetic ganglion which
Inferior Alveolar Nerve relays secretomotor fibres to the parotid gland.
Inferior alveolar nerve is the larger terminal branch of Topographically, it is intimately related to the
the posterior division of the mandibular nerve mandibular nerve, but functionally, it is a part of the
Head and Neck

(Fig. 6.16). It runs vertically downwards lateral to the glossopharyngeal nerve (Figs 6.17 and 6.18).
medial pterygoid and to the sphenomandibular
ligament. It enters the mandibular foramen and runs Size and Situation
in the mandibular canal. It is accompanied by the It is 2 to 3 mm in size, and is situated in the infra-
inferior alveolar artery (see Fig. 1.25). temporal fossa, just below the foramen ovale. It lies
medial to the mandibular nerve, and lateral to the tensor
Branches veli palatini. It surrounds the origin of the nerve to the
1 The mylohyoid branch contains all the motor fibres of medial pterygoid (Fig. 6.16).
the posterior division. It arises just before the inferior
alveolar nerve and enters the mandibular foramen. Connections and Branches
It pierces the sphenomandibular ligament with the The secretomotor motor or parasympathetic root is formed
mylohyoid artery, runs in the mylohyoid groove, and by the lesser petrosal nerve. Its origin and course is
supplies the mylohyoid muscle and the anterior belly shown in Flowchart 6.1.
of the digastric (Fig. 6.11b). The sympathetic root is derived from the plexus on
2 While running in the mandibular canal the inferior the middle meningeal artery. It contains postganglionic
alveolar nerve gives branches that supply the lower fibres arising in the superior cervical ganglion. The
teeth and gums. fibres pass through the otic ganglion without relay and
HEAD AND NECK
138
Flowchart 6.1: Secretomotor fibres for parotid gland

branches of mandibular nerve. Sometimes the
lingual nerve is divided to relieve intractable pain
of this kind. This may be done where the nerve lies
in contact with the mandible below and behind the
last molar tooth, covered only by mucous membrane.
• Mandibular neuralgia: Trigeminal neuralgia of the
mandibular division is often difficult to treat. In
such cases, the sensory root of the nerve may be
divided behind the ganglion, and this is now the
operation of choice when pain is confined to the
distribution of the maxillary and mandibular
nerves. During division, the ophthalmic fibres that
lie in the superomedial part of the root are spared,
to preserve the corneal reflex thus avoiding
damage to the cornea (Fig. 6.19).
• Lingual nerve lies in contact with mandible,
medial to the third molar tooth. In extraction of
malplaced ‘wisdom’ tooth, care must be taken not
to injure the lingual nerve (see Fig. 1.25). Its injury
results in loss of all sensations from anterior two-
thirds of the tongue.
reach the parotid gland via the auriculotemporal nerve. • A lesion at the foramen ovale leads to paraesthesia
They are vasomotor in function. along the mandible, tongue, temporal region and
The sensory root comes from the auriculotemporal paralysis of the muscles of mastication. This also
nerve and is sensory to the parotid gland. leads to loss of jaw-jerk reflex.
Other fibres passing through the ganglion are as • The mandibular nerve supplies both the efferent
follows: and afferent loops of the jaw-jerk reflex, as it is a
mixed nerve. Tapping the chin causes contraction
a. The nerve to medial pterygoid gives a motor root
of the pterygoid muscles.
to the ganglion which passes through it without
relay and supplies medially placed tensor veli
palatini and laterally placed tensor tympani muscles.
b. The chorda tympani nerve is connected to the otic
ganglion and also to the nerve of the pterygoid
canal (Fig. 6.18). These connections provide an
alternative pathway of taste from the anterior two-
thirds of the tongue.
Head and Neck
CLINICAL ANATOMY
• The motor part of the mandibular nerve is tested

clinically by asking the patient to clench her/his
teeth and then feeling for the contracting masseter
and temporalis muscles on the two sides. If one
masseter is paralysed, the jaw deviates to the para-
lysed side, on opening the mouth by the action of
the normal lateral pterygoid of the opposite side.
The activity of the pterygoid muscles is tested by
asking the patient to move the chin from side-to-
side.
• Referred pain: In cases with cancer of the tongue,
pain radiates to the ear and to the temporal fossa,
over the distribution of the auriculotemporal nerve
as both lingual and auriculotemporal nerves are Fig. 6.19: Partial cutting of the sensory root of trigeminal nerve
139
Masseteric
Pterygoid
Deep temporal
Buccal
Sphenopalatine
Descending palatine
V3 Innervated muscles (branchial arch 1 derivatives)
M.D. My TV
Mastication (masseter, temporalis, lateral and medial,
pterygoids)
Digastric (anterior belly)
Mylohyoid
tensor Tympani
tensor Veli palatini
Fig. 6.20: Injection given in mandibular foramen for
anaesthetising the inferior alveolar nerve before extraction of
last molar tooth FACTS TO REMEMBER
• Mandibular nerve is the only mixed branch of
• In extraction of mandibular teeth, inferior alveolar trigeminal nerve.
nerve needs to be anaesthetised. The drug is given • The nerve is associated with two parasympathetic
into the nerve before it enters the mandibular canal ganglia, i.e. otic and submandibular ganglia.
(Fig. 6.20). • Maxillary artery gives many branches; some
• Inferior alveolar nerve: Inferior alveolar nerve as it accompany branches of maxillary nerve and others
travels the mandibular canal can be damaged by branches of mandibular nerve as there is no
the fracture of the mandible. This injury can be mandibular artery.
assessed by testing sensation over the chin. • Only muscle of mastication which depresses the
• During extraction of the 3rd molar, the buccal TMJ is the lateral pterygoid muscle.
nerve may get involved by the local anaesthesia • Spine of sphenoid is related to chorda tympani and
causing temporary numbness of the cheek. auriculotemporal nerves. Injury to the spine will
hamper the secretion of three salivary glands.
• Auriculotemporal nerve and branches of facial
Mnemonics
nerve are related to temporomandibular joint.
Function of Lateral (La) vs. Medial (Me) ptery-
goid muscles
“La”: Jaw is open, so lateral pterygoid opens mouth. CLINICOANATOMICAL PROBLEM
Head and Neck

“Me”: Jaw is closed, so medial pterygoid closes the mouth.
A patient of carcinoma in anterior two-thirds of
V3: Sensory branches tongue complains of pain in his lower teeth, temporal
“Buccaneers Are Inferior Linguists” region and the temporomandibular joint.
Buccal • Why is pain of tongue referred to lower teeth?
Auriculotemporal • Which are the other areas of referred pain?
Inferior alveolar Ans: Sensations from anterior two-thirds of the
Lingual tongue are carried by lingual, branch of mandibular
Maxillary Artery Branches nerve. Since there are too many pain impulses due
to disease, these impulses course through other
“DAM I AM Piss Drunk But Stupid Drunk” branches of the nerve, where it is gets referred. So
Deep auricular pain is felt in lower teeth, from where sensations are
Anterior tympanic carried by inferior alveolar nerve. The mandibular
Middle meningeal nerve also carries sensation from temporo-
Inferior alveolar mandibular joint and temporal region so the pain
Accessory meningeal also gets referred to these regions.
HEAD AND NECK
140
Examples of referred pain are: • Langdon J, Berkovitz BKB, Moxham BJ. Infection and the
infratemporal fossa and associated tissue spaces. In: Langdon
• Pain of gallbladder is referred to right shoulder.
J, Berkovitz BKB, Moxham BJ (eds). Surgical Anatomy of the
• Pain of myocardial ischaemia is felt in the chest
Infratemporal Fossa. London: M. Duniatz, 2002; pp 77–99.
and medial side of left arm.
• Pain of foregut-derived organs is felt in epigastrium. A chapter that describes the tissue spaces in the floor of the mouth
and how they become involved in the spread of infection.
• Pain of midgut-derived organs is felt in
periumbilical region. • Lang J. Mandible. In: Clinical Anatomy of the Masticatory
• Pain of hindgut-derived organs is felt in suprapubic Apparatus and Peripharyngeal Spaces. New York: Thieme;
region. 1995; pp. 19–41.
Detailed anatomical descriptions including measurements of the
FURTHER READING maxilla and mandible, the infratemporal fossa and its contents,
and the temporomandibular joint, relating these to clinical practice.
• Cheung LK. The vascular anatomy of the human temporalis
• Nitzan DW. The process of lubrication impairment and its
muscle: Implications for surgical splitting techniques. Int J
Oral Maxillofac Surg 1996;25:414–21. involvement in temporomandibular joint disc displacement.
A cadaveric study of 15 cadavers/30 temporalis muscle specimens J Oral Maxillofac Surg 2001;59:36–45.
to assess the territory supplied by each of the three principal nutrient An overview of the lubrication impairment and its possible role in
arteries (angiosomes) and the clinical implications of the results. disc displacement.
1–5
Head and Neck
1. Describe temporomandibular joint under the a. Origin b. Insertion

following headings: c. Actions d. Clinical anatomy
a. Bones taking part 3. Write short notes on/enumerate:
b. Capsule and ligaments a. Otic ganglion and its connections
c. Relations b. Branches of 1st part of maxillary artery
d. Movements and their muscles c. Branches of mandibular nerve
e. Clinical anatomy d. Branches of 3rd part of maxillary artery
2. Describe muscles of mastication under the e. Sphenomandibular ligament and the structures
following headings: piercing it
141
1. Action of lateral pterygoid muscle is: 6. Dislocated mandible can be reversed by:
a. Elevation and retraction of mandible a. Depressing the jaw posteriorly and elevating the
b. Depression and retraction of mandible chin
b. Depressing the jaw and depressing the chin
c. Elevation and protrusion of mandible
c. Elevating the jaw and elevating the chin
d. Depression and protrusion of mandible
d. Depressing the chin and elevating the jaw
2. Which of the following muscles is used for opening posteriorly
the mouth? 7. Nervus spinosus is a branch of:
a. Medial pterygoid b. Temporalis a. Maxillary nerve b. Mandibular nerve
c. Lateral pterygoid d. Masseter c. Ophthalmic nerve d. 2nd cervical nerve
3. Which of the following ligaments is not a ligament 8. Lingual nerve is the branch of:
of temporomandibular joint? a. Facial nerve
a. Pterygomandibular b. Glossopharyngeal nerve
b. Sphenomandibular c. Mandibular nerve
c. Lateral ligament d. Hypoglossal nerve
d. Stylomandibular 9. Lingual nerve can be pressed against a bone inside
the mouth near the roots of the:
4. Which one is not a branch of maxillary artery?
a. Third upper molar tooth
a. Anterior tympanic b. Anterior ethmoidal
b. Second upper molar tooth
c. Middle meningeal d. Inferior alveolar c. Third lower molar tooth
5. Which of the following is not a muscle of masti- d. First lower molar tooth
cation? 10. Nerve piercing sphenomandibular ligament is:
a. Medial pterygoid a. Nerve to mylohyoid
b. Masseter b. Inferior alveolar
c. Temporalis c. Buccal
d. Orbicularis oris d. Lingual
1. d 2. c 3. a 4. b 5. d 6. a 7. b 8. c 9. c 10. a
Head and Neck

• Which parasympathetic ganglion has four roots? • Name the muscles supplied by mandibular division
Name four roots and branches of the ganglion. of trigeminal nerve.
• Which muscle of mastication acts to open the mouth? • What are the nerves related to the spine of sphenoid
• Name the branches of all the parts of the maxillary and what are their clinical importance?
artery.
• Which is the artery of epistaxis? • How does TMJ get dislocated? How can the
• Name the two compartments of temporomandibular dislocation be corrected?
joint. What movements occur in these compartments? • Which are the nerves related to TMJ?
7
Submandibular Region
Life is too short for men to take it too seriously .
—George Bernard Shaw
INTRODUCTION
SUPRAHYOID MUSCLES
Submandibular region includes deeper structures in
the area between the mandible and hyoid bone Features
including the floor of the mouth and the root of the The suprahyoid muscles are the digastric, the
tongue. stylohyoid, the mylohyoid and the geniohyoid. The
The submandibular region contains the suprahyoid muscles are in following layers.
muscles, submandibular and sublingual salivary glands 1 First layer formed by digastric (Greek two bellies) and
and submandibular ganglion. Chorda tympani nerve stylohyoid (Fig. 7.1).
from facial nerve provides preganglionic secretomotor 2 Second layer formed by mylohyoid (Greek pertaining
fibres to the glands. Chorda tympani also carries fibres to hyoid bone) (Fig. 7.2).
of sensation of taste from anterior two-thirds of tongue 3 Third layer formed by geniohyoid and hyoglossus
except from the circumvallate papillae. Taste from the (Fig. 7.4).
circumvallate papillae is carried by the glosso- 4 Fourth layer formed by genioglossus (Fig. 7.4).
pharyngeal nerve. The muscles are described in Table 7.1.
Fig. 7.1: Relation of marginal mandibular branch of facial nerve to the submandibular gland and its lymph nodes
142
Table 7.1: Suprahyoid muscles
Muscle Origin Fibres Insertion Nerve supply Actions
1. Digastric (DG): It has a. Anterior belly (DGA): a. Anterior belly runs Both heads meet at the a. Anterior belly by a. Depresses
two bellies united by From digastric fossa downwards and intermediate tendon nerve to mylohyoid mandible when
an intermediate tendon of mandible backwards which perforates SH and b. Posterior belly by mouth is opened
(Figs 7.1 and 7.2) b. Posterior belly (DGP): b. Posterior belly runs is held by a fibrous facial nerve widely or against
From mastoid notch downwards and pulley to the hyoid bone resistance; it is
of temporal bone forwards secondary to lateral
pterygoid
b. Elevates hyoid bone
2. Stylohyoid (SH): Small Posterior surface of Tendon is perforated by Junction of body and Facial nerve a. Pulls hyoid bone
muscle, lies on upper styloid process DGP tendon greater cornua of hyoid upwards and
border of DGP bone (see Fig. 1.47) backwards
(Fig. 7.2) b. With other hyoid
muscles, it fixes the
hyoid bone
1 and 2 are muscles of 1st muscular plane
3. Mylohyoid (MH): Flat, Mylohyoid line of Fibres run medially and a. Posterior fibres: Body Nerve to mylohyoid a. Elevates floor of
triangular muscle; two mandible (see Fig. 1.23b) slightly downwards of hyoid bone mouth in first stage
mylohyoids form floor (see Fig. 1.47) of deglutition
of mouth cavity, deep b. Middle and anterior b. Helps in depression
to DGA (Figs 7.1 and 7.2) fibres; median raphe, of mandible, and
between mandible elevation of hyoid
and hyoid bone bone
3 is muscle of 2nd muscular plane
4. Geniohyoid (GH): Inferior mental spine Runs backwards and Anterior surface of body C1 through hypo- a. Elevates hyoid bone
Short and narrow muscle; (genial tubercle) downwards of hyoid bone glossal nerve b. May depress
lies above medial part mandible when
of MH (Fig. 7.4) hyoid is fixed
5. Hyoglossus: It is a Whole length of greater Fibres run upwards and Side of tongue between Hypoglossal (XII) Depresses tongue
muscle of tongue. It cornua and lateral part forwards styloglossus and inferior nerve makes dorsum convex,
forms important land- of body of hyoid bone longitudinal muscle of retracts the protruded
mark in this region (see Fig. 1.47) tongue tongue
(Fig. 7.4)
4 and 5 are muscles of 3rd muscular plane
6. Genioglossus: It is the Upper genial tubercle Fibres radiate Upper fibres pass Hypoglossal (XII) Pulls posterior part of
bulkiest muscle of tongue. of mandible upwards and forwards tongue forwards, i.e.
It is fan-shaped to tip of tongue. Middle protrudes tongue. It is
fibres along whole length a life saving muscle
SUBMANDIBULAR REGION
of dorsum. Lower fibres

into body of hyoid.
6 is a muscle of 4th muscular plane.
143
Head and Neck

HEAD AND NECK
144
Fig. 7.2: Mylohyoid muscle dividing the gland into two parts
DISSECTION 4 Vagus, accessory and hypoglossal cranial nerves

(Fig. 7.3)
Cut the facial artery and vein present at the antero-
5 The hyoglossus muscle
inferior angle of masseter muscle. Separate the origin
of anterior belly of digastric muscle from the digastric Upper Border
fossa near the symphysis menti. Push the mandible
1 The posterior auricular artery (see Fig. 4.14)
upwards. Clean and expose the posterior belly of
2 The stylohyoid muscle
digastric muscle and its accompanying stylohyoid
muscle. Identify the digastrics, stylohyoid, mylohyoid, Lower Border
geniohyoid, and hyoglossus (refer to BDC App). Lower border is related to occipital artery (see Fig. 4.14).
Relations of Posterior Belly of Digastric Relations of Mylohyoid

Head and Neck
Superficial
Superficial
1 Anterior belly of digastric (Fig. 7.1)
1 Mastoid process with the sternocleidomastoid, 2 Superficial part of the submandibular salivary gland
splenius capitis and the longissimus capitis (Fig. 7.3, 3 Mylohyoid nerve and vessels
also see Fig. 5.4a) 4 Submental branch of the facial artery
2 The stylohyoid
3 The parotid gland with retromandibular vein Deep
4 Submandibular salivary gland (Fig. 7.3) and lymph 1 Hyoglossus with its superficial relations, namely the
nodes styloglossus, the lingual nerve, the submandibular
5 Angle of the mandible with medial pterygoid ganglion, the deep part of the submandibular
salivary gland, the submandibular duct, the hypo-
Deep glossal nerve, and the venae comitantes hypoglossi
1 Transverse process of the atlas with superior oblique (Figs 7.2 and 7.4).
and the rectus capitis lateralis 2 The genioglossus with its superficial relations,
2 Internal carotid, external carotid, lingual, facial and namely the sublingual salivary gland, the lingual
occipital arteries nerve, submandibular duct, the lingual artery, and
3 Internal jugular vein the hypoglossal nerve (Fig. 7.4).
145
Fig. 7.3: Posterior belly of the digastric muscle, and structures related to it, seen from below
Head and Neck
Fig. 7.4: Submandibular region showing the superficial relations of the hyoglossus and genioglossus muscles, the deep part of
submandibular gland is also shown
Relations of Hyoglossus Deep

Superficial 1 Inferior longitudinal muscle of the tongue
Styloglossus, lingual nerve, submandibular ganglion, 2 Genioglossus
deep part of the submandibular gland, submandibular 3 Middle constrictor of the pharynx
duct, hypoglossal nerve and veins accompanying it (Fig. 7.4). 4 Glossopharyngeal nerve
HEAD AND NECK
146
5 Stylohyoid ligament
6 Lingual artery
Structures passing deep to posterior border of
hyoglossus, from above downwards:
1 Glossopharyngeal nerve
2 Stylohyoid ligament
3 Lingual artery (Fig. 7.4).

AN 34.1 Describe and demonstrate the morphology, relations and
nerve supply of submandibular salivary gland and submandibular
ganglion.1
SUBMANDIBULAR SALIVARY GLAND Fig. 7.6: Fascial coverings of the superficial part of the sub-
mandibular salivary gland
Features
This is a large salivary gland, situated in the anterior
part of the digastric triangle. The gland is about the DISSECTION
size of a walnut weighing about 15 to 20 g. It is roughly Submandibular gland is seen in the digastric triangle.
J-shaped, being indented by the posterior border of the On pushing the superficial part of the gland posteriorly,
mylohyoid which divides it into a larger part superficial the entire mylohyoid muscle is exposed. The deep part
to the muscle, and a small part lying deep to the muscle of the gland lies on the superior surface of the muscle.
(Fig. 7.5). Separate the facial artery from the deep surface of gland
and identify its branches in neck. The hyoglossus
Coverings: The gland is partially enclosed between muscle is recognised as a quadrilateral muscle lying
two layers of deep cervical fascia. The superficial on deeper plane than mylohyoid muscle. Identify lingual
(Fig. 7.6) layer of fascia covers the inferior surface of nerve with submandibular ganglion, and hypoglossal
the gland and is attached to the base of the mandible. nerve running on the hyoglossus muscle from lateral
The deep layer covers the medial surface of the gland to the medial side. Deep part of gland and its duct
and is superiorly to the mylohyoid line of the mandible are also visible on this surface of hyoglossus muscle
(Fig. 7.6). (Fig. 7.4).
Carefully release the hyoglossus muscle from the
hyoid bone and reflect it towards the tongue. Note the
structures deep to the muscle, e.g. genioglossus
muscle, lingual artery, vein and middle constrictor of
the pharynx.
Head and Neck
Superficial Part
This part of the gland fills the digastric triangle. It
extends superiorly deep to the mandible up to the
mylohyoid line. Inferiorly: It overlaps stylohyoid and
the posterior belly of digastric (Figs 7.1 and 7.2). It has
three surfaces:
a. Inferior (Fig. 7.1)
b. Lateral
c. Medial.
Relations
The inferior surface is covered by:
a. Skin
b. Platysma
Fig. 7.5: Horizontal section through the submandibular region c. Cervical branch of the facial nerve
showing the location of the submandibular and sublingual glands d. Deep fascia
147
(Fig. 7.5). Anteriorly, it extends up to the posterior end

of the sublingual gland.
Relations
Present in between mylohyoid and hyoglossus.
Laterally – Mylohyoid
Medially – Hyoglossus
Above – Lingual nerve with submandibular ganglion
Below – Hypoglossal nerve
Blood Supply and Lymphatic Drainage

The submandibular gland is supplied by the facial
artery.
The facial artery arises from the external carotid just
above the tip of the greater cornua of the hyoid bone.
Fig. 7.7: Relationship of the facial vessels to the submandibular The cervical part of the facial artery runs upwards on
gland and to the mandible the superior constrictor of pharynx deep to the posterior
belly of the digastric, and stylohyoid to the ramus of
the mandible. It grooves the posterior end of the
submandibular salivary gland. Next the artery makes
an S-bend (two loops) first winding down over the
submandibular gland, and then up over the base of the
mandible (Figs 7.7 and 7.8). Facial artery is palpable
on the base of mandible at the anteroinferior angle of
masseter muscle.
The veins drain into the common facial or lingual
vein.
Lymph passes to submandibular lymph nodes.
Nerve Supply
It is supplied by branches from the submandibular
ganglion. These branches convey:
1 Secretomotor fibres (Fig. 7.9)
Fig. 7.8: Schematic horizontal section through the submandibular
region 2 Sensory fibres from the lingual nerve
3 Vasomotor sympathetic fibres from the plexus on the
facial artery.
e. Facial vein (Fig. 7.7) The secretomotor pathway is shown in Flowchart 7.1.
f. Submandibular lymph nodes (Fig. 7.1)
Head and Neck

The lateral surface is related to: SUBMANDIBULAR DUCT/WHARTON’S DUCT
a. The submandibular fossa on the mandible (ENGLISH SCIENTIST: 1614–73)
b. Insertion of the medial pterygoid (Fig. 7.7) It is thin walled, and is about 5 cm long. It emerges at
c. The facial artery (Figs 7.7 and 7.8). the anterior end of the deep part of the gland and runs
upwards and forwards on the hyoglossus, between the
The medial surface is related to:
lingual and hypoglossal nerves. At the anterior border
• Anterior part: Mylohyoid, submental branch of facial
of the hyoglossus, the duct is crossed by the lingual
artery, mylohyoid nerve and vessels
nerve (Fig. 7.4). It opens on the floor of the mouth, on
• Middle part: Hyoglossus, styloglossus, lingual artery,
the summit of the sublingual papilla, at the side of the
XII nerve
frenulum of the tongue (see Fig. 17.2).
• Posterior part: Stylohyoid, styloglossus, IX nerve.
Deep Part SUBLINGUAL SALIVARY GLAND

This part is small in size. It lies deep to the mylohyoid,
and superficial to the hyoglossus and the styloglossus This is smallest of the three salivary glands. It is almond-
(Fig. 7.4). Posteriorly, it is continuous with the super- shaped and weighs about 3 to 4 g. It lies above the
ficial part around the posterior border of the mylohyoid mylohyoid, below the mucosa of the floor of the mouth,
HEAD AND NECK
148
Flowchart 7.1: Secretomotor fibres to the glands About 15 ducts emerge from the gland. Most of them
open directly into the floor of the mouth on the summit
of the sublingual fold. A few of them join the sub-
mandibular duct (see Fig. 17.2).
The gland receives its blood supply from the lingual
and submental arteries. The nerve supply is similar to
that of the submandibular gland.
SUBMANDIBULAR GANGLION
This is a parasympathetic peripheral ganglion. It is a

relay station for secretomotor fibres to the submandibular
and sublingual salivary glands. Topographically, it is
related to the lingual nerve, but functionally, it is
connected to the chorda tympani branch of the facial
nerve (see Table 1.3 and Flowchart 7.1).
The fusiform ganglion lies on the hyoglossus muscle
just above the deep part of the submandibular salivary
gland, suspended from the lingual nerve by two roots
(Fig. 7.9).
medial to the sublingual fossa of the mandible and Connections and Branches
lateral to the genioglossus (Figs 7.2, 7.4 and 7.8). 1 The secretomotor fibres pass from the lingual nerve
to the ganglion through the posterior root. These
Relations are parasympathetic preganglionic fibres that arise
Front – Meets opposite side gland in the superior salivatory nucleus and pass through
Behind – Comes in contact with deeper part of nervus intermedius till the facial nerve, the chorda
submandibular gland tympani and the lingual nerve to reach the ganglion
Above – Mucous membrane of mouth for relay. Postganglionic fibres for the
Below – Mylohyoid muscle submandibular gland reach the gland through five
Lateral – Sublingual fossa or six branches from the ganglion. Postganglionic
Medial – Genioglossus muscles (Fig. 7.8) fibres for the sublingual and anterior lingual glands
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Fig. 7.9: Connection of the submandibular ganglion

149
re-enter the lingual nerve through the anterior root supply vasomotor fibres to the submandibular and
and travel to the gland through the distal part of the sublingual glands (Fig. 7.9).
lingual nerve (Flowchart 7.1). 3 Sensory fibres reach the ganglion through the lingual
2 The sympathetic fibres are derived from the plexus nerve (Table 7.2). Comparison of three salivary
around the facial artery. It contains postganglionic glands is depicted in Table 7.2.
fibres arising in the superior cervical ganglion which
arise from T1 segment of spinal cord and synapse in HISTOLOGY
superior cervical sympathetic ganglion. They pass The histological structure of parotid, submandibular
through submandibular ganglion without relay, and and sublingual salivary glands is shown in Figs 7.10–7.12.
Table 7.2: Comparison of the three salivary glands

Parotid Submandibular Sublingual
Location In relation to external ear, Lies in submandibular fossa Lies in sublingual fossa on
angle of mandible, mastoid close to angle of mandible the base of the mandible
process (see Fig. 5.1) (Fig. 7.6) (Fig. 7.2)
Size Largest Medium sized Smallest
Relation to Enclosed by investing Enclosed by investing Not enclosed
fascia layer of cervical fascia layer of cervical fascia
Type of gland Purely serous secreting (Fig. 7.10) Mixed, both serous and Purely mucus secreting
mucus secreting (Fig. 7.11) (Fig. 7.12)
Gross features Comprises 3 surfaces, Comprises 3 surfaces, Related closely to lingual
3 borders, apex and base, inferior, lateral and medial. nerve and submandibular
one artery, one vein, one nerve One artery which indents the duct
and lymph nodes lie within posterior end of the gland.
the gland (see Chapter 5) Only lymph nodes lie within it
Secretomotor root From IX cranial nerve From VII cranial nerve From VII cranial nerve
Sympathetic root Plexus around middle Plexus around facial artery Same as submandibular
meningeal artery gland
Sensory Auriculotemporal nerve Lingual nerve Lingual nerve
Development Ectoderm Endoderm Endoderm
Opening of Vestibule of mouth opposite Papilla on sublingual fold 10–12 ducts open on
the duct 2nd upper molar tooth (see Fig. 5.7) in the floor of the mouth sublingual fold in the floor
(see Fig. 17.2) of the mouth (see Fig. 17.2)
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Fig. 7.10: Histology of parotid gland

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150
Fig. 7.11: Histology of submandibular gland
Fig. 7.12: Histology of sublingual gland

Head and Neck
Competency achievement: The student should be able to: gland is to be removed, if lymph nodes are affected
AN 34.2 Describe the basis of formation of submandibular stones.2 in any disease especially carcinoma of tongue
(Fig. 7.1).
• Mylohyoid muscle divides the gland into
CLINICAL ANATOMY
superficial and deep parts (Fig. 7.5). Lymph nodes
• The chorda tympani nerve supplying secretomotor lie around and within the gland. Cancer of the
fibres to submandibular and sublingual salivary tongue or of the gland may metastasise into the
glands lies medial to the spine of sphenoid mandible also (Fig. 7.2).
(see Fig. 1.11b). The auriculotemporal nerve • Secretion of submandibular gland is more viscous,
supplying secretomotor fibres to the parotid gland so there are more chances of the gland getting
is related to lateral aspect of spine of sphenoid. calculi or small stones. The duct passes upwards
Injury to spine may involve both these nerves with against gravity, so flow is relatively slow.
loss of secretion from all three salivary glands. • Submandibular gland can be manually palpated
• Submandibular lymph nodes lie both within and by putting one finger within the mouth and one
outside the submandibular salivary gland. The finger outside, in relation to the position of the
151
• Suprahyoid muscles are disposed in four layers:

1st layer: Digastrics and stylohyoid
2nd layer: Mylohyoid
3rd layer: Geniohyoid and hyoglossus
4th layer: Genioglossus (Fig. 7.8)
A patient is diagnosed with cancer of the tongue.

The lesion was on the dorsum of tongue close to its
lateral border.
Fig. 7.13: Bimanual palpation of submandibular gland and
lymph nodes • Where does all the lymph from cancerous lesion
drain?
gland (Fig. 7.13). The enlarged lymph nodes lying • Which other parts have be removed during the
on the surface of the gland and within its sub- surgery to remove the lesion?
stance can also be palpated.
• The duct of submandibular gland may get impacted Ans: The lymph from dorsum of tongue close to
by a small stone, which can be demonstrated on lateral border chiefly drains into the submandibular
radiographs. group of lymph nodes. A few lymph vessels may
• Excision of the submandibular gland for calculus even cross the midline to drain into the opposite
or tumour is done by an incision below the angle submandibular lymph nodes.
of the jaw. Since the marginal mandibular branch These lymph nodes are present within and outside
of the facial nerve passes posteroinferior to the the submandibular salivary gland. So during
angle of the jaw before crossing it, the incision removal of lymph nodes this salivary gland is also
must be placed more than 4 cm below the angle to be removed.
to preserve the nerve (Fig. 7.1).
The incision in the neck is to be placed about 4 cm
The nerve also passes across the lymph nodes below the angle of mandible, to preserve the
of submandibular region. One should be careful
marginal mandibular branch of facial nerve as it
of the nerve while doing biopsy of lymph node.
passes posteroinferior to the angle of the jaw
before crossing it. If this branch is injured, muscles
FACTS TO REMEMBER of lower lip would get paralysed (Fig. 7.1).
• Chorda tympani nerve carries secretomotor
fibres to the submandibular ganglion. It also carries
Head and Neck

FURTHER READING
taste from most of the anterior two-thirds of the
• Garrett JR, Ekstrom J, Anderson LC (eds). Neural
tongue. Mechanisms of Salivary Secretion. Frontiers in Oral Bilogy,
• The submandibular lymph nodes are also present vol 11.Basel: Karger 1999.
in the submandibular gland. In cancer of the A book that contains much basic information concerning the role
tongue, this gland is also excised to get rid off the of nerves in the secretory process of salivary glands.
lymph nodes with secondaries from the tongue. • Scott J. Structure and function in aging human salivary
• Facial artery is tortuous to accommodate to the glands. Gerontology 1986;5:149–58.
movements of pharynx. It is the chief artery of the A paper that gives quantitative information on changes that occur
in the parenchyma of the major salivary glands with age and
palatine tonsil.
discusses the results in terms of xerostomia.
1–2
HEAD AND NECK
152
1. Describe the submandibular salivary gland under 2. Describe the attachments, nerve supply and actions
the following headings: of both bellies of digastric muscle.
a. Parts 3. Write short notes on:
b. Relations a. Hyoglossus muscle
c. Nerve supply b. Mylohyoid muscle
d. Clinical anatomy c. Submandibular ganglion
1. One of the following statements about chorda c. Marginal mandibular branch of facial
tympani nerve is not true: d. Cervical branch of facial
a. Branch of facial nerve 4. Submandibular lymph nodes drain all of the
b. Joins lingual nerve in infratemporal fossa following areas, except:
c. Carries postganglionic parasympathetic fibres a. Lateral side of tongue
d. Carries taste fibres from most of the anterior two- b. External nose, upper lip
thirds of tongue
c. Lateral halves of eyelids
2. Nerve carrying preganglionic parasympathetic
fibres to submandibular ganglion: d. Medial halves of eyelids
a. Greater petrosal b. Lesser petrosal 5. Which muscle divides the submandibular gland
c. Deep petrosal d. Chorda tympani into a superficial and deep parts?
3. Which of the following nerves lies posteroinferior a. Hyoglossus
to angle of mandible? b. Mylohyoid
a. Zygomatic branch of facial c. Geniohyoid
b. Buccal branch of facial d. Anterior belly of digastric
1. c 2. d 3. c 4. c 5. b
Head and Neck
• Name the layers of suprahyoid muscles. Which • Trace the secretomotor fibres of the submandibular
nerves supply these muscles? gland.
• Which muscle divides the submandibular gland into • Which areas are drained by the submandibular
a superficial and deep part? lymph nodes?
• Where does the duct of submandibular gland open? • Why are facial and lingual arteries tortuous?
• Name the roots of the submandibular ganglion. What • What are the main features of histological structure
are its branches? of submandibular gland?
8
Structures in the Neck
The extirpation of the thyroid gland for goitre typifies perhaps better
than any operation ,the supreme triumphs of the surgeon’s art .
—William S Halsted
INTRODUCTION superficially, it can easily be examined. This is the only

The thyroid gland lies in front of the neck. Skin incision gland using natural iodine for the synthesis of its
for its surgery should be horizontal, for better healing hormones which are stored within the follicles to be
and for cosmetic reasons. Branches of subclavian artery used according to the needs of the body.
anastomose with those of axillary artery around the The gland consists of right and left lobes that are
scapula. joined to each other by the isthmus (Fig. 8.1). A third,
Scalenus anterior is important. It may compress pyramidal lobe, may project upwards from the isthmus
the subclavian artery to cause ‘scalenus anterior (or from one of the lobes). Sometimes a fibrous or fibro-
syndrome’. muscular band (levator glandulae thyroideae) descends
Lymph nodes are clinically important in deciding from the body of the hyoid bone to the isthmus or to
the prognosis and treatment of malignancies. the pyramidal lobe (Fig. 8.2).
Contents: There are numerous structures in the neck.
For convenience, they may be grouped as follows: DISSECTION
a. Glands: Thyroid and parathyroid. Sternocleidomastoid muscle has already been reflected
b. Thymus: Involutes at puberty. laterally from its origin. Cut the sternothyroid muscle
c. Arteries: Subclavian and carotid. near its origin and reflect it upwards. Clean the surface
d. Veins: Subclavian, internal jugular and brachio- of trachea and identify inferior thyroid vein and remains
cephalic. of the thymus gland (darker in colour than fat).
e. Nerves: Glossopharyngeal, vagus, accessory (in Isthmus of the thyroid gland lies on the 2nd–4th
this Chapter), and hypoglossal (described in tracheal rings. Pyramidal lobe, if present, projects from
Chapter 17). the upper border of the isthmus. On each side of isthmus
f. Sympathetic trunk: It has three cervical ganglia. is the lateral lobe of the gland. Clean the lobes and
g. Lymph nodes and thoracic duct. identify the vessels of thyroid gland. Identify the recurrent
h. Styloid apparatus. laryngeal nerves tucked between the lateral surfaces of
trachea and oesophagus. Look for beaded thoracic duct
GLANDS present on the left of oesophagus. Trace the superior
and inferior thyroid arteries. Identify cricothyroid and
Competency achievement: The student should be able to: inferior constrictor muscles lying medial to the lobes of
AN 35.2 Describe and demonstrate location, parts, borders, thyroid gland (Figs 8.1 to 8.6) (refer to BDC App).
surfaces, relations and blood supply of thyroid gland.1 Thyroid gland (butterfly shaped)
Cut the isthmus of the thyroid gland and turn one of the
THYROID GLAND
lobes laterally. Locate an anastomosis between the
The thyroid (shield-like) is an endocrine gland with rich posterior branch of superior thyroid and ascending
blood supply situated in the lower part of the front and branch of inferior thyroid arteries supplying the gland.
sides of the neck. It regulates the basal metabolic rate, Identify the two parathyroid glands on the sides of this
stimulates somatic and psychic growth, and plays an anastomotic vessel (Figs 8.7 and 8.12).
important role in calcium metabolism. Since it is placed
153
HEAD AND NECK
154
Fig. 8.1: Position of thyroid gland
Capsules of Thyroid
1 The true capsule is the peripheral condensation of the
connective tissue of the gland.
A dense capillary plexus is present deep to the true
capsule. To avoid haemorrhage during operations,
the thyroid is removed along with the true capsule.
It can be compared with the prostate in which the
venous plexus lies between the two capsules of the
gland, and therefore, during prostatectomy, both
capsules are left behind (Figs 8.3a and b).
Fig. 8.2: Scheme to show the location and subdivisions of the

Head and Neck
thyroid gland including the false capsule
Situation and Extent

1 The gland lies against vertebrae C5–C7 and T1,
embracing the upper part of the trachea (Fig. 8.2).
2 Each lobe extends from the middle of thyroid
cartilage to the fourth or fifth tracheal ring.
3 The isthmus extends from the second to the fourth
tracheal ring.
Dimensions and Weight

Each lobe measures about 5 × 2.5 × 2.5 cm, and the Figs 8.3a and b: Schemes of comparing the relationship of
isthmus 1.2 × 1.2 cm. On an average, the gland weighs the venous plexuses related to: (a) The thyroid gland; (b) The
about 25 g. However, it is larger in females than in prostate, with the true and false capsules around these organs.
males, and further increases in size during menstrua- Note the plane of cleavage along which the organ is separated
tion and pregnancy. from neighbouring structures during surgical removal
STRUCTURES IN THE NECK
155
Fig. 8.4: Transverse section through the anterior part of the neck at the level of the isthmus of the thyroid gland
2 The false capsule is derived from the pretracheal layer

of the deep cervical fascia (Fig. 8.2). It is thin along
the posterior border of the lobes, but thick on the
inner surface of the gland where it forms a
suspensory ligament (of Berry), which connects the
lobe to the cricoid cartilage (Fig. 8.4).
Parts and Relations

The lobes are conical in shape having:
a. An apex
b. A base
c. Three surfaces: Lateral, medial and posterolateral.
d. Two borders: Anterior and posterior.
The apex is directed upwards and slightly laterally.
It is limited superiorly by the attachment of the sterno-
thyroid muscle to the oblique line of thyroid cartilage
which is medial to the apex. The apex is related to superior
thyroid artery and the external laryngeal nerve (Fig. 8.5).
The base is at level with the 4th or 5th tracheal ring.
Head and Neck

It is related to inferior thyroid artery and recurrent
laryngeal nerve (Fig. 8.7). Fig. 8.5: Deep relations of the thyroid gland
The lateral or superficial surface is convex, and is
The anterior border is thin and is related to the anterior
covered by:
branch of superior thyroid artery (Fig. 8.7).
a. The sternohyoid
The posterior border is thick and rounded and separates
b. The superior belly of omohyoid
the medial and posterior surfaces. It is related to:
c. The sternothyroid
a. Inferior thyroid artery.
d. The anterior border of the sternocleidomastoid
(Fig. 8.4). b. Anastomosis between the posterior branch of
The medial surface is related to: superior and ascending branch of inferior thyroid
a. Two tubes—trachea and oesophagus arteries.
b. Two muscles—inferior constrictor and cricothyroid c. Parathyroid glands.
c. Two nerves—external laryngeal and recurrent d. Thoracic duct only on the left side (Fig. 8.7).
laryngeal (Fig. 8.5). The isthmus connects the lower parts of the two lobes.
The posterolateral or posterior surface is related to the It has:
carotid sheath and overlaps the common carotid artery a. Two surfaces: Anterior and posterior.
(Fig. 8.4). b. Two borders: Superior and inferior.
HEAD AND NECK
156
The anterior surface is covered by: Arterial Supply

a. The right and left sternothyroid and sternohyoid The thyroid gland is supplied by the superior and
muscles. inferior thyroid arteries.
b. The anterior jugular veins.
1 The superior thyroid artery is the first anterior branch
c. Fascia and skin (Fig. 8.4).
of the external carotid artery (Figs 8.6 and 8.7). It runs
The posterior surface is related to the second to fourth
tracheal rings. downwards and forwards in intimate relation to the
The upper border is related to anterior branches of the external laryngeal nerve. After giving branches to
right and left superior thyroid arteries (Fig. 8.6) which adjacent structures, the artery pierces the pretracheal
anastomose here. fascia to reach the apex of the lobe where the nerve
Lower border: Inferior thyroid veins leave the gland deviates medially. At the upper pole, the artery
at this border (Fig. 8.8). divides into anterior and posterior branches.
Fig. 8.6: Arterial supply of anterior aspect of thyroid gland

Head and Neck
Fig. 8.7: Arterial supply of the surfaces of thyroid gland. Sites of ligatures of the superior and inferior thyroid arteries are shown
157
The anterior branch descends on the anterior border

of the lobe and continues along the upper border of
the isthmus to anastomose with its fellow of the
opposite side.
The posterior branch descends on the posterior border
of the lobe and anastomoses with the ascending
branch of inferior thyroid artery (Fig. 8.7).
2 The inferior thyroid artery is a branch of thyrocervical
trunk (which arises from the subclavian artery).
It runs first upwards, then medially, and finally
downwards to reach the base of the gland. During
its course, it passes behind the carotid sheath and
the middle cervical sympathetic ganglion; and in
front of the vertebral vessels; and gives off branches
to adjacent structures (see Fig. 9.5).
Its terminal part is intimately related to the recurrent
laryngeal nerve, while proximal part is away from
the nerve.
Fig. 8.8: Venous drainage and lymphatic drainage of the thyroid
The artery divides into 4 to 5 glandular branches gland (lateral view). Deep cervical lymph nodes are also shown
which pierce the fascia separately to reach the lower
part of the gland. One ascending branch anastomoses
with the posterior branch of the superior thyroid Nerve Supply
artery and supplies the parathyroid glands. Nerves are derived mainly from the middle cervical
3 Sometimes (in 3% of individuals), the thyroid is also ganglion and partly from the superior and inferior
supplied by the lowest thyroid artery (thyroidea ima cervical ganglia. These are vasoconstrictor.
artery) which arises from the brachiocephalic trunk
or directly from the arch of the aorta. It enters the Competency achievement: The student should be able to:
lower part of the isthmus. AN 35.8 Describe the anatomically relevant clinical features of
thyroid swellings.2
4 Accessory thyroid arteries arising from tracheal and
oesophageal arteries also supply the thyroid.
CLINICAL ANATOMY
Venous Drainage
The thyroid is drained by the superior, middle and • Any swelling of the thyroid gland (goitre) should
inferior thyroid veins. be palpated from behind (Fig. 8.9).
The superior thyroid vein emerges at the upper pole • Removal of the thyroid (thyroidectomy) with true
and accompanies the superior thyroid artery. It ends capsule may be necessary in hyperthyroidism.
Head and Neck

in the internal jugular vein (Fig. 8.8).
The middle thyroid vein is a short, wide channel which
emerges at the middle of the lobe and soon enters the
internal jugular vein.
The inferior thyroid veins emerge at the lower border
of isthmus. They form a plexus in front of the trachea,
and drain into the left brachiocephalic vein.
A fourth thyroid vein (Kocher) may emerge between
the middle and inferior veins, and drain into the internal
jugular vein.
Lymphatic Drainage
Lymph from the upper part of the gland reaches the
upper deep cervical lymph nodes either directly or
through the prelaryngeal nodes. Lymph from the lower
part of the gland drains to the lower deep cervical nodes
directly, and also through the pretracheal and para- Fig. 8.9: Palpation of thyroid gland from behind
tracheal nodes.
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158
• In subtotal thyroidectomy, the posterior parts of

both lobes are left behind. This avoids the risk of
simultaneous removal of the parathyroids and
also of postoperative myxoedema (caused by
deficiency of thyroid hormones).
• During thyroidectomy, the superior thyroid artery
is ligated near the gland to save the external
laryngeal nerve. The stem of inferior thyroid
artery is not ligated (Fig. 8.7). Its glandular
branches are ligated separately. In this way, blood
supply to parathyroid glands is maintained.
• Hypothyroidism causes cretinism in infants and
myxoedema in adults.
• Benign tumours of the gland may displace and
even compress neighbouring structures, like the
carotid sheath, the trachea, etc. Malignant growths
tend to invade and erode neighbouring structures.
Pressure symptoms and nerve involvements are
common in carcinoma of the gland giving rise to
dyspnoea, dysphagia and dysphonia.
Fig. 8.10: Histology of thyroid gland

AN 43.2 Identify, describe and draw the microanatomy of pituitary DEVELOPMENT
gland, thyroid, parathyroid gland, tongue, salivary glands, tonsil,
cornea, retina.3
The thyroid gland develops from a median endodermal
Microanatomy of thyroid and parathyroid glands is described in this
thyroid diverticulum which grows down in front of the
chapter. Rest of the tissues/glands are described in appropriate neck from the floor of the primitive pharynx (foramen
chapters. caecum), just caudal to the tuberculum impar (Figs 8.11a–
d).
HISTOLOGY
The thyroid gland is made up of the following two types
of secretory cells.
1 Follicular cells lining the follicles of the gland secrete
tri-iodothyronin and tetraiodothyronin (thyroxin)
which stimulate basal metabolic rate and somatic and
psychic growth of the individual. During active
Head and Neck
phase, the lining of the follicles is columnar, while

in resting phase, it is cuboidal. Follicles contain the
colloid (the hormone) in their lumina (Fig. 8.10).
2 Parafollicular cells (C cells) are fewer and light cells.
These lie in between the follicles. They secrete thyro-
calcitonin which promotes deposition of calcium
salts in skeletal and other tissues, and tends to
produce hypocalcaemia. These effects are opposite
to those of parathormone.

congenital anomalies of face, palate, tongue, branchial apparatus,
pituitary gland, thyroid gland and eye.4
Development of thyroid gland is described in this chapter. For
development of rest of the organs, please refer to appropriate
Figs 8.11a to d: Development of thyroid, parathyroid and thymus
chapters.
glands. Parathyroids are placed posteriorly
159
The lower end of the diverticulum enlarges to form

the gland. The rest of the diverticulum remains narrow
and is known as the thyroglossal duct. Most of the duct
soon disappears. The position of the upper end is marked
by the foramen caecum of the tongue, and the lower end
often persists as the pyramidal lobe. The gland becomes
functional during third month of development.
Remnants of the thyroglossal duct may form
thyroglossal cysts, or a thyroglossal fistula. Thyroid
tissue may develop at abnormal sites along the course
of the duct resulting in lingual or retrosternal thyroids.
Accessory thyroids may be present.
PARATHYROID GLANDS
Parathyroid glands are two pairs (superior and inferior)
of small endocrine glands, that usually lie on the
posterior border of the thyroid gland, within the false
capsule (Figs 8.12a and b). The superior parathyroids are
also referred to as parathyroid IV because they develop
from the endoderm of the fourth pharyngeal pouch. The
inferior parathyroids, similarly, are also called parathyroid
III because they develop from the third pouch (Fig. 8.11d).
The parathyroids secrete the hormone parathormone
which controls the metabolism of calcium and
phosphorus along with thyrocalcitonin.
Each parathyroid gland is oval or lentiform in shape,
measuring 6 × 4 × 2 mm (the size of a split pea). Each
gland weighs about 50 mg.
Position
The anastomosis between the superior and inferior
thyroid arteries is usually a good guide to the glands
because they usually lie close to it (Fig. 8.12a).
The superior parathyroid is more constant in position
and usually lies at the middle of the posterior border
of the lobe of the thyroid gland. It is usually dorsal to
the recurrent laryngeal nerve.
Head and Neck

The inferior parathyroid is more variable in position.
It may lie:
a. Within the thyroid capsule, below the inferior
thyroid artery and near the lower pole of the
thyroid lobe (Fig. 8.12b).
b. Behind and outside the thyroid capsule,
immediately above the inferior thyroid artery.
c. Within the substance of the lobe near its posterior
border. It is usually ventral to the recurrent laryn-
geal nerve.
Vascular Supply
The parathyroid glands receive a rich blood supply
from the inferior thyroid artery and from the anasto- Figs 8.12a to c: Schemes to show the location of the parathyroid
mosis between the superior and inferior thyroid glands: (a) Transverse section through the left lobe of the thyroid
arteries. The veins and lymphatics of the gland are gland; (b) Posterior view of the left lobe of the thyroid gland;
associated with those of the thyroid and the thymus. (c) Histology of the parathyroid gland
HEAD AND NECK
160
Nerve Supply
• Parathyroid glands are tough glands and will
Vasomotor nerves are derived from the middle and continue to function, if these are transplanted from
superior cervical ganglia. Parathyroid activity is an excised thyroid gland into the sternocleido-
controlled by blood calcium levels; low levels stimulate mastoid muscle.
and high levels inhibit the activity of the glands.
HISTOLOGY THYMUS
The reticular tissue forms framework of the parathyroid
gland. The parenchyma consists of principal cells and The thymus (Greek thyme leaf) is an important lymphoid
oxyphilic cells. Principal cells or chief cells are arranged organ, situated in the anterior and superior mediastina
in sheets with numerous sinusoids and capillaries of the thorax, extending above into the lower part of
traversing them. The principal cells are polygonal or the neck. It is well developed at birth, continues to grow
round with a centrally placed vesicular nuclei and a up to puberty, and thereafter, undergoes gradual
pale staining acidophilic cytoplasm (Fig. 8.12c). atrophy and replacement by fat.
Oxyphilic cells are a few in number, occur singly or in The thymus is a bilobed structure, made up of two
small groups. These are larger than principal cells. They pyramidal lobes of unequal size which are connected
have darkly staining nuclei and strongly acidophilic together by areolar tissue.
cytoplasm. Oxyphilic cells are seen to increase with age. Each lobe develops from the endoderm of the third
The principal or chief cells secrete parathormone pharyngeal pouch. It lies on the pericardium, the great
responsible for maintaining the blood calcium level. vessels of the superior mediastinum, and the trachea.
The thymus weighs 10–15 g at birth, 30–40 g at puberty,
and only 10 g after mid-adult life. Thus, after puberty,
CLINICAL ANATOMY
it becomes inconspicuous due to replacement by fat.
• Tumours of the parathyroid glands lead to
excessive secretion of parathormone (hyper- Blood Supply
parathyroidism). This leads to increased removal The thymus is supplied by branches from the internal
of calcium from bone, making them weak and thoracic and inferior thyroid arteries. Its veins drain
liable to fracture. Calcium levels in blood increase into the left brachiocephalic, internal thoracic and
(hypercalcaemia) and increased urinary excretion inferior thyroid veins.
of calcium can lead to the formation of stones in
the urinary tract. Nerve Supply
• Hypoparathyroidism may occur spontaneously or Vasomotor nerves are derived from the stellate
from accidental removal of the glands during ganglion. The capsule is supplied by the phrenic nerve
thyroidectomy. This results in hypocalcaemia and by the descendens cervicalis.
leading to increased neuromuscular irritability
causing muscular spasm and convulsions (tetany) Functions
(Fig. 8.13). 1 The thymus controls lymphopoiesis, and maintains
Head and Neck
an effective pool of circulating lymphocytes,

competent to react to innumerable antigenic
stimuli.
2 It controls development of the peripheral lymphoid
tissues of the body during the neonatal period. By
puberty, the main lymphoid tissues are fully
developed.
3 The cortical lymphocytes of the thymus arise from
stem cells of bone marrow origin. Most (95%) of the
lymphocytes (T lymphocytes) produced are
autoallergic (act against the host or ‘self’ antigens),
short-lived (3–5 days) and never move out of the
organ. They are destroyed within the thymus by
phagocytes. Their remnants are seen as Hassall’s
corpuscles.
The remaining 5% of the T lymphocytes are long-
Fig. 8.13: Spasm in the hand due to tetany
lived (3 months or more), and move out of the thymus
161
to join the circulating pool of lymphocytes where HISTOLOGY OF THYMUS

they act as immunologically competent but Thymus consists of a thin outer fibrous covering known
uncommitted cells, i.e. they can react to any un- as the capsule. From the capsule extend many thin
familiar, new antigen. On the other hand, the other connective tissue septa dividing it incompletely into
circulating lymphocytes (from lymph nodes, spleen, various lobules. Each lobule has a peripheral darker
etc.) are committed cells, i.e. they can mount an cortex and a central lighter medulla. The interlobular
immune response only when exposed to a particular septa are partial and do not extend into the medulla,
antigen. Thymic lymphopoiesis, lympholysis and so that there is continuity of the medullary tissue of
involution are all intrinsically controlled. the various lobules (Fig. 8.15).
4 The medullary epithelial cells of the thymus are Chief cells present in thymus are:
thought to secrete: a. Thymic lymphocytes: These are situated in the
a. Lymphopoietin, which stimulates lymphocyte interstices of the thymic reticulum and are immuno-
production both in the cortex of the thymus and logically competent but uncommitted cells.
in peripheral lymphoid organs.
b. Epithelial reticular cells: These are flattened cells
b. The competence-inducing factor, which may be with pale nuclei. Their processes branch and lie
responsible for making new lymphocytes compe- in apposition with the processes of the adjoining
tent to react to antigenic stimuli. cells forming thin membrane. These reticular cells
5 Normally, there are no germinal centres in the thymic develop from the endoderm of third pharyngeal
cortex. Such centres appear in autoimmune diseases. pouch. These cells secrete hormones, thymosin,
This may indicate a defect in the normal function of thymopoietin, thymulin and thymic humoral
the thymus. factor. These hormones are required for prolifera-
tion, differentiation, maturation of T lymphocytes.
Hassall’s corpuscles made up of concentric
CLINICAL ANATOMY
epithelial cells forming a hyaline mass is an
• Involution of the thymus is enhanced by hyper- important feature of the medulla.
trophy of the adrenal cortex, injection of cortisone
or of androgenic hormone. The involution is DEVELOPMENT OF THYMUS AND PARATHYROID GLANDS
delayed by castration and adrenalectomy. Development of Thymus
• Thymic hyperplasia or tumours are often • Thymus develops from the endoderm of the ventral
associated with myasthenia gravis, characterised wing of the third pharyngeal pouch and from the
by excessive fatigability of voluntary muscles. mesenchyme into which the epithelial tubes grow.
The precise role of the thymus in this disease is • The bilateral primordia of the thymus lose their
uncertain; it may influence, directly or indirectly, connections with the pharyngeal wall, come together
the transmission at the neuromuscular junction. in the median plane to form bilobed structure which
Figure 8.14 shows drooping of eyelids.
• Thymic tumours may press on the trachea,
Head and Neck

oesophagus and the large veins of the neck, causing
hoarseness, cough, dysphagia and cyanosis.
Fig. 8.14: Myasthenia gravis

Fig. 8.15: Histology of thymus
HEAD AND NECK
162
migrates into the superior mediastinum part of the

thoracic cavity.
• Thymus continues to grow after birth till puberty,
after which it begins to undergo involution.
Consequently, it is difficult to recognize in old age,
as it is atrophied and replaced by fatty tissue.
Development of Parathyroid Glands

Inferior parathyroid glands are derived from the dorsal
wing of the third pharyngeal pouch.
• Primordia of the inferior parathyroids along with
primordia of thymus lose their connection with the
pharyngeal wall.
• The downwards migrating thymus also pulls the
inferior parathyroids with it, which finally come to
rest on the inferior part of dorsal surface of the thyroid
gland.
Superior parathyroid glands are derived from the
endoderm of 4th pharyngeal pouch. Fig. 8.16: Origin and course of the subclavian arteries
• The primordia of superior parathyroid glands, after
loosing connection with the pharyngeal wall, come
to rest on the superior part of dorsal surface of the On the left side, it is a branch of the arch of the aorta. It
thyroid gland. ascends and enters the neck posterior to the left
• As mentioned above, because of downwards sternoclavicular joint. Both arteries pursue a similar
migration with the thymus, the parathyroid glands course in the neck (Fig. 8.17).
derived from 3rd pouch become inferiorly located Course
as compared to those derived from the 4th pouch.
1 Each artery arches laterally from the sternoclavicular
joint to the outer border of the first rib where it
BLOOD VESSELS OF THE NECK ends by becoming continuous with the axillary artery
(Fig. 8.17).
2 The scalenus anterior muscle crosses the artery
Competency achievement: The student should be able to: anteriorly and divides it into three parts. The first
AN 35.3 Demonstrate and describe the origin, parts, course and part is medial, the second part posterior, and the
branches of subclavian artery.5 third part lateral to scalenus anterior.
SUBCLAVIAN ARTERY
This is the principal artery which continues as axillary
Head and Neck
artery for the upper limb. It also supplies a considerable

part of the neck and brain through its branches
(Fig. 8.16).
Origin
On the right side, it is branch of the brachiocephalic
artery. It arises posterior to the sternoclavicular joint.
DISSECTION
Identify scalenus anterior muscle in the anteroinferior
part of the neck. Subclavian artery gets divided into
three parts by this muscle. Identify vertebral, internal
thoracic artery and the thyrocervical trunk with its
branches arising from the first part of the artery,
costocervical arising from second part and either dorsal
scapular or none from the third part.
Fig. 8.17: Course of subclavian and carotid arteries
163
Relations of the First Part Superior

Anterior Upper and middle trunks of the brachial plexus.
Immediate relations from medial to lateral side are:
1 Common carotid artery Relations of the Third Part
2 Vagus Anterior
3 Internal jugular vein 1 Middle one-third of the clavicle
4 The sternothyroid and the sternohyoid muscles 2 The posterior border of the sternocleidomastoid
5 Sternocleidomastoid
Posterior (Posteroinferior) Posterior (Posteroinferior)
1 Suprapleural membrane 1 Scalenus medius
2 Cervical pleura 2 Lower trunk of brachial plexus
3 Apex of lung (Fig. 8.18) 3 Suprapleural membrane
4 Cervical pleura
Relations of the Second Part 5 Apex of lung
Anterior Superior
1 Scalenus anterior Upper and middle trunks of brachial plexus
2 Right phrenic nerve deep to the prevertebral fascia
3 Sternocleidomastoid Inferior
Posterior (Posteroinferior) First rib (Fig. 8.19)
1 Suprapleural membrane Branches
2 Cervical pleura
3 Apex of lung From the first part
1 Vertebral artery (Fig. 8.19)
2 Internal thoracic artery
3 Thyrocervical trunk, which divides into three branches:
a. Inferior thyroid (Fig. 8.20)
b. Suprascapular
c. Transverse cervical arteries.
4 Costocervical trunk, which divides into two branches:
a. Superior intercostal
b. Deep cervical arteries.
Fig. 8.18: Schematic transverse section through the lower part This artery comes from second part on the right side.
of neck to show the relations of the left subclavian artery From the third part: Dorsal scapular artery—occasionally.
Head and Neck
Fig. 8.19: Branches of the subclavian artery. Note that the branches actually arise at different levels, but are shown at same level
schematically
HEAD AND NECK
164
suprascapular and transverse cervical arteries (Figs 8.19

and 8.20).
The inferior thyroid artery is described with the thyroid
gland. In addition to glandular branches to the thyroid,
it gives:
a. The ascending cervical artery which runs upwards
in front of the transverse processes of cervical
vertebrae.
b. The inferior laryngeal artery which accompanies
the recurrent laryngeal nerve, and enters the
larynx deep to the lower border of the inferior
constrictor (Fig. 8.7).
c. Other branches which supply the pharynx, the
trachea, the oesophagus and surrounding muscles.
The suprascapular artery runs laterally and down-
wards, and crosses the scalenus anterior and the phrenic
nerve.
Fig. 8.20: Branches of the right subclavian artery It lies behind the internal jugular vein and the
sternocleidomastoid. It then crosses the trunks of the
brachial plexus and runs in the posterior triangle,
Vertebral Artery behind and parallel with the clavicle, to reach the
Vertebral artery is the first and largest branch of the superior border of the scapula (see Fig. 3.9).
first part of the subclavian artery. It runs a long course It crosses above the suprascapular ligament and takes
and ends in the cranial cavity by supplying the brain. part in the anastomoses around the scapula (see Chapter 6,
It is divided into four parts. The first part extends BD Chaurasia’s Human Anatomy, Volume 1). In addition
from its origin to the foramen transversarium of the to branches to surrounding muscles, the artery also
sixth cervical vertebra (see Fig. 9.2). This part runs supplies the clavicle, scapula, shoulder and
upwards and backwards into the angle between the acromioclavicular joints.
scalenus anterior and the longus colli muscles, behind The transverse cervical artery runs laterally above the
the common carotid artery, the vertebral vein and the suprascapular artery (see Fig. 3.9).
inferior thyroid artery (see Fig. 9.5). Details of all the It crosses the scalenus anterior and the phrenic nerve
four parts are described in the section on the passing behind the internal jugular vein and the
prevertebral region (see Chapter 9). sternocleidomastoid.
Internal Thoracic Artery It then crosses the brachial plexus and the floor of
the posterior triangle to reach the anterior border of
Internal thoracic artery arises from the inferior aspect trapezius, where it divides into superficial and deep
of the first part of the subclavian artery opposite the
Head and Neck
branches. The superficial branch accompanies the spinal

origin of the thyrocervical trunk. The origin lies near root of accessory nerve till the lower end of the muscle.
the medial border of the scalenus anterior (Fig. 8.20). The deep branch passes deep to levator scapulae and
The artery runs downwards and medially in front of takes part in the anastomoses around the scapula
the cervical pleura. Anteriorly, the artery is related to (see Chapter 6, BD Chaurasia’s Human Anatomy, Volume 1).
the sternal end of the clavicle. The artery enters the
thorax by passing behind the first costal cartilage. It Sometimes the two branches may arise separately;
runs till 6th intercostal space where it ends by dividing the superficial from thyrocervical trunk and the deep
into superior epigastric and musculophrenic arteries. from the third part of subclavian artery. Then these are
For course of the artery in the thorax, see Chapter 14, named as superficial cervical and dorsal scapular
BD Chaurasia’s Human Anatomy, Volume 1. arteries.
Thyrocervical Trunk Dorsal Scapular Artery

Thyrocervical trunk is a short, wide vessel which This artery occasionally arises from the third part of
arises from the front of the first part of the subclavian subclavian artery. If transverse cervical does not divide
artery, close to the medial border of the scalenus into superficial and deep branches but continues as
anterior, and between the phrenic and vagus nerves. It superficial branch, the distribution of deep branch is
almost immediately divides into the inferior thyroid, taken over by dorsal scapular artery.
165
Costocervical Trunk
Costocervical trunk arises from the posterior surface
of the second part of the subclavian artery on the right
side; but from the first part of the artery on the left side.
It arches backwards over the cervical pleura, and
divides into the descending superior intercostal and
ascending deep cervical arteries at the neck of the first
rib (Fig. 8.19).
The superior intercostal artery descends in front of the
neck of the first rib, and divides into the first and second
posterior intercostal arteries.
The deep cervical artery is analogous to the posterior
branch of a posterior intercostal artery. It passes
backwards between the transverse process of the 7th
cervical vertebra and the neck of the first rib. It then
ascends between the semispinalis capitis and cervicis
up to the axis vertebra. It anastomoses with the occipital
and vertebral arteries.

AN 35.9 Describe the clinical features of compression of subclavian
artery and lower trunk of brachial plexus by cervical rib.6 Fig. 8.22: Subclavian steal syndrome
• An aneurysm may form in the third part of the

CLINICAL ANATOMY subclavian artery. Its pressure on the brachial
• The third part of the subclavian artery can be plexus causes pain, weakness, and numbness in
effectively compressed against the first rib after the upper limb.
depressing the shoulder. The pressure is applied • Obstruction to the subclavian artery proximal to
downwards, backwards, and medially in the angle the origin of vertebral artery may lead to ‘stealing
between the sternocleidomastoid and the clavicle. of blood from the brain through the opposite
• A cervical rib may compress the subclavian artery, vertebral artery’. This may provide necessary
diminishing the radial pulse (Fig. 8.21). blood to the affected side. The nervous symptoms
incurred are called ‘subclavian steal syndrome’
• The right subclavian artery may arise from the (Fig. 8.22).
descending thoracic aorta. In that case, it passes
posterior to the oesophagus which may be
compressed and the condition is known as COMMON CAROTID ARTERY
Head and Neck

(dysphagia lusoria). Features
The origin and course of the common carotid arteries
has been described in Chapter 4. The common carotid
artery is enclosed in the carotid sheath.
Course
Common carotid artery begins in the thorax in front of
the trachea opposite a point a little to the left of the
DISSECTION
The common carotid artery has been exposed in the
carotid triangle. Clean it in its entire course. Identify the
internal carotid artery and trace it till it leaves the neck.
Veins
Fig. 8.21: The cervical rib pressing on the subclavian artery Identify the tributaries of subclavian, internal jugular and
narrowing the axillary artery and diminishing the radial pulse brachiocephalic veins.
HEAD AND NECK
166
centre of the manubrium. It ascends to the back of left 2 Larynx and pharynx; trachea, oesophagus and
sternoclavicular joint and enters the neck. recurrent laryngeal nerve (Fig. 8.5).
In the neck, both arteries have a similar course. Each
Lateral Relation
artery runs upwards within the carotid sheath, under
cover of the anterior border of the sternocleidomastoid. Internal jugular vein.
It lies in front of the lower four cervical transverse Posterolateral Relation
processes. At the level of the upper border of the thyroid
Vagus nerve (Fig. 8.4).
cartilage, the artery ends by dividing into the external
and internal carotid arteries. External carotid artery has
been described in Chapter 3. CLINICAL ANATOMY
Relations of the Artery in the Neck The pulsation of common carotid artery can be felt
Anterior Relations by compressing against the carotid tubercle, i.e. the
1 The common carotid artery is crossed by the superior anterior tubercle of the transverse process of vertebra
belly of omohyoid at the level of cricoid cartilage C6 which lies at the level of the cricoid cartilage.
(see Fig. 4.14).
2 Below the omohyoid, the artery is deeply situated, INTERNAL CAROTID ARTERY
and is covered by:
a. The sternocleidomastoid The internal carotid artery is one of the two terminal
b. The anterior jugular vein branches of the common carotid artery. It begins at the
c. The sternohyoid level of the upper border of the thyroid cartilage
d. The sternothyroid and the middle thyroid vein. opposite the disc between the third and fourth cervical
vertebrae, and ends inside the cranial cavity by
Posterior Relations supplying the brain. This is the principal artery of the
1 Transverse process of vertebrae C4–C8, and the brain and the eye. It also supplies the related bones and
muscles attached to their anterior tubercles (longus meninges.
colli, longus capitis, scalenus anterior). For convenience of description, the course of the
2 The inferior thyroid artery crosses medially at the artery is divided into four parts:
level of the cricoid cartilage. a. Cervical part, in the neck
3 Vertebral artery (Fig. 8.23)
b. Petrous part, within the petrous temporal bone
4 On the left side, the thoracic duct crosses laterally
(see Fig. 12.16)
behind the artery at the level of vertebra C7, in front
of the vertebral vessels. c. Cavernous part, within the cavernous sinus
d. Cerebral part in relation to base of the brain.
Medial Relations
1 Thyroid gland Cervical Part
1 It ascends vertically in the neck from its origin to the
base of the skull to reach the lower end of the carotid
Head and Neck
canal. This part is enclosed in the carotid sheath (with

the internal jugular vein and the vagus nerve).
2 No branches arise from the internal carotid artery in
the neck.
3 Its initial part usually shows a dilatation, the carotid
sinus which acts as a baroreceptor (see Fig. 4.14).
4 The lower part of the artery (in the carotid triangle)
is comparatively superficial. The upper part, above
the posterior belly of digastric, is deep to the parotid
gland, the styloid apparatus, and many other struc-
tures.
Relations
Anterior or superficial
Fig. 8.23: Schematic sagittal section showing posterior relations 1 In the carotid triangle:
of the common carotid artery a. Anterior border of sternocleidomastoid
167
Fig. 8.24: Schematic sagittal section showing the anterior and posterior relations of the internal carotid artery
b. The external carotid artery is anteromedial to it tube and tensor tympani (anterolaterally); and the
(Fig. 8.16). trigeminal ganglion (superiorly) (see Fig. 12.14).
2 Above the carotid triangle (see Fig. 4.13): 3 Branches:
a. Posterior belly of digastric a. Caroticotympanic branches enter the middle ear,
b. Stylohyoid and anastomose with the anterior and posterior
c. Stylopharyngeus tympanic arteries (see Fig. 12.16).
b. The pterygoid branch (small and inconstant) enters
d. Styloid process
the pterygoid canal with the nerve of that canal
e. Parotid gland with structures within it. and anastomoses with the greater palatine artery.
Posterior Cavernous and Cerebral Parts
1 Superior cervical ganglion
Cavernous part runs in the cavernous sinus (see Fig. 12.6).
2 Carotid sheath Cerebral part lies at base of skull and gives ophthalmic,
3 The glossopharyngeal, vagus, accessory and hypo- anterior cerebral, middle cerebral, posterior communicat-
glossal nerves at the base of the skull. ing and anterior choroidal arteries (see BD Chaurasia’s
Medial Human Anatomy, Volume 4).
Head and Neck

1 Pharynx SUBCLAVIAN VEIN
2 The external carotid is anteromedial to it below the
parotid. Course
It is a continuation of the axillary vein. It begins at the
Lateral outer border of the first rib, and ends at the medial
1 Internal jugular vein border of the scalenus anterior by joining the internal
2 Temporomandibular joint (at the base of the skull) jugular vein to form the brachiocephalic vein.
It lies:
Petrous Part a. In front of the subclavian artery, the scalenus
1 In the carotid canal, the artery first runs upwards, anterior and the right phrenic nerve
and then turns forwards and medially at right angles. b. Behind the clavicle and the subclavius
It emerges at the apex of the petrous temporal bone, c. Above the first rib and pleura.
in the posterior wall of the foramen lacerum where Its tributaries are:
it turns upwards and medially. a. The external jugular vein (Fig. 8.25)
2 Relations: The artery is surrounded by venous and b. The dorsal scapular vein
sympathetic plexuses. It is related to the middle ear c. The thoracic duct on the left side
and the cochlea (posterosuperiorly); the auditory d. The right lymphatic duct on the right side.
HEAD AND NECK
168
Competency achievement: The student should be able to: Posterior

AN 35.4 Describe and demonstrate origin, course, relations, 1 Transverse process of atlas
tributaries and termination of internal jugular and brachiocephalic 2 Cervical plexus
veins.7
3 Scalenus anterior
INTERNAL JUGULAR VEIN 4 First part of subclavian artery
Course Medial
1 It is a direct continuation of the sigmoid sinus. It 1 Internal carotid artery
begins at the jugular foramen, and ends behind the 2 Common carotid artery
sternal end of the clavicle by joining the subclavian 3 Vagus nerve
vein to form the brachiocephalic vein.
2 The origin is marked by a dilation, the superior bulb Tributaries
which lies in the jugular fossa of the temporal bone,
1 Inferior petrosal sinus
beneath the floor of the middle ear cavity. The
termination of the vein is marked by the inferior bulb 2 Common facial vein
which lies beneath the lesser supraclavicular fossa. 3 Lingual vein
4 Pharyngeal veins
Relations 5 Superior thyroid vein
Superficial 6 Middle thyroid vein (Fig. 8.25)
1 Sternocleidomastoid The thoracic duct opens into the angle of union
2 Posterior belly of digastric between the left internal jugular vein and the left sub-
3 Superior belly of omohyoid clavian vein. The right lymphatic duct opens similarly
4 Parotid gland on the right side.
5 Styloid process In the middle of the neck, the internal jugular vein
6 The internal carotid artery, and the glossopharyn- may communicate with the external jugular vein
geal, vagus, accessory and hypoglossal cranial nerves through the oblique jugular vein which runs across the
(at the base of skull) anterior border of the sternocleidomastoid.
Head and Neck
Fig. 8.25: The veins of the neck

169
CLINICAL ANATOMY Course

1 It runs between internal carotid artery and internal
• Deep to the lesser supraclavicular fossa, the jugular vein, lying deep to the styloid process and
internal jugular vein is easily accessible for muscles attached to the process.
recording of venous pulse tracings. The vein can 2 Then it courses between internal carotid and external
be cannulated by direct puncture in the interval carotid arteries, where it curves round the lateral
between sternal and clavicular heads of sterno- border of stylopharyngeus muscle.
cleidomastoid muscle. 3 As it reaches submandibular region, it passes deep
• In congestive cardiac failure or any other disease to hyoglossus muscle to reach the area of palatine
where venous pressure is raised, the internal tonsil and base of the tongue (Fig. 8.26).
jugular vein is markedly dilated and engorged.
Branches
BRACHIOCEPHALIC VEIN
1 Tympanic branch courses through middle ear and
gives secretomotor root to otic ganglion.
1 The right brachiocephalic vein (2.5 cm long) is shorter 2 Carotid branch for carotid body and carotid sinus.
than the left (6 cm long) (Fig. 8.25). 3 Muscular for stylopharyngeus muscle.
2 Each vein is formed behind the sternoclavicular joint, 4 Carries taste from vallate papillae of tongue.
by the union of the internal jugular vein and the 5 Carries general sensations from posterior one-third
subclavian vein. of tongue and palatine tonsil.
3 The right vein runs vertically downwards. The left 6 Branch to pharyngeal plexus.
vein runs obliquely downwards and to the right
behind the upper half of the manubrium sterni. The VAGUS NERVE—X NERVE
two brachiocephalic veins unite at the lower border Vagus leaves the cranial cavity through jugular foramen
of the right first costal cartilage to form the superior lying posterior to IX nerve. Soon it is joined course by
vena cava. cranial root of XI nerve. In the neck, the nerve lies in
4 The tributaries correspond to the branches of the first the carotid sheath, medial to internal jugular vein and
part of the subclavian artery. These are as follows. posterior to internal carotid and common carotid
arteries (Fig. 8.27).
Right Brachiocephalic Then it passes through thorax and abdomen.
a. Vertebral
Branches in Neck
b. Internal thoracic
• Meningeal
c. Inferior thyroid • Auricular
d. First posterior intercostal • Pharyngeal for most muscles of soft palate 4 out of 5
and pharynx 5 out 6, carotid for carotid body and
Left Brachiocephalic carotid sinus, superior laryngeal gives internal
a. Vertebral (Fig. 8.25) laryngeal for mucous membrane of larynx and
Head and Neck

b. Internal thoracic external laryngeal for cricothyroid muscle.
• Right recurrent laryngeal is given off in neck while
c. Inferior thyroid
left one is given off in thorax. The nerves supply all
d. First posterior intercostal intrinsic muscles of larynx, and sensory branches to
e. Left superior intercostal mucous membrane of larynx below vocal cords.
f. Thymic and pericardial veins • Cardiac branches for deep cardiac plexus.
Competency achievement: The student should be able to: ACCESSORY NERVE—XI NERVE
AN 35.7 Describe the course and branches of IX, X, XI and XII nerve This nerve also leaves the cranial cavity through the
in the neck.8 jugular foramen. It is made up of a cranial root and a
spinal root. The two roots join in jugular foramen, but
again separate as it passes out of the foramen. Cranial
NERVES OF THE NECK root joins X nerve and gets distributed with it for 4 out
of 5 palatal muscles, 5 out of 6 pharyngeal muscles and
GLOSSOPHARYNGEAL NERVE—IX NERVE all laryngeal muscles (Fig. 8.27).
Glossopharyngeal nerve exits the cranial cavity via The spinal root descends between internal jugular
anterior part of jugular foramen. vein and internal carotid artery for some distance.
HEAD AND NECK
170
Fig. 8.26: Distribution of glossopharyngeal nerve

Head and Neck
Figs 8.27a and b: Distribution of vagus and cranial part of accessory nerves. Many branches of external carotid artery are not
depicted
171
It then lies superficial to internal jugular vein to reach DISSECTION

anterior border of sternocleidomastoid muscle. It enters
The course of IX–XI cranial nerves has been seen in
the muscle, supplies it and leaves the muscle at its
different chapters. Now trace these nerves and their
posterior border a little above its middle.
branches.
Then it passes downwards and backwards in the
posterior triangle of neck. Finally, it leaves posterior The sympathetic trunk has been identified as lying
triangle by passing deep to trapezius (see Fig. 3.10). posteromedial to the carotid sheath. Trace it upwards
Thus the spinal root of XI nerve supplies: and downwards and locate the three cervical ganglia.
Sternocleidomastoid and trapezius muscles. Dissect the formation and branches of the cervical
Details can be red from Chapter 4, BD Chaurasia’s plexus. Identify the phrenic nerve on the surface of
Human Anatomy, Volume 4. scalenus anterior muscle behind the prevertebral fascia.
fibres which emerge from segments T1 to T4 of the

spinal cord, and then ascend into the neck (Fig. 8.28).
AN 35.6 Describe and demonstrate the extent, formation, relation
Grey rami communicantes (i.e. outgoing roots) are
and branches of cervical sympathetic chain.9
present.
Relations
CERVICAL PART OF SYMPATHETIC TRUNK
Anterior
Features a. Internal carotid artery
The cervical parts of the right and left sympathetic b. Common carotid artery
trunks are situated one on each side of the cervical part c. Carotid sheath (Fig. 8.4)
of the vertebral column, behind the carotid sheath d. Inferior thyroid artery
(common carotid and internal carotid arteries) and in
front of the prevertebral fascia. Posterior
a. Prevertebral fascia
FORMATION b. Longus capitis and cervicis muscles
There are no white rami communicantes (i.e. incoming c. Transverse processes of the lower six cervical
root) in the neck and this part of the trunk is formed by vertebrae.
Head and Neck
Fig. 8.28: The cervical sympathetic trunks and their branches

HEAD AND NECK
172
GANGLIA Branches
Theoretically, there should be eight sympathetic ganglia 1 Grey rami communicantes are given to the ventral
corresponding to the eight cervical nerves, but due to rami of the 5th and 6th cervical nerves.
fusion, there are only three ganglia—superior, middle 2 Thyroid branches accompany the inferior thyroid
and inferior. artery to the thyroid gland. They also supply the
parathyroid glands (Fig. 8.28).
Superior Cervical Ganglion 3 Tracheal and oesophageal branches.
Size and Shape 4 The middle cervical cardiac branch is the largest of
This is the largest of the three ganglia. It is spindle- the sympathetic cardiac branches. It goes to the deep
shaped, and about 2.5 cm long (Fig. 8.28). cardiac plexus.
Situation and Formation Inferior Cervical Ganglion
It lies just below the skull, opposite the second and third Size, Shape and Formation
cervical vertebrae, behind the carotid sheath and in It is formed by fusion of 7th and 8th cervical ganglia.
front of the prevertebral fascia (longus capitis). It is This is often fused with the first thoracic ganglion and
formed by fusion of the upper 4 cervical ganglia. is then known as the cervicothoracic ganglion or stellate
Communications. With cranial nerves IX, X and XII, ganglion because it is star-shaped.
and with the external and recurrent laryngeal nerves. It is situated between the transverse process of
Branches vertebra C7 and the neck of the first rib. It lies behind
the vertebral artery, and in front of ramus of spinal
1 Grey rami communicantes pass to the ventral rami
nerve C8. A cervicothoracic ganglion extends in front of
of upper four cervical nerves (Fig. 8.28).
the neck of the first rib.
2 The internal carotid nerve arises from the upper end
of the ganglion and forms a plexus around the Branches
internal carotid artery. A part of this plexus supplies
1 Grey rami communicantes are given to the ventral
the dilator pupillae (see Chapter 19). Some of these
rami of nerves C7 and C8.
fibres form the deep petrosal nerve for pterygo-
2 Vertebral branches form a plexus around the
palatine ganglion; others give fibres along long
ciliary nerve for the ciliary ganglion. vertebral artery.
3 The external carotid branches form a plexus around 3 Subclavian branches form a plexus around the
the external carotid artery. Some of these fibres form subclavian artery. This plexus is joined by branches
the sympathetic roots of the otic and submandibular from the ansa subclavia (Fig. 8.28).
ganglia (see Table A.2, Appendix). 4 An inferior cervical cardiac branch goes to the deep
4 Pharyngeal branches take part in the formation of cardiac plexus.
the pharyngeal plexus. Branches of the cervical sympathetic ganglia are
5 The left superior cervical cardiac branch goes to the listed in Table 8.1.
superficial cardiac plexus while the right branch goes
Head and Neck
to the deep cardiac plexus. Competency achievement: The student should be able to:
AN 31.3 Describe anatomical basis of Horner's syndrome.10
Middle Cervical Ganglion
Size and Shape
CLINICAL ANATOMY
This ganglion is very small. It may be divided into
2 to 3 smaller parts, or may be absent. • The head and neck are supplied by sympathetic
Situation nerves arising from the upper four thoracic
segments of the spinal cord. Most of these
It lies in the lower part of the neck, in front of vertebra preganglionic fibres pass through the stellate
C6 just above the inferior thyroid artery, behind the ganglion to relay in the superior cervical ganglion.
carotid sheath (Fig. 8.28).
• Injury to cervical sympathetic trunk produces
Formation Horner’s syndrome. It is characterized by:
It is formed by fusion of the fifth and sixth cervical a. Ptosis—drooping of the upper eyelid.
ganglia connections. It is connected with the inferior b. Miosis—constriction of the pupil (Fig. 8.29).
cervical ganglion directly, and also through a loop that c. Anhydrosis—loss of sweating on that side of
winds round the subclavian artery. This loop is called the face.
the ansa subclavia.
173
Table 8.1: Branches of cervical sympathetic ganglia

Superior cervical ganglion Middle cervical ganglion Inferior cervical ganglion
Arterial branches i. Along internal carotid artery Along inferior thyroid artery Along subclavian and
as internal carotid nerve vertebral arteries
ii. Along common carotid and
external carotid arteries
Grey rami communicantes Along 1–4 cervical nerves Along 5 and 6 cervical nerves Along 7 and 8 cervical nerves
Along cranial nerves Along cranial nerves – –
IX, X, XI and XII
Visceral branches Pharynx, cardiac Thyroid, cardiac Cardiac
Features
d. Enophthalmos—retraction of the eyeball.
Lymph nodes in head and neck are as follows:
e. Loss of the ciliospinal reflex—pinching the skin
on the nape of the neck does not produce dilata- a. Superficial group
tion of the pupil (which normally takes place). b. Deep group
• Horner’s syndrome can also be caused by a lesion c. Deepest group
within the central nervous system anywhere at or
above the first thoracic segment of the spinal cord SUPERFICIAL GROUP
involving sympathetic fibres. Buccal and Mandibular Nodes
The buccal node lies on the buccinator, and the
mandibular node at the lower border of the mandible
near the anteroinferior angle of the masseter, in close
relation to the marginal mandibular branch of the facial
nerve. They drain part of the cheek and the lower eyelid.
Their efferents pass to the anterosuperior group of deep
cervical nodes (Fig. 8.30).
Preauricular Nodes
Drain parotid gland, temporal region, middle ear, etc.
Postauricular (Mastoid) Nodes

The postauricular nodes lie on the mastoid process,
superficial to the sternocleidomastoid and deep to the
auricularis posterior. They drain a strip of scalp just
Head and Neck

Fig. 8.29: Horner’s syndrome on left side
above and behind the auricle, the upper half of the
medial surface and margin of the auricle, and the
Competency achievement: The student should be able to: posterior wall of the external acoustic meatus. Their
AN 28.5 Describe cervical lymph nodes and lymphatic drainage of efferents pass to the posterosuperior group of deep
head, face and neck.11 cervical nodes (Fig. 8.30).
AN 35.5 Describe and demonstrate extent, drainage and applied
anatomy of cervical lymph nodes.12 Occipital Nodes
The occipital nodes lie at the apex of the posterior
triangle superficial to the attachment of the trapezius.
LYMPHATIC DRAINAGE OF HEAD AND NECK They drain the occipital region of the scalp. Their
efferents pass to the supraclavicular members of the
DISSECTION posteroinferior group of deep cervical nodes.
Identify the lymph nodes in the submental, the
Anterior Superficial Cervical Nodes
submandibular, the parotid, the mastoid and the occipital
regions including the deep cervical nodes. Dissect the The anterior cervical nodes lie along the anterior jugular
main lymph trunk present at the root of the neck. vein and are unimportant. The suprasternal lymph node
is a member of this group. They drain the skin of the
HEAD AND NECK
174
Figs 8.30a and b: Superficial lymph nodes of the neck
anterior part of the neck below the hyoid bone. Their round both borders of the muscle to reach the upper
efferents pass to the deep cervical nodes of both sides and lower deep cervical nodes.
(Fig. 8.30).
DEEP GROUP
Lateral Superficial Cervical Nodes It comprises five levels of lymph nodes (Fig. 8.31).
The superficial cervical nodes lie along the external
jugular vein superficial to the sternocleidomastoid. They Submental and Submandibular Nodes
drain the lobule of the auricle, the floor of the external Submental nodes lie deep to the chin. These drain the
acoustic meatus, and the skin over the lower parotid lymph from tip of tongue and anterior part of floor of
region and the angle of the jaw. Their efferents pass mouth. The submandibular nodes drain lateral surface
Head and Neck
Figs 8.31a and b: Deep and deepest groups of lymph nodes in the neck
175
of tongue, lower gums and teeth and central area of DEEPEST GROUP
forehead. Prelaryngeal and Pretracheal Nodes
The submandibular lymph nodes are clinically very
The prelaryngeal and pretracheal nodes lie deep to the
important because of their wide area of drainage. They
investing fascia, the prelaryngeal nodes on the
are very commonly enlarged. The nodes lie beneath the
cricothyroid membrane, and the pretracheal in front of
deep cervical fascia on the surface of the submandibular
salivary gland. They drain: the trachea below the isthmus of the thyroid gland.
a. Centre of the forehead. They drain the larynx, the trachea and the isthmus of
the thyroid. They also receive afferents from the anterior
b. Nose with the frontal, maxillary and ethmoidal
air sinuses. cervical nodes. Their efferents pass to the nearby deep
cervical nodes.
c. The inner canthus of the eye.
d. The upper lip and the anterior part of the cheek Paratracheal Nodes
with the underlying gum and teeth.
The paratracheal nodes lie on the sides of the trachea
e. The outer part of the lower lip with the lower
and oesophagus along the recurrent laryngeal nerves.
gums and teeth excluding the incisors.
They receive lymph from the oesophagus, the trachea
f. The anterior two-thirds of the tongue excluding
and the larynx, and pass it onto the deep cervical nodes.
the tip, and the floor of the mouth. They also
receive efferents from the submental lymph nodes. Retropharyngeal Nodes
The efferents from the submandibular nodes pass
The retropharyngeal nodes (Fig. 8.4) lie in front of the
mostly to the jugulo-omohyoid node and partly to
prevertebral fascia and behind the buccopharyngeal
the jugulodigastric node. These nodes are situated
along the internal jugular vein and are members of fascia covering the posterior wall of the pharynx. They
the deep cervical chain (Fig. 8.31). extend laterally in front of the lateral mass of the atlas
and along the lateral border of the longus capitis. They
Upper Lateral Nodes around Internal Jugular Vein drain the pharynx, the auditory tube, the soft palate,
The jugulodigastric node (Fig. 8.29) is a member of this the posterior part of the hard palate, and the nose. Their
group. It lies below the posterior belly of digastric, efferents pass to the upper lateral group of deep cervical
between the angle of the mandible and anterior border nodes (Fig. 8.4).
of the sternocleidomastoid, in the triangle bounded by
Waldeyer’s Ring
the posterior belly of digastric, the facial vein and the
internal jugular vein. It is the main node draining the The ring comprises lingual, palatine, tubal and
tonsil. nasopharyngeal tonsils (see Fig. 14.13).
Middle Lateral Nodes around Internal Jugular Vein MAIN LYMPH TRUNKS AT THE ROOT OF THE NECK
These drain thyroid and parathyroid glands. They 1 The thoracic duct is the largest lymph trunk of the
receive efferents from prelaryngeal, pretracheal and body. It begins in the abdomen from the upper end
Head and Neck

paratracheal lymph nodes. of the cisterna chyli enters the thorax through aortic
opening, traverses the thorax, and ends on the left
Lower Lateral Nodes around Internal Jugular Vein side of the root of the neck by opening into the angle
The jugulo-omohyoid node is a group of nodes. It lies just of junction between the left internal jugular vein and
above the intermediate tendon of the omohyoid, under the left subclavian vein (Fig. 8.25). Before its termina-
cover of the posterior border of the sternocleido- tion, it forms an arch at the level of the transverse
mastoid. It is the main lymph node of the tongue. process of vertebra C7 rising 3 to 4 cm above the
clavicle. The relations of the arch are:
Lymph Nodes in Posterior Triangle Anterior:
The lymph nodes are present around the spinal root of a. Left common carotid artery
accessory nerve. b. Vagus
Efferents of the deep cervical lymph nodes join c. Internal jugular vein.
together to form the jugular lymph trunks, one on each
side. The left jugular trunk opens into the thoracic duct. Posterior:
The right trunk may open either into the right lymphatic a. Vertebral artery and vein
duct, or directly into the angle of junction between the b. Sympathetic trunk
internal jugular and subclavian veins. c. Thyrocervical trunk and its branches
HEAD AND NECK
176
d. Prevertebral fascia
• Painful enlargement of the submandibular lymph
e. Phrenic nerve
nodes is common because infections in tongue,
f. Scalenus anterior.
mouth and cheek are quite common. These nodes
Apart from its tributaries in the abdomen and thorax, may be affected by tubercular bacteria.
the thoracic duct receives (in the neck): • Spinal root of accessory nerve may get entangled
a. The left jugular trunk in the enlarged lymph nodes situated in the
b. The left subclavian trunk posterior triangle of neck. While taking biopsy of
c. The left bronchomediastinal trunk. the lymph node, one must be careful not to injure
It drains most of the body, except for the right upper the accessory nerve lest trapezius gets damaged
limb, the right halves of the head, the neck and the (see Fig. 3.9).
thorax and the superior surface of the liver. The left supraclavicular nodes are called
2 The right jugular trunk drains half of the head and neck. Virchow’s lymph nodes. Cancer from stomach and
3 The right subclavian trunk drains the upper limb. testis may metastasize into these lymph nodes,
4 The bronchomediastinal trunk drains the lung, half of which may become palpable.
the mediastinum and parts of the anterior walls of
the thorax and abdomen. Common causes of lymph node enlargement
5 On the right side, the subclavian, jugular and a. Local causes: Acute infection, chronic infection,
bronchomediastinal trunks unite to form the right malignancy of any part of the body.
lymph trunk which ends in a manner similar to the b. General causes: Tuberculosis, secondary syphilis,
thoracic duct (Fig. 8.25). Hodgkin’s disease, lymphatic leukaemia.
CLINICAL ANATOMY STYLOID APPARATUS

• The deep cervical lymph nodes lie on the internal The styloid process with its attached structures is called
jugular vein. These nodes often become adherent the styloid apparatus. The structures attached to the
to the vein in malignancy or in tuberculosis. process are three muscles and two ligaments. The
Therefore, during operation on such patients, the muscles are the stylohyoid, styloglossus and stylo-
vein is also resected. These are examined from pharyngeus and ligaments are the stylohyoid and
behind with the neck slightly flexed. stylomandibular (Figs 8.33a and b).
• Superficial cervical, supraclavicular and lymph The apparatus is of diverse origin. The styloid
nodes of anterior triangle can easily be palpated process, the stylohyoid ligament and stylohyoid muscle
(Fig. 8.32). are derived from the second branchial arch; the
• Chronic infection of the palatine tonsil causes stylopharyngeus from the third arch; the styloglossus
enlargement of jugulodigastric lymph nodes from occipital myotomes; and the stylomandibular
which adhere to the internal jugular vein. ligament from a part of the deep fascia of neck.
The five attachments resemble the reins of a chariot. Two
Head and Neck
of these reins (ligaments) are nonadjustable, whereas

the other three (muscles) are adjustable and are
controlled each by a separate cranial nerve—seventh,
ninth and twelfth nerves.
The styloid process is a long, slender and pointed bony
process projecting downwards, forwards and slightly
medially from the temporal bone. It descends between
the external and internal carotid arteries to reach the
side of the pharynx. It is interposed between the parotid
gland laterally and the internal jugular vein medially.
The styloglossus muscle arises from the anterior
surface of the styloid process and is inserted into the
side of the tongue.
The stylopharyngeus muscle arises from the medial
surface of the base of the styloid process and is inserted
on the posterior border of the lamina of the thyroid
Fig. 8.32: Palpation of the lymph nodes
cartilage (see Fig. 14.23).
177
Figs 8.33a and b: The styloid apparatus: (a) Superior view; (b) Lateral view
Stylohyoid extends between posterior surface of Relation to recurrent laryngeal nerve (Fig. 8.34).
styloid process and hyoid bone. It splits at its lower end Recurrent laryngeal is given off from vagi in relation
to enclose the intermediate tendon of digastric muscle. to distal part of 6th arch artery. Since this distal part
The stylomandibular ligament is attached laterally to forms ligamentum arteriosum on left side only, the re-
styloid process above and angle of mandible below. current laryngeal nerve hooks around this ligamentum
The stylohyoid ligament extends from the tip of the in thorax to reach tracheo-oesophageal groove.
styloid process to the lesser cornua of the hyoid bone. On the right side, there is no ligamentum arteriosum,
the recurrent laryngeal nerve slips upwards in the neck
Features and hooks around the right subclavian artery to reach
1 External carotid artery crosses tip of styloid process the tracheo-oesophageal groove.
superficially and pierces stylomandibular ligament.
2 Facial nerve crosses the base of styloid process
laterally after it emerges from stylomastoid foramen.
DEVELOPMENT OF THE ARTERIES

Brachoicephalic : Right aortic sac
artery
Right subclavian : Proximal part from the right
artery 4th aortic arch artery and
Head and Neck

remaining part from right 7th
cervical intersegmental artery.
Left subclavian : Only left 7th cervical interseg-
artery mental artery.
Common carotid : Third aortic arch proximal to
external carotid bud.
Internal carotid : Third aortic arch, distal
artery to the external carotid bud and Fig. 8.34: Relation to recurrent laryngeal nerve
original dorsal aorta cranial to
the attachment of third aortic
Mnemonics
arch.
External carotid : Develop as sprout from the Tributaries of Internal Jugular Vein
artery third aortic arch.
Pulmonary trunk : Part of truncus arteriosus. “Medical Schools Let Confident People In”
Arch of aorta : Left aortic sac From inferior to superior:
: Left 4th aortic arch Middle thyorid
: Left dorsal aorta.
HEAD AND NECK
178
Superior thyroid CLINICOANATOMICAL PROBLEM

Lingual A 40-year-old woman complained of a swelling in
Common facial front of her neck, nervousness and loss of weight.
Pharyngeal Her diagnosis was hyperthyroidism. Partial
Inferior petrosal sinus thyroidectomy was performed, and she complained
of hoarseness after the operation.
• Why does thyroid swelling move up and down
FACTS TO REMEMBER during deglutition?
• Isthmus of thyroid gland acts as a shield for trachea. • Why does she complain of hoarseness after the
• Parathyroid glands lie along the anastomotic operation?
channel between posterior branch of superior • Which other gland can be removed with thyroid?
thyroid artery and ascending branch of inferior Ans: The thyroid gland is suspended from cricoid
thyroid artery. cartilage by the pretracheal fascia and ligament of
• Internal carotid artery comprises 4 parts: Cervical, Berry. So all the swellings associated with thyroid
petrous, cavernous and cerebral. gland move with deglutition.
• Superior cervical ganglion gives grey rami She complains of hoarseness. It may be due to injury
communicantes (grc) to C1–C4 nerves. to the recurrent laryngeal nerve as it lies close to the
• Middle cervical ganglion gives grc to C5, C6 nerves. inferior thyroid artery near the lower pole of the gland.
• Inferior cervical ganglion gives grc to C7, C8 nerves. The parathyroid gland lying on the back of thyroid
• Scalenus anterior can press upon the subclavian gland may be removed. Parathyroid controls calcium
artery and brachial plexus, causing nervous and level in the blood.
vascular changes in upper limb.
• Phrenic nerve (C4) supplies motor fibres to
musculature of diaphragm. It carries sensory fibres FURTHER READING
from peritoneum underlying diaphragm, media- • Mohebati A, Shaha AR. Anatomy of thyroid and parathyroid
stinal pleura and pericardium. glands and neurovascular relations. Clin Anat 2012;25:19–
• Styloid apparatus comprises styloglossus (XII), 31.
A review of the pertinent anatomy and embryology of the thyroid
stylohyoid (VII), stylopharyngeus muscles (IX);
and parathyroid glands and the critical structures that lie in their
and stylohyoid and stylomandibular ligaments.
proximity.
1–12
Head and Neck
1. Describe thyroid gland under the following headings: 3. Write short notes on/enumerate:
a. Position a. Styloid apparatus
b. Gross anatomy b. Branches of subclavian artery
c. Blood supply
c. Branches of superior cervical ganglion
d. Clinical anatomy
2. Enumerate the various group of lymph nodes in d. Horner’s syndrome
the neck. Mention the areas drained by these nodes. e. Tributaries of internal jugular vein
179
1. Where should the superior thyroid artery be ligated c. Costocervical trunk

during thyroidectomy? d. Subscapular
a. Close to its origin from external carotid artery 6. One of the following symptoms is not seen in
b. Close to the upper pole of the lateral lobe Horner’s syndrome:
c. Anterior and posterior branches separately a. Complete ptosis b. Miosis
d. Anywhere in its course c. Anhydrosis d. Enophthalmos
2. Where should inferior thyroid artery be ligated 7. One of the following statements about parathyroid
during thyroidectomy? gland is not true:
a. Away from the gland a. Inferior parathyroid arises from 3rd pharyngeal
b. At its distal or terminal part pouch
c. Anywhere in its course b. Parathyroid glands are supplied by superior
thyroid artery
d. The branches ligated separately
c. Superior parathyroid arises from 4th pharyngeal
3. Horner’s syndrome produces all symptoms, except:
pouch
a. Partial ptosis b. Miosis
d. Thymus develops along with inferior para-
c. Anhydrosis d. Exophthalmos thyroid gland
4. Which of the following muscles is not supplied by 8. Which one is not a branch of thyrocervical trunk?
ansa cervicalis? a. Inferior thyroid
a. Sternohyoid b. Suprascapular
b. Sternothyroid c. Transverse cervical
c. Inferior belly of omohyoid d. Deep cervical
d. Geniohyoid 9. Which one is not a component of carotid sheath?
5. One of the following is not a branch of subclavian a. Internal carotid artery
artery: b. Vagus nerve
a. Internal thoracic c. Sympathetic trunk
b. Vertebral d. Internal jugular vein
1. b 2. a 3. d 4. d 5. d 6. a 7. b 8. d 9. c
Head and Neck

• What does the word ‘thyroid’ mean? • Name the branches of 1st part of subclavian artery.
• Where does the thyroid venous plexus lie in relation • Name the branches of thyrocervical trunk.
to its capsules? • How many cervical sympathetic ganglia are there?
• Where is superior thyroid artery ligated during Name the branches of superior cervical ganglion.
thyroidectomy and why? • Name the branches of inferior cervical ganglion.
• Why is inferior thyroid artery not ligated during • What are the features of Horner’s syndrome?
thyroidectomy and which of its branches are ligated? • Which are the superficial group of cervical lymph
• How many veins drain the thyroid gland? nodes?
• How does thyroid gland develop? • Name the lymph nodes forming Waldeyer’s ring.
• Which artery is the guide to location of the • What are the structures attached to the styloid
parathyroid glands? process? Give the nerve supply of these muscles.
• What are the types of cells present in histological • What are the areas innervated by phrenic nerve
slide of parathyroid gland? branches?
• Name the functions of thymus gland. • Name the developmental components of arch of an
• Why is “parathyroid III” called the inferior para- aorta.
thyroid gland? • Enumerate the muscles supplied by ansa cervicalis
• Name the branches of arch of aorta. and its roots.
9 Prevertebral and
Paravertebral Regions
I profess to learn and to teach anatomy not from books but from dissections,
not from the tenets of philosophers but from the fabric of nature .
—William Harvey
INTRODUCTION VERTEBRAL ARTERY

The prevertebral region contains four muscles, vertebral Features
artery and joints of the neck. Vertebral artery, a branch
The vertebral artery is one of the two principal arteries
of subclavian artery, comprises four parts—1st, 2nd and
which supply the brain. In addition, it also supplies
3rd are in the neck and the fourth part passes through
the spinal cord, the meninges, and the surrounding
the foramen magnum to reach the subarachnoid space
muscles and bones. It arises from the posterosuperior
and the vertebral arteries of two sides unite to form a
aspect of the first part of the subclavian artery near its
single median basilar artery which gives branches to
commencement. It runs a long course, and ends in the
supply a part of cerebral cortex, cerebellum, internal
cranial cavity by supplying the brain (Fig. 9.2). The
ear and pons. Congenital or acquired diseases of cervical
artery is divided into four parts.
vertebrae or their joints give rise to lots of symptoms
related to branches of vertebral artery. First Part
The apical ligament of dens is a continuation of The first part extends from the origin of the artery (from
notochord. Transverse ligament, which is a part of the subclavian artery) to the transverse process of the
cruciate ligament, keeps the dens of axis in position. If sixth cervical vertebra.
this ligament is injured by disease or in ‘capital This part of the artery runs upwards and backwards
punishment’, there is immediate death due to injury to in the triangular space between the scalenus anterior and
vasomotor centres in medulla oblongata. Trachea and the longus colli muscles called the scalenovertebral
oesophagus are contents of prevertebral region. triangle (Fig. 9.3).
The paravertebral region contains three scalene
muscles, cervical plexus, its branches including the Relations
phrenic nerve. This region also includes the cervical Anterior
pleura. 1 Carotid sheath with common carotid artery
2 Vertebral vein
PREVERTEBRAL MUSCLES
(Anterior Vertebral Muscles)
The four prevertebral or anterior vertebral muscles are DISSECTION
the longus colli (cervicis), the longus capitis, the rectus Remove the scalenus anterior muscle. Identify deeply
capitis anterior and the rectus capitis lateralis (Figs 9.1a placed anterior and posterior intertransverse muscles.
and b). These are weak flexors of the head and neck. Cut through the anterior intertransverse muscles to
They extend from the base of the skull to the superior expose the second part of vertebral artery. First part
mediastinum. They partially cover the anterior aspect was seen as the branch arising from the first part of the
of the vertebral column. They are covered anteriorly subclavian artery. Its third part was seen in the
by the thick prevertebral fascia. The muscles are suboccipital triangle. The fourth part lies in the cranial
cavity.
described in Table 9.1.
180
PREVERTEBRAL AND PARAVERTEBRAL REGIONS
181
Figs 9.1a and b: The prevertebral muscles
Table 9.1: The prevertebral muscles

Muscle Origin Insertion Nerve supply Actions
1. Longus colli a. The upper oblique part is a. Upper oblique part is Ventral rami of a. Flexes the neck
(cervicis) from the anterior tubercles into the anterior nerves C3–C8 b. Oblique parts flex
This muscle extends of the transverse tubercle of the atlas the neck laterally
from the atlas to the processes of cervical b. Lower oblique part is c. Lower oblique part
third thoracic vertebra. vertebrae 3, 4, 5 into the anterior rotates the neck to
It has upper and b. Lower oblique part is from tubercles of the the opposite side
lower oblique parts bodies of upper 2–3 transverse processes
and a middle vertical thoracic vertebrae of 5th and 6th cervical
part (Fig. 9.1) c. Middle vertical part is from vertebrae
bodies of upper 3 thoracic c. Middle vertical part is
and lower 3 cervical into bodies of 2,3,4
vertebrae cervical vertebrae
Head and Neck

2. Longus capitis Anterior tubercles of Inferior surface of basilar Ventral rami of Flexes the head
It overlaps the longus transverse processes part of occipital bone nerves C1–C3
colli. It is thick above of cervical 3–6 vertebrae
and narrow below
3. Rectus capitis anterior Anterior surface of lateral Basilar part of Ventral ramus Flexes the head
This is a very short mass of atlas in front of the the occipital bone of nerve C1
and flat muscle. It lies occipital condyle
deep to the longus
capitis
4. Rectus capitis lateralis Upper surface of transverse Inferior surface of jugular Ventral rami of Flexes the head
This is a short, process of atlas process of the occipital nerves C1, C2 laterally
flat muscle bone
3 Inferior thyroid artery 2 Stellate ganglion

4 Thoracic duct on left side (Fig. 9.5). 3 Ventral rami of nerves C7, C8.
Posterior Scalenovertebral Triangle

1 Transverse process of 7th cervical vertebra (Fig. 9.2) The triangle is present at the root of the neck.
HEAD AND NECK
182
Boundaries
Medial: Lower oblique part of longus colli
Lateral: Scalenus anterior
Apex: Transverse process of C6 vertebra
Base: 1st part of subclavian artery
Posterior wall: Transverse process of C7, ventral ramus
of C8 nerve, neck of 1st rib and cupola of pleurae
Contents: First part of vertebral artery, cervical part
of sympathetic trunk (Fig. 9.12).
Second Part
The second part runs through the foramina trans-
versaria of the upper six cervical vertebrae. Its course
is vertically up to the axis vertebra. It then runs upwards
and laterally to reach the foramen transversarium of
the atlas vertebra.
Relations
1 The ventral rami of second to sixth cervical nerves
lie posterior to the vertebral artery.
2 The artery is accompanied by a venous plexus and a
large branch from the stellate ganglion (see Fig. 8.28).
Third Part
Fig. 9.2: Scheme showing parts of the vertebral artery, as seen Third part lies in the suboccipital triangle. Emerging
from the front from the foramen transversarium of the atlas, the artery
Head and Neck
Figs 9.3a and b: (a) Schematic sagittal section through the left scalenus anterior to show its relations; (b) Development of vertebral
artery
183
winds medially around the posterior aspect of the Second part: From postcostal anastomosis.
lateral mass of the atlas. It runs medially lying on the Third part: From spinal branch of the first cervical
posterior arch of this bone, and enters the vertebral intersegmental artery.
canal by passing deep to the lower arched margin of
the posterior atlanto-occipital membrane. Fourth part: From preneural branch of first cervical
intersegmental artery.
Relations
TRACHEA
Anterior: Lateral mass of atlas.
The trachea is a non-collapsible, wide tube, forming the
Posterior: Semispinalis capitis.
beginning of the lower respiratory passages. It is kept
Lateral: Rectus capitis lateralis. patent because of the presence of C-shaped carti-
Medial: Ventral ramus of the first cervical nerve. laginous ‘rings’ in its wall. The cartilages are deficient
posteriorly, this part of the wall-being made up of
Inferior:
muscle (trachealis) and fibrous tissue. The soft posterior
1 Dorsal ramus of the first cervical nerve (see Fig. 10.6) wall allows expansion of the oesophagus during
2 The posterior arch of the atlas (see Fig. 10.6). passage of food.
Fourth Part
Dimensions
1 The fourth part extends from the posterior atlanto-
The trachea (Latin rough air vessel) is about 10 to 15 cm
occipital membrane to the lower border of the pons.
long. Its upper half lies in the neck and its lower half in
2 In the vertebral canal, it pierces the dura and the
the superior mediastinum. The external diameter
arachnoid, and ascends in front of the roots of the
measures 2 cm in the male and 1.5 cm in the female.
hypoglossal nerve. As it ascends, it gradually
The lumen is smaller in the living than in cadavers. It
inclines medially to reach the front of the medulla.
is about 3 mm at 1 year of age, and corresponds to the
At the lower border of the pons, it unites with its
age in years during childhood, with a maximum of
fellow of the opposite side to form the basilar artery
12 mm at puberty.
(Fig. 9.2).
Cervical Part of Trachea
Branches of Vertebral Artery
1 The trachea begins at the lower border of the cricoid
First part has no branches.
cartilage opposite the lower border of vertebra C6.
Cervical Branches It runs downwards and slightly backwards in front
of the oesophagus, follows the curvature of the spine,
1 Spinal branches from the second part enter the
and enters the thorax in the median plane.
vertebral canal through the intervertebral foramina
and supply the spinal cord, the meninges and the 2 In the neck, the trachea is comparatively superficial
vertebrae. and has the following relations.
2 Muscular branches arise from the third part and Anterior
supply the suboccipital muscles.
Head and Neck

1 Isthmus of the thyroid gland covering the second
Cranial Branches and third tracheal rings (see Fig. 8.1).
These arise from the fourth part. They are: 2 Inferior thyroid veins below the isthmus (see Fig. 8.8).
1 Meningeal branches 3 Pretracheal fascia enclosing the thyroid and the
2 The posterior spinal artery inferior thyroid veins.
3 The anterior spinal artery 4 Sternohyoid and sternothyroid muscles (see Fig. 8.4).
4 The posterior inferior cerebellar artery 5 Investing layer of the deep cervical fascia and the
suprasternal space.
5 Medullary arteries
6 The skin and superficial fascia.
These are described in Chapter 11, BD Chaurasia’s
Human Anatomy, Volume 4. 7 In children, the left brachiocephalic vein extends into
the neck and then lies in front of the trachea.
DEVELOPMENT OF VERTEBRAL ARTERY Posterior
Different parts of vertebral artery develop in the 1 Oesophagus
following ways. 2 Longus colli
First part: From a branch of dorsal division of 7th 3 Recurrent laryngeal nerve in the tracheo-oesophageal
cervical intersegmental artery. groove (see Fig. 8.5).
HEAD AND NECK
184
On Each Side cervical lymph nodes. The oesophagus is narrowest at

1 The corresponding lobe of the thyroid glands. its junction with the pharynx, the junction being the
2 The common carotid artery within the carotid sheath narrowest part of the gastrointestinal tract, except for
(see Fig. 8.4). the vermiform appendix.
For thoracic part of oesophagus study, see Chapter 20,
Vessels and Nerves BD Chaurasia’s Human Anatomy, Volume 1.
The trachea is supplied by branches from the inferior
thyroid arteries. Its veins drain into the left brachio- CLINICAL ANATOMY
cephalic vein. Lymphatics drain into the pretracheal
Oesophagus has four natural constrictions. While
and paratracheal nodes.
passing any instrument, one must be careful at these
Parasympathetic nerves (from the vagus through the sites (Fig. 9.4).
recurrent laryngeal nerve) are sensory and secretomotor
to the mucous membrane, and motor to the trachealis
muscle. Sympathetic nerves (from the cervical ganglion)
are vasomotor.
CLINICAL ANATOMY
• The trachea may be compressed by pathological

enlargements of the thyroid, the thymus, lymph
nodes and the aortic arch. This causes dyspnoea,
irritative cough, and often a husky voice.
• Tracheostomy is an emergency operation done in
cases of laryngeal obstruction (foreign body,
diphtheria, carcinoma, etc.). It is commonly done
in the retrothyroid region after retracting the
isthmus of the thyroid gland.
OESOPHAGUS
The oesophagus is a muscular food passage lying
between the trachea and the vertebral column.
Normally, its anterior and posterior walls are in contact.
The oesophagus expands during the passage of food
by pressing into the posterior muscular part of the
trachea (see Fig. 8.4).
The oesophagus is a downward continuation of the
Head and Neck
Fig. 9.4: Natural constrictions of the oesophagus

pharynx and begins at the lower border of the cricoid
cartilage, opposite the lower border of the body of
vertebra C6. It passes downwards behind the trachea, JOINTS OF THE NECK
traverses the superior and posterior mediastina of the
thorax, and ends by opening into the cardiac end of Typical Cervical Joints between
the stomach in the abdomen. It is about 25 cm long. the Lower Six Cervical Vertebrae
The cervical part of the oesophagus is related: The bodies of cervical vertebra are united by
a. Anteriorly, to the trachea and to the right and left intervertebral disc. On each side of the disc are small
recurrent laryngeal nerves. synovial joints (Fig. 9.5a) called joints of Luschka or
b. Posteriorly, to the longus colli muscle and the uncovertebral joints. The adjacent vertebrae are
vertebral column. connected by several ligaments which are as follows.
c. On each side, to the corresponding (see Fig. 8.5) lobe 1. The anterior longitudinal ligament passes from the
of the thyroid gland; and on the left side, to the anterior surface of the body of one vertebra to
thoracic duct. another. Its upper end reaches the basilar part of the
The cervical part of the oesophagus is supplied by occipital bone (Fig. 9.5b).
the inferior thyroid arteries. Its veins drain into the left 2. The posterior longitudinal ligament is present on the
brachiocephalic vein. Its lymphatics pass to the deep posterior surface of the vertebral bodies within the
185
Figs 9.5a to d: (a) Joints between vertebral bodies as seen from front; (b) Side view showing the ligaments; (c) Anterior view of the
ligamentum flava; (d) Median section through the foramen magnum and upper two cervical vertebrae showing the ligaments in this
region
vertebral canal. Its upper end reaches the body of Joints between Atlas, Axis and Occipital Bone
the axis vertebra beyond which it continues as the 1 The atlanto-occipital and the atlantoaxial joints are
membrana tectoria (Fig. 9.5b). designed to permit free movements of the head on
3. The intertransverse ligaments connect adjacent trans- the neck (vertebral column).
verse processes. 2 The axis vertebra and the occipital bone are
4. The interspinous ligaments connect adjacent spines. connected together by very strong ligaments.
5. The supraspinous ligaments connect the tips of the Between these two bones, the atlas is held like a
spines of vertebrae from the seventh cervical to the washer. The axis of movement between the atlas and
skull is transverse, permitting flexion and extension
Head and Neck

sacrum. In the cervical region, they are replaced by
the ligamentum nuchae. (nodding), whereas the axis of movement between
the axis and the atlas is vertical, permitting rotation
6. Joint between vertebral arches: Joint between superior
of the head (Fig. 9.5d).
and inferior articular processes of adjacent vertebrae
is plane joint of synovial variety. The articular processes Competency achievement: The student should be able to:
slope inferiorly to allow rotation of neck. These are
AN 43.1 Describe and demonstrate the movements with muscles
also called zygapophyseal/facet joints (Fig. 9.10). producing the movements of atlanto-occipital joint and atlantoaxial
7. The laminae of adjacent vertebrae are united by joint.1
ligamentum flava, made up of elastic fibres. It ends
at C2 level (Fig. 9.5c). Atlanto-occipital Joints
The ligamentum nuchae is triangular in shape. Its apex Types and Articular Surfaces
lies at the seventh cervical spine and its base at the
external occipital crest. Its anterior border is attached These are synovial joints of the ellipsoid variety.
to cervical spines, while the posterior border is free Above: The convex occipital condyles (Fig. 9.6).
and provides attachment to the investing layer of Below: The superior articular facets of the atlas vertebra.
deep cervical fascia. The ligament gives origin to the These are concave. The articular surfaces are elongated,
splenius, rhomboids and trapezius muscles. and are directed forwards and medially.
HEAD AND NECK
186
Fig. 9.6: Posterior view of the ligaments connecting the axis with the occipital bone
Ligaments 3 Lateral bending is produced by the rectus capitis

1 The fibrous capsule (capsular ligament) surrounds the lateralis, the semispinalis capitis, the splenius capitis,
joint. It is thick posterolaterally and thin antero- the sternocleidomastoid, and the trapezius (Fig. 9.7).
medially.
Atlantoaxial Joints
2 The anterior atlanto-occipital membrane extends from
the anterior margin of the foramen magnum above, Types and Articular Surfaces
to the upper border of the anterior arch of the atlas These joints comprise:
below (Fig. 9.5). Laterally, it is continuous with the 1 A pair of lateral atlantoaxial joints between the
anterior part of the capsular ligament, and anteriorly, inferior facets of the atlas and the superior facets of
it is strengthened by the cord-like anterior longitu- the axis. These are plane joints.
dinal ligament. 2 A median atlantoaxial joint between the dens
3 The posterior atlanto-occipital membrane extends from (odontoid process) and the anterior arch and between
the posterior margin of the foramen magnum above, dens and transverse ligament of the atlas. It is a pivot
to the upper border of the posterior arch of the atlas joint. The joint has two separate synovial cavities—
below. Inferolaterally, it has a free margin which anterior and posterior (Figs 9.5 and 9.6).
arches over the vertebral artery and the first cervical
nerve (see Fig. 10.5). Laterally, it is continuous with Ligaments
Head and Neck
the posterior part of the capsular ligament. The lateral atlantoaxial joints are supported by:
Arterial and Nerve Supply a. A capsular ligament all around.
The joint is supplied by the vertebral artery and by the b. The lateral part of the anterior longitudinal
first cervical nerve. ligament.
c. The ligamentum flavum.
Movements
The median atlantoaxial joint is strengthened by the
Since these are ellipsoid joints, they permit movements following.
around two axes. Flexion and extension (nodding) a. The anterior smaller part of the joint between the
occur around a transverse axis. Slight lateral flexion is anterior arch of the atlas and the dens is surroun-
permitted around an anteroposterior axis. ded by a loose capsular ligament (Fig. 9.5).
1 Flexion is brought about by the longus capitis and b. The posterior larger part of the joint between the
the rectus capitis anterior. dens and transverse ligament (often called a bursa)
2 Extension is done by the rectus capitis posterior major is often continuous with one of the atlanto-
and minor, the obliquus capitis superior, the semi- occipital joints. Its main support is the transverse
spinalis capitis, the splenius capitis, and the upper ligament which forms a part of the cruciform
part of the trapezius. ligament of the atlas (Fig. 9.6).
187
Ligaments Connecting Axis with Occipital Bone

These ligaments are the membrana tectoria, the cruciate
ligament, the apical ligament of the dens and the alar
ligaments. They support both the atlanto-occipital and
atlantoaxial joints.
1 The membrana tectoria is an upward continuation of
the posterior longitudinal ligament. It lies posterior
to the transverse ligament. It is attached inferiorly
to the posterior surface of the body of the axis and
superiorly to the basiocciput (within the foramen
magnum) (Fig. 9.5d).
2 Cruciate ligament (see transverse ligament).
3 The apical ligament of the dens extends from the apex of
the dens to the basiocciput inferior to the attachment
of the cruciate ligament. It is the continuation of the
notochord (Fig. 9.5d).
4 The alar ligament, one on each side, extends from the
upper part of the lateral surface of the dens to the medial
surface of the occipital condyles. These are strong
ligaments which limit the rotation and flexion of the
head. They are relaxed during extension (Fig. 9.6).
CLINICAL ANATOMY
• Death in execution by hanging is due to

dislocation of the dens following rupture of the
transverse ligament of the dens, which then
crushes the spinal cord and medulla. However,
hanging can also cause fracture through the axis,
or separation of the axis from the third cervical
vertebra (Fig. 9.8).
• Cervical spondylosis: Injury or degenerative changes
of old age may rupture the thin lateral parts of
Figs 9.7a to c: Various movements of the neck the annulus fibrosus (of the intervertebral disc)
resulting in prolapse of the nucleus pulposus. This
The transverse ligament (Fig. 9.6) is attached on each
side to the medial surface of the lateral mass of the atlas.
Head and Neck

In the median plane, its fibres are prolonged upwards
to the basiocciput and downwards to the body of the
axis, thus forming the cruciform ligament of the atlas
vertebra. The transverse ligament embraces the narrow
neck of the dens, and prevents its dislocation.
Movements
Movements at all three joints are rotatory and take place
around a vertical axis. The dens forms a pivot around
which the atlas rotates (carrying the skull with it). The
movement is limited by the alar ligaments (Figs 9.6 and
9.7a–c).
The rotatory movements are brought about by the
obliquus capitis inferior, the rectus capitis posterior
major and the splenius capitis of one side (see Fig. 10.5),
acting with the sternocleidomastoid of the opposite Fig. 9.8: Fracture of the dens during hanging
side.
HEAD AND NECK
188
Fig. 9.9: Posterior intervertebral disc prolapse Fig. 9.10: Spondylitis
is known as disc prolapse or spondylosis and may

scalenus posterior the smallest, of three. These muscles
be lateral or median (Fig. 9.9). Although, it is
extend from the transverse processes of cervical
commonest in the lumbar region, it may occur in
vertebrae to the first two ribs. They can, therefore, either
the lower cervical region. This causes shooting
elevate these ribs or bend the cervical part of the
pain along the distribution of the cervical nerve
vertebral column laterally (Fig. 9.11).
pressed. A direct posterior prolapse may compress
These muscles are described in Table 9.2.
the spinal cord.
• Cervical vertebrae may be fractured, or dislocated Additional Features of the Scalene Muscles
by a fall on the head with acute flexion of the neck.
1 Sometimes a fourth, rudimentary scalene muscle, the
In the cervical region, the vertebrae can dislocate
scalenus minimus is present. It arises from the anterior
without any fracture of the articular processes due
border of the transverse process of vertebra C7 and
to their horizontal position.
is inserted into the inner border of the first rib behind
• Pithing of frog takes place when the cruciate
the groove for the subclavian artery and into the
Head and Neck
ligament of median atlantoaxial joint ruptures,

dome of the cervical pleura. The suprapleural
crushing the vital centres in medulla oblongata,
membrane is regarded as the expansion of this muscle.
resulting in immediate death. This occurs in
Contraction of the scalenus minimus pulls the dome
judicial hanging as well.
of the cervical pleura.
• The degenerative changes or spondylitis may
2 Relations of scalenus anterior. The scalenus anterior is
occur in the cervical spine, leading to narrowed
a key muscle of the lower part of the neck because of
intervertebral foramen, causing pressure on the
spinal nerves (Fig. 9.10).
DISSECTION
Clean and define the cervical parts of the trachea and
PARAVERTEBRAL REGION oesophagus.
Scalenus anterior has been seen in relation to
SCALENE MUSCLES subclavian artery. Scalenus medius is one of the muscle
Features forming floor of posterior triangle of neck. Scalenus
There are usually three scalene muscles, the scalenus posterior lies deep to the medius (Fig. 9.3).
anterior, the scalenus medius and the scalenus The relations of the cervical pleura are shown in
posterior. The scalenus medius is the largest, and the Fig. 9.11.
189
Fig. 9.11: Lateral view of the scalene muscles with a few related structures
Table 9.2: The scalene muscles

1. Scalenus anterior Anterior tubercles of Scalene tubercle and Ventral rami of a. Anterolateral flexion of
(Fig. 9.11) transverse processes adjoining ridge on the nerves C4–C6 cervical spine
of cervical vertebrae superior surface of the b. Rotates cervical spine to
3 to 6 first rib (between opposite side
subclavian artery c. Elevates the first rib
and vein) during inspiration
d. Stabilises the neck along
with other muscles
2. Scalenus medius a. Posterior tubercles of Superior surface of the Ventral rami of a. Lateral flexion of the
(Fig. 9.3) transverse processes first rib behind the groove nerves C3–C8 cervical spine.
of cervical vertebrae for the subclavian b. Elevation of first rib
3 to 7 artery c. Stabilises neck along
b. Transverse process of with other muscles
axis and sometimes
Head and Neck

also of the atlas vertebra
3. Scalenus Posterior tubercles of Outer surface of the Ventral rami of a. Lateral flexion of cervical
posterior transverse processes of second rib behind the nerves C6–C8 spine
(Fig. 9.3) cervical vertebrae tubercle for the serratus b. Elevation of the second
4 to 6 anterior rib
c. Stabilises neck along with
other muscles
its intimate relations to many important structures Posterior

in this region. It is a useful surgical landmark. a. Brachial plexus (Fig. 9.11)
b. Subclavian artery
Anterior c. Scalenus medius
a. Phrenic nerve covered by prevertebral fascia d. Cervical pleura covered by the suprapleural
b. Lateral part of carotid sheath containing the membrane (Fig. 9.13)
internal jugular vein The medial border of the muscle is related:
c. Sternocleidomastoid (Fig. 9.11) a. In its lower part to an inverted V-shaped interval,
d. Clavicle formed by the diverging borders of the scalenus
HEAD AND NECK
190
anterior and the longus colli. This interval Relations

contains many important structures as follows: Anterior
i. Vertebral vessels running vertically from the 1 Subclavian artery and its branches
base to the apex of this space. 2 Scalenus anterior (Fig. 9.13).
ii. Inferior thyroid artery arching medially at the
level of the 6th cervical transverse process. Posterior
iii. Sympathetic trunk. Neck of the first rib and the following structures in front
iv. The first part of the subclavian artery traverses of it.
the lower part of the gap. 1 Sympathetic trunk
v. On the left side, the thoracic duct arches 2 First posterior intercostal vein (Fig. 9.13)
laterally at the level of the seventh cervical 3 Superior intercostal artery
transverse process (Fig. 9.12). 4 The first thoracic nerve
vi. The carotid sheath covers all the structures
mentioned above. Lateral
vii. The sternocleidomastoid covers the carotid 1 Scalenus medius
sheath (see Fig. 8.4). 2 Lower trunk of the brachial plexus
b. In its upper part, the scalenus anterior is separated
from the longus capitis by the ascending cervical Medial
artery. 1 Vertebral bodies
The lateral border of the muscle is related to the 2 Oesophagus (Fig. 9.13)
trunks of the brachial plexus and the subclavian artery 3 Trachea
which emerges at this border and enter the posterior 4 Left recurrent laryngeal nerve
triangle (Fig. 9.11). 5 Thoracic duct (on left side)
6 Large arteries and veins of the neck
CERVICAL PLEURA
CERVICAL PLEXUS
The cervical pleura covers the apex of the lung. It rises
into the root of the neck, about 5 cm above the first Formation
costal cartilage and 2.5 cm above the medial one-third The cervical plexus is formed by the ventral rami of
of the clavicle. The pleural dome is strengthened on its the upper four cervical nerves (Fig. 9.14). The rami
outer surface by the suprapleural membrane, so that emerge between the anterior and posterior tubercles of
the root of the neck is not puffed up and down during the cervical transverse processes, grooving the
respiration (see Chapter 12, BD Chaurasia’s Human costotransverse bars. The four roots are connected with
Anatomy, Volume 1). one another to form three loops (Fig. 9.15).
Head and Neck
Fig. 9.12: Structures present in the triangular interval between scalenus anterior and the longus colli, i.e. scalenovertebral triangle
191
Fig. 9.13: Relations of the cervical pleura
Head and Neck

Fig. 9.14: Scheme to show the position of a cervical nerve relative to the muscles of the region
Position and Relations of the Plexus 4 Supraclavicular (C3, C4)

The plexus is related: These are described in Chapter 3.
1 Posteriorly, to the muscles which arise from the
posterior tubercles of the transverse processes, i.e. Deep Branches
the levator scapulae and the scalenus medius. Communicating branches
2 Anteriorly, to the prevertebral fascia, the internal 1 Grey rami pass from the superior cervical ganglion
jugular vein and the sternocleidomastoid. to the roots of C1–C4 nerves.
2 A branch from C1 joins the hypoglossal nerve and
Branches
carries fibres for supply of the thyrohyoid and
Superficial (Cutaneous) Branches geniohyoid muscles (directly) and the superior belly
1 Lesser occipital (C2) of the omohyoid through the ansa cervicalis.
2 Great auricular (C2, C3) 3 A branch each from C2, C3 to the sternocleidomastoid
3 Transverse (anterior) cutaneous nerve of the neck and branches from C3 and C4 to the trapezius com-
(C2, C3) municate with the accessory nerve.
HEAD AND NECK
192
Fig. 9.15: Right cervical plexus and its branches
Muscular branches cervical nerves. The contribution from C5 may come

Muscles supplied solely by cervical plexus: directly from the root or indirectly through the nerve
1 Rectus capitis anterior from C1. to the subclavius. In the latter case, the contribution is
2 Rectus capitis lateralis from C1, C2. known as the accessory phrenic nerve.
3 Longus capitis from C1 to C3.
4 Lower root of ansa cervicalis (descendens cervicalis) Course and Relations in the Neck
from C2, C3 (to sternohyoid, sternothyroid and 1 The nerve is formed at the lateral border of the
inferior belly of omohyoid). scalenus anterior, opposite the middle of the
Muscles supplied by cervical plexus along with the sternocleidomastoid, at the level of the upper border
brachial plexus or the spinal accessory nerve: of the thyroid cartilage.
a. Sternocleidomastoid from C2 to C3 along with 2 It runs vertically downwards on the anterior surface
accessory nerve (Fig. 9.8). of the scalenus anterior (Fig. 9.16). Since the muscle
Head and Neck
b. Trapezius from C3 to C4 along with accessory nerve. is oblique, the nerve appears to cross it obliquely
c. Levator scapulae from C3 to C5 (dorsal scapular from lateral to medial border. In this part of its
nerve). course, the nerve is related anteriorly to the prever-
d. The diaphragm from phrenic nerve from C3 to C5. tebral fascia, the inferior belly of the omohyoid, the
e. Longus colli from C3 to C8. transverse cervical artery, the suprascapular artery,
f. Scalenus medius from C3 to C8. the internal jugular vein, the sternocleidomastoid,
g. Scalenus anterior from C4 to C6. and the thoracic duct on left side (Fig. 9.12).
h. Scalenus posterior from C6 to C8. 3 After leaving the anterior surface of scalenus
anterior, the nerve runs downwards on the cervical
PHRENIC NERVE pleura behind the commencement of the bra-
This is a mixed nerve carrying motor fibres to the dia- chiocephalic vein. Here it crosses the internal thoracic
phragm and sensory fibres from the diaphragm, pleura, artery (either anteriorly or posteriorly) from lateral
pericardium, and part of the peritoneum (Fig. 9.15). to medial side, and enters the thorax behind the first
costal cartilage. On the left side, the nerve leaves
Origin (crosses) the medial margin of the scalenus anterior
Phrenic nerve arises chiefly from the fourth cervical at a higher level and crosses in front of the first part
nerve but receives contributions from third and fifth of the subclavian artery.
193
Fig. 9.16: Formation, course and distribution of phrenic nerve
CLINICAL ANATOMY CLINICOANATOMICAL PROBLEMS
The accessory phrenic nerve is commonly a branch Case 1

from the nerve to the subclavius. It lies lateral to the A person is to be hanged till death for his most
phrenic nerve and descends behind, or sometimes unusual and rare crime.
in front of the subclavian vein. It joins the main nerve • What anatomical changes occur during this
usually near the first rib, but occasionally the union procedure?
may even be below the root of the lung. • Name the ligaments of median atlantoaxial joint.
Ans: Death in execution by hanging is due to
Head and Neck

dislocation of the dens of the axis vertebra following
FACTS TO REMEMBER rupture of the transverse ligament of the dens. Dens
• Vertebral artery comprises 4 parts: all of a sudden is pushed backwards with great force,
a. First part in neck crushing the lowest part of medulla oblongata which
b. Second part in forearm transversaria of C6 to houses the vasomotor centres
C1 vertebrae The ligaments of atlantoaxial joint are:
c. Third part on the posterior arch of atlas. • Transverse ligament of dens
d. Fourth part through foramen magnum in the • Upper part of vertical band
cranial cavity. • Lower part of vertical band
• Apical ligament is a remnant of notochord. These three parts form cruciform ligament of the
• Median atlantoaxial joint is a pivot type of joint, atlas vertebra.
permitting movement of ‘No’ There are two joint cavities. The anterior one
• Atlanto-occipital joint is an ellipsoid joint between the posterior surface of anterior arch of atlas
permitting movement of ‘Yes’. and dens. It is surrounded by loose capsular ligament.
• Transverse ligament of atlas is part of the cruciate The posterior, larger one is between the dens and
ligament. It keeps the dens of axis in position. the transverse ligament of the dens (Fig. 9.5).
HEAD AND NECK
194
Case 2 goes to inferior group of deep cervical lymph

A man aged 55 years complained of dysphagia in nodes. These had metastasized to the lymph node at
eating solid and even soft food and liquids. There the anterior border of sternocleidomastoid muscle.
was a large lymph node felt at the anterior border of Since trachea lies just anterior to oesophagus, the
sternocleidomastoid muscle. The diagnosis on biopsy cancer can spread to trachea or any of the principal
was cancer of cervical part of oesophagus. bronchi. It may even of cause narrowing of trachea
• How was the large lymph node formed? or bronchi.
• Why did the patient have dysphagia?
• Where can the cancer spread around oesophagus? FURTHER READING
Ans: The pain during eating or drinking is due to • Bogduk N, Windsor M, Inglis A. The innervation of the
cancer of the oesophagus. The cancer obliterates cervical intervertebral discs. Spine 1988;13:2–8.
increasing part of the lumen, giving rise to pain. The A description of the cervical senuvertebral nerves, which have an
lymphatic drainage of cervical part of oesophagus upward course in the vertebral canal, supplying the lateral aspects
of the disc at their level of entry and the disc.
1
1. Describe median atlantoaxial joint. Name 3. Write short notes on/enumerate:

the movements which occur here with their a. Ligaments connecting axis to the skull
muscles. b. Cruciate ligament
2. Describe atlanto-occipital joint briefly. c. Parts of vertebral artery
Head and Neck
1. How many synovial cavities are there in median c. Ligamentum nuchae

atlantoaxial joint? d. Posterior longitudinal
a. One b. Three 4. Where is the intervertebral disc absent?
c. Two d. Four a. Between first and second cervical vertebrae
2. Which of the following ligaments is the upward b. Between thoracic twelve and first lumbar
continuation of membrana tectoria? vertebrae
a. Posterior longitudinal c. Between thoracic one and cervical seven vertebrae
b. Ligamentum nuchae d. Between lumbar five and first sacral vertebrae
5. Which of the following joints do not have a
c. Ligamentum flava
fibrocartilaginous intra-articular disc?
d. Anterior longitudinal a. Temporomandibular
3. Which ligament mentioned below is chiefly elastic? b. Shoulder
a. Anterior longitudinal c. Sternoclavicular
b. Ligamenta flava d. Inferior radioulnar
195
1. c 2. a 3. b 4. a 5. b
• Name the boundaries and contents of scaleno- • Give the attachment of posterior atlanto-occipital
vertebral triangle. membrane. What structures lie under its free
• Where are the various parts of vertebral artery margin?
placed? • Give the attachments of cruciate ligament of the atlas
• What is the relation of scalenus anterior muscle to vertebra.
the subclavian artery? • What are the attachments of apical ligament of dens
• What structure forms the posterior relation of the and alar ligament?
cervical pleura?
• What is tracheostomy and where is it performed? • What happens during judicial hanging?
• Name the ligaments between occipital bone and axis • What type of joint is median atlantoaxial joint?
vertebra. • What type of joint is atlanto-occipital joint?
Head and Neck

10
Back of the Neck
I bend, but do not break .
—Anonymous
INTRODUCTION
The second layer comprises splenius muscle, levator
The vertebral column at back provides a median axis scapulae, rhomboid major, rhomboid minor, serratus
for the body (see BD Chaurasia’s Human Anatomy, posterior superior and serratus posterior inferior muscles.
Volume 1—Chapter 13; Volume 2—Chapter 15; Volume The splenius is the highest of these muscles.
3—Chapter 1). The joints of neck are described in Levator scapulae forms part of the muscular floor of
Chapter 9. There are big muscles from the sacrum to the the posterior triangle. It is positioned between scalenus
skull in different strata which keep the spine straight. medius below and splenius capitis above. Follow its
The uppermost part of back of neck is the suboccipital nerve and blood supply from dorsal scapular nerve and
region. This region contains the suboccipital triangle deep branch of transverse cervical artery, respectively.
containing the third part of the vertebral artery, which Spinal root of accessory nerve and fibres from C3
enters the skull to supply the brain. If it gets pressed, and C4 to trapezius muscle lie on the levator scapulae.
many symptoms appear. Rhomboid minor and major lie on same plane as
levator scapulae. Both are supplied by dorsal scapular
DISSECTION nerve (C5).
Deep to the two rhomboid muscles is thin aponeurotic
Extend the incision from external occipital protuber- serratus posterior superior muscle from spines of C7
ance (i), to the spine of the seventh cervical vertebra. and T1–T2 vertebrae to be inserted into 2nd–5th ribs.
Give a horizontal incision from spine of 7th cervical Serratus posterior inferior muscle arises from T11 to
vertebra or vertebra prominens (iv), till the acromion T12 spines and thoracolumbar fascia and is inserted
process (v). This will expose the upper part and apex of into 9th–12th ribs.
posterior triangle of neck. Look for the occipital artery at The third layer is composed of erector spinae or
its apex. sacrospinalis with its three subdivisions and semi-
Extend the incision from vertebra prominens to spine spinalis with its three divisions (Figs 10.2a to c).
of lumbar 5 vertebra. Reflect the skin laterally along an Erector spinae arises from the dorsal surface of sacrum
oblique line from spine of T12 (ii), till the deltoid and ascends up the lumbar region. There it divides into
tuberosity (iii) (Fig. 10.1). three subdivisions, the medial one is spinalis—inserted
Close to the median plane in the superficial fascia into the spines, the intermediate one is longissimus—
are seen the greater occipital nerve and occipital artery. inserted into the transverse processes, and the lateral one
Cut through trapezius muscle vertically at a distance is iliocostalis—inserted into the ribs. Each of these divisions
of 2 cm from the median plane. Reflect it laterally and is made of short parts, fresh slips arising from the area
identify the accessory nerve, superficial branch of where the lower slips are inserted (Fig. 10.3).
transverse cervical artery and ventral rami of 3rd and Deep to erector spinae is the semispinalis again
4th cervical nerves (refer to BDC App). made up of three parts: Semispinalis thoracis, semi-
Latissimus dorsi has already been exposed by the spinalis cervicis, and semispinalis capitis.
students dissecting the upper limb. Otherwise extend Both these muscles are innervated by the dorsal rami
the incision from T12 spine till L5 spine. Reflect the of cervical, thoracic, lumbar and sacral nerves.
skin till lateral side of the trunk and define the margins Muscles of fourth layer are the multifidus, rotatores,
of broad thin latissimus dorsi. This muscle and trapezius interspinales, intertransversarii and suboccipital
form the first layer of muscles. muscles (Fig. 10.4).
196
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197
Fig. 10.1: Lines of dissection of back
NERVE SUPPLY OF SKIN better developed and is more elastic in quadrupeds in

The skin of the nape or back of the neck, and of the whom, it has to support a heavy head.
back of the scalp (Fig. 10.2) is supplied by medial
branches of the dorsal rami of C2 the greater occipital Competency achievement: The student should be able to:
nerve; C3 the third occipital nerve. Each posterior primary AN 42.3 Describe the position, direction of fibres, relations, nerve
ramus divides into a medial branch and a lateral branch, supply, actions of semispinalis capitis and splenius capitis.1
both of which supply the intrinsic muscles of the back.
The medial branch in this region supplies the skin as
well. The dorsal ramus of C1 does not divide into medial MUSCLES OF THE BACK
and lateral branches, and is distributed only to the
muscles bounding the suboccipital triangle. The muscles of the entire back can be grouped into the
The ligamentum nuchae is a triangular fibrous sheet following four layers from superficial to the deeper
that separates muscles of the two sides of the neck. It is plane.
Head and Neck
Figs 10.2a to c: Muscles of first and second layers: (a) First layer; (b) and (c) Second layer
HEAD AND NECK
198
Fig. 10.3: Third layer—the erector spinae/sacrospinalis muscle with its three columns
1 Trapezius and latissimus dorsi (Fig. 10.2a), levator Splenius muscles are two in number. These are
Head and Neck
scapulae, rhomboids (two) (Fig. 10.2b) (Tables 10.1 splenius cervicis and splenius capitis. These cover
and 10.2). the deeper muscles like a bandage (Fig. 10.2c).
2 Serratus posterior superior, serratus posterior Origin: From lower half of ligamentum nuchae and
inferior and splenius. These small muscles are spines of upper 6 thoracic vertebrae. These curve in
described briefly here. a half spiral fashion and separate into splenius
Serratus posterior superior cervicis and splenius capitis.
Origin: Ligamentum nuchae, spines of T1–T3 Splenius cervicis gets inserted into the posterior
vertebrae. tubercles of transverse processes of C1–C4 vertebrae.
Insertion: Upper borders of 2nd–5th ribs. Splenius capitis forms the floor of the posterior
Nerve supply: 2nd–5th intercostal nerves triangle and gets inserted into the mastoid process
Action: Elevates 2nd–5th ribs. beneath the sternocleidomastoid muscle (Fig. 10.5).
Serratus posterior inferior It is supplied by dorsal rami of C1–C6 nerves.
Origin: Spines of T11–L2 vertebrae. 3 a. Erector spinae or sacrospinalis is the true muscle of
Insertion: Lower borders of 9th–12th ribs. the back, supplied by posterior rami of the spinal
Nerve supply: 9th–12th intercostal nerves. nerves. It extends from the sacrum to the skull
Action: Depress the lower ribs. (Fig. 10.3).
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199
Fig. 10.4: Third layer—three parts of semispinalis. Fourth layer—the multifidus, levator costarum and intertransversarii muscles
Origin: Mainly from the back of sacrum between Longissimus cervicis—inserted into trans-
Head and Neck

median and lateral sacral crests, from the dorsal verse process of C2–C6 vertebrae.
segment of iliac crest and related ligaments. Longissimus capitis—inserted into mastoid
Soon it splits into three columns: Iliocostalis, process (Fig. 10.3).
longissimus, and spinalis. iii. Spinalis is the medial column, extending
i. Iliocostalis is the lateral column and comprises between lumbar and cervical spines. Its parts
iliocostalis lumborum, iliocostalis thoracis are: Spinalis lumborum, spinalis thoracis, and
and iliocostalis cervicis. spinalis cervicis.
These are short slips and are inserted into b. The other muscle of this layer is semispinalis
angles of the ribs and posterior tubercles of extending between transverse processes and
cervical transverse process. Origin of the spines of the vertebrae. It has three parts:
higher slips is medial to the insertion of the i. Semispinalis thoracis (Fig. 10.4).
lower slips.
ii. Semispinalis cervicis
ii. Longissimus is the middle column and is
composed of: iii. Semispinalis capitis
Longissimus lumborum It only lies in the upper half of vertebral column.
Longissimus thoracis—inserted into transverse Semispinalis capitis is its biggest component. It
processes of thoracic vertebrae. arises from transverse processes of C3–T4
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200
Table 10.1: Attachments of muscles connecting the upper limb to the vertebral column
Muscle Origin Insertion
Trapezius • Medial one-third of superior nuchal line • Upper fibres into the posterior border of
The right and left muscles • External occipital protuberance lateral one-third of clavicle
together form a trapezium that • Ligamentum nuchae • Middle fibres into the medial margin of
covers the upper half of the back • C7 spine the acromion process and upper lip of the
(Fig. 10.2a) • T1–T12 spines crest of spine of the scapula
• Corresponding supraspinous ligaments • Lower fibres on the apex of triangular
area at the medial end of the spine, with
a bursa intervening
Latissimus dorsi • Posterior one-third of the outer lip of The muscle winds round the lower
It covers a large area of iliac crest border of the teres major, and forms the
the lower back, and is • Posterior layer of lumbar fascia; thus posterior fold of the axilla
overlapped by the trapezius attaching the muscle to the lumbar and The tendon is twisted upside down and is
(Fig. 10.2a) sacral spines inserted into floor of the intertubercular
• Spines of T7–T12, lower four ribs sulcus
• Inferior angle of the scapula
Levator scapulae • Transverse processes of C1, C2 Superior angle and upper part of medial
(Fig. 10.2b) • Posterior tubercles of the transverse border (up to triangular area) of the scapula
processes of C3, C4
Rhomboid minor (Fig. 10.2b) • Lower part of ligamentum nuchae Base of the triangular area at the root of the
• Spines C7 and T1 spine of the scapula
Rhomboid major (Fig. 10.2b) • Spines of T2–T5 Medial border of scapula below the root of
• Supraspinous ligaments the spine
Table 10.2: Nerve supply and actions of muscles connecting the upper limb to the vertebral column
Muscle Nerve supply Actions
Trapezius • Spinal part of accessory nerve (XI) • Upper fibres act with levator scapulae, and elevate
• Branches from C3, C4 the scapula, as in shrugging. Upper fibres of both sides
extend the neck
• Middle fibres act with rhomboids, and retract the
scapula
• Upper and lower fibres act with serratus anterior, and
rotate the scapula forwards around the chest wall thus
Head and Neck
playing an important role in abduction of the arm

beyond 90°
• Steadies the scapula
Latissimus dorsi Thoracodorsal nerve (C6–C8) • Adduction, extension, and medial rotation of the
(nerve to latissimus dorsi) shoulder as in swimming, rowing, climbing, pulling,
folding the arm behind the back, and scratching the
opposite scapula
• Helps in violent expiratory effort like coughing, sneezing,
etc.
• Essentially a climbing muscle
• Hold inferior angle of the scapula in place
Levator scapulae • A branch from dorsal scapular nerve (C5) • Helps in elevation of scapula
• Branches from C3, C4 • Steadies the scapula during movements of the arm
Rhomboid minor Dorsal scapular nerve (C5) • Retraction of scapula
Rhomboid major Dorsal scapular nerve (C5) • Retraction of scapula
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201
vertebrae, passes up next to the median plane, and DISSECTION

gets inserted into the medial area between
It is deep triangle in the area between the occiput and
superior and inferior nuchal lines of the occipital
the spine of second cervical (the axis) vertebra. The
bone.
deepest muscles are the muscles of suboccipital
4 Multifidus, rotatores, interspinales, intertransversarii
triangle.
and suboccipital muscles. Multifidus is one of the
Cut the attachments of trapezius from superior nuchal
oblique deep muscles. It arises from mammillary
line and reflect it towards the spine of scapula. Cut the
process of lumbar vertebrae to be inserted into 2–3
splenius capitis from its attachment on the mastoid
higher spinous processes. Rotatores are the deepest
process and reflect it downwards. Clean the superficial
group. These pass from root of transverse process to
fascia over the semispinalis capitis medially and
the root of the spinous process. These are well
longissimus capitis laterally. Reflect longissimus capitis
developed in thoracic region. Interspinales lie
downwards from the mastoid process.
between the adjacent spines of the vertebrae. These
are better developed in cervical and lumbar regions. Cut through semispinalis capitis and turn it towards
Intertransversarii connect the transverse processes lateral side. Define the boundaries and contents of the
of the adjacent vertebrae. suboccipital triangle.
Suboccipital Muscles
SUBOCCIPITAL REGION The suboccipital muscles are described in Table 10.3.
The suboccipital triangle is a muscular space situated
Muscle Layers in Neck (Fig. 10.4) deep in the suboccipital region.
In the suboccipital region between the occiput and the
spine of the axis vertebra, the four muscular layers are
AN 42.2 Describe and demonstrate the boundaries and contents
represented by:
of suboccipital triangle.2
• Trapezius
• Splenius capitis Exposure of Suboccipital Triangle
• Semispinalis capitis and longissimus capitis
In order to expose the triangle, the following layers are
• The four suboccipital muscles.
reflected (Fig. 10.5).
The arteries found in the back of the neck are: 1 The skin is very thick.
a. Occipital 2 The superficial fascia is fibrous and dense. It contains:
b. Deep cervical a. The greater and third occipital nerves.
c. Third part of the vertebral artery b. The terminal part of the occipital artery, with
d. Minute twigs from the second part of the vertebral accompanying veins.
artery. 3 The fibres of the trapezius run downwards and
The suboccipital venous plexus is known for its laterally over the triangle. The sternocleidomastoid
extensive layout and complex connections. overlaps the region laterally.
Head and Neck

Table 10.3: The suboccipital muscles
1. Rectus capitis posterior Spine of axis Lateral part of the Suboccipital nerve 1. Mainly postural
major (Fig. 10.5) area below the or dorsal ramus C1 2. Acting alone, it turns the
inferior nuchal line chin to the same side
3. Acting together, the two
muscles extend the head
2. Rectus capitis posterior Posterior Medial part of the ” 1. Mainly postural
minor (Fig. 10.5) tubercle of atlas area below the inferior 2. Extends the head
nuchal line
3. Obliquus capitis superior Transverse Lateral area between ” 1. Mainly postural
(superior oblique) process of atlas the nuchal lines 2. Extends the head
3. Flexes the head laterally
4. Obliquus capitis inferior Spine of axis Transverse process of ” 1. Mainly postural
(inferior oblique; Fig. 10.5) atlas 2. Turns chin to the same side
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202
4 The splenius capitis runs upwards and laterally for Floor

insertion into the mastoid process deep to the 1 Posterior arch of atlas.
sternocleidomastoid. 2 Posterior atlanto-occipital membrane.
5 The semispinalis capitis runs vertically upwards for
insertion into the medial part of the area between Contents
the superior and inferior nuchal lines. In the same 1 Third part of vertebral artery (Fig. 10.6).
plane laterally, there lies the longissimus capitis 2 Dorsal ramus of nerve C1—suboccipital nerve.
which is inserted into the mastoid process deep to 3 Suboccipital plexus of veins.
the splenius.
Reflection of the semispinalis capitis exposes the Vertebral Artery
suboccipital triangle. It is the first and largest branch of the first part of the
subclavian artery, destined chiefly to supply the brain.
Boundaries Out of its four parts, only the third part appears in the
Superomedially suboccipital triangle (Figs 10.5 and 10.6). This part
Rectus capitis posterior major muscle supplemented by appears at the foramen transversarium of the atlas,
the rectus capitis posterior minor (Fig. 10.5). grooves the atlas, and leaves the triangle by passing
deep to the lateral edge of the posterior atlanto-occipital
Superolaterally membrane. The artery is separated from the posterior
Superior oblique capitis muscle. arch of the atlas by the first cervical nerve and its dorsal
and ventral rami. For complete description of the
Inferiorly vertebral artery, see Chapter 9.
Inferior oblique capitis muscle.
Dorsal Ramus of First Cervical Nerve
Roof It emerges between the posterior arch of the atlas and
Medially the vertebral artery, and soon breaks up into branches
Dense fibrous tissue covered by the semispinalis capitis. which supply the four suboccipital muscles and the
semispinalis capitis. The nerve to the inferior oblique
Laterally gives off a communicating branch to the greater
Longissimus capitis and occasionally the splenius capitis. occipital nerve capitis (Figs 10.5 and 10.6).
Head and Neck
Fig. 10.5: Right suboccipital triangle: Boundaries, floor and contents

BACK OF THE NECK
203
splenius capitis and longissimus capitis. The artery then

crosses the rectus capitis lateralis, the superior oblique
and the semispinalis capitis muscles at the apex of the
posterior triangle. Finally, it pierces the trapezius 2.5 cm
from the midline and comes to lie along the greater
occipital nerve. In the superficial fascia of the scalp, it
has a tortuous course.
Its branches in this region are:
a. Mastoid
b. Meningeal
c. Muscular.
Fig. 10.6: Relationship of the vertebral artery to the atlas vertebra One of the muscular branches is large, it is called the
and to the first cervical nerve, as seen from above descending branch and has superficial and deep branches.
The superficial branch anastomoses with the superficial
Suboccipital Plexus of Veins branch of the transverse cervical artery; while the deep
It lies in and around the suboccipital triangle, and drains branch descends between the semispinalis capitis
the: and cervicis, and anastomoses with the vertebral and
deep cervical arteries. It also gives two branches to
1 Muscular veins
sternocleidomastoid muscle.
2 Occipital veins
3 Internal vertebral venous plexus Deep Cervical Artery
4 Condylar emissary vein.
It is a branch of the costocervical trunk of the subclavian
It itself drains into the deep cervical and vertebral artery. It passes into the back of the neck just above the
plexus of veins. neck of the first rib. It ascends deep to the semispinalis
Other Related Structures capitis and anastomoses with the descending branch of
the occipital artery (see Fig. 8.19).
Greater Occipital Nerve
It is the large medial branch of the dorsal ramus of the
second cervical nerve. It is the thickest cutaneous nerve CLINICAL ANATOMY
in the body. It winds round the middle of the lower
border of the inferior oblique muscle, and runs upwards • Neck rigidity, seen in cases with meningitis, is due
and medially. It crosses the suboccipital triangle and to spasm of the extensor muscles. This is caused
pierces the semispinalis capitis and trapezius muscles by irritation of the nerve roots during their
to ramify on the back of the head reaching up to the passage through the subarachnoid space which is
vertex. It supplies the semispinalis capitis in addition infected. Passive flexion of neck and straight leg
to the scalp (Fig. 10.2c). raising test cause pain as the nerves are stretched
Head and Neck

(Figs 10.7a and b).
Third Occipital Nerve • Cisternal puncture is done when lumbar
It is the slender medial branch of the dorsal ramus puncture fails. The patient either sits up or lies
of the third cervical nerve. After piercing the semi-
spinalis capitis and the trapezius, it ascends medial
to the greater occipital nerve. It supplies the skin to
the back of the neck up to the external occipital pro-
tuberance.
Occipital Artery
It arises from the external carotid artery, opposite the
origin of the facial artery (Figs 10.2 and 10.5). It runs
backwards and upwards deep to the lower border of
the posterior belly of the digastric, crossing the carotid
sheath, and the accessory and hypoglossal nerves. Next
it runs deep to the mastoid process and to the muscles Fig. 10.7a: Passive flexion of neck
attached to it—the sternocleidomastoid, digastric,
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204
FACTS TO REMEMBER
Muscles of the back are disposed in four layers:
• Muscles of 1st and 2nd layers are supplied by
nerves of upper limb except trapezius, splenius
capitis and splenius cervicis.
• Muscles of 3rd and 4th layers are true muscles of
the back, supplied by dorsal primary rami.
• Artery lying on posterior arch of atlas is the third
part of vertebral artery.
• Greater occipital nerve is the thickest cutaneous
nerve of the body.
Fig. 10.7b: Straight leg raising test causes pain in meningitis
A child aged 8 years has been having high grade

down in the left lateral position. A needle is fever with bad throat. On 4th day, he could not
introduced in the midline above the spine of axis move his neck during drinking water or milk as there
in forward and upward direction parallel to an was severe pain in the neck.
imaginary line extending from external acoustic • Why is there pain even in drinking water?
meatus to nasion. It passes through the posterior • How has it become such a serious condition?
atlanto-occipital membrane between the
posterior arch of atlas and the posterior margin Ans: Due to bad throat, the infection from pharynx
of foramen magnum. The needle enters the reached middle ear via pharyngotympanic tube,
cerebellomedullary cistern and small amount of from where it infected the meninges of the brain. This
CSF is withdrawn. is a serious condition and is called meningitis. The
• Neurosurgeons approach the posterior cranial child shows neck rigidity. It is due to spasm of the
fossa through this region. extensor muscles and is caused by irritation of nerve
roots during their passage through subarachnoid
space, which is infected.
Passive flexion of neck and straight leg raising test
Mnemonics result in pain as the nerves are stretched.
“I Love Sunshine” FURTHER READING

From inferior to superior: • Adams MA, Bogduk, Burton K, et al. The Biomechanics of Back
Iliocostalis Pain. 2nd ed. Edinburgh: Elsevier, Churchill Livingstone 2006.
Head and Neck
Longissimus A comprehensive and detailed source of information on the functional

Spinalis anatomy, tissue biology and biomechanics of the lumbar spine.
• Groen GJ, Baljet, Drukker J. Nerves and nerve plexuses of
the human vertebral column. Am J Anat 1990;188:282–96.
An acetylcholinesterase whole-mount study of human fetal
material giving detail of the perivertebral nerve plexuses and of
the sinuvertebral nerves.
1–2
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205
1. Enumerate the boundaries and contents of the sub- 3. Write short notes on:
occiptal triangle. Name the muscles supplied by a. Occipital artery
dorsal ramus of 1st cervical nerve. b. Meningitis
2. Name the various parts of sacrospinalis/erector
spinae muscle.
1. Which action is not done by trapezius muscles? 4. Dorsal ramus of which of the cervical nerves has
a. Protraction of scapula no cutaneous branch?
b. Shrugging of shoulder a. 1st b. 2nd
c. 3rd d. 4th
c. Retraction of scapula
5. Which is the thickest cutaneous nerve of the body?
d. Overhead abduction of scapula
a. Greater occipital
2. Sacrospinalis does not form:
b. Lesser occipital
a. Spinalis b. Longissimus c. Great auricular
c. Iliocostalis d. Splenius d. Third occipital
3. Which part of vertebral artery lies in the sub- 6. Which of the following cervical nerves is known as
occipital triangle? suboccipital nerve?
a. 1st b. 3rd a. 1st b. 2nd
c. 2nd d. 4th c. 3rd d. 4th
1. a 2. d 3. b 4. a 5. a 6. a
• Name the muscles in all 4 layers of the back. • Name the thickest cutaneous nerve of the body.
• What are the parts of erector spinae muscle? • What are the parts of semispinalis muscle? Which
Head and Neck

• What are the boundaries of suboccipital triangle and nerves supply this muscle?
name its contents?
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206
11
Contents of Vertebral Canal
Remember that your patient is a human being like yourself. Your knowledge of anatomy may save his or her life .
—Richard Snell
INTRODUCTION
When the vertebrae are put in a sequence, their
vertebral foramina lie one below the other forming a
continuous canal which is called the vertebral canal. This
canal contains the three meninges with their spaces and
the spinal cord including the cauda equina. The
intervertebral foramina are a pair of foramina between
the pedicles of the adjacent vertebrae. Each foramen
contains dorsal and ventral roots, trunk and dorsal and
ventral primary rami of the spinal nerve, and spinal
vessels.

AN 42.1 Describe the contents of the vertebral canal.1
CONTENTS
The vertebral canal contains the following structures
Fig. 11.1: Schematic transverse section showing the spinal
from without inwards (Fig. 11.1).
meninges
1 Epidural or extradural space
2 Thick dura mater or pachymeninx
Head and Neck
3 Subdural capillary space

laminae of the vertebrae carefully and detach them so
4 Delicate arachnoid mater
5 Wide subarachnoid space containing cerebrospinal that the spinal medulla/spinal cord encased in the
fluid (CSF) meninges becomes visible.
Clean the external surface of dura mater enveloping
6 Firm pia mater. The arachnoid and pia together form
the leptomeninges. the spinal cord by removing fat and epidural plexus of
7 Spinal cord or spinal medulla and the cauda equina. veins. Carefully cut through a small part of the dura
mater by a fine median incision. Extend this incision
The spinal cord is considered along with the brain in
Chapter 3, BD Chaurasia’s Human Anatomy, Volume 4. above and below. See the delicate arachnoid mater.
The other contents are described below. Incise it. Push the spinal cord to one side and try to
identify the ligamentum denticulatum. Define the
DISSECTION attachments of the dorsal and ventral nerve roots on
the surface of spinal cord and their union to form the
Clean the spines and laminae of the entire vertebral trunk of the spinal nerve. Cut the trunk of all spinal
column by removing all the muscles attached to them. nerves on both the sides. Gently pull the spinal cord
Trace the dorsal rami of spinal nerves towards the with cauda equina out from the vertebral canal.
intervertebral foramina. Saw through the spines and
206
CONTENTS OF VERTEBRAL CANAL
207
Epidural Space Arachnoid Mater

Epidural space lies between the spinal dura mater, and Arachnoid mater is a thin, delicate and transparent
the periosteum with ligaments lining the vertebral canal. membrane that loosely invests the entire central
It contains: nervous system (Fig. 11.2). Inferiorly, it extends, like
a. Loose areolar tissue the dura, up to the lower border of the second sacral
b. Semiliquid fat vertebra. It is adherent to the dura only where some
c. Spinal arteries on their way to supply the deeper structures pierce the membrane, and where the
contents ligamentum denticulata are attached to the dura mater.
d. The internal vertebral venous plexus.
The spinal arteries arise from different sources at Subarachnoid Space
different levels; they enter the vertebral canal through Subarachnoid space is a wide space between the pia
the intervertebral foramina, and supply the spinal cord, and the arachnoid, filled with cerebrospinal fluid (CSF).
the spinal nerve roots, the meninges, the periosteum It surrounds the brain and spinal cord like a water
and ligaments. cushion. The spinal subarachnoid space is wider than
Venous blood from the spinal cord drains into the the space around the brain. It is widest below the lower
epidural or internal vertebral plexus. end of the spinal cord where it encloses the cauda
equina. Lumbar puncture is usually done in the lower
Spinal Dura Mater widest part of the space, between third and fourth
Spinal dura mater is a thick, tough fibrous membrane lumbar vertebrae.
which forms a loose sheath around the spinal cord
(Fig. 11.2). It is continuous with the meningeal layer of Spinal Pia Mater
the cerebral dura mater. The spinal dura extends from Spinal pia mater is thicker, firmer, and less vascular than
the foramen magnum to the lower border of the second the cerebral pia, but both are made up of two layers:
sacral vertebra; whereas the spinal cord ends at the a. An outer epi-pia containing larger vessels.
lower border of first lumbar vertebra. The dura gives b. An inner pia-glia or pia-intima which is in contact with
tubular prolongations to the dorsal and ventral nerve nervous tissue.
roots and to the spinal nerves as they pass through the Between the two layers, there are many small blood
intervertebral foramina. vessels and also cleft-like spaces which communicate
Subdural Space with the subarachnoid space. The pia mater closely
invests the spinal cord, and is continued below the spinal
Subdural space is a capillary or potential space between
cord as the filum terminale.
the dura and the arachnoid, containing a thin film of
serous fluid. This space permits movements of the dura Posteriorly, the pia is adherent to the posterior
over the arachnoid. The space is continued for a short median septum of the spinal cord, and is also connected
distance onto the spinal nerves, and is in free to the arachnoid by a fenestrated subarachnoid septum.
communication with the lymph spaces of the nerves. Anteriorly, the pia is folded into the anterior median
fissure of the spinal cord. It thickens at the mouth of
the fissure to form a median, longitudinal glistening
Head and Neck

band, called the linea splendens (Fig. 11.1).
On each side between the ventral and dorsal nerve
roots, the pia forms a narrow vertical ridge, called the
ligamentum denticulatum. This is so-called because it
gives off a series of triangular tooth-like processes
which project from its lateral free border (Fig. 11.3).
Each ligament has 21 processes; the first at the level of
the foramen magnum, and the last between twelfth
thoracic and first lumbar spinal nerves. Each process
passes through the arachnoid to the dura between two
adjacent spinal nerves. The processes suspend the spinal
cord in the middle of the subarachnoid space.
The filum terminale is a delicate, thread-like structure
about 20 cm long. It extends from the apex of the
conus medullaris to the dorsum of the first piece of the
Fig. 11.2: Ligamentum denticulatum and its relationship to the coccyx. It is composed chiefly of pia mater, although
dura mater and to the arachnoid mater a few nerve fibres rudiments of 2nd and 3rd coccygeal
HEAD AND NECK
208
• Lumbar puncture in infant/children: During 2nd

month of life, spinal cord usually reaches L3 level.
Lumbar puncture needle is introduced in flexed
spine between L4 and L5.
• Cisternal puncture: This procedure is rather difficult
and dangerous. Cerebellomedullary cistern is
approached through posterior atlanto-occipital
membrane.
• Lumbar epidural: The epidural space is the space
between vertebral canal and dura mater. The
epidural space is deeper in the midline. The
procedure is same as lumbar puncture, the needle
should reach only in the epidural space and
not deep to it in the dura mater. Epidural space
is utilized for giving anaesthesia or analgesia
(Fig. 11.5).
Fig. 11.3: Ligamentum denticulatum
nerves are found adherent to the upper part of its

outer surface. The central canal of the spinal cord
extends into it for about 5 mm.
The filum terminale is subdivided into a part lying
within the dural sheath called the filum terminale
internum; and a part lying outside the dural sheath,
below the level of the second sacral vertebra called the
filum terminale externum. The filum terminale internum
is 15 cm long, and the externum is 5 cm long.
Pial sheaths surround the nerve roots crossing the
subarachnoid space, and the vessels entering the
substance of the spinal cord.
CLINICAL ANATOMY
Leptomeningitis
• Inflammation due to infection of leptomeninges, Fig. 11.4: Lumbar puncture in an adult
i.e. pia mater and arachnoid mater is known as
Head and Neck
meningitis. This is commonly tubercular or

pyogenic. It is characterized by fever, marked
headache, neck rigidity, often accompanied by
delirium and convulsions, and a changed
biochemistry of CSF. CSF pressure is raised, its
proteins and cell content are increased, and sugars
and chloride are selectively diminished.
• Lumbar puncture in adult: Patient is lying on side
with maximally flexed spine. A line is taken
between highest points of iliac spine at L4 level.
Skin locally anaesthetized, and lumbar puncture
needle with trocar inserted carefully between L3
and L4 spines. Needle courses through skin fat,
supraspinous and interspinous ligaments, liga-
mentum flava, epidural space, dura, arachnoid,
subarachnoid space to release CSF (Fig. 11.4).
Fig. 11.5: Lumbar epidural anaesthesia and spinal block
209
• Caudal epidural: The needle is passed through

sacral hiatus, which lies equidistant from the right
and left posterior superior iliac spines. The needle
passes through posterior sacrococcygeal ligament
and enters the sacral canal. Then the hub of needle
is lowered so that it passes along sacral canal. This
space lies below S2 (Fig. 11.4).
SPINAL NERVES
The spinal cord gives rise to 31 pairs of spinal nerves:
Eight cervical, twelve thoracic, five lumbar, five sacral,
and one coccygeal. Each nerve is attached to the cord
by two roots—ventral motor and dorsal sensory. Each
dorsal nerve root bears a ganglion. The ventral and dorsal
nerve roots unite in the intervertebral foramen to form
the nerve trunk which soon divides into ventral and
dorsal rami (Fig. 11.6).
The uppermost nerve roots pass horizontally from
the spinal cord to reach the intervertebral foramina.
Lower down they have to pass with increasing Fig. 11.6: Formation of spinal nerve
obliquity, as the spinal cord is much shorter than the
vertebral column. Below the termination of the spinal The roots of spinal nerves are surrounded by sheaths
cord at the level of first lumbar vertebra, the obliquity derived from the meninges. The pial and arachnoid
becomes more marked (Fig. 11.7). sheaths extend up to the dura mater. The dural sheath
Below the lower end of the spinal cord, the roots form encloses the terminal parts of the roots, continues over
a bundle known as the cauda equina because of its the nerve trunk, and is lost by merging with the epi-
resemblance to the tail of a horse. neurium of the nerve.
Head and Neck
Fig. 11.7: Nomenclature of spinal nerves

HEAD AND NECK
210
An intervertebral foramen contains:

a. The ends of the nerve roots
b. The dorsal root ganglion
c. The nerve trunk
d. The beginning of the dorsal and ventral rami
e. A spinal artery
f. An intervertebral vein (Fig. 11.1).
CLINICAL ANATOMY
• Compression of the spinal cord by a tumour gives
rise to paraplegia or quadriplegia, depending on
the level of compression.
• Spinal tumours may arise from dura mater—
meningioma, glial cells—glioma, nerve roots—
neurofibroma, ependyma–ependymoma, and other
tissues. Apart from compression of the spinal cord, Fig. 11.8: The vertebral system of veins
the tumour causes obstruction of the subarachnoid
space so that pressure of CSF is low below the level and a prelaminar portion. Each portion is drained
of lesion (Froin’s syndrome). There is yellowish by two vessels. The plexus drains the structures in
discolouration of CSF below the level of the vertebral canal, and is itself drained at regular
obstruction. CSF reveals high level of protein but intervals by segmental veins—vertebral, posterior
the cell content is normal. Queckenstedt’s test does intercostal, lumbar and lateral sacral.
not show a sudden rise and a sudden fall of CSF 2 Plexus within the vertebral bodies: It drains backwards
pressure by coughing or by brief pressure over the into the epidural plexus, and anterolaterally into the
jugular veins. Spinal block can be confirmed either external vertebral plexus.
by myelography, CT scan or MRI scan. 3 External vertebral venous plexus: It consists of anterior
• Compression of the cauda equina gives rise to vessels lying in front of the vertebral bodies, and the
flaccid paraplegia, saddle anaesthesia and posterior vessels on the back of the vertebral arches
sphincter disturbances. This is called the cauda and on adjacent muscles. It is drained by segmental
equina syndrome. veins.
• Compression of roots of spinal nerves may be The suboccipital plexus of veins is a part of the
caused by prolapse of an intervertebral disc, by external plexus. It lies in the suboccipital triangle. It
osteophytes (formed in osteoarthritis), by a receives the occipital veins of the scalp, is connected
cervical rib, or by an extramedullary tumour. Such with the transverse sinus by emissary veins, and drains
compression results in shooting pain along the into the subclavian veins.
distribution of the nerve.
Communications and Implications
Head and Neck
VERTEBRAL SYSTEM OF VEINS Valveless vertebral system of veins communicates:

1 Above with the intracranial venous sinuses.
The vertebral venous plexus assumes importance in 2 Below with the pelvic veins, the portal vein, and the
cases of: caval system of veins.
1 Carcinoma of the prostate causing secondaries in the The veins are valveless and the blood can flow in them
vertebral column and the skull. in either direction. An increase in intrathoracic or intra-
2 Chronic empyema (collection of pus in the pleural abdominal pressure, brought about by coughing and
cavity) causing brain abscess by septic emboli. straining, may cause blood to flow in the plexus away
from the heart, either upwards or downwards. Such
Anatomy of the Vertebral Venous Plexus
periodic changes in venous pressure are clinically
The vertebral venous system is made up of a valveless, important because they make possible the spread of
complicated network of veins with a longitudinal tumours or infections. For example, cells from pelvic,
pattern. It runs parallel to and anastomoses with the abdominal, thoracic and breast tumours may enter the
superior and inferior venae cavae. This network has venous system, and may ultimately lodge in the
three intercommunicating subdivisions (Fig. 11.8). vertebrae, the spinal cord, the skull, or the brain.
1 The epidural plexus: Lies in the vertebral canal outside The common primary sites of tumours causing
the dura mater. The plexus consists of a postcentral secondaries in vertebrae are the breast and the prostate.
211
FACTS TO REMEMBER
A patient suffering from cancer of prostate gland has
• Spinal cord in adult ends at lower border of lumbar developed secondaries in the brain.
one vertebra. • What is the route taken by cancer cells to reach
• Spinal dura mater and arachnoid mater extend till the brain from the prostate gland, a pelvic organ?
second sacral vertebra. Ans: The veins from prostate drain into prostatic
• Spinal pia mater comprises an outer epi-pia and venous plexus which communicates with the pelvic
an inner pia-intima. veins. These veins send small tributaries through
pelvic sacral foramina into the vertebral canal. The
• Ligamenta denticulata of pia mater are two vertical vertebral canal lodges vertebral venous plexus which
ridges with 21 tooth-like processes which suspend continues up the whole height of the vertebral canal
the spinal cord in the subarachnoid space. and drains into segmental veins in abdominal cavity,
The lowest or 21st process lies between T12 and thoracic cavity, in the neck and in basilar venous
L1 spinal nerves. plexus. Thus, cancer cells ‘climb’ up to reach basilar
• Through the vertebral venous plexus, secondaries venous plexus which has connections with cerebral
of prostate or breast can reach up to the cranial veins. These cells travel through the cerebral veins
cavity. to settle in brain resulting in secondaries. This plexus
is valveless and dangerous.
1
1. Write short notes on: c. Filum terminale

a. Cauda equina d. Typical spinal nerve
b. Ligamentum denticulatum e. Caudal anaesthesia
1. Where does main part of vertebral venous plexus c. Pia mater

lie? d. Cauda equina
a. Subdural space 3. Intervertebral foramen contains all, except:
b. Epidural space a. Ends of nerve roots
c. Subarachnoid space b. Nerve trunk
Head and Neck

d. Outside the vertebrae c. Sympathetic ganglion
2. Following are the contents of thoracic part of d. Spinal artery
vertebral canal, except: 4. Subarachnoid space extends till:
a. Dura mater a. S1 vertebra b. S2 vertebra
b. Arachnoid mater c. L1 vertebra d. L3 vertebra
1. b 2. d 3. c 4. b
• Name the supports of the spinal cord. • Name the contents of an intervertebral foramen.
• Where is lumbar puncture done in a child and an • What are the symptoms of ‘cauda equina syndrome’?
adult and why? • Where does spinal cord end in an adult?
• What is ligamentum denticulatum? • Where do arachnoid and dura maters end?
• Name the types of spinal nerves. • Name the parts of vertebral venous plexus.
HEAD AND NECK
212
12
Cranial Cavity
Happiness is when head, heart and hand work in harmony .
—Krishna Garg
INTRODUCTION
Cranial cavity, the highest placed cavity, contains the Removal of skull cap or calvaria
brain, meninges, venous sinuses, all cranial nerves, four Draw a horizontal line across the skull 1 cm above the
petrosal nerves, parts of internal carotid artery and a orbital margins and 1 cm above the inion. Saw through
the skull. Be careful in the temporal region as skull is
part of the vertebral artery besides the special senses.
rather thin there. Separate the inner table of skull from
The anterior branch of middle meningeal artery lies at
the fused endosteum and dura mater.
the pterion and is prone to rupture resulting in extra-
dural haemorrhage. Removal of the brain
To remove the brain and its enveloping meninges, the
CONTENTS OF CRANIAL CAVITY structures leaving or entering the brain through various
foramina of the skull have to be carefully detached/
The convex upper wall of the cranial cavity is called incised. Start from the anterior aspect by detaching falx
the vault. It is uniform and smooth. The base of the cerebri from the crista galli.
cranial cavity is uneven and presents three cranial Put 2–3 blocks under the shoulders so that head
fossae (anterior, middle and posterior) lodging the falls backwards. This will expose the olfactory bulb,
uneven base of the brain. which may be lifted from the underlying anterior cranial
The cranial cavity contains the brain and meninges— fossa. Identify optic nerve, internal carotid artery,
the outer dura mater, the middle arachnoid mater, infundibulum passing towards hypophysis cerebri.
and the inner pia mater. The dura mater is the thickest Divide all three structures. Cut through the oculomotor
of the three meninges. It encloses the cranial venous and trochlear nerves in relation to free margin of
sinuses, and has a distinct blood supply and nerve tentorium cerebelli. Divide the attachment of tentorium
Head and Neck
supply. The dura is separated from the arachnoid by a from the petrous temporal bone.
potential subdural space. The arachnoid is separated Identify and divide trigeminal, abducent, facial, and
from the pia by a wider subarachnoid space filled with vestibulocochlear nerves. Then cut glossopharyngeal,
cerebrospinal fluid (CSF). The arachnoid, pia, sub- vagus, accessory and hypoglossal nerves. All these
arachnoid space and CSF are dealt with the brain; the nerves have to be cut first on one side and then on the
dura is described here. This chapter also includes other side. Lastly identify the two vertebral arteries
hypophysis cerebri, trigeminal ganglion, middle entering the skull through foramen magnum on each
meningeal artery and other structures seen after side of the spinal medulla. With a sharp knife, cut
removal of the brain, e.g. various cranial nerves and through these structures. Thus the whole brain with the
internal carotid artery. meninges can be gently removed from the skull.
Preserve it in 5% formaldehyde.
DISSECTION Cut through the dura mater on the ventral aspect of
brain till the inferolateral borders along the superciliary
Detach the epicranial aponeurosis, if not already done,
margin. Pull upwards the fold of dura mater present
laterally till the inferior temporal line. In the region of
between the adjacent medial surfaces of cerebral
the temple, detach the temporalis muscle with its over-
hemispheres. This will be possible till the occipital lobe
lying fascia and reflect these downwards over the pinna.
212
CRANIAL CAVITY
213
of brain. Pull backwards a similar but much smaller fold Endosteal Layer or Endocranium
between two lobes of cerebellum, i.e. falx cerebelli. 1 The endocranium is continuous:
Separating the cerebrum from the cerebellum is a a. With the periosteum lining the outside of the skull
double fold of dura mater called tentorium cerebelli. Pull or pericranium through the sutures and foramina.
it out in a horizontal plane by giving incision along the b. With the periosteal lining of the orbit through the
petrous temporal bone. superior orbital fissure.
Learn about the folds of dura mater, i.e. falx cerebri, 2 It provides sheaths for the cranial nerves, the sheaths
tentorium cerebelli, falx cerebelli, diaphragma sellae fuse with the epineurium outside the skull. Over the
including trigeminal cave from the specimen with the optic nerve, the dura forms a sheath which becomes
help of base of skull. Make a paper model of these dural continuous with the sclera.
folds for recapitulation (refer to BDC App). 3 Its outer surface is adherent to the inner surface of
the cranial bones by a number of fine fibrous and
vascular processes. The adhesion is most marked at
Competency achievement: The student should be able to: the sutures, on the base of the skull and around the
AN 30.3 Describe and identify dural folds and dural venous foramen magnum.
sinuses.1
Meningeal Layer
At places, the meningeal layer of dura mater is folded
CEREBRAL DURA MATER on itself to form partitions which divide the cranial
cavity into compartments which lodge different parts
The dura mater is the outermost, thickest and toughest of the brain (Fig. 12.1). The folds are:
membrane covering the brain (dura = hard) (mater = • Falx cerebri
mother). • Tentorium cerebelli (Fig. 12.2)
There are two layers of dura: • Falx cerebelli
a. An outer or endosteal layer which serves as an • Diaphragma sellae.
internal periosteum or endosteum or endo-
cranium for the skull bones. Falx Cerebri
b. An inner or meningeal layer which surrounds the The falx cerebri is a large sickle-shaped fold of dura
brain. The meningeal layer is continuous with the mater occupying the median longitudinal fissure
spinal dura mater. between the two cerebral hemispheres (Fig. 12.1). It has
The two layers are fused to each other at all places, two ends:
except where the cranial venous sinuses are enclosed 1 The anterior end is narrow, and is attached to the crista
between them. galli.
Head and Neck
Fig. 12.1: Folds of meningeal layer of dura mater

HEAD AND NECK
214
Figs 12.2a to c: Coronal sections through the posterior cranial fossa showing folds of dura mater and the venous sinuses enclosed
in them: (a) Section through the tentorial notch (anterior part of the fossa); (b) Section through the middle part of the fossa;
(c) Section through the posteriormost part
2 The posterior end is broad, and is attached along the Tentorium Cerebelli
median plane to the upper surface of the tentorium The tentorium cerebelli is a tent-shaped fold of dura
cerebelli. mater, forming the roof of the posterior cranial fossa. It
The falx cerebri has two margins: separates the cerebellum from the occipital lobes of the
1 The upper margin is convex and is attached to the lips cerebrum, and broadly divides the cranial cavity into
of the sagittal sulcus. supratentorial and infratentorial compartments. The
infratentorial compartment is the posterior cranial fossa
2 The lower margin is concave and free.
containing the hindbrain and the lower part of the mid-
The falx cerebri has right and left surfaces each of brain.
which is related to the medial surface of the corres- The tentorium cerebelli has a free margin and an
ponding cerebral hemisphere. attached margin (Fig. 12.3). The anterior free margin is
Three important venous sinuses are present in relation U-shaped and free. The ends of the ‘U’ are attached
to this fold. The superior sagittal sinus lies along the upper anteriorly to the anterior clinoid processes. This margin
margin; the inferior sagittal sinus along the lower margin; bounds the tentorial notch which is occupied by the
and the straight sinus along the line of attachment of midbrain and the anterior part of the superior vermis.
the falx to the tentorium cerebelli (Figs 12.2a–c). The outer or attached margin is convex. Posterolaterally,
Head and Neck
Fig. 12.3: Tentorium cerebelli and diaphragma sellae seen from above
CRANIAL CAVITY
215
The posterior margin is convex and is attached to the

internal occipital crest. It encloses the occipital sinus.
The anterior margin is concave and free.
Diaphragma Sellae
The diaphragma sellae is a small circular, horizontal
fold of dura mater forming the roof of the hypophyseal
fossa.
Anteriorly, it is attached to the tuberculum sellae.
Posteriorly, it is attached to the dorsum sellae. On each
side, it is continuous with the dura mater of the middle
cranial fossa (Fig. 12.5).
The diaphragma has a central aperture through
Fig. 12.4: Parasagittal section through the petrous temporal which the stalk of the hypophysis cerebri passes.
bone and meninges to show the formation of the trigeminal cave
Blood Supply
it is attached to the lips of the transverse sulci on the The outer layer is richly vascular. The inner meningeal
occipital bone, and on the posteroinferior angle of the layer is more fibrous and requires little blood supply.
parietal bone. Anterolaterally, it is attached to the superior 1 The vault or supratentorial space is supplied by the
border of the petrous temporal bone and to the posterior middle meningeal artery.
clinoid processes. Along the attached margin, there are 2 The anterior cranial fossa and the dural lining is
the transverse and superior petrosal venous sinuses. supplied by meningeal branches of the anterior
The trigeminal or Meckel’s cave is a recess of dura ethmoidal, posterior ethmoidal and ophthalmic
mater present in relation to the attached margin of the arteries.
tentorium. It is formed by evagination of the inferior 3 The middle cranial fossa is supplied by the middle
layer of the tentorium over the trigeminal impression meningeal, accessory meningeal, and internal carotid
on the petrous temporal bone. It contains the trigeminal arteries; and by meningeal branches of the ascending
ganglion (Fig. 12.4). pharyngeal artery.
The free and attached margins of the tentorium 4 The posterior cranial fossa is supplied by meningeal
cerebelli cross each other near the apex of the petrous branches of the vertebral, occipital and ascending
temporal bone. Anterior to the point of crossing, there pharyngeal arteries.
is a triangular area which forms the posterior part of
the roof of the cavernous sinus, and is pierced by the Nerve Supply
third and fourth cranial nerves. 1 The dura of the vault has only a few sensory nerves
The tentorium cerebelli has two surfaces—superior and which are derived mostly from the ophthalmic
inferior. The superior surface is convex and slopes to either division of the trigeminal nerve.
Head and Neck

side from the median plane. The falx cerebri is attached
to this surface, in the midline; the straight sinus lies along
the line of this attachment. The superior surface is related
to the occipital lobes of the cerebrum. The inferior surface
is concave and fits the convex superior surface of the
cerebellum. The falx cerebelli is attached to its posterior
part (Fig. 12.2c).
Falx Cerebelli
The falx cerebelli is a small sickle-shaped fold of dura
mater projecting forwards into the posterior cerebellar
notch (Fig. 12.2c).
The base of the sickle is attached to the posterior part
of the inferior surface of the tentorium cerebelli in the
median plane. The apex of the sickle is frequently
divided into two parts which are lost on the sides of Fig. 12.5: Diaphragma sellae as seen in a sagittal section
the foramen magnum. through the hypophyseal fossa
HEAD AND NECK
216
2 The dura of the floor has a rich nerve supply and is There is no muscle in their walls. They have no valves.
quite sensitive to pain. Venous sinuses receive venous blood from the brain,
a. The anterior cranial fossa is supplied mostly by the the meninges, and bones of the skull. Cerebrospinal
anterior ethmoidal nerve and partly by the fluid is poured into some of them.
maxillary nerve. Cranial venous sinuses communicate with veins
b. The middle cranial fossa is supplied by the maxillary outside the skull through emissary veins. These
nerve in its anterior half, and by branches of the communications help to keep the pressure of blood in
mandibular nerve and from the trigeminal the sinuses constant (see Table 1.1).
ganglion in its posterior half. There are 23 venous sinuses, of which 8 are paired
c. The posterior cranial fossa is supplied chiefly by and 7 are unpaired.
recurrent branches from first, second and third
cervical spinal nerves and partly by meningeal Paired Venous Sinuses
branches of the ninth and tenth cranial nerves. There is one sinus each on right and left side.
1 Cavernous sinus
2 Superior petrosal sinus (Fig. 12.4)
AN 30.4 Describe clinical importance of dural venous sinuses.2
3 Inferior petrosal sinus
4 Transverse sinus (Fig. 12.2)
CLINICAL ANATOMY
5 Sigmoid sinus
• Pain-sensitive intracranial structures are: 6 Sphenoparietal sinus
a. The large cranial venous sinuses and their 7 Petrosquamous sinus
tributaries from the surface of the brain 8 Middle meningeal sinus/veins
b. Dural arteries
c. The dural floor of the anterior and posterior Unpaired Venous Sinuses
cranial fossae These are median in position
d. Arteries at the base of the brain. 1 Superior sagittal sinus (Fig. 12.2)
• Headache may be caused by: 2 Inferior sagittal sinus
a. Dilatation of intracranial arteries 3 Straight sinus (Fig. 12.3)
b. Dilatation of extracranial arteries
4 Occipital sinus
c. Traction or distension of intracranial pain-
sensitive structures 5 Anterior intercavernous sinus
d. Infection and inflammation of intracranial and 6 Posterior intercavernous sinus
extracranial structures supplied by the sensory, 7 Basilar plexus of veins
cranial and cervical nerves.
• Extradural and subdural haemorrhages both are Cavernous Sinus
common. An extradural haemorrhage can be Each cavernous sinus is a large venous space situated
distinguished from a subdural haemorrhage in the middle cranial fossa, on either side of the body
because of the following differences. of the sphenoid bone. Its interior is divided into a number
Head and Neck
a. The extradural haemorrhage is arterial due to of spaces or caverns by trabeculae. The trabeculae are much
injury to middle meningeal artery, whereas less conspicuous in the living than in the dead (Fig. 12.6).
subdural haemorrhage is venous in nature. The floor and medial wall of the sinus is formed by
b. Symptoms of cerebral compression are late in the endosteal dura mater. The lateral wall, and roof are
extradural haemorrhage. formed by the meningeal dura mater.
c. In an extradural haemorrhage, paralysis first Anteriorly, the sinus extends up to the medial end of
appears in the face and then spreads to the the superior orbital fissure and posteriorly, up to the apex
lower parts of the body. In a subdural haemo- of the petrous temporal bone. It is about 2 cm long, and
rrhage, the progress of paralysis is haphazard. 1 cm wide (see Fig. 1.18).
d. In an extradural haemorrhage, there is no blood
in the CSF, while it is a common feature of sub- DISSECTION
dural haemorrhage. Define the cavernous sinuses situated on each side of
the body of the sphenoid bone. Cut through it between
VENOUS SINUSES OF DURA MATER the anterior and posterior ends and locate its contents.
Define its connections with the other venous sinuses
These are venous spaces, the walls of which are formed by
and veins (refer to BDC App).
dura mater. They have an inner lining of endothelium.
CRANIAL CAVITY
217
Fig. 12.6: Coronal section through the middle cranial fossa showing the relations of the cavernous sinus
Relations 2 Abducent nerve, inferolateral to the internal carotid

Structures outside the sinus artery.
1 Superiorly: Optic tract, optic chiasma, olfactory tract, The structures in the lateral wall and on the medial
internal carotid artery and anterior perforated aspect of the sinus are separated from blood by the
substance (see Fig. 4.1 of BD Chaurasia’s Human endothelial lining.
Anatomy, Volume 4).
Tributaries or Incoming Channels
2 Inferiorly: Foramen lacerum and the junction of the body
and greater wing of the sphenoid bone (see Fig. 1.18). From the orbit
3 Medially: Hypophysis cerebri and sphenoidal air 1 The superior ophthalmic vein.
sinus (Fig. 12.6). 2 A branch of the inferior ophthalmic vein or some-
4 Laterally: Temporal lobe with uncus. times the vein itself.
5 Below laterally: Mandibular nerve 3 The central vein of the retina may drain either into
6 Anteriorly: Superior orbital fissure and the apex of the superior ophthalmic vein or into the cavernous
the orbit. sinus (Fig. 12.7).
7 Posteriorly: Apex of the petrous temporal and the crus
cerebri of the midbrain. From the brain
1 Superficial middle cerebral vein.
Structures within the lateral wall of the sinus, from above 2 Inferior cerebral veins from the temporal lobe
downwards (Fig. 12.8).
1 Oculomotor nerve: In the anterior part of the sinus, it
From the meninges
Head and Neck

divides into superior and inferior divisions which leave
the sinus by passing through the superior orbital fissure. 1 Sphenoparietal sinus.
2 Trochlear nerve: In the anterior part of the sinus, it 2 The frontal trunk of the middle meningeal vein may
crosses superficial to the oculomotor nerve, and drain either into the pterygoid plexus through the
enters the orbit through the superior orbital fissure. foramen ovale or into the sphenoparietal or
3 Ophthalmic nerve: In the anterior part of the sinus, it cavernous sinus.
divides into the lacrimal, frontal and nasociliary Draining Channels or Communications
nerves (see Figs 13.4 and 13.6).
The cavernous sinus drains:
4 Maxillary nerve: It leaves the sinus by passing through
the foramen rotundum on its way to the ptery- 1 Into the transverse sinus through the superior
gopalatine fossa. petrosal sinus.
5 Trigeminal ganglion: The ganglion and its dural cave 2 Into the internal jugular vein through the inferior
may project into the posterior part of the lateral wall petrosal sinus and through a plexus around the
of the sinus (Fig. 12.4). internal carotid artery.
3 Into the pterygoid plexus of veins through the
Structures passing through the medial aspect of the sinus emissary veins passing through the foramen ovale,
1 Internal carotid artery with the venous and sympathetic the foramen lacerum and the emissary sphenoidal
plexus around it. foramen (Table 12.1).
HEAD AND NECK
218
Fig. 12.7: Side view of the tributaries and communications of the cavernous sinus. Arrows show the direction of blood flow
Head and Neck
Fig. 12.8: Superior view of the tributaries and communications of the cavernous sinus. Arrows show the direction of blood flow
4 Into the facial vein through the superior ophthalmic 2 Gravity

vein. 3 Position of the head
5 The right and left cavernous sinuses communicate
with each other through the anterior and posterior
intercavernous sinuses and through the basilar CLINICAL ANATOMY
plexus of veins (Fig. 12.8). • Thrombosis of the cavernous sinus may be caused
All these communications are valveless, and blood by sepsis in the dangerous area of the face, in nasal
can flow through them in either direction. cavities, and in paranasal air sinuses. This gives
Factors Helping Expulsion rise to the following symptoms.
of Blood from the Sinus a. Nervous symptoms:
– Severe pain in the eye and forehead in the
1 Expansile pulsations of the internal carotid artery
area of distribution of ophthalmic nerve.
within the sinus
CRANIAL CAVITY
219
– Involvement of the third, fourth and sixth veins of the frontal sinus, and occasionally with the
cranial nerves resulting in paralysis of the veins of the nose, through the foramen caecum. As the
muscles supplied. sinus runs upwards and backwards, it becomes
progressively larger in size. It is triangular on cross-
b. Venous symptoms: Marked oedema of eyelids, section. It ends near the internal occipital protuberance
cornea and root of the nose, with exophthalmos by turning to one side, usually the right, and becomes
due to congestion of the orbital veins. continuous with the right transverse sinus (Fig. 12.9).
• A communication between the cavernous sinus It generally communicates with the opposite sinus. The
and the internal carotid artery may be produced junction of all these sinuses is called the confluence of
by head injury. When this happens the eyeball pro- sinuses.
trudes and pulsates with each heart beat. It is
The interior of the sinus shows:
called the pulsating exophthalmos.
a. Openings of the superior cerebral veins.
b. Openings of venous lacunae, usually three on each
Superior Sagittal Sinus side.
The superior sagittal sinus occupies the upper convex, c. Arachnoid villi and granulations projecting into
attached margin of the falx cerebri (Figs 12.9 and 12.10). the lacunae as well as into the sinus (Fig. 12.10).
It begins anteriorly at the crista galli by the union of d. Numerous fibrous bands crossing the inferior
tiny meningeal veins. Here it communicates with the angle of the sinus.
Fig. 12.9: Scheme to show the lateral view of the intracranial venous sinuses. Arrows show the direction of blood flow
Head and Neck
Fig. 12.10: Coronal section through superior sagittal sinus showing arrangement of the meninges, the arachnoid villi and granulations,
and the various (emissary, diploic, meningeal and cerebral) veins in its relation
HEAD AND NECK
220
Tributaries internal occipital protuberance by continuing as the

The superior sagittal sinus receives following tributaries. transverse sinus usually left (Fig. 12.9). In addition to
the veins forming it, also receives a few of the superior
a. Superior cerebral veins which never open into the
cerebellar veins.
venous lacunae (Fig. 12.10).
At the termination of the great cerebral vein into the
b. Parietal emissary veins (Table 12.1). sinus, there exists a ball valve mechanism, formed by a
c. Venous lacunae, usually three on each side which sinusoidal plexus of blood vessels, which regulates the
first, receive the diploic and meningeal veins, and secretion of CSF.
then open into the sinus.
d. Occasionally, a vein from the nose opens into the Transverse Sinuses
sinus when the foramen caecum is patent. The transverse sinuses are large sinuses (Fig. 12.8). The
right sinus usually larger than the left, is situated in
CLINICAL ANATOMY
the posterior part of the attached margin of the
tentorium cerebelli. The right transverse sinus is usually
Thrombosis of the superior sagittal sinus may be caused a continuation of the superior sagittal sinus, and the
by spread of infection from the nose, scalp and left sinus a continuation of the straight sinus. Each sinus
diploe. This gives rise to: extends from the internal occipital protuberance to the
a. A considerable rise in intracranial tension due to posteroinferior angle of the parietal bone at the base of
defective absorption of CSF. mastoid process where it bends downwards and
b. Delirium and sometimes convulsions due to becomes the sigmoid sinus. Its tributaries are:
congestion of the superior cerebral veins. 1 Superior petrosal sinus
c. Paraplegia of the upper motor neuron type due 2 Inferior cerebral veins
to bilateral involvement of the paracentral lobules 3 Inferior cerebellar veins
of cerebrum where the lower limbs and perineum 4 Diploic (posterior temporal) vein
are represented. 5 Inferior anastomotic vein.
Sigmoid Sinuses
Inferior Sagittal Sinus
Each sinus, right or left, is the direct continuation of the
The inferior sagittal sinus, a small channel, lies in the transverse sinus (Fig. 12.9). It is S-shaped, hence the
posterior two-thirds of the lower, concave free margin name. It extends from the posteroinferior angle of the
of the falx cerebri. It ends by joining the great cerebral parietal bone to the posterior part of the jugular foramen
vein to form the straight sinus (Fig. 12.9). where it becomes the superior bulb of the internal
Straight Sinus jugular vein. It grooves the mastoid part of the temporal
The straight sinus lies in the median plane within the bone, where it is separated anteriorly from the mastoid
junction of falx cerebri and the tentorium cerebelli. It is antrum and mastoid air cells by only a thin plate of bone. Its
formed anteriorly by the union of the inferior sagittal tributaries are:
sinus with the great cerebral vein, and ends at the 1 The mastoid and condylar emissary veins
2 Cerebellar veins
Head and Neck
3 The internal auditory vein.

Table 12.1: Emissary veins: Valveless and communicate
intracranial with extracranial veins
CLINICAL ANATOMY
Sinus Connection Veins
Superior sagittal Parietal emissary vein Veins of scalp, • Thrombosis of the sigmoid sinus is always secondary
sinus Foramen caecum nasal veins to infection in the middle ear or otitis media, or in
Middle meningeal vein Pterygoid veins the mastoid process called mastoiditis.
Transverse sinus Petrosquamous External jugular • During operations on the mastoid process, one
Sigmoid sinus Mastoid vein Posterior auricular should be careful about the sigmoid sinus, so that
Hypoglossal vein IJV it is not exposed.
Posterior condylar Suboccipital vein • Spread of infection or thrombosis from the sigmoid
vein and transverse sinuses to the superior sagittal sinus
Cavernous sinus Emissary veins Pterygoid veins may cause impaired CSF drainage into the latter
Veins around ICA IJV and may, therefore, lead to the development of
Ophthalmic vein Facial vein hydrocephalus. Such a hydrocephalus associated
Inferior petrosal IJV with sinus thrombosis following ear infection is
known as otitic hydrocephalus.
ICA: Internal carotid artery; IJV: Internal jugular vein
CRANIAL CAVITY
221
Other Sinuses DISSECTION

The occipital sinus is small, and lies in the attached Identify diaphragma sellae over the hypophyseal fossa.
margin of the falx cerebelli. It begins near the foramen Incise it radially and locate the hypophysis cerebri
magnum and ends in the confluence of sinuses lodged in its fossa. Take it out and examine it in detail
(Figs 12.2 and 12.8). with the hand lens (Figs 12.11 and 12.12).
The sphenoparietal sinuses, right and left, lie along the
posterior free margin of the lesser wing of the sphenoid Relations
bone, and drain into the anterior part of the cavernous Superiorly
sinus. Each sinus may receive the frontal trunk of the 1 Diaphragma sellae (Fig. 12.5)
middle meningeal vein (Fig. 12.9). 2 Optic chiasma
The superior petrosal sinuses lie in the anterior part of 3 Tubercinerium
the attached margin of the tentorium cerebelli along 4 Infundibular recess of the third ventricle
the upper border of the petrous temporal bone. It drains
the cavernous sinus into the transverse sinus (Fig. 12.8). Inferiorly
The inferior petrosal sinuses, right and left, lie in the 1 Irregular venous channels between the two layers of
corresponding petro-occipital fissure, and drain the dura mater lining the floor of the hypophyseal fossa.
cavernous sinus into the superior bulb of the internal
jugular vein.
The basilar plexus of veins lies over the clivus of the
skull. It connects the two inferior petrosal sinuses and
communicates with the internal vertebral venous
plexus.
The middle meningeal veins form two main trunks, one
frontal or anterior and one parietal or posterior, which
accompany the two branches of the middle meningeal
artery. The frontal trunk may end either in the pterygoid
plexus through the foramen ovale, or in the spheno-
parietal or cavernous sinus. The parietal trunk usually
ends in the pterygoid plexus through the foramen
spinosum. The meningeal veins are nearer to the bone
than the arteries, and are, therefore, more liable to injury
in fractures of the skull.
The anterior and posterior intercavernous sinuses Fig. 12.11: Parts of the hypophysis cerebri as seen in a sagittal
connect the cavernous sinuses. They pass through the section
diaphragma sellae, one in front and the other behind
the infundibulum (Fig. 12.8).
Head and Neck

HYPOPHYSIS CEREBRI (PITUITARY GLAND)
The hypophysis cerebri is a small endocrine gland

situated in relation to the base of the brain. It is often
called the master of the endocrine orchestra because it
produces a number of hormones which control the
secretions of many other endocrine glands of the body
(Fig. 12.11).
The gland lies in the hypophyseal fossa or sella
turcica or pituitary fossa. The fossa is roofed by the
diaphragma sellae. The stalk of the hypophysis cerebri
pierces the diaphragma sellae and is attached above to
the floor of the third ventricle.
Fig. 12.12a: Arterial supply of the hypophysis cerebri. Note that
The gland is oval in shape, and measures 8 mm the neurohypophysis is supplied by the superior and inferior
anteroposteriorly and 12 mm transversely. It weighs hypophyseal arteries, and the adenohypophysis, exclusively by
about 500 mg. the portal vessels
HEAD AND NECK
222
2 Hypophyseal fossa. Arterial Supply

3 Sphenoidal air sinuses (Fig. 12.6). The hypophysis cerebri is supplied by the following
branches of the internal carotid artery.
On each side
1 One superior hypophyseal artery on each side
The cavernous sinus with its contents (Fig. 12.6).
(Fig. 12.12a).
Competency achievement: The student should be able to: 2 One inferior hypophyseal artery on each side.
AN 43.4 Describe the development and developmental basis of Each superior hypophyseal artery supplies:
congenital anomalies of face, palate, tongue, branchial apparatus, a. Ventral part of the hypothalamus
pituitary gland, thyroid gland and eye.3
b. Upper part of the infundibulum
c. Lower part of the infundibulum through a separate
Subdivisions/Parts and Development long descending branch, called the trabecular artery.
The gland has two main parts: Adenohypophysis and Each inferior hypophyseal artery divides into medial
neurohypophysis which differ from each other embryo- and lateral branches which join one another to form an
logically, morphologically and functionally. arterial ring around the posterior lobe. Branches from
The adenohypophysis develops as an upward this ring supply the posterior lobe and also anastomose
growth called the Rathke’s pouch from the ectodermal with branches from the superior hypophyseal artery.
roof of the stomodeum. The neurohypophysis develops The anterior lobe or pars distalis is supplied exclusi-
as a downward growth from the floor of the vely by portal vessels arising from capillary tufts formed
diencephalon, and is connected to the hypothalamus by the superior hypophyseal arteries (Fig. 12.12). The
by neural pathways. long portal vessels drain the median eminence and the
upper infundibulum, and the short portal vessels drain
Molecular Regulation the lower infundibulum. The portal vessels are of great
Expression of transcription factors and growth factors functional importance because they carry the hormone
in a tightly regulated pattern is responsible for the releasing factors from the hypothalamus to the anterior
formation of Rathke’s pouch, its orientation with lobe where they control the secretory cycles of different
posterior lobe, cell differentiation of anterior and glandular cells.
posterior lobes and the hormonal production by the
gland. Dysregulation of expression of these factors Venous Drainage
leads to congenital anomalies of pituitary and hormonal Short veins emerge on the surface of the gland and drain
imbalance. into neighbouring dural venous sinuses. The hormones
The subdivisions of each part are given below. pass out of the gland through the venous blood, and
are carried to their target cells.
Adenohypophysis
1 Anterior lobe or pars anterior, pars distalis, or pars
glandularis: This is the largest part of the gland AN 43.2 Identify, describe and draw the microanatomy of pituitary
(Fig. 12.11).
Head and Neck
epiglottis, cornea, retina.4

2 Intermediate lobe or pars intermedia: This is in the form
of a thin strip which is separated from the anterior HISTOLOGY
lobe by an intraglandular cleft, a remnant of the
Anterior Lobe (Fig. 12.12b)
lumen of Rathke’s pouch.
3 Tuberal lobe or pars tuberalis: It is an upward extension Chromophilic cells 50%
of the anterior lobe that surrounds and forms part 1 Acidophils/alpha cells; about 43%
of the infundibulum. a. Somatotrophs: Secrete growth hormone (STH, GH).
b. Mammotrophs (prolactin cells): Secrete lactogenic
Neurohypophysis hormone.
2 Basophils/beta cells, about 7% of cells
1 Posterior lobe or neural lobe, pars posterior: It is smaller a. Thyrotrophs: Secrete thyroid-stimulating
than the anterior lobe and lies in the posterior hormone (TSH).
concavity of the larger anterior lobe.
b. Corticotrophs: Secrete adrenocorticotrophic
2 Infundibular stem, which contains the neural connec- hormone (ACTH).
tions of the posterior lobe with the hypothalamus. c. Gonadotrophs: Secrete follicle-stimulating
3 Median eminence of the tubercinerium which is hormone (FSH).
continuous with the infundibular stem. d. Luteotrophs: Secrete luteinising hormone (LH).
CRANIAL CAVITY
223

AN 30.5 Explain effect of pituitary tumours on visual pathway.5
CLINICAL ANATOMY
Pituitary tumours give rise to two main categories

of symptoms:
A. General symptoms due to pressure over surroun-
ding structures:
a. The sella turcica is enlarged in size.
b. Pressure over the central part of optic chiasma
causes bitemporal hemianopia (Fig. 12.13).
c. Pressure over the hypothalamus may cause
one of the hypothalamic syndromes like
obesity of Frolich’s syndrome in cases with
Rathke’s pouch tumours.
d. A large tumour may press upon the third
Fig. 12.12b: Histology of hypophysis cerebri, 400X ventricle, causing a rise in intracranial pressure.
Chromophobic cells 50% represent the non-secretory B. Specific symptoms depending on the cell type of
phase of the other cell types, or their precursors. the tumour.
a. Acidophil or eosinophil adenoma causes acro-
Intermediate Lobe megaly in adults and gigantism in younger
It is made up of numerous basophil cells, and chromo- patients.
phobe cells surrounding masses of colloid material. It b. Basophil adenoma causes Cushing’s syndrome.
secretes the melanocyte-stimulating hormone (MSH). c. Chromophobe adenoma causes effects of
hypopituitarism.
Posterior Lobe
d. Posterior lobe damage causes diabetes
It is composed of: insipidus, although the lesion in these cases
1 A large number of nonmyelinated fibres forming usually lies in the hypothalamus.
hypothalamohypophyseal tract.
2 Modified neurological cells, called pituicytes. They
have many dendrites which terminate on or near the
sinusoids (Fig. 12.12b).
Hypothalamohypophyseal Portal System
Head and Neck

The hypothalamohypophyseal tract begins in the
preoptic and paraventricular nuclei of the hypothalamus.
Its short fibres terminate in relation to capillary tufts of
portal vessels, providing the possibility for a neural
control of the secretory activity of the anterior lobe. The
long fibres of the neurosecretory tract pass to the
posterior lobe and terminate near vascular sinusoids.
The hormones related to the posterior lobe are:
a. Vasopressin, antidiuretic hormone (ADH) which
acts on kidney tubules.
b. Oxytocin, which promotes contraction of the
uterine and mammary smooth muscle.
These hormones are actually secreted by the
hypothalamus, from where these are transported Fig. 12.13: Bitemporal hemianopia due to pressure of
through the hypothalamohypophyseal tract to the pituitary tumour on the central part of optic chiasma
posterior lobe of the gland.
HEAD AND NECK
224
TRIGEMINAL GANGLION
This is the sensory ganglion (gasserian ganglion) of the
fifth cranial nerve. It is homologous with the dorsal
nerve root ganglia of spinal nerves. All such ganglia
are made up of pseudounipolar nerve cells, with a ‘T’-
shaped arrangement of their process; one process arises
from the cell body which then divides into a central
and a peripheral process.
The ganglion is crescentic or semilunar in shape, with
its convexity directed anterolaterally. The three
divisions of the trigeminal nerve—ophthalmic V1
(see Chapter 13), maxillary V2 (see Chapter 15) and
mandibular V3 (see Chapter 6) emerge from this
convexity. The posterior concavity of the ganglion
receives the sensory root of the nerve (Fig. 12.13). Fig. 12.14: Superior view of the middle cranial fossa showing
some of its contents
Situation and Meningeal Relations
The ganglion lies on the trigeminal impression, on the attached to pons at its junction with the middle
anterior surface of the petrous temporal bone near its cerebellar peduncle.
apex. It occupies a special space of dura mater, called The peripheral processes of the ganglion cells form
the trigeminal or Meckel’s cave. There are two layers of three divisions of the trigeminal nerve, namely the
dura below the ganglion (Fig. 12.4). The cave is lined ophthalmic, maxillary and mandibular.
by pia-arachnoid, so that the ganglion along with the The small motor root of the trigeminal nerve is
motor root of the trigeminal nerve is surrounded by attached to the pons superomedial to the sensory root.
CSF. The ganglion lies at a depth of about 5 cm from It passes under the ganglion from its medial to the
the preauricular point. lateral side, and joins the mandibular nerve at the
foramen ovale.
Relations
Medially Blood Supply
1 Internal carotid artery The ganglion is supplied by twigs from:
2 Posterior part of cavernous sinus 1 Internal carotid
Laterally 2 Middle meningeal
Middle meningeal artery 3 Accessory meningeal arteries
Superiorly 4 By the meningeal branch of the ascending pharyn-
geal artery.
Head and Neck
Parahippocampal gyrus
Inferiorly Trigeminal Nerve
1 Motor root of trigeminal nerve Fifth cranial nerve is the largest cranial nerve. It
2 Greater petrosal nerve (Fig. 12.14) comprises three branches, two of which are purely
3 Apex of the petrous temporal bone sensory and third, the largest branch is mixed nerve.
4 The foramen lacerum. Trigeminal nerve is the nerve of first brachial arch.
Branches of this nerve provide sensory fibres to the
Associated Root and Branches
four parasympathetic ganglia associated with cranial
The central processes of the ganglion cells form the outflow of parasympathetic nervous system. These are
large sensory root of the trigeminal nerve which is ciliary, pterygopalatine, otic and submandibular.
Ophthalmic, the first division, carries sensory fibres
DISSECTION
from the structures derived from frontonasal process.
Identify trigeminal ganglion situated on the anterior Maxillary, the second division, conveys afferent fibres
surface of petrous temporal bone near its apex. Define from structures derived from maxillary process.
the three branches emerging from its convex anterior Mandibular, the third mixed division, carries sensory
surface.
fibres derives from mandibular process.
CRANIAL CAVITY
225
Sensory Components of V Nerve

Sensations of pain, temperature, touch and pressure
from skin of face, mucous membrane of nose, most of
the tongue, paranasal air sinuses travel along axons.
Their cell bodies lie in the V ganglion or semilunar
ganglion or Gasserian ganglion. This ganglion is
equivalent to the spinal ganglia of other nerves. It lies
at the apex of petrous temporal bone in a dural cave—
the Meckel’s cave. Peripheral processes form the three
nerves.
Motor Component for the Muscles

The motor nucleus receives impulses from the right and
left cerebral hemispheres, red nucleus and fibres of
motor root supply four muscles of mastication—
temporalis, masseter, lateral pterygoid and medial
pterygoid and four other muscles which are tensor veli
palatini, tensor tympani, mylohyoid and anterior belly Fig. 12.15: Pathways of fibres from the skin of face
of digastric.
In injury to: Origin

• Ophthalmic nerve: There is loss of corneal blink reflex. The artery is a branch of the first part of the maxillary
This reflex is mediated by V1 which is afferent artery, given off in the infratemporal fossa (see Figs 6.6
pathway and VII nerve which subserves as efferent and 6.7).
pathway.
• Maxillary nerve: There is loss of sneeze reflex. This
1 In the infratemporal fossa, the artery runs upwards
branch is the afferent path of sneeze reflex. Efferent
and medially deep to the lateral pterygoid muscle
pathway of sneeze reflex is nucleus ambigus,
and superficial to the sphenomandibular ligament.
respiratory centre in medulla oblongata, phrenic
Here it passes through a loop formed by the two roots
nerve nucleus, motor cells of spinal cord for
of the auriculotemporal nerve (see Fig. 6.15).
intercostal muscles.
2 It enters the middle cranial fossa through the fora-
Mandibular nerve: There is loss of jaw jerk reflex.
men spinosum (Fig. 12.14).
• Flaccid paralysis of muscles of mastication in injury
3 In the middle cranial fossa, the artery has an
of mandibular nerve leads to decrease strength for
extradural course, but the middle meningeal veins
biting.
are closer to the bone than the artery. Here the artery
runs forwards and laterally for a variable distance,
Head and Neck

CLINICAL ANATOMY grooving the squamous temporal bone, and divides
into a frontal and parietal branch (Fig. 12.14).
• Intractable facial pain due to trigeminal neuralgia 4 The frontal or anterior branch is larger than the parietal
or carcinomatosis may be abolished by injecting branch. First it runs forwards and laterally towards
alcohol into the ganglion. Sometimes cutting of the lateral end of the lesser wing of the sphenoid
the sensory root is necessary (Fig. 12.15). crossing the inner aspect of pterion (meeting point
• Congenital cutaneous naevi on the face (port wine of frontal, parietal, squamous temporal and greater
stains) map out accurately the areas supplied by wing of sphenoid). Then it runs obliquely upwards
one or more divisions of the V cranial nerve. and backwards, parallel to, and a little in front of
the central sulcus of the cerebral hemisphere. Thus
after crossing the pterion, the artery is closely related
MIDDLE MENINGEAL ARTERY to the motor area of the cerebral cortex (see Fig. 1.8).
5 The parietal or posterior branch runs backwards over,
The middle meningeal artery is important to the or near the superior temporal sulcus of the cerebrum,
surgeon because this artery is the commonest source about 4 cm above the level of the zygomatic arch. It
of extradural haemorrhage, which is an acute surgical ends in front of the posteroinferior angle of the
emergency (Fig. 12.14). parietal bone by dividing into branches.
HEAD AND NECK
226
DISSECTION DISSECTION
Dissect the middle meningeal artery which enters the Following structures are seen in the anterior cranial
skull through foramen spinosum. It is an important artery fossa: Crista galli, cribriform plate of ethmoid, orbital
for the supply of endocranium, inner table of skull and part of frontal bone, and lesser wing of sphenoid.
diploe. Examine the other structures seen in cranial Following structures are seen in the middle cranial
fossae after removal of brain. These are the cranial fossa: Middle meningeal vessels, diaphragma sellae
nerves, internal carotid artery, petrosal nerves and pierced by infundibulum, oculomotor nerves, internal
fourth part of vertebral artery. carotid arteries, optic nerve, posterior cerebral artery,
and great cerebral vein.
Branches Following structures are seen in the posterior cranial
The middle meningeal artery supplies only small fossa: Facial, vestibulocochlear, glossopharyngeal,
branches to the dura mater. It is predominantly a vagus, accessory, hypoglossal nerves, vertebral
periosteal artery supplying bone and red bone marrow arteries, and spinal root of accessory nerve.
in the diploe.
Internal Carotid Artery
Within the cranial cavity, it gives off:
Internal carotid artery begins in the neck as one of the
a. The ganglionic branches to the trigeminal ganglion.
terminal branches of the common carotid artery at the
b. A petrosal branch to the hiatus for the greater level of the upper border of the thyroid cartilage. Its
petrosal nerve. course is divided into the four parts (Fig. 12.16):
c. A superior tympanic branch to the tensor tympani. Cervical, pertous, cavernous and cerebral.
d. Temporal branches to the temporal fossa. Cervical part
e. Anastomotic branch that enters the orbit and In the neck, it lies within the carotid sheath. This part
anastomoses with the lacrimal artery. gives no branches (see Fig. 3.8).
Petrous part
CLINICAL ANATOMY Within the carotid canal situated in petrous part of the
• The middle meningeal artery is of great surgical temporal bone. It gives caroticotympanic branches and
importance because it can be torn in head injuries artery of pterygoid canal (Fig. 12.16).
resulting in extradural haemorrhage. The frontal Cavernous part
or anterior branch is commonly involved. The Within the cavernous sinus (Fig. 12.6). This part of the
haematoma presses on the motor area, giving rise artery gives off:
to hemiplegia of the opposite side. The anterior 1 Cavernous branches to the trigeminal ganglion.
division can be approached surgically by making 2 The superior and inferior hypophyseal branches to
a hole in the skull over the pterion, 4 cm above the hypophysis cerebri.
the midpoint of the zygomatic arch (see Fig. 1.8).
• Rarely, the parietal or posterior branch is Cerebral part
implicated, causing contralateral deafness. In this This part lies at the base of the brain after emerging
Head and Neck
case, the hole is made at a point 4 cm above and from the cavernous sinus. It gives off the following
4 cm behind the external acoustic meatus. arteries:
1 Ophthalmic
2 Anterior cerebral
Competency achievement: The student should be able to: 3 Middle cerebral
AN 30.1 Describe the cranial fossae and identify related 4 Posterior communicating
structures.6
5 Anterior choroidal.
Of these, the ophthalmic artery supplies structures
OTHER STRUCTURES SEEN IN CRANIAL in the orbit; while the others supply the brain.
The curvatures of the petrous, cavernous and cerebral
FOSSAE AFTER REMOVAL OF BRAIN
parts of the internal carotid artery together form an S-
shaped figure, the carotid siphon of angiograms.
Various Structures
The structures seen after removal of the brain are: Cranial Nerves
12 cranial nerves, cavernous part of internal carotid The first or olfactory nerve is seen in the form of 15 to 20
artery, four petrosal nerves and fourth part of the filaments on each side that pierce the cribriform plate
vertebral artery. of the ethmoid bone.
CRANIAL CAVITY
227
Fig. 12.16: Various parts of internal carotid artery
The second or optic nerve passes through the optic Petrosal Nerves
canal with the ophthalmic artery (Fig. 12.17). 1 The greater petrosal nerve (Fig. 12.14) carries gustatory
The third or oculomotor and fourth or trochlear nerves and parasympathetic fibres. It arises from the
pierce the posterior part of the roof of the cavernous geniculate ganglion of the facial nerve, and enters
sinus formed by crossing of the free and attached the middle cranial fossa through the hiatus for the
margins of the tentorium cerebelli; next they run in the greater petrosal nerve on the anterior surface of
lateral wall of the cavernous sinus. They enter the orbit the petrous temporal bone. It proceeds towards the
through the superior orbital fissure (see Fig. 13.4). foramen lacerum, where it joins the deep petrosal
The fifth or trigeminal nerve has a large sensory root nerve which carries sympathetic fibres to form the
and a small motor root. The roots cross the apex of the nerve of the pterygoid canal (see Table A.2).
petrous temporal bone beneath the superior petrosal
The nerve of the pterygoid canal passes through the
sinus, to enter the middle cranial fossa (Fig. 12.14).
pterygoid canal to reach the pterygopalatine
The sixth or abducent nerve pierces the lower part of the ganglion. The parasympathetic fibres relay in this
posterior wall of the cavernous sinus near the apex of the ganglion. Postganglionic parasympathetic fibres
petrous temporal bone. It runs forwards by the side of
Head and Neck

arising in the ganglion ultimately supply the lacrimal
the dorsum sellae beneath the petrosphenoidal ligament gland and the mucosal glands of the nose, palate and
to reach the centre of the cavernous sinus (Fig. 12.6).
pharynx (see Fig. 15.16b). The gustatory or taste fibres
The seventh or facial and eighth or statoacoustic or do not relay in the ganglion and are distributed to
vestibulocochlear nerves pass through the internal the palate.
acoustic meatus with the labyrinthine vessels.
The ninth or glossopharyngeal, tenth or vagus and 2 The deep petrosal nerve, sympathetic in nature, is a
eleventh or accessory nerves pierce the dura mater at the branch of the sympathetic plexus around the internal
jugular foramen and pass out through it. The glosso- carotid artery. It contains postganglionic fibres from
pharyngeal nerve is enclosed in a separate sheath of dura the superior cervical sympathetic ganglion. The
mater, while vagus and accessory nerves are enclosed nerve joins the greater petrosal nerve to form the
in one sheath. The spinal part of the accessory nerve nerve of the pterygoid canal. The sympathetic fibres
first enters the posterior cranial fossa through the are distributed through the branches of the pterygo-
foramen magnum, and then passes out through the palatine ganglion (see Table A.2 in Appendix).
jugular foramen along with cranial part. 3 The lesser petrosal nerve, parasympathetic in nature,
The two parts of the twelfth or hypoglossal nerve pierce is a branch of the tympanic plexus, deriving its pre-
the dura mater separately opposite the hypoglossal ganglionic parasympathetic fibres from the tympanic
canal and then pass out through it. branch of the glossopharyngeal nerve. It emerges
HEAD AND NECK
228
Fig. 12.17: Highlights of the cranial nerves
through the hiatus for the lesser petrosal nerve, situated

just lateral to the hiatus for the greater petrosal nerve, Trochlear nerve (IV)
passes out of the skull through the foramen ovale, Ophthalmic nerve (V1)
and ends in the otic ganglion (see Fig. 6.17). Post- Maxillary nerve (V2)
ganglionic fibres arising in the ganglion supply the Carotid artery (internal)
parotid gland through the auriculotemporal nerve Abducent nerve (VI)
(see Table A.2 in Appendix). T: Nothing
Head and Neck
4 The external petrosal nerve, sympathetic in nature, is

an inconstant branch from the sympathetic plexus
around the middle meningeal artery to the geniculate FACTS TO REMEMBER
ganglion of the facial nerve. • Meningeal layer of dura mater forms falx cerebri
and falx cerebelli in sagittal plane and tentorium
Fourth Part of the Vertebral Artery cerebelli and diaphragma sellae in horizontal
plane.
It enters the posterior cranial fossa through the foramen
magnum after piercing the dura mater near the skull. • Only spinal ganglia present in the cranial cavity is
It has been studied in Chapter 9. the trigeminal ganglion.
• Only mixed branch of trigeminal is the mandibular
branch. The other two are purely sensory.
Mnemonics
• Anterior branch of middle meningeal artery lies
Cavernous sinus contents: O TOM CAT on the inner aspect of pterion and is liable to injury,
Oculomotor nerve (III) leading to extradural haemorrhage.
CRANIAL CAVITY
229
CLINICOANATOMICAL PROBLEM Flowchart 12.1: Pathway of pain impulses
A young person complains of a little painful papules

on the right side of forehead along a nerve on the
right side. There is redness of the eyes with severe
pain.
• What is the diagnosis?
• Trace the pathway of pain impulses.
Ans: The diagnosis is ‘herpes zoster’.
The pathway of pain impulses is shown in
Flowchart 12.1.
FURTHER READING
• Rhoton AL. Cranial Anatomy and Surgical Approaches.
Baltimore: Lippincortt Williams & Wilkins 2007.
An essential masterpiece in microsurgical neuroanatomy and
surgical approaches developed by Professor Rhoton after 40 years
devoted to the field.
1–6
Head and Neck
1. Describe cavernous venous sinus under the 2. Write short notes on:
following headings: a. Falx cerebri
a. Extent b. Superior sagittal sinus
c. Hypophysis cerebri
b. Relations
d. Middle meningeal artery
c. Tributaries and communications e. Tentorium cerebelli
d. Clinical anatomy f. Trigeminal ganglion
HEAD AND NECK
230
1. One of the following structures is not related to 5. Which is not a part of internal carotid artery?
cavernous sinus: a. Cervical
a. Trochlear nerve b. Petrous
b. Oculomotor nerve c. Cerebral
c. Optic nerve
d. Ophthalmic
d. Ophthalmic nerve
6. Rupture of which commonly injured artery causes
2. Which is true about cavernous sinus?
extradural haemorrhage is:
a. Oculomotor nerve in medial wall a. Trunk of middle meningeal artery
b. Trochlear nerve on medial wall
b. Anterior branch of middle meningeal artery
c. Optic tract inferiorly
c. Posterior branch of middle meningeal artery
d. Drains into transverse sinus
d. None of the above
3. What is the correct position of VI nerve in relation
7. Which of the petrosal nerves carries preganglionic
to internal carotid artery in cavernous sinus?
fibres to the otic ganglion?
a. Medial b. Lateral a. Greater
c. Inferolateral d. Posterior
b. Deep
4. If III, IV, VI and ophthalmic nerves are paralysed, c. Lesser
the infection is localised to: d. External
a. Brainstem 8. Arachnoid villi drain into which of the following
b. Base of skull sinuses?
c. Cavernous sinus a. Transverse b. Straight
d. Apex of orbit c. Superior sagittal d. Sigmoid
1. c 2. d 3. c 4. c 5. d 6. b 7. c 8. c
• Where does superior sagittal and inferior sagittal • Name four emissary veins. What is their function
venous sinuses lie? and what is their clinical importance?
• What sinuses are present in relation to the tentorium • Name the parts of adenohypophysis.
Head and Neck
cerebelli? • Name the parts of neurohypophysis.

• How many roots are there in trigeminal ganglion?
• Name the cranial nerves in order.
Name its branches.
• Name the structures present in the lateral wall of • Name the four parts of internal carotid artery.
cavernous sinus. • Which artery lies on the inner aspect of the pterion?
• Name the tributaries of cavernous sinus. • Which is the mixed branch of trigeminal nerve?
13
Contents of the Orbit
My heart leaps up when I behold a rainbow in the sky .
—William Wordsworth
INTRODUCTION DISSECTION
The orbits are bony cavities lodging the eyeballs, Strip the endosteum from the floor of the anterior cranial
extraocular muscles, nerves, blood vessels and lacrimal fossa. Gently break the orbital plate of frontal bone
gland. Out of 12 pairs of cranial nerves; II, III, IV, VI, a forming the roof of the orbit and remove it in pieces so
part of V, and some sympathetic fibres are dedicated that orbital periosteum is clearly visible. Medially, the
to the contents of orbit only. Nature has provided orbit ethmoidal vessels and nerves should be preserved.
for the safety of the eyeball. We must also try and look Posteriorly, identify the optic canal and superior orbital
after our orbits and their contents. fissure and structures traversing these. Define the
orbital fascia and fascial sheath of eyeball.
ORBITS Divide the orbital periosteum along the middle of the
orbit anteroposteriorly. Cut through it horizontally close
Features to anterior margin of orbit (refer to BDC App).
The orbits are pyramidal cavities, situated one on each
side of the root of the nose. They provide sockets for an angle of 20–25° with the orbital axis (see Fig. 1.19),
rotatory movements of the eyeball. The long axis of the i.e. line passing through optic canal and centre of base
each orbit passes backwards and medially. The medial of orbit, i.e. opening on the face.
walls are parallel to each other at a distance of 2.5 cm
but the lateral walls are set at right angles to each other Orbital Fascia or Periorbita
(see Fig. 1.19). It forms the periosteum of the bony orbit. Due to the
Contents
loose connection to bone, it can be easily stripped.
Posteriorly, it is continuous with the dura mater and
1 Eyeball: Eyeball occupies anterior one-third of orbit. with the sheath of the optic nerve. Anteriorly, it is
It is described in Chapter 19. continuous with the periosteum lining the bones
2 Fascia: Orbital and bulbar. around the orbital margin (Fig. 13.1).
3 Muscles: Extraocular and intraocular. There is a gap in the periorbita over the inferior
4 Vessels: Ophthalmic artery, superior and inferior orbital fissure. This gap is bridged by connective tissue
ophthalmic veins, and lymphatics. with some smooth muscle fibres in it. These fibres
5 Nerves: Optic, oculomotor, trochlear and abducent; constitute the orbitalis muscle.
branches of ophthalmic and maxillary nerves, and a. At the upper and lower margins of the orbit, the
sympathetic nerves. orbital fascia sends off flap-like continuations into
6 Lacrimal gland: It has already been studied in the eyelids. These extensions form the orbital
Chapter 2. septum.
7 Orbital fat. b. A process of the fascia holds the fibrous pulley
of the tendon of the superior oblique muscle in
Visual Axis and Orbital Axis place.
Axis passing through centres of anterior and posterior c. Another process forms the lacrimal fascia which
poles of the eyeball is known as visual axis. It makes bridges the lacrimal groove.
231
HEAD AND NECK
232
c. The lateral check ligament is a strong triangular

expansion from the sheath of the lateral rectus
muscle; it is attached to the zygomatic bone
(Fig. 13.2).
4 The lower part of Tenon’s capsule is thickened, and
is named the suspensory ligament of the eye or the
suspensory ligament of Lockwood (Fig. 13.3). It is
expanded in the centre and narrow at its extremities,
and is slung like a hammock below the eyeball. It is
formed by union of the margins of the sheaths of the
inferior rectus and the inferior oblique muscles with
the medial and lateral check ligaments.
EXTRAOCULAR MUSCLES
Fig. 13.1: Orbital fascia and fascial sheath of the eyeball as seen
in a parasagittal section Involuntary Muscles
1 The superior tarsal muscle is the deeper portion of
the levator palpebrae superioris. It is inserted on the
Fascial Sheath of Eyeball or Bulbar Fascia
upper margin of the superior tarsus. It elevates the
1 Tenon’s capsule forms a thin, loose membranous upper eyelid.
sheath around the eyeball, extending from the optic 2 The inferior tarsal muscle extends from the fascial
nerve to the sclerocorneal junction or limbus. It is sheath of the inferior rectus and inferior oblique to
separated from the sclera by the episcleral space the lower margin of the inferior tarsus. It possibly
which is traversed by delicate fibrous bands. The depresses the lower eyelid.
eyeball can freely move within this sheath. 3 The orbitalis bridges the inferior orbital fissure. Its
2 The sheath is pierced by: action is uncertain (Fig. 13.1).
a. Tendons of the various extraocular muscles.
b. Ciliary vessels and nerves around the entrance of DISSECTION
the optic nerve.
Identify and preserve the trochlear nerve entering the
3 The sheath gives off a number of expansions. superior oblique muscle in the superomedial angle of
a. A tubular sheath covers each orbital muscle. the orbit. Find the frontal nerve lying in the midline on
b. The medial check ligament is a strong triangular the levator palpebrae superioris. It divides into two
expansion from the sheath of the medial rectus terminal divisions in the anterior part of orbit.
muscle; it is attached to the lacrimal bone.
Head and Neck
Fig. 13.2: Orbital fascia and fascial sheath of the eyeball as seen in transverse section
CONTENTS OF THE ORBIT
233
Voluntary Extraocular Muscles

1 Four recti:
a. Superior rectus
b. Inferior rectus
c. Medial rectus
d. Lateral rectus
2 Two obliques:
a. Superior oblique
b. Inferior oblique
3 The levator palpebrae superioris elevates the upper
eyelid.
Fig. 13.3: Fascial sheath of the eyeball as seen in coronal section Origin
1 The four recti arise from a common annular tendon or
tendinous ring of Zinn. The ring is attached to the
Beneath the levator palpebrae superioris is the middle part of superior orbital fissure (Fig. 13.4).
superior rectus muscle. The upper division of The lateral rectus has an additional small tendinous
oculomotor nerve lies between these two muscles, head which arises from the orbital surface of the
supplying both of them. Along the lateral wall of the greater wing of the sphenoid bone lateral to the
orbit, look for lacrimal nerve and artery to reach the tendinous ring. Through the gap between the two
superolateral corner of the orbit. heads abducent nerve passes.
2 The superior oblique arises from the undersurface
Follow the tendon of superior oblique muscle passing
of lesser wing of the sphenoid, superomedial to the
superolaterally beneath the superior rectus to be
optic canal.
inserted into sclera behind the equator. After identifica-
3 The inferior oblique arises from the orbital surface of
tion, divide frontal nerve, levator palpebrae superioris
the maxilla, lateral to the lacrimal groove. The muscle
and superior rectus in the middle of the orbit and reflect
is situated near the anterior margin of the orbit.
them apart. Identify the optic nerve and other structures
4 The levator palpebrae superioris arises from the
crossing it. These are nasociliary nerve, ophthalmic
orbital surface of the lesser wing of the sphenoid
artery and superior ophthalmic vein. With the optic nerve
bone, anterosuperior to the optic canal and to the
find two long ciliary nerves and 12–20 short ciliary
origin of the superior rectus.
nerves. Remove the orbital fat and look carefully in the
posterior part of the interval between the optic nerve Insertion
and lateral rectus muscle along the lateral wall of the
1 The recti are inserted into the sclera, a little posterior
orbit and identify the pinhead-sized ciliary ganglion.
to the limbus (corneoscleral junction). The average
Trace the roots connecting it to the nasociliary nerve
distances of the insertions from the cornea are:
and nerve to inferior oblique muscle.
Superior 7.7 mm; inferior 6.5 mm, medial 5.5 mm;
Head and Neck

Lastly, identify the abducent nerve closely adherent lateral 6.9 mm (Fig. 13.5).
to the medial surface of lateral rectus muscle. 2 The tendon of the superior oblique passes through a
Incise the inferior fornix of conjunctiva and palpebral fibrocartilaginous pulley attached to the trochlear
fascia. Elevate the eyeball and remove the fat and fascia fossa of the frontal bone. The tendon then passes
to identify the origin of inferior oblique muscle from the laterally, downwards and backward below the
floor of the orbit anteriorly. superior rectus. It is inserted into the sclera behind
Identify the levator palpebrae superioris and superior the equator of the eyeball, between the superior
rectus above the eyeball, superior oblique supero- rectus and the lateral rectus.
medially, medial rectus medially, lateral rectus laterally, 3 The inferior oblique is fleshy throughout. It passes
and inferior rectus inferiorly. laterally, upwards and backwards below the inferior
rectus and then deep to the lateral rectus. The inferior
The voluntary muscles are miniature ribbon muscles,
oblique is inserted close to the superior oblique a little
having short tendons of origin and long tendons of
below and posterior to the latter.
insertion.
4 The flat tendon of the levator splits into a superior
or voluntary and an inferior or involuntary lamellae.
Superior lamella of the levator is inserted into the
AN 31.1 Describe and identify extraocular muscles of eyeball.1
anterior surface of the superior tarsus, and into
HEAD AND NECK
234
Fig. 13.4: Apical part of the orbit showing the origin of the extraocular muscles, the common tendinous ring and the structures
passing through superior orbital fissure
the skin of the upper eyelid. The inferior lamella

(smooth part) is inserted into the upper margin of
the superior tarsus (see Fig. 2.21b) and into superior
conjunctival fornix.
Nerve Supply
1 The superior oblique is supplied by the IV cranial or
trochlear nerve (SO4) (Fig. 13.6).
2 The lateral rectus is supplied by the VI cranial or
abducent nerve (LR6).
3 The remaining five extraocular muscles; superior,
inferior and medial recti; inferior oblique and part
Fig. 13.5: Scheme to show the insertion of the oblique muscles of levator palpebrae superioris are all supplied by
of the eyeball the III cranial or oculomotor nerve.
Head and Neck
Fig. 13.6: Scheme showing the nerve supply of the extraocular muscles
235
Actions
1 The movements of the eyeball are as follows.
a. Around a transverse axis:
• Upward rotation or elevation (33°)
• Downwards rotation or depression (33°)
b. Around a vertical axis:
• Medial rotation or adduction (50°)
• Lateral rotation or abduction (50°)
c. Around an anteroposterior axis:
• Intorsion
• Extorsion
The rotatory movements of the eyeball upwards,
downwards, medially or laterally, are defined in
terms of the direction of movement of the centre
of the pupil. The torsions are defined in terms of
the direction of movement of the upper margin
of the pupil at 12 o’clock position.
d. The movements given above can take place in
various combinations.
2 Actions of individual muscles are shown in Fig. 13.7a
and Tables 13.1 and 13.2.
3 Single or pure movements are produced by combined Fig. 13.7a: Scheme to show the actions of the extraocular
actions of muscles. Similar actions get added muscles
Table 13.1: Actions of individual muscles according to their axes

Muscle Transverse axis Vertical axis Anteroposterior axis
Superior rectus (SR) Elevates Adducts Rotates medially (intorsion)
Inferior rectus (IR) Depresses Adducts Rotates laterally (extorsion)
Superior oblique (SO) Depresses Abducts Rotates medially (intorsion)
Inferior oblique (IO) Elevates Abducts Rotates laterally (extorsion)
Medial rectus (MR) — Adducts —
Lateral rectus (LR) — Abducts —
Table 13.2: Action of individual muscles according to the position of eye
Head and Neck

Muscle In primary position Abducted eye Adducted eye
1. Superior oblique Depression Only intorsion Only depression
Abduction
Intorsion
2. Inferior oblique Elevation Only extorsion Only elevation
Abduction
Extorsion
3. Inferior rectus Depression Only depression Only extorsion
Adduction
Extorsion
4. Superior rectus Elevation Only elevation Only intorsion
Adduction
Intorsion
5. Medial rectus Only adduction ___ ___
6. Lateral rectus Only abduction ___ ___
HEAD AND NECK
236
Fig. 13.7b: Single movement of the eye
together, while opposing actions cancel each other CLINICAL ANATOMY

Head and Neck
enabling pure movements (Fig. 13.7b).

a. Upward rotation or elevation: By the superior rectus • Weakness or paralysis of a muscle causes squint or
and the inferior oblique. strabismus, which may be concomitant or paralytic.
b. Downward rotation or depression: By the inferior Concomitant squint is congenital; there is no
rectus and the superior oblique. limitation of movement, and no diplopia (Fig. 13.8).
c. Medial rotation or adduction: By the medial rectus, In paralytic squint, movements are limited,
the superior rectus and the inferior rectus. diplopia and vertigo are present, head is turned
d. Lateral rotation or abduction: By the lateral rectus, in the direction of the function of paralysed muscle,
the superior oblique and the inferior oblique. and there is a false orientation of the field of vision.
e. Intorsion: By the superior oblique and the superior • Nystagmus is characterized by involuntary,
rectus. rhythmical oscillatory movements of the eyes. This
f. Extorsion: By the inferior oblique and the inferior is due to incoordination of the ocular muscles. It
rectus. may be either vestibular or cerebellar, or even
4 Combined movements of the eyes congenital.
Normally, movements of the two eyes are harmoni- Competency achievement: The student should be able to:
ously coordinated. Such coordinated movements of both
AN 31.2 Describe and demonstrate vessels in the orbit.2
eyes are called conjugate ocular movements (Fig. 13.7c).
237
Fig. 13.7c: Muscles for conjugate movements of the eyes

1 The artery enters the orbit through the optic canal,
lying inferolateral to the optic nerve. Both the artery
and nerve lie in a common dural sheath.
2 In the orbit, the artery pierces the dura mater, ascends
Head and Neck

over the lateral side of the optic nerve, and crosses
above the nerve from lateral to medial side along
with the nasociliary nerve. It then runs forwards
along the medial wall of the orbit between the
superior oblique and the medial rectus muscles and
Fig. 13.8: Medial squint of the right eye parallel to the nasociliary nerve.
3 It terminates near the medial angle of the eye by
dividing into the supratrochlear and dorsal nasal
VESSELS OF THE ORBIT branches (Fig. 13.9).
OPHTHALMIC ARTERY DISSECTION

Origin Trace the ophthalmic artery after it was seen to cross
over the optic nerve along with nasociliary nerve and
The ophthalmic artery is a branch of the cerebral superior ophthalmic vein. Identify its branches
part of the internal carotid artery, given off medial to especially the central artery of the retina which is an
the anterior clinoid process close to the optic canal ‘end artery’.
(Figs 13.9 and 13.10).
HEAD AND NECK
238
Fig. 13.9: The arteries of the eyeball

Head and Neck
Fig. 13.10: Branches of ophthalmic artery
Branches the nerve and runs forwards for a short distance

While still within the dural sheath, the ophthalmic between these two. It then enters the substance of the
artery gives off the central artery of the retina. After nerve and runs forwards in its centre to reach the optic
piercing the dura mater, it gives off a large lacrimal disc (Fig. 13.9). Here it divides into branches that supply
branch that runs along the lateral wall of the orbit. The the retina (see Fig. 19.10).
main artery runs towards the medial wall of the orbit The central artery of the retina is an end artery. It does
giving off a number of branches. The various branches not have effective anastomoses with other arteries.
are described below. Occlusion of the artery results in blindness. The
intraocular part of the artery can be seen, in the living,
Central Artery of Retina through an ophthalmoscope (see Fig. 19.16).
The central artery of retina (Fig. 13.10) is the first and
most important branch of the ophthalmic artery. It first Branches Arising from the Lacrimal Artery
lies below the optic nerve. It pierces the dural sheath of 1 Branches are given to the lacrimal gland.
239
2 Two zygomatic branches enter canals in the Lymphatics of the Orbit

zygomatic bone. One branch appears on the face The lymphatics drain into the preauricular parotid
through the zygomaticofacial foramen. The other lymph nodes (see Fig. 2.25).
appears on the temporal surface of the bone through
the zygomaticotemporal foramen. Competency achievement: The student should be able to:
3 Lateral palpebral branches supply the eyelids. AN 31.2 Describe and demonstrate nerves of the orbit.3
4 A recurrent meningeal branch runs backwards to
enter the middle cranial fossa through the superior
orbital fissure. NERVES OF THE ORBIT
5 Muscular branches supply the muscles of the orbit. These are:
1 Optic II (Fig. 13.10)
Branches Arising from the Main Trunk 2 Ciliary ganglion (Fig. 13.11)
1 The posterior (long and short) ciliary arteries supply 3 Oculomotor (III) and trochlear (IV) (Figs 13.12 and
chiefly the choroid and iris. The eyeball is also 13.13)
supplied through anterior ciliary branches which are 4 Abducent (VI) (Fig. 13.14)
given off from arteries supplying muscles attached 5 Branches of ophthalmic (V1) and maxillary divisions
to the eyeball (Fig. 13.10). (V2) of the trigeminal nerve (Figs 13.15 and 13.16)
2 The supraorbital and supratrochlear branches supply 6 Sympathetic nerves.
the skin of the forehead.
OPTIC NERVE
3 The anterior and posterior ethmoidal branches enter
foramina in the medial wall of the orbit to supply The optic nerve is the nerve of sight. It is made up
the ethmoidal air sinuses. They then enter the of the axons of cells in the ganglionic layer of the
anterior cranial fossa. The terminal branches of the retina. It emerges from the eyeball 3 or 4 mm nasal
anterior ethmoidal artery enter the nose and supply to its posterior pole. It runs backwards and medially,
part of it. and passes through the optic canal to enter the
middle cranial fossa where it joins the optic chiasma
4 The medial palpebral branches supply the eyelids. (see Fig. 12.13).
5 The dorsal nasal branch supplies the upper part of The nerve is about 4 cm long, out of which 25 mm
the nose. are intraorbital, 5 mm intracanalicular, and 10 mm
intracranial. The entire nerve is enclosed in three
CLINICAL ANATOMY meningeal sheaths. The subarachnoid space extends
around the nerve up to the eyeball (Fig. 13.10).
• The anterior ciliary arteries arise from the
Relations in the Orbit
muscular branches of ophthalmic artery. The
muscular arteries are important in this respect. 1 At the apex of the orbit, the nerve is closely sur-
• The central artery of retina is the only arterial supply rounded by the recti muscles. The ciliary ganglion
to most of the nervous layer, the retina of the eye. lies between the optic nerve and the lateral rectus.
Head and Neck

If this artery is blocked, there is sudden blindness. 2 The central artery and vein of the retina pierce the
optic nerve inferomedially about 1.25 cm behind the
eyeball (Fig. 13.9).
OPHTHALMIC VEINS 3 The optic nerve is crossed superiorly by the
Superior ophthalmic vein: It accompanies the ophthalmic ophthalmic artery, the nasociliary nerve and the
artery. It lies above the optic nerve. It receives tributaries superior ophthalmic vein.
corresponding to the branches of the artery, passes 4 The optic nerve is crossed inferiorly by the nerve to
through the superior orbital fissure, and drains into the the medial rectus.
cavernous sinus. It communicates anteriorly with the 5 Near the eyeball, the nerve is surrounded by fat
supraorbital and angular veins (see Fig. 2.6). containing the ciliary vessels and nerves (see Fig. 19.2).
Inferior ophthalmic vein: It runs below the optic nerve. It Structure
receives tributaries from the lacrimal sac, the lower 1 There are about 1.2 million myelinated fibres in each
orbital muscles, and the eyelids, and ends either by optic nerve, out of which about 53% cross in the optic
joining the superior ophthalmic vein or drains directly chiasma.
into the cavernous sinus. It communicates with the 2 The optic nerve is not a nerve in the strict sense as
pterygoid plexus of veins by small veins passing there is no neurolemmal sheath. It is actually a tract.
through the inferior orbital fissure. It cannot regenerate, if it is cut. Developmentally,
HEAD AND NECK
240
the optic nerve and the retina are a direct

prolongation of the brain.
CLINICAL ANATOMY
• The anastomoses between tributaries of facial vein

and ophthalmic veins may result in spread of
infection from the orbital and nasal regions to the
cavernous sinus leading to its thrombosis.
• Optic neuritis is characterized by pain in and
behind the eye on ocular movements and on
pressure. The papilloedema is less but loss of
vision is more. When the optic disc is normal as
seen by an ophthalmoscope the same condition is
called retrobulbar neuritis.
The common causes are demyelinating diseases of
the central nervous system, any septic focus in the
teeth or paranasal sinuses, meningitis, encephalitis,
syphilis, and even vitamin B deficiency.
• Optic nerve has no neurilemmal sheath, and has no
power of regeneration. It is a tract and not a nerve.
• Optic atrophy may be caused by a variety of Fig. 13.11: Roots and branches of ciliary ganglion
diseases. It may be primary or secondary.
the sclera around the entrance of the optic nerve.
CILIARY GANGLION They contain fibres from all the three roots of the
Ciliary ganglion is a peripheral parasympathetic ganglion.
ganglion placed in the course of the oculomotor nerve.
It lies near the apex of the orbit between the optic nerve OCULOMOTOR NERVE
and the tendon of the lateral rectus muscle. It has Course of oculomotor (III) nerve is shown by
parasympathetic, sensory and sympathetic roots. Flowchart 13.1 and Fig. 13.12.
The parasympathetic root arises from the nerve to the
inferior oblique (Fig. 13.11). It contains preganglionic
Flowchart 13.1: Oculomotor nerve—III nerve
fibres that begin in the Edinger-Westphal nucleus. The
fibres relay in the ciliary ganglion. Postganglionic fibres
arising in the ganglion pass through the short ciliary
nerves and supply the sphincter pupillae and the ciliaris
muscle (see Table 1.3). These intraocular muscles are
Head and Neck
used in accommodation.
The sensory root comes from the nasociliary nerve. It
contains sensory fibres for the eyeball. The fibres do
not relay in the ganglion (Fig. 13.11).
The sympathetic root is a branch from the internal
carotid plexus. It contains postganglionic fibres arising
in the superior cervical ganglion (preganglionic fibres
reach the ganglion from lateral horn of T1 spinal
segment) which pass along internal carotid, ophthalmic
and long ciliary arteries. They pass out of the ciliary
ganglion without relay in the short ciliary nerves to
supply the blood vessels of the eyeball. They also
supply the dilator pupillae.
Branches
The ganglion gives off 8 to 10 short ciliary nerves
which divide into 15 to 20 branches, and then pierce
241
ABDUCENT NERVE
Course of abducent (VI) nerve is depicted by Flow-
chart 13.3 and Fig. 13.14 (details can be read from Chapter
4, BD Chaurasia’s Human Anatomy, Volume 4).
Flowchart 13.3: Abducent nerve—VI nerve
Fig. 13.12: Distribution of oculomotor nerve
TROCHLEAR NERVE
Course of trochlear (IV) nerve is shown by Flow-
chart 13.2 and Fig. 13.13.
Flowchart 13.2: Trochlear—IV nerve
Fig. 13.14: Distribution of abducent nerve
Head and Neck

BRANCHES OF OPHTHALMIC DIVISION
OF TRIGEMINAL NERVE
Following are the branches of ophthalmic division of
trigeminal nerve (Fig. 13.15).
1 Frontal Supratrochlear
Supraorbital
2 Nasociliary Branch to ciliary ganglion
2–3 long ciliary nerves
Posterior ethmoidal
Infratrochlear
Anterior ethmoidal
3 Lacrimal Branch to the upper eyelid and
secretomotor fibres to lacrimal gland.
Lacrimal Nerve
This is the smallest of the three terminal branches of
Fig. 13.13: Course of trochlear nerve ophthalmic nerve (Fig. 13.15a). It enters the orbit
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242
Figs 13.15a and b: (a) Branches of right ophthalmic nerve including III, IV, VI cranial nerves and the extraocular muscles, and (b) branches
of nasociliary: (1) Branch to ciliary ganglion; (2) Long ciliary; (3) Posterior ethmoidal; (4) Infratrochlear; (5) Anterior ethmoidal
through lateral part of superior orbital fissure and runs and lateral branches which runs upwards over the
forwards along the upper border of lateral rectus forehead and scalp. It supplies the conjunctiva, the
muscle, in company with lacrimal artery. Anteriorly, it central part of the upper eyelid, the frontal air sinus and
receives communication from zygomaticotemporal the skin of the forehead and scalp up to the vertex, or
nerve, passes deep to the lacrimal gland, and ends in even up to the lambdoid suture.
the lateral part of the upper eyelid.
Nasociliary Nerve
The lacrimal nerve supplies the lacrimal gland, the
conjunctiva and the upper eyelid. Its own fibres to the This is one of the terminal branches of the ophthalmic
gland are sensory. The secretomotor fibres to the gland division of the trigeminal nerve (Fig. 13.15b). It begins
come from the greater petrosal nerve through its in the lateral wall of the anterior part of the cavernous
communication with the zygomaticotemporal nerve sinus. It enters the orbit through the middle part of the
(see Flowchart 2.2). superior orbital fissure between the two divisions of
the oculomotor nerve (Fig. 13.4). It crosses above the
Frontal Nerve optic nerve from lateral to medial side along with
Head and Neck
This is the largest of the three terminal branches of the ophthalmic artery and runs along the medial wall of
ophthalmic nerve (Figs 13.15a and b). It begins in the the orbit between the superior oblique and the medial
lateral wall of the anterior part of the cavernous sinus. rectus. It ends at the anterior ethmoidal foramen by
It enters the orbit through the lateral part of the superior dividing into the infratrochlear and anterior ethmoidal
orbital fissure, and runs forwards on the superior nerves. Its branches are as follows.
surface of the levator palpebrae superioris. At the 1 A communicating branch to the ciliary ganglion forms
middle of the orbit, it divides into a small supratrochlear the sensory root of the ganglion. It is often mixed
branch and a large supraorbital branch. with the sympathetic root (Fig. 13.15b).
The supratrochlear nerve emerges from the orbit above 2 Two or three long ciliary nerves run on the medial
the trochlea about one finger breadth from the median side of the optic nerve, pierce the sclera, and supply
plane. It supplies the conjunctiva, the upper eyelid, and sensory nerves to the cornea, the iris and the ciliary
a small area of the skin of the forehead above the root body. They also carry sympathetic nerves to the
of the nose (see Figs 2.5 and 2.16). dilator pupillae.
The supraorbital nerve emerges from the orbit through 3 The posterior ethmoidal nerve passes through the
the supraorbital notch or foramen about two fingers posterior ethmoidal foramen and supplies the
breadth from the median plane. It divides into medial ethmoidal and sphenoidal air sinuses.
243
4 The infratrochlear nerve is the smaller terminal branch the infraorbital foramen and terminates by dividing into
of the nasociliary nerve given off at the anterior palpebral, nasal and labial branches (see Fig. 2.16). The
ethmoidal foramen. It emerges from the orbit below nerve is accompanied by the infraorbital branch of the
the trochlea for the tendon of the superior oblique third part of the maxillary artery and the accompanying
and appears on the face above the medial angle of vein (Fig. 13.16).
the eye. It supplies the conjunctiva, the lacrimal sac
Branches
and caruncle, the medial ends of the eyelids and the
upper half of the external nose (see Fig. 2.16). 1 The middle superior alveolar nerve arises in the infra-
orbital groove, runs in the lateral wall of the maxillary
5 The anterior ethmoidal nerve is the larger terminal
sinus, and supplies the upper premolar teeth.
branch of the nasociliary nerve. It leaves the orbit by 2 The anterior superior alveolar nerve arises in the
passing through the anterior ethmoidal foramen. It infraorbital canal, and runs in a sinuous canal having
appears, for a very short distance, in the anterior a complicated course in the anterior wall of the
cranial fossa, above the cribriform plate of the maxillary sinus. It supplies the upper incisor and
ethmoid bone. It then descends into the nose through canine teeth, the maxillary sinus, and the antero-
a slit at the side of the anterior part of the crista galli. inferior part of the nasal cavity where it communi-
In the nasal cavity, it lies deep to the nasal bone. It cates with branches of anterior ethmoidal and
gives off two internal nasal branches—medial and anterior palatine nerves (see Fig. 15.16).
lateral to the mucosa of the nose. Finally, it emerges 3 Terminal branches—palpebral, nasal and labial which
at the lower border of the nasal bone as the external supply a large area of skin on the face. They also
nasal nerve which supplies the skin of the lower half supply the mucous membrane of the upper lip and
of the nose. cheek (see Fig. 2.16).
SOME BRANCHES OF MAXILLARY DIVISION Zygomatic Nerve

OF THE TRIGEMINAL NERVE It is a branch of the maxillary nerve, given off in the
pterygopalatine fossa. It enters the orbit through the
Infraorbital Nerve lateral end of the inferior orbital fissure, and runs along
It is the continuation of the maxillary nerve. It enters the lateral wall, outside the periosteum, to enter the
the orbit through the inferior orbital fissure. It then runs zygomatic bone. Just before or after entering the bone,
forwards on the floor of the orbit or the roof of the it divides into its two terminal branches, the zygomatico-
maxillary sinus, at first in the infraorbital groove and then facial and zygomaticotemporal nerves which supply the
in the infraorbital canal remaining outside the skin of the face and of the anterior part of the temple
periosteum of the orbit. It emerges on the face through (see Fig. 2.16). The communicating branch to the
Head and Neck
Fig. 13.16: Some branches of ophthalmic, maxillary and mandibular branches of trigeminal nerve
HEAD AND NECK
244
lacrimal nerve, which contains secretomotor fibres to

the lacrimal gland, arises from the zygomaticotemporal The fibres supply these muscles after relaying in
nerve, and runs in the lateral wall of the orbit (see the ciliary ganglion.
Chapter 2). Detailed description is given in Chapter 15. • Elevation and depression of the cornea occur
around a transverse axis.
Some Branches of Mandibular Division of • Adduction and abduction of the cornea take place
Trigeminal Nerve around a vertical axis.
1 Anterior division gives muscular branches to • Intorsion and extorsion occur around an antero-
masseter, temporalis and lateral pterygoid muscles. posterior axis.
2 Posterior division gives auriculotemporal nerve and
then divides into lingual and inferior alveolar nerves.
Details are given in Chapter 6.
SYMPATHETIC NERVES OF THE ORBIT
A hypertensive and diabetic lady with high
Sympathetic nerves arise from the internal carotid plexus cholesterol and lipids develops sudden blindness in
and enter the orbit through the following sources. her right eye.
1 The dilator pupillae of the iris is supplied by
• What has caused blindness in this particular case?
sympathetic nerves that pass through the ophthalmic
nerve, the nasociliary nerve, and its long ciliary • Name the other end arteries in the body.
branches. Ans: Hypertension causes atheromatous changes in
2 Other sympathetic nerves enter the orbit as follows: the arteries. Most of the nervous layers of retina are
a. A plexus surrounds the ophthalmic artery. supplied by a single ‘end artery’ with no anas-
b. A direct branch from the internal carotid plexus tomoses with any other artery. This artery is also
passes through the superior orbital fissure and vulnerable to blockage due to various changes in
joins the ciliary ganglion. blood chemistry. If it gets blocked, the result is blind-
c. Other filaments pass along the oculomotor, ness of that eye.
trochlear, abducent, and ophthalmic nerves. All
these sympathetic nerves are vasomotor in Other end arteries are:
function. • Labyrinthine artery for the inner ear
• Coronary arteries are functional end arteries
Mnemonics though these do anastomose
Extraocular muscles; cranial nerve innervation • Central branches of cerebral arteries
“LR6SO4 rest 3” • Segmental branches of the kidney and spleen
Lateral rectus by VI
FURTHER READING
Superior oblique by IV
Rest are by III cranial nerve, i.e. levator palpebrae • Graw J. Eye development. Curr Top Dev Biol 2010;90:343–86.
This paper presents the transcription factors in eye development
Head and Neck
superioris, superior rectus (SR), medial rectus (MR),

inferior rectus (IR) and inferior oblique (IO). and discusses their relevance to human eye disorders.
• Pedrosa-Domellof F, Holmgren Y, Lucas CA, et al. Human
extraocular muscles: Unique pattern of myosin heavy chain
expression during myotube formation. Invest Ophthalmol
FACTS TO REMEMBER Vis Sci 2000;41:1608–16.
• Levator palpebrae superioris is partly supplied by This paper presents a study of extraocular muscle development in
III nerve and partly by sympathetic fibres. human embryos and fetuses.
• Central artery of retina is an end artery. • Sinn R, Wittbrodt J. An eye of eye development. Mech of
Dev 2013;130:347–58.
• Nerve supply of extraocular muscles is LR6, SO4,
This paper reviews the transcription factors in development of the
rest (levator palpebrae sup., SR, MR, IR and IO)
eye.
by III.
• Miller JM. Understanding and misunderstanding extraocular
• Edinger-Westphal is the nucleus for the supply of muscle pulleys. J Vis 2007;7:10:1–15.
ciliaris muscles and constrictor pupillae muscles. A discussion of the issues and controversies regarding the role of
extraocular muscle pulleys in health and disease.
1–3
245
1. Describe extraocular muscles under the following 2. Write short notes on:
headings: a. Ciliary ganglion
a. Origin b. Insertion b. Levator palpebrae superioris
c. Actions d. Nerve supply c. Ophthalmic artery
e. Clinical importance d. Actions of oblique muscles
1. Which nucleus is related to ciliary ganglion? a. Medial rectus is supplied by III nerve
a. Superior salivatory b. Superior oblique turns the centre of cornea
upwards and laterally
b. Lacrimatory
c. Inferior oblique arises from medial wall of the
c. Inferior salivatory orbit
d. Edinger-Westphal d. Lateral rectus is supplied by IV nerve
2. Ophthalmic artery is a branch of which of the 5. Which nerve does not transverse the middle part
following arteries? of superior orbital fissure?
a. Internal carotid a. Two divisions of III nerve
b. External carotid
b. Frontal nerve
c. Maxillary
c. VI nerve
d. Vertebral
3. Supraorbital artery is a branch of: d. Nasociliary nerve
a. Maxillary 6. Which of the following arteries is an end-artery?
b. External carotid a. Lacrimal artery
c. Ophthalmic b. Zygomaticotemporal artery
d. Internal carotid c. Central artery of retina
4. Which of the following is true about ocular muscles? d. Anterior ethmoidal artery
1. d 2. a 3. c 4. a 5. b 6. c
Head and Neck
• Name the extraocular muscles with their nerve • What is the course of nerve to inferior oblique?
supply. • Name the branches of ophthalmic division of V
• What nerves course through superior orbital fissure? nerve.
• Which muscles are attached behind the equator of • What are the nerve supply and insertions of levator
the eyeball? palpebrae superioris muscle?
• What type of artery is ‘central artery of retina’ and why? • Which are the muscles innervated by fibres of
• Name the roots and branches of the ciliary ganglion. Edinger-Westphal nucleus?
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246
14
Mouth and Pharynx
At times it is better to keep your mouth shut and let people wonder if you
are a fool than to open it and remove all their doubts .
—James Sinclaire
ORAL CAVITY 4 Except for the teeth, the entire vestibule is lined by
mucous membrane. The mucous membrane forms
median folds that pass from the lips to the gums,
Oral cavity is used for ingestion of food and fluids. It is
and are called the frenula of the lips.
continued posteriorly into the oropharynx, the middle
part of the muscular pharynx. In its upper part, opens
the posterior part of the nasal cavity and the inlet of CLINICAL ANATOMY
larynx opens into its lower part. Roof of oral cavity is for-
med by the hard and the soft palates. Tongue is the biggest • The papilla of the parotid duct in the vestibule of
occupant of the oral cavity, described in Chapter 17. the mouth provides access to the parotid duct for
The cavity also contains 32 teeth in an adult. the injection of the radio-opaque dye to locate
calculi in the duct system or the gland (Fig. 14.1).
Identification • Koplik’s spots are seen as white pin point spots
Identify the structures in your own oral cavity. These are around the opening of the parotid duct in measles.
the vestibule, lips, cheeks, oral cavity proper and teeth. These are diagnostic of the disease.
Divisions Lips
The oral or mouth cavity is divided into an outer, 1 The lips are fleshy folds lined externally by skin and
smaller portion, the vestibule, and an inner larger part, internally by mucous membrane. The mucocutaneous
the oral cavity proper. junction lines the ‘edge’ of the lip, part of the mucosal
surface is also normally seen.
Head and Neck
VESTIBULE
2 Each lip is composed of:
1 The vestibule of the mouth is a narrow space bounded a. Skin
externally by the lips and cheeks, and internally by
b. Superficial fascia
the teeth and gums (Fig. 14.1).
2 It communicates: c. The orbicularis oris muscle
a. With the exterior through the oral fissure. d. The submucosa, containing mucous labial glands
b. With the mouth open, it communicates freely with and blood vessels
the oral cavity proper. Even when the teeth are e. Mucous membrane.
occluded a small communication remains behind 3 The lips bound the oral fissure. They meet laterally at
the third molar tooth. the angles of the mouth. The inner surface of each
3 The parotid duct opens on the inner surface of the lip is supported by a frenulum which ties it to the
cheek opposite the crown of the upper second molar gum. Philtrum is a median vertical groove on the
tooth (Fig. 14.1). Numerous labial and buccal glands outer surface of the upper lip.
(mucous) situated in the submucosa of the lips and 4 Lymphatics of the central part of the lower lip drain
cheeks open into the vestibule. Four or five molar to the submental nodes; the lymphatics from the
glands (mucous), situated on the buccopharyngeal rest of the lower lip pass to the submandibular
fascia, also open into the vestibule. nodes.
246
MOUTH AND PHARYNX
247
Fig. 14.1: Interior of the mouth cavity
Cheeks (Buccae) 2 The sublingual region presents the following features:

1 The cheeks are fleshy flaps, forming a large part of a. In the median plane, there is a fold of mucosa
each side of the face. They are continuous in front passing from the inferior aspect of the tongue to
with the lips, and the junction is indicated by the the floor of the mouth. This is the frenulum of the
nasolabial sulcus (furrow) which extends from the side tongue.
of the nose to the angle of the mouth. b. On each side of the frenulum, there is a sublingual
2 Each cheek is composed of: papilla. On the summit of this papilla, there is the
a. Skin opening of submandibular duct.
b. Superficial fascia containing some facial muscles, c. Running laterally and backwards from the
the parotid duct, mucous molar glands, vessels sublingual papilla, there is the sublingual fold which
and nerves. overlies the sublingual gland. A few sublingual
c. The buccinator covered by buccopharyngeal fascia ducts open on the edge of this fold.
and pierced by the parotid duct. 3 Lymphatics from the anterior part of the floor of the
d. Submucosa, with mucous buccal glands. mouth pass to the submental nodes. Those from the
e. Mucous membrane. hard palate and soft palate pass to the retro-
3 The buccal pad of fat is best developed in infants. It pharyngeal and upper deep cervical nodes. The gums
Head and Neck

lies on the buccinator partly deep to the masseter and the rest of the floor drain into the submandibular
and partly in front of it. nodes.
4 The lymphatics of the cheek drain chiefly into the
Gums (Gingivae)
submandibular and preauricular nodes, and partly
also to the buccal and mandibular nodes. 1 The gums are the soft tissues which envelop the
alveolar processes of the upper and lower jaws and
ORAL CAVITY PROPER surround the necks of the teeth. These are composed
1 It is bounded anterolaterally by the teeth, the gums of dense fibrous tissue covered by stratified
and the alveolar arches of the jaws. The roof is formed squamous epithelium.
by the hard palate and the soft palate. The floor is 2 Each gum has two parts:
occupied by the tongue posteriorly, and presents the a. The free part surrounds the neck of the tooth like
sublingual region anteriorly, below the tip of the a collar.
tongue. Posteriorly, the cavity communicates with b. The attached part is firmly fixed to the alveolar arch
the pharynx through the oropharyngeal isthmus of the jaw. The fibrous tissue of the gum is
(isthmus of fauces) which is bounded superiorly by continuous with the periosteum lining the alveoli
the soft palate, inferiorly by the tongue, and on each (periodontal membrane).
side by the palatoglossal arches. 3 Nerve supply of gums is shown in Table 14.1.
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248
Table 14.1: Nerve supply of gums

Upper gums Nerve supply
Labial side Posterior, middle and anterior
(Fig. 14.4) superior alveolar nerves (V2)
Lingual side Anterior palatine and
(see Fig. 15.16) nasopalatine nerves (from
pterygopalatine ganglion)
Lower gums
Labial side Buccal branch of mandibular and
incisive branch of mental nerve
(V3)
Lingual side Lingual nerve (V3)
4 Lymphatics of the upper gums pass to the submandi-

bular nodes. The anterior part of the lower gums
drains into the submental nodes, whereas the
posterior part drains into the submandibular nodes.
Figs 14.2a and b: Deciduous and permanent teeth. (1) Central

CLINICAL ANATOMY
incisor; (2) Lateral incisor; (3) Canine; (4) 1st premolar; (5) 2nd
Ludwig’s angina is the cellulitis of the floor of the premolar; (6) 1st molar; (7) 2nd molar; (8) 3rd molar
mouth. The tongue is forced upwards leading to
swelling both below the chin and within the mouth.
The disease is usually caused due to a carious molar
tooth.
TEETH
The teeth form part of the masticatory apparatus and
are fixed to the jaws. In man, the teeth are replaced only
once (diphyodont) in contrast with non-mammallian
vertebrates where teeth are constantly replaced
throughout life (polyphyodont). The teeth of the first set
(dentition) are known as milk, or deciduous teeth, and
the second set, as permanent teeth.
The deciduous teeth are 20 in number. In each half
Head and Neck
of each jaw, there are two incisors, one canine, and two
molars.
The permanent teeth are 32 in number, and consist
of two incisors (Latin to cut), one canine (Latin dog),
two premolars (Latin millstone), and three molars in
each half of each jaw (Fig. 14.2).
Fig. 14.3: Parts of a tooth
Parts of a Tooth
2 The dentine surrounding the pulp.
Each tooth has three parts:
3 The enamel covering the projecting part of dentine,
1 A crown, projecting above or below the gum.
or crown.
2 A root, embedded in the jaw beneath the gum.
3 A neck, between the crown and root and surrounded 4 The cementum surrounding the embedded part of
by the gum (Fig. 14.3). the dentine.
5 The periodontal membrane.
Structure The pulp is loose fibrous tissue containing vessels,
Structurally, each tooth is composed of: nerves and lymphatics, all of which enter the pulp
1 The pulp in the centre cavity through the apical foramen. The pulp is covered
MOUTH AND PHARYNX
249
by a layer of tall columnar cells, known as odontoblasts Table 14.2: Usual time of eruption of teeth and time of
which are capable of replacing dentine any time in life. shedding of deciduous teeth
The dentine is a calcified material containing spiral Tooth Eruption time Shedding time
tubules radiating from the pulp cavity. Each tubule is Deciduous (Fig. 14.2a)
occupied by a protoplasmic process from one of the Medial incisor 6–8 months 6–7 years
odontoblasts. The calcium and organic matter are in Lateral incisor 8–10 months 7–8 years
the same proportion as in bone. First molar 12–16 months 8–9 years
The enamel is the hardest substance in the body. It is Canine 16–20 months 10–12 years
made up of crystalline prisms lying roughly at right Second molar 20–24 months 10–12 years
angles to the surface of the tooth.
Permanent (Fig. 14.2b)
The cementum resembles bone in structure, but like First molar 6–7 years
enamel and dentine, there is neither any blood supply Medial incisor 7–8 years
nor any nerve supply. Over the neck, the cementum Lateral incisor 8–9 years
commonly overlaps the cervical end of enamel; or, less First premolar 10–11 years
commonly, it may just meet the enamel. Rarely, it stops Second premolar 11–12 years
short of the enamel (10%) leaving the cervical dentine Canine 12–13 years
covered only by gum. Second molar 13–14 years
The periodontal membrane (ligament) holds the root in Third molar 17–25 years
its socket. This membrane acts as a periosteum to both
the cementum as well as the bony socket. The lower teeth are supplied by the inferior alveolar
nerve (mandibular nerve) (Fig. 14.4).
Form and Function (Crowns and Roots)
1 The shape of a tooth is adapted to its function. The CLINICAL ANATOMY
incisors are cutting teeth, with chisel-like crowns. The
upper and lower incisors overlap each other like the • Being the hardest and chemically the most stable
blades of a pair of scissors. The canines are holding and tissues in the body, the teeth are selectively
tearing teeth, with conical and rugged crowns. These preserved after death and may be fossilized.
are better developed in carnivores. Each premolar has Because of this, the teeth are very helpful in
two cusps and is, therefore, also called a bicuspid medicolegal practice for identification of otherwise
tooth. The molars are grinding teeth, with square unrecognizable dead bodies. The teeth also
crowns, bearing four or five cusps on their crowns. provide by far the best data to study evolutionary
2 The incisors, canines and premolars have single changes and the relationship between ontogeny
roots, with the exception of the first upper premolar and phylogeny.
which has a bifid root. The upper molars have three • In scurvy (caused by deficiency of vitamin C), the
roots, of which two are lateral and one is medial. gums are swollen and spongy, and bleed on touch.
The lower molars have only two roots—an anterior In gingivitis, the edges of the gums are red and
Head and Neck

and a posterior. bleed easily.
• Improper oral hygiene may cause gingivitis and
Eruption of Teeth
suppuration with pocket formation between the
The deciduous teeth begin to erupt at about the sixth teeth and gums. This results in a chronic pus
month, and all get erupted by the end of the second year discharge at the margin of the gums. The condition
or soon after. The teeth of the lower jaw erupt slightly is known as pyorrhoea alveolaris (chronic
earlier than those of the upper jaw. The approximate periodontitis). Pyorrhoea is common cause of foul
ages of eruption of deciduous and permanent teeth are breath for which the patient hardly ever consults
given in Table 14.2. Blood supply of teeth—both upper a dentist because the condition is painless.
and lower are supplied by branches of maxillary artery.
• Decalcification of enamel and dentine with
Nerve Supply of Teeth consequent softening and gradual destruction of
the tooth is known as dental caries. A caries tooth
The pulp and periodontal membrane have the same is tender on mastication.
nerve supply which is as follows:
• Infection of apex of root (apical abscess) occurs
The upper teeth are supplied by the posterior superior only when the pulp is dead. The condition can be
alveolar, middle superior alveolar, and the anterior recognized in a good radiograph.
superior alveolar nerves (maxillary nerve).
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250
Fig. 14.4: Nerve supply of teeth
• Irregular dentition is common in rickets and the grow into underlying mesenchyme. This is the bud
upper permanent incisors may be notched, the stage (Figs 14.5a and b)
notching corresponds to a small segment of a large 3 The deeper enlarged parts of the tooth bud is called
circle. Even in congenital syphilis, the same teeth enamel organ.
are notched, but the notching corresponds to a 4 The enamel organ of dental bud is invaginated by
large segment of a small circle (Hutchinson’s teeth). mesenchyme of dental papilla making it cap-shaped.
This is the cap stage (Fig. 14.5c).
• The third molar teeth, also called wisdom teeth,
usually erupt between 18 and 20 years. These may The dental papilla together with enamel organ is
not erupt normally due to less space and may get known as the tooth germ. The cell of enamel organ
impacted causing enormous pain. adjacent to dental papilla cells get columnar and are
known as ameloblasts.
• Time of eruption of the teeth helps in assessing The mesenchymal cells now arrange themselves
the age of the person. along the ameloblasts and are called odontoblasts. The
• The upper canine teeth are called as the ‘eye teeth’ two cell layers are separated by a basement membrane.
as these have long roots which reach up to the The rest of the mesenchymal cells form the ‘pulp of the
Head and Neck
medial angle of the eye. Infection of these roots tooth’. This is the bell stage (Fig. 14.5d).
may spread in the facial vein and even lead to Now ameloblasts lay enamel on the outer aspect,
thrombosis of the cavernous sinus. while odontoblasts lay dentine on the inner aspect.
• The upper teeth need separate injections of the Later ameloblasts disappear while odontoblasts remain.
anaesthetic on both the buccal and palatal surfaces The root of the tooth is formed by laying down of
of the maxillary process just distal to the tooth. layers of dentine, narrowing the pulp space to a canal for
The thin layer of bone permits rapid diffusion of the passage of nerve and blood vessels only (Fig. 14.5e).
the drug up to the tooth. The dentine in the root is covered by mesenchymal cells
which differentiate into cementoblasts for laying down
STAGES OF DEVELOPMENT OF DECIDUOUS TEETH
the cementum. Outside, this is the periodontal ligament
connecting root to the socket in the bone.
1 By 6th week of development, the epithelium covering Ectoderm forms enamel of tooth. Neural crest cells
the convex border of alveolar process of upper and form dentine, dental pulp, cementum and periodontal
lower jaws becomes thickened to form C-shaped dental ligament.
lamina, which projects into the underlying mesoderm. Formation of permanent teeth: These develop from the
2 Dental laminae of upper and lower jaws develop dental buds arising from the dental lamina and lie on
10 centres of proliferation from which dental buds the medial side of each developing milk tooth.
MOUTH AND PHARYNX
251
Head and Neck

Figs 14.5a to e: Development of tooth
Molecular Regulation of Tooth Development Teeth may also be having a ‘signaling centre’ like an
Tooth development is an example of epithelial– organizer. This organizer region is called ‘enamel knot’
mesenchymal interaction. The mesenchyme is of and appears in the dental epithelium at the tips of the
neural-crest origin. tooth buds. This enamel knot enlarges at the ‘cap stage’
Tooth pattering from incisors to molars is an but disappears at the end of this stage. During the time
expression of HOX genes from mesenchyme. The of presence of the enamel knot, it expresses SHH, FGF4
epithelium causes differentiation to the bud stage. Then and BMP2 and 4. FGF4 could be regulating outgrowth
the mesenchyme causes the crest of the development. of cusps; while BMP4 may regulate timing of apoptosis
Various factors needed are WNTs, bone morphogenetic in the knot cells. Many factors affect tooth development,
proteins, BMP and fibroblast growth factors (FGFs). The including genetic and environmental factors.
transcription factors are MSX1 and 2 which interact to Enamel—ameloblasts lies on a thick layer of dentine.
produce cell differentiation of each tooth. Dentine—odontoblasts—neural crest derivative
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252
Cementum—cementoblast; mesenchymal derivative DISSECTION

found in the root of teeth.
Milk teeth—erupt between 6 to 24 months Cut through the centre of the frontal bone, internasal
Permanent teeth—erupt during 6th year to 25 years suture, intermaxillary sutures, chin, hyoid bone, thyroid,
Pharyngeal arches: Skeletal elements of pharyngeal cricoid and tracheal cartilages; carry the incision through
arches are regulated by genes expressed in endoderm the septum of nose, nasopharynx, tongue, and both the
of pharyngeal pouches. There is an interaction between palates.
epithelium and mesenchyme. Cut through the centre of the remaining occipital bone
Mesenchyme expression of genes is determined by and cervical vertebrae. This will complete the sagittal
homeodomain containing transcription factors OTX2 section of head and neck.
and HOX genes carried to pharyngeal arches by Hard palate: Strip the mucoperiosteum of hard palate.
migrating neural crest cells. The neural crest cells arise Soft palate: Remove the mucous membrane of the
from caudal part of midbrain and from segments in soft palate in order to identify its muscles. Also remove
hindbrain known as rhombomeres. These genes are the mucous membrane over palatoglossal and
controlled by endodermal signals and form the skeletal palatopharyngeal arches and salpingopharyngeal fold
elements from the respective arches. to visualise the subjacent muscles (refer to BDC App).
HARD PALATE
It is a partition between the nasal and oral cavities. AN 36.1 Describe the: 1) morphology, relations, blood supply and
Its anterior two-thirds are formed by the palatine applied anatomy of palatine tonsil, 2) composition of soft palate.1
processes of the maxillae; and its posterior one-third
by the horizontal plates of the palatine bones (Fig. 14.6). SOFT PALATE
The anterolateral margins of the palate are continuous
with the alveolar arches and gums. It is a movable, muscular fold, suspended from the
The posterior margin gives attachment to the soft posterior border of the hard palate.
palate. It separates the nasopharynx from the oropharynx,
The superior surface forms the floor of the nose. the crossroads between the food and air passages
The inferior surface forms the roof of the oral cavity. (Fig. 14.7).
The soft palate has two surfaces—anterior and
Vessels and Nerves posterior; and two borders—superior and inferior
Arteries: Greater palatine branch of maxillary artery (see (Fig. 14.8a).
Figs 6.6 and 6.7). The anterior (oral) surface is concave and is marked
by a median raphe.
Veins: Drain into the pterygoid plexus of veins.
The posterior surface is convex, and is continuous
Nerves: Greater palatine and nasopalatine branches of superiorly with the floor of the nasal cavity.
the pterygopalatine ganglion suspended by the The superior border is attached to the posterior border
maxillary nerve. of the hard palate, blending on each side with the
Lymphatics: The lymphatics drain mostly to the upper pharynx (Figs 14.9a and b).
Head and Neck
deep cervical nodes and partly to the retropharyngeal

nodes.
Fig. 14.6: Hard palate Fig. 14.7: Soft palate with palatine tonsils
MOUTH AND PHARYNX
253
Figs 14.8a and b: (a) Attachment of the muscles of the soft palate; (b) Muscles of soft palate
Head and Neck

Fig. 14.9a: Sagittal section through the pharynx, the nose, the mouth and the larynx
The inferior border is free and bounds the pharyngeal oropharyngeal isthmus or isthmus of fauces. The
isthmus. From its middle, there hangs a conical posterior fold is called the palatopharyngeal arch or
projection, called the uvula (Fig. 14.7). From each side posterior pillar of fauces. It contains the palato-
of the base of the uvula (Latin small grape), two curved pharyngeus muscle. It forms the posterior boundary
folds of mucous membrane extend laterally and down- of the tonsillar fossa, and merges inferiorly with the
wards. The anterior fold is called the palatoglossal arch lateral wall of the pharynx (Fig. 14.8).
or anterior pillar of fauces. It contains the
palatoglossus muscle and reaches the side of the Structure
tongue at the junction of its oral and pharyngeal parts. The soft palate is a fold of mucous membrane con-
This fold forms the lateral boundary of the taining the following parts.
HEAD AND NECK
254
Fig. 14.9b: Sagittal section of pharynx
• The palatine aponeurosis which is the flattened tendon 2 General sensory nerves are derived from:
of the tensor veli palatini forms the fibrous basis of a. The middle and posterior lesser palatine nerves,
the palate. Near the median plane, the aponeurosis which are branches of the maxillary nerve through
splits to enclose the musculus uvulae. the pterygopalatine ganglion (see Fig. 15.16).
• The levator veli palatini and the palatopharyngeus b. The glossopharyngeal nerve.
lie on the superior surface of the palatine aponeurosis. 3 Special sensory or gustatory nerves carrying taste
• The palatoglossus lies on the inferior or anterior sensations from the oral surface are contained in the
surface of the palatine aponeurosis. lesser palatine nerves. The fibres travel through the
• Numerous mucous glands, and some taste buds are greater petrosal nerve to the geniculate ganglion of
present. the facial nerve and from there to the nucleus of the
Soft palate comprises epithelium, connective tissue tractus solitarius (Flowchart 14.1).
and muscles. Epithelium is from the ectoderm of 4 Secretomotor nerves are also contained in the lesser
maxillary process. The muscles are derived from 1st, palatine nerves. They are derived from the superior
4th and 6th branchial arches and accordingly are salivatory nucleus and travel through the greater
innervated by mandibular and vagoaccessory complex.
Head and Neck
petrosal nerve (Flowchart 14.2).

Muscles of the Soft Palate Passavant’s Ridge
They are as follows: Some of the upper fibres of the palatopharyngeus pass
1 Tensor palati (tensor veli palatini) (Figs 14.8a and b) circularly deep to the mucous membrane of the
2 Levator palati (levator veli palatini) pharynx, to form a sphincter internal to the superior
3 Musculus uvulae constrictor. These fibres constitute Passavant’s muscle
4 Palatoglossus which on contraction raises a ridge called the
5 Palatopharyngeus. Passavant’s ridge on the posterior wall of the
Details of the muscles are given in Table 14.3. nasopharynx. When the soft palate is elevated it comes
in contact with this ridge, the two together closing the
Nerve Supply
pharyngeal isthmus between the nasopharynx and the
1 Motor nerves. All muscles of the soft palate except oropharynx.
the tensor veli palatini are supplied by the
pharyngeal plexus. The fibres of this plexus are Morphology of Palatopharyngeus
derived from the cranial part of the accessory nerve In mammals with an acute sense of smell, the epiglottis
through the vagus. The tensor veli palatini is lies above the level of the soft palate, and is supported
supplied by the mandibular nerve. by two vertical muscles (stylopharyngeus and
MOUTH AND PHARYNX
255
Table 14.3: Muscles of the soft palate

Muscle Origin Insertion Actions
1. Tensor veli palatini a. Lateral side of auditory Muscle descends, converges to a. Tightens the soft palate,
This is a thin, triangular tube form a delicate tendon which winds chiefly the anterior part
muscle (Figs 14.8a and b) b. Adjoining part of the base round the pterygoid hamulus, b. Opens the auditory tube
of the skull (greater wing passes through the origin of the to equalize air pressure
and scaphoid fossa of buccinator, and flattens out to form between the middle ear
sphenoid bone) the palatine aponeurosis. and the nasopharynx
Aponeurosis is attached to:
a. Posterior border of hard palate
b. Inferior surface of palate behind
the palatine crest
2. Levator veli palatini a. Inferior aspect of auditory Muscle enters the pharynx by a. Elevates soft palate and
This is a cylindrical tube passing over the upper concave closes the pharyngeal
muscle that lies deep to b. Adjoining part of inferior margin of the superior constrictor, isthmus
the tensor veli palatini surface of petrous runs downwards and medially and b. Opens the auditory tube-
temporal bone spreads out in the soft palate. It is like the tensor veli
inserted into the upper surface of palatini
the palatine aponeurosis
3. Musculus uvulae a. Posterior nasal spine Mucous membrane of uvula Pulls up the uvula
This is a longitudinal strip b. Palatine aponeurosis
placed on each side of
the median plane, within
the palatine aponeurosis
4. Palatoglossus Oral surface of palatine Descends in the palatoglossal Pulls up the root of the
(Figs 14.9a and b) aponeurosis arch, to the side of the tongue at tongue, approximates the
the junction of its oral and palatoglossal arches, and
pharyngeal parts thus closes the
oropharyngeal isthmus
5. Palatopharyngeus a. Anterior fasciculus from Descends in the palatopharyngeal Pulls up the wall of the
It consists of two fasciculi posterior border of hard arch and spreads out to form the pharynx and shortens it
that are separated by the palate greater part of longitudinal muscle during swallowing
levator veli palatini b. Posterior fasciculus coat of pharynx. It is inserted into:
(also see Passavant’s from the palatine a. Posterior border of the lamina
ridge) aponeurosis of the thyroid cartilage
b. Wall of the pharynx and its
median raphe
Flowchart 14.1: Gustatory nerves Flowchart 14.2: Secretomotor nerves
Head and Neck

HEAD AND NECK
256
salpingopharyngeus) and by a sphincter formed by 3 By varying the degree of closure of the pharyngeal
palatopharyngeus. The palatopharyngeal sphincter isthmus, the quality of voice can be modified and
clasps the inlet of the larynx. various consonants are correctly pronounced.
In man, the larynx descends and pulls the sphincter 4 During sneezing, the blast of air is appropriately
downwards leading to the formation of the human divided and directed through the nasal and oral
palatopharyngeus muscle. However, some fibres of the cavities without damaging the narrow nose. Similarly
sphincter are left behind and form a sphincter inner to during coughing, it directs air and sputum into the
the superior constrictor at the level of the hard palate. mouth and not into the nose (Figs 14.10a and b).
These fibres constitute Passavant’s muscle. Passavant’s
muscle is best developed in cases of cleft palate, as this Blood Supply
compensates to some extent for the deficiency in the Arteries
palate. 1 Greater palatine branch of maxillary artery (see
Fig. 6.6).
Movements and Functions of the Soft Palate
2 Ascending palatine branch of facial artery.
The palate controls two gates—upper air way or the
3 Palatine branch of ascending pharyngeal artery.
pharyngeal isthmus and the upper food way or
oropharyngeal isthmus. The upper air way crosses the Veins
upper food way (Figs 14.10a and b). The soft palate can They pass to the pterygoid and tonsillar plexuses of
completely close them, or can regulate their sizes veins.
according to requirements. Through these movements,
the soft palate plays an important role in chewing, Lymphatics
swallowing, speech, coughing, sneezing, etc. A few Drain into the upper deep cervical and retropharyngeal
specific roles are given below. lymph nodes.
1 It isolates the mouth from the oropharynx during
chewing, so that breathing is unaffected. Competency achievement: The student should be able to:
2 It separates the oropharynx from the nasopharynx AN 43.4 Describe the development and developmental basis of
by locking Passavant’s ridge during the second congenital anomalies of face, palate, tongue, branchial apparatus,
stage of swallowing, so that food does not enter the pituitary gland, thyroid gland and eye.2 (Palate is described here.
For the rest of organs, please see respective chapters.)
nose.
Head and Neck
Figs 14.10a and b: Crossing of upper airway and upper food passages
MOUTH AND PHARYNX
257
CLINICAL ANATOMY
• Cleft palate is a congenital defect caused by non-
fusion of the right and left palatal processes. It may
be of different degrees. In the least severe type,
the defect is confined to the soft palate. In the most
severe cases, the cleft in the palate is continuous
with harelip (Fig. 14.11).
• Paralysis of the soft palate in lesions of the vagus
nerve produces:
a. Nasal regurgitation of liquids
b. Nasal twang in voice
c. Flattening of the palatal arch
d. Deviation of uvula to normal side (Fig. 14.12).
• Choking by food/fluid causes laryngeal
obstruction and asphyxia. Heimlich maneuver can
remove the obstruction.
Heimlich Manoeuvre
Stand behind the patient. Pass your arm under his
arm. Put hand in his epigastrium; one hand made
into a fist and other hand over fist. Give 3–4
abdominal thrusts directed upwards and backwards. Fig. 14.12: Uvula deviated to right side in paralysis of left
This helps in squeezing residual air from lungs in vagus nerve
trachea, and larynx, dislodges the foreign body and
relieves laryngeal obstruction.
DEVELOPMENT OF PALATE
The premaxilla or primitive palate carrying upper
four incisor teeth is formed by the fusion of medial
nasal folds, which are folds of frontonasal process.
The rest of the palate is formed by the shelf-like
palatine processes of maxilla and horizontal plates of
palatine bone. Most of the palate gets ossified to form
the hard palate. The unossified posterior part of fused
palatal processes forms the soft palate.
PHARYNX
Head and Neck

The pharynx (Latin throat) is a wide muscular tube,
situated behind the nose, the mouth and the larynx.
Clinically, it is a part of the upper respiratory passages
where infections are common. The upper part of the
pharynx transmits only air, the lower part (below
the inlet of the larynx), only food, but the middle part
is a common passage for both air and food (Figs 14.9
and 14.10). The nasopharynx part of pharynx is
connected to the middle ear via the pharyngotympanic
tube.
Dimensions of Pharynx
Figs 14.11a to e: Types of congenital cleft palate: (a) Bilateral
complete; (b) Unilateral complete cleft palate; (c) Partial midline
Length: About 12 cm.
cleft; (d) Cleft of soft palate; (e) Bifid uvula Width:
1 Upper part is widest (3.5 cm) and non-collapsible
HEAD AND NECK
258
DISSECTION Parts of the Pharynx

Identify the structures in the interior of three parts of The cavity of the pharynx is divided into:
pharynx, i.e. nasopharynx, oropharynx and laryngo- 1 The nasal part—nasopharynx (Figs 14.9a and b)
pharynx. Clean the surfaces of buccinator muscle and 2 The oral part—oropharynx (Table 14.3)
adjoining superior constrictor muscles by removing 3 The laryngeal part—laryngopharynx (Fig. 14.18).
connective tissue and buccopharyngeal fascia over Comparison between nasopharynx, oropharynx and
these muscles. Detach the medial pterygoid muscle laryngopharynx shown in Table 14.4.
from its origin and reflect it downwards. This will expose
the superior constrictor muscle completely (refer to
BDC App).
AN 36.2 Describe the components and functions of Waldeyer’s
lymphatic ring.3
2 Middle part is narrow
3 The lower end is the narrowest part of the gastro- Waldeyer’s Lymphatic Ring
intestinal tract (except for the vermiform). In relation to the naso-oropharyngeal isthmus, there
are several aggregations of lymphoid tissue that
Boundaries constitute Waldeyer’s lymphatic ring (Fig. 14.13). The
Superiorly most important aggregations are the right and left
Base of the skull, including the posterior part of the palatine tonsils usually referred to simply as the tonsils.
body of the sphenoid and the basilar part of the occipital Posteriorly and above, there is the nasopharyngeal
bone, in front of the pharyngeal tubercle. tonsil; laterally and above, there are the tubal tonsils,
and inferiorly, there is the lingual tonsil over the
Inferiorly posterior part of the dorsum of the tongue.
The pharynx is continuous with the oesophagus at the
level of the sixth cervical vertebra, corresponding to
the lower border of the cricoid cartilage.
Posteriorly
The pharynx glides freely on the prevertebral fascia
which separates it from the cervical vertebral bodies.
Anteriorly
It communicates with the nasal cavity, the oral cavity
and the larynx. Thus, the anterior wall of the pharynx
is incomplete.
Head and Neck
On Each Side Fig. 14.13: Waldeyer’s lymphatic ring

1 The pharynx is attached to:
a. Medial pterygoid plate CLINICAL ANATOMY
b. Pterygomandibular raphe
• Hypertrophy or enlargement of the naso-
c. Mandible
pharyngeal tonsil or adenoids may obstruct the
d. Tongue posterior nasal aperture and may interfere with
e. Hyoid bone nasal respiration and speech leading to mouth
f. Thyroid and cricoid cartilages. breathing. These tonsils usually regress by puberty.
• Hypertrophy of the tubal tonsil may occlude the
2 It communicates on each side with the middle ear
auditory or pharyngotympanic tube leading to
cavity through the auditory tube.
middle ear problems.
3 The pharynx is related on either side to:
a. The styloid process and the muscles attached to it.
b. The common carotid, internal carotid, and external AN 36.1 Describe the 1) morphology, relations, blood supply and
carotid arteries, and the cranial nerves related to applied anatomy of palatine tonsil, 2) composition of soft palate.4
them.
MOUTH AND PHARYNX
259
Table 14.4: Comparison between nasopharynx, oropharynx and laryngopharynx

Particulars Nasopharynx Oropharynx Laryngopharynx
a. Situation Behind nose Behind oral cavity Behind larynx
b. Extent Base of skull (body of Soft palate to upper border of Upper border of epiglottis to
sphenoid) to soft palate epiglottis (Figs 14.9a and b) lower border of cricoid cartilage
c. Communications Anteriorly with nose 1. Anteriorly with oral cavity Inferiorly with oesophagus
(Fig. 14.9a) 2. Above with nasopharynx Anteriorly with larynx (Fig.14.9b)
Below with oropharynx 3. Below with laryngopharynx Above with oropharynx
d. Nerve supply Pharyngeal branches of IX and X nerves IX and X nerves
pterygopalatine ganglion
e. Relations: 1. Inlet of larynx
i. Anterior Posterior nasal aperture Oral cavity 2. Posterior surface of cricoid
cartilage
3. Arytenoid cartilage
ii. Posterior Body of sphenoid bone and Body of second and third cervical Fourth and fifth cervical vertebrae
and roof basiocciput and anterior arch vertebrae
of atlas. Presence of:
a. Nasopharyngeal tonsil
prominent in children
b. Nasopharyngeal bursa—
mucus diverticulum
iii. Lateral wall Opening of auditory tube Tonsillar fossa containing palatine Piriform fossa on each side of
above tube is tubal elevation tonsils inlet of larynx, bounded by
with tubal tonsil aryepiglottic fold medially and
thyroid cartilage laterally.
f. Lining epithelium Ciliated columnar epithelium Stratified squamous nonkeratinised Stratified squamous nonkerati-
epithelium nised epithelium
g. Function Passage for air Passage for air and food Passage for food
(respiratory function)
PALATINE TONSIL (THE TONSIL) palatopharyngeus muscle. This firm attachment keeps
Features the tonsil in place during swallowing (Fig. 14.15).
The palatine tonsil (Latin swelling) occupies the The tonsillar artery enters the tonsil by piercing the
tonsillar sinus or fossa between the palatoglossal and superior constrictor just behind the firm attachment
palatopharyngeal arches (Figs 14.7, 14.13 and 14.14). It (Fig. 14.15).
Head and Neck

can be seen through the mouth. The palatine vein or external palatine or paratonsillar
vein descends from the palate in the loose areolar tissue
The tonsil is almond-shaped. It has two surfaces—
on the lateral surface of the capsule, and crosses the
medial and lateral; two borders—anterior and posterior;
tonsil before piercing the wall of the pharynx. The vein
and two poles—upper and lower.
may be injured during removal of the tonsil or
The medial surface is covered by stratified squamous tonsillectomy (Fig. 14.15).
epithelium continuous with that of the mouth. This The bed of the tonsil is formed from within outwards
surface has 12 to 15 crypts. The largest of these is called by:
the intratonsillar cleft (Fig. 14.13). a. The pharyngobasilar fascia (Fig. 14.14)
The lateral surface is covered by a sheet of fascia which b. The superior constrictor and palatopharyngeus
forms the hemicapsule of the tonsil. The capsule is an muscles
extension of the pharyngobasilar fascia. It is only loosely c. The buccopharyngeal fascia
attached to the muscular wall of the pharynx, formed d. In the lower part, the styloglossus
here by the superior constrictor and by the styloglossus, e. The glossopharyngeal nerve.
but anteroinferiorly the capsule is firmly adherent to the Still more laterally, there are the facial artery with
side of the tongue (suspensory ligament of tonsil) just its tonsillar and ascending palatine branches. The internal
in front of the insertion of the palatoglossus and the carotid artery is 2.5 cm posterolateral to the tonsil.
HEAD AND NECK
260
Fig. 14.14: Horizontal section through the tonsil showing its deep relations
Fig. 14.15: Vertical section through the tonsil, showing its deep relations
Head and Neck
The anterior border is related to the palatoglossal arch Arterial Supply of Tonsil
with its muscle (Fig. 14.7). 1 Main source: Tonsillar branch of facial artery.
The posterior border is related to the palatopharyngeal 2 Additional sources:
arch with its muscle. a. Ascending palatine branch of facial artery
The upper pole is related to the soft palate, and the b. Dorsal lingual branches of the lingual artery
lower pole, to the tongue (Fig. 14.15). c. Ascending pharyngeal branch of the external
The plica triangularis is a triangular vestigial fold of carotid artery
mucous membrane covering the anteroinferior part of d. The greater palatine branch of the maxillary artery
the tonsil. The plica semilunaris is a similar semilunar (Fig. 14.16).
fold that may cross the upper part of the tonsillar sinus.
The intratonsillar cleft is the largest crypt of the tonsil. Venous Drainage
It is present in its upper part (Fig. 14.13). It is sometimes One or more veins leave the lower part of deep surface
wrongly named the supratonsillar fossa. The mouth of of the tonsil, pierce the superior constrictor, and join
cleft is semilunar in shape and parallel to dorsum of the palatine, pharyngeal, or facial veins.
tongue. It represents the internal opening of the second
pharyngeal pouch. A peritonsillar abscess or quinsy Lymphatic Drainage
often begins in this cleft. Lymphatics pass to jugulodigastric node (see Fig. 8.28).
MOUTH AND PHARYNX
261
• Suppuration in the peritonsillar area is called

quinsy. A peritonsillar abscess is drained by
making an incision in the most prominent point
of the abscess.
• Tonsils are often sites of a septic focus. Such a focus
can lead to serious disease like pulmonary tuber-
culosis, meningitis, etc. and is often the cause of
general ill health.
HISTOLOGY
The palatine tonsil is situated at the oropharyngeal
isthmus. Its oral aspect is covered with stratified
squamous nonkeratinised epithelium, which dips into
the underlying tissue to form the crypts. The
Fig. 14.16: Arterial supply of the palatine tonsil lymphocytes lie on the sides of the crypts in the form
of nodules. The structure of tonsil is not differentiated
There are no afferent lymphatics to the tonsil. into cortex and medulla (Fig. 14.17).
Nerve Supply DEVELOPMENT
Glossopharyngeal and lesser palatine nerves. The tonsil develops from endoderm of ventral part of
second pharyngeal pouch. Some part persists as the
intratonsillar cleft. The lymphocytes are mesodermal
AN 43.2 Identify, describe and draw the microanatomy of pituitary
gland, thyroid, parathyroid gland, tongue, salivary glands, tonsil, in origin.
cornea, retina.5
LARYNGEAL PART OF PHARYNX (LARYNGOPHARYNX)
AN 36.4 Describe the anatomical basis of tonsillitis, tonsillectomy,
adenoids and peritonsillar abscess.6 This is the lower part of the pharynx situated behind
Microanatomy of tonsil is described here. For the other tissues the larynx. It extends from the upper border of the
please see respective chapters. epiglottis to the lower border of the cricoid cartilage.
The anterior wall presents:
CLINICAL ANATOMY a. The inlet of the larynx (Fig. 14.18)
b. The posterior surfaces of the cricoid and arytenoid
• The tonsils are large in children. They retrogress
cartilages.
after puberty.
• The tonsils are frequently sites of infection,
specially in children. Infection may spread to
Head and Neck

surrounding tissue forming a peritonsillar abscess.
• Enlarged and infected tonsils often require
surgical removal. The operation is called
tonsillectomy. A knowledge of the relationship of
the tonsil is of importance to the surgeon.
• Tonsillectomy is usually done by the guillotine
method. Haemorrhage after tonsillectomy is
checked by removal of clot from the raw tonsillar
bed. This is to be compared with the method for
checking postpartum haemorrhage from the
uterus. These are the only two organs in the body
where bleeding is checked by removal of clots. In
other parts of the body, clot formation is
encouraged.
• Tonsillitis may cause referred pain in the ear as
glossopharyngeal nerve supplies both these areas.
Fig. 14.17: Histology of palatine tonsil
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262
Fig. 14.18: The three regions of the pharynx
The posterior wall is supported mainly by the fourth STRUCTURE OF PHARYNX

and fifth cervical vertebrae, and partly by the third and The wall of the pharynx is composed of the following
sixth vertebrae. In this region, the posterior wall of the five layers (Fig. 14.20) from within outwards.
pharynx is formed by the superior, middle and inferior
1 Mucosa
constrictors of the pharynx.
2 Submucosa
The lateral wall presents a depression called the
3 Pharyngobasilar fascia or pharyngeal aponeurosis.
piriform fossa, one on each side of the inlet of the larynx
This is a fibrous sheet internal to the pharyngeal
(Fig. 14.18). The fossa is bounded medially by the
muscles. It is thickest in the upper part where it fills
aryepiglottic fold, and laterally by the thyroid cartilage the gap between the upper border of the superior
and the thyrohyoid membrane. Beneath the mucosa of constrictor and the base of the skull, and also
fossa, there lies the internal laryngeal nerve. Removal posteriorly where it forms pharyngeal raphe.
of foreign bodies from the piriform fossa may damage Superiorly, the fascia is attached to basiocciput, the
the internal laryngeal nerve, leading to anaesthesia in petrous temporal bone, the auditory tube, posterior
the supraglottic part of the larynx (Fig. 14.19). border of the medial pterygoid plate, and pterygo-
mandibular raphe. Inferiorly, it is gradually lost deep
Head and Neck
to muscles, and hardly extend beyond the superior

constrictor.
4 The muscular coat consists of an outer circular layer
made up of the three constrictors (superior, middle and
inferior) and an inner longitudinal layer made up of
the stylopharyngeus, the salpingopharyngeus and the
palatopharyngeus muscles. These muscles are
described later.
5 The buccopharyngeal fascia covers the outer surface
of the constrictors of the pharynx and extends
forwards across the pterygomandibular raphe to
cover the buccinator. Like the pharyngobasilar fascia,
the buccopharyngeal fascia is best developed in the
upper part of the pharynx.
Between the buccopharyngeal fascia and the
Fig. 14.19: Posterior view of the piriform fossa after removal of muscular coat, there are the pharyngeal plexuses of
the tongue: Internal laryngeal nerve is shown only on left side veins and nerves (Fig. 14.20).
MOUTH AND PHARYNX
263
situated anteriorly in relation to the posterior openings

of the nose—the mouth and the larynx. From here their
fibres pass into the lateral and posterior walls of the
pharynx, the fibres of the two sides meeting in the mid-
line in a fibrous raphe.
The three constrictors are so arranged that the
inferior overlaps middle which in turn overlaps the
superior. The fibres of the superior constrictor reach
the base of skull posteriorly, in the middle line. On the
sides, however, there is a gap between the base of the
skull and the upper edge of the superior constrictor.
This gap is closed by the pharyngobasilar fascia which
is thickened in this situation (Fig. 14.21). The lower edge
of the inferior constrictor becomes continuous with the
circular muscle of the oesophagus. These muscles
develop from IV and VI pharyngeal arches (see Table
A.5 in Appendix).
Fig. 14.20: Structure of the pharynx
Origin of Constrictors
MUSCLES OF THE PHARYNX (REFER TO BDC APP) 1 The superior constrictor takes origin (Fig. 14.21) from
the following (from above downwards):
Preliminary Remarks about the
Constrictors of the Pharynx a. Pterygoid hamulus (pterygopharyngeus)
The muscular basis of the wall of the pharynx is formed b. Pterygomandibular raphe (buccopharyngeus)
mainly by the three pairs of constrictors—superior, c. Medial surface of the mandible at the posterior end
middle and inferior. The origins of the constrictors are of the mylohyoid line, i.e. near the lower attach-
Head and Neck
Fig. 14.21: Origin of the constrictors of the pharynx

HEAD AND NECK
264
ment of the pterygomandibular raphe (see Fig. 1.25)

(mylopharyngeus).
d. Side of posterior part of tongue (glossopharyngeus).
2 The middle constrictor takes origin from:
a. The lower part of the stylohyoid ligament
b. Lesser cornua of hyoid bone
c. Upper border of the greater cornua of the hyoid
bone (see Fig. 1.47).
3 The inferior constrictor consists of two parts. One part,
the thyropharyngeus, arises from the thyroid cartilage.
The other part, the cricopharyngeus, arises from the
cricoid cartilage.
The thyropharyngeus arises from:
a. The oblique line on the lamina of thyroid cartilage,
including the inferior tubercle (Fig. 14.21).
b. A tendinous band that crosses the cricothyroid
muscle and is attached above to the inferior
tubercle of the thyroid cartilage.
Fig. 14.23: Longitudinal muscles of pharynx: (1) Stylopharyngeus;
c. The inferior cornua of the thyroid cartilage. (2) Salpingopharyngeus; (3) Palatopharyngeus
The cricopharyngeus arises from the cricoid carti-
lage behind the origin of the cricothyroid muscle.
surface of the middle and inferior constrictors. The
fibres of the palatopharyngeus descend from the sides of
Insertion of Constrictors
the palate and run longitudinally on the inner aspect
All the constrictors of the pharynx are inserted into a of the constrictors (Fig. 14.23). The salpingopharyngeus
median raphe on the posterior wall of the pharynx. The descends from the auditory tube to merge with palato-
upper end of the raphe reaches the base of the skull pharyngeus.
where it is attached to the pharyngeal tubercle on the
basilar part of the occipital bone (Fig. 14.22).
STRUCTURES IN BETWEEN PHARYNGEAL MUSCLES
Longitudinal Muscle Coat Features
The pharynx has three muscles that run longitudinally. 1 The large gap between the upper concave border of the
The stylopharyngeus arises from the styloid process. It superior constrictor and the base of the skull is semilunar
passes through the gap between the superior and and is known as the sinus of Morgagni. It is closed by
middle constrictors to run downwards on the inner the upper strong part of the pharyngobasilar fascia
Head and Neck
(Fig. 14.24).
The structures passing through this gap are:
a. The auditory tube
b. The levator veli palatini muscle
c. The ascending palatine artery (Fig. 14.24)
d. Palatine branch of ascending pharyngeal artery.
2 The structures passing through the gap between the
superior and middle constrictors are: The stylopharyn-
geus muscle and the glossopharyngeal nerve.
3 The internal laryngeal nerve and the superior
laryngeal vessels pierce the thyrohyoid membrane
in the gap between the middle and inferior constrictors.
4 The recurrent laryngeal nerve and the inferior laryn-
geal vessels pass through the gap between the lower
Fig. 14.22: Insertion of the constrictors of pharynx border of the inferior constrictor and the oesophagus.
MOUTH AND PHARYNX
265
Figs 14.25a and b: (a) Pharyngeal diverticulum, and

(b) pharyngeal diverticulum after barium swallow
in the pig. Pharyngeal diverticula are often attributed

to neuromuscular incoordination in this region which
may be due to the fact that different nerves supply the
two parts of the inferior constrictor (Fig. 14.22). The pro-
pulsive thyropharyngeus is supplied by the pharyngeal
plexus, and sphincteric cricopharyngeus by the
Fig. 14.24: Schematic coronal section through the pharynx,
showing the gaps between pharyngeal muscles and the recurrent laryngeal nerve. If the cricopharyngeus fails
structures related to them to relax when the thyropharyngeus contracts, the bolus
of food is pushed backwards, and tends to produce a
diverticulum.
DISSECTION
Define the attachments of middle and inferior constrictors CLINICAL ANATOMY
of pharynx, and the structures situated traversing through
the gaps between the three constrictor muscles. Identify • Difficulty in swallowing is known as dysphagia.
structures above the superior constrictor muscle and • Pharyngeal diverticulum: Read Killian’s dehiscence
below the inferior constrictor muscle. (Fig. 14.25a).
Cut through the tensor veli palatini and reflect it
downwards. Remove the fascia and identify the NERVE SUPPLY OF PHARYNX
mandibular nerve again with otic ganglion medial to it.
The pharynx is supplied by the pharyngeal plexus of
Head and Neck

Identify the branches of the mandibular nerve. Locate
the middle meningeal artery at the foramen spinosum, nerves which lies chiefly on the middle constrictor. The
as it lies just posterior to mandibular nerve. plexus is formed by:
1 The pharyngeal branch of the vagus carrying fibres
Competency achievement: The student should be able to: of the cranial accessory nerve.
AN 36.5 Describe the clinical significance of Killian’s dehiscence.7
2 The pharyngeal branches of the glossopharyngeal
nerve.
Killian’s Dehiscence 3 The pharyngeal branches of the superior cervical
sympathetic ganglion.
In the posterior wall of the pharynx, the lower part of
the thyropharyngeus is a single sheet of muscle, not Motor fibres are derived from the cranial accessory
overlapped internally by the superior and middle nerve through the branches of the vagus. They supply
constrictors. This weak part lies below the level of the all muscles of pharynx, except the stylopharyngeus
vocal folds or upper border of the cricoid lamina and is which is supplied by the glossopharyngeal nerve.
limited inferiorly by the thick cricopharyngeal sphinc- The inferior constrictor receives an additional supply
ter. This area is known as Killian’s dehiscence. Pharyngeal from the external and recurrent laryngeal nerves.
diverticula are formed by outpouching of the dehi- Sensory fibres or general visceral afferent from
scence (Figs 14.25a and b). Such diverticula are normal the pharynx travel mostly through the glosso-
HEAD AND NECK
266
pharyngeal nerve, and partly through the vagus. Second Stage

However, the nasopharynx is supplied by the maxillary 1 It is involuntary in character. During this stage, the
nerve through the pterygopalatine ganglion; and the food is pushed from the oropharynx to the lower part
soft palate and tonsil by the lesser palatine and of the laryngopharynx.
glossopharyngeal nerves. 2 The nasopharyngeal isthmus is closed by elevation
Taste sensations from the vallecula and epiglottic of the soft palate by levator veli palatini and tensor
area pass through the internal laryngeal branch of the veli palatini and by approximation to it of the
vagus. posterior pharyngeal wall (ridge of Passavant). This
The parasympathetic secretomotor fibres to the prevents the food bolus from entering the nose.
pharynx are derived from the lesser palatine branches 3 The inlet of larynx is closed by approximation of the
of the pterygopalatine ganglion (see Fig. 15.15). aryepiglottic folds by aryepiglottic and oblique
arytenoid. This prevents the food bolus from entering
BLOOD SUPPLY OF PHARYNX the larynx (see Fig. 16.10).
The arteries supplying the pharynx are almost the same 4 Next, the larynx and pharynx are elevated behind
as those supplying the tonsil. These are as follows: the hyoid bone by the longitudinal muscles of the
pharynx. Then the bolus is pushed down over the
1 Ascending pharyngeal branch of the external carotid posterior surface of the epiglottis, the closed inlet of
artery. the larynx and the posterior surface of the arytenoid
2 Ascending palatine and tonsillar branches of the cartilages, by gravity, and by contraction of the
facial artery. superior and middle constrictors and the palato-
3 Dorsal lingual branches of the lingual artery. pharyngeus.
4 The greater palatine, pharyngeal and pterygoid
branches of the maxillary artery. Third Stage
The veins form a plexus on the posterolateral aspect 1 This is also involuntary in character. In this stage,
of the pharynx. The plexus receives blood from the food passes from the lower part of the pharynx to
pharynx, the soft palate and the prevertebral region. It the oesophagus.
drains into the internal jugular and facial veins. 2 This is brought about by the inferior constrictors of
the pharynx.
LYMPHATIC DRAINAGE OF PHARYNX
Lymph from the pharynx drains into the retro- DEVELOPMENT
pharyngeal and deep cervical lymph nodes. The primitive gut extends from the buccopharyngeal
membrane cranially, to the cloacal membrane caudally.
DEGLUTITION (SWALLOWING) It is divided into four parts—the pharynx, the foregut,
Swallowing of food occurs in three stages described the midgut and the hindgut. The pharynx extends
below. Muscles of pharynx act during swallowing. from buccopharyngeal membrane to the tracheo-
bronchial diverticulum. It is divided into upper part,
Head and Neck
First Stage the nasopharynx; middle part, the oropharynx; and

1 This stage is voluntary in character. the lower part, the laryngopharynx.
2 The anterior part of the tongue is raised and pressed
against the hard palate by the intrinsic muscles of Competency achievement: The student should be able to:
the tongue, especially the superior longitudinal and AN 40.2 Describe and demonstrate the boundaries, contents,
relations and functional anatomy of middle ear and auditory tube.8
transverse muscles. The movement takes place from
anterior to the posterior side. This pushes the food bolus
(Greek lump) into the posterior part of the oral cavity. PHARYNGOTYMPANIC TUBE
3 The soft palate closes down onto the back of the Auditory tube is also known as the pharyngotympanic
tongue, and helps to form the bolus. tube or the eustachian tube.
4 Next, the hyoid bone is moved upwards and The auditory tube is a trumpet-shaped channel
forwards by the suprahyoid muscles. The posterior which connects the middle ear cavity with the
part of the tongue is elevated upwards and nasopharynx. It is about 4 cm long, and is directed
backwards by the styloglossi; and the palatoglossal downwards, forwards and medially. It forms an angle
arches are approximated by the palatoglossi. This of 45° with the sagittal plane and 30° with the horizontal
pushes the bolus through the oropharyngeal isthmus plane. The tube is divided into bony and cartilaginous
to the oropharynx, and the second stage begins. parts (Fig. 14.26).
MOUTH AND PHARYNX
267
Fig. 14.26: Scheme showing anatomy of auditory tube and external auditory meatus
Bony Part middle meningeal artery and medial pterygoid plate

The bony part forms the posterior and lateral one-third (see Fig. 6.17).
of the tube. It is 12 mm long, and lies in the petrous 2 Posteromedially: Petrous temporal and levator veli
temporal bone near the tympanic plate. Its lateral end palatini.
is wide and opens on the anterior wall of the middle ear 3 The levator veli palatini is attached to its inferior
cavity. The medial end is narrow (isthmus) and is jagged surface, and the salpingopharyngeus to lower part
for attachment of the cartilaginous part. The lumen of near the pharyngeal opening.
the tube is oblong being widest from side-to-side.
Vascular Supply
Relations
The arterial supply of the tube is derived from the
1 Superior: Canal for the tensor tympani (see Fig. 18.13). ascending pharyngeal and middle meningeal arteries
2 Medial: Carotid canal. and the artery of the pterygoid canal.
3 Lateral: Chorda tympani, spine of sphenoid, auriculo- The veins drain into the pharyngeal and pterygoid
temporal nerve (Fig. 14.8) and the temporomandi- plexuses of veins. Lymphatics pass to the retro-
Head and Neck

bular joint. pharyngeal nodes.
Cartilaginous Part Nerve Supply

The cartilaginous part forms the anterior and medial 1 At the ostium, by the pharyngeal branch of the pterygo-
two-thirds of the tube. It is 25 mm long, and lies in the palatine ganglion suspended by the maxillary nerve.
sulcus tubae, a groove between the greater wing of the 2 Cartilaginous part, by the nervus spinosus branch
sphenoid and the apex of the petrous temporal. of mandibular nerve.
It is made up of a triangular plate of cartilage which 3 Bony part, by the tympanic plexus formed by glosso-
is curled to form the superior and medial walls of the pharyngeal nerve.
tube. The lateral wall and floor are completed by a
fibrous membrane. The apex of the plate is attached to Function
the medial end of the bony part. The base is free and The tube provides a communication of the middle ear
forms the tubal elevation in the nasopharynx (Fig. 14.9). cavity with the exterior, thus ensuring equal air
pressure on both sides of the tympanic membrane.
Relations The tube is usually closed. It opens during
1 Anterolaterally: Tensor veli palatini, mandibular nerve swallowing, yawning and sneezing, by the actions of
and its branches, otic ganglion, chorda tympani, the tensor and levator veli palatini muscles.
HEAD AND NECK
268
CLINICAL ANATOMY • All the muscles of soft palate are supplied by

vagoaccessory complex except tensor veli palatini,
• Infections may pass from the throat to the middle supplied by V3 nerve.
ear through the auditory tube. This is more • Tonsillar branch of facial artery is the main artery
common in children because the tube is shorter, of the palatine tonsil.
wider and straighter in them (Fig. 14.27).
• Tonsils have only efferent lymph vessels but no
• Inflammation of the auditory tube (Eustachian afferent lymph vessel.
catarrh) is often secondary to an attack of common
• Killian’s dehiscence is a potential gap between
cold, or of sore throat. This causes pain in the ear thyropharyngeus and cricopharyngeus.
which is aggravated by swallowing, due to
blockage of the tube. Pain is relieved by instillation
of decongestant drops in the nose, which help to CLINICOANATOMICAL PROBLEM
open the ostium. The ostium is commonly blocked
in children by enlargement of the tubal tonsil. A 12-year-old boy complained of sore throat and ear-
• Pharyngeal spaces (see Chapter 3). ache. He had 102°F temperature and difficulty in
swallowing. He was also a mouth breather.
• What is Waldeyer’s lymphatic ring?
• Explain the basis of boy’s earache.
• What lymph node would likely to be swollen and
tender?
Ans: Major collections of lymphoid tissue at the
oropharyngeal junction are called the tonsils.
These lie in a ring form called the Waldeyer’s lymphatic
ring. The components of this ring are lingual tonsil
anteriorly, palatine tonsil laterally, tubal tonsil
Fig. 14.27: Differences in Eustachian tube in adult and child posterolaterally and pharyngeal tonsil posteriorly.
The earache may be due to infection of the throat
reaching the middle ear. The pharyngotympanic tube
Mnemonics from the region of nasopharynx communicates with
the anterior wall of the middle ear cavity carrying the
Tonsils: The four types “PPLT (people) have
infection from pharynx to the ear causing the earache.
tonsils”
IX nerve supplies both the pharynx and the middle
Pharyngeal ear. So the pain of pharynx is referred to the ear.
Palatine The jugulodigastric lymph node belonging to
Lingual upper group of deep cervical group is most likely to
be tender and swollen, as the lymphatics from the
Tubal
tonsil penetrate the wall of the pharynx to reach these
Head and Neck
lymph nodes.
FACTS TO REMEMBER
FURTHER READING
• Both the maxillary and mandibular teeth are • Berkovitz BKB, Holland GR, Moxham BJ. Oral Anatomy,
supplied by the branches of maxillary artery only. Histology and Embryology, 4th ed. Edinburgh: Mosby, 2009.
• Upper teeth are supplied by branches of maxillary A textbook that describes in detail the gross morphology, histology
nerve. and development of human teeth.
• Graney DO, Retruzzelli GJ, Myers EW. Anatomy. In:
• Lower teeth are supplied by branches of mandi-
Cummings CW, Fredrickson JM, Harker LA, et al (eds).
bular nerve. Otolaryngology: Head and Neck Surgery, vol 2, 3rd end. St
• Waldeyer’s ring consists of lingual tonsil, palatine Louis: Elsevier, Mosby; 1998; pp. 1327–48
tonsils, tubal tonsils and nasopharyngeal tonsils. A concise account of the anatomy of the pharynx, highlighting
• All the 3 constrictors and 2 longitudinal muscles features of clinical relevance.
of pharynx are supplied by vagoaccessory • Hollinshead WH. Anatomy for Surgeons, Vol 1: The Head
complex, only stylopharyngeus is supplied by IX and Neck, 3rd ed. Philadelphia: Harper & Row, 1982.
An older textbook that provides a valuable account of the anatomy
nerve.
of the pharynx and of tissue spaces in the neck. It is also a through
guide to the earlier literature.
1–8
MOUTH AND PHARYNX
269
1. Describe the nerve supply and actions of the 3. Describe the attachments of the constrictor muscles
muscles of soft palate. Add a note on its develop- of pharynx. Enumerate the structures lying in
ment including congenital anomalies.
between these constrictor muscles.
2. Enumerate the components of Waldeyer’s ring.
Describe the palatine tonsil in detail. Add a note 4. Enumerate the length, parts, extent, relations and
on its clinical importance. functions of auditory tube.
1. The communication between vestibule and oral 6. Which of the following structures does not form
cavity proper lies: bed of the tonsil?
a. Behind 1st molar tooth a. Superior constrictor
b. Behind 2nd molar tooth b. Pharyngobasilar fascia
c. Behind 3rd molar tooth c. Buccinator muscle
d. No communication d. Buccopharyngeal fascia
7. Which one of the following muscles of pharynx is
2. The joint between tooth and gum is:
not supplied by vagoaccessory complex?
a. Syndesmosis a. Superior constrictor
b. Gomphosis b. Stylopharyngeus
c. Sutures c. Palatopharyngeus
d. Primary cartilaginous joint d. Salpingopharyngeus
3. The first permanent tooth to erupt is: 8. Which walls of cartilaginous part of auditory tube
a. First molar are formed by fibrous membrane?
b. First premolar a. Lateral wall and floor
c. Second molar b. Medial wall and floor
c. Superior wall and medial wall
d. Canine
d. Superior wall and floor
4. Most of the muscles of soft palate are supplied by
9. Paralysis of unilateral soft palate results in following
vagoaccessory complex, except:
effects, except:
a. Levator veli palatini a. Depressed palatal arch
Head and Neck

b. Tensor veli palatini b. Uvula deviated to paralysed side
c. Palatoglossus c. Nasal twang of voice
d. Musculus uvulae d. Nasal regurgitation of liquids
5. Which one of the following is not a component of 10. Tonsillitis pain is referred to pain in ear as both are
Waldeyer’s ring? supplied by:
a. Tubal tonsil a. Auricular branch of vagus
b. Pharyngeal tonsil b. Glossopharyngeal nerve
c. Palatine tonsil c. Sympathetic fibres
d. Submental lymph nodes d. Cranial root of XI nerve
1. c 2. b 3. a 4. b 5. d 6. c 7. b 8. a 9. b 10. b
HEAD AND NECK
270
• Give the nerve supply of all the gums. • Name the deep relations of the palatine tonsil.
• What are the parts of a tooth? • Which all arteries supply the palatine tonsil.
• Which nerves supply the teeth?
• Name the muscles of the soft palate and give their • What is the function of auditory/pharyngo-
nerve supply. tympanic tube? Name its parts and their length.
• Name the longitudinal and circular muscles of the • What is Killian’s dehiscence and what is its
pharynx with their nerve supply. importance?
Head and Neck
Nose, Paranasal Sinuses and 15
Pterygopalatine Fossa
Did God give us flowers and trees and also provide the allergies?
—E Y Harburg
INTRODUCTION the superior concha. It is thin and less vascular than

the respiratory mucosa. It contains receptors called
Sense of smell perceived in the upper part of nasal
olfactory cells.
cavity by olfactory nerve rootlets ends in olfactory bulb,
For descriptive purposes, the nose is divided into
which is connected to uncus and also to the dorsal
two main parts, the external nose and nasal cavity.
nucleus of vagus in medulla oblongata. Good smell of
food, thus stimulates secretion of gastric juice through
EXTERNAL NOSE
vagus nerve.
Most of the mucous membrane of the nasal cavity is Some features of the external nose have been described
respiratory and is continuous with various paranasal in Chapter 2. These are root, dorsum, tip, anterior nares,
sinuses. Since nose is the most projecting part of the nasal septum and columella.
face, its integrity must be maintained. The external nose has a skeletal framework that is
Environmental pollution causes inhalation of partly bony and partly cartilaginous. The bones are the
unwanted gases and particles, leading to frequent attacks nasal bones, which form the bridge of the nose, and
of sinusitis, respiratory diseases including asthma. the frontal processes of the maxillae. The cartilages are
Nasal mucous membrane is quite vascular. Some- the superior and inferior nasal cartilages, the septal
times picking of the nose may cause bleeding from cartilage, and small alar cartilages (Figs 15.1a and b).
‘Little’s area’. Bleeding from nose is called epistaxis. The skin over the external nose is supplied by the
external nasal, infratrochlear and infraorbital nerves
(see Fig. 2.16).
NOSE
NASAL CAVITY
The nose performs two functions. It is a respiratory The nasal cavity extends from the external nares or
passage. It is also the organ of smell. The receptors for nostrils to the posterior nasal apertures, and is
smell are placed in the upper one-third of the nasal subdivided into right and left halves by the nasal
cavity. This part is lined by olfactory mucosa. The rest septum (Figs 15.2 and 15.4). Each half has a roof, a floor,
of the nasal cavity is lined by respiratory mucosa. The and medial and lateral walls. Each half measures about
respiratory mucosa is highly vascular and warms the 5 cm in height, 5–7 cm in length, and 1.5 cm in width
inspired air. near the floor. The width near the roof is only 1–2 mm.
The secretions of numerous serous glands make the The roof is about 7 cm long and 2 mm wide. It slopes
air moist; while the secretions of mucous glands trap downwards, both in front and behind. The middle
dust and other particles. Thus the nose acts as an air horizontal part is formed by the cribriform plate of the
conditioner where the inspired air is warmed, ethmoid. The anterior slope is formed by the nasal part
moistened and cleansed before it is passed onto the of the frontal bone, nasal bone, and the nasal cartilages.
delicate lungs. The posterior slope is formed by the inferior surface of
The olfactory mucosa lines the upper one-third of the the body of the sphenoid bone (Fig. 15.4).
nasal cavity including the roof formed by cribriform The floor is about 5 cm long and 1.5 cm wide. It is
plate and the medial and lateral walls up to the level of formed by the palatine process of the maxilla and the
271
HEAD AND NECK
272
Figs 15.1a and b: (a) Skeleton of the external nose; (b) Anterior view
Fig. 15.2: Coronal section through the nasal cavity and the maxillary air sinuses
horizontal plate of the palatine bone. It is concave from • Fracture of cribriform plate of ethmoid with tearing
Head and Neck
side-to-side and is slightly higher anteriorly than off of the meninges may tear the olfactory nerve
posteriorly (Fig. 15.2). rootlets (Fig. 15.3). In such cases, CSF may drip from
the nasal cavity. It is called CSF rhinorrhoea.
CLINICAL ANATOMY
• Common cold or rhinitis is the commonest infection

of the nose. It may be infective or allergic or both.
It commonly occurs during change of the seasons.
• The paranasal air sinuses may get infected from
the nose. Maxillary sinusitis is the commonest of
such infections.
• The relations of the nose to the anterior cranial
fossa through the cribriform plate (Fig. 15.5),
and to the lacrimal apparatus through the
nasolacrimal duct are important in the spread of
infection (see Fig. 2.22a).
Fig. 15.3: CSF rhinorrhoea
NOSE, PARANASAL SINUSES AND PTERYGOPALATINE FOSSA
273
Competency achievement: The student should be able to: The septum has:
AN 37.1 Describe and demonstrate features of nasal septum, lateral a. Four borders—superior, inferior, anterior and
wall of nose, their blood supply and nerve supply.1 posterior.
b. Two surfaces—right and left.
NASAL SEPTUM
Arterial Supply
Features
Anterosuperior part is supplied by the anterior and
The nasal septum is a median osseocartilaginous parti- posterior ethmoidal artery (Fig. 15.5).
tion between the two halves of the nasal cavity. On each
Anteroinferior part is supplied by the septal branch
side, it is covered by mucous membrane and forms the
of superior labial branch of facial artery.
medial wall of both nasal cavities.
Posterosuperior part is supplied by the sphenopalatine
The bony part is formed almost entirely by:
artery. It is the main artery.
a. The vomer
The anteroinferior part or vestibule of the septum
b. The perpendicular plate of ethmoid. However, its contains anastomoses between all branches, e.g. the
margins receive contributions from the nasal spine septal branch of the superior labial branch of the facial
of the frontal bone, the rostrum of the sphenoid, artery, sphenopalatine artery, and anterior ethmoidal
and the nasal crests of the nasal, palatine and artery. These form a large capillary network called the
maxillary bones (Fig. 15.4). Kiesselbach’s plexus. This is a common site of bleeding
The cartilaginous part is formed by: from the nose or epistaxis, and is known as Little’s area.
a. The septal cartilage
b. The septal processes of the inferior nasal cartilages Venous Drainage
(Fig. 15.1b). The veins form a plexus which is more marked in the
The cuticular part or lower end is formed by fibrofatty lower part of septum or Little’s area. The plexus drains
tissue covered by skin. The lower margin of the septum anteriorly into the facial vein, and posteriorly through
is called the columella. the sphenopalatine vein to pterygoid venous plexus.
The nasal septum is rarely strictly median. Its central Nerve Supply
part is usually deflected to one or the other side. The
deflection is produced by overgrowth of one or more 1 General sensory nerves, arising from trigeminal nerve,
of the constituent parts. are distributed to whole of the septum (Fig. 15.6).
a. The anterosuperior part of the septum is supplied
DISSECTION by the internal nasal branches of the anterior
ethmoidal nerve.
Take the sagittal section of head and neck, prepared in
Chapter 14. b. The posteroinferior part is supplied by the naso-
Dissect and remove mucous membrane of the palatine branch of the pterygopalatine ganglion.
septum of nose in small pieces. The mucous membrane It is the main nerve.
is covering both surfaces of the septum of the nose. 2 Special sensory nerves or olfactory nerves are confined
Head and Neck

Dissect and preserve the nerves lying in the mucous to the upper part or olfactory area.
membrane. Remove the entire mucous membrane to
see the details in the interior of the nasal cavity (refer
to BDC App).
Fig. 15.5: Roof of the nasal cavity and arterial supply of nasal
Fig. 15.4: Formation of the nasal septum septum
HEAD AND NECK
274
Fig. 15.6: Nerve supply of nasal septum

Fig. 15.7: Deviated nasal septum
Lymphatic Drainage
Anterior half to the submandibular nodes. conchae. The conchae increase the surface area of the
Posterior half to the retropharyngeal and deep cervical nose for effective air-conditioning of the inspired air
nodes. (Fig. 15.2).
The lateral wall separates the nose:
CLINICAL ANATOMY a. From the orbit above, with the ethmoidal air
sinuses intervening.
• Sphenopalatine artery is the artery of epistaxis. b. From the maxillary sinus below.
• Little’s area on the septum is a common site of c. From the lacrimal sac and nasolacrimal duct in
bleeding from the nose or epistaxis (Fig. 15.5). front (see Fig. 2.22a).
• Pathological deviation of the nasal septum is often
The lateral wall can be subdivided into three parts:
responsible for repeated attacks of common cold,
a. A small depressed area in the anterior part is called
allergic rhinitis, sinusitis, etc. It requires surgical
the vestibule. It is lined by modified skin
correction (Fig. 15.7). containing short, stiff, curved hairs called vibrissae.
b. The middle part is known as the atrium of the
LATERAL WALL OF NOSE
middle meatus.
Features c. The posterior part contains the conchae. Spaces
The lateral wall of the nose is irregular owing to the separating the conchae are called meatuses
presence of three shelf-like bony projections called (Fig. 15.8).
Head and Neck
Fig. 15.8: Lateral wall of the nasal cavity seen after removing the conchae
275
Fig. 15.9: Formation of the lateral wall of the nasal cavity
The skeleton of the lateral wall is partly bony, partly CONCHAE AND MEATUSES
cartilaginous, and partly made up only of soft tissues. Features
The bony part is formed from before backwards by
The nasal conchae are curved bony projections
the following bones:
directed downwards and medially. The following
a. Nasal
three conchae are usually found:
b. Frontal process of maxilla (see Figs 1.22a and b)
1 The inferior concha (Latin shell) is an independent
c. Lacrimal
bone.
d. Labyrinth of ethmoid with superior and middle
2 The middle concha is a projection from the medial
conchae
surface of ethmoidal labyrinth (Fig. 15.8).
e. Inferior nasal concha, made up of spongy bone
3 The superior concha is also a projection from the
only (Fig. 15.9)
medial surface of the ethmoidal labyrinth. This is
f. Perpendicular plate of palatine bone together with
the smallest concha situated just above the
its orbital and sphenoidal processes
posterior part of the middle concha (Fig. 15.8).
g. Medial pterygoid plate.
The meatuses of the nose are passages beneath the
Head and Neck

The cartilaginous part is formed by:
a. The superior nasal cartilage (Fig. 15.1). overhanging conchae. Each meatus communicates
b. The inferior nasal cartilage. freely with the nasal cavity proper (Fig. 15.9).
c. 3 or 4 small cartilages of the ala. 1 The inferior meatus lies underneath the inferior
The cuticular lower part is formed by fibrofatty tissue concha, and is the largest of the three meatuses.
covered with skin. The nasolacrimal duct opens into it at the junction
of its anterior one-third and posterior two-thirds.
The opening is guarded by the lacrimal fold, or
DISSECTION Hasner’s valve.
Remove with scissors the anterior part of inferior nasal 2 The middle meatus lies underneath the middle concha.
concha. This will reveal the opening of the nasolacrimal It presents the following features:
duct. Pass a thin probe upwards through the nasolacrimal a. The ethmoidal bulla is a rounded elevation
duct into the lacrimal sac at the medial angle of the eye. produced by the underlying middle ethmoidal
Remove all the three nasal conchae to expose the sinuses which open at upper margin of bulla.
meatuses lying below the respective concha. This will b. The hiatus semilunaris is a deep semicircular
expose the openings of the sinuses present there (refer sulcus below the bulla.
to BDC App). c. The infundibulum is a short passage at the
anterior end of the hiatus.
HEAD AND NECK
276
d. The opening of frontal air sinus is seen in the DISSECTION

anterior part of hiatus semilunaris (Fig. 15.8).
Trace the nasopalatine nerve till the sphenopalatine
e. The opening of the anterior ethmoidal air sinus is foramen. Try to find a few nasal branches of the greater
present behind the opening of frontal air sinus. palatine nerve.
f. The opening of maxillary air sinus is located in Gently break the perpendicular plate of palatine
posterior part of the hiatus semilunaris. It is bone to expose the greater palatine nerve, branch of
often represented by two openings. the pterygopalatine ganglion. Follow the nerve and
3 The superior meatus lies below the superior concha. its accompanying vessels to the hard palate. Identify
This is the shortest and shallowest of the three the lesser palatine nerves and trace them till the soft
meatuses. It receives the openings of the posterior palate.
ethmoidal air sinuses.
The sphenoethmoidal recess is a triangular fossa just Venous Drainage
above the superior concha. It receives the opening of the The veins form a plexus which drains anteriorly into the
sphenoidal air sinus (Fig. 15.8). facial vein; posteriorly, into the pharyngeal plexus of veins;
The atrium of the middle meatus is a shallow depression and from the middle part, to the pterygoid plexus of veins.
just in front of the middle meatus and above the
vestibule of the nose. It is limited above by a faint ridge Nerve Supply
of mucous membrane, the agger nasi, which runs 1 General sensory nerves derived from the branches of
forwards and downwards from the upper end of the trigeminal nerve are distributed to whole of the
anterior border of the middle concha (Fig. 15.8). lateral wall:
a. Anterosuperior quadrant is supplied by the anterior
Arterial Supply
ethmoidal nerve branch of ophthalmic nerve
1 The anterosuperior quadrant is supplied by the anterior (Fig. 15.11).
ethmoidal artery assisted by the posterior ethmoidal b. Anteroinferior quadrant is supplied by the anterior
artery. superior alveolar nerve, branch of infraorbital,
2 The anteroinferior quadrant is supplied by branches continuation of maxillary nerve.
from the facial artery (Fig. 15.10). c. Posterosuperior quadrant is supplied by the lateral
3 The posterosuperior quadrant is supplied by a few posterior superior nasal branches from the
branches of the sphenopalatine artery. pterygopalatine ganglion.
4 The posteroinferior quadrant is supplied by branches d. Posteroinferior quadrant is supplied by the anterior
from greater palatine artery which pierce the palatine branch from the pterygopalatine
perpendicular plate of palatine bone and passes up ganglion.
through the incisive fossa. 2 Special sensory nerves or olfactory nerves are distributed
to the upper part of the lateral wall just below the
cribriform plate of the ethmoid up to the superior
concha.
Head and Neck
Fig. 15.10: Arteries supplying lateral wall of the nasal cavity Fig. 15.11: Nerve supply of lateral wall of the nasal cavity
277
Note that the olfactory mucosa lies partly on the Competency achievement: The student should be able to:
lateral wall and partly on the nasal septum. AN 37.2 Describe location and functional anatomy of paranasal
sinuses.2
Lymphatic Drainage
Lymphatics from the anterior half of the lateral wall
pass to the submandibular nodes, and from the PARANASAL SINUSES
posterior half, to the retropharyngeal and upper deep
cervical nodes. Features
Paranasal sinuses are air-filled spaces present within
some bones around the nasal cavities. The sinuses are
CLINICAL ANATOMY
frontal, maxillary, sphenoidal and ethmoidal. All of them
Hypertrophy of the mucosa over the inferior nasal open into the nasal cavity through its lateral wall
concha is a common feature of allergic rhinitis, which (Fig. 15.13). The function of the sinuses is to make the
is characterised by sneezing, nasal blockage and skull lighter, warm up and humidify the inspired air.
These also add resonance to the voice. In infections of
excessive watery discharge from the nose.
the sinuses or sinusitis, the voice is altered.
The sinuses are rudimentary, or even absent at birth.
OLFACTORY NERVE—1ST NERVE They enlarge rapidly during the ages of 6 to 7 years,
1 The olfactory cells (16–20 million in man) are bipolar i.e. time of eruption of permanent teeth and then after
neurons. They lie in the olfactory part of the nasal puberty. From birth to adult life, the growth of the
mucosa, and serve both as receptors as well as the sinuses is due to enlargement of the bones; in old age,
first neurons in the olfactory pathway (Fig. 15.12). it is due to resorption of the surrounding cancellous
2 The olfactory nerves, about 20 in number, represent bone.
The anatomy of individual sinuses is important as
central processes of the olfactory cells. They pass
they are frequently infected.
through the cribriform plate of ethmoid and make
synaptic glomeruli with cells of olfactory bulb.
Frontal Sinus
The mitral and tufted cells in the olfactory bulb give
off fibres that form the olfactory tract and reach the 1 The frontal sinus lies in the frontal bone deep to the
anterior perforated substance and uncus. superciliary arch. It extends upwards above the
medial end of the eyebrow, and backwards into the
medial part of the roof of the orbit (Fig. 15.13).
CLINICAL ANATOMY 2 It opens into the middle meatus of nose at the anterior
end of the hiatus semilunaris either through the infundi-
• Anosmia: Loss of olfactory fibres with ageing. bulum or through the frontonasal duct (Fig. 15.8).
• Sense of smell is tested separately in each nostril. 3 The right and left sinuses are usually unequal in size;
• Allergic rhinitis causes temporary olfactory and rarely one or both may be absent. Their average
impairment. height, width and anteroposterior depth are each
Head and Neck

about 2.5 cm. The sinuses are better developed in
males than in females.
DISSECTION
Remove the thin medial walls of the ethmoidal air cells,
and look for the continuity with the mucous membrane
of the nose. Remove the medial wall of maxillary air
sinus extending anteriorly from opening of nasolacrimal
duct till the greater palatine canal posteriorly. Now
maxillary air sinus can be seen. Remove part of the
roof of maxillary air sinus so that the maxillary nerve
and pterygopalatine ganglion are identifiable in the
pterygopalatine fossa.
Trace the infraorbital nerve in infraorbital canal in
floor of orbit. Try to locate the sinuous course of anterior
superior alveolar nerve into the upper incisor teeth.
Fig. 15.12: Olfactory nerve rootlets in lateral wall of nose
HEAD AND NECK
278
the size of opening is reduced to 3 or 4 mm as it is

overlapped by the following:
a. From above, by the uncinate process of the
ethmoid, and the descending part of lacrimal bone.
b. From below, by the inferior nasal concha.
c. From behind, by the perpendicular plate of the
palatine bone (Fig. 15.14). It is further reduced in
size by the thick mucosa of nose.
4 The size of sinus is variable. Average measurements
are: Height—3.5 cm, width—2.5 cm and antero-
posterior depth—3.5 cm (Fig. 15.13).
5 Its roof is formed by the floor of orbit, and is traversed
by the infraorbital nerve. The floor is formed by the
Fig. 15.13: Lateral wall of nasal cavity with location of paranasal alveolar process of maxilla, and lies about 1 cm below
sinuses the level of floor of the nose. The level corresponds
to the level of lower border of the ala of nose.
4 They are rudimentary or absent at birth. They are
well developed between 7 and 8 years of age, but The floor is marked by several conical elevations
reach full size only after puberty. produced by the roots of upper molar and premolar
5 Arterial supply: Supraorbital artery. teeth.
Venous drainage: Into the supraorbital and superior The roots may even penetrate the bony floor to lie
ophthalmic veins. beneath the mucous lining. The canine tooth may
Lymphatic drainage: To submandibular nodes. project into the anterolateral wall.
Nerve supply: Supraorbital nerve. 6 The maxillary sinus is the first paranasal sinus to
develop.
Maxillary Sinus 7 Arterial supply: Facial, infraorbital and greater
palatine arteries.
1 The maxillary sinus lies in the body of the maxilla
(Fig. 15.2), and is the largest of all the paranasal Venous drainage into the facial vein and the pterygoid
sinuses. It is pyramidal in shape, with its base plexus of veins.
directed medially towards the lateral wall of the nose, Lymphatic drainage into the submandibular nodes.
and the apex directed laterally in the zygomatic Nerve supply: Posterior superior alveolar branches
process of the maxilla. from maxillary nerve and anterior and middle
2 It opens into the middle meatus of the nose in the superior alveolar branches from infraorbital nerve.
lower part of the hiatus semilunaris (Fig. 15.8). The
opening/hiatus is nearer the roof (Fig. 15.2). Sphenoidal Sinus
3 In an isolated maxilla, the opening or hiatus of the 1 The right and left sphenoidal sinuses lie within the
maxillary sinus is large. However, in the intact skull, body of sphenoid bone (Fig. 15.13). They are
Head and Neck
Fig. 15.14: Reduced size of maxillary air sinus

279
separated by a septum. The two sinuses are usually

unequal in size. Each sinus opens into the • The maxillary sinus is most commonly involved.
sphenoethmoidal recess of corresponding half of the It may be infected from the nose or from a caries
nasal cavity (Fig. 15.8). tooth. Drainage of the sinus is difficult because
2 Each sinus is related superiorly to the optic chiasma its ostium lies at a higher level than its floor.
and the hypophysis cerebri; and laterally to the Hence, the sinus is drained surgically by making
internal carotid artery and the cavernous sinus an artificial opening near the floor in one of the
(see Fig. 12.5). following two ways:
3 Arterial supply: Posterior ethmoidal and internal a. Antrum puncture can be done by breaking
carotid arteries. the lateral wall of the inferior meatus and
Venous drainage: Into pterygoid venous plexus and pushing in fluid and letting it drain through
cavernous sinus. the natural orifice with head in dependent
Lymphatic drainage: To the retropharyngeal nodes. position (Fig. 15.15).
Nerve supply: Posterior ethmoidal nerve and orbital b. An opening can be made at the canine fossa
branches of pterygopalatine ganglion. through the vestibule of the mouth, deep to the
upper lip (Caldwell-Luc operation).
Ethmoidal Sinuses • Carcinoma of the maxillary sinus arises from the
1 Ethmoidal sinuses are numerous small inter- mucosal lining. Symptoms depend on the direction
communicating spaces which lie within the labyrinth of growth.
of the ethmoid bone (Fig. 15.2). They are completed a. Invasion of the orbit causes proptosis and
from above by the orbital plate of the frontal bone, diplopia. If the infraorbital nerve is involved,
from behind by the sphenoidal conchae and the there is facial pain and anaesthesia of the skin
orbital process of the palatine bone, and anteriorly over the maxilla.
by the lacrimal bone. The sinuses are divided into b. Invasion of the floor may produce a bulging
anterior, middle and posterior groups (Fig. 15.13). and even ulceration of the palate.
2 The anterior ethmoidal sinus is made up of 1 to 11 air c. Forward growth obliterates the canine fossa
cells, opens into the anterior part of the hiatus and produces a swelling of the face.
semilunaris of the nose. It is supplied by the anterior d. Backward growth may involve the palatine
ethmoidal nerve and vessels. Its lymphatics drain nerves and produce severe pain referred to the
into the submandibular nodes. upper teeth.
3 The middle ethmoidal sinus consisting of 1 to 7 air cells e. Growth in a medial direction produces nasal
open into the middle meatus of the nose. It is obstruction, epistaxis and epiphora.
supplied by the anterior ethmoidal nerve and vessels f. Growth in a lateral direction produces a
and the orbital branches of the pterygopalatine swelling on the face and a palpable mass in the
ganglion. Lymphatics drain into the submandibular labiogingival groove.
nodes (Fig. 15.8).
4 The posterior ethmoidal sinus consisting of 1 to 7 air
Head and Neck

cells open into the superior meatus of the nose. It is
supplied by the posterior ethmoidal nerve and
vessels and the orbital branches of the pterygo-
palatine ganglion. Lymphatics drain into the
retropharyngeal nodes.

AN 37.3 Describe anatomical basis of sinusitis and maxillary sinus
tumours.3
CLINICAL ANATOMY
• Infection of a sinus is known as sinusitis. It causes
headache and persistent, thick, purulent discharge
from the nose. Diagnosis is assisted by transillumi-
nation and radiography. A diseased sinus is Fig. 15.15: Antrum puncture. Directions showing the invasion
opaque. of the carcinoma of maxillary sinus
HEAD AND NECK
280
• Frontal sinusitis and ethmoiditis can cause Communications

oedema of the lids secondary to infection of the Anteriorly: With the orbit through the medial end of
sinuses. the inferior orbital fissure (Fig. 15.16).
• Pain from ethmoid air sinus may be referred to Posteriorly
forehead, as both are supplied by ophthalmic 1 Middle cranial fossa through the foramen rotundum.
division of trigeminal nerve.
2 Foramen lacerum through the pterygoid canal.
• Pain of maxillary sinusitis may be referred to
upper teeth and infraorbital skin as all these are 3 Pharynx through the palatinovaginal canal.
supplied by the maxillary nerve. Medially: With the nose through sphenopalatine foramen.
Laterally: With the infratemporal fossa through the
pterygomaxillary fissure.
PTERYGOPALATINE FOSSA
Inferiorly: With the oral cavity through the greater and
lesser palatine canals.
This is small pyramidal space situated deeply, below
the apex of the orbit (Fig. 15.16). Contents
Boundaries 1 Third part of the maxillary artery and its branches
which bear the same names as the branches of the
Study the boundaries on the skull.
pterygopalatine ganglia and accompany all of them
Anterior: Superomedial part of the posterior surface of
(see Chapter 6; Figs 6.6 and 6.7).
the maxilla.
2 Maxillary nerve and its branches—ganglionic,
Posterior: Root of the pterygoid process and adjoining zygomatic and posterior superior alveolar.
part of the anterior surface of the greater wing of the 3 Pterygopalatine ganglion and its numerous branches
sphenoid. containing fibres of the maxillary nerve mixed with
autonomic nerves (described below).
Medial: Upper part of the perpendicular plate of the
palatine bone. The orbital and sphenoidal processes of Maxillary Nerve
the bone also take part.
It arises from the trigeminal ganglion, runs forwards
Lateral: The fossa opens into the infratemporal fossa in the lateral wall of the cavernous sinus below the
through the pterygomaxillary fissure. ophthalmic nerve, and leaves the middle cranial
fossa by passing through the foramen rotundum
Superior: Undersurface of the body of sphenoid. (see Fig. 12.14). Next, the nerve crosses the upper part
Inferior: Closed by the pyramidal process of the palatine of pterygopalatine fossa, beyond which it is continued
as the infraorbital nerve.
bone in the angle between the maxilla and the pterygoid
process. In the middle cranial fossa, maxillary nerve gives a
meningeal branch.
Head and Neck
In the pterygopalatine fossa, the nerve is related to

the pterygopalatine ganglion, and gives off the
ganglionic, posterior superior alveolar and zygomatic
nerves.
Ganglionic Branches
The pterygopalatine ganglion is suspended by the
ganglionic branches.
Posterior Superior Alveolar Nerve

It enters the posterior surface of the body of the maxilla,
and supplies the three upper molar teeth and the
adjoining part of the gum.
Zygomatic Nerve
Fig. 15.16: Scheme to show the pterygopalatine fossa and its It is a branch of the maxillary nerve, given off in the
communications pterygopalatine fossa. It enters the orbit through the
281
Inset
Fig. 15.17: Branches of maxillary nerve with pterygopalatine ganglion
lateral end of the inferior orbital fissure, and runs along a complicated course in the anterior wall of the
the lateral wall, outside the periosteum, to enter the maxillary sinus. It supplies the upper incisor and
zygomatic bone. Just before or after entering the canine teeth, the maxillary sinus, and the antero-
bone, it divides into two terminal branches, the inferior part of the nasal cavity.
zygomaticofacial and zygomaticotemporal nerves which
3 Terminal branches—palpebral, nasal and labial supply
supply the skin of the face and of the anterior part of
a large area of skin on the face. They also supply
the temple (see Fig. 2.16). The communicating branch
the mucous membrane of the upper lip and cheek
to the lacrimal nerve, which contains secretomotor
fibres to the lacrimal gland, arises from the zygomatico- (Fig. 15.17).
temporal nerve, and runs in the lateral wall of the orbit
(Fig. 15.17 and inset). PTERYGOPALATINE GANGLION/SPHENOPALATINE
GANGLION/GANGLION OF HAY FEVER/MECKEL’S
Infraorbital Nerve GANGLION
It is the continuation of the maxillary nerve. It enters Features
Head and Neck

the orbit through the inferior orbital fissure. It then runs Pterygopalatine is the largest parasympathetic
forwards on the floor of the orbit or the roof of the peripheral ganglion. It serves as a relay station for
maxillary sinus, at first in the infraorbital groove and then secretomotor fibres to the lacrimal gland and to the
in the infraorbital canal remaining outside the periosteum mucous glands of the nose, paranasal sinuses, palate
of the orbit. It emerges on the face through the infraorbital and pharynx. Topographically, it is related to the
foramen and terminates by dividing into palpebral, nasal maxillary nerve, but functionally it is connected to facial
and labial branches. The nerve is accompanied by the nerve through its greater petrosal branch.
infraorbital branch of the third part of the maxillary The flattened ganglion lies in the pterygopalatine
artery and the accompanying vein (see Fig. 2.16). fossa just below the maxillary nerve, in front of the
pterygoid canal and lateral to the sphenopalatine
Branches foramen (Figs 15.17 and 15.18).
1 The middle superior alveolar nerve arises in the
infraorbital groove, runs in the lateral wall of the Connections
maxillary sinus, and supplies the upper premolar 1 The parasympathetic root of the ganglion is formed
teeth. by the nerve of the pterygoid canal. It carries
2 The anterior superior alveolar nerve arises in the preganglionic fibres that arise from neurons present
infraorbital canal, and runs in a sinuous canal having near the superior salivatory and lacrimatory nuclei, and
HEAD AND NECK
282
Figs 15.18a and b: (a) Connections and branches; (b) Roots and branches of pterygopalatine ganglion
pass through the nervus intermedius, the facial nerve, upper gums. The lesser or middle and posterior palatine
the geniculate ganglion, the greater petrosal nerve and nerves supply the soft palate and the tonsil
the nerve of the pterygoid canal to reach the ganglion. (Figs 15.18a and b).
The fibres relay in the ganglion. Postganglionic fibres 3 Nasal branches enter the nasal cavity through the
arise in the ganglion to supply secretomotor nerves sphenopalatine foramen (Figs 15.17 and 15.18). The
to the lacrimal gland and to the mucous glands of lateral posterior superior nasal branches, about six in
the nose, the paranasal sinuses, the palate and the number, supply the posterior parts of the superior
nasopharynx (Fig. 15.2). and middle conchae (Fig. 15.11).
2 The sympathetic root is also derived from the nerve The medial posterior superior nasal branches, two or
of the pterygoid canal. It contains postganglionic three in number, supply the posterior part of the roof
fibres arising in the superior cervical sympathetic of the nose and of the nasal septum (Fig. 15.6). The
ganglion which pass through the internal carotid largest of these nerves is known as the nasopalatine
plexus, the deep petrosal nerve and the nerve of the nerve which descends up to the anterior part of the
pterygoid canal to reach the ganglion. The fibres pass hard palate through the incisive foramen (Fig. 15.6).
through the ganglion without relay, and supply 4 The pharyngeal branch passes through the palatino-
vasomotor nerves to the mucous membrane of the vaginal canal and supplies the part of the nasopharynx
Head and Neck
nose, the paranasal sinuses, the palate and the behind the auditory tube (Figs 15.18a and b).
nasopharynx (see Table A.2). 5 Lacrimal branch: The postganglionic fibres pass back
3 The sensory roots come from the maxillary nerve. Its into the maxillary nerve to leave it through its
fibres pass through the ganglion without relay. They zygomatic nerve and its zygomaticotemporal branch,
emerge in the branches (Fig. 15.17) described below. a communicating branch to lacrimal nerve to supply
the secretomotor fibres to the lacrimal gland
Branches (Fig. 15.17).
The branches of the ganglion are actually branches of Flowchart 15.1 shows the pathway for secretomotor
the maxillary nerve. They also carry parasympathetic fibres to lacrimal gland.
and sympathetic fibres which pass through the
ganglion. The branches are: DISSECTION
1 Orbital branches pass through the inferior orbital
Trace the connections, and branches of pterygopalatine
fissure, and supply the periosteum of the orbit, and
ganglion. It is responsible for supplying secretomotor
the orbitalis muscle which is involuntary (Fig. 15.18).
fibres to the glands of nasal cavity, palate, pharynx and
2 Palatine branches, the greater or anterior palatine nerve the lacrimal gland. It is also called hay fever ganglion
descends through the greater palatine canal, and as inflammation of the ganglion causes allergic sinusitis.
supplies the hard palate and the labial aspect of the
283
Flowchart 15.1: The secretomotor fibres for lacrimal gland SUMMARY OF PTERYGOPALATINE FOSSA
It contains three or multiple of three structures:
Three contents:
• Maxillary nerve
• 3rd part of maxillary artery
• Pterygopalatine ganglion.
Three names of ganglion:
• Sphenopalatine
• Pterygopalatine
• Ganglion of hay fever/Meckel’s ganglion.
Three structures traversing in openings in posterior
wall:
• Maxillary nerve through foramen rotundum.
• Nerve of pterygoid canal through pterygoid canal.
• Pharyngeal branch through palatinovaginal canal.
Three structures through inferior orbital fissure:
• Infraorbital nerve.
• Zygomatic nerve.
• Orbital branches of the ganglion.
Three structures through inferior openings:
• One anterior palatine nerve with greater palatine
vessels.
• Two posterior palatine nerves including lesser
palatine vessels.
Three structures through medial opening:
• Nasopalatine nerve and sphenopalatine vessels.
• Medial posterior superior nasal branches.
• Lateral posterior superior nasal branches.
Three roots of the ganglion: Sensory, sympathetic
and secretomotor.
3 × 2 branches of the ganglion: Orbital, pharyngeal,
for lacrimal gland, anterior palatine, posterior palatine
and nasopalatine branches.
3 × 2 branches of 3rd part of maxillary artery:
Posterior superior alveolar, infraorbital, sphenopalatine,
pharyngeal, artery of pterygoid canal and greater
palatine.
Head and Neck

FACTS TO REMEMBER
CLINICAL ANATOMY
• Artery of epistaxis is sphenopalatine.
• Trigeminal neuralgia affecting its maxillary • Upper few mm of lateral wall of nose and septum
branch produces symptoms in the area of its of nose are lined by olfactory epithelium with
distribution. The nerve can be anaesthetised at the bipolar neurons in it.
foramen rotundum. • Most of the nerves and blood vessels to the lateral
• The pterygopalatine ganglion, if irritated or wall of nose and septum of nose are common. The
infected, causes congestion of the glands of palate difference is in their magnitude.
and nose including the lacrimal gland producing • Maxillary sinusitis is the commonest chronic sinusitis.
running nose and lacrimation. The condition is • Into the middle meatus of nose drain 4 sets of air
called hay fever. The ganglion is called ‘ganglion sinuses.
of hay fever. • Sinusitis may occur due to air pollution.
• Maxillary nerve carries the afferent limb fibres of • Pterygopalatine ganglion is the ganglion of ‘hay
the sneeze reflex as it carries general sensation fever’. It gives secretomotor fibres to lacrimal,
from the nasal mucous membrane. nasal, palatal and pharyngeal glands.
HEAD AND NECK
284
• Pain of maxillary sinusitis is referred to upper of the terminal branches of external carotid
teeth; of ethmoidal sinusitis to medial side of orbit artery.
and of frontal sinusitis to forehead. 4. Some branches from greater palatine artery, a
branch of maxillary artery.
CLINICOANATOMICAL PROBLEM FURTHER READING

A child during hot summer months is playing in the • Becker S. Applied anatomy of the paranasal sinuses with
emphasis on endoscopic sinus surgery. Ann ORL 1994;103:3–
park. He picks up his nose, and it starts bleeding
32.
• What is the source of the bleeding? A review of serial cadaveric sections in three planes, analysed with
• Name the arteries supplying septum of the nose. specific attention to the anatomy of the paranasal sinuses as it
pertains to endoscopic sinus surgery.
Ans: The source of the nasal bleeding or epistaxis is • Jafek BW. Ultrastructure of human nasal mucosa. Laryngo-
injury to the large capillary plexus situated at the scope 1983;93:1579–99.
anteroinferior part of the septum of nose. It is called A study that characterizes the normal ultrastructure of human
Kiesselbach’s plexus and the area is also known as nasal mucosa, emphasizing the differences between olfactory and
Little’s area. respiratory epithelia.
The arteries supplying the septum of nose are: • Lang J. Clinical Anatomy of the Nose, Nasal Cavity and
Paranasal Sinuses, Stuttgart: Thieme. 1989.
1. Anterior ethmoidal, branch of ophthalmic
A study with the emphasis on exact measurements between surgical
artery which is a branch of internal carotid. landmarks, with application to surgical procedures.
2. Superior labial, a branch of facial artery, which • Navarro JAC. The Nasal Cavity and Paranasal sinuses:
in turn is a branch of external carotid artery. Surgical Anatomy Berlin: Springer, 1997.
3. Large sphenopalatine artery. This is the con- A study that emphasizes anatomical variations and their surgical
tinuation of 3rd part of maxillary artery, one importance, with CT imaging accompanying three-place
dissections.
1–3
Head and Neck
285
1. Classify paranasal air sinuses. Describe the maxillary b. Pterygopalatine ganglion with its roots and
air sinus with its clinical importance. branches
2. Describe the course and branches of maxillary nerve. c. Nerve supply of lacrimal gland
3. Write short notes on: d. Nerve supply of septum of nose
a. Lateral wall of nose e. Artery of epistaxis
1. Which of the following is the artery of epistaxis? 4. Nerve to pterygoid canal is formed by which nerves?
a. Anterior ethmoidal a. Greater petrosal and deep petrosal
b. Greater palatine b. Lesser petrosal and deep petrosal
c. Sphenopalatine c. Greater petrosal and external petrosal
d. Superior labial d. Lesser petrosal and external petrosal
2. Which one of the following air sinuses does not 5. Which air sinus is most commonly infected?
drain in the middle meatus of nose? a. Ethmoidal
a. Anterior ethmoidal b. Frontal
b. Middle ethmoidal c. Maxillary
c. Posterior ethmoidal d. Sphenoidal
d. Maxillary 6. What is the length of auditory tube in adult person
3. Which of the following air sinuses is first to develop? in mm?
a. Maxillary a. 36
b. Ethmoidal b. 3.6
c. Frontal c. 46
d. Sphenoidal d. 48
1. c 2. c 3. a 4. a 5. c 6. a
• Name the boundaries of nasal cavity. • Why does maxillary sinusitis become chronic? Head and Neck
• Name the structures forming the nasal septum. • Which bones reduce the size of maxillary hiatus?
• Which nerves supply the nasal septum? • Name the communications of pterygopalatine fossa.
• What are the roots of pterygopalatine ganglion?
• What is Little’s area? Which arteries anastomose in
Name the branches of the pterygopalatine ganglion.
this area?
• Trace the pathway of secretomotor fibres to the
• Name the openings in the middle meatus of nose. lacrimal gland.
• How many air sinuses are there? What are their • How much of nasal cavity is lined by olfactory
functions? epithelium?
16
Larynx
Always laugh with others, never at them .
—Thackery
INTRODUCTION Competency achievement: The student should be able to:

The larynx (Latin upper windpipe) is the organ for pro- AN 38.1 Describe the morphology, identify structure of the wall,
duction of voice or phonation. It is also an air passage, nerve supply, blood supply and actions of intrinsic and extrinsic
and acts as a sphincter at the inlet of the lower muscles of the larynx.1
respiratory passages. The upper respiratory passages
include the nose, the nasopharynx and the oropharynx. CONSTITUTION OF LARYNX
Larynx or voice box is well developed in humans. The larynx is made up of a skeletal framework of
Its capabilities are greatly enhanced by the large cartilages. The cartilages are connected by joints,
‘vocalisation area’ in the lower part of motor cortex. ligaments and membranes; and are moved by a number
Our speech is guided and controlled by the cerebral of muscles. The cavity of the larynx is lined by mucous
cortex. God has given us two ears and one mouth; to membrane.
hear more, contemplate and speak less according to DISSECTION
time and need.
Identify sternothyroid muscle in the sagittal section of
A man’s language is an ‘index of intellect’. One head and neck and define its attachments on the thyroid
speaks during the expiratory phase of respiration. cartilage. Define the attachments of inferior constrictor
Larynx is a part of the respiratory system allowing two- muscle from both cricoid and thyroid cartilages including
way flow of gases. It is kept patent because an adult is the fascia overlying the cricothyroid muscle.
breathing about 15 times per minute, unlike the Cut through the inferior constrictor muscle to locate
oesophagus which opens at the time of eating or articulation of inferior horn of thyroid cartilage with
drinking only. cricoid cartilage, i.e. cricothyroid joint. Define the median
cricothyroid ligament (refer to BDC App).
Situation and Extent Identify thyrohyoid muscle. Remove this muscle to
The larynx lies in the anterior midline of the neck, identify thyrohyoid membrane. Identify superior laryngeal
extending from the root of the tongue to the trachea. In vessels and internal laryngeal nerve piercing this
the adult male, it lies in front of the third to sixth cervical membrane. Identify epiglottis, thyroepiglottic and hyoe-
vertebrae, but in children and in the adult female, it lies piglottic ligaments.
at a little higher level (at C1 to C4 level) (Figs 16.1a to c). Strip the mucous membrane from the posterior
surfaces of arytenoid and cricoid cartilages. Identify
Size posterior cricoarytenoid, transverse arytenoid and
oblique arytenoid muscles.
The length of the larynx is 44 mm in males and Recurrent laryngeal nerve was seen to enter larynx
36 mm in females. At puberty, the male larynx grows deep to the inferior constrictor muscle.
rapidly and becomes larger, seen as prominent angle Identify cricothyroid muscle, which is the only intrinsic
of thyroid cartilage (Adam’s apple); which makes his muscle of larynx placed on the external aspect of larynx.
voice louder and low pitched. The pubertal growth of Remove the lower half of lamina of thyroid cartilage
the female larynx is negligible, and her voice is high including the inferior horn of thyroid cartilage. Visualise
pitched. Internal diameter—up to 3 years, it is 3 mm; the thyroarytenoid muscle in the vocal fold.
and in an adult, it is 12 mm.
286
LARYNX
287
Figs 16.1a to c: Skeleton of the larynx: (a) Anterior view; (b) Posterior view; (c) Angle of thyroid laminae in male and female
CARTILAGES OF LARYNX
The larynx contains nine cartilages, of which three are
unpaired and three are paired.
Unpaired cartilages
1 Thyroid (Greek shield-like)
2 Cricoid (Greek ring-like)
3 Epiglottis (Greek leaf-like) (Fig. 16.1a)
Paired cartilages
1 Arytenoid (Greek cup-shaped) (Fig. 16.1b)
2 Corniculate (Latin horn-shaped)
3 Cuneiform (Latin wedge-shaped)
Thyroid Cartilage
This cartilage is V-shaped in cross-section. It consists
of right and left laminae (Fig. 16.1a). Each lamina is
roughly quadrilateral. The laminae are placed obliquely
relative to the midline, their posterior borders are far
apart, but the anterior borders approach each other at
an angle that is about 90° in the male and about 120° in Fig. 16.2: Cartilages of the larynx: Posterior view
the female (Fig. 16.1c).
Head and Neck

The lower parts of the anterior borders of the right inferior thyroid tubercle behind the middle of inferior
and left laminae fuse and form a median projection border. The (i) thyrohyoid, (ii) sternothyroid and
called the laryngeal prominence. The upper parts of the (iii) thyropharyngeus part of inferior constrictor of
anterior borders do not meet. They are separated by pharynx are attached to the oblique line (Fig. 16.1a).
the thyroid notch. The posterior borders are free. They
are prolonged upwards and downwards as the superior Attachments
and inferior cornua or horns. The superior cornua is Lower border and inferior cornua give insertion to
connected with the greater cornua of the hyoid bone triangular cricothyroid. Along the posterior border
by the lateral thyrohyoid ligament. connecting superior and inferior cornua are the inser-
The inferior cornua articulates with the cricoid tion of (i) palatopharyngeus, (ii) salpingopharyngeus,
cartilage to form the cricothyroid joint (Fig. 16.2). (iii) stylopharyngeus (Fig. 16.3).
The inferior border of the thyroid cartilage is convex On inner aspect are attached:
in front and concave behind. In the median plane, it is
a. Median thyroepiglottic ligament
connected to the cricoid cartilage by the conus elasticus.
The outer surface of each lamina is marked by an b. Thyroepiglottic muscle on each side
oblique line which extends from the superior thyroid c. Vestibular fold on each side
tubercle in front of the root of superior cornua to the d. Vocal fold on each side
HEAD AND NECK
288
Attachments
Anterior part of arch of cricoid gives origin to triangular
cricothyroid muscle, a tensor of vocal cord (Fig. 16.9c).
Anterolateral aspect of arch gives origin to lateral
cricoarytenoid muscle, an adductor of vocal cord.
Lamina of cricoid cartilage on its outer aspects gives
origin to a very important ‘safety muscle’, the posterior
cricoarytenoid muscle (Fig. 16.10).
Cricothyroid and quadrate membranes are also
attached (Fig. 16.5a).
Epiglottic Cartilage/Epiglottis
This is a leaf-shaped cartilage placed in the anterior wall
of the upper part of the larynx. Its upper end is broad
and free, and projects upwards behind the hyoid bone
and the tongue (Fig. 16.5b).
The lower end or thyroepiglottic ligament is pointed
Fig. 16.3: Cartilages of the larynx: Lateral view and is attached to the upper part of the angle between
the two laminae of the thyroid cartilage (Figs 16.1b
e. Thyroarytenoid and 16.4).
f. Vocalis muscle on each side (Figs 16.1 and 16.4). Attachments
Cricoid Cartilage The right and left margins of the cartilage provide
This cartilage is shaped like a ring and is a complete attachment to the aryepiglottic folds. Its anterior surface
cartilage. It encircles the larynx below the thyroid is connected:
cartilage and forms foundation stone of larynx. It is a. To the tongue by a median glossoepiglottic fold (see
thicker and stronger than the thyroid cartilage. The ring Fig. 17.1)
has a narrow anterior part called the arch, and a broad b. To the hyoid bone by the hyoepiglottic ligament
posterior part, called the lamina (Fig. 16.2). The lamina (Fig. 16.4). The posterior surface is covered with
projects upwards behind the thyroid cartilage, and mucous membrane, and presents a tubercle in the
articulates superiorly with the arytenoid cartilages. lower part (Fig. 16.15).
The inferior cornua of the thyroid cartilage articulates Thyroepiglottic muscle is attached between thyroid
with the side of the cricoid cartilage at the junction of cartilage and margins of epiglottis. It keeps the inlet of
the arch and lamina. larynx patent for breathing.
Aryepiglottic muscle closes inlet during swallowing
(Fig. 16.11a).
Head and Neck
Arytenoid Cartilage
These are two small pyramid-shaped cartilages lying on
the upper border of the lamina of the cricoid cartilage.
The apex of the arytenoid cartilage is curved
posteromedially and articulates with the corniculate
cartilage. Its base is concave and articulates with the
lateral part of the upper border of the cricoid lamina.
Base is prolonged anteriorly to form the vocal process,
and laterally to form the muscular process (Fig. 16.3).
The surfaces of the cartilage are anterolateral, medial
and posterior (Figs 16.2 to 16.4 and 16.5c).
Attachments
Vocal process: Vocal fold and vocalis muscle is attached.
Above vocal process: Vestibular fold attached.
Muscular process: Posterior aspect gives insertion to
Fig. 16.4: Cartilages of the larynx as seen in sagittal section posterior cricoarytenoid.
LARYNX
289
Figs 16.5a and b: (a) Ligaments and membranes of the larynx. Note the quadrate membrane and the conus elasticus, (b) vocal
cords and inlet of larynx seen, and (c) arytenoid cartiliage
Anterior aspect gives insertion to lateral crico- LARYNGEAL JOINTS

arytenoid. The cricothyroid joint is a synovial joint between the
Posterior surface: Transverse arytenoid across the two inferior cornua of the thyroid cartilage and the side of
cartilages. the cricoid cartilage. It permits rotatory movements
Between base and apex of arytenoid is oblique around a transverse axis passing through both
arytenoid which continues as aryepiglottic muscle into two cricothyroid joints permitting tension and relaxation
sides of epiglottis. of vocal cords. There are some gliding movements also
Quadrangular or quadrate membrane is attached in different directions (Fig. 16.2).
between arytenoid, epiglottis and thyroid cartilages. The cricoarytenoid joint is also a synovial joint between
Corniculate/Santorini Cartilages the base of the arytenoid cartilage and the upper border
Head and Neck

of the lamina of the cricoid cartilage. It permits rotatory
These are two small conical nodules which articulate movements around a vertical axis permitting adduction
with the apex of the arytenoid cartilages, and are and abduction of the vocal cords and also gliding
directed posteromedially. They lie in the posterior parts movements in all directions (Fig. 16.2).
of the aryepiglottic folds (Fig. 16.5a).
Cuneiform/Wrisberg Cartilages LARYNGEAL LIGAMENTS AND MEMBRANES

These are two small rod-shaped pieces of cartilage Extrinsic
placed in the aryepiglottic folds just ventral to the 1 The thyrohyoid membrane connects the thyroid
corniculate cartilages (Fig. 16.5a). cartilage to the hyoid bone. Its median and lateral
parts are thickened to form the median and lateral
Histology of Laryngeal Cartilages thyrohyoid ligaments (Fig. 16.5a). The membrane is
The thyroid, cricoid cartilages, and the basal parts of pierced by the internal laryngeal nerve, and by the
the arytenoid cartilages are made up of the hyaline superior laryngeal vessels.
cartilage. They may ossify after the age of 25 years. 2 The hyoepiglottic ligament connects the upper end of
The other cartilages of the larynx, e.g. epiglottis, the epiglottic cartilage to the hyoid bone (Fig. 16.4).
corniculate, cuneiform and processes of the arytenoid 3 The cricotracheal ligament connects the cricoid
are made of the elastic cartilage and do not ossify. cartilage to the upper end of the trachea (Fig. 16.1).
HEAD AND NECK
290
Intrinsic
The intrinsic ligaments are part of a broad sheet of
fibroelastic tissue, known as the fibroelastic membrane of
the larynx. This membrane is placed just outside the
mucous membrane. It is interrupted on each side by
the sinus of the larynx. The part of the membrane above
the sinus is known as the quadrate membrane, and the
part below the sinus is called the conus elasticus
(Fig. 16.5a).
The quadrate membrane extends from the arytenoid
cartilage to the epiglottis. It has a lower free border
which forms the vestibular fold and an upper border
which forms the aryepiglottic fold.
The conus elasticus or cricovocal membrane extends
upwards and medially from the arch of the cricoid
Fig. 16.6: Cavity of the larynx
cartilage. The anterior part is thick and is known as the
cricothyroid ligament. The upper free border of the conus
elasticus forms the vocal fold (Fig. 16.5b).
CAVITY OF LARYNX
1 The cavity of the larynx extends from the inlet of the
larynx to the lower border of the cricoid cartilage.
The inlet of the larynx is placed obliquely. It looks
backwards and upwards, and opens into the
laryngopharynx. The inlet is bounded anteriorly, by
the epiglottis; posteriorly, by the interarytenoid fold
of mucous membrane; and on each side, by the
aryepiglottic fold (Figs 16.5a and b).
Internal diameter: Up to 3 years, 3 mm; every year it
increases by 1 mm up to 12 years.
2 Within the cavity of larynx, there are two folds of
mucous membrane on each side. The upper fold is
the vestibular fold, and the lower fold is the vocal fold.
The space between the right and left vestibular folds Fig. 16.7: Cavity of larynx and position of piriform fossa
is the rima vestibuli; and the space between the vocal
folds is the rima glottidis (Fig. 16.6).
c. The part below the vocal folds is called the infra-
Head and Neck
The vocal fold is attached anteriorly to the middle

glottis (Fig. 16.7).
of the angle of the thyroid cartilage on its posterior
The sinus of Morgagni or ventricle of the larynx is a
aspect; and posteriorly to the vocal process of the
narrow fusiform cleft between the vestibular and vocal
arytenoid cartilage (Fig. 16.11b).
folds. The anterior part of the sinus is prolonged
The rima is limited posteriorly by an interarytenoid upwards as a diverticulum between the vestibular fold
fold of mucous membrane. and the lamina of the thyroid cartilage. This extension
The rima glottidis, therefore, has an anterior is known as the saccule of the larynx. The saccule contains
intermembranous part (three-fifth) and a posterior mucous glands which help to lubricate the vocal folds.
intercartilaginous part (Fig. 16.15a). It is often called oil can of larynx.
The rima is the narrowest part of the larynx. It is
longer (23 mm) in males than in females (17 mm). MUCOUS MEMBRANE OF LARYNX
3 The vestibular and vocal folds divide the cavity of 1 The anterior surface and upper half of the posterior
the larynx into three parts: surface of the epiglottis, the upper parts of the
a. The part above the vestibular fold is called the aryepiglottic folds, and the vocal folds are lined by
vestibule of the larynx or supraglottis. the stratified squamous epithelium. The rest of the
b. The part between the vestibular and vocal folds is laryngeal mucous membrane is covered with the
called the sinus or ventricle of the larynx (Fig. 16.6). ciliated columnar epithelium.
LARYNX
291
2 The mucous membrane is loosely attached to the cause referred pain in the ear partly supplied by
cartilages of the larynx except over the vocal auricular branch of X nerve.
ligaments and over the posterior surface of the • Large foreign bodies may block laryngeal inlet
epiglottis where it is thin and firmly adherent. leading to suffocation.
3 The mucous glands are absent over the vocal cords, • Small foreign bodies may lodge in laryngeal
but are plentiful over the anterior surface of the ventricle, cause reflex closure of the glottis and
epiglottis, around the cuneiform cartilages and in the suffocation.
vestibular folds. The glands are scattered over the • Inflammation of upper larynx may cause oedema
rest of the larynx. of supraglottis part. It does not extend below vocal
cords because mucosa is adherent to vocal
ligament.
AN 36.3 Describe the boundaries and clinical significance of
pyriform fossa.2
AN 38.2 Describe the anatomical aspects of laryngitis.3
CLINICAL ANATOMY
• Since the larynx or glottis is the narrowest part of
the respiratory passages, foreign bodies are
usually lodged here.
• Infection of the larynx is called laryngitis. It is
characterized by hoarseness of voice.
• Laryngeal oedema may occur due to a variety of
causes. This can cause obstruction to breathing.
• Misuse of the vocal cords may produce nodules on
the vocal cords mostly at the junction of anterior Fig. 16.8: Indirect laryngoscopic examination
one-third and posterior two-thirds. These are called
Singer’s nodules or Teacher’s nodules (Fig. 16.8).
• Fibreoptic flexible laryngoscopy: Under local
INTRINSIC MUSCLES OF LARYNX
anaesthesia, flexible laryngoscope is passed and
larynx well visualised. The attachments of intrinsic muscles of larynx are
• Microlaryngoscopy: This procedure is performed presented in Table 16.1 and their main action shown in
under operating microscope. Vocal cord tumors Table 16.2.
and diseases are excised by this method.
• External examination of larynx: Head is flexed in Nerve Supply
sitting position. Examiner stands behind and All intrinsic muscles of the larynx are supplied by the
palpates larynx and neck with finger tips for recurrent laryngeal nerve except for the cricothyroid
tumour, swelling, lymphadenitis, etc. which is supplied by the external laryngeal nerve.
Head and Neck

• Speech analysis is also necessary in laryngeal
diseases. Actions
• Foreign body in larynx: At times fish bones may get The vocal and muscular processes move in opposite
impacted in the vallecula or piriform fossa. Often directions. Any muscle which pulls the muscular
these bones just scratch the mucosa on their way process medially, pushes the vocal process laterally,
down, and the person gets a feeling of foreign resulting in abduction of vocal cords. This is done by
body sensation, due to a dull visceral pain caused only one pair of muscle, the posterior cricoarytenoid
by the scratch. (Fig. 16.9a).
• Piriform fossa lies between quadrate membrane Muscles which pull the muscular process forward and
and medial side of thyroid cartilage. It is traversed laterally will push the vocal process medially (Fig. 16.9b)
by internal laryngeal nerve. Piriform fossa is used causing adduction of vocal cords. This is done by lateral
to smuggle out precious stones, diamonds, etc. It cricoarytenoid and transverse arytenoid.
is called smuggler's fossa (Fig. 16.7). The cricothyroid causes rocking movement of thyroid
• The mucous membrane of the larynx is supplied forwards and downwards at cricothyroid joints, thus
by X nerve through superior laryngeal or recurrent tensing and lengthening the vocal cords (Fig. 16.9c).
laryngeal nerves. So laryngeal tumours may also The thyroarytenoid pulls the arytenoid forward,
relaxing the vocal cords (Table 16.2 and Fig. 16.11).
HEAD AND NECK
292
Fig. 16.9a: Abduction of vocal cords Fig. 16.9b: Adduction of vocal cords
Table 16.1: Intrinsic muscles of the larynx

Muscle Origin Fibres Insertion
1. Cricothyroid Lower border and lateral Fibres pass Inferior cornua and lower border of thyroid cartilage.
The only muscle outside surface of cricoid backwards It is called ‘tuning fork of larynx’
the larynx (Fig. 16.9c) and upwards
2. Posterior cricoarytenoid Posterior surface of the Upwards and Posterior aspect of muscular process of arytenoid
triangular (Fig. 16.10) lamina of cricoid laterally
3. Lateral cricoarytenoid Lateral part of upper border Upwards and Anterior aspect of muscular process of arytenoid
(Figs 16.11a and b) of arch of cricoid backwards
4. Transverse arytenoid Posterior surface of one Transverse Posterior surface of another arytenoid
Unpaired muscle arytenoid
(Fig. 16.10)
5,6. Oblique arytenoid Muscular process of one Oblique Apex of the other arytenoid. Some fibres are
and aryepiglottic arytenoid continued as aryepiglottic muscle to the edge
(Fig. 16.10) of the epiglottis
7,8. Thyroarytenoid and Thyroid angle and adjacent Backwards Anterolateral surface of arytenoid cartilage.
thyroepiglottic cricothyroid ligament and upwards Some of the upper fibres of thyroarytenoid curve
(Figs 16.11a and b) upwards into the aryepiglottic fold to reach the edge
of epiglottis, known as thyroepiglottic
9. Vocalis (Fig. 16.12) Vocal process of Pass Vocal ligament and thyroid angle
arytenoid cartilage forwards
Table 16.2: Muscles acting on the larynx

Head and Neck
Movement Muscle
1. Elevation of larynx Thyrohyoid, mylohyoid
2. Depression of larynx Sternothyroid, sternohyoid
3. Opening inlet of larynx Thyroepiglottic
4. Closing inlet of larynx Aryepiglottic
5. Abductor of vocal cords Posterior cricoarytenoid only
6. Adductor of vocal cords Lateral cricoarytenoid, trans-
verse and oblique arytenoids
7. Tensor of vocal cords Cricothyroid
and modulation of voice
8. Relaxor of vocal cords Thyroarytenoid and vocalis
a. Muscles which abduct the vocal cords: Only

posterior cricoarytenoids (safety muscle of larynx).
b. Muscles which adduct the vocal cords:
i. Lateral cricoarytenoids Fig. 16.9c: Cricothyroid muscle
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293
ii. Transverse arytenoid

iii. Cricothyroids (tuning fork of larynx)
iv. Thyroarytenoids (Figs 16.11a and b).
Fig. 16.12: Scheme to show the direction of pull of some intrinsic

muscles of the larynx
c. Muscles which tense the vocal cords: Cri-

cothyroids (Fig. 16.9c).
d. Muscles which relax the vocal cords:
i. Thyroarytenoids (Fig. 16.12)
Fig. 16.10: Muscles of larynx: Posterior view
ii. Vocalis.
e. Muscles which close the inlet of the larynx:
i. Oblique arytenoids
ii. Aryepiglottic (Fig. 16.11a).
f. Muscles which open the inlet of larynx:
Thyroepiglotticus (Fig. 16.11b).
Arterial Supply and Venous Drainage

Up to the Vocal Folds
By the superior laryngeal artery, a branch of the
superior thyroid artery. The superior laryngeal vein
drains into the superior thyroid vein.
Below the Vocal Folds
Head and Neck

By the inferior laryngeal artery, a branch of the inferior
thyroid artery. The inferior laryngeal vein drains into
the inferior thyroid vein.
Nerve Supply
Motor Nerves
Recurrent laryngeal nerve supplies posterior
cricoarytenoid, lateral cricoarytenoid, transverse and
oblique arytenoid, aryepiglottic, thyroarytenoid,
thyroepiglottic muscles. It supplies all intrinsic muscles
except cricothyroid.
External laryngeal nerve only supplies cricothyroid
muscle.
Sensory Nerves
Figs 16.11a and b: Muscles of the larynx: (a) Lateral view; The internal laryngeal nerve supplies the mucous
(b) Horizontal view membrane up to the level of the vocal folds. The
HEAD AND NECK
294
recurrent laryngeal nerve supplies it below the level

of the vocal folds.
Lymphatic Drainage
Lymphatics from the part above the vocal folds drain
along the superior thyroid vessels to the anterosuperior
group of deep cervical nodes by piercing thyrohyoid
membrane.
Those from the part below the vocal folds drain to
the posteroinferior group of deep cervical nodes. A few
of them drain into the prelaryngeal nodes by piercing
cricothyroid. True vocal folds, i.e. glottis acts as
watershed for lymphatics. It has ‘no’ lymphatics.
Carcinoma of glottis carries best prognosis.

AN 38.3 Describe anatomical basis of recurrent laryngeal nerve
injury.4
CLINICAL ANATOMY Fig. 16.13: Various positions of the vocal cords
• When any foreign object enters the larynx severe

protective coughing is excited to expel the object.
However, damage to the internal laryngeal nerve
produces anaesthesia of the mucous membrane in
the supraglottic part of the larynx breaking the
reflex arc so that foreign bodies can readily enter it.
• Damage to the external laryngeal nerve causes some
weakness of phonation due to loss of the tightening
effect of the cricothyroid on the vocal cord.
• When both recurrent laryngeal nerves are
interrupted, the vocal cords lie in the cadaveric
position in between abduction and adduction and
phonation is completely lost. Deep breathing also
becomes difficult through the partially opened
glottis (Fig. 16.13).
• When only one recurrent laryngeal nerve is
Head and Neck
paralysed, the opposite vocal cord compensates

Figs 16.14a and b: Position of vocal cords: (a) Normal;
for it and phonation is possible but there is (b) Abnormal conditions
hoarseness of voice. There is failure of forceful
explosive part of voluntary and reflex coughing
(Fig. 16.14c).
neck, so it is not affected by mediastinal tumours.
• Tumours in the piriform fossa cause dysphagia. • The larynx can be examined either directly through
These also cause referred pain in the ear. Pain of a laryngoscope or indirectly through a laryngeal
pharyngeal tumours may be referred to the ear, mirror (indirect laryngoscopy) (Fig. 16.15).
as X nerve carries sensation both from the pharynx
and the external auditory meatus and the tympanic • By laryngoscopy, one can inspect the base of the
membrane. tongue, the valleculae, the epiglottis, the aryepiglottic
• Recurrent laryngeal nerve: Mediastinal tumours folds, the piriform fossae, the vestibular folds, and
may press on the left recurrent laryngeal nerve, the vocal folds.
as it is given off in the thorax. The pressure on • Tumours of the vocal cords can be diagnosed
early, because there are changes in the voice.
the nerve may present as alteration in the voice.
Tumours in subglottic area present late so are
Right recurrent laryngeal nerve is given off in the
diagnosed late and have poor prognosis.
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295
MOVEMENTS OF VOCAL FOLDS

Movements of the vocal folds affect the shape and size
of the rima glottidis.
1 During quiet breathing or condition of rest, the inter-
membranous part of the rima is triangular, and the
intercartilaginous part is quadrangular (Fig. 16.17a).
2 During phonation or speech, the glottis is reduced
to a chink by the adduction of the vocal folds
(Figs 16.17b and 16.18).
3 During forced inspiration, both parts of the rima are
triangular, so that the entire rima is lozenge-shaped;
the vocal folds are fully abducted (Fig. 16.17c)
(i.e. diamond-shaped glottis).
4 During whispering, the intermembranous part of the
rima glottidis is closed, but the intercartilaginous
part is widely open (Fig. 16.17d) (i.e. funnel-shaped
glottis).
Fig. 16.15: Parts of larynx seen by indirect laryngoscopy INFANT’S LARYNX

Cavity of infant’s larynx is short and funnel-shaped.
• Size is one-third of an adult. Lumen is very narrow.
• Position is higher than in adult.
Head and Neck

Fig. 16.16: Laryngotomy
• Laryngotomy: The needle is inserted in the midline

of cricothyroid membrane, below the thyroid
prominence. This is done as an emergency
procedure (Fig. 16.16).
• Tracheostomy is a permanent procedure. Part of
2nd–4th rings of trachea are removed after incising
the isthmus of the thyroid gland.
• If the patient is unconscious, one must remember—
A: Airway, B: Breathing, C: Circulation in that
order. For the patency of airway, pull the tongue
out and also endotracheal tube needs to be passed.
The tube should be passed between the right and Figs 16.17a to d: Rima glottidis: (a) In quiet breathing; (b) In
left vocal cords down to the trachea. phonation or speech; (c) During forced inspiration; (d) During
whispering
HEAD AND NECK
296
resonators. One can make out change of quality of voice

even on the telephone.
Articulators
These are formed by palate, tongue, teeth and lips.
These narrow or stop the exhaled air. Vowels are
produced due to vibrations of vocal cords. Many of the
consonants are produced by the intrinsic muscles of
tongue. Consonants produced by lips are—Pa, Pha, Ba,
Bha, Ma
Labiodental—Ta, Tha, Da, Dha, Na
Lingual—Cha, Ja, Jha
Palatal—Ka, Kha, Ga, Gha.
FACTS TO REMEMBER
• Only intrinsic muscle of larynx placed on the outer
aspect of laryngeal cartilages is cricothyroid.
• Cricothyroid is the only muscle supplied by
Fig. 16.18: Direct laryngoscopic view of vocal cords in adducted external laryngeal nerve.
position • External laryngeal nerve runs with superior
thyroid artery near the gland.
• Epiglottis lies at C2 and during elevation, it reaches • Posterior cricoarytenoid is the only abductor of
C1, so that infant can use nasal airway for breathing vocal cord and so it is a life-saving muscle.
while suckling. • Piriform fossa is called smuggler’s fossa as
• Laryngeal cartilages are softer, more pliable than in precious stones, etc. can be hidden here.
adult. • The primary function of larynx is to protect the
• Thyroid cartilage is shorter and broader. lower respiratory tract. Phonation has developed
• Vocal cords are only 4–4.5 mm long, shorter than in with evolution and is related to motor speech area
childhood and in adult. of the cerebral cortex.
• Supraglottic and subglottic mucosa are lax, swelling
results in respiratory obstruction.
• One must be careful while giving anaesthesia to an CLINICOANATOMICAL PROBLEM
infant (birth to one year).
Due to a severe infection of the voice box and with
MECHANISM OF SPEECH high temperature, a patient is not able to speak and
breathe at all.
The mechanism of speech involves the following four • Paralysis of which muscles causes extreme
processes:
Head and Neck
difficulty in breathing?
• Expired air from lungs • Name the muscles of larynx and their actions.
• Vibrators
• Resonators Ans: Due to infection of the larynx, the branches of
• Articulators recurrent laryngeal nerve supplying posterior
cricoarytenoid muscles are infected. Since this pair
Expired Air of muscle is the only abductor of vocal cord, the vocal
As the air is forced out of lungs and larynx, it produces cords get adducted, resulting in extreme difficulty
voice. Loudness or intensity of voice depends on the in breathing. Tracheostomy is the main line of
force of expiration of air. treatment, if infection is not controlled.
Movement of larynx Muscles
Vibrators
Abduction of vocal cord Posterior
The expired air causes vibrations of the vocal cords. cricoarytenoid
Pitch of voice depends on the rate of vibration of vocal Adduction of vocal cord Lateral cricoarytenoid
cords. Vowels are produced in the larynx. Transverse arytenoid
Resonators Oblique arytenoid
The column of air between vocal cords and nose and Opening inlet of larynx Thyroepiglottic
lips act as resonators. Quality of sound depends on
LARYNX
297
A comprehensive summary of the organic disorders of voice due to

Closing inlet of larynx Aryepiglottic laryngeal structural changes and neurological disease, as well as
Tensor of vocal cord Cricothyroid psychogenic voice disorders.
Relaxor of vocal cord Thyroarytenoid • Berkovitz BKB, Moxham BJ, Hickey S. The anatomy of the
larynx. In: Ferlito A (ed). Diseases of the Larynx. London:
Chapman & Hall; 2000; pp. 25–44.
FURTHER READING A description of all aspects of laryngeal anatomy, together with a
• Moreau S, de Rugy MG, Babin E, et al. The recurrent laryngeal very useful bibliography.
nerve: related vascular anatomy. Laryngoscope 1998; • Dickson DR, Maue-Dickson W. Anatomical and Physiological
108:1351–55. Bases of Speech, Boston: Little, Brown. 1982.
An explanation of the considerable variability in the perineural Some highly detailed descriptions of the structure of the larynx.
vasculature of the recurrent laryngeal nerve, which lies in close • Welsh LW, Welsh II, Rizzo TA. Laryngeal spaces and
proximity to and is usually supplied by the posterior branch of the lymphatics: Current anatomic concepts. Ann Otol Rhinol
inferior thyroid artery. Laryngol Suppl 1983;105:19–31.
• Aronson AE, Bless. Clinical Voice Disorders, 4th ed, New A description of the 'tissue spaces' and lymphatic drainage of the larynx
York: Thieme, 2009. and their importance in determining the route of spread of tumours.
1–4
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298
1. Describe the intrinsic muscles of larynx. Add a note 3. Write short notes on:
on their clinical importance. a. Rima glottidis b. Epiglottis
2. Mention the structures attached to various parts of c. Cricoid cartilage d. Vocal folds
thyroid cartilage. e. Pyriform fossa
1. Which histological type of cartilage is epiglottis? 5. Which of the following muscles is not inserted in
a. Fibrous b. Elastic the posterior border of thyroid cartilage?
c. Hyaline d. Fibroelastic a. Palatopharyngeus b. Salpingopharyngeus
2. Which is the only abductor muscle of the vocal c. Stylopharyngeus d. Levator veli palatini
cord? 6. Which muscle is not attached to cricoid cartilage?
a. Lateral cricoarytenoid a. Cricothyroid
b. Thyroarytenoid b. Oblique arytenoid
c. Posterior cricoarytenoid c. Lateral cricoarytenoid
d. Thyroepiglottic d. Posterior cricoarytenoid
3. Recurrent laryngeal nerve supplies all muscles, 7. Which of the following muscles is the ‘safety’
except: muscle of larynx?
a. Posterior cricoarytenoid a. Lateral cricoarytenoid
b. Oblique arytenoids b. Posterior cricoarytenoid
c. Lateral cricoarytenoid c. Oblique arytenoid
d. Cricothyroid d. Transverse arytenoids
4. Angle of anterior borders of laminae of thyroid 8. Pain of pharyngeal tumours is referred to ear due
cartilage in adult male is: to which of the following nerves?
a. 90° b. 100° a. IX b. X
c. 80° d. 120° c. V d. VII
Head and Neck
1. b 2. c 3. d 4. a 5. d 6. b 7. b 8. b
• How much is the angle of thyroid laminae in male • Name the intrinsic muscles of larynx.
and female? • Which muscles cause tension and relaxation of the
• Name the muscles attached to the posterior border vocal cords?
of thyroid cartilage. • Which is a life-saving muscle and why?
• Name the paired and unpaired cartilages of the • Which muscles open/close the laryngeal inlet?
larynx. • Name the positions of vocal cords during. quiet
• Name the laryngeal joints. breathing, phonation, forced inspiration and
• Name the sensory nerves innervating the mucous whispering.
membrane of larynx. • Which is the only muscle supplied by external
• Name the boundaries of piriform fossa. What is its laryngeal nerve?
importance? • Name the functions of larynx.
• Where and why do the singer’s nodules develop? • What are the boundaries of inlet of larynx?
17
Tongue
Tongue is not steel, yet it cuts
Taste makes waist .
—Anonymous
INTRODUCTION
The tongue is a muscular organ situated in the floor
of the mouth. It is associated with the functions of
(i) taste, (ii) speech, (iii) chewing, (iv) deglutition, and
(v) cleansing of mouth.
Tongue comprises skeletal muscles which are
voluntary. These voluntary muscles start behaving as
involuntary in any classroom—funny?
Thanks to the taste buds that the multiple hotels,
restaurants, fast food outlets, chat–pakori shops, etc. are
flourishing. One need not be too fussy about the taste
of the food. Nutritionally, it should be balanced and
hygienic.
DISSECTION
In the sagittal section, identify fan-shaped genioglossus
muscle. Cut the attachments of buccinator, superior
constrictor muscles and the intervening pterygomandi-
bular raphe and reflect these downwards exposing the Fig. 17.1: The dorsum of the tongue, epiglottis and palatine
lateral surface of the tongue. Look at the superior, inferior tonsil
surfaces of your own tongue with the help of hand lens
(refer to BDC App). The tip of the tongue forms the anterior free end
which, at rest, lies behind the upper incisor teeth.
The dorsum of the tongue (Fig. 17.1) is convex in all
PARTS OF TONGUE
directions. It is divided into:
The tongue has: • An oral part or anterior two-thirds.
1 A root
• A pharyngeal part or posterior one-third, by a faint
2 A tip V-shaped groove, the sulcus terminalis. The two
3 A body, which has: limbs of the ‘V’ meet at a median pit, named the
a. A curved upper surface or dorsum (Fig. 17.1), and foramen caecum. They run laterally and forwards
b. An inferior surface confined to the oral part only. up to the palatoglossal arches. The foramen
The root is attached to the styloid process and soft caecum represents the site from which the thyroid
palate above, and to mandible and the hyoid bone diverticulum grows down in the embryo. The oral
below. Because of these attachments, we are not able and pharyngeal parts of the tongue differ in their
to swallow the tongue itself. In between the mandible development, topography, structure, and function
and hyoid bones, it is related to the geniohyoid and (Table 17.3).
mylohyoid muscles. • Small posteriormost part
299
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300
1 The oral or papillary part of the tongue is placed on the CLINICAL ANATOMY
floor of the mouth. Its margins are free and in contact
with the gums and teeth. Just in front of the palato- • Glossitis is usually a part of generalized ulceration
glossal arch, each margin shows 4 to 5 vertical folds, of the mouth cavity or stomatitis. In certain
named the foliate papillae. anaemias, the tongue becomes smooth due to
atrophy of the filiform papillae.
The superior surface of the oral part shows a median
• The presence of a rich network of lymphatics and
furrow and is covered with papillae which make it
of loose areolar tissue in the substance of tongue
rough (Fig. 17.1).
is responsible for enormous swelling of tongue in
The inferior surface is covered with a smooth mucous acute glossitis. The tongue fills up the mouth cavity
membrane, which shows a median fold called the and then protrudes out of it.
frenulum linguae. • The undersurface of the tongue is a good site along
On either side of the frenulum, there is a prominence with the bulbar conjunctiva for observation of
produced by the deep lingual veins. More laterally, jaundice.
there is a fold called the plica fimbriata that is directed • In unconscious patients, the tongue may fall back
forwards and medially towards the tip of the tongue and obstruct the air passages. This can be
(Fig. 17.2). prevented either by lying the patient on one side
2 The pharyngeal or lymphoid part of the tongue lies with head down (the ‘tonsil position’) or by
behind the palatoglossal arches and the sulcus keeping the tongue out mechanically.
terminalis. Its posterior surface, sometimes called the • Lingual tonsil in the posterior one-third of the
base of the tongue, forms the anterior wall of the tongue forms part of Waldeyer’s ring (see Fig. 14.13).
oropharynx. The mucous membrane has no papillae,
but has many lymphoid follicles that collectively Competency achievement: The student should be able to:
constitute the lingual tonsil (Fig. 17.1). Mucous glands AN 43.2 Identify, describe and draw the microanatomy of pituitary
are also present. gland, thyroid, parathyroid gland, tongue, salivary glands, tonsil,
3 The posteriormost part of the tongue is connected Microanatomy of tongue is given here. For the rest of tissues, please
to the epiglottis by three folds of mucous membrane. see the appropriate chapters.
These are the median glossoepiglottic fold and the
right and left lateral glossoepiglottic folds. On either PAPILLAE OF THE TONGUE
side of the median fold, there is a depression called These are projections of mucous membrane or corium
the vallecula (Fig. 17.1). The lateral folds separate the which give the anterior two-thirds of the tongue, its
vallecula from the piriform fossa. characteristic roughness. These are of the following four
types (Fig. 17.3).
1 Vallate or circumvallate papillae: They are large in size,
1–2 mm in diameter and are 8–12 in number. They
are situated immediately in front of the sulcus
terminalis. Each papilla is a cylindrical projection
Head and Neck
surrounded by a circular sulcus. The walls of the

papilla have taste buds.
2 The fungiform papillae are numerous near the tip and
margins of the tongue, but some of them are also
scattered over the dorsum. These are smaller than
the vallate papillae but larger than the filiform
papillae. Each papilla consists of a narrow pedicle
and a large rounded head. They are distinguished
by their bright red colour (Fig. 17.3).
3 The filiform papillae or conical papillae cover the
presulcal area of the dorsum of the tongue, and give
it a characteristic velvety appearance. They are the
smallest and most numerous of the lingual papillae.
Each is pointed and covered with keratin; the apex
is often split into filamentous processes.
Fig. 17.2: The inferior surface of tongue and the floor of the 4 Foliate papillae are present at the lateral border just
mouth infront of circumvallate papillae. They are leaf shaped.
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301
membrane. The superior longitudinal muscles act to

elevate the tip and sides of the tongue superiorly.
This shapes the tongue dorsum into a concavity and
it shortens the tongue.
2 Inferior longitudinal: It originates from the fibrous
tissue beneath the mucous membrane stretching
from tip of tongue longitudinally back to the root of
the tongue and the hyoid bone. They insert into the
mucous membrane of the tongue dorsum. It lies
between the genioglossus and the hyoglossus.
The inferior longitudinal muscles act to curl the tip
of the tongue inferiorly. This makes the dorsum of
the tongue convex in shape and shortens the tongue.
3 Transverse: It lies as a sheet on either side of the
Fig. 17.3: Types of papillae and taste buds midline in a plane that is deep to the superior
longitudinal muscles but superficial to genioglossus.
Competency achievement: The student should be able to: They run transversely from their origin at the fibrous
AN 39.1 Describe and demonstrate the morphology, nerve supply, lingual septum to insert into the submucous fibrous
embryological basis of nerve supply, blood supply, lymphatic tissue at the lateral margins of the tongue.
drainage and actions of extrinsic and intrinsic muscles of tongue.2 Contraction of the transverse muscles acts to narrow
and increases the thickness of the tongue.
MUSCLES OF THE TONGUE 4 Vertical: It is found at the borders of the anterior part
A middle fibrous septum divides the tongue into right of the tongue. It makes the tongue broad.
and left halves. Each half contains four intrinsic and
four extrinsic muscles. Extrinsic Muscles
1 Genioglossus
Intrinsic Muscles
2 Hyoglossus
They occupy the upper part of the tongue, and are 3 Styloglossus
attached to the submucous fibrous layer and to the 4 Palatoglossus
median fibrous septum. They alter the shape of the The extrinsic muscles connect the tongue to the mandible
tongue (Fig. 17.4). via genioglossus; to the hyoid bone through hyoglossus;
1 Superior longitudinal: It arises from the fibrous tissue to the styloid process via styloglossus, and the palate
deep to the mucous membrane on the dorsum of the via palatoglossus. These are described in Table 17.1.
tongue and the midline lingual septum. They pass The actions of intrinsic and extrinsic muscles are
longitudinally back from the tip of the tongue to its mentioned in Table 17.2.
root posteriorly. It inserts into the overlying mucous
Arterial Supply
Head and Neck

It is derived from the tortuous lingual artery, a branch
of the external carotid artery. The root of the tongue is
also supplied by the tonsillar artery, a branch of facial
artery, and ascending pharyngeal branch of external
carotid artery (Fig. 17.6). See Chapter 4 for the course
and branches of the lingual artery.
Venous Drainage
1 Deep lingual vein: The chief vein of tongue, seen on
the inferior surface of tongue near median plane.
2 Venae comitantes, accompany lingual artery. They are
joined by dorsal lingual veins.
3 Venae comitantes accompanying the hypoglossal
nerve.
These veins unite at the posterior border of the
Fig. 17.4: Coronal section of the tongue showing arrangement hyoglossus to form the lingual vein which ends in the
of the intrinsic muscles and extrinsic muscles internal jugular vein.
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302
Table 17.1: Extrinsic muscles of tongue

Muscle Origin Insertion Actions
Palatoglossus Oral surface of palatine Descends in the palatoglossal arch Pulls up the root of tongue,
(Fig. 17.6) aponeurosis to the side of tongue at the junction approximates the palatoglossal
of oral and pharyngeal parts arches and thus closes the
oropharyngeal isthmus
Hyoglossus Whole length of greater Side of tongue between styloglossus Depresses tongue, makes dorsum
(Fig. 17.6) cornua and lateral part of and inferior longitudinal muscle of convex, retracts the protruded
hyoid bone tongue tongue
Styloglossus Tip and part of anterior Into the side of tongue Pulls tongue upwards and back-
(Fig. 17.6) surface of styloid process wards, i.e. retracts the tongue
Genioglossus Upper genial tubercle of Upper fibres into the tip of tongue Retracts the tongue
Fan-shaped bulky mandible Middle fibres into the dorsum Depresses the tongue
muscle (Fig. 17.5) Lower fibres into the hyoid bone Pulls the posterior part of tongue
forwards and protrudes the tongue.
It is a life-saving muscle`
Table 17.2: Summary of the actions of muscles

Intrinsic muscles Actions
Superior longitudinal Shortens the tongue, makes its
dorsum concave
Inferior longitudinal Shortens the tongue, makes its
dorsum convex
Transverse Makes the tongue narrow and
elongated
Vertical (Fig. 17.4) Makes the tongue broad and
flattened
Extrinsic muscles Actions
Genioglossus (Fig. 17.5). Protrudes the tongue
Hyoglossus (Fig. 17.6). Depresses the tongue
Styloglossus (Fig. 17.6). Retracts the tongue
Palatoglossus Elevates the tongue
Fig. 17.5: Genioglossus
Head and Neck
Fig. 17.6: Arterial supply and extrinsic muscles of the tongue

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303
Lymphatic Drainage one-third of the tongue including the circumvallate

1 The tip of the tongue drains bilaterally to the papillae.
submental nodes (Figs 17.7a and b). The posteriormost part of the tongue is supplied by
2 The right and left halves of the remaining part of the vagus nerve through the internal laryngeal branch
the anterior two-thirds of the tongue drain uni- (Table 17.3).
laterally to the submandibular nodes. A few central
lymphatics drain bilaterally to the deep cervical HYPOGLOSSAL NERVE—XII NERVE
nodes (Fig. 17.7b). Hypoglossal nerve is the nerve of muscles of the tongue.
3 The posteriormost part and posterior one-third of the It leaves the cranial cavity through anterior
tongue drain bilaterally into the upper deep cervical condylar/hypoglossal canal.
lymph nodes including jugulodigastric nodes. Course: Lies between internal jugular vein and
internal carotid artery in front of vagus
4 The whole lymph finally drains to the jugulo-
Lower down it curves forwards to cross both internal
omohyoid nodes. These are known as the lymph nodes of and external carotid arteries. It also crosses loop of
the tongue. lingual artery to lie on hyoglossus muscle. Finally it
enters substance of tongue. It supplies 3 extrinsic
Nerve Supply
muscles and all 4 intrinsic muscles of tongue (details
Motor Nerves can be read from Chapter 4, BD Chaurasia’s Human
All the intrinsic and extrinsic muscles, except the Anatomy, Volume 4.
palatoglossus, are supplied by the hypoglossal nerve.
The palatoglossus is supplied by the cranial root of the Competency achievement: The student should be able to:
accessory nerve through the pharyngeal plexus. AN 39.2 Explain the anatomical basis of hypoglossal nerve palsy.3
So seven out of eight muscles are supplied by XII
nerve (Fig. 17.8a). CLINICAL ANATOMY
Sensory Nerves • Carcinoma of the tongue is quite common. The
The lingual nerve is the nerve of general sensation affected side of the tongue is removed surgically.
and the chorda tympani is the nerve of taste for the All the deep cervical lymph nodes are also removed,
i.e. block dissection of neck because recurrence of
anterior two-thirds of the tongue except vallate papillae
malignant disease occurs in lymph nodes. Carci-
(Fig. 17.8b).
noma of the posterior one-third of the tongue is
The glossopharyngeal nerve is the nerve for more dangerous due to bilateral lymphatic spread.
both general sensation and taste for the posterior
Head and Neck
Figs 17.7a and b: Lymphatic drainage of tongue: (a) Lateral surface; (b) Dorsum, dark areas of tongue drain bilaterally
HEAD AND NECK
304
Fig. 17.8a: Hypoglossal nerve innervating three extrinsic muscles of the tongue
left genioglossus will pull the base to left side and

apex will get pushed to right side (apex and base
lie at opposite ends) (Fig. 17.9).
Head and Neck
Fig. 17.9: Effect of paralysis of right XII nerve

Fig. 17.8b: Nerve supply of tongue
• Sorbitrate is taken sublingually for immediate HISTOLOGY

relief from angina pectoris. It is absorbed fast 1 The bulk of the tongue is made up of striated muscles.
because of rich blood supply of the tongue and
2 The mucous membrane consists of a layer of connective
bypassing of portal circulation.
tissue (corium), lined by stratified squamous epithe-
• Genioglossus is called the ‘safety muscle of the
lium. On the oral part of the dorsum, it is thin, forms
tongue’ because if it is paralysed, the tongue will
papillae (Fig. 17.3), and is adherent to the muscles.
fall back on the oropharynx and block the air
On the pharyngeal part of the dorsum, it is very rich
passage. During anaesthesia, the tongue is pulled
in lymphoid follicles. On the inferior surface, it is
forwards to clear the air passage.
thin and smooth. Numerous glands, both mucous
• Genioglossus is the only muscle of the tongue and serous, lie deep to the mucous membrane.
which protrudes it forwards. It is used for testing
the integrity of hypoglossal nerve. If hypoglossal 3 Taste buds are most numerous on the sides of the
nerve of right side is paralysed, the tongue on circumvallate papillae, and on the walls of
protrusion will deviate to the right side. Normal the surrounding sulci. Taste buds are numerous over
the foliate papillae and over the posterior one-third
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305
Fig. 17.11: Development of tongue
DEVELOPMENT OF TONGUE
Fig. 17.10: Structure of taste bud Epithelium
of the tongue; and sparsely distributed on the fungi- 1 Anterior two-thirds: From two lingual swellings,
form papillae, the soft palate, the epiglottis and the which arise from the first branchial arch (Fig. 17.11).
pharynx. There are no taste buds on the mid-dorsal Therefore, it is supplied by lingual nerve (post-
region of the oral part of the tongue (Fig. 17.10). trematic) of 1st arch and chorda tympani (pre-
trematic) of 1st arch.
Structure 2 Posterior one-third: From cranial large part of the
There are two types of cells, the sustentacular or hypobranchial eminence, i.e. from the third arch.
supporting cells and gustatory cells. The supporting Therefore, it is supplied by the glossopharyngeal
cells are spindle-shaped while gustatory cells are long nerve (Table 17.3).
slender and centrally situated. 3 Posteriormost part from the fourth arch. This is
supplied by the vagus nerve.
Competency achievement: The student should be able to: Table 17.3 shows the comparison of three parts of
AN 43.4 Describe the development and developmental basis of the tongue.
pituitary gland, thyroid gland and eye.4 (Development of tongue is Muscles
described here. For the development of other organs please see
the appropriate chapters.) The muscles develop from the occipital myotomes
which are supplied by the hypoglossal nerve.
Head and Neck

Table 17.3: Comparison of the parts of the tongue
Anterior two-thirds Posterior one-third Posteriormost part and vallecula
Situation Lies in mouth cavity Oropharynx Oropharynx
Structure Contains papillae Contains lymphoid tissue —
Function Chewing Deglutition Deglutition
Sensory nerve Lingual (post-trematic Glossopharyngeal Internal laryngeal branch of
branch of 1st arch) nerve of 3rd arch vagus (nerve of 4th arch)
Sensation of taste Chorda tympani except circum- Glossopharyngeal including Internal laryngeal branch of
vallate papillae (pre-trematic the vallate papillae vagus
branch of 2nd arch)
Development of Lingual swellings of 1st arch. Third arch which forms large Fourth arch which forms small
epithelium from endoderm Tuberculum impar which soon ventral part of hypobranchial dorsal part of hypobranchial
disappears eminence eminence
Muscles develop from occipital myotomes, so the cranial nerve XII (hypoglossal nerve) supplies all intrinsic and three extrinsic
muscles. Only palatoglossus is supplied by cranial root of accessory through pharyngeal plexus and is developed from mesoderm
of sixth arch
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306
Connective Tissue
The connective tissue develops from the local
mesenchyme.
TASTE PATHWAY
• The taste from anterior two-thirds of tongue, except
from vallate papillae, is carried by chorda tympani
branch of facial nerve till the geniculate ganglion.
The central processes go to the tractus solitarius in
the medulla.
• Taste from posterior one-third of tongue including
the circumvallate papillae is carried by cranial nerve
IX till the inferior ganglion. The central processes
also reach the tractus solitarius (Fig. 17.12).
• Taste from posteriormost part of tongue and
epiglottis travels through vagus nerve till the inferior
ganglion of vagus. These central processes also reach
tractus solitarius. Fig. 17.13: Examples of referred pain
• After a relay in tractus solitarius, the solitariothalamic
tract is formed which becomes a part of trigeminal
lemniscus and reaches posteroventromedial nucleus
of thalamus of the opposite side. Another relay here
takes them to lowest part of postcentral gyrus, which is
the area for taste. FACTS TO REMEMBER
• All 4 intrinsic muscles of tongue are supplied by
XII nerve.
• Out of 4 extrinsic muscles of tongue, 3 are supplied
by XII nerve. Only palatoglossus is supplied by
vagoaccessory complex.
• Lingual artery is a tortuous artery as it moves up
and down with movements of pharynx.
• Tongue is kept in position by its attachment to
neighbouring structures through the 4 pairs of
extrinsic muscles.
• Circumvallate papillae are only 10–12 in number,
Head and Neck
but have maximum number of taste buds. The taste

from here is carried by IX nerve.
• Nerve supply correlates with development.
Anterior two-thirds develop from 1st arch, the
nerves being lingual and chorda tympani. Chorda
tympani is pre-trematic branch of the 1st arch.
Fig. 17.12: Taste pathways
• Posterior one-third develops from cranial part of
CLINICAL ANATOMY 3rd arch. So it is supplied by IX nerve.
• Posteriormost part develops from 4th arch. So it is
• Injury to any part of the pathway causes abnor- supplied by internal laryngeal branch of X nerve.
mality in appreciation of taste. • Sorbitrate, the drug for prevention of angina, is
• Referred pain is felt in the ear in diseases of taken sublingually as it reaches the blood very fast,
posterior part of the tongue, as ninth and tenth bypassing the portal circulation.
nerves are common supply to both the regions.
• Genioglossus is the life-saving muscle as it
Other examples of referred pain are seen in
protrudes the tongue forwards.
Fig. 17.13.
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307
CLINICOANATOMICAL PROBLEM c. Paralysis of muscles of tongue on the same side

due to paralysis of XII nerve. The tip of tongue on
A patient is diagnosed as ‘medial medullary protrusion will get protruded to the side of lesion.
syndrome’ on right side XII nerve belongs to general somatic efferent
• What is the effect on tongue? column (GSE).
• Name the nuclear column to which XII nerve Muscles of tongue are intrinsic and extrinsic:
belongs? Intrinsic muscle Extrinsic muscle
• Name the muscles of tongue. Superior longitudinal Genioglossus
Inferior longitudinal Hyoglossus
Ans: In medial medullary syndrome, XII nerve,
pyramidal fibres and medial lemniscus are damaged Transverse Palatoglossus
due to blockage of anterior spinal artery. Vertical Styloglossus
a. There is contralateral hemiplegia due to damage
FURTHER READING
to pyramid of medulla oblongata.
b. Loss of sense of vibration and position due to • Netter FH. Atlas of Human Anatomy. Los Angels: Icon
Learning Systems, 1997.
damage to medial lemniscus.
• Whillis J. Movements of tongue in swallowing. Journal of
Anatomy, 1996;80:115–16.
1–4
Head and Neck

HEAD AND NECK
308
1. Describe tongue under the following headings: 2. Describe the extrinsic and intrinsic muscles of
a. Gross anatomy tongue. Discuss their actions and importance of
genioglossus muscle.
b. Dorsum of tongue
3. Write short notes on:
c. Blood supply and nerve supply a. Taste fibres from the tongue
d. Lymphatic drainage b. Sensory nerve supply
e. Clinical anatomy c. Development of tongue
1. Epithelium of tongue develops from all the 3. Lymph from tongue drains into all the following
following arches, except: lymph nodes, except:
a. 1st arch b. 2nd arch a. Submandibular b. Submental
c. 3rd arch d. 4th arch c. Deep cervical d. Preauricular
4. Taste from the tongue is carried by all nerves, except:
2. Muscles of tongue are mostly supplied by XII nerve,
except: a. VII b. IX
c. X d. XI
a. Genioglossus
5. Sensory fibres from tongue is carried by all nerves,
b. Palatoglossus except:
c. Hyoglossus a. V b. VIII
d. Styloglossus c. IX d. X
1. b 2. b 3. d 4. d 5. b
• What are the parts of the tongue? • How do the various parts of the tongue develop?
• Name the subdivisions of dorsum of tongue.
Head and Neck
• Name the sensory and special sensory nerves of the

• How many types of papillae are there in the tongue? various parts of the tongue.
Which ones have the maximum number of taste • If right XII nerve is injured, which side will the tip of
buds? tongue deviate on protrusion and why?
• Name the extrinsic muscles of tongue with their
nerve supply. • Trace the taste fibres from circumvallate papillae to
• Name the intrinsic muscles of tongue with their the cerebrum.
nerve supply. • Which drug is put sublingually during angina
• Which is the lymph node of the tongue? pectoris and why?
• What is the importance of genioglossus muscle? • What is the clinical importance of colour and
What is its other name? roughness of the tongue?
18
Ear
Nature is wonderful. A million years ago SHE didn’t know we
are going to wear spectacles, yet look at the way she placed our ears
“The ear is an engineering marvel.”
—Anonymous
INTRODUCTION 5 Petrotympanic fissure gives passage to anterior

Tympanic membrane comprises all the three embryonic tympanic artery, anterior ligament of malleus and
layers—outer layer is ectodermal, inner layer is endo- chorda tympani nerve.
dermal while middle one is mesodermal in origin. The 6 Stylomastoid foramen gives passage to posterior
ossicles of the ear are the only bones fully formed at birth. tympanic artery for middle ear and facial nerve.
One hears with the ears. The centre for hearing is in 7 Hiatus for greater petrosal nerve gives passage to
the temporal lobe of brain above the ear. Reading aloud nerve of the same name and a branch of middle
is a quicker way of memorising, as the ear, temporal lobes meningeal artery.
and motor speech area are also activated. The labyrinth 8 Tegmen tympani on the anterior face of petrous
is also supplied by an ‘end artery’ like the retina. temporal bone forms roof of the middle ear, mastoid
Noise pollution within the four walls of the homes antrum and canal for tensor tympani muscle.
from the music albums and advertisements emitted 9 The aqueduct of vestibule opens on posterior aspect
from the television sets cause a lot of damage to the of petrous temporal bone. It is plugged by ductus
cochlear nerves and temporal lobes, besides causing endolymphaticus.
irritation, hypertension and obesity. 10 Organ of Corti is the end organ for hearing, situated
The ear is an organ of hearing. It is also concerned in in the cochlear duct.
maintaining the equilibrium of the body. It consists of 11 Crista is an end organ in the semicircular canal.
three parts: The external ear, the middle ear and the These are kinetic balance receptors.
internal ear. Tympanic membrane separates external 12 Macula are end organs in the utricle and saccule
ear from middle ear. Mastoid antrum lies in the petrous and are static balance receptors.
part of temporal bone. Mastoid air cells are situated in
the mastoid process. Competency achievement: The student should be able to:
AN 40.1 Describe and identify the parts, blood supply and nerve
Features of the Temporal Bone supply of external ear.1
1 External auditory meatus is for air waves.
2 Internal auditory meatus is for passage of VII, VIII
nerves and labyrinthine vessels. EXTERNAL EAR
3 Suprameatal triangle is the landmark for mastoid
antrum. It is bounded by supramastoid crest, The external ear consists of:
posterosuperior margin of external acoustic meatus • The auricle or pinna
and a tangent drawn from the crest to the margin. • The external acoustic meatus.
Mastoid antrum lies about 15 mm deep to the
suprameatal triangle in adult (see Fig. 1.9b). AURICLE/PINNA
4 Tympanic canaliculus lies on the inferior surface of The auricle is the part seen on the surface. The greater
petrous temporal bone between carotid canal and part of it is made up of a single crumpled plate of elastic
jugular fossa. cartilage which is lined on both sides by skin. It supports
309
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310
Figs 18.1a and b: Pinna of the ear: (a) Nerve supply and lymph nodes on the lateral surface, and (b) nerve supply on the medial surface
the spectacles. However, the lowest part of the auricle

is soft and consists only of fibrofatty tissue covered by
skin: This part is called the lobule for wearing the ear
rings. The rest of the auricle is divided into a number
of parts. These are helix, antihelix, concha, tragus, and
scaphoid fossa (see Fig. 20.2). In particular, note the large
depression called the concha; it leads into the external
acoustic meatus.
In relation to the auricle, there are a number of
muscles. These are all vestigeal in man. In lower animals,
the intrinsic muscles alter the shape of the auricle, while
the extrinsic muscles move the auricle as a whole.
Nerve Supply
The upper two-thirds of the lateral surface of the
auricle are supplied by the auriculotemporal nerve; and
Fig. 18.2: Blood supply of the auricle
the lower one-third by the great auricular nerve
Head and Neck
(Figs 18.1a and b). The upper two-thirds of the medial

surface are supplied by the lesser occipital nerve; and is S-shaped. Its outer part is directed medially, forwards
the lower one-third by the great auricular nerve. The and upwards. The middle part is directed medially,
root of the auricle is supplied by the auricular branch backwards and upwards. The inner part is directed
of the vagus (Figs 18.1a and b). The auricular muscles medially, forwards and downwards. The meatus can
are supplied through branches of the facial nerve. be straightened for examination by pulling the auricle
upwards, backwards and slightly laterally.
Blood Supply The meatus or canal is about 24 mm long, of which
The blood supply of the auricle is derived from the the medial two-thirds or 16 mm is bony, and the lateral
posterior auricular and superficial temporal arteries one-third or 8 mm is cartilaginous. Due to the obliquity
(Fig. 18.2). The lymphatics drain into the preauricular, of the tympanic membrane, the anterior wall and
and postauricular lymph nodes (Figs 18.1a and b). floor are longer than the posterior wall and roof
(Figs 18.3a and b).
EXTERNAL ACOUSTIC MEATUS The canal is oval in section. The greatest diameter is
vertical at the lateral end, and anteroposterior at the
Features medial end. The bony part is narrower than the
The external auditory meatus conducts sound waves cartilaginous part. The narrowest point, the isthmus, lies
from the concha to the tympanic membrane. The canal about 5 mm from the tympanic membrane.
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311
Figs 18.3a and b: (a) The normal ear, and (b) otitis media causing mastoid abscess
The bony part is formed by the tympanic plate of the It is oval in shape, measuring 9 × 10 mm. It is placed
temporal bone which is C-shaped in cross-section. obliquely at an angle of 55° with the floor of the meatus.
The posterosuperior part of the plate is deficient. Here It faces downwards, forwards and laterally (Figs 18.4a
the wall of the meatus is formed by a part of the and b).
squamous temporal bone. The meatus is lined by thin The membrane has outer and inner surfaces.
skin, firmly adherent to the periosteum. The outer surface of the membrane is lined by thin
The cartilaginous part is also C-shaped in section; and skin. It is concave.
the gap of the ‘C’ is filled with fibrous tissue. The lining The inner surface provides attachment to the handle
skin is adherent to the perichondrium, and contains of the malleus which extends up to its centre. The inner
hairs, sebaceous glands, and ceruminous or wax glands. surface is convex. The point of maximum convexity lies
Ceruminous glands are modified sweat glands. at the tip of the handle of the malleus and is called the
umbo.
Blood Supply The membrane is thickened at its circumference
The outer part of the canal is supplied by the superficial which is fixed to the tympanic sulcus of the temporal
temporal and posterior auricular arteries, and the inner bone on the tympanic plate. Superiorly, the sulcus is
part, by the deep auricular branch of the maxillary artery. deficient. Here the membrane is attached to the
tympanic notch. From the ends of the notch, two bands,
Lymphatics the anterior and posterior malleolar folds, are
The lymphatics pass to preauricular, postauricular and prolonged to the lateral process of the malleus.
superficial cervical lymph nodes. While the greater part of the tympanic membrane is
tightly stretched, and is, therefore, called the pars tensa,
Head and Neck

Nerve Supply the part between the two malleolar folds is loose and is
The skin lining the anterior half of the meatus is called the pars flaccida. The pars flaccida is crossed
supplied by the auriculotemporal nerve, and that lining internally by the chorda tympani (Fig. 18.5). This part
the posterior half, by the auricular branch of the vagus. is more liable to rupture than the pars tensa.
The membrane is held tense by the inward pull of
DISSECTION the tensor tympani muscle which is inserted into the
Expose the external auditory meatus by cutting the upper end of the handle of the malleus.
tragus of the auricle. Put a probe into the external
auditory meatus and remove the anterior wall of Structure
cartilaginous and bony parts of the external auditory The tympanic membrane is composed of the following
meatus with the scissors. Be slow and careful not to three layers:
damage the tympanic membrane (refer to BDC App). 1 The outer cuticular layer of skin (Fig. 18.4a).
2 The middle fibrous layer made up of superficial
TYMPANIC MEMBRANE radiating fibres and deep circular fibres. The circular
This is a thin, translucent partition between the external fibres are minimal at the centre and maximal at the
acoustic meatus and the middle ear. It forms the lateral periphery (Fig. 18.4b). The fibrous layer is replaced
wall of middle ear. by loose areolar tissue in the pars flaccida (Fig. 18.5).
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312
Figs 18.4a and b: (a) Tympanic membrane as seen in section; (b) Fibres of tympanic membrane
Nerve Supply
1 Outer surface: The anteroinferior part is supplied by
the auriculotemporal nerve, and the posterosuperior
part by the auricular branch of the vagus nerve with
a communicating branch from facial nerve (Fig. 18.1).
2 Inner surface: This is supplied by the tympanic branch
of the glossopharyngeal nerve through the tympanic
plexus (Fig. 18.4a).

AN 40.5 Explain anatomical basis of myringotomy.2
CLINICAL ANATOMY
• As already stated, for examination of the meatus

Fig. 18.5: Inner surface of the tympanic membrane and tympanic membrane, the auricle should
be drawn upwards, backwards and slightly
3 The inner mucous layer (Fig. 18.4a) is lined by a low laterally. However, in infants, the auricle is drawn
ciliated columnar epithelium. downwards and backwards because the canal is
only cartilaginous and the outer surface of the
Head and Neck
Blood Supply tympanic membrane is directed mainly down-

1 The outer surface is supplied by the deep auricular wards (Fig. 18.6).
branch of the maxillary artery. • Boils and other infections of the external auditory
2 The inner surface is supplied by the anterior meatus cause a little swelling but are extremely
tympanic branch of the maxillary artery (see Fig. 6.6) painful, due to the fixity of the skin to the
and by the posterior tympanic branch of the underlying bone and cartilage. Ear should be dried
stylomastoid branch of the posterior auricular artery. after head bath or swimming.
• Irritation of the auricular branch of the vagus in
Venous Drainage the external ear by ear wax or syringing may
Veins from the outer surface drain into the external reflexly produce persistent cough called ear cough,
jugular vein. Those from the inner surface drain into vomiting or even death due to sudden cardiac
the transverse sinus and into the venous plexus around inhibition. On the other hand, mild stimulation of
the auditory tube. this nerve may reflexly produce increased appetite.
• Accumulation of wax in the external acoustic meatus
Lymphatic Drainage is often a source of excessive itching, although
Lymphatics pass to the preauricular and retro- fungal infection and foreign bodies should be
pharyngeal lymph nodes.
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313
excluded. Troublesome impaction of large foreign promises blood supply to cartilage. Fibrosis leads
bodies, like seeds, grains, insects, is common. to ‘cauliflower ear’. It is usually seen in wrestlers.
Syringing is done to remove these (Fig. 18.7). • Tympanic membrane is divided into an upper
• Involvement of the ear in herpes zoster of the smaller sector, the pars flaccida bounded by
geniculate ganglion depends on the connection anterior and posterior malleolar folds and a larger
between the auricular branch of the vagus and the sector, the pars tensa. Behind pars flaccida lies the
facial nerve within the petrous temporal bone. chorda tympani, so disease in pars flaccida should
• Small pieces of skin from the lobule of the pinna be treated carefully (Fig. 18.8).
are commonly used for demonstration of lepra • When the tympanic membrane is illuminated for
bacilli to confirm the diagnosis of leprosy. examination, the concavity of the membrane
• Pinna is used as grafting material. produces a ‘cone of light’ over the anteroinferior
• Hair on pinna in male represents Y-linked inheri- quadrant which is the farthest or deepest quadrant
tance. with its apex at the umbo (Fig. 18.9). Through the
• A good number of ear traits follow mendelian membrane, one can see the underlying handle of
inheritance. the malleus and the long process of the incus.
• Infection of elastic cartilage may cause perichondritis. • The membrane is sometimes incised to drain pus
• Bleeding within the auricle occurs between the present in the middle ear. The procedure is called
perichondrium and auricular cartilage. If left
untreated, fibrosis occurs as haematoma com-
Fig. 18.8: Care to be taken in disease of pars flaccida
Head and Neck

Fig. 18.6: Otoscopic examination
Fig. 18.9: The left tympanic membrane seen through the external
acoustic meatus. (1) Posterosuperior quadrant; (2) Anterosuperior
Fig. 18.7: Syringing of the ear quadrant; (3) Posteroinferior quadrant; (4) Anteroinferior quadrant
HEAD AND NECK
314
myringotomy (Fig. 18.9). The incision for myringo-

tomy is usually made in the posteroinferior
quadrant of the membrane where the bulge is most
prominent. In giving an incision, it has to be
remembered that the chorda tympani nerve runs
downwards and forwards across the inner surface
of the membrane, lateral to the long process of the
incus, but medial to the neck of the malleus. If the
nerve is injured, taste from most of anterior two-
thirds of tongue is not perceived. Also salivation
from submandibular and sublingual glands gets
affected.
MIDDLE EAR
Features
The middle ear is also called the tympanic cavity, or
Fig. 18.11: Measurements
tympanum.
The middle ear is a narrow air-filled space situated
in the petrous part of the temporal bone between the DISSECTION
external ear and the internal ear (Fig. 18.10).
Remove the dura mater and endosteum from the floor
Shape and Size of the middle cranial fossa. Identify greater petrosal
The middle ear is shaped like a cube. Its lateral and nerve emerging from a canaliculus on the anterior
medial walls are large, but the other walls are narrow, surface of petrous temporal bone. Trace it as it passes
because the cube is compressed from side-to-side. Its inferior to trigeminal ganglion to reach the carotid canal.
vertical and anteroposterior diameters are both about Carefully break the roof of the middle ear formed by
15 mm. When seen in coronal section the cavity of the tegmen tympani which is a thin plate of bone situated
middle ear is biconcave, as the medial and lateral walls parallel and just lateral to the greater petrosal nerve.
are closest to each other in the centre. The distances Cavity of the middle ear can be visualised. Try to put a
separating them are 6 mm near the roof, 2 mm in the probe in the anteromedial part of the cavity of middle
centre, and 4 mm near the floor (Fig. 18.11). ear till it appears at the opening in the lateral wall of
nasopharynx. Identify the posterior wall of the middle
ear which has an opening in its upper part. This is the
aditus to mastoid antrum, which in turn, connects the
Head and Neck
cavity to the mastoid air cells (refer to BDC App).

Ear ossicles
Identify the bony ossicles. Locate the tendon of tensor
tympani muscle passing from the malleus towards the
medial wall of the cavity where it gets continuous with
the muscle. Trace the tensor tympani muscle traversing
in a semicanal above the auditory tube. Break one wall
of the pyramid to visualise the stapedius muscle. Just
superior to the attachment of tendon of tensor tympani,
look for chorda tympani traversing the tympanic
membrane.
Parts
The cavity of the middle ear can be subdivided into the
tympanic cavity proper which is opposite the tympanic
membrane; and the epitympanic recess which lies above
Fig. 18.10: Scheme to show the three parts of the ear the level of the tympanic membrane.
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315
Communications tympanic cavity. Outlet is auditory tube. Handle is aditus

The middle ear communicates anteriorly with the to mastoid antrum and mastoid air cells (Fig. 18.12b).
nasopharynx through the auditory tube, and posteriorly The mucous membrane lining the middle ear cavity
with the mastoid antrum and mastoid air cells through invests all the contents and forms several vascular folds
the aditus to the mastoid antrum (Fig. 18.12a). which project into the cavity. This gives the cavity, a
The middle ear is likened to a pistol in the sloping honeycombed appearance.
course of the aditus to the epitympanic recess and the
auditory tube (Fig. 18.12a). The trigger of pistol is Competency achievement: The student should be able to:
AN 40.2 Describe and demonstrate the boundaries, contents,
relations and functional anatomy of middle ear and auditory tube.3
Boundaries
Roof or Tegmental Wall
1 The roof separates the middle ear from the middle
cranial fossa. It is formed by a thin plate of bone
called the tegmen tympani. This plate is prolonged
forwards as the roof of the canal for the tensor
tympani (Fig. 18.13).
2 In young children, the roof presents a gap at the
unossified petrosquamous suture where the middle
ear is in direct contact with the meninges. In adults,
the suture is ossified and transmits a vein from the
middle ear to the superior petrosal sinus.
Floor or Jugular Wall

The floor is formed by a thin plate of bone which
separates the middle ear from the superior bulb of the
internal jugular vein. This plate is a part of the temporal
bone (Fig. 18.13).
Near the medial wall, the floor presents the tympanic
canaliculus which transmits the tympanic branch of the
Figs 18.12a and b: (a) Scheme to show some relationships of glossopharyngeal nerve to the medial wall of the
the middle ear cavity; (b) Note that the cavity resembles a pistol middle ear.
Head and Neck
Fig. 18.13: Scheme to show the landmarks on the medial wall of the middle ear. Some related structures are also shown
HEAD AND NECK
316
Fig. 18.14: Lateral wall of the middle ear viewed from the medial side
Anterior or Carotid Wall Lateral or Membranous Wall

The anterior wall is narrow due to the approximation 1 The lateral wall separates the middle ear from the
of the medial and lateral walls, and because of descent external acoustic meatus. It is formed:
of the roof. a. Mainly by the tympanic membrane along with the
The uppermost part of the anterior wall bears the tympanic ring and sulcus (described earlier).
opening of the canal for the tensor tympani. b. Partly by the squamous temporal bone, in the region
The middle part has the opening of the auditory tube. of the epitympanic recess (Figs 18.13 and 18.5).
The inferior part of the wall is formed by a thin plate
2 Near the tympanic notch, there are two small
of bone which forms the posterior wall of the carotid
apertures.
canal. The plate separates the middle ear from the
internal carotid artery. This plate of bone is perforated a. The petrotympanic fissure lies in front of the upper
by the superior and inferior sympathetic carotico- end of the bony rim. It lodges the anterior process
tympanic nerves and the tympanic branch of the internal of the malleus and transmits the tympanic branch
carotid artery (Fig. 18.14). of the maxillary artery.
The bony septum between the canals for the tensor b. The anterior canaliculus for the chorda tympani
tympani and for the auditory tube is continued nerve lies either in the fissure or just in front of it.
posteriorly on the medial wall as a curved lamina called The nerve leaves the middle ear through this
the processus cochleariformis. Its posterior end forms a canaliculus to emerge at the base of the skull
pulley around which the tendon of the tensor tympani (Figs 18.5 and 18.14).
turns laterally to reach the upper part of the handle of
the malleus. Medial or Labyrinthine Wall
Head and Neck
The medial wall separates the middle ear from the

Posterior or Mastoid Wall internal ear. It presents the following features.
The posterior wall presents these features from above 1 The promontory is a rounded bulging produced by
downwards. the first turn of the cochlea. It is grooved by the
1 Superiorly, there is an opening or aditus through tympanic plexus (Fig. 18.13).
which the epitympanic recess communicates with the 2 The fenestra vestibuli is an oval opening postero-
mastoid or tympanic antrum (Figs 18.12a and 18.13). superior to the promontory. It leads into the vestibule
2 The fossa incudis is a depression which lodges the of the internal ear and is closed by the foot-plate of
short process of the incus. the stapes.
3 A conical projection, called the pyramid, lies near the 3 The fenestra cochleae is a round opening at the bottom
junction of the posterior and medial walls. It has an of a depression posteroinferior to the promontory.
opening at its apex for passage of the tendon of the It opens into the scala tympani of the cochlea, and is
stapedius muscle. closed by the secondary tympanic membrane.
4 Lateral to pyramid and near the posterior edge of 4 The prominence of the facial canal runs backwards just
the tympanic membrane, is the posterior canaliculus above the fenestra vestibuli, to reach the lower
for the chorda tympani through which the nerve enters margin of the aditus. The canal then descends behind
the middle ear cavity (Fig. 18.14). the posterior wall to end at the stylomastoid foramen.
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317
5 Prominence of lateral semicircular canal above the

facial canal.
6 The sinus tympani is a depression behind the
promontory, opposite the ampulla of the posterior
semicircular canal.
Contents
The middle ear contains the following.
1 Three small bones or ossicles, namely the malleus,
the incus and the stapes. The upper half of the
malleus, and the greater part of the incus lie in the
epitympanic recess.
2 Joints between the ear ossicles. Fig. 18.15: Ossicles of the left ear, seen from the medial side
3 Two muscles—the tensor tympani and the stapedius.
4 Vessels supplying and draining the middle ear. It has the following parts:
5 Nerves—chorda tympani and tympanic plexus. a. The small head has a concave facet which
articulates with the lentiform nodule of the incus.
6 Air.
b. The narrow neck provides insertion, posteriorly,
to the thin tendon of the stapedius.
Ear Ossicles
c. Two limbs or crura; anterior, the shorter and less
Malleus curved; and posterior, the longer which diverge
The malleus (Latin hammer) is so-called because it from the neck and are attached to the footplate.
resembles a hammer. It is the largest, and the most d. The footplate, a footpiece or base, is oval in shape,
laterally placed ossicle. It has the following parts: and fits into the fenestra vestibuli.
1 The rounded head lies in the epitympanic recess. It Joints of the Ossicles
articulates posteriorly with the body of the incus. It 1 The incudomalleolar joint is a saddle joint.
provides attachment to the superior and lateral 2 The incudostapedial joint is a ball and socket joint. Both
ligaments (Fig. 18.5). of them are synovial joints. They are surrounded by
2 The neck lies against the pars flaccida and is related capsular ligaments. Accessory ligaments are three
medially to the chorda tympani nerve (Fig. 18.14). for the malleus, and one each for the incus and the
3 The anterior process is connected to the petrotympanic stapes which stabilize the ossicles. All ligaments are
fissure by the anterior ligament. extremely elastic (Fig. 18.15).
4 The lateral process projects from the upper end of the
handle and provides attachment to the malleolar folds. Muscles of the Middle Ear
5 The handle extends downwards, backwards and There are two muscles—the tensor tympani and the
medially, and is attached to the upper half of the stapedius. Both act simultaneously to damp down the
Head and Neck

tympanic membrane (Figs 18.4b and 18.14). intensity of high-pitched sound waves and thus protect
Incus or Anvil the internal ear (Fig. 18.8).
The tensor tympani lies in a bony canal that opens at
It is so-called because it resembles an anvil, used by
its lateral end on the anterior wall of the middle ear,
blacksmiths. It resembles a molar tooth and has the
and at the medial end on the base of the skull. The
following parts:
auditory tube lies just below this canal.
1 The body is large and bears an articular surface that
is directed forwards. It articulates with the head of The muscle arises from the walls of the canal in which
the malleus. it lies. Some fibres arise from the cartilaginous part of
2 The long process projects downwards just behind and the auditory tube and some from the base of the skull.
parallel with the handle of the malleus. Its tip bears a The muscle ends in a tendon which reaches the
lentiform nodule directed medially which articulates medial wall of the middle ear and bends sharply around
with the head of the stapes (Figs 18.9 and 18.15). the processus cochleariformis. It then passes laterally
across the tympanic cavity to be inserted into the handle
Stapes of the malleus.
This bone is so-called because it is shaped like a stirrup. The tensor tympani is supplied by the mandibular nerve.
It is the smallest, and the most medially placed ossicle The fibres pass through the nerve to the medial ptery-
of the ear (Fig. 18.15). goid, and through the otic ganglion, without any relay.
HEAD AND NECK
318
It develops from the mesoderm of first branchial arch. 2 The intensity of the sound waves is increased ten
The stapedius lies in a bony canal that is related to times by the ossicles. It may be noted that the
the posterior wall of the middle ear. Posteriorly, and frequency of sound does not change.
below, this canal is continuous with the vertical part of
the canal for the facial nerve. Anteriorly, the canal opens TYMPANIC OR MASTOID ANTRUM
on the summit of the pyramid. Features
The muscle arises from the walls of this canal. Its Mastoid antrum is a small, circular, air-filled space
tendon emerges through the pyramid and passes situated in the posterior part of the petrous temporal
forwards to be inserted into the posterior surface of the bone. It is of adult size at birth, size of a small pea, or
neck of the stapes. 1 cm in diameter and has a capacity of about one
The stapedius is supplied by the facial nerve. It milliliter (Fig. 18.13).
develops from the mesoderm of the second branchial arch.
Boundaries
Arterial Supply
1 Superiorly: Tegmen tympani, and beyond it the
The main arteries of the middle ear are as follows. temporal lobe of the cerebrum.
1 The anterior tympanic branch of the maxillary artery 2 Inferiorly: Mastoid process containing the mastoid air
which enters the middle ear through the petro- cells.
tympanic fissure. 3 Anteriorly: It communicates with the epitympanic
2 The posterior tympanic branch of the stylomastoid recess through the aditus. The aditus is related
branch of the posterior auricular artery which enters medially to the ampullae of the superior and lateral
through the stylomastoid foramen. semicircular canals, and posterosuperiorly to the
3 Petrosal and superior tympanic branches of middle facial canal.
meningeal artery. 4 Posteriorly: It is separated by a thin plate of bone from
4 Branches of ascending pharyngeal artery. the sigmoid sinus. Beyond the sinus there is the
5 Tympanic branches of internal carotid artery. cerebellum.
5 Medially: Petrous temporal bone.
Venous Drainage 6 Laterally: It is bounded by part of the squamous
Veins from the middle ear drain into the superior temporal bone. This part corresponds to the
petrosal sinus and the pterygoid plexus of the veins. suprameatal triangle seen on the surface of the bone.
This wall is 2 mm thick at birth, but increases in
Lymphatic Drainage thickness at the rate of about 1 mm per year up to a
Lymphatics pass to the preauricular and retro- maximum of about 12 to 15 mm.
pharyngeal lymph nodes.
DISSECTION
Nerve Supply Clean the mastoid temporal bone off all the muscles
The nerve supply is derived from the tympanic plexus and identify suprameatal triangle and supramastoid
which lies over the promontory. The plexus is formed
Head and Neck
crest. Use a fine chisel to remove the bone of the triangle

by the following. till the mastoid antrum is reached. Examine the extent
1 The tympanic branch of the glossopharyngeal nerve. of mastoid air cells.
Its fibres are distributed to the mucous membrane Remove the posterior and superior walls of external
of the middle ear, the auditory tube, the mastoid auditory meatus till the level of the roof of mastoid
antrum and air cells. It also gives off the lesser antrum. Identify the chorda tympani nerve at the
petrosal nerve. posterosuperior margin of tympanic membrane.
2 The superior and inferior caroticotympanic nerves Look for arcuate eminence on the anterior face of
arise from the sympathetic plexus around the petrous temporal bone. Identify internal acoustic meatus
internal carotid artery. These fibres are vasomotor on the posterior face of petrous temporal bone, with
to the mucous membrane. the nerves in it. Try to break off the superior part of
petrous temporal bone above the internal acoustic
FUNCTIONS OF THE MIDDLE EAR meatus. Identify the facial nerve as it passes towards
the aditus. Identify the sharp bend of the facial nerve
1 It transmits sound waves from the external ear to
with the geniculate ganglion.
the internal ear through the chain of ear ossicles, and
Identify the facial nerve turning posteriorly into the
thus transforms the air-borne vibrations from the
medial wall. Trace it above the fenestra vestibuli till it
tympanic membrane to liquid-borne vibrations in the
turns inferiorly in the medial wall of aditus.
internal ear.
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319
Identify facial nerve at the stylomastoid foramen. Try c. It may erode the floor and spread downwards,
to break the bone vertically along the lateral edge of causing thrombosis of the sigmoid sinus and
the foramen to expose the whole of facial nerve canal. the internal jugular vein (Fig. 18.16).
Facial nerve is described in detail in Chapter 4, Voulme 4. d. It may spread backwards, causing mastoid
Learn it from there. abscess (Fig. 18.3).
Break off more of the superior surface of the petrous Chronic otitis media and mastoid abscess are
temporal bone. Remove the bone gently. Examine the responsible for persistent discharge of pus
holes in the bone produced by semicircular canals and through the ear. Otitis media is more common in
look for the semicircular ducts lying within these canals. children than in adults.
Note the branches of vestibulocochlear nerve entering • Inflammation of the auditory tube (eustachian
the bone at the lateral end of the meatus. Study the catarrh) is often secondary to an attack of common
internal ear from the models in the museum. cold. This causes pain in the ear which is aggravated
by swallowing, due to blockage of the tube. Pain is
Mastoid Air Cells relieved by installation of decongestant drops in
the nose which helps to open the ostium.
Mastoid air cells are a series of intercommunicating
spaces of variable size present within the mastoid • Otosclerosis: Sometimes bony fusion takes place
process. Their number varies considerably. Sometimes between the foot plate of the stapes and the
there are just a few, and are confined to the upper part margins of the fenestra vestibuli. This leads to
of the mastoid process. Occasionally, they may extend deafness. The condition may be surgically corrected
beyond the mastoid process into the squamous or by putting a prosthesis (Figs 18.17a and b).
petrous parts of the temporal bone (Fig. 18.12a). • Mastoid abscess is secondary to otitis media. It
is difficult to treat. A proper drainage of pus from
Vessels, Lymphatics and Nerves the mastoid requires an operation through the supra-
meatal triangle. The facial nerve should not be
The mastoid antrum and air cells are supplied by the
injured during this operation (Fig. 18.18).
posterior tympanic artery derived from the stylomastoid
• Infection from the mastoid antrum and air cells
branch of the posterior auricular artery. The veins drain
can spread to any of the structures related to them
into the mastoid emissary vein, the posterior auricular
including the temporal lobe of the cerebrum, the
vein and the sigmoid sinus.
cerebellum, and the sigmoid sinus.
Lymphatics pass to the postauricular and upper deep • The ear on infected side is displaced laterally and
cervical lymph nodes. can be appreciated from the back.
Nerves are derived from the tympanic plexus formed • Hyperacusis: Due to paralysis of stapedius muscle,
by the glossopharyngeal nerve and from the meningeal movements of stapes are dampened; so sounds
branch of the mandibular nerve. get distorted and get too high in volume. This is
called hyperacusis.
AN 40.4 Explain anatomical basis of otitis externa and otitis media.4
Head and Neck

CLINICAL ANATOMY
• Fracture of the middle cranial fossa breaks the roof

of the middle ear, ruptures the tympanic
membrane, and thus causes bleeding through the
ear along with discharge of CSF.
• Throat infections commonly spread to the middle
ear through the auditory tube and cause otitis
media. The pus from the middle ear may take one
of the following courses:
a. It may be discharged into the external ear
following rupture of the tympanic membrane.
b. It may erode the roof and spread upwards,
Fig. 18.16: Otitis media causing thrombosis of the sigmoid
causing meningitis and brain abscess.
sinus and the internal jugular vein
HEAD AND NECK
320
Figs 18.17a and b: (a) Otosclerosis; (b) Treated by a prosthesis
It forms the anterior part of the labyrinth. It has a conical

central axis known as the modiolus around which the
cochlear canal makes two and three quarter turns.
The modiolus is directed forwards and laterally. Its
apex points towards the anterosuperior part of the
medial wall of the middle ear and the base towards the
fundus of the internal acoustic meatus.
A spiral ridge of the bone, the spiral lamina, projects
from the modiolus and partially divides the cochlear
canal into the scala vestibuli above, and the scala
tympani below. These relationships apply to the lowest
Fig. 18.18: Chances of injury to facial nerve during mastoid part or basal turn of the cochlea. The division between
operation the two passages is completed by the basilar membrane.
The scala vestibuli communicates with the scala
tympani at the apex of the cochlea by a small opening,
called the helicotrema.
AN 40.3 Describe the features of internal ear.5
Vestibule
Head and Neck
INTERNAL EAR This is the central part of the bony labyrinth. It lies
medial to the middle ear cavity. Its lateral wall opens
The internal ear, or labyrinth, lies in the petrous part of into the middle ear at the fenestra vestibuli which is
the temporal bone. It consists of the bony labyrinth closed by the footplate of the stapes.
within which there is a membranous labyrinth. The Three semicircular canals open into its posterior wall.
membranous labyrinth is filled with a fluid called The medial wall is related to the internal acoustic
endolymph. It is separated from the bony labyrinth by meatus, and presents the spherical recess in front, and
another fluid called the perilymph. the elliptical recess behind. The two recesses are
separated by a vestibular crest which splits inferiorly to
BONY LABYRINTH enclose the cochlear recess (Fig. 18.19).
The bony labyrinth consists of three parts: Just below the elliptical recess, there is the opening
• Cochlea, anteriorly (Fig. 18.19a). of a diverticulum, the aqueduct of the vestibule which
• Vestibule, in the middle. opens at a narrow fissure on the posterior aspect of the
• Semicircular canals, posteriorly (Fig. 18.19). petrous temporal bone, posterolateral to the internal
acoustic meatus. It is plugged in life by the ductus
Cochlea endolymphaticus and a vein; no perilymph escapes
The bony cochlea resembles the shell of a common snail. through it.
EAR
321
Figs 18.19a and b: (a) Scheme to show some features of the bony labyrinth (seen from the lateral side); (b) Schematic diagram
Semicircular Canals
There are three bony semicircular canals: (1) An anterior
or superior, (2) posterior, and (3) lateral; each has two
ends. They lie posterosuperior to the vestibule, and are
set at right angles to each other. Each canal describes
two-thirds of a circle, and is dilated at one end to form
the ampulla. These three canals open into the vestibule
by five openings.
The anterior or superior semicircular canal lies in a
vertical plane at right angles to the long axis of the
petrous temporal bone. It is convex upwards. Its
Head and Neck

position is indicated by the arcuate eminence seen on
the anterior surface of the petrous temporal bone. Its
ampulla is situated anterolaterally. Its posterior end Fig. 18.20: The semicircular canals
unites with the upper end of the posterior canal to form side lies in the plane of the posterior canal of the other
the crus commune which opens into the medial wall of side (Figs 18.19 and 18.20).
the vestibule.
The posterior semicircular canal also lies in a vertical MEMBRANOUS LABYRINTH
plane parallel to the long axis of the petrous temporal
bone. It is convex backwards. Its ampulla lies at its It is in the form of a complicated, but continuous closed
lower end. The upper end joins the anterior canal to cavity filled with endolymph. The epithelium of the
form the crus commune. membranous labyrinth is specialized to form receptors
The lateral semicircular canal lies in the horizontal for sound, i.e. organ of Corti; for static balance, the
plane with its convexity directed posterolaterally. The maculae; and for kinetic balance, the cristae.
ampulla lies anteriorly, close to the ampulla of the Like the bony labyrinth, the membranous labyrinth
anterior canal. also consists of three main parts:
Note that the lateral semicircular canals of the two a. The spiral duct of the cochlea or organ of Corti,
sides lie in the same plane. The anterior canal of one anteriorly.
HEAD AND NECK
322
of Corti which is the end organ for hearing (Fig. 18.22).

It comprises rods of Corti and hair cells. Hair is embe-
dded in a gelatinous membrane called the membrana
tectoria. The organ of Corti is innervated by peripheral
processes of bipolar cells located in the spiral ganglion.
This ganglion is located in the spiral canal present within
the modiolus at the base of the spiral lamina. The central
processes of the ganglion cells form the cochlear nerve.
Posteriorly, the duct of the cochlea is connected to
the saccule by a narrow ductus reunions.
Fig. 18.21: Parts of the membranous labyrinth (as seen from The sound waves reaching the endolymph through
the lateral side) the vestibular membrane make appropriate parts of the
basilar membrane vibrate, so that different parts of the
b. The utricle and saccule with maculae, the organs organ of Corti are stimulated by different frequencies
of static balance, within the vestibule. of sound. The loudness of the sound depends on the
c. The semicircular ducts with cristae, the organs of amplitude of vibration.
kinetic balance, posteriorly (Fig. 18.21).
Saccule and Utricle
AN 43.3 Identify, describe and draw microanatomy of olfactory
The saccule lies in the anteroinferior part of the vestibule,
epithelium, eyelid, lip, sclerocorneal junction, optic nerve, cochlea— and is connected to the basal turn of the cochlear duct
organ of Corti, pineal gland.6 by the ductus reunions.
Microanatomy of cochlea and organ of corti is given here. For The utricle is larger than the saccule and lies in the
microanatomy of other structures please refer to appropriate posterosuperior part of the vestibule. It receives the ends
chapters. of three semicircular ducts through five openings. The
duct of the saccule unites with the duct of the utricle
Duct of the Cochlea or the Scala Media to form the ductus endolymphaticus. The ductus
The spiral duct occupies the middle part of the cochlear endolymphaticus ends in a dilatation, the saccus
canal between the scala vestibuli and the scala tympani. endolymphaticus. The ductus and saccus occupy the
It is triangular in cross-section. The floor is formed by the aqueduct of the vestibule.
basilar membrane; the roof by the vestibular or Reissner’s The medial walls of the saccule and utricle are
membrane; and the outer wall by the bony wall of the thickened to form a macula in each chamber. The maculae
cochlea. The basilar membrane supports the spiral organ are end organs that give information about the position
Head and Neck
Fig. 18.22: Schematic section through one turn of the cochlea

EAR
323
of the head. They are static balance receptors. They are nuclei. From cochlear nuclei, fibres travel through pons,
supplied by peripheral processes of neurons in the midbrain, thalamus and internal capsule to reach
vestibular ganglion. auditory area in temporal pole (Fig. 18.23).
Saccule gets stimulated by vertical linear motions,
e.g. going in ‘lift’. Utricle gets stimulated by horizontal Vestibular Pathway
linear motion, e.g. going in car. The vestibular receptors are the maculae of the saccule
and utricle (for static balance) and in the crista of the
Semicircular Ducts ampullaris of semicircular ducts (for kinetic balance).
The three semicircular ducts lie within the Fibres from cristae of anterior and lateral semicircular
corresponding bony canals. Each duct has an ampulla canals and some fibres from the two maculae lie in
corresponding to that of the bony canal. In each superior vestibular area of internal acoustic meatus.
ampulla, there is an end organ called the ampullary Fibres of crista of posterior semicircular canal lie in
crest or crista or cupola (Fig. 18.21). Cristae respond to foramen singulare.
pressure changes in the endolymph caused by Most of the fibres from maculae of utricle and saccule
movements of the head. lie in inferior vestibular area (Fig. 18.23).
These three nerve divisions are peripheral processes
Blood Supply of Labyrinth
of bipolar neurons of the vestibular ganglion. This
The arterial supply is derived mainly from the labyrin- ganglion is situated in the internal acoustic meatus. The
thine branch of the basilar artery which accompanies central processes arising from the neurons of the
the vestibulocochlear nerve; and partly from the ganglion form the vestibular nerve which ends in the
stylomastoid branch of the posterior auricular artery. vestibular nuclei.
The labyrinthine vein drains into the superior These nuclei send fibres:
petrosal sinus or the transverse sinus. Other inconstant a. To the archicerebellum through the inferior
veins emerge at different points and open separately cerebellar peduncle.
into the superior and inferior petrosal sinuses and the b. To the motor nuclei of the brainstem (chiefly of the
internal jugular vein. III, IV, VI and XI nerves)
Through the vestibular pathway, the impulses
VESTIBULOCOCHLEAR NERVE
arising in the labyrinth can influence the movements
Cochlaear Pathway of the eyes, the head, the neck and the trunk.
Vestibulocochlear nerve comprises hearing and Facial nerve: Facial nerve enters the petrous temporal
vestibular parts. The first neurons of the pathway are bone through internal acoustic meatus. It travels in
located in the spiral ganglion. They are bipolar. Their relation to internal ear and middle ear and exits through
peripheral processes innervate the spiral organ of Corti, stylomastoid foramen. The course and branches of this
while central processes form the cochlear nerve. This part are given in BD Chaurasia’s Human Anatomy, Vol 4,
nerve terminates in the dorsal and ventral cochlear Chapter 4.
Head and Neck
Fig. 18.23: Course of vestibulocochlear nerve

HEAD AND NECK
324
CLINICAL ANATOMY Molecular Regulation

The proteins WNT and bone morphogenetic protein
• Endolymph is produced by striae vascularis. This (BMP) of surrounding region are important for the
process requires melanocytes. The disorders of formation of otic placode.
melanocytes, i.e. albinism, are associated with Retinoic acid plays an important role in the
deafness. anteroposterior differentiation of otic vesicle.
• Acoustic neuroma is a tumour of Schwann cells of WNT and SHH are required for the formation of
VIII nerve. If neuroma extends into internal semicircular canals and cochlear duct.
auditory meatus, VII nerve will get pressed. There Defects in Noggin and PAX2 genes result in sensory
will be VIII nerve paralysis and VII nerve paralysis neural deafness that plays a role in formation of cochlea.
as well.
• Reasons of earache are depicted in Flowchart 18.1. Mnemonics
Ear: Bones of middle ear MISs
DEVELOPMENT M–Malleus
1 External auditory meatus: Dorsal part of 1st ectodermal I–Incus
cleft. Ss–Stapes
2 Auricle: Tubercles appearing on 1st and 2nd branchial
arches around the opening of external auditory
meatus. FACTS TO REMEMBER
3 Middle ear cavity and auditory tube: Tubotympanic • Tympanic membrane develops from ectoderm,
recess (see Tables A.6 and A.7 in Appendix). mesoderm and endoderm.
4 Ossicles • Outer aspect of tympanic membrane is supplied
a. Malleus and incus: From 1st arch cartilage. by part of V and X nerves.
b. Stapes: From 2nd arch cartilage (see Table A.5 in • Syringing the ear may cause slowing of the heart
Appendix). rate and feeling of nausea.
5 Muscles • Malleus and incus develop from 1st pharyngeal
a. Tensor tympani: From 1st pharyngeal arch mesoderm. arch, while stapedius develops from second
pharyngeal arch.
b. Stapedius: From 2nd pharyngeal arch mesoderm.
• Tensor tympani develops from 1st arch and is
6 Membranous labyrinth from ectodermal vesicle on
supplied by V3, while stapedius develops from
each side of hindbrain vesicle. Organ of Corti—
2nd arch and is supplied by VII nerve.
ectodermal.
Flowchart 18.1: Reasons of earache

Head and Neck
EAR
325
• Suprameatal triangle (Macewen’s triangle) demar- • A small bit of skin is taken to examine lepra bacilli
cates the position of mastoid antrum at a depth of • Hairy pinna is the only symptom of Y chromosome
12–13 mm in adult. • Pinna used to be pulled as a part of punishment
• Eustachian tube equalizes the pressure on both for disobedience.
sides of the tympanic membrane. This tube Nerve supply: Medial surface in its upper two-
connects the nasopharynx to the anterior wall of thirds part is supplied by lesser occipital and in its
middle ear. lower one-third part by great auricular. Lateral
• Malleus, incus and stapes are bone within bone, as surface in its upper two-thirds part is supplied by
these 3 bony ossicles lie within the petrous auriculotemporal nerve and in its lower one-third
temporal bone. part by great auricular again.
• There are 2 synovial joints between these three
bony ossicles, which are fully developed at birth.
FURTHER READING
• Ear is an engineering marvel.
• One may slowly become deaf to soft sounds, if one • Allam AF. Pneumatization of the temporal bone: Ann Otol
is continuously exposed to a lot of loud sounds. Rhino Laryngol 1969;78:49–64.
• Anderson SD. The Intratympanic muscles. In: Hinchcliffe R
(ed). Scientific Foundations of Otolaryngology. London:
Heinemann; 1976; pp. 257–80.
CLINICOANATOMICAL PROBLEM • Duman D, Tekin M. Autosomal recessive nonsyndromic
deafness genes: A review. Front Biosci 2013;17:2213–36.
A young boy has only deformity of the auricle/
pinna. No treatment is done and he is fine in studies, A review that summarizes genes and mutations reported in families
with ARNSHL. Mutations in GJB2, encoding connexin 26, make
games, etc.
this gene the most common cause of hearing loss in many
• What are the uses of the auricle? populations. Other relatively common deafness genes include
• Name its nerve supply. SLC26A4, MYO15A, OTOF, TMC1, CDH23 and TMPRSS3.
Ans: There is hardly any medical use of the pinna in • Fettiplace R. Hackney CM. The sensory and motor roles of
human. It is mainly cosmetic. However, there are auditory hair cells. Nat Rev Neurosci 2006;7:19–29.
other uses. These are: A description of proteins involved in the sensory and motor
• Lobule, the lowest part of auricle is used for functions of auditory hair cells, with evidence for each force
generator.
wearing ear rings of different shape, size, colour
and quality. • Proctor B, Nager GT. The facial canal: Normal anatomy, varia-
tions and anomalis. Ann Rhinol Laryngol 1982;91:33–61.
• It is used for supporting glasses. Nature knew
million of years ago that human would need A detailed anatomical description, emphasising the relations of the
facial canal to adjacent structures and variations in the course of
glasses, and the auricles were not removed.
the canal.
1–6
Head and Neck

NOISE POLLUTION
‘‘Noise pollution leads to mind body suffering
Plug the ears, decrease volume, seek policing
Sweet soft “lecture” induces happy sleeping

Loud prolonged noise causes auditory crippling
One should not even mind job changing

But do not, at any cost lose your hearing
Lest one’s very dear cell phone

One would not be hearing’’
HEAD AND NECK
326
1. Discuss the middle ear under the following 2. Write short notes on:
headings. a. Tympanic membrane
a. Walls b. Contents of middle ear
b. Ossicles c. Chorda tympani nerve
c. Muscles d. Parts of internal ear
d. Clinical anatomy
e. Cochlear duct
1. Tegmen tympani forms the roof of the following, 4. Which of the following nerves supplies the outer
except: aspect of the tympanic membrane?
a. Mastoid antrum a. Auricular branch of vagus
b. Tympanic cavity b. Greater occipital
c. Canal for tensor tympani c. Lesser occipital
d. Internal auditory meatus d. Anterior ethmoidal
5. Which of the following nerves supplies middle ear
2. Which nerve supplies stapedius muscle?
cavity?
a. Oculomotor b. Trochlear a. Facial b. Trigeminal
c. Trigeminal d. Facial c. Glossopharyngeal d. Vagus
3. By how many openings do the semicircular canals 6. Derivatives of all the germ layers; ectoderm,
open in the vestibule? mesoderm and endoderm are present in:
a. 3 b. 5 a. Heart b. Tympanic membrane
c. 4 d. 2 c. Cornea d. Urachus
1. d 2. d 3. b 4. a 5. c 6. b
Head and Neck
• What is type of cartilage present in the auricle/ • Which two tubes lie in the anterior wall of the middle
pinna? ear?
• What is the nerve supply of tympanic membrane on • How many semicircular canals (bony and
both its surfaces? membranous) are there in internal ear?
• Name the bony ossicles and the types of joints • How many cristae are there in three membranous
formed between them. semi-circular canals?
• Name the muscles of the middle ear with their nerve • What is the receptor in saccule and utricle?
supply. • Which is the end organ for hearing?
• Which embryonic layers form the tympanic • How do auditory tube and middle ear cavity
membrane? develop?
• How can syringing of the ear cause nausea and • Which embryonic layer gives rise to the membranous
bradycardia? labyrinth?
• Name the walls of the middle ear. • Enumerate the reasons for ‘earache’.
• Which structures form posterior wall of the middle • How does one mark the suprameatal triangle? What
ear? is its importance?
• Which structures form the medial wall of the middle • Enumerate the complications of otitis media.
ear? • What are the parts of the tympanic membrane?
19
Eyeball
Our eyes are placed in front because it is more important to look ahead than look back .
—Anonymous
INTRODUCTION middle or vascular coat also called the uveal tract consists
Sense of sight perceived through retina of the eyeball of the choroid, the ciliary body and the iris. The inner
is one of the five special senses. Its importance is or nervous coat is the retina (Fig. 19.1).
obvious in the varied ways of natural protection. Bony Light entering the eyeball passes through several
orbit, projecting nose and various coats protect the refracting media. From before backwards, these are the
precious retina. Each and every component of its three cornea, the aqueous humour, the lens and the vitreous
coats is assisting the retina to focus the light properly. body.
A lot of advances have been made in correcting the
defects of the eye. Eyes can be donated at the time of
death, and a ‘will’ can be prepared accordingly. AN 41.1 Describe and demonstrate parts and layers of eyeball.1
About 75% of afferents reach the brain through the
eyes. Adequate rest to eye muscles is important. A good
place for rest could be the ‘classroom’ where palpebral OUTER COAT
part of orbicularis oculi closes the eyes gently. The
eyeball is the organ of sight. The camera closely SCLERA
resembles the eyeball in its structure. It is almost The sclera (skleros = hard) is opaque and forms the
spherical in shape and has a diameter of about 2.5 cm. posterior five-sixths of the eyeball. It is composed of
Eyeball is made up of three concentric coats. The outer dense fibrous tissue which is firm and maintains the
or fibrous coat comprises the sclera and cornea. The shape of the eyeball. It is thickest behind, near the
Fig. 19.1: Sagittal section through the eyeball
327
HEAD AND NECK
328
entrance of the optic nerve, and thinnest about 6 mm

behind the sclerocorneal junction where the recti
muscles are inserted. However, it is weakest at the
entrance of the optic nerve. Here the sclera shows
numerous perforations for passage of fibres of the optic
nerve. Because of its sieve-like appearance, this region
is called the lamina cribrosa (crib = sieve).
The outer surface of the sclera is white and smooth, it
is covered by Tenon’s capsule (see Fig. 13.3). Its anterior
part is covered by conjunctiva through which it can be
seen as the white of the eye. The inner surface is brown
and grooved for the ciliary nerves and vessels. It is
separated from the choroid by the perichoroidal space
which contains a delicate cellular tissue, termed the
suprachoroidal lamina or lamina fusca of the sclera.
The sclera is continuous anteriorly with the cornea Fig. 19.2: Structures piercing the posterior aspect of the eyeball
at the sclerocorneal junction or limbus (Fig. 19.1). The deep
part of the limbus contains a circular canal, known as d. Four venae vorticosae or the choroid veins pass out
the sinus venosus sclerae or the canal of Schlemm. The through the sclera just behind the equator
aqueous humour drains into the anterior scleral or (Figs 19.2 and 19.3).
ciliary veins through this sinus. The sclera is almost avascular. However, the loose
The sclera is fused posteriorly with the dural sheath connective tissue between the conjunctiva and sclera
of the optic nerve. It provides insertion to the extrinsic called as the episclera is vascular.
muscles of the eyeball: The recti in front of the equator,
and the oblique muscles behind the equator. DISSECTION
The sclera is pierced by a number of structures: Use the fresh eyeball of the goats for this dissection.
a. The optic nerve pierces it a little inferomedial to Clean the eyeball by removing all the tissues from its
the posterior pole of the eyeball. surface. Cut through the fascial sheath around the margin
of the cornea. Clean and identify the nerve with posterior
b. The ciliary nerves and arteries pierce it around the
ciliary arteries and ciliary nerves close to the posterior
entrance of the optic nerve.
pole of the eyeball. Identify venae vorticosae piercing
c. The anterior ciliary arteries, derived from muscular the sclera just behind the equator (refer to BDC App).
arteries to the recti, pierce it near the limbus.
Head and Neck
Fig. 19.3: Structures piercing the eyeball seen in a sagittal section

EYEBALL
329
Incise only the sclera at the equator and then cut

through it all around and carefully strip it off from the
choroid. Anteriorly, the ciliary muscles are attached to
the sclera, offering some resistance. As the sclera is
steadily separated, the aqueous humour will escape from
the anterior chamber of the eye. On dividing the optic
nerve fibres, the posterior part of sclera can be removed.
CORNEA
Features
The cornea is transparent. It replaces the sclera over
the anterior one-sixth of the eyeball. Its junction with
the sclera is called the sclerocorneal junction or limbus.
The cornea is more convex than the sclera, but the
curvature diminishes with age. It is separated from the
iris by a space called the anterior chamber of the eye.
The cornea is avascular and is nourished by lymph
Fig. 19.4: Histology of cornea
which circulates in the numerous corneal spaces and
by the lacrimal fluid.
It is supplied by branches of the ophthalmic nerve CLINICAL ANATOMY
and the short ciliary nerves (through the ciliary
ganglion). Pain is the only sensation aroused from the • Cornea can be grafted from one person to the
cornea. other, as it is avascular.
• Injury to cornea may cause opacities. These
DISSECTION opacities may interfere with vision.
Identify the cornea. Make an incision around the • Eye is a very sensitive organ and even a dust
corneoscleral junction and remove the cornea so that particle gives rise to pain.
the iris is exposed for examination. Identify the middle • Bulbar conjunctiva is vascular. Inflammation of
coat comprising choroid, ciliary body and iris deep to the conjunctiva leads to conjunctivitis. The look
the sclera. Lateral to iris is the ciliary body with ciliary of palpebral conjunctiva is used to judge haemo-
muscles and ciliary processes. globin level.
Strip off the iris, ciliary processes, anterior part of • The anteroposterior diameter of the eyeball and
choroid. Remove the lens and put it in water. As the shape and curvature of the cornea determine the
lens is removed, the vitreous body also escapes. Only focal point. Changes in these result in myopia or
the posterior part of choroid and subjacent retina is left. short-sightedness, hypermetropia or long-
sightedness (Fig. 19.5).
Head and Neck

AN 43.2 Identify, describe and draw the microanatomy of pituitary
Microanatomy of cornea is described here. For the other organs,
please see appropriate chapters.
Histology/Microanatomy
Structurally, the cornea consists of these layers, from
before backwards:
1 Corneal epithelium (stratified squamous non-
keratinized type) (Fig. 19.4)
2 Bowman’s membrane or anterior elastic lamina
3 The substantia propria
4 Descemet’s membrane or posterior elastic lamina
Fig. 19.5: Optical defects
5 Simple squamous mesothelium.
HEAD AND NECK
330
MIDDLE COAT black (pars plana). The anterior part is ridged

anteriorly (pars plicata) to form about 70 ciliary
CHOROID processes. The central ends of the processes are free
and rounded.
Choroid is a thin pigmented layer which separates the
2 Ciliary zonule is thickened vitreous membrane fitted
posterior part of the sclera from the retina. Anteriorly,
to the posterior surfaces of ciliary processes (Fig. 19.7).
it ends at the ora serrata by merging with the ciliary
The posterior layer lines hyaloid fossa and anterior thick
body. Posteriorly, it is perforated by the optic nerve to
layer form the suspensory ligament of lens (Fig. 19.6).
which it is firmly attached.
Its outer surface is separated from the sclera by the 3 The ciliary muscle (Fig. 19.6) is a ring of unstriped
suprachoroidal lamina which is traversed by the ciliary muscle which are longitudinal or meridional, radial
vessels and nerves. Its attachment to the sclera is loose, and circular. The longitudinal or meridional fibres arise
so that it can be easily stripped. The inner surface is from a projection of sclera or scleral spur near the
firmly united to the retina. limbus. They radiate backwards to the suprachoroidal
lamina. The radial fibres are obliquely placed and get
Structurally, it consists of:
continuous with the circular fibres.
a. Suprachoroid lamina
b. Vascular lamina The circular fibres lie within the anterior part of the
c. The choriocapillary lamina ciliary body and are nearest to the lens. The
d. The inner basal lamina or membrane of Bruch. contraction of all the parts relaxes the suspensory
ligament so that the lens becomes more convex
Competency achievement: The student should be able to: (Fig. 19.6). All parts of the muscle are supplied by
AN 41.3 Describe the position, nerve supply and actions of parasympathetic nerves. The pathway involves the
intraocular muscles.3 Edinger-Westphal nucleus, oculomotor nerve and
AN 43.3 Identify, describe and draw microanatomy of olfactory the ciliary ganglion (see Flowchart A.4).
epithelium, microanatomy of iridio eyelid, lip, sclerocorneal junction,
optic nerve, cochlea— organ of Corti, pineal gland.4 IRIS
CILIARY BODY 1 This is the anterior part of the uveal tract. It forms a
circular curtain with an opening in the centre, called
Ciliary body is a thickened part of the uveal tract lying the pupil. By adjusting the size of the pupil, it controls
just posterior to the corneal limbus. It is continuous the amount of light entering the eye, and thus
anteriorly with the iris and posteriorly with the choroid. behaves like an adjustable diaphragm (Fig. 19.3).
It suspends the lens and helps it in accommodation for 2 It is placed vertically between the cornea and the lens,
near vision. thus divides the anterior segment of the eye into
1 The ciliary body is triangular in cross-section. It is anterior and posterior chambers, both containing
thick in front and thin behind (Fig. 19.6). The scleral aqueous humour. Its peripheral margin is attached to
surface of this body contains the ciliary muscle. The the middle of the anterior surface of the ciliary body
posterior part of the vitreous surface is smooth and and is separated from the cornea by the iridocorneal
Head and Neck
Fig. 19.6: Components of ciliary body and iris (sclerocorneal junction)

EYEBALL
331
Fig. 19.7: Anterior part of the inner aspect of the eyeball seen
after vitreous has been removed Figs 19.8a and b: (a) Relaxed ciliary muscles with flattened
lens; (b) Contracted ciliary muscles with round lens
angle or angle of the anterior chamber. The central
free margin forming the boundary of the pupil rests
against the lens (Fig. 19.1).
3 The anterior surface of the iris is covered by a single
layer of mesothelium, and the posterior surface by a
double layer of deeply pigmented cells which are
continuous with those of the ciliary body (Fig. 19.6).
The main bulk of the iris is formed by stroma made
up of blood vessels and loose connective tissue in
which there are pigment cells. The long posterior and
the anterior ciliary arteries join to form the major
arterial circle at the periphery of the iris. From this
circle, vessels converge towards the free margin of
the iris and join together to form the minor arterial
circle of the iris (see Fig. 13.10).
The colour of the iris is determined by the number
of pigment cells in its connective tissue. If the Figs 19.9a and b: (a) Normal eyes; (b) In squinting eyes
pigment cells are absent, the iris is blue in colour
due to the diffusion of light in front of the black
• Human vision is coloured, binocular and three-
Head and Neck

posterior surface.
dimensional. Normally, right and left eyes are
4 The iris contains a well-developed ring of muscle
focused on one object (Fig. 19.9a). In squinting,
called the sphincter pupillae which lies near the margin
fixing eye (F) focuses on the object, but the
of the pupil. Its nerve supply (parasympathetic) is
squinting eye (S) is ‘turned inwards’ resulting in
similar to that of the ciliary muscle. The dilator pupillae
a convergent squint (Fig. 19.9b).
is an ill-defined sheet of radial muscle fibres placed
near the posterior surface of the iris. It is supplied
by sympathetic nerves (Fig. 19.6).
INNER COAT/RETINA
CLINICAL ANATOMY 1 This is the thin, delicate inner layer of the eyeball. It is
• While looking at infinite far, the light rays run continuous posteriorly with the optic nerve. The outer
parallel; ciliary muscle is relaxed, suspensory surface of the retina (formed by pigment cells) is
ligament is tense and lens is flat (Fig. 19.8a). attached to the choroid, while the inner surface is in
• While reading a book, the ciliary muscles contract contact with the hyaloid membrane (of the vitreous).
and suspensory ligament is relaxed making the Opposite the entrance of the optic nerve (infero-
lens more convex (Fig. 19.8b). medial to the posterior pole), there is a circular area
known as the optic disc. It is 1.5 mm in diameter.
HEAD AND NECK
332
Fig. 19.10: Histological layers of the retina
2 The retina diminishes in thickness from behind b. Layer of rods and cones
forwards and is divided into optic, ciliary and iridial c. External limiting membrane
parts. The optic part of the retina contains nervous d. Outer nuclear layer
tissue and is sensitive to light. It extends from the e. Outer plexiform layer
optic disc to the posterior end of the ciliary body. f. Inner nuclear layer (bipolar cells)
The anterior margin of the optic part of the retina g. Inner plexiform layer
forms a wavy line called the ora serrata (Fig. 19.1). h. Ganglion cell layer
Beyond the ora serrata, the retina is continued i. Nerve fibre layer
forwards as a thin, non-nervous insensitive layer that j. The internal limiting membrane.
covers the ciliary body and iris, forming the ciliary 6 The retina is supplied by the central artery. This is an
and iridial parts of the retina. These parts are made up end artery. In the optic disc, it divides into an upper
of two layers of epithelial cells (Fig. 19.6). and a lower branch, each giving off nasal and
3 The depressed area of the optic disc is called the physio- temporal branches. The artery supplies the deeper
logical cup (Fig. 19.3). It contains no rods or cones layers of the retina up to the bipolar cells. The rods
and is, therefore, insensitive to light, i.e. it is the physio- and cones are supplied by diffusion from the
logical blind spot. At the posterior pole of the eye 3 mm capillaries of the choroid. The retinal veins run with
lateral to the optic disc, there is another depression the arteries (Fig. 19.11).
of similar size, called the macula lutea. It is avascular
and yellow in colour. The centre of the macula is
further depressed to form the fovea centralis. This is
the thinnest part of the retina. It contains cones only,
and is the site of maximum acuity of vision (Fig. 19.3).
Head and Neck
4 The rods and cones are the light receptors of the eye.
The rods contain a pigment called visual purple. They
can respond to dim light (scotopic vision). The
periphery of the retina contains only rods, but the
fovea has none at all. The cones respond only to bright
light (photopic vision) and are sensitive to colour. The
fovea centralis has only cones. Their number
diminishes towards the periphery of the retina. Fig. 19.11: Distribution of central artery of the retina

AN 43.2 Identify, describe and draw the microanatomy of pituitary CLINICAL ANATOMY
epiglottis, cornea, retina.5 Retinal detachment occurs between outer single
Microanatomy of retina is given here. For rest of the topics, please pigmented layer and inner nine nervous layers.
see respective chatpers. Actually, it is an inter-retinal detachment. Silicone
sponge is put over the detached retina, which is kept
5 The retina is composed of ten layers (Fig. 19.10): in position by a ‘band’ (Figs 19.12a and b).
a. The outer pigmented layer
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333
LENS
Features
The lens is a transparent biconvex structure which is
placed between the anterior and posterior segments of
the eye. It is circular in outline and has a diameter of
1 cm. The central points of the anterior and posterior
surfaces are called the anterior and posterior poles
(Fig. 19.13). The line connecting the poles constitutes
the axis of the lens, while the marginal circumference
is termed the equator. The chief advantage of the lens is
that it can vary its dioptric power. It contributes about
Figs 19.12a and b: (a) Detached retina; (b) Banding of the 15 dioptres to the total of 58 dioptric power of the eye.
retina A dioptre is the inverse of the focal length in meters. A
lens having a focal length of half meter has a power of
two dioptres.
The posterior surface of the lens is more convex than
AQUEOUS HUMOUR the anterior. The anterior surface is kept flattened by
This is a clear fluid which fills the space between the tension of the suspensory ligament. When the
the cornea in front and the lens behind the anterior ligament is relaxed by contraction of the ciliary muscle,
segment. This space is divided by the iris into anterior the anterior surface becomes more convex due to
and posterior chambers which freely communicate with elasticity of the lens substance.
each other through the pupil. The lens is enclosed in a transparent, structureless
The aqueous humour is secreted into the posterior elastic capsule which is thickest anteriorly near the
chamber from the capillaries in the ciliary processes. It circumference. Deep to capsule, the anterior surface of
passes into the anterior chamber through the pupil. the lens is covered by a capsular epithelium. At the centre
From the anterior chamber, it is drained into the ante- of the anterior surface, the epithelium is made up of a
rior ciliary veins through the spaces of the iridocorneal single layer of cubical cells, but at the periphery, the
angle or angle of anterior chamber (located between cells elongate to produce the fibres of the lens. The fibres
the fibres of the ligamentum pectinatum) and the canal are concentrically arranged to form the lens substance.
of Schlemm (Figs 19.3 and 19.6). The centre (nucleus) of the lens is firm (and consists of
Interference with the drainage of the aqueous the oldest fibres), whereas the periphery (cortex) is soft
humour into the canal of Schlemm results in an increase
of intraocular pressure (glaucoma). This produces
cupping of the optic disc and pressure atrophy of the
retina causing blindness.
Head and Neck

The intraocular pressure is due chiefly to the aqueous
humour which maintains the constancy of the optical
dimensions of the eyeball. The aqueous is rich in
ascorbic acid, glucose and amino acids, and nourishes
the avascular tissues of the cornea and lens.

AN 41.2 Describe the anatomical aspects of cataract, glaucoma and
central retinal artery occlusion.6
CLINICAL ANATOMY
Over production of aqueous humour or lack of its
drainage or combination of both raise the intraocular
pressure. The condition is called glaucoma. It must
be treated urgently.
Fig. 19.13: The lens
HEAD AND NECK
334
and is made up of more recently formed fibres • The central artery of retina is an end-artery.
(Fig. 19.13). Blockage of the artery leads to sudden blindness.
The suspensory ligament of the lens (or the zonule of • Left third nerve paralysis causes partial ptosis and
Zinn) retains the lens in position and its tension keeps dilated pupil. The cornea is turned downwards
the anterior surface of the lens flattened. The ligament and outwards (Fig. 19.14).
is made up of a series of fibres which are attached • Horner’s syndrome results in partial ptosis and
peripherally to the ciliary processes, to the furrows miosis (Fig. 19.15).
between the ciliary processes, and to the ora serrata. • In brainstem death, both the pupils are dilated and
Centrally, the fibres are attached to the lens, mostly in fixed (Fig. 19.16).
front, and a few behind the equator (Fig. 19.5). • Eye sees everyone. One can see the interior of the
eye by ophthalmoscope. Through the ophthal-
DISSECTION moscope, one can see the small vessels in the retina
Give an incision in the anterior surface of lens and with and judge the changes in diabetes and hyper-
a little pressure of fingers and thumb press the body of tension (Figs 19.17a and b). In addition, one can
lens outside from the capsule. also examine the optic disc for evidence of papillo-
edema, caused by raised intracranial pressure.
AN 41.2 Describe the anatomical aspects of cataract, glaucoma and
central retinal artery occlusion.7 VITREOUS BODY
It is a colourless, jelly-like transparent mass which fills
CLINICAL ANATOMY the posterior segment (posterior four-fifths) of the
• Lens becomes opaque with increasing age eyeball. It is enclosed in a delicate homogeneous hyaloid
(cataract). Since the opacities cause difficulty in membrane. Behind, it is attached to the optic disc, and
vision, lens has to be replaced. in front to the ora serrata; in between it is free and lies
in contact with the retina. The anterior surface of the
Fig. 19.14: Left third nerve paralysis

Head and Neck
Fig. 19.15: Horner’s syndrome in left eye
Figs 19.17a and b: (a) Procedure for ophthalmoscopy;

Fig. 19.16: Brainstem death (b) Retina as seen by ophthalmoscope
EYEBALL
335
vitreous body is indented by the lens and ciliary • Central artery of retina is an ‘end artery’
processes (Fig. 19.1).
• Through dilated pupil, one can see the state of
Competency achievement: The student should be able to: blood vessels of the retina.
pituitary gland, thyroid gland and eye.8 CLINICOANATOMICAL PROBLEM
DEVELOPMENT A patient was diagnosed as a case of ‘retinal

detachment’.
Optic vesicle forms optic cup. It is an outpouching from • Is retinal detachment, detachment of retina from
the forebrain vesicle. the choroid?
Lens from lens placode (ectodermal)
• Name the layers of retina with its blood supply.
Retina—pigment layer from the outer layer of optic cup;
nervous layers from the inner layer of optic cup. Ans: The retinal detachment is actually an inter-
Choroid, sclera—mesoderm retinal detachment. The outer pigmented layer stays
Cornea—surface ectoderm forms the epithelium, other with choroid, while the inner nine layers get
layers develop from mesoderm. detached and cause the problem. The outer layer is
developed from the outer layer of optic cup whereas
Molecular Regulation the inner layers arise from the inner layer of optic
The proteins WNT, BMP, TGF- and FGF (fibroblast cup. The blood supply of the outer five layers is
growth factor) are responsible for optic vesicle and from choroidal arteries whereas those of the inner
PAX6 for lens vesicle differentiation. nervous layers is by the ‘central artery of retina’,
Inhibition of sonic hedgehog (SHH) and expansion which is an absolute end-artery. The layers of retina
of PAX2 expression causes failure of separation of eyes (Fig. 19.10) are:
resulting in cyclops. Overexpression of SHH causes loss 1. Outer pigmented layer
of eye structures. 2. Layer of rods and cones
Vitamin A deficiency during embryonic development 3. External limiting membrane
can result in anterior segment defects (of cornea and
eyelid). 4. Outer nuclear layer
5. Outer plexiform layer
6. Bipolar cell layer
FACTS TO REMEMBER 7. Inner plexiform layer
• Cornea is used for grafting or transplantation. 8. Ganglionic cell layer
• Sclera is pierced by number of structures including 9. Layer of optic nerve fibres
the optic nerve. 10. Inner limiting membrane
• Choroid contains big capillaries. These nourish the
layer of rods and cones of retina by diffusion. FURTHER READING
• Ciliary body contains ciliary muscles supplied by • O'Rahilly R. The timing and sequence of events in the
Head and Neck

short ciliary nerves. These contract to relax the development of the human eye and ear during the embryonic
suspensory ligament of lens, so that the anterior period proper. Anat Embryol Berl 1983;168:87–99.
surface of lens can become more convex for accom- This paper presents the stages of human ear development.
modation. • Kolb H, Linberg KA, Fisher SK. Neurons of the human
• Iris contains a weak dilator pupillae at the retina—a Golgi study. J Comp Neurol 1992;318:147–87.
periphery, supplied by sympathetic fibres. It also The most comprehensive description of the morphology of neural
contains a strong constrictor or sphincter pupillae cell types in the human retina.
near the pupillary margin. This is supplied by • Tabinda Hasan, Satyam Khare, Shilpi Jain, Puneet Gupta,
parasympathetic fibres relayed through ciliary Sanjay Sharma. Retinal Vasculature—an imaging based
ganglion. morphological study. Journal of the Anatomical Society of
India, 2013;62:146–56.
1–8
HEAD AND NECK
336
1. Write short notes/enumerate: d. Layers of retina

a. Cornea e. Ciliary muscles
b. Choroid f. Lens
c. Structures piercing the sclera g. Aqueous humour
1. Which of the following muscles does not develop c. Radial fibres of ciliaris muscle
from mesoderm? d. Circular fibres of ciliaris muscle
a. Muscles of heart b. Muscles of iris 4. Retina consists which of the following number of
c. Deltoid d. Superior rectus layers?
a. Eight
2. Which of the following nerves supplies the cornea?
b. Ten
a. Supraorbital b. Nasociliary c. Nine
c. Lacrimal d. Infraorbital d. Eleven
3. Parasympathetic fibres supply all the following 5. One of the following symptoms is not seen in
muscles, except: Horner’s syndrome:
a. Constrictor pupillae a. Partial ptosis b. Miosis
b. Dilator pupillae c. Anhydrosis d. Exophthalmos
1. b 2. b 3. b 4. b 5. d
• Name the layers of the eyeball. • Why is optic disc called the ‘blind spot’?
• Enumerate the structures piercing the sclera. • Trace the secretion, circulation and absorption of
• Name the histological layers of the cornea. aqueous humour.
Head and Neck
• What is myopia? How is it corrected? • What are the results of Horner's syndrome?
• Name the muscles present in the ciliary body. • How does lens develop?
• What is the action and nerve supply of ciliary muscles? • How does retina develop?
• Name the muscles present in the iris. Which nerves • How does cornea develop?
supply these muscles? • Where does retinal detachment occur?
• What are the layers of retina? • Why do cataract and glaucoma develop?
Surface Marking and 20
Radiological Anatomy
Prayer does not change God, it changes us .
—B. Graham
INTRODUCTION
SURFACE LANDMARKS
The bony and soft tissue landmarks on the head, face
and neck help in surface marking of various structures. LANDMARKS ON THE FACE
These landmarks are of immense value to the clinician
Some important named features to be identified on the
for locating the part to be examined or to be operated.
living face have been described in Chapter 2. Other
landmarks are as follows.
AN 43.5 Demonstrate: 1) Testing of muscles of facial expression,
1 The supraorbital margin lies beneath the upper margin
extraocular muscles, muscles of mastication, 2) Palpation of carotid of the eyebrow. The supraorbital notch (Fig. 20.1) is
arteries, facial artery, superficial temporal artery, 3) Location of palpable at the junction of the medial one-third with
internal and external jugular veins, 4) Location of hyoid bone, thyroid the lateral two-thirds of the supraorbital margin
cartilage and cricoid cartilage with their vertebral levels.1 (except in those cases in which the notch is converted
Fig. 20.1: Foramina in norma frontalis
337
HEAD AND NECK
338
into a foramen). A vertical line drawn from the

supraorbital notch to the base of the mandible,
passing midway between the lower two premolar
teeth, crosses the infraorbital foramen 5 mm below
the infraorbital margin, and the mental foramen
midway between the upper and lower borders of the
mandible (Fig. 20.1).
2 The superciliary arch is a curved bony ridge situated
immediately above the medial part of each
supraorbital margin. The glabella is the median
elevation connecting the two superciliary arches and
corresponds to the elevation between the two
eyebrows.
3 The nasion is the point where the internasal and
frontonasal sutures meet. It lies a little above the floor
Fig. 20.2: Named features on the pinna
of the depression at the root of the nose, below the
glabella (Fig. 20.1).
preauricular point lies on the posterior root of the
LANDMARKS ON THE LATERAL SIDE OF THE HEAD zygoma immediately in front of the upper part of
The external ear or pinna is a prominent feature on the the tragus (Fig. 20.3).
lateral aspect of the head. The named features on 2 The head of the mandible lies in front of the tragus.
the pinna are shown in Fig. 20.2. Other landmarks It is felt best during movements of the lower jaw.
on the lateral side of the head are as follows. The coronoid process of the mandible can be felt below
1 The zygomatic bone forms the prominence of the cheek the lowest part of the zygomatic bone when the
at the inferolateral corner of the orbit. The zygomatic mouth is opened. The process can be traced
arch bridges the gap between the eye and the ear. It downwards into the anterior border of the ramus of
is formed anteriorly by the temporal process of the the mandible. The posterior border of the ramus,
zygomatic bone, and posteriorly by the zygomatic though masked by parotid gland, can be felt through
process (zygoma) of the temporal bone. The the skin. The outer surface of the ramus is covered
Head and Neck
Fig. 20.3: Parts of mandible seen in norma lateralis

SURFACE MARKING AND RADIOLOGICAL ANATOMY
339
by the masseter which can be felt when the teeth are

clenched. The lower border of the mandible can be
traced posteriorly into the angle of the mandible
(Fig. 20.3).
3 The parietal eminence is the most prominent part of
the parietal bone, situated far above and a little
behind the auricle.
4 The mastoid process is a large bony prominence
situated behind the lower part of the auricle. The
supramastoid crest, about 2.5 cm long, begins
immediately above the external acoustic meatus and
soon curves upwards and backwards. The crest is
continuous anteriorly with the posterior root of the
zygoma, and posterosuperiorly with the temporal
line (Fig. 20.3).
5 The temporal line forms the upper boundary of the Fig. 20.4: Middle meningeal artery (a–e) and facial artery (1–3)
temporal fossa which is filled up by the temporalis with facial vein
muscle. The upper margin of the contracting
temporalis helps in defining this line which begins LANDMARKS ON THE SIDE OF THE NECK
at the zygomatic process of the frontal bone, arches 1 The sternocleidomastoid muscle is seen prominently
posterosuperiorly across the coronal suture, passes when the face is turned to the opposite side. The
a little below the parietal eminence, and turns ridge raised by the muscle extends from the sternum
downwards to become continuous with the to the mastoid process (Fig. 20.6).
supramastoid crest. The area of the temporal fossa
2 The external jugular vein crosses the sternocleido-
on the side of the head, above the zygomatic arch, is
mastoid obliquely, running downwards and
called the temple or temporal region.
backwards from near the auricle to the clavicle. It is
6 The pterion is the area in the temporal fossa where better seen in old age (Fig. 20.7).
four bones (frontal, parietal, temporal and sphenoid)
3 The greater supraclavicular fossa lies above and behind
adjoin each other across an H-shaped suture. The
the middle one-third of the clavicle. It overlies the
centre of the pterion is marked by a point 4 cm above
cervical part of the brachial plexus and the third part
the midpoint of the zygomatic arch, falling 3.5 cm
of the subclavian artery (Fig. 20.6).
behind the frontozygomatic suture. Deep to the
pterion lie the anterior branch of the middle 4 The lesser supraclavicular fossa is a small depression
meningeal artery, the middle meningeal vein, and between the sternal and clavicular parts of the sterno-
deeper still the stem of the lateral sulcus of the cleidomastoid. It overlies the internal jugular vein.
cerebral hemisphere (at the Sylvian point) dividing 5 The mastoid process is a large bony projection behind
Head and Neck

into three rami. The pterion is a common site for the auricle (concha) (Fig. 20.6).
trephining (making a hole in the skull) during 6 The transverse process of the atlas vertebra can be felt
operation (Fig. 20.4). Surface marking of middle on deep pressure midway between the angle of the
meningeal artery is given later. mandible and the mastoid process, immediately
7 The junction of the back of the head with the neck is anteroinferior to the tip of the mastoid process. The
indicated by the external occipital protuberance and fourth cervical transverse process is just palpable at the
the superior nuchal lines. The external occipital level of the upper border of the thyroid cartilage;
protuberance is a bony projection felt in the median and the sixth cervical transverse process at the level of
plane on the back of the head at the upper end of the the cricoid cartilage. The anterior tubercle of the
nuchal furrow. The superior nuchal lines are indistinct transverse process of the sixth cervical vertebra is the
curved ridges which extend from the protuberance largest of all such processes and is called the carotid
to the mastoid processes. The back of the head is tubercle (of Chassaignac). The common carotid artery
called the occiput. The most prominent median point can be best pressed against this tubercle, deep to the
situated on the external occipital protuberance is anterior border of the sternocleidomastoid muscle.
known as the inion. However, the posterior 7 The anterior border of the trapezius muscle becomes
most point on the occiput lies a little above the prominent on elevation of the shoulder against
protuberance (Fig. 20.5). resistance (Fig. 20.6).
HEAD AND NECK
340
Fig. 20.5: Structures felt in norma occipitalis

Head and Neck
Fig. 20.6: Muscles: Sternocleidomastoid, trapezius and inferior Fig. 20.7: External jugular vein and cutaneous nerves
belly of omohyoid
LANDMARKS ON THE ANTERIOR ASPECT OF THE NECK

2 The body of the U-shaped hyoid bone can be felt in
1 The mandible forms the lower jaw. The lower border the median plane just below and behind the chin, at
of its horseshoe-shaped body is known as the base of the junction of the neck with the floor of the mouth.
the mandible (Fig. 20.8). Anteriorly, this base forms On each side, the body of hyoid bone is continuous
the chin, and posteriorly it can be traced to the angle posteriorly with the greater cornua which is
of the mandible. Numerous structures are attached to overlapped in its posterior part by the sterno-
mandible. cleidomastoid muscle (Fig. 20.9).
341
commonly palpated in the suprasternal notch which

lies between the tendinous heads of origin of the right
and left sternocleidomastoid muscles. In certain
diseases, the trachea may shift to one side from the
median plane. This indicates a shift in the media-
stinum (Fig. 20.10).
OTHER IMPORTANT LANDMARKS

1 The frontozygomatic suture can be felt as a slight
depression in the upper part of the lateral orbital
margin.
2 The marginal tubercle lies a short distance below the
frontozygomatic suture along the posterior border
of the frontal process of the zygomatic bone.
3 The Frankfurt’s plane is represented by a horizontal
line joining the infraorbital margin to the centre of
the external acoustic meatus. Posteriorly, the line
Fig. 20.8: Attachments on the mandible passes through a point just below the external
occipital protuberance (see Fig. 1.1).
3 The thyroid cartilage of the larynx forms a sharp 4 The jugal point is the anterior end of the upper border
protuberance in the median plane just below the of the zygomatic arch where it meets the frontal
hyoid bone. This protuberance is called the laryngeal process of the zygomatic bone.
prominence or Adam’s apple. It is more prominent in 5 The mandibular notch is represented by a curved line
males than in females (Fig. 20.10). concave upwards, extending from the head of the
4 The rounded arch of the cricoid cartilage lies below mandible to the anterior end of the zygomatic arch.
the thyroid cartilage at the upper end of the trachea The notch is 1–2 cm deep (Fig. 20.8).
(Fig. 20.10).
5 The trachea runs downwards and backwards from Competency achievement: The student should be able to:
the cricoid cartilage. It is identified by its carti- AN 43.6 Demonstrate surface projection of: Thyroid gland, parotid
laginous rings. However, it is partially masked by gland and duct, pterion, common carotid artery, internal jugular
vein, subclavian vein, external jugular vein, facial artery in the face
the isthmus of the thyroid gland which lies against the
and accessory nerve.2
second to fourth tracheal rings. The trachea is
Head and Neck
Fig. 20.9: Attachments on hyoid bone and thyroid cartilage

HEAD AND NECK
342
Fig. 20.10: Landmarks on anterior aspect of neck
SURFACE MARKING OF VARIOUS

STRUCTURES
ARTERIES
Facial Artery
It is marked on the face by joining these three points
(Fig. 20.4).
• Point 1, on the base of the mandible at the anterior
border of the masseter muscle.
• Point 2, 1.2 cm lateral to the angle of the mouth.
• Point 3, at the medial angle of the eye.
The artery is tortuous in its course and is more so
Head and Neck
between the first two points (Fig. 20.4).
Common Carotid Artery

It is marked by a broadline along the anterior border
of the sternocleidomastoid muscle by joining the
following two points (Fig. 20.11).
• Point 1, on the sternoclavicular joint.
• Point 2, on the anterior border of the sternocleido- Fig. 20.11: Some arteries of head and neck
mastoid muscle at the level of upper border of the
thyroid cartilage (Fig. 20. 11). • Point 2, on the anterior border of the sterno-
The thoracic part of the left common carotid artery cleidomastoid muscle at the level of the upper border
is marked by a broadline extending from a point a little of the thyroid cartilage.
to the left of the centre of the manubrium to the left • Point 3, on the posterior border of the condyle of the
sternoclavicular joint. mandible (Fig. 20.11).
Internal Carotid Artery External Carotid Artery

It is marked by a broadline joining these two points The artery is marked by joining these two points
(Fig. 20.11). (Fig. 20.11).
343
• Point 2, on the anterior border of the sterno- It can be marked, if not visible, by joining these points
cleidomastoid muscle at the level of the upper border (Fig. 20.12).
of the thyroid cartilage. • Point 1, a little below and behind the angle of the
• Point 4, on the posterior border of the neck of the mandible.
mandible. • Point 2, on the clavicle just lateral to the posterior
The artery is slightly convex forwards in its lower border of the sternocleidomastoid (Fig. 20.12).
half and slightly concave forwards in its upper half
(Fig. 20.11). Internal Jugular Vein
Internal jugular vein is marked by a broadline by joining
Subclavian Artery
these two points (Fig. 20.12).
It is marked by a broad curved line, convex upwards, • Point 3, on the neck medial to the lobule of the ear.
by joining these two points (Fig. 20.11). • Point 4, at the medial end of the clavicle (Fig. 20.12).
• Point 1, on the sternoclavicular joint. The lower bulb of the vein lies beneath the lesser
• Point 5, at the middle of the lower border of the supraclavicular fossa between the sternal and clavicular
clavicle (Fig. 20.11). heads of the sternocleidomastoid muscle.
The artery rises about 2 cm above the clavicle.
Subclavian Vein
The thoracic part of the left subclavian artery is
marked by a broad vertical line along the left border of Subclavian vein is represented by a broadline along the
the manubrium a little to the left of the left common clavicle extending from a little medial to its midpoint
carotid artery. to the medial end of the bone.
Superior Sagittal Sinus
Middle Meningeal Artery
It is marked by joining these points (Fig. 4.20). Superior sagittal sinus is marked by two lines (diverging
• First point (a), immediately above the middle of the posteriorly) joining these two points (Fig. 20.13).
zygoma. The artery enters the skull opposite this • One point (1), at the glabella.
point (Fig. 20.4). • Two points (2), at the inion, situated side by side,
• Second point (b), 2 cm above the first point. The 1.2 cm apart (Fig. 20.13).
artery divides deep to this point. Transverse Sinus
• Third point (c) (centre of pterion), 3.5 cm behind and
1.5 cm above the frontozygomatic suture. Transverse sinus is marked by two parallel lines, 1.2 cm
• Fourth point (d), midway between the nasion and apart extending between the following points (Fig. 20.13).
inion. • Two points (2), at the inion, situated one above the
other and 1.2 cm apart.
• Fifth point (e) (lambda), 6 cm above the external
occipital protuberance.
The line joining points (a) and (b) represents the stem
of the middle meningeal artery inside the skull.
The line joining points (b), (c) and (d) represents the
Head and Neck

anterior (frontal) branch. It first runs upwards and
forwards (b), (c) and then upwards and backwards,
towards the point (d).
The line joining points (b) and (e) represents the
posterior (parietal) branch. It runs backwards and
upwards, towards the point (e) (Fig. 20.4).
VEINS/SINUSES
Facial Vein
It is represented by a line drawn just behind the facial
artery (Fig. 20.4).
External Jugular Vein

The vein is usually visible through the skin and can be
made more prominent by blowing with the mouth and
nostrils closed (Fig. 20.12). Fig. 20.12: Internal and external jugular veins
HEAD AND NECK
344
Fig. 20.13: Superior sagittal, transverse and sigmoid sinuses
• Two points (3), at asterion 3.75 cm behind external

auditory meatus and 1.25 cm above this point Fig. 20.14: Position of facial and some branches of mandibular
(Fig. 20.13). nerves
• Two points (4), at the base of the mastoid process,
situated one in front of the other and 1.2 cm apart.
Lingual and Inferior Alveolar Nerves
Sigmoid Sinus Lingual nerve is marked by a curved line running
Sigmoid sinus is marked by two parallel lines situated downwards and forwards by joining these points
1.2 cm apart and extending between the following two (Fig. 20.14).
points (Fig. 20.13): • Point 3, on the posterior part of the mandibular notch,
• Two points (4), at the base of the mastoid process, in line with the mandibular nerve.
situated one in front of the other and 1.2 cm apart. • Point 5, a little below and behind the last lower molar
• Two similar points (5), near the posterior border and tooth.
1.2 cm above the tip of mastoid process. • Point 6, opposite the first lower molar tooth.
NERVES The concavity in the course of the nerve is more
marked between the 5 and 6 points and is directed
Facial Nerve upwards.
Facial nerve is marked by a short horizontal line joining Inferior alveolar nerve lies a little below and parallel
the following two points (Fig. 20.14). to the lingual nerve.
• Point 1, at the middle of the anterior border of the
Head and Neck
mastoid process. The stylomastoid foramen lies 2 cm Glossopharyngeal Nerve

deep to this point. Glossopharyngeal nerve is marked by joining the
• Point 2, behind the neck of mandible. Here the nerve following points (Fig. 20.15).
divides into its five branches to the facial muscles
• Point 1, on the anteroinferior part of the tragus.
(Fig. 20.14, also see Fig. 5.3).
• Point 2, anterosuperior to the angle of the mandible.
Auriculotemporal Nerve From 2nd point, the nerve runs forwards for a
Auriculotemporal nerve is marked by a line drawn first short distance above the lower border of the mandible.
backwards from the posterior part of the mandibular The nerve describes a gentle curve in its course
notch (point 3) (site of mandibular nerve) across the (Fig. 20.15).
neck of the mandible, and then upwards across the
preauricular point 4 (Fig. 20.14). Vagus Nerve
The nerve runs along the medial side of the internal
Mandibular Nerve jugular vagus vein. It is marked by joining these two
Mandibular nerve is marked by a short vertical line in points (Fig. 20.15).
the posterior part of the mandibular notch just in front • Point 1, at the anteroinferior part of the tragus.
of the head of the mandible. • Point 3, at the medial end of the clavicle (Fig. 20.15).
345
Fig. 20.16: Position of phrenic nerve and sympathetic trunk
Cervical Sympathetic Chain

Fig. 20.15: Position of last four cranial nerves
Cervical sympathetic chain is marked by a line joining
the following points (Fig. 20.16).
Accessory Nerve (Spinal Part) • Point 3, at the sternoclavicular joint.
Accessory nerve (spinal part) is marked by joining the • Point 5, at the posterior border of the condyle of the
following four points (Fig. 20.15). mandible.
• Point 1, at the anteroinferior part of the tragus. The superior cervical ganglion extends from the
• Point 4, at the tip of the transverse process of the transverse process of the atlas (point 4) to the tip of the
atlas. greater cornua of the hyoid bone. The middle cervical
• Point 5, at the middle of the posterior border of the ganglion lies at the level of the cricoid cartilage, and the
sternocleidomastoid muscle. inferior cervical ganglion, at a point 3 cm above the sterno-
clavicular joint (Fig. 20.16).
• Point 6, on the anterior border of the trapezius 6 cm
above the clavicle (Fig. 20.15).
Trigeminal Ganglion
Hypoglossal Nerve Trigeminal ganglion lies a little in front of the preauri-
cular point at a depth of about 4.5 cm.
Hypoglossal nerve is marked by joining these points
Head and Neck

(Fig. 20.15). GLANDS
• Point 1, at the anteroinferior part of the tragus.
Parotid Gland
• Point 7, posterosuperior to the tip of the greater
cornua of the hyoid bone. Parotid gland is marked by joining these four points
with each other (Fig. 20.17).
• Point 8, midway between the angle of the mandible
• The first point (a), at the upper border of the head of
and the symphysis menti.
the mandible.
The nerve describes a gentle curve in its course
• The second point (b), just above the centre of the
(Fig. 20.15).
masseter muscle.
• The third point (c), posteroinferior to the angle of
Phrenic Nerve
the mandible.
Phrenic nerve is marked by a line joining the following • The fourth point (d), on the upper part of the anterior
points (Fig. 20.16). border of the mastoid process.
• Point 1, on the side of the neck at the level of the The anterior border of the gland is obtained by
upper border of the thyroid cartilage and 3.5 cm from joining the points (a), (b), (c); the posterior border, by
the median plane. joining the points (c), (d); and the superior curved
• Point 2, at the medial end of the clavicle (Fig. 20.16). border with its concavity directed upwards and
HEAD AND NECK
346
and below to the greater cornua of the hyoid bone

(Fig. 20.17).
Thyroid Gland
The isthmus of thyroid gland is marked by two
transverse parallel lines (each 1.2 cm long) on the
trachea, the upper 1.2 cm and the lower 2.5 cm below
the arch of the cricoid cartilage.
Each lobe extends up to the middle of the thyroid
cartilage, below to the clavicle, and laterally to be
overlapped by the anterior border of sternocleido-
mastoid muscle. The upper pole of the lobe is pointed,
and the lower pole is broad and rounded (Fig. 20.18).
Palatine Tonsil
Palatine tonsil is marked by an oval (almond-shaped)
area over the masseter just anterosuperior to the angle
of the mandible (Fig. 20.17).
Fig. 20.17: Position of parotid gland with its duct, submandibular
gland, palatine tonsil and frontal sinus PARANASAL SINUSES
Frontal Sinus
Frontal sinus is marked by a triangular area formed by
backwards, by joining the points (a), (d) across the
joining these three points (Fig. 20.17).
lobule of the ear (Fig. 20.17).
• The point 3, at the nasion.
• The point 4, 2.5 cm above the nasion.
Parotid Duct
• The point 5, at the junction of medial one-third and
To mark this duct, first draw a line joining these two lateral two-thirds of the supraorbital margin, i.e. at
points (Fig. 20.17). the supraorbital notch.
• First point 1, at the lower border of the tragus.
• Second point 2, midway between the ala of the nose Maxillary Sinus
and the red margin of the upper lip. The roof of maxillary sinus is represented by the inferior
The middle-third of this line represents the parotid orbital margin; the floor, by the alveolus of the maxilla;
duct (Fig. 20.17). the base, by the lateral wall of the nose. The apex lies
on the zygomatic process of the maxilla.
Submandibular Gland
The submandibular salivary gland is marked by an
AN 43.7 Identify the anatomical structures in: 1) Plain X-ray skull;
oval area over the posterior half of the base of the
Head and Neck
2) AP view and lateral view, 3) Plain X-ray cervical spine—AP and

mandible, including the lower border of the ramus. The lateral view, 4) Plain X-ray of paranasal sinuses.3
area extends 1.5 cm above the base of the mandible,
Fig. 20.18: Thyroid gland

347
RADIOLOGICAL ANATOMY posterior branch runs backwards and upwards at

a lower level across the upper part of the shadow
In routine clinical practice, the following X-ray pictures of the auricle.
of the skull are commonly used. b. The transverse sinus may be seen as a curved dark
1 Lateral view for general survey of the skull including shadow, convex upwards, extending from the
cervical vertebrae. internal occipital protuberance to the petrous
2 A special posteroanterior view (in Water’s position) temporal.
to study the paranasal sinuses. c. The diploic venous markings are seen as irregularly
anastomosing, worm-like shadows produced by
LATERAL VIEW OF SKULL (PLAIN SKIAGRAM)
the frontal, anterior temporal, posterior temporal
The radiogram is studied systematically as described and occipital diploic veins. These markings
here. become more prominent in raised intracranial
Cranial Vault pressure.
1 Shape and size: It is important to be familiar with the 5 Cerebral moulding, indicating normal impressions of
normal shape and size of the skull so that cerebral gyri, can be seen. In raised intracranial
abnormalities, like oxycephaly (a type of cranio- tension, the impressions become more pronounced
stenosis), hydrocephalus, microcephaly, etc. may be and produce a characteristic silver beaten (or copper
diagnosed. beaten) appearance of the skull.
2 Structure of cranial bones: The bones are unilamellar 6 Arachnoid granulations may indent the parasagittal
during the first three years of life. Two tables area of the skull to such an extent as to simulate
separated by diploe appear during the fourth year, erosion by a meningioma.
and the differentiation reaches its maximum by about 7 Normal intracranial calcifications
35 years when diploic veins produce characteristic a. Pineal concretions (brain sand) appear by the age
markings in radiograms. The sites of the external of 17 years. The pineal body is located 2.5 cm
occipital protuberance and frontal bone are normally above and 1.2 cm behind the external acoustic
thicker than the rest of the skull. The squamous meatus. When visible it serves as an important
temporal and the upper part of the occipital bone radiological landmark.
are thin. b. Other structures which may become calcified
Generalized thickened bones are found in Paget’s
include the choroid plexuses, arachnoid granu-
disease. Thalassaemia, a congenital haemolytic
lations, falx cerebri, and other dural folds.
anaemia, is associated with thickening and a charac-
8 The auricle: The curved margin of the auricle is seen
teristic sunray appearance of the skull bones. A
localised hyperostosis may be seen over a above the petrous temporal.
meningioma. In multiple myeloma and secondary 9 The frontal sinus produces a dark shadow in the
carcinomatous deposits, the skull presents large anteroinferior part of the skull vault.
punched out areas. Fractures are more extensive in
Base of Skull
Head and Neck

the inner table than in the outer table.
3 Sutures: The coronal and lambdoid sutures are 1 The floor of the anterior cranial fossa slopes backwards
usually visible clearly. The coronal suture runs and downwards. The shadows of the two sides are
downwards and forwards in front of the central often seen situated one above the other. The surface
sulcus of the brain. The lambdoid suture traverses is irregular due to gyral markings. It also forms the
the posteriormost part of the skull. roof of the orbit (Fig. 20.19).
Obliteration of sutures begins first on the inner 2 The hypophyseal fossa represents the middle cranial
surface (between 30 and 40 years) and then on the fossa in this view. It is overhung anteriorly by the
outer surface (between 40 and 50 years). Usually, the anterior clinoid process (directed posteriorly), and
lower part of the coronal suture is obliterated first, posteriorly by the posterior clinoid process. It
followed by the posterior part of the sagittal suture. measures 8 mm vertically and 14 mm antero-
Premature closure of sutures occurs in cranio- posteriorly. The interclinoid distance is not more than
stenosis, a hereditary disease. Sutures are opened up 4 mm. The fossa is enlarged in cases of pituitary
in children by an increase in intracranial pressure. tumours, arising particularly from acidophil or
4 Vascular markings chromophobe cells.
a. Middle meningeal vessels: The anterior branch runs 3 The sphenoidal air sinus lies anteroinferior to the
about 1 cm behind the coronal suture. The hypophyseal fossa. The shadows of the orbit, the
HEAD AND NECK
348
shadows of the internal acoustic meatuses may also

be seen. The posterior part of the dense shadow
merges with the mastoid air cells producing a honey-
comb appearance.
5 In addition to the features mentioned above, the
mandible lies anteriorly forming the lower part of
the facial skeleton. The upper cervical vertebrae lie
posteriorly and are seen as a pillar supporting the
skull.
Cervical Vertebrae
The cervical vertebrae can be visualised in lateral view
of the neck. In this view, the body of cervical vertebrae,
intervertebral discs, pedicles, spines, the adjacent
inferior articular and superior articular processes and
intervertebral foramen are visualised (Fig. 20.19).

AN 43.8 Describe the anatomical route used for carotid angiogram.4
Fig. 20.19: Lateral view of the skull and cervical vertebrae SPECIAL PA VIEW OF SKULL FOR PARANASAL SINUSES
This picture is taken with the head extended in such a
nasal cavities, and the ethmoidal and maxillary way that the chin rests against the film and the nose is
sinuses lie superimposed on one another, below the raised from it (Water’s position). This view shows the
anterior cranial fossa. frontal and maxillary sinuses clearly (Fig. 20.20).
4 The petrous part of the temporal bone produces a dense The frontal sinuses are seen immediately above the
irregular shadow posteroinferior to the hypophyseal nose and medial parts of the orbits. The nasal cavities
fossa. Within this shadow, there are two dark areas are flanked on each side by the orbits above, and the
representing the external acoustic meatuses of the maxillary sinuses below. The normal sinuses are clear
two sides; each shadow lies immediately behind the and radiolucent, i.e. they appear dark. If a sinus is
head of the mandible of that side. Similar dark infected, the shadow is either hazy or radio-opaque.
Head and Neck
Fig. 20.20: X-ray of skull showing paranasal sinuses Fig. 20.21: Carotid angiogram
349

AN 43.9 Identify anatomical structures in carotid angiogram and
vertebral angiogram.5
Carotid Angiogram
Carotid angiogram lateral view. A radio-opaque dye
was injected into the carotid artery just before the
radiograph was taken (Fig. 20.21). Internal carotid
artery is seen to give an ophthalmic branch and then
ends by dividing into a smaller anterior cerebral and a
larger middle cerebral arteries.
Vertebral Angiogram
Figure 20.22.
FURTHER READING
• Abrahams PH, Meminn RMH, Hutchings RT, et al. Mcminns
color atlas of human anatomy (5th edition). Philadelphia:
Mosby 2003.
• A Halim. Surface and Radiological Anatomy, 3ed. CBS
Fig. 20.22: Vertebral angiogram Publishers and Distributors Pvt Ltd.
1–5
Head and Neck

HEAD AND NECK
350
Parasympathetic Ganglia, Arteries,

Pharyngeal Arches and Clinical Terms
What matters is not to add years to your life but life to your years .
—Alexis Carrel
INTRODUCTION PHRENIC NERVE

The appendix contains upper cervical nerves, and Phrenic nerve arises primarily from ventral rami of C4
sympathetic trunk of the neck in Table A.1. with small contributions from C3 and C5 nerve roots or
The four parasympathetic ganglia are shown in through nerve to subclavius. It is the only motor supply
Flowcharts A.1 to A.4 and Table A.2. to its own half of diaphragm and sensory to mediastinal
Summary of the arteries is depicted in Tables A.3 pleura, peritoneum and fibrous pericardium. Inflam-
to A.5. mation of peritoneum under diaphragm causes referred
The pharyngeal arches, pouches and clefts are shown pain in the area of supraclavicular nerves supply,
in Tables A.6 to A.8. It also includes the Clinical Terms. especially tip of the shoulders as their root value is also
ventral rami of C3 and C4 (see Fig. 9. 9).
CERVICAL PLEXUS
SYMPATHETIC TRUNK
Ventral rami of C1–C4 form the cervical plexus. C1
runs along hypoglossal and supplies geniohyoid and Branches of cervical sympathetic ganglia of sympathetic
thyrohyoid. It also gives superior limb of ansa trunk are given in Table A.1.
cervicalis, which supplies superior belly of omohyoid
and joins with inferior limb to form ansa. Inferior limb PARASYMPATHETIC GANGLIA (TABLE A.2)
of ansa cervicalis is formed by ventral rami of C2, C3.
Branches from ansa supply sternohyoid, sterno-
SUBMANDIBULAR GANGLION
thyroid, and inferior belly of omohyoid. Cervical
Head and Neck
plexus also gives four cutaneous branches—lesser Situation (Fig. A.1)

occipital (C2), great auricular (C2, C3), supraclavicular The submandibular ganglion lies superficial to
(C3, C4) and transverse or anterior nerve of neck (C2, hyoglossus muscle in the submandibular region.
C3) (see Figs 3.6 and 9.8). Functionally, submandibular ganglion is connected to
Table A.1: Branches of cervical sympathetic ganglia

Superior cervical ganglion Middle cervical ganglion Inferior cervical ganglion
Arterial branches i. Along internal carotid artery Along inferior thyroid artery Along subclavian and
as internal carotid nerve vertebral arteries
ii. Along common carotid and
external carotid arteries
Grey rami communicantes Along 1–4 cervical nerves Along 5 and 6 cervical nerves Along 7 and 8 cervical nerves
along cervical and cranial Along cranial nerves – –
nerves IX, X, XI and XII
Visceral branches Pharynx, cardiac Thyroid, cardiac Cardiac
350
PARASYMPATHETIC GANGLIA, ARTERIES, PHARYNGEAL ARCHES AND CLINICAL TERMS
351
Flowchart A.1: Connections of submandibular ganglion Flowchart A.4: Connections of ciliary ganglion
facial nerve, while topographically it is connected to

Flowchart A.2: Connections of pterygopalatine ganglion lingual branch of mandibular nerve (see Fig. 7.10).
Roots
The ganglion has sensory, sympathetic and secreto-
motor or parasympathetic roots.
1 Sensory root is from the lingual nerve. It is suspended
by two roots of lingual nerve.
2 Sympathetic root is from the sympathetic plexus
around the facial artery. This plexus contains
postganglionic fibres from the superior cervical
ganglion of sympathetic trunk. These fibres pass
express through the ganglion and are vasomotor to
the gland.
3 Secretomotor root is from superior salivatory nucleus
through nervus intermedius via chorda tympani
which is a branch of cranial nerve VII. Chorda
tympani joins lingual nerve. The parasympathetic
fibres get relayed in the submandibular ganglion
(Flowchart A.1).
Branches
The ganglion gives direct branches to the submandi-
Head and Neck

Flowchart A.3: Connections of otic ganglion
bular salivary gland.
Some postganglionic fibres reach the lingual nerve
to be distributed to sublingual salivary gland and
glands in the oral cavity.
PTERYGOPALATINE GANGLION
Situation
Pterygopalatine or sphenopalatine is the largest
parasympathetic ganglion, suspended by two roots of
maxillary nerve. Functionally, it is related to cranial
nerve VII. It is called the ganglion of ‘hay fever’.
Roots
The ganglion has sensory, sympathetic and secreto-
motor or parasympathetic roots.
1 Sensory root is from maxillary nerve. The ganglion
is suspended by 2 roots of maxillary nerve.
HEAD AND NECK
352
Table A.2: Connections of parasympathetic ganglia (Fig. A.1)

Ganglia Sensory root Sympathetic root Secretomotor root/ Motor root Distribution
parasympathetic root
Submandibular Two branches Branch from Superior salivatory — a. Submandibular
(Fig. A.1) from lingual nerve plexus around nucleus  facial nerve b. Sublingual
facial artery  chorda tympani — c. Anterior lingual glands
(joins the lingual nerve)
Pterygopalatine Two branches Deep petrosal Superior salivatory — a. Mucous glands of
(Fig. A.1) from maxillary from plexus nucleus, and lacrima- nose, paranasal
nerve around internal tory nucleus  nervus sinuses, palate,
carotid artery intermedius facial nasopharynx
nerve  geniculate b. Some fibres pass
ganglion  greater through zygomatic
petrosal nerve + deep nerve  zygomatico-
temporal
petrosal nerve = nerve nerve  communica-
of pterygoid canal ting branch to lacrimal
nerve lacrimal gland
Otic Branch from Plexus along Inferior salivatory Branch from a. Secretomotor to
(Fig. A.1) auriculotemporal middle meningeal nucleus  glosso- nerve to medial parotid gland via
nerve artery pharyngeal nerve  pterygoid auriculotemporal
tympanic branch  nerve
tympanic plexus  b. Tensor veli palatini
lesser petrosal nerve. and tensor tympani
via nerve to med.
pterygoid (unrelayed)
Ciliary From nasociliary Plexus along Edinger-Westphal — a. Ciliaris muscles
(Fig. A.1) nerve ophthalmic nucleus  b. Sphincter pupillae
artery oculomotor nerve 
nerve to inferior
oblique
2 Sympathetic root is from postganglionic plexus nasopalatine; and lateral posterior superior branches
around internal carotid artery. The nerve is called for the supply of glands and mucous membrane of
deep petrosal. It unites with greater petrosal to form lateral wall of nasal cavity.
the nerve of pterygoid canal. The fibres of deep
4 Palatine branches: These are one greater palatine and
petrosal do not relay in the ganglion.
2–3 lesser palatine branches. These pass through the
3 Secretomotor or parasympathetic root is from greater respective foramina to supply sensory and
petrosal nerve which arises from geniculate ganglion secretomotor fibres to mucous membrane and glands
of cranial nerve VII. These fibres relay in the ganglion
of soft palate and hard palate.
(Flowchart A.2).
Head and Neck
5 Orbital branches for the orbital periosteum.

Branches 6 Pharyngeal branches for the glands of pharynx.
The ganglion gives number of branches. These are:
1 For lacrimal gland: The postganglionic fibres pass OTIC GANGLION
through zygomatic branch of maxillary nerve. These Situation
fibres hitch hike through zygomaticotemporal nerve
The otic ganglion lies deep to the trunk of mandibular
into the communicating branch between zygo-
nerve, between the nerve and the tensor veli palatini
maticotemporal and lacrimal nerves, then to the
lacrimal nerve for supplying the lacrimal gland. muscle in the infratemporal fossa, just distal to the
foramen ovale. Topographically, it is connected to
2 Nasopalatine nerve: This nerve runs on the nasal mandibular nerve, while functionally it is related to
septum and ends in the anterior part of hard palate. cranial nerve IX.
It supplies secretomotor fibres to both nasal and
palatal glands. Roots
3 Nasal branches: These are medial, posterior, superior This ganglion has sensory, sympathetic, parasym-
branches for the supply of glands and mucous pathetic or secretomotor and motor roots (see Figs 6.15
membrane of nasal septum; the largest is named and 6.16).
353
Head and Neck

Fig. A.1: Parasympathetic ganglia
1 Sensory root is by the auriculotemporal nerve. Branches

2 Sympathetic root is by the sympathetic plexus The postganglionic branches of the ganglion pass
around middle meningeal artery. through auriculotemporal nerve to supply the parotid
3 Secretomotor root is by the lesser petrosal nerve from gland.
the tympanic plexus formed by tympanic branch of The motor branches supply the two muscles—tensor
cranial nerve IX. Fibres of lesser petrosal nerve relay veli palatini and tensor tympani.
in the otic ganglion. Postganglionic fibres reach the
parotid gland through auriculotemporal nerve CILIARY GANGLION
(Flowchart A.3).
4 Motor root is by a branch from nerve to medial Situation
pterygoid. This branch passes unrelayed through the The ciliary ganglion is very small ganglion present in
ganglion and divides into two branches to supply the orbit. Topographically, the ganglion is related to
tensor veli palatini and tensor tympani. nasociliary nerve, branch of ophthalmic division of
HEAD AND NECK
354
ARTERIES OF HEAD AND NECK

Table A.3: Common carotid artery
Artery Beginning, course and termination Area of distribution
Common It is a branch of brachiocephalic trunk on right side and a This artery has only two terminal branches. These
carotid direct branch of arch of aorta on the left side. The artery are internal carotid and external carotid. Their area
runs upwards along medial border of sternocleidomastoid of distribution is described below.
muscle enclosed within the carotid sheath. The artery ends
by dividing into internal carotid and external carotid at the
upper border of thyroid cartilage (see Fig. 4.14)
Internal It is a terminal branch of common carotid artery. It first runs Cervical part of the artery does not give any branch.
carotid through the neck (cervical part), then passes through the Petrous part gives branches for the middle ear;
petrous bone (petrous part), then courses through the sinus cavernous part supplies hypophysis cerebri. The
(cavernous part) and lastly lies in relation to the brain cerebral part gives ophthalmic artery for orbit, anterior
(cerebral part) cerebral, middle cerebral, anterior choroidal and
posterior communicating for the brain
External It is one of the terminal branches of common carotid artery It supplies structures in the front of neck, i.e. thyroid
carotid and lies anterior to internal carotid artery. External carotid gland, larynx, muscles of tongue, face, scalp, and
artery starts at the level of upper border of thyroid cartilage, ear
runs upwards and laterally to terminate behind the neck of
mandible by dividing into larger maxillary and smaller
superficial temporal branches (see Fig. 4.13)
Superior It arises from anterior aspect of external carotid artery close Superior laryngeal branch which pierces thyroid
thyroid to its origin. It runs downwards and forwards deep to membrane to supply larynx. Sternocleidomastoid and
the infrahyoid muscles to the upper pole of thyroid gland cricothyroid branches are to the muscles. Terminal
(see Fig. 8.6) branches supply the thyroid gland
Lingual It arises from anterior aspect of external carotid artery forms As the name indicates, it is the chief artery of the
a typical loop which is crossed by XII nerve. Its 2nd part lies muscular tongue. It supplies various muscles,
deep to the hyoglossus. The 3rd part runs along the anterior papillae and taste buds of the tongue. It also gives
border of hyoglossus and 4th part runs forwards on the under branches to the tonsil
surface of tongue (see Fig. 4.15)
Facial This tortuous artery from anterior side also arises a little Cervical part gives off ascending palatine, tonsillar,
higher than lingual artery. It runs in the neck as cervical part glandular branches for the submandibular and
and in the face as facial artery (see Fig. 2.17) sublingual salivary glands. The facial part lies on the
face giving branches to muscles of face and its skin
Occipital It arises form the posterior aspect of external carotid artery It gives two branches to sternocleidomastoid muscle,
and runs upwards along the lower border of posterior belly of and branches to neighbouring muscles. It also gives
digastric muscle. Then it runs deep to mastoid process and a meningeal and mastoid branch
the muscles attached to it. The artery then crosses the apex
Head and Neck
of suboccipital triangle and then it pierces trapezius 2.5 cm

from midline to supply the layers of scalp (see Fig. 4.14)
Posterior It arises from posterior aspect of external carotid artery, it It gives branches to scalp. Its stylomastoid branch
auricular runs along the upper border of posterior belly of digastric enters the foramen of the same name to supply
muscle to reach the back of auricle mastoid antrum, nerve air cells and the facial
Ascending It arises from the medial side of external carotid artery, close It gives branches to tonsil, pharynx and a few
pharyngeal to its origin. It runs upwards and between pharynx and tonsil meningeal branches
on medial side and medial wall of middle ear on the lateral
side (see Fig. 4.13)
Superficial It is the smaller terminal branch of external carotid artery. Its two terminal branches supply layers of scalp and
temporal It begins behind the neck of the mandible, runs upwards superficial temporal region. It also supplies parotid
and crosses the preauricular point, where its pulsations can gland, facial muscles and temporalis muscle
be felt. 5 cm above the preauricular point it ends by dividing
into anterior and posterior branches (see Fig. 2.5)
Maxillary It is the larger terminal branch of external carotid artery. It is Branches of—1st part: Deep auricular, anterior
given off behind the neck of the mandible. Its course is tympanic, middle meningeal and inferior alveolar.
divided into 1st, 2nd and 3rd parts according to its relations 2nd part: Muscular branches to medial pterygoid,
with lateral pterygoid muscle. 1st part lies below the lateral masseter, temporalis and lateral pterygoid
pterygoid, 2nd part lies on the lower head of lateral pterygoid 3rd part: Posterior superior alveolar, infraorbital,
and 3rd part lies between the two heads greater palatine and sphenopalatine branches,
pharyngeal and artery of pterygoid canal
355
Table A.4: Maxillary artery

Branches Foramina transmitting Distribution
A. Of first part (see Fig. 6.6)
1. Deep auricular Foramen in the floor (cartilage or Skin of external acoustic meatus, and outer surface
bone) of external acoustic meatus of tympanic membrane
2. Anterior tympanic Petrotympanic fissure Inner surface of tympanic membrane
3. Middle meningeal Foramen spinosum Supplies more of bone and less of meninges; also V
and VII nerves, middle ear and tensor tympani
4. Accessory meningeal Foramen ovale Main distribution is extracranial to pterygoids
5. Inferior alveolar Mandibular foramen Lower teeth and mylohyoid muscle
B. Of second part
1. Masseteric — Masseter
2. Deep temporal (anterior) — Temporalis
3. Deep temporal (posterior) — Temporalis
4. Pterygoid — Lateral and medial pterygoids
5. Buccal — Skin of cheek
C. Of third part (see Fig. 6.7)

1. Posterior superior alveolar Alveolar canals in body of maxilla Upper molar and premolar teeth and gums; maxillary sinus
2. Infraorbital Inferior orbital fissure Lower orbital muscles, lacrimal sac, maxillary sinus,
upper incisor and canine teeth
3. Greater palatine Greater palatine canal Soft palate, tonsil, palatine glands and mucosa; upper gums
4. Pharyngeal Pharyngeal (palatinovaginal) canal Roof of nose and pharynx, auditory tube, sphenoidal sinus
5. Artery of pterygoid canal Pterygoid canal Auditory tube, upper pharynx, and middle ear
6. Sphenopalatine (terminal part) Sphenopalatine foramen Lateral and medial walls of nose and various air sinuses
Table A.5: Subclavian artery

Course Branches and area of distribution
It is the chief artery of the upper limb. It also supplies part of Branches of 1st part:
neck and brain. On the right side, subclavian artery is a branch • Vertebral artery is the largest branch. It supplies the brain.
of the brachiocephalic trunk. On the left side, it is a direct The artery passes through foramina transversaria of C6–
branch of arch of aorta. The artery on either side ascends C1 vertebrae, then it courses through suboccipital triangle
and enters the neck posterior to the sternoclavicular joint. to enter cranial cavity
The arteries of two sides have similar course.
Head and Neck

• Internal thoracic artery runs downwards and medially to
The artery arches from the sternoclavicular joint to the outer enter thorax by passing behind first costal cartilage. It runs
border of the first rib where it continues as the axillary artery. vertically 2 cm, on lateral side of sternum till 6th intercostal
It is divided into three parts by the crossing of scalenus space to divide into musculophrenic and superior
anterior muscle (see Figs 8.19 and 8.20) epigastric branches
• Thyrocervical trunk is a short wide vessel which gives
suprascapular, transverse cervical and important inferior
thyroid branch. Inferior thyroid artery gives glandular
branches to thyroid and parathyroid glands. In addition,
this artery gives inferior laryngeal branch for the supply of
mucous membrane of larynx
• Costocervical trunk arises from 2nd part of subclavian
artery on right side and from 1st part on left side. It ends
by dividing into superior intercostal and deep cervical
branches
• 3rd part may give dorsal scapular branch
HEAD AND NECK
356
PHARYNGEAL APPARATUS
Table A.6: Structures derived from skeletal and muscular components of pharyngeal arches
Pharyngeal arch Nerve of the arch Muscles derived Skeletal and ligamentous
structures derived
First (mandibular) arch (I) Trigeminal and mandibular Muscles of mastication Mandible
divisions of trigeminal (temporalis, masseter, Malleus Quadrate cartilage
Meckel’s cartilages (V cranial nerve) medial and lateral pterygoids) Incus
Mylohyoid Anterior ligament of malleus
Anterior belly of digastric Sphenomandibular ligament
tensor tympani Spine of sphenoid
Tensor veli palatini Most of the mandible
Genial tubercles
Second (hyoid) arch (II) Facial (VII cranial nerve) Muscles of facial expression Stapes
Reichert’s (buccinator, auricularis, frontalis, Styloid process
cartilage platysma, orbicularis oris, and Lesser cornua of hyoid
orbicularis oculi) Upper part of body of hyoid
Posterior belly of digastric Stylohyoid ligament
Stylohyoid, stapedius
Third (III) Glossopharyngeal Stylopharyngeus Greater cornua of hyoid

(IX cranial nerve) Lower part of body of hyoid bone
Fourth (IV) Superior laryngeal branch Cricothyroid Thyroid cartilage

of vagus Levator veli palatini Corniculate cartilage
Striated muscles of oesophagus Cuneiform cartilage
Constrictors of pharynx
Sixth (VI) Recurrent laryngeal branch Intrinsic muscles of larynx Cricoid cartilage
of vagus (X cranial nerve) Arytenoid cartilage
By intramembranous ossification of mesenchyme of I arch, maxilla, zygomatic, squamous part of temporal are developed.
Table A.7: Derivatives of endodermal pouches

Pharyngeal pouch Derivatives
Dorsal ends of I and II pouches form Proximal part of tubotympanic recess gives rise to auditory tube
Head and Neck
tubotympanic recess Distal part gives rise to tympanic cavity and mastoid antrum
Mastoid cells develop at about 2 years of age
Ventral part of II pharyngeal pouch Epithelium covering the palatine tonsil and tonsillar crypts
Lymphoid tissue is mesodermal in origin
III pharyngeal pouch Thymus and inferior parathyroid gland or parathyroid III.
Thymic epithelial reticular cells and Hassall’s corpuscles are endodermal.
Lymphocytes are derived from haemopoietic stem cells during 12th week
IV pharyngeal pouch Superior parathyroid or parathyroid IV
V pharyngeal pouch (ultimobranchial body) Parafollicular or ‘C’ cells of the thyroid gland
Table A.8: Derivatives of ectodermal clefts

Pharyngeal cleft Derivatives
Dorsal part of I ectodermal cleft Epithelium of external auditory meatus.
Auricle Six auricular hillocks; three from I arch and three from II arch
Rest of ectodermal clefts Obliterated by the overgrowth of II pharyngeal arch. The closing membrane
of the first cleft is the tympanic membrane.
357
trigeminal nerve, but functionally it is related to

oculomotor nerve. This ganglion gets parasympathetic incision does not endanger the various branches of
fibres (Flowchart A.4). facial nerve, coursing through the gland (see Fig. 5.8).
Frey’s syndrome: The sign of Frey’s syndrome is
Roots the appearance of perspiration on the face while the
patient eats food. In certain healing of wounds, the
It has three roots—the sensory, sympathetic and auriculotemporal nerve and great auricular nerves
parasympathetic. Only the parasympathetic root fibres may join with each other. When the person eats food,
relay to supply the intraocular muscles. instead of saliva, sweat appears on the face.
1 Sensory root is from the long ciliary nerve. Waldeyer’s ring: It is the ring of lymphoid tissue
2 Sympathetic root is by the long ciliary nerve from present at the oropharyngeal junction. Its compo-
plexus around ophthalmic artery. nents are lingual tonsils anteriorly, palatine tonsils
laterally, tubal tonsils above and laterally and
3 Parasympathetic root is from a branch to inferior pharyngeal tonsils posteriorly (see Fig. 14.13).
oblique muscle. These fibres arise from Edinger- Killian’s dehiscence: It is a potential gap between
Westphal nucleus, join oculomotor nerve and leave upper thyropharyngeus and lower cricopharyngeus
it via the nerve to inferior oblique, to be relayed in parts of inferior constrictor muscle. Thyropharyngeus
the ciliary ganglion (Flowchart A.5). is the propulsive part of the muscle, supplied by
recurrent laryngeal nerve, while cricopharyngeus is
Branches the sphincteric part, supplied by external laryngeal
The ganglion gives 10–12 short ciliary nerves containing nerve. If there is incoordination between these two
postganglionic fibres for the supply of constrictor or parts, bolus of food is pushed backwards in region
sphincter pupillae for narrowing the size of pupil and of Killian’s dehiscence, producing pharyngeal pouch
or diverticula (see Fig. 14.22).
ciliaris muscle for increasing the curvature of anterior
Safety muscle of larynx: Posterior cricoarytenoid
surface of lens required during accommodation of the muscles are the only abductors of vocal cords. The
eye. paralysis of both these muscles causes unopposed
adduction of vocal cords, with severe dyspnoea. So
MOLECULAR REGULATION OF posterior cricoarytenoid is the life-saving muscle
PHARYNGEAL ARCHES (see Figs 16.10, 16.11b).
Neural crest cells arise from caudal midbrain and from Singer’s nodules: These are little swellings on the
rhombomeres—the segments in the hindbrain. vocal cords at the junction of anterior one-third and
Pharyngeal pouch endoderm expresses genes which posterior two-thirds of vocal cords. During
regulate the patterning of the skeletal parts in the phonation, the cords come close together, and there
pharyngeal arches. is slight friction as well. If friction is more and
The mechanism of epithelial–mesenchymal inter- continuous, there is some inflammation with
action with endoderm of the pouches send signals to thickening of vocal cords, leading to Singer’s or
Teacher’s nodules (see Fig. 16.8).
the mesenchyme. Mesenchymal gene expression is
Tongue is pulled out during anaesthesia: Genio-
determined by OTX2 and HOX genes carried by
Head and Neck

glossus muscles are responsible for protrusion of
pharyngeal arches by migrating neural crest cells. tongue. If these muscles are paralysed, the tongue
falls back upon itself and blocks the airway. So
tongue is pulled out during anaesthesia to keep there
CLINICAL TERMS
air passage clean (see Fig. 17.5).
Anaesthetist’s arteries: These are the arteries used Passavant’s ridge: The horizontal fibres of right
by the anaesthetists who are sitting at the head end and left palatopharyngeus muscles form a
of the patient being operated: Passavant’s fold at the junction of nasopharynx and
• The superficial temporal artery as it crosses the oropharynx. During swallowing, palatopharyngeus
root of zygoma in front of ear (see Fig. 5.3a). muscles form a ridge, which closes nasopharynx
• Facial artery at the anteroinferior angle of masseter from oropharynx, so that bolus of food passes,
muscle (see Fig. 2.17). through oropharynx only. In paralysis of these
• Common carotid at the anterior border of muscles, there is nasal regurgitation.
sternocleidomastoid. Ludwig’s angina: When there is cellulitis of floor
Hilton’s method of draining parotid gland abscess: of the mouth, due to infected teeth, the condition is
The incision given to drain parotid abscess is the known as Ludwig’s angina. The tongue is pushed
horizontal incision or by making many holes. This upwards and mylohyoid is pushed downwards. This
HEAD AND NECK
358
cellulitis may spread backwards to cause oedema of Injury to spine of sphenoid: Chorda tympani nerve
larynx and asphyxia. is related on the medial side of spine of sphenoid,
Little’s area of nose: This is the area in the antero- while auriculotemporal nerve is related on the lateral
inferior part of nasal septum. Four arteries take part side. Chorda tympani gives secretomotor fibres to
in Kiesselbach’s plexus formed by: submandibular and sublingual salivary glands,
Septal branch of superior labial from facial artery, whereas auriculotemporal gives secretomotor fibres
terminal part of sphenopalatine artery: to the parotid gland. So injury to spine of sphenoid
may injure both these nerves affecting the secretion
• Anterior ethmoidal artery,
from all three salivary glands (see Fig. 6.11a).
• Greater palatine artery. Extradural haemorrhage: There is collection
Picking of the nose may give rise to nasal bleeding of blood due to rupture of middle meningeal vessels
or epistaxis (see Fig. 15.5). in the space between skull and the endosteum. It may
Syringing of ear causes decreased heart rate: The press upon the motor area of brain. Blood has to be
external auditory meatus is supplied by auricular branch drained out from the point called ‘pterion’ (see Fig. 1.8).
of vagus. Vagus also supplies the heart with cardio- Loss of corneal blink reflex: In case of injury to
inhibitory fibres. During syringing of the ear, vagus nerve ophthalmic nerve, there is loss of corneal blink reflex
is stimulated which causes bradycardia (see Fig. 18.7). as the afferent part of reflex arc is damaged.
Nerve of near vision: Oculomotor nerve is the Loss of sneeze reflex: In injury to maxillary nerve,
nerve of close vision. It supplies medial rectus, the sneeze reflex is lost, as afferent loop of the reflex
superior and inferior recti. The sphincter pupillae arc formed by the maxillary nerve is damaged.
and ciliaris muscles are supplied by parasympathetic Loss of jaw jerk reflex: The afferent and efferent
fibres via III nerve. It also supplies levator palpebrae limbs of the reflex arc are by V nerve. Damage to
superiors which opens the eye. mandibular nerve causes loss of jaw jerk reflex.
Head and Neck
359
SPOTS
1. a. Identify the foramen. 6. a. Identify the structure.

b. Name the structures b. Name its branches in
passing through it. order.
2. a. Identify the foramen. 7. a. Identify the marked

b. Name the structures area.
passing through it. b. Name the vessels
present here.
3. a. Identify the muscle. 8. a. Identify the structure.

b. Name its parts. b. Name its extrinsic
muscles with their nerve
supply.
4. a. Identify the arrow 9. a. Identify the highlighted

marked circled muscle.
structure. b. What is its action?
Head and Neck

b. What are types of fibres
carried by it?
5. a. Identify the highlighted 10. a. Identify the organ.

structure. b. Name the arteries
b. Trace its secretomotor supplying it.
fibres.
359
HEAD AND NECK
360
ANSWERS OF SPOTS
1. a. Foramen magnum
b. Lowest part of medulla oblongata
Three meninges
One anterior spinal artery
Two posterior spinal arteries
Two vertebral arteries
Spinal root of XI
2. a. Mandibular canal
b. Inferior alveolar artery and nerve
3. a. Orbicularis oculi
b. Orbital part, palpebral part and lacrimal part
4. a. Chorda tympani nerve

b. General visceral efferent (GVE) fibres and special visceral afferent (Sp. VA) fibres
5. a. Parotid gland
b. Inferior salivatory nucleusIX nervetympanic plexuslesser petrosal nerveotic ganglionpostganglionic
fibres join auriculotemporal nerveparotid gland
6. a. External carotid artery.

b. Anterior: Superior thyroid, lingual and facial
Medial: Ascending pharyngeal
Posterior: Occipital and posterior auricular
Terminal: Superficial temporal and maxillary
7. a. Little’s area
b. Superior labial, greater palatine, anterior ethmoidal and sphenopalatine veins and capillaries.
8. a. Tongue
b. Palatoglossus, hyoglossus, styloglossus, genioglossus
Palatoglossus is supplied by vagoaccessory complex, other three are supplied by hypoglossal nerve.
9. a. Posterior cricoarytenoid muscle

b. Only abductor of the vocal cords
Head and Neck
10. a. Palatine tonsil

b. Ascending palatine, ascending pharyngeal, dorsal lingual branches of lingual and greater palatine branch of
maxillary artery.
Index
Cartilages of larynx 287 dissection 165

A arytenoid 288 external carotid 110, 354
corniculate 289 ascending pharyngeal 111, 354
Accumulation of wax 312
cricoid 288 facial 111, 354
Acute retropharyngeal abscess 89
attachments 288 lingual 111, 354
Adenoids 258
cuneiform 289 maxillary 112, 354
Air embolism 88, 94 epiglottis 288 occipital 111, 354
Allergic rhinitis 277 attachments 288 posterior auricular 111, 354
Anaesthetist's arteries 75, 165, 166, 357 laryngeal joints 289 superficial temporal 112, 354
Aneurysm 165 laryngeal ligaments and membranes 289 superior thyroid 110, 354
Anosmia 277 extrinsic 289 internal carotid 166, 354
Ansa cervicalis or ansa hypoglossi 107 intrinsic 290 Common cold 272
formation 107 thyroid 287 Comparison of the three salivary glands 149
Anterior triangle subdivisions 103 attachments 287 Compression of the spinal cord 209
carotid triangle 105 Cataract 334 Compression of trachea 184
digastric triangle 103 Cauda equina syndrome 209 Conjunctivitis 79, 329
muscular triangle 107 Caudal epidural 209 Corneal graft 329
submental triangle 103 Causes of headache 216 Corneal opacity 329
Anterior triangle of the neck 99 Cephalhaematoma 67 Cranial cavity 212
surface landmarks 99 Cerebral dura mater 213 contents 212
Antrum puncture 279 blood supply 215 dissection 212
Apical abscess of tooth 249 endosteal layer 213 Cut throat wounds 102
Aqueous humour 333 meningeal layer 213
diaphragma sellae 215
Arteries 342
falx cerebelli 215 D
common carotid 165, 342
falx cerebri 213 Dacrocystitis 80
facial 75, 342
tentorium cerebelli 214
internal carotid 166, 342 Dangerous area of face 76, 81
nerve supply 215
middle meningeal 129, 343 Dangerous area of the scalp 67
Cervical caries 89
subclavian 162, 343 Dangerous space in neck 90
Cervical part of sympathetic trunk 171
Arteries of head and neck 162, 354 Death in execution 187
dissection 171
Artery of epistaxis 130, 274 Decalcification of atlas vertebra 56
formation 171
Assessing of the venous pressure 94 Deep cervical fascia 86
inferior cervical ganglion 172
Auriculotemporal syndrome 120 buccopharyngeal fascia 90
branches 172
middle cervical ganglion 172 carotid sheath 90
branches 172 relations 90
B superior cervical ganglion 172 investing layer 86
branches 172 attachments 86
Back of the neck 196 other features 88
Cervical pleura 190
dissection 196 pharyngobasilar fascia 90
Cervical plexus 190, 350
nerve supply of skin 197 pretracheal fascia 89
phrenic nerve 192, 350
Bell's palsy 118 prevertebral fascia 89
Cervical rib 55, 96, 165
Biopsy of the lymph node 96 attachments and relations 89
Cervical spondylosis 187
Black eye 67 other features 89
Cervical vertebrae 51
Blepharitis 79 Deglutition 266
Cervical vertebrae, fracture of 188
Block dissection of the neck 96 development 266
Chalazion 79
Blood vessels of the neck 162 first stage 266
Choking by food 257
Boils in external auditory meatus 312 second stage 266
Choroid 330
Brachiocephalic vein 169
Chronic otitis media 319 third stage 266
Ciliary body 330 Dental caries 249
C Cisternal puncture 208 Derangement of the articular disc 134
Cleft palate 257 Development of the arteries 176
Caldwell-Luc operation 279 Common anterior midline swellings of the Deviation of the nasal septum 274
Cannulation of internal jugular vein 169 neck 102 Dislocation of mandible 134
Caput succedaneum 6 Common carotid artery 109, 165, 354 Dysphagia 96, 158, 265
Carcinoma of the maxillary sinus 279 carotid body 109 Dysphagia lusoria 96, 165
Carcinoma of the tongue 303 carotid sinus 109 Dysphonia 158
Carotid sinus syndrome 109 course 165 Dyspnoea 158
361
362 HUMAN ANATOMY—HEAD AND NECK
Fontanelles 6 hypothalamohypophyseal portal system 223

E Foramina of skull bones and their molecular regulation 222
contents 56 neurohypophysis 222
Ear cough 312
Foreign bodies in eyelid 79 subdivisions/parts and development 222
Ectropion 79
Foreign body in larynx 291 Hypothyroidism 158
Epiphora 81
Fracture at the canine socket 36
Ethmoid bone 47
cribriform plate 47
Fracture of cribriform plate 272
Fracture of the anterior cranial fossa 23
I
crista galli 47
Fracture of the mandible 36 Inferior alveolar nerve to be
labyrinths 47
perpendicular plate 47 Fracture of the middle cranial fossa 25, 319 anaesthetized 139
Eustachian catarrh 268, 319 Fracture of the posterior cranial fossa 26 Inferior nasal conchae 48
External ear 309 Fractures of skull 56 Infranuclear lesion of the facial nerve 73
auricle/pinna 309 Frey's syndrome 120, 357 Infratemporal fossa 123
dissection 311 Frontal bone 41 boundaries 123
external acoustic meatus 310 anatomical position 41 contents 124
tympanic membrane 311 nasal part 42 Injury to spine of sphenoid 358
blood supply 312 orbital parts 41 Interior of the skull 21
lymphatic drainage 312 squamous part 41 Attachments and relations 26
nerve supply 312 internal surface of cranial vault 22
venous drainage 312 G internal surface of the base of skull 22
External examination of larynx 291 anterior cranial fossa 22, 27
Extracranial and subdural haemorrhages 216 Ganglion of hay fever 283 middle cranial fossa 24, 27
Extraction of malplaced 'wisdom' tooth 138 Glands 345 posterior cranial fossa 25, 27
Extradural haemorrhage 13, 130, 226, 358 parotid 114, 345 structures passing through foramina 27
Extraocular muscles 232 parotid duct 119, 346 Internal ear 320
dissection 232 submandibular 146, 346 bony labyrinth 320
involuntary muscles 233 thyroid 153, 346 cochlea 320
Eyeball 327 semicircular canals 320
Eyelids or palpebrae 78 vestibule 320
blood supply 79
H membranous labyrinth 321
dissection 78 Internal jugular vein 168
Hangman's fracture 56
lymphatic drainage 79 Involution of the thymus 161
Hard palate 252
nerve supply 79 Iris 330
dissection 252
structure 78 vessels and nerves 252
Head and neck 3 J
F compartments of neck 3
functions of 3 Jaw-jerk reflex 138
Face 67 regions 3 Joints of the neck 184
dissection 67 anterior triangle 4 atlantoaxial 186
facial artery 75 auricular 3 atlanto-occipital 185
facial muscles 68 frontal 3 between atlas, axis and occipital bone 185
around the mouth 69 nasal 4 ligaments connecting axis with occipital
of the auricle 68 occipital 3 bone 187
of the eyelids 68 ocular 3 typical cervical 184
of the neck 71 oral cavity 4 Judicial hanging 56
of the nose 68 parietal 3
of the scalp 68 parotid 4
lymphatic drainage 77 posterior 4 K
nerve supply 71 temporal 3
motor 71 Heimlich maneuver 257 Kiesselbach's plexus 130
sensory 74 Herpes zoster of the geniculate ganglion 313 Killian's dehiscence 265, 357
skin 68 Hilton's method of draining parotid gland Koplik's spots
superficial fascia 68 abscess 120, 357
transverse facial artery 76 Horner's syndrome 172 L
veins of the face 76 Hutchinson's teeth 250
Facial nerve 323 Hyoid bone 50 Lacrimal apparatus 79
Features of the temporal bone 309 attachments 51 conjunctival sac 80
Fibreoptic flexible laryngoscopy 291 body 50 dissection 79
First cervical vertebra 53 development 51 lacrimal gland 79
attachments and relations 53 greater cornua 50 lacrimal puncta and canaliculi 80
ossification 54 lesser cornua 51 lacrimal sac 80
Foetal skull/neonatal skull 30 Hyperacusis 319 nasolacrimal duct 80
abnormal crania 32 Hypermetropia 329 Lacrimal bones 49
craniometry 31 Hyperparathyroidism 160 Borders 49
dimensions 30 Hypertrophy of the tubal tonsil 258 Surfaces 49
facial angle 32 Hypoglossal nerve 303 Landmarks on the anterior aspect of the
orbits 30 Hypoparathyroidism 160 neck 340
ossification 30 Hypophysis cerebri 221 Landmarks on the face 337
paranasal air sinuses 30 adenohypophysis 222 Landmarks on the lateral side of the head 338
sex differences in the skull 31 arterial supply 222 Landmarks on the side of the neck 339
structure of bones 30 dissection 221 Laryngeal oedema 291
temporal bone 30 histology 222 Laryngitis 291
INDEX 363
Larynx 286 of second part 129, 355 facial 71, 344

arterial supply and venous drainage 293 buccal 129, 355 glossopharyngeal 169, 344
cavity of 290 deep temporal 129, 355 hypoglossal 303, 345
constitution of larynx 286 masseteric 129, 355 lingual and inferior alveolar 136, 137, 344
dissection 286 pterygoid 129, 355 mandibular 134, 344
intrinsic muscles of larynx 291 of third part 129, 355 phrenic 192, 345
lymphatic drainage 294 artery of pterygoid canal 129, 355 vagus 169, 344
mucous membrane of 290 course and relations 128 Nerves of the orbit 239
nerve supply 293 greater palatine 129, 355 abducent nerve 241
sensory nerves 233 infraorbital 129, 355 branches of ophthalmic division of
Lateral wall of nose 274 pharyngeal 129, 355 trigeminal nerve 241
arterial supply 276 posterior superior alveolar 129, 355 frontal 242
conchae and meatuses 274 pterygoid plexus of veins 130 lacrimal 241
atrium of the middle meatus 276 sphenopalatine (terminal part) 129, 355 nasociliary 242
inferior meatus 273 pterygoid plexus of vein 130 ciliary ganglion 240
middle meatus 273 Maxillary nerve 280 oculomotor nerve 240
superior meatus 276 ganglionic branches 280 optic nerve 239
dissection 274, 276 infraorbital nerve 281 sympathetic nerves of the orbit 244
features 274 posterior superior alveolar nerve 280 trochlear nerve 241
lymphatic drainage 277 zygomatic nerve 281 Norma basalis 13
nerve supply 276 Microlaryngoscopy 291 anterior part 13
venous drainage 276 Middle ear 314 alveolar arch 13
Lens 333 boundaries 315 hard palate 13
Leptomeningitis 208 communications 315 attachments 18
Little's area 274, 358 dissection 314 middle part 14
Loss of corneal blink reflex 358 ear ossicles 317 lateral area 15
Loss of jaw jerk reflex 138, 358 functions of the middle ear 318 median area 14
Loss of sneeze reflex 358 joints of the ossicles 317 posterior part 16
Ludwig's angina 102, 357 muscles of the middle ear 317 lateral area 16
Lumbar epidural 208 shape and size 314 median area 16
Lumbar puncture in adult 208 Middle meningeal artery 225 structures passing through foramina 18
Lumbar puncture in infant/children 208 branches 226 Norma frontalis 8
Luschka's joints 56 course and relations 225 anterior bony aperture of the nose 9
Lymphatic drainage of head and neck 173 dissection 226 attachments 10
deep group 174 Mixed parotid tumour 120 bones 8
deepest group 175 Motor part of the mandibular nerve 138 frontal region 8
Müller's muscle 79
main lymph trunks 175 lower part of the face 9
Mumps 115
superficial group 173 mandible 10
Muscles connecting the upper limb to the
Waldeyer's ring 175 orbital openings 8
vertebral column 200
structures passing through foramina 10
Muscles of mastication 124
sutures of 10
M dissection 124
zygomatic bone 10
lateral pterygoid 125
Mandible 32 masseter 125 Norma lateralis 10
age changes 35 medial pterygoid 125 bones 10
attachments and relations of 34 relations of lateral pterygoid 126 external acoustic meatus 12
body 33 temporalis 125 features 11
foramina and relations to nerves and Muscles of the back 197 mastoid part of the temporal bone 12
vessels 34 Muscles of prevertebral region structures passing through foramina 13
ossification 35 longus capitis 181 styloid process 12
ramus 33 longus colli 181 temporal fossa 12
structures related 35 rectus capitis anterior 181 zygomatic arch 11
Mandibular nerve 134 rectus capitis lateralis 181 Norma occipitalis 6
branches 135 scalenovertebral triangle 181 attachments 6
course and relations 134 Myopia 329 bones 6
dissection 134 Myringotomy 314 other features 6
Mandibular neuralgia 138 sutures 6
Mastoid abscess 319 N Norma verticalis 6
bones 6
Maxilla 36
age changes 39 Nasal bones 49 some other named features 6
articulations 39 borders 49 sutures 6
body 36 Surfaces 49 Nose 271
ossification 39 Nasal septum 273 external nose 271
processes 38 arterial supply 273 nasal cavity 271
side determination 36 dissection 273 Nystagmus 236
Maxillary artery 127, 129, 355 features 273
course and relations 128 lymphatic drainage 274 O
of first part 129, 356, 546 nerve supply 273
accessory meningeal 129, 355 venous drainage 273 Occipital bone 40
anterior tympanic 129, 355 Nerve of near vision 358 anatomical position 40
deep auricular 129, 355 Nerves basilar part 41
first part 129, 356 accessory 169, 345 condylar part 41
inferior alveolar 129, 355 auriculotemporal 67, 136, 344 features 40
middle meningeal 129, 355 cervical sympathetic chain 171, 345 squamous part 40
364 HUMAN ANATOMY—HEAD AND NECK
Occipitalization of atlas 56 borders 40

Oesophagus 184 side determination 40 R
Olfactory nerve 277 surfaces 40 Radiological anatomy 347
Optic atrophy 240 Parotid calculi 120 carotiod angiogram 348
Optic neuritis 240 Parotid gland 114 cervical vertebrae 348
Oral cavity 246 capsule 115 lateral view of skull 347
cheeks 247 dissection 114 special PA view of skull for paranasal
gums 247 external features 115 sinuses 348
lips 246 lymphatic drainage 119 Referred pain of cancer of tongue 138
oral cavity proper 247 nerve supply 118 Retina 331
vestibule 246 parotid duct 119 histology 332
Orbits 231 relations 115 Retinal detachment 332
dissection 231 structures within the parotid gland 117
fascial sheath of eyeball 232 Parotid region 114
ophthalmic artery 237
ophthalmic veins 239
Parotid swellings 88, 115 S
Passavant's ridge 254, 357
orbital fascia 231 Perichondritis 313 Safety muscle of larynx 357
visual axis and orbital axis 231 Pharyngeal apparatus 356 Safety muscle of the tongue 304
Ossification of cranial bones 56 derivatives of ectodermal clefts 356 Scalene muscles 188, 189
Other structures seen in cranial fossae 226 derivatives of endodermal pouches 356 dissection 188
cranial nerves 226 molecular regulation 357 Scalp, temple 62
fourth part of the vertebral artery 228 structures derived from skeletal and dissection 63
internal carotid artery 226 muscular components of pharyngeal extent of scalp 63
petrosal nerves 227 arches 356 five layers 63
deep petrosal nerve 227 Pharyngeal diverticulum 265 surface landmarks 62
external petrosal nerve 228 Pharyngeal spaces 80 Second cervical vertebra 54
lesser petrosal nerve 227 lateral pharyngeal space 90 attachments 54
Otic ganglion 137 retropharyngeal space 90 body and dens 54
connections and branches 137 Pharyngotympanic tube 266 Seventh cervical vertebra 55
Otitis media 319 bony part 267 attachments 55
Otosclerosis 319 cartilaginous part 267 ossification 55
Outer coat of eyeball 327 function 267 Side of the neck 84
cornea 329 nerve supply 267 boundaries 84
dissection 329 vascular supply 267 dissection 85
sclera 327 Pharynx 257 landmarks 84
dissection 328 blood supply 266 skin 84
boundaries 258 superficial fascia 85
P comparison between nasopharynx, Singer's nodules 291, 357
oropharynx and laryngopharynx 259 Sinusitis 279
Palatine bones 50 dimensions 257 Sites for sebaceous cysts 66
plates 50 dissection 258 Skin incisions 102
processes 50 lymphatic drainage 266 Skull 4
Palatine tonsil 259, 346 muscles of 263 anatomical position of 5
arterial supply 260 nerve supply 265 bones of 4
development 261 parts of 258 calvaria 4
features 259 structure of 262 facial skeleton 4
histology 261 Phrenic nerve 192 skull joints 4
lymphatic drainage 260 Pituitary tumours 223 methods of study of 5
venous drainage 260 Posterior triangle 93 peculiarities of 5
Palpebral conjunctiva 79 boundaries 93 Smuggler's fossa 291
Paralysis of the soft palate 257 division of 94 Sneeze reflex 283
Paranasal sinuses 277, 346 relevant features of the contents 94 Soft palate 252
dissection 277 Potential tissue spaces in head and neck 112 blood supply 256
ethmoidal sinuses 279 parapharyngeal space 112 development of palate 257
anterior 279 parotid space 112 movements and functions 256
middle 279 peritonsillar space 112 muscles of the soft palate 254
posterior 279 retropharyngeal space 112 nerve supply 254
features 277, 346 submandibular space 112 Passavant's ridge 254
frontal sinus 277 submental space 112 structure 253
maxillary sinus 278, 346 Principles governing fractures of the skull 27 Sphenoid bone 45
sphenoidal sinus 279 Prolapse of an intervertebral disc 56, 209 body of sphenoid 45
Parasympathetic ganglia Pterion 13 greater wings 45
ciliary 240, 353 Pterygopalatine fossa 280 lesser wings 46
otic 137, 352 boundaries 280 pterygoid processes 47
pterygopalatine 181, 351 communications 280 superior orbital fissure 46
submandibular 148, 350 contents 280 Spinal nerves 209
Parathyroid glands 159 Pterygopalatine ganglion 281 Spinal tumours 209
development 162 branches 282 Spondylitis 188
histology 160 connections 281 Squint/strabismus 236
position 159 dissection 282 Stealing of blood 165
vascular supply 159 features 281 Sternocleidomastoid muscle 91
Parietal bone 40 Pulsation of common carotid artery 166 actions 91
angles 40 Pyorrhoea alveolaris 249 blood supply 91
INDEX 365
insertion 91 nerve supply of 249 Trigeminal ganglion 224

nerve supply 91 parts of a tooth 248 associated roots and branches 224
origin 91 stages of development of deciduous other relations 224
relations 91 teeth 250 situation and meningeal relations 224
Structures in the anterior median region of Temporal bone 42 Trigeminal nerve 224
the neck 100 features 42 motor component 225
deep fascia 100 petromastoid part 43 sensory components 225
dissection 101 side determination 42 Trigeminal neuralgia 74, 283
skin 100 squamous part 43 Tympanic or mastoid antrum 318
structures lying above the hyoid bone 101 styloid process 44 dissection 318
structures lying below the hyoid bone 101 tympanic part 44 mastoid air cells 319
superficial fascia 100 Temporal fossa 123 vessels, lymphatics and nerves 319
Stye or hordeolum 79 boundaries 123 Typical cervical vertebrae 51
Styloid apparatus 176 contents 123 attachments and relations 52
Subclavian artery 162, 355 Temporomandibular joint 130 ossification 52
branches 163 articular disc 131
costocervical trunk 165, 355
course 162
articular surfaces 130
blood supply 132
V
internal thoracic artery 164, 355 dissection 130 Veins/sinuses
origin 162 ligaments 130 cavernous sinus 216
thyrocervical trunk 164, 355 movements 132 dissection 216
vertebral artery is 164, 180, 355 muscles producing movements 133 external jugular 94, 343
Subclavian vein 167 nerve supply 132 facial 76, 343
Sublingual salivary gland 147 relations of 132 internal jugular 168, 343
relations 148 Testing facial muscles 73 relations 217
Submandibular ganglion 148 The orbit 28 sigmoid 220, 344
connections and branches 148 floor 28 sigmoid sinuses 220
Submandibular salivary gland 146 foramina in relation to 30 straight sinus 220
blood supply 147 lateral wall 28 superior sagittal 219, 343
deep part 147 medial wall 29 superior sagittal sinus 219
dissection 146 roof 28 transverse 220, 343
features 146 shape and disposition 28
lymphatic drainage 147 draining channels 217
Thrombosis of sinuses 220
nerve supply 147 cavernous sinus 218, 240
submandibular duct 147 tributaries 217
sigmoid sinus 220 Vertebral artery 180
superficial part 146 superior sagittal sinus 220
Suboccipital region 201 development 183
Throttling or strangulation 51 dissection 180
boundaries of suboccipital triangle 202 Thymic hyperplasia 161
contents 202 Vertebral canal 206
Thymic tumours 161 arachnoid mater 207
dissection 201 Thymus 160
other related structures 203 contents 206
blood supply 160 epidural space 207
suboccipital muscles 201 development 161
Subtotal thyroidectomy 158 spinal dura mater 207
functions 160 spinal pia mater 207
Superficial temporal region 65 histology 161
arterial supply 65 subarachnoid space 207
Thyroid gland 153 subdural space 207
lymphatic drainage 66 arterial supply 156
nerve supply 66 Vertebral system of veins 209
capsules of thyroid 154
venous drainage 65 anatomy of the vertebral venous plexus 209
dimensions and weight 154
Suprahyoid muscles 142 communications and implications 209
dissection 153
digastric 143 Vestibulocochlear nerve 323
lymphatic drainage 157
dissection 144 Virchow's lymph nodes 176
parts and relations 155
genioglossus 143 Vitreous body 334
situation and extent 154
geniohyoid 143 Voluntary extraocular muscles 233
venous drainage 157
hyoglossus 143 actions 235
Thyroidectomy 157
mylohyoid 143 insertion 233
Tongue 299
relations of hyoglossus 145 nerve supply 234
arterial supply 301
relations of mylohyoid 144 origin 233
development 304
relations of posterior belly of digastric 144 Vomer 48
histology 304
stylohyoid 143 lymphatic drainage 303
Supranuclear lesions of the facial nerve 73
Supraventricular tachycardia 109
muscles of 301 W
extrinsic 301
Suspensory ligaments of Berry 89 intrinsic 301 Waldeyer's lymphatic ring 258, 357
Sympathetic trunk 171, 350 nerve supply 303 Wisdom teeth 250
Syringing of ear 313, 358 papillae of 300 Wounds of the scalp 66
parts of 299 Wry neck 93
T referred pain 306
taste pathway 306
Teacher's nodules 291 venous drainage 301 Z
Teeth 248 Torticollis 92
eruption of 249 Trachea 183 Zygomatic bones 48
form and function 249 cervical part of 183 borders 48
molecular regulation of tooth Tracheostomy 102, 184 processes 49
development 251 Trachoma 79 surfaces 48
Index of Competencies
Competency based Undergraduate Curriculum for the Indian Medical Graduate
Code Competency Chapter Page no

AN 26.1 Demonstrate anatomical position of skull, Identify and locate individual skull bones 1 5, 32
in skull
AN 26.2 Describe the features of norma frontalis, verticalis, occipitalis, lateralis and basalis 1 6
AN 26.3 Describe cranial cavity, its subdivisions, foramina and structures passing through them 1 22
AN 26.4 Describe morphological features of mandible 1 32
AN 26.5 Describe features of typical and atypical cervical vertebrae (atlas and axis) 1 51
AN 26.6 Explain the concept of bones that ossify in membrane 1 56
AN 26.7 Describe the features of the 7th cervical vertebra 1 55
AN 27.1 Describe the layers of scalp, its blood supply, its nerve supply and surgical Importance 2 63
AN 27.2 Describe emissary veins with its role in spread of infection from extracranial route to 1 5
intracranial venous sinuses
AN 28.1 Describe and demonstrate muscles of facial expression and their nerve supply 2 68
AN 28.2 Describe sensory innervation of face 2 74
AN 28.3 Describe and demonstrate origin /formation, course, branches /tributaries of facial vessels 2 75
AN 28.4 Describe and demonstrate branches of facial nerve with distribution 5 118
AN 28.5 Describe cervical lymph nodes and lymphatic drainage of head, face and neck 2, 8 77, 173
AN 28.6 Identify superficial muscles of face, their nerve supply and actions 2 68
AN 28.7 Explain the anatomical basis of facial nerve palsy 2 73
AN 28.8 Explain surgical importance of deep facial vein 2 76
AN 28.9 Describe and demonstrate the parts, borders, surfaces, contents, relations and nerve 5 114
supply of parotid gland with course of its duct and surgical importance
AN 28.10 Explain the anatomical basis of Frey’s syndrome 5 120
AN 29.1 Describe and demonstrate attachments, nerve supply, relations and actions of 3 91
sternocleidomastoid
AN 29.2 Explain anatomical basis of Erb’s and Klumpke’s palsy 4 (vol 1) 62
AN 29.3 Explain anatomical basis of wry neck 3 93
AN 29.4 Describe and demonstrate attachments of:
1) inferior belly of omohyoid 2 (Vol 1) 12
2)scalenus anterior 9, 10 189, 200
3) scalenus medius
4) levator scapulae
AN 30.1 Describe the cranial fossae and identify related structures 1 22
AN 30.2 Describe and identify major foramina with structures passing through them 1 58, 59
AN 30.3 Describe and identify dural folds and dural venous sinuses 12 213, 216
AN 30.4 Describe clinical importance of dural venous sinuses 12 218
AN 30.5 Explain effect of pituitary tumours on visual pathway 12 223
AN 31.1 Describe and identify extra ocular muscles of eyeball 13 233
AN 31.2 Describe and demonstrate nerves and vessels in the orbit 13 237
AN 31.3 Describe anatomical basis of Horner's syndrome 8 172
AN 31.4 Enumerate components of lacrimal apparatus 2 79
AN 31.5 Explain the anatomical basis of oculomotor, trochlear and abducent nerve palsies 4 (vol 4) 71
along with strabismus
HUMAN ANATOMY—HEAD AND NECK

AN 32.1 Describe boundaries and subdivisions of anterior triangle 4 103
AN 32.2 Describe and demonstrate boundaries and contents of muscular, carotid, digastric 4 103
and submental triangles
AN 33.1 Describe and demonstrate extent, boundaries and contents of temporal and 5 123, 134
infratemporal fossae
AN 33.2 Describe and demonstrate attachments, direction of fibres, nerve supply and actions of 5 124
muscles of mastication
AN 33.3 Describe and demonstrate articulating surface, type and movements 5 130
oftemporomandibular joint
AN 33.4 Explain the clinical significance of pterygoid venous plexus 5 130
AN 33.5 Describe the features of dislocation of temporomandibular joint 5 134
AN 34.1 Describe and demonstrate the morphology, relations and nerve supply of submandibular 6 146
salivary gland and submandibular ganglion
AN 34.2 Describe the basis of formation of submandibular stones 7 150
AN 35.1 Describe the parts, extent, attachments, modifications of deep cervical fascia 3 86
AN 35.2 Describe and demonstrate location, parts, borders, surfaces, relations and blood supply 8 153
of thyroid gland
AN 35.3 Demonstrate and describe the origin, parts, course and branches subclavian artery 8 162
AN 35.4 Describe and demonstrate origin, course, relations, tributaries and termination of 8 168
internal jugular and brachiocephalic veins
AN 35.5 Describe and demonstrate extent, drainage and applied anatomy of cervical lymph nodes 8 173
AN 35.6 Describe and demonstrate the extent, formation, relation and branches of cervical 8 171
sympathetic chain
AN 35.7 Describe the course and branches of IX, X, XI and XII nerve in the neck 8 169
AN 35.8 Describe the anatomically relevant clinical features of thyroid swellings 8 157
AN 35.9 Describe the clinical features of compression of subclavian artery and lower trunk of 8 165
brachial plexus by cervical rib
AN 35.10 Describe the fascial spaces of neck 3 90
AN 36.1 Describe the 14 252, 259
1) morphology, relations, blood supply and applied anatomy of palatine tonsil
2) composition of soft palate
AN 36.2 Describe the components and functions of Waldeyer's lymphatic ring 14 258
AN 36.3 Describe the boundaries and clinical significance of pyriform fossa 16 291
AN 36.4 Describe the anatomical basis of tonsillitis, tonsillectomy, adenoids and peri-tonsillar abscess 14 261
AN 36.5 Describe the clinical significance of Killian's dehiscence 14 265
AN 37.1 Describe and demonstrate features of nasal septum, lateral wall of nose, their blood supply 15 273
and nerve supply
AN 37.2 Describe location and functional anatomy of paranasal sinuses 15 277
AN 37.3 Describe anatomical basis of sinusitis and maxillary sinus tumours 15 279
AN 38.1 Describe the morphology, identify structure of the wall, nerve supply, blood supply and 16 286
actions of intrinsic and extrinsic muscles of the larynx
AN 38.2 Describe the anatomical aspects of laryngitis 16 294
AN 38.3 Describe anatomical basis of recurrent laryngeal nerve injury 16 294
AN 39.1 Describe and demonstrate the morphology, nerve supply, embryological basis of 17 299
nerve supply, blood supply, lymphatic drainage and actions of extrinsic and intrinsic
muscles of tongue
AN 39.2 Explain the anatomical basis of hypoglossal nerve palsy 17 304
AN 40.1 Describe and identify the parts, blood supply and nerve supply of external ear 18 309
AN 40.2 Describe and demonstrate the boundaries, contents, relations and functional anatomy 18 266, 311
of middle ear and auditory tube
INDEX OF CONTENTS
COMPETENCIES

AN 40.3 Describe the features of internal ear 18 320
AN 40.4 Explain anatomical basis of otitis externa and otitis media 18 312, 319
AN 40.5 Explain anatomical basis of myringotomy 18 313
AN 41.1 Describe and demonstrate parts and layers of eyeball 19 327
AN 41.2 Describe the anatomical aspects of cataract, glaucoma and central retinal artery occlusion 19 333
AN 41.3 Describe the position, nerve supply and actions of intraocular muscles 19 330
AN 42.1 Describe the contents of the vertebral canal 11 206
AN 42.2 Describe and demonstrate the boundaries and contents of suboccipital triangle 10 201
AN 42.3 Describe the position, direction of fibres, relations, nerve supply, actions of 10 198
semispinalis capitis and splenius capitis
AN 43.1 Describe and demonstrate the movements with muscles producing the movements of 9 184
atlantooccipital joint and atlantoaxial joint
AN 43.2 Identify, describe and draw the microanatomy of pituitary gland, thyroid, parathyroid gland, 149, 158, 160,
tongue, salivary glands, tonsil, epiglottis, cornea, retina 222, 261, 300,
329, 331
AN 43.3 Identify, describe and draw microanatomy of sclero-corneal junction, cochlea- organ of corti 18, 19 322, 330
AN 43.4 Describe the development and developmental basis of congenital anomalies of face, palate, 81, 158, 257,
tongue, branchial apparatus, pituitary gland, thyroid gland and eye 222, 305
335, 356
AN 43.5 Demonstrate:
1) Testing of muscles of facial expression, extraocular muscles, muscles of mastication 73, 127, 235
2) Palpation of carotid arteries, facialartery, superficial temporal artery 75, 112
3) Location of internal and external jugular veins 66
4) Location of hyoid bone, thyroid cartilage and cricoid cartilage with their vertebral levels 99-100
AN 43.6 Demonstrate surface projection of: Thyroid gland, parotid gland and duct, pterion, common 20 342
carotid artery, internal jugular vein, subclavian vein, External jugular vein, facial artery in
the face and accessory nerve
AN 43.7 Identify the anatomical structures in: 20 347
1) Plain X-ray skull
2) AP view andlateral view
3) Plain X-ray cervical spine-AP and lateral view
4) Plain xray of paranasal sinuses
AN 43.9 Identify anatomical structures in carotid angiogram and vertebral angiogram 20 348, 349

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Volume 3

Head and Neck

Head and Neck

Ex-Professor and Head, Department of Anatomy

Pragati Sheel Mittal MBBS MS Mrudula Chandrupatla MBBS MD

CBS Publishers & Distributors Pvt Ltd

Eight eBook Edition: 2020

Published by Satish Kumar Jain and produced by Varun Jain for

Lots of tables for the muscles are provided

Tables for muscles acting on joints are given

Handle me with little love and care

You dissect me, cut me, section me

Couldn't dream of a fridge for cold water

When my parts are buried post-dissection

If not as skeletons as loose bones

I won't leave you, even if you pass anatomy

One humble request I'd make

Preface to the Eighth Edition vii

1. Introduction and Osteology 3 Maxilla 36

Seventh Cervical Vertebra 55 Skin 84

Clinicoanatomical Problem 112 7. Submandibular Region 142

Dissection 173 Frequently Asked Questions 205

Frequently Asked Questions 229 Pharynx 257

Clinical Anatomy 283 External Acoustic Meatus 310

1. Introduction and Osteology 3

INTRODUCTION blood vessels. Brain is the highest seat of intelligence.

AN 26.1 Demonstrate anatomical position of skull, identify and 3. Nasal (2)

Head and Neck

Table 1.1: The emissary veins of the skull

Fig. 1.3: Fontanelles of skull

• Fontanelles are sites of growth of skull, permitting

• If fontanelles fuse early, brain growth is stunted; NORMA OCCIPITALIS

Head and Neck

Fig. 1.5: Norma occipitalis

occipitofrontalis muscle laterally (Fig. 1.6). In case frontonasal suture.

Head and Neck

2 The procerus muscle arises from the nasal bone near

Head and Neck

5 Sphenoid Zygomatic Arch or Zygoma

4 The lateral ligament of the temporomandibular joint

Head and Neck

2 The pterygoid process projects downwards from the

Head and Neck

nuchal line (occasionally).

Head and Neck

minor, and laterally to the rectus capitis posterior

Head and Neck

Fig. 1.15a: Structures related to the foramen lacerum

Fig. 1.16a: Structures passing through foramen magnum

16 The jugular foramen transmits the following structures:

Table 1.2: Diploic veins

Head and Neck

INTERNAL SURFACE OF CRANIAL VAULT Floor

anterior cranial fossa from the orbit. It supports the

Head and Neck

Fig. 1.19: Features of the middle cranial fossa

Head and Neck

Fig. 1.20: Features of the posterior cranial fossa

Anterior Cranial Fossa foramen, hypoglossal canal, and posterior condylar