INTRODUCTION TO THE HEAF AND NECK

DESCRIBE THE BONY STRUCTURES OF THE FACE AND THEIR RELATIONSHIPS

Cranium
 This is the skeleton of the head. It is composed of 22 bones.
 A series of bones forms its 2 parts: neurocranium and
viscerocranium
o The neurocranium is the bony case of the brain and
its membranous coverings (cranial meninges)
 Th neurocranium contains proximal parts of the cranial nerves
and vasculatures of the brain
 The neurocranium in adults is formed by a series of
8 bones: 4 singular bones centered on the midline
(frontal, ethmoidal, sphenoidal, and occipital), and
2 sets of bones occurring as bilateral pairs (temporal
and parietal)

o The viscerocranium (aka facial skeleton) develop in the

mesenchyme of the pharyngeal arches.
 It forms the structure and support for soft tissues of the face
 It consist of 15 irregular bones: 3 singular bones centered on the midline (mandible, ethmoid, and vomer), and 6
bones occurring at the bilateral pairs (maxillae; inferior nasal conchae; and zygomatic, palatine, nasal, and lacrimal
bones)

Bones of the neurocranium

 Frontalforehead, roof orbit, median prominence glabella
 2 parietal
 Sphenoidalbody of which houses sphenoid sinus; greater and lesser wings, pterygoid process
 Occipitalforamen magnum conduit for spinal cord
 2 temporallateral skull, houses ear
 Ethmoidalminimal contribution to neurocranium – between orbits, cribriform plate, and ethmoidal cells
 Temporal bone

Remember to identify
these bone landmarks:
Mastoid Process
External Acoustic Meatus
Styloid Process
Zygomatic Arch
Border with Sphenoid
Bone

Sphenoid bone

Anterior view Posterior view

Sutures of the skull (fibrous joints)
 Sutures are immovable strong fibrous joints between
the bones of the skull.
o The coronal suture joins the frontal bone and
the two parietal bones and course in the coronal plane
o The sagittal suture joins the paired parietal bones and
courses in the sagittal plane
o The lambdoid suture joins the parietal bones with the
occipital bone

Clinical importance
Fracture of pterion
 Fracture of the pterion can be life-threatening because it overlies the frontal
branches of the middle meningeal vessels, which lie in grooves on the
internal aspect of the lateral wall of the calvaria.
o A hard blow to the side of the head (e.g., during boxing) may fracture
the thin bones forming the pterion, producing a rupture of the frontal
branch of the middle meningeal artery or vein crossing the pterion
o Pterion is formed by 4 bones temporal (squamous part), frontal, sphenoid, and parietal bones.

Epidural hematoma
 Blood from torn branches of a middle meningeal artery collects between the external periosteal layer of the dura and the
calvaria.
 The extravasated blood strips the dura from the cranium. Usually this follows a hard blow to the head and forms an extradural
(epidural) hematoma.

Bones of the viscerocranium

 Maxillait is the greatest part of the upper facial skeleton; it forms the upper jaw
 Nasal and lacrimal bones
o Nasion is the bridge of the nose at intersection of nasal and frontal bones
 Zygomatic archthe arch articulates with the zygomatic process of the temporal bone
 Palatine
o It articulates with the maxilla, vomer, inferior nasal concha, and ethmoid bone
 o It is a thin, fragile bone
o It forms part of the hard palate and floor of the nasal cavity
o It is part of the roof of the oral cavity
o It contributes to the Pterygopalatine fossa

 Mandibleforms the skeleton of the lower jaw

o It articulates with the cranium via the temporomandibular joint
(movable) not by sutures
o The ramus and coronoid process provide attachment for muscles of
mastication
o It contains the mental and mandibular foramen

 Ethmoid bonecontributes to viscerocranium and minimally to the

neurocranium
o Sometimes, it is not counted with the other bones of the face
o It is a pneumatized bone

Pneumatized bones
 Several bones of the cranium (frontal, temporal, sphenoid, and ethmoid bones) are pneumatized bones.
 These bones contain air spaces (air cells or large sinuses), presumably to decrease their weight.
 The total volume of the air spaces in these bones increases with age.

Vomer
 It is an unpaired (plowshare) bone of trapezoidal shape that forms
a major part of the bony nasal septum
 It separates the posterior nasal openings (choanae)
Base of the skull
 Occipital condyle – articulate with superior facets of Maxilla
C1 atlas Palatine
 Pharyngeal tubercle – attachment site of raphe of the Zygoma
pharynx
Vomer
 Choanae – posterior nasal apertures, opening between
Sphenoid
 nasal cavity and nasopharynx,
Occipital
 Hard Palate – made up of palatine processes of maxillae
Temporal
(anteriorly) and the horizontal Plate of the palatine bones
(post) Parietal
 Incisive Fossa

Cranial foramina

Foramina/Apertures Contents
Anterior cranial fossa
Foramen cecum Nasal emissary vein (in a small percentage of population postpartum)
Cribriform foramina in
Axons of olfactory cells in olfactory epithelium that form olfactory nerves
cribriform plate
Anterior and posterior
Vessels and nerves with same names
ethmoidal foramina
Middle cranial fossa
Optic canals Optic nerves (CN II) and ophthalmic arteries
Ophthalmic veins; ophthalmic nerve (CN V1); CN III, IV, and VI; and
Superior orbital fissure
sympathetic fibers
Foramen rotundum Maxillary nerve (CN V2)
Foramen ovale Mandibular nerve (CN V3) and accessory meningeal artery
Foramen spinosum Middle meningeal artery and vein and meningeal branch of CN V3
Foramen laceruma Deep petrosal nerve and some meningeal arterial branches and small veins
Groove or hiatus of
Greater petrosal nerve and petrosal branch of middle meningeal artery
greater petrosal nerve
Posterior cranial fossa
Medulla and meninges, vertebral arteries, CN XI, dural veins, anterior and
Foramen magnum
posterior spinal arteries
CN IX, X, and XI; superior bulb of internal jugular vein; inferior petrosal and
Jugular foramen sigmoid sinuses; and meningeal branches of ascending pharyngeal and
occipital arteries
Hypoglossal canal Hypoglossal nerve (CN XII)
Condylar canal Emissary vein that passes from sigmoid sinus to vertebral veins in neck
Mastoid emissary vein from sigmoid sinus and meningeal branch of occipital
Mastoid foramen
artery

DESCRIBE THE ACTIONS AND INNERVATIONS OF THE MUSCLES OF FACIAL EXPRESSION

Muscles of facial expression
 There are 16 of them
 They originate from the skull
 They insert in the skin
 They are all innervated by the facial nerve (CN VII) via its posterior auricular branch (1) or via the temporal (2), zygomatic
(3), buccal (4), marginal mandibular (5), or cervical branches of the parotid plexus.
o The action is to move the skin which changes facial expression to convey mood motor root of CN VII supplies the muscles of
facial expression, including the superficial muscle of the neck (platysma), auricular muscles, scalp muscles, and certain other
muscles derived from mesoderm in the embryonic second pharyngeal arch

Muscles of scalp and forehead

 Occipitofrontalis is a flat digastric muscle with occipital and
frontal bellies that share a common tendon, the epicranial
aponeurosis.
o The frontal belly elevates eyebrows and wrinkles skin of forehead;
protracts scalp (indicating surprise or curiosity)

Muscle of orbital opening

  Orbicularis oculi protects the eyeballs from injury and excessive light
 The muscle closes the eyelids by narrowing the palpebral fissure
 It has 3 parts:
o Palpebralgentle blinking
o Lacrimalcourses behind lacrimal sac and aids in drainage of tears
(deep part of muscle)
o Orbital – winking or squinting to present glare or dust
 Corrugator supercilii is located deep to the orbicularis oculi
o draws the eyebrows medially

Muscles of nose and ears

 Procerus wrinkles skin over the nose
 Nasalis and levator labii superioris alaquae nasi flare the nostrils
o Clinical applicationflaring of the nostrils. The nasalis muscle can
be used because of their diagnostic value. True nasal breathers can
flare the nostrils distinctly.
 Chronic nasal obstruction may diminish the flaring ability
from disuse. In children nasal flaring may indicate respiratory
distress.

Muscles of mouth, lips, and cheeks

 Orbicularis orisforms oral sphincter that closes the mouth (Tonus
closes oral fissure).
o Phasic contraction compresses and protrudes lips (kissing)
 Levator labii superioris and levator anguli orisraise upper lips
 Zygomaticus major and minorraise corners of lips (SMILE)
 Risoriusdraws corners of lips laterally
 Buccinatorcompresses the check when whistling, blowing, or sucking (trumpeter); holds food in the mouth while chewing

Neck
 Platysmatenses the skin of the neck
DIFFERENTIATE THE NERVES (AND BRANCHES) THAT INNERVATE STRUCTURES OF THE FACE AND SCALP
Trigeminal nerve (CN V)
 Originates from 3 sensory ganglia (merge to form trigeminal ganglion) and one motor nucleus
 4 parasympathetic ganglia are associated with the trigeminal nerves
 The trigeminal has 3 divisions:
1. Ophthalmic nerve (CN V1)
 It passes through the lateral wall of the cavernous sinus and enters
into the orbit through superior orbital fissure
 Its supraorbital and supratrochlear branch supply the anterior scalp
 Gives off the lacrimal nerve which supplies skin of upper eyelid
 Gives off the external nasal nerve which supplies all of nose except
alae and infratrochlear – bridge of nose
 Gives off the nasociliary branch– sensory to cornea
 Injury results in a loss of sensation in the skin of the forehead,
bridge of the nose and anterior scalp. Since it provides
sensory innervation to the cornea via the nasocilliary branch, injury
may abolish the corneal reflex.

2. Maxillary nerve (CN V2)

 It passes through the lateral wall of the cavernous sinus (just inferior to
the ophthalmic nerve) and through the foramen rotundum into the pterygopalatine fossa
 Zygomaticofacial and zygomaticotemporal branch supply skin along zygomatic arch
 Infraorbital nerve exits the maxilla through the infra-orbital foramenskin of maxillary region, lower eyelid, and upper
lip, alae of nose
 Injury may result in a loss of sensation in the skin over the maxilla, maxillary teeth, and palate

3. Mandibular nerve (CN V3)

 It passes through the foramen ovale into the infratemporal fossa
 Buccal nerveskin covering the mandible that is on the surface of the buccinator muscle supplying the cheek
 Mental nerve (branch of inferior alveolar nerve) exits through the mental foramen and supplyskin of the lower lip
 Auriculotemporallargest cutaneous branch, skin of lateral aspect of the scalp and the lateral face, anterior to the
external acoustic meatus, carry post synaptic parasympathetic fibers from CN IX to parotid gland
  Injury may result in a loss of sensation in the mandibular skin and teeth as well as the anterior two-thirds of the tongue. Its
motor division innervates the muscles of mastication (e.g., temporalis and masseter muscles), the patient may experience
weakness in chewing and deviation of the mandible on the side of the lesion when the mouth is opened

 SummaryMandibular nerve (CN V3) gives rise to several terminal branches in the
infra-temporal fossa: buccal nerve, inferior alveolar nerve, auriculotemporal nerve
and lingual nerve.

 The inferior alveolar nerve, a branch of V3, travels through the mandibular foramen
and mandibular canal. Within the mandibular canal, the inferior alveolar nerve forms
the inferior dental plexus, which innervates the lower teeth.

 A major branch of this plexus, the mental nerve, supplies the skin and mucous membranes of the lower lip, skin of the chin, and
the gingiva of the lower teeth.

 In some dental procedures which require a local anaesthesia, the inferior alveolar nerve is blocked before it gives rise to the
plexus.

 The anaesthetic solution is administered at the mandibular foramen, causing numbness of area supplied by the inferior alveolar
nerve. The anaesthetic fluid also spreads to the lingual nerve which originates near the inferior alveolar nerve, causing
numbness of the anterior 2/3 of the tongue
NB = Unlike the ophthalmic (V1) and
Clinical applicationTrigeminal Neuralgia (tic douloureax) maxillary (V2) nerves, which are
 It is a sensory disorder of the sensory root of CN V. purely sensory, the mandibular
 It is characterized by sudden attacks of excruciating, lightning-like jabs of facial pain. nerve (V3) is both motor and
sensory
 It is paroxysmal (comes and goes) pain along course of CN V
 Dividing the nerve at the trigeminal ganglion may relieve pain

Facial nerve (CN VII)

 The facial nerve is associated with the derivatives of the second pharyngeal arch:
 It motor division supplies muscles of facial expression, posterior belly of the digastric, stylohyoid and stapedius muscles.
 Its sensory branch supplies a small area around the concha of the external ear (also known as the intermediate nerve)
o Special Sensory – provides special taste sensation to the anterior 2/3 of the tongue via the chorda tympani nerve
 o Parasympathetic (general visceral efferent) – supplies many of the glands of the head and neck, including:
 Submandibular and sublingual salivary glands.
 Nasal, palatine, and pharyngeal mucous glands.
 Lacrimal glands.

Facial nerve path

 The facial nerve exit the skull through the stylomastoid foramen in the
temporal bone
 First branch posterior auricular nerve – occipitalis, important to dogs,
sensory to concha
 Branches to digastric and stylohyoid mm MOTOR root continues anteriorly and
inferiorly into the parotid gland and then branches
 It DOES NOT supply the parotid gland

Motor innervation to muscles of facial expression

 The facial nerve via its posterior auricular branch (1) or via the temporal (2), zygomatic (3), buccal (4), marginal
mandibular (5), or cervical (6) branches of the parotid plexus.

*NB = Look textbook for chart of facial nerve branches

Clinical applicationparalysis of facial muscles

 Injury to the facial nerve (CN VII) or its branches produces paralysis of some or
all facial muscles on the affected side (Bell palsy).
 The affected area sags, and facial expression is distorted, making it appear passive or
sad.
 The loss of tonus of the orbicularis oculi causes the inferior eyelid to evert
(fall away from the surface of the eyeball). Thus, lacrimal fluid is not spread over the cornea,
preventing adequate lubrication, hydration, and flushing of the surface of the cornea.
 Loss of buccinator and orbicularis oris can affect eating as food will not stay in the mouth
easily or it may gather in the cheeks
 Other effect such as drooling, inability to whistle or blow a wind instrument
Glossopharyngeal nerve (CN IX)
 The glossopharyngeal nerve leaves the skull through the jugular foramen
 Embryologically, the glossopharyngeal nerve is associated with the derivatives of the third pharyngeal arch.
 Sensory: Innervates the oropharynx, carotid body and sinus, posterior 1/3 of the tongue, middle ear cavity, and Eustachian
tube.
 Special sensory: provides taste sensation to the posterior 1/3 of the tongue.
 Motor: Innervates the stylopharyngeus muscle of the pharynx.
 Parasympathetic (GVE): provides parasympathetic innervation to the parotid gland.
o CN IX sends presynaptic parasympathetic (secretomotor) fibers to the otic ganglion via a convoluted route; postsynaptic
fibers pass from the ganglion to the parotid gland via the auriculotemporal nerve

DESCRIBE THE ANATOMY OF THE PAROTID GLAND, ITS RELATIONSHIPS & INNERVATION

Parotid Gland and Duct

 The parotid gland is covered in dense, investing fascia, deep cervical fascia
 Embedded in the gland:
1. Parotid lymph nodes
2. External carotid artery and peri-arterial plexus
3. Retromandibular vein
4. Parotid plexus of the facial nerve-divides into branches within the gland
 DOES NOT INNERVATED THE GLAND
 The parotid duct travels over the masseter muscle (muscle of mastication,)
and pierces the buccinator and empties into the oral cavity opposite the
2nd maxillary molar tooth

Innervation of the parotid gland

 Parasympatheticsincrease secretions
 Parasympathetic innervation is from glossopharyngeal nerve (CN IX)
o Preganglionic fibers will enter the otic ganglion where they synapse with postganglionic fibers
 o Postganglionic fibers exist the otic ganglion and travel within the auriculotemporal nerve (branch of mandibular nerve
(CN V3) to the parotid gland
 Sympatheticsreduce secretions
o The preganglionic fibers originate from T1-T4
 They enter the superior cervical ganglion where they synapse with the postganglionic fibers
o Postganglionic – carotid plexus
****confirm whether they enter the carotid plexus

DESCRIBE THE ARTERIAL SUPPLY AND VENOUS DRAINAGE AND LYMPH DRAINAGE OF FACE, HEAD, AND SCALP

 The common carotid divides into internal and external arteries

 The external carotid is primary blood supply to the face and scalp, and it gives off the following branches
o Facial
 This is the major vessel supplying the face.
 It curves around the inferior border of the mandible just
anterior to the masseter, where its pulse can be felt, the
facial artery then enters the face
 It passes along the side of the nose and terminates as the
angular artery at the medial corner of the eye.
o Occipital
o Posterior Auricular
o Superficial temporal
o Transverse facial

 Branches of facial artery include

o Inferior labialsupplies the lower lip;
o Superior labialsupplies the upper lip and also provide
a branch to nasal septum
o Lateral nasalsupplies lateral and dorsum of the nose
o Angular (terminal branch)

 The internal carotid contributes to blood supply to orbital region and

 forehead via two major branches
o supraorbital and supratrocheal arteries
o They supply muscles and skin of forehead and scalp and
superior conjunctiva

Veins of the face and scalp

 The facial vein is the primary superficial drainage of the face.
 Tributaries of the facial vein include the deep facial vein, which drains the pterygoid venous plexus of the infratemporal
fossa
o The facial vein drains directly or indirectly into the internal jugular vein (IJV)
 The retromandibular vein is a deep vessel of the face formed by the union of the superficial temporal vein and the maxillary
vein, the latter draining the pterygoid venous plexus.

 The venous drainage of the superficial parts of the scalp is through the accompanying veins of the scalp arteries, the supra-
orbital, and supratrochlear veins.

 The superficial temporal veins and posterior auricular veins

drain the scalp anterior and posterior to the auricles, respectively.
 The occipital veins drain the occipital region of the scalp.
 Venous drainage of deep parts of the scalp in the temporal
region is through deep temporal veins, which are tributaries
of the pterygoid venous plexus.

Clinical applicationDanger zone of the face

 Unlike other systemic veins, the facial and superior ophthalmic veins
lack valves. Therefore, the medial angle of the eye, nose, and middle
upper lips form a triangular area of potential danger in the face.

 The blood in this region usually drains inferiorly via the facial vein.

 However, blood can also drain superiorly through the facial vein to the superior ophthalmic vein to the cavernous sinus.
Therefore, an infection of the face may spread to the cavernous sinus resulting in a cavernous sinus thrombosis or meningitis.
Textbook The facial vein makes clinically important connections with the cavernous sinus through the superior ophthalmic vein,
and the pterygoid venous plexus through the inferior ophthalmic and deep facial veins. Because of these connections, an infection
of the face may spread to the cavernous sinus and pterygoid venous plexus

SCALP
 This is a multilayered structure with layers that can be defined by the words itself.
o Sskin
 Contains many sweat and sebaceous glands
 Hair follicles
o Cconnective tissue
 It is a dense connective tissue and highly vascular and holds blood vessels open
 Lots of bleeding
o Aaponeurosis
 Tendinous attachment of occipitofrontalis
o Lloose connective tissue
 It separates the aponeurotic layer from the pericranium.
 Because of its consistency, infection can spread quickly through it
o Ppericranium or periosteum
 Infection from scalp can spread into the bone or inside the cranial vault via emissary veins

Lymphatics of the head and neck

 There are no lymph nodes in the face
 The only lymph nodes in scalp are parotid/buccal-which drain lateral face and scalp including eyelids
 Lymph from face, scalp, and neck drains into the superficial cervical lymph nodes
o Superficial lymphatic vessels accompany veins

Lymphatics of the lips

 Lymph from upper lip drain into submandibular
 Lymph from middle lower lip drain into ipsilateral submental
 Lymph from lateral lower lip drain into bilateral submandibular nodes
Deep cervical nodes
 All lymphatic vessels of the head and neck drain directly or indirectly into the deep cervical nodes
 Deep lymphatic vessels follow arteries
 Chain of nodes along the Internal Jugular Vein
o They drain into jugular lymphatic trunks
 Left  thoracic duct
 Right Brachiocephalic V;
 Since lower lip drains to both, it can reach both left and right lymphatic ducts with different clinical outcomes
 Example: bilateral neck dissections instead of one side only

Textbook
 Lymph from the lateral part of the face and scalp, including the eyelids, drains to the superficial parotid lymph nodes.
 Lymph from the deep parotid nodes drains to the deep cervical lymph nodes.
 Lymph from the upper lip and lateral parts of the lower lip drains to the submandibular lymph nodes.
 Lymph from the chin and central part of the lower lip drains to the submental lymph nodes.

Other important information

Nerves and their branches

QUESTIONS
A 4-year-old child was brought to the emergency room by the parents for a complication of otitis media and infection of the mastoid
process leading to spontaneous perforation of the otic membrane. The child demonstrates several facial deficits. On examination, the
child is unable to close the right eye and food collects in the right oral vestibule. Which one of the following nerves have been affected
by these complications?
A. Facial
B. Glossopharyngeal
C. Vagus
D. Maxillary division of the trigeminal nerve
E. Mandibular division of the trigeminal nerve

A patient presents to the oncologist for a biopsy of a growth on his lower lip that has been present for several months. The patient has a
history of tobacco use and a recent unplanned weight loss of 15 pounds. Surgical excision and neck dissection is planned for treatment.
Which one of the following lymph nodes is most likely the first to be involved?
A. Occipital
B. Parotid
C. Retropharyngeal
D. Jugulodigastric
E. Submental

A teenager presents with a painful cavity involving one of the mandibular molar teeth. Which one of the following nerves would be
dentist need to anesthetize to treat the cavity?
A. Lingual
B. Inferior alveolar
C. Buccal
D. Mental
E. Mylohyoid
b

A child is brought to the emergency room with a severe infection of the mastoid process of the temporal bone after an untreated ear
infection. Complications of this infection have led to Bell’s palsy. On examination, an accumulation of saliva in the vestibule of the oral
cavity and dribble from the corner of the mouth is noted. Which of the following muscles is most likely paralyzed?
A. Zygomaticus major
B. Orbicularis oculi
C. Levator plaplebrae superiorris
D. Buccinator
E. Orbicularis oris

A patient presents with an abcess immediately lateral to the nose after a dermatology procedure to inject fillers into the face. Which one
of the following veins is as risk of leading to a serious infection of the cavernous sinuses since it drains the area and has no valves?
A. Superficial temporal
B. Retromandibular
C. Facial
D. Supraorbital
E. Supratrochlear

A patient involved in a head-on collision is evaluated for a head injury. The corneal reflex is tested and found to be normal. Which one
of the following nerves is responsible for the afferent limb of this reflex?
A. Frontal
B. Lacrimal
C. Nasociliary
D. Oculomotor
E. Optic
c