Week 7

The pterygopalatine fossa

and its communications
• The structure of the
orbits
• The extrinsic muscles of
the eye
• The innervation and blood supply of the orbits

The pterygomaxillary fissure

a slit or fissure can be seen between the
posterior surface of the maxilla and the
pterygoid plates of the sphenoid bone. This
fissure leads into a fossa, or hollow area, called the
pterygopalatine fossa where the maxilla forms the
anterior wall, the palatine bone forms the medial wall
and part of the posterior wall, and the anterior part
of the pterygoid plates form the rest of the posterior
wall. The infratemporal fossa is continuous with the
pterygopalatine fossa via the pterygomaxillary fissure.
Palatine bone,L-shaped bone with a vertical plate and horizontal
plate. It has three processes; orbital and sphenoidal processes
separated by sphenopalatine notch (form sphenopalatine foramen
with sphenoid bone); and a pyramidal process or tubercle.
There are eight passageways that lead directly to and from the fossa, communicates with the following:
- The middle cranial fossa via foramen rotundum - The vault (roof) of the pharynx via the
pharyngeal (palatovaginal) canal - Foramen lacerum via the pterygoid canal
- The infratemporal fossa via the
pterygomaxillary fissure -
The soft palate via the lesser palatine canal
- The hard palate via the greater palatine canal
- The face via the inferior orbital fissure,
infraorbital groove, canal and foramen
- The nose via the sphenopalatine foramen
- The molar teeth via the posterior superior
alveolar foramina

Contents,
Nerves
The maxillary nerve passes through foramen rotundum and gives off several branches in the fossa
including: the zygomatic nerve which enters the orbit via the inferior orbital fissure; roots to the
sphenopalatine ganglion which hangs off the maxillary nerve; one or two posterior superior alveolar
nerves. The maxillary nerve then continues on as the infraorbital nerve that appears on the face at the
infraorbital foramen. The sphenopalatine ganglion is one of the four parasympathetic ganglia in the head
and neck. Associated with the ganglion are – the nerve of the pterygoid canal formed by greater and deep
petrosal nerves; the pharyngeal nerve; the greater and lesser palatine nerves; the nasopalatine and the
posterior superior nasal nerves.
Vessels
The maxillary artery is divided into three portions : first part: posterior to lateral pterygoid muscle (five
branches), second part: within lateral
pterygoid muscle (five branches) and third
part: anterior to lateral pterygoid muscle
(six branches)
The sphenopalatine artery may need to be
ligated in cases of serious epistaxis
(nosebleed). The surgical approach to ligate
this vessel is via the canine fossa and
maxillary sinus. A window is cut in the
posterior wall of the sinus and then the
vessel is located by blunt dissection.

The structure of the orbits

The orbital cavities are
shaped like four-sided
pyramids and their
long axes are directed
backwards and
medially. Each orbit
has a roof, a floor,
medial and lateral
walls, a base (orbital
opening), and an
apex.
= Antero-laterally,
there is the deep
hollow lacrimal fossa
that contains the
lacrimal gland. = The
optic canal or
foramen. It connects
the orbit to the middle
cranial fossa and
contains the optic
nerve and the
ophthalmic artery.
= At the back, between the lesser and greater wings of
the sphenoid bone is the superior orbital fissure
which communicates with middle cranial fossa. It
transmits the oculomotor, trochlear and abducent
nerves, as well as terminal branches of the ophthalmic
nerve and veins.
= The inferior orbital fissure between the GWS and the
maxilla provide communication with the infratemporal
fossa and the pterygopalatine fossa and the maxillary
nerve runs across here.

Other features of the orbits include the trochlear fossa, the supraorbital notch, the anterior
and posterior ethmoidal foramina, and the zygomatico-facial and zygomatico-temporal
foramina. There are six muscles that enable the eyeball to be moved in various directions.
They are the extrinsic muscles of eyeball. Four of these muscles arise from a fibrous cuff
around the optic nerve (the annular tendon of Zinn). They are the superior, medial, inferior
and lateral recti muscles. There are two other muscles that are called the superior oblique
(found in the roof of the orbit) and the inferior oblique (found in the floor of the orbit just
lateral to the opening of the nasolacrimal canal).
The recti muscles insert into the sclera of the eye (the white part) just anterior to the
equator (about 6mm behind the cornea). The oblique muscles insert into the sclera just
posterior to the equator. The orbits are directed outwardly but the eyes look straight ahead
and the recti muscles follow the direction of the orbits. So the superior and inferior recti
muscles only act as true elevators and depressors when the eyeballs are lined up with the
orbital axis and the direction of the recti muscles. (LR6(SO4)3).
levator palpebrae superioris muscle passes forward and fans out to have broad
attachments into the skin of the upper eyelid, into the superior tarsal plate and also into
the superior fornix of the conjunctiva. It raises the upper eyelid also has some smooth
muscle fibres (involuntary) that are
supplied by sympathetic nerves.
Therefore, if denervation occurs,
drooping of the eyelid (ptosis) is a
consequence.
The superior and inferior tarsal plates
are crescent- shaped plates of dense
connective tissue that serve as the
framework for the eyelids. The
orbital septum is a sheet of fascia
that is attached to the periosteum of
the orbital margin and the tarsal
plates.
The trigeminal nerve, consists of
three divisions- ophthalmic,
maxillary and mandibular. The ophthalmic nerve passes through the superior orbital
fissure and travels into the orbit. Just before passing through the fissure it divides into
three main branches:
(a) Lacrimal nerve
This branch travels to the lacrimal gland and also to the skin of the eyelids and conjunctiva
(palpebral branch). The lacrimal gland lies in the upper lateral part of the orbit and has a
series of lacrimal ducts (6-12) that open into the superior fornix of conjunctival sac. Tears
pass across the eye, aided by action of the orbicularis oculi muscle, and flow into lacrimal
sac. They then run down into the nasolacrimal duct which opens in the nasal cavity.
(b) Frontal nerve
This branch passes over the top of the levator palpebrae superioris muscle and then divides
into two further branches: the supratrochlear nerve (located medially) innervates the skin
of the eyelids and the forehead. It goes above the trochlear of the superior oblique muscle,
hence its name. The supraorbital nerve (located laterally) innervates the skin of the eyelid,
forehead, scalp and mucoperiosteum of the frontal sinus.
(c) Nasociliary nerve
The nasociliary nerve gives branches to the ciliary ganglion (one of four parasympathetic
ganglia in head and neck region, along with otic, submandibular and sphenopalatine). It
also gives short ciliary nerves that pass to the eye and carry post-ganglionic
parasympathetic fibres to the sphincter pupillae and the ciliary muscle. There are also long
ciliary nerves that are sensory to the eyeball, except the retina, and also carry post-
ganglionic sympathetic fibres from the internal carotid plexus to the dilator pupillae
muscle.
Other branches include the ethmoidal nerves, the posterior ethmoidal nerve passes
through the posterior ethmoidal foramen and supplies the mucous membrane of the
ethmoidal and spenoidal sinuses. The anterior ethmoidal nerve leaves the orbit via the
anterior ethmoidal foramen, crosses above the ethmoidal sinuses, appears at the lateral
part of the cribriform plate, then runs forward under the dura mater. It descends through a
slit alongside the crista galli and gives internal nasal branches to the mucous membrane. It
then appears on the face between the nasal bone and the nasal cartilage as the external
nasal branch that supplies the skin of the lower half of the nose.
The infratrochlear nerve leaves the orbit below the trochlear and appears on the face
above the medial canthus (corner) of the eye. It supplies the skin of the eyelids and the
upper half of the external nose. Other nerves related to the orbits that we should mention
briefly are the optic nerve, the oculomotor nerve, the trochlear nerve and the abducent
nerve.
The optic nerve enters the orbit via the optic canal (foramen). It is surrounded by meninges
(dura, arachnoid, pia) and can be considered to be an extension of the brain. It runs into the
back of the eyeball and is the sensory nerve from the retina.
The oculomotor nerve (3rd cranial nerve) has upper and lower divisions. It enters the orbit
through the superior orbital fissure, between the two heads of the lateral rectus muscle. it
supplies the medial rectus, inferior rectus and inferior oblique muscles. It carries
parasympathetic fibres that pass to the ciliary ganglion (preganglionic) where they synapse.
The postganglionic fibres travel in the short ciliary nerves and reach the ciliary muscle and
the iris. They cause the ciliary muscle to contract thereby allowing us to focus on near
objects (accommodation). They also lead to contraction of the sphincter pupillae muscle
which reduces the size of the pupil.
The trochlear nerve is a very slender nerve that runs forward in the lateral wall of
cavernous sinus through the superior orbital fissure. It supplies the superior oblique
muscle.
The abducent nerve also runs forward through the cavernous sinus, through the superior
orbital fissure, and then supplies the lateral rectus muscle.

The

ophthalmic artery is a branch of the internal carotid artery. It enters the orbit through the
optic canal and gives a number of branches corresponding with the nerves. One very
important branch is the central artery of retina that runs with the optic nerve. It provides
the only direct arterial supply to the retina so if it is occluded it leads to blindness. The
ophthalmic artery enters orbit inside the arachnoid mater of the optic nerve initially then
pierces the arachnoid and the dura.
The ophthalmic veins include superior and inferior branches. The superior ophthalmic vein
begins in the anterior part of the orbit and communicates with the supraorbital veins and
supratrochlear veins. The inferior branch lies below the optic nerve and may communicate
with veins on the face. The ophthalmic veins drain back into the cavernous sinuses by
passing through the superior orbital fissure.
Pain receptors are free nerve endings found in epithelial tissues, including skin and oral
mucosa and in deeper structures, including ligaments, joint capsules and the pulps of teeth.
The neurons carrying pain sensations are classified as either A delta (fast responding
myelinated) and C-type (slower responding unmyelinated). The A delta fibres transmit the
initial sensation of sharp pain in response to a stimulus, whereas the C-type fibres transmit
the subsequent wave of dull pain.
The pathway for pain, temperature and crude touch from the body, excluding most of the
cranial region, is referred to as the spino-thalamic tract. The afferent fibres from receptors
for pain, temperature and crude touch in the limbs, trunk and neck are the peripheral
processes of first-order neurons whose cell bodies lie in the dorsal root ganglia of the spinal
nerves, and whose central processes enter the spinal cord via their dorsal roots. Here they
divide into ascending and descending branches which travel up or down the spinal cord for
one or two segments. These first-order neurons synapse with second-order neurons in the
dorsal horn of the spinal cord.
These second-order neurons cross the midline before passing up the spinal cord in the
spinothalamic tract, which is located in the ventro-lateral region of the white matter. These
tract fibres pass up the cord, then through the brainstem where they are referred to as the
spinal lemniscus (ribbon). They end by synapsing with third- order neurons in the ventral
posterior lateral nucleus (VPLN) of the thalamus. The third-order neurons then pass up
through the posterior limb of the internal capsule to the post-central gyrus of the cerebral
cortex.
The trigeminal nerve (cranial nerve V) carries most of the sensory information for pain,
temperature and crude touch from the cranial region, including the oral cavity and the teeth.
The cell bodies of the primary neurons are located in the trigeminal (semi-lunar) ganglion
and the central processes of these neurons enter the brainstem where they synapse with
second-order neurons, mainly in the spinal nucleus of V. The second-order neurons travel
upwards and cross over to the opposite side as a ribbon of fibres referred to as the trigeminal
lemniscus. They synapse in the ventro- posterior nucleus of the thalamus with third-order
neurons that then pass through the posterior limb of the internal capsule to reach the
sensory cortex.
The sensations of discriminative touch and proprioception arise from various receptors, eg.
Pacinian and Meissner's corpuscles, then travel in the peripheral and central processes of
first-order neurons. For the limbs, trunk and neck, the cell bodies of the first-order neurons
are located in the dorsal root ganglia of spinal nerves. The central processes of these neurons
enter the dorsal horn of the spinal cord where they may synapse with inter-neurons for
spinal reflexes, or they travel up the cord in the dorsal white column to the medulla
oblongata. These fibres do not cross over in the spinal cord but ascend on the same side of
the spinal cord as they entered. New fibres are added to the lateral side of the column as it
passes up the spinal cord. Fibres from the lower part of the body form a medial fasciculus
gracilis, while those from the upper part of the body form the lateral fasciculus cuneatus.
These fasciculi synapse with second-order neurons in the nucleus gracilis and the nucleus
cuneatus respectively which are located in the medulla. The axons of the second-order
neurons sweep downwards initially then cross the midline before travelling up to the
thalamus (they are referred to as internal arcuate fibres initially, then they form a band of
ascending fibres referred to as the medial lemniscus). The second-order neurons synapse at
the VPLN of the thalamus, then third-order neurons travel on through the posterior limb
of the internal capsule to the sensory cortex.
Proprioception has both conscious and subconscious components. The conscious pathway
travels upwards via the thalamus to the cerebral cortex, thereby enabling us to describe the
position of our limbs and mandible, whereas the subconscious pathway travels to the
cerebellum via the spinocerebellar tract and allows us to walk and perform a wide variety of
tasks without having to think about them.
The spinocerebellar tract is essentially ipsilateral, so lesions of the cerebellum tend to
produce problems on the same side of the body. The cerebellum connects to the brainstem
via three peduncles (stalks). These are the superior, middle and inferior peduncles that
connect to the midbrain, pons and medulla respectively.
The trigeminal nerve is the main sensory cranial nerve supplying the face and oral cavity but
the pathways for fine discriminative touch and for proprioception are separated.
Fine touch from the face and oral cavity travels in the peripheral processes of first- order
neurons whose cell bodies are located in the trigeminal ganglion. The central processes of
these first-order neurons enter the brainstem to synapse in the main sensory nucleus of V
(also referred to as the pontine nucleus). The second-order neurons then pass up in the
trigeminal lemniscus to the VPMN of the thalamus.
Some fibres cross the midline and some stay on the same side. The third-order neurons travel
on through the internal capsule to the sensory cortex.
The pathway for proprioception involving the trigeminal nerve is unusual in that the cell
bodies of the relevant first-order neurons are located in a separate nucleus, referred to as the
mesencephalic nucleus, within the brainstem. It appears that proprioceptive information from
the muscles of mastication, TMJ and periodontal ligament travels to the mesencephalic
nucleus in peripheral processes of first-order neurons. The central processes of these neurons
then connect with neurons in the reticular formation which have connections with the motor
nucleus of V to enable reflex actions. Second-order fibres also pass upwards in the
trigeminal lemniscus to the thalamus, and from there third-order neurons travel to the
sensory cortex.
The tracts that arise from the cerebral cortex include:
 corticospinal tracts that pass down from the motor cortex to synapse with neurons whose
cell bodies are in the ventral horn of the grey matter of the spinal cord.
 corticonuclear (corticobulbar)tracts that pass from the motor cortex to synapse with
neurons whose cell bodies are in motor nuclei of the cranial nerves.

The corticospinal tracts are often referred to as the pyramidal tracts as they form prominent
bulges (pyramids) on either side of the midline on the ventral surface of the medulla. The
corticonuclear tracts are also usually included within the pyramidal system. These pathways
are involved in skilled voluntary movements of the limb muscles (corticospinal) or orofacial
muscles (corticonuclear). They synapse on interneurons that in turn synapse mainly with
alpha motor neurons which travel to muscle fibres.
There are two main neurons in the descending motor pathways: the upper motor neurons
(UMNs) arise in the motor area of the cerebral cortex (pre-central gyrus), and the lower
motor neurons (LMNs) arise in the ventral horn of the spinal cord or the motor nuclei of
cranial nerves.
Upper and lower motor neuron injuries lead to different signs and symptoms: Upper motor
neuron defect Lower motor neuron defect
spastic paralysis (initially flaccid) flaccid paralysis
no significant muscle atrophy significant atrophy
fasciculations and fibrillations not present fasciculations and fibrillations
hyperreflexia (reflexes lost initially) hyporeflexia

Apart from the motor tracts that commence at the level of the motor cortex, there are other
descending tracts that arise from subcortical centres. These include the following tracts:
rubrospinal, vestibulospinal, reticulospinal, tectospinal. These pathways (often referred to as
extrapyramidal) are involved mainly in posture, balance, locomotion, as well as
non-skilled movements involving proximal limb muscles. These fibres synapse with
interneurons that in turn synapse mainly with gamma motor neurons which travel to muscle
spindles.
The separation of the motor system into pyramidal and extrapyramidal is essentially
artificial, as the various motor pathways work together as a functionally and anatomically
integrated unit. Fibres from the primary motor cortex (pre-central gyrus) travel downwards
via the corona radiata, through the internal capsule, and then the cerebral peduncles of the
midbrain.
The corticospinal tract is broken up into many bundles as it passes downward through the
basal part of the pons. The fibres come together again in the medulla to form the pyramids.
At the lower end of the medulla approximately 80% of fibres cross over (decussate) then run
vertically down as the lateral corticospinal tract.
Approximately 20% stay on the same side and form the anterior corticospinal tract.

The corticonuclear (bulbar) tract travels down through the brainstem and diminishes in size
as bundles branch off to go to synapse in the motor nuclei of the cranial nerves. The
majority of the corticobulbar fibres cross the midline to the opposite side but there are also
many ipsilateral connections. The only exceptions are the lower half of the motor nucleus
of the facial nerve (VIIth cranial nerve) and the part of the motor nucleus of the hypoglossal
nerve (XIIth cranial nerve) which supplies the genioglossus muscle – in both of these cases
there is only contralateral innervation.
The basal ganglia are a collection of subcortical grey matter nuclei which include:
 the corpus striatum (this includes the caudate nucleus and putamen)
 the subthalamic nucleus
 the substantia nigra of the midbrain

Disorders affecting the neurotransmitters that are involved in the pathways between these
nuclei can lead to motor problems, eg. Parkinson's disease and chorea.
Reticular formation
The reticular formation is a region in the brainstem that has an important role in determining
the level of consciousness and it is also important in controlling voluntary muscle activity. It
has connections with numerous regions of the brain, including the cerebellum. Sensory
information comes from the spinal lemniscus, the spinal nucleus of V, ascending fibres from
the spinal cord (spinoreticular), as well as visual and olfactory centres. From the reticular
formation, fibres travel to
the thalamus and the hypothalamus, and then to the lower motor neurons in the ventral horns of the grey matter
of the spinal cord or to the lower motor neurons of the cranial nerves. The reticular formation also includes vital
centres associated with the respiratory and cardiovascular systems.
Cerebellum
The cerebellum plays an important role in the control of muscle activity. It has connections
with the cerebral cortex, proprioceptive receptors in muscles, tendons and joints, and other
nuclei in the brain. Via its connections with the motor cortical areas, the cerebellum helps to
ensure that voluntary movements are performed smoothly and precisely.
The combination of signs and symptoms displayed by Mr Mydulloso is referred to as medial
medullary syndrome. The stroke probably involved occlusion of a branch of the anterior
spinal artery leading to damage of the neural tissue in the medial part of the medulla
oblongata on the right side, above the decussation of the pyramids.
In contrast, Emilia’s problems lie in the spinal cord, although the lesion there is obviously
increasing in size and extending further up the spinal cord.