Head and Neck Anatomy: A. Arsalan, MD M. Martin MD, DMD October 4-5, 2017

Head and Neck Anatomy
A. Arsalan, MD
M. Martin MD, DMD
October 4-5, 2017
Outline
Layers of the face and neck
Nerves
Blood supply
Muscles
Nose
Orbit
Ear
Danger Zones
MCQ
Fascial Planes
Fascia in the Neck
Superficial
Encloses Platysma
Continuation of SMAS into
neck
Deep (3 layers)
Superficial/investing fascia
Pretracheal
Prevertebral (floor of posterior
triangle of neck)
Investing Fascia
Most superficial of the deep

cervical fascia
Splits to invest SCM and
Trapezius
Pretracheal Fascia
- Surrounds trachea, esophagus,

thyroid gland and infrahyoid
muscles
- Hyoid Bone to superior thorax,
merges into pericardium
Prevertebral Fascia
Surrounds vertebral column and
encloses all muscles lateral and
posterior to it
Fixed to base of skull, extends down
behind esophagus into posterior
mediastinum
Fuses with anterior longitudinal
ligament at T3
Forms sheath for brachial plexus
and subclavian vessels (posterior
triangle of neck)
Infection
Problem areas:
1. Compromise of prevertebral
fascia and drainage into
retropharyngeal space can
cause extension into the
posterior mediastinum and/or
pericardium
2. Between investing fascia and
pretracheal fascia -> anterior
mediastinum to pericardium
Fascia in the Face
Fascia Temporal Region
Separated from cheek and lower
face by the zygomatic arch
2 layers:
Superficial temporal fascia (aka
Temporoparietal fascia)
Deep temporal fascia (lies on
surface of temporalis muscle
Around zygomatic arch, facial n.
pierces through deep fascia to
become more superficial Zone of
Caution (more on this later)
Retaining Ligaments
Areas where skin and subcutaneous
tissue are relatively fixed to
underlying bone
Midface
Direct: periosteum to dermis (e.g.
Zygomatic and Mandibular)
Indirect: Coalesence between
superficial and deep fascia (e.g.
Parotid and Masseteric
Prevent descent of fat from moving
further -> signs of aging (e.g.
mandibular retaining ligament and
jowls)
Retaining Ligaments
Facial Nerve
Facial Nerve
Facial Nerve
Facial Nerve
Facial Nerve
Facial Nerve
Facial Nerve
Temporal
- 3-4 branches, innervate orbicularis
oculi, corrugators and frontalis
- After emerging from Parotid gland,
protected by deep facial fascia
(parotidomasseteric fascia)
- In temporal area, nerve is on
undersurface of superficial
temporal fascia
- Transition zone from deep ->
superficial extends over
zygomatic arch
10 cadaver heads
Average age 76.5 (range, 57-90
years)
Incision made in temporal scalp
between Temporoparietal and
deep temporal fascia until
sentinel v. identified
Sentinel v. important and
consistent landmark
Predicts zone of caution
preoperatively
Allows surgeon to operate
rapidly with confidence until
zone of caution is reached
Facial Nerve
Zygomatic + Buccal
- Emerging from parotid, under
deep facial fascia
(parotidomasseteric fascia) but
lying over masseter muscle
- Pierces deep fascia at anterior
edge of masseter (close to
masseteric cutaneous
ligaments)
- Orbicularis oculi, midfacial
muscles, orbicularis oris,
buccinator
Facial Nerve
Marginal Mandibular
- After exiting parotid gland, travels
downward (often below mandibular
border) into submandibular triangle
- Passes upward into face midway
between angle and mental protuberance
- Underneath the deep facial fascia
(parotidomasseteric fascia) initially but
found between platysma and deep
cervical fascia in submandibular triangle
- Lower lip depressors, depressor anguli
oris, mentalis, upper part of platysma
Facial Nerve
Cervical
- Primarily supplies platysma
- Passes behind angle of
mandible then travels
forward in subplatysmal
plane
Muscles of Facial Expression
Muscles of Facial Expression
Great Auricular N.
- Originates from cervical plexus
(C2 and C3)
- With head turned to opposite
side, found 6.5cm below external
auditory meatus
- 0.5 to 1cm posterior to the
external jugular vein
- Sensation to lower 2/3 of ear,
mastoid process and skin
overlying parotid gland
- Most commonly injured nerve
during rhytidectomy
Trigeminal N.
Sensory (3 branches)
- Ophthalmic (V1): 100% sensory
- Eye: cornea, ciliary body, iris, lacrimal gland,
conjunctiva
- Superior Orbital Fissure into orbit
- Maxillary (V2): 100% sensory
- Dura, forehead, lower eyelid, upper lip, gums,
teeth of upper jaw, mucous membrane, skin of
cheek and nose
- Foramen Rotundum to Pterygopalatine Fossa
- Mandibular (V3): Sensory+Motor
- Temple, auricle, lower lip, lower part of face,
teeth/gums of mandible, anterior tongue
- Muscles of mastication, tensor tympanum, tensor
veli palatini, mylohyoid, anterior belly digastric
- Foramen Ovale to Infratemporal Fossa
Muscles of Mastication
Triangles of the Neck
Anterior Triangle
Borders
- Superior: Inf. Border Mandible
- Lateral: Medial Border SCM
- Medial: Imaginary sagittal line
down midline
Structures
- CCA bifurcates
- Int. Jugular V.
Posterior Triangle
Borders
- Ant: Posterior border of SCM
- Post: Ant border of Trapezius
- Inf: Middle 1/3 of Clavicle
- Floor: Prevertebral Fascia
Structures
- Spinal Accessory N.
- Cervical Plexus (Phrenic N.)
- Trunks of Brachial Plexus
- Subclavian A. (b/t ant & mid scalene)
- External Jugular V.
Muscles of the Neck
Arterial Supply
External Carotid A.
Common Carotid A. bifurcates at level of
thyroid cartilage
External Carotid A. courses upward through
submandibular gland into parotid
Branches
- Superior Thyroid a.
- Ascending Pharyngeal
- Lingual
- Facial
- Occipital
- Posterior Auricular
- Maxillary
- Superficial Temporal
Internal Jugular V.
Course:
Begins at jugular foramen as a
continuation of the sigmoid (dural)
sinuses and runs in the carotid sheath,
uniting with the subclavian vein to form
the brachiocephalic vein.
Main Branches of IJV:
Pharyngeal
Facial drains face
Lingual drains area around tongue
Superior and Middle thyroid
Subclavian vein - continuation of the
axillary vein running over 1st rib
External jugular vein
Internal Maxillary A. Branches
Nose
Nose
The Orbit
The Orbit
External Ear
External Ear
A 35 year old woman is evaluated because of numbness of the upper helical rim of the left
ear 30 days after she underwent neurosurgical decompression to treat facial pain. Which of
the following nerves was most likely injured?
A. A) Auriculotemporal
B. B) Glossopharyngeal
C. C) Great Auricular
D. D) Lesser Occipital
E. E) Vagus
Option A
Knowledge of the innervation of the external ear is critical to the understanding of its
embryologic development, as well as in the delivery of adequate local anesthesia for
minor surgical procedures. Sensation to the external ear is derived from several cranial
and extracranial nerve branches. The great auricular (C2 to C3) and lesser occipital (C2)
are cranial nerves which innervate the posterior aspect of the auricle and lobule. While
the distribution is variable, in most cases the lesser occipital supplies the superior ear and
mastoid region while the great auricular nerve supplies the inferior ear and a portion of the
preauricular area. The anterior surface of the ear, including the helix, scapha, and concha,
is supplied by the auriculotemporal nerve (V3 trigeminal) and is most likely to be injured in
a microvascular decompression for the treatment of trigeminal neuralgia. Branches of the
vagus (X) and glossopharyngeal (IX) nerve innervate the external auditory meatus.
The innervation to the external ear follows its embryologic branchial arch origins with the
great auricular nerve innervating first branchial arch structures and the auriculotemporal
nerve innervating second branchial arch structures. An auriculotemporal nerve block
provides anesthesia to the helix and tragus and is approached by injecting 2 to 4 mL of
anesthesia superiorly and anteriorly to the tragus. The great auricular nerves and lesser
occipital nerves are blocked by injecting 2 to 4 mL of anesthetic to the posterior sulcus
from the inferior aspect of the earlobe. This will provide anesthesia to the earlobe and
lateral helix.
A 67 year old woman comes to the office because of a mass on the left side
of the roof of the mouth. The patient notes that it has enlarged gradually
since she first noticed it 6 months ago. Examination shows a 2-cm mass on
the left hard palate and loss of sensation over the left cheek. Examination of
a specimen obtained on biopsy shows adenoid cystic carcinoma. Which of
the following skull-base foramina is most likely to be involved by this tumor?
A. A) Jugular
B. B) Lacerum
C. C) Ovale
D. D) Rotundum
E. E) Stylomastoid
Option D
Adenoid cystic carcinoma of the hard or soft palate is a slow-
growing, insidious disease with a tendency to spread via a
perineural mechanism along the palatine branches of the
maxillary division of the trigeminal nerve. The facial nerve exits
the skull base from the stylomastoid foramen. The foramen
lacerum, foramen ovale, and foramen rotundum contain the
internal carotid artery, mandibular (V3) nerve, and maxillary (V2)
nerve, respectively. The glossopharyngeal (IX), vagus (X), and
spinal accessory (XI) nerves emerge from the jugular foramen
A 32 year old woman comes to the office for consultation regarding cosmetic
improvement of her nose. On examination, facial animation (smiling) causes
markred descent of the nasal tip, shortening of the upper lip, and a
transverse crease in the mid philtral area. These findings are most
consistent with the action of which of the following muscles?
A. A) Depressor septi nasi

B. B) Nasalis
C. C) Procerus
D. D) Risorius
E. E) Zygomaticus major
Option A
A deformity upon facial animation characterized by descent of the nasal tip, shortening of the upper
lip, and a transverse crease in the mid philtral area may be created or accentuated by the action of the
depressor septi nasi muscles. These are small, paired muscles located on each side of the nasal
septum, which originate at the medial crura foot plates and insert either on the incisive fossa of the
maxilla or into the fibers of the orbicularis oris muscle.
Physical examination upon facial animation should be part of the routine preoperative evaluation of
the rhinoplasty patient. Those who present with the dynamic deformity as described may benefit from
excision or transection of the depressor septi nasi muscles. Several surgical techniques have been
described, as well as the use of botulinum toxin type A.
The nasalis muscle compresses the cartilaginous part of the nose and draws the ala toward the
septum. Although this may generate some depression of the tip of the nose, it should not cause
shortening of the upper lip.
The procerus muscle depresses the medial angle of the eyebrows, creating transverse rhytides over
the bridge of the nose. The risorius muscles retract the angle of the mouth, as in a grinning
expression. The zygomaticus major muscles draw the angles of the mouth posteriorly and superiorly,
as in laughing. These muscles do not cause depression of the tip of the nose.
A 22-year-old man comes to the emergency department after he
sustained a machete laceration of the left cheek extending from the
tragus through the midpoint of the upper lip. The wound is full thickness
along the central third. Examination shows left upper lip droop and
flattening of the associated nasolabial fold. Which of the following
structures were most likely injured?
A. Lacrimal sac, mandibular
branch of the facial nerve, and
pterygoid muscle
B. Maxillary sinus, zygomatic
pterygoid muscle
C. Parotid duct, buccal branch of
the facial nerve, and masseter
muscle
D. Zygomatic arch, zygomatic
orbicular muscle
Resources
Neligan, P.C. (2013). Plastic Surgery (Vol 3, Chapter 1 Head
and Neck)
Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an
important reference point for surgery in the temporal region.
Plast Reconstr Surg. 1998;101(1):27-32.
Thank You

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Head and Neck Anatomy

Most superficial of the deep

- Surrounds trachea, esophagus,

A. A) Depressor septi nasi

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