Head And Neck Flashcards
Scalp
1) Layers
2) extend
3) nerve supply
4) blood supply
Boundary - From supra ciliary arch to superior nuchal line and supra temporal line.
LAYER
1) Skin - hair, sweet gland and sebaceous gland.
2) Connective tissue - highly vascular and nerve, blood vessels are attach to surrounding tissue make it hard to stop bleeding, mostly arterial bleeding
3) Aponeurotic layer :- Frontalis - From upper eye brows to aponurosis, nerve - Temporal branch of facial nerve
:- Occipitalis - from superior nuchal line to aponurosis, nerve - Posterior auricular nerve.
THIS THREE LAYER ARE SURGICAL LAYER OF SCALP - TISSUE EXPANDER OR IMPLANT IS KEPT.
4) Loose areolar layer
- have valve less emissary vein which connect to Dural sinus, blood shunt in vein due to increase in ICP.
- can form black eye.
- dangerous area of scalp
5) pericranium of skull
- skin loosely attach except suture line
NERVE SUPPLY
> Infront of aurical
- Sensory = supraorbital, supratrochlear (opthalmic branch), zygomaticotemporal (maxillary), auriculotemporal (mandibular)
- motor = Temporal branch of facial nerve.
> Behind aurical
Sensory
- greater auricular
- greater occipital
- lesser occipital
- 3rd occipital
Motor - Posterior auricular nerve (facial)
ARTERY SUPPLY
- Infront of aurical - supraorbital, supratrochlear (opthalmic - ICA), superior temporal Artery (ECA)
- Behind the aurical - Posterior auricular artery (ECA), occipital (ECA)
Face
1) Muscle
2) Artery
3) Vein
4) Nerve
1)
- orbicularis oculi - close the eyelid
- orbicularis oris - close mouth
- Risorius - retract angle of mouth
- mentalis - wrinkling of skin
- corrugator supercilli- frowning
- zygomaticus major and minor - laughing
- depressor anguli oris - depression of angle of mouth
- levator labii superioris - elevates upper lips
- depressor labii inferioris - depression of lower lips.
- buccinator - whistling / blowing
2)
> Facial artery
Lateral surface of submandibular gland and mandible —⟩ loop —⟩ 1.25 cm lateral to angle of mouth —⟩ lateral of nose till middle angle of eye —⟩ anastomosis with dorsal nasal artery (opthalmic branch - ICA)
Branch
- Inferior labial Artery
- Superior labial Artery
- Lateral nasal artery
- angular ( terminal segment)
> Transverse facial Artery - branch of Superior Temporal Artery
3)
Supraorbital + supratrochlear —⟩ angular vein —⟩ facial vein
Superficial Temporal vein + maxillary vein —⟩ retromandibular —⟩ Anterior and Posterior division
Anterior division + facial vein —⟩ common facial vein —⟩ IJV
Posterior division + Posterior aurical vein —⟩ EJV
DANGEROUS AREA OF FACE - UPPER LIPS AND LOWER PART OF NOSE
4) Nerve
> Sensory - trigeminal, except angle of mandible - great auricular nerve.
- opthalmic - forehead and tip of nose, Upper eyelid
- maxillary - Upper lips, lower eyelid, cheek
- mandibular - chin, lower lips, auricle and temple
> Motor - facial.
1) panniculus carnosus
2) nerve supply to pinna
1) muscle attach to skin, no deep fascia
- face, anal canal (corrugator cuti Ani), palm (palmaris brevis), scrotum ( dartos muscle)
2)
-Auriculotemporal - trigeminal - part of helix and tragus
-Greater auricular - cervical plexus - majority of aurical and lobules
-Lesser occipital - cervical plexus - Posterior part of aurical
-Arnold/ alderman - auricular branch of vagus- external auditory meatus, concha, tympanic membrane
-facial - Posterior Superior aspect of meatus
-jacobson’s - tympanic part of glossopharyngeal nerve - middle ear, tympanic membrane, eustachian tube.
Deep cervical fascia
Part
- superficial
- middle —⟩ muscular and visceral- pretracheal and bacopharyngeal
- deep —⟩ dorsal - prevertebral, ventral - alar fascia
SUPERFICIAL LAYER
- Muscle intraped -: sternocleidomastoid and trapezius
- Ligament formed - sphenomedibular and stylomandibular
- make roof of Posterior triangle
- false capsule - parotid and submandibular
- enclose two space in neck
> Suprasternal of burns - jugular arch, lower part of sternocleidomastoid, interclavicular lig.
> Supraclavicular - terminal part of EJV and supraclavicular nerve
Middle layer
- muscular - covering to infrahyoid muscle
- visceral
> Pretracheal - enclose thyroid, trachea and esophagus —⟩ attach thyroid to cricoid with Berry’s ligament (mc site of injury to recurrent laryngeal nerve)
Deep layer
> Prevertebral layer
- enclose vertebral muscle
- floor of Posterior triangle
Between it have spinal accesory nerve - most superficial
- continue as axillary sheath
Carotid sheath - by all layer f deep cervical fascia
Content - IJV and CCA vagus,
Anterior - ansa cervicalis, Posterior - sympathetic chain
Content at level of base of skull - ICA and IJV with CN 9,10 (inside sheath through out corse) ,11,12.
sympathetic chain Posterior
Pharynx
- Anterior - pharyngo - basilar fascia (thickening of submucosa)
- Posterior - bucco - pharyngeal fascia
- alar fascia - join buccopharyngeal layer at level of C6-T4 (C7)
Retropharyngeal area
- Anterior - buccopharyngeal
- Posterior - alar
Danger area of neck -
Anterior - alar
Posterior - prevertebral
Muscle and Triangle of neck
1) Muscle
2) Posterior triangle
3) submental
4) digastric
5) carotid
6) muscular
1)
> Suprahyoid
- geniohyoid - C1 through hypoglossal
- stylohyoid - Facial
- Ant belly of digastric - Nerve to mylohyoid (Inferior alveolar nerve - mandibular nerve)
- Posterior belly of digastric - facial nerve
- mylohyoid - nerve to mylohyoid.
> Infrohyoid
- sternohyoid, omohyoid, sternothyroid - ansa cervicalis
- thyrohyoid - C1 through hypoglossal
2)
> Boundary
- Anterior - sternocleidomastoid
- Posterior - trapezius
- INFERIOR BELLY OF OMOHYOID DIVIDE IT INTO OCCIPITAL AND SUPRACLAVICULAR TRIANGLE/SUB CLAVICLE TRIANGLE
- Floor - semispinalis capitis, splenius capitis, scalenus medius, Anterior, levator scapulae
- Roof - skin, superficial fascia, platysma
- investing layer of deep cervical fascia
- cutaneous branch of cervical plexus = from Posterior border of sternocleidomastoid
- content
-: occipital triangle
— spinal accesory - most superficial, supply sternocleidomastoid and trapezius.
— occipital artery
— cutaneous nerve of cervical trunk - lesser occipital, greater auricular, transcervical, supraclavicular
— root of brachial plexus, dorsal scapular nerve
— transverse cervical Artery - branch of thyrocervical trunk.
— occipital node : class 5
:- subclavian triangle
— trunk of brachial plexus
— long thorasic Nerve, suprascapular nerve, nerve to subclavius
— suprascapular artery
— subclavian vein
— 3rd part of subclavian Artery and dorsal scapular artery
3)
Boundary
- Above - mandible
- below - hyoid
- either side - Anterior belly of digastric
- content - submental nodes
4)
Boundary
- Above - mandible, mastoid
- Below infront - Anterior belly of digastric
- below behind - Posterior belly of digastric and stylohyoid
Floor - middle constrictor, Inferior constrictor, mylohyoid
Content
- lower part of submandibular gland
- facial vessels
- hypoglossal nerve
- nerve to mylohyoid
- apex of parotid
5)
Boundary
- Above infront - Posterior belly of digastric, stylohyoid
- Below infront - Superior belly of omohyoid
- behind - sternocleidomastoid
- Floor - medial constrictor, Inferior constrictor, hyoglossus, thyrohyoid
Content
- Comman carotid, internal carotid, ECA with 5 branches
- Internal Jugular vein
- vagus
- hypoglossal
- ansa cervicalis
- cervical plexus
- superficial laryngeal branch which divide into external laryngeal and internal laryngeal
6) Muscular
Boundary
Above - Superior belly of omohyoid
Front - imaginary line
Behind - Anterior border of sternocleidomastoid
Floor - sternohyoid, thyrohyoid, sternothyroid
Content - trachea and esophagus
1) External carotid artery
2) Cervical plexus
3) Ansa cervical
4) phrenic nerve
5) Level of lymph node
1) Branches
- Anterior side = Superior thyroid, lingual, facial
- medial side = Ascending pharyngeal - 1st branch to arise
- Posterior = Posterior aurical, occipital
- Terminal branch - maxillary and superficial Temporal (at level of neck of mandible)
2 TERMINAL BRANCH AND POSTERIOR AURICULAR BRANCH ARE NOT PRESENT IN CAROTID TRIANGLE, OTHERS ARE.
2) Cervical plexus
- Arise from C1,2,3,4
> Cutaneous branch
- greater auricular nerve - aurical and angle of mandible
- lesser occipital - occipital region and adjoining area of aurical
- transverse cervical - skin of transverse
- supraclavicular - Above clavicle
3) Ansa cervicalis
- by C1,2,3
- C1 form superior root of ansa is the descendens hypoglossi and also give meningial branch of Posterior cervical fossa while joining hypoglossal.
- C2 and 3 forms the descendens cervicalis - Inferior root
Motor supply
Sternohyoid, omohyoid and sternothyroid
Ansa cervicalis is embedded in Anterior wall of carotid sheath
Posterior to carotid sheath is cervical sympathetic plexus
C1 also supply geniohyoid and thyrohyoid.
4) by C345, major - 4
C4 give dermatome to tip of shoulder - referred pain
Function - mixed nerve -
Motor - diaphragm, sensory - diaphragm, pleura, pericranium
Relation
- pass Anterior to scalenus Anterior
- between subclavian vein infront and subclavian Artery behind.
- phrenic nerve pass through Anterior to hillum of lung (vagus pass through Posterior)
- right one is shorter then left
5)
1a - submental
1b - digastric
2 - upper jugular nodes
3 - mid jugular nodes
4 - lower jugular nodes
(All three are associated with internal jugular vein - under the cover of sternocleidomastoid)
5 - occipital
6 - b/w hyoid bone upto sternum in Anterior triangle - Anterior node
7 - mediastinal nodes
1) Temporal fossa
2) Temporalis muscle
3) Massater
4) Infratemporal fossa
5) Lateral pterygoid
6) medial pterygoid
1)
Superior - Temporal line
Inferior - zygomatic arch
Content - temporalis muscle
2)
Origin - Temporal fossa and temporal fascia
Insertion - coranoid process of ramus
Action - Elevation > retraction
Nerve - Deep temporal nerve
3) Massater
Origin - zygomatic arch
Insertion - lateral of ramus of mandible
Action - strong elevation > protrusion
Nerve - masseteric branch
4) Infratemporal fossa
Boundary
- Lateral - Ramus of mandible, obstruct Infratemporal fossa
- medial - Lateral pterygoid plate
- Anterior - maxilla
- Posterior - styloid process
- Superior - greater wing of sphenoid
- Inferior - connect with neck tissue
Communication
- Orbit - infraorbital fissure - Junction of roof and Anterior wall
- Pterygopalatine fossa - pterygomaxillary fissure - junction of Anterior and medial wall
- tissue space around pharynx and larynx - Inferior wall
- middle cranial fossa - foramen ovale and spinosum - Superior wall
Structure
- Muscle - lateral and medial pterygoid
- nerve - chorda tympani, mandibular, otic ganglion
- artery - maxillary, (2nd part), pterygoid venous plexus
5)
Origin
- upper fibers = Infratemporal crest
- lower = lateral surface of lateral pterygoid plate
Insertion
- head of mandible with neck, articular disc, capsule of temporomandibular joint
Action - Depression > protrusion
Relation
- Superficial - ramus of mandible, Massater, maxillary artery, superficial fibers of medial pterygoid.
- Deep - mandibular nerve, middle meningial artery
- Inferior - Inferior alveolar nerve, lingual nerve
6) Medial pterygoid
Origin
- superficial - maxillary pterygoid
- deep - medial surface of lateral pterygoid
Insertion
- Posterior Inferior aspects of the inner surface of ramus of mandible, angle of mandible
Nerve - trunck of mandibular nerve
Action Elevation > protrusion
ELEVATION - MASSETER > TEMPORALIS > MP
PROTRUSION - LP> MP> MASSATER
Relation
- superficial - Inferior alveolar nerve and vessels, lingual nerve
- deep - styloglossus, stylopharyngeus, tensor and levator vali palatine
Superior constrictor
Nerve in Infratemporal fossa
Trigeminal nerve —⟩ Trigeminal ganglion - sensory root ———⟩ Division - Opthalmic, maxillary, mandibular
Pons ——⟩ motor root of trigeminal —⟩ join with mandibular devision ——⟩ pass through Foramen oval - form trunck of mandible —⟩ ottic attach to it below FO
Trunk of mandible —⟩ nerve to Medial pterygoid —⟩ medial pterygoid, tensor palatini, tensor tympani
Trunk of mandible —⟩ Two division
- Anterior division = deep temporal, branch to pterygoid, masseteric branch, buccal sensory branch which pierced bussinator
- Posterior division = Inferior auricular, lingual with chorda tympani and Auriculotemporal
> Auriculotemporal - It suspended middle meningial artery and give GSA - temporal and aurical and GVE - to parotid from otic ganglion
Lingual nerve - receive chorda tympani and goes to Anterior ⅔ of tongue.
Ottic ganglion - parasympathetic to parotid gland
Course
- topographically = mandibular, functionally = glossopharyngeal
Fibers from Inferior salivary nucleus —⟩ glosopharyngeal - tympanic branch —⟩ join with carotico - tympanic branches + sympathetic plexus —⟩ Tympanic plexus —⟩ lesser petrosal nerve —⟩ ottic ganglion —⟩ Auriculotemporal nerve —⟩ parotid gland
Relation
Medial - tensor palatini
Lateral - mandibular nerve
Above - foramen ovale
Below - middle meningial artery
Chorda tympani :-
- join lingual nerve 2 cm below base of skull in Infratemporal fossa, closely related to mucosa of 3rd molar tooth.
—> suspended submandibular ganglion (topographically) functional - facial nerve (chorda tympani) —⟩ parasympathetic to submandibular and sublingual from Inferior salivary nucleus
- course
Facial nerve —⟩ 6 cn below stylomastoid foramen - chorda tympani —⟩ Posterior canaliculus (Posterior wall of middle ear) —⟩ lateral wall of middle ear —⟩ between handle of malleus and long process of incus —⟩ Anterior canaliculus —⟩ petrotympanic fissure —⟩ Infratemporal fossa —⟩ join lingual
- fibers GVA - preganglionic fibers to submandibular and sublingual
- SVA - taste sensation
Inferior alveolar nerve
1) mental - pass through mandibular Foramen —⟩ dental plexus —⟩ sensory supply to lower jaw —⟩ comes out of mental foramen —⟩ mental nerve —⟩ chin.
2) mylohyoid —⟩ before passing in mandibular foramen - supply to mylohyoid and ant belly of digastric
Pterygopalatine fossa
1) Boundary
Lateral - pterygomaxillary fissure
Medial - perpendicular plate of palatine bone
Anterior - maxilla
Posterior - pterygoid process (MP and LP plate below)
Superior - under surface of sphenoid and orbit, infra orbital fissure
2) communication
- Orbit - infraorbital fissure - Superior wall
- Infratemporal fossa - pterygomaxillary fissure - lateral wall
- nose - sphenopalatine foramen - medial wall
- middle cranial cavity - foramen rotundum, pterygoid canal, pharyngeal canal - Posterior wall
- Inferior wall - Greater palatine Foramen
3) Content - maxillary nerve and artery
Parotid Gland
1) Relation of parotid bed
2) capsule
3) Relation
4) Stensor duct
5) Nerve supply
6) Nerve injury in partid surgery
Glands
- Parotid - ectoderm - 6th wks
- submandibular - endoderm - end of 6th wks
- sublingual - endoderm - 8th wks
1) Relations of parotid bed
- Anterior - ramus of mandible
- Posterior - mastoid
- Superior - external acoustic meatus
- medially - styloid
2) capsule
- true = fibrous tissue
- false = investing layer of deep cervical fascia by two lamellae
A) Superficial - attach to zygomatic arch
B) deep attach to tympanic membrane - stylomandibular ligament - divide parotid from submandibular
3) Relation
—⟩ Lateral = parotid lymph nodes
—⟩ Anterolateral - Ramus of mandible, Massater and medial pterygoid
—⟩ Posteromedial - mastoid - sternocleidomastoid, Posterior belly of digastric, styloid - styloglossus, stylohyoid, stylopharyngeus, behind it is ICA, IJV, CN - 9,10,11,12
—⟩ Medial border - pharyngeal wall
—⟩ Anterior - Branch of Fascial nerve - temporal, zygomatic, upper buccal, lower buccal, mandibular, transverse Fascial Artery, Stenson’s duct
—⟩ Posterior - Posterior auricular nerve and Artery
—⟩ Structure from Superficial to deep - facial nerve —⟩ retromandibular nerve —⟩ ECA
4) Stenson’s - pierce
- buccal pad of fat
- buccopharyngeal fat
- buccinator
- mucosa of cheek opposite to 2nd molar
5) Nerve supply
Parasympathetic - glossopharyngeal —⟩ otic ganglion —⟩ Auriculotemporal nerve = watery
Sympathetic - plexus around Medial meningial artery which carry postganglionic sympathetic fibers from Superior cervical ganglion.
6) Nerve injured in parotid surgery
- Fascial
- greater auricular nerve - anaesthesia at beard part
- Auriculotemporal - Frey syndrome
- marginal mandibular - dropping of angle of mouth. Prevent by giving lazy S incision. - 2cm below angle of mandible.
Submandibular gland
1) capsule
2) Relation
3) Duct
4) nerve
Mylohyoid divide into Superficial and deep
1)
- True - Fibrous
- False - investing layer of deep cervical fascia divide into Superficial layer (Inferior surface, attach to base of mandible) Deep (medial, attach to mylohyoid line)
2)
—⟩ Superior part
- Anterior - Anterior belly of digastric
- Posterior - stylomandibular
- Lateral - not covered with fascia, facial artery
- medial - 3 muscle (hyoglossus mylohyoid styloglossus), 3 nerve (hypoglossal glossopharyngeal mylohyoid)
- Inferior - Fascial vein, submandibular lymph nodes
—⟩ Deep part
- hyoglossus medially and mylohyoid laterally
3) Wharton duct -
- From deep part to sublingual papilla
- Lateral to hyoglossal
- cross by lingual nerve - injured in OT
4)
Parasympathetic - watery - Superior salivary nucleus —⟩ chorda tympani —⟩ lingual nerve —⟩ submandibular ganglion
Sympathetic - thick - plexus around Fascial artery from superficial cervical ganglion.
Thyroid Gland
1) Capsule
2) Relation
3) Blood supply
4) Berry triangle
Parathyroid
Situation between C5 - T1
1) capsule
- True - fibrous
- False - pretracheal layer, Ligament of berry joint it with cricoid cartilage.
2) Part
—⟩ Apex - reach upto oblique line f thyroid cartilage
- between sternothyroid and Inferior constrictor muscle
- related to Superior thyroid Artery and external laryngeal nerve
—⟩ base
- 5th tracheal ring
- related to Inferior thyroid Artery and left recurrent laryngeal nerve.
—⟩ Anterolateral surface
- from deep to Superficial - sternothyroid sternohyoid Superior belly of omohyoid sternocleidomastoid
—⟩ posterolateral
- carotid sheath - CCA and IJV, vagus nerve
—⟩ medial
- thyroid and cricoid cartilage
- trachea and esophagus
- cricothyroid and Inferior constrictor.
—⟩ Isthmus
- over 2,3,4 ring
- upper border - anastomosis f Superior thyroid Artery
- lower border - Artery of thyroidea ima, Inferior thyroid vein
- mid line structure got injured in tracheostomy - Isthmus, Inferior thyroid vein, Artery of thyroidea ima.
(INFERIOR THYROID ARTERY DON’T GET INJURY)
3) Blood supply
- Superior thyroid Artery - branch of ECA
- Inferior thyroid Artery - branch to thyrocervical trunk - supply thyroid, thymus, parathyroid, cervical part of esophagus
- Artery of thyroidea ima - branch f brachiocephalic truck > arch of aorta.
—⟩ Vein
- STV - in IJV
- MTV - in IJV and ligate first in OT
- ITV - brachiocephalic vein.
Note
- most common nerve injury in sx - ELN > RLN
- MC RLN affected n Sx - Right> left
MC nerve affected above berry ligament - RLN
4) Berry triangle
- to prevent damage to RLN
- form by CCA, RLN, ITA
Superior - at level of cricoid cartilage or middle of Posterior border of thyroid
Inferior - Above ITA or below roof of ITA.
Dural fold
1) Flax Cerebri
- between two cerebral
- Contain = S. Saggital sinus, I.S.S, straight sinus
2) Tentorium Cerebri
- bet. Cerebrum and cerebellum
- contain = transveres, S. Petrosal, straight sinus
- forms meckel’s canal - cantain trigeminal ganglion and proximal part of nerve.
3) Falx Cerebri - contain - occipital
4) Diphragma sellae - roof of pitutary gland
Dural venous sinus
1) Paired
2) Unpaired
3) sinus in meningial layer
4) Fact of sinus
5) Confluence of sinus
6) Lateral sinus
7) sigmoid sinus
8) Basilar venous plexus
9) Nerve and arterial supply
1) Cavernous sinus, superior and interior petrosal, tranvers sinus, sigmoid sinus, spheno parital sinus, petro squamous, middle meningial vein
2) Superior sagital, Inferior sagital sinus, straight sinus, occipital, ant and post. Internal cavernous, basilar venous plexus
3) Inferior sagital sinus and straight sinus
4) Superior sagital ——⟩ Rt transverse sinus
Inferior sagital ——⟩ straight sinus and Great vein of Gallen ——⟩ Lt transvers sinus
Both transveres sinus —⟩ sigmoid sinus —⟩ IJV
Great cerebral vein of galen - between splenium and cerebellum there is quadrigeminal cistern and that contains Great cerebral vein of galen.
5) Confluence of sinus - meeting point of four sinus
- Superior sagital, transveres, occipital and straight
6) Lateral sinus - sigmoid + transveres
7) sigmoid sinus is present on inner surface of mastoid area. Infection in ear can cause thrombosis.
8) Inferior petrosal, Posterior intercavernous and cavernous
9) Nerve supply
- Anterior Cranial fossa - before greater wing od sphenoid - CN 5(1) - Anterior Ethmoidal, CN 5(2), CN 5(3) - Ant and posterior ethmoidal + Branch of MMA
- Middle Cranial fossa - between greater wing of sphenoid to superior border of petrous temporal bone - CN 5(2) by nervous meningus medius, CN 5(3) - nervous spinosus - MMA and accesory branch of MMA and ICA
- Posterior cranial fossa - Tectorial branch CN 5(1), C1 by hypoglossal fibers, C2,3 by vagus fibers - Vertebral and occipital
Ascending pharyngeal Artery supply middle and posterior cranial fossa.
Cavernous sinus
1) Relations
- medial - Spinoid sinus and pitutary gland
- lateral - trigeminal ganglion
- passing through - ICA and Abducent nerve
Structure passing Lateral - oculomotor, trochlear and opthalmic division of trigeminal
Note - maxillary Division don’t pass lateral side
2) Tributary
- Superior and Inferior opthalmic vein, cental vein of retina
- superficial middle cerebral vein, middle cerebral vein, Inferior cerebral vein, sphenoparaital
3) Communicating Channel
- CS —⟩ SPS —⟩ TS
- CS —⟩ IPS —⟩ IJV
- CS —⟩ Ant and post intercavernous —⟩ CS
4) Connection with Fascial vein
- Fascial vein —⟩ Angular vein —⟩ SOV —⟩ sinus
- FV —⟩ Deep FV —⟩ pterygoid plexus —⟩ emissary vein —⟩ Sins
Superior OV act as tributary + connecting veins.
5) Feature of thrombosis
- Nerve - 3,4,6, opthalmic division
- opthalmoplegia, loss of vision, exopthalmus, pain in corse of opthalmic nerve, papilledema, increase ICP, meningitis, swelling of eye lid.
