Generalities 1. N. Pirogov founder of operative surgery and topographic anatomy (primary contributions). 2. Surgery act - definition, stages by N.

. Burdenko requirements.

Operative surgery studies regional antomy. Not by systems by topagraphy

Stages of surgical operation Surgical approach beginning of surgery / Denudation. E.g. incision & searching for appendix. 3. Classification of surgical operations. Triad of principles which determine the action of a surgeon: Anatomical accessibility Rational incision.

Operative action main stage / fundamental stage. E.g. appendectomy. Resoration of sutures e.g. suturing by layers.

Technique possibility Possessing instruments.

Physiological permission preservation of function. 4. Transplantation of tissue - types of grafts, harvesting and conservation methods.

5. Methods for preserving organs and tissues for transplantation.

Topographic anatomy of the head

1. Landmarks and topographic regions of cerebral portion of the head. Topographic regions of cerebral portion of the head and their landmarks : Fronto-parieto-occipital r. Anterior limit - border/margin of orbits . Lateral limit - superior temporal line (external auditory canal and mastoid process , which can be palpated ). posterior limit - external occipital protuberance and superior nuchal line . Temporal r. Medial limit - the neurocranial bones : Frontal , Parietal , temporal , sphenoid , occipital bone . Lateral limit - temporal fascia . Anterior - Pair of temporal lines , superior & inferior temporal lines,( that arch across the skull from the zygomatic process of the frontal bone to the supramastoid crest of the temporal bone ). Inferior l. - zygomatic arch laterally and by the infratemporal crest of the greater wing of the sphenoid medially . Mastoid r. Anterior - external acoustic meatus .

 posterior - mastoid tuberosity . superior - the continuation of the zygomatic arch .

2. Age peculiarities in the structure of the cerebral portion of the head.

The first period (the first 7 years) is characterized by intensive growth, mainly of the posterior part of the skull. The second period (from the age of 7 to the beginning of puberty), and this is the period of relative rest. The third period, from the beginning of puberty (13-16 years of age) to the end of skeletal growth (20-23 years of age), is again one of intensive growth, and during this period growth mainly the anterior part of the skull. I. Fusion of the separate parts of bones forming a single bone: Both halves of the mandible fuse at 1-2 years of age. Fusion of both halves of the frontal bone at the site of the frontal suture occurs from 2 years until 7 years of age. Fusion of all parts of the occipital bone between ages 3 and 5. Synostosis between the body of the occipital bone and the sphenoid bone to form a single os basilare at the level of sphenooccipital synchondrosis occurs between the ages of 18-20, and with the development of this synostosis growth of the base of the skull in length ceases. II. Disappearance of the fontanelles and the formation of sutures with typical serrated contours at 2-3 years of age. III. Appearance and future development of pneumatization. The maxillary sinus begins to develop in the 5-6th month of the intrauterine life and is demonstrated on radiograph of the skull at birth as an elongated clear space the size of a pea. It reaches full development in the period of replacement of deciduous teeth by the permanent teeth and is distinguished by great variability. The air sinuses are still not developed in the skull of a new born. The crests, muscular tuberosities, and lines are not pronounced because the muscles do not function yet and are therefore weakly developed. Weakness of the muscles of mastication due to the absence of the masticating function causes weak development of the jaws: the alveolar processes are hardly formed and the mandible consists of two non-united halves. As a result the visceral cranium is less prominent in relation to the cerebral skull and is only 1:8 the size of the cerebral, whereas in adult their ratio is 1:4.

3. Stratigraphy of frontoparietooccipital region. a. Skin .

b. Subcotaneous fatty tissue . i. CT septa/bridges : medical importance any bleeding dont spread to big region (in a horizontally manner) ii. Superficial vessels and nerves : there is wide supply of vessels in this region , The vessels usually are attached to the septa (that is why the vessels cant constrict). In this layer just necrotic tissue removal & minimal incisions in surgery are indicated . c. Apicranial apeneurosis d. Subaponeurotic space . e. Periosteum ( it is fixed only to the bone sutures). f . Subperiosteal space ( blood fluctuation in region = osteomylitis , pus spreading is regional - the space between the periosteum that is attached to the sutures ). g . Bone of skull h. Epidural space ( normally it is not an actual space , but potential one in this area lay branches of the middle meningeal artery , while hematoma here spreads very fast till death sometimes ). i . Cranial dura matter insephalic pachymaydex j . Subdural space . k. Meningea / cranial archonoid space . l . sub-archonoid space . m . Pia matter / vascular meningea . n . subpial space . * Lastly parenchyma of the brain .

4. Spaces of celluloadipose tissue and dissemination of the pus and hematoma in frontoparietooccipitale region. 5. Venous system of cerebral portion of the head, anastomoses and their practical significance.
The venous drainage of the cerebrum can be separated into two subdivisions: superficial and deep. The superficial system is composed of dural venous sinuses, which have wall composed of dura mater as opposed to a traditional vein. The dural sinuses are, therefore located on the surface of the cerebrum. The most prominent of these sinuses is the superior sagittal sinus which flows in the sagittal plane under the midline of the cerebral vault, posteriorly and inferiorly to the torcula, forming the confluence of sinuses, where the superficial drainage joins with the sinus the primarily drains the deep venous system. From here, two transverse sinuses bifurcate and travel laterally and inferiorly in an S-shaped curve that form thesigmoid sinuses which go on to

form the two jugular veins. In the neck, the jugular veins parallel the upward course of the carotid arteries and drain blood into the superior vena cava. The deep venous drainage is primarily composed of traditional veins inside the deep structures of the brain, which join behind the midbrain to form the vein of Galen. This vein merges with the inferior sagittal sinus to form the straight sinus which then joins the superficial venous system Role of Specific Anatomic Features of Cerebral Venous System in Pathophysiology of Cerebral Venous Thrombosis The cerebral veins and sinuses neither have valves nor tunica muscularis. Because they lack valves, blood flow is possible in different directions. Moreover, the cortical veins are linked by numerous anastamoses, allowing the development of a collateral circulation and probably explaining the good prognosis of some cerebral venous thromboses. Lack of tunica muscularis permits veins to remain dilated. This is important in understanding the huge capacity to compensate even an extended occlusion. Venous sinuses are located between two rigid layers of duramater.15 This prevents their compression, when intracranial pressure rises. Superficial cortical veins drain into SSS against the blood flow in the sinus, thus causing turbulence in the blood stream that is further aggravated by the presence of fibrous septa at the inferior angle of the sinus. This fact explains greater prevalence of SSS thrombosis. In addition to draining most of the cerebral hemisphere, the superior sagittal sinus also receives blood from diploic, meningeal and emissary veins. Same is the case with other dural venous sinuses. This explains the frequent occurrence of CVT as a complication of infective pathologies in the catchments areas e.g. cavernous sinus thrombosis in facial infections, lateral sinus thrombosis in chronic otitis media and sagittal sinus thrombosis in scalp infections The dural sinuses especially the SSS contain most of the arachnoid villi and granulations, in which absorption of CSF takes place. So dural sinus thrombosis blocks villi and leads to intracranial hypertension and papilloedema.

6. Particularities of arterial supply of the epicranial tissue .

The galea aponeurotica (epicranial aponeurosis, aponeurosis epicranialis) is a tough layer of dense fibrous tissue which covers the upper part of the cranium; behind, it is attached, in the interval between its union with the occipitales, to the external occipital protuberance and highest nuchal lines of the occipital bone; in front, it forms a short and narrow prolongation between its union with the Frontales. On either side it gives origin to the Auriculares anterior and superior; in this situation it loses its aponeurotic character, and is continued over the temporal fascia to the zygomatic arch as a layer of laminated areolar tissue. It is closely connected to the integument by the firm, dense, fibro-fatty layer which forms the superficial fascia of the scalp: it is attached to the pericranium by loose cellular tissue, which allows the aponeurosis, carrying with it the integument to move through a considerable distance.

7. Stratigraphy of the temporal region. Question 3 8. Hematoma and pus collections paths of diffusion on the temporal region. 9. Surgical Anatomy of the mastoid region. Mastoid r. limits Anterior - external acoustic meatus . posterior - mastoid tuberosity . superior - the continuation of the zygomatic arch . Innervation and vascularization : innervation : - Occipital branch - some branches of facial nerve - posterior auricular - External acoustic meatus . vascularization : - posterior auricular artery 10. The trepanation triangle and "square of attack" on the mastoid process. Triangle of Chipold operation / Anthromastoidotomy : It is the place for operation performance in case of inflammation it is opened for the removal of pus . 11. Topographic anatomy of the cerebral meninges. Cerebral meninges is a 3 membrane structure , which serrounds the brain and spinal cord .
Mainly made of Connective tissue . Functions : Cover, Protect CNS Enclose, protect blood vessels supplying CNS Contain CSF

its 3 Layers : Dura Mater (external) Arachnoid Mater (middle)

Pia Mater (internal)

Dura mater Strongest, 2 Layers, Fibrous Connective Tissue Periosteal layer (Periosteum): External/superficial layer Meningeal layer: Internal/deep layer Layers fused except around dural sinuses (venous blood filled internal jugular vein) Falx Cerebri vertical, between cerebral hemispheres Falx Cerebelli -vertical, between cerebellar hemispheres Tentorium Cerebelli horizontal, between cerebrum and cerebellum

Partitions: limit movement of brain

Arachnoid Mater Middle layer Subarachnoid Space-between arachnoid mater and pia mater (contains most of CSF, blood vessels) Arachnoid Villi- projections of arachnoid mater through dura into superior sagittal sinus, act as valves to help CSF pass into dural sinuses

Pia Mater 1. Innermost layer 2. Delicate, highly vascular 3. Clings directly to brain tissue, dips into convolutions

12. Intermeningeals spaces and cerebral cisterns and their content. Cerebral cisterna
In neuroanatomy, a cistern (Latin: "box") is any opening in the subarachnoid space of the brain created by a separation of thearachnoid and pia mater. These spaces are filled with cerebrospinal fluid. Each cisterna has its name , and here are some major subarachnoid cisterns: Cerebellomedullary cistern (Cisterna magna) - the largest of the subarachnoid cisterns. It lies between the cerebellum and the medulla. It receives CSF from the fourth ventricle via the median foramen of Magendie and the paired lateral foramina of Luschka. The cerebellomedullary cistern contains: 1. The vertebral artery and the origin of the posteroinferior cerebellar artery (PICA).

2. The ninth (IX), tenth (X), eleventh (XI) and twelfth (XII) cranial nerves. 3. The choroid plexus. Pontine cistern (Prepontine cistern or cisterna pontis). Surrounds the ventral aspect of the pons. It contains: 1. The basilar artery and the origin of the anteroinferior cerebellar artery (AICA). 2. The origin of the superior cerebellar arteries. 3. The sixth (VI) cranial nerve. Cerebellopontine cistern (Angle cistern or cerebellopontine angle cistern). It is situated in the lateral angle between the cerebellum and the pons. It contains: 1. The seventh (VII) and eighth (VIII) cranial nerves. 2. The anteroinferior cerebellar artery (AICA). 3. The fifth (V) cranial nerve and the petrosal vein. Interpeduncular cistern (Cisterna interpeduncularis). It is situated between the two cerebral peduncles. It contains: 1. The bifurcation of the basilar artery. 2. Peduncular segments of the PICA. 3. Peduncular segments of the superior cerebellar arteries. 4. Perforating branches of the PICA. 5. The posterior communicating arteries (PCoA). 6. The basal vein of Rosenthal. 7. The third (III) cranial nerve, which passes between the posterior cerebral and superior cerebellar arteries. Superior cistern (Quadrigeminal cistern or cistern of the great cerebral vein). It is situated dorsal to the midbrain. It contains: 1. The great vein of galen. 2. The posterior pericallosal arteries. 3. The third portion of the superior cerebellar arteries. 4. Perforating branches of the posterior cerebral and superior cerebellar arteries. 5. The third portion of the posterior cerebral arteries.

Subdural space The subdural space (or subdural cavity) is an artificial space created by the separation of the arachnoid mater from the dura mater as the result of trauma, pathologic process, or the absence ofcerebrospinal fluid as seen in a cadaver. In the cadaver, due to the absence of cerebrospinal fluid in the subarachnoid space, the arachnoid mater falls away from the dura mater. It may also be the site of trauma, such as a subdural hematoma, causing abnormal

separation of dura and arachnoid mater. Hence, the subdural space is referred to as "potential" or "artificial" space.

13. Arterial system of the head, anastomoses and their practical significance ask the doctor
.The arterial cerebral circulation is normally divided into anterior cerebral circulation and posterior cerebral circulation. There are two main pairs ofarteries that supply the cerebral arteries and the cerebrum: Internal carotid arteries and vertebral arteries. The anterior and posterior cerebral circulations are interconnected via bilateral posterior communicating arteries. They are part of the Circle of Willis, which provides backup circulation to the brain. In case one of the supply arteries is occluded, the Circle of Willis provides interconnections between the anterior and the posterior cerebral circulation along the floor of the cerebral vault, providing blood to tissues that would otherwise becomeischemic. Anterior cerebral circulation The anterior cerebral circulation is the blood supply to the anterior portion of the brain. It is supplied by the following arteries: Internal carotid arteries: These large arteries are the left and right branches of the common carotid arteries in the neck which enter the skull, as opposed to the external carotid branches which supply the facial tissues. The internal carotid artery branches into the anterior cerebral arteryand continues to form the middle cerebral artery Anterior cerebral artery (ACA) Anterior communicating artery: Connects both anterior cerebral arteries, within and along the floor of the cerebral vault. Middle cerebral artery (MCA)

Posterior cerebral circulation The posterior cerebral circulation is the blood supply to the posterior portion of the brain, including the occipital lobes, cerebellum andbrainstem. It is supplied by the following arteries: Vertebral arteries: These smaller arteries branch from the subclavian arteries which primarily supply the shoulders, lateral chest and arms. Within the cranium the two vertebral arteries fuse into the basilar artery. Posterior inferior cerebellar artery (PICA)

Basilar artery: Supplies the midbrain, cerebellum, and usually branches into the posterior cerebral artery Anterior inferior cerebellar artery (AICA) Pontine branches Superior cerebellar artery (SCA)

Posterior cerebral artery (PCA) Posterior communicating artery

14. The Kroenlein scheme of the craniocerebral topography.

15. Landmarks and topographic regions of the facial portion of the head

.MUSCLES OF THE HEAD CRANIOFACIAL MUSCLES origin from the bones of face are inserted to the skin ! nerve supply Facial n. Epicranius m. frontal belly, occipital belly (two parts are inserted to the galea aponeurotica) Muscles of eyelids: Orbicularis oculi (Levator palpebrae superioris) Corrugator supercilii Muscles of the nose: Procerus Nasalis Muscles of the mouth: Orbicularis oris Buccinator Levator labii superioris alaequae nasi Zygomaticus major Levator labii superioris Zygomaticus minor Levator anguli oris Risorius Depressor anguli oris Depressor labii inferioris Mentalis MASTICATORY MUSCLES nerve supply Trigeminal n. (Mandibular br.) Masseter m.: O: zygomatic arch I: the angle of mandible masseteric tuberosity Temporalis m.: O: tempral fossa I: coronoid proces Lateral pterygoid m.: O: lateral plate of pterygoid process I: the neck of the mandible Medial pterygoid m.: O: pterygoid fossa I: the angle of the mandible internal surface MUSCLES OF THE NECK Platysma m.: O: the skin over the clavicle I: the skin along the body of mandible N.S.: Facial n. Sternocleidomastoid m. F: F and E of head N.S.: XI. n. Suprahyoid group of muscles: Digastricus m.: O: digastric fossa of mandible I: mastoid notch anterior belly (N.S. trigeminal n.)

posterior belly (N.S. facial n.) 2 Stylohyoid m. Mylohyoid m.: O: mylohyoid line of mandible (N.S. trigeminal n.) Geniohyoid m.: O: the spine of the mandible (N.S. hypoglossal ansa) Infrahyoid group: N.S.: ansa cervicalis = hypoglossal ansa Sternohyoid m. Thyrohyoid m. Sternothyroid m. Omohyoid m. O: scapula Scaleni muscles function: flection of cervical spine, elevation of 1st and 2nd ribs Nerve supply: cervical spinal nerves Scalenus anterior O: C3-C6 vertebrae (trensverse processes) I: the 1st rib (in front of the groove for the subclavian a.) Scalenus medius O: C2-C7 vertebrae (trensverse processes) I: the 1st rib (behind the groove for the subclavian a.) Scalenus posterior O: C4-C5 vertebrae (trensverse processes) I: the 2nd rib Fissura scalenorum scalenic fissure the gap between scalenus anterior COMMON CAROTID ARTERY external carotid, internal carotid EXTERNAL CAROTID ARTERY supplies - the structures on the neck and face, - the oral and nasal cavities (palate, teeth, tongue, paranasal sinuses) - superf. structures of the cranium 1. Superior thyroid a. gives superior laryngeal a. 2. Lingual a. 3. Facial a. - submental a. - superior and inferior labial a. - nasal and angular a. 4. Ascending pharyngeal a. 5. Occipital a. 6. Posterior auricular a. 7. Temporal superficial a. - transverse facial a. - frontal and parietal branches 8. Maxillary a. supplies the mandible and lower teeth, the maxilla and upper teeth, the nasal cavity and paranasal sinuses,the masticatory muscles, middle meningeal a. - infraorbital a., mental a.

INTERNAL CAROTID ARTERY Supplies the brain and some organs of senses VEINS OF THE HEAD AND NECK External jugular v. - opens into the internal jugular v. receives tributaries: occipital and posterior auricular veins Internal jugular vein opens into the brachiocephalic v. receives tributaries: - sinus of dura mater (draining brain and organs of senses) - superior thyroid v. - lingual v. - facial v. - pharyngeal v. - retromandibular v. maxillary vein (pterygoid plexus) and temporal superficial v. 5 REGIONS OF THE HEAD CRANIUM: frontal region parietal region temporal region occipital region FACE: nasal orbital oral infraorbital and zygomatic mental buccal (here - parotideomasseteric) REGIONS OF THE NECK Boundaries: cranially mandiblemastoid processexternal occipital protuberance caudally jugular notchclavicleacromion7th cervical vertebra spine ANTERIOR NECK REGION - between sternocleidomastoid muscles submental triangle digastric (submandibular) triangle carotid triangle laryngeal region STERNOCLEIDOMASTOID REGION LATERAL NECK REGION between sternocleidomastoid m. and trapezius m. omoclavicular triangle = greater supraclavicular fossa suprascapular region POSTERIOR NECK REGION overlying trapezii muscles 16. The facial venous system, anastomoses and their practical importance.

17. Through what veins of the face can penetrate the infection in cavernous sinus in case of pus in the naso-labial triangle?

18. Topography of facial nerve.

The facial nerve is the seventh (VII) of twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla, and controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia.

Inside skull Greater petrosal nerve - provides parasympathetic innervation to several glands, including
the nasal gland,palatine gland, lacrimal gland, and pharyngeal gland. It also provides parasympathetic innervation to the sphenoid sinus, frontal sinus, maxillary sinus, ethmoid sinus, nasal cavity, as well as special sensory taste fibers to the palate via the Vidian nerve.

Nerve to stapedius - provides motor innervation for stapedius muscle in middle ear Chorda tympani
Submandibular gland Sublingual gland Special sensory taste fibers for the anterior 2/3 of the tongue.

Outside skull
Distal to stylomastoid foramen, the following nerves branch off the facial nerve:

Posterior auricular nerve - controls movements of some of the scalp muscles around the
ear

Branch to Posterior belly of Digastric muscle as well as the Stylohyoid muscle Five major facial branches (in parotid gland) - from top to bottom (a helpful mnemonic
being To Zanzibar ByMotor Car): Temporal branch of the facial nerve Zygomatic branch of the facial nerve Buccal branch of the facial nerve Marginal mandibular branch of the facial nerve

Cervical branch of the facial nerve

19. Outlet projection of terminal branches of trigeminal nerve. Ophthalmic branch:It is the smallest of the three divisions of the trigeminal, and arises from the upper part of the semilunar ganglion as a short, just before entering the orbit, through the superior orbital fissure, it divides into three branches, lacrimal, frontal, and nasociliary Maxillary branch (Scheme):Arises from the middle of Trigeminal Ganglion (which is located on the internal sup. sulcus on the temporal bone) , Its sensory in function. Maxillary N leaves the cranium through Foramen Rotondum and goes to Pterygopalatine fossa . Mandibular division of trigeminal N :its the largest branch of trigeminal , and it has 2 roots : sensory and motor. Sensory - originates from the inferior angle of trigeminal Gangliom Motor - originates in motor cells located in Pons& Medulla Olbongata. Both roots exist from Foramen Ovaly (but separately - the motor lying medially yto sensory) they unite just outside the skull and make V3 of trigeminal , then will devide.

20. Topography of maxillary nerve.

Maxillary branch (Scheme) Arises from the middle of Trigeminal Ganglion (which is located on the internal sup. sulcus on the temporal bone) , Its sensory in function. Maxillary N leaves the cranium through Foramen Rotondum and goes to Pterygopalatine fossa . the Maxillary nerve gives branches in 4 regions: i. Within the Cranium. ii. in the pterygopalatine fossa. iii. in Infraorbital canal. iv. On the face. 1. Within the Cranium : As it leaves it gives off small branches - Maningial nerrves for Dura Matter 2. In pterygopalatine fossa when it reaches this fossa it gives 5 branches a. Zygomatic arises in the pterygopalatine fossa, enters the orbit by the inferior orbital fissure, and divides at the back of that cavity into two branches, zygomaticotemporal (runs along the lateral wall of the orbit in a groove in the zygomatic bone, and, passing through a foramen in the zygomatic bone, enters the temporal fossa.) and zygomaticofacial(passes along the infero-lateral angle of the orbit, emerges upon the face through a foramen in the zygomatic bone). b. Sphenopalatine Branches :two in number, descend to the sphenopalatine c. Pterygopalatine N its 2 short trunks(post ganglion- unite in ganglion and then re distributed) - For Orbit

- For Nonse : Nasopalatine (lies between the mucous m and periosteum of nasal septum till reach the frool of nasal and then it devides into 2 then becom insicve. d. Greater and Lesser palatine its post ganglionic . The Greater : comes from PP fossa to hard palate through greater palatine foramen The Lesser : through lesser palatine foramen e. Posterior Sup. Alveolar N: comes from the main trunk just before inteing infraorbital F , reaching the posterior of maxilla. Commonly theres 2 branches (1. remains external to max bone, 2. enters into maxilla through PSA canals 3-4) f. pharyngeal branch. 3. Infraorbital Canal branch: Now its known as Infra-Orbital nerve , here it gives 2 important branches within the canal a. Middle Sup. Alveolar branch (MSA): its origin varies from anterior to posterior of the canal , it innervates the Premolars and the Mesiobuccal root of 1st Max Molar. b. Anterior Sup Alveolar branch (ASA) branched before 6-10mm before exiting the foramen , innervates frontal teeth -with periodonteum. (MSA) & (ASA) & (PSA) form the Sup. Dental Plexus. (MSA) & (ASA) communicates, and gives off a nasal branch. The Sup Dental Plexus give branch to each tooth , 3 types of nerves: i. Dental nerve - enter the tooth through apical foramen ii. Interdental nerve- innervates radicular septum, periodontal ligament, gingiva and interdental papilla iii. Inter-radicular nerve - to interraicular and interalveolar septum. 4. On the face branch after exisint infraorbital canal ,it wil give 3 branches on the posterior side of Max. , where it will reach its targets : a. Inferior eyeled (palpebral) - supply the skin and conjunctiva of the lower eyelid, joining at the lateral angle of the orbit. b. External nasal (lateral) - supply the skin of the side of the nose and of the septum mobile nasi, and join with the terminal twigs of the nasociliary nerve.. c. Superior labial - is the largest and go to the skin of the upper lip, the mucous membrane of the mouth, and labial glands.joined with the facial nerve filaments , forming with them the infraorbital plexus.

21. Topography of mandibular nerve.

Mandibular division of trigeminal N its the largest branch of trigeminal , and it has 2 roots : sensory and motor. Sensory - originates from the inferior angle of trigeminal Gangliom Motor - originates in motor cells located in Pons& Medulla Olbongata. Both roots exist from Foramen Ovaly (but separately - the motor lying medially yto sensory) they unite just outside the skull and make V3 of trigeminal , then will devide. Branches The Man N gives branches in 3 areas: 1. From the Undivided area 2. From Anterior area

3. From Posterior area

1. Undevided area after leaving foramen ovale in 2-3mm gives 2 branches a. Spinosus - retuns to the skull through the foramen spinosum. It divides into two branches, anterior and posterior, supply the dura mater&e mastoid air cells; b. Medial pterygoid - its motor n. to medial pterygoid mscules.

2. Anterior Division : this is divided into motor innervation (for mastication m.) and sensory innervation (teeth cheeks and soft tissues) This division runs under the external/ lateral pterygoid m. and then reach the external surface of it (passes through the 2 heads of the muscle), and from this moment its known an Buccal nerve (Buccinator) At the time that this N. was under the muscle it gave branches for masticatory m.: Masseter m. - it crosses the mandibular notch with the masseteric artery, to the deep surface of the Masseter. Deep Temporal - are two in number, anterior and posterior. lateral / external pterygoid - It enters the deep surface of the muscle

Now, after reaching the external sirface of the muscle , it continue emerges and at the level of occlusal plane of Mandibular 3rd/ 2nd molar it enters the cheek through Buccinator m. and also give some branches to Retro Molar triangle ( provide innervation to muccobucal fold and gingiva of that region) *Buccal nerve doesnt innervate the buccinator m. althought if passes through it ( the facial N does)

3. Posterior Division its primary sensory innervation , emerges downdawrd medially to external pterygoid and gives 3 branches : Auriculotemporalis: travelson the upper part of parotid gland to post. part of zygomatic arch and give branches: communication with facial nerve communication with otic ganglion anterior auricular branch to external auditory meatus atricular branch to TMJ superfecial temporal branches Lingual :

passes downward medially on the external ptrygoid m..(It lies at first beneath the Pterygoideus externus, medial to and in front of the inferior alveolar nerve), and then passes and lies between ramus of mandibule and internal pterygoid surface in pterygomandibular space. continueing down & inferior deep to mandibular raphe till it reaches the base of the tounge below and behind the mandibular 3rd Molar, there it lies just below mucous membrane in lingual sulcus , supplies the mucous membrane of the anterior two-thirds of the tongu then continue to reach the sublingual gland , and there it gives terminal branches. Inferior Alveolar N : the biggest branch of mandibular n. and has the same path with Lingual N. , on the medial surface of mandibular ramus it enters the Man canal through the foramen going forward to reach Mental foramen . Branches: mylohyoid - is derived from the inferior alveolar just before it enters the mandibular foramen. It descends in a groove on the deep surface of the ramus of the mandible, and reaching the under surface of the Mylohyoideus supplies this muscle and the anterior belly of the Digastricus. dental - supply the molar and premolar teeth. They correspond in number to the roots of those teeth; each nerve entering the root orifice, and supplying the pulp of the tooth; above the alveolar nerve they form an inferior dental plexus with the incisive b. incisive - is continued onward within the bone, and supplies frontal teeth with 1st Premolar Mental - exits the canal through mental formen and innervate the : skin of the area , chin , lower lip

22. Stratigraphy of genian region.

23. Stratigraphy of parotidomasseteric region.

Layers:

Skin Subcotaneous fatty tissue. SUPERficial facia & Auricolotemporal neurovascular bundle. Deep fascia / Fascia parotidomasseteric / Capsule of the parotid gland divided by CT that divide it in lobes. Can appear pain and edema but edema is not well palpated, never this gland affected all together but from some places. There are two weak (fascia is thin can be perforated by ifection) places in this fascia: Superior pole if there is infection here, it may perforate it and the pus may pass to the subcutaneous fatty tissue and will appear redness, and it may be

pass to the middle ear (and may lose its sense of hearing) in this case it is important to make drainage immediately . Middle surface of the gland infection may spread to the parapharyngeal space, and from there it may spread upward to the skull or downward to the heart and medistaneum. Medistinitis may die from.

24. The lodge and the sheath of the parotid gland.

25. Anatomical structures located in the parotid gland.

In to the tissue fo the gland is immersed a few structures External carotid artery (diameter is about 4mm of this artery) bleeding may be stopped by pressing the common carotid artery (4 arerteries supply the brain 2 internal carotid, and 2 vertebral). Nervous facialis injury will result in a very serious paralisis of the face. Lymph nodes (1-3mm in diameter) infection result in inlargment much more bigger than normal, Can caouse explosion and spread. Retromandibular vein Auriculotemporal nerve.

26. Deep region of the face.

imits:

Laterally to the region lays the branch of mandible and temporal muscle together. Medially maxillary tuberosity and pterygoid process of sphenoid bone. Superiorly can be seen part of the skull infratemporal crest

Contents: Yellow fat (in clinical cases can be seen which hide the structures) Pteregoid venous plexus Pterygoid mascules Temporo-peterygoid space/interstitium, & interpeterygoid space. Maxillary artery Mandibular nerve

27. Borders and content of temporopterigoidian, interpterygoidian and pterigomandibular celluloadipose spaces.

28. Buccal floor topography. limits:superior- mucous membrane of the mouth floor inferior- the skin of submental and submandibular regions posterior- the root of the tonque and muscles that insert on the styloid apophysis anterior- internal surface of the mandible

buccal floor contais the following region:1.submandibular 2.submental 3.sublinqual 29. Pus diffusion in the deep region of the face.

30. Pus diffusion in the buccal floor.

pus diffusion in the buccal floor mostly come from inflammatory process appears in sublinqual or submandibular region that can spreads to the whole mouth floor , and the pus accumulate in the subcutaneous adipose tissue above the mylohyoid muscle.

31. Topography of the lateral wall of the nasal cavity.

- is irregular due to the projections nasal conchae ( inferior , middle , superior) - it is formed by 6 bones , maxilla , lacrimal bone, ethmoid, sphenoid, perpendicularplate of palatine , inferior nasal conchea .

32. Communications of the orbit with adjacent regions.

33. Bichat fat body, clinic value.

is one of several encapsulated fat masses in the cheek. It is a deep fat pad located on either side of the face between the buccinator muscle and several more superficial muscles (including the masseter, the zygomaticus major, and the zygomaticus minor) The Buccal fat pad is commonly used in facial recontouring , Buccal flaps (not always including the buccal fat pad) are used in reconstruction of the periorbital area after injury. used to repair congenital defects of the oral cavity
[9][10] [8]

They are also

[11]

or for repair of congenital cleft palate.

34. Topography of the ophthalmic nerve.

Ophthalmic branch Leaves the cranial cavity through superior orbital fissure, first division of the trigeminal, is a sensory nerve. It supplies branches to the cornea, ciliary body, and iris; to the lacrimal gland and conjunctiva; to the part of the mucous membrane of the nasal cavity; and to the skin of the eyelids, eyebrow, forehead, and nose. It is the smallest of the three divisions of the trigeminal, and arises from the upper part of the semilunar ganglion as a short, just before entering the orbit, through the superior orbital fissure, it divides into three branches, lacrimal, frontal, and nasociliary. a. Frontal nerve the most thick branch, goes postero-anterior on the superior wall of the orbit and gives 2 branches: Supraorbital (extern) innervates medial part of superior eyelid, frontal region, mucous membrane of frontal sinus. Supratrochlear (intern) the skin of the root of the nose, eyelids. b. Nasociliary nerve is situated medial, gives branches:

 Communicant branch with ciliar ganglion Infratrochlear branch medial part of eyelids, lateral aspect of the nose, conjunctiva, lacrimal sac, caruncula lacrimalis. Long ciliary nerves iris and cornea Posterior ethmoidal nerves gives some filaments to sphenoidal sinus. Anterior ethmoidal nerves ethmoidal cells Intern nasal branch innervates the front part of nasal septum, lateral wall of nasal cavity Extern nasal branch cartilage of the nose, inferior part of the nose apex and ala c. Lacrimal nerve the most thin branch, innervates lateral part of upper eyelid, conjunctiva, receives a communicant branch from the zygomatic nerve for the secretory innervations of the lacrimal gland.

35. Topography of the maxillary artery.

I.Pterygoid part: Masseteric artery supplies the masseter muscle. Deep temporal arteries supply the temporal muscle. Pterygoid branches supply the homonymous muscles. Buccal artery supplies buccinators muscles II.Pterygopalatine part: Superior posterior alveolar artery mucosa of the maxillary sinus. Dental branches lateral superior teeth and gingiva. Infraorbital artery: Orbital branches supply rectus inferior and oblique inferior muscles, lacrimal sac. Anterior superior alveolar artery gives dental branches that supply frontal superior teeth, gingiva and the mucous membrane of the maxillary sinus. Descending palatine artery: Greater palatine artery supplies the hard palate and nasal cavity. Lesser palatine artery soft palate and palatine tonsils. Artery of the pterygoid canal (Vidian artery) can arise from external or internal carotid artery or serve as an anastamosis between them two. Sphenopalatine artery (nasopalatine): Posterior lateral nasal branches supply the frontal,maxillary, ethmoidal, sphenoidal sinuses. Posterior septal branches

36. Topography of the tongue.

TONGUE. Its main functions, Muscle of the tongue. The tongue, lingua is a muscular organ located in the oral cavity. The tongue role :

taste. digestion (mixing , lubrication , mastication , deglutition ). It has an important role in phonation and articulated(accent) speech.

Three parts are distinguished in the tongue: 1)The body, corpus linguae- The body of the tongue is separated from the root by terminal sulcus, in the middle of which the foramen caecum is placed. 2)The tip, apex 3)The root, radix linguae (it attaches the tongue to the mandible and to the hyoid bone). Topographically the tongue can be divided into two parts: 1)Oral part (placed in the oral cavity proper); 2)Pharyngeal part (faces the pharynx). On the dorsal surface of the tongue are numerous small elevations called papillae and they give the tongue a roughened surface that aids the handling of food. 1-Papillae of the tongue: 2-Filiform papillae 3-Conical papillae 4-Fungiform papillae 5-Foliate papillae 6-Vallate papillae The muscles of the tongue are divided into two groups: 1)Extrinsic, or skeletal muscles of the tongue 1-Genioglossus muscle 2-Hyoglossus muscle 3-Styloglossus muscle 2)Intrinsic, or proper muscles of the tongue 1-Superior longitudinal muscle 2-Inferior longitudinal muscle 3-Transverse muscle 4-Vertical muscl Tongue. Vascularisation and innervation. Limph drenaje.

Vasculature:1- lingual artery, a branch of the external carotid artery and lingual veins which drain into internal jugular
vein. 2-There is also secondary blood supply to the tongue from the tonsillar branch of the facial artery and the ascending pharyngeal artery.

Innervation:Anterior 2/3rds of tongue General somatic afferent: lingual nerve branch of V3 of the trigeminal nerve CN V Taste: chorda tympani branch of facial nerve CN VII (carried to the tongue by the lingual nerve).

Posterior 1/3rd of tongue

 Motor

General somatic afferent and taste: Glossopharyngeal nerve CN IX

All intrinsic and extrinsic muscles of the tongue are supplied by the hypoglossal nerve (CN XII), except for one of the extrinsic muscles, palatoglossus, which is innervated by the Vagus nerveCN X of the pharyngeal plexus.

37. Topography of the oral vestibule.

he area between the tooth rows and the lips or cheeks is called the oral vestibule (vestibulum oris). According to the Latin terms the directional names are oral ("towards the oral cavity") and vestibular ("towards the oral vestibule").

38. Topography of the hard and soft palate of the mouth.

the palate forms the upper wall of the oral cavity , it consists of two parts:1)hard palate - anterior 2/3 is occupied by the hard palate , is formed by the palatine process of the maxilla and horizontal plate of palatine bone. the mucous membrane which cover the palte adheres to the periosteum by dense fibrous tissue . that the mucous contains alot of palatine glands which open of small orifices on the surface of the palate . 2)soft palate - posterior 1/3 is the soft palate , the mucous membrane of the soft palte contain glands. the anterior margin of the soft palate is attached to the posterior edge of the hard palate , but its posterior part velum palatinum extends freely downward and to the back , have in the midline a tongue like projection named uvula. on lateral side of the soft palate forms two arches :1) palatoglossal arch 2) palatopharyngeal arch between the two named arch forms the tonsilar fossa in which palatine tonsil is placed . the muscles of the soft palate are :1) palatopharynges m 2) palatoglossus m 3) levator veli palatine m 4) tensor veli palatini m 5) musculus uvuale

39. Topography of maxillary teeth. 40. Topography of mandibular teeth.

Operative surgery
1. Peculiarities of the craniocerebral wounds debridement.
Peculiarities : It is necessary to considers connections of the superficial and deep venous. Local anesthesia is preferable Economic excisions Avoid lesions of te nerve and salivary glands

Minimal incisions Extraction fo the bony fragments and broken teeth. Restoration or displacement of parotid duct. Exact repositioning of bony fragments. Hemostatic suture of the tongue wounds. - U shaped sutures Microsurgical restoration of the facial nerve.

2. Anatomical argumentation of rational incision on craniocerebral region. 3. Methods of hemostasis in epicranial tissue bleeding. 4. Hemostasys methods in bleeding from the skull bones. 5. Hemostasis procedures in medial meningeal artery injury. 6. Methods of hemostasis in dura mater venous sinus injury. 7. Skull trephination - definition, indications, methods.
rephining or making a burr hole, is a surgical intervention in which a hole is drilled or scraped into the human skull, exposing the dura mater to treat health problems related to intracranial diseases

indications :8. Osteoplastic skull trepanation by Olivecron and Wagner-Wolfe. 9. Decompressive skull trephination by Cushing. 10. Cranioplasty - definition, indications, types of materials used.
A Cranioplasty is a surgical procedure to correct a deformity or defect of the skull and it is usually performed following a traumatic injury to the skull or after a previous brain surgery such as a craniotomy or craniectomy. In order to correct the defect the physician may have to use a prosthetic or other synthetic surgical material to complete the procedure.

11. Platic surgery methods on epicranial tissue defects. 12. Antrotomy indications, operative stages, complications. 13. Anatomical argumentation of the rational incisions on the facial region.

14. Peculiarities of surgical debridement in maxillofacial wounds.

Peculiarities : It is necessary to considers connections of the superficial and deep venous. Local anesthesia is preferable

Economic excisions Avoid lesions of te nerve and salivary glands Minimal incisions Extraction fo the bony fragments and broken teeth. Restoration or displacement of parotid duct. Exact repositioning of bony fragments. Hemostatic suture of the tongue wounds. - U shaped sutures Microsurgical restoration of the facial nerve.

15. Maxillary sinus punctures. 16. Maxillary sinus trephination. 17. Dental nerve plexus anesthesia. 18. Tuberal anesthesia.
During this anesthesia are blocked: Posterior superior alveolar nerves (PSA), which are situated in pterygopalatine fossa and on the posterior-external surface of maxillary tuberosity. Landmarks PSA are situtated in pterygopalatine fossa and on the posterior-external surface of maxillary tuberosity, where are osseous/bony orifices through which the nerves enter inside the tuberosity. These orifices are situated on the middle of tuberositys height, but their level can differ depending on the age (at dentate/that have teeth adults they are situated higher, at edentate/[that dont have teeth old] persons - situated lower because of alveolar bone resorption). rd 18-25 mm above the alveolar edge of superior 3 molar. st Second superior molar, at children under 12 years as landmark will serve 1 superior molar. In case of lateral teeth absence as landmark serves zygomaticoalveolar crest (crista zygomatico-alveolaris). It is situated at the level of 1st superior molar, the needle in such case is introduced posterior this crest. Intra-oral technique: At a half-opened mouth of the patient with a mirror or with fingers the cheek is withdrawn outwards. The needle is disposed at an angle of 45 degrees to the alveolar bone, its bevel (the tip of the needle) must be turned to the bone. The needle is introduced in the mucous membrane, 0.5 cm downwards the muco-bucal fold at the level of second molars crown or between the second and the third molars. The needle is advanced superior, posterior and medially at a depth of 2.5 cm (2.5 is for big maxilla, therefore normally 2 cm), always keeping the contact with the bone and injecting during the way small amounts of LA. Is introduced/injected 2ml of LA (1.5 ml for good anesthetic solution), anesthesia installs in 5-6 minutes.

After needles withdrawal/removed is made check compression with the back of the hand under zygomatic bone for better LA diffusion.

Area of anesthesia: st nd 1 , 2 and third superior molars. Periosteum, mucous membrane in the region of these teeth (only from vestibular side). Mucous membrane and osseous tissue of postero-lateral wall of maxillary sinus. Extra oral technique Doctor stand on the right to the patient. The needle is introduced at anteroinferior angle of zygomatic bone (located at the same line of the lateral edge of the orbit, downward), it is directed superior and interior (posterior), at an angle of 45 degrees to the medial, sagittal surface. The needle is advanced at a depth which is equal with the distance measured between the place of injection and inferiolateral angle of the orbit. About 2 cm.

19. Infraorbital anesthesia.

Infraorbital anesthesia (anesthesia at foramen infraorbitalis) During infrarbital anesthesia are blocked peripheral fibers of infraorbital nerve: Superior anterior and medial alveolar nerve. Infrior palpebral nerve. Lateral nasal nerve. Superior labial nerve. Landmarks (where we find the foramen or how to find them): The main landmark is infraorbital foramen which is situated: 0.5-0.75 cm downwards the intersection point of infraorbital edge with vertical line drawn through the middle of second superior premolar. During palpation is determined maxilla-zygomatic suture (place where zygomatical process of maxilla unites with zygomatic bone). 0.5-0.75 cm downwards this suture is situated foramen infraorbitalis. 0.5-0.75 cm downwards the intersection place of infraorbital edge with vertical mediopupilar (middle of pupil), when patient is looking straight. On the skull on the vertical line which passes through supraorbital notch and mental formen. The axes of infraorbital formen is oriented anterior, medial, and inferior. In this way the axes of both formen intersect on the medial line between superior central incisors. (the formen opens to the medial and a little bit inferior). Needle direction Is opposite to the formen axes: Posterior, lateral and superior. Infraorbital anesthesia can be performen by 2 ways: 1. Intraoral (endooral) way. 2. Extra-oral (exo-oral) way. Intraoral ways (technique): Founding the projection of infraorbital formen on the skin with index of the left hand, soft tissues are fixed in this place to the bone.

With the thumb, superior lip is elevated upwards and forward. The needle size is 27 - 30 gadge (nasal). The needle is introduced in the depth of muco-bucal fold, at the level of the interval between central and lateral superior incisors. The needle is introduced posterior, superior, and lateral (in one movement) till it reaches the bone. Keeping the contact with the bone (not nessesarly keeping contact with the bone) the needle is advanced to the formen and during all the way small amounts of LA (local anesthetic) are introduced in the tissues. In the region of infraortibal formen 0.5-1 ml of LA is deposited, then is searched the entrance in the canal which can be detected by characteristic falling of the needle and painful reaction of the patient. Inside the canal, the needle is introduced at the depth of 2 mm (or 5mm), and is deposited 0.5-1 ml of LA. Ask from the patient to stop bleeding (by compressing the area), if entered the canal and damaged. (Parasthesia - stays paralized cupple of mouth). Press to diffuse inside the bone. Anesthesia appears during 2-5 minutes.

Extraoral way: Using the landmarks s detected the projection of infraorbital formen on the skin. Process skin with alcohol sulotion. With the index of the left hand the tissues are fixed to the bone, in order to avoid accidental injury of the eyeball. The needle is introduced 0.5 cm downward and medially the projection of infraorbital foramen till it reaches the bone, giving it the correct direction: superior, posterior and laterally. Next stepts are the same in the intraoral way of the infraorbital anesthesia . The area of anesthesia (what will be anesthesiased): st Incisors, canine, premolars and mesio-vestibular root of 1 superior molar. Alveolar bone and gingiva in the region of these teeth only from the vestibular side. Mucous membrane and osseous tissue of the anterior, postero-lateral (partially), superior and inferior walls of maxillary sinus. The skin of infraorbital region, inferior eyelid, lateral part of the nose, nasal septum, the skin and mucosa of superior lip.

20. Palatinal anesthesia.

During this anesthesia is blocked major/greater palatine nerve which lies in the homonym (same name) foramen and canal (Major palatine foramen). Landmarks: rd Major/greater palatine foramen is situated at the level of crowns midline of the 3 superior molar. In case of its absence, the foramen can be found posteriorly and medially the second superior molar. 0.5 cm anteriorly the border between the hard and the soft palate (Ah line called in orthopedy).

draw line through the midline of 3rd molar, former will be located in the intersection point of half of the side part of the jaw (draw line through the middle of half the jaw which is separated by the jaw midline). The foremen will be in the junction between the alveolar process line and the midline through the 3rd molar. the region of the foremen can be a little bit whiter than the neighbouring mucosa.

Technique intra oral (there is no extraoral): Patients head in maximal extension, mouth wide opened. Needle is introduced at 1 cm anteriorly and medially from the projection of major palatine foramen. The needle is advanced superior, posterior and laterally till the contact with the bone and till it reaches the foramen. the needle should not nessesarly be introduced inside the foremen (some patient may feel uncomfortable). 0.5 ml of LA is injected. Anesthesia installs in 2-3 minutes. Area of anesthesia: rd Mucous membrane of hard palate, alveolar process from the palatal side (from 3 superior molar till the midline of canine). Till 1st premolar will be anesthesia completely. Anterior 1/3 of soft palate.

21. Incisive anesthesia.

Nasopalatine anesthesia (incisive nerve block) During this anesthesia is blocked nasopalatine nerve. This is an additional anesthesia method, used inorder to anesthesis the palatal mocousa. Landmarks: Incisive formen is situated on the palatal bone on the medial line between central incisors, 7-8 mm posteriorly the gingival edge (incisive papilla). Draw imaginary line between the middle of canines the intersection point with the midline of palatal line. Two incisive canals open superior at both sides of nasal septum at 1.5cm posteriorly the narionar threshold (the beginning of the nose), and they unite together downwards at incisive foramen. Intraoral technique: Apply topical on mocusa. The head of the patient must be maximal extension, mouth wide open. The needle is introduced in the lateral edge of incisive papilla (a little elevation of mucous), a little anteriorly the incisive foramen. Small amount of LA 0.3-0.5 ml is deposited under papilla. Then the needle is advanced into the canal at a depth of 5mm, and 0.25-0.5 ml of LA is injected. Extraoral technique: The top of the nose is pulled up with doctors fingers.

The needle is introduced 1.5 cm posterior to the narinar threshold at the base of nasal septum from the both sides. Needle direction is straight down.

Area of anesthesia: Mucous membrane, periosteum of alveolar process and hard palate in a shape of a triangle which angles pass through the midlines of canines.

22. Maxillary nerve anesthesia (Pterygopalatine anesthesia). 23. Manidibular nerve anesthesia at the oval foramina (infrazigomatic way).
IAN block through subzygomatic way Technique: Needle is inserted below the inferior edge of zygomatical arch, 2cm anteriorly from the tragus. The needle is placed perpendicularly to the teguments and is advanced 3-3.5 cm strictly horizontal, gradually injecting LA.

24. Mandibular anesthesia.

Mandibular anesthesia or also called Inferior alveolar NB or Anesthesia at Spina Spix (spina spix is the lingula) Infiltration techniques do not work in the adult mandible due to the dense cortical bone. Nerve blocks are utilized to anesthetize the inferior alveolar, lingual, and buccal nerves. Provides anesthesia to the pulpal, alveolar, lingual, and buccal gingival tissue, and skin of lower lip and medial aspect of chin on side injected. Inferior alveolar nerve block (IAN): Technique involves blocking the inferior alveolar nerve (IAN) prior to entry into the mandibular lingual on the medial aspect of the mandibular ramus. Anatomical guidelines/landmarks of mandibular foremen (variation generally different from children and old) It is situated on the internal surface of mandibular ramus: 1. From its anterior edge at a distance of 15 mm. 2. From the posterior edge 13mm. 3. From the mandibular notch 22mm. 4. From the inferior edge 27mm. The height of foremens location at adults is equal to the level of occlusal plane of inferior molars, at aged persons (old) and children it is situated slightly lower. In front and inside, mandibular foramen is covered by osseous prominence mandibular lingual (osseus proimenance). Thats why LA should be introduced at 0.75-1 cm higher the foramens level, where the nerve before entering the foramen lies in the groove sulcus colli mandibulae. At this level is found LCT through which LA spreads fairly well. Intraoral ways of alveolar nerve block: 3. Anesthesia using palpation. 4. Anesthesia using specific landmarks.

IAN block using palpation Is necessary to determine, by palpating the location of fovea retromolaris and crista temporalis. retromolar pit is not the depression made between the pedicles of the temporal crist. But it is located between the external/lateral foot of the crista temporalis and the anterior edge of the ramus, the oblique line. From coronoid process to the lingual side of alveolar process descends an osseous shaft (like roller) called temporal crest. At its inferior level the crest divides into internal and external pedicles, which outline a small triangular region- retromolar triangle. Between anterior edge of mandibular ramus, passing downwards into the external oblique line, and temporal crest is located a small triangular depression fovea retromolaris. Technique IAN block using palpation Osseous landmarks are pulpated with the index of left hand when anesthesia is performed on the right side, or with the thumb if anesthesia is made on the left side. Patients mouth is wide open. Is palpated anterior edge of the ramus at the level of distal surface of third inferior molar. Moving the finger madialy, is determined temporal crest, which projection is transferred on the mucous membrane. The finger is fixed in retromolar fovea which is located between these anatomical landmarks. Placing the syringe at the level of premolars from the opposite side, the needle is introduced medially from the temporal crest and 0.75-1 cm higher the occlusal plane of inferior molars. The needle is directed laterally and posteriorly (backwards). The needle should be directed as much as possible perpendicular to the bone. At a depth of 0.5-0.7 cm it reaches the bone. Injecting 0.5-1 ml of LA is blocked lingual nerve. Then the needle is introduced 2 cm till it reaches sulcus colli mandibulae, where lies inferior Alveolar Nerve, and 2 ml of LA are injected. The mandibles ramus is not strictly in sagittal plane but at an angle to it, thats why the syringe after it reaches the bone should be moved on the teeth from the side anesthesia is performed. AND thumb - anterior edge of ramus, the thumb also used to retract the cheek to see the place of insertion. index externally - posterior ramus palpating. Anesthesia using specific landmarks - the main landmark is pterygomandibular raphe (plica pterigo mandibularis) (it is a mocusa not a bony structure), which is situated medially from the temporal crest. Technique using specific landmarks Patients mouth wide open, the syringe is placed at the level of premolars or first molar from the opposite side. The needle is inserted in pterygomandibular raphe in the middle of the distance between occlusal surfaces of superior and inferior molars. The needle is advanced laterally and posteriorly till the contact with the bone, 1.5-2 cm Are introduced 2-3 ml of LA to block inferior alveolar and lingual nerves. Extraoral ways - probably not necessary , but can be read in material taken in OMF .

25. Peripheral truncular anesthesia of the mandible.

26. Torusal anesthesia. 27. Surgery in congenital fissures of the lips (heioplasty). Cleft lip repair (cheiloplasty) is surgical procedure to correct a groove-like defect in the lip . Important structures of the embryo's mouth form at four to seven weeks of gestation. Development during this period entails migration and fusion of mesenchymal cells with facial structures. If this migration and fusion is interrupted (usually by a combination of genetic and environmental factors), a cleft can develop along the lip. The type of clefting varies with the embryonic stage when its development occurred. surgery The edges of the cleft between the lip and nose are cut (A and B). The bottom of the nostril is formed with suture (C). The upper part of the lip tissue is closed (D), and the stitches are extended down to close the opening entirely (E). (Illustration by Argosy.) Cleft lip repair can be initiated at any age, but optimal results occur when the first operation is performed between two and six months of age. Surgery is usually scheduled during the third month of life. While the patient is under general anesthesia, the anatomical landmarks and incisions are carefully demarcated with methylene blue ink. An endotracheal tube prevents aspiration of blood. The surgical field is injected with a local anesthestic to provide further numbing and blood vessel constriction (to limit bleeding). Myringotomy (incisions in one or both eardrums) is performed, and myringotomy tubes are inserted to permit fluid drainage.

28. Surgery in congenital fissure of the hard palate (uranoplasty).

Facial tissues, including lip and palate, are produced from mesenchymal migration, penetration, and fusion of cranioneural crest cells Each of the 3 main facial prominences (nose, lips, palate) is derived embryologically from bilateral converging facial processes. Formation of the primary palate begins at approximately 35 days of gestation. Complete lip development generally occurs by the sixth week of gestation, followed by palatal fusion. Three paired anatomic processes are involved with this phenomenon of migration and penetration: (1) the medial nasal process coalesces with the (2) maxillary process, followed by the coalescence of the (3) lateral nasal process with the medial nasal process Development of the secondary palate begins after the

primary palate has formed. This process is initiated when outgrowths (palatal shelves) push medially and bilaterally from the maxilla At first, the palatal shelves grow downward and adjacent to the tongue Gradually, they elevate to a level above the tongue and assume a horizontal position Contact of these 3 processes and fusion of the tissues then occurs, resulting in the development of a normal secondary palate. If the palatal shelves fail to fuse, a cleft palate results. This mechanism may be the most common origin of cleft palate deformity. Other possible reasons for palatal clefting involve abnormal growth of the palatal shelves, cell death (postfusion), and failure of mesenchymal consolidation and differentiation. Clefts of the secondary palate are usually the result of different morphogenic events when compared with cleft lip with or without cleft palate.

principle of Palatoplasty

Closure of the defect. Correction of the abnormal position of the muscles of the soft palate, especially Levator Palati.

Reconstruction of the muscle sling. Retropositioning of the soft palate so much so that during speech the posterior part of the soft palate comes in contact with the posterior pharyngeal wall during speech.

Minimal or no raw area should be left on the nasal side or the oral surface. Tension-free suturing. Two-layer closure in the hard palate region and a three-layer closure of the soft palate.

The surgical techniques of cleft palate repair which are presently practised by different surgeons in various centres are being presented. There are many variations of each of these techniques. However, only a few of them which are most relevant and useful are being presented. von Langenbeck's bipedicle flap technique Veau-Wardill-Kilner Pushback technique Bardach's two-flap technique Furlow Double opposing Z-Plasty Two-stage palatal repair Hole in one repair Raw area free palatoplasty Alveolar extension palatoplasty (AEP) Primary pharyngeal flap Intravelar veloplasty Vomer flap Buccal myomucosal flap

Topographical anatomy of neck region

1. Landmarks and topographic triangles on the neck.

Anterior Triangle.The anterior triangle is bounded, in front, by the middle line of the neck; behind, by the anterior margin of the Sternocleidomastoideus; its base, directed upward, is formed by the lower border of the body of the mandible, and a line extending from the angle of the mandible to the mastoid process; its apex is below, at the sternum. And this triangle divided into :1)the inferior carotid 2) the superior carotid 3) the submaxillary 4) the suprahyoid Posterior Triangle.The posterior triangle is bounded, in front, by the Sternocleidomastoideus; behind, by the anterior margin of the Trapezius; its base is formed by the middle third of the clavicle; its apex, by the occipital bone. The space is crossed, about 2.5 cm. above the clavicle, by the inferior belly of the Omohyoideus, which divides it into two triangles, an upper or occipital, and a lower or subclavian.

2. Cervical fasciae by V. Shevkunenko.

Cervical fascia 1. Superficial cervical fascia - this fascia forms the sheath for platysma muscle. internal cervical vein & cervical plexus. It is a thin layer of subcutaneous connective tissue that lies between the dermis of the skin and the deep cervical fascia. It contains the platysma, cutaneous nerves, blood, and lymphatic vessels. It also contains a varying amount of fat, which is its distinguishing characteristic. 2. Superficial lamina of deep fascia - forms the sheath for sternocleidomastoid muscle, trapezius m., & for submandibular salivary gland. 3. Deep lamina of deep fascia (pretracheal fascia) - forms the sheath for pretracheal muscles, its very important fascia which has a triangular shape. 4. Fascia endocervicalis - this fascia has 2 leaves a. Parietal - forms the sheath for main neurovascular bundle of neck. b. Visceral - forms the cover for cervical organs. In this structure there are the carotid, vagus, jugular vessels. 5. Prevertebral fascia - covers cervical vertebra, lungi cervical muscles & Scalene muscles

3. Celluloadipose spaces of the neck, practical importance.

1-sternoclidomastoid space 2-Submandibular space( sub-mandibular salivary gland and one -3 lymph node ) 3-intraabrauntic supra-sterna space 4-pretrachial space( limited by parietal and visceral lamina of endo cervical fascia this space contain pre-tracheal lymph node / thyroid venous plexus/ superior lobe of thymus/ inferior thyroid artery/ arterial brachiocephalic track/ left brachiocephalic vein 5- retro-visceral space( behind esophagus and tracheal )

6- para-pharengel space 7- preverttebral space(deep space of neck ) 8-neuro vascular space this space conatin -vagus -internal jugular vein -Lymph node 9- autosclenic space 10- intersclanic space 11-sclenovertebral space 12- superficial space of lateral triangle of neck

4. Topography of the superficial cervical vessels and nerves. external jugular vein It commences in the substance of the parotid gland, on a level with
the angle of the mandible, and runs perpendicularly down the neck, in the direction of a line drawn from the angle of the mandible to the middle of the clavicle at the posterior border of the sternocleidomastoideus. In its course it crosses the sternocleidomastoideus obliquely, and in the subclavian triangle perforates the deep fascia, and ends in the subclavian vein lateral to or in front of the scalenus anterior, piercing the roof of the posterior triangle. It is separated from the sternocleidomastoideus by the investing layer of the deep cervical fascia, and is covered by the platysma, the superficial fascia, and the integument; it crosses the cutaneous cervical nerve, and its upper half runs parallel with the great auricular nerve. The external jugular vein varies in size, bearing an inverse proportion to the other veins of the neck, it is occasionally double. The external jugular vein drains into the subclavian vein lateral to the junction of the subclavian vein and the internal jugular vein.

superficial plexus 5. Topography of the phrenic nervs in the cervical region.

The phrenic nerve is a nerve that originates in the neck (C3-C5) and passes down between the lung and heart to reach the diaphragm. It is important for breathing, as it passes motor information to the diaphragm and receives sensory information from it. There are two phrenic nerves, a left and a right one.

6. Critical arterial segments on the neck - terrain reasoning. 7. Previsceral celluloadipose space of the neck - delimitation, content, possible ways of pus dissemination.

8. Topography of sternocleidomastoid region.

. Sternocleidomastoid region ) Covered by sternocleidomastoid .M The sternocleidomastoid passes obliquely across the side of the neck. It is thick and narrow at its central part, but broader and thinner at either end. The medial or sternal head is a rounded fasciculus, tendinous in front, fleshy behind, which arises from the upper part of the anterior surface of the manubrium sterni, and is directed superiorly, laterally, and posteriorly. The lateral or clavicular head, composed of fleshy and aponeurotic fibers, arises from the superior border and anterior surface of the medial third of the clavicle; it is directed almost vertically upward.

The two heads are separated from one another at their origins by a triangular interval (supraclavicular fossa) but gradually blend, below the middle of the neck, into a thick, rounded muscle which is inserted, by a strong tendon, into the lateral surface of the mastoid process, from its apex to its superior border, and by a thin aponeurosis into the lateral half of the superior nuchal line of the occipital bone. The function of this muscle is to rotate the head to the opposite side or obliquely rotate the head. It also flexes the neck. ) Contents 1. Ansa cervicalis 2. Carotid sheath 3. Cervical plexus 4. Cervical part of sympathetic trunk

9. Projection, composition and sintopy of the medial neurovascular bundle of the neck.
line which correlated to anterior sternocleidomastoid muscle

10. Topography of the submandibular triangle.

Limits and sides of traiangle :

margin of mandible bellis of the gastricus muscle

Layers :

skin subcotaneous fatty tissue superficial fascia with platisma muscle deep fascia ( 2nd cervical fascia) - this fascia splits to form the capsule for submandibular salivery gland.

Deep lamina of this fascia covers the floor of trangle. Between these two leaves (lamina of deep fascia) lies submandibular gland. Arround and within the gland there are 3-5 lymph nodes : Floor of the region or traiangle :

Meloheodeous Hayogleous muscle.

The salivary duct, lingual vein, lingual nerve, and hypoglosal nerve pass through the split between the meyohyloedeous and hayogloussous muscles.The lingual artery lies below the haylogloussous muscle, within the perigovs triangle.

11. Topography of the Pirogovs triangle.

Perigouvs triangle is formed (sides of submandibular triangle): 1. Superior- hypogglousal nerve 2. Margin of myoloudeous muscle 3. Inferior - intermediat tendon of the gastricous. Floor of perigouvs triangle - hyogloussous muscle. Next layer - sub mocousal loss connective tissue. Last layer - tunica mucosa (mocusal layer).

12. Topography of the carotid triangle.

Coverings and boundaries

It is bounded: posteriorly by the Sternocleidomastoideus; inferiorly, by the superior belly of the Omohyoideus superiorly, by the Stylohyoideus and the posterior belly of the Digastricus.

It is covered by the integument, superficial fascia, Platysma and deep fascia; ramifying in which are branches of the facial and cutaneous cervical nerves. Its floor is formed by parts of the Thyrohyoideus, Hyoglossus, and the Constrictores pharyngis medius and inferior.

The Inferior Carotid, or Muscular Triangle, is bounded, in front, by the median line of the neck from the hyoid bone to the sternum; behind, by the anterior margin of the Sternocleidomastoideus; above, by the superior belly of the Omohyoideus. It is covered by the integument, superficial fascia, Platysma, and deep fascia, ramifying in which are some of the branches of the supraclavicular nerves. Beneath these superficial structures are the Sternohyoideus and Sternothyreoideus, which, together with the anterior margin of the Sternocleidomastoideus, conceal the lower part of the common carotid artery. The Superior Carotid, or Carotid Triangle, is bounded, behind by the Sternocleidomastoideus; below, by the superior belly of the Omohyoideus; and above, by the Stylohyoideus and the posterior belly of the Digastricus. It is covered by the integument, superficial fascia, Platysma and deep fascia; ramifying in which are branches of the facial and cutaneous cervical nerves. Its floor is formed by parts of the Thyrohyoideus, Hyoglossus, and the Constrictores pharyngis medius and inferior. This space when dissected is seen to contain the upper part of the common carotid artery, which bifurcates opposite the upper border of the thyroid cartilage into the external and internal carotid

13. Hallmarks of external and internal carotid arteries.

the pulse of the carotid artery:, palpated by gently pressing a finger in the area between the larynx and the sternocleidomastoid muscle in the neck The bifurcation into the external and internal carotid arteries occurs at the upper border of the thyroid cartilage, at around the level of the fourth cervical vertebra The left common carotid artery can be thought of as having two parts: a thoracic (chest) part and a cervical (neck) part. The right common carotid originates in or close to the neck, so contains a small thoracic portion .The pulse is taken by palpating the artery just deep to the anterior border of the sternocleidomastoid muscle at the level of the superior border of the thyroid cartilage.

14. Topography of scaleno-vertebral triangle.

Scaleno-vertebral triangle Its boundaries are the Longus colli ; scalenus anterior and the transverse process of 6th cervical vertebra. It contains 1st part of subclavian artery ; sympathetic chain ; vertebral artery and the thoracic duct

15. Topography of the lateral triangle of the neck.

it has the following boundaries:

Apex: Union of the sternocleidomastoid and the trapezius muscles at the superior nuchal line of the occipital bone Anterior: Posterior border of the sternocleidomastoideus Posterior: Anterior border of the trapezius Base: Middle one third of the clavicle

which divides the space into two triangles:

an upper or occipital triangle

The occipital triangle, the larger division of the posterior triangle, is bounded, in front, by the Sternocleidomastoideus; behind, by the Trapezius; below, by the Omohyoideus. Its floor is formed from above downward by the Splenius capitis, Levator scapul, and the Scaleni medius and posterior. It is covered by the skin, the superficial and deep fasci, and by the Platysma below. The accessory nerve is directed obliquely across the space from the Sternocleidomastoideus, which it pierces, to the under surface of theTrapezius; below, the supraclavicular nerves and the transverse cervical vessels and the upper part of the brachial plexus cross the space. The roof of this triangle is formed by the cutaneous nerves of cervical plexus and the external jugular vein and platysma muscle. A chain of lymph glands is also found running along the posterior border of the Sternocleidomastoideus, from the mastoid process to the root of theneck.

a lower or subclavian triangle (or supraclavicular triangle)

The Subclavian Triangle, the smaller division of the posterior triangle, is bounded, above, by the inferior belly of the Omohyoideus; below, by the clavicle; its base is formed by the posterior border of the Sternocleidomastoideus. Its floor is formed by the first rib with the first digitation of the Serratus anterior. The size of the subclavian triangle varies with the extent of attachment of the clavicular portions of the Sternocleidomastoideus and Trapezius, and also with the height at which the Omohyoideus crosses the neck. This space is covered by

the integument, the superficial and deep fasci and the Platysma, and crossed by the supraclavicular nerves

16. Possible diffusion paths of pus collections of the lateral cervical triangle. 17. Topography of antescalene space.
Its located on the anterior part of anterior scalene muscle

18. Topography of interscalene space.

The interscalene space (or interscalene groove) is a potential space between the anterior and middle scalene muscles. Interscalenic space - through this space passes - subclavian artery, Branchial neurovascular plexus.

19. Clinical anatomy of thyroid and parathyroid glands. The parathyroid glands are four or more small glands, about the size of a grain of rice, located on the
posterior surface (back side) of the thyroid gland. The parathyroid glands usually weigh between 25 mg and 40 mg in humans. There are typically four parathyroid glands. The two parathyroid glands on each side which are positioned higher (closer to the head) are called the superior parathyroid glands, while the lower two are called the inferior parathyroid glands. Occasionally, some individuals may have six, eight, or even more parathyroid glands.The parathyroid glands are named for their proximity to the thyroid but serve a completely different role than the thyroid gland. The parathyroid glands are quite easily recognizable from the thyroid as they have densely packed cells, in contrast with the follicle structure of the thyroid.

[1][2]

However, at surgery, they are harder to differentiate from the thyroid or fat.

Because the inferior thyroid arteries provide the primary blood supply to the posterior aspect of the thyroid gland where the parathyroid glands are located, branches of these arteries usually supply the parathyroid glands. However they may also be supplied by the branches of the superior thyroid arteries; the thyroid ima artery; or the laryngeal, tracheal and esophageal artery. Parathyroid veins drain into thyroid plexus of veins of the thyroid gland.Lymphatic vessels from the parathyroid glands drain into deep cervical lymph nodes and paratracheal lymph nodes.

The thyroid gland is a butterfly-shaped organ and is composed of two cone-like lobes or wings, lobus dexter (right
lobe) and lobus sinister (left lobe), connected via the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at the oblique line on thethyroid cartilage (just below the laryngeal prominence, or 'Adam's Apple'), and extends inferiorly to approximately the fifth or sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels because it moves position in relation to these during swallowing.The thyroid gland is covered by a thin fibrous sheath, the capsula glandulae thyroidea, composed of an internal and external layer. The external layer is anteriorly continuous with the lamina pretrachealis fasciae cervicalis and posteriorolaterally continuous with the carotid sheath. The gland is covered anteriorly with infrahyoid muscles and laterally with the sternocleidomastoid musclealso known as sternomastoid muscle. On the posterior side, the gland is fixed to the cricoid and tracheal cartilage and cricopharyngeus muscle by a thickening of the fascia to form the posterior suspensory ligament of Berry.

[1]

[2][3]

The

thyroid gland's firm attachment to the underlying trachea is the reason behind its movement with swallowing. In variable extent, Lalouette's Pyramid, a pyramidal extension of the thyroid lobe, is present at the most anterior side of the lobe. In this region, the recurrent laryngeal nerve and the inferior thyroid artery pass next to or in the ligament and tubercle.Between the two layers of the capsule and on the posterior side of the lobes, there are on each side two parathyroid glands.

[4]

20. Report of the recurrent nerves with the trachea and esophagus in the cervical region. 21. Surgical anatomy of the thoracic duct in the neck.
In human anatomy, the thoracic duct is the largest lymphatic vessel of the lymphatic system. It is also known as the left lymphatic duct,

22. Areas of lymph drainage of thoracic duct and right lymphatic duct. Thoracic duct :- It drains into the systemic (blood) circulation at the left brachiocephalic vein between the left
subclavian and left internal jugular veins. It also collects most of the lymph in the body other than from the right side which is drained by the right lymphatic duct.

The right duct drains lymph fluid from:

the upper right section of the trunk, (right thoracic cavity, via the right bronchomediastinal trunk), the right arm (via the right subclavian trunk),

and right side of the head and neck (via the right jugular trunk), also, in some individuals, the lower lobe of the left lung.

[2]

All other sections of the human body are drained by the thoracic duct.

23. Sino carotid reflexogen area.

the carotid sinus is a dilated area in the bifurcation of the common carotid at the level of the superior border of thyroid cartilage. The carotid sinus is sensitive to pressure changes in the arterial blood at this level. Carotid sinus reflex death is a disputed mechanism of death in which manual stimulation of the carotid sinus allegedly causes strong glossopharyngeal nerve (Vagus nerve is for aortic arch baroreceptors) impulses leading to terminal cardiac arrest. Carotid sinus reflex death has been pointed out as a possible cause of death in cases of strangulation, hanging and [citation needed] Autoerotic Strangulation, but such deductions remain controversial. Studies have also suggested that the carotid sinus reflex can be a contributing factor in other mechanisms of death by reducing blood pressure and heart rate, especially in the elderly or in people suffering from carotid sinus hypersensitivity. A carotid massage can also possibly dislodge a thrombus, or some plaque. This could lead to any number of life threatening effects, including stroke

Operative surgery
1. Rational incisions in case of the phlegmon of the medial neurovascular bundle of the neck.

2. Rational incisions in case of the suprasternal phlegmon, stratigraphy and possible complications.

3. Rational incisions on the neck in case of retrovisceral phlegmon.

4. Particularly in primary surgical debridment of the neck wounds.

Areas of lesions of neck Suprahyoid zone. Cricoid-hyoid zone (cricohyoid zone) - also may spread to mediastenoum Cricosternal zone - infection may be spread to mediastenoum. Features of neck wounds: Canal of the wound usually is sinosoidal (zigzaged). Trauma of soft tissue - hollow organs in vertibral coloumn can be found in combination. Banale/baneil (simple) and anaerobic infection - can spread to the oral floor and mediastenoum. Risk of lesion of carotid arteries - press carotid artery if there is an injury. Risk of arterial and venous gas/air embolism.

5. Vagosimpatic block on the neck by A.Vishnevski.

6. Ligation of external carotide artery indications, surgical access, the segment of

Indications Bleeding from Oral Malignancies Slipping of Superior pedicle of Thyroid Gland Arterio Venous Malformation of Scalp

Anaesthesia- General Anaesthesia Position- Supine with neck extended to opposite side Incision-Oblique incision along the anterior border of Sterno Mastoid over the middle third. Procedure1. 2. 3. 4. 5. 6. 7. 8. Skin and Platysma are cut along the line of incision Anterior border of Sternomastoid is retracted posteriorly Internal Jugular Vein (IJV) is identified Common carotid Artery is found medial to IJV Bifurcation of the Common carotid artery defined External Carotid Artery (ECA) is identified by its branches Internal Carotid Artery (ICA) has no branch in the neck Safeguard the Hypoglossal Nerve which crosses ICA and ECA just above hyoid bone.

The incision is the same as for ligating theexternalcarotid low down, viz., 5 cm. along theanterioredge of the sternomastoid muscle, its middle being opposite the upper edge of the thyroid cartilage.Veinsfrom the thyroid gland - superior thyroid - will probably cover it. Afterthe deepfascia has been opened, theexternalcarotid is to be recognized at its origin from the common carotid and then the superior thyroid artery found and followed out from that point. The ligature is to be passed from above downward to avoid the superior laryngeal nerve. This nerve lies distinctly above the artery and is not liable to be injured if the thyroid artery is followed out from its origin at theexternalcarotid. Treves suggests ligating it between the sternomastoid and superior laryngeal branches, but it is more readily reached closer to theexternal carotid artery.

7. Surgical approach to the thoracic duct on the neck.

Approaches : Longitudinal incisions - have access to both sides of neck.

At the margins of sternocleodomastoid muscle. Transverse incisions - when it is nessery to perform cosmetic surgiry, because it can be hidden by clothes. Near by to the clavical Combined incisions - for a more large approach. Flap incisions - e.g. U shape incison in lateral traingle of neck.

8. Ligation of lingual artery - indications, access, preferred area. : The lingual artery constitutes one of the branches of the external carotid artery, which is responsible for the vascularization of the tongue and neighbour regions. The hemorrhage caused by a lesion of the lingual artery can occur during a dental procedure (surgical accidents by the use of an instrument or rotating disc), by trauma, biopsy and dental implant. In some cases is difficult to stop the hemorrhage of injured vase, so is necessary to realize the extraoral ligature of this artery. Hence, this work studied the anatomic aspects of the lingual artery, by forty-eight dissections of twenty-four corpses settled in formol 10%, aiming to detail the origin, pathway and anatomic relations of the lingual artery in the region of anterior trigone of the neck, and also to measure the distances among the lingual artery and the arteries: facial, superior thyroid and with the bifurcation of the common carotid. The results concluded that the lingual artery is found in a position more inferior than classicaly described, based on the digastric muscle and the hypoglossal nerve; and that the hyoid bone can be used as a point of reference for the surgical access to the lingual artery in the region of the anterior trigone of the neck
Ligation of the Lingual Artery. - The lingual artery may be ligated forwounds, as a preliminary step to excision of thetongue, and to check the growth of or bleeding from malignant growths of the tongue,mouth, orlower jaw. The lingual artery springs from theexternalcarotid opposite the hyoid bone about 1 cm. above thebifurcationof the common carotid. It is composed of three parts: the first, from its point of origin to theposterioredge of the hyoglossus muscle; the second, the part beneath the hyoglossus muscle; and the third, the part beyond this muscle to the tip of the tongue. The artery is usually ligated beneath the hyoglossus muscle in the second part of its course, although it is sometimes desirable to ligate it in the first part of its course. The first part inclines upward and forward, above the greater horn of the hyoid bone, to the hyoglossus muscle, beneath which it passes in a direction somewhat parallel to the upper edge of the hyoid bone. It lies on the middle constrictor of thepharynxand superior larnygeal nerve and is covered by theskin, platysma, andfascia. It lies immediately below the stylohyoid and digastric muscles and is crossed by the hypoglossal nerve and some veins. This portion frequently gives off a hyoid branch which runs above the hyoid bone. It is often missing, in which case the parts are supplied by the hyoid branch of the superior thyroid. From either the end of the first part or the beginning of the second part, the dorsalis linguae branch arises.

The second part of the lingual lies on the superior constrictor and geniohyoglos-sus muscles and is covered by the hyoglossus. It runs in a direction somewhat parallel to the upper edge of the hyoid bone and from 0.5 to 1 cm. above it

9. Surgical approach to the esophagus on the neck.

The esophagus has three anatomical points of narrowing, the cricopharyngeus muscle, the broncho-aortic constriction, and the esophagogastric junction surgical approach:

The SCM muscle and carotid sheath are retracted laterally. The middle thyroid vein and the omohyoid muscle are divided. The trachea and esophagus are bluntly retracted medially. The esophagus is carefully and bluntly dissected posteriorly along the retropharyngeal
plane

10. Superior tracheostomy - indications, technique, possible earlier and late Complications.
Trachiostomy (stomy = connection of simple skin to a hollow organ). Trachiotomy - incison. Trachiosynthesis - punture of trachea, trocare (needle about 8mm in diameter). Indications for trachiostomy: Diffrerent obstructions of trachea: Foreign body between vocal cord or trachea. Edema. Radicale (big surgery) head and neck surgery, usually because of cancer. Classification of Trachiostomy - it can be : Urgent Planned Unexpected - outside hospital. Steps - Main stages of trachiostomy: 1. Determination of landmarks- sternal notch, crecoid & thyroid cartilage. 2. Incision of skin - longitudinal or transversal. 3. Disection of superficial fascia just in the middle. 4. Disection of deep fascia & access to pretracheal space. 5. Exposure of the carotid cartilage & trachea. 6. Retraction upward or downward of the thyroid esthmus. 7. Imobbilization or fixation of trachea to prevent it's respiratory excations (with especial hock).

8. Sectioning of the trachea - proved by the triad of symptoms (some presymptomesExcite, Convulsions, Pale then Cyanosis). Triad of symptoms that trachea is cutten: 1. Wisteling sound of insperation of trachea. 2. Temporary apnea - stop breathing. ~1min 3. Cough - aboundent coughing and everything in trachea exits. 9. Dilatation of tracheal incision & opening of tracheal lumen. (Necessary to dilate trachea with instrument). 10. Insertion of tracheal tube/canula in lumen of trachea - from metal, plastic or othe kind. 11. Fixation of canula with notes - e.g. With a thread behaid neck. 12. Suturing - Closure of the wound. Complications in trachiotomy :1. Aspiration of blood & as a result asfixia (sufication) and pneumonia. 2. Insertion of tracheal tube in submocousal layer of trachea. 3. Lesion of the posterior wall of trachea and esophagous. Between them the ring is not full, so the perforation would not be felt. 4. Subcotaneous emphysema - infection may be present too. 5. Injury of the left brachio sefalic vein & pellicle of air embolism.

11. Inferior tracheostomy - indications, technique, possible earlier and late complications.
Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. The traditional semantic difference between "ostomy" and "otomy" is blurred in this instance, The trachea is a conduit between the upper airway and the lungs. It delivers moist warm air, and it expels carbon dioxide and sputum. Failure or blockage at any point along that conduit can be corrected most readily by providing access for mechanical ventilators and suction equipment. In the case of upper airway obstruction, tracheostomy provides a path of low resistance for air exchange. INDICATIONS To bypass obstruction Congenital anomaly (eg, hypoplasia, vascular web) Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers Suprasternal and intercostal retractions, increased work of breathing in general Neck trauma Subcutaneous emphysema Appears in face, neck, or chest Air dissects readily, especially through inflamed or traumatized tissue planes. Palpable fractures (eg, mid-face, hyoid, thyroid, cricoid, mandible, midface) Tumor Bilateral vocal cord paralysis Edema Trauma

Burns Infection Anaphylaxis Indicated to provide a long-term route for mechanical ventilation in cases of respiratory failure (not enough oxygen in) Hypoxia - Symptoms of agitation and confusion Cyanosis - Indicates ventilatory failure (reduced carbon dioxide exhalation) Hypercarbia - Increased carbon dioxide - symptoms of headache, dizziness, twitching, sweating, and flushing To provide pulmonary toilet Inadequate cough due to chronic pain or weakness Aspiration and the inability to handle secretions. The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. Thus, this intervention can prevent aspiration as well as provide for the removal of any aspirated substances. Prophylaxis (as preparation for extensive head and neck procedures and the convalescent period) Palpate the landmarks (eg, thyroid notch, sternal notch, cricoid cartilage) and mark them with an ink pen. Plan a 3-cm vertical incision extending inferiorly from the cricoid cartilage and infiltrate Lidocaine (1%) with 1:150,000 parts epinephrine. This is sufficient anesthesia in the awake patient and facilitates hemostasis in all patients. Make the vertical incision. Many advocate the horizontal skin incision, which is made along relaxed skin tension lines, giving better cosmesis. A horizontal incision may trap more secretions. Meticulous hemostasis is important throughout, beginning with the skin edges. Subcutaneous fat may be removed with electrocautery to aid in exposure and prevent later fat necrosis. Dissection proceeds through the platysma until the midline raphe between the strap muscles is identified. Palpate the inferior limit of the field to assess the proximity of the innominate artery. Cauterize or ligate aberrant anterior jugular veins and smaller vessels. Midline dissection is essential for hemostasis and avoidance of paratracheal structures. The strap muscles are separated and retracted laterally, exposing the pretracheal fascia and the thyroid isthmus. The lateral retraction also serves to stabilize the trachea in the midline. Immediate complications Apnea due to loss of hypoxic respiratory drive. This is mainly important in the awake patient. Ventilatory support must be available. Bleeding: Intraoperative bleeding arises from laceration of vessels in the field that should be cauterized or ligated and from the cut edges of the very vascular thyroid gland. Care should be taken to stop all thyroid bleeding before allowing the cut edges to retract laterally, where they become difficult to expose. Pneumothorax or pneumomediastinum: These can result from direct injury to the pleura or the cupola of the lung (especially in children) or from high negative-inspiratory pressures of patients who are awake and distressed. Early recognition is critical and routine post-operative chest radiographs should be considered after tracheotomy. Injury to adjacent structures: The paratracheal structures vulnerable to injury are the recurrent laryngeal nerves, the great vessels, and the esophagus. This danger is most

prevalent in children because the softness of the trachea hinders its identification if it is not distended with a rigid object. Post-obstructive pulmonary edema; although rare, a transient pulmonary edema can occur after tracheostomy, which provides relief of upper airway obstruction. Early complications Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia (and relative hypotension) and begins to cough. Although this may necessitate a return to the OR, it may be controlled with local packing and control of hypertension. Packing should be antibiotic-impregnated gauze (eg, iodophor), and while it is in place, the patient should given antistaphylococcal antibiotics. Bloody secretions issuing from the tube itself may represent diffuse tracheitis (most commonly), rundown bleeding from the skin or thyroid, or ulceration from an ill-fitting tube or overzealous suctioning. Plugging with mucus: The use of dual cannula tubes makes this less of a threat, as the inner cannula can be removed for cleaning while the outer cannula safely maintains patency of the fresh tract. Vigilance, however, is still required, and all measures to thin and remove secretions should be undertaken. Tracheitis: To some degree, tracheitis is present in all fresh tracheostomy patients. Again, humidification, minimizing the fraction of inspired oxygen (FIO2) as high oxygen exacerbates drying, and irrigation are essential. Moreover, motion of the tube within the trachea is extremely irritating and should be prevented by stabilizing the ventilator circuitry so that torsion is minimized. Cellulitis: The wound will quickly be colonized; however, infection is unlikely if the incision has not been closed tightly and drainage is allowed. Opening the wound and instituting appropriate antibiotics should suffice to treat any early cellulitis. Displacement: It is not uncommon to be called to the bedside to replace a new tracheostomy tube. In the heat of the moment it is important not to forget the access that the upper airway still affords. Bag ventilate the patient and prepare for intubation if the tracheostomy tube cannot be replaced. Initial management includes passing something (eg, a smaller tube, a clear nasogastric tube [which will show the fogging of respiration]) into the open wound. A physician may attempt recannulation. This is facilitated by placing the tube over the fiberoptic laryngoscope and reentering the trachea under direct vision. However, endotracheal intubation remains the mainstay of airway management and should not be ignored while laboring over an increasingly traumatized tracheostomy site. Misplacement of the tracheostomy tube into the dreaded "false passage," usually in the pretracheal space, should be suspected if there is difficulty ventilating or passing a suction catheter or if there is subcutaneous air orpneumothorax. Subcutaneous emphysema: This results from a tight closure of tissue around the tube, tight packing material around the tube, or false passage of the tube into pretracheal tissue. It can progress to pneumothorax and/or pneumomediastinum and should be treated by loosening the closure or packing and by making a tube thoracotomy if necessary. Incidence of pneumothorax after tracheostomy is 0-4% in adults and 10-17% in children; thus, postoperative chest radiograph is recommended in children.

12. Conicotomy - indications, surgical technique.

Conicotomy / cricoteriotomy (part of laryngotomy) - incision or punture/persing between cricoid and thyroid cartilage. Superior trachiotomy - upward to the thyroid esthmus. Inferior trachiotomy - downward to the thyroid esthmus
indications : Can't intubate Can't ventilate Severe facial or nasal injuries (that do not allow oral or nasal tracheal intubation) Massive midfacial trauma Possible cervical spine trauma preventing adequate ventilation Anaphylaxis Chemical inhalation injuries

technique :n a typical cricothyrotomy procedure, a scalpel is used to create a 1 cm vertical incision through the skin and the cricothyroid membrane, and the resulting hole is opened by either inserting the scalpel handle into the wound and rotating 90 degrees or by using a clamp. A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is then inserted, the cuff is inflated, and the tube is secured. A bagvalve device with the highest available concentration of oxygen is used to provide ventilation, the success of which is assessed by bilateral ausculation and observation of the rise and fall of the chest. No attempts are made to remove the tracheostomy orendotracheal tube in a prehospital setting.
[3]

complications :Acute laryngeal disease Tracheal transection.

13. Subclavian vein punctures.

The subclavian vein is frequently used to obtain central venous access and to administer parenteral fluids and medications . Several landmarks exist to determine the puncture site and angle, but they may require patient manipulation and anatomic measurements. We studied the feasibility of using the deltoid tuberosity, located on the lateral aspect of the clavicle, as an anatomic landmark.

14. Incisions and special surgical anatomical particularities of the submandibular phlegmon drenage. limits:superior :- myloide muscle inferior :- cervical propria fascia

medial :- anterior base of bellyes of digastric m . lateral :- marginal base of the mandibule in this region include the following structures :1- warthon duct 2- facial artey and vein 3-lymph node 4- hypoglosis nerve 5-lingual artery 6- subcutaneous fatty tissue treatment :incision on the skin , subcutaneous tissue platysma , in the length of 6-7 cm , parallel and inside of the basilar limit of the mandibule. draingae made with rubber tubes and make general treatment .

Operations on vessels and nerves on the head and neck

1. Vein punctures technique. 2. Vein section technique. 3. Denudation and ligation of the arteries (facial, maxillary and lingual). 4. Collateral circulation in ligation of the arteries (facial, maxillary and lingual). 5. Blood vessels ligation in bleeding, sutures and grafting. 1- transfiex legation - by punch the vessel 2- broaching legation steps of vascular suture :1- mobilization of the artery end and application of vascular clamps (foreceps) 2- excision of the artey edges 3- to connect the end of the artery 4- application of sutures 5- excision of the continues circular sutures 6. Nerves surgery (neurorraphy, neurolysis, neurotomy, nerves plastic surgery). neurorraphy- suture of the nerve neurolysis- destruction of nervous tissue (as by the use of chemicals or radio frequencies)
to temporarily or permanently block nerve pathways especially to relieve pain

neurotomy- The surgical cutting or stretching of a nerve, usually to relieve pain. nerves plastic surgery :- Surgery to repair or restore nerve tissue.

Maxilla and mandible bones operations

1. Notion : osteotomy, osteosynthesis, osteoplasty, bone resection and trepanation.
osteosynthesis: A surgical procedure that stabilizes and joins the ends of fractured (broken) bones by mechanical devices such as metal plates, pins, rods, wires or screws. osteoplasty :plastic surgery on bone; especially : replacement of lost bone tissue or
reconstruction of defective bony parts

osteotomy : is surgical operation when bone is cut to shorten . lengthen or change its alignment it is performing to correct facial asymmetry . type of osteotomy : 1- transversal 2- oblique 3- in step 4- semicircular 5- segmental bone resection : surgical removal of part of bone _subperiostal - transperiostal - partial - total trepanation.:use of the trephine for creating an opening in the skull or in the sclera.

2. Bone defects replacements methods.

bone grafting Bone grafting is a surgical procedure by which new bone or a replacement material is placed into spaces between or around broken bone (fractures) or holes in bone (defects) to aid in healing.Bone grafting is used to repair bone fractures that are extremely complex, pose a significant risk to the patient, or fail to heal properly. Bone graft is also used to help fusion between vertebrae, correct deformities, or provide structural support for fractures of the spine. In addition tofracture repair, bone graft is used to repair defects in bone caused by birth defects, traumatic injury, or surgery for bone cancer. There are three ways in which a bone graft can help repair a defect. The first is called osteogenesis, the formation of new bone by the cells contained within the graft. The second is osteoinduction, a chemical process in which molecules contained within the graft (bone morphogenetic proteins) convert the patient's cells into cells that are capable of forming bone. The third is osteoconduction, a physical effect by which the matrix of the graft forms a scaffold on which cells in the recipient are able to form new bone. .

3. Temporo mandibular joint arthrocentesis.

The arthrocentesis is done by inserting needles into the affected joint space by the ear, while sterile solution is used to wash out the joint and surrounding areas. The idea is that this wash out will remove any extra scar tissue and increase mobility in the joint. At this point steroids, lubricants, or other medications may be injected The ear and preauricular skin over the TMJ was prepared and draped with topical antiseptic solution, Two points are then marked over the articular fossa and eminence, 1 and 2 cm in front of the tragus along the canthal tragus line, similar to the entry points used for arthroscopic procedures The point of the first needle entry is 5 mm below the 1 cm mark from the tragus The point of the second needle entry is 10 mm below the 2 cm mark from the tragus. The auriculotemporal nerve is blocked with about 2 ml of local anesthetic and a 18-gauge needle is then introduced into the superior joint space at the glenoid fossa (posterior mark) Approximately 2 ml of Hartmanns (Ringer's lactate) solution is then injected to distend the superior joint space. A second 18-gauge needle is inserted into the distended compartment in the area of the articular eminence to establish a free flow of the solution through the superior joint space. A syringe filled with Hartmann's solution is then connected to one of the needles, and fluid is injected into the superior joint space. The second needle provides an outflow for the solution which is collected in a kidney dish. A total of 50-100 ml of solution is used to lavage the superior joint space, during which time the outlet needle is momentarily blocked with finger pressure two or three times to help distend and break up the joint adhesions.

4. Temporo mandibular joint arthroplasty and total joint repacement.

Arthroplasty (literally "surgical repair of joint") is an orthopedic surgery where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure. It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis or some other type of trauma. joint replacement surgery, is a procedure of orthopedic surgery in which the arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when there is severe joint pain or dysfunction is not alleviated by less-invasive therapies
total jaw replacement due to one or more of the following conditions:

severe arthritic conditions fused joints previous multiple surgeries severe fractures tumors severely degenerated joints severe developmental abnormalities that cannot be treated by other means

5. Bone grafts and bone substitutes.

bone grafting: is the procedure of transplanting bone from a donor area to recipient area the technique consist of placing live bone pieces in close contact with healthy raw bone surface to stimulate growth of bone tissue in new area the type of bone grafts:

1)autologous grafts .. free bone grafts and vascularized graft 2) allograft 3) xenograft 4) bone substitutes 5) distraction osteogenesis bone substitutes bioactive glass bone substitues : Synthetic or natural materials for the replacement of bones or bone tissue. They include hard tissue replacement polymers, natural coral, hydroxyapatite, beta-tricalcium phosphate, and various other biomaterials. The bone substitutes as inert materials can be incorporated into surrounding tissue or gradually replaced by original tissue.