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Preface to the Sirth Edition vil

Preface to the Firsf Edition (excerpts) VIII

Section K

I-Iii{rdduction qnd Osteology Noso/ Bones 48

Locrimol Bone 48
Skull 4 Hyoid Bone 49
Bones of the Skull 4 ClinicalAnatomy 50
Exterior of the Skull 5 TypicolCervicolVertebro 50
Normo Verticolis 5 First Cervicol Vertebro 5l
Clinical Anatomy 6 Second Ceruicol Vertebro 52
Normo Occipitolis 6 Seventh CervicolVertebro 53
Normo Frontolis 8 Clinical Anatomy 54
Clinical Anatomy 9 Ossificotion of Croniol Bones 55
Normo Loterolis I I Foromino of Skull Bones ond their Contents 56
Clinical Anatomy 12 Facts to Remember 58
Normo Bosolis 13 ClinicoanatomicalProblem 58
lnterior of the Skull 20 Multiple Choice Questions 58
Clinical Anatomy 23
Clinical Anatomy 24
The Orbit 27 .eir. . find Focc 59
Foetol Skull/Neonotol Skull 29 Scolp ond SuperficiolTemporol Region 60
Clinical Anatomy 30 Dissection 60
Croniometry 3l Clinical Anatomy 63
Mondible 3l Foce 64
Structure reloted to Mondible 34 The Fociol Muscles 66
Clinical Anatomy 35 Clinical Anatomy 69
Moxillo 35 Arteries of the Foce 7l
Porietol Bone 38 Dissection 7l
Occipitol Bone 39 Fociol Arlery 7l
Frontol Bone 40 Clinical Anatomy 73
Temporol Bone 4l Eyelids on Polpebrae 73
Sphenoid Bone 43 Dissection 73
Ethmoid Bone 45 ClinicalAnatomy 74
Vomer 46 Clinical Anatomy 75
lnferior Nosol Concho 46 LocrimolApporotus 75
Zygomotic Bone 47 Dissection 75
! \i| I

Anatomy 76
Clinical 5. Porolid Region t06
Developmenl of Foce 77
Mnemonics 77 Porotid Glond 106
Facts to Rennernbsr 77 Dissection 106
ClinicoanatomicalProblems 77 Clinical Anatomy 107
Multiple Choice Questions 78 Relotions 107
Clinical Anatomy I l0

3. SIde of the Neck 79

Development I I I
Clinical Anatomy lll
The Neck 79 Facts to Remember I 12
Dissection 79 Clinicoanatomical Problem I l2
Clinical Anatomy Bl Multiple Choice Questions I 12
Deep Cervicol Foscio 8l
lnvesting Loyer Bl 6. Iempoil]l ond lnfrotemporol Regions n4
Clinical Anatomy 83
Pretrocheol Foscio 83 Temporol Fosso l14
Clinical Anatomy 83
lnfrotemporol Fosso I l4
Prevertebrol Foscio 83 Muscles of Mosticotion I l5
Clinical Anatomy 84
Dissection I l5
Moxillory Artery l19
Posterior Triongle 85
Dissection I l9
Dissection 85
Temporomondibulor Joint l2l
Clinical Anatomy 86
Clinical Anatomy 124
Contents of the Posterior Triongle 86
Mondibulor Nerve 125
Clinical Anatomy 88
Dissection 125
Sternocleidomostoid 89 Otic Gonglion 127
Clinical Anatomy 90 Clinical Anatomy 128
Phoryngeol Spoces 90 Mnemonics 129
Mnemonic 90 Fects to R*mernber 129
Fects to Remember 9l Clinicoanatomical Problem 129
Clinicoanatomical Problem 9l Multiple Choice Questions 130
Multiple Choice Questions 9l
7. $ubmsndibulor Region l3l
4. Antefior Triongle of the Neck 92
Suprohyoid Muscles l3l
Structure in the Anterior Medion Region of the Dissection l3l
Neck 93 Submondibulor Solivory Glond 133
Dissection 93 Dissection 133
Clinical Anatomy 95 Clinical Anatomy 137
Submentol ond Digostric Triongle 95 Comporison of Three Solivory Glonds 138
Dissection 95 Facts to Remember l3B
Anterior Triongle 95 Clinicoanatomical Problem l38
Corotid Triongle 98 Multiple Choice Questions 139
Dissection 98
Clinical Anatomy 100 8. $lrucluree in the Neck 140
Externol Corotid Artery 100 Glonds 140
Musculor Triongle 104 Dissection 140
Dissection 104 Thyroid Glond 140
Mnemonics 105 Histology 144
Facts to Ramernber 105 Development lU
Clinicoanatomical Problem 105 Clinical Anatomy 145
Multiple Choice Questions 105 Porothyroid Glonds 145
Clinical Anatomy 146 Dissection 179
Thymus 147 Clinical Anatomy l8l
Clinical Anatomy 147 Facts to Rernenrber l82
Blood Vessels l48 Clinicoanatomical Problem I 82
Dissection l48 Multiple Choice Questions 182
Subclovion Artery 148
Clinical Anatomy 150 I l. Gontent$ of Verlebrol Conol t83
Common Corotid Artery l5l
Dissection l5l Removol of Spinol Cord 183
Clinical Anatomy 152 Dissection I 83
Internol Corotid Artery 152 Clinical Anatomy l85
lnternol Jugulor Vein 153 Spinol Nerves 186
Clinical Anatomy 154 Clinical Anatomy 186
Cervicol Port of Sympothetic Trunk 154 Vertebrol System of Veins 187
Dissection 154 Fs.ts t0 Remember 187
Clinical Anatomy 156 Clinicoanatomical Problem 187
Lymphotic Droinoge of Heod ond Neck 156 Multiple Choice Questions 188
Dissection 156
Clinical Anatomy 159 12. Croniol Covity t89
Apporotus 159
Development of Arteries 160
lntroductio n 189
F*cts to Rememb*r 160 Dissection 189
Clinicoanatomical Problem l6l Cerebrol Duro Moter 190
Multiple Choice Questions l6l Clinical Anatomy 192
Covernous Sinus 193
9 rPreverfebrol snd Poroverlebrol Regions Dissection 193
Clinical Anatomy 195
Superior Sogittol 195
Vertebrol Artery 162 Clinical Anatomy 195
Dissection 162 Sigmoid Sinuses 196
Scolenovertebrol Triongle 162 Clinical Anatomy 197
Scolene Muscles 165 Hypophysis Cerebri 197
Dissection 165 Dissection 197
Cervicol Pleuro 167 Clinical Anatomy 199
Cervicol Plexus 167 Trigeminol Gonglion 199
Phrenic Nerve 169 Dissection 199
Clinical Anatomy 169 Clinical Anatomy 200
Trocheo 169 Middle Meningeol Artery 201
Clinical Anatomy 170 Clinical Anatomy 201
Oesophogus l7l Croniol Fossoe 201
Clinical Anatomy l7l Dissection 201
Joints of the Neck l7l lnternol Corotid Artery 202
Clinical Anatomy 173 Petrosol Nerves 203
F*cts to Remember 174 Mnemonics 203
Clinicoanatomical Problems 174 fe$s t$ ftarnember 203
Multiple Chbice Questions 175 Clinicoanatomical Problems 243
Multiple Choice Questions 203
l0. BSek of lhe NEck t76
13. Conlents of lhe Odcit 205
The Muscles 176
Dissection 176 Orbits 205
Suboccipitol Triongle 179 Dissection 205
nuMnN nNntdMy;nEno-t\Ecx nND :gnArrv

Extrooculor Muscles 206 Nosol Septum 240

Dissection 206 Dissection 240
Clinical Anatomy 209 Clinical Anatomy 242
Vessels of the Orbit 209 LoterolWollof Nose 242
Dissection 209 Dissection 242
Clinical Anatomy 2l I Conchoe ond Meotuses 243
Optic Nerve 213 Dissection 243
Clinical Anatomy 213 Clinical Anatomy 245
Ciliory Gonglion 213 Poronosol Sinuses 245
Mnemonics 216 Dissection 245
Fflcts to Rer*ember 216 Clinical Anatomy 246
Clinicoanatomical Problem 216 Pterygopolotine Fosso 246
Multiple Choice Questions 216 Moxillory Nerve 248
Pterygopolotine Gonglion 249
14. Itl|oulh and Phorynx 2t7 Dissection 249
Clinical Anatomy 250
Orol Covity 217 Fects to Renremher 251
Clinical Anatomy 217 ClinicoanatomicalProblem 251
Orol Covity Proper 218 Multiple Choice Questions 251
Clinical Anatomy 219
Teeth 219 16. Lorynx 252
Stoges of Development of Deciduous Anotomy of Lorynx 252
Teeth 220 Dissection 252
Anatomy 221
Cortiloges of Lorynx 253
Hord ond Soft Polotes 222
Covity of Lorynx 256
Dissection 222
Clinical Anatomy 257
Muscles of the Soft Polote 222
lntrinsic Muscles of Lorynx 258
Development of Polote 226
Clinical Anatomy 258
Clinical Anatomy 227
Movements of Vocol Fold 259
Phorynx 227
Clinical Anatomy 261
Dissection 227
Ports of the Phorynx 228 Mechonism of Speech 262
Faets to Remsmben 262
Woldeyer's Lymphotic Ring 228
Clinical Anatomy 229 Clinicoanatomical Problem 262
Polotine Tonsils 229 Multiple Choice Questions 262
Clinical Anatomy 231
Structure of Phorynx 232 17. Tongue 264
Structures in between Phoryngeol Externol Feotures 264
Muscles 234 Dissection 264
Dissection 234 Clinical Anatomy 265
Killions' Dehiscence 234
Muscles of the Tongue 266
Clinical Anatomy 235
Clinical Anatomy 268
Deglutition 235
Histology 268
Auditory Tube 236
Development of Tongue 270
Clinical Anatomy 237
Clinical Anatomy 270
Mnemonics 237
Fects to Rem*mber 271
Faets to Remember 237
Clinicoanatomical Problem 271
ClinicoanatomicalProblem 238
Multiple Choice Questions 238 Multiple Choice Questions 271

15. Note ond Fcrsnffiol Sinuses 239 18. Eor 272

Nose 239 Externol Eor 272
Clinical Anatomy 240 Externol Acoustic Meotus 273

Dissection 273 Dissection 294
Tymponic Membrone 274 ClinicalAnatomy 294
Clinical Anatomy 275 Viireous Body 294
Middle Eor 277 Development 295
Dissection 277 Facts to Remember 296
Tymponic or Mostoid Antrum 281 Clinicoanatomical Problem 296
Dissection 281 Multiple Choice Questions 296
Clinical Anatomy 282
lnternol Eor 283 20. $urfuce Morking ond Rodiologicol
Development 285 Anolomy 297
Clinical Anatomy 285
Surfoce Londmorks 297
Regions of Eor Ache 286
Surfoce Morking of Vorious Structures 302
Mnemonics 286 Arteries 302
Feet$ t0 Rernemben 286
Veins/Sinuses 303
Clinicoanatomical Problem 286 Nerves 304
Multiple Choice Questions 287 Glonds 305
Nolse Pollution 287 PoronosolSinuses 306
19. Eyeboll 288 RodiologicolAnotomV 307
Outer Coot 288 Appendix I 309
Dissection 2BB
Corneo 289 Cervicol Plexus 309
Dissection 289 Sympothetic Trunk 309
Clinical Anatomy 290 PorosympotheticGonglio 309
Middle Coot
290 Arteries of Heod ond Neck 372
Clinical Anatomy 292 Structures Derived From
lnner Coot/Retino 292 Phoryngeol Arches 3 74
Clinical Anatomy 293 Endodermol Pouches 3.l4
Aqueous Humour 293 EctodermolClefts 374
Clinical Anatomy 294 ClinicolTerms 314
Lens 294 Furl-her Reoding 316

$ection',Z' BHAIN

2I. lnlroduction 319 Clinical Anatomy 330

CerebrospinolFluids 331
Divisions of Nervous System 319
Clinical Anatomy 332
CellulorArchitecture 319
Mnemonics 332
Synopse 321
Facts to Ramember 333
Neurogliol Cells 321
Reflex Arc 322 Clinicoanatomical Problem 333
Ports of the Nervous System 323 Multiple Choice Questions 333
Clinical Anatomy 324
Facts t* Rernember 326 23. Spinol Cord 334
Clinicoanatomical Problem 326
Multiple Choice Questions 326 lntroduction 334
Dissection 334
22. Mening6$ of the Bruin ond Cerebrospinol MeningeolCoverings 334
Fluid 327 Externol Feotures of Spinol Cord 335
The Meninges 327 lnternol Structure 335
Dissection 326 Anatomy 336
Cisterns 329 Spinol Nerves 336

Meningeal branch
Lesser petrosal nerve
Nerve to medial pterygoid
Mandibular nerve
Vll nerve Otic ganglion

lX nerve Lateral pterygoid

Chorda tympani
Lingual nerve Styloglossus

lnferior alveolar
Submandibular ganglion Genioglossus
on hyoglossus

Nerve to mylohyoid


Fig. 6.14: Distribution of mandibular nerve (V3)

Tympanic plexus
Tympanic branch
Mandibular nerve
(deeP asPect) Glossopharyngeal'nerve
Motor root
Lesser petrosal nerve

Nerve to tensor veli palatini

Nerve to iensor tympani

Otic ganglion
Postganglionic fibres
Sympathetic root
Sensory root
Auriculotemporal nerve giving
branches to parotid gland
Nerve to medial pierygoid
Sympathetic plexus along
middle meningeal artery

Maxillary artery

External caroiid artery

Base of mandible
Medial pterygoid

Fig. 6.15: Right otic ganglion seen from medial side

zo trmgur/ f\Jervs two-thirds of the tongue, are also distributed through
ttr the lingual nerve (Fig.6.16).
(E Lingual nerve (Table 6.3) is one of the two terminal
t,(E branches of the posterior division of the mandibular Course
o nerve (Fig. 6.1a). It is sensory to the anterior two-thirds Lingual nerve begins one cm below the sku1l. About
of the tongue and to the floor of the mouth. However, 2 cm below skull, it is joined by chorda tympani nerve
c the fibres of the chorda tympani (branch of facial nerve) at an acute angle. Then it lies in contact with mandible
o which is secretomotor to the submandibular and medial to 3rd molar tooth. Finally, it lies on surface of
a sublingual salivary glands and gustatory to the anterior hyoglossus and genioglossus to reach the tongue.

Nuclei of Spinol Cord 338 Sensory Components of V Nerve 366

Nuclei in Anterior Grey Column 338 Motor Components for Muscles 367
Nucleiin Loterol Horn 339 TrigeminolNerve 367
Nuclei in Posterior Grey Column 339 Ophtholmic Nerve Division 368
Sensory Receptors 340 Moxillory Nerve Division 368
Trocts of the Spinol Cord 340 Mondibulor Nerve Division 369
Descending Trocts 340 ClinicalAnatomy 369
Pyromidollracls 340 Seventh CroniolNerve (Fociol) 370
Extropyromidol Trocts 340 Functionol Componenls 370
Ascending Trocts 342 Nuclei370
lntersegmentol Trocts 345 Course ond Relotions 370
Clinical Anatomy 347 Bronches ond Distribution 371
Facts ta Rememb*r 348 Gonglio 373
ClinicalAnatomy 373
Clinicoanatomical Problems 348
Eighth Croniol Nerve (/estibulocochlear) 374
Multiple Choice Questions 349
Pothwoy of Nearing 374
Vestibulor Pothwoy 375
24. Cronial Nerves 350
ClinicalAnatomy 375
lntroduction 350 Ninth Croniol Nerve (Glossophoryngeal) 376
Embryology 350 Functionol Componenls 376
Nuclei 351 Nuclei 378
Generol Somotic Efferent Nuclei 357 Course ond Relotion 378
Speciol Viscerol Efferents Nuclei 35
Bronches ond Distribution 378
Generol Viscerol Efferent Nuclei 352 Clinical Anatomy 379
Generol Viscerol Afferent ond Tenth Croniol Nerve (Vogus) 379
Speciol Viscerol Afferent Nuclei 352 Functionol Componenls 379
Generol Somotic Afferent Nuclei 355 Nuclei 379
Speciol Somotic Afferent Nuclei 355 Course ond Relotion in Heod ond Neck 387
Bronches in Heod ond Neck 38 7
First Croniol Nerve (Olfoctory) 355
Clinical Anatomy 382
Olfoctory Pothwoys 355
Eleventh Croniol Nerve (Accessory) 383
Clinical Anatomy 356
Functionol Components 383
Second Croniol Nerve (Optic) 356
Nuclei 383
Optic Pothwoys 356
Course ond Distribution of the Croniol
Reflexes 358
Root 383
Clinical Anatomy 360 Course ond Distribution of Spinol Root 384
Third Croniol Nerve (Oculomotor) 360
Clinical Anatomy 384
Functionol Components 360 Twelfth Croniol Nerve (Hypoglossol) 385
Nucleus 360 Functionol Components 385
Course ond Distribution 36 / Nuclei 385
Clinical Anatomy 362 Course ond Relotions 385
Fourih Croniol Nerve (rochlear) 362 Extrocroniol Course 385
Functionol Componenls 364 Bronches ond Distribution 385
Nucleus 364 Clinical Anatomy 386
Course ond Disiribution 364 Mnemonics 387
Clinical Anatomy 364 Facts ts) Remembcr 387
Sixth Croniol Nerve (Abducent) 364 Clinicoanatomical Problem 387
Functionol Components 364 Multiple Choice Questions 387
Nucleus 365
Course ond Distribution 365 25. Broin Slem 389
Clinical Anatomy 366
Fifth Croniol Nerve (l-rigeminol) 366 lntroduction 389
Nucleor Columns 366 Externol Feotures 389
co*rirvrs il
lnternolStructure 390 Fects t* Remernbrr 412
Tronsverse Section through Pyromidol ClinicoanatomicalProblem 412
Decussotion 390 Multiple Choice Questions 412
Tronsverse Section through Sensory
Decussotion 391 28. Cerebrum 413
Tronsverse Section through Floor of Fourth lntroduction 413
Ventricle 391 Dissection 413
Cllnical Anatomy 393 CerebrolHemisphere 414
Pons 393 Lobes of Cerebrol Hemisphere 415
Externol Feotures 393 lnsulo 416
lnternolStructure of Pons 393 CerebrolSulci ond Gyri 416
Tegmentum in Lower Port of Pons 394 Functionol Areos of Cerebrol Corlex 418
Tegmentum in Upper Porl of Pons 395 Moior Areos 419
Clinical Anatomy 395 Clinical Anatomy 421
Midbroin 396 Sensory Areos 422
Subdivision 396 Clinical Anatomy 422
lnternol Structure of Midbroin 39i Areos of Speciol Senses 423
Tronsverse Section of Midbroin ot Clinical Anatomy 423
Level of lnferior Colliculus 396 Functions of Cerebrol Cortex 423
Tronsverse Section of Midbroin ot Clinical Anatomy 424
Level of Superior Colliculus 398 Diencepholon 424
Clinical Anatomy 398 Tholomus 424
Development 398 Metotholomus 426
Mnemonics 399 Clinical Anatomy 427
f;acts to Rsnrember 399 Epitholomus 427
ClinicoanatomicalProblem 400 Pineol Body 427
Multiple Choice Questions 400 Hypotholomus 429
Functions 430
25. Cerebetlum 40t Clinical Anatomy 431
Locotion 401 Subtholomus 431
Externol Feotures 401 Clinical Anatomy 431
Ports of Cerebellum 401 Bosol Nuclei 431
Divisions of Cerebellum 403 Dissection 431
Corpus Striotum 432
Connections of Cerebellum 404
Grey Motter of Cerebellum 404 Connections of Corpus Striotum 433
Clinical Anatomy 434
Histologicol Slruclure 404
White Motter of Cerebrum 434
Functions of Cerebellum 406
Dissection 434
Developmenl 406
Associotion Fibres 435
Clinical Anatomy 407
CommissurolFibres 435
Summory 407
Corpus Collosum 436
Fo*ts to fier*amber 408
Projection Fibres 436
Clinicoanatomical Problem 408
lnternolCopsule 436
Multiple Choice Questions 408
Gross Anolomy 436
Fibres of lnternol Copsule 437
27. Fourth Venlricle 409
Blood Supply 438
Loterol Boundories 409 Clinical Anatomy 438
Floor 409 Development 439
Roof 410 F*ets t* Remeru:ber 439
Recesses of Fourth Ventricle 4l I Clinicoanatomical Problems 440
Clinical Anatomy 412 Multiple Choice Questions 440

29. Third Ventricle, Lqterol Venlricle qnd ClinicalAnatomy 460

Arteriol Supply of Different Areos 461
lirnbic $yslem 441
Blood-BroinBorrier 461
Third Ventricle 441 PerivosculorSpoces 463
Dissection Ul Veins of the Cerebrum 463
Anatomy U2
Clinical Blood Supply of the Broin Stem 464
Loterol Ventricle 442 Clinical Anatomy 465
Dissection 442 Mnemonics 465 1{

Centrol Port 443 Faets t<:Rem*nnber 465

Anterior Horn 444 Clinicoanatomical Problems 465
Posterior Horn 445 Multiple Choice Questions 466
lnferior Horn 445
Limbic System 445
ClinicalAnatomy U8 32. Investigotions of o Neurologicol Cose,
Faets tc R*rn*rnber 449 $urface ond Rodiological Anolomy ond
Clinicoanatomical Problem 449 Evolul*on ofHeod 467
Multiple Choice Questions 449 lnvestigotions Required in o Neurologicol
Cose 467
30. $ome Neurql Polhwoys ond Reticulor Surfoce Anotomy 468
Formslion 450
Rodiologicol Anotomy of the Broin 469
PyromidolTroct 450 Evolution of Heod 469
Anatomy 451
Pothwoy of Poin ond Temperoture 451 Appendix 2 472
Toste Pothwoy 452 Summory of the Ventricles of the Broin 472
ReticulorFormotion 453 Nucleor Components of Croniol Nerves 473
Fects ts} fiemernbsr 454 Arteries of Broin 474
Multiple Choice Questions 454 ClinicalTerms 475
Gross Anotomy of Brain 477
31. Blood Supply of Spinol Cord ond Multiple Choice Questions 479
Braln 455 Further Reoding 479

Blood Supply of Spinol Cord 455 $pots 481

Clinical Anatomy 455 Spots on Heod ond Neck 481
Arteries of Broin 455
Answers 482
VertebrolArteries 455
Spots on Broin 483
Bosilor Arleries 456
Anatomy 458
Answers 484
lnternol Corotid Artery 458 lndex 485
Circulus Arteriosus or Circle of Willis 459
,,i:t.,.iiai:rl ,r ' :'

X" lmiroduction ond Osteology 3 t:t.. .,

2. Scolp, Temple ond Foce 59 s&,f

l ;l

3. Side of the Neck 79

4. Anterior Triongle of the Neek E2 . : : -*:S liir.. .

5. Porotid Region 106

6. Temporol ond lnfrotemporol Regions 114
. i,' :
7. Submondibulor Region t3t
8. Skuciures in the Neck 1N
9" Preverlebrol snd Porqverlebral Regions 162
n0. Bqck of lhe t{eek 176
i X " Contents of Vcrfebrol Csnol r83
I2. CroniolCovlty r89
13. Contents of the Orbif 205
'!d. Mouth ond Phorynx
T$. lrlose ond PCIrsrrascl$lnuses 239
i 6. Lorynx 252
tr 7" Tongure 2U
lE. Ior 272
1S" Eyeholl 2BB
2S. Su#oce Morking ond Rsdiologlcol 297
Appendix I 309
Introduction and Osteology
6ll*"e.tagz ha, &w i.e.a.d {r/to} *o* ilri/ rnil&*

INTRODUCIION change into fluid waves and finally into nerve impulses
to be received in the temporal lobe of the cerebrum.
Head and neck is the uppermost part of the body.
Head comprises skull and lodges the meninges, brain, Nasal region; The region of the external nose, its muscles
hypophysis cerebri, special senses, teeth and blood and the associated cavity comprise the nasal region.
vessels. Brain is the highest seat of intelligence. Human Sense of smell is perceived from this region.
is the most evolved animal so far, as there is maximum Oral region: Comprises upper and lower lips and the
nervous tissue. To accommodate the increased volume angle of the mouth, where the lips join on each side.
of nervous tissue, the cranial cavity had to enlarge. Numerous muscles are present here, to express the
Correspondingly the lower jaw or mandible had to feelings and emotions. These muscles are part of the
retract. The eyes also had come more anteriorly, on each muscles of facial expression. They show the feelings,
side of the nose. The external nose also got prominent. without words.
External ear becomes vestigeal and chin is pushed Aral caaity: It houses the mobile talking tongue. Tongue
forwards to accommodate the broad tongue. Tongue, is not swallowed though everything put on the tongue
the organ for speech is securely placed in the oral cavity passes downwards. It is held in position by extrinsic
for articulation of words, i.e. speech. In human, the muscles arising from surrounding bones. It says so
vocalisation centre is quite big to articulate various much and manages to hide inside the oral cavity to be
words and speak distinctly. Speech is a special and chief protected by 32 teeth in adult.
characteristic of the human.
Paratid rcgion: Lies on the side of the face. It contains
Skull comprises number of bones and their respective
the biggest serous parotid salivary gland, which lies
regions are:
around the external auditory meatus.
Frontal; Lies in front of skull Head is followed by the tubular neck which
Foriet*l: Lies on top of skull, formed chiefly by the continues downwards with chest or thorax.
parietal bones. It is seen from the top Each half of the neck comprises two triangles between
anterior median line and posterior median lines.
Occipital: Forms back of skull
Posterior triangle: Lies between sternocleidomastoid, the
Temporril: It is the area above the ears. The sense of chin turning muscle; trapezfits, the shrugging muscle and
hearing and balance is appreciated and understood in middle one-third of the clavicle. It contains proximal
the temporal lobe of brain situated on its inner aspect. parts of the important brachial plexus, subclavian
Actilar region: It is the region around the large orbital vessels with its branches and tributaries. Its apex is
openings, containing the precious eyeball, muscles to above and base below.
move the eyeball, nerves and blood vessels to supply Arutevior triangle: Lies between the anterior median line
those muscles. There are accessory structures like the and the anterior border of sternocleidomastoid muscle.
lacrimal apparatus and protective eyelids. Its apex is in lower part of neck, close to sternum and
Auricular region: The region of the external ear with base above. It contains the common carotid artery and
external auditory meatus comprises the auricular its numerous branches. Isthmus of thyroid gland lies
region. Air waves enter the ear through the meatus which in the lower part of the triangle.

Bones of head and neck include the skull, i.e. SkullJoints

cranium with mandible, seven cervical vertebrae, the The joints in the skull are mostly sutures, a few primary
hyoid, and six ossicles of the ear. cartilaginous joints and three pairs of synovial joints.
The skull cap formed by frontal, parietal, squamous Two pairs of synovial joints are present between the
temporal and a part of occipital bones, develop by ossicles of middle ear. One pair is the largest
intramembranous ossification, being a quicker one temporomandibular joint. This mobile joint permits us
stage process. to speak, eat, drink and laugh.
The base of the skull in contrast ossifies by intra-
Sutures are:
cartilaginous ossification which is a two-stage process
(membrane-cartila ge-bone). Plane - internasal suture
Skull lodges the brain, teeth and also special senses Serrate - coronal suture
like cochlear and vestibular apparatus, retina, olfactory Denticulate - lambdoid suture
mucous membrane, and taste buds. Squamous - parietotemporal suture
The weight of the brain is not felt as it is floating in the
cerebrospinal fluid. Our personality, power of speech, Anqtomicol Position of Skull
attention, concentration, judgement, and intellect are The skull can be placed in proper orientation by
because of the brain that we possess and its proper use. considering any one of the two planes.
1 Reid's base line is a horizontal line obtained by
joining the infraorbital margin to the centre of
external acoustic meatus, i.e. auricular point.
TERMS 2 The Frankfurt's horizontal plane of orientation is
The skeleton of the head is called the skull.It consists obtained by joining the infraorbital margin to
of several bones that are joined together to form the the upper margin of the external acoustic meatus
cranium. The term skull also includes the mandible or (Fig. 1.1).
lower jaw which is a separate bone. However, the two
terms skull and cranium, are often used synonymously.
The skull can be divided into two main parts:
a. The calaaria or brain &ox is the upper part of the
cranium which encloses the brain.
b. The facial skeleton constitutes the rest of the skull Frankfurt's
and includes the mandible. horizontal plane


The skull consists of the 28 bones which are named as
a. The calvaria or brain case is composed of 14 bones
including 3 paired ear ossicles.
fifigfl, rl.'':',r' :'l:,:.:

1. Parietal (2) L. Frontal (1) Fig. 1.1: Anatomical position of skull

2. Temporal (2) 2. Occipital (1)
3. Malleus (2) 3. Sphenoid (1)
4. Incus (2) 4. Ethmoid (1) Methods of Study of the Skull
5. Stapes (2) The skull can be studied as a whole.
3, 4,5 are described in Chapter 18 The whole skull can be studied from the outside or
5 externally in different views:
o b. The facial skeleton is compose d of 1,4 bones.
z a. Superior view or norma verticalis.
tt Fairqd.-, .,'',,,.,;., :. Unf.ei* iid.'',, i,,:,',,',,,; t,.,,,',.','.,' b. Posterior view or norma occipitalis.
.. ;
L. Maxilla (2) t. Mandible (1) c. Anterior view or norma frontalis.
o 2. Zygomattc (2) 2. Vomer (t) d. Lateral view or norma lateralis.
3. Nasal (2) e. Inferior view or norma basalis.
C 4. Lacrimal (2) The whole skull can be studied from the inside or
o 5. Palatine (2) intemally after removing the roof of the calvaria or skull
o 6. Inferior nasal concha (2)
a cap:

a. Internal surface of the cranial vault. Bones Seen in Normo Verticolis

b. Internal surface of the cranial base which shows 1,Upper part of frontal bone anteriorly.
a natural subdivision into anterior, middle and 2 Uppermost part of occipital bone posteriorly.
posterior cranial fossae. 3 A parietal bone on each side.
The skull can also be studied as individual bones.
Mandible, maxilla, ethmoid and zygomatic, etc. have Sutures
been described. I Coronal suture: This is placed between the frontal
bone and the two parietal bones. The suture crosses
Peculiorities of Skull Bones the cranial vauft from side to side and runs
1 Base of skull ossifies in cartilage while the skull cap downwards and forwards (Fig. 1.2).
ossifies in membrane. 2 Sagittal suture: It is placed in the median plane
2 At birth, skull comprises of one table only. By 4 years between the two parietal bones.
or so, two tables are formed. Between the two tables, Lambdoid suture: It lies posteriorly between the
there are diploe (Greek double), i.e. spaces containing occipital and the two parietal bones, and it runs
red bone marrow forming RBCs, granular series of downwards and forwards across the cranial vault.
WBCs and platelets. Four diploic veins drain the Metopic (Latin forehead) suture: This is occasionally
formed blood cells into neighbouring veins. present in about 3 to B% individuals. It lies in the
3 At birth, the 4 angles of parietal bone have median plane and separates the two halves of the
membranous gaps or fontanelles. These allow frontal bone. Normally it fuses at 6 years of age.
overlapping of bones during vaginal delivery, if
required. These also allow skull bones to increase in Some olher Nomed Feotures
size after birth, for housing the delicate brain.
1 Vertex is the highest point on sagittal suture.
4 Some skullbones have air cells in them and are called , Vault of sklll is the arched roof for the dome of skull.
pneumatic bones, e.g. frontal, maxilla. 3 Bregma is the meeting point between the coronal and
a. They reduce the weight of skull sagittal sutures. In the foetal skull, this is the site of
b. They maintain humidity of inspired air a membranous gap, called the anterior fontanelle,
c. They give resonance to voice which closes at 18 months of age. It allows growth
d. These may get infected resulting in sinusitis. of brain (Fig. 1.3).
5 Skull bones are united mostly by sutures. The lambda is the meeting point between the sagittal
6 Skull has foramina for "emissary veins" which and lambdoid sutures. In the foetal skull, this is the
connect intracranial venous sinuses with extracranial site of the posterior fontanelle which closes at2 to 3
veins. These try to relieve raised intracranial months of age.
pressure. Infection may reach through the emissary
veins into cranial venous sinuses as these veins are
7 Petrous temporal is the densest bone of the body. It
lodges internal ear, middle ear including three
ossicles, i.e. malleus, incus and stapes. Ossicles are
"bones within the bone" and are fully formed at Frontal bone
8 Skull lodges brain, meninges, CSF, glands like
hypophysis cerebri and pineal, venous sinuses, teeth, Coronal suture
special senses like retina of eyeball, taste buds of
tongue, olfactory epithelium, cochlear and vestibular
nerve endings. Parietal bone
Sagittal suture z


Parietal foramen o
Shope Occipital bone
When viewed from above the skull is usually oval in .o
Lambdoid suture
shape. It is wider posteriorly than anteriorly. The shape o
may be more nearly circular. Fig. 1.2: Norma verticalis ao

Anterolateral or Anterior fonianelle

sphenoidal fontanelle (18 months)
(2-3 months) Posterior
pntanelle {2-3 months)

*,,,", ffii'ijlllljil L%
Fig. 1.3: Fontanelles of skull Fig. 1.4:

The parietal tuber (eminence) is the area of maximum

convexity of the parietal bone. This is a common site NORMA OCCIPITATIS
of fracture of the skull. Norma occipitalis is convex upwards and on each side,
The parietal foramen, one on each side, pierces the and is flattened below.
parietal bone near its upper border, 2.5 to 4 cm in
front of the lambda. The parietal foramen transmits Bones Seen
an ernissary vein from the veins of scalp into superior 1 Posterior parts of the parietal bones, above.
sagittal sinus (Fig. 1.2). 2 Upper part of the squamous part of the occipital bone
The obelion is the point on the sagittal suture between below (Fig. 1.5).
the two parietal foramina. 3 Mastoid part of the temporal bone, on each
T}:le temporal linesbegin at the zygomatic process of side.
the frontal bone, arch backwards and upwards, and
cross the frontal bone, the coronal suture and the Sulures
parietal bone. Over the parietal bone there are two 1 The lambdoid suture lies between the occipital bone
lines, superior and inferior. Traced anteriorly, they and the two parietalbones. Sutural or wormianbones
fuse to form a single line. Traced posteriorly, the are corunon along this suture.
superior line fades out over the posterior part of the 2 The occipitomastoid suture lies between the occipital
parietal bone, but the inferior temporal line continues
bone and mastoid part of the temporal bone.
downwards and forwards.
3 The parietomastoid suture lies between the parietal
bone and mastoid part of the temporal bone.
4 The posterior part of the sagittal suture is also seen.
Fontanelles are sites of growth of skull, permitting
growth of brain and pulps to determine age. Other Feofures
If fontanelles fuse early, brain growth is stunted;
such children are less intelligent. 1 Lnmbda, parietal fornmina and obelion have been
examined in the norma verticalis.
If anterior fontanelle is bulging, there is raised
o intracraniai pressure. If anterior fontanelle is 2 The external occipital protuberance is a median
o prominence in the lower part of this norma. It marks
z depressed, it shows decreased intracranial
!t pressure, mostly due to dehydration. the junction of the head and the neck. The most
prominent point on this protuberance is called the
Bones override at the fontanelle helping to xnnn.
decrease size of head during vaginal delivery.
o 3 The superior nuchal lines are curved bony ridges
Caput sutcedaneum is saft tissue swelling on any passing laterally from the protuberance. These also
part of skull due to rupture of eapillaries during mark the junction of the head and the neck. The area
.9 delivery. Skullbecomesnormalwithin a few days below the superior nuchal lines willbe studied with
ao (Fig. 1.4). the norma basalis.

Parietal foramen

Parietal bone
Sagittal suture


Lambdoid suture

Occipital bone

Squamous part of
temporal bone

Temporal bone

Superior nuchal line

Mastoid foramen
lnferior nuchal line
Mastoid process

External occipital protuberance

Fig. 1.5: Norma occipitalis

The highest nuchal lines are not always present. They apex of the squamous occipital. This is not a sutural
are curved bony ridges situated about l- cm above or accessory bone but represents the membranous
the superior nuchal lines. They begin from the upper part of the occipital bone which has failed to fuse
part of the external occipital protuberance and are with the rest of the bone.
more arched than the superior nuchal lines.
The occipital point is a median point a little above the Attochments
inion. It is the point farthest from the glabella.
The mastoid (Greek breast) foramen is located on the
1 The upper part of the external occipital protuberance
gives origin to the trapezius, and the lower part gives
mastoid part of the temporal bone at or near the occi-
attachment to the upper end of the ligamentumnuchae
pitomastoid suture. Internally, it opens at the
(Fig. 1.1a).
sigmoid sulcus. The mastoid foramen transmits an
emissary vein (Table 1.1) and the meningeal branch 2 The medial one-third of the superior nuchal line gives
of the occipital artery. origin to the trapezius, and the lateral part provides
The interparietal bone (inca bone) is occasionally insertion to the sternocleidomastoid above and to the
present. It is a large triangular bone located at the spl enius c apitis below.

Table 1.1: The emissary veins of the skull

Name Foramen of skull Veins outside skull Venous sinus o
1. Parietal emissary vein Parietal foramen Veins of scalp Superior sagittal z
2. Mastoid emissary vein Mastoid foramen Veins of scalp Sigmoid sinus (s
3. Emissary vein Hypoglossal canal lnternal jugular vein Sigmoid sinus t,(E
Suboccipital venous Plexus Sigmoid sinus o
4. Condylar emissary vein Posterior condylar foramen I
5. 2-3 emissary veins Foramen lacerum Pharyngeal venous plexus Cavernous sinus
6. Emissary vein Foramen ovale Pterygoid venous plexus Cavernous sinus o
7. Emissary vein Foramen caecum Veins of roof of nose Superior sagittal ao

The norma frontalis is roughly oval in outline, being
wider above than below.

1, Frontal bone forms the forehead. Its upper part is
smooth and convex, but the lower part is irregular
and is interrupted by the orbits and by the anterior
bony aperture of nose (Fig. 1.7).
2 The right and left mnxillae form the upper jaw.
3 The right and left nasnl bones form the bridge of the
Occipital belly 4 The zygomatic (Greek yoke) bones form the bony
prominence of the superolateral part of the cheeks.
Fig. 1.6: Attachments of the occipitofrontalis muscle 5 The mnndible forms the lower jaw.
The norma frontalis will be studied under the
The highest nuchal lines i{ present provide following heads:
attachment to the epicranial aponeurosls medially, and a. Frontal region.
give origin to the occipitalis or occipital belly of b. Orbital opening.
occipitofrontalls muscle laterally (Fig. 1.6). In case of c. Anterior piriform-shaped bony aperture of the
absence of highest nuchal lines, these structures are nose.
attached to superior nuchal lines. d. Lower part of the face.

Fronial bone

Frontal tuber
Temporal line

0rbit suture

Nasal bone
Zygomatic bone
Superior orbital
bone lnfraorbital
Orbii line
t( Anterior Maxilla
o nasal
o Nasal
z bone Zygomatic spine
t,c Nasal
bone Angle of
E(s Maxilla
Alveolar Symphysis menti
o process foramen
Angle of
Mandible mandible Menial protruberance
U) Fig. 1.7: Norma frontalis: Walls of orbit and nasal aperture. lnset showing apertures

Frontol Region The anterior nasal spine is a sharp projection in the

The frontal region presents the following features: median plane in the lower boundary of the piriform
aperture (Fig. L.7).
1 The superciliary arch is a rounded, curved elevation
situated just above the medial part of each orbit. It
3 Rhinion is the lowermost point of the internasal
overlies the frontal sinus and is better marked in
males than in females.
2 The glabella is a median elevation connecting the two
superciliary arches. Below the glabella, the skull T1ae ncsal bone is ffie of the most cammonly fiactured
recedes to frontonasal suture at root of the nose. bones al the fate. Mandible and parietal eminence are

3 The nasion is a median point at the root of the nose the next bones to be &actured (Fig. 1.8).
where the internasal suture meets with the
frontonasal suture. Lower Poil of lhe Foce
4 The frontal tuber or eminence is a low rounded Nlaxills
elevation above the superciliary arch, one on each Maxilla contributes a large share in the formation of
side. It is more prominent in females and in children. the facial skeleton. The anterior surface of the body of
the maxilla presents:
Obitol Openings a. The nasalnotch medially;
Each orbital (Latin circle) opening is quadrangular in b. The anterior nasal spine;
shape and is bounded by the following four margins. c. The infraorbitalforamen,l cmbelow the infraorbital
1, Thesupraorbitalmargin is formedby the frontalbone. margin;
At the junction of its lateral two-thirds and its medial d. The incisiue fossa above the incisor teeth, and
one-third, it presents the supraorbital notch or e. The canine fossa lateral to the canine eminence.
foramen (Fi9.1.7).
In addition, three out of four processes of the maxilla
2 The infraorbital margin is formed by the zygomatic are also seen in this norma.
bone laterally, and maxilla medially.
a. The frontal process of the maxilla is directed
3 The medial orbital margin is ill-defined. It is formed upwards. It articulates anteriorly with the nasal
by the frontal bone above, and by the lacrimal crest bone, posteriorly with the lacrimal bone, and
of the frontal process of the maxilla below. superiorly With the frontal bone (Fig. 1.7).
4 The lateral orbital margin is formed mostly by the b . The zygomatic process of the maxilla is short but stout
frontal process of zygomatic bone but is completed and articulates with the zygomatic bone.
above by the zygomatic process of frontal bone.
c. The slaeolar process of the maxillabears sockets for
Frontozygomatic suture lies at their union.
the upper teeth.
Anterior Bony Aperlure of the Nose
Zyg*mati* Eone {rne:lor b*ne)
The anterior bony aperture is pear-shaped, being wide
Zygomatic bone forms the prominence of the cheek.
below and narrow above.
The zygomaticofacial foramen is seen on its surface.
Mandr"h/e (l*w*r j*w i:one)
Aboae: By the lower border of the nasal bones.
Mandible (Latin to cheut) forms the lower jaw.
Below: By the nasal notch of the body of maxilla on each The upper border or alzteolar arch lodges the lower
side. teeth.
T}re lower border or base is rounded.
Features The middle point of the base is called the ment al point t(o
Note the following: or gnathion.
1, Articulations of the nasal bone: The point on the angle of mandible is called gonion. zo
a. Anteriorly, with the opposite bone at the internasal The anterior surface of the body of the mandible G
suture. presents: t,G
b. Posteriorly, with the frontal process of the maxilla. a. The symphysis menti, the mental protuberance and o
c. Superiorly, with the frontal bone at the frontonasal the mental tubercles anteriorly (Fig.1,.7).
suture. b. The mental for amen below the interval between the o
d. Inferiorly, the upper nasal cartilage is attached to two premolar teeth, transmittingthe mental nerae o
it. and aessels. U)

Posterior branch

Middle meningeal artery

Maxillary artery

Fig. 1.8: Fracturednasal boneandpositionof anteriordivisionof middlemeningeal arteryagainstthepterion

c. wlichruns upwards and backwards

Tlne oblique line 6 The leaator labii superiorls arises from the maxilla
from the mental tubercle to the anterior border of between the infraorbital marlin and the infraorbital
the ramus (Latin branch) of the mandible. foramen (see Fig.2.9).
7 The leaator anguli orls arises from the canine fossa.
S*rfurcs sf ffte l$ormo Fr*rufcjss 8 The nasalis and the depressor septi arise from the
. Internasal (Fig. 1.7) surface of the maxilla bordering the nasal notch.
o Frontonasal 9 The incisiaus muscle arises from an area just below
. Nasomaxillary the depressor septi. It forms part of orbicularis oris.
o Lacrimomaxillary 10 The zygomaticus maior and minor arise from the
. Frontomaxillary surface of the zygomaticbone (see Fig.2.9).
'fhe zygomaticus minor muscle arises below the
o Intermaxillary
. Zygomaticomaxillary zygomiticofacial foramen. The zygomaticus major
aiiies lateral to the minor muscle (seeFig.2.9).
' Zygornaticofrontal' 77 Buccinafor arises from maxilla and mandible
opposite molar teeth and fuorr- pterygomandib.ular
ripne 6ee Fig. 2.10). It also forms part of orbicularis
1 The medial part of the superciliary arch gives origin oris..
to the corrugator supercilii muscle.
2 The procerus muscle arises from the nasal bone near $frs**fsrres Fa*srng ffurougl* Forer:tr*cx
.Y the median plane (see Fig.2.9). 1 The supraorbital notch or foramen transmits the
o 3 The orbital part of the orbicularis oculi arises from rt essels (see Fig. 2.5).
supr aorbit al nera es and
z the frontal piocess of the maxilla and from the nasal 2 The external nasal nerae emerges between the nasal
part of the frontal bone (see Fig.2.9). bone and upper nasal cartilage (seeFig.2.22).
t,(E 4 The medial p alp ebr al ligamenf is attached to the frontal 3 The infraorbltal foramentransmits the infraorbital nerae
0) process of the maxilla between the frontal and and aessels (see Fig. 2.22).
maxillary origins of the orbicularis oculi. 4 The zygomaticofaiial foramen transmits the nerve of
E 5 The leoator labii superioris alaeque nasi arises from the the same name, a branch of maxillnry nertte.
o frontal process of the maxilla in front of the 5 The mental foramen on the mandible transmits the
o mental nerve and vessels (seeFig.2.22).
a orbicularis oculi (see fig.2.9).

NORMA LATERALIS part, turns downwards and forwards and becomes
Bones continuous with the supramastoid crest on the squamous
temporal bone near its junction with the mastoid
1 Frontal temporal. This crest is continuous anteriorly with the
2 Parietal (Fig. 1.9a) posterior root of the zygomatic arch (Fig. 1.9b).
3 Occipital
4 Temporal
5 Sphenoid #ygmm*9d*: .4 #y$r*m*
r*fu *pr
6 Zygomatic The zygomatic arch is a horizontal bar on the side of the
7 Mandible head, in front of the ear, a little above the tragus, It is
8 Maxilla formed by the temporal process of the zygomatic bone
9 Nasal in anterior one-third and the zygomatic process of the
temporal bone in posterior two-thirds. The zygomatico-
temporal suture crosses the arch obliquely downwards
fl*:'t';p*r*f Arm*s and backwards.
The temporal lines have been studied in the norma Above the zygomatic arch is temporal fossa, which
verticalis. The inferior temporal line, in its posterior is filled by temporalis muscle. Attached to lower margin
Parietal bone temporal line
Coronal suture
Temporal bone, squamous part
Frontal bone
Position of anterior margin ol
foramen magnum and facial angle
lnferior temporal line
Supramasloid crest


Lambdoid suture
Nasal bone
External occipital protuberance

Asterion Zygomatic bone

Zygomatic arch lnfraorbital foramen

Mastoid process

External acoustic meatus

Styloid process

Ramus of mandible

Parietal bone
Coronal suture
Squamous Frontal bone
Temporal bone
Temporal Iines

Supramastoid crest Pterion J

Lambdoid o
Suprameatal iriangle suture Nasal bone
Zygomatic bone tttr
Mastoid process 6
Vertical tangent to Maxilla
posierior border of Extemal acoustic meatus t(E
external acoustic meatus
Styloid process o
Body of mandible I
External acoustic Ramus of mandible
meatus (b) (c)
Figs 1.9a to c:
(a) Norma lateralis with facial angle, (b) bones forming norma lateralis, and (c) tympanic plate forming margins of o
external acoustic meatus ao

of zygomatic arch is masseter muscle; contraction of site of the po sterolateral or mastoidfontanelle, which closes
both temporalis and masseter may be felt by clenching (Fig. 1.3)by L2 months.
the teeth. The mastoid process is a breast like projection from
The arch is separated from the side of the skull by a the lower part of the mastoid temporal bone, postero-
gap which is deeper in front than behind.Its lateral inferior to the external acoustic meatus. It appears
surface is subcutaneous. The anterior end of the upper during the second year of life. The tympanomastoid
border is called t}lre jugal point. The posterior end of the fissure is placed on the anterior aspect of the base of
zygomalic arch is attached to the squamous temporal the mastoid process. Ttrre mastoidforamen lies at or near
bone by anterior andposterior roots.The articular tubercle the occipitomastoid suture (Fig. 1.5).
of the root of the zygorrra lies on its lower border, at the
junction of the anterior and posterior roots. The anterior Sfyf*fd Frseess
root passes medially in front of the articular fossa. The The styloid (Latin pen) process is a needle-like thin, long
posterior root passes backwards along the lateral projection from the norma basalis situated anteromedial
margin of the mandibular or articular fossa, then above to the mastoid process. It is directed downwards,
the external acoustic meatus to become continuous with forwards and slightly medially. Its base is partly
the supramastoid crest. Two projections are visible in ensheathed by the tympanic plate. The apex or tip is
relation to these roots. One is srticular tubercle at its usually hidden from view by the posterior border of
lower border. Another tubercle is visible just behind the ramus of the mandible.
the mandibular or articular fossa and is known as
postglenoid tubercle. I*rmBcrol fiosss
Sxfe*"1*i A r#{r$fi# fufssfus 1 Abooe, by the superior temporal line.
The external acoustic mentus opens just below the 2 Below, by the upper border of the zygomatic arch
posterior part of the posterior root of zygoma. Its laterally, and by the infratemporal crest of the greater
anterior and inferior margins and the lower part wing of the sphenoid bone medially. Through the
of the posterior margin are formed by the tympanic gap deep to the zygomatic arch, temporal fossa
plate, and the posterosuperior margin is formed communicates with the infratemporal fossa.
by the squamous temporal bone. The margins 3 The anterior tnall is formed by the zygomatic bone
are roughened for the attachment of auricular cartilage. and by parts of the frontal and sphenoid bones. This
The suprameatal triangle (trianlge of Macewen) is a small wall separates the fossa from the orbit.
depression posterosuperior to the meatus. Itisbounded Floar: The anterior part of the floor is crossed by an H-
above by the supramastoid crest, in front by the shaped suture where four bones, frontal, parietal,
posterosuperior margin of the external meatus, and greater wing of sphenoid and temporal adjoin each
behind by a vertical tangent to the posterior margin of other. This area is termed tlrre pterion.It lies 4 cm above
the meatus. The suprameatal spine may be present on the midpoint of the zygomatic arch and 2.5 cm behind
the anteroinferior margin of the triangle. The triangle the frontozygomatic suture. Deep to the pterion lie the
forms the lateral wall of the tyrnpanic or mastoid middle meningeal aein, the anterior diaision of the middle
antrum (Fig.1.9c). meningeal artery , and the stem of the lateral sulcus of brain
( Syloian point) (Fig. 1..8).

&4*rsf*rd fr*rf *f flie temBCIr*:d Serue On the temporal surface of the zygomatic bone
The mastoid part of the temporal boneliesjust behind the forming the anterior wall of the fossa there is the
external acoustic meatus. It is continuous antero- zy gomat icot emp or al for am en.
superiorly with the squamous temporalbone (Fig. 1.9c).
A partially obliterated squamomastoid suture may be
visible in front of and parallel to the roughened area Pteilonis the thin part of skull. Lr roadside accidents,
o for muscular insertion. the anterior division of middle meningeal artery may
z The mastoid temporal bone articulates postero-
tttr be ruptured, leading to clot formation between the
(! superiorly with the posteroinferior part of the parietal skulf bone and dura mater or extradural
!tG bone at the horizontal parietomastoid suture, and haemorrhage (Fig. 1.8). The clot compresses the
o posteriorly with the squamous occipital bone at the motor area of brain, leading to paralysis of the
occipitomastoid suture. These two sutures meet at the opposite side. The clot must be sucked out at the
c lateral end of the lambdoid suture. The asterion is the eirliest by trephining (Fig. 1.10). The head must be
o point where the parietomastoid, occipitomastoid and protected by a helmet.
ao lambdoid sutures meet. L:r infants, the asterion is the

Slructures Possing through Foromino

Superior 1 The tympanomastoid fissure on the anterior aspect of
sagittal sinus the base of the mastoid process transmits the auricular
branch of aagus nerae.
Extradural 2 The mastoid foramen transmits:
haemorrhage a. An emissary aein connecting the sigmoid sinuswith
l}:le posterior auricular aein.
b. A meningeal branch of the occipital artery
(Table 1.1).
3 The zygomaticotemporal fornmen trarlsmits the nerve
of the same name and a minute artery (seeFig.2.22).


Fig. 1.10: Extradural haemorrhage For convenience of study, the norma basalis is divided
arbitrarily into anterior, middle and posterior parts. The
anterior part is formed by the hard palate and the
alveolar arches. The middle and posterior parts are
fnfr*fe*rp*rrtr, Fs$$# separated by an imaginary transverse line passing
Boundaries and the contents are described in Chapter 6. through the anterior margin of the foramen magnum
(Figs 1.11a and b).
Ff*ry6mp*f*uffne F*sss
Pterygopalatine fossa is described in Chapter 15. Anterior Porl of Normo Bosolis
1 The temporal Alveolar arch bears sockets for the roots of the upper
fascia is attached to the superior teeth.
temporal line and to the area between the two
temporal lines. Inferiorly, it is attached to the outer
and inner lips of the upper border of the zygomatic f{srdF*Jmfe
arch. 'l." Formntion:
2 The temporalis muscle arises from the whole of the a. Anterior two-thirds, by the palatine processes of
temporal fossa, except the part formed by the the maxilla bones.
zygomaticbone (Fig. 1.14). Beneath the muscle there b. Posterior one-third by the horizontal plates of the
lie the deep temporal aessels and neraes. Tlne middle palatine bones.
temporal aessels produce vascular markings on the 2 Sutures: The palate is crossed by a cruciform suture
temporal bone just above the external acoustic made up of intermaxillary, interpalatine and
meatus. palatomaxillary sutures.
3 The medial surface and lower border of the 3 Dome:
zygomatic arch give origin to the masseter. a. It is arched in all directions.
4 The lateral ligament of the temporomandibular joint is b. Shows pits for the palatine glands.
attached to the tubercle of the root of the zygoma 4 The incisizte fossa is a deep fossa situated anteriorly
(see Chapter 6). in the median plane (Fig. 1.12).
5 The sternocleidomastoid, splenius capitis and longissimus Two incisiae canals, right and left, pierce the walls of
capitis are inserted in that order from before the incisive fossa, usually one on each side, but
backwards on the posterior part of the lateral occasionally in the median plane, the left being ta
surface of the mastoid process (Fig. 1.1a). Posterior anterior and the right, posterior. o
belly of digastric arises from mastoid notch. The 5 The greater palatine foramen, one on each side, is
groove obliquely placed is due to occipital artery tt
situated just behind the lateral part of the palato- G
maxillary suture. A groove leads from the foramen !,(E
6 The gapbetween the zygomatic arch and the side of towards the incisive fossa. o
the skull transmits: 6 The lesser palatine foramina, two or three in number
a. Tendon of the temporalis muscle. on each side, lie behind the greater palatine foramen, o
b. Deep temporal vessels. and perforate the pyramidal process of the palatine C)
c. Deep temporal nerves. bone (see Fig. 15.1a). ao

lntermaxillary suture
lncisive foramen (nasopalatine nerves)
lnterpalatine suture
Palatine process (bony palate)

Zygomatic arch
Medial and lateral
pterygoid plates
Greater palatine foramen (anterior
palatine nerve)
Foramen lacerum
(nerve of pterygoid canal)
lnferior orbital fissure (zygomatic and
Mandibular fossa infraorbital nerves)

Sulcus tubae Les$er palatine foramen

(middle and posterior palatine nerves)
Petrotympanic fissure
Pharyngeal tubercle Foramen ovale (mandibular and
lesser petrosal nerves)
Carotid canal (internal
Styloid process
carotid artery)

Mastoid process Stylomastoid foramen (Vll nerve)

Foramen spinosum and sPine of

Jugular foramen (lX, X, Xl and sphenoid (middle meningeal artery)
internal jugular vein)
Occipital condyle
Hypoglossal canal (Xll nerve)
Foramen magnum (spinal cord with
Posterior condylar canal
meninges,anterior and Posterior
Superior nuchal line spinal arteries, vertebral arteries.
spinal roots of Xl nerves)
External occipital crest
lnferior nuchal line
External occipital protuberance

lnfratemporal crest Posterior margin of inferior

orbital fissure

Continuous with pterygoid process

(medial surface)
Foramen spinosum
(middle meningeal
Foramen ovale (mandibular nerve,
acce$sory meningeal artery lesset
Articulates with petrosal nerve and emissarY vein)
squamous temporal
Sulcus tubae
Auriculotemporal nerve

Spine of sphenoid Peirous part of temPoral bone

Chorda tympani
zo Figs 1.1i a and (a) Norma basalis showing passage of main nerves and arteries, and (b) infratemporal surface of greater wing
tt from below
of sphenoid seen
o 7 The posterior border of the hard palate is free and Middle Porl of Normo Bosolis
presents theposterior nasal spine in the median plane. The middle part extends from the posterior border of
c 8 The palatine crest is a curved ridge near the posterior the hard pilate to the arbitrary transverse line
C) border. It begins behind the greater palatine foramen passing thiough the anterior margin of the foramen
ao and runs medially (Fig. 1.12). maSnum.

lncisive foramen 5 The broad bar of the bone is marked in the median
with openings of
plane by the pharyngeal tubercle, a little in front of
incisive canals
the foramen magnum (Fig. 1.11a).

Palato - Palatine process i.ofererfAres

maxillary of maxilla
suture The lateral area shows two parts of the sphenoid
Horizontal plate
of palatine bone
bone-pterygoid process and greater wing. Also
seen are three parts of the temporal bone, i.e. petrous
sulure Greaier palatine temporal, tympanic plate and squamous temporal.
foramen The pterygoid process projects downwards from the
process of Lesser palatine junction of greater wing and the body of sphenoid
Palatine Posterior
palatine bone
cre$t nasal spine
foramen behind the third molar tooth.
Inferiorly, it divides into the medial and lateral
Fig. 1.12: Anterior part of the norma basalis
pterygoid plates whicli. are fused together anteriorly,
but are separated posteriorly by the V-shaped
Median Area pterygoid fossa.
The median area shows: The fused anterior borders of the two plates
a. The posterior border of the aomer. articulate medially with the perpendicular plate of
b . Abroad bar of bone formed by fusion of the posterior the palatine bone, and are separated laterally from
part of the body of sphenoid and the basilar part the posterior surface of the body of the maxilla by
of occipital bone (Fig. 1.13). the pterygomaxillary fissure.
The vomer separates the two posterior nasal The medial pterygoid plate is directed backwards.
apertures. Its inferior border articulates with the Ithas medial and lateral surfaces and a free posterior
bony palate. The superior border splits into two alae border.
and articulates with thre rostrum of the sphenoid bone The upper end of this border divides to enclose a
(Fig. 1.13). triangular depression called the scnphoid fossa. The
The palatinooaginal canal. T}ire inferior surface of the lower end of the posterior border is prolonged
vaginal process of the medial pterygoid plate is downwards and laterally to form the pterygoid
marked by an anteroposterior groove which is hamulus.
converted into the palatinovaginal canal by the upper The lateral pterygoid plate is directed backwards
surface of the sphenoidal process of the palatine and laterally. It has medial and lateral surfaces and
bone. The canal opens anteriorly into the posterior a free posterior border. The lateral surface forms the
wall of the pterygopalatine fossa (see Fig. 15.14). medial wall of the infratemporal fossa. The lateral
The aomeroztaginal canal. The lateral border of each and medial surfaces give origin to muscles.
ala of the vomer comes into relationship with the The posterior border sometimes has a projection
vaginal process of the medial pterygoid plate, and at its middle called the pterygospinous process
may overlap it from above to enclose the which projects towards the spine of the sphenoid.
vomerovaginal canal (Fig. 1.13). The infratemporal surface of the greater wing of the
sphenoid is pentagonal:
Horizontal plate of Posterior nasal a.Its anterior margin forms the posterior border of
palatine bone aperiure the inferior orbital fissure (Fig. 1.11b).
Medial pterygoid plate b.Its anterolateral margin forms the infratemporal
Lateral pterygoid plate crest.
Sphenoidal process
of palatine bone Perpendicular c. Ils posterolateral margin articulates with the
plate of palatine
squamous temporal. 5
Palatinovaginal bone o
d.Its posteromedial margin articulates with petrous o
canal Root of pterygoid
process temporal.
Ala of vomer E
Greater wing e. Anteromedially , it is continuous with the pterygoid c
of sphenoid process and with the body of the sphenoid bone. !,(E
of sphenoid Vaginal process The posteriormost point between the posterolateral o
Body of sphenoid
Vomerovaginal canal of sphenoid and posteromedial margins projects downwards to
Fig. 1.13: Posterior view of a coronal section through the form the spine of the sphenoid. o
posterior nasal aperture showing the formation of the Along the posteromedial margin, the surface is ()
palatinovaginal and vomerovaginal canals pierced by the following foramina: ao

a. The foramen oaale is large and oval in shape. It is Its anterior surface forms the posterior wall of the
situated posterolateral to the upper end of the mandibular fossa. The p osterior surface is concave and
posterior border of lateral pterygoid plate forms the anterior wall, floor, and lower part of the
(Fig. 1.11b). posterior wall of the bony external acoustic meatus
b. The foramen spinosum is small and circular in (Fig.
shape. It is situated posterolateral to the foramen Its upper borderbounds the petrotympanic fissure.
ovale, and is limited posterolaterallyby the spine The lower border is sharp and free.
of sphenoid (Fig. 1.11). Medially: It passes along the anterolateral margin
c. Sometimes there is the emissary sphenoidal foramen of the lower end of the carotid canal.
or foramen of Vesalius.It is situated between the Laterally: It forms the anterolateral part of the
foramen ovale and the scaphoid fossa.Internally, sheath of the styloid process.
it opens between the foramen ovale and the lnternally: The tympanic plate is fused to the
foramen rotundum. petrous temporal bone.
d. At times there is acanaliculus innominatus situated 6 The squamous part of the temporal bone forms:
between the foramen ovale and the foramen a. The anterior part of the mandibular articular fossa
spinosum. which articulates with the head of the mandible
Tlne spine of the sphenoid may be sharply pointed or to form the temporomandibular joint.
blunt (Fig. 1.11b). b. The articular tubercle which is continuous with
The sulcus tubae is the groove between the postero- the anterior root of the zygoma.
medial margin of the greater wing of the sphenoid c. A small posterolateral part of the roof of the
and the petrous temporal bone. It lodges the infratemporal fossa.
cartilaginous part of the auditory tube. Posteriorly, the
groove leads to the bony part of the auditory tube Poslerior Port of Normo Bosqlis
which lies within the petrous temporal bone Medisffi Ar*s
(Fig. 1.11a).
The median area shows from before backwards:
The inferior surface of the petrous (Greek rock) part
a. The foramen magnum.
of the temporal bone is triangular in shape with its
apex directed forwards and medially. b. The external occipital crest.
It lies between the greater wing of the sphenoid c. The external occipital protuberance.
and the basiocciput.Its apex is perforated by the d. Nuchal lines
upper end of the carotid canal, and is separated from a. The foramen magnum (Latin great) is the largest
the sphenoid by the foramen lacerum. The inferior foramen of the skull. It opens upwards into the
surface is perforated by the lower end of the carotid
posterior cranial fossa, and downwards into the
canal posteriorly. vertebral canal. It is oval in shape, being wider
The carotid canal runs forwards and medially behind than in front where it is overlapped on each
within the petrous temporal bone. side by the occipital condyles (Fig. 1.1a).
The foramen lacerum is a short, wide canal, L cm b. The external occipital crest begins at the posterior
long. Its lower end is bounded posterolaterally by margin of the foramenmagnum and ends posteriorly
the apex of the petrous temporal, medially by the and above at the extemal occipital protuberance.
basiocciput and the body of the sphenoid, and c. The external occipitalprotubernnceis a projection located
anteriorly by the root of the pterygoid process and at the posterior end of the crest. It is easily felt in the
the greater wing of the sphenoid bone. living, in the midline, at the point where the back of
A part of the petrous temporal bone, called the the neck becomes continuous with the scalp (Fig. 1.5).
tegmen tympani, is present in the middle cranial fossa. d. Nuchal lines: The superior nuchal lines begin at the
It has a down turned edge which is seen in the external occipital protuberance and the inferior
.Y squamotympanic fissure and divides it into the nuchal lines at the middle of the crest. Both of them
o curve laterally and backwards and then laterally and
zo posterior p etr otymp anic and anterior p etr o s quamous
fissures (Fig. 1.11a). forwards.
t Highest nuchal line is faded and seen above
(Er The tympanic part of the temporal bone also called as the
tt(E tympanic plate is a triangular curved plate which lies superior nuchal line (occasionally).
o in the angle between the petrous and squamous
parts. {.sferaf Are*
c Its apex is directed medially and lies close to the The lateral area shows;
o spine of the sphenoid. o The condylar part of the occipital bone.
ao Thebase or Latualborder is curved, free and roughened. r The squamous part of the occipital bone.

Palatine aponeurosis

Musculus uvulae
(pharyngeal plexus)

Tensor veli palatini (V3)

Levator veli palatini

{pharyngeal plexus)
Styloglossus (Xll)
Stylohyoid (Vll)
Stylopharyngeus (lX)
Lonous caoitis -_l Ventral rami
of cervical
Longissimus Rectus caoitis lateralis I nerves and
capitis ' I cervical
Rectus capitis anterior plexus
Dorsal Splenius capitis
rami Superior oblique Digastric posterior belly (Vll)
cervical Sternocleidomastoid Spinal root
nerves of xl
Rectus capitis posterior Trape.ius I
major and minor

Semispinalis capitis

Occipitalis (Vll)

Superior constrictor of pharynx (pharyngeal plexus)

Fig. 1.14; Muscles attached to the base of skull with their nerve supply

The jugular foramen between the occipital and fossa present behind the occipital condyle.
petrous temporal bones. Superiorly, it opens into the sigmoid sulcus.
a The styloid process of the temporal bone. iv. The jugular process of the occipital bone lies
a The mastoid part of the temporal bone. lateral to the occipital condyle and forms the
posterior boundary of jugular foramen
a. The condylar or lateral part of the occipital bone (Fis. 1.11).
presents the following. b. Squamous part of occipital bone is marked by the
i. The occipital condyles are oval in shape and are superior and inferior nuchal lines mentioned
situated on each side of the anterior part of above (Fig. 1.5).
the foramen magnum. Their long axis is c. The jugular foramen is large and elongated,
directed forwards and medially. They with its long axis directed forwards and medially. .Y
articulate with the superior articular facets of
the atlas vertebra to form the atlanto-occipital
It is placed at the posterior end of the petro- zo
occipital suture (Fig. 1.11a). !ttr
joints (Fig. 1.11). At the posterior end of the foramen, its anterior (E

ii. The hypoglossal or snterior condylar canal pierces wall (petrous temporal) is hollowed out to form t,(E
the bone anterosuperior to the occipital the jugular fossa which lodges the superior bulb of o
condyle, and is directed laterally and slightly the internal jugular vein. The fossa is larger on
forwards. the right side than on the left. C
iii. The condylar or posterior condylar canal is The lateral wall of the jugular fossa is pierced o
occasionally present in the floor of a condylar by a minute canal, the mastoid canaliculus. a

Near the medial end of the jugular foramen, e. The pterygospinous process which is present at
there is the jugular notch. At the apex of the notch, the middle of medial pterygoid plate gives
there is an opening that leads into the cochlear attachment to the ligament of same name.
cannliculus. 5 The attachments on the lateral pterygoid plate are
The tympanic canaliculus opens on or near the as follows:
thin edge of bone between the jugular fossa and a. Its lateral surface gives origin to the lozuerhead of
the lower end of the carotid canal. lateral pterygoid muscle (Fig. 1.14).
d. Styloid process will be described in Chapter 8. b. Its medial surface gives origin to the deep head of
The stylomastoid foramerz is situated posterior to the medial pterygoid. The small, superficial head
the root of the styloid process, at the anterior end of this muscle arises from the maxillary tuberosity
of the mastoid notch. and the adjoining part of the pyramidal process
e. The mastoid process is a large conical projection of the palatine bone (Fig. 1.14).
located posterolateral to the stylomastoid 6 The infratemporal surface of the greater wing of the
foramen. It is directed downwards and for wards. sphenoid gives origin to the upper head of the lateral
It forms the lateral waIl of the mastoid notch pterygoid muscle, and is crossed by the deep temporal
(Fis. 1.s). and masseteric nerves.
7 The spine of lhe sphenoid is related laterally to the
Attacltments an exterior of skull auriculotemporal nerae, and medially to the chorda
1 The posterior border of the hard palate provides tympani nerae and auditory tube.
attachment to the palatine aponeurosis. The Its tip provides attachment to the (i) sphenomandi-
posterior nasal spine gives origin to the musculus bular ligament, (ii) anterior ligament of malleus, and
uvulae (Fig. 1.14). (iii) pterygospinous ligament.
2 The palatine crest provides attachment to a part of Its anterior aspect gives origin to the most posterior
the tendon of tensor r:eli palatini muscle (Fig. 1.1a). fibres of the tensor oeli palatini and tensor tympani
3 The attachments on the inferior surface of the muscles.
basiocciput are as follows: 8 The inferior surface of petrous temporal bone gives
a. The pharyngeal tubercle gives attachment origin to the leztator aeli palatini (Fig. 1.1a).
to the raphe which provides insertion to the 9 The margins of the foramen magnum provide
upper fibres of the superior constrictor muscle of attachment to:
the pharymx (Fig. 1.l4). a. The anterior atlanto-occipital membrane anteriorly
(see Fig.9.11).
b. The area in front of the tubercle forms the roof of
the nasopharynx and supports the pharyngeal b . T}lre posterior atlanto-occipital membrane posteriorly.
tonsil. c. The alar ligaments on the roughened medial
c. The longus capitis is inserted lateral to the surface of each occipital condyle (seeFig.9.12).
pharyngeal tubercle (Fig. 1.1a). 10 The ligamentum nuchae is attached to the external
occipital protuberance and crest.
d. The rectus capitis anterior is inserted a little
11 The rectus capitis lateralis is inserted into the inferior
posterior and medial to the hypoglossal canal
(Fig. 1.1a). surface of the jugular process of the occipital bone
(Fig. 1.1a).
4 The attachments on the medial pterygoid plate are
12 The following are attached to the squamous part of
as follows:
the occipital bone (Fig. 1.1a).
a. The pharyngobasilar fascia is attached below to the
The area between the superior and inferior nuchal
processus tuberis.
lines provides insertion medially to the semispinalis
Processus tuberis is a triangular projection capitis, and laterally to the superior oblique muscle.
which is present at the middle of the posterior The area below the inferior nuchal line provides
5 border of medial pterygoid plate. It supports the insertion medially to tlne rectus capitis posterior minor,
o medial end of cartilaginous part of auditory tube.
o and laterally to the rectus capitis posterior major
z b. The lower part of the posterior border, and the
!, (Fig. i.1a).
c(E pterygoid hamulus, give origin to the superior 13 The mastoid notch gives origin to the posterior belly of
!,(E constrictor of the pharynx. digastric muscle (Fig. 1.1a).
o c. The upper part of the posterior border is notched
by the auditory tube. Structures P assing through F orarnina
o d. The pterygomandibular raphe is attached to the tip 1 Each incisizte foramen transmits:
o of the pterygoid hamulus at one end and to the a. The terminal parts of the greater palatine aessels
a mandiblebehind 3rd molar tooth at the other end. from the palate to the nose.

b. The terminal part of the nasopalatine neroe from 11 The structures passing through the for amen lacerum :
the nose to the palate (Fig. 1.11a). During life the lower part of the foramen is filled
2 The greater palatine foramen transmits: with cartilage, and no significant structure passes
a. The grenter palatine aessels. through the whole length of the canal, except for
b. The anterior pnlatine nerT)e, both of which run the meningeal branch of the ascending pharyngeal
forwards in the groove that passes forwards from artery and an emissary vein from the cavernous
the foramen (see Fig. 15.14). sinus.
3 The lesser palatine foramina transmit the middle and However, the upper part of the foramen is
posterior palatine neraes. traversed by the internal carotid artery with venous
4 The palatinoaaginal cannl transmits: and sympathetic plexuses around it. In the anterior
a. A pharyngeal branch from the pterygopalatine part of the foramen, the greater petrosal nerae lunites
ganglion (see Fig. 15.1.4). with the deep petrosal neroe to form the nerae of the
b. A small pharyngealbranch of the maxillary artery. pterygoid canal (Yidian's nerve) which leaves the
5 The aomerooaginal canal (if patent) transmits foramen by entering the pterygoid canal in the
branches of the pharyngeal branch from pterygo- anterior wall of the foramen lacerum (Fig. 1.15).
palatine ganglion and vessels. 12 The medial end of the p etrotympanicfissure transmits
6 T}ee foramen oaale transmits (mnemonic-MAlE) the chorda tympani nerve, anterior ligament of
a. The mandibular nerae (Fi1.1,.1,1) malleus and the anterior tympanic artery (Fig.
b. The accessory meningeal artery. 1.11a).
c. The lesser petrosal neruse L3 The foramen magnum (Fig. 1.16) transmits the
d. An emissaty aein connecting the cavernous sinus
with the pterygoid plexus of veins.
e. Anterior trunk of middle meningeal vein Through the narrow anterior part
(occasionally). a. Apical ligament of dens.
7 Tlaeforamen spinosumtransmits the middle meningeal b. Vertical band of cruciate ligament.
artery (Fig. f .i1a) the meningeal branch of the c. Membrana tectoria.
mandibular nerve or nervus spinosus, and the Through wider posterior part
posterior trunk of the middle meningeal vein. a. Lowest part of medulla oblongata.
8 The emissary sphenoidalforamen (foramen of Vesalius) b Three meninges.
transmits anemissary aein connecting the cavernous
Through the subarachnoid space pass:
sinus with the pterygoid plexus of veins.
9 \Mhen present the canaliculus innominatus transmils a. Spinal accessory nerves.
the lesser petrosal nerve, (in place of foramen ovale). b. Vertebral arteries.
L0 The carotid canal transmits the internal carotid artery, c. Sympathetic plexus around the vertebral arteries.
and the oenous and sympathetic plexuses around the d. Posterior spinal arteries.
artery (Fig. 1.11a). e. Anterior spinal artery.

Anterior Posterior

lnternal carotid artery and

sympathetic plexus

Greater petrosal nerve Deep petrosal nerve

(from sympathetic
Pterygoid process
Petrous temporal .Y
Nerve of pterygoid canal
in pterygoid canal zo
Emissary vein
Meningeal branch of o
ascending pharyngeal
Pterygoid plexus of veins artery
Cartilage filling lower .9
end of foramen lacerum ()
Fig. 1.15: Structures related to the foramen lacerum ao

Apical ligament
Upper vertical band of cruciate ligament

Arachnoid mater

Dura mater
Lefl Righi Vertebral artery (4th part)
with sympathetic plexus
First tooth of ligamentum
Posterior denticulatum

Spinal root of accessory

Posterior spinal artery

Lowest part of medulla oblongata Pia mater

Fig. 1.16: Structures passing through foramen magnum

14 The hypoglossal or anterior condylar canal transmits 19 The stylomastoid foramen transmits the facial nerve
the hypoglossal nerae, the meningeal branch of the and the stylomastoid branch of the posterior
hypoglossal nerve (these are the sensory fibres of auricular artery.
cervical first spinal nerve supplying the duramater
of posterior cranial fossa) the meningeal branch of
the ascending pharyngeal artery, and an emissary
oein conrrecting the sigmoid sinus with the internal
Before beginning a systematic study of the interior, the
jugular vein (Table 1.1).
following general points may be noted.
15 The posterior condylar canal transmits an emissary
vein connecting the sigmoid sinus with suboccipital
1 The cranium is lined intemallyby endocranium which
is continuous with the pericranium through the
venous plexus (Table 1.1).
foramina and sutures.
16 The jugular foramen transmits the following 2 The thickness of the cranial vault is variable. The
structures: bones covered with muscles, i.e. temporal and
i. Through the anterior part: posterior cranial fossae are thinner than those
(a) Inferior petrosal sinus. covered with scalp. Further, the bones are thinner in
(b) Meningeal branch of the ascending pharyngeal females than in males, and in children than in adults.
artery. 3 Most of the cranial bones consist of:
ii. Through the middle part:IX,X andXl cranial nerves. a. An outer table of compact bone which is thick,
iii. Through the posterior part: resilient and tough.
a. Internal jugular vein (Fig. 1.11a). b. An inner table of compact bone which is thin and
b. Meningeal branch of the occipital artery. brittle.
The glossopharyngeal notch near the medial end of c. The diploe which consists of spongy bone filled
the jugular foramen lodges the inferior ganglion of with red marrow in between the two tables.
the glossopharyngeal nerve. The skull bones derive their blood supply mostly
L7 The mastoid canaliculus (Arnold's canal) in the from the meningeal arteries from inside and very little
lateral wall of the jugular fossa transmits the from the arteries of the scalp. Blood supply from the
auricular branch of the vagus (Arnold's nerve). The outside is rich in those areas where muscles are
.Y nerve passes laterally through the bone, crosses the attached, e.g. the temporal fossa and the suboccipital
o region. The blood from the diploe is drained by four
zo facial canal, and emerges at the tympanomastoid
fissure. The nerve is extracranial at birth, but diploic veins on each side draining into venous sinuses
t (Table 1..2 and Fig. 1.17).
(E becomes surrounded bybone as the tympanic plate
t,(E and mastoid process develop (also called Many bones like vomer (Latin plowshare), pterygoid
o Alderman's nerve). plates do not have any diploe.
18 The tymp anic canaliculus on the thin edge of partition
c between the jugular fossa and carotid canal INTERNAL SURFACE OF CRANIAL VAUIT
o transmits the tympanic branch of glossopharlmgeal The shape, the bones present and the sutures uniting
ao nerve (Jacobson's nerve) to the middle ear cavity. them have been described with the norma verticalis.
rr'rrRoouciroN Ar'ro OstE6tbGi'

:;;'r;;';'','" :. :: : :.: ': ::. .r.::' ,.::::,1:::tlj:.,a:i.::t1.1]ii:ti;,

'-,::';:t!ute'iii]: i,.Fiddi*-vli 1.,;:"::::,ii::i:i:,,:,

Vein Foramen Drainage

1. Frontal diploic vein Supraorbital foramen Drain into supraorbital vein
2. Anterior temporal or parietal diploic vein ln the greater wing of sphenoid Sphenoparietal sinus or in anterior
deep temporal vein
3. Posterior temporal or parietal diploic vein Mastoid foramen Transverse sinus
4. Occipital diploic vein (largest) Foramen in occipital bone Occipital vein or confluence of sinuses
5. Small unnamed diploic veins Pierce inner table of skull close to the Venous lacunae
margins of superior sagittal sinus

Anterior lemporal
Posterior temporal



Fig. 1.17: Diploic veins in an adult

The following features may be noted: accompanying vein runs upwards L cm behind
a. The inner table is thin and brittle. It presents the coronal suture. Smaller grooves for the
markings produced by meningeal vessels, venous branches from the anterior and posterior branches
sinuses, arachnoid granulations, and to some of the middle meningeal vessels run upwards and
extent by cerebral gyri. It also presents raised backwards over the parietal bone (Fig. 1.8).
ridges formed by the attachments of the dural f. The parietal foramina open near the sagittal
folds. sulcus 2.5 to 3.75 cm in front of the lambdoid
b. The frontal crest lies anteriorly in the median suture (Fig. 1.2).
plane. It projects backwards. g. The impressions for cerebral gyri are less distinct. .Y
These become very prominent in cases of raised
c. The sagittal sulcusruns from before backwards in
the median plane. It becomes progressively wider intracranial tension.
posteriorly. It lodges the superior sagittal sinus. tr
d. The granular fozteolae are deep, irregular,large, pits
situated on each side of the sagittal sulcus. They The interior of the base of skull presents natural o
are formed by arachnoid granulations. They are subdivisions into the anterior, middle and posterior
larger and more numerous in aged persons. cranial fossae. The dura mater is firmly adherent to the C
e. The oascular markings. The groove for the anterior floor of fossae and is continuous with pericranium o
branch of the middle meningeal artety, and the through the foramina and fissures. ao

Anterior Croniol Fosso #fit*rSsmfures

#*:*st#egryes 1 The cribrifurm plate of the ethmoid bone separates the
Anteriorly and on the sides,by the frontal bone (Fig. 1.18). anterior cranial fossa from the nasal cavity. It is
quadrilateral in shape (Fig. 1.18).
Posteriorly, it is separated from the middle cranial
a. Anterior margin articulates with the frontal bone
fossa by the free posterior border of the lesser wing of the
atthefrontoethmoidal suturewhich is marked in the
sphenoid, the anterior clinoid process, and the anterior
median planeby theforamen caecum. This foramen
margin of the sulcus chiasmaticus.
is usually blind, but is occasionally patent.
b. Posterior margin articulates with the jugum
fff**r sphenoidale. At the posterolateral corners, we see
In the median plane, it is formed anteriorly by the the posterior ethmoidal canals.
cribrifurm plate of the ethmoid bone, and posteriorly by c. Its lateral margins articulate with the orbital plate
the superior surface of the anterior part of the body of of the frontal bone: the suture between them
the sphenoid or jugum sphenoidale. presents the anterior ethmoidal canal placedbehind
On each side, the floor is formed mostly by the orbital the crista galli (Fig. 1.18).
plate of the frontal bone, and is completed posteriorly by Anteriorly, the cribriform plate has a midline
the lesser wing of the sphenoid. projection called the crista galli (Latin cock's comb).

Anterior ethmoidal canal

Posterior ethmoidal canal
Ethmoid bone
Frontal sinus
Cribriform plaie of ethmoid
Optic canal
Crista galli

Frontal bone
Lesser wing of sphenoid bone

Superior orbital fissure

Greater wing of sphenoid bone

Hypophyseal fossa (sella turcica)

Posterior clinoid process

Space for trigeminal ganglion

Temporal bone, petrous part

lnternal acoustlc meatus

Groove for sigmoid sinus

Jugular foramen

zo Foramen magnum
t Hypoglossal canal
(E Cerebellar fossa
o Groove for
I transverse sinus Confluence of the sinuses
(internal occipital protuberance)
Cerebral fossa
(occipital lobe)
U) Fig. 1.18: The cranial fossae. The boundaries of the bones present in the floor of the fossae are shown in interrupted lines

On each side of the crista galli there are foramina temporal and anterior surface of petrous temporal on
through which the anterior ethmoidal nerzte and oessels each side.
pass to the nasal cavity. The plate is also perforated
by numerous foramina for the passage of olfactory #fftprFesfures
nerve rootlets.
Median area
The jugum sphenoidale separates the anterior cranial
The body of the sphenoid presents the following
fossa from the sphenoidal sinuses.
The orbital plate of the frontal bone separates the
anterior cranial fossa from the orbit. It supports the 1 The sulcus chiasmaticus or optic grooae leads, on each
orbital surface of the frontal lobe of the brain, and side, to the optic canal. The optic chiasma does not
presents reciprocal impression s. The fr ont al air sinus occupy the sulcus, it lies at a higher level well behind
may extend into its anteromedial part. The medial the sulcus.
margin of the plate covers the labyrinth of the 2 The optic cannl leads to the orbit. It is bounded
ethmoid; andtheposterior margin articulates with the laterally by the lesser wing of the sphenoid, in front
lesser wing of the sphenoid. and behind by the two roots of the lesser wing, and
Thelesser roing of the sphenoid isbroad medially where medially by the body of sphenoid.
it is continuous with the jugum sphenoidale and tapers 3 The sella turcica (pituitary fossa or hypophyseal fossa)
laterally. The free posterior border fits into the stem of The upper surface of the body of the sphenoid is
the lateral sulcus of the brain It ends medially as a hollowed out in the form of a Turkish saddle, and is
prominent proj ection, th e ant er ior clinoid p r o c e s s. Inf e- known as the sella turcica. It consists of the tub er culum
riorly, the posterior border forms the upper boundary sellae infront, the hypophyseal fossa in the middle and
of the superior orbitalfissure.Medially, the lesser wing the dorsum sellnebehind (Fig. 1.18).
is connected to the body of the sphenoidby anterior The tuberculum sellae separates the optic groove from
and posterior roots, which enclose the optic canal. llre hypophyseal fossa.Its lateral ends form the middle
clinoid process which may join the anterior clinoid
Fracture of the anterior cranial fossa may cause The hypophy seal fossa lodges the hypophysis cerebri.
bleeding and discharge of cerebrospinal fluid Beneath the floor of fossa lie the sphenoidal air sinuses.
through thenose.Itmay also cause a conditioncalled The dorsum sellae is a transverse plate of bone
btackeye whieh is produced by seepage of blood into projecting upwards; it forms the back of the saddle. The
the eyelid, as frontalis muscle has no bony origin superolateral angles of the dorsum sellae are expanded
(see Fig.2.8). to form the posterior clinoid processes.

Middle Cronio! Fosso Lateral area

It is deeper than the anterior cranial fossa, and is shaped 1 The lateral area is deep and lodges the temporal lobe
like abutterfly,beingnarrow and shallow in the middle; of the brain.
and wide and deep on each side. 2 It is related anteriorly to the orbit, laterally to the
temporal fossa, and inferiorly to the infratemporal
#sumd*riss fossa.
Anteriar 3 The superior orbital fissure opens anteriorly into the
1 Posterior border of the lesser wing of the sphenoid. orbit. It is bounded above by the lesser wing, below
2 Anterior clinoid process. by the greater wing, and medially by the body of
3 Anterior margin of the sulcus chiasmaticus. the sphenoid (see Fig. 13.4).
Posterior The medial end is wider than the lateral.
1 Superior border of the petrous temporal bone. The long axis of the fissure is directed laterally, ,,x
upwards and forwards. The lower border is marked o
2 The dorsum sellae of the sphenoid.
by a small projection, which provides attachment to zo
Lateral !tc
the common tendinous ring of Zinn The ring divides (E
1 Greater wing of the sphenoid. the fissure into three parts. !,
2 Anteroinferior angle of the parietal bone. 4 The greater wing of the sphenoidpresents the following
3 The squamous temporal bone. features:
Floor a. The foramen rotundum.It leads anteriorly to the o
Floor is formed by body of sphenoid in the median pterygopalatine fossa containing pterygopalatine o
region and by greater wing of sphenoid, squamous ganglia (Table 1.3). a0)

b. Theforamen ooalelies posterolateral to the foramen e. The tegmen tympani is a thin plate of bone
rotundum and lateral to the lingula. It leads anterolateral to the arcuate eminence. It forms a
inferiorly to the infratemporal fossa (Fig. 1.18). continuous sloping roof for the tympanic antrum,
c. The foramen spinosum lies posterolateral to the for the tympanic cavity and for the canal for the
foramen ovale. It also leads, inferiorly, to the tensor tympani.
infratemporal fossa (Fig. 1.18). The lateral margin of the tegmen tympani is
d. The emissary sphenoidal foramen or foramen of turned downwards, it forms the lateral wall of the
Vesalius. It carries an emissary vein. bony auditory tube.
The fornmen lacerum lies at the posterior end of the Its lower edge is seen in the squamotympanic
carotid groove, posteromedial to the foramen fissure and divides it into the petrosquamous and
ovale. petrotympanic fissures.
The anterior surface of the petrous temporal bone presents 7 The cerebral surface of the squamous temporal bone is
the following features: concave. It shows impressions for the temporal lobe
a. The trigeminal impression lies near the apex, behind and grooves for branches of the middle meningeal
the foramen lacerum. It lodges the trigeminal vessels.
ganglion within its dural cave (see Fig. 12.13).
b. The hiatus and grooae for the greater petrosal neroe
are present lateral to the trigeminal impression. Fracture of the middle cranial fossa produces:
They lead to the foramen lacerum (Table 1.3). a. Bleeding and discharge of CSF through the ear.
c. The hiatus and grooae for the lesser petrosal nerae,lie b, Bleeding through the nose or mouth may occur
lateral to the hiatus for the greater petrosal nerve. due to involvement of the sphenoid bone,
They lead to the foramen ovale or to canaliculus c. The $eventh and eighth cranial nelves may be
innominatus to relay in otic ganglion. damaged if the foacture al6o passes through the
d. Still more laterally there is the arcuate eminence intemal acoustic meatus. If a semicirculd canal is
produced by the superior semicircular canal. damaged, vertigo may occur.

Gangtia Sensory root Sympathetic roort Secretotmotor root/ Motor root Distribution
parasympathetic root
Ciliary From nasociliary Plexus along Edinger-Westphal a. Ciliaris muscles
(see Fig.13.11) nerve ophthalmic nucleus -+ b. Sphincter pupillae
artery oculomotor
nerve -+nerve to
inferior oblique
Otic from
Branch Plexus along lnferior salivatory Branch from a. Secretomotor to
(see Fig. 6.15) auriculotemporal middle meningeal nucleus -+glosso- nerve to medial parotid gland via
nerve artery pharyngeal nerve -+ pterygoid auriculotemporal
tympanic branch -+ nerve
tympanic plexus --> Tensor veli palatini
lesser petrosal nerve. and tensor tympani
via nerve to med.
pterygoid (unrelayed)
Pterygopalatine 2 branches from Deep petrosal Superior salivatory a. Mucous glands of
(see Fig. 15.15) maxillary nerve from plexus nucleus, and lacrima- nose, paranasal
around internal tory nucleus -)nervus sinuses, palate,
carotid intermedius -+facial nasopharynx
o nerve -rgeniculate b. Some fibres pass
zo ganglion -+greater through zygomatic
tc petrosal nerve + deep nerve - zytemp.
(E petrosal D€fv€ = fleIV€ nerve - communica-
ttG of pterygoid canal ting branch to lacrimal
o nerve - Iacrimal gland
Submandibular 2 branches from Branch from Superior salivatory a. Submandibular,
C (see Fig.7.10) lingual nerve plexus around nucleus -->facial nerve b. Sublingual and
o facial artery -+chorda tympani c. Anterior lingual glands
o (oins the lingual nerve)

Poslerior Croniol Fosso b. The internal occipital crest runs in the median plane
This is the largest and deepest of the three cranial fossae. from the internal occipital protuberance to the
The posterior cranial fossa contains thehindbrain which foramen magnum where it forms a shallow
consists of the cerebellum behind and the pons and medulla depression, the aermian fossa (Fig.1..1.8).
in c. The transoerse sulcus is quite wide and runs
laterally from the internal occipital protuberance
Sqrum#rynes to the mastoid angle of the parietal bone where it
becomes continuous with the sigmoid sulcus. The
transverse sulcus lodges tlrLe transoerse sinus. T}:.e
1 The superior border of the petrous temporal bone. right transverse sulcus is usually wider than the
2 The dorsum sellae of the sphenoid bone (Fig. 1.18). left and is continuous medially with the superior
Posterior sagittal sulcus (Fig. 1.18).
Squamous part of the occipital bone. d. On each side of the internal occipital crest there
are deep fossae which lodge the cerebellar
On each side hemispheres (Fig. 1.18).
1 Mastoid part of the temporal bone.
2 The mastoid angle of the parietal bone. Lateral srea
L The condylar part of the occipitnlbone is marked by the
Fkpor following:
a. The jugular tubercle lies over the occipital condyle.
Median area
b. The hypoglossal canal (anterior condylar canal)
L Sloping area behind the dorsum sellae or clivus in
pierces the bone posteroanterior to the jugular
front tubercle and runs obliquely forwards and laterally
2 The foramen magnum in the middle along the line of fusion between the basilar and
3 The squamous occipital behind. the condylar parts of the occipital bone.
Lnteral area c. The condylar canal (posterior condylar canal) opens
L Condylar or lateral part of occipital bone. in the lower part of the sigmoid sulcus which
2 Posterior surface of the petrous temporal bone. indents the jugular process of occipital bone.
3 Mastoid temporal bone. 2 The posterior surface of the petrous part of the temporal
bone forrns the anterolateral wall of the posterior
4 Mastoid angle of the parietal bone. cranial fossa. The following features may be noted:
a. The internal acoustic meatus opens above the
anterior part of the jugular foramen. It is about
Median ares 1 cm long and runs transversely in a lateral
1 The clious isthe sloping surface in front of the foramen direction. It is closed laterally by a perforated plate
magnum. It is formed by fusion of the posterior part of bone known aslamina cribrosa which separates
of the body of the sphenoid including the dorsum it from the internal ear (Fig. 1.18).
sellae with the basilar part of the occipital bone or b. The orifice of the aqueduct of the aestibule is a
basiocciput. It is related to the basilar plexus of oeins, narrow slit lying behind the internal acoustic
and supports the pons and medulla (Fig. 1.18). meatus.
On each side, the clivus is separated from the petrous c. The subarcuate fossa lies below the arcuate
temporal bone by the petro-occipital fissure which is eminence, lateral to the internal acoustic meatus.
grooved by the inferior petrosal sinus, and is 3 The jugular foramen lies at the posterior end of the
continuous behind with the jugular foramen. petro-occipital fissure. The upper margin is sharp
2 The foramen magnum lies in the floor of the fossa. The and irregular, and presents the glossopharyngeal notch.
anterior part of the foramen is narrow because it is The lower margin is smooth and regular. .|a
oaerlapped by the medial surfaces of the occipital 4 The mastoid part of the temporal bone forrns the lateral zo
condyles. wall of the posterior cranial fossa just behind the !tc
3 The squamous part of the occipital bone shows the petrous part of the bone. Anteriorly, it is marked by (E

following features: the sigmoid sulcus which begins as a downward tt(6

a. The internal occipital protuberance lies opposite continuation of the transverse sulcus at the mastoid o
the external occipital protuberance. It is related angle of the parietal bone, and ends at the jugular
to the confluence of sinuses, and is grooved on foramen. The sigmoid sulcus lodges t}i.e sigmoid sinus o
each side by the beginning of transverse sinuses which become the internal jugular vein at the jugular ()
(see Fig.12.2). foramen (Fig. 1.18). The sulcus is related anteriorly ao

to the tympanic antrum. The mastoid foramen opens 4 The jugular tubercle is grooved by the ninth, tenth
into the upper part of the sulcus. and eleaenth uanial neroes as they pass to the jugular
5 The subarcuate fossa on the posterior surface of
petrous temporal bone lodges the flocculus of the
Fracture of the posterior cranial fossa causes bruising cerebellum.
over the mastoid region extending down over the
sternocleidomastoid muscle. Sfrrurfures F*ssi*g fftr*a;grf'l Fererrurrta
The following foramina seen in the cranial fossae have
,&ffex*ftm*r:fs *n# ffsf*fr+ms; fr:fsri*r *f ffte Sfue.rff been dealt with under the normal basalis: foramen
Attschment on uault ovale, foramen spinosum, emissary sphenoidal
foramen, foramen lacerum, foramen magnum/ jugular
1 The frontal crest gives attachment to the falx cerebri foramen, hypoglossal canal, and posterior condylar
(see Fig. 12.1).
canal. Additional foramina seen in the cranial fossae
2 The lips of the sagittal sulcus give attachment to the
are as follows.
falx cerebri (see Fig. 12.1).
1 The foramen caecum in the anterior cranial fossa is
Anterior cranial fassa usually blind, but occasionally it transmits a vein
1 The crista galli gives attachment to the falx cerebri. from the upper part of nose to the superior sagittal
2 The orbital surface of the frontal bone supports the sinus.
frontal lobe of the brain. 2 The posterior ethmoidal canal transmit the vessels of the
3 The anterior clinoid processes give attachment to the same name. Note that the posterior ethmoidal nerye
free margin of the tentorium cerebelli (see Fig.12.2). does not pass throughthe canal as it terminate earlier'
3 The anterior ethmoidal canal transmit the corres-
Middle cranial fassa ponding nerve and vessels.
1 The middle cranial fossa lodges the temporal lobe of 4 The optic canal transmits the optic nerve and the
the cerebral hemispher e. ophthalmic artery.
2 The tuberculum sellae provides attachment to the 5 The three parts of the superior orbital fissure (see
diaphragma sellae (see Fig.12.$. Fig. 13.a) transmit the following structures:
3 The hypophyseal fossa lodges the hypophysis cerebri. Lateral part
4 Upper margin of the dorsum sellae provides a. Lacrimal nerve
attachment to the diaphragma sellae, and the b. Frontal nerve
posterior clinoid process to anterior end of the c. Trochlear nerve
attached margin of tentorium cerebelli and to the d. Superior ophthalmic vein
petrosphenoidal ligament (see Fig. 12.2). Middle part
5 One caTJernous sinus lies on each side of the body of a. Upper and lower divisions of the oculomotor
the sphenoid. The internal carotid artery passes nerve (Table 1.5).
through the cavernous sinus (see Fig.12.5). b. Nasociliary nerve in between the two divisions of
6 The superior border of the petrous temporal bone is the oculomotor.
grooved by the superior petrosal sinus and provides c. The abducent nerve, inferolateral to the foregoing
attachment to the attached margin of the tentorium nerves (see Fig. 13.4).
cerebelli.It is grooved in its medial part by the
trigeminnl neroe (trigeminal impression). Medial part
a. Inferior ophthalmic vein.
Pastefiar cranial Jbssa b. Sympathetic nerves from the plexus around the
.!< 1 The posterior cranial fossa contains the hindbrain internal carotid artery.
o 5 The foramen rotundum transmits the maxillary nerve
which consists of the cerebellum behind, and the
zo pons and medulla in front. (see Fig.
tc 7 The internal acoustic meatus transmits the seaenth and
(E 2 The lower part of the clivus provides attachment to
t,(E the apical ligament of the dens near the foramen eighth cranial neraes and the labyrinthine aessels.
o magnum, upper vertical band of cruciate ligament
and to the membrana tectoria just above the apical Frsrueipfes #*v*rnrng Frs*fs.rres sf ffte Skq,rdd

ligament (Fig.1.16). 1 Fractures of the skull are prevented by:
O 3 The internal occipital crest gives attachment to the a. Its elasticity.
ao falx cerebelli. b. Rounded shape.

c. Construction from a number of secondary elastic

arches, each made up of a single bone.
d. The muscles covering the thin areas.
Since the skull is an elastic sphere filled with the
semifluid brain, a violent blow on the skull produces
a splitting ffict cornmencing at the site of the blow
and tending to pass along the lines of least resistance.
T}ne base of the skull is more fragile the vault, and
is more commonly involved in such fractures,
particularly along the foramina.
The inner table is more brittle than the outer table.
Therefore, fractures are more extensive on the inner
table. Occasionally only the inner table is fractured
and the outer table remains intact.
The common sites of fracture in the skull are:
a. The parietal nrea of the vault.
b. The middle uanial fossa of the base. This fossa is
Fig. 1.19: Diagram comparing the orientation of the orbital axis
weakened by numerous foramina and canals.
and the visual axis
The facial bones commonly fractured are:
a. The nasalbone
b. The mandible. ffsfite{, F*qxfuras
L The lacrimnl fossa, placed anterolaterally, lodges the
lacrimal gland (Fig. 1.20).
2 The optic canal lles posteriorly, at the junction of the
roof and medial wall (Figs L.20 and 1.21).
The orbits are pyramidal bony cavities, situated one
3 The trochlear fossa, lies anteromedially' It provides
on each side of the root of the nose. They provide
attachment to the fibrous pulley or trochlea for the
sockets for rotatory movements of the eyeballs. They
tendon of the superior oblique muscle (Fig. 1.20).
also protect the eyeballs.
This is the thickest and strongest of all the walls of the
Each orbit resembles a four-sided pyramid. Thus, it has:
orbit. It is formed:
. An apex situated at the posterior end of orbit at the
medial end of superior orbital fissure. L By the anterior surface of the greater wing of the
. sphenoid bone posteriorly (Fig. 1.21).
A base seen as the orbital opening on the face.
. Four walls:
2 The orbital surface of the frontal Process of the
zy gornatic bone anteriorlY.
Roof, floor,lateral and medial walls.
The long axis of the orbit passes backwards and #eJsfvovts
medially. The medial walls of the two orbits are parallel 1 The greater wing of the sphenoid separates the orbit
and the lateral walls are set at right angles to each other from the middle cranial fossa.
(Fig. 1.1e).
2 The zygomatic bone separates it from the temporal
It is concave from side to side. It is formed: Fdmnne# Fe*fe*res o
L Mainly by the orbital plate of the frontal bone, 1 The superior orbitalfissure occupies the posterior part
2 It is completed posteriorly by the lesser wing of the t,tr
of the junction between the roof and lateral wall. (E
sphenoid (Fig.1.20). in the
2 The foramen for the zygomatic nerzte is seen !,(E
zygomatic bone. o
treislfror?s 3 lMitnall's or zygomatic tubercle is a palpable elevation
1 It separates the orbit from the anterior cranial fossa' on the zygomaticbone just within the orbital margin. o
2 The frontal air sinus may extend into its anteromedial It provides attachment to the lateral check ligament ()

part. of eyeball (Fig. 1.20). ao

Supraorbital notch
Lacrimal fossa
Trochlear fo$sa
Lesser wing
of sphenoid
Superior orbital fissure Optic canal

Anterior and posterior

Whitnall's tubercle
Ethmoidal canal

Orbital plate of ethmoid

Greater wing of sphenoid

Lacrimal groove
Orbital branches of pterygopalatine ganglion
Lacrimal bone
Orbital surface of zygomatic bone
Frontal process of maxilla

Foraman for zygomatic nerve Body of the sphenoid

Zygomatic nerve in
inferior orbital fissure
Origin of inferior oblique muscle
lnfra-orbital nerve and
arterv with oroove Orbital surface of maxilla
lnfra-orbital foraman
Orbital process of palatine
Fig. 1.20: The orbit seen from the front (schematic)

Optic canal

Orbital surface of lesser

wing of sphenoid bone
Supraorbital notch
Superior orbital fi ssure
Orbital surface of frontal bone
Orbital surface of greater
wing of sphenoid bone Orbital plate of ethmoid bone

Lacrimal bone
Orbital process of palatine bone
Fossa for lacrimal sac

Zygomaticofacial foramen lnfraorbital groove

Orbiial surface of zygomatic bone

lnfraorbiial foramen

lnferior orbital fissure

Orbital surface of maxilla
Fig. 1.21 : The orbit seen from the front

Floor f\$mnlsd Fesferres

L It slopes upwards and medially to join the medial wall.
o 1 The inferior orbital fissure occupies the posterior part
z It is formed: of the junction between the lateral wall and floor.
t,tr 1. Mainly by the orbital surface of the maxilla (Fig. 1.21). Through this fissure, the orbit communicates with
G 2 By the lower part of the orbital surface of the the infratemporal fossa anteriorly and with the
tt(E zy gomatic bone, anterolaterally. pterygopalatine fossa posteriorly (Figs 1.20 md1..2l).
3 The orbital process of the palatine bone, at the 2 The infraorbital groooe runs forwards in relation to
posterior angle. the floor.
#sJmfion 3 A small depression on anteromedial part of the
a It separates the orbit from the maxillary sinus. floor gives origin to inferior oblique muscle.

MediolWoll 2 Foetal skeleton is small as compared to calvaria. In

It is very thin. From before backwards it is formed by: foetal skull, the facial skeleton is 1./7th of calvaria;
1 The frontal process of the maxilla. in adults, it is half of calvaria. The foetal skeleton is
2 The lacrimal bone (Fig. 1.21). small due to rudimentary mandible and maxillae,
3 The orbital plate of the ethmoid. non-eruption of teeth, and small size of maxillary
4 The body of the sphenoid bone. sinus and nasal cavity. The large size of calvaria is
due to precocious growth of brain.
&efsffons 3 Base of the skull is short and narrow, though internal

1 The lacrimal grooT)e, formed by the maxilla and the ear is almost of adult size the petrous temporal has
lacrimal bone, separates the orbit from the nasal not reached the adult length.
2 The orbital plate of the ethmoid separates the orbit STRUCTURE OF BONES
from the ethmoidal air sinuses. The bones of cranial vault are smooth and unilamellar;
3 The sphenoidal sinuses, are separated from the orbit there is no diploe. The tables and diploe appear by
only by a thin layer of bone. fourth year of age (Fig. 1.17 and Table 1.2).
ffamed Features Bony Prominences
1 The lacrimal groove lies anteriorly on the medial 1 Frontal and parietal tubera are prominent.
wall. It is bounded anteriorly by the lacrimal crest of 2 Glabella, superciliary arches and mastoid processes
the frontal process of the maxilla, and posteriorly by are not developed.
the crest of the lacrimal bone. The floor of the groove
is formed by the maxilla in front and by the lacrimal Poronosol Air Sinuses
bone behind. The groove lodges the lacrimal sac
These are rudimentary or absent.
which lies deep to the lacrimal fascia bridging the
lacrimal groove. The groove leads inferiorly, through
Temporol Bone
the nasolacrimal duct, to the inferior meatus of the
nose (Fig. 1.21). 1 The intemal ear, tympanic cavity, tympanic antrum,
2 The anterior and posterior ethmoidal foramina lie on the and ear ossicles are of adult size.
frontoethmoidal suture, at the junction of the roof 2 The tympanic part is represented by an incomplete
and medial wall. tympanic ring.
3 Mastoid process is absent, it appears during the later
Sorsrxrn* m R*loffon fo ffte #rbif
part of second year.
1 The structures passing through the optic canal and 4 External acoustic meatus is short and straight. Its
through the superior orbital fissure have been bony part is unossified and representedby a
described in cranial fossae (see Fig. 13.4). fibrocartilaginous plate.
2 The inferior orbital fissure transmits:
5 Tympanic membrane faces more downwards than
a. The zygomatic nerue,
laterally due to the absence of mastoid process.
b. The orbital branches of the pterygopalatine ganglion,
c. The infraorbital nerae and oessels, and the 6 Stylomastoid foramen is exposed on the lateral
communication between the inferior ophthalmic surface of the skull because mastoid portion is flat.
vein and the pterygoid plexus of veins (Fig. 1.20). 7 Styloid process lies immediately behind the
3 The infraorbital grooue and canal transmit the tympanic ring and has not fused with the remainder
corresponding nerve and vessels. of the temporal bone.
4 The zygomntic foramen transmits the zygomatic nerve. 8 Mandibular fossa is flat and placed more laterally,
5 The anterior ethmoidal foramen transmit the and the articular tubercle has not developed.
corresponding nerve and vessels. 5
9 The subarcuate fossa is very deep and prominent. o
6 Posterior ethmoidal foramen only transmit vessels of 10 Facial canal is short. z
same name (Fig. 1.20). E'
Orbils !t(E
These are large. The germs of developing teeth lies close o
to the orbital floor. Orbit comprises base or an outer
DIMENSIONS opening with upper, lower medial and lateral waIls. C
1, Skull is large in proportion to the other parts of Its apex lies at the optic foramen/canal. It also has F()

skeleton. superior and inferior orbital fissures. ao

Closure of Fontonelles
Two halves of frontal bone are separated by Anterior fontanelle (bregma) by 18 months, mastoid
metopic suture. fontanelle by 12 months, posterior fontanelle (lambda)
The mandible is also present in two halves. It is a
by 2-3 months and sphenoidal fontanelle also by 21
derivative of first branchial arch. months (Fig. 1.3).
Occipital bone is in four parts (squamous one,
condylar two, and basilar one).
. The four bony elements of temporal bone are
r Fontanelles helps to determine the age in l1yearc
separate, except for the commencing union of the of child.
tympanic part with the squamous and petrous . Helps to know the intracranial pressure. In case
parts. The second centre for styloid process has of increased pressure bulging is seen and in case
not appeared. of dehydration depression is seen at the site of
. Unossified membranous Baps, a total of 6 fontanelles.
fontanelles at the angles of the parietal bones are
present (Fig. 1.3). Thickening of Bones
. Squamous suture between parietal and squamous L Two tables and diploe aPPear by fourth year.
temporal bone is present. Differentiation reaches maximum by about 35 years/
when the diploic veins produce characteristic
marking in the radiographs.
2 Mastoid process appears during second year, and
The growth of calvaria and facial skeleton proceeds at the mastoid air cells during 6th year.
different rates and over different periods. Growth of
calvaria is related to growth of brain, whereas that of Obliterotion of Sulures of the Voult
the facial skeleton is related to the development of L Obliteration begins on the inner surface between 30
dentition, muscles of mastication, and of the tongue. and 40 years, and on the outer surface between 40
The rates of growth of the base and vault are also and 50 years.
2 The timings are variable, but it usually takes place
first in the lower part of the coronal suture, next in
Growlh of the Voull
the posterior part of the sagittal suture, and then in
"1. Rate: Rapid during first year, and then it slows up to
the lambdoid suture.
. the seventh year when it is almost of adult size.
2 Grctwth in breadth: This growth occurs at the sagittal ln Old Age
suture, sutures bordering greater wings, occipito- The skull generally becomes thinner and lighter but
mastoid suture, and the petro-occipital suture at the in small proportion of cases it increases in thickness
base. and weight. The most striking feature is reduction in
3 Growth in height: This growth occurs at the fronto- the size of mandible and maxillae due to loss of teeth
zygomatic suture, pterion, squamosal suture, and and absorption of alveolar processes. This causes
asterion. decrease in the vertical height of the face and a change
4 Growth in anteraposterior dinmeter: This growth occurs in the angles of the mandible which become more
at the coronal and lambdoid sutures. obtuse.


The base grows in anteroposterior diameter at three There are no sex differences until puberty. The
ta cartilaginous plates situated between the occipital and postpubertal differences are listed in Table 1.4'
o sphenoid bones, between the pre- and post-sphenoids,
zo and between the sphenoid and ethmoid. Wolmion or Sululol Bones
(E These are small irregular bones found in the region of
t,G Growth of the Foce the fontanelles, and are formed by additional
o 1 Growth of orbits and ethmoid is complete by seventh ossification centres.
yeat. They are most common at the lambda and at the
c 2 In the face, the growth occurs mostly during first asterion; common at the pterion (epipteric bone); and
o year, although it continues till puberty and even rare at the bregma (os Kerkring). Wormian bones are
@ later. common in hydrocephalic skulls.
tNrRoDUcloN AND osrEor-oGy "!"
Table 1.4: Sex differenceC'in'the skull
Features Males Females
1. Weight Heavier Lighter
2. Size Larger Smaller
3. Capacity Greater in males 10% less than males
4. Walls Thicker Thinner
5. Muscular ridges, glabella, More marked Less marked
superciliary arches, temporal
lines, mastoid processes,
superior nuchal lines, and
external occipital protuberance
6. Tympanic plate Larger and margins are more roughened Smaller and margins are
less roughened
7. Supraorbital margin More rounded Sharp
8. Forehead Sloping (receding) Vertical
9. Frontal and parietal tubera Less prominent More prominent
10. Vault Rounded Somewhat flattened
11 . Contour of face Longer due to greater depth of the jaws. Chin is bigger Rounded, facial bones are
and projects more forwards. ln general, the skull is smoother, and mandible
more rugged due to muscular markings and and maxillae are smaller.
processes; and zygomatic bones are more massive

CRANIOMETRY i.e. neurocranium, which are inversely proportional to

Cepholic lndex each other. The angle is smallest in the most evolved
races of man, it is larger in lower races/ and still larger
It expresses the shape of the head, and is the proportion
in anthropoids.
of breadth to length of the skull. Thus:
Abnormol Cronio
Cephalic index = P'1F
* 1ss
O xycephaly or acrocephaly, tower-skull, or steeple-skull
is an abnormally tall skull. It is due to premature closure
'The length or longest diameter is measured from the
of the suture between presphenoid and postsphenoid
glabella to the occipital point, the breadth or widest
in the base, and the coronal suture in skull cap, so that
diameter is measured usually a little below the parietal
the skull is very short anteroposteriorly. Compensation
is done by the upward growth of skull for the enlarging
Human races may be: brain.
a. Dolichocephalic or long-headed when the index is Scaphocephaly or boat-shaped skull is due to
75 or less. premature synostosis in the sagittal sufure, as a result
b. Mesaticephnlicwhenthe index is between 75 and 80. the skull is very narrow from side to side but greatly
c. Brachycephalic or short-headed or round-headed elongated.
when the index is above 80. Dolichocephaly is a
feature of primitive races like Eskimos, Negroes,
etc. Brachycephaly through mesaticephaly has
been a continuous change in the advanced races,
like the Europeans. The mandible, or the lower jaw, is the largest and the ta
strongest bone of the face. It develops from the first o
FociolAngle pharyngeal arch.It has a horseshoe-shaped body which zo
lodges the teeth, and a pair of rami which project tc
This is the angle between two lines drawn from the (g
nasion to the basion or anterior margin of foramen upwards from the posterior ends of thebody. The rami !,
magnum and a line drawn from basion to the prosthion provide attachment to the muscles of mastication. G
or central point on upper incisor alveolus (Fig. 1.9).
Facial angle is a rough index of the degree of BODY L
development of the brain because it is the angle between Each half of the body has outer and inner surfaces, and ()
facial skeleton, i.e. splanchnocranium, and the calvaria, upper and lower borders. ao

The outer surface presents the following features. Right

a. The symphysis menti is the line at which the right condyle
and left halves of the bone meet each other. It is Coronoid process
marked by a faint ridge (Fig. 1.22).
b. The mental protuberance (mentum = chin) is a Lingula
median triangular projecting area in the lower part Sphenomandibular
of the midline. The inferolateral angles of the ligament
protuberance form the mental tubercles. forarnen
c. The ment al for amen lies below the interval between Sublingual fossa
the premolar teeth (Table 1.5). Mylohyoid
d. The oblique line is the continuation of the sharp
anterior border of the ramus of the mandible. It
runs downwards and forwards towards the line
mental fubercle.
Submandibular fossa
e. The incisioefossa is a depression that lies justbelow
the incisor teeth. Genial tubercles
The inner surface presents the following features. Digastric fossa
a. The mylohyoid line is a prominent ridge that runs
Fig. 1.23: lnner surface of right half of the mandible
obliquely downwards and forwards from below
the third molar tooth to the median area below
Four borders-upper, lower, anterior and posterior
the genial tubercles (see below) (Fig. 1.23).
Two processes-coronoid and condyloid.
b. Below the mylohyoid line, the surface is slightly
Thelateral surface is flatand bears a number of oblique
hollowed out to form the submandibular fossa,
which lodges the submandibular gland.
The medial surface presents the following:
c. Above the mylohyoid line, there is the sublingual
1 The mandibularforamefl lies a little above the centre
fossa in which the sublingual gland lies.
d. The posterior surface of the symphysis menti is of ramus at the level of occlusal surfaces of the
marked by four small elevations called the superior teeth. It leads into the mandibular canal which
and inferior genial tubercles. descends into the body of the mandible and opens
e. The mylohyoid groove (present on the ramus) at the mental foramen (Fig.1..23).
extends on to the body below the posterior end of 2 The anterior margin of the mandibular foramen
is marked by a sharp tongue-shaped projection
, the mylohyoid line. called the lingula. The lingula is directed towards
Theupper or aloeolarborderbears sockets for the teeth.
Tlte lower border of the mandible is also called the the head or condyloid process of the mandible.
base. Near the midline the base shows an oval 3 The mylohyoid grooae begins just below the
depression called lhe digastric fossa. mandibular foramery and runs downwards and
forwards to be gradually lost over the submandi-
bular fossa.
The upper border of the ramus is thin and is curved
The ramus is quadrilateral in shape and has: downwards forming tiire mandibular notch.
Two surfaces-lateral and medial The lower border is the backward continuation of the
base of the mandible. Posteriorly, it ends by becoming
Mandibular nolch
continuous with the posterior border at the angle of the
Coronoid process mandible.
Gondylar Body The anterior border is thin, while the posterior border
l( is thick.
o Alveolar process
o Neck The coronoid (Greek uo'u)'sbeak) process is a flattened
z (bearing teeth)
triangular upward projection from the anterosuperior
t,q Ramus
(E related to part of the ramus. Its anterior border is continuous with
parotid gland
!,(E the anterior border of the ramus. The posterior border
o Mental
Angle foramen
bounds the mandibular notch.
The condyloid (Latrn l<nuckle like) process is a strong
C Oblique line upward projection from the posterosuperior part of the
o Mental Mental
() iubercle prominence ramus. Its upper end is expanded from side to side to
ao Fig.'1.22:. Outer surface of right half of the mandible form the head.The head is covered with fibrocartilage

and articulates with the temporal bone to form the 4 Mylohyoid line gives origin to the mylohyoid muscle
temporomandibular joint. The constriction below the (Fig. 1.23).
head is the neck. Its anterior surface presents a 5 Superior constrictor muscle of the pharynx arises from
depression called the pterygoid foaea. an area above the posterior end of the mylohyoid
Atlochments ond Relolions of the Mondible
6 Pterygomandibular raphe is attached immediately
1 The oblique line on the lateral side of the body gives behind the third molar tooth in continuation with
originto thebuccinator asfar forwards as the anterior the origin of superior constrictor.
border of the first molar tooth. In front of this origio
7 Upper genial tubercle gives origin to the genioglossus,
the depressor labii inferioris and the depressor anguli
and the lower tubercle to geniohyoid (Fig.1..25).
oris arise from the oblique line below the mental
foramen (Fi9.1..2q. 8 Anterior belly of the digastric muscle arises from the
2 The incisive fossa gives origin to the mentalis and digastric fossa (Fig. 1.25).
mental slips of the orbicularis oris. 9 Deep ceraical fascia (tnvesting layer) is attached to
3 The parts of both the inner and outer surfaces just the whole length of lower border.
below the alveolar margin are covered by the 10 The platysma is inserted into the lower border
mucous membrane of the mouth. (Fis.1..2q.
Masseteric nerve and vessels


Orbicularis oris

Depressor anguli oris

Fig. 1.24: Muscle attachments and relations of outer surface of the mandible

Lateral pterygoid

artery Auriculotemporal nerve

lnferior alveolar artery and nerve Superficial temporal artery

Lingual nerve External carotid

Superior constrictor Mylohyoid groove with nerve

and artery to mylohyoid
Pterygomandibular raphe
Medial pterygoid z

Digastric: anterior belly F
Fig. 1.25: Muscle attachments and relations of inner surface of the mandible U)

L1 Whole of the lateral surface of ramus except the

intrauterine life in the mesenchym al sheath of Meckel's
posterosuperior part provides insertion to the cartilage near the future mental foramen. Meckel's
masseter muscle (Fig. LZq.
cartilage is the skeletal element of first pharyngeal arch.
12 Posterosuperior part of the lateral surface is covered At birth the mandible consists of two halves
by the parotid gland. connected at the symphysis menti by fibrous tissue.
13 Sphenomandibular ligament is attached to the lingula Bony union takes place during the first year of life.
(Fig. 1.23).
14 The medial pterygoid muscle is inserted on the medial
surface of the ramus, on the roughened area below AGE CHANGES !N THE MANDIBTE
and behind the mylohyoid groove (Fig. 1.25). ln lnfonls ond Children
15 The temporalis is inserted into the apex and medial I The two halves of the mandible fuse during the first
surface of the coronoid process. The insertion year of life (Fig. 1.26a).
extends downwards on the anterior border of the 2 At birth, the mental foramen, opensbelow the sockets
ramus (Fig. Lzq. for the two deciduous molar teeth near the lozuer
16 The lateral pterygoid muscle is inserted into the border. This is so because the bone is made up only
pterygoid fovea on the anterior aspect of the neck of the alveolar part with teeth sockets. The mandibular
(Fig.1.2\. canal runs near the lower border. The foramen and canal
17 The lateral surface of neck provides attachment to gradually shift upwards.
the lateral ligament of the temporomandibular joint 3 The angle is obtuse.It is 140 degrees or more because
(see Fig.6.9). the head is in line with the body. The coronoid
process is large and projects upwards above the level
1 The mental foramen transmits the mental nerae and
oessels (Fig.1,.2q. In Adulls
2 The inferior alzteolar nerae and aessels enter the 1 The mental foramen opens midway between the upper and
mandibular canal through the mandibular foramen, and lower borders because the alveolar and subalveolar
run forwards within the canal. parts of the bone are equally developed. The mandi-
3 The mylohyoid neroe and zsessels lie in the mylohyoid bular canal runs parallel with the mylohyoid line.
grooae (Fig. 1.25). 2 The angle reduces to about 110 or L20 degrees because
4 The lingual nerzte is related to the medial surface of the ramus becomes almost vertical (Fig.1.26b).
the ramus in front of the mylohyoid groove (Fig. 1.25).
5 The area above andbehind the mandibular foramen ln Old Age
is related to the inferior alaeolar nerae and oessels and 1 Teeth fall out and the alveolar border is absorbed,
to the maxillary artery (Fig.1.25). so that the height of body is markedly reduced
The masseteric nerae and zsessels pass through the (Fig. 1.26c).
mandibular notch (Fig. L.2q. 2 The mental foramen and the mandibular canal are close
The auriculotemporal nerae and superficial tempornl to the aloeolar border.
artery are related to the medial side of the neck of 3 The angle again becomes obtuse about 140 degrees
mandible (Fig. 1.25). because the ramus is oblique.
I Facial artery is palpable on the lower border of
mandible at anteroinferior angle of masseter (Fig.1.2\. Slructures Reloted to Mondible
9 Facial and maxillary arteries are not accompanied S alizt ary glands : P ar otid,submandibular and sublingual

by respective nerves. The lingual nerve does not get (Figs 1.22 and 1.23).
company of its artery. Lymph nodes: Parotid, submandibular and submental.
l< Arteries: Maxillary, superficial temporal, masseteric,
o inJerior alveolar, mylohyoid, mental and facial (Fig. L.2q.
z The mandible is the secondbone, next to the claoicle, to
ossifutnthebody. Its greater part ossifies inmembrane. p or al, masseteric, inferior
N ero es : Lingual, auriculotem
The parts ossifying in cartilage include the incisiae alveolar, mylohyoid and mental (Fig. 1.25).
partbelow the incisor teeth, the coronoid and condyloid Muscles of masticatloru; Insertions of temporalis,
Io processes, and the upper half of the rnmus above the masseter, medial pterygoid and lateral pterygoid.
level of the mandibular foramen. Ligaments: Lateral ligament of temporomandibular
o Each half of the mandible ossifies from only one
o joint, stylomandibular ligament, sphenomandibular
ao centre which appears at about the 6th week of
and pterygomandibular raphe (Fig. 1.25).

(a) Child (b) Adult (c) Old age

Figs 1.26a to c: Age changes in the mandible: (a) Child, (b) adult, and (c) old age

2 Alveolar border with sockets for upper teeth faces

downwards with its convexity directed outwards.
The mandible is commonly fractured at the canine
Frontal process is the longest process which is
socket where it is weak. Involvement of the directed upwards.
inferior alveolar nerve in the callus may cause 3 Medial surface is marked by a large irregular
neuralgic pain, which may be referred to the areas
opening, thLe maxillary hiatus/antrum of Highmore
of distribution of the buccal and auriculotemporal for maxillary air sinus.
nerves. If the nerve is paralysed, the areas supplied
by these nerves become insensitive (Fig, 1.2Q. FEATURES
The next common fracture of the mandible occurs
Each maxilla has a body and four processes, the frontal,
at the angle and neck of mandible (Fig. 1,.2n.
zy gornatic, alveolar and palatine.

The body of maxilla is pyramidal in shape, with itsbase
directed medially at the nasal surface, and the apex
directed laterally at the zygornatic process. It has four
surfaces and encloses a large cavity, the maxillary sinus
described in Chapter L5.
The surfaces are:
. Anterior or facial,
o Posterior or infratemporal,
. Superior or orbital, and
. Medial or nasal.
Fig. 1.27: Fracture of the mandible at the neck, at the angle Anterior or Fociol Surfoce
and at canine fossa I Anterior surface is directed forwards and laterally.
2 Above the incisor teeth, there is a slight depression,
the incisioe fossa, which gives origin to depressor septi.
Incisiztus arises from the alveolar margin below the
fossa, and the nasalis superolateral to the fossa along
the nasal notch.
Maxilla is the second largest bone of the face, the first Lateral to canine eminence, there is a larger and .Y
each being the mandible. The two maxillae form the o
whole of the upper jaw, and each maxilla forms a part
deeper depression, the canine fossa, which gives zo
origin toleoator anguli oris. t,E
each in the formation of face, nose, mouth, orbit, the
Above the canine fossa, there is infraorbital fornmen, (E
infratemporal and pterygopalatine fossae. It
which trans mlts infraorbital nerrse and aessels (Fig. 1 .28). G
Leaator labii superioris arises between the infraorbital o
SIDE DETERMINATION margin and infraorbital foramen.
1 Anterior surface ends medially into a deeply concave Medially, the anterior surface ends in a deeply .9
border, called tLre nasal notch. Posterior surface is concave border, the nasal notch, which terminates C)

convex (Fig. 1.28). below into process which with the corresponding ao
; H'AD n*p'*rck

Frontal process,
anterior lacrimal crest

Orbital surface
lnfraorbital margin

lnfratemporal surface
Infraorbital foramen
Zygomatic process

Anterior nasal spine

Nasalis Anterior surface


Alveolar process
Maxillary tuberosity

Fig. 1.28: Lateral aspect of maxilla with muscular attachments

process of opposite maxilla forms the anterior nasal 4 Medinl border presents anteriorly the lacrimal notch
spine. Anterior surface bordering the nasal notch which is converted into nasolacrimal canal by the
gives origin to nasalis and depressor septi. descending process of lacrimal bone. Behind the
notch, the border articulates from before backwards
Posierior or lnfrotemporol Surfoce with the lacrimal,labyrinth of ethmoid, and the orbital
1 Posterior surface is convex and directed backwards process of palatine bone (Fi9. 1.29).
and laterally. 5 The surface presents infraorbital grooae leading
2 It forms the anterior wall of infraternporal forwards to infraorbital canal which opens on the
fossa, and
is separated from anterior surface by the zygomatic anterior surface as infraorbital foramen. The groove,
process and a rounded ridge which descends from canal and foramen transmit the infraorbital nerae and
oessels. Near the midpoint, the canal gives off laterally
the process to the first molar tooth.
3 Near the centre of the surface open two or three a branch, t}i.e canalis sinuous, for the passage of
anterior superior alzseolar nerae and ztessels.
alzteolar canals for posterior superior aloeolar nerae and
5 Inferior oblique muscle of eyeball arises from a
depression just lateral to lacrimal notch at the
4 Posteroinferiorly, there is a rounded eminence, the
anteromedial angle of the surface.
maxillary tuberosity, which articulates superomedially
with pyramidal process of palatine bone, and gives Mediol or NosolSurfoce
origin laterally to the superficinl head of medial ptery goid
1 Medial surface forms apart of the lateral wall of nose.
2 Posterosuperiorly, it displays a large irregular opening
5 Above the maxillary tuberosity, the smooth surface of the maxillary sinus, the maxillary hiatus (Figs 1.30).
forms anterior wall of pterygopalatine fossa, and is 3 Above the hiatus, there are parts of air sinuses which
grooved by maxillary nerae.
are completed by the ethmoid and lacrimal bones.
4 Below the hiatus, the smooth concave surface forms
J Superior or Orbitol Surfoce a part of inferior meatus of nose.
o L Superior surface is smooth, triangular and slightly 5 Behind the hiatus, the surface articulates with
z concave, and forms the greater part of the floor of perpendicular plate of palatine bone, enclosing the
tr orbit. greater palatine canal w!;rich runs downwards and
t,G Anterior border forms a part of infraorbital margin. forwards, and transmits greater palatine r:essels and the
o Medially, it is continuous with the lacrimal crest of anterior, middle and posterior palatine neroes (Fig. 1.12).
the frontal process. 6 In front of the hiatus, there is nasolacrimal grooae,

Posterior border is smooth and rounded, it forms most which is converted into the nasolacrimal canal by
of the anterior margin of inferior orbital fissure. In articulation with the descendingprocess of lacrimalbone
U) the middle, it is notched by the infraorbital groove. and the lacrimal process of inferior nasal concha. The
tNrRoDUcIoN AND osrEolocY

Sphenoethmoidal recess Frontal air sinus

Sphenoidal air sinus Middle concha

Superior meatus Ethmoid bulla

Sphenopalatine foramen
Descending part of lacrimal
Opening of maxillary air sinus
in middle meatus Uncinate process

Perpendicular plate of palatine bone

lnferior nasal concha
Palatomaxillary suture
lnferior meatus

Fig. 1.29: Medial aspect of intact maxilla

Ethmoidal cresi

Nasolacrimal groove
Middle meatus

Conchal crest
Maxillary hiatus

lnferior meatus

Perpendicular plate
of palatine bone Anterior nasal spine

Greater palatine canal Palatine process

Fig. 1.30: Medial aspect of disarticulated left maxilla

canal transmits nasolauimal duct to the inferior meatus Frontol Process

of nose. I The frontal process projects upwards and backwards
7 More anteriorly, an oblique ridge forms tLre conchal to articulate above with the nasal margin of frontal
crest for articulation with the inferior nasal concha. bone, in front with nasal bone, and behind with
8 Above the conchal crest, the shallow depression lacrimal bone.
forms a part of the atrium of middle meatus of nose 2 Lateral surface is divided by a vertical ridge, the
(see Fig. 15.8).
anterior lacrimal crest,into a smooth anterior part and
a grooved posterior part. o
FOUR PROCESSES OF MAXILLA The lacrimal crest gives attachment to lacrimal fascia z
Zygomotic Process and the medial palpebral ligament, and is continuous ttr
The zygomatic process is a pyramidal lateral projection below with the infraorbital margin. t,(E
on which the anterior, posterior, and superior surfaces The anterior smooth area gives origin to the orbital o
of maxilla converge. In front and behind, it is part of orbicularis oculi arrdletsator labii superioris alaeque
continuous with the corresponding surfaces of the nasi. The posterior grooved area forms the anterior c
body, but superiorly it is rough for articulation with half of the floor of lacrimal grooae (Fig. 1.a5). C)

the zygomatic bone. 3 Medinl surface forms apafiof the lateral wall of nose. ao

The surface presents following features: ARTICULATIONS OF MAXIILA

a. Uppermost area is rough for articulation with L Superiorly, it articulates with three bones, the nasal,
ethmoid to close the anterior ethmoidal sinuses. frontal and lacrimal.
b. Ethmoidal crest is a horizontal ridge about the 2 Medially, it articulates with five bones, the ethmoid,
middle of the process. Posterior part of the crest inferior nasal concha/ vomer, palatine and opposite
articulates with middle nasal concha, and the maxilla.
anterior part lies beneath the agger nasi (see Fig. 3 Laterally, it articulates with one bone, the zygomatic.
c. The area below the ethmoidal crest is hollowed
out to form the atrium of the middle meatus.
Maxilla ossifies in membrane from three centers, one
d. Below the atrium is the conchal uest w]r.ich
for the maxilla proper, and two for os incisivum or
articulates with inferior nasal concha.
premaxilla. The center for maxilla proper appears
e. Below the conchal crest, there lies the inferior
meatus of the nose with nasolacrimal groove
above the canine fossa during sixth week of
intrauterine life.
ending just behind the crest (see Fig. 15.8).
Of the two premaxillary centers, the main centre
Alveolqr Process appears above the incisive fossa during seventh week
of intrauterine life. The second center (paraseptal or
1 The alveolar process forms half of the alveolar arch,
prevomerine) appears at the ventral margin of nasal
and bears sockets for the roots of upper teeth. In
septum during tenth week and soon fuses with the
adults, there are eightsockets: canine socket is deepest;
palatal process of maxilla. Though premaxilla begins
molar sockets are widest and divided into three minor
to fuse with alveolar process almost immediately
sockets by septa; the incisor and secondpremolar sockets
are single; and the first premolar socket is sometimes
after the ossification begins, the evidence of
premaxilla as a separate bone may persist until the
dioided into two.
middle decades.
2 Buccinator arises from the posterior part of its outer
surface up to the first molar tooth (Fig. 1.28).
3 A rough ridge, the maxillary torus, is sometimes AGE CHANGES
present on the inner surface opposite the molar 1" At birth:
sockets. a. The transverse and anteroposterior diameters are
each more than the vertical diameter.
Polotine Process
b. Frontal process is well marked.
1 Palatine process is a thick horizontal plate projecting c. Body consists of a little more than the alveolar
medially from the lowest part of the nasal surface. It process, the tooth sockets reaching to the floor of
forms a large part of the roof of mouth and the floor orbit.
of nasal cavity (Fig. 1.30). d. Maxillary sinus is a mere furrow on the lateral wall
2 lnferior surface is concave, and the two palatine of the nose.
processes form anterior three-fourths of the bony 2 In the adult: Vertical diameter is greatest due to
palate. It presents numerous vascular foramina and development of the alveolar process and increase in
pits for palatine glands. the size of the sinus.
Posterolaterally, it is marked by two anteroposterior 3 [n tlrc old: The bone reverts to infantile condition. Its
grooves for the greater palatine vessels and anterior height is reduced as a result of absorption of the
palatine nerves. alveolar process.
Superior surface is concave from side to side, and
forms greater part of the floor of nasal cavity.
Medial border is thicker in front than behind. It is
-to raised superiorly into the nasal crest.
o Groove between the nasal crests of two maxillae Two parietal bones form a large part of the roof and
z receives lower border of vomer; anterior part of the sides of vault of skull. Eachbone is roughly quadrilateral
t,c in shape with its convexity directed outwards (Fig. 1.31).
(E ridge is high and is known as incisor crest which
t,(E terminates anteriorly into the anterior nasal spine.
o Incisive canal traverses near the anterior part of the SIDE DETERMINATION
medial border. Outer surface is convex and smooth, inner surface is
gs Posterior border articulates with horizontal plate of concave and depicts vascular markings.
o palatine bone. Anteroinferior angle is pointed and shows a groove
ab Lateralborder is continuous with the alveolar process. for anterior division of middle meningeal artery

Superior Parietal tuber Superior sagittal sinus

temporal line
Frontal angle
Frontal temporal line
angle Grooves for
Parietal anterior division
Anterior angle
foramen of middle
border meningeal
Occipital Posierior vessels
angle border
Posterior border
Mastoid Sphenoidal angle
Sphenoidal Temporalis angle
angle Groove for posterior division
Mastoid angle of middle meningeal vessels
Fig. 1.31 : Outer surface of left parietal bone Fig. 1.32: lnner surface of left parietal bone

FEATURES 3 Posterosuperior or occipital

Parietal bone has two surfaces/ four borders, four angles 4 Posteroinferior or mastoid
At each of the 4 angles are 4 fontanelles. These are:
Surfoces 1 One anterior fontanelle, closes at 18 months.
1 Outer convex and 2 One posterior fontanelles, closes at 3 months
2 Inner concave surface (Fig. 1.32) 3 Two anterolateral or sphenoidal fontanelles, close at
3 months.
Borders 4 Two posterolateral or mastoid fontanelles, closes at
L Superior or sagittal about 12 months of life.
2 Inferior or squamosal Details can be studied from norma verticalis and
3 Anterior or frontal norma lateralis and inner aspect of skull cap.
4 Posterior or occipital
Four Angles
1. Anterosuperior or frontal Single occipital bone occupies posterior and inferior
2 Anteroinferior or sphenoidal parts of the skull (Fig. 1.33)

Superior angle

Superior sagittal sinus

Iniernal occipital protuberance

Lambdoid border
Cerebral fossa

Internal occipital crest

Lefi transverse sinus

Right transverse sinus
Cerebellar fossa
Vermian fossa o
Lateral angle
Mastoid border !,q
Foramen magnum (E
Sigmoid sinus

Anterior border of basiocciput .o
Fig. 1.33: lnner surface of occipital bone ao

ANATOMICAI. POSITION Borders are anterior, posterior, lateral border on each

It is concave forwards and encloses the largest foramen side.
of skull, foramen, magnum, through which cranial Condylor Porl
cavity communicates with the vertebral canal.
On each side of foramen magnum is the occipital It comprises:
condyle which articulates with atlas vertebra.
o Superior surface
o Inferior surface which shows occipital condyles and
Feotures hypoglossal canal
The details can be read from descriptions of norma
Occipital bone is divided into three parts: occipitalis and posterior cranial fossa.
1 Squamous part above, below and behind foramen
, Basilar part lies in front of foramen magnum
., Condylar or lateral part on each side of foramen
magnum. Frontal bone forms the forehead, most of the roof of
orbit, most of the floor of anterior cranial fossa. Its parts
Squomous Porl are squamous, orbital and nasal (Fig. 1.3a).
Comprises two surfaces, three angles and four borders
$urf**es Squamous part of vertical and is convex forwards
External convex surface and internal concave surface. Two orbital plates are horizontal thin plates
projecting backwards
Nasal part is directed forwards and downwards.

One superior angle and two lateral angles. SOUAMOUS PART

The squamous part presents 2 surfaces, 2 borders and
encloses a pair of frontal air sinuses.
Two lamboid borders in upper part and two mastoid
borders in lower part. Outer Surfoce
1 It is smooth and shows
Bosilor Port 2 Frontal tuberosity
The basilar part of occipital bone is called as basiocciput. 3 Superciliary arches
It articulates with basisphenoid to form the base of 4 G1abella
skull. It is quadrilateral in shape and comprises two 5 Frontal air sinus
surfaces and four borders. 6 Metopic suture
Surfaces are superior and inferior 7 Upper or parietal border

Groove for superior sagittal sinus

Granular pits
Part of greater wing of
Ethmoidal notch

Temporal surface For lesser wing

.Y of sphenoid
o Groove for posterior
zo ethmoidal canal Fossa for lacrimal
tt gland
t,(E Orbital surface Zygomatic process
Trochlear fossa
Groove for anterior ethmoidal canal
C Nasal spine
o For nasal bone
a Fig. 1.34: Frontal bone from below

8 Lower or orbital border SIDE DETERMINATION

9 Zygomatrc process r Plate like squamous part is directed upwards and
10 Temporal line and temporal surfaces laterally
lnner Surfoce
r StronB zygomatic process is directed forwards
r Petrous part, triangular in shape is directed medially
It is concave and presents following features: o External acoustic meatus, enclosed between
L Sagittal sulcus squamous and tympanic parts is directed laterally.
2 Frontal crest
Two surfaces: Outer and inner
Orbital plates are separated from each other by a wide
Tztso borders; Superior and anteroinferior
gap, the ethmoidal notch.
Orbital or inferior surface of the plate is smooth and Ouler or Temporol Surfoce
presents lacrimal fossa anterolaterally and trochlear
It is smooth and forms a part of temporal fossa
spine anteromedially.
Above external acoustic meatus, there is a groove
Ethmoidal notch is occupied by cribriform plate of
for middle temporal artery
ethmoid bone. On each side of notch are small air spaces
Its posterior part presents supramastoid crest
which articulates with the labyrinth of ethmoid to
Below the anterior end of supramastoid crest and
complete ethmoidal air sinuses. At the margins are
posterosuperior to external acoustic meatus there is
anterior and posterior ethmoidal canals.
suprameatal triangle.
Zygomatic process springs forwards from the outer
surface of squamous part. Its posterior part comprises
Lies between two supraorbital margins superior and inferior surfaces. The inferior surfaces is
The margins of the nasal notch on each side articulate bounded by two roots which converge at the tubercle
with nasal, frontal process of maxilla and lacrimal bones. of root of the zygorna. Anterior root projects as the
Details can be seen from descriptions of norma articular tubercle in front of mandibular fossa.
frontalis, norma lateralis, inner aspect of skull cnp and Posterior root begins above the external acoustic
anterior cranial fossa. meatus.
Mandibular fossa lies behind articular tubercle and
consists of anterior articular part formed by squamous
part of temporal bone and a posterior nonarticular
Temporal bones are situated at the sides and base of portion formed by tympanic plate.
skulI. It comprises following parts: lnner or Cerebrol Surfoce
a. Squamous part (Fig. 1.35) It is concave and shows grooves for the middle
b. Petromastoid part meningeal vessels. Its superior border articulates with
c. Tympanic part the lower border of parietal bone. Its anteroinferior
d. Styloid process border articulates with the greater wing of sphenoid.

Squamous part

Suprameatal zo
triangle Ittr
Mastoid process !,(E
External acoustic o
Styloid process
Fig. 1.35: Outer aspect of left temporal bone ao

MASTOID PART Tegmen tympani lying most laterally. In the anterior

Mastoid part (Greek breast) forms posterior part of
part of tegmen tympani are hiatus and groove for
greater petrosal nerve and a smaller hiatus and groove
temporal bone. It has:
for the lesser petrosal nerve.
Two surfaces-outer and inner
Two borders-superior and posterior, and enclose the Posleliol Surfoce
mastoid air cells. [The outer surface forms a downwards
Internal acoustic meatus is present here
projecting conical process, the mastoid process.]
Aqueduct of vestibule lies behind internal acoustic
Two Surfoces meatus.
The outer surface give attachment to occipitalis muscle. lnferior Surfoce
Mastoid foramen opens near its posterior border and
Forms part of norma basalis. It shows lower opening
transmits an emissaryvein and abranch of occipital artery.
Mastoid process appears at the end of 2nd year.
of carolid canal (refer to normal basalis for details)
Lateral surface gives attachment to sternocleido- Jugular fossa lies behind carotid canal (Fig. 1.37).
mastoid, splenius capitis, and longissimus capitis
Medial surface of the process shows a deep mastoid It is a curved plate of bone below squamous part and
notch for the origin of posterior belly of digastric. in front of mastoid process. It comprises:
Medial to this notch is a groove for the occipital artery.
Two Surfoces
fmmer Ssrrdme* Anterior and posterior concave part forming anterior
The inner surface is marked by a deep sigmoid sulcus wall, floor and lower part of the posterior wall of
(Fig. 1.36). external acoustic meatus.

PETROUS PART Three Bolders

Petreous part (Latin rock) triangular in shape. It has Lateral which forms the margin of external acoustic
base, apex
Three surfaces-anterior, posterior and inferior Upper border and lower border which in its lateral
Three borders-superior, anterior and posterior part splits to enclose the root of styloid Process
Base is fused with squamous and mastoid parts
Externol Acouslic Meotus
Apex is irregular and forms posterolateralboundary
of foramen lacerum. Bony part of meatus is about 16 mm long
Its anterior wall, floor and lower part of posterior
Anterior Surfoce wall are formed by tympanic part. Its roof and upper
Trigeminal impression hatf of the posterior wall are formed by the squamous
Part forming roof of anterior part of carotid canal part (Fig. 1.35).
Arcuate eminence Its inner end is closed by tympanic membrane.

Parietal bone Greater wing of sPhenoid

Groove for middle meningeal

Arcuate eminence
z Sigmoid sinus
Zygomatic process
petrosal sinus
t,(E Aqueduct of vestibule
o lnternal acousiic meatus
Subarcuate fossa
c Occipital bone
.9 Styloid process
o Fig. 1.36: lnner aspect of the left temporal bone

Zygomatic process
Upper end of carotid canal Articular tubercle

Apex of petrous part

Mandibular fossa

Squamotympanic flssure
Tympanic part (plate)
Tympanic canaliculus
Stylomastoid foramen
Jugular fossa

Mastoid process
Mastoid canaliculus
Mastoid notch
Occipital groove
Mastoid foramen

Fig. 1.37: lnferior view of the temporal bone

STYLOID PROCESS o Two pterygoid (wing-like) processes, directed

Styloid (Greek pillar form) process) long pointed downwards from the junction of body and greater
process directed downwards, forwards and medially wings.
between parotid gland and internal jugular vein
. Its base is related to facial nerve It comprises six surfaces and enclose a pair of
. Its apex is crossed by external carotid artery. sphenoidal air sinuses.
o It gives attachment to three muscles and 2ligaments
Superior or Cerebrol Surfoce
(see Chapter 8) (refer to norma lateralis for details).
It articulates with ethmoid bone anteriorly and basilar
part of occipital bone posteriorly. It shows:
1 Jugum sphenoidale
2 Sulcus chiasmaticus
Sphenoid (Greek wedge) bone resembles a bat with 3 Tuberculum sellae
outstretched wings. It comprises: 4 Sella turcica
. A body in the centre (Fig. 1.38). 5 Dorsum sellae
o Two lesser wings from the anterior part of body 6 Clivus
o Two greater wings from the lateral part of body Refer to middle cranial fossa for details.

Optic groove Lesser wing

Greater wing
Optic canal
Anterior clinoid :o
orbital Tuberculum sellae
Posterior clinoid (E
Foramen process !,
rotundum G
Spine o
Spinosum Foramen Dorsum Sella turcica
ovale sellae
Fig. 1.38: Superior view of the sphenoid bone U)

lnferior Surfoce lower or infratemporal surface. It is pierced by

1 Rostrum of sphenoid (Fig. 1.39a) foramen ovale and foramen spinosum' Its posterior
part presents spine of sphenoid. Refer to norma
2 Sphenoid conchae (Fig. 1.39b) basalis in details.
3 Vaginal processes of medial pterygoid plate
Refer to norma basalis for details. Orbilol Surfoce
Forms the posterior wall of the lateral wall of orbit.
Anterior Surfoce Its medial border bears a small tubercle for
Sphenoidal crest articulates with perpendicular plate attachment of a common tendinous ring for the origin
o? ethmoid to form a small part of septum of nose of recti muscles of the eyeball. Below the medial end of
Opening of sphenoidal air sinus is seen (Fig. 1.39b) superior orbital fissure, the grooved area forms the
Sphenoidal conchae close the sphenoid air sinuses poiterior wall of the pterygopalatine fossa and is
leaving the openings. Each half of anterior surface has pierced by foramen rotundum (Fig. 1.39b).
two parts: superolateral and inferomedial. Borders are surrounding the greater wing of
The superolateral depression articulates with sphenoid.
labyrinth of ethmoid to complete the posterio,r
ethmoidal air sinuses. The inferomedial smooth TESSER WINGS
triangular area forms the posterior part of the root of Lesser wings are two triangular plates projecting
the nose. laterally from the anterosuperior part of the body. It
Posterior Surfoce . A base forming medial end of the wing. It is connected
It articulates with basilar part of occipital bone to the body by two roots which enclose the optic canal
. Tip forms the lateral end of the wing
Lolerol Surfoce . Superior surface forming floor of anterior cranial
Carotid sulcus, a broad groove curved like letter 'f' for fossa
lodging cavernous sinus and internal carotid artery. o Inferior surface forming upper boundary of superior
gelow the sulcus it articulates with greater wing of
orbital fissure.
sphenoid laterally and with pterygoid Process which
is directed downwards.
r Anterior border articulates with the posterior border
of orbital plate of frontal bone
o Posterior border is free and projects into the stem of
lateral sulcus of brain. Medially it terminates in to
These are asymmetrical air sinuses in the body of the anterior clinoid Process.
sphenoid, and are closed by sphenoidal conchae. The
sin.,s opens into the lateral wall of nose in the SUPERIOR ORBIIAL FISSURE
sphenoethmoidal recess above the superior concha
It is a triangular gap through which middle cranial fossa
communicltes with the orbit. The structures passing
through it are put in list of foramina and structures
two strong Processes which curve laterally
These are passing through them (see Fig. 13.4).
and upwards from the sides of the body. Its three

Superior or Cerebrol Surfoce One pterygoid (Greek wing) Process-on each side
presents db*nwards from th9 Junction of the body with
It forms the floor of middle cranial fossa q^u
and vrLovrrru Projeits
the greater wing of sphenoid (Fig' 1'38)'
l( from before backwards:
r Foramen rotundum (Fig. 1.3ea) -"H:i,'"fil,::iiri"?T:iri'fi!!:r1ilj"1,:,tlJ:trXil;
2 Foramen ovale in their upper parts, but are separated in their
t,(E 3 Emissary sphenoidale foramen lower parts by the-pterygoid fis-qure. ?osteriorly the
o 4 Foramen spinosum pterygbid a "V-shaped interval" , the
I -plaies.enclose pterygoid plate in its upper
pteryfold fossa. The medial
c LOterOl SurfOCe part presents a scaphoid fossa.
A horizontal ridge, the infratemporal crest divides
.o Refertononnabasalisformedialandlateralpterygoid
ao this surface into upper or temporal surface and a plates'

Lesser wing


Superior orbital fissure

Scaphoid fossa Lateral pterygoid plate

Pterygoid fossa Medial pterygoid plate

Posterior View Pterygoid hamulus

Vaginal process
Opening of sphenoidal sinus Sphenoidal crest
Lesser wing

Temporal surface ----1 o,

Superior orbital fissure Orbital surface | 9r"rt",
Foramen rotundum lnfratemporal ,urfu"" J

Pterygoid canal Sphenoidal concha

Palatovaginal groove

Pterygoid hamulus
Lateral pterygoid lamina
Vaginal process
Figs 1.39a and b: (a) Posterior view of sphenoid, and (b) greater wing and lesser wing of sphenoid

Cristo Golli
Crista galli is a median, tooth like upward projection
Ethmoid (Greek sierse) is a very light cuboidal bone in the floor of anterior cranial fossa. Foramen
situated in the anterior of base of cranial cavity between transmitting anterior ethmoidal nerve to nasal cavity
the two orbits. It forms: is situated by the side of crista galli.
1 Part of medial orbital walls Perpendiculor Plole
2 Part of nasal septum (Fig. 1.40a) It is a thin lamina projecting downwards from the
3 Part of roof of orbit undersurface of the cribriform plate, forming upper part
4 Lateral walls of the nasal cavity of nasal septum.
E thmoid bone comprises : o
1 Cribriform plate (Fig. 1.a0b)
These are two light cubical masses situated on each side
2 Perpendicular plate t,tr
of the perpendicular plate, suspended from the
3 A pair of labyrinth undersurface of the cribriform plate (Fig. 1.40c).
Each labyrinth also encloses large number of "air o
cells" arranged in three groups; the anterior, middle
It is a horizontal perforated bony lamina, occupying and posterior ethmoidal air sinuses. Its surfaces are: c
ethmoidal notch of frontal bone. Contains foramina for o Anterior surface articulates with frontal process of ()
olfactory nerve rootlets maxilla to complete anterior ethmoidal air cells @

For frontal
For nasal
bone Ethmoid sinus

Orbital (lateral)
For septal
cartilage Middle nasal concha
Superior nasal

Perpendicular plate

Cribriform Crista galli


$uperior Anterior
concha ethmoidal sinuses
orbit- Orbital plate of
ethmoidal labyrinth
concha Perpendicular plate
process Middle ethmoidal
sinus and bulla
Vomer ethmoidalis
Floor of nose

Patate forming Upper tooth

floor of nasal cavity

Figs 1.40a to c: (a) Articulations of perpendicular plate, (b) posterior view of the ethmoid bone, and (c) ethmoid bone articulating
with neighbouring bones

o Posteriorsurfacearticulateswithsphenoidalconchea r Anterior, longest border articulates with per-

to complete posterior ethmoidal iir cells pendicular plate of ethmoid above and with sePtal
. Superior surface articulates with orbital plate of cartilage below.
frontal bone. o Posterior border is free and separates the two
r Inferior surface articulates with nasal surface of posterior nasal openings.
r Lateral surface forms medial wall of orbit.
r Medial surface presents small superior nasal concha,
middle nasal concha, superior meatus below
superior conchea, middle meatus below middle The inferior nasal conchae are two curved bony
concha. laminae, these are horizontally placed in the lower part
of lateral walls of the nose. Between this concha and
floor of the nose lies the inferior meatus of the nose. It
l< comprises 2 surfaces, 2 borders and 2 ends.
o Vomer (Latin plough share) is a single thin, flat bone o Medial convex surface is marked by vascular grooves
z forming posteroinferior part of the nasal septum. It
t,tr o Lateral concave surface forms the medial wall of
. inferior meatus of the nerve.
!t(E Right and left surfaces marked by nasopalatine
o nerves which course downwards and forwards
. Superior border is irregular and articulates
T . with maxilla,lacrimal, ethmoid and palatine bones
Superior border splits into two alae with a groove is
occupied by rostrum of sphenoid (Fig. 1.41).
(Fig. La\.
() r Inferior border articulates with nasal crests of r Inferior border is free, thick and spongy.
ao maxillae and palatine tones. o Posterior end is more pointed than the anterior end.


Free border
plate of ethmoid

Septal cartilage

Palatine process
of maxilla
Horizontal plate
of palatine bone

Fig. 1.41 : Vomer forming posteroinferior part of the nasal septum and its various borders. Left lateral view of the vomer

Frontal process
Maxillary process

foramen Marginal tubercle

Levator labii Lateral surface

superioris Zygomaticus major
Temporal process
For maxilla

Frontal process
Fig. 1.42: Lateral view of the left inferior nasal concha
Temporal surface With greater wing

Temporal Zygomatico-orbital
process foramina

F For maxilla
These are two small quadrilateral bones present in the
upper and lateral part of face. The bone forms
;, prominence of the cheeks. Each bone takes part in the
formation of: Figs 1.43a and b: Features of the left zygomatic bone. (a) Outer
o Floor and lateral wall of the orbit view, and (b) inner view
. Walls of temporal and infraorbital fossae
Zygornaticbone comprises 3 surfaces,5 borders and
2 processes.
Borders ta
Surfaces o
1 Anterosuperior or orbital
1 Lateral surface presenting zygomaticofacial foramen 2 Anteroinferior or maxillary zo
(Fig. 1.a3a) t,c
3 Posteroinferior or temporal border (E
Temporal surface is smooth and concave and 4 Posteroinferior border tt(E
presents zygomaticotemporal foramen (Fig.1.a3b). 5 Posteromedial border. o
Orbital surface is also smooth and concave one or
two zygomaticoorbital foramen on this surface and Processes
this bads to zygomaticofacial and zygomatico 1. Frontal process, which is directed upwards. ()
temporal foramina (Fig. 1.20). 2 Temporal process, directed backwards. @


Superior border
Nasal bones are two small oblong bones, which form Anterior border
Orbital sudace
the bridge of the nerve.
Groove for lacrimal
Each nasal bone has two surfaces and four borders Posterior border
(Fig. 1.aa).

1 The outer surface is convex from side to side. Descending process
for inferior nasal concha
2 The inner surface is concave from side to side and is
traversed by a vertical groove or anterior ethmoidal Fig. 1.45: Lateral surface of the left lacrimal bone

Borders Borders
1 Superior border is thick and serrated and articulates 1 Anterior border articulates with frontal process of
with nasal part of frontal bone. maxilla.
2 Inferior border is thin and notched and articulates 2 Posterior border with orbital plate of ethmoid.
with lateral nasal cartilage. 3 Superior border with frontal bone.
3 Medial border articulates with opposite nasal bone 4 Inferior border with orbital surface of maxilla.
4 Lateral border articulates with frontal process of

Palatine bones are two L-shaped bones present in the

posterior part of nasal cavity. Each bone forms:
. Lateral wall and floor of nasal cavity (Fig. 1.46a).
. Roof of mouth cavity
Medial border and . Floor of the orbit
nasal crest
r Parts of pterygopalatine fossa
Each palatine bone has 2 plates and 3 processes.
Vascular foramen
Two PIotes
1 Horizontal plate forms posterior one-fourth part of
Notched Inferior
bony palate. It has 2 surface and 4 borders (Fig.

Fig. 1.44: lnner view of the left nasal bone

2 Perpendicular plate of palatine bone is oblong in
shape and comprises 2 surfaces and 4borders (refer
to norma basalis).

Three Processes
Fyr*rnidotr FrCIeess
Pyramidal process projects downwards from the
Lacrimal bones are extremely delicate and smallest of junction of two plates. Its inferior surface is pierced by
the skull bones. These form the anterior part of the lesser palatine foramina.
medial part of the orbit. Each lacrimal bone comprises
l. 2 surfaces and 4 borders.
ffrbifsf Frpcess
Orbital process projects upwards and laterally from
zo Surfoces the perpendicular plate. Its orbital surface is triangular
(E 1 Lateral or orbital surface is divided by posterior and foims the posterior part of the floor of the orbit
t,(E lacrimal crest into anterior and posterior parts. The (Fig. 1.46b).
o anterior grooved part forms posterior half of the floor
of lacrimal groove for lacrimal sac. The posterior Spfiel.l*idof Prsce$$
c smooth part forms part of medial wall of orbit. Sphenoidal process projects upwards and medially
() 2 Medial or nasal surface forms a part of middle fiom the perpendicular plate. Its lateral surface
ao meatus of the nose (Fig. 1.45). articulates with medial pterygoid plate.

Orbital process
Maxillary surface

Orbital surface For sphenoid

Ethmoidal crest Orbital process

Sphenoidal Sphenoidal process
process Sphenopalatine foramen Sphenopalatine
notch Superior meaius
Middle meatus
Ethmoidal crest
Middle meatus
Conchal crest
Conchal crest
lnferior meatus
Inferior meatus

For lateral Nasal

pterygoid plate crest

Pterygoid fossa nasal spine
Horizontal plate

Horizontal part For medial pterygoid plate

(a) (b)

Figs 1.46a and b: (a) Medial view of the left palatine bone, and (b) various proceses of palatine bone

The hyoid bone provides attachment to the muscles

of the floor of the mouth and to the tongue above, to
The hyoid (Greek U'shaped) bone is U-shaped.
the larynx below, and to the epiglottis and pharyrrx
It develops from second and third branchial arches. behind (
It is situated in the anterior midline of the neck The bone consists of the central part, called the
between the chin and the thyroid cartilage. body, and of two pairs of cornua, greater and lesser.
At rest, it lies at the level of the third cervical vertebra
behind and the base of the mandible in front. Body
It is kept suspended in position by muscles and It has anterior and posterior surfaces, and upper and
ligaments (Fig.Lan. lower borders.

Middle constrictor
(cranial root of Xl)

Investing fascia

Digastric pulley
Genioglossus (Xll)
Geniohyoid (Cl) zo
Mylohyoid (V3) Stylohyoid muscle (Vll) (E
and ligament tG,
Sternohyoid (ansa cervicalis)
Hyoglossus (Xll) o
Thyrohyoid (Cl )
Prekacheal fascia Superior belly of omohyoid c
Fig. 1.47: Anterosuperior view of the left half of hyoid bone showing its attachments a

Tl:re antedor surface ts convex and is directed forwards

and upwards. It is often divided by a median ridge into
In a suspected case of murder. fracture of the hyoid
two lateral halves.
bone strongly indicates throttling or strangulation.
The posterior surface is concave and is directed
backwards and downwards.
Each lateral end of the body is continuous posteriorly
with the greater horn or cornua. However, till middle
life the connection between the body and greater comua IDENTIFICATION
is fibrous.
The cervical vertebrae are identified by the presence of
Greoler Cornuo foramina transversaria.
These are flattened from above downwards. Each There are seven cervical vertebrae, out of which the
cornua tapers posteriorly, but ends in a tubercle. It has third to sixth are typical, while the first, second and
two surfaces-upper and lower, two borders-medial seventh are atypical (Fig. 1.48).
and lateral and a tubercle.
Lesser Cornuo
These are small conical pieces of bone which project
upwards from the junction of the body and greater
cornua. The lesser cornua are connected to the body
by fibrous tissue. Occasionally, they are connected to
the greater cornua by synovial joints which usually
persist throughout life, but may get ankylosed.
Affsct?rnenfs on ffte *tyoid fran*
The anterior surface of the body provides insertion
to the geniohyoid and mylohyold muscles and gives
origin to a part of the hyoglossus which extends to
the greater cornua (Fig. Lan.
Tlae upper border of the body provides insertion to
the lower fibres of the genioglossi and attachment
to the thyrohyoid membrane.
The lower border of the body provides attachment to
the pretracheal fascia.In front of the fascia , t!;re sternohyoid
is inserted medially and the superior belly of omohyoid
Below the omohyoid, there is the linear attachment Fig. 1.48: Cervical vertebrae-anterior view
of the thyrohyoid, extending back to the lower border of
the greater cornua. WPICAL CERVICAL VERTEBRA
The medial border of the greater cornua provides
attachment to the tlryrohyoid membrane, stylohyoid muscle
and dignstric pulley. 1 The body is small and broader from side to side than
The lateral border of the greater cornua provides from before backwards.
insertion to the thyrohyoid muscle anteriorly. The Its superior surface is concave transversely with
.!< inaesting fascia is attached throughout its length. upward projecting lips on each side. The anterior
o The lesser cornua provides attachment to the border of this surface may be bevelled.
zo stylolry oid ligament at lls tip. The middle constrictor muscle The inferior surface is saddle-shaped, being convex
c(E arises from its posterolateral aspect extending on to the from side to side and concave from before
tt(E greater cornua (see Fig. 14.21). backwards. The lateralborders arebevelled and form
o sy,novial joints with the projecting lips of the next
DEVETOPMENT lower vertebra. The anterior border projects
C Upper part of body and lesser cornua develop from downwards and may hide the intervertebral disc.
C) second branchial arch, while lower part of body and Tlre anterior and posterior surfaces resemble those of
ao greater cornua develop from the third arch. other vertebrae (Fig. 1.49).

Verlebtol Foromen The upper borders and lower parts of the anterior
Vertebral foramen is larger than the body. It is surfaces of the laminae provide attachment to the
triangular in shape because the pedicles are directed ligamenta flaaa.
backwards and laterally. T}:.e foramen transaersarium transmits the oertebral
artery, the aertebral oeins and abranch from the inferior
Verlebrol Arch ceroical ganglion. The anterior tubercles give origin to
the scalenus anterior , the longus capitis, and the oblique
1 Thepedicles are directed backwards and laterally. The
part of the longus colli.
superior and inferior vertebral notches are of equal
T}ne costotransrerse bars are grooved by the anterior
primary rami of the corresponding cervical nerves.
2 The laminae are relatively long and narrow, being The posterior tubercles give origin to the scalenus
thinner above than below.
medius, scalenus posterior, the leaator scapulae, the
3 The superior and inferior articular processes form splenius cerzticis, the longissimus ceroicis, and the
articular pillars which project laterally at the junction iliocostalis ceroicis (see Fig. 10.3).
of pedicle and the lamina. The superior articular The spine gives origin to the deep muscles of the
facets are flat. They are directed backwards and back of the neckinterspinales, semispinalis thoracis and
upwards. The inferior articular facets are also flat ceraicis, spinalis ceruicis, and multifidus (see Figs 10.2
but are directed forwards and downwards. and 10.4).
4 The transuerse processes are pierced by foramina
transversaria. Each process has anterior andposterior
roots which end in tubercles joined by the
costotransoerse bar. The costal element is represented by A typical cervical vertebra ossifies from three
the anterior root, anterior tubercle the costotransaersebar primary and six secondary centres. There is one
and the posterior tubercle. The anterior tubercle of the primary centre for each half of the neural arch during
sixth cervical vertebra is large and is called the carotid 9 to 10 weeks of foetal life and one for the centrum in
tubercle because the common carotid artery can be 3 to 4 months of foetal life. The two halves of the
compressed against it. neural arch fuse posteriorly with each other during
5 The spine is short and bifid. The notch is fitled up by the first year. Synostosis at the neurocentral
the ligamentum nuchae (Fig. 1.a9). synchondrosis occurs during the third year.
T}ae secondary centres, two for the annular
Affcv*fsrnemfs arl# tr*Cofrarns epiphyseal discs for the peripherai parts of the upper
1 The anterior and posterior longitudinal ligaments are and lower surfaces of the body, two for the tips of
attached to the upper and lower borders of the body the transverse processes, and two for the bifid spine
in front and behind, respectively. On each side of appear during puberty, and fuse with the rest of the
the anterior longitudinal ligament, the rsertical part vertebra by 25 years.
of the longus colli is attached to the anterior surface.
The posterior surface has two or more foramina for
passage of basioertebrnl oeins. FIRST CERVICAL VERTEBRA

It is called the atlas (Tiltan, who supported the heavans).

It can be identified by the following features:
1 It is ring-shaped. It has neither a body nor a spine
(Fis. 1.50).
Anterior tubercle
2 The atlas has a short anterior arch, a long posterior
arch, right and left lateral masses, and transverse
Processes. lr
Costotransverse 3 The anterior arch is marked by a median anterior
tubercle on its anterior aspect. Its posterior surface t,
bears an ooal facet which articulates with tt:.e dens cl
(Fis. 1.50). t,G
4 The posterior arch forrns about two-fifths of the ring o
facel and is much longer than the anterior arch. Its
posterior surface is marked by a median posterior c
tubercle. The upper surface of the arch is marked o
Fig. 1.49: Typical cervical vertebra seen from above behind the lateral mass by a groore. ao

Transverse ligament
Rectus capitis anterior
Superior articular facet
Rectus capitis lateralis
Foramen transversarium
Levator scapulae

Transverse process

Superior oblique Groove with vertebral artery

Posterior arch

Rectus capitis posterior minor

Posterior iubercle
Fig. 1.50: Atlas vertebra seen from above

Each latersl mass shows the following important 5 The groove on the upper surface of the posterior arch
features: is occupied by the aertebral artery and by the first
a. Its upper surface bears the superior articular facet. ceroical nense. Behind the groove, the upper border
This facet is elongated (forwards and medially), of the posterior arch gives attachment to the posterior
concave, and is directed upwards and medially. atlanto-occipital membrane (see Figs 10.5 and 10.6).
It articulates with the corresponding condyle to 6 The lower border of the posterior arch gives
form an atlanto-occipital joint. attachment to the highest pair of ligamenta flaoa.
b. The lower surface is marked by the inferior articular 7 The tubercle on the medial side of the lateral mass
gives attachment to tilre transaerseligament of the atlas.
facet.This facet is nearly circular, more or less flat,
and is directed downwards, medially and 8 The anterior surface of the lateral mass gives origin
backwards. It articulates with the corresponding to the rectus capitis anterior.
facet on the axis vertebra to form an atlantoaxial 9 The transverse process giaes origin to the rectus
joint. capitis lateralis from its upper surface anteriorly, the
c. The medial surface of the lateral mass is marked superior oblique from its upper surface posteriorly,
by a small roughened tubercle. the inferior oblique from its lower surface of the tip,
theleaator scapulae from its lateral margin and lower
d. The transaerse process projects laterally from the
lateral mass. It is unusually long and can be felt border, the splenius ceraicis, and the scalenus medius
from the posterior tubercle of transverse process.
on the surface of the neck between the angle of
mandible and the mastoid process. Its long length
allows it to act as an effective lever for rotatory
movements of the head. The transverse process is Atlas ossifies from three centres, one for each lateral
pierced by the foramen transversarium. mass with half of the posterior arch, one for the
anterior arch. The centres for the lateral masses
Affmeft rmemfs cru# &*fsfions appear during seventh week of intrauterine life and
unite posteriorly at about three years. The centre for
1 The anterior tubercle provides attachment (in the
anterior arch appears at about first year and unites
median plane) to the anterior longitudinal ligament,
ta and provides insertion on each side to l}i.e upper
with the lateral mass at about 7 years.
zo 2 oblique part of longus colli.
The upper border of the anterior arch gives
tr attachment to the anterior atlanto-occipital membrane.
t,(E 3 The lower border of the anterior arch gives attachment This is called the axis (Latin axile).It is identified by
o to the lateral fibres of the anterior longitudinal ligament. the presence of the dens or odontoid (Greek tooth)
4 The posterior tubercle provides attachment to the process which is a strong, tooth-like process projecting
c ligamentum nuchae in the median plane and gives upwards from the body. The dens is usually believed
o origin to the rectus capitis posterior minor on each side to represent the centrum or body of the atlas which has
ao (Fig. 1.50). fused with the centrum of the axis (Fig. 1.51).

Facet for atlas 1 The dens provides attachment at its apex to the apicnl
ligament, and on each side, below the apex to the alar
ligaments (see Fig. 9.12).
transversarium 2 The anterior surface of the body receives the insertion
of the longus colli.The anterior longitudinal ligament is
Transverse process
also attached to the anterior surface.
Vertebral loramen 3 The posterior surface of the body provides
Inferior articular
attachment, from below upwards, to the posterior
process longitudinal ligament, the membrana tectoria and the
aertical limb of the cruciate ligament.
4 The laminae provide attachment to the ligamenta
Fig. 1.51 ; Axis vertebra, posterosuperior view 5 The transverse process gives origin by its tip to the
leaator scnpulae, the scalenus medius anteriorly and the
Body ond Dens splenius ceroicis posteriorly . The intertransoerse
muscles are attached to the upper and lower surfaces
1 The superior surface ofthe body is fused with the dens,
and is encroached upon on each side by the superior
of the process.
articular facets. The dens articulates anteriorly with 6 The spine gives attachment totheligamentumnuchae,
oval fact on posterior surface of the anterior arch of the semispinalis ceraicis, the rectus capitis posterior
the atlas, and posteriorly with the transverse major, the inferior oblique, the spinalis centicis, the
ligament of the atlas. interspinalis and the multifidus (see Chapter 10).
2 The inferior surface has a prominent anterior margin
which projects downwards. SEVENTH CERVICAT VERTEBRA
3 The anterior surface presents a median ridge on each It is also known as the aertebra prominens because of its
side of which there are hollowed out impressions. long spinous process, the tip of which can be felt
through the skin at the lower end of the nuchal furrow.
VertebrolArch Its spine is thick, long and nearly horizontal. It is
1 The pedicles are concealed superiorly by the superior not bifid, but ends in a tubercle (Fig. 1.52).
articular processes. The inferior surface presents a The transverse processes are comparatively large in
deep and wide inferior aertebral notch, placed in front size, the posterior root is larger than the anterior. The
of the inferior articular process. The superior anterior tubercle is absent. The foramen transversarium
vertebral notch is very shallow and is placed on the is relatively smalI, sometimes double, or maybe entirely
upper border of the lamina, behind the superior absent. It does not transmit the vertebral artery.
articular process.
2 The laminae are thick and strong. *ff#cfirnenfs
3 Articular facets: Each superior articular facef occupies 1 The tip of the spine provides attachment to the
the upper surfaces of the body and of the massive ligamentum nuchae, trapezius, rhomboid minor, serratus
pedicle. LateraTly, it
overhangs the foramen
transversarium. It is a large, flat, circular facet which
is directed upwards and laterally. It articulates with Foramen
the inferior facet of the atlas vertebra to form the
atlantoaxial joint. Each inferior articular facet lies
posterior to the transverse process and is directed tto
downwards and forwards to articulate withthe third
cervical vertebra.
4 The transrserse processes are very small and represent (E

the true posterior tubercles only. The foramen !t(E

transversarium is directed upwards and laterally o
5 The spine islarge, thick and very strong. It is deeply c
grooved inferiorly. Its tip is bifid, terminating in two o
rough tubercles. Fig. 1.52: Seventh cervical vertebra seen from above a
r-: .--- l

p o st er ior sup er io r, spl eniu s cap itis, s emisp inalis thor aci s, vertebrobasilar insufficiency. This may cause
spinalis centicis, interspinales. and the multifidus (see
vertigo, dizziness, etc.
Fig. 10.3).
Prolapse of the intervertebral disc occurs at the
2 Transzterse process: The fornmen transoersarium :usually
junction of different curvatures. So the common
transmits only an accessory vertebral vein. The
site is lower cervical and upper lurnbar vertebral
posterior tubercle provides attachment to the
region. In the cervical regio+ the disc involved is
suprapleural membrane. The lower border provides
above or below 6th cervical vertebra. The nerve
attachment to the lersator costarum.
roots affected are C6 and C7. There is pain and
The anterior root of the transverse process may numbness along the lateral side of forearm and
sometimes be separate. It then forms a ceraical rib of hand. There may be wasting of muscles of thenar
variable size. eminence.
During judicial hanging, the odontoid process
usually breaks to hit upon the vital centres in the
medulla oblongata (Fig. 1.56).
Its ossification is similar to that of a typical cervical
vertebra. In addition, separate centre for each costal
Atlas may fuse with the occipital bone. This is
process appears during sixth month of intrauterine
called occipitalization of ntlas and this may at times
life and fuses with the body and transverse process compress the spinal cord which requires surgical
during fifth to sixth years of life.
The pharyngeal and retropharyngeal inflam-
mations may cause decalcification of atlas
vertebra. This may lead to loosening of the
attachments of transverse ligament which may
The costal element of seventh cervical vertebra eventually yield, causing sudden death from
may get enlarged to form a cervical rib (Fig. 1.53). dislocation of dens.
A cervical rib is an additional rib arising from the Fractures of skull may be depressed, linear and
C7 vertebra and usually gets attached to the 1st basilar (Fig. 1.57).
rib near the insertion of scalenus anterior. If the Hangman's fracture occurs due to fracture of the
rib ls more than 5 cm long, it usually displaces pedilles of axis vertebra. As the vertebral canal
the brachial plexus and the subclavian artery gets enlarged, the spinal cord does not get
upwards (Fig. 1.5a). pressed.
The symptoms are tingling pain along the inner
border of the forearm andhand including weakness
and even paralysis of the muscles of the palm.
The intervertebral foramina of the cervical
vertebrae, lie anterior to the joints between the
articular processes. Arthritic changes in these
joints, if occur, cause tiny projections or
osteophytes. These osteophytes may press on the
anteriorly placed cervical spinal nerves in the
foramina causing pain along the course and
distribution of these nerves (fig. 1.55).
The joints in the lateral parts of adiacent bodies of
.Y cervical vertebrae are called Luschka's joints. The
o osteophytes commonly occur in these joints. The
z cervical nerve roots lying posterolateral to these
joints may get pressed causing pain along their
t,6 diskibution (Flg. 1.55).
O. The vertebral artery coursing through the foramen
transversarium lies lateral to these joints. The
c osteophytes of Luschka joints may cause
o distortion of the vertebral artery leading to Fig. 'l .53: Bilateral cervical ribs




Cervical rib

Brachial plexus
Fig. 1.54: Cervical rib causing pressure on the lower trunk
of the brachial plexus Fig. 1.56: Fracture of the odontoid process during hanging

Joint between
articular processes


Bony changes

Luschka's joints

Fig. 1.55: Pressure onthecervical nervedueto bonychanges Fig. 1.57: Types of the fracture of the skull

Two centres for squamous part below highest

Frontal: It ossifies in membrane. Two primary nuchal line appear during seventh week. One
centres appear during eighth week near frontal Kerkring centre appears for posterior margin of
eminences. At birth, the bone is in two halves, foramen magnum during sixteenth week.
separated by a sufure, which soon start to fuse. But Two centres one for each lateral parts appear
remains of metopic suture may be seen in about during eighth week. One centre appears for the
3-8% of adult skulls. basilar part during sixth week.
Parietal: It also ossifies in membrane. Two centres Temporal: Squamous and tympanic parts ossify in o
appear during seventh week near the parietal membrane. Squamous part by one centre which zo
eminence and soon fuse with each other. appears during seventh week. Tympanic part from ttr
Occipital: It ossifies partly in membrane and one centre which appears during third month. (E

partly in cartilage. The part of the bone above highest Petromastoid and styloid parts ossify in cartilage.
I o
nuchal line ossifies in membrane by two centres Petromastoid part is ossified by several centres which
which appear during second month of foetal life, it appear in cartilaginous ear capsule during fifth
r may remain separate as interparietal bone. month. Styloid process develops from cranial end of o
The following centres appear in cartilage: second branchial arch cartilage. Two centres appear

in it. Tympanohyal before birth and stylohyal after week near the mental foramen. The upper half of
birth. ramus ossifies in cartilage. Ossification spreads in
Sphenoid: It ossifies in two parts: condylar and coronoid processes above the level of
Presphenoidal part whichlies in front of tuberculum the mandibular foramen.
sellae and lesser wings ossifies from six centres in lnferior nasal concha; It ossifies in cartilage. One
cartilage: Two for body of sphenoid during ninth centre appears during fifth month in the lower border
week; two for the two lesser wings during ninth of the cartilaginous nasal capsule.
week; two for the two sphenoidal conchae during Palatine: One centre appears during eighth week
fifth month. in perpendicular plate. It ossifies in membrane.
Postsphenoidal part consisting of posterior part of Lacrimal: It ossifies in membrane. One centre
body, greater wings and pterygoid processes ossifies appears during twelfth week.
from eight centres: Nasal: It also ossifies in membrane from one
Two centres for two greater wings during eighth centre which appears during third month of intra-
week forming the root only; two for postsphenoidal uterine life.
part of body during fourth month; two centres appear
Vomer: It ossifies in membrane. Two centres
for the two pterygoid hamulus during third month
appear during eighth week on either side of midline.
of foetal life. These six centres appear in cartilage.
These fuse by twelfth week.
Two centres for medial pterygoid plates appear
during ninth week and the remaining portion of the Zygomatic: It ossifies in membrane by one centre
greater wings and lateral plates ossify in membrane which appears during eighth week.
from the centres for the root of greater wing only. Maxilla: It also ossifies in membrane by three
Ethmoid: It ossifies in cartilage. Three centres centres. One for main body which appears during
appear in cartilaginous nasal capsule. One centre sixth week above canine fossa.
appears in perpendicular plate during first year of Two centres appear for premaxilla during seventh
life. Two centres one for each labyrinth appear week and fuse soon.
between fourth and fifth months of intrauterine life. Various foramina of anterior, middle and
Mandible: Each half of the body is ossified in posterior cranial fossae and other foramina with their
membrane by one centre which appears during sixth contents are shown in Table L.5.

:..i1 :-ja:: j. :,' ...:.:....

'! -. -:....,. - !,

Groove for superior sagittal sinus Superior sagittal sinus
Foramen caecum Emissary vein to superior sagittal sinus from upper part of nose
Anterior ethmoidal foramen Anterior ethmoidal nerve and vessels
Foramina of cribiform plate Olfactory nerve rootlets
Posterior ethmoidal foramen Posterior ethmoidal vessels
Optic canal Optic nerve and ophthalmic artery
Superior orbital fissure:
. Lateral part Lacrimal and frontal nerues, (branches of ophthalmic nerve); trochlear nerue; superior
ophthalmic vein; meningeal branch of lacrimal artery; anastomotic branch of middle
meningeal artery, which anastomoses with recurrent branch of lacrimal artery.
l. .
o Middle part Upper and lower divisions of oculomotor nerue (CN lll), nasociliary nerue, abducent
z nerue (CN Vl)
. Medial part lnferior ophthalmic vein; sympathetic nerve from plexus around internal carotld artery.
Foramen rotundum Maxillary nerve (CN V2)
o Foramen ovale Mandibular nerve (CN V3); accessory meningeal artery; lesser petrosal nerve;
I emissary vein connecting cavernous sinus with pterygoid plexus (male)
C Foramen spinosum Middle meningeal artery and vein, meningeal branch of mandibular nerve (CN V3)
o Emissary sphenoidal foramen Emissary vein connecting cavernous sinus with pterygoid plexus of veins
U) (Contd...)

Foramina/apertures Contents
Foramen lacerum During life, the foramen is filled with cartilage
No significant structure passes through it; internal carotid artery and nerve plexus pass
across its superior end; nerve to pterygoid canal passes through its anterior wall;
meningeal branch of ascending pharyngeal artery and emissary vein pass through it.
Carotid canal lnternal carotid artery and nerve plexus (sympathetic)
Groove for lesser petrosal nerve Lesser petrosal nerve
Groove for greater petrosal nerve Greater petrosal nerve
Foramen magnum Lowest part of medulla oblongata and three meninges; vertebral arteries; spinal roots
of CN Xl; anterior and posterior spinal afieries; apical ligament; vertical band of cruciate
ligament and membrana tectoria.
Jugular foramen CN lX; X; Xl; inferior petrosal and sigmoid sinuses; meningeal branches of ascending
pharyngeal and occipital arteries.
Hypoglossal canal/anterior condylar canal CN XII
Internal acoustic meatus CN Vll; Vlll and labyrinthine vessels
External opening of vestibular aqueduct Endolymphatic duct
Posterior condylar canal Emissary vein connecting sigmoid sinus with the suboccipital venous plexus
Mastoid foramen Mastoid emissary vein and meningeal branch of occipital artery
External acoustic meatus Air waves
External nasal foramen External nasal nerve
Greater palatine foramen Greater palatine vessels; anterior palatine nerve
lncisive canal Greater palatine vessels; terminal part of nasopalatine nerve
lnferior orbital fissure Zygomatic nerve; orbital branches of pterygopalatine ganglion; infraorbital nerve and
lnfraorbital foramen lnfraorbital nerve and vessels
Lesser palatine foramen Middle and posterior palatine nerves
Mandibular foramen/canal lnferior alveolar nerve and vessels
Mandibular notch Masseteric nerve and vessels
Mastoid canaliculus Auricular branch of vagus nerve
Mental foramen Mental nerve and vessels
Palatinovaginal canal Pharyngeal branch from pterygopalatine ganglion; pharyngeal branch of maxillary
Parietal foramen Emissary vein from scalp to superior sagittal sinus
Petrotympanic fissure Chorda tympanic nerve and anterior tympanic artery.
Pterygoid canal Nerve to pterygoid canal and vessels
Pterygomaxillary f issure Maxillary nerve
Pterygopalatine fossa Pterygopalatine ganglion
Stylomastoid foramen Facial nerve; stylomastoid branch of posterior auricular artery.
Supraorbital foramen Supraorbital nerve and vessels zo
Tympanic canaliculus Tympanic branch of glossopharyngeal nerve t,c
Tympanomastoid fissure Auricular branch of vagus nerve !,(E
Vomerovaginal canal Branch of pharyngeal nerve and vessels o
Zygomatic foramen Zygomatic nerve
Zygomaticofacial foramen Zygomaticofacial nerve .9
Zygomaticotemporal foramen Zygomaticotemporal nerve

A young woman complains of pain and numbness

. B bones in the skull and L4 facral bones make up along the lateral side of forearm and hand, with
the skull. wasting of the muscles of thenar eminence
r Most of the joints are 'suture' type of joints. The
. \,fhy is there pain in forearm and hand with no
jointbetween teeth and gums is gomphosis' There injury to the affected area?
is a pair of temporomandibularloint, which is of . lrvhy are thenar muscles gettmg weaker?
synwial variety. Ans: There is na obvious injury in the hand or
. {*rearm, These syrnptorrrs arenervous innafure. One
The bony ossicles are malleus, incus and stapes and
has to l*ok far thenerrre rootwhich supply this area,
are "bone within bone", as these are present in the
The nerve root is cervical 6. Seel the cervical spine
petrous temporal bone. Between these three
-ossicles f*r anypain. An X-ray/CT scan may rev*al pr+lapse
ure tr,iro symovial joints.
*f thi intervertebral disc between C6 and C7
. Diploe veins contain manufacturred RBCs, vertebrae compressitg the cervical 6 nerve root"
granulocytes and platelets. These drain into the Yhese rcr:t forrlr part nf lateral cutaneous nerve c{
neighbouring veins. f*rearm, and median nerves. Sinee rnedian fierve
(CS) supplies thenar rnusclqs. there is wasting/
. Paranasal sinuses give resonance to the voice,
weakness cf these muscles. As lateral tutane$us
besides humidifying and warming up the inspired
nerrre of forearrn is pressed, there is rn-rmbrtess on
lateral side of farearrtt and hand'


1.. Which of the following structure does not pass 3. Which is the thickest boundary of the orbit?
through foramen magnum? a. Lateral b. Medial
a. Accessory pharyngeal arterY c. Roof d. Floor
4. Which bone is not a "bone within the bone" 1n
b. Vertebral artery
petrous temporal bone?
c. Spinal accessory nerve a. Malleus b. Hyoid
d. Vertical band of cruciate ligament c. Incus d. Stapes
, Which of the following nerve does not pass through 5. Which of the ParasymPathetic ganglia does not
jugular foramen? have a secretomotor root?
a. Vagus b. Hypoglossal a. Submandibular b. Pterygopalatine
c. Glossopharyngeal d. AccessorY c. Otic d. CiliarY

L,a|-' 2:b 5.rd

Scalp, Temple and Face
An;aa. ,;o. {,/ee, anataru*at;aa.{tzfza;.6An"of lrca, aa.e*aha,i* a+;it ba *, $a{* ol ea*a*;on.

Plica Eyebrow
Face is the most prominent part of the body. Facial semilunaris Eyelashes
muscles, being the muscles of facial expression, express
Lacrimal caruncle Laterai angle
a variety of emotions like happiness, joy, sadness, anger,
of eye
frowning, grinning, etc. The face, therefore, is an index
Lacrimal papilla lris and pupil seen
of mind. One's innerself is expressed by the face itself with punctum through cornea
as it is controlled by the higher centres.
Fig.2.1: Some features to be seen on the face around the left
Use of cosmetics should be limited because of their
ill-effects and the tendency to cause allergic reactions.
Cosmetics try to enhance the external beauty only The eyeballs are lodged in bony sockets, called the
temporarily. The real beauty of good and helping orbits.
nature comes fromwithinwhich no cosmetic can match. The conj unctia a is a moist, transparent membrane.
The part which covers the anterior surface of the
eyeball is the bulbar conjunctiaa, and the part lining
1 The forehead is the part of the face between the the inner surfaces of the lids is the palpebral
hairline of adolescent's scalp and the eyebrows. The conjunctiaa. The line along which the bulbar
superolateral prominence of the forehead is known conjunctiva becomes the palpebral conjunctiva is
as the frontal eminence. known as the conjunctiaal fornix. The space between
2 Identify the following in relation to the nose: The the two is the conjunctizsal sac.
prominent ridge separating the right and left halves The oral fissure or mouth is the opening between the
of the nose is called the dorsum. The upper narrow upper and lower lips.It lies opposite the cutting edges
end of the nose just below the forehead, is the root of of the upper incisor teeth. The angle of the mouth
the nose. The lower end of the dorsum is in the form usually lies just in front of first upper premolar tooth.
of a somewhat rounded ttp. At the lower end of the Each lip has a red margin at mucocutaneous junction
nose, we see the rightandleftnostrils or anterior nares. and a dark margin, with a nonhairy thin skin inter-
The two nostrils are separated by a soft median vening between the two margins. The lips normally
partition called the columella. This is continuous with close the mouth along their red margins. Thephiltrum
th.e nasal septum which separates the two nasal is the median vertical groove on the upper lip.
cavities. Each nostril is bounded laterally by the ala. The external ear isrnade up of two parts: a superficial
3 The palpebral fissure is an elliptical opening between projecting part, called the auricle or pinna; and a deep
the two eyelids. The lids are joined to each other at canal, called the external acoustic meatus. The mobile
the medial and lateral angles or canthi of the eye. auricle helps in catching the sound waves, and is a
The free margin of each eyelid has eyelashes or cilia characteristic feature of mammals. Details of the
arranged along its outer edge (Fig.2.1). structure of the auricle will be considered later.
Through the palpebral fissure are seen: The supraorbital margin lies beneath the upper margin
a. The opaque sclera or white of the eye. of the eyebrow. The supraorbital notch is palpable
b. The transparent circular cornea through which at the junction of the medial one-third with the lateral
the coloured iris and the dark circular pupil can two-thirds of the supraorbital margin. A vertical line
be seen. drawn from the supraorbital notch to the base of the

mandible, passing midway between the lower two STRUCTURE

premolar teeth, crosses the infraorbital foramen Conventionally, the superficial temporal region is
5 mm below the infraorbital margin, and the mental studied with the scalp, and the following description,
foramen midway between the upper and lower therefore, will cover both the regions.
borders of the mandible.
The scalp is made up of five layers (mnemonic
7 The superciliary arch is a curved bony ridge situated
immediately above the medial part of each
a. Skin
supraorbital margin. the glabella is the median
elevation connecting the two superciliary arches, and b. Superficial fascia (Connective tissue)
corresponds to elevationbetween the two eyebrows. c. Deep fascia in the form of the epicranial
aponeurosis or galea aponeurotica with the
occipitofrontalis muscle
d. Loose areolar tissue
e. Pericranium (Figs 2.3a and b).
The skin is thick and hairy. It is adherent to the
Place 2-3 wooden blocks under the head to raise it
epicranial aponeurosis through the dense superficial
about 10-12 cm from the table. Give a median incision
fascia, as in the palms and soles.
in the skin of scalp extending from root of the nose (i),
The subcutaneous or superficial fascin is more fibrous
to the prominent external occipital protuberance
(ii) (Fig. 2.2).Give a coronal incision across the previous
and dense in the centre than at the periphery of the
incision from root of one auricle to the other (iii). Extend
the incision from the auricles to the mastoid process It binds the skin to the subjacent aponeurosis, and
posteriorly (iv), and to root of zygoma anteriorly (v), provides the proper medium for passage of vessels and
Reflect the skin in four flaps. Usually the skin is so nerves to the skin.
adherent to the subjacent connective tissue and The occipitofrontalis muscle has two bellies, occipital
aponeurotic layers that these all come off together. or occipitalis and frontal or frontalis, both of which are
Dissect the layers, including the nerves, vessels, inserted into the epicranial aponeurosis. The occipitnl
lymphatics and identify these structures in the cadaver. bellies are small and separate. Each arises from the
lateral two-thirds of the superior nuchal line, and is
supplied by the posterior auricular branch of the facial
The soft tissues covering the cranial vault form the scalp Thefrontalbellies are longer, wider and partly united
(Fig. 2.3). in the median plane. Each arises from the skin of the
forehead, mingling with the orbicularis oculi and the
EXTENT OI SCALP corrugator supercilli. It is supplied by the tempornl
Anteriorly, supraorbital margins; posteriorly, external branch of the facial nerve (seeFig.1.6).
occipital protuberance and superior nuchal lines; and The muscle raises the eyebrows and causes
on each side, the superior temporal lines. horizontal wrinkles in the skin of the forehead(Fig.z.\.
The epicranial aponeurosis, or galea aponeurotica is
freely movable on the pericranium along with the
overiying and adherent skin and fascia (Figs 2.3a and
2.9). Anteriorly, it receives the insertion of the frontalis,
posteriorly, it receives the insertion of the occipitalis
ind is attached to the external occipital protuberance,
and to the highest nuchal lines in between the occipital
.Y bellies. On each side, the aponeurosis is attached to the
o superior temporal line, but sends down a thin
z expansion which passes over the temporal fascia and
ttc is attached to the zygornatic arch (Fig. 2.3b).
E First three layers of scalp are called surgical layers of
o the scalp, These are called as scalp proper also.
The fourth layer of the scalp, is made up of loose
C areolar tissue. It extends anteriorly into the eyelids
o (Fig.2.a) because the frontalis muscle has no bony
ao Fig.2.2: Lines of dissection for scalp, face and eyelids attachment; posteriorly to the highest and superior

Skin with hair (S) Superflcial fascia
Extension of
Superficial fascia wiih epicranial .
Emissary blood vessels (C) aponeurosrs
Epicranial aponeurosis (A) Temporal fascia
Loose connective tissue (L)
Diploe in
between outer Pericranium (P)
and inner tables
of skull

Dura mater


Figs 2.3a and b: (a) Layers of the scalp, and (b) layers of superficial temporal region

L Skin
Epicranial 2 Superficial fascia
3 Thin extension of epicranial aponeurosis which gives
origin to extrinsic muscles of the auricle,
Frontal bone 4 Temporal fascia
Layer of loose areolar
5 Temporalis muscle (Fig.2.3b)
tissue or subaponeurotic 6 Pericranium.
tissue Tempus means time. Greying of hair first starts here.

Orbicularis oculi Arteriol Supply of Scolp ond

Superficiol Temporol Region
In front of the auricle, the scalp is supplied from before
backwards by the:
Conjunctiva . Supratrochlear;
Fig. 2.4: Schematic section through the scalp and upper eyelid c Supraorbital;
to show how fluids can pass from the subaponeurotic space or o Superficial temporal arteries (Fig. 2.5).
layer of loose areolar tissue of the scalp into the eyelid, and Into The first two are branches of the ophthalmic artery
the subconjunctival area. Note that this is possible because the which in turn is a branch of the internal carotid artery.
frontalis muscle has no bony attachment The superficial temporal is a branch of the external
carotid artery.
nuchal lines; and on each side to the superior temporal Behind the auricle, the scalp is supplied from before
lines. It gives passage to the emissary veins which backwards by the:
connect extracranial veins to intracranial venous sinuses o Posterior auricular;
(Fig. 2.3a). .Occipital arteries, both of which are branches of
The fifth layer of the scalp, called the pericranium, the external carotid artery. J(,
is loosely attached to the surface of the bones, but is Thus, the scalp has a richblood supply derived from
firmly adherent to their sutures where the sutural both the internal and the external carotid arteries, the zo
ligaments bind the pericranium to the endocranium two systems anastomosing over the temple.
Venous Droinoge o
The veins of the scalp accompany the arteries and have
It is the area between the superior temporal lineand similar names. The supratrochlear and supraorbitalveins o
the zygomatic arch. This area contains the following unite at the medial angle of the eye forming the angular o
6 layers: vein which continues down as the facial vein. U)

Supratrochlear nerve
Supratrochlear artery
Supraorbital nerve
Supraorbital artery

Zygomaticotemporal nerve

Temporal branch of facial (motor)

Auriculotemporal nerve
Superfi cial temporal artery

Great auricular nerve
Lesser occipital nerve
Posterior auricular artery
Posterior auricular nerve (motor)

Occipital artery
Greater occipital nerve
Third occipital nerve
Fig.2.5: Arterialand nerve supply of scalp and superficial temporal region

Thre superficial temporal aein descends in front of the subclaoian ztein. The occipital veins terminate in the
tragus, enters the parotid gland, and joins the maxillary suboccipital venous plexus (Fig. 2.6).
vein to form the retromandibular vein. This vein divides Emissnry veins connect the extracranial veins with
into two divisions. the intracranial venous sinuses to equalise the pressure.
The anterior division of the retromandibular vein Tlre parietal emissary zsein passes through the parietal
unites with the facial vein to form the common facial foramen to enter the superior sagittal sinus. Themastoid
vein which drains into the internal jugular vein. emissary oein passes through the mastoid foramen to
The posterior division of the retromandibular vein reach the sigmoid sinus. Remaining emissary veins are
unites with the posterior auricular oein to form the shown in Table 1.1. Extracranial infections may spread
external jugular aein wlitich ultimately drains into the through these veins to intracranial venous sinuses.

Superior and inferior

ophlhalmic veins Cavernous sinus

Superficial temporal


Angular vein
Retromandibular vein
Emissary vein
Anterior division

-Y Deep facial Posterior division

o Pterygoid plexus
z Posierior auricular
E External jugular
tr Common facial vein
o lnternal jugular

Subclavian vein
ao Fig. 2.6: The veins of the face and their deep connections with the cavernous sinus and the pterygoid plexus of veins

Diploic veins start from the cancellous bone within Wounds of the scalp bleed profusely because the
the two tables of skull. These carry the newly formed
vessels are prevented from retracting by the fibrous
blood cells into the general circulation. These are four fascia. Bleeding. can he arrested by applying
veins on each side (see Fi9.1,.17).
pressure above theears by a tight cottonbandage
The frontal diploic aein ernerges at the supraorbital
again*t the bone.
notch open into the supraorbital vein. Anterior temporal
Because of the density of fascia, subcutaneous
diploic ztein ends in anterior deep temporal vein o-r
haemorrhages are never extensive, and the
sphenoparietal sinus. Posterior temporal diploic oein ends
inflammations in this layer causelittle sw'ellingbut
in the transverse sinus. The occipital diploic aein opens
much pain.
either into the occipital vein, or into the transverse sinus
Because the pericranium is adherent to sutures,
near the median plane (see Table 1.2).
collections of fluid deep to the pericranium known
Lymphotic Droinoge as cephalhaematoma take the ;hape oJ the bone
The anterior part of the scalp drains into the concerned.
preauricular or parotid ll ph nodes, situated on the The layer of loose areolar tissue is known as the
surface of the parotid gland. The posterior part of the dangerous areaaf thr scalpbecause the emissaryveins,
scalp drains into the posterior auricular or mastoid and which course here maytransmit infection from the
occipital lymph nodes. scalp to the oanial venous sirurses (Fig. 2.3a).
Coliection of blood in the layer of loose connective
Nerve Supply tissue causes generalised swellingof the scalp. The
The scalp and temple are supplied by ten nerves on blood may extend anteriorly into the rcot of the
each side. Out of these five nerves (four sensory and nose and into the eyelids, as frontalis muscle has
one motor) enter the scalp in front of the auricle. The no bony origin causing black eye (Fig.2:8). The
remaining five nerves (again four sensory and one posterior limit of such haemorrhage is not seen. If
motor) enter the scalp behind the auricle (Fi9.2.5 and bleeding is due to local injury, the posterior limit
Table 2.1). of haemorrhage is seen.
Because of ttre spread of blood, compression of
Table2.1: Nerves of the scalp and superficial temporal
brain is not seen and so thi$ layer is also called
region safety layer.
ln front of auricle
Since the blood supply of sealp and superficial
Behind the auricle
temporal region is very rich; avulsed portions
Sensory nerues Sensory nerues
need not be cut away, They can be replaced in
. Supratrochlear, branch of . Posterior division of great position and stitched: they usually take up and heal
the frontal (ophthalmic auricular nerve (C2, C3) well.
division of trigeminal nerve) from cervical plexus
. Supraorbital, branch of . Lesser occipital nerve
frontal (ophthalmic division (C2), from cervical plexus
of trigeminal nerve)
. Zygomaticotemporal, . Greater occipital nerve
branch of zygomatic nerve (C2, dorsal ramus)
(maxillary division of
trigeminal nerve)
. Auriculotemporal branch of . Third occipital nerve
mandibular division of (C3, dorsal ramus)
trigeminal nerve
Motor nerue Motor nerue
. Temporal branch of facial . Posteriorauricularbranch !
nerve of facial nerve o
r Wounds of the scalp do not gape unless the o
epicranial aponeurosis is divided transversely.
I Because of the abundance of sebaceous glands, the C
scalp is a common site for sebaceous cysts (Fig. 2.7). o

5 Facial skin is very elastic and thick because the facial

muscles are inserted into it. The wounds of the face,
therefore, tend to gape.

It contains: (i) The facial muscles, all of which are
inserted into the skin, (ii) the vessels and nerves, to the
muscles and to the skin, and (iii) a variable amount of
Fig. 2.8: Right eye-black eye due to injury to the scalp; left
fat. Fat is absent from the eyelids, but is well developed
eye-black eye due to local injury
in the cheeks, forming the buccal pads that are very
prominent in infants in whom they help in sucking.
The deep fascia is absent from the face, except over the
parotid gland where it forms the parotid fascia, and
over the buccinator where it forms tlire buccopharyngeal
Give a median incision from the root of nose, across
the dorsum of nose, centre of philtrum of upper lip, to FACIAL MUSCLES
centre of lower lip to the chin (vi). Give a horizontal The facial muscles, or the muscles of facial expression,
incision from the angle of the mouth to posterior border are subcutaneous muscles. They bring about different
of the mandible (vii). Reflect the lowerflap towards and facial expressions. These have small motor units.
up to the lower border of mandible (Fig. 2.2; line with Embryologically,they develop from the mesoderm of
dots). Direct and reflect the upper flap till the auricle. the second branchial arch, and are, therefore, supplied
Subjacent to the skin, the facial muscles are directly by the facial nerve.
encountered as these are inserted in the skin. ldentify Morphologically, they represent the best remnants of
the various functional groups of facial muscles. the panniculus carnosus, a continuous subcutaneous
Trace the various motor branches of facial nerve muscle sheet seen in some animals. All of them are
emerging from the anterior border of parotid gland to inserted into the skin.
supply these muscles. Amongst these motor branches Topographically, the muscles are grouped under the
on the face are the sensory branches of the three following six heads.
divisions of the trigeminal nerve. Try to identify allthese Functionally, most of these muscles may be regarded
with the help of their course given in the text (Fig. 2.18). primarily as regulators of the three openings situated
on the face, namely the palpebral fissures, the nostrils
Feotures and the oral fissure. Each opening has a single sphincter,
The face, or countenance, extends superiorly from the and a variable number of dilators. Sphincters are
adolescent position of hairline, inferiorly to the chin naturally circular and the dilators radial in their
and the base of the mandible, and on each side to the arrangement. These muscles are better developed around
auricle. The forehead is, therefore, common to both the the eyes and mouth than around the nose (Table2.2).
face and the scalp.
; ' Tart€2,2i-Funciionat groups of facial mu*cles.r,
SKIN Opening Sphincter Dilators
1 The facial skin is aery oascular. Rich vascularity makes A. Palpebral Orbicularis 1. Levator palpebrae
the face blush and blanch. Wounds of the face bleed fissure oculi superioris
profusely but heal rapidly. The results of plastic 2. Frontalis part of
surgery on the face are excellent for the same reason. occipitof rontalis
o 2 The facial skin is rich in sebaceous and sweat glands. B. Oral fissure Orbicularis All the muscles around the
z Sebaceous glands keep the face oily, but also cause oris mouth, except the orbicularis
acne inyoung adults. Sweat glands help in regulation oris the sphincter, and the
(E of the body temperature. mentalis which does not
mingle with orbicularis oris
E(E 3 Laxity of the greater part of the skin facilitates rapid (see above)
o spread of oedema. Renal oedema appears first in the
C. Nostrils Compressor 1. Dilator naris
eyelids and face before spreading to other parts of
C the body.
naris 2. DePressor sePti
o 3. Medial slip of levator labii
() 4 Boils in the nose and ear are acutely painful due to superioris alaeque nasi
ao tlrre fixity of the skin to the underlying cartilages.

Muscle of the Scolp 3 Dilator naris

Occipitofrontalis described in scalp 4 Depressor septi

Muscles of the Auricle

Muscles oround the Mouth
Situated around the ear
1 Orbicularis oris (Fig.2.9)
1 Auricularis anterior
2 Buccinator (Latin cheek) (Fig.2.l})
2 Auricularis superior
3 Auricularis posterior 3 Levator labii superioris alaeque nasi (Fig. 2.10)
These are vestigeal muscles 4 Zygomaticus major (Fi9.2.9)
5 Levator labii superioris
Muscles of the Eyelids/Orbitol Openings 6 Levator anguli oris
1 Orbicularis oculi (Fig.2.9 and Table 2.3) 7 Zygornaticus minor
2 Corrugator (Latin to wrinkle) supercilii (Fig. 2.9 and 8 Depressor anguli oris (Fig. 2.10)
Table 2.3) 9 Depressor labii inferioris
3 Levator palpebrae superioris (an extraocular muscle, 10 Mentalis (Latin chin)
supplied by sympathetic fibres and the third cranial 1"1" Risorius (Latin laughter)
nerve) is described in Chapter 13.

Muscles of the Nose Muscles of lhe Neck

L Procerus (Fi9.2.9) Platysma (Greek broad)
2 Compressor naris. Details of the other muscles are given in Table 2.3.

Galea aponeurotica

Frontal belly of occipitofrontalis


Procerus Corrugator supercilli

Orbicularis oculi
Levator labii superioris
alaeque nasi


Levator labii superioris Levator labii superioris

Zygomaticus minor Zygomaticus minor
Zygomaticus major Zygomaticus major
Levator anguli oris
Levator anguli oris
Parotid duct
Risorius Buccinator
Platysma Masseter o
Orbicularis oris zo
Depressor anguli oris
Depressor anguli oris
Depressor labii inferioris Depressor labii inferioris

Mentalis o
Fig. 2.9: The facial muscles a

Origii lnsertion Actions

Muscles of eyelid/orbital opening

1. Corrugator supercilii Medial end of superciliary arch Skin of mid-eyebrow Vertical lines in forehead,
(Fig.2.e) as in frowning
2. Orbicularis oculi (Fig.2.9) Medial part of medial palpe- Concentric rings return to Protects eye from bright light,
a. Orbital part, on and bral ligament, frontal process the point of origin wind and rain. Cause forceful
around the orbital of maxilla and nasal part of closure of eyelids
margin frontal bone
b. Palpebral part, in the lids Lateral part of medial Lateral palpebral raphe Closes lids gently as in
palpebral ligament blinking and sleeping
c. Lacrimal part, lateral and Lacrimal fascia and posterior Pass laterally in front of Dilates lacrimal sac for
deep to the lacrimal sac lacrimal crest, forms tarsal plates of eyelids sucking of lacrimal fluid into
sheath for lacrimal sac to the lateral palpebral the sac, directs lacrimal
raphe puncta into lacus lacrimalis;
supports the lower lid

Muscles around nasal opening

3. Procerus Nasal bone and upper part Skin of forehead Causes transverse wrinkles
of lateral nasal cartilage between eyebrows and on
bridge of the nose
4. Compressor Maxilla just lateral to nose Aponeurosis across Nasal aperture compressed
naris dorsum of nose
5. Dilator naris Maxilla over the lateral incisor Alar cartilage of nose Nasal apefture dilated
6. Depressor Maxilla over the medial incisor Lower mobile part of Nose pulled inferiorly
septi nasal septum
Mucles around the lips
7. Orbicularis oris Superior incisivus, from Angle of mouth Closes lips and protrudes lips,
a. lntrinsic part, deep maxilla; inferior incisivus, numerous extrinsic muscles
stratum, very thin sheet from mandible make it most versatile for
various types of grimaces
b. Extrinsic part, two Thickest middle stratum, Lips and the angle of the
strata, formed by derived from buccinator; thick mouth
converging muscles superficial stratum, derived
(Fis. 2.e) from elevators and depressors
of lips and their angles
8. Buccinator, the muscle of 1. Upper fibres, from maxilla 1. Upper fibres, straight to Flattens cheek against gums
the cheek (Fig. 2.10) opposite molar teeth the upper lip and teeth; prevents accumu-
lation of food in the vestibule.
Pierced by This is lhe whistling muscle
- Parotid duct and 2. Lower fibres, from 2. Lower fibres, straight to
- Buccal branch of mandible, opposite molar the lower lip
mandibular nerve. teeth
3. Middle fibres, from pterygo- 3. Middle fibres decussate
mandibular raphe

9. Levator labii Frontal process of maxilla Upper lip and alar Lifts upper lip and dilates
o superioris cartilage of nose the nostril
z alaeque nasi
E Posterior aspect of lateral Skin at the angle of the Pulls the angle upwards and
c(E 10. Zygomaticus
major surface of zygomatic bone mouth laterally as in smiling
o 11. Levator labii lnfraorbital margin Skin of upper lateral Elevates the upper liP,
I of maxilla half of the upper lip forms nasolabial groove
12. Levator anguli Maxilla just below Skin of angle of the Elevates angle of mouth,
.o infraorbital foremen mouth forms nasolabial groove
() oris
ao (Contd-..)

Talle 2.3: The tacial muscJes {corrd...) .,.,.tt,-,:,t1,:,;..t...,.,'

Name Origin lnsertion Actions
13. Zygomaticus Anterior aspect of lateral Upper lip medialto Elevates the upper lip
minor surface of zygomatic bone its angle
14. Depressor Oblique line of mandible Skin at the angle of mouth Draws angle of mouth
anguli oris below first molar, premolar and fuses with orbicularis downwards and laterally
and canine teeth oris
15. Depressor Anterior part of oblique line Lower lip at midline, fuses Draws lower lip
labii inferioris of mandible with muscles from opposite downward
16. Mentalis Mandible inferior to incisor Skin of chin Elevates and protrudes
teeth lower lip as it wrinkles skin
on chin
17. Risorius Fascia on the masseter Skin at the angle Retracts angle of mouth
muscle of the mouth

Muscles of the neck

18. Platysma Upper parts of pectoral and Anterior fibres, to the base Releases pressure of skin on
(Fis. 2.e) deltoid fasciae of the mandible; posterior the subjacent veins; depres-
Fibres run upwards and fibres to the skin of the ses mandible; pulls the angle
medially lower face and lip, and of the mouth downwards as
may be continuous with in horror or fright
the risorius

Modiolus: lt is a compact, mobile fibromuscular structure present at about 1.25 cm lateral to the angle of the mouth opposite the
upper second premolar tooth. The five muscles interlacing to form the modiolus are: zygomaticus major, buccinator, levator anguli
oris, risorius and depressor anguli oris.

Levator labii
4 Anger: Dilator naris and depressor septi.
superioris 5 Frornning: Corrugator supercilii and procerus.
alaeque nasi (Figs 2.13 and 2.1.4)
Levator labii 6 Horror, terror and fright: P1'atysma (Fig. 2.15)
superioris 7 Surprise: Frontalis (Fig. 2.16)
I Doubt: Mentalis
Levator anguli 9 Grinning: Risorius
oris 10 Contempt: Zygomaticus minor.
1'1. Closing the mouth: Orbicularis oris
Buccinator with
modiolus 12 Wistling: Buccinator, and orbicularis orts (Fig.2.17).

Depressor labii Molor Nerve Supply

The facial nerae is the motor nerve of the face. Its five
anguli oris
terminal branches, temporal, zygornatic, buccal, -Y
marginal mandibular and cervical emerge from the o
Fig. 2.10: Some of the facial muscles parotid gland and diverge to supply the various facial zo
muscles as follows.
A few of the commonfacinl expressions and the muscles Temporal-frontalis, auricular muscles, orbicularis E'
producing them are given below: oculi. o
1 Smiling atdlauglting: Zygomattctts major (Fig. 2.11) Zy gomatic-orbicularis oculi.
2 Sadness: Levator labii superioris and levator Buccal-muscles of the cheek and upper lip (Fig' 2.18)' c
anguli oris (Fig. 2.12). Marginal mandibular-muscles of lower lip. ()
3 Grief: Depressor anguli oris. Cervical-platysma. ao

Fig. 2.11: Zygomaticus major smile Fig.2.12: Levator labii superioris sadness
- -

Fig. 2.13: Corrugator supercilii frowning Fig.2.14t Procerus dislike

- -


@ Fig. 2.15: Platysma fright Fig. 2.16: Frontalis surprise
- -






Fig.2.'|7: Buccinator and orbicularis oris whistling Fig. 2.18: Terminal branches of the facial nerve
This can be understood by putting your right wrist
on the right ear and spreading five digits; the thumb The affected side is motionless. Wrinkles
over the temporal region, the index finger on the disappear from the forehead. The eye cannot be
zygomatic bone, middle finger on the upper lip, the closed. Any attempt to smile draws the mouth to
ring finger on the lower lip and the little finger over the normal side. During mastication, food
the neck (Fig. 2.18). accumulates between the teeth and the cheek.
Articulation of labials is impaired.
r In supranuclear lesions of the facial nerve; usually
. The facial nerve is examined by testing the a part of hemiplegia, with inj.ury of corticonuclear
following facial muscles (Fig. 2.19). fibres only the lower part of the opposite side of face
a. Frontalis; Ask the patient to look upwards is paralysed. The upper part with the frontalis and
without moving his head, and look for the orbicularis oculi escapes due to its bilateral reprc-
normal horizontal wrinkles on the forehead sentatironinthecerebral cortex (Fig. 2.21.). On1ywhile
(Fig.2.19a). voluntary movements are affected emotional
b. Dilatar s af mnuth: Showing the teeth (Fig. 2. 19b). expressions remain normal as there are separate
c. Orbicularis ocuti: Tight closure of the eyes pathways for voluntary and emotional movements.
d. Buccinatsn Puffing the mouth and then blowing Sensory Nerve Supply
forcibly as in whistling (Fig.2.19d). The trigeminal nerae through its three branches is the
r Infranuclear lesion (Fig,z,zq of the facial nerve, chief sensory nerve of the face (Fig. 2.22 and Table 2.4).
at the styiomastoid. foramen is known as Bell's The skin over the angle of the jaw and over the parotid
palsy, upper and lower halves of the face on the gland is supplied by the great auricular nerve (C2, C3).
same side get paralysed. The face becomes In addition to most of the skin of the face, the sensory
asymmetrical and is drawn up to the normal side. distribution of the trigeminal nerve is also to the nasal


(b) (c) (d) o
frontalis, (b) test for dilators of mouth, (c) test for orbicularis oculi, and (d) test for buccinator o

mater, including that lining the anterior and middle
q ry
Factat nerve ar
stylomastoid foramen cranial fossae (Fig. 2.22).

The sensory distribution of the trigeminal nerve

explaim why headache is a uniformly common
symptom in involvements of the nose (common
.ota, Uoitr), the paranasal ak sinuses (sinusitis),
{#@% infections and inflammations of teeth and gums,
refractive errors of the eyes, and infection of the
meninges as in meningitis.
Trigeriinal neuralgia ilay involve one or more of
the three divisions of lhe trigeminal newe. lt
causes attacks of very severe burning and scalding
Paralysis pain along the distribution of the affected nerve.
of upper and Pain is relieved either: (a) By injecttnggl% alcohol
lower halves of
facial muscles into the affected division of the trigeminal
ganglion, or (b) by sectioning the affected nerve,
the main sensory root, or the spinal tract of the
Fig.2.2A: lnfranuclear lesion of right facial nerve or Bell's palsy trigeminal nerve which is situated superficially in
the medulla. The procedure is cailed medullary
Cerebral cortex

Paralysis of only lower

J half of facial muscels
zo on the contralateral
E' Fig.2.21: Supranuclear lesion of right facial nerve
6 Fig. 2.22l. The sensory nerves of the face. 1. Supratrochlear,
2. supraorbital, 3. palpebral branch of lacrimal, 4. infratrochlear,
5. external nasal, 6. infraorbital, T. zygomaticofacial,
o cavity, the paranasal air sinuses, the eyeball, the mouth 8. zygomaticotemporal, 9. auriculotemporal, 10. buccal,
o cavity, palate, cheeks, gums, teeth and anterior two- 11. mental, 12. great auricular, 13. transverse cutaneous nerve
ac) thirds of tongue and the supratentorial part of the dura of neck, 14. lesser occipital, and 15. supraclavicular

T*ble'2'4r,, Cutan.eous nerveg of ' the faee

Source Cutaneous nerve Area of distribution
a. Ophthalmic division of Supratrochlear nerve Upper eyelid and forehead
trigeminal nerve Supraorbital nerve Upper eyelid, frontal air sinus, scalp
Lacrimal nerve Lateral part of upper eyelid
lnfratrochlear Medial parts of both eyelids
External nasal Lower part of dorsum and tip of nose
b. Maxillary division of lnfraorbital nerve Lower eyelid, side of nose and upper lip
trigeminal nerve Zygomaticofacial nerve Upper part of cheek.
Zygomaticotemporal nerve Anterior part of temporal region
c. Mandibular division oi Auriculotemporal nerve Upper two-thirds of lateral side of
trigeminal nerve Buccal nerve auricle, temporal region
Mental nerve Skin of lower part of cheek
Skin over chin
d. Cervical plexus 1. Anterior dlvision of great auricular nerve 1. Skin over angle of the jaw and over
(c2, c3) the parotid gland
2. Upper division of transverse (anterior) 2. Lower margin of the lower jaw
cutaneous nerve of neck (C2, C3)

L It enters the face by winding around the base of the
DIS$ECTION mandible, and by piercing the deep cervical fascia,
at the anteroinferior angle of the masseter muscle. It
Tortuous facial artery enters the face at the lower border
can be palpated here and is called 'anaesthetist's
of mandible. Dissect its course from the anteroinferior
angle of masseter muscle running to the angle of mouth
till the medial angle of eye, reflecting off some of the
2 First it runs upwards and forwards to a point 1.25 cm
lateral to the angle of the mouth. Then it ascends by
facial muscles if necessary.
the side of the nose up to the medial angle of the
Straight facial vein runs on a posterior plane than
eye, where it terminates by supplying the lacrimal
the artery.
sac; and by anastomosing with the dorsal nasal
ldentify buccopharyngeal fascia on the external branch of the ophthalmic artery.
sudace of buccinator muscle. Clean the deeply placed 3 The facial artery is very tortuous. The tortuosity of
buccinator muscle situated lateralto the angle of mouth. the artery prevents its walls from being unduly
ldentify parotid duct, running across the cheek 2 cm stretched duringmovements of the mandible, the lips
below the zygomatic arch. The duct pierces buccal pad and the cheeks.
of fat, buccopharyngeal fascia, buccinator muscle, 4 It lies between the superficial and deep muscles of
mucous membrane of lhe mouth to open into its the face.
vestibule opposite second upper molartooth (Fig. 2.26). The course of the artery in the neck is described in
submandibular region.
The face is richly vascular. It is supplied by: 8r#ncftes
1 The facial artery, The anterior branches on the face are large and named.
2 The transverse facial artery, and They are:
3 Arteries that accompany the cutaneous nerves. I lnferior labial, to the lower lip.
These are small branches of ophthalmic, maxillary 2 Superiorlabial,to the upper lip and the anteroinferior l(
and superficial temporal arteries. part of the nasal septum.
3 Lateral nasal, to the ala and dorsum of the nose.
Fociol Artery (Fociol Port)
The posterior branches are small and unnamed. (E

The facial artery is the chief artery of the face (Fig. 2.23). t,(E
It is a branch of the external carotid artery given off in An$sfomoses o
the carotid triangle just above the level of the tip of the 1 The large anterior branches anastomose with similar
greater cornua of the hyoid bone. In its cervical course, branches of the opposite side and with the mental C
it passes through the submandibular regiory and finally artery. In the lips, anastomoses arelarge, so that cut o
enters the face. arteries spurt from both ends. ao

Supraorbital artery
Supratrochlear artery
Superfi cial temporal artery Dorsal nasal artery

Angular artery

Transverse facial
Lateral nasal
Maxillary artery

lnferior alveolar artery I

I Labial arteries
lnferior I

Mental artery

Fig. 2.23: Arteries of the face

2 Small posterior branches anastomose with the deep fascia, crosses the submandibular gland, and
transverse facial and infraorbital arteries. joins the anterior division of the retromandibular
3 At the medial angle of the eye, terminal branches of vein below the angle of the mandible to form the
the facial artery anastomose with branches of the common facial vein. The latter drains into the
ophthalmic artery. This is, therefore, a site for internal jugular vein. It is represented by a line
anastomoses between the branches of the external drawn just behind the facial artery. The other veins
and internal carotid arteries. drain into neighbouring veins.
4 Deep connections of the facial vein include:
Tronsverse Fociol Adery a. A communication between the supraorbital and
This small artery is a branch of the superficial temporal superior ophthalmic veins.
artery. After emerging from the parotid gland, it runs b. Another connection with the pterygoid plexus
forwards over the masseter between the parotid duct through the deepfacial vein which passes
and the zygomatic arch, accompanied by the upper backwards over the buccinator. The connection
buccal branch of the facial nerve. It supplies the parotid between facialvein and cavernous sinus is shown
gland and its duct, masseter and the overlying skin, in Flow chart 2.1.
and ends by anastomosing with neighbouring arteries
(Fi9.2.23). Dongerous Areo of Foce
The facial vein communicates with the cavernous sinus
Veins of the Foce
through emissary veins. Infections from the face can
1 The veins of the face accompany the arteries and
drain into the common facial and retromandibular Flow chart 2.1 : Connection between facial vein and cavernous
veins. They communicate with the cavernous sinus. sinus
2 The veins on each side form a 'W-shaped' arrangement.
.Y Each corner of the'W' is prolonged upwards into
zo 3 the scalp and downwards into the neck (Fig. 2.6).
The facial oein isthe largest vein of the face with no
(E valves. It begins as the angular vein at the medial
t,G angle of the eye. It is formed by the union of the
o supratrochlear and supraorbital veins. The angular
vein continues as the facial vein, running
downwards and backwards behind the facial artery,
C) but with a straighter course. It crosses the
ao anteroinferior angle of the masseter, pierces the Cavernous sinus I

Fig. 2.24; Dangerous area of the face (stippled). Spread of Fig.2.25: The lymphatic territories of the face. Area (A) drains
infection from this area can cause thrombosis of the cavernous into the preauricular nodes, area (B) drains into the submandibular
sinus nodes, and area (C) drains into the submental nodes

spread in a retrograde direction and cause thrombosis *s&r*f, ##*rmf mrc# fuI+$*s rLS#*##$ #f#fi #s
of the cavernous sinus. This is specially likely to occur The labial and buccal mucous glands are numerous.
in the presence of infection in the upper lip and in the They lie in the submucosa of the lips and cheeks.
lower part of the nose. This area is, therefore, called The molar mucous glands, four or five, lie on the
the dangerous area of the face (Fig.2.2a). buccopharyngeal fascia around the parotid duct. All
these glands open into the vestibule of the mouth
The facial veins and its deep connecting veins are
devoid of valves, making an uninterrupted passage
of blood to cavernous sfuus. Squeezing the pustules
or pimples in the area of the upper lip or side of nose
or even the cheeks may cause infection which may
be carried to the cavernous sinus leading to its Give a circular incision around the roots of eyelids
thrombosis. So the cheek area may also be included (Fig.2.2_.viii and ix). This will separate the orbital part
as the dangerous area (Fig. 2.24). of orbicularis oculi from the palpebral parts. Carefully
reflect the palpebral part towards the palpebral fissure.
ldentify the structures present beneath the muscle as
Lymphotic Droinoge of the Foce given in the text.
The face has three lymphatic territories: The upper and lower eyelids are movable curtains
'1. Upper territory, including the greater part of the which protect the eyes from foreign bodies and bright
forehead, lateral halves of eyelids, conjunctiva, lateral light. They keep the cornea clean and moist. The upper
part of the cheek and parotid area, drains into the eyelid is larger and more movable than the lower eyelid
(Figs 2.27a and b). o
preauricular parotid nodes.
2 Middle territory, including a strip over the median zo
part of the forehead, external nose, upper lip, lateral (E
part of the lower lip, medial halves of the eyelids, The space between the two eyelids is the palpebral E
medial part of the cheek, and the greater part of lower fissure. The two lids are fused with each other to form o
jaw, drains into the submandibular nodes. the medial and lateral angles or canthi of the eye. At
3 Lower territory, including the central part of the lower the inner canthus, there is a small triangular space, the o
lip and the chin, drains into the submental nodes lacus lacrimalis. Withtn it, there is an elevated lacrimal ()
(Fig.2.2s). caruncle, made up of modified skin and skin glands. ao

3 The palpebral fascia of tlrre two lids forms the orbital
septum.Its thickenings form tarsal plates or tarsi in
Buccal glands
the lids andthepalpebralligamenfs at the angles. Tarsi
Buccinator are thin plates of condensed fibrous tissue located
Buccopharyngeal fascia near the lid margins. Th"y give stiffness to the lids
Molar mucous gland
Parotid duct The upper tarsus receives two tendinous slips from
Cheek the leaator palpebrne superioris, or one from voluntary
part and another from involuntary part (Fi9.2.27b).
Buccal lymph node
Tarsal glands or meibomian glands are embedded in
Buccal pad offat
the posterior surface of the tarsi; their ducts open in
Second molar teeth
a row behind the cilia.
Fi1.2.26: Scheme of coronal section showing structures in the
4 The conjunctizta lines the posterior surface of the
cheek. The parotid duct pierces buccal pad offat, buccopharyngeal
fascia, buccinator muscle and the mucous membrane to open
Apart from the usual glands of the skin, and mucous
into the vestibule of mouth opposite the crown of the upper second
glands in the conjunctiva, the larger glands found in
molar tooth
the lids are:
a. Large sebaceous glands also called as Zeis's glands
Lateral to the caruncle, the bulbar conjunctiva is at the lid margin associated with cilia.
pinched up to form a vertical fold called the plica b. Modified sweat glands or Moll's glands at the lid
semilunaris (Fig. 2.1). margin closely associated with Zeis's glands and
Each eyelid is attached to the margins of the orbital cilia.
opening. Its free edge is broad and has a rounded outer c. Sebaceous or tarsal glands, these are also known
lip anda sharp inner lip. The outer lip presents two or as meibomian glands.
more rows of eyelashes or cilia, except in the boundary
of the lacus lacrimalis. At the point where eyelashes
cease, there is alacrimal papilla on the summit of which
The Muller's muscle or involuntary partof levator
there is thre lauimal punctum (Fig.2.1). Near the inner
palpebrae superioris is supplied by sympathetic
lip of the free edge, there is a row of openings of the
tarsal glands. fibres from the superior cervical ganglion.
Paralysis of this rnuscle leads to partial ptosis. This
ia part of ttre Horner's syndrome.
The palpebral conjunctiva is examined for
Each lid is made up of the following layers from without
anaemia and for coniunctivitis; the bulbar
coniunctiva for jaundice.
L The skin is thin, loose and easily distensible by Conjunctivitis is one of the commonest diseases
oedema fluid or blood. of the eye. It may be caused by infection or by
2 The superficial fascia is without any fat. It contains allergy.
the palpebral part of the orbicularis oculi.

Superior Orbicularis oculi

iarsus (orbikl part)
septum Levator palpebrae
0rbital septum superioris, voluntary part
Lacrimal sac
:o Lateral Orbicularis oculi and involuntary part
zo Medial
palpebral raphe
(palpebral part)
Superior conjunctival fornix
E ligament Superior tarsus Conjunctiva
E' lnferior Part of
tarsus Ciliary glands conjunctival sac
o lnfraorbital
vessels and Tarsal gland
nerve Cornea
F() (a) (b)
@ Flgs.2.27a and b: (a) Orbital septum, and (b) sagittal section of the upper eyelid


The eyelids are supplied by: The structures concerned with secretion and drainage of
I The superior and inferior palpebral branches of the the lacrimal or tear fluid constitute the lacrimal
ophthalmic artery apparatus. It is made up of the following parts:
2 The lateral palpebral branch of the lacrimal artery. 1 Lacrimal gland and its ducts (Figs 2.28a andb).
They form an arcade in each lid. 2 Conjunctival sac.
The veins drain into the ophthalmic and facial veins. 3 Lacrimal puncta and lacrimal canaliculi.
4 Lacrimal sac.
Nerve Supply 5 Nasolacrimal duct.
The upper eyelid is supplied by the lacrimal,
supraorbital, supratrochlear and infratrochlear nerves Locrimql Glond
from lateral to medial side.
It is a serous gland situated chiefly in the lacrimal fossa
The lower eyelid is supplied by the infraorbital and
on the anterolateral part of the roof of the bony orbit
infratrochlear nerves (Fig. 2.22).
and partly on the upper eyelid. Small accessory lacrimal
glands are found in the conjunctival fornices.
Lymphotic Droinoge
The gland is'J'shaped, being indented by the tendon
The medial halves of the lids drain into the of the leaator pnlpebrae superioris muscle. It has:
submandibular nodes, and the lateral halves into
a. An orbital part which is larger and deeper, and
the preauricular nodes (Fig. 2.25).
b. A palpebral part smaller and superficial, lying
within the eyelid (Figs2.28a and b).
About a dozen of its ducts pierce the conjunctiva of
Foreign bodies are ofte* lodged in a groove the upper lid and open into the conjunctival sac near
situated 2 mm from the edge of each eyelid. the superior fornix. Most of the ducts of the orbital part
Chalazion is inflammation o{ a tarsal gland, pass through the palpebral part. Removal of the latter
causing a localized swelling pointing inwards. is functionally equivalent to removal of the entire gland.
Ectropion is due to eversion of the lower lacrimal After removal, the conjunctiva and cornea are
punctum. It usually occurs in old age due to laxity moistened by accessory lacrimal glands.
of skin. The gland is supplied by the lacrimal branch of the
Trachoma is a contagious granular conjunctivitis ophthalmic artery and by the lacrimal neroe.The nerve
caused by the trachoma virus. It is regarded as has both sensory and secretomotor fibres. Flow chart 2.2
the commonest cause of blindness. shows the secretomotor fibres for lacrimal gland.
Stye orhordeolum is a suppurative inflammation The lacrimal fluid secreted by the lacrimal gland
of one of the glands of Zeis. The gland is swollen, flows into the conjunctival sac where it lubricates the
hard and pai:rful, and the whole of the lid is front of the eye and the deep surface of the lids. Periodic
oedematous. The pus points near the base of one blinking helps to spread the fluid over the eye. Most of
of the cilia. the fluid evaporates. The rest is drained by the lacrimal
canaliculi. When excessive, it overflows as tears.
Blepharitis is inflammation of the eyelids, specially
of the lid margin.
Conjunctivol Soc
The conjunctiva lining the deep surfaces of the eyelids
is called palpebral conjunctiva and that lining the front
of the eyeball is bulbar conjunctiva. The potential space
, DISSECTION between the palpebral and bulbar parts is the .Y
conjunctizsal sac. The lines along which the palpebral
On the lateral side of the upper lid cut the palpebral
conjunctiva of the upper and lower eyelids is reflected zo
fascia. This will show the presence of the lacrimal gland T'
deep in this area. lts palpebral part is to be traced in on to the eyeball are called the superior and inferior tr

the upper eyelid. On the medial ends of both the eyelids c onj un ct io al fornic es. t,(E
look for lacrimal papilla. Palpate and dissect the medial The palpebral conjunctiaa is thick, opaque, highly o
palpebral ligament binding the medial ends of the vascular, and adherent to the tarsal plate. The bulbar
eyelids. Try to locate the small lacrimalsac behind this conjunctiua covers the sclera. It is thin, transparent, and c
ligament. loosely attached to the eyeball. Over the cornea, it is ()
represented by the anterior epithelium of the cornea. ao

Superior lacrimal Lacrimal

papilla and punctum
Lacrimal sac
Levator palpebrae superioris
Lacrimal canaliculi Orbital part

Nasolacrimal duci
Palpebral part
Lacrimal ducts
Inferior lacrimal papilla
and punctum

Lacrimal caruncle

Figs 2.28a and b: Lacrimal apparatus: (a) Components, and (b) two parts of the lacrimal gland

Flow chart 2.2: Secretomotor fibres for lacrimal gland Locrimql Puncto ond Conoliculi
Lacrimatory nucleus I Each lacrimal canaliculus begins atthelacrimal punctum,

Nervus intermedius I

and is 10 mm long. It has a vertical part which is 2 mm
long and a horizontal part which is, 8 mm long. There
is a dilated ampulla at the bend. Both canaliculi oPen
close to each other in the lateral wall of the lacrimal sac
Facial I behind the medial palpebral ligament.

It is membranous sac \2 mm long and 5 mm wide,
Greater petrosal nerve + deep petrosal nerve
situated in the lacrimal groove behind the medial
palpebral ligament. Its upper end is blind. The lower
end is continuous with the nasolacrimal duct.
The sac is related anteriorly to the medial palpebral
ligament and to the orbicularis oculi. Medially, the
lacrimal groove separates it from the nose. Laterally,lt
is related to the lacrimal fascia and the lacrimal part of
the orbicularis oculi.
)etrosal I Relays
nerve +
Nosolocrimol Duct
Postganglionic fibres
It is a membranous passage 18 mm long. It begins at
Pass along the lower end of the lacrimal sac, runs downwards,
Maxilldry nerve
backwards and laterally, and oPens into the inferior
meatus of the nose. A fold of mucous membrane called
Pass along the aalae of Hasner forms an imperfect valve at the lower
--o end of the duct.
(E Inflammation of the lacrimal sac is called dacra'
t,G' cystitis.
o The duets of lacrimal gland open through its
palpebral pert into the conjunctival sac, Because
.o of this arrangement, the rernoval of palpehral part
o neeessitates the removal of the orbital part as well.
Lacrimal gland

Excessive secretion of lacrimal fluid, i.e. tears is comes closer to the spinal nucleus of V nerve at the
mostly due to emotional reasons. The tears not level of lower pons. This is called "neurobiotaxis".
only flow on the cheeks but aiso flow out through . Facial nerve though courses through the parotid
nasolacrimal duct and the nasal cavity, due to gland, does not give any branch to the largest
stimulation of pterygopalatine ganglion.' salivary gland.
Excessive secretion of the lacrimal fluid o Buccinator is an accessory muscle of mastication,
overflowing on the cheeks is called epiphora. as it prevents food entering the vestibule of mouth.
Epiphora may result due to obstruction in the I Part of the face is called as "dangerous area of face"
lacrimal fluid pathway, either at the level of as the facial vein communicates with cavemous
puncfum or canaliculi or nasolacrimal duct. venous sinus situated in the cranial cavity. Any
infection from this part of face can infect the
DEVELOPMENT OF FACE intracranial venous sinus, i.e. cavernous sinus.
Five processes of face, one frontonasal, two maxillary
. Levator palpebrae superioris is supplied partly by
oculomotor nerve and partly by sympathetic fibres.
and two mandibular processes form the face. .
Frontonasal process forms the forehead, the nasal The facial muscles are subcutaneous in position
septum, philtrum of upper lip and premaxilla bearing
and represents morphologically remnants of
panniculus carnosus.
upper four incisor teeth.
Maxillary process forms whole of upper lip except
the philtrum and most of the hard and soft palate except
the part formed by the premaxilla.
Case 1
Mandibular process forms the whole lower lip.
A man of about 30 years comes to OPD with inability
Cord of ectoderm gets buried at the junction of to close his left eye tears overflowing on the left cheek
frontonasal and maxillary processes. Canalisation of
and saliva dribbling from his left angle of the mouth.
ectodermal cord of cells gives rise to nasolacrimal duct. o What is the reason for his sad condition?
r What nerve is damaged and how is the integrity
Mnemonics of the nerve tested?
Ans; The reason for the patient's sad condition is
Bell's palsy
paraiysis of his left facial nerrre at the stylomastoid
Blink re{lex abnormal ?oramen. It is called Bell's palsy. It is ireaied by
Ear ache physiotherapy and rrredicines.
Lacrimation ( deficient) Facial nerve is tested by:
Loss of taste in anterior two-thirds of tongue Asking the patient;
Sudden onset i. To lookupwards without moving his head,
Palsy of muscles of facial expression all symptoms and iaok for the normal harizontal wrinkies
are unilateral on the forehead"
Five branches of the facial nerve (Vtl)
ii. To show the teeth
Ten Zebras Bit My Cat
iii. Tightly closc the eyes to test the orbicularis
ocuii muscle.
iv. Puffing the mouth and then blowing out air
Zygomatic forciblv to test the buccinator muscle.
Case 2
Marginal mandibular
Cervical A teenage girl with infected acne tried to drain the
pustules on her upper lip with her bare hands.
After few davs she noticed severe weakness in her eve
muscles. :o
o How are the pustules connected to nerves zo
Forehead is common to both the scalp and the face supplying eye muscles? ttg
There are 5 layers in scalp and 5 layers in the Ans: Infection from pr-sruJes travels via facial veirl deep G
superficial temporal region !t(E
facial vein, pterygoid veno19_ qlexus, emissary-vein to o
Impulses from skin of the face reach the three cavemous venous sin*; and trtr, trV and \rI cranial nerves t
branches of trigeminal nerve, whereas the muscles reiated in its lateral wail. Since the qerves are infeeted
of facial expression are supplied by the facial nerve. co
the extraocular muscles gel weak and may get
To establish the reflex arc, nucleus of VII nerve pararyseo. o
1. Nasolacrimal duct opens into: c. Lrferior oblique
a. Anterior part of inferior meatus d. Levator palpabrae superioris
b. Vestibule of nose 4. Infection in dangerous area of face usually leads
c. Middle meatus to:
d. Superior meatus a. Superior sagittal sinus thrombosis
2. Dangerous area of face is named because of b. Transverse sinus thrombosis
connection of cavernous sinus with facial vein c. Cavernous sinus thrombosis
d. Brain abscess
a. Maxillary vein
5. Supraorbital artery is a branch of:
b. Anterior ethmoidal vein
c. Posterior ethmoidal vein a. Maxillary b. External carotid
d. Deep facial vein c. Ophthalmic d. Intemal carotid
3. \tVhich of the following muscle separates the orbital 6. Which of the following nerve ascends along with
and palpebral parts of the lacrimal gland: occipital artery in the scalp?
a. Superior oblique a. Greater occipital b. Lesser occipital
b. Superior rectus c. Third occipital d. Suboccipital


Side of the Neck
9l*,, ta, a, can&n oooun luczlt (m,

INTRODUCTION mandible and the mastoid process, immediately

The beauty of the neck lies in its deep or cervical fascia. anteroinferior to the tip of the mastoid process,
The sternocleidomastoid is an important landmark 7 The fourth ceraical transoerse process is just palpable
between the anterior and posterior triangles. The at the level of the upper border of the thyroid
posterior triangle contains the spinal root of accessory cartilage; and the sixth ceruical transzserse process at
nerve deep to its fascial roof and the roots and trunks the level of the cricoid cartilage.
of brachial plexus deep to its fascial floor. It also 8 The anterior tubercle of the transaerse process of the
contains a part of the subclavian artery, which continues sixth centical oertebra is the largest of all such
as the axillary artery for the upper limb. Arteries like processes and is called the cnrotid tubercle of
the rivers are named according to the regions they pass Chassaignac. The common carotid artery can be best
through. Congestive cardiac failure can be seen at a pressed against this tubercle, deep to the anterior
glance by the raised jugular venous pressure. This border of the sternocleidomastoid muscle.
external jugular vein lies in the superficial fascia and if 9 The anterior border of the trapezius muscle becomes
cut,leads to air embolism, unless the deep fascia pierced prominent on elevation of the shoulder against
by the vein is also cut to collapse the vein. resistance.

1 The sternocleidomastoid m:uscle is seen prominently
when the chin is turned to the opposite side. The
ridge raised by the muscle extends from the clavicle Give a median incision from the chin downwards
and sternum to the mastoid process. towards the suprasternal notch situated above the
2 The external jugular oein crosses the sterno- manubrium of sternum.
cleidomastoid obliquely, running downwards and Make one incision in the skin of base of mandible.
backwards from near the auricle to the clavicle. It is Continue it by oblique incision along posterior border
better seen in old age. of ramus of mandible up to mastoid process and further
3 The greater supraclarsicular fossa lies above and behind along the superior nuchal line till the external occipital
the middle one-third of the clavicle. It overlies the protuberance.
cervical part of the brachial plexus and the third part One incision is given along the upper border of
of the subclavian artery. clavicle (Fig. 3.1a). Reflect only the skin up towards
4 The lesser supraclaaicular fossa is a small depression the anterior border of trapezius muscle.
between the sternal and clavicular parts of the Platysma, a part of the subcutaneous muscle is
sternocleidomastoid. It overlies the internal jugular visible. Reflect the platysma towards the mandible.
vein. ldentify the anterior or transverse culaneous nerve of
5 The mastoid process is a large bony projection behind the neck in the upper part of superficialfascia. Anterior
jugular vein running vertically close to the median plane
the auricle.
6 The transaerse process of the atlas oertebra can be felt is also encountered. Remove the superficial fascia till
on deep pressure midway between the angle of the the deep fascia of neck is seen (Fig.3.6). 79

Externaljugular vein is seen above the clavicle. BOUNDARIES

To open up the suprasternal space make a horizontal The side of the neck is roughly quadrilateral in outline.
incision just above the sternum. Extend this incision It is bounded anteriorly, by the anterior median line;
along the anterior border of sternocleidomasloid muscle posteriorly, by the anterior border of trapezirs;
for 3-4 cm. Beflect the superficial lamina to expose the superiorly, by the base of mandible, a line joining angle
suprasternal space and identify its contents. of the mandible to mastoid process, and superior nuchal
Define the attachments of investing layer, pretracheal line; and inferiorly, by the clavicle.
layer, prevertebral layer and carotid sheath. This quadrilateral space is divided obliquely by the
sternocleidomastoid muscle into the anterior and
posterior triangles (Fig. 3.1b).

The skin of the neck is supplied by the second, third
and fourth cervical nerves. The anterolateral part is
supplied by anterior primary rami through the
(i) anterior cutaneous, (ii) great auricular, (iii) lesser
occipital and (iv) supraclavicular nerves. A broad band
of skin over the posterior part is supplied by dorsal or
posterior primary rami (see Fig.2.22).
First cervical spinal nerve has no cutaneous
distribution. Cervical fifth, sixth, seventh, eighth and
thoracic 1st nerves supply the upper limb through the
brachial plexus; and, therefore, do not supply the neck.
The territory of fourth cervical nerve extends into the
pectoral region through the supraclavicular nerves and
meets second thoracic dermatome at the level of the
Fig. 3.1a: Lines of dissection second costal cartilage.

Superior nuchal line

Mastoid process


Base of mandible
o Trapezius
zo Anterior triangle
Occipital part of posterior triangle
t,c Sternal head of sternocleidomastoid
Inferior belly of omohyoid
Clavicular head of sternocleidomastoid
(s Supraclavicular part of posterior triangle Acromion
o Fig. 3.'t b: Boundaries of the posterior triangle. Note that the inferior belly of the omohyoid divides the triangle into upper or occipital
o and lower or supraclavicular parts


Contains areolar tissue with platysma (see Table 2.3). $up*riorfy
Lying deep to platysma are cutaneous nerves (Fig.3.6),
a. External occipital protuberance
superficial veins (see Fig. 2.6),Iymph vessels, lymph
b. Superior nuchal line
nodes and small arteries.
c. Mastoid process
d. External acoustic meatus
e. Base of the mandible.
The surgeon has to stitch platysma muscle separately Between the angle of the mandible and the mastoid
so that skin does not adhere to deeper neck muscles, process/ the fascia splits to enclose the parotid gland
othelwise the skin will get an agly scar. (Fig.3.a).
The superficial lamina named asparotidfascza is thick
DEEP CERVICAL FASCTA (FASC|A COLLT) and dense, and is attached to the zygomatic arch. The deep
The deep fascia of the neck is condensed to form the lamina is thin and is attached to the styloid process, the
following layers: mandible and the tympanic plate. Between the styloid
process and the angle of the mandible, the deep lamina
1 Investing tayer (Fig. 3.2) is thick and forms the stylomandibular ligament which
2 Pretracheal layer separates the parotid gland from the submandibular
3 Prevertebral layer gland, and is pierced by the extemal carotid artery.
4 Carotid sheath At the base of mandible, it encloses submandibular
5 Buccopharyngeal fascia gland. The superficial lamina is attached to lower
5 Pharyngobasilar fascia. border of body of mandible and deep lamina to the
mylohyoid line.
It liesdeep to the platysma, and surrounds the neck Infan*rly
like a collar. It forms the roof of the posterior triangle a. Spine of scapula,
of the neck (Fig. 3.3). b. Acromion process,

Soft plate

Alar fascia

fascia Mandible

Spines of cervical
vertebrae Hyoid

Investing layer
lnvesting layer

Prevertebral fascia Thyroid cartilage I

Cricoid cartilage o
Pretracheal fascia tt(E
lsthmus of thyroid gland .J-

Suprasternal space c
Manubrium sterni .9
Fig. 3.2: Vertical extent of the first three layers of the deep cervical fascia s)

Thyroid gland

Trachea lnvesting layer
Pretracheal fascia

Internal jugular vein

Retropharyngeal lymph
Common carotid artery
Vagus nerve
Carotid sheath
Sympathetic trunk
Longus colli lnvesting layer
Scalenus anterior
Trunks of brachial plexus Prevedebral fascia

Scalenus medius
Muscles of back

C7 vertebra

Ligamentum nuchae

Fig. 3.3: Transverse section through the neck at the level of the seventh cervical vertebra

Base of mandible
a. Symphysis menti.
ligament with b. Hyoid bone.
external carotid Submandibular gland Both above and below the hyoid bone, it is
artery Parotid fascia continuous with the fascia of the opposite side.
Parotid gland
Styloid process
Other Feotures
Mastoid process L The investing layer of deep cervical fascia splits to
Sternocleidomastoid Superior nuchal line enclose:
External occipital
a. Muscles: Trapezius and sternocleidomastoid.
protuberance b. Salizsary glands: Parotid and submandibular.
c. Spaces: Suprasternal and supraclavicular.
Fig. 3.4: Superior attachment of investing layer of deep cervical
The suprasternal space or space of Burns contains:
r The sternal heads of the right and left sterno-
o cleidomastoid muscles (Fig. 3.5).
z c. Clavicle, and
o The iugular venous arch/
t,tr d. Manubrium.
(E The fascia splits to enclose the suprasternal and . A lymph node, and
tt(E supraclavicular spaces, both of which are described o The interclavicular ligament.
o below (Fig.3.5).
I The supraclaoicular space is traversed by:
F*srs+rr."#rfy o The external jugular vein (Fig. 3.6),
() a. Ligamentum nuchae; and r The supraclavicular nerves, and
ao b. Spine of seventh cervical vertebra. o Cutaneous vessels, including lymphatics.

Manubrium un frffierSfd6
space of Burns It forms the front of the carotid sheath, and fuses with
the fascia deep to the sternocleidomastoid (Fig.3.3).

Supraclavicular Olher Feotures

space pierced by The posterior layer of the thyroid capsule is thick.
external jugular vein
Acromion On either side, it forms a suspensory lignment for the
Trapezius thyroid gland known asligament of Berry (seeFig.8.4).
The ligaments are attached chiefly to the cricoid
Spine of scapula
cartilage, and may extend to the thyroid cartilage.
They support the thyroid gland, and do not let it sink
Fig. 3.5: lnferior attachment of investing layer of deep cervical into the mediastinum. The capsule of the thyroid is
fascia very weak along the posterior borders of the lateral
2 It also forms pulleys to bind the tendons of the The fascia provides a slippery surface for free
digastric and omohyoid muscles. movements of the trachea during swallowing.
3 Forms roof of anterior and posterior triangles.
4 Forms stylomandibular ligament and parotido-
masseteric fasciae. Neck infections in front of the pretracheal fascia
maybulgein thesuprastemal area or extend down
into the anterior mediastinum.
r Parotid swellings are very painful due to the
r The thyroid gland and all thyroid swellings move
with deglutition because the thyroid is attached
unyielding nature of parotid fascia.
r to cartilages of the larynx by the suspensory
14trhi1e excising the submandibular salivary gland,
ligaments of Berry.
the external carotid artery should be secured
before dividing it, otherwise it may rekact through
the stylomandibular ligament and cause serious
bleeding. The figure also shows the superior It lies in front of the prevertebral muscles, and forms
attachment of investing layer of deep cervical the floor of the posterior triangle of the neck (Fig. 3.2).
fascia (Fig. 3.4).
r Division of the external jugular vein in the Altochments ond Relotions
supraclavicular space may cause air embolism and $upenorly
consequent deathbecause the cut ends of the vein It is attached to the base of the skull (Fig. 3.2).
are prevented from retraction and closure by the
fascia, attached firmly to the vein (Figs 3,5 and 3.5). {nferiorly
It extends into the superior mediastinum where it splits
into anterior and posterior layers. Anterior l'ayer / alar
fascia blends with buccopharyngeal fascia and posterior
The importance of this fascia is that it encloses and layer is attached to the anterior longitudinal ligament
suspends the thyroid gland and forms its false capsule and to the body of the fourth thoracic vertebra.
Altochmenls It is separated from the pharynx and buccopharyngeal
$rup*rlmrfp fascia by the retropharyngeal space containing loose
areolar tissue. L
1 Hyoid bone in the median plane. o
2 Oblique line of thyroid cartilage laterally. l*fereJ{y
3 Cricoid cartilage-more laterally. It is lies deep to the trapezius and is attached to fascia (E

of sternocleidomastoid muscle. E'

driferuorfy o
Below the thyroid gland, it encloses the inferior thyroid Other Feotures
veins, passes behind the brachiocephalic veins, and L The cervical and brachial plexuses lie behind the .e
finally blends with the arch of the aorta and fibrous prevertebral fascia. The fascia is pierced by the four o
pericardium. cutaneous branches of the cervical plexus (Fig. 3.6). ao

Greater occipital nerve Great auricular nerve

Lesser occipital nerve

Spinal root of accessory nerve

Transverse cervical vein

Supraclavicular nerves
Suprascapular vein

Anierior jugular vein

Fig. 3.6: Structures seen in relation to the fascial roof of the posterior triangle

As the trunks of the brachial plexus, and the in the median plane, The infection may extend
subclavian artery, pass laterally through the interval down through the superior mediastinum into the
between the scalenus anterior and the scalenus posterior mediastinum (see Fig. 8,4).
medius, they carry with them a covering of the
prevertebral fascia knor,rm asthe axillary sheathwhich
extends into the axilla. The subclavian and axillary
Chronic retropharyngeal
veins lie outside the sheath and as a result they can abscess
dilate during increased venous return from the limb. 5th cervical ventral ramus
Fascia provides a fixed base for the movements of Abscess in posterior triangle
the pharynx, the oesophagus and the carotid sheaths
Upper trunk of brachial plexus
during movements of the neck and during Axillary sheath

Subclavian artery
Neck infections behind the prevertebral fascia
1st rib
arise usually from tuberculosis of the cervical
vertebrae or cervical caries. Pus produced as a Abscess in lateral
result may extend in various directions. It may wall of axilla
pass forwards forming a chronic retropharyngeal
abscess which may form a bulging in the posterior
wall of the pharynx, in the median plane (Fig. 3.7).
The pus may extend laterally through the axillary
sheath and point in the posterior triangle, or in
Extent of tuberculosis of cervical vertebrae
the lateral wall of the axilla. It may extend
downwards into the superior mediastinurry where
.Y its descent is limited by fusion of the prevertebral
zo fascia to the fourth thoracic vertebra.
It is a condensation of the fibroareolar tissue around
E. Neck infections in front of the prevertebral fascia
G in the retropharyngeal space usually arise from the main vessels of the neck. It is formed on anterior
(E suppuratior; i.e. formation of pus in the retro- aspect by pretracheal fascia and on posterior aspect by
pharyngeal lymph nodes. The pus forms an acute prevertebral fascia. The contents are the common or
retropharyngeal abscess which bulges forwards intemal carotid arteries, internal jugular vein and the
c in the paramedian position due to fusion of the vagus nerve. It is thin over the vein (Figs 3.8a and b). In
6 buccopharyngeal fascia to the prevertebral fascia the upper part of sheath there are IX,XI, XII nerves also.
ac) These nerves pierce along with extemal carotid artery.

posterior triangle to reach the anterior border of

trapezius which it supplies (Fig.3.9).
Define the boundaries, roof, floor, divisions and
contents of the posterior triangle (Fig. 3.1b).
ldentify and clean the inferior belly of omohyoid. Find
the transverse cervical artery along the upper border
of this muscle. Trace it both ways. Deep to this muscle
is the upper or supraclavicular part of brachial plexus.
Anterior Identify the roots, trunks and their branches carefully.
The branches are suprascapular nerve, dorsalscapular
Common carotid
nerve, long thoracic nerve, nerve to subclavius
(Fig. 3.10). Medial to the brachial plexus locate the third
lnternal jugular part of subclavian artery.
Follow the terminal part of external jugular vein
Vagus nerve through the deep fascia into the deeply placed
Sympathetic trunk subclavian vein. ldentify suprascapular artery running
(a) Posterior
-----****---6 (b) just above the clavicle (Fig. 3.9).
Figs 3.8a and b: Right carotid sheath with its contents: (a) Surface Define the atlachments and relations of sternocleido-
view, and (b) sectional view mastoid muscle. To expose scalenus anterior muscle
cut across the clavicular head of sternocleidomastoid
Relolions muscle and push it medially. Scalenus anlerior muscle
1 The ansa cervicalis lies embedded in the anterior wall covered by well-defined prevertebral fascia can be
of the carotid sheath (Figs 3.8a and b). identified. Clean the subclavian artery and upper part
2 The cervical sympathetic chain lies behind the sheath, of brachial plexus deep to the scalenus anterior muscle.
plastered to the prevertebral fascia.
3 The sheath is overlapped by the anterior border of Feotures
the sternocleidomastoid, and is fused to the layers The posterior triangle is a space on the side of the neck
of the deep cervical fascia. situated behind the sternocleidomastoid muscle.
This fascia covers the superior constrictor muscle Affifl*rcsr
externally and extends on to the superficial aspect of
Posterior border of sternocleidomastoid (Fig. 3.1b).
the buccinator muscle.
Anterior border of trapezius.
This fascia is especially thickened between the upper
border of superior constrictor muscle and the base of fmferf*rorhmsa
the skull. It lies deep to the pharyngeal muscles (see
Fig.1.4.21). Middle one-third of clavicle.

Lies on the superior nuchal line where the trapezius
and sternocleidomastoid meet.
Try to dissect and clean the cutaneous nerves which Roof o
pierce the investing layer of fascia at the middle of
The roof is formed by the inaesting layer of deep ceraical zo
posterior border of sternocleidomastoid muscle (Fig. 3.6). !t
Demarcate the course of external jugular vein. Cut fascia, The superficial fascia over the posterior triangle (E
contains: !t
carefully the deep fascia of posterior border of sterno- 6
cleidomastoid muscle and reflect it towards trapezius
L The platysma. o
muscle. ldentify the accessory nerve lying just deep to
2 The external jugular and posterior extemal jugular
the investing layer seen at the middle of the posterior o
border of sternocleidomastoid muscle and across the 3 Parts of the supraclavicular, great auricular, transverse ()
cutaneous and lesser occipital nerves (Fig. 3.6). oo

Occipltal artery and

greater occipiial nerve

Splenius capitis

Cervical lymph nodes
around accessory nerve
Levator scapulae

Transverse cervical Scalenus anterior

and suprascapular arteries with phrenic nerve

Dorsal scapular nerve

Trapezius lnferior thyroid artery

Trunks of brachial plexus

on scalenus medius

Fig. 3.9: The posterior triangle of neck and its contents

4 Unnamed arteries derived from the occipital, Floor

transverse cervical and suprascapular arteries. The floor of the posterior triangle is formed by the
5 Lymph vessels which pierce the deep fascia to end prevertebral layer of deep cervical fascia, covering the
in the supraclavicular nodes. following muscles:
T};re external jugular oein: Il lies deep to the platysma 1 Splenius capitis.
(Fig. 3.6). It is formed by union of the posterior auricular 2 Levator scapulae.
vein with the posterior division of the retromandibular 3 Scalenus medius (Fig. 3.9).
vein. It begins within the lower part of the parotid gland, 4 Semispinalis capitis may also form part of the floor.
crosses the sternocleidomastoid obliquely, pierces the
anteroinferior angle of the roof of the posterior triangle, Division of lhe Postetiot Ttiongle
and opens into the subclavian vein(seeFig.2.6). It is subdivided by the inferior belly of omohyoid into:
Its tributaries are: L A larger upper part, called t}ire occipital trinngle.
a. The posterior external jugular vein. 2 A smaller lower part, called the supraclarsicular or the
subclazsian triangle (Fig. 3.1b).
b. The transverse cervical vein.
c. The suprascapular vein. Conients of the Posterior lriongle
d. The anterior jugular vein. These are enumerated inTable 3.1. Some of the contents
The oblique jugular vein connects the external are considered below:
jugular vein with the internal jugular vein across the
middle one-third of the anterior border of the Spievonf Fp*fa,*res mf f*e #mruf*mfs*f Fosfericrflnon6#*
sternocleidomastoid. 1 The spinal accessory neroe emerges a little above the
middle of the posterior border of the sterno-
cleidomastoid. It runs through a tunnel in the fascia
. The right extemal jugular vein is exarnined to assess forming the roof of the triangle, passing downwards
o the aenous pressare; the right atrial pressure is and laterally, and disappears under the anterior
zo reflected in it because there are no valves in the border of the trapezius about 5 cm above the clavicle
(Figs 3.6 and 3.9). It is the only structure beneath
!, entire course of this vein and it is straight.
c(E r the roof of triangle
As external jugular vein pierces the fascia, the
!tc, margins of the vein get adherent to the fascia. So 2 The for;:" cutaneous branches of the ceraical plexus
o if the vein gets cut, it cannot close and air is sucked pierce the fascia covering the floor of the triangle,
in due to negative intrathoracic pressure. That pass through the triangle and pierce the deep fascia
o causes air embolism. To prevent this, the deep at different points to become cutaneous (Fig. 3.6).
o fascia has to be cut. a. Transaerse cutaneous nerae: Arises from ventral
o0) rami of C2 and C3 nerves runs transversely across

' 'Table 3.1: Eontents'of;the posterior triengle (Figs 3.6 and 8,9)
Contents Occipital triangte Subclavian triangle
A. Nerves 1. Spinal accessory nerve 'l . Three trunks of brachial plexus
2. Four cutaneous branches of cervical plexus: 2. Nerve to serratus anterior (long thoracic,
a. Lesser occipital (C2) c5, c6, c7)
b. Great auricular (C2, C3) 3. Nerve to subclavius (C5, CO)
c. Anterior cutaneous nerve of neck (C2, C3) 4. Suprascapular nerve (C5, C6)
d. Supraclavicular nerves (C3, C4)
3. Muscular branches:
a. Two small branches to the levator scapulae
(c3, c4)
b. Two small branches to the trapezius (C3, C4)
c. Nerve to rhomboids (proprioceptive) (C5)
4. C5, C6 roots of the brachial plexus
B. Vessels 1. Transverse cervical artery and vein 1. Third part of subclavian artery and subclavian vein
2. Occipital artery 2. Suprascapular artery and vein
3. Commencement of transverse cervical artery and
termination of the corresponding vein
4. Lower paft of external jugular vein
C. Lymph nodes Along the posterior border of the sternocleidomastoid, A few members of the supraclavicular chaln
more in the lower part-the supraclavicular nodes
and a few at the upper angle-the occipital nodes

the sternocleidomastoid to supply skin and of sternocleidomastoid. Those to the levator scapulae
neck, till the sternum. soon end in iU those to the trapezirs run below and
b. Supraclaaicular nerues; Formed from ventral rami parallel to the accessory nerve across the middle of
of C3 and C4 nerves. Emerges at posterior border the triangle. Both nerves lie deep to the fascia of the
of sternocleidomastoid. It descends downwards floor.
and diverges into three branches. Medial one 4 Three trunks of the brachial plexus emerge between
supplies the skin over the manubrium till the scalenus anterior and medius, and carry the axil-
manubriosternal joint. Lrtermediate nerve crosses lary sheath around them. The sheath contains the
the clavicle to supply skin of first intercostal space brachial plexus and the subclavian artery. These
till the second rib. Lateral nerve runs across the structures lie deE lo the floor of posterior triangle. If
lateral side of clavicle and acromion to supply prevertebralfascia is left intact, all these structures are
skin over the upper half of the deltoid muscle. safe.
c. Great attriculnr nerae: It is the largest ascending 5 The nerae to the rhomboid is from C5 root, pierces the
branch of cervical plexus. Arises from ventral scalenus medius and passes deep to the levator
rami of C2 and C3 nerves. Ascends on the scapulae to reach the back where it lies deep or
sternocleidomastoid muscle to reach parotid anterior to the rhomboid muscles (Fig. 3.10).
gland, where it divides into anterior and 6 The nerae to the seruatus anterior (C5, C6, C7) arises
posterior branches. Anterior branch supplies by three roots. The roots from C5 and C6 pierce the
lower one-third of skin on lateral surface of pirura scalenus medius and join the root fromCT over the
and skin over the parotid gland and connects the first digitation of the serratus anterior. The nerve
gland to the auriculotemporal nerve. This cross passes behind the brachial plexus. It descends over
connection is the anatomical basis for Frey's the serratus anterior in the medial wall of the axilla
syndrome. Posterior branch supplies lower one- and gives branches to the digitations of the muscle J
third of skin on medial surface of the pinna. (Fig. 3.10). zo
d. Lesser occipital: Arises from ventral ramus of C2 7 The nerzte to the subclaaius (C5, C6) descends in front t,c
segment of spinal cord. Seen at the posterior of the brachial plexus and the subclavian vessels, but (E

border of sternocleidomastoid muscle. It then behind the omohyoid, the transverse cervical and t,(E
winds around and ascends along its posterior suprascapular vessels and the clavicle to reach the o
border to supply skin of upper two-thirds of deep surface of the subclavius muscle. As itrunsnear
medial surface of pirura adjoiningpart of the scalp. the lateral margin of the scalenus anterior, it sometimes c
Muscular branches to the leztator scapulae and to the gives off the accessory phrenic nerae whichjoins the o
trapezius (C3, C4) appear about the middle of the phrenic nerve in front of the scalenus anterior. U)

Dorsat scapular nerve

Suprascapular nerve

Nerve to subclavius

Long thoracic nerve

Lateral pectoral


Upper subscapular nerve

Branches Nerve to latissimus dorsi
Lower subscapular nerve
Musculoculaneous nerve
Medial pectoral nerve
Axillary nerve
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Lateral rool and medial
root of median nerve Ulnar nerve
Median nerve
Fig. 3.10: Brachial plexus

8 The suprascapular nerTre (C5, C6) arises from the

upper trunk of the brachial plexus and crosses the
The most conunon swelling in the po$terior triangle
lower part of the posterior triangle just above and
is dueto enlarg€ment of the supraclayicular lymph
lateral to the brachial plexus, deep to the transverse
nodes, While doing biopsy af the lymph node, one
cervical vessels and the omohyoid. It passes
mustbe careful in prcserving the'accessory nerve
backwards over the shoulder to reach the scapula.
whieh,may. get entangled amongst enlarged
It supplies the supraspinatus and infraspinatus lymph nndes (Fig. 3.9).
muscles (Fig.3.10).
Supraclavicular lymph'nsdes' are commonly
9 The subclaaian artery passes behind the tendon of enlarged in, fuberculosis, Hodgkin's disease, and
the scalenus anterior, over the first rib. in.malignant growth$ o{ the breast arfft.or chest.
10 The transrserse ceraical artery is a branch of the Block dissection of the neck for malignant diseases
thyrocervical trunk. It crosses the scalenus anterior/ istheremoval of cervical lyrnphnodes along with
the phrenic nerve, the upper trunks of the brachial other $tructures involved in the growth. This
plexus, the nerve to the subclavius, the procedrrte does not endanger those nerves of the
suprascapular nerve, and the scalenus medius. At posterior, trian$le which }ie deep to the
:o the anterior border of the levator scapulae, it divides prcvertebral fascia, i.e- the brachial and cervical
into superficial and deep branches. The inferior belly
zo of the omohyoid crosses the artery (Fig. 3.9).
ptrexusesr'and their muscular branches.
.A cervical rib may compress the second part'of
LL The suprascapular artery is also a branch of the $rlbctrayian artery,In'these easee, bloo supply to
t,(E thyrocervical trunk. It passes laterally and back- upper lirnb reaches via:anastolnoees around the
o wards behind the clavicle. scapula. , I

12 The occipital artery crosses the apex of the posterior Dysphagiacausedbyeompression of the oesophagus
triangle superficial to the splenius capitis. by,u* abnormal:subclavian artery is called
C) 13 The subclavian vein passes in front of the tendon of dyEhagia lusoria.
ao scalenus anterior muscle.
SroE or iur NEcx

Elective arterial surg€ry. of the conrmon carutid depression of the lesser supraclavicular fossa,
arteqy is done for-aneurysms, AV fistulae or overlying the internal jugular vein.
arteriosclerotic ocelusions. It is better to expose
the eommon carotid :artery in.its upper part where
it is superficial. While ligating the artery. care It is inserted:
should be taken'notto include the vagus nerve or '1. By a thick tendon into the lateral surface of mastoid
the sympathetic chain. process, from its tip to superior border.
Second,part of the:subctravian artery nlay get 2 By a thin aponeurosis into the lateral half of the
pressed by the ecaleryrs, anterior' rnusde, resulting superior nuchal line of the occipital bone.
in decreased blood supply to the upper lirnb. If
the muscle is divided:the effects are abolished Nerve Supply
(Fis. 3.11).
1 The spinal accessory nerve provides the motor
supply. It passes through the muscle.
2 Branches from the ventral rami of C2 are pro-
prioceptive (Fig. 3.9).

BIood Supply
Arterial supply-one branch each from superior
thyroid artery and suprascapular artery and, two
branches from the occipital artery supply the big
muscle. Veins follow the arteries.

Narrowed Aclions
artery 1 When one muscle contracts:
a. It turns the chin to the opposite side.
Clavicle b. It can also tilt the head towards the shoulder of
same side.
2 When both muscles contract together:
a. They draw the head forwards, as in eating and in
Fig. 3.11: Second part of subclavian artery narrowed by the
lifting the head from a pillow.
short scalenus anterior
b. With the longus colli, they flex the neck against
c. It also helps in forced inspiration.

The sternocleidomastoid is enclosed in the investing
layer of deep cervical fascia, and is pierced by the
The sternocleidomastoid and trapezius are large super- accessory nerve and by the four sternocleidomastoid
ficial muscles of the neck. Both of them are supplied by arteries. It has the following relations:
the spinal root of the accessory nerve. The trapezius,
because of its main action on the shoulder girdle, is Superfi*r"of
considered with the upper limb (see Volume 1, 1 Skin
Section 1). The sternocleidomastoid is describedbelow. 2 a. Superficial fascia.
b. Superficial lamina of the deep cervical fascia xo
ORIGIN (Fig.3.3).
1 The sternal head is tendinous and arises from the 3 Platysma. zo
superolateral part of the front of the manubrium 4 External jugular vein, and superficial cervical lymph (E
stemi (Fig.3.1b). nodes lying along the vein (Fig. 3.6). tt(E
2 The clar.ticular head is musculotendinous and arises 5 a. Great auricular. o
from the medial one-third of the superior surface of b. Transverse or anterior cutaneous.
the clavicle. It passes deep to the sternal head, and c. Medial supraclavicular nerves (Fig.3.6).
the two heads blend below the middle of the neck. d. Lesser occipital nerve o
Between the two heads, there is a small triangular 6 The parotid gland overlaps the muscle. ao

0eep a. Rheumadc torticollis due to expoflrre to cold
1 Bones and joints: or drauglrt.
a. Mastoid process above b. Reflex torticollis due to inffamed. or suppura'
b. Sternoclavicular joint below. ting cervical lynnph nodes which irritate the
2 Carotid sheath (Fig.3.B). spinal acce sorynerve.
3 Muscles: c. Congenital torticollis due to birth iniury.
a. Sternohyoid Wry neck: Shortening of the muscle fibres due to
b. Sternothyroid intravascular clotting of veins within the muscle. It
c. Omohyoid usually occur$ during difficult delivery of the baby.
d. Three scaleni
e. Levator scapulae
f. Splenius capitis
g. Longissimus capitis RETROPHARYNGEAT SPACE
h. Posterior belly of digastric.
4 Arteries:
Situation: Dead space behind pharynx.
a. Common carotid
Function: Acts as a bursa for expansion of
pharynx during deglutition
b. Internal carotid Boundaries: Anterior: Buccopharymgeal fascia
c. External carotid Posterior: Prevertebral fascia
d. Sternocleidomastoid arteries, two from the Sides: Carotid sheath (Fig. 3.3)
occipital artery, one from the superior thyroid, one Superior: Base of skull
from the suprascapular Inferior: Open and continuous with superior
e. Occipital mediastinum.
f. Subclavian Contents: Retropharyngeal lymph nodes,
g. Suprascapular pharyngeal plexus of vessels and
h. Transverse cervical (Fig.3.9). nerves/ loose areolar tissue.
Veins: Clinical Pus collection due to lymph node
a. Internal jugular anatomy: abscess. It should be differentiated
b. Anterior jugular from cold abscess of spine of cervical
c. Facial vertebrae (see Fig. 8.4).
d. Lingual
a. Vagus Situation: Side of pharynx
b. Parts of IX, XI, XII Boundaries: Medial: Pharynx
Posterolateral: Parotid gland
c. Cervical plexus
Anterolateral: Medial PterYgoid
d. Upper part of brachial plexus
Posterior: Carotid sheath
e. Phrenic (Fig.3.9)
Contents: Maxillary nerve and branches of
f. Ansa cervicalis maxillary artery
Lymph nodes, deep cervical. Fibrof atty tissue flbr of atty
Clinical Pus collection/Ludwig's angina.
Figure 3.5 shows inferior attachment of investing
layer of deep cervical fascia. Fascia of sqpra*
o clavicular space is pierced by extemal jugular vein
z to drain into subclavian vein. C"rrl"^l ph*t, A,
?r' Torticollis is a deformity inwhich thehead is bent nerves ilGLAST':
(E to one side and the chin points to the other side. 4 compass points: Clockwise from narth on the right side of neck
This is a result of spasm or contracture of the Great auricular
o muscles supplied by the spinal accessory nerve/ Lesser occipital
these being the stemocleidomastoid and trapezius, Accessory nerve pops out between L and S
c Although there are many varieties of torticollis Supraclavicular
depending on the causes, the common types are: Transverse cervical

Investing layer of deep cervical fascia encloses A middle-aged woman had a deep cut in the middle
2 muscles,2 salivary glands, forms 2 pulleys, encloses, of her right posterior triangle of neck. The bleeding
2 spaces and forms roof of posterior triangle. was arrested and wound was sutured. The patient
. Prevertebral fascia forms the axillary sheath. later felt difficulty in combing her hair.
o Pretracheal fascia suspends the thyroid gland.
r What blood vessel is severed?
. Cold abscess of caries spine can track doivn to the . Why did the patient have difficulty in combing
her hair?
posterior triangle or axilla.
o Occipital part of posterior triangle contains the Ans: The exfernatr iugular vein was severed. It passes
spinal root of accessory nerve as the most across the sternocleidomastoid muscle tr: ioin the
important constituent. subclavian vein above the clavicle. Her accessory
. Supraclavicular part of posterior triangle contains nerve is also injured as it crosses the posterior triangle
close to its roof, causing paralysis of trapezius
roots, trunks, branches of brachial plexus and third
muscle. The trapezius with seuatus anteri.or cau$es
part of subclavian artery.
o Sternocleidomastoid divides the side of neck into overhead abduition required for combing the hair.
Due to paralysis of trapezius, she felt difficulty in
anterior and posterior triangles.
combing her hair.


1. \Afhich of the following structures is not seen in the c. Interclavicular ligament

posterior triangle of neck: d. Sternohyoid muscles
a. Spinal accessory nerve 4. Posterior triangle does not contain one of the
b. Transverse cervical artery following nerves:
c. Middle trunk of brachial plexus a. Spinal accessory nerve
d. Superior belly of omohyoid b. Lesser occipital nerve
, Spinal root of accessory nerve innervates; c. Creater occipital nerve
a. Serratus anterior d. Great auricular nerve
b. Stylohyoid 5. Investing layer of cervical fascia encloses all except:
c. Styloglossus a. Two muscles b. Two salivary glands
d. Sternocleidomastoid c. Axillary vessels d. Two spaces
J. Suprasternal space contains all except one of the 5' Ligament of Berry is formed by:
following structures: a. Investing layer of cervical fascia
a. Sternal heads of right and left sternocleido - b. Pretracheal layer
mastoid muscles c. Prevertebral layer
b. jugular venous arch d. Buccophary.ngeal fascia

1.d 2.d 3.d 4.c 5.c 6.b

Anterior Triangle of the Neck
Onz /zatwze, t o, rt t.od/u mazz {haru tfi.oaaand. uootz/e,

INTRODUCTION The body of the U-shaped hyoid bone can be felt in

the median plane just below and behind the chin, at
The anterior triangle of the neck lies between midline
the junction of the neck with the floor of the mouth.
of the neck and sternocleidomastoid muscle. It is On each side, the body of hyoid bone is continuous
subdivided into smaller triangles. posteriorly with lhe grenter cornua which is
overlapped in its posterior part by the sterno-
SURFACE TANDMARKS cleidomastoid muscle.
L The mandible forms the lower jaw (Fig.4.1). The lower The thyroid cartilnge of the larynx forms a
border of its horseshoe-shaped body is knor,rm as the sharp protuberance in the median plane just below
base of the mandible.Anteriorly, this base forms the the hyoid bone. This protuberance is called the
chin, and posteriorly it can be traced to the angle of laryngeal prominence or Adam's apple. It is more
the mandible. prominent in males.

External occipital protuberance

Mastoid process

Transverse process of atlas Mandible

Floor of mouth

Hyoid bone

Thyroid cartilage

Cricoid cartilage


Fig.4.1: Surface landmarks of neck


The rounded arch of the uicoid cartilage lies below

the thyroid cartilage at the upper end of the trachea.
Base of mandible
The trachea runs downwards and backwards from
the cricoid cartilage. It is identified by its carti-
laginous rings. However, it is partially masked by
the isthmus of the thyroid gland which lies against Siernocleidomastoid
second to fourth tracheal rings. The trachea is
commonly palpated in the suprasternal notch which Platysma
lies between the tendinous heads of origin of the right
and left sternocleidomastoid muscles. In certain
Anterior jugular vein
diseases, the trachea may shift to one side from the
median plane. This indicates a shift in the medi- Jugular venous arch
astinum. Clavicle

Fig. 4.2: Anterior triangles of the neck showing the platysma

and the anterior jugular veins in the superficial fascia


The skin over the anterior triangle has already been Deep Foscio
reflected following dissection in chapter 3. Platysma is Above the hyoid bone the investing layer of deep fascia
also reflected upwards. ldentify the structures present is a single layer in the median plane, but splits on
in the superficial fascia and structures present in the each side to enclose the submandibular salivary gland
anterior median region of neck. (see Fig.7.6).
Between the hyoid bone and the cricoid cartilage, it
Feolures is a single layer extending between the right and left
This region includes a strip 2 to 3 cm wide extending sternocleidomastoid muscles.
from the chin to the stemum. The strucfures encountered
Below the cricoid, the fascia splits to enclose the
are listed below from superficial to deep.
suprasternal space.
Deep Slruclures lying obove lhe Hyoid Bone
The mylohyoid muscle is overlapped by:
It is freely movable over the deeper structures due to a. Anterior belly of digastric above the hyoid bone.
the looseness of the superficial fascia. b. Superficial part of the submandibular saliuary gland
(Figs 4.3 and 4.4).
Superficiol Foscio c. Mylohyoid nerae and aessels.
It contains: d. Submental branch of the facial artery.
1 The upper decussating fibres of the platysma for 1 to The anteroinferior part of the hyoglossus muscle wlth
2 cm below the chin. its superficial relations may also be exposed during
2 The anterior jugular aeins beginning in the submental dissection. Structures lying in this corner are:
region below the chin. It descends in the superficial a. The intermediate tendon of the digastric muscle
fascia about 1 cm from the median plane. About with its fibrous pulley (Fig. a.3).
2.5 cm above the sternum, it pierces the investing b. The bifurcated tendon of the stylohyoid muscle
layer of deep fascia to enter the suprasternal space embracing the digastric tendon.
where it is connected to its fellow of the opposite The subhyoidbursa lies between the posterior surface :o
side by a transverse channel, tlrre jugular aenous arch. of the body of the hyoid bone and the thyrohyoid
The vein then turns laterally, runs deep to the sterno- membrane. It lessens friction between these two zo
cleidomastoid just above the clavicle, and ends in the structures during the movements of swallowing tr
external jugular oein at the posterior border of the (Fig. a.s). E(E
sternocleidomastoid (Fig. a.4. o
3 A few smallsubmentallymphnodeslyingon the deep Slructures lying Below the Hyoid Bone
fascia below the chin (Fig. a.3). These structures may be grouped into three planes:
4 The terminal filaments of the transoerse or anterior (1) Superficial plane containing the infrahyoid muscles, ()
cutnneous nerae of the neck may be present in it. (2) a middle plane consisting of the pretracheal fascia ao

Nerve to mylohyoid Submental lymph nodes

Facial artery

Submental artery Anterior belly of digastric



Posterior belly of digastric

Hyoid bone

Fig. 4.3: Suprahyoid region, surface view

Hyoglossus Superior and inferior longitudinal muscles of tongue


Lingual nerve

Sublingual gland
Submandibular duct

Hypoglossal nerve
Mylohyoid nerve and artery
Submandibular gland Mylohyoid


Deep fascia
Fig.4,4: Coronal section through the floor of the mouth

o-Foramen caecum lnfrahyoid muscles:

on tongue
a. Sternohyoid;
Track of
thyroglossal b. Sternothyroid;
duct c. Thyrohyoid; and
d. Superior belly of omohyoid. These are described
Hyoid bone
Subhyoid bursa
in Table 4.1. andFig.4.6.
Pretracheal fnscin: Itforms the false capsule of the thyroid
gland andthe suspensory ligaments of Berry which attach
the thyroid gland to the cricoid cartilage (seeEig.8.4).
Deep to the pretracheal fascia there are:
Thyrohyoid membrane a. The thyrohyoid membrane deep to the thyrohyoid
muscle: it is pierced by the intemal laryngeal nerve
and the superior laryngeal vessels (Fig. a.n.
b. Thyroid cartilage.
o c. Cricothyroidmembrane with the anastomosis of the
z cricothyroid arteries on its surface.
(E d. Arch of the cricoid cartilage.
!,(E Thyroid cartilage
e. Cricothyroid muscle supplied by the external
o laryngeal nerve.
Fig.4.5: Sagittal section through the hyoid region of the neck
showing the subhyoid bursa and its relations
f. Trachea, partly covered by the isthmus of the
C thyroid gland from the second to fourth rings.
o and the thyroid gland, and (3) a deep plane containing g. Carotid sheaths lie on each side of the trachea
ao the laryrnx, trachea and structures associated with them. (see Fig. 3.3).

Hyoid bone

Thyroid ca(ilage
Oblique line of thyroid cartilage

Omohyoid (superior belly)



Omohyoid (inferior belly)


First costal cartilage

Superior border of scapula
Manubrium sterni

Fig.4.6: The infrahyoid muscles

. The common anterior midline swellings of the

neck are: DISSECTION
a. Enlarged submental lymph nodes and Remove the deep fascia from anterior bellies of digastric
sublingual dermoid in the submental region. muscles to expose parts of two mylohyoid muscles. Clean
b. Thyroglossal cyst and inflamed subhyoid bursa the boundaries and contents of the submental triangle.
;'ust below the hyoid bone (Fig. 4.5). Cut the deep fascia from the mandible and reflect it
c. Goitre, carcinoma of larynx and enlarged downwards to expose the submandibular gland. ldentify
lymph nodes in the suprasternal region. and clean anterior and posterior bellies of digastric
Tracheostomy is an operation in which the trachea muscles, which form the boundaries of digastric triangle.
is opened and a tube inserted into it to facilitate ldentify the intermediate tendon of digastric after pulling
breathing. It is most commonly done in the the submandibular gland laterally. Clean the stylohyoid
retrothyroid region after retracting the isthmus of muscle which envelops the tendon of digastric and is
the thyroid g1and. A suprathyroid tracheostomy lying along with the posterior belly of digastric muscle.
is liable to stricture, and an infuathyroid one is ldentify the contents of digastric triangle.
difficult due to the depth of the trachea and is also
dangerous because numerous vessels lie anterior
to the trachea here (Fig. 4.8).
Cut throat wounds are most commonly situated
iust above or just below the hyoid bone. The main
vessels of the neck usually escape injury because The boundaries of the anterior triangle of neck are:
they are pushed backwards to a deeper plane The anterior median plane of the neck medially;
sternocleidomastoid laterally; base of the mandible and t(
during voluntary extension of the neck. o
a line joining the angle of the mandible to the mastoid o
Skin incisions to be made parallel to natural z
crea$es or Langer's lines (Fig.4.9).
process/ superiorly (Fig. a.10). E
Ludwig's angina is the cellulitis of the floor of the t,(E
mouth. The infection spreads above the mylo- o
hyoid forcing the tongue upwards. Mylohyoid is The anterior triangle is subdivided (by the digastric
pushed downwards. There is swelling within the muscle and the superior belly of the omohyoid into: c
mouth as well asbelow the chin. .e
a. Submental o
b. Digastric ao

Thyrohyoid ligament
Hyoid bone

C3 level

Openings for internal laryngeal nerve

and superior laryngeal vessels Thyrohyoid membrane

C4 level
Oblique line on thyroid cartilage

C5 level
Cricothyroid muscle Cricothyroid membrane
C6 level Cricoid cartilage

First tracheal ring

Thyroid gland

Fifth tracheal ring

T2ff3 level
Fig.4.7; The thyroid gland, the larynx and the trachea seen from the front

c. Carotid
d. Muscular triangles (Fig.4.10).

This is a median triangle. It is bounded as follows.
Epiglottis On each side, there is the anterior belly of the
corresponding digastric muscles. Its base is formed by
the body of the hyoid bone. Its apex lies at the chin.
Thyroid cartilage cartilage The floor of the triangle is formed by the right and left
Larynx Cricoid
mylohyoid muscles and the median raphe uniting them
Trachea cartilage @ig. a.3).
Tracheostomy tube
1 Two to four small submental lymph nodes are situated
in the superficial fascia between the anterior bellies
Fig. 4.8: Tracheostomy tube in position of the digastric muscles. They drain:
a. Superficial tissues below the chin.
b. Central part of the lower lip.
c. The adjoining gums.
d. Anterior part of the floor of the mouth.
e. The tip of the tongue. Their efferents pass to the
submandibular nodes.
2 Small submental veins join to form the anterior
jugular veins.
(E The area between the body of the mandible and the
tt(E hyoid bone is known as the submandibular region. The
o superficial structures of this region lie in the submental

%vd# and digastric triangles. The deep structures of the floor
of mouth and root of the tongue will be studied
separately at a later stage under the heading of
o Fig. 4.9: Langer's lines in the neck
a submandibular region in Chapter 7.

Digastric triangle

Posterior belly of digastric

Chin Sternocleidomastoid
Half submental triangle Stylohyoid
Posterior triangle

Carotid triangle
Occipital part
Muscular triangle

Superior belly of omohyoid

lnferior belly of omohyoid

Supraclavicular part
Fig. 4.10: The triangles of the neck. The anterior triangle is subdivided by digastrics and superior belly of omohyoid. Posterior
triangle is subdivided by inferior belly of omohyoid

Boundolies Conlents
The boundaries of the digastric triangle are as follows. Arferior po r{ af f h e friongfe
Ant er oinferiorly : Anterior belly of digastric. Structures superficial to mylohyoid are:
Posteroinferiorly: Posterior belly of digastric and the 1 Superficial part of the submandibular salivary gland
stylohyoid. Gig. a.3).
Superiorly or base: Base of the mandible and a line
2 The facial vein and the submandibular lymph nodes
are superficial to it and the facial artery is deep to it.
joining the angle of the mandible to the mastoid process
(Fig.4.10). 3 Submental artery
4 Mylohyoid nerve and vessels.
troof 5 The hypoglossal nerve. Other relations will be
The roof of the triangle is formed by: studied in the submandibular region.
1. Skin.
FosfencrForf of fhe Fnong{e
2 Superficial fascia, containing:
a. The platysma. 1. Superficial structures are:
b. The cervical branch of the facial nerve. a. Lower part of the parotid gland.
c. The ascendingbranch of the transverse or anterior b. The external carotid artery before it enters the
cutaneous nerve of the neck.
parotid gland. xo
3 Deep fascia, which splits to enclose the submandi- 2 Deep structures, passing between the external and zo
bular salivary gland (see Fig. 7 -6). internal carotid arteries are: ttc
a. The styloglossus. (6

b. The stylopharyngeus.
Flg,*r o
Thefloor is formed by the mylohyoid muscle anteriorly, c. The glossopharyngeal nerve (Fig. a.13).
and by the hyoglossus posteriorly. A small part of the d. The pharyngeal branch of the vagus nerve.
r middle constrictor muscle of the pharynx, appears in e. The styloid process. C)

r the floor (Fig. 4.11). f. A part of the parotid gland. ao


Middle constricior
Posterior belly of digastric

Anterior belly of digastric Hyoglossus

Mylohyoid Hyoid pulley for tendon of

digastric bellies

Fig. 4.11: Floor of the digastric triangle

3 Deepest structures include: Carefully clean and preserve superior root, the loop
a. The internal carotid artery. and inferior root of ansa cervicalis in relation to anterior
b. The internal jugular vein. aspect of carotid sheath. Locate the sympathetic trunk
c. The vagus nerve. situated posteromedial to the carotid sheath. Dissect
Most of these structures will be studied later. the branches of external carotid artery.
The submandibular lymph nodes are clinically very ldentify and preserve internal laryngeal nerve in the
important because of their wide area of drainage. They thyrohyoid interval. Trace it posterosuperiorly till vagus.
are very commonly enlarged. The nodes lie beneath the
Also look lor external laryngeal nerve supplying the
deep cervical fascia on the surface of the submandibular cricothyroid muscle.
salivary gland. They drain:
The carotid triangle provides a good view of all the
a. Centre of the forehead.
large vessels and nerves of the neck, particularly when
b. Nose with the frontal, maxillary and ethmoidal
its posterior boundary is retracted slightly backwards.
air sinuses.
c. The inner canthus of the eye.
d. The upper lip and the anterior part of the cheek BOUNDARIES
with the underlying gum and teeth. Ant er o sup er iorly : P osterior belly of the digastric muscle;
e. The outer part of the lower lip with the lower and the stylohyoid (Fig. a.12).
gums and teeth excluding the incisors.
Anteroinferiorly: Sttperior belly of the omohyoid.
f. The anterior two-thirds of the tongue excluding
the tip, and the floor of the mouth. They also Posteriorly: Anterior border of the sternocleidomastoid
receive efferents from the submental lyrnph nodes. muscle.
The efferents from the submandibular nodes pass
mostly to the jugulo-omohyoid node and partly to Roof
the jugulodigastric node. These nodes are situated 1 Skin.
along the internal jugular vein and are members of 2 Superficial fascia containing:
.!( the deep cervical chain (see Fig. B.2B). a. The plastysma.
b. The cervical branch of the facial nerve.
zo c. The transverse cutaneous nerve of the neck.
(E 3 Investing layer of deep cervical fascia.
E Clean the area situated between posterior belly of It is formed by parts of:
digastric and superior belly of omohyoid muscle, to a. The middle constrictor of pharynx.
o expose the three carotid arteries with internal jugular vein. b. The inferior constrictor of the pharynx (Fig. a.12).
o Trace lX, X, Xl and Xll nerves in relation to these vessels.
U) c. Thyrohyoid membrane.

Stylohyoid ligament

Hyoglossus Styloid process

Upper border of triangle formed bY
posterior belly of digastric

Middle constrictor

Hyoid bone

Thyrohyoid Thyrohyoid membrane (with openings for internal

laryngeal nerve and superior laryngeal vessels)
Thyrohyoid membrane

Thyroid cartilage lnferior constrictor

lnsertion of sternohyoid
(on oblique line) Lateral border of triangle formed by anterior
border of sternocleidomastoid
Cricothyroid membrane
Medial border of triangle formed by
Cricoid cartilage superior belly of omohyoid


Recurrent laryngeal nerve

Fig. 4.12: Floor of the carotid triangle

CONTENTS 5 Sympathetic chain runs (see Fig. 3.8b) vertically

downwards posterior to the carotid sheath.
Carotid sheath with its contents (see Fig. 3.8).
1 The common carotid artery with the carotid sinus Lymph nodes: The deep cervical lymph nodes are
and the carotid body at its termination;
situated along the internal jugular vein, and include
2 Internal carotid artery; and the jugulodigastric node below the posterior belly of
3 The external carotid artery with its superior thyroid, the digastric and the jugulo-omohyoid node above the
lingual, facial, ascending pharyngeal and occipital
inferior belly of the omohyoid (see Fig. 8.28).
branches (Fig. a.12).
Veins Common Corolid Arlery
1 The internal jugular vein. The right common carotid artery is a branch of the
2 The common facial vein draining into the internal brachiocephalic artery. It begins in the neck behind the
jugular vein. right sternoclavicular joint (Fig.4.13). The left common
3 A pharyrgeal vein which usually ends in the internal carotid artery is branch of the arch of the aorta. It begins
jugular vein. in the thorax in front of the trachea opposite a point a
4 The lingual vein which usually terminates in the little to the left of the centre of the manubrium. It
internal jugular vein. ascends to the back of left sternoclavicular joint and
enters the neck.
Nerves In the neck, both arteries have a similar course. Each
L The vagus running vertically downwards. artery runs upwards within the carotid sheath, under J
2 The superior larlmgeal branch of the vagus, dividing covei of the anterior border of the sternocleidomastoid. zo
into the external and internal laryngeal nerves. It lies in front of the lower four cervical transverse t,c
3 The spinal accessory nerve running backwards over processes. At the level of the upper border of the thyroid (E

the internal iugular vein. iartilage, the artery ends by dividing into the external !t(s
and internal carotid arteries (Fig. a.1a). o
4 The hypoglossal nerve running forwards over the I
external and internal carotid arteries. The hypo-
glossal nerve gives off the upper root of the ansa Corsffd$rnus c
cervicalis or descendens hypoglossi, and another The termination of the common carotid artery, or the ()

branch to the thyrohyoid. beginning of the internal carotid artery shows a slight ao

Maxillary artery Superficial temporal artery

External carotid
Styloid processs

lnternal carotid
Accessory nerve
Glossopharyngeal nerve
Pharyngeal branch of vagus Occipital ariery

Facial adery Posterior auricular artery

Outline of carotid traingle

Hypoglossal nerve Superior laryngeal nerve
Lingual artery
Ascending pharyngeal
lnternal laryngeal nerve
External laryngeal nerve Vagus nerve

Superior thyroid
lnferior root of ansa cervicalis
Superior root of ansa cervicalis

Ansa cervicalis

Fig. 4.13: The ninth, tenth, eleventh and twelfth cranial nerves and their branches related to the carotid arteries and to the internal
jugular vein, in and around the carotid triangle

dilatation, known as the carotid sinus. In this region, Externol Corotid Adery
the tunica media is thin, but the adventitia is relatively External carotid artery is one of the terminal branches
thick and receives a rich innervation from the of the common carotid artery. In general, it lies anterior
glossopharyngeal and sympathetic nerves. The carotid to the internal carotid artery, and is the chief artery of
sinus acts as a baroreceptor ot pressure receptor and supply to structures in the front of the neck and in the
regulates blood pressure. face (Fig. 4.14).
#*rurse #d?#R*Jotrrofi$
Carotid body is a small, oval reddish brown structure
situated behind the bifurcation of the common carotid
1 The external carotid artery begins in the carotid
artery. It receives a rich nerve supply mainly from the triangle at the level of the upper border of the thyroid
glossopharyngeal nerve, but also from the vagus and
cartilage opposite the disc between the third and
sympathetic nerves. It acts as a chemoreceptor arrd fourth cervical vertebrae. It runs upwards and
responds to changes in the oxygen, carbon dioxide and
slightly backwards and laterally, and terminates
pH content of the blood. behind the neck of the mandible by dividing into
the maxillary and superficial temporal arteries.
Other allied chemoreceptors are found near the arch of
the aorta, the ductus arteriosus, and the right subclavian 2 The external carotid artery has a slightly curaed course,
artery. These are supplied by the vagus nerve. so that it is anteromedial to the internal carotid artery
in its lower part, and anterolateral to the internal
carotid artery in its upper part.
The carotid sinus is richly supplied by nerves. In 3 ln the carotid triangle, the external carotid artery is
some peffions, the sinus may be hypersensitive. comparatively superficial, and lies under cover of
o In such persons, sudden rotation of the head may the anterior border of the sternocleidomastoid. The
z cause slowing of heart. This condition is called as artery is crossed superficially by the cervical branch
t,tr "carotid sinus syndrome". of the facial nerve, the hypoglossal nerve, and the
The supraventricular tachycardia may be facial,lingual and superior thyroid veins. Deep to
o controlled by carotid sinus massage/ due to the artery, there are:
I inhibitory effects of vagus nerve on the heart. a. The wall of the pharynx.
c The necktie should not be tied tightly, as it may b. The superior laryngeal nerve which divides into
.9 compress both the internal carotid arteries, the external and internal laryrrgeal nerves.
(!) supplying the brain.
c. The ascending pharyngeal artery (Fig. aJ,$.

Superficial temporal
Middle temporal

Transverse facial
Posterior auricular
Ascending palatine and tonsillar branch
Descending branch
Jugulodigastric lymph nodes
Sternocleidomastoid branch Submental branch
Ascending pharyngeal Lingual
lnternal carotid
Posterior belly of digastric
Carotid sinus Superior thyroid
Carotid body

External carotid

Common carotid

Sternocleidomastoid branch

Jugulo-omohyoid lymph nodes --------------- --ooo

--@ O
Common carotid

Fig. 4.14: Carotid arteries, branches of the external carotid artery

4 Abooe the carotid triangle, the external carotid Tenninal

artery lies deep in the substance of the parotid 1 Maxillary
gland. Within the gland, it is related superficially 2 Superficial temporal (Fig. a.1 ).
to the retromandibular vein and the facial nerve
(seeFig.5.4). Deep to the extemal carotid artery, there
$uperior Thysoid Artery
a. The internal carotid artery. The superior thyroid artery arises from the external
b. Structures passing between the external and carotid artery just below the level of the greater cornua
internal carotid arteries; these being styloglossus, of the hyoid bone.
stylopharyngeus, IX nerve, pharyngeal branch of It runs downwards and forwards parallel and just
X, and styloid process. superficial to the external laryrrgeal nerve.
c. Two structures deep to the internal carotid attery, It passes deep to the three long infrahyoid muscles
namely the superior laryngeal nerve (Fig.4.13) to reach the upper pole of the lateral lobe of the thyroid
and the superior cervical sympathetic ganglion. gland.
Its relationship to the external laryngeal nerve, which
Broncfies supplies the cricothyroid muscle is important to the
The external carotid artery gives off eight branches surgeon during thyroid surgery. The artery and nerve
which may be grouped as follows. are close to each other higher up, but diverge slightly
near the gland. To avoid injury to the nerve, the superior
Anterior thyroid artery is ligated as near the gland as possible .Y
1 Superior thyroid (Fig. a.1a) (see Fig. 8.5).
2 Lingual Apart from its terminal branches to the thyroid ttr
3 Facial (see Appendix 1) gland, it gives one important branch, the superior (E

Posterior laryngeal artery whichpierces the thyrohyoid membrane t,G

in company with the internal laryngeal nerve (Fig. a.\. o
1 Occipital
The superior thyroid artery also gives a sternocleido-
2 Posterior auricular.
mastoid branch to that muscle and a cricothyroid C
Medial branch that anastomoses with the artery of the opposite ()
Ascending pharyngeal. side in front of the cricovocal membrane. ao

ArnguolArfery the mandible, the lips and the cheek during mastication
The lingual artery arises from the external carotid artery and during various facial expressions. The artery
opposite the tip of the greater cornua of the hyoid bone. escapes traction and pressure during these movements.
It is tortuous in its course. The ceroicalpart of the facial artery runs upwards on
Its course is divided into three parts by the the superior constrictor of pharynx deep to the posterior
hyoglossus muscle. belly of the digastric, with the stylohyoid and to the
ramus of the mandible.
The first part lies in the carotid triangle. It forms a
characteristic upward loop which is crossed by the It grooves the posterior border of the submandibular
hypoglossal nerve (Fig. 4.15). The lingual loop permits salivary gland. Next the artery makes an S-bend (two
free movements of the hyoid bone. loops) first winding down over the submandibular
Tl:.e second partlies deep to the hyoglossus along the gland, and then up over the base of the mandible
upper border of hyoid bone. It is superficial to the (see Fig.7.B).
middle constrictor of the pharynx. The facinl part of the facial artery enters the face at
The third part is called the arteria profunda linguae, anteroinferior angle of masseter muscle, runs upwards
or the deep lingual artery.It runs upwards along the close to angle of mouth, side of nose till medial angle
anterior border of the hyoglossus, and then hoizontally of eye. It is described in Chapter 2.
forwards on the undersurface of the tongue as the fourth The cervical part of the facial artery gives off the
part. In its vertical course, it lies between the ascending palatine, tonsillar, submental, and glandular
genioglossus medially and the inferior longitudinal branches for the submandibular salivary gland and
muscle of the tongue laterally. The horizontal part of lymph nodes.
the artery is accompanied by the lingual nerve. The ascending palatine artery arises near the origin of
During surgical removal of the tongue, the first part the facial artery. It passes upwards between the
of the artery is ligated before it gives any branch to the styloglossus and the stylopharyngeus, crosses over the
tongue or to the tonsil. upper border of the superior constrictor and supplies
the tonsil and the root of the tongue.
FCIcr*fArfery The submental branch is a large artery which accom-
The facial artery arises from the external carotid just panies the mylohyoid nerve, and supplies the
above the tip of the greater cornua of the hyoid bone. submental triangle and the sublingual salivary gland.
It runs upwards first in the neck as cervical part and
then on the face as facial part. The course of the artery #ccipitalArfery
in both places is tortuous. The tortuosity in the neck The occipital artery arises from the posterior aspect of
allows free movements of the pharynx during the external carotid artery, opposite the origin of the
deglutition. On the face, it allows free movements of facial artery.

Circumvallate papillae

Styloid process with

stylohyoid ligament Tongue

Deep lingual artery
Lingual artery

Hypoglossal nerve
Sublingual gland
Ascending pharyngeal
zo Genioglossus
Middle constrictor
!,(E Geniohyoid
o Descendens hypoglossi

c External carotid artery Geniohyoid

o Hyoglossus
a Fig.4.15: The lingual aftery

It is crossed at its origin by the hypoglossal nerve. studied with the face,
transoerse facial artery, already
In the carotid triangle, the artery gives two and a middle temporal artery which runs on the
sternocleidomastoid branches. The upper branch temporal fossa deep to the temporalis muscle.
accompanies the accessorynerve, and the lowerbranch
arises near the origin of the occipital artery. Anso Cervicolis or Anso Hypoglossi
The further course of the artery in scalp has been This is a thin nerve loop that lies embedded in the
described in Chapter 1.0 (see Fig. 10.5). anterior wall of the carotid sheath over the lower part of
the laryrrx. It supplies the infrahyoid muscles (Fig a.16).
Fosferior A urf *ufmr Arferpr
The posterior auricular artery arises from the posterior Formgfr'on
aspect of the external carotid just above the posterior It is formed by a superior and an inferior root. The
belly of the digastric (Fig. 4.14). superior root is the continuation of the descending
It runs upwards and backwards deep to the parotid branch of the hypoglossal nerve. Its fibres are derived
gland, but superficial to the styloid process. It crosses from the first cervical nerve. This root descends over
the base of the mastoid process, and ascends behind the internal carotid artery and the common carotid
the auricle. artery.
It supplies the back of the auricle, the skin over the The inferior root or descending cervical nerve is
mastoid process, and over the back of the scalp. It is derived from second and third cervical spinal nerves.
cut in incisions for mastoid operations. Its stylomastoid As this root descends, it winds round the internal
branch enters the stylomastoid foramen, and supplies jugular vein, and then continues anteroinferiorly to join
the middle ear, the mastoid antrum and air cells, the the superior root in front of the common carotid artery
semicircular canals, and the facial nerve. (Fig. a.16).
As*endfng Phcryrgeaf Arlery
This is a small branch that arises from the medial side
Superior root: To the superior belly of the omohyoid.
of the external carotid artery. It arises very close to the
lower end of external carotid artery (see Fig.14.1.6). Arusa ceraicslis: To the sternohyoid, the sternothyroid
It runs vertically upwards between the side wall of and the inferior belly of the omohyoid.
the pharynx, and the tonsil, medial wall of the middle Note that the thyrohyoid and geniohyoid are
ear and, the auditory tube. It sends meningeal branches supplied by separate branches from the first cervical
into the cranial cavity through the foramen lacerum, nerve through the hypoglossal nerve (Fig. a.16).
the jugular foramen and the hypoglossal canal.

Mcxrlfr*y Arf*rXr Hypoglossal

This is the larger terminal branch of the external carotid
artery. It begins behind the neck of the mandible under ramus of C1
cover of the parotid gland. It runs forwards deep to
the neck of the mandible below the auriculotemporal Ventral
nerve, and enters the infratemporal fossa where it will ramus of C2
be studied at a later stage (see Chapter 6).
$xp erficiol lerr:porcJ A riery ramus of C3

1 It is the smaller terminal branch of the extemal carotid

artery. It begins, behind the neck of the mandible lnferior root
To thyrohyoid of ansa cervicalis
under cover of the parotid gland (see Fig. 5.5a).
2 It runs vertically upwards, crossing the root of the To geniohyoid .|a
zygoma or preauricular point, where its pulsations zo
can be easily felt. About 5 cm above t}:.e zygoma, it t,c
To superior belly
divides into anterior and posterior branches which of omohyoid (E

supply the temple and scalp. The anterior branch !,(E

anastomoses with the supraorbital and supra- To sternohyoid To inferior belly o
of omohyoid
trochlear branches of the ophthalmic artery.
3 In addition to the branches which supply the temple, To sternothyroid
the scalp, the parotid gland, the auricle and the facial Fig. 4.16: Ansa cervicalis, and branches of the first cervical o
muscles, the superficial temporal artery gives off a nerve distributed through the hypoglossal nerve @

The infrahyoid muscles are:

a. Sternohyoid
:' r' '] r "tsf$sEcTtoil ' b. Sternothyroid
ldentify the infrahyoid muscles on each side of the c. Thyrohyoid
median plane. Cut through the origin of sternocleido- d. Omohyoid.
mastoid muscle and reflect it upwards. Trace the nerve
These ribbon muscles have the following general
supply of infrahyoid muscles.
The superficial structures in the inlrahyoid region
a. They are arranged in two layers, superficial
are included in this triangle. The deeper structures
(thyroid gland,lrachea, oesophagus, etc.) will be studied
(sternohyoid and omohyoid) and deep (ster-
nothyroid and thyrohyoid) (Fig. 4.6).
separately at a later stage.
b. All of them are supplied by the ventral rami of
BOUNDARIES first, second and third cervical spinal nerves.
Anteriorly: Anterior median line of the neck from the
c. Because of their attachment to the hyoid bone and
hyoid bone to the sternum.
to the thyroid cartilage, they move these
Posterosuperiarly: Sttperior belly of the omohyoid muscle
d. Sternohyoid, superior belly of omohyoid, sterno-
(Fis. a.6).
thyroid lie superficial to the lateral or superficial
Pasteroinferiorly: Anterior border of the sterno- convex surface of the thyroid gland.
cleidomastoid muscle. e. The anterior surface of isthmus of thyroid gland
Conlents is covered by right and left sternothyroid and
sternohyoid muscles.
The infrahyoid muscles are the chief contents of the
triangle. These muscles may also be regarded arbitrarily The specific details of infrahyoid muscles are shown
as forming the floor of the triangle (Fig.4.6). in Table 4.1.

T6hle4il :.-;Llffahfcid, rmuStle+.

Muscle Praximal attachment Distal attachment Nerue supply Actions
1. Sternohyoid a. Posterior surface Medial part of lower Ansa cervicalis Depresses the hyoid
(Fig. a.6) of manubrium border of hyoid bone C1, C2, C3 bone following its
sterni elevation during
b. Adjoining pafts of swallowing and during
the clavicle and vocal movements
the posterior
2. Sternothyroid: a. Posterior surface Oblique line on the Ansa cervicalis Depresses the larynx
It lies deep to the of manubrium sterni lamina of the thyroid C1, C2, C3 after it has been elevated
sternohyoid b. Adjoining part of cadilage in swallowing and in
first costal cartilage vocal movements
3. Thyrohyoid: Oblique line of thyroid Lower border of the C1 through a. Depresses the hyoid
It lies deep to the cartilage body and the greater hypoglossal nerve bone
sternohyoid cornua of the hyoid b. Elevates the larynx
bone when the hyoid is fixed
by the suprahyoid
L muscles
z 4. Omohyoid: lt has a. Upper border of Lower border of body of Superior belly by Depresses the hyoid
E an inferior belly, a scapula near the hyoid bone lateral to the the superior root of bone following its
(E common tendon and suprascapular sternohyoid. The central the ansa cervicalis, elevation during
E' a superior belly. lt notch tendon lies on the and inferior belly by swallowing or in vocal
o arises by the inferior b. Adjoining part of internal jugular vein at inferior root of movements
belly, and is inserted suprascapular the level of the cricoid ansa cervicalis
through the superior ligament cartilage and is bound
.o belly to the clavicle by a
o fascial pulley

Mnemonics o The necktie should not be tied tightly, as it may

compress both the internal carotid arteries,
External carotid artery branches supplying the brain.
Superior thyroid ( anterior)
Ascending pharyngeal (medial )
Lingual (anterior)
A patient is undergoing abdominal surgery.
Facial (anlerior) Anaesthetist is sitting at the head end of the table
Occipital (posterior) and monitoring patient's pulse by palpatrng arteries
Poslerior auricular ( posLerior) in the head and neck region
Superficial temporal (termi nal )
r What artery is the anaesthetist palpating?
r Name the other palpable arteries in the body.
Maxillary (terminal)
Ans: The anaesthetist has been monitoring the pulse
by paipating the ccmmon carotid artery at the
anterior border of sternocleidomastoid muscle. He
need not get up to feel the radial pulse repeatedly.
Apex of anterior triangle of neck is close to the Other palpable arteries in head and neck are
sternum, while that of posterior triangle is close superficial ternporal and facial. In upper limb
to the mastoid process. palpable arteries are third part of axillary artery,
Submental triangle is half on each of the brachial artery and radial pulse.
midline. In abdomcn one can feel abdominal aorta
Maximum blood vessels are present in the carotid pulsation when one lies supine
triangle Palpable arteries in lower linnb are femoral athead
Superficial temporal artery can be palpated at the of femur, popliteal. dorsalis pedis and posterior
preauricular point. tibial.


1. Only medial branch external carotid artery is: 4. Hyoid bone develops from:
a. Superior thyroid a. Lst and 2nd arches b. 2nd and 3rd arches
b. Lingual c. 3rd and 4th arches d. 1st,2nd and 3rd arches
c. Ascending pharyngeal 5. Which of the following is not a palpable artery in
d. Maxillary head and neck?
2. All the following are branches of external carotid a. Facial artery
except: b. Superficial temporal artery
a. Posterior ethmoidal c. Lingual artery
b. Occipital d. Common carotid arlery
c. Lingual 6. Which of the following is not a infrahyoid muscle?
d. Facial a. Sternohyoid b. Sternothyoid
J. Muscles forming boundaries of carotid triangle are c. Thyrohyoid d. Omohyoid-inferior belly
all except: 7. Which of the following nerve runs with vagus l<
a. Posterior belly of digastric between internal carotid artery and internal jugular zo
b. Superior belly of omohyoid vein till the angle of the mandible? !,
c. Inferior belly of omohyoid a. Hypoglossal b. Accessory
d. Sternocleidomastoid c. Glossopharyrrgeal d. Maxillary o

1.c 2,. a 3.C 4.b 5.c 6,d 7.a ao
Parotid Region
Eal, doi./,/y am/,/zal,.a/ tan4aua;,San, LrL.eze, magr nal /pe, * lonaa.+aus

INTRODUCTION Facial nerve is the main nerve of the face, supplying

Parotid region contains the largest serous salivary gland all the muscles of facial expression, carrying
and the "queen of the flace", the facial nerve. Parotid secretomotor fibres to submandibular, sublingual
gland contains vertically disposed blood vessels and salivary glands, including those in tongue and floor of
horizontally situated faciaL nerve and its various mouth. lt is also secretomotor to glands in the nasal
branches. Parotid gland gets affected by virus of cavity, palate and the lacrimal gland. lt is responsible
mumps, which can extend the territory of its attack up enough for carrying the taste fibres from anterior two-
to gonads as well. One must be careful of the branches thirds of tongue also except from the vallate papillae
of facial nerve while incising the parotid abscess by (see Chapter 24).
giving horizontal incision. Facial nerve is described in
Chapter 24. Feolures
(Para = around; otic = eat)
There are three pairs of large salivary glands-the The parotid is the largest of the salivary glands. It
parotid, submandibular and sublingual. In addition, weighs about 15 g. It is situated below the external
acoustic meatus, between the ramus of the mandible
there are numerous small glands in the tongue, the
and the sternocleidomastoid. The gland overlaps these
palate, the cheeks and the lips. These glands produce
saliva which keeps the oral cavity moist, and helps in
structures. Anteriorly, the gland also overlaps the
masseter muscle (Fig. 5.1). A part of this forward
chewing and swallowing. The saliva also contains
extension is often detached, and is known as the
enzymes that aid digestion.
accessory parotid, and it lies between the zygomatic arch
and the parotid duct.

Carefully cut through the fascial covering of the parotid
gland from the zygomatic arch above to the angle of
mandible below. While removing tough fascia, dissect External
the structures emerging at the periphery of the gland. meatus
Trace the duct of the parotid gland anteriorly till the
buccinator muscle. Trace one or more of the branches
of facial nerve till its trunk in the posterior part of the
gland. The trunk can be followed till the stylomastoid Outline of
paroiid gland
foramen. Trace its posterior auricular branch. Trace the
course of retromandibular vein and external carotid
artery in the gland, removing the glands in pieces. Clean
Angle of
the facial nerve already dissected. Study the entire mandible
course of facial nerve from its beginning to the end.
Fig.5.'l; Position of parotid gland

Anterior parotid gland from the submandibular salivary gland.

The ligament is pierced by the external carotid artery.

Parotid gland t Paratid sweltings are very painful due to the
Retromandibular vein unyielding nature of theparotid fascia.
and facial nerve o Mumps is an infectious disease of the salivary
lnternal Parotid fascia
(superficial lamina
glands (usually the parotid) caused by a specific
carotid artery
of investing layer) virus, Viral parotitis or mumps characteristically
Styloid process with does not suppurate. Its complications are orchitis
aitached muscles External carotid
ariery piercing and pancreatitis.
ligament Externol Feotures
Sternocleidomastoid The gland resembles a three sided pyramid.
The apex of the pyramid is directed downwards
(Fig. 5.3).
Fig. 5.2: Capsule of the parotid gland
The gland has four surfaces:
a. Superior (base of the pyramid)
Copsule of Porotid Glond b. Superficial (Fig. 5.3)
The investing layer of the deep cervical fascia forms a c. Anteromedial
capsule for the gland (Fig. 5.2). The fascia splits d. Posteromedial (Fig. 5.4a).
(between the angle of the mandible and the mastoid The surfaces are separated by three borders:
process) to enclose the gland. The superficial lamina, a. Anterior (Fig.s.ab)
thick and adherent to the gland, is attached above to b. Posterior
the zygomatic arch. The deep lamina is thin and is c. Medial/pharyngeal
attached to the styloid process, the angle and posterior
border of the ramus of the mandible and the tympanic ffpXtrfions
plate. Aportion of the deep lamina, extendingbetween The apex (Fig. 5.3) overlaps the posterior belly of the
the styloid process and the mandible, is thickened to digastric and the adjoining part of the carotid triangle.
form the stylomandibular ligamenf which separates the The cervical branch of the facial nerve and the two

Temporal Auriculoiemporal nerve

Superficial temporal vessels

External auditory meatus
Upper buccal
Posterior auricular nerve
Transverse facial artery
Posterior auricular artery and vein
Accessory parotid gland Apex --o
Parotid duct
Posterior auricular vein
Lower buccal
External jugular vein tG
Marginal mandibular
Cervical Anterior and posterior divisions of
retromandibular vein
Facial vein Common facial vein o
Fig. 5.3: Structures emerging at the periphery of the parotid gland ao

divisions of the retromandibular vein emerge near the a. The mastoid process, with the sternocleido-
aPex. mastoid and the posterior belly of the digastric.
b. The styloid process, with structures attached to
The superior surface or base forms the upper end of the
gland which is small and concave. It is related to: c. The external carotid artery enters the gland
through this surface and the intemal carotid artery
a. The cartilaginous part of the external acoustic
lies deep to the styloid process (Fig. S.aa).
b. The posterior surface of the temporomandibular Borders
joint. from
The anterior border separates the superficial surface
c. The superficial temporal vessels. the anteromedial surface. It extends from the anterior
d. The auriculotemporal nerve (Fig. 5.3). part of the superior surface to the apex. The following
T}:.e superficial surface is the largest of the four
structures emerge at this border:
surfaces. It is covered with:
a. The parotid duct.
a. Skin
b. Superficial fascia containing the anterior branches b. Most of the terminal branches of the facial nerve.
of the great auricular nerve, the preauricular or c. The transverse facial vessels. In addition, the
superficial parotid lymph nodes and the posterior accessory parotid gland lies on the parotid duct
fibres of the platysma and risorius. close to this border (Fig. 5.3).
c. The parotid fascia which is thick and adherent to The posterior border separates the superficial surface
the gland (Fig. 5.2). from the posteromedial surface. It overlaps the
d. A few deep parotid lymph nodes embedded in sternocleidomastoid (Fig. s.ab).
the gland (Fig. 5.1). The medial edge or pharyngeal border separates the
"l}rre anteromedial surface (Fig. 5.4a) is grooved by the anteromedial surface from the posteromedial
posterior border of the ramus of the mandible. It is surface. It is related to the lateral wall of the pharynx
related to: (Fig. 5.aa).
a. The masseter
b. The lateral surface of the temporomandibular Structures within the parotid gland
joint. From medial to the lateral side, these are as follows.
c. The posterior border of the ramus of the mandible 't Arteries: The external carotid artery enters the gland
d. The medial pterygoid through its posteromedial surface (Fig. 5.5a). The
e. The emerging branches of the facial nerve. maxillary artery leaves the gland through its
Theposteromedial surface (Fig. 5. a) is moulded to the anteromedial surface. The superficial temporal artery
mastoid and the styloid processes and the structures gives transverse facial artery and emerges at the
attached to them. Thus it is related to: anterior part of the superior surface.

Medial pterygoid
Branches of
facial nerve Ramus of mandible

Wall of pharynx
Parotid gland
Medial edge
Retromandibular vein
Styloid process with Anteromedial
attached muscles surface
External carotid artery
ffi-* Internal carotid artery Medial edge

!tc Lymph nodes dP-tnternat jugutar vein

(E Sternocleidomastoid Facial nerve Posteromedial
(E surface
Masioid process
Posterior belly
c (a) of digastric (b)
o Figs 5,4a and b: (a) Horizontal section through the parotid gland showing its relations and the structures passing through it, and
a (b) gross features of parotid gland

Veins: The retromandibular veinis formed within the a. Temporofacinl: Dividesinto temporal and zygomatic
gland by the union of the superficial temporal and branches.
maxillary veins. In the lower part of the gland, the b. Cerr,ticofacial: Divides into buccal, marginal
vein divides into anterior and posterior divisions mandibular and cervical branches.
which emerge close to the apex (lower pole) of the The various branches (5-6) of facial nerve radiate like
gland (Fig.5.5b). a goose-foot from the curved anterior border of the
Tl:.e facial nerzte exits from cranial cavity through parotid gland to supply the respective muscles of
stylomastoid foramen and enters the gland through facial expression. This pattern of branching is called
the upper part of its posteromedial surface, and "pes anserinus".
divides into its terminal branches within the gland. 4 Parotid lymph nodes.
The branches leave the gland through its
anteromedial surface, and appear on the surface at
P atey's facioae nous plane
The gland is composed of a large superficial and a small
the anterior border (Fig. 5.5c).
deep part the two being connected by an 'isthmus' around
Facial nerve lies in relation to isthmus of the gland
which facial nerve divides (Fig.5.5d).
which separates large superficial part from small
deep part of the gland. Facial nerve divides into two Accessory processes af parotid gland
branches (Figs 5.5d and e): Facial process along parotid duct

Transverse facial Transverse facial

Superficial temporal
temporal Maxillary

Posterior Facial Posterior auricular

External jugular
External carotid Common facial
Anterior division Posterior division

(a) (b)

Zygomatic Temporal branch


Facial Superficial
Upper part
buccal nerve
branch Cervico- Isthmus
facial I
nerve o
Deep part z
branch Cervical ttc
branch G

Figs 5.5a to e: Structures within the parotid gland: (a) Arteries, (b) veins, (c) nerves, (d) two parts of the parotid gland are separated o
by isthmus, and (e) superficial part overlapping the deep part U)

Pterygoid process between mandibular ramus

and medial pterygoid.- I
Glenoid process external acoustic A psrotid dbscess may be caused by spread of
- betweenjoint
meatus and temporomandibular infection from the opening of parotid duct in the
mouth cavity (Fig. 5.6).
Poststyloid process
r Parotidectomy is the removal of the paroiid gland.
Porotid DuciAlenson's Duct
.l638-86) After this operation, at tirnes, there may be
(Dutch Anotomist regeneration of the secretomotor fibres in the
It is thick walled and is about 5 cm long. It emerges auriculotemporal nerve which join the great
from the middle of the anterior border of the gland auricular nerve. This causes stimulation of the
(Fig. 5.1).It runs forwards and slightly downwards on sweat glands and hyperaemia in the area of its
the masseter. Here its relations are: distribution, thus producingredness and sweating
in the area of skin supplied by the nerve. This
$up*rferrfy clinical entity is called Frey syndroffie. Whenever,
L Accessory parotid gland. such a person chews there is increased sweating
2 The transverse facial vessels (Fig. 5.3). in the region supplied by auriculotemporalnerve.
3 Upper buccal branch of the facial nerve. $o it is also called'auriculotemporal syndrome'.

The lower buccal branch of the facial nerve. BIood Supply
At the anterior border of the masseter, the parotid The parotid gland is supplied by the external carotid
duct turns medially and pierces:
artery and its branches that arise within the gland. The
a. The buccal pad of fat.
veins drain into the external jugular vein and internal
b. The buccopharyngeal fascia. jugular vein.
c. The buccinator (obliquely).
Because of the oblique course of the duct through
the buccinator, inflation of the duct is prevented during Nerve Supply
blowing. 1. Parasympathetic nerves are secretomotor (Fig. 5.7).
The duct runs forwards for a short distance between They reach the gland through the auriculotemporal
the buccinator and the oral mucosa. Finally, the duct nerve.
turns medially and opens into the vestibule of the The preganglionic fibres begin in the inferior
mouth (gingivobuccal vestibule) opposite the crown of salivatory nucleus; pass through the glossophaqmgeal
the upper second molar tooth (see Fig.2.26). nerve, its tympanic branctq the tympanic plexus and

Opening of parotid duct


J Undersurface of tongue
6 Sublingual fold
t,G Submandibular duct

ao of salivary glands
Mandibular nerve
ihrough foramen ovale

Otic ganglion

Auriculotemporal nerve

Glossopharyngeal nerve

Parotid gland
Tympanic branch

Fig.5.7; Parasympathetic nerve supply to the parotid gland

the lesser petrosal nerve; and relay in the otic Porotid Lymph Nodes
ganglion. The parotid lymph nodes lie partly in the superficial
The postganglionic fibres pass through the fascia and partly deep to the deep fascia over the parotid
auriculotemporal nerve and reach the gland. This is gland (Fig.5.1). They drain:
shown in Flow chart 5.1. a. Temple
2 Sympathetic nerves are vasomotor, and are derived b. Side of the scalp
from the plexus around the middle meningeal artery. c. Lateral surface of the auricle
3 Sensory nerves to the gland come from the d. External acoustic meatus
auriculotemporal nerve, but the parotid fascia is e. Middle ear
innervated by the sensory fibres of the great auricular f. Parotid gland
nerve (C2, Cg). g. Upper part of the cheek
h. Parts of the eyelids and orbit.
Lymphotic Droinoge Efferents from these nodes pass to the upper group
of deep cervical nodes.
Lymph drains first to the parotid nodes and from there
to the upper deep cervical nodes. DEVELOPMENT
The parotid gland is ectodermal in origin. It develops
from the buccal epithelium just lateral to the angle of
Flow chart 5.1 : Tracing nerve supply of parotid gland mouth. The outgrowthbranches repeatedly to form the
duct system and acini. The mesoderm forms the
lnferior salivalory,nucleus intervening connective tissue septa.

A parotid abscess is best drained by horizontal

incision kno$/n as Hilton's method (Fig. 5.8) below
the angle of mandible
During surgical removal of the parotid gland or
parotidectomp the facial nerve is preserved by
removing the gland in two parts, superficial and o
deep separately, The plane of cleavage is defined zo
by tracing the nerve from behind forwards. tc
Mixedpdrotid tumour is a slow growing lobulated (E
painless tumour without any involvement of the
facial nerve. Malignant change of such a tumour
Postganglionic fibres pass through auriiulotemporal nerve
is indicated by pain, rapid growth, fixity with c
hardness, involvement of the facial nerye, and .9
enlargement of cervical lymph nodes.
Parotid gland

o The parotid calculi may get formed within the Facial nerve passes through two foramina of skull,
parotid gland or in its Stenson's duct. These can i.e internal acoustic meatus and stylomastoid
be located by injecting a radiopaque dye through foramen.
its opening in the vestibule of the mouth. The
procedure is called 'Sialogram'. The duct can be
examined by a spatula or bidigital examination.
A young man complained of fever and sore throat,
noied a swelling ana felt pain on both sides of his
face in front of the ear. Within a few days, he noted
swellings below his jaw and below his chin. He
suddenly started looking very healthy by facial
appearance. The pain increased while chewing or
drinking lemon juice. The physician noted
enlargement of all three salivary glands on both sides
{at*\ of the face.
* o Where do the ducts of salivary glands open?
. Why did the pain increase while chewing?
. Why did the pain increase while drinking lemon
Parotid gland wiih
branches of facial nerve Ans; illlte duct of the parotid. gland opens at a papilla
Horizontal incision for
in the vestibule af mouth opposite the 2nd uPper
drainage of abscess molar tooth. The duct of submandibular gland opens
Parotid duct at the papiila on the sublingual fold" The sublinguai
Fig. 5.8: Horizontal incision for draining parotid abscess. gland opens by 10-12 ducts on ihe sublingual fold.
Branches of facial nerve also seen The investing Layer of cervical fascia encl*ses boih
the parotid and the submanclihuiar giands and is
attached to the iower border of the manciible. As
mandible movqs during chewing, the fascia gets
Facial nerve courses through the parotid gland, siretched which results in pain. The fascia and skin
without supplying any structure in it. are suppiied by the great auricular nerve.
Skin over the parotid gland is supplied by great Ii\rhile drinking lemon juice, there is lot of pain, as
auricular nerve/ C2, C3. the salivary secretion is stimulated by the acid of the
Deepest structure in the substance of parotid gland lemon juice.
is the external carotid artery The investing layer *f cervical fa*qcia encloses: f\ffo
Otic ganglion is the onlyparasympathetic ganglion muscles, the trapezius and the sternocleidomastoid;
with 4 roots two spaces, the suprasternal space and the
Facial nerve divides into temporofacial and supraclavicular space; twa glands, the parotid and
cervicofacial branches. The formei gives temporal ti"re submandibutar glands; and forms tw'a puileys,
and zygomatic branches. The latter gives buccal, one for the intermediate tendon of digastric and one
marginal mandibular and cervical branches for the interrnediate tendon of om*hiroid muscle.

o c. Otic ganglion
o 1. Nerve carrying postganglionic parasympathetic
z fibres of the parotid gland is: d. Submandibular ganglion
(E a. Facial b. Auriculotemporal 3. Which of the following artery passes between the
€c, c. Inferior alveolar d. Buccal roots of the auriculotemporal nerve?
I 2. Somata of postganglionic secretomotor fibres to a. Maxillary
parotid gland lie in: b. Middle meningeal
.o a. Ciliary ganglion c. Superficial temporal
U) b. Pterygopalatine ganglion d. Accessory meningeal
Vein formed by union of posterior division of c. Superficial temporal
retromandibular and posterior auricular vein is: d. Maxillary
a. Internal jugular b. External jugular 7. One of the following nerves is not related to parotid
c. Common facial d. Anterior jugular gland:
All of the following are peripheralparasympathetic a. Temporal branch of facial
ganglia except: b. Zygomatic branch of facial
c. Buccal branch of facial
a. Otic b. Ciliary
d. Posterior superior alveolar branch of maxillary
c. Pterygopalatine d. Geniculate Pes anserinus is the arrErngement in which of the
6. Which artery is not inside the parotid gland? following nerves?
a. External carotid a. Vagus b. Trigeminal
b. Intemal carotid c. Facial d. Glossopharyngeal

Temporal and
lnfratemporal Regions
lB e*t y'.h.y,;aiaru. ata: A ac.l.a,z 9*r,et1 Oaclaa. fie$ g'v g iel ar.d g aclo".Uc4ryrri/tz,
of Solerno

Coronal bone
Temporal and infratemporal regions include muscles suture
of mastication, which develop from mesoderm of first Frontal
temporal line
branchial arch. Only one joint, the temporomandibular bone
joint, is present on each side between the base of skull Sphenoid temporal line
and mandible to allow movements during speech and bone
Zygomatic Squamous
The parasympathetic ganglion is the otic ganglion, temporal
the only ganglion with four roots, i.e. sensory, sym- Occipital
pathetic, motor and secretomotor or parasympathetic. Maxilla bone
The blood supply of this region is through the
Mastoid process
maxillary artery. Middle meningeal artery is its most Pterygomaxillary
important branch, as its injury results in extradural Zygomatic arch
Laieral pterygoid
haemorrhage. plate
Fig.6"1 : Some features seen on the lateral side of the skull

J Zygomaticotemporal nerve and artery.

In order to understand these regions, the osteology of 4 Deep temporal nerves for supplying temporalis
the temporal fossa, and the infratemporal fossa should muscle.
be studied. Tlne temporal fossalies on the side of the skull, Deep temporal artery, branch of maxillary artery.
and is bounded by the superior temporal line and the
zygomatic arch.

Anterioy: Zygomatic and frontal bones (Fig. 6.1).
It is an irregular space below zygomatic arch.
Pasterior: Inferior temporal line and supramastoid crest. BOUNDARIES
Superior: Superior temporal line
Anterior: Posterior surface of body of maxilla.
lnferiar : Zy gomatic arch.
Roaf:Infuatemporal surface of greater wing of sphenoid.
Floor: Pafis of frontal, parietal, temporal and greater
wing of sphenoid. Temporalis muscle is attached to the Medinl: Lateral pterygoid plate and pyramidal process
floor and inferior temporal line. of palatine bone.
Lsteral: Ramus of mandible (Fig. 6.2).
L Temporalis muscle. CONTENIS
2 Middle temporal artery (branch of superficial L Lateral pterygoid muscle.
temporal artery) (see Chapter 4). 2 Medial pterygoid muscle. 114

Middle cranial fossa DISSECTION

ldentify the masseter muscle extending from the
zygomatic arch to the ramus of the mandible, Cut the
Temporal fascia zygomatic arch in front of and behind the attachment
o, masseter muscle and reflect it downwards. Divide
Temporal fossa
the nerve and blood vessels to the muscle. Clean the
ramus of mandible by stripping off the masseter muscle
from it.
Zygomatic arch
Give an oblique cut from the centre of mandibular
lnfratemporal cresi of notch to the lower end of anterior border of ramus of
greaier wing of sphenoid mandible. Turn this part of the bone including the
lnfratemporal surface of greater wing insertion of temporalis muscle upwards. Strip the muscle
Ramus of mandible from the skull and identify deep temporal nerves and
Lateral pterygoid plate
Make one cut through the neck ol the mandible. Give
Medial pterygoid plate another cut through the ramus at a distance of 4 cm
Fig.6.2: Scheme to show the outline of the temporal and from the neck. Remove the bone carefully in between
infratemporal fossae in a coronal section these two cuts, avoiding injury to the underlying
structures. The lateral pterygoid is exposed in the upper
J Mandibular nerve with its branches. part and medial pterygoid in the lower part of the
4 Maxillary nerve with posterior superior alveolar dissection.
nerve (see Chapter 15).
5 Chorda tympani, branch of VII nerve. FEATURES
5 Lst and 2nd parts of maxillary artery with their The muscles of mastication move the mandible during
branches. mastication and speech. They are the masseter, the
7 Posterior superior alveolar artety,branch of 3rd part temporalis, the lateral pterygoid and the medial
of maxillary artery. pterygoid. They develop from the mesoderm of the first
8 Accompanying veins. branchial arch, and are supplied by the mandibular
nerve which is the nerve of that arch. The muscles are
enumerated in Table 6.1 and shown in Figs 6.3 to 6.5.
Temporal fascia and relations of lateral and medial
pterygoid muscles are described.
The external ear or pinna is a prominent feature on the
lateral aspect of the head. TEMPORAT FASCIA
1. The zygomaticbone forms the prominence of the cheek The temporal fascia is a thick aponeurotic sheet
at the inferolateral corner of the orbit. The zygomatic that roofs over the temporal fossa and covers the
archbridges the gap between the eye and the ear. temporalis muscle. Superiorly, the fascia is single
2 The head of the mandible lies in front of the tragus. layered and is attached to the superior temporal line.
It is felt best during movements of the lower jaw. Inferiorly, it splits into two layers which are attached
3 The mastoid process is a large bony prominence to the inner and outer lips of the upper border of the
situated behind the lower part of the auricle. zygomatic arch. The small gap between the two layers
4 The superior temporalline forms the upperboundary contains fat, a branch from the superficial temporal so
of the temporal fossa which is filled up by the artery and the zygomaticotemporal nerve.
temporalis muscle. The superficial surface of the temporal fascia receives E
5 The pterion is the area in the temporal fossa an expansion from the epicranial aponeurosis. This G
where four bones (frontal, parietal, temporal and surface gives origin to the auricularis anterior and It
sphenoid) adjoin each other across an H-shaped superior, and is related to the superficial temporal o
suture (Fig. 6.1). vessels, the auriculotemporal nerve, and the temporal
6 The junction of the back of the head with the neck is branch of the facial nerv e (seeEig.5.3). The deep surface C
indicated by the external occipital protuberance and of the temporal fascia gives origin to some fibres of the o
the superior nuchal lines. temporalis muscle. @
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Parietal bone


(deep head)

(superficial head)

Fig.6.3: Origin and insertion of the masseter muscle. Origin of temporalis also shown

Zygomatic arch


joini capsule

Lateral ligameni

Fig.6.z[: Origin and insertion of the temporalis muscle

The fascia is extremely dense. In some species (e.g. Deep

tortoise), the temporal fascia is replaced by bone. 1 Mandibular nerve
2 Middle meningeal artery (Fig. 6.10).
RELATIONS OF IATERAI PIERYGOID 3 Sphenomandibular ligament
The lateral pterygoid may be regarded as the key 4 Deep head of the medial pterygoid.
muscle of this region because its relations provide a Structures Emerging ot the Upper Border
fair idea about the layout of structures in the infra- zo
temporal fossa. The relations are as follows: 1 Deep temporal nerves (Fig. 6.6) t
2 Masseteric nerve. G
Superficiol Structures Emerging of the lower Border o
1. Masseter (Fig. 6.5) L Lingual nerve
2 Ramus of the mandible 2 Inferior alveolar nerve c
3 Tendon of the temporalis 3 The middle meningeal artery passes upwards deep o
4 The maxillary artery (Fig. 6.6). to it (Fig. 6.6). a

lnsertion of lateral pterygoid

into pterygoid fovea

Articular disc

Upper and lower heads

of lateral pterygoid

Deep head of
medial pterygoid
alveolar nerve
Lingual nerve
Superficial head of medial pterygoid
Mandible (cut)

Fig.6.5: The lateral and medial pterygoid muscles

Accessory meningeal
Middle meningeal

Masseteric artery and nerve

Deep auricular

Maxillary artery

Anterior tympanic

lnferior alveolar nerve and artery

Mylohyoid nerve and artery

Fig.6.6: Some relations of the lateral pterygoid muscle and branches of maxillary artery
zo Slruclures Possing through RELAIIONS OF MEDIAL PTERYGOID
(E the Gop Between the Two Heods The superficial and deep heads of medial pterygoid
t,(E L The maxillary artery enters the gap enclose the lower head of lateral pterygoid muscle
o (Fib. 6.s).
I 2 The buccal branch of the mandibular nerve comes
out through the gap (Fig. 6.6). Superficiol Relotions
(J The pterygoid plexus of veins surrounds the lateral The upper part of the muscle is separated from the
ao pterygoid. lateral pterygoid muscle by:

1 The lateral pterygoid plate The external and middle ears, and the auditory tube
2 The lingual nerve (Fig. 6.5). (Fig.6.7)
3 The inferior alveolar nerve. , The dura mater
Lower down the muscle is separated from the ramus 3 The upper and lower jaws and teeth
of the mandible by the lingual and inferior alveolar 4 The muscles of the temporal and infratemporal
nerves, the maxillary artery, and the sphenomandibular regions
ligament. 5 The nose and paranasal air sinuses
6 The palate
Deep Relotions 7 The root of the pharynx.
The relations are:
1 Tensor veli palatini COURSE AND RELATIONS
2 Superior constrictor of pharynx For descriptive purposes, the maxillary artery is divided
3 Styloglossus into three parts (Fig. 6.7 andTable 6.2).
4 Stylopharyngeus attached to the styloid process. I Thefirst (mandibular) part ntnshorizontally forwards,
first between the neck of the mandible and the
sphenomandibular ligament, below the auriculo-
temporal nerve, and then along the lower border of
the lateral pterygoid.
DISSECTION 2 The second (pterygoid) part runs upwards and
External carotid artery divides into its two terminal forwards superficial to the lower head of the lateral
branches, maxillary and superficial temporal on the pterygoid.
anteromedial surface of the parotid gland. The maxillary 3 The third (pterygopalatine) parl passes between the two
artery, appears in this region. ldentify some of its heads of the lateral pterygoid and through the
branches" Most important to be identified is the middle pterygomaxillary fissure, to enter the ptery-
meningeal artery. Revise its course and branches from gopalatine fossa.
Chapter 12. Accompanying these branches are the
veins and pterygoid venous plexus and the superficial BRANCHES OF FIRST PART OF THE MAXITLARY ARTERY
content of infratemporal fossa. Remove these veins. L The deE nuricular artery supplies the external acoustic
Try to see its communication with the cavernous sinus meatus, the tympanic membrane and the
and facialvein. temporomandibular joint (Fig. 6.7).
2 The anterior tympanicbranch supplies the middle ear
Feotures including the medial surface of the tympanic
This is the larger terminalbranch of the external carotid membrane.
artery, given off behind the neck of the mandible. It 3 The middle meningeal artery has been described in
has a wide territory of distribution, and supplies: Chapter 12. It lies between lateral pterygoid and

First part of maxillary artery

ffi 1. Deep auricular
2. Anterior iympanic
3. Middle meningeal
4. Accessory meningeal
5. lnferior alveolar

Second part of maxillary artery

ffi 1. Masseteric
2. Deep temporal
3. Pterygoid l.
4. Buccal o
Third part of maxillary artery
ffi t. Posterior superior alveolar

2. lnfraorbital !t(E
3. Greater palatine o
4. Pharyngeal
5. Arlery of pterygoid canal
6. Sphenopalatine o
Fig.6.7: Branches of three parts of the maxillary artery ao

Table 6.2: Branches of maxillary artery (Figs 6.6 and 6.7f

Branches Foramina transmitting Distribution
A. Of first part
1 . Deep auricular Foramen in the floor (cartilage or bone) of Skin of external acoustic meatus, and outer sudace
external acoustic of tympanic membrane
2. Anterior tympanic Petrotympanic fissure lnner surface of tympanic membrane
3. Middle meningeal Foramen spinosum Supplies more of bone and less of meninges; also
5th and 7th nerves, middle ear and tensor tympani
4. Accessory meningeal Foramen ovale Main distribution is extracranial to pterygoids
5. lnferior alveolar Mandibular foramen Lower teeth and mylohyoid muscle

B. Of second part
1. Masseteric Masseter
2. Deep temporal Temporalis (two branches)
3. Pterygoid Lateral and medial pterygoids
4. Buccal Skin of the cheek

C. Of third part
1. Posterior Alveolar canals in body of maxilla Upper molar and premolar teeth and gums;
alveol'ar maxillary sinus
2. lnfraorbital lnferior orbital fissure Lower orbita.l muscles; lacrimal sac; maxillary
sinus; upper incisor and canine teeth
3. Greater palatine Greater palatine canal Soft palate; tonsil; palatine glands and mucosa of
upper gums
4. Pharyngeal Pharyngeal (palatovaginal) canal Roof of nose and pharynx;auditorytube; sphenoidal

5. Artery of pterygoid canal Pterygoid canal Auditory tube; upper pharynx; and middle ear
6. Sphenopalatine Sphenopalatine foramen Lateral and medial walls of nose and various air
(terminal part) sinuses

sphenomandibular ligament, then between two roots It also gives off a mental branch that passes through
of auriculotemporal nerve, enters the skull through the mental foramen to supply the chin.
foramen spinosum to reach middle cranial fossa. It
divides into a large frontal branch which courses BRANCHES OF SECOND PART OF THE MAXILLARY
towards pterion and a smaller parietal branch
(Figs 6.10 and 12.13). These are mainly muscular. These are 1. masseteri c,2. arrrd
Tlee accessory meningeal artery enters the cranial cavity 3. deep temporalbranches (anterior and posterior) ascend
through the foramen ovale. Apart from the on the lateral aspect of the skull deep to the temporalis
meninges, it supplies structures in the infratemporal muscle, 4. to the pterygoid muscles, and 5. buccal branch
fossa. supplies the skin of cheek.
The inferior alaeolar artery runs downwards and
forwards medial to the ramus of the mandible to BRANCHES OT THIRD PART OF THE MAXILLARY ARTERY
reach the mandibular foramen. Passing through this
foramen, the artery enters the mandibular canal
1 The posterior superior alaeolar artery arises just before
the maxillary artery enters the pterygomaxillary
(within the body of the mandible) in which it runs
L fissure. It descends on the posterior surface of the
o downwards and then forwards.
maxilla and gives branches that enter canals in the
zo Before entering the mandibular canal, the artery gives bone to supply the molar and premolar teeth, and
t,c off a lingual branch to the tongue; and a mylohyoid
(E the maxillary air sinus.
E(E branch that descends in the mylohyoid groove (on the 2 The infraorbital artery also arises just before the
o medial aspect of the mandible) and runs forwards maxillary artery enters the pterygomaxillary fissure.
I above the mylohyoid muscle (seeFig.1..25). It enters the orbit through the inferior orbital fissure.
o Within the mandibular canal, the artery gives It then runs forwards in relation to the floor of the
() branches to the mandible and to the roots of the each orbit, first in the infraorbital groove and then in the
U) tooth attached to the bone. infraorbital canal to emerge on the face through the

infraorbital foramen. It gives off some orbitnlbranches,

for structures in the orbit; middle superior aloeolar
branch for premolar teeth and the anterior superior
alaeolar branches that enter apertures in the maxilla
to reach the incisor and canine teeth attached to the Cut the lateral pterygoid muscle close to its insertion.
bone. Dislodge the head of mandible from the articular disc.
Locate the articular cartilages covering the head of the
After emerging on the face, the infraorbital artery
mandible and the mandibular fossa. Take out the
gives branches to the lacrimal sac, the nose and the
articular disc as well and study its shape and its role in
upper lip.
increasing the varieties of movements.
The remaining branches of the third part arise within
the pterygopalatine fossa (Fig. 6.7).
Type of Joint
3 The greater palatine artery runs downwards in the
greater palatine canal to emerge on the posterolateral This is a synovial joint of the condylar variety.
part of the hard palate through the greater palatine Atticulor Surfoces
foramen. It then runs forwards near the lateral
margin of the palate to reach the incisive canal (near The upper articular surface is formed by the following
the midline) through which some terminal branches parts of the temporal bone:
enter the nasal cavity (see Fig. 15.15). 1 Articular tubercle
Branches of the artery supply the palate and gums.
2 Anterior part of mandibular fossa (Fig. 6.8).
\A/hile still within the greater palatine canal, it gives
3 Posterior nonarticulat part formed by the tympanic
off the lesser palatine arteries that emerge on the palate
The inferior articular surface is formed by the head
through the lesser palatine foramina, and run of the mandible.
backwards into the soft palate and tonsil.
The articular surfaces are covered withfibrocartilage.
4 The pharyngeal branch runs backwards through a The joint cavity is divided into upper and lower parts
canal related to the inferior aspect of the body of the by an intra-articular disc.
sphenoid bone (pharyngeal or palatinovaginal
canal). It supplies part of the nasopharynx, the [igoments
auditory tube and the sphenoidal air sinus.
The ligaments are the fibrous capsule, the lateral
5 The artery of the pterygoid canal runs backwards in
ligament, the sphenomandibular ligament, and the
the canal of the same name and helps to supply the
stylomandibular ligament.
pharynx, the auditory tube and the tympanic cavity.
1 The fibrous capsule is attached aboae to the articular
f, 6 The sphenopalatine artery passes medially through the
tubercle, the circumference of the mandibular fossa
sphenopalatine foramen to enter the cavity of the in front and the squamotympanic fissurebehind, and
nose. It gives off posterolateral nasal branches to the
below to the neck of the mandible. The capsule is loose
lateral wall of the nose and to the paranasal sinuses;
above the intra-articular disc, and tightbelow it. The
and posteromedial branches to the nasal septum. s;movial membrane lines the fibrous capsule and the
Sphenopalatine artery is the artery of "epistaxis" (see neck of the mandible (Fig. 6.9).
Fig. 15.15).
2 The lateral temporomandibular ligament reinforces and
strengthens the lateral part of the capsular ligament.
Its fibres are directed downwards and backwards. It
It lies around and within the lateral pterygoid muscle. is attached above to the articular tubercle, and below
The tributaries of the plexus correspond to the branches to the posterolateral aspect of the neck of the
of the maxillary artery. The plexus is drained by the mandible.
maxillary vein which begins at the posterior end of the 3 The sphenomandibular ligament is an accessory .x
plexus and unites with the superficial temporal vein to ligament, that lies on a deep plane away from the o
form the retromandibular vein. Thus the maxillary vein fibrous capsule. It is attached superiorly to the spine zo
accompanies only the first part of the maxillary artery. !tc
of the sphenoid, and inferiorly to the lingula of the (E
The plexus communicates: mandibular foramen. It is a remnant of the dorsal !l(E
a. With the inferior ophthalmic vein through the part of Meckel's cartilage. o
inferior orbital fissure. The ligament is related laterally to:
b. With the cavernous sinus through the emissary a. Lateral pterygoid muscle. o
veins. b. Auriculotemporal nerve. ()
c. With the facial vein through the deep facial vein. c. Maxillary artery (Fig. 6.10). ao

Mandibular fossa

Meniscotemporal compartment

Posterior band
Intra-articular disc
lntermediate zone
Bilaminar region
Anterior band
Anterior extension
Squamotympanic fissure
Articular tubercle

Fibrous capsule Fibrocartilage

Tympanic plate
Lateral pterygoid

Head of mandible

Meniscomandibular compartment

Fig. 6.8: Articular surfaces of the left temporomandibular joint

compartments. The upper compartment permits gliding

movements, and the lower, rotatory as well as gliding
The disc has a concavo-convex superior surface, and
a concave inferior surface. The periphery of the disc is
attached to the fibrous capsule. The disc is composed
of an anterior extension, anterior thick band,
intermediate zorre, posterior thick band and bilaminar
region (Fig. 6.8) containing venous plexus. The disc
represents the degenerated primitive insertion of lateral
pterygoid. The disc prevents friction between the
articulating surfaces.
It acts as a cushion and helps in shock absorption. It
Fig. 6.9: Fibrous capsule and lateral ligament of the temporo- stabilises the condyle by filling up the space between
mandibular joint articulating surfaces.
The proprioceptive fibres present in the disc help to
regulate movements of the joint.
The ligament is related medially to the disc helps in distribution of weight across the
a. Chorda tympani nerve. TMI by increasing the area of contact.
b. Wall of the pharlmx. Near its lower end, it is Pierced
by the mylohyoid nerve and vessels. RETATIONS OF TEMPOROMANDIBULAR JOINT
4 The stylomandibular ligamenf is another accessory
ligament of the joint. It represents a thickened part Loterol
of the deep cerrsical fascia which separates the parotid 1 Skin and fasciae
zo and submandibular salivary glands. It is attached 2 Parotid gland (see Fig. 5.2)
!ttr above to the lateral surface of the styloid Process/ 3 Temporal branches of the facial nerve.
!,(E and below to the angle and adjacent part of posterior
o border of the ramus of the mandible (Fig. 6.10). Mediol
1 The tympanic plate separates the joint from the
C ARTICUTAR DISC internal carotid artery.
The articular disc is an oval predominantly fibrous plate 2 Spine of the sphenoid, with upper end of the spheno-
a that divides the joint into an upPer and a lower mandibular ligament attached to it.

Spine of sphenoid
Foramen spinosum
Superficial temporal artery

Lingual nerve Nervous spinosus

Sphenomandibular ligament

Middle meningeal artery

Maxillary artery

Stylomandibular ligament
and external carotid artery
lnferior alveolar nerve and artery

Mylohyoid artery and nerve

lnner surface

Fig.6.10: Superficial relations of the sphenomandibular ligament seen after removal of the lateral pterygoid

3 Auriculotemporal and chorda tympani nerves.

4 Middle meningeal artery (Fig. 6.10).
Anfedor muscle
1. Lateral pterygoid
2 Masseteric nerve and artery (Fig 6.8). Masseter
L The parotid gland separates the joint from the
extemal auditory meatus.
2 Superficial temporal vessels.
3 Auriculotemporal nerve (see Fig. 5.3).

1 Middle cranial fossa Fig. 6.11: Movements of temporomandibular joint (arrows) by
muscles of mastication
2 Middle meningeal vessels.
lnferior 4 Retrusion (retraction of chin)
Maxillary artery and vein. 5 Lateral or side to side movements during chewing
or grinding.
BTOOD SUPPLY Movements of this joint can be palpated by putting
Branches from superficial temporal and maxillary finger at preauricular point or into external auditory
arteries. Veins follow the arteries. meatus. The movements at the joint can be divided into --C)
those between the upper articular surface and the
articular disc, i.e. meniscotemporal compartment and zo
those between the disc and the head of the mandible, i.e. tr
Auriculotemporal nerve and masseteric nerve. G
meniscomandibular compartment. Most movements tt
occur simultaneously at the right and left temporo- o
mandibular joints.
L Depression (open mouth) (Fig. 6.i1) Lr forward movement or protraction of the mandible, o
2 Elevation (closed mouth) the articular disc glides forwards over the upper o
3 Protrusion (protraction of chin) articular surface, the head of the mandible moving with ao

it. In retraction, the articular disc glides backwards over

the upper articular surface taking the head of mandible
Dislocation of mandible: During excessive
with it. Mandible rotates around a horizontal axis opening of the mouth, the head of the mandible
extending from left to right condyle.
of one or both sides may slip anteriorly into the
In slight opening of the mouth or depression of the
infratemporal fossa, as a result of which there is
mandible, the head of the mandible moves on the inability to close the mouth. Reduction is done by
undersurface of the disc like a hinge. The movement depressing the jaw with the thumbs placed on the
occurs around a vertical axis passing through the last molar teeth, and at the same time elevating
condyle and posterior border of the ramus of mandible.
the chin (Fig.6.1,2).
In wide opening of the mouth, this hinge-like Derangement of the articular disc may result from
movement is followed by gliding of the disc and the any injury,like overclosure or malocclusion. This
head of the mandible, as in protraction. At the end of
gives rise to clicking and pain during movements
this movement, the head comes to lie under the articular
of the jaw.
tubercle. These movements are reversed in closing the
In operations on the temporomandibular joint, the
mouth or elevation of the mandible.
VII nerve and auriculotemporal nerve/ branch of
Chewingmovements involve side to side movements
mandibular division of V should be preserved
of the mandible. In these movements, the head of (say)
with care (Fig. 6.13).
right side glides forwards along with the disc as in
protraction, but the head of the left side merely rotates
on a vertical axis. As a result of this, the chin moves
forwards and to left side (the side on which no gliding
has occurred). Alternate movements of this kind on the
two sides result in side to side movements of the jaw.
Here the mandible rotates around an imaginary axis
running along the mid sagittal plane.
Muscles Producing Movements
! Depression is brought about mainly by the lateral
pterygoid. The digastric, geniohyoid and mylohyoid
muscles help when the mouth is opened wide or against
The origin of only lateral pterygoid is anterior,
slightly lower and medial to its insertion. During Mandibular fossa
contraction, it rotates the head of mandible and opens
Articular eminence Head of mandible
the mouth. During wide opening, it pulls the articular
disc forwards. So movement occurs in both the Fi9.6.12: Dislocation of the head of mandible
compartments. It is also done passively by gravity
(Figs 6.8 and 6.1L).
t Eleaation is brought about by the masseter, the
anterior vertical, middle oblique fibres of temporalis,
and the medial pterygoid muscles of both sides. These
are antigravity muscles. nerve
<-Protrusion is done by the lateral and medial
pterygoids and superficial oblique fibres of masseter.
-+Retraction is produced by the posterior horizontal
5 fibres of the temporalis and deep vertical fibres of
o Facial nerve and
o masseter
z Lateral or side to side moaements, e.g. chewing from
its branches
6 left side produced by right lateral pterygoid, right
tt(E medial pterygoid which push the chin to left side. Then
o left temporalis (anterior fibres), left masseter (deep
fibres). (++) chew the food. Chewing from right side
o involves left lateral pterygoid, left medial pterygoid, Fig.6.13: Close relation of the two nerves to the temporo-
right temporalis and right masseter. Since so many mandibular joint
o muscles are involved, chewing becomes tiring.

JVerye fo JWedrsf Fferygord

Nerve to medial pterygoid arises close to the otic
DISSECTION ganglion and supplies the medial pterygoid from
ldentify middle meningeal artery arising from the its deep surface. This nerve gives a motor root to the
maxillary artery and trace it till the foramen spinosum. otic ganglion which does not relay and supplies the
Note the two roots of auriculotemporal nerve tensor veli palatini, and the tensor tympani muscles
(Fig. 6.1s).
surrounding the artery. Trace the origin of the auriculo-
temporal nerve from mandibular nerve (Fig.6.10).
Dissect all the other branches of the nerve. ldentify the
Euecof Alerye
chorda tympani nerve joining the lingual branch of Buccal nerve is the only sensory branch of the anterior
mandibular nerve. Lift the trunk of mandibular nerve division of the mandibular nerve. It passes between the
laterally and locate the otic ganglion. two heads of the lateral pterygoid, runs downwards
Trace all connections of the otic ganglion. and forwards, and supplies the skin of cheek and
mucous membrane related to the buccinator (Fig. 6.6).
It also supplies the labial aspect of gums of molar and
premolar teeth.
This is the largest mixed branch of the trigeminal nerve.
It is the nerve of the first branchial arch and supplies lklossefegc frferve
all structures derived from that arch (Fig. 6.14). Otic
Masseteric nerve emerges at the upper border of the
and submandibular ganglia are associated with this
lateral pterygoid just in front of the temporomandibular
joint, passes laterally through the mandibular notch in
COURSE AND RELATIONS company with the masseteric vessels, and enters the
deep surface of the masseter. It also supplies the
Mandibular nerve begins in the middle cranial fossa temporomandibular jotnt (see Fig. 1,.2$.
through a large sensory root and a small motor root.
The sensory root arises from the lateral part of the
Deep lernBorciflIeryes
trigeminal ganglion, and leaves the cranial cavity
through the foramen ovale (Figs 6.17 and 12.13). Deep temporal nerves are two nerves, anterior and
The motor root lies deep to the trigeminal ganglion posterior. They pass between the skull and the lateral
and to the sensory root. It also passes through the pterygoid, and enter the deep surface of the temporalis.
foramen ovale to join the sensory root just below the
foramen thus forming the main trunk. The main trunk Nerve fo {ofsrmd Pferygofd
lies in the infratemporal fossa, on the tensor veli Nerve to lateral pterygoid enters the deep surface of
palatini, deep to the lateral pterygoid. After a short the muscle.
course, the main trunk divides into a small anterior
trunk and a large posterior trunk (Fig. 6.1a). A*ricuI*fempord,Vsry#
BRANCHES Auriculotemporal nerve arises by two roots which run
backwards, encircle the middle meningeal artery, and
From the main trunk: unite to form a single trunk (Figs 6.14 and 6.15). The
a. Meningeal branch nerve continues backwards between the neck of the
b. Nerve to the medial pterygoid. mandible and the sphenomandibular ligament, above
From the anterior trunk: the maxillary afiery. Behind the neck of the mandible,
a. A sensorybranch, the buccal nerve it turns upwards and ascends on the temple behind the
b. Motor branches, the masseteric and deep temporal superficial temporal vessels.
neryes and the nerve to the lateral pterygoid. The auricular part of thenerve supplies the skin of the so
From the posterior trunk:
a. Auriculotemporal
tragus; and the upper parts of the pinna, the external
acoustic meatus and the tympanic membrane. (Note
b. Lingual that the lower parts of these regions are supplied by the (E
c. Inferior alveolar nerves. great auricular nerve and the auricular branch of the !t(E
vagus nerve). The temporal part supplies the skin of o
Menrngeaf Sr*nch cr lVeryus $pdn*sus J-
the temple (see Fig. 2.5). ln addition, the atriculotemporal
Meningeal branch enters the skull through the foramen nerve also supplies the parotid gland (secretomotor
spinosum with the middle meningeal artery and and also sensory) and the temporomandibular joint o
supplies the dura mater of the middle cranial fossa. (see Table 1.3). oo

Iable 63l Branches of !ft! maldibular nerve {CN.V3) incisive branch supplies the labial aspect of gums
Muscular Sensory Others of canine and incisor teeth.
Temporalis and masseter Meningeal Carries
Auriculotemporal taste
Medial and lateral pterygoids lnferior alveolar Carries It is a peripheral parasympathetic ganglion which
and mental secreto- relays secretomotor fibres to the parotid gland.
motor fibres
Topographically, it is intimately related to the
Tensor veli palatini and Lingual Articular mandibular nerve, but functionally it is a part of the
tensor tympani
glossopharyngeal nerve (Figs 6.15 and 6.1.6).
Mylohyoid and digastric Buccal
(anterior belly)
It is 2 to 3 mm in size, and is situated in the infra-
Relations temporal fossa, just below the foramen ovale. It lies
It begins 1 cm below the skull. It runs first between the medial to the mandibular nerve, and lateral to the tensor
tensor veli palatini and the lateral pterygoid, and then veli palatini. It surrounds the origin of the nerve to the
between the lateral and medial pterygoids. medial pterygoid (Fig. 6.15).
About 2 cm below the skull, it is joined by the chorda
Emerging at the lower border of the lateral pterygoid,
The secretomotor motor or parasympathetic root is formed
the nerve runs downwards and forwards between the
ramus of the mandible and the medial pterygoid. Next by the lesser petrosal nerve. Its origin and course is
it lies in direct contact with the mandible, medial to the shown in Flow chart 6.1.
third molar tooth between the origins of the superior The sympathetic root is derived from the plexus on
constrictor and the mylohyoid muscles (seeFig.1.25). the middle meningeal artery. It contains postganglionic
It soon leaves the gum and runs over the hyoglossus fibres arising in the superior cervical ganglion. The
deep to the mylohyoid. Finally, it lies on the surface of
fibres pass through the otic ganglion without relay and
reach the parotid gland via the auriculotemporal nerve.
the genioglossus deep to the mylohyoid. Here it winds
around the submandibular duct and divides into its They are vasomotor in function.
terminal branches (see Fig.7.4). The sensory root from the auriculotemporal
nerve and is sensory to the parotid gland.
$mfenmr Afvemj*r fferv*
Inferior alveolar nerve is the larger terminal branch of Flovv charl 6.1: Secretomotor fibres for parotid gland
the posterior division of the mandibular nerve
(Fig.6.1a). It runs vertically downwards lateral to the
medial pterygoid and to the sphenomandibular ----r----
Preganglionic fibres from inferior salivatory nucleus I

ligament. It enters the mandibular foramen and runs

in the mandibular canal. It is accompanied by the
inferior alveolar artery (see Fig. 1,.25).

1 The mylohyoidbranch contains all the motor fibres of Tympanic plexus
the posterior division. It arises justbefore the inferior
alveolar nerve enters the mandibular foramen. It
Lesser petrosal.nerve
pierces the sphenomandibular ligament with the .Y
mylohyoid artery,runs in the mylohyoid groove, and zo
supplies the mylohyoid muscle and the anteriorbelly Otic ganglion E
of the digastric (Fig. 6.10). G
While running in the mandibular canal the inferior Postganglionic fibres I t,(E
alveolar nerve gives branches that supply the lower o
teeth and gums. Join auriculotemporal nerve I
T}:le mental nerae err,erges at the mental foramen and C

supplies the skin of the chin, and the skin and t .o

mucous membrane of the lower lip (Fig. 6.14). Its
I ao

Sensory root

Geniculate ganglion of facial nerve

Motor root
Greater petro$al nerve
Tympanic plexus
Sympathetic nerve
Nerve to stapedius
Nerve of pterygoid canal

Deep petrosal nerve

Facial nerve
lnternal carotid plexus

Communication between chorda

tympani and neve of pterygoid canal
Facial canal
Nerve to parotid gland

Otic ganglion
Chorda tympani
Communication between otic ganglion
Glossopharyngeal nerve and chorda tympani
Sympatheiic root
Tympanic branch Inferior alveolar nerve
Lingual nerve
Auriculotemporal nerve
Middle meningeal artery
Lesser petrosal nerve
Fig. 6.15: Connections of otic ganglion (schematic)

Other fibres passing through the ganglion are as is divided to relieve intractable pain of this kind .
follows: This may be done where the nerve lies in contact
a. The nerve to medial pterygoid gives a motor root with the mandible below and behind the last molar
to the ganglion which passes through it without tooth, covered only by mucous membrane.
relay and supplies medially placed tensor veli Mandibular neuralgia: Trigeminal neuralgia of the
palatini and laterally placed tensor tympani mandibular division is often difficult to treat. In
muscles. such cases, the sensory root of the nerve may be
b. The chorda tympani nerve is connected to the otic divided behind the ganglion, and this is now the
ganglion and also to the nerve of the pterygoid operation of choice when pain is confined to the
canal (Fig. 6.16). These connections provide an distribution of the maxillary and mandibular
alternative pathway of taste from the anterior two- nerves. During division, the ophthalmic {ibres that
thirds of the tongue. lie in the superomedial part of the root are spared/
to preserve the corneal reflex thus avoiding
damage to the cornea (Fig. 6.17).
. The motor part of the mandibular nerve is tested
Lingual nerve lies in contact with mandible,
clinieally by asking the patient to clench her/his medial to the third molar tooth. In extraction of
teeth and then feeling for the contracting masseter
malplaced 'wisdom' tooth, care must be taken not
and temporalis muscles on the two sides. If one to injure the lingual nerve (Fig. 6.18). Its injury
masseter is paralysed, the jaw deviates to the results in loss of all sensations from anterior two-
paralysed sid,e, on opening the mouth by the thirds of the tongue.
o action of the normal lateral pterygoid of the
zo opposite side. The activity of the pterygoid A lesion at the foramen ovale leads to paraesthesia
!, along the mandible, tongue, temporal region and
tr muscles is tested by asking the patient to move
(E paralysis of the muscles of mastication: This also
t,(E the chin from side to side.
. Referred pain: In cases with cancer of the tongue,
leads to loss of iaw-jerk reflex.
I pain radiates to the ear and to the temporal fossa, The mandibular nerve supplies both the ef{erent
over the distribution of the auriculotemporal nerve and afferent loops of the jaw-jerk reflex, as it is a
.F as both lingual and auriculotemporal are branches mixed nerve. Tapping the chin causes contraction
o of mandibular nerve. Sometimes the lingual nerve of the pterygoid muscles.

In extraction of mandibular teeth, inferior alveolar Mnemonics S

nerve needs to be anaesthetised. The drug is given
into the nerve before itenters the mandibular canal
Fr*tl"rrft t*rtrt.M"dktptu S-
(Fig. 6.18). "La": ]aw is open, so lateral pterygoid opens mouth.
lnferiar alveolar neyve: Infenor alveolar nerve as it "Me": Jaw is closed, so medial pterygoid closes the
travels the mandibular canal can be damaged by mouth.
the fracture of the mandible. This injury can be
assessed by testing sensation over the chin.
During extraction of the 3rd molar, the buccal
nerve may get inrrolved by the local anaesthesia
causing temporary numbness of the cheek. Mandibular nerve the only mixed branch of
trigeminal nerve
The nerve is associated with two parasympathetic
ganglia, i.e. otic and submandibular ginglia
Maxillary artery gives many branches; some
accompany branches of maxillary nerve and others
branches of mandibular nerve as there is no
mandibular artery
Only muscle of mastication which depresses the
TMJ is the lateral pterygoid muscle
Spine of sphenoid is related to chorda tympani and
auriculotemporal nerves. Injury to the spine will
Trigeminal ganglion
hamper the iecretion of 3 sriiviry glandi.
Auriculotemporal nerve and branches of facial
nerve are relited to temporomandibular joint.

A patient of carcinoma in anterior two-thirds of

tongue complains of paininhis lower teeth, ternporal
region and the temporomandibular joint.
. l\rhy is pain of tongue referred to lower teeth?
r Which are the other areas of referred pain?
Fig. 6.17: Partial cutting of the sensory root of trigeminal nerue
Ansr Sensations from anterior two-thirds of the
tongue are carried by lingual, branch of mandibular
nerve. $ince there are toa mafiy pain impul$es due
tc disease, thene impulses course through other
branches of the nerve, where it is gets referred. So
pain is felt inlower teeth, from where $ensations are
carried by inferiar alveolar nerve. The mandibular
nerve also carries sensation from temporo-
mandibular joint and temporal region so the pain
also gets referred to these regions.
Examples of referred pain are: :o
r Pain of gallbladder is referred to right shoulder; zo
r Pain of myocardial ischaemia is felt in the chest !,
and mediai side of left arm (E

I Pain of foregut derived orgafls i* felt in epigastrium !t

a Pain r:f midgut derived organ$ is feit in o
periumbilical region
Fig. 6.18: lnjection given in mandibular foramen for Pain *f hindgut derived organs is f*lt in suprapubic
anaesthetising the inferior alveolar nerve before extraction of
region o
last molar tooth o
L. Action of lateral pterygoid muscle is: 6. Dislocated mandible can be reversed by:
a. Elevation and retraction of mandible a. Depressing the jaw posteriorly and elevating the
b. Depression and retraction of mandible chin
b. Depressing the jaw and depressing the chin
c. Elevation and protrusion of mandible
c. Elevating the jaw and elevating the chin
d. Depression and protrusion of mandible
d. Depressing the chin and elevating the jaw
2. \ /hich of the following muscles is used for opening posteriorly
the mouth? 7. Nervus spinosus is a branch of:
a. Medial pterygoid b. Temporalis a. Maxillary nerve b. Mandibular nerve
c. Lateral pterygoid d. Masseter c. Ophthalmic nerve d. 2nd cervical nerve
3. Which of the following ligaments is not a ligament 8. Lingual nerve is the branch of:
of temporomandibular joint? a. Facial nerve
a. Pterygomandibular b. Glossopharyngeal nerve
b. Sphenomandibular c. Mandibular nerve
c. Lateral ligament d. Hypoglossal nerve
d. Stylomandibular 9. Lingual nerve can be pressed against a bone inside
the mouth near the roots of the:
4. Which one is not a branch of maxillary artery?
a. Third upper molar tooth
a. Anterior tympanic
b. Second upper molar tooth
b. Anterior ethmoidal c. Third lower molar tooth
c. Middle meningeal d. First lower molar tooth
d.Inferior alveolar 10. Nerve piercing sphenomandibular ligament is:
5. Which of the following is not a muscle of masti- a. Nerve to mylohyoid
cation? b. Inferior alveolar
a. Medial pterygoid b. Masseter c. Buccal
c. Temporalis d. Orbicularis oris d. Lingual

t:,' !


Submandibular Region
Bernord Show

INTRODUCTION 4 Fourth layer formed by genioglossus (Fig.7.a).

The muscles are described in Table 7.1.
Submandibular region includes deeper structures in the
area between the mandible and hyoid bone including RETATIONS OF POSTERIOR BELTY OF DIGASTRIC
the floor of the mouth and the root of the tongue.
The submandibular region contains the suprahyoid Supefficiol
muscles, submandibular and sublingual salivary glands 1 Mastoid process with the sternocleidomastoid,
and submandibular ganglion. Chorda tympani from splenius capitis and the longissimus capitis (Figs 5.4a
facial nerve provides preganglionic secretomotor fibres and7.3).
to the glands. Chorda tympani also carries fibres of 2 The stylohyoid.
sensation of taste from anterior two-thirds of tongue 3 The parotid gland with retromandibular vein.
except from the circumvallate papillae, from where it 4 Submandibular salivary gland (Fi1.7.3) and lymph
is carried by the glossopharyngeal nerve. nodes.
5 Angle of the mandible with medial pterygoid.


L Transverse process of the atlas with superior oblique
and the rectus capitis lateralis.
Cut the facial artery and vein present at the 2 Internal carotid, external carotid, lingual, facial and
anteroinferior angle of masseter muscle. Separate the occipital arteries
origin of anterior belly of digastric muscle from the 3 Internal jugular vein.
digastric fossa near the symphysis menti. Push the 4 Vagus, accessory and hypoglossal cranial nerves
mandible upwards. Clean and expose the posterior belly (Fis.7.3).
of digastric muscle and its accompanying stylohyoid 5 The hyoglossus muscle.
muscle. ldentify the digastrics, stylohyoid, mylohyoid,
geniohyoid, hyoglossus. Upper Border
1 The posterior auricular artery (see Fig. 4.1.4).

Feotures 2 The stylohyoid muscle.

The suprahyoid muscles are the digastric, the lower Bordel
stylohyoid, the mylohyoid and the geniohyoid. The Lower border is related to occipital artery (seeFig.4.1.4).
muscles are in following layers:
1 First layer formed by digastric (Greek two bellies) and RELATIONS OF MYTOHYOID
stylohyoid (Fi9.7.1). Superficiol
2 Secondlayerformedbymylohyoid (Greek pertaining 1 Anterior belly of the digastric (Fig. 7.1)
to hyoid bone) (Fig. 7.2). 2 Superficial part of the submandibular salivary gland.
3 Third layer formed by geniohyoid and hyoglossus 3 Mylohyoid nerve and vessels.
, (Fig.7.\. 4 Submental branch of the facial artery.
I 131


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