HEAD AND NECK

Bones of the Skull

 The bones of the skull is divided into those of the
cranium and those of the face.
 The cranium is further divided into an:
◦ Upper part – vault
◦ Lower part – base of the skull

• There are 5 cranial bones, three of which are paired

making a total of 8.
• There are 8 facial bones, two of which are unpaired,
making a total of 14.
 Parts of the Skull

Anterior View Lateral View

Important considerations:
 Head circumference: 33-35 cm
 Fontanelles ( Anterior vs. Posterior )
 Anatomical landmarks
 Meninges
 CSF
 Cavernous sinus triangle
 Blood supply to the brain
 Cranial nerves exits
Cranial nerves
 CN I: Olfactory
 CN II: Optic
 CN III: Oculomotor
 CN IV: Trochlear
 CN V: Trigeminal
 CN VI: Abducens
 CN VII: Facial
 CN VIII: Vestibulocochlear
 CN IX: Glossopharyngeal
 CN X: Vagus
 CN XI: Spinal accessory nerve
 CNXII: Hypoglossal
Foramina of the Skull
 Anterior cranial fossa
1. Foramen of cecum
2. Cribriform plate
 Middle cranial fossa
1. Optic canal
2. Superior orbital fissure
3. Foramen spinosum
4. Foramen lacerum
5. Carotid canal
 Posterior cranial fossa
1. Foramen magnum
2. Hypoglossal canal
3. Jugular foramen
4. Internal auditory meatus
 Conditions:

 Hydrocephalus ( types, assessment,

pathophysiology, positioning, sign and symptoms, PT
interventions)
 Bells palsy and differential diagnosis.( UMNL vs
LMNL)
 Other conditions affecting the face:
 Trigeminal neuralgia, facial paralysis.
 Muscles of the Head
 Muscles of the Scalp
◦ Occipitofrontalis – surprise and horror
 Occipital belly
 Frontal belly*
 Seen in what layer of the scalp?
 Timing of recovery in Bell’s Palsy?
 Older nomenclature?
 Muscles of Facial Expression
 Orbicularis oculi
 Palpebral part – closes the eyelids, dilates lacrimal sac
 Orbital part – throws the skin around into folds to protect the eyeball
- Affected in what dse condition? Type of ptosis?
- Bell’s phenomenon? Prosopoplegia?
- Levator palpebrae superioris – eye opening
- Type of ptosis? Innervation?
- Difference between CVA and Bell’s Palsy when it comes to facial muscle
affectation?
 Muscles of facial expression

 Risorius – grimace, plastic smile, sarcastic

 Platysma – egad, grief, sadness, sorrow
 Procerus – distaste, yuck
 Zygomaticus minor – smile
 Zygomaticus major – laugh
 Orbicularis oris – kiss, whistle, suck
 Buccinator- blow, timing of recovery in Bell’s?
 Mentalis – pout (lower only), sulk (upper and lower lips)
 Levator anguli oris – sneer (contempt)
 Depressor labii inferioris – irony, melancholy
Bones of the Neck

 Cervical Spine
 Hyoid – mobile, single bone found in the midline of
the neck below the mandible and beside the larynx.
 It does not articulate with any other bones
 U shaped and consists of a body and two greater and
two lesser cornua (horns)
 It forms the base of the tongue and is suspended in
position by muscles that connect it to the mandible.
Bony Landmarks
 C3,4-5,6 – HTC
 T2 – SUP < OF SCAPULA
 T3 – ROOT OF SPINE OF SCAPULA
 T4 – JXN BET. MANUBRIUM AND STERNUM
 T7 – INF < OF SCAPULA
 T10 – XIPHOID PROCESS
 L1 – SC ENDS
 L2 – PLL TAPERS
 L3 – L4 – HEIGHT OF UMBILICUS, AORTA DIVIDES INTO COMMON
ILIAC ARTERIES
 L4-L5 – SPINOUS PROCESSES DON’T OVERLAP, GOOD
LANDMARK TO LOCATE OTHER VERTEBRA
 L4- ILIAC CREST
 S2 – DIMPLES OF VENUS, PSIS
Triangles of the neck
Triangles of the neck
Triangles of the neck
Contents of the triangles
 Carotid triangle
◦ Common carotid artery -stroke
◦ IJV – CVP measurement
◦ CN12 – gahasapa, tongue deviation, dysgeusia
◦ Deep cervical lymph nodes
 Muscular triangle
◦ Thyroid gland – hyper and hypo s/sx
◦ Larynx – dysphonia, dysarthria, dysprosody
◦ Trachea – mediastinal shift
◦ Esophagus – GERD, positioning, meds, exercise
 Digastric triangle
◦ Submandibular gland
◦ Facial artery and vein
◦ Submandibular lymph nodes
Contents of the triangles

 Posterior triangles
 Arteries – subclavian (TOS), superior cervical,
suprascapular, occipital
 Veins – EJV and tributaries

 Nerves – Brachial Plexus, CN 11, ansa Cervicalis

branches
Important muscles: Evaluation and Assessment:

 Trapezius
 Sternocleidomastoid ( Torticolis )
 Scalenes ( TOS )
 Anterior neck muscle versus posterior neck muscle
Muscles of the neck:
Trapezius and Levator scapulae:
Platysma:
Sternocleidomastoid:
 Torticollis:
 Spastic torticollis versus Paralytic torticollis
 Evaluation
 PT intervention
 Positioning
 Stretching
Torticollis
1. Congenial
2. Infectious
3. Spasmodic
4. Arthritic
5. Paracicatrial
6. Hysterical
7. Paralytic
Condition? Muscle involved? Cause? Treatment? Muscle with similar action?
Classification?
Scalenes:
TOS ( Scalene tightness )
 Assessment:
 Pathophysiology
 Structures involved
 Stretching
 Special Test
The vertebral artery
 Assessment:
 Anatomical consideration
 movements induced for vertebral artery symptoms
 pre- cervical traction assessment
 special test:
 Signs and symptoms of Vertebral artery syndrome.
Forward head posture:
Upper Crossed Syndrome
 Cervical crossed syndrome versus
Pelvic crossed syndrome:
Conditions
 Down’s syndrome
 Hydrocephalus
 Bell’s palsy
 TMJ
 Klippel Feil syndrome
 Torticollis
 TOS
 Vertebral Artery
 Forward head posture
 Upper crossed syndrome
TEMPOROMANDIBULAR
JOINT
Functional Anatomy
Temporomandibular Joint

Formed by:
• condyle of the mandible
•Articular eminence of the temporal bone
•Articular disk
Temporomandibular Joint

Type of Joint:
• Between condyle and inferior surface of the
disk – Hinge joint

•Between the articular eminence and the superior

surface of the disk – gliding joint
Temporomandibular Joint
Temporomandibular Joint
Temporomandibular Joint

Resting position:
mouth slightly open, lips together, teeth
not in contact
Close packed :
Teeth tightly clenched
Capsular pattern:
Limitation of mouth opening
Muscular control of TMJ
Muscular control of TMJ
TEMPOROMANDIBULAR
JOINT
Assessment and Evaluation
Examination
Examination Active movement

Opening & closing of the mouth

Examination Active movement

Functional opening
Examination Active movement

Protrusion of the mandible : 3 – 6 mm

Retrusion of the mandible: 3 – 4 mm
Lateral deviation: 10 – 15 mm
Examination Passive movement

Normal End Feel

Opening: Tissue stretch

Closing: Bone to bone
Special Test

TMJ Compression Test

Patient History
 Patient History

•Vertical dimension:
• The distance between two arbitrary points of
the face
•Lost with loss of molars or worn denture
•Pain on chewing
Observation
Observation
 Patient History

•Chewing on one side – malocclusion

•Stiffness on waking with pain on function that
disappears as the day goes on – OA
•Action that causes discomfort
Observation
 Patient History

•Clicking:
•Results from abnormal motion of the disc and
mandible
•Early clicking implies a developing
dysfunction while late clicking is more likely
to mean a chronic problem.
TEMPOROMANDIBULAR
JOINT
Normal Arthrokinematics
TMJ Dysfunction : Categories

1: OA or RA of the TMJ
2: Myofascial pain
- most common form of TMJ dysfunction.
3: Internal derangement
 Trauma
 Congenital anomalies
 Abnormal function
Disc Displacement (dislocation) with Reduction
Reciprocal Click

“My Jaw produces a popping or clicking

sound on opening and closing”
 Disc displacement without reduction
 Closed lock
 Opening lim. To 20-25mm w/ deviation to affected side
 Limited Lateral movement to uninvolved side

“ I can’t make a big bite as my

jaw locks on opening”
 TMJ Hypermobility
 Depression > 40mm
 True disloc. Open lock
 Reduction is required
 Deviation - contralateral

“ My jaw feels like it goes out of place” “episode

of catches in a fully opened position”
 Possible Causes of Pain

 Trauma to the joint–blow to the jaw or head

 Excessive stress to the joint from gum chewing,
fingernail biting, yawning, chewing on a pen, chewing
on ice, and grinding teeth
 Jaw abnormalities, missing teeth, poor bite
(malocclusion)
 Resting the head in the hand
 Arthritis of the TMJ
 Dislocation of the disc
 Possible Causes of Pain

 Myofascial pain dysfunction

 Postural abnormalities, especially with a forward
head posture
 Whiplash injury
 Prolonged mouth and upper respiratory breathing
 Thumb sucking
 Ligamentous laxity
 Birth/Congenital trauma
 Common signs and symptom
 Clicking or popping with opening or closing
 Pain at rest or with opening/closing of jaw
 Decreased ability to open the jaw (hypomobility)
 Neck pain
 Tooth sensitivity
 Dry or burning sensation in mouth
 Uncomfortable bite
 Forehead or temple headache
 Buzzing or ringing in ears
 Hearing loss
 Management

 Decrease pain & muscle spasm

 Correct muscle imbalance
 Teach control of jaw muscles
 Increase ROM, if necessary
 Management

 Habit Modification: Avoid the activity that is causing the

increased stress to the joint such as nail biting, gum chewing, and
ice biting.
 Diet Modification: Eat a diet of soft foods in addition to
chewing evenly. You may want to cut your food into small pieces
which will help decrease overuse of the TMJ.
 Pharmacological: Anti-inflammatory medications such as aspirin
or ibuprofen can help to decrease pain and inflammation.
 Hot compresses: Use a washcloth soaked in warm water or a
commercial moist hot pack over the area of pain or tenderness.
This will help reduce any muscle spasm you may be
experiencing. Keep the compress on for about 10- 15 minutes..
 Management

 Cold packs: These can be used to help reduce any swelling,

pain and muscle spasm. Leave the cold pack on for about 10-
15 minutes.

 Dental Appliances: Need some type of intra-oral splint,

nightguard or other appliance which can be given by your
dentist or physical therapist upon diagnosis. This may help to
stabilize the TMJ so the muscles, teeth, and joints work together
without adding additional strain to the TMJ.

 Positioning: The best position to keep your TMJ in is with your

teeth slightly apart and lips together. Placing the tongue on the
roof of the palate (top of the mouth) is also wise to ensure the
position is kept. In addition, try to breathe the nose as much as
possible.
 Management

 Stress Management: Stress is a common

contributing factor to TMD. If stress is the
contributing factor to your TMD, deep relaxation
training, breathing, meditation or biofeedback are
of great benefit.

 Posture: A forward head posture is a big

contributor to TMD. Use of a lumbar roll, will help
maintain the proper body positioning when sitting
for long periods of time.
The End