Dr Hamza Rizwan

MBBS
FCPS (Emergency Medicine)
MRCEM - Primary
Anatomy of Bony Orbit

There are 7 bones that comprise the orbit:

Sphenoid

Ethmoid

Lacrimal

Frontal

Palatine

Maxillary

Zygomatic
Boundaries of Orbital Rim

• Superior: Frontal bone

• Medial: Frontal Process of Maxilla
• Inferior: Zygomatic Process of maxilla and zygomatic bone
• Lateral: Zygomatic bone,. Frontal process of zygomatic bone and zygomatic process of frontal
bone
Walls of Orbit:
Orbit is pyramidal in shape with apex in postero-medial
direction and wide base extending anteriorly as orbital rim

• Roof - Orbital surface of frontal bone, Lesser wing of Sphenoid

• Medial wall - Frontal Process of Maxilla, Lacrimal bone, Ethmoid,
Body of Sphenoid
• Floor - Maxilla, Zygomatic Bone, Palatine Bone
• Lateral wall -Zygomatic bone, Greater wing of Sphenoid

The weakest part of the orbit is the orbital floor, making it

susceptible to fractures from blunt trauma.
Foramina of Orbit
Foramen Contents
Superior Orbital Cranial nerves (oculomotor, trochlear,
Fissure ophthalmic branch the trigeminal, abducens),
superior ophthalmic vein, orbital branch of the
middle meningeal artery, sympathetic fibers
Optic Canal Optic nerve, ophthalmic artery, sympathetic
fibers
Infra-orbital Maxillary branch of the trigeminal nerve,
Canal infraorbital artery and vein
Blood Supply of Orbit
• Arterial- Ophthalmic Artery (Internal Carotid
artery)

• Venous- Superior and Ophthalmic Vein,

communicate with cavernous. Hence infection of
face can spread to cavernous sinus

• Lymphatic Drainage- deep cervical LN via pre-

auricular and parotid group
Eyeball:
Eyeball has three Layers
1. Outer fibrous layer of Sclera posteriorly and
cornea anteriorly
2. Middle vascular layer of Choroid posteriorly,
Ciliary body and Iris anteriorly
3. Inner Retina

Anterior and Posterior Chambers: Between Cornea and

lens.

Vitreous Chamber: Posterior four-fifth of eyeball,

from lens to retina, filled with vitreous body.
Cornea and Sclera:
Sclera provides attachment for muscles involved in movement of eyeball

Transparent cornea allows light to enter

Sensory supply from CN V (Afferent limb of Corneal reflex)

Vascular Layer of Eye:
Choroid is posterior two-third of vascular layer, thin, firmly
attached with retina but loose attachment with sclera

Lens is transparent, biconvex elastic disc, involved in

refraction of light by changing its shape.

Ciliary body- Consists of ciliary muscles and ciliary

processes. It is attached to lens with suspensory ligaments. Its contraction changes the shape of lens. It
is innervated by parasympathetic fibers of CN III
Iris and Pupil
• Iris is the colored part of eye with central opening forming pupil.
Smooth muscles of iris control pupil size
• Sphincter Pupillae- Innervated by parasympathetic fibess of CN III, act
as efferent pathway of light reflex, optic nerve forms the afferent
pathway. Injury causes fixed dilated pupils
• Dilator pupillae- Innervated by post-ganglionic fibers from superior
cervical ganglion. Injury causes miosis
Chambers:
Anterior Chamber: Anterior to Iris
Posterior Chamber: Between iris and Lens
They are filled with aqueous humour which is secreted into
posterior chamber, flows into anterior chamber and is
absorbed in Canal of Schlemm
Retina
Has outer pigmented and inner
neural layer

Optic disc- Where optic nerve leaves

retina

Fovea- thinnest area in retina with

highest sensitivity because it has
fewer rods and more cones.

Retina is supplied by central retinal

artery, branch of the ophthalmic
artery
EYELIDS
• Palpebral fissure is the space between upper and lower eyelid
Layers: From anterior to posterior, eyelids consist of following layers
• Skin: no subcutaneous fat
• Subcutaneous tissue
• Orbicularis oculi
• Orbital septum: A connective tissue structure that attaches to the periosteum of
the orbital margin
• Tarsal plates: The main structural component of the eyelid, made of dense
connective tissue
• Palpebral conjunctiva: A thin, clear membrane that covers the inside of the eyelid
• Muscles of eyelids:
Orbicularis Oculi- Innervated by facial nerve, closes eyelids. Loss of function causes ectropion and
inability to close eyes tightly

Levator palpebrae superioris- Innervated by CN III, raises upper eyelid. Loss of function causes
complete ptosis

Superior tarsus- Group of smooth muscles that maintains to keep eye open in coordination with
Levator palpebrae superioris-, innervated bt postganglionic sympathetic fibres. Loss of function causes
partial ptosis
Sensory Supply
of Eyelids
Glands of Eyelids
• Meibomian glands- modified sebaceous glands, embedded in tarsal
plate. Its blockage causes chalazion (Inner surface of eyelid)

• External sebaceous and sweat glands- blockage causes stye at edge of

eyelid
Extraocular Muscles

• The extraocular muscles (EOM) are responsible for controlling the movements of the eyeball and
upper eyelid. These muscles are also known as the extrinsic eye muscles, distinguishing them
from intrinsic eye muscles which are responsible for controlling the movement of the iris.
• Recti Muscles:
There are four recti; superior, inferior, medial, and lateral. They all share a common origin, a
fibrous ring of connective tissue located posteriorly at the apex of the orbit, called
the tendinous ring or the annulus of Zinn.
• A useful mnemonic for remembering the nerve supply to the extraocular muscles is:
• LR6SO4AO3
• LR = Lateral rectus: innervated by the sixth nerve
• SO = Superior oblique: innervated by the fourth nerve
• AO = All other extraocular muscles: innervated by the third nerve
Extraocular Muscles
LACRIMAL APPARATUS
• The lacrimal apparatus is the physiological system containing the orbital structures for tear
production and drainage.
It consists of:
• The lacrimal gland, which secretes the tears, and its excretory ducts, which convey the fluid to the
surface of the eye; it is a j-shaped serous gland located in lacrimal fossa.
• The lacrimal canaliculi, the lacrimal sac, and the nasolacrimal duct, by which the fluid is conveyed
into the cavity of the nose, emptying anterioinferiorly to the inferior nasal conchae from the
nasolacrimal duct.
• The innervation of the lacrimal apparatus, which involves both a sympathetic supply through
the carotid plexus of nerves around the internal carotid artery, and parasympatheticallyfrom
the lacrimal nucleus of the facial nerve.
• The blood supply to the lacrimal gland is provided by the ophthalmic artery with its branch - the
lacrimal artery, while the venous blood is drained from this region via the superior ophthalmic
vein
External Ear
• The external ear is the part of the ear we can see with the naked eye. It is attached to the
lateral aspect of the head and is characteristically divided into two parts: the auricle or
pinna and the external acoustic meatus
• the auricle is a cartilaginous structure covered by skin
• The outer curve of the auricle is called the helix, which connects with the lobule of the
ear. Parallel and anterior to the helix is a smaller curve, aptly called the antihelix.
• In the centre of the auricle, there is a depression called the concha of the auricle, which
gives rise to the external acoustic meatus.
• Anterior to the opening of the external acoustic meatus is an elevation of cartilage called
the tragus.
• Innervation of the auricle
• The auricle has several sources of sensory innervation:
• The superficial surface is supplied by the great auricular nerve and lesser occipital nerve, both of
which are branches of the cervical plexus (C2 & C3), and the auriculotemporal branch of the
mandibular nerve, which is a branch of the trigeminal nerve (cranial nerve V)
• The deep part of the auricle is supplied by the vagus nerve (cranial nerve X) and facial nerve
(cranial nerve VII)
External Acoustic Meatus
• The external acoustic meatus is a tube that travels from the deepest aspect of the concha to the
tympanic membrane, which marks the divide of the external and middle ear.
• The composition of the walls of the external acoustic meatus changes the deeper it travels:
• The lateral one-third of the external acoustic meatus is cartilaginous, which extends slightly
deeper on the inferior portion external acoustic meatus
• The medial two-thirds of the external acoustic meatus is bony, derived from the temporal bone of
the skull
• There is a slightly raised constriction located at the junction of the cartilaginous and bony portion
Nerve Supply of Pinna
• The auriculotemporal nerve, which is a branch of the mandibular nerve,( CN V)
• The auricular nerve, which is a branch of the vagus nerve (cranial nerve X)
• Innervation of the tympanic membrane
The medial surface of the tympanic membrane is supplied by the vagus (cranial nerve
X) and glossopharyngeal nerve (IX).
The lateral surface of the tympanic nerve is supplied by the auriculotemporal nerve (a branch of the
mandibular division of trigeminal nerve) and facial nerve.
 MIDDLE EAR
• The middle ear, also referred to as the tympanic cavity, is an air-filled section in the temporal boneand is
lined with a mucous membrane
• The medial surface of the tympanic membrane is supplied by the vagus (cranial nerve
X) and glossopharyngeal nerve (IX).
• The auditory ossicles
• The auditory ossicles consist of three separate bones: the malleus, incus and stapes. These connect to
form a mobile chain to join the tympanic membrane of the external ear to the oval window of the inner
ear.
• The handle of the malleus is attached to the tympanic membrane, whilst its head links with the body of
the incus in the epitympanic recess.
• The incus consists of three parts: the body links with the head of the malleus, the short limb attaches to
the posterior wall of the tympanic cavity and the long limb links with the stapes.
• The stapes is the smallest bone in the human body and its footplate attaches to the oval window of the
inner ear.
Muscles of Middle Ear
• Tensor tympani
• Innervation: mandibular branch of the trigeminal nerve (cranial nerve V)
• Function: when contracting, it pulls the handle of the malleus medially to tense the tympanic
membrane and reduces the amplitude of sound vibrations. This prevents damage to the internal
ear when there are loud sounds.
• Stapedius
• This is the smallest muscle in the human body and is located in the pyramidal eminence; a hollow
prominence on the posterior wall of the tympanic cavity:
• Innervation: stapedius is supplied by the facial nerve (cranial nerve VII)
• Function: when stapedius contracts it pulls stapes posteriorly and changes the shape of the oval
window. This is to reduce the amplitude of sound vibrations reaching the internal ear, as a form of
protection.
Boundaries of Middle Ear
• Posterior Wall- Mastoid area
• Anterior Wall (Carotid Wall)- Nasopharynx and eustachian tube in
superior part, internal carotid artery in inferior part
• Lateral Wall- External Ear/ Tympanic Membrane
• Medial Wall (Labyrinthine Wall)- The promontory of tympanic cavity
which is formed by the basal coil (initial part) of the cochlea,
tympanic plexus. The labyrinthine wall also bears
the cochlear window which lies posterosuperior to the promontory,
and the vestibular window which is situated posteroinferior to the
promontory.
Blood supply of
Face (Arterial)
• Facial artery- Chief artery, branch
of external carotid artery.
Course and Relations: Passes
through deep structures of neck and
appears at lower border of
mandible, posterior to
submandibular gland, curves around
inferior border of mandible, anterior
to masseter, enters face and runs
upwards in a tortuous course. It
terminates as the angular artery at
the medial corner of eye
• Transverse Facial Artery: Arises from superficial temporal artery
within substance of parotid gland

• Superficial Temporal Artery: Smaller terminal branch of external

carotid artery , passes anterior to the ear , supplies entire lateral
aspect of the scalp
Blood supply of Face (Venous)
• Facial Vein is the major vein draining the face. Formed by union of
supraorbital and supratrochlear vein at medial corner of eye and
drains into internal jugular vein

• Connections of Facial vein:

• Near the medial corner of orbit with ophthalmic veins.
• In cheek, with veins passing into infraorbital foramen.
• In deep regions of face it communicates with pterygoid venous plexus.
Cutaneous Innervation of Face
• Supplied by all three divisions of CN V
Ophthalmic:
Supraorbital branch- upper eyelid, conjunctiva, upper forehead till back of middle scalp

Supratrochlear branch- lower central forehead, conjunctiva and skin of upper eyelid

Infraorbital branch- medial half of upper eyelid, medial angle and side of nose

Lacrimal Branch- Lateral Half of upper eyelid and lateral angle

External Nasal Branch- anterior part of nose

Maxillary Nerve
Zygomatico-temporal branch-small area over anterior temple above zygomatic arch

Zygomatico-facial branch- small area over zygomatic bone

Infraorbital Nerve- innervating the lower eyelid, cheek, side of nose and upper lip
Mandibular Nerve
Auriculotemporal Branch- External Acoustic meatus, tympanic membrane and large area of temple

Buccal Nerve- Cheek

Mental Nerve- skin and mucous membrane of lower lip and skin of chin
Lymphatic Drainage of Face
Three groups
• Submental Nodes- Medial part of lower lip and chin bilaterally, Tip of
tongue

• Submandibular nodes- Medial orbit, external nose, medial cheek,

upper lip and lateral part of lower lip

• Preauricular and Parotid Nodes- Most of the eyelids, part of external

nose, lateral cheek, external acoustic meatus and posterior orbit
Cervical Lymph Nodes
• Jugulo-digastric Nodes- Near posterior belly of digastric muscle
receives lymphatic drainage from tonsils and tonsillar region

• Jugulo-omohyoid Nodes- Inferior to omohyoid muscle, receives

lymphatic drainage from tongue
Facial Muscles
• Muscles of facial expression
• All innervated by CN VII
• Function:
• Orbucularis Oculi- Closes eyelids gently and forcefully
• Occipitofrontalis- Raises eyebrows and wrinkles forehead
• Orbicularis Oris- Closes lips and protrudes lips in whistling
• Buccinator- Presses cheeks against teeth, helps in forceful expulsion
of air from distended cheek
LARYNX
The larynx is a complex hollow structure located in the anterior midline region of the neck. It is
anterior to the esophagus and at the level of the third to the sixth cervical vertebrae in its normal
position.

It consists of a cartilaginous skeleton connected by membranes, ligaments and associated muscles

that suspend it from surrounding structures.
Cartilages:
Unpaired (3): Cricoid, thyroid, and epiglottis
Paired (3): Arytenoid, corniculate, and cuneiform
• Thyroid Cartlage:
• The thyroid cartilage is the largest of the laryngeal cartilages and is composed of hyaline cartilage.
The broad flat right and left halves (laminae) of the cartilage fuse anteriorly in the midline to form a
V-shaped anterior projection called the laryngeal prominence (commonly called the “Adam’s
apple”).
• Superior to this prominence is the superior thyroid notch. A less prominent inferior thyroid notch is
present along the base of the thyroid cartilage. The posterior margin of each lamina extends
upward into a superior horn and downward into an inferior horn. The longer superior horn, along
with the entire superior border of the thyroid cartilage, attaches to the hyoid bone by
the thyrohyoid membrane. This board fibroelastic sheet has a thick median region called
the median thyrohyoid ligament as well as lateral parts called the lateral thyrohyoid ligaments,
which directly attach to the superior horn. The inferior horn bears a facet on its medial surface with
which its articulates with the posterolateral surface of the cricoid cartilage to form the cricothyroid
joint.
• Cricoid cartilage:
• The cricoid cartilage is a much smaller signet ring-shaped hyaline cartilage located directly below
the thyroid cartilage. It forms the inferior aspect of the larynx and is connected to the trachea
inferiorly. It is the only complete ring of cartilage that encircles the airway. The cricoid cartilage has
a narrow anterior arch (band portion) and a wider posterior lamina (signet portion) with a midline
ridge that serves as a surface of attachment for the esophagus. A dense band of connective tissue,
the cricothyroid ligament, attaches the cricoid cartilage to the inferior border of the thyroid
cartilage.

• Located on the superolateral aspects of the wider posterior cricoid cartilage lamina are the paired
pyramidal-shaped arytenoid cartilages. Attached to the apices of the arytenoid cartilage are the
small, paired and conical- shaped corniculate cartilages.
• Epiglottis:
The last unpaired cartilage, the epiglottis, is a large leaf-shaped elastic cartilage that is
covered by mucous membrane. It is attached by its stalk to the inner aspect of the angle
formed by the laminae of the thyroid cartilage via the thyroepiglottic ligament in the midline.
During swallowing, as the larynx moves up and forwards, the epiglottis swings downward to
close off the laryngeal inlet, and thus prevents materials from entering the airway.
A thin layer of connective tissue, the quadrangular membrane extends between the lateral borders of
the epiglottis and the anterolateral margins of the arytenoid cartilage. Its free lower edge is thickened
and forms the vestibular ligament. This ligament is enclosed by a fold of mucous membrane to form
the vestibular fold(false vocal cord) which extends from the thyroid cartilage to the arytenoid cartilage
Cavity of Larynx
The laryngeal cavity is divided into three regions:
1. Vestibule: between the laryngeal inlet and the vestibular folds
2. Middle part: between the vestibular folds above and vocal folds below
3. Infra-glottic cavity: between the vocal fold and the trachea
The vocal apparatus of the larynx is called the glottis and consists of two vocal folds(true vocal
cords) and the rima glottidis. Running parallel to each vocal ligament is the vocalis muscle which is
responsible for adjusting the tension of the vocal folds. The vocal folds are the “true” structures that
produce sound as air passes over them, whereas the vestibular folds (false vocal cords) have no role
in sound production but protect the vocal cords.
The opening between the vocal cords is referred to as the rima glottidis. The shape of this opening
depends on the position of the vocal folds. Rotational movements of the arytenoid cartilages at
the cricoarytenoid joints can separate (abduct) the vocal folds, widening the rima glottidis or
appose (adduct) the vocal folds and narrow the rima glottidis.
Muscles of Larymx
• There are two groups of muscles that are associated with the larynx, the extrinsic and intrinsic
muscles. The extrinsic laryngeal muscles move the larynx as a whole. They consist of
the suprahyoid muscles that elevate the hyoid bone and the larynx during swallowing and
vocalization, and the infrahyoid musclesthat depress the hyoid bone and the larynx.
Blood supply and lymphatic drainage

• The arterial supply of the larynx is by the superior and inferior laryngeal arteries which are
branches of the thyroid arteries. The larynx is drained by corresponding veins, namely the
superior and inferior laryngeal veins. The lymphatic vessels above the vocal folds drain into the
superior deep cervical lymph nodes whereas those below the vocal folds drain first to nodes
around the trachea (pretracheal and paratracheal nodes) and subsequently into the inferior deep
cervical lymph nodes.
Nerve Supply
• The right and left superior and inferior laryngeal nerves which are branches of the vagus nerve,
the tenth cranial nerve (CN X), provide motor and sensory innervation to the larynx. Each superior
laryngeal nerve divides into the internal and external laryngeal nerves. The internal laryngeal
nerve accompanies the superior laryngeal artery through the thyrohyoid membrane and provides
the sensory and autonomic innervation of the laryngeal cavity to the level of the vocal cords. The
smaller external laryngeal nerve provides motor innervation to the cricothyroid [Link] lesion
can cause loss of sensation above vocal cords and loss of taste on the epiglottis and a hoarse
voice
• The recurrent laryngeal nerves which are ascending branches of the vagus nerves continue
toward the larynx as the right and left inferior laryngeal nerves. They provide motor innervation
to all the intrinsic muscles of the larynx except the cricothyroid muscles and sensory innervation
to the laryngeal cavity below the vocal cords.
•
MAXILLARY ARTERY
Foramina of Skull
TONGUE
• The tongue is a muscular structure in the mouth covered by mucosa It can be divided into the
anterior two-thirds which makes up part of the oral cavity and the posterior-third, part of the
oropharynx.
• MUSCLES:
• The tongue consists of a tip, dorsal surface, ventral surface, and root. It is made up of four pairs of
muscles:1
• Intrinsic (entirely within the tongue): Their role is to change the shape of the tongue, having a
role in facilitating speech, eating, and swallowing.
• Extrinsic (which have bony attachments): genioglossus, hyoglossus, styloglossus and
palatoglossus. Their role is to alter the tongue’s position.
• LYMPHATIC DRAINAGE:
The lymphatic drainage of the tongue is complex, consisting of superficial and deep networks. This
can be simplified into the following:
• Anterior two-thirds of the tongue: initially into submental and submandibular nodes, which then
empty into the deep cervical lymph nodes.
• Posterior one-third of the tongue: directly into the deep cervical nodes.

• Appreciation of the lymphatic drainage of the tongue into lymph node levels of the neck is
important when understanding the metastatic spread of tongue malignancies
Innervation of the tongue:
• Sensory:
Anterior two-thirds: Lingual nerve (a branch of the mandibular division of the trigeminal nerve – V3)
Posterior one-third: Glossopharyngeal nerve (cranial nerve IX), plus a small branch of the internal
laryngeal nerve (branch of the vagus nerve, cranial nerve X).
Taste sensation is carried by special sensory nerve fibres of the chorda tympani (branch of the facial
nerve). This nerve also carries secretomotor fibres to the submandibular and sublingual glands.
Motor:
All the intrinsic and extrinsic tongue muscles are supplied by the hypoglossal nerve (cranial nerve
XII) EXCEPTthe palatoglossus, which is supplied by the pharyngeal branch of the vagus nerve.
Damage to the hypoglossal nerve can lead to weakness and atrophy of the ipsilateral tongue. When
one of the two nerves are damaged the tongue when protruded will deviate towards the side of the
damaged nerve, due to overaction the functioning genioglossus on the unaffected side.
THYROID GLAND:
• The thyroid gland is a butterfly shaped, vascular, red-brown endocrine gland situated in the
midline of the anterior neck. Under normal circumstances, it extends from the level of the
5th cervical vertebra (C5) to the first thoracic vertebra (T1).
• The irregular structure is encased in the pretracheal part of the deep cervical fascia . It is made up
of a central isthmus that connects the right and left lobes of the organ inferomedially.
• Important Relations:Medially, the gland is related with larynx and trachea and is fixed to
the cricoid cartilage, along with the first two tracheal rings, by the suspensory ligament of
Berry. The external laryngeal nerve passes by the gland along this border as well. Both
the recurrent laryngeal nerve and the trachea are posteroinferiorly related to the medial
border of the thyroid gland. The carotid sheath can be found near the posterolateral
border of the gland. The anterior branch of the superior, and the inferior, thyroid arteries
are related to the anterior and posterior borders of the thyroid gland, respectively. Another
important structure that has a posteroinferior relationship to the left lobe of the thyroid
gland is the thoracic duct
Blood supply of Thyroid gland
• ARTERIAL: The superior thyroid artery (arising from the external carotid artery) and
the inferior thyroid artery(originating from the thyrocervical branch of the subclavian artery)

• It is of great importance that the surgeon is aware of the very close relationship between the
superior thyroid artery and the external laryngeal nerve. This nerve is very close to the artery at
the superior pole. Additionally, the recurrent laryngeal nerve is most often related to the
posterior branch of the inferior thyroid artery. Damage to the either nerve is associated with
serious complications.

• VENOUS: Superior and middle thyroid vein draining to internal juguklar vein and inferior thyroid
vein draining to brachiocephalic vein
• Lymphatic Drainage:Paratracheal nodes and deep cervical
Sympathetic Trunk
• Two parallel trunks which run parallel from the base of the skull to the coccyx.
• Three ganglia: Superior, middle and inferior cervical ganglion
• Ascending preganglionic fibers from upper thoracic spinal cord synapse in them, postganglionic
sympathetic fibers connect with spinal nerves c1-c8 through grey rami communicantes.
• Superior Cervical Ganglion:
Sympathetic innervation to head and neck, lies in area of C1- C2 vertebrae and has branches to:
Internal and external carotid arteries, cervical spinal nerves c1-4, pharynx and heart
• Middle Cervical Ganglion:
Lies in the area of C6 vertebra and supplies to cervical spinal nerves C5 C6 and heart
• Inferior Cervical Ganglion:
Lies in the area of C7 vertebra, combines with first thoracic ganglion to form cervico-thoracic ganglion.
It has branches to cervical spinal nerves C7-T1, vertebral and subclavian artery, the heart.
HORNER’S SYNDROME
Damage to sympathetic trunk unilaterally
Triad of
Partial ptosis(due to paralysis of superior tarsal muscle)
Miosis (due to paralysis of dilator pupillae muscle)
Anhidrosis (due to damage to innervation to sweat glands)
Enophthalmos may occur due to paralysis of orbitalis muscle

• Causes include:
• Apical Lung tumor
• Penetrating Neck Trauma
• Thyroid CA
• Cervical Rib
• Injury to Carotids
Innervation of the Oral Cavity
• Sensory:
General sensory innervation: Upper part including palate and upper teeth by maxillary nerve.
Lower parts including lower teeth and anterior two-third of the tongue by mandibular nerve.
General sensations from posterior third of tongue by CN IX
• Motor
All muscles of tongue by CN XII except palatoglossus (CN X)
All muscles of soft palate by CN X except tensor veli palatini (Mandibular Nerve)
Mylohyoid also innervated by Mandibular nerve
• Special: Taste from anterior two third of tongue by chorda tympani CN VII and from posterior third by CN IX
Autonomic: Parasympathetic fibers to glands in oral cavity carried by CN VII, distributed with branches of CN V
Sympathetic fibers in oral cavity from spinal cord levcel T1 synapse in superior cervical ganglion and are
eventually distributed to oral cavity along CN V
Neck Fasciae

Superficial cervical Subcutaneous connective tissue located between the dermis and
fascia investing layer of deep cervical fascia
Contents: Neurovascular supply to skin, superficial veins and lymph
nodes, fat, Platysma muscle

Deep cervical fascia Investing layer: most superficial, enclosing trapezius, sternocleidomastoid,
submandibular and parotid glands
Pretracheal layer: occupies the anterior part of the neck, consisting of
muscular and visceral parts
Prevertebral layer: encloses vertebral column, longus colli and longus
capitis muscles
Carotid sheath: contains the common carotid arteries, internal carotid
arteries, internal jugular vein, the vagus nerve (CN X), some deep cervical
lymph nodes, carotid sinus nerve, and sympathetic nerve fibres
Neck Spaces
• Pretracheal space lies between investing layer of cervical facias and pretracheal fascia and passes
between neck and anterior part of superior mediastinum.
• Retropharyngeal Space lies between the buccopharyngeal facia (part of deep cervical fascia
postreior to pharynx) and prevertebral fascia and extends from base of skull to the posterior
mediastinum
• Prevertebral Space is within the prevertebral layer as it splits into two laminae , extending from
the base of skull and extend through the posterior mediastinum to the diaphragm
NECK TRAINGLES
• The triangles of the neck are the topographic areas of the neck bounded by the neck muscles. The
sternocleidomastoid muscle divides the neck into the two major neck triangles; the anterior
triangle and the posterior triangle of the neck.
Anterior triangle Borders:
- Superior - inferior border of mandible
- Medial - midline of neck
- Lateral - anterior border of sternocleidomastoid muscle
Subdivisions:
- Muscular (omotracheal) triangle
- Carotid triangle
- Submandibular triangle
- Submental triangle
Contents:
Muscles: thyrohyoid, sternothyroid, sternohyoid muscles
Organs: thyroid gland, parathyroid glands, larynx, trachea, esophagus, submandibular gland, caudal part of the parotid gland
Arteries: superior and inferior thyroid, common carotid, external carotid, internal carotid artery (and sinus), facial, submental, lingual arteries
Veins: anterior jugular veins, internal jugular, common facial, lingual, superior thyroid, middle thyroid veins, facial vein, submental vein, lingual veins
Nerves: vagus nerve (CN X), hypoglossal nerve (CN XII), part of sympathetic trunk, mylohyoid nerve

Posterior triangle Borders:

- Anterior - posterior margin of sternocleidomastoid muscle
- Posterior - anterior margin of trapezius muscle
- Inferior - middle one-third of clavicle
Subdivisions:
- Occipital triangle
- Supraclavicular (omoclavicular) triangle
Contents:
Vessels: the third part of the subclavian artery, suprascapular and transverse cervical branches of the thyrocervical trunk, external jugular vein, lymph nodes
Nerves: accessory nerve (CN XI), the trunks of the brachial plexus, fibers of the cervical plexus
PHRENIC NERVE
• Anterior rami of C3-C5
• Passes around upper border of each anterior scalene muscle, then continues inferiorly across
anterior surface of anterior scalene muscle within prevertebral fascia
• It enters the thorax with subclavian artery and vein to continue to the diaphragm
RECURRENT LARYNGEAL NERVE
• Right recurrent laryngeal nerve originates in the root of the neck, as a branch of right vagus
nerve it reaches the lower edge of the first part of the subclavian artery. Then it travels in groove
between trachea and the esophagus as it heads to larynx.
• Left recurrent laryngeal nerve originates more inferiorly from the left vagus as it cross the arch of
aorta in the superior mediastinum, it passes below and behind the arch of aorta and then ascends
behind trachea to the larynx
SUBCLAVIAN ARTERY
• Right subclavian artery is a branch of the brachio-cephalic trunk .
• Left subclavian artery is a branch of arch of aorta and ascends posterior to left common carotid
artery
• Each subclavian artery arches superior to the extension of pleural cavity in the root of the neck
and posterior to the anterior scalene muscle becoming the axillary artery as it crosses the lateral
border of first rib
QUESTIONS?
 QUIZ

• In a patient with head injury with fractured internal acoustic meatus,

which two nerves will be damaged?
• Answer: CN VII and CN VIII
• Female with malignancy in anterior two-third of tongue, where will
the lymph drain?
• Answer: Submental (Tip) and Submandibular nodes