HEAD AND NECK

Crisle Dychingco, MD, DPBS

Department of Anatomy
AUFSOM
Skeleton of the Head
• Mastoid process
• Styloid process
• External auditory/
acoustic meatus
(ear opening)
• Ear drum
• Hyoid bone
• Epiglottis
• Thryroid cartilage
• Cricoid cartilage
• Tracheal rings
 Neck
• Neck is anatomically complex
• Vertebral compartment – cervical (=neck) vertebrae and muscles
• Visceral compartment – parts of respiratory and digestive tracts, and
some endocrine organs
• Vascular compartments – major blood vessels of head and neck
 Anterior and posterior triangles of neck
• Aid regional description of anatomy
• Anterior and posterior triangles separated by sternocleidomastoid
 Platysma muscle
• Muscle of facial expression in superficial fascia (subcutaneous)
• Supplied by facial nerve (CN VII), cervical branch

Netter 21, Moore&Agur 597

 Dermatomes of neck

• Dermatome: area of skin supplied by

cutaneous branches derived from a
single spinal nerve
• C2-C4, also C5 posteriorly
• Adjacent dermatomes overlap

Netter 150, 155

• Spinal nerves branch into dorsal and
ventral rami Cutaneous
• Posteriorly: dorsal rami of spinal nerves of neck
nerves C2 or C3 - C5
• Anteriorly: branches of cervical plexus
from ventral rami of C2 - C4
– Lesser occipital, great auricular,
transverse cervical, supraclavicular
Netter 18, 156
 Deep fascia of neck
• Investing (superficial) layer
• Visceral (pretracheal/buccopharyngeal) layer
• Prevertebral layer
• Carotid sheath
• Retropharyngeal space

Netter 30
 Posterior triangle of neck
Netter 18
• Borders: SCM, trapezius, middle 1/3 of clavicle Backhouse 57
• Roof: investing layer of deep cervical fascia
• Floor: prevertebral fascia and deep muscles of neck
• Surface anatomy: supraclavicular fossa, CN XI
 Sternocleidomastoid muscle
• Individually: laterally flexes (abducts) head/neck to same
side, laterally rotates head/neck to opposite side
• Together: flexes head/neck
•

Netter 23, Devinsky 41, 43

 Trapezius muscle
• Elevate, retract, depress shoulder girdle
• Lateral rotation of scapula (aids abduction of upper limb)

Netter 160, Devinsky 45

 Innervation of SCM and trapezius: CN XI

• (spinal) accessory nerve (CN XI)

Netter 121, Fix 19

 Floor of posterior triangle of neck
• Splenius, levator scapulae, scalenes (posterior, middle,
anterior)
• Anterior to anterior scalene: phrenic n, subclavian v, IJV,
inferior belly of omohyoid
• Between anterior and middle scalenes: brachial plexus
(ventral rami, trunks), subclavian artery
Netter 22, 28
 Anterior triangle of neck
• Borders: SCM, midline, mandible
• Roof: investing layer of deep cervical fascia Netter 22,23
• Floor: pretracheal fascia over viscera of neck
 Subtriangles in anterior triangle of neck
• Submandibular, submental, carotid, muscular
• Additional borders: digastric, omohyoid muscles; hyoid bone

Netter 22,23
 Submandibular, submental triangles
• Hyoid bone
• Digastric, stylohyoid muscles Netter 22,63
• Mylohyoid - floor of mouth
• Submandibular salivary gland, facial and lingual
aa,vv, hypoglossal n
 Infrahyoid (strap) muscles
• Sternohyoid, omohyoid; sternothyroid, thyrohyoid
• Action: depress hyoid and larynx after swallowing, help stabilise hyoid
bone
• Carotid D
– Common carotid
bifurcation; IJV
• Muscular D
– Viscera of neck

Netter 24
 Contents of carotid sheath
• Location: in carotid triangle superiorly, deep to SCM
inferiorly
Netter 30, 24
• Common (and internal) carotid artery
• Internal jugular vein
• Vagus nerve
• Deep cervical lymph nodes
 Autonomic nerves in neck
• Vagus nerve - in carotid
sheath
• Sympathetic chain: superior
and middle cervical ganglia,
cervicothoracic (stellate)
ganglion Netter 30, 124
 Viscera of neck
• Larynx (thyroid, cricoid cartilages) and trachea
• Pharynx and oesophagus
Netter 30, 68b
• Thyroid and parathyroid glands
 Thyroid, parathyroid glands
• Thyroid: isthmus (midline), right and left lobes,
pyramidal lobe
• Parathyroids: superior and inferior, on posterior
surface of thyroid

Netter 26,
68,70
 Blood supply to thyroid, parathyroids
• Superior, inferior thyroid artery
• Superior, middle, inferior thyroid veins
• Note relationships to laryngeal nerves

Netter 68,69
Common Carotid Artery
• Right Common Carotid Artery
– from brachiocephalic a behind R
sternoclavicular joint
• Left Common Carotid Artery
– from arch of aorta

• Both run upward through the neck in

the carotid sheath
• Under cover by anterior border of
SCM
• Divides into ICA and ECA at the
upper border of thyroid cartilage
• Laterally: internal jugular vein (vagus
n between)
Posterior View
 Common Carotid Artery
• Carotid Sinus
– Localized dilatation of CCA
– Located at point of division
– Bulbous
– 2 cm long
– Supplied by glossopharyngeal
n (sinus nerve of Hering)
– Pressoreceptor, baroreceptor
– Assists in regulation of BP
Common Carotid Artery
• Carotid Body
– Small neurovascular
structure posterior to point
of division
– Supplied by
glossopharyngeal n
– Chemoreceptor
– Sensitive to excess CO2
and reduced O2 tension in
blood
– Assists in regulating heart
and respiratory rates
 Branches of the CCA
EXTERNAL CAROTID INTERNAL CAROTID
ARTERY ARTERY
• one of terminal • ascends with internal
branches of CCA jugular v and vagus n
• from the level of upper • passes deep into
border of thyroid parotid gland
cartilage • enters cranial cavity via
• ascends to terminate in carotid canal in petrous
parotid gland behind part of temporal bone
neck of mandible • terminate by dividing
• divides into superficial into anterior and middle
temporal and maxillary cerebral aa
aa
External Carotid Artery
• Superior thyroid artery
• Ascending pharyngeal
artery
• Lingual artery
• Facial artery
• Occipital artery
• Posterior auricular
artery
• Superficial temporal
artery
• Maxillary artery
"Some Angry Lady Figured Out PMS":
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Maxillary
Superificial temporal
 SUPERIOR THYROID ARTERY
• Curves downward to
upper pole of thyroid
gland
• Accompanied by
external laryngeal
nerve (cricothyroid
m)
ASCENDING PHARYNGEAL ARTERY

• ascends along and

supplies the
pharyngeal wall
LINGUAL ARTERY
• loops upward and
forward
• Crossed
superficially by
hypoglossal nerve
 FACIAL ARTERY
• loops upward on lateral
surface of pharynx close to
the tonsil
• tunnels the submandibular
gland
• bends around lower border
of mandible
• ascends close to anterior
border of masseter
• ascends lateral to mouth
• terminates at medial angle of
orbit
• pulsations felt against the
mandible
• branches supply: tonsil,
submandibular gland,
muscles and skin of face
OCCIPITAL ARTERY
• supplies the back of the
scalp

POSTERIOR AURICULAR
ARTERY
• auricle and scalp

SUPERFICIAL
TEMPORAL ARTERY
• ascends over zygomatic
arch
• palpated in front of
auricle
• accompanied by
auriculotemporal nerve
• supplies the scalp
MAXILLARY ARTERY
• Runs forward medial to
neck of mandible
• Splits into branches that
follow maxillary
branches of trigeminal
nerve
• Supply upper and lower
jaws, muscles of
mastication, nose,
palate and meninges
 MAXILLARY ARTERY
Middle meningeal artery
• ascends between roots of auriculotemporal
nerve to enter skull via foramen spinosum
• Runs laterally within skull and divides into
anterior and posterior branches
• Anterior branch
– lies close to motor area of cerebral cortex
– alongside its vein, grooves the upper part of
greater wing of sphenoid bone and anteroinferior
angle of parietal bone (prone to trauma)
– lie between meningeal layer and periosteal layer
(extradural hemorrhage)
Weakest part of skull….middle meningeal artery runs beneath it….
risk of extradural haematoma
 Internal Carotid Artery
• Begins at level of upper border of thyroid
cartilage
• Ascends within carotid sheath with IJV and
Vagus n
• Passes deep to parotid gland
• Branches
– No branches in the neck
– Ophthalmic artery
– Posterior communicating artery
– Anterior cerebral artery
– Middle cerebral artery
 Ophthalmic Artery
• Arises from ICA as it leaves cavernous
sinus
• Passes through orbital cavity to optic
canal
• Gives off central artery of retina
– Enters optic nerve to enter eyeball
– End artery
– Only blood supply to retina
 Posterior Communicating Artery
• Runs backward to join posterior
cerebral artery
 Anterior Cerebral Artery
• Terminal branch of ICA
• Passes forward
between cerebral
hemispheres
• Winds around corpus
callosum
• Supply medial and
superolateral surfaces
of cerebral hemispheres
• Joined to artery of
opposite side by
anterior
communicating artery
 Middle Cerebral Artery
• Largest terminal branch of ICA
• Runs laterally in lateral cerebral sulcus
• Supplies lateral surface of cerebral hemisphere
except
– narrow strip along superolateral margin (supplied by
anterior cerebral a)
– Occipital pole and inferolateral surface of hemisphere
(posterior cerebral a)
• Supplies all motor area of cerebral cortex except leg
area
• Gives off central branches that supply masses of
gray matter and the internal capsule
 Subclavian Arteries
• Right subclavian artery
– Arises from brachiocephalic behind R
sternoclavicular joint
– Arches upward and laterally over pleura
and scalenus anterior and medius muscles
– Becomes axillary artery at outer border of
first rib
 Subclavian Arteries
• Left Subclavian Artery
– Arises from the arch of aorta
– Ascends to root of neck then arches
laterally

• Scalenus anterior muscle used to divide

the subclavian artery into 3 parts
 First Part of the Subclavian Artery

• Extends from the origin of subclavian a

to medial border of scalenus anterior
muscle
• Branches
– Vertebral a
– Thyrocervical trunk
– Internal thoracic a
 Vertebral Artery
• Ascends through foramina of
transverse processes of C1-
C6
• Passes medially above
posterior arch of atlas then
through foramen magnum
into the skull
• Joins vessel from the
opposite side to form basilar
artery on the anterior surface
of medulla
• Basilar artery
– Ascends on the groove
anterior to the pons
– Gives off branches to pons,
cerebellum, internal ear
– Divides into 2 posterior
cerebral arteries
 Vertebral Artery
• Posterior Cerebral a
– Curves laterally and
backward around the
midbrain
– Cortical branches
supply inferolateral
surfaces of temporal
lobe and visual
cortex on lateral and
medial surfaces of
occipital lobe
 Thyrocervical Trunk
Short trunk that gives off 3 terminal
branches
• Inferior thyroid artery
– Ascends to reach posterior surface
of thyroid gland
– Closely related to recurrent
laryngeal n
– supplies thyroid and inferior
parathyroid glands
• Superficial cervical artery
– Runs laterally over phrenic nerve
and crosses brachial plexus
• Suprascapular artery
– Follows suprascapular n into
supraspinous fossa of scapula
– Takes part in anastomosis around
scapula
 Internal Thoracic Artery
• Enters thorax behind
first costal cartilage and
in front of pleura
• Descends vertically one
fingerbreadth lateral to
the sternum
• Divides into superior
epigastric and
musculophrenic aa in
the 6th ICS
Second Part of Subclavian Artery
• Lies behind scalenus
anterior muscle
• Branches
– Costocervical trunk
• Runs backward over
dome of pleura
• Divides into…
– Superior intercostal a
» Supplies 1st and
2nd ICS
– Deep cervical a
» Supplies deep
muscles of neck
 Third Part of Subclavian Artery
• From lateral border of scalenus anterior m
across posterior triangle of neck to lateral
border of 1st rib
• Surrounded by axillary sheath of fascia with
nerves of brachial plexus
• Branches
– Usually no branches
– Occasionally, superficial cervical aa, scapular aa
or both arise
 Veins of the Head and Neck
• Divided into
– Veins of the brain, venous sinuses, diploic
veins and emissary veins
– Veins of scalp, face and neck
 Veins of the Brain
• Thin-walled
• Valveless
• Cerebral veins, cerebellar veins and
veins of brain stem
• Drain into neighboring venous sinuses
 Venous Sinuses
• Situated between
periosteal and
meningeal layers of
dura mater
• With thick fibrous walls
• Valveless
• Receive tributaries from
brain, skull bones, orbit
and internal ear
 Venous Sinuses
• Superior Sagittal Sinus
– Lies in upper fixed border
of falx cerebri
– Runs backward becomes
continuous with right
transverse sinus
– Communicates on each
side with venous lacunae
– Numerous arachnoid villi
and granulations project
into the lacunae
 Venous Sinuses
• Inferior Sagittal Sinus
– Lies in lower free margin of falx cerebri
– Runs backward and joins the great cerebral vein
to form straight sinus
• Straight Sinus
– Lies at junction of falx cerebri and tentorium
cerebelli
– Formed by union of inferior sagittal sinus and
great cerebral vein
– Drains into left tranverse sinus
 Venous Sinuses
• Transverse Sinuses
– R transverse sinus
begins as
continuation of
superior sagittal s
– Left transverse
continuation of
straight sinus
– End on each side by
becoming sigmoid
sinus
 Venous Sinuses
• Sigmoid Sinuses
– Direct continuation of
the transverse
sinuses
– Each curves
downward behind
the mastoid antrum
– Leaves skull through
jugular foramen to
become IJV
 Venous Sinuses
• Occipital Sinus
– Lies in the attached
margin of falx
cerebelli
– Communicates with
vertebral veins
through foramen
magnum and with
transverse sinuses
 Venous Sinuses
• Cavernous sinuses
– Each cavernous
sinus lies on lateral
side of the body of
sphenoid bone
– Receives inferior
ophthalmic v and
central v of retina
anteriorly
– Drains posteriorly
into transverse sinus
through superior
petrosal sinus
 Important Structures Associated
with the Cavernous Sinuses

• ICA and CN6

travel through it

• CN3 and CN4,

ophthalmic and
maxillary divisions
of CN5 laterally
 Dangerous Area of the Face
• Triangular area
bounded by root of
nose and angles of
mouth
• Venous drainage enters
angular vein (facial
vein) at medial angle of
eye
• Communicates with
cavernous sinus via
superior ophthalmic v
• Infections may lead to
cavernous sinus
thrombosis
 Venous Sinuses
• Superior and Inferior
Petrosal Sinuses
– Run along the upper
and lower border of
the petrous part of
the temporal bone
• Diploic Veins
– Occupy channels within
bones of the vault of the
skull

• Emissary Veins
– Valveless veins that pass
through skull bones
– Connect veins of scalp to
venous sinuses
– Route for spread of
infection
Veins of the Face and Neck
• Facial Vein
– Formed at the medial
angle of the eye by
union of supraorbital
and supratrochlear vv
– Connected through
ophthalmic veins with
the cavernous sinus
– Descends down with
facial artery, passes
lateral to the mouth
– Crosses the mandible
– Joined by
retromandibular v and
drains into IJV
 Veins of the Face and Neck
• Superficial Temporal
Vein
– Formed on the side
of the scalp
– Follows superficial
temporal a and
auriculotemporal n
– Enters parotid gland
– Joins maxillary v to
form the
retromandibular v
 Veins of the Face and Neck
• Maxillary Vein
– Formed in the
infratemporal fossa
from pterygoid
venous plexus
– Joins the superficial
temporal v to form
the retromandibular v
 Veins of the Face and Neck
• Retromandibular Vein
– Formed by the union of
the superficial temporal
and maxillary vv
– On leaving parotid gland,
divides into anterior and
posterior branch
– Anterior joins facial v
– Posterior joins posterior
auricular v to form EJV
 Veins of the Face and Neck
• External Jugular Vein
– Formed behind the angle
of the jaw
– Union of posterior
auricular v and
retromandibular v
– Descends across SCM
muscle and beneath
platysma muscle
– Drains into subclavian v
behind the middle 3rd of
clavicle
 Tributaries of EJV
• Posterior external
jugular vein from the
back of the scalp
• Superficial cervical vein
from skin and fascia
over posterior triangle
• Suprascapular vein
from suprascapular
fossa
• Anterior jugular vein
 Veins of the Face and Neck
• Anterior Jugular Vein
– Descends in the neck
close to the midline
– Joined to opposite vein
by jugular arch above the
sternum
– Anterior jugular v joins
external jugular v deep to
the SCM muscle
 Veins of the Face and Neck
• Internal Jugular Vein
– Large vein that drains blood from the brain, face,
scalp and neck
– Starts as continuation of sigmoid venous sinus
– Leaves the skull through jugular foramen
– Descends through neck in the carotid sheath
– Lateral to the vagus n and internal and common
carotid aa
– Ends by joining subclavian v to form
brachiocephalic v behind medial end of clavicle
– Closely related to deep cervical lymph nodes
throughout its course
 Tributaries of IJV
• Inferior petrosal
sinus
• Facial vein
• Pharyngeal veins
• Lingual vein
• Superior thyroid vein
• Middle thyroid vein
 Subclavian Vein
• Continuation of axillary
v at the outer border of
1st rib
• Joins IJV to form
brachiocephalic v
• Receives external
jugular v
• Receives thoracic duct
on the left and right
lymphatic duct on the
right
 Lymphatic Drainage of the
Head and Neck
• Lymph nodes are arranged in 2
groups
– Regional group
• surrounds neck below chin like a collar
– Deep vertical group
• embedded in carotid sheath
 Lymphatic Drainage of
Head and Neck
• Regional Lymph Nodes
– Occipital nodes
• Apex of posterior
triangle
• Drains back of scalp
– Mastoid nodes
• Over mastoid process
• Scalp above ear, auricle
and external auditory
meatus
– Parotid nodes
• On or within parotid
gland
• Scalp above parotid,
eyelids, auricle, external
auditory meatus
 Lymphatic Drainage of
Head and Neck
• Regional Lymph Nodes
– Buccal nodes
• On buccinator muscle
• Face and anterior part of scalp
• Pass lymph to submandibular nodes
– Submandibular nodes
• Superficial to submandibular gland below body of
mandible
• Front of scalp, nose, cheek, upper and lower lip (except
central part of lower lip); frontal, maxillary and ethmoid
sinuses; upper and lower teeth (except lower incisors);
anterior 2/3 of tongue (except tip); floor of the mouth,
vestibule, gums
 Lymphatic Drainage of
Head and Neck
• Regional Lymph Nodes
– Submental nodes
• Submental triangle just below chin
• Tip of tongue, floor of anterior part of the mouth, lower
incisors, central part of lower lip, skin over chin
– Anterior cervical nodes
• Along course of AJV
• Skin of front of the neck
– Superficial cervical nodes
• Along EJV
• Skin over angle of jaw, lower part of parotid and ear lobe
 Lymphatic Drainage of
Head and Neck
• Regional Lymph Nodes
– Retropharyngeal nodes
• Between pharynx and vertebral column
• Nasopharynx, auditory canal, vertebral column
– Laryngeal nodes
• In front
• Larynx
– Tracheal (paratracheal) nodes
• Alongside trachea
• Trachea and thyroid gland
 Lymphatic Drainage of
Head and Neck
• Deep Cervical Lymph Nodes
– Arranged in vertical chain along course of IJV within carotid
sheath
– Receive lymph from all regional nodes
– Efferent lymph vessels from deep cervical nodes join to form
jugular trunk which drains into thoracic duct or right
lymphatic duct
• Jugulodigastric nodes
– Behind angle of jaws
– Drains the tonsil
• Jugulo-omohyoid node
– Approximately halfway down the neck
– Drainage of the tongue
 Eye Movements,
the Extrinsic Muscles
 Eye Movements,
the Extrinsic Muscles
 Extrinsic Eye Muscles
Muscle Movement Test Nerve Supply Origin Insertion
Medial Medial Lateral Occulomotor Common Sclera,
Rectus (III) Tendinous anterior half
Ring of eye
Lateral Lateral Medial Abducens (VI) (5mm behind
Rectus corneal margin)

Superior Superior and medial Lat and dwn Occulomotor

Rectus (adduction) (III)
Inferior Inferior and medial Lat and up Occulomotor
Rectus (adduction) (III)
Superior Inferior and lateral Med and dwn Trochlear (IV) Body of sphenoid Post/Superior
Oblique (abduction) Quadrant via
trochlear
Inferior Superior and lateral Med and dwn Occulomotor Orbital surface of Post/inferior
Oblique (abduction) (III) maxilla quadrant
 Extrinsic Eye Muscles
Muscle Movement Nerve Supply Origin Insertion
Medial Medial Occulomotor (III) Common Sclera, anterior
Rectus Tendinous half of eye (5mm
Ring behind corneal
Isolated Muscle Actions margin)
Lateral Lateral Abducens (VI)
Rectus
Superior Superior and Occulomotor (III)
Rectus medial
Inferior Inferior and Occulomotor (III)
Rectus medial
Superior Inferior and Trochlear (IV) Body of Post/Superior
Oblique lateral sphenoid Quadrant via
trochlear
Inferior Superior and Occulomotor (III) Orbital Post/inferior
Oblique lateral surface of quadrant
maxilla
Testing Eye Movements
 Third nerve palsy
Accompanied by double vision (PS fibres run with
III)
 Parts of the Ear
• External ear
• Middle ear
• Inner ear
External Ear
• Auricle (pinna)
– Elastic cartilage
– Skin

• External Auditory Meatus

– S-shaped canal
– Inner bony, outer
cartilaginous
– Ceruminous glands
 Middle Ear
Tympanic Cavity
• Lateral - tympanic membrane
• Medial - lateral wall of internal ear
– Promontory
– Fenestra vestibuli
– Fenestra cochlea
– Facial canal prominence
• Anterior - eustachian tube
• Posterior - mastoid antrum to mastoid air cells
• Roof - tegmen tympani to cranial cavity
• Floor - adjacent to jugular bulb
 Middle Ear
Contents
• Auditory ossicles
– Malleus
– Incus
– Stapes

• Muscles
– Tensor tympani (CN V)
– Stapedius (CN VII)
 Internal Ear
Bony (osseus) Labyrinth
• Contains perilymph
– Transudate from blood vessels
– Fluid spaces around CN VII and possibly CSF
• Composed of
– Vestibule
– Semicircular canals
– Cochlea
Bony Labyrinth of the Internal
Ear
• Semicircular canals
– Superior (anterior)
– Lateral (horizontal)
– posterior
Bony Labyrinth of the Internal
Ear
Cochlea
• 2 1/2 turns around mediolus
• Scala vestibuli and scala
tympani connect at
helicotrema
• Oval window opens into
scala vestibuli
• Round window closed by
secondary tympanic
membrane, expands with
excessive movement of
perilymph in scala tympani
 Internal Ear
Membranous Labyrinth
• Contains endolymph
– Secreted at stria vascularis
• Composed of
– Utricle and saccule
– Semicircular ducts
– Cochlear duct
– Vestibular membrane
Membranous Labyrinth of the
Inner Ear
– Utricle and
saccule
(vestibule)
• Maculae
– sensory area of
utricle and
saccule
– macula utriculi,
macula sacculi
– receptors for
static equilibrium
 Membranous Labyrinth of the
Inner Ear
• Semicircular
ducts (canals)
– Cristae
ampullares
• sensory area of
semicircular ducts
at ampullae
• receptors for
kinetic equilibrium
Membranous Labyrinth of the
Inner Ear
• Cochlear duct or
scala media
(cochlea)
– Organ of Corti
• sensory area of
cochlear duct
• lies on basilar
membrane
• receptor for hearing
Membranous Labyrinth of the
Inner Ear
• Vestibular
(Reissner’s
membrane)
– Separates scala
vestibuli from scala
media (or cochlear
duct)