DENT2062: Block Notes

Amro Farag Cranial Nerves:

I Olfactory Nerve:
o Has only sensory function which is for sense of smell
o Consists of olfactory epithelium, bulbs and tracts
o Olfactory epithelium Damage to this nerve is manifested by anosmia
II Optic Nerve:
o Sensory function where it conveys visual information from the retina till it
reaches the visual centers of the brain for interpretation
o Damage to this nerve leads to blindness
III Oculomotor:
o Somatic motor (general somatic effect) supplies four of the six extraocular
muscles of the eye and the levator palpebrae superioris muscle of the upper
eyelid
o Visceral motor (general visceral effect) provides parasympathetic innervation
of the constrictor pupillae and ciliary muscles involved in the pupillary light
and accommodation reflexes
o Damage to the oculomotor can lead to lazy eye, dilated pupil and ptosis
IV Trochlear:
o Somatic motor (general somatic efferent) innervates the superior oblique
muscle of the contralateral orbit
o Trochlear nerve palsy/Superior oblique dysfunction Damage produces
vertical diplopia and hypertropia. Most commonly injured cranial nerve in
head trauma
V Trigeminal:
o 5th cranial nerve, also the largest and most complicated. Different clinical
implications as local anaesthesia, traumatic injuries and viral infections could
affect this nerve.
o Natures of Fibres and Innervations:
Components:
Afferent general Somatic:
o Function :
General sensibility
o Peripheral Distribution:
Sensory branches of the ophthalmic, maxillary
and mandibular nerves to skin, mucous
membranes of the face and head
Efferent Special Visceral:
o Function:
Motor (masticatory function)
o Peripheral Distribution:
Branches to temporalis, masseter, pterygoids,
mylohyoid, tensor timpani and tensor palati
Afferent Proprioceptive:
o Function:
Muscular sensibility
o Peripheral Distribution:
Sensory endings in muscles of mastication

o Branches of the Trigeminal Nerve:

Sensory:
Supplies touch, pain and temperature to the face
Motor:
Supplies muscles of mastication (masseter, temporalis,
pterygoids, mylohyoid and anterior belly of digastric)
These muscles produce elevation, depression, retrusion,
retraction and side-to-side movements of the mandible
The motor division also supplies tensor tympani and tensor
palati
3 branches of the Trigeminal nerve:
Opthalmic
Maxillary
Mandibular
Opthalmic Division:
Purely sensory
Innervates:
o Forehead
o Upper eyelid
o Cornea (corneal reflex), conjunctiva
o Dorsum of nose
Branches into:
o Frontal nerve
o Lacrimal nerve
o Nasociliary nerve
Maxillary Division:
Pure sensory division
Arises from trigeminal ganglion
Leaves cranial cavity through foramen rotundum
Branches of maxillary nerve are:
o Meningeal branch near origin
o Two ganglionic branches arising in the pterygo-palatine
fossa and the sphenopalatine ganglion
o The posterior superior alveolar (dental) nerve and
zygomatic nerve
o The infra-orbital nerve (which is the continuation of the
maxillary nerve)
Innervations of Maxillary Dentition:
o Posterior Superior Alveolar Nerve (With presence of
middle superior alveolar nerve):
Dental pulp
Investing structure
Buccal mucosa upper molars and may give
nerve supply to upper 2nd premolar

o Middle Superior alveolar Nerve:

Upper premolars
Mesiobuccal root of upper 6
Note: Sometimes can be missing and instead
anterior superior and posterior superior alveolar
nerves innervate the premolars instead
o Anterior Superior Alveolar Nerve:
Upper anteriors
Might give supply to upper 1st premolar and if
middle superior alveolar nerve is missing, the
2nd as well
o Palatine Innervations:
Greater palatine - Provides sensation to palatine
mucosa and anastomose with sphenopalatine
fibres in the anterior part of the hard palate
Lesser Palatine - Provides taste nerve fibres,
secretomotor fibres and common sensation to
tissues of the soft palate
Sphenopalatine - Supplies the palatine
supporting structures (palatine mucosa) of the
central and lateral incisors
Mandibular Division:
Largest branch of trigeminal nerve
Mixed sensory/motor fibres
Exits skull through foramen ovale
Carries sensation from:
o Lower lip
o Lower teeth/gums
o Chin/jaw (except angle of mandible which is innervated
by CN2 and CN3)
o Parts of external ear
o Parts of dura of middle cranial fossa
o Mandibular nerve carries touch/position and
pain/temperature sensations from the mouth
Branches:
o Recurrent meningeal nerve
o Medial pterygoid nerve
o Masseteric nerve
o Deep temporal nerve
o Lateral pterygoid nerve
o Buccal nerve
o Auriculotemporal nerve
o Lingual nerve (joined by chorda tympani - branch of
facial nerve)
o Inferior alveolar nerve:
Mylohyoid
Dental
Incisive
Mental

Innervations of lower teeth:

o Inferior Alveolar Nerve:
Supplies pulp and investing structures of
mandibular molars, premolars and anterior teeth
o Lingual Nerve:
Supplies lingual mucoperiosteum of all lower
teeth, anterior 2/3 of the tongue and floor of the
mouth
o Buccal Nerve:
Supplies buccal mucoperiosteum opposite to
lower molars
Accessory Innervations of Mandibular Teeth:
o Lower anterior teeth cross innervate (incisive nerve
crosses midline from one side to another)
o Lower premolars may receive additional nerve supply
from the cutaneous coli nerve (branch from the cervical
plexus of nerves) for their labial mucoperiosteum
o Lower molars may receive additional nerve supply from
the nerve to mylohyoid for the pulp and investing
structures

IV Abducens:
o Somatic motor Innervates lateral rectus muscle of ipsilateral orbit
o Damage to the abducens causes issue in left to right movement of the eye
VII Facial:
o Motor control of most of the muscles of facial expression and posterior belly
of the digastric, the stylohyoid and stapedius of middle ear
o Also receives taste from anterior 2/3 of the tongue via chorda tympani,
VIII Vestibulocochlear:
o Vestibulocochlear nerve (also called auditory nerve, acoustic nerve or 8th
cranial nerve) consists of two anatomically and functionally distinct parts
which serve equilibrium and hearing
Cochlear nerve is distributed to hearing organ
Vestibular nerve is distributed to organ of equilibrium
o Damage to VIII leads to vertigo and deafness
o Intracranial Branches:
Greater petrosal nerve which provides parasympathetic innervation to
nasal gland, lacrimal gland, palatine gland and pharyngeal gland as
well as the cranial sinuses and nasal cavity
Nerve to stapedius provides motor innervation for stapedius in middle
ear
Chorda tympani innervates submandibular gland, sublingual gland and
taste fibres for the anterior 2/3 of the tongue

o Extracranial Branches:
Posterior auricular controls some movements of scalp muscles around
ear
Branch to posterior belly of the digastric as well as some of the
stylohyoid
Five major facial branches (in parotid gland):
Temporal branch of facial nerve
Zygomatic branch of facial nerve
Buccal branch of facial nerve
Marginal mandibular branch of facial nerve
Cervical branch of facial nerve
IX Glossopharyngeal:
o Branchial motor (special visceral efferent) Supplies stylopharyngeus muscle
o Visceral motor (general visceral efferent) Parasympathetic innervation of the
parotid salivary gland, smooth muscle and glands of the pharynx, larynx and
viscera of the thorax and abdomen
o General visceral afferent Caries visceral sensory information from the
carotid sinus and body
o General somatic afferent Provides general sensory information from skin of
external ear, internal surface of the tympanic membrane, upper pharynx and
posterior third of the tongue
o Special sensory (special afferent) Provides taste sensation from posterior 1/3
of the tongue
X Vagus Nerve:
o Mixed sensory and motor nerve which wanders into thorax and abdomen and
provides parasympathetic innervation of organs
o Damage to vagus results in dysphagia, hoarseness of voice, loss of cough
reflex (pharynx/larynx), loss of taste sensation in palate (epiglottis)
XI Accessory Nerve:
o Has cranial root and spinal root both consisting of branchial motor fibres:
Branchial motor cranial root (special visceral efferent) Innervates
muscles of larynx and pharynx
Branchial motor spinal root (special visceral efferent) Innervates
trapezius and sternocleidomastoid muscles
XII Hypoglossal Nerve:
o Has only somatic motor (general somatic efferent) component
o Somatic motor innervates all intrinsic and most of extrinsic tongue muscles
o CN XII supplies three of the four extrinsic muscles of the tongue including
genioglossus, styloglossus and hyoglossus
o Palatoglossus is supplied by CN X (Vagus)
o Runs inferior to the tongue and innervates tongue muscles
o Damage can lead to paralysis of the tongue

Edward Hsu Arterial Supply of Head and Neck:

Arterial Systems:
o Carotid Artery
Common Carotid Artery Internal Carotid Artery/External Carotid
Artery
o Subclavian Artery
Subclavian Artery:
o Chief arterial supply of upper limb and root of neck contributing branches to
head and brain
o Right artery is a branch of the innominate (branchiocephalic) artery whereas
left is a branch of the arch of the aorta
o Each artery enters neck behind corresponding sternoclavicular joint, curves
upwards for one inch above clavicle (half an inch below apex of the lung) to
end at the outer (lateral) border of the first rib behind the mid clavicular point
where it becomes the axillary artery
o The artery runs behind the scalenus anterior muscle which divides its course
into first, second and third parts
o 3 Parts of the Subclavian Artery as it Relates to the Scalenus Anterior:
Medial part has 3 branches vertebral, thyrocervical trunk and internal
thoracic
Posterior part has 2 branches, costocervical trunk and dorsal scapula
which may also arise from costocervical trunk
Lateral part has no branches
o Branches of the Vertebral Artery:
Grouped as cervical and intra-cranial branches
Cervical Branches:
Spinal branches (into each intervertebral foramen: second
part/segment)
Muscular branches
Intracranial Branches:
Meningeal arteries supply the dura mater of the posterior
cranial fossa
Posterior spinal arteries which descend along the medulla
oblongata
Anterior spinal arteries
Posterior inferior cerebellar artery (perhaps the most tortuous
artery in the body)
o Branches of First Part of the Subclavian Artery:
Thyrocervical Trunk:
Short, wide trunk that arises lateral to vertebral artery and from
upper surface of the subclavian artery and immediately breaks
into 3 branches
Transverse cervical artery
Suprascapular artery
Inferior thyroid artery (largest branch of the trunk)

Internal Thoracic (Mammary) Artery:

Rises from lower surface of the subclavian artery about one
inch above the clavicle. It passes downwards over lung apex
and is crossed by or crosses the phrenic nerve
o Branches of the 2nd and 3rd Parts of the Subclavian Artery:
Branches of the 2nd part of the subclavian are the costocervical
trunk
The 3rd part has no branches
Common Carotid Artery:
o Main arterial supply to the head and neck
o Right artery is a branch of the innominate (brachiocephalic) and the left is a
branch from the aortic arch
o The arteries of the two sides lie deep at the root of the neck where they are
separated by a narrow interval
o Their upper parts are wide apart being separated by the larynx and the pharynx
and become more superficial at the carotid triangles
o Each artery divides at the upper border of the thyroid cartilage (C4) into
external and internal carotid branches at which point there is a dilatation (the
carotid sinus, a baroreceptor). On the posterior aspect of the bifurcation there
is the carotid body (a chemo receptor)
o Each artery lies in its carotid sheath with the internal jugular vein lateral to it
and the vagus nerve between and posterior to them both
Internal Carotid Artery:
o Arises at upper border of thyroid cartilage to enter infratemporal region
o Extends along the side of pharynx until it reaches base of the skull where it
enters carotid canal
o The beginning of the artery shows dilation of the carotid sinus in which walls
are contained (the baroreceptors) which regulate blood pressure (carotid sinus
and carotid body are both supplied by the glossopharyngeal nerve)
o Internal carotid artery is really external (lateral) to the external carotid at its
origin but soon slopes up posteriorly to occupy a medial and deeper level
o No branches in the neck
o Relations of the Petrous Part of the Internal Carotid Artery:
Enters lower opening of the carotid canal in the petrous temporal bone
Within the carotid canal it turns 90o anteromedially to run through the
petrous temporal bone where it lies medial to the middle ear. It then
turns 90o superiorly to pass across upper limit of the foramen lacerum
into the cranial cavity
It the turns 90o anteriorly to pass forwards, lateral to the body of the
sphenoid which it groves. Here it lies in the medial wall of the
cavernous sinus with the abducens nerve (CN VI) on its lateral side

o Relations of the Cavernous Part of the Internal Carotid Artery:

Artery enters cavernous sinus by piercing its posterior wall, it then runs
in its medial wall
At anterior end of cavernous sinus it turns 90o superiorly then 90o
posteriorly to pass medial to anterior clinoid process and lateral to
pituitary stalk and optic chiasma
Pierces roof of cavernous sinus 4mm behind the optic foramen
The ICA ends as terminal branches on the medial surface of the
temporal lobe
Optic nerve runs above and in front of the artery
The oculomotor (CNIII) and trochlear (CNIV) nerves with the
ophthalmic and maxillary divisions of the trigeminal nerve (V1 and
V2) lie in the lateral wall of the sinus
o Relations of the Cerebral Part of the Internal Carotid Artery:
The carotid artery pierces the roof of the cavernous sinus bending
upwards and backwards above it
It lies below the optic nerve but above the oculomotor, finally dividing
into anterior and middle cerebral arteries
o Branches of the Internal Carotid Artery Summary:
Petrous Part:
Caroticotympanic arteries
Pterygoid branch
Cavernous Part:
Hypophyseal branches to the pituitary gland
Meningeal branches
Cerebral Part:
Ophthalmic artery
Posterior communication artery
Anterior choroidal artery
Anterior cerebral artery
Middle cerebral artery
External Carotid Artery:
o Supplies Extracranial structures
o Arises in carotid triangle as terminal branch of common carotid opposite the
upper border of the thyroid cartilage (C4)
o The artery leaves the triangle deep to the digastric muscle, runs upwards and
backwards to enter the submandibular and parotid regions where it ends in the
parotid gland behind the neck of the mandible by dividing into the superficial
temporal and maxillary branches
o It lies at first anteromedially to the internal carotid artery but spirals over it to
the come to lie lateral to it at the level C2
o During its course upwards it is crossed by from below upwards The upper
root of the ansa cervicalis the hypoglossal nerve, the posterior belly of the
digastric muscle, stylohyoid, muscle, the stylohyoid ligament and facial nerve
within the parotid

o Passing between it and the internal carotid artery are from below and upwards,
the pharyngeal branch of the vagus (CN X), glossopharyngeal
o It lies on, below and upwards, the pharyngeal wall, superior laryngeal branch
of the vagus (CNX) and deep parotid lobe
o Branches:
Mostly arise in carotid triangle at different levels related to tip of the
greater horn of the hyoid bone
Ascending pharyngeal artery
Superior thyroid artery
Lingual artery
Facial artery
Occipital artery
Posterior auricular artery
Maxillary artery
Superficial temporal artery
o Anatomically before the ECA enters the parotid gland, the ECA gives off six
branches, three from in front, one from behind and one deep (medial)
Three in front are superior thyroid, lingual and facial
Two from behind are occipital and posterior auricular
One from medial is ascending pharyngeal
o Ascending Pharyngeal Artery:
Arises from medial side of external carotid, close to its origin, ascends
along the side of pharynx deep to the carotid sheath to reach the base
of the skull. Alongside the ICA (deep) and in front of the prevertebral
fascia
Branches:
Pharyngeal branches
Tonsillar branches
Inferior tympanic branch
Meningeal branches
o Superior Thyroid Artery:
Arises from anterior surface of external carotid (near commencement)
just below tip of greater horn of the hyoid bone, descends almost
vertically downwards with the vein to the upper pole of the thyroid
gland. Close behind it is the external laryngeal nerve
Branches:
Infra-hyoid artery
Superior laryngeal artery
Sterno-mastoid branches to the sterno-mastoid muscle
Crico-thyroid artery runs along the cricothyroid muscle and
membrane anastomosing with the opposite side

o Lingual Artery:
Arises from anterior surface of external carotid artery opposite the tip
of the greater horn of the hyoid bone above the superior thyroid artery
Forms short upward loop, then passes forwards along the upper b order
of the greater horn of the hyoid bone, deep to the hyoglossus muscle
before it enters the submandibular region
Its course is divided into three parts, relative to the hyoglossus muscle
First Part:
Runs in carotid triangle which it leaves by crossing deep to the
digastric muscle to enter the submandibular region
Branches:
o Small, supra-hyoid artery runs along the upper border of
the hyoid bone to anastomose with the opposite side
Second Part:
Runs horizontally under cover of the hyoglossus muscle along
the upper border of the hyoid bone with the lingual vein
Branches:
o 1-2 dorsalis lingulae arteries supply the dorsum of the
tongue, the palate and the tonsils
Third Part:
Ascends upwards under anterior border of hyoglossus between
it and the genioglossus towards tip of the tongue where it
becomes the deep artery of the tongue
Branches:
o Deep artery of the tongue (deep lingual artery)
o Sublingual artery which supplies the sublingual salivary
gland and gums anastomosing with the submental artery
o Facial Artery:
Arises in carotid triangle from anterior surface of ECA above the
lingual artery above the tip of the greater horn of the hyoid bone
Leaves carotid region, running upwards on the superior constrictor,
deep to the digastric and stylohyoid muscles to enter the submandibular region deep to the submandibular salivary gland. It indents
the surface of the gland
Makes S-bend, curling down over submandibular gland and up over
the mandible. Reaching the lower border of the mandible it hooks
around it (its pulsation can be felt 2.5cm in front of the angle of the
mandible at the anterior border of the masseter). It thus enters the face
at the antero-inferior angle of the masseter muscle where it ascends
upwards, forwards and medially towards the angles of the mouth, the
nose and the eye where it ends by anastomosing with the dorsal nasal
branches of the ophthalmic artery
Course of the artery is tortuous so that it can accommodate itself to the
movements of the pharynx during deglutition and the mandible during
opening of the mouth
Can be considered to be of two parts, cervical and facial

Branches of the Cervical Part of the Facial Artery:

Ascending palatine artery
Tonsillar artery
Glandular branches to the sub-mandibular salivary gland
Submental artery (largest branch of the cervical portion)
Branches of the Facial Part of the Facial Artery:
Inferior labial artery Supplies lower lip anastomosing with
the other side to form the inferior labial arch
Superior labial artery Supplies the other lip anastomosing
with the other side to form the superior labial arch
The lateral nasal branches Supplies the ala of the nose
Angular artery Ends as angular artery which anastomoses
with Infraorbital artery
Muscular branches Supply adjacent muscle. Posterior belly of
the digastric, stylohyoid, styloglossus, mylohyoid and medial
pterygoid muscle
o Occipital Artery:
Arises from posterior aspect of external carotid artery level with the
facial artery. Ascends upwards and backwards along the lower border
of the posterior belly of the digastric muscle till it reaches the medial
side of the mastoid process crossing the apices of the posterior and
sub-occipital triangles of the neck
Groves the base of the skull at the occipitomastoid suture deep to the
digastric notch on the mastoid process
Finally pierces trapezius muscle to end in posterior part of the scalp
Branches:
Two sternocleidomastoid branches, the upper one accompanies
the accessory nerve to the deep surface the muscle. The lower
branch holds down the hypoglossal nerve
Mastoid branch, enters the mastoid foramen to supply the
mastoid air cells
Auricular branches, to the auricle and the muscles of the back
The descending occipital artery
o Posterior Auricular Artery:
Arises from the external carotid artery at the upper border of the
posterior belly of the digastric within the parotid gland under which it
ascends upwards to the back of the auricle till the groove between the
mastoid process and the cartilaginous part of the external acoustic
meatus
It runs superficial to the Styloid process across the upper border of the
digastric
Branches:
Stylomastoid branch
Auricular and occipital branches to the back of the scalp and
the mastoid regions

o Superficial Temporary Artery:

Superficial temporal artery is a terminal branch of the external carotid
arises behind the neck of the mandible within the substance of the
parotid gland
It appears in the temple at the upper pole of the parotid gland where it
crosses the zygomatic arch with its vein in front and the
auriculotemporal nerve behind it
Branches:
Transverse facial artery
Anterior auricular artery
Zygomatico-orbital branch
Middle temporal artery Largest branch, arises above the
zygomatic arch, pierces temporal fascia and runs deep to the
temporalis muscle supplying it and grooving the bone just
above the external acoustic meatus
Terminal frontal and parietal branches
o Maxillary Artery:
Larger terminal branch, arises in parotid region and ends in pterygopalatine fossa where it becomes infra-orbital artery
Arises behind and deep to the neck of the mandible and runs forwards
until it reaches lower border of the lateral pterygoid muscle (first or
mandibular part). It then crosses lower head of the lateral pterygoid
(second or pterygoid part) and finally dips medially between the two
heads of the muscle to enter the pterygo-palatine fossa (third or
pterygo-palatine part)
5 branches from each part. From the first and third parts the five
branches all enter foramina in bones. From the second part none go
through foramina in bones.
First Part (Mandibular) Branches:
Deep auricular artery
Anterior tympanic artery
Middle meningeal artery
Accessory meningeal artery
The inferior alveolar artery is the largest branch of the first part,
descends downwards and forwards behind its own nerve lateral
to the medial pterygoid and the spheno-mandibular ligament, it
enters the mandibular foramen where it divides into incisor and
mental branches
Inferior alveolar and middle meningeal arteries are the most
important, in dissections they arise very near one another and
pass respectively straight down and straight up

Inferior Alveolar Artery:

o Branches:
The mylohyoid artery accompanies mylohyoid
nerve the mylohyoid groove of the mandible. It
anastomoses with the submental branch of facial
artery
The incisor/dental branch arises in mandibular
canal opposite third molar, supplies branches to
the pulps of the teeth and finally anastomoses
with the opposite side
Mental artery leaves the mandible through the
mental foramen to supply the chin region and
anastomose with the inferior labial and
submental branches of the facial artery
Second Part (Pterygoid) Branches:
Deep temporal branches Supply the deep surface of the
temporalis muscle anastomosing with the middle temporal
artery
Pterygoid branches Supply pterygoid muscles
The buccal artery Supplies the buccinators muscle
The masseteric artery Supplies the masseter muscle
A small artery accompanies the lingual nerve to the tongue
Third Part (Pterygo-Palatine Branches):
The posterior superior alveolar artery enters the back of the
maxilla and supplies branches to the branches of the maxillary
nerve
The greater palatine artery descends through the greater
palatine canal with its nerve to reach the greater palatine
foramen in the hard palate
o It then runs forward in the groove between the palate
and the alveolar part of the maxilla till it reaches the
incisive fossa; there it leaves the fossa through its lateral
foramen to anastomose with branches of the sphenopalatine artery. 2-3 lesser palatine branches are given to
supply the tonsil and the soft palate
Pharyngeal branches run through a canal to supply the roof of
the nasopharynx and the Eustachian tube
The artery to the pterygoid canal enters the pterygoid canal and
has the same distribution as the pharyngeal branches
The spheno-palatine artery is a long slender branch that leaves
pterygopalate fossa through the spheno-palatine foramen to
enter the posterior part of the nasal cavity where it gives
posterior lateral nasal branches to the superior concha and
meatus of the nose anastomosing for the nasal branches of the
ethmoidal arteries

Infra-Orbital Artery:
Continuation of the maxillary artery, enters the orbit through
the inferior orbital fissure occupying the infra-orbital notch,
groove and canal which carries it to the face where it leaves the
skull through the infraorbital foramen
Throughout its course the artery is accompanied by the
infraorbital nerve and both run in the floor of the orbital cavity
Branches:
o Zygomatic branch, divides into zygomaticofacial and
zygomaticotemporal branches
o Middle superior alveolar artery supplies the sockets of
the premolar teeth and their pulp spaces
o Orbital branches to the contents of the orbit
o Anterior superior alveolar artery supplies the socket and
pulp spaces of the canine and incisors
o Terminal palpebral, nasal and labial
Circle of Willis:
o Anterior cerebral artery (left and right)
o Anterior communicating artery
o Internal carotid artery (left and right)
o Posterior cerebral artery (left and right)
o Posterior communicating artery (left and right)

Alistair Reid Veins and Lymphatics of the Head and Neck:

Blood Vessels:
o Arteries and veins have same basic structure:
Intima (single layer of endothelium)
Media (muscular) with inner and outer elastic lamina
Adventitia (connective tissue)
o Veins less muscular and elastic
o Veins contain valves
Veins:
o Passively return blood to the heart
o In some instances can actively pulp blood (e.g. deep calf veins and pterygoid
venous plexus via use of muscle pump)
o Controls venous return and therefore cardiac output via nervous and chemical
signalling
Veins of the Head and Neck:
o Internal and External Jugular Systems:
Drain blood from deep and superficial structures
Venous return to the heart
Systems not exclusive to each other (points of communication are
clinically important)
Few valves
Some veins are encased in bone
o External Jugular System:
Formed by union of posterior auricular vein and posterior division of
retromandibular vein behind the angle of the mandible
Runs superficially across the sternocleidomastoid
Runs deep to the platysma and pierces the deep fascia of the neck in
the posterior triangle to enter the subclavian vein
Valves about 4cm about the subclavian
External Jugular Vein:
Drains most of scalp and the face Superficial temporal vein is
joined by maxillary veins (from pterygoid venous plexus) to
form the retromandibular vein
Just above the clavicle the external jugular vein also receives
the transverse cervical vein, suprascapular vein and anterior
jugular vein
Tributaries:
o Retromandibular vein
Superficial temporal vein
Maxillary veins
o Posterior auricular vein
o Transverse cervical vein
o Suprascapular vein
o Anterior jugular vein

o Internal Jugular Vein:

Begins as continuation of sigmoid sinus as it exits the skull via the
jugular foramen
Drains most of the head and neck
Runs within carotid sheath
Deep to sternocleidomastoid
Marks surface at earlobe to sternoclavicular joint
Tributaries:
Inferior petrosal sinus
Pharyngeal plexus
Facial vein
Lingual vein
Superior thyroid vein
Middle thyroid vein
May receive occipital vein but usually drains to vertebral
plexus
As it exits the skull within the carotid sheath it is initially posterior to
the internal carotid artery and then runs lateral to it
The vagus nerve lies between the internal carotid artery and the
internal jugular vein
The deep cervical nodes are closely adjacent to the internal jugular
vein throughout its course in the neck
Veins are highly variable but the following tributaries usually join at
the level of the hyoid bone (C3)
Pharyngeal plexus
Facial vein
Lingual vein
Distended at superior and inferior ends
o Carotid Sheath:
Connective tissue sheath running from base of skull (at carotid canal)
to aortic arch
Thin over internal jugular vein to allow distension
Contains:
Internal jugular vein
Internal and common carotid arteries
Vagus nerve
Deep cervical nodes
Sympathetic plexus of arteries
Ansa cervicalis
In upper part only contains accessory nerve, hypoglossal nerve
and glossopharyngeal nerve

o Facial Vein:
Supraorbital and suptratrochlear veins pass medial to the medial
canthus of the eyelids to form the angular vein
The angular vein continues as the facial vein
Accompanies the facial artery as it crosses the lower border of the
mandible
Then pierces investing fascia of the neck and is joined by anterior
division of the retromandibular
Tributaries:
Angular vein (supraorbital and suptratrochlear veins)
External nasal vein
Superior labial vein
Inferior labial vein
Anterior branch of retromandibular vein
Submental vein
Sometimes lingual vein and superior thyroid vein
o Lingual Vein:
Joins IJV at level of hyoid
May join IJV directly or have a common trunk with facial vein
Tributaries:
Dorsal lingual vein
Deep lingual vein (from tip of tongue, runs along under surface
of tongue)
Sublingual vein (joins deep lingual vein at anterior border of
hyoglossus to form the venae commitans of the hypoglossal
nerve). Drains either into lingual, facial or internal jugular vein
o Thyroid Veins:
Superior thyroid vein:
Exits upper pole of gland with artery
Drains into IJV or facial vein
Middle thyroid vein:
Short and wide
Drains into IJV
Inferior thyroid vein:
Forms a plexus on pretracheal fascia
Drains into brachiocephalic vein and/or IJV
o Retromandibular Vein:
Tributaries:
Superficial temporal vein
Maxillary veins
Runs down within parotid gland and drains it
Divides into anterior and posterior branches. Posterior branch joins
posterior auricular vein to form the EJV whereas anterior branch joins
facial vein to drain into the IJV

Veins of the Scalp:

o Run with corresponding arteries
o Receive diploic veins from the calvarial bones
Pterygoid Venous Plexus:
o Network of tiny veins within and around lateral pterygoid muscle
o Dilated and easily punctured by needle
o Drains into the paired maxillary veins
Large and short veins
Deep to neck of mandible
Drain into superficial temporal vein
o Aid venous return via pump action of the muscle
Sucks blood from the incompressible parts of head and neck (facial
bones and orbit)
o Tributaries:
Nasopalatine vein
Lateral posterior superior nasal vein
Greater palatine vein
Pharyngeal vein
Infraorbital vein
Inferior ophthalmic vein
Deep facial vein (communicates between plexus and facial vein
anterior to masseter)
Small vein from cavernous sinus via foramen ovale (or foramen of
Vesalius)
o On the posterior aspect of the middle constrictor muscle
o Drains to pterygoid venous plexus or IJV directly
o Communicates with inferior thyroid vein also
o Paratonsillar vein enters Tonsillar bed from soft palate (bleeding posttonsillectomy
Ophthalmic Veins:
o Superior ophthalmic vein:
Runs above optic nerve with ophthalmic artery
Communicates with angular vein
o Inferior ophthalmic vein:
Communicates with infraorbital vein and superior ophthalmic vein
Drains to pterygoid venous plexus
Venous Sinuses:
o All lie between inner and outer layers of dura mater (except inferior sagittal
and straight sinuses)
o Drain brain and adjacent skull
o Important communications with veins outside skull
o Cannot collapse
o Valveless

o Include:
Superior sagittal sinus:
Midline between layers of falx cerebri
From foramen caecum to internal occipital protuberance
Usually turns right into lateral (transverse) sinus
Inferior sagittal sinus:
From above crista galli back to free margin of falx cerebri
Flows into straight sinus where falx meets tentorium cerebelli
Straight sinus:
From inferior sagittal IOP
Slopes down at 45o
Turns left to form transverse sinus
Tributaries:
o Inferior sagittal sinus
o Cerebral veins
o Great cerebral vein of Galen
o Veins from occipital lobe and cerebellum
Transverse sinus:
From IOP runs between layers of tentorium cerebelli
Right usually larger
Runs forwards then downwards to become sigmoid sinus.
Superior petrosal sinus ends at this turn
Confluence of sinuses
Sigmoid sinus:
Exits at jugular foramen to become the internal jugular vein
Tributaries:
o Transverse sinus
o Occipital sinus
o Superior petrosal sinus
Occipital sinus
Basilar sinus
Cavernous sinus:
Adjacent to body of sphenoid bone
Middle cranial fossa
Contains internal carotid artery, abducens nerve, oculomotor
nerve, trochlear nerve (ophthalmic and maxillary branches)
Receives blood from orbit, skull and cerebral hemispheres
Tributaries:
o Ophthalmic veins
o Superficial middle cerebral veins
o Sphenoparietal vein
o Superior petrosal sinus
o Inferior petrosal sinus
o Pterygoid venous plexus

Drains Via:
o Superior petrosal sinus
o Inferior petrosal sinus
o Small veins to pterygoid venous plexus
Superior petrosal sinus
Inferior petrosal sinus
Cavernous Sinus Thrombosis:
o Facial infection can produce thrombosis
o Spread of infection via valveless veins
o Painful ophthalmoplegia
o Retrograde thrombosis of inferior petrosal sinus and medullary veins is usually
fatal
Central/Peripheral Venous Communications:
o Facial vein and cavernous sinus Angular vein communicates with superior
ophthalmic vein
o Deep facial vein and cavernous sinus Via pterygoid venous plexus
o Posterior auricular vein and sigmoid sinus Via mastoid emissary vein,
mastoiditis can lead to temporal abscess, meningitis, encephalitis, retrograde
thrombosis and death
Lymph Nodes:
o Lymph transports foreign material to nodes
o Initiation of immune response
o Principally B cells but T cells help
o Innate immune cells also involved
o Enlarge when active
o May be affected by disease:
Reaction to infection
Abscess
Cancer (primary or metastatic)
Granuloma
o Enlarged lymph nodes may:
Indicate presence of infection
Indicate presence of neoplasia
Indicate primary site of either based on knowledge of normal
lymphatic drainage
Lymphatics of Head and Neck:
o No lymphatics in following systems:
Central nervous system
Globe
Inner ear
Cartilage
Bone
Epidermis

o Eventually all lymphs from the head and neck pass through the deep cervical
nodes eventually draining into the thoracic duct (drains whole body except
upper right limb, right thorax, right head and neck), right lymphatic duct and
subclavian vein
o Occipital Nodes:
Apex of posterior triangle
Drains posterior scalp
o Supraclavicular Nodes:
Numerous nodes above clavicle
Outlying deep cervical nodes
o Deep Cervical Nodes:
Lie in loose connective tissue around internal jugular vein
Posterior group pass under sternocleidomastoid to become
supraclavicular group
Parotid drains via upper cervical group
Orbit drains to pre-auricular and then parotid nodes and then to upper
deep cervical nodes
o Submental Nodes:
3-4
Below chin
Drain to submandibular nodes
Drain anterior floor of mouth, lower incisors, lower anterior gingivae,
lower lip and tip of tongue
o Submandibular Nodes:
6 or so
Within and on surface of submandibular gland
Remove gland if treating nodal metastatic disease
Drains submental nodes, lateral of lower lip, external nose, anterior 2/3
of the tongue, anterior nasal walls, paranasal sinus, all other teeth and
submandibular gland
o Retropharyngeal Nodes:
Drain posterior nasal cavity, posterior ethmoidal sinus, sphenoidal
sinus and pharynx
o Jugulodigastric Nodes:
Drain tonsil
Just below angle of mandible
o Tongue Lymphatic Drainage:
Anterior to submental lymph nodes
Lateral to submandibular lymph nodes
Centre to inferior deep cervical lymph nodes
Posterior to deep cervical lymph nodes

Mohammed Mansour Tissue Spaces of the Face and Neck:

Deep Fascia of the Neck:

o Varies from one region to the other, may be loose layer of connective tissue
when it covers expansible organs such as the buccal cavity or the pharynx or it
may be a firm fibrous membrane as that covering the pre-vertebral muscles
Attachments of the Investing Fascia of the Neck:
o Above To the external occipital protuberance, the super nuchal line, the
mastoid process and the lower border of the mandible
o Below To the 7th cervical spine, spine of the scapula, the acromion, the
clavicle and the upper border to the sternum
o Posteriorly To the nuchal ligament
o Anterior To the bony prominences of the neck (symphysis menti, hyoid
bone, thyroid and cricoid cartilages and the sternum) and becomes continuous
with the opposite side encasing the infra-hyoid muscles
Investing Fascia of the Neck:
o Between the mastoid process and the angle of the mandible the fascia is split
to enclose the parotid salivary gland blending with and forming its capsule and
covering the masseter muscle to form the parotidomassteric fascia
o At the lower border of the mandible the fascia splits again to enclose the
submandibular salivary gland, its deep lamina ascends to be attached to the
mylohyoid line
o Investing fascia of the neck ensheathes the trapezium lengthwise, behind and
the sternomastoid in front. In between them it forms the roof of the posterior
triangle of the neck
Carotid Sheath:
o Condensation of investing layer of deep fascia, deep to and along the posterior
border of the sternomastoid
o Sheath is well formed over carotid artery but is loosely constructed over
internal jugular vein so as not to interfere with its dilation during times of
increased venous return
o Loosely fixes and supports the vein to the artery
o Attachments:
Above To base of skull, the tympanic plate and petrous parts of the
temporal bone
Below Extends behind sternoclavicular joint to the superior
mediastinum of the thorax where it becomes continuous with the
adventitia of the aortic arch
Anterior Blended to and is continuous with both the pretracheal and
prevertebral fascia which extend between carotid sheaths of both sides
Posterior Continuous with investing layer of deep fascial and
prevertebral fascia

o Contents:
Above posterior belly of the digastric it contains the ICA
anteromedially, the IJV posterolaterally and CN IX to XII in between
Below the digastric it contains the CCA and the lower part of the ICA
as well as the IJV with the vagus nerve only in between
The limbs of the ansa cervicalis and its loop are embedded on the
anterior wall of the sheath whereas the sympathetic chain is embedded
lengthwise along the posterior wall of the sheath
Pre-Tracheal Fascia:
o Well-formed membrane on which the infra-hyoid muscles can move during
movements of larynx and pharynx
o Attachments:
Above To hyoid bone and oblique line of thyroid cartilage
Below Fascia extends behind sternum around the inferior thyroid
veins to blend with fibrous pericardium and adventitia of the aortic
arch
o Split to enclose the thyroid gland, fixing it to the larynx and the 2nd, 3rd and 4th
tracheal rings. Its anterior surface is blended to the fascial sheaths of the infrahyoid muscles
Pre-Vertebral Fascia:
o Tough, fibrous membrane that lies in front of the prevertebral muscles forming
a base on which the pharynx, oesophagus and carotid sheaths move during
swallowing
o Attachments:
Medially Fascia continuous across the median plane with other side
blending with the anterior longitudinal ligament of the vertebral
column
Sideways Fascia is continuous deep to the carotid sheath and the
sternomastoid muscle with the deep fascia covering the floor of the
posterior triangle
Above Fascia fixed to base of the skull
Below Extends to superior mediastinum to be attached to the 3rd
thoracic vertebra
Pharyngeal Fascia:
o Bucco-Pharyngeal Fascia - Covers outer surface of pharyngeal muscles and is
prolonged anteriorly over the buccinator muscle
o Pharyngo-Basilar Fascia Tough, fibrous membrane that fills gap between the
upper border of the pharynx and base of the skull. Pierced by Eustachian tube
and palatal muscles
o Retro-Pharyngeal Fascia Forms a loose areolar tissue between posterior wall
of the pharynx, oesophagus and the prevertebral fascia allowing their free
movement

Odontogenic Infections:
o Spread to Primary Spaces:
Sinus
Nasal cavity
Palate
Sublingual
Submandibular
Vestibular
Buccal
o Spread to Secondary Spaces:
Pterygomandibular Between medial and lateral pterygoid muscles
Masseteric Spreads from submandibular and buccal
Superficial and deep temporal
Infratemporal space
Lateral pharyngeal space Migrates from Pterygomandibular space
and contains many vital structures
Retropharyngeal
Prevertebral Danger Space 4 between prevertebral and alar
extension
Grodinsky and Holyoke spaces

Amro Farag Anatomy of the Facial Nerve:

Origin of Facial Nerve:

o Facial nerve nucleus which resides in dors-lateral portion of the pons
o In the cerebellopontine angle the facial nerve is in close proximity to the
nervus intermedius
o Then travels through internal auditory canal
Infratemporal Course (1st Branch):
o 1st branch is the greater superficial petrosal nerve
o Parasympathetic secretory fibres to the nose, mouth and lacrimal gland and
sensory taste fibres from the palate
Infratemporal Course (2nd and 3rd Branches):
o Nerve to stapedius muscle
o Chorda tympani nerve leaves in mastoid bone through petrotympanic fissure
carrying parasympathetic secretory fibres to the submandibular and sublingual
glands and sensory taste fibres from the anterior two-thirds of the tongue
Extratemporal Course:
o Emerges from the stylomastoid foramen
o Mostly divide into upper and lower main branches
o The frontal (temporal) branch and marginal mandibular branches are most
consistent in anatomy
o The other three branches zygomatic, buccal and cervical branches
Muscles:
o Facial nerve innervates a total of 23 paired muscles and the single orbicularis
oris muscle
o Only 18 of the paired muscles act in final expression
o Remaining 5 pairs of muscles move the scalp and ears
o Main muscles of expression:
Frontalis muscle raises the eyebrows
Orbicularis oculi muscle Closes the eyelids
Zygomaticus major and minor muscles Instrumental in smiling and
grimacing
Orbicularis oris muscle Purses the lips
Lower lip depressors Keep the lip from riding up where it may be
bitten during chewing
Facial Nerve Paralysis:
o Unilateral facial weakness
o Unilateral loss of taste sensation
o Decreased salivation (insignificant)
o Decreased tear secretion (causes eye dryness and corneal ulceration)
Aetiology:
o Idiopathic (Bells Palsy)
o Viral infection (Herpes Zoster Virus)
o Trauma (Fractures)
o Tumours (Parotid Salivary Gland Tumours)

Transient Facial Nerve Paralysis:

o Could occur after administrator of inferior alveolar nerve block anaesthesia
o If the needle inserted too deep (not touching bone), injecting the local
anaesthetic solution into the parotid salivary tissue