NEUROSURGICAL ANAESTHESIA

Anatomy of the skull

Learning objectives

John Craven
After reading this article you should be able to locate the:
C
surface marking of the pterion
C
site of injection when performing a lingual nerve block
C
site of injection when performing an inferior alveolar nerve
block.

Abstract
The external bony characteristics of the skull are described in this article,
with emphasis on surface anatomical features, bony landmarks and relationships to nervous and vascular structures. Common fractures are
described, together with their associated complications and diagnostic
features.

Lateral aspect (Figure 1)

The zygomatic arch is formed by the zygomatic process of the
squamous temporal bone and the temporal process of the zygomatic bone. The masseter muscle arises from the lower border
and medial surface of the arch. The squamous part of the temporal bone extends upwards to articulate with the parietal bone.
The temporal line curves upwards and backwards from the
zygomatic process of the frontal bone across the parietal bone,
and then down and forwards over the squamous temporal bone
to end above the external acoustic meatus. Below the temporal
line, deep to the zygomatic arch, is the temporal fossa, roofed by
the temporal fascia attached to the temporal line and the zygomatic arch. Temporalis muscle arises from the inferior temporal
line and the whole surface of the temporal fossa. The medial wall
of the fossa is formed by the frontal, parietal, temporal and
greater wing of the sphenoid bones. Their H-shaped union, the
pterion, lies about 3.5 cm behind and 1.5 cm above the palpable
frontozygomatic suture. Here the middle meningeal artery
grooves the inner surface of the bone. A blow to the side of the
head may fracture the thin bones of the pterion and rupture the
middle meningeal vessels. The resulting extradural haematoma
puts pressure on the underlying brain.
Below the temporal fossa is the infratemporal fossa, limited
medially by the lateral pterygoid plate, which communicates
with the pterygopalatine fossa through the pterygomaxillary
fissure and with the orbit through the inferior orbital fissure. The
external acoustic meatus opens below the posterior zygomatic
arch and the palpable mastoid process is prominent behind the
meatus. To this is attached sternomastoid.

Keywords External features; fractures; skull; surface markings

Royal College of Anaesthetists CPD matrix: 1A00

The skull (a term that includes the mandible) is described as

viewed from above, the front, the side and from below.

Superior aspect
The vault is crossed by three sutures. The coronal suture
separates the frontal bone from the two parietal bones posteriorly
(Figure 1). The midline sagittal suture separates the two parietal
bones. Its junction with the coronal suture, the bregma, is
incompletely ossified at birth and can be felt as a diamondshaped deficiency known as the anterior fontanelle. This
closes by about 18 months. The lambdoid suture separates the
two parietal bones and the occipital bone posteriorly and meets
the sagittal suture at the lambda. This, too, is not ossified at birth
and presents as a small bony deficiency, the posterior fontanelle, which closes by the third to sixth month.

Anterior aspect (Figure 2)

The smooth convexity of the frontal bone lies above the openings
of the orbital, nasal and oral cavities, forming the upper third of the
facial skeleton e the maxillae and the mandible form the lower
two-thirds. The supraorbital margin possesses a supraorbital
notch or foramen in its inner third that transmits the supraorbital
vessels and nerve. The lateral orbital margin is formed by the
frontal and zygomatic bones; the medial margin by the frontal bone
and the frontal process of the maxilla; the inferior margin by the
maxillary bone medially and the zygomatic bone laterally. Above
the supraorbital margins are the superciliary arches.
The prominence of the cheek is produced by the zygomatic
bone. About 1 cm below the orbit on the maxilla, in line with the
supraorbital notch, is the infraorbital foramen, from which
emerge the infraorbital vessels and nerve. The nasal aperture is
bounded above by the nasal bones, and below and laterally by
the maxillae. The opening of the oral cavity is surrounded by the
alveolar margins of the maxillae and mandible. The mental foramen of the mandible, in line with the supraorbital and
infraorbital foramina, conveys the mental vessels and nerve.

Inferior aspect (Figure 3)

Anteriorly is the hard palate, formed by the palatine processes of
the maxillae in front of the horizontal plates of the palatine
bones. It is bounded anterolaterally by the alveolar processes of
the maxillae. Anteriorly a midline incisive foramen communicates with the nose and transmits the greater palatine arteries
and nasopalatine nerves; on the posterolateral palate are the
greater and lesser palatine foramina, which convey vessels and
nerves of the same name. The posterior nasal apertures
(choanae) open above the palate, bounded above by the body of
the sphenoid bone, below by the horizontal plates of the palatine
bones, and laterally by the medial pterygoid plates. The apertures
are separated by the tiny, wedge-shaped midline vomer. From
the medial pterygoid plate projects the hamulus that gives
attachment to the pterygomandibular raphe. Behind the base of
the lateral pterygoid process is the foramen ovale, which transmits the mandibular nerve; and posterolateral to the foramen is
the spine of the sphenoid and the foramen spinosum, which

John Craven FRCS was formerly Consultant Surgeon at York District

Hospital, York, UK. He is past chairman of the primary examiners of the
Royal College of Surgeons of England. Conflicts of interest: none
declared.

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NEUROSURGICAL ANAESTHESIA

Anterior aspects of the skull showing foramina

and their contents

Lateral aspect of the skull

Bregma

External acoustic meatus

Coronal suture

Parietal bone

Temporal fossa

Temporal line

Greater wing
of sphenoid

Lambdoid
suture

Frontal bone

Lambda

Frontal bone
Supraorbital
foramen
(supraorbital N
from ophthalmic
division of fifth
cranial N)
Superior
orbital
fissure
(third, fourth
and sixth
cranial Ns,
nasociliary,
lachrymal
and frontal
branches of
fifth cranial N,
orbital branch of
middle
meningeal A,
ophthalmic veins,
sympathetic
fibres)

Zygoma
Glabella
Nasal
bone

Occipital
External
occipital
protuberance

Mandible
Maxilla
Zygomatic arch
Pterion

Squamous
Mastoid
Tympanic
Styloid

Frontozygomatic
suture

Parietal
bone
Greater wing
of sphenoid
Optic canal
(second cranial
N, ophthalmic A)
Middle concha
Inferior concha

Inferior orbital
fissure (maxillary
and zygomatic
Ns, infraorbital
vessels)

Parts of
temporal
bone

Maxilla
Mandible

Infraorbital
foramen (infraorbital N
from maxillary branch
of fifth cranial N)

The external acoustic meatus (opening) is surrounded by the squamous and

the tympanic parts of the temporal bone

Nasal septum
Mental foramen
(mental N from mandibular
branch of fifth cranial N)

N, nerve; A, artery

Figure 2

Figure 1

Inferior aspect of the skull showing foramina and their contents

Maxilla

Incisive canal (nasopalatine N and greater palatine A)

Vomer

Palate

Greater palatine foramen

(greater palatine N and vessels)

Hamulus of the medial pterygoid plate

Lateral pterygoid plate

Maxillary tuberosity

Foramen lacerum (filled with cartilage only)

Foramen spinosum (middle meningeal A)
Posterior nasal choanae

Carotid canal (internal carotid A,

sympathetic fibres)

Foramen ovale (mandibular division

of fifth cranial N)

Jugular foramen (internal jugular vein,

ninth, tenth, eleventh cranial Ns)

Mandibular fossa
Styloid process

Condyle

External acoustic meatus

Mastoid process

Stylomastoid foramen (seventh cranial N)

Foramen magnum (spinal cord, ascending
part of eleventh cranial N, spinal and
vertebral As, branches of spinal Ns C1C3)

Hypoglossal canal (twelfth cranial N)

Inferior nuchal line
Superior nuchal line
External occipital protuberance
N, nerve; A, artery

Figure 3

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NEUROSURGICAL ANAESTHESIA

The mandible, medial aspect

Lateral pterygoid
Temporalis
Mandibular foramen
Medial pterygoid

Position of the
sublingual gland

Position of the
submandibular gland

Genioglossus
Geniohyoid

Mylohyoid

Diagastric

Figure 4

transmits the middle meningeal artery. The sphenomandibular

ligament is attached to the spine, and lateral to the spine is the
mandibular fossa, with which the mandibular condyle articulates. The petrous temporal bone lies between the occipital and
sphenoid bones and contains the carotid canal, whose inferior
opening lies behind the spine of the sphenoid. Posterolateral to
the carotid opening is the jugular foramen, which transmits the
internal jugular vein and the glossopharyngeal, vagus and
accessory nerves. Posterolateral to the styloid process is the
stylomastoid foramen, which transmits the facial nerve. The
occipital bone contains the foramen magnum, bounded on each
side by the occipital condyles, and a small foramen transmitting
the hypoglossal nerve. Behind the foramen magnum are the superior and inferior nuchal lines, between which are attached the
postvertebral muscles. In the middle of the superior line is the
prominent and palpable external occipital protuberance.
The mandible (Figure 4) is formed by the midline union of
its two halves each with a horizontal body joining with a vertical ramus at the palpable angle. The flat ramus bears two
prominences superiorly; the coronoid process giving attachment to temporalis and the posterior condylar process

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:4

articulates with the mandibular fossa of the temporal bone.

Masseter is attached to the external surface of the ramus and in
the centre of its medial surface is the mandibular foramen that
conveys the inferior alveolar vessels and nerve. To the lower lip
of the foramen is attached the sphenomandibular ligament.
Palpation of this ligament helps to locate the inferior alveolar
nerve. The medial pterygoid muscle is attached to the medial
surface of the angle below the mandibular foramen. The body
has a smooth inferior border and an upper alveolar border
bearing sockets for the teeth. The mental foramen, conveying
the mental vessels and nerve, lies on the lateral surface below
the premolar teeth. The medial (inner), surface is ridged by the
mylohyoid line, to which mylohyoid is attached, passing
downwards and forwards to the midline. The lingual nerve lies
close to the medial surface of the mandible just behind the last
molar tooth.
A
FURTHER READING
Abrahams P, Craven J, Lumley J. Illustrated clinical anatomy. 2nd Edn. CRC
Press, 2011.

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