The A to Z of the Head and Neck

A to Z Book Head and Neck18E™:A to Z Book 18/02/09 9:52 AM Page A

The A to Z of the Head and Neck

Dr A. L. Neill BSc MSc MBBS PhD FACBS [email protected] Front

A to Z Book Head and Neck18E™:A to Z Book 18/02/09 9:08 AM Page 1

Introduction

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Acknowledgement

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Since the beginning of the A to Zs there has been a demand for a book to deal with the structures of the Head and Neck - so here it is! As usual I have included a feedback page at the end of this book and I hope that from it, if there are any suggestions or ideas about the publication that this will be used as a guide to any of you who may have some ideas for this project. However if you just want to write fax, email or other send your suggestions to me, I am always pleased to hear them.

Thankyou Apsenpharmacare Australia particularly the CEO Greg Lan, and the head of sales and marketing Robert Koster. Thank you to those doctors, students and others who made suggestions gave feedback and have supported this project.

Dedication

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This book is dedicated to solitude.

How to use this book

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The format of this book is similar to others in the A to Z series, with a few minor adjustments. As far as possible alphabetical listing of the structures is incorporated in the book. This continues the style, as with other A to Z books, of making the book its own index. References at the bottom of the page redirect the reader to where that structure is listed. As well as the brief Table of Contents in the beginning of the book, there is an expanded version at the beginning of each of the main sections, which also acts as a specialized index to that section. Basic concepts necessary for the understanding of Anatomy are placed as usual in the beginning of the book. The muscles and layers of the face and neck and the muscles of the specialist structures present are discussed in a summary overview form and then listed individually in alphabetical order in the usual muscle format: Origin (O), Insertion (I), Action (A), nerve supply (NS) & blood supply (BS) and Testing (T) where appropriate. This book is extensively cross referenced against the other A to Z books, and expands on them. While the nerves of the head and neck are not discussed here, the nerves of the cervical / neck region are discussed in detail in the A to Z of Peripheral Nerves and the Cranial Nerves will be discussed in the A to Z of the Brain and Cranial Nerves. Thank you

Amanda Neill

BSc MSc MBBS PhD FACBS ISBN 1 74138 167 5


The A to Z of the Head & Neck

Abbreviations

MCP med MT N NR NS

= lower limb = ligament = lumbar plexus = Latin = metacarpal / metacarpo(hand) = metacarpo-phalangeal = medial = metatarsal / metatarso (foot) = nerve = nerve root origin = Nerve supply / nervous system = nervous tissue = origin = phalangeal / phalanges / phalango= plural = posterior longitudinal ligament = peripheral nerve = posterior = right / resistance = range of motion = sacral = singular = spinal cord = spinal nerve = spinous process / sacral plexus = signs and symptoms = TEST / thoracic = thoracic outlet syndrome = transverse process = upper limb, arm = vertebral body = vertebral column = within = without

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LL lig LP Lt. MC

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= actions /movements of a joint aa = anastomosis or anastomoses adj. = adjective aka = also known as ALL = anterior longitudinal ligament alt. = alternative ant. = anterior art. = articulation (joint w/o the additional support structures) AS = Alternative Spelling, generally referring to the diff. b/n British & American spelling ASIS = anterior superior iliac spine (of hip bone) b/n = between BP = brachial plexus BS = Blood Supply C = cervical c.f. = compared to CN = cranial nerve CNS = central nervous system Co = coccygeal CP = cervical plexus collat. = collateral CSF = Cerebrospinal fluid CT = connective tissue e.g. = example EC = extracellular (outside the cell) ES = Erector Spinae group of muscles ext. = extensor (as in muscle to extend across a joint) Gk. = Greek I = insertion IC = intercarpal / intercarpo - (b/n wrist) IMC = intermetacarpal IP = interphalangeal (b/n fingers / toes) IT = intertarsal / intertarso jt(s) = joints = articulations L = lumbar / left

NT O P

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PN post. R ROM S sing. SC SN SP

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SS T TOS TP UL VB VC w/n w/o

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Table of contents

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Introduction Acknowledgement Dedication

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How to use this book

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Anatomical position and Anatomical planes

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Anatomical movements of the Head & Neck

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Sites of referred pain and Examination of the Head & Neck

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The Skull & Neck

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Abbreviations Table of contents

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Common terms used in the study & examination of Bones, Joints, Muscles and other structures of the Head & Neck

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The Bones, Joints & Ligaments of the Head & Neck 60 122

OVERVIEWS of the Head & Neck

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The Muscles of the Head & Neck Arteries & Anastomoses of the Head & Neck

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Nerves of the Head & Neck

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Transverse section & fascial planes of the neck

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Topography / surface anatomy

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Venous & Lymphatic drainage (extracranial)

A to Z Pocket reference medical medical books

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Feedback form

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Common terms in the Study and Examination of Bones, Joints, Muscles and other Structures of the Head and Neck. Ablation

Additus Adenoid Ala Alveolus Annulus fibrosis Ansa Aperture Areola

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Arytenoid Atlas

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Attrition Auditory Axial

Basiocranium Boss

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Bregma

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Acoustic Acromegaly

the removal of part of the body, generally a boney part, most commonly the teeth pertaining to hearing a continuation of growth of the ends of cartilage covered bone (after fusion of the long bones) hence a gross change in the features (most noticeable in the jaw and digits) without growth in height, due mainly to the over activity of the pituitary gland opening /entrance gland a wing, hence a wing-like process as in the Ethmoid bone pl. - alae. air filled bone - tooth socket adj - alveolar (as in air filled bone in the maxilla) the peripheral fibrous ring around the intervertebral disc a loop like structure an opening or space between bones or within a bone. small, open spaces as in the areolar part of the Maxilla may lead or develop into sinuses. ladle or pitcher (arytenoids cartilages move in and out like ladle with changing sounds) after Atlas the Greek Demigod who held up the world on his shoulders tooth wear and tear pertaining to hearing, hence, pertaining to the ear. (Auditory exostosis = a bony growth on the walls of the External Auditory Meatus) refers to the head and trunk (vertebrae, ribs and sternum) of the body bones of the base of the skull a smooth round broad eminence - mainly in the frontal bone female > male refers to a junction of more than 2 bones in a joint as in the Bregma of the skull, junction between the coronal and sagittal sutures which in the infant is not closed and can be felt pulsating – site of the anterior fontanelle pertaining to the cheek consists of the calvaria from which the base has been removed refers to the cranium without the facial bones attached. tunnel / extended foramen as in the carotid canal at the base of the skull adj canular (canicular - small canal) the head or of a head, adj.- capitate = having a head (c.f. decapitate)

Buccal Calotte Calvaria Canal

Caput / Kaput

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to put to sleep; compression of the common or internal carotid artery causes coma - the term came from referral to bony points related to the Carotid vessels Cavity an open area or sinus within a bone or formed by two or more bones (adj. cavernous), may be used interchangeably with fossa. Cavity tends to be more enclosed fossa a shallower bowl like space (Orbital fossa-Orbital cavity). Cephalic pertaining to the head Cervicopertaining to the neck Clinoid like a bed-post, part of a four poster bed so that clinoid process looks like a bed post (generally with other posts) as in the Sphenoid bone. Cleido key or bar (as in the bar of the Clavicle in Sternocleidomastoid) Clivus slope hence in the anterior cranial fossa referring to a slope on the base of the cavity. Cochlea a snail hence snail-like shape relating to the Organ of Corti in the ear. Compact bone bone found in the shafts and on external bone surfaces highly Cortical bone structured in concentric circles or Haversian systems constantly Dense bone changing and remodeling depending upon the lines of force, often enclosing the lighter trabecula bone. Concha a shell shaped bone as in the ear or nose (pl. conchae adj. chonchoid) old term for this turbinate. Condyle a rounded enlargement or process possessing an articulating surface. Constrictor to squeeze Cornu a horn (as in the Hyoid) Corona a crown. adj.- coronary, coronoid or coronal; hence a coronal plane is parallel to the main arch of a crown which passes from ear to ear (c.f. coronal suture). Cranium the cranium of the skull comprises all of the bones of the skull except for the mandible. Crest prominent sharp thin ridge of bone formed by the attachment of muscles particularly powerful ones eg Temporalis/Sagittal crest Cribiform/Ethmoid a sieve or bone with small sieve-like holes. Cricoid a ring Cutus skin - hence cutaneous branches refer to the nerves supplying the skin and adnexae Dens A tooth hence dentine and dental relating to teeth, denticulate having tooth-like projections adj dentate See odontoid Depression a concavity on a surface Diaphysis the shaft or body of a long bone. In the young this is the region between the growth plates and is composed of compact bone. pl.= diaphyses adj.= diaphyseal Diploë the cancellous bone between the inner and outer tables of the skull, adj.- diploic. Distal further away from the axial skeleton (opposite of Proximal) Dorsi back

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Carotid

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without teeth a smooth projection or elevation on a bone as in iliopubic eminence refers to the interior of the “braincase” adj. endocranial divided into the 3 major fossae anterior (for the Frontal lobes) middle (containing Temporal lobes) and posterior (for the containment of the Cerebellum). Endostium a mesodermal CT which lines the inner surface of all bones and is the conduit for the NS and BS of the bone - lifting of the endostium causes cancellous bone to be laid down to fill the gap b/n the bone and the cellular layer and this device may be used to encourage bone growth/repair. Ethmoid sieve Exostosis a bony outgrowth from a bony surface, often due to irritation (as in Swimmers ear) and may involve ossification of surrounding tissues such as muscles or ligaments. External Auditory Meatus ear hole Facet a face, a small bony surface (occlusal facet on the chewing surfaces of the teeth) seen in planar joints. Fascia face Fasciule small bundle Fauces jaws or throat Fissure a narrow slit or gap from cleft. Fontanelle a fountain, associated with the palpable pulsation of the brain as in the anterior fontanelle of an infant. These soft spots on the skull are cartilagenous connective tissue coverings “joints” which allow for skull cranial expansion and then become the mould for the bone development and shape joining long the sutural lines, later becoming the Bregma Foramen a natural hole in a bone usually for the transmission of blood vessels and/or nerves.(pl. foramina). Fossa a pit, depression, or concavity, on a bone, or formed from several bones as in temporomandibular fossa - shallower and more like a “bowl” than a cavity Fovea a small pit (usually smaller than a fossa)- as in the fovea of the occlusal surface of the molar tooth. Frankfurt plane the correct anatomical position to view the skull – the EAM is at the same level as the inferior orbital margin (equivalent to the eyes looking straight ahead). Gallus / Galli a cock, hence, crista galli, the cock's comb (i.e. possessive form of gallus). Gastric belly (as in the belly of a muscle) Glottis pertaining to the vocal cords and structures involved in the production of the voice pl. glottedis Gomphosis joint b/n the roots of the teeth and the jaw bones pl - gomphoses Groove long pit or furrow Hamus a hook hence the term used for bones which “hook around other bones or where other structures are able to attach by hooking - hamulus = a small hook. Hyoid U-shaped

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Edentulous Eminence Endocranium

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Levator Ligament

Linea Lingual Malar Malleus Mandible

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Masseter Mastoid Maxilla Meatus

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Lamina

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Lacrimal Lambda

a notch. anvil under between within an orifice or point of entry to a cavity or space + supporting structures bone X bone a bridge between 2 halves of a bone pl.( juga) as in Sphenoid pertaining to the lips something lacerated, mangled or torn eg foramen lacerum small sharp hole at the base of the skull often ripping tissue in trauma. related to tears and tear drops. (noun lacrima) from the Greek letter a capital 'L' and written as an inverted V.(adj. lambdoid) and used to name the point of connection between the 3 skull bones Occiput and the 2 Temporal bones a plate as in the lamina of the vertebra a plate of bone connecting the vertical and transverse spines (pl. laminae) to raise a band of tissue which connects bones (articular ligaments) or viscera - organs (visceral ligaments). A Ligament is a tie or a connection sing. ligamentum pl ligamenta from ligate or to tie up, generally composed of collagen fibres a line as in the Nuchal lines of the Occitipum pertaining to the tongue cheek hammer (as in the ear ossicle) from the verb to chew, hence, the movable lower jaw; adj.- mandibular. to chew a breast or teat shape - mastoid process of the Temporal bone the jaw-bone; now used only for the upper jaw; adj.- maxillary a short passage; adj.- meatal as in external acoustic meatus connecting the outer ear with the middle ear. relating to the chin (mentum = chin not mens = mind). hub or cental core used in the face to indicate that fibrous hub at the edge of the mouth for the insertion of a number of muscles / used in the ear to indicate the centre of the spongy bone of the cochlea tubes nostrils pl. Nares an indentation in the margin of a structure. the nape or back of the neck adj.- nuchal. the prominent convexity of the back of the head Occipitum = Occipital bone adj. occipital an eye relating to teeth, toothlike see Dens shoulder a circle; the name given to the bony socket in which the eyeball rotates; adj - orbital.

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Incisura Incus Inferior Inter Intra Introitus Joint = Articulation Jugum Labial Lacerum

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Mental Modiolus

Naris Notch Nucha Occiput

Occulus Odontoid Omo Orbit

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Orifice Ossicle

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Otic Oto Palate Palpebral Parietal Parotid Pars Pecten Perikymata Periosteum Petrous Pinna Process

Pterygoid Raphe Recess

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Rectus Rhinus/rhinoRidge Rima Glottidis Rostral Rotundum Sagittal

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Proximal Pterion

Scalene Sclersosis Sella Septum Sinus

an opening. a small bone as in the ear ossicles: stapes(stirrup), incus (anvil) and malleus (hammer). pertaining to the ear pertaining to the ear a roof adj.- palatal or platatine. pertaining to the eyelid pertaining to the outer wall of a cavity from paries, a wall. pertaining to a region beside or near the ear a part of a comb. transverse ridges and the grooves on the surfaces of teeth layer of fascial tissue connective tissue on the outside of compact bone not present on articular (joint) surfaces see endostium pertaining to a rock / rocky / stoney adj. petrosal feather or fin as in “pinna of the ear” a general term describing any marked projection or prominence as in the mandibular process. closer to the axial skeleton (opposite of distal) a wing; the region where the tip of the greater wing of the sphenoid meets or is close to the parietal, separating the frontal from the squamous region of the temporal bone. (TERY-on) alternatively the region where these 4 bones meet. wing shaped line of joint b/n 2 halves, generally of bone or muscles for example a fibrous raphe in the tongue allowing for muscle insertion a secluded area or pocket; a small cavity set apart from a main cavity. straight - erect pertaining to the nose elevated bony growth often roughened. space b/n the vocal cords towards the anterior/front (of the brain) round an arrow, the sagittal suture is notched posteriorly, making it look like an arrow by the lambdoid sutures. uneven hard a saddle; adj. - sellar, sella turcica = Turkish saddle. a division a space usually within a bone lined with mucous membrane, such as the frontal and maxillary sinuses in the head, (also, a modified BV usually vein with an enlarged lumen for blood storage and containing no or little muscle in its wall). Sinuses may contain air, venous or arterial blood, lymph or serous fluid depending upon location and health of the subject adj.- sinusoid the skull refers to all of the bones that comprise the head. a wedge i.e. the Sphenoid is the bone which wedges in the

Skull Spheno8

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base of the skull between the unpaired frontal and occipital bones adj. - sphenoid . Spine a thorn adj. - spinous descriptive of a sharp, slender process/protrusion. Splanchocranium the splanchocranium refers to the facial bones of the skull. Stapes stirrup Sternum chest Sulcus long wide groove often due to a BV indentation Suture the saw-like edge of a cranial bone that serves as joint between bones of the skull. Stylos an instrument for writing hence adj. - styloid a pencil-like structure. Sulcus furrow Superior above Symphysis a cartilagenous joint or a growth with bone-cartilage-bone Synmeans together ie the close proximity of or fusion of 2 structures Syndesmosis tight inflexible joints b/n 2 bones little to no movement many axial joints Synostosis fusion of any joints Temporal refers to time and the fact that grey hair (marking the passage of time) often appears first at the site of the temporal bone from the consideration of wisdom in the temple Tensor to stretch Tentorium a tent. Thyroid door Tonsil little pole Trachea rough Transverse to go across Trochlea a pulley that part of the bone or ligamantous attachment that pulls the bone in another direction as in the elbow or the ankle Tubercle a small process or bump, an eminence.. Tuberosity a large rounded process or eminence, a swelling or large rough prominence often associated with a tendon or ligament attachment. Turbinate a child’s spinning top, hence shaped like a top. An old term for the nasal conchae. Tympanum a drum pl. tympani Uncus a hook adj. - uncinate. Uvula little grape Vagina a sheath; hence, invagination is the acquisition of a sheath by pushing inwards into a structure, and evagination is similar but produced by pushing outwards adj. - vaginal. Vertebra turning point Vomer plough Wormian bone extrasutural bone in the skull Zygal H-shaped Zygoma a yoke , hence, the bone joining the maxillary, frontal, temporal & sphenoid bones adj zygomatic. © A. L. Neill

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A to Z Book Head and Neck18E™:A to Z Book 25/02/09 12:50 PM Page 10


Anatomical position and Anatomical planes

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This is the anatomical position.

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A = Anterior aspect from the front, Posterior Aspect from the back, used interchangeably with ventral and dorsal respectively. B= Lateral Aspect from either side C = Transverse / Horizontal plane D= Midsagittal plane = Median plane; trunk moving away from this plane = lateral flexion or lateral movement moving into this plane medial movement; limbs moving away from this direction = abduction; limbs moving closer to this plane = adduction E = Coronal plane F = Median

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neck flexion

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Anatomical movements of the Head and Neck

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neck extension/hyper-extension

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lateral flexion

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lateral rotation

note: extension of the neck is in the normal anatomical position

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lateral flexion - testing for mobility and spinal tenderness

lateral rotation - testing for mobility and spinal tenderness

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cervical flexion - testing for mobility and spinal tenderness

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lateral flexion - testing for strength against R

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neck flexion - testing for strength against R

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lateral rotation - testing for strength against R

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extension / hyperextension testing for strength against R

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cervical traction - testing for R and N irritation

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scalp (1) to SP of C2 ear (2) to body of C2 face (3) to C3 jaw and teeth (4) to C3/4 thyroid, cricoid cartilages (5) to C5

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sites of referred pain in the cervical spine

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testing for mobility of C7/T1 and the first rib

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examination for tenderness of the cervical spinous process

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examination for tenderness of the cervical transverse processes

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The Skull & Neck 19-59

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Table of Articulations of the Skull External Skull Anterior (norma frontalis) radiology - occipitofrontal (complete) radiology - occipitofrontal (upper aspect) radiology - occipitomental (lower aspect) External Skull Inferior (Base of Skull) (norma basilaris) radiology - submentovertical view (view from below) External Skull Lateral (norma lateralis) radiology - lateral External Skull Posterior (norma occipitalis) External Skull Superior (norma verticularis) Internal Skull Inferior - Skull Cap Internal Skull Para-Sagittal/Lateral Internal Skull Superior - Internal Base - cranial fossae

Cavities of the Skull 44-51

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Maxillary Sinus Orbital cavity (Orbital fossa) Anterior radiology orbital cavity anterior Sinuses Overview Coronal

Cervical Spine Radiological Overview 52-59

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Anterior-Posterior AP Anterior-Oblique AO Lateral Open Mouth - Dens process

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Red spots indicate when there is an articulation or joint between the bones. Please note the hyoid does not articulate with any bones and the mandible articulates at the only synovial joint in the skull- the TMJ -temporomandibular joint. All other joints are secondary cartilagenous bone-fibrocartilage-bone.

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Frontal bone Fronto-Nasal suture Inter-Nasal suture Nasal bone, Lacrimal bone Supra-Orbital foramen Spheno-Parietal suture Spheno-Frontal suture Spheno-Squamosal suture Zygoma Zygomatico-Maxillary suture Infra-orbital foramen Middle Nasal concha – turbinate (from Ethmoid bone) Inferior nasal concha – turbinate (from Ethmoid bone) Vomer Mandible Mental foramen Inter-Maxllary suture Maxilla Ethmoid bone (Orbital plate) Inferior Orbital fissure Temporo-Zygomatic suture Superior Orbital suture Fronto-Zygomatic suture Greater wing of the Sphenoid Coronal suture - Fronto-Parietal suture Lesser wing of the Sphenoid Optic foramen

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THE SKULL

Skull External Views anterior

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External Skull Anterior

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Sagittal suture Lamboid suture (view to the posterior) meeting at the Bregma Frontal sinus Lesser wing of the Sphenoid Supraorbital fissure Greater wing of the Sphenoid Fronto-Zygomatic suture Petrous ridge Anterior clinoid process Floor of the hypophyseal fossa + upper apex of nasal cavity adjacent to nasal sinuses Lateral pterygoid plate Base of the skull - floor of posterior cranial cavity Foramen rotundum Mastoid process Upper central incisor tooth Mandible

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THE SKULL

radiology occipitofrontal

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THE SKULL

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THE SKULL

External Skull Anterior upper and lower views in detail radiology occipitofrontal (upper)

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Frontal sinus Ethmoid sinus Maxillary sinus Foramen rotundum Supraorbital fissure Anterior clinoid process Posterior clinoid process Petrous ridge Floor of the hypophyseal fossa + upper apex of nasal cavity adjacent to nasal sinuses Crista galli Frontal process of zygoma Middle concha - turbinate Inferior concha - turbinate Lateral border of Greater wing of sphenoid Greater wing of sphenoid Lesser wing of sphenoid Hard palate Infraorbital foramen Zygomaticofacial foramen Coronoid process of the mandible Soft tissue of lower lid Pterygoid plates of the sphenoid

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External Skull Anterior THE SKULL

upper and lower views in detail radiology occipitomental (lower)

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Frontal sinus Ethmoid sinus Maxillary sinus Foramen rotundum Supraorbital fissure Anterior clinoid process Posterior clinoid process Petrous ridge Floor of the hypophyseal fossa + upper apex of nasal cavity adjacent to nasal sinuses Crista galli Frontal process of zygoma Middle concha - turbinate Inferior concha - turbinate Lateral border of Greater wing of sphenoid Greater wing of sphenoid Lesser wing of sphenoid Hard palate Infraorbital foramen Zygomaticofacial foramen Coronoid process of the mandible Soft tissue of lower lid Pterygoid plates of the sphenoid

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THE SKULL

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Skull External Views

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Incisive fossa - Alveolare Medial Pterygoid plate and Hamulus (Ethmoid) Posterior Nasal aperture Pterygoid plate (ethmoid) Lateral Pterygoid plate (Ethmoid) Zygomatic arch Mandibular fossa External Auditory meatus Styloid process Mastoid process Parieto-Mastoid suture Occipito-Mastoid suture Foramen magnum External Occipital proturberance Sagittal suture - Parieto-Parieto suture Lambda Lambda suture Superior nuchal line (Occipital) Inferior nuchal line (Occipital) Occipital condyle Jugular foramen (fossa) Stylo-Mastoid foramen Carotid foramen - Carotid canal Foramen spinosum Foramen lacerum - Basilar suture Greater Palatine foramen Horizontal plate of Palatine Palatine process of the Maxilla

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THE SKULL

inferior base of skull

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THE SKULL

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External Skull Inferior

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Nasal septum (vomer and perpendicular plate of the ethmoid) Posterior border of vomer Maxillary sinus Ethmoid sinus Greater palatine foramen Lesser palatine foramen Sphenoid sinus Posterior orbital margin - greater wing of the sphenoid Posterior boundary of the maxillary sinus Zygomatic arch Lesser wing of the sphenoid Head of mandible condyloid process Foramen ovalae Foramen spinosum Spine of the sphenoid Foramen lacerum Clivus - base of the occipital and sphenoid bones Eustachian tube - (pharyngotympanic tube) Carotid canal Jugular foramen Stylomastoid foramen Anterior arch of the atlas (C1) Odontoid process of axis (C2) Occipital condyles Foramen magnum Canaliculus for tympanic nerve Inner and outer tables of the skull - Diploe

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radiology submentovertical view

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Skull External Views

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THE SKULL

lateral 1 Frontal bone - Temporal ridges for attachment of Temporalis 2 Parietal bone 3 Occipital bone 4 Mastoid process 5 Temporal bone 6 Zygomatic arch 7 Mandible 8 Body of Mandible 9 Maxilla 10 Zygoma 11 Nasal bone 12 Lacrimal bone 13 Frontal bone 14 Greater Wing of the Sphenoid

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THE SKULL

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External Skull Lateral / oblique

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Coronal suture Impression for Middle meningeal artery Lambdoid suture Wormian bone - Extrasutural bone Styloid process Posterior wall of Nasopharynx Clivus - (base of Sphenoid and Occiptal bones) Hypophyseal fossa Sphenoid sinus Greater wing of the Sphenoid Posterior Air cells in the Ethmoid - Ethmoid sinus Anterior Air cells in the Ethmoid - Ethmoid sinus Frontal sinus Zygoma - frontal process Maxilla - malar process Zygoma - Arch Posterior border of the Maxillary sinus Hard palate - Palatine bone Alveolar bone in Maxilla Pterygoid plates Soft tissue of Soft Palate and Uvula Mandibular canal Head of Mandible Coronoid process of Mandible

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

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THE SKULL

radiology

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THE SKULL

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Skull External Views Sagittal sinus

2

Parietal foramen

3

Lambda Pareito-Occipital suture

4

Occipital bone

5

Lambdoid suture -

6

Inferior nuchal groove

7

External Occitipal protruberance

8

Occitipal bone

9

Superior nuchal groove

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1

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THE SKULL

posterior

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10 Sutural bones - Inca 11 Parietal bone

Skull External Views superior

Occipital bone

2

Lambdoid suture - Occipito-Parieto suture

3

Parietal eminence - Euryon

4

Frontal bone

5

Bregma

6

Coronal suture

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Parietal bone

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Sagittal suture

9

Lambda

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THE SKULL

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Skull Internal Views Lambda

2

Lambdoid suture

3

Parietal foramen

4

Diploe

5

Bregma

6

Coronal suture

7

Frontal crest

8

Frontal bone

9

Depressions for arachnoid granulations

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1

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THE SKULL

inferior Skull cap

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10 Grooves for middle meningeal vessels 11 Parietal bone

12 Sagittal suture

13 Groove for superior sagittal sinus

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14 Occipital bone

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THE SKULL

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1

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Skull Internal Views

groove for the middle meningeal artery

2

Frontal sinus

3

superior nasal concha

4

middle nasal concha

5

inferior nasal concha

6

hard palate

7

mandible

8

lateral pterygoid plate

9

medial pterygoid plate

ma

10 styloid process

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1

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THE SKULL

Lateral -looking out to the sides of the skull from the inside

11 mastoid process

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12 sphenoid sinus

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THE SKULL

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Skull Internal Views

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Cribiform plate

2

Frontal sinus

3

Crista Galli

4

Orbital plate of Frontal bone

5

Jugum of Sphenoid

6

Optic canal

7

Lesser wing of the Sphenoid bone

8

Anterior Clinoid process

9

Foramen rotundum

aN

1

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THE SKULL

superior internal base - cranial fossae

10 Foramen lacerum

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11 Foramen ovale

12 Foramen spinosum 13 Dorsum sellae

14 Internal acoustic meatus

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15 Jugular foramen

16 Foramen magnum

POSTERIOR FOSSA

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MIDDLE FOSSA

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ANTERIOR FOSSA

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THE SKULL

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11 12 13 14 15 16

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Maxillary Sinus (Left) Sagittal

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Frontal sinus Anterior Ethmoidal foramen Orbital plate of Ethmoid Posterior Ethmoidal foramen Lesser wing of the Sphenoid Pterygo-Maxillary fissure Perpendicular plate of the Palatine Alveolar processes of the Maxilla Maxillary Sinus - opened Inferior concha, Maxillary process Anterior Nnasal spine Uncinate process of the Ethmoid Nasal bone Lacrimo-Maxillary suture Supra-Orbital foramen Frontal bone

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Description: Maxilla - sinuses within this bone -particularly around the teeth may cause toothache, complicate endodontic (root canal) treatment; or act as a conduit for tooth/nasal/other infection to enter the blood stream.

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Orbital Cavity / Fossa (Left) Anterior view from the front

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Lesser wing of the Sphenoid Optic foramen Anterior and Posterior Ethmoidal foramina Lacrimal bone Nasal bone Orbital plate of the Ethmoid bone Orbital plate of the Maxilla Infraorbital foramen Infraorbital groove Zygoma Inferior Orbital fissure Foramina for Zygomatic branch of the Facial nerve Orbital surface of the Zygoma Greater wing of the Sphenoid Superior Orbital fissure Orbital plate of the Frontal bone Supra-Orbital margin Supra-Orbital foramen

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Eyeball and muscles all sit in this cavity with the Optic nerve entering from the posterior part of the cavity through the Orbital foramen.

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Orbital cavity Inferoanterior

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radiology (also Orbital fossa Optic cavity Optic foramen)

nd

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Frontal sinus Foramen ovale Infraorbital foramen Foramen rotundum Hard palate –floor of nasal cavity Maxillary antrum Lateral wall of maxillary antrum Zygomatic arch Sphenoid sinus Soft tissue of nose and lower lid

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Sinus Overviews Coronal

Cranial Vault

2

ethmoid air cells of Frontal bone and Maxilla

3

Maxillary sinus

4

nasal cavity

5

boney palate

6

inferior meatus 6A inferior concha

7

middle meatus 7A middle concha

8

superior meatus 8A superior concha

9

orbit

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Neck Anterior-Posterior radiology

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body of C3

2

Transverse processes - C5, C6, C7

3

first rib

4

Transverse process - T1

5

Spinous processes - C4, C5, C6

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Neck Anterior-Oblique radiology Dens

2

body of C2

3

body of C3

4

body of C4

5

body of C5

6

body of C6

7

body of C7

8

first rib

9

inferior articulating processes

10

intervertebral foraminae C2/3, C3/4

11

Pedicles

12

superior articulating processes

13

Spinous processes C5, C6

nd

ma

rA second rib

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aN

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Neck Lateral radiology occipital condyles

2

anterior arch of C1

3

Dens process (C2)

4

body of C2

5

zygapophyseal joints = facet joints

6

intervertebral space - intervertebral discs (radiologically lucent)

7

inferior articulating surfaces

8

vertebral bodies C6, C7, T1

9

Pedicles

10

Spinous processes

11

Lamina

12

superior articulating processes

13

posterior arch of C1

nd

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rA Occiput

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Neck Open Mouth - Dens process radiology occipital condyles

2

lateral mass of C1

3

Dens process (C2)

4

body of C2

5

Spinous processes C2, C3

6

Occiput

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Bones, Cartilages, Joints & Ligaments, Overviews

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Arytenoid cartilages (see Larynx overview) Atlas (C1 ) - (Vertebra - cervical) Atlanto-Axial joints Atlanto-Occipital joint (see Craniovertebral joint) Auditory Ossicles: Malleus, Incus and Stapes enclosed within the Temporal bone Axial-Occipital joint (see Craniovertebral joint) Axis (C2) - (Vertebra - cervical) CHEEK BONES (see Zygoma ) CHIN (see Mandible) Cranial Fossae (see Skull internal views) Craniovertebral joints (HEAD/SPINE joints aka Atlanto-Occipital joints & Axial-Occipital joints) Cricoid cartilage (see Larynx overview) Ear Bones – see also Auditory Ossicles Ethmoid bone Frontal bone HANGING joint (see Atlanto-Axial median joint) HEAD/SPINE JOINTS (see Craniovertebral joints Hyoid Incus – see Auditory Ossicles Inferior Nasal Concha (see Nasal bones and cavity) JAW (see Mandible) Lacrimal Laryngeal cartilages - overview Malleus – see Auditory Ossicles Mandible (aka JAW aka CHIN) Mandibular joint (see Temporomandibular joint) Maxilla (aka UPPER JAW) Nasal bones and cavity = NOSE NOSE see Nasal bones and cavity Occipital bone (aka Occiput) Odontoid Joint (see Atlanto-Axial median joint) Palate Palatine bones Parietal bone 60

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Skull – see separate listing Sphenoid Stapes – see Auditory Ossicles Temporal bone Teeth - overview Temporomandibular joint Thyroid cartilage (see Larynx overview) Vertebrae cervical (typical) Vomer Zygoma (aka CHEEK BONES )

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A

Atlas = C1 = First Cervical Vertebra

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anterior / superior

(Atlas - Gk demigod who held up the world on his shoulders)

aN

Articulations: Atlanto-Axial jts (3) C1-C2 Atlanto-Occipital jts (2) C1-Occiput (Base of the skull) Special no vertebral body special anterior features no spinous process facet for dens no articular discs (odontoid process) facet for odontoid / dens process

2

ant. tubercle

3

superior articular facet

4

inferior articular facet

5

posterior tubercle

6

posterior arch

7

groove for vertebral BVs & suboccipital N

8

Foramen Transversarium = transverse foramen

9

TP

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1

10 lat. mass

11 vertebral foramen

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12 ant. arch

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nd

4

9

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A

BS spinal branches of vertebral art. NS spinal Ns dorsal rami (C1-2) rotation, circumduction

aN

A

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Atlanto - Axial joint - median = ODONTOID JOINT AKA hanging joint

Atlanto-Axial joints - lateral = zygapophyseal joints of C1/C2 BS spinal branches of vertebral art.

flexion, extension, lateral flexion, rotation

ma

Dens - Odontoid process (C2) transverse lig of Axis (C2) transverse foramen of Axis (C2) medial tubercle of Atlas (C1) tranverse foramen of Axis (C2) post arch and tubercle of Atlas (C1) lamina and spine of Axis (C2) body of Axis (C2) superior articular facet of atlanto-occipital jt ant arch of Atlas (C1) facet for Dens (C2) ant tubercle of Atlas (C1)

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NS spinal Ns dorsal rami (C1-2)

Atlanto-Occipital joint (see Craniovertebral joint)

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A

Overview - In situ -individual bones

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Auditory ossicles = Ear bones - middle ear (in the Temporal bone)

aN

Description - 3 bones incus = anvil, malleus = hammer, stapes = stirrup in the Temporal bone middle ear cavity Malleus abuts the Tympanic membrane of the middle ear (eardrum) articulates with the Incus and then the Stapes which abuts to the round window

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External Auditory Meatus = Earhole External ear Tympanic membrane = Lateral border for the middle ear Inner ear Auditory tube Cochlea Cochlea N Facial N Vestibular N Oval Window with Stapes Vestibular canals Incus Malleus Promontory Round Window

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Articulations: Malleo-Incus Hammer with the eardrum Incus-Stapes inter ear ossicle articulation Stapo - Temporal stirrup with the Temporal bone round membrane Special small bones with articulate with membrane features delicate balance to stretched across bone transmit sound at both ends

View of individual bones actual size Right and Left sides respectively from above down Stapes Incus Malleus

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A

Axis = C2 = Second Cervical Vertebra

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anterior / superior

(Axis - pivot for movement of the head all movements but nodding)

C1-C2 C1-Occiput

Dens acts as an AXIS for rotation at C1

aN

Articulations: Atlanto-Axial jts (3) vertebro-axial Axial jts (2) (Base of the skull) Special no vertebral body features dens / odontoid process no articular discs Dens = Odontoid process (tooth) attachment of Alar ligament groove for Transverse ligament pedicle body vertebral foramen

7 8 9 10 11 12 13

spinous process lamina inferior articular process transverse process transverse notch / foramen (if closed) superior articular facet facet for odontoid / dens process

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CHEEK BONES (see Zygoma) CHIN (see Mandible)

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Craniovertebral joints = HEAD/SPINE joints C

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anterior

(made up of median and lateral Atlanto-Occipital (C1/head) and AxialOccipital joints (C2/head) joints)

BS vertebral arteries

A

aN

NS medial branches of dorsal rami, recurrent laryngeal spinal branches of ventral rami (C1-3) flexion/extension, lateral flexion, rotation basilar of Occiput

2

jugular foramen (transverse foramen in the base of the skull)

nd

1

mastoid process

4

transverse process of C1

5

ALL = anterior longitudinal lig, attached to tubercle of Atlas

ma

3

intervertebral disc C2, C3

7

ALL

8

C2/C3 zygapophyseal joint L

9

capsule of the lateral atlanto-occiptal joint

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6

10 capsule of the lateral atlanto-axial joint

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11 ant atlanto-occipital membrane

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lateral

(made up of median and lateral Atlanto-Occipital (C1/head) and AxialOccipital joints (C2/head) joints)


A

aN

NS smedial branches of dorsal rami, recurrent laryngeal spinal branches of ventral rami (C1-3) flexion/extension, lateral flexion, rotation basilar of Occiput

2 3 4 5 6 7 7A 8 9 10 11 12 13 14 15 16 17 17A

tectorial membrane ant atlanto-occipital membrane leads to the (3A) apical lig of Dens ant arch of Atlas C1 Dens of C2 longitudinal band of cruciform lig superior (becomes 7A) longitudinal band of cruciform lig inferior C2/C3 intervertebral disc body of C3 post. longitudinal lig =PLL lamina of C2 transverse lig of atlas (C1) post atlanto-axial lig post arch of C1 vertebral artery post atlanto-occipital lig space which leads to foramen magnum and then … vertebral foramen

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17A

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posterior

(made up of median and lateral Atlanto-Occipital (C1/head) and Axial-Occipital joints (C2/head) joints)


A

aN

NS medial branches of dorsal rami, recurrent laryngeal spinal branches of ventral rami (C1-3) flexion/extension, lateral flexion, rotation jugular foramen

2

transverse process of Atlas

3

tectoral membrane

nd

1

3A PLL

capsule of zygapophyseal joints

5

C2/C3 intervertebral disc

6

longitudinal band of cruciform lig inferior

7

capsule of lat joint of C1 C2

8

transverse band of cruciform lig over the deeper

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ma

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stronger transverse lig of the Atlas (C1) 9

alar lig*

10 capsule of lat atlanto-occipital jt

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11 longitudinal band of cruciform lig superior *broken in hanging

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EAR BONES = Auditory Ossicles middle ear / INCUS, MALLEUS & STAPES

aN

nd

E

head of Malleus body of Incus short process of Incus ant malleolar process post crus of stapes base of Stapes ant crus of Stapes long process of Stapes lenticular process of Incus handle of Malleus ant process of Malleus neck of Malleus lateral malleolar process

cochlea / labyrinth

rA

ant semicircular canal ant bony ampulla elliptical recess spherical recess cochlea cupola of cochlea base of cochlea oval window - fenestra vestibuli post bony ampulla round window - fenestra cochlea lat semicircular canal post semicircular canal lat bony ampulla

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in situ

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33

32

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Ethmoid bones

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anterior / lateral / medial / superior (Ethmoid = sieve light spongy cubic bone sitting b/n the 2 orbital cavities).

1

E

Ethmoidal labyrinth containing air cells (part of the

aN

Ethmoid sinus) continuous with the Sphenoid sinus 2

Crista Galli

3

Orbital plate of Ethmoid bone (part of the Orbital cavity)

4

Middle Nasal concha

5

Jugum of Sphenoid - Jugum Sphenoidale

nd

(Bridge connecting the 2 wings of the Sphenoid bone) Perpendicular plate of the Palatine bone

7

Uncinate process

8

Ala (of Crista Galli)

9

Anterior groove (on the Ethmoid)

ma

6

10 Posterior groove (on the Ethmoid) 11 Cribiform plate (entrance for the Olfactory nerve)

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12 Vomer

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lateral

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superior

12

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Frontal bones

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anterior / lateral / inferior Description - Unpaired largest and very robust anterior bone forming the forehead - horizontal section forming the roof of the orbit.

2

Superciliary arch

3

Supraorbital margin and notch

4

Nasal spine

5

Superior and inferior temporal lines

6

Superior Orbital plate - pars orbitalis

7

Frontal and Ethmoid air cells - Frontal sinus

8

Posterior Ethmoidal foramen

9

Anterior Ethmoidal foramen

nd

aN

Frontal tuberosity -Frontal bossing

ma

F

1

10 Zygomatic process

11 Supra-Orbital notch or foramen 12 Lacrimal fossa

rA

13 Metopic suture - frontal suture, Glabella 14 Frontal squama

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15 Ethmoidal notch

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Hyoid

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Description - Small U-shaped bone. Attached to the styloid processes via ligaments. This bone has no articulations -the only bone in the body - and is not normally broken in trauma, protected by the mandible / CHIN. It may be broken in hanging and strangulation.

1

body of hyoid

2

greater horn (cornu)

3

lesser horn (cornu)

nd

H

aN

Articulations: nil Special of interest in Forensic investigation rarely features broken unless specific pressure on this bone because of its site, acts to shape the jawline by supporting and bending the strap muscles

MUSCLE ATTACHMENTS Genioglossus

5

Geniohyoid

6

Middle Phayngeal Constrictor

7

Hypoglossus

8

Stylohyoid

9

Thyrohyoid

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ma

4

10 Omohyoid

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11 Sternohyoid 12 Mylohyoid

Incus – see Auditory Ossicles Inferior Nasal Concha (see Nasal bones and cavity)

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2

3

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Description - Small cone shaped bone.

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Lacrimal

Apex – articulates with Frontal

2

Lacrimal crest and groove

3

Hammulus

4

Descending process

5

Inferior edge

6

Medial edge

nd

1

ma

L

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Articulations with Ethmoid laterally All 2º with Frontal superiorly fibrocartilagenous with Inferior Nasal joints Concha inferiorly with Maxilla medially

rA

JAW – see Mandible

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Malleus – see Auditory Ossicles

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L 3

4

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Larynx Hyoid bone

2

Epiglottis

3

Thyroid membrane

4

Thyroid cartilage

aN

1

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Cartilages articulated and disarticulated

4A/B Thyroid cartilage - superior horn - inferior horn 6

Cricoid cartilage

7

Arytenoid cartilages

8

Tracheal “rings”

9

Corniculate cartilages

nd

Medial cricothyroid ligament

ma

L

5

10 Attachment for Transverse Arytenoid 11 Muscular process (for arytneoids)

rA

12 Attachment for vocal cords

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Mandible = JAW

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lateral / posterior

(Mandible - lower jaw bone joins the skull via the condyles and a cartilaginous articular plate in the Temporal fossa. Primary function - mastication, houses all the bottom teeth).

rA

ma

nd

mandibular notch pterygoid fovea head of Mandible - condylar process neck of Mandible post. border of ramus of Mandible ramus - vertical ramus angle of mandible oblique line inferior border body - horizontal ramus base mental foramen mental tubercle - Gnathion mental protuberance alveolar bone surrounding teeth anterior border of ramus coronoid process - endocoronial ridge mandibular foramen lingula superior and inferior mental spines digastric fossa mylohyoid line mylohyoid groove

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Articulations with the Temporal TMJ = fossa - this shallow temporomandibular fossa makes it easy to joint dislocate this joint

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changes in the mandible from child <1yo to adult

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Mandible Anterior radiology orthopantomogram = OPG

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Central incisor (21)* Lateral incisor (22) Canine (23) First premolar (24) Second premolar (25) First molar (26) Second molar (27) Pulp chamber of molars (16, 17) Coronoid process Head of mandible Zygoma Maxillary sinus Anterior nasal spine of maxilla Vomer (nasal septum) Sites for the third molar (18, 28, 38, 48) Hard palate

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Mandible Lateral

radiology Showing relationship to surrounding soft tissue

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Head of mandible – Condylar process Neck of the Mandible Hard Palate Soft Palate Anterior arch of the Atlas (C1) Odontoid process of the Axis (C2) – Dens Posterior aspect of the tongue Retropharyngeal sac Epiglottis Vallecula - fold anterior to epiglottis Hyoid bone

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Maxilla / Maxillae Bones

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anterior / lateral / medial

(The Maxillae are 2 paired bones which form the dominant portion of the face and hold the upper teeth. The “overgrowth” of the Maxilla is often the reason for orthodontic treatment.)

premaxillary suture is here - fuses with completed jaw growth

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Incisive canal supported by the canine jugun Greater Palatine canal - groove articulating surface – with Palatine bones maxillary hiatus continues with the sinus Nasal Lacrimal process alveolus -bone containing tooth root canine jugun inferior meatus

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frontal process medial orbital surface infra-orbital margin zygomatic process infra-orbital foramen nasal notch nasal crest anterior nasal spine alveolar bone around teeth tuberosity infra-temporal surface orbital surface palatine process ethmoid crest middle meatus conchal crest which tooth is this?

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Nasal Bones and Cavity = NOSE BONES external / internal / paired - posterior

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The NOSE consists of: - 2 small thin rectangular bones below the Glabella, the NASAL BONES; 2 lateral walls which house the 3 PAIRED TURBINATES or CONCHAE; the MEDIAL SEPTUM - made up of the VOMER and the ETHMOID bones and the many cartilages which determine the length and shape of the nose and nasal nares (nostrils). The cavity is surrounded by sinuses which open into it and superiorly by the Ethmoid plate allowing the OLFACTORY nerves to drop processes into the cavity.

2 small snail like bones lying on top of Palantine bones

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frontal sinus Nasal spine of frontal bone articulation with frontal bone Nasal bone - external surface Nasal bone internal surface perpendicular plate of Ethmoid ant. nasal spine Maxilla articulation b/n Nasal bones and Maxilla Sphenoid bone - (pterygoid plates) Vomer Sphenoidal sinus Crista Galli foramen for Nasal vein notch for external nasal Nerve articulation with other Nasal bone Lacrimal bone Inferior concha and meatus Palantine bone - perpendicular plate and incisive fossa sphenopalantine meatus superior concha and meatus middle concha and meatus groove for Ethmoidal Ns articulation with lateral nasal cartilages

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BS in septum does not extend to cartilage

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All 2º fibrocartilagenous joints

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SPECIAL FEATURES superior & middle nasal conchae inferior nasal conchae

with Frontal superiorly with Lacrimal laterally with itself medially with Ethmoid inferiorly “articulates” with nasal cartilages anteriorly parts of the Ethmoid bone

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Articulations

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Occipital bone external / internal onteriorly inferiorly laterally

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superior angle highest nuchal line superior nuchal line inferior nuchal line Mastoid margin jugular process condylar fossa Occipital condyle foramen magnum hypoglossal canal condylar canal lateral surface lateral angle Occipital crest (external) squamous surface Occipital protuberance (internal) lamboid margin groove for superior sagittal sinus posterior cerebral fossa / Occipital fossa groove for transverse sinus attachment for Tentorium Cerebelli groove for sigmoid sinus jugluar notch jugular tubercle attachments for Falx Cerebri opisthion basion Occipital sulcus - sagittal sinus

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Articulations with Sphenoid with Vertebral Column with C1 with C2 Special large bowl- like bone with a features hole at the infero-posterior portion of the skull

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Palate

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Inferior view - looking up into the Palate - roof of the mouth Maxilla + Upper Teeth + Palatine bones Nasopalatine Ns emerging from the Incisive Foramen (Alveolare)

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Greater Palatine Ns emerging from the Greater Palatine Foraminae

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Lesser Palatine Ns emerging from the Lessser Palatine Foraminae

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Hard Palate

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Soft Palate

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Nasal process

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Palatine bones (Left)

2o fibrocartilagenous joints

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Articulations mainly with the upper jaw (Maxilla) and the Sphenoid Special L-shaped bones features forms the floor of the Nasal cavity

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sagittal / medial / anterior / posterior

perpendicular plate - vertical plate

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Palato-Maxillary suture

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Maxilla

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Orbital process

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Spheno-Papalatine notch

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Sphenoidal process -

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Parietal bone (Left)

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external / internal

superior temporal line parietal eminence articulation with the Occipital bone (Lambdoid suture) articulation with the Temporal bone (Mastoid)

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All 2o fibrocartilagenous joints

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Articulations with the Frontal - anterior with the Temporal - inferiorly with the Occipital - posteriorly with itself medially Special large square bone - largest of features the cranial vault - even thickness all 4 corners made up the basis of the fontanelles in the infant

Parieto-Mastoid suture

articulation with the Temporal (Squamous)

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Temporo-Parietal suture

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articulation with the Sphenoid (Greater wing) Spheno-Parietal suture

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articulation with the Frontal bone Coronal suture inferior Temporal line articulation between Parietal bones Sagittal suture frontal angle sphenoidal angle groove for frontal branch of Middle Meningeal vessels groove for parietal branch of Middle Meningeal vessels mastoid angle groove for sigmoid sinus occipital angle groove for superior sagittal sinus

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Sphenoid

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anterior / posterior / schema - developement A single wedge-shaped bone consisting of four parts: the central body; the lateral greater wings, the medial lesser wings and the lower ptergoid plates. The bone looks like a bat in flight and is the centre piece of the skull.

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articulation with L Temporal bone orbital surface infratemporal crest body of the Sphenoid openings for sphenoidal sinuses lesser wing (come accross and meet to form jugum) squamosal suture - articulation with R Temporal bone superior orbital fissure foramen rotundum pterygoid canal rostrum vaginal process medial pterygoid plate pterygoid hamulus pterygoid notch lateral pterygoid plate pterygoid process sphenoid spine greater wing cerebral surface of the greater wing anterior clinoid process posterior clinoid process dorsum sellae articulation with occiput

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Teeth Overview

Maxillary upper right quadrant - adult Maxillary upper left quadrant - adult Mandibular lower left quadrant - adult Mandibular lower right quarant - adult Maxillary upper right quadrant - child Maxillary upper left quadrant - child Mandibular lower left quadrant - child Mandibular lower right quarant - child

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Central Incisor Lateral Incisor Canine First Pre-molar Second Pre-molar First Molar Second Molar Third Molar

A B C D E F

Palatal Buccal Mesial Distal Lingual Occlusal -

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upper tooth surface facing the inside of the mouth any tooth surface facing the cheek any tooth more anterior than the 1st molar all teeth behind the 1st molar lower tooth surface facing the tongue any tooth surface which abuts with another tooth-bite surface (shown surface) - any tooth surface facing the lips

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There are many different methods used to name teeth, define their positions and dentitions and describe their surfaces. This overview shows the 1o & 2 o dentitions, describes their positions and tooth types using some of the better known methods. Teeth are labeled XY on the Left and Right - X is the quadrant of the teeth and dentition type - adult or child - Y is the tooth type (devised by the Federation Dentaire Internationale)

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Teeth are labeled by letters and subscripts on the Right letters i = incisors 1o dentition (child) I = incisors 2o dention (adult) C = canine c = canine M = molar m= molar P = premolar Teeth are labeled using roman numerals in the smaller circle to demonstrate this method - (not commonly used) Each tooth has several surfaces and lies in different oral regions

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Temporal bone (Left)

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external / inferior / internal

Temporal = TIME. This bone shows first signs of aging - grey hair. It is involved in both the wall and the base of the skull. Temporal bones contain the auditory ossicles/ear bones & form the only joint with the mandible.

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suprameatal triangle groove for middle Temporal artery parietal notch squamo-Mastoid suture mastoid area mastoid process sheath of styloid process styloid process tympanic part l external acoustic meatus / anterior border (bony ear hole) tympanosquamosal (squamotympanic) fissure mandibular fossa zygomatic process articular tubercle postglenoid tubercle squamous part - Squama stylomastoid foramen mastoid notch - Digastric groove occipital groove jugular surface jugular fossa canaliculus (opening) for Tympanic nerve petrous part carotid canal edge of tegmen tympani groove for the middle meningeal vessels groove for the superior Petrosal sinus articulation with the greater wing of the Sphenoid Spheno-Temporal suture Zygomatic process groove for the middle meningeal vessels internal acoustic meatus articulates with the Occipital bone aqueduct of the vestibule mastoid foramen groove for sigmoid sinus - sigmoid sulcus arcuate eminence articulates with the parietal bone Temporoparietal suture

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Temporo-Mandibular joint = TMJ

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closed - lateral / medial open - sagittal

(only SYNOVIAL joint in the skull)

BS superficial temporal & maxillary arteries

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NS auriculotemporal & masseteric branches of mandibular branch of Trigeminal N (CN5)

depression/elevation, protrusion/retraction, lateral movements fibrous capsule

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lateral TMJ lig

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stylomandibular lig

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Mandible

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ant Temporal attachment of Meniscus

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meniscus

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ant. mandibular attachment

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condyle of mandible

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posterior attachment

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Temporo-Mandibular joint (TMJ) Lateral

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Head of mandible – Condylar process Neck of the Mandible Coronoid process Zygomatic arch External auditory meatus + Handle of the malleus Articular cubicle Tympanic plate Mastoid process Groove for posterior belly of Digastric muscle Mandibular fossa Greater wing of the sphenoid (basal surface) Lesser wing of the sphenoid

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radiology Open - upper Shut - lower

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Typical cervical C3-7 superior

transverse foramen bifid spinous process small curved bodies

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Special features

VB -VB joints symphysis Spinous process joints syndesmosis paired zygapophyseal planar synovial paired TP joints fibrous sydesmosis

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Articulations with vertebra above & below -2 unpaired joints 2 paired joints

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Vertebrae

body

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pedicle

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superior articular facet

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vertebral foramen

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lamina

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spinous process -bifid*

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post tubercle of TP

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transverse foramen*

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sulcus for peripheral N outlet

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Vomer

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lateral / posterior / in situ A single small narrow frail plough-shaped midline bone. It is the deviation of this bone which may obstruct the nasal airways.

Ala (Alae)

2

Articulation with Maxillae and Palatine

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Maxillovomer suture / Palatinovomer suture

Groove for the nasopalantine nerves and vessels

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articulation with nasal cartilages

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articulation with Sphenoid bone

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articulation with the Ethmoid plate

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Perpendicular plate of the Ethmoid

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Body of Vomer

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Maxillae areolar bone

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10 Medial pterygoid plate 11 Frontal bone

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13 anterior of nasal bones

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Zygoma = CHEEK BONES

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antero-lateral / postero-medial

These bones form the prominent corners of the face under the orbital rim.

frontal process

2

Zygomatico-Facial formina

3

articulation with the Frontal bone

4

articulation with the Sphenoid

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Zygomatico-Orbital foramina

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articulation with Maxilla

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Zyomatico-Temporal foramina

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temporal process

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maxillary process

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The Muscles of the Head & Neck 126

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Classification, Naming and Examination of Muscles

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Summaries of Skeletal muscles of the Head & Neck 128-143 Muscles and muscle layers of the Back & Neck Muscles of the Eye Muscles of the Face - expression - mastication - speech (articulation) Muscles of the Hyoid & Thyroid Muscles of the Larynx and Pharynx

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MUSCLES OF THE HEAD & NECK - regional and functional guide

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Muscles of caput/basocranium & cervical spine Muscles of expression Muscles of the eye & ear Muscles of mastication Muscles of the hyoid & thyroid Muscles of pharynx & larynx Muscles of the tongue

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Index of Muscles Aryepiglotticus Arytenoids Oblique, Transverse (Crico-) Auricularis = Extrinsic Auricular Muscles

B

148

Buccinator

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C

Ciliary muscle (Ciliaris) Constrictors - see Pharyngeal Constrictors Corrugator Supercilii Cricothyroid

D

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Depressor - Anguli Oris Depressor Labii Inferioris Digastric Dilator Pupillae - see Pupillary muscles

E

144

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A

150

156

160

F

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Epicranius = Frontalis + Occipitus = Occipitofrontalis Erector Spinae - Capitus and Cervicis regions see Summaries of the intrinsic Back muscles Extrinsic Auricular Muscles see Auricularis Extrinsic Ocular Muscles see Summaries of the muscles of the Eye Frontalis - see Epicranius

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Genioglossus Geniohyoid

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I

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Hypoglossus

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Incisivus Labii Inferioris Incisivus Labii Superioris Inferior Lingualis see Linguali muscles / Intrinsic muscles of the Tongue Inferior Oblique Inferior Pharyngeal Constrictor see Pharyngeal Constrictors Inferior Rectus Interspinalis Cervicus Intertransversarii Cervicus Intrinsic muscles of Tongue see Linguali muscles

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The A to Z of the Head and Neck

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M

Nasalis

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Oblique Arytenoid - see Arytenoids Obliquus Capitis Inferior Obliquus Capitis Superior Occipitalis see Epicranius Occipitofrontalis see Epicranius Omohyoid Orbicularis Oculi Orbicularis Oris

P

186

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Masseter Medial Pterygoid see Pterygoids Medial Rectus Mentalis Multifidus Capitus Multifidus Cervicis Muscularis Uvulae Mylohyoid

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Lateral Cricoarytenoid Lateral Pterygoid - see Pterygoids Lateral Rectus Levator Anguli Oris (Caninus) Levator Labii Superioris Levator Labii Superioris Alaeque Nasi Levator Palpebrae Superioris Levator Veli Palatini Linguali muscles = Intrinsic muscles of the Tongue Longissimus Capitus Longissimus Cervicis Longus Capitus Longus Colli

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Palatoglossus Palatopharyngeus Pharyngeal Constrictors - inferior Pharyngeal Constrictors - middle Pharyngeal Constrictors - superior Platysma Posterior Cricoarytenoid Procerus Pterygoids -Lateral, Medial

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R

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Rectus Capitus Anterior Rectus Capitus Lateralis Rectus Capitus Posterior Major Rectus Capitus Posterior Minor Risorius Rotatores Longus and Brevis (Cervical region)

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Salpingopharyngeus Scalenus Anterior Scalenus Medius Scalenus Minimus Scalenus Posterior Semispinalis Capitus, Cervicis Sphincter Pupillae (see Pupillary mucles) Spinalis Capitus, Cervicis Splenius Capitus Splenius Cervicus Stapedius Sternocleidomastoid Sternohyoid Sternothyroid Styloglossus Stylohyoid Stylopharyngeus Superior Lingualis see Linguali muscles /Intrinsic muscles of the Tongue Superior Oblique Superior Rectus

T

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Temporalis Temporoparietalis Tensor Tympani Tensor Veli Palatini Thyroarytenoid Thyroepiglotticus Thyrohyoid Transverse Arytenoid see Arytenoids Transverse Lingualis see Linguali muscles / Intrinsic muscles of the Tongue

UV

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WXYZ

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Vertical Lingualis see Linguali muscles / Intrinsic muscles of the Tongue Vocalis see Thyroarytenoid Zygomaticus Major Zygomaticus Minor

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Classification, Naming and Examination of Muscles

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There are 3 types of muscle tissue and this book discusses only one of them SKELETAL MUSCLE. The other 2 are smooth muscle (for the gut and other areas of involuntary movement) and cardiac muscle (for the heart).

nd

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SKELETAL muscle is defined as muscle which is “striated” or striped, indicating and ordered cell structure, of myosin and actin filaments, and is generally under voluntary control, which has an action on the skeleton or bones in the body. In its relaxed form it is at its maximum length and this is generally how the tissue is found. Stimulation generally causes contraction and a shortening and thickening of the tissue. As it is attached to a minimum of 2 points, the Origin (O) and the insertion (I) - although these may be arbitrarily named – this “contraction” brings these 2 points closer together. To reverse this, another muscle must be attached to 2 different points which when they move together cause a reversal of the position of the 2 or more affected bones, hence for each muscle there is an antagonist (opposing muscle) and in many situations a synergist (a muscle which enhances the original movement).

ma

There are a few exceptions to this, for example SPHINCTERS are circular groups of muscle fibres which upon contraction close the circle they have formed and may not be attached to bones at all. Their function is to prevent leakage or passage of material from one area to another. Modified Sphincters are observed in the Head and Neck as the ORBICULARIS muscles - they are circular but not true sphincters as they can modify their circular shape which allows for the pronunciation of sounds (muscles of Articulation or Speech) and different degrees of closure. As a secondary function they also prevent the passage of material from one area to another.

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Many of the MUSCLES OF FACIAL EXPRESSION are inserted into the deep fascia of the skin and hence change the soft tissues of the face but do not affect the bones underneath. We as humans have a great deal of these muscles, and they may be shifted or injured in many cosmetic procedures because of this structure.

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Muscle are shaped to allow their contraction to occur in the most efficient manner, for example sheets of muscles cover expanses of tissue to contain them, as in the OBLIQUES to contain and move bulky abdominal contents, or DIAPHRAGMS to separate as well as move large anatomical regions around, while TERES muscles are small, cordlike, focused groups of fibres for very specific movements. Generally the smaller the muscles, the deeper they are placed, so larger and more powerful muscles ones can cover them, for example ZYGOMATICUS MAJOR covers ZYGOMATICUS MINOR. Smaller muscles generally have more

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aN

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specific actions, are more resilient but weaker, they contract and relax repeatedly for example, to maintain position of the face, as in the small muscles around the nose and upper lips of the face. They are essential for a “balanced” even facial expression and lip movement and can be affected greatly in cosmetic surgery and increasingly injected procedures. Larger, longer muscles by definition cannot be as precise but have larger ranges of motion and more power and are placed more superficially – closer to the surface, as in ERECTOR SPINAE. Fibrous tissue inserts give the muscle more strength but less ability to move, as in EPICRANIUS.

ma

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Muscles are named using many different criteria singly or in combination: for example they may be named according to their action – Pharyngeal Constrictor and size – Zygomaticus Major and Minor; their shape and location- Orbicularis Oris, or Orbicularis Oculi, Longus Colli, the direction of their muscle fibres and anatomical layer – Anterior, Posterior or Superior Auricularis but there does not seem to be a consistent pattern in this naming - only that from the name it is often possible to determine their site, action &/or shape and this helps when memorizing these muscles. Between each muscle group is a fascial layer to transport in the BVs and the Nerves. This is particularly important in the Head and Neck because of the great mobility in this region and its many, often similtaneously occurring actions.

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Testing of a muscle is often impossible to do singly and they must be tested as an anatomical and functional group. The tests are generally graded 1-5, with 5 being the strongest and 3 being the point where when appropriate the muscle can overcome. Gravity often a natural form of resistance to the muscle action. This level of testing muscles is not dealt with in this book but will be discussed in the A to Z of Muscle and Sensory testing to follow - it is also examined in some detail in the A to Z of Peripheral Nerves and the updated version of the A to Z of Skeletal Muscles - however testing of the primary action of most muscles is listed on each page as a guide to the practitioner for basic testing and grouping of muscles. Please use this testing section as a guide only.

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Muscles and muscle layers of the Back and Neck

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NECK - has 2 major groups of muscles

those concerned with the neck movement i.e. movement of the cervical spine and head; 2 those concerned with the anterior neck structures. These muscles are dealt with in the laryngeal, pharyngeal and other related structures. Other muscles are concerned with the anterior regions of the head and are mentioned here.

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deep posterior - suboccipital muscles - extensors (see the next page included with the back muscles) / hyperextensors / rotators and stabilizers Rectus Capitus Posterior - Major and Minor Obliquuis Capitus muscles Cervical and Cephalic / Capitus regions of the muscles of the VC

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NS segmental - dorsal rami of the related SNs BS dorsal branches of the carotids

deep anterior - prevertebral A flexors, rotators and stabilizers Rectus Capitus Anterior and Lateral Longus Colli and Capitus

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NS segmental - ventral rami of related SNs BS branches of carotids and other local vessels

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anterior - flexors, rotators B Scalenii muscles NS segmental anterior branches of the ventral rami BS superficial cervical

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BACK - has 2 major groups of muscles

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those which are intrinsic to the VC basically segmental muscles concerned with movements and stability of the VC particularly the deepest layers – connected with the movement of the neck etc. those which use the VC as an immoveable post and move structures around the back extrinsic concerned with the anterior neck structures.

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The Extrinsic muscles do not affect the Head and Neck but are discussed in detail in the A to Z of Skeletal Muscles.

EXTRINSIC

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muscles which move the shoulder and arm Trapezius, Latissimus Dorsi, Rhomboids Levator Scapulae muscles which move the rib cage Serratus Posterior inferior and superior

NS segmental - ventral rami of related SNs BS branches of carotids and other local vessels

INTRINSIC

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most superficial Erector Spinae (ES) - Iliocostalis, Longissimus, Spinalis. - ES divided into a number of muscle groups with regional distinctions. (Part of the Intrinsic muscles of the back) medial lateral Spinalis Iliocostalis Longissimus Iliocostalis - Lumborum, Thoracis, Cervicus Longissimus - Thoracis, Cervicus, Capitus Spinalis - Thoracis, Cervicus, Capitus

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O & I listed individually in the text as a group as a group O along the VC + Ribs I into the VC + Ribs A listed individually A as a group the ES in these regions extend and rotate the head & neck. NS segmental spinal roots generally the dorsal rami but may also have innervation from the dorsal branches of the ventral rami branches (C1-T1). BS segmental dorsal branches of the carotids. T to extend and hyper-extend the neck and head and maintain a correct carriage of the head.

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Muscles of the Eye - note all 6 of these muscles act “in concert” in eye

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movement and depend upon the fixation and focus of the eye included is the muscle which moves the eyelid to follow the eye gaze, hence 6+1.

Extrinsic

Muscles responsible for movement of the upper eyelid

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1 Levator Palpebrae Superioris NS Occulomotor N (CN III) BS supraorbital, branches of ophthalmic N (from CN V1) Muscles responsible for movement of the eyeball

2 Recti muscles - Inferior /Superior, Medial/Lateral. These muscles are straight and are responsible for one movement up/down, in/out

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3 Oblique muscles - Inferior, Superior These muscles are attached via a trochlea or pulley and movements therefore vary on eye position and are diagonal up and out / down and in All are attached to the scleral surface, the Recti via the optic canal on the common annular tendon, and the Obliques via bones in the optic cavity

Intrinsic

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NS oculomotor N (CN III) - except Lateral Rectus - abducent N (CN VI) and Superior Oblique - trochlea N (CN IV) BS ophthalmic and branches of internal carotid

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These muscles are responsible for moving structures within the eyeball and are not shown. NS oculomotor N (CN III) parasympathetic outflow BS ophthalmic and branches of internal carotid

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Ciliaris, Dilator Pupillae, Sphincter Pupillae

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Eye structures

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in situ removal of superficial tissue / coronal section/enucleation with muscle bed intact Levator Palpabrae Superioris

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4 x Recti muscles (superior, inferior, lateral, medial)

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2 x Oblique Muscles (superior, inferior)

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Trochlear N (CN IV)

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ciliary ganglion (CN III)

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Abducens N (CN VI)

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Oculomotor N + branches (CN III)

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Trochlea

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superior orbital notch

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10 superior orbital fissure 11 Optic N (CN II)

12 Lacrimal gland

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see orbital cavity for bony orbit p48

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Muscles of the Face

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Buccinator Corrugator Supercili Depressor Anguli Oris Depressor Labii Inferioris, (overlying Incisivus inf.) Depressor Septi Frontalis (of Occipitofrontalis) Incisivus Labii Inferioris Incisivus Labii Superioris Levator Anguli Oris (Caninus), Levator Labii Superioris (overlying Incisivus sup.) Levator Labii Superioris alaeque nasi Mentalis Nasalis (compressor & dilator) Orbicularis Oculi Orbicularis Oris Platysma Procerus Risorius Zygomaticus Major & Minor

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NS facial N (CN VII) BS facial These muscles are often involved in cosmetic surgery and their function may be compromised by incisions at the level of the deep fascia.

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Mastication 19 20 21 22

Masseter, Pterygoids Lateral (deep to Masseter) Pterygoids Medial (deep to Buccinator) Temporalis + Temporoparietalis

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Muscles of the Face and Neck

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All are attached to the Mandible – Jaw bone and part of the Splanchnocranium NS trigeminal N –mandibular branch (CN V3) BS trigeminal and facial branches

Speech - Articulation Genioglossus Geniohyoid Styloglossus Hypoglossus Stylohyoid Thyrohyoid Sternothyroid

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NS hypoglossal (CN XII) and C1-3 of ansa cervicalis BS facial branches These muscles are often involved in stroke and overlap with the muscles used for swallowing, and the muscles of the Hyoid and Thyroid and Tongue

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- superficial anterior neck muscles - muscles of the Anterior Triangle - strap muscles Digastricus Geniohyoid Mylohyoid Mylohyoid central raphe

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Muscles of the Thyroid & Hyoid

These muscles elevate and position the Hyoid and the floor of the mouth to facilitate swallowing and occlusion of the Larynx NS hypoglossal (CN XII) and C1 of ansa cervicalis BS facial branches Omohyoid , (4A tendinous sling) Sternohyoid Sternothyoid

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facilitate swallowing and occlusion of the Larynx NS ansa cervicalis C1-3 BS thyroid vessels Stylohyoid Thyrohyoid

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These muscles are involved in support of swallowing - Thyrohyoid both lowers and elevates the Hyoid NS ansa cervicalis C1-3 BS facial and thyroid vessels

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As a group, these muscles define the neck line and shape, are involved in swallowing and sound production may be tightened in cosmetic surgery – they may attach to the Hyoid, Sternum and other bones in the region as a “through” bones – i.e. they have fascial slings to support them and separate them into 2 muscle bellies

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Muscles of the Larynx and Pharynx

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1 Salpingopharyngeus - attaches to the inferior of the auditory tube (1A) and blends with Palatopharyngeus to raise the pharyngeal wall, close off the auditory tube for swallowing 2 Palatopharyngeus - attaches to the Thyroid cartilages and the Palate to bring the pharynx forward allowing food to leave the mouth and enter the pharynx

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3 Stylopharyngeaus - attaches to the styloid process and the constrictors to elevate and dilate the pharynx in the early stages of swallowing*

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4 Pharygneal Constrictors - superior (4A), middle (4B), inferior (4C) attach to the Medial Pterygoid plate, Hyoid bone and Thyroid cartilages and blend in with each other and the posterior root of the tongue in order to commence swallowing and the resultant peristaltic movement at the beginning of the oesophagus (5). They also have ligament support - the Stylohyoid ligament (5A). NS vagus (CN X) and branches of ansa cervicalis (C1-3) BS maxillary, facial

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Note in CVAs - strokes these muscles under voluntary control and are involved in the early stages of swallowing - so may be affected greatly limiting the person’s capacity to swallow 6 Cricothyroid - attached to the cricoid cartilage (6A) 7 Arytenoids muscles - attached to the arytenoids cartilages (7A) at the back of the vocal cords responsible for altering the shape and angle of these cartilages - cricoid and thryroid cartilages (7B),

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Cricoarytenoids - posterior and lateral, Thyroarytenoid, Transverse arytenoids, 8 Vocalis - also attached to the arytenoids cartilages for voice regulation. NS for most of these muscles comes from the vagus (CN X) BS from the thyroid vessels and branches of the carotids

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9 Middle concha 10 Hard palate 11 L Upper M2 tooth (27) 12 Thyroid memebrane (connecting Thyroid and Cricoid cartilages) 13 Arytenoid cartilages 14 Cricothyroid fibres Note surface anatomy guides 15 Sternohyoid 16 Disc b/n C4/5 opp. Thyroid cartilage 17 Body of C3 opposite Hyoid bone

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Aryepiglotticus

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part of the muscles of the Larynx O apex of the arytenoid cartilage I lateral border of epiglottus A aids in the closure of the opening of the larynx (additis) moves the arytenoids to the epiglottic tubercle NS recurrent laryngeal N (branch of vagus CN X) BS laryngeal and thyroid vessels

Arytenoids

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Crico - Oblique, Transverse part of the muscles of the Larynx

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Oblique O/I b/n the muscular processes of the arytentoid cartilages A adduction of the aryepiglottic fold and the vocal cords to cause closure with Aryepiglotticus forms a sphincter of the laryngeal outlet NS recurrent laryngeal N (branch of vagus CN X) BS laryngeal and thyroid vessels

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Transverse O/I b/n the muscular processes of the arytenoid cartilages - medial on one to the posterior surface of the other A adduction of the arytenoid cartilages and attached vocal cords - closure with of the rima glottis NS recurrent laryngeal N (branch of vagus CN X) BS laryngeal and thyroid vessels note the larynx is normally closed – antagonistic muscular contraction forces the structure open, hence in paralysis the larynx will close and prevent the passage of air note the CRICOARYTENOID muscle below attaching to the base of the arytenoids and important in pitch and tone

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Auricularis

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anterior, posterior, superior Extrinsic muscles of the Ear (present in 30%) O ant. Epicranial Aponeurosis post. Mastoid process of Temporalis sup. Epicranial Aponeurosis I ant. root of Auricle post. root of Auricle sup. root of Auricle A moves ear Pinna NS facial N (CN VII) BS facial / temporal T present if there is movement of the ear

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Buccinator

B part of the muscles of the mastication

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O lateral – outer surface of alveolar process of Maxilla lateral surface (Mandible) I deep part of the Orbicularis Oris deep fascia of the face A compresses cheeks against the teeth - draws the angle of the mouth down and laterally NS facial N (CN VII) BS facial and maxillary T ability to blow a saxophone or shape lips in this way

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Ciliaris part of the muscles of the Eye

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C O scleral spur

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I stroma of the choroid A modify the shape of the lens for distant (thinning of the lens – less convexity) or close focus (thickening of the lens – increased convexity) NS oculomotor (CNIII) parasympathetic fibres - for near focus - superior cervical ganglion - long ciliary Ns for far vision BS lacrimal and ophthalmic branches of internal carotid T ability to focus (note other factors are relevant but the loss of elasticity of the lens and the muscle to contract effectively contribute to changes in vision)

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Corrugator Supercili part of the muscles of facial expression

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A NS BS T

deep fascia of the skin in the midpart of the orbital arch glabella pulls brows down and medially, frowning facial N, supraorbital supratrochlear branches (CN VII) facial, ophthalmic ability to wrinkle brow as in frowning

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C O medial suprorbital margin (Frontal bone)

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Cricothyroid part of the muscles of the Larynx

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C O anterolateral aspect of the cricoid cartilage

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I inferior cornu and lower lamina of the thyroid cartilage A tilts thyroid cartilage forwards, lengthening and tightening the vocal cords NS superior laryngeal N (branch of the vagus N = CN X) BS cricothyroid branches of superior and inferior thyroid arteries T ability to change voice pitch and tone

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Depressors

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part of the muscles of facial expression Depressor Anguli Oris

D O oblique lines (Mandible) below and lateral to Labii Inferioris A NS BS T

deep fascia - at the corner of the lips interdigitating other facial muscles turns the corners of the lips down as in frowning facial N, maxillary branch (CN VII) facial -mandibular + inferior labial branches ability to turn the corners of the mouth down as in frowning

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Depressor Labii Inferioris O anterior-medial surfaces of Mandible I deep fascia medial to the corners of the lips A pulls lips down and back (with Platysma) NS facial N, superior buccal & mandibular branches (CN VII) BS facial – inferior labial branches + inferior alveolar T ability to draw back lips and tighten neck (continuous with Platysma)

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Depressor Septi O anterior-medial surfaces of Maxilla (incisive fossa) I deep fascia at the base of the nose A pulls nostrils inwards and lips up NS facial N, maxillary branch (CN VII) BS facial -maxillary, superior buccal branches T ability to constrict nostrils (difficult to detect)

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Digastricus

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Digastric muscle part of the muscles of the Hyoid (anterior neck) 2 muscular bellies anterior / posterior passing through a fibrous loop O anterior - inner side (lingular) of jaw (Mandible) posterior - mastoid notch (Temporal bone) I slides through the Hyoid tendon/ligamentous loop A elevates, retracts and protracts Hyoid depresses Mandible NS anterior - trigeminal N (CN V) - mylohyoid branch posterior - facial N (CN VII) BS facial mandibular branch superior cervical T open jaw against R note movement of Hyoid on swallowing

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Epicranius

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Frontalis + Occipitalis = Occipito-Frontalis Galea Aponeurosis = fibrous connection b/n the 2 muscle « bellies » 2 heads anterior = Frontalis posterior = Occipitalis

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Frontalis O skull aponeurosis I superficial fascia superior to brow A raises eyebrows / wrinkles forehead NS facial N temporal branches (CN VII) BS supraorbital supratrochlear branches of ophthalmic artery

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Occipitalis O Occipital bone - mastoid process (Temporalis) I skull aponeurosis A draws scalp back NS facial N postauricular branch BS facial T ability to raise one and both eyebrows

Erector Spinae (ES) - Iliocostalis, Longissimus, Spinalis Part of the Intrinsic muscles of the back - see the summary of the Muscles of the Back and Neck and individual listings of Iliocostalis - Lumborum, Thoracis, Cervicus Longissimus - Thoracis, Cervicus, Capitus Spinalis Thoracis, Cervicus, Capitus Frontalis see Epicranius

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Genioglossus

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O superior mental spine of Symphysis Menti (Mandibular symphysis) I ventral surface of the central mass of tongue and its mucous membrane interdigitating with intrinsic muscles of the tongue hypoglossal membrane and the upper anterior surface of the Hyoid interdigitates with the Superior Pharyngeal Constrictor A protracts tongue / pokes out tongue depression of the centre of the tongue to form a tunnel NS C1 travelling + Hypoglossal N (CN XII) BS facial – lingual branches T ability to poke out tongue ability to curl up tongue into a tube/tunnel

Geniohyoid

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O inferior mental spine posterior of Symphysis Menti (Mandibular symphysis) I anterior surface of Hyoid A elevation and protrusion of Hyoid depression of Mandible (fixed Hyoid) NS C1 travelling with Hypoglossal N (CN XII) BS facial – mandibular branch T observe swallowing open jaw against R

Hypoglossus

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O superior border + anterior surface of the Hyoid bone and greater cornu I sides of the tongue, interdigitating with the intrinsic muscles of the tongue A depresses the tongue NS Hypoglossal N (CNXII) BS facial – lingual branches T observe swallowing in early stages

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Iliocostalis Cervicus

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part of ES O angles of ribs 3-6 I TPs of cervical VBs 4-6 A bilateral action - extension of the cervical spine unilateral action - lateral flexion of the neck / cervical spine NS segmental dorsal branches of SNs BS segmental dorsal branches of the carotids T extend neck against R and laterally flex against R

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Incisivus Labii

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Inferior, Superior upper and lower parts of the one muscle helping Orbicularis Oris to protrude lips from above and below

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Superior O incisive fossa of Maxilla superior to the lateral incisor (tooth) I into Orbicularis Oris + Levator Anguli Oris fascia at the corner of the mouth A protrudes upper lip NS facial N (CN VII) superior buccal branches BS facial – labial branches T ability to protrude lips note these muscles are often missed as they lie deep to other facial muscles, and may cause imbalance or crookedness if neglected in surgery / injection procedures performed in this region

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Inferior O inferior border of Mandible, lateral to Mentalis, near eminence of the lateral incisor (tooth) I into Orbicularis Oris + fascia at the corner of the mouth A protrudes lower lip NS facial N (CN VII) inferior buccal branches BS facial – labial branches T ability to protrude lips

Inferior Lingualis see Linguali muscles

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Inferior Oblique

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Inferior Pharyngeal Constrictor see Pharyngeal Constrictors

Inferior Rectus

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part of the extrinsic muscles of the eye O inferior surface of common annular ring I anteroinferior surface of sclera in front of the equator of the eyeball A with eye adducted - moves eyeball laterally with eyeball to the front - moves eyeball downwards ie DOWN & OUT NS oculomotor N (CN III) BS infraorbital, ophthalmic T test eye movements (note works in conjunction with other eye muscles)

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part of the extrinsic muscles of the eye O orbital surface (Maxilla) lateral to nasolacrimal groove I sclera in the back lower outer quadrant behind the equator of the eyeball b/n Inf. and Lat. Recti A with eye adducted - moves eyeball up with eyeball abducted - moves eyeball laterally ie UP & OUT NS oculomotor N (CN III) BS infraorbital T test eye movements (note works in conjunction with other eye muscles)

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Interspinalis Cervicus

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(note thoracic and lumbar regions not discussed) O cervical SP of C3-7 I SP of the immediate VB above A draws adjacent VBs together extending the cervical VC NS segmental – dorsal branches of relative SNs (C1-T1) BS cervical –branches of the internal carotid T ability to extend neck / maintain upright neck position

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Intertransversarii Cervicus

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(note thoracic and lumbar regions not discussed) O cervical TP of C1-T1 on the anterior & posterior surfaces I TP of the immediate VB above on the same surface A draws adjacent VBs together extending the cervical VC NS segmental – ventral branches of relative SNs BS cervical –branches of the internal carotid T ability to extend and rotate neck / maintain upright neck position

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Lateral Cricoarytenoid

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O lateral aspect of cricoid arch I muscular process of arytenoid cartilage A adductor of vocal cords -closes rima glottidis/vocal cord opening NS recurrent laryngeal branch of vagus N (CN X) BS branches of inferior and superior thyroids T ability to open vocal cords - note this may be compromised in stroke victims

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Lateral Pterygoid –see Pterygoids

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part of the intrinsic muscles of the eye

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Lateral Rectus

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O inferior surface of common annular ring I anteroinferior surface of sclera in front of the equator of the eyeball A with eye adducted - moves eyeball laterally with eyeball to the front - moves eyeball downwards ie DOWN & OUT NS abducens N (CN VI) BS infraorbital, ophthalmic T test eye movements (note works in conjunction with other eye muscles)

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Levator Anguli Oris (Caninus)

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O below the infraorbital foramen / canine fossa (Maxilla) I outer edge upper lip & modiolus interdigitating with other facial muscles and nasolabial fold A elevates the angle of the mouth / smiling muscle NS facial N (CN VII) buccal branches BS facial, infraorbital T ability to smile

Levator Labii Superioris

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infraorbital margin (Maxilla and Zygoma) upper lip interdigitating with other facial muscles elevates and everts the upper lip / “curling the lip” facial N (CN VII) buccal branches facial, infraorbital ability to smile

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Levator Labii Superioris Alaeque Nasi

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O frontal process of Maxilla I upper lip interdigitating with other facial muscles greater alar cartilages and skin of the nose A elevates and everts the upper lip / “curling the lip” dilates nares and moves edge of nose out and up NS facial N (CN VII) buccal branches BS facial, infraorbital T ability to sneer (often works unilaterally)

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Levator Palpabrae Superioris

Levator Veli Palatini

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O inferior surface of Temporal bone - petrous part rim of auditory tube upper part of carotid sheath I palatine aponeurosis soft palate interdigitates with its opposite and Palatopharnygeus muscle A elevates soft palate, closing off nasopharynx from oropharynx NS vagus N (CN X) pharyngeal branch accessory N (CN XI) BS facial, maxillary ± ascending pharyngeal T snoring indicates poor muscle function often affected in stroke where fluids are directed out of the nose

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O inferior aspect of the lesser wing of Sphenoid, superior to the optic canal I superior tarsal plate and skin of upper eyelid A elevates eyelid NS oculomotor N (CN III) superior division BS ophthalmic , supraorbital T ability to raise eyelids /”open eyes”

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Linguali Muscles

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Intrinsic muscles of the Tongue – Inferior, Superior, Transverse & Vertical

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Inferior Linguali O lingual root / root of the tongue body of the Hyoid I apex of the tongue A depresses apex and shortens tongue

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Superior Linguali O submucosa of the epiglottus median fibrous septum I apex and margins of the tongue A raises apex and shortens tongue

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Transverse Linguali O median fibrous septum I margins of the tongue palatoglossus and palatoglossal arch A narrows and elongates tongue

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Vertical Linguali O/I top to bottom of tongue at the sides (runs dorsoventrally) A flattens and widens tongue NS hypoglossal N (CN XII) BS lingual and branches T as a group test the mobility of tongue and speech clarity ability to swallow and masticate effectively

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Longissimus Capitus

part of ES O TP of C1-5 I TP of C2-6 A extension and rotation of the neck NS segmental spinal roots generally the dorsal branches (C1-T1) BS segmental dorsal branches of the ascending cervical BVs, T to rotate head and neck and laterally flex

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Longissimus Cervicis

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part of ES O TP of C1-5 I mastoid process (Temporalis) A extension and rotation of the head NS segmental spinal roots generally the dorsal branches (C1-2) BS segmental dorsal branches of the ascending cervical BVs T ability to extend head and laterally flex head

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Longus Capitus

O TP and anterior surface of C1-T3 I anterior arch of Atlas (C1) A flexion neck (bilaterally action) rotation of neck (unilateral action) NS N to Longus Colli (C1-C3) BS vertebral – maybe damaged in Whiplash accidents T flexion of Neck against R rotation of neck against R

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Longus Colli

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O TP of C3-7 I anterior surface of Occiput A flexion neck (bilaterally action) rotation of neck (unilateral action) NS N to Longus Capitus (C1-C3) BS vertebral – maybe damaged in Whiplash accidents T flexion of Neck against R rotation of neck against R

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Masseter

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part of the muscles of mastication O zygomatic arch (Maxilla) I angle and lower ramus of the Mandible, interdigitates with Medial Pterygoid coronoid process of Mandible A closes jaw clenches teeth protraction and retraction of jaw assists in side to side movement of jaw NS trigeminal N- mandibular branch (CN V3) BS maxillary, facial, transverse facial T to clench teeth and move jaw in and out

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Medial Pterygoid see Pterygoids

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Medial Rectus

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part of the extrinisic muscles of the eye O medial surface of common annular ring I medial surface of sclera in front of the equator of the eyeball A moves eyeball medially - adduction ie CROSS EYED IF BOTH CONTRACT AT ONCE NS oculomotor N (CNIII) inf. division BS infraorbital, ophthalmic T test eye movements (note works in conjunction with other eye muscles) ability to “cross eyes”

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Mentalis

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part of the muscles of facial expression O Mandible - incisive fossa I deep fascia of the skin of the chin A protrudes lips raises bottom lip NS facial N - mandibular branch (CN VII) BS facial - mandibular branch, inferior alveolar T to lift up and protrude bottom lip

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Middle Pharyngeal Constrictor see Pharyngeal Constrictors

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Multifidus Capitus Multifidus Cervicis

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part of deep spinal muscle layer O articular processes (zygapophyseal) of C1-T4 I SP of 2-3 VB above A extension and rotation of the VC stability of the VC NS segmental spinal roots generally the dorsal branches (C1-T4) BS segmental dorsal branches of the ascending cervical BVs, T to maintain an erect and correctly postured head and neck mobilization of this region is facilitated by these deep muscles

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Muscularis Uvulae

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O posterior border of hard palate palatine aponeurosis I uvular mucosa A elevation and retraction of the Uvula NS pharyngeal branch of vagus N (CN X) and accessory N (CN XI) BS maxillary - greater palatine branch T say AHHH and watch uvula

O mylohyoid line (Mandible) I posterior fibres - anterior surface of Hyoid ant & middle fibres - decussate along median fibrous raphe from mandibular symphysis to the Hyoid A elevation of Hyoid elevation of the floor of the mouth depression of Mandible NS inferior alveolar branch of Trigeminal N (CN V3 division)

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Mylohyoid

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BS facial - submental branch, lingual - sublingual branch, T observe swallowing - elevation of the floor of the mouth

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Nasalis Compressor Naris Dilator Naris

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complex pair of muscles which pull the nostrils down and flatten them opening and closing them O frontal process of Maxilla interdigitating with Procerus and Depressor Septi I nasal aponeurosis (which connects it to its opposite side) cartilaginous ala nasi A dilation and compression of nostrils in forced respiration NS superior buccal branches of facial N (CN VII) BS facial and infraorbital branches T no real test observation in situations of respiratory stress

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Oblique Arytenoid see Arytenoids and Aryepiglotticus

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Obliquuis Capitus Inferior

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SP of C2 Axis TP of C1 Atlas rotates head at the Atlanto-axial joint suboccipital N (C2) and dorsal rami of C1-2 vertebral ability to rotate head ±R

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O I A NS BS T

Obliquuis Capitus Superior

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O TP of C1 Atlas I base of skull (Occiput) lateral _ of inferior nuchal line A extends head (bilateral) lateral flexion of head (unilateral) NS suboccipital N (C2) and dorsal rami of C1-2 BS ascending cervical T ability to flex head ± R

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O Occipitalis see Occipito-Frontalis = Epicranius

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Omohyoid

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part of the muscles of the Hyoid (anterior neck) 2 muscular bellies inferior / superior O inferior – upper border of Scapula inner side (lingular) of jaw (Mandible) superior – intermediate tendon (attached to 1st rib and Clavicle) I the inferior belly slides through a sling of deep fascia intermediate tendon to become the superior belly and attach to the lower border of Hyoid A lower the raised Hyoid (for e.g. after swallowing) lower the Larynx NS ansa cervicalis (C1-3) BS subscapular thyroid T observe movement of Hyoid after swallowing

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Orbicularis Oculi

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part of the muscles of facial expression O Frontalis, medial margin of Maxilla, Lacrimal bone I inserts into deep fascia of the orbit on all sides lateral palpebral raphe A tight closure of closure of eyelids and closure of eyebrows = “screwing up eyes” blinking drainage of tear ducts NS facial N (CN VII) temporal and zygomatic branches BS zygomatico-orbital, palpebral branches of ophthalmic and lacrimal T ability to “screw up eyes and eyebrows” on command against R

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Orbicularis Oris

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part of the muscles of facial expression O Maxilla, Mandible and Modiolus at the angle of the mouth I deep fascia of skin and muscles around the mouth interdigitating with surrounding muscles decussation with opposite side at the modiolus of the lips A tight closure (deep fibres), pursing and protrusion of lips (superficial fibres) assists in the actions of other muscles here NS facial N (CN VII) BS facial, inferior alveolar branches T ability to protrude lips and close mouth against R

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Palatoglossus

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part of the Palatine Arch - palatoglossal = anterior pillar O palatine aponeurosis I posterolateral surface of the tongue / interdigitates with its opposite and lateral lingualis A raises the posterior of the tongue closes oropharyngeal isthmus initiates swallowing NS vagus N (CN X) BS maxillary, greater palatine branch T ability to swallow

Palatopharyngeus

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part of the Palatine Arch - palatopharyngeal = posterior pillar O palatine aponeurosis posterior margin of the hard palate interdigitates with its opposite, Levator Veli Palatini, Salpingopharyngeus and Stylopharyngeus I upper posterior border of Thyroid cartilage interdigitates with other side and with Pharyngeal constrictors A continues swallowing, raises and protracts Pharynx and closes nasopharyngeal isthmus NS vagus N (CN X) pharyngeal branch BS facial, maxillary, pharyngeal, palatine branches T ability to swallow

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Pharyngeal Constrictors

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These are circular skeletal muscles which act to coordinate swallowing before it becomes completely reflexive.

Inferior Pharyngeal Constrictor

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O/I Cricopharyngeal part - lateral aspect of Cricoid cartilage Thyropharyngeus part - oblique line of Thyroid cartilage connecting fibrous tissue b/n the 2 cartilages - fibrous cricothyroid arch A Cricopharyngeal part acts as an upper sphincter in the oesophagus BS thyroid arteries

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Middle Pharyngeal Constrictor

Superior Pharyngeal Constrictor O/I Anterior - lower 2/3 of Medial Pterygoid Plate Pterygomandibular raphe Mandible - mylohyoid line I Posterior - upper part of posterior pharyngeal raphe aponeurosis to the clivus of Occiput interdigitates with Middle Pharyngeal Constrictor A commencement of swallowing BS facial maxillary lingual and pharyngeal branches

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O/I Anterior - lower 1/3 of the Stylohyoid ligament lesser and greater cornu of the Hyoid Posterior - posterior median pharyngeal raphe interdigitates with the other constrictors A commencement of peristaltic swallowing contractions BS thyroid arteries, lingual

NS pharyngeal plexus with fibres from: glosso pharyngeal (CN IX) vagus N (CN X), hypoglossal N (CN XI) and sympathetic fibres

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Platysma

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part of the muscles of facial expression muscle completely in the superficial fascia of the face O superficial fascia of the upper chest I superficial fascia of the chin and jaw up to the lower lips interdigitates with the muscles at the modiolus of the corners of the mouth A moves the skin from lower jaw to chest depresses the lower lip assists in depression of the Mandible NS facial N cervical branch (CN VII) BS facial, inferior alveolar, laryngeal T ability to tighten neck and jaw muscles and skin

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Posterior Cricoarytenoid

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part of the muscles of the Larynx O posterior aspect of the cricoid cartilage I muscular process of the arytenoid cartilage A abducts the arytenoid cartilages opening the rima glottidis NS recurrent laryngeal N (branch of the vagus N = CN X) BS cricothyroid branches of superior and inferior thyroid arteries T ability to breathe

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This is the only muscle which opens the normally closed rima glottidis and allows for the passage of air into the lungs -note if the recurrent laryngeal nerve is damaged it may be impossible for air to enter the trachea. Note the direct antagonist the CRICOARYTENOID has similar attachments but different placement causing reverse swivelling of the cartilages and closing the vocal cords.

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Procerus

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part of the muscles of facial expression O facial aponeurosis covering the lower part of the nose and lateral nasal cartilages I superficial fascia b/n eyebrows continuous with Frontalis (Epicranius) A depresses medial end of the eyebows - frowning muscle NS facial N (CN VII) temporal branch BS ophthalmic - supraorbital, supratrochlear branches T ability to wrinkle forehead

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Pterygoid Lateral, Medial

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part of the muscles of mastication Lateral Pterygoid O superior head - infratemporal crest of Sphenoid inferior head - lateral surface of lateral pterygoid plate of Sphenoid I intra-articular cartilage of temporomandibular joint pterygoid fovea inferior to the condyloid process of the Mandible A opens jaw via depressing and protracting Mandible pulls the intra-articular cartilage of the TMJ forward moves Mandible from side to side NS N to Lateral Pterygoid from trigeminal N mandibular division (CN V3) BS maxillary and its branches T open jaw against R Medial Pterygoid O medial surface of lateral pterygoid plate of Sphenoid Palatine bones, Maxilla I medial surface of the angle of the Mandible A closes jaw / Mandible moves Mandible back and clenches teeth assists in side to side action of the Mandible NS trigeminal N mandibular division (CN V3) BS maxillary and its branches T abililty to clench teeth and pull jaw back

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part of the intrinsic muscles of the eye Dilator Pupillae

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Pupillary muscles = Dilator Pupillae + Sphincter Pupillae

Sphincter Pupillae

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O/I collagenous connective tissue at the pupillary end of the dilator pupillae circumferentially around the pupil A constriction of pupil aperature for light and focus NS oculomotor N (CN III) - parasympathetic fibres BS internal carotid and ophthalmic branches to the eye T ability to adjust to light and focus

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O mesodermal stroma in the periphery of the iris I the iris interdigitates with the outer parts of the Sphincter Pupillae A constriction of pupil aperature for light and focus NS oculomotor N (CN III) - parasympathetic fibres BS internal carotid and ophthalmic and lacrimal branches to the eye T ability to adjust to light and focus

Recti muscles part of muscles of the Eye see Inferior Rectus, Lateral Rectus, Medial Rectus, and Superior Rectus - medial/lateral - superior/inferior

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Rectus Capitus

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Anterior / Lateralis / Posterior Rectus Capitus Anterior

TP of Atlas (C1) Occiput - inferior surface of basilar part flexion (head) at the Atlanto-Occipital joint N to Rectus Capitus part of CP (C2-3), suboccipital N (C1) vertebral flex head against R

Rectus Capitus Lateralis

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TP of Atlas (C1) Occiput - jugular process lateral flexion (head) unilateral action N to Rectus Lateralis (C1-3) part of CP vertebral laterally flex head against R

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O I A NS BS T

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O I A NS BS T

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Rectus Capitus

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Posterior - Major O SP of Axis (C2) I Occiput - lateral to the inferior nuchal line A bilateral extension (head) unilateral ipsi-rotation - (to the same side) NS suboccipital N (C1) BS vertebral, occipital T extend head against R / turn head against R

Rectus Capitus

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Posterior - Minor O posterior arch of Atlas (C1) I Occiput - medial to the inferior nuchal line A extension (head) NS suboccipital N (C1) BS vertebral, occipital T extend head against R

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Risorius

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deep fascia of the face superficial to Masseter skin at the angle of the mouth grinning (variable) - retracting the angle of the mouth facial N inferior buccal branch (CN VII) facial - transverse facial branch

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Rotatores - Longus, Brevis

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part of the deepest layer of muscles of the Spine - VC series of small muscles extending from Atlas to Sacrum Longus completely overlays Brevis. Has slips in the Neck - Cervicis region although not individually named O&I Longus - SP to lamina of the VB 2 above Brevis - SP to lamina of the VB 1 above A bilateral - extension of the VC -neck region unilateral - rotation of the VC at the level of individual VBs NS segmental dorsal rami of the SNs BS vertebral carotid, posterior branches of

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Salpingopharyngeus

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part of the muscles of the anterior triangle in the neck O inferior surface of auditory tube I blends with Palatopharyngeus A elevation of upper pharyngeal wall opens auditory tube in swallowing NS vagus N (CN X) accessory N (CN XI) BS facial, maxillary pharyngeal branches T ability to swallow – early stages

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note this is the muscle which helps to equalize the pressure in the ears and why there is relief when yawning or opening the mouth in a plane

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Scalenus

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Anterior, Medial & Posterior (Minimus) Dilator Pupillae

note on Scalenus Minimus - variable slip pf muscle which attaches to the Suprapleural membrane (Sibson’s fascia) and TP of C7 maintains the elevation of this pleura above the Clavicle often considered part of Scalenus Anterior

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O anterior TP of C3-7 medial TP of C3-7 posterior TP of C5-7 I anterior anteromedial surface of rib 1 medial lateral to the anterior muscle rib 1 posterior rib 2 inferior to the Clavicle A with fixed neck and Clavicle elevation of the ribs in forced inspiration accessory muscle of inspiration bilateral - flexion (neck) unilateral - rotation & lateral flexion of the neck NS segmental - SNs anterior branches (C4-7 anterior & lateral C6-8 posterior) supraclavicular branches of the BP Ns (C4-8) N to Longus Colli and N to Scaleni muscles BS superficial cervical T flex neck against R laterally flex neck against R

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Semispinalis - Capitus, Cervicis

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part of the deep muscles of the spine / neck more lateral than Spinalis

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Capitus O TP of C4-7 I superior & inferior nuchal lines (Occiput) A bilateral extension (head) unilateral rotation (head) NS suboccipital N - dorsal rami (C1)

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Cervicis O TP of T1-6 I SP of C1-5 A bilateral extension (neck) unilateral rotation (head) NS dorsal rami of the segmental SNs (C2-T5) BS segmental branches from local BVs T ability to extend and rotate neck

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Soft Palate Muscles – Musculus Uvulae, Palatoglossus, Levator & Tensor Veli Palatini

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Sphincter pupillae see Pupillary muscles

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Splenius - Capitus, Cervicis

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superficial to Spinalis

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Capitus O SP and supraspinous ligaments of T1-3 I lateral superior nuchal lines (Occiput) mastoid process (Temporal bone) A bilateral hyperextension, extension (head and neck) stabilization (head) unilateral rotation (head and neck) NS dorsal branches of SN - dorsal rami (C1-4) suboccipital N, greater occipital N (C1-4)

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Cervicis O ligamentum nuchae and TP of C1-3 I SP and interspinous ligaments of T1-4 A bilateral extension, hyperextension (neck and upper VC) unilateral stabilization (neck) NS dorsal rami of the segmental SNs (C3-8) BS branches of the internal carotids T neck movements

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Stapedius S

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posterior wall of the inner ear neck of Stapes dampens down the ossicle chain to reduce vibrations facial N (CN VII) inner ear branch internal carotid, maxillary, facial, middle meningeal branches

Tensor Tympani T

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O I A NS BS

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O cartilaginous and boney margins of the auditory tube greater wing of the Sphenoid I handle of the Malleus A pulls the Malleus medially and tenses the “ear drum” NS N to Medial Pterygoid (from mandibular division of trigeminal N (CN V3)

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BS middle meningeal of mandibular pharyngeal, internal carotid branches T involved in control of hearing adjustment to sound levels

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Sternocleidomastoid

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O Manubrium (breastbone) anterior surface of medial 1/3 of the Clavicle I mastoid process (Temporal bone) anterior 1/3 of superior nuchal line A bilateral flexion (head and neck) unilateral rotation (head and neck) NS accessory N (CN XI) N to Sternocleidomastoid (ventral rami of SNs C1-2) BS superficial cervical T turn head against R flex head against R

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Sternohyoid

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part of the muscles of the Hyoid (anterior neck) O posterior surface of Clavicle and Manubrium I inferior border of Hyoid A depress the Hyoid (for swallowing) NS ansa cervicalis (C1-3) BS thyroid T observe movement of Hyoid with swallowing

Sternothyoid

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part of the muscles of the anterior triangle in the neck O posterior surface of Manubrium and 1st costal cartilage I oblique lines of the laminae of the Thyroid cartilage A depress the Hyoid and Larynx (for swallowing) NS ansa cervicalis (C1-3) BS thyroid T observe movement of Hyoid with swallowing

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O apex of styloid process (Sphenoid) stylomandibular ligament I superolateral sides of the tongue decussating with Hypoglossus A retracts and elevates tongue NS hypoglossal N (CN XII) BS facial, lingual T ability to initiate swallowing

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Styloglossus

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Stylohyoid

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part of the muscles of the anterior triangle in the neck O base of styloid process (Sphenoid) I posterior surface of the Hyoid to the greater cornu A elevate and retract the Hyoid and larynx (for swallowing) NS facial N (CN VII) BS posterior auricular, occipital T ability to swallow

Stylopharyngeus

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part of the muscles of the Pharynx O medial aspect of styloid process (Sphenoid) I posteriolateral border of the laminae of the Thyroid cartilage A elevates the Hyoid and Larynx (for swallowing) NS glossopharyngeal N (CN XII) BS thyroids, tonsillar, lingual T ability to swallow

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Superior Oblique

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O lesser wing of Sphenoid superomedial to tendinous ring I through the trochlea/fibrocartilagneous loop to the sclera behind the equator A depresses eye in adduction medially rotates eye in abduction NS trochlear N (CN IV) BS ophthalmic T test eye movements (note works in conjunction with other eye muscles)

Superior Rectus

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O superior tendinous ring I superior scleral equator A elevates eye medially rotates eye in adduction NS oculomotor N (CN III) BS ophthalmic T test eye movements (note works in conjunction with other eye muscles)

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Temporalis

Temporparietalis

Tensor Tympani see Stapedius

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deep to Temporalis, aponeurosis above Auricularis galeal aponeurosis (b/n Frontalis and Occipitals) fixes galeal aponeurosis facial N (CN VII) maxillary middle & superior temporals T test strength of closed jaw or close against R (with care)

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O temporal fossa of the Frontal, Parietal and Temporal bones I coronoid process and ramus (Mandible) A closes jaw retracts Mandible clenches teeth NS mandibular division of trigeminal N (CNV) BS maxillary middle & superior temporals T test strength of closed jaw or close against R (with care)

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Tensor Veli Palatini

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O scaphoid fossa (Sphenoid) rim of auditory tube spine of Sphenoid I palatine aponeurosis, crest and osseous surface via a pulley through the pterygoid hamulus soft palate A elevates soft palate, closing off nasopharynx from oropharynx NS N to Medial Pterygoid from mandibular division of trigeminal N (CN V3)

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BS facial, maxillary ± ascending pharyngeal T poorly function in snoring often affected in stroke where fluids are directed out of the nose

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Thyroarytenoid + Vocalis

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O inferior surface of thyroid cartilage cricothyroid ligament I vocal processes of the arytenoid cartilages A relaxes the vocal folds by protracting the arytenoid cartilages NS vagus N (CN X) recurrent laryngeal branch BS hyroids pharyngeal branches T ability to change voice tone

lower posterior surface of thyroid cartilage epiglottic fold and margin closes additus to the Larynx vagus N (CN X) recurrent laryngeal branch thyroids pharyngeal branches ability to change voice tone

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Thyroepiglotticus (not shown)

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these small muscles interdigitate, work together in a coordinated manner and are responsible for the tone and special qualities of the voice

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Thyrohyoid

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part of the muscles of the anterior triangle in the neck O oblique lines of the laminae of the Thyroid cartilage I Hyoid - cornu and body A depresses & elevates the Larynx NS C1 with hypoglossal N (CN XII) BS thyroid T observe movement of Hyoid with swallowing Transverse Arytenoid see Arytenoids

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Transverse Lingualis see Linguali muscles/Intrinsic muscles of the Tongue

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Vertical Lingualis see Linguali muscles/Intrinsic muscles of the Tongue

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Vocalis see Thyroarytenoid

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Zygomaticus – Major, Minor

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part of muscles of facial expression

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Zygomaticus Major O Zygoma - cheekbone I deep fascia at the angle of the mouth (modiolus) A draws mouth back smiling/laughing NS facial N (CN VII) BS facial T smile

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Zygomaticus Minor O Zygoma - cheekbone deep fascia of the upper lip A maintains nasolabial furrow - philtum everts upper lip NS facial N (CN VII) buccal branch BS facial often lost in cosmetic surgery i.e. no skin crease from nose to lips

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Overviews of Structures and features of the Head and Neck Arteries and Anastomoses (AA) of the Head and Neck

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The arterial supply of the Head and Neck and face is particularly rich and overlapping (anastomotic). This is most important due to the poor definition of the fascial layers, the extensive mobility of the region, the concentration of Ns and special sensory structures. The major supply of the extracranial BVs are from the external carotid. Supply also comes from the internal carotid and the vertebral arteries, and communication exists b/n all 3 sources.

Major Arteries of the Head and Neck

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supraorbital supratrochlear frontal parietal zygomatico-orbital infraorbital transverse facial anterior & posterior auricular external carotid from the common carotid facial mandibular - sublingual + submental branches maxillary - superior +inferior alveolar branches superfical temporal middle temporal labial vessels

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Major Anastomoses of the Head and Neck

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1 AA b/n the supratrochlear / supraorbital / superficial temporal arteries from both the internal and external carotid arteries 2 AA b/n the anterior ethmoidal / maxillary branches and deep facial arteries in the nasal septum - (Little’s area) 3 AA b/n the R & L and the upper & lower labial arteries 4 AA b/n the sublingual / submental /inferior alveolar arteries - all from the external carotid artery 5 AA b/n the superior and inferior thyroid arteries - from the external and common carotid arteries 6 AA b/n the ascending & deep cervical / vertebral arteries - from the aortic arch and common carotid artery 7 AA b/n the occipital and deep cervical arteries 8 AA b/n the posterior auricular / occipital / superficial temporal arteries - from the external carotid 9 AA b/n the superficial temporal arteries communicating b/n different sides of the scalp 10 AA b/n the deep temporal and the middle meningeal arteries -communicating b/n the extra-cranial and intra-cranial BSs 11 AA b/n the superficial and deep arteries of the face communicating b/n the fascial and muscle layers which are poorly defined in the face

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Nerves of the Head and Neck -

CN I II III

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Cervical Ns, Cranial Ns and Cutaneous Ns The Cervical Ns are from the PNS. They are the 8 paired Spinal Ns which come from the SC and exit from the intervertebral foraminae of the Cervical Vertebrae - (discussed in the A to Z of Peripheral Ns). The Dorsal rami of these Ns innervate most of the posterior muscles of the neck and the overlying skin and the Ventral rami form the Cervical Plexus (CP) and innervate, combining with the CNs: the neck structures, including the muscles and skin, anterior to the VC. The Cranial Nerves are defined as those Ns which exit directly from the Cranium/ Skull. There are 12 pairs and their functions are summarized in the table below. They are numbered according to the order at which they exit the cranium and they are named to reflect their function. Their pathways are discussed in detail in the A to Z of the Brain and Cranial Ns but an overview showing their origin is demonstrated in the diagram showing the Head & Neck in the sagittal plane.

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VI VII

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Cranial Ns

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Olfactory tract and bulb (CN I) Optic chiasma and N (CN II) Occulomotor (CN III) Trochlear (CN IV) Trigeminal (CN V) Abducens (CN VI) Facial N and Nervus Intermedius (CN VII) Vestibulococchlear (CN VIII) Glossophayngeal N (CN IX) Vagus (CN X) Accessory spinal and cranial component (CN XI) Hypoglossal (CN XII)

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The Cutaneous Ns

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The Cutaneous Ns are those PNs which innervate the skin of the Head & Neck. They are derived from: the Cervical Plexus = CP - (Ventral rami of the Cervical Spinal Ns), Dorsal rami of the Cervical SNs = dr, and branches of the Trigeminal N in all divisions (CN V1, V2, V3).

2 Supraorbital (CN V1)

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Cutaneous Ns 1 Supratrochlear (CN V1)

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There is extensive overlap of the innervation of this region and supply of Ns is considerable. Nerves are found to supply the muscles, skin and special structures with a fair degree of variation. The commonest distribution and emergence of the cutaneous Ns is demonstrated in this diagram.

3 Palpebral branch of the Lacrimal N (CN V1)

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4 Zygomaticotemporal + Zygomaticofacial (CN V2) 5 Auriculotemporal (CN V3)

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Greater Occipital N (C2 dr) Occipital Ns - (C3-C8 dr) Lesser Occipital N (C2-3 dr) Greater Auricular N (C2-3 CP) Supraclavicular Ns (C3-4 CP) Transverse Cutaneous N of the neck = Tansverse Cervical N (C2-3 CP) 12 Mental N (CN V3)

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13 Buccal N (CN V2)

14 Infraorbital (CN V2) 15 External Nasal Br of the Anterior Ethmoidal N (CN V1)

16 Infratrochlear (CN V2)

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Major Veins + Lymphatic vessels

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Extra-cranial Venous and Lymphatic drainage of the Head & Neck

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1 Superficial Temporal V (drains the scalp) 2 Supraorbital V (drains the scalp) 3 Supratrochlear and communicating branches (drains the scalp) 4 Pterygoid plexus (drains the deep facial layers) 5 Maxillary V 6 Facial V (drains most of the face superficial and deep) 7 Mandibular V 8 Lingual V 9 Common facial Vs 10 Anterior Jugular Vs (drains chin and superficial tissues of the neck - drains to the External Jugular V) 11 R Thoracic Lymphatic Duct 12 R Subclavian 13 Superior Vena Cava 14 L Brachiocephalic V 15 venous arch - communicating Vs 16 L Subclavian 17 Thoracic duct 18 Internal Jugular (commences at the end of the sigmoid sinus) 19 External Jugular (superfical to the deep fascial layer of the neck) 20 External Jugular posterior branch 21 Retromandibular V 22 Posterior Auricular V 23 Occipital V (draining into the Vertebral V)

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Extra-cranial Venous and Lymphatic drainage of the Head and Neck

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The venous and lymphatic drainage is subject to great variation, extensive anastomoses and communication. However the major vessels demonstrated here tend to be consistent. Many of the veins in this region do not have the same name as the arteries, and do not run with them. In the face there is no separation b/n the deep and superficial fascial layers, but in the neck, veins are either superficial to the deep fascia or deep to it traveling in these cases with the respective arteries, as in other areas of the body. Except for the cornea and CNS, all the structures of the Head and Neck have extensive lymphatic drainage. Major groups are : MASTOID - behind the ear, draining the ear & side of the head OCCIPITAL - at the base of the skull, draining the posterior scalp PAROTID - superficial to the parotid salivary gland, draining the side of face and scalp SUBMANDIBULAR - near the submandibular salivary gland, draining the side of the face and scalp SUBMENTAL - under the chin, draining the chin, bottom teeth, lower face and anterior of the tongue also the PRE-AND POST-AURICULAR AND SUPRACLAVICULAR NODES are of significance clinically.

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The major groups of Lymph nodes drain to the: UPPER DEEP CERVICAL NODES

LOWER DEEP CERVICAL NODES

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at the root of the neck

LINGUAL TONSIL

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Deep lymphatic drainage from the orbit, nose and pharynx drains to the: PALATINE TONSIL at the root of the neck

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THEN ALL DRAIN to the major lymphatic ducts:

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RIGHT THORACIC DUCT

at the venous junction b/n R subclavian & R internal jugular veins

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LEFT THORACIC DUCT or

at the venous junction b/n the L subclavian & L internal subclavian veins

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Transverse section and fascial planes of the Neck

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The neck unlike the face has well defined fascial planes which allow for gross movements, and all the muscles lie as usual deep to the investing fascial layer. These defined planes are well demonstrated in the transverse section of the neck opposite. Only one muscle is an extension from the face and lies outside these deep layers - Platysma. 1 skin, subcutaneous tissue, superficial fascia 2 SP of cervical vertebra 3 deep fascia and investing layers 4 Trapezius 5 Splenius 6 Spinalis 7 loose CT / with LNs + vessels / autonomic ganglion / BVs 8 Transverse foramen + Vertebral artery 9 Platysma 10 Sternocleidomastoid muscle 11 External Jugular V 12 anterior neck muscles / strap muscles 13 Anterior Jugular V 14 Trachea + cartilagenous ring and surrounding fascia 15 Thyroid = 2 lobes + connecting Isthmus 16 Oesophagus 17 Carotid sheath and contents = carotid artery + internal jugular vein + Vagus N 18 Pretracheal fascia to allow for movement as a whole of the trachea + thyroid and cricoid cartilages + glands in swallowing 19 deep muscles of the neck and back = Rotatores, Multifius, Intertransversarii 20 SC - Nervous tissue + coverings

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Head & Neck Topography Surface Anatomy

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These regions do not reflect the Dermatomes or Langerhans lines, but act as a sensible regional guide to the skin areas of the Head and Neck. 1 supraorbital 2 orbital 3 Nasal 4 Infraorbital 5 Zygomatic 6 Oral / labial 7 Buccal / cheek 8 Parotid / masseteric 9 Mental / chin 10 Submental 11 Submandibular 12 Hyoid 13 Carotid 14 Infrahyoid 15 laryngeal 16/25 sternocleidomastoid 17 thyroid 18 suprasternal/jugular notch 19 Infraclavicular 20 Acromial 21 Clavicular 22 Supraclavicular 23 Nuchal/posterior neck 24 Lateral cervical 26 Occipital 27 Mastoid 28 Auricular 29 Temporal 30 Parietal 31 Frontal 32 Glabella (b/n the eyes)

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(origins insertions actions BS & NS of each muscle listed alphabetically)

(including radiology of the Skull)

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Order now to complete your ‘A to Z’ set so far!

(including pronunciation guide, anatomy word builder, abbrev. of medical qualifications and organ wgt.)

(each bone’s features and (including a clinical its articulation group section with examination relations, individual joints, techniques for general movements, BS & NS, and nerve disorders and joint classifications listed) assessments)

Website www.aspenatlas.com (www.aspenpharma.com.au/atlas/student.htm) email us for complete access to the many A to Z educational aids

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• The A to Z of Histological and Anatomical images • The A to Z of Skeletal Muscles • The A to Z of Medical quizzes

Coming soon!

list in order of priority

The A to Z of Brain and Cranial Nerves The A to Z of Surface Anatomy. The A to Z of Emergency Medicine The A to Z of Anatomical Quizzes The A to Z of Gynecological anatomy The A to Z of Radiology

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• • • • • •

Research projects

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The A to Z of Topographical anatomical mapping in conjunction with the Forensic Institute of NSW and Anatomy Update

What did you use this text for ?

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Student use Medical use - continuing education/patient explanation Forensic use Health professional use / other Personal use

please email any comments, or to order additional copies (special student rates) [email protected] [email protected] fax 61 2 93651000 phone 0414248747 mobile: 0414248747 Name: E-mail: Other contact:


Dr. A. L. NEILL BSc MSc MBBS PhD FACBS [email protected] www.amandasatoz.com 0414 248 747 Contact www.aspenpharma.com.au for login and passwords for the complete A to Z and the AspenAtlas online special student sites for atlas and other helpful study guides available on request..

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The A to Z of the Head and Neck

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