Head & Neck

ANATOMY
(head & neck)
SYLLABUS
Pharyngeal arches (P. 837)
Development of: (P. 838)
Face and eye
Face: (P. 839)
Muscles of facial expression, nerves and vessels
Scalp:(P. 841)
Layers, blood supply, nerve supply, applied anatomy.
Temporo-mandibular joint: (P. 842)
Type, movements and applied aspects, including muscles involved in producing movements.
Major Joints: (P. 844)
Atlanto-axial joint and Atlanto-occipital joint:
Type, subtype, ligaments, movements and applied aspect.
Deep fascia of neck: (P. 845)
Distribution and clinical important
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Triangles of neck: (P. 845)
Boundaries, contents and applied aspects:
Infratemporal fossa: (P. 849)
Boundaries, contents and applied aspects
Pteryopalatine fossa: (P. 850)
Boundaries, contents and applied aspects
Parotid and submandibular regions Muscles:(P. 850)
Names and nerve-supply of muscles of facial expressions
Attachments, nerve supply, and actions of following muscles: (P. 850)
- Sternocleidomastoid
- Muscles of mastication
- Orbicularis oculi
- Buccinator
- Scalenus anterior (including Scalenus anterior syndrome)
Blood vessels: (P. 853)
Origin, course, termination and branches/tributaries of:
- Common carotid artery (P. 853)
- Internal carotid artery (P. 854)

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- Subclavian arteries (right and left)

- Maxillary artery (P. 854)
- Internal jugular vein (P. 854)
Cervical group of lymph nodes: (P. 855)
Subgroups, drainage areas, applied aspects.
Bones:
Gross and special features of Bones
Maxilla, zygomatic bone
Cranial bones- frontal, parietal, temporal, sphenoid
Foetal skull
Names of skull bone in adult
Cranial fossae with structures passing through major foramina
Cervical vertebrae: general and special features
Mandible: attachments of muscles and ligaments, differences in mandible at different ages.
Radiological anatomy
X- Rays of skull, cervical spine (A.P and lateral views)
Angiogram of external and internal carotid arteries
Surface anatomy
External carotid artery, internal carotid artery, Sub clavian arteries (right and left) and Internal jugular vein

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HEAD AND NECK – ANATOMY

PHARYNGEAL ARCHES / BRANCHIAL  These arches appear in the fourth and fifth weeks
of development.
ARCHES
 They consist of bars of mesenchymal tissue
Past Questions: separated deep clefts called pharyngeal clefts.
1. Name the muscles direct from pharyngeal arches  With development of the arches and clefts, a
[3] [KU 2003] number of outpocketings appear called
pharyngeal pouches.
2. Write short notes on development of vertebrae
 They also play important role in formation of the
[2] [06 June] face.
Pharyngeal Arch Nerve Muscles [KU 2003] Skeleton Artery
st th
1 Arch: Mandibular Trigeminal (5 Mastication (temporalis; Premaxilla, maxilla, Maxillary artery
(maxillary and CN): Mandibular masseter; medial and zygomatic bone, part of
mandibular division lateral pterygoids); temporal bone, Meckel's
process) mylohyoid; anterior belly of cartilage, mandible,
digastric; tensor palatine, malleus, incus, anterior
tensor tympani ligament of malleus,
sphenomandibular
ligament
2nd Arch: Hyoid Facial (7th CN) Facial expression Stapes, styloid process, Stapedial hyoid VIII
(buccinators, auricularis, stylohyoid ligament, artery
frontalis, platysma, lesser horn and upper
orbicularis oris, orbicularis portion of body of
oculi) posterior belly of hyoid bone
digastric, stylohyoid,
stapedius
3rd Arch Glosso- Stylopharyngeus Greater horn and lower Common carotid,
pharyngeal portion of body of internal carotid
(9th CN) hyoid bone
4th – 6th Arch Vagus (10th CN)
- Superior Cricothyroid, levator Laryngeal cartilages Proximal part
laryngeal palatine, constrictors of (thyroid, cricoids, present subclavian
branch (nerve pharynx arytenoid, corniculate, and brachiocephalic
to 4th arch) cuneiform) artery
- Recurrent Intrinsic muscles of larynx Right: right
laryngeal pulmonary artery
branch (nerve Left: left pulmonary
to sixth arch) artery and ductus
arteriosus

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Note:
DEVELOPMENT OF FACE
i. Frontonasal process is only unpaired structure
 Structure contributing to formation of face:
(other are paired)
Prominence Structure formed ii. The main part of Palate is formed by outgrowths
(Processes) of two maxillary processes.
1. Frontonasal i. Forehead
Development of Vertebral Column
ii. Bridge of nose
[KU 2006]
iii. Medial and lateral nasal
prominences  Developed from sclerotome compartments of the
somites. (derived from Paraxial mesoderm)
2. Maxillary i. Cheeks
 A definitive vertebra is formed by condensation of
ii. Lateral portion of upper the caudal half of one Sclerotome and fusion with
lip the cranial half of the adjacent sclerotome.
3. Medial Nasal i. Philtrum of upper lip Note:
ii. Crest
i. Ribs developed from the sclerotome cells that
iii. Tip of nose remain in the paraxial mesoderm.
4. Lateral Nasal i. Alae of nose ii. Sternum develops independently in the parietal
layer of lateral plate mesoderm.
5. Mandibular i. Lower lip
Base of Cranial Cavity
Foramen Structures passing through foramen
Anterior cranial fossa
Foramen cecum Emissary veins to nasal cavity
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Olfactory foramina in cribriform plate Olfactory nerves (I)
Optic canal Optic nerve (II); ophthalmic artery
Middle cranial fossa
Superior orbital fissure Oculomotor nerve (III); trochlear nerve (IV); ophthalmic division of
the trigeminal nerve (V1); abducent nerve (VI); ophthalmic veins
Foramen rotundum Maxillary division of the trigeminal nerve (V2)
Foramen ovale Mandibular division of the trigeminal nerve (V3); lesser petrosal nerve
Foramen spinosum Middle meningeal artery
Hiatus for the greater petrosal nerve Greater petrosal nerve
Hiatus for the lesser petrosal nerve Lesser petrosal nerve
Posterior cranial fossa
Foramen magnum End of brainstem/beginning of spinal cord; vertebral arteries; spinal
roots of the accessory nerve meninges
Internal acoustic meatus Facial nerve (VII); vestibulocochlear nerve (VIII); labyrinthine artery
Jugular foramen Glossopharyngeal nerve (IX); vagus nerve (X); accessory nerve (XI);
inferior petrosal sinus, sigmoid sinus (forming internal jugular vein)
Hypoglossal canal Hypoglossal nerve (XII); meningeal branch of the ascending
pharyngeal artery
Condylar canal Emissary vein
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 Head & Neck

2. Nerve Supply of Face:

FACE
1. Common facial expression and Muscles Motor Sensory [KU 1998]
involved: A. Branches of A. Divisions of Trigeminal Nerve VIII
A. Frowning i. Corrugator supercilli Facial nerve 1. Opthalmic...
ii. Procerus 1. Temporal i. Lacrimal
B. Surprise, Horror or i. Frontalis muscle 2. Zygomatic ii. Supra-orbital
Fright 3. Buccal iii. Supra-trochlear
C. Anger i. Dilator nares 4. Marginal iv. Infra-trochlear
ii. Depressor septi Mandibular v. External nasal
D. Sadness i. Lavator anguli oris 5. Cervical 2. Maxillary...
ii. Lavator labii superioris i. Infra-orbital
iii. Zygomaticus minor ii. Zygomatico-facial
iv. Depressor anguli oris. iii. Zygomatico-temporal
E. Laughing (smiling) i. Zygomaticus major 3. Mandibular....

F. Irony i. Depressor labii inferioris i. Auriculo-temporal

ii. Buccal
G. Grinning i. Risorius
iii. Mental
H. Disdain i. Mentalis
B. Nerve of Cervical Plexus
I. Whistling i. Buccinator
1. Great auricular (C2, C3)
ii. Orbicularis oris

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3. Blood Supply of Face: a. Upper area:

Arterial Supply Venous Drainage  Comprising greater part of forehead,
temple, lateral halves of the eye lids,
1. Facial artery: 1. Facial Vein:
conjunctiva, cheek and parotid region
Branches Communicates with:
 Drains into pre-auricular or superficial
i. Inferior labial i. Cavernous sinus via: parotid lymph nodes
ii. Superior labial a. Angular and superior b. Intermediate area:
iii. Lateral nasal opthalmic vein.  Comprising central forehead, frontal
2. Transverse facial b. Deep facial vein and sinuses, medial halves of the eye lids, nose
artery (Branch of Pterygoid venous plexus with maxillary sinuses, upper lip, lateral part
superficial temporal ii. Frontal diploic vein of lower lip, medial part of cheek and
artery) greater part of lower jaw
2. Retromandibular vein
 Drains into submandibular lymph nodes
Note: These are branches Note: They ultimately drain
c. Lower area:
of External Carotid artery. into internal jugular vein.
 Comprising central part of lower lip and
4. Lymphatic Drainage of Face: chin
- The face possesses three areas from which the  Drains into submental lymph nodes
lymphatics are drained

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Applied Aspects: - Reasons:

Dangerous area of face: i. Facial vein is devoid of valves and rests directly
- Area of upper lips and adjoining nose i.e. area on facial muscles.
between angular and deep facial veins. ii. The movement of facial muscles facilitates the
spread of septic emboli from dangerous area of
- May lead to thrombosis of cavernous sinus face.

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 Head & Neck

SCALP c. Minor scalp injury produce profuse bleeding.

Past Questions: d. Epicranius: Occipito-frontalis and Temporo-
parietalis.
1. Mention different layers of scalp with their
e. Fourth layer: Dangerous area of scalp.
clinical importance. (3)[08 July]
f. Operation on the scalp should be preferably done
2. Arterial supply of scalp (2)[09 July]
under general anesthesia.
3. Layers of scalp (2)[06 June]
g. The scalp is the site of free anastomosis between
Layers of Scalp [KU 2008, 2006] the branches of external and internal carotid
- The scalp is formed of 5 layers: arteries.
(@ SCALP  Memory key)
Arterial Supply [KU 2009]
i. S Skin
ii. C Close network of subcutaneous tissue. 1. Internal Carotid artery
(Connective tissue)
Opthalmic artery i. Supra-Trochlear
iii. A Aponeurosis (Galea) and Occipitofrontalis ii. Supra-orbital
muscle
iv. L Loose subaponeurotic tissue. iii. Superficial temporal
v. P Paricranium or outer periosteum of skull. (Pre auricular area)
(Post auricular area)
Note:
a. First 3 layers acts as a single unit. iv. Posterior auricular
2. External Carotid
v. Occipital
b. Scalp is the common site for formation of artery
sebaceous cysts.

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Nerve Supply 3. Write briefly the composition, main relations,

nerve supply and movements of the temporo-
Pre auricular area Post auricular area
mandibular joints. Name the muscles which help
A. Sensory opening of mouth during mastication and their
1. Supply-trochlear 1. Great auricular mechanism of actions. (9) [04 Nov]
2. Supra-orbital 2. Lesser occipital 4. Describe the temporo-mandibular joint the
following headings (1+1+2+1=5) [05 Dec]
3. Zygomatico temporal 3. Greater occipital
a. Type and subtype
4. Auriculo temporal 4. Third occipital
b. Articular parts
B. Motor
c. Ligaments
1. Temporal 1. Posterior auricular d. Movements possible
(facial branch) (facial branch) 5. Describe the atlantoaxial joint under the
Applied Aspects: [08] following headings:

i. Skin: Common site for the formation of Sebaceous a. Type and subtype (1+1+1+2=5) [05 June]
cysts. b. Articulating parts
ii. Sub Cutaneous tissue: Minor injury produces c. Ligaments
profuse bleeding because the walls of vessels are d. Movement possible
adherent to the fibrous network and are prevented 6. List the types and movements of (1+1+1=3) [07 July]
from retracting. a. Temporomandibular joint
iii. Aponeurosis layer: The wounds of the scalp gape, b. Atlanto-occipital joint
only when the galea or epicranius is divided c. Atlanto-axial joint
transversely.
7. Atlanto-axial joint (2, 3) [11 July, 09 July]
VIII iv. Loose tissue or fourth layer is called dangerous
8. Atlanto occipital joint (2)[06 June]
area of scalp: Because, an infection in the
9. Sphenomandiublar ligament (2) [10 July]
subaponeurotic space with accumulation of Pus,
may spread readily into intracranial sinuses
Temporomandibular Joint (TMJ)
through emissary vein (devoid of valves)
[KU 2008, 2007, 2005, 2004, 2003]
v. Pericranium: Collection of fluid beneath this layer
produces localized swelling in the form of 1. Type: Synovial Joint
cephalohaematoma or traumatic cephalohydrocele. 2. Subtype: Bicondylar (Both joints move as one unit)
3. Articular Parts: [KU 2005]
JOINTS a. Bone:
Past Questions: i. Above
1. Describe the type and internal subdivision of the - Articular tubercle
temporo-mandibular joints. Name the muscles - Anterior articular part of the mandibular
producing its different movements. fossa of temporal bone.
(1+3=4) [03 Nov] ii. Below: Head or condyle of mandible
2. Name the components of the temporo- b. Articular surface: Fibrocartilage
mandibular joint. Mention the muscles, which
c. Articular disc:
are involved during openings of the mouth at
these joints and their mechanism of actions. i. Upper menisco-temporal compartment.
(2+1+2=4) [08 July] ii. Lower menisco-mandibular compartment.

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8. Muscles Producing Movements: [KU 04, 03, 08]

Movement of
Muscle (s)
Mandible
1. Elevation - Temporalis, masseter and
(closing Medial pterygoid.
mouth)
2. Depression - Prime mover: Lateral pterygoid.
(opening - Assists: Geniohyoid, Mylo-hyoid,
mouth) Digastric
3. Protrusion - Simultaneous action of lateral
4. Ligaments: (Protrude and medial Pterygoid.
a. Capsular ligament with synovial membrane. chin)
b. Articular disc 4. Retrusion - Prime mover: Posterior fibers of
c. Lateral or temporo-mandibular ligament. (Retrude chin) Temporalis.
d. Accessory ligaments: - Assists: Deep and middle fibers
i. Spheno-mandibular ligament of masseter, Digastric and
ii. Stylomandibular ligament. Geniohyoid.
5. Arterial Supply:
5. Side-to-side - Contraction of lateral and
a. Branches of superficial temporal artery
b. Branches of Maxillary artery. movement medial pterygoid of one side,
6. Nerve Supply: (Lateral or acting alternately with other
Grinding and side. VIII
a. Auriculo temporal (Posterior division of
Mandibular) chewing)
b. Masseteric Branch (Anterior division of
Mandibular)
7. Relations of Joint:
a. In front: Lateral pterygoid, temporalis and
masseteric vessels and nerves.
b. Behind:
- Parotid gland
- Superficial temporal vessels
- Auriculo-temporal nerve
- External acoustic meatus
c. Laterally: Subcutaneous
d. Medially:
- Lateral Pterygoid
- Roots of auriculo-temporal nerve enclosing
middle-meningeal artery.
- Spine of spheroid and sphenomandibular
ligament.
- Chorda tympani nerve
e. Above: floor of cranial fossa.

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Note: i. Transverse axis for hinge movement:

- Maximum range of opening of Jaw is 50mm. Depression and elevation of mandible.
- Functional range of opening is 40mm (25 mm by ii. Vertical axis for side to side movement.
rotation and 15 mm by anterior translatory gliding) c. Both Compartments participate in: Depression,
- Maximal ranges of Protrusion and lateral elevation and side to side chewing.
displacement are about 10 mm each. Note: The force of impact by the occlusion of teeth of
9. Mechanism of Movements: [KU 08, 05, 04] both jaws during mastication ranges between 150 to
300 pounds.
a. Menisco-temporal compartment allows
rotation or gliding movements in Protrusion, Applied Aspects:
Retrusion and in chewing.
- Dislocation of Mandible takes place in forward
b. Menisco-mandibular compartment allows direction only (mainly during wide opening of
rotation around 2 independent axes: mouth i.e. yawning)

Major Joint (Cranio-Vertebral Joints) [KU 2009, 2007, 2006, 2005]

Atlanto-occipital Joints Atlanto-axial Joints [KU 09, 07, 05]
[KU 07, 06] Median Lateral
1. No. of Joints Paired Single Paired

2. Types Synovial

3. Subtypes Ellipsoid Pivot Plane

4. Articular surface
VIII
i. Upper Occipital condyle Anterior arch of atlas Inferior articular facet of
atlas
ii. Lower Superior articular facets of atlas. Dens or odontoid Superior articular facet of
process of axis. axis
5. Ligaments i. Capsular ligament i. Transverse i. Capsular ligament
ii. Anterior atlanto-occipital membrane ligament ii. Anterior longitudinal
iii. Posterior atlanto-occipital membrane ii. Apical ligament ligament
iii. Alar ligament iii. Ligamentum flavum

6. Nerve Supply C1 nerve C2 nerve

7. Movements i. Flexion: Rectus capitis anterior, longus i. Rotation: Obliquus capitis inferior, rectus
and muscles capitis and sternocleidomastoid (together) capitis posterior major and splenius capitis of
involved ii. Extension: Recti capitis, posterior major and one side acting with sternocleidomastoid of
minor, obliquus capitis superior, opposite side.
semispinalis capitis, Splenius capitis and
upper part of trapezius.
iii. Lateral flexion: Rectus capitis lateralis,
semispinalis capitis, splenius capitis,
sternocleidomastoid & upper part of trapezius.

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Note: Longus Coli, longus capitis, scalenes and deep

i. Atlano-occipital Joints are called "Joints of Yes" cervical muscles)
and Atlanto-axial Joints are called "Joints of No" B. Carotid sheath:
(negative expression) - Tubular investment of deep cervical fascia
ii. Ligaments joining axis with Occipital bone: - Formed by pretracheal fascia anteriorly and
a. Membrana tectoria prevertebral fascia posteriorly.
b. Cruciate ligament - Contains:
c. Apical ligament of dens i. Common and internal carotid arteries.
d. Alar ligament ii. Internal Jugular vein
iii. Applied: Death by judicial hanging may be due to iii. Vagus nerve
rupture of the transverse ligament of atlas or iv. Some deep cervical lymph nodes.
fracture of dens of axis. Thus, atlas is dislocated
Note:
from axis and compresses the spinal cord.
- Axillary sheath is formed by the tubular
prolongation of Prevertebral fascia.

DEEP FASCIA OF NECK / DEEP C. Function:

CERVICAL FASCIA / FASCIA COLLI i. To provide containment of muscles and viscera
in compartments with varying degree of
Past Question:
rigidity.
1. Write short notes on deep cervical fascia. ii. To provide the slipperiness that allows
[3] [KU 2013 (BDS)] structures to slide over each other.
A. Distribution: iii. To serve as a conduit for the passage of
- Posses 3 layers from outside inwards: neurovascular structure. VIII
i. Investing fascia: Applied Aspects:
- Attaches to the cranium superiorly and - The carotid sheath is frequently exposed in block
pectoral girdle inferiorly. dissection of the neck during surgical remove of
deep cervical lymph nodes.
- Includes the superficial muscles (trapezius and
- Pus may be collected in the retropharyngeal space
sternocleidomastoid)
due to acute pyogenic infection which may extend
- Is the most superficial deep fascial layer, into
surrounds the entire neck deep to the skin and i. Mediastinum (downward)
subcutaneous tissue.
ii. Posterior border of sternomastoid (laterally)
ii. Pretracheal fascia: iii. Posterior wall of pharynx and produce
- Limited to anterior part of neck. Paramedian swelling.
- Surrounds the cervical viscera and the extrinsic
musculature associated with it (suprahyoid and
infrahyoid muscle) TRIANGLES OF NECK
iii. Prevertebral fascia: Past Question:
- Confined to posterior part of neck. 1. Draw a neat and labeled diagram to show the
- Surrounds the musculoskeletal elements of boundaries of the triangles of the neck.
neck including the cervical vertebra (Muscles: [5] [02 June]

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VIII
Sub divisions:
ANTERIOR TRIANGLES OF NECK
a. Muscular (a pair)
Past Question:
b. Carotid (a pair)
1. Mention boundaries and contents of carotid c. Digastric (a pair)
triangle of neck. (3) [10 July]
d. Sub-mental (single)
Boundaries:
A. Muscular Triangle
a. In front: Anterior median line of neck.
- Boundaries:
b. Behind: Anterior border of sterno-
i. Behind and above: Superior belly of
cleidomastoid.
omohyoid.
c. Base (directed above): Lower border of the
ii. Behind and below: Anterior border of
body of mandible.
sternocleidomastoid
d. Apex (directed below): Supra-sternal notch of
iii. Floor: Sternohyoid and sternothyroid muscles.
manubrium sterni.
iv. Infront: Anterior median line of neck.
e. Roof:
B. Carotid triangle: [KU 2010]
- Skin
a. Boundaries:
- Superficial fascia
i. In front and above:
- Platysma
- Posterior belly of digastric
- Investing layer of deep fascia
- Stylohyoid muscles
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 Head & Neck

ii. In front and below: Superior belly of omohyoid. - Occipital artery

iii. Behind: Anterior border of sternocleidomastoid. - Ascending pharyngeal artery.
iv. Floor: iii. Veins:
- Thyrohyoid - Internal Jugular vein
- Hyoglossus - Tributaries of internal Jugular vein:
- Inferior and middle constrictor of  Superior thyroid, lingual, common
pharynx. facial and pharyngeal.
b. Contents: [KU 2010]
iv. Nerves:
i. Common carotid artery and its 2 terminal
- CN X (Vagus), CN XI (Spinal part), CN XII.
branches:
- Cervical part of sympathetic trunk
- Internal carotid and
v. Other structures:
- External carotid arteries
ii. Branches of external carotid artery - Deep cervical lymph nodes: Jugulo-
digastric group and Jugulo-omohyoid
- Superior thyroid artery
group.
- Lingual artery
- Apex of the Parotid gland.
- Facial artery

VIII

C. Digastric triangle ii. Below and behind:

a. Boundaries: - Posterior belly of digastric
i. Above: Lower border of the body of - Stylohyoid muscles
mandible.

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iii. Below and in front: Anterior belly of POSTERIOR TRIANGLE OF NECK

digastric.
Past Questions:
iv. Floor: 1. Describe the boundaries floor and content of the
- Mylohyoid posterior triangle of neck. (4) [06 Dec]
- Hyoglossus 2. Name the muscle forming floor of posterior
triangle. Mention its contents. (5) [05 June]
- Middle constrictor of pharynx
3. Mention boundaries and contents of posterior
b. Sub divisions and contents: triangle of neck. (5) [11 July]
Anterior Part Posterior Part 4. Boundary, contents and division of posterior
triangle (5) [09 Dec]
1. Superficial part of 1. Lower part of parotid 1. Boundaries:
submandibular gland gland
i. Infront: Posterior border of sternocleidomastoid
2. Facial vein and 2. External carotid artery ii. Behind: Anterior border of trapezius.
submandibular iii. Base: Middle one-third of clavicle.
lymph nodes iv. Apex: Meeting Point of sternocleidomastoid and
3. Facial artery 3. Carotid sheath trapezius at superior nuchal line of occipital bone.
4. Mylohyoid vessel v. Roof:
and nerve a. Skin (outside)
b. Superficial fascia
5. Hypoglossal nerve
c. Platysma
(CN XII)
d. Investing layer of deep cervical fascia.
D. Sub-mental Triangle vi. Floor: [@Sc] [KU 2006, 2005]
VIII a. Boundaries: a. Semispinalis Capitis (apex)
i. Apex: Lower border of symphysis menti. b. Splenius Capitis
c. Levator Scapulae
ii. Base: Body of hyoid bone.
d. Scalenus posterior, medius and anterior.
iii. Sides: Anterior belly of the digastric muscle.
iv. Floor: Left and right mylohyoid muscles
meeting at median fibrous raphe.
b. Contents:
i. Sub-mental lymph nodes
ii. Anterior jugular vein (Just formed)
Applied Aspects:
- There are common swellings in anterior triangles:
i. Enlarged sub-mental lymph node and
sublingual dermoid (sub mental triangle)
ii. Thyroglossal cyst and inflamed subhyoid bursa
(below the hyoid bone)
iii. Goitre, carcinoma of larynx and enlarged
lymph nodes (in suprasternal region)

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2. Subdivisions [KU 2009]

Note:
- Inferior belly of omohyoid divides posterior - Accessory spinal nerve divides posterior triangle into:
triangle obliquely into: i. Upper carefree triangle
i. Upper large occipital triangle ii. Lower careful triangle: It is called so because it
contains important structures like brachial
ii. Lower small supra-clavicular triangle plexus, IIIrd and IVth cranial nerves, subclavian
vessels etc.
3. Contents: [KU 2011, 2009, 2006, 2005]
Contents Occipital triangle Subclavian triangle
A. Nerves 1. Spinal accessory nerve 1. 3 trunks of brachial plexus
2. 4 cutaneous branches of cervical plexus: 2. Nerve to sarratus anterior (long thoracic, C5,
a. Lesser occipital (C2) C6, C7)
b. Greater auricular (C2, C3) 3. Nerve to subclavius (C5, C6)
c. Anterior cutaneous nerve of neck (C2, C3) 4. Suprascapular nerve (C5, C6)
d. Supraclavicular nerves (C3, C4)
3. Muscular branches:
a. 2 small branches to the levator scapulae (C3, C4)
b. 2 small branches to the trapezius (C3, C4)
c. Nerve to rhomboideus (proprioceptive) (C5)
4. C5, C6 roots of the brachial plexus
B. Vessels 1. Transverse cervical artery and vein 1. 3rd part of subclavian artery and subclavian
2. Occipital artery vein
2. Suprascapular artery and vein
3. Commencement of transverse cervical VIII
artery and termination of the
corresponding vein
4. Lower part of external jugular vein
C. Lymph 1. Along the posterior border of the A few members of the supraclavicular chain
nodes sternocleidomastoid, more in lower part: the
supraclavicular nodes
2. A few at the upper angle : The occipital nodes.

Applied Aspects:
INFRATEMPORAL FOSSA
a. Boundaries:
- The most common swelling in posterior triangle is due i. Infront: Posterior surface of body of maxilla.
to enlargement of supraclavicular lymph nodes. ii. Behind:
- Supraclavicular lymph nodes are commonly - Styloid process of temporal bone
- Carotid sheath
enlarged in: iii. Medially: Lateral pterygoid plate.
i. Tuberculosis iv. Laterally: Ramus of the mandible and its
coronoid process.
ii. Hodgkin's disease v. Above: Infratemporal surface of greater wing
iii. Malignant growth of breast, arm or chest of sphenoid.
vi. Below (open): Continues with tissue space
along pharynx and oesophagus.

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b. Contents:  Contains:
i. Muscles: 1. Glands: Submandibular and sublingual glands.
- Lateral and medial pterygoid muscles. 2. Muscle:
- Lower part of temporalis. i. Suprahyoid muscles
ii. Nerve: ii. Extrinsic muscles of tongue like hyoglossus,
- Mandibular nerve and its branches. genioglossus and styloglossus.
- Chorda tympani nerve. 3. Nerve: Lingual and Hypoglossal (CN XII)
- Otic ganglion and its connections. 4. Ganglion: Submandibular
iii. Vessels: 5. Arteries: Lingual and part of the facial arteries.
- Maxillary artery and its branches.
- Pterygoid venous plexus.
PAROTID REGION
 Forms the bed for the parotid gland.
PTERYGO-PALATINE FOSSA  Fascial lined space
a. Boundaries: Contains:
i. Infront: Posterior surface of the body of 1. Parotid gland: Largest serous salivary gland.
maxilla. 2. Facial nerve (CN VII)
ii. Behind: Anterior surface of the root of Applied Aspects:
pterygoid process of the sphenoid.
1. Parotid swellings are very painful due to
Note: unyielding nature of parotid fascia.
- Posterior wall of fossa presents 3 openings (lateral 2. Mumps is an infectious disease of the salivary
to medial): glands (usually parotid)
1. Foramen rotundum: For maxillary nerve.
2. Anterior opening of pterygoid canal: For MUSCLES
VIII pterygoid vessels and nerve Past Questions:
3. Palatino - vaginal canal: For pharyngeal vessels 1. Enumerate the muscles of mastication. Name the
and nerve. muscles that are involved in opening and closing
iii. Above: the mouth. (1+1+1=3) [06 Dec]
- Body of the sphenoid (medially) 2. Name the muscle of mastication, their nerve
- Communicate with orbit via inferior orbital supply and actions in a tabulated from.
fissure (laterally) (1+1+2=6) [08 Dec]
iv. Below: 3. Enumerate the muscles of mastication. Mention
- Anterior and posterior walls meet to form apex. different movements of tempero- mandibular
joint. Name the muscles producing the
- Greater palatine canal is present.
movements. (1+2+2=5) [03 June]
v. Medially: Perpendicular plate of Palatine bone.
4. Mention the attachments, nerve supply and
vi. Laterally: Communicates with infratemporal actions of the sternocleido-mastoid muscles.
fossa through the pterygo-maxillary fissure. Name the nerve, which are related to its
b. Contents: posterior border. (3+1=4) [03 Nov]
i. Maxillary nerve 5. Name the muscles of mastication of their actions.
ii. Pterygo-palatine ganglion and its connection. (1+1=2) [03 Nov]
iii. Third part of maxillary artery and its branches. 6. Buccinator (2) [09 Dec]
7. Muscles of mastication and their nerve supply
SUBMANDIBULAR REGION (2)[09 July]
 Extends from submandibular fossa of the body of 8. Medial pterygoid muscle (2) [11 July]
the mandible to the hyoid bone. 9. Lateral pterygoid muscle (2) [10 July]
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Muscle (s) Proximal attachment Distal Attachment Innervation Action

A. Muscles of mastication [KU 2011, 10, 09, 08, 06, 04, 03]
Temporalis Triangular muscle Narrow Via deep Elevates mandible,
with broad attachment to tip temporal closing jaws; posterior,
attachment to floor of and medial surface branches more horizontal fibers are
temporal fossa and of coronoid 10 retractors of mandible
deep surface of process and
temporal fascia anterior border of
ramus of mandible
Masseter Quadrate muscle Angle and lateral Via Elevates mandible,
attaching to inferior surface of ramus of masseteri closing jaws; superficial
border and medial mandible c nerve fibers make limited
surface of maxillary contribution to
process of zygomatic protrusion of mandible
bone and the
zygomatic arch
Medial pterygoid Quadrangular two - Medial surface of Via Acts synergistically with
[KU 2011] headed muscles from ramus of medial masseter to elevate
1. Medial surface of mandible, interior Anterior pterygoid mandible, contributes to
lateral pterygoid to mandibular trunk of nerve protrusion; alternate
plate and foramen; in mandibular unilateral activity
pyramidal process essence, a "mirror nerve (CN produces small grinding
and palatine bone image" of V3) movements.
and ipsilateral
2. Tuberosity of
masseter, two VIII
muscles flanking
maxilla
ramus
Lateral pterygoid Triangular two - Upper head Via lateral Acting bilaterally,
[KU 2010] headed muscles from attaches primarily pterygoid protracts mandible and
1. Infratemporal to joint capsule nerve depresses chin; acting
surface and crest and articular disc unilaterally, swings jaw
to greater wing of of TMJ; inferior toward contralateral side,
sphenoid and head attaches alternate unilateral
primarily to contraction produces
2. Lateral surface of
pterygoid fovea on larger lateral chewing
lateral pterygoid
anteromedial movements
plate
aspect of neck of
condyloid process
of mandible
B. Muscles of facial expression
Orbicularis oculi Medial orbital Skin around Via Closes eyelids; palpebral
(orbital sphincter) margin; medial margin of orbit; part does so gently;
palpebral ligament; superior and
Facial nerve
{Temporal
Zygomatic orbital part tightly
lacrimal bone inferior tarsal (CN VII) (winking)
plates

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Buccinator (cheek Mandible, alveolar Angle of mouth Via Buccal Presses cheek against
muscle) processes of maxilla (modiolus); molar teeth; works with
[KU 2009] and mandible, orbicularis oris tongue to keep food
pterygo-mandibular between occlusal
raphe surfaces and out of oral
vestibule; resists
distension (when
blowing)
Platysma Subcutaneous tissue Base of mandible; Via Depresses mandible
of infraclavicular and skin on cheek and cervical (against resistance);
supraclavicular lower lip; angle of branch tenses skin of interior
regions mouth (modiolus); face and neck (conveying
orbicularis oris tension and stress)
C. Muscles of Neck
Sternocleido- Lateral surface of Sternal head: Spinal accessory nerve Unilateral contraction:
mastoid mastoid process of Anterior surface of (CN XI, motor); C2 and Tilts head to same side
(Steromastoid) temporal bone and manubrium of C3 nerves (pain and (i.e. laterally flexes neck)
[KU 2003] lateral half of superior sternum proprioception) and rotates it so face is
nuchal line Clavicular head: turned superiorly toward
Superior surface of opposite side
medial third of Bilateral Contraction:
clavicle 1. Extends neck at
atlanto-occipital joints,
VIII 2. Flexes cervical
vertebrae so that chin
approaches
manubrium, or
3. Extends superior
cervical vertebrae
while flexing inferior
vertebrae so chin is
thrust forward with
head kept level
- With cervical
vertebrae fixed, may
elevate manubrium
and medial ends of
clavicles, assisting
pump-handle action of
deep respiration
Anterior scalene Transverse processes 1st rib Cervical spinal nerves Flex head: Anterior (or
of C3 - C6 vertebrae C4 - C6 lateral) bending of the
head relative to the
vertebral column at the
atlanto-occipital joints.

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Applied Aspects:
Scalenus anterior syndrome/Thoracic outlet syndrome:
- Resulting from excess pressure placed on a
neurovascular bundle passing between the
anterior scalene and middle scalene muscles.
- Signs and symptoms:
i. Pain is almost always present in arms and
hands.
ii. Decoloration of hands.
iii. One hand colder than other hand
iv. Weakness of arm and hand muscles.

BLOOD VESSELS
Past Question: B. External Carotid Artery
1. Mention the formation, termination and 1. Origin:
tributaries of internal jugular vein. (3) [08 Dec] - Is anterior terminal branch of the common
A. Common carotid artery carotid artery.
- Extends from the level of upper border of the
1. Origin:
lamina of thyroid cartilage to neck of mandible.
a. Right artery: Bifurcation of the brachiocephalic
trunk (Innominate Artery) 2. Course:
- It describes italic 'f' shaped curved course from
VIII
b. Left-artery: Arises directly from arch of aorta.
commencement to termination.
2. Course:
- At origin, the artery lies in the carotid triangle
- Each artery extends upwards and laterally
antero-medial to internal carotid artery.
within the carotid sheath.
- Ascends up by passing deep to posterior belly
- At the level of upper border of lamina of
of digastric and stylohyoid muscles and enters
thyroid cartilage, divides into
the parotid gland.
i. External carotid.
3. Termination and Branches:
ii. Internal carotid.
- Provides eight branches:
3. Termination:
a. Ascending pharyngeal (first branch)
- Bifurcation of the artery takes place in carotid
b. Superior thyroid
triangle opposite the disc between C3 and C4
c. Lingual
vertebra.
d. Facial
- Carotid sinus (Baro-receptor) is formed at the
bifurcation of common carotid artery. e. Occipital

- Carotid body (chemoreceptor) is a small, oval f. Posterior auricular

reddish-brown structure situated behind the g. Superficial temporal Terminal

bifurcation of common carotid artery. h. Maxillary  branches

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C. Internal Carotid Artery 4. Accessory meningeal artery

Branches: 5. Inferior alveolar (dental) artery
1. Cervical part: b. Second/Pterygoid Part: (4 branches)
- No branch 6. Deep temporal artery
2. Petrous Part: 7. Pterygoid branches
i. Carotico-tympanic branches 8. Masseteric artery
ii. Branches to pterygoid canal 9. Buccal artery
3. Cavernous Part: c. Third/Pterygo-palatine Part: (6 branches)
iii. Inferior hypophyseal arteries 10. Posterior superior alveolar (dental) artery
iv. Meningeal branch 11.Infra-orbital artery
4. Cerebral part: 12.Greater palatine artery
v. Superior hypophyseal arteries 13. Pharyngeal artery
vi. Ophthalmic artery 14. Artery of the pterygoid canal
vii. Posterior communicating artery 15. Spheno-palatine artery
viii.Anterior choroid artery E. Internal Jugular Vein [KU 2008]
ix. Anterior cerebral artery
1. Formation and Course:
x. Middle cerebral artery - Begins as continuation of sigmoid sinus at the
base of the skull in the posterior compartment
of the jugular foramen.
- At the commencement the vein presents
superior bulb which lodges in the Jugular fossa
of temporal bone.
VIII Note: Jugular fossa is related to the floor of tympanic
cavity.
- Course: The vein passes downward through
the neck within the carotid sheath.
2. Termination:
- Behind the medial end of the clavicle, it unites
with subclavian vein to form the corresponding
brachiocephalic vein.
- Near to the termination, it presents inferior
bulb (guarded by a pair of valves).
D. Maxillary Artery 3. Tributaries:
i. Inferior petrosal sinus (first tributary and
- Larger terminal branch of the external carotid.
communicates with cavernous sinus)
- The course of the artery is divided into 3 parts
ii. Pharyngeal vein
by lower head of the lateral pterygoid muscle.
iii. Common facial vein
Parts and Braches
iv. Lingual vein
a. First/Mandibular Part: (5 branches)
v. Superior thyroid vein
1. Deep auricular artery
vi. Middle thyroid vein
2. Anterior tympanic artery
vii. Occipital vein (sometimes)
3. Middle meningeal artery (artery of eipdural
hemorrhage)

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viii. Thoracic duct on left side or right lymphatic duct on right side.

VIII
ii. Deep cervical lymph nodes:
CERVICAL LYMPH NODES
- Are arranged along and around internal jugular
 They include nodes, superficial and deep to
vein.
sternocleidomastoid muscle and in the posterior
triangle. Level Lymph nodes Drainage region
i. Superficial group: Submental
I Face
- Lies along external jugular vein. Submandibular
- Drains into deep cervical lymph nodes.
II Upper lateral
Lymph nodes Drainage region Lateral group Nuchal region,
Retroauricular Jugular
III Middle lateral laryngo-tracheo
lymph
Occipital Occipital region group - thyroidal
nodes
Mastoid IV Lower Lateral region
group
Superficial parotid group
Parotid-auricular region
Deep parotid V. Lymph nodes in posterior
Nuchal region
Anterior superficial cervical triangle
cervical Stenocleidomastoid VI Anterior Cervical lymph Laryngo-tracheo-
Lateral superficial region
nodes thyroidal region
cervical
Subdivision:
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a. Jugulo-digastric nodes (upper groups) on left side.

b. Jugulo-omohyoid nodes (lower groups) ii. Right lymphatic
Jugulo-digastric Jugulo-omohyoid duct on right
nodes nodes side.

Note: Jugulo-digastric Jugulo-omohyoid

1. Location - Upper to - Lower to omohyoid
omohyoid muscle muscle. node act as nodes form the
Principal nodes of principal lymph
2. Afferents - Palatine tonsils - Directly from
the palatine nodes of the tongue
- Posterior one- tongue
tonsils.
third of tongue - Indirectly from: Sub-
mental, sub-
mandibular & upper
deep cervical nodes.

3. Efferents - Drains into lower - Drains into internal

group of deep jugular vein
cervical nodes. through
i. Thoracic duct

VIII

Applied Aspects: 3. Painful enlargement of the submandibular lymph

1. Superficial cervical and supraclavicular lymph nodes is common because infections in tongue,
nodes can easily be palpated. mouth and cheek are quite common.
4. Cancer from stomach and testis may metastasize
2. Enlargement of Jugulo-digastric lymph nodes is into left scalene node (Virchow's node) which may
caused by chronic infection of palatine tonsil. become palpable.

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SPECIAL POINTS FOR MCQs

1. Skin overlying the angle of mandible is supplied by great auricular nerve.
2. Lateral boundary of the orbit is the thickest boundary.
3. Nasolacrimal duct opens into anterior part of inferior meatus.
4. Levator palpebral superioris muscle separates the orbital and palpebral parts of the lacrimal
gland.
5. Inferior belly of omohyoid separates occipital triangles with subclavian triangle (supraclavicular
triangle)
6. Sternocleidomastoid separates anterior triangle with posterior triangle.
7. Clinical subdivision of posterior triangle into upper carefree and lower careful triangles; by
accessory spinal nerve. Because many important structures are located in lower careful triangle.
8. Left supraclavicular nodes or Virchow’s or scalene nodes are commonly involved in malignant
growth of distant organs.
9. Vertebral arteries, anterior and posterior spinal arteries, and spinal part of CN XI passes through
foramen magnum.
10. CN IX, X and XI passes through Jugular foramen.
11. Content of anterior condylar canal (Hypoglossal canal) is CN XII. VIII
12. Content of carotid sheath are common and internal carotid arteries, vagus nerve and internal
jugular vein but not external carotid artery.
13. Neck rigidity in meningitis is due to spasm of the extensor muscles of neck.
14. Thrombosis of the sigmoid sinus is always secondary to infection in the middle ear (otitis
media).
15. Superior belly of omohyoid is the content of anterior triangle while inferior belly of omohyoid is
of posterior triangle.
16. Thyroid cervical trunk and costocervical trunk are the branches of subclavian artery.
17. Deep cervical artery is the branch of costocervical trunk. [KU 13 MCQ]
18. Inferior thyroid artery is the branch of thyrocervical trunk (Superior thyroid is 2nd branch of
external carotid artery)
19. Death in execution by hanging is due to dislocation of the dens following rupture of the
transverse ligament of the dens, which crushes the spinal card and medulla.
20. Position of Vth nerve in cavernous sinus is anterolateral to the artery.
21. If III, IV, VI and ophthalmic nerves are paralyzed, the infection is localized to cavernous sinus.

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22. Supraorbital artery is a branch of ophthalmic and ophthalmic is a branch of internal carotid artery.
23. Ascending pharyngeal is first and only medial branch of external carotid artery.
24. Parotid gland is provided secretomotor fibres from inferior salvatory nucleus.
25. Lateral pterygoid muscles are used for opening of the mouth.
26. Membrana tectoria is the upward continuation of posterior longitudinal ligament.
27. All the constricting muscle of pharynx finally inserted to Median raphe of pharynx.
28. On its way to the tongue, lingual artery is crossed by hypoglossal nerve.
29. Facial artery is a branch of external carotid artery which enters the face by winding around base of
mandible and can be palpated over there k/a 'anesthetist’s artery".
30. Anastomotic point of external carotid artery and internal carotid artery (ICA) is at the 'medial
angle of eye' where terminal branches of facial artery (branch of external carotid) anastomoses
with ophthalmic artery (branch of ICA).
31. Sternocleidomastoid muscle is supplied by spinal accessary nerve.
32. Best site for lumbar puncture is in between L3 and L4.
33. Muscles of Mastication are developed from 1st branchial arch and is supplied by mandibular
nerve whereas all the muscle for facial expression is developed from 2nd branchial arch and
supplied by facial nerve.
34. Temporomandibular joint (condylar variety) is different from other synovial joint in a sense that
there articular surfaces are covered with fibrocartilage; Blood supply is by superficial temporal and
VIII
maxillary artery and nerve supply by Auriculotemporal nerve.
35. Dangerous area of face is an area above tip of nose up to upper lip and is named because of
connection of cavernous sinus to facial vein through superior ophthalmic vein.
36. Cavernous sinus drains into transverse sinus via superior petrosal sinus.
37. Falx cerebri is a large sickle shaped fold of dura mater between two cerebral fissure attached to
crista galli anteriorly and tentorium cerebelli posteriorly.
38. Falx cerebri is a vertical, sagittally placed fibrous septum that separates two cerebral hemispheres.
39. Tentorium cerebelli (tent shaped fold of dura mater) is horizontally placed and separates
cerebellum from occipital lobes of cerebrum.
40. Parotid glands receive secretomotor fibers from inferior salivatory nucleus whereas nasal,
lacrimal and submandibular gland receives fibers from facial nerve.
41. Chorda tympani is branch of facial nerve that carries taste sensation from ant. 2/3rd of tongue;
posterior 1/3rd by glossopharyngeal nerve and from larynx by CN X.
42. Main signs of Horner's syndrome are Ipsilateral ptosis, miosis and anhydrosis.
43. Temporo-mandibular joint is synovial bicondylar joint but covered by fibrocartilage.
44. Median atlanto-axial joint is Pivot joint while lateral atlanto-axial joint is Plane synovial joint.

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45. Atlanto–occipital, Incudo–malleolar and Incudo–stapedial joints are Synovial joints.

46. Inferior petrosal sinus is first tributary of Internal Jugular vein.
47. The first and last tributaries of internal jugular vein are peculiar because the former is venous
sinus and the latter is lymphatic duct.
48. Internal Jugular vein acts as a guide for surgeons during removal of deep cervical lymph nodes.
49. Internal Jugular vein may require a ligature to prevent the spread of septic embolic from infected
tympanic cavity.
50. 4th layer of scalp i.e. loose connective tissue is the most dangerous layer of scalp.
51. First 3 layers of scalp acts as a single unit.
52. Scalp is the common site for formation of sebaceous cysts.
53. Minor scalp injury produces profuse bleeding.
54. Epicranius: Occipito-frontalis and Temporo-parietalis.
55. Operation on the scalp should be preferably done under general anesthesia.
56. The scalp is the site of free anastomosis between the branches of external and internal carotid
arteries.
57. Vertebral artery is a branch of 1st part of subclavian artery.
58. Cervical part of internal carotid artery gives no branches.
59. Right common carotid artery arises from brachiocephalic trunk while left arises directly from arch
of aorta. VIII
60. Carotid sinus and carotid body are situated at the bifurcation of common carotid artery.
61. Maxilla is 2nd largest facial bone.
62. Maxillary sinus is largest sinus and 1st sinus to appear.
63. Zygomatic bones (Quadrangular-shaped) are ossified in membrane.
64. Remnant of the metopic suture of frontal bone in some skull may persist at glabella.
65. Parietal foramen transmits an emissary vein of scalp into superior sagittal sinus.
66. Unossified membranous gap, at 4 angles of parietal bones – known as fontanelles.
67. Petrous part of Temporal bone contains trigeminal impression (Meckel's cave) for CN V.
68. Sphenoid bone is an unpaired pneumatic irregular bone.
69. Mandible is largest and strongest facial bone.
70. In fetal skull, Facial skeletal = 1/7 of cranium.
71. Anterior fontanale is largest and diamond shaped where pulsation of cerebral artery occurs.
72. Zygomaticus major is muscle of smiling and laughing while Buccinator and orbicularis oris are
muscles of whistling.

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73. Chief action of mentalis is on suspecting doubt.

74. Lingual artery divided into 3 parts by– Hyoglossus
75. Ciliary ganglion is located in orbit.
76. Pulsation felt just above zygomatic arch and in front of ear is in superficial temporal artery.
77. The hiatus semilunaris receives drainage from – maxillary sinus.
78. The thickest cutaneous nerve of head is Greater occipital nerve.
79. Parotid duct pierces the muscle – Buccinators.
80. Fascial covering eye ball is – Tenon's capsule.
81. The only sensory nerve in anterior division of mandibular nerve – Buccal nerve.
82. The lymphoid aggregation of nasopharynx is adenoid.
83. Sub-mental lymph node usually receives Lymph from tip of tongue.
84. Sheath of thyroid gland is derived from carotid sheath.

VIII

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