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Skull and Face Boonsirm Withyachumnarnkul, M.D., Ph.D. Department of Anatomy, Faculty of Science Mahidol University Bony Landmarks of Skull and Face • • • • • • Vertex Superciliary arch Zygoma Mental symphysis Entrance to orbit Anterior nasal aperture Three foramina vertically alligned • Supraorbital foramen … for supraorbital nerve • Infraorbital foramen … for infraorbital nerve • Mental foramen ... for mental nerve Muscles of Facial Expression • Develop from the 2nd branchial arch, thus all are supplied by CN VII. • Most are thin, originate from facial bones to insert on facial skin, except platysma, and are intermingled at their insertions. Muscles of Facial Expression • Muscle of the forehead … frontalis, as part of the occipitofrontalis • Muscles of the mouth • Muscle of the eyelids • Muscle of the nose • Platysma Muscles of the Mouth • • • • • • • • • • • Orbicularis oris Zygomaticus major Zygomaticus minor Levator labii superioris Levator labii superioris alaque nasi Buccinator Depressor anguli oris Depressor labii inferioris Mentalis Risorius Platysma Muscles of the Mouth Muscle of the Eyelids • Orbicularis oculi – Orbital part – Palpebral part Buccal Pad Fat • Between masseter and buccinator muscles • Brown fat … for heat generation, especially for children Parotid Duct • One finger-breadth below zygomatic arch • Open into the mouth cavity (vestibule) at the level of the 2nd molar tooth (crown) Facial Nerve • Comes out from stylomastoid foramen • Five branches – – – – – Temporal Zygomatic Buccal Mandibular Cervical Facial Palcy • No wrinkle of forehead • Angle of mouth drops • Sagging lower eyelid • Other signs relating to malfunctions of structures innervated by facial nerve Trigeminal Nerve • Sensory – Ophthalmic division – Maxillary division – Mandibular division • Motor .. To 1st branchial arch – Muscles of mastication • Messeter • Temporalis • Medial pterygoid • Lateral pterygoid Arteries of the Face (rich, tortuous and highly anastomosed) • From external carotid artery – Facial artery – Superficial temporal artery – Transverse facial artery • From internal carotid artery – supraorbital artery – supratrochlear artery Veins of the Face • Two important veins – Facial vein – Retromandibular vein • Facial veins have no valves • Connection of facial veins, pterygoid plexus and cavernous sinus Lymph Drainage of the Face • Submental lymph nodes • Submandibular lymph nodes • Parotid lymph nodes Scalp, Cranial Cavity and Venous Sinuses Boonsirm Withyachumnarnkul, M.D., Ph.D. Department of Anatomy, Faculty of Science Mahidol University Head2.ppt in C (Mahidol) Scalp • Five layers of scalp – skin – dense subcutaneous tissue – epicranial aponeurosis – loose areolar connective tissue – periosteum Scalp • Clinical relevance – infection spreading from loose areolar connective tissue, via emissary veins, to meninges-meningitis – hematoma Skull Cap or Calvaria • Suture – coronal (frontoparietal) • anterior fontanelle – sagittal (interparietal) – lambdoid (occipitoparietal) • posterior fontanelle Skull Cap or Calvaria • Three layers of skull cap – outer table – diploe – inner table Cranial Fossae • Anterior cranial fossa • Middle cranial fossa • Posterior cranial fossa • Boundaries – lesser wing of sphenoid – superior border of petrous bone Anterior Cranial Fossa • important landmarks – crista galli & cribriform plate of ethmoid – sella turcica • tuberculum sellae • hypophyseal fossa • dorsum sellae Middle Cranial Fossa • important landmarks – foramina • • • • superior orbital fissure foramen rotundum foramen ovale foramne spinosum – groove for middle meningeal artery Posterior Cranial Fossa • important landmarks – grooves for transverse & sigmoid sinuses – foramen magnum Dura Mater • Outer and inner layers – position of the middle meningeal artery Dura Mater • • • • Falx cerebri Falx cerebelli Tentorial cerebelli and notch Diaphragmatic sellae Intradural Venous Sinuses • • • Superior and inferior sagittal sinuses Straight sinus Transverse and sigmoid sinuses Intradural Venous Sinuses • Cavernous sinus – relationship among internal carotid artery, CN III, CN IV, CN V1 and CN VI – venous connections – clinical relevance • thrombophlebitis Orbit and Eye Boonsirm Withyachumnarnkul, M.D., Ph.D. Department of Anatomy, Faculty of Science Mahidol University Eye From the Outside •eyelids •palpebral fissure •plica semilunaris •caruncle •lacrimal puncta •cornea •sclera •conjunctiva •bulbar •palpebral •Sty •pterygium Bony Parts of the Orbit Entrance of the Orbit •frontal bone •zygomatic bone •maxillary bone More Bones Inside •ethmoid bone •greater and lesser wing of sphenoid •lacrimal bone Foramina of the Orbit •optic foramen (canal) •optic n. •ophthalmic a. •superior orbital fissure •all other nerves •superior ophthalmic vein •inferior orbital fissure •infraorbital n. & a. •inferior ophthalmic v. •infraorbital groove & foramen •zygomatic & infraorbital n. •supraorbital notch & foramen •supraorbital n. Eyeball Eyeball Muscles •Extrinsic (Extra-ocular) •Intrinsic Levator Palpebrae Superioris •Supplied by CN III •insert on the upper lid ptosis •if paralyzed Extra-Ocular Muscles • • • • Superior Rectus Inferior Rectus Lateral Rectus Medial Rectus • Superior Oblique • Inferior Oblique Actions of the Extra-Ocular Muscles • Around vertical axis – medial or adduction – lateral or abduction • Around horizontal axis – upward or elevation – downward or depression • Around antero-posterior axis – medial rotation – lateral rotation Superior Rectus Make a 10-15 o with an AP axis adduct medial rotate elevate Inferior Rectus depress adduct lateral rotate Medial and Lateral Recti Medial Rectus •adduction Lateral Rectus •abduction Superior Oblique •depress •abduction •medial rotate Inferior Oblique •elevate •abduction •lateral rotate Periorbita and Orbital Fat Insertions of the Extra-Ocular Muscles Nerves of the Extra-Ocular Muscles • Oculomotor Nerve (CN III) – supplies all except lateral rectus and superior oblique • Trochlear Nerve (CN IV) – superior oblique • Abducens Nerve (CN VI) – lateral rectus Oculomotor nerve (CN III) Superior Division • levator palpebrae superioris* • superior rectus Inferior Division • inferior rectus • inferior oblique • medial rectus *not an extra-ocular muscle Functional Tests of the Extra-Ocular Muscle Principle •align the muscle axis with the eyeball AP axis •contract the muscle e.g., for Superior Rectus •abduct, first •then, elevate Therefore, test for the superior rectus function is to abduct and elevate Parts of the Eyeball Three layers •sclera •choroid •anterior chamber •retina •posterior chamber •cornea •iris •ciliary muscle •suspensory ligament •lens •hyaloid canal •vitreous body •aqueous humor Clinical Relevance •lenticular cataract •glaucoma •Schlemn’s canal •Myopia (near sightedness) •hyperopia (far sightedness) •presbiopia (old-aged sightedness) Blood Vessels of the Orbit & Eyeball Ophthalmic •Frontal •anterior & posterior ethmoidal •supraorbital •supratrochlear •lacrimal •central retinal in the choroid layer Ophthalmoscopic Examination •optic disc •macula lutea & fovea centralis •retinal vessels in DM & hypertension Veins of the Eyeball •superior & inferior ophthalmic veins •drained to cavernous sinus •connection to pterygoid plexus •connection to facial veins Sensory Nerves of the Eyeball and Orbit •frontal •supraorbital •supratrochlear •lacrimal nerve •nasociliary nerve •anterior ethmoidal •posterior ethmoidal •infratrochlear Autonomic Nerves of the Eyeball and Orbit Sympathetic post-ganglionic sympathetic fibers artery (ophthalmic a) long ciliary n. eyeball iris (radial fibers) Parasympathetic pre-ganglionic parasympathetic fibers (in the nerve to ciliary ganglion short ciliary n. inferior oblique) Eyeball ciliary muscle & iris (circular fibers) Ciliary Ganglion Lacrimal Gland and Lacrimal Apparatus •Lacrimal puncta •lacrimal canaliculi •lacrimal sac •nasolacrimal duct •opening into the inferior meatus of nasal cavity Parasympathetic Supply to the Lacrimal Gland Preganglionic parasympathetic fibers maxillary n zygomatic branch lacrimal n lacrimal gland pterygopalatine ganglion zygomatico-temporal branch Eyelid •upper & lower eyelids •conjunctiva •palpebral fissure & palpebral sac •tarsal plates (superior & inferior) •tarsal muscle & nerve (sympathetic n) •tarsal gland & ciliary gland; Meibomitis & sty •attachment of levator palpebrae superioris Orbital Septum, Medial & Lateral Palpebral Ligament Submandibular Region, Nasal Region and Oral Cavity Boonsirm Withyachumnarnkul, M.D., Ph.D. Department of Anatomy, Faculty of Science Mahidol University Head 6. ppt in C (Mahidol) Submandibular Region • • • • • • • Inferior border of mandible Suprahyoid muscles Including submandibular triangle Submandibular gland Nerves – lingual – hypoglossal – mandibular branch of CN VII Blood vessels – lingual – facial Lymph nodes, submandibular lymph nodes Submandibular Triangle • Anterior belly of digastric muscle – Origin, digastric fossa of mandible – Nerve, nerve to mylohyoid (CN V) • Posterior belly of digastric muscle – Origin, mastoid notch – Nerve, CN VII • Inferior border of mandible Actions of Digastric Muscle • Elevate hyoid bone • Open jaw • Raising floor of mouth for swallowing reflex Suprahyoid Muscles • • • • • Digastric Mylohyoid Geniohyoid Hyoglossus Stylohyoid Mylohyoid Muscle • Origin, mylohyoid line of mandible • Insertion – Body of hyoid bone – Median fibrous raphe • Nerve, nerve to mylohyoid (CN V) Geniohyoid Muscle • Origin, mental spine • Insertion, hyoid bone • Nerve, C1 spinal nerve Hyoglossus Muscle • From hyoid bone to side of the tongue • Nerve, hypoglossal nerve Stylohyoid Muscle • Origin, styloid process • Insertion, hyoid bone (two slips) • Nerve, CN VII Concerted Action of Suprahyoid Muscles Elevate floor of mouth for swallowing reflex Submandibular Gland • superficial part • deep part • the two parts are separated by mylohyoid muscle • mixed serous and mucous gland • submandibular duct – from deep part – open at sublingual caruncle Anatomical Relationship • Hypoglossal and lingual nerves are between mylohyoid and hyoglossus muscles • Closed relationship between lingual nerve and submandibular duct Chorda tympani • special sense (taste) from anterior 2/3 of tongue • preganglionic parasympathetic fibers to submandibular and sublingual gland, via submandibular ganglion The Nasal Region • • • • • Nostrils Vestibule Nasal cavity Choanae Nasal septum – Cartilage, septal cartilage – Bone • perpendicular plate of ethmoid • vomer • maxillary & palatine Lateral Wall of the Nasal Cavity Chonchae • superior, part of ethmoid • middle, part of ethmoid • inferior, separate bone Lateral Wall of the Nasal Cavity Meatuses • sphenoethmoidal recess, opening of sphenoidal sinus • superior, opening of posterior ethmoidal air cells • middle – bulla ethmoidalis, opening of middle ethmoidal air cells – hiatus semilunaris, opening of • maxillary sinus • anterior ethmoidal air cells • frontal sinus, infundibulum • inferior, opening of nasolacrimal duct • common meatus Nerves of the Nasal Cavity • Special sense, olfactory n. "olfactory mucosa" • General sense, "respiratory mucosa" – branch of nasociliary n. • anterior ethmoidal n. – branches of maxillary n. • nasopalatine n. • posterior superior lateral nasal n. • posterior inferior lateral nasal n. • Test of olfactory function Third Part of the Maxillary Artery • superior alveolar a. – posterior – anterior, from infraorbital a. • infraorbital a. • descending palatine a. – greater palatine a. – lesser palatine a. • sphenopalatine a. Blood Supply of the Nasal Cavity • from sphenopalatine a. – posterior lateral nasal br. – posterior septal br. • from ophthalmic a. – anterior and posterior ethmoidal a Paranasal Air Sinuses • • Locations – frontal sinuses – ethmoidal air cells • posterior • middle • anterior – sphenoidal sinuses – maxilary sinus Functions – warm and humidify air – resonance Maxillary Nerve • out of the skull through foramen rotundum • branches – zygomatic n. • zygomaticotemporal n. • zygomaticofacial n. – infraorbital n., out from the infraorbital foramen – superior alveolar n.; anterior, middle, posterior – two small br. to pterygopalatine ganglion Pterygopalatine Ganglion In • pterygopalatine br. from maxillary n., general sense • nerve of pterygoid canal – parasympathetic – sympathetic Out • pterygopalatine br. to maxillary n., parasympathetic fibers to lacrimal gland • pharyngeal n. • greater and lesser palatine n. • superior and inferior lateral nasal n. • nasopalatine n Pterygopalatine Ganglion All the "out" branches supply • submucosal gland, parasympathetic • general sense • lacrimal gland, parasympathetic Mouth & Lips • • • • • • • • • • vestibule oral cavity proper nasolabial sulcus philtrum labial gland frenulum palatoglossal arch palatopharyngeal arch opening of parotid duct opening of submandibular & sublingual ducts The Teeth Types • incisor, 2 • canine, 1 • premolar, 2 • molar, 3 Nerves and vessels (to teeth and gingivae) • alveolar – superior (maxillary n. and a.) • anterior • middle • posterior – inferior (mandibular n., maxillary a.) • nasopalatine (maxillary n. and a.) • greater palatine (maxillary n. and a.) The Tongue • sulcus terminalis • foramen caecum • papillae – circumvallate – fungiform – filiform – foliform • lingual tonsil Muscles of the Tongue • Intrinsic – longitudinal – transverse – vertical • Extrinsic – hyoglossus – genioglossus (movement of tongue) – styloglossus – palatoglossus Artery & Nerves of the Tongue Artery • lingual a. Nerves • motor, hypoglossal n., except palatoglossus (vagus n.) • sensory – general, CN V, IX & X – special, CN VII (anterior 2/3) & CN IX (posterior 1/3), CN X The Palate • Hard palate • Soft palate, muscles – – – – – tensor veli palatini (CN V) levator veli palatini (CN X) musculus uvulae (CN X) palatoglossus (CN X) palatopharyngeus (CN X) • Clinical relevant – openning of auditory tube – test of CN X Blood Supply of Palatine Tonsil (important for tonsillectomy) from lingual a. • dorsal lingual a. from facial a. • tonsillar br. • ascending palatine a. from ascending pharyngeal a. • palatine br. lesser palatine a.
