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Lab 1
Skull
Neck I and II
Face
Cranial cavity
THE SKULL
Objectives
Be able to identify all major bones of the skull: frontal, temporal,
occipital, parietal, maxillary, mandible (also individual parts), in both
skulls and basic radiographic films.
Realize the presence of bony sinuses which may not be directly
visualized on the intact skull, but may be seen in radiographs.
Know all major foramina through which pass cranial nerves, blood
vessels, spinal cord.
Lab 2-
NECK I
Objectives
Know the boundaries and contents of the triangles of the neck, especially
the submandibular triangle.
Know the superficial and deep nerves of the neck and what is innervated.
Know the branches of the external carotid artery.
Know the relationship of longitudinal structures in the neck to each
other.
Know the fascial planes of the neck.
Grants
10th, fig. ;
Clementes
4th, fig 704
fascia.
.
The vertebral fascia is subdivided into prevertebral and vertebral. The
prevertebral fascia attaches between the anterior tubercles of the transverse
vertebral processes with intermediate attachments to the body of the vertebrae. The
remaining vertebral fascia attaches between the anterior tubercle of the transverse
process and the spinous process. A subdivision of the prevertebral fascia is the alar
fascia which attaches to the anterior tubercles of the cervical vertebrae. The carotid
sheath is formed by contributions from the three fascial layers, i.e., deep investing
fascia, prevertebral and visceral fasciae.
The retropharyngeal space is posterior to the pharyngeal and visceral fasciae and
anterior to the alar fascia. The retropharyngeal space is continuous inferiorly to the
posterior mediastinum.
Between the alar and vertebral fasciae is the "danger space", which is continuous to
the diaphragm. Between the vertebral fascia and the vertebrae is the prevertebral
Posterior Triangle
The posterior triangle is the area of the neck bordered by the
posterior margin of the sternocleidomastoid muscle, the
anterior margin of the trapezius muscle and the intermediate
third of the clavicle (removed earlier). The deep (investing)
fascia of the neck forms a tough roof for this region; the fascia
extends across the posterior triangle from the posterior border
of the sternocleidomastoid to the anterior border of the
trapezius.
Dissect:
Thespinal accessory nerve lies below the deep fascia in
the posterior triangle. The nerve crosses the triangle obliquely, appearing
at the mid-point of the posterior border of the sternocleidomastoid
muscle, then passing out of view under the edge of the trapezius muscle
close to the lower third of its anterior border. Note the position of the
nerve in your atlas and its innervation of the sternocleidomastoid and the
trapezius muscles. What are the actions of these muscles? Because
the nerve frequently lies very deep and can be difficult to locate, please
wait and identify it later after reflecting the sternocleidomastoid.
Examine the greater auricular nerve, which runs on the
sternocleidomastoid, parallel and posterior to the external jugular vein
towards the angle of the mandible. The nerve supplies the back of the
auricle and the skin from the angle of the mandible to the mastoid
process. Look for the transverse cervical nerve which runs
transversely across the middle of the sternocleidomastoid, and supplies
the skin of the anterior triangle of the neck. These two nerves may
contribute innervation to the vestibule of the mouth, and occasionally
Posterior
triangle
Anterior
triangle
Clavicle
Cut the external jugular vein in half and reflect the superior half
towards the head and the inferior half downwards. Separate the
sternocleidomastoid muscle from the surrounding fascia and cut
it in half transversely, about 5cm above the sternum, reflecting one
half superiorly and the other inferiorly.
You should now see the posterior (inferior) belly of the
omohyoid muscle which passes deep to the sternocleidomastoid
muscle. The omohyoid muscle is attached to the hyoid bone in the
anterior part of the neck, runs inferiorly and laterally under the
sternocleidomastoid muscle, and appears in the posterior triangle
immediately above the clavicle, and running parallel to it.
Omorefers to shoulder; the omohyoid attaches inferiorly to the
superior border of the scapula.
Follow the omohyoid muscle from the hyoid bone down to the floor of
the posterior triangle. If you have not yet identified the spinal
accessory nerve innervating the sternocleidomastoid and trapezius
muscles, try to do so now. The spinal accessory should be seen
entering the deep surfaces of the sternocleidomastorid and trapezius
muscles. Do not spend too much time looking for the nerve, but ask
for help from an instructor if you dont see it.
Anterior Triangle
Observe: The anterior triangles are enclosed laterally by
the two sternocleidomastoid muscles; superiorly, by the
lower border of the mandible; and medially by the
anterior midline of the neck. This area contains the
visceral compartment of the neck (containing the larynx,
esophagus, and trachea) which freely communicates with
the mediastinal compartment of the thorax.
Identify by Palpation: Before beginning your dissection
of the anterior triangle, identify the following landmarks,
both on yourself and your cadaver. Palpate the soft
tissues of the floor of the mouth, starting under the lower
border of the mandible at the chin, and continuing
posteriorly. Deep in the tissues just below the floor of the
mouth, the hyoid bone can be located through firm, but
gentle palpation between your index finger and thumb.
Note that the bone seems to disappear when you swallow;
it is actually elevated and drawn posteriorly during
swallowing.
Inferior to the hyoid bone is the upper border of the
thyroid cartilage, a bilaminar structure with a
characteristic median notch along its superior border. In
the midline, just inferior to the notch, is the pronounced
thyroid prominence (Adam's apple). The thyroid
cartilage also moves up and down during swallowing.
Continue to follow the angle of the thyroid cartilage
below the prominence until you can feel the space which
separates the thyroid cartilage from the cricoid cartilage;
the crico-thyroid ligament fills this space between the
cricoid and thyroid cartilages. You can feel changes in the
height of this space as you change the pitch of your voice
over a wide range. Emergency cricothyrotomy can be
done by piercing this ligament and introducing a tube to
form an artificial airway. Tracheotomy tubes will be
provided during class which you should use to try this
Grants 10th,
fig. 8.23, 8.46
Netters 2nd,
fig. 68, 71
Clementes 4th,
fig. 711-713,
695
A. Muscular Triangle
Dissect:
The space below the hyoid bone is subdivided into
two muscular triangles containing the strap muscles
arranged in two layers. The superficial layer on each side
consists of the sternohyoid medially, and the anterior
(superior) belly of the omohyoid laterally. The deeper layer
consists of the sternothyroid and thyrohyoid muscles; to
expose these deep muscles transect the sternohyoid at its middle,
and reflect the cut ends. The strap muscles cover the thyroid
gland; they are innervated by the cervical plexus nerves (C1 C3) through the ansa cervicalis.
Grants 10th,
fig. 8.26
Netters 2nd,
fig. 24, 68
Clementes 4th,
fig. 706
Grants 10th,
fig. 8.3
Netters 2nd,
fig. 23
Clementes 4th,
fig. 693, 700,
706-708
10
Sternocleidomastoid
Submandibilar tr.
Occipital tr.
Submental tr.
CN XI
Carotid tr.
Muscular tr.
Supraclavicular triangle
B. Carotid Triangle
Dissect:
This small, bilateral triangle is bounded by the
anterior belly of the omohyoid, the sternocleidomastoid, and
the posterior belly of the digastric muscles. Major structures
located within this triangle include internal ande xternal
carotid arteries, hypoglossal nerve, and internal
jugular vein.
Grants 10th,
fig. Table 8.2,
8.13, 8.12B
Netters 2nd, fig
23-4, 26-7
Clementes 4th,
fig. 701,702,
706,707
11
NECK II
Deep Dissection of the Neck
The deep structures of the neck can best be
examined after the sternocleidomastoid muscles have
been reflected. This should have already been done.
Carotid Sheath
Dissect:
Examine the contents of the carotid
sheath, deep to the sternocleidomastoid muscle. The sheath
12
Grants 10th,
fig. 8.12B-.13;
Netters 2nd,
fig. 65
Clementes
4th, fig. 701
13
14
Thyroid Gland
Dissect:
Cut the strap muscles transversely
and reflect them from the surface of the thyroid gland to expose the
two lobes and isthmus of the gland. The lobes extend superiorly to
the oblique line of the lamina of the thyroid cartilage, and inferiorly
to the level of the sixth tracheal ring. The trachea and esophagus
are adjacent to the medial surface of each lobe.
Expose the recurrent laryngeal nerve as it runs superiorly
in the gutter between the lateral surfaces of the trachea and
esophagus. Superior to the trachea and esophagus,the lateral lobes
of the thyroid gland are adjacent to the cricoid and thyroid
cartilages of the larynx, and to the inferior constrictor muscles of
the pharynx. The posterior border of the gland is related to the
carotid sheath. The isthmus of the gland, connecting the two
lateral lobes, overlies the 2nd, 3rd and 4th tracheal rings; inferior
to the isthmus the trachea is subcutaneous, covered only by loose
connective tissue and the inferior thyroid veins. A tracheotomy is
usually performed inferior to the isthmus of the gland; however, it
is sometimes necessary to split the isthmus to gain access to the
trachea.
The parathyroid glands are embedded in the connective
tissue on the posterior surface of the thyroid gland, usually two on
each side superiorly and inferiorly. In the cadaver they are difficult
to distinguish grossly from thyroid tissue. Do not spend time
looking for them.
15
Grants 10th,
fig. 8.26,
8.30-.31
Netters 2nd,
fig. 68-70
Clementes
4th, fig. 703,
715
16
17
18
19
Facial nerve.
After emerging from the base of the skull, the facial
nerve turns anteriorly and runs through the parotid gland,
where it divides into the branches (temporal, zygomatic,
buccal, mandibular, cervical) which innervate the muscles of
the face.
The facial nerve is the ONLY motor supply to the facial muscles, and
is also sensory to the taste buds on the anterior two-thirds of the
tongue, as well as providing parasympathetic innervation to the
submandibular and sublingual glands. Bells Palsy is a common
problem of the facial nerve, usually temporary, which causes loss of
function of the nerve.
20
The facial vein provides the major venous drainage of the face. It has
important connections with the cavernous sinus (inside the cranial
cavity) through the superior and inferior ophthalmic veins, and with
the pterygoid plexus (in the infratemporal fossa) through the deep
facial vein. Since it has no valves, blood containing potential
infection or clots can pass from the facial region to the inside of the
cranial cavity.
21
Orbital region
Dissect: The circular fibers of the orbicularis oculi. This
consists of two portions: a thick orbital part surrounding the
orbital margin which is responsible for the tight closure of the eye,
and a thin palpebral portion in the eyelids involved in the
blinking of the eye. Do not spend time dissecting the
palpebral portion unless you have extra time.
The levator palpebrae superioris is the muscle which opens the
eye by lifting the eye lid. (It is innervated by the oculomotor
nerve, III.)
Sensory nerves of the face
Dissect: Examine the sensory nerves of the face which are
derived from the three divisions of the trigeminal nerve:
22
Grants 10th,
fig. 7.18A
Netters 2nd,
fig. 94
Clementes
4th, fig. 765-6
Grants 10th,
fig. 7.18-.21
Netters 2nd,
fig. 96-7
Clementes
4th, fig. 765-7
Grants 10th,
fig. 7.22-.23
Netters 2nd,
fig. 7, 112
Clementes
4th, fig. 77780
23
Just lateral to the internal carotid arteries identify the rather larger
oculomotor nerves, and still slightly more laterally the thinner trochlear
nerves; cut these nerves on both sides. Also in this general region, identify
the single midline infundibulum of the pituitary gland which connects the
gland to the hypothalamic region of the brain. If this delicate structure has
not already been torn, cut it.
The large trigeminal nerves exit the brainstem at the level of the
pons, then enter the dura high in the anterior wall of the posterior cranial
fossa. In their subdural course, they run along either side of a median bony
ridge in the middle cranial fossa, the body of the sphenoid bone. Locate
these nerves, and cut them.
Identify the tentorium cerebelli. This dural sheet is firmly attached
to the lateral walls of the calvarium, then anteriorly at the boundary
between the middle and posterior cranial fossae (the petrous portion of the
temporal bone on both sides),and lastly, to the posterior clinoid processes
of the sphenoid bone near the midline. A midline opening in the "tent-like"
tentorium allows passage of the brainstem . Carefully cut through the bony
attachments of the tentorium and expose the cerebellum and caudal portion
of the brainstem.
Sever the attachments of the remaining cranial nerves and cut the
brainstem transversely as far caudally as possible.
Identify the two vertebral arteries as they enter the cranial cavity
through the foramen magnum; cut these arteries just before their union at
the lower border of the pons, forming the basilar artery.
Remove the hemispheres and brainstem in one piece. Examine the
following cranial nerves where they exit from the brainstem and where they
enter the dura:
abducens nerve, piercing the dura covering the posterior surface of
the clivus
Grants 10th,
fig. 6.11
Netters 2nd,
fig. 130-133
Clementes
4th, fig. 773-6
Grants 10th,
fig. 7.22-.23
Netters 2nd,
fig. 98
Clementes
4th, fig. 773,
778
Grants 10th,
fig. 6.11
Netters 2nd,
fig. 399
Clementes
4th, fig. 777
Grants 10th,
fig. 7.23
Netters 2nd,
fig. 98
Clementes
4th, fig.777
Grants 10th,
fig. 7.23, 7.4
Netters 2nd,
fig. 98, 7
Clementes
4th, fig.777, 780
24
cavity. For a very short distance, it joins the cranial component of the
accessory nerve to exit the cranial cavity through the jugular
foramen. The two components again separate, and the spinal
accessory nerve runs independently through the posterior triangle of
the neck (note: the CRANIAL portion of the accessory nerve joins
the vagus nerve and is distributed with that nerve's branches; some
authors consider the cranial portion of the accessory to be part of the
vagus).
hypoglossal nerve, formed from a series of rootlets arising in the
medulla, this nerve exits the skull via the hypoglossal canal, located
at the base of the skull next to the articular condyles for the joint
with the first cervical vertebra.
The Neurosciences program in year II has requested that we preserve
the brains form the cadavers for use in that course next fall. Please
follow the instructions for removal of the brain, or ask an instructor
to assist you.
At the end of the lab period, place the brain from your cadaver into the
bucket of fixative provided in each room, unless it is inadequately
presreved.
After you have attempted to identify the cranial nerves of the posterior fossa
with the brain and brainstem in place, remove the brain and brainstem from
the cadaver in the following manner:
Place several fingers of one hand under the frontal lobe of the brain and
lift it off the floor of the cranial cavity until you can see the inclined
surface of the clivus upon which the brainstem rests. (This is only
possible if you have previously slit open the tentorium cerebelli on each
side.)
Use your other hand to slide a scalpel down the surface of the clivus to
the level of the foramen magnum, or slightly more distal into the
vertebral canal if possible.
Use a side-to-side movement of the scalpel to transect the spinal cord.
Remove the scalpel and lift the brain and brainstem out of the cranial
cavity. Use the scalpel to section any remaining attachments of cranial
nerves, blood vessels, etc. as you lift the brain out of the cavity. Put the
brain aside for any additional study.
25
The dura mater consists of two fused layers: the endosteum of the
cranial cavity and the dura mater proper. The two layers are fused, except in
certain locations where they form the walls of the dural venous sinuses. These
sinuses receive blood from the brain, but they also connect with superficial
veins of the scalp and face and veins draining other regions of the head (orbit).
Grants 10th,
fig. 6.11;
Clementes 4th,
fig. 399;
Netters 2nd,
fig. 18, 20.
Examine:
Refer to your atlas to review in the dried skull and cadaver the course of the
following major dural venous sinuses
Opthalmic vv.
Superior
sagittal
Inferior
sagittal
Cavernous
Superior
petrosal
Inferior
petrosal
Great cerebral
vein
Sigmoid
Tentorium
cerebelli
Sigmoid
Straight
Int. jug. v.
Transverse
Tentorium
Straight
Transverse
Superior
sagittal
26
Grants 10th,
fig. 7.19;
Clementes 4th,
fig. 767-8;
Netters 2nd,
fig. 97-8.
Grants 10th,
fig. 7.19,7.40;
Clementes 4th,
fig. 770;
Netters 2nd,
fig. 98.
Dissect:
Slit open the superior sagittal sinus and examine its interior. Look for the
arachnoid granulations, the site of return of the cerebrospinal fluid from the subarachnoid
space to the venous system. Also look for lateral evaginations of the endothelial lining of the
sinus, the lateral lacunae, where veins from the cortical region of the brain open into the
Grants 10th,
fig. 7.19, 7.23;
Clementes 4th,
fig. 767-8;
Netters 2nd,
fig. 97-8.
Grants 10th,
fig. 7.15;
Clementes 4th,
fig. 767-8;
Netters 2nd,
fig. 92.
Grants 10th,
fig. 7.18, .19 ;
Clementes 4th,
fig.766,765 ;
Netters 2nd,
fig. 94,96.
27
(4th cranial) and the ophthalmic division (first division) of the trigeminal (5th)
cranial nerve in the lateral wall of the sinus. The internal carotid artery runs through the
cavity of the sinus, together with the abducens (6th cranial) nerve; the nerve is below the
artery, and both are separated from the blood by the endothelial lining of the sinus.
Grants 10th,
fig. 7.23, 7.39 ;
Clementes 4th,
fig.770,773;
Netters 2nd,
fig. 98.
Grants 10th,
fig. 7.23,7.4;
Clementes 4th,
fig.777, 779;
Netters 2nd,
fig. 98.
Grants 10th,
fig. 7.41;
Clementes 4th,
fig.770;
Netters 2nd,
fig.98, 114.
Grants 10th,
fig. 7.4;
Clementes 4th,
fig.780;
Netters 2nd,
fig. 6.
Grants 10th,
fig. 7.4;
Clementes 4th,
fig.780;
Netters 2nd,
fig. 6.
Grants 10th,
fig. 7.17;
Clementes 4th,
fig. 766, 777;
Netters 2nd,
fig. 95.
28
Grants 10th,
fig. 7.4;
Clementes 4th,
fig. 780;
Netters 2nd,
fig. 6-7.
optic canal
hypophyseal fossa
anterior and posterior clinoid processes
dorsum sellae.
Grants 10th,
fig. 7.18 ;
Clementes 4th,
fig.765 ;
Netters 2nd,
fig. 96.
Pia-Arachnoid
Realize:
The arachnoid is a delicate membrane, loosely covering
the surface of the brain, and bridging over the sulci intervening
between adjacent gyri. The arteries of the brain run in the
subarachnoid space, bathed in cerebrospinal fluid; therefore,
subarachnoid hemorrhages can be detected early by examination of
the cerebrospinal fluid. The pia mater intimately covers the outer
surface of the brain, dipping down into the dividing fissures and sulci.
Arteries and Veins of the Brain
Realize:
Veins of the brain are mostly cortical, and drain into the
neighboring dural venous sinuses. Veins from the interior of the brain
drain into the great cerebral vein of Galen, which empties into the
straight sinus posterior to the splenium of the corpus callosum.
Grants 10th,
fig. 7.21;
Clementes 4th,
fig.767 ;
Netters 2nd,
fig. 96, 103
The arterial supply of the brain comes from two main sources:
two vertebral arteries and
two internal carotid arteries.
The vertebral artery, a branch of the first part of the subclavian
artery, ascends through the foramina transversaria of the upper six
cervical vertebrae, then enters the cranial cavity through the foramen
magnum. The two vertebral arteries unite at the lower border of the
pons to form a single basilar artery. The latter divides opposite the
upper border of the pons into two posterior cerebral arteries. The
posterior cerebral artery winds around the brainstem, supplying the
tentorial surface of the hemisphere and the occipital lobe; it is
connected to the internal carotid by the posterior communicating
artery.
Grants 10th,
fig. 7.36 ;
Clementes
4th, fig.775-6;
Netters 2nd,
fig. 130-33.
29
the sinus, gives rise to the ophthalmic artery, then divides at the
base of the brain into anterior and middle cerebral arteries.
The anterior cerebral artery passes forward and medially, to the
median fissure of the brain where it is distributed to the medial surface
of the cerebral hemisphere, except for the occipital lobe. It also supplies
the orbital surface of the brain, and a small strip of the lateral surface.
The two anterior cerebral arteries are connected by the anterior
communicating artery.
The middle cerebral artery enters the lateral fissure of the brain,
supplying the cortex of the insula and lateral surface of the brain, except
for the occipital lobe, and a strip next to the superior border which is
supplied by the anterior cerebral. Therefore, the middle cerebral artery
supplies that portion of cortex which controls the opposite side of the
body, except for regions controlling the movements of the leg and foot,
which are supplied by the anterior cerebral artery.
Posterior Cranial Fossa
Examine:
This space houses the cerebellum and the caudal portion of the
brainstem (pons and medulla, collectively called the hindbrain). The
tentorium cerebelli separates the contents of the fossa from the occipital lobes
of the cerebral hemispheres. The foramen magnum lies in the midline, just
posterior to the basilar part of the occipital bone. The jugular foramen,
hypoglossal canal, and internal acoustic meatusare easily identifiable.
Identify the grooves for the transverse andsigmoid sinuses , just
posterior to the lateral margin of the petrous portion of the temporal bone. In
this location, the sigmoid sinus is related laterally to the mastoid air cells.
In the cadaver, reveiw the blood supply of the dura mater as follows:
middle meningeal artery, a branch of the maxillary artery, this vessel
passes through the foramen spinosum, pierces the outer layer of the
dura and proceeds in the plane between the two dural layers, dividing
into anterior and posterior branches. The anterior branch of the middle
meningeal artery is clinically important as it can be cut by a depressed
fracture of the bone,s near the pterion, a common cause of extradural
hemorrhage
The circle of Willis is a system of anastomotic arteries
connecting the internal carotid and vertebral arteries; it consists of the
posterior cerebral arteries (from the basilar arteries), posterior
communicating arteries, internal carotid arteries, anterior cerebral
arteries, and anterior communicating artery(s). It is located at the base
of the brain in the interpeduncular cistern, an expanded region of the
subarachnoid space These communications ensure an adequate supply
Grants 10th,
fig. 7.4, 7.23 ;
Clementes 4th,
fig. 779-80;
Netters 2nd,
fig. 6-7, 98.
30
Grants 10th,
fig. 7.17, .18 ;
Clementes
4th, fig. 777;
Netters 2nd,
fig. 95.
31
Lab 5
Objectives:
Be able to identify parts of the skull in the temporal region and
mandible.
Know the muscles, arteries and nerves in the region of the
parotid.
Know function and destination of the facial nerve branches
emerging from the parotid gland.
Know the venous routes to the interior of the skull.
Know the organization of the muscles of mastication (temporal,
masseter, medial and lateral pterygoids) and their actions.
Know the organization of the temporomandibular joint and its
movements.
Know the limits and contents of the infratemporal fossa,
including its arterial supply. Know the organization and course
of the trigeminal nerve branches to upper and lower teeth.
Skull review
Review on a skull the following landmarks:
temporal bone- styloid process, mastoid process, external
acoustic meatus, mandibular fossa (for the head of the mandible),
articular tubercle
mandible- head, neck, angle, ramus and mandibular notch
base of skull (exterior)- stylomastoid foramen (foramen through
which VII exits the skull)
zygomatic arch- composed of the zygomatic process of the
temporal bone and the temporal process of the zygomatic bone
temporal fossa- space formed by several bony components:
parietal and frontal bones, squamous part of temporal bone and greater
wing of sphenoid bone
Parotid gland
Dissect: The parotid gland should be cut away carefully as much as possible to
expose, embedded in it, the trunk of the facial nerve, the terminal part of the
external carotid artery, and the retromandibular vein. To find the facial trunk,
clean the sternocleidomastoid up to the mastoid process. Reflect it and push the
remaining parotid gland forward. Hold it in this position and push upward
32
Clementes
4th,
figs.935,936
Grants 10th,
fig. 7.65 ;
Clementes
4th, figs,.749,
750 ;
Netters 2nd,
fig.35 .
Grants 10th,
fig. 7.8 ;
Clementes
4th, fig.731.
33
Z. ARCH
MANDIBLE
Observe: Now with the temporal fascia exposed, note that the
temporal muscle arises partly from the fascia, and inserts into the
coronoid process of the mandible.
Infratemporal Region
The infratemporal fossa contains muscles of mastication (the
medial and lateral pterygoids), branches of the mandibular nerve
(V3), and the maxillary vessels. The lateral wall of the fossa is the
ramus of the mandible, which will need to be removed in order to
gain access to the space.
Observe: Begin by reviewing the following bony landmarks on
a skull:
1. On the inner aspect of the mandible:
coronoid process
lingula for the attachment of the sphenomandibular
ligament
mandibular foramen for the inferior alveolar nerve and
vessels
mylohyoid groove, for the nerve and vessels to the
mylohyoid and anterior belly of the digastric
2. In the infratemporal fossa (after removing the mandible from the
skull):
lateral pterygoid plate of sphenoid bone
pterygopalatine fossa, a cleft for passage of nerves and blood
vessels
infratemporal surface of maxilla
Grants 10th,
fig. 7.62 ;
Clementes 4th,
figs.750-754 ;
Netters 2nd,
fig. 9.
34
Dissect:
Make three saw cuts through the mandible according to
the diagram. After cut one, reflect the coronoid process upward with the
attached temporal muscle, looking deep to the muscle for nerves and
arteries. The second saw cut must be above the lingula, in order not to
cut the inferior alveolar nerve and vessels, which enter the foramen
below the lingula on the medial aspect of the center of the ramus (see
figure below).
Identify the inferior alveolar nerve and artery within the
infratemporal fossa. Trace the nerve downward (with the inferior
alveolar artery) to the mandibular foramen and canal, and upward to the
lower border of the lateral pterygoid muscle. Locate the mental nerve and
artery exiting from the mental foramen. Starting at the mental foramen
use the hand drill to remove the outer table of the mandible over the
mandibular canal and expose the nerve and as much of the inferior dental
plexus to the teeth as possible. Note the branches of the nerve and arteries
MANDIBLE
35
pterygoid from the roof. Then define the lower border of the muscle by
inserting the handle between the lateral and medial pterygoids., where the
inferior alveolar and lingual nerves emerge. Free the muscle from the lateral
pterygoid plate. Finally, sever the muscle close to its insertion into the neck of
the mandible and into the articular disc and remove the muscle completely.
Now clean the medial pterygoid muscle. It arises from two heads, one
from the maxillary tuberosity and palatine bone, the other from the pterygoid
fossa. The muscle runs downward and laterally to be inserted into the medial
side of the ramus of the mandible.
Now examine the structures in the infratemporal fossa in detail:
inferior alveolar and lingual nerves, branches of the trigeminal,
carrying sensation generally from the mandibular teeth and tongue,
respectively
chorda tympani , a branch of the facial nerve carrying taste fibers
from the tongue; it joins the lingual nerve from behind
buccal nerve, its branches pierce the buccinator to supply the
buccal mucosa with sensory fibers
maxillary artery, identify two branches, the inferior alveolar
artery and the middle meningeal artery
muscular branches of maxillary a. to muscles of mastication
(most of these have probably been torn or cut)
posterior superior alveolar nerve and artery, pass through
foramena on the maxilla. The nerve originates from the main trunk of
the maxillary nerve just before it enters the infraorbital canal. One
branch of the nerve may remain external on the bone, continuing
downward to innervate the buccal gingiva in the maxillary molar region
and nearby facial mucosal surfaces, and another enters the posterior
superior alveolar canal to travel through the maxillary sinus and
innervate its mucous membrane. This branch continues on to provide
sensation to the maxillary first, second, and third molars.
branches in the infraorbital canal - these cannot be seen now,
but are the origin of the middle and anterior superior alveolar nerves.
The middle superior alveolar nerve (MSA) provides sensation to the
two maxillary premolars and possibly the mesiobuccal root of the first
molar as well as the periodontal tissues, buccal soft tissue, and bone in
the premolar region. When this nerve is absent (about 30-50% of
individuals), these areas are supplied by branches of the anterior
superior alveolar nerve (ASA). The ASA nerve branches off the
Grants 10th,
fig. 7.65 ;
Clementes 4th,
fig.750, 751.
Clementes
4th,fig. 738.
36
Grants 10th,
fig. 7.58A ;
Clementes
4th, figs.740744;
Netters 2nd,
fig. 11.
37
Lab 6
Objectives:
Be able to identify structures located around the pharynx
(nerves, arteries).
Know the fascial spaces of the neck.
Know the pharyngeal constrictor muscles and their
attachments.
Know the structures of the nasal cavity and the openings which
connect the nasal fossae to the different sinuses.
Know the arterial supply and innervation to the nasal mucosa,
and the contents and location of the pterygopalatine fossa.
Know the muscles and nerves involved in opening and closing
the larynx.
The major goal of the following dissection is the separation of the
anterior part of the skull, face, pharynx, and larynx from the posterior
part of the skull which articulates with the vertebral column. Only
then is it possible to complete a thorough study of the visceral
compartment of the neck.
Dissect:
Refer to the following illustration of the cranial floor to
understand the placement of the saw and chisel cuts necessary for separation
of the anterior and posterior portions of the cranium.
IAM
JUG. FOR.
FOR. MAGNUM
When using the chisel, be careful to direct the chisel edge so as
to make a vertical cut in relationship to the anatomical position; a
38
Start by cutting along the suture line between the body of the
sphenoid bone and the basilar portion of the occipital bone.
Continue the cut laterally on each side, keeping just posterior to the
jugular foramen, (jug. for.) until you reach the suture between the
temporal bone and the occipital bone. Stay anterior to the foramen
magnum (for. magnum).With a saw, cut the two sides of the skull
vertically, posterior to the mastoid process. Use a chisel and hammer to
cautiously separate the two parts of the skull ; use a scalpel to cut the soft
parts (skin and muscle) along a vertical plane passing just behind the
mastoid process (be careful to stay behind the neurovascular bundle
of the neck and the sympathetic trunks). Reflect the anterior portion
of the cranium and attached neck viscera onto the anterior thoracic wall.
The plane of separation should lie in the retropharyngeal space. The
prevertebral musculature should remain attached to that portion of the
skull still articulated with the vertebral column, and the neurovascular
bundles of the neck should remain attached to the posterior surface of the
viscera of the neck.
It is now possible to examine the posterior aspect of the viscera of the
neck.
Grants 10th,
fig. 8.36;
Clementes 4th,
pl. 892;
Netters 2nd,
fig. 65.
39
Pharynx
Dissect: Clean the posterior surface of the pharyngeal constrictor
muscles and observe the pharyngeal plexus of nerves. The plexus
derives its fibers from three sources:
pharyngeal branches of the vagus nerve, provide motor
fibers to the constrictors of the pharynx
glossopharyngeal branches, are sensory to the mucosal
lining of the pharynx
sympathetic branches, are vasoconstrictor.
Superior pharyngeal
constrictor
Middle pharyngeal
constrictor
Inferior pharyngeal
constrictor
Grants 10th,
fig. 8.36 ;
Clementes 4th,
fig. 892 ;
Netters 2nd,
fig. 56
Lateral pterygoid
plate
Buccinator
Mandible
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Esophagus
Grants 10th,
fig. 8.34-.36;
Clementes 4th,
fig. 888, 891;
Netters 2nd, fig.
61-62.
40
follows:
laryngopharynx, the portion of the pharynx located
posterior to the larynx, it merges with the esophagus anterior
to the 6th cervical vertebra. Its anterior wall is marked by the
leaf-like epiglottis, situated posterior to the tongue. The
epiglottis guards the obliquely positioned aperture of the
larynx. Extending inferiorly along each side of the laryngeal
aperture are the piriform fossae. Two branches of the vagus,
the internal and recurrent laryngeal nerves, pierce the walls of
the laryngopharynx to innervate the larynx. These nerves lie
deep to the mucosa in the piriform fossae and will be
examined later.
oropharynx, the part of the pharynx posterior to the oral
cavity; it can be shut off from the nasopharynx by the elevation
of the soft palate, an action normally occurring during
swallowing of food or fluid with the contraction of the levator
veli palatini muscle. In the oropharynx, observe the
palatoglossal and palatopharyngeal folds, (overlying the
palatoglossal and palatopharyngeal muscles); the palatine
tonsil is located in the depressed area between the two folds.
Although these tonsils are large and bulging in children, in
adults the site of the tonsil is marked by crypts and no bulging
should be expected. The bed of the tonsil is related to the
superior constrictor muscle, and deeper still to the facial
artery. The anterior wall of the oropharynx is the posterior
portion of the tongue.
Think about the nasopharynx as described here, but realize
that most of it will be more visible after you have cut the face
in the sagittal plane as outlined in the section Nasal Fossae
to follow. Proceed to make the sagittal cut and then
continue with the nasopharynx examination.
nasopharynx, located posterior to the two nasal fossae and
septum, and extending to the base of the skull superiorly.
Anteriorly it communicates with the nasal fossae via the
choanae (apertures) which are separated from one another by
the posterior margin of the nasal septum. The roof of the
nasopharynx in children contains aggregations of lymphoid
tissue, the nasopharyngeal tonsil. The openings of the
auditory tubes are the main features of the nasopharynx; each
opening produces a tubal elevation opposite the posterior end
Grants 10th,
fig. 8.37,
8.50;
Clementes
4th, figs.
893,898;
Netters 2nd,
fig. 60-1,70.
Grants 10th,
fig. 8.39-.40,
8.43;
Clementes 4th,
figs. 830;
Netters 2nd,
fig. 54,58
41
Grants 10th,
fig. 7.82-.88 ;
Clementes 4th,
fig. 826-32,
837-41;
Netters 2nd,
fig. 32-4,42-4 .
Grants 10th,
fig. 7.82.84,7.87-.88 ;
Clementes 4th,
fig. 826, 832 ;
Netters 2nd,
fig. 32-3 .
42
Clementes 4th,
fig. 863.
Grants 10th,
fig. 8.46-.47;
Clementes 4th,
fig. 899-907;
Netters 2nd,
fig. 71.
43
Grants 10th,
fig. 8.56;
Clementes 4th,
fig. 908-10;
Netters 2nd,
fig. 57,72.
44
Lab 7
ORAL CAVITY
Objectives:
Know the bones, nerves, and arteries of the oral cavity
and palate.
Know the location and function of the Eustachian tube.
Know the limits of the vestibule and the oral cavity
proper.
Know what structures can be palpated around the
mouth, both inside and outside.
Know where to locate the major nerves for anesthesia
inside the oral cavity (nerves from both maxillary and
mandibular trunks of the trigeminal).
Know the spaces of the face and neck which allow
passage of infection.
Be able to identify major structures (bones, arteries and
nerves, etc.) in cross-sectional drawings of the head
through the occlusal plane.
Know the location of the pterygomandibular raphe in
yourself and your cadaver, and its relationship to
injections of the inferior alveolar nerve.
45
Dissect: In order to expose the sublingual gland, make a thin cut in the
mucous membrane just medial to the mandible, and lateral and inferior
to the tongue and retract the tongue medially to separate the tongue
from the mylohyoid muscle. (Do not extend the cut posterior to the
second molar.) Now you will be able to expose the sublingual gland,
submandibular gland and duct, lingual and hypoglossal nerves, and
extrinsic muscles of the tongue.
Identify:
Sublingual gland- identify several short ducts which open at the
plica sublingualis.
Submandibular duct- runs diagonally across the medial aspect
of the sublingual gland. Find the papilla of the duct lateral to the
frenulum linguae, then follow the duct posteriorly to the
submandibular gland.
Lingual nerve- find the nerve behind the last molar running
between the ramus of the mandible and the medial pterygoid
and trace it forward into the floor of the mouth. It should be
followed downward across the muscles of the tongue deep to the
sublingual gland where its terminal branches originate. These are
sensory nerves to the anterior 2/3 of the tongue. It also carries
the taste fibers originating from the chorda tympani (of the VII
nerve) for taste on the anterior 2/3 of the tongue.
Submandibular ganglion- In the region of the 3rd molar look for
the submandibular ganglion which is suspended from the lingual
nerve by several short branches.
Dissect:
From the lateral side, identify the mylohyoid muscle and detach it
from the hyoid bone; reflect it superiorly to expose the hyoglossus
muscle. Identify the hypoglossal and lingual nervesfrom this side.
Notice that the hypoglossal nerve is situated between the
submandibular gland and hyoglossus muscle, inferior to the lingual
nerve. Follow it to the tongue musculature. Locate the lingual artery
medial to the hyoglossus muscle and follow it to the tongue.
46
Tongue
The tongue has a tip, body, and base. On its superior, or palatine
surface observe the V-shaped terminal sulcus that separates the
body from the base. In front of the terminal sulcus are 8 to 12
circumvallate papillae; behind the sulcus, the surface of the
tongue appears irregularly folded due to the presence of bumps
and depressions representing accumulations of lymphoid tissue,
collectively called the lingual tonsil.
Note that the lingual tonsil, palatine tonsils, and lymphoid
nodules in the thickness of the soft palate form a complete ring of
lymphoid tissue around the oropharyngeal isthmus.
In a similar fashion, the nasopharyngeal tonsil in the
pharyngeal vault, lymphoid tissue near the opening of the
auditory tube (tubal tonsil), and lymphoid nodules in the
thickness of the soft palate, all contribute to a ring of lymphoid
tissue around the choanae (the opening of the nasal cavity into
the nasopharynx).
Look for the following features on the tongue of the
cadaver, as well as on your own:
Sulcus terminalis- divides the anterior two thirds and
the posterior one third
Foramen cecum- at the site of the embryonic
thyroglossal duct that was attached to the developing
thyroid gland
Fungiform papillae- mushroom-shaped papillae that
appear to be red spots in your tongue
Filiform papillae- sensitive to touch
Circumvallate papillae- located anterior to the sulcus
terminalis
Glossoepiglottic fold- running from the tongue to the
epiglottis, with the valleculae located on either side
Lingual tonsils- lymphoid follicles on the posterior
third of the tongue
Palate
Review on a skull:
The base of the nasal cavity is formed by the bony palate,
which is composed of, anteriorly, the palatine process of the
maxilla, and, posteriorly, the horizontal plates of the palatine
bones. Behind the incisor teeth at the midline of the hard palate
Grants 10th,
fig. 7.83;
Clementes 4th,
fig. 860;
Netters 2nd, fig.
52.
47
48