Chaurasia's Human Anatomy Head, Neck and Brain, 6e - Bhagwan Din Chaurasia PDF

Sixth
Edition
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Contents
Preface to the Sirth Edition vil

Preface to the Firsf Edition (excerpts) VIII
Section K
I-Iii{rdduction qnd Osteology Noso/ Bones 48

Locrimol Bone 48
Skull 4 Hyoid Bone 49
Bones of the Skull 4 ClinicalAnatomy 50
Exterior of the Skull 5 TypicolCervicolVertebro 50
Normo Verticolis 5 First Cervicol Vertebro 5l
Clinical Anatomy 6 Second Ceruicol Vertebro 52
Normo Occipitolis 6 Seventh CervicolVertebro 53
Normo Frontolis 8 Clinical Anatomy 54
Clinical Anatomy 9 Ossificotion of Croniol Bones 55
Normo Loterolis I I Foromino of Skull Bones ond their Contents 56
Clinical Anatomy 12 Facts to Remember 58
Normo Bosolis 13 ClinicoanatomicalProblem 58
lnterior of the Skull 20 Multiple Choice Questions 58
Clinical Anatomy 23
Clinical Anatomy 24
The Orbit 27 .eir. . find Focc 59
Foetol Skull/Neonotol Skull 29 Scolp ond SuperficiolTemporol Region 60
Clinical Anatomy 30 Dissection 60
Croniometry 3l Clinical Anatomy 63
Mondible 3l Foce 64
Structure reloted to Mondible 34 The Fociol Muscles 66
Clinical Anatomy 35 Clinical Anatomy 69
Moxillo 35 Arteries of the Foce 7l
Porietol Bone 38 Dissection 7l
Occipitol Bone 39 Fociol Arlery 7l
Frontol Bone 40 Clinical Anatomy 73
Temporol Bone 4l Eyelids on Polpebrae 73
Sphenoid Bone 43 Dissection 73
Ethmoid Bone 45 ClinicalAnatomy 74
Vomer 46 Clinical Anatomy 75
lnferior Nosol Concho 46 LocrimolApporotus 75
Zygomotic Bone 47 Dissection 75
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HUMAN ANATOMY-HEAD_NECK AND BRAIN
t-ffi
! \i| I
tuj
Anatomy 76
Clinical 5. Porolid Region t06
Developmenl of Foce 77
Mnemonics 77 Porotid Glond 106
Facts to Rennernbsr 77 Dissection 106
ClinicoanatomicalProblems 77 Clinical Anatomy 107
Multiple Choice Questions 78 Relotions 107
Clinical Anatomy I l0
3. SIde of the Neck 79

Development I I I
Clinical Anatomy lll
The Neck 79 Facts to Remember I 12
Dissection 79 Clinicoanatomical Problem I l2
Clinical Anatomy Bl Multiple Choice Questions I 12
Deep Cervicol Foscio 8l
lnvesting Loyer Bl 6. Iempoil]l ond lnfrotemporol Regions n4
Clinical Anatomy 83
Pretrocheol Foscio 83 Temporol Fosso l14
Clinical Anatomy 83
lnfrotemporol Fosso I l4
Prevertebrol Foscio 83 Muscles of Mosticotion I l5
Clinical Anatomy 84
Dissection I l5
Moxillory Artery l19
Posterior Triongle 85
Dissection I l9
Dissection 85
Temporomondibulor Joint l2l
Clinical Anatomy 86
Clinical Anatomy 124
Contents of the Posterior Triongle 86
Mondibulor Nerve 125
Clinical Anatomy 88
Dissection 125
Sternocleidomostoid 89 Otic Gonglion 127
Phoryngeol Spoces 90 Mnemonics 129
Mnemonic 90 Fects to R*mernber 129
Fects to Remember 9l Clinicoanatomical Problem 129
Clinicoanatomical Problem 9l Multiple Choice Questions 130
Multiple Choice Questions 9l
7. $ubmsndibulor Region l3l
4. Antefior Triongle of the Neck 92
Suprohyoid Muscles l3l
Structure in the Anterior Medion Region of the Dissection l3l
Neck 93 Submondibulor Solivory Glond 133
Dissection 93 Dissection 133
Submentol ond Digostric Triongle 95 Comporison of Three Solivory Glonds 138
Dissection 95 Facts to Remember l3B
Anterior Triongle 95 Clinicoanatomical Problem l38
Corotid Triongle 98 Multiple Choice Questions 139
Dissection 98
Clinical Anatomy 100 8. $lrucluree in the Neck 140
Externol Corotid Artery 100 Glonds 140
Musculor Triongle 104 Dissection 140
Dissection 104 Thyroid Glond 140
Mnemonics 105 Histology 144
Facts to Ramernber 105 Development lU
Clinicoanatomical Problem 105 Clinical Anatomy 145
Multiple Choice Questions 105 Porothyroid Glonds 145
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. CONTENTS
il,
Clinical Anatomy 146 Dissection 179
Thymus 147 Clinical Anatomy l8l
Clinical Anatomy 147 Facts to Rernenrber l82
Blood Vessels l48 Clinicoanatomical Problem I 82
Dissection l48 Multiple Choice Questions 182
Subclovion Artery 148
Clinical Anatomy 150 I l. Gontent$ of Verlebrol Conol t83
Common Corotid Artery l5l
Dissection l5l Removol of Spinol Cord 183
Clinical Anatomy 152 Dissection I 83
Internol Corotid Artery 152 Clinical Anatomy l85
lnternol Jugulor Vein 153 Spinol Nerves 186
Cervicol Port of Sympothetic Trunk 154 Vertebrol System of Veins 187
Dissection 154 Fs.ts t0 Remember 187
Clinical Anatomy 156 Clinicoanatomical Problem 187
Lymphotic Droinoge of Heod ond Neck 156 Multiple Choice Questions 188
Dissection 156
Clinical Anatomy 159 12. Croniol Covity t89
Apporotus 159
Styloid
Development of Arteries 160
lntroductio n 189
F*cts to Rememb*r 160 Dissection 189
Clinicoanatomical Problem l6l Cerebrol Duro Moter 190
Multiple Choice Questions l6l Clinical Anatomy 192
Covernous Sinus 193
9 rPreverfebrol snd Poroverlebrol Regions Dissection 193
t62
Sinus
Superior Sogittol 195
Vertebrol Artery 162 Clinical Anatomy 195
Dissection 162 Sigmoid Sinuses 196
Scolenovertebrol Triongle 162 Clinical Anatomy 197
Scolene Muscles 165 Hypophysis Cerebri 197
Cervicol Pleuro 167 Clinical Anatomy 199
Cervicol Plexus 167 Trigeminol Gonglion 199
Phrenic Nerve 169 Dissection 199
Trocheo 169 Middle Meningeol Artery 201
Oesophogus l7l Croniol Fossoe 201
Clinical Anatomy l7l Dissection 201
Joints of the Neck l7l lnternol Corotid Artery 202
Clinical Anatomy 173 Petrosol Nerves 203
F*cts to Remember 174 Mnemonics 203
Clinicoanatomical Problems 174 fe$s t$ ftarnember 203
Multiple Chbice Questions 175 Clinicoanatomical Problems 243
Multiple Choice Questions 203
l0. BSek of lhe NEck t76
13. Conlents of lhe Odcit 205
The Muscles 176
Dissection 176 Orbits 205
Suboccipitol Triongle 179 Dissection 205
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nuMnN nNntdMy;nEno-t\Ecx nND :gnArrv
Extrooculor Muscles 206 Nosol Septum 240

Vessels of the Orbit 209 LoterolWollof Nose 242
Clinical Anatomy 2l I Conchoe ond Meotuses 243
Optic Nerve 213 Dissection 243
Ciliory Gonglion 213 Poronosol Sinuses 245
Mnemonics 216 Dissection 245
Fflcts to Rer*ember 216 Clinical Anatomy 246
Clinicoanatomical Problem 216 Pterygopolotine Fosso 246
Multiple Choice Questions 216 Moxillory Nerve 248
Pterygopolotine Gonglion 249
14. Itl|oulh and Phorynx 2t7 Dissection 249
Orol Covity 217 Fects to Renremher 251
Clinical Anatomy 217 ClinicoanatomicalProblem 251
Orol Covity Proper 218 Multiple Choice Questions 251
Teeth 219 16. Lorynx 252
Stoges of Development of Deciduous Anotomy of Lorynx 252
Teeth 220 Dissection 252
Anatomy 221
Clinical
Cortiloges of Lorynx 253
Hord ond Soft Polotes 222
Covity of Lorynx 256
Dissection 222
Muscles of the Soft Polote 222
lntrinsic Muscles of Lorynx 258
Development of Polote 226
Movements of Vocol Fold 259
Phorynx 227
Dissection 227
Ports of the Phorynx 228 Mechonism of Speech 262
Faets to Remsmben 262
Woldeyer's Lymphotic Ring 228
Clinical Anatomy 229 Clinicoanatomical Problem 262
Polotine Tonsils 229 Multiple Choice Questions 262
Structure of Phorynx 232 17. Tongue 264
Structures in between Phoryngeol Externol Feotures 264
Muscles 234 Dissection 264
Dissection 234 Clinical Anatomy 265
Killions' Dehiscence 234
Muscles of the Tongue 266
Deglutition 235
Histology 268
Auditory Tube 236
Development of Tongue 270
Mnemonics 237
Fects to Rem*mber 271
Faets to Remember 237
Clinicoanatomical Problem 271
ClinicoanatomicalProblem 238
Multiple Choice Questions 238 Multiple Choice Questions 271
15. Note ond Fcrsnffiol Sinuses 239 18. Eor 272

Nose 239 Externol Eor 272
Clinical Anatomy 240 Externol Acoustic Meotus 273
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CONTENTS
[w'
Tymponic Membrone 274 ClinicalAnatomy 294
Clinical Anatomy 275 Viireous Body 294
Middle Eor 277 Development 295
Dissection 277 Facts to Remember 296
Tymponic or Mostoid Antrum 281 Clinicoanatomical Problem 296
Dissection 281 Multiple Choice Questions 296
lnternol Eor 283 20. $urfuce Morking ond Rodiologicol
Development 285 Anolomy 297
Surfoce Londmorks 297
Regions of Eor Ache 286
Surfoce Morking of Vorious Structures 302
Mnemonics 286 Arteries 302
Feet$ t0 Rernemben 286
Veins/Sinuses 303
Clinicoanatomical Problem 286 Nerves 304
Multiple Choice Questions 287 Glonds 305
Nolse Pollution 287 PoronosolSinuses 306
19. Eyeboll 288 RodiologicolAnotomV 307
Outer Coot 288 Appendix I 309
Dissection 2BB
Corneo 289 Cervicol Plexus 309
Dissection 289 Sympothetic Trunk 309
Clinical Anatomy 290 PorosympotheticGonglio 309
Middle Coot
290 Arteries of Heod ond Neck 372
Clinical Anatomy 292 Structures Derived From
lnner Coot/Retino 292 Phoryngeol Arches 3 74
Clinical Anatomy 293 Endodermol Pouches 3.l4
Aqueous Humour 293 EctodermolClefts 374
Clinical Anatomy 294 ClinicolTerms 314
Lens 294 Furl-her Reoding 316
$ection',Z' BHAIN
2I. lnlroduction 319 Clinical Anatomy 330

CerebrospinolFluids 331
Divisions of Nervous System 319
CellulorArchitecture 319
Mnemonics 332
Synopse 321
Facts to Ramember 333
Neurogliol Cells 321
Reflex Arc 322 Clinicoanatomical Problem 333
Ports of the Nervous System 323 Multiple Choice Questions 333
Facts t* Rernember 326 23. Spinol Cord 334
Multiple Choice Questions 326 lntroduction 334
Dissection 334
22. Mening6$ of the Bruin ond Cerebrospinol MeningeolCoverings 334
Fluid 327 Externol Feotures of Spinol Cord 335
The Meninges 327 lnternol Structure 335
Dissection 326 Anatomy 336
Clinical
Cisterns 329 Spinol Nerves 336
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I
HEAD AND NECK
Meningeal branch
Lesser petrosal nerve
Nerve to medial pterygoid
Mandibular nerve
Vll nerve Otic ganglion
Masseieric
Temporal
lX nerve Lateral pterygoid
Auriculotermporal
Buccal
Chorda tympani
Lingual nerve Styloglossus
lnferior alveolar
Submandibular ganglion Genioglossus
on hyoglossus
Nerve to mylohyoid
Mylohyoid
Fig. 6.14: Distribution of mandibular nerve (V3)
Tympanic plexus
Tympanic branch
Mandibular nerve
(deeP asPect) Glossopharyngeal'nerve
Motor root
Nerve to tensor veli palatini

Nerve to iensor tympani
Otic ganglion
Postganglionic fibres
Sympathetic root
Sensory root
Auriculotemporal nerve giving
branches to parotid gland
Nerve to medial pierygoid
Sympathetic plexus along
middle meningeal artery
Maxillary artery
External caroiid artery

Base of mandible
Medial pterygoid
Fig. 6.15: Right otic ganglion seen from medial side

L
o
zo trmgur/ f\Jervs two-thirds of the tongue, are also distributed through
ttr the lingual nerve (Fig.6.16).
(E Lingual nerve (Table 6.3) is one of the two terminal
t,(E branches of the posterior division of the mandibular Course
o nerve (Fig. 6.1a). It is sensory to the anterior two-thirds Lingual nerve begins one cm below the sku1l. About
I
of the tongue and to the floor of the mouth. However, 2 cm below skull, it is joined by chorda tympani nerve
c the fibres of the chorda tympani (branch of facial nerve) at an acute angle. Then it lies in contact with mandible
,9
o which is secretomotor to the submandibular and medial to 3rd molar tooth. Finally, it lies on surface of
o
a sublingual salivary glands and gustatory to the anterior hyoglossus and genioglossus to reach the tongue.
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HUMAN ANATOMY_HEAD-NECK AND BRAIN
Nuclei of Spinol Cord 338 Sensory Components of V Nerve 366

Nuclei in Anterior Grey Column 338 Motor Components for Muscles 367
Nucleiin Loterol Horn 339 TrigeminolNerve 367
Nuclei in Posterior Grey Column 339 Ophtholmic Nerve Division 368
Sensory Receptors 340 Moxillory Nerve Division 368
Trocts of the Spinol Cord 340 Mondibulor Nerve Division 369
Descending Trocts 340 ClinicalAnatomy 369
Pyromidollracls 340 Seventh CroniolNerve (Fociol) 370
Extropyromidol Trocts 340 Functionol Componenls 370
Ascending Trocts 342 Nuclei370
lntersegmentol Trocts 345 Course ond Relotions 370
Clinical Anatomy 347 Bronches ond Distribution 371
Facts ta Rememb*r 348 Gonglio 373
ClinicalAnatomy 373
Clinicoanatomical Problems 348
Eighth Croniol Nerve (/estibulocochlear) 374
Pothwoy of Nearing 374
Vestibulor Pothwoy 375
24. Cronial Nerves 350
ClinicalAnatomy 375
lntroduction 350 Ninth Croniol Nerve (Glossophoryngeal) 376
Embryology 350 Functionol Componenls 376
Nuclei 351 Nuclei 378
Generol Somotic Efferent Nuclei 357 Course ond Relotion 378
Speciol Viscerol Efferents Nuclei 35
7
Bronches ond Distribution 378
Generol Viscerol Efferent Nuclei 352 Clinical Anatomy 379
Generol Viscerol Afferent ond Tenth Croniol Nerve (Vogus) 379
Speciol Viscerol Afferent Nuclei 352 Functionol Componenls 379
Generol Somotic Afferent Nuclei 355 Nuclei 379
Speciol Somotic Afferent Nuclei 355 Course ond Relotion in Heod ond Neck 387
Bronches in Heod ond Neck 38 7
First Croniol Nerve (Olfoctory) 355
Olfoctory Pothwoys 355
Eleventh Croniol Nerve (Accessory) 383
Functionol Components 383
Second Croniol Nerve (Optic) 356
Nuclei 383
Optic Pothwoys 356
Course ond Distribution of the Croniol
Reflexes 358
Root 383
Clinical Anatomy 360 Course ond Distribution of Spinol Root 384
Third Croniol Nerve (Oculomotor) 360
Functionol Components 360 Twelfth Croniol Nerve (Hypoglossol) 385
Nucleus 360 Functionol Components 385
Course ond Distribution 36 / Nuclei 385
Clinical Anatomy 362 Course ond Relotions 385
Fourih Croniol Nerve (rochlear) 362 Extrocroniol Course 385
Functionol Componenls 364 Bronches ond Distribution 385
Nucleus 364 Clinical Anatomy 386
Course ond Disiribution 364 Mnemonics 387
Clinical Anatomy 364 Facts ts) Remembcr 387
Sixth Croniol Nerve (Abducent) 364 Clinicoanatomical Problem 387
Functionol Components 364 Multiple Choice Questions 387
Nucleus 365
Course ond Distribution 365 25. Broin Slem 389
Fifth Croniol Nerve (l-rigeminol) 366 lntroduction 389
Nucleor Columns 366 Externol Feotures 389
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co*rirvrs il
lnternolStructure 390 Fects t* Remernbrr 412
Tronsverse Section through Pyromidol ClinicoanatomicalProblem 412
Decussotion 390 Multiple Choice Questions 412
Tronsverse Section through Sensory
Decussotion 391 28. Cerebrum 413
Tronsverse Section through Floor of Fourth lntroduction 413
Ventricle 391 Dissection 413
Cllnical Anatomy 393 CerebrolHemisphere 414
Pons 393 Lobes of Cerebrol Hemisphere 415
Externol Feotures 393 lnsulo 416
lnternolStructure of Pons 393 CerebrolSulci ond Gyri 416
Tegmentum in Lower Port of Pons 394 Functionol Areos of Cerebrol Corlex 418
Tegmentum in Upper Porl of Pons 395 Moior Areos 419
Midbroin 396 Sensory Areos 422
Subdivision 396 Clinical Anatomy 422
lnternol Structure of Midbroin 39i Areos of Speciol Senses 423
Tronsverse Section of Midbroin ot Clinical Anatomy 423
Level of lnferior Colliculus 396 Functions of Cerebrol Cortex 423
Tronsverse Section of Midbroin ot Clinical Anatomy 424
Level of Superior Colliculus 398 Diencepholon 424
Clinical Anatomy 398 Tholomus 424
Development 398 Metotholomus 426
Mnemonics 399 Clinical Anatomy 427
f;acts to Rsnrember 399 Epitholomus 427
ClinicoanatomicalProblem 400 Pineol Body 427
Multiple Choice Questions 400 Hypotholomus 429
Functions 430
25. Cerebetlum 40t Clinical Anatomy 431
Locotion 401 Subtholomus 431
Externol Feotures 401 Clinical Anatomy 431
Ports of Cerebellum 401 Bosol Nuclei 431
Divisions of Cerebellum 403 Dissection 431
Corpus Striotum 432
Connections of Cerebellum 404
Grey Motter of Cerebellum 404 Connections of Corpus Striotum 433
Histologicol Slruclure 404
White Motter of Cerebrum 434
Functions of Cerebellum 406
Dissection 434
Developmenl 406
Associotion Fibres 435
CommissurolFibres 435
Summory 407
Corpus Collosum 436
Fo*ts to fier*amber 408
Projection Fibres 436
lnternolCopsule 436
Gross Anolomy 436
Fibres of lnternol Copsule 437
27. Fourth Venlricle 409
Blood Supply 438
Loterol Boundories 409 Clinical Anatomy 438
Floor 409 Development 439
Roof 410 F*ets t* Remeru:ber 439
Recesses of Fourth Ventricle 4l I Clinicoanatomical Problems 440
Clinical Anatomy 412 Multiple Choice Questions 440
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HUMAN ANATOMV:..HEAD_NECK AND ERAIN
29. Third Ventricle, Lqterol Venlricle qnd ClinicalAnatomy 460

Arteriol Supply of Different Areos 461
lirnbic $yslem 441
Blood-BroinBorrier 461
Third Ventricle 441 PerivosculorSpoces 463
Dissection Ul Veins of the Cerebrum 463
Anatomy U2
Clinical Blood Supply of the Broin Stem 464
Loterol Ventricle 442 Clinical Anatomy 465
Dissection 442 Mnemonics 465 1{
Centrol Port 443 Faets t<:Rem*nnber 465

Anterior Horn 444 Clinicoanatomical Problems 465
Posterior Horn 445 Multiple Choice Questions 466
lnferior Horn 445
Limbic System 445
ClinicalAnatomy U8 32. Investigotions of o Neurologicol Cose,
Faets tc R*rn*rnber 449 $urface ond Rodiological Anolomy ond
Clinicoanatomical Problem 449 Evolul*on ofHeod 467
Multiple Choice Questions 449 lnvestigotions Required in o Neurologicol
Cose 467
30. $ome Neurql Polhwoys ond Reticulor Surfoce Anotomy 468
Formslion 450
Rodiologicol Anotomy of the Broin 469
PyromidolTroct 450 Evolution of Heod 469
Anatomy 451
Clinical
Pothwoy of Poin ond Temperoture 451 Appendix 2 472
Toste Pothwoy 452 Summory of the Ventricles of the Broin 472
ReticulorFormotion 453 Nucleor Components of Croniol Nerves 473
Fects ts} fiemernbsr 454 Arteries of Broin 474
Multiple Choice Questions 454 ClinicalTerms 475
Gross Anotomy of Brain 477
31. Blood Supply of Spinol Cord ond Multiple Choice Questions 479
Braln 455 Further Reoding 479
Blood Supply of Spinol Cord 455 $pots 481

Clinical Anatomy 455 Spots on Heod ond Neck 481
Arteries of Broin 455
Answers 482
VertebrolArteries 455
Spots on Broin 483
Bosilor Arleries 456
Anatomy 458
Clinical
Answers 484
lnternol Corotid Artery 458 lndex 485
Circulus Arteriosus or Circle of Willis 459
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$HLt
,,i:t.,.iiai:rl ,r ' :'
X" lmiroduction ond Osteology 3 t:t.. .,
2. Scolp, Temple ond Foce 59 s&,f

,:}isi
t
l ;l
3. Side of the Neck 79

4. Anterior Triongle of the Neek E2 . : : -*:S liir.. .
5. Porotid Region 106

6. Temporol ond lnfrotemporol Regions 114
. i,' :
7. Submondibulor Region t3t
8. Skuciures in the Neck 1N
9" Preverlebrol snd Porqverlebral Regions 162
n0. Bqck of lhe t{eek 176
i X " Contents of Vcrfebrol Csnol r83
I2. CroniolCovlty r89
13. Contents of the Orbif 205
'!d. Mouth ond Phorynx
217
T$. lrlose ond PCIrsrrascl$lnuses 239
i 6. Lorynx 252
tr 7" Tongure 2U
lE. Ior 272
1S" Eyeholl 2BB
2S. Su#oce Morking ond Rsdiologlcol 297
Anotomy
Appendix I 309
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Introduction and Osteology
6ll*"e.tagz ha, &w i.e.a.d {r/to} *o* ilri/ rnil&*
-Shokespeore
INTRODUCIION change into fluid waves and finally into nerve impulses
to be received in the temporal lobe of the cerebrum.
Head and neck is the uppermost part of the body.
Head comprises skull and lodges the meninges, brain, Nasal region; The region of the external nose, its muscles
hypophysis cerebri, special senses, teeth and blood and the associated cavity comprise the nasal region.
vessels. Brain is the highest seat of intelligence. Human Sense of smell is perceived from this region.
is the most evolved animal so far, as there is maximum Oral region: Comprises upper and lower lips and the
nervous tissue. To accommodate the increased volume angle of the mouth, where the lips join on each side.
of nervous tissue, the cranial cavity had to enlarge. Numerous muscles are present here, to express the
Correspondingly the lower jaw or mandible had to feelings and emotions. These muscles are part of the
retract. The eyes also had come more anteriorly, on each muscles of facial expression. They show the feelings,
side of the nose. The external nose also got prominent. without words.
External ear becomes vestigeal and chin is pushed Aral caaity: It houses the mobile talking tongue. Tongue
forwards to accommodate the broad tongue. Tongue, is not swallowed though everything put on the tongue
the organ for speech is securely placed in the oral cavity passes downwards. It is held in position by extrinsic
for articulation of words, i.e. speech. In human, the muscles arising from surrounding bones. It says so
vocalisation centre is quite big to articulate various much and manages to hide inside the oral cavity to be
words and speak distinctly. Speech is a special and chief protected by 32 teeth in adult.
characteristic of the human.
Paratid rcgion: Lies on the side of the face. It contains
Skull comprises number of bones and their respective
the biggest serous parotid salivary gland, which lies
regions are:
around the external auditory meatus.
Frontal; Lies in front of skull Head is followed by the tubular neck which
Foriet*l: Lies on top of skull, formed chiefly by the continues downwards with chest or thorax.
parietal bones. It is seen from the top Each half of the neck comprises two triangles between
anterior median line and posterior median lines.
Occipital: Forms back of skull
Posterior triangle: Lies between sternocleidomastoid, the
Temporril: It is the area above the ears. The sense of chin turning muscle; trapezfits, the shrugging muscle and
hearing and balance is appreciated and understood in middle one-third of the clavicle. It contains proximal
the temporal lobe of brain situated on its inner aspect. parts of the important brachial plexus, subclavian
Actilar region: It is the region around the large orbital vessels with its branches and tributaries. Its apex is
openings, containing the precious eyeball, muscles to above and base below.
move the eyeball, nerves and blood vessels to supply Arutevior triangle: Lies between the anterior median line
those muscles. There are accessory structures like the and the anterior border of sternocleidomastoid muscle.
lacrimal apparatus and protective eyelids. Its apex is in lower part of neck, close to sternum and
Auricular region: The region of the external ear with base above. It contains the common carotid artery and
external auditory meatus comprises the auricular its numerous branches. Isthmus of thyroid gland lies
region. Air waves enter the ear through the meatus which in the lower part of the triangle.
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HEAD AND NECK
Bones of head and neck include the skull, i.e. SkullJoints

cranium with mandible, seven cervical vertebrae, the The joints in the skull are mostly sutures, a few primary
hyoid, and six ossicles of the ear. cartilaginous joints and three pairs of synovial joints.
The skull cap formed by frontal, parietal, squamous Two pairs of synovial joints are present between the
temporal and a part of occipital bones, develop by ossicles of middle ear. One pair is the largest
intramembranous ossification, being a quicker one temporomandibular joint. This mobile joint permits us
stage process. to speak, eat, drink and laugh.
The base of the skull in contrast ossifies by intra-
Sutures are:
cartilaginous ossification which is a two-stage process
(membrane-cartila ge-bone). Plane - internasal suture
Skull lodges the brain, teeth and also special senses Serrate - coronal suture
like cochlear and vestibular apparatus, retina, olfactory Denticulate - lambdoid suture
mucous membrane, and taste buds. Squamous - parietotemporal suture
The weight of the brain is not felt as it is floating in the
cerebrospinal fluid. Our personality, power of speech, Anqtomicol Position of Skull
attention, concentration, judgement, and intellect are The skull can be placed in proper orientation by
because of the brain that we possess and its proper use. considering any one of the two planes.
1 Reid's base line is a horizontal line obtained by
joining the infraorbital margin to the centre of
external acoustic meatus, i.e. auricular point.
TERMS 2 The Frankfurt's horizontal plane of orientation is
The skeleton of the head is called the skull.It consists obtained by joining the infraorbital margin to
of several bones that are joined together to form the the upper margin of the external acoustic meatus
cranium. The term skull also includes the mandible or (Fig. 1.1).
lower jaw which is a separate bone. However, the two
terms skull and cranium, are often used synonymously.
The skull can be divided into two main parts:
a. The calaaria or brain &ox is the upper part of the
cranium which encloses the brain.
b. The facial skeleton constitutes the rest of the skull Frankfurt's
and includes the mandible. horizontal plane
BONES OF IHE SKUTL

The skull consists of the 28 bones which are named as
follows.
a. The calvaria or brain case is composed of 14 bones
including 3 paired ear ossicles.
fifigfl, rl.'':',r' :'l:,:.:
1. Parietal (2) L. Frontal (1) Fig. 1.1: Anatomical position of skull

2. Temporal (2) 2. Occipital (1)
3. Malleus (2) 3. Sphenoid (1)
4. Incus (2) 4. Ethmoid (1) Methods of Study of the Skull
5. Stapes (2) The skull can be studied as a whole.
3, 4,5 are described in Chapter 18 The whole skull can be studied from the outside or
5 externally in different views:
o
o b. The facial skeleton is compose d of 1,4 bones.
z a. Superior view or norma verticalis.
tt Fairqd.-, .,'',,,.,;., :. Unf.ei* iid.'',, i,,:,',,',,,; t,.,,,',.','.,' b. Posterior view or norma occipitalis.
.. ;
G
L. Maxilla (2) t. Mandible (1) c. Anterior view or norma frontalis.
E
(E
o 2. Zygomattc (2) 2. Vomer (t) d. Lateral view or norma lateralis.
3. Nasal (2) e. Inferior view or norma basalis.
C 4. Lacrimal (2) The whole skull can be studied from the inside or
o
o 5. Palatine (2) intemally after removing the roof of the calvaria or skull
o 6. Inferior nasal concha (2)
a cap:
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INTRODUCTION AND OSTEOLOGY
a. Internal surface of the cranial vault. Bones Seen in Normo Verticolis

b. Internal surface of the cranial base which shows 1,Upper part of frontal bone anteriorly.
a natural subdivision into anterior, middle and 2 Uppermost part of occipital bone posteriorly.
posterior cranial fossae. 3 A parietal bone on each side.
The skull can also be studied as individual bones.
Mandible, maxilla, ethmoid and zygomatic, etc. have Sutures
been described. I Coronal suture: This is placed between the frontal
bone and the two parietal bones. The suture crosses
Peculiorities of Skull Bones the cranial vauft from side to side and runs
1 Base of skull ossifies in cartilage while the skull cap downwards and forwards (Fig. 1.2).
ossifies in membrane. 2 Sagittal suture: It is placed in the median plane
2 At birth, skull comprises of one table only. By 4 years between the two parietal bones.
or so, two tables are formed. Between the two tables, Lambdoid suture: It lies posteriorly between the
there are diploe (Greek double), i.e. spaces containing occipital and the two parietal bones, and it runs
red bone marrow forming RBCs, granular series of downwards and forwards across the cranial vault.
WBCs and platelets. Four diploic veins drain the Metopic (Latin forehead) suture: This is occasionally
formed blood cells into neighbouring veins. present in about 3 to B% individuals. It lies in the
3 At birth, the 4 angles of parietal bone have median plane and separates the two halves of the
membranous gaps or fontanelles. These allow frontal bone. Normally it fuses at 6 years of age.
overlapping of bones during vaginal delivery, if
required. These also allow skull bones to increase in Some olher Nomed Feotures
size after birth, for housing the delicate brain.
1 Vertex is the highest point on sagittal suture.
4 Some skullbones have air cells in them and are called , Vault of sklll is the arched roof for the dome of skull.
pneumatic bones, e.g. frontal, maxilla. 3 Bregma is the meeting point between the coronal and
a. They reduce the weight of skull sagittal sutures. In the foetal skull, this is the site of
b. They maintain humidity of inspired air a membranous gap, called the anterior fontanelle,
c. They give resonance to voice which closes at 18 months of age. It allows growth
d. These may get infected resulting in sinusitis. of brain (Fig. 1.3).
5 Skull bones are united mostly by sutures. The lambda is the meeting point between the sagittal
6 Skull has foramina for "emissary veins" which and lambdoid sutures. In the foetal skull, this is the
connect intracranial venous sinuses with extracranial site of the posterior fontanelle which closes at2 to 3
veins. These try to relieve raised intracranial months of age.
pressure. Infection may reach through the emissary
veins into cranial venous sinuses as these veins are
valveless.
7 Petrous temporal is the densest bone of the body. It
lodges internal ear, middle ear including three
ossicles, i.e. malleus, incus and stapes. Ossicles are
"bones within the bone" and are fully formed at Frontal bone
birth.
8 Skull lodges brain, meninges, CSF, glands like
hypophysis cerebri and pineal, venous sinuses, teeth, Coronal suture
special senses like retina of eyeball, taste buds of
Bregma
tongue, olfactory epithelium, cochlear and vestibular
nerve endings. Parietal bone
J
o
o
Sagittal suture z
t'tr
(E
NORMA VERTICATIS E'

(E
Parietal foramen o
I
Shope Occipital bone
When viewed from above the skull is usually oval in .o
Lambdoid suture
shape. It is wider posteriorly than anteriorly. The shape o
may be more nearly circular. Fig. 1.2: Norma verticalis ao
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HEAD AND NECK
Anterolateral or Anterior fonianelle

sphenoidal fontanelle (18 months)
(2-3 months) Posterior
pntanelle {2-3 months)
*,,,", ffii'ijlllljil L%
",n,
r
"
Fig. 1.3: Fontanelles of skull Fig. 1.4:
The parietal tuber (eminence) is the area of maximum

convexity of the parietal bone. This is a common site NORMA OCCIPITATIS
of fracture of the skull. Norma occipitalis is convex upwards and on each side,
The parietal foramen, one on each side, pierces the and is flattened below.
parietal bone near its upper border, 2.5 to 4 cm in
front of the lambda. The parietal foramen transmits Bones Seen
an ernissary vein from the veins of scalp into superior 1 Posterior parts of the parietal bones, above.
sagittal sinus (Fig. 1.2). 2 Upper part of the squamous part of the occipital bone
The obelion is the point on the sagittal suture between below (Fig. 1.5).
the two parietal foramina. 3 Mastoid part of the temporal bone, on each
T}:le temporal linesbegin at the zygomatic process of side.
the frontal bone, arch backwards and upwards, and
cross the frontal bone, the coronal suture and the Sulures
parietal bone. Over the parietal bone there are two 1 The lambdoid suture lies between the occipital bone
lines, superior and inferior. Traced anteriorly, they and the two parietalbones. Sutural or wormianbones
fuse to form a single line. Traced posteriorly, the are corunon along this suture.
superior line fades out over the posterior part of the 2 The occipitomastoid suture lies between the occipital
parietal bone, but the inferior temporal line continues
bone and mastoid part of the temporal bone.
downwards and forwards.
3 The parietomastoid suture lies between the parietal
bone and mastoid part of the temporal bone.
4 The posterior part of the sagittal suture is also seen.
Fontanelles are sites of growth of skull, permitting
growth of brain and pulps to determine age. Other Feofures
If fontanelles fuse early, brain growth is stunted;
such children are less intelligent. 1 Lnmbda, parietal fornmina and obelion have been
examined in the norma verticalis.
If anterior fontanelle is bulging, there is raised
I
o intracraniai pressure. If anterior fontanelle is 2 The external occipital protuberance is a median
o prominence in the lower part of this norma. It marks
z depressed, it shows decreased intracranial
!t pressure, mostly due to dehydration. the junction of the head and the neck. The most
prominent point on this protuberance is called the
G,
Bones override at the fontanelle helping to xnnn.
!,
decrease size of head during vaginal delivery.
TE
o 3 The superior nuchal lines are curved bony ridges
Caput sutcedaneum is saft tissue swelling on any passing laterally from the protuberance. These also
C
part of skull due to rupture of eapillaries during mark the junction of the head and the neck. The area
.9 delivery. Skullbecomesnormalwithin a few days below the superior nuchal lines willbe studied with
o
ao (Fig. 1.4). the norma basalis.
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Parietal foramen
Parietal bone
Sagittal suture
Lambda
Lambdoid suture
Occipital bone
Squamous part of
temporal bone
Temporal bone
Superior nuchal line
Mastoid foramen
lnferior nuchal line
Mastoid process
External occipital protuberance

Fig. 1.5: Norma occipitalis
The highest nuchal lines are not always present. They apex of the squamous occipital. This is not a sutural
are curved bony ridges situated about l- cm above or accessory bone but represents the membranous
the superior nuchal lines. They begin from the upper part of the occipital bone which has failed to fuse
part of the external occipital protuberance and are with the rest of the bone.
more arched than the superior nuchal lines.
The occipital point is a median point a little above the Attochments
inion. It is the point farthest from the glabella.
The mastoid (Greek breast) foramen is located on the
1 The upper part of the external occipital protuberance
gives origin to the trapezius, and the lower part gives
mastoid part of the temporal bone at or near the occi-
attachment to the upper end of the ligamentumnuchae
pitomastoid suture. Internally, it opens at the
(Fig. 1.1a).
sigmoid sulcus. The mastoid foramen transmits an
emissary vein (Table 1.1) and the meningeal branch 2 The medial one-third of the superior nuchal line gives
of the occipital artery. origin to the trapezius, and the lateral part provides
The interparietal bone (inca bone) is occasionally insertion to the sternocleidomastoid above and to the
present. It is a large triangular bone located at the spl enius c apitis below.
Table 1.1: The emissary veins of the skull

ta
Name Foramen of skull Veins outside skull Venous sinus o
o
1. Parietal emissary vein Parietal foramen Veins of scalp Superior sagittal z
!tc
2. Mastoid emissary vein Mastoid foramen Veins of scalp Sigmoid sinus (s
3. Emissary vein Hypoglossal canal lnternal jugular vein Sigmoid sinus t,(E
Suboccipital venous Plexus Sigmoid sinus o
4. Condylar emissary vein Posterior condylar foramen I
5. 2-3 emissary veins Foramen lacerum Pharyngeal venous plexus Cavernous sinus
6. Emissary vein Foramen ovale Pterygoid venous plexus Cavernous sinus o
'E
()
7. Emissary vein Foramen caecum Veins of roof of nose Superior sagittal ao
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HEAD AND NECK
NORMA FRONTATIS
The norma frontalis is roughly oval in outline, being
wider above than below.
Bones
1, Frontal bone forms the forehead. Its upper part is
smooth and convex, but the lower part is irregular
and is interrupted by the orbits and by the anterior
bony aperture of nose (Fig. 1.7).
2 The right and left mnxillae form the upper jaw.
3 The right and left nasnl bones form the bridge of the
nose.
Occipital belly 4 The zygomatic (Greek yoke) bones form the bony
prominence of the superolateral part of the cheeks.
Fig. 1.6: Attachments of the occipitofrontalis muscle 5 The mnndible forms the lower jaw.
The norma frontalis will be studied under the
The highest nuchal lines i{ present provide following heads:
attachment to the epicranial aponeurosls medially, and a. Frontal region.
give origin to the occipitalis or occipital belly of b. Orbital opening.
occipitofrontalls muscle laterally (Fig. 1.6). In case of c. Anterior piriform-shaped bony aperture of the
absence of highest nuchal lines, these structures are nose.
attached to superior nuchal lines. d. Lower part of the face.
Fronial bone
Frontal tuber
Temporal line
Nasion
Frontozygomatic
0rbit suture
Nasal bone
Zygomatic bone
Superior orbital
fissure
Frontal
bone lnfraorbital
foramen
Temporal
Orbii line
t( Anterior Maxilla
o nasal
o Nasal
z bone Zygomatic spine
t,c Nasal
bone Angle of
mandible
(E
aperture
E(s Maxilla
Mental
Alveolar Symphysis menti
o process foramen
Angle of
Mandible mandible Menial protruberance
E
o
o
o
U) Fig. 1.7: Norma frontalis: Walls of orbit and nasal aperture. lnset showing apertures
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Frontol Region The anterior nasal spine is a sharp projection in the

The frontal region presents the following features: median plane in the lower boundary of the piriform
aperture (Fig. L.7).
1 The superciliary arch is a rounded, curved elevation
situated just above the medial part of each orbit. It
3 Rhinion is the lowermost point of the internasal
suture.
overlies the frontal sinus and is better marked in
males than in females.
2 The glabella is a median elevation connecting the two
superciliary arches. Below the glabella, the skull T1ae ncsal bone is ffie of the most cammonly fiactured
recedes to frontonasal suture at root of the nose. bones al the fate. Mandible and parietal eminence are
3 The nasion is a median point at the root of the nose the next bones to be &actured (Fig. 1.8).
where the internasal suture meets with the
frontonasal suture. Lower Poil of lhe Foce
4 The frontal tuber or eminence is a low rounded Nlaxills
elevation above the superciliary arch, one on each Maxilla contributes a large share in the formation of
side. It is more prominent in females and in children. the facial skeleton. The anterior surface of the body of
the maxilla presents:
Obitol Openings a. The nasalnotch medially;
Each orbital (Latin circle) opening is quadrangular in b. The anterior nasal spine;
shape and is bounded by the following four margins. c. The infraorbitalforamen,l cmbelow the infraorbital
1, Thesupraorbitalmargin is formedby the frontalbone. margin;
At the junction of its lateral two-thirds and its medial d. The incisiue fossa above the incisor teeth, and
one-third, it presents the supraorbital notch or e. The canine fossa lateral to the canine eminence.
foramen (Fi9.1.7).
In addition, three out of four processes of the maxilla
2 The infraorbital margin is formed by the zygomatic are also seen in this norma.
bone laterally, and maxilla medially.
a. The frontal process of the maxilla is directed
3 The medial orbital margin is ill-defined. It is formed upwards. It articulates anteriorly with the nasal
by the frontal bone above, and by the lacrimal crest bone, posteriorly with the lacrimal bone, and
of the frontal process of the maxilla below. superiorly With the frontal bone (Fig. 1.7).
4 The lateral orbital margin is formed mostly by the b . The zygomatic process of the maxilla is short but stout
frontal process of zygomatic bone but is completed and articulates with the zygomatic bone.
above by the zygomatic process of frontal bone.
c. The slaeolar process of the maxillabears sockets for
Frontozygomatic suture lies at their union.
the upper teeth.
Anterior Bony Aperlure of the Nose
Zyg*mati* Eone {rne:lor b*ne)
The anterior bony aperture is pear-shaped, being wide
Zygomatic bone forms the prominence of the cheek.
below and narrow above.
The zygomaticofacial foramen is seen on its surface.
SoundCIri*s
Mandr"h/e (l*w*r j*w i:one)
Aboae: By the lower border of the nasal bones.
Mandible (Latin to cheut) forms the lower jaw.
Below: By the nasal notch of the body of maxilla on each The upper border or alzteolar arch lodges the lower
side. teeth.
T}re lower border or base is rounded.
Features The middle point of the base is called the ment al point t(o
Note the following: or gnathion.
1, Articulations of the nasal bone: The point on the angle of mandible is called gonion. zo
ttE
a. Anteriorly, with the opposite bone at the internasal The anterior surface of the body of the mandible G
suture. presents: t,G
b. Posteriorly, with the frontal process of the maxilla. a. The symphysis menti, the mental protuberance and o
c. Superiorly, with the frontal bone at the frontonasal the mental tubercles anteriorly (Fig.1,.7).
suture. b. The mental for amen below the interval between the o
d. Inferiorly, the upper nasal cartilage is attached to two premolar teeth, transmittingthe mental nerae o
o
it. and aessels. U)
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[_::ANDNE.K
Posterior branch
Middle meningeal artery
Maxillary artery
Fig. 1.8: Fracturednasal boneandpositionof anteriordivisionof middlemeningeal arteryagainstthepterion
c. wlichruns upwards and backwards

Tlne oblique line 6 The leaator labii superiorls arises from the maxilla
from the mental tubercle to the anterior border of between the infraorbital marlin and the infraorbital
the ramus (Latin branch) of the mandible. foramen (see Fig.2.9).
7 The leaator anguli orls arises from the canine fossa.
S*rfurcs sf ffte l$ormo Fr*rufcjss 8 The nasalis and the depressor septi arise from the
. Internasal (Fig. 1.7) surface of the maxilla bordering the nasal notch.
o Frontonasal 9 The incisiaus muscle arises from an area just below
. Nasomaxillary the depressor septi. It forms part of orbicularis oris.
o Lacrimomaxillary 10 The zygomaticus maior and minor arise from the
. Frontomaxillary surface of the zygomaticbone (see Fig.2.9).
'fhe zygomaticus minor muscle arises below the
o Intermaxillary
. Zygomaticomaxillary zygomiticofacial foramen. The zygomaticus major
aiiies lateral to the minor muscle (seeFig.2.9).
' Zygornaticofrontal' 77 Buccinafor arises from maxilla and mandible
opposite molar teeth and fuorr- pterygomandib.ular
Aff'm*ftr,nsmf*
ripne 6ee Fig. 2.10). It also forms part of orbicularis
1 The medial part of the superciliary arch gives origin oris..
to the corrugator supercilii muscle.
2 The procerus muscle arises from the nasal bone near $frs**fsrres Fa*srng ffurougl* Forer:tr*cx
.Y the median plane (see Fig.2.9). 1 The supraorbital notch or foramen transmits the
o 3 The orbital part of the orbicularis oculi arises from rt essels (see Fig. 2.5).
supr aorbit al nera es and
o
z the frontal piocess of the maxilla and from the nasal 2 The external nasal nerae emerges between the nasal
!tc
(E
part of the frontal bone (see Fig.2.9). bone and upper nasal cartilage (seeFig.2.22).
t,(E 4 The medial p alp ebr al ligamenf is attached to the frontal 3 The infraorbltal foramentransmits the infraorbital nerae
0) process of the maxilla between the frontal and and aessels (see Fig. 2.22).
maxillary origins of the orbicularis oculi. 4 The zygomaticofaiial foramen transmits the nerve of
E 5 The leoator labii superioris alaeque nasi arises from the the same name, a branch of maxillnry nertte.
.9
o frontal process of the maxilla in front of the 5 The mental foramen on the mandible transmits the
o mental nerve and vessels (seeFig.2.22).
a orbicularis oculi (see fig.2.9).
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r-ffi] INTRODUCTION AND OSTEOLOGY
tMl
NORMA LATERALIS part, turns downwards and forwards and becomes
Bones continuous with the supramastoid crest on the squamous
temporal bone near its junction with the mastoid
1 Frontal temporal. This crest is continuous anteriorly with the
2 Parietal (Fig. 1.9a) posterior root of the zygomatic arch (Fig. 1.9b).
3 Occipital
4 Temporal
5 Sphenoid #ygmm*9d*: .4 #y$r*m*
r*fu *pr
6 Zygomatic The zygomatic arch is a horizontal bar on the side of the
7 Mandible head, in front of the ear, a little above the tragus, It is
8 Maxilla formed by the temporal process of the zygomatic bone
9 Nasal in anterior one-third and the zygomatic process of the
temporal bone in posterior two-thirds. The zygomatico-
Feotures
temporal suture crosses the arch obliquely downwards
fl*:'t';p*r*f Arm*s and backwards.
The temporal lines have been studied in the norma Above the zygomatic arch is temporal fossa, which
verticalis. The inferior temporal line, in its posterior is filled by temporalis muscle. Attached to lower margin
Superior
Parietal bone temporal line
Coronal suture
Temporal bone, squamous part
Frontal bone
Position of anterior margin ol
foramen magnum and facial angle
lnferior temporal line
Supramasloid crest
Pterion
Lambdoid suture
Nasal bone
Asterion Zygomatic bone
Zygomatic arch lnfraorbital foramen

Maxilla
Mastoid process
External acoustic meatus
Styloid process
Ramus of mandible
(a)
Parietal bone
Coronal suture
Squamous Frontal bone
temporal
Temporal bone
Temporal Iines
Supramastoid crest Pterion J

Lambdoid o
Suprameatal iriangle suture Nasal bone
zo
Zygomatic bone tttr
Mastoid process 6
Vertical tangent to Maxilla
posierior border of Extemal acoustic meatus t(E
external acoustic meatus
Styloid process o
Body of mandible I
External acoustic Ramus of mandible
meatus (b) (c)
o
.F
Figs 1.9a to c:
(a) Norma lateralis with facial angle, (b) bones forming norma lateralis, and (c) tympanic plate forming margins of o
external acoustic meatus ao
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HEAD AND NECK
of zygomatic arch is masseter muscle; contraction of site of the po sterolateral or mastoidfontanelle, which closes
both temporalis and masseter may be felt by clenching (Fig. 1.3)by L2 months.
the teeth. The mastoid process is a breast like projection from
The arch is separated from the side of the skull by a the lower part of the mastoid temporal bone, postero-
gap which is deeper in front than behind.Its lateral inferior to the external acoustic meatus. It appears
surface is subcutaneous. The anterior end of the upper during the second year of life. The tympanomastoid
border is called t}lre jugal point. The posterior end of the fissure is placed on the anterior aspect of the base of
zygomalic arch is attached to the squamous temporal the mastoid process. Ttrre mastoidforamen lies at or near
bone by anterior andposterior roots.The articular tubercle the occipitomastoid suture (Fig. 1.5).
of the root of the zygorrra lies on its lower border, at the
junction of the anterior and posterior roots. The anterior Sfyf*fd Frseess
root passes medially in front of the articular fossa. The The styloid (Latin pen) process is a needle-like thin, long
posterior root passes backwards along the lateral projection from the norma basalis situated anteromedial
margin of the mandibular or articular fossa, then above to the mastoid process. It is directed downwards,
the external acoustic meatus to become continuous with forwards and slightly medially. Its base is partly
the supramastoid crest. Two projections are visible in ensheathed by the tympanic plate. The apex or tip is
relation to these roots. One is srticular tubercle at its usually hidden from view by the posterior border of
lower border. Another tubercle is visible just behind the ramus of the mandible.
the mandibular or articular fossa and is known as
postglenoid tubercle. I*rmBcrol fiosss
Boundaries
Sxfe*"1*i A r#{r$fi# fufssfus 1 Abooe, by the superior temporal line.
The external acoustic mentus opens just below the 2 Below, by the upper border of the zygomatic arch
posterior part of the posterior root of zygoma. Its laterally, and by the infratemporal crest of the greater
anterior and inferior margins and the lower part wing of the sphenoid bone medially. Through the
of the posterior margin are formed by the tympanic gap deep to the zygomatic arch, temporal fossa
plate, and the posterosuperior margin is formed communicates with the infratemporal fossa.
by the squamous temporal bone. The margins 3 The anterior tnall is formed by the zygomatic bone
are roughened for the attachment of auricular cartilage. and by parts of the frontal and sphenoid bones. This
The suprameatal triangle (trianlge of Macewen) is a small wall separates the fossa from the orbit.
depression posterosuperior to the meatus. Itisbounded Floar: The anterior part of the floor is crossed by an H-
above by the supramastoid crest, in front by the shaped suture where four bones, frontal, parietal,
posterosuperior margin of the external meatus, and greater wing of sphenoid and temporal adjoin each
behind by a vertical tangent to the posterior margin of other. This area is termed tlrre pterion.It lies 4 cm above
the meatus. The suprameatal spine may be present on the midpoint of the zygomatic arch and 2.5 cm behind
the anteroinferior margin of the triangle. The triangle the frontozygomatic suture. Deep to the pterion lie the
forms the lateral wall of the tyrnpanic or mastoid middle meningeal aein, the anterior diaision of the middle
antrum (Fig.1.9c). meningeal artery , and the stem of the lateral sulcus of brain
( Syloian point) (Fig. 1..8).
&4*rsf*rd fr*rf *f flie temBCIr*:d Serue On the temporal surface of the zygomatic bone
The mastoid part of the temporal boneliesjust behind the forming the anterior wall of the fossa there is the
external acoustic meatus. It is continuous antero- zy gomat icot emp or al for am en.
superiorly with the squamous temporalbone (Fig. 1.9c).
A partially obliterated squamomastoid suture may be
.v
()
visible in front of and parallel to the roughened area Pteilonis the thin part of skull. Lr roadside accidents,
o for muscular insertion. the anterior division of middle meningeal artery may
z The mastoid temporal bone articulates postero-
tttr be ruptured, leading to clot formation between the
(! superiorly with the posteroinferior part of the parietal skulf bone and dura mater or extradural
!tG bone at the horizontal parietomastoid suture, and haemorrhage (Fig. 1.8). The clot compresses the
o posteriorly with the squamous occipital bone at the motor area of brain, leading to paralysis of the
occipitomastoid suture. These two sutures meet at the opposite side. The clot must be sucked out at the
c lateral end of the lambdoid suture. The asterion is the eirliest by trephining (Fig. 1.10). The head must be
.o
o point where the parietomastoid, occipitomastoid and protected by a helmet.
ao lambdoid sutures meet. L:r infants, the asterion is the
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INTHODUCT]ON AND OSTEOLOGY
Slructures Possing through Foromino

Superior 1 The tympanomastoid fissure on the anterior aspect of
sagittal sinus the base of the mastoid process transmits the auricular
branch of aagus nerae.
Extradural 2 The mastoid foramen transmits:
haemorrhage a. An emissary aein connecting the sigmoid sinuswith
l}:le posterior auricular aein.
b. A meningeal branch of the occipital artery
(Table 1.1).
3 The zygomaticotemporal fornmen trarlsmits the nerve
of the same name and a minute artery (seeFig.2.22).
NORMA BASALIS
Fig. 1.10: Extradural haemorrhage For convenience of study, the norma basalis is divided
arbitrarily into anterior, middle and posterior parts. The
anterior part is formed by the hard palate and the
alveolar arches. The middle and posterior parts are
fnfr*fe*rp*rrtr, Fs$$# separated by an imaginary transverse line passing
Boundaries and the contents are described in Chapter 6. through the anterior margin of the foramen magnum
(Figs 1.11a and b).
Ff*ry6mp*f*uffne F*sss
Pterygopalatine fossa is described in Chapter 15. Anterior Porl of Normo Bosolis
AlvemisrAr*fi
Attachments
1 The temporal Alveolar arch bears sockets for the roots of the upper
fascia is attached to the superior teeth.
temporal line and to the area between the two
temporal lines. Inferiorly, it is attached to the outer
and inner lips of the upper border of the zygomatic f{srdF*Jmfe
arch. 'l." Formntion:
2 The temporalis muscle arises from the whole of the a. Anterior two-thirds, by the palatine processes of
temporal fossa, except the part formed by the the maxilla bones.
zygomaticbone (Fig. 1.14). Beneath the muscle there b. Posterior one-third by the horizontal plates of the
lie the deep temporal aessels and neraes. Tlne middle palatine bones.
temporal aessels produce vascular markings on the 2 Sutures: The palate is crossed by a cruciform suture
temporal bone just above the external acoustic made up of intermaxillary, interpalatine and
meatus. palatomaxillary sutures.
3 The medial surface and lower border of the 3 Dome:
zygomatic arch give origin to the masseter. a. It is arched in all directions.
4 The lateral ligament of the temporomandibular joint is b. Shows pits for the palatine glands.
attached to the tubercle of the root of the zygoma 4 The incisizte fossa is a deep fossa situated anteriorly
(see Chapter 6). in the median plane (Fig. 1.12).
5 The sternocleidomastoid, splenius capitis and longissimus Two incisiae canals, right and left, pierce the walls of
capitis are inserted in that order from before the incisive fossa, usually one on each side, but
backwards on the posterior part of the lateral occasionally in the median plane, the left being ta
surface of the mastoid process (Fig. 1.1a). Posterior anterior and the right, posterior. o
belly of digastric arises from mastoid notch. The 5 The greater palatine foramen, one on each side, is
zo
groove obliquely placed is due to occipital artery tt
situated just behind the lateral part of the palato- G
Fig.7.1).
(see
maxillary suture. A groove leads from the foramen !,(E
6 The gapbetween the zygomatic arch and the side of towards the incisive fossa. o
the skull transmits: 6 The lesser palatine foramina, two or three in number
a. Tendon of the temporalis muscle. on each side, lie behind the greater palatine foramen, o
b. Deep temporal vessels. and perforate the pyramidal process of the palatine C)
c. Deep temporal nerves. bone (see Fig. 15.1a). ao
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HEAD AND NECK
lntermaxillary suture
lncisive foramen (nasopalatine nerves)
lnterpalatine suture
Palatine process (bony palate)
Zygomatic arch
Medial and lateral
pterygoid plates
Greater palatine foramen (anterior
palatine nerve)
Foramen lacerum
(nerve of pterygoid canal)
lnferior orbital fissure (zygomatic and
Mandibular fossa infraorbital nerves)
Sulcus tubae Les$er palatine foramen

(middle and posterior palatine nerves)
Petrotympanic fissure
Pharyngeal tubercle Foramen ovale (mandibular and
lesser petrosal nerves)
Carotid canal (internal
Styloid process
carotid artery)
Mastoid process Stylomastoid foramen (Vll nerve)
Foramen spinosum and sPine of

Jugular foramen (lX, X, Xl and sphenoid (middle meningeal artery)
internal jugular vein)
Occipital condyle
Hypoglossal canal (Xll nerve)
Foramen magnum (spinal cord with
Posterior condylar canal
meninges,anterior and Posterior
Superior nuchal line spinal arteries, vertebral arteries.
spinal roots of Xl nerves)
External occipital crest
lnferior nuchal line
(a)
lnfratemporal crest Posterior margin of inferior

orbital fissure
Continuous with pterygoid process

(medial surface)
Foramen spinosum
(middle meningeal
artery)
Foramen ovale (mandibular nerve,
acce$sory meningeal artery lesset
Articulates with petrosal nerve and emissarY vein)
squamous temporal
Sulcus tubae
Auriculotemporal nerve
Spine of sphenoid Peirous part of temPoral bone
Chorda tympani
nerve
.Y
o
zo Figs 1.1i a and (a) Norma basalis showing passage of main nerves and arteries, and (b) infratemporal surface of greater wing
b:
tt from below
of sphenoid seen
(E
!,
G'
o 7 The posterior border of the hard palate is free and Middle Porl of Normo Bosolis
presents theposterior nasal spine in the median plane. The middle part extends from the posterior border of
c 8 The palatine crest is a curved ridge near the posterior the hard pilate to the arbitrary transverse line
.9
C) border. It begins behind the greater palatine foramen passing thiough the anterior margin of the foramen
ao and runs medially (Fig. 1.12). maSnum.
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INTRODUCTION AND'OSTEOLOGY
lncisive foramen 5 The broad bar of the bone is marked in the median
with openings of
plane by the pharyngeal tubercle, a little in front of
incisive canals
the foramen magnum (Fig. 1.11a).
Palato - Palatine process i.ofererfAres

maxillary of maxilla
suture The lateral area shows two parts of the sphenoid
Horizontal plate
of palatine bone
bone-pterygoid process and greater wing. Also
seen are three parts of the temporal bone, i.e. petrous
lnterpalatine
sulure Greaier palatine temporal, tympanic plate and squamous temporal.
foramen The pterygoid process projects downwards from the
Pyramidal
process of Lesser palatine junction of greater wing and the body of sphenoid
Palatine Posterior
palatine bone
cre$t nasal spine
foramen behind the third molar tooth.
Inferiorly, it divides into the medial and lateral
Fig. 1.12: Anterior part of the norma basalis
pterygoid plates whicli. are fused together anteriorly,
but are separated posteriorly by the V-shaped
Median Area pterygoid fossa.
The median area shows: The fused anterior borders of the two plates
a. The posterior border of the aomer. articulate medially with the perpendicular plate of
b . Abroad bar of bone formed by fusion of the posterior the palatine bone, and are separated laterally from
part of the body of sphenoid and the basilar part the posterior surface of the body of the maxilla by
of occipital bone (Fig. 1.13). the pterygomaxillary fissure.
The vomer separates the two posterior nasal The medial pterygoid plate is directed backwards.
apertures. Its inferior border articulates with the Ithas medial and lateral surfaces and a free posterior
bony palate. The superior border splits into two alae border.
and articulates with thre rostrum of the sphenoid bone The upper end of this border divides to enclose a
(Fig. 1.13). triangular depression called the scnphoid fossa. The
The palatinooaginal canal. T}ire inferior surface of the lower end of the posterior border is prolonged
vaginal process of the medial pterygoid plate is downwards and laterally to form the pterygoid
marked by an anteroposterior groove which is hamulus.
converted into the palatinovaginal canal by the upper The lateral pterygoid plate is directed backwards
surface of the sphenoidal process of the palatine and laterally. It has medial and lateral surfaces and
bone. The canal opens anteriorly into the posterior a free posterior border. The lateral surface forms the
wall of the pterygopalatine fossa (see Fig. 15.14). medial wall of the infratemporal fossa. The lateral
The aomeroztaginal canal. The lateral border of each and medial surfaces give origin to muscles.
ala of the vomer comes into relationship with the The posterior border sometimes has a projection
vaginal process of the medial pterygoid plate, and at its middle called the pterygospinous process
may overlap it from above to enclose the which projects towards the spine of the sphenoid.
vomerovaginal canal (Fig. 1.13). The infratemporal surface of the greater wing of the
sphenoid is pentagonal:
Horizontal plate of Posterior nasal a.Its anterior margin forms the posterior border of
palatine bone aperiure the inferior orbital fissure (Fig. 1.11b).
Vomer
Medial pterygoid plate b.Its anterolateral margin forms the infratemporal
Lateral pterygoid plate crest.
Sphenoidal process
of palatine bone Perpendicular c. Ils posterolateral margin articulates with the
plate of palatine
squamous temporal. 5
Palatinovaginal bone o
d.Its posteromedial margin articulates with petrous o
canal Root of pterygoid
process temporal.
z
Ala of vomer E
Greater wing e. Anteromedially , it is continuous with the pterygoid c
G
Rostrum
of sphenoid process and with the body of the sphenoid bone. !,(E
of sphenoid Vaginal process The posteriormost point between the posterolateral o
Body of sphenoid
Vomerovaginal canal of sphenoid and posteromedial margins projects downwards to
Fig. 1.13: Posterior view of a coronal section through the form the spine of the sphenoid. o
posterior nasal aperture showing the formation of the Along the posteromedial margin, the surface is ()
palatinovaginal and vomerovaginal canals pierced by the following foramina: ao
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HEAD.AND.NECK
a. The foramen oaale is large and oval in shape. It is Its anterior surface forms the posterior wall of the
situated posterolateral to the upper end of the mandibular fossa. The p osterior surface is concave and
posterior border of lateral pterygoid plate forms the anterior wall, floor, and lower part of the
(Fig. 1.11b). posterior wall of the bony external acoustic meatus
b. The foramen spinosum is small and circular in (Fig. 1.ec).
shape. It is situated posterolateral to the foramen Its upper borderbounds the petrotympanic fissure.
ovale, and is limited posterolaterallyby the spine The lower border is sharp and free.
of sphenoid (Fig. 1.11). Medially: It passes along the anterolateral margin
c. Sometimes there is the emissary sphenoidal foramen of the lower end of the carotid canal.
or foramen of Vesalius.It is situated between the Laterally: It forms the anterolateral part of the
foramen ovale and the scaphoid fossa.Internally, sheath of the styloid process.
it opens between the foramen ovale and the lnternally: The tympanic plate is fused to the
foramen rotundum. petrous temporal bone.
d. At times there is acanaliculus innominatus situated 6 The squamous part of the temporal bone forms:
between the foramen ovale and the foramen a. The anterior part of the mandibular articular fossa
spinosum. which articulates with the head of the mandible
Tlne spine of the sphenoid may be sharply pointed or to form the temporomandibular joint.
blunt (Fig. 1.11b). b. The articular tubercle which is continuous with
The sulcus tubae is the groove between the postero- the anterior root of the zygoma.
medial margin of the greater wing of the sphenoid c. A small posterolateral part of the roof of the
and the petrous temporal bone. It lodges the infratemporal fossa.
cartilaginous part of the auditory tube. Posteriorly, the
groove leads to the bony part of the auditory tube Poslerior Port of Normo Bosqlis
which lies within the petrous temporal bone Medisffi Ar*s
(Fig. 1.11a).
The median area shows from before backwards:
The inferior surface of the petrous (Greek rock) part
a. The foramen magnum.
of the temporal bone is triangular in shape with its
apex directed forwards and medially. b. The external occipital crest.
It lies between the greater wing of the sphenoid c. The external occipital protuberance.
and the basiocciput.Its apex is perforated by the d. Nuchal lines
upper end of the carotid canal, and is separated from a. The foramen magnum (Latin great) is the largest
the sphenoid by the foramen lacerum. The inferior foramen of the skull. It opens upwards into the
surface is perforated by the lower end of the carotid
posterior cranial fossa, and downwards into the
canal posteriorly. vertebral canal. It is oval in shape, being wider
The carotid canal runs forwards and medially behind than in front where it is overlapped on each
within the petrous temporal bone. side by the occipital condyles (Fig. 1.1a).
The foramen lacerum is a short, wide canal, L cm b. The external occipital crest begins at the posterior
long. Its lower end is bounded posterolaterally by margin of the foramenmagnum and ends posteriorly
the apex of the petrous temporal, medially by the and above at the extemal occipital protuberance.
basiocciput and the body of the sphenoid, and c. The external occipitalprotubernnceis a projection located
anteriorly by the root of the pterygoid process and at the posterior end of the crest. It is easily felt in the
the greater wing of the sphenoid bone. living, in the midline, at the point where the back of
A part of the petrous temporal bone, called the the neck becomes continuous with the scalp (Fig. 1.5).
tegmen tympani, is present in the middle cranial fossa. d. Nuchal lines: The superior nuchal lines begin at the
It has a down turned edge which is seen in the external occipital protuberance and the inferior
.Y squamotympanic fissure and divides it into the nuchal lines at the middle of the crest. Both of them
o curve laterally and backwards and then laterally and
zo posterior p etr otymp anic and anterior p etr o s quamous
fissures (Fig. 1.11a). forwards.
t Highest nuchal line is faded and seen above
(Er The tympanic part of the temporal bone also called as the
tt(E tympanic plate is a triangular curved plate which lies superior nuchal line (occasionally).
o in the angle between the petrous and squamous
I
parts. {.sferaf Are*
c Its apex is directed medially and lies close to the The lateral area shows;
.o
o spine of the sphenoid. o The condylar part of the occipital bone.
ao Thebase or Latualborder is curved, free and roughened. r The squamous part of the occipital bone.
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I NTRODUCTION AND -OSTEOLOGY
Palatine aponeurosis
Musculus uvulae
(pharyngeal plexus)
Tensor veli palatini (V3)
Levator veli palatini

{pharyngeal plexus)
Styloglossus (Xll)
Stylohyoid (Vll)
Stylopharyngeus (lX)
Lonous caoitis -_l Ventral rami
of cervical
I
Longissimus Rectus caoitis lateralis I nerves and
capitis ' I cervical
Rectus capitis anterior plexus
I
Dorsal Splenius capitis
rami Superior oblique Digastric posterior belly (Vll)
of
cervical Sternocleidomastoid Spinal root
I
nerves of xl
Rectus capitis posterior Trape.ius I
major and minor
Semispinalis capitis
Occipitalis (Vll)
Superior constrictor of pharynx (pharyngeal plexus)

Fig. 1.14; Muscles attached to the base of skull with their nerve supply
The jugular foramen between the occipital and fossa present behind the occipital condyle.
petrous temporal bones. Superiorly, it opens into the sigmoid sulcus.
a The styloid process of the temporal bone. iv. The jugular process of the occipital bone lies
a The mastoid part of the temporal bone. lateral to the occipital condyle and forms the
posterior boundary of jugular foramen
a. The condylar or lateral part of the occipital bone (Fis. 1.11).
presents the following. b. Squamous part of occipital bone is marked by the
i. The occipital condyles are oval in shape and are superior and inferior nuchal lines mentioned
situated on each side of the anterior part of above (Fig. 1.5).
the foramen magnum. Their long axis is c. The jugular foramen is large and elongated,
directed forwards and medially. They with its long axis directed forwards and medially. .Y
o
articulate with the superior articular facets of
the atlas vertebra to form the atlanto-occipital
It is placed at the posterior end of the petro- zo
occipital suture (Fig. 1.11a). !ttr
joints (Fig. 1.11). At the posterior end of the foramen, its anterior (E
ii. The hypoglossal or snterior condylar canal pierces wall (petrous temporal) is hollowed out to form t,(E
the bone anterosuperior to the occipital the jugular fossa which lodges the superior bulb of o
condyle, and is directed laterally and slightly the internal jugular vein. The fossa is larger on
forwards. the right side than on the left. C
o
iii. The condylar or posterior condylar canal is The lateral wall of the jugular fossa is pierced o
o
occasionally present in the floor of a condylar by a minute canal, the mastoid canaliculus. a
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HEAD AND NECK
Near the medial end of the jugular foramen, e. The pterygospinous process which is present at
there is the jugular notch. At the apex of the notch, the middle of medial pterygoid plate gives
there is an opening that leads into the cochlear attachment to the ligament of same name.
cannliculus. 5 The attachments on the lateral pterygoid plate are
The tympanic canaliculus opens on or near the as follows:
thin edge of bone between the jugular fossa and a. Its lateral surface gives origin to the lozuerhead of
the lower end of the carotid canal. lateral pterygoid muscle (Fig. 1.14).
d. Styloid process will be described in Chapter 8. b. Its medial surface gives origin to the deep head of
The stylomastoid foramerz is situated posterior to the medial pterygoid. The small, superficial head
the root of the styloid process, at the anterior end of this muscle arises from the maxillary tuberosity
of the mastoid notch. and the adjoining part of the pyramidal process
e. The mastoid process is a large conical projection of the palatine bone (Fig. 1.14).
located posterolateral to the stylomastoid 6 The infratemporal surface of the greater wing of the
foramen. It is directed downwards and for wards. sphenoid gives origin to the upper head of the lateral
It forms the lateral waIl of the mastoid notch pterygoid muscle, and is crossed by the deep temporal
(Fis. 1.s). and masseteric nerves.
7 The spine of lhe sphenoid is related laterally to the
Attacltments an exterior of skull auriculotemporal nerae, and medially to the chorda
1 The posterior border of the hard palate provides tympani nerae and auditory tube.
attachment to the palatine aponeurosis. The Its tip provides attachment to the (i) sphenomandi-
posterior nasal spine gives origin to the musculus bular ligament, (ii) anterior ligament of malleus, and
uvulae (Fig. 1.14). (iii) pterygospinous ligament.
2 The palatine crest provides attachment to a part of Its anterior aspect gives origin to the most posterior
the tendon of tensor r:eli palatini muscle (Fig. 1.1a). fibres of the tensor oeli palatini and tensor tympani
3 The attachments on the inferior surface of the muscles.
basiocciput are as follows: 8 The inferior surface of petrous temporal bone gives
a. The pharyngeal tubercle gives attachment origin to the leztator aeli palatini (Fig. 1.1a).
to the raphe which provides insertion to the 9 The margins of the foramen magnum provide
upper fibres of the superior constrictor muscle of attachment to:
the pharymx (Fig. 1.l4). a. The anterior atlanto-occipital membrane anteriorly
(see Fig.9.11).
b. The area in front of the tubercle forms the roof of
the nasopharynx and supports the pharyngeal b . T}lre posterior atlanto-occipital membrane posteriorly.
tonsil. c. The alar ligaments on the roughened medial
c. The longus capitis is inserted lateral to the surface of each occipital condyle (seeFig.9.12).
pharyngeal tubercle (Fig. 1.1a). 10 The ligamentum nuchae is attached to the external
occipital protuberance and crest.
d. The rectus capitis anterior is inserted a little
11 The rectus capitis lateralis is inserted into the inferior
posterior and medial to the hypoglossal canal
(Fig. 1.1a). surface of the jugular process of the occipital bone
(Fig. 1.1a).
4 The attachments on the medial pterygoid plate are
12 The following are attached to the squamous part of
as follows:
the occipital bone (Fig. 1.1a).
a. The pharyngobasilar fascia is attached below to the
The area between the superior and inferior nuchal
processus tuberis.
lines provides insertion medially to the semispinalis
Processus tuberis is a triangular projection capitis, and laterally to the superior oblique muscle.
which is present at the middle of the posterior The area below the inferior nuchal line provides
5 border of medial pterygoid plate. It supports the insertion medially to tlne rectus capitis posterior minor,
o medial end of cartilaginous part of auditory tube.
o and laterally to the rectus capitis posterior major
z b. The lower part of the posterior border, and the
!, (Fig. i.1a).
c(E pterygoid hamulus, give origin to the superior 13 The mastoid notch gives origin to the posterior belly of
!,(E constrictor of the pharynx. digastric muscle (Fig. 1.1a).
o c. The upper part of the posterior border is notched
by the auditory tube. Structures P assing through F orarnina
C
o d. The pterygomandibular raphe is attached to the tip 1 Each incisizte foramen transmits:
o of the pterygoid hamulus at one end and to the a. The terminal parts of the greater palatine aessels
o
a mandiblebehind 3rd molar tooth at the other end. from the palate to the nose.
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b. The terminal part of the nasopalatine neroe from 11 The structures passing through the for amen lacerum :
the nose to the palate (Fig. 1.11a). During life the lower part of the foramen is filled
2 The greater palatine foramen transmits: with cartilage, and no significant structure passes
a. The grenter palatine aessels. through the whole length of the canal, except for
b. The anterior pnlatine nerT)e, both of which run the meningeal branch of the ascending pharyngeal
forwards in the groove that passes forwards from artery and an emissary vein from the cavernous
the foramen (see Fig. 15.14). sinus.
3 The lesser palatine foramina transmit the middle and However, the upper part of the foramen is
posterior palatine neraes. traversed by the internal carotid artery with venous
4 The palatinoaaginal cannl transmits: and sympathetic plexuses around it. In the anterior
a. A pharyngeal branch from the pterygopalatine part of the foramen, the greater petrosal nerae lunites
ganglion (see Fig. 15.1.4). with the deep petrosal neroe to form the nerae of the
b. A small pharyngealbranch of the maxillary artery. pterygoid canal (Yidian's nerve) which leaves the
5 The aomerooaginal canal (if patent) transmits foramen by entering the pterygoid canal in the
branches of the pharyngeal branch from pterygo- anterior wall of the foramen lacerum (Fig. 1.15).
palatine ganglion and vessels. 12 The medial end of the p etrotympanicfissure transmits
6 T}ee foramen oaale transmits (mnemonic-MAlE) the chorda tympani nerve, anterior ligament of
a. The mandibular nerae (Fi1.1,.1,1) malleus and the anterior tympanic artery (Fig.
b. The accessory meningeal artery. 1.11a).
c. The lesser petrosal neruse L3 The foramen magnum (Fig. 1.16) transmits the
d. An emissaty aein connecting the cavernous sinus
following
with the pterygoid plexus of veins.
e. Anterior trunk of middle meningeal vein Through the narrow anterior part
(occasionally). a. Apical ligament of dens.
7 Tlaeforamen spinosumtransmits the middle meningeal b. Vertical band of cruciate ligament.
artery (Fig. f .i1a) the meningeal branch of the c. Membrana tectoria.
mandibular nerve or nervus spinosus, and the Through wider posterior part
posterior trunk of the middle meningeal vein. a. Lowest part of medulla oblongata.
8 The emissary sphenoidalforamen (foramen of Vesalius) b Three meninges.
transmits anemissary aein connecting the cavernous
Through the subarachnoid space pass:
sinus with the pterygoid plexus of veins.
9 \Mhen present the canaliculus innominatus transmils a. Spinal accessory nerves.
the lesser petrosal nerve, (in place of foramen ovale). b. Vertebral arteries.
L0 The carotid canal transmits the internal carotid artery, c. Sympathetic plexus around the vertebral arteries.
and the oenous and sympathetic plexuses around the d. Posterior spinal arteries.
artery (Fig. 1.11a). e. Anterior spinal artery.
Anterior Posterior
lnternal carotid artery and

sympathetic plexus
Greater petrosal nerve Deep petrosal nerve

(from sympathetic
plexus)
Pterygoid process
Petrous temporal .Y
o
Nerve of pterygoid canal
in pterygoid canal zo
E
tr
G
Emissary vein
tt(E
Meningeal branch of o
ascending pharyngeal
Pterygoid plexus of veins artery
C
Cartilage filling lower .9
end of foramen lacerum ()
Fig. 1.15: Structures related to the foramen lacerum ao
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HEAD AND NECK
Apical ligament
Upper vertical band of cruciate ligament
Arachnoid mater
Anterior
Dura mater
Lefl Righi Vertebral artery (4th part)
with sympathetic plexus
First tooth of ligamentum
Posterior denticulatum
Spinal root of accessory

Posterior spinal artery
nerve
Lowest part of medulla oblongata Pia mater
Fig. 1.16: Structures passing through foramen magnum
14 The hypoglossal or anterior condylar canal transmits 19 The stylomastoid foramen transmits the facial nerve
the hypoglossal nerae, the meningeal branch of the and the stylomastoid branch of the posterior
hypoglossal nerve (these are the sensory fibres of auricular artery.
cervical first spinal nerve supplying the duramater
of posterior cranial fossa) the meningeal branch of
the ascending pharyngeal artery, and an emissary
oein conrrecting the sigmoid sinus with the internal
Before beginning a systematic study of the interior, the
jugular vein (Table 1.1).
following general points may be noted.
15 The posterior condylar canal transmits an emissary
vein connecting the sigmoid sinus with suboccipital
1 The cranium is lined intemallyby endocranium which
is continuous with the pericranium through the
venous plexus (Table 1.1).
foramina and sutures.
16 The jugular foramen transmits the following 2 The thickness of the cranial vault is variable. The
structures: bones covered with muscles, i.e. temporal and
i. Through the anterior part: posterior cranial fossae are thinner than those
(a) Inferior petrosal sinus. covered with scalp. Further, the bones are thinner in
(b) Meningeal branch of the ascending pharyngeal females than in males, and in children than in adults.
artery. 3 Most of the cranial bones consist of:
ii. Through the middle part:IX,X andXl cranial nerves. a. An outer table of compact bone which is thick,
iii. Through the posterior part: resilient and tough.
a. Internal jugular vein (Fig. 1.11a). b. An inner table of compact bone which is thin and
b. Meningeal branch of the occipital artery. brittle.
The glossopharyngeal notch near the medial end of c. The diploe which consists of spongy bone filled
the jugular foramen lodges the inferior ganglion of with red marrow in between the two tables.
the glossopharyngeal nerve. The skull bones derive their blood supply mostly
L7 The mastoid canaliculus (Arnold's canal) in the from the meningeal arteries from inside and very little
lateral wall of the jugular fossa transmits the from the arteries of the scalp. Blood supply from the
auricular branch of the vagus (Arnold's nerve). The outside is rich in those areas where muscles are
.Y nerve passes laterally through the bone, crosses the attached, e.g. the temporal fossa and the suboccipital
o region. The blood from the diploe is drained by four
zo facial canal, and emerges at the tympanomastoid
fissure. The nerve is extracranial at birth, but diploic veins on each side draining into venous sinuses
t (Table 1..2 and Fig. 1.17).
(E becomes surrounded bybone as the tympanic plate
t,(E and mastoid process develop (also called Many bones like vomer (Latin plowshare), pterygoid
o Alderman's nerve). plates do not have any diploe.
I
18 The tymp anic canaliculus on the thin edge of partition
c between the jugular fossa and carotid canal INTERNAL SURFACE OF CRANIAL VAUIT
.9
o transmits the tympanic branch of glossopharlmgeal The shape, the bones present and the sutures uniting
ao nerve (Jacobson's nerve) to the middle ear cavity. them have been described with the norma verticalis.
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:;;'r;;';'','" :. :: : :.: ': ::. .r.::' ,.::::,1:::tlj:.,a:i.::t1.1]ii:ti;,

'-,::';:t!ute'iii]: i,.Fiddi*-vli 1.,;:"::::,ii::i:i:,,:,
Vein Foramen Drainage

1. Frontal diploic vein Supraorbital foramen Drain into supraorbital vein
2. Anterior temporal or parietal diploic vein ln the greater wing of sphenoid Sphenoparietal sinus or in anterior
deep temporal vein
3. Posterior temporal or parietal diploic vein Mastoid foramen Transverse sinus
4. Occipital diploic vein (largest) Foramen in occipital bone Occipital vein or confluence of sinuses
5. Small unnamed diploic veins Pierce inner table of skull close to the Venous lacunae
margins of superior sagittal sinus
Anterior lemporal
Posterior temporal
Occipital
Diploe
Fig. 1.17: Diploic veins in an adult
The following features may be noted: accompanying vein runs upwards L cm behind
a. The inner table is thin and brittle. It presents the coronal suture. Smaller grooves for the
markings produced by meningeal vessels, venous branches from the anterior and posterior branches
sinuses, arachnoid granulations, and to some of the middle meningeal vessels run upwards and
extent by cerebral gyri. It also presents raised backwards over the parietal bone (Fig. 1.8).
ridges formed by the attachments of the dural f. The parietal foramina open near the sagittal
folds. sulcus 2.5 to 3.75 cm in front of the lambdoid
b. The frontal crest lies anteriorly in the median suture (Fig. 1.2).
plane. It projects backwards. g. The impressions for cerebral gyri are less distinct. .Y
o
These become very prominent in cases of raised
c. The sagittal sulcusruns from before backwards in
the median plane. It becomes progressively wider intracranial tension.
zo
E
posteriorly. It lodges the superior sagittal sinus. tr
(E
INTERNAL SURFACE OF THE BASE OF SKULL !,(E
d. The granular fozteolae are deep, irregular,large, pits
situated on each side of the sagittal sulcus. They The interior of the base of skull presents natural o
are formed by arachnoid granulations. They are subdivisions into the anterior, middle and posterior
larger and more numerous in aged persons. cranial fossae. The dura mater is firmly adherent to the C
.9
e. The oascular markings. The groove for the anterior floor of fossae and is continuous with pericranium o
branch of the middle meningeal artety, and the through the foramina and fissures. ao
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HEAD AND NECK
Anterior Croniol Fosso #fit*rSsmfures

#*:*st#egryes 1 The cribrifurm plate of the ethmoid bone separates the
Anteriorly and on the sides,by the frontal bone (Fig. 1.18). anterior cranial fossa from the nasal cavity. It is
quadrilateral in shape (Fig. 1.18).
Posteriorly, it is separated from the middle cranial
a. Anterior margin articulates with the frontal bone
fossa by the free posterior border of the lesser wing of the
atthefrontoethmoidal suturewhich is marked in the
sphenoid, the anterior clinoid process, and the anterior
median planeby theforamen caecum. This foramen
margin of the sulcus chiasmaticus.
is usually blind, but is occasionally patent.
b. Posterior margin articulates with the jugum
fff**r sphenoidale. At the posterolateral corners, we see
In the median plane, it is formed anteriorly by the the posterior ethmoidal canals.
cribrifurm plate of the ethmoid bone, and posteriorly by c. Its lateral margins articulate with the orbital plate
the superior surface of the anterior part of the body of of the frontal bone: the suture between them
the sphenoid or jugum sphenoidale. presents the anterior ethmoidal canal placedbehind
On each side, the floor is formed mostly by the orbital the crista galli (Fig. 1.18).
plate of the frontal bone, and is completed posteriorly by Anteriorly, the cribriform plate has a midline
the lesser wing of the sphenoid. projection called the crista galli (Latin cock's comb).
Anterior ethmoidal canal

Posterior ethmoidal canal
Ethmoid bone
Frontal sinus
Cribriform plaie of ethmoid
Optic canal
Crista galli
Frontal bone
Lesser wing of sphenoid bone
Superior orbital fissure
Greater wing of sphenoid bone
Hypophyseal fossa (sella turcica)
Posterior clinoid process
Space for trigeminal ganglion
Temporal bone, petrous part
lnternal acoustlc meatus
Groove for sigmoid sinus
Jugular foramen
J
o
zo Foramen magnum
t Hypoglossal canal
E
(E Cerebellar fossa
!,(E
o Groove for
I transverse sinus Confluence of the sinuses
(internal occipital protuberance)
Cerebral fossa
(occipital lobe)
.o
()
o)
U) Fig. 1.18: The cranial fossae. The boundaries of the bones present in the floor of the fossae are shown in interrupted lines
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On each side of the crista galli there are foramina temporal and anterior surface of petrous temporal on
through which the anterior ethmoidal nerzte and oessels each side.
pass to the nasal cavity. The plate is also perforated
by numerous foramina for the passage of olfactory #fftprFesfures
nerve rootlets.
Median area
The jugum sphenoidale separates the anterior cranial
The body of the sphenoid presents the following
fossa from the sphenoidal sinuses.
features.
The orbital plate of the frontal bone separates the
anterior cranial fossa from the orbit. It supports the 1 The sulcus chiasmaticus or optic grooae leads, on each
orbital surface of the frontal lobe of the brain, and side, to the optic canal. The optic chiasma does not
presents reciprocal impression s. The fr ont al air sinus occupy the sulcus, it lies at a higher level well behind
may extend into its anteromedial part. The medial the sulcus.
margin of the plate covers the labyrinth of the 2 The optic cannl leads to the orbit. It is bounded
ethmoid; andtheposterior margin articulates with the laterally by the lesser wing of the sphenoid, in front
lesser wing of the sphenoid. and behind by the two roots of the lesser wing, and
Thelesser roing of the sphenoid isbroad medially where medially by the body of sphenoid.
it is continuous with the jugum sphenoidale and tapers 3 The sella turcica (pituitary fossa or hypophyseal fossa)
laterally. The free posterior border fits into the stem of The upper surface of the body of the sphenoid is
the lateral sulcus of the brain It ends medially as a hollowed out in the form of a Turkish saddle, and is
prominent proj ection, th e ant er ior clinoid p r o c e s s. Inf e- known as the sella turcica. It consists of the tub er culum
riorly, the posterior border forms the upper boundary sellae infront, the hypophyseal fossa in the middle and
of the superior orbitalfissure.Medially, the lesser wing the dorsum sellnebehind (Fig. 1.18).
is connected to the body of the sphenoidby anterior The tuberculum sellae separates the optic groove from
and posterior roots, which enclose the optic canal. llre hypophyseal fossa.Its lateral ends form the middle
clinoid process which may join the anterior clinoid
procEss.
Fracture of the anterior cranial fossa may cause The hypophy seal fossa lodges the hypophysis cerebri.
bleeding and discharge of cerebrospinal fluid Beneath the floor of fossa lie the sphenoidal air sinuses.
through thenose.Itmay also cause a conditioncalled The dorsum sellae is a transverse plate of bone
btackeye whieh is produced by seepage of blood into projecting upwards; it forms the back of the saddle. The
the eyelid, as frontalis muscle has no bony origin superolateral angles of the dorsum sellae are expanded
(see Fig.2.8). to form the posterior clinoid processes.
Middle Cronio! Fosso Lateral area

It is deeper than the anterior cranial fossa, and is shaped 1 The lateral area is deep and lodges the temporal lobe
like abutterfly,beingnarrow and shallow in the middle; of the brain.
and wide and deep on each side. 2 It is related anteriorly to the orbit, laterally to the
temporal fossa, and inferiorly to the infratemporal
#sumd*riss fossa.
Anteriar 3 The superior orbital fissure opens anteriorly into the
1 Posterior border of the lesser wing of the sphenoid. orbit. It is bounded above by the lesser wing, below
2 Anterior clinoid process. by the greater wing, and medially by the body of
3 Anterior margin of the sulcus chiasmaticus. the sphenoid (see Fig. 13.4).
Posterior The medial end is wider than the lateral.
1 Superior border of the petrous temporal bone. The long axis of the fissure is directed laterally, ,,x
upwards and forwards. The lower border is marked o
2 The dorsum sellae of the sphenoid.
by a small projection, which provides attachment to zo
Lateral !tc
the common tendinous ring of Zinn The ring divides (E
1 Greater wing of the sphenoid. the fissure into three parts. !,
2 Anteroinferior angle of the parietal bone. 4 The greater wing of the sphenoidpresents the following
G
o
3 The squamous temporal bone. features:
Floor a. The foramen rotundum.It leads anteriorly to the o
Floor is formed by body of sphenoid in the median pterygopalatine fossa containing pterygopalatine o
region and by greater wing of sphenoid, squamous ganglia (Table 1.3). a0)
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HEAD AND NECK
b. Theforamen ooalelies posterolateral to the foramen e. The tegmen tympani is a thin plate of bone
rotundum and lateral to the lingula. It leads anterolateral to the arcuate eminence. It forms a
inferiorly to the infratemporal fossa (Fig. 1.18). continuous sloping roof for the tympanic antrum,
c. The foramen spinosum lies posterolateral to the for the tympanic cavity and for the canal for the
foramen ovale. It also leads, inferiorly, to the tensor tympani.
infratemporal fossa (Fig. 1.18). The lateral margin of the tegmen tympani is
d. The emissary sphenoidal foramen or foramen of turned downwards, it forms the lateral wall of the
Vesalius. It carries an emissary vein. bony auditory tube.
The fornmen lacerum lies at the posterior end of the Its lower edge is seen in the squamotympanic
carotid groove, posteromedial to the foramen fissure and divides it into the petrosquamous and
ovale. petrotympanic fissures.
The anterior surface of the petrous temporal bone presents 7 The cerebral surface of the squamous temporal bone is
the following features: concave. It shows impressions for the temporal lobe
a. The trigeminal impression lies near the apex, behind and grooves for branches of the middle meningeal
the foramen lacerum. It lodges the trigeminal vessels.
ganglion within its dural cave (see Fig. 12.13).
b. The hiatus and grooae for the greater petrosal neroe
are present lateral to the trigeminal impression. Fracture of the middle cranial fossa produces:
They lead to the foramen lacerum (Table 1.3). a. Bleeding and discharge of CSF through the ear.
c. The hiatus and grooae for the lesser petrosal nerae,lie b, Bleeding through the nose or mouth may occur
lateral to the hiatus for the greater petrosal nerve. due to involvement of the sphenoid bone,
They lead to the foramen ovale or to canaliculus c. The $eventh and eighth cranial nelves may be
innominatus to relay in otic ganglion. damaged if the foacture al6o passes through the
d. Still more laterally there is the arcuate eminence intemal acoustic meatus. If a semicirculd canal is
produced by the superior semicircular canal. damaged, vertigo may occur.
Gangtia Sensory root Sympathetic roort Secretotmotor root/ Motor root Distribution
parasympathetic root
Ciliary From nasociliary Plexus along Edinger-Westphal a. Ciliaris muscles
(see Fig.13.11) nerve ophthalmic nucleus -+ b. Sphincter pupillae
artery oculomotor
nerve -+nerve to
inferior oblique
Otic from
Branch Plexus along lnferior salivatory Branch from a. Secretomotor to
(see Fig. 6.15) auriculotemporal middle meningeal nucleus -+glosso- nerve to medial parotid gland via
nerve artery pharyngeal nerve -+ pterygoid auriculotemporal
tympanic branch -+ nerve
tympanic plexus --> Tensor veli palatini
lesser petrosal nerve. and tensor tympani
via nerve to med.
pterygoid (unrelayed)
Pterygopalatine 2 branches from Deep petrosal Superior salivatory a. Mucous glands of
(see Fig. 15.15) maxillary nerve from plexus nucleus, and lacrima- nose, paranasal
around internal tory nucleus -)nervus sinuses, palate,
artery
carotid intermedius -+facial nasopharynx
.Y
o nerve -rgeniculate b. Some fibres pass
zo ganglion -+greater through zygomatic
tc petrosal nerve + deep nerve - zytemp.
(E petrosal D€fv€ = fleIV€ nerve - communica-
ttG of pterygoid canal ting branch to lacrimal
o nerve - Iacrimal gland
I
Submandibular 2 branches from Branch from Superior salivatory a. Submandibular,
C (see Fig.7.10) lingual nerve plexus around nucleus -->facial nerve b. Sublingual and
.9
o facial artery -+chorda tympani c. Anterior lingual glands
o (oins the lingual nerve)
U)
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Poslerior Croniol Fosso b. The internal occipital crest runs in the median plane
This is the largest and deepest of the three cranial fossae. from the internal occipital protuberance to the
The posterior cranial fossa contains thehindbrain which foramen magnum where it forms a shallow
consists of the cerebellum behind and the pons and medulla depression, the aermian fossa (Fig.1..1.8).
in c. The transoerse sulcus is quite wide and runs
front.
laterally from the internal occipital protuberance
Sqrum#rynes to the mastoid angle of the parietal bone where it
becomes continuous with the sigmoid sulcus. The
Anterior
transverse sulcus lodges tlrLe transoerse sinus. T}:.e
1 The superior border of the petrous temporal bone. right transverse sulcus is usually wider than the
2 The dorsum sellae of the sphenoid bone (Fig. 1.18). left and is continuous medially with the superior
Posterior sagittal sulcus (Fig. 1.18).
Squamous part of the occipital bone. d. On each side of the internal occipital crest there
are deep fossae which lodge the cerebellar
On each side hemispheres (Fig. 1.18).
1 Mastoid part of the temporal bone.
2 The mastoid angle of the parietal bone. Lateral srea
L The condylar part of the occipitnlbone is marked by the
Fkpor following:
a. The jugular tubercle lies over the occipital condyle.
Median area
b. The hypoglossal canal (anterior condylar canal)
L Sloping area behind the dorsum sellae or clivus in
pierces the bone posteroanterior to the jugular
front tubercle and runs obliquely forwards and laterally
2 The foramen magnum in the middle along the line of fusion between the basilar and
3 The squamous occipital behind. the condylar parts of the occipital bone.
Lnteral area c. The condylar canal (posterior condylar canal) opens
L Condylar or lateral part of occipital bone. in the lower part of the sigmoid sulcus which
2 Posterior surface of the petrous temporal bone. indents the jugular process of occipital bone.
3 Mastoid temporal bone. 2 The posterior surface of the petrous part of the temporal
bone forrns the anterolateral wall of the posterior
4 Mastoid angle of the parietal bone. cranial fossa. The following features may be noted:
a. The internal acoustic meatus opens above the
#ffumrFe*fures
anterior part of the jugular foramen. It is about
Median ares 1 cm long and runs transversely in a lateral
1 The clious isthe sloping surface in front of the foramen direction. It is closed laterally by a perforated plate
magnum. It is formed by fusion of the posterior part of bone known aslamina cribrosa which separates
of the body of the sphenoid including the dorsum it from the internal ear (Fig. 1.18).
sellae with the basilar part of the occipital bone or b. The orifice of the aqueduct of the aestibule is a
basiocciput. It is related to the basilar plexus of oeins, narrow slit lying behind the internal acoustic
and supports the pons and medulla (Fig. 1.18). meatus.
On each side, the clivus is separated from the petrous c. The subarcuate fossa lies below the arcuate
temporal bone by the petro-occipital fissure which is eminence, lateral to the internal acoustic meatus.
grooved by the inferior petrosal sinus, and is 3 The jugular foramen lies at the posterior end of the
continuous behind with the jugular foramen. petro-occipital fissure. The upper margin is sharp
2 The foramen magnum lies in the floor of the fossa. The and irregular, and presents the glossopharyngeal notch.
anterior part of the foramen is narrow because it is The lower margin is smooth and regular. .|a
o
oaerlapped by the medial surfaces of the occipital 4 The mastoid part of the temporal bone forrns the lateral zo
condyles. wall of the posterior cranial fossa just behind the !tc
3 The squamous part of the occipital bone shows the petrous part of the bone. Anteriorly, it is marked by (E
following features: the sigmoid sulcus which begins as a downward tt(6

a. The internal occipital protuberance lies opposite continuation of the transverse sulcus at the mastoid o
the external occipital protuberance. It is related angle of the parietal bone, and ends at the jugular
to the confluence of sinuses, and is grooved on foramen. The sigmoid sulcus lodges t}i.e sigmoid sinus o
each side by the beginning of transverse sinuses which become the internal jugular vein at the jugular ()
(see Fig.12.2). foramen (Fig. 1.18). The sulcus is related anteriorly ao
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HEAD AND NECK
to the tympanic antrum. The mastoid foramen opens 4 The jugular tubercle is grooved by the ninth, tenth
into the upper part of the sulcus. and eleaenth uanial neroes as they pass to the jugular
foramen.
5 The subarcuate fossa on the posterior surface of
petrous temporal bone lodges the flocculus of the
Fracture of the posterior cranial fossa causes bruising cerebellum.
over the mastoid region extending down over the
sternocleidomastoid muscle. Sfrrurfures F*ssi*g fftr*a;grf'l Fererrurrta
The following foramina seen in the cranial fossae have
,&ffex*ftm*r:fs *n# ffsf*fr+ms; fr:fsri*r *f ffte Sfue.rff been dealt with under the normal basalis: foramen
Attschment on uault ovale, foramen spinosum, emissary sphenoidal
foramen, foramen lacerum, foramen magnum/ jugular
1 The frontal crest gives attachment to the falx cerebri foramen, hypoglossal canal, and posterior condylar
(see Fig. 12.1).
canal. Additional foramina seen in the cranial fossae
2 The lips of the sagittal sulcus give attachment to the
are as follows.
falx cerebri (see Fig. 12.1).
1 The foramen caecum in the anterior cranial fossa is
Anterior cranial fassa usually blind, but occasionally it transmits a vein
1 The crista galli gives attachment to the falx cerebri. from the upper part of nose to the superior sagittal
2 The orbital surface of the frontal bone supports the sinus.
frontal lobe of the brain. 2 The posterior ethmoidal canal transmit the vessels of the
3 The anterior clinoid processes give attachment to the same name. Note that the posterior ethmoidal nerye
free margin of the tentorium cerebelli (see Fig.12.2). does not pass throughthe canal as it terminate earlier'
3 The anterior ethmoidal canal transmit the corres-
Middle cranial fassa ponding nerve and vessels.
1 The middle cranial fossa lodges the temporal lobe of 4 The optic canal transmits the optic nerve and the
the cerebral hemispher e. ophthalmic artery.
2 The tuberculum sellae provides attachment to the 5 The three parts of the superior orbital fissure (see
diaphragma sellae (see Fig.12.$. Fig. 13.a) transmit the following structures:
3 The hypophyseal fossa lodges the hypophysis cerebri. Lateral part
4 Upper margin of the dorsum sellae provides a. Lacrimal nerve
attachment to the diaphragma sellae, and the b. Frontal nerve
posterior clinoid process to anterior end of the c. Trochlear nerve
attached margin of tentorium cerebelli and to the d. Superior ophthalmic vein
petrosphenoidal ligament (see Fig. 12.2). Middle part
5 One caTJernous sinus lies on each side of the body of a. Upper and lower divisions of the oculomotor
the sphenoid. The internal carotid artery passes nerve (Table 1.5).
through the cavernous sinus (see Fig.12.5). b. Nasociliary nerve in between the two divisions of
6 The superior border of the petrous temporal bone is the oculomotor.
grooved by the superior petrosal sinus and provides c. The abducent nerve, inferolateral to the foregoing
attachment to the attached margin of the tentorium nerves (see Fig. 13.4).
cerebelli.It is grooved in its medial part by the
trigeminnl neroe (trigeminal impression). Medial part
a. Inferior ophthalmic vein.
Pastefiar cranial Jbssa b. Sympathetic nerves from the plexus around the
.!< 1 The posterior cranial fossa contains the hindbrain internal carotid artery.
o 5 The foramen rotundum transmits the maxillary nerve
which consists of the cerebellum behind, and the
zo pons and medulla in front. (see Fig.1.5.1.6).
tc 7 The internal acoustic meatus transmits the seaenth and
(E 2 The lower part of the clivus provides attachment to
t,(E the apical ligament of the dens near the foramen eighth cranial neraes and the labyrinthine aessels.
o magnum, upper vertical band of cruciate ligament
and to the membrana tectoria just above the apical Frsrueipfes #*v*rnrng Frs*fs.rres sf ffte Skq,rdd
c
o
ligament (Fig.1.16). 1 Fractures of the skull are prevented by:
.F
O 3 The internal occipital crest gives attachment to the a. Its elasticity.
ao falx cerebelli. b. Rounded shape.
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I NTRODUCTION AND OSTEOLOGY
c. Construction from a number of secondary elastic

arches, each made up of a single bone.
d. The muscles covering the thin areas.
Since the skull is an elastic sphere filled with the
semifluid brain, a violent blow on the skull produces
a splitting ffict cornmencing at the site of the blow
and tending to pass along the lines of least resistance.
T}ne base of the skull is more fragile tt.an the vault, and
is more commonly involved in such fractures,
particularly along the foramina.
The inner table is more brittle than the outer table.
Therefore, fractures are more extensive on the inner
table. Occasionally only the inner table is fractured
and the outer table remains intact.
The common sites of fracture in the skull are:
a. The parietal nrea of the vault.
b. The middle uanial fossa of the base. This fossa is
Fig. 1.19: Diagram comparing the orientation of the orbital axis
weakened by numerous foramina and canals.
and the visual axis
The facial bones commonly fractured are:
a. The nasalbone
b. The mandible. ffsfite{, F*qxfuras
L The lacrimnl fossa, placed anterolaterally, lodges the
lacrimal gland (Fig. 1.20).
2 The optic canal lles posteriorly, at the junction of the
roof and medial wall (Figs L.20 and 1.21).
The orbits are pyramidal bony cavities, situated one
3 The trochlear fossa, lies anteromedially' It provides
on each side of the root of the nose. They provide
attachment to the fibrous pulley or trochlea for the
sockets for rotatory movements of the eyeballs. They
tendon of the superior oblique muscle (Fig. 1.20).
also protect the eyeballs.
LqterolWoll
SHAPE AND DISPOSITION
This is the thickest and strongest of all the walls of the
Each orbit resembles a four-sided pyramid. Thus, it has:
orbit. It is formed:
. An apex situated at the posterior end of orbit at the
medial end of superior orbital fissure. L By the anterior surface of the greater wing of the
. sphenoid bone posteriorly (Fig. 1.21).
A base seen as the orbital opening on the face.
. Four walls:
2 The orbital surface of the frontal Process of the
zy gornatic bone anteriorlY.
Roof, floor,lateral and medial walls.
The long axis of the orbit passes backwards and #eJsfvovts
medially. The medial walls of the two orbits are parallel 1 The greater wing of the sphenoid separates the orbit
and the lateral walls are set at right angles to each other from the middle cranial fossa.
(Fig. 1.1e).
2 The zygomatic bone separates it from the temporal
fossa.
Roof
.:a
It is concave from side to side. It is formed: Fdmnne# Fe*fe*res o
L Mainly by the orbital plate of the frontal bone, 1 The superior orbitalfissure occupies the posterior part
zo
2 It is completed posteriorly by the lesser wing of the t,tr
of the junction between the roof and lateral wall. (E
sphenoid (Fig.1.20). in the
2 The foramen for the zygomatic nerzte is seen !,(E
zygomatic bone. o
treislfror?s 3 lMitnall's or zygomatic tubercle is a palpable elevation
1 It separates the orbit from the anterior cranial fossa' on the zygomaticbone just within the orbital margin. o
2 The frontal air sinus may extend into its anteromedial It provides attachment to the lateral check ligament ()
part. of eyeball (Fig. 1.20). ao
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HEAD AND NECK
Supraorbital notch
Lacrimal fossa
Trochlear fo$sa
Lesser wing
of sphenoid
Superior orbital fissure Optic canal
Anterior and posterior

Whitnall's tubercle
Ethmoidal canal
Orbital plate of ethmoid
Greater wing of sphenoid

Lacrimal groove
Orbital branches of pterygopalatine ganglion
Lacrimal bone
Orbital surface of zygomatic bone
Frontal process of maxilla
Foraman for zygomatic nerve Body of the sphenoid
Zygomatic nerve in
inferior orbital fissure
Origin of inferior oblique muscle
lnfra-orbital nerve and
arterv with oroove Orbital surface of maxilla
lnfra-orbital foraman
Orbital process of palatine
Fig. 1.20: The orbit seen from the front (schematic)
Optic canal
Orbital surface of lesser

wing of sphenoid bone
Supraorbital notch
Superior orbital fi ssure
Orbital surface of frontal bone
Orbital surface of greater
wing of sphenoid bone Orbital plate of ethmoid bone
Lacrimal bone
Orbital process of palatine bone
Fossa for lacrimal sac
Zygomaticofacial foramen lnfraorbital groove
Orbiial surface of zygomatic bone

lnfraorbiial foramen
lnferior orbital fissure

Orbital surface of maxilla
Fig. 1.21 : The orbit seen from the front
Floor f\$mnlsd Fesferres

L It slopes upwards and medially to join the medial wall.
o
o 1 The inferior orbital fissure occupies the posterior part
z It is formed: of the junction between the lateral wall and floor.
t,tr 1. Mainly by the orbital surface of the maxilla (Fig. 1.21). Through this fissure, the orbit communicates with
G 2 By the lower part of the orbital surface of the the infratemporal fossa anteriorly and with the
tt(E zy gomatic bone, anterolaterally. pterygopalatine fossa posteriorly (Figs 1.20 md1..2l).
o
3 The orbital process of the palatine bone, at the 2 The infraorbital groooe runs forwards in relation to
posterior angle. the floor.
c
o
(J
o
#sJmfion 3 A small depression on anteromedial part of the
a It separates the orbit from the maxillary sinus. floor gives origin to inferior oblique muscle.
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MediolWoll 2 Foetal skeleton is small as compared to calvaria. In

It is very thin. From before backwards it is formed by: foetal skull, the facial skeleton is 1./7th of calvaria;
1 The frontal process of the maxilla. in adults, it is half of calvaria. The foetal skeleton is
2 The lacrimal bone (Fig. 1.21). small due to rudimentary mandible and maxillae,
3 The orbital plate of the ethmoid. non-eruption of teeth, and small size of maxillary
4 The body of the sphenoid bone. sinus and nasal cavity. The large size of calvaria is
due to precocious growth of brain.
&efsffons 3 Base of the skull is short and narrow, though internal
1 The lacrimal grooT)e, formed by the maxilla and the ear is almost of adult size the petrous temporal has
lacrimal bone, separates the orbit from the nasal not reached the adult length.
cavity.
2 The orbital plate of the ethmoid separates the orbit STRUCTURE OF BONES
from the ethmoidal air sinuses. The bones of cranial vault are smooth and unilamellar;
3 The sphenoidal sinuses, are separated from the orbit there is no diploe. The tables and diploe appear by
only by a thin layer of bone. fourth year of age (Fig. 1.17 and Table 1.2).
ffamed Features Bony Prominences
1 The lacrimal groove lies anteriorly on the medial 1 Frontal and parietal tubera are prominent.
wall. It is bounded anteriorly by the lacrimal crest of 2 Glabella, superciliary arches and mastoid processes
the frontal process of the maxilla, and posteriorly by are not developed.
the crest of the lacrimal bone. The floor of the groove
is formed by the maxilla in front and by the lacrimal Poronosol Air Sinuses
bone behind. The groove lodges the lacrimal sac
These are rudimentary or absent.
which lies deep to the lacrimal fascia bridging the
lacrimal groove. The groove leads inferiorly, through
Temporol Bone
the nasolacrimal duct, to the inferior meatus of the
nose (Fig. 1.21). 1 The intemal ear, tympanic cavity, tympanic antrum,
2 The anterior and posterior ethmoidal foramina lie on the and ear ossicles are of adult size.
frontoethmoidal suture, at the junction of the roof 2 The tympanic part is represented by an incomplete
and medial wall. tympanic ring.
3 Mastoid process is absent, it appears during the later
Sorsrxrn* m R*loffon fo ffte #rbif
part of second year.
1 The structures passing through the optic canal and 4 External acoustic meatus is short and straight. Its
through the superior orbital fissure have been bony part is unossified and representedby a
described in cranial fossae (see Fig. 13.4). fibrocartilaginous plate.
2 The inferior orbital fissure transmits:
5 Tympanic membrane faces more downwards than
a. The zygomatic nerue,
laterally due to the absence of mastoid process.
b. The orbital branches of the pterygopalatine ganglion,
c. The infraorbital nerae and oessels, and the 6 Stylomastoid foramen is exposed on the lateral
communication between the inferior ophthalmic surface of the skull because mastoid portion is flat.
vein and the pterygoid plexus of veins (Fig. 1.20). 7 Styloid process lies immediately behind the
3 The infraorbital grooue and canal transmit the tympanic ring and has not fused with the remainder
corresponding nerve and vessels. of the temporal bone.
4 The zygomntic foramen transmits the zygomatic nerve. 8 Mandibular fossa is flat and placed more laterally,
5 The anterior ethmoidal foramen transmit the and the articular tubercle has not developed.
corresponding nerve and vessels. 5
9 The subarcuate fossa is very deep and prominent. o
o
6 Posterior ethmoidal foramen only transmit vessels of 10 Facial canal is short. z
same name (Fig. 1.20). E'
c(E
Orbils !t(E
These are large. The germs of developing teeth lies close o
E
to the orbital floor. Orbit comprises base or an outer
DIMENSIONS opening with upper, lower medial and lateral waIls. C
o
1, Skull is large in proportion to the other parts of Its apex lies at the optic foramen/canal. It also has F()
skeleton. superior and inferior orbital fissures. ao
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HEAD AND NECK
Closure of Fontonelles
Two halves of frontal bone are separated by Anterior fontanelle (bregma) by 18 months, mastoid
metopic suture. fontanelle by 12 months, posterior fontanelle (lambda)
The mandible is also present in two halves. It is a
by 2-3 months and sphenoidal fontanelle also by 21
derivative of first branchial arch. months (Fig. 1.3).
Occipital bone is in four parts (squamous one,
condylar two, and basilar one).
. The four bony elements of temporal bone are
r Fontanelles helps to determine the age in l1yearc
separate, except for the commencing union of the of child.
tympanic part with the squamous and petrous . Helps to know the intracranial pressure. In case
parts. The second centre for styloid process has of increased pressure bulging is seen and in case
not appeared. of dehydration depression is seen at the site of
. Unossified membranous Baps, a total of 6 fontanelles.
fontanelles at the angles of the parietal bones are
present (Fig. 1.3). Thickening of Bones
. Squamous suture between parietal and squamous L Two tables and diploe aPPear by fourth year.
temporal bone is present. Differentiation reaches maximum by about 35 years/
when the diploic veins produce characteristic
marking in the radiographs.
POSTNATAI. GROWTH OF SKULL
2 Mastoid process appears during second year, and
The growth of calvaria and facial skeleton proceeds at the mastoid air cells during 6th year.
different rates and over different periods. Growth of
calvaria is related to growth of brain, whereas that of Obliterotion of Sulures of the Voult
the facial skeleton is related to the development of L Obliteration begins on the inner surface between 30
dentition, muscles of mastication, and of the tongue. and 40 years, and on the outer surface between 40
The rates of growth of the base and vault are also and 50 years.
different.
2 The timings are variable, but it usually takes place
first in the lower part of the coronal suture, next in
Growlh of the Voull
the posterior part of the sagittal suture, and then in
"1. Rate: Rapid during first year, and then it slows up to
the lambdoid suture.
. the seventh year when it is almost of adult size.
2 Grctwth in breadth: This growth occurs at the sagittal ln Old Age
suture, sutures bordering greater wings, occipito- The skull generally becomes thinner and lighter but
mastoid suture, and the petro-occipital suture at the in small proportion of cases it increases in thickness
base. and weight. The most striking feature is reduction in
3 Growth in height: This growth occurs at the fronto- the size of mandible and maxillae due to loss of teeth
zygomatic suture, pterion, squamosal suture, and and absorption of alveolar processes. This causes
asterion. decrease in the vertical height of the face and a change
4 Growth in anteraposterior dinmeter: This growth occurs in the angles of the mandible which become more
at the coronal and lambdoid sutures. obtuse.
Growth of the Bose SEX DIFFERENCES IN THE SKULT

The base grows in anteroposterior diameter at three There are no sex differences until puberty. The
ta cartilaginous plates situated between the occipital and postpubertal differences are listed in Table 1.4'
o sphenoid bones, between the pre- and post-sphenoids,
zo and between the sphenoid and ethmoid. Wolmion or Sululol Bones
tttr
(E These are small irregular bones found in the region of
t,G Growth of the Foce the fontanelles, and are formed by additional
o 1 Growth of orbits and ethmoid is complete by seventh ossification centres.
yeat. They are most common at the lambda and at the
c 2 In the face, the growth occurs mostly during first asterion; common at the pterion (epipteric bone); and
.9
o year, although it continues till puberty and even rare at the bregma (os Kerkring). Wormian bones are
o
@ later. common in hydrocephalic skulls.
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tNrRoDUcloN AND osrEor-oGy "!"
W
Table 1.4: Sex differenceC'in'the skull
Features Males Females
1. Weight Heavier Lighter
2. Size Larger Smaller
3. Capacity Greater in males 10% less than males
4. Walls Thicker Thinner
5. Muscular ridges, glabella, More marked Less marked
superciliary arches, temporal
lines, mastoid processes,
superior nuchal lines, and
external occipital protuberance
6. Tympanic plate Larger and margins are more roughened Smaller and margins are
less roughened
7. Supraorbital margin More rounded Sharp
8. Forehead Sloping (receding) Vertical
9. Frontal and parietal tubera Less prominent More prominent
10. Vault Rounded Somewhat flattened
11 . Contour of face Longer due to greater depth of the jaws. Chin is bigger Rounded, facial bones are
and projects more forwards. ln general, the skull is smoother, and mandible
more rugged due to muscular markings and and maxillae are smaller.
processes; and zygomatic bones are more massive
CRANIOMETRY i.e. neurocranium, which are inversely proportional to

Cepholic lndex each other. The angle is smallest in the most evolved
races of man, it is larger in lower races/ and still larger
It expresses the shape of the head, and is the proportion
in anthropoids.
of breadth to length of the skull. Thus:
Abnormol Cronio
Cephalic index = P'1F
Length
* 1ss
O xycephaly or acrocephaly, tower-skull, or steeple-skull
is an abnormally tall skull. It is due to premature closure
'The length or longest diameter is measured from the
of the suture between presphenoid and postsphenoid
glabella to the occipital point, the breadth or widest
in the base, and the coronal suture in skull cap, so that
diameter is measured usually a little below the parietal
the skull is very short anteroposteriorly. Compensation
tubera.
is done by the upward growth of skull for the enlarging
Human races may be: brain.
a. Dolichocephalic or long-headed when the index is Scaphocephaly or boat-shaped skull is due to
75 or less. premature synostosis in the sagittal sufure, as a result
b. Mesaticephnlicwhenthe index is between 75 and 80. the skull is very narrow from side to side but greatly
c. Brachycephalic or short-headed or round-headed elongated.
when the index is above 80. Dolichocephaly is a
feature of primitive races like Eskimos, Negroes,
etc. Brachycephaly through mesaticephaly has
been a continuous change in the advanced races,
like the Europeans. The mandible, or the lower jaw, is the largest and the ta
strongest bone of the face. It develops from the first o
FociolAngle pharyngeal arch.It has a horseshoe-shaped body which zo
lodges the teeth, and a pair of rami which project tc
This is the angle between two lines drawn from the (g
nasion to the basion or anterior margin of foramen upwards from the posterior ends of thebody. The rami !,
magnum and a line drawn from basion to the prosthion provide attachment to the muscles of mastication. G
o
or central point on upper incisor alveolus (Fig. 1.9).
Facial angle is a rough index of the degree of BODY L
o
development of the brain because it is the angle between Each half of the body has outer and inner surfaces, and ()
facial skeleton, i.e. splanchnocranium, and the calvaria, upper and lower borders. ao
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HEAD,AND,NECK
The outer surface presents the following features. Right

a. The symphysis menti is the line at which the right condyle
and left halves of the bone meet each other. It is Coronoid process
marked by a faint ridge (Fig. 1.22).
b. The mental protuberance (mentum = chin) is a Lingula
median triangular projecting area in the lower part Sphenomandibular
of the midline. The inferolateral angles of the ligament
Mandibular
protuberance form the mental tubercles. forarnen
c. The ment al for amen lies below the interval between Sublingual fossa
the premolar teeth (Table 1.5). Mylohyoid
groove
d. The oblique line is the continuation of the sharp
anterior border of the ramus of the mandible. It
Mylohyoid
runs downwards and forwards towards the line
mental fubercle.
Submandibular fossa
e. The incisioefossa is a depression that lies justbelow
the incisor teeth. Genial tubercles
The inner surface presents the following features. Digastric fossa
a. The mylohyoid line is a prominent ridge that runs
Fig. 1.23: lnner surface of right half of the mandible
obliquely downwards and forwards from below
the third molar tooth to the median area below
Four borders-upper, lower, anterior and posterior
the genial tubercles (see below) (Fig. 1.23).
Two processes-coronoid and condyloid.
b. Below the mylohyoid line, the surface is slightly
Thelateral surface is flatand bears a number of oblique
hollowed out to form the submandibular fossa,
ridges.
which lodges the submandibular gland.
The medial surface presents the following:
c. Above the mylohyoid line, there is the sublingual
1 The mandibularforamefl lies a little above the centre
fossa in which the sublingual gland lies.
d. The posterior surface of the symphysis menti is of ramus at the level of occlusal surfaces of the
marked by four small elevations called the superior teeth. It leads into the mandibular canal which
and inferior genial tubercles. descends into the body of the mandible and opens
e. The mylohyoid groove (present on the ramus) at the mental foramen (Fig.1..23).
extends on to the body below the posterior end of 2 The anterior margin of the mandibular foramen
is marked by a sharp tongue-shaped projection
, the mylohyoid line. called the lingula. The lingula is directed towards
Theupper or aloeolarborderbears sockets for the teeth.
Tlte lower border of the mandible is also called the the head or condyloid process of the mandible.
base. Near the midline the base shows an oval 3 The mylohyoid grooae begins just below the
depression called lhe digastric fossa. mandibular foramery and runs downwards and
forwards to be gradually lost over the submandi-
RAMUS
bular fossa.
The upper border of the ramus is thin and is curved
The ramus is quadrilateral in shape and has: downwards forming tiire mandibular notch.
Two surfaces-lateral and medial The lower border is the backward continuation of the
base of the mandible. Posteriorly, it ends by becoming
Mandibular nolch
continuous with the posterior border at the angle of the
Coronoid process mandible.
Gondylar Body The anterior border is thin, while the posterior border
process
l( is thick.
o Alveolar process
o Neck The coronoid (Greek uo'u)'sbeak) process is a flattened
z (bearing teeth)
triangular upward projection from the anterosuperior
t,q Ramus
(E related to part of the ramus. Its anterior border is continuous with
parotid gland
!,(E the anterior border of the ramus. The posterior border
o Mental
Angle foramen
bounds the mandibular notch.
The condyloid (Latrn l<nuckle like) process is a strong
C Oblique line upward projection from the posterosuperior part of the
o Mental Mental
() iubercle prominence ramus. Its upper end is expanded from side to side to
ao Fig.'1.22:. Outer surface of right half of the mandible form the head.The head is covered with fibrocartilage
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INTRODUCT]ON AND OSTEOLOGY
and articulates with the temporal bone to form the 4 Mylohyoid line gives origin to the mylohyoid muscle
temporomandibular joint. The constriction below the (Fig. 1.23).
head is the neck. Its anterior surface presents a 5 Superior constrictor muscle of the pharynx arises from
depression called the pterygoid foaea. an area above the posterior end of the mylohyoid
line.
Atlochments ond Relolions of the Mondible
6 Pterygomandibular raphe is attached immediately
1 The oblique line on the lateral side of the body gives behind the third molar tooth in continuation with
originto thebuccinator asfar forwards as the anterior the origin of superior constrictor.
border of the first molar tooth. In front of this origio
7 Upper genial tubercle gives origin to the genioglossus,
the depressor labii inferioris and the depressor anguli
and the lower tubercle to geniohyoid (Fig.1..25).
oris arise from the oblique line below the mental
foramen (Fi9.1..2q. 8 Anterior belly of the digastric muscle arises from the
2 The incisive fossa gives origin to the mentalis and digastric fossa (Fig. 1.25).
mental slips of the orbicularis oris. 9 Deep ceraical fascia (tnvesting layer) is attached to
3 The parts of both the inner and outer surfaces just the whole length of lower border.
below the alveolar margin are covered by the 10 The platysma is inserted into the lower border
mucous membrane of the mouth. (Fis.1..2q.
Masseteric nerve and vessels
Masseter
Mentalis
Orbicularis oris
Depressor anguli oris

Platysma
Fig. 1.24: Muscle attachments and relations of outer surface of the mandible
Lateral pterygoid
Maxillary
artery Auriculotemporal nerve
Temporalis
lnferior alveolar artery and nerve Superficial temporal artery
Lingual nerve External carotid
Superior constrictor Mylohyoid groove with nerve

and artery to mylohyoid
Pterygomandibular raphe
5
o
o
Medial pterygoid z
E'
c(E
tt(E
Mylohyoid
Genioglossus
o
Geniohyoid
o
Digastric: anterior belly F
o
o
Fig. 1.25: Muscle attachments and relations of inner surface of the mandible U)
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HEAD AND NECK
L1 Whole of the lateral surface of ramus except the

intrauterine life in the mesenchym al sheath of Meckel's
posterosuperior part provides insertion to the cartilage near the future mental foramen. Meckel's
masseter muscle (Fig. LZq.
cartilage is the skeletal element of first pharyngeal arch.
12 Posterosuperior part of the lateral surface is covered At birth the mandible consists of two halves
by the parotid gland. connected at the symphysis menti by fibrous tissue.
13 Sphenomandibular ligament is attached to the lingula Bony union takes place during the first year of life.
(Fig. 1.23).
14 The medial pterygoid muscle is inserted on the medial
surface of the ramus, on the roughened area below AGE CHANGES !N THE MANDIBTE
and behind the mylohyoid groove (Fig. 1.25). ln lnfonls ond Children
15 The temporalis is inserted into the apex and medial I The two halves of the mandible fuse during the first
surface of the coronoid process. The insertion year of life (Fig. 1.26a).
extends downwards on the anterior border of the 2 At birth, the mental foramen, opensbelow the sockets
ramus (Fig. Lzq. for the two deciduous molar teeth near the lozuer
16 The lateral pterygoid muscle is inserted into the border. This is so because the bone is made up only
pterygoid fovea on the anterior aspect of the neck of the alveolar part with teeth sockets. The mandibular
(Fig.1.2\. canal runs near the lower border. The foramen and canal
17 The lateral surface of neck provides attachment to gradually shift upwards.
the lateral ligament of the temporomandibular joint 3 The angle is obtuse.It is 140 degrees or more because
(see Fig.6.9). the head is in line with the body. The coronoid
process is large and projects upwards above the level
FORAMINA AND RELATIONS TO NERVES AND VESSETS of the condyle.
1 The mental foramen transmits the mental nerae and
oessels (Fig.1,.2q. In Adulls
2 The inferior alzteolar nerae and aessels enter the 1 The mental foramen opens midway between the upper and
mandibular canal through the mandibular foramen, and lower borders because the alveolar and subalveolar
run forwards within the canal. parts of the bone are equally developed. The mandi-
3 The mylohyoid neroe and zsessels lie in the mylohyoid bular canal runs parallel with the mylohyoid line.
grooae (Fig. 1.25). 2 The angle reduces to about 110 or L20 degrees because
4 The lingual nerzte is related to the medial surface of the ramus becomes almost vertical (Fig.1.26b).
the ramus in front of the mylohyoid groove (Fig. 1.25).
5 The area above andbehind the mandibular foramen ln Old Age
is related to the inferior alaeolar nerae and oessels and 1 Teeth fall out and the alveolar border is absorbed,
to the maxillary artery (Fig.1.25). so that the height of body is markedly reduced
The masseteric nerae and zsessels pass through the (Fig. 1.26c).
mandibular notch (Fig. L.2q. 2 The mental foramen and the mandibular canal are close
The auriculotemporal nerae and superficial tempornl to the aloeolar border.
artery are related to the medial side of the neck of 3 The angle again becomes obtuse about 140 degrees
mandible (Fig. 1.25). because the ramus is oblique.
I Facial artery is palpable on the lower border of
mandible at anteroinferior angle of masseter (Fig.1.2\. Slructures Reloted to Mondible
9 Facial and maxillary arteries are not accompanied S alizt ary glands : P ar otid,submandibular and sublingual
by respective nerves. The lingual nerve does not get (Figs 1.22 and 1.23).
company of its artery. Lymph nodes: Parotid, submandibular and submental.
l< Arteries: Maxillary, superficial temporal, masseteric,
o
o inJerior alveolar, mylohyoid, mental and facial (Fig. L.2q.
z The mandible is the secondbone, next to the claoicle, to
E
ossifutnthebody. Its greater part ossifies inmembrane. p or al, masseteric, inferior
N ero es : Lingual, auriculotem
tr
(E
The parts ossifying in cartilage include the incisiae alveolar, mylohyoid and mental (Fig. 1.25).
t,G
partbelow the incisor teeth, the coronoid and condyloid Muscles of masticatloru; Insertions of temporalis,
Io processes, and the upper half of the rnmus above the masseter, medial pterygoid and lateral pterygoid.
C
level of the mandibular foramen. Ligaments: Lateral ligament of temporomandibular
o Each half of the mandible ossifies from only one
o joint, stylomandibular ligament, sphenomandibular
ao centre which appears at about the 6th week of
and pterygomandibular raphe (Fig. 1.25).
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(a) Child (b) Adult (c) Old age
Figs 1.26a to c: Age changes in the mandible: (a) Child, (b) adult, and (c) old age
2 Alveolar border with sockets for upper teeth faces

downwards with its convexity directed outwards.
The mandible is commonly fractured at the canine
Frontal process is the longest process which is
socket where it is weak. Involvement of the directed upwards.
inferior alveolar nerve in the callus may cause 3 Medial surface is marked by a large irregular
neuralgic pain, which may be referred to the areas
opening, thLe maxillary hiatus/antrum of Highmore
of distribution of the buccal and auriculotemporal for maxillary air sinus.
nerves. If the nerve is paralysed, the areas supplied
by these nerves become insensitive (Fig, 1.2Q. FEATURES
The next common fracture of the mandible occurs
Each maxilla has a body and four processes, the frontal,
at the angle and neck of mandible (Fig. 1,.2n.
zy gornatic, alveolar and palatine.
BODY OF MAXILLA
The body of maxilla is pyramidal in shape, with itsbase
directed medially at the nasal surface, and the apex
directed laterally at the zygornatic process. It has four
surfaces and encloses a large cavity, the maxillary sinus
described in Chapter L5.
The surfaces are:
. Anterior or facial,
o Posterior or infratemporal,
. Superior or orbital, and
. Medial or nasal.
Fig. 1.27: Fracture of the mandible at the neck, at the angle Anterior or Fociol Surfoce
and at canine fossa I Anterior surface is directed forwards and laterally.
2 Above the incisor teeth, there is a slight depression,
the incisioe fossa, which gives origin to depressor septi.
Incisiztus arises from the alveolar margin below the
fossa, and the nasalis superolateral to the fossa along
the nasal notch.
Maxilla is the second largest bone of the face, the first Lateral to canine eminence, there is a larger and .Y
each being the mandible. The two maxillae form the o
whole of the upper jaw, and each maxilla forms a part
deeper depression, the canine fossa, which gives zo
origin toleoator anguli oris. t,E
each in the formation of face, nose, mouth, orbit, the
Above the canine fossa, there is infraorbital fornmen, (E
infratemporal and pterygopalatine fossae. It
which trans mlts infraorbital nerrse and aessels (Fig. 1 .28). G
Leaator labii superioris arises between the infraorbital o
SIDE DETERMINATION margin and infraorbital foramen.
1 Anterior surface ends medially into a deeply concave Medially, the anterior surface ends in a deeply .9
border, called tLre nasal notch. Posterior surface is concave border, the nasal notch, which terminates C)
convex (Fig. 1.28). below into process which with the corresponding ao
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; H'AD n*p'*rck
Frontal process,
anterior lacrimal crest
Orbital surface
lnfraorbital margin
lnfratemporal surface
Infraorbital foramen
Zygomatic process
Anterior nasal spine
Nasalis Anterior surface

Buccinator
Alveolar process
Maxillary tuberosity
Fig. 1.28: Lateral aspect of maxilla with muscular attachments
process of opposite maxilla forms the anterior nasal 4 Medinl border presents anteriorly the lacrimal notch
spine. Anterior surface bordering the nasal notch which is converted into nasolacrimal canal by the
gives origin to nasalis and depressor septi. descending process of lacrimal bone. Behind the
notch, the border articulates from before backwards
Posierior or lnfrotemporol Surfoce with the lacrimal,labyrinth of ethmoid, and the orbital
1 Posterior surface is convex and directed backwards process of palatine bone (Fi9. 1.29).
and laterally. 5 The surface presents infraorbital grooae leading
2 It forms the anterior wall of infraternporal forwards to infraorbital canal which opens on the
fossa, and
is separated from anterior surface by the zygomatic anterior surface as infraorbital foramen. The groove,
process and a rounded ridge which descends from canal and foramen transmit the infraorbital nerae and
oessels. Near the midpoint, the canal gives off laterally
the process to the first molar tooth.
3 Near the centre of the surface open two or three a branch, t}i.e canalis sinuous, for the passage of
anterior superior alzseolar nerae and ztessels.
alzteolar canals for posterior superior aloeolar nerae and
rsessels.
5 Inferior oblique muscle of eyeball arises from a
depression just lateral to lacrimal notch at the
4 Posteroinferiorly, there is a rounded eminence, the
anteromedial angle of the surface.
maxillary tuberosity, which articulates superomedially
with pyramidal process of palatine bone, and gives Mediol or NosolSurfoce
origin laterally to the superficinl head of medial ptery goid
muscle.
1 Medial surface forms apart of the lateral wall of nose.
2 Posterosuperiorly, it displays a large irregular opening
5 Above the maxillary tuberosity, the smooth surface of the maxillary sinus, the maxillary hiatus (Figs 1.30).
forms anterior wall of pterygopalatine fossa, and is 3 Above the hiatus, there are parts of air sinuses which
grooved by maxillary nerae.
are completed by the ethmoid and lacrimal bones.
4 Below the hiatus, the smooth concave surface forms
J Superior or Orbitol Surfoce a part of inferior meatus of nose.
o
o L Superior surface is smooth, triangular and slightly 5 Behind the hiatus, the surface articulates with
z concave, and forms the greater part of the floor of perpendicular plate of palatine bone, enclosing the
E
tr orbit. greater palatine canal w!;rich runs downwards and
(E
t,G Anterior border forms a part of infraorbital margin. forwards, and transmits greater palatine r:essels and the
o Medially, it is continuous with the lacrimal crest of anterior, middle and posterior palatine neroes (Fig. 1.12).
the frontal process. 6 In front of the hiatus, there is nasolacrimal grooae,
.9
Posterior border is smooth and rounded, it forms most which is converted into the nasolacrimal canal by
o
o
of the anterior margin of inferior orbital fissure. In articulation with the descendingprocess of lacrimalbone
U) the middle, it is notched by the infraorbital groove. and the lacrimal process of inferior nasal concha. The
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I
tNrRoDUcIoN AND osrEolocY
t
Sphenoethmoidal recess Frontal air sinus
Sphenoidal air sinus Middle concha
Superior meatus Ethmoid bulla
Sphenopalatine foramen
Descending part of lacrimal
bone
Opening of maxillary air sinus
in middle meatus Uncinate process
Perpendicular plate of palatine bone

lnferior nasal concha
Palatomaxillary suture
lnferior meatus
Fig. 1.29: Medial aspect of intact maxilla
Ethmoidal cresi
Nasolacrimal groove
Middle meatus
Conchal crest
Maxillary hiatus
lnferior meatus
Perpendicular plate
of palatine bone Anterior nasal spine
Greater palatine canal Palatine process
Fig. 1.30: Medial aspect of disarticulated left maxilla
canal transmits nasolauimal duct to the inferior meatus Frontol Process

of nose. I The frontal process projects upwards and backwards
7 More anteriorly, an oblique ridge forms tLre conchal to articulate above with the nasal margin of frontal
crest for articulation with the inferior nasal concha. bone, in front with nasal bone, and behind with
8 Above the conchal crest, the shallow depression lacrimal bone.
forms a part of the atrium of middle meatus of nose 2 Lateral surface is divided by a vertical ridge, the
(see Fig. 15.8).
anterior lacrimal crest,into a smooth anterior part and
.t
a grooved posterior part. o
o
FOUR PROCESSES OF MAXILLA The lacrimal crest gives attachment to lacrimal fascia z
Zygomotic Process and the medial palpebral ligament, and is continuous ttr
G
The zygomatic process is a pyramidal lateral projection below with the infraorbital margin. t,(E
on which the anterior, posterior, and superior surfaces The anterior smooth area gives origin to the orbital o
of maxilla converge. In front and behind, it is part of orbicularis oculi arrdletsator labii superioris alaeque
continuous with the corresponding surfaces of the nasi. The posterior grooved area forms the anterior c
o
body, but superiorly it is rough for articulation with half of the floor of lacrimal grooae (Fig. 1.a5). C)
the zygomatic bone. 3 Medinl surface forms apafiof the lateral wall of nose. ao
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HEAD AND NECK
The surface presents following features: ARTICULATIONS OF MAXIILA

a. Uppermost area is rough for articulation with L Superiorly, it articulates with three bones, the nasal,
ethmoid to close the anterior ethmoidal sinuses. frontal and lacrimal.
b. Ethmoidal crest is a horizontal ridge about the 2 Medially, it articulates with five bones, the ethmoid,
middle of the process. Posterior part of the crest inferior nasal concha/ vomer, palatine and opposite
articulates with middle nasal concha, and the maxilla.
anterior part lies beneath the agger nasi (see Fig. 3 Laterally, it articulates with one bone, the zygomatic.
15.8).
c. The area below the ethmoidal crest is hollowed
out to form the atrium of the middle meatus.
Maxilla ossifies in membrane from three centers, one
d. Below the atrium is the conchal uest w]r.ich
for the maxilla proper, and two for os incisivum or
articulates with inferior nasal concha.
premaxilla. The center for maxilla proper appears
e. Below the conchal crest, there lies the inferior
meatus of the nose with nasolacrimal groove
above the canine fossa during sixth week of
intrauterine life.
ending just behind the crest (see Fig. 15.8).
Of the two premaxillary centers, the main centre
Alveolqr Process appears above the incisive fossa during seventh week
of intrauterine life. The second center (paraseptal or
1 The alveolar process forms half of the alveolar arch,
prevomerine) appears at the ventral margin of nasal
and bears sockets for the roots of upper teeth. In
septum during tenth week and soon fuses with the
adults, there are eightsockets: canine socket is deepest;
palatal process of maxilla. Though premaxilla begins
molar sockets are widest and divided into three minor
to fuse with alveolar process almost immediately
sockets by septa; the incisor and secondpremolar sockets
are single; and the first premolar socket is sometimes
after the ossification begins, the evidence of
premaxilla as a separate bone may persist until the
dioided into two.
middle decades.
2 Buccinator arises from the posterior part of its outer
surface up to the first molar tooth (Fig. 1.28).
3 A rough ridge, the maxillary torus, is sometimes AGE CHANGES
present on the inner surface opposite the molar 1" At birth:
sockets. a. The transverse and anteroposterior diameters are
each more than the vertical diameter.
Polotine Process
b. Frontal process is well marked.
1 Palatine process is a thick horizontal plate projecting c. Body consists of a little more than the alveolar
medially from the lowest part of the nasal surface. It process, the tooth sockets reaching to the floor of
forms a large part of the roof of mouth and the floor orbit.
of nasal cavity (Fig. 1.30). d. Maxillary sinus is a mere furrow on the lateral wall
2 lnferior surface is concave, and the two palatine of the nose.
processes form anterior three-fourths of the bony 2 In the adult: Vertical diameter is greatest due to
palate. It presents numerous vascular foramina and development of the alveolar process and increase in
pits for palatine glands. the size of the sinus.
Posterolaterally, it is marked by two anteroposterior 3 [n tlrc old: The bone reverts to infantile condition. Its
grooves for the greater palatine vessels and anterior height is reduced as a result of absorption of the
palatine nerves. alveolar process.
Superior surface is concave from side to side, and
forms greater part of the floor of nasal cavity.
Medial border is thicker in front than behind. It is
-to raised superiorly into the nasal crest.
o Groove between the nasal crests of two maxillae Two parietal bones form a large part of the roof and
z receives lower border of vomer; anterior part of the sides of vault of skull. Eachbone is roughly quadrilateral
t,c in shape with its convexity directed outwards (Fig. 1.31).
(E ridge is high and is known as incisor crest which
t,(E terminates anteriorly into the anterior nasal spine.
o Incisive canal traverses near the anterior part of the SIDE DETERMINATION
I
medial border. Outer surface is convex and smooth, inner surface is
gs Posterior border articulates with horizontal plate of concave and depicts vascular markings.
o palatine bone. Anteroinferior angle is pointed and shows a groove
o-
ab Lateralborder is continuous with the alveolar process. for anterior division of middle meningeal artery
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Superior Parietal tuber Superior sagittal sinus

temporal line
Frontal angle
lnferior
Frontal temporal line
angle Grooves for
Parietal anterior division
Anterior angle
foramen of middle
border meningeal
Occipital Posierior vessels
angle border
Posterior border
Mastoid Sphenoidal angle
Sphenoidal Temporalis angle
angle Groove for posterior division
Mastoid angle of middle meningeal vessels
Sigmoid
sulcus
Fig. 1.31 : Outer surface of left parietal bone Fig. 1.32: lnner surface of left parietal bone
FEATURES 3 Posterosuperior or occipital

Parietal bone has two surfaces/ four borders, four angles 4 Posteroinferior or mastoid
At each of the 4 angles are 4 fontanelles. These are:
Surfoces 1 One anterior fontanelle, closes at 18 months.
1 Outer convex and 2 One posterior fontanelles, closes at 3 months
2 Inner concave surface (Fig. 1.32) 3 Two anterolateral or sphenoidal fontanelles, close at
3 months.
Borders 4 Two posterolateral or mastoid fontanelles, closes at
L Superior or sagittal about 12 months of life.
2 Inferior or squamosal Details can be studied from norma verticalis and
3 Anterior or frontal norma lateralis and inner aspect of skull cap.
4 Posterior or occipital
Four Angles
1. Anterosuperior or frontal Single occipital bone occupies posterior and inferior
2 Anteroinferior or sphenoidal parts of the skull (Fig. 1.33)
Superior angle
Superior sagittal sinus

Iniernal occipital protuberance
Lambdoid border
Cerebral fossa
Internal occipital crest
Lefi transverse sinus

Right transverse sinus
Cerebellar fossa
-Y
Vermian fossa o
Lateral angle
zo
Mastoid border !,q
Foramen magnum (E
Sigmoid sinus
t,
G
o
C
Anterior border of basiocciput .o
o
Fig. 1.33: lnner surface of occipital bone ao
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HEADAND NECK
ANATOMICAI. POSITION Borders are anterior, posterior, lateral border on each

It is concave forwards and encloses the largest foramen side.
of skull, foramen, magnum, through which cranial Condylor Porl
cavity communicates with the vertebral canal.
On each side of foramen magnum is the occipital It comprises:
condyle which articulates with atlas vertebra.
o Superior surface
o Inferior surface which shows occipital condyles and
Feotures hypoglossal canal
The details can be read from descriptions of norma
Occipital bone is divided into three parts: occipitalis and posterior cranial fossa.
1 Squamous part above, below and behind foramen
maSnum
, Basilar part lies in front of foramen magnum
., Condylar or lateral part on each side of foramen
magnum. Frontal bone forms the forehead, most of the roof of
orbit, most of the floor of anterior cranial fossa. Its parts
Squomous Porl are squamous, orbital and nasal (Fig. 1.3a).
Comprises two surfaces, three angles and four borders
ANATOMICAL POSITION
$urf**es Squamous part of vertical and is convex forwards
External convex surface and internal concave surface. Two orbital plates are horizontal thin plates
projecting backwards
Amgfes
Nasal part is directed forwards and downwards.
One superior angle and two lateral angles. SOUAMOUS PART

The squamous part presents 2 surfaces, 2 borders and
fiordsrs
encloses a pair of frontal air sinuses.
Two lamboid borders in upper part and two mastoid
borders in lower part. Outer Surfoce
1 It is smooth and shows
Bosilor Port 2 Frontal tuberosity
The basilar part of occipital bone is called as basiocciput. 3 Superciliary arches
It articulates with basisphenoid to form the base of 4 G1abella
skull. It is quadrilateral in shape and comprises two 5 Frontal air sinus
surfaces and four borders. 6 Metopic suture
Surfaces are superior and inferior 7 Upper or parietal border
Groove for superior sagittal sinus
Granular pits
Part of greater wing of
sphenoid
Ethmoidal notch
Temporal surface For lesser wing

.Y of sphenoid
o Groove for posterior
zo ethmoidal canal Fossa for lacrimal
tt gland
(E
t,(E Orbital surface Zygomatic process
o
Trochlear fossa
Groove for anterior ethmoidal canal
C Nasal spine
.o
o For nasal bone
o
a Fig. 1.34: Frontal bone from below
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8 Lower or orbital border SIDE DETERMINATION

9 Zygomatrc process r Plate like squamous part is directed upwards and
10 Temporal line and temporal surfaces laterally
lnner Surfoce
r StronB zygomatic process is directed forwards
r Petrous part, triangular in shape is directed medially
It is concave and presents following features: o External acoustic meatus, enclosed between
L Sagittal sulcus squamous and tympanic parts is directed laterally.
2 Frontal crest
SQUAMOUS PART
oRBrTAr PARTS (PLATES)
Two surfaces: Outer and inner
Orbital plates are separated from each other by a wide
Tztso borders; Superior and anteroinferior
gap, the ethmoidal notch.
Orbital or inferior surface of the plate is smooth and Ouler or Temporol Surfoce
presents lacrimal fossa anterolaterally and trochlear
It is smooth and forms a part of temporal fossa
spine anteromedially.
Above external acoustic meatus, there is a groove
Ethmoidal notch is occupied by cribriform plate of
for middle temporal artery
ethmoid bone. On each side of notch are small air spaces
Its posterior part presents supramastoid crest
which articulates with the labyrinth of ethmoid to
Below the anterior end of supramastoid crest and
complete ethmoidal air sinuses. At the margins are
posterosuperior to external acoustic meatus there is
anterior and posterior ethmoidal canals.
suprameatal triangle.
Zygomatic process springs forwards from the outer
NASAL PART
surface of squamous part. Its posterior part comprises
Lies between two supraorbital margins superior and inferior surfaces. The inferior surfaces is
The margins of the nasal notch on each side articulate bounded by two roots which converge at the tubercle
with nasal, frontal process of maxilla and lacrimal bones. of root of the zygorna. Anterior root projects as the
Details can be seen from descriptions of norma articular tubercle in front of mandibular fossa.
frontalis, norma lateralis, inner aspect of skull cnp and Posterior root begins above the external acoustic
anterior cranial fossa. meatus.
Mandibular fossa lies behind articular tubercle and
consists of anterior articular part formed by squamous
part of temporal bone and a posterior nonarticular
Temporal bones are situated at the sides and base of portion formed by tympanic plate.
skulI. It comprises following parts: lnner or Cerebrol Surfoce
a. Squamous part (Fig. 1.35) It is concave and shows grooves for the middle
b. Petromastoid part meningeal vessels. Its superior border articulates with
c. Tympanic part the lower border of parietal bone. Its anteroinferior
d. Styloid process border articulates with the greater wing of sphenoid.
Squamous part
Supramastoid
crest
.l.
o
Suprameatal zo
triangle Ittr
(E
Mastoid process !,(E
External acoustic o
J-
meatus
Styloid process
.o
o
Fig. 1.35: Outer aspect of left temporal bone ao
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HEAD AND NECK
MASTOID PART Tegmen tympani lying most laterally. In the anterior

Mastoid part (Greek breast) forms posterior part of
part of tegmen tympani are hiatus and groove for
greater petrosal nerve and a smaller hiatus and groove
temporal bone. It has:
for the lesser petrosal nerve.
Two surfaces-outer and inner
Two borders-superior and posterior, and enclose the Posleliol Surfoce
mastoid air cells. [The outer surface forms a downwards
Internal acoustic meatus is present here
projecting conical process, the mastoid process.]
Aqueduct of vestibule lies behind internal acoustic
Two Surfoces meatus.
The outer surface give attachment to occipitalis muscle. lnferior Surfoce
Mastoid foramen opens near its posterior border and
Forms part of norma basalis. It shows lower opening
transmits an emissaryvein and abranch of occipital artery.
Mastoid process appears at the end of 2nd year.
of carolid canal (refer to normal basalis for details)
Lateral surface gives attachment to sternocleido- Jugular fossa lies behind carotid canal (Fig. 1.37).
mastoid, splenius capitis, and longissimus capitis
ryMPANIC PART
(Fig.1.1a).
Medial surface of the process shows a deep mastoid It is a curved plate of bone below squamous part and
notch for the origin of posterior belly of digastric. in front of mastoid process. It comprises:
Medial to this notch is a groove for the occipital artery.
Two Surfoces
fmmer Ssrrdme* Anterior and posterior concave part forming anterior
The inner surface is marked by a deep sigmoid sulcus wall, floor and lower part of the posterior wall of
(Fig. 1.36). external acoustic meatus.
PETROUS PART Three Bolders

Petreous part (Latin rock) triangular in shape. It has Lateral which forms the margin of external acoustic
meatus
base, apex
Three surfaces-anterior, posterior and inferior Upper border and lower border which in its lateral
Three borders-superior, anterior and posterior part splits to enclose the root of styloid Process
Base is fused with squamous and mastoid parts
Externol Acouslic Meotus
Apex is irregular and forms posterolateralboundary
of foramen lacerum. Bony part of meatus is about 16 mm long
Its anterior wall, floor and lower part of posterior
Anterior Surfoce wall are formed by tympanic part. Its roof and upper
Trigeminal impression hatf of the posterior wall are formed by the squamous
Part forming roof of anterior part of carotid canal part (Fig. 1.35).
Arcuate eminence Its inner end is closed by tympanic membrane.
Parietal bone Greater wing of sPhenoid
Groove for middle meningeal

vessels
Arcuate eminence
.Y
o
o
z Sigmoid sinus
Zygomatic process
tttr
(E
Superior
petrosal sinus
t,(E Aqueduct of vestibule
o lnternal acousiic meatus
t
Subarcuate fossa
c Occipital bone
.9 Styloid process
o
o Fig. 1.36: lnner aspect of the left temporal bone
a
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Zygomatic process
Upper end of carotid canal Articular tubercle
Apex of petrous part

Mandibular fossa
Squamotympanic flssure
Tympanic part (plate)
Tympanic canaliculus
Stylomastoid foramen
Jugular fossa
Mastoid process
Mastoid canaliculus
Mastoid notch
Occipital groove
Mastoid foramen
Fig. 1.37: lnferior view of the temporal bone
STYLOID PROCESS o Two pterygoid (wing-like) processes, directed

Styloid (Greek pillar form) process) long pointed downwards from the junction of body and greater
process directed downwards, forwards and medially wings.
between parotid gland and internal jugular vein
(Fig. 1.36). BODY OF SPHENOID
. Its base is related to facial nerve It comprises six surfaces and enclose a pair of
. Its apex is crossed by external carotid artery. sphenoidal air sinuses.
o It gives attachment to three muscles and 2ligaments
Superior or Cerebrol Surfoce
(see Chapter 8) (refer to norma lateralis for details).
It articulates with ethmoid bone anteriorly and basilar
part of occipital bone posteriorly. It shows:
1 Jugum sphenoidale
2 Sulcus chiasmaticus
Sphenoid (Greek wedge) bone resembles a bat with 3 Tuberculum sellae
outstretched wings. It comprises: 4 Sella turcica
. A body in the centre (Fig. 1.38). 5 Dorsum sellae
o Two lesser wings from the anterior part of body 6 Clivus
o Two greater wings from the lateral part of body Refer to middle cranial fossa for details.
Optic groove Lesser wing
Greater wing
Optic canal
Anterior clinoid :o
process
Superior
orbital Tuberculum sellae
zo
fissure
t,tr
Posterior clinoid (E
Foramen process !,
rotundum G
Spine o
Foramen
Spinosum Foramen Dorsum Sella turcica
co
ovale sellae
()
o
Fig. 1.38: Superior view of the sphenoid bone U)
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HEAD AND NECK
lnferior Surfoce lower or infratemporal surface. It is pierced by

1 Rostrum of sphenoid (Fig. 1.39a) foramen ovale and foramen spinosum' Its posterior
part presents spine of sphenoid. Refer to norma
2 Sphenoid conchae (Fig. 1.39b) basalis in details.
3 Vaginal processes of medial pterygoid plate
Refer to norma basalis for details. Orbilol Surfoce
Forms the posterior wall of the lateral wall of orbit.
Anterior Surfoce Its medial border bears a small tubercle for
Sphenoidal crest articulates with perpendicular plate attachment of a common tendinous ring for the origin
o? ethmoid to form a small part of septum of nose of recti muscles of the eyeball. Below the medial end of
Opening of sphenoidal air sinus is seen (Fig. 1.39b) superior orbital fissure, the grooved area forms the
Sphenoidal conchae close the sphenoid air sinuses poiterior wall of the pterygopalatine fossa and is
leaving the openings. Each half of anterior surface has pierced by foramen rotundum (Fig. 1.39b).
two parts: superolateral and inferomedial. Borders are surrounding the greater wing of
The superolateral depression articulates with sphenoid.
labyrinth of ethmoid to complete the posterio,r
ethmoidal air sinuses. The inferomedial smooth TESSER WINGS
triangular area forms the posterior part of the root of Lesser wings are two triangular plates projecting
the nose. laterally from the anterosuperior part of the body. It
comprises:
Posterior Surfoce . A base forming medial end of the wing. It is connected
It articulates with basilar part of occipital bone to the body by two roots which enclose the optic canal
. Tip forms the lateral end of the wing
Lolerol Surfoce . Superior surface forming floor of anterior cranial
Carotid sulcus, a broad groove curved like letter 'f' for fossa
lodging cavernous sinus and internal carotid artery. o Inferior surface forming upper boundary of superior
gelow the sulcus it articulates with greater wing of
orbital fissure.
sphenoid laterally and with pterygoid Process which
is directed downwards.
r Anterior border articulates with the posterior border
of orbital plate of frontal bone
SPHENOIDAT AIR SINUSES
o Posterior border is free and projects into the stem of
lateral sulcus of brain. Medially it terminates in to
These are asymmetrical air sinuses in the body of the anterior clinoid Process.
sphenoid, and are closed by sphenoidal conchae. The
sin.,s opens into the lateral wall of nose in the SUPERIOR ORBIIAL FISSURE
sphenoethmoidal recess above the superior concha
It is a triangular gap through which middle cranial fossa
GREATER WINGS
communicltes with the orbit. The structures passing
through it are put in list of foramina and structures
two strong Processes which curve laterally
These are passing through them (see Fig. 13.4).
and upwards from the sides of the body. Its three
surfaces. PTERYGOID PROCESSES
Superior or Cerebrol Surfoce One pterygoid (Greek wing) Process-on each side
presents db*nwards from th9 Junction of the body with
It forms the floor of middle cranial fossa qû
and vrLovrrru Projeits
the greater wing of sphenoid (Fig' 1'38)'
l( from before backwards:
o
zo
!,
r Foramen rotundum (Fig. 1.3ea) -"H:i,'"fil,::iiri"?T:iri'fi!!:r1ilj"1,:,tlJ:trXil;
tr
(E
2 Foramen ovale in their upper parts, but are separated in their
together
t,(E 3 Emissary sphenoidale foramen lower parts by the-pterygoid fis-qure. ?osteriorly the
o 4 Foramen spinosum pterygbid a "V-shaped interval" , the
I -plaies.enclose pterygoid plate in its upper
pteryfold fossa. The medial
c LOterOl SurfOCe part presents a scaphoid fossa.
A horizontal ridge, the infratemporal crest divides
.o Refertononnabasalisformedialandlateralpterygoid
o
ao this surface into upper or temporal surface and a plates'
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Lesser wing
Lingula
Scaphoid fossa Lateral pterygoid plate
Pterygoid fossa Medial pterygoid plate
Posterior View Pterygoid hamulus

Vaginal process
(a)
Rostrum
Opening of sphenoidal sinus Sphenoidal crest
Lesser wing
Temporal surface ----1 o,

Superior orbital fissure Orbital surface | 9r"rt",
*'n9
Foramen rotundum lnfratemporal ,urfu"" J
Pterygoid canal Sphenoidal concha
Spine
Palatovaginal groove
Pterygoid hamulus
Lateral pterygoid lamina
Vaginal process
Rostrum
(b)
Figs 1.39a and b: (a) Posterior view of sphenoid, and (b) greater wing and lesser wing of sphenoid
Cristo Golli
Crista galli is a median, tooth like upward projection
Ethmoid (Greek sierse) is a very light cuboidal bone in the floor of anterior cranial fossa. Foramen
situated in the anterior of base of cranial cavity between transmitting anterior ethmoidal nerve to nasal cavity
the two orbits. It forms: is situated by the side of crista galli.
1 Part of medial orbital walls Perpendiculor Plole
2 Part of nasal septum (Fig. 1.40a) It is a thin lamina projecting downwards from the
3 Part of roof of orbit undersurface of the cribriform plate, forming upper part
4 Lateral walls of the nasal cavity of nasal septum.
.:a
E thmoid bone comprises : o
Lobyrinihs
1 Cribriform plate (Fig. 1.a0b)
These are two light cubical masses situated on each side
zo
2 Perpendicular plate t,tr
of the perpendicular plate, suspended from the
3 A pair of labyrinth undersurface of the cribriform plate (Fig. 1.40c).
G
tt(E
Each labyrinth also encloses large number of "air o
CRIBRIFORM PLATE T
cells" arranged in three groups; the anterior, middle
It is a horizontal perforated bony lamina, occupying and posterior ethmoidal air sinuses. Its surfaces are: c
.9
ethmoidal notch of frontal bone. Contains foramina for o Anterior surface articulates with frontal process of ()
o
olfactory nerve rootlets maxilla to complete anterior ethmoidal air cells @
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HEAD AND NECK
For frontal
bone
Cribriform
(horizontal)
plate
For nasal
bone Ethmoid sinus
Orbital (lateral)
plate
For septal
cartilage Middle nasal concha
Superior nasal
concha
Perpendicular plate
Cribriform Crista galli

plate
$uperior Anterior
concha ethmoidal sinuses
orbit- Orbital plate of
ethmoidal labyrinth
Middle
concha Perpendicular plate
Uncinate
process Middle ethmoidal
sinus and bulla
Vomer ethmoidalis
lnferior
Floor of nose
concha
Patate forming Upper tooth

floor of nasal cavity
(c)
Figs 1.40a to c: (a) Articulations of perpendicular plate, (b) posterior view of the ethmoid bone, and (c) ethmoid bone articulating
with neighbouring bones
o Posteriorsurfacearticulateswithsphenoidalconchea r Anterior, longest border articulates with per-

to complete posterior ethmoidal iir cells pendicular plate of ethmoid above and with sePtal
. Superior surface articulates with orbital plate of cartilage below.
frontal bone. o Posterior border is free and separates the two
r Inferior surface articulates with nasal surface of posterior nasal openings.
maxilla.
r Lateral surface forms medial wall of orbit.
r Medial surface presents small superior nasal concha,
middle nasal concha, superior meatus below
superior conchea, middle meatus below middle The inferior nasal conchae are two curved bony
concha. laminae, these are horizontally placed in the lower part
of lateral walls of the nose. Between this concha and
floor of the nose lies the inferior meatus of the nose. It
l< comprises 2 surfaces, 2 borders and 2 ends.
o
o Vomer (Latin plough share) is a single thin, flat bone o Medial convex surface is marked by vascular grooves
z forming posteroinferior part of the nasal septum. It
t,tr o Lateral concave surface forms the medial wall of
comprises:
(E
. inferior meatus of the nerve.
!t(E Right and left surfaces marked by nasopalatine
o nerves which course downwards and forwards
. Superior border is irregular and articulates
T . with maxilla,lacrimal, ethmoid and palatine bones
Superior border splits into two alae with a groove is
occupied by rostrum of sphenoid (Fig. 1.41).
(Fig. La\.
o
.F
() r Inferior border articulates with nasal crests of r Inferior border is free, thick and spongy.
ao maxillae and palatine tones. o Posterior end is more pointed than the anterior end.
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Alae
Free border
Perpendicular
plate of ethmoid
Septal cartilage
Palatine
bone
Palatine process
of maxilla
Horizontal plate
of palatine bone
Fig. 1.41 : Vomer forming posteroinferior part of the nasal septum and its various borders. Left lateral view of the vomer
Frontal process
Maxillary process
Zygomaticofacial
foramen Marginal tubercle
Levator labii Lateral surface

superioris Zygomaticus major
Temporal process
For maxilla
Masseter
Zygomaticus
minor
Frontal process
Fig. 1.42: Lateral view of the left inferior nasal concha
Temporal surface With greater wing
Temporal Zygomatico-orbital
process foramina
surface
F For maxilla
These are two small quadrilateral bones present in the
Masseter
upper and lateral part of face. The bone forms
;, prominence of the cheeks. Each bone takes part in the
formation of: Figs 1.43a and b: Features of the left zygomatic bone. (a) Outer
o Floor and lateral wall of the orbit view, and (b) inner view
. Walls of temporal and infraorbital fossae
Zygornaticbone comprises 3 surfaces,5 borders and
2 processes.
Borders ta
Surfaces o
1 Anterosuperior or orbital
1 Lateral surface presenting zygomaticofacial foramen 2 Anteroinferior or maxillary zo
(Fig. 1.a3a) t,c
3 Posteroinferior or temporal border (E
Temporal surface is smooth and concave and 4 Posteroinferior border tt(E
presents zygomaticotemporal foramen (Fig.1.a3b). 5 Posteromedial border. o
Orbital surface is also smooth and concave one or
two zygomaticoorbital foramen on this surface and Processes
o
this bads to zygomaticofacial and zygomatico 1. Frontal process, which is directed upwards. ()
o
temporal foramina (Fig. 1.20). 2 Temporal process, directed backwards. @
'
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I
HEADAND NECK
Superior border
Nasal bones are two small oblong bones, which form Anterior border
Orbital sudace
the bridge of the nerve.
Groove for lacrimal
Each nasal bone has two surfaces and four borders Posterior border
sac
(Fig. 1.aa).
Surfoces
1 The outer surface is convex from side to side. Descending process
for inferior nasal concha
2 The inner surface is concave from side to side and is
traversed by a vertical groove or anterior ethmoidal Fig. 1.45: Lateral surface of the left lacrimal bone
nerve.
Borders Borders
1 Superior border is thick and serrated and articulates 1 Anterior border articulates with frontal process of
with nasal part of frontal bone. maxilla.
2 Inferior border is thin and notched and articulates 2 Posterior border with orbital plate of ethmoid.
with lateral nasal cartilage. 3 Superior border with frontal bone.
3 Medial border articulates with opposite nasal bone 4 Inferior border with orbital surface of maxilla.
4 Lateral border articulates with frontal process of
maxilla.
Palatine bones are two L-shaped bones present in the

posterior part of nasal cavity. Each bone forms:
. Lateral wall and floor of nasal cavity (Fig. 1.46a).
. Roof of mouth cavity
Medial border and . Floor of the orbit
nasal crest
r Parts of pterygopalatine fossa
Each palatine bone has 2 plates and 3 processes.
Vascular foramen
Two PIotes
1 Horizontal plate forms posterior one-fourth part of
Notched Inferior
border
bony palate. It has 2 surface and 4 borders (Fig.
1..46b).
Fig. 1.44: lnner view of the left nasal bone

2 Perpendicular plate of palatine bone is oblong in
shape and comprises 2 surfaces and 4borders (refer
to norma basalis).
Three Processes
Fyr*rnidotr FrCIeess
Pyramidal process projects downwards from the
Lacrimal bones are extremely delicate and smallest of junction of two plates. Its inferior surface is pierced by
the skull bones. These form the anterior part of the lesser palatine foramina.
medial part of the orbit. Each lacrimal bone comprises
l. 2 surfaces and 4 borders.
ffrbifsf Frpcess
o
Orbital process projects upwards and laterally from
zo Surfoces the perpendicular plate. Its orbital surface is triangular
tttr
(E 1 Lateral or orbital surface is divided by posterior and foims the posterior part of the floor of the orbit
t,(E lacrimal crest into anterior and posterior parts. The (Fig. 1.46b).
o anterior grooved part forms posterior half of the floor
of lacrimal groove for lacrimal sac. The posterior Spfiel.l*idof Prsce$$
c smooth part forms part of medial wall of orbit. Sphenoidal process projects upwards and medially
.9
() 2 Medial or nasal surface forms a part of middle fiom the perpendicular plate. Its lateral surface
ao meatus of the nose (Fig. 1.45). articulates with medial pterygoid plate.
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Orbital process
Maxillary surface
Orbital surface For sphenoid
Ethmoidal crest Orbital process

Sphenoidal Sphenoidal process
process Sphenopalatine foramen Sphenopalatine
notch Superior meaius
Middle meatus
Ethmoidal crest
Middle meatus
Conchal crest
Conchal crest
lnferior meatus
Inferior meatus
For lateral Nasal

pterygoid plate crest
Posterior
Pterygoid fossa nasal spine
Horizontal plate
Horizontal part For medial pterygoid plate

(a) (b)
Figs 1.46a and b: (a) Medial view of the left palatine bone, and (b) various proceses of palatine bone
The hyoid bone provides attachment to the muscles

of the floor of the mouth and to the tongue above, to
The hyoid (Greek U'shaped) bone is U-shaped.
the larynx below, and to the epiglottis and pharyrrx
It develops from second and third branchial arches. behind (Fig.1..al.
It is situated in the anterior midline of the neck The bone consists of the central part, called the
between the chin and the thyroid cartilage. body, and of two pairs of cornua, greater and lesser.
At rest, it lies at the level of the third cervical vertebra
behind and the base of the mandible in front. Body
It is kept suspended in position by muscles and It has anterior and posterior surfaces, and upper and
ligaments (Fig.Lan. lower borders.
Middle constrictor
(cranial root of Xl)
Investing fascia
Digastric pulley
Genioglossus (Xll)
l<
o
Geniohyoid (Cl) zo
!tc
Mylohyoid (V3) Stylohyoid muscle (Vll) (E
and ligament tG,
Sternohyoid (ansa cervicalis)
Hyoglossus (Xll) o
Thyrohyoid (Cl )
Prekacheal fascia Superior belly of omohyoid c
o
o
q)
Fig. 1.47: Anterosuperior view of the left half of hyoid bone showing its attachments a
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HEAD AND NECK
Tl:re antedor surface ts convex and is directed forwards

and upwards. It is often divided by a median ridge into
In a suspected case of murder. fracture of the hyoid
two lateral halves.
bone strongly indicates throttling or strangulation.
The posterior surface is concave and is directed
backwards and downwards.
Each lateral end of the body is continuous posteriorly
with the greater horn or cornua. However, till middle
life the connection between the body and greater comua IDENTIFICATION
is fibrous.
The cervical vertebrae are identified by the presence of
Greoler Cornuo foramina transversaria.
These are flattened from above downwards. Each There are seven cervical vertebrae, out of which the
cornua tapers posteriorly, but ends in a tubercle. It has third to sixth are typical, while the first, second and
two surfaces-upper and lower, two borders-medial seventh are atypical (Fig. 1.48).
and lateral and a tubercle.
Lesser Cornuo
These are small conical pieces of bone which project
upwards from the junction of the body and greater
cornua. The lesser cornua are connected to the body
by fibrous tissue. Occasionally, they are connected to
the greater cornua by synovial joints which usually
persist throughout life, but may get ankylosed.
Affsct?rnenfs on ffte *tyoid fran*
The anterior surface of the body provides insertion
to the geniohyoid and mylohyold muscles and gives
origin to a part of the hyoglossus which extends to
the greater cornua (Fig. Lan.
Tlae upper border of the body provides insertion to
the lower fibres of the genioglossi and attachment
to the thyrohyoid membrane.
The lower border of the body provides attachment to
the pretracheal fascia.In front of the fascia , t!;re sternohyoid
is inserted medially and the superior belly of omohyoid
laterally.
Below the omohyoid, there is the linear attachment Fig. 1.48: Cervical vertebrae-anterior view
of the thyrohyoid, extending back to the lower border of
the greater cornua. WPICAL CERVICAL VERTEBRA
The medial border of the greater cornua provides
Body
attachment to the tlryrohyoid membrane, stylohyoid muscle
and dignstric pulley. 1 The body is small and broader from side to side than
The lateral border of the greater cornua provides from before backwards.
insertion to the thyrohyoid muscle anteriorly. The Its superior surface is concave transversely with
.!< inaesting fascia is attached throughout its length. upward projecting lips on each side. The anterior
o The lesser cornua provides attachment to the border of this surface may be bevelled.
zo stylolry oid ligament at lls tip. The middle constrictor muscle The inferior surface is saddle-shaped, being convex
E
c(E arises from its posterolateral aspect extending on to the from side to side and concave from before
tt(E greater cornua (see Fig. 14.21). backwards. The lateralborders arebevelled and form
o sy,novial joints with the projecting lips of the next
DEVETOPMENT lower vertebra. The anterior border projects
C Upper part of body and lesser cornua develop from downwards and may hide the intervertebral disc.
o
C) second branchial arch, while lower part of body and Tlre anterior and posterior surfaces resemble those of
ao greater cornua develop from the third arch. other vertebrae (Fig. 1.49).
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Verlebtol Foromen The upper borders and lower parts of the anterior
Vertebral foramen is larger than the body. It is surfaces of the laminae provide attachment to the
triangular in shape because the pedicles are directed ligamenta flaaa.
backwards and laterally. T}:.e foramen transaersarium transmits the oertebral
artery, the aertebral oeins and abranch from the inferior
Verlebrol Arch ceroical ganglion. The anterior tubercles give origin to
the scalenus anterior , the longus capitis, and the oblique
1 Thepedicles are directed backwards and laterally. The
part of the longus colli.
superior and inferior vertebral notches are of equal
T}ne costotransrerse bars are grooved by the anterior
size.
primary rami of the corresponding cervical nerves.
2 The laminae are relatively long and narrow, being The posterior tubercles give origin to the scalenus
thinner above than below.
medius, scalenus posterior, the leaator scapulae, the
3 The superior and inferior articular processes form splenius cerzticis, the longissimus ceroicis, and the
articular pillars which project laterally at the junction iliocostalis ceroicis (see Fig. 10.3).
of pedicle and the lamina. The superior articular The spine gives origin to the deep muscles of the
facets are flat. They are directed backwards and back of the neckinterspinales, semispinalis thoracis and
upwards. The inferior articular facets are also flat ceraicis, spinalis ceruicis, and multifidus (see Figs 10.2
but are directed forwards and downwards. and 10.4).
4 The transuerse processes are pierced by foramina
transversaria. Each process has anterior andposterior
roots which end in tubercles joined by the
costotransoerse bar. The costal element is represented by A typical cervical vertebra ossifies from three
the anterior root, anterior tubercle the costotransaersebar primary and six secondary centres. There is one
and the posterior tubercle. The anterior tubercle of the primary centre for each half of the neural arch during
sixth cervical vertebra is large and is called the carotid 9 to 10 weeks of foetal life and one for the centrum in
tubercle because the common carotid artery can be 3 to 4 months of foetal life. The two halves of the
compressed against it. neural arch fuse posteriorly with each other during
5 The spine is short and bifid. The notch is fitled up by the first year. Synostosis at the neurocentral
the ligamentum nuchae (Fig. 1.a9). synchondrosis occurs during the third year.
T}ae secondary centres, two for the annular
Affcv*fsrnemfs arl# tr*Cofrarns epiphyseal discs for the peripherai parts of the upper
1 The anterior and posterior longitudinal ligaments are and lower surfaces of the body, two for the tips of
attached to the upper and lower borders of the body the transverse processes, and two for the bifid spine
in front and behind, respectively. On each side of appear during puberty, and fuse with the rest of the
the anterior longitudinal ligament, the rsertical part vertebra by 25 years.
of the longus colli is attached to the anterior surface.
The posterior surface has two or more foramina for
passage of basioertebrnl oeins. FIRST CERVICAL VERTEBRA
It is called the atlas (Tiltan, who supported the heavans).

It can be identified by the following features:
Foramen
transversarium
1 It is ring-shaped. It has neither a body nor a spine
(Fis. 1.50).
Anterior tubercle
2 The atlas has a short anterior arch, a long posterior
arch, right and left lateral masses, and transverse
Processes. lr
o
Costotransverse 3 The anterior arch is marked by a median anterior
zo
bar
tubercle on its anterior aspect. Its posterior surface t,
bears an ooal facet which articulates with tt:.e dens cl
(Fis. 1.50). t,G
Superior
articular
4 The posterior arch forrns about two-fifths of the ring o
facel and is much longer than the anterior arch. Its
posterior surface is marked by a median posterior c
.o
tubercle. The upper surface of the arch is marked o
Fig. 1.49: Typical cervical vertebra seen from above behind the lateral mass by a groore. ao
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I
HEAD AND NECK
Transverse ligament
Rectus capitis anterior
Superior articular facet
Rectus capitis lateralis
Foramen transversarium
Levator scapulae
Transverse process
Superior oblique Groove with vertebral artery
Posterior arch
Rectus capitis posterior minor

Posterior iubercle
Fig. 1.50: Atlas vertebra seen from above
Each latersl mass shows the following important 5 The groove on the upper surface of the posterior arch
features: is occupied by the aertebral artery and by the first
a. Its upper surface bears the superior articular facet. ceroical nense. Behind the groove, the upper border
This facet is elongated (forwards and medially), of the posterior arch gives attachment to the posterior
concave, and is directed upwards and medially. atlanto-occipital membrane (see Figs 10.5 and 10.6).
It articulates with the corresponding condyle to 6 The lower border of the posterior arch gives
form an atlanto-occipital joint. attachment to the highest pair of ligamenta flaoa.
b. The lower surface is marked by the inferior articular 7 The tubercle on the medial side of the lateral mass
gives attachment to tilre transaerseligament of the atlas.
facet.This facet is nearly circular, more or less flat,
and is directed downwards, medially and 8 The anterior surface of the lateral mass gives origin
backwards. It articulates with the corresponding to the rectus capitis anterior.
facet on the axis vertebra to form an atlantoaxial 9 The transverse process giaes origin to the rectus
joint. capitis lateralis from its upper surface anteriorly, the
c. The medial surface of the lateral mass is marked superior oblique from its upper surface posteriorly,
by a small roughened tubercle. the inferior oblique from its lower surface of the tip,
theleaator scapulae from its lateral margin and lower
d. The transaerse process projects laterally from the
lateral mass. It is unusually long and can be felt border, the splenius ceraicis, and the scalenus medius
from the posterior tubercle of transverse process.
on the surface of the neck between the angle of
mandible and the mastoid process. Its long length
allows it to act as an effective lever for rotatory
movements of the head. The transverse process is Atlas ossifies from three centres, one for each lateral
pierced by the foramen transversarium. mass with half of the posterior arch, one for the
anterior arch. The centres for the lateral masses
Affmeft rmemfs cru# &*fsfions appear during seventh week of intrauterine life and
unite posteriorly at about three years. The centre for
1 The anterior tubercle provides attachment (in the
anterior arch appears at about first year and unites
median plane) to the anterior longitudinal ligament,
ta and provides insertion on each side to l}i.e upper
with the lateral mass at about 7 years.
o
zo 2 oblique part of longus colli.
The upper border of the anterior arch gives
!, SECOND CERVICAL VERTEBRA
tr attachment to the anterior atlanto-occipital membrane.
(E
t,(E 3 The lower border of the anterior arch gives attachment This is called the axis (Latin axile).It is identified by
o to the lateral fibres of the anterior longitudinal ligament. the presence of the dens or odontoid (Greek tooth)
4 The posterior tubercle provides attachment to the process which is a strong, tooth-like process projecting
c ligamentum nuchae in the median plane and gives upwards from the body. The dens is usually believed
.9
o origin to the rectus capitis posterior minor on each side to represent the centrum or body of the atlas which has
ao (Fig. 1.50). fused with the centrum of the axis (Fig. 1.51).
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INTRODUCTION AND'OS'="'"NV ;
"4ffoclrmenfs
Facet for atlas 1 The dens provides attachment at its apex to the apicnl
ligament, and on each side, below the apex to the alar
ligaments (see Fig. 9.12).
Foiamen
transversarium 2 The anterior surface of the body receives the insertion
of the longus colli.The anterior longitudinal ligament is
Transverse process
also attached to the anterior surface.
Vertebral loramen 3 The posterior surface of the body provides
Inferior articular
attachment, from below upwards, to the posterior
process longitudinal ligament, the membrana tectoria and the
aertical limb of the cruciate ligament.
Spine
4 The laminae provide attachment to the ligamenta
flaaa.
Fig. 1.51 ; Axis vertebra, posterosuperior view 5 The transverse process gives origin by its tip to the
leaator scnpulae, the scalenus medius anteriorly and the
Body ond Dens splenius ceroicis posteriorly . The intertransoerse
muscles are attached to the upper and lower surfaces
1 The superior surface ofthe body is fused with the dens,
and is encroached upon on each side by the superior
of the process.
articular facets. The dens articulates anteriorly with 6 The spine gives attachment totheligamentumnuchae,
oval fact on posterior surface of the anterior arch of the semispinalis ceraicis, the rectus capitis posterior
the atlas, and posteriorly with the transverse major, the inferior oblique, the spinalis centicis, the
ligament of the atlas. interspinalis and the multifidus (see Chapter 10).
2 The inferior surface has a prominent anterior margin
which projects downwards. SEVENTH CERVICAT VERTEBRA
3 The anterior surface presents a median ridge on each It is also known as the aertebra prominens because of its
side of which there are hollowed out impressions. long spinous process, the tip of which can be felt
through the skin at the lower end of the nuchal furrow.
VertebrolArch Its spine is thick, long and nearly horizontal. It is
1 The pedicles are concealed superiorly by the superior not bifid, but ends in a tubercle (Fig. 1.52).
articular processes. The inferior surface presents a The transverse processes are comparatively large in
deep and wide inferior aertebral notch, placed in front size, the posterior root is larger than the anterior. The
of the inferior articular process. The superior anterior tubercle is absent. The foramen transversarium
vertebral notch is very shallow and is placed on the is relatively smalI, sometimes double, or maybe entirely
upper border of the lamina, behind the superior absent. It does not transmit the vertebral artery.
articular process.
2 The laminae are thick and strong. *ff#cfirnenfs
3 Articular facets: Each superior articular facef occupies 1 The tip of the spine provides attachment to the
the upper surfaces of the body and of the massive ligamentum nuchae, trapezius, rhomboid minor, serratus
pedicle. LateraTly, it
overhangs the foramen
transversarium. It is a large, flat, circular facet which
is directed upwards and laterally. It articulates with Foramen
transversarium
the inferior facet of the atlas vertebra to form the
atlantoaxial joint. Each inferior articular facet lies
posterior to the transverse process and is directed tto
downwards and forwards to articulate withthe third
cervical vertebra.
zo
!tc
4 The transrserse processes are very small and represent (E
the true posterior tubercles only. The foramen !t(E

transversarium is directed upwards and laterally o
(Fig.1.51).
5 The spine islarge, thick and very strong. It is deeply c
o
grooved inferiorly. Its tip is bifid, terminating in two o
o
rough tubercles. Fig. 1.52: Seventh cervical vertebra seen from above a
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r-: .--- l
HEAD AND NECK leM I
tMl
p o st er ior sup er io r, spl eniu s cap itis, s emisp inalis thor aci s, vertebrobasilar insufficiency. This may cause
spinalis centicis, interspinales. and the multifidus (see
vertigo, dizziness, etc.
Fig. 10.3).
Prolapse of the intervertebral disc occurs at the
2 Transzterse process: The fornmen transoersarium :usually
junction of different curvatures. So the common
transmits only an accessory vertebral vein. The
site is lower cervical and upper lurnbar vertebral
posterior tubercle provides attachment to the
region. In the cervical regio+ the disc involved is
suprapleural membrane. The lower border provides
above or below 6th cervical vertebra. The nerve
attachment to the lersator costarum.
roots affected are C6 and C7. There is pain and
The anterior root of the transverse process may numbness along the lateral side of forearm and
sometimes be separate. It then forms a ceraical rib of hand. There may be wasting of muscles of thenar
variable size. eminence.
During judicial hanging, the odontoid process
usually breaks to hit upon the vital centres in the
medulla oblongata (Fig. 1.56).
Its ossification is similar to that of a typical cervical
vertebra. In addition, separate centre for each costal
Atlas may fuse with the occipital bone. This is
process appears during sixth month of intrauterine
called occipitalization of ntlas and this may at times
life and fuses with the body and transverse process compress the spinal cord which requires surgical
decompression.
during fifth to sixth years of life.
The pharyngeal and retropharyngeal inflam-
mations may cause decalcification of atlas
vertebra. This may lead to loosening of the
attachments of transverse ligament which may
The costal element of seventh cervical vertebra eventually yield, causing sudden death from
may get enlarged to form a cervical rib (Fig. 1.53). dislocation of dens.
A cervical rib is an additional rib arising from the Fractures of skull may be depressed, linear and
C7 vertebra and usually gets attached to the 1st basilar (Fig. 1.57).
rib near the insertion of scalenus anterior. If the Hangman's fracture occurs due to fracture of the
rib ls more than 5 cm long, it usually displaces pedilles of axis vertebra. As the vertebral canal
the brachial plexus and the subclavian artery gets enlarged, the spinal cord does not get
upwards (Fig. 1.5a). pressed.
The symptoms are tingling pain along the inner
border of the forearm andhand including weakness
and even paralysis of the muscles of the palm.
The intervertebral foramina of the cervical
vertebrae, lie anterior to the joints between the
articular processes. Arthritic changes in these
joints, if occur, cause tiny projections or
osteophytes. These osteophytes may press on the
anteriorly placed cervical spinal nerves in the
foramina causing pain along the course and
distribution of these nerves (fig. 1.55).
The joints in the lateral parts of adiacent bodies of
.Y cervical vertebrae are called Luschka's joints. The
o osteophytes commonly occur in these joints. The
o
z cervical nerve roots lying posterolateral to these
E
joints may get pressed causing pain along their
(E
t,6 diskibution (Flg. 1.55).
O. The vertebral artery coursing through the foramen
I
transversarium lies lateral to these joints. The
c osteophytes of Luschka joints may cause
.9
o distortion of the vertebral artery leading to Fig. 'l .53: Bilateral cervical ribs
o)
a
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c6
c7
c8
Cervical rib
Brachial plexus
*lstrib
Fig. 1.54: Cervical rib causing pressure on the lower trunk
of the brachial plexus Fig. 1.56: Fracture of the odontoid process during hanging
Joint between
articular processes
lntervertebral
foramen
Bony changes
Luschka's joints
Fig. 1.55: Pressure onthecervical nervedueto bonychanges Fig. 1.57: Types of the fracture of the skull
Two centres for squamous part below highest

Frontal: It ossifies in membrane. Two primary nuchal line appear during seventh week. One
centres appear during eighth week near frontal Kerkring centre appears for posterior margin of
eminences. At birth, the bone is in two halves, foramen magnum during sixteenth week.
separated by a sufure, which soon start to fuse. But Two centres one for each lateral parts appear
remains of metopic suture may be seen in about during eighth week. One centre appears for the
3-8% of adult skulls. basilar part during sixth week.
.Y
Parietal: It also ossifies in membrane. Two centres Temporal: Squamous and tympanic parts ossify in o
appear during seventh week near the parietal membrane. Squamous part by one centre which zo
eminence and soon fuse with each other. appears during seventh week. Tympanic part from ttr
Occipital: It ossifies partly in membrane and one centre which appears during third month. (E
partly in cartilage. The part of the bone above highest Petromastoid and styloid parts ossify in cartilage.
!,(E
I o
nuchal line ossifies in membrane by two centres Petromastoid part is ossified by several centres which
which appear during second month of foetal life, it appear in cartilaginous ear capsule during fifth
E
r may remain separate as interparietal bone. month. Styloid process develops from cranial end of o
()
L
The following centres appear in cartilage: second branchial arch cartilage. Two centres appear
ao
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HEAD AND NEOK
in it. Tympanohyal before birth and stylohyal after week near the mental foramen. The upper half of
birth. ramus ossifies in cartilage. Ossification spreads in
Sphenoid: It ossifies in two parts: condylar and coronoid processes above the level of
Presphenoidal part whichlies in front of tuberculum the mandibular foramen.
sellae and lesser wings ossifies from six centres in lnferior nasal concha; It ossifies in cartilage. One
cartilage: Two for body of sphenoid during ninth centre appears during fifth month in the lower border
week; two for the two lesser wings during ninth of the cartilaginous nasal capsule.
week; two for the two sphenoidal conchae during Palatine: One centre appears during eighth week
fifth month. in perpendicular plate. It ossifies in membrane.
Postsphenoidal part consisting of posterior part of Lacrimal: It ossifies in membrane. One centre
body, greater wings and pterygoid processes ossifies appears during twelfth week.
from eight centres: Nasal: It also ossifies in membrane from one
Two centres for two greater wings during eighth centre which appears during third month of intra-
week forming the root only; two for postsphenoidal uterine life.
part of body during fourth month; two centres appear
Vomer: It ossifies in membrane. Two centres
for the two pterygoid hamulus during third month
appear during eighth week on either side of midline.
of foetal life. These six centres appear in cartilage.
These fuse by twelfth week.
Two centres for medial pterygoid plates appear
during ninth week and the remaining portion of the Zygomatic: It ossifies in membrane by one centre
greater wings and lateral plates ossify in membrane which appears during eighth week.
from the centres for the root of greater wing only. Maxilla: It also ossifies in membrane by three
Ethmoid: It ossifies in cartilage. Three centres centres. One for main body which appears during
appear in cartilaginous nasal capsule. One centre sixth week above canine fossa.
appears in perpendicular plate during first year of Two centres appear for premaxilla during seventh
life. Two centres one for each labyrinth appear week and fuse soon.
between fourth and fifth months of intrauterine life. Various foramina of anterior, middle and
Mandible: Each half of the body is ossified in posterior cranial fossae and other foramina with their
membrane by one centre which appears during sixth contents are shown in Table L.5.
:..i1 :-ja:: j. :,' ...:.:....

:,.:.
'! -. -:....,. - !,
Foramina/apertures
ANTERIOR CRANIAL FOSSA
Groove for superior sagittal sinus Superior sagittal sinus
Foramen caecum Emissary vein to superior sagittal sinus from upper part of nose
Anterior ethmoidal foramen Anterior ethmoidal nerve and vessels
Foramina of cribiform plate Olfactory nerve rootlets
Posterior ethmoidal foramen Posterior ethmoidal vessels
MIDDLE CRANIAL FOSSA
Optic canal Optic nerve and ophthalmic artery
Superior orbital fissure:
. Lateral part Lacrimal and frontal nerues, (branches of ophthalmic nerve); trochlear nerue; superior
ophthalmic vein; meningeal branch of lacrimal artery; anastomotic branch of middle
meningeal artery, which anastomoses with recurrent branch of lacrimal artery.
l. .
o Middle part Upper and lower divisions of oculomotor nerue (CN lll), nasociliary nerue, abducent
o
z nerue (CN Vl)
E
tr
. Medial part lnferior ophthalmic vein; sympathetic nerve from plexus around internal carotld artery.
(E
Foramen rotundum Maxillary nerve (CN V2)
ItG
o Foramen ovale Mandibular nerve (CN V3); accessory meningeal artery; lesser petrosal nerve;
I emissary vein connecting cavernous sinus with pterygoid plexus (male)
C Foramen spinosum Middle meningeal artery and vein, meningeal branch of mandibular nerve (CN V3)
o
o Emissary sphenoidal foramen Emissary vein connecting cavernous sinus with pterygoid plexus of veins
o
U) (Contd...)
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Foramina/apertures Contents
Foramen lacerum During life, the foramen is filled with cartilage
No significant structure passes through it; internal carotid artery and nerve plexus pass
across its superior end; nerve to pterygoid canal passes through its anterior wall;
meningeal branch of ascending pharyngeal artery and emissary vein pass through it.
Carotid canal lnternal carotid artery and nerve plexus (sympathetic)
Groove for lesser petrosal nerve Lesser petrosal nerve
Groove for greater petrosal nerve Greater petrosal nerve
POSTERIOR CRANIAL FOSSA
Foramen magnum Lowest part of medulla oblongata and three meninges; vertebral arteries; spinal roots
of CN Xl; anterior and posterior spinal afieries; apical ligament; vertical band of cruciate
ligament and membrana tectoria.
Jugular foramen CN lX; X; Xl; inferior petrosal and sigmoid sinuses; meningeal branches of ascending
pharyngeal and occipital arteries.
Hypoglossal canal/anterior condylar canal CN XII
Internal acoustic meatus CN Vll; Vlll and labyrinthine vessels
External opening of vestibular aqueduct Endolymphatic duct
Posterior condylar canal Emissary vein connecting sigmoid sinus with the suboccipital venous plexus
Mastoid foramen Mastoid emissary vein and meningeal branch of occipital artery
OTHER FORAMINA
External acoustic meatus Air waves
External nasal foramen External nasal nerve
Greater palatine foramen Greater palatine vessels; anterior palatine nerve
lncisive canal Greater palatine vessels; terminal part of nasopalatine nerve
lnferior orbital fissure Zygomatic nerve; orbital branches of pterygopalatine ganglion; infraorbital nerve and
vessels
lnfraorbital foramen lnfraorbital nerve and vessels
Lesser palatine foramen Middle and posterior palatine nerves
Mandibular foramen/canal lnferior alveolar nerve and vessels
Mandibular notch Masseteric nerve and vessels
Mastoid canaliculus Auricular branch of vagus nerve
Mental foramen Mental nerve and vessels
Palatinovaginal canal Pharyngeal branch from pterygopalatine ganglion; pharyngeal branch of maxillary
artery
Parietal foramen Emissary vein from scalp to superior sagittal sinus
Petrotympanic fissure Chorda tympanic nerve and anterior tympanic artery.
Pterygoid canal Nerve to pterygoid canal and vessels
Pterygomaxillary f issure Maxillary nerve
Pterygopalatine fossa Pterygopalatine ganglion
Stylomastoid foramen Facial nerve; stylomastoid branch of posterior auricular artery.
xo
Supraorbital foramen Supraorbital nerve and vessels zo
Tympanic canaliculus Tympanic branch of glossopharyngeal nerve t,c
(5
Tympanomastoid fissure Auricular branch of vagus nerve !,(E
Vomerovaginal canal Branch of pharyngeal nerve and vessels o
Zygomatic foramen Zygomatic nerve
C
Zygomaticofacial foramen Zygomaticofacial nerve .9
()
Zygomaticotemporal foramen Zygomaticotemporal nerve
ao
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HEAD AND NECK
A young woman complains of pain and numbness

. B bones in the skull and L4 facral bones make up along the lateral side of forearm and hand, with
the skull. wasting of the muscles of thenar eminence
r Most of the joints are 'suture' type of joints. The
. \,fhy is there pain in forearm and hand with no
jointbetween teeth and gums is gomphosis' There injury to the affected area?
is a pair of temporomandibularloint, which is of . lrvhy are thenar muscles gettmg weaker?
synwial variety. Ans: There is na obvious injury in the hand or
. {*rearm, These syrnptorrrs arenervous innafure. One
The bony ossicles are malleus, incus and stapes and
has to l*ok far thenerrre rootwhich supply this area,
are "bone within bone", as these are present in the
The nerve root is cervical 6. Seel the cervical spine
petrous temporal bone. Between these three
-ossicles f*r anypain. An X-ray/CT scan may rev*al pr+lapse
ure tr,iro symovial joints.
*f thi intervertebral disc between C6 and C7
. Diploe veins contain manufacturred RBCs, vertebrae compressitg the cervical 6 nerve root"
granulocytes and platelets. These drain into the Yhese rcr:t forrlr part nf lateral cutaneous nerve c{
neighbouring veins. f*rearm, and median nerves. Sinee rnedian fierve
(CS) supplies thenar rnusclqs. there is wasting/
. Paranasal sinuses give resonance to the voice,
weakness cf these muscles. As lateral tutane$us
besides humidifying and warming up the inspired
nerrre of forearrn is pressed, there is rn-rmbrtess on
air.
lateral side of farearrtt and hand'
MUTT|PLE CHOICE OUESTIONS
1.. Which of the following structure does not pass 3. Which is the thickest boundary of the orbit?
through foramen magnum? a. Lateral b. Medial
a. Accessory pharyngeal arterY c. Roof d. Floor
4. Which bone is not a "bone within the bone" 1n
b. Vertebral artery
petrous temporal bone?
c. Spinal accessory nerve a. Malleus b. Hyoid
d. Vertical band of cruciate ligament c. Incus d. Stapes
, Which of the following nerve does not pass through 5. Which of the ParasymPathetic ganglia does not
jugular foramen? have a secretomotor root?
a. Vagus b. Hypoglossal a. Submandibular b. Pterygopalatine
c. Glossopharyngeal d. AccessorY c. Otic d. CiliarY
L,a|-' 2:b 5.rd
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Scalp, Temple and Face
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INTRODUCTION
Plica Eyebrow
Face is the most prominent part of the body. Facial semilunaris Eyelashes
muscles, being the muscles of facial expression, express
Lacrimal caruncle Laterai angle
a variety of emotions like happiness, joy, sadness, anger,
of eye
frowning, grinning, etc. The face, therefore, is an index
Lacrimal papilla lris and pupil seen
of mind. One's innerself is expressed by the face itself with punctum through cornea
as it is controlled by the higher centres.
Fig.2.1: Some features to be seen on the face around the left
Use of cosmetics should be limited because of their
eye
ill-effects and the tendency to cause allergic reactions.
Cosmetics try to enhance the external beauty only The eyeballs are lodged in bony sockets, called the
temporarily. The real beauty of good and helping orbits.
nature comes fromwithinwhich no cosmetic can match. The conj unctia a is a moist, transparent membrane.
The part which covers the anterior surface of the
FEATURES THAT CAN BE IDENTIFIED
eyeball is the bulbar conjunctiaa, and the part lining
1 The forehead is the part of the face between the the inner surfaces of the lids is the palpebral
hairline of adolescent's scalp and the eyebrows. The conjunctiaa. The line along which the bulbar
superolateral prominence of the forehead is known conjunctiva becomes the palpebral conjunctiva is
as the frontal eminence. known as the conjunctiaal fornix. The space between
2 Identify the following in relation to the nose: The the two is the conjunctizsal sac.
prominent ridge separating the right and left halves The oral fissure or mouth is the opening between the
of the nose is called the dorsum. The upper narrow upper and lower lips.It lies opposite the cutting edges
end of the nose just below the forehead, is the root of of the upper incisor teeth. The angle of the mouth
the nose. The lower end of the dorsum is in the form usually lies just in front of first upper premolar tooth.
of a somewhat rounded ttp. At the lower end of the Each lip has a red margin at mucocutaneous junction
nose, we see the rightandleftnostrils or anterior nares. and a dark margin, with a nonhairy thin skin inter-
The two nostrils are separated by a soft median vening between the two margins. The lips normally
partition called the columella. This is continuous with close the mouth along their red margins. Thephiltrum
th.e nasal septum which separates the two nasal is the median vertical groove on the upper lip.
cavities. Each nostril is bounded laterally by the ala. The external ear isrnade up of two parts: a superficial
3 The palpebral fissure is an elliptical opening between projecting part, called the auricle or pinna; and a deep
the two eyelids. The lids are joined to each other at canal, called the external acoustic meatus. The mobile
the medial and lateral angles or canthi of the eye. auricle helps in catching the sound waves, and is a
The free margin of each eyelid has eyelashes or cilia characteristic feature of mammals. Details of the
arranged along its outer edge (Fig.2.1). structure of the auricle will be considered later.
Through the palpebral fissure are seen: The supraorbital margin lies beneath the upper margin
a. The opaque sclera or white of the eye. of the eyebrow. The supraorbital notch is palpable
b. The transparent circular cornea through which at the junction of the medial one-third with the lateral
the coloured iris and the dark circular pupil can two-thirds of the supraorbital margin. A vertical line
be seen. drawn from the supraorbital notch to the base of the
59
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HEAD AND NECK
mandible, passing midway between the lower two STRUCTURE

premolar teeth, crosses the infraorbital foramen Conventionally, the superficial temporal region is
5 mm below the infraorbital margin, and the mental studied with the scalp, and the following description,
foramen midway between the upper and lower therefore, will cover both the regions.
borders of the mandible.
The scalp is made up of five layers (mnemonic
7 The superciliary arch is a curved bony ridge situated
scALP)
immediately above the medial part of each
a. Skin
supraorbital margin. the glabella is the median
elevation connecting the two superciliary arches, and b. Superficial fascia (Connective tissue)
corresponds to elevationbetween the two eyebrows. c. Deep fascia in the form of the epicranial
aponeurosis or galea aponeurotica with the
occipitofrontalis muscle
d. Loose areolar tissue
e. Pericranium (Figs 2.3a and b).
The skin is thick and hairy. It is adherent to the
Place 2-3 wooden blocks under the head to raise it
epicranial aponeurosis through the dense superficial
about 10-12 cm from the table. Give a median incision
fascia, as in the palms and soles.
in the skin of scalp extending from root of the nose (i),
The subcutaneous or superficial fascin is more fibrous
to the prominent external occipital protuberance
(ii) (Fig. 2.2).Give a coronal incision across the previous
and dense in the centre than at the periphery of the
head.
incision from root of one auricle to the other (iii). Extend
the incision from the auricles to the mastoid process It binds the skin to the subjacent aponeurosis, and
posteriorly (iv), and to root of zygoma anteriorly (v), provides the proper medium for passage of vessels and
Reflect the skin in four flaps. Usually the skin is so nerves to the skin.
adherent to the subjacent connective tissue and The occipitofrontalis muscle has two bellies, occipital
aponeurotic layers that these all come off together. or occipitalis and frontal or frontalis, both of which are
Dissect the layers, including the nerves, vessels, inserted into the epicranial aponeurosis. The occipitnl
lymphatics and identify these structures in the cadaver. bellies are small and separate. Each arises from the
lateral two-thirds of the superior nuchal line, and is
supplied by the posterior auricular branch of the facial
DEFINITION
neroe.
The soft tissues covering the cranial vault form the scalp Thefrontalbellies are longer, wider and partly united
(Fig. 2.3). in the median plane. Each arises from the skin of the
forehead, mingling with the orbicularis oculi and the
EXTENT OI SCALP corrugator supercilli. It is supplied by the tempornl
Anteriorly, supraorbital margins; posteriorly, external branch of the facial nerve (seeFig.1.6).
occipital protuberance and superior nuchal lines; and The muscle raises the eyebrows and causes
on each side, the superior temporal lines. horizontal wrinkles in the skin of the forehead(Fig.z.\.
The epicranial aponeurosis, or galea aponeurotica is
freely movable on the pericranium along with the
overiying and adherent skin and fascia (Figs 2.3a and
2.9). Anteriorly, it receives the insertion of the frontalis,
posteriorly, it receives the insertion of the occipitalis
ind is attached to the external occipital protuberance,
and to the highest nuchal lines in between the occipital
.Y bellies. On each side, the aponeurosis is attached to the
o superior temporal line, but sends down a thin
o
z expansion which passes over the temporal fascia and
ttc is attached to the zygornatic arch (Fig. 2.3b).
(E
E First three layers of scalp are called surgical layers of
(s
o the scalp, These are called as scalp proper also.
The fourth layer of the scalp, is made up of loose
C areolar tissue. It extends anteriorly into the eyelids
.9
o (Fig.2.a) because the frontalis muscle has no bony
ao Fig.2.2: Lines of dissection for scalp, face and eyelids attachment; posteriorly to the highest and superior
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SCALq TEMPLE AND FACE
Skin
Skin with hair (S) Superflcial fascia
Extension of
Superficial fascia wiih epicranial .
Emissary blood vessels (C) aponeurosrs
vein
Epicranial aponeurosis (A) Temporal fascia
Loose connective tissue (L)
Diploe in
between outer Pericranium (P)
and inner tables
of skull
Dura mater
Pericranium
Figs 2.3a and b: (a) Layers of the scalp, and (b) layers of superficial temporal region
L Skin
Epicranial 2 Superficial fascia
aponeurosis
3 Thin extension of epicranial aponeurosis which gives
Frontalis
origin to extrinsic muscles of the auricle,
Frontal bone 4 Temporal fascia
Layer of loose areolar
5 Temporalis muscle (Fig.2.3b)
tissue or subaponeurotic 6 Pericranium.
tissue Tempus means time. Greying of hair first starts here.
Orbicularis oculi Arteriol Supply of Scolp ond

Superficiol Temporol Region
Eyelid
In front of the auricle, the scalp is supplied from before
Iarsus
backwards by the:
Conjunctiva . Supratrochlear;
Fig. 2.4: Schematic section through the scalp and upper eyelid c Supraorbital;
to show how fluids can pass from the subaponeurotic space or o Superficial temporal arteries (Fig. 2.5).
layer of loose areolar tissue of the scalp into the eyelid, and Into The first two are branches of the ophthalmic artery
the subconjunctival area. Note that this is possible because the which in turn is a branch of the internal carotid artery.
frontalis muscle has no bony attachment The superficial temporal is a branch of the external
carotid artery.
nuchal lines; and on each side to the superior temporal Behind the auricle, the scalp is supplied from before
lines. It gives passage to the emissary veins which backwards by the:
connect extracranial veins to intracranial venous sinuses o Posterior auricular;
(Fig. 2.3a). .Occipital arteries, both of which are branches of
The fifth layer of the scalp, called the pericranium, the external carotid artery. J(,
is loosely attached to the surface of the bones, but is Thus, the scalp has a richblood supply derived from
firmly adherent to their sutures where the sutural both the internal and the external carotid arteries, the zo
ligaments bind the pericranium to the endocranium two systems anastomosing over the temple.
!tc
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(Fig.2.3a).
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Venous Droinoge o
SUPERFICIAL TEMPORAT REGION
The veins of the scalp accompany the arteries and have
It is the area between the superior temporal lineand similar names. The supratrochlear and supraorbitalveins o
the zygomatic arch. This area contains the following unite at the medial angle of the eye forming the angular o
o
6 layers: vein which continues down as the facial vein. U)
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I{EAD AND NECK
Supratrochlear nerve
Supratrochlear artery
Supraorbital nerve
Supraorbital artery
Zygomaticotemporal nerve
Temporal branch of facial (motor)
Superfi cial temporal artery
Pinna
Great auricular nerve
Lesser occipital nerve
Posterior auricular artery
Posterior auricular nerve (motor)
Occipital artery
Greater occipital nerve
Third occipital nerve
Fig.2.5: Arterialand nerve supply of scalp and superficial temporal region
Thre superficial temporal aein descends in front of the subclaoian ztein. The occipital veins terminate in the
tragus, enters the parotid gland, and joins the maxillary suboccipital venous plexus (Fig. 2.6).
vein to form the retromandibular vein. This vein divides Emissnry veins connect the extracranial veins with
into two divisions. the intracranial venous sinuses to equalise the pressure.
The anterior division of the retromandibular vein Tlre parietal emissary zsein passes through the parietal
unites with the facial vein to form the common facial foramen to enter the superior sagittal sinus. Themastoid
vein which drains into the internal jugular vein. emissary oein passes through the mastoid foramen to
The posterior division of the retromandibular vein reach the sigmoid sinus. Remaining emissary veins are
unites with the posterior auricular oein to form the shown in Table 1.1. Extracranial infections may spread
external jugular aein wlitich ultimately drains into the through these veins to intracranial venous sinuses.
Superior and inferior

ophlhalmic veins Cavernous sinus
Superficial temporal
Supraorbiial
Supratrochlear
Angular vein
Maxillary
Retromandibular vein
Emissary vein
Anterior division
Facial
-Y Deep facial Posterior division

o
o Pterygoid plexus
z Posierior auricular
E External jugular
tr Common facial vein
(E
t,(E
o lnternal jugular
Subclavian vein
.o
o
ao Fig. 2.6: The veins of the face and their deep connections with the cavernous sinus and the pterygoid plexus of veins
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SCALP, TEMPLE AND FACE
Diploic veins start from the cancellous bone within Wounds of the scalp bleed profusely because the
the two tables of skull. These carry the newly formed
vessels are prevented from retracting by the fibrous
blood cells into the general circulation. These are four fascia. Bleeding. can he arrested by applying
veins on each side (see Fi9.1,.17).
pressure above theears by a tight cottonbandage
The frontal diploic aein ernerges at the supraorbital
again*t the bone.
notch open into the supraorbital vein. Anterior temporal
Because of the density of fascia, subcutaneous
diploic ztein ends in anterior deep temporal vein o-r
haemorrhages are never extensive, and the
sphenoparietal sinus. Posterior temporal diploic oein ends
inflammations in this layer causelittle sw'ellingbut
in the transverse sinus. The occipital diploic aein opens
much pain.
either into the occipital vein, or into the transverse sinus
Because the pericranium is adherent to sutures,
near the median plane (see Table 1.2).
collections of fluid deep to the pericranium known
Lymphotic Droinoge as cephalhaematoma take the ;hape oJ the bone
The anterior part of the scalp drains into the concerned.
preauricular or parotid ll ph nodes, situated on the The layer of loose areolar tissue is known as the
surface of the parotid gland. The posterior part of the dangerous areaaf thr scalpbecause the emissaryveins,
scalp drains into the posterior auricular or mastoid and which course here maytransmit infection from the
occipital lymph nodes. scalp to the oanial venous sirurses (Fig. 2.3a).
Coliection of blood in the layer of loose connective
Nerve Supply tissue causes generalised swellingof the scalp. The
The scalp and temple are supplied by ten nerves on blood may extend anteriorly into the rcot of the
each side. Out of these five nerves (four sensory and nose and into the eyelids, as frontalis muscle has
one motor) enter the scalp in front of the auricle. The no bony origin causing black eye (Fig.2:8). The
remaining five nerves (again four sensory and one posterior limit of such haemorrhage is not seen. If
motor) enter the scalp behind the auricle (Fi9.2.5 and bleeding is due to local injury, the posterior limit
Table 2.1). of haemorrhage is seen.
Because of ttre spread of blood, compression of
Table2.1: Nerves of the scalp and superficial temporal
brain is not seen and so thi$ layer is also called
region safety layer.
ln front of auricle
Since the blood supply of sealp and superficial
Behind the auricle
temporal region is very rich; avulsed portions
Sensory nerues Sensory nerues
need not be cut away, They can be replaced in
. Supratrochlear, branch of . Posterior division of great position and stitched: they usually take up and heal
the frontal (ophthalmic auricular nerve (C2, C3) well.
division of trigeminal nerve) from cervical plexus
. Supraorbital, branch of . Lesser occipital nerve
frontal (ophthalmic division (C2), from cervical plexus
of trigeminal nerve)
. Zygomaticotemporal, . Greater occipital nerve
branch of zygomatic nerve (C2, dorsal ramus)
(maxillary division of
trigeminal nerve)
. Auriculotemporal branch of . Third occipital nerve
mandibular division of (C3, dorsal ramus)
trigeminal nerve
Motor nerue Motor nerue
. Temporal branch of facial . Posteriorauricularbranch !
o
nerve of facial nerve o
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r Wounds of the scalp do not gape unless the o
epicranial aponeurosis is divided transversely.
I Because of the abundance of sebaceous glands, the C
.9
scalp is a common site for sebaceous cysts (Fig. 2.7). o
ao
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HEAD AND NECK
5 Facial skin is very elastic and thick because the facial

muscles are inserted into it. The wounds of the face,
therefore, tend to gape.
SUPERFICIAT FASCIA
It contains: (i) The facial muscles, all of which are
inserted into the skin, (ii) the vessels and nerves, to the
muscles and to the skin, and (iii) a variable amount of
Fig. 2.8: Right eye-black eye due to injury to the scalp; left
fat. Fat is absent from the eyelids, but is well developed
eye-black eye due to local injury
in the cheeks, forming the buccal pads that are very
prominent in infants in whom they help in sucking.
The deep fascia is absent from the face, except over the
parotid gland where it forms the parotid fascia, and
over the buccinator where it forms tlire buccopharyngeal
fascia.
Give a median incision from the root of nose, across
the dorsum of nose, centre of philtrum of upper lip, to FACIAL MUSCLES
centre of lower lip to the chin (vi). Give a horizontal The facial muscles, or the muscles of facial expression,
incision from the angle of the mouth to posterior border are subcutaneous muscles. They bring about different
of the mandible (vii). Reflect the lowerflap towards and facial expressions. These have small motor units.
up to the lower border of mandible (Fig. 2.2; line with Embryologically,they develop from the mesoderm of
dots). Direct and reflect the upper flap till the auricle. the second branchial arch, and are, therefore, supplied
Subjacent to the skin, the facial muscles are directly by the facial nerve.
encountered as these are inserted in the skin. ldentify Morphologically, they represent the best remnants of
the various functional groups of facial muscles. the panniculus carnosus, a continuous subcutaneous
Trace the various motor branches of facial nerve muscle sheet seen in some animals. All of them are
emerging from the anterior border of parotid gland to inserted into the skin.
supply these muscles. Amongst these motor branches Topographically, the muscles are grouped under the
on the face are the sensory branches of the three following six heads.
divisions of the trigeminal nerve. Try to identify allthese Functionally, most of these muscles may be regarded
with the help of their course given in the text (Fig. 2.18). primarily as regulators of the three openings situated
on the face, namely the palpebral fissures, the nostrils
Feotures and the oral fissure. Each opening has a single sphincter,
The face, or countenance, extends superiorly from the and a variable number of dilators. Sphincters are
adolescent position of hairline, inferiorly to the chin naturally circular and the dilators radial in their
and the base of the mandible, and on each side to the arrangement. These muscles are better developed around
auricle. The forehead is, therefore, common to both the the eyes and mouth than around the nose (Table2.2).
face and the scalp.
; ' Tart€2,2i-Funciionat groups of facial mu*cles.r,
SKIN Opening Sphincter Dilators
1 The facial skin is aery oascular. Rich vascularity makes A. Palpebral Orbicularis 1. Levator palpebrae
the face blush and blanch. Wounds of the face bleed fissure oculi superioris
profusely but heal rapidly. The results of plastic 2. Frontalis part of
surgery on the face are excellent for the same reason. occipitof rontalis
,:(
o 2 The facial skin is rich in sebaceous and sweat glands. B. Oral fissure Orbicularis All the muscles around the
o
z Sebaceous glands keep the face oily, but also cause oris mouth, except the orbicularis
acne inyoung adults. Sweat glands help in regulation oris the sphincter, and the
E'
tr
(E of the body temperature. mentalis which does not
mingle with orbicularis oris
E(E 3 Laxity of the greater part of the skin facilitates rapid (see above)
o spread of oedema. Renal oedema appears first in the
C. Nostrils Compressor 1. Dilator naris
eyelids and face before spreading to other parts of
C the body.
naris 2. DePressor sePti
o 3. Medial slip of levator labii
() 4 Boils in the nose and ear are acutely painful due to superioris alaeque nasi
ao tlrre fixity of the skin to the underlying cartilages.
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Muscle of the Scolp 3 Dilator naris

Occipitofrontalis described in scalp 4 Depressor septi
Muscles of the Auricle

Muscles oround the Mouth
Situated around the ear
1 Orbicularis oris (Fig.2.9)
1 Auricularis anterior
2 Buccinator (Latin cheek) (Fig.2.l})
2 Auricularis superior
3 Auricularis posterior 3 Levator labii superioris alaeque nasi (Fig. 2.10)
These are vestigeal muscles 4 Zygomaticus major (Fi9.2.9)
5 Levator labii superioris
Muscles of the Eyelids/Orbitol Openings 6 Levator anguli oris
1 Orbicularis oculi (Fig.2.9 and Table 2.3) 7 Zygornaticus minor
2 Corrugator (Latin to wrinkle) supercilii (Fig. 2.9 and 8 Depressor anguli oris (Fig. 2.10)
Table 2.3) 9 Depressor labii inferioris
3 Levator palpebrae superioris (an extraocular muscle, 10 Mentalis (Latin chin)
supplied by sympathetic fibres and the third cranial 1"1" Risorius (Latin laughter)
nerve) is described in Chapter 13.
Muscles of the Nose Muscles of lhe Neck

L Procerus (Fi9.2.9) Platysma (Greek broad)
2 Compressor naris. Details of the other muscles are given in Table 2.3.
Galea aponeurotica
Frontal belly of occipitofrontalis
Temporalis
Procerus Corrugator supercilli

Orbicularis oculi
Levator labii superioris
alaeque nasi
Nasalis
Levator labii superioris Levator labii superioris

Zygomaticus minor Zygomaticus minor
Zygomaticus major Zygomaticus major
Levator anguli oris
Levator anguli oris
Parotid duct
Risorius Buccinator
Risorius
J
Platysma Masseter o
Orbicularis oris zo
t,tr
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t,G
Depressor labii inferioris Depressor labii inferioris
o
E
Mentalis o
F
o
o
Fig. 2.9: The facial muscles a
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HEAD AND NEOK
Origii lnsertion Actions
Muscles of eyelid/orbital opening

1. Corrugator supercilii Medial end of superciliary arch Skin of mid-eyebrow Vertical lines in forehead,
(Fig.2.e) as in frowning
2. Orbicularis oculi (Fig.2.9) Medial part of medial palpe- Concentric rings return to Protects eye from bright light,
a. Orbital part, on and bral ligament, frontal process the point of origin wind and rain. Cause forceful
around the orbital of maxilla and nasal part of closure of eyelids
margin frontal bone
b. Palpebral part, in the lids Lateral part of medial Lateral palpebral raphe Closes lids gently as in
palpebral ligament blinking and sleeping
c. Lacrimal part, lateral and Lacrimal fascia and posterior Pass laterally in front of Dilates lacrimal sac for
deep to the lacrimal sac lacrimal crest, forms tarsal plates of eyelids sucking of lacrimal fluid into
sheath for lacrimal sac to the lateral palpebral the sac, directs lacrimal
raphe puncta into lacus lacrimalis;
supports the lower lid
Muscles around nasal opening

3. Procerus Nasal bone and upper part Skin of forehead Causes transverse wrinkles
of lateral nasal cartilage between eyebrows and on
bridge of the nose
4. Compressor Maxilla just lateral to nose Aponeurosis across Nasal aperture compressed
naris dorsum of nose
5. Dilator naris Maxilla over the lateral incisor Alar cartilage of nose Nasal apefture dilated
6. Depressor Maxilla over the medial incisor Lower mobile part of Nose pulled inferiorly
septi nasal septum
Mucles around the lips
7. Orbicularis oris Superior incisivus, from Angle of mouth Closes lips and protrudes lips,
a. lntrinsic part, deep maxilla; inferior incisivus, numerous extrinsic muscles
stratum, very thin sheet from mandible make it most versatile for
various types of grimaces
b. Extrinsic part, two Thickest middle stratum, Lips and the angle of the
strata, formed by derived from buccinator; thick mouth
converging muscles superficial stratum, derived
(Fis. 2.e) from elevators and depressors
of lips and their angles
8. Buccinator, the muscle of 1. Upper fibres, from maxilla 1. Upper fibres, straight to Flattens cheek against gums
the cheek (Fig. 2.10) opposite molar teeth the upper lip and teeth; prevents accumu-
lation of food in the vestibule.
Pierced by This is lhe whistling muscle
- Parotid duct and 2. Lower fibres, from 2. Lower fibres, straight to
- Buccal branch of mandible, opposite molar the lower lip
mandibular nerve. teeth
3. Middle fibres, from pterygo- 3. Middle fibres decussate
mandibular raphe
.Y
9. Levator labii Frontal process of maxilla Upper lip and alar Lifts upper lip and dilates
o superioris cartilage of nose the nostril
o
z alaeque nasi
E Posterior aspect of lateral Skin at the angle of the Pulls the angle upwards and
c(E 10. Zygomaticus
major surface of zygomatic bone mouth laterally as in smiling
t,(E
o 11. Levator labii lnfraorbital margin Skin of upper lateral Elevates the upper liP,
I of maxilla half of the upper lip forms nasolabial groove
superioris
12. Levator anguli Maxilla just below Skin of angle of the Elevates angle of mouth,
.o infraorbital foremen mouth forms nasolabial groove
() oris
ao (Contd-..)
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Talle 2.3: The tacial muscJes {corrd...) .,.,.tt,-,:,t1,:,;..t...,.,'

Name Origin lnsertion Actions
13. Zygomaticus Anterior aspect of lateral Upper lip medialto Elevates the upper lip
minor surface of zygomatic bone its angle
14. Depressor Oblique line of mandible Skin at the angle of mouth Draws angle of mouth
anguli oris below first molar, premolar and fuses with orbicularis downwards and laterally
and canine teeth oris
15. Depressor Anterior part of oblique line Lower lip at midline, fuses Draws lower lip
labii inferioris of mandible with muscles from opposite downward
said
16. Mentalis Mandible inferior to incisor Skin of chin Elevates and protrudes
teeth lower lip as it wrinkles skin
on chin
17. Risorius Fascia on the masseter Skin at the angle Retracts angle of mouth
muscle of the mouth
Muscles of the neck

18. Platysma Upper parts of pectoral and Anterior fibres, to the base Releases pressure of skin on
(Fis. 2.e) deltoid fasciae of the mandible; posterior the subjacent veins; depres-
Fibres run upwards and fibres to the skin of the ses mandible; pulls the angle
medially lower face and lip, and of the mouth downwards as
may be continuous with in horror or fright
the risorius
Modiolus: lt is a compact, mobile fibromuscular structure present at about 1.25 cm lateral to the angle of the mouth opposite the
upper second premolar tooth. The five muscles interlacing to form the modiolus are: zygomaticus major, buccinator, levator anguli
oris, risorius and depressor anguli oris.
Levator labii
4 Anger: Dilator naris and depressor septi.
superioris 5 Frornning: Corrugator supercilii and procerus.
alaeque nasi (Figs 2.13 and 2.1.4)
Levator labii 6 Horror, terror and fright: P1'atysma (Fig. 2.15)
superioris 7 Surprise: Frontalis (Fig. 2.16)
I Doubt: Mentalis
Levator anguli 9 Grinning: Risorius
oris 10 Contempt: Zygomaticus minor.
1'1. Closing the mouth: Orbicularis oris
Buccinator with
modiolus 12 Wistling: Buccinator, and orbicularis orts (Fig.2.17).
Depressor labii Molor Nerve Supply

inferioris
The facial nerae is the motor nerve of the face. Its five
Depressor
anguli oris
terminal branches, temporal, zygornatic, buccal, -Y
marginal mandibular and cervical emerge from the o
Fig. 2.10: Some of the facial muscles parotid gland and diverge to supply the various facial zo
ttc
muscles as follows.
6
A few of the commonfacinl expressions and the muscles Temporal-frontalis, auricular muscles, orbicularis E'
(E
producing them are given below: oculi. o
1 Smiling atdlauglting: Zygomattctts major (Fig. 2.11) Zy gomatic-orbicularis oculi.
2 Sadness: Levator labii superioris and levator Buccal-muscles of the cheek and upper lip (Fig' 2.18)' c
o
anguli oris (Fig. 2.12). Marginal mandibular-muscles of lower lip. ()
3 Grief: Depressor anguli oris. Cervical-platysma. ao
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HEAD AND NECK
Fig. 2.11: Zygomaticus major smile Fig.2.12: Levator labii superioris sadness
- -
Fig. 2.13: Corrugator supercilii frowning Fig.2.14t Procerus dislike

- -
ta
o
zo
t,tr
(g
!,(E
o
o
.F
o
0)
@ Fig. 2.15: Platysma fright Fig. 2.16: Frontalis surprise
- -
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Temporal
Zygomatic
Buccal
Marginal
mandibular
Cervical
Fig.2.'|7: Buccinator and orbicularis oris whistling Fig. 2.18: Terminal branches of the facial nerve
-
This can be understood by putting your right wrist
on the right ear and spreading five digits; the thumb The affected side is motionless. Wrinkles
over the temporal region, the index finger on the disappear from the forehead. The eye cannot be
zygomatic bone, middle finger on the upper lip, the closed. Any attempt to smile draws the mouth to
ring finger on the lower lip and the little finger over the normal side. During mastication, food
the neck (Fig. 2.18). accumulates between the teeth and the cheek.
Articulation of labials is impaired.
r In supranuclear lesions of the facial nerve; usually
. The facial nerve is examined by testing the a part of hemiplegia, with inj.ury of corticonuclear
following facial muscles (Fig. 2.19). fibres only the lower part of the opposite side of face
a. Frontalis; Ask the patient to look upwards is paralysed. The upper part with the frontalis and
without moving his head, and look for the orbicularis oculi escapes due to its bilateral reprc-
normal horizontal wrinkles on the forehead sentatironinthecerebral cortex (Fig. 2.21.). On1ywhile
(Fig.2.19a). voluntary movements are affected emotional
b. Dilatar s af mnuth: Showing the teeth (Fig. 2. 19b). expressions remain normal as there are separate
c. Orbicularis ocuti: Tight closure of the eyes pathways for voluntary and emotional movements.
(Fig.2.19c).
d. Buccinatsn Puffing the mouth and then blowing Sensory Nerve Supply
forcibly as in whistling (Fig.2.19d). The trigeminal nerae through its three branches is the
r Infranuclear lesion (Fig,z,zq of the facial nerve, chief sensory nerve of the face (Fig. 2.22 and Table 2.4).
at the styiomastoid. foramen is known as Bell's The skin over the angle of the jaw and over the parotid
palsy, upper and lower halves of the face on the gland is supplied by the great auricular nerve (C2, C3).
same side get paralysed. The face becomes In addition to most of the skin of the face, the sensory
asymmetrical and is drawn up to the normal side. distribution of the trigeminal nerve is also to the nasal
xo
zo
t,tr
(E
ttG
o
c
(b) (c) (d) o
o
frontalis, (b) test for dilators of mouth, (c) test for orbicularis oculi, and (d) test for buccinator o
a
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HEAD AND NECK
W
mater, including that lining the anterior and middle
ffi-
q ry
Factat nerve ar
stylomastoid foramen cranial fossae (Fig. 2.22).
ll
The sensory distribution of the trigeminal nerve

explaim why headache is a uniformly common
symptom in involvements of the nose (common
.ota, Uoitr), the paranasal ak sinuses (sinusitis),
{#@% infections and inflammations of teeth and gums,
refractive errors of the eyes, and infection of the
meninges as in meningitis.
Trigeriinal neuralgia ilay involve one or more of
the three divisions of lhe trigeminal newe. lt
causes attacks of very severe burning and scalding
Paralysis pain along the distribution of the affected nerve.
of upper and Pain is relieved either: (a) By injecttnggl% alcohol
lower halves of
facial muscles into the affected division of the trigeminal
ganglion, or (b) by sectioning the affected nerve,
the main sensory root, or the spinal tract of the
Fig.2.2A: lnfranuclear lesion of right facial nerve or Bell's palsy trigeminal nerve which is situated superficially in
the medulla. The procedure is cailed medullary
Cerebral cortex
tractotomy.
Paralysis of only lower

J half of facial muscels
o
zo on the contralateral
side
E'
tr
(E
E' Fig.2.21: Supranuclear lesion of right facial nerve
6 Fig. 2.22l. The sensory nerves of the face. 1. Supratrochlear,
o)
2. supraorbital, 3. palpebral branch of lacrimal, 4. infratrochlear,
5. external nasal, 6. infraorbital, T. zygomaticofacial,
C
o cavity, the paranasal air sinuses, the eyeball, the mouth 8. zygomaticotemporal, 9. auriculotemporal, 10. buccal,
o cavity, palate, cheeks, gums, teeth and anterior two- 11. mental, 12. great auricular, 13. transverse cutaneous nerve
ac) thirds of tongue and the supratentorial part of the dura of neck, 14. lesser occipital, and 15. supraclavicular
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SCALP TEMPLE AND FACE
T*ble'2'4r,, Cutan.eous nerveg of ' the faee

Source Cutaneous nerve Area of distribution
a. Ophthalmic division of Supratrochlear nerve Upper eyelid and forehead
trigeminal nerve Supraorbital nerve Upper eyelid, frontal air sinus, scalp
Lacrimal nerve Lateral part of upper eyelid
lnfratrochlear Medial parts of both eyelids
External nasal Lower part of dorsum and tip of nose
b. Maxillary division of lnfraorbital nerve Lower eyelid, side of nose and upper lip
trigeminal nerve Zygomaticofacial nerve Upper part of cheek.
Zygomaticotemporal nerve Anterior part of temporal region
c. Mandibular division oi Auriculotemporal nerve Upper two-thirds of lateral side of
trigeminal nerve Buccal nerve auricle, temporal region
Mental nerve Skin of lower part of cheek
Skin over chin
d. Cervical plexus 1. Anterior dlvision of great auricular nerve 1. Skin over angle of the jaw and over
(c2, c3) the parotid gland
2. Upper division of transverse (anterior) 2. Lower margin of the lower jaw
cutaneous nerve of neck (C2, C3)
Course
L It enters the face by winding around the base of the
DIS$ECTION mandible, and by piercing the deep cervical fascia,
at the anteroinferior angle of the masseter muscle. It
Tortuous facial artery enters the face at the lower border
can be palpated here and is called 'anaesthetist's
of mandible. Dissect its course from the anteroinferior
artery'.
angle of masseter muscle running to the angle of mouth
till the medial angle of eye, reflecting off some of the
2 First it runs upwards and forwards to a point 1.25 cm
lateral to the angle of the mouth. Then it ascends by
facial muscles if necessary.
the side of the nose up to the medial angle of the
Straight facial vein runs on a posterior plane than
eye, where it terminates by supplying the lacrimal
the artery.
sac; and by anastomosing with the dorsal nasal
ldentify buccopharyngeal fascia on the external branch of the ophthalmic artery.
sudace of buccinator muscle. Clean the deeply placed 3 The facial artery is very tortuous. The tortuosity of
buccinator muscle situated lateralto the angle of mouth. the artery prevents its walls from being unduly
ldentify parotid duct, running across the cheek 2 cm stretched duringmovements of the mandible, the lips
below the zygomatic arch. The duct pierces buccal pad and the cheeks.
of fat, buccopharyngeal fascia, buccinator muscle, 4 It lies between the superficial and deep muscles of
mucous membrane of lhe mouth to open into its the face.
vestibule opposite second upper molartooth (Fig. 2.26). The course of the artery in the neck is described in
submandibular region.
Feotures
The face is richly vascular. It is supplied by: 8r#ncftes
1 The facial artery, The anterior branches on the face are large and named.
2 The transverse facial artery, and They are:
3 Arteries that accompany the cutaneous nerves. I lnferior labial, to the lower lip.
These are small branches of ophthalmic, maxillary 2 Superiorlabial,to the upper lip and the anteroinferior l(
o
and superficial temporal arteries. part of the nasal septum.
3 Lateral nasal, to the ala and dorsum of the nose.
zo
Fociol Artery (Fociol Port)
t,c
The posterior branches are small and unnamed. (E
The facial artery is the chief artery of the face (Fig. 2.23). t,(E
It is a branch of the external carotid artery given off in An$sfomoses o
the carotid triangle just above the level of the tip of the 1 The large anterior branches anastomose with similar
greater cornua of the hyoid bone. In its cervical course, branches of the opposite side and with the mental C
.o
it passes through the submandibular regiory and finally artery. In the lips, anastomoses arelarge, so that cut o
enters the face. arteries spurt from both ends. ao
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HEAD AND NECK
Supraorbital artery
Supratrochlear artery
Superfi cial temporal artery Dorsal nasal artery
Angular artery
Transverse facial
Lateral nasal
Maxillary artery
Superior--1
lnferior alveolar artery I
I Labial arteries
lnferior I
Mental artery
Fig. 2.23: Arteries of the face
2 Small posterior branches anastomose with the deep fascia, crosses the submandibular gland, and
transverse facial and infraorbital arteries. joins the anterior division of the retromandibular
3 At the medial angle of the eye, terminal branches of vein below the angle of the mandible to form the
the facial artery anastomose with branches of the common facial vein. The latter drains into the
ophthalmic artery. This is, therefore, a site for internal jugular vein. It is represented by a line
anastomoses between the branches of the external drawn just behind the facial artery. The other veins
and internal carotid arteries. drain into neighbouring veins.
4 Deep connections of the facial vein include:
Tronsverse Fociol Adery a. A communication between the supraorbital and
This small artery is a branch of the superficial temporal superior ophthalmic veins.
artery. After emerging from the parotid gland, it runs b. Another connection with the pterygoid plexus
forwards over the masseter between the parotid duct through the deepfacial vein which passes
and the zygomatic arch, accompanied by the upper backwards over the buccinator. The connection
buccal branch of the facial nerve. It supplies the parotid between facialvein and cavernous sinus is shown
gland and its duct, masseter and the overlying skin, in Flow chart 2.1.
and ends by anastomosing with neighbouring arteries
(Fi9.2.23). Dongerous Areo of Foce
The facial vein communicates with the cavernous sinus
Veins of the Foce
through emissary veins. Infections from the face can
1 The veins of the face accompany the arteries and
drain into the common facial and retromandibular Flow chart 2.1 : Connection between facial vein and cavernous
veins. They communicate with the cavernous sinus. sinus
2 The veins on each side form a 'W-shaped' arrangement.
.Y Each corner of the'W' is prolonged upwards into
o
zo 3 the scalp and downwards into the neck (Fig. 2.6).
The facial oein isthe largest vein of the face with no
l,
tr
(E valves. It begins as the angular vein at the medial
t,G angle of the eye. It is formed by the union of the
o supratrochlear and supraorbital veins. The angular
I
vein continues as the facial vein, running
-
.9
downwards and backwards behind the facial artery,
C) but with a straighter course. It crosses the
ao anteroinferior angle of the masseter, pierces the Cavernous sinus I
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SCALq TEMPLE AND FACE
Fig. 2.24; Dangerous area of the face (stippled). Spread of Fig.2.25: The lymphatic territories of the face. Area (A) drains
infection from this area can cause thrombosis of the cavernous into the preauricular nodes, area (B) drains into the submandibular
sinus nodes, and area (C) drains into the submental nodes
spread in a retrograde direction and cause thrombosis *s&r*f, ##*rmf mrc# fuI+$*s rLS#*##$ #f#fi #s
of the cavernous sinus. This is specially likely to occur The labial and buccal mucous glands are numerous.
in the presence of infection in the upper lip and in the They lie in the submucosa of the lips and cheeks.
lower part of the nose. This area is, therefore, called The molar mucous glands, four or five, lie on the
the dangerous area of the face (Fig.2.2a). buccopharyngeal fascia around the parotid duct. All
these glands open into the vestibule of the mouth
(Fig.2.26).
The facial veins and its deep connecting veins are
devoid of valves, making an uninterrupted passage
of blood to cavernous sfuus. Squeezing the pustules
or pimples in the area of the upper lip or side of nose
Dts$EcTtot{
or even the cheeks may cause infection which may
be carried to the cavernous sinus leading to its Give a circular incision around the roots of eyelids
thrombosis. So the cheek area may also be included (Fig.2.2_.viii and ix). This will separate the orbital part
as the dangerous area (Fig. 2.24). of orbicularis oculi from the palpebral parts. Carefully
reflect the palpebral part towards the palpebral fissure.
ldentify the structures present beneath the muscle as
Lymphotic Droinoge of the Foce given in the text.
The face has three lymphatic territories: The upper and lower eyelids are movable curtains
'1. Upper territory, including the greater part of the which protect the eyes from foreign bodies and bright
forehead, lateral halves of eyelids, conjunctiva, lateral light. They keep the cornea clean and moist. The upper
part of the cheek and parotid area, drains into the eyelid is larger and more movable than the lower eyelid
L
(Figs 2.27a and b). o
preauricular parotid nodes.
2 Middle territory, including a strip over the median zo
Feotures
tttr
part of the forehead, external nose, upper lip, lateral (E
part of the lower lip, medial halves of the eyelids, The space between the two eyelids is the palpebral E
(5
medial part of the cheek, and the greater part of lower fissure. The two lids are fused with each other to form o
J-
jaw, drains into the submandibular nodes. the medial and lateral angles or canthi of the eye. At
3 Lower territory, including the central part of the lower the inner canthus, there is a small triangular space, the o
.F
lip and the chin, drains into the submental nodes lacus lacrimalis. Withtn it, there is an elevated lacrimal ()
(Fig.2.2s). caruncle, made up of modified skin and skin glands. ao
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HEAD AND NECK
Palate
Vestibule
3 The palpebral fascia of tlrre two lids forms the orbital
septum.Its thickenings form tarsal plates or tarsi in
Buccal glands
the lids andthepalpebralligamenfs at the angles. Tarsi
Buccinator are thin plates of condensed fibrous tissue located
Buccopharyngeal fascia near the lid margins. Th"y give stiffness to the lids
Molar mucous gland
(Fig.2.27a).
Parotid duct The upper tarsus receives two tendinous slips from
Cheek the leaator palpebrne superioris, or one from voluntary
part and another from involuntary part (Fi9.2.27b).
Buccal lymph node
Tarsal glands or meibomian glands are embedded in
Buccal pad offat
the posterior surface of the tarsi; their ducts open in
Second molar teeth
a row behind the cilia.
Fi1.2.26: Scheme of coronal section showing structures in the
4 The conjunctizta lines the posterior surface of the
cheek. The parotid duct pierces buccal pad offat, buccopharyngeal
tarsus.
fascia, buccinator muscle and the mucous membrane to open
Apart from the usual glands of the skin, and mucous
into the vestibule of mouth opposite the crown of the upper second
glands in the conjunctiva, the larger glands found in
molar tooth
the lids are:
a. Large sebaceous glands also called as Zeis's glands
Lateral to the caruncle, the bulbar conjunctiva is at the lid margin associated with cilia.
pinched up to form a vertical fold called the plica b. Modified sweat glands or Moll's glands at the lid
semilunaris (Fig. 2.1). margin closely associated with Zeis's glands and
Each eyelid is attached to the margins of the orbital cilia.
opening. Its free edge is broad and has a rounded outer c. Sebaceous or tarsal glands, these are also known
lip anda sharp inner lip. The outer lip presents two or as meibomian glands.
more rows of eyelashes or cilia, except in the boundary
of the lacus lacrimalis. At the point where eyelashes
cease, there is alacrimal papilla on the summit of which
The Muller's muscle or involuntary partof levator
there is thre lauimal punctum (Fig.2.1). Near the inner
palpebrae superioris is supplied by sympathetic
lip of the free edge, there is a row of openings of the
tarsal glands. fibres from the superior cervical ganglion.
Paralysis of this rnuscle leads to partial ptosis. This
ia part of ttre Horner's syndrome.
Struclure
The palpebral conjunctiva is examined for
Each lid is made up of the following layers from without
anaemia and for coniunctivitis; the bulbar
inwards:
coniunctiva for jaundice.
L The skin is thin, loose and easily distensible by Conjunctivitis is one of the commonest diseases
oedema fluid or blood. of the eye. It may be caused by infection or by
2 The superficial fascia is without any fat. It contains allergy.
the palpebral part of the orbicularis oculi.
Superior Orbicularis oculi

iarsus (orbikl part)
Orbital
septum Levator palpebrae
0rbital septum superioris, voluntary part
Lacrimal sac
:o Lateral Orbicularis oculi and involuntary part
palpebral
zo Medial
palpebral raphe
(palpebral part)
Superior conjunctival fornix
E ligament Superior tarsus Conjunctiva
tr
(E
E' lnferior Part of
(E
tarsus Ciliary glands conjunctival sac
o lnfraorbital
vessels and Tarsal gland
nerve Cornea
C
o
F() (a) (b)
o
@ Flgs.2.27a and b: (a) Orbital septum, and (b) sagittal section of the upper eyelid
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;
Blood Supply COMPONENTS

The eyelids are supplied by: The structures concerned with secretion and drainage of
I The superior and inferior palpebral branches of the the lacrimal or tear fluid constitute the lacrimal
ophthalmic artery apparatus. It is made up of the following parts:
2 The lateral palpebral branch of the lacrimal artery. 1 Lacrimal gland and its ducts (Figs 2.28a andb).
They form an arcade in each lid. 2 Conjunctival sac.
The veins drain into the ophthalmic and facial veins. 3 Lacrimal puncta and lacrimal canaliculi.
4 Lacrimal sac.
Nerve Supply 5 Nasolacrimal duct.
The upper eyelid is supplied by the lacrimal,
supraorbital, supratrochlear and infratrochlear nerves Locrimql Glond
from lateral to medial side.
It is a serous gland situated chiefly in the lacrimal fossa
The lower eyelid is supplied by the infraorbital and
on the anterolateral part of the roof of the bony orbit
infratrochlear nerves (Fig. 2.22).
and partly on the upper eyelid. Small accessory lacrimal
glands are found in the conjunctival fornices.
Lymphotic Droinoge
The gland is'J'shaped, being indented by the tendon
The medial halves of the lids drain into the of the leaator pnlpebrae superioris muscle. It has:
submandibular nodes, and the lateral halves into
a. An orbital part which is larger and deeper, and
the preauricular nodes (Fig. 2.25).
b. A palpebral part smaller and superficial, lying
within the eyelid (Figs2.28a and b).
About a dozen of its ducts pierce the conjunctiva of
Foreign bodies are ofte* lodged in a groove the upper lid and open into the conjunctival sac near
situated 2 mm from the edge of each eyelid. the superior fornix. Most of the ducts of the orbital part
Chalazion is inflammation o{ a tarsal gland, pass through the palpebral part. Removal of the latter
causing a localized swelling pointing inwards. is functionally equivalent to removal of the entire gland.
Ectropion is due to eversion of the lower lacrimal After removal, the conjunctiva and cornea are
punctum. It usually occurs in old age due to laxity moistened by accessory lacrimal glands.
of skin. The gland is supplied by the lacrimal branch of the
Trachoma is a contagious granular conjunctivitis ophthalmic artery and by the lacrimal neroe.The nerve
caused by the trachoma virus. It is regarded as has both sensory and secretomotor fibres. Flow chart 2.2
the commonest cause of blindness. shows the secretomotor fibres for lacrimal gland.
Stye orhordeolum is a suppurative inflammation The lacrimal fluid secreted by the lacrimal gland
of one of the glands of Zeis. The gland is swollen, flows into the conjunctival sac where it lubricates the
hard and pai:rful, and the whole of the lid is front of the eye and the deep surface of the lids. Periodic
oedematous. The pus points near the base of one blinking helps to spread the fluid over the eye. Most of
of the cilia. the fluid evaporates. The rest is drained by the lacrimal
canaliculi. When excessive, it overflows as tears.
Blepharitis is inflammation of the eyelids, specially
of the lid margin.
Conjunctivol Soc
The conjunctiva lining the deep surfaces of the eyelids
is called palpebral conjunctiva and that lining the front
of the eyeball is bulbar conjunctiva. The potential space
, DISSECTION between the palpebral and bulbar parts is the .Y
conjunctizsal sac. The lines along which the palpebral
o
On the lateral side of the upper lid cut the palpebral
conjunctiva of the upper and lower eyelids is reflected zo
fascia. This will show the presence of the lacrimal gland T'
deep in this area. lts palpebral part is to be traced in on to the eyeball are called the superior and inferior tr
(E
the upper eyelid. On the medial ends of both the eyelids c onj un ct io al fornic es. t,(E
look for lacrimal papilla. Palpate and dissect the medial The palpebral conjunctiaa is thick, opaque, highly o
palpebral ligament binding the medial ends of the vascular, and adherent to the tarsal plate. The bulbar
eyelids. Try to locate the small lacrimalsac behind this conjunctiua covers the sclera. It is thin, transparent, and c
o
ligament. loosely attached to the eyeball. Over the cornea, it is ()
represented by the anterior epithelium of the cornea. ao
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I-IEAD AND NECK
Superior lacrimal Lacrimal

papilla and punctum
ducts
Lacrimal sac
Levator palpebrae superioris
Lacrimal
gland
Lacrimal canaliculi Orbital part
Nasolacrimal duci
Palpebral part
Lacrimal ducts
Inferior lacrimal papilla
and punctum
Lacrimal caruncle
Figs 2.28a and b: Lacrimal apparatus: (a) Components, and (b) two parts of the lacrimal gland
Flow chart 2.2: Secretomotor fibres for lacrimal gland Locrimql Puncto ond Conoliculi
Lacrimatory nucleus I Each lacrimal canaliculus begins atthelacrimal punctum,
_--r
Nervus intermedius I
nerve
and is 10 mm long. It has a vertical part which is 2 mm
long and a horizontal part which is, 8 mm long. There
is a dilated ampulla at the bend. Both canaliculi oPen
close to each other in the lateral wall of the lacrimal sac
Facial I behind the medial palpebral ligament.
LocrimolSoc
It is membranous sac \2 mm long and 5 mm wide,
Greater petrosal nerve + deep petrosal nerve
situated in the lacrimal groove behind the medial
palpebral ligament. Its upper end is blind. The lower
end is continuous with the nasolacrimal duct.
The sac is related anteriorly to the medial palpebral
ligament and to the orbicularis oculi. Medially, the
lacrimal groove separates it from the nose. Laterally,lt
is related to the lacrimal fascia and the lacrimal part of
the orbicularis oculi.
)etrosal I Relays
nerve +
Nosolocrimol Duct
It is a membranous passage 18 mm long. It begins at
Pass along the lower end of the lacrimal sac, runs downwards,
Maxilldry nerve
backwards and laterally, and oPens into the inferior
meatus of the nose. A fold of mucous membrane called
Pass along the aalae of Hasner forms an imperfect valve at the lower
--o end of the duct.
zo
t,c
(E Inflammation of the lacrimal sac is called dacra'
t,G' cystitis.
o The duets of lacrimal gland open through its
I
palpebral pert into the conjunctival sac, Because
C
.o of this arrangement, the rernoval of palpehral part
o
o neeessitates the removal of the orbital part as well.
Lacrimal gland
@
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Excessive secretion of lacrimal fluid, i.e. tears is comes closer to the spinal nucleus of V nerve at the
mostly due to emotional reasons. The tears not level of lower pons. This is called "neurobiotaxis".
only flow on the cheeks but aiso flow out through . Facial nerve though courses through the parotid
nasolacrimal duct and the nasal cavity, due to gland, does not give any branch to the largest
stimulation of pterygopalatine ganglion.' salivary gland.
Excessive secretion of the lacrimal fluid o Buccinator is an accessory muscle of mastication,
overflowing on the cheeks is called epiphora. as it prevents food entering the vestibule of mouth.
Epiphora may result due to obstruction in the I Part of the face is called as "dangerous area of face"
lacrimal fluid pathway, either at the level of as the facial vein communicates with cavemous
puncfum or canaliculi or nasolacrimal duct. venous sinus situated in the cranial cavity. Any
infection from this part of face can infect the
DEVELOPMENT OF FACE intracranial venous sinus, i.e. cavernous sinus.
Five processes of face, one frontonasal, two maxillary
. Levator palpebrae superioris is supplied partly by
oculomotor nerve and partly by sympathetic fibres.
and two mandibular processes form the face. .
Frontonasal process forms the forehead, the nasal The facial muscles are subcutaneous in position
septum, philtrum of upper lip and premaxilla bearing
and represents morphologically remnants of
panniculus carnosus.
upper four incisor teeth.
Maxillary process forms whole of upper lip except
the philtrum and most of the hard and soft palate except
the part formed by the premaxilla.
Case 1
Mandibular process forms the whole lower lip.
A man of about 30 years comes to OPD with inability
Cord of ectoderm gets buried at the junction of to close his left eye tears overflowing on the left cheek
frontonasal and maxillary processes. Canalisation of
and saliva dribbling from his left angle of the mouth.
ectodermal cord of cells gives rise to nasolacrimal duct. o What is the reason for his sad condition?
r What nerve is damaged and how is the integrity
Mnemonics of the nerve tested?
Ans; The reason for the patient's sad condition is
Bell's palsy
paraiysis of his left facial nerrre at the stylomastoid
Blink re{lex abnormal ?oramen. It is called Bell's palsy. It is ireaied by
Ear ache physiotherapy and rrredicines.
Lacrimation ( deficient) Facial nerve is tested by:
Loss of taste in anterior two-thirds of tongue Asking the patient;
Sudden onset i. To lookupwards without moving his head,
Palsy of muscles of facial expression all symptoms and iaok for the normal harizontal wrinkies
are unilateral on the forehead"
Five branches of the facial nerve (Vtl)
ii. To show the teeth
Ten Zebras Bit My Cat
iii. Tightly closc the eyes to test the orbicularis
ocuii muscle.
Temporal
iv. Puffing the mouth and then blowing out air
Zygomatic forciblv to test the buccinator muscle.
Buccal
Case 2
Marginal mandibular
Cervical A teenage girl with infected acne tried to drain the
pustules on her upper lip with her bare hands.
After few davs she noticed severe weakness in her eve
muscles. :o
o How are the pustules connected to nerves zo
Forehead is common to both the scalp and the face supplying eye muscles? ttg
There are 5 layers in scalp and 5 layers in the Ans: Infection from pr-sruJes travels via facial veirl deep G
superficial temporal region !t(E
facial vein, pterygoid veno19_ qlexus, emissary-vein to o
Impulses from skin of the face reach the three cavemous venous sin*; and trtr, trV and \rI cranial nerves t
branches of trigeminal nerve, whereas the muscles reiated in its lateral wail. Since the qerves are infeeted
of facial expression are supplied by the facial nerve. co
the extraocular muscles gel weak and may get
To establish the reflex arc, nucleus of VII nerve pararyseo. o
o
@
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1. Nasolacrimal duct opens into: c. Lrferior oblique
a. Anterior part of inferior meatus d. Levator palpabrae superioris
b. Vestibule of nose 4. Infection in dangerous area of face usually leads
c. Middle meatus to:
d. Superior meatus a. Superior sagittal sinus thrombosis
2. Dangerous area of face is named because of b. Transverse sinus thrombosis
connection of cavernous sinus with facial vein c. Cavernous sinus thrombosis
through:
d. Brain abscess
a. Maxillary vein
5. Supraorbital artery is a branch of:
b. Anterior ethmoidal vein
c. Posterior ethmoidal vein a. Maxillary b. External carotid
d. Deep facial vein c. Ophthalmic d. Intemal carotid
3. \tVhich of the following muscle separates the orbital 6. Which of the following nerve ascends along with
and palpebral parts of the lacrimal gland: occipital artery in the scalp?
a. Superior oblique a. Greater occipital b. Lesser occipital
b. Superior rectus c. Third occipital d. Suboccipital
vo
2o
tttr
(U
!l(E
o
c
.o
o
ao
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Side of the Neck
9l*,, ta, a, can&n oooun luczlt (m,
INTRODUCTION mandible and the mastoid process, immediately

The beauty of the neck lies in its deep or cervical fascia. anteroinferior to the tip of the mastoid process,
The sternocleidomastoid is an important landmark 7 The fourth ceraical transoerse process is just palpable
between the anterior and posterior triangles. The at the level of the upper border of the thyroid
posterior triangle contains the spinal root of accessory cartilage; and the sixth ceruical transzserse process at
nerve deep to its fascial roof and the roots and trunks the level of the cricoid cartilage.
of brachial plexus deep to its fascial floor. It also 8 The anterior tubercle of the transaerse process of the
contains a part of the subclavian artery, which continues sixth centical oertebra is the largest of all such
as the axillary artery for the upper limb. Arteries like processes and is called the cnrotid tubercle of
the rivers are named according to the regions they pass Chassaignac. The common carotid artery can be best
through. Congestive cardiac failure can be seen at a pressed against this tubercle, deep to the anterior
glance by the raised jugular venous pressure. This border of the sternocleidomastoid muscle.
external jugular vein lies in the superficial fascia and if 9 The anterior border of the trapezius muscle becomes
cut,leads to air embolism, unless the deep fascia pierced prominent on elevation of the shoulder against
by the vein is also cut to collapse the vein. resistance.
TANDMARKS
1 The sternocleidomastoid m:uscle is seen prominently
DI$SECTION
when the chin is turned to the opposite side. The
ridge raised by the muscle extends from the clavicle Give a median incision from the chin downwards
and sternum to the mastoid process. towards the suprasternal notch situated above the
2 The external jugular oein crosses the sterno- manubrium of sternum.
cleidomastoid obliquely, running downwards and Make one incision in the skin of base of mandible.
backwards from near the auricle to the clavicle. It is Continue it by oblique incision along posterior border
better seen in old age. of ramus of mandible up to mastoid process and further
3 The greater supraclarsicular fossa lies above and behind along the superior nuchal line till the external occipital
the middle one-third of the clavicle. It overlies the protuberance.
cervical part of the brachial plexus and the third part One incision is given along the upper border of
of the subclavian artery. clavicle (Fig. 3.1a). Reflect only the skin up towards
4 The lesser supraclaaicular fossa is a small depression the anterior border of trapezius muscle.
between the sternal and clavicular parts of the Platysma, a part of the subcutaneous muscle is
sternocleidomastoid. It overlies the internal jugular visible. Reflect the platysma towards the mandible.
vein. ldentify the anterior or transverse culaneous nerve of
5 The mastoid process is a large bony projection behind the neck in the upper part of superficialfascia. Anterior
jugular vein running vertically close to the median plane
the auricle.
6 The transaerse process of the atlas oertebra can be felt is also encountered. Remove the superficial fascia till
on deep pressure midway between the angle of the the deep fascia of neck is seen (Fig.3.6).
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HEAO.AND NECI(
Externaljugular vein is seen above the clavicle. BOUNDARIES

To open up the suprasternal space make a horizontal The side of the neck is roughly quadrilateral in outline.
incision just above the sternum. Extend this incision It is bounded anteriorly, by the anterior median line;
along the anterior border of sternocleidomasloid muscle posteriorly, by the anterior border of trapezirs;
for 3-4 cm. Beflect the superficial lamina to expose the superiorly, by the base of mandible, a line joining angle
suprasternal space and identify its contents. of the mandible to mastoid process, and superior nuchal
Define the attachments of investing layer, pretracheal line; and inferiorly, by the clavicle.
layer, prevertebral layer and carotid sheath. This quadrilateral space is divided obliquely by the
sternocleidomastoid muscle into the anterior and
posterior triangles (Fig. 3.1b).
SKIN
The skin of the neck is supplied by the second, third
and fourth cervical nerves. The anterolateral part is
supplied by anterior primary rami through the
(i) anterior cutaneous, (ii) great auricular, (iii) lesser
occipital and (iv) supraclavicular nerves. A broad band
of skin over the posterior part is supplied by dorsal or
posterior primary rami (see Fig.2.22).
First cervical spinal nerve has no cutaneous
distribution. Cervical fifth, sixth, seventh, eighth and
thoracic 1st nerves supply the upper limb through the
brachial plexus; and, therefore, do not supply the neck.
The territory of fourth cervical nerve extends into the
pectoral region through the supraclavicular nerves and
meets second thoracic dermatome at the level of the
Fig. 3.1a: Lines of dissection second costal cartilage.
Superior nuchal line
Mastoid process
Sternocleidomastoid
Base of mandible
.:(
o Trapezius
zo Anterior triangle
Occipital part of posterior triangle
t,c Sternal head of sternocleidomastoid
(E
Inferior belly of omohyoid
Clavicular head of sternocleidomastoid
E
(s Supraclavicular part of posterior triangle Acromion
o
Clavicle
Manubrium
o
o Fig. 3.'t b: Boundaries of the posterior triangle. Note that the inferior belly of the omohyoid divides the triangle into upper or occipital
o
o and lower or supraclavicular parts
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SIDE OF THE NECK
SUPERFICIAL FASCIA Atlochmenls

Contains areolar tissue with platysma (see Table 2.3). $up*riorfy
Lying deep to platysma are cutaneous nerves (Fig.3.6),
a. External occipital protuberance
superficial veins (see Fig. 2.6),Iymph vessels, lymph
b. Superior nuchal line
nodes and small arteries.
c. Mastoid process
d. External acoustic meatus
e. Base of the mandible.
The surgeon has to stitch platysma muscle separately Between the angle of the mandible and the mastoid
so that skin does not adhere to deeper neck muscles, process/ the fascia splits to enclose the parotid gland
othelwise the skin will get an agly scar. (Fig.3.a).
The superficial lamina named asparotidfascza is thick
DEEP CERVICAL FASCTA (FASC|A COLLT) and dense, and is attached to the zygomatic arch. The deep
The deep fascia of the neck is condensed to form the lamina is thin and is attached to the styloid process, the
following layers: mandible and the tympanic plate. Between the styloid
process and the angle of the mandible, the deep lamina
1 Investing tayer (Fig. 3.2) is thick and forms the stylomandibular ligament which
2 Pretracheal layer separates the parotid gland from the submandibular
3 Prevertebral layer gland, and is pierced by the extemal carotid artery.
4 Carotid sheath At the base of mandible, it encloses submandibular
5 Buccopharyngeal fascia gland. The superficial lamina is attached to lower
5 Pharyngobasilar fascia. border of body of mandible and deep lamina to the
mylohyoid line.
INVESIING LAYER
It liesdeep to the platysma, and surrounds the neck Infan*rly
like a collar. It forms the roof of the posterior triangle a. Spine of scapula,
of the neck (Fig. 3.3). b. Acromion process,
Soft plate
Tongue
Alar fascia
Buccopharyngeal
fascia Mandible
Spines of cervical
vertebrae Hyoid
Investing layer
lnvesting layer
Prevertebral fascia Thyroid cartilage I

o
Cricoid cartilage o
z
tttr
(5
Pretracheal fascia tt(E
o
lsthmus of thyroid gland .J-
Suprasternal space c
Manubrium sterni .9
o
o
Fig. 3.2: Vertical extent of the first three layers of the deep cervical fascia s)
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HEAD AND NECK
Thyroid gland
Oesophagus
Trachea lnvesting layer
Sternohyoid
Plaiysma
Sternothyroid
Omohyoid
Sternocleidomastoid
Pretracheal fascia
Internal jugular vein

Retropharyngeal lymph
Common carotid artery
nodes
Vagus nerve
Carotid sheath
Sympathetic trunk
Longus colli lnvesting layer
Scalenus anterior
Trunks of brachial plexus Prevedebral fascia
Scalenus medius
Muscles of back
Trapezius
C7 vertebra
Ligamentum nuchae
Fig. 3.3: Transverse section through the neck at the level of the seventh cervical vertebra
"&r"lf*rf*rrJ5r
Base of mandible
a. Symphysis menti.
Stylomandibular
ligament with b. Hyoid bone.
external carotid Submandibular gland Both above and below the hyoid bone, it is
artery Parotid fascia continuous with the fascia of the opposite side.
Parotid gland
Styloid process
Other Feotures
Mastoid process L The investing layer of deep cervical fascia splits to
Sternocleidomastoid Superior nuchal line enclose:
External occipital
a. Muscles: Trapezius and sternocleidomastoid.
protuberance b. Salizsary glands: Parotid and submandibular.
c. Spaces: Suprasternal and supraclavicular.
Fig. 3.4: Superior attachment of investing layer of deep cervical
The suprasternal space or space of Burns contains:
fascia
l<
o
r The sternal heads of the right and left sterno-
o cleidomastoid muscles (Fig. 3.5).
z c. Clavicle, and
o The iugular venous arch/
t,tr d. Manubrium.
(E The fascia splits to enclose the suprasternal and . A lymph node, and
tt(E supraclavicular spaces, both of which are described o The interclavicular ligament.
o below (Fig.3.5).
I The supraclaoicular space is traversed by:
F*srs+rr."#rfy o The external jugular vein (Fig. 3.6),
o
() a. Ligamentum nuchae; and r The supraclavicular nerves, and
ao b. Spine of seventh cervical vertebra. o Cutaneous vessels, including lymphatics.
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SIDE OF THE NECK
Manubrium un frffierSfd6
Suprasternal
space of Burns It forms the front of the carotid sheath, and fuses with
Sternocleidomastoid
the fascia deep to the sternocleidomastoid (Fig.3.3).
Supraclavicular Olher Feotures

space pierced by The posterior layer of the thyroid capsule is thick.
external jugular vein
Acromion On either side, it forms a suspensory lignment for the
Trapezius thyroid gland known asligament of Berry (seeFig.8.4).
The ligaments are attached chiefly to the cricoid
Spine of scapula
cartilage, and may extend to the thyroid cartilage.
They support the thyroid gland, and do not let it sink
Fig. 3.5: lnferior attachment of investing layer of deep cervical into the mediastinum. The capsule of the thyroid is
fascia very weak along the posterior borders of the lateral
lobes.
2 It also forms pulleys to bind the tendons of the The fascia provides a slippery surface for free
digastric and omohyoid muscles. movements of the trachea during swallowing.
3 Forms roof of anterior and posterior triangles.
4 Forms stylomandibular ligament and parotido-
r
masseteric fasciae. Neck infections in front of the pretracheal fascia
maybulgein thesuprastemal area or extend down
into the anterior mediastinum.
r Parotid swellings are very painful due to the
r The thyroid gland and all thyroid swellings move
with deglutition because the thyroid is attached
unyielding nature of parotid fascia.
r to cartilages of the larynx by the suspensory
14trhi1e excising the submandibular salivary gland,
ligaments of Berry.
the external carotid artery should be secured
before dividing it, otherwise it may rekact through
PREVERTEBRAL FASCIA
the stylomandibular ligament and cause serious
bleeding. The figure also shows the superior It lies in front of the prevertebral muscles, and forms
attachment of investing layer of deep cervical the floor of the posterior triangle of the neck (Fig. 3.2).
fascia (Fig. 3.4).
r Division of the external jugular vein in the Altochments ond Relotions
supraclavicular space may cause air embolism and $upenorly
consequent deathbecause the cut ends of the vein It is attached to the base of the skull (Fig. 3.2).
are prevented from retraction and closure by the
fascia, attached firmly to the vein (Figs 3,5 and 3.5). {nferiorly
It extends into the superior mediastinum where it splits
PRETRACHEAT FASCIA
into anterior and posterior layers. Anterior l'ayer / alar
fascia blends with buccopharyngeal fascia and posterior
The importance of this fascia is that it encloses and layer is attached to the anterior longitudinal ligament
suspends the thyroid gland and forms its false capsule and to the body of the fourth thoracic vertebra.
(Fig.3.2).
Anter*rJy
Altochmenls It is separated from the pharynx and buccopharyngeal
$rup*rlmrfp fascia by the retropharyngeal space containing loose
areolar tissue. L
1 Hyoid bone in the median plane. o
o
2 Oblique line of thyroid cartilage laterally. l*fereJ{y
z
t,
3 Cricoid cartilage-more laterally. It is lies deep to the trapezius and is attached to fascia (E
of sternocleidomastoid muscle. E'

(E
driferuorfy o
I
Below the thyroid gland, it encloses the inferior thyroid Other Feotures
veins, passes behind the brachiocephalic veins, and L The cervical and brachial plexuses lie behind the .e
finally blends with the arch of the aorta and fibrous prevertebral fascia. The fascia is pierced by the four o
pericardium. cutaneous branches of the cervical plexus (Fig. 3.6). ao
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HEAD AND NECK
Greater occipital nerve Great auricular nerve
Lesser occipital nerve
Spinal root of accessory nerve
Transverse cervical vein

Supraclavicular nerves
Suprascapular vein
Anierior jugular vein
Fig. 3.6: Structures seen in relation to the fascial roof of the posterior triangle
As the trunks of the brachial plexus, and the in the median plane, The infection may extend
subclavian artery, pass laterally through the interval down through the superior mediastinum into the
between the scalenus anterior and the scalenus posterior mediastinum (see Fig. 8,4).
medius, they carry with them a covering of the
prevertebral fascia knor,rm asthe axillary sheathwhich
extends into the axilla. The subclavian and axillary
Chronic retropharyngeal
veins lie outside the sheath and as a result they can abscess
dilate during increased venous return from the limb. 5th cervical ventral ramus
Fascia provides a fixed base for the movements of Abscess in posterior triangle
the pharynx, the oesophagus and the carotid sheaths
Upper trunk of brachial plexus
during movements of the neck and during Axillary sheath
swallowing.
Clavicle
Subclavian artery
Neck infections behind the prevertebral fascia
1st rib
arise usually from tuberculosis of the cervical
vertebrae or cervical caries. Pus produced as a Abscess in lateral
result may extend in various directions. It may wall of axilla
pass forwards forming a chronic retropharyngeal
abscess which may form a bulging in the posterior
wall of the pharynx, in the median plane (Fig. 3.7).
The pus may extend laterally through the axillary
sheath and point in the posterior triangle, or in
Extent of tuberculosis of cervical vertebrae
the lateral wall of the axilla. It may extend
downwards into the superior mediastinurry where
.Y its descent is limited by fusion of the prevertebral
o CAROTID SHEATH
zo fascia to the fourth thoracic vertebra.
It is a condensation of the fibroareolar tissue around
E. Neck infections in front of the prevertebral fascia
G in the retropharyngeal space usually arise from the main vessels of the neck. It is formed on anterior
E
(E suppuratior; i.e. formation of pus in the retro- aspect by pretracheal fascia and on posterior aspect by
0)
pharyngeal lymph nodes. The pus forms an acute prevertebral fascia. The contents are the common or
retropharyngeal abscess which bulges forwards intemal carotid arteries, internal jugular vein and the
c in the paramedian position due to fusion of the vagus nerve. It is thin over the vein (Figs 3.8a and b). In
.o
6 buccopharyngeal fascia to the prevertebral fascia the upper part of sheath there are IX,XI, XII nerves also.
ac) These nerves pierce along with extemal carotid artery.
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SIDE OF THE NECK
posterior triangle to reach the anterior border of

trapezius which it supplies (Fig.3.9).
Define the boundaries, roof, floor, divisions and
contents of the posterior triangle (Fig. 3.1b).
ldentify and clean the inferior belly of omohyoid. Find
the transverse cervical artery along the upper border
of this muscle. Trace it both ways. Deep to this muscle
is the upper or supraclavicular part of brachial plexus.
Anterior Identify the roots, trunks and their branches carefully.
The branches are suprascapular nerve, dorsalscapular
Common carotid
artery
nerve, long thoracic nerve, nerve to subclavius
(Fig. 3.10). Medial to the brachial plexus locate the third
lnternal jugular part of subclavian artery.
vein
Follow the terminal part of external jugular vein
Vagus nerve through the deep fascia into the deeply placed
Sympathetic trunk subclavian vein. ldentify suprascapular artery running
(a) Posterior
-----****---6 (b) just above the clavicle (Fig. 3.9).
Figs 3.8a and b: Right carotid sheath with its contents: (a) Surface Define the atlachments and relations of sternocleido-
view, and (b) sectional view mastoid muscle. To expose scalenus anterior muscle
cut across the clavicular head of sternocleidomastoid
Relolions muscle and push it medially. Scalenus anlerior muscle
1 The ansa cervicalis lies embedded in the anterior wall covered by well-defined prevertebral fascia can be
of the carotid sheath (Figs 3.8a and b). identified. Clean the subclavian artery and upper part
2 The cervical sympathetic chain lies behind the sheath, of brachial plexus deep to the scalenus anterior muscle.
plastered to the prevertebral fascia.
3 The sheath is overlapped by the anterior border of Feotures
the sternocleidomastoid, and is fused to the layers The posterior triangle is a space on the side of the neck
of the deep cervical fascia. situated behind the sternocleidomastoid muscle.
BUCCOPHARYNGEAL FASCIA Boundofies
This fascia covers the superior constrictor muscle Affifl*rcsr
externally and extends on to the superficial aspect of
Posterior border of sternocleidomastoid (Fig. 3.1b).
the buccinator muscle.
Fosferu*r
PHARYNGOBASILAR FASCIA
Anterior border of trapezius.
This fascia is especially thickened between the upper
border of superior constrictor muscle and the base of fmferf*rorhmsa
the skull. It lies deep to the pharyngeal muscles (see
Fig.1.4.21). Middle one-third of clavicle.
Ap*x
Lies on the superior nuchal line where the trapezius
and sternocleidomastoid meet.
DTSSECflON
.Y
Try to dissect and clean the cutaneous nerves which Roof o
pierce the investing layer of fascia at the middle of
The roof is formed by the inaesting layer of deep ceraical zo
posterior border of sternocleidomastoid muscle (Fig. 3.6). !t
Demarcate the course of external jugular vein. Cut fascia, The superficial fascia over the posterior triangle (E
contains: !t
carefully the deep fascia of posterior border of sterno- 6
cleidomastoid muscle and reflect it towards trapezius
L The platysma. o
muscle. ldentify the accessory nerve lying just deep to
2 The external jugular and posterior extemal jugular
veins.
the investing layer seen at the middle of the posterior o
border of sternocleidomastoid muscle and across the 3 Parts of the supraclavicular, great auricular, transverse ()
cutaneous and lesser occipital nerves (Fig. 3.6). oo
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HEAD AND NECK
Occipltal artery and

greater occipiial nerve
Splenius capitis
Sternocleidomastoid
Cervical lymph nodes
around accessory nerve
Levator scapulae
Transverse cervical Scalenus anterior

and suprascapular arteries with phrenic nerve
Dorsal scapular nerve
Trapezius lnferior thyroid artery
Trunks of brachial plexus

on scalenus medius
Fig. 3.9: The posterior triangle of neck and its contents
4 Unnamed arteries derived from the occipital, Floor

transverse cervical and suprascapular arteries. The floor of the posterior triangle is formed by the
5 Lymph vessels which pierce the deep fascia to end prevertebral layer of deep cervical fascia, covering the
in the supraclavicular nodes. following muscles:
T};re external jugular oein: Il lies deep to the platysma 1 Splenius capitis.
(Fig. 3.6). It is formed by union of the posterior auricular 2 Levator scapulae.
vein with the posterior division of the retromandibular 3 Scalenus medius (Fig. 3.9).
vein. It begins within the lower part of the parotid gland, 4 Semispinalis capitis may also form part of the floor.
crosses the sternocleidomastoid obliquely, pierces the
anteroinferior angle of the roof of the posterior triangle, Division of lhe Postetiot Ttiongle
and opens into the subclavian vein(seeFig.2.6). It is subdivided by the inferior belly of omohyoid into:
Its tributaries are: L A larger upper part, called t}ire occipital trinngle.
a. The posterior external jugular vein. 2 A smaller lower part, called the supraclarsicular or the
subclazsian triangle (Fig. 3.1b).
b. The transverse cervical vein.
c. The suprascapular vein. Conients of the Posterior lriongle
d. The anterior jugular vein. These are enumerated inTable 3.1. Some of the contents
The oblique jugular vein connects the external are considered below:
jugular vein with the internal jugular vein across the
middle one-third of the anterior border of the Spievonf Fp*fa,*res mf f*e #mruf*mfs*f Fosfericrflnon6#*
sternocleidomastoid. 1 The spinal accessory neroe emerges a little above the
middle of the posterior border of the sterno-
cleidomastoid. It runs through a tunnel in the fascia
. The right extemal jugular vein is exarnined to assess forming the roof of the triangle, passing downwards
ta
o the aenous pressare; the right atrial pressure is and laterally, and disappears under the anterior
zo reflected in it because there are no valves in the border of the trapezius about 5 cm above the clavicle
(Figs 3.6 and 3.9). It is the only structure beneath
!, entire course of this vein and it is straight.
c(E r the roof of triangle
As external jugular vein pierces the fascia, the
!tc, margins of the vein get adherent to the fascia. So 2 The for;:" cutaneous branches of the ceraical plexus
o if the vein gets cut, it cannot close and air is sucked pierce the fascia covering the floor of the triangle,
in due to negative intrathoracic pressure. That pass through the triangle and pierce the deep fascia
c
o causes air embolism. To prevent this, the deep at different points to become cutaneous (Fig. 3.6).
o fascia has to be cut. a. Transaerse cutaneous nerae: Arises from ventral
o0) rami of C2 and C3 nerves runs transversely across
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SIDE OF THE NECK
' 'Table 3.1: Eontents'of;the posterior triengle (Figs 3.6 and 8,9)
Contents Occipital triangte Subclavian triangle
A. Nerves 1. Spinal accessory nerve 'l . Three trunks of brachial plexus
2. Four cutaneous branches of cervical plexus: 2. Nerve to serratus anterior (long thoracic,
a. Lesser occipital (C2) c5, c6, c7)
b. Great auricular (C2, C3) 3. Nerve to subclavius (C5, CO)
c. Anterior cutaneous nerve of neck (C2, C3) 4. Suprascapular nerve (C5, C6)
d. Supraclavicular nerves (C3, C4)
3. Muscular branches:
a. Two small branches to the levator scapulae
(c3, c4)
b. Two small branches to the trapezius (C3, C4)
c. Nerve to rhomboids (proprioceptive) (C5)
4. C5, C6 roots of the brachial plexus
B. Vessels 1. Transverse cervical artery and vein 1. Third part of subclavian artery and subclavian vein
2. Occipital artery 2. Suprascapular artery and vein
3. Commencement of transverse cervical artery and
termination of the corresponding vein
4. Lower paft of external jugular vein
C. Lymph nodes Along the posterior border of the sternocleidomastoid, A few members of the supraclavicular chaln
more in the lower part-the supraclavicular nodes
and a few at the upper angle-the occipital nodes
the sternocleidomastoid to supply skin and of sternocleidomastoid. Those to the levator scapulae
neck, till the sternum. soon end in iU those to the trapezirs run below and
b. Supraclaaicular nerues; Formed from ventral rami parallel to the accessory nerve across the middle of
of C3 and C4 nerves. Emerges at posterior border the triangle. Both nerves lie deep to the fascia of the
of sternocleidomastoid. It descends downwards floor.
and diverges into three branches. Medial one 4 Three trunks of the brachial plexus emerge between
supplies the skin over the manubrium till the scalenus anterior and medius, and carry the axil-
manubriosternal joint. Lrtermediate nerve crosses lary sheath around them. The sheath contains the
the clavicle to supply skin of first intercostal space brachial plexus and the subclavian artery. These
till the second rib. Lateral nerve runs across the structures lie deE lo the floor of posterior triangle. If
lateral side of clavicle and acromion to supply prevertebralfascia is left intact, all these structures are
skin over the upper half of the deltoid muscle. safe.
c. Great attriculnr nerae: It is the largest ascending 5 The nerae to the rhomboid is from C5 root, pierces the
branch of cervical plexus. Arises from ventral scalenus medius and passes deep to the levator
rami of C2 and C3 nerves. Ascends on the scapulae to reach the back where it lies deep or
sternocleidomastoid muscle to reach parotid anterior to the rhomboid muscles (Fig. 3.10).
gland, where it divides into anterior and 6 The nerae to the seruatus anterior (C5, C6, C7) arises
posterior branches. Anterior branch supplies by three roots. The roots from C5 and C6 pierce the
lower one-third of skin on lateral surface of pirura scalenus medius and join the root fromCT over the
and skin over the parotid gland and connects the first digitation of the serratus anterior. The nerve
gland to the auriculotemporal nerve. This cross passes behind the brachial plexus. It descends over
connection is the anatomical basis for Frey's the serratus anterior in the medial wall of the axilla
syndrome. Posterior branch supplies lower one- and gives branches to the digitations of the muscle J
o
third of skin on medial surface of the pinna. (Fig. 3.10). zo
d. Lesser occipital: Arises from ventral ramus of C2 7 The nerzte to the subclaaius (C5, C6) descends in front t,c
segment of spinal cord. Seen at the posterior of the brachial plexus and the subclavian vessels, but (E
border of sternocleidomastoid muscle. It then behind the omohyoid, the transverse cervical and t,(E
winds around and ascends along its posterior suprascapular vessels and the clavicle to reach the o
border to supply skin of upper two-thirds of deep surface of the subclavius muscle. As itrunsnear
medial surface of pirura adjoiningpart of the scalp. the lateral margin of the scalenus anterior, it sometimes c
o
.F
Muscular branches to the leztator scapulae and to the gives off the accessory phrenic nerae whichjoins the o
o
trapezius (C3, C4) appear about the middle of the phrenic nerve in front of the scalenus anterior. U)
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I
HEAD AND'NEOK
Dorsat scapular nerve
Suprascapular nerve
Nerve to subclavius
Divisions
y<6;
Long thoracic nerve
ffi-
Lateral pectoral
T,I
Upper subscapular nerve

Branches Nerve to latissimus dorsi
Lower subscapular nerve
Musculoculaneous nerve
Medial pectoral nerve
Axillary nerve
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Lateral rool and medial
root of median nerve Ulnar nerve
Radial
Median nerve
Fig. 3.10: Brachial plexus
8 The suprascapular nerTre (C5, C6) arises from the

upper trunk of the brachial plexus and crosses the
The most conunon swelling in the po$terior triangle
lower part of the posterior triangle just above and
is dueto enlarg€ment of the supraclayicular lymph
lateral to the brachial plexus, deep to the transverse
nodes, While doing biopsy af the lymph node, one
cervical vessels and the omohyoid. It passes
mustbe careful in prcserving the'accessory nerve
backwards over the shoulder to reach the scapula.
whieh,may. get entangled amongst enlarged
It supplies the supraspinatus and infraspinatus lymph nndes (Fig. 3.9).
muscles (Fig.3.10).
Supraclavicular lymph'nsdes' are commonly
9 The subclaaian artery passes behind the tendon of enlarged in, fuberculosis, Hodgkin's disease, and
the scalenus anterior, over the first rib. in.malignant growth$ o{ the breast arfft.or chest.
10 The transrserse ceraical artery is a branch of the Block dissection of the neck for malignant diseases
thyrocervical trunk. It crosses the scalenus anterior/ istheremoval of cervical lyrnphnodes along with
the phrenic nerve, the upper trunks of the brachial other $tructures involved in the growth. This
plexus, the nerve to the subclavius, the procedrrte does not endanger those nerves of the
suprascapular nerve, and the scalenus medius. At posterior, trian$le which }ie deep to the
:o the anterior border of the levator scapulae, it divides prcvertebral fascia, i.e- the brachial and cervical
into superficial and deep branches. The inferior belly
zo of the omohyoid crosses the artery (Fig. 3.9).
ptrexusesr'and their muscular branches.
.A cervical rib may compress the second part'of
Ittr
G
LL The suprascapular artery is also a branch of the $rlbctrayian artery,In'these easee, bloo supply to
t,(E thyrocervical trunk. It passes laterally and back- upper lirnb reaches via:anastolnoees around the
o wards behind the clavicle. scapula. , I
12 The occipital artery crosses the apex of the posterior Dysphagiacausedbyeompression of the oesophagus
c
o
triangle superficial to the splenius capitis. by,u* abnormal:subclavian artery is called
C) 13 The subclavian vein passes in front of the tendon of dyEhagia lusoria.
ao scalenus anterior muscle.
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SroE or iur NEcx
Elective arterial surg€ry. of the conrmon carutid depression of the lesser supraclavicular fossa,
arteqy is done for-aneurysms, AV fistulae or overlying the internal jugular vein.
arteriosclerotic ocelusions. It is better to expose
INSERTION
the eommon carotid :artery in.its upper part where
it is superficial. While ligating the artery. care It is inserted:
should be taken'notto include the vagus nerve or '1. By a thick tendon into the lateral surface of mastoid
the sympathetic chain. process, from its tip to superior border.
Second,part of the:subctravian artery nlay get 2 By a thin aponeurosis into the lateral half of the
pressed by the ecaleryrs, anterior' rnusde, resulting superior nuchal line of the occipital bone.
in decreased blood supply to the upper lirnb. If
the muscle is divided:the effects are abolished Nerve Supply
(Fis. 3.11).
1 The spinal accessory nerve provides the motor
supply. It passes through the muscle.
2 Branches from the ventral rami of C2 are pro-
prioceptive (Fig. 3.9).
BIood Supply
Arterial supply-one branch each from superior
thyroid artery and suprascapular artery and, two
branches from the occipital artery supply the big
muscle. Veins follow the arteries.
Narrowed Aclions
subclavian
artery 1 When one muscle contracts:
a. It turns the chin to the opposite side.
Clavicle b. It can also tilt the head towards the shoulder of
same side.
2 When both muscles contract together:
a. They draw the head forwards, as in eating and in
Fig. 3.11: Second part of subclavian artery narrowed by the
lifting the head from a pillow.
short scalenus anterior
b. With the longus colli, they flex the neck against
resistance.
c. It also helps in forced inspiration.
Relolions
The sternocleidomastoid is enclosed in the investing
layer of deep cervical fascia, and is pierced by the
The sternocleidomastoid and trapezius are large super- accessory nerve and by the four sternocleidomastoid
ficial muscles of the neck. Both of them are supplied by arteries. It has the following relations:
the spinal root of the accessory nerve. The trapezius,
because of its main action on the shoulder girdle, is Superfi*r"of
considered with the upper limb (see Volume 1, 1 Skin
Section 1). The sternocleidomastoid is describedbelow. 2 a. Superficial fascia.
b. Superficial lamina of the deep cervical fascia xo
ORIGIN (Fig.3.3).
1 The sternal head is tendinous and arises from the 3 Platysma. zo
t,
superolateral part of the front of the manubrium 4 External jugular vein, and superficial cervical lymph (E
stemi (Fig.3.1b). nodes lying along the vein (Fig. 3.6). tt(E
2 The clar.ticular head is musculotendinous and arises 5 a. Great auricular. o
from the medial one-third of the superior surface of b. Transverse or anterior cutaneous.
the clavicle. It passes deep to the sternal head, and c. Medial supraclavicular nerves (Fig.3.6).
.o
the two heads blend below the middle of the neck. d. Lesser occipital nerve o
Between the two heads, there is a small triangular 6 The parotid gland overlaps the muscle. ao
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I{EAD AND NEEK
ffi
0eep a. Rheumadc torticollis due to expoflrre to cold
1 Bones and joints: or drauglrt.
a. Mastoid process above b. Reflex torticollis due to inffamed. or suppura'
b. Sternoclavicular joint below. ting cervical lynnph nodes which irritate the
2 Carotid sheath (Fig.3.B). spinal acce sorynerve.
3 Muscles: c. Congenital torticollis due to birth iniury.
a. Sternohyoid Wry neck: Shortening of the muscle fibres due to
b. Sternothyroid intravascular clotting of veins within the muscle. It
c. Omohyoid usually occur$ during difficult delivery of the baby.
d. Three scaleni
e. Levator scapulae
f. Splenius capitis
g. Longissimus capitis RETROPHARYNGEAT SPACE
h. Posterior belly of digastric.
4 Arteries:
Situation: Dead space behind pharynx.
a. Common carotid
Function: Acts as a bursa for expansion of
pharynx during deglutition
b. Internal carotid Boundaries: Anterior: Buccopharymgeal fascia
c. External carotid Posterior: Prevertebral fascia
d. Sternocleidomastoid arteries, two from the Sides: Carotid sheath (Fig. 3.3)
occipital artery, one from the superior thyroid, one Superior: Base of skull
from the suprascapular Inferior: Open and continuous with superior
e. Occipital mediastinum.
f. Subclavian Contents: Retropharyngeal lymph nodes,
g. Suprascapular pharyngeal plexus of vessels and
h. Transverse cervical (Fig.3.9). nerves/ loose areolar tissue.
Veins: Clinical Pus collection due to lymph node
a. Internal jugular anatomy: abscess. It should be differentiated
b. Anterior jugular from cold abscess of spine of cervical
c. Facial vertebrae (see Fig. 8.4).
d. Lingual
LATERAL PHARYNGEAL SPACE
Nerves:
a. Vagus Situation: Side of pharynx
b. Parts of IX, XI, XII Boundaries: Medial: Pharynx
Posterolateral: Parotid gland
c. Cervical plexus
Anterolateral: Medial PterYgoid
d. Upper part of brachial plexus
Posterior: Carotid sheath
e. Phrenic (Fig.3.9)
Contents: Maxillary nerve and branches of
f. Ansa cervicalis maxillary artery
Lymph nodes, deep cervical. Fibrof atty tissue flbr of atty
Clinical Pus collection/Ludwig's angina.
anatomy:
Figure 3.5 shows inferior attachment of investing
layer of deep cervical fascia. Fascia of sqpra*
Mnemonics
o clavicular space is pierced by extemal jugular vein
o
z to drain into subclavian vein. C"rrl"^l ph*t, A,
?r' Torticollis is a deformity inwhich thehead is bent nerves ilGLAST':
(E to one side and the chin points to the other side. 4 compass points: Clockwise from narth on the right side of neck
E'
(E
This is a result of spasm or contracture of the Great auricular
o muscles supplied by the spinal accessory nerve/ Lesser occipital
I
these being the stemocleidomastoid and trapezius, Accessory nerve pops out between L and S
c Although there are many varieties of torticollis Supraclavicular
Io
(I)
depending on the causes, the common types are: Transverse cervical
U)
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SIDE OF THE NECK
Investing layer of deep cervical fascia encloses A middle-aged woman had a deep cut in the middle
2 muscles,2 salivary glands, forms 2 pulleys, encloses, of her right posterior triangle of neck. The bleeding
2 spaces and forms roof of posterior triangle. was arrested and wound was sutured. The patient
. Prevertebral fascia forms the axillary sheath. later felt difficulty in combing her hair.
o Pretracheal fascia suspends the thyroid gland.
r What blood vessel is severed?
. Cold abscess of caries spine can track doivn to the . Why did the patient have difficulty in combing
her hair?
posterior triangle or axilla.
o Occipital part of posterior triangle contains the Ans: The exfernatr iugular vein was severed. It passes
spinal root of accessory nerve as the most across the sternocleidomastoid muscle tr: ioin the
important constituent. subclavian vein above the clavicle. Her accessory
. Supraclavicular part of posterior triangle contains nerve is also injured as it crosses the posterior triangle
close to its roof, causing paralysis of trapezius
roots, trunks, branches of brachial plexus and third
muscle. The trapezius with seuatus anteri.or cau$es
part of subclavian artery.
o Sternocleidomastoid divides the side of neck into overhead abduition required for combing the hair.
Due to paralysis of trapezius, she felt difficulty in
anterior and posterior triangles.
combing her hair.
MUITIPIE CHOICE OUESTIONS
1. \Afhich of the following structures is not seen in the c. Interclavicular ligament

posterior triangle of neck: d. Sternohyoid muscles
a. Spinal accessory nerve 4. Posterior triangle does not contain one of the
b. Transverse cervical artery following nerves:
c. Middle trunk of brachial plexus a. Spinal accessory nerve
d. Superior belly of omohyoid b. Lesser occipital nerve
, Spinal root of accessory nerve innervates; c. Creater occipital nerve
a. Serratus anterior d. Great auricular nerve
b. Stylohyoid 5. Investing layer of cervical fascia encloses all except:
c. Styloglossus a. Two muscles b. Two salivary glands
d. Sternocleidomastoid c. Axillary vessels d. Two spaces
J. Suprasternal space contains all except one of the 5' Ligament of Berry is formed by:
following structures: a. Investing layer of cervical fascia
a. Sternal heads of right and left sternocleido - b. Pretracheal layer
mastoid muscles c. Prevertebral layer
b. jugular venous arch d. Buccophary.ngeal fascia
ANSWERS
1.d 2.d 3.d 4.c 5.c 6.b
.Y
o
zo
E
(E
!,
GI
o
C
o
o
o
a
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Anterior Triangle of the Neck
Onz /zatwze, t o, rt t.od/u mazz {haru tfi.oaaand. uootz/e,
-Anonymous
INTRODUCTION The body of the U-shaped hyoid bone can be felt in

the median plane just below and behind the chin, at
The anterior triangle of the neck lies between midline
the junction of the neck with the floor of the mouth.
of the neck and sternocleidomastoid muscle. It is On each side, the body of hyoid bone is continuous
subdivided into smaller triangles. posteriorly with lhe grenter cornua which is
overlapped in its posterior part by the sterno-
SURFACE TANDMARKS cleidomastoid muscle.
L The mandible forms the lower jaw (Fig.4.1). The lower The thyroid cartilnge of the larynx forms a
border of its horseshoe-shaped body is knor,rm as the sharp protuberance in the median plane just below
base of the mandible.Anteriorly, this base forms the the hyoid bone. This protuberance is called the
chin, and posteriorly it can be traced to the angle of laryngeal prominence or Adam's apple. It is more
the mandible. prominent in males.
Mastoid process
Transverse process of atlas Mandible
Floor of mouth
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Trachea
Fig.4.1: Surface landmarks of neck

92
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ANTERIOR TRIANGLE OF THE NECK
The rounded arch of the uicoid cartilage lies below

the thyroid cartilage at the upper end of the trachea.
Base of mandible
The trachea runs downwards and backwards from
the cricoid cartilage. It is identified by its carti-
laginous rings. However, it is partially masked by
the isthmus of the thyroid gland which lies against Siernocleidomastoid
second to fourth tracheal rings. The trachea is
commonly palpated in the suprasternal notch which Platysma
lies between the tendinous heads of origin of the right
and left sternocleidomastoid muscles. In certain
Anterior jugular vein
diseases, the trachea may shift to one side from the
median plane. This indicates a shift in the medi- Jugular venous arch
astinum. Clavicle
Fig. 4.2: Anterior triangles of the neck showing the platysma

and the anterior jugular veins in the superficial fascia
DI$$ECTION :
The skin over the anterior triangle has already been Deep Foscio
reflected following dissection in chapter 3. Platysma is Above the hyoid bone the investing layer of deep fascia
also reflected upwards. ldentify the structures present is a single layer in the median plane, but splits on
in the superficial fascia and structures present in the each side to enclose the submandibular salivary gland
anterior median region of neck. (see Fig.7.6).
Between the hyoid bone and the cricoid cartilage, it
Feolures is a single layer extending between the right and left
This region includes a strip 2 to 3 cm wide extending sternocleidomastoid muscles.
from the chin to the stemum. The strucfures encountered
Below the cricoid, the fascia splits to enclose the
are listed below from superficial to deep.
suprasternal space.
Deep Slruclures lying obove lhe Hyoid Bone
Skin
The mylohyoid muscle is overlapped by:
It is freely movable over the deeper structures due to a. Anterior belly of digastric above the hyoid bone.
the looseness of the superficial fascia. b. Superficial part of the submandibular saliuary gland
(Figs 4.3 and 4.4).
Superficiol Foscio c. Mylohyoid nerae and aessels.
It contains: d. Submental branch of the facial artery.
1 The upper decussating fibres of the platysma for 1 to The anteroinferior part of the hyoglossus muscle wlth
2 cm below the chin. its superficial relations may also be exposed during
2 The anterior jugular aeins beginning in the submental dissection. Structures lying in this corner are:
region below the chin. It descends in the superficial a. The intermediate tendon of the digastric muscle
fascia about 1 cm from the median plane. About with its fibrous pulley (Fig. a.3).
2.5 cm above the sternum, it pierces the investing b. The bifurcated tendon of the stylohyoid muscle
layer of deep fascia to enter the suprasternal space embracing the digastric tendon.
where it is connected to its fellow of the opposite The subhyoidbursa lies between the posterior surface :o
side by a transverse channel, tlrre jugular aenous arch. of the body of the hyoid bone and the thyrohyoid
The vein then turns laterally, runs deep to the sterno- membrane. It lessens friction between these two zo
E'
cleidomastoid just above the clavicle, and ends in the structures during the movements of swallowing tr
(E
external jugular oein at the posterior border of the (Fig. a.s). E(E
sternocleidomastoid (Fig. a.4. o
J-
3 A few smallsubmentallymphnodeslyingon the deep Slructures lying Below the Hyoid Bone
fascia below the chin (Fig. a.3). These structures may be grouped into three planes:
.9
4 The terminal filaments of the transoerse or anterior (1) Superficial plane containing the infrahyoid muscles, ()
cutnneous nerae of the neck may be present in it. (2) a middle plane consisting of the pretracheal fascia ao
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HEAD AND NECK
Nerve to mylohyoid Submental lymph nodes

Facial artery
Submental artery Anterior belly of digastric

Mylohyoid
Hyoglossus
Posterior belly of digastric
Pulley
Hyoid bone
Fig. 4.3: Suprahyoid region, surface view
Hyoglossus Superior and inferior longitudinal muscles of tongue
Styloglossus
Lingual nerve
Sublingual gland
Submandibular duct
Hypoglossal nerve
Mylohyoid nerve and artery
Genioglossus
Submandibular gland Mylohyoid
Geniohyoid
Deep fascia
Fig.4,4: Coronal section through the floor of the mouth
o-Foramen caecum lnfrahyoid muscles:

on tongue
a. Sternohyoid;
Track of
thyroglossal b. Sternothyroid;
duct c. Thyrohyoid; and
d. Superior belly of omohyoid. These are described
Hyoid bone
Subhyoid bursa
in Table 4.1. andFig.4.6.
Pretracheal fnscin: Itforms the false capsule of the thyroid
gland andthe suspensory ligaments of Berry which attach
the thyroid gland to the cricoid cartilage (seeEig.8.4).
Deep to the pretracheal fascia there are:
Thyrohyoid membrane a. The thyrohyoid membrane deep to the thyrohyoid
muscle: it is pierced by the intemal laryngeal nerve
and the superior laryngeal vessels (Fig. a.n.
'v
(.)
b. Thyroid cartilage.
o c. Cricothyroidmembrane with the anastomosis of the
z cricothyroid arteries on its surface.
!tc
(E d. Arch of the cricoid cartilage.
!,(E Thyroid cartilage
e. Cricothyroid muscle supplied by the external
o laryngeal nerve.
Fig.4.5: Sagittal section through the hyoid region of the neck
showing the subhyoid bursa and its relations
f. Trachea, partly covered by the isthmus of the
C thyroid gland from the second to fourth rings.
.9
o and the thyroid gland, and (3) a deep plane containing g. Carotid sheaths lie on each side of the trachea
ao the laryrnx, trachea and structures associated with them. (see Fig. 3.3).
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Hyoid bone
Thyrohyoid
Thyroid ca(ilage
Oblique line of thyroid cartilage
Omohyoid (superior belly)
Sternothyroid
Sternohyoid
Tendon
Omohyoid (inferior belly)
Clavicle
First costal cartilage

Superior border of scapula
Manubrium sterni
Fig.4.6: The infrahyoid muscles
. The common anterior midline swellings of the

neck are: DISSECTION
a. Enlarged submental lymph nodes and Remove the deep fascia from anterior bellies of digastric
sublingual dermoid in the submental region. muscles to expose parts of two mylohyoid muscles. Clean
b. Thyroglossal cyst and inflamed subhyoid bursa the boundaries and contents of the submental triangle.
;'ust below the hyoid bone (Fig. 4.5). Cut the deep fascia from the mandible and reflect it
c. Goitre, carcinoma of larynx and enlarged downwards to expose the submandibular gland. ldentify
lymph nodes in the suprasternal region. and clean anterior and posterior bellies of digastric
Tracheostomy is an operation in which the trachea muscles, which form the boundaries of digastric triangle.
is opened and a tube inserted into it to facilitate ldentify the intermediate tendon of digastric after pulling
breathing. It is most commonly done in the the submandibular gland laterally. Clean the stylohyoid
retrothyroid region after retracting the isthmus of muscle which envelops the tendon of digastric and is
the thyroid g1and. A suprathyroid tracheostomy lying along with the posterior belly of digastric muscle.
is liable to stricture, and an infuathyroid one is ldentify the contents of digastric triangle.
difficult due to the depth of the trachea and is also
dangerous because numerous vessels lie anterior
to the trachea here (Fig. 4.8).
Cut throat wounds are most commonly situated
BOUNDARIES
iust above or just below the hyoid bone. The main
vessels of the neck usually escape injury because The boundaries of the anterior triangle of neck are:
they are pushed backwards to a deeper plane The anterior median plane of the neck medially;
sternocleidomastoid laterally; base of the mandible and t(
during voluntary extension of the neck. o
a line joining the angle of the mandible to the mastoid o
Skin incisions to be made parallel to natural z
crea$es or Langer's lines (Fig.4.9).
process/ superiorly (Fig. a.10). E
tr
(E
Ludwig's angina is the cellulitis of the floor of the t,(E
SUBDIVISIONS
mouth. The infection spreads above the mylo- o
hyoid forcing the tongue upwards. Mylohyoid is The anterior triangle is subdivided (by the digastric
pushed downwards. There is swelling within the muscle and the superior belly of the omohyoid into: c
mouth as well asbelow the chin. .e
a. Submental o
b. Digastric ao
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FIEAD AND NECK
Thyrohyoid ligament
Hyoid bone
C3 level
Openings for internal laryngeal nerve

and superior laryngeal vessels Thyrohyoid membrane
C4 level
Oblique line on thyroid cartilage
C5 level
Cricothyroid muscle Cricothyroid membrane
C6 level Cricoid cartilage
First tracheal ring
Thyroid gland
Fifth tracheal ring

T2ff3 level
Fig.4.7; The thyroid gland, the larynx and the trachea seen from the front
c. Carotid
d. Muscular triangles (Fig.4.10).
SUBMENTAL TRIANGLE
This is a median triangle. It is bounded as follows.
Epiglottis On each side, there is the anterior belly of the
corresponding digastric muscles. Its base is formed by
the body of the hyoid bone. Its apex lies at the chin.
Arytenoid
Thyroid cartilage cartilage The floor of the triangle is formed by the right and left
Larynx Cricoid
mylohyoid muscles and the median raphe uniting them
Trachea cartilage @ig. a.3).
Oesophagus
Contents
Tracheostomy tube
1 Two to four small submental lymph nodes are situated
in the superficial fascia between the anterior bellies
Fig. 4.8: Tracheostomy tube in position of the digastric muscles. They drain:
a. Superficial tissues below the chin.
b. Central part of the lower lip.
c. The adjoining gums.
d. Anterior part of the floor of the mouth.
e. The tip of the tongue. Their efferents pass to the
submandibular nodes.
2 Small submental veins join to form the anterior
jugular veins.
.-o
zo DIGASTRIC TRIANGLE
ttr
(E The area between the body of the mandible and the
tt(E hyoid bone is known as the submandibular region. The
o superficial structures of this region lie in the submental
c
o
.F
o
%vd# and digastric triangles. The deep structures of the floor
of mouth and root of the tongue will be studied
separately at a later stage under the heading of
o Fig. 4.9: Langer's lines in the neck
a submandibular region in Chapter 7.
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ANTEHIOR TRIANGLE OF THE NECK
Digastric triangle
Chin Sternocleidomastoid
Half submental triangle Stylohyoid
Posterior triangle
Carotid triangle
Occipital part
Muscular triangle
Superior belly of omohyoid
lnferior belly of omohyoid

Supraclavicular part
Fig. 4.10: The triangles of the neck. The anterior triangle is subdivided by digastrics and superior belly of omohyoid. Posterior
triangle is subdivided by inferior belly of omohyoid
Boundolies Conlents
The boundaries of the digastric triangle are as follows. Arferior po r{ af f h e friongfe
Ant er oinferiorly : Anterior belly of digastric. Structures superficial to mylohyoid are:
Posteroinferiorly: Posterior belly of digastric and the 1 Superficial part of the submandibular salivary gland
stylohyoid. Gig. a.3).
Superiorly or base: Base of the mandible and a line
2 The facial vein and the submandibular lymph nodes
are superficial to it and the facial artery is deep to it.
joining the angle of the mandible to the mastoid process
(Fig.4.10). 3 Submental artery
4 Mylohyoid nerve and vessels.
troof 5 The hypoglossal nerve. Other relations will be
The roof of the triangle is formed by: studied in the submandibular region.
1. Skin.
FosfencrForf of fhe Fnong{e
2 Superficial fascia, containing:
a. The platysma. 1. Superficial structures are:
b. The cervical branch of the facial nerve. a. Lower part of the parotid gland.
c. The ascendingbranch of the transverse or anterior b. The external carotid artery before it enters the
cutaneous nerve of the neck.
parotid gland. xo
3 Deep fascia, which splits to enclose the submandi- 2 Deep structures, passing between the external and zo
bular salivary gland (see Fig. 7 -6). internal carotid arteries are: ttc
a. The styloglossus. (6
b. The stylopharyngeus.
!,(E
Flg,*r o
Thefloor is formed by the mylohyoid muscle anteriorly, c. The glossopharyngeal nerve (Fig. a.13).
2
and by the hyoglossus posteriorly. A small part of the d. The pharyngeal branch of the vagus nerve.
o
r middle constrictor muscle of the pharynx, appears in e. The styloid process. C)
r the floor (Fig. 4.11). f. A part of the parotid gland. ao

a
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HEAD AND NECK
Middle constricior
Anterior belly of digastric Hyoglossus
Mylohyoid Hyoid pulley for tendon of

digastric bellies
Fig. 4.11: Floor of the digastric triangle
3 Deepest structures include: Carefully clean and preserve superior root, the loop
a. The internal carotid artery. and inferior root of ansa cervicalis in relation to anterior
b. The internal jugular vein. aspect of carotid sheath. Locate the sympathetic trunk
c. The vagus nerve. situated posteromedial to the carotid sheath. Dissect
Most of these structures will be studied later. the branches of external carotid artery.
The submandibular lymph nodes are clinically very ldentify and preserve internal laryngeal nerve in the
important because of their wide area of drainage. They thyrohyoid interval. Trace it posterosuperiorly till vagus.
are very commonly enlarged. The nodes lie beneath the
Also look lor external laryngeal nerve supplying the
deep cervical fascia on the surface of the submandibular cricothyroid muscle.
salivary gland. They drain:
The carotid triangle provides a good view of all the
a. Centre of the forehead.
large vessels and nerves of the neck, particularly when
b. Nose with the frontal, maxillary and ethmoidal
its posterior boundary is retracted slightly backwards.
air sinuses.
c. The inner canthus of the eye.
d. The upper lip and the anterior part of the cheek BOUNDARIES
with the underlying gum and teeth. Ant er o sup er iorly : P osterior belly of the digastric muscle;
e. The outer part of the lower lip with the lower and the stylohyoid (Fig. a.12).
gums and teeth excluding the incisors.
Anteroinferiorly: Sttperior belly of the omohyoid.
f. The anterior two-thirds of the tongue excluding
the tip, and the floor of the mouth. They also Posteriorly: Anterior border of the sternocleidomastoid
receive efferents from the submental lyrnph nodes. muscle.
The efferents from the submandibular nodes pass
mostly to the jugulo-omohyoid node and partly to Roof
the jugulodigastric node. These nodes are situated 1 Skin.
along the internal jugular vein and are members of 2 Superficial fascia containing:
.!( the deep cervical chain (see Fig. B.2B). a. The plastysma.
o
b. The cervical branch of the facial nerve.
zo c. The transverse cutaneous nerve of the neck.
tc
(E 3 Investing layer of deep cervical fascia.
t,(E
o DISSECTION FIoor
E Clean the area situated between posterior belly of It is formed by parts of:
digastric and superior belly of omohyoid muscle, to a. The middle constrictor of pharynx.
o
F
o expose the three carotid arteries with internal jugular vein. b. The inferior constrictor of the pharynx (Fig. a.12).
o Trace lX, X, Xl and Xll nerves in relation to these vessels.
U) c. Thyrohyoid membrane.
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ffi
Stylohyoid ligament
Hyoglossus Styloid process
Mylohyoid
Upper border of triangle formed bY
posterior belly of digastric
Middle constrictor
Hyoid bone
Thyrohyoid Thyrohyoid membrane (with openings for internal

laryngeal nerve and superior laryngeal vessels)
Thyrohyoid membrane
Thyroid cartilage lnferior constrictor
lnsertion of sternohyoid
(on oblique line) Lateral border of triangle formed by anterior
border of sternocleidomastoid
Cricothyroid membrane
Medial border of triangle formed by
Cricoid cartilage superior belly of omohyoid
Oesophagus
Recurrent laryngeal nerve
Fig. 4.12: Floor of the carotid triangle
CONTENTS 5 Sympathetic chain runs (see Fig. 3.8b) vertically

downwards posterior to the carotid sheath.
Arleries
Carotid sheath with its contents (see Fig. 3.8).
1 The common carotid artery with the carotid sinus Lymph nodes: The deep cervical lymph nodes are
and the carotid body at its termination;
situated along the internal jugular vein, and include
2 Internal carotid artery; and the jugulodigastric node below the posterior belly of
3 The external carotid artery with its superior thyroid, the digastric and the jugulo-omohyoid node above the
lingual, facial, ascending pharyngeal and occipital
inferior belly of the omohyoid (see Fig. 8.28).
branches (Fig. a.12).
Veins Common Corolid Arlery
1 The internal jugular vein. The right common carotid artery is a branch of the
2 The common facial vein draining into the internal brachiocephalic artery. It begins in the neck behind the
jugular vein. right sternoclavicular joint (Fig.4.13). The left common
3 A pharyrgeal vein which usually ends in the internal carotid artery is branch of the arch of the aorta. It begins
jugular vein. in the thorax in front of the trachea opposite a point a
4 The lingual vein which usually terminates in the little to the left of the centre of the manubrium. It
internal jugular vein. ascends to the back of left sternoclavicular joint and
enters the neck.
Nerves In the neck, both arteries have a similar course. Each
L The vagus running vertically downwards. artery runs upwards within the carotid sheath, under J
o
2 The superior larlmgeal branch of the vagus, dividing covei of the anterior border of the sternocleidomastoid. zo
into the external and internal laryngeal nerves. It lies in front of the lower four cervical transverse t,c
3 The spinal accessory nerve running backwards over processes. At the level of the upper border of the thyroid (E
the internal iugular vein. iartilage, the artery ends by dividing into the external !t(s
and internal carotid arteries (Fig. a.1a). o
4 The hypoglossal nerve running forwards over the I
external and internal carotid arteries. The hypo-
glossal nerve gives off the upper root of the ansa Corsffd$rnus c
.9
cervicalis or descendens hypoglossi, and another The termination of the common carotid artery, or the ()
branch to the thyrohyoid. beginning of the internal carotid artery shows a slight ao
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HEAD AND NECK
Maxillary artery Superficial temporal artery
External carotid
Styloid processs
lnternal carotid
Accessory nerve
Glossopharyngeal nerve
Pharyngeal branch of vagus Occipital ariery
Facial adery Posterior auricular artery
Outline of carotid traingle

Hypoglossal nerve Superior laryngeal nerve
Lingual artery
Ascending pharyngeal
lnternal laryngeal nerve
External laryngeal nerve Vagus nerve
Superior thyroid
lnferior root of ansa cervicalis
Superior root of ansa cervicalis
Ansa cervicalis
Fig. 4.13: The ninth, tenth, eleventh and twelfth cranial nerves and their branches related to the carotid arteries and to the internal
jugular vein, in and around the carotid triangle
dilatation, known as the carotid sinus. In this region, Externol Corotid Adery
the tunica media is thin, but the adventitia is relatively External carotid artery is one of the terminal branches
thick and receives a rich innervation from the of the common carotid artery. In general, it lies anterior
glossopharyngeal and sympathetic nerves. The carotid to the internal carotid artery, and is the chief artery of
sinus acts as a baroreceptor ot pressure receptor and supply to structures in the front of the neck and in the
regulates blood pressure. face (Fig. 4.14).
f*r*fidhodpr
#*rurse #d?#R*Jotrrofi$
Carotid body is a small, oval reddish brown structure
situated behind the bifurcation of the common carotid
1 The external carotid artery begins in the carotid
artery. It receives a rich nerve supply mainly from the triangle at the level of the upper border of the thyroid
glossopharyngeal nerve, but also from the vagus and
cartilage opposite the disc between the third and
sympathetic nerves. It acts as a chemoreceptor arrd fourth cervical vertebrae. It runs upwards and
responds to changes in the oxygen, carbon dioxide and
slightly backwards and laterally, and terminates
pH content of the blood. behind the neck of the mandible by dividing into
the maxillary and superficial temporal arteries.
Other allied chemoreceptors are found near the arch of
the aorta, the ductus arteriosus, and the right subclavian 2 The external carotid artery has a slightly curaed course,
artery. These are supplied by the vagus nerve. so that it is anteromedial to the internal carotid artery
in its lower part, and anterolateral to the internal
carotid artery in its upper part.
The carotid sinus is richly supplied by nerves. In 3 ln the carotid triangle, the external carotid artery is
some peffions, the sinus may be hypersensitive. comparatively superficial, and lies under cover of
.Y
o In such persons, sudden rotation of the head may the anterior border of the sternocleidomastoid. The
o
z cause slowing of heart. This condition is called as artery is crossed superficially by the cervical branch
t,tr "carotid sinus syndrome". of the facial nerve, the hypoglossal nerve, and the
(E
The supraventricular tachycardia may be facial,lingual and superior thyroid veins. Deep to
E
(E
o controlled by carotid sinus massage/ due to the artery, there are:
I inhibitory effects of vagus nerve on the heart. a. The wall of the pharynx.
c The necktie should not be tied tightly, as it may b. The superior laryngeal nerve which divides into
.9 compress both the internal carotid arteries, the external and internal laryrrgeal nerves.
o
a
(!) supplying the brain.
c. The ascending pharyngeal artery (Fig. aJ,$.
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Middle temporal
Transverse facial
Posterior auricular
Maxillary
Occipital
Ascending palatine and tonsillar branch
Descending branch
Facial
Jugulodigastric lymph nodes
Sternocleidomastoid branch Submental branch
Ascending pharyngeal Lingual
lnternal carotid
Carotid sinus Superior thyroid
Carotid body
External carotid
Common carotid
Sternocleidomastoid branch
Jugulo-omohyoid lymph nodes --------------- --ooo

--@ O
Common carotid
Fig. 4.14: Carotid arteries, branches of the external carotid artery
4 Abooe the carotid triangle, the external carotid Tenninal

artery lies deep in the substance of the parotid 1 Maxillary
gland. Within the gland, it is related superficially 2 Superficial temporal (Fig. a.1 ).
to the retromandibular vein and the facial nerve
(seeFig.5.4). Deep to the extemal carotid artery, there
$uperior Thysoid Artery
are:
a. The internal carotid artery. The superior thyroid artery arises from the external
b. Structures passing between the external and carotid artery just below the level of the greater cornua
internal carotid arteries; these being styloglossus, of the hyoid bone.
stylopharyngeus, IX nerve, pharyngeal branch of It runs downwards and forwards parallel and just
X, and styloid process. superficial to the external laryrrgeal nerve.
c. Two structures deep to the internal carotid attery, It passes deep to the three long infrahyoid muscles
namely the superior laryngeal nerve (Fig.4.13) to reach the upper pole of the lateral lobe of the thyroid
and the superior cervical sympathetic ganglion. gland.
Its relationship to the external laryngeal nerve, which
Broncfies supplies the cricothyroid muscle is important to the
The external carotid artery gives off eight branches surgeon during thyroid surgery. The artery and nerve
which may be grouped as follows. are close to each other higher up, but diverge slightly
near the gland. To avoid injury to the nerve, the superior
Anterior thyroid artery is ligated as near the gland as possible .Y
o
1 Superior thyroid (Fig. a.1a) (see Fig. 8.5).
zo
2 Lingual Apart from its terminal branches to the thyroid ttr
3 Facial (see Appendix 1) gland, it gives one important branch, the superior (E
Posterior laryngeal artery whichpierces the thyrohyoid membrane t,G

in company with the internal laryngeal nerve (Fig. a.\. o
1 Occipital
The superior thyroid artery also gives a sternocleido-
2 Posterior auricular.
mastoid branch to that muscle and a cricothyroid C
.o
Medial branch that anastomoses with the artery of the opposite ()
Ascending pharyngeal. side in front of the cricovocal membrane. ao
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HEAD AND NECK
ffi
ArnguolArfery the mandible, the lips and the cheek during mastication
The lingual artery arises from the external carotid artery and during various facial expressions. The artery
opposite the tip of the greater cornua of the hyoid bone. escapes traction and pressure during these movements.
It is tortuous in its course. The ceroicalpart of the facial artery runs upwards on
Its course is divided into three parts by the the superior constrictor of pharynx deep to the posterior
hyoglossus muscle. belly of the digastric, with the stylohyoid and to the
ramus of the mandible.
The first part lies in the carotid triangle. It forms a
characteristic upward loop which is crossed by the It grooves the posterior border of the submandibular
hypoglossal nerve (Fig. 4.15). The lingual loop permits salivary gland. Next the artery makes an S-bend (two
free movements of the hyoid bone. loops) first winding down over the submandibular
Tl:.e second partlies deep to the hyoglossus along the gland, and then up over the base of the mandible
upper border of hyoid bone. It is superficial to the (see Fig.7.B).
middle constrictor of the pharynx. The facinl part of the facial artery enters the face at
The third part is called the arteria profunda linguae, anteroinferior angle of masseter muscle, runs upwards
or the deep lingual artery.It runs upwards along the close to angle of mouth, side of nose till medial angle
anterior border of the hyoglossus, and then hoizontally of eye. It is described in Chapter 2.
forwards on the undersurface of the tongue as the fourth The cervical part of the facial artery gives off the
part. In its vertical course, it lies between the ascending palatine, tonsillar, submental, and glandular
genioglossus medially and the inferior longitudinal branches for the submandibular salivary gland and
muscle of the tongue laterally. The horizontal part of lymph nodes.
the artery is accompanied by the lingual nerve. The ascending palatine artery arises near the origin of
During surgical removal of the tongue, the first part the facial artery. It passes upwards between the
of the artery is ligated before it gives any branch to the styloglossus and the stylopharyngeus, crosses over the
tongue or to the tonsil. upper border of the superior constrictor and supplies
the tonsil and the root of the tongue.
FCIcr*fArfery The submental branch is a large artery which accom-
The facial artery arises from the external carotid just panies the mylohyoid nerve, and supplies the
above the tip of the greater cornua of the hyoid bone. submental triangle and the sublingual salivary gland.
It runs upwards first in the neck as cervical part and
then on the face as facial part. The course of the artery #ccipitalArfery
in both places is tortuous. The tortuosity in the neck The occipital artery arises from the posterior aspect of
allows free movements of the pharynx during the external carotid artery, opposite the origin of the
deglutition. On the face, it allows free movements of facial artery.
Circumvallate papillae
Styloid process with

stylohyoid ligament Tongue
Styloglossus
Deep lingual artery
Lingual artery
Hypoglossal nerve
Sublingual gland
Ascending pharyngeal
J
o
zo Genioglossus
t,c
(E
Middle constrictor
!,(E Geniohyoid
o Descendens hypoglossi
c External carotid artery Geniohyoid

o Hyoglossus
C)
Thyrohyoid
o
a Fig.4.15: The lingual aftery
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It is crossed at its origin by the hypoglossal nerve. studied with the face,
transoerse facial artery, already
In the carotid triangle, the artery gives two and a middle temporal artery which runs on the
sternocleidomastoid branches. The upper branch temporal fossa deep to the temporalis muscle.
accompanies the accessorynerve, and the lowerbranch
arises near the origin of the occipital artery. Anso Cervicolis or Anso Hypoglossi
The further course of the artery in scalp has been This is a thin nerve loop that lies embedded in the
described in Chapter 1.0 (see Fig. 10.5). anterior wall of the carotid sheath over the lower part of
the laryrrx. It supplies the infrahyoid muscles (Fig a.16).
Fosferior A urf *ufmr Arferpr
The posterior auricular artery arises from the posterior Formgfr'on
aspect of the external carotid just above the posterior It is formed by a superior and an inferior root. The
belly of the digastric (Fig. 4.14). superior root is the continuation of the descending
It runs upwards and backwards deep to the parotid branch of the hypoglossal nerve. Its fibres are derived
gland, but superficial to the styloid process. It crosses from the first cervical nerve. This root descends over
the base of the mastoid process, and ascends behind the internal carotid artery and the common carotid
the auricle. artery.
It supplies the back of the auricle, the skin over the The inferior root or descending cervical nerve is
mastoid process, and over the back of the scalp. It is derived from second and third cervical spinal nerves.
cut in incisions for mastoid operations. Its stylomastoid As this root descends, it winds round the internal
branch enters the stylomastoid foramen, and supplies jugular vein, and then continues anteroinferiorly to join
the middle ear, the mastoid antrum and air cells, the the superior root in front of the common carotid artery
semicircular canals, and the facial nerve. (Fig. a.16).
As*endfng Phcryrgeaf Arlery
Eisfrib*rfron
This is a small branch that arises from the medial side
Superior root: To the superior belly of the omohyoid.
of the external carotid artery. It arises very close to the
lower end of external carotid artery (see Fig.14.1.6). Arusa ceraicslis: To the sternohyoid, the sternothyroid
It runs vertically upwards between the side wall of and the inferior belly of the omohyoid.
the pharynx, and the tonsil, medial wall of the middle Note that the thyrohyoid and geniohyoid are
ear and, the auditory tube. It sends meningeal branches supplied by separate branches from the first cervical
into the cranial cavity through the foramen lacerum, nerve through the hypoglossal nerve (Fig. a.16).
the jugular foramen and the hypoglossal canal.
Mcxrlfr*y Arf*rXr Hypoglossal

nerye
This is the larger terminal branch of the external carotid
Ventral
artery. It begins behind the neck of the mandible under ramus of C1
cover of the parotid gland. It runs forwards deep to
the neck of the mandible below the auriculotemporal Ventral
nerve, and enters the infratemporal fossa where it will ramus of C2
be studied at a later stage (see Chapter 6).
Ventral
$xp erficiol lerr:porcJ A riery ramus of C3
1 It is the smaller terminal branch of the extemal carotid

artery. It begins, behind the neck of the mandible lnferior root
To thyrohyoid of ansa cervicalis
under cover of the parotid gland (see Fig. 5.5a).
2 It runs vertically upwards, crossing the root of the To geniohyoid .|a
o
zygoma or preauricular point, where its pulsations zo
can be easily felt. About 5 cm above t}:.e zygoma, it t,c
To superior belly
divides into anterior and posterior branches which of omohyoid (E
supply the temple and scalp. The anterior branch !,(E

anastomoses with the supraorbital and supra- To sternohyoid To inferior belly o
of omohyoid
trochlear branches of the ophthalmic artery.
3 In addition to the branches which supply the temple, To sternothyroid
o
the scalp, the parotid gland, the auricle and the facial Fig. 4.16: Ansa cervicalis, and branches of the first cervical o
o
muscles, the superficial temporal artery gives off a nerve distributed through the hypoglossal nerve @
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HEAD AND NECK
The infrahyoid muscles are:

a. Sternohyoid
:' r' '] r "tsf$sEcTtoil ' b. Sternothyroid
ldentify the infrahyoid muscles on each side of the c. Thyrohyoid
median plane. Cut through the origin of sternocleido- d. Omohyoid.
mastoid muscle and reflect it upwards. Trace the nerve
These ribbon muscles have the following general
supply of infrahyoid muscles.
features.
The superficial structures in the inlrahyoid region
a. They are arranged in two layers, superficial
are included in this triangle. The deeper structures
(thyroid gland,lrachea, oesophagus, etc.) will be studied
(sternohyoid and omohyoid) and deep (ster-
nothyroid and thyrohyoid) (Fig. 4.6).
separately at a later stage.
b. All of them are supplied by the ventral rami of
BOUNDARIES first, second and third cervical spinal nerves.
Anteriorly: Anterior median line of the neck from the
c. Because of their attachment to the hyoid bone and
hyoid bone to the sternum.
to the thyroid cartilage, they move these
structures.
Posterosuperiarly: Sttperior belly of the omohyoid muscle
d. Sternohyoid, superior belly of omohyoid, sterno-
(Fis. a.6).
thyroid lie superficial to the lateral or superficial
Pasteroinferiorly: Anterior border of the sterno- convex surface of the thyroid gland.
cleidomastoid muscle. e. The anterior surface of isthmus of thyroid gland
Conlents is covered by right and left sternothyroid and
sternohyoid muscles.
The infrahyoid muscles are the chief contents of the
triangle. These muscles may also be regarded arbitrarily The specific details of infrahyoid muscles are shown
as forming the floor of the triangle (Fig.4.6). in Table 4.1.
T6hle4il :.-;Llffahfcid, rmuStle+.

Muscle Praximal attachment Distal attachment Nerue supply Actions
1. Sternohyoid a. Posterior surface Medial part of lower Ansa cervicalis Depresses the hyoid
(Fig. a.6) of manubrium border of hyoid bone C1, C2, C3 bone following its
sterni elevation during
b. Adjoining pafts of swallowing and during
the clavicle and vocal movements
the posterior
sternoclavicular
ligament
2. Sternothyroid: a. Posterior surface Oblique line on the Ansa cervicalis Depresses the larynx
It lies deep to the of manubrium sterni lamina of the thyroid C1, C2, C3 after it has been elevated
sternohyoid b. Adjoining part of cadilage in swallowing and in
first costal cartilage vocal movements
3. Thyrohyoid: Oblique line of thyroid Lower border of the C1 through a. Depresses the hyoid
It lies deep to the cartilage body and the greater hypoglossal nerve bone
sternohyoid cornua of the hyoid b. Elevates the larynx
bone when the hyoid is fixed
by the suprahyoid
L muscles
o
o
z 4. Omohyoid: lt has a. Upper border of Lower border of body of Superior belly by Depresses the hyoid
E an inferior belly, a scapula near the hyoid bone lateral to the the superior root of bone following its
tr
(E common tendon and suprascapular sternohyoid. The central the ansa cervicalis, elevation during
E' a superior belly. lt notch tendon lies on the and inferior belly by swallowing or in vocal
G,
o arises by the inferior b. Adjoining part of internal jugular vein at inferior root of movements
belly, and is inserted suprascapular the level of the cricoid ansa cervicalis
through the superior ligament cartilage and is bound
.o belly to the clavicle by a
o
o fascial pulley
a
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Mnemonics o The necktie should not be tied tightly, as it may

compress both the internal carotid arteries,
External carotid artery branches supplying the brain.
Superior thyroid ( anterior)
Ascending pharyngeal (medial )
Lingual (anterior)
A patient is undergoing abdominal surgery.
Facial (anlerior) Anaesthetist is sitting at the head end of the table
Occipital (posterior) and monitoring patient's pulse by palpatrng arteries
Poslerior auricular ( posLerior) in the head and neck region
Superficial temporal (termi nal )
r What artery is the anaesthetist palpating?
r Name the other palpable arteries in the body.
Maxillary (terminal)
Ans: The anaesthetist has been monitoring the pulse
by paipating the ccmmon carotid artery at the
anterior border of sternocleidomastoid muscle. He
need not get up to feel the radial pulse repeatedly.
Apex of anterior triangle of neck is close to the Other palpable arteries in head and neck are
sternum, while that of posterior triangle is close superficial ternporal and facial. In upper limb
to the mastoid process. palpable arteries are third part of axillary artery,
Submental triangle is half on each of the brachial artery and radial pulse.
midline. In abdomcn one can feel abdominal aorta
Maximum blood vessels are present in the carotid pulsation when one lies supine
triangle Palpable arteries in lower linnb are femoral athead
Superficial temporal artery can be palpated at the of femur, popliteal. dorsalis pedis and posterior
preauricular point. tibial.
: MUIJIPTE CHOICE QUESTION$
1. Only medial branch external carotid artery is: 4. Hyoid bone develops from:
a. Superior thyroid a. Lst and 2nd arches b. 2nd and 3rd arches
b. Lingual c. 3rd and 4th arches d. 1st,2nd and 3rd arches
c. Ascending pharyngeal 5. Which of the following is not a palpable artery in
d. Maxillary head and neck?
2. All the following are branches of external carotid a. Facial artery
except: b. Superficial temporal artery
a. Posterior ethmoidal c. Lingual artery
b. Occipital d. Common carotid arlery
c. Lingual 6. Which of the following is not a infrahyoid muscle?
d. Facial a. Sternohyoid b. Sternothyoid
J. Muscles forming boundaries of carotid triangle are c. Thyrohyoid d. Omohyoid-inferior belly
all except: 7. Which of the following nerve runs with vagus l<
o
a. Posterior belly of digastric between internal carotid artery and internal jugular zo
b. Superior belly of omohyoid vein till the angle of the mandible? !,
c(E
c. Inferior belly of omohyoid a. Hypoglossal b. Accessory
tt(E
d. Sternocleidomastoid c. Glossopharyrrgeal d. Maxillary o
I
C
ANSWERS .9
o
1.c 2,. a 3.C 4.b 5.c 6,d 7.a ao
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Parotid Region
Eal, doi./,/y am/,/zal,.a/ tan4aua;,San, LrL.eze, magr nal /pe, * lonaa.+aus
INTRODUCTION Facial nerve is the main nerve of the face, supplying

Parotid region contains the largest serous salivary gland all the muscles of facial expression, carrying
and the "queen of the flace", the facial nerve. Parotid secretomotor fibres to submandibular, sublingual
gland contains vertically disposed blood vessels and salivary glands, including those in tongue and floor of
horizontally situated faciaL nerve and its various mouth. lt is also secretomotor to glands in the nasal
branches. Parotid gland gets affected by virus of cavity, palate and the lacrimal gland. lt is responsible
mumps, which can extend the territory of its attack up enough for carrying the taste fibres from anterior two-
to gonads as well. One must be careful of the branches thirds of tongue also except from the vallate papillae
of facial nerve while incising the parotid abscess by (see Chapter 24).
giving horizontal incision. Facial nerve is described in
Chapter 24. Feolures
(Para = around; otic = eat)
SALIVARY GTANDS
There are three pairs of large salivary glands-the The parotid is the largest of the salivary glands. It
parotid, submandibular and sublingual. In addition, weighs about 15 g. It is situated below the external
acoustic meatus, between the ramus of the mandible
there are numerous small glands in the tongue, the
and the sternocleidomastoid. The gland overlaps these
palate, the cheeks and the lips. These glands produce
saliva which keeps the oral cavity moist, and helps in
structures. Anteriorly, the gland also overlaps the
masseter muscle (Fig. 5.1). A part of this forward
chewing and swallowing. The saliva also contains
extension is often detached, and is known as the
enzymes that aid digestion.
accessory parotid, and it lies between the zygomatic arch
and the parotid duct.
Dts$EefloN
Carefully cut through the fascial covering of the parotid
gland from the zygomatic arch above to the angle of
mandible below. While removing tough fascia, dissect External
auditory
the structures emerging at the periphery of the gland. meatus
Trace the duct of the parotid gland anteriorly till the
buccinator muscle. Trace one or more of the branches
of facial nerve till its trunk in the posterior part of the
gland. The trunk can be followed till the stylomastoid Outline of
paroiid gland
foramen. Trace its posterior auricular branch. Trace the
Sternocleidomastoid
course of retromandibular vein and external carotid
artery in the gland, removing the glands in pieces. Clean
Angle of
the facial nerve already dissected. Study the entire mandible
course of facial nerve from its beginning to the end.
Fig.5.'l; Position of parotid gland
106
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PAROTID REGION
Anterior parotid gland from the submandibular salivary gland.

Skin
The ligament is pierced by the external carotid artery.
Posterior
Parotid gland t Paratid sweltings are very painful due to the
Retromandibular vein unyielding nature of theparotid fascia.
and facial nerve o Mumps is an infectious disease of the salivary
lnternal Parotid fascia
(superficial lamina
glands (usually the parotid) caused by a specific
carotid artery
of investing layer) virus, Viral parotitis or mumps characteristically
Styloid process with does not suppurate. Its complications are orchitis
aitached muscles External carotid
ariery piercing and pancreatitis.
stylomandibular
ligament Externol Feotures
Sternocleidomastoid The gland resembles a three sided pyramid.
The apex of the pyramid is directed downwards
(Fig. 5.3).
Fig. 5.2: Capsule of the parotid gland
The gland has four surfaces:
a. Superior (base of the pyramid)
Copsule of Porotid Glond b. Superficial (Fig. 5.3)
The investing layer of the deep cervical fascia forms a c. Anteromedial
capsule for the gland (Fig. 5.2). The fascia splits d. Posteromedial (Fig. 5.4a).
(between the angle of the mandible and the mastoid The surfaces are separated by three borders:
process) to enclose the gland. The superficial lamina, a. Anterior (Fig.s.ab)
thick and adherent to the gland, is attached above to b. Posterior
the zygomatic arch. The deep lamina is thin and is c. Medial/pharyngeal
attached to the styloid process, the angle and posterior
border of the ramus of the mandible and the tympanic ffpXtrfions
plate. Aportion of the deep lamina, extendingbetween The apex (Fig. 5.3) overlaps the posterior belly of the
the styloid process and the mandible, is thickened to digastric and the adjoining part of the carotid triangle.
form the stylomandibular ligamenf which separates the The cervical branch of the facial nerve and the two
Temporal Auriculoiemporal nerve
Superficial temporal vessels
Zygomatic
External auditory meatus
Upper buccal
Posterior auricular nerve
Transverse facial artery
Posterior auricular artery and vein
Accessory parotid gland Apex --o
Parotid duct
Posterior auricular vein
zo
!tc
Lower buccal
(E
External jugular vein tG
Marginal mandibular
o
Cervical Anterior and posterior divisions of
retromandibular vein
Facial vein Common facial vein o
()
Fig. 5.3: Structures emerging at the periphery of the parotid gland ao
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HEAD AND NECK
divisions of the retromandibular vein emerge near the a. The mastoid process, with the sternocleido-
aPex. mastoid and the posterior belly of the digastric.
b. The styloid process, with structures attached to
Surfaces
it.
The superior surface or base forms the upper end of the
gland which is small and concave. It is related to: c. The external carotid artery enters the gland
through this surface and the intemal carotid artery
a. The cartilaginous part of the external acoustic
lies deep to the styloid process (Fig. S.aa).
meatus.
b. The posterior surface of the temporomandibular Borders
joint. from
The anterior border separates the superficial surface
c. The superficial temporal vessels. the anteromedial surface. It extends from the anterior
d. The auriculotemporal nerve (Fig. 5.3). part of the superior surface to the apex. The following
T}:.e superficial surface is the largest of the four
structures emerge at this border:
surfaces. It is covered with:
a. The parotid duct.
a. Skin
b. Superficial fascia containing the anterior branches b. Most of the terminal branches of the facial nerve.
of the great auricular nerve, the preauricular or c. The transverse facial vessels. In addition, the
superficial parotid lymph nodes and the posterior accessory parotid gland lies on the parotid duct
fibres of the platysma and risorius. close to this border (Fig. 5.3).
c. The parotid fascia which is thick and adherent to The posterior border separates the superficial surface
the gland (Fig. 5.2). from the posteromedial surface. It overlaps the
d. A few deep parotid lymph nodes embedded in sternocleidomastoid (Fig. s.ab).
the gland (Fig. 5.1). The medial edge or pharyngeal border separates the
"l}rre anteromedial surface (Fig. 5.4a) is grooved by the anteromedial surface from the posteromedial
posterior border of the ramus of the mandible. It is surface. It is related to the lateral wall of the pharynx
related to: (Fig. 5.aa).
a. The masseter
b. The lateral surface of the temporomandibular Structures within the parotid gland
joint. From medial to the lateral side, these are as follows.
c. The posterior border of the ramus of the mandible 't Arteries: The external carotid artery enters the gland
d. The medial pterygoid through its posteromedial surface (Fig. 5.5a). The
e. The emerging branches of the facial nerve. maxillary artery leaves the gland through its
Theposteromedial surface (Fig. 5. a) is moulded to the anteromedial surface. The superficial temporal artery
mastoid and the styloid processes and the structures gives transverse facial artery and emerges at the
attached to them. Thus it is related to: anterior part of the superior surface.
Masseter
Medial pterygoid
Branches of
facial nerve Ramus of mandible
Wall of pharynx
Parotid gland
Medial edge
Styloid process with Anteromedial
attached muscles surface
.Y
o
o
z
External carotid artery
ffi-* Internal carotid artery Medial edge
!tc Lymph nodes dP-tnternat jugutar vein

(E Sternocleidomastoid Facial nerve Posteromedial
T'
(E surface
Masioid process
o
Posterior belly
c (a) of digastric (b)
o
o Figs 5,4a and b: (a) Horizontal section through the parotid gland showing its relations and the structures passing through it, and
o
a (b) gross features of parotid gland
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PAROTID REGION
Veins: The retromandibular veinis formed within the a. Temporofacinl: Dividesinto temporal and zygomatic
gland by the union of the superficial temporal and branches.
maxillary veins. In the lower part of the gland, the b. Cerr,ticofacial: Divides into buccal, marginal
vein divides into anterior and posterior divisions mandibular and cervical branches.
which emerge close to the apex (lower pole) of the The various branches (5-6) of facial nerve radiate like
gland (Fig.5.5b). a goose-foot from the curved anterior border of the
Tl:.e facial nerzte exits from cranial cavity through parotid gland to supply the respective muscles of
stylomastoid foramen and enters the gland through facial expression. This pattern of branching is called
the upper part of its posteromedial surface, and "pes anserinus".
divides into its terminal branches within the gland. 4 Parotid lymph nodes.
The branches leave the gland through its
anteromedial surface, and appear on the surface at
P atey's facioae nous plane
The gland is composed of a large superficial and a small
the anterior border (Fig. 5.5c).
deep part the two being connected by an 'isthmus' around
Facial nerve lies in relation to isthmus of the gland
which facial nerve divides (Fig.5.5d).
which separates large superficial part from small
deep part of the gland. Facial nerve divides into two Accessory processes af parotid gland
branches (Figs 5.5d and e): Facial process along parotid duct
-
Transverse facial Transverse facial
Superficial
temporal Maxillary
Retromandibular
Posterior Facial Posterior auricular

auricular
External jugular
External carotid Common facial
Anterior division Posterior division
(a) (b)
Zygomatic Temporal branch

branch
Temporofacial
nerve
Facial Superficial
Upper part
buccal nerve
branch Cervico- Isthmus
facial I
nerve o
o
Lower
buccal
Deep part z
branch Cervical ttc
branch G
!,ct
Marginal
mandibular
o
branch
o
Figs 5.5a to e: Structures within the parotid gland: (a) Arteries, (b) veins, (c) nerves, (d) two parts of the parotid gland are separated o
o
by isthmus, and (e) superficial part overlapping the deep part U)
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HEAD AND NECK
Pterygoid process between mandibular ramus

and medial pterygoid.- I
Glenoid process external acoustic A psrotid dbscess may be caused by spread of
- betweenjoint
meatus and temporomandibular infection from the opening of parotid duct in the
mouth cavity (Fig. 5.6).
Poststyloid process
r Parotidectomy is the removal of the paroiid gland.
Porotid DuciAlenson's Duct
.l638-86) After this operation, at tirnes, there may be
(Dutch Anotomist regeneration of the secretomotor fibres in the
It is thick walled and is about 5 cm long. It emerges auriculotemporal nerve which join the great
from the middle of the anterior border of the gland auricular nerve. This causes stimulation of the
(Fig. 5.1).It runs forwards and slightly downwards on sweat glands and hyperaemia in the area of its
the masseter. Here its relations are: distribution, thus producingredness and sweating
in the area of skin supplied by the nerve. This
$up*rferrfy clinical entity is called Frey syndroffie. Whenever,
L Accessory parotid gland. such a person chews there is increased sweating
2 The transverse facial vessels (Fig. 5.3). in the region supplied by auriculotemporalnerve.
3 Upper buccal branch of the facial nerve. $o it is also called'auriculotemporal syndrome'.
f*femorJy
The lower buccal branch of the facial nerve. BIood Supply
At the anterior border of the masseter, the parotid The parotid gland is supplied by the external carotid
duct turns medially and pierces:
artery and its branches that arise within the gland. The
a. The buccal pad of fat.
veins drain into the external jugular vein and internal
b. The buccopharyngeal fascia. jugular vein.
c. The buccinator (obliquely).
Because of the oblique course of the duct through
the buccinator, inflation of the duct is prevented during Nerve Supply
blowing. 1. Parasympathetic nerves are secretomotor (Fig. 5.7).
The duct runs forwards for a short distance between They reach the gland through the auriculotemporal
the buccinator and the oral mucosa. Finally, the duct nerve.
turns medially and opens into the vestibule of the The preganglionic fibres begin in the inferior
mouth (gingivobuccal vestibule) opposite the crown of salivatory nucleus; pass through the glossophaqmgeal
the upper second molar tooth (see Fig.2.26). nerve, its tympanic branctq the tympanic plexus and
Opening of parotid duct
Frenulum
J Undersurface of tongue
o
o
z
t,c
6 Sublingual fold
t,G Submandibular duct
o
C
.o
o
ao of salivary glands
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pnnoiro'nr.,.*
il
Mandibular nerve
ihrough foramen ovale
Otic ganglion
Parotid gland
Tympanic branch
Fig.5.7; Parasympathetic nerve supply to the parotid gland
the lesser petrosal nerve; and relay in the otic Porotid Lymph Nodes
ganglion. The parotid lymph nodes lie partly in the superficial
The postganglionic fibres pass through the fascia and partly deep to the deep fascia over the parotid
auriculotemporal nerve and reach the gland. This is gland (Fig.5.1). They drain:
shown in Flow chart 5.1. a. Temple
2 Sympathetic nerves are vasomotor, and are derived b. Side of the scalp
from the plexus around the middle meningeal artery. c. Lateral surface of the auricle
3 Sensory nerves to the gland come from the d. External acoustic meatus
auriculotemporal nerve, but the parotid fascia is e. Middle ear
innervated by the sensory fibres of the great auricular f. Parotid gland
nerve (C2, Cg). g. Upper part of the cheek
h. Parts of the eyelids and orbit.
Lymphotic Droinoge Efferents from these nodes pass to the upper group
of deep cervical nodes.
Lymph drains first to the parotid nodes and from there
to the upper deep cervical nodes. DEVELOPMENT
The parotid gland is ectodermal in origin. It develops
from the buccal epithelium just lateral to the angle of
Flow chart 5.1 : Tracing nerve supply of parotid gland mouth. The outgrowthbranches repeatedly to form the
duct system and acini. The mesoderm forms the
lnferior salivalory,nucleus intervening connective tissue septa.
A parotid abscess is best drained by horizontal

incision kno$/n as Hilton's method (Fig. 5.8) below
the angle of mandible
During surgical removal of the parotid gland or
parotidectomp the facial nerve is preserved by
.Y
removing the gland in two parts, superficial and o
deep separately, The plane of cleavage is defined zo
by tracing the nerve from behind forwards. tc
Mixedpdrotid tumour is a slow growing lobulated (E
E(!
painless tumour without any involvement of the
o
facial nerve. Malignant change of such a tumour
Postganglionic fibres pass through auriiulotemporal nerve
is indicated by pain, rapid growth, fixity with c
hardness, involvement of the facial nerye, and .9
o
enlargement of cervical lymph nodes.
Parotid gland
ao
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ffi
HEAD AND NECK
o The parotid calculi may get formed within the Facial nerve passes through two foramina of skull,
parotid gland or in its Stenson's duct. These can i.e internal acoustic meatus and stylomastoid
be located by injecting a radiopaque dye through foramen.
its opening in the vestibule of the mouth. The
procedure is called 'Sialogram'. The duct can be
examined by a spatula or bidigital examination.
A young man complained of fever and sore throat,
noied a swelling ana felt pain on both sides of his
face in front of the ear. Within a few days, he noted
swellings below his jaw and below his chin. He
suddenly started looking very healthy by facial
appearance. The pain increased while chewing or
drinking lemon juice. The physician noted
enlargement of all three salivary glands on both sides
{at*\ of the face.
* o Where do the ducts of salivary glands open?
. Why did the pain increase while chewing?
. Why did the pain increase while drinking lemon
juice?
Parotid gland wiih
branches of facial nerve Ans; illlte duct of the parotid. gland opens at a papilla
Horizontal incision for
in the vestibule af mouth opposite the 2nd uPper
drainage of abscess molar tooth. The duct of submandibular gland opens
Parotid duct at the papiila on the sublingual fold" The sublinguai
Fig. 5.8: Horizontal incision for draining parotid abscess. gland opens by 10-12 ducts on ihe sublingual fold.
Branches of facial nerve also seen The investing Layer of cervical fascia encl*ses boih
the parotid and the submanclihuiar giands and is
attached to the iower border of the manciible. As
mandible movqs during chewing, the fascia gets
Facial nerve courses through the parotid gland, siretched which results in pain. The fascia and skin
without supplying any structure in it. are suppiied by the great auricular nerve.
Skin over the parotid gland is supplied by great Ii\rhile drinking lemon juice, there is lot of pain, as
auricular nerve/ C2, C3. the salivary secretion is stimulated by the acid of the
Deepest structure in the substance of parotid gland lemon juice.
is the external carotid artery The investing layer *f cervical fa*qcia encloses: f\ffo
Otic ganglion is the onlyparasympathetic ganglion muscles, the trapezius and the sternocleidomastoid;
with 4 roots two spaces, the suprasternal space and the
Facial nerve divides into temporofacial and supraclavicular space; twa glands, the parotid and
cervicofacial branches. The formei gives temporal ti"re submandibutar glands; and forms tw'a puileys,
and zygomatic branches. The latter gives buccal, one for the intermediate tendon of digastric and one
marginal mandibular and cervical branches for the interrnediate tendon of om*hiroid muscle.
OUESTIONS
L
o c. Otic ganglion
o 1. Nerve carrying postganglionic parasympathetic
z fibres of the parotid gland is: d. Submandibular ganglion
E'
c,
(E a. Facial b. Auriculotemporal 3. Which of the following artery passes between the
€c, c. Inferior alveolar d. Buccal roots of the auriculotemporal nerve?
o
I 2. Somata of postganglionic secretomotor fibres to a. Maxillary
parotid gland lie in: b. Middle meningeal
.o a. Ciliary ganglion c. Superficial temporal
o
o
U) b. Pterygopalatine ganglion d. Accessory meningeal
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Vein formed by union of posterior division of c. Superficial temporal
retromandibular and posterior auricular vein is: d. Maxillary
a. Internal jugular b. External jugular 7. One of the following nerves is not related to parotid
c. Common facial d. Anterior jugular gland:
All of the following are peripheralparasympathetic a. Temporal branch of facial
ganglia except: b. Zygomatic branch of facial
c. Buccal branch of facial
a. Otic b. Ciliary
d. Posterior superior alveolar branch of maxillary
c. Pterygopalatine d. Geniculate Pes anserinus is the arrErngement in which of the
6. Which artery is not inside the parotid gland? following nerves?
a. External carotid a. Vagus b. Trigeminal
b. Intemal carotid c. Facial d. Glossopharyngeal
.Y
o
2o
't5
(!
tt6
o
T
o
.E
o
o
6
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Temporal and
lnfratemporal Regions
lB e*t y'.h.y,;aiaru. ata: A ac.l.a,z 9*r,et1 Oaclaa. fie$ g o.la'v g iel ar.d g aclo".Uc4ryrri/tz,
of Solerno
-Regimen
INTRODUCTION Parietal
Coronal bone
Temporal and infratemporal regions include muscles suture
of mastication, which develop from mesoderm of first Frontal
Superior
temporal line
branchial arch. Only one joint, the temporomandibular bone
Inferior
joint, is present on each side between the base of skull Sphenoid temporal line
and mandible to allow movements during speech and bone
Pterion
mastication.
Zygomatic Squamous
The parasympathetic ganglion is the otic ganglion, temporal
bone
the only ganglion with four roots, i.e. sensory, sym- Occipital
pathetic, motor and secretomotor or parasympathetic. Maxilla bone
The blood supply of this region is through the
Mastoid process
maxillary artery. Middle meningeal artery is its most Pterygomaxillary
fissure
important branch, as its injury results in extradural Zygomatic arch
Laieral pterygoid
haemorrhage. plate
Fig.6"1 : Some features seen on the lateral side of the skull
J Zygomaticotemporal nerve and artery.

In order to understand these regions, the osteology of 4 Deep temporal nerves for supplying temporalis
the temporal fossa, and the infratemporal fossa should muscle.
be studied. Tlne temporal fossalies on the side of the skull, Deep temporal artery, branch of maxillary artery.
and is bounded by the superior temporal line and the
zygomatic arch.
BOUNDARIES
Anterioy: Zygomatic and frontal bones (Fig. 6.1).
It is an irregular space below zygomatic arch.
Pasterior: Inferior temporal line and supramastoid crest. BOUNDARIES
Superior: Superior temporal line
Anterior: Posterior surface of body of maxilla.
lnferiar : Zy gomatic arch.
Roaf:Infuatemporal surface of greater wing of sphenoid.
Floor: Pafis of frontal, parietal, temporal and greater
wing of sphenoid. Temporalis muscle is attached to the Medinl: Lateral pterygoid plate and pyramidal process
floor and inferior temporal line. of palatine bone.
Lsteral: Ramus of mandible (Fig. 6.2).
CONIENTS
L Temporalis muscle. CONTENIS
2 Middle temporal artery (branch of superficial L Lateral pterygoid muscle.
temporal artery) (see Chapter 4). 2 Medial pterygoid muscle.
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TEMPORAL AND I NFRATEMPORAL REGIONS
Middle cranial fossa DISSECTION

ldentify the masseter muscle extending from the
zygomatic arch to the ramus of the mandible, Cut the
Temporal fascia zygomatic arch in front of and behind the attachment
o, masseter muscle and reflect it downwards. Divide
Temporal fossa
the nerve and blood vessels to the muscle. Clean the
ramus of mandible by stripping off the masseter muscle
from it.
Zygomatic arch
Give an oblique cut from the centre of mandibular
lnfratemporal cresi of notch to the lower end of anterior border of ramus of
greaier wing of sphenoid mandible. Turn this part of the bone including the
lnfratemporal surface of greater wing insertion of temporalis muscle upwards. Strip the muscle
Ramus of mandible from the skull and identify deep temporal nerves and
vessels.
Lateral pterygoid plate
Make one cut through the neck ol the mandible. Give
Medial pterygoid plate another cut through the ramus at a distance of 4 cm
Fig.6.2: Scheme to show the outline of the temporal and from the neck. Remove the bone carefully in between
infratemporal fossae in a coronal section these two cuts, avoiding injury to the underlying
structures. The lateral pterygoid is exposed in the upper
J Mandibular nerve with its branches. part and medial pterygoid in the lower part of the
4 Maxillary nerve with posterior superior alveolar dissection.
nerve (see Chapter 15).
5 Chorda tympani, branch of VII nerve. FEATURES
5 Lst and 2nd parts of maxillary artery with their The muscles of mastication move the mandible during
branches. mastication and speech. They are the masseter, the
7 Posterior superior alveolar artety,branch of 3rd part temporalis, the lateral pterygoid and the medial
of maxillary artery. pterygoid. They develop from the mesoderm of the first
8 Accompanying veins. branchial arch, and are supplied by the mandibular
nerve which is the nerve of that arch. The muscles are
enumerated in Table 6.1 and shown in Figs 6.3 to 6.5.
Temporal fascia and relations of lateral and medial
pterygoid muscles are described.
The external ear or pinna is a prominent feature on the
lateral aspect of the head. TEMPORAT FASCIA
1. The zygomaticbone forms the prominence of the cheek The temporal fascia is a thick aponeurotic sheet
at the inferolateral corner of the orbit. The zygomatic that roofs over the temporal fossa and covers the
archbridges the gap between the eye and the ear. temporalis muscle. Superiorly, the fascia is single
2 The head of the mandible lies in front of the tragus. layered and is attached to the superior temporal line.
It is felt best during movements of the lower jaw. Inferiorly, it splits into two layers which are attached
3 The mastoid process is a large bony prominence to the inner and outer lips of the upper border of the
situated behind the lower part of the auricle. zygomatic arch. The small gap between the two layers
4 The superior temporalline forms the upperboundary contains fat, a branch from the superficial temporal so
of the temporal fossa which is filled up by the artery and the zygomaticotemporal nerve.
zo
temporalis muscle. The superficial surface of the temporal fascia receives E
5 The pterion is the area in the temporal fossa an expansion from the epicranial aponeurosis. This G
where four bones (frontal, parietal, temporal and surface gives origin to the auricularis anterior and It
G
sphenoid) adjoin each other across an H-shaped superior, and is related to the superficial temporal o
suture (Fig. 6.1). vessels, the auriculotemporal nerve, and the temporal
6 The junction of the back of the head with the neck is branch of the facial nerv e (seeEig.5.3). The deep surface C
o
indicated by the external occipital protuberance and of the temporal fascia gives origin to some fibres of the o
o
the superior nuchal lines. temporalis muscle. @
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TEMPORAL AND INFRATEMPORAL REGIONS
Parietal bone
Temporalis
Masseter
(deep head)
Masseter
(superficial head)
Fig.6.3: Origin and insertion of the masseter muscle. Origin of temporalis also shown
Zygomatic arch
(cut)
Temporalis
Temporomandibular
joini capsule
Lateral ligameni
Fig.6.z[: Origin and insertion of the temporalis muscle
The fascia is extremely dense. In some species (e.g. Deep

tortoise), the temporal fascia is replaced by bone. 1 Mandibular nerve
2 Middle meningeal artery (Fig. 6.10).
RELATIONS OF IATERAI PIERYGOID 3 Sphenomandibular ligament
The lateral pterygoid may be regarded as the key 4 Deep head of the medial pterygoid.
so
muscle of this region because its relations provide a Structures Emerging ot the Upper Border
fair idea about the layout of structures in the infra- zo
temporal fossa. The relations are as follows: 1 Deep temporal nerves (Fig. 6.6) t
2 Masseteric nerve. G
t,G
Superficiol Structures Emerging of the lower Border o
1. Masseter (Fig. 6.5) L Lingual nerve
2 Ramus of the mandible 2 Inferior alveolar nerve c
o
3 Tendon of the temporalis 3 The middle meningeal artery passes upwards deep o
o
4 The maxillary artery (Fig. 6.6). to it (Fig. 6.6). a
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HEAD AND NECK
lnsertion of lateral pterygoid

into pterygoid fovea
Articular disc
Upper and lower heads

of lateral pterygoid
Deep head of
medial pterygoid
lnferior
alveolar nerve
Lingual nerve
Superficial head of medial pterygoid
Mandible (cut)
Fig.6.5: The lateral and medial pterygoid muscles
Accessory meningeal
Middle meningeal
Masseteric artery and nerve
Deep auricular
Maxillary artery
Anterior tympanic
lnferior alveolar nerve and artery
Mylohyoid nerve and artery
Fig.6.6: Some relations of the lateral pterygoid muscle and branches of maxillary artery
.Y
o
zo Slruclures Possing through RELAIIONS OF MEDIAL PTERYGOID
E
tr
(E the Gop Between the Two Heods The superficial and deep heads of medial pterygoid
t,(E L The maxillary artery enters the gap enclose the lower head of lateral pterygoid muscle
o (Fib. 6.s).
I 2 The buccal branch of the mandibular nerve comes
out through the gap (Fig. 6.6). Superficiol Relotions
.o
(J The pterygoid plexus of veins surrounds the lateral The upper part of the muscle is separated from the
ao pterygoid. lateral pterygoid muscle by:
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TEMPORAL AND INFRATEMPORAL REGIONIS
1 The lateral pterygoid plate The external and middle ears, and the auditory tube
2 The lingual nerve (Fig. 6.5). (Fig.6.7)
3 The inferior alveolar nerve. , The dura mater
Lower down the muscle is separated from the ramus 3 The upper and lower jaws and teeth
of the mandible by the lingual and inferior alveolar 4 The muscles of the temporal and infratemporal
nerves, the maxillary artery, and the sphenomandibular regions
ligament. 5 The nose and paranasal air sinuses
6 The palate
Deep Relotions 7 The root of the pharynx.
The relations are:
1 Tensor veli palatini COURSE AND RELATIONS
2 Superior constrictor of pharynx For descriptive purposes, the maxillary artery is divided
3 Styloglossus into three parts (Fig. 6.7 andTable 6.2).
4 Stylopharyngeus attached to the styloid process. I Thefirst (mandibular) part ntnshorizontally forwards,
first between the neck of the mandible and the
sphenomandibular ligament, below the auriculo-
temporal nerve, and then along the lower border of
the lateral pterygoid.
DISSECTION 2 The second (pterygoid) part runs upwards and
External carotid artery divides into its two terminal forwards superficial to the lower head of the lateral
branches, maxillary and superficial temporal on the pterygoid.
anteromedial surface of the parotid gland. The maxillary 3 The third (pterygopalatine) parl passes between the two
artery, appears in this region. ldentify some of its heads of the lateral pterygoid and through the
branches" Most important to be identified is the middle pterygomaxillary fissure, to enter the ptery-
meningeal artery. Revise its course and branches from gopalatine fossa.
Chapter 12. Accompanying these branches are the
veins and pterygoid venous plexus and the superficial BRANCHES OF FIRST PART OF THE MAXITLARY ARTERY
content of infratemporal fossa. Remove these veins. L The deE nuricular artery supplies the external acoustic
Try to see its communication with the cavernous sinus meatus, the tympanic membrane and the
and facialvein. temporomandibular joint (Fig. 6.7).
2 The anterior tympanicbranch supplies the middle ear
Feotures including the medial surface of the tympanic
This is the larger terminalbranch of the external carotid membrane.
artery, given off behind the neck of the mandible. It 3 The middle meningeal artery has been described in
has a wide territory of distribution, and supplies: Chapter 12. It lies between lateral pterygoid and
First part of maxillary artery

ffi 1. Deep auricular
2. Anterior iympanic
3. Middle meningeal
4. Accessory meningeal
5. lnferior alveolar
Second part of maxillary artery

ffi 1. Masseteric
2. Deep temporal
3. Pterygoid l.
4. Buccal o
zo
t,tr
Third part of maxillary artery
ffi t. Posterior superior alveolar
(E
2. lnfraorbital !t(E
3. Greater palatine o
4. Pharyngeal
5. Arlery of pterygoid canal
C
6. Sphenopalatine o
()
Fig.6.7: Branches of three parts of the maxillary artery ao
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HEAD ANDNEGK''
Table 6.2: Branches of maxillary artery (Figs 6.6 and 6.7f

Branches Foramina transmitting Distribution
A. Of first part
1 . Deep auricular Foramen in the floor (cartilage or bone) of Skin of external acoustic meatus, and outer sudace
meatus
external acoustic of tympanic membrane
2. Anterior tympanic Petrotympanic fissure lnner surface of tympanic membrane
3. Middle meningeal Foramen spinosum Supplies more of bone and less of meninges; also
5th and 7th nerves, middle ear and tensor tympani
4. Accessory meningeal Foramen ovale Main distribution is extracranial to pterygoids
5. lnferior alveolar Mandibular foramen Lower teeth and mylohyoid muscle
B. Of second part
1. Masseteric Masseter
2. Deep temporal Temporalis (two branches)
3. Pterygoid Lateral and medial pterygoids
4. Buccal Skin of the cheek
C. Of third part
superior
1. Posterior Alveolar canals in body of maxilla Upper molar and premolar teeth and gums;
alveol'ar maxillary sinus
2. lnfraorbital lnferior orbital fissure Lower orbita.l muscles; lacrimal sac; maxillary
sinus; upper incisor and canine teeth
3. Greater palatine Greater palatine canal Soft palate; tonsil; palatine glands and mucosa of
upper gums
4. Pharyngeal Pharyngeal (palatovaginal) canal Roof of nose and pharynx;auditorytube; sphenoidal
SINUS
5. Artery of pterygoid canal Pterygoid canal Auditory tube; upper pharynx; and middle ear
6. Sphenopalatine Sphenopalatine foramen Lateral and medial walls of nose and various air
(terminal part) sinuses
sphenomandibular ligament, then between two roots It also gives off a mental branch that passes through
of auriculotemporal nerve, enters the skull through the mental foramen to supply the chin.
foramen spinosum to reach middle cranial fossa. It
divides into a large frontal branch which courses BRANCHES OF SECOND PART OF THE MAXILLARY
towards pterion and a smaller parietal branch
tLre ARTERY
(Figs 6.10 and 12.13). These are mainly muscular. These are 1. masseteri c,2. arrrd
Tlee accessory meningeal artery enters the cranial cavity 3. deep temporalbranches (anterior and posterior) ascend
through the foramen ovale. Apart from the on the lateral aspect of the skull deep to the temporalis
meninges, it supplies structures in the infratemporal muscle, 4. to the pterygoid muscles, and 5. buccal branch
fossa. supplies the skin of cheek.
The inferior alaeolar artery runs downwards and
forwards medial to the ramus of the mandible to BRANCHES OT THIRD PART OF THE MAXILLARY ARTERY
reach the mandibular foramen. Passing through this
foramen, the artery enters the mandibular canal
1 The posterior superior alaeolar artery arises just before
the maxillary artery enters the pterygomaxillary
(within the body of the mandible) in which it runs
L fissure. It descends on the posterior surface of the
o downwards and then forwards.
maxilla and gives branches that enter canals in the
zo Before entering the mandibular canal, the artery gives bone to supply the molar and premolar teeth, and
t,c off a lingual branch to the tongue; and a mylohyoid
(E the maxillary air sinus.
E(E branch that descends in the mylohyoid groove (on the 2 The infraorbital artery also arises just before the
o medial aspect of the mandible) and runs forwards maxillary artery enters the pterygomaxillary fissure.
I above the mylohyoid muscle (seeFig.1..25). It enters the orbit through the inferior orbital fissure.
c
o Within the mandibular canal, the artery gives It then runs forwards in relation to the floor of the
() branches to the mandible and to the roots of the each orbit, first in the infraorbital groove and then in the
o
U) tooth attached to the bone. infraorbital canal to emerge on the face through the
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infraorbital foramen. It gives off some orbitnlbranches,

for structures in the orbit; middle superior aloeolar
branch for premolar teeth and the anterior superior
DISSECTION
alaeolar branches that enter apertures in the maxilla
to reach the incisor and canine teeth attached to the Cut the lateral pterygoid muscle close to its insertion.
bone. Dislodge the head of mandible from the articular disc.
Locate the articular cartilages covering the head of the
After emerging on the face, the infraorbital artery
mandible and the mandibular fossa. Take out the
gives branches to the lacrimal sac, the nose and the
articular disc as well and study its shape and its role in
upper lip.
increasing the varieties of movements.
The remaining branches of the third part arise within
the pterygopalatine fossa (Fig. 6.7).
Type of Joint
3 The greater palatine artery runs downwards in the
greater palatine canal to emerge on the posterolateral This is a synovial joint of the condylar variety.
part of the hard palate through the greater palatine Atticulor Surfoces
foramen. It then runs forwards near the lateral
margin of the palate to reach the incisive canal (near The upper articular surface is formed by the following
the midline) through which some terminal branches parts of the temporal bone:
enter the nasal cavity (see Fig. 15.15). 1 Articular tubercle
Branches of the artery supply the palate and gums.
2 Anterior part of mandibular fossa (Fig. 6.8).
\A/hile still within the greater palatine canal, it gives
3 Posterior nonarticulat part formed by the tympanic
plate.
off the lesser palatine arteries that emerge on the palate
The inferior articular surface is formed by the head
through the lesser palatine foramina, and run of the mandible.
backwards into the soft palate and tonsil.
The articular surfaces are covered withfibrocartilage.
4 The pharyngeal branch runs backwards through a The joint cavity is divided into upper and lower parts
canal related to the inferior aspect of the body of the by an intra-articular disc.
sphenoid bone (pharyngeal or palatinovaginal
canal). It supplies part of the nasopharynx, the [igoments
auditory tube and the sphenoidal air sinus.
The ligaments are the fibrous capsule, the lateral
5 The artery of the pterygoid canal runs backwards in
ligament, the sphenomandibular ligament, and the
the canal of the same name and helps to supply the
stylomandibular ligament.
pharynx, the auditory tube and the tympanic cavity.
1 The fibrous capsule is attached aboae to the articular
f, 6 The sphenopalatine artery passes medially through the
tubercle, the circumference of the mandibular fossa
sphenopalatine foramen to enter the cavity of the in front and the squamotympanic fissurebehind, and
nose. It gives off posterolateral nasal branches to the
below to the neck of the mandible. The capsule is loose
lateral wall of the nose and to the paranasal sinuses;
above the intra-articular disc, and tightbelow it. The
and posteromedial branches to the nasal septum. s;movial membrane lines the fibrous capsule and the
Sphenopalatine artery is the artery of "epistaxis" (see neck of the mandible (Fig. 6.9).
Fig. 15.15).
2 The lateral temporomandibular ligament reinforces and
strengthens the lateral part of the capsular ligament.
PTERYGOID PTEXUS OF VEINS
Its fibres are directed downwards and backwards. It
It lies around and within the lateral pterygoid muscle. is attached above to the articular tubercle, and below
The tributaries of the plexus correspond to the branches to the posterolateral aspect of the neck of the
of the maxillary artery. The plexus is drained by the mandible.
maxillary vein which begins at the posterior end of the 3 The sphenomandibular ligament is an accessory .x
plexus and unites with the superficial temporal vein to ligament, that lies on a deep plane away from the o
form the retromandibular vein. Thus the maxillary vein fibrous capsule. It is attached superiorly to the spine zo
accompanies only the first part of the maxillary artery. !tc
of the sphenoid, and inferiorly to the lingula of the (E
The plexus communicates: mandibular foramen. It is a remnant of the dorsal !l(E
a. With the inferior ophthalmic vein through the part of Meckel's cartilage. o
inferior orbital fissure. The ligament is related laterally to:
b. With the cavernous sinus through the emissary a. Lateral pterygoid muscle. o
veins. b. Auriculotemporal nerve. ()
c. With the facial vein through the deep facial vein. c. Maxillary artery (Fig. 6.10). ao
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FIEAD AND NECK
Mandibular fossa
Meniscotemporal compartment
Posterior band
Intra-articular disc
lntermediate zone
Bilaminar region
Anterior band
Anterior extension
Squamotympanic fissure
Articular tubercle
Fibrous capsule Fibrocartilage
Tympanic plate
Lateral pterygoid
Head of mandible
Meniscomandibular compartment
Fig. 6.8: Articular surfaces of the left temporomandibular joint
compartments. The upper compartment permits gliding

movements, and the lower, rotatory as well as gliding
movements.
The disc has a concavo-convex superior surface, and
a concave inferior surface. The periphery of the disc is
attached to the fibrous capsule. The disc is composed
of an anterior extension, anterior thick band,
intermediate zorre, posterior thick band and bilaminar
region (Fig. 6.8) containing venous plexus. The disc
represents the degenerated primitive insertion of lateral
pterygoid. The disc prevents friction between the
articulating surfaces.
It acts as a cushion and helps in shock absorption. It
Fig. 6.9: Fibrous capsule and lateral ligament of the temporo- stabilises the condyle by filling up the space between
mandibular joint articulating surfaces.
The proprioceptive fibres present in the disc help to
regulate movements of the joint.
The ligament is related medially to the disc helps in distribution of weight across the
a. Chorda tympani nerve. TMI by increasing the area of contact.
b. Wall of the pharlmx. Near its lower end, it is Pierced
by the mylohyoid nerve and vessels. RETATIONS OF TEMPOROMANDIBULAR JOINT
4 The stylomandibular ligamenf is another accessory
ligament of the joint. It represents a thickened part Loterol
-v
()
of the deep cerrsical fascia which separates the parotid 1 Skin and fasciae
zo and submandibular salivary glands. It is attached 2 Parotid gland (see Fig. 5.2)
!ttr above to the lateral surface of the styloid Process/ 3 Temporal branches of the facial nerve.
(E
!,(E and below to the angle and adjacent part of posterior
o border of the ramus of the mandible (Fig. 6.10). Mediol
1 The tympanic plate separates the joint from the
C ARTICUTAR DISC internal carotid artery.
.9
C)
(l)
The articular disc is an oval predominantly fibrous plate 2 Spine of the sphenoid, with upper end of the spheno-
a that divides the joint into an upPer and a lower mandibular ligament attached to it.
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Spine of sphenoid
Foramen spinosum
Superficial temporal artery
Lingual nerve Nervous spinosus

Auriculotemporal
Sphenomandibular ligament
Maxillary artery
Stylomandibular ligament
and external carotid artery
lnferior alveolar nerve and artery
Mylohyoid artery and nerve
lnner surface
Fig.6.10: Superficial relations of the sphenomandibular ligament seen after removal of the lateral pterygoid
3 Auriculotemporal and chorda tympani nerves.

4 Middle meningeal artery (Fig. 6.10).
Lateral
pterygoid
Anfedor muscle
1. Lateral pterygoid
2 Masseteric nerve and artery (Fig 6.8). Masseter
muscle
Posterior
L The parotid gland separates the joint from the
extemal auditory meatus.
2 Superficial temporal vessels.
3 Auriculotemporal nerve (see Fig. 5.3).
Supefior
1 Middle cranial fossa Fig. 6.11: Movements of temporomandibular joint (arrows) by
muscles of mastication
2 Middle meningeal vessels.
lnferior 4 Retrusion (retraction of chin)
Maxillary artery and vein. 5 Lateral or side to side movements during chewing
or grinding.
BTOOD SUPPLY Movements of this joint can be palpated by putting
Branches from superficial temporal and maxillary finger at preauricular point or into external auditory
arteries. Veins follow the arteries. meatus. The movements at the joint can be divided into --C)
those between the upper articular surface and the
articular disc, i.e. meniscotemporal compartment and zo
NERVE SUPPLY !,
those between the disc and the head of the mandible, i.e. tr
Auriculotemporal nerve and masseteric nerve. G
meniscomandibular compartment. Most movements tt
G
occur simultaneously at the right and left temporo- o
MOVEMENTS
mandibular joints.
L Depression (open mouth) (Fig. 6.i1) Lr forward movement or protraction of the mandible, o
2 Elevation (closed mouth) the articular disc glides forwards over the upper o
3 Protrusion (protraction of chin) articular surface, the head of the mandible moving with ao
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HEAD AND NECK
it. In retraction, the articular disc glides backwards over

the upper articular surface taking the head of mandible
Dislocation of mandible: During excessive
with it. Mandible rotates around a horizontal axis opening of the mouth, the head of the mandible
extending from left to right condyle.
of one or both sides may slip anteriorly into the
In slight opening of the mouth or depression of the
infratemporal fossa, as a result of which there is
mandible, the head of the mandible moves on the inability to close the mouth. Reduction is done by
undersurface of the disc like a hinge. The movement depressing the jaw with the thumbs placed on the
occurs around a vertical axis passing through the last molar teeth, and at the same time elevating
condyle and posterior border of the ramus of mandible.
the chin (Fig.6.1,2).
In wide opening of the mouth, this hinge-like Derangement of the articular disc may result from
movement is followed by gliding of the disc and the any injury,like overclosure or malocclusion. This
head of the mandible, as in protraction. At the end of
gives rise to clicking and pain during movements
this movement, the head comes to lie under the articular
of the jaw.
tubercle. These movements are reversed in closing the
In operations on the temporomandibular joint, the
mouth or elevation of the mandible.
VII nerve and auriculotemporal nerve/ branch of
Chewingmovements involve side to side movements
mandibular division of V should be preserved
of the mandible. In these movements, the head of (say)
with care (Fig. 6.13).
right side glides forwards along with the disc as in
protraction, but the head of the left side merely rotates
on a vertical axis. As a result of this, the chin moves
forwards and to left side (the side on which no gliding
has occurred). Alternate movements of this kind on the
two sides result in side to side movements of the jaw.
Here the mandible rotates around an imaginary axis
running along the mid sagittal plane.
Muscles Producing Movements
! Depression is brought about mainly by the lateral
pterygoid. The digastric, geniohyoid and mylohyoid
muscles help when the mouth is opened wide or against
resistance:
The origin of only lateral pterygoid is anterior,
slightly lower and medial to its insertion. During Mandibular fossa
contraction, it rotates the head of mandible and opens
Articular eminence Head of mandible
the mouth. During wide opening, it pulls the articular
disc forwards. So movement occurs in both the Fi9.6.12: Dislocation of the head of mandible
compartments. It is also done passively by gravity
(Figs 6.8 and 6.1L).
t Eleaation is brought about by the masseter, the
anterior vertical, middle oblique fibres of temporalis,
and the medial pterygoid muscles of both sides. These
Auriculotemporal
are antigravity muscles. nerve
<-Protrusion is done by the lateral and medial
pterygoids and superficial oblique fibres of masseter.
-+Retraction is produced by the posterior horizontal
5 fibres of the temporalis and deep vertical fibres of
o Facial nerve and
o masseter
z Lateral or side to side moaements, e.g. chewing from
its branches
E
6 left side produced by right lateral pterygoid, right
tt(E medial pterygoid which push the chin to left side. Then
o left temporalis (anterior fibres), left masseter (deep
fibres). (++) chew the food. Chewing from right side
o involves left lateral pterygoid, left medial pterygoid, Fig.6.13: Close relation of the two nerves to the temporo-
o
o
right temporalis and right masseter. Since so many mandibular joint
o muscles are involved, chewing becomes tiring.
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JVerye fo JWedrsf Fferygord

Nerve to medial pterygoid arises close to the otic
DISSECTION ganglion and supplies the medial pterygoid from
ldentify middle meningeal artery arising from the its deep surface. This nerve gives a motor root to the
maxillary artery and trace it till the foramen spinosum. otic ganglion which does not relay and supplies the
Note the two roots of auriculotemporal nerve tensor veli palatini, and the tensor tympani muscles
(Fig. 6.1s).
surrounding the artery. Trace the origin of the auriculo-
temporal nerve from mandibular nerve (Fig.6.10).
Dissect all the other branches of the nerve. ldentify the
Euecof Alerye
chorda tympani nerve joining the lingual branch of Buccal nerve is the only sensory branch of the anterior
mandibular nerve. Lift the trunk of mandibular nerve division of the mandibular nerve. It passes between the
laterally and locate the otic ganglion. two heads of the lateral pterygoid, runs downwards
Trace all connections of the otic ganglion. and forwards, and supplies the skin of cheek and
mucous membrane related to the buccinator (Fig. 6.6).
INTRODUCTION
It also supplies the labial aspect of gums of molar and
premolar teeth.
This is the largest mixed branch of the trigeminal nerve.
It is the nerve of the first branchial arch and supplies lklossefegc frferve
all structures derived from that arch (Fig. 6.14). Otic
Masseteric nerve emerges at the upper border of the
and submandibular ganglia are associated with this
lateral pterygoid just in front of the temporomandibular
nerve.
joint, passes laterally through the mandibular notch in
COURSE AND RELATIONS company with the masseteric vessels, and enters the
deep surface of the masseter. It also supplies the
Mandibular nerve begins in the middle cranial fossa temporomandibular jotnt (see Fig. 1,.2$.
through a large sensory root and a small motor root.
The sensory root arises from the lateral part of the
Deep lernBorciflIeryes
trigeminal ganglion, and leaves the cranial cavity
through the foramen ovale (Figs 6.17 and 12.13). Deep temporal nerves are two nerves, anterior and
The motor root lies deep to the trigeminal ganglion posterior. They pass between the skull and the lateral
and to the sensory root. It also passes through the pterygoid, and enter the deep surface of the temporalis.
foramen ovale to join the sensory root just below the
foramen thus forming the main trunk. The main trunk Nerve fo {ofsrmd Pferygofd
lies in the infratemporal fossa, on the tensor veli Nerve to lateral pterygoid enters the deep surface of
palatini, deep to the lateral pterygoid. After a short the muscle.
course, the main trunk divides into a small anterior
trunk and a large posterior trunk (Fig. 6.1a). A*ricuI*fempord,Vsry#
BRANCHES Auriculotemporal nerve arises by two roots which run
backwards, encircle the middle meningeal artery, and
From the main trunk: unite to form a single trunk (Figs 6.14 and 6.15). The
a. Meningeal branch nerve continues backwards between the neck of the
b. Nerve to the medial pterygoid. mandible and the sphenomandibular ligament, above
From the anterior trunk: the maxillary afiery. Behind the neck of the mandible,
a. A sensorybranch, the buccal nerve it turns upwards and ascends on the temple behind the
b. Motor branches, the masseteric and deep temporal superficial temporal vessels.
neryes and the nerve to the lateral pterygoid. The auricular part of thenerve supplies the skin of the so
From the posterior trunk:
a. Auriculotemporal
tragus; and the upper parts of the pinna, the external
acoustic meatus and the tympanic membrane. (Note
zo
t,tr
b. Lingual that the lower parts of these regions are supplied by the (E
c. Inferior alveolar nerves. great auricular nerve and the auricular branch of the !t(E
vagus nerve). The temporal part supplies the skin of o
Menrngeaf Sr*nch cr lVeryus $pdn*sus J-
the temple (see Fig. 2.5). ln addition, the atriculotemporal
Meningeal branch enters the skull through the foramen nerve also supplies the parotid gland (secretomotor
.o
spinosum with the middle meningeal artery and and also sensory) and the temporomandibular joint o
supplies the dura mater of the middle cranial fossa. (see Table 1.3). oo
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TEMPOFIAL AND INFRATEM PORAL REGIONS
Iable 63l Branches of !ft! maldibular nerve {CN.V3) incisive branch supplies the labial aspect of gums
Muscular Sensory Others of canine and incisor teeth.
Temporalis and masseter Meningeal Carries
Auriculotemporal taste
fibres
Medial and lateral pterygoids lnferior alveolar Carries It is a peripheral parasympathetic ganglion which
and mental secreto- relays secretomotor fibres to the parotid gland.
motor fibres
Topographically, it is intimately related to the
Tensor veli palatini and Lingual Articular mandibular nerve, but functionally it is a part of the
tensor tympani
glossopharyngeal nerve (Figs 6.15 and 6.1.6).
Mylohyoid and digastric Buccal
(anterior belly)
SIZE AND SITUATION
It is 2 to 3 mm in size, and is situated in the infra-
Relations temporal fossa, just below the foramen ovale. It lies
It begins 1 cm below the skull. It runs first between the medial to the mandibular nerve, and lateral to the tensor
tensor veli palatini and the lateral pterygoid, and then veli palatini. It surrounds the origin of the nerve to the
between the lateral and medial pterygoids. medial pterygoid (Fig. 6.15).
About 2 cm below the skull, it is joined by the chorda
tympani nerve. CONNECTIONS AND BRANCHES
Emerging at the lower border of the lateral pterygoid,
The secretomotor motor or parasympathetic root is formed
the nerve runs downwards and forwards between the
ramus of the mandible and the medial pterygoid. Next by the lesser petrosal nerve. Its origin and course is
it lies in direct contact with the mandible, medial to the shown in Flow chart 6.1.
third molar tooth between the origins of the superior The sympathetic root is derived from the plexus on
constrictor and the mylohyoid muscles (seeFig.1.25). the middle meningeal artery. It contains postganglionic
It soon leaves the gum and runs over the hyoglossus fibres arising in the superior cervical ganglion. The
deep to the mylohyoid. Finally, it lies on the surface of
fibres pass through the otic ganglion without relay and
reach the parotid gland via the auriculotemporal nerve.
the genioglossus deep to the mylohyoid. Here it winds
around the submandibular duct and divides into its They are vasomotor in function.
terminal branches (see Fig.7.4). The sensory root corr.es from the auriculotemporal
nerve and is sensory to the parotid gland.
$mfenmr Afvemj*r fferv*
Inferior alveolar nerve is the larger terminal branch of Flovv charl 6.1: Secretomotor fibres for parotid gland
the posterior division of the mandibular nerve
(Fig.6.1a). It runs vertically downwards lateral to the
medial pterygoid and to the sphenomandibular ----r----
Preganglionic fibres from inferior salivatory nucleus I
ligament. It enters the mandibular foramen and runs

in the mandibular canal. It is accompanied by the
inferior alveolar artery (see Fig. 1,.25).
Branches
1 The mylohyoidbranch contains all the motor fibres of Tympanic plexus
I
the posterior division. It arises justbefore the inferior
alveolar nerve enters the mandibular foramen. It
Lesser petrosal.nerve
pierces the sphenomandibular ligament with the .Y
o
mylohyoid artery,runs in the mylohyoid groove, and zo
supplies the mylohyoid muscle and the anteriorbelly Otic ganglion E
of the digastric (Fig. 6.10). G
While running in the mandibular canal the inferior Postganglionic fibres I t,(E
alveolar nerve gives branches that supply the lower o
teeth and gums. Join auriculotemporal nerve I
T}:le mental nerae err,erges at the mental foramen and C
supplies the skin of the chin, and the skin and t .o

o
mucous membrane of the lower lip (Fig. 6.14). Its
Parotid'gland
I ao
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HEAD AND NECK
Sensory root
Geniculate ganglion of facial nerve

Motor root
Greater petro$al nerve
Tympanic plexus
Sympathetic nerve
Nerve to stapedius
Deep petrosal nerve

Facial nerve
lnternal carotid plexus
Communication between chorda

tympani and neve of pterygoid canal
Facial canal
Nerve to parotid gland
Otic ganglion
Chorda tympani
Communication between otic ganglion
Glossopharyngeal nerve and chorda tympani
Sympatheiic root
Tympanic branch Inferior alveolar nerve
Lingual nerve
Fig. 6.15: Connections of otic ganglion (schematic)
Other fibres passing through the ganglion are as is divided to relieve intractable pain of this kind .
follows: This may be done where the nerve lies in contact
a. The nerve to medial pterygoid gives a motor root with the mandible below and behind the last molar
to the ganglion which passes through it without tooth, covered only by mucous membrane.
relay and supplies medially placed tensor veli Mandibular neuralgia: Trigeminal neuralgia of the
palatini and laterally placed tensor tympani mandibular division is often difficult to treat. In
muscles. such cases, the sensory root of the nerve may be
b. The chorda tympani nerve is connected to the otic divided behind the ganglion, and this is now the
ganglion and also to the nerve of the pterygoid operation of choice when pain is confined to the
canal (Fig. 6.16). These connections provide an distribution of the maxillary and mandibular
alternative pathway of taste from the anterior two- nerves. During division, the ophthalmic {ibres that
thirds of the tongue. lie in the superomedial part of the root are spared/
to preserve the corneal reflex thus avoiding
damage to the cornea (Fig. 6.17).
. The motor part of the mandibular nerve is tested
Lingual nerve lies in contact with mandible,
clinieally by asking the patient to clench her/his medial to the third molar tooth. In extraction of
teeth and then feeling for the contracting masseter
malplaced 'wisdom' tooth, care must be taken not
and temporalis muscles on the two sides. If one to injure the lingual nerve (Fig. 6.18). Its injury
masseter is paralysed, the jaw deviates to the results in loss of all sensations from anterior two-
.Y
paralysed sid,e, on opening the mouth by the thirds of the tongue.
o action of the normal lateral pterygoid of the
zo opposite side. The activity of the pterygoid A lesion at the foramen ovale leads to paraesthesia
!, along the mandible, tongue, temporal region and
tr muscles is tested by asking the patient to move
(E paralysis of the muscles of mastication: This also
t,(E the chin from side to side.
o
. Referred pain: In cases with cancer of the tongue,
leads to loss of iaw-jerk reflex.
I pain radiates to the ear and to the temporal fossa, The mandibular nerve supplies both the ef{erent
over the distribution of the auriculotemporal nerve and afferent loops of the jaw-jerk reflex, as it is a
o
.F as both lingual and auriculotemporal are branches mixed nerve. Tapping the chin causes contraction
()
o of mandibular nerve. Sometimes the lingual nerve of the pterygoid muscles.
U)
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In extraction of mandibular teeth, inferior alveolar Mnemonics S

nerve needs to be anaesthetised. The drug is given
into the nerve before itenters the mandibular canal
Fr*tl"rrft t*rtrt.M"dktptu S-
(Fig. 6.18). "La": ]aw is open, so lateral pterygoid opens mouth.
lnferiar alveolar neyve: Infenor alveolar nerve as it "Me": Jaw is closed, so medial pterygoid closes the
travels the mandibular canal can be damaged by mouth.
the fracture of the mandible. This injury can be
assessed by testing sensation over the chin.
During extraction of the 3rd molar, the buccal
nerve may get inrrolved by the local anaesthesia
causing temporary numbness of the cheek. Mandibular nerve the only mixed branch of
trigeminal nerve
The nerve is associated with two parasympathetic
ganglia, i.e. otic and submandibular ginglia
Maxillary artery gives many branches; some
accompany branches of maxillary nerve and others
branches of mandibular nerve as there is no
mandibular artery
Only muscle of mastication which depresses the
TMJ is the lateral pterygoid muscle
Spine of sphenoid is related to chorda tympani and
auriculotemporal nerves. Injury to the spine will
Trigeminal ganglion
hamper the iecretion of 3 sriiviry glandi.
Auriculotemporal nerve and branches of facial
nerve are relited to temporomandibular joint.
A patient of carcinoma in anterior two-thirds of

tongue complains of paininhis lower teeth, ternporal
region and the temporomandibular joint.
. l\rhy is pain of tongue referred to lower teeth?
r Which are the other areas of referred pain?
Fig. 6.17: Partial cutting of the sensory root of trigeminal nerue
Ansr Sensations from anterior two-thirds of the
tongue are carried by lingual, branch of mandibular
nerve. $ince there are toa mafiy pain impul$es due
tc disease, thene impulses course through other
branches of the nerve, where it is gets referred. So
pain is felt inlower teeth, from where $ensations are
carried by inferiar alveolar nerve. The mandibular
nerve also carries sensation from temporo-
mandibular joint and temporal region so the pain
also gets referred to these regions.
Examples of referred pain are: :o
r Pain of gallbladder is referred to right shoulder; zo
r Pain of myocardial ischaemia is felt in the chest !,
tr
and mediai side of left arm (E
I Pain of foregut derived orgafls i* felt in epigastrium !t

G
a Pain r:f midgut derived organ$ is feit in o
periumbilical region
Fig. 6.18: lnjection given in mandibular foramen for Pain *f hindgut derived organs is f*lt in suprapubic
anaesthetising the inferior alveolar nerve before extraction of
o
region o
last molar tooth o
U)
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W''
L. Action of lateral pterygoid muscle is: 6. Dislocated mandible can be reversed by:
a. Elevation and retraction of mandible a. Depressing the jaw posteriorly and elevating the
b. Depression and retraction of mandible chin
b. Depressing the jaw and depressing the chin
c. Elevation and protrusion of mandible
c. Elevating the jaw and elevating the chin
d. Depression and protrusion of mandible
d. Depressing the chin and elevating the jaw
2. \ /hich of the following muscles is used for opening posteriorly
the mouth? 7. Nervus spinosus is a branch of:
a. Medial pterygoid b. Temporalis a. Maxillary nerve b. Mandibular nerve
c. Lateral pterygoid d. Masseter c. Ophthalmic nerve d. 2nd cervical nerve
3. Which of the following ligaments is not a ligament 8. Lingual nerve is the branch of:
of temporomandibular joint? a. Facial nerve
a. Pterygomandibular b. Glossopharyngeal nerve
b. Sphenomandibular c. Mandibular nerve
c. Lateral ligament d. Hypoglossal nerve
d. Stylomandibular 9. Lingual nerve can be pressed against a bone inside
the mouth near the roots of the:
4. Which one is not a branch of maxillary artery?
a. Third upper molar tooth
a. Anterior tympanic
b. Second upper molar tooth
b. Anterior ethmoidal c. Third lower molar tooth
c. Middle meningeal d. First lower molar tooth
d.Inferior alveolar 10. Nerve piercing sphenomandibular ligament is:
5. Which of the following is not a muscle of masti- a. Nerve to mylohyoid
cation? b. Inferior alveolar
a. Medial pterygoid b. Masseter c. Buccal
c. Temporalis d. Orbicularis oris d. Lingual
t:,' !
L
o
o
z
ttr
(5
t,(E
o
C
.o
o
ao
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Submandibular Region
9,i/c,,io.ko.ilrazl,/na.nenh"l..zAc,illm*.aia.algr
Bernord Show
-George
INTRODUCTION 4 Fourth layer formed by genioglossus (Fig.7.a).

The muscles are described in Table 7.1.
Submandibular region includes deeper structures in the
area between the mandible and hyoid bone including RETATIONS OF POSTERIOR BELTY OF DIGASTRIC
the floor of the mouth and the root of the tongue.
The submandibular region contains the suprahyoid Supefficiol
muscles, submandibular and sublingual salivary glands 1 Mastoid process with the sternocleidomastoid,
and submandibular ganglion. Chorda tympani from splenius capitis and the longissimus capitis (Figs 5.4a
facial nerve provides preganglionic secretomotor fibres and7.3).
to the glands. Chorda tympani also carries fibres of 2 The stylohyoid.
sensation of taste from anterior two-thirds of tongue 3 The parotid gland with retromandibular vein.
except from the circumvallate papillae, from where it 4 Submandibular salivary gland (Fi1.7.3) and lymph
is carried by the glossopharyngeal nerve. nodes.
5 Angle of the mandible with medial pterygoid.
Deep
DISSECTION
L Transverse process of the atlas with superior oblique
and the rectus capitis lateralis.
Cut the facial artery and vein present at the 2 Internal carotid, external carotid, lingual, facial and
anteroinferior angle of masseter muscle. Separate the occipital arteries
origin of anterior belly of digastric muscle from the 3 Internal jugular vein.
digastric fossa near the symphysis menti. Push the 4 Vagus, accessory and hypoglossal cranial nerves
mandible upwards. Clean and expose the posterior belly (Fis.7.3).
of digastric muscle and its accompanying stylohyoid 5 The hyoglossus muscle.
muscle. ldentify the digastrics, stylohyoid, mylohyoid,
geniohyoid, hyoglossus. Upper Border
1 The posterior auricular artery (see Fig. 4.1.4).
Feotures 2 The stylohyoid muscle.

The suprahyoid muscles are the digastric, the lower Bordel
stylohyoid, the mylohyoid and the geniohyoid. The Lower border is related to occipital artery (seeFig.4.1.4).
muscles are in following layers:
1 First layer formed by digastric (Greek two bellies) and RELATIONS OF MYTOHYOID
stylohyoid (Fi9.7.1). Superficiol
2 Secondlayerformedbymylohyoid (Greek pertaining 1 Anterior belly of the digastric (Fig. 7.1)
to hyoid bone) (Fig. 7.2). 2 Superficial part of the submandibular salivary gland.
3 Third layer formed by geniohyoid and hyoglossus 3 Mylohyoid nerve and vessels.
, (Fig.7.\. 4 Submental branch of the facial artery.
I
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I
HEAD AND NECK
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SUBMANDIBULAR REGION
Facial artery
Submental lymph node
Submandibular gland
with lymph nodes
Facial vein
Bellies of digastric muscle
Mylohyoid muscle
Hyoid bone
Fig.7.1 : Relationof marginal mandibularbranchof facial nervetothesubmandibularglandanditslymphnodes
nerve, submandibular duct, the lingual artery, and

the hypoglossal nerve (Fig.7.\.
Submandibular duct RELATIONS OF HYOGLOSSUS

Sublingual gland Superficiol
with ducts
Styloglossus, lingual nerve, submandibular ganglion,
deep part of the submandibular gland, submandibular
Tongue
duct, hypoglossal nerve and veins accompanying it.
Deep
Mylohyoid 1. Inferior longitudinal muscle of the tongue.
Mandible muscle
sectioned 2 Cenioglossus.
Submandibular
3 Middle constrictor of the pharynx.
gland with
Digaskic
4 Glossopharyngeal nerve.
lymph nodes
muscle 5 Stylohyoid ligament.
6 Lingual artery.
Hyoid bone
Structures passing deep to posterior border of
Fig.7.2: Mylohyoid muscle dividing the gland into two parts
hyoglossus, from above downwards:
1 Glossopharyngeal nerve. J
Deep 2 Stylohyoid ligament. o
1" Hyoglossus with its superficial relations, namely the 3 Lingual artery (Fig.7.\. zo
t,c
styloglossus, the lingual nerve, the submandibular (E
ganglion, the deep part of the submandibular !t(E
salivary gland, the submandibular duct, the I
o
hypoglossal nerve, and the venae comitantes DISSECTION
hypoglossi (Figs 7.2 and 7.4). Submandibular gland is seen in the digastric triangle. o
.F
2 The genioglossus with its superficial relations, On pushing the superficial part of the gland posteriorly,
()
namely the sublingual salivary gland, the lingual ao
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HEAD AND NECK
FEATURES
the entire mylohyoid muscle is exposed. The deep part
of the gland lies on the superior surface of the muscle. This is a large salivary gland, situated in the anterior
Separate the lacial artery from the deep surface of gland part of the digastric triangle. The gland is about the
and identify its branches in neck. The hyoglossus size of a walnut. It is roughly ]-shaped, being indented
muscle is recognised as a quadrilateral muscle lying by the posterior border of the mylohyoid which divides
on deeper plane than mylohyoid muscle. ldentify lingual it into a larger part superficial to the muscle, and a small
nerve with submandibular ganglion, and hypoglossal part lying deep to the muscle (Fig. 7.5).
nerve running on the hyoglossus muscle from lateralto
the medial side. Deep part of gland and its duct are also SUPERFICIAL PART
visible on this surface of hyoglossus muscle (Fig. 7.a). This part of the gland fills the digastric triangle. It
Carefully release the hyoglossus muscle from the extends upwards deep to the mandible up to the
hyoid bone and reflect it towards the tongue. Note the mylohyoid line. It has:
structures deep to the muscle, e.g. genioglossus
a. Inferior (Fig.7.1)
muscle, lingual artery, vein and middle constrictor of
b. Lateral
the pharynx.
c. Medial surfaces.
Superior oblique muscle

Occipital artery Rectus capitis lateralis
Stern0cleidomastoid process of atlas
Splenius capitis
lnternal jugular vein
Longissimus capitis
Hypoglossal nerve
Mastoid process
J({ -,-
Vagus nerve
-,2'
v lnlarnal aarn
Parotid gland
Spinal accessory
Facial artery
External carotid artery
Submandibular gland
Hyoid bone
Tendon of digastric
Fig.7.3: Posterior belly of the digastric muscle, and structures related to it, seen from below
Siyloglossus
Tongue
Lingual nerve
Submandibular duct Stylohyoid ligament
5 Outline of sublingual gland

o Submandibular ganglion
o
z
t, Genioglossus
(E Lingual artery
E
(E
6) Hypoglossal nerve
Geniohyoid
Hyoid bone
Hyoglossus Deep part of submandibular

o gland
o
o
U) Fig.7.4; Submandibular region showing the superficial relations of the hyoglossus and genioglossus muscles
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Mylohyoid The lateral surface is related to:

Geniohyoid a. The submandibular fossa on the mandible.
b. Insertion of the medial pterygoid (Fig.7.7).
Genioglossus
c. The facial artery (Figs 7.8 and7.9).
The medial surface is related to:
Sublingual Mylohyoid, hyoglossus and styloglossus muscles
gland from before backwards (Fi9.7.9).
Inferiorly: It overlaps stylohyoid and the posterior
Hyoglossus belly of the digastric (Figs 7 .1. and 7 .2).
DEEP PARI
Deep part of
submandibular gland This part is small in size. It lies deep to the mylohyoid,
and superficial to the hyoglossus and the styloglossus
(Fig. 7.a). Posteriorly, it is continuous with the super-
ficial part round the posterior border of the mylohyoid
Superificial part of (Fig. 7.5). Anteriorly, it extends up to the posterior end
submandibular gland
of the sublingual gland.
Fig. 7.5: Horizontal section through the submandibular region
showing the location of the submandibular and sublingual glands Relolions
Present in between mylohyoid and hyoglossus
The gland is partially enclosed between two layers Laterally - Mylohyoid
of deep cervical fascia. The superficial (Fig. 7.6) layer Medially - Hyoglossus
of fascia covers the inferior surface of the gland and is Above - Lingual nerve with submandibular
attached to the base of the mandible. The deep layer ganglion
covers the medial surface of the gland and is attached Below - Hypoglossal nerve
to the mylohyoid line of the mandible (Fig. 7.6).
SUBMANDIBULAR DUCT/WHARTON'S DUCT
(ENGLISH SCIENTIST: 1 61 4-7 3)
Relotions
The inferior surface is covered by: It is thin walled, and is about5 cm long. It emerges at
the anterior end of the deep part of the gland and runs
a. Skin forwards on the hyoglossus, between the lingual and
b. Platysma hypoglossal nerves. At the anterior border of the
c. Cervical branch of the facial nerve hyoglossus, the duct is crossed by the lingual nerve
d. Deep fascia (Fig. 7.q.It opens on the floor of the mouth, on the
e. Facial vein (Fig. 7.7). summit of the sublingual papllla, at the side of the
f. Submandibular lymph nodes (Fig. 7.1). frenulum of the tongue (Fig.7.2).
Myiohyoid line
Deep lamina Mandibular canal

with inferior Medial
of fascia pierygoid
alveolar nerve I()
and vessels o
Submandibular
gland
z
t,tr
Submandibular Submandibular (E
Greater--Srl(ry
gornuq \p* ***
fossa gland !t(i,
Base of
o
J-
g mandible
Superficial lamina of fascia d o
Fig. 7.6; Fascial covering of the superficial part of the sub- Fig. 7.7: Relationship of the facial vein to the submandibular gland o
o
mandibular salivary gland and to the mandible @
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HEAD AND NECK
Blood Supply ond Lymphotic Droinoge Flow chart 7.1: Secretomotor fibres to the glands
It is supplied by the facial artery. Supeiior salivatory nucleus
The facial artery arises from the external carotid just
above the tip of the greater cornua of the hyoid bone.
The ceraical part of the facial artery runs upwards on
the superior constrictor of pharynx deep to the posterior
belly of the digastric, and stylohyoid to the ramus of
the mandible. It grooves the posterior end of the
submandibular salivary gland. Next the artery makes Chorda tympani I
an S-bend (two loops) first winding down over the
-..]t
submandibular gland, and then up over the base of the
Joins lingual nerve, branch3lll
mandible (Figs 7.8 and7.9).
The veins drain into the common facial or lingual vein.
Lymph passes to submandibular lymph nodes.
T Submandibular ganglion
I
Nerve Supply ,/N

It is supplied by branches from the submandibular
Y
I n"try
ganglion. These branches convey:
Submandibular and sublingual glands I
Anteroinferior 1 Secretomotor fibres (see Table 1.3)

part of masseter 2 Sensory fibres from the lingual nerve
3 Vasomotor sympathetic fibres from the plexus on the
facial artery.
The secretomotor pathway is shornm in Flow chart 7.1.
Facial artery
SUBLINGUAL SALIVARY GLAND

This is smallest of the three salivary glands. It is almond-
shaped and weighs about 3 to 4 g. It lies above the
mylohyoid, below the mucosa of the floor of the mouth,
lnvesting fascia medial to the sublingual fossa of the mandible and
lateral to the genioglossus (Figs 7.2,7.3 and7.7).
Submandibular gland
Fig.7,8: Relationship of the facial artery to the submandibular Relotions
gland and to the mandible Front - Meet with opposite side gland
Behind - Comes in contact with deeper part of
Skin submandibular gland
Mylohyoid
Anterior belly of (2nd layer) Above - Mucous membrane of mouth
digastric (1st layer)
Eublingual
Below - Mylohyoid muscle
gland Lateral - Sublingual fossa
Submandibular
gland Genioglossus
Medial - Genioglossus muscles
(4th layer) About 15 ducts emerge from the gland. Most of them
L open directly into the floor of the mouth on the summit
o Hyoglossus Submandibular
of the sublingual fold. A few of them join the sub-
zo (3rd layer) duct
mandibular duct.
E Facial artery Tongue
tr
(E
The gland receives its blood supply from the lingual
t,(E Stylohyoid Pharynx and submental arteries. The nerve supply is similar to
o that of the submandibular gland.
T
Posterior belly of digastric SUBMANDIBUTAR GANGLION
.o
o Fig. 7.9: Schematic horizontal section through the submandibular This is a parasympathetic peripheral ganglion. It is a
o
U) region relay station for secretomotor fibres to the submandibular
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Taste bud Lingual nerve Chorda tympani
Secretomotor root
Taste fibres
Fibres carrying
general sensations
Sublingual gland
Preganglionic fibres
Sensory root
Sympathetic plexus
on facial artery
Submandibular gland
Fig, 7.10: Connection ol the submandibular ganglion
and sublingual salivary glands. Topographically, it is

related to the lingual nerve/ but functionally, it is .
connected to the chorda tympani branch of the facial
The chorda tympani supptrying secretomotor
nerve (see Table 1.3 and Flow chart 7.1). fibres to submandibular and sublingual salivary
glands lies medial to the spine of sphenoid (see
The fusiform ganglion lies on the hyoglossus muscle
Fig. 6.10). The auriculotempbral nerve $upplying
just above the deep part of the submandibular salivary
secretomotor fibres to the parotid gland is related
gland, suspended from the lingual nerve by two roots
to lateral aspect of spine of spheroid. Iniury to
(Fig.7.B).
Bplne may involve both these nerves with loss of
secretion from all three salivary glands.
CONNECTIONS AND BRANCHES . Submandibular lfrnph nodes lie both within and
1 The secretomotor fibres pass from the lingual nerve outside the submandibuiar salivary gland. The
to the ganglion through the posterior root. These are gland is to be removed if lymph nodes are affected
parasympathetic preganglionic fibres that arise in the in any disease especially carcinoma of tongue
superior saliuatory nucleus and pass through nervus (Fig, 7.1).
intermedius till the facial nerve, the chorda tympani . fuIylohyoidmuscle dividesthe glandintosuperficial
and the lingual nerve to reach the ganglion or relay. and deep parts (Fig. 7.5). Lymph nodes lie around
Postganglionic fibres for the submandibular gland and within the gland. Cancer of the tongue or of
reach the gland through five or six branches from the gland may metastasise into the mandible also
the ganglion. Postganglionic fibres for the sublingual {Fig.7.2).
and anterior lingual glands re-enter the lingual r The duct of submandibular gland may get
nerve through the anterior root and travel to the impacted by a small $tofter which can be demons-
gland through the distal part of the lingual nerve trated on radiographs. ]a
(Flow chart7.l). o Secretion of submandibular gland is more viscous, o
2 The sympathetic fibres are derived from the plexus so there are more chances of the gland getting zo
calculi or small stones. t,tr
around the facial artery.It contains postganglionic
fibres arising in the superior cervical ganglion. They
r Submandibular gland can be manually palpated (E
t,(E
pass through submandibular ganglion without relay, by putting one Iinger within the mouth and one o
and supply vasomotor fibres to the submandibular finger outside, in relation to the position of the
and sublingual glands (Fig. 7.10). gland (Fig. 7.11). The enlarged lymphnodes lying L
3 Sensory fibres reach the ganglion through the lingual

on the surface of the gland and within its .o
o
substance can also be palpated. o
, nerve (Table7.2). U)
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HEAD AND NECK
Table 7. 2: Comparison ol the three salivary glands

Parotid Submandibular Sublingual
Location ln relation to external ear, Lies in submandibular Lies in sublingual
angle of mandible, mastoid fossa close to angle fossa on the base of
process (see Fig. 5.1) of mandible the mandible
Size Largest Medium sized Smallest
Relation to Enclosed by investing Enclosed by investing Not enclosed
fascia layer of cervical fascia layer of cervical fascia
Type of gland Purely serous secreting Mixed, both serous Purely mucus secreting
and mucus secreting.
Gross features Comprises 3 sudaces, Comprises 3 surfaces, Related closely to lingual
3 borders, apex and base inferior, lateral and medial. nerve and submandibular
one artery, one vein, one nerve One artery which indents the duct
and lymph nodes lie within posterior end of the gland.
the gland (see Chapter 5) only lymph nodes lie within it
Secretomotor rool From lX cranial nerve From Vll cranial nerve From Vll cranial nerve
Sympathetic root Plexus around middle Plexus around facial artery Same as submandibular
meningeal artery gland
Sensory Auriculotemporal Lingual nerve Lingual nerve
Development Ectoderm Endoderm Endoderm
Opening or Vestibule of mouth opposite Papilla on in sublingual fold 10-12 ducts open on
the duct 2nd upper molar tooth in the floor of the mouth sublingual fold in the floor
of the mouth.
r Excision of the submandibular gland for calculus

or tumour is done by an incision below the angle . Chorda tympani nerve carries secretomotor
of the jaw. Since the marginal mandibular branch fibres to the submandibular ganglion. It also carries
of the facial nerve passes posteroinferior to the taste from most of the anterior two-thirds of
angle of the iaw before crossing it, the incision tongue.
must be placed mo{e than 4 cm below the angle e The submandibular lymph nodes are also present
to preserve the nerve (Fig. 7.1). in the submandibular gland. In cancer of the
The nerve also passes across the lymph nodes
tongue, this gland is also excised to get rid off the
of submandibular region. One should be careful lymph nodes with secondaries from the tongue.
of the nerve while doing biopsy of lymph node. o Facial artery is tortuous to accommodate to the
movements of pharynx. It is the chief artery of the
palatine tonsil.
o Suprahyoid muscles are disposed in four layers:
1st layer: Digastrics and stylohyoid
2nd layer: Mylohyoid
3rd layer: Geniohyoid and hyoglossus
4th layer: Genioglossus (Fig. 7.9)
ta
o
zo A patient is diagnosed with cancer of the tongue.
t,c The lesion was on the dorsum of tongue close to its
(E
lateraI border.
E(tl
o r Where does all the lymph from cancerous lesion
drain?
C
. Which other parts have be removed during the
o Fig. 7.11: Bimanual palpation of submandibular gland
() surgery to remove the lesion?
o lymph nodes
a
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Ans: The lymph fram dorsum of tnngue close to this salivary glaqd ir also to be rernoved, T'he insidion
lateral border chieflSr drains into the submandibular in the neck is to be placed about 4 crn below the
group of lyrnnh nodes. Ferar lymph vessels may even of mandible, to preserve the rnargi4-almandibular
crs$s the midline to drain into the oppo*ite branch of faeial nerve a* it passes poster*inferior t*
suhmenditr-ular lymph nsdes. Thes* lymph nodes are the angle af the law befsre mossing it. If this branch
presenf rarithin and outside the submandibular is injured muscles of lower lip would get paralysed
ralivary gland" $o during removal of lyurph nodes ffis.7.U.
t. One of the following statements about chorda c. Marginal mandibular branch of facial
tympani nerve is not true: d. Cervical branch of facial
a. Branch of facial nerve 4. Submandibular lymph nodes drain all of the
b. Joins lingual nerve in infratemporal fossa following areas except:
c. Carries postganglionic parasympathetic fibres a. Lateral side of tongue
d. Carries taste fibres from most of the anterior two- b. External nose, upper lip
thirds of tongue
) c. Lateral halves of eyelids
Nerve carrying preganglionic parasympathetic
fibres to submandibular ganglion: d. Medial halves of eyelids
a. Greater petrosal b. Lesser petrosal 5. \Mhich muscle divides the submandibular gland
c. Deep petrosal d. Chorda tympani into a superficial and deep parts?
J. \Mhich of the following nerves lies posteroinferior a. Hyoglossus
to angle of mandible? b. Mylohyoid
a. Zygomattc branch of facial c. Geniohyoid
b. Buccal branch of facial d. Anterior belly of digastric
ir,' G1 ;Ei:$ .1ffi{r.;i
J
o
zo
t,tr
(E
t(E
Io
C
o
o
o
a
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Structures in the Neck
INTRODUCTION identily the vessels of thyroid gland. ldentify the

The thyroid gland lies in front of the neck. Skin incision recurrent laryngeal nerves tucked between the lateral
for its surgery should be horizontal, for better healing sudaces of trachea and oesophagus. Look for beaded
and for cosmetic reasons. Branches of subclavian artery thoracic duct present on the left of oesophagus. Trace
anastomose with those of axillary artery around the the superior and inferior thyroid arteries. ldentify
scapula. cricothyroid and inferior constrictor muscles lying medial
Scalenus anterior is important. It may compress the to the lobes of thyroid gland.
subclavian artery to cause "scalenus anterior Thyroid gland
syndrome".
Lymph nodes are clinically important in deciding Cut the isthmus of the thyroid gland and turn one of the
the prognosis and treatment of malignancies. lobes laterally. Locate an anastomosis between the
posterior branch of superior thyroid and ascending
Contents:There are numerous structures in the neck.
branch of inferior thyroid arteries supplying the gland.
For convenience, they may be grouped as follows:
ldentify the lwo parathyroid glands just lateral to this
a. Glnuls: Thyroid and parathyroid. anastomotic vessel.
b. Tlrymus: Involutes at puberty.
c. Arteries: Subclavian and carotid.
THYROID GTAND
d. Veins: Subclavian, internal jugular and brachio-
cephalic. The thyroid (shield like) is an endocrine gland, situated
e. Neraes: Glossopharyngeal, vagus, accessory/ in the lower part of the front and sides of the neck. It
hypoglossal described in Chapter 24. regulates the basal metabolic rate, stimulates somatic
f . Sympnthetic trunk: Has three cervical ganglia. and psychic growth, and plays an important role in
g. Lymph nodes and thoracic duct. calcium metabolism.
h. Styloid apparatus. The gland consists of right and left lobes that are
joined to each other by the isthmus (Fig. 8.1). A third,
pyramidal lobe, may project upwards from the isthmus
(or from one of the lobes). Sometimes a fibrous or fibro-
DISSECTION muscular band (levator glandulae thyroidae) descends
from the body of the hyoid bone to the isthmus or to
Sternocleidomastoid muscle has already been reflected the pyramidal lobe (Fig. 8.2).
laterally from its origin. Cut the sternothyroid muscle
near its origin and reflect it upwards. Clean the surface Situotion ond Exlent
of trachea and identify inferior thyroid vein and remains
of the thymus gland (darker in colour than fat).
1 The gland lies against vertebrae C5, C6, C7 andT1.,
embracing the upper part of the trachea (Fig. 8.2).
On the 2nd4lh tracheal rings lies the isthmus of the
thyroid gland. Pyramidal lobe if present projects from 2 Each lobe extends from the middle of thyroid
the upper border of the isthmus. On each side of isthmus
cartilage to the fourth or fifth tracheal ring.
are the lateral lobes of the gland. Clean the lobes and 3 The isthmus extends from the second to the fourth
tracheal ring.
140
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STRUCTURES IN THE NEOK
Sternocleidomastoid muscle Hyoid bone
Lobe of thyroid gland Thyroid cartilage
Cricoid cartilage
Manubrium sterni
Fig. 8.1: Position of thyroid gland
Vertebral
levels Hyoid
2 Thefalse capsule is derived from the pretracheal layer
of the deep cervical fascia (Fig. 8.2). It is thin along
caI Levator glandulae the posterior border of the lobes, but thick on the
thyroidae inner surface of the gland where it forms a
suspensory ligament (of Berry), which connects the
C4 r"d I lobe to the cricoid cartilage (Fig. 8.a).
",L Thyroid cartilage
Porls ond Relotions

True capsule
The lobes are conical in shape having:
Cricoid cartilage
Pyramidal lobe
a. An apex
b. A base
Lateral lobe
Cricotracheal membrane
lsthmus False capsule
t- False capsule
,rl Fourth tracheal ring
Plane of cleavage
Venous plexus True capsule
Fig. 8.2: Scheme to show the location and subdivisions of the Venous plexus
thyroid gland including the false capsule
Gland substance
Dimensions ond Weight
Each lobe measures about 5 cm x 2.5 cm x 2.5 cm, and
the isthmus 1.2 cm x 1.2 cm. On an a-verage, the gland False capsule
weighs about25 g. However, itis largerinfemales than
in males, and further increases in size during Venous plexus
menstruation and pregnancy.
True capsule
Copsules of lhyroid Plane of cleavage ,.Y
1 The true capsule is the peripheral condensation of the o
connective tissue of the gland. Gland substance
zo
ttc
A dense capillary plexus is present deep to the true G
t capsule. To avoid haemorrhage during operations, (b) t,(E
the thyroid is removed along with the true capsule. o
Figs 8.$a and b: Schemes of comparing the relationship of
It can be compared with the prostate in which the the venous plexuses related to: (a) The thyroid gland, and
venous plexus lies between the two capsules of the (b) the prostate, with the true and false capsules around these o
gland; and, therefore, during prostatectomy both organs. Note the plane of cleavage along which the organ is o
o
capsules are left behind (Figs 8.3a ahd b). separated from neighbouring structures during surgical removal a
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HEAD AND NECK
Sternohyoid

Trachea and oesophagus
Sternothyroid
Sternocleidomastoid Platysma
Ansa cervicalis
Thyroid and
Ligament of paraihyroid glands
Berry
lnternal jugular vein
Carotid sheath
and deep cervical
lymph
Vagus nerve
Common carotid artery Sympathetic trunk
Retropharyngeal lymph nodes Prevertebral muscles
Fused prevertebral and buccopharyngeal fasciae

Fig.8.4: Transverse section through the anterior part of the neck at the level of the isthmus ol the thyroid gland
C. Three Surfaces: Lateral, medial and posterolateral. Superior laryngeal nerve and
superior thyroid artery
d. Two Borders: Anterior and posterior.
lnternal laryngeal nerve and
The apex is directed upwards and slightly laterally.
superior laryngeal artery
It is limited superiorly by the attachment of the sterno-
thyroid to the oblique line of thyroid cartilage. The apex Hyoid bone
is related to superior thyroid artery and external Thyrohyoid
laryngeal nerve (Fig. 8.5). membrane
The base is at level with the 4th or 5th tracheal ring.
It is related to inferior thyroid artery and recurrent Thyroid cartilage
laryngeal nerve (Fig. 8.7).
The lsteral or superficial surface is convex, and is Cricothyroid
covered by: muscle
a. The sternohyoid
Cricoid cartilage
b. The superior belly of the omohyoid
c. The sternothyroid Outline of isthmus
Oesophagus
d. The anterior border of the sternocleidomastoid of thyroid gland
(Fig. 8.4). Recurrent
laryngeal nerve
Tlne medial surface is related to:
Trachea
a. Two fubes, trachea and oesophagus
b. Two muscles, inferior constrictor and cricothyroid Fig.8.5: Deep relations of the thyroid gland
c. Two nerves, external laryngeal and recurrent
laryngeal (Fig. 8.5). c. Parathyroid glands.
The posterolateral or posterior surface is related to the d. Thoracic duct only on the left side (Fig. 8.7).
-Y
o carotid sheath and overlaps the common carotid artery The isthmus connects the lower parts of the two lobes.
zo (Fig. B.a).
It has:
!ttr The nnteriorborder isthinand is related to the anterior
a. Two surfaces: Anterior and posterior.
(E branch of superior thyroid artery (Fig. 8.7).
E b. Two borders: Superior and inferior.
(E
Theposteriorborder isthick and rounded and separates
o the medial and posterior surfaces. It is related to: The anterior surface is covered by:
a. Inferior thyroid artery. a. The right and left sternothyroid and sternohyoid
C b. Anastomosis between the posterior branch of muscles.
.o
o superior and ascending branch of inferior thyroid b. The anterior jugular veins.
ao arteries. c. Fascia and skin (Fig. B. ).
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STRUCTURES IN THE NECK
Theposterior surface is related to the second to fourth and the middle cervical sympathetic ganglion; and
tracheal rings. in front of the vertebral vessels; and gives off
The upper border is related to anterior branches of the branches to adjacent structures (Fig. 8.7).
right and left superior thyroid arteries (Fig. 8.6) which Its terminal part is intimately related to the recurrent
anastomose here. laryngeal nerve, while proximal part is away from
Lower border: Inferior thyroid veins leave the gland the nerve.
at this border (Fig. 8.8). The artery divides into 4 to 5 glandular branches
which pierce the fascia separately to reach the lower
Aileriol Supply part of the gland. One ascending branch anastomoses
The thyroid gland is supplied by the superior and with the posterior branch of the superior thyroid
inferior thyroid arteries. artery, and supplies the parathyroid glands.
1 The superior thyroid artery is the first anterior branch Sometimes (in3% of individuals), the thyroid is also
of the external carotid artery (Figs 8.6 and 8.7). It runs supplied by the lowest thyroid artery (thyroidea ima
downwards and forwards in intimate relation to the artery) which arises from the brachiocephalic trunk
external laryngeal nerve. After giving branches to or directly from the arch of the aorta. It enters the
adjacent structures, it pierces the pretracheal fascia lower part of the isthmus. Accessory thyroid arteries
to reach the upper pole of the lobe where the nerve arising from tracheal and oesophageal arteries also
deviates medially. At the upper pole the artery supply the thyroid.
divides into anterior and posterior branches.
The anterior branch descends on the anterior border Venous Droinoge
of the lobe and continues along the upper border of The thyroid is drained by the superior, middle and
the isthmus to anastomose with its fellow of the inferior thyroid veins.
opposite side. The superior thyroid aein emerges at the upper pole
The posterior branch descends on the posterior border and accompanies the superior thyroid artery. It ends
of the lobe and anastomoses with the ascending in the internal jugular vein (Fig. 8.8).
branch of inferior thyroid artery (Fig. 8.7). The middle thyroid aein is a short, wide channel which
2 The inferior thyroid artery is a branch of thyrocervical emerges at the middle of the lobe and soon enters the
trunk (which arises from the subclavian artery). internal jugular vein.
It runs first upwards, then medially, and finally The inferior tlryroid oeins emerge at the lower border
downwards to reach the lower pole of the gland. of isthmus. They form a plexus in front of the trachea,
During its course, it passes behind the carotid sheath and drain into the left brachiocephalic vein.
Thyrohyoid membrane
internal laryngeal nerve and
superior laryngeal artery Hyoid bone
Superior thyroid arising from

external carotid
Thyroid
External laryngeal nerve lnferior thyroid artery

supplying cricothyroid muscle
Thyrocervical trunk
Right vagus nerve
Left subclavian artery
Left recurrent laryngeal nerve

l(
Left vagus nerve o
Right recurrent laryngeal nerve
Trachea zo
E'
Brachiocephalic trunk Arch of aorta tr
G
t,G
Right bronchus Left bronchus
o
c
.9
o
Fig. 8.6: Afterial supply of anterior aspect of thyroid gland ao
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HEAD AND NECK
Superior thyroid artery
Site of ligation of artery
Posterior branch
Ascending branch of
inferior thyroid artery
Scalenus anterior
Anastomosing branch
lnferior thyroid artery
and its site of ligation
Outline of thyroid gland
Transverse cervical artery

lnferior laryngeal artery
Suprascapular artery
Recurrent laryngeal nerve
Subclavian artery
Fig. 8.7: Arterial supply of posterior surface of thyroid gland
Nerve Supply
Nerves are derived mainly from the middle cervical
ganglion and partly from the superior and inferior
cervical ganglia. These are vasoconstrictor.
Hyoid bone Superior thyroid
Superior laryngeal vein VEIN HISTOTO
Middle thyroid The thyroid gland is made up of the following two types
VEINS
of secretory cells.
I Follicular cells lining the follicles of the gland secrete
lnferror
thyroid vein
tri-iodothyronin and tetraiodothyronin (thyroxin)
Left internal which stimulatebasal metabolic rate and somatic and
Left jugular vein psychic growth of the individual. During active
brachiocephalic
veln
phase, the lining of the follicles is columnar, while
lst rib in resting phase, it is cuboidal. Follicles contain the
colloid in their lumina (Fig. 8.9).
Manubrium Left subclavian 2 Parafollicular cells (C cells) are fewer and light cells
sterni vetn lie in between the follicles. They secrete thyro-
Fig.8.8: Venous drainage of the thyroid gland (lateral view) calcitonin which promotes deposition of calcium
salts in skeletal ind other tissues, and tends to
Afourth thyroid oein (Kocher) may emerge between produce hypocalcaemia. These effects are oPposite
the middle and inferiorveins, anddraininto the internal to those of parathormone.
l(
o jugular vein.
zo DEVETOPMENT
t,tr
(E
Lymphotic Droinoge The thyroid develops from a medinn endodermal thyroid
tt(E Lymph from the upper part of the gland reaches the dizserticulum which grows down in front of the neck
o upper deep cervical lymph nodes either directly or from the floor of the primitive pharynx, just caudal to
through the prelaryrgeal nodes. Lymph from the lower the tuberculum impar (Figs 8.10a to d).
C
o part of the gland drains to the lower deep cervical nodes The lower end of the diverticulum enlarges to form
() directly, and also through the pretracheal and the gland. The rest of the diverticulum remains narrow
ao paratracheal nodes. and is known as the thyroglossal duct.Most of the duct
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tissue may develop at abnormal sites along the course

of the duct resulting in lingual or retrosternal thyroids.
Accessory thyroids may be present.
Any swelling of the thyroid gland (goitre) should

be palpated from behind (Fig. 8.11).
Removal of the thyroid (thyroidectomy) with true
capsule may be necessary in hyperthyroidism.
In subtotal thyroidectomy, the posterior parts of
both lobes are left behind. This avoids the risk of
simultaneous removal of the parathyroids and
also of postoperative myxoedema (caused by
deficiency of thyroid hormones).
. Thyroid follicles lined by cuboidal to
columnar cells containing colloid During thyroidectomy, the superior thyroid artery
. Scanty connective tissue with is ligated near the gland to save the external
capillaries laryngeal nerve; and the inferior thyroid artery is
. 'C'cells in connective tissue orwithin ligated away from the gland to save the recurrent
the follicles
laryngeal nerve (Fig. 8.7).
Fig. 8.9: Histology of thyroid gland Hypothyroidism causes cretinism in infants and
myxoedema in adults.
Benign tumours of the gland may displace and
Tuberculum
even compress neighbouring structures, like the
First arch
rmpar carotid sheath, the trachea, etc. Malignant growths
Lingual tend to invade and erode neighbouring structures.
Foramen
swelling
caecum Pressure symptoms and nerire involvements are
Second
arch
Hypobranchial common in carcinoma of the glands.
emtnence
Third arch
Fourth arch
Tracheal
Fifth arch has groove
disappeared
Sixth arch
Lateral
thyroid
from 4th
pouch
Thyroid developing
yroglopsal
from thyroglossal duct
ct
(c) (d)
Fig.8.11: Palpation of thyroid gland from behind x()
Figs 8.10a to d: Development of thyroid gland
zo
t,c
soon disappears. The position of the upper end is PARATHYROID GTANDS (E
marked by the foramen caecutn of the tongue, and the Parathyroid glands are two pairs (superior and inferior) !,(E
lower end oftenpersists asthepyramidallobe. The gland of small endocrine glands, that usually lie on the o
becomes functional during third month of deve- posterior border of the thyroid gland, within the false
lopment. capsule (Fig. 8.12a). The superior paratlryroids are also c
o
Remnants of the thyroglossal duct may form referred to asparathyroidlVbecause they develop from o
o
thyroglossal cysts, or a thyroglossal fistula. Thyroid the endoderm of the fourth pharyngeal pouch. The inferior a
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HEAD AND NECK
Lobe of
ihyroid gland
Superior thyroid artery
Capsule
Suspensory
ligament
of Berry Superior parathyroid
Posterior branch
of superior thyroid
Ascending
branch of Ascending branch lnferior parathyroid
inferior thyroid of inferior thyroid
artery
(a) (b)
Figs8.12a and b: Schemes to show the location of the parathyroid glands: (a) Transverse section through the left lobe of the
thyroid gland, and (b) posterior view of the left lobe of the thyroid gland
parathyroids, similarly, are also called parathyroid III Nerve Supply

because they develop from the third pouch (Fig.8.72). Vasomotor nerves are derived from the middle and
The parathyroids secrete the hormone parathormone superior cervical ganglia. Parathyroid activity is
which controls the metabolism of calcium and controlled by blood calcium levels; low levels stimulate
phosphorus along with thyrocalcitonin. and high levels inhibit the activity of the glands.
Each parathyroid gland is oval or lentiform in shape,
measuring 6 x 4 x 2 mm (the size of a split pea). Each
gland weighs about 50 mg. Tumours of the parathyroid glands lead to
excessive secretion of parathormone (hyper-
Posilion parathyroidism). This leads to increased removal
The anastomosis between the superior and inferior of calcium from bone making them weak and
thyroid arteries is usually a good guide to the glands liable to fracture. Calcium levels in blood increase
because they usually lie close to it (Fig. 8.72b). (hypercalcaemia) and increased urinary excretion
The superior parathyroid is more constant in position of calcium can lead to the formation of stones in
the urinary tract.
and usually lies at the middle of the posterior border
of the lobe of the thyroid gland. It is usually dorsal to Hlpoparathyroidism may occur spontaneously or
the recurrent laryngeal nerve.
from accidental removal of the glands during
thyroidectomy. This results in hypocalcaemia
Tlae inferior parathyroid is more variable in position. leading to increased neuromuscular irritability
It may lie: causing muscular spasm and convulsions (tetany)
a. Within the thyroid capsule, below the inferior (Fis. 8.13).
thyroid artery and near the lower pole of the Parathyroid glands are tough glands and will
thyroid lobe (Fig. 8.12a). continue to function if these are transplanted from
b. Behind an{ outside the thyroid capsule, an excised thyroid gland into the sternocleido-
immediately above the inferior thyroid artery. mastoid muscle.
l(
c. Within the substance of the lobe near its posterior
o border. It is usually ventral to the recurrent
zo laryngeal nerve.
!ttr
G
t(E Vosculor Supply
o The parathyroid glands receive a rich blood supply
from the inferior thyroid artery and from the
c anastomosis between the superior and inferior thyroid
.o
o arteries. The veins and lymphatics of the gland are Fig.8.13: Spasm in the hand due to tetany
ao associated with those of the thyroid and the thymus.
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immune response only when exposed to a particular

The thymus (Greek thyme leafl is an important antigen. Thymic lymphopoiesis, lympholysis and
lymphoid organ, situated in the anterior and superior involution are all intrinsically controlled.
mediastina of the thorax, extending above into the The medullary epithelial cells of the thymus are
lower part of the neck. It is well developed at birth, thought to secrete:
continues to grow up to puberty, and thereafter, a. Lymphopoietin, which stimulates lymphocyte
undergoes gradual atrophy and replacement by fat. production both in the cortex of the thymus and
The thymus is a bilobed structure, made up of two in peripheral lymphoid organs.
pyramidal lobes of unequal size which are connected b. The competence-inducing factor, which may be
together by areolar tissue (Fig. 8.a). responsible for making new lymphocytes
Each lobe deaelops from the endoderm of the third competent to react to antigenic stimuli.
pharyngeal pouch.It lies on the pericardium, the great Normally there are no germinal centres in the thymic
vessels of the superior mediastinum, and the trachea. cortex. Such centres appear in autoimmune diseases.
The thymus weighs 10-15 g at birth, 30-40 g at This may indicate a defect in the normal function of
puberty, and only 10 g after mid-adult life. Thus after the thymus.
puberty, it becomes inconspicuous due to replacement
by fat.
Involution of the thymus is enhanced by hyper-
Blood Supply trophy of the adrenal cortex, injection of cortisone
The thlrmus is supplied by branches from the internal or of androgenic hormone. The involution is
thoracic and inferior thyroid arteries. Its veins drain delayed by castration and adrenalectomy.
into the left brachiocephalic, internal thoracic and Thymic hyperplasia or tumours are often
inferior thyroid veins. associated with myasthenia gravis, characterized
by excessive fatiguability of voluntary muscles.
Nerve Supply The precise role of the thymus in this disease is
Vasomotor nerves are derived from the stellate uncertain; it may influence, directly or indirectly,
ganglion. The capsule is supplied by the phrenic nerve the transmission at the neuromuscular junction.
and by the descendens cervicalis. Figure 8.14 shows drooping of eyelids.
Thymic tumours may press on the trachea,
Functions
oesophagus and the large veins of the neck, causing
1 The thymus controls lymphopoiesis, and maintains hoarseness, cough, dysphagia and cyanosis.
an effective pool of circulating lymphocytes,
competent to react to innumerable antigenic stimuli.
2 It controls development of the peripheral lymphoid
tissues of the body during the neonatal period. By
puberty, the main lymphoid tissues are fully
developed.
3 The cortical lymphocytes of the thymus arise from
stem cells of bone marrow origin. Most (95%) of the
lymphocytes (T lymphocytes) produced are
autoallergic (act against the host or 'self' antigens),
short-lived (3-5 days) and never move out of the
organ. They are destroyed within the thymus by
phagocytes. Their remnants are seen as Hassall's !
corpuscles. o
zo
The remaining 5% of the T lymphocytes are long- !,
C
lived (3 months or more), and move out of the (E
a thymus to join the circulating pool of lymphocytes t,(E

where they act as immunologically competent but o
I
uncommitted cells, i.e. they can react to any un-
i Fig. 8.14: Myasthenia gravis c
familiar, new antigen. On the other hand, the other o
E
circulating lymphocytes (from lymph nodes, spleen, o
o
l
etc.) are committed cells, i.e. they can mount an o
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I
HEAD AND NECK
Scalenus anterior
DISSECTION
First rib
ldentify scalenus anterior muscle in the anteroinferior
part of the neck. Subclavian aftery gets divided into Right and left
three parts by this muscle. ldentify vertebral, internal common carotid
thoracic artery and the thyrocervical trunk with its
branches arising from the first part of the artery, Left subclavian
costocervical arising from second part and either dorsal
scapular or none from the third part.
Arch of aorta
Right
subclavian
SUBC IAN ARTERY artery
This is the principal artery which continues as axillary
artery for the upper limb. It also supplies a considerable Brachiocephalic
part of the neck and brain through its branches (Fig. 8.15). Fig. 8.16: Origin and course of the subclavian arteries
Oilgin
Relotions of lhe First Pod
On the right side, it is branch of the brachiocephalic
.Amferdor
artery. It arises posterior to the sternoclavicular joint.
On the left side, it is a branch of the arch of the aorta. It Immediate relations from medial to lateral side are:
ascends and enters the neck posterior to the left 1 Common carotid artery
sternoclavicular joint. Both arteries pursue a similar 2 Vagus
course in the neck (Fig. 8.16). 3 Internal jugular vein
4 The sternothyroid and the sternohyoid muscles
Coulse 5 Sternocleidomastoid.
1 Each artery arches laterally from the sternoclavicular
joint to the outer border of the first rib where it Posferior (postero n fer ior)
i
ends by becoming continuous with the axillary artery 1, Suprapleural membrane

(Fig. 8.15). 2 Cervical pleura
2 The scalenus anterior muscle crosses the artery 3 Apex of lung (Fig. 8.17).
anteriorly and divides it into three parts. The first
part is medial, the second part posterior, and the Relotions of lhe Second Porl
third part lateral to scalenus anterior. Anterior
1 Scalenus anterior
2 Right phrenic nerve deep to the prevertebral fascia
3 Sternocleidomastoid.
Fosferior (pos f e rc nfer or)

i i
1 Suprapleural membrane
2 Cervical pleura
3 Apex of lung.
Subclavian
!(J artery
zo
Internal
carotid
Lowertrunkof=C LAn.. subclavia
t,c
G Suprapleural
Hyoid bone membrane
t(E
o Thyroid cartilage Cervical pleura
Apical part
C of lung
o Subclavian
o Fig. 8.17: Schematic transverse section through the lower part
o
a Fig.8.15: Course of subclavian and carotid arteries of neck to show the relations of the left subclavian artery
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Costocervical trunk
Deep cervical artery
Vertebral
Transverse process of C7
Superior intercostal
Thyrocervical trunk Neck of first rib
Subclavian First posterior intercostal
Second rib
Cervical pleura
Second posterior intercostal
lnternal thoracic
Apex of lung
Fig.8.'18: Branches of the subclavian adery. Note that the branches actually arise at different levels, but are shown at one level
schematically
Superiar
Upper and middle trunks of the brachial plexus.
Relolions of the lhird Poil

Antarior
1 Middle one-third of the clavicle Phrenic nerve
Scalenus anterior
2 The posterior border of the sternocleidomastoid.
Vertebral
Posterior (posf e ro nf e ri o r)
i lnferior thyroid
1 Scalenus medius Longus colli
2 Lower trunk of brachial plexus Thyrocervical trunk
3 Suprapleural membrane
4 Cervical pleura Right common carotid
5 Apex of lung. Subclavian artery
Suprascapular
Superior Brachiocephalic
lnternal thoracic
Upper and middle trunks of brachial plexus.
Fig.8.19: Branches of the right subclavian artery
lnferior
First rib (Fig. 8.18). Vertebrul Artery
Vertebral artery is the first and largest branch of the
Bronches first part of the subclavian artery. It runs a long course
The subclavian artery gives off four branches. These and ends in the cranial cavity by supplying the brain.
are: It is divided into four parts. The first part extends
from its origin to the foramen transversarium of the
1 Vertebral artery (Fig. 8.18). sixth cervical vertebra (see Fig. 9.2). This part runs
2 Internal thoracic artery. upwards and backwards into the angle between the .Y
3 Thyrocervical trunk, which divides into three o
branches:
scalenus anterior and the longus colli muscles, behind
the common carotid artery, the vertebral vein and the
zo
!ttr
a. Inferior thyroid (Fig. 8.19). inferior thyroid artery (Fig. 8.19). Details of all the four G
b. Suprascapular. parts are described in the section on the prevertebral E
G
c. Transverse cervical arteries. region (see Chapter 9). o
4 Costocervical trunk, which divides into two branches:
a. Superior intercostal. lnlernsl Thorocic Artery E
.9
b. Deep cervical arteries. Internal thoracic artery arises from the inferior aspect o
5 Dorsal scapular artery-occasionally. of the first part of the subclavian artery opposite the ao
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HEAD AND NECK
origin of the thyrocervical trunk. The origin lies near The deep branch passes deep to levator scapulae and
the medial border of the scalenus anterior (Fig. 8.19). takes part in the anastomoses around the scapula (see
The artery runs downwards and medially in front of Chapter 6, Volume 1).
the cervical pleura. Anteriorly, the artery is related to Sometimes the two branches may arise separately;
the sternal end of the clavicle. The artery enters the the superficial from thyrocervical trunk and the deep
thorax by passing behind the first costal cartilage. It from the third part of subclavian artery. Then these are
runs till 6th intercostal space where it ends by dividing named as superficial cervical and dorsal scapular
into superior epigastric and musculophrenic arteries. arteries.
For course of the artery in the thorax see Chapter 1,4,
Volume 1. Oorssf Sc ulsl Artery
This artery arises occasionally from the third part of
subclavian artery. If transverse cervical does not divide
Thyrocervical trunk is a short, wide vessel which into superficial and deep branches but continues as
arises from the front of the first part of the subclavian superficial branch, the distribution of deep branch is
artery, close to the medial border of the scalenus taken over by dorsal scapular artery.
anterior, and between the phrenic and vagus nerves. It
almost immediately divides into the inferior thyroid,
suprascapular and transverse cervical arteries (Figs 8.18 Costocervical trunk arises from the posterior surface
and 8.19). of the second part of the subclavian artery on the right
The inferior thyroid artery is described with the thyroid side; but from the first part of the artery on the left side.
gland. In addition to glandular branches to the thyroid, It arches backwards over the cervical pleura, and
it gives: divides into the descending superior intercostal and
a. The ascending cervical artery which runs upwards ascending deep cervical arteries at the neck of the first
in front of the transverse processes of cervical rib (Fig. 8.18).
vertebrae. The superior intercostal artery descends in front of the
b. The inferior laryngeal artery which accompanies neck of the first rib, and divides into the first and second
the recurrent laryngeal nerve, and enters the posterior intercostal arteries.
larynx deep to the lower border of the inferior The deep ceruical artery is analogous to the posterior
constrictor (Fig. 8.7). branch of a posterior intercostal artery. It passes
c. Other branches which supply the pharynx, the backwards between the transverse process of the 7th
trachea, the oesophagus and surrounding muscles. cervical vertebra and the neck of the first rib. It then
The suprascapular artery runs laterally and down- ascends between the semispinalis capitis and cervicis
wards, and crosses the scalenus anterior and the phrenic up to the axis vertebra. It anastomoses with the occipital
nerve. and vertebral arteries.
It lies behind the internal jugular vein and the
sternocleidomastoid. It then crosses the trunks of the
brachial plexus and runs in the posterior triangle, The third part of the subclavian artery can be
behind and parallel with the clavicle, to reach the effectively compressed against the first rib after
superior border of the scapula. depressing the shoulder. The pressure is applied
It crosses above the suprascapular ligament and takes downwards, backwards, and medially in the angle
part in the anastomoses around the scapula (see Chapter between the sternocleidomastoid and the clavicie.
6, Volume 1). In addition to branches to surrounding
A cervical rib may compress the subclavian artery,
muscles, the artery also supplies the clavicle, scapula,
diminishing the radial pulse (Fig. 8.20).
shoulder and acromioclavicular joints.
.Y The transuerse ceruical artery runs laterally above the The right subclavian artery may arise from the
o descending thoracic aorta. In that case, it passes
o suprascapular artery (see Fig. 3.9).
z It crosses the scalenus anterior and the phrenic nerve posterior to the oesophagus which may be
!tc
(5 passing behind the internal jugular vein and the compressed and the condition is known as
!,(E sternocleidomastoid (Fig. 8.19). (dysphagia lusoria).
o It then crosses the brachial plexus and the floor of An aneurysm may form in the third part of the
the posterior triangle to reach the anterior border of subclavian artery. Its pressure on the brachial
o lrapezis, where it divides into a superficial and deep plexus causes pain, weakness/ and numbness in
'F
o branches. The superficial branch accompanies the spinal the upper limb.
ao root of accessory nerve till the lower end of the muscle.
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o Obstruction to the subclavian artery proximal to

the origin of vertebral artery may lead to "stealing
of blood from the brain through the opposite DISSECIION
vertebral artery. This may provide necessary The common carotid artery has been exposed in the
blood to the affected side. The nervous sl.rnptoms carotid triangle. Clean it in its entire course. ldentify
incurred are called "subclavian steal slmdrome" the internal carotid anery and trace it till it leaves the
(Fig. 8.21).
neck.
Veins
ldentify the tributaries of subclavian, internaljugular and
brachiocephalic veins.
Feolures
The origin and course of the common carotid arteries
has been described in Chapter 4. The relations of the
artery in the neck are given:
Muscles of neck The comrnon carotid artery is enclosed in the carotid
sheath. The three contents of the sheath are:
Brachial plexus a. The common carotid artery, medially
Cervical rib b. The internal jugular vein, laterally
pressing on the c. The vagus in between the artery and the vein,
subclavian posteriorly (see Fig. 3.8).
artery
Narrowed axillary
artery Relotions
Anterior ffiedsffons
1 The common carotid artery is crossed by the superior
Fig. 8.20: The cervical rib pressing on the subclavian artery belly of the omohyoid at the level of cricoid cartilage
narrowing the axillary artery and diminishing the radial pulse (see Fig. 4.74).
2 Below the omohyoid, the artery is deeply situated,
and is covered by:
a. The sternocleidomastoid
b. The anterior jugular vein
Basilar artery
c. The sternohyoid
d. The sternothyroid and the middle thyroid vein.
Fosferior Relsfioms
Vertebral artery 1 Transverse process of vertebrae C4-8, and the
muscles attached to their anterior tubercles (longus
colli, longus capitis, scalenus anterior)
2 The inferior thyroid artery crosses medially at the
level of the cricoid cartilage
3 Vertebral artery (Fig.8.22)
Blocked 4 On the left side the thoracic duct crosses laterally
subclavian artery behind the artery at the level of vertebra C7, inhont ta
of the vertebral vessels. o
zo
dictr Re,fofioms !t
(E
1 Thyroid gland tt(5
2 Larynx and pharynx; trachea, oesophagus and o
J-
recurrent laryngeal nerve (Fig. 8.5).
c
o
Subclavian steal syndrome {.mferoJffiefs#om o
o
Internal jugular vein. a
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HEAD AND NECK
Prevertebral fascia
3 Its initial part usually shows a dilatation, the carotid
sinus which acts as a baroreceptor (see Fig. a.1.\.
4 The lower part of the artery (in the carotid triangle)
Longus colli is comparatively superficial. The upper part, above
Sympathetic kunk the posterior belly of the digastric, is deep to the
parotid gland, the styloid apparatus, and many other
Common carotid artery
structures.
Relofions
Middle cervical ganglion Anterior or superficial
Vertebral artery 1 In the carotid triangle:
Transvere process of C7 a. Anterior border of sternocleidomastoid
lnferior cervical ganglion b. The external carotid artery is anteromedial to it.
Thoracic duct
2 Above the carotid triangle (Fig. 8.23):
Ansa subclavia
a. Posterior belly of the digastric
Fig.8.22:. Schematic sagittal section showing posterior relations b. Stylohyoid
of the common carotid artery c. Stylopharyngeus
d. Styloid process
Posterolqle Relofion e. Parotid gland with structures within it.
Vagus nerve (Fig. 8.a). Posterior
L Superior cervical ganglion
2 Carotid sheath
The pulsation of common carotid artery can be felt 3 The glossopharyngeal, vagus, accessory and
by compressing against the carotid tubercle, i.e, the hypoglossal nerves at the base of the skull.
anterior tubercle of the transverse process of vertebra
C6 which lies at the level of the cricoid cartilage. Medial
1 Pharynx
INIERNAI CAROIID ARTERY
2 The external carotid is anteromedial to it below the
parotid.
The internal carotid artery is one of the two terminal
branches of the common carotid artery. It begins at the Lateral
level of the upper border of the thyroid cartilage L Internal jugular vein
opposite the disc between the third and fourth cervical 2 Temporomandibular joint (at the base of the skull).
vertebrae, and ends inside the cranial cavity by
supplying the brain. This is the principal artery of the Pelrous Poil
brain and the eye. It also supplies the related bones and 1 In the carotid canal, the artery first runs upwards,
merunges. and then turns forwards and medially at right angles.
For convenience of description, the course of the It emerges at the apex of the petrous temporal bone,
artery is divided into four parts: in the posterior wall of the foramen lacerum where
a. Cervical part, in the neck it turns upwards and medially.
b. Petrous part,'within the petrous temporal bone 2 Relations: The artery is surrounded by venous and
(see Fig. 12.15) sympathetic plexuses. It is related to the middle ear
! c. Cavernous part, within the cavernous sinus and the cochlea (posterosuperiorly); the auditory
o d. Cerebral part in relation to base of the brain. tube and tensor tympani (anterolaterally); and the
zo trigeminal ganglion (superiorty) (see Fig. L2.1.3).
!ttr Cervicol Pod
G
3 Branches:
tG 1 It ascends vertically in the neck from its origin to the a. Caroticotympanic branches enter the middle ear,
o base of the skull to reach the lower end of the carotid and anastomose with the anterior and posterior
canal. This part is enclosed in the carotid sheath (with tympanic arteries (see Fig. 12.1.5).
c the internal jugular vein and the vagus). b. The pterygoidbranch (small and inconstant) enters
o
o
o
2 No branches arise from the internal carotid artery in the pterygoid canal with the nerve of that canal
a the neck. and anastomoses with the greater palatine artery.
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lnternal carotid Glossopharyngeal nerve

Auditory tube Vagus nerve
Tensor veli palatini Hypoglossal nerve
Parotid gland Accessory nerve
Styloid process Superior cervical sympathetic gangllon
Stylopharyngeus Prevertebral fascia
Pharyngeal branch of vagus Longus capitis
External carotid Superior laryngeal nerve

Stylohyoid
Occipital artery
Sternocleidomastoid
Hypoglossal nerve
Common facial vein
Lingual vein Descendens hypoglossi
Fig. 8.23: Schematic sagittal section showing the anterior and posterior relations of the internal carotid artery
Covernous ond Cerebrol Porls of Internol beneath the floor of the middle ear cavity. The
Corotid Arlery termination of the vein is marked by the inferior bulb
Cavernous part runs in the cavernous sinus (see Fig. which lies beneath the lesser supraclavicular fossa.
72.15). Cerebral part lies at base of skull and gives
ophthalmic, anterior cerebral, middle cerebral and Relations
anterior choroidal arteries (see Chapter 31). Superficial
1 Sternocleidomastoid
SUBC IAN VEIN 2 Posterior belly of digastric
Coulse 3 Superior belly of omohyoid
It is a continuation of the axillary vein. It begins at the 4 Parotid gland
outer border of the first rib, and ends at the medial 5 Styloid process
border of the scalenus anterior by joining the internal 6 The internal carotid artety, and the glossopharyn-
jugular vein to form the brachiocephalic vein. geal, vagus, accessory and hypoglossal cranial nerves
It lies: (at the base of skull).
a. In front of the subclavian aftety, the scalenus Posteilor
anterior and the right phrenic nerve 1 Transverse process of atlas
b. Behind the clavicle and the subclavius 2 Cervical plexus
c. Above the first rib and pleura. 3 Scalenus anterior
Its tributaries are: 4 First part of subclavian artery.
a. The external jugular vein (Fig. 8.24)
b. The dorsal scapular vein dial
c. The thoracic duct on the left side 1 Internal carotid artery
d. The right lymphatic duct on the right side. 2 Common carotid artery
ta
3 Vagus nerve. o
INTERNAT JUGULAR VEIN zo
utailes !tc
Coulse (E
1 It is a direct continuation of the sigmoid sinus. It 1 Inferior petrosal sinus E'

begins at the jugular foramen, and ends behind the 2 Common facial vein
(6
o
sternal end of the clavicle by joining the subclavian 3 Lingual vein
vein to form the brachiocephalic vein. 4 Pharyngeal veins c
o
2 The origin is marked by a dilation, the superior bulb 5 Superior thyroid vein o
o
which lies in the jugular"fossa of the temporal bone, 6 Middle thyroid vein (Fig. 8.24). @
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HEAD AND NECK
lnferior petrosal sinus

Superior bulb of
internaljugular vein lnternal jugular vein
Occipital Common facial
Lingual
Pharyngeal
Superior thyroid
Middle thyroid
Right lymphatic duct Thoracic duct
External jugular
lnferior bulb of internal jugular vein
Dorsal scapular
Vertebral
Right subclavian
lnternal thoracic
Right brachiocephalic First, second and

third posterior intercostal veins
Superior vena cava
Left superior intercostal vein
lnferior thyroid
Left brachiocephalic
Fig.8.24': The veins of the neck
The thoracic duct opens into the angle of union two brachiocephalic veins unite at the lower border
between the left internal jugular vein and the left of the right first costal cartilage to form the superior
subclavian vein. The right lymphatic duct opens vena cava.
similarly on the right side. 4 The tributaries correspond to the branches of the first
In the middle of the neck, the internal jugular vein part of the subclavian artery. These are as follows:
may communicate with the external jugular vein
through the oblique jugular vein which runs across the Right Brochiocepholic
anterior border of the sternocleidomastoid. a. Vertebral
b. Internal thoracic
c. Inferior thyroid
. Deep to the lesser supraclavicular fossa, the d. First posterior intercostal.
internal jugular vein is easily accessible for
recording of venous pulse tracings. The vein can Lefl Brochiocepholic
be cannulated by direct puncture in the interval
a. Vertebral (Fig. 8.2a)
between sternal and clavicular heads of b. Internal thoracic
sternocleidomastoid muscle.
o In congestive cardiac failure or any other disease c. Inferior thyroid
where venous pressure is raised, the internal d. First posterior intercostal.
jugular vein is markedly dilated and engorged. e. Left superior intercostal.
l<
f. Thymic and pericardial veins.
o BRACHIOCEPHATIC VEIN
zo 1 The rightbrachiocephalic vein (2.5 cm long) is shorter
E
c(E than the left (6 cm long) (Fig. B.2a).
t,(E 2 Each vein is formed behind the sternoclavicular joint, DISSECIION
o by the union of the internal jugular vein and the The course of lX-Xll cranial nerves has been seen
subclavian vein. in different chapters. Now trace these nerves and
tr
o 3 The right vein runs vertically downwards. The left their branches. Read their course and branches in
O vein runs obliquely downwards and to the right Chapter 24.
ao behind the upper half of the manubrium sterni. The
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Sympathetic Trunk Poslerior

The sympathetic trunk has been identified as lying a. Prevertebral fascia
posteromedial to the carotid sheath. Trace it upwards b. Longus capitis and cervicis muscles
and downwards and locate the three cervical ganglia. c. Transverse processes of the lower six cervical
Dissect the formation and branches of the cervical vertebrae.
plexus. ldentify the phrenic nerve on the surface of
scalenus anterior muscle behind the prevertebralfascia. GANGLIA
Theoretically there should be eight sympathetic ganglia
Feotules corresponding to the eight cervical nerves, but due to
fusion there are only three ganglia, superior, middle
The cervical parts of the right and left sympathetic
and inferior.
trunks are situated one on each side of the cervical part
of the vertebral column, behind the carotid sheath Supeilor Cervicol Gonglion
(common carotid and internal carotid arteries) and in
front of the prevertebral fascia. "Srze sndsft G
This is the largest of the three ganglia. It is spindle-
shaped, and about 2.5 cm long (Fig. 8.25).
FORMATION
There ommunic ans (i. e. incoming root)
ar e no uthit e r ami c $r uoffon #nd fofrn#f,sn
f
in the neck and this part of the trunk is formed by fibres It lies just below the skull, opposite the second and third
which emerge from segments T1 to T4 of the spinal cervical vertebrae, behind the carotid sheath and in
cord, and then ascend into the neck (Fig. 8.25). Grey front of the prevertebral fascia (longus capitis). It is
rami communicans (i.e. outgoing roots) are present. formed by fusion of the upper 4 cervical ganglia.
Communications. Wilh cranial nerves IX, X and XII,
RETATIONS and with the external and recurrent laryngeal nerves.
Anteilor # #f?es
a. Intemal carotid artery L Grey rami communicans pass to the ventral rami of
b. Common carotid artery upper four cervical nerves (Fig. 8.25).
c. Carotid sheath (Fig. 8.a) 2 The internal carotid nerve arises from the upper end
d. Inferior thyroid artery. of the ganglion and forms a plexus around the
External carotid
Pharynx and pharyngeal
lnternal carotid branch
Superior cervical ganglion

Grey rami communicans
to cervical ventral rami
Thyroid gland
Superior cardiac branch

Trachea
Oesophagus
Superficial cardiac plexus

.Y
Middle cervical ganglion o
zo
Vertebral artery tc
(E
Subclavian artery lnferior cervical ganglion tt(E

(stellate ganglion) o
Ansa subclavia I
Middle and inferior

c
Deep cardiac plexus .9
cardiac branches o
Fig. 8.25: The cervical sympathetic trunks and their branches ao
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HEAD AND NECK
internal carotid artery. A part of this plexus supplies Eranches

the dilator pupillae (see Chapter 19). Some of ther" L Grey rami communicans are given to the ventral rami
fibres form the deep petrosal nerve for pterygo- of nerves C7 and C8.
palatine ganglion; others give fibres along long 2 Vertebral branches form a plexus around the
ciliary nerve for the ciliary ganglion. vertebral artery.
The external carotid branches form a plexus around 3 Subclavian branches form a plexus around the
the external carotid artery. Some of these fibres form subclavian artery. This plexus is joined by branches
the sympathetic roots of the otic and submandibular from the ansa subclavia (Fig. 8.25).
ganglia (see Table 1.3). 4 An inferior cervical cardiac branch goes to the deep
Pharyngeal branches take part in the formation of cardiac plexus.
the pharyngeal plexus.
5 The left superior cervical cardiac branch goes to the
superficial cardiac plexus while the rightbranch goes The head and neck are supplied by sympathetic
to the deep cardiac plexus. nerves arising from the upper four thoracic
Middle Cervicol Gonglion segments of the spinal cord. Most of these
preganglionic fibres pass through the stellate
"Siae ond
$fi e ganglion to relay in the superior cervical ganglion.
This ganglion is very small. It may be divided into Injury to cervical sympathetic trunk produces
2 to 3 smaller parts, or may be absent. Horner's syndrome. It is characterizedby:
a. Ptosis-drooping of the upper eyelid.
Sifucfron
b. Miosis<onstriction of the pupil (Fig. 8.26).
It lies in the lower part of the neck, in front of vertebra c. Anhydrosis-loss of sweating on that side of
C6 just above the inferior thyroid artery, behind the the face.
carotid sheath (Fig. 8.7)).
d. Enophthalmos-retraction of the eyeball.
Formation e. Loss of the ciliospinal reflex-pinching the skin
It is formed by fusion of the fifth and sixth cervical on the nape of the neck does not produce
ganglia connections. It is connected with the inferior
dilatation of the pupil (which normally takes
place).
cervical ganglion directly, and also through a loop that
winds round the subclavian artery. This loop is called Horner's syndrome can also be caused by a lesion
the ansa subclavia. within the central nervous system anywhere at or
above the first thoracic segment of the spinal cord
Ersnches involving sympathetic fibres.
1 Grey rami communicans are given to the ventral rami
of the 5th and 6th cervical nerves.
2 Thyroid branches accompany the inferior thyroid
artery to the thyroid gland. They also supply the
parathyroid glands (Fig. 8.25).
3 Tracheal and oesophageal branches.
4 The middle cervical cardiac branch is the largest of
the sympathetic cardiac branches. It goes to the deep
cardiac plexus..
Inferior Cervicol Gonglion Fig. 8.26: Horner's syndrome on left side
! Sree $hope #fid Formaliorl

o
It is formed by fusion of 7th and 8th cervical ganglia.
zo This is often fused with the first thoracic ganglion and
t,c
G is then known as the ceroicothoracic ganglion or stellate
t(E ganglion because it is star-shaped. DISSECTION
o It is situated between the transverse process of ldentify the lymph nodes in the submental, the
vertebra C7 and the neck of the first rib. It lies behind submandibular, the parotid, the mastoid and the occipital
c
o the vertebral artery, and in front of ramus of spinal regions including the deep cervical nodes. Dissect the
o nerve C8. A ceraicothoracic ganglion extends in front of main lymph trunk present at the root of the neck.
o
a the neck of the first rib.
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Feotures efferents pass to the supraclavicular members of the

Lymph nodes in head and neck are as follows: posteroinferior group of deep cervical nodes.
a. Superficial group
b. Deep group Anlerior Superficiol Cervicol Nodes
c. Deepest group The anterior cervical nodes lie along the anterior jugular
vein and are unimportant. The suprasternal lymph
SUPERFICIAT GROUP node is a member of this group. They drain the skin of
the anterior part of the neck below the hyoid bone. Their
Buccol ond Mondibulor Nodes efferents pass to the deep cervical nodes of both sides
The buccal node lies on the buccinator, and the (Fig.8.27).
mandibular node at the lower border of the mandible
near the anteroinferior angle of the masseter, in close lolerol Superficiol Cervicol Nodes
relation to the mandibular branch of the facial nerve. The superficial cervical nodes lie along the external
They drain part of the cheek and the lower eyelid. Their jugular vein superficial to the sternocleidomastoid.
efferents pass to the anterosuperior group of deep They drain the lobule of the auricle, the floor of the
cervical nodes (Fig. 8.27). external acoustic meafus, and the skin over the lower
parotid region and the angle of the jaw. Their efferents
Preouriculor Nodes pass round both borders of the muscle to reach the
Drain parotid gland, temporal region, middle ear, etc. upper and lower deep cervical nodes.
Poslouriculor (Mosloid) Nodes DEEP GROUP

The postauricular nodes lie on the mastoid process It comprises five levels (Fig. 8.28).
superficial to the sternocleidomastoid and deep to the
auricularis posterior. They drain a strip of scalp just Submenfol ond Submondibulor Nodes
above and behind the auricle, the upper half of the Submental nodes lie deep to the chin. These drain the
medial surface and margin of the auricle, and the lymph from tip of tongue and anterior part of floor of
posterior wall of the external acoustic meatus. Their mouth. The submandibular nodes drain lateral surface
efferents pass to the posterosuperior group of deep of tongue, lower gums and teeth and central area of
cervical nodes (Fig. 8.a). forehead.
Occipitol Nodes Upper lolerol Group oround lniernol Jugulor Vein

The occipital nodes lie at the apex of the posterior The jugulodigastric node (Fig. B.2B) is a member of this
triangle superficial to the attachment of the lrapezius. group. It lies below the posterior belly of the digastric,
They drain the occipital region of the scalp. Their between the angle of the mandible and the anterior
Postauricular lymph nodes
Occipital lymph nodes Preauricular lymph nodes

with greater occipital nerve
Buccal and mandibular

lymph nodes
ta
o
Spinal accessory
nerve zo
Anterior superficial cervical group t,
Lateral superficial o
cervical group tt(E
o
External jugular vein I
c
.o
()
o
Fig.8.27: Superficial lymph nodes of the neck U)
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I
HEAD AND NECK
Facial vein
Digastric muscle
Upper lateral group

fi ugulodigastric lymph node)
Middle lateral group

(internaljugular vein with deep
cervical lymph nodes)
Pretracheal and Lymph nodes in posterior triangle

prelaryngeal nodes
Lower lateral group

Paratracheal nodes (jugulo-omohyoid node)
Omohyoid muscle
Supraclavicular nodes
Fig.8.28: Deep and deepest groups of lymph nodes in the neck
border of the sternocleidomastoid, in the triangle cricothyroid membrane, and the pretracheal in front of
bounded by the posterior belly of the digastric, the facial the trachea below the isthmus of the thyroid gland.
vein and the internal jugular vein. It is the main node They drain the larynx, the trachea and the isthmus of
draining the tonsil. the thyroid. They also receive afferents from the anterior
cervical nodes. Their efferents pass to the nearby deep
Middle Loterol Group olound Inlemol cervical nodes.
Jugulor in
These drain thyroid and parathyroid glands. They Polotlocheol Nodes
receive efferents from prelaryngeal, pretracheal and The paratracheal nodes lie on the sides of the trachea
paratracheal lymph nodes. and oesophagus along the recurrent laryngeal nerves.
They receive lymph from the oesophagus, the trachea
Lower Lolerol Nodes olound lnternolJugulor in and the larynx, and pass it on to the deep cervical nodes.
The j ugulo- omolry oid no de is a this group. It lies j ust above
the intermediate tendon of the omohyoid, under cover Retrophoryngeol Nodes
of the posterior border of the sternocleidomastoid. It is The retropharyngeal nodes (Fig. 8.a) he in front of the
the main lymph node of the tongue. prevertebral fascia and behind the buccopharyngeal
fascia covering the posterior wall of the pharynx. They
Lymph Nodes in Poslerior Tilongle extend laterally in front of the lateral mass of the atlas
Efferents of the deep cervical lymph nodes join together and along the lateral border of the longus capitis. They
to form the jugulnr lymph trunks, one on each side. The drain the pharynx, the auditory tube, the soft palate,
.!(
o left jugular trunk opens into the thoracic duct. The right the posterior part of the hard palate, and the nose. Their
zo trunk may open either into the right lymphatic duct, efferents pass to the upper lateral group of deep cervical
E
tr or directly into the angle of junction between the nodes (Fig. 8.28).
(E
internal jugular and subclavian veins. Waldeyer's ring comprises lingual, palatine, tubal
E'
G and nasopharlmgeal tonsils (see Fig.14.73).
o
DEEPESI GROUP
c Preloryngeol ond Prehocheol Nodes MAIN TYMPH TRUNKS AT THE ROOT OF IHE NECK
.9
() The prelaryngeal and pretracheal nodes lie deep to the 1 The thoracic duct is the largest lymph trunk of the
ao investing fascia, the prelaryngeal nodes on the body. It begins in the abdomen from the upper end
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of the cisterna chyli, traverses the thorax, and ends

mouth and cheek are quite common. These nodes
on the left side of the root of the neck by opening
may be affected by tubercular bacteria.
into the angle of junction between the left internal
jugular vein and the left subclavian vein(seeEig.20.7,
. Spinal root of accessory nerve may get entangled
Vol. 1). Before its termination, it forms an arch at the in the enlarged lymph nodes situated in the
level of the transverse process of vertebra C7 rising posterior triangle of neck. While taking biopsy of
3 to 4 cm above the clavicle. The relations of the arch
the lymph node, one must be careful not to injure
are:
the accessory nerve lesl trapezius gets damaged
lsee Fig. 3.9).
Anterior:
The left supraclavicular nodes are called
a. Left common carotid artery (Fig.8.22)
Virchow's lymph nodes. Cancer from stomach and
b. Vagus testis may metastasize into these lymph nodes,
c. Internal jugular vein. which may become palpable,
Posterior:
a. Vertebral artery and vein (Fig.8.22)
b. Sympathetic trunk
c. Thyrocervical trunk and its branches
d. Prevertebral fascia (see Fig. 9.5)
e. Phrenic nerve
f. Scalenus anterior.
Apart from its tributaries in the abdomen and
thorax, the thoracic duct receives (in the neck):
a. The left jugular trunk
b. The left subclavian trunk Lymph nodes of
c. The left bronchomediastinal trunk. anterior triangle
It drains most of the body, except for the right upper
limb, the right halves of the head, the neck and the
thorax and the superior surface of the liver.
The right jugular trunk drains half of the head and
neck. Fig. 8.29: Palpation of the lymph nodes
3 The right subclauian trunk drains the upper limb.
4 The bronchomediastinal trunk drains the lung, half of
the mediastinum and parts of the anterior walls of
the thorax and abdomen.
On the right side, the subclavian, jugular and
bronchomediastinal trunks unite to fiorrn thLe right The styloid process with its attached structures is called
lymph trunk which ends in a manner similar to the the styloid apparatus. The structures attached to the
thoracic duct (Fig. 8.24). process are three muscles and two ligaments. The
muscles are the stylohyoid, styloglossus and stylo-
pharyngeus and ligaments are the stylohyoid and
stylomandibular (Figs 8.30a and b).
The deep cervical lymph nodes lie on the internal
jugular vein. These nodes often become adherent The apparatus is of diverse origin. The styloid
process/ the stylohyoid ligament and stylohyoid muscle
to the vein in malignancy or in tuberculosis. are derived from the second branchial arch; the
Therefore, during operation on such patients the
stylopharyngeus from the third arch; the styloglossus
vein is also resected. These are examined from
behind with the neck slightly flexed.
from occipital myotomes; and the stylomandibular 5
ligament from a part of the deep fascia of neck. o
o
Superficiai cervical, supraclavicular and lymph
The fiae attachments resemble the reins of a chariot. Two
z
nodes of anterior triangle can easily be palpated t,tr
(Fig.8.2e). of these reins (ligaments) are nonadjustable, whereas G
Chronic infection of the palatine tonsil causes the other three (muscles) are adjustable and are ttG
enlargement of jugulodigastric lymph nodes controlled each by a separate cranial nerve, seventh, o
ninth and twelfth nerves. I
which adhere to the internal jugular vein.
Painful enlargement of the submandibular lyrnph The styloid process is a long, slender and pointed bony o
nodes is common because infections in tongue, process projecting downwards, forwards and slightly o
o
medially from the temporal bone. It descends between @
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HEAD AND NECK
Mandible Styloglossus (Xll)
Tongue Stylohyoid (Vll)
Stylopharyngeus (lX)
Styloglossus
Stylohyoid ligament
Stylomandibular
ligament
Stylopharyngeus
Pharynx
(a) (b)
Figs 8.30a and b: The styloid apparatus: (a) Superior view, and (b) lateral view
the external and internal carotid arteries to reach the Intemal carotid Third aortic arch, distal
side of the pharynx. It is interposed between the parotid artery to the external carotid bud and
gland laterally and the internal jugular vein medially. original dorsal aorta cranial to
The styloglossus tttuscle arises from the anterior the attachment of third aortic
surface of the styloid process and is inserted into the arch.
side of the tongue. External carotid Develop as sprout from the
The stylopharyngeus muscle arises from the medial artery third aortic arch.
surface of the base of the styloid process and is inserted Pulmonary tnrnk Part of truncus arteriosus.
on the posterior border of the lamina of the thyroid Arch of aorta Left aortic sac
cartilage (see Fig. t4.23). Left 4th aortic arch
Stylohyoid extends between posterior surface of Left dorsal aorta.
styloid process and hyoid bone.
The stylomandibular ligament is attached laterally to
styloid process above and angle of mandible below. a Isthmus of thyroid gland acts as a shield for trachea.
The stylohyoid ligamenf extends from the tip of the a Parathyroid glands lie along the anastomotic
stytoid process to the lesser cornua of the hyoid bone. channel between posterior branch of superior
thyroid artery and ascending branch of inferior
Feolules thyroid artery.
1 External carotid artery crosses tip of styloid process Internal carotid artery comprises 4 parts: Cervical,
superficially. petrous, cavernous and cerebral.
2 Facial nerve crosses the base of styloid Process Superior cervical ganglion gives grey rami
laterally after it emerges from stylomastoid foramen. communicates (grc) to C1-C4 nerves.
a Middle cervical ganglion gives grc to C5, C5 nerves.
DEVELOPMENT OF THE ARTERIES a Lrferior cervical ganglion gives grc to C7, CSnerves.
a Scalenus anterior can Press upon the subclavian
Brachoicephalic Right aortic sac
l( artery and brachial plexus, causing nervous and
o artery
vascular changes in upper limb.
zo Right subclavian Proximal part from the right Phrenic nerve (C4) supplies motor fibres to
!, artery 4th aortic arch artery and
tr musculature of diaphragm. It carries sensory fibres
o remaining part from right 7th
t,(5 from peritoneum underlying diaphragm, media-
o cervical intersegmental artery. stinal pleura and pericardium.
I
Left subclavian Only left 7th cervical interseg- ),
C artery mental artery. );
o
.F
() Common carotid Third aortic arch proximal to
ao) external carotid bud.
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A 4O-year-old woman complained of a swelling in cartilag;e by the pretracheal fascia a ligament of
front of her neck, nervousness and loss of weight. Berry. So all the swellings associated with thyroid
Her diagnosis was hyperthyroidism. Partial gland move with deglutition.
thyroidectomy was performed, and she complained She complains of hoarseness. It y be due to
of hoarseness after the operation. injury of the recurrent Ia geai nerve as it lies close
. Why does thyroid swelling move up and down to the inferior roid artery near the lower pole of
during deglutition? gland.
. Why does she complain of hoarseness after the
operation? gland canberemoved. Para roid controls calcium
o lAlhich other gland can be removed with thyroid? level in the biood.
1. Where should the superior thyroid artery should c. Costocervical trunk

be ligated during thyroidectomy? d. Subscapular
a. Close to its origin from external carotid artery 6. One of the following symptoms is not seen in
b. Close to the upper pole of the lateral lobe Horner's syndrome:
c. Anterior and posterior branches separately a. Complete ptosis b. Miosis
d. Anywhere in its course c. Anhydrosis d. Enophthalmos
2. Where should inferior thyroid artery be ligated 7. One of the following statements about parathyroid
during thyroidectomy? gland is not true:
a. Away from the gland a. Inferior parathyroid arises from 3rd pharyngeal
b. At its distal or terminal part pouch
c. Anywhere in its course b. Parathyroid glands are supplied by superior
d. The branches ligated separately
thyroid artery
3. Horner's syndrome produces all symptoms except:
c. Superior parathyroid arises from 4th pharlmgeal
pouch
a. Partial ptosis b. Miosis
d. Thymus develops along with inferior para-
c. Anhydrosis d. Exophthalmos thyroid gland
4. \A/hich of the following muscles is not supplied by 8. Which one is not a branch of thyrocervical trunk?
ansa cervicalis?
a. Inferior thyroid
a. Sternohyoid
b. Suprascapular
b. Sternothyroid
c. Transverse cervical
c. Inferior belly of omohyoid
d. Deep cervical
d. Geniohyoid
9. \Mhich one is not a component of carotid sheath?
5. One of the following is not a branch of subclavian
a. Internal carotid artery
artery:
b. Vagus nerve
a. Internal thoracic
c. Sympathetic trunk
b. Vertebral .Y
d. Internal jugular vein o
zo
!ttr
(E
!,(E
o
C
.o
o
ao
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I
4 Horvey
-Williom
INTRODUCTION
The prevertebral region contains four muscles, vertebral
artery and joints of the neck. Vertebral artery, a branch
DISSECTION
of subclavian artery, comprises four parts 7st,2nd
and 3rd are in the neck and the fourth - passes
part Remove the scalenus anterior muscle. ldentify deeply
through the foramen magnum to reach the subarac- placed anterior and posterior inteftransverse muscles.
hnoid space and the vertebral arteries of two sides unite Cut through the anterior intertransverse muscles to
to form a single median basilar artery which gives expose the second part of veftebral artery. First part
branches to supply a part of cerebral cortex, cerebellum, was seen as the branch arising from the first part of the
internal ear and pons. Congenital or acquired diseases subclavian artery. lts third part was seen in the
of cervical vertebrae or their joints give rise to lots of suboccipital triangle. The fourth part lies in the cranial
symptoms related to branches of vertebral artery. cavity.
The apical ligament of dens is a continuation of

notochord. Transverse ligament, which is a part of Feolures
cruciate ligament, keeps the dens of axis in position. If
The vertebral artery is one of the two principal arteries
this ligament is injured by disease or in "capital which supply the brain. In addition, it also supplies
punishment" , there is immediate death due to injury
the spinal cord, the meninges, and the surrounding
to vasomotor centres in medulla oblongata. Trachea and
muscles and bones. It arises from the posterosuperior
oesophagus are contents of prevertebral region.
aspect of the first part of the subclavian artery near its
The paravertebral region contains three scalene commencement. It runs a long course, and ends in the
muscles, cervical plexus, its branches including the cranial cavity by supplying the brain (Fig. 9.2). The
phrenic nerve. This region also includes the cervical artery is divided into four parts.
pleura.
First Pod
PREVERTEBRAT MUSCLES The first part extends from the origin of the artery (from
(Anterior Verlebrol Muscles) the subclavian artery) to the transverse process of the
The four prevertebral or anterior vertebral muscles are sixth cervical vertebra.
the longus colli (cervicis), the longus capitis, the rectus This part of the artery runs uPwards and backwards
capitis anterior and the rectus capitis lateralis (Fig. 9.1). inthe triangular spacebetweenthe scalenus anterior and
These are weak flexors of the head and neck. They the longus colli muscles called as the scalenovertebral
extend from the base of the skull to the superior triangle (Fig.9.3).
mediastinum. They partially cover the anterior aspect
of the vertebral column. They are covered anteriorly SCALENOVERTEBRAL TRIANGTE
by the thick prevertebral fascia. The muscles are
described in Table 9.1. The triangle is present at the root of the neck.
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PREVERTEBRAL AND PARAVERTEBRAL REGIONS
Occipital bone
Rectus capitis lateralis
Rectus capitis anterior Longus capitis
Upper oblique part of longus colli
Scalenus medius
Lower oblique part of longus colli Vertical part of longus colli
Scalenus posterior
Scalenus anterior
1 st rib
Fig.9.1: The preverlebral muscles
Table 9.1 : The prevertebral muscles

Muscle Origin from lnsertion into Nerve supply Actions
1. Longus colli a. The upper oblique part is a. Upper oblique part is Ventral rami of a. Flexes the neck
(cervicis). from the anterior tubercles into the anterior neryes C3-C8 b. Oblique parts flex
This muscle extends of the transverse tubercle of the atlas the neck laterally
from the atlas to the processes of cervical b. Lower oblique part is c. Lower oblique part
third thoracic vertebra vertebrae 3, 4, 5 into the anterior rotates the neck to
It has upper and b. Lower oblique part is from tubercles of the the opposite side
lower oblique parts bodies of upper 2-3 transverse processes
and a middle vertical thoracic vertebrae of 5th and 6th cervical
part (Fig. 9.1) c. Middle vertical part is from vertebrae
bodies of upper 3 thoracic c. Middle vertical part is
and lower 3 cervical into bodies o'12,3,4
vertebrae ceruical vertebrae
2 Longus capitis. Anterior tubercles of lnferior surface of basilar Ventral rami of Flexes the head
It overlaps the longus transverse processes part of occipital bone nerves C1-C3
colli. lt is thick above of cervical 3-6 vedebrae
and narrow below
Rectus capitis anterior. Anterior surface of lateral Basilar part of Ventral ramus Flexes the head
This is a very short mass of atlas in front of the the occipital bone of nerve C1
and flat muscle. lt lies occipital condyle
deep to the longus
capitis
l<
Bectus capitis lateralis. Upper surface of transverse lnferior surface of jugular Ventral rami of Flexes the head o
This is a short, process of atlas process of the occipital nerves C1 , C2 laterally zo
flat muscle bone !,
tr
G
!tG
Sou.rm e$ Base: 1,st part of subclavian artery o
Medial: Lower oblique part of longus colli Posterior wnll: Transverse process of C7, Ventral ramus
of C8 nerve, neck of 1st rib and cupola of pleurae c
Lateral: Scalenus anterior .o
Contents:1st part of vertebral artery, cervical part o
Apex: Transverse process of cervical C6 vertebra of sympathetic trunk (Fig. 9.3). ao)
I
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I
PeJsfierls
Fourth part of Anterior
vertebral artery
1 Carotid sheath with common carotid artery
Third part of
2 Vertebral vein
vertebral artery 3 Inferior thyroid artery
(in suboccipital triangle) 4 Thoracic duct on left side (Fig. 9.3).
Posterior
Second part of
vertebral artery 1- Transverse process of Tthcervical vertebra (Fig. 9.2)
2 Stellate ganglion
3 Ventral rami of nerves C7, C8.
Second Pqrl
The second part runs through the foramina
Scalenus medius transversaria of the upper six cervical vertebrae. Its
course is vertical up to the axis vertebra. It then runs
First part of upwards and laterally to reach the foramen trans-
vertebral artery versarium of the atlas vertebra.
Scalenus
Posterior
Relofions
Subclavian
1 The ventral rami of second to sixth cervical nerves
artery lie posterior to the vertebral artery.
2 The artery is accompanied by a venous plexus and a
large branch from the stellate ganglion (seeEig.8.25).
Third Pod
Fig. 9.2: Scheme showing parts of the vertebral artery, as seen Third part lies in the suboccipital triangle. Emerging
from the front from the foramen transversarium of the atlas, the artery
Transverse process of atlas
Ventral ramus of nerves

on costotransverse bar Transverse process of axis
Anterior tubercle of Posterior tubercles of

transverese process transverse processes
Levator scapulae
Scalenus medius
Sternocleidomastoid
Scalenus posterior
vo Scalenus anterior
zo
ttc Clavicle
G Scapula
E
(E
Subclavian vein
o
First rib Lower trunk of brachial plexus
c
.9 Second rib Subclavian artery
(,)
0)
a Fig. 9.3: Structures present in the triangular interval between scalenus anterior and the longus colli, i.e. scalenovertebral triangle
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winds medially around the posterior aspect of the Third part: From spinal branch of the first cervical
lateral mass of the atlas. It runs medially lying on the intersegmental artery.
posterior arch of this bone, and enters the vertebral Fourth part: From preneural branch of first cervical
canal by passing deep to the lower arched margin of intersegmental artery.
the posterior atlanto-occipital membrane.
treleffons
Anterior: Lateral mass of atlas.
DISSECTION
P osterior : Semispinalis capitis.
Clean and define the cervical parts of the trachea and
Lateral: Rectus capitis lateralis.
oesophagus.
Medial: Ventral ramus of the first cervical nerve.
Scalenus anterior has been seen in relation to
I rior: subclavian anery. ldentify scalenus medius as one of
1 Dorsal ramus of the first cervical nerve (seeFrg.10.6) the muscle forming floor of posterior triangle of neck.
2 The posterior arch of the atlas (see Frg. 70.6). Scalenus posterior lies deep to the medius.
ldentify the relations of the cervical pleura.
Fourlh Port
1 The fourth part extends from the posterior atlanto- Feotules
occipital membrane to the lower border of the pons. There are usually three scalene muscles, the scalenus
2 In the vertebral canal, it pierces the dura and the anterior, the scalenus medius and the scalenus
arachnoid, and ascends in front of the roots of the posterior. The scalenus medius is the largest, and the
hypoglossal nerve. As it ascends, it gradually scalenus posterior the smallest, of three. These muscles
inclines medially to reach the front of the medulla. extend from the transverse processes of cervical
At the lower border of the pons, it unites with its vertebrae to the first two ribs. They can, therefore, either
fellow of the opposite side to form the basilar artery elevate these ribs or bend the cervical part of the
(Fis. e.2). vertebral column laterally (Fig. 9.q.
These muscles are described in Table 9.2.
BRANCHES OF VERTEBRAT ARTERY
First part has no branches. Additionol Feotures of the Scolene Muscles
1 Sometimes a fourth, rudimentary scalene muscle, the
Cervicol Bronches scalenus minimus is present. It arises from the anterior
1 Spinal branches from the second part enter the border of the transverse process of vertebra C7 and
vertebral canal through the intervertebral foramina, is inserted into the inner border of the first rib behind
and supply the spinal cord, the meninges and the the groove for the subclavian artery and into the
vertebrae. dome of the cervical pleura. Tii.e suprapleural
2 Muscular branches arise from the third part and membrane is regarded as the expansion this muscle.
supply the suboccipital muscles. Contraction of the scalenus minimus pulls the dome
of the cervical pleura.
Cloniol Bronches 2 Relations of scalenus anterior. The scalenus anterior is
These arise from the fourth part. They are: akey muscle of the lower part of the neck because of
"1. Meningeal branches its intimate relations to many important structures
2 The posterior spina.l in this region. It is a useful surgical landmark.
3 The anterior spinal artery Anterior:
4 The posterior inferior cerebellar artery a. Phrenic nerve covered by prevertebral fascia.
5 Medullary arteries b. Lateral part of carotid sheath containing the ta
()
These are described in Chapter 31 internal jugular vein.
c. Sternocleidomastoid (Fig. 9.5). zo
!,
DEVETOPMENI OF VERTEB t ARIERY d. Clavicle.
(E
Different parts of vertebral artery develop in the Posterior: !t

G
following ways. a. Brachial plexus. o
I
b. Subclavian artery.
First pnrt: From a branch of dorsal division of 7th
c. Scalenus medius. o
cervical intersegmental artery.
d. Cervical pleura covered by the suprapleural o
o
Second part: From postcostal anastomosis. membrane (Fi9.9.6). o
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HEAD AND NECK
Stemocleidomastoid
Scalenus medius
Descendens cervicalis
Prevertebral fascia
Sternocleidomastoid branch
of occipital artery Scalenus anterior
lnferior belly of omohyoid Phrenic nerve
Transverse cervical artery Brachial plexus
Suprascapular artery
'I st rib
Anterior jugular vein
Costocervical trunk
Sternocleidomastoid branch of
superior thyroid artery
Suprapleural membrane
Clavicle Subclavian artery
Subclavius
Subclavian vein
Fig. 9.4: Lateral view of the scalene muscles with a few related structures
Table 9.2: The scalene muscles

Muscle Origin from lnseftion into Nerve supply Actions
1. Scalenus anterior Anterior tubercles of Scalene tubercle and Ventral rami of a. Anterolateral flexion of
'cervical spine
(Fig. e.4) transverse processes adjoining ridge on the neryes C4-C6
of cervical vertebrae, superior surface of the b. Botates cervical spine to
3, 4, 5 and 6 first rib (between opposite side
subclavian artery c. Elevates the first rib
and vein) during inspiration
d. Stabilises the neck along
with other muscles
2. Scalenus medius a. Posterior tubercles of Superior sudace of the Ventral rami of a. Lateral flexion of the
(Fis. e.5) transverse processes first rib behind the groove nerves C3-C8 cervical spine.
of cervical vertebrae for the subclavian b. Elevation of first rib
3, 4, 5, 6,7 artery c. Stabilises neck along
b. Transverse process of with other muscles
axis and sometimes
also of the atlas vedebra
3. Scalenus posterior Posterior tubercles of Outer surface of the Ventral rami of a. Lateral flexion of cervical
(Fis. s.a) transverse processes of second rib behind the nerves C6-C8 sprne
cervical vertebrae tubercle for the serratus b. Elevation of the second
4,5,6 anterior rib
c Stabilises neck along with
other muscles
.l
o
zo The medial border of the muscle is related: ii. Inferior thyroid artery arching medially at the
!ttr
o a. In its lower part to an inverted 'V'-shaped level of the 6th cervical transverse process.
E
(E
interval, formed by the diverging borders of the iii. Sympathetic trunk.
o scalenus anterior and the longus colli. This iv. The first part of the subclavian artery traverses
interval contains many important structures as the lower part of the gap.
C
.9
follows: v. On the left side, the thoracic duct arches
O i. Vertebral vessels running vertically from the laterally at the level of the seventh cervical
ao base to the apex of this space. transverse process (Fig. 9.5).
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Sympathetic trunk Ascending cervical

Phrenic nerve
Middle cervical ganglion

lnferior thyroid
Vertebral
Transverse cervical
Edge of longus colli Suprascapular
Thoracic duct Thyrocervical trunk
lnferior cervical ganglion Subclavian vessels
lnternal jugular vein Edge of scalenus anterior
lnternal thoracic artery
Fig. 9.5: Schematic sagittal section through the left scalenus anterior to show its relations
vi. The carotid sheath covers all the structures 3 Superior intercostal artery,
mentioned above. 4 The first thoracic nerye.
vii. The sternocleidomastoid covers the carotid
sheath (see Fig. 8.4). Lateral
b. In its upper part, the scalenus anterior is separated i. Scalenus medius
from the longus capitis by the ascending cervical ii. Lower trunk of the brachial plexus.
artery.
T}:.e lateral border of the muscle is related to the ldediat
trunks of the brachial plexus and the subclavian artery 1 Vertebral bodies
which emerges at this border and enter the posterior 2 Oesophagus
triangle (Fig. 9.5). 3 Trachea
4 Left recurrent laryngeal nerve
5 Thoracic duct (on left side)
6 Large arteries and veins of the neck.
The cervical pleura covers the apex of the lung. It rises
into the root of the neck, about 5 cm above the first
costal cartilage and 2.5 cm above the medial one-third
of the clavicle. The pleural dome is strengthened on its FORMATION
outer surface by the suprapleural membrane so that The cervical plexus is formed by the ventral rami of
the root of the neck is not puffed up and down during the upper four cervical nerves (Frg. 9.7). The rami
respiration (see Chafter t2,Vol. t1. emerge between the anterior and posterior tubercles of
Relolions
the cervical transverse processes, grooving the
Anterior
costotransverse bars. The four roots are connected with :o
one another to form three loops (Fig. 9.8).
L Subclavian artery and its branches zo
Position ond Relotions of lhe Plexus t,tr
2 Scalenus anterior (Fig. 9.6). (E
The plexus is related: !,(E
Fosferior "1. Posteriorly, to the muscles which arise from the o
I
Neck of the first rib with the following structures in posterior tubercles of the transverse processes, i.e.
front of it. the levator scapulae and the scalenus medius. o
1 Sympathetic trunk (see Chapter 13, Volume 1) 2 Anteriorly, to the prevertebral fascia, the internal F
o
o
2 First posterior intercostal vein jugular vein and the sternocleidomastoid. a
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Scalenus medius
lnsertion of scalenus medius

Cervical dome of pleura
Trachea and oesophagus
Subclavian artery
lnsertion of scalenus anterior Subclavian vein
First costal cartilage
Fig. 9.6: Relations of the cervical pleura
Longus capitis
Prevertebral fascia
Longus cervicis
Foramen transversarium
Scalenus anterior
Anterior tubercle
Vertebral artery
Costotransverse bar
Ventral ramus
Posterior tubercle
Scalenus medius Superior articular facet
Levator scapulae
Dorsal ramus
Fig. 9.7: Scheme to show the position of a ceruical nerve relative to the muscles of the region
Bronches geniohyoid muscles (directly) and the superiorbelly

of the omohyoid through the ansa cervicalis.
L Lesser occipital (C2)
3 A branch from C2 to the sternocleidomastoid and
branches from C3 and C4 to the trapezius com-
2 Great auricular (C2, C3)
municate with the accessory nerve.
3 Transverse (anterior) cutaneous nerve of the neck
.Y (c2, c3) Mursculsr B cr?es
o 4 Supraclavicular (C3, C4)
o Muscles supplied solely by cervical plexus:
z These are described in Chapter 3. L Rectus capitis anterior from C1.
EI
tr
G
Deep Blonches
2 Rectus capitis lateralis from C1., C2.
tt(E 3 Longus capitis from C1{3.
o
I
4 Lower root of ansa cervicalis (descendens cervicalis)
1 Grey rami pass from the superior cervical ganglion from C2, C3 (to sternohyoid, sternothyroid and
o
C to the roots of C1.-C4 nerves. inferior belly of omohyoid.
'F
o 2 A branch from C1 joins the hypoglossal nerve and Muscles supplied by cervical plexus along with the
ao carries fibres for supply of the thyrohyoid and brachial plexus or the spinal accessory nerve:
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PBEVERTEBHAL AND PABAVERTEBRAL REGIONS
To rectus capitis lateralis and

rectus capitis anterior
Hypoglossal nerve
Lesser occipital
To sternocleidomastoid
Geniohyoid Great auricular

Thyrohyoid
Superior and inferior roots

of ansa cervicalis
Transverse cervical
nerve
To trapezius, levator
scapulae, scalenus medius
To infrahyoid muscles
Supraclavicular nerves
Phrenic nerve
Fig. 9.8: Cervical plexus and its branches
a. Stemocleidomastoid from C2 along with accessory course, the nerve is related anteriorly to the prever-
nerve (Fig. 9.8). tebral fascia, the inferior belly of the omohyoid, the
b. Trapezius from C3, C4 along with accessory nerve. transverse cervical artety, the suprascapular artety,
c. Levator scapulae from C3, C4 with C5 (dorsal the internal jugular vein, the sternocleidomastoid,
scapular nerve). and the thoracic duct on left side (Fig. 9.5).
d. Phrenic nerye from C3, C4, C5. 3 After leaving the anterior surface of scalenus
e. Longus colli from C3-C8. anterior, the nerve runs downwards on the cervical
f. Scalenus medius from C3-C8. pleura behind the commencement of the bra-
o Scalenus anterior from C4-C6.
b' chiocephalic vein. Here it crosses the internal thoracic
h. Scalenus posterior from C6-C8. artery (either anteriorly or posteriorly) from lateral
to medial side, and enters the thorax behind the first
PHRENIC NERVE costal cartilage. On the left side, the nerve leaves
This is a mixed nerve carrying motor fibres to the (crosses) the medial margin of the scalenus anterior
diaphragm and sensory fibres from the diaphragm, at a higher level and crosses in front of the first part
pleura, pericardium, and part of the peritoneum. of the subclavian artery.
Oilgin
Phrenic nerve arises chiefly from the fourth cervical The accessory phrenic nerve is commonly a branch
nerve but receives contributions from third and fifth from the nerve to the subclavius. It lies lateral to the
cervical nerves. The contribution from C5 may come phrenic nerve and descends behind, or sometimes
directly from the root or indirectly through the nerve in front of the subclavian vein. It joins the main nerve
to the subclavius. In the latter case, the contribution is usually near the first rib, but occasionally the union
known as the accessory phrenic nerae. may even be below the root of the lung.
xo
Coutse ond Relotions in the Neck
1 The nerve is formed at the lateral border of the zo
!tc
scalenus anterior, opposite the middle of the (E
sternocleidomastoid, at the level of the upper border EG
of the thyroid cartilage. The trachea is a noncollapsible, wide tube forming the o
2 It runs vertically downwards on the anterior surface beginning of the lower respiratory passages. It is kept
of the scalenus anterior (Fig. 9.9). Since the muscle is patent because of the presence of C-shaped carti- c
o
oblique, the nerve appears to cross it obliquely from laginous 'rings'in its wall. The cartilages are deficient ()
its lateral to its medial border. In this part of its posteriorly, this part of the wall being made up of oo
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HEAD AND NECK
Left phrenic nerve
From parietal pleura,

mediastinal part
From parietal pleura,

diaphragmatic part
lntercostal nerves
Fig. 9.9: Formation, course and distribution of phrenic nerve
muscle (trachealis) and fibrous tissue. The soft posterior Posteilor

wall allows expansion of the oesophagus during 1 Oesophagus
passage of food. 2 Longus colli
DIMENSIONS
3 Recurrent laryrngeal nerve in the tracheo-oesophageal
groove (see Fig. 8.5).
The trachea (Latin rough air oessel) is about 10 to 15 cm
long. Its upper half lies in the neck and its lower half in On Eoch Side
the superior mediastinum. The external diameter 1 The corresponding lobe of the thyroid glands.
measures 2 cm in the male and 1.5 cm in the female.
The lumen is smaller in the living than in cadavers. It
2 The common carotid artery within the carotid sheath
(see Fig. 8.4).
is about 3 mm at l year of age, and corresponds to the
age in years during childhood, with a maximum of
Vessels ond Nerves
12 mm at puberty.
The trachea is supplied by branches from the inferior
CERVI L PART OF TRACHEA thyroid arteries. Its veins drain into the left brachio-
1 The trachea begins at the lower border of the cricoid
cephalic vein. Lymphatics drain into the pretracheal
and paratracheal nodes.
cartilage opposite the lower border of vertebra C6.
It runs downwards and slightly backwards in front Parasympathetic nerves (from the vagus through the
of the oesophagus, follows the curvature of the spine, recurrent laryngeal nerve) are sensory and secretomotor
and enters the thorax in the median plane. to the mucous membrane, and motor to the trachealis
2 In the neck, the trachea is comparatively superficial muscle. Sympathetic nerves (from the cervical ganglion)
and has the following relations. are vasomotor.
Anteilor
L Isthmus of the thyroid gland covering the second . The trachea may be compressed by pathological
J
o and third tracheal rings (see Fig. 8.1).
o enlargements of the thyroid, the thymus, lymph
z 2 Inferior thyroid veins below the isthmus (see Fig. 8.8). nodes and the aortic arch. This causes dyspnoea,
t,c 3 Pretracheal fascia enclosing the thyroid and the irritative cough, and often a husky voice.
(E inferior thyroid veins.
E
(5 4 Sternohyoid and sternothyroid muscles (seeFig.8.4). . Tracheostomy is an emergency operation done in
o 5 Investing layer of the deep cervical fascia and the cases of laryngeal obstruction (foreign body,
suprasternal space. diphtheria, carcinoma, etc.). It is commonly done
C
o 6 The skin and superficial fascia. in the retrothyroid region after retracting the
o 7 Lr children, the left brachiocephalic vein extends into isthmus of the thyroid gland.
o
a the neck and, then, lies in front of the trachea.
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PREVEBTEBRAL AND PABAVERTEBRAL REGIONS
F'rB
The oesophagus is a muscular food passage lying IffiI Pharynx
ffisl
between the trachea and the vertebral column. E i
Cricopharyngeus
C6
Normally, its anterior and posterior walls are in contact. 1 st --, .15 cm
The oesophagus expands during the passage of food Oesophagus
by pressing into the posterior muscular part of the Arch of aorta
Trachea
trachea (see Frg. 8.4).
2nd !_4.
---' 25 cm
The oesophagus is a downward continuation of the 3rd 27 cm
pharynx and begins at the lower border of the cricoid is
cartilage, opposite the lower border of the body of Left
bronchus
vertebra C6. It passes downwards behind the trachea, T10
traverses the superior and posterior mediastina of the 4th i---- ---------.40 cm
thorax, and ends by opening into the cardiac end of

the stomach in the abdomen. It is about 25 cm long.
Stomach
The cervical part of the oesophagus is related:
a. Anteriorly, to the trachea and to the right and left
recurrent laryrrgeal nerves.
b. Posteriorly, to the longus colli muscle and the Fig. 9.10: Natural constrictions of the oesophagus
vertebral column.
c. On ench side, to tlire correspondtng (seeFig.3.3) lobe
of the thyroid gland; and on the left side, to the cervical fascia. The ligament gives origin to the splenius,
thoracic duct. rhomboids and trapezius muscles.
The cervical part of the oesophagus is supplied by
the inferior thyroid arteries. Its veins drain into the left Joints between the Allos,
brachiocephalic vein. Its lymphatics pass to the deep the Axis ond lhe Occipitol Bone
cervical lymph nodes. The oesophagus is narrowest at 1 The atlanto-occipital and the atlantoaxial joints are
its junction with the pharynx, the junction being the designed to permit free movements of the head on
narrowest part of the gastrointestinal tract, except for the neck (vertebral column).
the vermiform appendix. 2 The axis vertebra and the occipital bone are con-
For thoracic part of oesophagus study see Chapter 20, nected together by very strong ligaments. Between
Volume 1. these two bones, the atlas is held like a washer. The
axis of movement between the atlas and skull is
transverse, permitting flexion and extension
Oesophagus has four natural constrictions. While (nodding), whereas the axis of movement between
passing any instrument, one must be careful at these the axis and the atlas is vertical, permitting rotation
sites (Fig. 9.10). of the head (Fig. 9.11).
Allonto-occipitol Joinls
These are slmovial joints of the ellipsoid variety.

Typicol Cervicol Joints between Abaae: The occipital condyles, which are convex
the Lower Six CeruicolVertebroe (Fig.e.12).
These correspond in structure to typical intervertebral Beloru: The superior articular facets of the atlas vertebra. ta
joints already described in Chapter 13, Vol. 1. The only o
additional point to be noted is that in the cervical region
These are concave. The articular surfaces are elongated,
and are directed forwards and medially.
zo
!,
the supraspinous ligaments are replaced by the o
ligamentum nuchae. Ligaments t,(E
Theligamentumnuchae is triangular in shape. Its apex I The fibrous capsule (capsular ligament) surrounds the o
I
lies at the seventh cervical spine and its base at the joint. It is thick posterolaterally and thin antero-
external occipital crest. Its anterior border is attached medially. o
c
.F
to cervical spines, while the posteriorborder is free and 2 The anterior atlanto-occipital membrane extends from o
provides attachment to the investing layer of deep the anterior margin of the foramen magnum above, ao
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Occipital bone
Cruciform ligament (upper band)
Foramen magnum
Anterior atlanto-occipital membrane
Posterior atlanto-occipital membrane
Joint cavity
Posterior arch of atlas
Anterior arch of atlas
Transverse ligament
Cruciform ligament (lower Part)

Body and dens of axis
lnterspinous ligament
Anterior longitudinal ligament Posterior longitudinal ligament
Fig. 9.11 : Median section through the foramen magnum and upper two cervical vertebrae showing the ligaments in this region
Membrana tectoria Upper vertical band of cruciate ligament
Apical ligament Anterior margin of foramen magnum
Occipital condyle
Alar ligament
Transverse ligament Lateral mass of atlas
Lateral atlantoaxial joint

Lower vertical band of cruciate ligament
Axis vertebra
Membrana tectoria
Fig.9.12: Posterior view of the ligaments connecting the axis with the occipital bone
to the upper border of the anterior arch of the atlas occur around a transverse axis. Slight lateral flexion is
below (Fig. 9.11). Laterally, it is continuous with the permitted arormd an anteroposterior axis'
anterior part of the capsular ligament, and anteriorly I Flexion is brought about by the longus capitis and
it is strengthened by the cord-like anterior the rectus capitis anterior.
longitudinal ligament.
3 The posterior atlanto-occipital membrane extends from
2 Extension is done by the rectus capitis posterior major
and minor, the obliquus capitis superior, the
the posterior margin of the foramen magnum above,
semispinalis capitis, the splenius capitis, and the
to the upper border of the Posterior arch of the atlas
upper part of the trapezius.
below. Inferolaterally, it has a free margin which
arches over the vertebral artery and the first cervical 3 Lateralbending is produced by the rectus capitis, the
L nerve. Laterally, it is continuous with the posterior semispinalis capitis, the splenius capitis, the
o
stemocleidomastoid, and the trapezius (Fig. 9.13).
zo part of the capsular ligament.
tttr
(E Allontooxiol Joints
!t(E The joint is supplied by the vertebral artery and by the
o first cervical nerve. These joints comprise:
C
o
Mavemenfs 1 A pair of lateral atlantoaxial joints between the
O Since these are ellipsoid joints, they permit movements inferior facets of the atlas and the superior facets of
ao around two axes. Flexion and extension (nodding) the axis. These are plane joints.
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2 A median atlantoaxial joint between the dens Extension

(odontoid process) and the anterior arch and between
dens and transverse ligament of the atlas. It is a pivot
joint. The joint has two separate synovial cavities,
anterior and posterior.
Lrgonnenls
The lateral atlantoaxial joints are supported by:
a. A capsular ligament all around.
b. The lateral part of the anterior longitudinal
ligament.
c. The ligamentum flavum.
The median atlantoaxial joint is strengthened by the
following:
a. The anterior smaller part of the joint between the
anterior arch of the atlas and the dens is
surrounded by a loose capsular ligament.
b. The posterior larger part of the joint between the
dens and transverse ligament (often called a bursa)
is often continuous with one of the atlanto-
(b)
occipital joints. Its main support is the transverse
ligament which forms a part of the cruciform
ligament of the atlas (Fig. 9.12).
The transoerse ligament (Fig. 9.12) is attached on each
side to the medial surface of the lateral mass of the atlas.
In the median plane, its fibres are prolonged upwards
to the basiocciput and downwards to the body of the
axis, thus forming the crucifurm ligament of the atlas
aertebra. The transverse ligament embraces the narrow
neck of the dens, and prevents its dislocation.
(c)
Movernents Figs 9.13a to c: Various movements of the neck
Movements at all three joints are rotatory and take place
around a vertical axis. The dens forms a pivot around 2 Cruciate ligament (see transverse ligament).
which the atlas rotates (carrying the skull with it). The 3 T}ae apical ligament of the dens extends from the apex of
movement is limited by the alar ligaments (Figs 9.12 the dens close to the anterior margin of the foramen
and 9.13a to c). magnum behind the attachment of the cruciate
The rotatory movements are brought about by the ligament. It is the continuation of the notochord.
obliquus capitis inferior, the rectus capitis posterior The alar ligament, one on each side, extends from the
major and the splenius capitis of one side, acting with upper paft of the lateral surface of the dens to the
the sternocleidomastoid of the opposite side. medial surface of the occipital condyles. These are
strong ligaments which limit the rotation and flexion
ligamen fs Co n ne ci in g fhe Axis of the head. They are relaxed during extension
with lhe Accipilal Bone (Fig. e.12).
These ligaments are the membrana tectoria, the cruciate .|a
o
ligament, the apical ligament of the dens and the alar
ligaments. They support both the atlanto-occipital and r Death in zo
execution by hanging is due to t,tr
atlantoaxial joints. dislocation of the dens following rupture of the G
t
1 The membrana tectoria is an upward continuation of transverse ligament of the dens, which then tl(E
the posterior longitudinal ligament. It lies posterior crushes the spinal cord and medulla. However, o
to the transverse ligament. It is attached inferiorly hanging can also cause fracture through the axis,
1 to the posterior surface of the body of the axis and or separation of the axis from the third cervical c
o
superiorly to the basiocciput (within the foramen vertebra (Fig.9.1a). o
o
magnum) (Fig.9.11). a
T
I
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I
HEAD AND NECK
Ceraical spondylosis. Injury or degenerative changes

of old age may rupture the thin lateral parts of
the annuius fibrosus (of the intervertebral disc)
resuiting in prolapse of the nucleus pulposus. This
is known as disc prolapse or spondylosis and may
be lateral or median (Fig. 9.15). Although it is
commonest in the lumbar region, it may occur in
Bony changes
the lower cervical region. This causes shooting
pain along the distribution of the cervical nerve
pressed. A direct posterior prolapse may cornPress
the spinal cord.
Cervical vertebrae may be fractured or, dislocated
by a fallon the head with acute flexion of the neck.
In the cervical region, the vertebrae can dislocate Fig. 9.16: Spondylitis
without any fracture of the articular processes due
to their horizontal position.
Pithing of frog takes place when the cruciate
ligament of median atlantoaxial joint ruptures, Vertebral artery comprises 4 parts
crushing the vital centres in medulla oblongata, a. First part in neck
resulting in immediate death. This occurs in b. Second part in forearm transversaria of C6 to
judicial hanging as well. C1 vertebrae
The degenerative changes or spondylitis may Third part on the posterior arch of atlas.
occur in the cervical spine, leading to narrowed Fourth part through foramen magnum in the
intervertebral foramen, causing Pressure on the cranial cavity
spinal nerves (Fig. 9.16). a Apical ligament is a remnant of notochord
a Median atlantoaxial joint is a pivot type of joint,
permitting movement of 'No'
Atlanto-occipital joint is an ellipsoid joint
permitting movement of 'Yes'
Transverse ligament of atlas is part of the cruciate
ligament. It keeps the dens of axis in position.
Case 1
A person is to be hanged till death for his most
unusual and rare crime
o What anatomical changes occur during this
Fig. 9.14: Fracture of the dens during hanging procedure?
r Name the ligaments of median atlantoaxial joint.
Herniated nucleus
pulposus pressing
Ans: I)eath in execution by hanging is due to
on the spinal
ta
o crush the lowestpart of medulla oblongata which
zo
ttr
o
E' Section of . Transverse ligament of dens
o spinal cord Spinal nerve
o '. Upper part of vertical band
T
Lower part of vertical band
o se three parts form cruciform ligament of the
.F
o Fig. 9.15: Lateral intervertebral disc prolapse atlas vertebra
ao
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PREVERTEBRAL AND PARAVEBTEBBAL REGIONS
There are two joint cavities. e anterior one . Why did the patient have dysphagia?
between the posterior surface of anterior areh of atlas . Where can the cancer spread around oesophagus?
posterior, larger one is between the dens and cancer of the oesophagus. The cancff obliterates
Case 2 t hatic drainage of cervical part of oesophagus

A man aged 55 years complained of dysphagia in
eating solid and even soft food and liquids. There
was a large lymph node felt at the anterior border of
stemocleidomastoid muscle. The diagnosis onbiopsy
was cancer of cervical part of oesophagus. can spread to trachea or any of the pr ipal bronchi.
. How was the large lymph node formed?
MULT1PIE CHO]CE QUESTIONS
L. How many slmovial cavities are there in median c. Ligamentum nuchae

atlantoaxial joint? d. Posterior longitudinal
a. One b. Three 4. Where is the intervertebral disc absent?
c. Two d. Four a. Between first and second cervical vertebrae
2. Which of the following ligament is the upward b. Between thoracic twelve and first lumbar
continuation of membrana tectoria? vertebrae
a. Posterior longitudinal c. Between thoracic one and cervical seven vertebrae
b. Ligamentum nuchae d. Between lumbar five and first sacral vertebrae
5. Which of the following joints do not have a
c. Ligamentum flava
fibrocartilaginous intra-articular disc?
d. Anterior longitudinal a. Temporomandibular
J. \Mhich ligament mentioned below is chiefly elastic? b. Shoulder
a. Anterior longitudinal c. Sternoclavicular
b. Ligamenta flava d. Inferior radioulnar
ANSW
1. c 2.a 4.a ).D
.Y
o
zo
!,
c(E
!t(E
o
I
C
o
.F
()
ao
mebooksfree.com
INTRODUCTION posterior superior and serratus posterior inferior muscles.
The vertebral column at back provides a median axis for The splenius is the highest of these muscles.
the body. There are big muscles from the sacrum to the Levator scapulae forms part of the muscular floor of
skull in different strata which keep the spine straight. the posterior triangle. lt is positioned between scalenus
The only triangle in the upper most part of back is the medius below and splenius capitis above. Follow its
suboccipital triangle containing the third part of the nerve and blood supply from dorsal scapular nerve and
vertebral artery, which enters the skull to supply the deep branch of transverse cervical artery, respectively.
brain. If it gets pressed, many symptoms appear. Spinal root of accessory nerve and proprioceptive
fibres from C3 and C4 to trapezius muscle lie on the
levator scapulae.
Rhomboid minor and major lie on same plane as
levator scapulae. Both are supplied by dorsal scapular
DISSECTION
nerve (C5).
Extend the incision from external occipital pro- Deep to the two rhomboid muscles is thin aponeurotic
tuberance (i), to the spine of the seventh cervical serratus posterior superior muscle from spines of C7
vertebra. Give a horizontal incision from spine of 7th and T1-T2 vertebrae to be insefied into 2-5th ribs.
cervical vertebra or vertebra prominens (iv), till the Serratus posterior inferior muscle artses from T11-T1 2
acromion (v). This will expose the upper part and apex spines and thoracolumbar fascia and is insefted into
of posterior triangle of neck. Look for the occipital artery 9th-12th ribs.
at its apex. The third layer is composed of erector spinae or
Extend the incision from vertebra prominens to spine sacrospinalis with its three subdivisions and
of lumbar 5 veftebra. Reflect the skin laterally along an semispinalis with its three divisions (Figs 10.2a to c).
oblique line from spine of T12 (ii), till the deltoid Erector spinae arises from the dorsal surface of
tuberosity (iii) (Fig. 10.1). sacrum and ascends up the lumbar region. There it
Close to the median plane in the supedicial fascia divides into three subdivisions, the medial one is
are seen the greater occipital nerve and occipital artery. spinalis, inserted into the spines, the intermediate one
Cut through trapezius muscle vertically at a distance is longissimus inserted into the transverse processes
of 2 cm from the median plane. Reflect it laterally and and the lateral one is iliocostalis, inserted into the ribs.
identify the accessory nerve, superficial branch of Each of these divisions is made of short pafis, fresh
transverse cervical aftery and ventral rami of 3rd and slips arising from the area where the lower slips are
4th cervical nerves. insefted (Fig. 10.3).
Latissimus dorsi has already been exposed by the Deep to erector spinae is the semispinalis again
students dissecting the upper limb. Otherwise extend made up of three parts: semispinalis thoracis,
the incision from T12 spine till L5 spine. Reflect the semispinalis cervicis and semispinalis capitis.
skin till lateral side of the trunk and define the margins Both these muscles are inneruated by the dorsal rami
of broad thin latissimus dorsi. This muscle and trapezius of ceruical, thoracic, lumbar and sacral nerves.
form the first layer of muscles. Muscles of fourth layer are the multifidus, rotatores,
The second layer comprises splenius muscle, levator interspinales, inteftransversii and suboccipital muscles
scapulae, rhomboid major, rhomboid minor, serratus (Fis. 10.a).
mebooksfree.com 176
BACK OF THE NECK
Back of scalp primary ramus divides into a medial and a lateral

External ociipital
branch, both of which supply the intrinsic muscles of
Vertebra
prominens (iv) protuberance (i) the back. The medial branch in this region supplies the
skin as well. The dorsal ramus of C1 does not divide into
Acromion (v) medial and lateral branches, and is distributed only to
Scapula
Eighth rib
Deltoid the muscles bounding the suboccipital triangle.
tuberosity (iii) The ligamentum nuchae is a triangular fibrous sheet
that separates muscles of the two sides of the neck. It is
Twelfth rib T12 spine (ii)
better developed and is more elastic in quadrupeds in
whom it has to support a heavy head.
Sacrum
MUSCTES OF THE BACK
The muscles of the entire back can be grouped into the
following four layers from superficial to the deeper
lliac crest plane.
1 Trapezius and latissimus dorsi (see Chapter 5 in
Volume 1).
2 Levator scapulae, rhomboids (two), serratus
posterior superior have been studied in Chapter 5,
Volume 1. Serratus posterior inferior is mentioned
in Chapter 24, Volume 2. Splenius is described briefly
here.
Splenius muscles are two in number. These are
splenius cervicis and splenius capitis. These cover
Fig. 10.1: Lines of dissection the deeper muscles like a bandage (Figs 10.2a
and b).
Origin: From lower half of ligamentum nuchae and
Nerve Supply of Skin spines of upper 5 thoracic vertebrae. These curve in
The skin of the nape or back of the neck, and of the a half spiral fashion and separate into splenius
back of the scalp (Fig. 10.1) is supplied by medial cervicis and splenius capitis.
branches of the dorsal rami of C2 the greater occipital Splenius cervicis gets inserted into the posterior
nerae; C3 the third occipital neroe and C4. Each posterior tubercles of transverse processes of C1-C4 vertebrae.
Occlpital artery
qt Trapezius
j I Sternocleido- Greater
occipital nerve
3L mastoid St
Splenius capitis 3rd occipital S
o) nerve
Ligamentum
o l-Superior oblique capitis nuchae
Ligamentum
E
(o I
tnferior oblique capitis
nuchae
Longissimus capitis o c7
J
Spines
(u T1 o
Semispinalis capitis o
N
T2 z
Transverse T3 ttr
process r4 G,
E E
(E
E T5 o
T6
(a)
c
.9
Figs 10.2a and b: Three layers of muscles covering the suboccipital triangle: (a) First and third layers, and (b) second layer of ()
muscles ao
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HEAD AND NECK
Splenius capitis forms the floor of the posterior Longissimus cervicis-inserted into trans-
triangle and gets inserted into the mastoid process verse process of C2-C6 vertebrae.
beneath the sternocleidomastoid muscle (Fig. 10.5). Longissimus capitis-inserted into mastoid
It is supplied by dorsal rami of C1-C6 nerves. process (Fig. 10.3).
3 a. Erector spinae or sacrospinalis is the true muscle
iii. Spinalis is the medial column, extending
of the back, supplied by posterior rami of the between lumbar and cervical spines. Its parts
spinal nerves. It extends from the sacrum to the are: spinalis lumborum, spinalis thoracis, and
skull (Fi9.10.3). spinalis cervicis.
Origin from the back of sacrum between median b. The other muscle of this layer is semispinalis
and lateral sacral crests, from the dorsal segment extending between transverse processes and
of iliac crest and related ligaments. Soon it splits spines of the vertebrae. It has three parts:
into three columns: Iliocostalis, longissimus, and
spinalis:
i. Semispinalis thoracis (Fig. 10.4).
i. Iliocostalis is the lateral column and comprises ii. Semispinalis cervicis
iliocostalis lumborum, Iliocostalis thoracis and iii. Semispinalis capitis
iliocostalis cervicis. It only lies in the upper half of vertebral column.
These are short slips and are inserted into Semispinalis capitis is its biggest component. It
angles of the ribs and posterior tubercles of arises from transverse processes of C3-T4
cervical transverse process. Origin of the vertebrae, passes up next to the median plane, and
higher slips is medial to the insertion of the gets inserted into the medial area between
lower slips. superior and inferior nuchal lines of the occipital
ii. Longissimus is the middle column and is bone.
composed of: Multifidus, rotatores, interspinales, intertransversii
Longissimus thoracis-inserted into transverse and suboccipital muscles. Multifidus is one of the
processes of thoracic vertebrae. oblique deep muscles. It arises from mammillary
Semispinalis capitis Semispinalis

capitis
Longissimus capitis
Semispinalis
lliocostalis cervtcts
cervtcts
lliocostalis
thoracis Levatores costarum
,ta lliocostalis
o
o lumborum
z ntertransversarii
t,c I
(E
t,(E
o
c
o
o Fig. 10.3: The erector spinae/sacrospinalis muscle with its three Fig. 10.4: Splenius cervicis and capitis; three pafts of semispinalis-
o
a columns the multifidus, levator costiarum and intertransversalis muscles
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BACK OF THE NECK
process of lumbar vertebrae to be inserted into 2-3 a. The greater and third occipital nerves.
higher spinous processes. Rotatores are the deepest b. The terminal part of the occipital artery, with
group. These pass from root of transverse process to accomPanylnS vems.
the root of the spinous process. These are well The fibres of the trapezius run downwards and
developed in thoracic region. Interspinales lie between laterally over the triangle. The sternocleidomastoid
the adjacent spines of the vertebrae. These are better overlaps the region laterally.
developed in cervical and lumbar regions. The splenius capitis runs upwards and laterally for
Intertransversii connect the transverse processes of the
insertion into the mastoid process deep to the
adjacent vertebrae. Suboccipital muscles are described
sternocleidomastoid.
below in the suboccipital triangle (Fig. 10.a).
5 The semispinnlis capitis runs vertically upwards for
insertion into the medial part of the area between
the superior and inferior nuchal lines. In the same
plane laterally there lies thelongissimus capitis which
DISSECTION is inserted into the mastoid process deep to the
It is deep triangle in the area between the occiput and splenius.
the spine of second ceruical, the axis vertebra. The Reflection of the semispinalis capitis exposes the
deepest muscles are the muscles of suboccipital sub o c cipit al trian gl e.
triangle.
Cut the attachments of trapezius from superior nuchal Boundoties
line and reflect it towards the spine of scapula. Cut the Superonne ltf
splenius capitis from its attachment on the mastoid
Rectus capitis posterior major mrscle supplemented by
process and reflect it downwards. Clean the superficial
the rectus capitis posterior minor (Fig. 10.5).
fascia over the semispinalis capitis medially and
longissimus capitis laterally. Reflect longissimus capitis
$uperolofercfly
downwards from the mastoid process.
Cut through semispinalis capitis and turn it towards Superior oblique capitis muscle.
lateral side. Define the boundaries and contents of the
suboccipital triangle. lnferiorly
Inferior oblique capitis muscle.
Muscle Loyers in Neck
Poof
In the suboccipital region between the occiput and the
spine of the axis vertebra, the four muscular layers are Medially
represented by: Dense fibrous tissue covered by the semispinalis capitis.
. Trapezius. Laterally
. Splenius capitis. Longissimus capitis and occasionally the splenius capitis.
o Semispinalis capitis and longissimus capitis.
. The four suboccipital muscles. QT
Tlne arteries found in the back of the neck are:
L Posterior arch of atlas.
a. Occipital, 2 Posterior atlanto-occipital membrane.
b. Deep cervical,
c. Third part of the vertebral artery and Conlenls
d. Minute twigs from the second part of the vertebral
artery. 1 Third part of vertebral artery (Fig. 10.6).
Tlee suboccipital aenous plexus is known for its 2 Dorsal ramus of nerve C1-suboccipital nerve. l(
extensive layout and complex connections. 3 Suboccipital plexus of veins. o
The suboccipital triangle is a muscular space situated zo
!,
deep in the suboccipital region. Suboccipitol Muscles tr
(E
The suboccipital muscles are described in Table 10.1. t,(E

Exposure of Suboccipitol lriongle o
In order to expose the triangle, the following layers are Dorsclffonnu$ of Firsf Ceflvdem, &Jerve
reflected (Fig. 10.5). It emerges between the posterior arch of the atlas and C
.9
1 The skinisverythick. the vertebral afiery, and soon breaks up into branches o
2 The superficial fascia is flbrorts and dense. It contains: which supply the four suboccipital muscles and the ao
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Table 10.1: The suboccipital muscles
Muscle Origin lnsertion Nerve supply Actions
1. Rectus capitis posterior Spine of axis Lateral part of the Suboccipital nerve 1 Mainly postural
major (Fig. 10.5) area below the or dorsal ramus Cl 2 Acting alone it turns the
inferior nuchal line chin to the same side
Acting together the two
muscles extend the head
2. Rectus capitis posterior Posterior Medial part of the 1. Mainly postural

minor (Fig. 10.5) tubercle of atlas area below the inferior 2. Extends the head
nuchal line
3. Obliquus capitis superiorTransverse Lateral area between 1. Mainly postural
(superior oblique) process of atlas the nuchal lines 2. Extends the head
3. Flexes the head laterally
Obliquus capitis inferior Spine of axis Transverse process of 1. Mainly postural

(inferior oblique Fig. 10.5) atlas 2. Turns chin to the same side
and the semispinalis capitis muscles at the apex of the

posterior triangle. Finally, it pierces the trapezius 2.5 cm
Neck rigidity, seen in cases with meningitis, is due
from the midline and comes to lie along the greater
to spasm of the extensor muscles. This is caused
occipital nerve. In the superficial fascia of the scalp, it
has a tortuous course.
by irritation of the nerve roots during their
passage through the subarachnoid space which is
Its branches in this region are: infected. Passive flexion of neck and straight leg
a. Mastoid, raising test cause pain as the nerves are stretched
b. Meningeal, and (Figs 10.7a and b).
Cisternal puncture is done when lumbar puncture
c. Muscular.
fails. The patient either sits up or lies down in the
One of the muscular branches is large, it is called the left lateral position. A needle is introduced in the
descendingbranch andhas superficial and deep branches. midline above the spine of axis in forward and
The superficial branch anastomoses with the superficial upward direction parallel to an imaginary line
branch of the transverse cervical artery; while the deep extending from external acoustic meatus to nasion.
branch descends between the semispinalis capitis and It passes through the posterior atlanto-occipital
cervicis, and anastomoses with the vertebral and deep membrane between the posterior arch of atlas and
cervical arteries. It also gives two branches to the posterior margin of foramen magnum. The
sternocleidomastoid muscle. needle enters the cerebellomedullary cistern and
small amount of CSF is withdrawn.
Oeep al Artery Neurosurgeons approach the posterior cranial
fossa through this region.
It is a branch of the costocervical trunk of the subclavian
artery. It passes into the back of the neck just above the
neck of the first rib. It ascends deep to the semispinalis
capitis and anastomoses with the descending branch of
the occipital artery.
L
Sll,boccipilol Plexus of Veins o
o
It lies in and around the suboccipital triangle, and drains
z
t,c
the: (E
1 Muscular veins !,(E

o
a
2 Occipital veins
3 Internal vertebral venous plexus C
o
4 Condylar emissary vein. It itself drains into the deep o
o
cervical and vertebral plexus of veins. a
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I
HEAD AND NECK
Artery lying on posterior arch of atlas is the third

part of vertebral artery
Greater occipital nerve is the thickest cutaneous
nerve of the body.
A child aged I years has been having high grade

fever with bad throat. On 4th day he could not
movehisneck during drinkingwater or milk as there
was severe pain in the neck,
. lVhy is there pain even in drinking water?
o FIow has it become such a serious condition?
Fig. 10.7b: Straight leg raising test causes pain in meningitis
reached middle ear via pharyngotympanic tube,
is a serious condition and is called meningitis. e
Muscles of the back are disposed in four layers:

extensor muscles and is caused by irritation of nerve
. Muscles of 1st and 2nd layer are supplied by nerves during ir passage through subarachnoid
roots
of upper limb except trapezius, splenius capitis space, ch is infected.
and splenius cervicis. Passive flexion of neck and straight leg raising
o Muscles of 3rd and 4th layers are true muscles of test result in pain as the nerves are stretehed
the back, supplied by dorsal primary rami (Figs 10.7a b).
MUTIIPTE CHOICE OUESTIONS
1. \Atrhich action isnot done by trapezius muscles? 4. Dorsal ramus of one of the cervical nerve has no
a. Protraction of scapula cutaneous branch:
b. Shrugging of shoulder a. 1st cervical b. 2nd cervical
c. Retraction of scapula c. 3rd cervical d. 4th cervical
5. Which is the thickest cutaneous nerve of the body?
d. Overhead abduction of scapula
a. Greater occipital
, Sacrospinalis does not form:
b. Lesser occipital
a. Spinalis b. Longissimus c. Creat auricular
c. Iliocostalis d. Splenius d. Third occipital
3. Which part of vertebral artery lies in the sub- 6. \A/hich of the following cervical nerves is known as
occipital triangle? suboccipital nerve?
a. 1st part b. 3rd part a. 1st b.2nd
c. 2nd part d. 4th part c. 3rd d. 4th
.Y
o
zo ANSWERS
ttr 1.. a 2. d, 3-b 4.a 5:a 6.a
G
!,
o
o
L
.o
()
c.)
U)
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Snell
-Richord
When the vertebrae are put in a sequence, their 1 Epidural or extradural space.
vertebral foramina lie one below the other forming a 2 Thick dura mater or pachymeninx.
continuous canal which is called the aertebral canal. This 3 Subdural capillary space.
canal contains the three meninges with their spaces and 4 Delicate arachnoid mater.
the spinal cord including the cauda equina. The 5 Wide subarachnoid space containing cerebrospinal
intervertebral foramina are a pair of foramina between fluid (CSF).
the pedicles of the adjacent vertebrae. Each foramen 6 Firm pia mater. The arachnoid and pia together form
contains dorsal and ventral roots, trunk and dorsal and the leptomeninges.
ventral primary rami of the spinal nerve, and spinal 7 Spinal cord or spinal medulla and the cauda equina.
vessels. The spinal cord is considered along with the brain
in Chapter 23. The other contents are described below.
EpidurolSpoce
DISSECTION
Epidural space lies between the spinal dura mater, and
the periosteum with ligaments lining the vertebral canal.
Clean the spines and laminae of the entire vefiebral
It contains:
column by removing allthe muscles attached to them.
Trace the dorsal rami of spinal nerves towards the a. Loose areolar tissue.
intervertebral foramina. Saw through the spines and b. Semiliquid fat.
laminae of the vertebrae carefully and detach them so Dura mater
that the spinal medulla/spinal cord encased in the Arachnoid mater
meninges becomes visible.
Pia mater
Clean the external surface of dura mater enveloping
the spinal cord by removing fat and epidural plexus of Subarachnoid space
veins. Carefully cut through a small part of the dura Posterior median septum
mater by a fine median incision. Extend this incision
Dorsal root ganglion
above and below. See the delicate arachnoid mater.
lncise it. Push the spinal cord to one side and try to Trunk of spinal
nerve
identify the ligamentum denticulatum. Define the
Dorsal ramus
attachments of the dorsal and ventral nerve roots on
the sudace of spinal cord and their union to form the Ventral ramus
trunk of the spinal nerve. Cut the trunk of all spinal Ventral nerve root
nerves on both the sides. Gently pull the spinal cord
with caudaequina out from the vertebral canal. Ligamentum denticulatum
Subdural space
CONTENTS Linea splendens
The vertebral canal contains the following structures Fig. 11.1: Schematic transverse section showing the spinal
from without inwards (Fig. 11.1). menrnges
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HEAD AND NECK
c. Spinal arteries on their way to supply the deeper the dura, up to the lower border of the second sacral
contents. vertebra. It is adherent to the dura only where some
d. The internal vertebral venous plexus. structures pierce the membrane, and where the
The spinal arteries arise from different sources at ligamentum denticulata are attached to the dura mater.
different levels; they enter the vertebral canal through
the intervertebral foramina, and supply the spinal cord, Suborochnoid Spoce
the spinal nerve roots, the meninges, the periosteum Subarachnoid space is a wide space between the pia
and ligaments. and the arachnoid, filled with cerebrospinal fluid (CSF).
Venous blood from the spinal cord drains into the It surrounds the brain and spinal cord like a water
epidural or internal vertebral plexus. cushion. The spinal subarachnoid space is wider than
the space around the brain. It is widest below the lower
Spinol Duro Moler end of the spinal cord where it encloses the cauda
Spinal dura mater is a thick, tough fibrous membrane equina. Lumbar puncture is usually done in the lower
which forms a loose sheath around the spinal cord widest part of the space, between third and fourth
(Fig. 11.2). It is continuous with the meningeal layer of lumbar vertebrae.
the cerebral dura mater. The spinal dura extends from
the foramen magnum to the lower border of the second Spinol Pio Moler
sacral vertebra; whereas the spinal cord ends at the Spinal pia mater is thicker, firmer, and less vascular than
lower border of first lumbar vertebra. The dura gives the cerebral pia, but both are made up of fwo layers:
tubular prolongations to the dorsal and ventral nerve a. An orfier epi-pia containing larger vessels.
roots and to the spinal nerves as they pass through the b. An inner pia-glia or pia-intima which is in contact with
intervertebral foramina. nervous tissue.
Between the two layers, there are many small blood
SubdurolSpoce vessels and also cleft like spaces which communicate
Subdural space is a capillary or potential space between with the subarachnoid space. The pia mater closely
the dura and the arachnoid, containing a thin film of invests the spinal cord, and is continuedbelow the spinal
serous fluid. This space permits movements of the dura cord as the filum terminale.
over the arachnoid. The space is continued for a short Posteriorly, the pia is adherent to the posterior
distance on to the spinal nerves, and is in free median septum of the spinal cord, and is also connected
communication with the lymph spaces of the nerves. to the arachnoid by a fenestrated subarachnoid septum.
Anteriorly, the pia is folded into the anterior median
Arochnoid Moler fissure of the spinal cord. It thickens at the mouth of
Arachnoid mater is a thin, delicate and transparent the fissure to form a median, longitudinal glistening
membrane that loosely invests the entire central band, called the linea splendens (Fig. 11.1).
nervous system (Fig. 11.2). Inferiorly, it extends, like On each side between the ventral and dorsal nerve
roots, the pia forms a narrow vertical ridge, called the
ligamentum denticulatum. This is so called because it
gives off a series of triangular tooth-like processes
which project from its lateral free border (Fig. 11.3).
Each ligament has 21 processes; the first at the level of
the foramen magnum, and the last between twelfth
thoracic and first lumbar spinal nerves. Each process
passes through the arachnoid to the dura between two
adjacent spinal neraes. The processes suspend the spinal
cord in the middle of the subarachnoid space.
L Thefilumterminale is a delicate, thread-like structure
o
about 20 cm long. It extends from the apex of the
zo conus medullaris to the dorsum of the first piece of the
!,
tr
(E coccyx. It is composed chiefly of pia mater, although
!,(E a few nerve fibres rudiments of 2nd and 3rd coccygeal
o nerves are found adherent to the upper part of its
I outer surface. The central canal of the spinal cord
c extends into it for about 5 mm.
o
.F
() The filum terminale is subdivided into a part lying
ao within the dural sheath called the filum terminale
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CONTENTS OF VERTEBRAL CANAL
approached through posterior atlanto-occipital

membrane.
Lumbar epidural: The epidural space is the space
between vertebral canal and dura mater. The
epidural space is deeper in the midline. The
procedure is same as lumbar puncture, the needle
should reach only in the epidural space and
Spinal cord
not deep to it in the dura mater. Epidural space
is utilized for giving anaesthesia or analgesia
(Fig. 11.5).
Caudal epidural: The needle is passed through
Fork made by sacral hiatus, which lies equidistant from the right
the lowest process
and left posterior superior iliac spines. The needle
First lumbar nerve passes through posterior sacrococcygeal ligament
and enters the sacral canal. Then the hub of needle
is lowered so thatitpasses along sacral canal. This
space lies below 52 (Fig. 11.6).
Fig. 11.3: Ligamentum denticulatum
internum; and a part lying outside the dural sheath,

Conus medullaris
below the level of the second sacral vertebra called the
filum terminale externum. The filum terminale internum
is 20 cm long, and the externum is 5 cm long.
Pial sheaths surround the nerve roots crossing the L3
subarachnoid space, and the vessels entering the
substance of the spinal cord. CSF in lumbar
cistern
L5
Leptomeningitis Dura mater

o Inflammation due to infection of leptomeninges, S2
i.e. pia mater and arachnoid mater is known as
Sacrum
meningitis. This is commonly tubercular or
pyogenic. It is characterized by fever, marked
headache, neck rigidity, often accompanied by
Fig. 11.4: Lumbar puncture in an adult
delirium and convulsions, and a changed
biochemistry of CSF. CSF pressure is raised, its
proteins and cell content are increased, and sugars
and chloride are selectively diminished.
o Lumbttr puncture in adult: Patient is lying on side
with maximally flexed spine. A line is taken
between highest points of iliac spine at L4 level.
Skin locally anaesthetized, and lumbar puncture
needle with trocar inserted carefully between L3
and L4 spines. Needle courses through skin fat,
supraspinous and interspinous ligaments, liga- l(
o
mentum flava, epidural space, dura, arachnoid, zo
subarachnoid space to release CSF (Fig. 11.4). tttr
o Lumbar puncture in infant, children: During 2nd (E
month of life, spinal cord usually reaches L3 level. !,

G
Lumbar puncture needle is introduced in flexed o
spine between L4 and L5.
. Cisternal puncture: This procedure is rather difficult C
.9
and dangerous. Cerebellomedullary cistern is o
Fig. 11.5: Lumbar epidural anaesthesia and spinal block o
U)
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HEAD AND NECK
Dorsal intermediate
septum
Dorsal median septum
Dorsal grey horn
Dorsal column
Lateral column
Central canal
Ventral grey horn Ventral column
Ventral rootlets
lnterspinous ligamenl Dorsal rootlets Spinal
ganglion
Pia mater
Arachnoid
mater
Extradural space
Dura mater
Fig. 11.6: Caudal epidural anaesthesia Fig. 11.7: Formation of spinal nerve
SPINAT NERVES
The spinal cord gives ride to thirty-one pairs of spinal
Vertebral canal
neraes: eight cervical, twelve thoracic, five lumbar, five
o Compression of the spinal cord by a tumour gives
sacral, and one coccygeal. Each nerve is attached to the
rise to paraplegia or quadriplegia, depending on
cord by two roots, ventral motor and dorsal sensory.
the level of compression.
Each dorsal nerve root bears a ganglion. The aentrnl
and dorsal nerue roots unite in the intervertebral foramen
. Spinal tumours may arise from dura mater-
to form the nerae trunkwhich soon divides into ventral meningioma, glial cells-glioma/ nerve roots-
and dorsal rami (Fig.77.7). neurofibroma, ependyma-ependymoma, and
The uppermost nerve roots pass horizontally from other tissues. Apart from compression of the
the spinal cord to reach the intervertebral foramina. spinal cord, the tumour causes obstruction of the
Lower down they have to pass with increasing subarachnoid space so that pressure of CSF is low
obliquity, as the spinal cord is much shorter than the below the level of lesion (Eroin's syndrome). There
vertebral column. Below the termination of the spinal is yellowish discolouration of CSF beiow the level
cord at the level of first lumbar vertebra, the obliquity of obstruction. CSF reveals high level of protein
becomes much more marked (Fig. 11.3). but the cell content is normal. Queckenstedt's test
Below the lower end of the spinal cord, the roots form does not show a sudden rise and a sudden fall of
a bundle known as the cauda equina because of its CSF pressure by coughing or by brief pressure
resemblance to the tail of a horse. over the jugular veins. Spinal block can be
The roots of spinal nerves are surrounded by sheaths confirmed either by myelography CT scan or MRI
derived from the meninges. The pial and arachnoid scan.
sheaths extend up to the dura mater. The dural sheath o Compression of the cauda equina gives rise to
!
o encloses the terminal parts of the roots, continues over flaccid paraplegia, saddle anaesthesia and
the nerve trunk, and is lost by merging with the sphincter disturbances. This is called ttie
zo epineurium of the nerve. equina syndrome.
cauda
E
o An intervertebral foramen contains: . Compression of roots of spinal nerves may be
!,(E a. The ends of the nerve roots. caused by prolapse of an intervertebral disc, by
o b. The dorsal root ganglion. osteophytes (formed in osteoarthritis), by a
c. The nerve trunk. cervical rib, or by an extramedullary tumour. Such
o d. The beginning of the dorsal and ventral rami compression results in shooting pain along the
o e. A spinal artery. distribution of the nerve.
o
a f. An intervertebral vein (Fig. 11.1).
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CONTENTS OF VERTEBRAL CANAL
VERTEBRAL SYSIEM OF VEINS Communicotions ond Implicolions

The vertebral venous plexus assumes importance in Valveless vertebral system of veins communicates;
cases of: 1 Above with the intracranial venous sinuses.
L Carcinoma of the prostate causing secondaries in the
2 Below with the pelvic veins, the portal vein, and the
caval system of veins.
vertebral column and the skull.
The veins are aalaeless and the blood can flow in them
2 Chronic empyema (collection of pus in the pleural
in either direction. An increase in intrathoracic or intra-
cavity) causing brain abscess by septic emboli.
abdominal pressure, brought about by coughing and
straining, may cause blood to flow in the plexus away
Anolomy of the debrol Venous Plexus
from the heart, either upwards or downwards. Such
The vertebral venous system is made up of a valveless, periodic changes in venous pressure are clinically
complicated network of veins with a longitudinal important because they make possible the spread of
pattern. It runs parallel to and anastomoses with the tumours or infections. For example, cells from pelvic,
superior and inferior venae cavae. This network has abdominal, thoracic and breast tumours may enter the
three intercommunicating subdivisions (Fig. 1 1.8). venous system, and may ultimately lodge in the
7 The epiduralplexus: Lies in the vertebral canal outside vertebrae, the spinal cord, the skull, or the brain.
the dura mater. The plexus consists of a postcentral The common primary sites of tumours causing
and a prelaminar portion. Each portion is drained secondaries in vertebrae are the breast and the prostate.
by two vessels. The plexus drains the structures in
the vertebral canal, and is itself drained at regular
intervals by segmental veins-vertebral, posterior
intercostal, lumbar and lateral sacral. Spinal cord in adult ends at lower border of lumbar
2 Plexus toithin the ztertebrnl bodies: It drains backwards one vertebra
into the epidural plexus, and anterolaterally into the Spinal dura mater and arachnoid mater extend till
external vertebral plexus. sacral two vertebra.
3 External uertebral Tenous plexus: It consists of anterior Spinal pia mater comprises an outer epi-pia and
vessels lying in front of the vertebral bodies, and the an inner pia-intima.
posterior vessels on the back of the vertebral arches Ligamentum denticulata of pia mater are two
and on adjacent muscles. It is drained by segmental vertical ridges with 21 tooth like processes which
ve1ns. suspend the spinal cord in the subarachnoid space.
The lowest or 21.st process lies between T12 and
The suboccipital plexus of veins is a part of the
L1 spinal nerves.
external plexus. It lies in the suboccipital triangle. It
Through the vertebral venous plexus, secondaries
receives the occipital veins of the scalp, is connected
of prostate or breast can reach up to the cranial cavity.
with the transverse sinus by emissary veins, and drains
into the subclavian veins.
A patient suffering from cancer of prostate gland has

lnferior vena cava
developed secondaries in the brain
r What route is taken by cancer cells to reach the
brain from the prostate gland, a pelvic organ?
Ans: The veins from prostate drain into prostatic
Anterior part of external
vertebral venous plexus veins. These veins send small tributaries ough
Basivertebral vein
vertehral canal lodges vertebral venous p us which :a
o
Segmental vein continues up the whole hei of the vertebral canal zo
Dura mater and drains into seg ntal veins in abdominal cavity, !,g
Epidural plexus
thoracic cavity, in the neck and in basilar venous (E
plexus. Thus cancer cells "cli " up to reach basilat !t(E

o
venous plexus which has connections with cerebral I
Posterior part of
external vertebral
venous plexus to setile inbrain resulting in seco,ndaries. is plexus o
.F
in valveless and dangertrus. o
Fig. 11.8: The vertebral system of veins ao
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1. Where does main part of vertebral venous plexus c. Pia mater
lie? d. Cauda equina
a. Subdural space Intervertebral foramen contains all except:
b. Epidural space a. Ends ofnerve roots
c. Subarachnoid space b. Nerve tunk
d. Outside the vertebrae c. Sympathetic ganglion
2. Contents of thoracic part of vertebral canal are d. Spinal artery
following except: Subarachnoid space extends till:
a. Duramater a. 51 vertebra b. 52 vertebra
b. Arachnoid mater c. LL vertebra d. L3 vertebra
xo
zo
t,tr
G
!tG
o
c
o
o
o
a
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-Krishno Gorg
INTRODUCIION tentorium cerebelli (Figs 12.1a to c and 12.2). Divide the

Cranial cavity, the highest placed cavity, contains the attachment of tentorium from the petrous temporal bone.
brain, meninges, venous sinuses, all cranialnerves, four ldentify and divide trigeminal, abducent, facial, and
petrosal nerves, parts of internal carotid artery and a vestibulo-cochlear nerves. Then cut glossopharyngeal,
part of the vertebral artery besides the special senses. vagus, accessory and hypoglossal nerves. All these
The anterior branch of middle meningeal artery lies at nerves have to be cut first on one side and then on the
the pterion and is prone rupture resulting in extradural other side. Lastly identify the two vertebral arteries
haemorrhage. entering the skull through foramen magnum on each
side of the spinal medulla. With a sharp knife cut through
these structures. Thus the whole brain with the
meninges can be gently removed from the skull.
Preserve it in 5% formaldehyde.
DISSECTION
Cut through the dura mater on the ventral aspect of
Detach the epicranial aponeurosis if not already done
brain tillthe inferolateral borders along the superciliary
laterally till the inferior temporal line. ln the region of margin. Pull upwards the fold ol dura mater present
the temple, detach the temporalis muscle with its between the adjacent medial surfaces of cerebral
overlying fascia and reflect these downwards over the
hemispheres. This will be possible tillthe occipital lobe
prnna.
of brain. Pull backwards a similar but much smaller fold
Removal of Skull Cap or Calvaria between two lobes of cerebellum, i.e. falx cerebelli.
Draw a horizontal line across the skull 1 cm above the Separating the cerebrum from the cerebellum is a
orbital margins and 1 cm above the inion. Saw through double fold of dura mater called tentorium cerebelli. Pull
the skull. Be careful in the temporal region as skull is it out in a horizontal plane by giving incision along the
rather thin there. Separate the inner table of skull from petrous temporal bone.
the fused endosteum and dura mater. Learn about the folds of dura mater, i.e. falx cerebri,
Removal of the Brain tentorium cerebelli, falx cerebelli, diaphragma sellae
To remove the brain and its enveloping meninges, the including trigeminal cave from the specimen with the
structures leaving or entering the brain through various help of base of skull. Make a paper model of these dural
foramina of the skull have to be carefully detached/ folds for recapitulation.
incised. Start from the anterior aspect by detaching falx
cerebri from the crista galli. Contenls
Put 2-3 blocks under the shoulders so that head
The convex upper wall of the cranial cavity is called
falls backwards. This will expose the olfactory bulb,
the oault.It is uniform and smooth. The base of the
which may be lifted from the underlying anterior cranial
cranial cavity is uneven and presents three cranial
fossa. ldentify optic nerve, internal carotid artery,
fossae (anterior, middle and posterior) lodging the
infundibulum passing towards hypophysis cerebri.
uneven base of the brain (Figs 12.1a to c).
Divide all three structures. Cut through the oculomotor
The cranial cavity contains the brain and meninges;
and trochlear nerves in relation to free margin of
the outer dura mater, the middle arachnoid mater, and
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HEAD AND NECK
the inner pia mater. The dura mater is the thickest of vascular processes. The adhesion is most marked at
the three meninges. It encloses the cranial venous the sutures, on the base of the skull and around the
sinuses, and has a distinct blood supply and nerve foramen magnum.
supply. The dura is separated from the arachnoid by a
potential subdural space. The arachnoid is separated
from the piaby a wider subarachnoid space filled with At places, the meningeal layer of dura mater is folded
cerebrospinal fluid
(CSF). The arachnoid, pia, on itself to form partitions which divide the cranial
subarachnoid space and CSF are dealt with the brain; cavity into compartments which lodge different parts
the dura is described here. of the brain (Figs 72.\a to c). The folds are:
. Falx cerebri,
Celeblol Dulo Moler o Tentorium cerebelli,
The dura mater is the outermost, thickest and toughest o Falx cerebelli,
membrane covering the brain (dura = hard) (mater = . Diphragma sellae.
mother).
Ealx cerebri
There are two layers of dura:
The falx cerebri is a large sickle-shaped fold of dura
a. An outer or endosteal layer whict:. serves as an mater occupying the median longitudinal fissure
internal periosteum or endosteum or endo- between the two cerebral hemispheres (Fig. 12.L). It has
cranium for the skull bones. two ends:
b. An inner or meningeal layer wiitich surrounds the L The anterior end is narrow, and is attached to the crista
brain. The meningeal layer is continuous with the galli.
spinal dura mater. 2 The posterior end isbroad, and is attached along the
The two layers are fused to each other at all places, median plane to the upper surface of the tentorium
except where the cranial venous sinuses are enclosed cerebelli.
between them.
The falx cerebri has two margins:
L The upper margi;n is convex and is attached to the lips
L The endocranium is continuous: of the sagittal sulcus.
a. With the periosteum lining the outside of the skull 2 The lower margin is concave and free.
or pericranium through the sutures and foramina. The falx cerebri has right and left surfaces each of
b. With the periosteal lining of the orbit through the which is related to the medial surface of the
superior orbital fissure. corresponding cerebral hemisphere.
2 It provides sheaths for the cranial nerves, the sheaths Three important venous sinuses are present
fuse with the epineurium outside the skull. Over the in relation to this fold. The superior sagittal sinus lies
optic nerve, the dura forms a sheath which becomes along the upper margin; tlrre inferior sngittal sinus along
continuous with the sclera. the lower margin; and the straight sinus along t}i.e
3 Its outer surface is adherent to the inner surface of line of attachment of the falx to the tentorium cerebelli
the cranial bones by a number of fine fibrous and (Figs 12.1a and b).
Superior sagittal
SINUS
Superior
sagittal sinus Falx cerebri
Falx cerebri
lnferior sagittal Falx cerebri Straight sinus
SINUS
Straight sinus Tentorium
Outer and inner
l( Tentorium cerebelli
o layers of dura mater
zo
cerebelli Transverse
Tentorium cerebelli SINUS
t, Right transverse
Transverse
SINUS Falx cerebelli
(E
SINUS
!l(E Falx
Tentorial notch cerebelli
o
Foramen magnum
(b) (c)
C
o Figs 12,1a to c: Coronal sections through the posterior cranial fossa showing folds of dura mater and the venous sinuses enclosed
o in them: (a) Section through the tentorial notch (anterior part of the fossa), (b) section through the middle part of the fossa, and
oo) (c) section through the posterior-most part
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CRANIAL CAVITY
Tentorium cerebelli it is attached to the lips of the transverse sulci on the

The tentorium cerebelli is a tent-shaped fold of dura occipital bone, and on the posteroinferior angle of the
mater, forming the roof of the posterior cranial fossa. It parietal bone. Anterolaterally, it is attached to the
separates the cerebellum from the occipital lobes of the superior border of the petrous temporal bone and to
cerebrum, and broadly divides the cranial cavity into the posterior clinoid processes. Along the attached
supratentorial and infratentorial compartments. The margin, there are the transverse and superior petrosal
infratentorial compartment, in other words, is the venous sinuses.
posterior cranial fossa containing the hindbrain and the The trigeminal or Meckel's caoe is a recess of dura
lower part of the midbrain. mater present in relation to the attached margin of the
The tentorium cerebelli has a free margin and an tentorium. It is formed by evagination of the inferior
attached margin (Fig. 12.2). The anterior free margin is layer of the tentorium over the trigeminal impression
U-shaped and free. The ends of the 'lJ' are attached on the petrous temporal bone. It contains the trigeminal
anteriorly to the anterior clinoid processes. This margin ganglion (Fig. 12.3).
bounds tLre tentorial notch which is occupied by the The free and attached margins of the tentorium
midbrain and the anterior part of the superior vermis. cerebelli cross each other near the apex of the petrous
The outer or attached margin is convex. Posterolaterally, temporal bone. Anterior to the point of crossing, there
Diapharagma sellae covering

hypophyseal fossa
Anterior clinoid process
Optic nerve
lnternal carotid artery
lnfundibulum
Aperture for oculomotor nerve
Oculomotor nerve
Aperture for trochlear nerve
Trochlear nerve
Attached margin of tentorium cerebelli
Great cerebral vein with superior petrosal sinus
Free margin of tentorium cerebelli
Transverse sinus within layers of tentorium
Opening of superior sagittal sinus

Fig. 12.2: Tentorium cerebelli seen from above
is a triangular area which forms the posterior part of The tentorium cerebelli has two surfa ces. The sup er ior
the roof of the cavernous sinus, and is pierced by the from the median
surface is convex and slopes to either side
third and fourth cranial nerves. plane. The falx cerebri is attached to this surface, in the
midline; the straight sinus lies along the line of this
attachment. The superior surf ace is related to the occipital
Tentorium
lobes of the cerebrum. Theinferior surfaceisconcave and
Superior
pehosal cerebelli fits the convex superior surface of the cerebellum. The
SINUS
root
falx cerebelli is attached to its posterior part (Fig. 12.1c).
.:a
o
Falx cerebelli
Trigeminal or
-Sensory
Meckel's cave The falx cerebelli is a small sickle-shaped fold of dura
zo
ttr
lnner and outer
mater projecting forwards into the posterior cerebellar G
Trigeminal
layers of dura notch (Fig. 12.1c). !t(E
mater The base of the sickle is attached to the posterior part o
Petrous temporal of the inferior surface of the tentorium cerebelli in the
bone
median plane. The apex of the sickle is frequently c
.o
Fig. 12.3: Parasagittal section through the petrous temporal divided into two parts which are lost on the sides of o
bone and meninges to show the formation of the trigeminal cave the foramen magnum. ao
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HEAD AND NECK
The posterior margin is convex and is attached to the

internal occipital crest. It encloses the occipital sinus. o Pain sensitiae intracranial sttuctures are:
T}ne anterior margin is concave and free.
a. The large cranial venous sinuses and their
Diaph ma sellae tributaries from the surface of the brain.
b. Dural arteries.
The diaphragma sellae is a small circular, horizontal
fold of dura mater forming the roof of the hypophyseal c. The dural floor of the anterior and posterior
cranial fossae.
fossa.
d. Arteries at the base of the brain.
Anteriorly, it is attached to the tuberculum sellae. Hendache may be caused by:
Posteriorly, it is attached to the dorsum sellae. On each a. Dilatation of intracranial arteries.
side, it is continuous with the dura mater of the middle b. Dilatation of extracranial arteries.
cranial fossa (Fig. 12.4). c. Traction or distension of intracranial pain
The diaphragma has a central aperture through sensitive structures.
which the stalk of the hypophysis cerebri passes. d. Infection and inflammation of intracranial and
extracranial structures supplied by the sensory
cranial and cervical nerves.
Diaphragma sellae
Extradural and subdural hnernorrhages are bolh
common. An extradural haemorrhage can be
Hypophysis
distinguished from a subdural haemorrhage
cerebri because of the following differences.
a. The extradural haemorrhage is arterial due to
lnner and injury to middle meningeal attery, whereas
outer layers subdural haemorrhage is venous in nature.
of dura mater
b. Symptoms of cerebral compression are late in
extradural haemorrhage.
c. In an extradural haemorrhage, paralysis first
appears in the face and then spreads to the
lower parts of the body.In
)dy a subdural haemo-
Hypophyseal fossa ilhage, the progress ofrparalysis is haphazard.
rrhage,
d. Inanextraduralhaethaemorrhage, there is no blood
Fig. 12.4: Diaphragma sellae as seen in a sagittal section in the CSF; while it is a common feature of
through the hypophyseal fossa subdural haemorrhage'
BIood Supply 2 The dura of the floor has a rich nerve supply and is
quite sensitive to pain.
The outer layer is richly vascular. The inner meningeal
a. The anterior cranial fossa is supplied mostly by the
layer is more fibrous and requires little blood supply. anterior ethmoidal nerve and partly by the
1 The vault or supratentorial space is supplied by the maxillary nerve.
middle meningeal artery. b. The middle cranial fossa is supplied by the maxillary
2 The anterior cranial fossa and the dural lining is nerve in its anterior half, and by branches of the
supplied by meningeal branches of the anterior mandibular nerve and from the trigeminal
ethmoidal, posterior ethmoidal and ophthalmic ganglion in its posterior half.
arteries. c. The posterior cranial fossa is supplied chiefly by
3 The middle cranial fossa is supplied by the middle recurrent branches from first, second and third
meningeal, accessory meningeal, and internal carotid cervical spinal nerves and partly by meningeal
J arteries; and by meningeal branches of the ascending branches of the ninth and tenth cranial nerves.
o pharyngeal artery.
zo 4 The posterior cranial fossa is supplied by meningeal VENOUS SINUSES OF DURA MAIER
E
tr
(E
branches of the vertebral, occipital and ascending These are venous spaces, the walls of which are formed
t,(E pharymgeal arteries. by dura mater. They have an inner lining of endo-
o thelium. There is no muscle in their walls' They have
J-
Nerue Supply no valves.
L The dura of thLe oault has only a few sensory nerves Venous sinuses receive venous blood from the brain,
o
o which are derived mostly from the ophthalmic the meninges, and bones of the skull' Cerebrospinal
o
a division of the trigeminal nerve. fluid is poured into some of them.
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CBANIAL CAVITY
Cranial venous sinuses communicate with veins

outside the skull through emissary aeins. These
communications help to keep the pressure of blood in Endothelium
the sinuses constantlsee Table 1.1).
Oculomotor
There are 23 venous sinuses, of which 8 are paired nerve
and7 are unpaired. Trochlear
nerve
Ophthalmic
There is one sinus each on right and left side. nerve
1 Cavernous sinus. Maxillary

nerve
2 Superior petrosal sinus (Fig. 12.3).
3 Inferior petrosal sinus. lnternal carotid artery
4 Transverse sinus (Fig.72.2). Abducent nerve
Mandibular nerve
5 Sigmoid sinus.
Fig. 12.5: Coronal section through the middle cranial fossa
6 Sphenoparietal sinus. showing the relations of the cavernous sinus
7 Petrosquamous sinus.
8 Middle meningeal sinus/veins. Relolions
Structures outside the sinus:
1 Superiorly: Optrc tract, optic chiasma, olfactory tract,
These are median in position. internal carotid artery and anterior perforated
1 Superior sagittal sinus (Fig. 12.1). substance (see Fig. 24.1).
2 Inferior sagittal sinus. 2 rly,Foramenlacerumandthejunctionofthebody
3 Straight sinus (Fig. 12.2). and greater wing of the sphenoid bone (see Fig. 1.18).
4 Occipital sinus. 3 Medially; Hypophysis cerebri and sphenoidal air
sinus (Fig. 12.5).
5 Anterior intercavernous sinus. 4 Laterally: Temporal lobe with uncus.
6 Posterior intercavernous sinus. 5 Below laterally: Mandibular nerve
7 Basilar plexus of veins. 6 Anteriorly; Superior orbital fissure and the apex of
the orbit.
7 Posteriorly; Apex of the petrous temporal and the crus
cerebri of the midbrain.
DISSECTION Sfrucfures wifh intha Laters[ tt

Define the cavernous sinuses situated on each side of
the body of the sphenoid bone. Cut through it between Oculomotor nerue:In the anterior part of the sinus, it
the anterior and posterior ends and locate its contents. divides into superior and inferior divisions which
Define its connections with the other venous sinuses leave the sinus by passing through the superior
and veins. orbital fissure.
Trochlenr nerae: In the anterior part of the sinus, it
Introduclion crosses superficial to the oculomotor nerve, and
Each cavernous sinus is a large venous space situated enters the orbit through the superior orbital fissure.
in the middle cranial fossa, on either side of the body Ophthalmic nerzse: In the anterior part of the sinus, it
of the sphenoid bone. Its interior is divided into a divides into the lacrimal, frontal and nasociliary
number of spaces or caverns by trabeculae. The nerves (see Figs 13.4 and 73.6). L
trabeculae are much less conspicuous in the living than xillnry nerae:Itleaves the sinus by passing through o
o
in the dead (Fig. 12.5). the foramen rotundum on its way to the ptery- z
gopalatine fossa. !tc
The floor and medial wall of the sinus is formed by (E
Trigeminal ganglion: The ganglion and its dural cave
the endosteal dura mater. The lateral wall, and roof are t(E
formed by the meningeal dura mater. project into the posterior part of the lateral wall of o
the sinus (Fig. 12.3). I
Anteriorly, the sinus extends up to the medial end of
the superior orbital fissure andposteriorly,tp to the apex Structures passing through the medial aspect of the sinus: c
o
of the petrous temporal bone. It is about 2 cm long, and a. lnternal carotid artery with the venous and sympathetic o
o
1 cm wide (see Fig. 1.18). plexus around it. a
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HEAD AND NECK
b. Abducent neroe, inferolateral to the internal carotid FromtheBrain

artery. 1 Superficial middle cerebral vein.
The structures in the lateral wall and on the medial 2 Inferior cerebral veins from the temporal lobe
aspect of the sinus are separated from blood by the (Fis.I2.7).
endothelial lining.
rn lhe Menfnges
Iribulories oI !ncoming Chonnels 1 Sphenoparietal sinus.
rntke orbit 2 The frontal trunk of the middle meningeal vein may
1 The superior ophthalmic vein. drain either into the pterygoid plexus through the
2 A branch of the inferior ophthalmic vein or some- foramen ovale or into the sphenoparietal or
times the vein itself. cavernous sinus.
3 The central vein of the retina may drain either into
the superior ophthalmic vein or into the cavernous Droining Chonnels oI Communicotions
sinus (Fig. 12.6). The cavernous sinus drains:
Sphenoparietal sinus Superficial middle cerebral vein
Frontal trunk of middle meningeal vein

Supraorbital vein
Supratrochlear vein lnferior cerebral veins
Superior petrosal sinus

Superior ophthalmic vein
Cavernous sinus
Central vein of retina
lnferior ophthalmic vein
Facial vein Emissary veins
Pterygoid venous plexus
Deep facial vein
Fig. 12.6: Side view of the tributaries and communications of the cavernous sinus
Anterior intercavernous sinus lnfundibulum

Sphenoparietal sinus
Frontal trunk of middle meningeal vein Cavernous sinus

Superficial middle cerebral vein
lnferior cerebral veins
Posterior intercavernous sinus
Basilar plexus of veins
I
o
o
z Sigmoid sinus
t,tr lnternal jugular vein
(E
!t(E Connection with internal
o vertebral venous plexus
Transverse sinus
C
o Occipital sinus
Confluence of sinuses
o
o
o Fig. 12.7: Superior view of the tributaries and communications of the cavernous sinus
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CRANIAL CAVITY
L Into the transverse sinus through the superior section. It ends near the internal occipital protuberance
petrosal sinus. by turning to one side, usually the right, and becomes
2 Into the internal jugular vein through the inferior continuous with the right transverse sinus (Figs 12.8
petrosal sinus and-through a plexus around the and72.9).It generally communicates with the opposite
internal carotid artery. sinus. The junction of all these sinuses is called the
3 Into the pterygoid plexus of veins through the confluence of sinuses.
emissary veins passing through the foramen ovale, T]:re interior
of the sinus shows:
the foramen lacerum and the emissary sphenoidal a. Openings of the superior cerebral veins.
foramen (Table 12.1). b. Openings of venous lacunae, usually three on each
4 Into the facial vein through the superior ophthalmic side.
veln. c. Arachnoid villi and granulations projecting into
5 The right and left cavernous sinuses communicate the lacunae as well as into the sinus (Fig.12.9).
with each other through the anterior and posterior d. Numerous fibrous bands crossing the inferior
intercavernous sinuses and through the basilar angle of the sinus.
plexus of veins (Fig.12.7).
All these communications are valveless, and blood
can flow through them in either direction. The superior sagittal sinus receives these tributaries.
a. Superior cerebral veins which never open into the
Fmcfmrs FieJprlg frfoodfrorn ffte$rnuss
uCsion of venous lacunae (Fig. 12.9).
1 Expansile pulsations of the internal carotid artery b. Parietal emissary veins.
within the sinus. c. Venous lacunae, usually three on each side which
2 Gravity. first, receive the diploic and meningeal veins, and
3 Position of the head. then open into the sinus.
d. Occasionally, a vein from the nose opens into the
sinus when the foramen caecum is patent.
. Thrombosis of the caaertlous sinus may be caused
by sepsis in the dangerous area of the iace, in nasal Thrombosis of the superior sagittal sinus maybe caused
cavities, and in paranasal air sinuses. This gives by spread of infection from the nose, scalp and
rise to the following symptoms. diploe. This gives rise to:
a. Neraous symptoms: a. A considerable rise in intracranial tension due to
- Severe pain in the eye and forehead
in the defective absorption of CSF.
ol distribution of ophthalmic nerve.
area b. Delirium and sometimes convulsions due to
- Lrvolvement of the third, fourth and sixth congestion of the superior cerebral veins.
cranial nerves resulting in paralysis of the c. Paraplegia of the upper motor neuron type due
muscles supplied. to bilateral involvement of the paracentral lobules
b. Venous symptoms: Marked oedema of eyelids, of cerebrum where the lower limbs and perineum
comea and root of the nose, with exophthalmos are represented.
due to congestion of the orbital veins.
o A communication between the cavernous sinus lnferior Sogittol Sinus
and the intemal carotid artery may be produced
The inferior sagittal sinus, a small channel lies in the
byhead injury. W.hen this happens the eyeball pro-
posterior two-thirds of the lower, concave free margin
trudes and pulsates with each heart beat. It is
of the falx cerebri. It ends by joining the great cerebral
called the pulsating exophthalmos.
vein to form the straight sinus (Fig. 12.8).
.Y
Superior Sogittol Sinus Stroight Sinus o
The superior sagittal sinus occupies the upper convex, The straight sinus lies in the median plane within the
zo
!ttr
attached margin of the falx cerebri (Figs 12.8 and 72.9). junction of falx cerebri and the tentorium cerebelli. It is (E
It begins anteriorly at the crista galli by the union of formed anteriorly by the union of the inferior sagittal t,G
tiny meningeal veins. Here it communicates with the sinus with the great cerebral vein, and ends at the o
veins of the frontal sinus, and occasionally with the internal occipital protuberance by continuing as the
veins of the nose, through the foramen caecum. As the transverse sinus usually left (Fig. 12.8). In addition to C
.o
sinus runs upwards and backwards, it becomes the veins forming it, it also receives a few of the superior o
o
progressively larger in size. It is triangular on cross- cerebellar veins. U)
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HEAD AND NECK
I nferior sagittal sinus Great cerebral vein
Cavernous sinus
Sigmoid sinuses Transverse sinuses
Continues as IJV
Fig. 12.8: Scheme to show the intracranial venous sinuses. Lateral view
Emissary vein
Endosteal layer of Superior sagittal sinus
dura mater Diploic vein
Meningeal layer of Meningeal vein within

dura mater venous lacuna
Arachnoid mater
Subarachnoid space with Superior cerebral vein
cerebrospinal fluid
Pia mater Arachnoid villi and granulation
Arachnoid granulation
Falx cerebri
Fig. 12.9: Coronal section through superior sagittal sinus showing arrangement of the meninges, the arachnoid villi and granulations,
and the various (emissary, diploic, meningeal and cerebral) veins in its relation
At the termination of the great cerebral vein into the 3 Inferior cerebellar veins
sinus, there exists a ball valve mechanism, formed by a 4 Diploic (posterior temporal) vein
sinusoidal plexus of blood vessels, which regulates the 5 Inferior anastomotic vein.
secretion of CSF.
Ttonsverse Sinus
Sigmoid Sinuses
Each sinus right or left is the direct continuation of the
The transverse sinuses are large sinuses (Fig. 12.8). The
right sinus usually larger than the left, is situated in transverse sinus (Fig. 12.8). It is S-shaped: hence the
name. It extends from the posteroinferior angle of the
.Y the posterior part of the attached margin of the
o parietal bone to the posterior part of the jugular foramen
zo tentorium cerebelli. The right transverse sinus is usually
a continuation of the superior sagittal sinus, and the
where it becomes the superior bulb of the internal
!, jugular vein. It grooves the mastoid part of the temporal
tr left sinus a continuation of the straight sinus. Each sinus
(E
bone, where it is separated anteriorly from the mastoid
t,G extends from the internal occipital protuberance to the
antrum and mastoid air cells by only a thin plate of bone.Its
o posteroinferior angle of the parietal bone at the base of
mastoid process where it bends downwards and tributaries are:
c becomes the sigmoid sinus. Its tributaries are: L The mastoid and condylar emissary veins.
.9
() 1 Superior petrosal sinus 2 Cerebellar veins.
ao 2 Inferior cerebral veins 3 The internal auditory vein.
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CRANIAL CAVITY
Table 12.1: Emissary veins: Valveless and communicate

intracranial with extracranial veins
Thrombosis of the sigmoid sinus is always secondary
to infection in the middle ear or otitis media, or in Stnus Connection Veins
the mastoid process called mastoiditis. Superior sagittal Parietal emissary vein Veins of scalp,
During operations on the mastoid process, one
sinus Foramen caecum nasal veins
Middle meningeal vein Pterygoid veins
should be careful about the sigmoid sinus, so that Transverse sinus Petrosquamous External jugular
it is not exposed. Sigmoid sinus Mastoid vein Posteriorauricular
Spread of infection or thrombosis from the Hypoglossal vein IJV
sigmoid and transverse sinuses to the superior Posterior condylar Suboccipital vein
vetn
sagittal sinus may cause impaired CSF drainage
Cavernous sinus Emissary veins Pterygoid veins
into the latter and may, therefore, lead to the Veins around ICA IJV
development of hydrocephalus. Such a hydro- Ophthalmic vein Facial vein
cephalus associated with sinus thrombosis lnferior petrosal IJV
following ear infection is known as otitic hydro-
cephalus.
ICA - lnternal carotid artery; IJV - lnternal jugular vein
Other Sinuses
The occipital sinus is small, and lies in the attached
DISSECI]ON
margin of the falx cerebelli. It begins near the foramen
magnum and ends in the confluence of sinuses ldentify diaphragma sellae over the hypophyseal fossa.
(Figs 12.1 and 12.8). lncise it radially and locate the hypophysis cerebri
lodged in its fossa. Take it out and examine it in detail
Tl;le sphenoparietal sinuses, right and left lie along the
with the hand lens (Figs 12.10 and 12.11).
posterior free margin of the lesser wing of the sphenoid
bone, and drain into the anterior part of the cavernous
sinus. Each sinus may receive the frontal trunk of the Introduclion
middle meningeal vein (Fig. 12.8). The hypophysis cerebri is a small endocrine gland
Tlae superior petrosal sinuses lie in the anterior part of situated in relation to the base of the brain. It is often
the attached margin of the tentorium cerebelli along called the master of the endocrine orchestra because it
the upper border of the petrous temporal bone. It drains produces a number of hormones which control the
the cavernous sinus into the transverse sinus (Fig. 12.7). secretions of many other endocrine glands of the body
The inferior petrosal sinuses right and left lie in the (Fig. 12.10).
corresponding petro-occipital fissure, and drain the The gland lies in the hypophyseal fossa or sella
cavernous sinus into the superior bulb of the internal turcica or pituitary fossa. The fossa is roofed by the
jugular vein. diaphragma sellae. The stalk of the hypophysis cerebri
The basilar plexus of zseins lies over the clivus of the
lnfundibular. recess
skull. It connects the two inferior petrosal sinuses and of third ventricle Median eminence
communicates with the internal vertebral venous
plexus. Optic
The middle meningeal aeins formtwo main trurks, one chiasma
frontal or anterior and one parietal or posterior, which
accompany the two branches of the middle meningeal
Mammillary
artery. Thefrontal trunkmay end either in the pterygoid body
plexus through the foramen ovale, or in the spheno- Pars tuberalis j
parietal or cavernous sinus. The parietal trunk :usually o
ends in the pterygoid plexus through the foramen zo
!,
spinosum. The meningeal veins are nearer to the bone tr
(E
than the arteries, and are, therefore, more liable to injury !,(E
in fractures of the skull. o
The anterior and posterior intercauernous sinuses Pars
anterior
connect the cavernous sinuses. They pass through the c
.o
diaphragma sellae, one in front and the other behind Fig. 12.10: Parts of the hypophysis cerebri as seen in a sagittal o
o
the infundibulum (Fig. 12.8). section ct)
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HEAD AND NECK
pierces the diaphragma sellae and is attached above to Arleilol Supply

the floor of the third ventricle. The hypophysis cerebri is supplied by the following
The gland is oval in shape, and measures 8 mm branches of the internal carotid artery.
anteroposteriorly and 72 mm transversely. It weighs 1 One superior hypophyseal artery on each side
about 500 mg. (Fig. 12.11).
2 One inferior hypophyseal artery on each side. Each
Relotions superior hypophyseal artery supplies:
Superiorly a. Ventral part of the hypothalamus.
1 Diaphragma sellae (Fig.72.\. b. Upper part of the infundibulum.
2 Optic chiasma. c. Lower part of the infundibulum through a
3 Tubercinerium. separate long descending branch, called the
4 Infundibular recess of the third ventricle. trabecular artery.
riorly Each inferior hypophyseal artery divides into medial
1 Irregular venous channels between the two layers of and lateral branches which join one another to form an
dura mater lining the floor of the hypophyseal fossa. arterial ring around the posterior lobe. Branches from
2 Hypophyseal fossa. this ring supply the posterior lobe and also anastomose
3 Sphenoidal air sinuses (Fig. 12.5). with branches from the superior hypophyseal artery.
The ante.rior lobe or pars distalis is supplied
On each side exclusively by portal oessels arising from capillary tufts
The cavernous sinus with its contents (Fig. 12.5). formed by the superior hypophyseal arteries
(Fig. 12.11). The long portal vessels drain the median
Subdivisions/Pods ond Developmenl eminence and the upper infundibulum, and the short
The gland has two main parts: Adenohypophysis and portal vessels drain the lower infundibulum. The portal
neurohypophysis which differ from each other vessels are of great functional importance because they
embryologically, morphologically and functionally. The carry the hormone releasing f actors from the
adenohypophysis develops as an upward growth called hypothalamus to the anterior lobe where they control
the Rathke's pouch from the ectodermal roof of the the secretory cycles of different glandular cells.
stomodeum. The neurohypophysis develops as a
downward growth from the floor of the diencephalon, Venous Droinoge
and is connected to the hypothalamus by neural Short veins emerge on the surface of the gland and drain
pathways. Further subdivisions of each part are given into neighbouring dural venous sinuses. The hormones
below. pass out of the gland through the venous blood, and
are carried to their target cells.
L Anterior lobe or pars anterior, Pars distalis, or pars

glandularis: This is the largest part of the gland Capillary tufts in
(Fig. 12.10). median eminence
Superior
2 lntermediate lobe ot pafi intermedin: This is in the form and in infundibulum
hypophyseal
of a thin strip which is separated from the anterior artery
lobe by an intraglandular cleft, a remnant of the Long
Trabecular artery
porta vessels
lumen of Rathke's pouch. to lower infundibulum
3 Tuberal lobe or pais tuberalis: It is an upward extension
of the anterior lobe that surrounds and forms part Capillary tufts in
of the infundibulum. lower infundibulum
l< Short portal vessels
o fferurofiyp hysrs
o
z 1. Posterior lobe or neurnl lobe, pars posterior: It is smaller Anastomoses between
!ttr superior and inferior
(E than the anterior lobe and lies in the posterior hypophyseal arteries
E'
(5
concavity of the larger anterior lobe.
I
o lnfundibular stem, which contains the neural I nferior hypophyseal artery
connections of the posterior lobe with the hypo- Fig. 12.11: Arterial supply of the hypophysis cerebri. Note that
o thalamus. the neurohypophysis is supplied by the superior and inferior
.F
o Median eminence of the tubercinerium which is hypophyseal arteries, and the adenohypophysis, exclusively by
o
a continuous with the infundibular stem. the portal vessels
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CRANIAL CAVITY
Holmones
c. Pressure over the hypothalamus may cause
Anferiorlobe one of the hypothalamic syndromes like
Chr omophilic cells 507. obesity of Frolich's syndrome in cases with
1 Acidophils/alpha-cells; abotfi 43"h Rathke's pouch fumours.
a. Somatotrophs: Secrete growth hormone (STH, d. A large tumour may press upon the third
GH). ventricle, causing a rise in intracranial pressure.
b. Mammotrophs (prolactin cells): Secrete lactogenic B. Specific symptoms depending on the cell type of
hormone. the tumour.
c. Corticotrophs: Secrete ACTH. a. Acidophil or eosinophil adenoma causes
2 Basophils/beta-cells, about 7"/" of cells acromegaly in adults and gigantism in younger
a. Thyrotrophs: Secrete TSH. patients.
b. Gonadotrophs: Secrete FSH. b. Basophil adenoma causes Cushing's slmdrome.
c. Luteotrophs: Secrete LH or ICSH. c. Chromophobe adenoma causes effects of
Chromophobic cells 50%" represent the non-secretory hypopituitarism.
phase of the other cell types, or their precursors. d. Posterior lobe damage causes diabetes
insipidus, although the lesion in these cases
Jmlermie fe [obe usually lies in the hypothalamus.
It is made up of numerous basophil cells, and chromo-
phobe cells surrounding masses of colloid material. It
Temporal
secretes the melanocyte stimulating hormone (MSH). field
Posfec',"*r Aobe
It is composed of:
1 A large number of nonmyelinated fibres hypo-
thalamo-hypophyseal tract.
2 Modified neurological cells, called pituicytes. They
have many dendrites which terminate on or near the
sinusoids.
pothalam o-hypophyseal portal system
Optic nerve
The hypothalamo-hypophyseal tract begins in the
preoptic and paraventricular nuclei of the hypothalamus.
Its short fibres terminate in relation to capillary tufts of Temporal field
portal vessels, providing the possibility for a neural fibres pressed
by pituitary tumour
control of the secretory activity of the anterior lobe. The
long fibres of the neurosecretory tract pass to the
posterior lobe and terminate near vascular sinusoids.
The hormones related to the posterior lobe are: Fig. 12.12:. Bitemporal hemlanopia due to pressure
a. Vasopressin (ADH) which acts on kidney tubules. pituitary tumour on the central part of optic chiasma
b. Oxytocin which promotes contraction of the
uterine and mammary smooth muscle.
These hormones are actually secreted by the
hypothalamus, froin where these are transported
through the hypothalamo-hypophyseal tract to the
posterior lobe of the gland. DISSECIION
ldentify trigeminal ganglion situated on the anterior j
surface of petrous temporal bone near its apex. Define o
Pituitary tumours give rise to two main categories the three branches emerging from its convex anterior zo
t,tr
of symptoms: surface.
G
A. General symptoms due to pressure over surroun- !,(E
ding structures: Iniroduclion o
a. The sella turcica is enlarged in size. This is the sensory ganglion of the fifth cranial nerve. It
b. Pressure over the central part of optic chiasma is homologous with the dorsal nerve root ganglia of C
.9
causes bitemporal hemianopia (Fig. 72.12). spinal nerves. All
such ganglia are made up of O
pseudounipolar nerve cells, with a'T'-shaped arrange- ao
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HEAD AND NECK
Greater wing Associoled Rool ond Bronches

of sphenoid lnternal carotid artery The centralprocesses of the ganglioncells formthe large
Frontal branch
sensory root of the trigeminal nerve which is attached
Ophthalmic nerve
to pons at its junction with the middle cerebellar
Maxillary nerve
in foramen rotandum
peduncle.
Mandibular nerve The peripheral processes of the ganglion cells form
Middle Cavernous
three divisions of the trigeminal nerve, namely the
meningeal artery SINUS ophthalmic, maxillary and mandibular.
Parietal branch
Motor root The small motor root of the trigeminal nerve is
Squamous attached to the pons superomedial to the sensory root.
temporal bone
Sensory root It passes under the ganglion from its medial to the
Trigeminal ganglion
lateral side, and joins the mandibular nerve at the
Petrous
temporal bone
foramen ovale.
Greater petrosal nerve
Fig. 12.13: Superior view of the middle cranial fossa showing Blood Supply
some of its contents
The ganglion is supplied by twigs from:
1 Internal carotid
ment of their process; one process arises from the cell 2 Middle meningeal
body which then divides into a central and a peripheral 3 Accessory meningeal arteries
Process. 4 By the meningeal branch of the ascending pharyngeal
The ganglion is crescentic or semilunar in shape, with artery.
its convexity directed anterolaterally. The three
divisions of the trigeminal nerve emerge from this
convexity. The posterior concavity of the ganglion
Intractable facial pain due to trigeminal neuralgia
receives the sensory root of the nerve (Fig. 12.13).
or carcinomatosis may be abolished by injecting
Siluotion ond Meningeol Relotions alcohol into the ganglion. Sometimes cutting of
the sensory root is necessary (Fig. 12.14).
The ganglion lies on tlire trigeminal impression, on the
Congenital cutaneous naevi on the face (port wine
anterior surface of the petrous temporal bone near its
stains) map out accurately the areas supplied by
apex. It occupies a special space of dura mater, called
one or more divisions of the V cranial nerve.
the trigeminal or Meckel's caae. There are two layers of
dura below the ganglion (Fig. 12.3). The cave is lined
by pia-arachnoid, so that the ganglion along with the
motor root of the trigeminal nerve is surrounded by
CSF. The ganglion lies at a depth of about 5 cm from Spinal nucleus of trigeminal nerve
the preauricular point. Pons
Trigeminal ganglion
Relolions
Ophthalmic nerve
dially
L L:rternal carotid artery.
2 Posterior part of cavernous sinus.
Laterally
J Middle meningeal artery.
o
o
z Superiorly
t,tr Parahippocampal gyrus. Sensory root of V nerve
(E
!,(E Mandibular nerve
riorly
o 1 Motor root of trigeminal nerve. Maxillary nerve
C
2 Greater petrosal nerye. Fig. 12.14: Pathways of fibres from the skin of face
o
.F
() 3 Apex of the petrous temporal bone.
ao 4 The foramen lacerum (Fig. 12.13).
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CRANIAL CAVITY
periosteal artery supplying bone and red bone marrow

in the diploe.
DISSECTION Within the cranial cavily, it gives off:
Dissect the middle meningeal artery which enters the a. The ganglionicbranches to the trigeminal ganglion.
skullthrough foramen spinosum. lt is an important artery b. A petrosal branch to the hiatus for the greater
for the supply of endocranium, inner table of skull and petrosal nerve.
diploe. Examine the other structures seen in cranial c. A superior tympanic branch to the tensor tympani.
fossae after removal of brain. These are the cranial d. Temporal branches to the temporal fossa.
nerves, internal carotid artery, petrosal nerves and e. Anastomotic branch that enters the orbit and
fourth part of vertebral artery. anastomoses with the lacrimal artery.
Inlroduction
The middle meningeal artery is important to the The middle meningeal artery is of great surgical
surgeon because this artery is the commonest source importance because it can be torn in head injuries
of extradural haemorrhage, which is an acute surgical resulting in extradural haemorrhage. The frontal or
emergency (Fig. 12.13). anterior branch is commonly involved. The
haematoma presses on the motor area, giving rise
Origin to hemiplegia of the opposite side. The anterior
division can be approached surgically by making
The artery is a branch of the first part of the maxillary
a hole in the skull over the pterion, 4 cm above
artery, given off in the infratemporal fossa (seeFigs 6.6 the midpoint of the zygomalic arch (see Fig. 1.8).
and 6.7). Rarely, the parietal or posterior branch is
implicated, causing contralateral deafness. In this
Coulse ond Relolions case, the hole is made at a point 4 cm above and
1 In the infratemporal fossa, the artery runs upwards 4 cm behind the external acoustic meatus.
and medially deep to the lateral pterygoid muscle
and superficial to the sphenomandibular ligament.
Here it passes through a loop formed by the two roots
of the auriculotemporal nerve (see Fig. 6.15).
2 It enters the middle cranial fossa through the
foramen spinosum (Fig. 12.13). DISSECTION
3 In the middle cranial fossa, the artery has an ldentify following structures in the anterior cranial fossa.
extradural course, but the middle meningeal veins Crista galli, cribriform plate of ethmoid, orbital part
are closer to the bone than the artery. Here the artery of frontal bone, lesser wing of sphenoid.
runs forwards and laterally for a variable distance,
ldentify following structures in the middle cranial
grooving the squamous temporal bone, and divides
fossa: Middle meningeal vessels, diaphragma sellae
into a frontal and parietal branch (Fig. 12.13). pierced by infundibulum, oculomotor nerves, internal
4 Tlne frontal or anterior branch is larger than the parietal carotid arteries, optic nerve, posterior cerebral artery,
branch. First it runs forwards and laterally towards great cerebral vein.
the lateral end of the lesser wing of the sphenoid.
ldentify following structures in the posterior cranial
Then it runs obliquely upwards and backwards,
fossa: Facial, vestibulo-cochlear, glossopharyngeal,
parallel to, and a little in front of the central sulcus
vagus, accessory, hypoglossal nelves, vefiebral arteries,
of the cerebral hemisphere. Thus after crossing the
spinal root of accessory nerve.
pterion, the artery is closely related to the motor area
of the cerebral cortex (see Fig. 7.9a). ta
5 The parietal or posterior branch runs backwards over, Vorious Strucfules o
or near, the superior temporal sulcus of the cerebrtrm, The structures seen after removal of the brain are: 72 crantal zo
E'
about 4 cm above the level of the zygomatic arch. It nerves, cavemous part of internal carotid artery, four tr
(E
ends in front of the posteroinferior angle of the petrosal nerves and fourth part of the vertebral artery. !,
parietal bone by dividing into branches. o
o
rsl ffer I
Bronches The first or olfactory nerae is seen in the form of 15 to 20 c
o
.F
The middle meningeal artery supplies only small filaments on each side that pierce the cribriform plate ()
branches to the dura mater. It is predominantly a of the ethmoid bone (see Fig.za.l. ao
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HEAD AND NECK
The second or optic nerae passes through the optic IntemolCorotid Artery
canal with the ophthalmic artery. The internal carotid artery begins in the neck as one
The third or oculomotor and fourth or trochlear neraes of the terminal branches of the corunon carotid artery
pierce the posterior part of the roof of the cavernous at the level of the upper border of the thyroid
sinus formed by crossing of the free and attached cartilage. Its course is divided into the four parts (Fig.
margins of the tentorium cerebelli; next they run in the 12.15). These are:
lateral wall of the cavernous sinus. They enter the orbit
through the superior orbital fissure (see Fig. 73.4). Ceraical part
Thefifth or trigeminal nerae, has a large sensory root In the neck, it lies within the carotid sheath. This part
gives no branches (see Fig. 3.8).
and a small motor root. The roots cross the apex of the
petrous temporal bone beneath the superior petrosal Petrous part
sinus, to enter the middle cranial fossa (Fig. 1,2.1,3). Within the petrous part of the temporal bone, in the
The sixth or abducent neroe pierces the lower part of the carotid canal. It gives caroticotympanic branches and
posterior wall of the cavemous sinus near the apex of the artery of pterygoid canal (Fig. 12.15).
petrous temporal bone. It runs forwards by the side of
Caaernous part
the dorsum sellae beneath the petrosphenoidal ligament
Within the cavernous sinus (see Fi9.31.3). This part of
to reach the centre of the cavemous sinus (Fig. 12.5).
the artery gives off:
The seztenth or facial and eighth or stato-acoustic or
vestibulo-cochlear nerves pass through the internal
1 Cavernous branches to the trigeminal ganglion.
acoustic meatus with the labyrinthine vessels (see 2 The superior and inferior hypophyseal branches to
Fig.2a.\. the hypophysis cerebri.
The ninth or glossopharyngeal, tenth or aagus and Cerebral part
eleaenth or accessory neroes pierce the dura mater at the This part lies at the base of the brain after emerging
jugular foramen and pass out through it. The glosso- from the cavernous sinus (see Fig. 31.1). It gives off the
phnryngeal nerve is enclosed in a separate sheath of dura following arteries:
mater, while vagus and accessory nerves are enclosed 1 Ophthalmic
in one sheath. The spinal part of the accessory nerve 2 Anterior cerebral
first enters the posterior cranial fossa through the 3 Middle cerebral
foramen magnum, and then passes out through the
jugular foramen along with cranialpart (seeFig.2a.\. 4 Posterior communicating.
The two parts of the twelfth or hypoglossal nerae pierce 5 Anterior choroidal.
the dura mater separately opposite the hypoglossal Of these, the ophthalmic artery supplies structures
canal and then pass out through it. in the orbit; while the others supply the brain.
Anterior cerebral branch
Ophthalmic branch
Superior hypophyseal branch

I
I
I
I
I
Cavernous oartl Trigeminal ganglion branch

'i
j lnferior hypophyseal branch
!
o
zo Caroticotympa nic
!tc I
I
branches
(E Petrous part I
I
E' I
t_--
(6
o Artery of pterygoid canal
C
.9
o
ao Fig. 12.15: Various parts of internal carotid artery
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CRANIAL CAVITY
The curvatures of the petrous, cavernous and Mnemonics

cerebral parts of the internal carotid artery together
form an 'S'-shaped figue, the carotid siphon of Cavernous sinus contents O TOM CAT
angiograms. Oculomotor nerve (lll)
Trochlear nerve (lV)
Pelrosol Nerves Ophthalmic nerve (Vl)
Maxillary nerve (V2)
I Tlre greater petrosal nerae (Fig. 72.73) carries gustatory
Carotid artery ( internal )
and parasympathetic fibres. It arises from the
geniculate ganglion of the facial nerve, and enters Abducent nerve (Vl)
the middle cranial fossa through the hiatus for the T: Nothing
greater petrosal nerve on the anterior surface of the
petrous temporal bone. It proceeds towards the
foramen lacerum, where it joins the deep petrosal Meningeal layer of dura matter forms falx cerebri
nerve which carries sympathetic fibres to form the and falx cerebelli in sagittal plane and tentorium
nerve of the pterygoid canal (see Table 1.3). cerebelli and diaphragma sellae in horizontal plane.
The nerve of the pterygoid canal passes through the Only spinal ganglia present in the cranial cavity is
pterygoid canal to reach the pterygopalatine the trigeminal ganglion.
ganglion. The parasympathetic fibres relay in this Only mixed branch of trigeminal is the mandibular
ganglion. Postganglionic parasympathetic fibres branch. The other two are purely sensory.
arising in the ganglionultimately supply the lacrimal
Anterior branch of middle meningeal artery lies
on the inner aspectof pterion and is liable to injury,
gland and the mucosal glands of the nose, palate and
leading to extradural haemorrhage.
pharynx (seeFig.15.16b). The gustatory or taste fibres
do not relay in the ganglion and are distributed to
the palate.
A young person complains of little painful papules
The deep petrosal neroe, sympathetic in nature, is a
on the right side of forehbad along a nerve on the right
branch of the sympathetic plexus around the internal
side. There is redness of the eyes with severe pain.
carotid artery. It contains postganglionic fibres from . What is the diagnosis?
the superior cervical sympathetic ganglion. The r Trace the pathway of pain impulses
nerve joins the greater petrosal nerve to form the
nerve of the pterygoid canal. The sympathetic fibres
in it are distributed through the branches of the The pathway of pain impulses is shown in Flow
pterygopalatine ganglion (see Table 1.3). chart 12.1
The lesser petrosal nerae, parasympathetic in nature, FIow chart 12.1: Pathway of pain impulses
is a branch of the tympanic plexus, deriving its
preganglionic parasympathetic fibres from the
tympanic branch of the glossopharyngeal nerve. It
emerges through the hiatus for the lesser petrosal Ophthalmic division of V nerve
nerve, situated just lateral to the hiatus for the greater
petrosal nerve, passes out of the skull through the V ganglion (sensory ganglion) in its dural cave
foramen ovale, and ends in the otic ganglion (see
Fig. 6.15). Postgdnglionic fibres arising in the
ganglion supply the parotid gland through the Sensory root of V nerve
auriculotemporal nerve (see Table 1.3).
Spinal nucleus of V nerve (relay occurs) ta
The external petrosnl nerae, sympathetic in nature is o
an inconstant branch from the sympathetic plexus zo
around the middle meningeal artery to the geniculate !,
c(E
ganglion of the facial nerve.
!t(E
Brainstem, thalamus (another relay) o
Fourlh Fartof lhe rlebralArtery
It enters the posterior cranial fossa through the foramen Postcentral gyrus on the superolateral surface c
o
magnum after piercing the dura mater near the skull. of brain close to its lower part o
o
It has been studied in Chapter 9 a
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1. One of the following structures is not related to \Mhich is not a part of internal carotid artery?
cavernous sinus: a. Cervical part
a. Trochlear nerve
b. Petrous part
b. Oculomotor nerve
c. Optic nerve c. Cerebral part
d. Ophthalmic nerve d. Ophthalmic part
2. Which is true about cavernous sinus? 6. Rupture of which commonly injured artery causes
a. Oculomotor nerve in medial wall extradural haemorrhage:
b. Trochlear nerve on medial wall a. Trunk of middle meningeal artery
b. Anterior branch of middle meningeal artery
c. Optic tract inferiorly
c. Posterior branch of middle meningeal artery
d. Drains into transverse sinus
d. None of the above
3. Correct position of VI nerve in cavernous sinus is: 7. \tVhich of the petrosal nerve carries preganglionic
a. Medial to the internal carotid artery fibres to the otic ganglion?
b. Lateral to the artery a. Greater petrosal nerve
c. Inferolateral to the artery b. Deep petrosal nerve
d. Posterior to the artery c. Lesser petrosal nerve
d. Extemal petrosal nerve
4. If III, IV, VI and ophthalmic nerves are paralysed 8. Arachnoid villi drain into which of the following
the infection is localized to:
sinus?
a. Brainstem a. Transverse sinus
b. Base of skull b. Straight sinus
c. Cavernous sinus c. Superior sagittal sinus
d. Apex of orbit d. Sigmoid sinus
ta
o
zo
E
tr
G
t(E
o
c
.o
o
ao
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o
-Williom Wordsworth
INTRODUCTION 4 Vessels: Ophthalmic artery, superior and inferior

The orbits are bony cavities lodging the eyeballs, ophthalmic veins, and lymphatics.
extraocular muscles, nerves, blood vessels and lacrimal 5 Neraes: Optic, oculomotor, trochlear and abducent;
gland. Out of T2pairs of cranial nerves; II, ilI, IV, VI, a branches of ophthalmic and maxillary nerves, and
part of V, and some sympathetic fibres are dedicated sympathetic nerves.
to the contents of orbit only. Nature has provided orbit 6 Lacrirnal gland: It has already been studied in
for the safety of the eyeball. We must also try and look Chapter 2.
after our orbits and their contents. 7 Orbrtal fat.
Visuol Axis ond Orbitol Axis

Axis passing through centres of anterior and posterior
poles of the eyeball is known as visual axis. It makes
DISSECflON an angle of 2015" with the orbital axis (see Fig. 7.23),
Strip the endosteum from the floor of the anterior cranial i.e. line passing through optic canal and centre of base
fossa. Gently break the orbital plate of frontal bone of orbit, i.e. opening on the face.
forming the roof of the orbit and remove it in pieces so
that orbital periosteum is clearly visible. Medially, the Orbitol Foscio or Periorbilo
ethmoidal vessels and nerves should be preserved. It forms the periosteum of the bony orbit. Due to the
Posteriorly, identify the optic canal and superior orbital loose connection to bone, it can be easily stripped.
fissure and structures traversing these. Define the Posteriorly, it is continuous with the dura mater and
orbital fascia and fascial sheath of eyeball. with the sheath of the optic nerve. Anteriorly, it is
Divide the orbital periosteum along the middle of the continuous with the periosteum lining the bones
orbit anteroposteriorly. Cut through it horizontally close around the orbital margin (Fig. 13.1).
to anterior margin of orbit. There is a gap in the periorbita over the inferior
orbital fissure. This gap is bridged by connective tissue
Feolures with some smooth muscle fibres in it. These fibres
The orbits are pyramidal cavities, situated one on each constitute the orbitalis muscle.
side of the root of the nose. They provide sockets for a. At the upper and lower margins of the orbit, the
rotatory movements of the eyeball. The long axis of the orbital fascia sends off flap-like continuations into
each orbit passes backwards and medially. The medial the eyelids. These extensions form the orbital septum.
walls are parallel to each other at a distance of 2.5 cm b. A process of the fascia holds the fibrous pulley of
but the lateral walls are set at right angles to each other. the tendon of the superior oblique muscle in place.
c. Another process forms the lacrimal fascia whic}":.
Conlenls bridges the lacrimal groove.
I Eyebnll: Eyeball occupies anterior one-third of orbit.
It is described in Chapter 19. Fosciol Sheoth of Eyeboll oI Bulbor Foscio
2 Fascia: Orbital and bulbar. L Tenon's capsule forms a thin, loose membranous
3 Muscles: Extraocular and intraocular. sheath around the eyeball, extending from the optic
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HEAD AND NECK
Optic nerve
Beneath the levator palpebrae superioris is the
superior rectus muscle. The upper division of
oculomotor nerve lies between these two muscles,
supplying both of them. Along the lateral wall of the
orbit look for lacrimal nerve and artery to reach the
superolateral corner of the orbit.
Follow the tendon of superior oblique muscle passing
superolaterally beneath the superior rectus to be
inserted into sclera behind the equator. After
identification, divide frontal nerve, levator palpebrae
Orbitalis
superioris and superior rectus in the middle of the orbit
muscle and reflect them apart. ldentify the optic nerue and other
Orbital fascia structures crossing it. These are nasociliary nerve,
ophthalmic artery and superior ophthalmic vein. Along
with the optic nerve find two long ciliary nerves and
lnferior
12-20 short ciliary nerves. Remove the orbital fat and
Fig. 13.1: Orbital fascia and fascial sheath of the eyeball as seen look carefully in the posterior part of the interual between
in a parasagittal section the optic nerve and lateral rectus muscle along the
lateral wall of the orbit and identify the pin head sized
nerve to the sclerocorneal junction or limbus. It is ciliary ganglion. Trace the roots connecting it to the
separated from the sclera by the episcleral space nasociliary nerve and nerve to inferior oblique muscle.
which is traversed by delicate fibrous bands. The Lastly, identify the abducent nerve closely adherent
eyeball can freely move within this sheath. to the medial surface of lateral rectus muscle.
2 The sheath is pierced by: lncise the inferior fornix of conjunctiva and palpebral
a. Tendons of the various extraocular muscles. fascia. Elevate the eyeball and remove the fat and fascia
b. Ciliary vessels and nerves around the entrance of to identify the origin of inferior oblique muscle from the
the optic nerve. floor of the orbit anteriorly.
3 The sheath gives off a number of expansions. ldentify the levator palpebrae superioris and superior
a. A tubular sheath covers each orbital muscle. rectus above the eyeball, superior oblique supero-
b. The medial check ligament is a strong triangular medially, medial rectus medially, lateral rectus laterally,
expansion from the sheath of the medial rectus and inferior rectus inferiorly.
muscle; it is attached to the lacrimal bone. The voluntary muscles are miniature ribbon muscles,
c. The lateral check ligament rs a strong triangular having short tendons of origin and long tendons of
expansion from the sheath of the lateral rectus insertion.
muscle; it is attached to the zygomatic bone
(Fig.13.2).
TYPES OF EXTRAOCUTAR MUSCTES
4 The lower part of Tenon's capsule is thickened, and
is named the suspensory ligament of the eye or lhe Volunlory Muscles
suspensory ligament of Lockwood (Fig.13.3). It is 1- Four recti:
expanded in the centre and narrow at its extremities, a. Superior rectus.
and is slung like a hammock below the eyeball. It is b. Inferior rectus.
formed by union-of the margins of the sheaths of the c. Medial rectus.
inferior rectus and the inferior oblique muscles with d. Lateral rectus.
the medial and lateral check ligaments. 2 Two obliqui:
J a. Superior oblique.
o b. InJerior oblique.
zo 3 The levator palpebrae superioris elevates the upper
tc eyelid.
(E DISSECTION
tt(E ldentify and preserve the trochlear nerve entering the
o lnvoluntory Muscles
I superior oblique muscle in the superomedial angle of
the orbit. Find the frontal nerve lying in the midline on 1 The superior tarsal muscle is the deeper portion of
the levator palpebrae superioris. lt divides into two the levator palpebrae superioris. It is inserted on the
o
F
o terminal divisions in the anterior part of orbit. upper margin of the superior tarsus. It elevates the
o
a upper eyelid.
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CONTENTS OF THE ORBIT
Anterior
Lacrimal fascia
Lateral Medial
Lacrimal sac
Posterior Lacrimal bone
Medial check ligament
Lateral palpebral Iigament
Sheath of medial rectus
Lateral check ligament Orbital fascia
Zygomatic bone Ethmoid bone
Sheath of lateral rectus

Sheath of optic nerve
Orbital fascla
Body of sphenoid
Fig. 13.2: Orbital fascia and fascial sheath of the eyeball as seen in transverse section
Levator palpebrae 2 The inferior tarsal muscle extends from the fascial
supeflofls
sheath of the inferior rectus and inferior oblique to
Tenon's capsule the lower margin of the inferior tarsus. It possibly
depresses the lower eyelid.
Episcleral space
3 The orbitalis bridges the inferior orbital fissure. Its
Lateral action is uncertain (Fig. 13.1).
check Medial
Iigament check
ligament Voluntoly Muscles
Suspensory Origin
ligament
of eye
lnferior rectus L The four recti arise from a cotnmon annular tendon ot
muscle
tendinous ring of zinn. The ring is attached to the
lnferior oblique middle part of superior orbital fissure (Fig. 13.a).
muscle The lateral rectus has an additional small tendinous
Fig. 13.3: Fascial sheath of theeyeball as seen in coronal section head which arises from the orbital surface of the
Superior rectus Lesser wing of sphenoid

Trochlear nerve
Recurrent meningeal branch
of ophthalmic artery Common tendinous ring
Superior oblique
Lacrimal nerve
Frontal nerve Medial rectus
Superior ophthalmic vein Body of sphenoid
Optic nerve and ophthalmic :o

Upper and lower divisions
artery in optic canal
zo
of oculomotor nerve Nasociliary nerve t,tr
Abducent nerve (E
lnferior rectus
!tG
lnferior ophthalmic vein o
I
Superior orbital fi ssure
Greater wing of sphenoid co
Fig. 13.4; Apical part of the orbit showing the origins of the extraocular muscles, the common tendinous ring and the structures ()
o
passing through superior orbital fissure U)
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HEAD AND NECK
greater wing of the sphenoid bone lateral to the 2 The tendon of the superior oblique passes through a
tendinous ring. Through the gap between the two fibrocartilaginous pulley attached to the trochlear
heads abducent nerve passes. fossa of the frontal bone. The tendon then passes
2 The superior oblique arises from the undersurface laterally, downwards and backward below the
of lesser wing of the sphenoid, superomedial to the superior rectus. It is inserted into the sclera behind
optic canal. the equator of the eyeball, between the superior
3 The inferior oblique arises from the orbital surface of rectus and the lateral rectus.
the maxilla,lateral to the lacrimal groove. The muscle 3 The inferior oblique is fleshy throughout. It passes
is situated near the anterior margin of the orbit. laterally, upwards and backwards below the inferior
4 The levator palpebrae superioris arises from the rectus and then deep to the lateral rectus. The inferior
orbital surface of the lesser wing of the sphenoid oblique is inserted close to the superior oblique a little
bone, anterosuperior to the optic canal and to the below and posterior to the latter.
origin of the superior rectus. 4 The flat tendon of the levator splits into a superior
or voluntary and an inferior or involuntary lamellae.
frnse n The superior lamella of the levator is inserted into
L The recti are inserted into the sclera, a little posterior the anterior surface of the superior tarsus, and into
to the limbus (corneo-scleral junction). The average the skin of the upper eyelid. The inferior lamella
distances of the insertions from the cornea are: (smooth part) is inserted into the upper margin of
superior 7.7 mm; inferior 6.5 mm, medial 5.5 mm; the superior tarsus (see Fig.2.27b) and into superior
lateral 6.9 mm (Fig. 13.5). conjunctival fornix.
Superior oblique
Nerve $ ty
Superior rectus
1 The superior oblique is supplied by the fV cranial or
trochlear nerve (SOa) (Fig. 13.6).
Pulley 2 The lateral rectus is supplied by the VI cranial or
abducent nerve (LR6).
Lateral rectus Medial rectus
3 The remaining five extraocular muscles; superior,
inferior and medial recti; inferior oblique and part
of levator palpebrae superioris are all supplied by
the III cranial or oculomotor nerve.
lnferior oblique
,4cfrons
lnferior
L The moaements of the eyeball are as follows.
rectus a. Around a transoerse axis
Fig. 13.5: Scheme to show the insertion of the oblique muscles . Upward rotation or elevation (33').
of the eyeball o Do'vvnwards rotation or depression (33').
Superior rectus

Upper division of third nerve
Trochlear nerve
Lacrimal nerve
Superior oblique
Frontal nerve Optic nerve

ta
o
o
z Nasociliary nerve
tE Lateral rectus
(E
Abducent nerve
tl(5
o
I Ciliary ganglion
.o
() lnferior rectus
ao Fig. 13.6: Scheme to show the nerve supply of the extraocular muscles
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b. Around a aerticnl axis

. Medial rotation or adduction (50").
o Lateral rotation or abduction (50').
DISSECTION
c. Around an anteroposterior axis
o Intortion Trace the ophthalmic adery after it was seen to cross
o Extortion. over the optic nerve along with nasociliary nerve and
superior ophthalmic vein. ldentify its branches especially
The rotatory movements of the eyeball upwards,
the central artery of the retina which is an 'end anery'.
downwards, medially or laterally, are defined in
terms of the direction of movement of the centre
of the pupil. The tortions are defined in terms of OPHTHATMIC ARTERY
the direction of movement of the upper margin Origin
of the pupil at 12 o'clock position. The ophthalmic artery is a branch of the cerebral part
d. The movements given above can take place in of the internal carotid artery, given off medial to the
various combinations. anterior clinoid process close to the optic canal (Figs
2 Actions of indiaidual muscles shown in Fig. 1,3.7a and 13.9 and 13.10).
Table 13.1.
3 Single or pure mooements are produced by combined Course ond Relotions
actions of muscles. Similar actions get added 1 The artery enters the orbit through the optic canal,
together, while opposing actions cancel each other lying inferolateral to the optic nerve. Both the artery
enabling pure movements. and nerve lie in a common dural sheath.
a. Upward rotation or eleaation: By the superior rectus 2 In the orbit, the artery pierces the dura mater, ascends
and the inferior oblique (Fig. 13.7b). over the lateral side of the optic nerve, and crosses
b. Dozunward rotation or depression: By the inferior above the nerve from lateral to medial side along
rectus and the superior oblique. with the nasociliary nerve. It then runs forwards
c. Medial rotation or adduction; By the medial rectus, along the medial wall of the orbit between the
the superior rectus and the inferior rectus. superior oblique and the medial rectus muscles, and
d. Lateral rotation or abduction: By the lateral rectus, parallel to the nasociliary nerve.
the superior oblique and the inferior oblique. 3 It terminates near the medial angle of the eye by
e. Intortion: By the superior oblique and the superior dividing into the supratrochlear and dorsal nasal
rectus. branches (Fig. 13.9).
f . Extortion: By the inferior oblique and the inferior
rectus. Bronches
4 Combined mouements of the eyes While still within the dural sheath, the ophthalmic
Normally, movements of the two eyes are harmoni- artery gives off the central artery of the retina. After
ously coordinated. Such coordinated movements of piercing the dura mater, it gives off a large lacrimal
both eyes are called conjugate ocular moaements branch that runs along the lateral wall of the orbit. The
(Fig. 13.7c). main artery runs towards the medial wall of the orbit
giving off a number of branches. The various branches
are described below.
Weakness or paralysis of a muscle causes squint or
strabismus, which maybe concomitant or paralytic.
Concomitant s{uint is congenital; there is no The central artery of retina (Fig. 13.10) is the first and
lirnitation of movement, andno diplopia (Fig. 13.8). most importantbranch of the ophthalmic artery. It first
In paralytic squint, movements are limited, lies below the optic nerve. It pierces the dural sheath of
diplopia and vertigo are present, head is turned the nerve and runs forwards for a short distance .Y
o
in the direction of the function of paralysed between these two. It then enters the substance of the zo
muscle, and there is a false orientation of the field nerve and runs forwards in its centre to reach the optic tttr
of vision. disc (Fig. 13.9). Here it divides intobranches that supply G
Nystagmus is characterized by involuntary, the retina (see Fig. 19.10). t,G
rhythmical oscillatorymovements of the eyes. This The central artery of the retina is an end artery .It does o
is due to incoordination of the ocular muscles. It not have effective anastomoses with other arteries.
may be either vestibular or cerebellar/ or even Occlusion of the artery results in blindness. The c
.o
congenital. intraocular part of the artery can be seen, in the living, o
through an ophthalmoscope. ao
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HEAD AND NECK
L Branches are given to the lacrimal gland.

2 Two zygomatic branches enter canals in the
zygomatic bone. One branch appears on the face
through the zygomaticofacial foramen. The other
appears on the temporal surface of the bone through
the zygomaticotemporal foramen.
3 Lateral palpebral branches supply the eyelids.
4 A recurrent meningeal branch runs backwards to
enter the middle cranial fossa through the superior
orbital fissure.
5 Muscular branches supply the muscles of the orbit.
f Elevation { Depression * Medial rotation G Lateral rotation
\lntortion
\ E*torrion 1 The posterior (long and short) ciliary arteries supply
chiefly the choroid and iris. The eyeball is also
Fig. 13.7a: Scheme to show the action of the extraocular musdes supplied through anterior ciliary branches which are
Elevators Depressors
lnferior oblique
Transverse axis
Superior rectus
Adductors Abductors
lnferior oblique
Medial rectus Superior oblique
Lateral rectus
Superior rectus
Vertical axis
lnferior rectus
lntorters Extorters
ta
o
zo
E' Superior oblique
c(E
!t(E
o
Superior rectus
c
o
o
o
a 13.7b: Single movement of the eye
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r lnferior recti
Superior
rectus
I Normal
Both superior rectus and Lorn inferior rectus I

inferior oblique on each side and superior oblique on each side
I
Lateral rectus Medial rectus Lateral rectus
Fig. 13.7c: Muscles for conjugate movements of the eyes
Table 13.1: Actions of individual muscles

Muscle Vertical axis Main action horizontal axis Anteroposterior axis
Superior rectus (SR) Elevates Adducts Rotates medially (intorsion)
lnferior rectus (lR) Depresses Adducts Rotates laterally (extorsion)
Superior oblique (SO) Depresses Abducts Botates medially (intorsion)
lnferior oblique (lO) Elevates Abducts Rotates laterally (extorsion)
Medial rectus (MR) Adducts
Lateral rectus (LR) Abducts
given off from arteries supplying muscles attached

to the eyeball (Fig. 13.10). r The anterior ciliary arteries arise from the
The supraorbital and supratrochlear branches supply muscular branches of ophthalmic artery. The .Y
the skin of the forehead. ()
muscular arteries are important in this respect.
The anterior and posterior ethmoidal branches enter r The central artery of retina is the only arterial zo
foramina in the medial wall of the orbit to supply supply to most of the nervous layer, the retina of
!ttr
cl
the ethmoidal air sinuses. They then enter the the eye. If this artery is blocked, there is sudden !tG
anterior cranial fossa. The terminal branches of the blindness. o
anterior artery enter the nose and supply part of it.
4 The medial palpebral branches supply the eyelids. OPHIHALMIC VEINS c
.9
5 The dorsal nasal branch supplies the upper part of The superior ophthalmic aein: It accompanies the O
the nose. ophthalmic artery. It lies above the optic nerve. It ao
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HEAD AND NECK
receives tributaries corresponding to the branches of

the artery, passes through the superior orbital fissure,
and drains into the cavernous sinus. It communicates
anteriorly with the supraorbital and angular veins
(see Fig.2.6).
The i rior ophthalmic oein: It runs below the optic nerve.

It receives tributaries from the lacrimal sac, the lower
orbital muscles, and the eyelids, and ends either by
joining the superior ophthalmic vein or drains directly
into the cavernous sinus. It communicates with the
pterygoid plexus of veins by small veins passing
through the inferior orbital fissure.
Supraorbital
Supratrochlear Anterior ciliary

Dorsal nasal
Lacrimal gland
Zygomaticofacial
Anterior ethmoidal Zygomaticotemporal
Posterior ethmoidal Lacrimal
Posterior ciliary
Superior oblique
Recurrent meningeal branch
Central artery of retina

Middle meningeal
Ophthalmic artery
Optic nerve
lnternal carotid
Fig. 13.9: The arteries of the eyeball
Rectus muscle with artery
Anterior ciliary
Long posterior ciliary artery
Circulus arteriosus major

Short posterior ciliary artery
! Circulus arteriosus minor
o
o Dura mater
z Cornea
Optic nerve
E lris
c Pia mater
G
t(E
o Arachnoid mater
Subarachnoid space
C Central artery of retina
.o
(J
ao Fig. 13.10: Branches of ophthalmic artery
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lymphotics of the Orbit

The lymphatics drain into the preauricular parotid . The anastomoses between tributaries of facial vein
lymph nodes (see Fi9.2.25). and ophthalmic veins may result in spread of
infection from the orbital and nasal regions to the
caverrrous sinus leading to its thrombosis.
. Optic neuritis is characterized by pain in and
These are: behind the eye on ocular movements and on
1 Optic, .4*' pressure. The papilloedema is less but loss of
2 Oculomotor with ciliary ganglion, vision is more. When the optic disc is normal as
3 Trochlear, seenby an ophthalmoscope the same condition is
4 Branches of ophthalmic and maxillary divisions of called retrobulbar neuritis.
the trigeminal, . The common causes are demyelinating diseases of
5 Abducent, and the central nervous system, any septic focus in the
6 Sympathetic nerves. teeth or paranasal sinuses, meningitis, encephalitis,
Only optic nerve, ciliary ganglion and sympathetic syphilis, and even vitamin B deficiency.
nerves are described in this Chapter. III, IV and VI . Optic nerve has no neurilemma sheath, and has no
cranial nerves are described in Chapter 24. power of regeneration. It is a tract and not a nerve.
. Optic atrophy may be caused by a variety of
OPIIC NERVE diseases. It may be primary or secondary.
The optic nerve is the nerve of sight. It is made up of
the axons of cells in the ganglionic layer of the retina. CILIARY GANGTION
It emerges from the eyeball 3 or 4mm nasal to its Ciliary ganglion is a peripheral parasympathetic
posterior pole. It runs backwards and medially, and
ganglion placed in the course of the oculomotor nerve.
passes through the optic canal to enter the middle
It lies near the apex of the orbitbetween the optic nerve
cranial fossa where it joins the optic chiasma.
and the tendon of the lateral rectus muscle. It has
The nerve is about 4 cm long, out of which 25 mm
parasympathetic, sensory and sympathetic roots.
are intraorbital, 5 mm intracanalicular, and 10 mm
The parasympathetic root arises from the nerve to the
intracranial. The entire nerve is enclosed in three
inferior oblique (Fig. 13.11). It contains preganglionic
meningeal sheaths. The subarachnoid space extends
fibres that begin in the Edinger-Westphal nucleus. The
around the nerve up to the eyeball (Fig. 13.10).
fibres relay in the ciliary ganglion. Postganglionic fibres
Relolions in the Orbit arising in the ganglion pass through the short ciliary
nerves and supply the sphincter pupillae and the ciliaris
1 At the apex of the orbit, the nerve is closely sur-
rounded by the recti muscles. The ciliary ganglion
lies between the optic nerve and the lateral rectus.
2 The central artery and vein of the retina pierce the
optic nerve inferomedially about 1.25 cmbehind the
eyeball (Fig. 13.9).
3 The optic nerve is crossed superiorly by the
ophthalmic artety, the nasociliary nerve and the Optic nerve
superior ophthalmic vein. Short ciliary nerve
4 The optic nerve is crossed inferiorly by the nerve to
the medial rectus.
5 Near the eyeball, the nerve is surrounded by fat
containing the ciliary vessels and nerv es (see Fig. 79 .2) . .Y
o
Ciliary ganglion
Slructure zo
!ttr
There are about 1.2 million myelinated fibres in each Sensory root (E
optic nerve, out of which about 53% cross in the optic Sympathetic root E'
(E
chiasma. Parasympathetic root o
The optic nerve is not a nerve in the strict sense. It is Nerve to inferior oblique
actually a tract. It cannot regenerate after it is cut. C
.o
Developmentally, the optic nerve and the retina are o
a direct prolongation of the brain. Fig. 13.11 : Roots and branches of ciliary ganglion ao
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HEAD AND NECK
muscle (see Table 1.3). These intraocular muscles are The lacrimal nerve supplies the lacrimal gland, the
used in accommodation. conjunctiva and the upper eyelid. Its own fibres to the
The sensory roof comes from the nasociliary nerve. It gland are sensory. The secretomotor fibres to the gland
contains sensory fibres for the eyeball. The fibres do come from the greater petrosal nerve through its
not relay in the ganglion (Fig. 13.11). communication with the zygomaticotemporal nerve (see
T}:.e sympathetic root is a branch from the internal Table 1.3).
carotid plexus. It contains postganglionic fibres arising
in the superior cervical ganglion (preganglionic fibres FRONTAL NERVE
reach the ganglion from lateral horn of T1 spinal
segment) which pass along intemal carotid, ophthafunic This is the largest of the three terminal branches of the
and long ciliary arteries. They pass out of the ciliary ophthalmic nerve (Figs 13.12a and b). It begins in the
ganglion without relay in the short ciliary nerves to lateral wall of the anterior part of the cavernous sinus.
supply the blood vessels of the eyeball. They also supply It enters the orbit through the lateral part of the superior
the dilator pupillae. orbital fissure, and runs forwards on the superior
surface of the levator palpebrae superioris. At the
Btonches middle of the orbit, it divides into a small supratrochlear
The ganglion gives off 8 to 10 short ciliary nerves which branch and a large supraorbital branch.
divide into 15 to 20 branches, and then pierce the sclera Tiae supratrochlear nerae emerges from the orbit above
around the entrance of the optic nerve. They contain the trochlea about one finger breadth from the median
fibres from all the three roots of the ganglion. plane. It supplies the conjunctiva, the upper eyelid, and
a small area of the skin of the forehead above the root
RIMAL NERVE of the nose (see Figs 2.5 and2.22).
This is the smallest of the three terminal branches of The supraorbital nerae emerges from the orbit through
ophthalmic nerve (Fig.73.12a). It enters the orbit the supraorbital notch or foramen about two fingers
through lateral part of superior orbital fissure and runs breadth from the median plane. It divides into medial
forwards along the upper border of lateral rectus and lateral branches which runs upwards over the
muscle, in company with lacrimal artery. Anteriorly, it forehead and scalp. It supplies the conjunctiva, the
receives communication from zygomaticotemporal central part of the upper eyelid, thefrontal air sinus and
nerve, passes deep to the lacrimal gland, and ends in the skin of the forehead and scalp up to the vertex, or
the lateral part of the upper eyelid. even up to the lambdoid suture.
Trochlear nerve Levator palpebrae superioris

Superior rectus
Ophthalmic nerve with frontal, Superior oblique
lacrimal and nasociliary branches
Oculomotor nerve
Abducent nerve
Trigeminal ganglion
j E
o Mandibular nerve Maxillary nerve !
o o
z Medial rectus
!,
tr lnferior rectus
G
t,(E lnferior oblique supplied by oculomotor nerve
o Lateral rectus supplied by abducent
I Posterior
(b)
o
o
o
Figs 13.12a and b: (a) Branches of right ophthalmic nerve including lll, lV, Vl cranial neryes and the extraocular muscles, and
a (b) branches of nasociliary: 1. Branch to ciliary ganglion, 2. long ciliary, 3. posterior ethmoidal, 4. infratrochlear, and 5. anterior ethmoidal
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NASOCITIARY NERVE palpebral, nasal and labial branches (see Fig.2.22).The

This is one of the terminal branches of the ophthalmic nerve is accompanied by the infraorbital branch of the
division of the trigeminal nerve (Fig. 13.12H. It begins third part of the maxillary artery and the accompanying
in the lateral wall of the anterior part of the cavernous vein.
sinus. It enters the orbit through the middle part of the
superior orbital fissure between the two divisions of Bronches
the oculomotor nerve (Fig. 13.a). It crosses above the 1 The middle superior alaeolar nerrse arises in the
optic nerve from lateral to medial side along with infraorbital groove, runs in the lateral wall of the
ophthalmic artery and runs along the medial wall of maxillary sinus, and supplies the upper premolar
the orbit between the superior oblique and the medial teeth.
rectus. It ends at the anterior ethmoidal foramen by 2 The nnterior superior alaeolar nerae arises in the
dividing into the infratrochlear and anterior ethmoidal infraorbital canal, and runs in a sinuous canal having
nerves. Its branches are as follows. a complicated course in the anterior wall of the
I A communicating branch to the ciliary ganglion forms maxillary sinus. It supplies the upper incisor and
the sensory root of the ganglion. It is often mixed canine teeth, the maxillary sinus, and the antero-
with the sympathetic root (Fig. 13.12b). inferior part of the nasal cavity where it
2 Two or three long ciliary neraes run on the medial communicates with branches of anterior ethmoidal
side of the optic nerve, pierce the sclera, and supply and anterior palatine nerves (see Fig. 15.16).
sensory nerves to the cornea, the iris and the ciliary 3 Terminal branches palpebral, nasal and labial sttpply a
body. They also carry sympathetic nerves to the large area of skin on the face. They also supply the
dilator pupillae (Fig. 13.1i). mucous membrane of the upper lip and cheek (see
3 The posterior ethmoidal neroe passes through the Fi9.2.22).
posterior ethmoidal foramen and supplies the
ethmoidal and sphenoidal air sinuses. ZYGOMATIC NERVE
4 The infratrochlear fierae is the smaller terminal branch It is a branch of the maxillary nerve, given off in the
of the nasociliary nerve given off at the anterior pterygopalatine fossa. It enters the orbit through the
ethmoidal foramen. It emerges from the orbit below lateral end of the inferior orbital fissure, and runs along
the trochlea for the tendon of the superior oblique the lateral wall, outside the periosteum, to enter the
and appears on the face above the medial angle of zygomatic bone. just before or after entering the bone
the eye. It supplies the conjunctiva, the lacrimal sac it divides into its two terminal branches, the
and caruncle, the medial ends of the eyelids and the zy gomaticofacial and zy gomatico t emp or al nero es
which
upper half of the external nose (see Fig.2.22). supply the skin of the face and of the anterior part of
5 The anterior ethmoidal nerae is the larger terminal the temple (see Fig.2.22). The communicating branch
branch of the nasociliary nerve. It leaves the orbit by to the lacrimal nerve, which contains secretomotor
passing through the anterior ethmoidal foramen. It fibres to the lacrimal gland, arises from the
appears, for a very short distance, in the anterior zygomaticotemporal nerve, and runs in the lateral wall
cranial fossa, above the cribriform plate of the of the orbit (see Chapter 2).
ethmoid bone. It then descends into the nose through
a slit at the side of the anterior part of the crista galli. SYM HETIC NERVES OF THE ORBII
In the nasal cavity, it lies deep to the nasal bone. It Sympathetic nerves arise from the intemal carotid plexus
gives off two internal nasal branches, medial and and enter the orbit through the following sources.
lateral to the mucosa of the nose. Finally, it emerges 1 The dilator pupillae of the iris is supplied by
at the lower border of the nasal bone as the external sympathetic nerves that pass through the ophthalmic
nasal nerae which supplies the skin of the lower half nerve, the nasociliary nerve, and its long ciliary
of the nose. branches. .!<
o
2 Other sympathetic nerves enter the orbit as follows: zo
INFR RBITAL NERVE a. A plexus surrounds the ophthalmic artery. E
b. A direct branch from the internal carotid plexus tr
It is the continuation of the maxillary nerve. It enters G
the orbit through the inferior orbital fissure. It then runs passes through the superior orbital fissure and t,G
forwards on the floor of the orbit or the roof of the joins the ciliary ganglion. o
maxillary sinus, at first inthe infraorbital groorse and then c. Other filaments pass along the oculomotor,
in the infraorbital canal remaining outside the trochlear, abducent, and ophthalmic nerves. AII C
.9
periosteum of the orbit. It emerges on the face through these sympathetic nerves are vasomotor in o
the infraorbitnl foramen and terminates by dividing into function. ao
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HEAD AND NECK
BRANCHES OF OPHTHATMIC DIVISION

Edinger Westphal is the nucleus for the supply of
OF TRIGEMINAL NERVE
ciliaris muscles and constrictor pupillae muscles.
Following are the branches of ophthalmic division of The fibres supply these muscles after relaying in
trigeminal nerve. the ciliary ganglion.
1 Frontal Supratrochlear Elevation and depression of the cornea occurs
Supraorbital around a transverse axis.
2 Nasociliary Branch to ciliary ganglion Adduction and abduction of the cornea takes place
2-3 long ciliary nerves around a vertical axis.
Posterior ethmoidal Intortion and extortion occurs around an antero-
Infratrochlear posterior axis.
Anterior ethmoidal
3 Lacrimal Branch to the upper eyelid and
secretomotor fibres to lacrimal gland.
A hypertensive and diabetic lady with high
Mnemonics cholesterol and lipids develops sudden blindness in
Extraocular muscleq cranial nerve innervation her right eye.
'LR6SO4 rest 3t'
r What has caused blindness in this particular case?
Lateral rectus by Vl
o Name the other end arteries in the body.
Superior oblique by lV
Rest are by lll cranial nerve, i.e. levator palpebrae arteries. Most of the nervous layers of retina are
superioris, superior rectus, medial rectus, inferior
rectus and inferior oblique. with any other artery. s artery is also vulnerable
ff it biocked, the result is blindness of that eye.

s
Other end arteries are:
Levator palpebrae superioris is partly supplied by . Labyrinthine artery for the inner ear
III nerve and partly by sympathetic fibres o Coronary arteries are functional end arteries
a Central artery of retina is an end artery. though these do anagtomose
a Nerve supply of extraocular muscles is LR6, SO4, o Central branches of cerebral arteries
Rest (levator palpebrae sup., SR, MR, IR and IO) by 3. r Segrnental blanches of kidney and spleen
MUITIPIE CHOICE QUESTIONS

1. \Alhich nucleus is related to ciliary ganglion? c. Inferior oblique arises from medial wall of the
a. Superior salivatory b. Lacrimatory orbit
c. Inferior salivatory d. Edinger-Westphal d. Lateral rectus is supplied by IV nerve.
2. Ophthalmic artery is a branch of which of the 5. Which nerve does not transverse the middle part
following artery? of superior orbital fissure?
a. Internal carotid b. External carotid a. Two divisions of III nerve
c. Maxillary d. Vertebral b. Frontal nerve
3. Supraorbital artery is a branch of: c. VI nerve
a. Maxillary b. External carotid d. Nasociliary nerve
:o
c. Ophthalmic d. Internal carotid 6. Which out of the following arteries is an end-artery?
zo 4. \Arhich of the following is true about ocular muscles? a. Lacrimal artery
!ttr
o a. Medial rectus is supplied by III nerve b. Zygomaticotemporal
E
(E b. Superior oblique turns the centre of cornea c. Central artery of retina
o upwards and laterally d. Anterior ethmoidal artery
C
.o
AN ERS
o
o 1.d 2.a 3.c 4.a 5.b 6.c
a
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Sincloire
-Jomes
INTRODUCTION glands (mucous), situated on the buccopharyngeal

Oral cavity is used for ingestion of food and fluids. It is fascia also open into the vestibule.
continued posteriorly into the oropharyrx, the middle 4 Except for the teeth, the entire vestibule is lined by
part of the muscular pharynx. In its upper part opens mucous membrane. The mucous membrane forms
the posterior part of the nasal cavity and the inlet of median folds that pass from the lips to the gums,
larynx opens into its lower part. Roof of oral cavity is and are called the frenula of the lips.
formed by the hard and the soft palates. Biggest
occupant of the oral cavity is the tongue, described in
Chapter 77.The cavity also contains thirty-two teeth in o The papilla of the parotid duct in the vestibule of
an adult. the mouth provides access to.the parotid duct for
the injection of the radiopaque dye to locate calculi
IDENTIFICAIION in the duct system or the gland (Fig. 1a.1).
Identify the structures in your own oral cavity. These . Koplik's spots are seen as white pin point spots
are the vestibule, lips, cheeks, oral cavity proper and around the opening of the parotid duct inmeasles.
teeth. These are diagnostic of the disease.
Orol Covity 1.,1fl?i:l
The oral or mouth cavity is divided into an outer, 1 The lips are fleshy folds lined externally by skin and
smaller portion, the vestibule, and an inner larger part, internally by mucous membrane. The mucocutaneous
the oral cavity proper. junction lines the 'edge' of the lip, part of the mucosal
surface is also normally seen.
Mes/rhutre 2 Each lip is composed of:
a. Skin.
The vestibule of the mouth is a narrow space bounded
externally by the lips and cheeks, and internally,by b. Superficial fascia.
the teeth and gums. c. The orbicularis oris muscle.
It communicates: d. The submucosa, containing mucous labial glands
a. With the exterior through the oral fissure. and blood vessels.
b. With the mouth open it communicates freely with e. Mucous membrane.
the oral cavity proper. Even when the teeth are 3 The lips bound the oral fissure. They meet laterally at
occluded a small communication remains behind the angles of the mouth. The inner surface of each
the third molar tooth. lip is supported by a frenulum which ties it to the
The parotid duct opens on the inner surface of the gum. The outer surface of the upper lip presents a
cheek opposite the crown of the upper second molar median vertical groove, the philtrum.
tooth (Fig. 14.1). Numerous labial and buccal glnnds 4 Lymphatics of the central part of the lower lip drain
(mucous) situated in the submucosa of the lips and to the submental nodes; the lymphatics from the rest
cheeks open into the vestibule. Four or five molar of the lower lip pass to the submandibular nodes.
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HEAD AND NECK
Tongue lifted upwards
Frenulum
Undersudace of tongue
Openings of sublingual gland
Sublingual fold
Submandibular ducl
Fig. 14.1: lnterior of the mouth cavity
efueeks 4t:ucc*e,l The sublingual region presents the following features'

1 The cheeks are fleshy flaps, forming a large part of a. In the median plane, there is a fold of mucosa
each side of the face. They are continuous in front passing from the inferior aspect of the tongue to
with the lips, and the junction is indicated by the the floor of the mouth. This is the frenulum of the
nasolabial sulcus (furrow) which extends from the side tongue (see Fig. 17.2).
of the nose to the angle of the mouth. b. On each side of the frenulum, there is a sublingual
2 Each cheek is composed of: papilla. On the summit of this papilla, there is the
a. Skin. opening of submandibular duct.
b. Superficial fascia containing some facial muscles, c. Running laterally and backwards from the
the parotid duct, mucous molar glands, vessels sublingual papilla, thereis the sublingual fold which
and nerves. overlies the sublingual gland. A few sublingual
c. The buccinator covered by buccopharyrgeal fascia ducts open on the edge of this fold.
and pierced by the parotid duct. Lymphatics from the anterior part of the floor of the
d. Submucosa, with mucous buccal glands. mouth pass to the submental nodes. Those from the
e. Mucous membrane. hard palate and soft palate pass to the retro-
3 The buccal pad of fat is best developed in infants. It pharyngeal and upper deep cervical nodes. The gums
lies on the buccinator partly deep to the masseter and the rest of the floor drain into the submandibular
and partly in front of it. nodes.
4 The lymphatics of the cheek drain chiefly into the
Gums (gingivoe)
submandibular and preauricular nodes, and partly
also to the buccal and mandibular nodes. The which envelop the
alve and lower jaws and
Orol Covity Proper surr These are composed
.!( 1 It is bounded anterolaterally by the teeth, the gums of dense fibrous tissue covered by stratified
o squamous epithelium.
o and the alveolar arches of the jaws. The roof is formed
z by the hard palate and the soft palate. The floor is Each gum has two parts:
ttr
G occupied by the tongue posteriorly, and presents the a. The free part surrounds the neck of the tooth like
t,(E sublingual region anteriorly, below the tip of the a collar.
o tongue. Posteriorly, the cavity communicates with b. The nttachedparf is firmly fixed to the alveolar arch
I of the jaw. The fibrous tissue of the gum is
the pharynx through the oropharyngeal isthmus
c (isthmus of fauces) which is bounded superiorly by continuous with the periosteum lining the alveoli
o
.F
o the soft palate, inferiorly by the tongue, and on each (periodontal membrane).
ao side by the palatoglosgal arches. Nerve supply of guns is shown in Table 14.1.
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MOUTH AND PHARYNX
Table 14.1: Nerve supply of gums 1
2
Upper gums Nerve Supply
3
Labial side Posterior, middle and anterior
6
(see Fig. 15.16) superior alveolar nerves (V2) Deciduous 1
Lingual side Anterior palatine and
(see Figs 15.6 and 15.11 ) nasopalatine nerves (from
pterygopalatine ganglion)
Lower gums
Labial side Buccal branch of mandibular
and incisive branch of mental
nerve (V3)
Lingual side Lingual nerve (V3)
Permanent
3 Lymphatics of the upper gums pass to the submandi-
bular nodes. The anterior part of the lower gums
drains into the submental nodes, whereas the
posterior part drains into the submandibular nodes.
Figs14.2a and b: Deciduous and permanent teeth (a) and (b):

Ludwig's angina is the cellulitis of the floor of the 1. Central incisor, 2.laleral incisor, 3. canine, 4. 1st premolar, 5. 2nd
mouth. The tongue is forced upwards leading to premolal 6. 1st molar, 7.2nd molar, and 8. 3rd molar
swelling both beloW the chin and within the mouth.
The disease is usually caused due to a carious rnolar
tooth.
c
3
o
o Dentine
Teelh
The teeth form part of the masticatory apparatus and
Pulp cavity
l
are fixed to the jaws. In man, the teeth are replaced only (lined by odontoblasts)
once (diphyodont) in contrast with non-mammalian v
vertebrates where teeth are constantly replaced d) Gum
z
throughout life (polyphyodont). The teeth of the first set Cementum
(dentition) are known as milk, or deciduous teeth, and
the second set, as permanent teeth. Periodontal membrane
The deciduous teeth are 20 in number. In each half
of each jaw, there are two incisors, one canine, and two o Alveolar bone
o
molars (Fig.1.4.2a). t
The permanent teeth are 32 in number, and consist Apical foramen
of two incisors (Latin to cut) one canine (Latin dog) Wo
premolars (Latin millstone) and three molars in each
half of each jaw (Fig, ru.zb).
Fig. 14.3: Parts of a tooth
s foof/t
Feirfs of
Each tooth has three parts: 3 The enamel covering the projecting part of dentine, .Y
T A crown, projecting above or below the gum. or crown. o
2 A root, embedded in the jaw beneath the gum. 4 The cementum surrounding the embedded part of zo
tttr
3 Aneck,between the crown and root and surrounded the dentine. (E
by the gum (Fig. 14.3). 5 The periodontal membrane. !,
G
The pulp is loose fibrous tissue containing vessels, o
Sfruefure nerves and lymphatics, all of which enter the pulp
Structurally, each tooth is composed of: cavity through the apical foramen. The pulp is covered C
.9
1 The pulp in the centre by a layer of tall columnar cells, known as odontoblasts o
2 The dentine surrounding the pulp. which are capable of replacing dentine any time in life. ao
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HEAD AND NECK
The dentine is a calcified material containing spiral Table 14.2: Usual time of eruption of teeth and time of
tubules radiating from the pulp cavity. Each tubule is shedding of deciduous teeth
occupied by a protoplasmic process from one of the Tooth Eruption time Shedding time
odontoblasts. The calcium and organic matter are in
Deciduous (Fi1.14.2a)
the same proportion as in bone.
Medial incisor 6-8 months 6-7 years
The enamel is the hardest substance in the body. It is Lateral incisor 8-10 months 7-8 years
made up of crystalline prisms lying roughly at right First molar 12-16 months 8-9 years
angles to the surface of the tooth. Canine 16-20 months 10-12 years
The cementuz resembles bone in structure, but like Second molar 20-24 months 10-12 years
enamel and dentine it has no blood supply, nor any Permanent (Fig.1a.2b)
nerve supply. Over the neck, the cementum commonly First molar 6-7 years
overlaps the cervical end of enamel; or, less commonly, Medial incisor 7-8 years
it may just meet the enamel. Rarely, it stops short of Lateral incisor 8-9 years
the enamel (10%) leaving the cervical dentine covered First premolar 10-1 1 years
only by gum. Second premolar 11-12 years
T}ee periodontal membrane (ligament) holds the root in Canine 12-1 3 years
its socket. This membrane acts as a periosteum to both Second molar 13-14 years
the cementum as well as the bony socket. Third molar 17-25 years
1 The shape of a tooth is adapted to its function. The SIAGES OF DEVETOPMENT OF DECIDUOUS TEEIH
incisors are cutting teeth,with chisel-like crowns. The
upper and lower incisors overlap each other like the 1 By 6th week of development, the epithelium covering
blades of a pair of scissors. The canines are holding and the convex border of alveolar process of upper and
tearing teeth, with conical and rugged crowns. These lower jaws become thickened to form C-shaped dental
are better developed in carnivore s. Each pr emol ar has lamina, which projects into the underlying mesoderm.
two cusps and is, therefore, also called a bicuspid 2 Dental laminae of upper and lower jaws develop
tooth. The molars nre grinding teeth, with square 10 centres of proliferation from which dental buds
crowns, bearing four or five cusps on their crowns. grow into underlying mesenchyme. This is tiire bud
stage (Figs 14.5a and b)
2 The incisors, canines and premolars have single
roots, with the exception of the first upper premolar 3 The deeper enlarged parts of the tooth bud is called
enamel organ.
which has a bifid root. The upper molars have three
roots, of which two are lateral and one is medial. 4 The enamel organ of dental bud is invaginated by
The lower molars have only two roots, an anterior mesenchyme of dental papilla making it cap shaped.
and a posterior. This is the cap stage (Fig.14.5c).
The dental papilla together with enamel organ is
Frupfion sf leeffl known as the tooth germ. The cell of enamel organ
adjacent to dental papilla cells get columnar and are
The deciduous teeth begin to erupt at about the sixth
known as ameloblasts.
month, and all get erupted by the end of the second year
or soon after. The teeth of the lower jaw erupt slightly
The mesenchymal cells now arrange themselves
along the ameloblasts and are called odontoblasts. The
earlier than those of the upper jaw. The approximate
ages of eruption are given in Table1,4.2. Blood supply of
two cell layers are separated by a basement membrane.
teeth-Both upper and lower are supplied by branches The rest of the mesenchymal cells form the "prip of
the tooth". This is the bell stage (Fig. 14.5d).
of maxillary artery.
.Y
o
Now ameloblasts lay enamel on the outer aspect,
o while odontoblasts lay dentine on the inner aspect.
z fferveSurpplyof fleeffr
Later ameloblasts disappear while odontoblasts remain.
E The pulp and periodontal membrane have the same
tr
(E The root of the tooth is formed by laying down of
nerve supply which is as follows:
!, layers of dentine, narrowingthepulp space to a canal for
G
o The upper teeth are supplied by the posterior superior the passage of nerve and blood vessels only (Fig. 14.5e).
I alveolar, middle superior alveolar, and the anterior The dentine in the root is covered by mesenchymal cells
c superior alveolar nerves (maxillary nerve). which differentiate into cementoblasts for laying down
.o
() The lower teeth are supplied by the inferior alveolar the cementum. Outside this is the periodontal ligament
ao nerve (mandibular nerve) (Fig. 7a.\. connecting root to the socket in the bone.
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MOUTH AND PHARYNX
Sensory root
Trigeminal ganglion
Maxillary nerve Superior

alveolar nerves
Mandibular nerve
lnferior alveolar nerve
Lingual nerve
Superior alveolar plexus
Nerve to mylohyoid
lnferior alveolar plexus
Fig. 14.4: Nerve supply of teeth
Ectoderm forms enamel of tooth. Neural crest cells

Decalcification of enamel and dentine with
form dentine, dental pulp, cementum and periodontal
consequent softening and gradual destruction of
ligament.
the tooth is known as dental caries. A caries tooth
Formation of permanent teeth: These develop from the
is tender on mastication.
dental buds arising from the dental lamina and lie on
Infection of apex of root (apical abscess) occurs
the medial side of each developing milk tooth.
only when the pulp is dead. The condition canbe
recognized in a good radiograph.
o Irregular dentition is common in rickets and the
Being the hardest and chemically the most stable upper permanent incisors may be notched, the
tissues in the body, the teeth are selectively notching corresponds to a small segment of a large
preserved after death and may be fossilized. circle. In congenital syphilis, also the same teeth
Because of this, the teeth are very helpful in are notched, but the notching corresponds to a
medicolegal practice for identification of otherwise large segment of a small circle (Hutchinson's teeth).
unrecognizable dead bodies. The teeth also The third molar teeth also called wisdom teeth
provide by Iar the best data to study evolutionary usually erupt between 18 and 2Ayears. These may
changes and the relationship between ontogeny not erupt normally due to less space and may get
and phylogeny. impacted causing enormous pain.
r In scurvy (caused by deficiency of vitamin C), the Time of eruption of the teeth helps in assessing
gums are swollen and spongy, and bleed on touch. the age of the person.
In gingivitis, the edges of the gums are red and The upper canine teeth are called as the "eye teeth"
.:<
bleed easily. as these have long roots which reach up to the o
r Improper oral hygiene may cause gingivitis and medial angle of the eye. hfection of these roots zo
suppuration with pocket formation between the may spread in the facial vein and even lead to t,
teeth and gums. This results in a chronic pus thrombosis of the cavernous sinus.
(E
discharge at the margin of the gums. The condition E

The upper teeth need separate injections of the G
o
is known as pyorrhoea akseolatis (chronic anaesthetic onboth the buccal and palatal surfaces
periodontitis). Pyorrhoea is common cause of foul of the maxillary process just distal to the tooth. C
breath for which the patient hardly ever consults The thin layer of bone permits rapid diffusion of o
()
a dentist because the condition is painless. the drug up to the tooth.
ao
t
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I
HEAD AND NECK
Dental lamina
Upper lip
Tongue
Dental lamina Tooth bud
Lower lip
First
Mesenchyme pharyngeal
(derived from Bud stage
arch
neural crest) cartilage (b)
Generating dental
lamina
Permanent tooth bud
Ameloblasts
Basement membrane
Odontoblasts
Dental papilla
Dental sac
Cap stage Bell stage
(c) (d)
Enamel
Dentine
Pulp cavity
(lined by odontoblasts)
Gum
Cementum
Periodontal membrane
Alveolar bone
Apical foramen
(e)
Figs 14.5a to e: Development of tooth
Hard palate; Strip the mucoperiosteum of hard palate.

Soft palate.' Remove the mucous membrane of the
DISSECIION soft palate in order to identify its muscles. Also remove
ta
o the mucous membrane over palatoglossal and
o Cut through the centre of the frontal bone, internasal palatopharyngeal arches and salpingopharyngeal fold
z suture, intermaxillary sutures, chin, hyoid bone, thyroid,
tc to visualise the subjacent muscles.
(E cricoid and tracheal cartilages; carry the incision through
!,(5 the septum of nose, nasopharynx, tongue, and both the
HARD PA E
o palates.
I It is a partition between the nasal and oral cavities.
Cut through the centre of the remaining occipital bone
C and cervical veftebrae. This will complete lhe sagittal Its anterior two-thirds are formed by the palatine
o
F
o section of head and neck. processes of the maxillae; and its posterior one-third
o by the horizontal plates of the palatine bones (Fig' 14.6).
a
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MOUTH AND PHABYNX
lncisive foramen The soft palate has two surfaces, anterior and
with openings of
incisive canals
posterior; and two borders, superior and inferior.
The anterior (oral) surface is concave and is marked
by a median raphe.
Palato- Palatine process The posterior surface is convex, and is continuous
maxillary of maxilla
superiorly with the floor of the nasal cavity.
suture
Horizontal plate The superior border is attached to the posterior border
of palatine bone
of the hard palate, blending on each side with the
lnterpalatine
suture Greater palatine pharynx (Fig. 1a.9).
foramen The inferior border is free and bounds the phaq,,ngeal
Pyramidal isthmus. From its middle, there hangs a conical
process of Lesser palatine
palatine bone
Posterior
foramen
projection, called the uvula (Fig. ruI). From each side
nasal spine
of the base of the uvula (Latin small grape) two curved
folds of mucous membrane extend laterally and down-
wards. The anterior fold is called the palatoglossal arch
The anterolateral margins of the palate are continuous or anterior pillar of fauces. It contains the palatoglossus
with the alveolar arches and gums. muscle and reaches the side of the tongue at the junction
The posterior margin gives attachment to the soft of its oral and pharyngeal parts. This fold forms the
>/
palate. lateral boundary of the oropharyngeal isthmus or
The superior surface forms the floor of the nose. isthmus of fauces. The posterior fold is called the
Tlte inferior surface forms the roof of the oral cavity. palatopharyngeal arch or posterior pillar of fauces. It
contains the palatopharyngeus muscle. It forms the
Vessels ond Nerves
posterior boundary of the tonsillar fossa, and merges
Arteries: Greater palatine branch of maxillary artery (see inferiorly with the lateral wall of the pharynx.
Figs 6.6 and 6.7).
Veins: Drain into the pterygoid plexus of veins. Struclure
Neroes: Creater palatine and nasopalatine branches of The soft palate is a fold of mucous membrane con-
the pterygopalatine ganglion suspended by the taining the following parts:
maxillary nerve. The palatine aponeurosis which is the flattened
tendon of the tensor veli palatini forms the fibrous basis
Lymphatics: The lymphatics drain mostly to the upper
of the palate. Near the median plane, the aponeurosis
deep cervical nodes and partly to the retropharyngeal
splits to enclose the musculus uvulae.
nodes.
The levator veli palatini and the palatopharyngeus
SOFT PA E
lie on the superior surface of the palatine aponeurosis.
The palatoglossus lies on the inferior or anterior
It is a movable, muscular fold, suspended from the surface of the palatine aponeurosis.
posterior border of the hard palate. Numerous mucous glands, and some taste buds are
It separates the nasopharynx from the oropharlmx, present.
and is often looked upon as traffic controller at the
crossroads between the food and air passages (Fig.1,a.7). Muscles of the Soft Polote
They are as follows:
1 Tensor palati (tensor veli palatini) (Figs 14.8a and b).
Palato- Soft palate 2 Levator palati (levator veli palatini).
glossal 3 Musculus uvulae.
arch 4 Palatoglossus.
Posterior
Palato-
pharyngeal
5 Palatopharymgeus (Fig. 1a.1a). l<
o
wall of
oropharynx
arch
Details of the muscles are given in Table 14.3.
zo
E'
Nerve Supply (E
Palatine
tonsil I Motor nerves. All muscles of the soft palate except t,G
the tensor veli palatini are supplied by the o
I
uvula pharyngeal plexus. The fibres of this plexus are
derived from the cranial part of the accessory nerve c
.9
through the vagus. The tensor veli palatini is C)
Fig.14.7: Soft palate with palatine tonsils supplied by the mandibular nerve. ao
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HEAD AND NECK
Chorda tympani nerve
Auditory tube
Spine of sphenoid
Palatine aponeurosis
Posterior nasal aperture
Tensor veli palatini
Tensor veli palatini
Pterygoid hamulus
Palatine aponeurosis Pterygoid hamulus
Palatoglossus
Patatopharyngeus
Musculus uvulae
Musculus uvulae
Palatopharyngeus
Tongue Palatoglossus
(a) (b)
Figs. 14.8a and b: (a) Attachment of the muscles of the soft palate, and (b) muscles of soft palate
Sphenoidal air sinus

Roof of nasal cavity
Body of sphenoid
Superior concha Nasopharyngeal bursa with
pharyngeal tonsil
Middle concha
Tubal tonsil and tubal elevation

lnferior concha
Levator veli palatini Anteriorarch of atlas
Hard palate Salpingopharyngeal fold
Palatoglossal arch Passavant's ridge

Soft palate (posterior surface)
Tongue
Palatopharyngeal arch
Palatine tonsil
Epiglottis
Wall of pharynx
Hyoid bone
Thyroid cartilage
Cricoid cartilage Beginning of oesophagus

Beginning oftrachea
Fig. 14.9: Sagittal section through the pharynx, the nose, the mouth and the larynx
General sensory nerves are derived from: 4 Secretomotor nerves are also contained in the lesser
l( a. The middle and posterior lesser palatine nerves/ palatine nerves. They are derived from the suPerior
o
salivatory nucleus and travel through the greater
zo which are branches of the maxillary nerve through
the pterygopalatine ganglion (see Fig. 15.16). petrosal nerve (Flow chartl4.2).
tttr
(E b. The glossopharyngeal nerve.
rr3
(E
Special sensory or gustatory nerves carrying taste Possovonl's Ridge
o sensations from the oral surface are contained in the Some of the upper fibres of the palatopharyrgeus Pass
I
lesser palatine nerves. The fibres travel through the circularly deep to the mucous membrane of the
C greater petrosal nerve to the geniculate ganglion of pharynx, and form a sphincter internal to the superior
.9
o the facial nerve and from there to the nucleus of the constrictor. These fibres constitute Passavant's muscle
o
U) tractus solitarius (Flow chart 14.1). which on contraction raises a ridge called the
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MOUTH AND PHARYNX
Table 14.3: Muscles of the soft palate

Muscle Origin lnsertion Actions
1. Tensor veli palatini a. Lateral side of auditory Muscle descends, converges to a. Tightens the soft palate,
This is a thin, triangular tube form a delicate tendon which winds chiefly the anterior part
muscle (Fig. 14.8) b. Adjoining part of the base round the pterygoid hamulus, b. Opens the auditory tube
of the skull (greater wing passes through the origin of the to equalize air pressure
and scaphoid fossa of buccinator, and flattens out to form between the middle ear
sphenoid bone) the palatine aponeurosis. and the nasopharynx
Aponeurosis is attached to:
a. Posterior border of hard palate
b. lnferior surface of palate behind
the palatine crest
Levator veli palatini a. lnferior aspect of auditory Muscle enters the pharynx by a. Elevates soft palate and
This is a cylindrical tube passing over the upper concave closes the pharyngeal
muscle that lies deep to b. Adjoining part of inferior margin of the superior constrictor, isthmus
the tensor veli palatini sudace of petrous runs downwards and medially and b. Opens the auditory tube,
temporal bone spreads out in the soft palate. lt is like the tensor veli
inserted into the upper surface of palatini
the palatine aponeurosis
3 Musculus uvulae a. Posterior nasal spine Mucous membrane of uvula Pulls up the uvula
This is a longitudinal strip b. Palatine aponeurosis
placed on each side of
the median plane, within
the palatine aponeurosis
4 Palatoglossus Oral surface of palatine Descends in the palatoglossal Pulls up the root of the
aponeurosls arch, to the side of the tongue at tongue, approximates the
the junction of its oral and palatoglossal arches, and
pharyngeal parts thus closes the
oropharyngeal isthmus
5 Palatopharyngeus a. Anterior fasciculus from Descends in the palatopharyngeal Pulls up the wall of the
It consists of two fasciculi posterior border of hard arch and spreads out to form the pharynx and shortens it
that are separated by the palate greater part of longitudinal muscle during swallowing
levator veli palatini b. Posterior fasciculus; coat of pharynx. lt is inserted into:
(also see Passavant's from the palatine a. Posterior border of the lamina
ridge) aponeurosls of the thyroid cartilage
b. Wall of the pharynx and its
median raphe
Passavant's ridge on the posterior wall of the These fibres constitute Passavant's muscle. Passavant's
nasopharynx. \Mhen the soft palate is elevated it comes muscle is best developed in cases of cleft palate, as this
in contact with this ridge, the two together closing the compensates to some extent for the deficiency in the
pharyngeal isthmus between the nasopharynx and the palate.
oropharynx
Morphology of Polotophoryngeus Movemenls ond Funclions of the Soft Poloie
In mammals with an acute sense of smell, the epiglottis The palate controls two gates, upper air way or the
lies above the level of the soft palate, and is supported pharyngeal isthmus and the upper food way or L
oropharyngeal isthmus. The upper air way crosses the o
by two vertical muscles (stylopharyngeus and o
z
salpingopharyngeus) and by a sphincter formed by upper food way (Fig. 1a.10). The soft palate can comple-
tely close them, or can regulate their size according to
t,c
palatopharyngeus. The palatopharyngeal sphincter (E
clasps the inlet of the larynx. requirements. Through these movements, the soft !t(E
In man, the larynx descends and pulls the sphincter palate plays an important role in chewing, swallowing, o
downwards leading to the formation of the human speech, coughing, sneezing, etc. A few specific roles
palatopharyngeus muscle. However, some fibres of the are given below. c
o
sphincter are left behind and form a sphincter inner to 1 It isolates the mouth from the oropharynx during o
o
the superior constrictor at the level of the hard palate. chewing, so that breathing is unaffected. a
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Flow chart 14.1: Gustatory nerves Flow chart 14.2: Secretomotor nerves
Taste from soft palate Superior salivatory nucleus
Geniculate ganglion
Pterygopalatine ganglion (no relay)
Deep petrosal nerve
Nerve of pterygoid canal (Vidian's nerve)
Geniculate ganglion (pseudounipolar neuron)
2 It separates the oropharynx from the nasopharynx

by locking Passavant's ridge during the second stage
of swallowing, so that food does not enter the nose.
3 By varying the degree of closure of the pharyngeal
isthmus, the quality of voice can be modified and Choanae
various consonants are correctly pronounced.

4 During sneezing, the blast of air is appropriately
divided and directed through the nasal and oral
cavities without damaging the narrow nose. Basiocciput
Similarly during coughing, it directs air and sputum
into the mouth and not into the nose (Fig. 14.10). Nasopharynx
Blood Supply Pharyngeal isthmus

A ffes
1 Greater palatine branch of maxillary artery (see
Fig. 6.6). Oropharynx
2 Ascending palatine branch of facial artery.

3 Palatine branch of ascending pharyngeal artery Laryngopharynx
(Fig. 1a.16).
Hedns
They pass to the pterygoid and tonsillar plexuses of
.Y velns.
o
zo L hofles
!ttr
(E Drain into the upper deep cervical and retropharyngeal Oesophagus
t,(E lymph nodes.

o Fig. 14.10: Crossing of upper airway and upper food passages
DEVETOPMENT OF PA E
c The premaxilla or primitive palate carrying uPPer The rest of the palate is formed by the shelf-like
.o
o four incisor teeth is formed by the fusion of medial palatine processes of maxilla and horizontal plates of
o
<t) nasal folds, which are folds of frontonasal process. palatine bone. Most of the palate gets ossified to form
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MOUTH AND PHARYNX
the hard palate. The unossified posterior part of fused

palatal processes forms the soft palate.
STRUCTURE
Soft palate comprises epithelium, connective tissue and Depressed

muscles. Epithelium is from the ectoderm of maxillary palatal arch
process. The muscles are derived from 1st,4th and 6th
branchial arches and accordingly are innervated by Uvula deviated
mandibular and vagoaccessory complex. to normal site
Cleft palate is a congenital defect caused by non-

fusion of the right and left palatal processes. It may
be of different degrees. In the least severe type,
Fig. 14.12: Uvula deviated to right side in paralysis of left
the defect is confined to the soft palate. In the most vagus nerve
severe cases, the cleft in the palate is continuous
with harelip (Fig. 14.11).
Paralysis of the soft palate in lesions of the vagus
nerve produces:
a. Nasal regurgitation of liquids DISSECTION
b. Nasal twang in voice ldentify the structures in the interior of three parts of
c. Flattening of the palatal arch pharynx, i.e. nasopharynx, oropharynx and laryngo-
d. Deviation of uvula to normal side (Fig. 1,4.12). pharynx. Clean the surfaces of buccinator muscle and
adjoining superior constrictor muscles by removing
connective tissue and buccopharyngeal fascia over
these muscles. Detach the medial pterygoid muscle
Median part of lip from its origin and reflect it downwards. This will expose
the superior constrictor muscle completely.
Introduction
The pharynx (Latin throat) is a wide muscular tube,
situated behind the nose, the mouth and the larynx.
Clinically, it is a part of the upper respiratory passages
where infections are common. The upper part of the
Premaxilla
pharynx transmits only air, the lower part (below
the inlet of the larynx), only food, but the middle part
is a common passage for both air and food (Figs 14.9
and 14.10).
Dimensions of Phorynx
Hard palate
Length: About 12 cm.
width:
L Upper part is widest (3.5 cm) and noncollapsible .-o
2 Middle part is narrow
Soft palate 3 The lower end is the narrowest part of the gastro- zo
tttr
intestinal tract (except for the appendix). (E
E
(e)
Boundories G
o
$u6:erforJy
Figs. 14.11a to e: Types of congenital cleft palate: (a) Bilateral
complete, (b) unilateral complete cleft palate, (c) partial midline Base of the skull, including the posterior part of the c
o
cleft, (d) cleft of soft palate, and (e) bifid uvula body of the sphenoid and the basilar part of the occipital o
o
bone, in front of the pharyngeal tubercle. @
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I
HEAD AND NECK
lnferisNy 3 The pharynx is related on either side to:

ous with the oesophagus at the a. ched to it'
cal vertebra, r u to b' dexternal
"orr"rpo'r,ding
cricoid cartilage. related to
The pharynx glides freely on the prevertebral fascia Porls of the Phorynx
which separates it from the cervical vertebral bodies. The cavity of the pharynx is divided into:
Anteriarty I Ti:ll;il,:ff:ffifl:fifi;jIi3,'-'j)
It communicates with the nasal cavity, the oral cavity 3 The laryngeal part, laryngopharynx (Fig 1a.18).
and the larynx. Thus the anterior wall of the pharyT rx Comparisonbetween nosopharynx, oropharlmx and
is incomplete. laryngopharlmx shown in Table 14.4.
*n esef, sdde WALDEYER'S TYMPHAIIC RING
1 The pharyrrx is attached to: In relation to the naso-oropharyngeal isthmus, there
a. Medial pterygoid plate are several aggregations of lymphoid tissue that
b. Pterygomandibular raphe constitute Waldeyer's lymphatic ring (Fig. 14.13). The
c. Mandible most important aggregations are the right and left
d. Tongue palatine tonsils usually referred to simply as the tonsils.
e. Hyoid bone Posteriorly and above, there is the nasopharyngeal
f. Thyroid and cricoid cartilages. tonsil; laterhlly and above, there are the tubal tonsils,
2 It communicates on each side with the middle ear and inferiorly, there is the lingual tonsil over the
cavity through the auditory tube. posterior part of the dorsum of the tongue.
Table 14.4: Comparison between nasopharynx, oropharynx and laryngopharynx

Pafticulars Nasopharynx Oropharynx Laryngopharynx
a. Situation Behind nose Behind oral cavity. Behind larynx.
b. Extent Base of skull (body of Soft palate to upper border of Upper border of epiglottis to
sphenoid) to soft palate epiglottis (Fig. 14.9) lower border of cricoid caftilage
c. Communications Anteriorly with nose 1. Anteriorly with oral cavity, lnferiorly with oesophagus
(Fig 1a.e) 2. Above with nasopharynx Anteriorly with larynx (Fig.14.9)
Below with oropharynx 3. Below with laryngopharynx Above with oropharynx
d. Nerve supply Pharyngeal branches of lX and X nerves lX and X nerves
pterygopalatine ganglion
e. Relations: 1 lnlet of larynx,
i. Anterior Posterior nasal aperture Oral cavity 2 Posterior surface of cricoid
cartilage
3. Arytenoid cartilage
ii. Posterior Body of sphenoid bone and Body of second and third cervical Fourth and fifth cervical vertebrae
and roof . basiocciput and anterior arch vertebrae
of atlas. Presence of
a. Nasopharyngeal tonsil
prominent in children
l( b. Nasopharyngeal bursa-
o mucus divefticulum
zo iii. Lateral wall Opening of auditory tube Tonsillar fossa containing palatine Piriform fossa on each side of
tttr
(E
above this is tubal elevation tonsils inlet of larynx, bounded by
!, with tubal tonsil aryepiglottic fold medially and
o thYroid carlilage laterallY.
o
f. Lining epithelium Ciliated columnar epithelium Stratified squamous nonkeratinised Stratified squamous nonkerati-
epithelium nised epithelium
C
o
o
g. Function Passage for air Passage for air and food Passage for food
o (respiratory function)
a
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MOUTH AND PHARYNX
The tonsil is almond-shaped. It has two surfaces

medial and lateral; two borders, anterior and posterior
Nasopharyngeal
tonsil and two poles, upper and lower.
The medial surface is covered by stratified squamous
epithelium continuous with that of the mouth. This
surface has 12 to 15 crypts. The largest of these is called
Tubal tonsil
the intratonsillar cleft (Fig. 1a.13).
The lateral surface is covered by a sheet of fascia which
lntratonsillar cleft forms the hemicapsule of the tonsil. The capsule is an
extension of the pharyngobasilar fascia. It is only loosely
Palatine tonsil attached to the muscular wall of the pharynx, formed
here by the superior constrictor and by the styloglossus,
but anteroinferiorly the capsule is firmly adherent to the
Lingual tonsil
side of the tongue (suspensory ligament of tonsil) just
in front of the insertion of the palatoglossus and the
Fig. 14.13: Waldeyer's lymphatic ring palatopharyngeus muscle. This firm attachment keeps
the tonsil in place during swallowing.
The tonsillar artery enters the tonsil by piercing the
o Hypertrophy or enlargement of the naso- superior constrictorlust behind the firmâttachment
pharyngeal tonsil or adenoids may obstruct the (Fig. 14.1s).
The palatine vein or external palatine or paratonsillar
posterior nasal aperture and may interfere with
nasal respiration and speech leading to mouth vein descends from the palate in the loose areolar tissue
breathing. These tonsils usually regress by puberty. on the lateral surface of the capsule, and crosses the
o Hypertrophy of the tubal tonsil may occlude the tonsil before piercing the wall of the pharlmx. The vein
auditory or pharyngotympanic tube leading to may be injured during removal of the tonsil or
middle ear problems. tonsillectomy (Fig. 14.15).
The bed of the tonsil is formed from within outwards
Polotine Tonsil (the tonsil) by,
a. The pharyngobasilar fascia (Fig. 1a.1a).
FeTr;if i.JiHi"s
b. The superior constrictor and palatopharyngeus
The palatine tonsil (Latin swelling) occupies the muscles.
tonsillar sinus or fossa between the palatoglossal and c. The buccopharyngeal fascia.
palatopharyngeal arches (Figs 14.7, 14. 13 and 74.74). It d. In the lower part, the styloglossus.
can be seen through the mouth. e. The glossopharyngeal nerve.
Buccopharyngeal fascia
Superior constrictor
Mucous membrane Salpingopharyngeus
Pharyngobasilar fascia
Palatopharyngeal arch
Palatopharyngeus
Ascending pharyngeal artery
Loose areolar tissue Ascending palatine artery .Y

o
Tonsillar artery
zo
Crypts of tonsil
Facial artery
ttr
(E
Palatoglossal arch Palatine vein !,G

o
Palatoglossus Hemicapsule of tonsil
c
Pharyngobasilar fascia .9
o
Fig. 14.14: Horizontal section through the tonsil showing its deep relations ao
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HEAD AND NECK
Superior constrictor
Buccopharyngeal fascia
Pharyngobasilar
Pharyngeal venous plexus fascia
Soft palate
Ramus of mandible
Medial pterygoid Tonsillar fossa
Masseter Paratonsillar vein
Glossopharyngeal nerve Hemicapsule Superior

of tonsil
Styloglossus
Suspensory
Facial artery ligament of
tonsil
Submandibular
salivary gland Tongue lnferior
Fig. 14.15: Vertical section through the tonsil, showing its deep relations
Still more laterally, there are the facial artery with Maxillary
its tonsillar and ascending palatine branches. The
internal carotid artery is 2.5 cm posterolateral to the Superficial
temporal
tonsil. Greater
palatine
The anterior border is related to the palatoglossal arch
with its muscle (Fig. M.7).
Palatine
The posterior border isrelated to the palatopharyngeal Ascending tonsil
arch with its muscle. pharyngeal
The upper pole is related to the soft palate, and the
Ascending Tonsillar
lower pole, to the tongue (Fig. 1a.15). branches
Palatine
The plica triangularis is a triangular vestigial fold of
mucous membrane covering the anteroinferior part of Facial
the tonsil. The plica semilunaris, is a similar semilunar
fold that may cross the upper part of the tonsillar sinus. Lingual
Dorsal
The intratonsillar cleft is the largest crypt of the tonsil. External carotid
linguae
It is present in its upper part (Fig. 1,4.13).It is sometimes
Fig. 14.16: Arterial supply of the palatine tonsil
wrongly named the supratonsillar fossa. The mouth of
cleft is semilunar in shape and parallel to dorsum of
tongue. It represents the internal opening of the second
pharyngeal pouch. A peritonsillar abscess or quinsy Lymphatics pass to jugulodigastric node (see Fig. 8.28).
often begins in this cleft. There are no afferent lymphatics to the tonsil.
Arferuaf $uppfy of fionsrl

Glossopharyngeal and lesser palatine nerves.
L Main source: Tonsillar bra-trch of facial artery.
Z Additional sources: HISIOTOGY
a. Ascending palatine branch of facial artery. The palatine tonsil is situated at the oropharyngeal
b. Dorsal lingual branches of the lingual artery. isthmus. Its oral aspect is covered with stratified
ll
o c. Ascending pharyngeal branch of the external squamous nonk hich diPs into
zo carotid artery. the underlyin crYPts. The
I,
tr
(E
d. The greater palatine branch of the maxillary artery lymphocytes lie ts in the form
t,o @ig. 1a.16). of nodules. The differentiated
o into cortex and medulla (Fig. 74.77).
DEVELOPMENT
o One or more veins leave the lower part of deep surface
o of the tonsil, pierce the superior constrictor, and join The tonsil develops from ventral part of second pharyn-
o
a the palatine, pharyngeal, or facial veins. geal pouch. The lymphocytes are mesodermal in origin.
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MOUTH AND PHARYNX
Stratified other parts of the body, clot formation is

squamous
epithelium
encouraged.
Tonsillitis may cause referred pain in the ear as
glossopharyngeal nerve supplies both these areas.
Lymphoid Suppuration in the peritonsillar area is called
follicle
quinsy. Aperitonsillar abscess is drained by rnaking
an incision in the most prominent point of the
Capillary abSCeSS.
Tonsils are olten sites of a septic focus. Such a focus
Crypt
can lead to serious disease like pulmonary
tuberculosis, meningitis, etc. and is often the cause
of general ill health.
Fig. 14.17: Histology of palatine tonsil loryngeol Porl of Phorynx (loryngophorynx)

This is the lower part of the pharynx situated behind
the larynx. It extends from the upper border of the
The tonsils are large in children. They retrogress epiglottis to the lower border of the cricoid cartilage.
after puberty. The anterior wall presents:
The tonsils are frequently sites of infection, a. The inlet of the larynx.
specially in children. Infection may spread to
b. The posterior surfaces of the cricoid and arytenoid
surrounding tissue for:rning a peritonsillar abscess.
cartilages.
Enlarged and infected tonsils often require
The posterior wall is supported mainly by the fourth
surgical removal. The operation is c\lled
and fifth cervical vertebrae, and partlyby the third and
sixth vertebrae. In this region, the posterior wall of the
pharynx is forrned by the superior, middle and inferior
constrictors of the pharynx.
The laterol wall presents a depression called the
bed. This is to be compared with the method for piriform fossa, orre on each side of the inlet of the larynx
checking postpartum haemorrhage from the (Fig. 1a.18). The fossa is bounded medially by the
uterus. These are the only two organs in the body aryepiglottic fold, and laterallyby the thyroid cartilage
where bleeding is checked by removal of clots. In and the thyrohyoid mernbrane. Beneath the mucosa of
fossa, there lies the internal laryngeal nerve. Removal
' Base of skull
rChoanae with nasal conchae

Nasal septum (posterior edge)
Nasopharynx I tubal elevation
L Opening ot auditory tube
Cavity of mouth
Epiglottis .!a
()
Aryepiglottic fold Laryngeal inlet -----r zo
Laryngopharynx t,tr
I
Prriform f6s53 -- l G
lnteraryienoid fold
ttG
Uncord uarttlage o
I
o
.F
o
Fig. 14.18: The three regions of the pharynx o0)
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HEAD AND NECK
of foreign bodies from the piriform fossa may damage

the intemal laryngeal nerve, leading to anaesthesia in Base of skull
the supraglottic part of the larynx (Fig. 1a.19).
Pharyngotympanic
Structure of Phorynx tube/auditory tube
The wall of the pharynx is composed of the following
five layers (Fig.1,a.20) from within outwards. Mucosa (1)
I Mucosa
Pharyngobasilar
2 Submucosa Superioi fascia (3)
constrictor (4)
3 Pharyngobasilnr fascia or pharyngeal aponeurosis. Submucosa (2)
This is a fibrous sheet internal to the pharyngeal
muscles. It is thickest in the upper part where it fills Buccopharyngeal Middle constrictor (4)
the gap between the upper border of the superior faseia (5)
constrictor and the base of the skull, and also
posteriorly where it forms pharyngeal raphe. lnferior
constrictor (4)
Superiorly, the fascia is attached to basiocciput, the
petrous temporal bone, the auditory tube, posterior Venous plexus
border of the medial pterygoid plate, and pterygo- FiE. 14.20: Structure of the pharynx
mandibular raphe. Inferiorly, it is gradually lost deep
to muscles, and hardly extend beyond the superior
Muscles of the Phorynx
constrictor.
4 The muscular coat consists of an outer circular layer
made up of the three constrictors (superior, middle Consfri*fors of fhe Fh x
and inferior) and an inner longitudinal layer made The muscular basis of the wall of the pharynx is formed
up of the stylopharyngeus, the salpingopharyngeus mainly by the three pairs of constrictors-superior,
and the palatopharlmgeus muscles. These muscles middle and inferior. The origins of the constrictors are
are described later. situated anteriorly in relation to the posterior openings
5 The buccopharyngeal fascin covers the outer surface of the nose, the mouth and the larynx. From here their
of the constrictors of the pharynx and extends fibres pass into the lateral and posterior walls of the
forwards across the pterygomandibular raphe to pharynx, the fibres of the two sides meeting in the mid
cover the buccinator. Like the pharyngobasilar fascia, line in a fibrous raphe.
the buccopharyngeal fascia is best developed in the The three constrictors are so arranged that the
upper part of the pharynx. inferior overlaps middle which in turn overlaps the
Between the buccopharyngeal fascia, and the superior. The fibres of the superior constrictor reach
muscular coat there are the pharyngeal plexuses of the base of the skull posteriorly, in the middle line. On
veins and nerves (Fig. 1a.20). the sides, however, there is a gap between the base of
the skull and the upper edge of the superior constrictor.
Epiglottis This gap is closed by the pharyngobasilar fascia which
Hyoid is thickened in this situation (Frg. M.27). The lower edge
lnternal laryngeal of the inferior constrictor becomes continuous with the
nerve prerces Thyrohyoid circular muscle of the oesophagus. These muscles
thyrohyoid membrane develop from IV and VI pharyngeal arch (see Table A1.5
membrane
and runs through in Appendix 1).
Piriform
piriform fossa
fossa
to reach larynx
I
o
zo 1 The superior constrictor takes origin (Fig. 14.21) from
ttc Aryepiglottic the following (from above downwards):
fold Arytenoid
G a. Pterygoid hamulus (pterygopharlmgeus).
!t(6 b. Pterygomandibular raphe (buccopharyngeus).
Thyroid
o c. Medial surface of the mandible at the posterior end
cartilage
Cricoid
(lamina)
of the mylohyoid line, i.e. near the lower attach-
c ment of the pterygomandibular raphe (see Fig. 7.25)
o
o Fig. 14.19: Posterior view of the piriform fossa after removal of (mylopharyngeus).
o
a the tongue: lnternal laryngeal nerve is shown only on left side d. Side of posteriorpartof tongue (glossophaqmgeus).
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MOUTH AND PHARYNX
Thick pharyngobasilar fascia

Medial pterygoid plate
Styloid process Pterygoid hamulus (a)
Superior constrictor Pterygomandibular raphe (b)
Tongue (d)
Part of mandible (c)

Middle constrictor
Stylohyoid ligament
Hyoid bone
Thyropharyngeal part of
inferior constrictor
Cricopharyngeal part of
inferior constrictor Tendinous band
Oesophagus Cricoid cartilage
Fi1.14.21: Origin of the constrictors of the pharynx
2 The middle constrictor takes origin from:

a. The lower part of the stylohyoid ligament
b. Lesser cornua ofhyoid bone Superior
c. Upper border of the greater cornua of the hyoid constrictor
bone (see Fig.7.47). Stylo-

Middle pharyngeus
3 The inferior constrictor consists of two parts. One part constrictor muscle
the thyropharyngeus arises from the thyroid cartilage.
The other part the cricopharyngeus arises from the Pharyngeal
cricoid cartilage. Thyro- raphe
pharyngeus
The thyropharyngeus arises from: part of inferior
Killian's
a. The oblique line on the lamina of thyroid cartilage, constrictor
dehiscence
including the inferior tubercle (Fig. 1a.21).
Cricopharyngeus
b. A tendinous band that crosses the cricothyroid Oesophagus part of inferior
muscle and is attached above to the inferior constrictor
tubercle of the thyroid cartilage. Fig. 14.222 lnsertion of the constrictors of pharynx
c. The inferior cornua of the thyroid cartilage. L(,
The cricopharyngeus arises from the cricoid carti- Longitw slR uscle eosf o
lage behind the origin of the cricothyroid muscle. z
The pharynx has three muscles that run longitudinally. Ittr
The stylopharyngeus arises from the styloid process. It G
lnserffon of Consfricfors passes through the gap between the superior and t,(E
All the constrictors of the pharynx are inserted into a middle constrictors to run downwards on the inner o
I
median raphe on the posterior wall of the pharynx. The surface of the middle and inferior constrictors. The
upper end of the raphe reaches the base of the skull fibres of the palatopharyngeus descend from the sides of o
.F
where it is attached to the pharyngeal tubercle on the the palate and run longitudinally on the inner aspect ()
basilar part of the occipital bone (Fi9.1.a.22). of the constrictors (Fig. 1,a.8). The salpingopharyngeus ao
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HEAD AND NECK
Auditory tube Midline
Auditory tube
Styloid process
Uvula
Ascending palatine artery
Palatopharyngeus Stylopharyngeus
Hyoid Glossopharyngeal nerve
Epiglottis Superior constrictor
Middle constrictor
Thyroid cartilage
Arytenoid
Superior laryngeal artery
and vein
Cricoid
lnferior constrictor
Constrictors
of pharynx
Fig. 14.23: Longitudinal muscles of pharynx: 1. Stylopharyngeus, Recurrent laryngeal nerve
2. salpingopharyngeus, and 3. palatopharyngeus
lnferior laryngeal vein
and artery
descends from the auditory tube to merge with Fig. 14.24: Schematic coronal section through the pharynx,
palatopharyngeus. showing the gaps between pharyngeal muscles and the
structures related to them
2 The structures passing through the gap between the

superior and middle constrictors are: The stylopharyrr-
DISSECTION geus muscle and the glossopharlmgeal nerve.
Define the attachments of middle and inferior 3 The internal laryngeal nerve and the superior
constrictors of pharynx, and the structures situated laryngeal vessels pierce the thyrohyoid membrane
traversing through the gaps between the three in the gnp between the middle and inferior constrictors.
constrictor muscles. ldentify structures above the 4 The recurrent laryngeal nerve and the inferior laryrr-
superior constrictor muscle and below the inferior geal vessels pass through the gap between the lower
constrictor muscle. border of the inferior constrictor and the oesophagus.
Cut through the tensor veli palatini and reflect it
downwards. Remove the fascia and identify the Killion's Dehiscence
mandibular nerve again with otic ganglion medialto it.
In the posterior wall of the pharynx, the lower part of
ldentify the branches of the mandibular nerve. Locate
the thyropharyngeus is a single sheet of muscle, not
the middle meningeal artery at the foramen spinosum,
overlapped internally by the superior and middle
as it lies just posterior to mandibular nerve.
constrictors. This weak part lies below the level of the
vocal folds or upper border of the cricoid lamina and is
Feolules
limited inferiorly by the thick cricopharyngeal sphinc-
J 1 The large gap between the upper concaae border of the ter. This area is known as Kllian's dehiscence. Pharyngeal
o superior constrictor and the base of the skull is semilunar
zo and is known as the sinus of Morgagni.Itrs closed by
diverticula are formed by outpouching of the dehi-
scence (Figs1.4.25a and b). Such diverticula are normal
t,tr
(E
the upper strong part of the pharyngobasilar fascia in the pig. Pharyngeal diverticula are often attributed
E (Fig.1.a.2a). to neuromuscular incoordination in this region which
(E
o The structures passing through this gap are: may be due to the fact that different nerves supply the
a. The auditory tube. two parts of the inferior constrictor (Fig. 1.4.27). The pro-
C b. The levator veli palatini muscle. pulsive thyropharyngeus is supplied by the pharyngeal
.9
(.) c. The ascending palatine artery (Fig.1.a.2\. plexus, and sphincteric cricopharyngeus, by the
ao) d. Palatine branch of ascending pharyngeal artery. recurrent larlngeal nerve. If the cricopharyngeus fails
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MOUTH AND PHARYNX
BIood Supply
Hyoid
The arteries supplying the pharynx are as follows.
Thyro- 1 Ascending pharyngeal branch of the external carotid
pharyngeus arlery.
2 Ascending palatine and tonsillar branches of the
facial artery.
3 Dorsal lingual branches of the lingual artery.
4 The greater palatine, pharyngeal and pterygoid
branches of the maxillary artery.
The veins form a plexus on the posterolateral aspect
of the pharynx. The plexus receives blood from the
Pharyngeal diverticulum pharynx, the soft palate and the prevertebral region. It
after barium swallow
(b)
drains into the internal jugular and facial veins.
Figs 14.25a and b: (a) Pharyngeal diverticulum, and Lymphotic Droinoge
(b) pharyngeal diverticulum after barium swallow
Lymph from the pharynx drains into the retro-
pharyngeal and deep cervical lymph nodes.
to relax when the thyropharyngeus contracts, the bolus
of food is pushed backwards, and tends to produce a
diverticulum. . Difficulty in swallowing is known as dysphagia.
o Pharyngeal dioerticulum; Read Killian's dehiscence,
Nerve Supply ond Aclions
above (Fig.14.25a).
The nerve supply of the muscles of the pharynx is
considered below. For actions, see text on deglutition.
Deglutifion (Swollowin g)
Nerve Supply Swallowing of food occurs in three stages described
The pharynx is supplied by the pharyngeal plexus of below.
nerves which lies chiefly on the middle constrictor. The
Fursf $fa.glc
plexus is formed by:
1 The pharyngeal branch of the vagus carrying fibres 1 This stage is voluntary in character.
of the cranial accessory nerve.
2 The anterior part of the tongue is raised and pressed
against the hard palate by the intrinsic muscles of
2 The pharyngeal branches of the glossopharyngeal the tongue, especially the superior longitudinal and
nerve.
transverse muscles. The movement takes place from
3 The pharyngeal branches of the superior cervical anterior to the posterior side. This pushes the food
sympathetic ganglion. bolus (Greeklump) into the posterior part of the oral
Motor fibres are derived from the cranial accessory cavity.
nerve through the branches of the vagus. They supply 3 The soft palate closes down on to the back of the
all muscles of pharynx, except the stylopharyngeus tongue, and helps to form the bolus.
which is supplied by the glossopharyngeal nerve. 4 Next, the hyoid bone is moved upwards and
The inferior constrictor receives an additional supply forwards by the suprahyoid muscles. The posterior
from the external and recurrent laryngeal nerves. part of the tongue is elevated upwards and
Sensory fibres or general visceral afferent from backwards by the styloglossi; and the palatoglossal
the pharynx travel mostly through the glosso- arches are approximated by the palatoglossi. This
pharyngeal nerve, and partly through the vagus. pushes the bolus through the oropharyngeal isthmus l<
However, the nasopharynx is supplied by the maxillary o
nerve through the pterygopalatine ganglion; and the
to the oropharynx, and the second stage begins.
zo
tc
soft palate and tonsil, by the lesser palatine and $eeondSfs (E
glossopharyngeal nerves. 1 It is involuntary in character. During this stage, the !t(E
Taste sensatrons from the vallecula and epiglottic area food is pushed from the oropharynx to the lower part o
pass through the internal laryngeal branch of the vagus. of the laryngophargrx.
The parasympathetic secretomotor fibres to the 2 The nasopharyngeal isthmus is closed by elevation q
.9
pharynx are derived from the lesser palatine branches of the soft palate by levator veli palatini and tenser ()
of the pterygopalatine ganglion (see Fig. 15.15) veli palatini and by approximation to it of the ao
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HEAD AND NECK
posterior pharyngeal wall (ridge of Passavant). This

prevents the food bolus from entering the nose.
3 The inlet of larynx is closed by approximation of the
Auditory tube is also known as the pharyngotympanic
aryepiglottic folds by aryepiglottic and oblique
tube or the eustachian tube.
arytenoid. This prevents the food bolus from entering
The auditory tube is a trumpet-shaped channel
the larynx (see Fig. 16.10).
which connects the middle ear cavity with the
4 Next, the laryrx and pharynx are elevated behind nasopharynx. It is about 4 cm long, and is directed
the hyoid bone by the longitudinal muscles of the downwards, forwards and medially. It forms an angle
pharynx, and the bolus is pushed down over the of 45 degrees with the sagittal plane and 30 degrees
posterior surface of the epiglottis, the closed inlet of with the horizontal plane. The tube is divided into bony
the larynx and the posterior surface of the arytenoid
and cartilaginous parts (Fig. ru.26).
cartilages, by gravity, and by contraction of the
superior and middle constrictors and of the BONY PART
palatopharyngeus.
The bony part forms the posterior and lateral one- third
Tk $fmge of the tube. It is 12 mm long, and lies in the petrous
temporal bone near the tympanic plate. Its lateral end
1 This is also involuntary in character. In this stage, is wide and opens on the anterior wall of the middle ear
food passes from the lower part of the pharynx to cavity. The medial end is narrow (isthmus) and is jagged
the oesophagus. for attachment of the cartilaginous part. The lumen of
2 This is brought about by the inferior constrictors of the tube is oblong being widest from side to side.
the pharynx.
Relolions
DEVELOPMENI I Superior : Canal for the tensor tymp ant (see Fig. 18. 13).
The primitive gut extends from the buccopharyngeal 2 Medial: Carotid canal.
membrane cranially, to the cloacal membrane caudally. 3 Laternl: Chordatlrmpani, spine of sphenoid, auriculo-
It is divided into four parts the pharynx, the temporal nerve (Fig. 1a.8) and the temporomandi-
-
foregut, the midgut and the hindgut. The pharynx bular joint.
extends from buccopharyngeal membrane to the
tracheobronchial diverticulum. It is divided into upper CARTILAGINOUS PART
part, the nasopharynx; middle part, the oropharynx; The cartilaginous part forms the anterior and medial
and the lower part, the laryngopharynx. two-thirds of the tube. It is 25 mm long, and lies in the
Canal for tensor tympani
Middle ear
Base of skull
Mastoid antrum
Tympanic end
Pharyngeal end
Bony part of auditory tube
Nasopharynx
lsthmus
Cartilaginous part of auditory tube
J
o
o
z Tensor veli palatini
t,tr
G Palatine aponeurosis
E
(5 Superior constrictor
o
J-
C
o
()
oo Fig. 14.26: Scheme showing anatomy of auditory tube
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MOUTH AND PHARYNX
sulcus tubae, a groove between the greater wing of the blockage of the tube. Pain is relieved by instillation
sphenoid and the apex of the petrous temporal. of decongestant drops in the nose, which he$ to
It is made up of a triangular plate of cartilage which open the ostium. The ostium is commonlyblocked
is curled to form the superior and medial walls of the
in children by enlargement of the tubal tonsil.
tube. The lateral wall and floor are completed by a . Pharyngeal spaces (see Chapter 3).
fibrous membrane. The apex of the plate is attached to
the medial end of the bony part. The base is free and
forms the tubal elevation in the nasopharynx (Fig. 14.9).
Relotions
Middle
I Anterolaternlly: Tensor veli palatini, mandibular ear cavity
nerve and its branches, otic ganglion, chorda
tympani, middle meningeal artery and medial Eustachian tube
pterygoid plate (see Fig. 6.15).
2 Posteromedially: Petrous temporal and levator veli
palatini. Fig. 14.27: Differences in eustachian tube in adult and child
3 The levator veli palatini is attached to its inferior
surface, and the salpingopharyngeus to lower part
near the pharyngeal opening.
Mnemonics
Vosculor Supply Tonsils: The four types'PPLT (people) have
The arterial supply of the tube is derived from the tonsils"
ascending pharyngeal and middle meningeal arteries
Pharyngeal
and the artery of the pterygoid canal.
The veins drain into the pharyngeal and pterygoid Palatine
plexuses of veins. Lymphatics pass to the retro- Lingual and
pharyngeal nodes. Tubal
Nerve Supply
1 At the ostium, by the pharyngeal branch of the
pterygopalatine ganglion suspended by the
maxillary nerve. Both the maxillary and mandibular teeth are
2 Cartilaginous part, by the nervus spinosus branch supplied by the branches of maxillary artery only.
of mandibular nerve. Upper teeth are supplied by branches of maxillary
3 Bony part, by the tympanic plexus formed by glosso- nerve.
pharyngeal nerve. Lower teeth are supplied by branches of
mandibular nerve
Funclion
Waldeyer's ring consists of lingual tonsil, palatine
The tube provides a communication of the middle ear tonsils, tubal tonsils and nasopharyngeal tonsils,
cavity with the exterior, thus ensuring equal air
pressure on both sides of the tympanic membrane. All the 3 constrictors and 2 longitudinal muscles
The tube is usually closed. It opens during of pharynx are supplied by vagoaccessory
swallowing, yawning and sneezing, by the actions of complex, only stylopharyrrgeus is supplied by IX
the tensor and levator veli palatini muscles. nerve.
All the muscles of soft palate are supplied by
vagoaccessory complex except tensor veli palatini, l<
o
Infections may pass from the throat to the middle supplied by V3 nerve. zo
ear through the auditory tube, This is more Tonsillar branch of facial is the main artery of the E'
C
corunon in children because the tube is shorter, palatine tonsil. o
wider and straighter in them (Fig.7a.27). !l(E
Tonsils have only efferent lymph vessels but no o
Inflammation of the auditory tube (eustachian
afferent lpph vessel. I
catarrh) is often secondary to an attack of common
cold, or of sore throat. This causes pain in the ear Killian's dehiscence is a potential gap between o
.F
which is aggravated by swallowing, due to thyropharyr:rgeus and cricopharyngeus. o
ao
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HEAD AND NECK
tubal tonsil posterolaterally and pha geal tonsil

A 12-year-old boy complained of sore throat and ear
ache. He had 102'F temperature and difficulty in
swallowing. He was also a mouth breather. reachingthemiddleear. epharyngotympanictuLre
. What is Waldeyer's lymphatic ring? from the region of nasopharyn-\ communicates rvith
. Explain the basis of boy's ear ache.
r What lymph node would likely to be swollen and
tender?
ear. So the pain of pharynx is referred to ear.
Ans: Major collections of I phoid tissue at the The jugulodigastric lymph node belonging to
oropharyngeal junetion are called the tonsils.
These lie in a ring form called the Waldeyer's
lymphatic ring. The components of this ring are tonsil, penetrate the wall of the pharynx to reach
lingual tonsil anteriorly, palatine tonsil laterally, these I ph nodes.
1. The communication between vestibule and oral c. Buccinator muscle

cavity proper lies: d. Buccopharyngeal fascia
a. Behind 1st molar tooth 7. Which one of the following muscles of pharynx is
b. Behind 2nd molar tooth not supplied by vagoaccessory complex?
c. Behind 3rd molar tooth a. Superior constrictor
d. No communication b. Stylopharygeus
2. The joint between tooth and gum is:
c. Palatopharyngeus
a. Syndesmosis
d. Salpingopharymgeus
b. Gomphosis
c. Sutures
8. Which walls of cartilaginous part of auditory tube
are formed by fibrous membrane?
d. Primary cartilaginous joint
a. Lateral wall and floor
3. The first permanent tooth to erupt is:
a. First molar b. First premolar b. Medial wall and floor
c. Second molar d. Canine c. Superior wall and medial wall
4. Most of muscles of soft palate are supplied by d. Superior wall and floor
vagoaccessory complex except: 9. Paralysis of unilateral soft palate result in following
a. Levator veli palatini effects except:
b. Tensor veli palatini a. Depressed palatal arch
c. Palatoglossus b. Uvula deviated to paralysed side
d. Musculus uvulae c. Nasal twang of voice
5. Which one of the following is not a component of d. Nasal regurgitation of liquids
Waldeyer's ring?
10. Tonsillitis pain is referred to pain in ear as both are
a. Tubal tonsil b. Pharyngeal tonsil
supplied by:
c. Palatine tonsil d. Submental lymph nodes
a. Auricular branch of vagus
ta
o 6. Which of the following structures does not form
o bed of the tonsil? b. Glossopharyngeal nerve
z
t,c a. Superior constrictor c. Sympathetic fibres
(E
b. Pharyngobasilar fascia d. Cranial root of XI nerve
t,(E
o
c
o
o
o
o
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b
g*d
Y Horburg
-E
INTRODUCIION plate and the medial and lateral walls up to the level of
Sense of smell perceived in the upper part of nasal the superior concha. It is thin and less vascular than
cavityby olfactorynerve rootlets ends in olfactorybulb, the respiratory mucosa. It contains receptors called
which is connected to uncus and also to the dorsal olfactory cells.
nucleus of vagus in medulla oblongata. Good smell of
For descriptive purposes, the nose is divided into
food, thus stimulates secretion of gastric juice through two main parts, the external nose and nasal cavity.
vagus nerve. EXIERNAT NOSE
Most of the mucous membrane of the nasal cavity is
Some features of the external nose have been described
respiratory and is continuous with various paranasal
in Chapter 2. These are root, dorsum, tip, anterior nares,
sinuses. Since nose is the most projecting part of the
nasal septum and columella.
face, its integrity must be maintained and efforts should
be made to see that nose is "not cut". Great mythological
The external nose has a skeletal framework that is
war has been fought for "cutting the nose". partly bony and partly cartilaginous. The bones are the
nasal bones, which form the bridge of the nose, and
Environmental pollution causes inhalation of
the frontal processes of the maxillae. The cartilages are
unwanted gases and particles,leading to frequent attacks
of sinusitis, respiratory diseases including asthma.
the superior and inferior nasal cartilages, the septal
cartilage, and small alar cartilages (Figs 15.1a and b).
Nasal mucous membrane is quite vascular. The skin over the external nose is supplied by the
Sometimes picking of the nose may causebleeding from
"Little's area" . Bleeding from nose is called epistaxis. external nasal, infratrochlear and infraorbital nerves
(see Frg.2.22).
NASAT C ITY
The nasal cavity extends from the external nares or

The nose performs two functions. It is a respiratory nostrils to the posterior nasal apertures, and is
passage. It is also the organ of smell. The receptors for subdivided into right and left halves by the nasal
smell are placed in'the upper one-third of the nasal septum (Fig. 15.2). Each half has a roof, a floor, and
cavity. This part is lined by olfactory mucosa. The rest medial and lateral walls. Each half measures about 5 cm
of the nasal cavity is lined by respiratory mucosa. The in height, 5-7 cm in length, and 1.5 cm in width near
respiratory mucosa is highly vascular and warms the the floor. The width near the roof is only 1-2 mm.
inspired air. Theroof is about 7 cm long and 2 mm wide. It slopes
The secretions of numerous serous glands make the downwards, both in front and behind. The middle
air moist; while the secretions of mucous glands trap horizontal part is formed by the cribriform plate of the
dust and other particles. Thus the nose acts as an air ethmoid. The anterior slope is formed by the nasal part
conditioner where the inspired air is warmed, of the frontal bone, nasal bone, and the nasal cartilages.
moistened and cleansed before it is passed on to the The posterior slope is formed by the inferior surface of
delicate lungs. the body of the sphenoid bone (Fig. 15.5).
The olfactory mucosa lines the upper one-third of the The floor is about 5 cm long and 1.5 cm wide. It is
nasal cavity including the roof formed by cribriform formed by the palatine process of the maxilla and the
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HEAD AND NECK
Root
Nasal bone
Dorsum
Superior nasal
cartilage
Septal process
lnferior nasal of inferior nasal
caftilage cartilage
Tip
Ala of nose Ala of
nose
(b)
Figs 15.1a and b: (a) Skeleton of the external nose, and (b) inferior nasal cartilage
horizontal plate of the palatine bone. It is concave from o Fracture of cribriform plate of ethmoid with tearing
side to side and is slightly higher anteriorly than off of the meninges may tear the olfactory nerve
posteriorly (Fig. 15.2). rootlets. In such cases, CSF may drip from the nasal
cavity. It is called CSF rhinorrhoea (Fig. 15.3).
Common cold or rhinitis is the commonest infec-

tion of the nose. It may be infective of allergic
or both. It commonly occurs during change of the
seasons.
DISSECIION
The paranasal air sinuses may get infected from Take the sagittalsection of Head and Neck, prepared in
the nose. Maxillary sinusitis is the commonest of Chapter 14.
such infections. Dissect and remove mucous membrane of the
The relations of the nose to the anterior cranial septum of nose in small pieces. The mucous membrane
fossa through the cribriform plate (Fig. 15.5), is covering both surfaces of the septum of the nose.
and to the lacrimal apparatus through the Dissect and preserve the nerves lying in the mucous
nasolacrimal duct are important in the spread of membrane. Remove the entire mucous membrane to
infection (see Fig. 2.28). see the details in the interior of the nasal cavity.
Floor of anterior
cranial fossa
Anterior ethmoidal sinuses

- Medial wall
of orbit
Superior concha Nasal septum
L Middle ethmoidal sinus

o
o and ethmoidal bulla
z Middle concha
!, Maxillary hiatus
c(E Maxillary sinus
t,(E lnferior concha

o Floor of nose
C Palate forming Upper tooth

o
O
ao Fig". 15.2: Coronal section through the nasal cavity and the maxillary air sinuses
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NOSE AND PARANASAL SINUSES
deflection is produced by overgrowth of one or more

of the constituent parts.
The septum has:
a. Four borders-superior, inferior, anterior and
posterior.
b. Two surfaces-right and left.
Aileriol Supply
Anterosuperior part is supplied by the anterior and
posterior ethmoidal arteries (Fig. 15.5).
Anteroinferior part by the superior labial branch of
facial artery.
Posterosuperior part is supplied by the sphenopalatine
artery. It is the main artery.
Posteroinferior part by branches of greater palatine
artery.
Fig. 15.3: CSF rhinorrhoea The anteroinferior part or vestibule of the septum
contains anastomoses between the septal ramus of the
superior labial branch of the facial artery, branch of
Feotures sphenopalatine artery, greater palatine and of anterior
Thenasal septum is median osseocartilaginous partition ethmoidal artery. These form a large capillary network
between the two halves of the nasal cavity. On each called lhe Kiesselbach's plexus. This is a common site of
side, it is covered by mucous membrane and forms the bleeding from the nose or epistaxis, and is known as
medial wall of both nasal cavities. Little's area.
The bony part is formed almost entirely by:
a. The vomer, and
b. The perpendicular plate of ethmoid. However, its
margins receive contributions from the nasal spine
of the frontal bone, the rostrum of the sphenoid, Anterior
and the nasal crests of the nasal, palatine and ethmoidal
maxillary bones (Fig. 15.a).
The cartilaginous part is formed by:
a. The septal cartilage, and Little's
afea
b. The septal processes of the inferior nasal cartilages
(Fig. 15.1b). Superior
The cuticular part orlower end is formed by fibrofatty labial
tissue covered by skin. The lower margin of the septum
Greater Sphenopalatine
is called the columella. palatine
The nasal septum is rarely strictly median. Its central
Fig.15.5: Roof of the nasal cavity and afterial supply of nasal
part is usually deflected to one or the other side. The septum
Venous Droinoge
Nasal spine of
frontal bone The veins form a plexus which is more marked in the
Cribriform plate lower part of septum or Little's area. The plexus drains
of eihmoid J
anteriorly into the facial vein, posteriorly through the o
Nasal crest of
Perpendicular sphenopalatine vein to pterygoid venous plexus. zo
nasal bone
plate of ethmoid
ttr
Septal cartilage G
Rostrum
Nerve Supply t,G
Septal process of sphenoid 'I, General sensory nerues, arising from trigeminal nerve, o
of inferior nasal
cartilage are distributed to whole of the septum (Fig. 15.6).
Vomer a. The anterosuperior part of the septum is supplied C
Columella .9
by the internal nasal branches of the anterior ()
Fig. 15.4: Formation" of the nasal septum ethmoidal nerve. ao
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deflection is produced by overgrowth of one or more

of the constituent parts.
The septum has:
a. Four borders-superior, inferior, anterior and
posterior.
b. Two surfaces-right and left.
Aileriol Supply
Anterosuperior part is supplied by the anterior and
posterior ethmoidal arteries (Fig. 15.5).
Anteroinferior part by the superior labial branch of
facial artery.
Posterosuperior part is supplied by the sphenopalatine
artery. It is the main artery.
Posteroinferior part by branches of greater palatine
artery.
Fig. 15.3: CSF rhinorrhoea The anteroinferior part or vestibule of the septum
contains anastomoses between the septal ramus of the
superior labial branch of the facial artery, branch of
Feotures sphenopalatine artery, greater palatine and of anterior
Thenasal septum is median osseocartilaginous partition ethmoidal artery. These form a large capillary network
between the two halves of the nasal cavity. On each called lhe Kiesselbach's plexus. This is a common site of
side, it is covered by mucous membrane and forms the bleeding from the nose or epistaxis, and is known as
medial wall of both nasal cavities. Little's area.
The bony part is formed almost entirely by:
a. The vomer, and
b. The perpendicular plate of ethmoid. However, its
margins receive contributions from the nasal spine
of the frontal bone, the rostrum of the sphenoid, Anterior
and the nasal crests of the nasal, palatine and ethmoidal
maxillary bones (Fig. 15.a).
T}:.e cartilaginous part is formed by:
a. The septal cartilage, and Little's
afea
b. The septal processes of the inferior nasal cartilages
(Fig. 15.1b). Superior
The cuticular part orlower end is formed by fibrofatty labial
tissue covered by skin. The lower margin of the septum
Greater Sphenopalatine
is called the columella. palatine
The nasal septum is rarely strictly median. Its central
Fig. 15.5: Roof of the nasal cavity and arterial supply of nasal
part is usually deflected to one or the other side. The septum
Venous Droinoge
Nasal spine of
frontal bone The veins form a plexus which is more marked in the
Cribriform plate lower part of septum or Little's area. The plexus drains
of eihmoid J
anteriorly into the facial vein, posteriorly through the o
Nasal crest of
Perpendicular sphenopalatine vein to pterygoid venous plexus. zo
nasal bone
plate of ethmoid
ttr
Septal cartilage G
Rostrum
Nerve Supply t,G
Septal process of sphenoid 'I, General sensory nerues, arising from trigeminal nerve, o
of inferior nasal
cartilage are distributed to whole of the septum (Fig. 15.6).
Vomer a. The anterosuperior part of the septum is supplied C
Columella .9
by the internal nasal branches of the anterior ()
Fig. 15.4: Formation" of the nasal septum ethmoidal nerve. ao
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HEAD AND NECK
Olfactory rootlets
Medial posterior superior

nasal branches
Nasopalatine
Nasal cavitY
Fig. 15.7: Deviated nasal sePtum
Anterior
supeflor
alveolar Feolures
lncisive The lateral wall of the nose is irregular owing to the
foramen presence of three shelf-like bony projections called
Fig. 15,6: Nerve supply of nasal septum conchae. The conchae increase the surface area of the
b. Its anteroinferior part is suPPlied by anterior nose for effective air-conditioning of the inspired air
(Fig. 15.2).
superior alveolar nerve.
c. The posterosuperior part is supplied by the medial The lateral wall separates the nose:
posterior superior nasal branches of the a. From the orbit above, with the ethmoidal air
pterygopalatine ganglion sinuses intervening.
d. The posteroinferior part is supplied by the b. From the maxillary sinus below.
nasopalatine branch of the pterygopalatine c. From the lacrimal groove and nasolacrimal canal
ganglion. lt is the main neroe. in front.
2 Special sensory neraes or olfactory nerves are confined The lateral wall can be subdivided into three parts.
to the upper part or olfactory area. a. A small depressed area in the anterior part is called
lymphotic Droinoge the vestibule. It is lined by modified skin
containing short, stiff, curved hairs called aibrissae.
Anterior half to the submandibular nodes.
b. The middle part is known as the atrium of the
Posteriorhalfto the retropharyngeal and deep cervical
middle meatus.
nodes.
c. The posterior part contains the conchae' Spaces
separating the conchae are called meatuses
(Fig. 15.8).
a Sphenopalatine artery is the artery of epistaxis.
The skeleton of the lateral wall is partly bony, partly
a Little's area on the septum is a common site of
cartilaginous, and partly made up only of soft tissues.
bleeding from the nose or epistaxis (Fig. 15.5).
Pathological deviation of the nasal septum is often Tlre bony part is formed from before backwards by
responsible for repeated attacks of common cold, the following bones:
allergic rhinitis, sinusitis, etc. It requires surgical a. Nasal.
correction (Fig: 15.7). b. Frontal process of maxilla.
c. Lacrimal.
d. Labyrinth of ethmoid with superior and middle
conchae.
L
o e. Inferior nasal concha, made up of spongy bone
o
z DISSECTION only.
!l Remove with scissors the anterior part of inferior nasal f . Perpendicular plate of palatine bone together with
(5
concha. This will reveal the opening of the nasolacrimal its orbital and sphenoidal processes.
!,
G
o duct. Pass a thin probe upwards through the nasolacrimal g. Mediat pterygoid plate (Fig. 15.9).
duct into the lacrimal sac at the medial angle of the eye. The cartilaginous part is formed by:
c Remove all the three nasal conchae to expose the a. The superior nasal cartilage (Fig. 15.1).
.o meatuses lying below the respective concha. This will b. The inferior nasal cartilage.
o
ao expose the openings of the sinuses present there. c. 3 or 4 small cartilages of the ala'
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Opening of frontal air sinus in infundibulum

Frontal air sinus
Opening of anterior ethmoidal air sinus
Sphenoethmoidal recess
Middle concha (cut)
Sphenoidal sinus
Agger nasi
Superior concha (cut)
Atrium
Openings of posterior
Hiatus semilunaris
ethmoidal air sinus
Vestibule
Middle ethmoidal air sinus
Opening of nasolacrimal duct and ethmoidal bulla
lnferior concha (cut)
lnferior meatus Maxillary air sinus
Fig. 15.8: Lateral wall of the nasal cavity seen after removing the conchae
Frontal air sinus Ethmoid bone

Superior concha
Lacrimal bone
Nasal bone Sphenopalatine foramen
Frontal process of maxilla

Hypophyseal fossa
Superior nasal cartilage Sphenoidal sinus

Middle concha
lnferior nasal cartilage

Medial pterygoid plate
Alar cartilages
Cuticular part Perpendicular plate of palatine
lnferior nasal concha Uncinate process of ethmoid
Fig. 15.9: Formation of the lateral wall of the nasal cavity
The cuticular lower part is formed by fibrofatty tissue 1 The inferior concha (Latin shell) is an independent
covered with skin. bone.
2 The middle concha is a projection from the medial
surface of ethmoidal labyrinth (Fig. 15.9).
3 The superior concha is also a projection from the
medial surface of the ethmoidal labyrinth. This is
DISSECTION the smallest concha situated just above the
Trace the nasopalatine nerve till the sphenopalatine posterior part of the middle concha (Fig. 15.2).
foramen. Try to find.few nasal branches of the greater The meatuses of the nose are passages beneath the
palatine nerve. overhanging conchae. Each meatus communicates
Gently break the perpendicular plate of palatine freely with the nasal cavity proper (Fig. 15.8).
bone to expose the greater palatine nerve, branch of 1 The inferior meatus lies underneath the inferior
the pterygopalatine ganglion. Follow the nerve and concha, and is the largest of the three meatuses. l.(,
its accompanying vessels to the hard palate. ldentify The nasolacrimal duct opens into it at the junction
of its anterior one-third and posterior two-thirds.
zo
the lesser palatine nerves and trace them till the soft t,c
palate. The opening is guarded by the lacrimal fold, or G
Hasner's zsalzte. E'
(E
2 The middle meatus lies underneath the middle o
Feoiures concha. It presents the following features:
T}re nasal conchae are curved bony projections a. The ethmoidal bulla, is a rounded elevation c
o
directed downwards and medially. The following producedby the underlying middle ethmoidal o
o
three conchae are usually found: sinuses which open at upper margin of bulla. a
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HEAD AND NECK
b. The hiatus semilunaris, is a deep semicircular 4 The posteroinferior quadrant is supplied by branches
sulcus below the bulla. from greater palatine artery which pierce the
c. The infundibulum is a short passage at the perpendicular plate of palatine bone and passes uP
anterior end of the hiatus. through the incisive fossa.
d. The opening of frontal air sinus is seen in the
anterior part of hiatus semilunaris (Fig. 15.8). Venous Droinoge
e. The opening of the anterior ethmoidal air sinus is The veins form a plexus which drains anteriorly into
present behind the opening of frontal air the facial vein; posteriorly, into the pharyngeal plexus
sinus. of veins; and from the middle part, to the pterygoid
f . The opening of maxillary air sinus is located in plexus of veins.
posterior part of the hiatus semilunaris. It is
often represented by two openings. Nerve Supply
3 The superior meafzs lies below the superior concha. I General sensory neroes derived from the branches of
This is the shortest and shallowest of the three
trigeminal nerve are distributed to whole of the
meatuses. It receives lhe openings of the posterior
lateral wall:
ethmoidal air sinuses.
a. Anterosuperior quadrant is supplied by the anterior
The sphenoethmoidal recess is a triangular fossa just
ethmoidal nerve branch of ophthalmic nerve
above the superior concha. It receives lhe opening of the
(Fig. 15.11).
sphenoidal air sinus (Fig. 15.8).
Theatriumof themiddlemeatus is a shallow depression b. Anteroinferior quadranf is supplied by the anterior
just in front of the middle meatus and above the superior alveolar nerve, branch of infraorbital,
vestibule of the nose. It is limited above by a faint ridge continuation of maxillary nerve.
of mucous membrane, the agger nasi, which rluns c. Posterosuperior quadrant is supplied by the lateral
forwards and downwards from the upper end of the posterior superior nasal branches from the
anterior border of the middle concha (Fig. 15.8). pterygopalatine ganglion.
d. Posteroinferior quadranf is supplied by the anterior
Arteriol Supply palatine branch from the pterygopalatine
1. The anterosuperior quadrant is supplied by the anterior ganglion.
ethmoidal artery assisted by the posterior ethmoidal 2 Special sensory neraes or olfactory nerves are
artery. distributed to the upper part of the lateral wall just
2 The anteroinferior quadrant, is supplied by branches below the cribriform plate of the ethmoid up to the
from the facial artery (Fig. 15.10). superior concha.
3 The posterosuperior quadrant, is supplied by few Note that the olfactory mucosa lies partly on the
branches of the sphenopalatine artery. lateral wall and partly on the nasal septum.
Anterior and posterior ethmoidal
Sphenopalatine
!
o
zo
tttr Greater
(E
palatine
E'
(E
o
co Branches from
facial artery Anterior palatine nerve
o
o
a Fig. 15.10: Arteries supplying the lateralwall of the nasal cavity Fig. 15.11: Nerue supply of lateral wall of nasal cavity
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lymphotic Droinoge Frontal
Lymphatics from the anterior half of the lateral wall Anterior and
pass to the submandibular nodes, and from the middle ethmoidal
posterior half, to the retropharyngeal and upper deep Posterior ethmoidal

cervical nodes.
Sphenoidal
Hypertrophy of the mucosa over the inferior nasal Maxillary

concha is a common feature of allergic rhinitis, which
Nasopharynx
is characterized by sneezing, nasal blockage and
excessive watery discharge from the nose.
Fig. 15.12: Lateral wall of nasal cavity with location of paranasal

srnuses
DISSECI]ON
Remove the thin medialwalls of the ethmoidal air cells,
and look for the continuity with the mucous membrane
infundibulum or through the frontonasal duct
(Fig. 1s.8).
of the nose. Remove the medial wall of maxillary air
sinus extending anteriorly from opening of nasolacrimal 3 The right and left sinuses are usually unequal in
duct till the greater palatine canal posteriorly. Now size; and rarely one or both may be absent. Their
maxillary air sinus can be seen. Remove part of the arerage height, width and anteroposterior depth are
roof of maxillary air sinus so that the maxillary nerve each about 2.5 cm. The sinuses are better developed
and pterygopalatine ganglion are identifiable in the in males than in females.
pterygopalatine fossa. 4 They are rudimentary or absent at birth. They are
Trace the infraorbital nerve in infraorbital canal in well developed between 7 and 8 years of age, but
floor of orbit. Try to locate the sinuous course of anterior reach full size only after puberty.
superior alveolar nerve into the upper incisor teeth. 5 Arterial supply: Supraorbital artery.
Venous drainage: Into the supraorbital and superior
Feotules ophthalmic veins.
Paranasal sinuses are air filled spaces present within Lymphatic drainage: To submandibular nodes.
some bones around the nasal cavities. The sinuses, are Nerae supply: Supraorbital nerve.
frontal, maxillary, sphenoidal and ethmoidal. All of them
open into the nasal cavity through its lateral wall Moxillory Sinus
(Fig. 15.12). The function of the sinuses is to make the 1 The maxillary sinus lies in the body of the maxilla
skull lighter and add resonance to the voice. In (Fig. 15.2), and is the largest of all the paranasal
inJections of the sinus es or sinusitls, the voice is altered. sinuses. It is pyramidal in shape, with its base
The sinuses are rudimenlary, or even absent at birth. directed medially towards the lateral wall of the nose,
They enlarge rapidly during the ages of 6 to 7 years, and the apex directed laterally in the zygomatic
i.e. time of eruption of permanent teeth and then after process of the maxilla.
puberty. From birth to adult life, the growth of the 2 It opens into the middle meatus of the nose in the
sinuses is due to enlargement of the bones; in old age it lower part of the hiatus semilunaris (Fi9.1.5.8). The
is due to resorption of the surrounding cancellous bone. opening is nearer the roof (Fig. 15.13).
The anatomy of individual sinuses is important as 3 In an isolated maxilla, the opening or hiatus of the .Y
they are frequently infected. ()
maxillary sinus is large. However, in the intact skull
the size of opening is reduced to 3 or 4 mm as it is zo
Fronlol Sinus ttr
overlapped by the following: (E
1 The frontal sinus lies in the frontal bone deep to the a. From above, by the uncinate process of the !,(6
superciliary arch. It extends upwards above the ethmoid, and the descending part of lacrimal bone. o
medial end of the eyebrow, and backwards into the b. From below, by the inferior nasal concha.
medial part of the roof of the orbit (Fig. 1.5.12). c. From behind, by the perpendicular plate of the C
o
2 It opens into the middle meatus of nose at the anterior palatine bone (Fig. 15.9). It is further reduced in o
o
end of the hiatus semilunaris either through the sizeby the thick mucosa of nose. a
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HEAD AND NECK
The size of sinus is variable. Average measurements The anterior ethmoidal sinus is made up of 1 to 11 air
are: height-3.5 cm, width-2.S cm and antero- cells, opens into the anterior Part of the hiatus
posterior depth-3.5 cm (Fig. 15.12). semilunaris of the nose. It is supplied by the anterior
Its roof rs formed by the floor of orbit, and is traversed ethmoidal nerve and vessels. Its lymphatics drain
by the infraorbital nerve. The floor is formed by the into the submandibular nodes.
alveolar process of maxilla, and lies about 1 cm below The middle ethmoidal sinus consisting of 1 to 7 air cells
the level of floor of the nose. The level corresponds open into the middle meatus of the nose. It is
to the level of lower border of the ala of nose. supplied by the anterior ethmoidal nerve and vessels
The floor is marked by several conical elevations and the orbital branches of the pterygopalatine
produced by the roots of uPPer molar and premolar ganglion. Lymphatics drain into the submandibular
teeth. nodes (Fig. 15.8).
The posterior ethmoidal sinus consisting of 1 to 7 ait
The roots may even penetrate the bony floor to lie
cells open into the superior meatus of the nose. It is
beneath the mucous lining. The canine tooth may
supplied by the posterior ethmoidal nerve and
project into the anterolateral wall.
vessels and the orbital branches of the pterygo-
The maxillary sinus is the first paranasal sinus to
deaelop.
palatine ganglion. Lymphatics drain into the
retropharyngeal nodes.
7 Arterial supply: Facial, infraorbital and greater
palatine arteries.
Venous drainage into the facial vein and the pterygoid
Infection of a sinus is known as sinusitis. It causes
plexus of veins.
headache and persistent, thick, purulent discharge
Lymphatic drainage into the submandibular nodes. from the nose. Diagnosis is assistedby transillumi
Nerae supply; Posterior superior alveolar nerves from nation and radiography. A diseased sinus is
maxillary and anterior and middle superior alveolar oPaque.
nerves from infraorbital. The maxillary sinus is most commonly involved.
It may be infected from the nose or from a caries
Sphenoidol Sinus tooth. Drainage of the sinus is difficult because
1 The right and left sphenoidal sinuses lie within the its ostium lies at a higher level than its floor.
(Fig. 15.12). They are Hence, the sinus is drained surgically by making
e two sinuses are usually an artificial opening near the floor in one of the
sinus oPens into the following two ways:
corresponding half of the a. Antrum puncture can be done by breaking
nasal cavity (Fig. 15.8). the lateril wall of the inferior meatus and
2 Each sinus is related superiorly to the optic chiasma pushing in fluid and letting it drain through
and the hypophysis cerebri; and laterally to the the natural orifice with head in dependent
internal carotid artery and the cavernous sinus position (Fig. 15.13).
(see Fi9.12.5). b. An opening can be made at the canine fossa
3 Arterial supply: Posterior ethmoidal and internal through the vestibule of the mouth, deep to the
carotid arteries. upper lip (Caldwell-Luc operation).
Venous drainage: Into pterygoid venous plexus and Carcinoma of the maxillary sinus arises from the
cavernous sinus. mucosal lining. Symptoms depend on the direction
Lymphatic draincige: To the retropharyngeal nodes. of growth.
Nense supply: Posterior ethmoidal nerve and orbital a. Invasion of the orbit causes proptosis and
branches of pterygopalatine ganglion. diplopia. If the infraorbital nerve is involved,
l( ttrere is facial pain and anaesthesia of the skin
o Ethmoidol Sinuses over the maxilla.
zo 1 Ethmoidal sinuses are numerous small inter- b. Invasion of the floor may produce a bulging
E'
tr
(5 communicating spaces which lie within the labyrinth and even ulceration of the Palate.
t, of the ethmoid bone (Fig. 15.2). They are completed c. Forward growth obliterates the canine fossa
G
o from above by the orbital plate of the frontal bone, and produces a swelling of the face.
from behind by the sphenoidal conchae and the d. Backward growth may involve the palatine
o orbital and anteriorlY nerves and produce severe pain referred to the
() by the e divided into upper teeth.
o
@ anterio s (Fig. L5.12).
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e. Crowth in a medial direction produces nasal

obstruction, epistaxis and epiphora.
f. Growth in a lateral direction produces a This is small pyramidal space situated deeply, below
swelling on the face and a palpable mass in the the apex of the orbit (Fig. 15.14).
labiogingival groove.
Frontal sinusitis and ethmoiditis can cause BOUNDARIES
oedema of the lids secondary to infection of the
Study the boundaries on the skull.
sinuses.
Anterior: Superomedial part of the posterior surface of
Pain from ethmoid air sinus may be referred to
the maxilla.
forehead, as both are supplied by ophthalmic
division of trigeminal nerve. Posterior: Root of the pterygoid process and adjoining
Pain of maxillary sinusitis may be referred to part of the anterior surface of the greater wing of the
upper teeth and infraorbital skin as all these are sphenoid.
supplied by the maxillary nerve. dial: Upper part of the perpendicular plate of the
palatine bone. The orbital and sphenoidal processes of
the bone also take part.
Lateral: The fossa opens into the infratemporal fossa
through the pterygomaxillary fissure.
Superior: Undersurface of the body of sphenoid.
rior: Closedby the pyramidal process of the palatine
bone in the angle between the maxilla and the pterygoid
Process.
COMMUNICATIONS
Anteriorly: With the orbit through the medial end of
the inferior orbital fissure (Fig. 15.1a).
Posteriorly:
1 Middle cranial fossa through the foramen rotundum.
2 Foramen lacerum through the pterygoid canal.
3 Pharyrrx through the palatinovaginal canal.
dially : W ith the nose through sphenopalatine foramen.
Fig. 15.13: Antrum puncture. Directions to show the invasion
of the carcinoma of maxillary srnus Laterally: With the infratemporal fossa through the
pterygomaxillary fissure.
Anterior Posterior
Undersurface of body of sphenoid
lnferior orbital fissure (leading to orbit) Root of pterygoid process
Foramen rotundum
Posterior surface of maxilla
Pterygoid canal
Sphenopalatine foramen (on medial wall)
J
Maxillary air sinus Palatinovaginal canal o
zo
Pterygomaxillary fissure t,tr
G
Part of palatine bone
Greater palatine canal ttG
o
Lesser palatine canals
c
Pyramidal process of palatine .o
o
Fig- 15.14: Scheme to show the pterygopalatine fossa and its communications ao
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HEAD AND NECK
riorly: With the oral cavity through the greater and Posferior Su p e il o r Alveordr Iverve
lesser palatine canals. Enters the posterior surface of the body of the maxilla,
and supplies the three upper molar teeth and the
CONTENTS
adjoining part of the gum.
1 Third part of the maxillary arlery and its branches
which bear the same names as the branches of the
pterygopalatine ganglia and accompany all of them. It is a branch of the maxillary nerve, given off in the
2 Maxillary nerve and its two branches, zygomatic and pterygopalatine fossa. It enters the orbit through the
posterior superior alveolar. lateral end of the inferior orbital fissure, and runs along
3 Pterygopalatine ganglion and its numerous branches
the lateral wall, outside the periosteum, to enter the
containing fibres of the maxillary nerve mixed with zygomaticbone. Just before or after entering the bone,
autonomic nerves. it divides into two terminal branches, the
Moxillory Nerve zy gomaticofacial and zy gomaticot emp or al fiera es which
supply the skin of the face and of the anterior part of
It arises from the trigeminal ganglion, runs forwards the temple (see Fig.2.22). The communicating branch
in the lateral wall of the cavernous sinus below the to the lacrimal nerve, which contains secretomotor
ophthalmic nerve, and leaves the middle cranial fossa
by passing through the foramen rotundum fibres to the lacrimal gland, arises from the
zygomaticotemporal nerve, and runs in the lateral wall
(seeFig.12.13). Next, the nerve crosses the upper part
of the orbit (Fig. 15.15).
of pterygopalatine fossa, beyond which it is continued
as the infraorbital nerve.
In the middle cranial fossa maxillary nerve gives a fin a'f.itel Nerve
meningeal branch. It is the continuation of the maxillary nerve. It enters
In the pterygopalatine fossa, the nerve is related to the orbit through the inferior orbital fissure. It then runs
the pterygopalatine ganglion, and gives off the forwards on the floor of the orbit or the roof of the
ganglionic, posterior superior alveolar and zygomatic maxillary sinus, at first in the infraorbital groooe and then
nerves. in the infraorbital canal remaining outside the
periosteum of the orbit. It emerges on the face through
Gon nrc Ersncfles the infraorbital foramen and terminates by dividing into
The pterygopalatine ganglion is suspended by the palpebral, nasal and labial branches. The nerve is
ganglionic branches. accompanied by the infraorbital branch of the third part
Anterior Posterior
Lacrimal nerve
Lacrimal gland
Communicating branch between
Zygomatic and zygomaticotemporal and lacrimal
zygomaticofacial
Zygomaticotemporal
lnfraorbital
Maxillary nerve
Palpebral
Foramen rotundum
lnfraorbital foramen
Facial nerve
Nasal
Ganglionic branches
Labial
Geniculate ganglion
Posterior, middle
.v E
o
o
and anterior
superior alveolar -rE-
z Greater petrosall[i f
t,tr le.2
to- o
_-] q *
Sphenopalatine Deep petrosal
(E
foramen
t,(E 0)
o
Lesser palatine
co Pterygopalatine ganglion
F() Greater palatine
o)
U) Fig. 15.15: Maxillary nerve with pterygopalatine ganglion, postganglionic fibres are dashed
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of the maxillary artery and the accompanying vein (see to the lacrimal gland and to the mucous glands of
Fi9.2.22). the nose, the paranasal sinuses, the palate and the
Brsnches nasopharynx (Fig. 15.2).
1 The middle superior alaeolar nerae arises in the 2 The sympathetic root is also derived from the nerve
infraorbital groove, runs in the lateral wall of the of the pterygoid canal. It contains postganglionic
maxillary sinus, and supplies the upper premolar fibres arising in the superior cerrsical sympathetic
teeth. ganglion which pass through the internal carotid
2 The anterior superior alaeolar nerz;e arises in the plexus, lhe deep petrosal neroe and the nerr,te of the
infraorbital canal, and runs in a sinuous canal having pterygoid canal to reach the ganglion. The fibres pass
a complicated course in the anterior wall of the through the ganglion without relay, and supply
maxillary sinus. It supplies the upper incisor and vasomotor nerves to the mucous membrane of the
canine teeth, the maxillary sinus, and the antero- nose, the paranasal sinuses, the palate and the
inferior part of the nasal cavity. nasopharynx (see Table 1.3).
3 Terminal branches palpebral, nasal and labial supply a 3 The sensory roots corne from the maxillary nerve. Its
large area of skin on the face. They also supply fibres pass through the ganglion without relay. They
the mucous membrane of the upper lip and cheek emerge in the branches described below (Fig. 15.15).
(see Fig.2.22).
BRANCHES
The branches of the ganglion are actually branches of
the maxillary nerve. They also carry parasympathetic
and sympathetic fibres which pass through the
ganglion. The branches are:
DISSECTION t Orbital branches pass through the inferior orbital
fissure, and supply the periosteum of the orbit, and
Trace the connections, and branches of pterygopalatine
ganglion. lt is responsible for supplying secretomotor the orbitalis muscle which is involuntary (Fig. 15.15).
fibres to the glands of nasal cavity, palate, pharynx 2 Palntine branches the greater or anterior palatine neroe
and the lacrimal gland. lt is also called Hay fever descends through the greater palatine canal, and
ganglionas inflammation of the ganglion causes allergic supplies the hard palate and the labial aspect of the
sinusitis. upper gums. The lesser or middle and posterior palatine
neraes supply the soft palate and the tonsil
(Figs 15.16a and b).
Feotures
Pterygopalatine is the largest parasympathetic
3 Nasal branches enter the nasal cavity through the
sphenopalatine foramen (Fig. 15.15). The lateral
peripheral ganglion. It serves as a relay station for posterior superior nasal branches, about six in number
secretomotor fibres to the lacrimal gland and to the supply the posterior parts of the superior and middle
mucous glands of the nose, paranasal sinuses, palate conchae (Fig. 15.11).
and pharynx. Topographically, it is related to the
maxillary nerve, but functionally it is connected to facial The medial posterior superior nasal branches, two or
nerve through its greater petrosal branch. three in number supply the posterior part of the roof
The flattened ganglion lies in the pterygopalatine of the nose and of the nasal septum (Fig. 15.5). The
fossa just below the maxillary nerve, in front of the largest of these nerves is known as the nasopalatine
pterygoid canal and lateral to the sphenopalatine neruse which descends up to the anterior part of the
foramen (Figs 15.15 and 15.16). hard palate through the incisive foramen (Fig. 15.6).
4 The pharyngeal branch passes through the palatino-
CONNECTIONS vaginal canal and supplies the part of the nasopharynx .Y
behind the auditory tube (Figs 15.16a and b). ()
L The parasympnthetic root of the ganglion is formed
zo
by the nerve of the pterygoid canal. It carries 5 Lacrimal branch: The postganglionic fibres pass back
t,tr
preganglionic fibres that arise from neurons present into the maxillary nerve to leave it through its G
near the superior saliaatory andlacrimatory nuclei, and zygomatic nerve and its zygomaticotemporal branch, E'
a communicating branch to lacrimal nerve to supply G
pass through the neraus intermedius, the facial nerz)e, o
the geniculate ganglion, the greater petrosal nerve and the secretomotor fibres to the lacrimal gland
the nerae of the pterygoid canal to reach the ganglion. (Fig. 15.15). c
o
The fibres relay in the ganglion. Postganglionic fibres Flow chart 15.1 shows the pathway for secretomotor o
o
arise in the ganglion to supply secretomotor nerves fibres to lacrimal gland. a
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HEAD AND NECK
Greater Maxillary
Zygomatic nerve petrosal nerve nerve
containing lacrimal
branch of the ganglion Nerve of Lacrimal
Maxillary nerve pterygoid gland
Sensory roots Nasal
(constituting
Orbital branches parasympathetic branches
and sympathetic Greater
Pterygopalatine
roots) palatine
ganglion
nerve
Nasal branches
Pharyngeal
branch Deep petrosal
Posterior inferior nasal nerve
branch of anterior
palatine nerve Lesser (middle Pharyngeal branch
and posterior)
Anterior (greater) palatine nerves Sympathetic plexus
palatine nerve around internal carotid artery
Superior cervical sympathetic
ganglion
(a) (b)
Figs 15.16a and b: (a) Connections of the pterygopalatine ganglion, and (b) roots and branches of pterygopalatine ganglion
Flow chart 15.1 : The secretomotor fibres for lacrimal gland
Lacrimatory nucleus Trigeminal neuralgia affecting its maxillary

branch produces symptoms in the area of its
distribution. The nerve can be anaesthetized at the
foramen rotundum.
The pterygopalatine ganglion if irritated or
infected causes congestion of the glands of palate
and nose including the lacrimal gland Producing
Ge on running nose and lacrimation. The condition is
called hay fever. The ganglion is called 'Sanglion
of hay feoer.
Greater petrosal nerve + Deep petrosal nerve
Maxillary nerve carries the afferent limb fibres of
the sneeze reflex as it carries Eeneral sensation
Nerve of pierygoid canal (Vidian's nerve) from the nasal mucous membrane.
SUMMARY OF PTERYGOPATAIINE FOSSA

It contains three or multiple of three structures:
Three contents:
Postgangllonic fibres
. Maxillary nerve
o 3rd part of maxillary artery
. Pterygopalatine ganglion.
Three names of ganglion:
' SPhenoPalatine
o Pterygopalatine
t( . Ganglion of hay fever.
o
o Three structures traversing in openings in posterior
z Z
wall:
E'
tr
(E
. Maxillary nerve th
t,G o Nerve of pterygoid nal.
o . Pharlmgealbranch nal.
I
Three structures through inferior orbital fissure:
c . Lrfraorbital nerve.
.9
o o Zygornatic nerve'
ao) . Orbital branches of the ganglion.
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Three structures through inferior openings: a Sinusitis may occur due to air pollution.
. Anterior palatine nerve and greater palatine vessels. a Pterygopalatine ganglion is the ganglion of "hay
. Two posterior palatine nerves and lesser palatine fevet" . It gives secretomotor fibres to lacrimal
vessels. gland, nasal, palatal and pharyngeal gland.
Three structures through medial opening: Pain of maxillary sinusitis is referred to upper
. Nasopalatine nerve and sphenopalatine vessels. teeth; of ethmoidal sinusitis to medial side of orbit
.Medial posterior superior nasal branches. and of frontal sinusitis to forehead.
.Lateral posterior superior nasal branches.
Three roots of the ganglion: Sensory, sympathetic
and secretomotor.
3 x 2branches of the ganglion: Orbital, pharyngeal, A child during hot summer months is playing in the
for lacrimal gland, anterior palatine, posterior palatine park. He picks up his nose, and it starts bleeding
and nasopalatine branches. . What is the source of the bleeding?
3 x 2 branches of 3rd part of maxillary artery: o Name the arteries supplying septum of the nose.
Posterior superior alveolar, infraorbital, sphenopalatine,
Ans: The source of the nasal bleeding or epistaxis is
pharyngeal, artery of pterygoid canal and greater
palatine.
*jrty to the large capillary plexus situated at the
anteroinferior part of the septurrL of nose. It is called
Kiesselbach's plexus and the area is also known as
Little's area.
Artery of epistaxis is sphenopalatine
Upper few mm of lateral wall of nose and septum 1. Anterior ethmoidal, branch of ophthalmic
of nose are lined by olfactory epithelium with ich is a branch of internal carotid
bipolar neurons in it. 2. Superiorlabial,abranchoffacialaftery, ich
Most of the nerves and blood vessels to the lateral in turn is a branch of external carotid artery
wall of nose and septum of nose are common. The 3. Large sphenopalatine artery. This is the
difference is in their magnitude. conti tion of 3rd part of maxillary artery, one
Maxillary sinusitis is the commonest chronic of the terminal branches of external carotid
sinusitis. artery.
Into the middle meatus of nose drain 4 sets of air 4. S e branches from greater palatine artery, a
sinuses. branch of maxillary artery.
MULTIPLE CHOICE SUESTIONS
1. following is the artery of epistaxis?

\Atrhich of the c. Frontal air sinus
a. Anterior ethmoidal b. Greater palatine d. Sphenoidal air sinus
c. Sphenopalatine d. Superior labial 4. Nerve to pterygoid canal is formed by:
2. Which one of the following air sinuses does not a. Greater petrosal and deep petrosal
drain in the middle meatus of nose? b. Lesser petrosal and deep petrosal
a. Anterior ethmoidal air sinuses c. Greater petrosal and external petrosal
b. Middle ethmoidal air sinuses d. Lesser petrosal and external petrosal
5' \A[hich air sinus is most commonly infected?
c. Posterior ethmoidal air sinuses
a. Ethmoidal b. Frontal
d. Maxillary air sinus
c. Maxillary d. Sphenoidal L
o
Which of the following air sinus is first to develop? 6. Length of auditory tube in adult person is:
zo
J.
a. Maxillary air sinus a. 36 mm b. 3.6 mm E

tr
b. Ethmoidal air sinus c. 46 mm d. 48 mm (E
E
G
o
ANSWERS
C
1.c 2.c 3.a 4.a 5.c 6.a o
o
o
a
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-Thockery
INTRODUCTION ldentify epiglottis, thyroepiglottic and hyoepiglottic

The larynx (Latin upper windpipe) is tlr.e organ for pro- ligaments.
duction of voice or phonation. It is also an air passage, Strip the mucous membrane from the posterior
and acts as a sphincter at the inlet of the lower surfaces of arytenoid and cricoid cartilages. ldentify
respiratory passages. The upper respiratory Passages posterior cricoarytenoid, transverse arytenoid and
include the nose, the nasopharyrx and the oropharymx. oblique afienoid muscles.
Larynx or voice box is well developed in humans. Recurrent laryngeal nerve was seen to enter larynx
Its capabilities are greatly enhanced by the large deep to the inferior constrictor muscle.
"vocalisation area" in the lower part of motor cortex. ldentify cricothyroid muscle, which is the only intrinsic
Our speech is guided and controlled by the cerebral muscle of larynx placed on the external aspect of larynx.
cortex. God has given us two ears and one mouth; to Remove the lower half of lamina of thyroid cartilage
hear more, contemplate and speak less according to including the inferior horn of thyroid cartilage. Visualise
time and need. the thyroarytenoid muscle in the vocalfold.
A man's language is an "index of intellect". One
speaks during the expiratory phase of respiration. SITUATION AND EXTENI
Larynx is a part of the respiratory system allowing two- The larynx lies in t
way flow of gases. It is kept patent because an adult is extending from the r
breathing about 15 times per minute, unlike the the adult male, it lies
oesophagus which opens at the time of eating or vertebrae, but in children and in the adult female it lies
drinking only. at a little higher level (Figs 16.1a to c).
SIZE
The length of the larynx is 44 mm in males and

DISSECTION 36 mm in females. At puberty, the male laryrx grows
ldentify sternothyroid muscle in the sagittal section of rapidly and beco
head and neck and define its attachments on the thyroid of thyroid cartila
carlilage. Define the attachments of inferior constrictor voice louder and
muscle from both cricoid and thyroid cartilages including the female laryrnx is negligible, and her voice is high
the fascia overlying the cricothyroid muscle. pitched. Internal diameter up to 3 yrs it is 3 mm and
Cut through the inferior constrictor muscle to locate adult it is 12 mm.
articulation of inferior horn of thyroid cartilage with
cricoid cartilage, i.e. cricothyroid joint. Define the median CONSIIIUIION OF LARYNX
cricothyroid ligament.
ldentify ligament thyrohyoid muscle. Remove this
muscle to identify thyrohyoid membrane. ldentify superior
laryngeal vessels and internal laryngeal nerve piercing
this membrane. membrane.
mebooksfree.com 252
LARYNX
Epiglottis
Hyoid bone
Median thyroepiglottic
Lateral thyrohyoid Thyrohyoid ligament
ligament membrane
Vestibular
ligament
Thyrohyoid
Thyroepiglottic
Sternothyroid muscle
Thyroid
Thyropharyngeus Male
Oblique line Vocal ligament
Conus elasticus
Arch and lamina Cricothyroid
\ w,ro"-/
of cricoid cartilage joint
Cricotracheal
ligament Thyroarytenoid
and vocalis
(a) (b) (c)
Figs 16.1a to c: Skeleton of the larynx: (a) Anterior view, (b) posterior view, and (c) angle of thyroid laminae in male and female
Cortiloges of lorynx
The larprx contains nine cartilages, of which three are
Epiglottis
unpaired and three, paired.
Unpoired Coililoges
1 Thyroid (Greek shield like)
2 Cricoid (Creek ring like) Thyroid cartilage
3 Epiglottis (Greek leaf like) (Fig. 16.1a) Arytenoid cartilage
Poired Cortiloges Cricoarytenoid joint
1 Arytenoid (Greek cup shaped) (Fig. 16.1b) Lamina of cricoid
2 Corniculate (Latin horn shaped)
Cricothyroid joint
3 Cuneiform (Latin wedge shaped)
Thyroid e Tracheal rings
deflcient posteriorly
This cartilage is V-shaped in cross-section. It consists
of right and left laminae (Fig. 16.1a). Each lamina is
roughly quadrilateral. The laminae are placed obliquely
relative to the midline, their posterior borders are far Fig. 16.2: Cartilages of the larynx: Posterior view
apart, but the anterior borders approach each other at
an angle that is about 90 degrees in the male and about fubercle in front of the root of superior cornua to the
120 degrees in the female (Fig. 16.1c). inferior thyroid tubercle behind the middle of inferior
The lower parts of the anterior borders of the right border. The (i) thyrohyoid, (ii) sternothyroid and
and left laminae fuse and form a median projection (iii) thyropharyngeus part of inferior constrictor of
called the laryngeal p.rominence. The upper parts of the pharynx are attached to the oblique line.
anterior borders do not meet. They are separated by
the thyroid notch. The posterior borders are free. They Attachments
are prolonged upwards and downwards as the superior Lower border and inferior cornua gives insertion to
and inferior cornua or horns. The superior cornua is triangular cricothyroid. Along the posterior border J
o
connected with the great'er cornua of the hyoid bone connecting superior and inferior cornua is the insertion
by the lateral thyrohyoid ligament. of (i) palatopharyngeus, (ii) salpingopharyngeus, (iii)
zo
t,tr
The inferior cornua articulates with the cricoid stylopharyngeus (Fig. 16.3). (E
cartilage to form the cricothyroid joint (Fi9.1.6.2).

On inner aspect are attached
to
The inferior border of the thyroid cartilage is convex o
a. Median thyroepiglottic ligament, I
in front and concave behind. In the median plane, it is
connected to the cricoid cartilage by the conus elasticus. b. Thyroepiglottic muscle on each side, c
.o
The outer surface of each lamina is marked by an c. Vestibular fold on each side, o
o
oblique line which extends from the superior thyroid d. Vocal fold on each side, U)
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HEAD AND NECK
Attachments
Anterior part of arch of cricoid gives origin to triangular
cricothyroid Tnuscle, a tensor of vocal cord (Fig. 16.9).
Hyoid bone
Anterolateral aspect of arch gives origin to lateral
Epiglottis cricoarytenoid muscle, an adductor of vocal cord.
Lamina of cricoid cartilage on its outer aspects gives
Thyroid origin to a very important "safety muscle", the posterior
cartilage
cricoarytenoid muscle (Fig. 16.10).
Cricothyroid and quadrate membranes are also
attached (Fig. 16.5a).
Cricoid This is aleaf-shaped cartilage placed in the anterior wall

cartilage
of the upper part of the larymx. Its upper end is broad
Tracheal and free, ind projects upwards behind the hyoid bone
nng and the tongue (Fig. 16.5b).
The lower end or thyroepiglottic ligament is pointed
Fig. 16.3: Cartilages of the larynx: Lateral view
and is attached to the uPper part of the angle between
the two laminae of the thyroid cartilage (Figs 16.1b
e. Thyroarytenoid and and1.6.4).
f. Vocalis muscle on each side (Figs 76.7 and 16.4).
Attachments
Crfcord ge The right and left margins of the cartilage provide
This cartilage is shaped like a ring. It encircles the larynx attachment to the aryepiglottic folds' lts anterior surface
below the thyroid cartilage and forms foundation stone is connected:
of larlmx. It is thicker and stronger than the thyroid a. To the tongue by a median glossoepiglottic fold (see
cartilage. The ring has a narrow anterior part called the Fig.17.1)
nrch, and a broad posterior part, called t},.:.e lamina b. To the hyoid bone by the hyoepiglottic ligament
(Fig.1,6.2). The lamina projects upwards behind the (Fig. 16.a). The posterior surface is covered with
thyroid cartilage, and articulates superiorly with the *ucous membrane, and presents a tubercle in the
arytenoid cartilages. lower part (Fig. 16.15).
The inferior cornua of the thyroid cartilage articulates Thyroepigtottic muscle is attached between thyroid
with the side of the cricoid cartilage at the junction of cartilage and margins of epiglottis. It keeps the inlet of
the arch and lamina. larynx patent for breathing.
Aryepiglottic muscle closes inlet during swallowing
Epiglottis
(Fig. 16.11a).
Hyoid bone Hyoepiglottic

ligament These are two smallpyramid-shaped cartilages lying on
Subhyoid bursa Thyrohyoid

membrane
Thyroid
cartilage
Aryepiglottic
Thyroepiglottic fold and muscle
.Y ligament Corniculate
(J
o and muscle cartilage
z
!ttr Thyroarytenoid
ro 76.4).
(E and vocalis posterior (Figs 1.6.2
Arytenoid
t(E cartilage Attachments
o fold and vocalis muscle is attached.
Vocal prôcess: Vocal
C
Cricoid Abot;e uocnl process; Vestibular fold attached.
cartilage
.9
o Muscular process: Posterior aspect gives insertion to
o posterior cricoarytenoid.
a Fig. 16.4: Cartilages of the larynx as seen in sagittal section
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LARYNX
Epigtottis
Aryepiglottic fold
Quadrate
membrane
Hyoid bone
Pre-epiglottic space Piriform fossa
Thyrohyoid Laryngopharynx
membrane
Cuneiform cartilage
Epiglottis
Vestibular fold Corniculate cartilage
Conus elasticus
Thyroid cartilage Arytenoid cadilage
Glottis
Vocal fold Sinus of larynx
Conus elasticus
Vocal cords
(cricothyroid Cricoid cartilage
membrane) Thyroid cartilage
Cricoid cartilage
Oesophagus
(a) (b)
Figs 16.5a and b: (a) Ligaments and membranes of the larynx. Note the quadrate membrane and the conus elasticus, and (b) vocal
cords and inlet of larynx seen
Anterior aspect gives insertion to lateral crico- [oryngeolJoinls

arytenoid. The cricothyroid joint is a synooial joint between the
Posterior surfacei Transverse arytenoid across the two inferior cornua of the thyroid cartilage and the side of
cartilages. the cricoid cartilage. It permits rotatory movements
Between base and apex of arytenoid is oblique around a transverse axis passing through both
two
arytenoid which continue s as aryEiglottic muscle into cricothyroid joints permitting tension and relaxation
sides of epiglottis. of vocal cords. There is some gliding movement also in
Quadrangular or quadrate membrane is attached different directions (Fig. 1.6.2).
between arytenoid, epiglottis and thyroid cartilages. The cricoarytenoid joint is also a synoaial joint between
the base of the arytenoid cartilage and the upper border
of the lamina of the cricoid cartilage. It permits rotatory
These aretwo small conical nodules which articulate movements around a vertical axis permitting adduction
with the apex of the arytenoid cartilages, and are and abduction of the vocal cords and also gliding
directed posteromedially. They lie in the posterior parts movements in all directions (Fig. 16.2).
of the aryepiglottic folds (Fig. 16.5a).
euneiform C $
Loryngeol Ligomenls ond Membrones
These are two small rod-shaped pieces of cartilage Fx sic
placed in the aryepiglottic folds just ventral to the 1 The thyrohyoid membrane connects the thyroid l<
corniculate cartilages (Fig. 16.5a). cartilage to the hyoid bone. Its median and lateral o
parts are thickened to form the median and lateral zo
thyrohyoid ligaments (Fig. 16.5). The membrane is !t
Histology of Loryngeol Cortiloges (E
The thyroid, cricoid cartilages, and the basal parts of pierced by the internal laryngeal nerve, and by the ttG
the arytenoid cartilages are made up of the hyaline superior laryngeal vessels. o
cartilage. They may ossify after the age of 25 years. 2 The hyoepiglottic ligament connects the upper end of
The other cartilages of the larlmx, e.g. epiglottis, the epiglottic cartilage to the hyoid bone (Fig. 16.4). c
.o
corniculate, cuneiform and processes of the arytenoid 3 The cricotrncheal ligament connects the cricoid o
are made of the elastic cartilage and do not ossify. cartilage to the upper end of the trachea (Fig. 16.1). ao
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HEAD AND NECK
ln sic
The intrinsic ligaments are part of a broad sheet of Epiglottis
fibroelastic tissue, known as the fibroelastic membrane of
Venkicle
the larynx. This membrane is placed just outside the
mucous membrane. It is interrupted on each side by
the sinus of the larynx. The part of the membrane above
the sinus is known as the quadrate membrane, and the
part below the sinus is called t}:.e conus elasticus
(Fig. 16.5a).
The quadrate membrane extends from the arytenoid
cartilage to the epiglottis. It has a lower free border
which forms t}.e ztestibulnr fold and an upper border
which forms the aryepiglottic fold.
The conus elasticus or cricoaocal membrane extends
upwards and medially from the arch of the cricoid
cartilage. The anterior part is thick and is known as the
cricothyroidligament. The upper freeborder of the conus
elasticus forms the rsocal fold (Fig.16.5b). Fig. 16.6: Posterior view of spread out larynx
Covity of Lolynx
1 The cavity of the larynx extends from the inlet of the
larynx to the lower border of the cricoid cartilage. Hyoid
The inlet of the larynx is placed obliquely. It looks Supraglottis
backwards and upwards, and opens into the
laryngopharynx. The inlet is bounded anteriorly, by
the epiglottis; posteriorly, by the interarytenoid fold Thyroid cartilage
Ventricle
of mucous membrane; and on each side, by the Vestibular fold
aryepiglottic fold (Fig. 16.5).
Internal diameter: Up to 3 years,3 mm; every year it lnfraglottis Vocal fold
increases by 1 mm up to 12 years.
Within the cavity of larlmx, there are two folds of
mucous membrane on each side. The upper fold is
the oestibular fold, and the lower fold is the uocal fold.
The space between the right and left vestibular folds
is the rima oestibuli; and the space between the vocal
folds is the rima glottidis (Fig. 16.5). Fig. 16.7: Cavity of larynx and position of piriform fossa
The vocal fold is attached anteriorly to the middle
of the angle of the thyroid cartilage on its posterior
c. The part below the vocal folds is called the infra-
aspect; and posteriorly to the vocal process of the
glottis (Fig.1.6.7).
arytenoid cartilage (Fig. 16.11b).
The sinus of Morgagni or aentricle of the larynx is a
The rima glottidis is limited posteriorly by an narrow fusiform cleft between the vestibular and vocal
interarytenoid fold of mucous membrane. folds. The anterior part of the sinus is prolonged
The rima, therefore, has an anterior intermem- upwards as a diverticulum between the vestibular fold
l( branous part (three-fifth) and a posterior intercarti- and the lamina of the thyroid cartilage. This extension
o laginous part (Fig. 16.15a). is known as the saccule of the larynx . The saccule contains
zo The rima is the narrowest part of the larynx. It is mucous glands which help to lubricate the vocal folds.
ttr It is often called oil can oflarynx.
(E longer (23 mm) in males than in females (17 mm).
!,3
o
The vestibular and vocal folds divide the cavity of
the larynx into three parts. Mucous Memblone of lo]ynx
Io a. The part above the vestibular fold is called the 1 The anterior surface and upper half of the posterior
C aestibule of the larynx or supraglottis. surface of the epiglottis, the upper parts of the
.o
o b. The partbetween lhe vestibulaiand vocal folds is aryepiglottic folds, and the vocal folds are lined by
ao called the sinus or aentricle of the larynx (Fig. 16.5). the stratified squamous epithelium. The rest of the
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LARYNX
laryngeal mucous membrane is covered with the Large foreign bodies may block laryngeal inlet
ciliated columnar Eithelium.
leading to suffocation.
The mucous membrane is loosely attached to the Small foreign bodies may lodge in laryngeal
cartilages of the larynx except over the vocal ventricle, cause reflex closure of the glottis and
ligaments and over the posterior surface of the suffocation.
epiglottis where it is thin and firmly adherent. hflammation of upper larynx may cause oedema
The mucous glands are absent over the vocal cords, of supraglottis part. It does not extend below vocal
but are plentiful over the anterior surface of the cords because mucosa is adherent to vocal
epiglottis, around the cuneiform cartilages and in the ligament.
vestibular folds. The glands are scattered over the
rest of the larynx.
Median glossoepiglottic
fold
Since the larynx or glottis is the narrowest part
of Vallecula
the respiratory passages, foreign bodies are
usually lodged here.
Epiglottis
Infection of the larynx is called laryngitis. It is
characterized by hoarseness of voice.
Laryngeal oedema may occur due to a variety of
causes. This can cause obstruction to hreathing.
Misuse of the vocal cords may produce nodules
on the vocal cords mostly at the junction of
anterior one-third and posterior two-thirds. These
are called Singer's nodules or Teacher's nodules
(Fig. 16.8).
Fibreoptic flexible laryngoscopy : Under local
anaesthesia flexible laryngoscope is passed and
Singer's or teacher's nodules
laryrnx well visualised.
Fig. 16.8: lndirect laryngoscopic examination
Microlaryngoscopy: This procedure is performed
under operating microscope. Vocal cord tumors
and diseases are excised by this method. Intrinsic Muscles of Lorynx
External examindtion of larynx: Head is flexed in The attachments of intrinsic muscles of larynx are
sitting position. Examiner stands behind and presented in Table 16.1 and their main action shown in
palpates larynx and neck with finger tips for Table16.2.
tumour, swelling, lymphadenitis, etc.
Speech analysis is also necessary in laryngeal
diseases. All intrinsic muscles of the larynx are supplied by the
Foreignbody inlarynx: At times fishbones may get recurrent laryngeal nerve except for the cricothyroid
impacted in the vallecula or piriform fossa. Often which is supplied by the external laryngeal nerve.
these bones just scratch the mucosa on their way
dowry and the person gets a feeling of foreign Acfioms
body sensation, due to a dull visceral pain caused The vocal process and muscular processes move in
by the scratch. opposite directions. Any muscle which pulls the
Piriform fossa lies between quadrate membrane muscular process medially, pushes the vocal process
and medial side of thyroid cartilage. It is traversed laterally, resulting in abduction of vocal cords. This is .!t
o
by internal laryngealnerve. Piriform fossa is used done by only one pair of muscle, the posterior o
z
to smuggle out precious stones, d,iamonds, etc. It cricoarytenoid. !tc
is called smuggler's fossa (Fig.1,6.7). Muscles which pull the muscular process forward (E
The mucous membrane of the larynx is supplied and laterally will push the vocal process medially !,
G
by X nerve through superior larlmgeal or recurrent causing adduction of vocal cords (Fig. 15.11b). This is o
laryngeal nerves. So lary,ngeal tumours may also done by lateral cricoarytenoid and transverse arytenoid.
cause referred pain in the ear partly supplied by The cricothyroid causes rocking movement of C
.9
auricular branch of X nerve. thyroid forwards and downwards at cricothyroid joints, o
thus tensing and lengthening the vocal cords (Fig. 16.9). ao
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HEAD AND NECK
Table 16.1: lntrinsic muscles of the larynx

Muscle Origin Fibres lnsertion
1. Cricothyroid Lower border and lateral Fibres pass lnferior cornua and lower border of thyroid cartilage.
The only muscle outside surface of cricoid backwards lt is called 'tuning fork of larynx'
the larynx (Fig. 16.9) and upwards
2. Posterior cricoarytenoid Posterior sudace of the Upwards and Posterior aspect of muscular process of arytenoid
triangular (Fig. 1 6.10) lamina of cricoid laterally
3. Lateralcricoarytenoid Lateral part of upper border Upwards and Anterior aspect of muscular process of arytenoid
(Figs 16.11a and b) of arch of cricoid backwards
4. Transverse arytenoid Posterior surface of one Transverse Posterior surface of another arytenoid
Unpaired muscle arytenoid
(Fis. 16.10)
5,6. Oblique arytenoid Muscular process of one Oblique Apex of the other arytenoid. Some fibres are
and aryepiglottic arytenoid continued as aryepigloftic muscle to the edge
(Fig. 16.10) of the epiglottis
7,8. Thyroarytenoid and Thyroid angle and adjacent Backwards Anterolateral su rf ace of arytenoid carti lage.
thyroepiglottic cricothyroid ligament and upwards Some of the upper fibres of thyroarytenoid curve
(Figs 16.11a and b) upwards into the aryepiglottic fold to reach the edge
of epiglottis, known as thyroepiglottic
9. Vocalis (Fig. 16.12) Vocal process of Pass Vocal ligament and thyroid angle.
arytenoid cartilage forwards
Table 16.2: Muscles acting on the Iarynx e. Muscles which close the inlet of the larynx:
Movement Muscle i. Oblique arytenoids
1. Elevation of larynx Thyrohyoid, mylohyoid
ii. Aryepiglottic (Fig. 16.11).
2. Depression of larynx Sternothyroid, sternohyoid f. Muscles which open the inlet of larynx:
Thyroepiglotticus (Fig. 16.11).
3. Opening inlet of larynx Thyroepiglottic
4. Closing inlet of larynx Aryepiglottic
5. Abductor of vocal cords Posterior cricoarytenoid only
6. Adductor of vocal cords Lateral cricoarytenoid \Mhen any foreign object enters the larynx severe
transverse and oblique
protective coughing is excited to expel the object.
arytenoids
However, damage to the internal laryngeal nerve
7. Tensor of vocal cords Cricothyroid
produces anaesthesia of the mucous membrane in
and modulation of voice
the supraglottic part of the larynx breaking the
8. Relaxor of vocal cords Thyroarytenoid and vocalis reflex arc so that foreign bodies can readily enter it.
Damage to the external laryngeal nerve causes
The thyroarytenoid pulls the arytenoid forward, some weakness of phonation due to loss of the
relaxing the vocal iords (Table 76.2 and Fig. 76.17). tightening effect of the cricothyroid on the vocal
a. Muscles which abduct the vocal cords: Only cord.
posterior cricoarytenoids (safety muscle of laryT rx). When both recurrent laryngeal nerves are
.v b. Muscles which adduct the vocal cords: interrupted, the vocal cords lie in the cadaveric
()
i. Lateral cricoarytenoids
zo ii. Transverse arytenoid
position in between abduction and adduction and
phonation is completely lost. Deep breathing also
t,
(E
iii. Cricothyroids (tuning fork of larynx) becomes difficult through the partially opened
!t(5 iv. Thyroarytenoids (Figs 16.11a and b). glottis (Fig. 16.13).
o c. Muscles which tense the vocal cords: Cri-
cothyroids (Fig. 16.9). When only one recurrent laryngeal nerve is
c d. Muscles which relax the vocal cords:
paralysed, the opposite vocal cord compensates
.o
i. Thyroarytenoids (Fig. 1.6.72) for it and phonation is possible but there is
o
ao ii. Vocalis.
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LARYNX
hoarseness of voice. There is failure of forceful

explosive part of voluntary and reflex coughing Movements of the vocal folds affect the shape and size
(Figs 16.14a and b). of the rima glottidis.
Tumours in the piriform fossa cause dysphagia. 1 During quiet breathing or condition of rest, the inter-
These also cause referred pain in the ear. Pain of membranous part of the rima is triangular, and the
pharyngeal tumours may be referred to the ear, intercartilaginous part is quadrangular (Fig. 16.15a).
as X nerve carries sensation both from the pharyrrx 2 During phonation or speech, the glottis is reduced
and the external auditory meatus and the to a chink by the adduction of the vocal folds
tympanic membrane. (Figs 16.15b and 16.76).
Recurrent laryngeal nerl)e: Mediastinal tumours 3 During forced inspiration, both parts of the
may press on the left recurrent laryngeal nerve, rima are triangular, so that the entire rima is lozenge-
as it is given off in the thorax. The pressure on shaped; the vocal folds are fully abducted
the nerve may present as alteration in the voice. (Fig. 16.15c) (i.e. diamond shaped glottis).
Right tecurrent laryngeal nerve is given off in 4 During whispering, the intermembranous part of the
the neck, so it is not affected by mediastinal rima glottidis is closed, but the intercartilaginous
tumours. part is widely open (Fig. 16.15d) (i.e. funnel shaped
glottis).
lnlet of larynx
Transverse
arytenoid
Arytenoid
cartilage
Tense vocal
cord
Cricothyroid
Oblique
fibres
Fig. 16.9: Cricothyroid muscle Fig. 16.10: Muscles of larynx: Posterior view
Epiglottis
Thyroepiglottic
Thyroid cartilage
Aryepiglottic
fold and
muscle Thyroarytenoid
muscle
Cuneiform
ta
cartilage o
Thyroarytenoid
Corniculate zo
cartilage Lateral E
Thyroid cartilage cricoarytenoid tr
(5
Arytenoid (adductor) t,(5
Lateral cartilage Posterior o
cricoarytenoid Posterior
cricoarytenoid I
(abductor)
cricoarytenoid
C
o
.F
(a) (b) o
o
Figs 16.11a and b: Muscles of the larynx: (a) Lateral view, and (b) horizontal view @
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HEAD AND NECK
On inspiration On phonation
Transverse
arytenoid
Posterior
cricoafienoid
Fig. 16.12: Schemeto showthe direction of pull of some intrinsic
muscles of the larynx
Paralysed left vocal

cord in cadaveric
Position (b)
Figs 16.14a and b: Position of vocal cords: (a) Normal, and
(b) abnormal conditions
AileriolSupply ond nous Droinoge

to lhe Vocal Folds
By the superior laryngeal artery, a branch of the
superior thyroid artery. The superior laryngeal vein
drains into the superior thyroid vein.
Belaw the Vocol Fo

Median By the inferior laryngeal artety, a branch of the inferior
Fig. 16.13: Various positions of the vocal cords thyroid artery. The inferior larlmgeal vein drains into
the inferior thyroid vein.
Pentagonal Linear chink
I lntermembranous
o
o part
z
!tc lnterca rtilaginous
G part
!t(6 Arytenoid cartilage
o
Posterior
cricoarytenoid cricoarytenoid
c (a) (b) (c) (d)
o
o Figs 16.15a to d: Rima glottidis: (a) ln quiet breathing, (b) ln phonation or speech, (c) During forced inspiration, and (d) During
o
a whispering
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LARYNX
Anterior
Tumours in subglottic area present late so are
diagnosed late and have poor prognosis.
Laryngotomy; The needle is inserted in the midline
of cricothyroid membrane, below the thyroid
prominence. This is done as an emergency
procedure (Fig. 16.18).
Tracheostomy is a permanent procedure. Part of
2nd-4th rings of trachea are removed after incising
the isthmus of the thyroid gland.
If the patient is unconscious, one must remember
A-Airway, B-Breathing, C-Circulation in that
order. For the patency of afuway, pull the tongue
out and also endotracheal tube needs to be passed.
Posterior The tube should be passed between the right and
Fig. 16.16: Direct laryngoscopic view of vocal cords in adducted left vocal cords down to the trachea.
position
Nerve Supply
f*r SJeryms
Recurrent laryngeal nerve supplies posterior
cricoarytenoid, lateral cricoarytenoid, transverse and
oblique arytenoid, aryepiglottic, thyroarytenoid,
thyroepiglottic muscles. It supplies all intrinsic muscles
except cricothyroid.
External laryngeal nerve only supplies cricothyroid Laryngeal
mtrror
muscle.
Reflected
Semsmrp $ light
The internal laryngeal nerve supplies the mucous

membrane up to the level of the vocal folds. The
recurrent laryngeal nerve supplies it below the level of
the vocal folds.
Lymphotic Droinoge
Lymphatics from the part above the vocal folds drain Fig. 15.17: Pafts of larynx seen by laryngoscopy
along the superior thyroid vessels to the anterosuperior
group of deep cervical nodes by piercing thyrohyoid
membrane.
Those from the part below the vocal folds drain to Hyoid bone
the posteroinferior group of deep cervical nodes. A few
of them drain into the prelaryngeal nodes by piercing Epiglottis
cricothyroid
Vocal
ligament
The larynx can be examined either directly Laryngotomy .Y

through a lar;rngoscope (direct laryngoscopy); or o
indirectly through a laryngeal mirror (indirect Median zo
laryngoscopy) (Fig. 76.L7). cricothyroid t,c
ligament (g
By laryngoscopy, one c€m inspect the base of the E
tongue, the valleculae, the epiglottis, the G
o
aryepiglottic folds, the piriform fossae, the Tracheal ring
vestibular folds, and the vocal folds (Fig. 16.8). C
Tumours of the vocal cords can be diagnosed o
o
early, because there are changes in the voice. Fig. 16.18: Laryngotomy o
a
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HEAD AND NECK
INFANT'S LARYNX Labiodental-Ta, Tha, Da, Dha, Na

Cavity of infant's larynx is short and funnel-shaped. Lingual-Cha, Ja, Jha
o Size is one-third of an adult. Lumen is very narrow. Palatal-Ka, Kha, Ga, Cha.
o Position is higher than in adult.
. Epiglottis lies at C2 and during elevation, it reaches
C1, so that infant can use nasal airway for breathing
Only intrinsic muscle of larynx placed on the outer
while suckling.
. Laryngeal cartilages are softer, more pliable than in aspect of laryngeal cartilages is cricothyroid.
Cricothyroid is the only muscle supplied by
adult.
. Thyroid cartilage is shorter and broader. external laryngeal nerve.
. Vocal cords are only 4-4.5 mm long, shorter than in External laryngeal nerve runs suPerlor
thyroid artery near the gland
childhood and in adult.
. Supraglottic and subglottic mucosa are lax, swelling Posterior cricoarytenoid is the only abductor of
vocal cord and so it is a life saving muscle.
results in respiratory obstruction.
o One must be careful while giving anaesthesia to an Piriform fossa is called smuggler's fossa as
precious stones, etc. can be hidden here.
infant (birth to one year).
The primary function of larynx is to protect the
lower respiratory tract. Phonation has developed
MECHANISM OF SPEECH
with evolution and is related to motor speech area
The mechanism of speech involves the following four of the cerebral cortex.
Processes.
c Expired air from lungs.
. Vibrators.
r Resonators. Due to a severe infection of the voice box and with
o Articulators.
high temperature, a patient is not able to speak and
Expired Air breathe at all.
. Paralysis of which muscles causes extreme
As the air is forced out of lungs and larynx, it produces
difficulty in breathing
voice. Loudness or intensity of voice depends on the . Name the muscles of larynx and their actions
force of expiration of air.
Ans; Due to infection of the latynx, the branches of
Vibrotors recurrent larvngeal nerve supplying posterior
The expired air causes vibrations of the vocal cords. cricoarytenoid scies are infected. Since this pair
Pitch of voice depends on the rate of vibration of vocal of muscle is the only abductor of r"ocal cord, vocal
cords. Vowels are produced in the larynx. cords get adducted, resulting in extreme difficulty
in breathing. Tracheeistomy is the main line of
Resonotols trea ent if infection is not controlled.
The column of air between vocal cords and nose and M.or:ewent af lttryttx Nluscles
Iips act as resonators. Quality of sound depends on duction of vocal crrrd Posterior
resonators. One can make out change of quality of voice cricoarytenoid
even on the telephone. Adduction of vocal cord Lateral cricoarytenoid
Transverse arytenoid
Articulotors Oblique arytenoid
These are formed by palate, tongue, teeth and lips.
These narrow or stop the exhaled air. Many of the Closing inlet of larynx Aryepiglottic
consonants are produced by the intrinsic muscles of
ta
o Tensor of vocal cord Cricothyroid
tongue. Consonants produced by lips are - Pa, Pha, Ba,
zo Bha, Ma
Relaxor ofvocal cord roarytenoid
t,tr
(E
t,G
o MUTTIPLE CHOICE QUESTIONS
C
1. Which histological type of cartilage is epiglottis? 2. Which is the only abductor of the vocal cord?
.9
o a. Fibrous b. Elastic a. Lateral cricoarytenoid
ao c. Hyaline d. Fibroelastic b. Thyroarytenoid
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c. Posterior cricoarytenoid c. Stylopharyngeus
d. Thyroepiglottic d. Levator veli palatini
3. Recurrent laryngeal nerve supplies all muscles 6. ItVhich muscle is not attached to cricoid cartilage?
except: a. Cricothyroid
a. Posterior cricoarytenoid b. Oblique arytenoid
b. Oblique arytenoids c. Lateral cricoarytenoid
c. Lateral cricoarytenoid d. Posterior cricoarytenoid
7. \A/hich of the following muscle is th e ' safety' muscle
d. Cricothyroid
of larynx?
4. Angle of anterior borders of laminae of thyroid
a. Lateral cricoarytenoid
cartilage in adult male is:
b. Posterior cricoarytenoid
a. 90" b. 100" c. Oblique arytenoid
c. 80" d. 120" d. Transverse arytenoids
5. \A/hich of the following muscles is not inserted in 8. Pain of pharyngeal tumours is referred to ear due
the posterior border of thyroid cartilage? to which of the following nerves?
a. Palatopharyngeus a. IX b.x
b. Salpingopharyngeus c.V d. VII
:o
zo
tttr
6
tG
o
c
.9
o
oo
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INTRODUCTION below. Because of these attachments, we are not able
The tongue is a muscular organ situated in the floor of to swallow the tongue itself. In between the mandible
the mouth. It is associated with the functions of (i) taste, and hyoid bones, it is related to the geniohyoid and
(ii) speech, (iii) chewing, and (iv) deglutition. mylohyoid muscles.
Tongue comprises skeletal muscle which is Tlrre tip of the tongue forms the anterior free end
voluntary. These voluntary muscles start behaving as which, at rest, lies behind the upper incisor teeth.
involuntary in any classroom - furury?
Thanks to the taste buds that the multiple hotels, The dorsum of the tongue (Fig. 17.1) is convex in all
restaurants, fast food outlets, chatlakori shops, etc. are directions. It is divided into:
flourishing. One need not be too fussy about the taste . An oral part or anterior two-thirds.
of the food. Nutritionally, it should be balanced and . Apharyngeal part or posterior one-third, by a faint
hygienic. V-shaped groove, tlte sulcus terminalis. The two
limbs of the 'V' meet at a median pit, named the
foramen caecum. They run laterally and forwards
up to the palatoglossal arches. The foramen
DISSECTION caecum represents the site from which the thyroid
diverticulum grows down in the embryo. The oral
ln the sagittal section, identify fan-shaped genioglossus
and pharlmgeal parts of the tongue differ in their
muscle. Cut the attachments of buccinator, superior
development, topography, structure, and function
constrictor muscles and the intervening pterygo-
mandibular raphe and reflect these downwards Table 77.3.
exposing the lateral surface of the tongue. Look at the . Small posteriormost part
superior, inferior surfaces of your own tongue with the 1 The oral or papillary part of the tongue is placed on the
help of hand lens. floor of the mouth. Its margins are free and in contact
with the gums and teeth. |ust in front of the palato-
PARIS glossal arch, each margin shows 4 to 5 vertical folds,
The tongue has: named the foliate papillae.
1 A root, Ttre superior surface of the oral part shows a median
2 A tip, and furrow and is covered with papillae which make it
3 A body, which has: rough (Fig. 17.1).
a. A curved upper surface or dorsum (Fig. 17.1).
T}ae inferior surface is covered with a smooth mucous
b. An inferior surface.
membrane, which shows a median fold called the
The dorsum is divided into oral and pharyngeal parts
by a V-shaped, the sulcus terminalis. The inferior frenulum linguae.
surface is confined to the oral part only. On either side of the frenulum, there is a prominence
ThLe root is attached to the styloid process and soft produced by the deep lingual veins. More laterally
palate above, and to mandible and the hyoid bone there is a fold called theplicafimbriatalhatis directed
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TONGUE
Lateral glossoepiglottic fold Vallecula
Lymphoid follicles
Median glossoepiglottic fold
Palatine tonsil
Sulcus terminalis
Foramen caecum Circumvallate papillae
Foliate papillae
Filiform papillae
Fungiform papillae
Fig. 17.1 : The dorsum of the tongue, epiglottis and palatine tonsil
o Glossitis is usually a part of generalized

ulceration of the mouth cavity or stomatitis. In
certain anaemias, the tongue becomes smooth
Plica fimbriata
due to atrophy of the filiform papillae.
. The presence of a rich network of lymphatics and
of loose areolar tissue in the substance of the
tongueis responsible for enormous swelling of the
tongue in acute glossitis. The tongue fills up the
mouth cavity and then protrudes out of it.
. The undersurface of the tongue is a good site along
with the bulbar conjunctiva for observation of
jaundice.
Sublingual fold . In unconscious patients, the tongue may fall back
with openings
Orifice of submandibular of sublingual and obstruct the air passages. This can be
duct on sublingual papailla ducts prevented either by lpng the patient on one side
Fig. 17.2: The inferior surface of tongue and the floor of the mouth with head down (the 'tonsil position') or by
keeping the tongue out mechanically.
forwards and medially towards the tip of the tongue . Lingual tonsil in the posterior one-third of tongue
(Fig. t7.2). forms part of Waldeyer's ring (see Fig. 14.13).
2 The pharyngeal or lymphoid part of the tongue lies
behind the palatoglossal arches and the sulcus PAPIIIAE OF IHE TONGUE
terminalis. Its posterior surface, sometimes called the
base of the tongue, forms the anterior wall of the These are projections of mucous membrane or corium
oropharynx. The mucous membrane has no papillae, which give the anterior two-thirds of the tongue its
but has many lymphoid follicles that collectively characteristic roughness. These are of the following I
three t1pes. o
constitute thelingual tonsil (Fig.17.1). Mucous glands o
are also present. I Vallate or circumaallate papillae; They are large in size
z
t,tr
3 The posteriormost part of the tongue is connected 1-2 mm in diameter and are 8-12 in number. They (E
to the epiglottis by three-folds of mucous membrane. are situated immediately in front of the sulcus tt(E
These are the median glossoepiglottic fold and the terminalis. Each papilla is a cylindrical projection o
I
right and left lateral glossoepiglottic folds. On either surrounded by a circular sulcus. The walls of the
side of the median fold, there is a depression called papilla have taste buds. C
o
the oallecula (Fig. 17 .1). The lateral folds separate the 2 Tkre fungiform papillae are numerous near the tip and ()
vallecula from the piriform fossa. margins of the tongue, but some of them are also ao
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HEAD AND NECK
scattered over the dorsum. These are smaller than 3 Transverse

the vallate papillae but larger than the filiform 4 Vertical.
papillae. Each papilla consists of a narrow pedicle T}ae intrinsic muscles (Fig. 17.a) occupy the upper part
and a large rounded head. They are distinguished of the tongue, and are attached to the submucous
by their bright red colour (Fig. 17.3). fibrous layer and to the median fibrous septum. They
3 The filiform papillae or conical papillae cover the alter the shape of the tongue. The superior longitudinal
presulcal area of the dorsum of the tongue, and give muscle lies beneath the mucous membrane.
it a characteristic velvety appearance. They are the Tlae inferior longitudinal muscle is a narrow band lying
smallest and most numerous of the lingual papillae. close to the inferior surface of the tongue between the
Each is pointed and covered with keratin; the apex genioglossus and the hyoglossus.
is often split into filamentous processes. The transoerse muscle extends from the median
4 Few foliate papillae are also present. septum to the margins. The aertical muscle is found at
the borders of the anterior part of the tongue (Fig. 17.4).
MUSCTES OF THE TONGUE
Extrinsic Muscles
A middle fibrous septum divides the tongue into right 1 Genioglossus
and left halves. Each half contains four intrinsic and
2 Hyoglossus
four extrinsic muscles. 3 Styloglossus
lnlrinsic Muscles
4 Palatoglossus
The extrinsic muscles connect the tongue to the
1 Superior longitudinal mandible via genioglossus; to the hyoid bone through
2 Inferior longitudinal hyoglossus; to the styloid process via styloglossus, and
the palate via palatoglossus. These are described in
Table 77.1.
The actions of intrinsic and extrinsic muscles are
mentioned in T able 17 .2.
Arleriol Supply of Tongue
It is derived from the tortuous lingual artery a branch
of the external carotid artery. The root of the tongue is
also supplied by the tonsillar artery a branch of facial
arlery, and ascending pharyngeal branch of external
carotid (Fig. 77.6). See Chapter 4 and Appendix 1 for
the course and branches of the lingual artery.
Venous Droinoge
The arrangement of the vena comitantes/veins of the
Fig. 17.3: Types of papillac and taste buds tongue is variable. Two venae comitantes accompany
Table 17.1 : Extrinsic muscles of tongue

Muscle Origin lnsertion Actions
Palatoglossus palatine
Oral surface of Descends in the palatoglossal arch Pulls up the root of tongue,
(Fis. 17.6) aponeurosis to the side of tongue at the junction approximates the palatoglossal
of oral and pharyngeal parts arches and thus closes the
oropharyngeal isthmus
:o Hyoglossus Whole length of greater Side of tongue between styloglossus Depresses tongue, makes dorsum
(Fis. 17.6) cornua and lateral parl of and inferior longitudinal muscle of convex, retracts the protruded
zo hyoid bone tongue tongue
E
c Styloglossus Tip and part of anterior lnto the side of tongue Pulls tongue upwards and back
G
tt(E (Fis. 17.6) surface of styloid process wards, i.e. retracts the tongue.
o Genioglossus Upper genial tubercle of Upper fibres into the tip of tongue Retracts the tongue
fan shaped bulky mandible Middle fibres into the dorsum Depresses the tongue
c muscle (Fig. 17.5) Lower fibres into the hyoid bone Pulls the posterior part of tongue
o forwards and protrude the tongue
o
o forwards. llis a life-saving muscle
a
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TONGUE
Table 17.2: Summary of the actions of muscles

lntrinsic muscles Actions
Superior longitudinal Shortens the tongue makes its
dorsum concave
lnferior longitudinal Shortens the tongue makes its
dorsum convex
Transverse Makes the tongue narrow and
elongated
Veftical (Fig. 17.4) Makes tongue broad and flattened.
Extrinsic muscles Actions

Genioglossus
Genioglossus (Fig. 17.5). Protrudes the tongue
Hyoglossus (Fig. 17.6). Depresses the tongue
Styloglossus (Fig. 1 7.6). Retracts the tongue
Palatoglossus. Elevates the tongue
Fig. 17.5: Genioglossus
Median fibrous
septum
the lingual attery, and one vena comitant accompanies
Vertical muscle the hypoglossal nerve. The deep lingual vein is the
largest and principal vein of the tongue. It is visible on
Transverse
muscle the inferior surface of the tongue. It runs backwards
and crosses the genioglossus and the hyoglossus below
lnferior
longitudinal the hypoglossal nerve.
muscle These veins unite at the posterior border of the
hyoglossus to form the lingual vein which ends in the
Genioglossus internal jugular vein.
Hyoglossus
lympholic Droinoge
Greater L The tip of the tongue drains bilaterally to the
cornua of hyoid submental nodes (Figs77.7a and b).
Fig. 17.4: Coronal section of the tongue showing arrangement 2 The right and left halves of the remaining part of the
of the intrinsic muscles and extrinsic muscles anterior two-thirds of the tongue drain unilaterally to
Palatoglossus
Soft palate
Circumvallate papillae
Styloid process with

stylohyoid ligament Tongue
Styioglossus
lX nerve
Deep lingual artery
Lingual artery
Hypoglossal nerve
.!a
Sublingual gland o
zo
t,tr
Genioglossus G
!,(E
Middle conskictor Geniohyoid o
External carotid
artery Lingual nerve with C
submandibular ganglion o
Hyoglossus ()
Fig. 17.6: Arterial supply and extrinsic muscles of tongue ao
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HEAD AND NECK
Circumvalatte
papillae
Deep cervical group
Posterior belly
of digastric
Mylohyoid
Jugulodigastric
group
Mandible
Deep cervical
group
Submental
group
Superior belly Anterior belly

of omohyoid of digastric
Submandibular
group
(a) (b)
lnferior belly of omohyoid
Figs 17.7a and b: Lymphatic drainage of tongue: (a) Lateral surface, and (b) dorsum
the submandibular nodes. A few central lymphatics recurrence of malignant disease occurs in lymph
drain bilaterally to the deep cervical nodes. nodes. Carcinoma of the posterior one-third of the
3 The posteriormost part and posterior one third of the tongue is more dangerous due to bilateral lym-
tongue drain bilaterally into the upper deep cervical phatic spread.
lymph nodes including jugulodigastric nodes. o Sorbitrate is taken sublingually for immediate
4 The whole lymph finally drains t o the jugulo-omohyoid relief from angina pectoris. It is absorbed fast
nodes. These are knousn as the lymph nodes of the tongue. because of rich blood supply of the tongue and
Nerve Supply bypassing of portal circulation.
. Genioglossus is called the 'safety muscle of the
Mofor Nervss
tongue'because if it is paralysed, the tongue will
A11 the intrinsic and extrinsic muscles, except the fall back on the oroPharynx and block the air
palatoglossus, are supplied by the hypoglossal nerve. passage. During anaesthesia, the tongue is pulled
The palatoglossus is supplied by the cranial root of the forwards to clear the air passage.
accessory nerve through the pharyngeal plexus. . Genioglossus is the only muscle of the tongue
So seven out of eight muscles are supplied by XII which protrudes it forwards. It is used for testing
nerve (Fig. 17.8). the integrity of hypoglossal nerve. If hypoglossal
nerve of right side is paralysed, the tongue on
$emsory ,s
protrusion will deviate to the right side. Normal
The lingual nerve is the nerve of general sensation Ieft genioglossus will pull the base to left side and
and the chorda tympani is the nerve of taste for the apex will get pushed to right side (apex and base
anterior two-thirds of the tongue exceptvallate papillae lie at opposite ends) (Figs 17.9 and 17.10a and b).
(Fig. 17.8).
The glossopharyngeal nerve is the nerve for both HISIOTOGY
general sensation and taste for the posterior one-third
of the tongue including the circumvallate papillae. L The butk of the tongue is made up of striated muscles.
ta The posteriormost part of the tongue is supplied by 2 The mucous membrane consists of a layer of connective
o tissue (corium), lined by stratified squamous
zo the vagus nerve through the intemal laryngeal branch
(Table 17.3). epithelium. On the oral part of the dorsum, it is thin,
!l
tr
(E
forms papillae, and is adherent to the muscles. On
t,(E the pharyngeal part of the dorsum, it is very rich in
o . lymphoid follicles. On the inferior surface, it is thin
I Carcinoma of the tongue is quite common. The
and smooth. Numerous glands, both mucous and
affected side of the tongue is removed surgically.
serous lie deep to the mucous membrane.
C
o All the deep cervical lymph nodes are also
o
o removed, i.e. block dissection of neck because 3 Taste buds are most numerous on the sides of the
a circumvallate papillae, and on the walls of the
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TONGUE
Table 17.3; Comparison of the parts of the tongue

Anterior two-thirds Posterior one-third Posteriormost paft and vallecula
Situation Lies in mouth cavity Oropharynx Oropharnx
Structure papillae
Contains Contains lymphoid tissue
Function Chewing Deglutition Deglutition
Sensory nerve Lingual (post-trematic Glossopharyngeal lnternal laryngeal branch of
branch of 1st arch) vagus
Sensation of taste Chorda tympani except circum- Glossopharyngeal including lnternal laryngeal branch of
vallate papillae (pre{rematic the vallate papillae vagus
branch of 2nd arch)
Development of Lingual swellings of I arch. Third arch which forms large Foufth arch which forms small
epithelium from endoderm Tuberculum impar which soon ventral part of hypobranchial dorsal part of hypobranchial
disappears eminence emrnence
Muscles develop from occipital myotomes, so the cranial nerve Xll (hypoglossal nerve) supplies all intrinsic and three extrinsic
muscles. Only palatoglossus is supplied by cranial root of accessory through pharyngeal plexus and is developed from mesoderm
of sixth arch
Both general sensation
and taste by internal Retraction
laryngeal nerve,
branch of vagus
Both general
sensation and taste
Only palatoglossus by glossopharyngeal
supplied by vago- nerve
accessory complex Circumvallate
papillae Depression
Seven muscles of
tongue supplied by General sensation Apex of tongue
hypoglossal nerve by lingual and taste
by chorda tympani Protrusion
Fig. 17.8: Nerve supply of tongue Fig. 17.9: Actions of extrinsic muscles of tongue
Base pulled to right

by normal genio-
glossus
Paralysed left
genioglossus
Base pushed to left xo

by normal left genio-
glossus zo
Tip pointing to t,c
the left paralysed G
Tip of tongue deviated
side tG
to paralysed right side o
(a) (b)
c
o
Figs 17.10a and b: (a) Effect of paralysis of right Xll nerve, and (b) effect of paralysed left genioglossus o
o
a
2
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I
HEAD AND NECK
surrounding sulci. Taste buds are numerous over the

foliate papillae and over the posterior one-third of
the tongue; and sparsely distributed on the
fungiform papillae, the soft palate, the epiglottis and
the pharynx. There are no taste buds on the mid-
dorsal region of the oral part of the tongue.
Thalamus
DEVETOPMENI OF TONGUE
Epithelium
I Anterior two-thirds: From two lingual swellings,
which arise from the first branchial arch (Fig. 77.11).
Therefore, it is supplied by lingual nerve (post-
trematic) of 1st arch and chorda tympani (pre-
trematic) of 2nd arch.
2nd arch
Fig. 17.12: Taste pathways

Taste from posteriormost part of tongue and
1 st arch epiglottis travels through aagusnetve till the inferior
ganglion of vagus. These central processes also reach
tractus solitarius.
After a relay in tractus solitarius,the solitario-thalamic
tract is formed which becomes a part of trigeminal
lemniscus and reaches postero-ventromedial nucleus
of thalamus of the opposite side. Another relay here
takes them to lowest pnrt of postcentral gyrus, which is
Fig. 17.11: Development of tongue the area for taste.
2 Posterior one-third: From cranial large part of the

hypobranchial eminence, i.e. from the third arch. Injury to any part of the pathway causes
Therefore, it is supplied by the glossopharyngeal abnormality in appreciation of taste.
nerve (Table 17.3). Referred pain is felt in the ear in diseases of
3 Posteriormost part from the fourth arch. This is posterior part of the tongue, as ninth and tenth
supplied by the vagus nerve. nerves are common supply to both the regions.
Muscles
Other examples of referred pain are seen in
Fig.77,13.
The muscles develop from the occipital myotomes
which are supplied by the hypoglossal nerve.
Connective Tissue Gallbladder
The connective tissue develops from the local

mesenchyme.
ra
o
zo . The taste from anterior two-thirds of tongue except
!ttr from vallate papillae is carried by chorda tympani
(E branch of facial till the geniculate ganglion. The
Small intestine
t,G central processes go to the tractus solitarius in the
o medulla.
I
o Taste from posterior one-third of tongue including
Large intestine
C the circumvallate papillae is carried by cranial nerve
.o
o IX till the inferior ganglion. The central processes
Fig. 17.13: Examples of referred pain
ao also reach the tractus solitarius (Fig.17.12).
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TONGUE
All4 intrinsic muscles of tongue are supplied by A patient is diagnosed as 'lmedial medullary
XII nerve syndrome on right side
Out of 4 extrinsic muscles of tongue 3 are supplied o What is the effect on tongue?
by XII nerve. Only palatoglossus is supplied by . Name the nuclear column to which XII nerve
vagoaccessory complex. belongs?
Lingual artery is a tortuous artery as it moves up o Name the muscles of tongue?
and down with movements of pharynx
Tongue is kept in position by its attachment to Ans: In medial medullary syndro , XII nerve,
neighbouring structures through the 4 pairs of pyramidai fibres and mediall niscus are damaged
extrinsic muscles due to blockage of anterior sp 1 artery
Circumvallate papillae are only 10-12 in number,
but have maximum number of taste buds. The taste
from here is carried by IX nerve. b. Loss of sense of vibration and position due to
Nerve supply correlates with development. damage to medial le iscus
Anterior two thirds develop from 1st arch, the c. Paralysis of muscles of tongue on the same side
nerves being lingual and chorda tympani. Chorda due to paralysis of XII nerve. tip of tongue on
tympani is pre-trematic branch of the second arch. protrusion will get protruded to the side of lesion.
Posterior one-third develops from cranial part of XII nerve belongs to general somatic efferent
3rd arch. So it is supplied by IX nerve. c (GSE).
Posteriormost part develops from 4th arch. So it is
supplied by internal laryngeal branch of X.
Sorbitrate, the drug for prevention of angina is
Intrinsie muscle Extrinsic muscle
taken sublingually as it reaches the blood very fast, Superior longitudinal Genioglossus
bypassing the portal circulation. Lrferior longitudinal Hyoglossus
Genioglossus is the life saving muscle as it Transverse Palatoglossus
protrudes the tongue forwards. Vertical Styloglossus
MULTIPLE CHOICE SUESTIONS

'1. Epithelium of tongue develops from all the J. Ll,rnph from tongue drains into all following lymph
following arches except: nodes except:
a. I arch b. II arch a. Submandibular b. Submental
c. III arch d. IV arch c. Deep cervical d. Preauricular
4. Taste from the tongue is carried by all nerves except:
2. Muscles of tongue are mostly supplied by XII nerve
except:
a. VII b. IX
a. Cenioglossus
c.X d. XI
5. Sensory fibres from tongue is carried by all nerves
b. Palatoglossus except:
c. Hyoglossus a.V b. VIII
d. Styloglossus c. IX d.x
ANSWERS .Y
(J
1. b 2.b 3.d 4. d, s.b zo
E
c(E
!,(E
o
C
o
o
o0)
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INTRODUCI!ON 6 Stylomastoid foramen gives Passage to posterior
tympanic artery for middle ear and facial nerve.
Tympanic membrane comprises all the three embryonic
layers-outer layer is ectodermal, inner layer is endo- 7 Hiatus for greater petrosal nerve gives passage to
dermal while middle one is mesodermal in origin. The nerve of the same name and a branch of middle
ossicles of the ear are the only bones fully formed at birth. meningeal artery.
One hears with the ears. The centre for hearing is in 8 Tegmen tympani on the anterior face of petrous
the temporal lobe of brain above the ear. Reading aloud temporal bone, forms roof of the middle ear,
is a quickerway of memorising, as the ear, temporallobes mastoid antrum and canal for tensor tympani
and motor speech area are also activated. The labyrinth muscle.
is also supplied by * "end artery" like the retina. 9 The aqueduct of vestibule oPens onposterior aspect
Noise pollution within the four walls of the homes of petrous temporal bone. It is plugged by ductus
from the music albums and advertisements emitted endolymphaticus.
from the television sets cause a lot of damage to the L0 Organ of Corti is the end organ for hearing, situated
cochlear nerves and temporal lobes, besides causing in the cochlear duct.
irritation, hypertension and obesity. 11 Crista is an end organ in the semicircular canal.
The ear is an organ of hearing. It is also concerned in These are kinetic balance receptors.
maintaining the equilibrium of the body. It consists of 12 Macula are end organs in the utricle and saccule
three parts: The external ear, the middle ear and the and are static balance receptors.
internal ear.
Feolures of the Temporol Bone

L External auditory meatus is for air waves.
2 Internal auditory meatus is for passage of VII, VIII The external ear consists of:
nerves and labyrinthine vessels. . The auricle or pinna.
3 Suprameatal triangle is the landmark for mastoid . The extemal acoustic meatus.
antrum. It is bounded by supramastoid crest,
posterosuperior margin of external acoustic meatus AURICLE/PINNA
and a tangent drawn from the crest to the margin. The auricle is the part seen on the surface, the part the
Mastoid antrum lies about 15 mm deep to the Ial,rnan calls the ear. The greater part of it is made up
suprameatal triangle in adult (see Fig.7.9b). of a single crumpled plate of elastic cartilage which is
4 Tympanic canaliculus lies on the inferior surface of lined on both sides by skin. It supports the spectacles.
petrous temporal bone between carotid canal and However, the lowest part of the auricle is soft and
jugular fossa. consist ered bY skin: This
5 Petrotympanic fissure gives passage to anterior part is the ear rings. The
tympanic artery, anterior ligament of malleus and iest of number of parts.
chorda tympani nerve. These are helix, antihelix, concha, tragus, scaphoid fossa
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(see Fig. 20.2).In particular, note the large depression Feotules
called the concha;it leads into the external acoustic The external auditory meatus conducts sound waves
meatus. from the concha to the tympanic membrane. The canal
In relation to the auricle, there are a number of is S-shaped. Its outer part is directed medially, forwards
muscles. These are all vestigeal in man. Lr lower animals, and upwards. The middle part is directed medially,
the intrinsic muscles alter the shape of the auricle, while backwards and upwards. The inner part is directed
t]:re extrinsic muscles move the auricle as a whole. medially, forwards and downwards. The meatus can
be straightened for examination by pulling the auricle
Nerve Supply upwards, backwards and slightly laterally.
The upper two-thirds of the lateral surface of the The meatus or canal is about 24mrll long, of which
auricle are supplied by the auriculotemporal nerve; and the medial two-thirds or 16 mm is bony, and the lateral
the lower one-third by the great auricular nerve (Figs one-third or 8 mm is cartilaginous. Due to the obliquity
18.1a and b). The upper two-thirds of the medial surface of the tympanic membrane, the anterior wall and
are supplied by the lesser occipital nerve; and the lower floor are longer than the posterior wall and roof
one-third by the great auricular nerve. The root of the (Figs 18.3a and b).
auricle is supplied by the auricular branch of the vagus The canal is oval in section. The greatest diameter is
(Figs 18.1a and b). The auricular muscles are supplied vertical at the lateral end, and anteroposterior at the
through branches of the facial nerve. medial end. The bony part is narrower than the
cartilaginous part. The narrowest point, the isthmus,lies
BIood Supply about 5 mm from the tympanic membrane.
The blood supply of the auricle is derived from the Thebony part is formed by the tympanic plate of the
posterior auricular and superficial temporal arteries temporal bone which is C-shaped in cross-section. The
(Fig. 18.2). Tiire lymphatics drain into the preauricular, posterosuperior part of the plate is deficient. Here the
and postauricular lymph nodes (Figs 18.1a and b). wall of the meatus is formed by apart of the squamous
temporal bone. The meatus is lined by thin skin, firmly
adherent to the periosteum.
The cartilaginouspart is also C-shaped in section; and
the gap of the 'C' is filled with fibrous tissue. The lining
DISSECTION skin is adherent to the perichondrium, and contains
Expose the external auditory meatus by cutting the hairs, sebaceous glands, and ceruminous or wax glands.
tragus of the auricle. Put a probe into the external Ceruminous glands are modified sweat glands.
auditory meatus and remove the anterior wall of
Blood Supply
cartilaginous and bony parts of the external auditory
meatus with the scissors. Be slow and careful not to The outer part of the canal is supplied by the superficial
damage the tympanic membrane. temporal and posterior auricular arteries, and the inner
part, by the deep auricular branch of the maxillary artery.
Preauricular
lymph nodes
Branches
Auricular Postrauricular of lesser ta
lymph nodes occipital o
zo
branch of X
ttc
Lesser occipital (E
(c2, c3) t,(E
o
Great auricular I
Great auricular
(c2, c3)
C
(c2, c3) o
o
o
Figs 18.1a and b: Pinna of the ear: (a) Nerve supply and lymph nodes on the lateral surface, and (b) nerve supply on the medial surface a
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HEAD AND NECK
The outer surface of the membrane is lined by thin

skin. It is concave.
The inner surface provides attachment to the handle
of the malleus which extends up to its centre. The inner
surface is convex. The point of maximum convexity lies
at the tip of the handle of the malleus and is called the
umbo.
Superficial The membrane is thickened at its circumference
temporal which is fixed to the tympanic sulcus of the temporal
bone on the tympanic plate. Superiorly, the sulcus is
Maxillary
deficient. Here the membrane is attached to the
Posterior tympanic notch. From the ends of the notch, two bands,
auricular
the anterior and posterior malleolar folds, are
Branches of posterior prolonged to the lateral process of the malleus.
auricular to medial
External
surface of external ear While the greater part of the tyrnpanic membrane is
carotid
tightly stretched and is, therefore, called the pars tensa,
Fig. 18.2: Blood supply of the auricle
the part between the two malleolar folds is loose and is
called the pars flaccida. The pars flaccida is crossed
Lympholics internally by the chorda tympani (Fig. 18.5). This part
The lymphatics pass to preauricular, postauricular and is more liable to rupture than the pars tensa.
superficial cervical lymph nodes. The membrane is held tense by the inward pull of
the tensor tympani muscle which is inserted into the
Nerve Supply upper end of the handle of the malleus.
The skin lining the anterior half of the meatus is
supplied by the auriculotemporal nerve, and that lining Structule
the posteriorhalf,by the auricular branch of the vagus. The tympanic membrane is composed of the following
three layers:
TYMPANIC MEMBRANE 1 The outer cuticular layer of skin (Fig. 18.4a).
This is a thin, translucent partition between the external 2 The middle fibrous layer rnade up of superficial
acoustic meatus and the middle ear. radiating fibres and deep circular fibres. The circular
It is oval in shape, measuring 9 x 10 mm. It is placed fibres are minimal at the centre and maximal at the
obliquely at an angle of 55 degrees with the floor of the periphery (Fig. 18.ab). The fibrous layer is replaced
meatus. It faces downwards, forwards and laterally by loose areolar tissue in the pars flaccida (Fig. 18.5).
(Figs 18.4a and b). 3 The inner mucous lnyer (Fig. 18.4a) is lined by a low
The membrane has outer and inner surfaces. ciliated columnar epithelium.
Scaphoid fossa
Facial
nerve
Cochlea
.!a
o Concha
o
z Eustachian
t,c Tragus tube
G
t,(E Stapes
Lobule
o lncus
J-
External Tympanic
c auditory membrane
o (b)
() meatus (a)
o
a Figs 18.3a and b: (a) The normal ear, and (b) otitis media causing mastoid abscess
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EAR
Pars flaccida
Anterior
malleolar Posterior
fold malleolar fold
Deep circular
Outer fibres
cuticular layer
Middle
Tympanic plexus fibrous layer
of nerves (lX) Superficial
lnner mucous radiating fibres
layer
Handle of
malleus
(a) (b)
Figs18.4a and b: (a) Tympanic membrane as seen in section, and (b) fibres of tympanic membrane
Head of partby the auricular branch of the vagus nerve with

malleus
Short process and a communicatingbranch from facial nerve (Fig. 18.1).
body of incus Chorda
tympani
2 Irurcr surface: This is supplied by the tympanic branch
Pars flaccida of the glossopharyngeal nerve through the tympanic
Anterior
canaliculus
plexus (Fig. 18.aa).
Handle of
malleus
o As already stated, for examination of the meatus
Pars tensa and tympanic membrane, the auricle should
be drawn upwards, backlvards and slightly
laterally. However, in infants, the auricle is drawn
Anterior
downwards and backwards because the canal is
only cartilaginous and the outer surface of the
tympanic membrane is directed mainly down-
wards (Fig.18.6).
Fig. 18.5: lnner sudace of the tympanic membrane o Boils and other infections of the external auditory
meatus cause little swelling but are extremely
Blood Supply painful, due to the fixity of the skin to the
1 The outer surface is supplied by the deep auricular underlyingbone and carlilage. Ear shouldbe dried
branch of the maxillary artery. after head bath or swimming.
2 The inner surface is supplied by the anterior o Irritation of the auricular branch of the vagus in
tympanic branch of the maxillary artery (seeFig.6.6) the external ear by ear wax or syringing may
and by the posterior tympanic branch of the reflexly produce persistent cough called eat cough,
stylomastoidbranch of the posterior auricular artery. vomiting or even death due to sudden cardiac
inhibition. On the other hand, mild stimulation of
Venous Droinoge
this nerve may reflexly produce increased appetite.
Veins from the outer surface drain into the external . Accumulation of wax in the external acoustic
jugular vein. Those from the inner surface drain into meatus is often a source of excessive itching, j
the transverse sinus and into the venous plexus around although fungal infection and foreign bodies o
the auditory tube. should be excluded. Troublesome impaction of zo
large foreign bodies like seeds, grains, insects is !ttr
lymphotic Droinoge
common. Syringing is done to remove these (E
Lymphatics pass to the preauricular and retro- !,

(Fig. 18.7). o
ll*ph o
pharyngeal nodes. r Involvement of the ear in herpes zoster of the I
Nerve Supply geniculate ganglion depends on the connection c
between the auricular branch of the vagus and the o
I Outer surface: The anteroinferior part is supplied by facial nerve within the petrous temporal bone.
F()
o
the auriculotemporal nerve, and the posterosuperior U)
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HEAD AND NECK
Small pieces of skin from the lobu1e of the pinna When the tympanic membrane is illuminated for
are corunonly used for demonstration of lepra examination, the concavity of the membrane
bacilli to confirm the diagnosis of leprosy. produces a'cone of light'over the anteroinferior
a Pinna is used as grafting material. quadrant which is the farthest or deepest quadrant
a Hair on pinna in male represents y-linked with its apex at the umbo (Fig. 18.9). Through the
inheritalce. membtane, one can see the underlying handle of
A good number of ear traits follow mendelian the malleus and the long process of the incus.
inheritance. The membrane is sometimes incised to drain pus
Infection of elastic cartilage may cause peri- present in the middle ear. The procedure is called
chondritis. myringotorny (Fig. 18.9). The incision for my-
Bleeding within the auricle occurs between the ringotomy is usually made in the posteroinferior
perichondrium and auricular cartilage. If left quadrantof the membrane where thebulge is most
untreated fibrosis occurs as haematoma com- prominent. In giving an incision, it has to be
promises blood supply to cartilage. Fibrosis leads remembered that the chorda tympani nerve runs
to "cauliflower ear". It is usually seen in wrestlers. downwards and forwards across the inner surface
Tympanic membrane is divided into an upper of the membrane, lateral to the long process of the
smaller sector, the pars flaccida bounded by incus, but medial to the neck of the malleus. If the
anterior and posterior malleolar folds and a larger nerve is injured taste from most of anterior two-
sector, the pars tensa. Behind pars flaccida iies the thirds of tongue is not perceived. Also salivation
chorda tympani, so diseaseinpars flaccida should from submandibular and sublingual glands gets
be treated carefully (Fig. 18.8). affected.
Posterior
lncus
Chorda tympani
nerve
Tympanic membrane
Stapedius
Stapes
Fig. 18.8: Care to be taken in disease of pars flaccida

Fig. 18.6: Otoscopic examination Pars
flaccida
Lateral
process
of malleus
Anterior
malleolar
fold
Handle of
malleus
-v
o
zo
lncisions
are grven
t,c in ihis
quadrant
o Cone of
!, light
G
o
Fig. 18.7: Syringing of the ear
Fig. 18.9: The left tympanic membrane seen through the external
.9 acoustic meatus. 1. Posterosuperior quadrant, 2. anterosuperior
o
quadrant, 3. posteroinferior quadrant, and 4. anteroinferior quadrant
ao
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EAR
Shope ond Size

The middle ear is shaped like a cube. Its lateral and
DISSECTION medial walls are large, but the other walls are narrow,
because the cube is compressed from side to side. Its
Remove the dura mater and endosteum from the floor
vertical and anteroposterior diameters are both about
of the middle cranial fossa. ldentify greater petrosal
15 mm. When seen in coronal section the cavity of the
nerve emerging from a canaliculus on the anterior
middle ear is biconcave, as the medial and lateral walls
surface of petrous temporal bone. Trace it as it passes
are closest to each other in the centre. The distances
inferior to trigeminal ganglion to reach the carotid canal.
separating them are 6 mm near the roof,2 mm in the
Carefully break the roof of the middle ear formed by centre, and 4 mm near the floor (Fig. 18.11).
tegmen tympani which is a thin plate of bone situated
parallel and just lateral to the greater petrosal nerve.
Cavity of the middle ear can be visualised. Try to put a
probe in the anteromedial part of the cavity of middle
ear till it appears at the opening in the lateral wall of
nasopharynx. ldentify the posterior wall of the middle
ear which has an opening in its upper part. This is the
aditus to mastoid antrum which in turn connects the
cavity to the mastoid air cells.
Ear ossicles
ldentify the bony ossicles. Locate the tendon of tensor
tympani muscle passing from the malleus towards the
medial wall of the cavity where it gets continuous with
the muscle. Trace the tensortympani muscle traversing Fig. 18.11 : Measurements
in a semicanal above the auditory tube. Break one wall
of the pyramid to visualise the stapedius muscle. Just Porls
superior to the attachment of tendon of tensor tympani, The cavity of the middle ear can be subdivided into the
look for chorda tympani traversing the tympanic tympanic cavity proper which is opposite the tympanic
membrane. membrane; and the epitympanic recess which lies above
the level of the trr.,rnpanic membrane.
Feotures
The middle ear is also called the tympanic cavity, or Communicotions
tympanum. The middle ear communicates anteriorly with the
The middle ear is a narrow air filled space situated nasopharyrnx through the auditory tube, and posteriorly
in the petrous part of the temporal bone between the with the mastoid antrum and mastoid air cells through
external ear and the internal ear (Fig. 18.10). the aditus to the mastoid antrum (Fig. 18.12a).
The middle ear is likened to a pistol in the sloping
course of the aditus to the epitympanic recess and the
auditory tube (Fig. 1.8.12a). The trigger of pistol is
tympanic cavity. Outlet is auditory tube. Handle is
aditus to mastoid antrum and mastoid air cells
Stapes (Fig. 18.12b).
CONTENTS
External The middle ear contains the following. xo
acoustic
meatus 1 Three small bones or ossicles namely the malleus, zo
the incus and the stapes. The upper half of the ttr
Tympanic
membrane
malleus, and the greater part of the incus lie in the (E
epitympanic recess. tG
2 Ligaments of the ear ossicles. o
3 Two muscles, the tensor tympani and the stapedius.
tympanic 4 Vessels supplying and draining the middle ear. C
o
membrane 5 Nerves: Chorda tympani and tympanic plexus. o
o
Fig. 18.10: Scheme to show the three parts of the ear 6 Air. a
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Canal for backwards as the roof of the canal for the tensor
tensor tympani
tympani (Fig. 18.13).
Aditus to antrum
2 In young children, the roof presents a gap at the
unossified petrosquamous suture where the middle
Mastoid antrum ear is in direct contact with the meninges. In adults,
the suture is ossified and transmits a vein from the
Auditory Mastoid middle ear to the superior petrosal sinus.
tube air cells
lnternal Mastoid
Floor or Jugulor II
carotid process The floor is formed by a thin plate of bone which
artery
separates the middle ear from the superior bulb of the
internal jugular vein. This plate is a part of the temporal
bone (Fig. 18.13).
Near the medial wall, the floor presents the tl,rnpanic
canaliculus which transmits the tlrmpanic branch of the
glossopharyngeal nerve to the medial wall of the
middle ear.
Anierior or Corolid ll
The anterior wall is narrow due to the approximation
(b)
of the medial and lateral walls, and because of descent
Figs 18,12a and b:(a) Scheme to show some relationships of
of the roof.
the middle ear cavity, and (b) note that the cavity resembles a
pistol
The uppermost part of the anterior wall bears the
opening of the canal for the tensor tympani.
The middleparthas the openingof the auditorytube.
The mucous membrane lining the middle ear cavity
The inferior part of the wall is formed by a thin plate
invests all the contents and forms several vascular folds
of bone which forms the posterior wall of the carotid
which project into the cavity. This gives the cavity a
canal. The plate separates the middle ear from the
honeycombed appearance.
internal carotid artery. This plate of bone is perforated
BOUNDARIES
by the superior and inferior sympathetic carotico-
tympanic nerves and the tympanic branch of the intemal
Roof or Tegmentol ll carotid artery (Fig. 18.1a).
1 The roof separates the middle ear from the middle The bony septum between the canals for the tensor
cranial fossa. It is formed by a thin plate of bone tympani and for the auditory tube is continued
called the tegmen tympani. This plate is prolonged posteriorly on the medial wall as a curved lamina called
Anterior Posterior
Promontory Prominence of lateral
semicircular canal
Tegmen tympani
Tympanic antrum
Processes cochleariformis
Facial canal
Canal for tensor tympani Fenestra vestibuli
Canal of auditory tube Pyramid

.Y
o
o Two sympathetic Sinus tympani
z carotlcotympanic nerves
!tc Fenestra cochleae
G Tympanic branch of
!t(E internal carotid artery Jugular fossa
o lnternal carotid artery with Jugular bulb
I sympathetic plexus
c Tympanic canaliculus with

o lnternal jugular vein
o tympanic branch of lX nerue
o
a Fig. 18.13: Scheme to show the landmarks on the medial wall of the middle ear. Some related structures are also shown
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Anterior Posterior
Head of malleus
Tegmen tympani
Anterior ligament of malleus
and petrotympanic fissure
Aditus
Tensor tympani muscle
within canal Chorda tympani
Bony septum
Posterior canaliculus
Auditory tube for chorda tympani
Anterior canaliculus Tympanic membrine

for chorda tympani
Handle of malleus
Fig. 18.14: Lateral wall of the middle ear viewed from the medial side
the processes cochlenriformis. Its posterior end forms a nerve leaves the middle ear through this
pulley around which the tendon of the tensor tympani canaliculus to emerge at the base of the skull
turns laterally to reach the upper part of the handle of (Figs 18.5 and 18.13).
the malleus.
MediolorLobyilnthine !l
Poslerior or Mostoid II
The medial wall separates the middle ear from the
The posterior wall presents these features from above internal ear. It presents the following features.
downwards. 1 The promontory is a rounded bulging produced by
1 Superiorly, there is an opening or aditus through the first turn of the cochlea..It is grooved by the
which the epitl,,rnpanic recess communicates withthe tympanic plexus (Fig. 18.13).
mastoid or tympanic antrum (Figs 18.12 and 18.13). 2 The fenestra oestibuli is an oval opening postero-
2 The fossa incudis is a depression which lodges the superior to the promontory. It leads into the vestibule
short process of the incus. of the internal ear and is closed by the foot-plate of
3 A conical projection, called thepyramid, lies near the the stapes.
junction of the posterior and medial walls. It has an 3 The prominence of the facial canal n:ns backwards just
opening at its apex for passage of the tendon of the above the fenestra vestibuli, to reach the lower
stapedius muscle. margin of the aditus. The canal then descends behind
4 Lateral to pyramid and near the posterior edge of the posterior wall to end at the stylomastoid foramen.
the tympanic membrane, is the posterior canaliculus 4 Thefenestra cochleae is a round opening at the bottom
for the chorda tympani through which the nerve enters of a depression posteroinferior to the promontory.
the middle ear cavity. It opens into the scala tympani of the cochlea, and is
LoterolorMembronous closed by the secondary tympanic membrane.
l!
5 The sinus tympani is a depression behind the
1 The lateral wall separates the middle ear from the promontory, opposite the ampulla of the posterior
external acoustic meatus. It is formed: semicircular canal.
a. Mainlyby the tympanic membrane along with the 6 The processus cochlearifurmis (see lhe anterior'wall).
tympanic ring and sulcus. 7 Prominence of lateral seinicircular canal above the
b. Partly by the squamous temporal bone, in the region .Y
facial canal. o
of the epitympanic recess (Figs 18.13 and 18.5). zo
2 Near the tympanic notch, there are two small Eor Ossicles t,tr
apertures. G
a. The petrotympanic fissure lies in front of the upper lleus E'
(E
end of the bony rim. It lodges the anterior process The malleus (Latin hammer) is so called because it o
I
of the malleus and transmits the tympanic branch resembles a hammer. It is the largest, and the most
of the maxillary artery. laterally placed ossicle. It has the following parts: C
o
b. The anterior canaliculusfor the chordatympaninerve 1 The rounded head lies in the epitympanic recess. It o
lies either in the fissure or just in front of it. The articulates posteriorly with the body of the incUs. It ao)
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HEAD AND NECK
provides attachment to the superior and lateral Joints of the Ossicles

ligaments (Fig. 18.5). L The incudomalleolar joint is a saddle joint.
2 The necklies against the pars flaccida and is related 2 The incudostapedial j oint is a ball and socket joint. Both
medially to the chorda tympani nerve (Fig. 18.1a). of them are synovial joints. They are surrounded by
3 The anterior process is connected to the petrotympanic capsular ligaments. Accessory ligaments are three
fissure by the anterior ligament. for the malleus, and one each for the incus and the
4 The lateral process projects from the upper end of the stapes which stabilize the ossicles. All ligaments are
handle and provides attachment to the malleolar extremely elastic (Fig. 18.15).
folds.
5 The handle extends downwards, backwards and Muscles of the Middle Eor
medially, and is attached to the upper half of the There are two muscles, the tensor tympani and the
tympanic membrane (Figs 18.4b and 18.14). stapedius. Both act simultaneously to damp down the
intensity of high-pitched sound waves and thus protect
lncus or Anvil the internal ear (Fig. 18.8).
It is so called because it resembles an anvil, used by The tensor tympani lies in a bony canal that opens at
blacksmiths. It resembles a molar tooth and has the its lateral end on the anterior wall of the middle ear,
following parts: and at the medial end on the base of the skull. The
L The body is large and bears an articular surface that auditory tube lies just below this canal.
is directed forwards. It articulates with the head of The muscle arises from the walls of the canal in which
the malleus. it lies. Some fibres arise from the cartilaginous part of
2 The long process projects downwards just behind and the auditory tube, and some from the base of the skull.
parallel with the handle of the malleus. Its tip bears a The muscle ends in a tendon which reaches the
lentiform nodule directed medially which articulates medialwall of the middle ear andbends sharply arormd
with the head of the stapes (Figs 18.9 and 18.15). the processus cochleariformis. It then Passes laterally
across the tympanic cavity to be inserted into the handle
Ses of the malleus.
This bone is so called because it is shaped like a stirrup. The tensor tympani is supplied by the mandibular
It is the smallest, and the most medially placed ossicle nerae.The fibres pass through the nerve to the medial
of the ear (Fig. 18.15). pterygoid, and through the otic ganglion, without any
It has the following parts: relay.
a. The small head has a concave facet which It develops from the mesoderm of first branchial arch.
articulates with the lentiform nodule of the incus. The stapeditrs lies in a bony canal that is related to
b. The narrow neck provides insertion, posteriorly, the posterior wall of the middle ear. Posteriorly, and
to the thin tendon of the stapedius. below, this canal is continuous with the vertical part of
c. Two limbs or crura; anterior, the shorter and less the canal for the facial nerve. Anteriorly, the canal opens
curved; and posterior, the longer which diverge on the summit of the pyramid.
from the neck and are attached to the footplate. The muscle arises from the walls of this canal. Its
d. The footplate, a footpiece or base, is oval in shape, tendon emerges through the pyramid and Passes
and fits into the fenestra vestibuli. forwards to be inserted into the posterior surface of the
neck of the stapes.
The stapedius is supplied by the facial neroe. It
develops from the mesoderm of the second brnnchial arch.
BodY lncudomalleolar
joint (saddle type) Arteilol Supply
Short process
The main arteries of the middle ear are as follows.
Head
ta
o 1 The anterior tympanic branch of the maxillary artery
o which enters the middle ear through the petro-
z Long process Neck
t tympanic fissure.
o Anterior process 2 The posterior tympanic branch of the stylomastoid
!t(E Head branch of the posterior auricular artery which enters
Handle
o Neck through the stylomastoid foramen.
lncudostapedial
Posterior limb joint (ball and
C nous Droinoge
Foot plate socket type)
.9
o Veins from the middle ear drain into the superior
ao Fig. 18.15: Ossicles of the left ear, seen from the medial side petrosal sinus and the pterygoid plexus of the veins.
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EAR
Lymphotic Droinoge the foramen to expose the whole of facial nerve canal.
Lymphatics pass to the preauricular and retro- Facial nerve is described in detail in Chapter 24. Learn
pharyngeal lymph nodes. it from there.
Break off more of the superior surface of the petrous
Nerve Supply temporal bone. Remove the bone gently. Examine the
The nerve supply is derived from the tympanic plexus holes in the bone produced by semicircular canals and
which lies over the promontory. The plexus is formed look for the semicircular ducts lying within these canals.
by the following. Note the branches of vestibulo-cochlear nerve entering
1 The tympanic branch of the glossopharyngeal nerve. the bone at the lateral end of the meatus. Study the
Its fibres are distributed to the mucous membrane internal ear from the models in the museum.
of the middle ear, the auditory tube, the mastoid
antrum and air cells. It also gives off the lesser Feotules
petrosal nerve. Mastoid antrum is a small, circular, air filled space
2 The superior and inferior caroticotympanic nerves situated in the posterior part of the petrous temporal
arise from the sympathetic plexus around the bone. It is of adult size at birth, size of a small pea, or
internal carotid aitery. These fibr"r are vasomotor 1 cm in diameter and has a capacity of about one
to the mucous membrane. milliliter (Fig. 18.13).
FUNCTIONS OF THE MIDDLE EAR BOUNDARIES

1 It transmits sound waves from the external ear to 1, Superiorly: Tegmen tympani, and beyond it the
the internal ear through the chain of ear ossicles, and temporal lobe of the cerebrum.
thus transforms the air-borne vibrations from the 2 riorly: Mastoid process containing the mastoid air
tympanic membrane to liquid-borne vibrations in the s.J
internal ear. 3 Anteriorlq: It communicates with the epitympanic
2 The intensity of the sound waves is increased ten recess through the aditus. The aditus is related
times by the ossicles. It may be noted that the medially to the ampullae of the superior and lateral
frequency of sound does not change. semicircular canals, and posferosuperiorly to the
facial canal.
4 It is separated by a thin plate of bone from
P osteriorly :
the sigmoid sinus. Beyond the sinus there is the
DISSECT]ON cerebellum.
Clean the mastoid temporal bone off all the muscles
5 Medially: Petrous temporal bone.
and identify suprameatal triangle and supramastoid
6 Laterally: It is bounded by part of the squamous
temporal bone. This part corresponds to the
crest. Use a fine chiselto remove the bone of the triangle
suprameatal triangle seen on the surface of the bone.
till the mastoid antrum is reached. Examine the extent
This wall is 2 mm thick at birth, but increases in
of mastoid air cells.
thickness at the rate of about 1 mm per year up to a
Remove the posterior and superior walls of external
maximum of about 12 to 15 mm.
auditory meatus till the level of the roof of mastoid
antrum. ldentify the chorda tympani nerve at the MASIOID AIR CEttS
posterosuperior margin of tympanic membrane.
Look for arcuate'eminence on the anterior face of Mastoid air cells are a series of intercommunicating
petrous temporal bone. ldentify internal acoustic meatus spaces of variable size present'within the mastoid
on the posterior face of petrous temporal bone, with process. Their number varies considerably. Sometimes
the nerves in it. Try to break off the superior part of there are just a few, and are confined to the upper part
of the mastoid process. Occasionally, they may extend t(
petrous temporal bone above the internal acoustic o
beyond the mastoid process into the squamous or o
meatus. ldentify the facial nerve as it passes towards z
the aditus. ldentify the sharp bend of the facial nerve petrous parts of the temporal bone (Fig. 18.12). E'
tr
(E
with the geniculate ganglion.
ond Nerves
ssels, lymphotics E'
ldentify the facial nerve turning posteriorly into the G
The mastoid antrum and air cells are supplied by the o
medial wall. Trace it above the fenestra vestibuli till it
turns inferiorly in the medial wall of aditus. posterior tympanic artery derived from the stylomastoid
ldentify facial nerue at the stylomastoid foramen. Try branch of the posterior auricular artery. The oeins dratn C
.o
to break the bone vertically along the lateral edge of into the mastoid emissary vein, the posterior auricular o
q)
vein and the sigmoid sinus. U)
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HEAD AND NECK
Lymphatics pass to the postauricular and upper deep margins of the fenestra vestibuli. This leads to
cervical lymph nodes. deafness. The condition maybe surgically corrected
Neraes are derived from the tympanic plexus formed by putting a prosthesis (Figs 18.17a and b).
by the glossopharyngeal nerve and from the meningeal Mastoid abscess is secondary to otitis media. It is
branch of the mandibular nerve. difficult to treat. A proper drainage of pus from
the mastoid requires an operation through the
suprameatal triangle. The facial nerve should not
Fracture of the middle cranial fossa breaks the roof be injured during this operation (Fig. 18.18).
of the middle ear, rupture the tympanic Infection from the mastoid antrum and air cells
membrane, and thus cause bleeding through the can spread to any of the structures related to them
ear along with discharge of CSF. including the temporal lobe of the cerebrum, the
Throat infections commonly spread to the middle cerebellum, and the sigmoid sinus.
ear through the auditory tube and cause otitis The ear on infected side is displaced laterally and
media. The pus frorn the middle ear may take one can be appreciated from the back.
of the following courses: Hyperacusis; Due to paralysis of stapedius muscle,
a. It may be discharged into the external ear movements of stapes are dampened; so sounds
following rupture of the tympanic membrane. get distorted and get too high in volume. This is
b.It may erode the roof and spread upwards, called hyperacusis.
causing meningitis and brain abscess.
c. It may erode the floor and spread downwards,
causing thrombosis of the sigmoid sinus and Aditus to
the internal jugular vein (Fig. 18.16). antrum
d.It may spread backwards, causing mastoid

abscess (Fig. 18.3).
Chronic otitis media and mastoid abscess are
Posterior
responsible for persistent discharge of pus
through the ear. Otitis media is mote common in
children than in adults.
Inflammation of the auditory tube (eustachian
Thrombosis
catarrh) is often secondary to an attack of common of sigmoid
cold. This causes paininthe earwhichis aggravated sinus and
by lwallowing, due to blockage of the tube. Pain is internal
jugular vein
relieved by installation of decongestant drops in
the nose which helps to open the ostium.
@tosclerosis; Sometimes bony fusion takes place Fig, 18.16: Otltis media causing thrombosis of the sigmoid
between the foot plate of the stapes and the sinus and the internal jugular vetn
.Y
o
o
z
!ttr
(E
E'
(E
o
I
c (a) (b)
.F
o Figs 18.17a and b: (a) Otosclerosis, and (b) treated by a prosthesis
o
a
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EAR
central axis known as the modiolus around which the

cochlear canal makes two and three quarter turns.
The modiolus is directed forwards and laterally. Its
apex points towards the anterosuperior part of the
Mastoid medial wall of the middle ear and the base towards the
process
fundus of the internal acoustic meatus.
A spiral ridge of the bone, the spiral lamina, projects
Facial nerve from the modiolus and partially divides the cochlear
canal into the scala vestibuli above, and the scala
tympani below. These relationships apply to the lowest
Stylomastold part or basal turn of the cochlea. The division between
Pharyngotympanic tube foramen the two passages is completed by the basilar membrane.
Anterior Posterior The scala vestibuli communicates with the scala
Fig. 18.18: Chances of injury to facial nerue during mastoid tympani at the apex of the cochlea by a small opening,
operation called the helicotrema.
stibule
This is the central part of the bony labyrinth. It lies
The internal ear, or labyrinth, lies in the petrous part of medial to the middle ear cavity. Its lateral wall opens
the temporal bone. It consists of the bony labyrinth into the middle ear at the fenestra vestibuli which is
within which there is a membranous labyrinth. The closed by the footplate of the stapes.
membranous labyrinth is filled with a fluid called Three semicircular canals open into its posterior wall.
endolymph. It is separated from the bony labyrinth by The medial wall is related to the internal acoustic
another fluid called the perilymph. meatus, and presents the spherical recess in front, and
the elliptical recess behind. The two recesses are
BONY TABYRINTH separated by a oestibular crest which splits inferiorly to
The bony labyrinth consists of three parts: enclose the cochlear recess (Fi9.18.19).
. Cochlea anteriorly. Just below the elliptical recess, there is the opening
o Vestibule, in the middle. of a diverticulum, the aqueduct of the vestibule which
o Semicircular canals posteriorly (Fig. 18.19). opens at a narrow fissure on the posterior aspect of the
petrous temporal bone, posterolateral to the internal
Cochleo acoustic meatus. It is plugged in life by the ductus
Thebony cochlea resembles the shell of a common snail. endolymphaticus and a vein; no perilymph escapes
It forms the anterior part of the labyrinth. It has a conical through it.
Anterior semicircular canal
Lateral semicircular canal
Spherical recess Posterior semicircular canal J

o
Scala vestibuli zo
t,c
Scala tympani (E
ttG
Opening of aqueduct
o
of cochlea I
Opening of aqueduct of vestibule
co
Cochlear recess O
Fig. 18.19: Scheme to show some features of the bony labyrinth (seen from the lateral side) ao
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HEAD AND NECK
Semicirculol Conols Like the bony labyrinth, the membranous labyrinth

There ar ree bony semicircular canals: (1) An anterior also consists of three main parts:
or superior, (2) posterior, and (3) lateral; each has two a. The spiral duct of the cochlea or organ of Corti,
ends. They lie posterosuperior to the vestibule, and are anteriorly.
set at right angles to each other. Each canal describes b. The utricle and saccule with maculae, the organs
two-thirds of a circle, and is dilated at one end to form of static balance, within the vestibule.
the ampulla. These three canals open into the vestibule c. The semicircular ducts with cristae the organs of
by fiae openings. kinetic balance, posteriorly (Fig. 18.21).
The anterior or superior semicircular canal lies in a
vertical plane at right angles to the long axis of the Anterior
petrous temporal bone. It is convex upwards. Its semicircular
duct
position is indicated by the arcuate eminence seen on
the anterior surface of the petrous temporal bone. Its Posterior
semicircular
ampulla is situated anterolaterally. Its posterior end a duct
unites with the upper end of the posterior canal to form
Lateral
the crus commune which opens into the medial wall of S
semicircular
the vestibule. duct
The posterior semicircular canal also lies in a vertical Endolymphatic Utriculosaccular
duct and sac
plane parallel to the long axis of the petrous temporal duct
bone. It is convex backwards. Its ampulla lies at its Fig. 18.21 : Parts of the membranous labyrinth (as seen from
lower end. The upper end joins the anterior canal to the lateral side)
form the crus cofiunune.
The lateral semicircular canal lies in the horizontal Ducl of the Cochleo oI lhe Scolo Medio
plane with its convexity directed posterolaterally. The The spiral duct occupies the middle part of the cochlear
ampulla lies anteriorly, close to the ampulla of the canalbetween the scala vestibuli and the scala tympani.
anterior canal. It is triangular in cross-section. The floor is formed by
Note that the lateral semicircular canals of the two the basilar membrane; the roof by the oestibular or
sides lie in the same plane. The anterior canal of one Reissner' s membr an e ; and the outer wall by the bony wall
side lies in the plane of the posterior canal of the other of the cochlea. The basilar membrane supports the
side (Figs 18.19 and 18.20). spiral organ of Corfl which is the end organ for hearing
(Fig.78.22). The organ of Corti is innervated by
MEMBRANOUS TABYRINTH peripheral processes of bip olar cells located in the sp ir al
ganglion. This ganglion is located in the spiral canal
It is in the form of a complicated, but continuous closed
present within the modiolus at the base of the spiral
cavity filled with endolymph. The epithelium of the
membranous labyrinth are specialized to form receptors lamina. The central processes of the ganglion cells form
for sound, i.e. organ of Corti; for static balance, the the cochlear nerve.
maculae; and for kinetic balance, the cristae.
Posteriorly, the duct of the cochlea is connected to
the saccule by a narrow ductus reunions.
The sound waves reaching the endolymph through
the vestibular membrane make appropriate parts of the
basilar membrane vibrate, so that different parts of the
organ of Corti are stimulated by different frequencies
of sound. The loudness of the sound depends on the
amplitude of vibration.
t(
o Soccule ond Utlicle
o
z The sacculelrres in the anteroinferior part of the vestibule,
t,c
G
Crus commune and is connected to the basal tum of the cochlear duct
!,(5 by the ductus reunions.
o (\ 7 T\te utricle is larger than the saccule and lies in the
I
posterosuperior part of the vestibule. It receives the end
c Posterior -o7
three semicircular ducts through fioe openings. The
o
o duct of the saccule unites with the duct of the utricle to
o form the ductus endolymphaticus. The ductus endo-
o Fig. 18.20: The semicircular canals
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EAR
Membrana tectoria Tunnel between

rods of Corti
Scala vestibuli Vestibular membrane
Osseous spiral lamina

Cochlear duct
Stria vascularis
Spiral ganglion with Spir'al ligament

bipolar neurons
Supporting cells
Basilar membrane
Cochlear nerve Outer hair cells
Scala tympani
lnner hair cells

Fig. 18,22: Schematic section through one turn of the cochlea
lymphaticus ends in a dilatation, the saccus DEVETOPMENT

endoll,rnphaticus. The ductus and saccus occupy the I External auditory meatas: Dorsal part of 1st ectodermal
aqueduct of the vestibule.
cleft.
The medial walls of the saccule and utricle are 2 Auricle: Tubercles appearing on 1st and 2nd branchial
thickened to formamacula in each chamber. The maculae arches around the opening of external auditory
are end organs that give information about the position meafus.
of the head. They are static balance receptors. They are 3 Middle ear cnaity and auditory ttfue: Ttbotympanic
supplied by peripheral processes of neurons in the recess (see Tables ,{1.6 and Al.1 tnAppendix 1).
vestibular ganglion (see Fig. 24.45). 4 Ossicles
Saccule gets stimulated by linear motions, e.g. going a. lleus and incus: From 1st arch cartilage.
in "lift". Utricle gets stimulated by horizontal linear b. Stapes: From 2nd arch cartilage (see Table A1.5 in
motion, e.g. going in car. Appendix 1).
5 Muscles
Semicirculor Ducls a. Tensor tympani: From lst pharyngeal arch mesoderm.
The three semicircular ducts lie within the corresponding b. Stapedius; From 2nd pharyngeal arch mesoderm.
bony canals. Each duct has an ampulla corresponding 6 Membranous labyrinth from ectodermal vesicle on
to that of the bony canal. Lr each ampulla, there is an each side of hind brain vesicle. Organ of Corti-
end organ called the ampullary crest or crista or cupola ectodermal.
(see Fig. 24.49). Cristae respond to pressure changes in
the endolymph caused by movements of the head. Vestibulocochleor Nerve
This nerve is described in Chapter 24.
BLOOD SUPPTY OF LABYRINTH
The arterial supply is derived mainly from the !
o
labyrinthine branch of the basilar artery which
accompanies the vestibulocochlear nerve; and partly
zo
t,tr
from the stylomastoid branch of the posterior auricular (E
deafness.
artery. o Acoustic nenroma is a fumour of Schwann cells of t,G
The labyrinthine vein drains into the superior MII nerve. If neuroma extends jnto intemal auditory
o
J-
petrosal sinus or the transverse sinus. Other inconstant
meatus, VII nerve will get pressed. There will be
veins emerge at different points and open separately c
VIII nerve paralysis and VII nerve paralysis as well. o
into the superior and inferior petrosal sinuses and the r o
Reasons of ear ache are depicted in Flow chart 18.1. o
internal jugular vein. a
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HEAD AND NECK
Flow chart 18.1: Reasons of ear ache
Dental causes (imp.acted Lesions of anterior

wisdom tooth, caries, 2/3rd of tongue
gingivitis, tooth abscess)
Tonsillar lesi
(inflammations, a
malignancy
Mnemonics There are 2 synovial joints between these three

bony ossicles, which are fully developed at birth.
Ear: Bones of middle ear MlSs a Ear is an e ering marvel
M-Malleus
a One may s become deaf to soft sounds, if one
l-lncus is continuously exposed to lot of loud sounds.
Ss-Stapes
A young boy has only deformity of the auricle/

o Tympanic membrane develops from ectoderm, pinna. No treatment is done and he is fine in studies,
games, etc.
mesoderm and endoderm
o Outer aspect of tympanic membrane is supplied
. What are the uses of the auricle
o Name its nerve supply
by part of V and X nerves
. Syringing the ear may cause slowing of the heart
rate and feeling of nausea.
. Malleus and incus develop from Lst pharyngeal r
arcir, while stapedius develops from second Lobule, the iowest part of auricle is used for
pharyngeal arch. wearing ear rings of different shape, size, colour
. and qual
Tensor tympani develops from 1st arch and is
,supplied by Y3, while stapedius develops from ' It is used for support
2nd arch and is supplied by VII nerve
million of years ago
. Suprameatal triangle (Macewen's triangle)
l. dermarcates the position of mastoid antrum at a
o depth of 12-1.3 mminadult.
zo . Eustachian tube equalizes the pressure on both
tttr for disobedience.
(E sides of the tympanic membrane. This tube Nerve Supply: dial surface in its upper 2/fud
E connects the nasopha{mx to the anterior wall of
G
o middle ear. 7/3rd part by great auricuiar. Lateral su ce in its
. Malleus, incus and stapes are bone within bone, as
C these 3 bony'ossicles lie within the petrous nerve and in its lower 1./3rd part by great icular
.o
o temporal bone. again.
o
a
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t. Tegmen tympani forms the roof of the following 4. Which of the following nerve supplies the outer
except: aspect of the tympanic membrane?
a. Mastoid antrum a. Auricular branch of vagus
b. Tympanic cavity b. Greater occipital
c. Canal for tensor tympani c. Lesser occipital
d. Internal auditory meatus d. Anterior ethmoidal
2. \Mhich nerve supplies stapedius muscle:
5. Which of the following nerve supplies middle ear
cavity?
a. Oculomotor b. Trochlear a. Facial b. Trigeminal
c. Trigeminal d. Facial c. Glossopharyngeal d. Vagus
3. By how many openings do the semicircular canals 5. Derivatives of all the germ layers; ectoderm,
open in the vestibule: mesoderm and endoderm are present in:
a.3 b.5 a. Heart b. Tympanic membrane
c.4 d.2 c. Cornea d. Urachus
NOISE POLLUTION
"Noise pollution leads to mind body suffering
Plug the ears, decrease volume, seek policing l(
o
Sweet soft "lecture" indLtces happy sleeping
zo
tttr
Loud prolonged noise causes auditory crippling G
!,(E
One should not even mind job changing o
But do not, at any cost lose your hearing
c
Lest one's very dear cell phone o
One would not be hearing" o
o
a
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II
INTRODUCTION lncise only the sclera at the equator and then cut
Sense of sight perceived through retina of the eyeball through it all around and carefully strip it off from the
is one of the five special senses. Its importance is choroid. Anteriorly, the ciliary muscles are attached to
obvious in the varied ways of natural protection. Bony the sclera, offering some resistance. As the sclera is
orbit, projecting nose and various coats protect the steadily separated, the aqueous humour will escape
precious retina. Each and every component of its three from the anterior chamber of the eye. On dividing the
coats is assisting the retina to focus the light properly. optic nerve fibres, the posterior part of sclera can be
Lots of advances have been made in correcting the removed.
defects of the eye. Eyes can be donated at the time of
death, and a "will" can be prepared accordingly. SCTERA
About 75% of afferents reach the brain through the
The sclera (skleros=hard) is opaque and forms the
eyes. Adequate rest to eye muscles is important. Could
posterior five-sixths of the eyeball. It is composed of
a good place for rest be the "classroom" where dense fibrous tissue which is firm and maintains the
palpebral part of orbicularis oculi closes the eyes gently?
shape of the eyeball. It is thickest behind, near the
The eyeball is the organ of sight. The camera closely
entrance of the optic nerve, and thinnest about 5 mm
resembles the eyeball in its structure. It is almost
behind the sclerocorneal junction where the recti
spherical in shape and has a diameter of about 2.5 cm.
muscles are inserted. However, it is weakest
It is made up of three concentric coats. The outer or at the entrance of the optic nerve. Here the sclera shows
fibrous coat cornprises the sclera and cornea. The middle numerous perforations f or passage of f ibres
or aascular coat also called the uveal tract consists of
of the optic nerve. Because of its sieve-like appearance,
choroid, the ciliary body and the iris. The inner or
this region is called the lamina cribrosa (crlb=sieve).
neraous cont is the retina (Fig. 19.1).
Light entering the eyeball passes through several The outer surface of the sclera is white and smooth, it
refracting media. From before backwards these are the is covered by Tenon's capsule (seeFig.7.3). Its anterior
cornea, the aqueous humour, the lens and the vitreous part is covered by conjunctiva through which it can be
body. seen as the white of the eye. The inner surface is brown
and grooved for the ciliary nerves and vessels. It is
separated from the choroid by the perichoroidal space
which contains a delicate cellular tissue, termed the
suprachoroidal lamina or lamina fusca of the sclera.
DISSECTION
The sclera is continuous anteriorly with the cornea
Use the fresh eyeball of the goats for this dissection. at the s cler o c orne al j unct ion o r limbus (Fig. 1 9. 1 ). The deep
Clean the eyeball by removing all the tissues from its part of the limbus contains a circular canal, known as
surface. Cut through the fascial sheath around the the sinus aenosus sclerne or the canal of Schlemm. The
margin of the cornea. Clean and identify the nerve with aqueous humour drains into the anterior scleral or
posterior ciliary arteries and ciliary nerves close to the ciliary veins through this sinus.
posterior pole of the eyeball. ldentify venae vorticosae
The sclera is fused posteriorly with the dural sheath
piercing the sclera just behind the equator.
of the optic nerae. It provides insertion to the extrinsic
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EYEBALL
Ora serrata
Conjunctiva Sclera
Choroid
Ciliary muscle
Sinus venosus sclerae Retina
Vitreous body
Anterior chamber
Optic disc
Cornea
Lens
Optic nerve
lris
Posterior chamber
Suspensory ligament Dura mater
Ciliary processes
Fig.19.1: Sagittal section through the eyeball
muscles of the eyeball: The recti in front of the equator,

and the oblique muscles behind the equator.
The sclera is pierced by a number of structures: DISSECTION
a. The optic nerae pierces it a little inferomedial to
ldentify the cornea. Make an incision around the
the posterior pole of the eyeball.
corneoscleral junction and remove the cornea so that
b. The ciliary neraes and arteries pierce it around the the iris is exposed for examination. ldentify the middle
entrance of the optic nerve. coat comprising choroid, ciliary body and iris deep to
c. The anterior ciliary arteries derived from muscular the sclera. Lateral to iris is the ciliary body with ciliary
arteries to the recti pierce it near the limbus. muscles and ciliary processes.
d. Four aenae aorticosae or the choroid veins pass out Strip off the iris, ciliary processes, anterior part of
through the sclera just behind the equator choroid. Remove the lens and put it in water. As the
(Figs 19.2 and 19.3). lens is removed, the vitreous body also escapes. Only
The sclera is almost avascular. However, the loose the posterior part of choroid and subjacent retina is left.
connective tissue between the conjunctiva and sclera
called as the episclera is vascular. Feolures
The cornea is transparent. It replaces the sclera over
the anterior one-sixth of the eyeball. Its junction with
Lateral
rectus
the sclera is called the sclerocorneal junction or limbus.
Optic The cornea is more convex than the sclera, but the
lnferior
nerve
oblique
curvature diminishes with age. It is separated from the
iris by a space called the anterior chamber of the eye.
Superior
oblique
The cornea is avascular and is nourished by lymph
which circulates in the numerous corneal spaces and l<
o
by the lacrimal fluid.
It is supplied by branches of the ophthalmic nerve zo
Venae
Venae tc
vorticosae
vorticosae
(through the ciliary ganglion) and the short ciliary o
nerves. Pain is the only sensation aroused from the !t(E
cornea. o
Short I
posterior
ciliary Histology C
o
.F
arteries Structurally, the cornea consists of these layers, from ()
Fig. 19.2: Structures piercing the posterior aspect of the eyeball before backwards: ao
J
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T
HEAD AND NECK
Cornea
Suspensory ligament Ciliary processes
of lens
Ciliary body Sinus venosus sclerae
Scleral spur
Anterior ciliary artery
Ciliary muscles
Visual axis
Orbital axis
Fovea centralis in centre of macula lutea
Long posterior ciliary artery
Fig. 19.3: Structures piercing the eyeball seen in a sagittal section
L Corneal epithelium (stratified squamous non-

keratinized type).
2 Bowman's tnembrane or anterior elastic lamina.
3 The substantia propria.
4 Descemet's membrane or posterior elastic lamina.
5 Simple squamous mesothelium.
e Cornea can be grafted from one person to the

other, as it is avascular. d
r Injury to cotnea may cause opacities. These
opacities may interfere with vision.
. Eye is a very sensitive organ and even a dust
particle gives rise to pain.
o Bulbar conjunctiva is vascular. Inflammation of ected
the conjunctiva leads to conjunctivitis. The look Fig. 19.4: Optical defects
of palpebral conjunctiva is used to judge haemo-
globin level.
. The anteroposterior diameter of the eyeball and
Its outer surface is separated from the sclera by the
shape and curvature of the cornea determine the
suprachoroidal lamina which is traversed by the ciliary
vessels and nerves. Its attachment to the sclera is loose,
focal point. Changes in these result in myopia or
short-sightedness, hypermetropia or long- so that it can be easily stripped. The inner sutface is
sightedness (Fig. 19.a).
firmly united to the retina.
L Structurally, it consists of:
o a. Suprachoroid lamina.
o
z b. Vascular lamina.
t,tr c. The choriocapillary lamina.
G
t,(E CHOROID d. The inner basnl lamina or membrane of Bruch.
o Choroid is a thin pigmented layer which separates the
posterior part of the sclera from the retina. Anteriorly, CITIARY BODY
C
.9
it ends at the ora serrata by merging with the ciliary Ciliary body is a thickened part of the uveal tract lying
o body. Posteriorly, it is perforated by the optic nerve to just posterior to the corneal limbus. It is continuous
ao which it is firmly attached. anteriorly with the iris and posteriorly with the choroid.
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EYEBALL
It suspends the lens and helps it in accommodation for lamina. The radial fibres are obliquely placed and get
near vision. continuous with the circular fibres.
1 The ciliary body is triangular in cross-section. It is The circular fibres lie within the anterior part of the
thick in front and thin behind (Fig. 19.5). The scleral ciliary body and are nearest to the lens. The
surface of this body contains the ciliary muscle. The contraction of all the parts relaxes the suspensory
posterior part of the vitreous surface is smooth and ligament so that the lens becomes more convex
black (pars plana). The anterior part is ridged (Fig. 19.8). All parts of the muscle are supplied by
anteriorly (pars plicata) to form about 70 ciliary parasympathetic nerves. The pathway involves the
processes. The central ends of the processes are free Edinger-Westphal nucleus, oculomotor nerve and
and rounded. the ciliary ganglion (see Fig. 24.1,0).
2 Clliary zonule is thickened vitreous membrane fitted
to the posterior surfaces of ciliary processes. The IRIS
posterior layer lines hyaloid fossa and anterior thick 1 This is the anterior part of the uveal tract. It forms a
layer form the suspensory ligament of lens (Fig. 19.6). circular curtain with an opening in the centre, called
3 The ciliary muscle (Fig. 19.7) is a ring of unstriped thepupil. By adjusting the size of the pupil, it controls
muscle which are longitudinal or meridional, radial the amount of light entering the eye, and thus
and circular. The longitudinal or meridionalfibres arise behaves like an adjustable diaphragm (Fig. i9.3).
from a projection of sclera or scleral spur near the 2 It is placed vertically between the comea and the lens,
limbus. They radiate backwards to the suprachoroidal thus divides the anterior segment of the eye into
Cornea I ris
Constrictor pupillae
Angle of anterior chamber
Dilator pupillae
Canal of Schlemm
Ciliary muscle Lens

Ciliary body
Posterior chamber
Suspensory ligament of lens
Ciliary processes
Fig. 19.5: Components of ciliary body and iris
Ciliary zonule anterior and posterior chambers, both containing

aqueous humour.Its peripheral margin is attached to
Sclera the middle of the anterior surface of the ciliary body
and is separated from the cornea by the iridocorneal
Choroid
angle or angle of the anterior chamber. Tiire central
free margin forming the boundary of the pupil rests
against the lens (Fig. 19.1).
Retina 3 The anterior surface of the iris is covered by a single .l.
o
Ora serrrata
layer of mesothelium, and the posterior surface by a
double layer of deeply pigmented cells which are
zo
tttr
continuous with those of the ciliary body (Fig. 19.7). (E
Ciliary process The main bulk of the iris is formed by stroma made tt(E
Suspensory
up of blood vessels and loose connective tissue in o
ligament which there are pigment cells. The long posterior and
the anterior ciliary arteries join to form t}:.e major C
o
Fig. 19.6: Anterior part of the inner aspect of the eyeball seen arterial circle at the periphery of the iris. From this ()
after vitreous has been removed circle vessels converge towards the free margin of oo
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HEAD AND NECK
lris
Sphincter pupillae
Double layer of
Dilator pupillae pigmented epithelium
Ciliary body
Ciliary muscle
Sclera
Fig.19.7: Epithelium lining the iris
the iris and join together to form the minor arterial Ciliary muscle
circle of the iris (seeFig.13.10). Suspensory ligament
The colour of the iris is determined by the number
of pigment cells in its connective tissue. If the Flattened lens
pigment cells are absent, the iris is blue in colour
due to the diffusion of light in front of the black
Far vision
posterior surface.
4 The iris contains a well-developed ring of muscle
called the sphincter pupillae which lies near the margin
of the pupil. Its nerve supply (parasympathetic) is
similar to that of the ciliary muscle.The dilator pupillae
is an ill-defined sheet of radial muscle fibres placed
near the posterior surface of the iris. It is supplied
by sympathetic nerves (Fi9.19.7).
While looking at infinite far the light rays run Figs 19.8a and b: (a) Relaxed ciliary muscles with flattened
parallel; ciliary muscle is relaxed, suspensory lens, and (b) contracted ciliary muscles with round lens
ligament is tense and lens is flat (Fig. 19.8a).
\tVhile reading a book, the ciliary muscles contract
and suspensory ligament is relaxed making the
lens more convex (Fig. 19.8b).
Human vision is coloured, binocular and three-
dimensional. Normally, right and left eyes are
focused on one object (Fig. 19.9a). In squinting,
fixing eye (F) focuses on the object, but the
squinting eye (S) is "turned inwards" resulting in ( (a)
--\
vo a convergent squint (Fig. 19.9b). * (-/
zo
tttr
(E
!,
G
o 1 This is the thin, delicate inner layer of the eyeball. It is
continuous posteriorly with the optic nerve. The outer (b)
c surface of the retina (formed by pigment cells) is
.o
(.) attached to the choroid, while the inner surface is in Figs 19.9a and: (a) Normal eyes, and (b) in squinting eyes
o
U) contact with the hyaloid membrane (of the vitreous).
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Opposite the entrance of the optic nerve
(inferomedial to the posterior pole) there is a circular
Superior
area known as the optic disc.It is 1.5 mm in diameter. temporal
The retina diminishes in thickness from behind Macula lutea and
Superior
nasal
forwards and is divided into optic, ciliary and iridial fovea centralis
parts. The optic part of the retina contains nervous Optic
disc
tissue and is sensitive to light. It extends from the Macular artery
optic disc to the posterior end of the ciliary body. lnferior
The anterior margin of the optic part of the retina nasal
lnferior temporal
forms a wavy line called the ora serrata (Fig. 19.1).
Beyond the ora serrata, the retina is continued
Fig. 19.10: Distribution of central artery of the retina
forwards as a thiry non-nervous insensitive layer that
covers the ciliary body and iris, forming the ciliary
and iridial parts of the retina. These parts are made up
of two layers of epithelial cells (Fig. 19.7). Retinal detachment occurs between outer single
The depressed area of the optic disc is called the pigmented layer and inner nine nervous layers.
physiological cup (Fig. 19.3). It contains no rods or Actually, it is an inter-retinal detachment. Silicone
cones and is therefore insensitive to light, i.e. it is sponge is put over the detached retina, which is kept
the physiological blind spot. At the posterior pole of in position by a "band" (Figs 19.11a and b).
the eye 3 mm lateral to the optic disc, there is another
depression of similar size, called the macula lutea.It
is avascular and yellow in colour. The centre of the
macula is further depressed to form the/oztea centralis.
This is the thinnest part of the retina. It contains cones
only, and is the site of maximum acuity of vision
(Fig. 1e.3).
The rods and cones are the light receptors of the eye.
The rods contain a pigment called aisual purple. They
can respond to dim light (scotopic aision). The
periphery of the retina contains only rods, but the
fovea has none at all. The cones respond only to bright
light (photopic zsision) and are sensitive to colour. The
fovea centralis has only cones. Their number Figs 19.11a and b: (a) Detached retina, and (b)banding of
diminishes towards the periphery of the retina. the retina
The retina is composed of ten layers (Fig.79.17):
a. The outer pigmented layer.
b. Layer of rods and cones.
c. External limiting membrane.
d. Outer nuclear layer. This is a clear fluid which fills the space between
e. Outer plexiform layer. the cornea in front and the lens behind the anterior
f. Inner nuclear layer (bipolar cells) segment. This space is divided by the iris into anterior
and posterior chambers which freely communicate with
g. Inner plexiform layer.
each other through the pupil.
h. Ganglion cell layer. The aqueous humour is secreted into the posterior
i. Nerve fibre layer. chamber from the capillaries in the ciliary processes. It J
j. The internal limiting membrane. o
The retina is supplied by the central artery. This is an
passes into the anterior chamber through the pupil.
From the anterior chamber, it is drained into the ante-
zo
tttr
end artery. In the optic disc, it divides into an upper rior ciliary veins through the spaces of the iridocorneal G
and a lower branch, each giving off nasal and angle or angle of anterior chamber (located between !,(E
temporal branches. The artery supplies the deeper the fibres of the ligamentum pectinatum) and the canal o
layers of the retina up to the bipolar cells. The rods of Schlemm (Fig. 19.5).
and cones are supplied by diffusion from the Interference with the drainage of the aqueous c
.9
capillaries of the choroid. The retinal veins run with humour into the canal of Schlemm results in an increase o
the arteries (seeFigs 13.10, 13.11 and 19.10). of intraocular pressure (glaucoma). This produces ao
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HEAD AND NECK
cupping of the optic disc and pressure atrophy of the A dioptre is the inverse of the focal length in meters. A
retina causing blindness. lens having a focal length of half meter has a power of
The intraocular pressure is due chiefly to the aqueous two dioptres.
humour which maintains the constancy of the optical The posterior surface of the lens is more convex than
dimensions of the eyeball. The aqueous is rich in the anterior. The anterior surface is kept flattened by
ascorbic acid, glucose and amino acids, and nourishes the tension of the suspensory ligament. When the
the avascular tissues of the cornea and lens. ligament is relaxed by contraction of the ciliary muscle,
the anterior surface becomes more convex due to
elasticity of the lens substance.
Over production of aqueous humour or lack of its The lens is enclosed in a transparent, structureless
drainage or combination of both raise the intraocular elastic capsule which is thickest anteriorly near the
pressure. The condition is called glaucoma. It must circumference. Deep to capsule, the anterior surface of
be treated urgently. the lens is covered by a capsular epithelium. At the centre
of the anterior surface, the epithelium is made up of a
single layer of cubical cells, but at the periphery, the cells
elongate to produce tLre fibres of the lens. The fibres are
concentrically arranged to form the lens substance. The
DISSECTION centre (nucleus) of the lens is firm (and consists of the
oldest fibres), whereas the periphery (cortex) is soft and
Give an incision in the anterior surface of lens and with
is made up of more recently formed fibres (Fig. 19.12).
a little pressure of fingers and thumb press the body of
The suspensory ligament of the lens (or the zonule of
lens outside from the capsule.
Zinn) retains the lens in position and its tension keeps
the anterior surface of the lens flattened. The ligament
Feotures
is made up of a series of fibres which are attached
The lens is a transparent biconvex structure which is peripherally to the ciliary processes, to the furrows
placed between the anterior and posterior segments of between the ciliary processes, and to the ora serrata.
the eye. It is circular in outline and has a diameter of Centrally, the fibres are attached to the lens, mostly in
1 cm. The central points of the anterior and posterior front, and a few behind the equator (Fig. 19.5).
surfaces are called the anterior and posterior poles
(Fig.19.12). The line connecting the poles constitutes
the axis of the lens, while the marginal circumference Lens becomes opaque with increasing age
is termed the equator. The chief advantage of the lens is (cataract). Since the opacities cause difficulty in
that it can vary its dioptric power. It contributes about vision, lens has to be replaced.
15 dioptres to the total of 58 dioptric power of the eye. The central artery of retina is an end-artery.
Blockage of th
Left third nerv
Anterior lens capsule dilated pupil.
and outwards (Fig. 19.13).
Epithelial cells
Horner's syndrome results in partial ptosis and
meiosis (Fig. 19.1a).
It brainstem death, both the pupils are dilated and
Lens fibres
fixed (Fig. 19.15).
Eye sees everyone. One can see the interior of the
eye by ophthalmoscope. Through the ophthal-
moscope, one can see the small vessels in the retina
L Anterior pole and judge the changes in diabetes and hyper-
o
o tension (Figs 19.16a and b). In addition/ one can
z also examine the optic disc for evidence of papillo-
!tc
(E edema, caused by raised intracranial pressure.
!tG Nucleus of lens flbre
o
c
o
o It is a colourless, jelly-like transparent mass which fills
o
a Fig.19.12: The lens the posterior segment (posterior 4/5th) of the eyeball.
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EYEBALL
Fig. 19.13: Left third nerve paralysis
Fig. 19.14: Horner's syndrome in left eye

Optic disc Macula
lutea
fovea
centralis
(b)
Figs 19.16a and b: (a) Procedure for ophthalmoscopy, and
Fig. 19.15: Brain stem death (b) retina as seen by ophthalmoscope
It is enclosed in a delicate homogeneo:us hyaloid DEVETOPMENT

membrane. Behind it is attached to the optic disc, and in Optic vesicle forms optic cup. It is an outpouching from
front to the ora serrata; in between it is free and lies in the forebrain vesicle.
contact with the retina. The anterior surface of the Lens from lens placode (ectodermal)
vitreous body is indented by the lens and ciliary Retina-pigment layer frorr.tiire outer layer of optic cup;
processes (Fig. 19.1). nervous layers from the inner layer of optic cup.
Pigment cell layer
Layer of rods and cones
Outer limiting membrane

Outer nuclear layer ta
o
Outer plexiform layer . Pigment cell layer zo
. Six more layers of retina
ttr
lnner nuclear layer
. Optic nerve fibres and two membranes
(E
E
(E
lnner plexiform layer o
T
Ganglion cell layer
Optic nerve fibres c
o
lnner limiting membrane F
o
o
Fig. 19.17: Histological layers of the retina a
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HEAD AND NECK
Choroid, scler a-mesoderm

Cornea-sarface ectoderm forms the epithelium, other
layers deaelop from mesoderm.
A patient was diagnosed as a case of "retinal
detachment"
. Is retinal detachment, detachment of retina from
the choroid?
a Comea is used for grafting or transplantation
o Name the layers of retina with its blood supply?
a Sclera is pierced by number of structures including
the optic nerve
Choroid contains big capillaries. These nourish the
layer of rods and cones of retina by diffusion.
Ciliary body contains ciliary muscles supplied by
short ciliary nerves. These contract to relax the
suspensory ligament of lens, so that the anterior supply of the outer five layers is fr choroidal
surface of lens canbecome more convex for accom-
modation.
Iris contains a weak dilator pupillae at the
periphery, supplied by synnpathetic fibres. It also 1. Outer pigmented layer
contains a strong constrictor or sphincter pupillae 2. Layer ofrods and cones
near the pupillary margin. This is supplied by
parasympathetic fibres relayed through ciliary 4. O rnuclearlayer
ganglion. 5. Outer plexiform layer
a Central artery of retina is an "end arfery" 5. Bipolar cell layer
a Through dilated pupil one can see the state of
blood vessels of the retina.
8. Gangl c cell layer
MULTIPLE CHOICE OUESIIONS

't. Which of the following muscles does not develop c. Radial fibres of ciliaris muscle
from mesoderm? d. Circular fibres of ciliaris muscle
a. Muscles of heart b. Muscles of iris 4. Retina consists of following number of layers:
c. Deltoid d. Superior rectus a. Eight layers
, Which of the following nerves supplies the cornea? b. Ten layers
a. Supraorbital b. Nasociliary c. Nine layers
c. Lacrimal d. Infraorbital d. Eleven layers
J. Parasympathetic fibres supply all the following 5. One of the following symptoms is not seen in
muscles except: Horner's syndrome:
a. Constrictor pupillae a. Partial ptosis b. Miosis
b. Dilator pupillae c. Anhydrosis d. Exophthalmos
J
o
zo 1. b 2.b 3:b 4rb 5,,d
!ttr
6
t(E
o
C
.o
o
q)
a
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o
-B, Grohom
INTRODUCI!ON the junction of the medial one-third with the lateral

The bony and soft tissue landmarks on the head, face two-thirds of the supraorbital margin (except in those
and neck help in surface marking of various structures. cases in which the notch is converted into a foramen).
These landmarks are of immense value to the clinician A vertical line drawn from the supraorbital notch to
for locating the part to be examined or to be operated. the base of the mandible, passing midway between
the lower two premolar teeth, crosses the infraorbital
foramen 5 mm below the infraorbital margin, and
the mental foramen midway between the upper and
lower borders of the mandible (Fig. 20.1).
TANDMARKS ON IHE FACE 2 The superciliary arch is a curved bony ridge situated
Some important named features to be identified on the immediately above the medial part of each
living face have been described in Chapter 2. Other supraorbital margin. The glabella is the median
landmarks are as follows. elevation connecting the two superciliary arches and
1 The supraorbital margin lies beneath the upper margin corresponds to the elevation between the two
of the eyebrow. T}",:re supraorbital notch is palpable at eyebrows.
Nasal bone Nasolacrimal canal
Supraorbital notch foramen Frontal bone
Supraorbital margin Coronal suture
Parietal bone
Lesser wing of sphenoid bone
Squampus temporal bone
Greater wing of sphenoid bone Optic canal / foramen

(temporal and orbital surface)
I nferior orbital fissure
Zygomatic foramen
Zygomaticomaxillary suture
Anterior nasal spine
lnferior nasal concha lntermaxillary suture
Angle of mandible
Nasal septum
Mental foramen
Mandible
Fig.20.1: Foramina in norma frontalis

i(
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I
HEAD AND NECK
3 The nasion is the point where the internasal and is formed anteriorly by the temporal process of the
frontonasal sutures meet. It lies a little above the floor zygomatic bone, and posteriorly by the zygornatic
of the depression at the root of the nose, below the process (zygoma) of the temporal bone. The
glabella (Fig. 20.1). preauricular point lies on the posterior root of the
zygorna immediately in front of the upper part of
TANDMARKS ON THE TATERAL SIDE OF THE HEAD the tragus (Fig.20.3).
The external ear or pinna is a prominent feature on the The head of the mandible lies in front of the tragus.
lateral aspect of the head. The named features on the It is felt best during movements of the lower jaw.
pinna are shown in Fig.20.2. Other landmarks on the The coronoid process of the mandible can be felt below
lateral side of the head are as follows. the lowest part of the zygomatic bone when the
I The zygomaticbone 6orms the prominence of the cheek
mouth is opened. The process can be traced
at the inferolateral corner of the orbit. The zygomatic downwards into the anterior border of the ramus oI
archbidges the gap between the eye and the ear. It the mandible. The posterior border of the ramus,
though masked by parotid gland, can be felt through
the skin. The outer surface of the ramus is covered
by the masseter which can be felt when the teeth are
Scaphoid fossa Helix clenched. The lower border of the mandible can be
Auricular tubercle traced posteriorly into the angle of the mandible
Triangular fossa (Darwin's tubercle) (Fig.20.3).
The parietal eminence is the most prominent part of
Cymba concha
the parietal bone, situated far above and a little
Antihelix behind the auricle.
Tragus The mastoid process is a large bony prominence
Concha situated behind the lower part of the auricle. The
lntertragic notch
suprnmastoid crest, about 2.5 cm long, begins
Preauricular immediately above the external acoustic meatus and
Antitragus
lymph nodes soon curves upwards and backwards. The crest is
continuous anteriorly with the posterior root of the
Lobule zy1orrra, and posterosuperiorly with the temporal
Fig.2O.2: Named features on the pinna line (Fig.20.3).
Superior temporal line
Coronal suture
Frontal bone
Supramastoid crest
lnferior temporal line
Base of mastoid Process Pterion
Lambdoid suture
Nasal bone
Asterion Zygomatic bone

.!<
()
zo Zygomatic arch
Maxilla
!,
tr
o Apex of mastoid Process
!t(E
o External acoustic meatus
Styloid process
C
.9 Ramus of mandible
O
o
a Fig. 20.3: Parts of mandible seen in norma lateralis
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SUBFACE MARKING AND RADIOLOGICAL ANATOMY
The temporal line fiorms the upper boundary of the

temporal fossa which is filled up by the temporalis
muscle. The upper margin of the contracting
temporalis helps in defining this line which begins Anterior branch
at the zygomatic process of the frontal bone, arches
posterosuperiorly across the coronal suture, passes Pterion
a little below the parietal eminence, and turns
downwards to become continuous with the Facial artery with
supramastoid crest. The area of the temporal fossa facial vein
on the side of the head, above the zygomatic arch, is
Middle
called the temple or temporal region. meningeal artery
T\e pterion is the area in the temporal fossa where
fourbones (frontal, parietal, temporal and sphenoid)
adjoin each other across an H-shaped suture. The Posterior branch
centre of the pterion is marked by a point 4 cm above
the midpoint of the zygomatic arch, falling 3.5 cm Fig. 20"4: Middle meningeal artery (a to e) and facial artery
behind the frontozygomatic suture. Deep to the with facial vein
pterion lie the anterior branch of the middle
meningeal artery, the middle meningeal vein, and protuberance is a bony projection felt in the median
deeper still the stem of the lateral sulcus of the plane on the back of the head at the upper end of the
cerebral hemisphere (at the Syksian point) dividing nuchal furrow. Thesuperior nuchallines are indistinct
into three rami. The pterion is a common site for curved ridges which extend from the protuberance
trephining (making a hole in the skull) during to the mastoid processes. The back of the head is
operation (Fig.20. ). Surface marking of middle called the occiput. The most prominent median point
meningeal artery is given later. situated on the external occipital protuberance is
The junction of the back of the head with the neck is known as the inion. However, the posterior
indicated by the external occipital protuberance and most point on the occiput lies a little above the
the superior nuchal lines. The external occipital protuberance (Fig. 20.5).
Parietal bone
Sagittal suture
Lambda
Lambdoid suture
Occipital bone
Squamous part of
temporal bone
ta
o
Temporal bone o
z
Superior nuchal line ttr
(E
Mastoid foramen !,
G
lnferior nuchal line o
Mastoid process I
o
.F
External occipital protuberance ()
Fig. 20.5: Structures felt in norma occipitalis oo
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HEAD AND NECK
TANDMARKS ON IHE SIDE OF IHE NECK

1 The sternocleidomastoid muscle is seen prominently
when the face is turned to the opposite side. The
ridge raised by the muscle extends from the sternum Greater
to the mastoid process (Fig.20.6). occipital nerve
T}ne external jugular aein crosses the sternocleido-
mastoid obliquely, running downwards and Lesser occipital
backwards from near the auricle to the clavicle. It is nerve
External
better seen in old age (Fi9.20.7). jugular vein Spinal root of
The greater supraclaoicular fossa lies above and behind Transverse accessory nerve
the middle one-third of the clavicle. It overlies the cutaneous nerve
cervical part of the brachial plexus and the third part
of the subclavian artery (Fig. 20.6).
Supraclavicular
The lesser supraclauicular fossa is a small depression
between the sternal and clavicular parts of the sterno-
Fig. 20.7: External jugular vein and cutaneous nerues
cleidomastoid. It overlies the internal jugular vein.
5 The mastoid process is a large bony projection behind
LANDMARKS ON IHE ANTERIOR ASPECT OF THE NECK
the auricle (concha) (Fi9.20.6).
6 The transoerse process of the atlas oertebra can be felt 1 The mandible forms the lower jaw. The lower border
on deep pressure midway between the angle of the of its horseshoe-shaped body is known as the base of
mandible and the mastoid process, immediately the mandible (Fig. 20.8), Anteriorly, this base forms
anteroinferior to the tip of the mastoid process. The the chin, and posteriorly it can be traced to the angle
fourth ceraical transaerse process is just palpable at the of the mandible. Numerous structures are attached to
level of the upper border of the thyroid cartilage; mandible.
and the sixth certsical transaerse process at the level of 2 The body of the U-shaped hyoid bone can be felt in
the cricoid cartilage. The anterior tubercle of the the median plane just below and behind the chin, at
transaerse process of the sixth ceroical aertebra is the the junction of the neck with the floor of the mouth.
largest of all such processes and is called the carotid On each side, the body of hyoid bone is continuous
tubercle (of Chassaignac). The common carotid artery posteriorly with the greater cornlta which is
can be best pressed against this tubercle, deep to the overlapped in its posterior part by the sterno-
anterior border of the sternocleidomastoid muscle. cleidomastoid muscle (Fig. 20.9).
7 Tlne anterior border of the trapezius muscle becomes 3 The thyroid cartilage of the larynx forms a sharp
prominent on elevation of the shoulder against protuberance in the median plane just below the
resistance (Fig. 20.6). hyoid bone. This protuberance is called the laryngeal
Depressor
Masseter labii inferioris
Mental foramen
Temporalis with mental nerve
Superior
and vessels
nuchal line
Mastoid Mentalis
process Buccinator
T Anterior border
o Base of mandible
o of trapezius
z Anterior triangle
lnferior belly
t,c Sternal head of of omohyoid
(E sternocleidomastoid
E Acromion process
G Manubrium
o Lesser Greater
Facial Platysma
supraclavicular supraclavicular vessels
Clavicular head of fossa
fossa
c sternocleidomastoid Depressor
o anguli oris
o Fig. 20"6: Sternocleidomastoid, trapezius and inferior belly of
o
a omohyoid Fig. 20.8: Attachments on the mandible
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SURFACE MARKING AND RADIOLOGICAL ANATOMY
Hyoid bone
Thyrohyoid
Thyroid cartilage

Omohyoid (superior belly)
Sternohyoid Sternothyroid
Tendon
Omohyoid (inferior belly)
Superior border of scapula
Fig. 20.9: Attachments on hyoid bone and thyroid cartilage
prominence or Adam's apple.It is more prominent in the isthmus of the tlryroid gland which lies against the
males than in females (Fig.20.10). second to fourth tracheal rings. The trachea is
The rounded arch of the cricoid cartilage lies below commonly palpated in the suprasternnl notch which
the thyroid cartilage at the upper end of the trachea lies between the tendinous heads of origin of the right
(Fig.20.10). and left sternocleidomastoid muscles. In certain
The trachea runs downwards and backwards from diseases, the trachea may shift to one side from the
the cricoid cartilage. It is identified by its carti- median plane. This indicates a shift in the media-
laginous rings. However, it is partially masked by stinum (Fig.20.10).
Mastoid process
Transverse process of atlas

Mandible
,!()
Floor of mouth
Hyoid bone zo
tt
Thyroid cartilage G
!,(E
Cricoid cartilage
o
Trachea
C
.o
o
Fig. 20.10: Landmarks on anterior aspect of neck ao
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HEAD AND NECK
OIHER IMPORTANT LANDMARKS

1 The frontozygomatic suture can be felt as a slight
depression in the upper part of the lateral orbital
margrn.
Condyle of
2 The mnrginal tubercle lies a short distance below the mandible
fuontozygomatic suture along the posterior border
of the frontal process of the zygomatic bone. Neck of
3 The Frnnkfurt's plane is represented by a horizontal mandible
line joining the infraorbital margin to the centre of lnternal carotid
the external acoustic meatus. Posteriorly, the line
passes through a point just below the external External carotid
occipital protuberance (see Fig. 1.1).
4 The jugal point is the anterior end of the upper border
of the zygomatic arch where it meets the frontal Hyoid bone
process of the zygomatic bone. Thyroid
5 The mandibular notch is represented by a curved line Subclavian cartilage
concave upwards, extending from the head of the
mandible to the anterior end of the zygomatic arch. Sternoclavicu lar
The notch is 1-2 cm deep (Fig. 20.8). joint
Fig. 20.11: Some arteries of head and neck
Exlernol Corotid Artery

The artery is marked by joining these two points.
ARIERIES . A point on the anterior border of the sterno-
Fociol Adery cleidomastoid muscle at the level of the upper border
It is marked on the face by joining these three points. of the thyroid cartilage.
. A point on the base of the mandible at the anterior . A second point on the posterior border of the neck
border of the masseter muscle. of the mandible.
. A second point 1.2 cm lateral to the angle of the mouth. The artery is slightly convex forwards in its lower
. A point at the medial angle of the eye. half and slightly concave forwards in its upper half
(Fig.20.11).
The artery is tortuous in its course and is more so
between the first two points (Fig.20.a).
Subclovion Artery
Common Corotid Artery It is marked by a broad curved line, convex upwards,
It is marked by a broad line along the anterior border by joining these two points.
of the sternocleidomastoid muscle by joining the . A point on the sternoclavicular joint.
following two points. . A second point at the middle of the lower border of
. A point on the sternoclavicular joint. the clavicle (Fig. 20.11).
. A second point on the anterior border of the The artery rises about 2 cm above the clavicle.
stemocleidomastoid muscle at the level of upper border The thoracic part of the left subclavian artery is
of the thyroid cartilage (Fig. 20. 11). marked by a broad vertical line along the left border of
The thoracic part of the left common carotid artery the manubrium a little to the left of the left common
is marked by a broad line extending from a point a little carotid artery.
.)a to the left of the centre of the manubrium to the left
o Middle Meningeol Ailery
o sternoclavicular joint.
z It is marked by joining these points.
tttr
(E
Inlernol Corotid Artery a. A point immediately above the middle of the
t(E It is marked by a broad line joining these two points. zy1orrra. The artery enters the skull opposite this
o o A point on the anterior border of the sterno- point (Fig. 20.4).
cleidomastoid muscle at the level of the upper border b. A second point 2 cm above the first point. The artery
c of the thyroid cartilage. divides deep to this point.
.9
o . A second point on the posterior border of the condyle c. A third point (centre of pterion) 3.5 cm behind and
o
ct) of the mandible. 1.5 cm above the frontozygomatic suture.
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d. A fourth point midway between the nasion and lntemolJugulor Vein

inion. Internal jugular vein is marked by a broad line by
e. A fifth point (lambda) 5 cm above the external joining these two points.
occipital protuberance. . The first point on the neck medial to the lobule of
The line joining points (a) and (b) represents the the ear.
stem of the middle meningeal artery inside the skull. . The second point at the medial end of the clavicle
The line joining points (b), (c) and (d) represents (Fig.20.12).
the anterior (frontal) branch. It first runs upwards The lower bulb of the vein lies beneath the lesser
and forwards (b), (c) and then upwards and supraclavicular fossa between the sternal and clavicular
backwards, towards the point (d). heads of the sternocleidomastoid muscle.
The line joining points (b) and (e) represents the Subclovion in
posterior (parietal) branch. It runs backwards and
Subclavian vein is represented by a broad line along
upwards, towards the point (e) (Fig. 20.a).
the clavicle extending from a little medial to its
midpoint to the medial end of the bone.
VEINS/SINUSES
Superior Sogittol Sinus
FociolVein
Superior sagittal sinus is marked by two lines
It is represented by a line drawn just behind the facial (diverging posteriorly) joining these two points.
artery (Fig. 20.a). o One point at the glabella.
o Two points at the inion, situated side by side, 1.2 cm
Externol Jugulor Vein apart (Fig. 20.73).
The vein is usually visible through the skin and can be
made more prominentbyblowing with the mouth and Superior
sagittal
nostrils closed (Fig. 20.12). stnus
It can be marked, if not visible, by joining these Transverse
points. SINUS
Glabella
. The first point a little below and behind the angle
of the mandible. lnion
. The second point on the clavicle just lateral to the
posterior border of the sternocleidomastoid Asterion
(Fig.20.12). Base of
mastoid
process
Sigmoid
SINUS
Tip of
mastoid
Fig.20"13: Superior sagittal, transverse and sigmoid sinuses
Tlonsverse Sinus
Transverse sinus is marked by two parallel lines, 1.2 cm
apart extending between the following points.
o Two points at the inion, situated one above the other
andL.2 cm apart (Fig. 20.13).
lnternal lugular
. Two points at asterion 3.75 cm behind external r(
o
auditory meatus and 1.25 cm above this point (Fig. zo
Hyoid bone 20.3). tttr
o Two points at the base of the mastoid process, (E
Thyroid
External jugular cartilage situated one in front of the other and 1..2 cm apart. t,G
o
Subclavian Sigmoid Sinus
Sigmoid sinus is marked by two parallel lines situated .9
1.2 cm apart and extending between the following two o
Fi1,20.12: lnternal and external jugular veins points: ao
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HEAD AND NECK
o Two points at the base of the mastoid process, . The first point on the posterior part of the mandibular
situated one in front of the other and 7.2 cm apart notch, in line with the mandibular nerve.
(Fig.20.13). . The second point a little below and behind the last
o Two similar points near the posterior border and lower molar tooth.
1.2 cm above the tip of mastoid process. . The third point opposite the first lower molar tooth.
The concavity in the course of the nerve is more
NERVES marked between the 2nd and 3rd points and is
Fqcisl Nerve directed upwards.
Inferior alveolar nerve lies a little below and parallel
Facial nerve is marked by a short horizontal line joining
to the lingual nerve.
the following two points.
. A point at the middle of the anterior border of the
Glossophqryngesl Norve
mastoid process. The stylomastoid foramen lies 2 cm
deep to this point. Glossopharyngeal nerve is marked by joining the
. A second point behind the neck of mandible. Here following points.
the nerve divides into its five branches to the facial . The first point on the anteroinlerior part of the tragus.
muscles (seeFigs 5.3 and 20.1.4). . The second point anterosuperior to the angle of the
mandible.
Aurlculotemporol NeIve From 2nd point, the nerve runs forwards for a short
Auriculotemporal nerve is marked by a line drawn first distance above the lower border of the mandible. The
backwards from the posterior part of the mandibular nerve describes a gentle curve in its course (Fig' 20.15).
notch (site of mandibular nerve) across the neck of the
mandible, and then upwards across the preauricular
point (Fig.20.1.4).
Mondlbulsr Nerve
Glosso-
Mandibular nerve is marked by a short vertical line in pharyngeal
the posterior part of the mandibular notch just in front nerve
of the head of the mandible.
Tragus
Llnguol qnd Inferlor Alveolor Nenres Transverse process
Lingual nerve is marked by a curved line running of atlas
downwards and forwards by joining these points Spinal

accessory
(Fig.20.1a). nerve
border
of mandible
Trapezius Hypoglossal
Au ricu lote m pora I
nerve
Vagus nerve
Flg. 20.15: Position of last four cranial nerves
gus Nerve
Masseter
The nerve runs along the medial side of the intemal
t(
o 3rd lower jugular vagus vein. It is marked by joining these two
o
z molar tooth
points.
t,tr 1st lower
molar tooth
. The first point at the anteroinferior part of the tragus.
G
!t(E Mental
. The second point at the medial end of the clavicle
o (Fig.20.15).
lnferior
C alveolar
Accesoory Nerve (spinol Porf)
o
() Flg. 20.14: Position of facial and some branches of mandibular Accessory nerve (spinal part) is marked by joining
oo nerves the following four points.
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SURFACE MARKING AND BADIOLOGICAL ANATOMY
. The first point at the anteroinferior part of the tragus The superior ceraical ganglion extends from the
(Fig.20.15). transverse process of the atlas to the tip of the greater
. The second point at the tip of the transverse process cornua of the hyoid bone. The middle ceraical ganglion
of the atlas. lies at the level of the cricoid cartilage, and the inferior
. The third point at the middle of the posterior border ceruical ganglion, at a point 3 cm above the sterno-
of the sternocleidomastoid muscle. clavicular joint (Fig. 20.16)
. The fourth point on the anterior border of the
trapezius 6 cm above the clavicle (Fi9.20.15). Irlgeminol Gonglion
Trigeminal ganglion lies a little in front of the preauri-
Hypoglossol Nerve cular point at a depth of about 4.5 cm.
Hypoglossal nerve is marked by joining these points.
. The first point at the anteroinferior part of the tragus. GTANDS
. The second point, posterosuperior to the tip of the
Porolid Glond
greater cornua of the hyoid bone.
. The third point, midway between the angle of the Parotid gland is marked by joining these four points
mandible and the symphysis menti. with each other (Fig. 20.17).
The nerve describes a gentle curve in its course a. The first point at the upper border of the head of the
(Fig.20.1s). mandible.
b. The second point, just above the centre of the
Phrenic Nerve masseter muscle.
Phrenic nerve is marked by a line joining the following c. The third point, posteroinferior to the angle of the
points. mandible.
. A point on the side of the neck at the level of the d. The fourth point on the upper part of the anterior
upper border of the thyroid cartilage and 3.5 cm from border of the mastoid process.
the median plane. The anterior border of the gland is obtained by
. The second point at the medial end of the clavicle joining the points (a), (b), (c); the posterior border, by
(Fi9.20.16). joining the points (c), (d); and the superior curved
border with its concavity directed upwards and
Gervicol $ympolhetlc Choin backwards, by joining the points (a), (d) across the
Cervical sympathetic chain is marked by a line joining lobule of the ear (Fig. 20.17).
the following points.
. A point at the sternoclavicular joint. Porotid Duel
. The second point at the posterior border of the To mark this duct first draw a line joining these two
condyle of the mandible. points.
Sympathetic
trunk
Transverse .Y
o
process
of atlas Duct of
zo
parotid gland
tttr
over masseter G
!,
Submandibular G
Phrenic Superior, middle o
nerye and inferior gland
cervical ganglia Hyoid bone
of sympathetic Parotid gland Palatine tonsil
C
.9
trunk Flg.2O.17t Position of parotid gland with its duct, submandibular o
Flg, 20.16: Position of phrenic nerue and sympathetic trunk gland and palatine tonsil ao
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HEAD AND NECK
. One point at the lower border of the tragus. Moxillory Sinus

. A second point midway between the ala of the nose The roof of maxillary sinus is represented by the
and the red margin of the upper lip. inferior orbital margin; the floor, by the alveolus of
The middle-third of this line represents the parotid the maxilla; the base, by the lateral waIl of the nose.
duct (Fig. 20.77). The apex lies on the zygomatic process of the maxilla.
Submondibulor Glond
The submandibular salivary gland is marked by an oval
area over the posterior half of the base of the mandible,
including the lower border of the ramus. The area In routine clinical practice, the following X-ray pictures
extends 1.5 cm above the base of the mandible, and of the skull are commonly used.
below to the greater cornua of the hyoid bone 1 Lateral view for general survey of the skull.
(Fi9.20.17). 2 A special posteroanterior view (in Water's position)
to study the paranasal sinuses.
Thyroid GIond 3 Anteroposterior and oblique views for the study of
The isthmus of thyroid gland is marked by two cervical vertebrae.
transverse parallel lines (each L.2 cm long) on the
trachea, the upper 1.2 cm and the lower 2.5 cm below ERAr VIEW OF SKULr (PLATN SKTAGRAM)
the arch of the cricoid cartilage. The radiogram is studied systematically as described
Each lobe extends up to the middle of the thyroid here.
cartilage, below to the clavicle, and laterally to be
overlapped by the anterior border of sternocleido- Croniol ult
mastoid muscle. The upper pole of the lobe is pointed, 'J, Shape and size: It is important to be familiar with the
and the lower pole is broad and rounded (Fig.20.18). normal shape and size of the skull so that
abnormalities, like oxycephaly (a type of cranio-
Pololine Tonsil
stenosis), hydrocephalus, microcephaly, etc. may be
Palatine tonsil is marked by an oval (almond-shaped) diagnosed.
area over the masseter just anterosuperior to the angle
2 Structure af cranial bones: The bones are unilamellar
of the mandible (Fi9.20.17). during the first three years of life. Two tables
separated by diploe appear during the fourth year,
PARANASAL SINUSES and the differentiation reaches its maximumby about
Frontol Sinus 35 years when diploic veins produce characteristic
Frontal sinus is marked by a triangular area formed by markings in radiograms. The sites of the external
joining these three points. occipital protuberance and frontal bone are normally
1 The first point at the nasion. thicker than the rest of the skull. The squamous
2 The second point 2.5 cm above the nasion. temporal and the upper part of the occipital bone
3 The third point at the junction of medial one-third are thin.
and lateral two-thirds of the supraorbital margin, Generalized thickened bones are found in Paget's
i.e. at the supraorbital notch. disease. Thalassaemia, a congenital haemolytic
Sternocleidomastoid muscle Hyoid bone

ta Thyroid cartilage
o Lobe of thyroid gland
o
z Cricoid ca(ilage
E
tr
(E
E'
G
o
c
o
o Manubrium of the sternum
o
a Fig. 20.18: Thyroid gland
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anaemia/ is associated with thickening and a 8 The auricle: The curved margin of the auricle is seen
characteristic sun-ray appearance of the skull bones. above the petrous temporal.
A localized hyperostosis may be seen over a 9 The frontal sinus produces a dark shadow in the
meningioma. In multiple myeloma and secondary anteroinferior part of the skull vault.
carcinomatous deposits, the skull presents large
punched out areas. Fractures are more extensive in Bose of Skull
the inner table than in the outer table. 1 The floor of the anterior crnninl fossa slopes backwards
3 Sutures: The coronal and lambdoid sutures are and downwards. The shadows of the two sides are
usually visible clearly. The coronal suture runs often seen situated one above the other. The surface
downwards and forwards in front of the central is irregular due to gyral markings. It also forms the
sulcus of the brain. The lambdoid suture traverses roof of the orbit (Fig. 20.19).
the posteriormost part of the skull. 2 The hypoplryseal fossa represents the middle cranial
Obliteration of sutures begins first on the inner fossa in this view. It is overhung anteriorly by the
surface (between 30 and 40 years) and then on the anterior clinoid process (directed posteriorly), and
outer surface (between 40 and 50 years). Usually the posteriorly by the posterior clinoid process. It
lower part of the coronal suture is obliterated first, measures 8 mm vertically and 14 mm antero-
followed by the posterior part of the sagittal suture. posteriorly. The interclinoid distance is not more than
Premature closure of sutures occurs in cranio- 4 mm. The fossa is enlarged in cases of pituitary
stenosis, a hereditary disease. Sutures are opened up tumours, arising particularly from acidophil or
in children by an increase in intracranial pressure. chromophobe cells.
The sphenoidal air sinus lies anteroinferior to the
4 Vascular markings: hypophyseal fossa. The shadows of the orbit, the
a. Middle meningeal aessels: The anterior branch runs nasal cavities, and the ethmoidal and maxillary
about 1 cm behind the coronal suture. The sinuses lie superimposed on one another, below the
posterior branch runs backwards and upwards at anterior cranial fossa.
a lower level across the upper part of the shadow The petrous part of the temporal bone prodtsces a dense
of the auricle. irregular shadow posteroinferior to the hypophyseal
b. The transaerse sinus rr.ay be seen as a curved dark fossa. Within this shadow there are two dark areas
shadow, convex upwards, extending from the representing the external acoustic meatuses of the
internal occipital protuberance to the petrous two sides; each shadow lies immediatelybehind the
temporal. head of the mandible of that side. Similar dark
c. The diploic oenous markings are seen as irregularly shadows of the internal acoustic meatuses may also
anastomosing, worm-like shadows produced by be seen. The posterior part of the dense shadow
the frontal, anterior temporal, posterior temporal merges with the mastoid air cells producing a
and occipital diploic veins. These markings honeycomb appearance.
become more prominent in raised intracranial
pressure.
5 Cerebral moulding, indicating normal impressions of
cerebral gyri, can be seen. In raised intracranial
tension, the impressions become more pronounced
and produce a characterislic siloer beaten (or copper
beaten) appearance of the skull.
6 Arachnoid graruilatioms may indent the parasagittal
area of the skull to such an extent as to simulate
erosion by a meningioma.
l(
7 Normal intraffanial calcificntions: o
a. Pineal concretions (brain sand) appear by the age zo
t
of 77 years. The pineal body is located 2.5 cm =
G
above and L.2 cm behind the external acoustic !,(E
meatus. When visible it serves as an important o
radiological landmark.
b. Other structures which may become calcified C
o
include the choroid plexuses, arachnoid granu- ()
o
lations, falx cerebri, and other dural folds. Flg. 20.19: Lateral view of the skull and cervical vertebrae a
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5 In addition to the features mentioned above, the
mandible lies anteriorly forming the lower part of the
facial skeleton. The upper ceraical aertebrae lie
posteriorly and are seen as a pillar supporting the
skull.
$PECIAL PAVIEW OF SKUtt FOR PARANASAT SINUSE$

This picture is taken with the head extended in such a
way that the chin rests against the film and the nose is
raised from it (Water's position). This view shows the
frontal and maxillary sinuses clearly (Fig. 20.20).
The frontal sinuses are seen immediately above the
nose and medial parts of the orbits. The nasal cavities
are flanked on each side by the orbits above, and the
maxillary sinuses below. The normal sinuses are clear
and radiolucent, i.e. they appear dark. If a sinus is
infected, the shadow is either hazy or radiopaque.
FI,1,20,202 X-ray of skull showing paranasal sinuses
CERVI t VERTEBRAE
The cervical vertebrae can be visualised in
anteroposterior view of the neck and in oblique view spines are seen. In the oblique view, the adjacent inferior
of the neck. In the anteroposterior view, the body of articular and superior articular processes and
cervical vertebrae, intervertebral discs, pedicles and intervertebral foramen are visualised.
l(
o
zo
E'
tr
(E
t,(E
o
I
C
.9
o
o)
ct)
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a
Correl
-Alexis
INIRODUCTION
The appendix contains upper cervical nerves, syrnpathetic
trunk of the neck Table A1.1. Phrenic nerve arises primarily from ventral rami of C4
The four parasympathetic ganglia are shown in Flow with small contributions from C3 and C5 nerve roots or
charts A1.1 to 41.4. through nerve to subclavius. It is the only motor supply
Summary of the arteries are depicted in Tables A1.2 to its own half of diaphragm and sensory to mediastinal
to ,A.1.4. pleura, peritoneum and fibrous pericardium. Inflam-
The pharyngeal arches, pouches and clefts are shor,rrn mation of peritoneum under diaphragm causes referred
in Tables A1.5 to A1,.7.Italso includes the clinical terms. pain in the area of supraclavicular nerves supply,
especially tip of the shoulders as their root value is also
ventral rami of C3 and C4 (see Fig. 9. 9).
Ventral rami of Cl, C2, C3, C4 form the cervical plexus.

C1 runs along hypoglossal and supplies geniohyoid
and thyrohyoid. It also gives superior limb of ansa Branches of cervical sympathetic ganglia of sympathetic
cervicalis, which supplies superior belly of omohyoid trunk are given in fiUte af .f .
and joins with inferior limb to form ansa. Inferior limb
of ansa cervicalis is formed by ventral rami of C2, C3.
Branches from ansa supply sternohyoid, sterno-
thyroid, inferior belly of omohyoid. Cervical plexus SUBMANDIBUTAR GANGI.ION
also gives four cutaneous branches lesser occipital
(C2), great auricular (C2,C3), supraclavicular (C3, C4) Situstlon
and transverse or anterior nerve of neck (C2, C3) (see The submandibular ganglion lies superficial to
Figs 3.6,4.16 and 9.8). hyoglossus muscle in the submandibular region.
Table A1 .1 : Branches of cervical sympathetic ganglia

Superior ceruical ganglion Middle cervical ganglion lnferior cervical ganglion
Arterial branches i. Along internal carotid artery Along inferior thyroid artery Along subclavian and
as internal carotid nerve vertebral arteries
ii. Along common carotid and
external carotid arteries
Grey rami communicans Along 1-4 cervical nerves Along 5 and 6 cervical nerves Along 7 and 8 cervical nerves
Along cranial nerves Along cranial nerves
lX, X, Xl and Xll
Visceral branches Pharynx, cardiac Thyroid, cardiac Cardiac
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HEAD AND NECK
Flow chart A1 .1: Connections of submandibular ganglion Flow chart A1 .4: Connections of ciliary ganglion
Superior salivatory
Branch to ciliary ganglion
Short ciliary nerves supply ciliaris

Relays to supply submandibular gland directly, sublingual and constrictor pupillae muscles
salivary gland and glands in the oral cavity via lingual nerve
Functionally, submandibular ganglion is connected to

Flow chart A1 .2: Connections of pterygopalatine ganglion facial nerve, while topographically it is connected to
Lacrimatory nucleus of Vll nerve lingual branch of mandibular nerve (seeFig.7.10).
Roots
The ganglion has sensory, sympathetic and secreto-
motor or parasympathetic roots.
1 Sensory root is from the lingual nerve. It is suspended
by two roots of lingual nerye.
Sympathetic root is from the sympathetic plexus
around the facial artery. This plexus contains
postganglionic fibres from the superior cervical
ganglion of sympathetic trunk. These fibres pass
Pterygopalatine ganglion
(for relay of fibres of greater petrosal nerve only) express through the ganglion and are vasomotor to
the gland.
Secretomotor root is from superior salivatory nucleus
Relays to supply glands of nose, palate, pharynx
and some pass along maxillary nerve, zygomatic nerve through nervus intermedius via chorda tympani
which is a branch of cranial nerve VII. Chorda
tympani joins lingual nerve. The parasympathetic
Zygomaticotemporal nerve, communicating fibres get relayed in the submandibular ganglion
branch to lacrimal nerve which supplies lacrimal gland
(Flow chart A1.1).
Flow chart A1 .3: Connections of otic ganglion Blonches

lnferior salivatory nucleus of lX nerve The ganglion gives direct branches to the submandi-
bular salivary gland.
Some postganglionic fibres reach the lingual nerve
to be distributed to sublingual salivary gland and
glands in the oral cavity.
PTERYGOPA INE GANGTION

--
o L
o Situqlion
z
t,c Pterygopalatine or sphenopalatine is the largest
(E Relay parasympathetic ganglion, suspended by two roots of
!to maxillary nerve. Functionally, it is related to cranial
o nerve VII. It is called the ganglion of "hay fever."
c Rools
o
() The ganglion has sensory, sympathetic and secreto-
ao motor or parasympathetic roots (see Figs 15.16a and b).
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,
APPENDIX 1
t
Sensory root is from maxillary nerve. The ganglion I Sensory root is by the auriculotemporal nerve.
is suspendedby 2 roots of maxillary nerve. 2 Sympathetic root is by the sympathetic plexus
Sympathetic root is from postganglionic plexus around middle meningeal artery.
around internal carotid artery. The nerve is called Secretomotor root is by the lesser petrosal nerve from
deep petrosal. It unites with greater petrosal to form the tympanic plexus formed by tympanic branch of
the nerve of pterygoid canal. The fibres of deep cranial nerve IX. Fibres of lesser petrosal nerve relay
petrosal do not relay in the ganglion. in the otic ganglion. Postganglionic fibres reach the
Secretomotor or parasympathetic root is from greater parotid gland through auriculotemporal nerve
petrosal nerve which arises from geniculate ganglion (Flow chart ,A.1.3).
of cranial nerve VII. These fibres relay in the ganglion 4 Motor root is by a branch from nerve to medial
(Flow chart A1.2). pterygoid. This branch passes unrelayed through the
ganglion and divides into two branches to supply
Bronches tensor veli palatini and tensor tympani.
The ganglion gives number of branches. These are:
'1. For lacrirnal gland: The postganglionic
fibres pass Bronches
through zygomatic branch of maxillary nerve. These The postganglionic branches of the ganglion pass
fibres hitch hike through zygomaticotemporal nerve through auriculotemporal nerve to supply the parotid
into the communicating branch between zygo- gland.
maticotemporal and lacrimal nerve, then to the The motor branches supply the two muscles tensor
lacrimal nerye for supplying the lacrimal gland. veli palatini and tensor tympani.
2 sopnlatine nerzre: This nerve runs on the nasal
septum and ends in the anterior part of hard palate. CII.IARY GANGTION
It supplies secretomotor fibres to both nasal and Situolion
palatal glands.
3 sal branches: These are medial, posterior, superior The ciliary ganglion is very small ganglion present in
branches for the supply of glands and mucous the orbit. Topographically, the ganglion is related to
membrane of nasal septum; the largest is named nasociliary nerve, branch of ophthalmic division of
nasopalatine; and lateral posterior superior branches trigeminal nerve, but functionally it is related to
for the supply of glands and mucous membrane of oculomotor nerve. This ganglion gets parasympathetic
lateral wall of nasal cavity. fibres (Flow chart A1.1).
4 Palatine branches: These are one greater palatine and
Roots
2-3 lesser palatine branches. These pass through the
respective foramina to supply sensory and It has three roots, the sensory, sympathetic and
secretomotor fibres to mucous membrane and glands parasympathetic. Only the parasympathetic root fibres
of soft palate and hard palate. relay to supply the intraocular muscles.
5 Orbital branches for the orbital periosteum. 1 Sensory root is from the long ciliary nerve.
6 Pharyngeal branches for the glands of pharynx. 2 Sympathetic root is by the long ciliary nerve from
plexus around ophthalmic artery.
OIIC GANGTION 3 Parasympathetic root is from a branch to inferior
oblique muscle. These fibres arise from Edinger-
Siluolion Westphal nucleus, join oculomotor nerve and leave
The otic ganglion lies deep to the trunk of mandibular it via the nerve to inferior oblique, to be relayed in
nerve, between the nerve and the tensor veli palatini the ciliary ganglion (Flow chart A1.4).
muscle in the infratemporal fossa, just distal to the
foramen ovale. Topographically, it is connected to Blonches
I
mandibular nerve, while functionally it is related to The ganglion gives 10-12 short ciliary nerves containing o
o
cranial nerve IX. postganglionic fibres for the supply of constrictor or z
sphincter pupillae for narrowing the size oI pupil and
ttr
Rools (!
ciliaris muscle for increasing the curvature of anterior E'
This ganglion has sensory, sympathetic, paraqrnpathetic surface of lens required during accommodation of the G
o
or secretomotor and motor roots (see Figs 6.15 and 6.16). eye.
c
.9
o
ao
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HEAD AND NECK
Table A1 .2: Arteries of head and neck

Artery Beginning, course and termination Area of distribution
Common It is a branch of brachiocephalic trunk on rlght side and a This artery has only two terminal branches. These
carotid direct branch of arch of aorta on the left side. The artery are internal carotid and external carotid. Their area
runs upwards along medial border of sternocleidomastoid of distribution is described below.
muscle enclosed within the carotid sheath. The artery ends
by dividing into internal carotid and external carotid at the
upper border of thyroid cartilage (see Fig. 4.14)
lnternal It is a terminal branch of common carotid artery. lt first runs Cervical part of the artery does not give any branch.
carotid through the neck (cervical paft), then passes through the Petrous part gives branches for the middle ear;
petrous bone (petrous part), then courses through the sinus cavernous part supplies hypophysis cerebri. The
(cavernous part) and lastly lies in relation to the brain cerebral part gives ophthalmic artery for orbit, anterior
(cerebral part) cerebral, middle cerebral, anterior choroidal and
posterior communicating for the brain
External It is the one of the terminal branches of common carotid It supplies structures in the front of neck, i.e. thyroid
carotid artery and lies anterior to internal carotid adery. External gland, larynx, muscles of tongue, face, scalp, ear.
carotid artery starts at the level of upper border of thyroid
cartilage, runs upwards and laterally to terminate behind
the neck of mandible by dividing into larger maxillary and
smaller superlicial temporal branches (see Fig. 4.13)
Superior It arises from anterior aspect of external carotid artery close Superior laryngeal branch which pierces thyroid
thyroid to its origin. lt runs downwards and forwards deep to membrane to supply larynx. Sternocleidomastoid and
the infrahyoid muscles to the upper pole of thyroid gland cricothyroid branches are to the muscles. Terminal
(see Fig.8.5) branches supply the thyroid gland.
Lingual It arises f rom anterior aspect of external carotid artery forms As the name indicates, it is the chief artery of the
a typical loop which is crossed by Xll nerue. lts 2nd part lies muscular tongue. lt supplies various muscles,
deep to the hyoglossus. The 3rd part runs along the anterior papillae and taste buds of the tongue. lt also gives
border of hyoglossus and 4th part runs fonruards on the under branches to the tonsil.
surface of tongue (see Fig. 4.15)
Facial This tortuous artery from anterior side also arises a little Cervical part gives off ascending palatine, tonsillar,
higher than lingual ar1ery. lt runs in the neck as cervical part glandular branches for the submandibular and
and in the face as facial artery @ee Fig. 2.23\ sublingual salivary glands. The facial part lies on the
face giving branches to muscles of face and its skin.
Occipital It arises form the posterior aspect of external carotid artery It gives two branches to sternocleidomastoid muscle,
and runs upwards along the lower border of posterior belly of and branches to neighbouring muscles. lt also gives
digastric muscle. Then it runs deep to mastoid process and a meningeal and mastoid branch.
the muscles attached to it. The artery then crosses the apex
of suboccipital triangle and then it pierces trapezius 2.5 cm
from midline to supply the layers of scalp (see Fig. 4.14)
Posterior It arises from posterior aspect of external carotid aftery, it It gives branches to scalp. lts stylomastoid branch
auricular runs along the upper border of posterior belly of digastric enters the foramen of the same name to supply
muscle to reach the back of auricle mastoid antrum, nerve air cells and the facial.
Ascending It arises from the medial side of external carotid artery, close It gives branches to tonsil, pharynx and a few
pharyngeal to its origin. lt runs upwards and between pharynx and tonsil meningeal branches.
on medial side and medial wall of middle ear on the lateral
side (see Fig. 4.13)
Superlicial It is the smaller terminal branch of external carotid artery. Its two terminal branches supply layers of scalp and
.!a temporal It begins behind the neck of the mandible, runs upwards superficial temporal region. lt also supplies parotid
o and crosses the preauricular point, where its pulsations can gland, facial muscles and temporalis muscle.
zo be felt. 5 cm above the preauricular point it ends by dividing
E into anterior and posterior branches (see Fig. 2.5)
tr
(E
Maxillary It is the larger terminal branch of external carotid ar1ery. lt is Branches of-1st part: Deep auricular, anterior
t(E given off behind the neck of the mandible. lts course is
tympanic, middle meningeal and inferior alveolar.
o divided into 1st, 2nd and 3rd parts according to its relations 2nd part: Muscular branches to medial pterygoid,
with lateral pterygoid muscle. 1st part lies belowthe lateral masseter, temporalis and lateral pterygoid.
c pterygoid,2nd part lies on the lower head of lateral pterygoid 3rd part: Posterior superior alveolar, infraorbital,
.9
o and 3rd part lies between the two heads greater palatine and sphenopalatine branches,
ao pharyngeal and artery of pterygoid canal.
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APPENDIX 1
Table A1 .3: Branches of maxillary artery

Branches Foramina transmitting Distribution
A. Of first part (see Fig. 6.6)
1. Deep auricular Foramen in the floor (cartilage or Skin of external acoustic meatus, and outer surface
bone) of external acoustic meatus of tympanic membrane
2. Anterior tympanic Petrotympanic fissure lnner surface of tympanic membrane
3. Middle meningeal Foramen spinosum Supplies more of bone and less of meninges; also V
and Vll nerves, middle ear and tensor tympani
4. Accessory meningeal Foramen ovale Main distribution is extracranial to pterygoids
5. lnferior alveolar Mandibular foramen Lower teeth and mylohyoid muscle
B. Of second part
1. Masseteric Masseter
2. Deep temporal (anterior) Temporalis
3. Deep temporal (posterior) Temporalis
4. Pterygoid Lateral and medial pterygoids
5. Buccal Skin of cheek
C. Of third part (see Fig. 6.7)
1. Posterior superior alveolar Alveolar canals in body of maxilla Upper molar and premolar teeth and gums; maxillary sinus
2. lnfraorbital lnferior orbital fissure Lower orbital muscles, lacrimal sac, maxillary sinus,
upper incisor and canine teeth
3. Greater palatine Greater palatine canal Soft palate, tonsil, palatine glands and mucosa; upper
gums
4. Pharyngeal Pharyngeal (palatinovaginal) canal Roof of nose and pharynx, auditory tube, sphenoidal sinus
5. Artery of pterygoid canal Pterygoid canal Auditory tube, upper pharynx, and middle ear
6. Sphenopalatine (terminal part) Sphenopalatine foramen Lateral and medial walls of nose and various air sinuses
Course Branches and area of distribution

It is the chief artery of the upper limb. lt also supplies Branches of 1st paft:
paft of neck and brain. On the right side, subclavian Vertebral artery is the largest branch. lt supplies the brain. The artery
aftery is a branch of the brachiocephalic trunk. On passes through foramina transversaria of C6-C1 veftebrae, then it
the left side, it is a direct branch of arch of aorta. courses through suboccipital triangle to enter cranial cavity
The artery on either side ascends and enters the
lnternal thoracic artery runs downwards and medially to enter thorax
neck posterior to the sternoclavicular joint. The
by passing behind first costal cartilage. lt runs vertically 2 cm, on
afteries of two sides have similar course.
lateral side of sternum till 6th intercostal space to divide into
The artery arches from the sternoclavicular joint to musculophrenic and superior epigastric branches
the outer border of the first rib where it continues as
Thyrocervical trunk is a shorl wide vessel which gives suprascapular,
the axillary artery. lt is divided into three parts by
transverse cervical and important inferior thyroid branch. lnferior
the crossing of scalenus anterior muscle (see
thyroid artery gives glandular branches to thyroid and parathyroid
Figs 8.18 and 8.19) .Y
glands. ln addition, this artery gives inferior laryngeal branch for the (J
supply of mucous membrane of larynx zo
Costocervical trunk arises from 2nd part of subclavian artery on right t,tr
(s
side and from 1st part on left side. lt ends by dividing into superior
intercostal and deep cervical branches. t,(s
o
3rd paft may give dorsal scapular branch.
c
.9
o
ao)
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HEAD AND NECK
Table A1.5: Structures derived from skeletal and muscular component of pharyngeal arches
Pharyngeal arch Nerve of the arch Muscles derived Skeletal and ligamentous
structures derived
First (mandibular) arch (l) Trigeminal and mandibular Muscles of mastication Mandible-l
divisions of trigeminal (temporalis, masseter, Malleus I Quadrate carlilage
Meckel's cartilages (V cranial nerve) medial and lateral pterygoids) lncus -l
Mylohyoid Anterior ligament of malleus
Anterior belly of digastric Sphenomandibular ligament
tensor tympani Splne ol sphenoid
Tensor veli palatini Most of the mandible
Genial tubercles
Second (hyoid) arch (ll) Facial (Vll cranial nerve) Muscles of facial expression Stapes
Reicheft's (buccinator, auricularis, frontalis, Styloid process
cartilage platysma, orbicularis oris, and Lesser cornua of hyoid
orbicularis oculi) Upper part of body of hyoid
Posterior belly of digastric Stylohyoid ligament
Stylohyoid, stapedius
Third (lll) Glossopharyngeal Stylopharyngeus Greater cornua of hyoid
(lX cranial nerve) Lower part of body of hyoid bone
Fourth (lV) Superior laryngeal branch Cricothyroid Thyroid cartilage
of vagus Levator veli palatini Corniculate cartilage
Striated muscles of oesophagus Cuneiform cartilage
Constrictors of pharynx
Sixth (Vl) Recurrent laryngeal branch lntrinsic muscles of larynx Cricoid cartilage
of vagus (X cranial) nerve). Arytenoid cartilage
By intramembranous ossification of mesenchyme of I arch, maxilla, zygomatic, squamous parl of temporal are developed.
Table A1.6: Derivatives of endodermal pouches

Pharyngeal pouch Derivatives
Dorsal ends of I and ll pouches form Proximal part of tubotympanic recess gives rise to auditory tube.
tubotympanic recess Distal parl gives rise to tympanic cavity and mastoid antrum.
Mastoid cells develop at about 2 years of age
Ventral part of ll pharyngeal pouch Epithelium covering the palatine tonsil and tonsillar crypts.
lymphoid tissue is mesodermal in origin
lll pharyngeal pouch Thymus and inferior parathyroid gland or parathyroid lll.
Thymic epithelial reticular cells and Hassall's corpuscles are endodermal.
Lymphocytes are derived from haemopoietic stem cells during 12th week
lV pharyngeal pouch Superior parathyroid or parathyroid lV
V pharyngeal pouch (ultimobranchial body) Parafollicular or 'C' cells of the thyroid gland
Table A1 .7: Derivatives of ectodermal clefts

Dorsal part of I ectodermal cleft Epithelium of external auditory meatus.
Auricle Six auricular hillocks; three from I arch and three from ll arch
J
o Rest of ectodermal clefts Obliterated by the overgrowth of ll pharyngeal arch. The closing membrane
zo of the first cleft is the tympanic membrane.
!tC
(E r Facial artery at the anteroinferior angle of
t,(E masseter muscle (see Fig, 2.23).
o Anaesthetist's atteries: These are the arteries used
by the anaesthetists who are sitting at the head end r Common carotid at the anterior border of
of the patient being operated: sternocleidomastoid.
c
.o r The superficial temporal aftery as it crosses the Hilton's method of fuaining parotid gland
o
ao root of zygoma in front of ear (see Fig. 5.3). abscess: The incision given to drain parotid abscess
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APPENDIX 1
on or by making many Ludwig's angina: When there is cellulitis of floor

not endanger the various of the mouth, due to infected teeth, the condition is
oursing through the gland knovrn as Ludwig's angina. The tongue is pushed
upwards andmylohyoid is pushed downwards. This
Frey's syndrome: The sign of Frey's syrdrome is ceilulitis may spread backwards to cause oedema of
the appearance of perspiration on the face while the larynx and asphyxia.
patient eats food. In certain healing of wounds, the Little's arca of nose: This is the area in the antero-
auriculotemporal nerve and great auricular nerves inferior part of nasal septum. Four arteries take part
may join with each other. \Atrhen the person eats food, in Kiesselbach's plexus formed by:
instead of saliva, sweat appears on the face. Septal branch of superior labial from facial artery,
Waldeyer's ring: It is the ring of lymphoid tissue terminal part of sphenopalatine artery:
present at the oropharyngeal junction. Its com- . Anterior ethmoidal artety,
ponents are lingual tonsils anteriorly, palatine tonsils . Greater palatine artery. Picking of the nose may
Iaterally. tubal tonsils above and laterally and give rise to nasalbleeding or epistaxis (see Fig. 15.5).
pharyngeal tonsils posteriorly (see Fig. 14.3). Syringing of ear cfluses deueasedheart rate: Tl-:Le
Killinn's dehiscence: It is a potential gap between external auditory meatus is supplied by auricular
upper thyropharyngeus and lower cricopharlmgeus branch of vagus. Vagus also supplies the heart with
parts of inferior constrictor muscle. Thyropharlmgeus cardioinhibitory fibres. During syringing of the ear,
is the propulsive part of the muscle, supplied by vagus nerve is stimulated which causes bradycardia
recurrent laryn (see Fig. 78.7).
the sphincteric Neroe of neu oision: Oculomotor nerve is the
nerve. If there nerve of close vision. It supplies medial rectus,
parts, bolus of food is pushed backwards in region of superior and inferior recti, The sphincter pupillae
Killian's dehiscence, producing pharyngeal pouch or and ciliaris muscles are supplied by parasympathetic
diverticula (see Fig. 1,4.22). fibres via III nerve. It also supplies levator palpebrae
Safety muscle of larynx: Posterior cricoarytenoid superiors which opens the eye (see Fig. 24.77).
muscles are the only abductors of vocal cords. The Injury to spine of sphenoid; Chorda tympani
paralysis of both these muscles causes unopposed nerve is related on the medial side of spine of
adduction of vocal cords, with severe dyspnoea. So sphenoid, while auriculotemporal nerve is related
posterior cricoarytenoid is the life-saving muscle on the lateral side. Chorda tympani gives secreto-
(see Fig.16.10). motor fibres to submandibular and sublingual
Singer's nodates; These are little swellings on the salivary glands, whereas auriculotemporal gives
vocal cords at the junction of anterior one-third and secretomotor fibres to the parotid gland. So injury
posterior two-thirds of vocal cords. During phonation, to spine of sphenoid may injure both these nerves
the cords come close together, and there is slight affecting the secretion from all three salivary glands
friction as well. If friction is more and continuous, (see Fig. 6.10).
there is some inflammation with thickening of Extradaral haemorthage; There is collection
vocal cords,leading to Singer's or Teacher's nodules of blood due to rupture of middle meningeal vessels
(see Fig.76.8). in the space between skull and the endosteum. It
Tongue is pulled out ilwing anaesthesia; Genio- may press upon the motor area of brain. Blood
glossus muscles dre responsible for protrusion of has to be drained out from the point called 'pterion'
tongue. If these muscles are paralysed, the tongue (see Fig. 1.10).
falls back upon itself and blocks the airway. So Loss of corneal blink reflex,' In case of injury to
tongue is pulled out during anaesthesia to keep there ophthalmic nerve, there is loss of corneal blink
air passage clean (see Fig. 17.5). reflex as the afferent part of reflex arc is damaged xo
Passaoant's ridge: The horizontal fibres of right
and left palatopharyngeus muscles form
(see Fig, 24.37).
Loss of sneeze reflex: In injury to maxillary nerve,
zo
a !ttr
Passavant's fold at the junction of nasopharynx and the sneeze reflex is lost, as afferent loop of the reflex G
oropharynx. Do.iog swallowing, palatophar),ngeus arc formed by the maxillary nerve is damaged. ttG
muscles form a ridge, which closes nasopharynx Loss of jaw jerk reflex: The afferent and efferent o
I
from oropharynx, so that bolus of food passes, limbs of the reflex arc are by V nerve. Damage to
through oropharynx only. In paralysis of these mandibular nerve causes loss of jaw jerk reflex c
o
muscles, there is nasal regurgitation. (see Fig. 24.38). E
o
a0)
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HEAD AND NECK
FURIHER READING
. Anderson SD. The intratympanic muscles. In: Hinchcliffe R (ed). Scientific Foundations of Otolaryngology Heinemann/
London, 7976; pp 257-80.
. Ashmare ]. The mechanics of hearing. In Roberts D (ed). Signals and Perception: The Fundamentals of Human Sensation.
Basingstoke and New York Palgrave Macmillan,2002;3-76.
o Barker BCW, Davies PL. The applied anatomy of the pterygomandibular space. Br J Surg 1972;70:43-55.
o Bennett AG, Rabbets RB. Clinical Visual Optics, 2nd edn London; Butterworth-Heinemann,1989.
. Berkovitz BKB, Moxham Bj, H Flickey S. The anatomy of the larynx. In: Ferlito A (ed). Diseases of the Larynx, London:
Chapman and Hall, 2000; 2544.
o Berkovitz, BKB, Moxham, B]. Colour Atlas of the Skull. London: Mosby-Wolfe, 1989.
r Broadbent CR, Maxwell WE, Ferrie R, Wilson D], Gawne-Cain M, Russell R. Ability of anaesthetists to identify a marked
lumbar interspace. Anaesthesia, 2000 ; 55:1122-26.
. Cady B, Rossi RL (eds). Surgery of the Thyroid and Parathyroid Glands. Philadelphia, Saunders 1991.
. Cagan RN (ed). Neural Mechanisms in Taste Boca Raton, Fl: CRC Press 1989.
. Davis RA, Anson B], Budinger ]M, Kurth LE. Surgical anatomy of the facial nerve and parotid gland based upon a study
of 350 cervicofacial halves. Surg Gymecol Obstet, 1956;702:385472.
. Doig TN, McDonald SW, McGregor OA. Possible routes of spread of carcinoma of the maxillary sinus to the oral cavity.
Clin Anat, 1998; 17:749-56.
. Ger R, Evans ]T. Tracheostomy, an anatomio-clinical review. Clin Anat, 7993;6:33741..
. Grey P. The clinical significance of the communicating branches of the somatic sensory supply of the middle and external
ear. J Laryngol Otol, 7995;109:71.4745.
o jones LT. The anatomy of the upper eyelid and its relation to ptosis surgery. Am ] Ophthalmol, 7964;57:943-59-
. Knop E, Knop N. A functional unit for ocular surface immune defence formed by the lacrimal gland, conjunctiva and
lacrimal drainage system. Adv Exp Med Biol, 2002;5068:635-44.
. Lahr, MM. The Evolution of Modern Human Diversity A Study of Cranial Variation, Cambridge: Cambridge University
Press, 1996.
o Lang ]. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses. Stuttgart Thieme 1989.
. Maclaughlin SM, Oldale KNM. Vertebral body diameters and sex prediction. Ann Hum Biol, 1992;79:285-93.
o Mc Gowan DA, Baxter PN, ]ames ]. The Maxillary Sinus, Oxford Wright 1993.
o Munir Turk L, Hogg DA. Age changes in the human larlmgeal cartilages.Clin Anat, 7993;6:754-62.
. Myint K, Azian Ai, Khairual FA. The clinical significance of the branching pattern of facial nerve in Malaysian Subjects.
Med J Malaysia,1992; 47:\14-27.
o Pracy R. The infant larynx. ] Lary'ngol Otol, 1983; 97:93347.
o Reidenbach MM. Normal topography of the conus elasticus. Anatomical basis for the spread of laryngeal cancer. Surg
Radiol Anat, 7995; 17 :107-77.
. Sade ] (ed). Basic Aspects of the Eustachian Tube and Middle Ear Disease. Geneva: Kugler and Ghedini,1989-
. Sato I, Shinada, K. Aiborization of the inferior laryngeal nerve and internal nerve on the posterior surface of larynx. Clin
Anat,7995; 8:379-87.
. Turker KS. Reflex control of human jaw muscles. Crit Rev Oral Biol }led2002;13:85-104.
. Vidarsdottir US, O'Higgins P, Stringer C. A geometric morphometric study of regional differences in the ontogeny of the
modern human facial skeleton. ] Anat, 2002;201:277)9.
. Wassle H, Boycott BB. Fr.rnctional architecture of the mammalian retina. Physiol Rev, 1991; 71,:447-80.
. Wilson-Pauwels I,.Akesson E], Stewart PA. Cranial Nerves. Anatomy and Clinical Comments, Toronto, Decker, 1998.
. Wood jones I. The nature of soft palate. I Anat,1940;77:147.
I
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i. lntroductlon
. emir: es of ?he Bnmin qm
eere rospinot Fluid
. Spinol Cord 334
. eronicl Nerv s 350
" Br inSt nm 389
" Cere ellur 401

?. Founth \fentricle 409
tS. Cerebrum 413
. Thir$ ntnicle, LoteraBVenfricle md 441
l-lrnbie Systern
. $orne Nleuro[ FothwCIys and
Reticul r Formatiom 450
I " Bloe uppfy ot Spinol Cord snd Broln 455
$ . Inv sti t* ns of urolo icol Ccse, 467
Surfqce snd Rqdiologico! Anolomy
ond Evolution of Hecd
Appendix 2 472
I
,t
ti:
,tl
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a
I
Long
-Wei
Nervous system is the chief controlling and co- 2 Efferent component carries motor information to
ordinating system of the body. muscles, glands, blood vessels and heart via:
It is responsible for judgement, intelligence and a. Somatic nervous system for the control of skeletal
memory. Nervous system is highly evolved at the cost muscles.
of regeneration. b. Autonomic nervous system for control of heart,
It is the most complex system of the body. smooth muscle of the organs, glands and blood
It adjusts the bodylo thesurroundings and regulates vessels. It is subdivided into sympathetic and
all bodily activities both voluntary and involuntary. The parasympathetic parts.
sensory part of the nervous system collects information
from the surroundings and helps in gaining knowledge
and experience, whereas the motor part is responsible
for responses of the body. The nervous tissue is made up of:
Average weight of adult brain in air is 1500 grams. L Nerve cells or neurons (Fig.21.1).
Since brain floats in cerebrospinal fluid, it only weighs 2 Neuroglial cells (neuroglia), forming the supporting
50 grams which is comfortable. (connective) tissue of the CNS. In peripheral nervous
There are about 130 billion neurons in an adult brain system, these are replaced by Schwann's cells.
(very rich). Both types of cells are supplied by abundant blood
vessels.
NEURON
ANATOMICAT Each neuron is made up of the following.
It is divided into: I A eell bady: Collectively they form grey matter and
1" Central nervous system (CNS) which comprises the nuclei in the CNS, and ganglia in the peripheral
brain and spinal cord. It is responsible for integrating, nervous system.
coordinating the sensory information and ordering 2 Cell pr0ces6es of two vdrieties:
appropriate motor actions. CNS is the seat of a. Dendrites (Greek branch of a tree) are many, short,
learning, memory, intelligence and emotions. richly branched and often varicose (Fig.21..2a).
2 Peripheral nervous system (PNS) includes 12 pairs b. The axon is a single elongated process. Collec-
of cranial nerves and 31 pairs of spinal nerves. These tively the axons form tracts (white matter) in the
provide afferent impulses to CNS and carries CNS, and nerves in the peripheral nervous system.
efferent impulses to muscles, glands and blood The branches of axons often arise at right angles
vessels (Flow chart 21.1). and are called the collaterals.
Functionall/, each neuron is specialized for sensi-
FUNCTIONAT tivity and conductivity. The impulses can flow in them
Peripheral nervous system functionally has two with great rapidity,in some cases about 125 meters per
components: second. A neuron shows dynamic polarity rn its processes.
1 Afferent component provides sensory information The impulse flows towards the cellbodyinthe dendrites,
to CNS. and away from the cell body in the axon (Fig. 21,.2b).
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I
BRAIN
FIow chart 21 .1 : Divisions of nervous system
Myelin sheath
Flg. 21.1 : Structure of a neuron
Closslficolion ol Neurons Pseudounipolar
Aceordlng fa fhe ffurnhe,rof fhefr

Frseg$sss, info Four ss
'1, Multipolar neurons. Most of the neurons in man are
Multipolar Bipolar
multipolar, e.g. all motor and internuncial neurons
(Fi9.21..2a).
.,,Q
2 Bipolar neurons are confined to the first neuron of the
retina, ganglia of eighth cranial nerve, and the
olfactory mucoSa (Fig. 21..2b). Pyramidal
cell (soma)
Pseudounipolar neurons are actually unipolar to begin
with but become bipolar functionally and are found
Basal
in dorsal nerve root ganglia and sensory ganglia of dendrites
the cranial nerves (Fig.21..2c).
Unipolar neurons are present in the mesencephalic Collateral
nucleus of trigeminal nerve and also occur during
foetal life. These cells are more common in lower
.E
(E
vertebrates. (a)
m
N
*ceo gto Lenglh o/Axon
.9
I Golgi e I: These neurons have long axons and
o
o
numerous short dendrites. These are seen in
@ pyramidal cells of cerebral cortex (Fig. 2L.2a), Figs 21.2a to c: Types of neuron
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Purkinje cells of cerebellum and anterior horn cells ,According fo $h e
of spinal cord. Stellate
2 Golgi Type Il: These are neurons with small axons, Basket
and establish synapses with neighbouring neurons.
Fusiform
These are also seen in cerebral cortex and cerebellar
Pyramidal
cortex.
3 Amacrine neurons without axon, only with dendrite.
Accor g fo Ske
They are seen in retina of eyeball.
Mature neuron is incapable of dividing. Recently Macroneuron: More thanT pm size
some neurons in olfactory region and hippocampus Microneuron: Less thanT pm size.
have been seen to divide. Brain tumours arise chiefly
from the neuroglial cells. SYNAPSE
The neurons are connected to one another by their
Funefionol Clossifiealion processes, forming long chains along which the
Neurons are classified into sensory neurons, autonomic impulses are conducted. The site of contact (contiguity
neurons, i.e. parasympathetic and sympathetic neurons without continuity) between the nerve cells in known
motor neurons. as 'symapse' (Greek together) (Fig.21.3). One cell may
establish such contacts through its dendrites with as
Sensary neurans
many as 1000 axonal terminals. However, it must be
These are of three types:
remembered that each neuron is an independent unit
I Primary or Lst order sensory neurons are present as and the contact between neurons is by contiguity and
spinal or sensory neurons in the dorsal root ganglion
not by continuity ('neuron theory' of Waldeyer,1.891).
of spinal neryes.
The impulse is transmitted across a synapse through
2 Secondary or 2nd order sensory neurons are present in biochemical neurotransmitters (acetylcholine).
the grey matter of spinal cord and in brain stem.
3 Tertiary or 3rd order sensory neurons are seen in
NEUROGTIAL CEILS
thalamus (see Fig. 23.1.4).
Various types of neuroglial (Greek nerae glue) cells are
Motor neurons as follows:
These carry impulses from CNS to distal part of the 1 Astrocytes are concerned with nutrition of the
body. These somatic motor are of two types: nervous tissue are star shaped cells. These formblood
1 Upper motor neurons are situated in motor area of brain barrier. These are of two types, protoplasmic
brain. These synapse with cranial nerve nuclei and and fibrous. Astrocytes are absent in pineal gland
anterior horn of spinal cord. and posterior pituitary (Fig. 2L.q.
2 Lower motor neurons are located in cranial nerve 2 Oligodendrocytes (Greek few processes) are
nuclei and anterior horn of spinal cord. Nerves
counterparts of the Schwann cells. Schwann cells
emerging from these nuclei supply the various
myelinate the peripheral nerves. Oligodendrocytes
skeletal muscles (see Fig. 23.71).
myelinate the tracts.
c neur ons (autonomic)
P ar asy mp at heti
1 Preganglionic neurons are located in cranial nerves

III, VII, IX and X and also in sacral2-4 segments of
Mitochondria
the spinal cord.
2 Postganglionic neurons are located close to the wall Axon
or within the wall of the viscera. terminal
Presynaptic
3 The parasympathetic outflow is called "craniosacral bouton Synaptic
outflow". vesicle
Sy mp athet ic neur ons (autonomic) Presynaptic dense

Synaptic
projection
1 Preganglionic neurons are located in the lateral horn cleft
of thoracic one to lumbar two segments of the spinal Subsynaptic web tr
'6
cord.
Postganglionic neurons are situated in the ganglia
Postsynaptic process o
C\I
of the sympathetic trunk away from the viscera. c
o
The sympathetic outflow is called "thoracolumbar o
o
outflow." Fig, 21.3: Typical synapse seen with electron microscope a
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BRA N
Outer granular layer
Outer pyramidal layer
ff*
lnner pyramidal layer
*ff )\
(i'
vo
ô
lnner granular layer @- o o
6^
Polymorphous layer
o o^
6
Capillary
Figs 21.4a and b: Types of neurons: (a) Cerebralcortex with inset, and (b) Purkinje cell
3 Microglia (Greek small glue)behave like macrophages

of the CNS. They develop from mesoderm.
4 Ependymal cells are columnar cells lining the cavities
of the CNS (Fig. 21.5).
Various features of these cells are shown in Table 21.1.
Proliferation of glial cells is called the 'gliosis'. A CNS
lesion heals by gliosis. A spontaneous gliosis is an
indication of a degenerative change in the nervous
tissue. Since the glial cells are capable of dividing, they
can form the CNS tumours. Fibrous astrocyte
Protoplasmic astrocyte
REFLEX ARC
A reflex arc is the functional unit of the nervous system.
In its simplest form (monosynaptic reflex arc) it consists
of:
1 A receptor, e.g. the skin/muscle.
2 The sensoryneuron.
3 The motor neuron.
4 The effector, e.g. the muscle.
In complex forms of the reflex arc, the internuncial
neurons (interneurons) are interposed between the
sensory and motor neurons. An involuntary motor
response to a sensory stimulus is known as the reflex Fig. 21.5: Types of neuroglia
Table21.1: Types of neuroglial cells

Protoplasmic astrocyte Fibrous astrocyte Oligodendroclrte Microglia
Cellsize Large Large Medium Small, elongated
Shape of nucleus stained Oval, light Oval, lightstained Small, spherical dark stained Small, elongated dark stained
Cytoplasmic Many, short thick Many long slender Few short, beaded Shoft, thin spine like
processes
c
'6 Cytoplasm Granular Fibrillar
o Situation Grey matter White matter matter
White Grey and white matters
N Function Blood brain barrier BBB Myelination Phagocytosis
o (BBB)
o
o
a
Embryological origin Neural crest Neural crest Neural crest Mesoderm
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INTRODUCTION
Table21.2: Some common reflexes

Name of reflex Way of eliciting Result Comment
Biceps jerk Striking biceps brachii Flexion of the elbow joint C5, CO segments intact
tendon Tendon jerks may be exaggerated in upper motor
neuron lesion or lost in lower motor neuron lesion
Triceps jerk Striking triceps brachii Extension of the elbow joint C7, C8, segments intact
tendon
Knee jerk Striking the ligamentum Extension of the knee joint L3, L4 segments of spinal cord intact
(Fig. 21.6) patellae
Ankle jerk Striking tendocalcaneus Plantar flexion of the ankle 51 , 52 segments intact
joint
Abdominal Striking a quadrant of Contraction of abdominal Positive reflex indicates normal pyramidal tract
reflex abdomen muscles with T7-T12 nerves intact
Plantar reflex Scratching the sole of Plantar flexion of the great A normal plantar response indicates intact
foot from lateral side toe and other toes pyramidal tract
towards big toe
Babinski's sign Same as in plantar reflex Dorsiflexion of the great toe Babinski's sign indicates pyramidal tract
(Fig.21.7) and fanning of other toes injury, except in infants
action. Only cortical responses are voluntary in nature. PERIPHERAL NER US SYSIEM
All subcortical responses are involuntary and therefore 1 Somatic (cerebrospinal) nervous system. It is made
are the reflex activities. Reflex action is chief function up of 1,2 pairs of cranial nerves and 31 pairs of spinal
of spinal cord. Knee jerk and ankle jerk are mono- nerves. Its efferent fibres reach the effectors without
qmaptic reflex arcs (Fig. 21.5). Some common reflex arcs interruption (Fig. 21.8a).
are shown tnTable27.2. 2 Autonomic (splanchnic) nervous system. It consists
of sympathetic and parasymPathetic systems. Its
efferent fibres first relay in a ganglion, and then the
postganglionic fibres pass to the effectors (Fig. 21.8b).
CENIRAL NER US SYSTEM (CNS)
L Brain: Occupies cranial cavity. Porls of Broin

2 Spinal cord: Occupies upper two-thirds of the The main parts and their subdivisions are shown in
vertebral canal. Table 21.3 and Fig. 21.9.
Muscle spindle
Quadriceps
femoris
Motor end plate in skeleial muscle
Patellar tendon
.E
(E
o
o,t
c
o
o
o
Fig. 21.6: Knee jerk a
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BRAIN
If a nerve (axons) is injured or cut, a series of

degenerative and then regenerative changes
follow. The degenerative changes occur in:
a. Cell body: It undergoes chromatolysis. Nissl
granules disappear; cell becomes swollen and
rounded; and the nucleus is pushed to the
periphery.
b. The proximal part of the cut fibre: So long the
mother cell is intact, it survives, and only a part
near the cut end degenerates in a way similar
to the distal part (Figs 21.11a to e).
c. The distal part of the cut fibre: It degenerates
completely. Axis cylinder becomes fragmented;
myelin sheath breaks up into fat droplets, and
the nuclei of Schwarur ce1ls multiply and fill up
the neurilemmal tube. During regeneration, the
Flg" 21.7: Babinski's sign tip of the axon still connected with the cell body
begins to grow through the neurilemmal tube.
The brain stem includes the midbrain, pons and The rate of growth is about 1-2 mm per day in
medulla. man. Myelin sheath is reformed. Restoration of
Hindbrain includes pons, medulla and cerebellum. function may be considerable but rarely
The dilated part of the central canal of spinal cord complete. The role of neurilemmal tube as a
within the conus medullaris is known as the terminal guiding factor to the regenerating proximal axon
ventricle. Similarly, the cavity of septum pellucidum is considered to be of paramount importance.
is sometimes called as the fifth ventricle. . Thus a nerve can regenerate because it has a
neurilemmal sheath. A tract cannot regenerate
GROSS STUDY OF BRAIN because it has no such sheath. However, a tract
Brain can be cut in the following planes: after demyelination can remyelinate, as is seen in
b{.orizontnl plane: When it is cut from side to side demyelinating diseases.
(Fig. 21.10a). ' Tumours of the nervous tissue arise mostly from
the neuroglia, as developed neurons have lost the
Caronsl plane: When brain is cut through dorsal and
power of multiplication except in a few areas.
ventral surfaces in the coronal plane (Fig.21.10b).
Tumours fromneuroglial cells are called gliomas.
Sagittal plane: When brain is cut in relation to longi- These are highly malignant and rapidly growing
tudinal axis, i.e. from anterior to posterior aspect tumours.
(Fig. 21.10c).
Table 21.3: Parts of brain

Pafts Subdivisions Cavity
1. Forebrain A Telencephalon (cerebrum), made up of two cerebral hemispheres and Lateral ventricle
(prosencephalon) the median part in front of the interventricular foramen
B. Diencephalon (thalamencephalon), hidden by the cerebrum, consists of: Third ventricle
a. Thalamus
b. Hypothalamus
c. Metathalamus, including the medial and lateral geniculate bodies, and
d. Epithalamus, including the pineal body, habenular trigone and posterior
commissure
.= e. Subthalamus
.E
tr 2. Midbrain Crus cerebri, substantia nigra, tegmentum, and tectum, from before Cerebral
N (mesencephalon) aqueduct backwards
c
.o
()
3. Hindbrain A. Metencephalon, made up of pons and cerebellum Fourth ventricle
o (rhombencephalon) B. Myelencephalon or medulla oblongata
U)
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INTRODUCTION
Neuron
Lateral veniricle
lnterventricu la r
foramen
lll ventricle
Cerebral aqueduct
lV ventricle
l
Skeletal muscle Smooth muscle Central canal
(a) (b)
Figs 21.8a and b: Difference between: (a) Somatic, and Fig. 21.9: Parls of developing brain
(b) autonomic nervous systems
Figs 21.10a to c: Gross study of brain. (a) Horizontal, (b) coronal, and (c) sagittal planes
Axon
-
sprouting
Target
reinnervated
tr
'6
E
N
Figs 21 .11a to muscle fibre, (b) motor axon has been severed, and the cell
e; (a) Normal motor neuron innervating a skeletal c
o
body is undergoing chromatolysis, (c) this is associated with sprouting of axon terminal, (d) with regeneration of the axon. The o
excess sprouts degenerate, and (e) when the target cell is reinnervated, chromatolysis is no longer present o
U)
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I
BRAIN
a Neurons in human brain are about 180-200 billion A man aged 60 and his son aged 72had injuries to
a Mature neurons do not divide after birth except their arm region and wrist region respectively in an
in olfactory region and in hippocampus. automobile accident.
o Who will have better return of functions?
a If neurons divide one will have fleating memory. . More effective regeneration will be in the father
a Impulse travels from dendrite to cell body and then
or son and why?
into axon
Contact between neurons is by contiguity (like Ans" All repair occur faster in younger n older
hand shake) and not by continuity persans- So son's injuny will heal eartrier.
More effective regeneration will be again in
a Human has the largest cerebrum so far
son as the inj is in a distal area. In a dlstal area
a Ependymal cells are responsible for the formation
few structures are left to be supplied; so there are
of cerebrospinal fluid. Astrocytes form the blood-
less chances of innervating the wrong structures
brain barrier.
dr-rr the reparative process"
MUTTIPLE CHOICE QUESTIONS
1. Branched nerve fibre that convey impulses towards 5. Cut neurons possess limited capabilities for
cell body of a neuron is called: regeneration. The type of neuroglial cells that aids
a. Axon b. Dendrites regenerationby forming a regeneration tube to help
establish firm connection is:
c. Axon collaterals d. Axon terminals
, a. Schwann cells b. Astrocytes
Myelin sheath on peripheral nerves is contributed
by, c. Microglial d. Ependymal
a. Axon itself 7. The cells that conduct message towards brain:
b. Secretory vesicles a. Motor neuron
c. Schwann cells b. Sensory neuron
d. Cell bodies of neuron c. Interneuron
3. A neuron with many dendrites arising from cell
d. Neuroglia
body and carrying impulses away from the neuron 8. Myelin sheath is produced by:
via the axon is: a. Neuron
a. Multipolar b. Axon
b. Bipolar c. Dendrite
c. Unipolar and sensory d. Schwann's cells/oligodendrocyte
d. Multipolar and motor 9. The three regions of brainstem:
4. The grey appearance of spinal grey matter is due to a. Cerebrum, diencephalon, midbrain
a. Neuronal body b. Neuroglia b. Pons, cerebellum, midbrain
c. Neurites d. Blood vessels c. Diencephalon, midbrain cerebrum
5. Which type of cells helps regulate composition of d. Midbrainz porrs, medulla oblongata
CSF? L0. Three parts of hindbrain are:
a. Astrocyte a. Cerebrumr ponS, cerebellum
b. Oligodendeocyte b. Pons, medulla oblongata, cerebellum
c. Microglia c. Pons, midbrain, cerebellum
tr d. Ependymal cells d. Thalamus, pons, cerebellum
'6
o
N SWIRS
C
o
() 1.b 2.c 3.d 4.a 5.d 6.a 7.b 8. d 9.d 10.b
0)
a
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Robbins
-Anthony
INTRODUCIION Pull it on a horizontal plane. Thus the fused endosteum

The brain is a very important delicate organ. It is and dura mater get separated from the underlying
protected by the following coverings. subarachnoid mater, pia mater and the brain.
1 Bony covering of the cranium. ldentify various venous sinuses between the
2 Three membranous coverings (meninges): endosteum and folds of dura mater. Underneath the
a. The outer dura mater (pachymeninx). dura mater and separated by a flimsy subdural space
b. The middle arachnoid mater. is the cobweb-like arachnoid mater. lt is separated from
c. The inner pia mater. The arachnoid and pia are the underlying pia mater by the subarachnoid space,
together known as the leptomeninges. containing cerebrospinal fluid and blood vessels of the
3 The cerebrospinal fluid fills the space between the brain. Cranial nerves also pass through this space. Near
arachnoid and the pia maters (subarachnoid space) the superior sagittal sinus, araehnoid mater forms
and acts as a water cushion. arachnoid villi. The subarachnoid space is dilated
The brain almost floats in the cerebrospinal fluid around the brainstem and at the base of the brain
without putting "its weight" on the neck. The outermost forming the subarachnoid cisterns.
meninx, the dura mater not only separates the right and Cerebrospinal fluid formed by choroid plexuses flows
left cerebral hemisphere, but also partitions the through the ventricles of the brain into the subarachnoid
cerebrum from cerebellum and hypophysis cerebri. In space to be absorbed via subarachnoid villi into the
addition, it encloses various venous sinuses. The CSF superior sagittal sinus.
forms watery cushions around the blood vessels to give
them shock-free environment. DU MATER
The cerebral dura (Latin hard mother) mater has been
studied in detail with the head and neck in Chapter 12.
However, it may be recapitulated that it is made up of
DISSECTION two layers, an outer endosteal layer and an inner
Cut through the fused endosteum and dura mater on
meningeal layer, enclosing the cranial venous sinuses
between the two. The meningeal layer forms four folds
the ventral aspect of brain from the inferolateral borders
extending along the superolateral margin. Pull upwards
which divide the cranial cavity into intercommuni-
the endosteum along with the fold of dura mater present
cating compartments for different parts of the brain
(Figs22.La to c and Table22.1).
between the adjacent medial surfaces of cerebral
hemispheres, extending from the frontal lobe till the
occipital lobe. This is falx cerebri. Pull backwards a
AR I.INOID MAIER
similar but much smaller fold between two adjacent The arachnoid (Latin cobweb like) mater is a thin
lobes of cerebellum-the falx cerebelli. transparent membrane that loosely surrounds the brain
Separating the cerebrum and the cerebellum is without dipping into its sulci. Thus it bridges all
another fold of dura mater called the tentorium cerebelli. irregularities of the brain. It enters following sulcus/
fissure:
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BRAIN
Superior sagittal
stnus
Superior
sagittal sinus Falx cerebri
Falx cerebri
lnferior sagittal Falx cerebri Straight sinus
stnus
Straight sinus Tentorium
Outer and inner
layers of dura mater Tentorium cerebelli
cerebelli Transverse
Tentorium cerebelli SINUS
Transverse
Right transverse SINUS Falx cerebelli
sinus
Falx
Tentorial notch cerebelli
Foramen magnum
(b) (c)
Figs 22.1a to c: Coronal sections through the posterior cranial fossa showing folds of dura mater and the venous sinuses enclosed
in them: (a) Section through the tentorial notch (anterior part of the fossa), (b) section through the middle part of the fossa, and
(c) section through the posterior-most part
Table22.1: The meningeal layer sends inwards following folds of dura mater
Folds Shape Attachments Venous slnuses enclosed
Falx cerebri Sickle-shaped, separates the Superior, convex margins are attached to Superior sagittal sinus
(Fis.22.2) right from left cerebral sides of the groove lodging the superior
hemisphere sagittal sinus.
lnferior concave margin is free lnferior sagittal sinus
Anterior attachment is to crista galli, Stralght sinus
posterior to upper surface of tentorium
cerebelli
Tentorium cerebelli Tent-shaped, separates the Has a free anterior margin. lts ends are Transverse sinuses,
(Fis.22.3) cerebral hemispheres from attached to anterior clinoid processes. superior petrosal sinuses
hindbrain and lower part of Rest is free and concave.
midbrain Posterior margin is attached to the lips of
Lifts off the weight of occipital groove containing transverse sinuses,
lobes from the cerebellum superior petrosal sinuses and to posterior
clinoid processes
Falx cerebelli Small sickle-shaped fold partly Base is attached to posterior part of inferior Occipital sinus
cerebellar
separating two surface of tentorium cerebelli
hemispheres Apex reaches till foramen magnum
Diaphragma sellae Small horizontal fold Anterior attachment is to tuberculum sellae Anterior and posterior
(Fis.22.3) Posterior attachment is to dorsum sellae; intercavernous sinuses
laterally continuous with dura mater of
middle cranial fossa
1 The stem of lateral sulcus where it is pushed by lesser

wing of sphenoid.
2 The longitudinal cerebral fissure where it is carried
in by falx cerebri.
3 It cannot be identified in the hypophyseal fossa.
Relolions
It is separated from the dura by the subdural space,
tr and from the pia by the subarachnoid space containing
'6 cerebrospinal fluid (CSF) and blood vessels.
E
N
C Prolongolions
o
o
o Fig,22.2: Falx cerebri, arachnoid granulation and superior sagittal 1 It provides sheaths for the cranial nerves as far as
a sinus their exit from the skull.
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MENINGES OF THE BRAIN AND CEREBROSPINAL FLUID
Diapharagma sellae covering

hypophyseal fossa
Anterior clinoid process
Optic nerve
lnternal carotid artery
lnfundibulum
Aperture for oculomotor nerve
Oculomotor nerve
Aperture for trochlear nerve
Trochlear nerve
Great cerebral vein with superior petrosal sinus
Free margin of tentorium cerebelli
Transverse sinus within layers of tentorium
Opening of superior sagittal sinus
Fig.22.3z Tentorium cerebelli and diaphragma sellae
2 Arachnoid villi are small, finger-like processes of SUBARACHNOID SPACE

arachnoid tissue, projecting into the cranial venous This is the space between the arachnoid and the pia
sinuses. They absorb CSF. With advancing age, the maters. It is traversed by a network of arachnoid
arachnoid villi enlarge in size to form pedunculated trabeculae which give it a sponge-like appearance.
tufts, called arachnoid granulations. These It surrounds the brain and spinal cord, and ends
granulations may produce depressions in bone below at the lower border of the second sacral vertebra.
(Fis.22.2). The subarachnoid space contains CSF, and large
vessels of the brain. Cranial nerves pass through the
PIA MATER sPace.
The pia (Latin loving mother) mater is a thin vascular Larger arteries lie in subarachnoid space. Smaller
membrane which closely invests the brain, dipping into ones carry sheaths of pia. Subarachnoid space and
various sulci and other irregularities of its surface. It perivascular spaces are separated by layer of pia matter.
comprises epi-pia and pia-glia. On the cerebellum pia Space between the nervous tissue and fold of pia
mater dips and forms folds in relation to larger fissures mater with arterioles is known as Virchow-Robin's
of cerebellum. perivascular space.
Prolongolions Cislerns
1 It provides sheaths for the cranial nerves merging At the base of the brain and around the brainstem, the
with the epineurium around them. subarachnoid space forms intercommunicating pools,
2 It also provides perivascular sheaths for the minute called cisterns. These reinforce the protective effect of
vessels entering and leaving the brain substance. CSF on the vital centres situated in the medulla. The
3 Folds of pia mater enclosing tufts of capillaries form subarachnoid cisterns are as follows.
the telachoroidea. Such pia mater lined by secretory 1 Cerebellomedwllary cistern or cisterna magna: It is the
ependyma form the choroid plexus. largest cistern lying in the angle between medulla
oblongata, cerebellum and occipital bone. It is
EXTRADURAT (EPIDURAI) AND SUBDURAL SPACES triangular in section. It bridges the interval between
The extradural or epidural space is a potential space inferior surface of cerebellum and medulla oblongata
between the inner aspect of skull bone and the endosteal (Fi1.22.\.
layer of dura mater. This cistern communicates with three openings in tr
(E
The subdural space is also a potential space between the roof of fourth ventricle and with the posterior o
the dura and arachnoid maters. These become actual part of subarachnoid space. OI
spaces in pathological conditions. The subdural space 2 Cisterna pontis: It is present on the ventral aspect of c
o
is traversed by cerebral veins on their path for draining pons and contains basilar artery and its branches. It o
o
into dural venous sinuses. is continuous with interpeduncular cistern cranially, a
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BRAIN
Choroid plexus of lateral ventricle Great cerebral vein
Choroid plexus of third ventricle

Third ventricle Cistern of great cerebral vein
(cisterna ambiens)
lnterpeduncular cistern
Cisterna pontis
Choroid plexus of fourth ventricle Cerebellomedullary cistern

(cisterna magna)
Median aperture
Lumbar cistern
Fig. 22.4: Subarachnoid cisterns
with cerebellomedullary cistern behind and with 1 A median foramen of Magendie.

spinal subarachnoid space caudally. 2 Two lateral foramina of Luschka, situated in the roof
3 lnterpedunculfir cistern: This is a large cistern as the of the fourth ventricle. The CSF passes through these
arachnoid mater passes across the two temporal foramina from the fourth ventricle to the
lobes. It contains important circle of Willis. The subarachnoid space.
cistem is continuous with the subarachnoid spaces
around anterior, middle and posterior cerebral Prolongolions
artery. 1 The space is prolonged into the arachnoid sheaths
4 Cistern of lateral sulcus: It lies in front of each temporal around nerves where it communicates with the
pole and is formed due to bridging of arachnoid neural lymphatics, particularly around the first,
mater over the lateral sulcus. This cistern contains second and eighth cranial nerves.
middle cerebral artery. 2 The space also extends into the pial sheaths around
5 Cistern of great cerebral oein (cisterna aml)iens): Tirris the vessels entering the brain substance (perivascular
cistern lies in the space between splenium of corpus space). Thus CSF comes into direct contact with nerve
callosum and superior surface of cerebellum. It cells.
contains pineal.gland and great cerebral vein of
Galen.
5 Lumbar cistern: This is a large subarachnoid space in . CSF can be obtained by:
the lumbar region of the vertebral column distal to a. Lumbar puncture;
the termination of the spinal cord. In the space b. Cisternal puncture; or
between L3 and L4 which is part the lumbar cistern, c. Ventricular puncture.
lumbar puncture is done to obtain a sample of CSF. Lumbar puncture is the easiest method and is
The arterial pulsations within the cisterns help to commonly used (see Fig. 11.a)
force the CSF from the cisterns on to the superolateral It is done by passing a needle in the interspace
'6 surface of the hemispheres. The cisterns themselves between the third and fourth lumbar spines.
o form cushions around the medulla. o Biochemical analysis of CSF is of diagnostic value
N in various diseases.
C Communicolions . Papilloedems: The subarachnoid space sends
o
o
o
The subarachnoid space communicates with the extensions along the optic nerves till the back of
a ventricular system of the brain at:
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eyeball. Increased CSF pressure compresses the The total quantity of CSF is about 150 ml. It is formed
wall of retinal vein leading to forward bulging of at the rate of about 200 ml per hour or 5000 ml per day.
optic disc with oedema of the disc. Oedema of the The normal pressure of CSF is 60 to 100 mm of water.
optic disc is known as papilloedema. It can be
CIRCULATION
viewed by an ophthalmoscope.
Lumbar epidural: The epidural space is the space CSF passes from each lateral ventricle to the third
between vertebral canal and dura mater. The ventricle through the interventricular foramen of
epidural space is deeper in the midline. The Monro. From the third ventricle, it passes to the fourth
procedure is same as lumbar puncture, the needle ventricle through the cerebral aqueduct. From the
should reach only in the epidural space and not fourth ventricle, the CSF passes to the subarachnoid
deep to it in the dura mater. Epidural space is spaces of the cerebrum and the vertebral canal through
utilized for giving anaesthesia or analgesia the median and lateral apertures of the fourth ventricle
(see Fig.77.5). (Flow chart 22.1). Some of it passes down the central
Inflammation of pia mater and arachnoid mater canal of spinal cord.
is known as meningitis. This is commonly
tubercular or pyogenic. It is characterised by fever, ABSORPTION
marked headache, neck rigidity, and a changed
biochemistry of CSF.
L CSF is absorbed chiefly through the arachnoid villi
and granulations, and is thus drained into the cranial
venous sinuses.
2 It is also absorbed partly by the perineural
lymphatics around the first, second and eighth
The cerebrospinal fluid is a modified tissue fluid. It is cranial nerves.
contained in the ventricular system of the brain and in 3 It is also absorbed by veins related to spinal nerves.
the subarachnoid space around the brain and spinal
cord. CSF replaces lymph in the CNS (Fig.22.5). FUNCTIONS OF CSF
1 CSF decreases the sudden p.ressure or forces on
FORMATION delicate nervous tissue.
1 The bulk of the CSF is formed by the choroid plexuses 2 CSF nourishes nervous tissue. Only CSF comes in
of the lateral ventricles and lesser amounts by the contact with neurons. Even blood cannot directly
choroid plexuses of the third and fourth ventricles. come in contact with neurons. It provides nourish-
2 Possibly, it is also formed by the capillaries on the ment and returns products of metabolism to the
surface of the brain and spinal cord. venous sinuses.
Lateral ventricles
I nterventricular foramen
Cerebral aqueduct
3rd ventricle
lV ventricle
Median aperture
'6
E
N
C
.o
o
Flg. 22.5: Formation, circulation and absorption of CSF ao
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BRAIN
Flow chafi 22.1: Cerebrospinal fluid (CSF) Obstruction in the vertebral canal produces Froin's
Forms in lateral ventricles syndrome or loculation syndrome. This is charac-
terized by yellowish discolouration of CSF
(xanthochromia) below the level of obstruction,
and its spontaneous coagulation alter withdrawal
due to a high protein content. Biochemical examin-
ation of such fluid reveals that the protein content
is raised, but the cell content is normal. This is
known as albuminocytologic dissociation.
HydrocEhalas; It is the dilatation of the ventricular
system and occurs due to obstruction of CSF
circulation. It may be of the following types:
a. Communicating: If the obstruction is outside the
3 apertures in roof one median and two lateral
- ventricular system, usually in the subarachnoid
space or arachnoid granulations, it is termed
as corrununicating. This occurs due to fibrosis
following meningitis. It is also called external
hydrocephalus.
Subarachnoid Cerebellomedullary cistern
space around and pontine cistern, Clinical features are:
spinal cord and i.e. subarachnoid spaces in cranial cavity
cauda equina - Head size is rather large.
- Tense anterior fontanelle
- Dilated veins over thin scalp.
b. Non-communicating: If the obstruction is within
lnferior surface of cerebrum
the ventricular system. It is called non-
communicating or internal hydrocephalus. This
Superolaieral surface of cerebrum
is usually caused by a tumour or inflammation
(Figs 22.6a and b). A shunt procedure is
employed to divert the CSF from the ventricular
system into the peritoneal cavity.
Neurons cannot live without glucose and oxygen for

more than 3-5 minutes. These are constantly
provided by CSF.
4 Pineal gland secretions reach pituitary gland via CSF.
5 A major function of CSF is to cushion the brain within
its solid vault. The brain and CSF have approximately
the same specific gravity, so that the brain simply
floats in the fluid.
There is no CSF brain barrier, so drugs can reach the
neurons through CSF
(b)
There is blood CSF barrier. There are no antibodies (a)
in CNS, making infections of brain very serious Figs 22.6a and b: (a) Ventricles in normal case, and (b)
entity. ventricles in hydrocephalus case
Mnemonics
c .
'6 Drainage of CSF at regular intervals is of PAD
o therapeutic value in meningitis. Certain intrac-
N table headaches of unknown aetiology are also P - Pia mater
C
o known to have been cured by a mere lumbar A - Arachnoid mater
o puncture with drainage of CSF. D - Dura mater
o0)
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Cisterns contain increased amount of CSF to An infant of 3 months was brought to a neurologist
protect the big veins, circle of Willis etc. for abnormal large size of her head with, differently
CSF is present outside the brain in the sub- looking eyes. On examination, she showed large and
arachnoid space; within the brain in its ventricles. tense fontanelles
Thus the brain is floating in CSF and its weight is o What is the condition called?
not felt by the person. Ans: The condition is called hydroceplralus. It is due
Increased formation or decreased absorption or to blockage of flow of CSF. If excessive CSF collects
any obstruction in its flow leads to hydro- within, ve icular system, it is called internal \dro-
cephalus. cephalus.
Cerebrospinal fluid is present in the central canal If excessive fluid collects in the subarachnoicl
of spinal cord and in subarachnoid space around space, it is called external hydrocephalus.
the spinal cord. e treatment is surgery.
MULTIPLE CHOICE QUESTIONS
L. \Mhich sequence lists cranial meninges in order c. Deliver nutrition and chemical messengers
from superficial to deep? d. All of above
a. Pia, arachnoid, dura maters 6. Which structure produces CSF in each ventricle?
b. Dura, pia, arachnoid maters a. Choroid plexus
c. Dura, arachnoid, pia maters b. Arachnoid villus
d. Arachrioid, dura, pia maters c. Arachnoid granulation
2. In region where two layers of dura mater separate, d. Diaphragma sellae
the gap between them contains:
7. From subarchnoid space, CSF flows into dural
a. Dural venous sinus venous sinus through:
b. Epidural veins a. Lateral apertures
c. Subdural fluid b. Median aperture
d. Subarachnoid fluid c. Arachnoid villi
3. Largest of cranial dural partition is: d. Arachnoid trabeculae
a. Sella turcica 8. Blood brain barrier of CNS is missing or markedly
b. Falx cerebri reduced in which of following locations?
c. Tentorium cerebelli a. Spinal cord and cerebellum
d. Falx cerebelli b. Pituitary gland and thalamus
4. Dura and arachnoid extend up to the lower border c. Choroid plexus, pons and medulla oblongata
of which vertebra? d. Choroid plexus, hypothalamus and pineal gland
a.2nd lumbar
- b. 3rd lumbar 9. Total volume of CSF is:
c. 2nd sacral d. sth sacral a. 50 ml
5. CSF perform which of following functions? b. L00 ml
a. Provide buoyancy for brain c. 150 ml
b. Cushion neural structure from sudden jerks d.275 ml
ANSWERS c
'6
1.c 2.a 3.b 4.c s.d 6.a 7.c 8.d 9.c o
N
c
o
()
ao
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-Anonymous
INTRODUCTION
Pia mater enclosing
The spinal cord is the long cylindrical lower part of central the spinal cord
nervous system.Itoccupies upper two-thirds of vertebral Arachnoid mater
Epidural space
canal and is enclosed in the three meninges. It gives rise
to 3l pairs of spinalnerves and retains thebasic structural
pattern.
Subdural space
DISSECIION Dura mater
Study the spinal cord after it was removed from vertebral

canal (see Chapter 1'1) and separated from the dura
mater and arachnoid mater. ldentify the dorsal root to
the presence of dorsal root ganglion or spinal ganglion.
Note the position of ceruical enlargement in the upper
part and lumbo-sacral enlargement in the lower par1. See
the numerous nerve roots surrounding the filum terminale Flg. 26,1t Spinal cord with its meninges
forming the cauda equina (Figs 23.2 and 23.3).
segment. The level of spinal segment with their
Cut transverse sections of spinal cord at cervical,
vertebral level is shown in Table 23.1.
thoracic, lumbar, and sacral regions to note the shape
and size of the horns in relation to white matter MENINGEAI" COVERINGS
(Table 23.2).
The spinal cord is surrounded by three meninges. The
outermost is the dura mater, the middle one is
Feolures arachnoid mater and the innermost is the pia mater.
The spinal cord is-18 inches or 45 cm in an adult male The space between dura mater and arachnoid mater is
and 42 cm in adult female. It is surrounded by the three called subdural space. The arachnoid and pia maters
meninges (Fig. 23.1). are separated by subarachnoid space which contains
It extends from upper border of atlas vertebra to the cerebrospinal fluid (Fig. 23.1).
lower border of first lumbar vertebra in an adult. In The spinal cord extends in the lower part of 1st
children it extends up to L3 vertebra. Superiorly, it is lumbar vertebra as conus medullaris. Below the level of
continuous with the medulla oblongata, inferiorly it
terminates as conus medullaris (Fig.23.2).
Tahle23'1 : Level ofvertebral levelsandspinal segments
Vertebral levels Spinal segments
As the spinal cord is much shorter than the length of
the vertebral column, the spinal segments do not lie c1-c7 c1-c8
T1_T6 T1_T8
opposite the corresponding vertebrae. In estimating the
T7-T9 T1 0-T1 2
position of a spinal segment in relation to the surface
T'10-T11 L1_L5
of the body, it is important to remember that a vertebral
T12-L1 S1-S5 and Co1
spine is always lower than the corresponding spinal
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SPINAL CORD
conus medullaris only pia mater is continued as a thin

fibrous cord, the filum terminale.
The spinal cord is enclosed only by the meningeal
layer of dura mater. The space between the meningeal C1-C8 segmenis
t
layer and endosteum of the vertebral canal is called
epidural space, where epidural anaesthesia can be Cervical
I
given. enlargement
(c3 - T2)
The spinal pia mater undergoes modification as
follows:
a. Ligamentum denticulatum with 21 pairs of teeth
like projection which keep the spinal cord in
position.
b. Linea splendens is a thickening seen at the
anteromedian sulcus. T1-T12 segments
The filum terminale is 20 cm long and after leaving
through sacral hiatus ends by getting attached to the
periosteum of dorsal surface of first segment of coccyx.
The dura and arachnoid along with subarachnoid
space containing CSF extend up to 2nd sacral vertebra.
Between the lower border of L1 and 52 vertebrae,
the subarachnoid space contains spinal nerve roots
which constitute the cauda equina.
It is due to this feature that lumbar puncture is done L1-L5 segments Lumbar enlargement
(11-S3)
below L2 vertebra without any danger to spinal cord.
ENTARGEMENIS Sacral enlargement

(s1-s5)
Limbs form the appendages of the trunk. Their muscles
have to be supplied by neurons of spinal cord. Neurons
Col segment
at appropriate levels form enlargements to be able to
supply increased musculature. Spinal cord presents
cervical enlargement for supply of upper limb muscles.
This extends from C4 to T1 spinal segments with
maximum diameter at level of C6 segment (Fig.23.2).
Another enlargement is the lumbar enlargement for
Fig.23.2: The enlargements of spinal cord
supply of muscles of lower limb. It extends from level
of L2to 53 segments.Its maximum diameter is at level end only filum terminale remains to be attached to the
of 51 segment. coccyx.
CAUDA ESUINA
EXTERNAT FEATURES OF SPINAT CORD
Dorsal and ventral nerve roots of right and left sides of
L2 to L5, 51 to 55 and Co1 nerves lie almost vertically Anteriorly, the spinal cord reveals a deep anterior
around filum terminale (Fig. 23.3). These are called median fissure lodging the anterior spinal artery.
cauda equina as these resemble a horse's tail. Dorsal Posterior median sulcus is a thin longitudinal groove
and ventral nerve roots of one segment join together at from which a septum runs in the depth of spinal cord
respective intervertebral foramen to exit as the spinal (Fis.n.$.
nerve. There are 40 nerve roots at the beginning of Each half is subdivided into anterior, lateral and
cauda equina. These are dorsal and ventral nerve roots posterior regions by anterolateral and posterolateral
of right and left sides for each segment. So each segment sulci. Ventral or motor nerve roots emerge from the
has 4 nerve roots. Thus there are 4 x 4 = 16 lumbar anterolateral sulcus. Dorsal or sensory nerve roots enter
nerve roots; 4 x 5 = 20 sactalnerve roots and 4 x 7 = 4 spinal cord from posterolateral sulcus. tr
'6
coccygeal nerve roots, making it to 40 nerve roots. One
INIERNAL STRUCTURE E
dorsal root and one ventral root joins to form one spinal N
nerve and (Fig. 23.3) leaves through the foramen on White matter, i.e. nerve fibres lie outside and grey o
one side. So at every intervertebral foramen 4 nerve matter lies inside. In the centre of grey matter is the ()
o
roots exit the cauda equina; leaving it thinner. In the central canal containing CSF (Fig.n.$. a
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BRAIN
I ntervertebral forami na Shape and size of the horns differ in different

09
segments due to functional reasons (Figs 23.5a to e).
I
These are placed in Table 23.2.
a
o
o
o
.o
I0) o Conus medullaris syndrome: Due to injury to 52,53,
O 54 segments of spinal cord. Features are:
a. Anaesthesia in the perineum. The region is
N supplied by these three segments.
I b. Involvement of bladder and bowel is early 52,
a 53, 54 segments carry sacral component of the
I parasympathetic system which supplies the
(E
bladder and lower bowel.
.E c. Sexual functions are affected as same nerves
F
carry out sexual functions as well.
o Cauda equina syndrome: Damage to cauda equina
results in:
ro
I
a. Lower motor neuron type of paralysis in the
Sacral
a lower limbs due to compression of ventral
o
segments nerve roots.
(U
Coccygeal
-o b. Root pains is an important symptom due to
E
segments J= involvement of dorsal nerve roots.
ro c. Bladder and bowel involvement is late.
Cauda a
I
. Poliomyelitis: It is a viral disease which involves

o
equrna o anterior horn cells leading to flaccid paralysis of
6
o
the affected segments. It is a lower motor neuron
a
(5
paralysis (Fig.23.6).
If poliomyelitis affects the upper cervical segments
Coccygeal root
of spinal cord it may be fatal because of the
Fig. 23.3: Spinal cord with its 31 pairs of spinal nerues involvement of C4 segment which supplies the
diaphragm.
Posterolateral Posterior . Tabes dorsalis (Fig. 23.7): It occurs during tertiary
sulcus median septum stage of syphilis. There is degenerative lesions
Posterior
Posterior of dorsal nerve roots and of posterior white
horn
funiculus columns. Its feature is severe pain in lower limbs,
Lateral horn Lateral as the disease occurs in lower thoracic and
funiculus lumbosacral segments. The lower limbs are
Anterior horn Central mainly affected.
canal
GreY
Anterolateral
commlssure SPINAL NERVES
sulcus
Anterior
median Anterior Spinal nerves arise in pairs, 8 cervical, 12 thoracic,
fissure funiculus 5lumbar, 5 sacral and 1 coccygeal (Fig.23.8).
Fig. 23.4: Transverse section of thoracic segment of spinal cord Each spinal nerve arises by a series of dorsal
and ventral nerve rootlets. These rootlets unite in or
The grey matter is in the form of "H" with a grey near the intervertebral foramen to form the spinal
commissure joining the grey matter of right and left nerve.
.= sides.
(E
Grey matter comprises one posterior horn and one Dorsol Rool Gonglion
o As the dorsal rootlets converge, there is a swelling, the
N anterior horn on each side in the entire extent of the
c
o cord. Only in T1-L2 and S2-S4 segments, there is an dorsal or posterior root ganglion (Fig.23.8), which
() additional lateral horn for the supply of the viscera. houses the cell bodies of all the sensory neurons in that
ao This is part of autonomic nervous system. particular nerve.
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SPINAL CORD
Grey commissure
Substantia gelatinosa
Posterior grey column
Third cervical Nucleus proprius

segment
Accessory nucleus for innervation of
sternocleidomastoid and trapezius muscles
Anterior grey column Phrenic nucleus for innervation of diaphragm
Medial group for innervation of neck muscles
Nucleus proprius
Lateral white column
Sixth cervical Lateral group for innervation
segment of upper limb muscles
Anterior white column Medial group for innervation

of neck muscles
Nucleus proprius
Sixth thoracic
segment Nucleus dorsalis
Preganglionic sympathetic outflow
Medial group for innervation

of trunk muscles
Nucleus proprius
Third lumbar
segment Nucleus dorsalis
Lateral group for innervation

of lower limb muscles
Nucleus proprius
Third sacral
segment Preganglionic parasympathetic outflow
Lateral group for innervation

of lower limb muscles
Figs 23.5a to e: Features of spinal cord at various levels
Table23.2: Shape of horns in different segments of spinal cord

Segments of spinal cord Posterior horn Lateral horn Anterior horn
Cervical, oval shape Slender Absent Narrow in 1- 3 segments
(Fis. 23.5) Broad in C4 to C8 segments for supply
of upper limbs
tr
Thoracic, circular shape Slender Present for thoracolumbar outllow Slender inf2-f12 segments, broad in .G
Tl segment E
Lumbar, circular shape Bulbous Present only in lumbar 1 segment Bulbous for supply of lower limbs N
C
Sacral, circular but smaller Thick Present in sacral 2-4 segments for Bulbous for supply of lower limbs o
sacral outflow o
ao)
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BRA N
Bronches of o Typicol Nerve

#*rssi {Js
It supplies the dorsal one-third of the body wall. Dorsal

rami do not supply the limbs (Fig.23.8).
It supplies the ventral two-thirds of the body wall

including the limbs.
SPINAL SEGMENT
Segment or part of spinal cord to which apair of dorsal
nerve roots, (right and left) and a pair of ventral nerve
roots is attached is called a spinal segment.
Since length of spinal cord (45 cm) is smaller than
the length of vertebral column (65 cm), the spinal
segments do not correspond to the vertebral levels.
Spinal segments being shorter lie above the
corresponding vertebrae. Table 23.1 gives level of spinal
segments and vertebral levels.
NUCLEI OF SPINAL CORD

The grey matter of spinal cord is arranged in three
horns. Anterior is motor, lateral being visceral efferent
and afferent in function, and posterior is sensory in
function.
Nuclei in Anterior Gley Column oI Horn

The anterior horn is divided into a ventral part, the head
and a dorsal part, the base. The nuclei in anterior horn
innervate the skeletal muscles. Most prominent neurons
are alpha neurons. Their axons leave the spinal cord
Spinal cord
Dorsal root ganglion
Spinal nerve
Dorsal ramus of spinal nerve

Ventral rootlets
Ventral ramus of spinal nerve
Dorsal rootlets
Sympathetic chain
tr
'6 -I Grev
E Ram commun cans I .... . '
I
N LWhtte
tr
.9
C)
ao Fig. 23.8: Typical spinal nerve with sympathetic trunk
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SPINAL CORD
through ventral nerve roots to innervate skeletal Nuclei in Posterior Grey Column
muscles. Smaller neurons are gamma neurons. These AfferenfNuefetrrGroup lumn
supply intrafusal fibres of muscle spindles. The cells in
The four main afferent nuclei are seen in this are:
the anterior horn are arranged in the following three
main groups.
I Posteromarginal nucleus: Thin layer of neurons caps
the posterior horn. It receives some of incoming
I Medial group: It is present throughout the entire
dorsal root fibres.
extent of spinal cord and innervates the axial muscles
of the body (Fi9.23.9).
2 Substantin gelatinosa; This is found at the tip of
posterior horn through the entire extent of spinal
2 Lateral group:Present only in the cervical and lumbar
cord. It acts as a relay station for pain and tem-
enlargements and supplies musculature of limbs. It
perature fibres and is concerned with sensory
is subdivided into three subgroups.
associative mechanism. Its axons give rise to the
a. Anterolateral supplying proximal muscles of
Iateral spinothalamic tract.
limbs (shoulder and arm/ gluteal region and
thigh) (Fig.23.5)
3 cleus proprius: It lies subjacent to the substantia
gelatinosa throughout the entire extent of cord
b. Posterolateral supplying intermediate muscles of
(Fig.23.5).
limbs (forearm/leg).
It is concemed with sensory associative mechanism.
c. Post-posterolateral innervating the distal segment
(hand/foot).
4 cleus dorsalis also known as thoracic nucleus at
the medial part of base of posterior horn extending
3 Central groLtp: Only in upper cervical segments as
from C8 to L3 segments. It is a relay nuclear column
phrenic nerve nucleus and nucleus of spinal root of
for reflex or unconscious proprioceptive impulses to
accessory nerve.
the cerebellum and its axons give rise to the posterior
Substantia lntermediomedial spinocerebellar tract (Figs 23.5 and23.9).
gelatinosa nucleus
Posteromarginal lntermediolateral LAMINAR ORGANISAIION IN SPINAL CORD

nucleus nucleus
In thick sections/ spinal cord neurons appear to have a
laminar (layered) arrangement. Ten layers of neurons
are recognised, known also as laminae of Rexed. These
Nucleus are numbered consecutively by Roman numerals,
propnus
starting at the tip of the dorsal horn and moving
Dorsal ventrally into ventral horn (Fig.23.10).
nucleus
Posterolateral Lamina -tr; Corresponds to posteromarginal nucleus.
Anterolaterai Lamina II: Corresponds to substantia gelatinosa.
Lamina III and IV; Correspond to nucleus proprius.
Phrenic and accessory

LaminaeV andVl: Correspond to base of dorsal column.
Post-posterolateral
Lamina Occupies the territory between dorsal and
ventral horns. This lamina contains many cells that
Fig. 23.9: Cell groups in spinal cord
Nucleiin lolerol Holn

Nuclei in lateral horn are as follows: il
I lntermediolateral nwcleus: This acts as both efferent and il
afferent nuclear columns. This nucleus is seen at
two levels.
a. From T1 to L2 segments, giving rise to pre-
ganglionic sympathetic fibres (thoracolumbar
outflow).
b. From 52 to 54 segments/ giving rise to pre-
ganglionic parasympathetic fibres chiefly for the o
pelvic viscera (Fig. 23.5). E
At these two levels, the intermediolateral cell column ot
receives visceral afferent fibres. c
.9
2 Intermediomedinl nucleus: This is mostly internuncial Laminae C)
neuronal column. Fig. 23.10: Various laminae in spinal cord ao

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I
BRAIN
function as interneurons. Three clear cells columns are DESCENDING TRACIS

recognised within this lamina. These are inter- The descending tracts are of two types-pyramidal and
mediolateral, intermediomedial and nucleus dorsalis extrapyramidal (Table 23.3). The pyramidal or
(nucleus thoracis or Clarke's column). Nucleus dorsalis
corticospinal tracts consists of two parts:
is present on the medial aspect of dorsal horn from C8
to L3 segments. The sacral autonomic nucleus is an L Lateral corticospinal tract, which lies in the lateral
inconspicuous column of cells in the lateral part of funiculus.
lamina VII in segments 52, 53 and 54. 2 Anterior corticospinal tract, which lies in the anterior
funiculus.
Lamina : Corresponds to ventral horn in thoracic
segments but at the level of limb enlargements of spinal Extrapyramidal tracts. These are:
cord, it lies on the medial aspect of ventral horn. L Rubrospinal tract.
Lnmina IX; [:rcludes the lateral group of nuclei of the
2 Medial reticulospinal tract.
ventral horn. The axons of these neurons leave the 3 Lateral reticulospinal tract.
spinal cord to supply the striated or skeletal muscles 4 Olivospinal tract.
of limbs. 5 Vestibulospinal tract.
Lsmina X; Surrounds the central canal. It is composed
6 Tectospinal tract.
of decussating axons, neuroglia and some neurons in
Pyromidol or Codicospinol lrocts
the grey matter surrounding central canal that have
properties of interneurons. The pyramidal or corticospinal tract (Fig. 23.11) is for-
med by the axons of pyramidal cells predominantly
SENSORY RECEP RS lying in the motor area of cerebral cortex. There is some
The peripheral endings of afferent fibres which receive
contribution to it from axon of cells in premotor and
sensory areas. From here, the fibres course through the
impulses are known as receptors.
posterior limb of internal capsule, mid brain, pons and
F unct ion al cla ssific at ion medulla oblongata. At the lower level of medulla
'1. Exterocepfors: These respond to
stimuli from external oblongata, 80% of fibres cross to the opposite side. This
environment, that is pain, temperature, touch and is known as pyramidal decussation. The fibres that have
Pressure. crossed enter lateral column of white matter of spinal
2 Proprioceptors: These respond to stimuli in deeper cord and descend as lateral corticospinal tract. Most of
tissues that is contraction of muscles, movements, these fibres terminate by synapsing through the inter-
position and pressure related to joints. These are nuncial neurons at the anterior horn cells (Fig. 23.1.1).
responsible for coordination of muscles, maintenance The 20"/o of fibres that do not cross enter anterior white
of body posture and equilibrium. These actions are column of spinal cord to form anterior corticospinal
perceived both at unconscious level and at conscious tract. The fibres of this tract also cross at appropriate
level levels to reach grey matter of the opposite half of spinal
3 lnteroceptorsfEnteroceptors: These include receptor cord and s).napse with internuncial neurons similar to
end-organs in the walls of viscera, gland, blood those of lateral corticospinal tract (Fi9.23.12).
vessels and specialised structures in the carotid sinus, Thus the cerebral cortex through lateral and anterior
carotid bodies and osmoreceptors. Also carry corticospinal tracts controls anterior horns cells of
sensations of hunger, nausea and pain. opposite half of spinal cord (Table 23.3).
4 Special sense receptors; These are concerned with
vision, hearing, smell, balance and taste. Fesmefpm*cfS fds*srr**
1 The cerebral cortex controls voluntary movements
of opposite half of body through anterior hom cells.
2 Influence of this tract is supposed to be facilitatory
A collection of nerve fibres that connects two masses for flexors and inhibitory for extensors.
of grey matter within the central nervous system is
called a tract. Tracts may be ascending or descending. Extropyromidol Trocls
tr
'6 They are usually named after the masses of grey matter L l*tbraspinal tract: This tract is formed by the axons of
o connected by them. Some tracts are called fasciculi or red nucleus, situated in the midbrain. The fibres cross
N lemnisci. with the fibres of the opposite side in the tegmentum
o The following tracts are seen in a transverse section of midbrain; thus constituting tiire aentral tegmental
F
o through the spinal cord. Their location should be decussation (see Fig.25.13). The tract descends through
o
@ identified. the pons and medulla oblongata and enters the
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SPINAL CORD
It lies in the anterior white column of spinal cord.

It has uncrossed fibres (Fig.23.12).
Lat er al r eticulospinnl tr nct : The lateral reticulospinal
tract originates from reticular formation in brainstem
(midbrain, pons and medulla oblongata) and
descends up to thoracic segments of spinal cord. It
Fibres passing through
internal capsule has both crossed and uncrossed fibres. It lies in the
anterolateral white column of spinal cord. Both the
Fibres passing through pons tracts terminate by synapsing with the neurons in
lamina VII of the spinal cord.
Fibres course through
medulla oblongata Oliaospinal trnct: Its fibres originate from the inferior
olivary nucleus in medulla oblongata, descend to
Crossing of 80% pyramidal
flbres to opposite side
spinal cord, lie in the anterolateral column of white
matter and synapse with the anterior hom cells.
Lateral
corticospinal tract Vestibulospinal tract: The fibres arise from lateral
vestibular nucleus lying at ponto-medullary junction.
The fibres descend uncrossed to spinal cord. This
tract is situated in the anterior white column of spinal
cord. These fibres s).napse with anterior horn cells.
Tectospinal tract: The tract is formed by the axons of
neurons lying in the superior colliculus of the mid-
brain (see Fig. 25.12). The fibres cross to the opposite
side thus forming dorsal tegmental decussation inmid-
Anterior and lateral corticospinal tracts
Striated brain. The tract descends throughpons, medulla and
control anterjor horn cells of opposite side muscle anterior white column of spinal cord. The fibres ter-
Fig. 23.11: Course of cofticospinal fibres minate on the cells of anterior horn through inter-
nuncial neurons.
All these descending tracts control the voluntary
lateral white column of spinal cord. The fibres termi- movements of skeletal muscles of the body through
nate by synapsing through internuncial neurons with anterior horn cells directly or through internuncial
anterior horn cells (Fi9.23.12). neurons. The influence is on both alpha and gamma
2 Medisl reticulospinnl tract: The medial reticulospinal neurons. Gamma neurons also affect alpha neurons
tract is formed by the fibres from reticular formation through muscle spindles. So all influenceJfinally reach
in pons and descends to the cervical segments only. alpha neurons.
Fine touch, pressure, vibration, Fasciculus gracilis

movement, position
Fasciculus cuneatus
Posterolateral tract
Lateral
corticospinal
tract Posterior spinocerebellar tract
Rubrospinal tract Lateral

spinothalamic
Lateral reticulospinal tract
lntersegmental tract
Anterior
Anterior spinocerebellar
corticospinal tract tract
Spino-olivary
Olivospinal tract (E
tract
m
Vestibulospinal tract Medial N
Anterior spinothalamic tract
reticulospinal c
Tectospinal tract
.o
o
o
Fig.23.12: Location of ascending tracts and descending tracts in spinal cord (each shown only on one side) U)
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BRAIN
Table 23.3: The descending tracts

Name Function Crossed Beginning Termination
uncrossed
Pyramidal tracts
1. Lateral corticospinal ) Main motor tract for skillful Crosses in medulla Motor area of cortex Anterior grey column cells
I voluntary movements area number 4,6 alpha motor neurons
2. Anterior corticospinall Facilitates flerors Crosses in Motor area of cortex Anterior grey column cells
corresponding area number 4,6 alpha motor neurons
spinal segment
Extrapyramidal tracts
1. Rubrospinal Efferent pathway for Crossed Bed nucleus of Anterior grey
cerebellum and midbrain column cells
corpus striatum
2. Medial reticulospinal Extrapyramidal tract Uncrossed Beticular formation Anterior grey column cells
Facilitates extensors of grey matter of pons (interneurons)
3. Lateralreticulospinal Extrapyramidal tract Uncrossed Reticular formation of Anterior grey
Facilitates flexors and crossed grey matter of medulla column cells
oblongata (interneurons)
4. Olivospinal Extrapyramidal tract Uncrossed lnferior olivary nucleus Anterior grey column cells
5. Lateral Efferent pathway for Uncrossed Lateral vestibular Anterior grey column
vestibulospinal equilibratory control nucleus cells
6. Tectospinal Efferent pathway for Crossed Superior colliculus Anterior grey column
visual reflexes cells
ASCENDING IRACIS synapsing with neurons lying in the grey matter of

1 Lateral spinothalamic tract (Fig. 23.13). laminae II and III. Pain fibres relay in lamina II
2 Anterior spinothalamic tract (substantia gelatinosa). The second neuron fibres
cross immediately to opposite side close to the central
3 Fasciculus gracilis (medially) (Fig.23J.\.
4 Fasciculus cuneatus (laterally). canal and ascend as tract in the lateral white column
5 Dorsal or posterior spinocerebellar tract. of spinal cord (Figs 23.73 and23.15).
6 Ventral or anterior spinocerebellar tract 2 Anterior spinothalamic tract:This tract carries the fibres
7 Spino-olivary tract. for crude touch and pressure tickle and itch. First
8 Spinotectal tract. neuron fibres are in the dorsal root ganglia. These
For the sensory pathways, the first neuron fibres relay in the grey matter of posterior horn or nucleus
always start in the dorsal root ganglia which has proprius (laminae III-IV). The second neuron fibres
ascend for 11 segments and cross to opposite side in
pseudounipolar cells. The peripheral process of these
cells form the sensory fibres of peripheral nerves. The the white commissure and ascend as a tract in the
central process of the neurons in the dorsal root ganglia anterior white column of spinal cord (Fig. 23.1.5).
enter the spinal cord through dorsal nerve root and The anterior and lateral spinothalamic tracts carry
terminate either by synapsing with cells in posterior exteroceptive sensations from the opposite half of body
(Fig.23.12).
grey column of spinal cord or at higher level in the
These lie in continuity with each other in the antero-
medulla oblongata with the cells of nucleus gracilis and
nucleus cuneatus. lateral white column of spinal cord showing somato-
After relay in the nuclei, second neuron fibres start topic lamination. The sensations of pressure, touch,
and ascend to either thalamus or cerebellum. temperature and pain are lying medial to lateral.
The cerebellum finally receives second neurons Pressure sensations are medial most near the anterior
fibres, whereas from the thalamus relayed third neuron median fissure. Cervical segments are facing medially
fibres are projected to the sensory areas in the cerebral and sacral segments face laterally.
c
,d cortex (Table 23.4).
Proprioceplive Sensotions
o Exleroceptive Sensotions
N 1 The sensations like deep touch, pressure, tactile
c 1 Laternl spinothnlantic tract: This tract carries the localisation (the ability to locate exactly the pro-
.o
o sensation of pain and temperature. The first neuron prioceptive part touched), tactile discrimination (the
ao fibres start in the dorsal root ganglia. These relay by ability to localise two separate points on the skin
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SPINAL CORD
Table 23.4: Neurons of sensory tracts

7sf 2nd 3rd Clinical tests
Lateral spinothalamic Dorsal root Substantia gelatinosa Posterolateral ventral 1 Pain with pin prick
ganglion nucleus of thalamus 2 Temperature with hot and cold
water in the test tubes
Anterior spinothalamic Nucleus proprius 1 Joint sense
2 Vibration sense
Fasciculus gracilis Nucleus gracilis in medulla 3 Tactile localization
oblongata 4 Tactile discrimination
5 Bhomberg's test
Fasciculus cuneatus Nucleus cuneatus in medulla 6 Stereognosis
oblongata 7 Crude touch
8 Crude pressure
Dorsal spinocerebellar
Ventral spinocerebellar
Clark's column
Neurons of posterior horn

Ni
Ni l All cerebellar tests, like the finger

nose and heel-knee tests, for
intention tremors
Somatic
sensory cortex
Thalamus
Trigeminal
lemniscus
Midbrain Midbrain
Superior sensory
Spinal lemniscus/lateral nucleus of V Trigeminal
spinothalamic tract lemniscus
From face
Pons Pons
Anterior spinothalamic tract Gracile nucleus Medial lemniscus

joins medial lemniscus with anterior
Medulla oblongata
Lateral spinothalamic tract spinothalamic tract
Medulla oblongata Cuneate nucleus Sensory decussation

(2nd order neuron)
Cuneate fasciculus
From
upper limb
Cervical cord
Lateral spinothalamic tract 1 st order neuron

in spinal ganglion Gracile fasciculus
From
Lumbar cord lower limb
Fig. 23.13: Spinothalamic pathways Fig. 23.14: Tracts of dorsal dorsal columns tr
'6
o
that is touched), stereognosis (ability to recognise Fasciculus gracilis (tract of Goll);
It commences at the N
shape of object held in hand) and sense of vibration caudal limit of spinal cord and is composed mainly C
o
are carried by fasciculus gracilis and fasciculus of the long ascending branches of the medial division C)
cuneatus. of fibres of dorsal nerve roots. These are the first ao
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I
BRAIN
order neuron fibres from dorsal root ganglia. These Both fascicuii contain first neuron fibres from central
run directly upwards (without relaying in the spinal process of dorsal root ganglia and end by synapsing
grey matter) in the posterior column of white matter with the neurons in nucleus gracilis and nucleus
of spinal cord. As the tract ascends, it receives cuneatus, situated in the medulla oblongata from
accession from each dorsal root. The fibres which where second neuron fibres take origin.
enter in the coccygeal and lower sacral region are
thrust medially by fibres which enter at higher levels. Reflex Proprioceplive Sensotions
Fasciculus gracilis which contains fibres derived 1 The reflex proprioceptive sensations are carried by
from lower thoracic, lumbar, sacral and coccygeal dorsal and ventral spinocerebellar tracts. They
segments of spinal cord occupies the medial part of convey to the cerebellum both exteroceptive (touch)
posterior column of upper part of spinal cord and is and unconscious proprioceptive impulses arising in
separated from fasciculus cuneatus by postero- Golgi tendon organ and muscle spindle and are
intermediate septum (Figs23.12 to 23.15). essential for the control of posture (Table 23.5).
Fascit;ulus cunestus (tract of Bu ch): lt commences 2 Dorsal or posterior sTtinocerebellar tract: Ii begins at the
in mid-thoracic region. It derives its fibres from level of 3rd lumbar segment of spinal cord. The first
upper thoracic and cervical segments. neuron fibres are the central processes of dorsal root
Cerebral cortex (sensory area)
Third neuron fibre
Thalamus
Second neuron fibre
First neuron flbre
Lateral spinothalamic tract

or spinal lemniscus
Spinal lemniscus
Anterior spinothalamic
tract joining medial
lemniscus in brain stem
Receptors of
Medial lemniscus pain, temperature,
touch, pressure
Nucleus gracilis
Nucleus cuneatus
Fasciculus gracilis
Fasciculus cuneatus
First neuron fibres
tr
'6
E
N
C
o
()
ao Fig. 23-15: Pathway of posterior funiculus tracts and anterior with lateral spinothalamic tract
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SPINAL CORD
Table 23.5: The ascending tracts of the spinal cord

Name Function Crossed Beginning Termination
uncrossed
1. Lateral spinothalamic Pain and temperature Crosses to Substantia Forms spinal
(axons of 2nd order from opposite half of opposite side gelatinosa of lemniscus in medulla,
neurons) body in the same posterior grey reaches posterolateral ventral
spinal segment column nucleus of thalamus for another
relay and ends in arca 3, 1,2
2. Anterior spinothalamic Touch (crude) and Ascends to 2-3 Posterior grey Joins medial lemniscus in
(axons of 2nd order pressure from opposite spinal segments column of brainstem reaches postero-
neurons) half of body to cross to opposite side lateral ventral nucleus of
opposite side thalamus lor another relay
and ends in area 3, 1, 2
3. Fasciculus gracilis Conscious proprioception Uncrossed Dorsal root Relays in nucleus gracilis,
order Discriminatory touch
(axons of 1st ganglion cells 2nd order fibres form medial
sensory neurons) Vibratory sense lemniscus which reaches
(lower limb) Stereognosis posterolateral ventral nucleus
of thalamus for another relay
and ends in area 3, 1, 2
4. Fasciculus cuneatus Same as above Same as above Same as above Relays in nucleus cuneatus,
(axons of 1st order rest is same as above
sensory neurons)
(upper limb)
5. Posterior spino- Unconscious proprio- Uncrossed Thoracic nucleus Vermis of cerebellum
cerebellar (axons of ception from individual of posterior grey (via inferior cerebellar
2nd order neurons) muscles of lower limb column peduncle)
6. Anterior spinocere- Unconscious proprio- Crosses twice, Posterior grey Vermis of cerebellum (via
bellar (axons of 2nd ception from lower limb once in spinal column same superior cerebellar peduncle)
order neurons) as a whole cord and recros- side via recrossing
ses in midbrain
7. Spino-olivary (axons Proprioceptive sense Uncrossed Posterior grey Dorsal and medial accessory
of 2nd order neurons) column olivary nuclei
8. Spinotectal (axons of Afferent limb of reflex Crossed Posterior grey Tectum or superior colliculus
2nd order neurons) movements of eyes column of of midbrain
and head towards opposite side
ganglia. These relay in the dorsal nucleus (thoracic fibres of dorsal spinocerebellar tract to pass through
or Clark's column) which lies on the medial side of the medulla oblongata and pons. These fibres finally
the base of posterior grey column in these segments. curve along lateral aspect of superior cerebellar
This relay gives rise to second neuron fibres which peduncle, and recross with peduncle to regain their
form dorsal spinocerebellar tract. This uncrossed original site of origin (Fig.23.17).
tract ascends in the lateral column of white matter Functionally, both spinocerebellar tracts control the
of spinal cord. Here it is situated as a flattened band coordination and movements of muscles controlling
at the posterior region of lateral column, medially in
posture of the body. The ventral tract conveys muscle
contact with lateral corticospinal tract. It ascends to and joint information from the entire lower limb,
the level of medulla oblongata where its fibres pass
while the dorsal tract receives information from
through inferior cerebellar peduncle to reach the individual muscles of lower limb (Table 23.5).
cerebellum (Fig. 23.16).
V entr al or anterior spinocerebellar trnct : The first neuron
4 The other ascending tracts, Ihe spino-oliaary and
spinotectal, are responsible for proprioceptive and c
fibres are the central processes of dorsal root ganglia.
visual reflexes. (E
The second neuron fibres are derived from the large o
cells of posterior grey column (laminae V, VD in the ot
lumbar and sacral segments. The second neuron INIERSEGMENIAL IRACTS c
.o
fibres cross to opposite side. These ascend in the These are formed of fibres connectingvarious segments o
lateral white column of spinal cord anterior to the of spinal cord. These are present in anterior, posterior ao
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BRAIN
Cerebellum gets information about the trunk and

legs through dorsal and ventral spinocerebellar tracts
and from arm and neck via cuneocerebellar tracts.
Sensations from the face and mouth get carried via
trigeminal nerve.
Motor fibres start from motor areas of brain, pass
through corona radiata, posterior limb of internal
capsule and brainstem. L:r the lowest part of the medulla
Dorsal spinocerebellar oblongata, most of fibres cross go to opposite side
tract anterior horn cells (Fig. 23.18).
Proprioceptive input
Clarke's column
(T1-14)
Fig. 23.16: Pathway of dorsal spinocerebellar tract

lntemal capsule
Fibres for lower

limb
Fibres for head
Anterior lobe of cerebellum
Fibres to motor
nuclei of lll,
lV nerves
Midbrain
Crus cerebri
Fibres for head
V nerve nucleus
Vl and Vll
nerve nuclei
Second order neurons

fibres arise here (L1-S5) Basilar part
and decussate Cotticospinal of pons
(pyramid) tract
Fibres to motor
nuclei of lX, X,
Ventral spinocerebellar tract Xl, and Xll
Fig.23.17:. Pathway of ventral spinocerebellar tract nerves
Decussation
and lateral columns of white matter adjacent to the grey
matter of spinal cord.
Spinal cord
Lateral
.= (indirect)
(E
o Sensations enter the spinal cord via dorsal roots and Anterior (direct) corticospinal
corticospinal tract tract
C\I ascend in the dorsal colurnn as medial lemniscal system
o and in the anterolateral column as spinothalamic To anterior
o
o
pathways. Both sensory systems decussate, but at horn
a different levels (Figs 23.13 to 23.15). Fig. 23.18: Pathway of corticonuclear and corticospinal fibres
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Fibres arising {rommotor cortex till they reach anterior
a. Bilateral loss of pain and temperafure occurs
horn cells are called upper motor neuron fibres. Anterior
due to injury to the decussating fibres of lateral
horn cells and fibres arising from the cells till they reach
spinothalamic fibres (Fig. 23.20).
the muscle are called lower motor neuron fibres.
b. Bilateral loss of touch occurs due to injury to
anterior spinothalamic tract.
As the decussation of lateral and anterior
. In lower motor neuron lesion there is flaccidity, spinothalamic tracts occurs at different levels,
hyporeflexia, wasting and it is ipsilateral. there is dissociated sensory loss.
If all motor neurons reaching a muscle get affected, As this disease occurs in lower cervical and upper
muscle will be fuIly paralysed. It will feel flaccid. thoracic regions there is problem in both the upper
Since no impulses reach muscle, it will not respond limbs and front of chest.
to reflexes. Syringomyelia disrupts the crossing fibres of
As a result of denervatioru it will atrophy soon. anterolateral system. The medial lemniscal system
The paralysis is ipsilateral (Fig. 23.6). is spared.
o In upper motor neuron lesion there is spasticity, o Partial cord lesion (unilateral): In high cervical
hyperreflexia, usually no wasting, and it is lesions, there is weakness of finger movements
contralateral. accompanied by dragging of the leg.
a. If upper motor neurons to a muscle get affec- a. Upper motor neuron paralysis on the side of
ted, initiation of movement may get lost. Since lesion.
lower motor neurons are intact, basal ganglia b. Sensory loss: Numbness on the side of lesion.
may cause increase in muscle tone, leading to Joint position sense and two point discrimi-
spasticity. nation impaired on the side of lesion.
b. Also reflexes get disinhibited, leading to hyper- c. Burning pain, pin prick and temperature
reflexia. sensation impaired on the opposite side.
c. Muscles do not show wasting except by disuse. Pyramidal fibres synapse with anterior horn cells.
d. Mostly upper motor neuron lesions are in These control fine movements of hand and fingers.
internal capsule and since these fibres have not Extra-pyramidal fibres have multiple synapses.
yet decussated, the functional loss will be on These are concerned with large muscle groups
the contralateral side. used in posture and locomotion.
Table 23.6 shows comparison between lower motor
neuron (LMN) and upper motor neuron (UMN)
paralysis
t Brown-Siqttard's syndrome: This is caused due to
hemisection of the spinal cord (Fig. 23.19). Various
features are:
Below the leael of lesion:
a. Ipsilateral upper motor nenron paralysis caused lpsilateral root/
by pyramidal tract damage. segment signs
b. Ipsilateral loss of conscious proprioceptive
sensations caused due to damage to posterior
white column (Fig. 23.19).
c. Contralateral loss of pain and temperature and
touch caused due to damage to lateral spino-
thalamic and anterior spinothalamic tracts.
At the leoel of lesion:
a. Ipsilateral lower motor neuron paralysis caused Contralateral
due to damage to ventral nerve roots. impairment of
pain and
b. Ipsilateral anaesthesia over the skin of the temperature lpsilateral pyramidal
segment due to injury to the ventral nerve roots. sensation weakness and
impaired joint position
Aboae the lwel: Ipsilateral hlperaesthesia above the sense and accurate
'6
level of lesion due to irritation of dorsal nerve roots. touch localisation E
: Syringomyelia: There is formation of cavities AI
c
around the central canal usually in the lower .9
cervical region. Its features are: O
Fig. 23.19: Brown-S6quard's syndrome
ao
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BRAIN
Corticospinal fibres cross to the opposite

80% cross in pyramidal decussation, rest
cross in the spinal cord gradually.
Out of 5 main ascending tracts; two going to the
Crossing of cerebellum reach the ipsilateral side sooner /later.
lateral Two relay in nuclei of spinal cord to reach opposite
spinothalamic
side. Two relay in the nuclei present in the medulla
oblongata to reach the opposite side.
Poliomyelitis virus affects the neurons of anterior
horn cells of the spinal cord. Polio drops as a
vaccine has almost finished the dreadful disease.
Case 1
A7-year-old boy has been having high grade fever
for 5 days. One evening he complained of weakness
in his right lower limb. Soon he could not support
Fig. 23.20: Syringomyelia the weight.
o What is the probable diagnosis?
. Which part of the nervous system is affected?
Table 23.6: Comparison between Iower motor neuron
(LMN) and upper motor neuron (UMN) paralysis
. What type of paralysis is it and what are its
features?
LMN paralysis UMN paralysis
Muscle tone abolished Muscle tone increased Ans: The likely diagnosis is the viral infection of
Leads to flaccid paralysis Leads to spastic paralysis
poliomyenitis. The part of the nervous system
trffected is the anterior horn cells of the spinal cord
Muscles atrophy later No atrophy of muscles
from lu ar 2 to sacral 5 segn'rents of spinal cord.
Reaction of degeneration Beaction of degeneration not The type of paralysis is the lower motor neuron
seen seen
pararlysis. Muscles feel flaccid, tendon reflexes get
absent
Tendon reflexes Tendon reflexes exaggerated absent, reaction of degeneration is seen. Later there
Limited damage Extensive damage is muscular atrophy. The li becomes thinner and
lpsilateral Mostly contralateral shorter than the oppcrsite li
Case 2
A young person is involved in an automobile
accident with injury at cervical 5 and cervical 6
Spinal cord shows cervical enlargement for the vertebrae. He develops paralysis of all four limbs
supply of upper limb muscles. It also shows .
lumbosacral enlargement for the supply of lower What type of paralysis is the Person suffering
limb muscles. from?
Spinal cord in adult is much shorter than the . What are the differences between upper motor
vertebral canal. The cord ends at the lower border neuron and lower motor neuron paralysis?
of lumbar one vertebra. Ans: e young person has developed upper rnotor
Lateral horn is only present in T1--L2 and S2-S4 neuron paralysis in his limbs. His symptoms are:
segments of spinal cord. e Loss clf power of voiuntary movements
Sympathetic fibres (white ramus communicans) . Tendon reflexes are exaggerated
start from lateral hom -+ventral root -+trunk of
spinal nerve -+ ventral primary ramus -+ . Babinski sign is positive (see Fig. 21.7)
.E
(E
sympathetic ganglion (Fig. 23.8). * Reaction of degeneration is absent
o. The sympathetic ganglion gives grey ramus The differences between upper motot neuron and
C\I
C
o
communicans (grc), after receiving and relaying lower motor neuron types of paralysis are
() the white ramus communicans (wrc). mentioned in clinical anatomy of this chapter.
ao
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SPINAL CORD
MUITIPLE CHOICE OUESTIONS
1. Lr spinal cord, myelin sheath is formed by: 6. Following tracts are present in lateral white column
a. Schwann cells b. Oligodendrocytes except
c. Astrocytes d. Microglia a. Lateral spinothalamic
2. Medial lemniscus carries: b. Rubrospinal
u.
luT and temperature sensation from trunk and c. Ventral spinocerebellar
limbs d. Fasciculus gracilis
rimbs
and
7. Regarding spinar cord, ar are true except:
I ;;:il:::iil::H:li:li["#;:H a' It ends in adults at lower border of L1
d. Auditory sensation
3. Regarding spinal cord, the following are true except:
o' cord is covered by 3 meninges
1"
t, It shows thoracic and lumbar enlargements
a. It has cervical and lumbar enlargements
b. It ends at lower border of 3rd lumbar vertebra d' Grey matter occuPy its central part
c. It is traversed by the central canal 8. Lateral corticospinal tract terminates at:
d. It begins at level of foramen magnum as a a. Clark's column
continuation of medulla oblongata b. Substantia gelatinosa
4. Regarding corticospinal tract all of the following c. Anterior horn cells of spinal cord
are true except:
d. ventroposterolateral nucleus of thalamus
a. Most of fibres decussate o1 medulla
rssate at lower end of pyramidal fibres mostry arise from Brodmann's
9.
oprongara cortical area:
b. It arises from motor area of cerebral cc trtex a' 3' L' 2 b' I
c. It ends in anterior hom cells
d.Its lesion at level of pons produces paralysis of -^ i:.! d' 18
ipsilateral side 10. Which of the following tract contains primary
5- Injury of lateral spinothalamic tract results in:
afferent neuron fibres:
a. Ipsilateral loss of pain and temperature ?. Fasciculus gracilis and fasciculus cuneatus
b. Contralateral loss of touch and pressure b. Anterior spinothalamic tract
c. Contralateral loss of pain and temperature c' Lateral spinothalamic
d. None of above d. Dorsal spinocerebellar
AN ERS
1.b 2.b 3.b 4,d 5.c 6.d 7.c 8.c 9.c 10.a
tr
'6
E
N
C
o
o
o
a
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at42/
Hunt
-Leigh
INTRODUCIION x = Glossophary:rgeal give

X = Vagus value
The 12 pairs of cranial nerves supply muscles of eyeball,
XI = Accessory and
face, palate, pharynx, larynx, tongue and two large
XII = HyPoSlossal happiness
muscles of neck. Besides these are afferent to special
senses like smell, sight, hearing, taste and touch. Attachment of the nerves:
Some nerves form the afferent loop and others form I,II to the forebrain.
the efferent loop of the reflex arc. Optic nerve is afferent III,IV to midbrain.
from eye while III, IV and VI are efferent to the eye V, VI, VII Vil to the pons.
muscles. Statoacoustic nerve is afferent for hearing and IX,X,XI, XII to the medulla oblongata (Fig.2a.D.
balance while spinal root accessory acts as its efferent
component for turning the face to the side from where EMBRYOLOGY
sound is heard. VII,IX and X are carrying sensation of During early stages of development, the wall of the
taste from tongue and efferent component is XII nerve neural tube is made up of three layers:
for movements of tongue and nucleus ambiguus gives a. The inner ependymal layer.
fibres to IX, X, and cranial root of XI for the muscles of b. The middle mantle layer.
palate, pharynx and lary'nx. c. The outer marginal layer.
Olfactory takes the sense of smell and stimulates The mantle layer represents grey matter and the
dorsal nucleus of vagus for enhanced secretion if the marginal layer, the white matter.
smell is good. CN V, the largest cranial nerve, is mahly Soon the mantle layer differentiates into a dorsal alar
sensory to the face. The motor nerve of face is VII nerve. lamina (sensory) and a ventral basal lamina (motor),
To come close to V nerve nucleus, VII nucleus winds the two are partially separated internally by the sulcus
around VI nucleus so that a reflex arc can be mediated limitans.
between the afferent and efferent loops of the arc. It is
In the spinal cord, though grey matter forms a
termed as "neurobiotaxis". compact fluted column in the centre, it shows differen-
tiation into two somatic and two visceral functional
FEATURES
columns. The somatic columns are the general somatic
There areT2pairs of cranial nerves. Each cranial nerve efferent (motor or anterior horn) and the general
has a number and a name as follows. somatic afferent (sensory or posterior horn).
Mnemonic These supply structures derived from somites. The
I = Olfactory oh, visceral columns are the general visceral efferent
II = Optic oh, (motor) and the general visceral afferent (sensory).
III = Oculomotor oh, These are autonomic columns and supply the viscera,
IV = Trochlear try, vessels and glands (Fig24.2a).
V = Trigeminal tty, In the brain stem, particularly hindbrain, the alar and
VI = Abducent again basal laminae come to lie in the same ventral plane
V[ = Facial failure, because of stretching of the roof plate (dorsal wall) of
VIII =Vestibulocochlear(statoacoustic) victory neural tube by pontine flexure. Further, the grey matter
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CRANIAL NERVES
Olfactory bulb Olfactory nerves (l)
Optic tract Optic nerve (ll)
Oculomotor nerve (lll)
Optic chiasma
Trochlear nerve (lV)
lnterpeduncular fossa
Motor root I
I trigeminal nerve (V)
Sensory roo!l
Uncus
Abducent nerve (Vl)
Parahippocampal gyrus
Motor root I
I Facial nerve (Vll)
Sensory rooj_l
Middle cerebellar peduncle
Vestibulocochlear nerve (Vll l)
Glossopharyngeal nerve (lX)

Pons
Vagus nerve (X)
Pyramid and olive Accessory nerve (Xl)
Hypoglossal nerve (Xl l)

Spinal root of accessory nerve
Cerebellum
Fig. 24.1: Attachment of cranial nerves to the base of brain
forms separate longitudinal functional columns, where the oculomotor nerve and supply five extrinsic
the motor columns (frombasal lamina) are medial and muscles of the eyeball except the lateral rectus and
the sensory columns (from alar lamina) lateral in the superior oblique.
position. 2 The trochlear nucleus is situated in the midbrain at
In addition to the four functional columns differen- the level of the inferior colliculus. It supplies only
tiated in the spinal cord, there appear two more the superior oblique muscle through the trochlear
columns (a motor and a sensory) for the branchial nerve.
apparatus of the head region, namely the special
visceral (branchial) efferent and the special visceral
3 The abducent nucleus is situated in the lower part of
the pons. It supplies only the lateral rectus muscle
afferent; and one column more for the special sense,
through the abducent nerve.
namely the special somatic afferent. Thus a total of
seven columns (3 motor and 4 sensory) are formed. 4 The hypoglossnl nucleus lies in the medulla. It is
Each column, in its turn, breaks up into smaller elongated and extends into both the open and closed
fragments to form nuclei of the cranial nerves parts of the medulla. It supplies seven out of eight
muscles of the tongue through the hypoglossal nerve.
$ig.2a.2b).
NUCLEI Speciol Viscerol Efferent/Bronchiol Efferent Nuclei
The details of the nuclei of cranial nerves are These nuclei supply striated muscle derived from the
summarized in Table 24.1. branchial arches.
1 The Tnotor nucleus of the trigeminal nerue lies in the c
Generol Somolic Efferent (GSE) Nuclei upper part of the pons. It supplies the muscles of G
These nuclei supply skeletal muscle of somatic origin mastication through the mandibular nerve.
o
ol
(Figs24.3 and24.4a). 2 The nucleus of the facial nerae liesin the lower part of .o
1 The oculomotor nucleus is situated in the midbrain at the pons. It supplies the various muscles innervated o
the level of the superior colliculus. Its fibres enter by the facial nerve. ao)
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BRAIN
Special somatic afferent
General somatic afferent

Special visceral afferent
General visceral afferent

GSA: General somatic afferenl General visceral efferent
GVA General visceral afferent
Special visceral efferent
GVE. General visceral efferent
GSE . General somatic efferenl General somatic efferent
(b)
Figs 24.2a and b: ,r",11ll"*" section of the hindbrain of an embryo showing the arrangement of functional/nuclear columns of
cranial nerve nuclei. (a) spinal cord, and (b) in brain stem
Special somatic
afferent (Vlll)
General somatic
afferent (V, Vll, lX, X)
General and special
- , visceral afferent
---'(vtt, tx, x)
-*--+ General visceral
efferent (lll, Vll, lX, X)
Special visceral
efferent (V Vll, lX, X, Xl)
General somatic
efferent (lll, lV, Vl, Xll)
Fig. 24.3: Transverse section of medulla oblongata showing

the position of cranial nerve nuclear columns
3 The nucleus arnbiguus lies in the medulla. It forms an Spinal cord

elongated column lying in both the open and closed
parts of the medulla. It supplies:
a. The stylopharyngeus muscle through the
glossopharyngeal nerve; and
L o"n"r", viscerat
b. The muscles of the soft Palate, the pharynx and

the larynx through the vagus and the cranial part General and special visceral (a)
of the accessory nerve (Fig.za}. Fig. 24.4a: Position of cranial nerve nuclear columns in brain
stem
Generol Viscerol Effetent Nuclei
These nuclei give origin to preganglionic neurons that through the facial nerve and its branch, the greater
relay in a peripheral autonomic ganglion. Postganglionic petrosal nerve to relay in the pterygopalatine
fibres arising in the ganglion supply smooth muscles ganglion and supply the lacrimal, nasal, palatal and
or glands (Fig.24.4a). pharyngeal glands.
1 The Edinger-Westphal nucleus lies in the midbrain in
.E close relation to the oculomotor nucleus. Its fibres
(E
pass through the oculomotor nerve to the ciliary
o ganglion to supply the sphincter pupillae and the
N
C ciliaris muscles. salivary glands and glands in the oral cavity.
o
() 2 The lacrimatory nucleus lies near the salivatory nuclei 4 The inferior saliantory nucleus lies in the lower part of
ao (in the lower pons). It gives off fibres that pass the pons just below the superior nucleus. It sends
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CRANIAL NERVES
Edinger-Westphal nucleus
Mesencephalic nucleus
of trigeminal
Trochlear nucleus
Motor nucieus of Main sensory nucleus

trigeminal of trigeminal
Lacrimatory
nucleus
Facial nucleus
Four vestibular
Abducent nucleus
nuclei
Ventral cochlear
Salivatory nuclei nucleus
---'t
lt^
i Dorsal nucleus
of vagus
Spinal nucleus of IG
lo-
trigeminal (GSA) t-
lo
lo
lo-
Nucleus ambiguus Nucleus of
Hypoglossal
solitary tract
(GVA and SVA)
ls
_)(/)
nucleus ---
GVE column l6
lo-
t-
SVE column ld)
lB
GSE column lo
l<
t>
(b) lo
Figs 24.4b and c: (b) Scheme to show the cranial nerve nuclei as projected on to the posterior surface of the brain stem with four
vestibular nuclei, and (c) parts of nucleus of tractus solitarius: Vll-facial; lX-glossopharyngeal and X-vagus
fibres through the glossopharyngeal nerve to the otic Its lower part receives general oisceral sensations as
ganglion for supply of the parotid gland (Fig. 2a.afl. follows:
5 The dorsal nucleus of the aagus is a long column
a. Through the glossopharyngeal nerve, from the
extending into the open and closed parts of the tonsil, pharynx, the posterior part of the tongue,
medulla. It gives off fibres that pass through the vagus
carotid body and carotid sinus.
nerve to be distributed to thoracic and abdominal
viscera (the ganglia concerned are presentinthewalls
b. Through the vagus nerve, from the pharynx, the
of the viscera supplied).
larynx, the trachea, the oesophagus and other
thoracic and abdominal viscera.
Generol Viscerol Afferenl Nucleus ond Its upper part also receives sensations of taste (special (E
Speciol Viscerol Afferent Nucleus (loble 24.1) visceral afferent) as follows: E

ol
The only nucleus in this category is the nucleus of solitary a. From the anterior two-thirds of the tongue, and the c
tract or tractus solitarius. It lies in the medulla and .o
palate except circumvallate papillae through the o
extends into both its closed and open parts. facial (VQ nerve in its superior part (Fig.2a.aQ. ao
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BRAIN
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tr 5
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CRANIAL NERVES
b. From the posterior one-third of the tongue canals, the utricle and the saccule through the
through the glossopharyngeal nerve (IX) includ- vestibular nerves (Table 24.1).
ing the circumvallate papillae in its middle part.
c. From the posteriormost part of the tongue and Spe*r*J Fesft.sres
from the epiglottis through the vagus (X) nerve in Muscles of facial expression of lower face are supplied
its inferior part. only from contralateral motor cortex.
The muscles of upper face are supplied both from
Generol Somolic ereni Nuclei ipsilateral and contralateral motor cortex (Fig.2a.5a).
These are all related to the trigeminal nerve. Cranial part of nucleus ambiguus gives fibres to IX, X
and cranial root of XI nerve. The caudal part of this
1 The main or superior sensory nucleus of the trigeminal
nucleus gives fibres to spinal root of XI nerve (Fig. 2a.5b).
nerae lies in the upper part of the pons (Fig. 2a.\.
The genioglossus muscle of the tongue receives fibres
2 The spinal nucleus of the trigeminal neroe descends from contralateral motor cortex only. Rest of the
from the main nucleus into the medulla. It reaches muscles of the tongue receive from both ipsilateral
the upper two segments of the spinal cord (Fig. 24.4b). cortex and contralateral motor cortex (Fig.2a.5c).
3 The mesencEhalic nucleus of the trigeminal nerae extends
upwards from the main sensory nucleus into the
midbrain.
These nuclei receive the following fibres:
a. Exteroceptive sensations (touch, pair., tempera- It belongs to special visceral afferent column.
ture) from the skin of the face, through the trige- Receplors ond lhe Firsl Neuron
minal nerve; and from a part of the skin of the
auricle through the vagus (auricular branch) and
1 The olfactory cells (16-20 million in man) are bipolar
neurons. They lie in the olfactory part of the nasal
through the facial nerve.
mucosa, and serveboth as receptors aswell as the first
b. Proprioceptive sensations from muscles of neurons in the olfactory pathway.
mastication reach the mesencephalic nucleus 2 The olfactory nerves, about 20 in number, represent
through the trigeminal nerve. The nucleus is also central processes of the olfactory cells.
believed to receive proprioceptive fibres from the
ocular, facial and lingual muscles, teeth and Second Neulon
temporomandibular brain joint. The mitral and tufted cells in the olfactory bulb give
off fibres that form the olfactory tract and reach the
Speciol Somolic Afferenl Nuclei primary olfactory areas (Fig 24.6).
1 The cochlear nuclei (dorsal and ventral) that receive These are located in the primary olfactory cortex
impulses of hearing through the cochlear nerve. which includes the anterior perforated substance, and
2 The aestibular nuclei (superior, spinal, medial and several small masses of grey matter around it like
lateral) that receive fibres from the semicircular periamygdaloid and prepiriform area.
Rostral
From contralateral motor To muscles

Vagus nerve From contralateral
cortex only, nil from of lower face Nucleus
motor cortex only Genioglossus
ipsilateral ambiguus
From ipsilateral and To muscles From ipsilateral and Other muscles

contralateral motor cortex of upper face contralateral sides of of tongue
motor cortex
c
'6
Accessory nerve
(spinal root) joins
the cranial root to
o
(\I
split again C
Caudal o
(b) ()
o
Figs 24.5a to c: (a) Nucleus of facial nerve, (b) nucleus ambiguus, and (c) nucleus of hypoglossal nerve ct)
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BRA N
Olfactory afferent pathway comprises only two

neurons. The fibres reach the cerebral cortex without
Olfactory bulb synapsing in any of the thalamic nuclei.
Olfactory tract
Area subcallosal
Medial olfactory stria
a with ageing.
Anosmia: Loss of olfactory fibres
a in each nostril.
Sense of smell is tested separately
Lateral olfactory stria
a Allergic rhinitis causes temporary olfactory
Anterior perforated substance impairment.
Uncus
Hend injury: Olfactory bulbs may be torn away
from olfactory nerves as these pass through
Amygdaloid body fractured cribriform plate of ethmoid leading to
anosmia. Such a fracture may also cause CSF
Entorhinal area
rhinorrhoea, i.e. CSF leakage through the nose.
Abscess of frontal lobe of brain or meningioma in
the anterior cranial fossa may press on the
olfactory bulb or olfactory tract resulting in
anosmia.
Uncinate fits: Lesion of lateral olfactory area may
cause temporal lobe epilepsy or uncinate fits.
These fits are of imaginary disagreeable odors
Fig. 24.6: lnferior view of brain showing olfactory areas
with involvement of tongue and lips.
Foudh Neuron
Fibres arising in the primary olfactory cortex go to the
secondary olfactory cortex (entorhinal area) located in
the uncus and anterior part of the parahippocampal HUMAN VISION
gyrus. Smell is perceived in both the primary and Human vision is binocular, though one sees with both
secondary olfactory areas (Fig. 24.6). the eyes, the inverted images formed are seen as one
Some impulses from uncus travel via medial and straight only (Fig.2a.$.
forebrain bundle and reticular formation to dorsal Human vision is stereoscopic, i.e. one sees height,
nucleus of vagus and salivatory nuclei in medulla width and thickness of the object.
oblongata, where these may increase or decrease gastric Human vision is colored, one sees different colours
secretion according to type of smell (Fig.2a.l. put up by nature.
When one looks at an object, both eyes are focused
Cingulate gyrus on it. Right eye sees a little additional of right side
whereas left eye sees a little additional of left side of
the object. These visions are monocular visions. Main
Medial forebrain part is the binocular vision.
bundle
Medial olfactory OPTIC PATH

(septal) area
Field of Vision
There is a temporal field of vision and a nasal field of
Olfactory bulb vision.
Olfactory tract Field of vision are also upper and lower. So there
are four fields on each side.
Entorhinal area Upper temporal, lower temporal, upper nasal and
.E lower nasal.
(u lnterpeduncular nucleus
Most importantly there is a macular vision which is
o
N Raphe nuclei of midbrain (reticular formation) the most acute or sharp and coloured vision.
C Nasal fields are smaller than the temporal fields.
.o Salivatory nuclei of medulla oblongata
() Larger right temporal and smaller right nasal fields
oo Fi1.24.7: Some connections of olfactory cortical areas of vision fuse to form right part of binocular field.
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CRANIAL NERVES
vice versa. Macular fibres lie in the central part of optic

tract upper retinal fibres project dor,rmwards and lower
retinal fibres project upwards.
Retino
It is described in Chapter 19.
Optic Nerve
Optic nerve is made up of axons of ganglion cells of
the retina. In a strict sense, the optic nerve is not a
peripheral nerve because its fibres have no neurilemmal
sheaths. It is a tract. Its fibres have no power of
regeneration. The nerve is described in Chapter 13.
Optic nerve Optic Chiosmo
In the chiasma, the nasal fibres (i.e. fibres of the optic
Optic chiasma nerve arising in the nasal, or medial half of the retina)
including those from the nasal half of the macula, cross
Optic tract the midline and enter the opposite optic tract. The
Lateral geniculate temporal (lateral) fibres pass through the chiasma to
nucleus enter the optic tract of the same side (Fig. 2a.8).
Meyer's loop Optic lroci

(optic radiations)
Each optic tract winds round the cerebral peduncle of
the midbrain. Near the lateral geniculate body, it
divides into lateral and medial roots. The lateral root is
thick and terminates in the lateral geniculate body. A
few of its fibres pass to the superior colliculus, the
Occipital lobe
pretectal nucleus and the hypothalamus. The medial
(cortex) root is believed to contain the supraoptic commissural
fibres.
Fig. 24.8: Visual pathways
Each optic tract contains temporal fibres of retina of
the same side and nasal fibres of the opposite side.
Left halves of field of vision, i.e. larger temporal half
and smaller nasal half of left field of vision form left Lolerol Geniculote Body
half of binocular field (see Fi9.72.12). Lateral geniculate body receives the lateral root of the
Retina: In human the eyeballs are placed medially, optic tract. Medially, it is connected to the superior
with the nose intervening. Retina is also divided into colliculus, and laterally, it gives rise to the optic
temporal and nasal parts and each is further subdivided radiation.
into upper and lower parts. Macula lutea lies in the The cells in this body are arranged in six layers.
centre of the posterior part of the retina. Layers 2, 3, 5 receive ipsilateral fibres, andlayers 7, 4,6
Light rays travel in a straight line. Temporal field is receive contralateral fibres.
seen by nasal hemiretina and vice versa. Both these
hemiretinae include half part of macula each. Optic Rodiotion (geniculocolcorine troct)
The small right monocular field is seen by the Optic radiationbegins from the lateral geniculate body,
anterior part of the right nasal hemiretina. Similarly, passes through the retrolentiform part of internal
the left monocular field is appreciated by the anterior capsule, and ends in the visual cortex (Fig.za.q.
part of the left nasal hemiretina. Binocular field is seen
by both the eyes in the corresponding parts of retina. Visuol Cortex
Fibres from thenasalparts of the two retinae decussate The optic radiation terminate in the striate area where .s
(E
to form the optic chiasma and travel to the contralateral the colour, size, shape, motion, illumination and 6
side in the optic tract. Fibres from the temporal transparency are appreciated separately. Objects are C\t
hemiretinae continue ipsilaterally in the optic tract. identified by integration of these perceptions with past -
.9
Right optic tract carries the fibres of the right experience stored in the parastriate and peristriate o
temporal hemiretina and the left nasal hemiretina and areas 18, 19. ao
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BRAIN
The area of the visual cortex that receives impulses FIow chart 24.2: Accommodation reflex
from the macula is relatively much larger than the part Read a film magazine
related to the rest of the retina.
REFTEXES
These are: (1) pupillary light reflex (Fig.2a.9 and Flow
chart 24.7), (2) accommodation reflex (Fig. 24.10 and
Flow chart 24.2), (3) dilation of pupil (Flow chafi24.3),
(4) corneal/conjunctival reflex (Fig. 24.1.1. and Flow
chart24.4), (5) visual body reflex (Fig.24.72 and Flow
chart24.5). Late ody
Flow chart 24.1: Pupillary light reflex
Medial frontal gyrus (frontal eye field)
Few fibres go to pretectal
lll nerve and Edinger-Westphal nuclei of both sides
lll nerve nuclei of both sides

Some fibres go to Nerve to inferior oblique
medial recti which result
in medial convergence
of the eyes
Short ciliary nerves of both sides

|
Y
' n"t"y
Sphincter pupillae muscle of both eyes constrict
Shine light in left eye

To constrictor pupillae and ciliaris
muscles
Short ciliary nerve
Ciliary ganglion
Preganglionic parasympathetic fibres in lll
tr
'd Edinger-Westphal nucleus
E and lll nerve nucleus of both eyes
N
C
o To midbrain pretectal nuclei
o
o
a Fig. 24.9: Pupillary light and consensual light reflex
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Medial rectus muscle Constrictor pupillae muscle of
iris and ciliaris muscles
Short ciliary nerve
Ciliary ganglion
Frontal eye field
Superior longitudinal fasciculus
Lateral geniculate body
Midbrain
Main oculomotor nucleus

Optic radiation
Fig. 24.10: Accommodation reflex
cha n of pup FIow chart 24.4: Coneal/conjunctival reflex
Spinal cord-with lateral horn (thoracic segments)
T1-T4 roots
FIow chart 24.5: Visual body reflex
Fibres pass along internal carotid artery
.=
S (E
o
ot
c
Anterior horn cells of spinal .9
Motor nuclei of cranial nerves o
ao
movements of head and neck cord for movements of body
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BRAIN
Superior
sensory Trigeminal Ophthalmic of one side results in loss of the opposite half of
nucleus ganglion branch field of vision.
ofV A lesion on the right optic tract leads to left
homonymous hemianopia (left half of field of
vision).
Medial Papilloedema; Results due to increased intracranial
longitudlnal
pressure. It leads to swelling of optic disc due to
bundle
blockage of tributaries of the retinal veins.
Optic neuritls; Lesion of optic nerve that results in
Main motor nucleus Orbicularis decrease of visual acuity. Optic disc appears pale
of facial nerve oculi muscle
and smaller. Methyl alcohol is a usual toxic
Fig. 24.11 : Corneal/conjunctival reflex
chemical leading to blindness.
Argyll-Robertson pupil: In this condition. The
accommodation reflex is present but the
light reflex is absent. The pretectal area is affected
(see Fig. 25.L4).
Optic nerve
OCUTOMOIOR NERVE
Optic chiasma
This is the third cranial nerve. It is distributed to the
extraocular as well as the intraocular muscles. Since it
Optic tract
is a somatic motor nerve, it is in series with the IV, VI
and XII cranial nerves, and also with the ventral root
of spinal nerves.
Midbrain Functionol Components

1 General somatic efferent, for movements of the
eyeball (Fig.2a.7a).
2 General visceral efferent or parasympathetic, for
contraction of pupil and accommodation.
3 General somatic afferent column carries proprio-
Lateral ceptive fibres from the extraocular muscles to
geniculate
body mesencephalic nucleus of V.
Nucleus
Fig.24.'|-2: Visual body reflex
The oculomotor nucleus is situated in the ventromedial
part of central grey matter of midbrain at the level of
superior colliculus. The fibres for the constrictor
o Lesion in retina leads to scotoma, that is certain pupillae and for the ciliaris arise from the Edinger-
points may become blind spots. Westphal nucleus which forms part of the oculomotor
Loss of vision in one half (left or right) of visual nuclear complex.
field is called hemianopia. Ventrolaterally, it is closely related to the medial
If the defect is in same halves of both eyes, it is longitudinal bundle.
called homonymous. If defect is in different The nucleus is connected:
halves, it is called heteronymous.
a. To the pyramidal tracts of both sides which form
Optic nerve damage results in complete blindness
the supranuclear pathway of the nerve.
c of that eye (Fig. 24.1.3).
b. To the pretectal nuclei of both sides for the light
'6 Optic chiasma lesion if central will lead to reflex.
E bitemporal hemianopia, but if peripheral on both
(\I c. To the fourth, sixth and eighth nerve nuclei by
sides will lead to binasal hemianopia (Fig.zaJ$.
L medial longitudinalbundle for coordination of the
o Complete destruction of optic tract, lateral eye movements.
o
o geniculate body, optic radiation or visual cortex
a d. To the tectobulbar tract for visuoprotective reflexes.
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CHANIAL NERVES
Temporal Nasa Nasal Tempora

Optic nerve (.,
@ Optic chiasma @
@
Optic tract
(,
Lateral geniculate
@ nucleus
@
@ Optic radiations
(&
@ c
Fi1.24.13: Field defects associated with lesion of visual pathway. 1. Blindness of left eye, 2. bitemporal hemianopia, 3. left nasal
hemianopia, 4. right homonymous hemianopia with macular involvement, 5. right homonymous hemianopia, and 6. right homonymous
hemianopia with macular sparing
Superior colliculus Course ond Distribution

Aqueduct L In their intraneural course, the fibres arise from the
lll nerve nuclear nucleus and pass ventrally through the tegmentum,
complex red nucleus and substantia nigra.
Red nucleus 2 At the base of the brain, the nerve is attached to the
oculomotor sulcus on the medial side of the crus
Substantia nigra
cerebri (Fig. 2a.1).
Cerebral peduncle 3 The nerve passes between the superior cerebellar and
posterior cerebral arteries, and runs forwards in the
lll nerve interpeduncular cistern, on the lateral side of post-
erior communicating artery to reach the cavemous
F19.24.14t Third cranial nerve and its nucleus sinus (Fig. 24.15).
. Midbrain
lnferior colliculus
lnterpeduncular cistern
Oculomotor nerve
Trochlear nerve
Pehosphenoidal ligament
Cerebellum
Abducent nerve
Cavernous sinus c
'6
Apex of petrous temporal bone
Medulla oblongata o
Basiocciput N
Arachnoid mater C
o
Cisterna pontis Layers of dura mater o
o
Fig.24.15:. Scheme to show the precavernous courses of the third, fourth and sixth cranial nerves o
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BRAIN
Pituitary gland lll nerve
Cavernous sinus lV nerve
V1 nerve
V2 nerve
Vl nerve
lnternal carotid
artery
Fig. 24.16: Course of lll, lV, V and Vl nerves in the cavernous sinus
4 The nerve enters the caaernous sinus (Fig.2a.16) by a Pupillary light reflex in affected eye is absent.
piercing the posterior parl of its roof on the lateral a Dilatation of pupil due to paralysis of para-
side of the posterior clinoid process. It descends to sympathetic fibres to sphincter pupillae muscle
the lateral wall of the sinus where it lies above the
Eyeball gets turned downwards and laterally due
trochlear nerve. In the anterior part of the sinus, the
to r.rnopposed action of lateral rectus and superior
nerve divides into upper and lower divisions.
oblique muscles.
5 The two divisions of the nerve enter the orbit tkuough Loss of accommodation due to paralysis of ciliary
the middle part of the superior orbital fissure. In the
muscles.
fissure, the nasociliary nerve lies in between the two
divisions while the abducent nerve lies inferolateral Pupil dilates and becomes fixed to light.
to them. Features are:
6 In the orbit, the smaller upper division ascends on the Light shown in affected right eye (Fig. 24.21):
lateral side of optic nerve, and supplies the superior - No light reflex in affected eye.
rectus and part of the levator palpebrae superioris. - Consensual light reflex in normal eye/left eye.
The larger, lower, division divides into three Light shown in normal eye:
branches for the medial rectus, the inJerior recfus and
the inferior oblique. The nerve to the inferior oblique - Light reflex in normal eye.
is the longest of these. It gives off the parasym- - No consensual light reflex in affected eye
pathetic root to the ciliary ganglion and then supplies $ig.2a.22).
the inferior oblique muscle (Fig.2a.17). A midbrain lesion causing contralateral
All branches enter the muscles on their ocular hemiplegia and ipsilateral paralysis of the third
surfaces except that for the inferior oblique which enters
nerve is known asWeber's syndrome (seeFig.25.L4).
its posterior border. Supranuclear paralysis of the third nerve causes
Figures 24.78 and 24,13 show the actions of loss of conjugate movement of the eyes.
extraocular muscles. Compression of III nerae: Compression of III nerve
due to extradural haematoma causes dilatation of
pupil. Parasympathetic fibres lying superficial get
. Complete and total paralysis of the third nerve affected first. Pupil dilates on affected side and
results in: there is little response to light.
a. Ptosis, i.e. drooping of the upper eyelid. Aneurysm of posterior cerebral or superior cerebellar
b. Lateral squint artery: Aneurysm of any of these two arteries may
c. Dilatation of the pupil (Fig. 24.20) compress III nerve as it passes between them.
d. Loss of accommodation
e. Slight proptosis, i.e. forward projection of tl"re
G eye.
o f. Diplopia or double vision.
N
C . Ptosis or drooping of uppereyelid due toparalysis TROCHTEAR NERVE
o
o of voluntary part of levator palpebrae superioris This is the fourth cranial nerve. It supplies only the
o muscle.
a superior oblique muscle of the eyeball (Fig.za.n).
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CRANIAL NERVES
Levator palpebrae
supenons
Superior oblique
Superior rectus
Lateral rectus
Medial rectus
Ciliary ganglion
lnferior rectus
Wrinkled forehead
Upper division lnferior oblique Raised eyebrow
Drooping lid
Lower-larger
division Dilated pupil
Downward abducted
eye
Cavernous sinus
Oculomotor nerve
Fig. 24.20: Paralysis of Ieft third nerve
Edinger-Westphal
nucleus
Nucleus of third
nerve
Fig.24.17: The origin, course and the distribution of oculomotor
nerve. Superior oblique and lateral rectus also seen --, ^.
Fig" 24-2'l: Paralysis of right third nerve as tested by light

reflex in the right eye
Superior lnferior lnferior Superior
oblique rectus rectus oblique
Flg. 24.18: Action of individual extraocular muscle. Arrows indicate

direction of movement
lnferior oblique
(up and out) Superior rectus
(up and in)
Lateral rectus Medial rectus

tr
'6
o
lnferior rectus N
Superior oblique (down and in)
(down and out) Fig.24.22: Paralysis of right third nerve. Confirmed as tested o
from left eye for consensual light reflex in right eye o
o
Fig.24.19: Movements in the six different directions U)
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BRAIN
Funclionol Components
1 General somatic efferent, for lateral movement of the
eyeball.
Superior oblique
2 The general somatic afferent, for proprioceptive
impulses from the muscle to the mesencephalic
nucleus of V nerve.
Nucleus
The trochlear nucleus is situated in the ventromedial
part of the central grey matter of midbrain at the level
of inferior colliculus. Ventrally, it is closely related to
the medial longitudinal bundle.
The cormections of the nucleus are similar to those of
the oculomotor nucleus, except for the pretectal nuclei.
Course ond Distribution

Inits intraneural course, the nerve runs dorsally round
the central grey matter to reach the upper part of the
superior or anterior medullary velum where it
decussates with the opposite nerve to emerge on the
opposite side (Fig. 24.23).
Surface attachment. Trochlear nerve is attached to the
superior medullary velum one on each side of the
frenulum veli just below the inferior colliculus. It is
the only cranial nerve which emerges on the dorsal
aspect of the brainstem (Fig.2a.\. Fig.24.24t The origin, course and the distribution of the trochlear
nerve
The nerve winds round the superior cerebellar
peduncle and the cerebral peduncle iust above the
pons. It passes between the posterior cerebral and Trochlear nerve enters the orbit thrortgh the lateral
superior cerebellar arteries to appear ventrally part of the superior orbital fissure.
between the temporal lobe and upper border of pons. ln the orbit,lt passes medially, above the origin of
levator palpebrae superioris and ends by supplying
The nerve enters the caoernous sinus by piercing the
posterior corner of its roof. Next it runs forwards in
the superior oblique muscle on its orbital surface
the lateral wall of cavernous sinus between the $ig.2a.2a).
oculomotor and ophthalmic nerves. In the anterior
part of sinus, it crosses over the oculomotor nerve
. \Mhen trochlear nerve is damaged, diplopia occurs
Gig.2aJ.5).
on looking downwards; vision is single so long as
the eyes look above the horizontal plane.
o Paralysis of the trochlear nerve results in:
Emerging lV a. Defective depression of the adducted eye.
nerve b. Diplopia (Fig. 2a.25).
Aqueduct
lV nucleus
Medial lemniscus ABDUCENT NERVE

It is the sixth cranial nerve which supplies the lateral
Decussation of
tr
'6 rectus muscle of the eyeball (Fig. 24.26). One nerve fibre
superior cerebellar
m peduncles supplies approximately six muscle fibres.
Functionol Com nents
ot
C Corticobulbar and
o corticospinal tracts
o
o
1 General somatic efferent, for lateral movement of the
a Fi1.24.23l. Emerging fibres of trochlear nerves with their nuclei eyeball.
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CRANIAL NERVES
Connections of the nucleus are similar to those of

the third nerve, except for the pretectal nuclei.
Course ond Dislribution

L In their intraneural course, the fibres of the VI nerve
runventrally and downwards through the trapezoid
body, medial lemniscus and basilar part of pons to
Conjugate position
of eyes in primary reach the lower border of the pons (see Fig.25.7).
positions
2 The nerve is attached to the lower border of the pons,
opposite the upper end of the pyramid of the medulla
Gis.za.D.
3 The nerve then runs upwards, forwards and laterally
through the cisterna pontis and usually dorsal to the
anterior inferior cerebellar artery to reach the
No depression of
right adducted eye cavernous sinus.
4 The abducent nerve enters the caoernous sinus by
piercing its posterior wall at a point lateral to the
dorsum sellae and superior to the apex of the petrous
temporal bone. As the nerve crosses the superior
border of the petrous temporal bone, it passes
beneath the petrosphenoidal ligament, and bends
Tilting the head to left sharply forwards. In the cavernous sinus, at first it
side decreases diplopia lies lateral to the internal carotid artery and then
inferolateral to it (Figs 24.75 and 24.1.6).
The abducent nerve enters the orbit through the
middle part of the superior orbital fissure. Here it
Fig. 24.25: Paralysis of right fourth nerve lies inferolateral to the oculomotor and nasociliary
nerves (Fi9.2a.27).
ln the orbit, the nerve ends by supplying only the
Medial
lateral rectus muscle. It enters the ocular surface of
longitudinal the muscle (Fig. 2a.28).
Superior bundle
vestibular
nucleus Vl nerve
nucleus
V nucleus
and tract
Vllnerve
nucleus
Vll nerve
V1 nerve
Vl nerve V2 nerve
V3 nerve
Fig.24.26: Vl nerve with its nucleus. lt includes unusual course
Vl nerve
of Vll nerve Petrous temporal
bone
lnternal
2 The general somatic afferent, for proprioceptive auditory meatus
impulses from the muscle to the mesencephalic
Foramen magnum
nucleus of V nerve.
.s
Nucleus (E
Abducent nucleus is situated in the upper part of the

o
N
floor of fourth ventricle in the lower pons, beneath the
.9
facial colliculus. Ventromedially, it is closely related to o
the medial longitudinal bundle. Fig.24.27: V1 nerve about to enter the superior orbital fissure ao
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BRA N
TRIGEMINAT NERVE
Lateral
rectus
Fifth cranial nerve is the largest cranial nerve. It
comprises three branches, two of which are Purely
sensory and third, the largest branch is mixed nerve.
Superior Trigeminal nerve is the nerve of first brachial arch.
orbital Branches of this nerve provide sensory fibres to the
fissure
four parasympathetic ganglia associated with cranial
outflow of parasympathetic nervous system. These are
ciliary, pterygopalatine, otic and submandibular.
Cavernous Ophthalmic, the first division carries sensory fibres
SINUS
from the structures derived from frontonasal process.
Abducent Maxillary, the second division conveys afferent fibres
nerve from structures derived from maxillary Process.
Mandibular, the third mixed division carries sensory
fibres derives from mandibular process.
Nucleus
of Vl Nucleor Columns
NETVE
I General somatic rent column: This columnhas three
Fi9.2428: The origin, course and distribution of the abducent nerue

nuclei. These are:
a. Spinal nucleus of V nerue: Fibres conveying pain
and temperature sensations from most of the face
area relay here (Fig. 24.30).
Sixth nerve paralysis is one of the commonest false b. Swperior sensory nttcleus of V nerae: Fibres carrying
localizing signs in cases with raised intracranial touch and pressure relay in this nucleus.
pressure.Its susceptibility to such damage is due c. Mesenrcphalic nucleus: This nucleus extends in the
to its long course in the cisterna pontis, to its sharp midbrain. It receives proprioceptive impulses
bend over the superior border of petrous temporal from muscles of mastication, temporomandibular
bone and the downward shift of the brainstem joint and teeth.
towards the foramen magnum produced by raised 2 Branchial rent column; The nucleus of V nerve is
intracranial pressure. situated at the level of upper pons. The fibres of the
Sixth nerve paralysis causes failure of abduction motor nucleus supply eight muscles derived from
of the affected eye (Fig. 24.29). first branchial arch.
. Diplopia occurs due to paralysis of right lateral
rectus muscle. Sensory Components of V Nerve
Sensations of pain, temperature, touch and pressure
R
from skin of face, mucous membrane of nose, most of
the tongue, paranasal air sinuses travel along axons.
Their cell bodies lie in the V ganglion (Fig.24.31) or
Motor
nucleus
Conjugate position of eyes Superior

in primary positions sensory
nucleus
Mesen-
cephalic
root
tr Trigeminal
'6 ganglion
E Trigeminal
(\I
No abduction of right eye on nerve
c looking to the right paralysed side
o Pons
o
o Fig" 24.29: Paralysis of right sixth nerve
U) Fig. 24.30: Nuclei of trigeminal nerve at level of upper pons
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CRANIAL NERVES
Ophthalmic nerve fibres end in the inferior part,

maxillary nerve fibres end in the middle part and
mandibular nerve fibres terminate in the upper part of
spinal nucleus.
According to another view, the ophthalmic fibres lie
in the median part, maxillary fibres in the medial part
and the mandibular fibres in the lateral part of the
nucleus.
Proprioceptive fibres from muscles of mastication,
Trigeminal
extraocular muscles and facial muscles bypass V
ganglia ganglion to reach unipolar cells of mesencephalic
nucleus.
Axons of neurons of spinal nucleus, superior sensory
nucleus and central processes of cells of mesencephalic
nucleus cross to the opposite side and ascend as
Fig. 24.31 : Trigeminal ganglia and three of its branches trigeminal lemniscus. The lemniscus ends in the ventral
posteromedial nucleus of thalamus, where these fibres
relay (seeFig.23.13). The third neuron fibres end in areas
semilunar ganglion or Gasserian ganglion. This 3, 1 and 2 of cerebral cortex.
ganglion is equivalent to the spinal ganglia of other
nerves. It lies at the apex of petrous temporal bone in a
dural cave, the Meckel's cave. Peripheral processes form Molor Componenl for lhe Muscles
the three nerves. The motor nucleus receives impulses from the right
The central processes of V ganglion form sensory and left cerebral hemispheres, red nucleus and
root. Some fibres ascend and other descend. Ascending mesencephalic nucleus. Fibres of motor root supply
fibres end in superior sensory nucleus. Descending four muscles of mastication (Fig. 24.33) and four other
fibres end in the spinal nucleus of V nerve. muscles are tensor veli palatini, tensor tympani,
Pain and temperature reach spinal nucleus. Touch mylohyoid and anterior belly of digastric.
and pressure sensations go to superior sensory nucleus
$ig.2as\. TRIGEMINAL NERVE/CRANIAT NERVE V
Cranial nerve V/trigeminal nerve comprise three
Superior Trigeminal branches, ophthalmic V1, maxillary V2 andmandibular
sensory ganglion
V3 (Fig.24.34).
nucleus of V
Genu of
facial nerve
VI
nucleus
rotundum
Pons
Foramen ovale
vil
.. ,v3
nucleus Stylomastoid
foramen
Facial muscles
Spinal
cord
.s
G
Spinal
nucleus E
ofV N
C
Fig. 24.33: Distribution of mandibular nerve to muscles ol .o
Fig. 24.32: Sensory input of trigeminal (yellow) and motor output mastication. Arrow's show direction of movement at temporo- o
G)
of facial nerve (red) mandibular joint a
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BRAIN
Ophtholmic Nerue Division Moxillory Nerve Division

Ophthalmic nerve is sensory. Its branches are:
fmf
Meningeal branc
1 Supratrochlear:Upper eyelid, conjunctiva, lower part fru Ffe fime Foss*
of forehead.
2 Supr aorbital: Frontal air sinus, upper eyelid, forehead,
L Ganglionic branches
scalp till vertex (Fig.2a3Q. 2 Zygornafic:
a. ZygomatLcotemporal l S".,ro.,,
b. Zygomaticofacial I '
I Pasteriar ethmoidal: Sphenoidal air sinus, posterior
3 Posterior superior alveolar
ethmoidal air sinuses.
2 Long ciliary; Sensory to eyeball.
3 Branch to ciliary ganglion. Jn Cn #{&##d #CIm*f
4 It trcscliear: Both eyelids, side of nose, Iacrimal sac. 1 Middle superior alveolar
5 Anterior etlmoidal: 2 Anterior superior alveolar
a. Middle and anterior ethmoidal sinuses
b. Medial internal nasal #it F*e*
c. Lateral internal nasal Infraorbital
d. External nasal: Skin of ala of vestibule and tip of a. Palpebral
nose. Sensory
b. Labial
flrvg e":vd c. Nasal
Lateral part of upper eyelid; conveys secretomotor Sensory areas by maxillary nerve are depicted in
fibres from zygomatic nerve to lacrimal gland. Fig.24.35.
To scalp
Frontal nerve Nasociliary
Branches to dura mater Supraorbital nerve
Supratrochlear nerve
Lacrimal
Anterior ethmoidal
l''l t
\{5 {2 lnfraorbital nerve
r':.
Tensor tym.pani
Otic ganglion
Tensor veli palatini Buccal nerve
Lingual nerve Submandibular ganglion
Parotid gland
'6
= lnferior alveolar nerve
Mental nerve
o
N Nerve to mylohyoid
C
o Digastric
o Hyoid
o
a Fig. 24.34: Distribution of three branches of trigeminal nerve (for understanding only)
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CBANIAL NERVES
. Proprioceptive fibres terminate in mesencephalic

nucleus.
. Light touch fibres end in the main sensory or
superior sensory nucleus.
o Pain and temperature fibres terminate in nucleus
of spinal tract of trigeminal.
nerve
,c3
o Motor fibres begin from the motor nucleus of
trigeminal.
The separate location of main sensory nucleus and
spinal nucleus account for dissociated sensory
loss, i.e. low pontine or medullary lesion will
result in loss of pain and temperature sensation
while light sensation is preserved.
Low pontine, medullary and cervical lesions
produce a characteristic 'onion skin' distribution
of pin prick and temperature loss.
An ascending lesion spares the mrzzle area till
last (openings of nose and mouth).
Anterior cutaneous Test with pin prick, temperature and light touch
nerve of neck C2, C3
over each side of the whole face.
The sensations in three branches of V nerve can
Fig" 24.35: Clinical testing oI V nerve be tested clinically.
Brainstem lesion results in'onion skin'pattern as
Mondibulor Nerve Division shown in Fig. 24.36.
;*,r,liir:,r Motor examination: Look for wasting or thinning
1 Meningeal of temporalis muscle. There may be 'hollowing
2 Nerve to medial pterygoid supplies: out'of the temporal fossa.
a. Tensor veli palatini Ask the patient to press upper and lower teeth
b. Tensor tympani together and feel for temporalis and masseter
c. Medial pterygoid. muscles (Fig.2a3$.
Ask patient to open the mouth. If pterygoid muscles
,'i, irl l:*+t i* r iljit,.j $;,r:1rll are weak, the jaw would deviate to weak side as the
1. Deep temporal normal muscles will push the jaw to the weak side.
2 Lateral pterygoid In injury to:
J Masseteric Ophthalmic nerae: There is loss of corneal blink
4 Buccal-skin of cheek (Fig.2a3\. reflex. This reflex is mediated by V1 which is
afferent pathway and VII nerve which subserves
iii'/ i,,r i+::. i ii{ ;r y f ,}: i/,i,.,f .,.,1 r r"r
as efferent pathway (Fig.2a3l.
1 Auriculotemporal (Fig. 24.34): Maxillary nerae:There is loss of sneeze reflex. This
a. Auricular branch is the afferent path of sneeze reflex.
b. Superficial temporal Mandibular neroe: There is loss of jaw jerk reflex
c. Articular to temporomandibular joint (Fig. 24.38).
d. Secretomotor to parotid gland. Trigeminal neuralgia: The principal disease
2 Lingual-general sensation from anterior two-thirds affecting sensory root of V nerve is characterized
of tongue. by attacks of severe pain in the area of distribution
3 Inferior alveolar-lower teeth, mental for skin of chin of maxillary or mandibular divisions. Maxillary
and nerve to mylohyoid: nerve is most frequently involved.
a. Mylohyoid The trigeminal ganglion harbours the herpes zoster
b. Anterior belly of digastric. virus causing shingles in the distribution of the nerve.
.E
Flaccid paralysis of muscles of mastication in (E
injury of mandibular nerve leading to decrease E
. Fifth cranial nerve subserves sensation from face strength for biting. ot
and neighbouring areas. It also innervates the Hypoacusis, i.e. partial deafness to low pitched .9
sounds due to paralysis of tensor tympani muscle. o
muscles of mastication (Fig. 24.33).
ao
l
)
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T
BRAIN
F IAt NERVE
Facial nerve is the nerve of the second branchial arch.
Funclionol Componenis
1 Special visceral or branchial efferent, to muscles
V3 responsible for facial expression and for elevation
of the hyoid bone (Table 24.1).
v2
2 General oisceral efferent or parasympathetic. These
fibres are secretomotor to the submandibular and
sublingual salivary glands, the lacrimal gland,
V1
and glands of the nose, the palate and the pharynx
(Figs24.4a and b).
3 General uisceral afferent component carries afferent
impulses from the above mentioned glands.
Fig. 24.36: Brain stem lesion of V nerve
4 Special aisceral afferent fibres carry taste sensations
from the palate and from anterior two-thirds of the
tongue except from vallate papillae.
5 General somatic afferent fibres probably innervate a
part of the skin of the ear. The nerve does not give
any direct branches to the ear, but some fibres may
reach it through communications with the vagus
nerve. Proprioceptive impulses from muscles of the
face travel through branches of the trigeminal nerve
to reach the mesencephalic nucleus of the nerve.
Nuclei
The fibres of the nerve are connected to four nuclei
situated in the lower pons.
L Motor nucleus or branchiomotor (Fig.2a32).
2 Superior salivatory nucleus or parasympathetic.
3 Lacrimatory nucleus is also parasymPathetic.
Fig. 24.37: Testing the corneal blink reflex 4 Nucleus of the tractus solitarius which is gustatory.
It also receives afferent fibres from the glands (Figs
24.4b and24.4c).
The motor nucleus lies deep in the reticular formation
of the lower pons. The part of the nucleus that supplies
muscles of the upper part of the face receives
corticonuclear fibres from the motor cortex of both the
right and left sides.
In contrast, the part of the nucleus that supplies
muscles of the lower part of the face receive
corticonuclear fibres only from the opposite cerebral
hemisphere (Fig. 24.5a).
Course ond Relqlions

.= The facial nerve is attached to the brainstem by two
(E
roots, motor and sensory. The sensory root is also called
E
C\I
the nerrsus intermedius (Fig. 2a 39).
c The two roots of the facial nerve are attached to the
.o
o Fig. 24.38: Elicitation of jaw jerk reflex lateral part of the lower border of the pons just medial
to the eighth cranial nerve. The two roots run laterally
G)
a
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CRANIAL NERVES
Labyrinthine vessels
Canal for
facial nerve
Facial nerve (motor root) First part runs Second paft runs
laterally backwards
Nervus intermedius
Geniculate
Aditus to
ganglion
Dura mater mastoid antrum
Pyramid
Vestibulocochlear nerve
Arachnoid mater Nerve to

stapedius
Promontory
Third part runs
Fig. 24.39: Structures in the left internal acoustic meatus downwards
and forwards, with the eighth nerve to reach the

internal acoustic meatus.
In the meatus, the motor root lies in a groove on the Stylomastoid
foramen
eighth nerve, with the sensory root intervening (Fig.
24.39). Here the seventh and eighth nerves are Fi1.24.41: Course of facial nerve
accompanied by the labyrinthine vessels. At the bottom
or fundus of the meatus, the two roots, sensory and
motor, fuse to form a single trunk, which lies in the on the genu. The second bend is gradual, and lies
petrous temporal bone (Fig. 24.40). between the promontory and the aditus to the mastoid
antrum.
Within the canal, the course of the nerve can be
The facial nerve leaves the skull by passing through
divided into three parts by two bends (Fig.za.a\.
the stylomastoid foramen.
The first part is directed laterally above the vestibule;
Inits extracranial course, the facial nerve crosses the
the second part runs backwards in relation to the medial
lateral side of the base of the styloid process. It enters
wall of the middle ear, above the promontory. The third
the posteromedial surface of the parotid gland, runs
part is directed vertically downwards behind the forwards through the gland crossing the retromandi-
promontory.
bular vein and the external carotid artery. Behind the
The first bend at the junction of the first and second neck of the mandible, it divides into its five terminal
parts is sharp. It lies over the anterosuperior part of branches which emerge along the anterior border of
the promontory, and is also called the genu. The geni- the parotid gland.
culate ganglion of the nerve is so called because it lies
Bronches ond Disllibulion
lnferior vestibular Superior vestibular area 1 Within the facial canal:
area for fibres from for fibres from cristae a. Greater petrosal nerve
maculae of utricle of anterior and lateral
and saccule semicircular canals
b. The nerve to the stapedius
c. The chorda tympani (Fig.2a.a\.
2 At its exit from the stylomastoid foramen:
Canal for a. Posterior auricular
facial nerve
b. Digastric
Transverse c. Stylohyoid.
crest 3 Terminal branches within the parotid gland:
a. Temporal
Cochlear
b. Zygomalic
alea c. Buccal
d. Marginal mandibular (E
e. Cervical. 6
Foramen singulare for flbres 4 Communicating branches with adjacent cranial and ol
from crista of posterior semicircular canal spinal nerves. c
.o
Fig. 24.40: Some features seen on the fundus of the left internal Greater petrosal nerue-cotrse has been traced in o
q)
acoustic meatus Flow chart 24.6. a
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Lacrimatory and superior salivatory nuclei (GVE)
Nucleus of tractus solitarius (SVA and GVA)

GVA
Sensory root
Motor nucleus lnternal auditory meatus
(svE)
Geniculate Greater Nerve of
Spinal nucleus ganglion petrosal pterygoid
of V (GSA) canal
Sphenopalatine
ganglion
Deep petrosal
Nerve to stapedius Nasal, palatal

and pharyngeal
glands
Lingual nerve
Chorda tympani
Posterior
auricular
Temporal
Posterior belly
of digastric Zygomalic Sublingual gland
Stylohyoid
svA
cvE ----. csA -
GVA -**-"
-
Cervical Marginal mandibular
Fig. 24.42: Distribution of functional components of Vll nerve
The neroe to the stapedlus arises opposite the pyramid then passes medial to the spine of the sphenoid and
of the middle ear, and supplies the stapedius muscle. enters the infratemporal fossa. Here it joins the lingual
The muscle dampens excessive vibrations of the stapes nerve through which it is distributed. It carries:
caused by high-pitched sounds. In paralysis of the a. Preganglionic secretomotor fibres to the
muscle, even normal sounds appear too loud and is submandibular ganglion for supply of the
known as Wperacusls (Fig. 24.42). submandibular and sublingual salivary glands.
tr The chorda tympani arises in the vertical part of the b. Taste fibres from the anterior two-thirds of the
'6
o facial canal about 6 mm above the stylomastoid tongue except circumvallate papillae.
N foramen. It runs upwards and forwards in a bony canal. The posterior nuricular nerae arises just below
o It enters the middle ear and runs forwards in close the stylomastoid foramen. It ascends between the
o relation to the tympanic membrane. It leaves the middle mastoid process and the external acoustic meatus, and
o)
@ ear by passing through the petrotympanic fissure. It supplies:
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CRANIAL NERVES
Flow chaft 24.6: Tracing nerve supply of lacrimal gland Gonglio

Greater petrosal nerve The ganglia associatedwiththe facialnerve are as follows.
1 The geniculate ganglion (Fig.za.a\ is located on the
first bend of the facial nerve, in relation to the medial
Deep petrosal nerve
wall of the middle ear. It is a sensory ganglion. The
taste fibres present in the nerve are peripheral
processes of pseudounipolar neurons present in the
geniculate ganglion.
The submandibular ganglion is a parasympathetic
ganglion for relay of secretomotor fibres to the
submandibular and sublingual glands. The
preganglionic fibres come from the chorda tympani
nerve (Table 24.2).It is described in Chapter 7.
The pterygopalatine ganglion is also a parn-
sympathetic ganglion. Secretomotor fibres meant for
the lacrimal gland relay in this ganglion. The fibres
reach the ganglion from the nerve to the pterygoid
canal (Table 24.2).It is described in Chapter 15.
a. Auricularis posterior
b. Occipitalis Bell's palsy: Sudden paralysis of facial nerve at the
c. Intrinsic muscles on the back of auricle. stylomastoid foramen, results in asymmetry of
The digastricbranch, arises close to the previous nerve. corner of mouth, inability to close the eye,
It is short and supplies the posterior belly of the disappearance of nasolabial fold and loss of
digastric. wrinkling of skin of forehead on the same side
The stylohyoidbranch, arises with the digastric brancll (see Fig.2.20).
is long and supplies the stylohyoid muscle. Lesion above the origin of ch,orda tympani nerve
The temporal branches cross the zygomatic arch and will show symptoms of Bell's palsy plus loss of
supply: taste from anterior tr,vo-thirds of tongue except
a. Auricularis anterior vallate papillae (Fig. 2a.a$.
b. Auricularis superior Lesion above the origin of nerve to stapedius will
c. Intrinsic muscles on the lateral side of the ear cause symptoms 1,2. It also causes hyperacusis.
d. Frontalis Lesions 1,2 and 3 are lower motor neuron type.
e. Orbicularis oculi Upper motor neuron paralysis will not affect the
f. Corrugator supercilii. upper part of face, i.e. orbicularis oculi, only lower
The zygomatic branches run across the zygomatic bone
half of opposite side of face is affected. The upper
and supply the orbicularis oculi. half of face has bilateral representation, whereas
lower half has only contralateral representation
The buccal branches are two in number. The upper
(Fig. 24.5a).
buccal branch runs above the parotid duct and the
Facial nerve can be injured at any level during its
lower buccal branch below the duct. They supply
course. Figure 24.43 shows symptoms according
muscles in that vicinity especially the buccinator.
to level of injury of VII nerve.
The marginal mandibular branch runs below the angle
Lower motor neuron paralysis of VII nerve causes
of the mandible deep to the platysma. It crosses the paralysis of ipsilateral half of face, i.e. both upper
body of the mandible and supplies muscles of the lower quadrant and lower quadrant of same side as the
lip and chin (see Fig.7.1). injury.
The ceraical branch emerges from the apex of the Upper motor neuron paralysis of VII nerve results
parotid gland, and runs downwards and forwards in in paralysis of contralateral lower quadrant of face
the neck to supply the platysma (see Fig. 5.3). only.
C ommunic atin g br anches. For eff ective coordination For clinical testing of the facial nerve, and for .E
(E
between the movements of the muscles of the first, different types of facial paralysis-infranuclear 6
second and third branchial arches, the motor nerves of (see Fig. 2.20) and for supranu clear (see Fig. 2.21). C\l
the three arches communicate with each other. The facial c

Eacial nerae palsy in newborn: The mastoid process .9
nerve also communicates with the sensory nerves is absent in newborn and stylomastoid foramen o
distributed over its motor territory. ao
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BRAIN
is superficial. Manipulation of baby's head during Polhwoy of Heoilng

delivery may damage the VII nerve. This leads to 1 The first neurons of the pathway are located in the
paralysis of facial muscles especially the spiral ganglion. They are bipolar. Their peripheral
buccinator, required for sucking the milk. processes innervate the spiral organ of Corti
Crocodile tears syndrome: Lacrimation during eating (Fig.24.44), while central processes form the cochlear
occurs due to aberrant regeneration after trauma. nerve (Fig.za.afl. This nerve terminates in the dorsal
In case of damage to facial nerve proximal to and ventral cochlear nuclei.
geniculate ganglia, regenerating fibres for 2 The second neurons lie in the dorsal and ventral
submandibular salivary gland grow in endoneural cochlear nuclei. Most of the axons arising in these
sheaths of preganglionic secretomotor fibres nuclei cross to the opposite side (in the trapezoid
supplying the lacrimal gland. That is why patient body) and terminate in the superior olivary nucleus.
lacrimates while eating food. (many fibres end in the nucleus of trapezoid body
Rnmsay-Hunt syndrome: Involvement of geniculate or of the lateral lemniscus). Some fibres are uncrossed
ganglia by herpes zoster results in this slmdrome. $ig.za.aQ.
It shows following symptoms: 3 The third neurons lie in the superior olivary nucleus.
a. Hyperacusis.
Their axons form the lateral lemniscus and reach the
b. Loss of lacrimation.
inferior colliculus.
c. Loss of sensation of taste in anterior two-third
of tongue. 4 The fourth neurons lie in the inferior colliculus. Their
d. Bell's palsy and lack of salivation. axons pass through the inferior brachium to reach
e. Vesicles on the auricle. the medial geniculate body. (Some fibres of lateral
lemniscus reach the medial geniculate body without
relay in the inferior colliculus.)
5 The fifth neurons lie in the medial geniculate body.
Their axons form the auditory radiation, which
VESIIBUTOCOCHTEAR NERVE
passes through the sublentiform part of the internal
This nerve comprises of hearing and vestibular parts. It capsule to reach the auditory area (Figs 24.47a and b)
belongs to special somatic afferent column (Table 24.2). in the temporal lobe.
Table 24 ;2: Connections of parasympathetic ganglia

Ganglia Sensory root Sympathetic Secretomotor Motor root Distribution
root parasympathetic root
Ciliary From nasociliary Plexus along Edinger-Westphal - Ciliaris muscles
(see Fig. 13.11) nerve ophthalmic nucleus -+oculomotor Sphincter pupillae
artery nerve )nerve to
inferior oblique
Otic Branch from Plexus along lnferior salivatory
Branch from Secretomotor to parotid
(see Fig. 6.15) auriculotemporal middle nucleus -+glosso- nerve to medial gland via auriculotemporal
nerve meningeal pharyngeal nerve -i pterygoid nerve
artery tympanic branch + Tensor veli palatini and
tympanic plexus -+ tensor tympani via nerve
lesser petrosal nerve to medial pterygoid
(unrelayed)
Pterygopalatine 2 branches from Deep petrosal Lacrimatory nucleus --> Mucous glands of nose,
(see Fig. 15.15) maxillary nerve from plexus nervus intermedius --> paranasal sinuses, palate,
around internal facial nerve -+ nasopharynx
carotid artery geniculate ganglion -+ Some fibres pass through
greater petrosal nerve + zygomatic nerve -,
deeP Petrosal nerve = zygomaticotemporal nerve J
nerve of pterygoid canal communicating branch to
tr lacrimal nerve +lacrimal
'6
gland
6
OJ Submandibular 2 branches from Branch from Superior salivatory Submandibular,
C (see Fig. 7.10) lingual nerve plexus around nucleus +facial nerve sublingual, and
.9
o facial aftery -+chorda tympani -+ anterior lingual glands
ao joins the lingual nerve
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CRANIAL NERVES
1. Loss of lacrimation
2. Loss of stapedial reflex lnternal auditory meatus
3. Loss of taste from anterior 213rd of tongue
4. Lack of salivation Geniculate ganglion
E
Paralysis of muscles of facial expression (Bell's palsy)
Greater petrosal nerve
1,2,3,4,5
2,3,4,5
Nerve to stapedius
3,4,5
Chorda tympani
Stylomastoid foramen
Temporal
Zygomatic
Buccal
Marginal mandibular
Fi1.24.43:. Symptoms according to the level of injury to cranial nerve Vll
central processes arising from the neurons of the

ganglion form the vestibular nerve which ends in the
vestibular nuclei.
The second neurons in the pathway of balance lies
in the vestibular nuclei (Fig.za.ail. These nuclei send
fibres:
a. To the archicerebellum through the inferior
cerebellar peduncle (vestibulocerebellar tract).
b. To the motor nuclei of the brain stem (chiefly of
the III, IV, VI and XI nerves) through the medial
longitudinal bundle (Fig. 2a.50).
c. To the anterior horn cells of the spinal cord
Afferent and efr.erent through the vestibulospinal tract.
,3ffi:;. Through the vestibular pathwa/, the impulses
Fig,.24.44: Organ of Corti
arising in the labyrinth can influence the movements
Veslibulor Pothwoy of the eyes, the head, the neck and the trunk.
The vestibular receptors are the maculae of the saccule
and utricle (for static balance) (Fig.za.a$ and in the
Deqlness
cristae of the ampullaris of semicircular ducts (for
Three types of hearing loss are seen:
kinetic balance) (Fig.2a.a9). Fibres from cristae of
1. Conductive deafness is the failure of sound waves
anterior and lateral semicircular canals and some fibres
to reach to the cochlea.
from the two maculae lie in superior vestibular area of
2. Sensorineural deafness is the failure of production
internal acoustic meatus.
or transmission of action potential due to cochlear
Fibres of crista of posterior semicircular canal lie in
disease, cochlear nerve disease or defects in tr
foramen singulare. 'd
cochlear nerve central connections.
Most of the fibres from maculae of utricle and saccule E
3. Cortical deafness is a bilateral or dominant
lie in inferior vestibular area (Fig.za.aQ. ol
posterior temporal lobe lesion. It results in a failure tr
These three nerve divisions are peripheral processes o
of bipolar neurons of the vestibular ganglion. This
to understand spoken language even though o
hearing is preserved. o
ganglion is situated in the internal acoustic meatus. The a
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BRAIN
Vertigo: This is an illusion of rotatory movement General aisceral ffirent (GVE) fibres (preganglionic)
due to disturbed orientation of the body in space. arise in inferior salivatory nucleus and travel to the
The patient feels that the environment is moving. otic ganglion. Postganglionic fibres arising in the
It is due to disease of vestibular nerve. ganglion to supply the parotid gland (Table24.2).
Tinnitis is a sensationof btuzing, ringing, hissing General aisceral afferent (GVA) fibres are peripheral
or singing quality. Tinnitis may be unilateral or processes of cells in inferior ganglion of the nerve.
bilateral; high or low pitch; continuous or inter- These carry general sensations from the pharynx,
mittent. palate, posterior one-third of tongue tonsil, carotid
Meniere's syndrorne is characterizedby recurrent body and carotid sinus to the ganglion. The central
attacks of tinnitis, vertigo and hearing loss processes convey these sensations to lower part of
accompanied by a sensitivity to noises. It affects the nucleus of the solitary tract.
middle aged or older persons. In this condition,
there is an increase in volume of endolymph. To auditory cortex
Acoustic neuroma is a slow growingbenign tumor
of neurolemmal cells. It causes an early loss of
hearing. Medial
geniculate
body
Midbrain
GI.OSSOPHARYNGEAT NERVE
Glossopharyngeal is the ninth cranial nerve. It is the Lateral
lemniscus
nerve of the third branchial arch.
It is motor to the stylopharyrrgeus. It is secretomotor
Superior
to the parotid gland and gustatory to the posterior one- olivary
third of the tongue including the circumvallate papillae. nucleus
It is sensory to the pharynx, the tonsil, soft palate,
the posterior one-third of the tongue, carotid body and
carotid sinus.
Funcfionol Components
1 in nucleus
Special r:isceral efferent (SVE) fibres arise
ambiguus and supply the stylophar),,r:rgeus muscle
$ig.2a.5\. Fig. 24.46: Auditory pathway
Vestibular nuclei Fundus of internal

auditory meatus
Dorsal cochlear nucleus Vestibular

ganglion
Ventral cochlear nucleus
Ampullae with
cristae
Medial lemnisci
tr Cochlear nerve
.E
m
ot
C
o
o
o
a Fig.24.45: Course of cochlear and vestibular neryes
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CRANIAL NERVES
Association auditory
(area 22)
High frequency
sound
Lateral sulcus
Low frequency of cerebrum
sound
Primary auditory
(area 41, 42)
Primary and
association
auditory areas
Figs24.47a and b: Auditory cortex: (a) Posterior ramus of lateral sulcus, and (b) depth of lateral sulcus
To cortex
Gelatinous
MASS
Otoliths
Stereocilia
Hair cell
To nuclei of
eye muscles
Supporting (il, rv vr)
columnar
cells Medial
Iongitudinal
bundle
Vestibular
Fig.24.48: Structure of the macula nuclei
Fig.24.50: Vestibular pathway
lnferior salivatory nucleus
Nucleus of tractus solitarius
Spinal nucleus of trigeminal
Nucleus ambiguus
GSA
GVE
SVA
SVE
Fig.24.49: Structure of crista ampullaris lnferior ganglion tr
'6
Superior ganglion
E
Special aisceral afferer4f (SVA) fibres are also
peripheral Fig-24.51: Functional components and nuclei of lX nerve N
processes of cells in the inferior ganglion. They carry C
o
sensations of taste from the posterior one-third of inferior ganglion. The central processes convey these ()
the tongue including circumvallate papillae to the sensations to the nucleus of the solitary tract. ao)
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BRA N
5 General somatic ffiretzf (GSA) fibres are the peripheral vagus and accessory nerves. It has a separate sheath
processes of the cells in the inferior ganglion of the of dura mater (Fig.24.52a).
nerve. These cany general sensations from the middle 5 In the jugular foramen, the nerve is lodged in a deep
ear, proprioceptive fibres from stylophanTngeus. The groove leading to the cochlear canaliculus, and is
central processes carry these sensations to nucleus of separated from the vagus and accessory nerves by
spinal tract of trigeminal nerve. the inferior petrosal sinus.
Inits extracranial course, the nerve descends:
Nuclei a. Between the internal jugular vein and the internal
The three nuclei in the upper part of medulla are named carotid artery, deep to the styloid process and the
below: muscles attached to it.
1 Nucleus ambiguus (branchiomotor). b. It then turns forwards winding round the lateral
2 Inferior salivatory nucleus (parasympathetic). aspect of the stylophar)mgeus, passes between the
external and internal carotid arteries, and reaches
3 Nucleus of tractus solitarius (gustatory). the side of the pharyrx (Fig.2a.52b). Here it gives
pharyngeal branches.
Course ond Relolions
c. It enters the submandibular region by passing
L Irr their intraneural courset the fibres of the nerve pass deep to the hyoglossus (see Fig.7.2), where it
forwards and laterally, between the olivary nucleus breaks up into tonsillar and lingual branches.
and the inferior cerebellar peduncle, through the 6 At the base of skull, ninth nerve presents a superior
reticular formation of the medulla (see Fig.25.5). and an inferior ganglion. Superior ganglion is a
2 At the base of the brain, the nerve is attached by 3 to detached part of the inferior, and gives no branches.
4 filaments to the qpper part of the posterolateral The inferior ganglion is larger, occupies notch on the
sulcus of the medulla, just above the rootlets of the lower border of petrous temporal, and gives out
vagus nerve (see Fig.25.1). communicating and tympanic branches (Fig. za.a\.
3 In their intracranial course, the filaments unite to
form a single trunk which passes forwards and Bronches ond Dislribulion
laterally towards the jugular foramen, crossing and L The tympanic nerae isabranch of the inferior ganglion
grooving the jugular tubercle of the occipital bone. of the glossopharyngeal nerve. It enters the middle
4 The nerve leaoes the skull by passing through the ear through the tympanic canaliculus, takes part in
middle part of the jugular foramen, anterior to the the formation of the tympanic plexus in the middle
External carotid
Styloid process
Spinal root of
lnternal carotid accessory nerve
Pharyngeal branch of vagus Occipital artery
Facial artery
Posterior auricular
Superior laryngeal
Hypoglossal nerve branch of vagus
Lingual adery
Ascending
lnternal laryngeal nerve pharyngeal aftery
External laryngeal nerve Vagus nerve
Superior thyroid
lnferior root of
ansa cervicalis
Superior root of
tr ansa cervicalis
'6
E Ansa cervicalis
N
o (a) (b)
o
o
Figs24.52a and b: (a) Structures passing through jugular foramen, and (b) relation of cranial nerves lX, X, Xl, Xll to carotid arteries
a and internal jugular vein
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CRANIAL NERVES
ear and distributes its fibres to the middle ear, the

auditory tube, the mastoid antrum and air cells. One
branch of the plexus is called the lesser petrosal neroe.
GUS NERVE
It contains preganglionic secretomotor fibres for the
parotid gland and relays in the otic ganglion. Vagus nerve is the tenth cranial nerve. It is so called
Postganglionic fibres join auriculotemporal nerve to because of its extensive ('vague') course, through the
reach the gland. head, the neck, the thorax and the abdomen. The fibres
T}:le carotid branch descends on the internal carotid of the cranial root of the accessory nerve are also
artery and supplies the carotid sinus and the carotid distributed through it.
body (Fig. 24.53). The vagus nerve bears two ganglia, superior and
The pharyngeal branches take part in the formation of inferior. The superior ganglion is rounded and lies in the
the pharyngeal plexus, along with vagal and jugular foramen. The inferior ganglion is cylindrical and
sympathetic fibres. The glossopharyngeal fibres are lies near the base of the skull.
distributed to the mucous membrane of the pharynx
and palate. Functionol Componenls
The muscular branch supplies the stylopharyngeus I Special aisceral efferent fibres arise in the nucleus
@ig.2a.53). ambiguus and supply the muscles of the palate,
The tonsillar branches supply the tonsil and join the pharynx and larynx (Fig.2a.5a).
lesser palatine nerves to form a plexus from which 2 General oisceral ffirent frbres arise in the dorsal motor
fibres are distributed to the soft palate and to the nucleus of the vagus. These are preganglionic
palatoglossal arches. parasympathetic fibres. They are distributed to
Thelingualbranches carry taste and general sensations thoracic and abdominal viscera. The postganglionic
from the posterior one-third of the tongue including neurons are situated in ganglia lying close to (within)
the circumvallate papillae. the viscera to be supplied.
3 General aisceral alferent flbres are peripheral processes
of cells located in the inferior ganglion of the nerve.
Lesion of this nerve causes: They bring sensations from the pharynx, larynx,
a. Absence of secretions of parotid gland. trachea, oesophagus and from the abdominal and
b. Absence of taste from posterior one-third of thoracic viscera. These are conveyed by the central
tongue and the circumvallate papillae. processes of the ganglion cells to the lower part of
c. Loss of pain sensations from tongue, tonsil, nucleus of tractus solitarius. Some of these fibres
pharynx and soft palate. terminate in the dorsal nucleus of the vagus.
d. Gag reflex is absent. 4 Special aisceral afferent fibres are also peripheral
Glossophnryngeal neuralgia:Itis a short sharp severe processes of neurons in the inferior ganglion. They
attack of pain affecting posterior part of pharynx carry sensations of taste from the posteriormost part
or tonsillar area. of the tongue and from the epiglottis. The central
processes of the cells concerned terminate in the
]ugular foramen syndrome is due to injury at the
jugular foramen resulting in multiple cranial nerve upper part of the nucleus of the tractus solitarius.
palsies. 5 General somatic aferent fibres are peripheral processes
The glossopharyngeal nerve is tested clinically in of neurons inthe superior ganglion and are distributed
the following ryay: to the skin of the extemal ear. The central processes
a. On tickling the posterior wall of the pharynx, of the ganglion cells terminate in relation to the spinal
there is reflex contraction of the pharyngeal nucleus of the trigeminal nerve (Fig.2a.aq.
muscles. No such contraction occurs when the The upper part of the nucleus of tractus solitarius
ninth nerve is paralysed. comprises superior, middle and inferior parts. These
b. Taste sensibility on the posterior one-third of parts receive fibres from VII, IX and X nerves,
the tongue can also be tested. It is lost in ninth respectively (Fig. 24.4c).
nerve lesions.
Nuclei
Isolated lesions of the ninth nerve are almost
unknown. They are usually accompanied by L Nucleus ambiguus (branchiomotor): Mostly a part o
lesions of the vagus nerve. of the cranial root of accessory nerve; partly of vagus. 6
Pharyngitis may cause referred pain in the ear as 2 Dorsal nucleus of vagus (parasympathetic): It is a ol
both are supplied by IX nerve. However, in these mixed nucleus, being both motor (visceromotor and c
.9
cases eustachian catarrh should be excluded. secretomotor) and sensory (viscerosensory). Its fibres o
form the main bulk of the nerve. ao
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BBA N
Lesser superficial
petrosal nerve
Otic ganglion
SVE
SVA
GVA
Superior ganglion
lnferior ganglion
Tympanic nerve
itrl
r!
I
t
I
I Styloid process
I
I
Stylopharyngeus Soft palate
Nerve to stylopharyngeus
Carotid sinus
Circumvallate
papillae with
Carotid body taste buds
Tongue (posterior'1 /3)
Hyoid bone
Thyroid cartilage
Fig. 24.53: Distribution of functional components of glossopharyngeal nerue
Dorsal nucleus of vagus Course ond Relotions in Heod ond Neck

1 In the intracranial coLffse, fibres run forwards and
laterally through the reticular formation of medulla,
Spinal nucleus of trigeminal between the olivary nucleus and inferior cerebellar
peduncle (see Fig. 25.5).
Nucleus ambiguus 2 The nerve is attached, by about ten rootlets, to the
posterolateral sulcus of medulla (Fig.2a.\.
GSA
GVE
3 In the intracranial course, the rootlets unite to from
SVA a large trunk which passes laterally across the jugular
tubercle along with the glossopharyngeal and cranial
root of accessory nerves, and reaches the jugular
lnferior ganglion foramen.
Superior ganglion 4 The nerve leaaes the cranial caaityby passing through
the middle part of the jugular foramen, between the
c Fig.24.54: Functional components and nuclei of X nerve
sigmoid and inferior petrosal sinuses. In the foramen,
(E
it is joined by the cranial root of the accessory nerve.
E
c\l 5 Nucleus of tractus solitarius (gustatory): Distributed 5 Leaving the skull, the nerve descends within the
C through intemal laryngeal nerve to the taste buds of carotid sheath, inbetween and posterior to the intemal
.9
o epiglottis and vallecula. jugular vein (laterally), and the internal and common
E4 Nucleus of spinal tract of trigeminal. carotid arteries (medially) (seeFigs 3.8 and 24.52).
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CRANIAL NERVES
6 At the root of the neck, the right vagus enters the thorax carotid arteries, and reaches the upper border of the
by crossing the first part of the subclavian artery, middle constrictor of the pharynx where it takes part
and then inclining medially behind the in forming the pharyngeal plexus. Its fibres are
brachiocephalic vessels, to reach the right side of the ultimately distributed to the muscles of the pharynx
trachea. The left vagus enters the thorax by passing and soft palate (except the tensor veli palatini which
between the left common carotid and left subclavian is supplied by the mandibular nerve).
arteries, behind the internal jugular and brachio- T}:.e carotid branches supply the carotid body and
cephalic veins (see Fi9.129 in Volume 1). carotid sinus.
7 Vagus bears two ganglia, superior and inferior. The T}:le superior laryngeal nerue arises from the inferior
superior ganglion is rounded and lies in the jugular ganglion of the vagus, runs downwards and
foramen. It gives meningeal and auricular branches forwards on the superior constrictor deep to the
of vagus, and is connected to glossopharyngeal and internal carotid artery, and reaches the middle
accessory nerves and to superior cervical ganglion constrictor where it divides into the external and
of sympathetic chain. The inferior ganglion is internal laryrrgeal nerves.
cylindrical (2.5 cm) and lies near the base of skull. It
gives pharyngeal, carotid, superior laryngeal The external laryngeal nerae is thin. It accompanies
branches and is connected to hypoglossal nerve, the superior thyroid arlety, pierces the inferior
superior cervical ganglion and the loop between first constrictor and ends by supplying the cricothyroid
and second cervical nerves. muscle. It also gives branches to the inferior
constrictor and to the pharyngeal plexus.
Cranial root of XI nerve joins vagus nerve at the
inferior ganglion. Tlre internal laryngeal nerae is thick. It passes
downwards and forwards, pierces the thyrohyoid
Bronches in Heod ond Neck membrane with the superior laryngeal vessels
In the jugular foramen, the superior ganglion gives off: and enters the larynx. It supplies the mucous
o Meningeal, and membrane of the larlmx up to th'e level of the vocal
Iolds (see Fig. a.7).
. Auricular branches.
The right recurrent laryngeal nerae arises from the
The ganglion also gives off communicatingbranches
vagus in front of the right subclavian artery, winds
to the glossopharlmgeal and cranial root of accessory
backwards below the artery, and they runs upwards
nerves and to the superior cervical sympathetic
and medially behind the subclavian and common
ganglion.
carotid arteries to reach the tracheo-oesophageal
The branches arising from inferior ganglion the neck groove. In the upper part of the groove, it is
are: intimately related to the inferior thyroid artery. It
. Pharyngeal (Fig. 24.55) supplies:
o Carotid a. All intrinsic muscles of the larynx, except the
. Superior laryngeal cricothyroid.
. Right recurrent laryngeal b. Sensory nerves to the larynx below the level of
o Cardiac. the vocal cords.
I Meningeal branch supplies dura of the posterior c. Cardiac branches to the deep cardiac plexus.
cranial fossa. The fibres are derived from sympathetic d. Branches to the trachea and oesophagus.
and upper cervical nerves. e. To the inferior constrictor.
2 The auricularbranch arises from the superior ganglion Theleft recurrent laryngeal nerae arises from the vagus
of the vagus. It passes behind the internal jugular in the thorax, as the latter crosses the left side of the
vein, and enters the mastoid canaliculus (within the arch of the aorta. It loops around the ligamentum
petrous temporal bone). It crosses the facial canal 4 arteriosum and reaches the tracheo-oesophageal
mm above the stylomastoid foramen, emerges groove. Its distribution is similar to that of the right
through the tympanomastoid fissure, and ends by nerve. It does not have to pass behind the subclavian
supplying the concha and root of the auricle, the and carotid arteries; and usually it is posterior to the
posterior half of the external auditory meatus, and inferior thyroid artery. tr
'6
the tympanic membrane (outer surface). T}:le cardiac branches are superior and inferior. Out of
E
3 The pharyngeal branch arises from the lower part of the four cardiac branches of the vagi (two on each (\I
the inferior ganglion of the vagus, and contains side), the left inferior branch goes to the superficial c
o
chiefly the fibres of the cranial root of accessory cardiac plexus. The other three cardiac nerves go to o
o
nerve. It passes between the external and internal the deep cardiac plexus. a
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BRAIN
Nucleus ambiguus Nucleus of spinal tract of trigeminal

Dorsal nucleus
of vagus
Vagus nerve
Cranial root of accessory nerve

Superior ganglion
lnferior ganglion
Auricular branch
Pharyngeal branch
sinus nerve i Epiglottis with taste buds
I
I
Superior laryngeal nerve

Tongue
Thyrohyoid membrane
External laryngeal nerve
Oesophagus
svE_ svA _
GVE----- GSA
GVA -----,
- ..1,
Heart, lung and GIT
Fig.24.55: Distribution of functional components of vagus in head and neck
d. Flattening of the palatal arch (Fig. 24.56).

The vagus nerve is tested clinically by comParing e. Cadaveric position of the vocal cord.
the palatal arches on the two sides. On the f. Dysphagia.
paralysed side, there is no arching, and the uvula Irritation of the auricular branch of the vagus in
is pulled to the normal side. the external ear (by ear wax, syringing, etc.) may
'8.
tr
Paralysis of the vagus nerve produces:
reflexly cause persistent cough (ear cough),
o vomiting, or even death due to sudden cardiac
(\I a. Nasal regurgitation of swallowed liquids. inhibition.
c b. Nasal twang in voice.
o Stimulation of the auricular branch may reflexly
o c. Hoarseness of voice. produce increased appetite.
o
a
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CRANIAL NERVES
Irritation of the recurrent laryngeal nerve by

enlarged lymph nodes in children may also
produce a persistent cough. ACCESSORY NERVE
Some fibres arising in the geniculate ganglion of
It has
Accessory nerve is the eleventh cranial nerve.
facial nerve pass into the vagus through two roots, cranial and spinal. The cranial root is
communications between the two nerves. They
assisting to the vagus, and is distributed through the
reach the skin of auricle through the auricular
branches of the latter. The spinal root has a more
branch of vagus. Sometimes a sensory ganglion
independent course (Fig. 24.58).
may have a viral infection (called herpes zoster)
and vesicles appeal on the area of skin supplied Functionol Components
by the ganglion. In herpes zoster of the geniculate
ganglion, vesicles appear on the skin of auricle.
L The cranial root is special aisceral (branchial) efferent.
It arises from the lower part of nucleus ambiguus. It
Injury to pharyngeal branch causes dysphagia. is distributed through the branches of vagus to the
Paralysis of muscles of soft palate results in nasal
muscles of the palate, the pharynx, the larlmx, and
regurgitation of fluids and nasal tone of voice.
possibly the heart (Fig.2a.5B).
Lesions of superior laryngeal nerve produces 2 The spinal root is also special visceral efferent. It
anaesthesia in the upper part of larynx and
arises from a long spinal nucleus situated in the
paralysis of cricothyroidmuscle. Thevoice is weak
lateral part of the anterior grey column of the spinal
and gets tired easily.
cord extendingbetween segments C1 to C5.Its fibres
Injury to right recurrent laryngeal nerve results supply the sternocleidomastoid and the trapezius
in hoarseness and dysphonia due to paralysis of muscles.
the right vocal cord-(Fig.2a.57).
Paralysis of both vocal cords results in aphonia
Nuclei
and inspiratory stridor (high pitched and harsh
respiratory sound). It may occur during thyroid The cranial root arises from the lower part of thenucleus
sur8ery. ambiguus.
The spinal root arises from a long spinal nucleus
situated on the lateral part of anterior grey column of
spinal cord, extending from C1 to C5 segments. It is in
line with nucleus ambiguus.
Course ond Distribulion of the Croniol Rool

1 The cranial root emerges in the form of 4 to 5 rootlets
which are attached to the posterolateral sulcus of the
medulla. ]ust below, the rootlets soon join together
to form a single trunk.
Auricular
Glossopharyngeal lX Tympanic
Superior and
Fig. 24.56: Paralysis of muscles of soft palate on left side inferior ganglia
of lX
Cranial root of Xl
Anterior
Accessory Xl
Cranial root of
accessory Jornrng
inferior ganglion of X
tr
'6
Mucus pools o
on affected side C\I
Posterior o
o
Fi1.24.57: Paralysis of right recurrent laryngeal nerve
Fig. 24.58: Course of the accessory nerve ao)
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BRAIN
2 It runs laterally with the glossopharyngeal vagus

and spinal accessory nerves/ crosses the jugular
tubercle, and reaches jugular foramen.
3 In the jugular foramen, the cranial root unites for a
short distance with the spinal root, and again
separates from it as it passes out of the foramen
(Fig. 2a.58).
4 The cranial root finally fuses with the vagus at its
inferior ganglion, and is distributed through the
branches of the vagus to the muscles of the palate,
the pharynx, the larynx and possibly the heart.
Gourse ond Dlshlbullon of the Spinol

Accessory
1 It arises from the upper five segments of the spinal nerve
Lesser
cord (Fig. 24.58). occipital nerve
2 It emerges in the form of a row of filaments attached Lymph
to the cord midway between the ventral and dorsal nodes Transverse cutaneous
nerve of neck
nerve roots.
ln the aertebral canal, the filaments unite to form a Great auricular
nerve
single trunk which ascends in front of the dorsal
nerve roots and behind the ligamentum denticula- F19.24.59: Accessory nerve with some branches of cervical
plexus
tum.
The nerve enters the cranium through the foramen anterior border of the trapezius 5 cm above the
magnum lying behind the vertebral artery clavicle.
(see Fi1.1.16).
Within the cranium, the nerve runs upwards and On the deep surface of the trapezius, the nerve
laterally, crosses the jugular tubercle (with the ninth communicates with spinal nerves C3 and C4, and
and tenth cranial nerves) and reaches the jugular ends by supplying the trapezius.
foramen. 8 Distribution: Tlte spinal accessory nerve supplies:
The nerve leaaes the skull throtgh the middle part of a. The sternocleidomastoid, the chin turning
the jugular foramen where it fuses with a short length b. The trapezius, the shrugging muscle.
of the cranial root. It soon separates from the latter Cervical nerves provide a proprioceptive sensations
and passes out of the foramen. to these muscles.
Inlts extracranial course, the nerve descends vertically
between the internal jugular vein and the internal
carotid artery deep to the parotid and to the styloid
The accessory nerve is tested clinically:
process (Fi9.2a.52). It reaches a point midway
between the angle of mandible and the mastoid a. By asking the patient to shrug his shoulders
(trapezius) against resistance and comparing
process. Then it runs downwards and backwards
the power on the two sides.
superficial to the internal jugular vein and is
surrounded by'lymph nodes. b. By asking the patient to turn the chin to the
opposite side (sternocleidomastoid) against
The nerve pierces the anterior border of the resistance and again comparing the power on
sternocleidomastoid at the junction of its upper one-
the two sides (Fig. 24.60).
fourth with the lower three-fourths, and communi-
Lesions of spinal root of accessory nerve cause
cates with second and third cervical nerves within
drooping of the shoulder (Fig. 24.61) and inability
the muscle.
to turn chin to opposite side.
The nerve enters the posterior triangle of the neck Irritation of the nerve during biopsy of enlarged
by emerging through the posterior border of the caseous lymph nodes, may produce torticollis or
c
'd sternocleidomastoid a little above its middle. In the wry neck.
E triangle (Fig.2a.59), it runs downwards and Supranuclear connections act on the ipsilateral
N backwards embedded in the fascial roof of the sternocleidomastoid and on the contralateral
c
o triangle. Here it lies over the levator scapulae. It is trapezius. This results in turning of the head away
o related to the superficial lymph nodes. The nerve from relevant hemisphere during seizure.
o
a leaves the posterior triangle by passing deep to the
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CRANIAL NEBVES
Cerebral cortex
Corticonuclear fibres
Hypoglossal nucleus
Motor fibres to all

muscles except
geniglossus
Motor fibres to
genioglossus
Olivary nucleus
Pyramidal tracts
Xll nerve
Fig.24.62: Hypoglossal nerve with its nucleus

Fig. 2t1.60; Rotation of head to right side against resistance
to see the action of left sternocleidomastoid Nucleus
The hypoglossal nucleus,2 cm long, lies in the floor of
fourth ventricle beneath the hypoglossal triangle. It is
divided into a part for genioglossus and a part for a
rest of the muscles (Fig. 2a.5C).
Nucleus for genioglossus muscle receives only
contralateral corticonuclear fibres. Nucleus for rest of
the lingual muscles receives both ipsilateral and
contralateral corticonuclear fibres.
Course ond Relotlons

In their intraneural coltrse, the fibres pass forwards
lateral to the medial longitudinal bundle, medial
lemniscus and pyramidal tract, and medial to the
reticular formation and olivary nucleus (seeFig.25.5).
The nerve is attached to the anterolateral sulcus of
the medulla, between the pyramid and the olive, by
10 to 15 rootlets (Fig.za.D.
The rootlets run laterally behind the vertebral arlery,
Fig.24.61: Drooping of the right shoulder due to paralysis
and join to form two bundles which pierce the dura
of right trapezius
mater separately near the hypoglossal canal.
The nerve leaves the skull through the hypoglossal
(anterior condylar) canal.
E croniol Cource
HYPOGTOSSAT NERVE The nerve first lies deep to the internal jugular vein,
Hypoglossal is the twelfth cranial nerve. It supplies the but soon inclines between the internal jugular vein
muscles of the tongue. and the internal carotid artety, crosses the vagus
(laterally), and reaches in front of it (Fig. 24.52).
Funciionol Components/Nucleot Columns It then descends between the internal jugular vein
and the internal carotid artery in front of the vagus,
the hypoglossal nucleus which lies in the medulla, deep to the parotid gland, the styloid process, the .G
in the floor of fourth ventricle deep to the hypoglossal posterior belly of the digastric. o
triangle (Fig.2a.62). At the lower border of the posterior belly of the N
2 Genersl sowtltit rent coluntn: The nucleus is digastric, it curves forwards, crosses the internal and o
mesencephalic nucleus of (V) cranial nerve where external carotid arteries and the loop of the lingual o
proprioceptive fibres from tongue end. artery, and passes deep to the posterior belly of the a0)
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I
BRAIN
Palatoglossus
Tongue
Ventral ramus of
c't,c2,c3
Genioglossus
Hyoglossus
Thyrohyoid
Nerve to geniohyoid
Ansa cervicalis Hyoid bone
Superior belly
of omohyoid
lnferior belly
of omohyoid
Sternohyoid
Fig.24.63: Hypoglossal nerue and ansa cervicalis
digastric again to enter the submandibular region

(see Fig.7.4).
4 The nerve then continues forwards on the hyoglossus The hypoglossal nerve is tested clinicallyby asking
and genioglossus, deep to the submandibular gland the patient to protrude his/her tongue. Normally,
and the mylohyoid, and enters the substance of the the tongue is protruded straight forwards. If the
tongue to supply all its intrinsic muscles and most nerve is paralysed, the tongue deviates to the
of its extrinsic muscles (Fig.2a.$). paralysed side (Fig. 24.64).
An infranuclear lesion of the hypoglossal nerve
Bronches ond Distribution produces paralysis of the tongue on that side.
There is gradual atrophy of the paralysed half of
L:r addition to its own fibres, the nerve also carries some
the tongue. The tongue looks shrurrken.
fibres that reach it from spinal nerve C1, and are
Supranuclear lesions of the hypoglossal nerve
distributed through it.
causes paralysis without wasting. The tongue
Branches containing fibres of the hypoglossal nerae proper.
moves sluggishly resultingin defective speech. On
They supply the extrinsic and intrinsic muscles of the
protrusion, the tongue deviates to opposite side.
tongue. Extrinsic muscles are styloglossus, genio-
glossus, hyoglossus and intrinsic muscles are superior
Iongitudinal, inferior longitudinal, transverse and
vertical muscles. Only extrinsic muscle, the palato-
glossus is supplied by fibres of the cranial accessory
nerve through the vagus and the pharyngeal plexus
(see Fig. 17.8).
Branches of the hypoglossal nense containing fibres of nerae
Cl. These fibres join the nerve at the base of the skull.
a. The meningeal branch contains sensory and
sympathetic fibres. It enters the skull through the
.= hypoglossal canal, and supplies bone and meninges
.E
o in the anterior part of the posterior cranial fossa.
N b. The descendingbranch continues as the descendens
C
o hypoglossi or the upper root of the ansa cervicalis.
.F
o c. Branches are also given to the thyrohyoid and
ao geniohyoid muscles (Fig. 2a.$).
Fig. 24.64: Xll nerve paralysis on right side
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CRANIAL NERVES
Mnemonics X nerve carries parasympathetic fibres from dorsal

nucleus of vagus for the glands in the respiratory
BELL'S Palsy
tract and glands in the digestive tract till right two-
Blink reflex abnormal thirds of the transverse colon.
Ear ache 52, 53, 54 carry sacral outflow of the Parasym-
Lacr i m ati on ( defi cie nt) pathetic system to the distal part of digestive tract
Loss of taste in anterior two-thirds of tongue and other pelvic viscera.
Sudden onset V, V[, IX, nerves are the nerves of 1st, 2nd,3rd
Palsy of Vll nerve muscles arches respectively.
All symptoms are ipsilateral X, XI, i.e. vagoaccessory complex supplies
structures developed from 4th and 6th branchial
arches.
Cranial nerves I, II, VIII are almost sensory, cranial

nerves III, IV, VI, XI, XII are motor, cranial nerves.
V, VII, IX, X are mixed nerves. A 40-year-male had viral infection. One day he
III nerve carries
parasympathetic fibres from noticed tears running on his right side of face and
Edinger-Westphal nucleus of midbrain to the saliva dribbling from his right angle of mouth'
ciliaris and constrictor pupillae muscles for . \,Vhat is this paralysis called?
accommodation.
. How do you test for integrity of the facial muscles?
VII nerve carries parasympathetic fibres from
lacrimatory nucleus to pterygopalatine ganglion
for the lacrimal gland and glands in nasal cavity, stylomastoid foramen.
palate and pharynx. This nerve is tested as fol} s:
VII nerve also carries parasympathetic fibres from
superior salivatory nucleus to submandibular
ganglion for the supply of submandibular,
sublingual and glands in the oral cavity. formed in the forehead
IX nerve carries parasympathetic fibres from c Ask him to show the teeth
inferior salivatory nucleus to the otic ganglion for . Ask ldm to fill in air in the mouth and then f]orce
the supply of parotid gland. it out.
MULTIPLE CHOICE AUESTIONS
l. Cranial nerves which innervate extraocular muscles 4. Cranial nerve that are mainly sensory are:
include: a. Optic, vestibulocochlear, vagus
a. Oculomotor, abducent and trochlear b. Ophthalmic, optic, facial
I
b. Abducent, facial and trigeminal c. Ophthalmic, optic, vestibulocochlear

t d. Optic, olfactory, vestibulocochlear
c. Trochlear, oculomotor, facial
5. Cranial nerves that carry taste from the tongue are:
d. Oculomotor, facial, trigeminal
a. Trigemin al, facial, glossopharyngeal
I
2. The 3 divisions of trigeminal nerve include:
b. Facial, glossopharyn geal, hypoglossal
a. Oculomotor, palatine and lingual
c. Facial, glossopharlmgeal, accessory
b. Ophthalmic, maxillary, mandibular
d. Facial, glossopharyngeal and vagus
c. Ophthalmic, palatine, lingual 6. The cranial nerve that arise from both brain as well tr
d. Frontal, maxillary, mandibular as spinal cord: .E
3. Cranial nerve that does not pass through superior a. Hypoglossal E

ot
orbital fissure in skull: b. Accessory c
o
a. Oculomotor b. Trochlear c. Vagus C)
c. Facial d. Abducent d. Glossopharyngeal ao
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I
BRAIN
7. Which cranial nerve does not pass through jugular 12. Lst pharyrgeal arch give rise to:
foramen? a. Muscles of facial expression
a. Glossopharyngeal b. Vagus
b. Muscles of mastication
c. Accessory d. Hypoglossal c. Muscles of soft palate
8. Which is not a cranial nerve?
d. Stylopharyngeus (muscle of phanTnx)
a. Vagus b. Glossopharyngeal
13. Nucleus of tractus solitarius receives part of which
c. Phrenic d. Hypoglossal 3 cranial nerves?
9. \Aflhich structure is not innervated by vagus?
a. III,IV, VI b. VII,IX, X
a. Small intestine b. Heart
c. IX, X, XI d. None of above
c. Stomach d. Sternocleidomastoid '1.4.
Nucleus ambiguus is present in:
L0. \Atrhich cranial nerve innervates muscle that raises
the upper eyelid? a. Midbrain b. Spinal cord
a. Trochlear b. Oculomotor c. Pons d. Medulla oblongata
c. Abducent d. Facial 1.5. \A/hich cranial nerve is not involved in Wallenberg's
11. \Atrhich cranial nerve passes through stylomastoid syndrome?
foramen? a. XII b. IX
a. Facial nerve c.X d. XI
b. Glossopharymgeal nerve L6. \A/hich of the following is the largest cranial nerve?
c. Vagus nerve a. VI b.v
d. Hypoglossal nerve c. XII d. VII
]]
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T
I
Sorvopolli Rodhokrishnon
-
INTRODUCTION medulla, many fibres of the right and left pyramids

cross in the midline formingthepyramidal decussation.
The brain stem consists of the medulla oblongata, the
pons and the midbrain. It connects the spinal cord to Some fibres run transversely across the upper part
cerebrum. The various ascending and descending tracts of the pyramid. These are the anterior external arcuate
pass through the three components of the brain stem. fibres.
Medulla oblongata contains the respiratory and The upper part of the lateral region shows an oval
vasomotor centres. In hanging or capital punishment, elevation, thre olitse.It is produced by an underlying
the dens of axis breaks and strikes on these centres mass of grey matter called llrre inferior oliuary nucleus.
causing immediate death. Midbrain contains nuclei of A bundle of fibres curving around the lower edge of
oculomotor and trochlear nerves. Pons has the nuclei of the olive is the circumoliaary bundle.
trigeminal, abducent, faciai and statoacoustic nerves The rootlets of the hypoglossal nerve emerge from
while medulla houses the nuclei of last four cranial the anterolateral sulcus between the pyramid and
nerves, i.e. glossopharyngeal, vagus, accessory and the olive.
hypoglossal nerves. The rootlets of the cranial nerves IX and X and cranial
part of the accessory nerve emerge through the
posterolateral fissure, behind the olive.
7 The posterolateral region lies between the
The medulla is the lowest part of brain stem, extending posterolateral sulcus and the posterior median
from the lower border of pons to a plane just above the fissure. The upper part of this region is marked by a
first cervical nerve where it is continuous with the V-shaped depression which is the lower part of the
spinal cord. It lies in the anterior part of posterior cranial floor of the fourth ventricle. Below the floor we see
fossa, extending down to the foramen magnum. three longitudinal elevations. From medial to lateral
Anteriorly, it is related to the clivus and meninges and side, these are the fasciculus gracilis, the fasciculus
posteriorly, to the'vallecula of the cerebellum. Along cuneatus and the inferior cerebellar peduncle
with other parts of the hindbrain, medulla occupies the (Fig.25.2). The upper ends of fasciculus gracilis and
infratentorial space. cuneatus expand to form the gracile and cuneate
tubercles. These tubercles are formed by underlying
EXTERNAT FE RES masses of grey matter called rhe nucleus gracilis and
nucleus cuneatus.
1 The medulla is divided into right and left halves by
the anterior and posterior median fissures. These 8 In the lower part of the medulla, there is another
fissures end in foramen caecum at its junction with elevation the tubercinerium lateral to the fasciculus
pons. Eachhalf is further divided into anterior,lateral cuneatus. It is produced by a mass of grey matter
and posterior regionsby the anterolateral and postero- called the spinnl nucleus of the trigeminal nerae.
lateral sulci (Fig. 25.1). 9 The medulla is divided in two parts:Thelowet closed
2 The anterior region is in the form of a longitudinal part with a central canal; and the upPer open part
elevation called the pyramid The pyramid is made where the central canal opens out to form the fourth
up of corticospinal fibres. Lr the lower part of the ventricle.
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BRAIN
Abducent nerve Basilar sulcus

Pons
Motor root of facial nerve

Roots of trigeminal nerve
Sensory root offacial nerve
Vestibulocochlear nerve Foramen caecum
Glosssopharyngeal nerve
Roots of vagus nerye
Hypoglossal nerve
Accessory nerye
Cranial roots of accessory nerve
Spinal roots of accessory nerve
Central canal
Flg. 25.1: Attachment of cranial nerve to the ventral surface of brain stem
Superior colliculus
lnferior colliculus
Crus cerebri
Trochlear nerve
Medial eminence
Superior medullary velum
Superior cerebellar peduncle Facial colliculus
Vestibular area
Sulcus limitans Middle cerebellar peduncle

Median sulcus lnferior cerebellar peduncle
Stria medullaris Taenia
Vagal triangle
Tuber cinerium
Cuneate tubercle
Hypoglossal triangle
Area postrema
Obex
Gracile tubercle
Fasciculus cuneatus Fasciculus gracilis
lnferior cerebellar peduncle
Posterior median sulcus
Fig.25.2z Dorsal aspect of brain stem

.=
(E
o INIERNAT STRUCTURE Tronsverse Seclion lhrough the Lower Porl of the

N
co The internal structure of the medulla can be studied Medullo Possing through the Pyromidol Decussolion
o conveniently by examining transverse sections through It resembles a tuansverse section of the spinal cord in having
o
@ it at three levels. the same three funiculi and the same tracts (Fig. 25.3).
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BRAIN STEM
Fasciculus gracilis
Fasciculus cuneatus
Nucleus gracilis
Spinal tract of V nerve
Lateral corticospinal
Spinal nucleus of V nerve
Central canal Rubrospinal tract
Spinotectal tract
Spinal nucleus of accessory
Dorsal spinocerebellar tract nerve
Vestibulospinal iract
Ventral spinocerebellar tract
Tectospinal tract
Olivospinal tract
Anterior spinothalamic tract Pyramidal decussation
Spino-olivary tract Pyramid
Nucleus of first cervical nerve

Fig. 25.3: Transverse section (TS) of medulla oblongata at the level of pyramidal decussation
srey tter matter. The fasciculus gracilis and the fasciculus

1 The decussating pyramidal fibres separate the cuneatus end in these nuclei.
anterior horn from the central grey matter. The 2 Lateral to the cuneate nucleus we see the accessory
separated anterior horn forms the spinal nucleus of the cuneate nucleus which relays unconscious proprio-
accessory nerve laterally and the supraspinal nucleus ceptive fibres from the uppff limbs.
for motor fibres of the first cervical nerve medially. 3 The nucleus of the spinal tract of the trigeminal neroe is
2 The central grey matter (with the central canal) is also separate from the central,grey matter.
pushed backwards. 4 The lower part of the inferior oliaary nucleus is seen.
3 The nucleus gracilis and the nucleus cuneatus are 5 The central grey matter contains the following:
continuous with the central grey matter. a. Hypoglossal nucleus
4 Laterally, the central grey matter is continuous with b. Dorsal nucleus of the vagus.
the nucleus of the spinal tract of the trigeminal nerve. c. Nucleus of tractus solitarius.
A bundle of fibres overlying this nucleus forms the
spinal tract of the trigeminal nerve. ffe tufsff*s
1 The nucleus gracilis and cuneatus give rise to the
internal arcunte fibres. These fibres cross to the
1 The pyramids, anteriorly. opposite side where they form a paramedian band
2 The decussation of the pyramidal tracts forms the of fibres, called themediallemniscus.In the lemniscus,
most important features of the medulla at this level. the body is represented with the head posteriorly
The fibres of each pyramid run backwards and and the feet anteriorly.
laterally to reach the lateral white column of the 2 The pyramidal tracts lie anteriorly.
spinal cord where they form the lateral corticospinal 3 The medial longitudinal bundle lies posterior to the
tract. medial lemniscus.
3 The fasciculus gracilis and the fasciculus cuneatus 4 The spinocerebellar,lateral spinothalamlc and other
occupy the broad posterior white column. tracts lie in the anterolateral area.
4 The other features of the white matter are similar to 5 Emerging fibres of XII nerve.
those of the spinal cord (see Chapter 23).
Tronsverse Seclion lhrough the Upper Port of
Tronsverse Section through the Middle of Medullo Possing thtough the FIoor of Foudh
Medullo Possing through the Sensory Decussotion nlilcle/Open PoIt .E
(E
Identify the following features as shor,rm in Fig. 25.4. Identify the following features as shown in Fig. 25.5. ql
AI
#r*y ffer C
.9
1 The nucleus gracilis and the nucleus cuneatus are 1 The nuclei of several cranial nerves are seen in the o
much larger and are separate from the central grey floor of the fourth ventricle: ao
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BRAIN
Nucleus of tractus solitarius Nucleus gracilis
Nucleus cuneatus
Accessory cuneate nucleus

Dorsal nucleus of vagus
Spinal nucleus and
tract of V nerve
Nucleus of Xll nerve
I nternal arcuate fibres Nucleus ambiguus
Medial lemniscus
Rubrospinal tract
Dorsal spinocerebellar tract
Vestibulospinal tract
Olivospinal tract
Ventral spinothalamic tract
lnferior olivary nucleus
Arcuate nucleus
Spino-olivary tract
Pyramid
Xll nerve
Medial longitudinal bundle
Fig. 25.4: TS of medulla oblongata at the level of sensory decussation
Xll nerve nucleus
Medial longitudinal bundle Vestibular nuclei

Dorsal cochlear nucleus
Dorsal nucleus of X nerve
Nucleus of tractus solitarius Reticular formation
Nucleus ambiguus Spinal nucleus and tract ofV nerve

Dorsal spinocerebellar tract Ventral cochlear nucleus
Spinothalamic tracts Rubrospinal tract
Ventral spinocerebellar tract Tectospinal tract
Dorsal olivary nucleus Medial lemniscus
Olivocerebellar fibres
lnferior olivary nucleus
Emerging fibres of lX, X, Xl nerves

Pyramid
Emerging fibres of Xll nerve

Arcuate nucleus
MediaL olivary nucleus
Fig. 25.5: TS of medulla oblongata at the level of olivary nucleus passing through floor of fourth ventricle
a. The hypoglossal nucleus, in a paramedian position. The dorsal and ventral cochlear nuclei lie on the
b. The dorsal nucleus of the oagus, lateral to the XII surface of the inferior cerebellar peduncle. These
nerve nucleus. nuclei receive fibres of the cochlear nerve.
The nucleus of the spinal tract of the trigeminal nerve
c. The nucleus of the tractus solitarius, ventrolateral
lies in the dorsolateral part.
to the dorsal nucleus of vagus. The inferior olioary nucleus is the largest mass of grey
tr
'6 d. The inferior nnd medial aestibular nuclei, medial to matter seen at this level. It is responsible for
E the inferior cerebellar peduncle. producing the elevation of the olive. Its grey matter
N
C, The nucleus ambiguus lies deep in the reticular appears like a crumpled purse.
o-
.F
o formation of the medulla. It gives origin to motor Close to the inferior olivary nucleus there are the
ao fibres of the cranial nerves IX, X and XI. medial and dorsal accessory olivary nuclei.
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BRAIN STEM
6 The arcuate nucleus lies anteromedial to the lV ventricle

pyramidal tract.
7 Visceral centres are: Vestibular nuclei
a. Respiratory centre lnferior cerebellar

peduncle
b. Cardiac centre for regulation of heart rate
Spinal tract and
c. Vasomotor centre for regulation of blood pressure V nucleus
if+tufolfer X nerve and nuclei

Spinothalamic tract
It shows the following important features.
1 The inferior cerebellar peduncle occupies the Olive
posterolateral part, lateral to the fourth ventricle. Corticospinal tract
2 The olioocerebellar fibres are seen prominently in actual Xll nerve
sections. The fibres emerge at the hilum of the in-ferior
oblongata Iemniscus
olivary nucleus and pass to the opposite inferior
cerebellar peduncle, on their way to the opposite half Fig" 25.6: Lesions of medulla oblongata. 1. Medial medullary
syndrome, and 2. lateral medullary syndrome
of the cerebellum.
Striae medullaris are seen in the floor of the fourth
ventricle. word pons, means 'bridge' V, VI, VII, VIII nerves are
Identify the various ascending tracts in the attached here.
anterolateral part of medulla.
Emerging fibres of IX, X, XI nerves EXTERNAL FEATURES
The pons (Latin bridge) has two surfaces, ventral and
dorsal.
Medial medullary syndrome: It occurs due to T}ae aentral or anterior surface is convex in both
blockage of anterior spinal artery. Features are;
directions and is transversely striated. In the median
a. Contralateral hemiplegia (Fig. 25.6) due to plane, it shows a vertical basilar sulcus which lodges
damage to pyramid of medulla. the basilar artery (Fig. 25.1).
b. Loss of sense of vibration and position due to Laterally, the surface is continuous with the middle
damage to medial lemniscus. cerebellar peduncle.
c. Paralysis of muscles of tongue on the same side The trigeminal neroe is attached to this surface at the
due to injury to XII cranial nerve. junction of the pons with the peduncle. The nerve has
Lateral medullary syndrome: Occurs due to blockage
two roots, a small motor root which lies medial to the
ofposterior inferior cerebellar artery. Features are: much larger sensory root.
a. Ipsilateral paralysis of most of muscles of soft The attached abducent, facial and vestibulocochlear
palate, pharynx and larynx due to injury to nerves are at the lower border of the ventral surface at
nucleus ambiguus which gives fibres to IX, X the junction of pons and medulla oblongata.
and XI cranial nerves (Fig. 25.6).
T}:.e dorsal or posterior surface is hidden by the
b. Loss of pain and temperafure on same side of
cerebellum, and forms the upper half of the floor of the
face due to involvement of spinal nucleus and
fourth ventricle (Fig. 25.2).
spinal tract of trigeminal nerve.
Pons has 2 borders-superior and inferior.
c. Loss of pain and temperature on opposite side
Superiorborder: Crus cerebri is attached here. III and
of the body due to involvement of lateral
IV nerves are also seen.
spinothalamic tract.
d. Giddiness due to involvement of vestibular Inferior border: Lies at the junction of pons and
nuclei. medulla and VI nerve lies at this border.
lnjury to loroer part of medulla oblangata:Injury in this
part may be fatal due to rnjury to the vital centres INTERNAT STRUCTURE OF NS
like respiratory centre and vasomotor centre. In transverse sections, the pons is seen to be divisible
into ventral and dorsal parts. The ventral or basilar part tr
G
is continuous inferiorly with the pyramids of the o
medulla, and on each side with the cerebellum through N
the middle cerebellar peduncle. The dorsal or tegmental c
o
The pons is the middle part of the brain stem, con- part is a direct upward continuation of the medulla o
o
necting the midbrain with the medulla. Literally, the (excluding the pyramids). a
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BRA N
Bosilor Pod GreyMo r

The basilar part of the pons has a uniform structure 1 The sixth nerae nucleus lies beneath the facial colliculus.
throughout its length. 2 The seoenth neroe nucleus lies in the reticular
formation of the pons.
Tegmeniol Poil
3 The vestibular and cochlear nuclei lie in relation to
However, the structure of the tegmental part differs in the inferior cerebellar peduncle. The aestibular nuclei
the upper and lower parts of the pons. lie deep to the vestibular area in the floor of the fourth
ventricle, partly in the medulla and partly in the
#r+ptrklcffer
pons. They are divisible into four parts, superior,
It is represented by the nucleipontts which are scattered inferior, medial and lateral (Fig. 25.8). They receive
among longitudinal and transverse fibres. The pontine the fibres of the vestibular nerve, and give efferents
nuclei form an important part of the cortico- to the cerebellum (vestibulocerebellar), the medial
pontocerebellar pathway. Some of these nuclei get longitudinal bundle, the spinal cord (vestibulospinal
displaced during development, and form the arcuate tract arising in the lateral vestibularnucleus) and the
nucleus (see medulla) and the pontobulbar body. Fibres lateral lemniscus.
from all these nuclei go to the opposite half of the
cerebellum.
rfetu?sff*r
It consists of longitudinal and transverse fibres.
1 The longitudinal fibres include:
a. The corticospinal and corticonuclear (pyramidal)
tracts.
b. The corticopontine fibres ending in the pontine
nuclei.
2 The transverse fibres are pontocerebellar fibres
beginning from the pontine nuclei and going to the
opposite half of the cerebellum, through the middle Spinal/inferior
cerebellar peduncle.
Tegmentum in the Lo r PoIt of the Pons

Identify the following features as shown nFig.25.7. Fig. 25.8: Surface projection of vestibular nerve nuclei
Tectospinal tract
Abducent nucleus Dorsal cochlear nucleus
Vestibular nucleus complex

Ventral cochlear nucleus
Facial nucleus
Spinal nucleus and tract of
Nucleus of tractus solitarius V nerve
Lateral Iemniscus Superior olivary nucleus
Corpus trapezoideum Middle cerebellar peduncle
Transverse fibres
or spinal lemniscus Superior salivatory nucleus
Vll nerve
c
'6
Cut longitudinal corticospinal
Anterior spinothalamic tract and corticonuclear fibres
o Vl nerve
N Medial lemniscus
c Rubrospinal tract
o Nuclei pontis
o
o
a Fig. 25.7: TS of lower part of pons or TS at the level of facial colliculus
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BBAIN STEM
The dorsal and ventral cochlear nuclei are situated The superior cerebellar peduncles lie dorsolateral to
dorsal and ventral to the inferior cerebellar peduncle. the fourth ventricle (replacing the inferior peduncle
They receive the fibres of the cochlear nerve, and give seen in the lower part of the pons).
efferents mostly to the superior olivary nucleus and The medial longitudinal bundle is made up of fibres
partly to nuclei of the corpus trapezoideum, and to that interconnect the nuclei of the cranial nerves Itr, IV,
nuclei of the lateral lemniscus. These fibres form the VI and VIII and the spinal root of the XI. It coordinates
trapezoid body. movements of the head and neck in response to
The spinal nucleus of the trigeminal nerve lies in the stimulation of the cranial nerve VIII. However, the
lateral part. majority of fibres in the medial longitudinal bundle
Other nuclei present include the salivatory and arise in the vestibular nuclei.
lacrimatory nuclei.
c Pontine haemorrhage; This entity has following

1 The trapezoid body or corpus trapezoideum is a features:
transverse band of fibres lying just behind the ventral a. Bilateral paralysis of face and limbs due to
part of the pons. It consists of fibres that arise in the involvement of VII nerve nucleus and all
cochlear nuclei of both sides. It is a part of the auditory corticospinal fibres.
pathway. b. Deep coma due to damage to the reticular
2 The medial lemniscus forms a transverse band on formation.
either side of the midline, just behind the trapezoid c. Hyperpyrexia due to cutting off of the tem-
body. It is joined by anterior spinothalamic tract. perature regulating fibres from the hypu-
3 The lateral spinothalamic tract (spinal lemniscus) lies thalarnus.
lateral to the medial lemniscus. d. Pin point pupil due to damage to sympathetic
4 The inferior cerebellar peduncle lies lateral to the ocular fibres. Pontine haemorrhage is usually
floor of the fourth ventricle. fatal.
5 The fibres of the facial nerve follow a peculiar
. Cerebellopontine angle (Fig.25.10): The anatomical
course. They first pass backwards and medially to sfuuchrres located in the cerebellopontine angle
reach the medial side of the abducent nucleus. include choroid plexuses of IV ventricle, flocculus,
They then form a loop dorsal to the abducent VII and VIII cranial nerves. A tumour, acoustic
nucleus. This loop is responsible for producing neuroma/ in this angle arises usually in relation
an elevation, the facial colliculus, in the floor of the to VIII nerve. Features are:
fourth ventricle. a. Ipsilateral facial paralysis and loss of taste in
anterior two-thirds of tongue due to damage
to fibres of facial nerve.
Tegmentum in lhe Upper Porl of Pons b. Deafness and vertigo due to damage to both
Identify the following features as shown in Fig. 25.9. the parts of VIII nerve.
c. Ataxia on the affected side due to involvement
Gr*yMaft*r of the flocculus.
The special feafures are the ffiotor, and superior sensory d. Absence of corneal reflex on the side of lesion
nuclei of the trigeminal nente . The rnotor nucleus is medial due to damage to nucleus of V nerve including
to the superior sensory nucleus. its spinal tract.
. Millafi-Gubler's syndrome (Fig. 25.10): In this
iteMstter condition, there is damage to fibres of VI and VII
1 Immediately behind the ventral part of the pons we nerves along with pyramidal fibres. Features are:
see a transverse band of fibres that is made up (from
a. Paralysis of VII nerve on the same side due to
medial to lateral side) of the medial lemniscus, the damage to VII nerve fibres.
trigeminal lemniscus, the spinal lemniscus, and the b. Ipsilateral loss of abduction of the eye due to
lateral lemniscus (MTSL). damage to VI nerve.
c. Contralateral hemiplegia due to lesion of the
The trigeminal lemniscus contains fibres arising in the pyramidal fibres. c
(E
spinal nucleus of the trigeminal nerve and travelling c Tumours of pons: Astrocytoma is the most common m
to the thalamus. The lateral lemniscus is a part of the tumour of brain stem, usualty in childhood. Signs N
auditory pathway. It is formed by fibres arising in nuclei and symptoms vary according to area of origin of -
.9
ly-g i. close relation to the trapezoidbody (superior tumour. o
olivary nucleus and nucleus of trapezoid body). ao
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BRA N
Tectospinal tract Fourth ventricle
Ventral spinocerebellar Superior cerebellar peduncle

Superior sensory nucleus
of V nerve
Motor nucleus of V nerve
Lateral lemniscus
Spinal lemniscus
Rubrospinal tract
Trigeminal lemniscus Transverese fibres
Medial lemniscus Mesencephalic root of V nerve
V nerve
Cut longitudinal corticospinal
and corticonuclear fi bres
Nuclei pontis Corpus trapezoideum
Fig.25.9: TS of upper pons
SUBDIVISIONS
Superior cerebellar
peduncle When one examines a transverse section through the
midbrain one can make out the following major
lnferior cerebellar
peduncle subdivisions.
Spinal tract and
1 The tectum is the part posterior to aqueduct. It is
nucleus of V nerve made up of the right and left superior and inferior
Vll nerve nucleus colliculi (Fig. 25.11a).
Spinothalamic tract 2 Each half of the midbrain anterior to the aqueduct is
called the cerebral peduncle. Each cerebral peduncle
Medial lemniscus
is subdivided into:
Corticospinal
(pyramidal) tract
a. Crus cerebri, anteriorly.
b. Substantia nigra, in the middle.
Vl nerve Vll nerve
c. Tegmentum, posteriorly (Fig. 25.12).
The medial and lateral geniculate bodies
Fig.25.10: Lesion of pons. 1. Cerebellopontine angle tumour (metathalamus) are situated on the posterolateral aspect
and 2. Millard-Gubler's syndrome
of the midbrain. The superior colliculus is connected
to the lateral geniculate body by the superior brachium
(see Fig. 26.8).
Likewise, the inferior colliculus is conrtected to the
medial geniculate body by the inferior brachium
(seeFig.26.8) III and IV cranial nerves are attached to
The midbrain is also calledt}".:re mesencephalon. It connects
midbrain (Fig. 25.11b).
the hindbrain with the forebrain. Its cavity is known as
the cerebral aqueduct of Sylvius (French anatomist
INTERNAL STRUCTURE OF MIDBRAIN
1,478-1,555). It connects the third ventricle with the
fourth ventricle (Figs 25.11a and b). It is studied conveniently by examining sections, at the
The midbrain passes through the tentorial notch, and
level of the inferior colliculi and at the level of the
is related on each side to the parahipPocampal Syril superior colliculi.
the optic tracts, the posterior cerebral arlety, the basal
Tlonsverse Section of Midbroin
c vein, the trochlear nerve, and the geniculate bodies.
'6 ot the L I of lnferior Colliculi
E Anteriorly, it is related to the interpeduncular
structures, and posteriorly to the splenium of the corpus Grey&{offer
ol
c
o callosum, the great cerebral vein, the pineal body, 1 The central (periaqueductal) grey matter contains:
o and the posterior ends of the right and left thalami a. The nucleus of the trochlear nerzse in the ventro-
ao) (see Fig. 26.8). medial part; and
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BRAIN STEM
Tubercinerium
Mammillary body Optic nerve and chiasma
Crus cerebri of midbrain

Posterior perforated substance
Oculomotor nerve
lnterpeduncular fossa
Optic tract
Trochlear nerve
Motor root and

sensory root of
trigeminal nerve
Medulla oblongata
Figs 25.1'la and b: (a) Sagittal section of midbrain with pons, and (b) ventral aspect of midbrain
b. The Tnesencephalic nucleus of the trigeminal nerye deMeffer

in the lateral part. The mesencephalic nucleus is crus cerebri contains:
T}:,le
made up of unipolar cells (first neuron) and a. The corticospinal tract in the middle.
receives proprioceptive impulses from the muscles b. Frontopontine fibres in the medial one-sixth.
of mastication, the facial and ocular muscles, the c. Temporopontine, parietopontine and occipito-
teeth (Fig. 25.12) and temporomandibular joint. pontine fibres in the lateral one-sixth.
The inferior colliculus receives afferents from the T}ae tegmentum contains ascending tracts as follows.
Iateral lemniscus, and gives efferents to the medial a. The lemnisci (medial, trigeminal, spinal and lateral)
geniculate body. In the past, it has been considered are arranged in the form of a band in which they
as the centre for auditory reflexes, but the available lie in the order mentioned (from medial to lateral
evidence indicates that it helps in localizing the side) like a necklace.
source of sounds. b. The decussation of the superior cerebellar peduncles is
The substantia nigra is a lamina of grey matter made seen in the median plane.
up of deeply pigmented nerve cells. It is concerned c. The medial longitudinal bundle lies in close relation
with muscle tone (Fig.25.12). to the trochlear nucleus (somatic efferent column).
Trochlear nerve
lnferior colliculus
Aqueduct Reticular formation
Mesencephalic nucleus of V nerve Lateral lemniscus
Trochlear nerve nucleus Spinal lemniscus

Medial longitudinal bundle Tegmentum
Tectospinal tract
Trigeminal lemniscus
Decussation of superior
cerebellar peduncles Medial lemniscus
Substantia nigra
Corticospinal and corticonuclear '6
Temporo, parieto and
fibres (middle 2/3rd)
occipitopontine fibres (1 /6th) E
AI
Crus cerebri c
Frontopontine fi bres (1 /6th) o
Rubrospinal tract o
o
Fig.25-12: TS of midbrain at the level of inferior colliculus a
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BRAIN
Superior colliculus
Aqueduct
Pretectal nucleus
Mesencephalic nucleus of V
Edinger-Westphal and
oculomotor nerve nuclei Tegmentum
Reticular formation Medlal longitudinal bundle
Dorsal iegmental decussation

Red nucleus
Ventral tegmental decussation

Substantia nigra occipitopontine flbres
Crus cerebri
Frontopontine fibres
Somatic fibres of Parasympathetic fibres

oculomotor nerve of lll nerve
Fig. 25.13: TS of midbrain at the level of superior colliculus
d. The tectospinal tract and the rubrospinal tract are tr act), rettcular formation, thalamus, olivary nucleus,
present. subthalamic nucleus, etc. It has an inhibitory in-
3 The trochlear nerve passes laterally and dorsally fluence on muscle tone.
round the central grey matter. It decussates in the 5 Substantia nigra has already been described.
superior medullary velum/ and emerges lateral to
the frenulum veli. sfeiMsffer
1 The crus cerebri has the same tracts as described
Tronsverse Section of Midbroin of lhe above.
Level of Supeilor Colliculi 2 The tegmentum contains the following:
Gr*ytuf*fPer a. The same lemnisci as seen in the lower part except
for the lateral lemniscus which has terminated in
1 The central grey matter contains:
the inferior colliculus.
a. Nucleus of oculomotor nerae with Edinger-
b. The decussation of the tectospinal and tectobulbar
Westphat nucleus in the ventromedial part.
tracts forms tJne dorsal tegmental decussation.
b. Mesencephalic nucleus of the trigeminal nerve in the
c. The decussation of the rubrospinal tracts forms
lateral part. The oculomotor nuclei of the two sides
the u entral tegmental decussation.
are very close to each other (Fig. 25.13).
d. Medial longitudinal bundle.
2 Superior colliculus receives afferents from the retina e. Emerging fibres of oculomotor nerve.
(visual), and various other centres. It gives efferents
to the spinal cord (tectospinal tract). It controls reflex
3 The tectum shows the posterior commissure
connecting the two superior colliculi.
movements of the eyes, and of the head and neck in
response to visual stimuli.
3 Pretectal nucleus lies deep to the superolateral part . Webet's syndrome (Fig.25.1a): This syndrome
of the superior colliculus. It receives afferents from
involves III nerve nucleus and cofiicospinal fibres'
the lateral roots of the optic tract. It gives efferents Features are:
to the Edinger-Westphal nuclei of both sides. on the opposite side due to
a. Hemiplegia
The pretectal nucleus is an important part of the involvement of corticospinal fibres.
pathway for light reflex and the consensual reflex. O. UrnU points downwards and ,","rr:":;:":
Its lesion causes Argyll-Robertson pupil in which the
C
.G light reflex is lost but accommodation reflex remains .
intact. damaged.
E
N 4 Red nucleus is about 0.5 cm in diameter' It receives iscus, red
o afferents from the superior cerebellar peduncle, nucleus, superior cerebellar peduncle and fibres
'F
o globus pallidus, subthalamic nucleus and cerebral of III nerve. Features are:
ao iortex. It gives efferents to the spinalcord(rubrospinal
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BBAIN STEM
a Loss of proprioception due to lesion of medial Mnemonics

lemniscus.
Mahanagar Telephone Sitam (Nigam) Limited
b. Pupil points downwards and laterally due to
injury to III nerve, M - Medial lemniscus
c. Tremors and twitching of opposite side due to T -Trigeminal lemniscus with solitariothalamic
damage to red nucleus and superior cerebellar lemniscus
peduncle. S -Spinal lemniscus
Parinaud's syndrome (Fig. 25.13): Lesion of superior L -Lateral lemniscus
colliculi leads to this syrdrome. Features are:
a. Weakness of upward gaze and, vertical
nystagmus due to lesion of superior colliculus.
Argyll-Robertson pupil: Inthis condition, light reflex
. Pyramidal decussation cuts off the anterior horn
is lost but accommodation reflex is retained which forms nucleus of 1st cervical nerve and
due to lesion in the vicinity of pretectal nucleus nucleus of spinal accessory nerve.
(Fig. 25.1a). , Nucleus gracilis and nucleus cuneatus are
equivalent of the nuclei in the posterior horn of
spinal cord. These are present in the medulla
DEVELOPMENT
oblongata. Fasciculus gracilis and fasciculus
Medullo Oblongoto cuneatus relay in their respective nuclei.
From caudal myelencephalic part of the rhombencep- , At the lower section of pons, fibres of cochlear
halic vesicle. Olivary nucleus is formed by the migrated nuclei form trapezoid body which forms lateral
cells from alar lamina. lemniscus. Nuclei of VI, VII and VIII cranial nerves
are present here.
Pons r At the upper section of pons some of the nuclei
From cranial metencephalic part of rhombencephalic forming trigeminal nerve are situated. The nerve
vesicle. Cells of alar lamina migrate to form the pontine lies at the junction of pons with the middle
nuclei. cerebellar peduncle.
r Section, at the level of inferior colliculus shows
4 lemnisci: Medial, trigeminal, spinal and lateral
Midbroln
(MTSL) from medial to lateral side. It also shows
From middle vesicle, the mesencephalon. Alar lamina nucleus of IV nerve, the delicate cranial nerve.
cells multiply and fuse to form 4 colliculi. These r Section at the level of superior colliculus shows
cells also migrate ventrally to form red nucleus and prominent red nucleus. It also shows III nerve
substantia nigra. The basal lamina forms the crus nucleus with Edinger-Westphal nucleus.
cerebri.
Superior colliculus
Aqueduct
Parinaud's syndrome
Pretectal nucleus
Mesencephalic nucleus of V
Edinger-Westphal and
oculomotor nerve nuclei
Benedikt's syndrome Medial longitudinal bundle
Red nucleus
Medial lemniscus
Substantia nigra occipitopontine fibres
'6
Weber's syndrome
Crus cerebri E
N
Oculomotor nerve o
o
Flg. 25.14r Lesion of midbrain. 1. Weber's syndrome, 2. Benedikt's syndrome, 3. Parinaud's syndrome and 4. Argyll-Robertson pupil o
U)
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BRAIN
of lesion in the vicinity of pretectal cleus. Such a

A person suffering from syphilis complains of
inability to close the eyes in response to light thrown
in the eyes, whereas he can read and see nearby Retina *+ optic ncrve -+ optic chiasma -| optie
things:
r Where is the lesion?
. What is such a lesion called?
Anas In such ca$e$/ the light reflex is lost, whereas
1. The pontin nuclei form an important part of: c. Nucleus ambiguus

a. Corticorubral pathway d. Spinal nucleus of XI nerve
b. Cortico-ponto-cerebellar pathway 4. What is true about crus cerebri?
c. Vestibulocerebellar pathway a. The corticospinal tract is in its middle part
d. Olivocerebellar pathway b. Frontopontine fibres in medial 1/6 Part
, \Mhich of these fasciculus lies most medially?
c. Temporopontine, parietopontine and occipito-
a. Fasciculus cuneatus pontine fibres in lateral 1,/5 parl
b. Fasciculus gracilis d. All of the above
c. Inferior cerebellar peduncle
5. Pons contains which of following set of nuclei?
a. TX,X, XI, XII
3. \A/hich is not the content of central grey matter in
section of lower part of medulla? b. V, VI, VII, VIII
a. Hypoglossal nucleus c. III, IV
b. Nucleus of spinal tract of trigeminal nerve d.ry v vI, vII
1.b 2.b,. 3. d 4.d 5., b
'6
E
AI
C
o
o
o
a
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ll
'/ral
Frost
-R
INTRODUCTION Anterior lobe

Fissura
Cerebellum (Latin small brain) though small in size, pnma
subserves important functions for maintaining tone,
posture, and equilibrium of the body. Cerebellum
controls the same side of the body directly or indirectly.
The grey matter is highly folded to accommodate Middle/
posterior
millions of neurons in a small area and the arrangement lobe
is called "arbor vitae" (vital tree of life). The structure of
cerebellum is uniform throughout, i.e. it is homotypical.
Damage to gives rise to very typical symptoms.
LO ION
Flocculonodular
lobe
The cerebellum (little brain) is the largest part of the
hindbrain. It is situated in the posterior cranial fossa
behind the pons and medulla. It is an infratentorial Flg. 26.1r Anatomical lobes of the cerebellum
strucfure that coordinates voluntary movements of the Each hemisphere is divided into three lobes. Tli.e
body (Fig.26.1). anterior lobe lies on the anterior part of the superior
Reloiions surface. It is separated from the middle lobe by the
fissura prima. The middle lobe is the largest of three lobes
Arfteriorly: Fourth ventricle, pons and medulla. situated on both its surfaces. It is limited in front by
Posteroi riorly: Squamous occipital bone. the fissura prima (on the superior surface), and by the
Suy: eriorly : Tentorium cerebelli (Fig. 26.2). posterolateral fissure (on the inferior surface). The
fl o c cul ono dul ar lob e is the smallest lobe of the cerebellum.
EXTERNAT FEATURES It lies on the inferior surface, in front of the postero-
The cerebellum consists of two cerebellar hemispheres lateral fissure (Fig. 26.a).
that are united to each other through a median aermis.
It has two surfaces superior and inferior. The superior PARTS OF CEREBETLUM
surface is slightly convex. The two hemispheres are The cerebellum is subdivided into numerous small
continuous with each other on this surface (Fig.26.3a). parts by fissures. Each fissure cuts the vermis and both
The inferior surface shows a deep median notch called hemispheres. Out of the numerous fissures, however,
the ztallecula which separates the right and left convex only the following are worth remembering.
hemispheres (Fig. 26.3b). The anterior aspect of the 1 The horizontal fissure sepatates the superior surface
cerebellum is marked by a wide and deep notch in from the inferior surface (Fig.26.q.
which the pons and medulla are lodged. Posteriorly, 2 The primary fissure (fissura prima) separates the
there is a narrow and deep notch in which the falx anterior lobe from the middle lobe on the superior
cerebelli lies. surface of the cerebellum.
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I
Pons
Medulla oblongata
F19.26.2: Relations of cerebellum
Anterior
Superior aspect
of vermis
Primary fissure
Middle lobe
(posterior lobe) Culmen
Declive
Horizontal fissure
Folium of vermis
Posterior
lnferior semilunar
lobule
.s Posterolateral fissure
G
o
N
c
.o
(,)
ao Flgs 26.3a end bi Surfaces of cerebellum: (a) Superior surface, and (b) inferior surface
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CEREBELLUM
Ala
Primary fissure
Quadrangular lobule
Simplex lobule
Superior semilunar lobule
Horizontal fissure
lnferior semilunar lobule
Pyramid
Biventral lobule
Uvula Tonsil
Nodule Posterolateral fissure

Flocculus
Fig,26.4: Lobes and morphological subdivisions of cerebellum. Area above horizontal fissure represents superior surface and
area below the fissure shows inferior surface
3 The posterolateral fissure separates the middle lobe

from the flocculonodular lobe on the inferior surface.
The various parts of cerebellum are shown in
Fig.26.4. \rVhere both the superior and inferior surfaces
of the cerebellum are drawn in one plane. The upper
part of the diagram, above the horizontal fissure
represents the superior surface; and the lower part,
below the horizontal fissure represents the inferior
surface.
Parts of oermis Subdiaisions of the cerebellar

hemisphere
1. Lingula
2. Central lobule Ala
3. Culmen Quadrangular lobule ,A=Anterior lobe P= Posteriorlobe F = Flocculonodular lobe
4. Declive Simple lobule *"-"*-
5. Folium Superior semilunar lobule Fig. 26,52 Functional subdivisions of cerebellum
6. Tuber Inferior semilunar lobule in its connections. It controls the axial musculature
7. Pyramid Biventral lobule and the bilateral movements used for locomotion and
8. Uvula Tonsil maintenance of equilibrium (Fig. 26.5).
9. Nodule Flocculus 2 The paleocuebellum is thenext part of the cerebellum to
appear.Itismade up of the anteriorlobe (excepthgrlu),
In Fig. 26.4, note that each part of the vermis has a and the pyramid and uvula of the inferior vermis.
lateral extension. However, tli.e lingula does not have Its connections are chiefly spinocerebellar. It controls
any lateral extension. tone, posture and cmde movements of the limbs.
3 The neocerebellumis the newestpart of the cerebellum tr
'6
MORPHOTOGICAL AND FUNCIIONAL DIVISIONS OF to develop. It is made up of the posterior/middle
CEREBELTUM
o
lobe (the largest part of the cerebellum) except the N
"1, The archicerebellumphylogenetically is the oldest part pyramid and uvula of the inferior vermis. It is c
o
of the cerebellum. It is made up of the flocculo- primarily concerned with the regulation of fine ()
nodular lobe and the lingula. It is chiefly vestibular movements of the body. (to
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BRAIN
FUNCTIONATTY Flocculonodulor Lobe

The anterior and posterior lobes are organized into 3 This lobe functions with vestibular system in
longitudinal zones-lateral, intermediate and vermis controlling equilibrium.
(Fig.26.6).
CONNECIIONS OF CEREBETTUM
lolerolZone The fibres entering or leaving the cerebellum are
Connected with association areas of the brain and is grouped to form three peduncles (Latin small foot)
involved in planning and programming muscular which connect the cerebellum to the midbrain, the pons
activities. and the medulla (Fig.26.7). The constituent fibres in
them are given in Table 26.1, andFigs 26.7 and 26.8.
Inlelmediote Zone It is clear from Table 26.1 that the middle and inferior
Concerned with control of muscles of hands, fingers, peduncles are chiefly afferent to the cerebellum and that
feet and toes. the superior cerebellar peduncle is chiefly efferent in
nature.
Vermis
Concerned with control of muscles of trunk, neck,
GREY M ER OF CEREBETLUM
shoulders and hips. It consists of the cerebellar cortex and the cerebellar
nuclei. There are four pairs of nuclei:
1. Nucleus dentatus is neocerebellar.
Anterior lobe
2 Nucleus globosus, and
Lateral zone 3 Nucleus emboliformis are paleocerebellar.
lntermediate
4 Nucleus fnstigii rs archicerebellar (Fig. 26.9).
oE zone
Hislologicol $lructure
-d)
.!l o The structure of cerebellum is uniform throughout, i.e.
a9?
OY
is homotypical. In contrast the structure of cerebral
rE cortex varies in different areas, i.e. it is heterotypical.
Grey matter contains basket cells which inhibit body
of Purkinje cells.
Flocculonodular lobe It also has stellate cell which inhibits dendrites of
Flg, 26,6: Functions of cerebellum according to the zones Purkinje cell (Figs 26.L0a and b).
Anterior lobe
Superior cerebellar peduncle
Ventral spinocerebellar tract
Cerebro-pontocerebellar fibres
Pontocerebellar fibres
Posterior lobe Vestibu locerebellar tract

(to and fro)
Olivocerebellar and
tr Flocculonodular lobe
'6 reticulocerebellar tract (to and fro)
o Dorsal spinocerebellar and lnferior cerebellar peduncle
N trigeminocerebellar tracts
o Ventral spinocerebellar tract
o
o
a Fig, 26,7; Connections of cerebellum
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CEREBELLUM
Table 26.1 : Constituents of the cerebellar peduncles

Peduncle Afferent tracts Efferent tracts
A. Superior cerebellar peduncle 1. Anterior spinocerebellar 1. Cerebellorubral
(connects cerebellum to 2. Tectocerebellar 2. Dentatothalamic
midbrain) 3. Dentato-olivary
4. Fastigioreticular
B. Middle cerebellar peduncle Pontocerebellar (part of the cortico-pontocerebellar
(connects cerebellum to pons) pathway)
C. lnferior cerebellar peduncle 1. Posterior spinocerebellar 1. Cerebellovestibular

(connects cerebellum to 2. Cuneocerebellar (posterior external arcuate fibres) 2. Cerebello-olivary
medulla oblongata) 3. Olivocerebellar 3. Cerebelloreticular
4. Parolivocerebellar
5. Reticulocerebellar
6. Vestibulocerebellar
7. Anterior external arcuate fibres
8. Striae medullaris
9. Trigeminocerebellar
Posterior view Superior brachium
3rd ventricle lnferior brachium
Pulvinar of thalamus later{ Genicurate bodies

Medial]
Superior colliculus
lnferior colliculus
Pineal body
Dorsal median sulcus

Medial eminence
Facial colliculus
Vestibular area
Hypoglossal trigone Taenia
lnferior fovea Striae medullaris
Vagal trigone lnferior cerebellar peduncle
Cuneate fasciculus and tubercle
Gracile fasciculus and tubercle
Flg. 26,8: Position of cerebellar peduncles
Purklnle Cell The inner granular layer contains granule cell. It c

(E
It is the characteristic cell of cerebellum. It gets receives input from mossy fibres and send efferent to
Purkinje cell via parallel fibres. Axons of granule cell
6
stimulated by climbing fibres coming from inferior 6I
olivary nucleus. form parallel fibres. c
.9
The main output of this cell is to cerebellar nuclei Granular layer also contains Golgi cells which are (.)
and is inhibitory in nature. inhibitory interneurons. ao

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BRAIN
Globose Cerebellum controls tone, posture and equilibrium.

nucleus This is chiefly done by the archicerebellum and
paleocerebellum.
Emboliform Flocculonodular lobe is connected to vestibular
nucleus
nuclei. It is involved in maintenance of muscle tone and
posture. Spinocerebellum, vermis and intermediate
Dentate
nucleus regions receive afferents from motor cortex via cortico-
pontocerebellar fibres.
All sensory information of muscles, joints, cutaneous,
auditory and visual parts are relayed here.
Spinocerebellar tracts carry information from the same
Fig. 26.9: J:ffir. of intracerebellar nuctei side (Fig. 26.1.L).
Vermal part controls axial muscles, and thus
Mossy fibres carry most input to cerebellum. These maintains posture. Paramedian areas are involved in
end in the granule cells. control of distal group of muscles to bring smooth
Four types of neurons of cerebellum, i.e. Purkinje, coordinated activity.
basket, stellate, and Golgi are inhibitory. Only the Cerebellum functions as "comparator". It receives
granular cells are excitatory. information from cerebrum and spinal cord. It corrects
and modifies ongoing movements through thalamo-
BTOOD SUPPTY cortical projections, reticulospinal and rubrospinal tracts.
Cerebellum is supplied by two superior cerebellar Neocerebellum is responsible for fine tuning of motor
arteries, two anterior inferior cerebellar arteries and two performance for precise movements. It helps in
posterior inferior cerebellar arteries. planning and production of skilled movements along
Superior cerebellar is a branch of basilar artery. with cerebrum.
Anterior inferior cerebellar is a branch of basilar It has been seen by functional magnetic resonance
artery. imaging (fMRI) that if fingers of right hand are moved
Posterior inferior cerebellar is a branch of vertebral repetitively, the activity is seen in precentral gyrus of
artery. left cerebral cortex and in anterior quadrangular lobule
Veins drain into neighbouring venous sinuses. of right cerebellar hemisphere.
FUNCTIONS OF CEREBELLUM DEVETOPMENT

Cerebellum controls the same side of the body. Its Cerebellum develops from the neurons of alar lamina
influence is ipsilateral. This is inmarked contrastto other of metencephalic part of the rhombencephalic vesicle.
parts of brain most of which control the opposite half of These neurons migrate dorsally and form the rhombic
the body. lip which forms the cerebellum. The earliest part to
Coordinates voluntary movements so that they are develop is the archicerebellum. In its centre, the
smooth, balanced and accurate. paleocerebellum develops, splitting the archicerebellar
Molecular layer
Molecular layer
Golgi cell
Granular layer Granular layer
Granular cell
Axon of
White matter Purkinje cell
Stellate
.E cell
(E
Purkinje cell layer Mossy fibre
E Climbing fibre
c\l Basket
c cell
o
()
o
(a) (b)
U) Flgs 26.10a and b: (a) Histology of cerebellum, and (b) histological connections of cerebellar neurons
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CEREBELLUM
a. Muscular hypotonia
b. Intention tremors (tremors only during
movements) tested by finger-nose and heel-
knee tests.
c. Adiadochokinesia which is inability to perform
rapid and regular altemating movements,like
pronation and supination.
d. Nystagmus is to and fro oscillatory movements
of the eyeballs while looking to either side.
e. Scanning speech is jerky and explosive speech.
f. Ataxic or unsteady gait.
SUMMARY
Three parts: Archicerebellum
Paleocerebellum
! Parts receiving somatosensory impulses Neocerebellum
ffi Parts receiving visual and acoustic impulses Three lobes: Anterior lobe
! Parls receiving vestibular impulses Middle or posterior lobe
Fig. 26.11: Somatosensory projection areas in the cerebellar Flocculonodular lobe
cortex Three fissures: Fissura prima
Horizontal fissure
parts into two parts, the lingula and flocculonodular Posterolateral fissure
lobe. Lastly, the paleocerebellar part is also split by the Thr e e functional zones : Vermal zone for trunk and
development of neocerebellum in its centre into two girdle movement
parts, the anterior lobe except lingula and pyramid with Intermediate zone for hands/
uvu1a. feet
Lateral zone for planning and
programming movement
Cerebellor Dysfunclion Three hislological Molecular layer
o Vermis lesions lead to truncal ataxiaas connection layers of grey matter: Purkinje cell layer
of vermis to the vestibular nuclei are involved. Granular cell layer
o Nystagmus is due to loss of labyrinthine Three peduncles Superior cerebellar peduncle
connections of vermis to labyrinth. Vermis is also to midbrain
related to emotions. Middle cerebellar peduncle to
. Anterior lobe lesion: Lesion of anterior lobe causes
Pons
gait ataxia. There is incoordination of the lower Inferior cerebellar peduncle to
limbs resulting in staggering gait and inability to medulla oblongata
walk in a straight line. It is also seen in alcoholics. Three deeper nuclei: Nucleus dentate with neocere-
. Neocerebellar lesions: These lesions cause bellum
incoordination of voluntary movements of the Nucleus emboliformis and
upper limbs. It results in intention tremor, action nucleus globose with
tremor and overshoot movements. paleocerebellum
. Speech is also defective. Phonation is defective due
Nucleus fastigii with flocculo-
to loss of smoothness in expiratory muscles. nodular lobe
Articulation is defective as there is less coordi-
Three arteries for Superior cerebellar
nation befween muscles of lip, tongue and palate.
. each hemisphere: Anterior inferior cerebellar
If there is thrombosis of one of six arteries Posterior inferior cerebellar
nurturing cerebellum, "cerebellum cognitive
affective syndrome" develops. These patients Three functions: Tone, posture equilibrium by .E
G
show inattention, grammatical errors in speech flocculonodular lobe 6
and patchy memory loss. Involvement of vermis Tone posture and crude c\t
results in dulling of emotional response. It is movements by anterior lobe C

.o
characterised by: Smooth, accurate and balanced o
o
movements by middle lobe U)
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BBAIN
Three main symptoms Truncal ataxia

(one for each lobe): flocculonodular lobe defect
Staggering gait in anterior A40-year-old female complained of inabilityto work
lobe defect properly with her right hand. She would sway to
Defective speech middle lobe right side while walking. She could not do rapid pro-
defect nation and supination of her right forearm. Magnetic
resonance imaging showed a tumour in her right lobe
of the cerebellum
Cerebellum or little brain acts like younger sibling . Which cerebellar functions have been lost to give
of the large cerebrum. It controls tone, posture, rise to above symptoms?
equilibrium and fine movements of the body. It o Name the peduncles of the cerebellum.
cannot initiate the movement.
It is connected to medulla oblongata by inferior Ansr The eercbeitrum comtrols fr:rne, posturc,
cerebellar peduncle.
It is connected to pons by middle cerebellar bedy. The tumour h;ls disrupted these functiems,
peduncle
It is connected to midbrain by superior cerebellar Cerebetlum is cmnneeted fo medulla eiblongata by
peduncle. inferisrr eerebellar pecltrneLe
Number of neurons are about half of the cerebrum, It is eonneetcd to pt;ns by mieldle ccr#belLer
though it is much smaller than the cerebrum. pedunelc"
a Its structure is uniform throughout i.e. homotypical. lt is els6) co eetcd t*r midbrain by nuperior
a Its control is ipsilateral. cereheliar peelunele"
MULIIPTE CHOICE AUESTIONS
1. The ratio of cerebellum to cerebrum in an adult is: 5. Which of following region of cerebellum is
a. 1:8 b. 7:16 concerned with planning and programming
muscular activities?
c. 7:4 d. 1:20
a. Intermediate zone b. Vermis
2. Purkinje cells are situated in:
c. Lateral zone d. Flocculonodular zone
a. Cerebral cortex
6. Which is the afferent tract of superior cerebellar
b. Junction of molecular and granular layers of peduncle?
cerebellum a. Reticulocerebellar b. Frontocerebellar
c. Granular layer of cerebellum c. Tectocerebellar d. Striae medullaris
d. Nucleus emboliformis Which function of cerebellum is not true?
3. What is the true about cerebellum: a. Its function as comparator
a. It is situated in posterior cranial fossa behind b. Vermal part controls axial muscle and thus
pons and medulla oblongata maintains posture
b. It is an infiatentorial structure that coordinate c. Archicerebellum and paleocerebellum controls
voluntary movements of body muscles of hand, finger, feet and toes
c. Its structure is homotypical d. Flocculonodular lobe is connected to vestibular
nuclei. It maintains posture of the body
d. All of the above
8. Superior cerebellar peduncle contains which of the
4. Which lobe is smallest in cerebellum?
following fibres?
a. Flocculonodular lobe a. Posterior spinocerebellar
b. Middle lobe b. Olivocerebellar
tr c. Anterior lobe c. Vestibulocerebellar
'6
E d. Posterior lobe d. Anterior spinocerebellar
N
o ANS RS
o
o0) L.a 2.b 3.d 4.a 5.c 6.c 7.c 8.d
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-Bovee
INIRODUCTION FTOOR
The cavity of hindbrain is called the fourth ventricle. It It is also called 'Rhomboid fossa' because of its
is a tent-shaped space situated between the pons and rhomboidal shape. The floor is formed by:
upper part of medulla oblongata in front and I Posterior (dorsal) surface of lower or closed part of
cerebellum behind. So it lies dorsal to pons and upper pons (Fig.27.1).
part of medulla oblongata and ventral to cerebellum. 2 Posterior (dorsal) surface of open or upper part of
It has lateral boundaries, floor, roof and a cavity medulla oblongata.
(Figs 27.1 to 27.4).
Slructurol Loyers
ERAL BOUNDARIES The floor is lined by
On each side, fourth ventricle is bounded (Ft9.27.1): 1 Ependyma.
1 Inferolaterally by gracile, cuneate tubercles and 2 A thin layer of the neuroglia beneath the ependyma.
inferior cerebellar peduncles. 3 A layer of grey matter, forming the various nuclei
2 Superolaterally by the superior cerebellar peduncles. deep to neuroglia.
lnferior colliculus
Locus coeruleus
I superlor
I
I
Dorsal median sulcus
Cerebellar peduncles I
I
UiaOte Medial eminence and superior fovea
I
I lnferior Facial colliculus

Vestibular area
Taenia
Sulcus limitans
Hypoglossal trigone Striae medullaris
Vagal trigone and inferior fovea lnferior cerebellar peduncle
Cuneate fasciculus and tubercle

Area postrema
Gracile fasciculus and tubercle
Fi1"27.1: Boundaries of lV ventricle and structures in its floor
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BRAIN
Ports In the medullary part of floor, the sulcus limitans

It is divisible into: is marked by a depression the inferior foaea.
1 An upper triangular part formed by dorsal surface Descending from the fovea, there is a sulcus that runs
of pons. obliquely towards midline. This sulcus divides
2 A lower triangular part formed by dorsal surface of medial eminence into two triangles. These are
medulla. hypoglossal triangle medially and oagal triangle
3 The intermediate part is at the junction of pons and laterally. These overlie the hypoglossal nerve nucleus
medulla. The intermediate part is prolonged laterally and of vagus nerve, respectively. Between the vagal
over the inferior cerebellar peduncle as the floor of triangle above and gracile tubercle below there is
lateral recess. This part is marked by transversely small area called lhe area postrema which may
running fibres which are fibres of stria medullaris. function as chemoreceptor.
These fibres represent fibres from arcuate nucleus 4 Vestibular area: This lies lateral to the inferior fovea
to the opposite cerebellum. (sulcus limitans) which overlies the vestibular nuclei.
This area is partly in the pons and partly in the
medulla.
L Dorsal median sulcus divides the floor into two
symmetrical halves (Fig. 27.1). ROOF
2 Medial eminence: One on each side of the median The roof of the ventricle is diamond-shaped and can
sulcus. The eminence is wider above and narrow be divided into superior and inferior parts (Fig. 27.2).
below. It presents facial colliculus just opposite and The superior or cranial part of roof is formed by
medial to a depression called superior fovea. Deep superior cerebellar peduncles and superior medullary
to the colliculus is the genu of the facial nerve formed velum. The superior cerebellar peduncles on emerging
by this nerve looping around the abducent nucleus. from central white matter of cerebellum pass first
Hypoglossal triangle occupies the lower narrow part cranially and ventrally forming at first lateral
of the eminence. Beneath this triangle lies boundaries of ventricles. On approaching the inferior
hypoglossal nucleus. colliculi, they converge and then intermingle over the
3 A sulcus limits the medial eminence on the lateral ventricles and form part of the roof. The superior
side, in the upper most part (pontine part) the sulcus medullary velum fills the angular interval between the
limitans overlies an area that is bluish in colour and two superior cerebellar peduncles. It is covered on the
is called locus coeruleus.The colour is due to presence dorsal surface by lingula of superior vermis.
of pigmented neurons which constitute substantia The caudal inferior part of roof in most of its extent
ferruginea. consists of an exceedingly thin sheet, entirely devoid
The upper part of sulcus limitans is marked by a of nervous tissue and formed by the ventricular
depression, the superior fovea which lies just lateral ependyma and double fold of pia mater or the tela
to facial colliculus. choroidea of the fourth ventricle which covers it
Trochlear nerve
Superior cerebellar peduncle Facial colliculus

Flocculus
Lateral recess and aperture
Median aperture
c T-shaped choroid plexus

(E
o
N
c
o
o
o
a F19.27,2: Schematic diagram of roof of lV ventricle
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FOURTH VENTHICLE
posteriorly. Caudally, the continuity of sheet is broken Communicolion

by a gap termed the median aperture through which the The cavity of the fourth ventricle communicates
cavity of ventricle communicates freely with the inferiorly with the central canal and superiorly with
subarachnoid space in the region of the cerebello- cerebral aqueduct (Fig. 27.3).
medullary cistern. The inferior medullary velum forms
a small part of roof in the region lateral to the nodule Openings in the Roof
of cerebellum. hr the caudal part of roof of fourth ventricle there are
Superior to the region of inferior medullary velum three openings/ one median and two lateral (Fig.27.3).
on each side, the layer of tela choroidea in contact with The median aperture of fourth ventricle alternatively
the ependyma of caudal part of roof reaches the known as/oramen of Magendie is a large opening situated
inferolateral boundary of ventricular floor, which is caudal to nodule. This opening provides the principal
marked by a narrow, white ridge termed taenia. The communication between ventricular system and
two taenia are continuous below with a small curved subarachnoid space. The lateral apertures, also known
margin, the obex often used to denote the inferior angle asforamina of Luschka, are situated at the ends of lateral
itself. recesses and are partly occupied by parts of choroid
Ielo Choroideo of Fouilh Venlricle plexuses which protrude into subarachnoid space.
Through these also fourthventricle communicates with
It is a double layer of pia mater which occupies the subarachnoid space.
interval between the cerebellum and the lower part of
the ventricle. Its posterior layer provides a covering of ANGTES
pia mater to the inferior vermis and, after covering the
nodule, is reflected ventrally and caudallyin immediate Superior nngle: Continuous with cerebral aqueduct.
contact with ependyma. The tela choroidea with I rior angle: Contimous below with central canal of
vascular fringes covered by secretory ependyma form spinal cord (Fig. 27.3).
the choroid plexuses of fourth ventricle. These project
Lateral angles: One on each side towards the inferior
into lower part of roof of fourth ventricle. Each plexus
cerebellar peduncles.
(left or right) consists of a vertical limb lying next to
midline and a horizontal limb extending into lateral
RECESSES OF FOURTH VENTRICLE
recesses. The vertical limb of the two plexuses lie side
by side so that whole structure is T-shaped. The vertical These are extensions of the main cavity of ventricle.
limbs of the T-shaped structure reach the median Five recesses have been identified (Fig.27.4).
aperture and project into the subarachnoid space 1. Two lateral recesses one on each side. Each lateral
through it. The lateral ends of horizontal limbs reach recess passes laterally in the interval between the
the lateral apertures. The arterial supply of these inferior cerebellar peduncle (ventrally) and the
plexuses is from the posterior inferior cerebellar arteries peduncle of flocculus dorsally reaching as far as the
(Fig.27.2). medial part of flocculus.
Arachnoid mater Midbrain
Cerebral aqueduct
Median dorsal recess

lV ventricle
Pons
Medulla oblongata
Opening of median aperture in

cerebellomedullary cistern (E
E
Communication with central canal ot
C
.o
o
Fig" 27.0: Sagittal section of brain stem and cerebellum to show lV ventricle ao
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BRA N
Vital centres like respiratory, cardiovascular

centres are situated in the floor of IV ventricle.
Fourth ventricle has 3 openings, one foramen
of Magendie and two foramina of Luschka for
the exit of used CSF into the subarachnoid space
for absorption in the superior sagittal venous
sinus.
a It also has 5 recesses to keep the CSF
a In its floor are nuclei of VI, VII, V[I, X and XII
cranial nerves.
Median aperture
F19.27,4t Recesses and apertures of the fourth ventricle
A criminal was hanged to death
One recess present in the median plane, is known as o How does death occur in hanging?
median dorsal recess. It extends dorsally into white . Name the ligaments related to atlanto-occipital,
core of cerebellum and lies cranial to nodule. atlantoaxial joints and ligamentsbetween axis and
Two lateral dorsal recesses, one on each side. Each occipital condyles.
lateral dorsal recess extend dorsally lateral to the
nodule and cranial to the inferior medullary velum.
Ans: e death dtrring hanging occur$ due to injury
to transverse ligament of the atlas providing fueed.om
These lie on either side of median dorsal recess.
to the bound dens of axis, The freed dens hits
baekwards on the vital eentres in floor r:f fourth
ventriele, re*ulting in immediate death,
Vital centres are situated in the vicinity of vagal
triangle. An injury to this area, therefore, would
tiga nt$ ifl this regiern are:
prove fatal.
r Membrana tectoria
Infratentorial brain tumours block the foramina
r Vertieal band erf eruciate ligament
of Luschka and Magendie situated in the roof of . Apical ligament
fourth ventricle. This results in marked early rise c Alar )igament
of intracranial pressure which causes headache, r An.terior atlanto-occipital mc ranc
vomiting and papilloedema, etc. o Posterior atlantp-oecipital m.e rane
MUITIPIE CHOICE SUESTTONS

L. \tVhat is situated in the vicinity of vagal triangle? c. Vestibular nuclei
a. Vital centres d. All of the above
b. Respiratory centre 4. Area postrema functions as:
c. Cardiovascular centre a. Chemoreceptor
d. Vasomotor centre b. Osmoreceptor
, Inferolaterally IV ventricle is not bounded by? c. Nocireceptor
a. Gracile tubercles
b. Cuneate tubercles
5' Which structure form choroid plexus?
c. Lrferior cerebellar peduncles
a. Tela choroidea with secretory ependyma
d. Superior cerebellar peduncles
b. Obex
3. \tVhich of following nuclei are related to [V ventricle?
c c. Lateral recess
(E a. Facial nerve nucleus
o b. Hypoglossal nucleus d. Secretory ependyma
ol
c
o AN RS
o
6)
a l.a 2,d 3.d 4.a 5.a
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Aurelius
-M
INTRODUCIION
the anterior commissure just at the anterior end of the
The cerebrum (Latin brain) is the largest part of the anterior column of fornix.
brain. It occupies anterior and middle cranial fossae Turn the brain upside down and identify optic
and the supratentorial part of the posterior cranial fossa. chiasma. Divide the optic chiasma, anterior communi-
The cerebral hemispheres have complicated folds cating artery, infundibulum and a thin groove between
called gyri. The groves between the gyri are called sulci. the adjacent mammillary bodies, posterior cerebral
The appearance of sulci and gyri increases the surface adery close to its origin. Carry the line of division around
area for the neurons many times, without increasing the midbrain to join the two ends of the median cut.
the size of the brain. Separate the right and the left cerebral hemispheres.
There is free flow of information in the central
ln the two hemisphere, identify the three surfaces,
nervous system; between two hemispheres through the
four borders, three poles. ldentify the central sulcus,
commissural fibres; between various parts of one
posterior ramus of lateral sulcus, parieto-occipital sulcus
hemisphere through the association fibres and between
and preoccipital notch. Join parieto-occipital sulcus to
upper and lower parts through the projection fibres.
preoccipital notch. Extend the line of posterior ramus
Internal capsule contains lots of fibres packed in its
of lateral sulcus till the previous line. Now demarcate
"lirrr.:bs".It is supplied by the "end artery". The rupture
the four lobes of the superolateral surface of each
of "endartery" may causethe "end" of thehumanbeing
cerebral hemisphere (Figs 28.1 and 28.2).
concerned, if not treated properly.
Strip the meninges from the surfaces. ldentify the
vessels on the suffaces of hemisphere. Demarcate the
DISSECTION main sulci and gyri on the superolateral surface, medial
Keep the cerebrum in a position so that the longitudinal surface and inferior surface of hemisphere.
fissure faces superiorly. ldentify the convex strong band Make thin slice through the part of the calcarine
of white matter, the corpus callosum, binding parts of sulcus, posterior to its junction with the parieto-occipital
the medial surfaces of the two cerebral hemispheres. sulcus. ldentify the stria running through it. On cutting
Define splenium as the thick rounded part of corpus series of thin slices try to trace the extent of visual
callosum. stria.
Divide the corpus callosum in the median plane
starting from the splenium towards the trunk, genu and
Feotures
rostrum. lnferior to the trunk of corpus callosum extend
the incision into the tela choroidea of the lateral and The cerebrum is made of two cerebral hemispheres
third ventricles, and the interthalamic adhesion which are incompletely separated from each other by
connecting the medial surfaces of two thalami. the median longitudinal fissure. The two hemispheres
ldentify the thin septum pellucidum connecting the are connected to each other across the median plane
inferior surfaces of corpus callosum to a curued band by the corpus callosum. Each hemisphere contains a
of white matter-anterior column of the fornix. Look for cavity, called the lateral ventricle. The surface area of
cerebrum is 2000 sq. cm.
t
t
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I
BRAIN
the tentorial surface. The two parts are separated by a

deep cleft called the stem of the lateral sulcus.
EXTERNAL FEATURES Four Bordels
Each hemisphere has the following features: 1. Superomedial bor der separates the superolateral surface
from the medial surface (Fig. 28.1).
Ihree Suffoces 2 lnfer ol at er al b or der separates the superolateral surface
from the inferior surface. The anterior part of this
1 The superolateral surface is convex and is related to
border is called t}r.e superciliary border. There is a
the cranial vault (Figs 28.1. and28.2).
depression on the inferolateralborder situated about
2 The medial surface is flat and vertical. It is separated 5 cm in front of the occipital pole: it is called the
from the corresponding surface of the opposite preoccipital notch (Fig. 28.1).
hemisphere by the falx cerebri and the longitudinal 3 Medial orbitalborder separates the medial surface from
fissure (Fig.28.3). the orbital surface.
3 The inferior surface is irregular. It is divided into an 4 Medial occipital border separates the medial surface
anterior part, the orbital surface, and a posterior part, from the tentorial surface (Fi9.28.$.
Superomedial border
Central sulcus
Parieto-occipital sulcus
and preoccipital notch
Frontal pole 1st lmaginary line
2nd imaginary line
Occipital pole
Preoccipital notch
Fig. 28,1 l Superolateral sufface of cerebral hemisphere
Precentral gyrus
Posterior ramus of lateral sulcus
Central sulcus
Precentral sulcus
Postcentral gyrus
Superior frontal sulcus
Postcentral sulcus
Superior frontal gyrus
Middle frontal gyrus Superior parietal lobule
lnferior parietal lobule

lnferior frontal sulcus
lntraparietal sulcus
lnferior frontal gyrus
Horizontal ramus of lateral sulcus
Superior occipital gyrus
Ascending ramus of lateral sulcus
Lunate sulcus
Occipital pole
Superior temporal gyrus
G Lateral occipital sulcus
Superior temporal sulcus
o
C\l
Middle temporal gyrus lnferior occipital gyrus
c
o lnferior temporal sulcus
o
o)
o Flg. 28.2; Sulci and gyri on superolateral sudace of left cerebral hemisphere
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CEREBRUM
Central sulcus
Corpus callosum
Cingulate gyrus
Precuneus
Medial frontal gyrus
Suprasplenial sulcus
Cingulate sulcus
Callosal sulcus
Cuneus
Septum pellucidum
Calcarine sulcus
Paraterminal gyrus
Collateral sulcus
Occipitotemporal sulcus
Medial occipitotemporal gyrus
Lateral occipitotemporal gyrus
Fig. 28.3: Sulci and gyri on the medial surface of left cerebral hemisphere
Olfactory bulb
Medial orbital border
Olfactory tract in olfactory sulcus
Anterior perforated substance
Stem of lateral sulcus

Mammillary body
Rhinal sulcus
Uncus
Midbrain
Collateral sulcus
Occipitotemporal sulcus
Lingual gyrus
Medial occipitotemporal gyrus

Medial occipital border
Lateral occipitotemporal gyrus
Flg. 28.4: Gyri and sulci on the inferior aspect of cerebral hemisphere
Three Poles The central sulcus begins at the superomedial border

I Frontal pole, at the anterior end. of the hemisphere a little behind the midpoint
2 Occipital pole, at the posterior end. between the frontal and occipital poles. It runs on
3 T emp or al pole, at the anterior end of the temporal lobe the superolateral surface obliquely downwards and
(Fig.28.1). forwards and ends a little above the posterior ramus
of the lateral sulcus (Fig.28.2).
Lobes of Cerebrol Hemisphere It is seen that the lateral sulcus separates the orbital
Each cerebral hemisphere is divided into four lobes- and tentorial parts of the inferior surface. Laterally, c
.E
frontal, parietal, occipital and temporal. Their positions this sulcus reaches the superolateral surface where 6
correspond, very roughly, to that of the corresponding it divides into anterior, ascending and posterior N
bones. The lobes are best appreciated on the branches. The largest of these, t}rre posterior raffius of C
.o
superolateral surface (Fig.28.2). The sulci separating the lateral sulcus passes backwards and slightly (,)
o
the lobes on this surface are as follows: upwards over the superolateral surface. @
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BRAIN
3 The parieto-occipital slTlcrs is a sulcus of the medial Limiting sulcus Axial sulcus
surface. Its upper end cuts off the superomedial
border about 5 cm in front of the occipital pole.
4 The preoccipital notch is an indentation on the infero-
lateral border, about 5 cm in front of the occipital pole.
The division is completed by drawing one line
joining the parieto-occipital sulcus to the preoccipital
notch; and another line continuing backwards from the Operculated sulcus
posterior ramus of the lateral sulcus to meet the first
line. The boundaries of each lobe will now be clear from
Fig.28.1.
lneulo
(c)
Insula lies deep in floor of lateral fissure surrounded
by a circular sulcus and overlappedby adjacent cortical Flge 28,5a to c: TYPes of sulci
areas, the opercula.
Insula comprises frontal operculum between anterior
and ascending rami of lateral sulcus.
3 Operculated sulcus separates by its lips two areas, and
contains a third area in the walls of the sulcus. An
Frontoparietal operculum between ascending and example is the lunate sulcus (Fig.28.5c).
posterior rami of lateral sulcus.
The temporal opercula below posterior ramus of
lateral sulcus formed by superior temporal gyri.
.Aceor g f* Forn*fi*m
Insula is a pyramidal area, apex near anterior 1 Primary sulci formed before birth
perforated substance. 2 Secondary sulcus is produced by factors other than
Three zones are seen here-afferents reach from the exuberant growth in the adjoining areas of the
ventral posterior nucleus of the thalamus, medial cortex. Examples are the lateral and parieto-occipital
geniculate body and part of pulvinar. sulci.
Efferents reach from areas 5,7, olfactory, limbic
system and amygdala. Aero {yf#tr#p#t
Role of anterior insular cortex is in olfaction and taste. 1 Complete sulcus is very deep so as to cause elevation
Role of posterior insular cortex is in language function. in the walls of the lateral ventricle. Examples are the
collateral and calcarine sulci.
CerebrolSulelond @yri 2 Incomplete sulci are superficially situated and are
Cerebral cortex is folded into gyri (Greek circle)which not very deep, e.g. precentral sulcus.
are separated from each other by sulci. This pattern
increases the surface area of the cortex. In human brain, Sulei ond Gyrl on Superololerol Surfoce
the total area of the cortex is estimated to be more than These are shown in Fig. 28.2 and Table 28.1.
2000 cm2, and approximately two-thirds of this area is 1 The central sulcus (Latin furrow) has been described
hidden from the surface within the sulci. above. The upper end of the sulcus extends for a short
The pattern of folding of the cortex is not entirely distance on to the medial surface (where it will be
haphazard.It is largely determined by the differential examined later).
growth of specific functional areas of the cortex, because 2 r{e have seen that the lateral sulcus begins on the
many of the sulci bear a definite topographical relation inferior surface. On reaching the lateral surface, it
to these areas. A few types of sulci are given below. divides into three rami. The largest of these is the
posterior ramus. The posterior end of this ramus turns
Acco T# f# fluft#fd#n upwards into the temporal lobe. The other rami of
7 Limiting sulcus separates at its floor two areas which the lateral sulcus are the anteriorhorizontal and anterior
are different functionally and structurally. An ascending rami. They extend into the lower part of
tr example is the central sulcus between the motor and the frontal lobe.
'6
m
sensory areas (Fig. 28.5a). 3 The frontal lobe is further divided by the following
2 Axial sulcus develops in the long axis of a rapidly sulci.
N
growing homogeneous area. An example is the a. The precentral sulcus runs parallel to the central
o
o postcalcarine sulcus in the long axis of the striate area sulcus, a little in front of it. The precentral gyrus
ac) (Fig.28.5b). Iies between the two sulci (Table 28.1).
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Table28.1: Sulci and gyri of the cerebrum
Surface/Lobe Sulci Gyri
I. Superolateral surface
1. Frontal lobe A. Precentral a. Precentral
B. Superior frontal b. Superior frontal
C. lnferior frontal c. Middle frontal
d. lnferior frontal which also contains anterior horizontal and
anterior ascending rami of the lateral sulcus, and the pars
orbitalis, pars triangularis and pars opercularis
2. Parietal lobe A. Postcentral a. Postcentral
B. lntraparietal b. Superior parietal lobule
c. lnferior parietal lobule, which is divided into 3 parts:
i. The anterior, supramarginal,
ii. The middle, angular, and
ii i . The posterior, over the upturned end of inferior temporal
sulcus
3. Temporal lobe A. Superior temporal a. Superior temporal,
B. lnferior temporal b. Middle temporal
c. lnferior temporal
4. Occipital lobe A. Transverse occipital a. Arcus parieto-occipitalis
B. Lateral occipital b. Superior occipital
C. Lunate c. lnferior occipital
D. Superior and inferior polar d. Gyrus descendens
E. Calcarine
Il. Medial surface A. Anterior parolfactory a. Paraterminal
B. Posterior parolfactory b. Parolfactory (subcallosal area)
C. Cingulate c. Medial frontal
D. Callosal d. Paracentral lobule
E. Suprasplenial or subparietal e. Cingulate
F. Parieto-occipital f. Cuneus
G. Calcarine g. Precuneus
lll. lnferior surface A. Olfactory a. Gyrus rectus
B. H-shaped orbital sulci b. Anterior orbital
C. Collateral c. Posterior orbital
D. Rhinal d. Medial orbital
E. Occipitotemporal e. Lateral orbital
f. Lingual
g. Uncus
h. Parahlppocampal
i. Medial occipitotemporal
j. Lateral occipitotemporal
b. The area in front of the precentral sulcus is divided c. The inferior parietal lobule is invaded by the
into superior, middle and inferior frontal gyri by the upturned ends of the posterior ramus of the lateral
superior and inferior frontal sulci. sulcus, and of the superior and inferior temporal
c. The anterior horizontal and anterior ascending sulci. They divide the in-ferior parietal lobule into
rami of the lateral sulcus (see above) subdivide the anterior, middle and posterior parts. The anterior
inferior frontal gyrus into three parts, (pars part is called the supramarginal gyrus, and the
orbitalis, pars triangularis, and pars opercularis). middle part is called the angular Wrus.
The parietal lobe is further subdivided by the 5 The superior and inferior temporal sulci divide the
following sulci. temporal lobeinto superior,middle and inferior temporal
a. The postcentral sulcus runs parallel to the central gyri. .s
G
sulcus, a little behind it. The postcentral gyrts lies E
between the two sulci. 5 The occipital lobe is further subdivided by the
N
b. The area behind the postcentral gyrus is ditided into following sulci. c
o
the superior and inferior parietal lobulesby the intra- a. The lateral occipital sulcus divides this lobe into the o
parietal sulcus. superior and inferior occipital gyri. ao)
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BRAIN
b. The lunate sulcus separates these gyri from the Sulciond Gyrion the ObitolSuiloce
occipital pole. 1 Parallel to the medial orbital border there is the
c. The area around the parieto-occipital sulcus is the olfactory sulcus: between these two there is lhe gyrus
arcus parieto-occipitalis. It is separated from the rectus. The rest of the orbital surface is subdivided
superior occipital gyrus by the transoerse occipital by an H-shaped sulcus into anterior, posterior, medial
sulcus. and lateral orbital gyri.
2 The stem of the lateral sulcus lies deep between the
Sulci ond Gyri on Mediol Sutfoce temporal pole and orbital surface (Fig.28.a).
Confirm the following facts by examining (Fig. 28.3).
The central part of the medial aspect of the Sulci ond Gyti on the Tentotlol Surfoce
hemisphere is occupied by the corpus callosum. Tii.e This area presents two sulci running anteroposteriorly.
corpus callosum is divisible into thegena (anterior end), The medial one is the collateral sulcus, and the lateral is
the body, and the splenium (posterior end). It is made the occipitotemporal sulcus. On the medial side of the
up of nerve fibres connecting the two cerebral temporal pole, there is t},;re rhinal sulcus.
hemispheres. Below the corpus callosum, there are the The gyri are as follows.
septum pellucidum, the fornix and the thalamus.In the 1" The part medial to the rhinal sulcus is the uncus.
remaining part of the medial surface, identify the 2 The part medial to the collateral sulcus is the
following sulci. parahippocampalgyrus.Its posterior part is limited
1 The cingulate sulcus starts in front of the genu and medially by the calcarine sulcus. It is joined to the
runs backwards parallel to the upper margin of the cing isthmus (Fig.28.3).
corpus callosum. Its posterior end reaches the 3 The al sulcus is divided into
superomedial border a little behind the upper end med temPoral gYri bY the
of the central sulcus (Table 28.1). o c cipit ot emp or nl sul cus.
2 The suprasplenial sulcus lies above and behind the
splenium. Structutol ond Functionollypes of the Corlex
3 The calcarine sulcusbegins a little below the splenium
and runs towards the occipital pole. It gives off the
parieto-occipital sulcus which reaches the superolateral
area and hippocampal formation). Structurally, it is
surface.
simple and is made up of only three layers.
4 A little below the genu, there are two small anterior
za
and posterior parolfactory sulci.
The following gyri can now be identified.
1 The cingulate gyrusliesbetween the corpus callosum into the following.
and the cingulate sulcus. Its posterior part is bounded a. Granular cortex (koniocortex or dust cortex). It is
above by the suprasplenial sulcus and is divided into basically a sensory cortex.
anterior and posterior parts. b. Agranular cortex. This is the motor cortex.
2 The U-shaped gyrus around the end of the central
sulcus is the paracentral lobule. It is usually divided FUNCTIQNAL OR CORTI I. AREAS
into anterior and posterior parts. OF CEREBRAL CORTEX
3 The area between the cingulate gyrus and the There are three basic functional divisions of cerebral
superomedial border, in front of the paracentral
cortex:
lobule is called lhe medial frontal gyrus.
4 The quadrangular area between the suprasplenial 1 Mofor flrefis: The primary motor area has been
sulcus and the superomedial border is called the
identified on the basis of elicitation of motor
responses at a low threshold of electric stimulation
precuneus.
5 The triangular area between the parieto-occipital
which gives rise to contraction of skeletal
musculature. These areas give originto corticospinal
sulcus (above) and the calcarine sulcus (below) is
and corticonuclear fibres (Fig. 28.6).
called the cuneus.
6 A narrow strip between the splenium and the stem 2 sl In these areas, electrical activity can be
(E appropriate sensory stimulus is applied
o of the calcarine sulcus is the isthmus.
7 The paraterminal gyrus lies just in front of the lamina to a particular part of the body (Fig.28.7)-
C\I
terminalis. The ventral posterior nucleus of thalamus is main
o
o 8 The parolfactory gyruslies between the anterior and source of afferent fibres for the first sensory area.
o
a posterior parolfactory sulci. This thalamic nucleus is the site of termination of all
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CEREBRUM
of paracentral lobule on the medial surface of cerebral

hemispheres. This corresponds to area 4 of Brodmann.
Electrical stimulation of primary motor area elicits
contraction of muscles that are mainly on the opposite
side of body. Although cortical control of musculature
is mainly contralateral, there is significant ipsilateral
control of most of the muscles of the head and axial
muscles of the body. The contralateral half of the body
is represented as upside down, except the face. The
pharyngeal region, tongue are represented in the most
ventral and lower part of precentral gyrrts, followed
by the face, hand, arm, trunk and thigh. The remainder
of leg, foot and perineum is on the medial surface of
hemisphere in the paracentral lobule (Fig. 28.8).
Posterior Another significant feature in this area is that the
Fig. 28.6: Some of the areas of Brodmann on the superolateral size of the cortical area for a particular part of the body
sudace of right cerebral hemisphere is determined by the functional importance of the part
and its need for sensitivity and intricacy of the
Sensory movements of that region. The area for the face,
area especially the larynx and lips, is therefore dispro-
portionately large and a large area is assigned to the
hand particularly the thumb and index finger.
Movements of joints are represented rather than
individual muscles (Table 28.2).
,ffi j'#?f ??# f{}r $ i-#}€}
This area coincides with the Brodmann's area 6 and is

situated anterior to motor area in the superolateral and
medial surfaces of the hemisphere. The premotor area
contributes to motor function by its direct contribution
to the pyramidal and other descendingmotorpathways
and by its influence on the primary motor cortex
(Fig.28.e).
In general, the primary motor area is the cortex in
Fig. 28"71 Some of the areas of Brodmann on the medial surface which execution of movements originates and relatively
of right cerebral hemisphere simple movements are maintained. In contrast, the
the fibres of the medial lemniscus and of most of the Hand

spinothalamic and trigeminothalamic tracts.
3 Assaein.fion frreas: In these regions, the direct sensory
Thumb
or motor respohses are not elicited. These areas Neck

integrate and analyse the responses from various
sources. Many such areas are known to have motor
or sensory functions.
The motor and sensory functions also overlap in the
same region of cortex. If the motor function is
predominant, it is known as motor-sensory (Ms) and
where sensory function is predominant, it is called
sensorimotor (Sm). tr
'6
Motor Aleos E
(\l
fiPrH &/g#f#rr ffirfl#d# C
o
It is located in the precentral gyrus, including the o
o
anterior wall of centrll sulcus, atrd in the anterior part Fig. 28"8: Motor homunculus on the precentral gyrus a
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BRAIN
Effect of lesion
of body pafts
Frontal Motor area 4 Precentral gyrus Upside down Controls voluntary Contralateral
lobe and paracentral activities of the paralysis and
lobule opposite half of body Jacksonian fits
Premotor area 6 Posterior parts of Controls extrapyramidal Often mixed with

superior, middle system pyramidal effect
and inferior frontal
gyn
Frontal eye field 6, 8 Posterior part of Controls horizontal Horizontal conjugate

middle frontal conjugate movements movements are lost
gyrus of the eyes
Motor speech area 44,45 Pars triangularis Controls the spoken Aphasia (motor)
(Broca's area) and pars speech
opercularis
Prefrontalarea 9,10,11 The remaining Controls emotions, Loss of orientation

12 large, anterior concentration, attention
part of frontal initiative and judgement
lobe
Parietal Sensory 3,1,2 Postcentral gyrus Upside down Perception of Loss of appreciation
lobe (somesthetic) and paracentral exteroceptive (touch, of the impulses
area lobule pain and temperature) received
and proprioceptive
impulses
Sensory 5,7 Between sensory Stereognosis and Astereognosis and

association and visual areas sensory speech sensory aphasia
Wernicke's area 22 lnferior part of Sensory speech Sensory aphasia
parietal lobule
Occipital Visuosensory 17 ln and around the Macular area Reception and Homonymous
lobe area or striate postcalcarine has largest perception of the hemianopia with
atea sulcus representation isolated visual macular sparing
lmpressions of colour,
size, form, motion,
illumination and
transparency
Visuopsychic 18, 19 Surround the Correlation of visual Visual agnosia

area, parastriate striate area impulses with past
and peristriate memory and recognition
areas of objects seen, and
also the depth
Temporal Auditosensory 41 , 42 Posterior part Reception and lmpaired hearing

lobe area of superior perception of isolated
temporal gyrus auditory impressions
and anterior of loudness, quality
transverse and pitch
temporal gyrus
tr
.E
Auditopsychic 22 Rest of the Correlation of auditory Auditory agnosia
E area supeflor impressions with past
N
c temporal gyrus memory and identification
o (interpretation) of the
()
ao sounds heard
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CEREBRUM
Ms Sm
Sm ll
Frontal eye field
Wernicke's area
Visual lll
Broca's area
Visual ll
Auditory area (41 ,42) Visual I
Flg. 28.9: Functional areas of superolateral aspect of simian left cerebral hemisphere
premotor area programmes skilled motor activity and 98% of right handed persons. In70% of left handers, it
thus directs the primary motor area in its execution. is again present in left hemisphere. Only in 30%, it is
The premotor and primary motor areas are together situated in right hemisphere (Fig.28.9).
referred to as the primary somatomotor area (Ms I).
Both these areas give origin to corticospinal and rufrml#y* flr+dt;f
corticonuclear fibres and receive fibres from cerebellum It lies in the middle frontal gyrus just anterior to
after relay in ventral intermediate nucleus of thalamus. precentral gyrus. It is the lower part of area 8 of
Brodmann on the lateral surface of cerebral hemisphere,
$*p*pJ*r* mm f*ry Fo{* {**r 14 66av 1-l'".45r 1ii extending slightly beyond that area. Electrical
It is predominantly motor in function. This motor area stimulation of this area causes deviation of both the
is in the part of area 6 that lies on the medial surface of eyes to the opposite side. This is called conjugate
the hemisphere anterior to the paracentral lobule. movements of eyes. Movements of the head and
Different parts of body are represented within this area. dilatation of pupil may also occur. This area is
It differs from the main motor area in that its stimulation connected to the cortex of occipital lobe which is
produces bilateral movements (Fig. 28.10). concerned with vision.
&4*f*r Sp*m#ft Jq #f.? eFfl ffi d##dft '$

fl #i*+ f i** fcpd {-l* rl*"*r
i,i"t #i.rL.:/ I r]#!" i!
t:
j t,li-iilil i /i3i" #,-.]j Prefrontal cortex is a large area lying anterior to the
This area occupies the opercular and triangularportions precentral area. It includes the superior, middle, and
of the inferior frontal gyrus corresponding to the area 44 inferior frontal gyri, medial frontal gyrus, orbital gyri
and 45 of Brodmann. This is present on the left side in and anterior half of the cingulate gyrus. These include
Brodmann's areas 9, L0, 11 and 12. This area is
connected to other areas of the cerebral cortex, corpus
striatum, thalamus and hypothalamus. It is also
connected to cerebellum through the pontine nuclei. It
controls emotions concentration, attention, initiative
and judgement.
Motor areas
o Destructive lesion of primary motor area4 results
.E
in voluntary paresis of the affected part of body. o
Spastic voluntary paralysis of the opposite side o
of body characteristically follows if the Iesion N
c
spreads beyond area 4 or that interrupts projection o
F19.28,10: Functional areas on the medial surface of left cerebral fibres in the medullary centre or internal capsule. o
hemisphere a0)
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BRAIN
Irritative lesion of the motor area leads to focal The ventral posterior nucleus of thalamus is the main
convulsive movements of the corresponding part source of afferent fibres for the sensory area. This
of body, referred to as lacksonian epilepsy. thalamic nucleus is the site of termination of all the
Lesion of supplementary motor area 6leads to fibres of the medial lemniscus. Most of the fibres of the
apraxia. This is the condition which involves spinothalamic and trigeminothalamic tracts carrying
difficulty in performing the skilled movements fibres for cutaneous sensibility end in anterior part of
once learnt, in absence of paralysis, ataxia or the area and those for deep sensibility end in the
sensory loss. When the disability affects writing posterior part.
it is called ngraphia,
Frontal eye field: Destruction of this area causes Seeond $omesffieff c Areg
conjugate deviation of the eyes towards the side Second somesthetic area also known as second
of lesion. The patient cannot voluntarily move his somatosensory area (Sm II) has been demonstrated in
eyes in the opposite directiory but this movement primates including humans. This is situated in the
occurs involuntarily when he observes an object superior lip of the posterior ramus of lateral sulcus with
moving across the field of vision. postcentral gyrus. The parts of body are represented
Speech area: Lesion of Broca's area on the dominant bilaterally (Fig. 28.9).
side of hemisphere causes expressive aphasia. It is
characterised by hesitant and distorted speech with $cmesfftefic Associsfion rfex
relatively good comprehension. Somesthetic association cortex is mainly in the superior
A lesion involving language areas that is parietal lobule on the superolateral surface of the
Wernicke's area and Broca's area both leads to hemisphere and in the precuneus on the medial surface.
receptive aphasia. In this condition, auditory and It coincides with areas 5 and 7 of Brodmann. This
visual comprehension of language that is naming receives afferents from first sensory area and has
of objects and repetition of a sentence spoken by reciprocal corurection with dorsal tier of nuclei of lateral
the examiner are all defective. mass of thalamus. Data pertaining to the general senses
A lesion involving Wernicke's area and superior are integrated, permitting a comprehensive assessment
longitudinal fasciculus or arcuate fasciculus of the characteristic of an object held in hand and its
results in jargon aphasia in which speech is fluent identification without visual aid.
but unintelligible jargon.
Voluntary smile in a stroke patient will accentuate &ecepfrveSpeech Arca of rnicke
the asymmetry. A genuine smile which uses only
extrapyramidal pathways, will be symmetrical This is also known as sensory language area.It consists
and there will be no asymmetry for the duration
of auditory association cortex and of adjacent parts of
of the smile. One needs to remernber that motor the inferior parietal lobule (area 22).
cortex is required only for voluntary moment.
Sensory Areos
Sensory areas
f Soficesff?efrc Areo r First somesthetic or general sensory area (areas 3,
First somesthetic (general sensory) area is also called 7 and2 of Brodmann). \A/hen this part of cortex is
first somatosensory- area (Sm I). It occupies postcentral the site of destructive lesion, a crude form of
gyrus on the superolateral surface of the cerebral awareness persists for the sensation of pain, heat
hemisphere and posterior part of paracentral lobule on and cold on the opposite side of lesion. There is
the medial surface. It corresponds to areas 3,7 and2 of poor localization of stimulus. There is loss of
Brodmann (Figs 28,9 and 28.10). discriminative sensations of fine touch,
The representation of the body in this area corres- movements and position of part of the body.
ponds to that in the motor area that is contralateral half o Somesthetic association cortex (superior parietal
of body is represented upside down except the face. The
lobule) areas 5 artd 7 of Brodmann: A lesion in
area of the cortex that receives sensations from a
this area leads to defect in understanding the
.E particular part of body is not proportional to the size of
(E significance of sensory information, which is
that part, but rather to the intricacy of sensations recei-
tr called agnasia. A lesion that destroys a large
ved from it. Thus, the thumb, fingers,lips and tongue
N portion of this association cortex causes tactile
C
o have a disproportionately large representation. The
agnosia and astereogrzosis which are closely related.
() different sensations, i.e. cutaneous and proprioceptive
o This is the condition when a person is unable to
a are represented in different parts within sensory area.
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CEREBRUM
recognize the objects held in the hand, while the auditory area. This area lies behind the first auditory
eyes are closed. He is unable to correlate the area in superior temporal gyrus. It corresponds to area
Eurface, texture, shape, size and weight of the 22 of Brodmann on the lateral surface of superior
object or to compare the sensations with previous temporal gyrus. This region of the cortex is also known
experience. as Wernicke's area and is of major importance in
language functions.
Areos of Speciol Sensolions fe

lott The taste area (gustatory area) is located in dorsal wall
of posterior ramus of lateral sulcus, with extension into
T}:le uisual area is located above and below the calcarine
insula and corresponds to area 43 of Brodmann It places
sulcus on the medial surface of occipital lobe. It the taste area adjacent to first sensory area of cortex for
corresponds to area 17 of Brodmann. The visual area is
tongue and pharynx. Its location is similar to second
also called the striate area because the cortex here
somesthetic area.
contains the line of Gennari, which is just visible to the
unaided eye.
$mefd
The chief source of afferent fibres to area 17 is the
lateral geniculate nucleus of thalamus by way of Ends in pyriform lobe.
geniculocalcarine tract. Area 17 constitutes the first
visual area. It is continuous both above and below with
area 18 and beyond this with area 19 of Brodmann Special sensory areas
which are also known as visual association or a. Primary visual area 77 lesion of this area, leads to
psychovisual areas. Since fibres of geniculocalcarine loss of vision in the visual field of the opposite
tract (optic radiation) terminate in these regions also, side-homonymous hemianopia.
therefore, these areas are regarded as second and the b. Auditory area:
third visual areas respectively (Figs 28.9 and 28.10). - Primary auditory areas 41 and 42: A unilateral
The role of the second and third visual areas includes lesion involving the auditoty atea causes
among other complex aspects of vision, the relating of diminution in the acuity of hearing inboth ears
present to past visual experience, with recognition of and the loss is greater in the opposite ear.
what is seen and appreciation of its significance. The However, the impairment is slight because of
three areas are linked together by association fibres. the bilateral projection to the cortex and the
The visual areas give efferent fibres which reach frontal deficit is difficult to detect by clinical tests.
eye field. - Auditory association cortex or secondary arca
22.In lesions of this area, interpretation of the
Ffearingr sounds is lost.
The auditory (acoustic) area lies in the temporal lobe.
Most of it is concealed as it lies in that part of superior Funclions of Cerebrol Coriex
temporal gyrus which forms inferior wall of the '1. Carebrnl d*nrinance: One cerebral hemisphere
posterior ramus of lateral sulcus. It corresponds with
dominates the other one in relation to handedness,
areas 41. and 42 of Brodmann.
Tlee medial genic.ulate body of the thalamus is the
speech, perception of language and spatial
judgement. In 80-95% subjects, the left hemisphere
principal source of fibres ending in the auditory cortex
dominates the right one. The dominant lobe contains
with these fibres constituting the auditory radiation. the Broca's motor speech area. Since left hemisphere
There is spatial representation in the auditory area with
controls the right half of the body, all these subjects
respect to pitch of sounds. Impulses of low frequencies
are right-handed. The left hemisphere is verbal,
impinge on anterolateral part of area and impulses of
mathematical, analytical and has direct link to
high frequencies get heard on the posteromedial part.
consciousness.
Cortex gets afferents from both ears. Body receives
information that originates mainly in the organ of Corti The right hemisphere is active in understanding
of opposite side, the incomplete decussation of geometrical figures, and important for temporal c
'6
ascending pathways ensures a substantial input from synthesis and spatial comprehension. It helps in
recognition of faces, figures and appreciating music. E
the ear of same side as well (Fig. 28.9). N
The auditory radiation does not only end in first Localisation of speech on left side in 70"/" of left c
o
auditory area but extends to neighbouring area as well, handed and 98% of right handed is well known. o
that is known as auditory association area or second Association of negative emotions with right a0)
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BRA N
Table 28.3: Summary of functions and effects of damage of lobes of brain (Fig.28.1)
Lobes of brain Functions Effects of damage
Frontal Personality, emotional control, social behaviour, Lack of initiation, antisocial behaviour, impaired
contralateral motor control, language, micturition memory and incontinence
Parietal Spatial orientation, recognition of faces, Spatial disorientation, non-recognition of faces
(non-dominant) appreciation of music and figures
Parietal Language, calculation, analytical, logical, Dyscalculia, dyslexia, apraxia (inability to do
(dominant) geometrical complex movements) agnosia (inability to
recognize)
Temporal Auditory perception, pitch perception, non-verbal Beception aphasia, impaired musical skills
(non-dominant) memory, smell, balance
Temporal (dominant) Language, verbal memory, auditory perception Dyslexia, verbal memory impaired, receptive aphasia
Occipital Visual processing Visual loss, visual agnosia.
prefrontal activity and of positive emotions with left Dementia: In this condition, there is slow and
prefrontal activity is also known. Mahatma Candhi progressive loss of memoryr intellect and per-
father of the nation, Bill Clinton, Bill Gates, Amitabh sonality. The consciousness of the subject is
Bachchan and Abhishek Bachchan are all left handed. normal. Dementia usually occurs due to
Functional asymmetry in a structurally symmetrical Alzheimer's disease.
structure is a great and ingenious way of econo- Alzheimer's disease: The changes of normal ageing
mising on neural tissue. It practically doubles the are more pronounced in the parietal lobe,
capabilities of the brain. temporal lobe, and in the hippocampus.
Discriminatory aspects: Sensory cortex is not
concerned with recognition only, but is also involved
with discrimination of sensory function as:
a. Recognition of spatial relationship
b. Graded response to stimuli of different intensities
c. Appreciation of similarities and differences in
external objects, brought into contact with surface
of body.
Assoeintiae ftnrctions: The information thus discri-
minated and classified is correlated with previous
experience. This association forms the basis of
memory patterns. These are transmitted to frontal
cortex which synthesize it and forms basis of
thinking and related intellectual activities.
The motor area of one cerebral hemisphere controls
voluntary movements of opposite side of the body. (a) Normal brain Alzheimer's disease of brain
Normal Enlarged
arachnoid villi arachnoid villi
Table 28.3 depicts summary of functions and
effects of damage of lobes of brain. Figures 28.1.1.a
and c show normal brain. Enlarged
Ageing: Usually alter 60-70 years or so there are subarachnoid
changes in the brain. These are: space
a. Prominence of sulci due to cortical shrinkage Normal

tr Grey matter
(E (Fig.28.11b). (c) grey matter gets thin
6 b. The gyri get narrow and sulci get broad (Fig.
N 28.11.d). Figs 28.11a to d: (a) Normal brain, (b) Alzheimer's disease
c of brain, (c) normal grey matter and arachnoid villi, and
.9 c. The subarachnoid space becomes wider.
() d. There is enlargement of the ventricles. (d) changes in the elderly bratn
ao
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CEREBRUM
which is covered by the tela choroidea of the third

ventricle. It is limited laterally by the caudate nucleus,
the stria terminalis and the thalamostriate vein, and
The diencephalon is a middle structure which is largely
embedded in the cerebrum, and therefore hidden from
medially by the habenular stria (stria medullaris
thalami) (Fig.28.18).
surface view (Figs 28.1,2a and b). Its cavity forms the
greater part of the third ventricle. The hypothalamic The inferior surface rests on the subthalamus and the
sulcus, extending from the interventricular foramen to
hypothalamus (Fig. 28.19).
the cerebral aqueduct, divides each half of the The medial surface forms the posterosuperior part of
diencephalon into dorsal and ventral parts. Further the lateral wall of the third ventricle (seeFig.29.3). The
subdivisions are given below. medial surfaces of two thalami are interconnectedby an
interthalamic adhesion (Fig. 28.12b).
DORSAL PART OF DIENCEPHALON The lateral surface forms the medial boundary of the
1 Thalamus (dorsal thalamus). posterior limb of the internal capsule (Fi9.28.21).
2 Metathalamus, including the medial and lateral
Sfree*fur* #flld rudJ#d#r o$ flfu c*tervrus
geniculate bodies.
3 Epithalamus, including the pineal body and ite rnatter
habenula. The external medullary lamina covers the lateral surface.
The internal medulliry lamina divides the thalamus into
VENTRAT PARI OF DIENCEPHATON three parts, anterior, medial and lateral.
1 Hypothalamus, and Grey matter
2 Subthalamus (ventral thalamus). The grey matter is divided to from several nuclei.
Iholomus I Anterior nucleus in the anterior part (Fig. 28.13).
2 Medial nucleus in the medial part.
The thalamus (Greek inner chamber) is a large mass of
grey matter situated in the lateral wall of the third
3 The lateral part of the thalamus is largest and
represents the neothalamus. It is divided into the lateral
ventricle and in the floor of the central part of the lateral nucleus in the dorsolateral part, airtd the oentral nucleus
ventricle. It has anterior and posterior ends; superior, in the ventromedial part. The ventral nucleus is
inferior, medial and lateral surfaces.
subdivided into anterior, intermediate and posterior
T}ae anterior endwith anterior nucleus is narrow and
groups. The posterior group is further subdivided
forms the posterior boundary of the interventricular into the posterolateral and posteromedial groups.
foramen (Figs28.12a and b). 4 lntralaminar nuclei including centromedian nucleus
The posterior end is expanded, and is known as the (located in the internal medullary lamina), midline
pulvinar. It overhangs the lateral and medial geniculate nuclei (periventricular grey on the medial surface) and
bodies, and the superior colliculus with its brachium
reticular nuclei (on the lateral surface) are also present.
(Fi9.28.12a).
The superior surface is divided into a lateral ventricular Conneetions and functions of thalamus
part which forms the floor of the central part of the Afferent impulses from a large number of subcortical
lateral ventricle, and a medial extraventricular part centres converge on the thalamus. Exteroceptive and
1. Anterior nuclei Thalamic adhesion

2. Medial
lntralaminar nuclei
3. Lateral nuclei:
a Lateral dorsal Midline nuclei
b Lateral posterior
c Pulvinar Medial nuclei
Ventral nuclei:
lnternal medullary
4 Ventral anterior
lamina
5. Ventral lateral .E
6. Ventral posterior lateral G
7. Ventral posterior medial
B
o
(a) 8. Lateral geniculate nucleus C!
9. Medial geniculate nucleus c
.9
I o
Figs 28.12a and b: (a) Location of thalamus in the cerebral hemisphere, and (b) three-dimensional view of thalamus ao)
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BRAIN
lnterventricular foramen
lnterthalamic adhesion
Anterior commissure
Hypothalamic sulcus
Mammillary body
Optic chiasma Hypothalamus
Tegmentum of midbrain
Hypophysis cerebri
Fig. 28.13: Thalamus and hypothalamus as seen in sagittal section
proprioceptive impulses ascend to it through the medial body to the in{erior colliculus. The connections of the
Iemniscus, the spinothalamic tracts and the trigemino- medial geniculate body are as follows (see Fig.26.8).
thalamic tracts. Visual and auditory impulses reach the rcnts
medial and lateral geniculatebodies. Sensations of taste (1) Lateral lemniscus; and (2) fibres from both inferior
are conveyed to it through solitariothalamic fibres.
colliculi.
Although the thalamus does not receive direct olfactory
impulses, they probably reach it through the renfs
amygdaloid complex. Visceral information is conveyed It gives rise to the acoustic (auditory) radiation going
from the hypothalamus and probably through the to the auditory area of the cortex (in the temporal lobe)
reticular formation. through the sublentiform part of the internal capsule.
In addition to these afferents, the thalamus receives Futtction
profuse connections from all parts of the cerebral Medial geniculate body is the last relay station on the
cortex, the cerebellum and the corpus striatum. The pathway of auditory impulses to the cerebral cortex.
thalamus is, therefore, regarded as a great integrating
centre where information from all these sources is [cfercf Genfcufofe So#y
brought together. This information is projected to It is a small oval elevation situated anterolateral to the
almost the whole of the cerebral cortex through profuse medial geniculate body, below the thalamus. It is
thalamocortical projections. Efferent projections also overlapped by the medial part of the temporal lobe,
reach the corpus striatum, the hypothalamus and the and is connected to the superior colliculus by the
reticular formation. Besides its integrating function, superior brachium (see Fig.26.8).
the thalamus has some degree of ability to perceive
exteroceptive sensations, especially pain. The Structure
connections and functions of nuclei of thalamus are It is six-layered. Layers 7, 4 and 6 (pink) receive
shown in Table 28.4. contralateral optic fibres, and layers 2, 3 and 5 (light
blue) receive ipsilateral optic fibres (Fig.28.L7).
Mototholomue (Pqrt of Tholomus)
esnnections
The metathalamus consists of the medial and lateral rents: Optic tract (lateral root).
geniculate bodies, which are situated on each side of
the midbrain, below the thalamus.
rents: lt
gives rise to optic radiations going to the
.E
(E visual area of cortex through retrolentiform part of
E internal capsule.
(\t
c It is an oval elevation situated just below the pulvinar Function
o
o of the thalamus and lateral to the superior colliculus. Lateral geniculate body is the last relay station on the
o
@ The inferior brachium connects the medial geniculate visual pathway to the occipital cortex.
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CEBEBRUM
Table 28.4: Connection of

Nucleus Afferents Efferents Functions
Anterior nucleus Mammillothalamic tract To cingulate gyrus Relay station for
(Fig. 28.14) (Fig.28.16) hippocampal impulses
Medial nucleus From hypothalamus, frontal lobe To same parts from which Relay station for
in front of area 6, corpus striatum, the afferents are received visceral impulses
and other thalamic nuclei
Lateral nucleus: Lateral From precuneus and superior To precuneus and superior Correlative in function
dorsal, lateral posterior parietal lobule; also from parietal lobule
and pulvinar ventral and medial nuclei Temporal and occipital lobes
Temporal and occipital lobes
Ventral anterior nucleus From globus pallidus (subthalamic To areas number 6 and 8 Relay station for striatal
fasciculus) of cortex (Fig. 28.15) impulses
Ventral lateral nucleus From cerebellum (dentatothalamic To motor areas 4 and 6 Belay station for
fibres) and red nucleus cerebellar impulses
Ventral posterolateral Spinal and medial lemnisci To postcentral Relay station for exteroceptive
nucleus (Figs 28.14 gyrus (areas 3, 1,2') (touch, pain and temperature)
and 28.15) and proprioceptive impulses
from body, except face and head
Ventral posteromedial Trigeminal and solitariothalamic To postcentral Relay station for impulses from
nucleus (Fig. 28.16) lemnisci gyrus (areas 3, 1, 2) the face, head and taste impulses
lntralaminar, midline, and Reticular formation To all parts of cerebral Participate in arousal
reticular nuclei of brain stem cortex reactions
Centromedian nucleus From parts of corpus striatum; Not connected to cerebral Receive pain fibres
collaterals from spinal, medial, cortex, connected to other
trigeminal lemnisci, ascending thalamic nuclei, corpus
reticulothalamic fibres. lmpulses striatum
from areas 4, 6 of cerebral coftex
Medial geniculate body Auditory fibres from inferior Primary auditory areas Relay station for auditory
colliculus a1, a2 fig. 28.30) impulses
Lateral geniculate body Optic tract Primary visual cortex Relay station for visual impulses
area 17
o Lesions of the thalamus cause impairment of all The nucleus lies beneath the floor of the habenular
types of sensibilities; joint sense (posture and trigone. The trigone is a small, depressed triangular atea,
passive movements)being the most affected. situated above the superior colliculus and medial to the
r The thaiamic syndrome is characterized by dis- pulvinar of the thalamus. Medially, itisboundedbythe
turbances of s'ensations, hemiplegia, or hemi- stria medullaris thalami and stalk of the pineal body. The
paresis together with hyperaesthesia and severe habenular nucleus forms apartof the limbic system.
spontaneous pain. Pleasant as well as unpleasant Pineol Body/Pinool Glond
sensations or feelings are exaggerated.
The pineal (Latin pine, cone) body is a small, conical
organ, projecting backwards and downwards between
Epilholomus the two superior colliculi. It is placed below the
The epithalamus (Fig.2B.1B) occupies the caudal part splenium of the corpus callosum, but is separated from
of the roof of the diencephalon and consists of: it by the tela choroidea of the third ventricle.
1 The right and left habenular nuclei, each situated It consists of a conical body abofi 8 mm long, and a '6
beneath the floor of the corresponding habenular stalk or peduncle which divides anteriorly into two o
trigone. laminae separated by the pineal recess of the third (\I
2 The pineal body or epiphysis cerebri. ventricle. The superior lamina of the stalk contains the c
o
3 The habenular commissure. habenular commissure; and the inferior lamina contains ()
4 The posterior commissure. the posterior commissure (Fig. 28.18). oo
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BRAIN
From mammillary body From globus pallidus

1. Anterior nucleus
2. Medial nucleus
3. Lateral nuclei:
s Lateral dorsal,
b Lateral posterior
From cerebellum c Pulvinar
Ventral nuclei:
4. Ventral anterior
Medial lemniscus 5. Ventral lateral
From areas 4,6 of cerebrai 6. Ventral posterior lateral
cortex, corpus striatum, lemnisci
Spinal lemniscus 7 Ventral posterior medial
(lateral spinothalamic 8. Lateral geniculate nucleus
tract) 9. Medial geniculate nucleus
Trigeminal lemniscus
From colliculi
Optic tract
From inferior colliculus
Flg, 28.1 4: Parts of the thalamus. The afferents to the nuclei of thalamus are also indicated (colour coding in Figs 28.14 lo 28.1 6 is
same)
Ceniral sulcus
Ventral posterior
Ventral lateral
Lateral dorsal and lateral
posterior nuclei Ventral anterior
Mediodorsal nucleus
(mediat)
Medial geniculate body

Lateral geniculate body
Flg" 28.15: Projection from thalamic nuclei to superolateral surface of cerebral hemisphere
Ventral lateral
Ventral posterior
Lateral dorsal and

lateral posterior nuclei
Pulvinar
c
'6
E Lateral geniculate body
N
C
.9
o
ao Flg. 28.16: Projection from thalamic nuclei to medial sudace of cerebral hemisphere
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CEREBRUM
-n
ro Corpus callosum
E o
c(6 3
o
cf)
! Septum pellucidum
c\i o
@
p0)q o
o.
Dorsomedial nucleus
o o-
o lnterventicular
E
(o foramen
a -.
E 5
0) Preoptic nucleus
LL =
o-
O) Paraventricular nucleus
Ventromedial nucleus
Supraoptic nucleus
Mammillary nucleus
Posterior nucleus
Flg. 28.17: Six layers of lateral geniculate body
Hypothalamic sulcus
F19.28.19: Nuclei of medial zone of hypothalamus
Tela choroidea of third ventricle
Stria medullaris
thalami
Frun*ffon.t
The pineal body has for long been regarded as a
Habenular
nucleus vestigial organ of no importance. Recent investigations
have shown that it is an endocrine gland of great
Suprapineal
importance. It produces hormones that may have an
recess important regulatory influence on many other
Pineal gland
endocrine organs (including the adenohypophysis, the
neurohypophysis, the thyroid, the parathyroids, the
Posterior
commtssure
adrenal cortex and medulla, and the gonads). The best
known hormone is melatonin which causes changes in
skin colour in some species. The synthesis and
discharge of melatonin is remarkably influenced by
exposure of the animal to light and is more during dark
period.
Flg. 28.18: Components of the epithalamus
Hypotholumus
The hypothalamus is a part of the diencephalon
(Fig.28.19). It lies in the floor and lateral wall of the
In many reptiles, the epiphysis cerebri is represented by
a double structure. The anteriot pafi (parapineal organ)
third ventricle. It has been designated as the head
ganglion of the autonomic nervous system because it
develops into the pineal or parietal eye. The posterior part
takes part in the control of many visceral and metabolic
is glandular in nature. The human pineal body represents
activities of the body.
the persistent posterior glandular part only. The parietal
eye has disappeared. Anatomically, it includes:
a. The floor of the third ventricle, or structures in
$frucfure the interpeduncular fossa.
The pineal gland is composed of two types of cells, b. The lateral wall of the third ventricle below the
pinealocytes and neuroglial cells, with a rich network hypothalamic sulcus.
of blood vessels and sympathetic fibres. The vessels and
nerves enter the gland through the connective tissue Boun e.t
septa which partly separate the lobules. Sympathetic As seen on the base of the brain, the hypothalamus is '6
ganglion cells may be present. bounded anteriorly by the posterior perforated
E
Calcareous concretions are constantly present in the substance; and on each side by the optic tract and crus (\l
pineal after the 17th year of life and may form cerebri (Fig. 28.4). C
.o
aggregations (brain sand). Spaces or cysts may also be As seen in a sagittal section of the brain, it is bounded o
present. Pineal gland has no neural tissue in it. anteriorlyby the lamina terminalis; inferiorlyby the floor ao
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BRAIN
of the third ventricle (from the optic chiasma to the Neurosecretiott

posterior perforated substance); and posterosuperiorly Oxytocin and vasopressin (antidiuretic hormone, ADH)
by the hypothalamic sulcus. are secreted by the hypothalamus and transported to
the infundibulum and the posterior lobe of the
Fsrfs of fhe ff ypo ff;cx/mru* us hypophysis cerebri.
The hypothalamus is subdivided into optic, tuberal and
General autonomic ct
mammillary parts. The nuclei present in each part are
as follows. The anterior parts of the hypothalamus chiefly mediate
parasympathetic activity; and the posterior parts, chiefly
Optic part mediate sympathetic activity, but the effects often
L Preoptic and supraoptic nuclei overlap. Thus the hypothalamus controls cardio-
2 Paraventricular nucleus, just above the supraoptic vascular, respiratory and alimentary functions.
nucleus and lateral nucleus in lateral zone.
T emp er atu r e r e gul nt ion
Tubernl part The hypothalamus maintains a balance between heat
3 Ventromedial nucleus. production and heat loss of the body. Raised body
4 Dorsomedial nucleus. temperature is decreased through vasodilation,
5 Tuberal nucleus, lateral to the ventromedial nucleus. sweating, panting and reduced heat production.
mmillary part Lowered body temperature is elevatedby shivering and
in prolonged cases by hyperactivity of the thyroid.
5 Posterior nucleus, caudal to the ventromedial and
dorsomedial nuclei and mammillary nucleus. Regulation od and water intake
7 Laleral nucleus, lateral to the posterior nucleus. The hunger or feeding centre is placed laterally, the satiety
The nuclei 3, 4 and 6 (medial) are separated from centre, medially. Stimulation of the feeding centre or
nuclei 5 andT (lateral) by the column of the fornix, the damage of the satiety centre causes hyperphagia
mammillothalamic tract and the fasciculus retroflexus. (overeating) leading to obesity. Stimulation of the
satiety centre or damage of the feeding centre causes
i m parlanf Sosrmecffons
hypophagia or even aphagia and death from starvation.
rents The thirst or drinking centre is situated in the lateral
The hypothalamus receives visceral sensations through part of the hypothalamus. Its stimulation causes
the spinal cord and brainstem (reticular formation). It is copious drinking and overhydration.
also connected to several centres associated with
olfactory pathways, including the piriform cortex; the Sexual behauiour and reproductiorr
cerebellum; and the retina. Through its control of the anterior pituitary, the
hypothalamus controls gametogenesis, various
rents reproductive cycles (uterine, ovarian, etc.) and the
1 Supraoptico-hypophyseal tract from the optic nuclei maturation and maintenance of secondary sexual
to the pars posterior, the pars tuberalis and the pars characteristics.
intermedia of the hypophysis cerebri. Through its connections with the limbic system, it
2 Mammillothalamic tract. participates in the elementary drives associated with
3 Mammillotegmental tract (periventricular system of food (hunger and thirst) and sex.
fibres).
Biolagical clocks
Fmmefr*ms #f ffyp#ff? $H{J$ Many tissues and organ-systems of the body show a
The hypothalamus is a complex neuroglandular cyclic variation in their functional activity during the
mechanism concerned with regulation of visceral and 24 hours of a day (circadian rhythm). Sleep and
vasomotor activities of the body. Its functions are as wakefulness is an outstanding example of a circadian
follows. rhythm. Wakefulness is maintained by the reticular
actiuating system. Sleep is produced by the hypnogenic
Endoa'ine control zones, ma;rr7y of the thalamus and hypothalamus and
By forming releasing hormones or release inhibiting partly by the brain stem. Lesions of the anterior
tr hormones, the hypothalamus regulates secretion of hypothalamus seriously disturb the rhythm of sleep and
(E
o thyrotropin (TSH), corticotropin (ACTH), somatotropin wakefulness.

N (STH), prolactin, luteinizing hormone (LH), follicle
c
o stimulating hormone (FSH) and melanocyte stimula- Emotion, fear, r
, auersion, pleasure and rewstd
o ting hormone, by the pars anterior of the hypophysis These faculties are controlled by the hypothalamus, the
o
a cerebri. limbic system and the prefrontal cortex.
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CEREBRUM
appears to be an important site for integration of a

number of motor centres.
Lesions of the hypothalamus give rise to one of the
The zona incerta is a thin lamina of grey matter situated
following syndromes.
. between the thalamus and the subthalamic nucleus.
Obesity: Frolich's slmdrome, or Laurence-Moon-
Laterally, it is continuous with the reticular nucleus of
Biedl syrrdrome.
o the thalamus. Its activity influences drinking of water.
Diabetes insipidus.
o Diencephalic autonomic epilepsy. This is charac-
terized by flushing, sweating, salivation, lacri-
mation, tachycardia, retardation of respiratory Discrete lesions of the subthalamic nucleus result in
rate, unconsciousness, etc. hemiballismus characterised by involuntary
o Sexual disturbance. Either precocity or impotence. choreiform movements on the opposite side of the
o Disturbance of sleep. Somnolence (persistent body. The condition is abolished by ablation of the
sleep), or narcolepsy (paroxysmal sleep). globus pallidus or of its efferent tracts, the anterior
o Hyperglycaemia and glycosuria. ventralnucleus of the thalamus, area{of the cerebral
o Acute ulcerations in the upper part of the gastro- cortex, or of the corticospinal tract. From these facts,
intestinal tract. it appears that the subthalamic nucleus has an
inhibitory control on the globus pallidus and on the
cerebral cortex.
Sublholomus
The subthalamus lies between the midbrain and
thalamus, medial to internal capsule and the globus
pallidus (Fig.28.20).It consists of the following:
DISSECTION
i',,i;1,.; ir' ,!,,i,1":iI i:t t
Raise the lower border of the insula, stripping a thin
1 The cranial ends of the red nucleus and substantia
layer of grey matter situated deep to the white matter
nigra extend into it.
of insula. This grey matter is known as the claustrum.
2 Subthalamic nucleus.
As the insula is gradually raised, the e)dernal capsule
3 Zonaincerta.
and on a deeper plane, a fan-shaped layer of white
\
il tt i | 4 i,t,lt ; i {,,,,. matter, the corona radiata, is identifiable. lts fibres pass
on a deeper plane than that of superior longitudinal
1 Cranial ends of lemnisci, lateral to the red nucleus. fasciculus.
2 Dentatothalamic tract along with the rubrothalamic To explore the lentiform nucleus, strip the external
fibres.
capsule and identify rounded lentiform nucleus. Dissect
3 Ansa lenticularis (ventral) (Fig.28.23). the striate branches of the middle cerebral artery on
4 Fasciculus lenticularis (dorsal). the lateral surface of the lentiform nucleus.
5 Subthalamic fasciculus (intermediate fibres). Remove the genu and rostrum of corpus callosum
The subthalamic nucleus is biconvex (in coronal
from the cerebral hemisphere, identify the head of the
section) and is situated dorsolateral to the red nucleus
caudate nucleus and the anterior part of the corona
and ventral to the zona incerta. From its connections, it
radiata emerging from between the caudate and the
lentiform nuclei. ldentify the anterior commissure and
trace its fibres reaching till the temporal lobe.
Fasciculus
Internal Capsule
lenticularis To expose the internal capsule, remove the lentiform
nucleus as it forms the lateral boundary of the internal
lnternal capsule. lt is difficult to separate as many fibres of
capsule internal capsule enterthe lentiform nucleus. Some fibres
Thalamus
form two medullary laminae and divide the lentiform
Putamen Zona lncerta nucleus into outer dark part-the putamen and two paler
Subthalamic inner parts-the globus pallidus. Putamen is continuous
nucleus with the caudate nucleus. Trace the continuity of the 'd
Globus
pallidus corona radiata with the internal capsule and of the o
Ansa (\I
internal capsule with the crus cerebri. The latter part is
leniicularis o
visible after stripping the optic tract from the lateral side
FIg. 28.20; lmportant fibre bundle running through subthalamic O
of the internal capsule.
regron ao
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BRAIN
Feotures Fibres converging to the crus

cerebri of midbrain
The basal nuclei are subcortical, intracerebral masses
of grey matter forming important parts of the
extrapyramidal system. Th"y include the following:
1 The corpus striatum (Fi9.28.21), which is partially
divided by the internal capsule into two nuclei:
a. The caudate nucleus.
b. The lentiform nucleus. Thalamus
These two nuclei are interconnected by a few bands
Fibres of corona
of grey matter below the anterior limb of the internal Amygdaloid
radiata and
body with tail of
capsule. The bands give it a striped appearance, hence internal capsule
caudate nucleus
the name. The lentiform nucleus is divided into a
lateral part, theputamen and a medialpart,t}rre globus Concave margin lnferior hom of
of choroid fissure lateral ventricle
pallidus. The caudate nucleus and putamen (neostria-
tum) are often grouped as the striatum, whereas the Flg, 28.22: Relations of caudate nucleus to lateral ventricle,
globus pallidus (paleostriatum) is the pallidum. thalamus and internal capsule
2 The amygdaloidbody forms a part of the limbic system.
3 Claustrum. Tlne body forms the floor of the central part of the
The four nuclei (caudate,lentiform, amygdaloid and lateral ventricle, and lies medial to the posterior limb
claustrum) are joined to the cortex at the anterior of the internal capsule. It is separated from the thalamus
perforated substance. by the stria terminalis and the thalamostriate vein.
Superiorly, it is related to the fronto-occipital bundle
CORPUS STRIATUM and the corpus callosum.
Corpus striatum (Latin striped body) comprises the The tail forms the roof of the inferior horn of the
caudate nucleus and lentiform nucleus. lateral ventricle, and ends by joining the amygdaloid
body at the temporal pole. It is related medially to the
Coudote Nucleus stria terminalis,laterallyto the tapetum, and superiorly
It is a C-shaped or comma-shaped nucleus which is to the sublentiform part of the internal capsule and to
surrounded by the lateral ventricle. The concavity of the globus pallidus.
'C' encloses the thalamus and the internal capsule
(Fig.28.22). Lenllform Nucleus
The nucleus has a head, a body, and a tail. This is a large lens-shaped (biconvex) nucleus, forming
The head forms the floor of the anterior horn of the the lateral boundary of the internal capsule. It lies
lateral ventricle, and the medial wall of the anterior limb beneath the insula and the claustrum.
of the internal capsule. Bands of grey matter connect it
The lentiform nucleus has three surfaces.
to the putamen across the anterior limb of the internal
capsule near the anterior perforated substance. a. The lated surface is convex. It is related to the
external capsule, the claustrum, the outermost
capsule, insula, and is groovedby thelateral striate
arteries.
Claustrum b. The medial surface is more convex.It is related to
the internal capsule, the caudate nucleus and the
thalamus (Fig.28.21).
Extemal
Globus
capsule
c. The inferior surface is related to the sublentiform
pallidus
part of the intemal capsule which separates it from
the optic tract, the tail of the caudate nucleus, and
lnternal
capsule
the inferior horn of the lateral ventricle. The
surface is grooved by the anterior commissure just
tr behind the anterior perforated substance.
'6 Thalamus Putamen
The lentiform nucleus is divided into two parts by a
o thin lamina of white matter.
N
c The larger lateral part is called theputamen (Lattn to
o
o Fi1.28.21l. Horizontal section through corpus striatum, thalamus cut). Strtcturally, it is similar to the caudate nucleus
o
U) and internal capsule and contains small cells.
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CEBEBRUM
The smaller medial part is called the globus pallidus.

Motor and
It is made up of large (motor) cells. premotor
cortex of
Morphologicol Divisions of Corpus Slriofum frontal lobe
Caudate nucleus
1 The paleostriatum is the older and primitive part. It is
represented by the globus pallidus (pallidum).
2 The neostriatum is more recent in development. It is Thalamus
represented by the caudate nucleus and the putamen Globus
pallidus
of the lentiform nucleus. The neostriatum is often Thalamic
called the striatum. fasciculus Putamen
Ansa lenticularis Lenticular

Connections of Corpus Slriotum fasciculus
The caudate nucleus and putamen are afferent nuclei,
while the globus pallidus is the efferent nucleus, of the
corpus striatum (Fi9.28.23). The connections are shown
in Table 28.5.
Substantia nigra
Functions of rpus Slriolum
1 The corpus striatum regulates muscle tone and thus Reticular
helps in smoothening voluntary movements. formation
in midbrain
It controls automatic associated movements, like the
swinging of arms during walking. Similarly, it Fi1,28.23: Connections of corpus striatum
controls the coordinated movements of different
parts of the body for emotional expression. Corpus striatum, cerebellum and motor areas of
It influences the precentral motor cortex which is cerebrum jointly are responsible for planning,
supposed to control the extrapyramidal activities of execution and control of movements.
the body. Corpus striatum and cerebellum without sending
These do not receive any sensory input from spinal fibres to spinal cord modify the effect on spinal cord
cord unlike the cerebellum. Basal ganglia contribute through projections to motor cortex and extra-
to cognitive function of the brain. pyramidal fibres.
These help cortex in execution of learned patterns of Basal ganglia and cerebellum do not initiate mov-
movements subconsciously. ements but are able to adjust motor commands.
Alferents
A. Caudate nucleus and putamen From: Chiefly to globus pallidus, but also to substantia
1. Cerebral cortex (areas 4 and 6) nigra and thalamus.
2. Thalamus (medial, intralaminar and
midline nuclei)
3. Substantia nigra
B. Globus pallidus Mainly from: Efferents form three bundles, namely:
1. Caudate nucleus 1. Ansa lenticularis, ventrally
2. Putamen 2. Fasciculus lenticularis, dorsally
Also from: 3. Subthalamic fasciculus from the middle part
1. Thalamus of the globus pallidus
2. Subthalamic nucleus These bundles terminate in the following:
3. Substantia nlgra 1. Thalamus
2. Hypothalamus .=
3. Subthalamic nucleus G
4. Red nucleus o
ol
5. Olivary nucleus C
6. Substantia nigra .9
o
7. Reticular nuclei ao
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BRA N
AMYGDALOID BODY
This is a nuclear mass in the temporal lobe, lying
anterosuperior to the inferior hom of the lateral ventricle.
Topographically, it is continuous with the tail of the
caudate nucleus, but functionally, it is related to the stria
termtnalis.lt is a part oI the )imbic system (Fig. 28.22).
It is continuous with the cortex of the uncus, the
limen insulae and the anterior perforated substance.
rents: From the olfactory tract.
rents:It gives rise to the stria terminalis which ends
in the anterior commissure, the anterior perforated Flexed attitude
substance and in hypothalamic nuclei.
CLAUSTRUM
It is saucer-shaped nucleus situated between the
putamen and the insula, with which it is coextensive.
Inferiorly, it is thickest and continuous with the anterior
perforated substance.
. Lesions of basal ganglia and cerebellum do not

cause paralysis. These produce abnormal Fig. 28.24:. Posture in parkinsonism
movements or posture or changes in tone.
Parkinsonism: Lesions of corpus striatum leads to
parkinsonism (Fig. 28.24). Its features are:
a. Hypertonicity or lead pipe rigidity.
b. Loss of automatic associated movements and
also of facial expression. DISSECIION
c. Involuntarymovements like tremors, choreiform Scrape the grey matter between adjacent gyri till the
movements, athetoid movements. white matter connecting the adjacent gyri is visible. This
d. Continuous writhing movements of trunk and will expose the short association fibres. ldentify the
limbs may continue even in sleep. Voluntary cingulate gyrus on the medial surface of the left
movements may be impossible. hemisphere. Scrape the grey matter of this gyrus till a
Chorea: Chorea means dancing. Chorea is form of band of white matter-the cingulum is exposed. Define
involuntary movement characterised by fine the extent ol cingulum from the anterior end of corpus
random movements of hands and feet. These callosum, around its convex trunk and splenium into
movements are rather disorganized. the parahippocampal gyrus.
This occurs due to disease of caudate nucleus. Similarly scrape the coftex between temporal pole,
Athetasis: It is a form of movement which is slow
motor speech area and the orbital coftex to expose
repetitive and writhing in nature. It is due to lesion
uncinate fasciculus. Also expose superior longitudinal
of putamen.
fasciculus joining the frontal lobe to the occipital and
Ballismus: This is characterized by irregular
temporal lobes. Lastly, scrape the grey matter between
movements of trunk, girdles and both the limbs.
It is due to disease of subthalamic nucleus. occipital and temporal lobes to expose the inferior
L-dopa (a precursor of dopamine) is used as a longitudinal fasciculus.
replacement therapy in parkinsonism because ldentify the various parts of the corpus callosum.
dopamine the normal neurotransmitter in the Remove the fibres of the cingulum and identify the
striatum, is reduced in these cases. The nigrostriate superficial fibres of the genu of corpus callosum passing
fibres are considered important in the genesis of into the medial aspect of hemisphere. Such fibres of
parkinsonism tremor, since its neurons utilize the two sides form the forceps minor.
tr
.E
dopamine in the neurotransmission. Expose the band of fibres passing from splenium of
E corpus callosum towards the superior part of occipital
Neurosurgically, pallidectomy and thalamo-
N lobe. Trace the fibres of tapetum arising from the trunk
dectomy have been used with success to control
o the contralateral tremors in different types of and splenium of corpus callosum curving to reach the
O
disease of corpus striatum. inferior parts of the occipital and temporal lobes.
ao
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CEREBRUM
ldentify the anterior commissure lying just anterior 4 The inferior longitudinal fasciculus, connecting the
to column of fornix and the interventricular foramen. occipital and temporal lobes.
Examine the posterior commissure situated dorsal to 5 Fronto-occipital fasciculus seen on the medial surface
the upper part of aqueduct and inferior to the root of
the pineal body. Look for habenular commissure present COMMISSURAL FIBRES
at the root of the pineal body. Lastly, identify the These are the fibres which connect corresponding parts
commissure of the fornix and the hypothalamic of the two hemispheres. They constitute the commissures
commtssures. of the cerebrum. They are:
Lift up a strip of supefficialfibres of the genu of corpus 1 The corpus callosum connecting the cerebral cortex of
callosum and tear these laterally. ldentify the the two sides (Fig. 28.26).
intersectioning fibres of corpus callosum and those of 2 The anterior commissure, connecting the archipallia
the vertically disposed fibres of the corona radiata. (olfactory bulbs, piriform area and anterior parts of
temporal lobes) of the two sides (Fig.28.l2b).
SUBDIVISIONS 3 The posterior commissure, connecting the superior
The white matter of the cerebrum consists chiefly of colliculi, and also transmitting corticotectal fibres and
myelinated fibres which connect various parts of the fibres from the pretectal nucleus to the Edinger-
cortex to one another and also to the other parts of the Westphal nucleus of the opposite side.
CNS. The fibres are classified into three groups, 4 the fornix (hippocampal commissure),
The commissure of
association fibres, and commissural fibres and connecting the crura of the fornix and thus the
projection fibres. hippocampal formations of the two sides (Fig. 28.12b).
5 The habenular commissure, connecting the habenular
ASSOCIATION (ARCUATE) FIBRES nuclei.
These are the fibres which connect different cortical
areas of the same hemisphere to one another. These are Trunk
subdivided into the following two types.
Shod Associolion Fibtes

These fibres connect adjacent gyri to one another
(Fig.28.25).
long Associolion Fibres

These fibres connect more widely separated gyri to one
another. Some examples are:
1- The uncinatefasciculus, connecting the temporal pole
to the motor speech area and to the orbital cortex.
2 The cingulum, connecting the cingulate gyrus to the
parahippocampal gyrus seen on the medial surface.
3 The superior longitudinal fasciculus, connecting the
frontal lobe to occipital and temporal lobes. Fi1.28.26:. Parls of corpus callosum
Short association fibres

Long association fibres
Corpus callosum
Superior longitudinal fasciculus
Fornix
Cingulum tr
Anterior commissure 'd
lnferior longitudinal fasciculus
o
Uncinate fasciculus AI
c
o
O
o
Fi1.28.25:. White fibres of cerebrum U)
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]
I
CEREBRUM
Anterior
limb
Genu
Globus pallidus
of lentiform nucleus
Posterior
limb
External capsule
Thalamus Claustrum lnternal

capsule
Pyramid
Fig.28.28': Boundaries and parts of internal capsule Fig.28.29; Fibres of various parts of internal capsule
The internal capsule is divided into the following ffef*fr*r*s

Parts. Medially: Head of caudate nucleus and thalamus
of the
a. The anterior limb lies between the head Laterally : Lentiform nucleus
caudate nucleus and the lentiform nucleus
(Figs 28.28 and 28.29).
b. The posterior limb lies between the thalamus and Motor fibres
the lentiform nucleus. Corticopontine lie in anterior limb, genu and posterior
c. The genu rs the bend between the anterior and limb (Fig.28.30).
posterior limbs. Frontopontine start from frontal lobe to reach the
d. The retrolentifurm part lies behind the lentiform pontine nuclei where these relay to reach opposite
nucleus. cerebellar hemisphere. These are called corticoponto-
e. The sublentiform part lies below the lentiform cerebellar fibres.
nucleus. It can be seen in a coronal section, whereas Parietopontine and occipitopontine lie in retro-
the rest of the parts are seen in a horizontal section. lentiform part of internal capsule.
Head of caudate nucleus
Frontopontine fibres
Lentiform nucleus
Anterior thalamic radiation
Cortieonuclear fibres
Corticospinal fibres (head and neck)
Corticospinal fibres (upper limb)
Corticospinal (trunk) Corticorubral fibres
Thalamus
Auditory radiation
Superior thalamic radiation
Corticospinal fibres (lower limb)

tr
'6
Optic radiation 6
Medial geniculate body C!
o
o
Fig. 28.30: Fibre components of internal capsule o
o.)
.
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I
BRAIN
Temporopontine lie in sublentiform part of internal Constituent fibres

capsule. The fibres of internal capsule are shown in Fig. 28.30
Pyramidal fibres and presented in Table 28.6.
Corticonuclear to nuclei of III, IV, V, VI, V[, XII and
Blood Supply
nucleus ambiguus for IX, X, XI nerves of opposite side.
Corticospinal: Fibres for anterior horn cells of The arteries supplying different parts of the internal
muscles of head and neck lie in genu. capsule are shown in Fig. 28.31..
Fibres for upper limb, trunk and iower limb lie in
posterior limb of internal capsule in sequential order
(Fig.28.30). Lesions of the internal capsule are usually
Extrnpyramidnl fibres vascular, due to involvement of the medial and
These fibres start from cerebral cortex as corticostriate
lateral striate branches of the middle cerebral
and corticorubral fibres and reach corpus striatum and
artery. They give rise to hemiplegia on the
red nucleus. opposite half of the body (paralysis of one half of
the body, including the face).
Sensory fibres
It is an upper motor neuron type of paralysis
Thalamocortical fibres form thalamic radiations (3rd (Fig. 28.32). The larger lateral striate artery is
order neuron fibres): called, "Charcot's artery of cerebral haemo-
1 Anterior thalamic radiation: Fibres from anterior and rrhage".
dorsomedial nuclei of thalamus terminate in cortex Thrombosis of the recurrentbranch of the anterior
frontal lobe. cerebral artery gives rise to an upper motor neuron
2 Superior thalamic radiation: Fibres of ventral group type of paralysis of the opposite upper limb and
of nuclei of thalamus reach sensory areas of frontal of the face.
and parietal lobes.
A lesion in the genu of the internal capsule would
3 Posterior thalamic radiation: These fibres connect produce sensory and motor loss in the
lateral geniculate body to area 17 forming optic contralateral side of the head. This may not be
radiation.
complete since there is bilateral cortical inner-
4 Inferior thalamic radiation: Connect medial geniculate vation of most cranial nerve nuclei.
body with primary auditory cortex.
Table 28.6: Fibres in the internal capsule

Parl Descending tracts Ascending tracts Arterial supply
Anterior limb Frontopontine fibres (a part of the Anterior thalamic radiation (fibres from 1. Recurrent branch of
(Fis. 28.30) cortico-pontocerebellar pathway) anterior and medial nuclei of thalamus) anterior cerebral
2. Direct branches from
anterior cerebral
Genu Corticonuclear fibres (a part of the Anterior part of the superior thalamic 1. Direct branches from
pyramidal tract going to motor nuclei radiation (fibres from posterior ventral internal carotid
of cranial nerves and forming their nucleus of thalamus) 2. Posterior communicating
supranuclear pathway
Posterior limb 1. Corticospinal tract (pyramidal 1. Superior thalamic radiation 1. Lateral striate branches
tract for the upper limb, trunk and 2. Fibres from globus pallidus to of middle cerebral
Iower limb) subthalamic nucleus 2. Medial striate branches
2. Corticopontine fibres of middle cerebral
3. Corticorubral fibres 3. Anterior choroidal
Retrolentiform 1. Parietopontine and occipitopontine Posterior thalamic radiation made up of: Branches of posterior
part fibres 1. Mainly optic radiation cerebral
2. Fibres from occipital cortex to 2. Parlly fibres connecting thalamus to
tr superior colliculus and pretectal the parietal and occipital lobes
'6
regron
o Sublentiform 1. Parietopontine and temporopontine 1. Auditory radiation 1. Branches of posterior
N
C part fibres cerebral
.o 2. Fibres between temporal lobe and 2. Fibres connecting thalamus to 2. Anterior choroidal
(J
ao thalamus temporal lobe
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CEREBRUM
Recurrent branch of anterior cerebral
Branch of internal carotid

Branch of posterior communicating
]Genu
Branches of lateral and medial striate arteries :

Branch of anterior choroidal lposterior timU
Branch of posterior communicating I
Branch of anterior choroidal I

oart
Branch of posterior cerebrar
lSublentiform
Branches of posterior cerebral

(retrolentiform part)
Fig. 28.31 : Arteries supplying the internal capsule
Human's status as the most highljz evolved animal

so far is due to larger size of the cerebrum,
Upper limb flexed especially the frontal lobes.
Cerebrum comprises 3 borders: superomedial,
inferolateral and medial; 3 surfaces : superolateral,
medial and inferior;3 poles: frontal, occipital and
temporal and 4lobes: frontal, parietal, temporal
and occipital.
Cerebrum receives sensations from the opposite
side of body. It controls the movements of the
opposite side of body, few structures are controlled
by both sides.
Body is represented upside down, only the face
and area ofvocalizalion is represented straight.
Thalamus is the inner chamber receiving and
coordinating motor, sensory, visceral, visual,
Lower limb flexed auditory and emotional impulses.
Fig.28.32 Posture in left sided hemiplegia - Commissural fibre components are anterior
commissure, posterior commissure, habenular
commissure. The largest is the corpus callosum.
DEVETOPMENT These connect identical areas of 2 hemispheres.
Cerebral hemispheres arise as outgrowths from the - Association fibres connect different areas of
lateral wall of prosencephalon during 5-6 weeks. These same hemisphere
gradually enlarge to cover thalamus, midbrain and - Projection fibres connect upper areas of brain
pons. Further growth results in formation of lobes and with lower ones.
poles. Increased growth in a limited area result in Internal capsule is the most typical example of
formation of sulci and gyri. The basal part of the projection fibres.
hemisphere increases in size to form two big nuclei Its posterior limb is supplied by lateral and medial tr
'6
connected together by fibres. These nuclei are the striate arteries. These are end arteries. Blockage or o
caudate and lentiform nuclei. Between these two nuclei haemorrhage of these arteries causes upper motor N
pass fibres both ascending and descending fibres pass. neuron type of paralysis on the opposite side of c
o
These form internal capsule (projection fibres). The the body. o
o
commissural fibres develop in the lamina terminalis. a
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Case 2
Case 1 A 65-year-old person developed tremors in his
A hypertensive old lady of 88 years complained of hands. He cannot eat his food comfortably. His
sever-e headache on hei right side. After two hours movements have slowed down, and walks by
she could not move her left upper and left lower bending forwards. There is mostly a stare in his eyes
limbs. Her voice was also altered. CT scan showed with no emotional expression.
bleeding in the area of internai capsule. . What is the 1ikely diagnosis?
. Where is the lesion in brain responsible for her o \Alhat is the line of treatment?
symptoms? Ans: The likely diagnosis is parkinsonisrn. tr this
. What are the differences between central and condition, there is paucity of move nts r,r,'ith lead-
cortical branches? pipe rigidity. These are also associated with
involuntary movements Iike tremors"
Ans: ere has been a haemorrhage in the area of The line eif treatment is "L-dopa", given as a
internal capsule on right side of the cerebrum, replacement therapy, because deipamine the normal
leading to per motor neuron paraiysis of her left neurotransmitter in globus pallidus is reduced in
upper and lower li s. The lateral striate branches, these conditions. Surgical treatment include
the central branches of rniddle cerebral artery are pallidectomy to control tremors.
most vulnerable to injury.
Case 3
Differences between central and cortical branches :
A 45 years officer complained of resting tremors of
Central Corticaf, his hands, with inability to eat his food. He would
1" ,long, arise Arise gly, thicker walk with a forward bend as it trying to catch centre
in groups in size and shorter of gravity.
2, ese do not ese anastomose . What is the diagnosis and what neurotransmitter
anastomose freely on the surface ' is deficient in such a case?
and end arteries o What are the other features?
3. If these get blocked, If these get blocked, Ans: The patient is suffering from 'parkinsonism'. It
e is large infarct there is small infarct occurs due to degeneration of nigrostriate fibres.
Patient has pill-rolling movements of hands
including resting tr or$, and mask like face.
MULTIPTE CI{OICE AUESTIONS
1. Anterior limit of forebrain is represented by: 5. Brodmann's number given to auditosensory area is:
a. Stria medullaris b. Stria terminalis a. 41.,42 b. 44,45
c. Lamina terminalis d. Stria medullaris thalami c.3,7,2 d. 18,19
, Broca's area is located in: 5. Afferents to lateral geniculate body is:
a. Parietal lobe b. Frontal lobe a. Optic tract
c. Temporal lobe d. Occipital lobe b. Globus pallidus
3. All of following are part of basal ganglia except: c. Auditory fibres from inferior colliculus
a. Caudate nucleus b. Thalamus d. Reticular formation of brainstem
c. Putamen d. Globus pallidus 7. A saucer-shaped nucleus situated between
4. Which of the following structures is related to putamen and insula is:
auditory pathway? a. Claustrum b. Globus pallidus
a. Lateral geniculate body c. Zona incerta d. Subthalamic nuclei
b. Trapezoid body 8. Parkinsonism is due to lesion in:
c c. Medial lemniscus a. Corpus luteum b. Corpus striatum
'6
d, Spinal lemniscus c. Corpus callosum d. Substantia gelatinosa
E
ol
c ANSWERS
o
o
ao) 1.c 2.b 3.b 4.b 5.a 6.a 7.a 8.b
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-Thomos
INTRODUCTION Feotures
Third and lateral ventricles ofbrain secrete the cerebro- The third ventricle is a median cleft between the two
spinal fluid with the help of their choroid plexuses. thalami. Developmentally, it represents the cavity of
Rhinencephalon and limbic system are related to smell the diencephalon, except for the area in front of the
and various visceral activities. interventricular foramen which is derived from the
median part of the telencephalon. The cavity is lined
by ependym a (Fig. 29.I).
COMMUNICATIONS
DISSECTION
ldentify the extent of the third ventricle from the lamina
Anterosuperiorly, on each side, it communicates with
terminalis anteriorly to the upper end of the aqueduct the lateral ventricle through the interventricular
foramen (foramen of Monro). This foramen is bounded
and root of pineal body posteriorly. Examine its anterior
wall, posterior wall, roof, floor and lateral walls.
anteriorly by the column of the fornix, and posteriorly
by the tubercle of the thalamus.
Hypothalamic sulcus
Septum pellucidum
Anterior column of fornix
Tela choroidea of third ventricle
Body of corpus callosum
I nterventricular foramen
Splenium
Genu
Suprapineal recess
Anterior Posterior
Rostrum
lnterthalamic adhesion
Anterior wall Pineal body
Anterior commissure Posterior commissure
Lamina terminalis
Aqueduct
Optic chiasma
Optic recess
Pineal recess
lnfundibular recess
Pons
and infundibulum
Fig. 29.1 : Boundaries of third ventricle
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BRA N
Posteroinferiorly, in the median plane, it com- Note that:

municates with the fourth ventricle through the cerebral a. The interthalamic adhesion connects the medial
aqueduct (Fig.29.7). surfaces of the two thalami and crosses the
ventricular cavity.
RECESSES b. The habenular stria lies at the junction of the roof
Recesses are extensions of the cavity. These are:
and the lateralwall. The two striae joinposteriorly
1 Suprapineal. at the habenular commissure.
c. The columns of the fornix, as already indicated,
2 Pineal. run downwards and backwards to reach the
3 Infundibular (Latin funnel).
mammillary bodies. The columns lie beneath the
4 Optic (Fig.29.1). lateral wall of the ventricle.
BOUNDARIES
Anterior Il The third ventricle is a narrow space which is
L Lamina terminalis. easily obstructed by local brain tumours or by
2 Anterior commissure. developmental defects. The obstruction leads to
3 Anterior columns of fornix. The two columns of the raised intracranial pressure in adults and
fornix diverge, pass dovrnwards andbackwards, and hydrocephalus in infants.
sink into the lateral wall of the third ventricle to reach Tumours in the lower part of the third ventricle
the mammillary body. give rise to hypothalamic symptoms, like diabetes
Posierior ll
insipidus, obesity, sexual disturbance, disturbance
of sleep, hyperglycaemia and glycosuria.
L Pineal body.
The site of obstruction can be found out by CT
2 Posterior commissure (in the lower lamina of the
scan/MRI (magnetic resonance imaging) scans,
pineal stalk).
where, the third ventricle is seen, normally, as a
Cerebral aqueduct.
narrow vertical midline shadow. Dilatation of the
Roof third ventricle would indicate obstruction at a
lower level, e.g. the cerebral aqueduct. If the
It is formed by the ependyma lining the under surface obstruction is in the third ventricle, both the lateral
of the tela choroidea of the third ventricle. The choroid
ventricles are dilated symmetrically. Obstruction
plexus of the third ventricle projects downwards from
at an interventricular foramen causes unilaterai
the roof.
dilatation of the lateral ventricle of that side.
At the junction of the roof with the anterior and
lateral walls, there are the interventricular foramina.
Floor
It is formed by hypothalamic structures: DISSECTION
L Optic chiasma.
Take the right hemisphere and put the tip of the knife at
2 Tubercinerium.
3 Infundibulum (pituitary stalk). the interventricular foramen. Give a vertical incision
4 Mammillary bodies. through the fornix, septum pellucidum, body of corpus
5 Posterior perforated substance. callosum, the medial surface of the hemisphere till the
6 Tegmentum of the midbrain. superomedial border (Fig. 29.2a).
At the junction of the floor with the anterior wall, Turn the brain so that superolateral surface points
there is the optic recess (Fig.29.1). towards you. Continue the previous incision on this
surface lor 2 cm. Carry the incision posteriorly and then
Loterol ll curve it downwards till the end of the posterior ramus
It is formed by the following: of the lateral sulcus (Fig. 29.2b).
1 Medial surface of thalamus (in its posterosuperior Expose the insula by depressing the temporal lobe.
c
'd part). Cut through the medial part of the gyri situated on the
2 Hypothalamus (in its anteroinferior part). superior surface of the temporal lobe till the stem of the
6
C\I 3 The hypothalamic sulcus which separates the lateral sulcus (Fig. 29.2c).
c thalamus from the hypothalamus. The sulcus Now try to separate the f rontal lobe f rom the temporal
.9
() extends from the interventricular f.oramen to the lobe, and open up the stem of the lateral sulcus. Put
ao cerebral aqueduct.
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THIBD VENTBICLE, LATERAL VENTRICLE AND LIMBIC SYSTEM
the knife in the anterior part of stem of the lateral sulcus Feotures
and extend the incision medially to the inferior part of The lateral ventricles are two irregular cavities situated
stem of the lateral sulcus. Keep on opening the cut while one in each cerebral hemisphere. Each lateral ventricle
making it and identify the choroid plexus entering the communicates with the third ventricle through an
inferior horn of the lateral ventricle from its medial side. interventricular foramen (foramen of Monro). Each
Now brain is easily separable into an upper frontal lateral ventricle consists of:
part and a lower occipitotemporal part. Lift the fornix L A central part.
from the thalamus, separating the fornix from the 2 Three horns, anterior, posterior and inferior
choroid plexus. ldentify the choroidal branches of the (Figs 29.3 and 29.4).
posterior cerebral artery.
Cenlrol Port
ldentify structures in all horns of lateralventricle with
the help of the two par1s, i.e. frontal and occipitotemporal This part of the lateral ventricle extends from the
pafts of the cerebral hemisphere. interventricular foramen in front to the splenium of the
corpus callosum behind (Fig. 29.1).
Expose the anterior column of fornix by scraping the
ependyma of anterior part of third ventricle. Trace the ffi*ryr: rd*s
anterior column of fornix till the mammillary body. Trace
Roof
another bundle, the mammillothalamic tract till the
anterior nucleus of the thalamus. It is formed by the undersurface of the corpus callosum
(Fis.2e.5).
Medial
surface
Central part
of lateral
ventricle
Cut edge of
white matter
passing to
Posterior ramus of Hippocampus in temporal lobe
lateral sulcus
inferior horn of
(b) lateral ventricle
Figs 29.2a to c: Drawing to show: (a) The first incision to be made in the dissection to expose the lateral ventricle, (b) the second
paft of the incision to be made in the dissection to expose the lateral ventricle, and (c) the third part of the incision to complete the
exposure of the lateral ventricle
Anterior horn
lnterventricu lar
foramen
Lateral ventrlcle Central part of
Iateral ventricle
Third ventricle
Cerebral aqueduct
Lateral recess tr
Fourth ventricle
'6
E
N
Lateral dorsal C
Central canal o
recess o
o
FiE. 29.3: Ventricles seen from the ventral surface Fi1.29.4: Ventricles of brain (superior view) a
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BRAIN
Septum pellucidum Fornix
Body of corpus callosum Central part of lateral ventricle
Caudate nucleus
Choroid plexuses of lateral ventricle
Stria terminalis
Tela choroidea
Thalamostriate vein
Choroid fissure
Choroid plexus of third ventricle

Thalamus
Third ventricle
Hypothalamus
Fig. 29.5: Boundaries of central part of lateral ventricle and of third ventricle (coronal section)
Floor Posterior horn
It is formed (from lateral to medial side) by:

1 Body of caudate nucleus.
2 Stria terminalis.
3 Thalamostriate vein.
4 Lateral portion of the upper surface of the thalamus'
Anterior
dial zuall
It is formed by: lnterventricular
1 Septum pellucidum. foramen
2 Body of fornix (Fig. 29.5).

Third ventricle
Choroid fissure
The line along which the choroid plexus invaginates
into the lateral ventricle is called the choroid fissure. It Cerebral aqueduct
is a C-shaped slit in the medial wall of the cerebral

hemisphere. It starts at the interventricular foramen Fourth ventricle
(above and in front) and passes around the thalamus
Central canal
and cerebral peduncle to the uncus (in the temporal
lobe). Thus it is present only in relation to the central Fig. 29.6: Ventricle seen from the lateral sudace
part and I ventricle' Its convex
margin i (body and crus), the frontal lobe. It is directed forwards,laterally and down-
fimbria (Fig.29.6) and the wards, and is triangular on cross-section (Fig' 29.7 ).
concave margin is bounded by the thalamus (superior
and posterior surfaces), the tail of the caudate nucleus ffiaun ries
and the stria terminalis (Fig.28.5). At the fissure, the Anterior
pia mater and ependyma come into contact with each Posterior surface of genu and rostrum of the corPus
other and both are invaginated into the ventricle by callosum.
the choroid plexus. Roof
In the central part of lateral ventricle, the choroid Anterior part of the trunk of the corPus callosum.
fissure is a narrow gap between the edge of the fornix
Floor
and the upper surface of the thalamus. The gap is
.E
invaginated by the choroid plexus (Fig. 29.5). 1 Head of the caudate nucleus.
tr 2 Upper surface of the rostrum of the corPus callosum.
AI
E Anterior Hotn Medial
o
o This is the part of the lateral ventricle which lies in front 1 Septum pellucidum.
o 2 Column of fornix.
a of the interventricular foramen and extends into the
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THIRD VENTBICLE, LATERAL VENTRICLE AND LIMBIC SYSTEM
Corpus callosum
Anterior horn of lateral ventricle
Head of caudate nucleus
Lentiform nucleus
Anterior commissure
Fig.29.7: Boundaries of anterior horn of lateral ventricle (coronal section)
Posleriol Horn Tail of caudate

This is the part of the lateral ventricle which lies behind nucleus
the splenium of the corpus callosum and extends into
Stria terminalis
the occipital lobe. It is directed backwards and medially
(Fig.2e.8). Tapetum
Choroid plexus
lnferior horn
Boun rie6 Fimbria of lateral
ventricle
Floor and medial wall
Dentate gyrus
1 Bulb of the posterior horn raised by the forceps Collateral
major. Hippocampus emrnence
2 Calcar avis raised by the anterior part of the calcarine
Collateral
sulcus. sulcus
Temporal lobe
Roof and lateral wall Fig. 29.9: Boundaries of inferior horn of lateral ventricle
Tapetum.
Floor
lnferior Horn
1 Collateral eminence raised by the collateral sulcus
This is the largest horn of the lateral ventricle. It begins (Fig.2e.10).
at the junction of the central part with the posterior horn
2 Hippocampus/ medially.
of the lateral ventricle; and extends into the temporal In the inferior horn, the line of ependymal invagi-
lobe (Fig.29.9). nation by the choroid plexus (i.e. the choroid fissure)
Boun fres
lies between the stria terminalis and the fimbria.
Roof and latsrsl wall
1 Chiefly the tapetum.
2 Tail of caudate nucleus.
3 Stria terminalis. The main objects of primitive life are food and sex. Food
4 Amygdaloid body. is necessary for survival of the individual, and sex, for
survival of the species. The primitive brain is, therefore,
adapted to control and regulate behaviour of the animal
Optic radiation
with regards to seeking and procuring of food,
Bulb of
Cavity of courtship/ mating, housing, rearing of young, rage,
posterior horn aggression and emotions.
posterior
horn The parts of the human brain controlling such
Forceps Tapetum
behavioural patterns constitute the limbic system.
maJor These parts represent the phylogenetically older areas
of the cortex (archipallium and paleopallium) which tr
Calcarine
lnferior longitudinal '6
fasciculus have been grouped in the past with the rhinencephalon
sulcus 6
Occipital lobe of
and were earlier considered to be predominantly o,
Calcar cerebral hemisphere olfactory in function. However, their important role in
.9
AVIS controlling the behaviour patterns is now increasingly o
Fig.29.8: Boundaries of posterior horn of lateral ventricle realized. ao
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BRAIN
Pes hippocampi
Uncus
Hippocampus
Dentate gyrus
Fornix
Cavity of lateral ventricle
Splenium of corpus callosum
Posterior horn of lateral ventricle

Crus of fornix
Alveus and fimbria
Fig. 29.10: Cavity of lateral ventricle including its inferior and posterior horns
Structures comprising limbic system form a ring CONSTITUENT PARIS

along medial wall of cerebral hemisphere. These are 1 Olfactory nerves, bulb, tract, striae and trigone.
interposed between hypothalamus and the neocortex. 2 Anterior perforated substance (Fig. 29.11).
Limbic structures process and monitor emotional 3 Pyriform lobe, consisting of *te uncus, the anterior
aspects of experience and direct emotional resPonses. part of the parahippocampal gyrus, and few small
These aid in understanding the behavioural con- areas in the region.
sequences of our deeds with the help of frontal lobe. 4 Posterior part of the parahippocampal and cingulate
This system helps us to select various events which we gyri.
need to remember. Lesions of limbic system cause 5 Hippocampal formation, including the hippocampus,
disturbances of motivation, memory and emotions as the dentate gyrus, indusium griseumand longitudinal
occurs in schizophrenia. striae (Fig. 29.12).
Olfactory bulb
Olfactory tract
Medial olfactory stria Anterior perforated substance/

intermediate olfactory area
Midbrain
tr
(E Parahippocampal gyrus
E
N
c
.o
o
ao Fig.29.11: Olfactory bulb and olfactory stria
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THIRD VENTRICLE, LATERAL VENTRICLE AND LIMBIC SYSTEM
Corpus callosum Cingulate gyrus
Stria medullaris thalami Anterior commissure
Habenular nuclei
Medial olfactory
Medial forebrain bundle
(septal) area
(septal area to hypothalamus
and brain stem) Olfactory bulb
I nterpeduncular nucleus Olfactory tract
Raphe nuclei of midbrain Lateral olfactory area

(reticular formation)
Entorhinal area
Cortex of uncus and lntermediate olfactory area

amygdaloid body
Fig. 29.12: Some connections of the olfactory cortical areas
5 Amygdaloid nuclei: It is a part of limbic system. 3 It controls emotional behaviour expressed in form
Amygdala evokes anxieq/ and rage. Its afferents are of joy and sorrow, fear, fight and friendship,liking
from olfactory area and from cerebral cortex. Its and disliking, associated with a variety of somatic
efferentpass via stria terminalis and also go to uncus. and autonomic bodily alterations. This requires
Injury to amygdala causes placity, orality and integration of olfactory, somatic and visceral
hypersexuality (Fig. 29.13). impulses reaching the brain.
7 Septal region
8 Fornix, stria terminalis, stria habenularis, anterior IERMS
commissure. Following are the terms with their components related
to limbic system.
FUNCIIONS
1 It controls food habits necessary for survival of the Rhinencepholon
individual. Rhinencephalon comprises the following:
2 It controls sex behaviour necessary for survival of 1 Olfactory mucosa
the species. 2 Olfactory bulb
lndusium griseum and

longitudinal striae
I ndusium griseum continues Anterior nucleus of thalamus

with dentate gyrus Lamina terminalis
Mammillothalamic hact Septal area

Medial olfactory stria/root
Mammillotegmental tract
Olfactory tract
Mammillary body
Olfactory bulb tr
Alveus .G
Dentate gyrus E
Uncus C\I
Amygdaloid body
and stria terminalis c
Hippocampus o
o
o
Fig. 29.13: Fornix and related pathways of limbic system a
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BRA N
Flow chart 29.1a: Olfactory tracts Flow chart 29.1c: Papez circuit
Medial
olfactory root
lobe, insular cortex. These are all concerned with

Flow chart 29.1b: Hippocampus emotional states and behaviour.
Popez Circuil
It interconnects limbic structures, hippocampus, fornix,
Mammillary body mammillary body, mammillothalamic tract, anterior
.o
nucleus of thalamus, cingulate gyrus, cingulum,
E
g(U parahippocampal gyms (Fig. 29.15 and Flow chart29.1.c).
HIPPOCAMPUS
=o
_eE
E
E Fornix
o
Septum pellucidum
Continuous with
Anterior commissure
3 Olfactory tract-3 roots:

Subcallosal area and
a. Medial root ends in subcallosal or parolfactory paraterminal gyrus
gyrus (Flow charl 29.1a).
b. Intermediate root ends in anterior perforated Orbital gyri
substance and diagonal band of Broca (Fig. 29.11). Temporal pole
c. Lateral olfactory root ends in pyriform lobe
Uncus
(uncus, anterior part of parahippocampal gyrus/
cortex in region of limen insulae, dorsomedial Entorhinal cortex
part of amygdaloid nucleus) (Fi9.29.12 and Fig. 29.14: Parts of limbic sYstem
Flow chart 29.1,a).
Connecling Polhwoys
Alveus, fimbria, fornix mammillary body, mammillo-
. HippocamPus can be regarded as the cortical
thalamic tract, stria terminalis (Fig. 29.13).
centre for autonomic reflexes. Hippocampal-
amygdala complex is related to the memory of
Limbic Lobe recent events. Lesions of this complex are
associated with a loss of memory for tecent events
Hippocampus, parahippocampal gyrus, cingulate only. Patient is unable to commit any new facts to
gyrus, subcallosal gyrus, amygdala. These are non-
memory and does not remember recent events. In
neocortical structures (Fig. 29.1,\.
spite of this, his general intelligence remains
Hippocompol Formotion unaltered.
o Destruction of olfactory Rerves results in loss of
Hippocampus, dentate gyrus, part of parahippocampal the sense of smell (anosmia).
G
tr
gyrus (FIow chart 29.1b). . A tumour, usually a meningioma, in the floor of
N anterior cranial fossa may interfere with the sense
C limbic System
o of smell because of presEure on olfactory bulb and
o This is a functioning group.It includes hypothalamus, the olfactory tract. It is necessary to test each
o
a some nuclei of thalamus, tectum of midbrain, frontal
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THIRD VENTRICLE, LATERAL VENTRICLE AND LIMBIC SYSTEM
nostril separately because the olfactory loss is Aqueduct is the narrow duct connecting 3rd
likely to be unilateral. ventricle above with the fourth ventricle below.
A lesion that affects the uncus and amygdaloid Limbic system comprises connections of fornix and
body may cause, "uncinate fits" characterised Papez circuits. These are mostly present on the flat
by an imaginary disagreeable odour, by medial surface of cerebral hemisphere.
movements of lips and tongue, and often by a
"dreamy state".
A patient complained of severe headache and

vomiting off and on for a few months. Later these
Cingulum
Anterior
became persistent. On examination and investigations
thalamic there was a tumour below third ventricle which
Thalamocing u late
tract
nucleus prevented the normal flow of CSF. He also showed
Thalamus papilloedema.
Mamm illothalamic
tract Fornix
. Which organ would usually be involved in tumour?
o Name the nuclei of thalamus.
Mammillary body
Uncus Fornix from
Ans; Mostly the thalanrus is i.nvolved in this case,
Hippocampus hippocampus $inee third venkicLe is a very narr space between
Parahippocampal to mammillary the two thalami, it gets blocked easily cau$ing
gyrus body
headache and vomiting. The meninges and CSF
Fig. 29.15: Uncus and Papez circuit travel along the optic nerve till the optie disc.
raised intracranial pres$ure is projected at the optic
disc in the forrn of papilloedema
Nuclei of thalamus: Antetior, medial anel lateral
group$.
The right and left lateral ventricles communicates
Group lateral is divided into:
with the single third ventricle through the Doroolateral which comprises*lateral dorsal,
interventricular foramen.
lateral po$terior and pulvinar
Third ventricle is a slit like ventricle in between Ventrr:medial which ceimprises-anterior, inter-
the two thalami. mediate and posterior
MULTIPTE CHOICE AUESIIONS
t. Foramen of Monro connects: 4. What is correct form of Papez circuit?

a. Lateral ventricle to 4th ventricle a. Mammillary body - anterior nucleus of thalamus
b. 3rd ventricle to 4th ventricle - cingulate gyrus - hippocampal formation
c. 3rd ventricle to aqueduct b. Mammillary body - cingulate gyrus - anterior
d. Lateral ventricle to 3rd ventricle nucleus of thalamus - hippocampal formation
, Which of the following is largest horn of lateral c. Mammillary body - hippocampal formation -
ventricle? anterior nucleus of thalamus - cingulate gyrus
horn b. trferior horn
a. Posterior d. Anterior nucleus of thalamus - mammillary
c. Anterior horn d. Central part body - cingulate gyrus - hippocampal formation
3. Which is not a part of limbic system? 5. Hippocampal amygdala is related to:
a. Hypophysis cerebri a. Memory for recent events

b. Amygdaloid nuclei b. Movements
c. Olfactory nerve, bulbs, tracts and stria c. Emotional behaviour tr
'6
d. Fornix d. None of the above
o
C\I
c
ANSWERS o
o
1.. d 2.b 3.a 4.a 5.a o
a
i
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T
I
-PSyrcus
INIRODUCTION Oilgin
Course of pyramidal tracts responsible for voluntary Each pyramidal tract contains about one million fibres
movements is described here. The sensory pathways which originate from:
for exteroceptive, unconscious and conscious 1 The motor area 4 of the cortex,
proprioceptive are outlined. 2 Premotor area 6 and also
3 The somesthetic areas 3,2,7.
PYRAMIDAI IRACT: CORTICOSPINAL Certain notable features of the motor cortex are given.
AND CORTICONUCLEAR TRACTS L The body is represented upside dor,rm. The areas for
This is a descending tract, extending from the the legs and perineum lie in the paracentral lobule.
cerebral cortex to various motor nuclei of the cranial 2 The angle of mouth, tongue,larynx, the thumb and
and spinal nerves. It constitutes the upper motor the great toe are represented by relatively large
neuron in the motor pathway from the cortex to areas.
voluntary muscles. 3 It is the movements which are represented in the
Corticonuclear fibres reach the nuclei of cranial cortex rather than the individual muscles.
nerves (Fig. 30.1).
Coulse
Facial area of The tract passes through the following parts of the CNS.
motor cortex L Corona radiata.
2 Internal capsule, occupying the genu and the
posterior limb
3 Middle two-thirds of the crus cerebri of the midbrain.
4 Basilar part of the pons.
5 Pyramid of the medulla. In the lower part of the
medulla, about 75 to 80% of the fibres cross to
opposite side and descend as the lateral (crossed)
Oculomotor nucleus
corticospinal tract. About 20"/. flbres remain
uncrossed and run down as the anterior (uncrossed)
Trochlear nucleus
corticospinal tract (see Fig. 23.1,1).
Trigeminal nucleus 6 Thus in the spinal cord, there are two corticospinal
tracts: Lateral (crossed) and anterior (uncrossed).
Upper face (bilateral)
Ultimately most of the uncrossed fibres also cross to
the opposite side before termination (see Fig.23.72).
Lower face (crossed)
Ambiguus nucleus
Terminotion
Hypoglossal nucleus Before termination, all fibres of the pyramidal tract cross
to opposite side. They terminate, mostly through an
Fig. 30.1: Pathway of corticonuclear fibres interneuron, in the motor nuclei of cranial nerves and
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SOME NEURAL PATHWAYS AND RETICULAR FORMATION
in relation to the anterior horn cells of the spinal cord. PATH OF PAIN AND TEMPERAIURE
The fibres which terminate in the motor nuclei of the Receptors
cranial nerves collectively form the corticonuclear tract.
1 Free nerve endings for pain.
Functions
2 End bulbs of Krause for cold.
3 Organs of Ruffini for warmth, and of Golgi-Mazzoni
1 The pyramidal tract is concerned with voluntary for heat.
movements of the body.
2 Possibly, it is also the pathway for superficial First Neuron
reflexes. First neuron is located in the dorsal root ganglia.
Peripheral processes of neurons in the ganglia
constitute the sensory nerves. These processes end in
. Effects of lesion of the pyramidal tract: relation to the receptors. The central processes of the
Lesions above the level of decussation cause neurons pass through the dorsal nerve roots to enter
contralateral paralysis (Fig. 30.2), while lesions the spinal cord, where they synapse with the second
below the decussation cause ipsilateral paralysis. neuron.
It is an upper motor neuron type of paralysis
which is characterizedby the following. Second Neulon
a. Loss of the power of voluntary movements. Second neuron is located in the grey matter of the spinal
b. Clasp-knife type of rigidity (hypertonia). cord. Their axons form the lateral spinothalamic tract.
c. Tendon reflexes are exaggerated. This tract is crossed. It ascends through the lateral white
d. Superficial reflexes are lost. column of the spinal cord to enter the brainstem. Lr the
e. Babinski's sign is positive. brainstem, this tract is referred to as the spinal
f. Reaction of degeneration is absent. Iemniscus to end in the thalamus (Figs 30.3a and b).
Third Neuron
Lower limb
Third neuron lies in the posterolateral ventral nucleus
of the thalamus. Fibres arising in this nucleus pass
Upper limb through the internal capsule and the corona radiata to
Motor cortex reach the somatosensory areas 3,1,2 oI cerebral cortex.
Mouth
PATH OF TOUCH
Basal Receptols
ganglia
1 Tactile (Messiner's) corpuscles.
2 Merkel's discs.
3 Free nerve endings around the hair follicles.
Cerebellum first Neuron
First neuron is similar to that for pain and temperature
Decussation of pathway. The 2nd neuron is different for fine touch and
pyramids (medulla) for crude touch.
Quadriplegia/
Lateral corticospinal tetraplegia
E
o
tract (pyramidal)
PATH OF FINE TOUCH
Upper lipbs
t.c 1 The central processes of the neurons in the dorsal
o- nerve root ganglia enter the posterior white column
ct)
Paraplegia of the spinal cord and form the fasciculus gracilis and
the fasciculus cuneatus. These are uncrossed tracts.
2 The second neuron lies in the nucleus gracilis or
nucleus cuneatus. It gives off the internal arcuate tr
G
fibres which cross to the opposite side through the E
Skeletal muscle sensory decussation. Reaching the other side they OJ
of lower limbs run upwards as the medial lemniscus. The medial C
.o
lemniscus ends in the posterolateral ventral nucleus o
Fig. 30.2: Effects of damage to motor pathway Q)
of the thalamus. a
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BRAIN
Cerebral hemisphere PATH OF PROPRIOCEPTIVE (KINAESTHETIC)

IMPULSES
Caudate nucleus Receptors
lnternal capsule 1 Muscle spindles
2 Golgi tendon organs
3 Pacinian corpuscles
Trigeminal lemniscus 4 Uncapsulated nerve endings.
Fifth nerve First Neulon
sensory nucleus
Medial lemniscus First neuron is similar to that for pain and temperature.
and lateral In their further course, the proprioceptive pathways
Pain from face
spinothalamic are different for conscious and unconscious impulses.
tract or spinal
lemniscus
L.--
PATH FOR CONSCIOUS
Medulla PROPRIOCEPTIVE IMPULSES
Nucleus gracilis
Medial lemniscus Their course is similar to that for fine touch described
Nucleus cuneatus
Lateral earlier.
Posterior columns spinothalamic
(no relay) tract PATH OF UNCONSCIOUS
PROPRIOCEPIIVE IMPUTSES
Spinal cord These impulses end in the cerebellum (see Figs23.L6
Lateral and23.17).
spinothalamic
tract
1 The first neuron has been described above.
2 The second neuron fibres are represented by three
tracts, namely the posterior and anterior spino-
cerebellar tracts (from the lower limb and trunk) and
Lateral
spinothalamic
the cuneocerebellar tract (posterior external arcuate
kact (pain and fibres) from the upper limb.
temperature) The posterior spinocer ebellar tr act contains ipsilateral
fibres arising in dorsal (thoracic) nucleus of the spinal
cord. It enters the ipsilateral cerebellar hemisphere
through the inferior cerebellar peduncle.
(b)
The anterior spinocerebellar tract is made up mainly
of crossed fibres arising from the spinal grey matter
Flgs 30.3a and b: Pathway of: (a) Pain and temperature (posterior grey column). The fibres ascend to the upper
impulses, and (b) posterior column
part of pons and then fum dor,rm into the superior cere-
bellar peduncle to reach the cerebellum of same side.
3 Fibres starting in the thalamus pass through the The cuneocerebellar tract (posterior external arcuate
internal capsule and the corona radiata and end fibres), is functionally similar to the posterior
in the somatosensory area of the cerebral cortex spinocerebellar tract. It arises from the accessory
(areas 3,7,2). (extemal) cuneate nucleus which receives afferents from
the fasciculus cuneatus. The tract enters the ipsilateral
PATH FOR CRUDE TOUCH cerebellar hemisphere through the inferior cerebellar
1 The central processes of neurons in the dorsal nerve peduncle.
root ganglia terminate in the grey matter of the spinal
cord. TASIE PATH
2 The second neuron lies in the spinal cord (mainly L The taste from anterior two-thirds of tongue except
the posterior grey column). Axons of those neurons from vallate papillae is carried by chorda tympani
(E
E
cross the midline and form the anterior spino- branch of facial till the geniculate ganglion. The
N thalamic tract. In the brain stem, this tract merges central processes go to the tracfus solitarius in the
C
o
with the medial lemniscus. medulla (Fig.30.a).
C) 3 The third neuron and termination of the pathway 2 Taste from posterior one-third of tongue including
ao are the same as for fine touch. the vallate papillae is carried by cranial nerve IX till
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SOME NEURAL PATHWAYS AND RETICULAR FORMATION
From receptors in palate and nasopharynx
Pterygopalatine ganglion
Pterygoid canal
Geniculate ganglion
o Lingual nerve
(o
to
t_
o
o
o
o From taste receptors in anterlor
f
o twothirds of tongue and oral cavity
o
Submandibular ganglion
,o
F
Jugular foramen
From taste receptors in posterior one-third of tongue

and oropharynx
From taste receptors in epiglottis and pharynx
Fig. 30.4: Taste pathway
the inferior ganglion. The central processes also reach 3 It is better defined physiologically than anatomically
the tractus solitarius. (see Figs 25.5,25.12 and 25.13).
3 Taste from posterior most part of tongue and
epiglottis travel through vagus nerve till the inferior CONNECTIONS
ganglion of vagus. These central processes also reach The reticular formation is connected to all the principal
tractus solitarius. parts of the nervous system, including the motor,
4 After a relay in tractus solitarius, the solitario- sensory and autonomic pathways with their centres.
thalamic tract is formed which becomes a part of The connections are reciprocal (to and fro) providing
trigeminal lemniscus and reaches the ventro- feedback mechanisms. Thus the reticular formation is
posteromedial nucleus of thalamus of opposite side. connected to:
Another relay here takes the fibres to lowest part of 1 The motot neurons of the cerebral cortex, the basal
postcentral gyrus, which is the area for taste. ganglia, the cerebellum, various masses of grey
matter in the brain stem including the nuclei of
cranial and spinal nerves.
2 The sensory neurons of the somesthetic pathways
The reticular formation is a diffuse network of fine (cortex, thalamus and spinal cord), visual pathway,
nerve fibres intermingled with numerous poorly auditory pathway, and equilibratory pathways. In
defined nuclei. Phylogenetically, it is very old: in this group, the ascending reticular actiaating system
primitive vertebrates, it represents the largest part of (ARAS) is of prime importance.Itis formedby agreat
the CNS. In man, it is best developed in the brainstem, number of collaterals from the spinothalamic,
although it can be traced to all levels of the CNS. trigeminal and auditory pathways to the lateral parts
of the reticular formation, which themselves project .=
LO ION AND IDENIIry to the reticular and intralaminar nuclei of the
(E
6
1 The reticular formation, in general, is placed in the thalamus. These nuclei, in turn, project to N
deep and dorsal parts of the neural axis. widespread area of cerebral cortex.
.o
2 It is very diffuse in its distribution, and has ill-defined 3 The autonomic neurons of the hypothalamus, limbic o
boundaries. system and the general visceral efferent columns. a0)
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BRAIN
FUNCT!ONS narcotics used and its dosage. Narcotics depress the

lnhibitory ond Focilitotory lnfluences diffuse thalamocortical system as well.
Barbiturates depress the afferent impulses reaching
Through its connections with the motor areas of the
the reticular-activating pathways.
nervous system, certain areas of the reticular formation
Analgesics act by suppression of reactions concemed
inhibitvoluntary and reflex activities of thebody, while
with activation of reticular-activating pathways.
certain other areas facilitate them.
Morphine suppresses the corticoreticular pathways,
and stimulates the nonspecific thalamic system,
Stote of Arousol, Generol reness ond Alertness
rhinencephalon and its projections. It also depresses
The ascending reticular activating system (ARAS) is conduction along specific sensory pathways.
responsible for maintaining the state of wakefulness
and alertness, by its connections with a great number
of collaterals from sensory tracts. Thus sensory percep-
tion of any type is quickly and acutely appreciated, so . Corticonuclear fibres give fibres to cranial nerve
that an appropriate motor response by the body may nuclei.
be synthesized and actuated. The corticonuclear fibres of one side of cortex reach
Sleep is a normal, periodic inhibition of the reticular VII nerve nucleus of both sides which supply the
formation. Hypnotics and general anaesthetics produce muscles of upper half of face on both sides. It also
their effects by acting on this system. gives fibres to nucleus of VII and supply to lower
half of facial muscles only on the contralateral side.
Aulonomic lnfluences Unconscious impulses reach ipsilateral cerebellum,
Through its autonomic connections and certain specific while conscious impulses reach the contralateral
centres, the reticular formation influences respiratory cerebrum.
and vasomotor activities. They are stimulated or Anterior spinothalamic carrying crude touch and
suppressed according to the needs. pressure joins the medial lemniscus during its
Through its connections with the limbic system, it upward journey through the brain stem. Thus
participates in regulating emotional, behavioral and medial lemniscus carries conscious proprioceptive
visceral activities. It also takes part in neuroendocrine sensations, i.e. movement, vibration and position
regulation and the development of conditioned and including whole touch and pressure to the thalamus.
learned reflexes. Nucleus of tractus solitarius receives impulses of taste
through chorda tlrmpani, branch of VII from most of
ACTION OF DRUGS anterior two-thirds of tongue; through glosso-
phanTngeal from circumvallate papillae and posterior
1 Narcotics act more on nonspecific sensory system one third of tongue. It also receives impulses from
and less on the specific sensory system. Their main posterior most part of tongue and vallecula via
action is depression of reticular activating system, intemal laqmgeal branch of vagus nerve.
precise effects of which depend upon the type of
MUITIPIE CHOICE AUESTIONS

1. Nucleus receiving impulses of taste: 3. Ascending reticular activating system is formed by:
a. Dorsal nucleus of vagus a. Great number of collaterals from spinothalamic
b. Spinal nucleus of trigeminal nerve tract
c. Nucleus ambiguus b. Trigeminal lemniscus
c. Auditory pathway
d. Tractus solitarius
d. All of these
2. Action of barbiturates are:
4. Upper motor neuron type of paralysis is charac-
a. It suppresses the corticoreticular pathways terizedby:
b. Increases the activity of reticular activating system a. Clasp knife type of rigidity
c. Depresses the afferent impulses reaching b. Tendon reflexes are exaggerated
tr
(E reticular activating pathway c. Babinski's sign positive
o d. None of these d. All of these
(\I
co ANSWERS
O
ao 1.d 2.c 3. d 4.d
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I
S Holsted
-Williom
INIRODUCTION very large and is called the arteria radicularis magna.Its

The nervous tissue is too delicate to bear anoxia beyond position is variable. This artery may be responsible for
three minutes. The blood supply to nervous tissue per supplying blood to as much as the lower two-thirds of
unit tissue is maximum in the body. It shows the the spinal cord.
importance of the grey matter. The blood supply may The veins draining the spinal cord are arranged in
be erratic due to haemorrhage, thrombosis or embolism the form of six longitudinal channels. These are
of the arteries supplying the nervous tissue. Further anteromedian and posteromedian channels that lie in
the arteries are "end arteries" once these reach the the midline; also anterolateral and posterolateral
deeper level. Neurons die, in bits and pieces; an channels that are paired. These channels are
individual also walks slowly and steadily towards interconnected by a plexus of veins that form a venous
death, and that is the end of this physical life. vasocorona. The blood from these veins is drained by
radicular veins that open into a venous plexus lying
between the dura and the vertebral canal (epidural or
internal vertebral plexus) and through it into various
segmental veins.
The spinal cord receives its blood supply from three
longitudinal arterial channels that extend along the
length of the cord. The anterior spinal artery is present
in relation to the anterior median sulcus. Two posterior Anterior spinal artery supplies anterior two-thirds
spinal arteries (one on each side) run along the while posterior spinal artery supplies posterior one-
posterolateral sulcus (i.e. along the line of attachment third of spinal cord. Posterior column gets affected
of the dorsal nerve roots). In addition to these channels, in posterior spinal artery thrombosis. Anterolateral
the pia mater covering the spinal cord has an arterial columns get affected in anterior spinal artery
plexus (called the arterin aasocorona) which also sends thrombosis (Fig. 31.2).
branches into the substance of the cord (Fig. 31.1).
The main source of blood to the spinal arteries is from
the vertebral arteries (from which the anterior and
posterior spinal arteries take origin). However, the
blood from the vertebral arteries reaches only up to the Two vertebral and two internal carotid arteries carry
cervical segments of the cord. The spinal arteries also the total arterial supply to the brain.
receive blood through radicular arteries that reach the
cord along the roots of spinal nerves. These radicular VERTEBRAL ARTERIES
arteries arise from spinal branches of the vertebral, The vertebral artery on each side is a branch of first
ascending cervical, deep cervical, intercostal, lumbar part of subclavian artery.Its course is divided into four
and sacral arteries. parts:
Many of these radicular branches are small and end o 1st part lies from its origin to the foramen
by supplying the nerve roots. A few of them, which transversarium of 6th cervical vertebra.
are larger, contribute blood to the spinal arteries. o 2nd part courses through foramen transversaria of
Frequently, one of the anterior radicular branches is 6th to 1st cervical vertebrae (Fig. 31.3).
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BRAIN
Posteromedian vein It enters the subarachnoid space in the upper part of

Posterior
Posterior median vertebral canal after piercing the dura mater and
spinal artery septum arachnoid mater. Then it curves round the
Posterolateral ventrolateral aspect of the medulla oblongata
Posterior horn veln between the rootlets of hypoglossal nerve/ to unite
Posterior with its fellow at the lower border of pons and forms
funiculus
the median basilar artery.
Lateral horn Lateral
funiculus Introcloniol Blonches
Anterior horn
Fesferlor $p inal Arfe ry
Anterior median
Anterior
fissure
funiculus
It is the first intracranial branch. It passes inferiorly on
Anterior
the spinal medulla among dorsal roots of spinal nerves
Anterolateral
spinal artery veln (Fig.31.a).
Anteromedian vein
Fig. 31.1: Blood supply of spinal cord
PosferiorfmferiorCerebellar A tY
It is the largest branch which arises from vertebral
artery after it pierces the meninges. It pursues a tortuous
course, passes between rootlets of hypoglossal, vagus
Posterior spinal
artery territory and glossopharyngeal nerves supplies almost lateral
half of medulla as far as the lower border of pons,
reaches its posterior aspect between the thin roof of
cavity of fourth ventricle and cerebellum, gives a
choroidal branch to the choroid plexus of fourth
ventricle and turns downwards on the cerebellum
supplying it.
Anterior spinal
AnfenorSpinal Arlary
artery territory It is formed by the union of a branch from each vertebral
artery on ventral surface of medulla oblongata close to
the pons. It supplies the median part of medulla
Fig. 31 .2: Thrombosis of the anterior spinal artery
oblongata and continues inferiorly throughout the
length of spinal medulla/cord (Fig. 31.1).
Me llary Branehes
Ophthalmic As vertebral artery ascends along medulla oblongata,
artery
Posterior it gives number of branches to the medulla oblongata.
cerebral
artery
iMenrn a/ Eronches
Basilar A few meningeal branches are given.
Posterior
artery
communicating
Junction of
artery BASILAR ARIERY
External
vertebral
arteries carotid
It is formed by the union of two vertebral arteries
at the lower border of pons. It lies in the median Sroove
lnternal of pons in cisterna pontis and at the upper border of
carotid
Vertebral pons ends by dividing into two posterior cerebral
artery Common
carotid
arteries.
tr Fig. 31.3: Carotid and vedebral arteries Bronches

'6
E
I Anterior i rior cerebellar artery: It arises at the lower
(\I
a 3rd part lies on the posterior arch of atlas vertebra. border of pons, and passes laterally, supplying the
Ea 4th part of the vertebral artery enters the cranium sixth, seventh and eighth cranial nerves. It then loops
o
o through foramen magnum under the free margin of over the flocculus of cerebellum and supplies
o
a posterior atlanto-occipital membrane. anteroinferior aspect of cerebellum.
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BLOOD SUPPLY OF SPINAL CORD AND BRAIN
Posterior communicating
Posterior cerebral
Superior cerebellar
Roots of trigeminal nerve
Labyrinthine
Anterior inferior
cerebellar
Medullary
Meningeal
Anterior spinal Vertebral
Fig. 31.4: Arteries related to brain stem
Labyrinthine artery: It accompanies the vesti- surface of midbrain and then curve posterolateral
bulocochlear nerve and enters the internal auditory to midbrain at inferomedial surface of corresponding
meatus to supply the internal ear. It is an end artery. hemisphere supplying it with cortical branches.
Pantine brsnches: These are numerous slender p o st er ior cer ebr al arle rie s
Br a n ches of
branches which pierce the pons both in the medial 'l., Pasteromedisl centrsl brnnclrcs: These pierce ventral
and lateral parts (Fig. 31.4).
surface of base of brain thus forming the posterior
Suyeriar cerebellar artery: It arises close to superior perforated substance inthe interpeduncular fossa. These
border of pons. It winds posteriorly along the supply midbrain and caudal part of diencephalon.
superior border of pons and middle cerebellar 2 Posterior charoidsl arfet'y: Arises on the lateral aspect
peduncle supplying both. It sends many branches of central branches, supplies choroid plexus of the
to the superior surface of cerebellum. lateral ventricle and the third ventricle.
o terminal posterior cerebralbranches dirterge nt upper 3 Cortical branches namely temporal branches, parieto-
border of pons: These give rise to number of central occipital branch and occipital branch to cerebral
(posteromedial group) branches into the ventral cortex as shown in Figs 31.5a and b.
Posterior
cerebral artery
Basilar artery
Temporal branch
Central branches
Posterior choroidal
Occioital branch
' Yostenor
Calcarine branch cerebral artery
.E
Central branch IE
Temporal branch
Calcarine o
branch C\I
(a) (b) E
.9
Figs 31.5a and b: Posterior cerebral artery on: (a) lnferior surface of left cerebral hemisphere, and (b) medial sudace of right cerebral o
hemisphere ao
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BRAIN
X nuclei and
Thrombosis of posterior cerebral artery results nerve
in homonymous hemianopia on the opposite side. Sympathetic
fibres
Thrombosis of superior cerebellar artery results
in Fig. 31.6.
Xll nucleus and
a. Cerebellum: Disturbed gait,limb ataxia. emergrng nerve
b. Brain stem: Ipsilateral Horner's s)mdrome.
Contralateral sensory loss-pain and tem- V nerve nucleus
perature (including face). and tract
Damage to anterior inferior cerebellar artery Spinothalamic
results in Fig. 31.7. tract
a. Cerebellum: Ipsilateral limb ataxia.
b Brain stem: Ipsilateral-Homer's syndrome.
Sensory loss-pain and temperature of face. Fig. 31.8: Effects due to thrombosis of posterior inlerior
Facial weakness and paralysis of lateral gaze. cerebellar artery
Contralateral sensory loss-pain and tem-
perature of limbs and trunk.
Thrombosis of posterior inferior cerebellar artery INTERNAT CAROTID ARTERY
causes damage as given in Fig. 31.8: Each internal carotid artery enters the cranial cavity
a. Cerebellum: Dysarthria, ipsilateral limb ataxia, after traversing the carotid canal and superior aspect
vertigo and nystagmus (due to damage to of foramen lacerum. It then courses through the
vestibulo-fl occular connections). cavernous sinus, pierces the dural roof of sinus and
b, Brain stem: Ipsilateral-Horner's slmdrome. ends immediately lateral to optic chiasma and inferior
Sensory loss-pain and temperature of face.
to anterior perforated substance and divides into
Pharlngeal and laryngeal paralysis. middle and anterior cerebral arteries.
Contralateral sensory loss-pain and tem-
perature of limbs and trunk. Blonches
I Posterior conrmunicating artery: It passes posteriorly
across the crus cerebri to join the posterior cerebral
artery and helps to complete the arterial circle' It
gives branches to the crus cerebri, optic ttact,
hypophysis and hypothalamus.
Anterior choroidal artery: It passes posterolaterally,
supplies crus cerebri and turns laterally to the medial
aspect of temporal lobe to supply choroid plexus of
inferior horn of lateral ventricle.
Anterior cerebrul artery: It is a terminal branch of
intemal carotid artery and runs above the optic nerve
Fig.31.6: Effects due to thrombosis of superior cerebellar artery to follow the curve of corpus callosum. Close to its
origin, thi
Vl nucleus municating
supply part
Cortical br
Sympathetic hemisphere by giving:
a. Orbital
Vll nucleus and
emerging nerve b. Frontal
V nucleus c. Parietal branches (Fig. 31.9).
tr and tract
'd
E Spinothalamic
(\I tract the internal carotid artery (Figs 31.10a and b). It runs
laterally in the s s off:
o
o
Fig. 31.7: Effects due to damage to anterior inferior cerebellar a. Deep or per suPPlY
o
a artery anteiior limb of basal
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BLOOD SUPPLY OF SPINAL COBD AND BBAIN
The circulus arteriosus attempts to equalize the flow

Area for of blood to different parts of brain and provides a
micturition collateral circulation in the event of obstruction to one
and leg of its components. There is hardly any mixing of blood
streams on right and left sides of the circulus arteriosus
(Fig. 31.12).
Corpus
callosum BRANCHES
The branches of the circulus arteriosus are cortical and
the central. Cortical or external branches run on the
surface of the cerebrum, anastomose freely and if these
get blocked they give rise to small infarcts.
The central branches perforate the white matter to
supply the thalamus, the corpus striatum, and the
Fig. 31.9: Medial surface of right cerebral hemisphere
anterior cerebral aftery
Cortical branches
of middle cerebral
nuclei. The artery then passes out to the lateral artery in lateral
surface of hemisphere at the insula of the lateral sulcus
sulcus. It ends by giving cortical branches. Coriical branches
b. Temporal (Fig. 31.11) of anterior
cerebral artery
c. Frontal and
d. Parietal branches. Middle
cerebral
artery
Posterior
cerebral
It is an arterial circle, situated at the base of brain in Segments
artery
the interpeduncular fossa. It is formed by the anterior of internal
and middle cerebral branches of internal carotid and carotid aftery:
the posterior cerebral branches of basilar artery. Cerebral
Cavemous
FORMATION
The two anterior cerebral arteries are connected by Petrous
anterior communicating artety; the middle and Cervical

posterior cerebral arteries of same side are united by Fig. 31.11: The cortical branches of three cerebral arteries
the posterior communicating artery. illustrated on the lateral surface of cerebral hemisphere
Motor cortex
Sensory cortex
Trunk, upper
limbs, face, lips,
mouth
Parietal
lnternal
capsule Wernicke's
speech area
tr
Temporal
'6
Temporal
lobe
Middle
o
Middle cerebral artery (\I
cerebral artery c
(a) o
o
o
Figs 31.10a and b: (a) Deep branches of middle cerebral artery, and (b) cortical branches of middle cerebral artery U)
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BRAIN
Anterior cerebral of cerebral haemorrhage. It suPplies internal

capsule which has motor fibres for one side of the
Anterior
communicating body.
c. Posterolateral ar thalamogeniculnte: They supply
lntemal carotid
thalamus and geniculate bodies.
d. Pasteromedial supply thalamus and hypothalamus.
Middle cerebral
Important arteries of the brain are shown in Table 31.1.
Posterior
communicating
Posterior cerebral
Thrombosis of lateral striate branches of middle
Basilar
cerebral artery causes motor and sensory loss
to most of the opposite side of body except lower
Vertebral
limb.
Anterior spinal Hemiplegia is a common condition. It is an uPPer
motoi neuron type of paralysis of one-half of
Fig. 31 .12: Arteries seen on the inferior surface of brain It is usually due to
used by thrombosis
branches of middle
internal capsule. These do not anastomose and if these cerebral artery (cerebral thrombosis) (Fig. 31'14).
get blocked, they give rise to large infarcts.
One of the lenticulostriate branches is most
The central branches are arranged in six grouPs: frequently ruptured (cerebral haemorrhage); it is
a. Anteranredial: The largest branch is called the known as Charcot's artery of cerebral haemo-
medial striate or recurrent artery of Heubner. It rrhage. This lesion also produces hemiplegia with
supplies corpus striatum and internal capsule deep coma, and is ultimately fatal.
which has motor fibres lor face, tongue and Thrombosis of Heubner's recurrent branch of the
shoulder (Fig. 31.13). anterior cerebral artery causes contralateral upper
b. Anterolateral:These are in two groups. The largest monoplegia.
branch is called lenticulostriate or Charcot's artery
Anterior cerebral artery

Anterior communicating artery Anteromedial group
lnternal carotid aftery

Recurrent branch of anterior cerebral artery
Anterior choroidal artery
Middle cerebral artery

Anterolateral group
Posteromedial grouP Posterior communicating afiery
' Posterior choroidal artery Posterior cerebral artery
Posterolateral grouP
Superior cerebellar artery
Basilar artery
Labyrinthine artery
Pontine branches
Anterior inferior cerebellar artery

Posterior inferior cerebellar artery
tr Posterior spinal
G
6 Anterior spinal artery
Meningeal artery
N
co Medullary artery Vertebral artery
o
o
a Fig.31.13: Circle of willis and the branches of arteries supplying the brain
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BLOOD SUPPLY OF SPINAL CORD AND BRAIN
Occhrsion proximal to the anterior communicating ARTERIAT SUPPTY OF DIFFERENT AREAS

artery is normally well tolerated because of the Cerebrol Coilex
cross flow (Fig, 31.15a). Cerebral cortex is supplied by branches of all three
Distal occlusion results in weakness and cortical cerebral arteries. All the three surfaces receive branches
sensory loss in the contralateral lower limb with from all three arteries.
associated incontinence (Fig. 31.15b).
Middle cerebral is main artery on superolateral
Thrombosis of the paracentral artery (terminal
surface (Fig. 31.16).
cortical branch of the anterior cerebral artery)
Anterior cerebral artery is chief artery on medial
causes contralateral lower limb monoplegia.
Table 31.1: lmportant arteries of brain

Artery Origin Course Cortical branches Central branches
Middle cerebral Larlgest and direct ln the lateral sulcus and on 1. Orbital AL* central branches,
(Fig. 31.10) branch of ICA the insula 2. Frontal arranged as medial
3. Parietal and lateral striate artery
4. Temporal in two groups (Fig. 31.13)
Anteriorcerebral Smallerterminal Coextensive with corpus 1. Orbital AM* central branches,
(Fig. 31.9) branch of ICA callosum. Two arteries are 2. Frontal including a Heubner's
connected by the anterior 3. Parietal, including recurrent artery in one
communicating artery paracentral artery group
Posterior cerebral Terminal branch of Winds round cerebral . Temporal
'l 1. PM. central branches
(Fig. 31.5) basilar artery peduncle to reach the 2. Occipital rn one group
tentorial surface of cerebrum 3. Parieto-occipital 2. PL* central branches
in two groups
Posterior inferior Largest branch of rortuous course in relation lt supplies:
cerebellar vedebral artery of olive, lower border of pons 1. Posterolateral part of medulla
and vallecula of cerebellum 2. Lower part of pons
3. lnferior surface of cerebellum
*
AL = anterolateral; AM = anteromedial; PM = posteromedial; pL = posterolateral
Anterior
cerebral
artery
Occlusion
Anterior
(a) communicating (b)
artery
Figs 31.15a and b: Effects of occlusion of anterior cerebral artery
Posterior cerebral is principal artery on inferior

Cerebellum
The little brain is supplied by:
1 Superior cerebellar (Fig. 3i.19)
2 Anterior inferior cerebellar tr
.E
3 Posterior inferior cerebellar arteries. E
N
BIOOD-BRAIN BARRIER c
o
Fig, 31 .14: Posture of hemiplegic person The constituents of CSF are not exactly same as those o
o
of extracellular fluid (ECF) elsewhere in the body. Many a
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BRA N
Posterior cerebral
adery
Fig. 31 .16: Arterial supply of superolateral surface of cerebral Fig. 31 .19: Arterial supply of opened up cerebellum
hemisphere
Anterior cerebral arterY large molecular substances hardly pass from blood to
CSF or interstitial fluids of brain even though these can
pass to ECF of the body thereby reflecting the existence
of BBB.
The existence of a 'blood-brain barrier' (BBB or
haematoencephalic barrier) is due to the fact that the
endothelial cells of brain capillaries are held to each
other by tight junctions. The BBB is formed by
structures between the blood and nerve cells of brain'
The blood in the lumen of the capillary is separated
from the neurons by:
a. Capillary endothelium.
b. Basement membrane of endothelium.
Posterior cerebral artery
c. Intimately applied to the capillaries there are
numerous processes of astrocytes and it has been
Fig. 31.17: Arterial supply of medial and tentorial surfaces of
estimated that these Processes cover about 80%
cerebral hemisphere
of the capillary surface.
Some areas of brain are devoid of blood-brain
ba
ch
Anterior Middle
of
cerebral cerebral to certain substances than it is in adult.
artery artery
Funclions of Blood-Broin Botriel
Circle 1 To modulate entry of metabolic substrates notably
of Willis glucose.
2 It allows entry of gases/ water, electrolytes, amino
acids and lipid soluble substances.
Posterior
3 It restricts entry of macromolecules that is lipid
cerebral insoluble substances and thus blocks entry of toxins
tr ariery as either these are bound to the plasma albumin or
(E
their solubilities are inappropriate.
o 4 It blocks entry of transmitters from blood, notably
N
of epinephrine.
o
o 5 The drugs like penicillin, noradrenaline and
o thiopentone cannot cross it.
a Fig. 31.18: Afterial supply of inferior surface of cerebral hemisphere
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BLOOD SUPPLY OF SPINAL CORD AND BBAIN
6 Some drugs like atropine, chloramphenicol,

tetracycline and sulfas cross the barrier easily.
7 Its other important function is to pump ions- CHARACTERISTICS OF THE VEINS
notably potassium into and out of the blood.
8 Entry of hormones is restricted to certainplaces only,
1 The walls are devoid of muscle.
so that normal biological rhythm of the body is 2 The veins have no valves.
maintained. 3 To maintain patency, some of them open into the
cranial venous sinuses against the direction of blood
flow in the sinus, e.g. the superior cerebral veins
draining into the superior sagittal sinus.
The perivascular spaces (Virchow-Robin) are extensions
of subarachnoid space around vessels penetrating the GROUPS OF VEINS
brain surface. The spaces taper progressively. Although
these are inward extensions in anatomical sense. The Exlernol Cerebrol Veins
subarachnoid and perivascular spaces are separated a I Superior cerebrnl aeins: These are 6 to 12 in number.
thin layer of pia mater. The flow of extracellular fluid They drain the superolateral surface of the
is outward into the subarachnoid space. hemisphere. They terminate in the superior sagittal
The perivascular spaces are involved in auto- sinus (Fig.31.20).
regulation of brain arterioles which regulates the blood 2 Superficial middle cerebrnl uein: This drains the area
supply to tissues. round the posterior ramus of the lateral sulcus. It
The chief internal source of autoregulation is the terminates in the cavernous sinus, or at times into
adjustment of arterial muscle tone in response to the sphenoparietal sinus. Through the superior and
intraluminal pressure changes. Cerebral blood flow inferior anastomotic veins, it communicates with the
remains at 60-70 mll 100 g / min during systemic blood superior sagittal and transverse sinuses. It also
pressure; changes ranging from 80-180 mm Hg. This is communicates with the deep middle cerebral vein.
achieved by a direct myogenic response to distension 3 Deep middle cerebrpl r:ein: This drains the surface of
produced by rising intraluminal pressure. the insula and terminates in the basal vein.
The H+ ion concentration in the perivascular space 4 rior cerebral aeins: These are several in number.
is the chief external source of autoregulation of cerebral They are divided into orbital and tentorial veins. The
blood vessels. A rising H* (usually following orbital veins terminate in the superior cerebral veins
hypercapnia-excess plasma COr) travels along or in the superior sagittal sinus. The tentorial veins
perivascular space from the capillarybed and it inhibits terminate in the cavernous or any other surrounding
vascular muscle, perhaps by reducing ionized calcium sinus.
level. On the other hand, hypocapnia causes vaso- 5 Anterior cerebral ffsllzs: These are small veins which
constriction. drain the corpus callosum and the anterior part of

Superficial anastomotic vein
. Superior veins
lnferior veins
Superficial middle cerebral vein

lnferior anastomotic vein
Transverse sinus
Sigmoid sinus
.g
(E
E
Internal jugular vein
N
c
.o
o
Fig. 31.20: Veins on the superolateral surface of cerebral hemisphere ao
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BRA N
Anterior cerebral vein
Cavernous sinus
lnferior petrosal sinus Superior petrosal sinus
Sigmoid sinus
Occipital sinus
Transverse sinus
Fig. 31 .21 : Veins on the inferior surface of cerebral hemisphere
the medial surface of the hemisphere. They terminate It terminates in the straight sinus. Its tributaries
in the basal vein (Fig.31.21). include the basal veins, and veins from the pineal
body, the colliculi, the cerebellum and the adjoining
Internol Cereblol Veins part of the occipital lobes of the cerebrum.
There is one vein on each side. It is formed by the union 2 Basal ztein: Tl,:rere is one vein ort each side. It is formed
of the thalamostriate and choroidal veins at the apex of at the anterior perforated substance by the union of
the tela choroidea of the third ventricle. The right and the deep middle cerebral vein, the anterior cerebral
left veins run posteriorly parallel to each other in the veins, and the striate veins. It runs posteriorly, winds
tela choroidea, and unite together to form the great round the cerebral peduncle, and terminates by
cerebralveinbelow the splenium of the corpus callosum joining the great cerebral vein. Its tributaries include
(Fig.31.22). (apart from the veins forming it) small veins from
the cerebral peduncle, interpeduncular structures,
Telminol Veins the tectum of the midbrain, and the parahippocampal
I Great cerebral aein: This is a single median vein. It is gyrus.
formed by union of the two internal cerebral veins. Ultimately, all veins drain into the various cranial
venous sinuses which, in turn, drain into the internal
Thalamostriate jugular vein.
vetn
Choroidal
vein
lnternal The midbrain is supplied by branches from the posterior

cerebral
vetn
cerebral arteries, including their central branches, both
posteromedial and posterolateral.
Tela choroidea
of third ventricle
The pons is supplied by the pontine branches of
basilar artery.
c Themedulla is supplied by:
'6 a. The medullary branches of the vertebral artery.
o b. Branches from the posterior inferior cerebellar
N
artery.
.9
o The veins of the brain stem drain into neighbouring
ao Fig. 31.22: lnternal cerebral VE NS venous sinuses.
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BLOOD SUPPLY OF SPINAL COBD AND BBAIN
Posterior cerebral arteries are the terminal

o Anastomotic and end arteries: In the circle of branches of the basilar artery. It chiefly supplies
Willis, the blood in the three communicating the visual cortex.
arteries is normally static. Following occlusion of Middle cerebral artery is the larger terminal branch
one of the three large arteries contributing to the of internal carotid and supplies most of the supero-
circle, the other two compensate more or less lateral surface of the cerebral cortex.
completely, via communicating arteries. With Anterior cerebral is the smaller terminal branch of
occlusion of one internal carotid, the other internal the internai carotid artery. It runs along the corpus
carotid may perfuse both anterior cerebral arteries. callosum supplying maximum area on the medial
With occlusion of basilar, each posterior cerebral surface of the cerebral hemisphere.
artery may be perfused by the internal carotid of Two lobes of the cerebellum are supplied by 3 pairs
its own side. of cerebellar arteries. These are superior cerebellar,
Further anastomosis occur between cortical anterior inferior cerebellar and posterior inferior
branches of cerebral arteries, prior to perforation cerebellar arteries.
of the branches into brain substance. Once the Anterior two-thirds of spinal cord is supplied by
cortical and central branches perforate, they larger anterior spinal artery. Only posterior one-
become end arteries hardly communicating at third of the cord is supplied by posterior spinal
capillary level. arteries.
Cerebral vascular disease is quite corunon in old
age and manifest in different ways.
a. Haemorrhage-cortical or subcortical
b. Thrombosis Case L
c. Embolism. A A}-yearold obese man complains of nausea/
Hypertensive encephalopathy is a manifestation vomiting, hoarseness of voice for 15 days, difficulty
of sustained elevation of diastolic blood pressure in walking on the right side, with inability to feel
in the form of multiple diffuse small lesions pain, hot and cold sensations from the limbs and
distributed all over, result in a variegated picture trunk
of the circle of Willis (berry's aneurysm). o Where is the lesion?
The arteries of the brain are supplied with o Which nuclei and fibres are involved?
sympathetic nerves which run on to them from
carotid and vertebral plexuses. They are extremely Ansl'[he symptoms in the present ca$e are due to
sensitive to injury and readily react by passing into thrnmbosis of the largest l:ranch of fourth part of
prolonged spasms. This by itself may be sufficient vertebrai artery, the posterior inferior cerebellar
to cause damage to brain tissue since even the least artery. The various nuclei invoh,'ed are vestibular
sensitive neurons cannot withstand absolute nuclei, inferior cerebellar peduncle, nucleus
for a period more than 3-7
loss of blood supply ambiguus anel lateral spinothalamic tract of the
minutes. opposite side.
Case 2
A hypertensive patient aged 60 years was taking the
Mnemonics treatment very erratically. One night he felt severe
Cell is Clearly Circulating headache and soon paralysis of both his right sided
limbs.
C - Cortical branches . Where is the lesion?
C - Central branches . Explain the genesis of his symptoms.
C - Choroidal branches Ans: The hypertension should harre been treated
properlv" Since the treatment was not done along
the right lines, he suffered frnm haemorrhage of the
left lateral striate arteries which suppiy the internal tr
Posterior inferior cerebellar artery is the largest capsule. This leads to paralysis of his right half of '6
branch of vertebral artery. It supplies postero- the body. This is an upper motor neuron type of E
lateral part of medulla oblongata, lower part of paralysis urith exagserated reflexes, increased tone N
c
pons, inferior surface of cerebellum including of the muscles, etc. It is quite a serious condition and o
choroidal branches to 4th ventricle. is calied "cerebral stroke". o
o
a
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BRAIN
1. Labyrinthine artery is a branch of: c. Basilar

a. Basilar b. Vertebral d. Labyrinthine
c. Intemal carotid d. Posteriorinferiorcerebellar 5. \A/hich is the largest directbranch of internal carotid
2. Vein of Galen or great cerebral vein is formed by aftery?
union of: a. Middle cerebral
a. Right and left internal cerebral veins b. Anterior cerebral
b. Occipital and transverse sinuses c. Posterior cerebral
c. Inferior sagittal and straight sinuses
d. Posterior inferior cerebellar
d. Occipital and petrosal sinuses
6. What is not true about BBB (blood-brain barrier)?
3. \tVhich of the following arteries supply visual fibres?
a. Many larger molecular substances hardly pass
a. Anterior and middle cerebral from blood to CSF
b. Middle cerebral
b. Formed by structure between blood and nerve
c. Middle and posterior cerebral cells of brain
d. Posterior cerebral c. The constitution of CSF is exactly same as those
4. Anterior spinal artery is a branch of: of extracellular fluid elsewhere in body
a. Vertebral d. Pinealbody, hypophysis cerebri, choroid plexus,
b. Intemal carotid area postrema, fV ventricle are devoid of BBB.
.rE
E
'..c oI
.9
o
..(l)
a
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P Senn
-J
INTRODUCIION Cr:ntptLterised toruagrnphq or aT scnn: In this procedure,

A neurological case needs to have a detailed clinical X-ray beam traces an arc at multiple angles around
a section of the body. The resulting transverse section
history, family histo ry, and clinical examination besides
the investigations. is reproduced by the computer on its monitor screen
(Fig.32.2).
INVESTIGATIONS REQUIRED IN A NEUROTOGI t CASE Magnetic resonance imnging (MIa.{): The body is
exposed to high energy magnetic field, which
Study of brain is of importance in localising the lesion. permits protons in tissues to arrange themselves in
Besides detailed history and clinical examination, the relation to the field. Then a pulse of radiowaves
following investigations may have to be done according 'reads' these ion patterns and a colour-coded image
to the need of each case. is reproduced on the computer screen (Fig. 32.3).
1 X-ray ,-kull: Anteroposterior and lateral views Sanography: High frequency sound waves produced
(Fig. 32.1). by wand (held in hand) get reflected off body tissues
2 l;rniltnr punctwre: It is done between third and fourth and are detectedby the same instrument. The image,
lumbar spines. This is clinically useful for diagnostic the sonogram, is reproduced on the computer screen.
and prognostic purposes. It is also used for giving It is used to diagnose hydrocephaly or anencephaly
spinal anaesthesia. during intrauterine life.
Fig" 32.1: Lateral view of skull and cervical vertebrae Fig.32.2: Computerised tomography (CT) scan
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BRAIN
Fig.32.3: Magnetic resonance imaging (MRl) Fi1.32.4= Angiography
Positron emission tomography (PET): Substance b. Electroencephalography (EEG): The pattern of

emitting positrons are injected into the body which electrical activity of brain is analysed by putting
are taken up by tissues. Collision of positrons with electrodes in the scalp at different points and
electrons of body tissues produces gamma rays, recording it in the machine.
detected by gamma cameras, put around the patient. c. Nerve conduction studies done to estimate the rate
Thus, PET scan is seen on computer screen. Activity of conduction through the nerve fibres.
of different areas of brain is visualised. These procedures may be used according to the
Attgiography: requirement of the patient.
a. nngiography: This technique employs modi-
fication so that blood vessels can be visualised SUR E ANATOMY
without injecting the dye. The conventional angio- Botders of Cerebrol Hemisphere
graphy is still preferred. Mark the following points (Fig. 32.5).
b. Angiography: The contrast medium is injected into o Point (1)just superolateral to the inion
the common carotid or vertebral arteries. X-ray o Point (2)just superolateral to the nasion
pictures taken immediately show the arterial o Point (3) at the zygomatic process of the frontal bone
pattern. The capillary and venous pattern is seen just above the eyebrow
after a little time (Fig.32.\. o Point (4) at the pterion
c. Digital subtrnction angiography (DSA): In this . Point (5) at the middle of the upper border of the
procedure, low concentrations of contrast media zygomatic arch
are used. Bones and muscles are removed with The superomedial border is marked by joining points
the help of the computer. Ideal method is arterial 1. and2 by a paramedian line.
DSA wherein diluted contrast medium is injected The superciliary border is marked by first joining
into the artery to see its course, branches and their points 2 and 3 by a line arching upwards just above
diseases. the eyebrow, and then extending this line to point 4.
Because of these modern and safe procedures, the The inferolateral border is marked by first joining
older techniques-pneumoencephalo gr aphy, points 4 and 5 by a line convex forwards (temporal
ventriculography and myelography have become pole), and by then joining points 5 and 1 by a line convex
tr
(E
obsolete. upwards, passing just above the external acoustic
6u Electrophysiolagical methods: I
meatus.
N a. Electromyogrnphy (EMG): This is the study of
electrical activity accompanying the muscle Cenllol Sulcus
o
.F
o contraction. It is also used to study the action of o Point (6) is taken 7.2cm behind the midpoint of a
c)
U) various muscles. line joining the nasion with the inion
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INVESTIGATIONS OF A NEUROLOGICAL CASE, SURFACE AND RADIOLOGICAL ANATOMY
o Point (7) 5 cm above the preauricular point. The Cerebellum

sulcus is marked by joining these points by a It is marked behind the auricle, immediately below the
sinuously curved line running downwards and marking for the transverse sinus lying between inion
forwards making an angle of 70 degrees with the and base of mastoid process.
median plane
lolerol Sulcus
The following points are used to mark the lateral sulcus
Cerebrol Angiogrophy
and its posterior ramus Cerebral angiography is a radiological technique by
o Point (4) at the pterion which cerebral vessels can be visualized. The arterial
. Point (8) is taken 2 cm below the parietal eminence . system is visualized by carotid angiography, and the
vertebral system by vertebral angiography.
Point 4 (pterion) is also called Ihe Sylaian point. It is
the stem of the lateral sulcus. Dye: Abort\O to 12 ml of 30% pyelocil or diodone.
The posterior ramus of the lateral sulcus is about 7 cm Techtiqrrc: For carotid angiography, the common carotid
long and can be marked by joining points (a) and (8). artery is located at the carotid tubercle and the dye is
injected percutaneously. A series of skiagrams are taken
rapidly at intervals of 1 second. Within 2 seconds after
the commencement of injection, the dye reaches the
Sensory Motor area
alea
cerebral arteries, and after 2 seconds it is in the veins.
After another two seconds or so the dye passes into the
Motor speech intracranial venous sinuses. The skiagrams taken at
Parietal
eminence area different intervals provide arteriograms, venograms (or
Auditory area phlebograms) and sinograms.
Visual
Similarly for vertebral angiograPhy,the dye is
atea injected into the vertebral artery and skiagrams are
taken as described above.
lndications: Cerebral angiography is helpful in diagnosis
of intracranial fumours, haematomas, aneurysms and
angiomas.
Fig.32.5: Surface marking of borders of cerebral hemisphere E TUTION OF THE HEAD

and of lateral sulcus The head forms the fore-end of the body where all the
special sense organs (eyes, ears, nose and tongue) are
Superior Temporol Sulcus concentrated in and around the face. It is at this end of
This is marked by a line parallel and I cm below the the body that the central nervous system shows its
posterior ramus of the lateral sulcus. greatest development leading to the formation of the
brain. The various sense organs keep the individual
FunctionolAreos of Cerebrol Coilex in-formed about the surroundings so that he can better
adjust and sustain himself. The continuous inflow of
1 The motor area is marked by a strip about 1 cm broad
information collected by the sense organs is processed
in front of the central sulcus. and stored in the form of memorywhich forms thebasis
2 The sensory area is marked by a strip about I cm broad, of all knowledge and experience.
behind the central sulcus. Photosensitioity is one of the fundamental properties
3 The auditory area is marked between the superior of protoplasm. This has resulted in evolution of the eyes
temporal sulcus and the posterior ramus of the lateral which serve to determine the direction of movement
sulcus, immediately below the lower end of the with reference to light even in prevertebrate forms of
central sulcus. life. tr most mammals, however, vision appears to be
4 The aisual area (the part extending on to the supero- dominated (in importance) by the sense of smell. In '6
lateral surface) is marked immediately in front of the primates, including man, there is a progressive m
occipital pole. reduction in the importance of the sense of smell, with N
5 Motor speech area is marked by * area above and a concomitant increase in the importance of vision .9
anterior to pterion. It is mostly present in the left associated with the ability to perform skilled acts of a o
hemisphere. wide variety. ao
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BRAIN
Fig" 32.6: Size of the jaws relative to the size of the head during evolution
The evolution of the sense of hearing took place only of an erect posture in which the forelimbs are no longer
when water dwelling species evolved into those with a required to supportbodyweight, and are therefore free
terrestrial mode of life. This becomes obvious when we to perform various functions. (This is often referred to,
remember that the production and transmission of by anthropologists as emancipation of the forelimbs.)
sound requires air. The sense of hearing greatly helped Thus it would appear that the whole spectrum of
the animal in detectinghostile sounds madeby enemies. human sensibilities is acquired by man from his animal
In man, hearing assumed increasing importance in ancestors. In fact man is inferior to many animals (dogs,
receiving sounds of articulate speech. Homologous cattle, etc.) in his acuity of the senses of smell, vision and
with the ear there are lateral-line organs found in water hearing. However, the supremacy of man in the animal
dwelling vertebrates like fishes and amphibia. These kingdom is due to the large relative size of his brain
organs are sensitive to vibration produced by water which has given him unlimited powers of thought, of
currents and help their owners in judging the depth reason and of judgement, highly developed speech and
and direction of movement of water, and also in hands that can achieve perfectioh at craftsmanship.
detecting the presence of other animals in the The anatomical features of thehumanface are a result
neighbourhood. of a series of changes that have occurred during
The sense of smell (olfnctory sense) is one of the oldest evolution. The many changes observed are a result of
sensibilities which made its appearance first in aquatic two main factors. These are the progressive reduction
vertebrates, and was the first to receive cortical in the size of the jaws; and a concomitant increase in
representation. Most of the primitive mammals are the size of the cranial cavity in association with the
guided primarily and predominantly by their sense of increasing size of the brain. The alterations in the face
smell; the other senses of touch, hearing and vision and head are by-products of a change in posture from
being merely accessory to the dominating influence of pronograde (four-footed), through orthograde to a
smell. Man has freely exploited this uncanny plantigrade (two-footed) one. A pronograde animal
endowment of a sharp sense of smell in domesticated (dog, cow) has large jaws and a small head. An
animals, especially in dogs. orthograde animal (ape or monkey) has smaller jaws
The sense of smell played a significant role in the and a larger head than in pronograde animals.
animals search for food; and for sex. With the adoption Plantigrade man has the smallest jaws and the largest
of an arboreal (tree dwelling) mode of life by primates head. Thus the size of the jaws is inversely proportional
(monkeys and apes), the sense of smell became less to that of the head (Fig. 32.6).
important. This mode of life favoured a higher Reduction in jaw size is attributable to the liberty of
development of visual, tactile, acoustic, kinaesthetic, movements of the upper limbs, and also to changed
and motor functions in association with increasing habit of eating cooked food, both of which have greatly
intelligence. The reduced importance of the sense of relieved the jaws of their diverse functions (tactile
smell has been associated with the loss of a projecting feeling, holding, sorting, breaking, biting, tearing,
tr
.E snout (the region of the mouth and nose) that is so chewing, piercing, fighting, etc.) seen in lower animals.
typical of lower mammals. However, it is believed that The muscles acting on the jaws have obviously become
m
N
the tactile function of the snout is more important than smaller and weaker.
L
o
its olfactory function. The same is also true of muscles on the back of the
o The most important factor in the disappearance of the neck. In pronograde animals, these muscles support the
ao) snout in primates and man appears to be the adoption weight of the head. In order to permit freedom of
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INVESTIGATIONS OF A NEUROLOGICAL
mobility to the tongue for articular speech in man, the man than in any other primate, and the bony orbits are
alveolar arches are broadened and the chin is pushed decidedly smaller than in the great apes. Further, the
forwards, making the mouth cavity more roomy. With interorbital distance is greater in man than in apes in
recession of the jaws, the oral aperture is reduced in whom the nasal root is greatly constricted.
size, and the lips are supported by a much better The supraorbital margins of man are markedly
developed orbicularis oris. reduced remnants of the highly developed brow ridges
The distinctive external nose, with exuberant growth of other primates. The diminution in man is partly due
of cartilages forming the prominent dorsum, tip and to the receding jaws which relieve the ridges of their
alae is a characteristic human feature, although it function as buttresses, and partly to the development
appears to serve no special function. The eyes are of a prominent forehead because of increase in the size
directed forwards and not laterally as in lower of the cranial cavity. The forehead protects the eyes
mammals. This change in direction of the eyes enables from above, a similar function being performed by the
stereoscopic vision. The palpebral fissures are larger in brow ridges in apes.
.G
E
(\I
E
o
o
(l)
o
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a
I
aLtz/
Anteriar unll: Lamina terminalis, anterior commissure,

anterior column of fornix (seeFig.29.1).
ERAt VENTRICTE P aste r i or zo all : P ineal b ody, cerebral aqueduct.
The lateral ventricle comprises a central body and three

Floor: Optic chiasma, tubercinerium, infundibulum,
homs-anterior, posterior and inferior. Their walls are mammillary body, posterior perforated substance,
enumerated.
tegmentum of midbrain.
Roof: Ependyma, tela choroidea.
Body or Centtol Port Lateral wall: Medial surface of thalamus, medial aspect
Roof' Trunk of corpus callosum. of hypothalamus, epithalamus, interventricular
foramen.
Floor : Superior surface of thalamus, thalamostriate vein,
stria terminalis, body of caudate nucleus. Recesses: Infundibular recess/ optic recess, pineal recess,
suprapineal recess (see Fig. 29.1).
Medial: Septum pellucidum, body of fornix (see Fig. 29.5).
FOURTH VENIRICLE
Anteilor Horn
Roo/: Anterior part of trunk of corpus callosum. The cavity of fourth ventricle is situated dorsal to pons
and upper part of medulla oblongata and ventral to
Anterior: Genu and rostrum of corpus callosum.
the cerebellum. Its boundaries/ recesses/ apertures and
Floor:Head of caudate nucleus (seeFig.29.7). continuations are mentioned here:
Medinl wall: Septtm pellucidum and column of fomix. Lateral boundnries: Gracile tubercle, cuneate tubercle
inferior cerebellar peduncles, superior cerebellar
Poslerior Horn peduncles (see Fig. 27.7).
Raof and lateral wall: Tapetum of corpus callosum.
FIoor
dial uall: Bulb of posterior hom above and calcar avis upper part: Facial colliculus on the dorsal surface of pons
below (see Fig.29.8). (see Fig.27.2).
Infeilor Horn Intermediate part: Yestibular nuclei, medullary striae.
Roof and lateral wall: Tapetam, tail of caudate nucleus, Lower part: Upper part of medulla oblongata containing
stria terminalis, amygdaloid nucleus. hypoglossal and vagal triangles.
F lo or : P es hippocampus, hippocampus, alveus, fimbria, Superior medullaryvelum, thin sheet of pia mater
dentate gyrus, collateral eminence (see Fig. 29.9). ependyma with median aperture, inferior
medullary velum (see Fig. 27.2).
THIRD VENIRICLE Recesses in roof: One median dorsal, two lateral dorsal
The third ventricle lies between the two thalami. The and two lateral.
components of its boundaries and recesses are Altertures: One median foramen of Magendie, two
enumerated: lateral
-
foramina of Lushka (left and right).
-
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APPENDIX 2
Continuity: Above with cerebral aqueduct most of anterior two-thirds of tongue and afferents
Below with central canal of spinal cord. from glands supplied by it.
Table A2.1 shows arteries of brain. 4 General somatic afferent from part of skin of auricle.
CN Vll!: VESTIBULOCOCHLEAR
Special somatic afferent column:
CN I: O[ ORY
Tzoo parts: Vestibular nuclei: Medial, superior, spinal,
Part of forebrain lateral.
CN ll: OPTIC Cochlear nuclei: Dorsal and ventral.
Part of forebrain A1l at pontomedullary junction.
CN lll: OCUTOMOTOR CN IX: GTOSSOPHARYNGEAL

L Ceneral somatic efferent column for 5 extraocular 1 Special visceral efferent for one muscle of pharynx-
muscles at level of superior colliculus. the stylophar),ngeus in medulla oblongata.
2 General visceral efferent column for 2 sets of 2 Ceneral visceral efferent for parotid gland (see Flow
intraocular muscles (see Flow chart A1.4). chart ,A.1.3).
3 General somatic afferent-mesencephalic nucleus of 3 Special and general visceral afferent (nucleus of tractus
CN V. It receives proprioceptive impulses from solitarius) for sensations of taste from posterior one-
extraocular muscles (see Frg. 24.4). third tongue and circumvallate papillae, Also carries
general sensations from posterior one-third tongue,
CN IV: TROCHLEAR
tonsil carotid body and carotid sinus.
General somatic efferent column for supply of only 4 General somatic afferent for proprioceptive fibres
superior oblique muscle at level of inferior colliculus. from the muscle.
Ceneral somatic afferent-mesencephalic nucleus of
CN V. It receives proprioceptive impulses from the CN X + CN Xl: V US AND CRANIAI PART OF CN XI
superior oblique muscle. L Special visceral efferent for muscles of larynx,
CN V: TRIGEMINAL pharynx, soft palate in medulla oblongata.
1 Special visceral efferent column for 4 muscles of
2 Special and general visceral afferents carry (nucleus
of tractus solitarius) taste from posteriormost part
mastication and 4 other muscles at upper level of pons.
of tongue, epiglottis and afferents from foregut and
2 General somatic afferent column: midgut derivatives.
a. Spinal nucleus of CN V for pain and temperature
from face.
3 General visceral efferent for glands of respiratory
system and gastrointestinal tract till right two-thirds
b. Superior sensory nucleus of CN V for touch and of transverse colon.
pressure from face. 4 General somatic afferent from skin of external
c. Mesencephalic nucleus of CN V for proprioceptive auditory meatus.
impulses from extraocular muscles, muscles of
tongue and mastication. CN Xl: SPINAL PART OF ACCESSORY NERVE
CN VI: ABDUCENT 1 Special visceral efferent column in C1-C4 ventral
Ceneral somatic efferent column for lateral rectus at horn cells of spinal cord for sternocleidomastoid and
lower level of pons. trapezius.
General somatic afferent-mesencephalic nucleus of 2 General somatic afferent-dorsal horns of C2-C4
CN V. It receives proprioceptive impulses from the segments of spinal cord. These receive propriocep-
lateral rectus muscle. tive impulses from the above two muscles.
CN VII: FACIAL CN Xll: HYPOGLOSSAL

Special visceral efferent column for muscles of facial 1 General somatic efferent column for all 4 intrinsic
expression at lower level of pons. muscles of tongue and three extrinsic muscles: tr
'6
General visceral efferent for lacrimal, nasal, palatal Styloglossus, genioglossus and hyoglossus in medulla
and submandibular, sublingual glands
o
(see Flow oblongata. N
charts A1.1 and A7.2). 2 General somatic afferent-mesencephalic nucleus of o
Special visceral afferent and general visceral afferent CN V. It receives proprioceptive impulses from the o
o
(nucleus of tractus solitarius) for carrying taste from muscles of tongue. a
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BBAIN
Table A2.1: Arteries of brain

1. Vertebral artery a branch of 1st part of subclavian artery is divided into four parts
a. First part: Lies deep in the neck in the veftebral triangle; gives no branches.
b. Second parf.'Passes in the foramen transversaria of C6-C1 vertebrae; gives spinal branches for supply of meninges and
spinal cord (see Fig. 3'1.3).
' c. Third part: Lies in the suboccipital triangle, on the posterior arch of atlas vertebra and gives branches to muscles of
suboccipital triangle.
d. Fourth parf; Enters the cranial cavity through foramen magnum. Joins with the same artery of opposite side to form basilar
artery at the lower border of pons. The fourth paft gives:
i. Meningeal branches
ii. Posterior spinal aftery
iii. Anterior spinal artery
iv. Posterior inferior cerebellar artery
v. Medullary branches.
2. Right and left vertebral arteries unite at the lower border of the pons to form a median basilar artery, which gives
following branches:
a. Anterior inferior cerebellar (see Fig. 31.4)
b. Pontine branches
c. Labyrinthine branches
d. Superior cerebellar
e. Posterior cerebral
3. Internal Carotid Artery
a. Cervical part gives no branches.
b. Petrous parl gives (i) caroticotympanic for the middle ear, and (ii) pterygoid branch.
c. Cavernous part gives branches to (i) trigeminal ganglion, and (ii) superior and inferior hypophyseal branches.
d. Cerebral part gives following branches:
i. Ophthalmic artery which supplies outer layers of eyeball and through central artery of retina (end aftery), the retina.
ii. Anterior cerebral (see Fig. 31.13)
iii. Middle cerebral
iv. Posterior communicating
v. Anterior choroidal
4. Circle of Willis
Circle of Willis is formed by union of posterior cerebral of vertebral artery and posterior communicating branch of internal
carotid arteries on each side (see Fig. 31.13).
It gives:
a. Central branches:These are long thin, numerus end arteries with supply deeper structures like internal capsule and basal
ganglia.
b. Choroidal branches of internal carotid and posterior cerebral supply choroid plexuses of the ventricles.
c. Cortical branches: These are:
i. Anterior cerebral: Chiel artery on the medial surface of cerebral bemisphere till parieto-occipital sulcus. lt also supplies
E 1 cm wide area on the superolateral surface, along the superomedial border. The area includes motor and sensory
(E areas of lower limb and Perineum.
!o ii. Middte cerebral: Main artery of the superolateral surface supplying major parls of motor and sensory areas. lt also
N
E supplies motor speech area, auditory and vestibular areas.
.9.
() iii. Posterior cerebral: Chief artery of the tentorial surface and occipital lobe. This is the artery of visual cortex.
oo
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APPENDIX 2
Tabes dorsalis: Tabes dorsalis affects the posterior

white column of spinal cord. It leads to bilateral loss
of proprioceptive sensations and tactile discrimination
Preganglionic parasympathetic fibres are present in below the side of lesion. The finger nose test is past
4 cranial nerves, e.g. cranial nerves III, \{I, X, X and along pointing with eyes closed (seeFig.23.7).
spinal nerves 52,53, 54. Four ganglia namely ciliary, Lateral medullary syndrome or Wallenberg's
pterygopalatine, submandibular and otic are concemed syndrome: The lateral medullary syndrome leads to
with efferent parasympathetic fibres. Their connections slrnptoms as:
are shown in Flow charts A1.1 to A7.4 (see Section 1). a. On the side of lesion: Y ertigo, vomitin& nystagmus
(vestibular nuclei affected), ataxia of limbs
(inferior cerebellar peduncle). Horner's
Brown-S6quard's syndrome: The signs and syndrome (sympathetic fibres), dysphagia,
hoarseness (nucleus ambiguus).
symptoms are due to injury to one-half of the spinal
b. On the opposite side of lesion: Loss of pain and
cord. Following are at the level of injury:
temperature from limbs and trunk.
a. Ipsilateral upper motor neuron paralysis.
b. Ipsilateral loss of conscious proprioception.
Cerebellopontine angle syndrome: The
anatomical structures located in cerebellopontine
c. Contralateral loss of pain and temperature.
angle are choroid plexus of 4th ventricle, 7th and 8th
Following are due to injury to various tracts below
nerves. A tumour here gives symptoms: Facial nerve
the level of injury:
paralysis and 8th nerve paralysis leading to deafness
a. Ipsilateral lower motor neuron paralysis. and vertigo. Flocculus of cerebellum involved leads
b. Ipsilateral loss of sensation over the cranial to ataxia on the affected side.
dermatome. Millard-Gubler's syndrome: Millard-Gubler's
These (a), (b) are due to injury to nerve root at the syndrome occurs due to lesion in the lower pons
level of injury (see Fig. 23.19). affecting pyramidal tract and fibres of 6th and 7th
Cauda equina syndrome: It occurs due to cranial nerves. The symptoms are:
compression of cauda equina in the vertebral canal. a. Ipsilateral medial squint.
L2-55 nerve roots are affected. Its features are: b. Ipsilateral paralysis of muscles of facial
a. Loss of knee and ankle jerks. expression.
b. Sensory loss in nerve root distribution. c. Contralateral hemiplegia.
c. Asymmetric areflexic lower motor neuron type Benedikt's syndrome: Benedikt's syndrome
of paralysis. results due to lesion of tegmentum of midbrain
d. Later involvement of bowel and bladder. involving superior brachium, fibres of 3rd nerve, red
Syringomyelia: There are cavities around the nucleus and medial lemniscus (see Fi9.25.1,4).
central canal. There is bilateral loss of spinothalamic Weber's syndrome: Weber's syndrome involves
fibres. Lateral spinothalamic tracts cross at once while corticospinal tract and 3rd nerve nucleus. There is
anterior spinothalamic first ascend and then cross. lateral squint on same side and hemiplegia on the
There is loss of pain and temperature at one level and opposite side of body (see Fig. 25.1a).
loss of touch and pressure at another level. So it is Parinaud's syndrome: This syndrome occurs due
called " dissociated sensory loss" (s ee F ig. 23.20). to compression of superior colliculi when these get
Conus medullaris syndrome: It is produced due pressed by tumour of pineal gland. There is paralysis
to pressure on conus medullaris of spinal cord from of upper gaze only. Other eye movements are
where 52,53 and 54 nerves arise. The symptoms and unaffected (see Fig. 25.74).
sl8ns are: Thalamic syndrome: Thalamic syndrome is due
a. Saddle'shaped anaesthesia on the bottom. to a vascular lesion. It is characterized by distur-
b. Loss of anal sphincteric reflex. bances of sensations, hemiparesis or hemiplegia with
c. Urinary bladder and bowel get affected early. hyperaesthesia and severe spontaneous pain.
There is no motor weakness and patient has Pleasant as well as unpleasant sensations are
normal knee and ankle reflexes. exaggerated.
Medial medullary syndrome: This syndrome Subarachnoid haemorrhage: Subarachnoid (E
occurs due to thrombosis of anterior spinal artery. haemorrhage is the collection of blood in the E
There is paralysis of muscles of tongue on same side, subarachnoid space at the base of brain. These are N
associated with hemiplegia and loss of position sense also called the cisterns. The circle of Willis lies in the o
()
in limbs on the opposite side. interpeduncular cistern. Any small branch usually
ao
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BRAIN
due to persistent hypertension may rupture to give When corticospinal tract is damaged, the influence
rise to subarachnoid haemorrhage. of other tracts becomes obvious which cause
Cerebral stroke: The neurological signs and dorsiflexion of 1st toe and fanning of other toes. In
symptoms due to lack of blood supply constitute the infants and children up to two years Babinski's sign
cerebral stroke. It is mostly due to rupture of any of is normally present as the tracts are not fully
the arteries especially central branch of middle myelinated (see Fig. 27.7).
cerebral artery supplying the internal capsule. Poliomyelitis: It is a viral disease which involves
Charcot's artery of cerebral haemorrhage: The anterior horn cells leading to flaccid paralysis of
largest branch of anterolateral central branches of the affected segments. It is lower motor neuron
middle cerebral artery is called Charcot's artery of paralysis.
cerebral haemorrhage. It supplies internal capsule Following is the comparison between upPer motor
whichhas motor fibres for one side of body. Damage neuron and lower motor neuron paralysis:
to artery causes opposite side hemiplegia. LMN Paralysis UMN Paralysis
Sparing of macula in thrombosis of posterior
Muscle tone abolished Muscle tone increased
cerebral artery: Macula is represented at the occipital
Leads to flaccid paralysis Leads to spastic paralysis
pole. It is supplied by branches of middle cerebral
Muscles atrophy later No atrophy of muscles
artery or by anastomosis between middle and
Reaction of degeneration Reaction of degeneration
posterior cerebral artedes. So thrombosis of posterior
cerebral arlery does not harm the macula.
seen not seen
Tendon reflexes absent Tendon reflexes exag-
Hydrocephalus: Hydrocephalus is an abnormal
gerated
increase in the volume of CSF within the skull. It
Limited damage Extensive damage
may be due to increased production, blockage in
circulation or decreased absorption of CSF.
Cerebral vascular disease: It is quite common in
Hydrocephalus may be "internal" within
old age and manifest in different ways.
ventricular system causing increased intracranial
a. Haemorrhage - cortical or subcortical
pressure and brain damage. If CSF accumulates in
b. Thrombosis
the subarachnoid space the condition is called
c. Embolism.
external hydrocephalus.
Parkinsonism: Lesion of corpus striatum leads to Hypertensive encephalopathy: This is a
parkinsonism. It gives rise to: manifestation of sustained elevation of diastolic
a. Lead pipe rigidity or hypertonicity. blood pressure in the form of multiple diffuse small
b. Movements are slow (seeFig.28.24). Iesions distributed all over, result in a variegated
c. Loss of automatic associated movements and picture of the circle of Willis (berry's aneurysm).
also loss of facial expression. Nerve supply: The arteries of the brain are
d. Involuntary movement like tremors, pin rolling supplied with sympathetic nerves which run onto
movements of hand. them from carotid and vertebral plexuses.
e. Bends forwards during walking. They
Babinski's sign: In case of lesion of corticospinal reactby
tract there is dorsiflexion of big toe and fanning of may be
other toes in response to scratching the skin on the since even the least sensitive neurons cannot
Iateral side of sole. This sign is positive in case of withstand absolute loss of blood supply for a period
upper motor neuron lesion. more than 3-7 minutes.
(E
E
N
C
o
o
o)
U)
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I
t
I
I
A acoustic 423 hypophyseal
I motor 419 inferior 198
i Abnormal crania 31 motor speech 421 superior 198
I Abscess ofBroca 421 infraorbital 120
apical of tooth 221 of Brodmann 419 labial
t frontal lobe 356 premotor 419 inferior 71
mastoid 282 sensory 422 superior 71
I retropharyngeal 90 visual 423 lacrimal 21 1
t Accommodation reflex 358 of Kiesselbach ?41 laryngeal, superior 101
Acromegaly 199 Arteria thyroidea ima 143 lingual 102
Adam's apple 92 Arterial vasocorona 455 maxillary 119, 313
) Adenohypophysis 198 Artery, arteries meningeal
I Angle alveolar accessory 201
I
facial 11 anterior superior 120 middle 2Ol,l2O
li Anosmia 356 inferior 120 nasal
Ansa cervicalis 1O3 posterior superior 120 dorsal 210
t Ansa hypoglossi 103 auricular lateral 7l
i, Aperture of nose deep 120 occipital 180
anterior bony 9 posterior 103 ophthalmic 209
piriform 9 basilar 456 palatine
Aponeurosis caroticotympanic 2OZ ascending 102
epicranial 60 carotid greater 120
palatine 225 common 99, 151 pharyngeal
Apparatus external 100 ascending 103
lacrimal 75 branches of 101 pterygoid 120
styloid 159 internal 152, 458 scapular, dorsal 150
Aqueduct of vestibule 25 central of retina 209 sphenopalatine I2O
l
Aqueous humour 293 cerebellar spinal
Arachnoid rnater 327 posterior inferior 456 anterior 455
Arch alveolar 9, 13 cerebral posterior 455
of mandible 9 anterior 458 subclavian 88, 148,313
of atlas middle 458 submental lO2
anterior 51 posterior 457 supraorbital 61
posterior 5l cervical suprascapular 88, 150
palatoglossal 223 deep 181 supratrochlear 61
palatopharyngeal 223 transverse 76 thoracic, internal 149
vertebral 51 ciliary thyrocervicat 150
zygomatic 11 anterior 21 1 thyroid
Area, areas posterior 210 inferior 143
dangerous costocervical 15O superior 143,312
of face 72 ethmoidal 21 1 thyroidea ima 143
scalp 63 facial 71 to masseter l20
Little's 241 anastomoses of 71 to pterygoid muscles 120
of cerebral cortex 423 transverse 72 tympanic, anterlor 120
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HUMAN ANATOMY HEAD_NECK AND BRAIN
-
vertebral medial occipital 414 Centre

branches of 165 medial orbital 414 drinking 430
development of 165 superciliary 414 feeding 430
Asterion 12 superomedial 4t4 hunger 430
Atlas 51 Brain thirst 43O
Atrium of middle meatus of nose 244 blood supply of 461 Cephalhaematoma 63
Aluricle 272 introduction to 319 Cephalic index 31
Axis parts 327 Cerebellum 4O1
visual 205 radiological anatomy of 467 blood supply of 4OO
Brain stem 389 connections of 4O4
B functions of 406
c lobes of 401
Babinski's sign 323 vallecula of 401
Bar, costotransverse 51 vermis of 4O3
Calvaria 4
Baroreceptor 100 Canal, canals Cerebral hemisphere 414
Blind spot 293 carotid 57 Cerebrospinal fluid 331
Blood supply of condylar absorption of 331
brain 461 anterior 57 circulation of 331
brain stem 464 posterior 57 formation of 331
cerebellum 461 ethmoidal functions of 331
medulla 464 anterior 56 Cerebrum 414
midbrain 464 posterior 56 borders of 414
pons 464 hypoglossal 57 external features of 414
spinal cord 455 infraorbital 57 insula 416
Body mandibular 57 lobes of 415
carotid 1O0 of Schlemm 288 medial surface of 418
ciliary 290 optic 56 orbital surface of 418
geniculate palatinovaginal 57 poles of 415
lateral 426 semicircular 284 surfaces of 414
medial 426 vertebral, contents of 183 Cervical pleufa 167
of mandible 31 vomerovaginal 57 Chain, sympathetic, cervical 154
pineal 429 Canaliculus, canaliculi Chiasma optic 357
vitreous 294 for chorda tympani Choroid 290
Bone, bones Cistern
anterior 279
cranial posterior 279 cerebellomedullary 329
tables of 5
mastoid 57 interpeduncular 330
ethmoid 45 tympanic 57 of great cerebral vein 330
cribriform plate of 45 of lateral sulcus 33O
frontal 40 Capsule
pontine 329
hyoid 49 internal 436
Cisterna ambiens 330
inferior nasal concha 46 anterior limb of 437
Cisterna magna 329
lacrimal 48 blood supply of 438
Clinical anatomy
maxilla 35 fibres in 437
acoustic neuroma 376
nasal 48 genu of 437
adenoids 229
occipital parts of 437
ageing 424
condylar part of 40 posterior limb of 438
allergic rhinitis 242
squamous part of 40 retrolentiform part of 438
Alzheimer's disease 424
ossification of cranial bones 55 sublentiform part of 438
aneurysm of subclavian
palatine 48 Cartilages of larynx 253 artery 150
parietal 48 Cauda equina 335 anosmia 356
sphenoid 43 Cave anterior lobe lesion of
sutural 30 Meckel's 200 cerebellum 4O7
temporal 4l trigeminal 200 antrum puncture 246
squamous part of 41 Cavity Argyll-Robertson pupil 360
tympanic part of 42 cranial 189 athetosis 434
vomer 46 nasal 239 ballismus 434
wormian 30 oral 217 Bell's palsy 69
zygomatic 47 Cell, cells binasal hemianopia 360
Borders of cerebrum of hypophysis cerebri 199 black eye 63
inferolateral 414 of thyroid 144 blepharitis 75
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,
brain stem lesion 393, 395, 398 infant's larynx 262 puncture
Caldwell-Luc operation 246 injury to vital centres in cisternal 181
Caput succedaneum 6 medulla 412 lumbar 185, 330
carcinoma of maxillary sinus jaw jerk reflex 369 pyorrhoea alveolaris 221
246 judicial hanging 412 referred pain 128
carcinoma of tongue 268 jugular venous pressure 86 retinal detachment 293
cataract 294 Koplik's spots 217 scrlir.vy 221
caudal epidural 185 laryngitis 257 sebaceous cyst 63
cauliflower ear 276 laryngoscopy 257 Singer's nodules 257
cerebello-pontine angle 395 laryngotomy 261 sinusitis 246
cervical caries 84 lesions of cerebral cortex 424 smuggler's fossa 257
cervical rib 54, 88 lesions of cranial nerves/branches sneeze reflex 369
chalazion 75 III nerve 362 squint 2O9
Charcot's artery of cerebral IV nerve 364 strabismus/squint l23
haemorrhage 460 IX nerve 379 stye 75
chorea 434 optic atrophy 360 syndromes
chronic otitis media 282 optic neuritis 360 Benedict's 398
cisternal puncture 185 recurrent laryngeal 383 Brown-S6quard's 347
cleft palate 227 trigeminal neuralgia 369 cauda equina 186, 336
conjunctivitis 74 V nerve 70, 369 cerebellar 407
corneal blink reflex 369 VI nerve 366 conus medullaris 336
corneal opacities 290 VII nerve 69, 373 crocodiletear 374
cyst sebaceous 63 VIII nerve 375 Frey's 110
damage to motor pathways 451 X nerve 382 Froin's 186,332
deafness 375 XI nerve 384 Horner's 156
dernentia 424 XII nerve 386 lateral medullary 393
dental caries 221 lesions of hypothalamus 431 medial medullary 393
deviated nasal septum 242 lesions of internal capsule 438 Millard-Gubler's 395
dislocation of mandible 124 lingual tonsil 228 Parinaud's 399
drooping of shoulder 385 Little's area 241 Ramsay-Hunt 374
dysphagia lusoria 88 Ludwig's angina 210 subclavian steal 151
dysphonia 383 lumbar epidural 185, 331 Weber's 398
ear ache 286 lumbar puncture in syringing 275
ectropion 75 adult 185,330 syringomyelia 347
epiphora 77 children 185 tabes dorsalis 336
eustachian catarrh 282 mastoid abscess 282 Teacher's nodules 257
extradural and subdural maxillary sinusitis 246 tetany 146
haemorrhage 192 meningitis 182, 331 thrombosis of
extradural haemorrhage 192 mumps 107 anterior inferior cerebellar
fontanelles 6, 3O myasthenia gravis 147 artery 458
foreign body in larynx 257 myopia 29O anterior spinal artery 455
fracture of neck rigidity 181 cavernous venous sinus 195
anterior cranial fossa 23 neocerebellar lesion 4O7 Heubner's artery 460
hyoid bone 50 noise pollution 287 lateral striate artery 460
mandible 35' nystagmus ZO9, 4O7 paracentral artery 461
middle cranial fossa 24 optic neutritis 360 posterior cerebral artery 458
nasal bone 9 otosclerosis 282 posterior inferior cerebellar
posterior cranial fossa 26 papilloedema 360 artery 458
ganglion of hay fever 249 paralysis of III nerve 362 sigmoid venous sinus 197
glaucoma 294 parkinsonisrn 434 superior cerebellar artery 458
glossitis 265 parotid abscess 111 superior sagittal venous sinus
glossopharyngeal neuralgia 379 parotidectomy 111 195
homonymous hemianopia 36O perichondritis 276 thyroidectomy 145
Hutchinson's teeth 221 peritonsillar abscess 231 tonsillitis 231
hydrocephalus pharyngeal diverticula 235 torticollis 90
communicating 332 pituitary tumours 199 tracheostomy 95
non-communicating 332 poliomyelitis 336 trachoma 75
hyperacusis 282 pontine haemorrhage 395 trigeminal neuralgia 70
hypermetropia Z9O pterion 12 tumours of pons 395
hypoacusis 369 ptosis 74 VII nerve palsy in newborn 375
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viral parotitis 107 tongue 264 pharyngobasilar 18, 85
Virchow's lymph node 159 tonsil 229 pretracheal 83,94
Clinical Terms 314,375 vertebral artery 165 prevertebral 83
Cochlea, duct of 284 Diaphragma sellae 328 temporal 1 15
Colliculus Diencephalon 425 Fasciculus
inferior 397 Dilator pupillae 2OZ cuneatus 344
superior 398 Diploe 5,20,21 gracilis 343
Commissures Dislocation, of mandible 124 uncinate 435
anterior 435 Duct, ducts Fibres
of fornix 435 nasolacrimal 76 arcuate 435
posterior 435 parotid 1 10 association 435
Common annular tendon 207 submandibular 135 short 435
Conchae, nasal 243 thoracic 158 commissural 435
Cones 293 thyroglossal 144 projecton 436
Constrictors of pharynx 232 Dura mater Fontanelle, fontanelles 5, 6
gaps 234 cerebral 327 Foramen, foramina
Conus elasticus 253 meningeal layer 190 of skull 56, 57
Cornea 289 Dysphagia lusoria 88 of anterior cranial fossa 56
Corpus callosum of middle cranial fossa 56
body of 436 E of posterior cranial fossa 57
genu of 436 greater palatine 19
rostrum of 436 Ear lesses palatine 19
splenium of 436 external 272 ethmoidal
trunk of 436 internal 283 anterior 45
Corpus striatum 432 rniddle 277 ovale l9
connections of 433 boundaries of 278 posterior 45
functions of 433 ossicles of 279 spinosum 19
Crista galli 22 Endocranium 20 for zygomatic nerve 46
Cup, physiological 293 Epipia 184
incisive 18
Cysts, sebaceous 63 Episclera 289 magnum '19
Epistaxis 242 infraorbital 10
D Epithalamus 428 jugular 20
Evolution of head 469 of 4th ventricle
Dangerous area of face 73 Exophthalmos, pulsating 195
Deglutition 235 lateral 41 1
Eye black63 median 411
Dehiscence, Killian's 234 Eyeball 288
Dens 52 ofLuschka 411
Eyelids 73 of Magendie 41 1
Development
cerebellum 406 supraorbital 57
cerebral hemisphere 439
F transversarium 51
ear 272 Face 64 vertebral 51
ectodermal clefts 314 zygomaticofacial 57
arteries of 71
eyeball 288 zygomaticotemporal 57
dangerous area of 72
face 77 development 77 Forehead 59
hypophysis cerebri 198 motor nerve supply 67 Fornix
medulla oblongata 399 muscles 64 conjunctival 59
midbrain 399 sensory nerves of 69 Fossa
nuclear columns 399 veins of 72 canine 35
of arteries 160 Factor, hormone releasing 199 cranial
palate 222 Falx cerebelli 328 anterior 22
paranasal sinuses 245 Falx cerebri 328 middle 23
parathyroid 145 Fascia posterior 25
parotid gland 1 11 buccopharyngeal 85 hypophyseal 23
parts of brain 323 cervical incisive 32
pharyngeal arches 314 deep 81 infratemporal ll4
pharyngeal pouches 314 investing layer 81 pterygopalatine 247
pons 393 carotid sheath 81 sublingual 32
teeth 219 orbital 205 submandibular 32
thymus 147 palpebral 7 4 summary of pterygopalatine
thyroid 144 parotid capsule 107 fossa 250
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supraclavicular supramarginal 417 laryngeal 255
greater 79 temporal 417 of neck 171
lesser 79 middle 417 of ossicles of ear 279
temporal 1 14 superior 417 of skull 4
Frankfurt plane 4 temporomandibular l2l
H blood supply of 123
G disc of I22
Haemorrhage ligaments of l2l
Ganglion, ganglia pontine 395 movements of 123
ciliary 24, 213,3ll Hasner valve of 76 relations of 122
geniculate 426 Head Junction, sclerocorneal 288
otic 24, 127,3ll evolution of 469
pterygopalatine 24, 249, 3lO of mandible 470 K
submandibular 24, 136, 309 Helicotrema 283
sympathetic, cervical 293 Hiatus Killian's dehiscence 234
trigeminal 199 for greater petrosal newe 24
Gigantism 199 for lesser petrosal newe 24 L
Gland, glands Hilton's method 111 Labyrinth
lacrimal 75 Hormone bony 283
nerve supply of 76 ACTH 199 membranous 284
Meibomian 74 FSH 199 Lacrimal
of Moll 74 GH 199 apparatus 75
of Zeis 74 ICSH 199 canaliculi 76
parathyroid 145 lactogenic 199 sac 76
parotid 106 LH 199 Laryngeal prominence 253
accessory 109 STH I99 Laryngopharynx 228
external features of 107 TSH 19I Laryngoscopy 257
nerve supply of 1 10 Humour, aqueous 293 Larynx 252
structures within 108 Hyoid bone 49 cartilages of 254
pineal 429 Hyperparathyroidism I46 cavity of 256
pituitary 197 Hyperthyroidism 145 mucous membrane of 256
sublingual 136 Hypoparathyroidism 146 muscles of 258
submandibular 133 Hypophysis cerebri 197 nerve supply of 253
nerve supply of 136 arterial supply of 198 ventricle of 256
tarsal 74 hormones of 199 vestibule of 256
thyroid 140 lobes of 198 Lemniscus
arterial supply of 143 Hypothalamus lateral 395
relations of 14 I boundaries of 429 medial 391
venous drainage of 143 connections of 430 trigeminal 395
Glossitis 265 functions of 430 Lens 294
Goitre 145 parts of 430 capsule of 294
Gyrus, gyri suspensory ligament of 294
cingulate 418 I Leptomeninges 185
frontal Impression, trigeminal 199 Ligament,ligaments
inferior 417 Incus 280 alar 173
medial 417 Index, cephalic 3l apical 173
middle 417 Infundibular, of nose 244 apical of dens 173
superior 417 Inion 6 check
occipital Investigations in a neurological lateral 206
superior 417 case 467 medial 206
occipitotemporal Iris 291 cruciform 173
lateral 418 flavum 173
medial 418 J of atlas, transverse 173
orbital 418 of Berry 141
parahippocampal 418 Joint, joints of temporomandibular joint t2l
paraterminal 418 atlanto-axial 172 sphenomandibular 34
parolfactory 418 atlanto-occipital 171 stylohyoid l6O
postcentral 417 incudomalleolar 28O stylomandibular 160
precentral 416 incudostapedial 280 suspensory, of lens 294
rectus 418 intervertebral, cervical 17 I suspensory, of thyroid 141
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Ligamentum denticulatum 184 longus capitis 163 carotid 96
Limbic system 445 levator labii superioris alaeque digastric 96
Lobule nasi 66 muscular 104
paracentral 418 levator anguli oris 66 submental 96
parietal levator palpebrae superioris 74 Neocerebellum 403
inferior 417 longissimus capitis 178 Nerve roots
superior 417 masseter 1 16 dorsal 336
Locus coeruleus 4lO mentalis 67 ventral 336
Lymph node, nodes Muller's 74 Nerve, nerves
cervical deep 157 mylohyoid 132 abducent 364
deep circle 157 obliqus capitis accessory 86, 383
jugulo-omohyoid 158 inferior 181 cranial root of 383
jugulodigastric 157 superior 181 functional components of 383
of head and neck 156 occipitalis 8 spinal root of 384
of Virchow 159 occipitofrontalis 8 alveolar
superficial circle 157 of face 64 anterior superior 368
Lymphopoietin 147 of larynx 258 middle superior 368
of mastication 1 15 posterior 368
M of middle ear 280 auriculotemporal 368
of pharynx 228 buccal 125
Macula omohyoid 104 carotid 125
lutea 293 orbicularis ocwli 225 chorda tympani 128
of internal ear 285 orbicularis oris 66 cochlear 374
Mandible palatopharyngeus 225 cranial 350
attachments on 33 platysma 66 ethmoidal
ossification of 34 procerus 66 anterior 368
Maxilla 35 pterygoid posterior 368
Meckel's cave 200 lateral I 16 facial 370
Membrana tectoria 284 relations of ll7 branches of 371
Membrane, membranes medial 116 functional components of
basilar 284
37O a
rectus capitis nuclei of 37O
Bowman's 29O anterior 163 relations of 370
cricovocal 256 lateralis 163 frontal 214,368
Descemet's 290 posterior major 181 glossopharyngeal 376
laryngeal 255 posterior minor 181 branches of 378
quadrate 256 risorius 67 distribution of 378
thyrohyoid 94.255 scalene 165, 166 functional components of 376
tympanic 274 spinalis 178 inferior alveolar 127
Midbrain 396 semispinalis 178 infraorbital 215
internal structure of 396 splenius 177 infratrochlear 368
Movements sternocleidomastoid 89 lacrirnal 214
of eyeball 208 sternohyoid LO4 laryngeal
of vocal folds 259 sternothyroid 104 external 381
Muscle, muscles styloglossus 160 internal 381
aryepiglotticus .258 stylohyoid 132 recurrent 381
arytenoid stylopharyngeus 160 superior 381
oblique 258 temporalis 13, 116 lingual 126
transverse 258 thyroarytenoid 258 long ciliary 368
buccinator 66 thyroepiglotticus 258 mandibular 125
compressor naris 66 thyrohyoid 104 masseteric 369
constrictor of pharynx 232 zygomaticus major 66 maxillary 368
corrugator supercilii 66 zygomaticus minor 67 mental 369
cricoarytenoid, lateral 258 mylohyoid 369
cricothyroid 258 hl nasal
digastric 132 external 239, 368
extraocular 206 Neck internal 368
geniohyoid 132 anterior median region of 93 nasociliary 215
hyoglossus 132 back of 176 nasopalatine 242
relations of 133 triangles of oculomotor 360
longus colli 163 anterior 95 olfactory 355
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,
, optic 313, 356 hypoglossal 351 Parietal eminence 6
petrosal lacrimatory 352 Parietal foramen 6
, deep 203 oculomotor 35 1
,.
Parkinsonism 434
external 203 of hypothalamus Parotid region 106
greater 203 dorsomedial 43O Pars, of hypophysis cerebri 198
) phrenic 169,309 lateral 430 Pathway, pathways
statoacoustic 374 paraventricular 430 for pain 451
J
trigeminal 366 posterior 430 for proprioceptive impulses 452
, trochlear 362 supraoptic 43O for taste 27O, 452
vagus 379 tuberal 43O for touch 451
)
branches of 381 ventromedial 430 palate
I functional components of 379 of seventh cranial nerve 370 hard 222
nuclei 379 of sixth cranial nerve 364 soft 222
) relations of 38O of spinal tract of trigeminal Pharynx 227
) vestibulocochlear 374 nerve 355 blood supply of 235
zygomaticofacial 215 of thalamus constrictors of 232
) zygomaticotemporal 215 anterior 427 laryngeal part of 228,231
) Neuron, neurons intralaminar 425 nasal part of 228
bipolar 320 lateral 427 oral part of 228
, multipolar 320 medial 427 Pia mater 329
t pseudounipolar 32O midline 425 Pineal body
unipolar 32O reticular 425 functions of 429
) Noise pollution 287 ventral 427 structure of 429
I Norma (of skull) of tractus solitarius 353 Pituitary gland 197
basalis 13 of trigeminal nerve Plane, Frankfurt 4
t frontalis 8 main sensory 355 Plate pterygoid
I lateralis 1 I mesencephalic 355 lateral 15
occipitalis 6 motor 355 medial 15
I verticalis 5 spinal 355 Plexus
) Nose 239 superior 355 brachial
cavity of 239 of vagus, dorsal 353 cervical 167, 309
) conchae of243 olivary Poles, of cerebral hemisphere
t lateral wall of 242 inferior 391 frontal 415
blood supply 242 superior 395 occipital 415
, lymphatic drainage 245 pontine 394 temporal 415
nerve supply 244 pretectal 398 Pons 393
I
meatuses of red 398 basilar part of 394
) inferior 243 salivatory tegmentum of 394
middle 243 inferior 352 Portal vessels, in hypophysis
I
septum of 24O superior 352 cerebri 198
) Nucleus, nuclei trochlear 351
somatic vestibular 355 a
) general 355
) special 355 Quadriplegia 186
visceral 353 Queckenstedt's test 186
Oesophagus l7l
I cochlear 355
orbit 27, 205
)
dentate 404
contents of 2O5 R
efferent
neryes of 213 Radiation
, somatic 351
visceral
vessels of 2O9 auditory 438
a Oropharynx 228 optic 438
general 353
Ossification of brain 469
, special 351
cranial bones 55 Radiological anatomy
emboliformis 404
t of mandible 34 ofhead and neck 3O6
facial 370
of typical cervical vertebra 51 Reflex
t fastigii 404
Osteology, of head and neck 3 accommodation 358
globosus 4O4
, horn Region
P frontal of skull 8
) anterior 338
lateral 339 Palate h.afi,, soft 222 infratemporal ll4
)
posterior 339 Parathormone 146 parotid 106
)
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I
HUMAN ANATOMY HEAD_NECK AND BRAIN
-
prevertebral 162 Space 329 otbital 414

submandibular 131 epidural 183 superolateral 414
temporal 114 pharyngeal 90 tentorial 414
Reticular formation subarachnoid L84,329 Suture, sutures
connections of 453 subdural 184,329 of skull 4
functions of 454 Speech mechanism 262 coronal 5
Retina 292 Spinal cord frontomaxillary 10
iridial part of 293 blood supply of 455 frontonasal 10
optical part of 293 columns of intermaxillary 10
Ring, lymphatic, grey 336 internasal l0
Waldeyer's 228 white 336 lacrimomaxillary 10
commisure of lambdoid 5
S grey 336 metopic 5
white 336 nasomaxillary 10
Scalp 60 enlargement of occipitomastoid
arteries of 61 cervical 335 sagittal 5
lymphatic drainage of 63 lumbar 335 zygomaticofrontal l0
nerves of 63 internal structure of 335 zygomaticomaxillary 1O
structure 60 Stapes 279
venous drainage of 61 Styloid apparatus 159 T
Septum 240 Styloid process 12
nasal 240 Subthalamus 431 Teeth 219
blood supply Z4l Sulcus cementum of 219
nerve supply 241 calcarine 418 deciduous 219
Sheath carotid 84 central 416 dentine of 219
fascial, of eyeball 205 cingulate 418 development Z2O
Sign, Babinski's 323 parolfactory 418 enamel 219
Sinus postcentral 417 eruption 220
carotid 99 precentral 418 form and functions of 22O
Sinus, sinuses suprasplenial 418 permanent 221
paranasal 245 temporal Tetany 146
ethmoidal 246 inferior 417 Thalamus
anterior 246 superior 417 connections 425
middle 246 Surface landmarks functions of 425
posterior 246 of head and neck 298-300 Thymus, functions 147
frontal 245 Surface marking Thyrocervical trunk 150
maxillary 245 accessory nerve 304 Thyroidectomy 145
venous, of dura mater Tongue
auriculotemporal 304
cavernous 193 common carotid arteries 302 blood supply of 266
draining channels of 194 external carotid artery 3OZ development of Z7O
factors helping expulsion of facial artery on the face 302 histology of 268
blood 195 facial nerve 304 lymphatic drainage of 267
tributaries of 194 glossopharyngeal nerve 304 muscles of 266
sagittal hypoglossal nerve 3O5 nerve supply of 268
inferior 195 maxillary sinus 306 papillae of 265
superior 195 middle meningeal artery 302 filiform 266
sigmoid 196 palatine tonsil 306 fungiform 265
straight 195 parotid gland and duct 305 vallate 265
transverse 196 subclavian artery 3O2 Tonsil
Skull subclavian vein 153 palatine 229
anatomical position of 4 superior sagittal sinus 3O3 arterial supply 230
exterior of 5 thyroid gland 306 capsule of 229
foetal 29 transverse sinus303 lymphatic drainage of 23O
fractures of trigeminal ganglion 305 nerve supply of 23O
in old age 54 trunk of mandibular nerve 304 Trachea 169
interior of 20 vagus nerve 304 Tract, tracts
peculiarities 5 Surface, of cerebrum ascending 342
postnatal growth of 30 inferior 414 corticospinal 450
sex differences in 30 medial 414 descending 340
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_t :.. 1., . :- . i.- .::,',. . .
olivospinal 341
pyramidal 340
v lateral 442,472
anterior horn of 444
reticulospinal 341 Vallecula central part of 443
rubrospinal 34O of cerebellum 401 inferior horn 445
spinocerebellar Vault of skull 3o posterior horn of 445
anterior 345 Vein, veins third 441, 472
posterior 345 cerebral boundaries of 442
Ir spinothalamic anterior 463 communications of 441
anterior 345 deep middle 463 recesses 442
lateral 345 diploic 21 Vermis
tectospinal 342 emissary 7, 62 of cerebellum 401
vestibulospinal 342 external 463 Vertebrae
Triangle great 463
posterior 85 cervical 50
inferior 463 first 5 1
scalenoverteral 162 internal 464
of neck second 52
superficial middle 463 seventh 53
anterior 95 superior 463
carotid 96 typical 50
jugular Vestibulocochlear nerve 374
digastric 96 internal 153
muscular 104 Vestibule
ophthalmic of internal ear 283
submental 96
suboccipital 179 inferior 2l 1 of larynx 256
subclavian 85 superior 2 1 I of mouth 217
supraclavicular 85 pterygoid plexus of l2l Villi, arachnoid 329
Trunk subclavian 153
Vitreous body 294
bronchomediastinal 159 suboccipital plexus 181
Vocal folds
jugular 159 thyroid movements of 259
of corpus callosum 436 fourth 144
thyrocervical 150 inferior 143 w
Tube, auditory 236 middle 143
Tuber ofKocher 144 Waldeyer's lymphatic ring 228
frontal 9 superior 143 Water's position, for skiagram of
parietal 6 vertebral system of 187 sinuses 306
Tuberculum sellae 22 Ventricle White matter 434
fourth 472 Willis, circle of 459
U boundaries of 409
floor 409 Z.
Umbo 274 part
Utricle 284 recesses of 411 Zinn, common tendinous ring ZO7
Uvula 223 roof of 4lO Zonule, ciliary 29I
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Chaurasia's Human Anatomy Head, Neck and Brain, 6e - Bhagwan Din Chaurasia PDF

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Chaurasia's Human Anatomy Head, Neck and Brain, 6e - Bhagwan Din Chaurasia PDF

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Sixth

Preface to the Sirth Edition vil

I-Iii{rdduction qnd Osteology Noso/ Bones 48

3. SIde of the Neck 79

Extrooculor Muscles 206 Nosol Septum 240

15. Note ond Fcrsnffiol Sinuses 239 18. Eor 272

2I. lnlroduction 319 Clinical Anatomy 330

lX nerve Lateral pterygoid

Fig. 6.14: Distribution of mandibular nerve (V3)

Nerve to tensor veli palatini

External caroiid artery

Fig. 6.15: Right otic ganglion seen from medial side

Nuclei of Spinol Cord 338 Sensory Components of V Nerve 366

29. Third Ventricle, Lqterol Venlricle qnd ClinicalAnatomy 460

Centrol Port 443 Faets t<:Rem*nnber 465

Blood Supply of Spinol Cord 455 $pots 481

X" lmiroduction ond Osteology 3 t:t.. .,

2. Scolp, Temple ond Foce 59 s&,f

3. Side of the Neck 79

5. Porotid Region 106

Bones of head and neck include the skull, i.e. SkullJoints

BONES OF IHE SKUTL

1. Parietal (2) L. Frontal (1) Fig. 1.1: Anatomical position of skull

a. Internal surface of the cranial vault. Bones Seen in Normo Verticolis

NORMA VERTICATIS E'

Anterolateral or Anterior fonianelle

The parietal tuber (eminence) is the area of maximum

Superior nuchal line

External occipital protuberance

Table 1.1: The emissary veins of the skull

Frontol Region The anterior nasal spine is a sharp projection in the

Middle meningeal artery

Fig. 1.8: Fracturednasal boneandpositionof anteriordivisionof middlemeningeal arteryagainstthepterion

c. wlichruns upwards and backwards

Asterion Zygomatic bone

Zygomatic arch lnfraorbital foramen

External acoustic meatus

Supramastoid crest Pterion J

Slructures Possing through Foromino

Sulcus tubae Les$er palatine foramen

Mastoid process Stylomastoid foramen (Vll nerve)

Foramen spinosum and sPine of

lnfratemporal crest Posterior margin of inferior

Continuous with pterygoid process

Spine of sphenoid Peirous part of temPoral bone

Palato - Palatine process i.ofererfAres

Tensor veli palatini (V3)

Levator veli palatini

Superior constrictor of pharynx (pharyngeal plexus)

lnternal carotid artery and

Greater petrosal nerve Deep petrosal nerve

Spinal root of accessory

Lowest part of medulla oblongata Pia mater

Fig. 1.16: Structures passing through foramen magnum

:;;'r;;';'','" :. :: : :.: ': ::. .r.::' ,.::::,1:::tlj:.,a:i.::t1.1]ii:ti;,

Vein Foramen Drainage

Fig. 1.17: Diploic veins in an adult

Anterior Croniol Fosso #fit*rSsmfures

Anterior ethmoidal canal

Superior orbital fissure

Greater wing of sphenoid bone

Hypophyseal fossa (sella turcica)