NERVOUS SYSTEM MODULE

GROSS ANATOMY OF THE HEAD

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 Course outline
• Introduction
• Skull
• Meninges
• Eye and Ear
• NVS
• Clinical significance

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 Introduction to nervous system
• The nervous system is a complex network of nerves and cells
that carry messages to and from the brain and spinal cord to
various parts of the body
• The nervous system is divided structurally in to the
 central nervous system and
 peripheral nervous system.
• The central nervous system include the
brain and
 spinal cord.
• The peripheral nervous system includes:
 cranial nerves and
 spinal nerves
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 • The entire CNS is protected by a bony encasement
• The spinal cord is surrounded by
vertebral column &
brain by cranium.
• The meninges are connective tissue encasements that form
a protective membrane between the soft tissue of the
CNS.

The Skull
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 Introduction
• The skull is a bony structure that supports the face and
forms a protective cavity for the brain.

• It is comprised of many bones, formed by

intramembranous ossification, which are joined together
by sutures (fibrous joints).

• These joints fuse together in adulthood, thus permitting

brain growth during adolescence.

• The bones of the skull can be divided into two groups:

– the cranium (skullcap/ calvarium + cranial base)
– facial skeleton

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Introduction
• Formed by two sets of bones
• 8 cranial bones (calvaria/cranium) – enclose brain
• 14 facial bones - forms face
• These 22 bones combine to form the cranial cavity and the
facial features
• Most bones of the skull are flat bones
• Except for the mandible, all bones are firmly united by
interlocking sutures

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 Functions of the skull
• The bones of the skull provide
 a case to house the brain, the cranium
 a framework for the face
 cavities to house the organs of sight, taste, hearing
and smell
 passages for air and food
 attachment sites for the teeth
 attachment sites for muscle

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• Position of the skull in
erect posture:
– the lower margin of the orbit and
the upper margin of the external
acoustic meatus must be on the
same horizontal plane (eye-ear
plane).
• Layers of skull
– pericranium, lamellae, diploe and
endocranium
• Two types of skull bone based on
their development
– Neurocranium
– Viscerocranium
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 Cranial vault
• The cranial vault or
calvaria forms the
superior, lateral and
posterior aspects of
skull.

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 Cranial Base
• Cranial base forms the skull’s
inferior aspect.

• Three prominent ridges divide

the base into fossae.

• The brain rests on these cranial

fossae completely enclosed by
the cranial vault.

• The brain occupies the cranial

cavity.
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 Cavities of the Skull
• In addition to the large cranial cavity there are
many smaller cavities.
– Middle and inner ear cavities
– Nasal cavity
– Orbits for the eyes

– Several bones contain air filled sinuses

• Sinuses surround the nasal cavity thus referred
to as the paranasal sinuses

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 Cranium

• Composed of eight flat bones surrounding and

protecting the brain.

– Paired - parietal and temporal

– Unpaired - frontal, occipital, sphenoid and ethmoid

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 Frontal bone
• Forms the anterior
portion of the cranium;
the forehead, roofs of
the orbits, and most of
the anterior cranial
fossa.

• PARTS
– Zygomatic process

– orbital plate: forms

anterior cranial fossa.

– frontal squama: forms

forehead, in fetal skull
right and left halves are
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Frontal bone: bone markings
• Supraciliary arches - above the medial
part of the orbit
• Supraorbital notch (foramen) - transmit
supraorbital nerve and vessels
• Supraorbital margin - thickening above
orbits; from this margin, frontal bone
extends posteriorly to form roof of orbit
• Frontal eminence
• Glabella
• Nasion
• Frontal sinuses
• Sutures - coronal, frontonasal,
frontomaxillary, zygomaticofrontal
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 Parietal bones
• Forms most of the superior &
lateral aspects of the skull
• Articulates with other cranial
bones to form three major
sutures
– Coronal
– Lambdoid
– Parietotemporal/squamous
• Articulates with each other at
Sagittal suture

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• General features
– Two curved lines on lateral
surface
• Superior and inferior temporal
lines - gives attachment of
epicranial aponeurosis,
temporal fascia and temporalis
muscle
• Landmarks
– Emissary foramen; located at
the posterior end of the sagittal
suture (2-4cm anterior to the lambdoid
suture )
• It connects the veins of the
scalp with superior sagittal
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 Occipital bone
• Forms most of the posterior
wall and base of skull
• Articulates with parietal,
temporal and the first cervical
vertebrae
• Bound foramen magnum
• Parts
– Squamous
– basilar
• Sutures- lambdoid,
occipitomastoid, sagittal.

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 Occipital bone: landmarks
• Foramen magnum – large oval opening; communicate
cranial cavity with vertebral canal.

• Occipital condyles – oval processes on either side of

foramen magnum; articulate with atlas to form atlanto-
occipital joint.

• External occipital protuberance – midline projection

posteriorly
• External occipital crest - a ridge in the median plane
from external occipital protuberance to foramen magnum.

• Nuchal lines
• Superior nuchal line - runs laterally from external
occipital protuberance. It is a boundary between
scalp and neck
• Inferior nuchalHU,
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Temporal Bone
• Forms
– Inferolateral
aspects of the
skull
– Parts of the
cranial floor
• Divided into four
regions
– Squamous
– Tympanic
– Mastoid
– petrous
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Temporal Bone: Squamous part
• Anterior and superior part.

• Zygomatic process: projection from inferior part; meets

the zygomatic bone to form zygomatic arch.

• Zygomatic arch - formed by the union of processes of

the temporal and zygomatic bone; attachment for
masseter, temporal fascia and lateral ligament of
temporomandibular joint.

• Mandibular fossa – inferiorly, receives condyle of

mandible to form temporomandibular joint.

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Temporal Bone: Mastoid part
• Posterior and inferior to ear canal.

• Contains mastoid air cells.

• Mastoid process - point of attachment for muscles of neck.

• Mastoid foramen – transmit emissary vein, connects the

sigmoid sinus with occipital and posterior. auricular veins.

– It transmits also meningeal occipital artery.

• Styloid process - attachment for stylopharyngeus, stylohyoid

and styloglossus muscles and ligaments - stylohyoid and
stylomandibular.
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Temporal Bone: Tympanic part

• Contains external acoustic meatus

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 Temporal Bone: Petrous part
• Contributes to the cranial floor
• with sphenoid bone form the middle cranial fossa
• Houses internal and middle ear
• Contains carotid foramen
• Landmarks
– Jugular foramen: entry point for the
internal jugular vein
– Internal acoustic meatus: entry point for
the auditory nerve
– Stylomastoid foramen: exit for facial
nerve
– Carotid canal: entrance for the carotid
artery

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 Sphenoid bone

• Bone spanning the width of middle cranial fossa

• Resembles bat with stretched wings
• Articulates as central wedge with all cranial bones
• Parts
– Consists of central body and three processes;
greater and lesser wings and pterygoid process

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Body
– cube shaped medial portion
– superior surface is termed as Sella turcica
• tuberculum sellae – anterior horn
• hypophyseal fossa - for pituitary gland
• dorsum sellae – posterior horn
– contain sphenoidal sinuses

Greater wings
– forms anterolateral floor and lateral wall of middle cranial cavity
Lesser wings
– forms part of posterior floor of anterior cranial cavity and part of orbit.

Pterygoid Processes - medial and lateral pterygoid plates which

extends inferiorly from the junction of body and greater wings
– Pterygoid fossa - V shaped space b/n the two pterygoid plates
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Foramina
– Optic foramina – between body and
lesser wing
– Superior orbital fissure – between
greater and lesser wings
– Foramen rotundum, ovale and
spinosum on greater wing.

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 Sphenoid bone

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 Ethmoid bone
Forms;
1. Part of cranial floor(A)
2. Wall of orbit (M)
3. Portion of nasal septum and
nasal cavity (S)

• Lies between nasal bones &

sphenoid
• Forms most of the area
between the nasal cavity &
orbits of eyes.
• Complex shape gives rise to
nasal septum, sinuses and
cribiform plate.

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 Ethmoid bone: parts
• Lateral mass
– contain ethmoidal sinuses
– forms superior and middle nasal conchae
• Project into nasal cavity
• Middle part
– Perpendicular plate
• Forms superior part of nasal septum
– Cribiform plates
• Forms roof of nasal cavity
• Contains olfactory foramina for olfactory nerves
– Crista galli
• Project up ward from cribriform plate
• Attachment of the dura mater/falx cerebri
– Orbital plates
• Forms medial walls of orbits

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 Facial bones

• Consists of 14 bones
– Paired - maxilla, zygomatic,
palatine, nasal, lacrimal,
inferior nasal conchae
– Unpaired - mandible and
vomer

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 Nasal bones

• Forms bridge of the nose.

• Thin, rectangular shape.
• Fused medially.
• Articulate with the frontal
bone and maxillary bones
laterally and with nasal
cartilages.

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 Mandible
• Forms the lower jaw.

• Largest, strongest bone of

the face.

• The only movable bone of

the skull.

• Houses lower dentition.

• Two parts - the body and

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Mandible: body
• Curved, horizontal portion
• Two surfaces: external and internal
• Two boarders: upper and lower

• External surface
– Symphysis menti - between right and left parts, ossify at
the end of the first month of postnatal period, at birth
the right and the left halves are connected by
fibrocartilage.
– Mental protuberance- triangular area below the
symphysis.
– Mental tubercle- on each side of the base of the
protuberance.
– Oblique line- directs back ward and up ward from
mental tubercle to the anterior boarder of the ramus.
– Mental foramen - belowHU, theCOHMS
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2nd premolar; transmit mental nerve and
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• Internal surface of Mandible
– Four genial tubercles - two superior
and two inferior

– Mylohyoid line - from inferior genial

tubercle to behind the last molar teeth;
directs up and backward.

– Submandibular fossa - below the

mylohyoid line
– Sublingual fossa- above mylohyoid line

Upper (alveolar) boarder - contains

16 and 10 sockets in adults and
children respectively

Lower boarder- forms the base of

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 Mandible: Ramus
• Perpendicular portion
• Two surfaces - lateral and medial
• Four borders - anterior, posterior, upper and medial
• Medial surface - mandibular foramen, lingula, mylohyoid groove
• Superiorly posses two processes
– Coronoid process - the anterior process
– Condylar process - the posterior process having two parts,
the head and neck
• Head – articulate with mandibular fossa and articular
eminence to form TMJ
• Neck - anteriorly has Pterygoid fossa
• Mandibular foramen – entrance to mandibular canal
• Mandibular canal - begins at the mandibular foramen, passes
forward and downward, divides into incisive and mental canal
below the 2nd premolar
– Communicates with sockets of the teeth
– Transmit inferior alveolar vessels and nerve
• Dentists use mental and mandibular foramina to inject
anesthetics
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 External surface

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 Internal surface of Mandible

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 Maxillary bone
• Forms upper jaw and central portion of
facial skeleton
• Surround anterior nasal aperture and unite
in medial plane
• Articulates with all facial bones except
mandible
• Forms upper dentition
• Surfaces - nasal, orbital, infratemporal, and
anterior
• Parts – Body and Four processes - frontal,
alveolar, zygomatic and palatine
• Body – houses maxillary sinus
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• Frontal process
– Forms lateral aspects of nose
– articulate with the frontal bone and form the medial wall of the infraorbital
border
• Alveolar process - forms socket for maxillary teeth
• Zygomatic process - articulates with zygomatic bone and
completes the infraorbital rim
• Palatine process
– Forms anterior 2/3 of hard palate
– presents median palatine suture (between the two palatine processes of the
maxilla) and incisive foramen posterior to the maxillary central teeth
(transmits nasopalatine nerve and vessels)

• Foramina
• Infraorbital foramen – transmit Infraorbital nerve and blood vessels to face
• Inferior orbital fissure – between greater wing and maxilla

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 Maxillary bone

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 Zygomatic bones
• Commonly called the cheekbones
• Form prominences of cheeks and
inferolateral margins of orbits
• Articulate with the frontal, temporal,
sphenoidal and maxillary bones
• Three processes - frontal, temporal
and maxillary
• Two surfaces - lateral and temporal
• Foramen - Zygomaticotemporal and
Zygomaticofacial

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 Lacrimal Bones
• Forms part of the
medial border of
each orbit
• Articulates with frontal,
ethmoid & maxillae
• Forms part of Lacrimal
fossa

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Palatine bones
• L- shaped
• Parts
• Horizontal plate
– Forms posterior portion
of hard palate
• Vertical plate
– Forms part of the
posteriolateral walls of
nasal cavity
• Orbital surface
– Forms part of inferior
medial aspect of orbit

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 Inferior Nasal Conchae
• Form part of lateral
walls of nasal cavity
• Project medially from
the lateral walls of
nasal cavity
• Largest of nasal
conchae
• NB: superior and
middle concha are on
the ethmoid bone

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 Skull joints
• Sutures
– Immovable joint between skull bones
– 4 prominent
• Coronal suture - between frontal and the
two parietal bones
• Sagittal suture - between the two parietal
bones
• Lambdoid suture - between the two
parietals and occipital bone
• Squamous suture - between parietal and
temporal bones

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• Pterion
– Area at which bones forming the floor
of the temporal fossa articulate
(frontal, parietal, temporal and
sphenoid)
– H shaped suture
– Clinically important landmark because
anterior branch of middle meningeal
artery lies in a groove on internal
aspect of this area.
• Thus, it is vulnerable to tearing if there is
fracture and results in extradural
hematomas which can exert pressure on
cerebral cortex

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Temporomandibular joint (TMJ)
• Articulating surfaces
– Head of mandible
– Mandibular fossa and articular tubercle of the temporal
bone
• Type of joint
– Modified hinge synovial joint
• Articular Capsule
– surround the joint
– thickened laterally to form ligaments
• Articular disc
– dividing joint cavity into a lower compartment & upper
compartment
• Major supportive elements of the TMJ
• muscles of mastication

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• Ligaments of TMJ; Minor supportive of TMJ
– Temporomandibular ligament - thickening of the joint
capsule
– Stylomandibular ligament - behind and medial
– Sphenomandibular ligament - medially attached to the
sphenoid and mandible
• Synovial membrane – lines the capsule in the upper and
lower parts the joint cavity
• Nerve supply – Auriclotemporal and nerve to
masseter
• Arterial supply – from superficial temporal
• Relations of TMJ
• Posteriorly – external acoustic meatus
• Laterally – parotid gland
• Medially – maxillary vessels and auriclotemporal nerve

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 Internal surface of the base of the skull (Norma
basalis interna)
1. INTERNAL SURFACE OF THE SKULL CAP
(CALVARIA)
Bones: frontal anteriorly, two parietal
bones laterally and occipital bone
posteriorly
General and particular features
• Three sutures: sagittal, coronal and
lambdoid
• Frontal crest - attachment for the
anterior end of falx cerebri
• Sagittal sulcus - midline along the
sagittal suture ,anteriorly ending
on the frontal crest.
– It houses the superior sagittal sinus
and is attachment for falx cerebri
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• Granular pits (faveolae)- located
on the side of the frontal sulcus,
it is the impression of the
arachnoid granulation
• Groove for meningeal vessels-
impressions of anterior (frontal)
branch of middle meningeal
artery. It lies 1cm behind
coronal suture and is a land
mark of precentral gyrus
• Two parietal emissary foramina -
in front of the lambdoid suture
• Impression of the cerebral gyri
of the brain

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 Internal feature of the calvaria

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 Internal feature of the parietal bone

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2. INTERNAL SURFACE OF THE BASE OF THE SKULL
Cranial fossae
• Internal aspect of cranial base
• Supports the brain
• Three cranial fossae: anterior, middle and
posterior
– Has 3 levels, each is slightly inferior to the
one anterior to it

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 Anterior cranial fossa
• Bones forming are
– Median part- anteriorly ethmoid bone (cribriform plate and
crista galli ) and posteriorly anterior part of body of sphenoid
– Lateral part- anteriorly orbital plate of frontal and posteriorly
lesser wing of sphenoid
General and particular features
Median part presents
• frontal crest
• crista galli
• foramen caecum - between frontal crest and crista galli
transmitting emissary veins connecting sagittal sinus with veins of
the nose and frontal sinus

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• Cribriform plate of ethmoid- at the sides of the crista
galli, communicate cranial fossa and nasal cavity
• Anterior and posterior ethmoidal canals- communicate
orbit with cranial cavity
• Slit at the side of the crista galli- transmits anterior
ethmoidal nerves and vessels from cranial cavity to the
nasal cavity
Lateral part presents
• Anteriorly - orbital plate of frontal bone
• Posteriorly- lesser wing of the sphenoid, lateral end is
pterion and medial end is anterior clenoid process

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 Middle cranial fossa
 Deeper than anterior cranial fossa
 Bones forming are;
 body of sphenoid medially
 laterally greater wing of sphenoid,
petrous and squamous part of temporal
bone
General and particular features
Median part
• Sulcus chiasmaticus- leads into the optic
canal
• Hypophyseal fossa(sella turcica)- roof
of the sphenoid air sinus, contains
pituitary gland
• Dorsum sellae of sphenoid- plate of
bone behind the sella turcica;
attachment for the diaphragm sellae
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• Two posterior clenoid processes: attachment for the
anterior end of the tentorium cerebelli
• Groove for internal carotid artery and cavernous
sinus
Lateral part
• Lodges temporal lobe of cerebrum
• Anteriorly, inferiorly and laterally related to the
orbit, infratemporal fossa and the temporal fossa
respectively

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Foramina
• Optic canal – traversed by optic
nerve and ophthalmic artery
• Superior orbital fissure – slit
between greater and lesser wings
of sphenoid bone; traversed by
CN III, IV, V1 and ophthalmic
veins
• Foramen rotundum –
communicate middle cranial fossa
with pterygopalatine fossa; transmit
maxillary nerve
• Foramen ovale
– Communicate middle cranial
fossa with infratemporal fossa
– Transmit mandibular nerve,
accessory meningeal artery &
emissary veins (connect the
cavernous sinus with pterygoid
venous plexus)
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• Foramen spinosum – communicate middle cranial
fossa with infratemporal fossa; transmit middle
meningeal artery & vein and meningeal branch of
CN V
• Foramen lacerum - between body of sphenoid and
apex of petrous bone; in life is closed & only emissary
veins passes
– Carotid and pterygoid canals open into it
– Superior end contains internal carotid artery
• Trigeminal impression – formed by trigeminal
ganglion
• Groove for superior petrosal sinus - houses the
superior petrosal sinus and the lips of the grooves
for attachment of the tentorium cerebri

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• Inferior part
– Carotid canal – connect F. lacerum & pterygopalatine
fossa ; upper end directs anteriorly & medially to open
into the posterior wall of F. lacerum; contains internal
carotid A, sympathetic plexus and plexus of veins

– Squamotympanic fissure - for transmitting the chorda

tympani nerve to middle ear

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 Posterior cranial fossa
• The largest and the deepest fossa
containing pons and medulla
oblongata anteriorly and cerebellum
posteriorly
Formed by
• Anteriorly in order: dorsum sellae of
sphenoid, posterior part of body of
sphenoid and basilar part of occipital
bones
• Laterally: posterior surface of petrous
part of temporal bone, mastoid part
of temporal bone and condylar part
of the occipital bone
• Posteriorly:: squamous part of
occipital bone
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General and particular features
• Foramen magnum
– bounded by basilar, condylar and squamous part of
the occipital bone anteriorly, laterally and posteriorly
respectively
• Groove for inferior petrosal sinus
– located lateral to the clivus and passes dawn ward
along the petrooccipital suture to reach jugular
foramen
• Jugular foramen
– three parts; anterior part for inferior petrosal sinus,
middle parts for CN IX, X and XI and the posterior
part for internal jugular vein

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• Hypoglossal canal (anterior condylar canal)
– Transmit hypoglossal nerve, meningeal branch of
ascending pharyngeal A & emissary veins from
basilar plexus
• Internal acoustic meatus
– In the posterior surface of petrous temporal
– Its lateral end is closed
– Structures passing through it are facial nerve
(motor + sensory), vestibulo-cochlear nerve and
labyrinthine artery
• Sigmoid sulcus
– S shaped groove on the mastoid and petrous part
of temporal bone

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• Mastoid foramen
– Pierce the floor of the sigmoid sulcus and transmits
meningeal branch of occipital artery and emissary veins
• Posterior condylar canal
– Transmit emissary veins connecting sigmoid sinus with
sub occipital venous plexus
• Internal occipital crest
– related to the occipital sinus; attachment for falx cerebelli
• Internal occipital protuberance
– related to the confluence of sinuses
• Groove for transverse sinus
– contains transverse sinus and its margin is for attachment
for tentorium cerebelli
• Cerebellar fossa
– on both sides of internal occipital crest, housing the two
hemispheres of cerebellum

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Age difference in the skull bone
Skull at birth
• The cranium is large
• The bone of the face are small; it is 1/8 of the
size of the skull at birth but is 1/2 of the size
of the skull in adults
• Paranasal sinuses are absent
• The maxillae are short
• The teeth are absent
• Frontal (Metopic) suture between the two
frontal bones
• Bones are connected by membranous sutures
and fontanels

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Fontanels
• Membranous part of sutures
• Provide flexibility to skull
• 6 prominent
– Anterior fontanel
• Diamond shape
• At the meeting of coronal and sagittal suture
• Closes by 18 months to 2 years and is then known as the
bregma
– Posterior fontanel
• Triangular in shape, at the junction of sagittal and lambdoid
sutures
• Ossify at the 3rd month of postnatal life

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– Anteriolateral fontanels
• Present at the meeting of parietal,
frontal, greater wing of sphenoid
and squamous part of temporal
bone
• Ossify at the 3rd month of
postnatal life
– Posterolateral fontanels
• Present at the meeting of parietal,
mastoid part of temporal and
occipital bone
• Ossify at the 3rd month of
postnatal life

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 Introduction
• Meninges are three connective tissue membranes that
lie just external to the brain and spinal cord
• Functions
– Cover and protect the CNS structures
– Protect blood vessels and enclose venous sinuses
– Contain cerebrospinal fluid
– Form partitions within the skull
• From external to internal, the meningeal layers are
– Dura mater
– Arachnoid
– Pia mater

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 The Dura Mater
• The leathery dura mater is by far the strongest of the
meninges
• Where it surrounds the brain it is a double layer
membrane
– endosteal layer - superficial and lines the inner surface of
the skull (periosteum)
– meningeal layer - internal, forms the true external covering
of the brain
• The brain’s dural layers are fused together except in
certain areas where they enclose the blood filled dural
sinuses
– The dural sinuses collect venous blood and direct it into the
internal jugular veins of the neck

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 The Arachnoid Mater
• The middle membrane; forms a loose brain covering
• It is separated from the dura mater by a narrow cavity,
the subdural space
• Beneath the arachnoid membrane is the wide
subarachnoid space
– The subarachnoid space is filled with cerebrospinal fluid and
contains the largest blood vessels serving the brain
• Arachnoid villi protrude through the overlying dura
mater and into the dural sinuses overlying the superior
aspect of the brain.
– Cerebrospinal fluid is absorbed into the venous blood sinuses
through these villi.

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 The Pia Mater
• The pia mater is a delicate connective tissue
that is richly invested with tiny blood vessels
• It is the only membrane that clings tightly to
the brain, following its every convolution

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 Dural septa (folds)
• In several places the meningeal dura mater extends inward to
form flat septa (partitions) that limit movement of the brain within
the skull
• Falx cerebri
– Sickle-shaped, vertical in medial longitudinal fissure
between the two cerebral hemisphere
– Attachments
• Anterior end - the crista galli of the ethmoid bone
• Posterior end - upper surface of tentorium cerebelli
• Upper margin - internal surface of calvaria from frontal crest to
internal occipital protuberance
• Lower margin - free
– 3 venous sinuses in relation to it - superior sagittal, inferior
sagittal and straight sinuses.

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• Tentorium cerebelli
– forms roof of posterior cranial
fossa
– separate cerebellum from occipital
lobes of cerebrum
– free margin - anteriorly, u-shaped
opening called tentorial notch
surrounds midbrain
– attached margin - attached to
occipital bone (posterolaterally)
and petromastoid (anterolaterally)
– sinuses - transverse and superior
petrosal sinuses
– recess - trigeminal cave:
evagination over trigeminal
impression on petrous temporal
bone, containing trigeminal
ganglion
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• Falx cerebelli
– sickle-shaped, forms a midline partition that
project into posterior cerebellar notch
– extends vertically below tentorium
– base – attached to posterior part of
tentorium
– apex – divide and lost to sides of foramen
magnum
– posterior margin – attached to internal
occipital crest, enclose occipital sinus
– anterior margin – free
• Diaphragma sellae
– horizontal sheet, forms a roof for
hypophyseal fossa
– central aperture for hypophyseal stalk and
veins

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Blood supply of dura
• middle meningeal artery
– branch of maxillary
– course – enter cranial cavity through foramen spinosum;
descend laterally on greater wing; divide into anterior and
posterior branches; ramify
• other arteries – meningeal branches of many arteries
• veins – accompany arteries
– middle meningeal leave skull through foramen spinosum and
ovale and joins pterygoid plexus
Nerve supply
• sensory nerve – trigeminal (major), vagus and superior
cervical (minor)

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 Venous sinuses
• venous channels; drain blood from brain,
meninges and skull
• wall formed by dura and internal
periosteum
• usually found along attachment of dural septa
• Superior sagittal sinus
– along attached border of falx cerebri
– ends by turning to right transverse
sinus (usually) or dilate at termination
and join the straight sinus, together
form the confluence of the sinuses
• Inferior sagittal sinus
– along free edge of falx cerebri
– ends joining great cerebral vein to
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• Straight sinus
– lies along junction of falx cerebri and
tentorium
– ends by continuing as left transverse
sinus (usually)
• Transverse sinuses
– along attached margin of tentorium
– ends bending downwards to become
sigmoid sinus
• Sigmoid sinuses
– s-shaped
– at jugular foramen it becomes superior
bulb of internal jugular vein

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• Occipital sinus
– lies in attached margin of falx cerebelli
– begins near foramen magnum and ends in confluence of
sinuses
• Sphenoparietal sinuses
– lies along posterior margin of lesser wing of sphenoid
– drain into anterior part of cavernous sinus
• Superior petrosal sinuses
– lie in anterior part of attached margin of tentorium
– drain cavernous sinus to transverse sinus

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• Inferior petrosal sinuses
– lie in petro-occipital fissure
– drain cavernous sinus into internal jugular vein
• Basilar sinus (plexus of veins)
– venous plexus on clivus
– connect the two inferior petrosal sinuses
• Inter-cavernous sinuses
– connects cavernous sinuses
– pass through diaphragma sellae

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• Cavernous sinuses
– lie on each side of body of sphenoid, from superior
orbital fissure to apex of petrous temporal bone
– Relations
– structures out side the sinus
• superiorly – optic tract, internal carotid artery, anterior
perforated substance
• inferiorly – foramen lacerum, junction of body and greater
wing
• medially – hypophysis cerebri and body of sphenoid (air
sinuses)
• laterally – temporal lobe (uncus)
• anteriorly – superior orbital fissure
• posteriorly – apex of petrous and crus cerebri
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 – structures in lateral wall (from superior to inferior)
• occulomotor nerve, trochlear nerve, ophthalmic nerve,
maxillary nerve, trigeminal ganglion
– structures passing through the sinus
• internal carotid artery
• abducent nerve

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• Tributaries
– from orbit – superior and inferior ophthalmic veins, central
vein of retina
– from brain – superficial middle cerebral and inferior cerebral
veins
– from meninges – sphenoparietal sinus, anterior trunk of
middle meningeal vein
• Communications
– transverse sinus through superior petrosal sinus
– internal jugular vein through inferior petrosal sinus
– pterygoid plexus through emissary veins
– facial vein through ophthalmic veins
– NB: All communications are valve less. Thus blood can flow in
any direction
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• Applied anatomy
– Facial veins communicate with cavernous sinus through
ophthalmic veins. Thus, infections in facial vein can extend
into dural venous sinuses

– Internal carotid artery is enveloped by cavernous sinus.

– In fractures of skull base, the artery may rapture within the

sinus producing arterio-venous fistula, which allows arterial
blood to rush into cavernous sinus and thus to ophthalmic
vein resulting in protrusion of eye (exophtalmos) and
engorgement of conjunctiva

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 The Scalp
 A stiff structure coving the skull/cranium
 Boundaries
– Anteriorly- eye brows
– Posteriorly- superior nuchal line
– Laterally- temporal line

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• S - skin
• C - connective tissue or superficial fascia
• A - aponeurotic layer which consists of frontalis and
occipitalis muscles connected
by a dense fibrous sheet, the galea aponeurotica (epicranial
aponeurosis)
• L - loose subaponeurotic layer
• P - pericranium, the periosteum of the bone

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• Occiptofrontalis muscle
– Has two bellies, the frontal and the occipital
bellies connected by the aponeurosis
– Frontal belly (frontalis)
• Origin - the epicranial aponeurosis
• Insertion - the skin around the forehead and the
eye brow
• Nerve supply - temporal branch of facial nerve

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 – Occipital belly (occipitalis)
• Origin - the lateral 2/3 of the superior nuchal line
and mastoid part of temporal
• Insertion - epicranial aponeurosis
• Nerve supply - posterior auricular branch of the
facial nerve
– Action - move the scalp forward and backs ward.
The frontal belly raises the eyebrow to express
surprise.

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Nerves of the scalp
• 10 nerves on each side, 5 in front of the auricle and 5
behind the auricle
• In front of the auricle
– Motor - temporal branch of facial nerve
– Sensory -branches of all the 3 divisions of trigeminal
• Supraorbital nerve - branch of ophthalmic nerve
• Supratrochlear nerve - branch of ophthalmic nerve
• Zygomaticotemporal nerve - from maxillary nerve
• Auriculotemporal nerve - from mandibular nerve

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• Behind the auricle
– Motor - posterior auricular branch of facial nerve
– Sensory - branches from C2, C3
• Great auricular nerve
• Greater occipital n. (dorsal ramus C2)
• Lesser occipital n. (ventral ramus C2 and C3)
• Third occipital n. (dorsal ramus C3)

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 Blood supply
• Arteries of the scalp
– numerous anastomoses between external and
internal carotid arteries
– Branches of the external carotid
• Superficial temporal
• Occipital
• Posterior auricular
– Branches of the internal carotid, via the ophthalmic
artery
• Supraorbital
• Supratrochlear
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Veins of the scalp
• Veins draining into the anterior facial vein
– Supraorbital
– Supratrochlear
• Veins draining into maxillary /external jugular veins
– Superficial temporal
– Occipital
– Posterior auricular
• Emissary veins connect extra cranial veins with
venous sinuses. Infection may spread through them
into intracranial sinuses

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 Lymphatic drainage of the scalp
• Submandibular lymph nodes – forehead
• Parotid lymph nodes - from the area of the temple and
the scalp anterior the auricle
• Mastoid (retro auricular) and occipital lymph nodes -
from the scalp behind the auricle
– Mastoid lymph nodes - the upper end of the
sternocleidomastoid muscle
– Occipital lymph nodes - upper end of the trapezius
muscle

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Clinical correlations
 Few of the branches of arteries of the scalp cross down to
supply calvaria which is supplied by middle meningeal artery.

Thus, scalping does not produce necrosis of cranial bone

 Superficial infections of the scalp tend to remain superficial

because of the dense aponeurotic layer
 Due to the denseness of this layer of the scalp, blood vessels in this
area are unable to retract or contract when lacerated and because scalp has
rich blood supply, scalp wounds tend to bleed profusely

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 Infections in the loose subaponeurotic layer, however, can be
transmitted through bony channels by emissary and diploic
veins to the cranial cavity.
 Thus, this layer is considered as dangerous area of scalp

 Fluid accumulating in subaponeurtic layer cannot pass

posteriorly or laterally because of the bony attachments of
the occipitalis and galea aponeurotica to the occipital bone
and zygomatic arches.

 However, since the frontalis muscle is inserted into the skin

and not into bone, fluids can enter the eyelids and the nasion
region of the nose. HU, COHMS BY: Merga S. for PCII,
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 The face

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 Boundaries
 Superiorly – the margins of the hair
 Inferiorly – the chin
 Laterally – the auricle
N.B. the forehead is common for the scalp
and the face

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• Skin
– Very vascular; wounds bleed profusely but heal rapidly
– Rich in sebaceous and sweat glands
– Lax except in ear and nose; edema spread rapidly
– Elastic and thick; wounds tend to gap
• Superficial fascia
– Contain facial muscles, nerves, vessels and fat (buccal fat
pad in cheeks)
• Deep fascia
– Absent except over parotid gland and over buccinator
muscle

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 Muscles of the face
• Lie in subcutaneous tissue
• Inserted: in to the skin
• Named as muscles of facial expression
• Arranged in groups around the orbit, nose, mouth and
auricles
– functionally considered as regulators of openings
• Supplied from branches of facial nerve

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 Muscle of facial expression
• Originate in the superficial fascia or on the skull bones.

• Insert into the superficial fascia of the skin(dermis).

• Occipitofrontalis: is the muscle of the scalp.

 moves the scalp, forehead skin, and eyebrows.

• Orbicularis oculi: is sphincter encircled each eye that closes

the eye.

• levator palpebrae superioris: opens the eye

 it lies deep to the orbicularis oculi in the eyelid and roof

of the orbit.
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 Muscles of Mastication
• Refers to the process of chewing.
• Move the mandible at the
temporomandibular joint.
• Four paired muscles of mastication
 temporalis
 masseter

 lateral pterygoids

 medial pterygoids

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Muscles of the eyelids and eyebrow
• Orbicularis Oculi
– Three parts - supplied by temporal branches of
facial nerves
1. Palpebral
 Origin: Medial palpebral ligament and bones
above and below the ligament
 Insertion: Skin of the eye lid passing anterior
to the tarsal plate
 Action: Close the palpebral fissure firmly to
protect from danger
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 2. Orbital
 Origin: Medial palpebral ligament and bones above and
below the ligament
 Insertion: No lateral attachment b/c the fibers form
concentric ring
 Action: Gentle close , during sleeping
3. Lacrimal
 Origin: Two- posterior margin of the fossa of
lacrimal sac and sheath of the lacrimal sac
 Insertion: upper and lower eyelids, upper and lower tarsi
 Action: Passing tear into lacrimal puncta by drawing the eye-
lids medially, dilating the lacrimal fossa

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2. Corrugators supercilli
Origin: Medial part of superciliary arch
Insertion: Skin of eye brows
Action: Vertical wrinkling of middle part of fore
head (frowning )
N.S. Temporal branch of facial nerve
• Levator palpebrae superioris
• Raises upper eye lid

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 Muscles around nose

Muscle Origin Insertion Action

Medial part Transverse

Nasal bone
Proceruss of the skin wrinkles
& lateral
of the eye (horror )
cartilage
brows

Join the Compress

Maxilla
Compressor fibers of its anterior
(frontal
naris opposite nasal
process )
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opening 136
Dilator naris Maxilla Ala of nose

Dilates anterior nasal

openings
Depressor septi Maxilla (above Nasal septum
central incisor )

Levator labii Maxilla (frontal Cartilage and skin of Dilates anterior nasal
superioris alaeque process ) ala of anterior nasal openings Elevate the
nasi opening upper lip
Skin of upper lip

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Nerve supply – buccal branch
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137
 Muscles around mouth
Levator labii Cartilage and skin of Skin of upper lip
superioris alaeque ala of anterior nasal
nasi opening

Mussels elevating
the upper lip

Levator labi Maxilla and

superioris zygomatic bone

Zygomaticus minor Behind

zygomaticomaxillar
y suture

Nerve supply – buccal branch of facial nerve

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Mussels Zygomaticus Zygomatic Skin angle
elevating major bone of the
the angle of behind mouth
the mouth zygomatic Buccal
minor branch
Levator Maxilla
anguli oris below
infraorbita
l foramen
Muscles Depressor Oblique Skin angle
depressing anguli oris line of of the Mandibular
the angle of mandible mouth branch
the mouth

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Muscle pulling the Risorius Parotid Skin of angle Buccal
angle of mouth fascia of the mouth branch
laterally
Muscles Depressor Oblique Angle of the Mandib
depressing the labi line of mouth ular
lower lip inferioris mandible Skin of branch
lower lip
Muscles Incisor Skin of the Mandib
protruding the fossa of chin ular
lower lip and Mentalis the branch
wrinkling the skin mandible
of the chin

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• Buccinator
– Origin: Two site
• Pterogomandibular ligament
• Maxilla and mandible (opposite 3rd molar tooth)
– Insertion:
• Upper fibers – upper lip
• Middle – decussate at the angle
• Lower- lower lip
– Nerve supply: Buccal branches of facial nerve
– Action: Compress the cheek against the gum
– prevent accumulation of food in the vestibule
• Superficial to the buccinator muscle there is buccopharyngeal
fascia, structures piercing are
– Parotid duct – opposite the 2nd upper molar
– Buccal branches of facial nerve- supply the mucus of the
cheek
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Orbicularis Oris
Three parts
Origin:
intrinsic fibers – connect the skin and mucus membrane
Incisive bundles- maxilla and mandible
extrinsic fibers – surrounds the mouth
Insertion: No attachment because the fibers form
concentric ring
Nerve supply: Buccal and mandibular branches of facial
nerves
Action:
Close the oral fissure
Compress the lips against the teeth
protrude the mouth
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Muscles the auricle
• Rudimentary in human
– Anterior auricular
– Posterior auricular
– Superior auricular
• All are not functional in humans and supplied
by branches of facial nerve

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Sensory Nerves of the face
• Two sources
– Skin around the angle of the mandible – greater
auricular nerve (C 2, 3 )
– The rest of the face- trigeminal branches

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 Trigeminal nerve (CN V)
• Sensory to face and motor to muscles
of mastication
• 3 branches
• Ophthalmic nerve
– Sensory
– three branches; lacrimal, frontal and
nasociliary
– Lacrimal – supply lacrimal gland and
conjunctiva and lateral part of the upper eyelid
– Frontal – 2 branches
• Supraorbital –lateral forehead and front of
scalp
• Supratrochlear – supply middle forehead
– Nasociliary
• Infratrochlear – skin and conjunctiva of
the medial part of the eyelid, skin of the
upper ½ of the nose
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• External nasal - skin of the lower2016½
E.Cof the
nose
• Maxillary nerve
– three cutaneous branches
1. Infraorbital – terminal branch; three branches
1. Palpebral – skin and conjunctiva of the lower
eye lid
2. Nasal – skin of the side of the nose
3. Labial – skin and mucus membrane of the
upper lip
2. Zygomaticotemporal - skin over the anterior ½ of
the temple and the scalp
3. Zygomaticofacial - skin over the zygomatic bone

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• Mandibular nerve
– 4 sensory branches
1. Auriculotemporal - posterior 1/2 of the temple, upper
2/3 of the lateral surface of the auricle & skin of the
external acoustic meatus, ear drum
2. Buccal - skin and mucus lining of the cheeks
3. inferior alveolar – lower teeth
1. incisive nerve – incisor and gingiva
2. Mental nerve – skin and mucus lining of the lower
lip and chin
4. Lingual – general sensory to anterior 2/3 of tongue

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 Facial nerve (CN VII)
• Supply
– Motor to muscles of facial expression
– Sensory to taste buds in anterior 2/3 of tongue
– Secretomotor to submandibular and sublingual glands
• Emerge through stylomastoid foramen and enter parotid and gives
five branches
– Temporal – supplies orbital and forehead muscles
– Zygomatic – supplies muscles in zygomatic, orbital and
infraorbital region
– Buccal – supplies buccinator and muscles in upper lip
– Mandibular – supplies muscles in lower lip and chin
– Cervical – supplies platysma

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 Clinical correlations
• Bell's palsy
– Lesions of the facial nerve
– Results in dribbling of tears and saliva due to paralysis of
the orbicularis muscles; and paralysis of buccinators lead
to accumulation of food in the vestibule
– Test by asking patients to smile or to whistle
• loss of muscle tone causes the normal skin folds to
disappear on the side of the lesion

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Blood vessels of the face
Arteries
• six arteries which have free anastomosis
1. From ophthalmic artery - two arteries originating in the orbit
– Supratrochlear
– Supraorbital
2. From external carotid artery – four arteries
• external carotid artery in the parotid gland divides in to two
terminal branches: maxillary and superficial temporal arteries

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A. Facial artery
• Origin - arise from external carotid artery in the neck,
major blood supply of the face
• Course
– tortuous course
– run to lower border of mandible, at the anterior border of
the masseter the pulse is felt
– then ascends first to the angle of the mouth and then up at
the side of the nose to the medial angle of the eye
• The main branches
– Superior labial – upper lip
– Inferior labial – lower lip
– Lateral nasal – nose

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B. Transverse facial
• a branch of superficial temporal artery
– enters the face at the anterior upper border
of the gland
– distribution- the face, parotid gland and its
ducts
C. Infraorbital – one of the terminal branch of
maxillary artery
D. Mental artery- from inferior alveolar artery

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Veins
• Free anastomosis
1. Supratrochlear veins
1. Begins on forehead; descends near middle and joins supraorbital
vein near orbit to form facial vein
2. Supraorbital veins
1. begins near zygomatic process; descends medially and join
supratrochlear
3. Facial vein
1. formed by union of supratrochlear and supraorbital veins at the
medial angle of the orbit
2. Course - leave the face at the anteroinferior angle of masseter;
pierce the deep fascia of the neck; crosses the submandibular
gland; join the anterior division of retromandibular vein to form the
common facial vein draining into the internal jugular vein
3. Tributaries - veins accompanying facial artery

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Lymphatic drainage
• 3 territories
– upper territory - lateral forehead, lateral half of
eyelid and face drain into parotid lymph nodes
– middle territory - median forehead, nose, upper
lip, lateral part of lower lip, medial part of eyelid
and cheeks, most of lower jaw drain into
submandibular lymph nodes
– lower territory - median part of the lower lip
and chin drain into submental lymph nodes

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 THE ORBIT

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 Orbit
• Bony cavity in anterior side of skull
• Lodges eye ball and associated structures
• Shape - four-sided pyramid with a base, apex and four walls (roof,
floor, medial and lateral walls)
• the long axis directs medially and back ward
• Margins
– supraorbital – formed by frontal bone
– lateral – formed by zygomatic process of the frontal bone and
frontal process of zygomatic bone
– infraorbital – zygomatic laterally and maxilla medially
– median – frontal superiorly and maxilla medially

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• Medial wall
– Formed by
• Frontal process of maxilla
• Lacrimal bone
• Orbital pate of ethmoid
• Anterior part of body of sphenoid
– Lacrimal groove – formed by maxilla and lacrimal
bone; fossa for lacrimal sac
• Lateral wall
• Anteriorly – frontal process of zygomatic bone; separate
the orbit form the temporal fossa
• Posteriorly - greater wing of the sphenoid; separating the
middle cranial fossa from the orbit
• Superior orbital fissure
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• Floor
– Formed by
• Maxilla
• Zygomatic
• Orbital process of palatine bone
• Roof
• Anteriorly - orbital plate of frontal bone
• Posteriorly - lesser wing of sphenoid
• Separate orbit from anterior cranial fossa
• The medial walls of the orbit are parallel, whereas the lateral
walls diverge: the long axis of the orbit is at an angle to the long
axis of the eyeball.
• The fibromuscular cone
• A fascial sheath continuous around the muscles
• filled with fat and contains the optic nerve
• Except for the inferior oblique muscle, all the muscles of the
eyeball originate from or near a fibrous ring that encircle the
lower part of the superior orbital fissure and the optic canal.

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Features of the orbit
• Lacrimal fossa - anterolateral part of the roof
– Fossa of lacrimal sac
• Trochlear fossa – anteromedially, attachment for trochlea
• Anterior and posterior ethmoidal foramen - transmits anterior
and posterior ethmoid nerves and vessels.
• Optic canal - at the apex of the orbit, the passage for optic
nerve and ophthalmic artery
• Infraorbital groove and canal - passage for infraorbital nerve
and vessels
• Zygomaticofacial foramen - transmits zygomaticofacial nerve
• Zygomaticotemporal foramen - for Zygomaticotemporal nerve

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• Contents of the orbit
1. Eye ball
2. Fascia
3. Lacrimal glands
4. Muscles:
• Intrinsic – sphincter pupillae, dilator pupillae and ciliary muscles
• Extrinsic – four recti and two oblique
5. Nerves
• Sensory - optic, branches of ophthalmic, zygomatic
• Motor – CN III, IV and VI
6. Ganglion - ciliary
7. Blood vessels - ophthalmic veins and ophthalmic artery
8. Fat

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The eye lids
• Separated from each other by palpebral fissures
• Features
• Lacrimal papilla – small elevation at medial angle of eye
• Lacrimal punctum – opening at the submit of the papilla
• Eye lashes – at the free margins of the eye lid, lateral to the
papilla
• Structures of the eye lid from out side to inside
– Skin
– Subcutaneous tissue – no fat, contain orbicularis occuli
– Palpebral fascia – forms
• Orbital septum
• Tarsal plate – dense fibrous tissue that makes the eye lid hard
• Palpebral ligaments - lateral and medial palpebral ligaments
– Conjunctiva – lines the
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• Sensory nerves of the eye lid
– Upper eye lid
• Medial 1/3 - infratrochlear & Supratrochlear
• Middle 1/3 - supraorbital
• Lateral 1/3 - palpebral branch of lacrimal
– Lower eye lid - infraorbital
• Arterial supply
• Both eye lid - Medial and lateral palpebral
• Upper eye lid - Supratrochlear and supraorbital
• Lower eye lid - branches of facial and infraorbital
• Veins
• Supraconjunctival - ophthalmic
• pretarsal - facial and superficial temporal vein
• Lymph
• Medial half - submandibular
• lateral half - parotid
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Conjunctiva
• Membrane that lines the eye lids
• At point where it leave the eye lids to cover
the sclera it forms the superior and inferior
fornices
• Conjunctival sac – formed when the eye is
closed, communicate with lacrimal sac
through lacrimal canaliculi

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Lacrimal apparatus
• Structures concerned with secretion and drainage of
tear
• consists of
– Lacrimal gland – two parts
• Large orbital – in the lacrimal fossa
• Small palpebral – lateral part of eye lid, b/n palpebral fascia and
conjunctiva
– Excretory ducts open into superior fornix of conjuctival sac
– Secretory parasympatheCc nerve originate in the pons →
facial nerve → greater petrosal → nerve of pterygoid
canal → pterygopalaCne ganglion → zygomaCc nerve →
zygomaCcotemporal nerve → lacrimal nerve → lacrimal
gland

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• Conjunctival sac
• Lacrimal puncta
• Lacrimal canaliculi – 2 small channels begin at
lacrimal punctum and passes medially to
open into lacrimal sac
• Lacrimal sac – within lacrimal groove;
continuous with nasolacrimal duct
• Nasolacrimal duct – runs downwards and
open into inferior meatus of nose

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 Eyeball
• spherical in shape with anterior and posterior poles

• suspended in anterior half of orbital cavity

• The wall is composed of three concentric coats

(tunics) – fibrous, vascular, and sensory

• The internal cavity is fluid filled with humors –

aqueous and vitreous

• The lens separates the internal cavity into anterior

and posterior segments

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 Fibrous Tunic
• Forms the outermost coat of the eye and is composed of
– Opaque sclera (posterior)
– Clear cornea (anterior)
• Sclera
– protects the eye and anchors extrinsic muscles
– dense fibrous tissue
– form posterior 5/6 of eye ball
– posteriorly perforated for passage of optic nerve
– continues anteriorly with cornea at sclerocorneal junction
(limbus)
– inner part of limbus contains circular canal called sinus venosus
sclerae (canal of Schlemm)
– posteriorly fused with dura of optic nerve
– it provides insertion to extrinsic muscles
– pierced by optic nerve, ciliary ganglion, anterior ciliary arteries,
choroids veins
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– it is avascular
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190
• Cornea
– transparent and avascular
– lets light enter the eye
– forms anterior 1/6
– more convex than sclera
– made up of special connective tissue

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 Vascular Tunic (Uvea)
• Has three regions: choroid, ciliary body and iris
• Choroid region
– A dark brown membrane that forms the posterior portion of
the uvea
– Supplies blood to all eye tunics
– Anteriorly ends at ora-serrata by merging with ciliary body
– Posteriorly pierced by optic nerve
– Attached to sclera loosely and retina firmly
– Contain venous plexus and capillaries
• Ciliary Body
– A thickened ring of tissue surrounding the lens
– Connects choroids with iris
– Composed of smooth muscle bundles (ciliary muscles) and
ciliary processes
– Anchors the suspensory ligament that holds the lens in place
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• Iris
– The colored anterior part of the eye
– Posses pigment cells; determine eye color
– Form circular curtain with opening at center called
pupil
– Regulates the amount of light entering the eye by 2
muscles
• Sphincter pupillae (ring muscle)
• Dilator pupillae (radial muscle)
– Close vision and bright light – pupils constrict
– Distant vision and dim light – pupils dilate

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 Sensory Tunic: Retina
• A delicate membrane between choroids and vitreous
body
• Composed of two layers:
– Pigmented layer – the outer layer that absorbs light and
prevents its scattering
– Neural layer – inner layer which contains:
• Photoreceptors that transduce light energy
• Bipolar cells and ganglion cells
• Amacrine and horizontal cells
– Neural layer ends at posterior edge of ciliary body in a wavy
border called ora serrata retinae
– Beyond ora serrata it is continued as a non-nervous layer
– Ganglion cell axons: run along the inner surface of the retina
and leave the eye as the optic nerve
– The optic disc:
• A circular depression at the site where the optic nerve leaves the eye
• Lacks photoreceptors; it is insensitive to light thus called the blind
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• Photoreceptors
– Rods:
• Respond to dim light
– Cones:
• Respond to bright light
• Have high-acuity color vision
– Lateral to optic disc at posterior pole is a small oval
yellowish area called macula lutea; at center is
depressed area called fovea centralis (site of
maximum acuity of vision)

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• Blood Supply to the Retina

– The neural retina receives its blood supply from two

sources

• The outer third receives its blood from the choroids

• The inner two-thirds are served by the central artery and

vein (enter eye with optic nerve)

• Small vessels radiate out from the optic disc; can be

seen with an ophthalmoscope

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 Inner Chambers and Fluids
• The lens separates the internal eye into anterior
and posterior segments
• Posterior segment
– Filled with a clear gel called vitreous humor (body)
– Vitreous humor is not replaced continuously
– functions
• Transmits light
• Supports the posterior surface of the lens
• Holds the neural retina firmly against the pigmented layer
• Contributes to intraocular pressure
• Anterior Segment
– Composed of two chambers
• Anterior – between the cornea and the iris
• Posterior – between the iris and the lens

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• Aqueous humor
– A plasma like fluid that fills the anterior segment
– Produced by ciliary processes (capillaries)
– Drains at iridocorneal angle via the canal of Schlemm
– Function
• Produce intraocular pressure
• Provide nutrient and removes wastes for cornea and lens
– Interference with drainage results in an increase in
intraocular pressure (glaucoma) which lead to
atrophy of retina

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 The Lens
• A biconvex, transparent, flexible, avascular structure
• Allows precise focusing of light onto the retina
• Is composed of epithelium and lens fibers; encapsulated
• Held in position by radially arranged zonular fibers called
suspensory ligament of lens
• Contraction of ciliary muscles relax them and change curvature
of lens
• With age, the lens becomes more compact and dense and loses
its elasticity
• Refractive media of the eye
– Light waves pass through cornea, aqueous humor, lens and
vitreous body

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 Muscles of orbit
• Extraocular muscles
• Levator palpebrae superioris
– Elevates upper eye lid
– Origin – roof of orbit
– Insertion – tendon split into superior and inferior lamina
• Superior lamina – insert into skin
• Inferior lamina – contains some smooth muscle fibers
(superior tarsal muscle) which insert into tarsal plate
– Innervation
• Superior fibers – oculomotor nerve
• Superior tarsal muscle – fibers from cervical sympathetic trunk
– Applied anatomy
• CN III palsy – upper eye lid cannot be raised voluntarily
• Cervical sympathetic trunk interruption – superior tarsal
muscle is paralyzed causing drooping of eye lid (ptosis)

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 Muscles of orbit
Extraocular muscles
• Recti muscles
– 4 recti: superior, inferior, medial and lateral
– origin – from common tendenous ring surrounding
optic canal and middle part of superior orbital fissure
– insertion – sclera of eye ball posterior to
sclerocorneal junction

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 Oblique muscles
• superior oblique
– origin – body of sphenoid, superomedial to
common ring
– insertion – tendon pass through a fibrous pulley
(trochlea) and pass downwards and backwards and
insert into sclera at posterosuperior aspect
• inferior oblique
– origin – orbital surface of maxilla
– insertion – pass upwards and backwards and insert
below superior oblique

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• Nerve supply
– superior oblique – CN IV
– lateral rectus – CN VI
– the rest – CN III
• Actions: rotate eye ball around 3 axes
– superior rectus – elevates and rotates medially
– inferior rectus – depress and rotate medially
– medial rectus – medial rotation (adduct)
– lateral rectus – lateral rotation (abduct)
– superior oblique – downward rotation and laterally
– inferior oblique – upward rotation and laterally

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Blood vessels of the orbit
• Ophthalmic artery
– Branch of internal carotid artery after leaving the cavernous sinuses;
enter the orbit through the optic canal below the optic nerve; become
lateral to the optic nerve; finally positioned above the nerve
– Branches
• Central artery of the retina – enter optic nerve; at optic disc; divide and
spread on retina
• Ciliary arteries - supply the eye ball; anterior groups enter the eye ball at
the corneoscleral junction ; the posterior groups enter around the optic
nerve
• Muscular
• Lacrimal artery – supply lacrimal gland, conjunctiva and eye lid
• Anterior and posterior ethmoidal – for nasal mucosa and sinuses
• Supratrochlear and Supraorbital – supply forehead
• Medial palpebral – eye lid
• Dorsal nasal branches – supply upper nose
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• Ophthalmic veins
– Superior ophthalmic vein
• Accompany the artery, receive tributaries
• Pass through superior orbital fissure and ends in
cavernous sinus
• communicate with facial vein
– Inferior ophthalmic vein
• Begins on floor of orbit, receive tributaries
• Ends in superior ophthalmic or cavernous sinus
• communicate with pterygoid venous plexus
• central vein of retina
– ends in cavernous sinus or superior ophthalmic
vein
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• Applied anatomy
– cavernous sinus communicate with veins of the
face through superior and inferior ophthalmic
veins; all are valve less thus blood flow in either
direction which may result in spread of infection
to cavernous sinus

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Nerves of orbit
• Optic nerve (CN II)
– nerve of sight
– made up of axons of cells in ganglionic layer of retina
– emerge from eye ball medial to posterior pole
– runs posteromedially and pass through optic canal to
cranial cavity and forms optic chiasma
– entirely enclosed in meningeal sheaths
• relations
– apex – recti muscles surround it
– ciliary ganglion between it and lateral rectus
– inferomedially – pierced by central artery and vein
– superiorly – ophthalmic artery, vein and nasociliary nerve
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• Occulomotor nerve (CN III)
– Course - on the lateral wall of the cavernous sinus and divide
into superior and inferior divisions
– both divisions enter cranial cavity through superior orbital
fissure inside the tendinous ring
– Superior division – supply superior rectus and levator
palpebrae
– Inferior division – supply medial rectus, inferior rectus and
inferior oblique and gives branch to ciliary ganglion
– Send parasympathetic preganglionic fiber to ciliary ganglion.
The postganglionic fiber from the ciliary ganglion supply
sphincter pupilae and ciliary muscles

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• Trochlear nerve (CN IV)
– Course
• lateral wall of the cavernous sinus below CN III
• Enter orbit through superior orbital fissure lateral to
the tendinous ring
• Passes in the orbit superior to the levator palpabrae
muscle medially and supply the superior oblique
muscle
• Abducent nerve (CN VI)
– Passes inside the cavernous sinus inferolateral to
the internal carotid artery
– enter the orbit through the superior orbital fissure
inside the tendinous ring
– directs laterally to supply the lateral rectus
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• Infra orbital nerve
– Continuation of maxillary nerve, enter orbit
through inferior orbital fissure
– Runs on floor of orbit through infraorbital groove
and canal
– Emerges on face through infraorbital foramen and
divide into palpebral, nasal and labial branches
– Branches
• Middle superior alveolar nerve – supplies upper
premolar
• Anterior superior alveolar nerve – supplies upper
incisor and canine teeth and maxillary sinus
• Terminal branches – supply upper lip, nose and lower
eye lid
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 The Parotid Region

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 Introduction
• Space between mastoid process and neck
and ramus of mandible

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 Contents
• The parotid gland – the largest salivary gland
• Facial nerve and its branches (5)
• External carotid artery and its branches
• Facial vein
• Lymph nodes

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The parotid gland
• Location
• Parotid bed – space between mastoid process and
ramus
– Anteriorly – ramus of the mandible
– Posteriorly- mastoid process and sternocleidomastoid
muscle
– Superiorly – external acoustic meatus
– Inferiorly – little below the angle of the mandible
• Shape - pyramid; apex – downwards
• Feature – irregularly lobulated
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• Relations
– Apex – over posterior belly of digastric muscle and carotid
triangle
– Superior surface - external acoustic meatus, TMJ,
superficial temporal vessels and auriculotemporal nerve
– Laterally (superficial surface) – skin, superficial fascia
containing platysma and great auricular nerve, deep fascia
(parotid capsule) and parotid lymph nodes
– Posteromedial surface - mastoid process, posterior
auricular artery and occipital artery, styloid process and
attached muscles, carotid sheath, terminal braches of
external carotid artery
– Anteromedial surface – ramus border, masseter
muscle, TMJ, medial pterygoid muscle

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• Facial nerve
– Emerges from stylomastoid foramen
• Enter the gland at posteromedial surface
• Divide into 5 branches: temporal, zygomatic,
buccal, mandibular and cervical
• Leave through anteromedial surface

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• Retromandibular vein
– Formed by union of superficial temporal and
maxillary veins
– Divide at apex into anterior and posterior divisions
– Anterior joins facial vein to form common facial
vein
– Posterior joins posterior auricular vein to form
external jugular vein

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• External carotid artery
– Enters through posteromedial surface
– Divide into superficial temporal and maxillary
arteries

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• Capsule of the parotid gland
– Derived form deep fascia of the neck
– Firmly attached with the gland and its deep
part is thickened to form stylomandibular
ligament which separate the parotid gland
from submandibular salivary gland

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• The parotid duct
– 5 cm long
– Origin - from the anterior border of the gland; Superficial to
the masseter, below the transverse facial artery
– Course - runs forward on masseter and turn medially at
masseter border and pierce buccal fat pad, buccopharyngeal
fascia, buccinator muscle and mucus membrane consecutively
– Open to - vestibule of the mouth opposite to the 2nd
maxillary molar teeth

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• Blood supply
– Arteries - branches of external carotid
– Veins – drains into retromandibular vein
• Nerve supply
– Parasympathetic – secretomotor
• Reach through Auriclotemporal nerve
• Inferior salivary nucleus → Glossopharyngeal n → tympanic branch
→ tympanic plexus → lesser petrosal nerve → oCc ganglion →
auriclotemporal nerve → paroCd gland
– Sympathetic - vasomotor
• form cervical ganglion through sympathetic plexus around the
external carotid artery
– Sensory
• From auriculotemporal nerve
• Parotid fascia - great auricular
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• Lymphatic drainage
– Superficial and deep paroCd → superficial and
deep cervical nodes
• Applied anatomy
– Parotid fascia is adherent to the gland firmly
which limit swelling, thus parotid infection is
painful

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 The temporal and infratemporal region

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Temporal fossa
• Boundary
– Superior and posterior – temporal lines
– Anterior – frontal and zygomatic bones
– Temporal fascia – stretch over it
– Floor – formed by parietal, frontal, greater wing of
sphenoid and squamous temporal bone
• Contents – Temporalis muscles
– Fan shaped
• Origin – temporal fossa and fascia
• Insertion – coronoid process and anterior border of ramus
• Nerve supply – mandibular nerve
• Action – elevate and retract mandible

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The infratemporal fossa
• Inferior and deep to zygomatic arch and posterior to
maxilla
• Boundaries
– Anterior wall - posterior surface of maxilla
– Medial wall - lateral pterygoid plate
– lateral wall – ramus of mandible
– posterior wall - condylar process of mandible and styloid
process
– Roof - greater wing of sphenoid
– Inferior boundary – attachment of medial pterygoid
muscle to mandible

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• Contents
• Superficial
• Lateral Pterygoid muscle
• Medial Pterygoid muscle
• Temporomandibular joint
• Maxillary artery and vein
• Pterygoid plexus
• Deep
• Mandibular nerve and its branches
• Chorda tympani nerve
• Otic ganglion
• Part of the maxillary nerve
• Tensor palatini
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• Pterygoid plexus of veins
– Surrounds the lateral pterygoid muscle
– Receive tributaries of the corresponding branches
of the maxillary artery
– The plexus posteriorly unite to form the maxillary
vein
– Communications
• Inferior ophthalmic vein
• Cavernous sinus – through emissary veins passing
through foramen ovale and spinosum
• Facial vein – through inferior ophthalmic vein & deep
facial vein

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• Mandibular nerve
– Course
• Two roots – larger sensory and smaller motor
• Reach the infratemporal fossa through foramen ovale
and below the foramen the two roots unite
– Divisions
• anterior - motor only
• posterior - mainly sensory
– Relations
• Medial – tensor palatini and otic ganglion
• Laterally – lateral pterygoid muscle
• Posteriorly – middle meningeal artery

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• Branches
– From the trunk
• Meningeal branch – enter skull through foramen
spinosum; supply dura in middle cranial fossa
• Nerve to the medial pterygoid – supply medial
pterygoid, tensor palati and tensor tympani and send
fiber to the otic ganglion
– From the anterior division
• buccal – skin and mucosa over buccinator
• masseteric – masseter and TMJ
• nerve to lateral pterygoid
• deep temporal nerve – for temporalis muscle

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 – From the posterior division
• Auriculotemporal nerve
– Arise by two roots, surround the middle meningeal
artery
– Carry postganglionic parasympathetic fiber from
otic ganglion to the parotid gland
– Branches supply
» TMJ
» Auricle
» external acoustic meatus
» tympanic membrane
» temple with the scalp
» Parotid gland

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 PTERYGOPALATINE FOSSA

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 Location and boundaries
• Small pyramidal space below apex of orbit
• Boundaries
– anteriorly- posterior surface of maxilla
– posteriorly -upper part of pterygoid process
and greater wing of sphenoid
– Medially - perpendicular plate of palatine
– Superiorly – greater wing of sphenoid
– Floor – palatine bone (pyramidal process)

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• Contents
– terminal parts of maxillary artery, maxillary nerve
and pterygopalatine ganglion
• Communications
– Laterally - with infratemporal fossa through the
pterygomaxillary fissure
– Medially – with nasal cavity through sphenopalatine
foramen
– Posteriorly - with middle cranial fossa, pterygoid
canal and nasopharynx through foramen rotundum,
lacerum and palatinovaginal canal respectively
– Inferiorly – with oral cavity through greater and
lesser palatine canal

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• Pterygopalatine ganglion
– Relay station for secretomotor fibers to lacrimal
gland and mucus glands of nose, paranasal
sinuses, palate and pharynx
– Topographically related to maxillary nerve but
functionally to facial nerve
– Lies in the upper part of the pterygopalatine fossa
– Suspended by the two sensory roots of maxillary
nerve
– Surrounded by the terminal branches of maxillary
artery

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• Nerve of the Pterygoid canal
– formed in the foramen lacerum by the union of the
• greater petrosal nerve
• deep petrosal nerve – a branch from internal carotid plexus
containing postganglionic sympathetic fibers form superior cervical
ganglion
• Branches of the pterygopalatine ganglion
– Greater palatine nerve - mucus membrane and glands of
the hard palate. It also gives the lesser palatine supplying
the soft palate and tonsils
– Nasopalatine - mucus membrane and glands of the nasal
cavity
– Pharyngeal - mucus membrane and glands of the
nasopharynx
– 2-3 orbital branches - sensory fibers to the orbital
periosteum and parasympathetic fiber joining the
zygomatic nerve HU,
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 THE EAR

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