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1 / 425 Head and Neck page 1 1 Topographic Surface Anatomy STUDY AIMS At the end of your study, you should be able to: Identify the key landmarks in the midline of the neck and their significance State the structures that are situated at the level of C6 Outline the boundaries of the triangles of the neck Describe the landmarks for palpation of the main arteries, which can be palpated in the face and neck Identify prominent features of the face 2 / 425 GUIDE Head and Neck: Topographic Anatomy [Plate 1, Head and Neck] Key Landmarks Midline of Neck page 1 page 2 There are a number of landmarks visible on the body's surface that correspond to deeper structures. Hyoid bone Lies at level of C3 vertebra U-shaped bone Does not articulate with any other bone Is suspended by muscles from Mandible Styloid processes of temporal bones Thyroid cartilage Manubrium of sternum Scapulae Thyroid cartilage Formed from anterior, midline fusion of two laminar plates = laryngeal prominence (Adam's apple) Laminae diverge superiorly Form V-shaped thyroid notch Lie at the level of C4 vertebra C4 vertebral level Bifurcation of common carotid artery into external and internal carotid arteries Site of carotid sinus (baroreceptor) and carotid body (chemoreceptor) Carotid pulse can be palpated at anterior border sternocleidomastoid (level of C5 vertebra) Cricoid cartilage Only complete ring cartilage in respiratory tract Shaped like signet ring with band anteriorly Lower border corresponds to level of C6 vertebra 3 / 425 Lower border corresponds to level of C6 vertebra C6 vertebral level Junction of larynx and trachea Junction of pharynx and esophagus Level at which inferior and middle thyroid arteries enter the thyroid gland Vertebral artery (first branch subclavian artery) enters foramen transversarium of C6 transverse process to ascend to brain through successively higher foramina Superior belly of omohyoid muscle crosses carotid sheath Level of middle cervical sympathetic ganglion Carotid artery can be compressed and palpated against transverse process C6 Isthmus of thyroid gland overlies second and third tracheal cartilages Jugular (suprasternal) notch Concave center of superior border of manubrium Between medial ends of clavicles Other Landmarks in the Neck Platysma Thin, broad sheet of muscle within superficial fascia of the neck A muscle of facial expression, tensing the skin Draws corners of mouth down, as in a grimace, and depresses mandible External jugular vein Deep to platysma, descends from angle to mandible to midpoint of clavicle Useful for assessment of venous filling with patient sitting at 45 degrees Sternocleidomastoid (SCM) Key landmark of neck Divides neck into anterior and posterior triangles (Section 1-4: Head and Neck - Neck) Sternal head attaches to manubrium of sternum Clavicular head attaches to superior middle third of clavicle Can be seen and palpated when acting unilaterally to flex and rotate head and neck to one side, so that ear approaches shoulder and chin turns in the opposite direction Landmarks of the Face Glabella Smooth midline prominence on the frontal bone Located above the root of the nose, between supraorbital margins Zygomatic arch Forms prominence of cheek Can palpate superficial temporal artery at lateral end Prone to fractures in facial trauma Mastoid process Bony prominence behind external acoustic meatus Site of proximal attachment sternocleidomastoid muscle Inion-prominent point of external occipital protuberance at back of head Auricle-part of external ear Skin-covered cartilage, except for lobule Features include: pinna; tragus; antitragus and helix External nose Skeleton mainly cartilaginous Dorsum extends from root to apex Inferior surface has two openings or nares (nostrils) Bounded laterally by alae of nose Separated by skin over nasal septum Philtrum-midline infranasal depression of upper lip Masseter muscle Felt over ramus of mandible when teeth are clenched Parotid duct can be palpated at medial border (duct opens over second molar inside cheek) Temporalis muscle can be felt above zygomatic arch when teeth clenched Facial artery can be palpated over lower margin body of mandible in line with a point one fingerbreadth lateral to the angle of the mouth 4 / 425 FACTS & HINTS High-Yield Facts Clinical Points Tracheostomy Transverse incision through skin of neck and anterior wall of trachea Method for achieving a definitive airway Transverse incision made through skin, at midpoint between suprasternal notch and thyroid cartilage Platysma and pretracheal fascia divided Strap muscles retracted Thyroid isthmus divided or retracted Opening made between first and second tracheal rings or through second through fourth tracheal rings Tracheostomy tube inserted Clinical Points Needle Cricothyrotomy Done in extreme emergency Performed if proximal airway is obstructed, to temporarily oxygenate the patient Large-bore needle inserted into the cricothyroid membrane and connected to an oxygen supply Clinical Points Central venous line Large veins such as the subclavian have relatively constant relationships to easily identifiable anatomic landmarks Placement of large-bore venous catheter in an emergent situation to deliver high flow of fluid or blood products Used for administration of chemotherapeutic agents, hyperalimentation fluids, and so on Used for assessing right heart (venous) pressures Vein located in an area bounded by the sternal and clavicular attachments of sternocleidomastoid and the clavicle-just deep to middle third of clavicle Subclavian vein is inferior and anterior to subclavian artery and separated from it by anterior scalene muscle 5 / 425 2 Bones and Ligaments STUDY AIMS At the end of your study, you should be able to: Describe the anatomic division of the head into a neuro- and viscerocranium Describe the function of the neuro- and viscerocranium Outline the bones that form the neurocranium Know the major sutures of the skull Describe the division of the base of skull into anterior, middle, and posterior cranial fossae and the contents of each List the foramina and key structures that pass through them Identify the prominent features of the mandible Describe the structure of the temporomandibular joint and the ligaments that stabilize it 6 / 425 GUIDE Head and Neck: Bones and Ligaments Bones of head and neck Skull Mandible Cervical vertebrae Skull The skull is divided into the neurocranium or calvaria (contains the brain and its meningeal coverings) and the viscerocranium (facial skeleton). The skull is composed of 22 bones (excluding the middle ear ossicles), with 8 forming the cranium and 14 forming the face. The orbits (eye sockets) lie between the calvaria (skull cap) and the facial skeleton and are formed by contributions from 7 different bones. [Plate 5 - Skull: Anteroposterior Radiograph] Neurocranium Viscerocranium Ethmoid 1 Zygomatic 2 Frontal 1 Vomer 1 Occipital 1 Inferior nasal concha 2 Sphenoid 1 Maxilla 2 Parietal 2 Nasal 2 Temporal 2 Palatine 2 Lacrimal 2 (Mandible) 1 N=22 8 + 14 page 4 page 5 7 / 425 Function of skull Encloses, supports and protects brain and meninges Contains foramina for the transmission of nerves and vessels Forms foundation for the face Contains specialized cavities and openings for sense organs (e.g., nasal, oral) Neurocranium Cranial vault and base of skull Encloses and protects brain Composed of 8 bones Bones united by interlocking sutures Can be divided Calvaria-dome-like roof Cranial base Calvaria composed of 4 bones Frontal bone anteriorly Occipital bone posteriorly Two parietal bones laterally Cranial base formed from Ethmoid bone Parts of occipital and temporal bones Viscerocranium = facial skeleton Composed of 14 bones Encloses orbits, nose, paranasal sinuses, mouth, and pharynx Maxillae and mandible form upper and lower jaw, respectively, and house the teeth There are also three auditory ossicles Malleus, incus, and stapes Found spanning tympanic cavity First bones to be completely ossified during development Major sutures of the skull Most bones of the skull are bound by sutures, a type of fibrous joint that fuses with age and becomes immobile. Coronal suture separates frontal and parietal bones Sagittal suture separates two parietal bones Lambdoid suture separates parietal and temporal bones from occipital bones Squamous suture separates squamous part of temporal bone from parietal bone Sphenosquamous suture separates squamous part of temporal bone from greater wing of the sphenoid Metopic suture between two frontal bones is largely obliterated with fusion of frontal bones 8 / 425 [Plate 6, Skull: Lateral View] 9 / 425 [Plate 7, Skull: Lateral Radiograph] Internal Features of Base of Skull page 5 page 6 Divided into anterior, middle, and posterior cranial fossae Anterior cranial fossa Contains frontal lobe of brain Formed by frontal bone anteriorly, ethmoid bone medially, and lesser wing of sphenoid posteriorly Features Frontal crest-midline bony extension of frontal bone Foramen cecum-foramen at base of frontal crest Crista galli-Midline ridge of bone from ethmoid posterior to foramen cecum Cribriform plate-Thin, sieve-like plate of bone on either side of crista galli, which transmits olfactory nerves from nasal cavity to olfactory bulbs Middle cranial fossa Contains temporal lobe, hypothalamus, and pituitary gland Formed by greater wing and body of sphenoid, petrous temporal bone, lesser wing sphenoid Features Sella turcica-central depression in body of sphenoid for pituitary gland Tuberculum sellae-Swelling anterior to sella turcica Dorsum sellae-crest on body of sphenoid posterior to sella turcica Anterior clinoid processes-medial projections of lesser wings of sphenoid bones Posterior clinoid processes-swelling at either end of dorsum sellae Foramen lacerum (one on each side)-jagged opening closed by plate of cartilage in life, transmits nothing Contains four foramina in a crescent on either side in the body of the sphenoid Superior orbital fissure Foramen rotundum Foramen ovale Foramen spinosum Posterior cranial fossa: Contains cerebellum, pons, and medulla oblongata Composed largely of occipital bone, body of sphenoid, petrous, and mastoid parts of temporal bone Features Foramen magnum-transmits spinal cord Internal occipital crest-divides posterior fossa into two lateral cerebellar fossae Grooves for transverse and sigmoid dural venous sinuses Jugular foramen-transmits sigmoid sinus (internal jugular vein) and several cranial nerves 10 / 425