Head and Neck C Neck Triangles by fdh56iuoui

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									 Head and Neck – Neck Triangles
                                                                    Greater auricular n.
                                                                                                    Anterior Triangle
                                              Lesser occipital n.
 Can’t Miss Stuff
Strap muscles – innervated by ansa                                                      ast
                                                                                            ric,      Submandibular
cervicalis, pull hyoid down for swallowing                                                       pos
and speaking. Muscles are sternohyoid,                                                              t

                                                                                                  Hypoglossal n.

thyrohyoid, sternothyroid, omohyoid                                            SCM

Accessory nerve – CNXI, in post triangle,                                                                                              Submental

on top of levator scapulae, innervates
SCM and trap                                                                                ICA
                                                                                            ICA                               Hyoid
Cervical plexus – motor branches: ansa
                                                                                                               Carotid                         Why Do You Care

cervicalis (C1-2) innervates strap m.
except thyrohyoid, phrenic (C3-5)                                                                                                             Triangles – H&N cancers are usually
innervates diaphragm; cutaneous                                                                           IJ
                                                                                                          IJ                                  squamous cell cancer found in and around
                                                                                                               Common Carotid
                                                                                                               Common Carotid
branches: sensory to skin, all from ventral                                                                                                   the oral cavity, pharynx, and larynx.
                                                                         Levator           Tranverse
rami of cervical nerves except lesser

                                                                                                                                              Lymphatic drainage goes to zones defined
                                                                         Scapulae                               Vagus n.

                                                                                                                      , an
occipital from dorsal rami. C1 is the only                                                 cervical n.                                        by the location in these neck triangles.
motor-only cervical nerve.                                                                                                                    And, of course, every neck dissection

                                                        Spinal accessory n.                                                                   requires identification of all essential
Carotid Receptors – carotid body is at                                                        EJ
bifurcation senses oxygen tension, carotid                                                                                                    structures to excise the lymph nodes.
sinus is at origin of ICA is baroreceptor                                                                                                     Carotid Endarterectomy – The most
Contents of Carotid Sheath – vagus                                                                   Phrenic n.            Muscular           common cause of stroke is not thrombosis
(posterior), common carotid (medial),                                                                                                         but embolization of an unstable
internal jugular (lateral)                                                                                                                    atherosclerotic plaque in carotid, usually
                                                                                     Ant                                                      close to the carotid bifurcation. A CEA is a
Sympathetic nerves – run along ICA and                                               Scalene                                                  classic vascular surgical procedure to
ECA. They all synapse at the superior           Trapezius                                             t                                       excise the plaque and requires dissection
cervical ganglion.                                                                             p   os                                         of the carotid triangle and sheath.
                                                                                            o,                        IJ
                                                                                       Om                                                     Tachycardia – The carotid sinus contains
                                                                                                                                              baroreceptors that sense increases in
                                                                                                                                              blood pressure by mechanical stretch.
                                                Supraclavicular nn.                                                                           This signal is carried back to the brain by
                                                                                                                                              CNIX and X resulting in slowing of heart
                                                                                                                                              rate. In cases of atrial tachycardia (as

                                                                               Posterior Triangle                          Brachiocephalic
                                                                                                                           Brachiocephalic    opposed to ventricular tachycardia),
                                                                                                                                              carotid sinus massage is one method of
                                                                                                                                              immediate therapy by stretching the sinus.
  Head and Neck – Midline and Through the Scope

 Can’t Miss Stuff                                                                                                                       Normal Larynx via Laryngoscopy
Recurrent laryngeal nerve –                  RLN
                                             RLN                                                                                           arytenoid cartilages
Right wraps under                                                                                 RLN
brachiocephalic, left wraps                                                                                                                                                                  trachea
under aorta, travels up in                                                                       IJ
tracheoesophageal groove with
inf thyroid veins. Innervates all
intrinsic laryngeal muscles                                       Thyroid
except cricothyroid (sup
laryngeal n.).
                                                                  Cartilage                      Sup thyroid v.
                                                                                                 Sup thyroid v.
                                     Sup thyroid a.
                                     Sup thyroid a.
Thyroid blood supply – 2
arteries: sup thyroid off ECA,
inf thyroid off thyrocervical                                                                                                                                          vocal cords
trunk. 3 veins: sup, middle, inf.             Thyroid              Cricoid
Parathyroid embryo – sup from                                                                         Middle thyroid
                                                                                                      Middle thyroid
3rd, inf from 4th branchial
                                     Inf thyroid a.
                                     Inf thyroid a.
2 infections – epiglottitis and
retropharyngeal abscess can                                                 Inf thyroid v.
                                                                            Inf thyroid v.                                     Identify the Problem – Kid comes in with a
be airway emergencies
                                                                                                                               muffled voice and your film shows:
requiring intubation. Epiglottitis
is rapid onset, really sick kid                   Rings                                                                       Left image – note giant epiglottis, this is the “thumb-print” sign of epiglottitis.
with muffled voice.                                                                                                           Right image, see thick prevertebral soft tissue, this is retropharyngeal abscess.
Retropharyngeal abscess is kid
or adult with muffled voice,
starts as strep throat, then                                                                    Brachiocephalic v.
                                                                                                Brachiocephalic v.
spreads either locally or by
lymphatic drainage to the             Brachiocephalic a.
                                      Brachiocephalic a.
retropharyngeal space. This
abscess looks like a mass
between the buccopharyngeal
and prevertebral fascia.
 Why Do You Care
Intubation – intubation is an artificial airway made by sticking a tube between the vocal cords. It can be for emergencies
or for surgery. See the scope pic, ID the structures.
Surgical airway – Airway emergencies are definitively treated with a cricothyroidotomy with a needle or any instrument
available. Find the thyroid cartilage, go below, and stab. Risks are larynx and thyroid injury. Airway urgencies and
longterm intubation are usually treated with a tracheostomy. This involves cutting a hole through 2 tracheal rings, usually
2nd/3rd or 3rd/4th rings to spare the thyroid.                                                                                 Normal
                                                                                                                               Normal                                          Abnormal
                                                                                                                               prevertebral area
                                                                                                                               prevertebral area                               prevertebral area
                                                                                                                                                                               prevertebral area
Thyroidectomy - Indicated for thyroid CA, nodules. The most common risk is recurrent laryngeal nerve injury which
results in unilateral vocal cord paralysis manifested by hoarseness. Hypoparathyroidism can also occur due to the                                                                          Normal epiglottis
                                                                                                                                                                                           Normal epiglottis
location of the parathyroids behind the thyroid.                                                                                                  Abnormal epiglottis
                                                                                                                                                  Abnormal epiglottis
Thyroid CA – look for destruction of RLN via hoarseness
Fascia – not much to care about with fascia except the retropharyngeal abscess, see above
Head and Neck – Arteries and Veins/Sinuses
                                                                               Sup Sagittal
                                                                               Sup Sagittal

 Circle                                                                                                                                    Why Do You Care
 of Willis               Ophthalmic
                         Ophthalmic                                                Great Vein of Galen
                                                                                   Great Vein of Galen                                    Amaurosis Fugax – Vascular patients
                                                                                                                                          sometimes complain of losing their vision as
        MCA                                                                                    Inf Sagittal
                                                                                               Inf Sagittal                               if a window shade was pulled down. This is
                                Superficial Temporal
                                Superficial Temporal                                                                                      usually an embolic event in which a plaque
 PCA                                                                                                                                      floats from the ICA to block off its first
                                                                                                                                          branch, the ophthalmic artery.
                                      Maxillary                                                                                           Temporal Arteritis – Inflammatory vasculitis
                                                                                                    Cavernous                             that affects the superficial temporal artery
                 ICA      Post Auricular
                          Post Auricular                                                                                                  (terminal branch of ECA). Manifested by
                                           ECA and                                                                                        unilateral headache and jaw pain
                         Occipital                                                              Sup/Inf
                                                                        Transverse              Petrosal
                                                                                                Petrosal                                  Vertebrobasilar Insufficiency – Essentially
                                                                        Transverse                                                        stroke in the cerebellum due to
                         Ascending Pharyngeal
                         Ascending Pharyngeal                                                             Inf Ophthalmic
                                                                                                          Inf Ophthalmic                  atherosclerosis of the vertebral or basilar
                                                                                                                                          arteries. Presentation is cerebellar signs:
                                                                Intracranial       Sigmoid
                                                                                   Sigmoid                                                unsteadiness, vertigo.
                                                                                                                                          Sinus Venous Thrombosis – Happens
                                  Lingual                                                      IJ
                                                                                               IJ              Ptyergoid
                                                                                                               Ptyergoid                  rarely in people predisposed to coagulation
                                  Lingual                     Superficial Temporal
                                                              Superficial Temporal                             Plexus
                                                                                                               Plexus                     (cancer, pregnancy, infection). Problem is
             Vertebral                                                                                                                    venous backup and stroke.
                                   Sup Thyroid
                                   Sup Thyroid               Retromandibular
                                                             Retromandibular                                                              Danger Zone Infections – Check out the
                                                                                                                                          ptyerygoid plexus. This is a direct
                                                                                                                                          communication between the external and
Costocervical                                                             EJ
                                                                          EJ                                                              internal venous systems. Infections in the
        Thyrocervical                                                                                           3                         face around the eyes and nose drain via
                                                                                    Facial                              ICA
                                                                                                               4                          facial veins and can get into the brain
                                                                                                                    6                     sinuses through the pterygoid plexus.
                            Carotid                                Clavicle                               V1             Sphenoid
                                                                                                                                          Central Lines – Essentially, a big IV for
                                                      Subclavian                                         V2                               delivery of lots of stuff, pulmonary wedge

                                                                                                                                          pressures, and when you don’t have

                                                                                                                                          peripheral access. As an alternative, the

                         on R, Aorta on L
                         on R, Aorta on L                                                                           Cavernous Sinus       EJ and IJ are both good access vessels.
                                                                                                                    Cross Section         The EJ is superficial and visible. IJ access
                   Internal                                                                                                               is established by going between the 2
                                 Can’t Miss Stuff                         Brachiocephalic
                                                                          Brachiocephalic                                                 heads of the SCM. For subclavian, follow
                   Thoracic                                                                                                               the inferoposterior border of the clavicle.
Dorsal                        Carotid Branches – ICA has no branches in neck, first branch is ophthalmic in middle cranial fossa; ECA
                              is supply to anterior aspect of neck, face, scalp, oral and nasal cavities, skull bones, and dura mater.    Structures that are close by include lung,
Scapular                      ECA has 8 branches (sup thyroid, ascending pharyngeal, lingual, facial, occipital, post auricular,          phrenic nerve, thoracic duct, lymphatic duct,
             Subclavian                                                                                                                   and subclavian artery. But remember the
                              superficial temporal, maxillary). Guys, I know your dissector says otherwise but sup thyroid is the first
             and Branches     branch of the ECA.                                                                                          artery is behind anterior scalene and tends
                                                                                                                                          to lie superoposterior to the subclavian
                              Cavernous Sinus – CNIII-VI, except V3, and ICA. Only CNVI and ICA going through, CNIII, IV, V1, V2 in       vein.
                              lateral wall. Input: sup/inf ophthalmic, middle cerebral, sphenoparietal sinus. Output: inf/sup petrosal
                              sinuses, pterygoid plexus
                              Circle of Willis – combo of ICA and vertebral artery branches.
 Head and Neck – Cranial Nerves and Foramina
                                                      I Olfactory           Cribiform                  Smell                                               Lesion = loss of smell
                                                     II Optic               Optic foramen              Sight                                               Lesion = Marcus Gunn pupil (paradoxical
  Cribiform: CNI
                                                                                                                                                           dilatation of pupil in light), bitemporal
                                                                                                                                                           hemianopia in pituitary tumors
                                                    III Oculomotor          Sup orbital fissure        Motor: Superior, inferior, medial rectus, levator   Lesion = eye deviates lateral and down,
      Optic Canal: CNII                                                                                palpebrae; Parasymp: short ciliary n. to            ptosis, mydriasis, accomodation loss
                                                                                                       sphincter and ciliary m.
             Sup Orbital Fissure: CNIII, IV,        IV Trochlear            Sup orbital fissure        Superior oblique                                    Lesion = eye deviates up and medial
             V1, VI, sup opthlamic vein              V Trigeminal           V1 Sup orbital fissure     Cutaneous sensation to anterior and lateral         Cutaneous sensation to anterior and
                                                                            V2 Foramen rotundum        face. V3 also motor for muscles of                  lateral face but V3 also motor for muscles
                  Foramen Rotundum:                                         V3 Foramen ovale           mastication, ant belly digastric, mylohyoid,        of mastication. Affected nerve in face in
                  CNV2                                                                                 tensor veli palatini, tensor tympani; meningeal     post-herpetic neuralgia (shingles)
                                                    VI Abducens             Superior orbital fissure   Lateral rectus                                      Lesion = eye deviates medial, often first
                    Foramen Ovale: CNV3
                                                                                                                                                           sign of increased intracranial pressure
                                                   VII Facial               Internal acoustic meatus Motor: facial expression, auricle, occipitalis,       Divisions are temporal, zygomatic, buccal,
                      Foramen Spinosum:                                     to stylomastoid foramen post belly digastric, stylohyoid; Parasymp:            mandibular, cervical (Ten Zillion Bucks
Foramen               CNV3 (meningeal                                                                salivary glands (chorda tympani), nasolacrimal        Means Cash). Animates the face, divides
Lacerum: ICA          branch), middle                                                                glands (greater petrosal); Sensory: taste to          in parotid gland. Bell’s palsy – motor
                      meningeal artery/vein                                                          anterior 2/3 of tongue                                CNVII palsy associated post-infectious,
                                                                                                                                                           post-partum, mostly women.
                      Internal Acoustic Meatus:   VIII Vestibulocochlear    Internal acoustic meatus Hearing and balance                                   Acoustic neuroma/schwannoma =
                      CNVII, VIII, labyrinthine                                                                                                            dizziness and ringing in ears
                      artery/vein                   IX Glossopharyngeus Jugular foramen                Motor: stylopharyngeus; Parasymp: parotid;          Lesion = no gag
                                                                                                       Sensory: post 1/3 of tongue, gag reflex,
                                                                                                       carotid sinus
                                                    X Vagus                 Jugular foramen            Motor: all pharyngeal, laryngeal except             Divisions are meningeal, auricular,
Foramen                                                                                                stylopharyngeus, tensor palati, parasymp to         pharyngeal, superior laryngeal, right
                    Jugular Foramen: CNIX,
Magum:                                                                                                 thorax and abdomen; Sensory: tongue,                recurrent laryngeal, internal and external
                    X, XI, IJ, post meningeal
CNXI                                                                                                   pharynx, larynx, heart, lung, stomach,              laryngeals. Lesion = hoarseness, difficulty
spinal                                                                                                 intestines, carotid sinus                           swallowing, uvula deviates contralateral to
roots,                                                                                                                                                     lesion
brainstem,                                          XI Accessory            Jugular foramen            Spinal root: SCM/trap; Cervical: recurrent          Lesion = shoulder droop
vertebral        Hypoglossal Canal: CNXII                                                              laryngeal
arteries                                           XII Hypoglossal          Hypoglossal canal          All tongue m. except palatoglossus                  Lesion = tongue deviates ipsilateral to
                                                    Synapsing Ganglia                                                         Other Nerve Related Stuff
                                                  Sympathetics – all H&N sympathetics synapse at superior                   Sympathetic chain problems – what happens when you lose
             Non-Synapsing Ganglia                cervical ganglion, run along ECA and ICA                                  sympathetic innervation to the face? Horner’s syndrome –
        Trigeminal – sensory for CNV                                                                                        anhidrosis, ptosis, miosis. Commonly associated with
                                                  Parasympathetics – 4 ganglia, an excellent way to remember
                                                                                                                            tumors in the apices of lungs.
        Geniculate – all CNVII except ear sensory which CNs have parasympathetic fibers. Only exception is
                                                  vagus which synapses at terminal ganglia in the thorax and
        Inf Vagus – visceral sensory CNX          abdomen.
        Sup Vagus – somatic sensory CNX           Ciliary – CNIII, constricts/accommodates, runs with V1
                                                  Pterygopalatine – CNVII, nose palate lacrimal, runs with V2
                                                  Submandibular – CNVII, submandibular and sublingual glands,
                                                  runs with V3
                                                  Otic – CNIX, parotid, runs with V3
Head and Neck – Miscellaneous Can’t Miss Stuff
 Embryology                                                         Eating                                      Circle of Willis                              Congenital
Branchial Organization – cleft = ectoderm, arch – mesoderm        Salivation – innervation by both             Cerebral Perfusion – occurs via 2 systems:    Craniosynostosis – fusion of sutures in
and neural crest, pouch = endoderm                                sympathetics(T1-3) and parasympathetics internal carotid and vertebral. ICA gives          skull at birth, often syndromic, requires
                                                                  of CNVII, IX                                 off ACA and MCA. Vertebral gives off          surgical correction if intracranial pressure
Branchial arches – forms nerve, muscle, and skeletal
                                                                                                               PCA and the cerebellar arteries (AICA and     increased.
structures                                                        Parotid – innervated by CNIX, most
                                                                                                               PICA). Most common place for stroke: the                          metopic
                                                                  common place for salivary gland tumors
1st arch (CNV3) – remember the M’s: Meckel’s cartilage                                                         middle cerebral artery (MCA).
                                                                  but usually benign. CNVII lies within
(mandible, malleus, sphenomandibular ligament, incus),                                                                                                                            coronal
                                                                  parenchyma, any resection of parotid                ACA Ant Comm ACA
muscles of mastication (temporalis, masseter, pterygoids),
                                                                  masses requires facial nerve dissection.
mylohyoid, ant belly digastric, tensor veli palatini, tensor                                                                                                   fontanelles     sagittal
                                                                  Sjogren’s syndrome is an autoimmune
                                                                  disease classically seen with parotid
2nd arch (CNVII) – Reichert’s cartilage (remember the S’s:        enlargement, dry eyes, dry mouth, arthritis.    ICA        MCA         ICA
stapes, styloid process, stylohyoid ligament, less horn of                                                                                                          lambdoid
                                                                  Submandibular – lies in submandibular
hyoid), muscles of facial expression, post belly digastric,
                                                                  division of anterior triangle in neck. Most                 Post
stapedius, stylohyoid.                                                                                                       Comm                            Cleft – lip: lack of fusion of maxillary and
                                                                  tumors are malignant. Facial artery/vein,         PCA                 PCA                  nasal processes during 1st trimester,
3 arch (CNIX) – greater horn of hyoid, stylopharyngeus
 rd                                                               mandibular branch of V3 run next to it.                        basilar                     palate: lack of fusion of lateral palatine
4th/5th/6th arches (CNX) – all laryngeal structures: cartilage:    Muscles of Mastication – masseter,                                   AICA                 processes, nasal septum, and/or median
thyroid, cricoid, arytenoids, corniculate, cuneiform; muscles:     temporalis, medial pterygoid, lateral                                                     palatine process. Lip/palate more frequent
pharyngeal constrictors, intrinsic muscles of larynx, levator veli pterygoid. V3 innervation.                                            PICA                than palate more frequent that lip.
palatini                                                             Intracranial Bleed                                                                      Torticollis – contracted cervical m. due to
Branchial clefts – parts between arches                            Epidural – temporal area hit separates                                                    CNXI or SCM injury
                                                                   dura from bone tearing middle meningeal       Parts of Arteries                            Facial Trauma
1st cleft – external auditory meatus
                                                                   (branch of maxillary off ECA). Radiology is Subclavian – divided by ant scalene
2nd/3rd/4th clefts – obliterated or persists as fistula tracts and                                                                                           Le Forte Fractures
                                                                   convex collection. Manifested by loss of
called branchial cysts. Branchial cysts found along ant border consciousness, lucid interval, then crash. 1st part: proximal to ant scalene, branches        I – through maxilla above upper teeth,
of SCM anywhere from EAC to clavicle, but not midline                                                          are vertebral, thyrocervical, internal        teeth separated from head
                                                                   Dural – people talk about this less.        throacic
Branchial pouches                                                  Trauma to sphenoid ruptures ICA in                                                        II – maxilla from zygomatic, nose
                                                                   cavernous sinus resulting in clot.          2nd part: behind ant scalene, branch is       separated from head
1st pouch – middle ear cavity, eustachian tube, mastoid air cells                                              costocervical
                                                                   Subdural – bridging veins inside brain torn                                               III – zygomatic from frontal, face separated
2nd pouch – epithelial lining of palate                                                                        3rd part: distal to ant scalene, branch is
                                                                   after trauma, may open up the dural                                                       from head
3 rd pouch – thymus and inf parathyroids
                                                                   sinuses. Radiology is concave collection.   dorsal scapular
                                                                                                                                                             Orbital Blowout Fractures – fracture of
                                                                   Can be acute or subacute/chronic.           Thyrocervical – branches are inf thyroid,
4th pouch – sup parathyroids                                                                                                                                 bones in floor of orbit resulting in inferior
                                                                   Subarachnoid – usually due to berry         suprascapular, transverse cervical            rectus entrapment, requires surgical
DiGeorge syndrome is aberrant development of 3rd/4th pouches
                                                                   aneurysm rupture in stroke patients.        Maxillary – branches in infratemporal         correction. Orbital floor is combo of
= thymic hypoplasia/T cell immunodeficiency, hypocalcemia
                                                                   Classic complaint is “worst headache of     fossa, goes thru pterygopalatine fissure to   maxillary, palatine, and zygomatic. Where
Thyroglossal duct – remnant of thyroid diverticulum. Normal        my life”. Berry aneuryms occus at           pterygopalatine fossa                         is cutaneous sensation, that is, where do
remnant is foramen cecum, abnormal remnant can be found            bifurcations in circle of Willis, most                                                    you want to anesthetize? Go for the
                                                                   common site is ant communicating artery. 1 part: between neck of mandible and
midline as mass/cyst                                                                                                                                         infraorbital foramen where the infraorbital
                                                                   Associated also with adult polycystic       sphenomandibular ligament, branches are       nerve exits (branch of V3).
Tongue – 1st arch forms ant 2/3rd, sensation via CNV3 and
                                                                   kidney disease, Ehlers-Danlos, Marfan’s. middle meningeal, inf alveolar, deep
taste via CNVII; 3rd/4th arches form post 1/3rd, sensation and                                                 auricular, ant tympanic, accessory             Eye Muscles
taste via CNIX and extreme post via CNX; motor innervation by Intraparenchymal – can be trauma-related meningeal
                                                                                                                                                             Lat rectus – out, Med rectus – in
CNXII                                                              but usually caused by disease (i.e.
                                                                   hypertension or tumor)                      2nd part: related to lat pterygoid muscle,    Sup rectus – up and in
Ear – bones: incus/malleus = 1st arch, stapes = 2nd arch;                                                      branches are deep temporal, masseteric,
muscles: tensor tympani = 1st arch, stapedius = 2nd arch; EAM        Fossae                                    buccal, pterygoid                             Inf rectus – down and in
= 1st cleft; eardrum, eustachian tube = 1st pharyngeal             Infratemporal – maxillary artery and V3
                                                                                                               3rd part: in pterygopalatine fossa            Sup oblique – up and out
                                                                   Pterygopalatine – V2                                                                      Inf oblique – down and out
Head and Neck – Fossae
Temporal – Temporalis Muscle                                 Infratemporal- V3, maxillary artery                                                      Pterygopalatine – V2
  Roof – temporal lines on parietal                          Roof – Greater wing of sphenoid, temporal                                                                                                  Roof - sphenoid
                                                                                                                                                                                                                                                Inf orbital
                                                              Petrotympanic                                                                                                                                                                     fissure
                                                              fissure      Foramen foramina
   temporal fascia

                                          Medial – greater

                                                                                                                                                                                         Lateral – lateral pterygoid
                                                                         Foramen                                                                                                                                       Posterior - sphenoid

                                                                                                                                                                                                                                                                            Medial – lateral wall of palatine
                        Posterior –                                     spinosum
   Lateral –


                                                                                                                                                                                                                                                   Sphenopalatine foramen


                                          wing of

                                                                                                                           Pterygomaxillary fissure

                                                                                                                                                              Pterygomaxillary fissure
                        parietal,                                                 Posterior –


                                                                                                        pterygoid plate
                                                                                                        Medial – lateral

                                                                                  Temporal                                                                                                                              rotundum

                     Floor – zygomatic                        Anterior –

                     arch/infratemporal                       posterior



                     crest of sphenoid                        surface of                                                                                                                                                   canal


Anterior – post surface of frontal
process of zygomatic, post surface                                                                                                                                                                                             Palatine canal
of zygomatic process of frontal                              Contents and Entry Routes:
                                                             Vessels –
                                                             1. Maxillary artery via between mandible and                                                                                Anterior – posterior surface of maxilla
                                                                sphenomandibular ligament. Branches are middle
 Contents and Entry Routes:                                                                                                                            Contents and Entry Routes:
                                                                meningeal, inferior alveolar, deep auricular, ant tympanic,
 Vessels –                                                                                                                                             Vessels –
                                                                accessory meningeal, deep temporal, masseteric, buccal,
 1. Deep temporal of maxillary via around                                                                                                              1. Maxillary artery via pterygomaxillary fissure, branches are post sup
    infratemporal crest of sphenoid, supplies                                                                                                             alveolar, infraorbital, greater palatine, pharyngeal, sphenopalatine,
                                                             2. Pterygoid plexus formed by emissaries through foramen
    temporalis                                                                                                                                            artery of pterygoid canal
                                                                ovale and inferior ophthalmic via inf orbital fissure
 2. Middle temporal of superficial temporal,                                                                                                           2. Veins mirror maxillary artery branches exit out pterygomaxillary fissure
                                                             Nerves –
    supplies temporalis                                                                                                                                   to pterygoid plexus
                                                             1. V3 via foramen ovale, branches are meningeal, nerve to
 Nerves –                                                                                                                                              Nerves –
                                                                med pterygoid, anterior trunk (buccal, masseteric, deep
 1. Zygomaticotemporal branch of V2 via                                                                                                                1. V2 via foramen rotundum, sensory only. Branches into orbital (exits inf
                                                                temporal, nerve to lat pterygoid), posterior trunk
    zygomaticotemporal foramina on temporal                                                                                                               orbital fissure), greater and lesser palatine (exit palatine canal), nasal
                                                                (auriculotemporal, lingual, inf alveolar, nerve to mylohyoid).
    surface of zygoma for cutaneous sensation                                                                                                             (exits sphenopalatine foramen), pharyngeal (exits palatovaginal canal),
                                                                Note that ant trunk branches are motor except buccal, post
    at temple                                                                                                                                             zygomatic (exits inf orbital fissure), post sup alveolar (exits alveolar
                                                                trunk branches are sensory except nerve to mylohyoid
 2. Deep temporal from V3 via around                                                                                                                      foramen), infraorbital (exits inf orbital fissure)
                                                             2. Chorda tympani (CNVII) via petrotympanic fissure.
    infratemporal crest of sphenoid, supplies                                                                                                          2. Nerve of pterygoid canal via pterygoid canal, combo of parasymp
                                                                Parasymp to salivary via synapse at submandibular
    temporalis                                                                                                                                            greater petrosal (CNVII) and symp deep petrosal, innervates mucous
                                                                ganglion. Taste to ant 2/3rd of tongue do not synapse.
 Muscle – temporalis                                                                                                                                      glands in nasal cavity, upper salivary glands, lacrimal glands
                                                             3. Lesser petrosal (CNIX) via foramen ovale, parasymp to
                                                                parotid via synapse at otic ganglion                                                   3. Pterygopalatine ganglion
                                                             Muscles – med and lat pterygoid
 Petrotympanic fissure in floor – infratemporal                                                                                                        Communications:
                                                             Other – sphenomandibular ligament
   fossa                                                                                                                                               Foramen rotundum and ant opening of pterygoid canal in post wall –
                                                             Communications:                                                                              middle cranial fossa
                                                             Foramen spinosum and ovale in roof – middle cranial fossa                                 Palatovaginal canal in post wall – nasopharynx
                                                             Petrotympanic fissure in roof – temporal fossa                                            Palatine canal in floor – oral cavity
                                                             Pterygomaxillary fissure in medial wall – pterygopalatine fossa                           Sphenopalatine foramen in medial wall – nasal cavity
                                                                                                                                                       Pterygomaxillary fissure in lateral wall – infratemporal fossa
                                                                                                                                                       Inferior orbital fissue in anterior wall – orbit

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