CLINICAL ANATOMY LECTURE 5TH MAY:

Head region:
-consists of cerebral and facial part.

Cerebral part has:

-fornix of skull
-base of skull (includes external and internal base)

->Internal base is in cranial cavity, has free cranial fossa (anterior, middle and
posterior cranial fossas).

Fornix of the head consists of 3 regions:

-frontoparietal occipital region
-temporal region
-mastoid process region

Fronto parietal occipital region:

-anteriorly - bounded by superior margin of the orbit
-posteriorly - bounded by external occipital protuberance of the occipital bone
and superior line
-laterally - bounded on both sides by superior temporal line

->covered by the following layers:

-soft tissue layer
-bone (below soft tissue)

Soft tissue layers: (skin, subcutaneous tissue layer, muscular layer,

subaponeurotic space and pericranium).

-skin (thick, less mobile)- covered by hair

-subcutaneous fat tissue - includes fibrous septas which connects it to the
underlying muscular layer. There is also superficial arteries, superficial veins
and superficial nerves (cutaneous nerves), these provide blood supply and
innervation of the skin in this region. Most branches of arteries in this layer are
from external carotid artery and some from internal carotid arteries. Outer wall
of these arteries (adventitia of the vessels)- are closely connected to the
fibrous septa.
(bleeding?)
Hematoma in this layer- the fibrous septa does not allow it to spread to other
part of the fat connective tissue layer..

-muscular layer (under the subcutaneous fat tissue) - includes anteriorly:

frontalis muscle, posteriorly: occipitalis muscle. These muscles are connected
to each other by aponeurotic layer called Gallea aponeurotica.

-Sub aponeurotic space (under the muscular layer): also includes connective
tissue layer. Vessels of this region are emissary veins (does not have
valves?), emissary veins are connected to the superficial veins of the
subcutaneous fat tissue and also to the diploic veins located in the diploic
layer of the bone. And via the diploic veins it is communicated to the venous
sinuses which are located in the cranial cavity. The sub aponeurotic space is
known as dangerous layer of this region because spreading of infectious pus
in this layer may spread deeply through the cranial cavity.
(bleeding?)

-Periosteum (under the sub aponeurotic layer): covers the bone.

Pericranium is the periosteum of the skull. Attached to bone only at level of
suture does not cover bone completely.
Skull sutures ( coronary, sagittal, lambdoid)
-below pericranium- sub pericranial space (filled with connective tissue layer),
if pus spreads in this layer it is limited along one bone, due to the pericranium
being attached at level of suture which prevents spreading of pus from one
part of the bone to the other part of bone.

-Black eye (skin of forehead is black) - subaponeurotic layer is damaged.

-pus accumulated along one bone in skull examination - sub pericranial layer
is damaged.

Under soft tissue there is bone which consists of 3 layers:

-outer compact bone (lamina externa)
-inner compact bone (lamina interna)
-diploae (between the inner and outer layers): includes diploic veins.

Anterior part of fronto parieto occipital region is supplied by- supra orbital and
supra trochlear arteries. These arteries are branches from ophthalmic artery
from internal carotid artery. Also accompanied by supra orbital and supra
trochlear veins.
Parietal part of fronto parieto occipital region is supplied by- superficial
temporal artery which is branch of the external carotid artery, the artery is
accompanied by superficial temporal vein.

Posterior part of fronto parieto occipital region is supplied by- posterior

auricular artery and occipital arteries these are branches of external carotid
artery.

So most branches supplying this region are from ECA except supra orbital
and supra trochlear which come from ICA.

These arteries make anastomisis with each other so skull has rich blood
supply, so wounds in skull heal quickly.

Most of the branches of the cutaneous nerves of the subcutaneous tissue

layer come from the trigeminal nerve.

Trigeminal nerve is the 5th cranial nerve, consists of 3 divisions:

-ophthalmic division
-maxillary division
-mandibular division

This nerve also gives off muscular branches,

sensory branches- which provides innervation of skin of this region are:
-supra orbital and supra trochlear nerves - innervate anterior part of this region
-zygomatico temporal nerve(comes from the maxillary division of the
trigeminal nerve) and auriculo temporal nerve(comes from mandibular division
of trigeminal nerve) - innervates skin of parietal and temporal region.
- lesser and greater occipital nerves(branches of the cervical plexus) -
innervate posterior part of this region.

Cervical plexus- superficial plexus located on neck- formed by c1-c4 spinal

cervical nerves.

->Deep layer- muscular layer

Muscles of the fronto parieto occipital region is innervated by the branches of
the facial nerve(7th cranial nerve).

TEMPORAL REGION OF THE FORNIX:

Is bounded
Superiorly- by superior temporal line
Inferiorly- by zygomatic arch and by frontal process of the zygomatic bone

Superficial layers of the temporal region: skin, subcutaneous fat tissue,

superficial fascia.

Below these layers there is temporalis fascia which is continuation of the

gallea aponeurotica(lateral side of it).

Temporalis fascia is divided into 2 layers:

-Superficial layer (attached to the outer surface of the zygomatic arch).
-Deep layer (attached to the inner surface of the zygomatic arch).
Between these 2 layers there is fat connective tissue layer called intra
aponeurotic fat (which is second fat connective tissue layer of the temporal
region). This fat is closed fat.

Sub aponeurotic space (below temporalis fascia) - includes 3rd fat connective
tissue layer- sub aponeurotic fat which down is communicated to the
infratemporal fossa which is located below the zygomatic arch, it also
communicates to the fissure located between massetar muscle and ramus of
the mandible.

Temporalis muscle (below sub aponeurotic layer): function- one of the

muscles of mastication which originates from inferior temporal line of temporal
bone and is attached to the coronoid process of mandible. It occupies
temporalis fossa which lies between temporalis muscle and periosteum(which
covers the bone). The temporal fossa is also communicated to the
infratemporal fossa and also to the fissure located in the deep region of face.

Periosteum (below this layer): covers the bone of the temporal region and
consists of 2 layers: 2 compact bone layer (lamina externa and interna) there
is no diploic layer in the temporal bone.
To the inner surface of temporal bone is closely related the middle meningeal
artery. (sulcuses formed by the branches of MMA).The trunk of this artery
enters the cranial cavity by foramen spinosum(located in the middle cranial
fossa) . This artery is branch of maxillary artery which comes from external
carotid artery. The artery lies under temporal bone between bone and dura
matter in epidural space, most part of the dura matter is supplied by this artery
it is also supplied by A and P middle meningeal arteries. The trunk of this
artery is divided into anterior and posterior branches.
Trauma of temporal bone is dangerous since it can damage the middle
meningeal artery which is closely related to it.

Cronlain skin??

-Inferior horizontal line which passes from inferior margin of orbit along
zygomatic arch.
-Superior horizontal line which passes from superior margin of orbit and
parallel to the inferior horizontal line.
-Vertical lines there is 3 (anterior, middle, posterior vertical lines), anterior
vertical line starts from midpoint of zygomatic arch and above crosses
superior horizontal line , middle vertical line starts from temporal mandibular
joint above crosses the superior horizontal line, posterior vertical line starts
from apex of the mastoid process and extends to the sagittal line.

Intersections are formed by these horizontal and vertical lines.

Trunk of the middle meningeal artery is located in the point of intersection of
the inferior horizontal line and anterior vertical line.
-Projection point of anterior branch of MMA is located in the point of
intersection of superior horizontal line and anterior vertical line.
-Posterior branch of middle meningeal artery is located in the point of
intersection of superior horizontal line and posterior vertical line.

Superficial layer of temporal region has superficial arteries, veins and nerves.
Blood supply of superficial layer is formed by superficial temporal artery which
is branch of ECA, accompanied by superficial temporal vein and sensory
innervation of skin is formed by auriculo temporal nerve and zygomatico
temporal nerve.

Deep layer- temporalis muscle is supplied by deep temporal artery(2 branches

anterior and posterior) which is branch of maxillary artery, muscle is
innervated by deep temporal nerve(has 2 parts ant and post) which comes
from mandibular nerve that leaves cranial cavity by foramen ovale(located in
middle cranial fossa).

-In middle cranial fossa- superior orbital fissure and optic canals open.
Superior orbital fissure transmits ophthalmic division of the trigeminal nerve.

Trunk of the trigeminal nerve is located laterally to the sphenoid bone and is
divided into the 3 divisions, the first branch passes into the superior orbital
fissure, the maxillary nerve passes into the foramen rotundum, mandibular
nerve passes into the foramen ovale.

-Carotid canal lies in the middle cranial fossa which transmits internal carotid
artery which supplies brain.

-Internal acoustic meatus lies in posterior cranial fossa and this transmits 7
and 8 cranial nerves.
-When facial nerve(7th cranial nerve) passes the internal acoustic meatus it
leaves the cranial cavity by stylomastoid foramen. (On external base of skull is
located styloid and mastoid processes and between these processes is
located stylomastoid foramen). This nerve is closely located anteriorly to the
mastoid process so in surgical intervention of the mastoid process we should
be careful not to damage the facial nerve because all the branches of the
facial nerve innervates the muscles of facial expression lying superficially on
the face and damage of the nerve may cause paralysis of face.

-Jugular foramen transmits 9,10,11 cranial nerves and jugular vein(which is

continuation of the sigmoid sinus).

-Internal jugular vein is main vein which drains blood from the cranial cavity.

-Hypoglossal canal transmits the hypoglossal nerve (12th cranial nerve..).

-Big foramen in posterior cranial fossa - foramen magnum by which vertebral

arteries enter the cranial cavity (branches of subclavian artery) and it gives off
branches which anastamosis with branches of Internal carotid artery and
forms willis circle. Spinal cord also passes through it and also accessory nerve
which originates from spinal cord and via jugular foramen it leaves the cranial
cavity.

-Facial nerve enters the parotid gland and passes through it but does not
supply it , auriculotemporal nerve innervates the parotid gland, when facial
nerve leaves the gland in anterior part of face it gives off 5 branches which
innervate the muscles of facial expression.

(Pg 26 to the included 43 pg)