Hnss-Temporal Region, Oral Cavity, Tongue, Swallowing

Front 1

Temporal Bone and Region

Back 1

squamous portion
zygomatic arch
mastoid process
styloid process
Lateral Side of head- temporalis muscle and fascia, superficial temporal vessels, auriculotemporal nerve (V3)

Front 2

Infratemporal Region/fossa

Back 2

Below and deep to temporal region, behind maxilla, deep to ramus of mandible, in front of mastoid process; behind molars, extends medially to middle of mouth/palate line
Foramen ovale, foramen spinosum, stylomastoid foramen in this region
houses medial and lateral pterygoid(attach to wing of sphenoid), insertion of temporalis
TMJ joint here
Maxillary artery gives off Middle Meningeal artery here
Venous drainage here is pterygoid plexus (communicates with cavernous sinus)
Nerves: CN V, VII and IX
ganglia: pterygopalatine, otic and submandibular (all salivary)

Front 3

TMJ

Back 3

temporal-mandibular joint
Articular disc divides the joint cavity
Sphenomandibular and stylomandibular ligament supports it
Hinge joint, but ligament allows it to glide (creates popping)
Depression: gravity, digastric, geniohyoid, mylohyoid, Lateral pterygoid
Elevation: temporalis, masseter, medial pterygoid
Retraction: temporalis, deep part of masseter, geniohyoid, digastric
Protrusion: lateral pterygoid assisted by medial pterygoid
Side to side: temporalis, masseter and contralateral pterygoids
Dislocations: Forward dislocations more common (when yawning), or fraction of the mandible
otic ganglion and auriculotemporal nerve are close to the TMJ

Front 4

Pterygopalatine Fossa

Back 4

Depression on outside of skull in infratemporal region
Between sphenoid and palatine bone (palatine anterior to pterygoid plate)
Deep to this is sphenopalatine foramen (where find pterygopalatine ganglia)
Content: Maxillary artery, and maxillary artery is associated with nerve of pterygoid canal and pterygopalatine ganglion

Front 5

Pharynx

Back 5

Fibromuscular tube running from base of skull to cricoid cartilage
With deficiencies anteriorly = Opening to nasal and oral cavity
3 sections: nasopharynx (olfactory/respiratory function), oropharynx (digestive function), laryngopharynx (purely respiratory)
Extends to C6 where becomes continuous with esophagus

Front 6

nasopharynx

Back 6

Communicates with middle ear by Eustachian Tube (aud tube, or pharyngotympanic tube), guarded by tubul elevation and salpingopharyngeal fold (mucous membrane folds)
Small muscle at opening of eustachian tube that contracts when swallowing (swallowing helps equalize pressure in ear)
At base of skull there is pharyngeal tonsil (adenoids when inflammed)
Infections can get here from middle ear
lasts until level of soft palate

Front 7

Eustachian Tube

Back 7

Connects and communicates with nasopharynx
Vertical in adults, horizontal in kids (prone to ear infections)
Lateral 1/3 is bone, rest is cartilage

Front 8

Oropharynx

Back 8

Opening of oropharynx guarded on either side by palatine tonsils consisting of lymphoid tissue
palatoglossal arch/fold and palatopharyngeus arch and between two are the tonsils
palatine tonsils are just below the tongue

Front 9

Risk of Tonsillectomies

Back 9

Internal Carotid Artery just posterior to tonsil
Have to take tonsil out from fibromuscular wall which is paper thin, behind is pharyngeal constrictors and ICA, vagus and internal jugular
Sometimes can have an aneurysm right behind or tortuous internal carotid which are dangerous to operate on
Tonsils also have tonsillar branch of ascending palatine artery, tonsillar branch of facial artery
complications: bleeding from arterial supply, bleeding from veins, perforation of ICA
Lateral side is highly vascularized

Front 10

Vestibule (mouth)

Back 10

U shaped region between cheeks, lips, teeth and gums
Contains labia frenula and parotid papilla (where parotid ducts open)
Function: grasping

Front 11

Parotidectomy/benign tumor of parotid

Back 11

Encapsulated gland so tumor growth causes pain
Parotidectomy needed but watch out for facial nerve running through the gland

Front 12

Philtrum

Back 12

Provides human quality to our face, groove in middle between nose and lip
Missing philtrum can occur with FAS and cleft lip

Front 13

Squamous cell carcinoma of lip (Lymph drainage)

Back 13

Transitional Zone of lip most susceptible
Middle portion of lower lip drains to submental nodes
upper lip to ipsilateral submandibular and lower lip drains to submandibular nodes (ipsilateral and contralateral)
Submandibular and submental both superficial
submental drains to submandibular and submandibular drains deep
Cancer in lower middle lip is best outcome

Front 14

Palate (including foramina, nerves...)

Back 14

Separates oral and nasal cavity
Hard/bony- anterior is palatine process of maxilla, posterior is horizontal process of palatine bone
Soft/uvula region more posterior
Muscles: Tensor Veli Palatine (V3)- inserts onto soft palate and stretches uvula
Levator Veli Palatine (Vagus)- Elevates the uvula which closes the oropharynx from the nasopharynx/nasal cavity, palatopharyngeus, palatoglossus, muscular uvulae
Incisive canal (near incisors)- nasopalatine nerve and sphenopalatine artery
Greater palatine foramina- greater palatine nerve and vessels go through
Lesser palatine foramina- Lesser palatine nerve and vessels go through
innervation: branches of V2, greater palatine nerve and nasopalatine nerve, Muscles innervated by pharyngeal plexus (CN IX, X, XI) and tensor by V3

Front 15

Cleft Palate

Back 15

Palate bones fail to fuse
Face looks normal but difficulty swallowing in nursing, problems with phonation
May occur without cleft lips
1/2500 births, more common in females
may involve only uvula or extend to palate

Front 16

Teeth

Back 16

32 in adults
2 Incisors
1 Canine
2 Premolars
3 Molars
Joint is gomphosis- conical tooth inserted into socket like portion, grants mobility to teeth, mobility helps teeth from cracking while biting hard object

Front 17

Lower Jaw (innervation/anesthesia) aka mandibular nerve block

Back 17

Innervation: Inferior alveolar nerve (V3), travels through Mandibular foramen guarded by lingula (bony tongue)
Numbing jaw then aim for lingula- 1 injection
Inferior alveolar nerve becomes mental nerve so skin anteriorly 1/2 goes numb too

Front 18

Upper Jaw (innervation/anesthesia)

Back 18

Nasopalatine nerve (incisive foramen, mucosa, gingivae and palate of anterior 6 teeth), greater palatine nerve (greater palatine foramen, mucosa, lingual gingivae, palate posterior to canine teeth)
3 Injections: Incisive canal (nasopalatine nerve)- palatal mucosa, lingual gingivae, alveolar bone of 6 anterior maxillary teeth, hard palate
Greater palatine foramen (Greater palatine nere)- Palatal mucosa, lingual gingivae posterior to canine teeth, bone of palate
Vestibular side of tooth (aim for mucosa above tooth) bc other two only get lingual side of teeth
nb: needle in incisive canal very painful bc mucosa intimately related with bone of upper jaw
Superior alveolar nerve: from V2

Front 19

Tongue (attachments, paralysis)

Back 19

Attached to bony and cartilaginous structures-
Root: joined to epiglottis by 1 median and 2 lateral glossoepiglottic folds
Mandible, hyoid bone, styloid process and palate by muscles
Inferior surface: lingual frenulum attaches surface to floor of mouth
paralysis then tongue falls back, tilt head back to open airway
When comatose, tongue falls into oropharynx
Have to intubate during anesthesia bc paralysis
body and root (posterior 1/3) and separated by sulcus limitans with foramen cecum (remnant of thyroglossal duct) at the middle of it

Front 20

Under Tongue (glands/veins)

Back 20

Sublingual glands
submandibular ducts- on either side of frenulum
deep lingual plexus of veins (absorption of drugs) ie nitroglycerin

Front 21

Extrinsic muscles of Tongue

Back 21

Move the tongue
Palatoglossal (elevation of tongue- Vagus/pharyngeal plexus)- Fold guarding oropharynx and palatoglossus is behind it
genioglossal- protrudes tongue forward, very large
hypoglossal- depresses tongue
Styloglossal- elevates and retracts

Front 22

Intrinsic Muscles of Tongue

Back 22

Alter Shape the Tongue-curling of tongue
Attachments entirely within tongue
Interweaving bundles termed superior longitudinal, inferior longitudinal, transverse and vertical muscles

Front 23

Motor to Tongue

Back 23

Hypoglossal except palatoglossal (vagus)

Front 24

Special Sensory to Tongue (Taste)

Back 24

Anterior 2/3 by Chorda Tympani (Facial)
Posterior 1/3 by Glossopharyngeal
Very posterior by Vagus

Front 25

General Sensory to Tongue

Back 25

Anterior 2/3 by Lingual nerve (Trigeminal)
Posterior 1/3 by Glossopharyngeal
Very posterior by vagus/ internal laryngeal

Front 26

Gag Reflex

Back 26

Afferent is Glossopharyngeal
Efferent is Vagus

Front 27

Hypoglossal Nerve Injury

Back 27

Tongue deviates to side of lesion
Can be injured in boxing

Front 28

Arteries to Tongue/Oral cavity/palate

Back 28

Maxillary Artery- gives off (within infratemporal fossa) Inferior alveolar artery, descending palatine artery (accompanies greater and lesser palatine nerves) and sphenopalatine artery (through sphenopalatine foramen then enters oral cavity via incisive canal),
External Carotid artery- gives off lingual artery and facial artery
Getting blood supply from the front and back
Palate: sphenopalatine artery and palatine artery- blood supply travels with nerves
Veins follow arteris

Front 29

Sphenoid Bone

Back 29

Wedged shaped
Perpendicular to long axis of skull
Houses superior orbital fissure and foramen rotundum etc
Has pterygoid process (inferiorly)

Front 30

Pterygoids

Back 30

Both are lateral to pterygoid plate (sphenoid bone)
Lateral is more superior(near TMJ), medial more inferior (By ramus of mandible, other attachement is more medial on sphenoid), fibers have similar alignment as masseter(but on inside of mandible)

Front 31

Muscles of Mastication

Back 31

Temporalis: closure of jaw, retraction of lower jaw (attaches to coranoid process)
Masseter: Closure of jaw, Protraction of lower jaw (attaches from zygomatic arch/bone to angle of mandible)
Lateral pterygoid (opening of lower jaw, Protraction of lower jaw, produces larger chewing movements)
Medial Pterygoid (Closure of jaw, Protraction of lower jaw, produces smaller grinding movements)

Front 32

Lips

Back 32

Begin at nasolabial groove
skin of transitional zone: very thin, have color there
Vermillion border: where skin meets transitional zone
philtrum

Front 33

Missing a Philtrum

Back 33

Fetal alcohol syndrome compromises philtrum (more severe with increasing concentration of alcohol)
Cleft lip: congenital, 1/1000 births
60-80% in males
Can be small, large, unilateral or bilateral

Front 34

Oral Cavity

Back 34

for chewing, preparing food for digestion, phonation, grasping
consists of vestibule (between cheeks and lips superficially, and teeth and gingivae deep) and oral cavity proper
oral cavity proper: bonded by teeth and gums, palate, floor of mouth, and continuous posteriorly with facial isthmus

Front 35

Tongue (functions, papillae, tonsil)

Back 35

Mobile muscular organ
partly in oral cavity proper and partly in pharynx
Assists with: mastication, deglutition, articulation, and oral cleansing
Nerve damage to tongue...many more cavities
Lingual Tonsils, on root of tongue
Papilla on body of tongue: Vallate (Most posterior), foliate (folds on sides tongue, very posterior), fungiform (mid/sides in body) and filiform papillae (middle/body)- increase surface area of contact between surface of tongue and content of oral cavity, all except filiform have taste buds on surface

Front 36

Tongue Lymphatics

Back 36

Smoking also causes tongue, throat cancer
Closer to midline, more chance of metastasis to deep cervical LN making treatment more difficult
Malignant tumors of posterior/root of tongue to superior deep cervical LN,
Middle of body drains to inferior deep cervical LN
front tip to submental
Sides of the body of tongue to submandibular LN

Front 37

Deglutition

Back 37

Want to seal off nasal cavity so food doesn't go into nasal cavity- through tensor veli palatini (CN V3), then levator veli palatini (CN vagus) which seals off oropharynx from nasopharynx and nasal cavities
Superior, middle, and inferior pharyngeal constrictors will narrow oropharynx so uvula has small area to close off
1. Tongue forces compacted bolus into oropharynx (styloglossus)
2. Pharyngeal constrictors narrow oropharynx, Tensor and levator palatini raise uvula to seal off nasal cavity
salpingopharyngeus and stylopharyngeus elevate laryngopharynx (eustachian tube opens)
3. Larynx closes, bolus moves along esophagus and larynx returns
Epiglottis doesn't move, the pharynx elevates to meet the epiglottis and seal off the trachea (palatoglossus, palatopharyngeus and salpingopharyngeus all aid with this

Front 38

Nerves of Pharynx

Back 38

pharyngeal plexus formed by glossopharyngeal and vagus nerves- innervates all pharyngeal muscles but 2
stylopharyngeus (IX) and tensor veli palatini (V3)
Inferior constrictors may be from external laryngeal nerve (vagus)
Sensory: nasopharynx- maxillary nerve
Oropharynx- glossopharyngeal (gag reflex)
laryngopharynx- internal laryngeal nerve

Front 39

Damage to Pharyngeal Plexus

Back 39

Uvula deviates away from afflicted side due to unopposed action of levator veli palatini
Saying AHHHH

Front 40

Maxillary artery

Back 40

terminal branch of ECA
Supplies all deep structures of face: lower jaw, upper jaw, eye sockets, palate, and a little part of orbital cavity
Ends by going into pterygopalatine fossa

Front 41

Mandibular nerve (divisions)

Back 41

V3 trunk divides into Anterior and Posterior division
Branches off trunk: nerve to medial pterygoid and n.spinosus (sensory to meninges)
Anterior division (mostly motor): Deep temporal (to masseter and lateral pterygoid), Buccal (to mucos membrane of vestibule- tell if drinking something hot or cold)
Posterior Division (mostly sensory): auriculotemporal nerve, inferior alveolar, nerve to mylohyoid (comes off inferior alveolar), lingual (joined by chorda tympani), submandibular ganglia

Front 42

Palatine Tonsil (blood supply, lymph)

Back 42

Blood: branches of facial, maxillary, ascending pharyngeal, lingual arteries
venous: drains into a venous plexus which drains to the facial or internal jugular vein
lymph: drains to upper deep cervical nodes

Front 43

Laryngopharynx

Back 43

laryngeal inlet guarded by epiglottis
Lateral to epiglottis are two depressions called piriform recesses (foreign bodies can get lodged there, causing whistling noise, or infections)
Internal laryngeal nerve is located deep to the mucosa of the piriform recess

Front 44

Muscles of pharynx

Back 44

3 constrictors stacked like flowerpots
superior, middle and inferior constrictors
Origins: superior - mandible/sphenoid, middle - hyoid bone, inferior- thyroid/cricoid cartilage
muscles fan out and decussate posteriorly at fibromuscular insertion (raphe) which will attach to pharyngeal tubercle at base of skull

Front 45

Pharynx (blood supply)

Back 45

Ascending pharyngeal, facial, superior thyroid and inferior thyroid arteries
venous: drains into a plexus which drains into facial or internal jugular vein
Lymph: retropharyngeal LN (in front of spine), from there to deep cervical LN

Front 46

Oral Cavity Innervation

Back 46

upper jaw: superior alveolar branch of maxillary nerve
Lower jaw: Inferior alveolar branch of mandibular nerve