3.头面部

8、Skull To be divided into the cranium skeleton and facial skeleton with a connective line between the supraorbital margin and external acoustic meatus Cranium skeleton: paired & unpaired Cranium skeleton: unpaired: frontal, occipital,ethmoid & sphenoid bones paired: parietal, temporal bones Facial skeleton: paired & unpaired Facial skeleton:maxilla, mandible, zygomatic, nasal, lacrimal, vomer, palatine bones & I nferior nasal concha, (hyoid bones). Important bones Mandible All bones of skull are articulated by sutures, except mandible which is articulated by temporomandibular joints. Mandible consists of two parts: a horizontal portion (body) & a vertical portion (rami). Sphenoid bone Its pterygoid processes, consisting of lateral & medial pterygoid plates, extend inferiorly on each side from junction of body & greater wings. Groove for cartilaginous part of auditory tube lies medial to spine of sphenoid. 1. Anterior aspect · orbits, bony nose, bony oral · Supraorbital margin of frontal bone has a supraorbital notch or foramen on junction of its medial & middle third. · Infraorbital foramen is below midpoint of infraorbital margin on maxilla. · Upper jaw is formed by fused maxillae; their alveolar processes form sockets & supporting bone for upper teeth. · Alveolar processes of mandible bear lower teeth. · Mental foramen is inferior to 2nd premolar tooth. 1). Orbit: four-sided pyramid 4 surfaces Sup.-superior orbital fissure Inf.- inferior orbital fissure, groove, canal , foramen Int.-fossa for lacrimal sac, nasolacrimal canal (communicating with inf. nasal meatus) Lat.-lacrimal fossa apex-optic canal 2) Bony nasal cavity Anterior nasal aperture / piriform aperture Posterior nasal aperture *Lateral wall—superior,middle and inferior concha superior, middle and inferior meatus *Medial wall-median septum formed by vomer犁骨 and perpendicular plate of ethmoid *Inferior wall- bony palatine 骨腭separating oral * Paranasal sinuses are air-cells or air-containing sacs and around the nasal cavity;and open into the nasal meatus · To include (1) frontal sinuses—in the frontal bone, opening into middle meatus (2) ethmoidal sinuses—in the ethmoidal labyrinth, ant. and middle groups open into middle meatus posterior group-- superior meatus （inf. meatus—nasolacrimal duct） (3) sphenoidal sinuses---in the body of the sphenoid bone, opening into sphenoethmoidal recess蝶筛隐窝 (4) maxillary sinuses– in the body of maxillae, opening into the the middle meatus *Its opening is higher than its floor. not easy to drain the pus（脓）in the sinus, if infection in this sinus **The floor is the alveolar process of maxilla and is adjacent with roots of the premolars Ⅱ, molarsⅠand molarsⅡ.(maxilla) ***the apex is the inferior wall of orbit ****The medial wall is the lateral wall of bony nasal cavity 2.lateral aspect · Zygomatic arch · External acoustic meatus · Inf. and Sup. temporal lines · Temporal fossa · Infratemporal fossa Zygomatic arch is formed by union of temporal process of zygomatic bone & zygomatic process of temporal bone. The arch divided the lateral aspect of skull into temporal and infratemporal regions Temporal fossa is bounded superiorly & posteriorly by temporal lines, anteriorly by frontal & zygomatic bones, & inferiorly by zygomatic arch. Pterion–is indicated by H-shaped formation of sutures that unite frontal, parietal, sphenoid, & temporal bones. It locates in anterior part of temporal fossa, about 4 cm superior to midpoint of zygomatic arch H- shaped sutures; union of frontal, parietal, temporal and sphenoid bones Ant. Br.of middle meningeal a. passes through the deep surface of pterion Pterygopalatine fossa between the maxilla and pterygoid process, perpendicular plate of palatine medially pterygomaxilla fissure laterally Main Cmmunication: anterally—inferior orbital fissure orbit medially--sphenopalatine foramen nasal cavity laterally—pterygomaxilla fissure infratemporal fossa supraposteriorly—foramen rotundum middle cranial cavity inferiorly-pterygopalatine tubule oral cavity 3. Superior aspect · Coronal suture --separates frontal & parietal bones · Sagittal suture-- separates R & L parietal bones · Lambdoidal suture separates parietal & temporal bones from occipital bone. · Bregma(冠矢点) · Lambda(人字缝尖) Fractures of the Calvaria -- counterblow , depressed fractures Linear fracture、 depressed fracture、 comminuted fracture 、basilar fracture 4. Inferior Aspect of Skull anterior part is hard palate formed by palatine processes of maxillae anteriorly &horizontal plates of palatine bones posteriorly. Posterior to central incisor teeth is incisive fossa. Posterolaterally are greater & lesser palatine foramina. · Mandibular fossae are depressions in temporal bone that accommodate condyles of mandible. · Occipital condyles are two large protuberances on lateral parts of occipital bone. · Jugular foramen is large opening between occipital bone & petrous part of temporal bone · Carotid canal --Entrance to carotid canal lies just anterior to jugular foramen. · Stylomastoid foramen lies between styloid & mastoid processes. 5. Posterior aspect External occipital protuberance Superior nuchal line External occipital protuberance is an elevation in median plane of posterior aspect. Superior nuchal line extends laterally from each side of this protuberance 6.internal aspect Bowl-shaped floor of cranial cavity has 3 cranial fossae. Anterior cranial fossa is at the highest level, & posterior cranial fossa is at the lowest level. 1) Anterior cranial fossa is formed by frontal bone anteriorly, ethmoid bone in middle, body & lesser wings of sphenoid posteriorly. Its greater part is formed by ridged orbital plates of frontal bone, which support frontal lobes of brain and form roofs of orbits. cribriform foramen (筛孔)—olfactory nerve piercing the foramen and cribriform plate(筛板), crista galli(鸡冠), foramen cecum(盲孔) frontal crest, orbital plate(眶板) 2）middle cranial fossa is separated from posterior one by petrous ridge of the temporal bones laterally & dorsum sellae of sphenoid medially. （Sella turcica is composed of three parts: Tuberculum sellae, an olive-shaped swelling, anteriorly；Hypophyseal fossa, a saddle-like depression for hypophysis, in the middle；Dorsum sellae posteriorly） · Tuberculum sellae · optic canal · Chiasmatic groove, · anterior and posterior clinoid process · hypophyseal fossa · dorsal sellae · Superior orbital fissure (Ⅲ,Ⅳ,Ⅴ1,Ⅵ) 【 Ⅲ oculomotor, Ⅳ trochlear Ⅴ trigeminal, Ⅵabducent，Ⅴ1 ophthalmic】 · Foramen rotundum(into pterygopalatine fossa; V2), · Foramen ovale(into infratemporal fossa; V3), · Foramen spinosum(middle meningeal a.) · sulcus for ICA · Carotid canal,/ foramen lacerum · Trigeminal impression · Tegmen typani 3) Posterior cranial fossa is formed largely by occipital bone. Broad grooves in this fossa are formed by transverse and sigmoid sinuses. · Foramen magnum, · Hypoglossal canal (Ⅻ), is superior to anterolateral margin of foramen magnum. · Jugular foramen(beginning of internal jugular v., Ⅸ-- glossopharyngeal n., Ⅹ,Ⅺ), is at base of petrous ridge · Internal acoustic meatus (Ⅶ,Ⅷ-- vestibulocochlear n.)is at posterior surface of petrous ridge.【Ⅶ facial, Ⅷ vestibulocochlear Ⅸglossopharyngeal, Ⅹvagus Ⅺ accessory】 · Internal occipital protuberance, 枕内隆突 · Groove for transverse sinus · Groove for sigmoid sinus · Groove for superior sagittal sinus (上矢状窦沟) Clivus 斜坡？ 7. External aspect of the base of the skull · Incisive foramen(切牙孔) · Greater palatine foramen (腭大孔), · Posterior nasal aperture, · Occipital condyles(枕髁), · Mastoid process(乳突) · styloid process(茎突) · Stylomastoid foramen(茎乳孔) · Foramen lacerum(破裂孔) · Mandibular fossa(下颌窝) · Articular tubercle(关节结节) · …… 8. The skull at birth · Anterior fontanelle(前囟)---Bregma · Posterior fontanelle-- Lambda · Mastoid fontanelle--- Asterisk · Sphenoidal fontanelle--- Pterion 9、Face &Scalp Face The superficial structures of face 1. The skin: There are rich sebaceous glands (皮脂腺), sweat glands, hair follicles(毛囊), and blood supplying. 2) It is thin and rich elasticity. 2. Superficial fascia 1) loose connective tissue: *corpusadiposum buccae(颊脂体) at the buccal part * at the palpebra(睑), subcutaneous fat is lesser and looser. 2) The facial vessels (1) Facial artery arises from external carotid a.; runs upwards and forwards; turns around the lower border of mandible crossing with anterior border of the masseter; enters the face where the facial a.runs lateral to the angle of the mouth and wing of nose, and then reaches the medial canthus(内眦), where it becomes the angular a.; Anastomosis occurs between branches of the left and right facial aa.. (2) facial vein begins at the angular v. at the medial angle of the eye; accompanies with facial a., behind the a.; inferior to the margin of mandible, the facial v. is jointed with the anterior branch of the retromandibular v., and then drains into the internal jugular v.. ( directly or indirectly to the internal jugular vein) Feature of the facial v. Ⅰ. Having no valves Ⅱ. Communicating with cavernous sinus(belonging to dural venous sinuses) with the 2 routes: ① Facial V →angular V →ophthalmic v→ cavernous plexus ② Deep facial v→ pteygoid plexus→cavernous sinus appearing “danger area of the face”where is bordered by the root of nose, and left and right angles of the mouth.三角区的静脉与上下视静脉交通，注入眶后的海绵窦，危险三角的脓包的挤压可能会导致硬脑膜窦中的静脉窦感染 (3) Superficial temporal a. is one of terminal branches of external carotid artery within the parotid gland( the other branch is maxillary artery), the superificial temporal artery emerges on the face between the temporomandibular joint and the ear and ends in the scalp by dividing into frontal and parietal branches. it accompanies with auriculotemporal nerve Notice: where can you touch the beat of the artery and stop bleeding ? Anterior to the tragus耳屏（外耳门前面的突起由软骨和皮肤构成能遮住外耳门） (3) superficial temporal a. · It drains the forehead and scalp and receives tributaries from the veins of the temple and face. Near the auricle, the superficial temporal vein enters the parotid gland. (4) The retromandibular vein, It is formed by the union of the superificial temporal vein and maxillary veins, and descends within parotid gland 3) muscles of facial expression move the skin and change facial expressions to convey feeling. Most of the muscles are attached to skin of the face and lie in the subcutaneous tissue 1. They Surround the facial orifices 2. All of the facial expression muscles are innervated by facial nerve 3. Origion and insertion · (1) occipito-frontalis · (2) orbicularis oris (口轮匝肌) Muscles of the mouth · (3) orbicularis oculi · (4) buccinator producing negative pressure in the oral cavity and making suck(吸吮) · Depressor anguli oris m. · Zygomatic major/minor m. · Levator labii superioris m. There are several muscles that alter the shape of the mouth and lips. The most important M is the orbicularis oris M The orbicularis oris muscle is the sphincter M of the mouth. Its fibers lying within the lips encircle the mouth.The act of this muscle is close the mouth, purses the lips,and plays important role in articulation and mastication. In association with the buccinator muscle, it helps to hold food between the teeth during mastication. Depressor anguli oris M and Zygomaticus major (minor)M , Levator labii superioris M. 4) vessel- nerve bunches (1)supraorbital vessel-nerve a.from ophthalmic a.(眼动脉) n. from frontal n. of the ophthalmic n. (2)supratrochlear vessel-nerve(ditto同上) (3)infraorbital vessel-nerve from maxillary a. and n. (4)mental vessel-nerve a. from inferior alveolar a. n. from inferior alveolar n.(br. of mandibular n. of trigeminal n.) 5) the nerves (1) The cutaneous nn. of the trigeminal nerve: supraorbital supratrochlear lacrimal infratrochlear external nasal 以上来自CN V infraorbital zygomaticofacial &zygomaticotempral mental nerve auriculotemporal n. buccal nerve lesser occipital nn. (C2.3) greater occipital nn. (C2) The major cutaneous branches of the face are: Branches of trigeminal nerve CNⅤ The cutaneous branches of the ophthalmic nerve (CNⅤ1) Supraorbital arises from frontal nerve which is one of branches of the ophthalmic n (trigeminal n). Supratrochlear vessel-nerve branch  infraorbital vessel-nerve bunch the artery arises from maxillary artery. The nerve arises from maxillary nerve. CNⅤ2 Mental vessel-nerve brnch: the artery is terminal branch of inferior alveolar artery which arises from maxillary artery. The nerve arises from inferior alveolar nerve of submandibular nerve of CNⅤ3 Auriculotemporal nerve CNⅤ3 Buccal nerve CNⅤ3 (2) The br. of the facial n.: The motor nerves of the face temporal br. zygomatic br. buccal br.-buccinator mandibular br. cervical br.-- these branches pierce and leave the parotid gland from the anterior border of the the parotid gland, and supply the muscles of the facial expression. 6) The lymphatic vessels of the face （Mastoid、occipital、parotid、superficial cervical、buccal、submental、submandibular） Lymphatic vessels accompany with facial vessels Lymph from the lateral part of the face, including the eyelids, drain inferiorly to the parotid lymph nodes. Lymph from the deep parotid nodes drains into deep cervical lymph nodes. Lymph from the upper lip and lateral parts of the lower lip drain into the submandibular lymph nodes Lymph from in chin and central part of the lower lip drain into the submental lymph nodes. Scalp The scalp covers the calvaria extending from the superior nuchal lines on the occipital bone to the supraorbital margin of frontal bone. Laterally it extends over the temporal fascia to the zygomatid arches. The scalp consists of five layers, the first three of which are connected intimately and move as a unit. Each letter of the word scalp serves as a memory key for its layers: skin, connective tissue, aponeurosis epicranialis, loose connective tissue, and pericranium. 一。The layers of scalp 1. Skin : this except in the occipital region, contains many sweat gland, sebaceous gland, and hair follicles; it has an abundant arterial supply and good venous and lymphatic drainage. 2. Superficial fascia : is a thick, richly vascularized subcutaneous layer that is well supplied with nerves。many fibers bunches connect between the skin and aponeurosis epicranialis. So, many little apartments are formed. The vessels and nerves pierce and pass through these apartments. 3. Frontalis, occipitalis and aponeurosis epicranialis: aponeurosis epicranialis is a strong membranous tendinous sheet, between the frontalis and occipitalis. The sides of aponeurosis epicranialis became the superficial layer of temporal fascia. 4. Loose connective tissue: a broad and potential space of the loose tissue; many vv., communicating between the vv. in the scalp and diploic v. （板障静脉—颞浅静脉的属支）and dural venous sinuses through the duct—vessels (emissary v.导静脉) 5. Pericranium（颅骨外骨膜）: a dense layer of connective tissue， attach firmly to the cranial sutures and is continuous with the fibrous tissue in the cranial sutures. but the periostenum can be stripped fairly easily from the cranial bones of living persons, except where it is continuous with the fibrous tissue in the cranial sutures. **the bones of parietal part on the skull: internal plate 内板, external plate(compact substance) 外板, diploe(spongy substance) 板障 Hematoma 血肿？ 二．Innervations of the scalp · Anterior to the auricles ---- branches of all three divisions of CNV 眶上，滑车上，颧颞，耳颞 · Posterior to the auricles ---- spinal cutaneous nerves of the cervical plexus 枕小，枕大，c3等 三．Arterial supply of scalp Branches of ECA and ICA · Occipital a · Posterior auricular a · Superficial temporal a · Supratrochlear a. & supraorbital a. Parotid gland · 1) the largest one of the 3 paired salivary glands · 2) enclosed within the fascia parotid sheath— formed by enveloping fascia · 3)anteroinferior to the external acoustic meatus · 4) Parotid duct—It passes horizontally from the anterior edge of the gland, runs forwards at the surface of the masseter, inferior to the zygomatic arch. At the anterior border of the masseter, the duct turns medially, pierces buccinator, and opens on a small papilla on the buccal mucosa of oral surface of the cheek opposite the second maxillary molar tooth. · 5) Structures within the gland (1)Longitudinal structures external carotid a. superficial temporal v.and a. retromandibular v. auriculotemporal n. (2) Transverse maxillary a. and v. transverse facial a. and v. br. of the facial n. parotid duct · 6) The main structures leaving the edge of the parotid gland Temporal br. Zygomatic br. Buccal br. Mandibular br. Cervical br. Parotid duct Superficial temporal blood vessels and auriculotemporal n. Parotid –bed、A lot of m.attached to the styloid Carotid sheath、Lower 4 paired cranial n. 10、Contents of Cranial Cavity ----Brain & its coverings, vasculature Coverings of the brain Skull cranial meninges · dura mater: tough, thick external fibrous layer · arachnoid mater: thin intermediate layer · pia mater: delicate internal vasculated layer Protect the brain. Form the supporting framework for arteries, veins, and venous sinuses. Enclose a fluid-filled cavity, the subarachnoid space, which is vital to the normal function of the brain. 2 layers of dura Epidural space Dura venous sinuses：sup. sagittal sinus, inf. sagittal sinus, straight sinus transverse sinus, cavernous sinus, sigmoid sinus Cavernous sinuses-- a large irregular network of communicating venous channels on each side of the sphenoid sinus；It enclose the internal carotid artery and abducens nerve, etc. Intercranial hemorrhages ？ Septum · cerebral falx · cerebellar tentorium · The cerebral falx is the sickle-shaped that extends in the midline from the crista galli to the internal occipital protuberance · Posteriorly this septum is continuous with other transverse cerebellar tentorium The sellar diaphragm The diaphragm sellae roofs over the pituitary fossa and is perforated by the infundibulum middle meningeal a. & v.—supply large areas of dura Small areas of dura are supplied by other arteries: meningeal branches of the ophthalmic arteries, branches of the occipital arteries, and small branches of the vertebral arteries. The veins of the dura accompany the meningeal arteries, often in pairs. The middle meningeal veins accompany the middle meningeal artery, leave the cranial cavity through the foramen spinosum or foramen ovale, and drain into the pterygoid plexus Brain · Cerebral hemispheres · Diencephalon · Midbrain · Pons · Medulla oblongata (medulla) · Cerebellum Blood supply of brain · internal carotid a. ICA passes forwards through the cavernous sinus then upwards on the medial aspect of the anterior clinoid process lateral to optic chiasm · vertebral a. Ascending through the transverse foramen of cervical vertebrae。Enter the cranial cavity through the foramen magnum。Unit to form basilar artery at the junction between the medulla and pons。At the junction between the pons and midbrain, it gives superior cerebellar arteries and posterior cerebral arteries · will’s circle ：ICA, MCA, ACA, AC, PC, PCA, BA unit to form WILL’S CIRCLE · other branches 大脑动脉的皮支和中央支 The central arteries：they mainly supply the diencephalons corpus, striatum and internal capsule. Venous drainage of the brain · the superficial veins · the deep veins · dural venous sinuses none of these vessels contain valves.Three sets of vessels take part in venous drainag