INTRODUCTION TO THE SKULL FACE SCALP MUSCLES OF

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INTRODUCTION TO THE SKULL, FACE, SCALP, MUSCLES OF FACIAL EXPRESSION, & PAROTID GLAND Jessica

INTRODUCTION TO THE SKULL, FACE, SCALP, MUSCLES OF FACIAL EXPRESSION, & PAROTID GLAND Jessica N. Byram, Ph. D [email protected] edu November 17, 2017

SLO’s 1. Describe the neurocranial and viscerocranial portions of the skull and its ossification

SLO’s 1. Describe the neurocranial and viscerocranial portions of the skull and its ossification via intramembranous and endochondral processes. 2. Discuss the bones of the skull, major sutures, clinically important fontanelles, craniosynostoses, and the role of foramina in transmitting neurovascular structures. 3. Describe the principal muscles of facial expression, their nerve supply, and actions, including the blood supply to the face and scalp. 4. Summarize the venous drainage of the face and scalp and describe clinically important extracranial and intracranial venous communications. 5. 6. 7. Describe the cutaneous innervation of the face and scalp. 8. Describe abnormalities and clinical considerations of the trigeminal nerve – trigeminal neuralgia and herpes zoster affecting the trigeminal nerve. Describe the parotid gland its duct. Describe lesions and resulting deficits with injury to the facial nerve: Bell's palsy and herpes zoster oticus. 2

The Cranium Neurocranium § Bones that encase the brain (8) o Parietal (2) o

The Cranium Neurocranium § Bones that encase the brain (8) o Parietal (2) o Temporal (2) o Frontal o Occipital o Sphenoid o Ethmoid § Cranial sutures: o Coronal (frontal) o Sagittal o Squamosal o Lambdoidal 3

The Cranium Viscerocranium § Bones of the face that create cavities housing special sense

The Cranium Viscerocranium § Bones of the face that create cavities housing special sense organs (14) o Nasal (2) o Lacrimal (2) o Inferior Nasal Concha (2) o Zygomatic (2) o Maxilla (2) o Palatine (2) o Vomer o Mandible 4

Osteology Foramen Ovale Foramen Rotundum Internal Acoustic Meatus Jugular Foramen Lacerum Trigeminal Impression Petrous

Osteology Foramen Ovale Foramen Rotundum Internal Acoustic Meatus Jugular Foramen Lacerum Trigeminal Impression Petrous Portion Of Temporal Bone 5

Osteology Petrotympanic Fissure Stylomastoid Foramen Jugular Foramen Ovale Foramen Lacerum Petrous Portion Of Temporal

Osteology Petrotympanic Fissure Stylomastoid Foramen Jugular Foramen Ovale Foramen Lacerum Petrous Portion Of Temporal Bone 6

Foramina of the Face Superior Orbital Fissure Supraorbital Foramen Inferior Orbital Fissure Infraorbital Foramen

Foramina of the Face Superior Orbital Fissure Supraorbital Foramen Inferior Orbital Fissure Infraorbital Foramen Mental Foramen 7

Overview: Vasculature of Face & Scalp Arteries Veins § § External Carotid Artery (ECA)

Overview: Vasculature of Face & Scalp Arteries Veins § § External Carotid Artery (ECA) • Facial a. • Occipital a. • Posterior auricular a. • Maxillary a. • Superficial temporal a. Internal Carotid Artery (ICA) • Supraorbital a. o Ophthalmic a. § External Jugular Vein (EVJ) • Retromandibular v. (post. div. ) o o • § Superficial temporal v. Maxillary v. Posterior auricular v. Internal Jugular Vein (IJV) • Occipital v. • Common facial v. o o Facial v. Retromandibular v. (ant. div. ) 8

Overview: Peripheral Nervous System Spinal Nerves Cranial Nerves § § Contain all of the

Overview: Peripheral Nervous System Spinal Nerves Cranial Nerves § § Contain all of the following functional fiber types: – General somatic efferent (GSE): skeletal muscle – General somatic afferent (GSA): from skin – General visceral efferent (GVE): to glands, smooth muscle – General visceral afferent (GVA): from viscera Can contain the four “general” fiber types and may contain an additional three “special” fiber types – Special somatic afferent (SSA): vision [CN II], hearing, and balance [CN VIII] – Special visceral afferent (SVA): olfaction [CN I], taste [CN VII, IX, X] – Special visceral efferent (SVE): muscles derived from mesoderm of pharyngeal arches [CN V 3, VII, IX, X] 9

Overview: ANS of the H/N Sympathetic Parasympathetic § Preganglionic neurons in lateral horns in

Overview: ANS of the H/N Sympathetic Parasympathetic § Preganglionic neurons in lateral horns in levels T 1 -T 3 of spinal cord § Preganglionic parasympathetic with CNs: III, VII, IX, and X § Postganglionic neurons in cervical sympathetic ganglia § Synapse in associated ganglia in head § Postganglionic fibers form plexuses around branches of carotid arteries § Postganglionic parasympathetic fibers hitchhike on branches of CN V 10

Overview: Nerves of Face & Scalp § GSA from Scalp: – Greater occipital (C

Overview: Nerves of Face & Scalp § GSA from Scalp: – Greater occipital (C 2) – Lesser occipital (C 2) § GSA from Face: – Trigeminal Nerve (CN V) – Great Auricular Nerve (C 2, 3) § SVE to Muscles of Facial Expression: – 2 nd pharyngeal arch – Facial Nerve (CN VII) § GVE to Parotid Gland: – Glossopharyngeal Nerve (CN IX) 11

Layers of the Scalp § S: Skin § C: Connective tissue (dense CT) –

Layers of the Scalp § S: Skin § C: Connective tissue (dense CT) – Neurovasculature § A: Aponeurosis (of epicranius) § L: Loose connective tissue – Movement of scalp, accumulation of fluids § P: Periosteum of cranium 12

Muscles of Facial Expression Levator Frontal Belly of Occipitofrontalis Labii Superioris ■ All muscles

Muscles of Facial Expression Levator Frontal Belly of Occipitofrontalis Labii Superioris ■ All muscles innervated by branches of Facial nerve (CN VII) ■ Attach to bones of the skull and fascia ■ Move the skin Orbicularis Oculi Zygomaticus Major & Minor Buccinator Levator Anguli Oris Depressor Anguli Oris Orbicularis Oris Depressor Labii Inferioris Platsyma 13

Muscles of Facial Expression Anterior, Posterior, & Superior Auriculars Frontalis Orbicularis Oculi Zygomaticus Major

Muscles of Facial Expression Anterior, Posterior, & Superior Auriculars Frontalis Orbicularis Oculi Zygomaticus Major & Minor Occipital Belly of Occipitofrontalis Orbicularis Oris Depressor Labii Inferioris Depressor Anguli Oris Platysma 14

Muscles of Facial Expression Muscle of Facial Expression Action Occipitofrontalis (epicranius) Occipital belly: depress

Muscles of Facial Expression Muscle of Facial Expression Action Occipitofrontalis (epicranius) Occipital belly: depress posterior scalp Frontal belly: elevate eyebrows, wrinkle forehead Orbicularis oculi Close eye, wink Zygomaticus major & minor Raise corner of mouth superolateral Levator labii superioris Elevate upper lip Levator anguli oris Elevate angle of mouth Orbicularis oris Close and protrude lips Depressor labii inferioris Depress lower lip Depressor anguli oris Depress angle of mouth Buccinator Press cheek against teeth, draw mouth to one side Auricular muscles Elevate ear, move ear anterior/posterior 15

The Parotid Gland § Largest of 3 paired salivary glands § Boundaries: – Superficial

The Parotid Gland § Largest of 3 paired salivary glands § Boundaries: – Superficial to ramus of mandible – Base at zygomatic arch – Apex at mandibular angle – Wraps around posterior ramus § Parotid duct crosses over masseter, pierces buccinator – Enters oral cavity at 2 nd maxillary molar § Encloses facial nerve (CN VII), retromandibular vein, and ECA. Zygomatic Arch Ramus and Angle of Mandible 16

The Parotid Gland v Buccinator v Parotid Duct Masseter Facial n. 17

The Parotid Gland v Buccinator v Parotid Duct Masseter Facial n. 17

Parotid Gland § Sailolithiasis: – Swelling, pain around gland – Stone palpable in duct

Parotid Gland § Sailolithiasis: – Swelling, pain around gland – Stone palpable in duct § Parotid gland tumors: – Most benign pleomorphic adenomas – Parotidectomy § Total parotidectomy (deep tissue) need to be cognizant of: – _______________________ _ – ____________ 18

Blood Supply to Face and Scalp Supraorbital External Carotid Artery (ECA) Ophthalmic Facial A.

Blood Supply to Face and Scalp Supraorbital External Carotid Artery (ECA) Ophthalmic Facial A. : – Inferior labial A. – Superior labial A. – Angular A. Angular § Occipital A. Mental § Posterior Auricular A. § Maxillary A. § Superficial Temporal Maxillary Posterior Auricular Occipital ECA Facial ICA Internal Carotid Artery (ICA) § Ophthalmic A. : 19

Blood Supply to the Face Angular Superficial Temporal Superior Labial Maxillary Inferior Labial ICA

Blood Supply to the Face Angular Superficial Temporal Superior Labial Maxillary Inferior Labial ICA Mental ECA Facial 20

Blood Supply to the Scalp Occipital Superficial Temporal Posterior Auricular ECA 21

Blood Supply to the Scalp Occipital Superficial Temporal Posterior Auricular ECA 21

Venous Drainage of Face and Internal Jugular Vein (IJV) Scalp § Cavernous Sinus –

Venous Drainage of Face and Internal Jugular Vein (IJV) Scalp § Cavernous Sinus – Superior ophthalmic v. – Pterygoid venous plexus § Occipital v. Common Facial v. § Facial v. – Angular v. § Retromandibular v. – Maxillary v. • Pterygoid venous plexus – Superficial temporal v. External Jugular Vein (EJV) § Posterior Auricular v. § Retromandibular v. (post. div. ) Superficial Temporal Superior Ophthalmic Pterygoid Venous Plexus Angular Cavernous Sinus Maxillary Occipital Facial Posterior Auricular Retromandibular Common Facial EJV IJV 22

Venous Drainage of the Face Superior Ophthalmic Superficial Temporal Angular Cavernous Sinus Pterygoid Venous

Venous Drainage of the Face Superior Ophthalmic Superficial Temporal Angular Cavernous Sinus Pterygoid Venous Plexus Maxillary Facial Retromandibular - Posterior division - Anterior division Common Facial Internal Jugular 23

Venous Drainage of the Scalp Superficial Temporal Posterior Auricular Occipital Retromandibula r Common Facial

Venous Drainage of the Scalp Superficial Temporal Posterior Auricular Occipital Retromandibula r Common Facial IJV EJV 24

Sensory Supply to Face and Scalp § § Face: Trigeminal Nerve (CN V) –

Sensory Supply to Face and Scalp § § Face: Trigeminal Nerve (CN V) – CN V 1: Ophthalmic – CN V 2 : Maxillary – CN V 3 : Mandibular – Great auricular (C 2, C 3) Scalp: – CN V 1 – Greater occipital N. (C 2) – Lesser occipital N. (C 2) – 3 rd occipital N. (C 3) V 1 V 2 V 3 Great Auricular N. Greater Occipital N. Lesser Occipital N. 3 rd Occipital N. 25

CN V Division Innervation Ophthalmic (V 1) GSA: cornea, superior nasal cavity, sphenoid, ethmoid,

CN V Division Innervation Ophthalmic (V 1) GSA: cornea, superior nasal cavity, sphenoid, ethmoid, and frontal sinuses, dorsum nose, superior eyelid, forehead, and anterior scalp Maxillary (V 2) Mandibular (V 3) GSA: inferior nasal cavity, maxillary sinus, palate, superior oral vestibule, maxillary teeth and gums, lateral nose, inferior eyelid, anterior cheek, and upper lip GSA: anterior two thirds of tongue, floor of mouth, inferior oral vestibule, mandibular teeth and gums, lower lip, cheek, temporal, external ear, and tympanic membrane SVE: muscles of mastication, mylohyoid, anterior digastric, tensor veli palatini, & tensor tympani V 1 V 2 V 3 26

Ophthalmic Division (CNV 1) Supraorbital N. Supratrochlear N. Lacrimal N. SOF Frontal N. Nasociliary

Ophthalmic Division (CNV 1) Supraorbital N. Supratrochlear N. Lacrimal N. SOF Frontal N. Nasociliary N. Communicating Branch from Zygomatic N. § Frontal N. – Supraorbital N. * – Supratrochlear N. * § Lacrimal N. * § Nasociliary N. – Anterior & posterior ethmoidal Nn. – Long ciliary N. – Short ciliary Nn. – Infratrochlear N. * Infratrochlear N. 27

Maxillary Division Foramen (CNV 2) Rotundum § Infraorbital N. * – Anterior & Middle

Maxillary Division Foramen (CNV 2) Rotundum § Infraorbital N. * – Anterior & Middle Superior Alveolar Nn. § Zygomatic N. * – Zygomaticotemporal N. – Zygomaticofacial N. § Posterior Superior Alveolar Nn. § Greater & Lesser Palatine Nn. § Nasopalatine N. Zygomatic N. Infraorbital N. Posterior Superior Alveolar Nn. Anterior & Middle Superior Alveolar Nn. 28

Mandibular Division Auriculotemporal N. (CNV 3) § Auriculotemporal n. * § Buccal n. *

Mandibular Division Auriculotemporal N. (CNV 3) § Auriculotemporal n. * § Buccal n. * § Lingual n. § Inferior alveolar n. – Mental n. * § Motor branches: – Deep temporal nn. – Nerve to mylohyoid (& anterior digastric) – Masseteric n. Deep Temporal Nn. Foramen Ovale Buccal N. Masseteric N. Inferior Alveolar N. Mylohyoid N. Lingual N. Mental N. 29

Trigeminal Neuralgia § One of the most common causes of facial pain – More

Trigeminal Neuralgia § One of the most common causes of facial pain – More common in older women § Unilateral pain to area supplied by CN V – Most common V 2 and V 3; rarely V 1 § Pain is described as stabbing, sharp, or intense § Triggers such as lightly brushing against face, cold air, and/or smiling § Classification: – Classical: compression of nerve roots by blood vessels – Secondary: herpes zoster (postherpetic neuropathy) or other lesions 30

Innervation to Muscles of Facial Expression Facial Nerve (CN VII) § Terminal branches: –

Innervation to Muscles of Facial Expression Facial Nerve (CN VII) § Terminal branches: – Temporal – Zygomatic – Buccal – Marginal mandibular – Cervical § Posterior auricular n. § N. to posterior digastric & stylohyoid Temporal Zygomatic Buccal Marginal Mandibular Posterior Auricular Stylomastoid Foramen Cervical 31

The Facial Nerve (CNVII) Facial canal Geniculate Ganglion CN VII @ Internal Acoustic Meatus

The Facial Nerve (CNVII) Facial canal Geniculate Ganglion CN VII @ Internal Acoustic Meatus § Longest intraosseus path of any nerve § Enters internal acoustic meatus – Geniculate ganglion – Greater petrosal N. § Enters facial canal – Stapedial N. – Chorda tympani N. § Terminal branches exit skull via stylomastoid foramen Greater petrosal N. Chorda Tympani N. Stylomastoid Foramen 32

The Facial Nerve CNVII Branch Greater Petrosal Geniculate Ganglion Innervation Greater petrosal N. GVE:

The Facial Nerve CNVII Branch Greater Petrosal Geniculate Ganglion Innervation Greater petrosal N. GVE: Lacrimal gland Stapedial SVE: Stapedius muscle Chorda Tympani SVA: anterior 2/3 of tongue GVE: submandibular and sublingual salivary glands Chorda Tympani N. @ Petrotympanic Fissure Posterior GSA: skin of external ear Auricular SVE: occipitalis Terminal SVE: muscles of facial Motor expression, stylohyoid, and Branches posterior digastric Posterior Auricular N. Lingual N. Stapedial N. 33

Facial Palsy Inflammation and compression of facial nerve: § Bell’s Palsy o Herpes Simplex

Facial Palsy Inflammation and compression of facial nerve: § Bell’s Palsy o Herpes Simplex Virus 1 (HSV-1) and Herpes Zoster activation § Herpes Zoster Oticus o Reactivation of VZV in geniculate ganglion § Auditory and vestibular disturbances Possible patient symptoms: § Terminal branches: o _____________________ § Chorda tympani: o _________________________________________ § Stapedial nerve: o _____________________ § Greater petrosal nerve: o _____________________ 34

Parasympathetics of CN VII Communicating Branch to Lacrimal n. Internal carotid plexus Lacrimal gland

Parasympathetics of CN VII Communicating Branch to Lacrimal n. Internal carotid plexus Lacrimal gland CNV 1 CNV 2 Facial n. (CNVII) CNV 3 Geniculate Ganglion Greater Petrosal n. Chorda Tympani Lingual n. Submandibular Gland Sublingual gland 35

Parotid Gland Innervation CNV 1 CNV 2 CNV 3 Tympanic n. Lesser Petrosal n.

Parotid Gland Innervation CNV 1 CNV 2 CNV 3 Tympanic n. Lesser Petrosal n. Auriculotemporal n. Parotid Gland 36

Parasympathetic Nerve Supply Overview C N X enteric (within walls of GI tract) mucosal

Parasympathetic Nerve Supply Overview C N X enteric (within walls of GI tract) mucosal glands in pharynx and larynx 37

Clinical Case § A 30 -year-old man had a pleomorphic adenoma removed from his

Clinical Case § A 30 -year-old man had a pleomorphic adenoma removed from his left parotid gland. His postoperative course was uncomplicated. Two months later, he noticed the following symptoms: – Left cheek became wet while eating – No signs of a fistula – Lemon test was performed • § Left auricular and parotid regions became flushed and sweaty (See Panel B). What is your diagnosis? A B 38

Clinical Case § ______________________ – Regenerating __________ __ regrow and connect with __________ __

Clinical Case § ______________________ – Regenerating __________ __ regrow and connect with __________ __ – __________ __ become active during 39

Summary of Face & Scalp 40

Summary of Face & Scalp 40