LESSON #24 (6 HOURS)
Theme. Common carotid artery. Vascular nervous bundle of the neck. External carotid artery (neck branches). Practical skills on senses organs preparations.
Head and neck division of vagus nerve and sympathetic trunk. Terminal branches of external carotid artery: maxillary and superficial temporal arteries, topography distribution of branches. Veins of the head.
Lymphatic vessels and nodes of the head
Aіm: Study the structural and topographical peculiarities of carotid arteries and branches. Study the structural and topographical peculiarities of lymphatic and venous drainage of neck. To study the structure of lymphatic system, separate organs, tributaries to thoracic lymphatic trunk and to right lymphatic duct. Study the structural and topographical peculіarіtіes of autonomic nervous system, location of centres and peripheral parts and main functions.
The professіonal orіentatіon. Affection of aorta and its branches is a severe pathology, often dangerous to patient's life and is not infrequent in medical practice (pathology of vessels in atherosclerosis, infectious diseases, congenital anomalies). The diagnostic and medical manipulations on vessels cannot be executed without knowing their normal anatomy. It is also impossible to determine a place of localization of pathological process, relying on clinical signs.
Superior vena cava and brachiocephalic trunk are in complex relations with organs of mediastinum surrounding them. Therefore disturbance of blood flow in this vessels may be indicate not only of disease of veins, but also of pathological process of organs of this area. In a brain part of the head there is an anatomic unity of four layers of veins: veins of soft covers of fornix, intraosteal veins, veins of dura mater (venous sinuses), and also intracerebral veins. Therefore any infection of soft covers of the head is dangerous in view of spread of infection to the cavity of skull. Veins of the face form plexus, that anastomose with veins of the cavity of skull and the orbits, and these anastomosis lack valves, therefore there is a real danger of spreading odontogenous inflammatory processes of jaws and paramaxillary soft tissues on these anastomosis.
Knowledge the organisation of the sympathetic part of the autonomic nervous system is the base for understanding of neurophysiology and neuropathology. Anatomical peculiarities of the location of centres and peripheral parts is necessary for neurological therapy and surgery in brain. If the vagus nerve is damaged there is impairment of function in the throat and the larynx: unilateral paralysis of the levator veli palatini muscle causes the soft palate and the uvula to the displaced to the intact side. The vocal cord on the affected side will remain immobile in the cadaver position (recurrent laryngeal nerve palsy) as a result of paralysis of the internal laryngeal muscles.
I. Practical work – 9:00-12:00 am (4 hours)
1) Methodology of practical class.
Work 1. Dissection of superficial veins of neck.
The students under the direction of teacher are making skin cuts on the left side of the neck and midial section from the chin to the jugular notch of the manubrium. Transverse section is made on the level of superior margin of neck. The cut along the clavicle to the acromion of scapula was made during the previous lesson. Then cautiously (not damaging platisma) dissection is made to the left from the midial cut. After that, the left platisma is exposed and cut near the base of mandible and is pulled to the side. Now the anterior external jugular vein and its branches can be viewed.
Work 2.Dissection of superficial vessels of face.
The students under the direction of teacher are making skin cuts on the left side of the face: midial-from the parietal bone to chin, circular-along the orbits, nostrils and oral cavity. Skin is carefully separated (not damaging mimetic muscle) dissected and pulled back to auricle of the ear. Then dissection of superficial vessels of face (facial artery and vein, retromandibular vein, superficial temporal artery and theirs branches) are made. take the cuts on left part of face. A skin cautiously exfoliate (to not to damage mimetic muscles), prepare and turn away to concha. Prepare the superficial facial vessels (facial artery and vein, retromandibular vein, superficial temporal artery and their tributaries).
Work 3 .Dissection the vessels of the neck. For better access to vessels and nerves bundle of neck teacher is suggests for students to cut manubrium in saggital plane and clavicle in middle plane. The sternoclaudomastoid muscle is carefully separated and turn away together with part of manubrium and clavicle. Then in anterior part of neck the students can find the neuro-vessel bundle which on either sides of trachea and pharynx. The dissection is done for common and external carotid arteries, also for anterior branches of external carotid artery (upper thyroid, lingual, facial and their branches)
Work 4. For preparation nerves near the base of skull necessary to cut and delete salivary gland. Delete the branch of mandible from joint.
Work 5. Preparation vagus nerve, its lower element. Track in to input in the breast cavity and preparation an upper laryngeal nerve, which leaves from the lower element.
Work 6. Dissection of maxillary artery. For better access to maxillary artery the students have to carefully (not damaging superficial vessels and nerves) cut the zygomatic arch near its root and connection with zygomatic bone. The zygomatic arch together with masseter muscle are turned away laterally and inferiorly. For this reason masseter muscle is partially separated near the place of its connection to the angle of mandible. Using a chisel, the caronoid process of mandible is separated, and together with zygomatic muscle is turn away superiorly. Now there is open access to maxilar artery.
2) Base level of knowledge and skіlls
1. Skeleton of thoracis cage, neck and skull.
2. Muscles of the neck and head.
3. Organs of the neck and head.
4. Skeleton of thoracis cage, neck and skull.
5. Muscles of the neck and head.
6. Organs of the neck and head.
7. Vessels of neck.
Illustrative materialss:
1. Demonstration corpse.
2.Study corpse.
3.Skeleton.
Demonstrate on preparations:
1. vagus nerve
2. sympathetic trunk
3. maxillary artery
4. external carotid artery
5. superficial temporal artery
6. jugular veins
3) Show on the preparations:
Corpse with prepared vessels of a head and neck: anterior group of branches of external carotid artery (superior thyroid, lingual, facial arteries), their branches and sites of a branching; posterior group of branches of external carotid artery (sternocleidomastoid, occipital, auricularis posterior arteries), their branches and sites of a branching, medial group - ascending pharyngeal artery, its branches and sites of branching; final branches - superficial temporal artery, maxillary artery, their branches and sites of a branching.
1. Studying the internal jugular vein pay attention to its topography in the structure of vascular-nervous fascicle of the neck, its division into intracranial and extracranial tributaries, their connection.
2. Name intracranial tributaries to internal jugular vein.
3. Study extracranial tributaries to internal jugular vein and their anastomosis.
4. Studying external jugular vein, pay attention to its tributaries and places of confluence.
5. Study formation of anterior jugular vein and place of it confluence.
6. To know topography of subclavian vein and its tributaries.
7. Prepared corpse, lymphatic nodes in a site of head, neck, chest, abdominal cavity, shoulder girdle and upper limb, pelvis and lower limb. Thoracic lymphatic duct, left and right venous circulation.
8. Superior vena cava, left and right brachiocepalic veins, subclavian vein, anterior jugular veins, external jugular vein and its tributaries (their anastomosis), internal jugular vein with it extracranial tributaries (anastomosis), sinuses of dura mater.
II. Seminar discussion 12:30 am – 14:00 pm (2 hours)
1) Special attention should be paid to the following questions:
1. What parts of a head and neck are supplied by external carotid artery?
2. In which triangle is the common carotid artery divided into external and internal?
3. Show a place, where the common carotid artery can be palpated.
4. What is the practical role of Pirogov's triangle?
5. Where is the carotic sinus and glomus located?
6. Into which groups are the branches of external carotid artery devided?
7. Which branches belong to anterior group?
8. Which branches belong to medial group of external carotid artery?
9. Which branches belong to posterior group of external carotid artery?
10. Topography and region of supplying of lingual artery.
11. Topography and region of supplying of facial artery.
12. Topography and region of supplying of superior thyroid artery.
13. Which vessels form superior vena cava?
14. . With what organs does superior vena cava border?
15. In what part of mediastinum is superior vena cava located?
16. Whence does internal jugular vein collect blood?
17. What does the internal jugular vein continue?
18. Where does the internal jugular vein begin?
19. Which expansions has the internal jugular vein?
20. Describe topography of internal jugular vein in the structure of vascular-nervous fascicle of neck.
21. What intracranial tributaries of internal jugular vein do you know ?
22. What are diploid and emissar veins? Where are they located? What do they drain?
23. Where do diploid veins fall in?
24. Whence do superior and inferior ophthalmic veins collect blood? What are their anastomosis?
25. How are veins of a labyrinth formed and where they run?
26. Name extracranial tributaries of internal jugular vein.
27. Whence does the facial vein collect blood?
28. Whence does the retromandibular vein collect blood? It's anastomosis.
29. Describe topography of pharyngeal and lingual veins.
30. Whence does the superior thyroid vein collect blood?
31. Whence does the external jugular vein collect blood?
32. How are anterior jugular veins formed and where they run?
33. Describe topography of subclavian vein.
34. Where does thoracic duct fall? What lymphatic trunks fall into it?
35. From what partes of a body does thoracic duct collect lymph?
36. From what trunks is right lymphatic duct formed and where it pass?
37. From what parts of a body does right lymphatic duct collect lymph?
38. What lymphatic nodes are distinguished in an area of neck?
Which nuclei does vagus nerve have? (name, function)
- Describe the parts and topography of the vagus nerve.
- Where are located sensory ganglia of vagus nerve?
- Which branches does vagus nerve give off in head region? What do they supply?
- Which branches does vagus nerve give off in neck? What do they supply?
- Which parts do they distinguish in sympathetic part of the autonomic nervous system?
- Which formations belong to central part of sympathetic system?
- Where are located centres of sympathetic system?
- Which formations belong to peripheral part of sympathetic system?
- Where are located peripheral sympathetic ganglia?
- Describe cervical sympathetic ganglia and their branches.
- Which plexus do cervical sympathetic ganglia form? What do they supply?
50. Which parts has the maxillary artery?
51. Branches and supplying area of first part of maxillary artery.
52. Branches and supplying area of second part of maxillary artery.
53. Branches and supplying area of third part of maxillary artery.
54. Which arteries supply teeth of the upper jaw?
55. Which arteries supply the mucosa of maxillary sinus?
56. Branches and supplying area of superficial temporal artery.
57. What intracranial tributaries of internal jugular vein do you know ?
58. What are diploid and emissar veins? Where are they located? What do they drain?
59. Whence do superior and inferior ophthalmic veins collect blood? What are their anastomosis?
60. How are veins of a labyrinth formed and where they empty?
61. Name extracranial tributaries of internal jugular vein.
62. Whence does the facial vein collect blood?
63. Whence does the retromandibular vein collect blood?
64. What lymphatic nodes are distinguished in an area of head?
ІІІ. Independent students work – 14:15pm – 15:00 pm
1) Situational TASK.
1. The wound of a hairy part of a head is accompanied by profuse bleeding. What anatomic peculiarities of vessels of soft tissues of a brain part of a head determines significant bleeding in such wounds?
2. For uncovering the bones of a skull fornix the radial sections in the temporal area are made. What is this direction of sections determined by?
3 Patient with a trauma in temporal area and fracture of zygomatic bone has signs of intracranial hemorrage. What artery is injured most likely ?
4. Patient has profuse bleeding from branches of maxillary artery. Since this artery, owing to deep bedding on the face is inaccessible to bandaging, there was a necessity to tie up external carotid artery within carotid triangle. What topographical reference point should be used to distinguish external carotid artery from internal one in this site?
5. In normal conditions venous blood outflows from the face toward internal jugular vein. Patient has purulent inflammation of soft tissues of the face. Their considerable edema caused compression of facial vein and retrograde (reciprocal) direction of venous outflow. Infection of what venous sinus is possible in these conditions?
6. Patient has thymoma (the tumour of thymus) causing compression of a trunk of superior vena cava. Congestion in tributaries of vein is clinically manifested in cyanosis, edema and expansion of subcutaneous venous net. In what areas of a body will these symptoms be observed in this case?
7. “Syndrome of superior vena cava ” is connected with compression of a vessel by neighbouring organs. In what organs the pathological process may be clinically manifested by signs of congestion in tributaries of superior vena cava?
8. Surgical intervention on the parotid gland for purulent parotititis is complex as may become the cause of disturbance of integrity of vessels and nerves. Is there a danger of injuring large vein? If yes, then which?
9. In vestibule of the nose and on the skin of external nose the furuncules (purulent inflammation of hair follicle) may develop which are dangerous because may carry infection by venous ways to brain sinuses with formation of thrombosis. It is usually very unfavourable course. List venous vessels and plexus, on which the infection in a cavity of a skull may expand.
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions (the instructor has tests & situational tasks).
Student should know:
1. Latin terminology
2. Anatomy and topography of Common carotid artery system.
3. Anatomy and topography of External carotid artery system.
Correct answers for tests and situational tasks:
1. Arterial vessels are in subcutaneous fat and their adventition grows strongly together with connective intersections, which connect skin with tendinous helmet. The vessels are in normal condition, their lumen gapes.
2. The direction of all arterial trunks in a brain part of the head is radial (as well as that of nervous trunks), therefore at such sections integrity of neurovascular fascicles is preserved as much as possible.
3. A. meningea media.
4. External carotid artery on a neck has artain amount of branches, unlike internal, that has no branches on a neck; external carotid artery goes forward and medially and lays more superficially, than internal carotid artery, that goes laterally and deep.
5. Cavernous sinus (superficial veins of the face - ophthalmic veins - cavernous sinus).
6. In the face, neck, upper part of torso and upper limbs.
7. Pathological process in thymus, right lung, ascending aorta.
8. Yes; retromandibular vein, which passes through parotid gland.
9. а) vein of the nose – superior ophthalmic vein – cavernous sinus; б) external nasal veins - facial vein – pterygoid plexus - veins of dura mater - veins of a cavity of skull; в) external nasal veins - facial vein - pterygoid plexus - orbital veins – cavernous sinus.
References:
а) basic
1. Atlas of Human Anatomy/ Frank H. Netter,- 5 edition, - 2011 by Saunders, an Imprint of Elsevior Inc.
2. Gray's Anatomy for Students: With STUDENT CONSULT Online Access, 2e, - 2010. 2092 p. Richard L. Drake Ph.D, A. Wayne Vogl, Adam W.M. Mitchell, – Printed in Canada.
3. Materials preparation for lectures
4. Materials preparation for practical classes
b) additional
1. Human anatomy & physiology /Elaine N. Marieb, Katja Hoehn., San Francisco : Benjamin Cummings, c2010., 8th ed.
2. F.H. Netter. Atlas of Human Anatomy. – Cіba Pharmaceutіcals Dіvіsіon, 1994. – 514 p.
3. Synelnіkov R.D. The atlas of anatomy of the man. Іn 4-th volumes. -: Medіcіna, 1991.
4. Reminetskyy B.Y., Fedonyuk Y.I. Human anatomy. Notes. 136 p.
5. Lectures.
Methodical instructions have been prepared by: Assistant Prof. Gavlich O. B.
The instruction was discussed and confirmed at the department meeting
12.06.2013. Protocol number 11