01 Anatomy
01 Anatomy
01 Anatomy
Chapter
Anatomy
1 John Picard
Individual flowers may be pretty. But in a bouquet, it's Overenthusiastic openers of the mouth may some-
their relation to each other which makes the arrange- times find their jaw becomes stuck in subluxation (dur-
ment beautiful: context is key. The same is true of ing assessment for anaesthesia, for example). The
topological anatomy: context makes for clinical rele- patient is left phonating like a distant gargle, with the
vance. This chapter offers a selective account of the mouth wide open; to return the jaw to its joint, it
functional adult head and neck anatomy as it applies to suffices to push firmly on the mandible’s molars poster-
anaesthetic clinical practice. iorly and inferiorly.
Gape may be reduced by abnormal skin around
Mouth Opening and the mouth (e.g. scleroderma), by excessive tone in
masseter (e.g. induced by a neighbouring abscess) or
the Temporomandibular Joint by disease in the temporomandibular joint itself (e.g.
Cooking and cutlery both evolved after us; while our rheumatoid arthritis).
ancestors lived without tools or open fires, biting hard Mouth opening ability also depends on craniocervi-
and opening the mouth wide were both advantageous. cal flexion and extension. Head extension facilitates
A strong bite and a wide gape may seem to be opening. Normal humans extend about 26° from
conflicting ambitions. A firm bite, for instance, the neutral position at the craniocervical junction to
depends on a single, fused mandible, and on muscles achieve maximal mouth opening. If cervical extension,
inserting some way from the joint to gain greater from the neutral position, is prevented a subject can be
leverage, as in humans. (In snakes, in contrast, each expected to lose about one third of their normal inter-
of the two halves of the mandible and the maxilla dental distance. Patients with poor craniocervical exten-
move independently from the skull and from each sion therefore suffer a ‘double whammy’ in terms of
other, and their muscles insert close to the relevant airway management.
joints, to give an enormous gape, but a weak bite.) An
adequate gape is nevertheless achieved in most
humans by subluxation. When the jaw is closed, the The Oral Cavity and Oropharynx
head of the mandible rests in the mandibular fossa in The oral cavity is dominated by the tongue, and for
the temporal bone. But as the jaw opens, the head of anaesthetists, little else counts but its size. It may be
the mandible is pulled out of the fossa by the lateral swollen acutely (as in angioneurotic oedema) but is
pterygoids (Figure 1.1). Rather than turning on its also susceptible to disproportionate enlargement by
head, the mandible swivels on an axis which runs trisomy 21, myxoedema, acromegaly, tumours and
through the mandibular foramina (i.e. close to the glycogen storage diseases, among others.
insertion sites of temporalis and masseter). Angioneurotic oedema can cause such swelling as
This shift in the axis of rotation allows both strong to fill the entire pharynx, preventing both nasal and
bite and wide gape: at the limit of closure, as the molars mouth breathing and making a front of neck airway
meet, the jaw is turning on the temporomandibular joint, necessary for survival. Less dramatically, a large ton-
and masseter and temporalis are working with leverage. gue (relative to the submandibular space) can hinder
But at the jaw’s widest opening, it turns about the mus- direct laryngoscopy. That is, manoeuvred with rea-
cles’ insertion sites; they are not so passively stretched, sonable force, the laryngoscope blade should squeeze
and the bones of the joint do not so impinge on one the posterior tongue so as to achieve a direct view of
1
another. the glottis. If the tongue is too large, or the jaw
its socket the better. If the root is clean, the tooth can
simply be put back in; if dirty, the root should first be
rinsed with saline or whole milk. A dentist will then be
able to splint the tooth in place. If a displaced tooth
cannot be immediately replaced, whole milk is the best
storage medium; a dental cavity exposed too long to
saline, or worse water, dies. Calcification of the peri-
odontal ligament is then inevitable, and the tooth will
become brittle and discoloured, and may fracture,
loosen or fall out again.
The stage’s side wings are formed by mucosal folds
running over palatoglossal and palatopharyngeal
muscles (from anterior posteriorly). Between the two
folds on each side lie the tonsils (which may be invi-
sible in adults, but in children may be so large as to
meet, ‘kiss’, in the midline, hampering laryngoscopy).
The glossopharyngeal nerve runs under the mucosa of
the base of the palatoglossal arch (towards the poster-
ior tongue) and can be blocked there. Just as in the
theatre, so in the oral cavity: confusion surrounds the
wings. Properly called the palatoglossal and palato-
pharyngeal arches, they are also commonly called
fauces and pillars. They are all the same thing.
Access to the stage’s flies is controlled by the soft
palate, a flap of soft tissue which can move up to
separate the nasopharynx from the mouth and orophar-
ynx (during swallowing), or move down to separate/
shield the pharynx from the mouth (during chewing).
The soft tissues which surround the pharyngeal
airway are themselves contained by bony structures
(the maxilla, the mandible, the vertebrae and the base
of the skull). When awake, tone in the pharyngeal
musculature maintains airway patency. But once
a patient is asleep, sedated or anaesthetised, muscular
tone falls, and airway patency may depend on the
relative sizes of these bones and of the soft tissues
Figure 1.1 (a) Mandible and muscle actions. (b) Mandibular
movement for opening the mouth wide.
within them. Patients with more soft tissue, a shorter
mandible or squatter cervical vertebrae may be at
particular risk of obstructive sleep apnoea.
hypotrophied, it may not be possible directly to see
the glottis over the compressed tongue. The Nose and Nasal Cavities
Within the oral cavity, the tongue is like a thrust The nasal cavities have evolved to humidify and warm
stage in a theatre. It is surrounded by two tiers of teeth air before directing it to the pharynx and thence
(stalls and royal circle), and a series of wings and flies towards the lungs; all roles likely to be subverted by
(Figure 1.2). anaesthetists. Nevertheless, the anatomies of both inside
Each tooth consists of calcified dentine, cementum and outside of the nose have anaesthetic relevance.
and enamel surrounding a cavity filled (if the tooth is The nose encases the two nasal cavities which each
alive) with vessels and nerves. Each tooth is held in its lead from nostril to nasopharynx. Each cavity is lined by
socket in the jaw by a periodontal ligament. If a tooth is a mucous membrane of peculiar vascularity; luxuriant
2 inadvertently knocked out, the sooner it is returned to perfusion limits local cooling and desiccation despite
evaporation. It also means minimal trauma can cause concha is larger than that between inferior and middle
profuse bleeding. conchae. Furthermore, the ostia (holes) through
The mucosa’s innervation is so complex as to which the sinuses drain into the nose are all cephalad
make topical anaesthesia the most practical option to the inferior concha. For both reasons, a tracheal
for even the most ardent regional anaesthetist (no tube which runs through the nasal cavity may be best
less than nine nerves innervate each cavity). That placed along its floor, being less likely to cause
said, simply pouring a local anaesthetic solution damage, or to obstruct drainage and cause sinusitis.
down the nostrils of a supine anaesthetised patient is On the other hand, an optical bronchoscope advanced
profoundly unanatomical: the medicine can be direc- between middle and inferior conchae may execute
ted to its target by gravity. Before functional endo- a gentler turn inferiorly toward the glottis.
scopic sinus surgery, for example, if the solution is to The damage that can be done by tubes passed
reach the cephalad reaches of the nasal cavity, the blindly through the nose is remarkable; entire con-
head must be tilted back (with Trendelenburg tilt chae have been amputated, and tubes passed into the
and a pillow below the shoulders). To direct solution brain through fractures in the skull base. Clearly tra-
along the projected path of an optical bronchoscope, cheal tubes should be of as small a diameter
less Trendelenburg is necessary. Moreover, some sen- as possible, while bleeding diatheses and basal
sory fibres pass through the contralateral sphenopa- skull fractures are important relative contraindica-
latine ganglion. It is therefore sensible to apply local tions to nasal intubation. If a tracheal tube is never-
anaesthetic to both nostrils, even if only one is to be theless to be directed through the nose, using a flexible
subjected to a foreign body. optical bronchoscope may reduce the risk of damage.
Each nasal cavity is divided by three turbinates The nose’s external profile also determines how
(more properly conchae) which extend medially tightly a face mask can fit. Given too large a nasal
from the cavity’s lateral wall (Figure 1.3). The space bone, gas escapes around the mask’s sides, and too
between the floor of the nasal cavity and the inferior small, gas escapes at the midline.
3
Opening of Atrium
auditory tube
Vestibular area
Aryepiglottic fold
Ventricular fold
Glottis Vocal fold
Cuneiform cartilage
Corniculate cartilage
Arytenoid cartilage
Anterior belly of digastric Hyoid bone Figure 1.6 Thyroid gland and the front of
Submandibular gland Thyrohyoid
the neck.
Facial artery Mylohyoid
Facial vein
Parotid gland
Stylohyoid
Thyrohyoid membrane Superior belly of omohyoid
Laryngeal prominence Sternohyoid
External jugular vein Superior thyroid artery
Arch of cricoid cartilage Cricothyroid
Isthmus of thyroid gland Middle thyroid vein
Sternocleidomastoid Internal jugular vein
Inferior thyroid veins Transverse cervical artery
Anterior jugular vein Suprascapular nerve
Sternothyroid Suprascapular artery
Trachea
Phrenic nerve on
scalenus anterior
Recurrent laryngeal nerve