The Parotid & Temporal Regions

Today we will speak about two regions of five regions in the head (temporalis region and parotid region); we will start with the parotid region: The parotid region is so named because it contains mainly the parotid gland. Temporalis is the region that is occupied mainly by the temporalis muscle which is the largest muscle of mastication. Starting with the parotid region; like in other regions in anatomy we must know the boundaries and the contents, so we look to the boundaries of the parotid region. It usually extends between the ramus of the mandible anteriorly all the way passing to the level of the mastoid process and sternocledomastoid muscle; so its the region that is located between the ramus of the mandible and the mastoid process. Also its superior boundaries are the external auditory meatus and the tempomandibular joint, so in summary, it is bounded by: Anteriorly: ramus of the mandible Posteriorly: mastoid process Superiorly: external audiotory meatus & tempomandibular joint (TMJ) It contains the parotid gland and structures located inside the parotid gland: we have mainly three important structures inside the parotid gland, these are:
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Facial nerve with its terminal five branches Retromandibular vein External carotid artery (ECA)and its termination

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Q What are the terminations of the ECA? Superficial temporal and maxillary arteries.

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Starting with the parotid gland, it is a serous secreting gland and these are the structures inside the parotid gland, we have:
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Superficially: the facial nerve with five branches Middle: retromandibular vein (the vein located behind the ramus of the mandible, its formed usually by the superficial temporal vein and maxillary vein), so also in the middle we have end parts (terminal parts) of superficial temporal and maxillary veins, ok?

Q There are the five terminal branches of facial nerve, what are these?? 1- Temporal 2- Zygomatic 3- Buccal 4- Mandibular 4- Cervical

NOTE: We have another branch which is the posterior auricular nerve, but its not within the parotid gland . 3- Deeply: the ECA & start parts of its terminations; we just mentioned the terminations. 4- Parotid lymph nodes: those are distributed within parotid gland and on its surface (around it) and they usually drain into deep cervical lymph nodes. So in summary, structures located in the parotid region are: -the parotid gland -the structures from outside to inside within the parotid gland: 1-Superficially : facial nerve with its terminal branches 2-Retromandibular vein with two veins forming it, those are the superficial temporal vein and maxillary vein 3-Most deeply: ECA with two terminations (maxillary & superficial temporal arteries). 4-Parotid Lymph Nodes: distributed on the surface of the gland and deep within the gland. So the parotid gland is a very important structure because it contains many vital structures inside it; containing mainly the VAN (vein, artery & nerve).
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The facial nerve usually divides the gland into: * Superficial part of the gland tissue; the part that is located superficial to the facial nerve * Deep part of the parotid gland which is located deep to the facial nerve *So retromandibular vein and ECA are located within the deep part of parotid gland (inner part because they are deep to the facial nerve within the gland so they are in the deep part of the gland). We will start speaking now about parotid gland within the parotid region: -Its the largest salivary gland! Salivary glands are so many; we have three major ones (large in size) and there are so many minor salivary glands located within the oral cavity. The major ones are the parotid, submandibular and sublingual, we will speak later on about submandibular and sublingual , but now we will keep speaking about the parotid gland. Parotid gland is mainly a serous secreting gland: secretes serous saliva. The saliva in your mouth is two types: serous & mucous Q What is the difference?? The watery secretion mainly is the serous and the mucous secretion makes saliva more viscous; still what is the main difference??? The serous one is more rich in proteins, mainly enzymes (digesting enzymes) the most important one is amylase. What is the function of amylase?? Carbohydrate digestion that starts in the oral cavity by this amylase secreted within serous saliva. The mucous secretion is containing mainly antiseptic structures or enzymes. Relating to immunity, it contains antibodies and also lysozymes, which are enzymes for protection against microorganisms. So, parotid gland secretes which type of saliva? Serous secretion mainly . Concerning the shape of the parotid gland; it is wedge shaped.
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So this wedge shaped gland has a base and an apex : - the base is located superiorly just beneath zygomatic arch -the apex is located inferiorly behind the angle of the mandible . The parotid gland is covered by a dense connective tissue sheath that is forming what we called the connective tissue capsule. This connective tissue is an extension of which cervical facial layer?? Its derived from the investing layer of deep cervical fascia . Now, there are extensions of the parotid tissue that extend from the parotid gland into regions other than parotid region, these are called processes: processes of the parotid gland. They are extensions of parotid tissue into certain regions; we have mainly three processes and the fourth one is just an extension of one of them . First process or first extension of parotid tissue is called the glenoid process, it extends upwards and superiorly. It is in the superior aspect of the gland in what we call the posterior part of mandibular fossa in the temporal bone, so it extends posteriorly to the TMJ (glenoid cavity).
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You look to the skull, in the temporal bone there is a region where the TMJ (the condyle of the mandible) articulates, behind this articulation in this fossa (mandibular fossa), where the mandible articulates with the skull (cranium) just behind it is the glenoid process; tissue of the parotid gland is extending from there. Pterygoid process: extends forward anteriorly, but deep to ramus of the mandible (inside it) between a muscle called medial pterygoid muscle and the ramus of the mandible.
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If you look to the bony part of the ramus of the mandible, it has two muscle attachments, one from the outside and one from inside. - the one that attaches to the ramus from the outside is the masseter muscle which is a muscle of mastication.

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- the one that attaches to the ramus from inside is the medial pterygoid muscle ,which is also a muscle of mastication . So the ramus of the mandible is sandwiched between two muscles of mastication; from the outside is the masseter and from the inside is the medial pterygoid muscle. Now, in the space between medial pterygoid and the ramus of the mandible, you have some parotid tissue; this is what we call the pterygoid process, referring to the medial pterygoid muscle. The last process of the gland is the extension you see anteriorly; this triangular region, the facial process, is an anterior extension, but this type is superficial to the ramus and is even over or superficial to the masseter muscle.
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Now, some parotid tissue of the facial process gets separated from the main gland and remains alone over the masseter muscle; we call this the accessory part of the parotid gland . This is the parotid gland you see it in the black, this is the facial process a triangular region, now this structure anterior to it gets separated from the facial process of the parotid and it even has its main duct we call it the accessory duct into the main duct of the gland. So, the four parts of the parotid gland you have to know them . Relations to the parotid gland They are very important during surgery mainly, when we cut and open to reach the parotid gland, superficially, the first thing we have to remove is skin and after skin there is the fascia; what is the fascia covering the parotid gland??? Parotid capsule (parotid fascia) which is part of the investing layer of deep cervical fascia . And what is the nerve that provides sensation to this region (parotid region)?? Great auricular nerve (C2, C3).

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So, those are the superficial structures related to the parotid gland: skin, parotid fascia and there is a small cutaneous nerve located there, so if you cut the skin and fascia you reach to the parotid tissue. Q What is there superiorly (superior boundaries)?? External auditory meatus & TMJ. Medially, there are many structures: the parotid gland is sleeping on many structures that are deep to it (medially), those structures we refer to them as the parotid bed. So the deep relations to the parotid gland or the medial structures are referred as the parotid bed. In this section you see we have removed the parotid gland from this region and we look to the medial structures are the gland, if you look there are anterior structures and posterior. Antero-medial: masseter muscle, a small part of the ramus of the mandible, and part of the TMJ (so three structures anteriorly ). If you cut the bed in cross section, you will find constrictors of the pharynx, inside the pharynx and esophagus, this is outside the skin of the parotid. Postero-medial : Carotid sheath: what are the contents of the carotid sheath?? Carotid artery, IJV and the vagus nerve, so the carotid sheath with its contents form the postero-medial aspect of the parotid gland .
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There is a small bony process here, its the styloid process and the muscles attached to it; stylohyoid, styloglossus, stylopharyngus.
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Mastoid process and two muscles attached to it, what attaches to the mastoid process laterally? SCM. What attaches to it medially?? Posterior belly of digastric muscle.
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So all these structures form the parotid bed, you have to know these relations they are very important in parotid surgery.

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Deep to the SCM is the carotid sheath. Parotid duct or Stensons duct Passing from the anterior aspect of the gland, mainly from facial process, horizontally over the masseter muscle (superficial to the masseter muscle) at the anterior border of masseter muscle, it turns medially and pierces the buccinator muscle these relations are important (now deep to the buccinators muscle) to get into mucous membrane of the oral cavity. Once it leaves the buccinator muscle it goes forward within the mucous membrane, then it opens into the oral cavity; opens usually opposite to which tooth? in your book they said upper 2nd molar but it varies from one individual to another. You must know only that it opens opposite to the maxillary 2nd molar, some books say that it is the upper 1st molar, this is because it moves a little bit obliquely forward after the buccinator, and it is about one fingerbreadth beneath the zygomatic arch .
For those interested in more details , after the buccinator it doesnt go directly to the oral cavity, it turns obliquely forward and goes a little bit there, so this forward movement allows it to open in an oblique way (oblique opening ). This functions as a valve-like mechanism so once you have a blow, there is an increase in air pressure that will allow it to enter to the duct (to the gland), so it passes obliquely to allow for a valve-like mechanism.

Accessory parotid duct: This is another small duct; it drains the accessory part of the parotid gland (the separated part of facial process of the gland and it usually opens into the main duct (Stensons duct)). When you go home today, try to look at the mirror opposite to the upper 1 st or 2nd molar, you will see a small papilla, which is a projection (opening of the parotid duct). From your text you have to read about the blood supply, innervations & lymph drainage of parotid gland Blood supply to the parotid gland: from the structures within it (ECA, superficial temporal artery and maxillary artery)
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Innervation: great auricular nerve (c2,c3) Lymph drainage : parotid lymph node, where do they drain ?? Go and see it from your book. Some clinical notes you must know: Mumps Do you know what the meaning of mumps is?? () Its a viral infection to the parotid gland, usually carried by the blood stream, and causes swelling and pain in the parotid gland (parotid tissue). Mainly because of the swelling within a tight facial layer (parotid capsule) its very tightly covering the gland, gland gets enlarged and the facialtight (minute22:58), even the pain gets more severe during chewing or opening your mouth, why?? Because the gland is compressed between the ramus and mastoid process so when the mouth is open, you compress on the gland and the ramus moves backward producing pressure on this swollen gland. Another reason for the swelling of the parotid gland is formation of calculi in the parotid duct. Calcium mineral salts begin to accumulate in the parotid duct then it closes or is obstructed and so saliva accumulation occurs leading to parotid swelling. The 2nd clinical note is parotidectomy: Removal of the parotid gland; surgery in the parotid gland is very important because the parotid gland contains very dangerous and vital structures as I told you, those are the retromandibular vein, ECA and facial nerve . The most common cancers in salivary glands happen usually in the largest gland (parotid gland). Most of them are benign, however, but when you have a tumor there you have to remove it surgically, once you are going to do that there is the risk of damaging the facial nerve, ECA or retromandibular vein . Temporal region: Just superior to the parotid region, its located on the sides of your head and its boundaries are (important):
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Superiorly & posteriorly: superior temporal line; you have two temporal lines (two linear elevations on the sides of the head) one is the superior temporal line and the other is the inferior temporal line. The temporal region extends from the superior temporal line where the deep temporal fascia is attached. Anteriorly: frontal process of zygomatic bone Inferiorly: to the level of the zygomatic arch, where the deep temporal fascia is attached. It is continuous, inferiorly, deep to the zygomatic arch (if you look at the skull, there is a space continuous with the infratemporal region, the fossa beneath the temporal bone). What are the contents there?? Temporalis muscle, the largest muscle of mastication. The origin, the insertion, innervations, and the action you should know all these things for it. Origin: bony part of the temporal fossa and the deep part of deep temporal fascia; so it originates from the temporal region itself, from the bony part of the temporal region. Insertion: inserted in this bony process of the mandible: coronoid process of the mandible (all fibers converge together to be inserted into the coronoid process and to the anterior border of the ramus of the mandible). So part of the temporalis muscle gets inserted into the anterior border of ramus of the mandible. Innervations: it is a muscle of mastication so innervated by two deep temporal nerves going from the anterior division of the mandibular nerve of trigeminal (be specific). Action: the temporalis muscle is a very large muscle, when you look at its fibers; the anterior fiber look more vertical so when they contract they elevate the mandible. However, the posterior half is more horizontal so when they retract they retread the mandible (push it backwards).
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So it has 2 actions :
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Anterior half: vertical, elevates the mandible (close your mouth). Posterior half: horizontal, retreads the mandible

Temporal fascia: The deep fascial layer that covers the temporalis layer, and is attached to the superior temporal line, and it is a continuation of the epicranial aponeurosis in the 3rd layer of the scalp (so it attaches to the deep temporal fascia) What else is there in the temporal region? We have two small arteries and two small nerves to the temporalis muscle; temporalis is a very large muscle, so two nerves provide motor innervations from the same nerve (anterior division of mandibular: v3) and two arteries to the temporalis muscle (to the anterior half and posterior half) which come from 2nd part of maxillary artery. Additional structures you expect to see there: superficial temporal artery and superficial temporal vein, to the lat aspect of the head and the scalp; they are passing there on the temporal region posterior to the TMJ and posterior to them is an important nerve: Auriclotemporal nerve: goes to the lateral aspect of the head, it is the posterior division of mandibular nerve of trigeminal. Clinical case is your home work. End of the lecture : ... ... .. ... ... : ....
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