Instructions for Sonography of the Mimic Musculature





Based on the German version from Maik Sauer, Jena 2013 (Sauer M. 2013. Statische und dynamische Sonographie der mimischen Muskulatur bei Probanden und Patienten mit peripherer Fazialisparese – Erhebung geschlechtsspezifischer Referenzbereiche [Dissertation] Jena: Friedrich-Schiller-Universität).



Introduction


These instructions for sonography of the mimic musculature are intended to help sonographers to better understand the very complex sonographic cross-sections of the mimic and mastication musculature and to be able to reproduce them themselves. Because of the special anatomy of the mimic musculature, it is not always easy to differentiate single mimic muscles from the surrounding fat and connective tissue, so all sonographic images are accompanied by a schematic drawing to help make things clearer. To clarify the dynamic changes of the different muscles in motion, each sonographic image in relaxation is accompanied by an image in maximum arbitrary contraction. The anatomic structures marked with numbers are named and explained underneath the appropriate images. To simplify the orientation and to clearly arrange the atlas, only pictures of the right face were used. Furthermore, so-called markers were used, and their function and meaning will be illustrated in detail in section 3 .



General Information on Conducting the Examination


Always use a sufficient amount of ultrasound gel. Through this an optimal skin coupling is achieved and compression of the superficial muscles and vessels is prevented. In practice, the use of standoff pads has proven to be unsuitable as they are impractical for the examiner and uncomfortable for the patient. Additionally, image quality is not significantly improved by their use.


If the dynamic characteristics of the muscles are to be assessed, it has proven to be helpful to practice the appropriate movements before the examination. The movements will be explained in detail and be demonstrated by the examiner. As it is quite hard for many people to consciously perform mimic movements, we recommend using a mirror both in the training phase and during the examination itself.


Contractions of the appropriate target muscle might facilitate the clear identification of single muscles for the examiner. As the mimic musculature of elderly and/or obese people often contain a lot of connective and fat tissue and thus appear hyperechoic, identification by contraction is particularly important. The examiner should pay particular attention to ensuring the patient performs the required movement.


If perfusion is to be determined, it should take place before the contraction. Thus changes in blood flow by vascular compression or vasoactive mediators can be minimized.



Position of the Marker on the Ultrasound Transducer


To make the position of the ultrasound transducer easier to understand, we worked with “markers.” The marker is positioned at the leading end on an L 15-7io “hockey stick” linear ultrasound transducer. To illustrate the position of the ultrasound transducer within the different figures, a green scheme transducer with red head was used for the L 15-7io hockey stick transducer. The red head corresponds to the marker position on the transducer; the green part corresponds to the contact area of the transducer. The marker is represented by a brown line on the side of an L 12-3 linear ultrasound transducer. The corresponding scheme on this transducer is blue with a yellow head. Here, the yellow head corresponds to the marker position on the transducer; the blue part corresponds to the contact area. By using the markers, the examiner is always able to easily orientate him/herself. If the ultrasound transducer is aligned right on the patient, the corresponding structures are on the right side of the ultrasound image.


Fig. App.1


Explanation of the Markers.

(A) Position of the ultrasound transducer for the display of the M. procerus. 1 Position of the marker on an L 15-7io “hockey stick” linear ultrasound transducer. 2 Scheme ultrasound transducer green with red head. The red head corresponds to the marker on the ultrasound transducer. 3 Ultrasound image of the M. procerus with integrated scheme ultrasound transducer at the top left of the image. (B) Position of the ultrasound transducer to display the M. frontalis. 1 An L12-3 linear ultrasound transducer with marker line. 2 Scheme ultrasound transducer blue with yellow head. The yellow head represents the marker line on the ultrasound transducer. 3 Ultrasound image of the M. frontalis right with integrated scheme ultrasound transducer at the top left of the image.





Position and Handling of the Ultrasound Transducer


The ultrasound transducer should always be placed vertically on the skin surface, otherwise the respective muscle will be obliquely cut and the corresponding measuring values will be useless. The display of vessels is an exception from the previously described handling of the ultrasound transducer. Because of the variable course of vessels, it might be necessary to swivel the ultrasound transducer from the initial position through the cut of the vessel, i.e., to change the angle of the ultrasound transducer to the skin surface. Thus, it is possible to show a straight, axial cut of the vessel along its course.



Anatomy of the Mimic Musculature




Table App.1

Anatomy of the Mimic Musculature.

From Zilles K, Tillmann BN, Zilles T. 2010. Anatomie : mit 121 Tabellen. Aufl. Heidelberg [u.a.]: Springer. DOI 10.1007/978-3-540-69483-0 .
































































































































Muscle Origin/Approach Innervation/Blood Supply Function
Muscles of the Skullcap
M. epicranius
M. occipitofrontalis


  • Venter frontalis



  • Venter occipitalis (M. occipitalis)

Origin
Over the tendons of adjacent muscles in the range of pars nasalis of os frontale
Approach
Galea aponeurotica
Origin
Linea nuchalis suprema
Approach
Galea aponeurotica
Innervation


  • Rr. temporalis of the N. facialis

Blood Supply


  • A. supraorbitalis



  • A. supratrochlearis



  • A. lacrimalis



  • R. frontalis of the

A. temporalis superficialis
Innervation


  • R. occipitalis of the N. auricularis posterior of the N. facialis

Blood Supply


  • A. occipitalis

Shifting the scalp
Raising the eyebrows and the forehead skin
M. temporoparietalis Origin
Fascia temporalis
Approach
Galea aponeurotica
Innervation


  • Rr. temporalis of the N. facialis

Blood Supply


  • A. temporalis superficialis

No appreciable function
Muscles in the Range of the Eye Socket and the Palpebral Fissure
M. orbicularis oculi


  • Pars orbitalis



  • Pars palpebralis



  • Pars lacrimalis (Horner-muscle)

Origin
Crista lacrimalis and frontal process of the maxilla
Approach
Over the raphe palpebralis lateralis on Os zygomaticum
Origin
Lig. palpebrale mediale
Approach
Lig. palpebrale laterale
Origin
Crista lacrimalis of the os lacrimale
Approach
Canaliculi lacrimales into the pars palpebralis
Innervation


  • Rr. temporalis



  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. facialis



  • R. frontalis of the A. temporalis superficialis



  • A. infraorbitalis of the A. maxillaris



  • A. supraorbitalis, A. lacrimalis and A. supratrochlearis of the A. ophthalmica

Firm closure of the palpebral fissure
Closure of the palpebral fissure, participation in blinking, and stabilization of the lower eyelid for forming the lacrimal lake
Stimulation of lacrimation
Outflow of lacrimal fluid
M. corrugator supercilii Origin
Os frontale above the sutura frontomaxillaris, glabella, arcus superciliaris
Approach
Skin above the middle third of the eyebrow, Galea aponeurotica
Innervation


  • Rr. temporalis of the N. facialis

Blood Supply


  • A. supraorbitalis and A. supratrochlearis of the A. ophthalmica



  • R. frontalis of the A. temporalis superficialis

Shifting the eyebrow skin downwards medial
M. depressor supercilii Origin
Os frontale
Approach
Medial part of the eyebrow
Innervation


  • R. temporalis of the N. facialis

Blood Supply


  • Aa. supratrochlearis and supraorbitalis of the A. ophthalmica

Shifting the skin above the nasal root to a cross fold
Muscles in the Range of the Nose
M. procerus Origin
Os nasale, cartilago nasi lateralis
Approach
Skin of the glabella
Innervation


  • R. zygomaticus of the N. facialis

Blood Supply


  • A. dorsalis nasi,

A. supratrochlearis and branches of the A. ethmoidalis anterior of the A. ophthalmica
Shifting the skin above the glabella downwards to a cross fold above the nasal root
M. nasalis


  • Pars transversa



  • Pars alaris

Origin
Jugum alveolare of the canine until the fossa canina of the maxilla
Approach
Aponeurosis above the nasal root
Origin
Above the jugum alveolare of the lateral incisor
Approach
Skin of the nostril and the nasal septum
Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • Angularis of the A. facialis

Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. dorsalis nasi and branches of the A. ethmoidalis anterior of the A. ophthalmica

Pull the nostril and the nasal tip downwards, slight expansion of the nasal orifice, deepening of the nostril furrow
M. depressor septi nasi Origin
Above the alveolar process of the first incisor
Approach
Cartilaginous part of the nasal septum
Innervation


  • Rr. zygomatici and buccales of the N. facialis

Blood Supply


  • A. labialis superior of the A. facialis

Pull down of the nasal tip and expansion of the nasal orifices
M. levator labii superioris alaeque nasi Origin
Frontal process of the maxilla, margo infraorbitalis
Approach
Upper lip, skin of the nostrils
Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. infraorbitalis of the A. maxillaris



  • A. labialis superior and branches of the A. angularis of the A. facialis

Raising of the nostrils and upper lip, expansion of the nasal orifices
Muscles in the Range of the Mouth
M. orbicularis oris
M. buccinator
Origin
Jugum alveolare of the upper and the lower canine
Approach
Skin of the upper and lower lip
Origin
Alveolar process of the maxilla in the range of the molars, crista buccinatoria in the range of the mandibular molars
Approach
Modiolus anguli oris, above the M. orbicularis oris in the upper and lower lip
Innervation


  • Rr. zygomatici of the N. facialis in the range of the upper lip



  • Rr. buccales of the N. facialis in the range of the corner of the mouth



  • Rr. zygomatici of the N. facialis in the range of the upper lip

Blood Supply


  • Aa. labiales superior and inferior of the A. facialis

Innervation


  • Rr. buccales of the N. facialis

Blood Supply


  • Branches of the A. facialis and the A. temporalis superficialis



  • A. buccalis and A. alveolaris superior posterior of the A. maxillaris

Whole muscle:
Narrowing and closing the mouth opening, producing lip tension
Sole contraction of the Pars marginalis:
Retract the red part of the lips inside Sole contraction of the Pars labialis:
Bulging out the lips
Participation in the act of mastication by moving the food from the oral vestibule between the row of teeth and into the oral cavity. Producing tension of the cheeks and the lips
M. zygomaticus major Origin
Os zygomaticum before the sutura zygomaticotemporalis
Approach
Skin of the corner of the mouth and the upper lip
Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. zygomaticoorbitalis of the A. temporalis superficialis



  • Branches of the A. facialis

Raising of the corner of the mouth outwards and up, deepening of the nasolabial furrow and the lid furrow
M. zygomaticus minor Origin
Os zygomaticum medial of the M. zygomaticus major
Approach
Skin of the sulcus nasolabialis
Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. zygomaticoorbitalis of the A. temporalis superficialis



  • Branches of the A. facialis

Raising of the corner of the mouth outwards and up
M. risorius Origin
Facia masseterica
Approach
Skin of the upper lip, mucous membrane of the vestibulum oris, modiolus anguli oris
Innervation


  • Rr. buccales of the N. facialis

Blood Supply


  • Branches of the A. facialis

Movement of the corner of the mouth to lateral, deepening of the nasolabial furrow, production of the cheek dimple
M. levator labii superioris Origin
Margo infraorbitalis of the maxilla above the foramen infraorbitale
Approach
Skin of the upper lip and the nostril, M. orbicularis oris
Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. infraorbitalis of the A. maxillaris



  • A. labialis superior and branches of the A. angularis of the A. facialis

Raising of the upper lip, producing a fold above and sidewise to the nostril
M. levator anguli oris (M. caninus) Origin
Fossa canina below the foramen infraorbitale
Approach
Skin and mucous membrane of the corner of the mouth, Modiolus anguli oris, M. orbicularis oris
Innervation


  • Rr. zygomatici of the N. facialis

Blood Supply


  • A. infraorbitalis of the A. maxillaris



  • Branches of the A. angularis and A. labialis superior of the A. facialis

Raising of the corner of the mouth cranial-medial
M. depressor anguli Oris (M. triangularis)
M. depressor labii inferioris (M. quadratus inferioris)
Origin
Basis mandibulae of the tuberculum mentale up to the jugum alveolare of the first molar
Approach
Skin of the corner of the mouth, Modiolus anguli oris
Origin
Basis mandibulae below the foramen mentale (connection to the platysma)
Approach
Skin and mucous membrane of the lower lip, skin of the “chin bulge”, M. orbicularis oris
Innervation


  • Rr. buccales of the N. facialis



  • Variable: R. marginalis mandibulae

Blood Supply


  • Branches of the A. facialis



  • A. labialis inferior of the A. facialis

Innervation


  • R. marginalis mandibulae of the N. facialis

Blood Supply


  • A. labialis inferior of the A. facialis

Movement of the corner of the mouth downwards
Movement of the lower lip below and lateral, bulging the red part of lips
M. mentalis Origin
Jugum of the lateral incisor of the mandibula
Approach
Skin of the chin
Innervation


  • R. marginalis mandibulae of the N. facialis

Blood Supply


  • A. labialis inferior of the A. facialis

Shift skin of chin upwards
Muscles in the Range of the Outer Ear
M. auricularis anterior Origin
Fascia temporalis, galea aponeurotica
Approach
Spina helicis of the ear
Innervation


  • Rr. temporalis of the N. facialis

Blood Supply


  • A. temporalis superficialis

Minimal forward tension of the ear
M. auricularis superior Origin
Galea aponeurotica
Approach
Rear surface of the ear in the range of eminentia scaphae and the eminentia fossae triangularis, spina helicis
Innervation


  • Rr. temporalis and R. auricularis of the N. auricularis posterior of the N. facialis

Blood Supply


  • A. temporalis superficialis



  • A. auricularis posterior

Minimal upward tension of the ear
M. auricularis posterior Origin
Mastoid process, Linea nuchalis superior
Approach
Eminentia conchae of the ear
Innervation


  • R. auricularis of the N. auricularis posterior of the N. facialis

Blood Supply


  • A. auricularis posterior



  • R. auricularis of the A. occipitalis

Minimal backward tension of the ear
Muscles of the Neck
Platysma Origin
Basis mandibulae
Approach
Skin of the upper thoracic area
Innervation


  • R. colli of the N. facialis

Blood Supply


  • R. superficialis of the A. transversa colli



  • A. submentalis of the A. facialis

Facial part: Pulling down the corners of the mouth to lateral
Part of the neck: Shifting the skin of the mandibula;
Tension of skin and subcutaneous tissue

A , Artery; Aa , arteries; R , ramus, Rr , rami (latin for branch(s)).



Anatomy of the Muscles of Mastication































Muscle Origin/Approach Innervation/Blood supply Function
M. Masseter Origin
Pars profunda: Facies temporalis and inner side of the temporalis process of the os zygomaticum
Pars superficialis: Facies lateralis and temporalis process of the os zygomaticum
Approach
Pars profunda:
Ramus mandibulae up to the basis of the coronoideus process and the condylaris process
Pars superficialis: Tuberositas masseterica on the surface of the angulus mandibulae
Innervation


  • N. massetericus of the N. trigeminu



  • N. mandibularis from the N. trigeminus

Blood Supply


  • A. masseterica of the A. maxillaris



  • A. facialis



  • A. transversa faciei of the A. temporalis superficialis



  • A. buccales of the A. maxillaris

Strong lifting (adduction) of the lower jaw, support of the protrusion of the lower jaw
M. Temporalis Origin
Linea temporalis inferior of the facies externa of the os parietale and the facies temporalis of the os frontale, pars squamosa of the os temporale, facies temporalis of the os zygomaticum, facies temporalis of the os sphenoidale up to the crista infratemporalis
Approach
Coronoideus process of the mandibula to the trigonum retromolare
Innervation


  • Nn. temporales profundi of the N. mandibularis from the N. trigeminus

Blood Supply


  • Aa. temporales profundae anterior and posterior of the A. maxillaris




  • A. temporalis media of the A. temporalis superficialis

Ambilateral:
Strong lifting (adduction of the lower jaw, retrusion of the lower jaw, support of protrusion (anterior part)
Unilateral:
Stabilization of the caput mandibulae, shift of the caput mandibulae forward and rotation to the contralateral side
M. Pterygoideus Medialis Origin
Pars medialis: In the fossa pterygoidea on the facies medialis of the lamina lateralis Pterygoidei process of the os sphenoidale
Pars lateralis:
Facies lateralis of the lamina lateralis processus pterygoidea of the os sphenoidale, processus pyramidalis ossis palatine, tuber maxillae
Approach
Tuberositas pterygoidea on the inner side of the angulus mandibulae
Innervation


  • N. pterygoideus medialis of the N. mandibularis from the N. trigeminus

Blood Supply


  • A. alveolaris superior



  • A. alveolaris inferior



  • A. buccalis of the A. maxillaris

Ambilateral:
Lifting (adduction) and protrusion of the lower jaw
Unilateral:
Grinding movement, shift of the caput mandibulare forward and rotation to the contralateral side
M. Pterygoideus Lateralis Origin
Caput superius:
Facies temporalis and crista infratemporalis of the ala major of the os sphenoidale
Caput inferius:
Facies lateralis of the lamina lateralis processus pterygoidea of the os sphenoidale
Approach
Caput superius:
Fovea pterygoidea, discus articularis
Caput inferius:
Fovea pterygoidea
Innervation


  • N. pterygoideus lateralis of the N. mandibularis from the N. trigeminus

Blood Supply


  • R. pterygoideus of the A. maxillaris

Caput superius:
Ambilateral:
Fixation of the caput mandibulae
Unilateral:
Grinding movement, stabilization of the resting caput mandibulae
Caput inferius:
Ambilateral:
Initial stage of jaw opening
Unilateral:
Grinding movement

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Nov 21, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on Instructions for Sonography of the Mimic Musculature
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