#Adonia Haddad

#Rahaf Jreisat

#Ahmad Al-Zu'bi

The Neck

Generally from base of the skull to root of the neck

Superior :From superior nuchal line of occipital bone up to mastoid process down

to margin of the mandible margin

Inferior margin: inlet of thoracic cavity , the clavicle and root of the neck

Fascial layers of the neck:

Fascia is an internal connective tissue which forms bands or sheets that surround

and support muscles, vessels and nerves in the body.

In the neck, these layers of fascia not only act to support internal structures, but

also help to compartmentalise structures of the neck. There are two fascias in the

neck – the superficial cervical fascia and the deep cervical fascia.

1) Superficial fascia: (externally) is layer of connective tissue that lies deeper to

skin and part of hypodermis (lies between the dermis and the deep cervical

fascia). It contains numerous structures:

Neurovascular supply to the skin

Superficial veins (e.g. the external jugular vein)

Superficial lymph nodes

Fat

Platysma muscle (The superficial cervical fascia blends with the ‘paper thin’

platysma muscle. The platysma is a broad superficial muscle which lies anteriorly

in the neck .It has two heads, which originate from the fascia of the pectoralis

major and deltoid. The fibres from the two heads cross the clavicle, and meet in

the midline, fusing with the muscles of the face. Superiorly, the platysma inserts

into the inferior border of the mandible and its innervation from the cervical

branch of the facial nerve.)

2)Deep fascia : ‘deep’ to the superficial fascia and platysma muscle , it consists of

three layers , These layers act like a shirt collar.

*Investing layer is the most superficial of the deep cervical fascia.

It surrounds all the structures in the neck. Where it meets the trapezius and

sternocleidomastoid muscles, it splits into two, completely surrounding them.

The investing fascia can be thought of as a tube; with superior, inferior, anterior

and posterior attachments:

Superior – attaches to the external occipital protuberance and the superior nuchal

line of the skull.

Anteriorly – attaches to the hyoid bone.

Inferiorly – attaches to the spine and acromion of the scapula, the clavicle, and

the manubrium of the sternum.

Posterior – attaches along the nuchal ligament of the vertebral column

**Pretracheal layer :The middle layer , situated in the anterior neck. It spans

between the hyoid bone superiorly and the thorax inferiorly (where it fuses with

the pericardium). It has 2 parts:

1- Visceral part: it surrounds the thyroid , trachea ,parathyroid ,pharynx ,larynx

and esophagus

‐ the fascia surrounds the pharynx and down to esophagus ( in some references)

known as buccopharyngeal fascia (The posterior aspect of the visceral fascia is

formed by contributions from the buccopharyngeal fascia (a fascial covering of

the pharynx))

2- muscular part :it surrounds the all anterior muscles of the neck (infrahyoid and

suprahyoid muscles)

.***Prevertebral layer: the deepest one ,surrounds the vertebral column and its

associated muscles; scalene muscles, prevertebral muscles, and the deep muscles

of the back.

Posterior to pharynx(posterior to pretracheal layer)

it has attachments along the antero-posterior and supero-inferior axes:

Superior attachment – base of the skull.

Anterior attachment – transverse processes and vertebral bodies of the vertebral

column.

Posterior attachment – along the nuchal ligament of the vertebral column

Inferior attachment – fusion with the endothoracic fascia of the ribcage.

The anterolateral portion of prevertebral fascia forms the floor of the posterior

triangle of the neck. It also surrounds the brachial plexus as it leaves the neck and

subclavian artery as it passes through the lower neck region – in doing so, it forms

the axillary sheath.( Continue as axillary sheath)

Carotid sheath: Thickening of the other layers ,it is surrounded by all layers of

deep fascia

contents :

Common & internal carotid.aa

.Intrnal jugular v

.Vagus n

Deep cervical lymph nodes

Cervical Fascia extensions

1)Alar fascia:

-Division from prevertebral fascia

-From skull to T2 that means in superior mediastinum region (merge with

)buccopharyngeal fascia anteriorly)

Buccopharyngeal fascia :

Superior & posterior continuation of the pretracheal fascia That surrounds the

pharynx and esophagus

The Merging between alar fascia and buccopharyngeal fascia forms space in

sup.mediastinum known as real

retropharyngeal space

Cervical Fascia: Spaces

Retropharyngeal space :

Between buccopharyngeal fascia and Prevertebral fascia

Spread of infections •

(Real) Retropharyngeal space:

Between the alar fascia and buccopharyngeal

-Allow movement of pharynx, larynx, and trachea during swallowing

-Continuous with superior mediastinum toT2

the spread of infection in real space stops at t2 where fusion of alar and

buccopharyngeal

danger space

posteriorly to alar Between the alar fascia and the Prevertebral fascia

Continuous with mediastinum

The risk that an infection in this space can spread directly to the thorax ,because it

continuous with mediastinum

Neck triangles

The anterior triangle is a region located at the front of the neck.

Note: it is important to note that all triangles mentioned here are paired; they are

located on both the left and the right sides of the neck.

Borders

The anterior triangle is situated at the front of the neck. It is bounded:

Superiorly – inferior border of the mandible (jawbone).

Laterally – anterior border of the sternocleidomastoid.

Medially – sagittal line down the midline of the neck.

Investing fascia covers the roof of the triangle, while visceral fascia covers the

floor. It can be subdivided further into four triangles – which are detailed later on

in this chapter.

Contents

The contents of the anterior triangle include muscles, nerves, arteries, veins and

lymph nodes.

The muscles in this part of the neck are divided as to where they lie in relation to

the hyoid bone. The suprahyoid muscles are located superiorly to the hyoid bone,

and infrahyoids inferiorly.

Suprahyoid Muscles Infrahyoid Muscles

Stylohyoid omohyoid

Digastric Sternohyoid

Mylohyoid Thyrohyoid

Geniohyoid Sternothyroid

There are several important vascular structures within the anterior triangle. The

common carotid artery bifurcates within the triangle into the external and

internal carotid branches. The internal jugular vein can also be found within this

area – it is responsible for venous drainage of the head and neck.

Numerous cranial nerves are located in the anterior triangle. Some pass straight

through, and others give rise to branches which innervate some of the other

structures within the triangle. The cranial nerves in the anterior triangle are the

facial [VII], glossopharyngeal [IX], vagus [X], accessory [XI], and hypoglossal [XII]

nerves.

Subdivisions

The anterior triangle is subdivided by the hyoid bone, suprahyoid and infrahyoid

muscles into four triangles.

Carotid Triangle

The carotid triangle of the neck has the following boundaries:

Superior – posterior belly of the digastric muscle.

Lateral – medial border of the sternocleidomastoid muscle.

Inferior – superior belly of the omohyoid muscle.

The main contents of the carotid triangle are the common carotid artery (which

bifurcates within the carotid triangle into the external and internal carotid

arteries), the internal jugular vein, and the hypoglossal and vagus nerves.

Submental Triangle

The submental triangle in the neck is situated underneath the chin. It contains the

submental lymph nodes, which filter lymph draining from the floor of the mouth

and parts of the tongue.

It is bounded:

Inferiorly – hyoid bone.

Medially – midline of the neck.

Laterally – anterior belly of the digastric

The base of the submental triangle is formed by the mylohyoid muscle, which

runs from the mandible to the hyoid bone.

Submandibular Triangle

The submandibular triangle is located underneath the body of the mandible. It

contains the submandibular gland (salivary), and lymph nodes. The facial artery

and vein also pass through this area.

The boundaries of the submandibular triangle are:

Superiorly – body of the mandible.

Anteriorly – anterior belly of the digastric muscle.

Posteriorly – posterior belly of the digastric muscle.

Muscular Triangle

The muscular triangle is situated more inferiorly than the subdivisions. It is a

slightly ‘dubious’ triangle, in reality having four boundaries. The muscular triangle

contains some muscles and organs – the infrahyoid muscles, the pharynx, and the

thyroid, parathyroid glands.

The boundaries of the muscular triangle are:

Superiorly – hyoid bone.

Medially – imaginary midline of the neck.

Supero-laterally – superior belly of the omohyoid muscle.

Infero-laterally – inferior portion of the sternocleidomastoid muscle.

The posterior triangle of the neck is an anatomical area located in the lateral

aspect of the neck.

Borders

Its boundaries are as follows:

Anterior – posterior border of the SCM.

Posterior – anterior border of the trapezius muscle.

Inferior – middle 1/3 of the clavicle.

The posterior triangle of the neck is covered by the investing layer of fascia, and

the floor is formed by the prevertebral fascia (see fascial layers of the neck).

Contents

Muscles

The posterior triangle of the neck contains many muscles, which make up the

borders and the floor of the area.

A significant muscle in the posterior triangle region is the omohyoid muscle. It is

split into two bellies by a tendon. The inferior belly crosses the posterior triangle,

travelling in an supero-medial direction, and splitting the triangle into two. The

muscle then crosses underneath the SCM to enter the anterior triangle of the

neck.

A number of vertebral muscles (covered by prevertebral fascia) form the floor of

the posterior triangle:

Splenius capitis

Levator scapulae

Anterior, middle and posterior scalenes

Vasculature

The external jugular vein is one of the major veins of the neck region. Formed by

the retromandibular and posterior auricular veins, it lies superficially, entering the

posterior triangle after crossing the sternocleidomastoid muscle. Within the

posterior triangle, the external jugular vein pierces the investing layer of fascia

and empties into the subclavian vein.

The subclavian vein is often used as a point of access to the venous system, via a

central catheter.

The transverse cervical and suprascapular veins also lie in the posterior triangle

The subclavian, transverse cervical and suprascapular veins are accompanied by

their respective arteries in the posterior triangle.

The distal part of the subclavian artery can be located as it emerges between the

anterior and middle scalene muscles. As it crosses the first rib, it becomes the

axillary artery, which goes onto supply the upper limb.

Nerves

The accessory nerve (CN XI) exits the cranial cavity, descends down the neck,

innervates sternocleidomastoid and enters the posterior triangle. It crosses the

posterior triangle in an oblique, inferoposterior direction, within the investing

layer of fascia. It lies relatively superficially in the posterior triangle, leaving it

vulnerable to injury.

The cervical plexus forms within the muscles of the floor of the posterior triangle.

A major branch of this plexus is the phrenic nerve, which arises from the anterior

divisions of spinal nerves C3-C5. It descends down the neck, within the

prevertebral fascia, to innervate the diaphragm.

Other branches of the cervical plexus innervate the vertebral muscles, and

provide cutaneous innervation to parts of the neck and scalp.

The trunks of the brachial plexus also cross the floor of the posterior triangle.

Subdivisions

The omohyoid muscle splits the posterior triangle of the neck into two:

The larger, superior part is termed the occipital triangle.

The inferior triangle is known as the subclavian triangle and contains the distal

portion of the subclavian artery.

Lymph nodes

-superficial nodes of head

-superficial cervical nodes

-deep cervical nodes

1)superficial nodes of head

-occipital : near the attachmenet of trapezius muscle , associated with occipital

artery

Drainage :post scalp and neck

-mastoid/retro auricular/post auricular : pos. to ear near the attachment of scm

muscle – associated with post auricular artery

Drainage : posterolateral half of the scalp

(previous two pass external jugular vein )

-pre auricular and parotid nodes : ant to ear – associated with superficial

temporal and transverse facial artery

Drainage : ant surface of auricle / anterolateral scalp/upper half of face /eyelids

/cheecks

-submandibular nodes : inf to body of mandible , associated with facial artery

Drainage: structures along the path of the facial artery as high as the forehead

/gingiva/ teeth and tongue / upper and lower lips/ facial skin

-submental nodes :inf and pos to chin

Drainage : center part of the lower lip /floor of the mouth/tip of the tongue/lower

incisor teeth

(last three pass to deep cervical nodes)

2)cervical superficial lymph nodes

Along the external jugular vein on superficial surface of scm muscle

Drainage of posterior and postlateral scalp through occipital and mastoid nodes

and send lymphatics in directions of deep cervical nodes

Oral cavity l,ll,lll

Nasopharynx V

Oropharynx ll,lll,lV

Hypopharynx lll,lV

3)deep cervical lymph nodes :

-upper

-lower

Sup and inf – where the intermediate tendon of omohyoid muscle crosses the

common carotid artery and internal jugular vein

-upper:

Most sup : jugulodigastric nodes where posterior belly of digastric muscle crosses

the internal jugular vein

Drainage: tonsils and tonsilar region

-lower:

Juguloomohyoid node: just inf to omohyoid

Drainage:tongue

Clinically – neck levels

Level l: from medline of submental to submandibular gland

Level ll :from base of the skull –ant:hyoid bone /post: post border of scm

/ant:lateral border of sternohyoid and stylohoid

Level lll:inf aspect of hyoid bone to cricoid arch – post: post border of

scm/ant:sternohyoid

Level lV:inf aspect of cricoid to top of manibrium –post post border of

scm/ant:sternohyoid

Level V:post to scm and anterior to trapezius above clavicles

Level Vl :inf. To hyoid bone and sup to suprasternal notch in midline , medial to

carotid artery

level Vll: inf to suprasternal notch

(level 2-5: lateral compartment // level 6: central // level 7:mediastenal)

Level 1 : submental and submandibular

Level 2: sup spinal accessory/sub jugular nodes : oral cavity and pharynx ( soft

palate, base of the tongue, piriform sinus),parotid jugulodigastric

Level3: midjagular:thyroid ,hypopharynx,larynx

Level4: juguloomohyoid /inf jugular: thyroid,hypopharynx ,larynx,cervical

esophagus and trachea,Virchow nodes

Level5: inf spinal accessory /supraclavicular nodes/transverse cervical

:nasopharynx , thyroid, paranasal sinus and post scalp/perithyroid

Level 6:pretracheal / paratracheal/prelaryngeal/precricoid:delphian node:thyroid

and larynx

Level7: infraclavicular/ant mediastinal(thymic)

Importance: mets.infection for neck dissection

Neck masses :

-centrally:

1)submental lymph node enlargement –1)malignancy of the tip of the tongue +

floor of the mouth 2)ranula(if there is defect in floor of the mouth=plugging

ranula

2)thyroglossal cyst – children (early in life)/usually females

Commonly present with infection

Ask the patient to sit and extends the neck, open mouth

while you are holding it

m.c present as abcess- because there is lymphatic tissue in

its wall

before excession do U/S to make sure it is not the only

thyroid tissue

75%infrahyoid

3)lipoma –anywhere in the midline (rare in scalp)

4) dermoid cyst – most common in scalp and around orbits

In neck: 1st m.c :submental fossa

2nd m.c :suprasternal notch

There is a retention in part of the skin

Content: fluid , hair,teeth

5)subcalvian artery - might protrude in suprasternal notch

If pulsatile and swollen : aneurism

suprasternal notch – blocked by retrosternal descends of

thyroid gland +dermoid+lipoma

(submental LNS , dermoid , lipoma -in sub mental fossa // thyroglossal cyst

midline // suprasternal notch - suprasternally :D)

-laterally:

1)thyroid

2)m.c LNS

3)dermoid

4)branchial cyst -congenital anomaly

Retention cyst : incompelet fusion(failed) of 2nd branchial

cleft(pharyngeal pouches) at the junction btw upper1/3 and lower 2/3 of SCM

(m.c)

Usually deep

Contents : fluid-cystic(cystic swelling), sebum cholesterol

crystals(pathognomonic)

Tx: if not excised properly - recur

Confirm dx by 1)U/S- has extention to tonsilar bed btw 2 carotid

arteries

Excision is deep

2)Definite dx :aspiration – cholesterol crystals due to oil production of ectoderm

** pendren’s syndrome :thyroid goiter(hypo) + deft اصم+mutismابكم**

**thyroglossal+brancial cyst : can open to become a sinus**

5)carotid body tumor- in middle age and elderly =chemoductoma(read about

carotid body function)

Hard firm swelling/yellowish like potato

Signs of decrease BS : dizziness/fainting

Site: bifurcation of common carotid

Differential : if pulsating and soft - aneurism

Confirm dx :U/S sometimes angiogram

Chemoductoma – neuroendocrine tumors

TIA’s ? transient ischemic attack

Focal hypoperfusion

Be careful if you press on it –patient faint(reflux bradycardia)

7% malignant usually men ,elderly

6)bony:transverse process of c6

7)lipoma/fibroma/neuroma

8)rare: laryngocele in trumpet players اللي بنفخو كتير

Weakness in cricothyroid membrane ususally on left side

When you press on it ,it gergel

9)zenkler’s diverticulum – due to dehiscence of esophagus (usually on left side)

10)supraclavicular conginetal anomaly-wry-weck = SCM tumor

SCM tumorcalcified hematoma -tense neck to

side

- الطفل بتمزع بشدهاfibers منSCM

11)cystic hygroma-malformation of lymphatic tissue

Dx:tense shinny transilluminate-examine axilla

12)carotid artery aneurysm

-Scalp:

1)m.c sebaceous cyst –sebaceous glands are most common in face , scalp, back

and trunk ,, and less likely in periphery

Small and could be multiple

Sebum prevents bacteria from attacking and causing

surgical site infections

If blocked : sebum accumulate ( cheesy)(because gland will

be blocked characterized by punctum)

Exam : soft , fluctuating ,punctum

2) 2nd m.c osteoma- bony hard داعي نشيلها اذا المريض ما بده ال

Benign excession growth of bone

3)3rd m.c dermoid-soft cycstic and fluctuant(more common than lipoma)

Excision will erode outer plate of cranium and sometimes it

extends intracranially thus tentential مائل x-ray to exclude extension + CT (can be

seen with x-ray)

Sometimes intracranial communications associated with

garner syndrome(dysmoplastic tumor in GI + dermoid+FAP)

4)lipoma – can occur anywhere in the body

Swelling ,lobulated ,different sizes, slippery sign

Can be single or multiple

Dercum’s disease = multiple lipomatosis

Almost always sup to deep fascia , but can be deep and descends

over muscles (sacrum)

Not attached to skin

5)vascular tumors-compressible, soft , emptying sign (angioma)

6)bone cysts in infants

7)turban tumor- cylindrical and large عمامة- metastatic lesion(cylindroma)

8)multiple neurofibromatosis – von Recklinghausen disease

Café –au-lait spots

Diminished sensations

-periorbital swelling

1) medial angular dermoid

2)lateral angular dermoid

3)enlarged lacrimal glands –niculiks(??)

4)melanoma (mole)- melanin in skin +eye+anal region(2nd most common after

sq.ca)

Turns into malignancy

Melanoma in anal region – check LN in inguinal region

Mole- malignant - 1)increase in size 2)bleeding 3)irregular

4)black dots(satellite) … direction to LNS

Worst mole that turns into malignant -junctional nevi-

intradermal below nail bed of big toe

Any inflammation peri-orbit -abcess in nose -around mouth - dangerous area

due to cavernous sinus connection

Retention cysts (chalasia ) – swelling in eyelids

Stye بالجفن عند الشعر

-Ear -1)pre auricular lymph nodes 2)parotid gland(pay attention to angle of the

mouth)

Any swelling /mass :

Examine all LNS 1)neck2)supraclavicular 3)axilla 4)groin 5)hand-pretrochlear

m.c swelling in post triangle is LN enlargmnet

conditions for LN biopsy: 1) intact – minimal drainage

2) fresh – formalin/ saline ( within 1 hour)

Lymph node enlargement:

1)delphian – associated with papillary thyroid cancer

2)tonsillar in tonsillar pathology

3)scalene-GIT problems (adenocarcinoma),lung (squamous ),lymphoma

Neck Trauma

**Red color from the net

Neck zones :

Zone 1: This is the area between the clavicles ( thoracic inlet ) and the cricoid

cartilage.

(we have to open chest to treatment) This zone contains vital structures which

include the innominate vessels, the origin of the common carotid artery, the

subclavian vessels and the vertebral artery, the brachial plexus, the trachea, the

esophagus, the apex of the lung, and the thoracic duct. Furthermore, surgical

exposure and access can be difficult in this zone, because of the presence of the

clavicle and bony structures of the thoracic inlet.

Zone II: This is the area between the cricoid cartilage and the angle of

the mandible. The following structures are located here: the carotid and vertebral

arteries, the internal jugular veins, trachea, and the esophagus. This zone has

comparatively easy access for clinical examination and surgical exploration. It is

the largest zone and the most commonly injured in the neck.

Zone III: This is the area between the angle of the mandible and the base of the

skull. ( This area contains the distal carotid and vertebral arteries and the pharynx.

Since it is very close to the base of the skull, this area is less amenable to physical

examination and difficult to explore during surgical evaluation.

NOTE : zone 1 and 3 they are hard to manage because they are hard to

reach use angiography / bronchoscopy / esophagoscopy

A)cervical spine injury :

- bone injury : Dx: 1- X-ray

Standard projections

Note: in the absence of CT 5 views of the C-spine should be performed, AP, lateral, obliques and odontoid 5 .

AP

o anteroposterior projection of the cervical spine demonstrating the vertebral bodies and intervertebral spaces

lateral

o often utilised in trauma demonstrated

zygapophyseal joints

soft tissue structures around the c spine

spinous processes

anterior-posterior relationship of the vertebral bodies

odontoid

o also known as a 'peg' projection it demonstrates the C1 (atlas) and C2 (axis)

AP oblique

o demonstrates the intervertebral foramina of the side positioned further from the image receptor

PA oblique

o demonstrated the intervertebral foramina of the side positioned closer to the image receptor

2- CT without contrast

-ligament injury : DX: 1- MRI 2-flextion-extention lateral X-ray

NOTE: using neck collar for a long time can lead to neck pressure ulcer

B) Blunt injury :

- to say neck is clear without imaging :

1- the patient can move his neck ( active movement )

2- pain free

3- the patient is conscious

4- no distracting injury (Alert and awake)

5- no cervical spine tenderness ( by feeling the spinous process )

if all is good Neck is clear

C) Penetrating injury :

1-treacheal injury stridor / hoarseness / subcutaneous emphysema .

2-carotid (most dangerous ) bleeding / expanding or pulsatile hematoma /

stroke.

3-esophagus hematemesis / odynophagia / sometimes silent . WE have to look

for it : a)esophagoscopy b)contrast study each a and b : 90% sensitive and

together : 100%

4- thyroid

5-spinal cord quadriplegia / c4 affect diaphragm

6-lymphatic channels

NOTES:

- if there is no heart signs ( no obvious bleeding) CT with IV contrast if doesn’t

work we do angiography for ( int. carotid and vertebral artery(c2 to c6)

-vascular repair for : 1- internal carotid we use external jugular vein

2-vertebral artery ligation / angiograph / bone wax

- Blunt carotid artery injury is frequently missed caused by intimal tear

Dx: CT and angiograph Tx: stent and anticoagulant

- serious injuries : mid-facial / c3-c4 / mandibular injury .