Neck

DefinitionThe neck is a region of transition between the head and the thorax

BoundariesLandmarksRegions

Projections of organs

Tracheotomy

C3

C4

C6

Coniotomy

Regions of the neck

Anterior triangle� Submental� Submandibular� Muscular� Carotid

Sternocleidomastoid region

Posterior triangle� Occipital triangle� Omoclavicular triangle

Regio nuchalis

SUPERFICIAL STRUCTURES OF THE NECK

Platysma Anterior jugular vein External jugular vein

Lesser occipital nerveGreat auricular nerve Transverse cervical nerveSupraclavicular nerves

External jugular vein Great auricular nerve

(фотография на доц. Б. Владимиров, дм; катедра ЛЧХ)

SUPERFICIAL STRUCTURES OF NECK

Deep Cervical Fascia

INVESTING LAYERPRETRACHEAL LAYER

PRETRACHEAL LAYER - between hyoid, sternum, clavicle and omohyoid m.

• muscular part, which encloses the infrahyoid muscles

• visceral part, which encloses the thyroid gland, trachea, and esophagus

- Linea alba – from the hyoid to thyroid isthmus

- Spatium suprasternale

• arcus venosus jugularis

INVESTING LAYERsurrounds the entire neck deep to the

skin and subcutaneous tissue.

– it splits into superficial and deep layers to enclose :

• sternocleidomastoid m.• trapezius m.• submandibular gl.

PREVERTEBRAL LAYER

PREVERTEBRAL LAYER - is fixed to the cranial base superiorly- covers mm. longus capitis et colli- extends laterally as the axillary sheath

- Carotid sheath (Vagina carotica)- tubular fascial investment - the carotid sheath contains the:

• Common and internal carotid arteries.• Internal jugular vein.• Vagus nerve (CN X).

INVESTING LAYERPRETRACHEAL LAYER

PREVERTEBRAL LAYER

Deep Cervical Fascia

INVESTING LAYER

PRETRACHEAL LAYER

PREVERTEBRAL LAYER

Carotid triangle

Location – medially to the anterior border of the sternocleidomastoid muscle

Boundaries- digastric m., posterior belly- omohyoid m., superior belly- sternocleidomastoid m.

Carotid triangle

Located within the carotid triangle are the followi ng: Common carotid artery - at the level of the superior border of the thyroid cartilage divides into:

�External carotid artery:

• a. thyroidea superior

• a. lingualis

• a. facialis

• a. pharyngea ascendens

• a. sternocleidomastoidea

• a. occipitalis

�Internal carotid artery – has no branches

in the neck.

Internal jugular vein – the largest vein in the neckDeep cervical lymph nodes - form a chain along the course of the IJV

Carotid triangle

• Common carotid artery

• External and internal carotid arteries

medial view

LYMPH NODES

Vagus (CN X) nerve – posteriorly, between the comm. carotid a. and internal jugular v.

- superior laryngeal n.- ramus internus – enters the larynx together with superior laryngeal a.Hypoglossal nerve (CN XII) - deep to the posterior belly of the digastric m. – gives off the superior root of the ansa cervicalis– enters the submandibular triangle

Cervical plexus of nerves (С1-С4) – lies deep to the SCM

Ansa cervicalis ( С1-С3)- Radix superior (С1,2) – anterior to the common

carotid a.- Radix inferior (С2,3) – lateral to the internal

jugular v.

Carotid triangle

XII

C1

C2

C3

C4

Plexus cervicalis

Ansa cervicalis

n. phrenicus

Carotid triangle

Vagus (CN X) nerve – posteriorly, between the comm. carotid a. and internal jugular v.

- superior laryngeal n.- ramus internus – enters the larynx together with superior laryngeal a.Hypoglossal nerve (CN XII) - deep to the posterior belly of the digastric m. – gives off the superior root of the ansa cervicalis– enters the submandibular triangle

Cervical plexus of nerves (С1-С4) – lies deep to the SCM

Ansa cervicalis ( С1-С3)- Radix superior (С1,2) – anterior to the common

carotid a.- Radix inferior (С2,3) – lateral to the internal

jugular v.

Sympathetic Trunks – lie anterolateral to the vertebral column- posterior to the common/internal carotid a.- The cervical portion of the trunks includes three cervical

sympathetic ganglia:

- superior cervical ganglion - at the level of the C1 and C2 vertebrae

- middle cervical ganglion – at the level of the inferior thyroid a. (C6)

- inferior cervical ganglion - fuses with the first thoracic ganglion to form the large cervicothoracic ganglion (stellateganglion).

Sympathetic Trunks – lie anterolateral to the vertebral column- posterior to the common/internal carotid a.- The cervical portion of the trunks includes three cervical

sympathetic ganglia:

- superior cervical ganglion - at the level of the C1 and C2 vertebrae

- middle cervical ganglion – at the level of the inferior thyroid a. (C6)

- inferior cervical ganglion - fuses with the first thoracic ganglion to form the large cervicothoracic ganglion (stellateganglion).

The boundaries are:

• Basis mandibulae

• Digastric m.– anterior and posterior

bellies

The contents of the submandibular triangle are between:

� Invesing layer� Mylohyoid/hyoglossus muscles

Submandibular Triangle

Muscles Suprahyoid:

� digastric m.� stylohyoid m.� mylohyoid m.� geniohyoid m.

Muscles of the tongue: � hyoglossus m.

Submandibular Triangle

Superficial structures

PlatysmaFacial v.R. coli of facial n.Invesing layer

Submandibular Triangle

Submandibular gland

- the investing layer of deep fascia splits to enclose the submandibular gland

- posterior process - to the pterygoideusmedialis m.- anterior process - to the sublingual gl.- ductus submandibularis – arises from the deep part

�submandibular lymph nodes – laterally

• Facial a.

– gives off submental a.

• Mylohyoid n. – a branch of CN V 3

• Hypoglossal n. (CN XII)

• Lingual n.

• Submandibular ganglion

Submandibular Triangle

*Lingual n.

** Submandibular ganglion

Submandibular Triangle

*

**

Trigonum Pirogovi – access to the lingual a.– mylohyoid m. – intermediate tendon of the digastric m. – hypoglossal n.

Submandibular Triangle

N. hypoglossusTrigonum Pirogovi

Submandibular Triangle

(фотография на доц. Б. Владимиров, дм; катедра ЛЧХ)

Submandibular Triangle

Lingual a.

(фотография на доц. Б. Владимиров, дм; катедра ЛЧХ)

Infrahyoid region

Boundaries‒ hyoid, sternum‒ sternocleidomastoideus m. ‒ superior belly of the omohyoid m.

� Muscular triangle

Pretracheal layerMusclesа) infrahyoid:– sternohyoid m., omohyoid m., – sternothyroid m., thyrohyoid m. – depress hyoid

and larynx during swallowing processb) cricothyroid m. – tenses vocal folds

Infrahyoid region

Vessels

• anterior jugular v.

- arcus venosus jugularis – in spatium suprasternale

• superior thyroid a. and v.

• inferior thyroid a.

• a. thyroidea ima (in 10%)

• middle thyroid v.

• inferior thyroid v.

Nerves- recurrent laryngeal n.

Infrahyoid region

Vessels

• anterior jugular v.

- arcus venosus jugularis – in spatium suprasternale

• superior thyroid a. and v.

• inferior thyroid a.

• a. thyroidea ima (in 10%)

• middle thyroid v.

• inferior thyroid v.

Nerves- recurrent laryngeal n.

posterior view

Lymph nodes- Prelaryngeal

- Pretracheal

- Paratracheal

Visceraа) Endocrine layer

- Gl. Thyroidea

- Gll. Parathyroideae

b) Respiratory layer

- Larynx - C4-C6

- Trachea - C6-Th4

c) Alimentary layer

- Pharynx - basis cranii - C6

- Esophagus - C6 - Th11

Visceraа) Endocrine layer

- Gl. Thyroidea

- Gll. Parathyroideae

b) Respiratory layer

- Larynx - C4-C6

- Trachea - C6-Th4

c) Alimentary layer

- Pharynx - basis cranii - C6

- Esophagus - C6 - Th11

Ductus thyroglossus

Thyroglossal duct cyst

Root of the Neck

‒ Junction between the thorax and the neck.

‒ It lies superior to the superior thoracic aperture.

‒ All structures that pass between the head and thora x or the upper limb and thorax must pass through the root of the n eck.

Defined by:

� the first rib - laterally� manubrium sterni - anterior� the body of Тh1 - отзад

Includes:

� Spatium antescalenum

� Interscalene Triangle

� Trigonum scalenovertebrale

Root of the Neck

Structures in midplane

• Thymus – superior poles

•Thyroid gl. (lobus dexter/sinister)

• Parathyroid gl. (inferior)

• Inferior thyroid veins

• Trachea (pars cervicalis)

• Esophagus (pars cervicalis)

• Longus coli m.

Boundaries - sternocleidomastoid, sternohyoid, sternothyroid from anterior and scalenus anterior m. - posterior.

The contents are :

- angulus venosus juguli

- internal jugular v.

- subclavian v.

- ductus thoracicus/ductus lymphaticus dexter

- suprascapular a.

- superficial cervical a.

- phrenic n.

- deep cervical lymph nodes – along with

- internal jugular v.

Spatium antescalenum

Spatium antescalenum

Spatium antescalenum (right side)

Interscalene Triangle

The first rib and the adjacent borders of the anterior and middle scalene muscles form the boundaries of the interscalene triangle

The contents are:• subclavian a. (second part), gives off:

- truncus costocervicalis- deep cervical a.- a. intercostalis suprema – to the І and ІІ intercostal space

• brachial plexus - superior, middle and inferior trunks

Subclavian a.

Trigonum scalenovertebrale

Pyramidal space formed between the anterior scalene and the longus muscles (colli and capitis) The contents are:

� Subclavian a. , (first part) gives off:- vertebral a.- truncus thyrocervicalis

- a. thyroidea inferior- a. cervicalis ascendens- a. cervicalis superficialis- a. suprascapularis

- internal thoracic a.- Thoracic duct- Vagus n.

- n. laryngeus recurrens- Sympathetic trunk

- middle and inferior/stellatum ganglia- ansa subclavia

Trigonum scalenovertebrale

*Thoracic duct

*

Ansa subclavia

Brachial plexus, Sympathetic trunk, m. scalenusminimus

Trigonum scalenovertebrale

Vertebral a.

90%

C7C6

2%

5%C5