Neck

The muscles of neck



Superficial group
Platysma a thin sheet-like muscle of facial expression Sternocleidomastoid

Suprahyoid muscles
Digastric
Stylohyoid Mylohyoid Geniohyoid

Elevate (raise) hyoid bone and depress mandible.

Infrahyoid muscle
Sternohyoid Sternothyroid Thyrohyoid Omohyoid

Depress hyoid or larynx after elevation

Deep group
Lateral
  

Scalenus anterior Scalenus medius Scalenus posterior

Medial
 

longus capitis longus colli

Flex the head, bends the neck forward

Major muscles of the neck

Sternocleidomastoid


Origin: manubrium and sternal end of clavicle Insertion: mastoid process of temporal bone Action: contraction of one muscle draws head toward the same side, and turn face to opposite side; both muscles act together to draw head backward

Scalenus anterior
 

Origin: transverse processes of C3-C6. Insertion: tubercle for scalenus anterior Action: unilateral, bends neck laterally; bilateral, elevate first rib, an accessory muscle of inspiration; if rib is fixed, flex neck anteriorly Above the first rib, there is a triangular space between scalenus anterior and midius. The brachial plexus and the subclavine a. emerge from this space.

Scalene fissure

The arteries of neck

Common carotid artery


Origin (arises from) Brachiocephalic trunk on the right Aortic arch on the left Ascends in neck to upper border of thyroid cartilage; bifurcates into internal and external carotid arteries

Carotid sinus (baroreceptor), located at a localizes dilation of terminal part of common carotid artery or beginning of internal carotid artery, sensitive to blood pressure changes Carotid glomus (chemoreceptor), lies posterior to the point of bifurcation of common carotid artery, senses changes in blood carbon dioxide (oxygen) levels

Branches of external carotid a.



   

Superior thyroid a. descends to supply upper pole of thyroid gland and larynx Lingual a. Facial a. Occipital a. Posterior auricular a. Maxillary a. Superficial temporal a.

 

Subclavian artery


Origin (arises from)

Brachiocephalic trunk on right Aortic arch on left

Becomes axillary artery at lateral border of first rib Branches

Vertebral a. Internal thoracic a. Thyrocervical trunk


Inferior thyroid artery supplies inferior pole of thyroid gland

Costocervical trunk

Veins Draining the neck

Internal jugular vein


Begin at jugular foramen, descending to join the subclavian vein to form brachiocephalic vein Lies lateral first to internal and then to common carotid a. within carotid sheath Chief extracranial tributaries
Common facial vein Lingual v. Pharyngeal v. Superior thyroid v. Middle thyroid v.

Subclavian vein  It is an continuation of axillary vein at the lateral border of first rib  Joins internal jugular vein to form the brachiocephalic vein. Angle of union is termed venous angle

External jugular vein



Formed behind angle of mandible by union of posterior auricular, posterior branch of retromandibular and occipital vein Crossing sternocleidomastoid to enter subclavian vein

Anterior jugular vein

 

Drains submandibular and anterior neck regions Descends near midline, runs posterior to sternal end of sternocleidomastoid to drain into external jugular vein or subclavian vein

Lymph nodes of neck

Anterior cervical lymph nodes
 

Superficial anterior cervical lymph nodes Deep anterior cervical lymph nodes

Lateral cervical lymph node



Superficial lateral cervical lymph nodes lie along the external jugular vein

Deep lateral cervical lymph nodes



Extend along the internal jugular vein from the base of skull to the root of neck, divided into superior deep lateral cervical lymph nodes and inferior deep lateral cervical lymph nodes Receive lymphatic vessels from head, neck, tongue, larynx, cervical parts of esophagus and trachea, thyroid gland, upper parts of the thoracic wall and breast Efferent vessels form the jugular trunk the left jugular trunk joins the thoracic duct and right may joint the right lymphatic duct

Superior deep lateral cervical lymph nodes  Jugulodigastric lymph node : lies at the junction of posterior belly of digastric and internal jugular vein Inferior deep lateral cervical lymph nodes  Juguloomohyoid lymph node : lies at the junction of the intermediate tendon of omohyoid and internal jugular vein  Supraclavicular lymph nodes : lie along the subclavian artery

Right lymphatic duct



Formed by union of right jugular, subclavian, and bronchomediastinal trunks Ends by entering the right venous angle Receives lymph from right half of head, neck, thorax and right upper limb At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks

Thoracic duct


Cervical plexus
Formation: formed by anterior rami of C1-C4 spinal nerves Position: lies in front of the origin of levator scapulae and scalenus medius and deep to the superior part of the sternocleidomastoid

Branches


Cutaneous branches: emerge around middle of posterior border of sternocleidomastoid, to supply skin of neck and scalp between auricle and external occipital protuberance
Lesser occipital n. Greet auricular n. Transverse nerve of neck Supraclavicular n.

 

Muscular branches: supply the deep muscles of neck Phrenic nerve (anterior rami of C3-C5)
Lies on anterior scalene, deep to fascia To diaphragm (motor and sensory)

Ansa cervicalis

Hypoglossal nerve gives off superior root of ansa (descendens hypoglossi), composed of fibers picked up from nerve C1 Joins inferior root of ansa (descendens cervicalis, C2and C3) to form a loop, the ansa cervicalis, which supplies infrahyoid muscles

Vagus nerve ( )  Leaves skull via jugular foramen  Descends in the neck in carotid sheath between internal (or common) carotid artery and internal jugular vein

Branches
Superior laryngeal nerve passes down side of pharynx and given rise to


Internal branch which pierces thyrohyoid membrane to innervates mucous membrane of larynx above fissure of glottis External branch which innervates cricothyroid

Cervical cardiac branches : descending to terminate in cardiac plexus Recurrent laryngeal nerves
 

Ascend in tracheo-esophageal groove Enter larynx posterior to cricothyroid joint, the nerve is now called inferior laryngeal nerve Innervations: laryngeal mucosa below fissure of glottis , all laryngeal laryngeal muscles except cricothyroid

Accessory n. ( )  Deep to posterior belly of digastric  Supplies sternoclidomastoid and trapezius muscle Hypoglossal n.( )  Descends between internal carotid a. and internal jugular v., hooks around external carotid a., to lie on the hyoglossus before entering tongue  Supplies muscles of tongue

Cervical part of sympathetic trunk



Formed by superior , middle and inferior cervical ganglia and interganglionic branches Superior cervical ganglion: largest, situated in front of transverse processes of C1~C3 vertebra Middle cervical ganglion: smallest, is at level of transverse processes of C6 vertebra Inferior cervical ganglion: situated at level of C7 vertebra, and may be fused with first thoracic ganglion to form cervicothoracic ganglion

Regional anatomy of neck

Parts and regions of the neck

Boundaries  Superior inferior border of mandible, angle of mandible, tip of mastoid process, superior nuchal line, external occipital protuberance  Inferior jugular notch, sternoclavicular joint, superior border of clavicle, acromion, spinous processes of C7

Landmarks
      

Hyoid bone Thyroid cartilage Cricoid cartilage Catotid tubercle Sternocleidomastoid Suprasternal fossa Greater supraclaviclar fossa

Regions  Neck
Anterior region of neck Lateral region of neck Sternocleidomastoid region


Nape

Anterior region of neck  Suprahyoid region

Submental triangle Submandibular triangle


Infrahyoid region
Carotid triangle Muscular triangle

Lateral region of neck  Occipital triangle  supraclavicular triangle (greatsupraclavicular fossa)

Skin  The natural line of cleavage of the skin are constant and run almost horizontally around the neck

Superficial fascia  Consists of fat and connective tissue  Contents

Platysma Superficial veins
 

Anterior jugular v. External jugular v. Lesser occipital n. Greet auricular n. Transverse nerve of neck Supraclavicular n.

Cutaneous nerves
   

Cervical branch of facial n.

Cervical fascia
Superficial layer (investing fascia
 

three layers

) Encloses trapezius, sternocleidomastoid, posterior belly of digastric and parotid and submandibular glands Attached to bony landmarks of upper and lower boundaries of neck and zygomatic arch of face

Prevertebral layer


Encloses viscera of neck: pharynx, larynx, trachea, esophagus, thyroid gland and parathyroid glands Completely surrounds thyroid gland, forming a sheet for it, and bind the gland to larynx Extends from hyoid bone to fibrous pericardium of superior mediastinum

Prevertebral layer


 

Lies anterior to bodies of cervical vertebrae and prevertebral muscles; extends from base of skull downward into the superior mediastinum, continuous with anterior longitudinal lig. and endothoracic fascia Covers subclavian vessels and roots of brachial plexus Extends into upper limb as axillary sheath

Carotid sheath
  

Formed by components of all three layers of deep cervical fascia Contains common and internal carotid arteries, internal jugular vein, and vagus nerve Ansa cervicalis located on its anterior surface

Suprasternal space


Over the lower part of the anterior triangle, the inversting fascia splits into two layers, which are attached to the anterior and posterior margins of the upper border of the manubrium, between these two layers is a slitlike space, called the suprasternal space Contains connective tissue, and sometimes a lymph node

Pretracheal space
 

Lies between pretracheal layer and cervical part of trachea Contains arteria thyroidea ima, inferior thyroid v., unpaired thyroid venous plexus, brachiocephalic trunk and left brachiocephalic v.

Retropharyngeal space


Lies between prevertebral layer and buccopharyngeal fascia Lies between prevertebral muscles, cervical part of vertebral column and prevertebral layer

Prevertebral space


Suprahyoid region
Submental triangle


 

Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone Covered by skin, superficial fascia and investing fascia Floor mylohyoid muscles Contents submental lymph nodes

Submandibular triangle
   

Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible Covered by skin, superficial fascia, platysma and investing fascia Floor mylohyoid, hyoglossus and middle constrictor of pharynx Contents submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes

Infrahyoid region
Carotid triangle


 

Bounded by anterior border of sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles Covered by skin, superficial fascia, platysma and investing fascia Floor prevertebral fascia and lateral wall of pharynx Contents common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes

Posterior belly of digastic muscle  Superficial great auricular n., retromandibular v., cervical branch of facial n.  Deep internal and external carotid a., internal jugular v., cranial n. and cervical part of sympathetic trunk  Superior posterior auricular a., facial a. and glossopharyngeal n.  Infeior occipital a. and hypoglossal n.

Muscular triangle


 

Bounded by midline of the neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid. Covered by skin, superficial fascia, platysma, anterior jugular v., coutaneous n. and investing fascia Floor prevertebral fascia Contents sternohyoid, superior belly of omohyoid, sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus

Thyroid gland
Shape and position
 

 

H-shape Left and right lobes: lie on either side of inferior part of larynx and superior part of trachea, extend from middle of thyroid cartilage to level of sixth trachea cartilage Isthmus: overlies 2nd to 4th tracheal cartilage Pyramidal lobe: some times arises from isthmus
A sheath of pretracheal fascia which is attached to arch of cricoid and thyroid cartilages, hence, the thyroid gland moves with larynx during swallowing and oscillates during speaking

Fibrous capsule:

Relations


Anteriorlly skin , superficial fascia, investing fascia, infrahyoid muscles and pretracheal layer Posteromedialy larynx and trachea, pharynx and esophagus, recurrent laryngeal n. Posterolateraly carotid sheath and cervical part of sympathetic trunk

Arteries of thyroid gland and nerves of larynx

Superior thyroid a.  Branch of external carotid a.  Runs superficial and parallel to the external branch of superior laryngeal n. to reach the upper pole of thyroid gland  Gives off superior laryngeal a. in company with internal branch of superior laryngeal n.

Superior laryngeal nerve  Internal branch which pierces thyrohyoid membrane to innervates mucous membrane of larynx above fissure of glottis  External branch is fine n., which descends in company with the superior thyroid a. and supplies cricothyroid

Inferior thyroid artery  Branch of thyrocervical trunk off subclavian a.  Turns medially and downward, reaches the posterior border of the thyroid gland and is closely related to the recurrent laryngeal n.  Supplies inferior pole of thyroid gland Recurrent laryngeal nerves  Ascend in tracheo-esophageal groove  Pass deep to the lobe of the thyroid gland and come into close relationship with the inferior thyroid a.  Cross either in front of or behind the artery of may pass between its branches  Nerves enter larynx posterior to cricothyroid joint, the nerve is now called inferior laryngeal nerve  Innervations: laryngeal mucosa below fissure of glottis , all laryngeal laryngeal muscles except cricothyroid

Arteria thyroid ima  May arise (4%) from the brachiocephalic a. or aortic arch Venous drainage  Superior and middle thyroid veins into internal jugular vein  Inferior thyroid veins to left brachiocephalic vein

Parathyroid gland
 

Yellowish-brown, ovoid bodies Position

Two superior parathyroid glands: lie at junction of superior and middle third of posterior border of thyroid gland Two inferior parathyroid glands: lie near the inferior thyroid artery, close to the inferior poles of thyroid gland

Function: regulate calcium and phosphate balance and is therefore essential for life

Cervical part of trachea

 

 

Begins at lower end of larynx level of C6 vertebra Consists of a series of incomplete cartilage rings Extends into thorax Relations in the neck
Anteriorly The skin , superficial fascia, investing fascia, suprasternal space and jugular arch, infrahyoid muscles and pretracheal fascia, isthmus of thyroid gland ( in front of the 2nd to 4th tracheal cartilage), inferior thyroid v. and unpaired thyroid venous plexus, arteria thyroid ima ( if present), and left brachiocephalic v. in child

Laterally The lobes of the thyroid gland ( down as far as the sixth ring) and the carotid sheath Posteriorly The right and left recurrent laryngeal nerves, the esophagus

Cervical part of esophagus

  

Connecting the pharynx at level of C6 vertebra Consists of smooth muscle tube Relations of the neck
Anteriorly Trachea , recurrent laryngeal nerves ascend, one on each side, in the groove between the trachea and esophagus Posteriorly Prevertebral layer of cervicl fascia, longus colli, and vertebral column Laterally Lobe of the thyroid gland and carotid sheath

Sternocleidomastoid region


Covered by sternocleidomastoid Contents

Ansa cervicalis Carotid sheath Cervical plexus Cervical part of synpathetic trunk

Root of neck


Formed at thoracic inlet by

Anteriorly manubrium sterni Posteriorly body of first thoracic vertebra Laterally first rib and costal cartilage

Contents
Cupula of pleura extends up into the neck, over the apex of lung, 2 3cm above the medial third of clavicle Subclavian v. Subclavian a. Thoracic duct Right lymphatic duct Vagus n. Phrenic n.

Lateral region of neck



Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle Divided by inferior belly of omohyoid into occipital and supraclavicular triangles

Triangle of the vertebral a.



Boundaries
Medially longus colli Laterally scalenus anterior Inferiorly first part of subclavian a. Apex transvese procss of C6 Posteriorly cupula of pleura, transvese procss of C7, anterior rami of C8 spinal nerves, costal neck of 1st rib Anteriorly carotid sheath, phrenic n. and arch of thoracic duct (left)

Contents
Vertebral a. Inferior thyroid a. Cervical part of sympathetic trunk Cevicothoracic ganglion

Occipital triangle


 

Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid Covered by skin, superficial fascia, and investing fascia Floor prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae Conents
Accessory n. emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius Cervical and brachial plexuses

Supraclavicular triangle


Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle Covered by skin, superficial fascia, and investing fascia Floor prevertebral fascia and inferior parts of scalenus Conents
Subclavian v. and venous angle Subclavian a. Brachial plexus

Dissection

Platysma

Cutaneous nerves and superficial veins

Lesser occipital n. External jugular vein Greet auricular n. Transverse nerve of neck Anterior jugular vein Supraclavicular n.

Submendibular gland Digastric Hypoglossal n. Superior thyroid a. Ansa cervicalis Sternothyroid Sternohyoid Vagus n. Cervical plexus Phrenic n. Omohyoid Accessory n.

Hypoglossal n. Vagus n. Internal branch Superior thyroid a. Vertebral a. External branch

Inferior thyroid a.

Inferior thyroid a.

Vagus n.

Recurrent laryngeal n.

Thoracic duct

Vertebral a. Transvers cervical a. Costocervical trunk

Inferior thyroid a. Thyrocervical trunk Suprascapular a. Internal thoratic a.