surgicalanatomyoftheneck-131127094050-phpapp02

8/13/2019 surgicalanatomyoftheneck-131127094050-phpapp02

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Introduction

Surgeon should master surgical anatomy of the neck beforeembarking on any neck dissection

Upper border of the neck:

ant: FOM

post: BOS

Lower border:

ant: upper border of 1strib

post: body of the 1stthoracic vertebrae


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Developmental Anatomy

Skin of the neck from cervical dermatomes (2

nd

to 6

th

cervicalsegments)

SCM, strap muscles and trapezius cervical myotomes

Six branchial arches form at four weeks of POG has principal

nerve and vessel The first arch:

Form the upper border of the neck

Bone: mandible - derived from Meckelscartilage

Muscles: mylohyoid, ant. belly of digastric

Trematic nerve is the mandibular branch of the trigeminal nerve

The first pouch form ear structures only


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The second arch:

Bone: Styloid process, lesser cornu and upper body of hyoid bone - formed

from Reichartscartilage

Muscles: platysma, post belly of digastric and stylohyoid

Nerve: Facial nerve

The second pouchear related structures

The third arch:

Bone: greater cornu and inferior body of the hyoid bone

Cartilage: epiglottisdeveloped from hypobranchial eminence

Muscle: stylopharyngeus

Nerve: glossopharyngeal nerve

The third pouch:

ventral aspectthymus

posterior aspect - inferior parathyroid gland


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Arches four, five and six merge to form one

The fifth arch being completely absorbed

The 3rdand 4tharches fuse forming cervical sinus

If persists cervical sinus (in lower neck, btw ICA & ECA to the

apex of the pyriform fossa Fourth and Six arches

Cartilages: laryngeal cartilages

Muscles: cricothyroid constrictors of the pharynx, intrinsic muscles of the

larynx Nerve: SLN, RLN (X)

Fourth pouch: superior parathyroid gland

Fifth pouch: ultimobranchial body

Sixth pouch: intrinsic muscles of the larynx


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Pharyngeal archMuscular

contributions

Skeletal

contributionsNerve Artery

1st (also called

"mandibular arch")

Muscles of mastication,

anterior belly of the

digastric, mylohyoid,tensor tympani, tensor veli

palatini

Maxilla, mandible (only

as a model for mandible

not actual formation of

mandible), the incusand malleus of the

middle ear, also

Meckel's cartilage

Trigeminal nerve (V2

and V3)

Maxillary artery, external

carotid artery

2nd (also called the

"hyoid arch")

Muscles of facial

expression, buccinator,

platysma, stapedius,

stylohyoid, posterior bellyof the digastric

Stapes, styloid process,

hyoid (lesser horn and

upper part of body),

Reichert's cartilage

Facial nerve (VII)Stapedial artery, hyoid

artery

3rd Stylopharyngeus

Hyoid (greater horn and

lower part of body),

thymus, inferior

parathyroids

Glossopharyngeal nerve

(IX)

Common carotid,

internal carotid

4th

Cricothyroid muscle, all

intrinsic muscles of softpalate including levator veli

palatini

Thyroid cartilage,superior parathyroids,

epiglottic cartilage

Vagus nerve (X),superior laryngeal nerve

Right 4th aortic arch:

subclavian arteryLeft 4th aortic arch:

aortic arch

6th

All intrinsic muscles of

larynx except the

cricothyroid muscle

Cricoid cartilage,

arytenoid cartilages,

corniculate cartilage

Vagus nerve (X),

recurrent laryngeal

nerve

Right 6th aortic arch:

pulmonary artery

Left 6th aortic arch:

pulmonary artery and

ductus arteriosus


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POUCH Overall Structure Specific Structures

1 tubotympanic recesstympanic membrane, tympanic cavity,

mastoid antrum, auditory tube

2 intratonsillar cleftcrypts of palatine tonsil, lymphatic nodules

of palatine tonsil

3 inferior parathyroid gland, thymusgland

4superior parathyroid gland,

ultimobranchial body

5 becomes part of 4th pouch


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Triangles of the Neck

SCM divides the neck into anterior and posterior triangles Triangles of the neck

Anterior: submental, submandibular, carotid and muscular

Posterior: lateral neck, subclavian

Anterior triangle Boundaries: SCM, inf. ramus of mandible, midline

Submental:

Boundaries: anterior belly of digastric, midline and hyoid bone

Contains LN and submental salivary gland


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Submandibular: Boundaries: Inferior margin of mandible, anterior and posterior bellies of

digastric

Deep boundarystylohyoid and mylohyoid muscle

Contains: SM salivary gland, deep fascia, LN, ant. facial vein, facial artery,

MM br. of VII n.

Carotid:

Boundaries: ant. border of SCM, post belly of digastric, superior belly of

omohyoid

Contains: upper carotid sheath, LNs


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Muscular: Boundaries: lower anterior border of SCM, anterior belly of omohyoid, hyoidbone, midline

Contains: lower carotid sheath, infrahyoid strap muscles, upper

aerodigestive tract, thyroid and parathyroid gland

Posterior triangle

Divided into lateral neck, subclavian triangles

Lateral Neck:

Boundaries: Posterior border of SCM, ant border of trapezius, sup. border ofinf belly of omohyoid

Contains: cervical plexus, fibrofatty tissue, LN, XI nerve


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Sublavian:

Boundaries: Lower border of Inf. belly of omohyoid, clavicle, post. border of

SCM

Contains: fibrofatty tissue, scalene muscles, brachial plexus, subclavian

vessels, thyrocervical trunk, Sibsonssubpleural fascia and the pleura

Trapezius muscle covers cervico-occiptal region

represents the posterior neck

rarely involved in detail


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Fascial Layers

Superfical

Deep: investing layer, middle of visceral layer, deep layer

Superficial

Invests platysma muscle

Closely associated with adipose tissue

Penetrated by the blood vessels that supply the neck skin

Subplatysmal flap: protects the blood supply to the skin


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Deep

1. Investing layer

Arises from the ligamentum nuchae and the spinous process of

cervical vertebrae and invests the entire neck

Splits to enlose the trapezius, omohyoid, SCM, strap muscles and the

parotid gland Superior attachment: external occipital protruberance, superior nuchal

line, mastoid tip an zygomatic arch

The splitting of the facial layer around the parotid forms a deep layer

which fuses with the fascia around the ICA

Forms stylomandibular ligament

Anterior attachment: hyoid bone

Inferior attachment: acromium, clavicle, sternum


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2. Carotid sheath

Derived from the superficial layer of DCF medial to SCM

Contains 80% of the LN of the neck, carotid arteries, IJV, X nerve

3. Middle layer, or pretracheal of visceral layer

Derived from the superficial layer of DCF passes deep to the strap

muscles and encircles the tracheal, thyroid and esophagus

Movement of the hyoid and strap muscles during swallowing elevates

the fascia

4. Deep layer (prevertebral fascia)

Arises from the ligamentum nuchae and the spinous process of thecervical vertebrae

Splits to enclose the postvertebral muscles, passes laterally around

the scalene muscles and then forms a layer over the vertebrae

Forms the floor of the posterior triangles and allows the pharynx to

glide during deglutition


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Neck Spaces

Submental Space

Midline spaces that lies between the anterior bellies of digastric

muscles

Submandibular Space

Superf boundary: submandibular gland, digastric muscle Deep boundary: mylohyoid muscle

Communicates with FOM around the posterior border of

mylohyoid

Peritonsillar Space

Between tonsil and superior constrictor

Communicates through the fibres of the superior constrictor with

retropharyngeal and parapharyngeal space


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Parapharyngeal Space

Inverted pyramidal shape

Top: BOS; Inferior: Greater cornu of hyoid bone

Medial: Sup constrictor; Lateral: Pterygoid muscles, mandible and

deep lobe of parotid gland Divided by styloid process into pre- and poststyloid spaces

Prestyloid space contains ectopic salivary tissue

Poststyloid space contains carotid arteries, internal jugular vein

CN IX-XII, cervical sympathetic chain and lymph node


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Retropharyngeal Space

Sits between the two parapharyngeal spaces and is continuous

with both

Superiorly: Skull base

Anteriorly: musculature of pharynx Posteriorly: prevertebral fascia

Contains only lymph node

Continues inferiorly behind esophagus then with posterior

mediastinum


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Pretracheal Space

Lies anterior and lateral to the thyroid cartilage and deep to strapmuscles

Contains Delphian node and communicates with the superior

mediastinum

Prevertebral Space

Potential Space

Lies btw cervical vertebrae and anterior longitudinal ligament

(posteriorly) and the prevertebral fascia (anteriorly) Extends down to 3rdthoracic vertebrae where the fascia is bound

to the vertebrae

Infection in this space can rupture directly through into the

posterior mediastinum


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Muscles

Sternocleidomastoid muscle

Has two heads of origin; that are from manubrium of sternum and clavicle

The manubrial tendon is attached to the front of the bone below the jugular

notch

The clavicular head arises from the superior surface of the medial third of the

clavicle It is attached by a tendon to lateral surface of the mastoid process and by a thin

aponeurosis to the lateral half of the superior nuchal line

Spinal accessory nerve enters the muscle and runs through the deep part of it

and emerged at the posterior border of the muscle

It is enclosed within the investing layer of deep cervical fascia

It is crossed superficially by the greater auricular nerve, transverse cervical

nerve and external jugular vein

Deep to the upper half of the muscle lies the cervical plexus

Deep to its lower part lies the carotid sheath and its contents


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The blood supply is derived from the branches of the occipital and superior

thyroid arteries Is Innervated by the spinal part of accessory nerve mostly C2 and C3

Contraction of one muscle tilts the head towards ipsilateral shoulder, and

rotates the head and neck to opposite side

Both muscles acting together from below draw the head forwards

The muscles can assists in raising the roof of the thorax in forced inspiration

Can be tested by turning the face to the opposite side against resistance

and the muscle palpated


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Omohyoid muscle

It arises from the upper border of the scapula, and occasionally from the

superior transverse scapular ligament which crosses the scapular notch

Inferior belly inclines forward and slightly upward across the lower part of

the neck, being bound down to the clavicle by a fibrous expansion

Inferior belly passes behind the sternocleidomastoid, becomes tendinous

and changes its direction

Superior belly lies close to the lateral border of the sternohyoid and inserted

into the lower border of the body of the hyoid bone

The central tendon of this muscle is held in position by a fascial sling derived

from investing layer of deep cervical fascia and is prolonged down to beattached to the clavicle and first rib

The superior belly is supplied by the superior root of the ansa cervicalis with

the ansa supplies the inferior belly


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The inferior belly of the omohyoid divides the posterior triangle of the neck into

an upper or occipital triangle and a lower or subclavian triangle

Its superior belly divides the anterior triangle into an upper or carotid triangle and

a lower or muscular triangle


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Digastric muscles

Posterior belly arises from the digastic notch on the medial surface of thebase of the mastoid process

Posterior belly tapers down to the intermediate tendon, which is attached to

the junction to the body and the greater horn of the hyoid bone

The tendon is lubricated by a synovial sheath within the fibrous sling

Anterior belly lies on the inferior surface of mylohyoid

Anterior belly connects the intermediate tendon to the digastrics fossa on

the inner surface of the mandible

Posterior belly is supplied by facial nerve

Anterior belly is supplied by the nerve to mylohyoid The actions of the muscles are to depress and retract the chin and to assist

the lateral pterygoid in opening of mouth


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Strap muscles

Comprises of sternohyoid, omohyoid, thyrohyoid and sternothyroid

muscles

Move larynx and depress the mandible

Supplied segmentally from C1, C2, C3 via the ansa cervicalis Retracted to access the trachea and thyroid gland

Form the anterior boundaries of the neck level


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Cervical Lymphatics

Divided into superficial and deep

Superfical vessels perforate the cervical fascia and drain into the

deep

Deep vessels:

commonly found around blood vessels, nerves and muscles

drain the mucosa of the mouth, OP, NP, larynx and hypopharynx

group of nodes: submental, submandibular, jugular chain, posterior nodes

Submental

Situated in the midline, inferior to mandible and between anteriorbellies of digastric muscles

Drain the anterior floor of mouth


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Submandibular Divided into six groups: preglandular, prevascular, retrovascular,

retroglandular, intraglandular and deep nodes

Can be described as those related to submandibular gland those

related to facial vessels Cancers of FOM, tongue and buccal cavity metastasize more

commonly to the perivascular nodes - cleared in the neck

dissection

Jugular chain Closely associated with internal jugular vein

Upper jugular nodes: drain the posterior faucial region esp

palatine tonsil


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Middle jugular nodes:

Found between carotid bifurcation and the level at which omohyoid tendon

crosses IJV

Drain larynx, midhypopharynx and upper thyroid gland

Lower jugular nodes:

Between tendon of omohyoid and down to the thoracic inlet

Sometimes referred to as prescalene group of nodes

Form an important confluence between the mediastinal node group, the

axillary group and the neck

Neck nodes may appear secondary to disease outside the neck


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Posterior nodes:

Arranged into two groups:

Along the accessory nerve: first echelon for nasopharynx

Along the thyrocervical vessels: second echelon for the areas drained

by the anterior neck nodes

Lymph node levels

Level I

Refers submental and submandibular nodes

Drains the lip, oral cavity and tongue Subzone Ia: submental nodes; Drains ant FOM, lower lip, ventral tongue

Subzone Ib: submandibular nodes; Drains other subsite in oral cavity


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Level II

Forms upper jugular group of nodes

Drains the oropharynx, larynx, hypopharynx and parotid

IIa: Lies anterior inferior to Cr. XI

Iib: Lies posterosuperior

Positive Iia disease mandates Iib dissection Elective dissection for laryngeal and hypopharyngeal malignancy can

exclude level Iib

Level III

Refers to middle jugular node

Drains the larynx and pharynx


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Level IV

Refers to lower jugular group of nodes

Drains the larynx and hypopharynx

Level V

Refers to posterior triangle group of nodes

Drains the other lymphatic regions in the neck

Level Va:

Superior to inf belly of omohyoid

Contains the chain of nodes along the accessory nerve, which drain

the nasopharynx Level Vb:

Inferior to inf belly of omohyoid

Contains nodes related to the thyrocervical trunk which drains the

thyroid gland


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Level VI:

Anterior or central group of nodes

Paratracheal, perithyroidal, Delphian nodes

Level VII:

Corresponds to the superior mediastinal tissues


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Level Nodes Boundaries Possible primary

I

Submental

Submandibular

Midline, body of hyoid, posterior belly digastric,

body of mandible

Lower lip, floor of mouth,

lower gum

Face, nose, PNS, oral cavity,

submandibular gland

II

Upper deep cervical- upper 1/3 of IJV

- adjacent spinal accessory

(= upper half of carotid triangle)

Skull base above

Carotid bifurcation below (clinically level of

hyoid)

Posterior belly digastric anteriorly

Sternomastoid posteriorly

Nasopharynx, Oropharynx,

Hypopharynx,

Supraglottic larynx, Oral

cavity

III

Middle deep cervical- middle 1/3 of IJV

(=lower half of carotid triangle)

Carotid bifurcation above

Superior belly of omohyoid (clinically level of

cricothyroid notch)Sternomastoid posteriorly

Thyroid, Larynx,

Hypopharynx, Cervical

esophagus

IV

Lower deep cervical- lower 1/3 of IJV

(= part of muscular triangle behind carotid sheath)

Superior belly of omohyoid above (clinically

cricothyroid notch)

Clavicle below

Sternomastoid posteriorly

? Carotid sheath anteriorly

Thyroid, esophagus, breast,

lung, GI

VPosterior triangle- spinal accessory group

- supraclavicular group

Sternomastoid anteriorly

Trapezius posteriorly

Clavicle below

Occipitalscalp, external ear

Supraclavicular

nasopharynx, thyroid,

esophagus, lung, breast

VI

Anterior neck between carotid sheaths- prelaryngeal

- pretracheal

- paratracheal

(=part of muscular triangle in front of carotidsheath)

Midline anteriorly

Carotid sheath posteriorly?

Sup. Belly of omohyoid above?

Sternum below

Thyroid


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Major Blood Vessels

Common carotid artery

The common carotid artery on the left side arises from the arch of aorta, where it

lies in front of the subclavian artery up to the sternoclavicular joint

The common carotid artery on the right side arises from brachiocephalic trunk

where it bifurcates behind the sterno-clavicular joint

The common carotid artery gives off no branches proximal to its bifurcation It lies within the medial part of carotid sheath, where the internal jugular vein lies

lateral to it and the vagus nerve deeply placed between the two vessels

The sympathetic trunk is behind the artery and outside the sheath, which is

overlapped superficially by the infrahyoid mucles and sternocleidomastoid

It usually bifurcates into the external and internal carotids at the level of theupper border of the lamina of the thyroid cartilage (upper border of C4 vertebrae)


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The terminal portion of the artery is often dilated into the carotid sinus, which

includes the comancement of the internal carotid artery The surface markingof the common carotid artery is along a vertical line from

the sternoclavicular joint to the level of the upper border of the thyroid gland


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External carotid artery

It lies against the side wall of the pharynx somewhat medial to the internal

carotid artery

It then ascends in front of the internal carotid deep to the posterior belly of

digastric and stylohyoid

It pierces the deep lamina of the parotid fascia and enters the gland It divides within the gland behind the neck of the mandible into the maxillary

and superficial temporal arteries

It is separated from the internal carotid by deep part of the gland and its fascia,

styloid process and its continuation the styloid ligament, styloglossus and the

pharyngealstructures The facial vein crosses the artery, with the hypoglossal nerve lying between

The surface marking is along a line of bifurcation of the common carotid

passing up behind the angle of mandible to a midpoint immediately in front of

tragus of the ear


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Internal carotid artery

It arises at the bifurcation of the common carotid and continues upwards within

the carotid sheath

At its commencement is the carotid sinus where its contained baroreceptors

are supplied by the glossopharyngeal and vagus nerves

The carotid sinus contains baroreceptors which mediate blood pressureimpulses to medullary centres

The carotid body is a small structure from which it receives two or three small

glomic arteries

The carotid bodys cells are chemoreceptors concerned with respiratory

reflexes and are innervated by the glossopharyngeal and vagus nerves It lies lateral to lateral to the external carotid at its origin, but soon passes up

posteriorly to a medial and deeper level


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It has no branches in the neck

It passes straight up in the carotid sheath, beside the pharynx, to the carotidcanal in the base of the skull

Internal jugular vein

It emerges from the jugular bulb at the posterior compartment of the jugular

foramen At first behind the internal carotid artery, it lies on the transverse process of the

atlas, crossed by the accessory nerve

It receives the inferior petrosal sinus as its first tributary just below the base of

skull

The vein passes down to gain lateral side of the internal carotid artery


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The deep cervical lymph nodes are closely adjacent to the vein throughout its

course Its posterior relations include the cervical plexus and the phrenic nerve

The thoracic duct crosses behind the left vein at the level of C7 vertebrae

The inferior root of the ansa cervicalis curls around its lateral border, to unite

with the superior root at the variable level in front of the vein

The terminal part of the vein lies deep to the triangular interval between the

sterna and clavicular heads of sternocleidomastoid

It joins the subclavian veinto form the brachiocephalic vein behind the sternal

end of clavicle

Its tributaries below the inferior petrosal sinus are pharyngeal, lingual, facialand superior and middle thyroid veins

At its commencement and termination of the vein slightly dilated to from

superior and inferior bulb


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External jugular vein

Forms a variable superficial system of vein along with posterior EJV and AJV

Drains blood from the face and scalp

Enters the subclavian vein where there are valves at the entrance with a further

set of veins at 4 cm proximal

N


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Nerves

Marginal Mandibular br. of Cr. VII

Runs inferior to the angle of mandible

Dips down into the neck and runs superficial to the submandibular triangle

Runs just deep to platysma and superficial to the deep fascia

Runs inferior to the greater cornu of the hyoid bone

Curves upwards and crosses mandible for a second time to the facial artery andvein

Supplies depressor anguli oris, risorius, muscles of the lower lip


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Glossopharyngeal nerve

Trematic nerve of the third pharyngeal arch

Exits the skull at the anterior compartment of the jugular foramen

Has an inferior ganglion in the neck contains cell bodies of the

sensory fibres

Passes down on the ICA then curves anteriorly around

stylopharyngeus, deep to hyoglossus and reaches the tongue

Branches:

Tympanic branch (Jacobsonsnerve)

Supplies sensation to the middle ear

Parasympathetic supply to the parotid gland via tympanic plexus


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Motor branch to stylopharyngeus

Carotid sinus nerve:main supply to the carotid sinus and carotid body

Pharyngeal branches:join the pharyngeal plexus on the middle constrictor

muscle

Tonsillar branch:supplies the mucous membrane over the palatine tonsil

Lingual branch: Supplies the posterior one-third of the tongue with sensory fibres and

secretomotor fibres to the glands of the posterior third


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Vagus nerve

Trematic nerve for 4thbranchial arch

Exits the skull base through the middle compartment of jugular

foramen

The nerve dilates to form the inferior ganglion beneath the skull

base

Below the ganglion, the vagus receives a branch from the

accessory nerve

Runs in the carotid sheath between the IJV and the ICA and CCA

Branches:

Auricular branch (arnoldsnerve): supply the TM and ear canal skin

Carotid body branches: supplements the glossopharyngeal branch

Pharyngeal branches: supply motor innervation to the constrictors and

soft palate


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Superior laryngeal branches:

Leaves the vagus high in the neck

Divides at the level of the hyoid into external and internal laryngeal

nerves

Cardiac branches: Leave the vagus low in the neck and form the cardiac

plexus

Recurrent laryngeal branches:

Branches low in the neck

Left hooks around ligamentum arteriosum and arch of aorta and then

runs cranially in the tracheo-esophageal groove

Right runs along the subclavian artery before coursing medially towardsthe tracheo-esophageal groove


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Spinal accessory nerve

Formed in the posterior cranial fossa by the union of spinal and cranial part

Emerges from the skull base through the middle compartment of the jugular

foramen, lateral to the vagus nerve

Cranial component joins the vagus just inferior to the inferior ganglion

Runs in contact with IJV, inf to the lateral mass of atlas and passes into the SCM Supplies motor input only to SCM from C2 and C3 roots

Exits the SCM at the junction of the upper and middle thirds of the posterior

border

Runs across the posterior triangle btw the deep and superf layers of DCF

Enters trapezius at the junction of its lower and middle thirds


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Hypoglossal

Exits the skull through hypoglossal canal

Courses around the inferior vagal ganglion

Runs inferior around ICA then ECA to pass below the posterior belly of the

digastric

Runs around the stylomastoid branch of the occipital artery, ECA, lingual arteryand inferior to the greater horn of hyoid bone

It then courses upwards deep to hyoglossus and divides to supply all intrinsic

muscles of tongue and extrinsic muscle, except the palatoglossus

Gives the upper root of the ansa cervicalis


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Cervical plexus

Is formed by loops between the anterior rami of the upper four cervical nerves

Lies in the series with brachial plexus on the scalenus medius behind the

prevertebral fascia

It is covered by the upper part of sternocleidomastoid

Does not lie in the posterior triangle The upper three cervical nerves have meningeal branches for the posterior

cranial fossa

The C1 fibres ascend with the hypoglossal nerve

The C2 and C3 fibres ascend thru the foramen magnum


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Muscular branches of cervical plexus

Are given off segmentally to prevertebral vessels (longus capitis, longus colli

and scalenes)

The fibres from the branch of C1 are carried to superior root of ansa

cervicalis and nerves to thyrohyoid and geniohyoid

Branches from C2 and C3 are to the sternocleidomastoid, while branches

from C3 and C4 are to the trapezius

The inferior root of ansa cervicalis is formed by union of a branch each from

C2 and C3

The inferior root of ansa cervicalis descends to join the superior root (C1) at

the ansa


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Cutaneous branches of cervical plexus

Generally supply the front and sides of the neck and contribute to the supply

of the scalp, face and chest

Lesser occipital nerve (C2) supplies posterior aspect of the upper neck

adjacent scalp behind the auricle as well as the auricle

Transverse cervical nerve divides into ascending and descending branches

and innervate the skin of the front of neck from chin to the sternum

Supraclavicular nerve emerges with the other three nerves at the posterior

border of sternocleidomastoid and soon divides into several branches

Greater auricular nerve is a large trunk passing upwards over

sternocleidomastoid


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