Neck Definition The neck is a region of transition between the head and the thorax Boundaries Landmarks Regions Projections of organs C3 C4 C6 Tracheotomy 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 nerve Great auricular nerve Transverse cervical nerve Supraclavicular nerves SUPERFICIAL STRUCTURES OF NECK External jugular vein (фотография на доц. Б. Владимиров, дм; катедра ЛЧХ) Great auricular nerve Deep Cervical Fascia INVESTING LAYER surrounds 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. INVESTING LAYER PRETRACHEAL LAYER PREVERTEBRAL 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 Deep Cervical Fascia 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 LAYER PRETRACHEAL LAYER PREVERTEBRAL LAYER INVESTING LAYER PRETRACHEAL LAYER PREVERTEBRAL LAYER Carotid triangle Location – medially to the anterior border of the sternocleidomastoid muscle Carotid triangle Boundaries - digastric m., posterior belly - omohyoid m., superior belly - sternocleidomastoid m. Carotid triangle Located within the carotid triangle are the following: 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 neck Deep cervical lymph nodes - form a chain along the course of the IJV medial view • Common carotid artery • External and internal carotid arteries LYMPH NODES 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. Carotid triangle XII Vagus (CN X) nerve – posteriorly, between the comm. carotid a. and internal jugular v. C1 - superior laryngeal n. - ramus internus – enters the larynx together with C2 superior laryngeal a. Hypoglossal nerve (CN XII) - deep to the posterior C3 belly of the digastric m. C4 – gives off the superior root of the ansa cervicalis – enters the submandibular triangle Ansa Cervical plexus of nerves (С1-С4) – lies deep to cervicalis the SCM Ansa cervicalis (С1-С3) n. phrenicus - Radix superior (С1,2) – anterior to the common Plexus cervicalis 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 (stellate ganglion). 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 (stellate ganglion). Submandibular Triangle 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. Superficial structures Platysma Facial 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 pterygoideus medialis m. - anterior process - to the sublingual gl. - ductus submandibularis – arises from the deep part submandibular lymph nodes – laterally Submandibular Triangle • Facial a. – gives off submental a. • Mylohyoid n. – a branch of CN V3 • 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. hypoglossus Trigonum Pirogovi (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 layer Muscles а) infrahyoid: – sternohyoid m., omohyoid m., – sternothyroid m., thyrohyoid m. – depress hyoid and larynx during swallowing process b) 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 Viscera а) 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 Viscera а) 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 thorax or the upper limb and thorax must pass through the root of the neck. ‒ 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. Spatium antescalenum 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 (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 * Ansa subclavia *Thoracic duct Trigonum scalenovertebrale Brachial plexus, Sympathetic trunk, m. scalenus minimus Vertebral a. C5 5% C6 C7 90% 2%
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