Neck (1) of

• Neck is short region and contain over crowded

structuresl and jconnect the head with the body .

Order of structure in the neck from

superficial to deep :-
1. Skin .
2. Superficial fascia ( subcutaneous fat ) .
3. Platysma muscle .
4. Deep u fascia .

•-------------------------------------------------•

Platysma :-
• It is unusual muscle because it found superficial
to the deep cervical fascia .
• ORIGIN :- fascia over the upper parts of
pectoralis major and deltoid .
• Insertion :- lower border of the mandible .
• Regarded as one of the muscle of fascial
expression because it supplied by cervical branch
of the facial nerve ( CN 7).
• Platysma muscle is less developed in the humman
but well developed in the animal .
•-------------------------------------------------•

Deep cervical fascia :-

• has 4 parts :-.

• #A : Investing ( superficial ) layer of deep

cervical fascia :-
• Encircle the neck like collar
• Attach above to the lower border of the mandible,
mastoid process, superior nuchal line and
external occipital protuberance at the base of
the occipital bone .
• Between the angle of the mandible and the tip of
the mastoid process the investing layer is strong
and splits to enclose the parotid gland.
• The superficial part extends superiorly as the
parotidomasseteric fascia and reaches up to the
zygomatic arch. The deep part extends to the
base of the skull as stylomandibular ligament.

• #B : Carotid sheath :-
• contain :-
1. Common and Internal carotid arteries .
2. Internal jugular vein .
3. Vagus nerve .
4. Ansacervicalis nerve .
5. Deep cervical lymph nodes .
• Carotid sheet protect these structure to avoid
injury during the surgery .

• #C : pretracheal fascia :-
• lies deep to the infrahyoid strap muscles
(sternothyroid, sternohyoid and omohyoid) so
that its upward attachment is limited by the
respective attachments of those muscles, namely,
the body of the hyoid bone and the oblique line
of the thyroid cartilage.
• enclose the thyroid gland and blaster the gland to
the trachia , pharynx, larynx; esophagus .
• that is why pateint with thyroid gland
enlargement ( goitre ) when you ask to sollow
somthing the gland move because it firmly attach
to the the trachia, esophagus , larynx , pharynx by
this pre trachial fascia { like blaster} .
• Also this fascia attach to the percardium of the
heart in the thorax .

• #D : prevertebral fascia :-
• In front of the prevertebral muscle [cover them]
and behind the pharynx and esophagus.
• Continue in the upper limb wih the brachial
 plexus as the axillary sheet.
• The third part of the subclavian artery lies deep
to the fascia , but the fascia It does not invest the
subclavian or axillary vein;
• The fasica is pierced by the four cutaneous
branches of the cervical plexus (great auricular,
lesser occipital, transverse cervical and
supraclavicular nerves).

• All the above fasciae are potential spaces

‫ ﻳﻌﻨﻲ ﻓﺎﺿﻲ م ﻓﻴﻮ ﺣﺎﺟﻪ ﻟﻜﻦ ﻣﻤﻜﻦ‬potential space ‫ﻳﻌﻨﻲ ﺷﻨﻮ‬
abscess ‫ وﻻ‬blood‫ ﺑﻲ‬pathological condition ‫ﻳﺘﻤﻠﻲ ف‬
like prevertebral abscess in front of the ‫وﻻ اي ﺷﻲ‬
prevertebral muscle and behined the prevertebral
fascia and so on

•-------------------------------------------------•

STERNOCLIDOMASTOID :-
• important land mark in the neck region devided
the neck into triangles to describe it easy because
the neck contain overcrowded structure .

• ORIGIN :-
1. Sternal head from manubrium of sternum below
the jugular notch .
2. calvicular head from the medial third of
 the clavicle .

• A triangular interval exists between

the two heads .
• the lower end of the internal jugular vein lies in
this triangle , where it can be entered by needle or
catheter{ 30 degree to the body downward }.

Benefits of this catheterization

1. Measuring the pressure in the right atrium
( lead to the atrium )
2. introducing fluid in pateint with shock
for example .

• Internal jugular vein can also be cathetrize at the

anterior border of the SCM .

• Insertion :-
• The fiber of SCM that arise medially insert
laterally and vice versa .
• The clavicular fibres are directed mainly to the
mastoid process, while the sternal fibres run more
obliquely chiefly to the superior nuchal line , and
this produce twisting in the muscle .

• Relation :-
• The muscle is crossed superficially by the great
auricular nerve, the external jugular vein and
the transverse cervical nerves, in that order
from above downwards
• Deep to the upper half of the muscle lies the
cervical plexus; deep to its lower part lies
the carotid sheath and its contents, overlying
scalenus anterior .

• Innervation :-
• Innervated by the spinal part of the accessory
nerve { cranial nerve 11}.
• Accessory nerve has cranial part go with
vagus and spinal part innervate the SCM
and the trapezius .
• Branches from the cervical plexus (C2, 3) carrying
proprioceptive fibres enter the muscle directly or
by joining the accessory nerve.

• BLOOD SUPPLY :-
• is from branches of the occipital and superior
thyroid arteries .

• ACTION :-
1. Turning the face to the contra lateral side
{ most important action } ( by contraction
 of the two heads )
2. Tilt the head to the ipsilateral side ( by
contraction of one head )
3. Flex the head ( but the main flexors is
prevetebral muscles ) .
4. Elevate the sternum { accessory muscle for
respiration }, that is why they are prominent
and hypertrophied in patient with bronchial
asthma and COPD .
• We have narrow space between the SCM and the
mandible and we find in it the parotid gland .
•--------------------------------------------------•

★ INFRA HYOID MUSCLES { STRAP

MUSCLES } :-

1. Omohyoid muscle :- .
• Has superior and inferior belly .
• Superior belly arise from to the lateral side
of the hyoid bone .
• The inferior belly arise from the scapula medial
to the scapular notch .
• both bellies meet in the central tendon behined
the SCM over the carotid sheath. Where it lies
over the internal jugular vein, the muscle fibres
are replaced by a flat tendon, a useful guide at
 operation to the underlying vein .

2. Sternohyoid :-
• ORIGIN : jugular notch .
• Insertion : medial part of the body of the
hyoid bone .
• These two muscles ( Sternohyoid and Omohyoid )
are found bilaterally ( Omohyoid is laterally & the
sternohyoid is medially ) and there is very very
narrow space between them .
• Also these muscle is superficial to the two
other strap muscle

3. Sternothyroid :-
• Origin : sternum .
• Insertion : oblique line of the thyroid cartilage
not thyroid gland .
• This muscle has no space between it and the the
thyroid gland above act as blaster so enlarged
gland can't obstruct the larynx , BUT has space
below and extend to the thorax .
• There fore the enlarged gland can reach to
thorax by this space and embrylogicaly it pass
through this space .
4. Thyrohyoid :-
• Arise from the thyroid cartilage and inserted in
the hyoid cartilage .
• Don't attached to the hyoid bone but attached
to catilage that is attached to the bone , inspite it
regarded as infrahyoid strap muscle .
• The last two muscle are deep to the first two
muscle and all of them cover the thyroid gland .

Innervation Of The Infrahyoid Strap Muscles :-

Motor :-
• all of the mucsles by the MAIN TRUNK of the
ansa cervicalis except :-
• A/ Superior belly of omohyoid which supplied by
the the superior root of ansa cervicalis .
• B/ Thyrohyoid :- by branch from C1 which travell
with the hypoglossal nerve .

Action Of The Infrahyoid Strap Muscles :-

• 1. stabilize the hyoid bone { fix it } to allow the
supra hyoid muscle to open the mandible
• But is not strong and can you loss this action
without any effect
• infrahyoid ‫ ﻣﻤﻜﻦ ﺗﻘﻄﻊ ال‬Thyroidectomy‫ف ﻋﻤﻠﻴﺎت ال‬
‫ وﻧﺨﻴﻄﻬﺎ‬easy ‫ ﻳﻜﻮن‬dissection‫ ﻋﺎدي ﻋﺸﺎن ال‬muscle
‫واﻟﻤﺮﻳﺾ م ﻳﺘﺄﺛﺮ ﺑﻌﺪ داك‬
• 2. They are all depressors of the larynx,
Depression of the larynx increases the volume of
the resonating chambers during phonation and
thus affects the quality of the voice

•-------------------------------------------------•
Ansa cervicalis :-
• is made of two roots :-
• Sup.erior one from the C1 and travell with
hypoglossal nerve to join the inferior roots C2 ,C3
• The superior root gives branch to superior
belly of Omohyoid
• The main trunk gives branches to : inferior belly of
Omohyoid , Sternohyoid & Sternothyroid .
•--------------------------------------------------•

★ Supra-hyoid Strap muscle :-

1. Digastric muscle :-
• Has two bellies anterior & posterior .
• The posterior belly arise from digastric notch
medial to the mastoid process .
• The anterior belly atise from digastric fossa
of the mandible .
• The two bellies meet at central tendon which
attach to the hyoid bone.
• Nerve supply : The posterior belly is supplied
by the facial nerve, and the anterior belly by the
nerve to mylohyoid.
• Action : To depress and retract the chin, and to
assist the lateral pterygoid in opening the mouth.

2. mylohyoid muscle :-
• form the floor of the mouth
• Origin : Mylohyoid line in the mandible and the
two muscle interdigited with each other and
attach to the hyoid bone

3. Stylohyoid :-

• Origin :back of Styloid process .

• Insertion : Hyoid bone ( Its lower end divides to
embrace the digastric tendon and is inserted by
two slips to body of the hyoid bone.

4. Genihyoid :-

• Located Deep to the mylohyoid .

• ORIGIN : Genial tubercle ( inferior mental
spine ). in the mandible
• Insertion :hyoid bone

Action of The Supra-hyoid MUSCLES :-

• All of them they retract the mandible downward.

Innervation of The Supra-hyoid MUSCLES :-

• 1/ Stylohyoid with the posterior belly of the
digastric supplied the facial nerve .
• 2/ mylohyoid and anterior belly of the digastric
supplied by the nerve to mylohyoid muscle
which the branch of the inferior alveolar ( before
entering the mandibular foramin ) which is
branch of the mandibular which is branch of
the trigemnial { CN 5}.
• 3/ Geniohyoid like Thyrohyoid by branch of C1
that travell with hypoglossal nerve .

• Different in innervation due different pharyngeal

arches in the development { Revise the arches}.

•-------------------------------------------------•

Floor of the mouth is made from deep to

superficial by :-
1. Geniohyoid→ two .
2. mylohyoid → two .
3. Anterior bellies of the digastric → two .
•-------------------------------------------------•

Note :-
1. Mylohyoid line ==>origin of mylohyoid muscle
2. Mylohyoid groove ==> for nerve to mylohyoid
3. Mandibular foramin==> for inferior alveolar nerve
4. Hyoid bone at level of C3
5. Angel of the mandible at C2

•-------------------------------------------------•
★
TRIANGLES OF THE NECK:-

A : Posterior triangle :-
• Boundaries :
1. sternocleidomastoid medially
2. trapezius laterally
3. middle third of the clavicle forming the base
• the inferior belly of omohyoid devide the
posterior triangle into two triangles :-
1. Upper one → occipital triangle
2. Lower one → suprecalvicular triangle .
 B : Anterior triangle :-
• Boundaries :
1. sternocleidomastoid laterally
2. Lower border of the mandible forming the base
3. imaginary line ( midline ) medially .

• Roof :-
• skin , superficial fascia , platysma, deep
cervical fascia

• The anterior triangle can be subdivided by two

bellies of The digastric and superior belly of
omohyoid into submental, digastric, carotid and
muscular triangles .

# Note :-
• Hyoid bone has no articulation with another bone
and supendded by muscle & ligament

1/ Submental triangle :
• Single triangle and crosses the midline .

# Boundaries:-
• Anterior bellies of digastric at the side and body
 of hyoid bone below.

• # CONTENT :-
1. submental lymph node which drain the :-
• lower four incisor teeth, and central part of the
lower lip, and the tip of the tongue

2. Anterior jugular veins :-

• Very superficial vein and usually meet them

during thyroidectomy .
• Drain the same areas the drained by the
submental lymph node .
• They run downward toward the thorax close to
each other and after that diverge when reach the
thorax and drain into the external jugular vein
which also superficial vein .

2 /Digastric triangle [submandibular triangle ]:-

Boundaries :-
• Lower border of the Mandible, anterior and
posterior bellies of digastric.

CONTENTS :-
1. Sub mandibular salivary gland .
2. Sub mandibular lymph node .
3. Stylohyoid muscle .
4. submental and mylohyoid vessels; hypoglossal
and mylohyoid nerves
• Sub mandibular lymph node drain :-

1. Submental lymph node .

2. lateral parts of the lower lips
3. all the upper lip and external nose
4. Anterior two third of the tongue ( except the
tip of the tongue )
5. All the teeth (except lower 4 incisors)
• these structures in the form of wedge shape
of the face and exculding the ear , cheek and
eyes which are drained to the parotid { pre
auricular} lymph node .

# Common MCQs questions :-

• Posterior third of the tongue is drained with
pharynx and the tip of the tongue drain
indirectly to the submandibular through the
submental lymph node .

3/ Carotid triangle :-
Borders :-
• Superior belly of omohypid
• Upper part of sternocledomastoid SCM.
• Posterior belly of digastric .

Contents :-
1. Most important bifurcation of common
carotid artery .
2. External and internal carotid arteries
3. All branches of external carotid artery except
posterior auricular artery that arise above
digastric muscle and run behind the ear
4. Internal and external laryngeal nerves, and
superior root of ansa cervicalis .
5. Hypoglossal nerve :-
• cranial nerve number 12 that arise from the skull 
passing through the neck crossing the internal
then the external carotid arteries then the loop
of the lingual artery.

4/ Muscular triangle :-

Boundaries:-
• Lower half SCM lateraly & superior belly of
omohyoid lateraly and midline medially .

CONTENTS :-
• Parts of larynx, trachea, pharynx, oesophagus,
thyroid and parathyroid glands; their vessels ,
nerves and lymph nodes and infra hayoid muscles

•--------------------------------------------------•

SUBMANDIBULAR SALIVARY GLAND :-

• Triangular in shape , consists of a large superficial

part and a small deep part which are continuous
with one another round the free posterior
margin of mylohyoid .
• The superficial part has three surfaces :

# Lateral surface :-
• make the submandibular fossa in the mandible
below the mylohyoid line .

# Medial surface :-
• lies against the mylohyoid, and behind it on the
hyoglossus muscle , lingual nerve, hypoglossal
nerve and its accompanying veins ( Vena comitans
 of hypoglossal nerve ) & fascial artery

• These above two nerve cross the medial surface

of the gland to reach the tongue , lingual is above
and the hypoglossal nerve is bellow it

• Fasial artery firstly lie posterior then deep and

finally anterior to the gland and it is pulsation can
be felt at the angle of the mandible
• So The medial surface of the gland is related to
two nerves and one artery .

# Inferior surface :-
• Relate to the skin , superficial fascia, platysma
muscle, deep cervical fascia .
• This surface is crossed by the cervical and
marginal mandibula branches of the fasial nerve
and also by the fasial vein .
• So the inferior surface is related to two
nerves and one vein
• The above relation is very important to it during
surgery in the submandibular gland the most
dangerous injury is to the hypoglossal ( give
motor innervation to the tongue ) or the lingual
( give sensory innervation to the tongue ) because
they supply the tongue and after that to the
mandibular branch of the fasial nerve which sup-
 ply the muscle that move the mouth { if it injure
pateint will presented with mouth deviation } and
the least dangerous is the cervical branch of the
fasial nerve which supply the platysma .

• To avoid injury to this nerves when you want to

reach the galnd surgically the incision must be
done 4 cm below the mandible to see clearly the
nerves and not damage them .

# The deep part of the gland :

• Extends forwards for a variable distance, between
mylohyoid and hyoglossus, below the lingual
nerve and above the hypoglossal nerve.

Note :
• Submandibular lymph nodes lie in contact with
the surface of the gland and within its substance,
hence the need to remove the gland as well as
nodes in the operation of radical neck dissection

Sub mandibular ducts ( of Wharton ) :-

• emerges from the medial surface of superficial
part of the gland near the posterior border
of mylohyoid
• It runs first between mylohyoid and hyoglossus,
and then between the sublingual gland and
 genioglossus, to open into the floor of the
mouth on the sublingual papilla beside the
frenulum of the tongue.
• As it lies on hyoglossus, the duct is crossed
laterally by the lingual nerve which then turns
under the duct to pass medially to the tongue
• Above it we have the lingual nerve { cross the
duct from above and below} and below it we
have hypoglossal nerve .
• Important to know these relation during
the surgery of the duct { removal of stone
for example }.

Blood supply :-
• From the facial artery, with veins draining
into the facial vein.

Lymph drainage :-
• To the submandibular lymph nodes .

Nerve supply :-
• Secretomotor : fibres to the gland from cell bodies
in the submandibular ganglion .
• Vasoconstrictor : fibres come from the plexus
around the facial artery.
• submandibular ganglion hangs suspended from
the lingual nerve on the surface of hyoglossus.
• The preganglionic fibres pass from cell bodies in
the superior salivary nucleus in the pons by way
of the nervus intermedius, facial nerve, chorda
tympani and the lingual nerve .
• Postganglionic fibres pass to the submandibular
gland and also to the lingual nerve for
transmission to the sublingual gland.

•-------------------------------------------------•

Thyroid Gland :

• major endocrine glands .

• Control all of your body for this In medicine
patients with hypothyroidism can presented
with any thing
• thyroid gland has left and right lobe and
isthmus in the centre.
• Posterior relation to the isthmus is the 2nd, 3rd ,
4th trachial ring , trachea , esophagus.
• The lobes extend from the oblique line of the
thyroid cartilage to the sixth tracheal ring

• Medial relation to the lobes : The trachea , larynx ,

 lower part of the pharynx , upper part of the
esophagus , cricothyroid muscle of the larynx and
the inferior constrictor of the pharynx, external
and recurrent laryngeal nerves
• Lateral relation to the lobes : carotid
sheath ( most important ) , Sternohyoid and
sternothyroid muscles .
• posterior relation to the glands :
Parathyroid glands

• A small portion of gland substance that usually

absent or small know as pyramidal lobe . It may
be attached to the inferior border of the hyoid
bone by fibrous tissue or muscle fibres sometimes
present in it are named levator glandulae
thyroideae and are innervated by a branch of the
external laryngeal nerve

BLOOD SUPPLY :-

Arteries : -
1. Superior thyroid artery branch of the external
carotid artery
2. Inferior thyroid artery branch of the subclavian
artery { thyrocervical trunk}.
3. Thyroidiae ima artery in 3% of people
branch either from the arch of the aorta or
 brachiocephalic artery and cross anterior
to the trachea .
• May contribute to bleeding anterior to the trachea
during thyroidectomy { pulstile bleeding }.
• ‫ م ﺷﻮﻳﻪ ﻣﻤﻜﻦ ﻳﻼﻗﻴﻚ ﻋﺎدي ف اﻟﻌﻤﻠﻴﻪ وﻣﻤﻜﻦ‬%3 ‫اﻟﻨﺴﺒﻪ‬
. exam‫ﻳﻼﻗﻴﻚ ﺑﺮﺿﻮ ف ال‬
• Other source of bleeding anterior to the trachea :
1/ anterior jugular veins
2/ Inferior thyroid vein

VEINS :-
• 1. Superior thyroid vein .
• 2. middle thyroid vein .
• Both drain to the internal jugular vein
• 3. Inferior thyroid veins drain to the
brachiocephalic vein and cross anterior
to the trachea.

Lymphatic Draining :-
• To the pretracheal, and prelaryngeal lymph node
{ both are central cervical lymph node}.

Nerve Supply :-
• Sympathetic (vasoconstrictor) nerves from the
superior, middle and inferior cervical ganglia
accompany the thyroid arteries.
•-------------------------------------------------•

Important notes during thyroidectomy :-

1. Ligation of the superior thyroid artery Must
be done very close to the gland to avoid injury
to the external laryngeal nerve that supply
cricothyroid muscle .
2. Ligation of the inferior Thyroid artery Must
be done away from the gland to avoid injury
to the reccurent laryngeal nerves { main
nerve to larynx } .
3. Usually we doesn't ligate the inferior thyroid
artery because it is the main blood supply
to the parathyroid gland and if you ligate it
we have ischemia In the parathyroid gland →
hypoparathyroidism and some times must give
him active vitamin D replacement for life .

• The inferior thyroid artery is ligated in :-

1. removal of thyroid gland affected by cancer .
2. Parathyroidectomy .
• Other wise we try to make thyroidectomy without
ligation of the inferior thyroid artery BUT the
superior one must be ligated always.
• The superior and middle thyroid veins can be
torn in thyroid surgery, perhaps admitting an air
bubble (due to negative pressure in the veins)
that can ascend in the internal jugular vein into
the skull, with injurious or lethal results.

‫ وﻳﻨﺴﺄل ﻣﻨﻬﺎ ﻧﺎس ﺳﺎدﺳﻪ ف اﻣﺘﺤﺎن اﻟﺠﺮاﺣﺔ‬relation ‫اﻫﻢ‬

-: ‫ ﻫﻢ‬thyroid gland‫ﺑﺎﻟﻨﺴﺒﻪ ﻟﻞ‬
1. Parathyroid gland
2. reccurent laryngeal nerves.
• injury to this structure can be serious .
Last modified: 10:13 AM