MRCS Neck anatomy - Anterior triangle

Introduction

• The range of neck pathology and neck lumps requires a good understanding of the associated
anatomy.
• Classically the neck is arbitrarily organised into anterior and posterior triangles - separated by
the sternocleidomastoid (SCM) muscle:

Boundaries Anterior triangle Posterior triangle

Apex Jugular notch Union of SCM and trapezius

Base Lower border of mandible Middle third of clavicle

Anterior Midline of neck SCM

Posterior SCM Trapezius

• The anterior and posterior triangles can be further subdivided:

Post belly of Splenius

digastric

Stylohyoid
Levator
to id

scapulae
Mylohyoid
mas
id o

Scalene
Ant belly of medius
le

digastric
noc

Hyoglossus Scalene
Ster

anterior
Thyrohyoid
Medius
Constrictor
pharyngeus Inferior Inferior belly
omohyoid
Superior belly
omohyoid
Sternohyoid Trapezius

Anterior triangle regions

Posterior triangle regions
Submental
Occipital
Submandibular
Supraclavicular
Muscular

Carotid
MRCS Neck anatomy - Anterior triangle

Submandibular region
• The region immediately below the mandible.

Boundaries Anterior triangle

Superior Body of mandible

Anterior Anterior belly of digastric

Posterior Posterior belly of digastric

Roof Skin, superficial fascia, platysma, deep fascia

Floor Mylohyoid muscle

Superficial submandibular structures:

Platysma - broad sheet of superficial muscle arising from

the fascia that overlaps sternocleidomastoid.

Facial vein

Cervical branch of facial nerve - supplies platysma

Submandibular gland:
• Accounts for ≈ 70% of salivary production
• Wharton’s duct (submandibular duct) arises from the
gland and passes between mylohyoid, hyoglossus and
genioglossus - eventually opening either the side of the
lingula frenulum.
• Parasympathetic supply - from a branch of the facial
nerve the chorda tympani (CNVII) which runs in the
sheath of the lingual nerve (branch of mandibular nerve
CNV3) to synapse at the submandibular ganglion -
which supplies the submandibular gland and lies on
hyoglossus.

Deep submandibular structures:

Facial artery

Lingual nerve -branch of mandibular nerve (CNV3)

Submandibular ganglion

Hypoglossal nerve (CNXII) - supplies all muscles of

tongue except palatoglossus.

Lingual artery
MRCS Neck anatomy - Anterior triangle

Submental region
• The region between the two anterior bellies of digastric.

Boundaries Anterior triangle

Superior Body of mandible

Anterior Midline

Posterior Anterior belly of digastric

Roof Skin, superficial fascia, platysma, deep fascia

Floor Mylohyoid muscle

• Contents:
• Submental lymph nodes.
• Superficial veins which form tributaries of the anterior jugular veins.

Anterior belly of digastric

Submental lymph nodes

Stylohyoid

Posterior belly of digastric

Anterior jugular veins

Hyoid

Carotid triangle
• Contains the carotid sheath.

Boundaries Anterior triangle

Superior Stylohyoid and posterior belly of digastric

Inferior Superior belly of omohyoid

Posterior Sternocleidomastoid

Roof Skin, superficial fascia, platysma, deep fascia

Floor Thyrohyoid, hyoglossus, constrictor

pharyngeus medius/inferior.
 MRCS Neck anatomy - Anterior triangle

Carotid triangle
Superficial structures
The superficial veins are the first structures encountered
on removing the roof of the carotid triangle:

Common facial vein

Retromandibular vein
Posterior auricular vein
External jugular vein - commences at level of the angle of
the mandible runs obliquely over sternocleidomastoid. At
the midpoint of the clavicle - in the subclavian triangle
penetrates the deep fascia to drain into the subclavian
vein.
Internal jugular vein - deeper contained within the carotid
sheath (see below).
Anterior jugular vein (note not within carotid triangle)

Post removal/reflection of sternocleidomastoid -

overlying nerves and internal jugular vein
Hypoglossal nerve and branch of first cervical - a branch
of the first cervical nerve courses in the same sheath as
the hypoglossal nerve then leaves as two branches in the
carotid triangle:
1. Superior root of ansa cervicalis - supplies infrahyoid
muscles (see muscular triangle).
2. C1 nerve directly to thyrohyoid.

Ansa cervicalis - a loop of nerves derived from the

cervical plexus - receives supply from C1-3 nerve roots.
Innervates the infrahyoid muscles: sternohyoid,
sternothyroid and omohyoid.

Internal jugular vein - lies lateral to the internal carotid

and common carotid. At the root of the neck joins the
subclavian vein to form the brachiocephalic vein.
Combined with the carotid and vagus is contained within
Hypoglossal nerve continues to supply all muscles
the carotid sheath (see below).
of the tongue except palatoglossus.
MRCS Neck anatomy - Anterior triangle

Carotid triangle
Post removal of internal jugular vein
External carotid artery
Occipital artery
Facial artery
Lingual artery
Ascending pharyngeal artery
Superior thyroid artery

Internal carotid artery

Post removal of carotid artery

Vagus nerve - contained within carotid sheath (with

carotid and internal jugular vein)

Internal branch of superior laryngeal nerve - supplies

sensation to the epiglottis - irritation causes coughing.

External branch of superior laryngeal nerve- supplies

cricothyroid muscle - Clinical note: Susceptible to
damage during thyroidectomy as lies inferior and close to
superior thyroid artery (which is ligated during
thyroidectomy). Palsy results in loss of high pitch voice.
MRCS Neck anatomy - Anterior triangle

Muscular triangle

Boundaries Anterior triangle

Superior Superior belly of omohyoid

Anterior Midline of neck

Inferior Sternocleidomastoid

Roof Skin, superficial fascia, platysma, deep fascia

• The muscular triangle contains the infrahyoid muscles (also known as the strap muscles) whose
primary function is to depress the hyoid and larynx during swallowing.
• All are supplied by the ansa cervicalis (see above) except thyrohyoid which is directly supplied
by a branch of C1 nerve.

Superficial layer

Superior belly omohyoid - omohyoid consists of 2 bellies

separated by an intermediate tendon. It arises from the
scapula. The inferior belly then courses along the clavicle
bound by a fibrous expansion. Behind the
sternocleidomastoid it becomes tendinous then courses
vertically upwards as the superior belly to insert onto the
hyoid.

Sternohyoid- sternum to hyoid

Deep layer

Thyrohyoid - thyroid cartilage to hyoid

Sternothyroid - sternum to thyroid cartilage

Thyroid - see separate revision sheet

Inferior belly omohyoid