NECK Anatomyzkk
NECK Anatomyzkk
NECK Anatomyzkk
Zahid aimkhani
Clinical Anatomy of the Neck
Clinical Anatomy of the Neck
The neck is conveniently thought of as the tissue surrounding the 7 cervical vertebrae.
Objectives
to comprehend the topographic anatomy of the neck region
acquire relevant information of direct clinical importance without unnecessary details of pure academic
importance.
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Clinical Anatomy of the Neck
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The Cervical Spine
Salient Features:
Identified by the foramen transversarium ,transmits the vertebral artery, the vein,
and sympathetic nerve fibres.
The spines are small and bifid (except C1and C7 which are single).
The atlas (C1) has no body. The axis (C2) bears the dens (odontoid process. C7 is
the vertebra prominens.
Clinical Features:
The cervical vertebrae (particularly C7), may be fractured or, more commonly,
dislocated by a fall on the head with acute flexion of the neck e.g. diving into
shallow water.
Dislocation may even result from the sudden forward jerk (during car or aeroplane
crash). WHY NOT FRACTURE- the relatively horizontal intervertebral facets of
the cervical vertebrae allow dislocation to take place without their being fractured.
Cervical disc prolapse- This may sometimes occur at the lower cervical
intervertebral discs C5/6 and C6/7.
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Clinical Anatomy of the Neck – Surface Anatomy of the Neck
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General Topography of the Neck
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General Topography of the Neck
• Cervical spines gently convex forward support the skull.
• A mass of Extensor musculature lies behind the vertebrae.
• A much smaller –prevertebral Flexure musculatures covered by prevertebral
fascia lies in front of the vertebrae and behind the pharynx.
• The face is in front of the upper part of the pharynx.
• The larynx and trachea lies in front of the lower pharynx and upper esophagus.
• The sternocleidomastoid is tensed helps define the triangle of the neck.
• Violently clench the jaws; the platysma lying in the superficial fascia of the neck.
• The external jugular vein lies immediately deep to platysma, perforates the deep
fascia just above the clavicle and enters the subclavian vein.
It is readily visible in a thin subject on straining like in singer hits a sustained
high note or when an orthopaedic surgeon reduces a fracture.
• The carotid sheath on each side of pharynx and sympathetic chain behind it.
• The common carotid artery pulse can be felt by pressing backwards against the
long anterior tubercle of the transverse process of C6.
• The carotid bifurcates into the external and internal carotid arteries at the level of
the upper border of the thyroid cartilage; at this level the vessels lie just below the
deep fascia where their pulsation is palpable and often visible.
• Last 4 CNs, 9-12 passes forward, 11th runs backward and 10th conti. downward in
carotid sheath.
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The Fascial Compartments of the Neck
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The Fascial Compartments of the Neck
Extent:
The base of the skull superiorly and fuses
with the pericardium inferiorly.
The sympathetic chain lies behind
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Tissue Spaces of the Neck
Clinical feature. Ludwig’s angina -rare but severe cellulitis involve the
parapharyngeal spaces.
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The Triangles of the Neck
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Triangles of the Neck
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Anterior Triangle of the Neck
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Posterior Triangle of the Neck
Boundaries
Anteriorly: Posterior border of sternomastoid
Posteriorly: Anterior border of Trapezius
Apex : Meeting of Trapezius & Sternomastoid
Base: Middle 1/3 of the clavicle
Roof:Skin, Superficial fascia, Platysma and the Investing layer of the
deep cervical fascia.
Floor: from below upward, Scalenus anterior + ,Scalenus medius, levator
scapulae, splenius capitis, and semispinalis capitis +
Note. The scalenus anterior and 1st digit of serratus anterior MAY contribute to
floor depending on the size of the sternocleidomastoid muscle.
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Posterior Triangle of the Neck
Contents:
Nerves:
• Trunks of the brachial plexus,
• Cervical plexus.
• Spinal accessory.
Arteries:
1- 3rd part of subclavian artery.
2- Suprascapular artery.
3- Transverse cervical artery.
4- Occipital artery.
Veins:
1- Subclavian vein.
2- External jugular vein
Lymph nodes
• 2-3 occipital ( enlarged in scalp infection & rubella)
• Numerous are supraclavicular
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The Thyroid Gland
The isthmus:
Firmly adherent to 2nd ,3rd & 4th tracheal rings {fixation & investment in
pretracheal fascia responsible for the gland movement with larynx during
swallowing}
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The Thyroid Gland
Pyramidal lobe:
Represents a development of gland from the
caudal end of the thyroglossal duct.
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The Thyroid Gland
Blood Supply;
The superior thyroid artery, br of ECA (Ext
laryngeal N is immediately behind it)
The inferior thyroid artery—arises from the
thyrocervical trunk and have variable relations
with Recurrent Laryngeal N i.e why artery is
ligated well lateral to the gland.
The thyroidea ima artery—is inconstant (3%)
Three veins drain the thyroid gland:
The superior thyroid vein— drains the upper pole
to the internal jugular vein or facial vein;
Why thyroid gland bleed even all main vessels are tied during a partial
thyroidectomy ?
Numerous small vessels pass to the thyroid from the pharynx
and trachea so that even when all the main vessels are tied,
the gland still bleeds when cut across.”
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The Thyroid Gland
Clinical features
Thyroglossal cyst or sinus
Reterosternal goiter
Benign enlargement
Pressure on trachea- Difficulty in
breathing
Pressure on esophagus – difficulty in
swallowing
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The Parathyroid Gland
Salient Features:
• usually four in number(vary from two to six). , a superior and inferior
on either side;
• Ninety per cent are in close relationship to the thyroid, 10% are
aberrant, the latter invariably being the inferior glands.
• size -a split pea and is of a yellowish-brown colour.
• Position: The superior parathyroid is more
constant in position,
• The inferior parathyroid is most usually situated near the lower pole
of the thyroid gland. The next commonest site is within 1cm of the
lower pole of the thyroid gland.
• Aberrant inferior parathyroids may be found in front of the trachea
and may even track into the superior mediastinum.
Clinical features
• These possible aberrant sites are, of course, of great importance in
searching for a parathyroid adenoma in hyperparathyroidism.
• The parathyroids are usually safe in subtotal thyroidectomy because
the posterior rim of the thyroid is preserved. However, they may be
inadvertently removed or damaged, with resultant tetany due to the
lowered serum calcium.
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The Pharynx
Nasal cavity
Oral cavity
B
A-Nasopharynx
B-Oropharynx
C- Laryngopharynx
Nasopharynx :
• Pharyngeal opening of auditory tube & tubal elevation
• Pharyngeal tonsil: if enlarged in children (adenoids) Laryngopharynx:
causing obstruction of nasophaynx & difficulty in Extends from upper end of epiglottis (C3) to lower border of
breathing cricoid cartilage (C6)
Functional Anatomty:
The nasopharynx is kept opened to allow breathing by: The larynx itself bulges into this part of the pharynx leaving a deep
a. The rigidity of its wall (well developed recess anteriorly on either side, the piriform fossa, in which
pharyngobasilar fascia) sharp ingested foreign bodies (for example, fish bones), may
b. The lack of pharyngeal constrictors over its wall
lodge.
Salient Features
Is respiratory organ
Perform triple functions
1. An open valve in respiration,
2. A partially closed valve -phonation,
3. and a closed valve protecting the trachea and bronchial tree during deglutition.
“Coughing is only possible when the larynx can be closed effectively”.
Skeleton:
Cartilage- the epiglottis, thyroid , cricoid and the arytenoids, corniculate & cuneiform
Ligaments and membranes-Extrinsic (TH membrane & cricotracheal, hyoepiglottic &
thyroepiglottic ligaments.)
Intrinsic (quadrangular membrane & CT ligament
Slung from the U-shaped hyoid bone by the thyrohyoid membrane and thyrohyoid muscle.
The hyoid bone itself is attached to the mandible, tongue, styloid process and pharynx .
The corniculate cartilage,and the cuneiform cartilage,small nodules, no functional significance BUT
might mimic pathological nodules.
Anteriorly, the cricothyroid ligament, easily felt and is used in emergency cricothyroid puncture for
laryngeal obstruction.
Partially damaged or bruised “Semon’s law” apply .i.e. abductors (PCA) are affected more than the adductors. The affected cord adopts the midline adducted
position.
In bilateral incomplete paralysis, the cords come together, stridor is intense and tracheotomy may become essential.
WHY loss of voice must always be regarded as an warning symptom requiring careful investigation.
Thyroid malignancy or malignant lymph nodes in neck may damaged the either RLN.
The left recurrent laryngeal nerve can be involved in (Palsy): a bronchial or esophageal carcinoma, enlarged mediastinal nodes, or may become stretched over an
aneurysm of the aortic arch , the enlarged left atrium in advanced mitral stenosis may produce a recurrent laryngeal palsy by pushing up the left pulmonary artery
which compresses the nerve against the aortic arch.
Laryngoscopy
CERVICAL PART(Relations)
Anteriorly— the isthmus of TG, ITVs, SH and ST muscles;
Laterally—the lobes of thyroid gland and the CCA
Posteriorly—the esophagus with the recurrent laryngeal
Clinical Features:
• may be compressed or displaced by pathological enlargement
• ‘Tracheal-tug’ characteristic of aneurysms of the aortic arch
• Tracheotomy and tracheostomy
• Tracheotomy (making an incision in the trachea-in children)
• Tracheostomy (removal of small part of wall)
Indications
• Laryngeal obstruction (tumors, inhaled foreign bodies)
• Evacuation of excessive secretions (severe postoperative chest infection in a
patient who is too weak to cough adequately)
• For long-continued artificial respiration (poliomyelitis, severe chest injuries).
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Blood Vessels of the Neck -Arteries
Subclavian Arteries
The left subclavian artery arises from the arch of the aorta.
The right subclavian artery is formed by the bifurcation of the brachiocephalic artery.
Divided in to 3 parts by scalenus anterior
Branches includes:
• 1st part-The vertebral artery, the thyrocervical trunk[inferior thyroid, transverse
cervical, suprascapular] and the internal thoracic artery
• 2nd part — the costocervical trunk (supplying deep structures of the neck via its
deep cervical branch, and the superior intercostal artery, which gives off the 1st
and 2nd posterior intercostal arteries).
• 3rd part—gives no constant branch.
Clinical Features:
• The right subclavian artery is grafted end-to-side into the right pulmonary artery
to short-circuit the pulmonary stenosis of the tetralogy of Fallot (MUST KNOW
THE VARIATIONS)
• An aneurysm of the subclavian artery is not rare; in the third part of the artery
(NEVER in thoracic part). Usually pain, weakness and numbness in the arm bcz
of close relation with the brachial plexus.
• A cervical rib may elevate the subclavian artery and may closely simulate an
aneurysm.
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Blood Vessels of the Neck -Veins
The internal jugular vein
• Begins at the jugular foramen (continuation of sigmoid sinus) and terminates by
joining the subclavian vein to form the brachiocephalic vein
• Lies in the carotid sheath
Its tributaries are:
• the pharyngeal venous plexus; the common facial vein; the lingual vein; the
superior and middle thyroid veins.
Superficial veins
• The superficial temporal and maxillary veins join to form the
retromandibular vein. Its posterior division,together with the posterior
auricular vein, form the external jugular vein, whereas the anterior division
joins the facial vein to form the common facial vein which opens into the
internal jugular vein.
• The external jugular vein enter the subclavian vein and The anterior jugular
vein runs down join enter the external jugular vein.
• The subclavian vein continuation of the axillary vein joins the internal
jugular vein to form the brachiocephalic vein. ONLY tributary is the external
jugular vein. The left also receive thoracic duct.
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Blood Vessels of the Neck -Veins
Clinical Features:
Central Venous Catheterization
• to measure central venous pressure (c.v.p.)
• to allow rapid blood replacement
• long-term intravenous feeding
• The internal jugular vein can be cannulated by direct puncture in the triangular gap
between the sternal and clavicular heads of the sternocleidomastoid immediately
above the clavicle.
• Feel this landmark on yourself.
• The needle is inserted near the apex of this triangle at an angle of 30–40° to the skin
surface and is advanced caudally towards the inner border of the anterior end of the
first rib behind the clavicle. A reflux of blood confirms venepuncture.
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The lymph nodes of the neck
Salient Features:
• grouped into horizontal and vertically disposed aggregates.
• The horizontal nodes form a number of groups which encircle the junction of the head with the
neck and which are named, according to their position.
• These nodes drain the superficial tissues of the head and efferent then pass to the deep cervical
nodes (although some lymph vessels pass direct to the cervical nodes, bypassing the horizontal
nodes).
• The vertical nodes [superficial & deep cervical groups] drain the deep structures of the head and
neck.
• The most important is the deep cervical group, extends along the internal jugular vein from the base of the skull to
the root of the neck
• The superficial cervical nodes lie along the external jugular vein, serve the parotid and lower part
of the ear and drain into the deep cervical group.
• Others vertical nodes are :the infrahyoid, the prelaryngeal and the pre- and paratracheal nodes.
These drain the thyroid, larynx, trachea and part of the pharynx and empty into the deep cervical
group.
• The retropharyngeal nodes, lying vertically behind the pharynx, drain the back of the nose,
pharynx and Eustachian tube; their efferents pass to the upper deep cervical nodes.
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The lymph nodes of the neck
• Clinical features
• Significant changes in the evaluation and management of lymphatic metastases in the neck during the past several decades, and knowledge of the
functional anatomy of the cervical lymphatics is fundamental to the clinical management of metastasis in this region.
• Significant improvements in clinical care, namely, selective neck dissection and sentinel lymph node biopsy aided by lymphoscintigraphy, have been
developed and are based upon detailed studies of the pathways of metastatic spread. These advances have significantly decreased the morbidity
associated with the evaluation and treatment of metastatic disease to the neck.
• The jugulodigastric or tonsillar node. A constant lymph node, becomes enlarged in tonsillitis responsible for the commonest swelling to be encountered
in the neck.
• Block dissection of the neck for malignant disease is the removal of the lymph nodes of the anterior and posterior triangles of the neck and their
associated lymph channels, together with those structures which must be excised in order to make this lymphatic ablation possible.
o The block of tissue removed extends from the mandible above to the clavicle below and from the midline anteriorly to the anterior border of the trapezius
behind.
o The carotid arteries, the vagus, the cervical sympathetic chain and the lingual and hypoglossal nerves. The accessory nerve, passing across the posterior
triangle, is usually sacrificed.
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The Cervical Sympathetic Trunk
Salient Features:
• Continues upwards from the thorax by crossing the neck of the first rib, then ascends embedded in the posterior wall of
the carotid sheath to the base of the skull.
Three ganglia:
• the superior cervical ganglion (the largest) ,the middle ganglion and the inferior ganglion (C7+T1-the stellate ganglion)
Note: that these ganglia receive no white rami from the cervical nerves; their preganglionic fibers originate from the upper
thoracic white rami and then ascend in the sympathetic chain..
Branches:
• cardiac branches and vascular plexuses along the carotid, subclavian and vertebral vessels.
• to the dilator pupillae muscle (along the internal carotid artery).
• Grey rami pass from the superior ganglion to cranial nerves VII, IX, X and XII.
• Clinical features –Horner Syndrome
• Meiosis (pupillary constriction) , due to unopposed parasympathetic innervation via the oculomotor nerve),
• Partial ptosis (partial paralysis of levator palpebrae)
• the face on the affected side is dry and flushed).
• Enophthalmos
• Causes:
• Spinal cord lesions at the T1 segment (tumour or syringomyelia),
• Closed penetrating or operative injuries to the stellate ganglion
• Pressure on the chain or stellate ganglion by enlarged cervical lymph nodes, an upper mediastinal tumor, a carotid
aneurysm or a malignant mass in the neck.
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The Root of the Neck
Salient Features:
• Also called “The Thoracic Inlet” often called clinically “The Thoracic Outlet”
Boundaries:
• the 1st thoracic vertebra, the 1st pair of ribs and their cartilages and manubrium of
the sternum
Note: The KEY to the root of the neck is the “SCALENUS ANTERIOR MUSCLE”
& its relations
Clinical Features:
• A cervical rib occurs in 0.5% of subjects and is bilateral in half of these.
• Pressure on the lowest trunk of the brachial plexus arching over it may produce
paranesthesia along the ulnar border of the forearm and wasting of the small
muscles of the hand (T1).
• Vascular changes (Less commonly ), even gangrene, may be caused by pressure of
the rib on the overlying subclavian artery.
• This results in post-stenotic dilatation of the vessel distal to the rib in which a
thrombus forms from which emboli are thrown off.
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Clinical Anatomy of the Neck