Borders of the Muscular Triangle

• Borders - The hyoid bone superiorly,

the superior belly of omohyoid
laterally, and midline of the neck serve
as borders for this region and can be
viewed once the superficial fat and
fascia have been removed.  The hyoid
bone can be palpated superior to the
laryngeal eminence (Adam's Apple) of
the neck and the SCM can often be
seen by having a patient turn his or her
head from side to side.  Be sure to
understand these landmarks prior to
proceeding through the dissection.
 Infrahvoid Muscles of the Muscular
Triangle
• Infrahyoid Muscles - Expose the infrahyoid muscles that sit superficial to the larynx.  These
muscles include sternohyoid, superior belly of omohyoid (superficially, thyrohyoid, and
sternothyroid (deep); commonly referred to as the "Strap" muscles.  The infrahyoids are
important in depressing the hyoid bone during swallowing.  The names of the muscles are
derived from their origin and insertion in the neck.  Each muscle is innervated by a branch of
Ansa Cervicalis except thyrohyoid which is innervated by a branch of C1 that "hitches a ride"
with Cranial Nerve XII (Hypoglossal). Reference Netter Plates
22 - 24.
 Infrahyoid Reflection - Reflect the strap muscles superiorly exposing the laryngeal prominence ("Adam's
Apple") as well as the thyroid gland.  The thyroid gland is supplied by two arteries, the superior thyroid artery
and inferior thyroid artery (be sure to know the derivation of each branch).  Also locate the internal laryngeal
nerve and artery which pierce the thyrohyoid membrane, the recurrent laryngeal nerve which has different
paths for each side of the body, and the external laryngeal nerve which innervates the cricothyroid muscle.  
All nerves of the larynx are derived from Cranial Nerve X (Vagus).  For this dissection, you should be
concerned only with finding these nerves and structures and preserving them until the detailed larynx
dissection which will come later in the course.  Reference Netter Plates 
 Vasculature of the Muscular
Triangle
• Vasculature - Expose the
anterior jugular vein and trace its
path back to the external jugular
vein via coimmunicating veins. 
Also note the difference in
lymphatic drainage.  On the left
side of body, the thoracic duct
drains the left side of the head,
the left side of the neck and
thorax and the remainder of the
body into the left
brachiocephalic vein at the
junction of the left subclavian
vein  and left internal jugular.  On
the right side of the body, small
lymphatic trunks drain the right
upper limb of the body into the
right lymphatic duct which joins
the right subclavian vein.  You
should make an attempt to find
the thoracic duct on the left side
of the body.  However, this is a
very delicate structure that often
does not survive dissection. 
Reference Netter Plates 24, 26,
63, 64, and 68 - 70.
 Carotid Triangle
• Borders - The posterior
border of SCM posteriorly,
posterior belly of digastric
superiorly, and superior
belly of omohyoid
anteriorly serve as borders
for this region and can be
viewed once the
superficial fat and fascia
have been removed.

• Sternocleidomastoid
Reflection - Cut the SCM 1
centimeter from its
insertion on the sternum
and clavicle (two heads)
and reflect superiorly
toward the ear.  Do not cut
any of the cutaneous
branches of the cervical
plexus.  Any veins may be
cut to aid in reflecting the
space and opening the
area for viewing.  The
roots of the cervical
plexus, the carotid sheath,
and Ansa Cervicalis
should be visible.
 Ansa Cervicalis of the Carotid
Triangle
• Ansa Cervicalis - Running
over the outside of the
carotid sheath (but
sometimes deep to it) is the
Ansa Cervicalis, a motor
division of the cervical
plexus.  It is composed of
two limbs, a superior root
which is derived from C1,
associated with CN XII, and
anteriorly placed, and an
inferior root which is derived
from C2 and C3 and
posteriorly placed.  A loop is
formed where the superior
and inferior roots join and
from this loop, branches
arise which innervate the
infrahyoid muscles (except
thyrohyoid).  This is a very
delicate structure and time
should be spent dissecting
the roots and motor branches
to each of the infrahyoids
 Cervical Plexus of the Carotid
Triangle
• Cervical Plexus -
Composed of the ventral
primary rami of C1 - C4,
the cervical plexus is the
origin of the cutaneous
nerves of the posterior
triangle, the phrenic
nerve (which passes
into the thorax to
innervate the
diaphragm), and the
Ansa Cervicalis.  In
addition, there are also
communicating
muscular branches
which travel to CN XI
(Spinal Accessory).  It
therefore has both
motor and sensory
components.
 Hypoglossal Nerve of the Carotid
Triangle
• Hypoglossal Nerve -
Cranial Nerve XII
crosses the carotid
sheath superiorly just
beneath the
submandibular salivary
gland and passes deep
to the posterior belly of
the digastric running
posterior to anterior to
innervate the muscles
of the tongue.  There is
a small branch of C1
which "hitches a ride"
with CN XII to innervate
the thyrohyoid muscle. 
CN XII loops around
the occipital artery
which is travelling
posteriorly (The
occipital is a branch
from which artery?). 
Reference Netter
Plates 27, 29, 53, and
65.
 Carotid Sheath of the Carotid
Triangle
• Carotid Sheath -
Dissect the carotid
sheath (a tough
fascia) from three
structures contained
therein; the common
carotid artery, the
internal jugular vein,
and Cranial Nerve X
(Vagus).  Be sure to
preserve any
branches off the
carotid that may be
evident.  In addition,
be sure not to damage
the inferior or
superior root of the
ansa cervicalis which
may be descending
superficially or within
the caroitid sheath. 
This is a very delicate
structure that
provides motor
innervation to the
infrahyoid muscles.
 Carotid Artery of the Carotid Triangle
• Carotid Artery - Clean and examine the
common carotid artery.  Just below the
superior horn of the hyoid bone, the
common carotid bifurcates into the internal
carotid and the external carotid.  At the
bifurcation one can find the carotid sinus
which is a receptor of blood pressure for
the autonomic nervous system.  The
internal carotid ascends through the neck
and into the skull without any branches to
structures in the head; this is the primary
arterial supply to the brain.  The external
carotid has six major branches that supply
regions in the head and neck.  These
branches are classified by the catchphrase
SALFOPS Max:
    Superior Thyroid Artery - travels
inferiorly and medially toward the thyroid
gland with the external laryngeal nerve. 
Superior
        laryngeal artery is a branch that
pierces the thyrohoid membrane with the
internal laryngeal nerve
    Ascending Pharyngeal Artery - ascends
to supply the pharynx
    Lingual Artery - travels medially and
disapears into the hyoglossus muscle
    Facial Artery - travels medially and
disappears behind the submandibular gland
    Occipital Artery - travels posterior-
superiorly along the posterior digastric and
crosses CN XII
    Posterior Auricular Artery - ascends with
the posterior auricular nerve
    Superficial Temporal Artery - a terminal
branch of the external carotid
    Maxillary Artery - internal branch that
shall be dealt with later in detail
Reference Netter Plates 27, 29, and 63
Vagus Nerve - Cranial Nerve X travels in the carotid sheath deep to the common carotid artery and internal jugular vein.   The vagus
has a wide array of innervation in the head and neck as well as throughout the chest and abdomen.   The superior laryngeal nerve
arises from the vagus and travels inferior-medially.  Two branches are significant; the internal laryngeal nerve and the external
laryngeal nerve.  The internal laryngeal nerve pierces the thyrohyoid membrane with the superior laryngeal artery and is sensory to
the laryngeal mucosa above the vocal folds.  The external laryngeal nerve is a motor nerve to cricothyroid.  There is an additional
motor branch to the larynx in the recurrent laryngeal nerve which is a motor nerve to the laryngeal muscles and carries a sensory
component to the laryngeal mucosa below the vocal folds.  This nerve may be seen ascending along the lateral border of the thyroid

and entering the larynx.  Further detail will be given to this nerve later.  Reference Netter Plates 27, 65, 69, and 70.
 Sympathetic Trunk of the Carotid Triangle

• Sympathetic Trunk
- Deep to the
carotid sheath is a
sympathetic chain
of three cervical
ganglion (superior,
middle and
inferior).  From
these ganglia are
sent fibers carrying
sympathetic
information.  The
inferior cervical
ganglion and the
first thoracic
ganglion may fuse
to form a stellate
ganglion. 
Reference Netter
Plates 124 and
125.
• Borders - The inferior border of the
Submandibular Triangle
mandible superiorly, the anterior belly
of the digastric, and the posterior belly
of the digastric serve as borders for
this region and can be viewed once
the superficial fat and fascia have
been removed.  Be sure to trace the
outline of the border of the mandible
and be able to locate the general
position of lymph nodes in the head
and neck.  Understanding of their
location will prove invaluable when
examining patients in a clinical setting.

• Muscles - The anterior and posterior

bellies of the digastric are connected
by an intermediate tendon which is
held to the greater horn of the hyoid
bone by a tendinous sling.  The
stylohyoid muscle wraps around the
tendinous sling to insert on the hyoid
bone.  The mylohyoid muscle can be
seen deep to the anterior belly of the
digastric and forms a physical barrier
between the neck and the
submandibular region (floor of the
mouth). Hyoglossus can be found
deep to mylohyoid.  All suprahyoids
are important in elevating the hyoid
bone during swallowing.  Reference
Netter Plates 22, 23, 27, 41, 47, 62,
and 67.
Submandibular Region - Trace the path of the facial artery from the external carotid as it passes deep to the submandibular
salivary gland.  Trace the path of the facial vein as it passes superficial to the submandibular gland.  Trace the hypoglossal
nerve over the carotid sheath as it  passes deep between mylohyoid and hyoglossus.  Locate the mylohyoid nerve arising
from the inferior alveolar nerve (to come later) which supplies the anterior belly of the digastric and mylohyoid.   The
posterior belly of the digastric,the platysma muscle, and stylohyoid are all innervated by a branch of the Facial Nerve CN
VII.  Expose the submandibular salivary gland.  Reference Netter Plates 5, 17, 19,  22 - 24, 27, 29, 35, 41, 47, 53, 55, 62, 63,
and 65.