HUMAN ANATOMY Neck

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NECK
Cylindrical region connecting Head and Trunk

EXTENT LAYERS Skin, Superficial fascia with cutaneous vessels nerves and Platysma Deep fascia is cervical fascia Above - lower border of body of mandible, line joining angle of Mandible to Mastoid process, Mastoid process, Superior Nuchal line, External occipital protuberance. Below - Suprasternal notch of Manubrium sterni, Clavicle, Acromion Process, C7.

CUTANEOUS NERVES Branch Lesser Occipital Great auricular n Transverse cervical Ansa cervicalis Phrenic Supraclavicular CERVICAL FASCIA The deep fascia of the neck, divided into three layers Investing, Pretracheal and Prevertebral These form natural lines of cleavage through which tissues may be separated, and limit the spread of pus from infections in the neck. Origin C2 C2, C3 C2, C3 --C3 - C5 C3, C4 Muscles innervated Skin of neck, scalp posterosuperior to auricle Skin over parotid gland, posterior auricle, angle of mandible to mastoid process Skin of anterior triangle Infrahyoid (MAHE-95) Diaphragm Skin over shoulder

Investing layer of Deep Cervical Fascia Forms a collar around the neck, located between the superficial fascia and the muscular layer Attachments Superiorly: external occipital protuberance, superior nuchal line, mastoid process, lower border of the mandible Inferiorly: spine of the scapula, acromion process, clavicle, manubrium Posteriorly: ligamentum nuchae, C7 spine Anteriorly: symphysis menti, body of hyoid Pretracheal layer of Deep Cervical Fascia Attachments Superiorly: hyoid bone, oblique thyroid cartilage, cricoid cartilage Features Lies deep to Infrahyoids, splits to enclose thyroid, trachea and esophagus
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Features The investing layer splits to enclose 2 muscles Trapezius, Sternocleidomastoid 2 salivary glands Parotid, Submandibular 2 spaces Suprasternal, Supraclavicular 2 pulleys to bind tendons Digastric and Omohyoid

HUMAN ANATOMY Neck

Inferiorly: arch of the aorta (superior mediastinum) Laterally: fuses with the carotid sheath

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Prevertebral layer Attachments Superiorly: base of the skull Inferiorly: body of T4 vertebrae muscles The cervical plexus and proximal parts of the brachial plexus are deep to it; forms floor of posterior triangle of neck, axillary sheath is extension of this fascia Carotid sheath Completely enclosed within investing fascia, on either side of the pretracheal fascia Encloses the common and internal carotid arteries, internal jugular vein and Vagus nerve (KCET-2010) The sympathetic chain is located posterior to (and outside) the sheath, ansa cervicalis embedded in ant wall, runs from base of skull to sup mediastinum Retropharyngeal Space: Potential space between the pretracheal fascia and prevertebral fascia. MIDLINE STRUCTURES OF THE NECK Features Forms part of a fascial sleeve for the prevertebral

1. 2. 3. 4. 5. 6. 7. 8. 9.

Fibrous raphe of insertion of Mylohyoid extending from symphysis menti to hyoid bone-derived from 1st branchial arch Body of the hyoid bone-derived from 2nd, 3rd branchial arches Median thyrohyoid ligament and Thyrohyoid membrane pierced by Internal Laryngeal nerve and Superior Laryngeal vessels Laryngeal prominence. Derived from 4th and 6th branchial arches Cricothyroid ligament, Cricothyroid muscle Cricoid cartilage 1st tracheal ring Isthmus and pyramidal lobe of the thyroid gland Inferior thyroid veins

10. Jugular venous arch (joins the two anterior jugular veins)
TRIANGLES OF NECK Side of the neck is divided by Sternocleidomastoid into (AIPG-94, 95, 96) 1. 2. Anterior triangle with apex directed downwards Posterior triangle with apex directed upwards

ANTERIOR TRIANGLE OF THE NECK (AIPG-2003) Boundaries Base: lower border of mandible, line from the angle of mandible to mastoid process Apex: Jugular notch Anterior border: midline of neck extending from Symphysis menti to Suprasternal notch Posterior border: anterior border of sternocleidomastoid
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HUMAN ANATOMY Neck

Roof: skin, superficial fascia, investing layer of deep cervical fascia Floor: pharynx, larynx, prevertebral fascia

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The superior belly of Omohyoid and Digastric muscles divide the anterior triangle into 4 further triangles BOUNDARIES 1. Sides Base Apex Floor muscles Hyoid bone Symphysis menti Mylohyoid muscle (KCET-03, AIPG-99) 2. Anterior Anterior belly of Digastric CONTENTS SUB MENTAL TRIANGLE MEDIAN TRIANGLE Muscles Arteries & Veins Nerves Miscellaneous ------Sub mental lymph nodes

Anterior bellies of Digastric

DIGASTRIC TRIANGLE Anterior part Muscles Arteries & Veins Nerves --Facial artery Facial vein Mylohyoid vessels Mylohyoid nerve Superficial Miscellaneous part of Submandibular gland Submandibular lymph nodes Posterior part Muscles Arteries & Veins Nerves Miscellaneous Stylopharyngeus Internal carotid artery Internal jugular vein Hypoglossal nerve (AIPG-99) Vagus nerve Lower pole of parotid gland

Posterior

Posterior belly of Digastric Stylohyoid

Base of mandible Base Line from angle to mastoid process Skin Roof Superficial fascia Deep fascia Mylohyoid Floor Hyoglossus Middle constrictor of pharynx 3. Anterosuperiorly Posterior belly of Digastric Stylohyoid

CAROTID TRIANGLE Muscles --Common Carotid Artery and its two terminal branches Branches of External Carotid Artery

Anteroinferiorly

Superior belly of Omohyoid

Arteries

Superior Thyroid Lingual Facial Ascending pharyngeal Occipital

Posteriorly

Anterior

border

of

Sternocleidomastoid

Veins

Internal tributaries

Jugular

Vein

and

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HUMAN ANATOMY Neck

Hypoglossal Ansa cervicalis Skin Roof Superficial fascia Deep fascia Nerves Vagus External laryngeal Internal laryngeal

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Cervical part of Sympathetic trunk Thyrohyoid Floor Hyoglossus Middle and Inferior constrictors of pharynx 4. Behind Infront and above Infront and below Medial Anterior border Sternocleidomastoid Posterior belly of Digastric Stylohyoid Superior belly of Omohyoid Midline MUSCULAR TRIANGLE of Infrahyoid muscles - These are all innervated by the Ansa cervicalis except Thyrohyoid, which is innervated by C1 nerve Surgical approach for thyroid, larynx, trachea and esophagus (deep to this triangle) Miscellaneous ---

Importance of Carotid triangle

Carotid sinus baroreceptor at the bifurcation of the common carotid, innervated by the sinus branch of IX cranial nerve; Pressure on the carotid sinus syncope, cessation of heart beat Carotid body chemoreceptor posterior to the bifurcation of the common carotid; reflex change in respiration Important surgical approach for carotid arteries, internal jugular vein, vagus nerve, hypoglossal nerve, cervical sympathetic trunk Carotid pulse absence indicates cardiac arrest

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HUMAN ANATOMY Neck

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REGION

MUSCLE Mylohyoid Geniohyoid Stylohyoid

ORIGIN Mylohyoid line of mandible Inferior genial tubercle of

INSERTION Body of hyoid Body of hyoid Body of hyoid Intermediate tendon-in position by sling of deep fascia, gap at insertion of Stylohyoid

INNERVATION Inferior alveolar C1 (via XII) Facial (VII) Anterior belly: inferior alveolar (Mandibular branch of V3) (APPSC-99, AIPG-99, AIIMS03) Posterior belly: facial (VII) (COMEDK-2006) branch of

FUNCTION Elevate hyoid and floor of mouth (KCET-98) Pull hyoid antero-superiorly Elevate and retract hyoid Depress mandible (AIIMS-90) Elevate hyoid

Mandibular nerve (V3) Symphysis menti of mandible Styloid process Anterior belly - digastric fossa of Mandible Posterior Posterior belly - Mastoid notch of Temporal bone to fascial sling (PGI2003) Sternohyoid Infrahyoid (AIIMS-06) Thyrohyoid Omohyoid 2 belliesSuperior (near insertion) Inferior (near origin) Hyoglossus is not included in Suprahyoid muscles Sternothyroid Sternoclavicular manubrium sterni Posterior surface of manubrium sterni Oblique line on Thyroid cartilage Inferior belly from superior border of scapula near suprascapular notch Oblique cartilage Lower border of Body and greater horn of hyoid Superior belly into inferior Ansa cervicalis (C1-C3) C1 (via XII) line on Thyroid Ansa cervicalis (C1-C3) joint, clavicle, Lower border of body of hyoid Suprahyoid Digastric 2 bellies Anterior, (AIIMS-93, MAHE-94)

Ansa cervicalis (C1-C3)

Depress hyoid Depress hyoid Depress hyoid Depress hyoid

border of body of hyoid

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HUMAN ANATOMY Gross Anatomy

POSTERIOR TRIANGLE OF THE NECK Boundaries Apex: superior nuchal line Base: middle 1/3 of clavicle Anteriorly: posterior border of sternocleidomastoid Posteriorly: anterior border of trapezius Roof: skin, superficial fascia, investing cervical fascia Floor: prevertebral fascia (over splenius capitis, levator scapulae, scalenus anterior, medius, posterior) Posterior triangle is divided by inferior belly of Omohyoid into

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1. 2.

Upper larger Occipital triangle Lower Supraclavicular / Subclavian triangle

BOUNDARIES 1. Apex Superior nuchal line OCCIPITAL TRIANGLE Muscles ---

CONTENTS

Transverse cervical artery Anteriorly Posterior border of Sternocleidomastoid Arteries & Veins Occipital artery External Jugular Vein Posteriorly Anterior border of Trapezius Spinal accessory nerve Cutaneous branches of Cervical plexus Lesser Occipital nerve Great Auricular nerve Transverse Cervical nerve Nerves Base Inferior belly of Omohyoid Supra Clavicular nerves Muscular branches Levator Scapulae Trapezius(C3, 4) Rhomboids (C5) Upper part of Brachial plexus 2. Apex SUB CLAVIAN TRIANGLE Muscles --3rd part of Subclavian artery with its Anteriorly Lower part of posterior border of branches Arteries & Veins Subclavian vein Suprascapular artery (thyrocervical trunk) Posteriorly Anterior border of Trapezius Nerves Base Middle 1/3 of clavicle 3 trunks of brachial plexus Nerve to Serratus anterior Nerve to Subclavius Suprascapular nerve (last two are branches of upper trunk of brachial plexus)
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At junction of sternocleidomastoid and inferior belly of Omohyoid

Sternocleidomastoid

HUMAN ANATOMY Gross Anatomy

EXTERNAL JUGULAR VEIN (EJV) Formed by the union of the Retromandibular and Posterior Auricular Veins (KCET-2000)

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Pierces and fuses with investing cervical fascia about 5 cm above clavicle, if cut, fascia prevents it from closing and can cause intravenous air embolus. It can fill and become visible from holding breath, or from congestive heart failure. Most of the facial veins drain into the External Jugular Vein. Transverse Cervical (from back of danger zone) and Supra scapular veins drain into External Jugular vein.

BRACHIAL PLEXUS Forms from the anterior rami of cervical nerves C5 to C8 and thoracic nerve T1 The contributions of each of these nerves, which are between the anterior and middle scalene muscles, are the roots of the brachial plexus. Branches from the roots are dorsal scapular nerve to the rhomboid muscles, long thoracic nerve to the Serratus anterior muscle, nerve to the Subclavius muscle, suprascapular nerve to the supra spinatus and infra spinatus muscles. As the roots emerge from between these muscles - the anterior rami of C5 and C6 form the upper trunk, the anterior ramus of C7 forms the middle trunk; the anterior rami of C8 and T1 form the lower trunk. The trunks cross the base of the posterior triangle. Branches from upper trunk are nerve to Subclavius, Suprascapular nerve. Erbs point - 6 nerves meet at this point - C5,C6 roots joining to form upper trunk, anterior and posterior branches of upper trunk branches of upper trunk - nerve to Subclavius, Suprascapular nerve. Lesion of this region (forceps delivery, forced expulsion of fetal head in breech delivery) causes Erbs paralysis. CERVICAL PLEXUS C1-C4 Formed from ventral primary rami of upper four cervical nerves, supplies skin, muscles of neck, and Diaphragm. All come of Cervical Plexus and penetrate investing fascia of the posterior triangle

Cutaneous nerves Lesser occipital nerve (C2-3) supplies skin of the neck and the scalp posterosuperior to the auricle Great auricular nerve (C2-3) supplies skin over the parotid gland, posterior aspect of the auricle and skin extending from the angle of the mandible to the mastoid process Transverse cervical nerve (C2-3) skin covering the anterior triangle Supra Clavicular nerve (C2-4) skin of the neck, clavicle and anterior shoulder

Phrenic nerve (C3-C4-C5) Caries motor, sensory and sympathetic fibers; innervates diaphragm, mediastinal pleura and pericardium.

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HUMAN ANATOMY Gross Anatomy

Muscle Upper Sternal head Sternocleido mastoid (AIPG-09) Clavicular head Origin part of Lateral one-half of superior nuchal line Lateral surface of mastoid process Accessory nerve [XI] and branches from anterior rami of C2 to C3 (C4) of Insertion Innervation Function

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Individually - will tilt head towards shoulder on same side rotating head to turn face together to opposite side Acting draw forwards Assists in rotating head

anterior surface of manubrium sternum Superior surface of medial one-third of clavicle

Superior line; occipital Trapezius

nuchal external Lateral one-third of clavicle; acromion; spine of scapula Motor-accessory nerve C3 and C4 [XI]; proprioception

the scapula during abduction humerus horizontal Upper elevate, fibers lower Ansa to C3 cervicalis; fibers middle adduct, fibers of above

protuberance; ligamentum nuchae; spinous processes of vertebrae TXII Superior border of CVII to

depress scapula Omohyoid scapula medial to scapular notch Anterior of Anterior scalene the processes vertebrae CVI Transverse Middle scalene processes vertebrae CVII Posterior of Posterior scalene processes vertebrae CVI Lower Splenius capitis half of Together Mastoid one-third process, of skull below lateral superior nuchal line Posterior middle nerves rami cervical draw head back-wards Individually - draw and rotate head to one side (turn face to same side) CIV tubercles transverse of to Upper surface of rib II Anterior rami of C5 to C7 Elevation of rib II CII of to Upper surface of rib I between tubercle and groove for subclavian artery Anterior rami of C3 to C7 Elevation of rib I CIII tubercles transverse of to Scalene tubercle and upper surface of rib I Anterior rami of C4 to C7 Elevation of rib I Inferior border of body of hyoid bone anterior rami of C1 Depress the hyoid bone

ligamentum nuchae; spinous processes of vertebrae TIV CVII to

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HUMAN ANATOMY Gross Anatomy

SUB OCCIPITAL GROUP OF BACK MUSCLES Muscle Rectus capitis Origin Spinous process of axis (C2) Spinous atlas (C1) Transverse process of atlas (C1) Spinous process of axis (C2) process of Lateral Insertion portion of Innervation Posterior ramus of C1 Posterior ramus of C1 Posterior ramus of C1 Posterior ramus of C1 Function Extension of head

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posterior major Rectus capitis

occipital bone below inferior nuchal line Medial portion of occipital bone below inferior nuchal line Occipital bone between superior and inferior nuchal lines Transverse process of atlas (CI)

Rotation of face to same side as muscle Extension of head Extension side Rotation of face to same side of head

posterior minor Obliquus capitis superior Obliquus capitis inferior

and bends it to same

The sub occipital muscles are innervated by the posterior ramus of the first cervical nerve, which enters the area between the vertebral artery and the posterior arch of the atlas. The vascular supply to the muscles in this area is from branches of the vertebral and occipital arteries Contents of Sub Occipital Triangle Sub occipital nerve, Vertebral artery, Vertebral plexus of veins

BRANCHES OF THE EXTERNAL CAROTID ARTERY (KCET-97, AIPG-2001) Arteries Supplies Branches from Medial aspect of external carotid artery Ascending pharyngeal (AIPG-2003) artery Pharyngeal constrictors and Stylopharyngeus muscle, palate, tonsil, pharyngotympanic tube, meninges in posterior cranial fossa Branches from Anterior aspect of external carotid artery Superior artery Lingual artery (APPG-1994, 2001) Facial artery thyroid Thyrohyoid muscle, internal structures of the larynx, sternocleidomastoid and cricothyroid muscles, thyroid gland Muscles of the tongue, palatine tonsil, soft palate, epiglottis, floor of mouth, sublingual gland All structures in the face from the inferior border of the mandible anterior to the masseter muscle to the medial corner of the eye, soft palate, palatine tonsil, pharyngotympanic tube, submandibular gland (AIPG-92, 98, AIIMS-2001) Branches from Posterior aspect of external carotid artery Occipital artery Posterior artery auricular Sternocleidomastoid muscle, meninges in posterior cranial fossa, mastoid cells, deep muscles of the back, posterior scalp (MAHE-99) Parotid gland and nearby muscles, external ear and scalp posterior to ear, middle and inner ear structures

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HUMAN ANATOMY Gross Anatomy

Terminal Branches of external carotid artery (KCET-2001) Superficial temporal artery

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Parotid gland and duct, masseter muscle, lateral face, anterior part of external ear, temporalis muscle, parietal and temporal fossae External acoustic meatus, lateral and medial surface of tympanic membrane, temporomandibular joint, dura mater on lateral wall of skull and inner table of cranial

Maxillary (AIPG-94, 95)

artery

bones, trigeminal ganglion and dura in vicinity, mylohyoid muscle, mandibular teeth, skin on chin, temporalis muscle, outer table of bones of skull in temporal fossa, structures in infratemporal fossa, maxillary sinus, upper teeth and gingiva, infra-orbital skin, palate, roof of pharynx, nasal cavity (MAHE-2002)

Muscles Rectus anterior Rectus lateralis Longus colli capitis capitis Inferior bone Inferior jugular

Origin surface of

Insertion Anterior surface of

Innervation Branches from anterior rami of C1, C2

Function Flexes joint Flexes head laterally to same side head at

basilar part of occipital surface process of of

lateral part of atlas and its transverse process Superior atlas Anterior tubercle axis of to surface of transverse process of

Atlanto-occipital

occipital bone Body T3, C1-C3 Inferior surface of

Branches from anterior rami of C1, C2

Flex neck

Tendinous

slips

Longus capitis

basilar part of occipital bone

transverse processes of vertebrae CIII to CVI

Branches from anterior rami of C1 to C3

Flexes the head

LYMPH NODES AND THE LYMPHATIC DRAINAGE OF THE HEAD AND NECK Location Area of drainage-From To

Superior Horizontal Chain Sub mental nodes Sub mental triangle Skin of chin, lip, floor of mouth, tip of tongue Sub mental nodes, oral Submandibular nodes Pre auricular (parotid) nodes Post auricular (mastoid) nodes Submandibular triangle cavity, face, except forehead and part of lower lip In front of tragus Lateral surface of pinna, side of scalp Temporal scalp, medial Mastoid process Between mastoid process Occipital nodes and external occipital protuberance Vertical chain Posterior Superficial Along exterior jugular vein Sub parotid nodes, jugular Supraclavicular and Back of scalp Deep cervical nodes surface of pinna, external auditory meatus Deep cervical nodes Submandibular nodes or jugular chain Intermediate jugular nodes, deep posterior cervical nodes Deep cervical nodes

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HUMAN ANATOMY Gross Anatomy

cervical (posterior triangle) nodes Intermediate (jugular) nodes Juguloparotid (subparotid) nodes Jugulodigastric (subdigastric) nodes Jugulocarotid (bifurcation) nodes Juguloomohyoid (Omohyoid) nodes Anterior (visceral) nodes Parapharyngeal nodes Paralaryngeal nodes Paratracheal nodes Prelaryngeal (Delphian) nodes Pretracheal nodes Lateral and posterior wall of pharynx Lateral wall of larynx Lateral wall of trachea Cricothyroid ligament Anterior wall of trachea below isthmus of thyroid gland Deep face and esophagus Larynx and thyroid gland Thyroid gland, trachea, esophagus Thyroid gland, pharynx Thyroid gland, trachea, esophagus Intermediate nodes Deep cervical nodes Deep cervical and mediastinal nodes Deep cervical nodes Deep cervical and mediastinal nodes Angle of mandible, near parotid nodes Junction of common facial and internal jugular veins Bifurcation of common carotid artery close to carotid body Crossing of Omohyoid and internal jugular vein Tip of tongue Tongue, except tip Palatine tonsils All other nodes of neck Deep Along spinal accessory nerve chain, occipital, and mastoid area deep cervical nodes

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Lymphatic trunks to left and right thoracic ducts

ROOT OF THE NECK

The root of the neck is the junction between the neck and thorax Important structures are the superior thoracic aperture, cervical pleura and scalenus anterior muscle.

Boundaries of the thoracic inlet Posterior: T1 vertebra Lateral: 1st rib and costal cartilage Anterior: Manubrium Contents of the Root of the Neck Nerves

1. 2. 3.

Vagus nerve and recurrent laryngeal nerve Sympathetic chain Phrenic nerve (on scalenus anterior, deep to prevertebral fascia)

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HUMAN ANATOMY Gross Anatomy

Arteries

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1. 2. 3. 4.

Right brachiocephalic trunk (right subclavian, right common carotid posterior to Sternoclavicular joint) Left Subclavian artery Left common carotid artery Subclavian artery (medial, posterior and lateral parts by scalenus anterior) i. ii. Vertebral artery, internal thoracic artery, thyrocervical trunk Costo cervical trunk (from 1st part on the left)

iii. Suprascapular and/or dorsal scapular arteries Veins (unite posterior to Sternoclavicular joint)

1. 2.

Subclavian vein Internal jugular vein

Lymphatics

1. 2.
Viscera

Left side thoracic duct Right side Jugular, Subclavian, Broncho mediastinal lymph trunks (right lymphatic duct)

1. 2. 3.
Muscles

Trachea Oesophagus Apex of the lung (and pleural cupula)

1. 2. 3.

Longus colli Sternal ends of sternocleidomastoid, Sternohyoid, Sternothyroid Scalene muscles (marginal)

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HUMAN ANATOMY Gross Anatomy

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